Toe Pulp Flap Research Articles

Comparison of nerve block and spinal anesthesia in second toe pulp free flap surgery for fingertip reconstruction.

Toe pulp flap surgery is a viable option for soft tissue defects of the fingertips, effectively addressing patient needs and fingertip characteristics. The preferred anesthesia for lower-extremity surgery includes spinal and regional anesthesia. However, the choice between these methods depends on patient safety and surgical efficacy. In this retrospective study, we aimed to ascertain the optimal anesthetic technique by examining the efficacy, safety, pain control, and potential side effects of spinal and peripheral nerve block anesthetics. We included 40 patients aged 18-60 years who underwent partial second toe pulp free flap surgery for fingertip reconstruction. Twenty patients received spinal anesthesia (SA), while the remaining 20 received peripheral nerve block anesthesia. We conducted a comparative analysis of postoperative pain scores, adverse effects, analgesic usage, and patient satisfaction scores associated with each anesthesia method. Independent t-test, Mann-Whitney U test, and chi-squared test were performed. The SA group exhibited hypotension, bradycardia, urinary retention, and postdural puncture headache rates of 10%, 10%, 5%, and 5%, respectively. A significant difference in the timing of first analgesic use was observed (spinal, 3.7 ± 0.8 vs. peripheral nerve block, 13.2 ± 6.6; P = 0.006). Visual analog scale (VAS) scores of the patients at the 2nd, 4th, and 6th h were significantly lower in the peripheral nerve block group (P < 0.001, P < 0.001, P < 0.001, respectively). VAS scores at 12 and 24 h were similar between the groups (P = 0.07, P = 0.135, respectively). Peripheral nerve block anesthesia is superior to SA for partial second toe pulp free flap surgery, offering lower complication rates, reduced postoperative pain, and improved patient comfort.

Sensory re-education after free neurovascular toe pulp flap for digital pulp reconstruction

PurposeTo evaluate the effectiveness of a sensory re-education (SR) program after free neurovascular toe pulp flap for finger or thumb pulp defect reconstruction. MethodsFrom January 2015 to January 2020, 49 patients with finger or thumb pulp defects treated with free fibular side flaps of the great toe or tibial side flaps of the second toe were recruited. The patients were randomly divided into two groups one month after surgery. The training group received the SR program and the control group underwent the traditional rehabilitation program. Clinical evaluation included Semmes-Weinstein Monofilament (SWM) tests, static two-point discrimination (2-PD), and sensibility grading, measured at 1, 3, 6, 9 and 12 months postoperatively. ResultsA total of 42 patients completed the follow-up, including 22 (16 males) patients in the training group and 20 patients (12 males) in the control group. Compared with 1 month after the operation, significant improvements in sensory recovery were observed at 3, 6, 9, and 12 months postoperatively in both groups. In addition, earlier sensory recovery was seen in the SR group compared to the control group, showing significant differences at 3 and 6 months but not at 9 and 12 months postoperatively. ConclusionAlthough SR seemed to accelerate preliminary sensory recovery after free neurovascular toe pulp flaps for digital defect reconstruction, the program should be reconsidered as it offers no significant improvement over the control group at later follow-up stages.

To Do or Not to Do? Neurorrhaphy in Great Toe Pulp Flap Fingertip Reconstruction.

Background:Since its inception, the great toe pulp (GTP) flap has represented a valid therapeutic choice in the reconstruction of defects of the hand. This study illustrates the clinical outcomes of GTP free flaps performed without nerve anastomosis‚ mainly for fingertip defect reconstruction.Methods:We performed a retrospective, monocentric cohort study. All patients included in this study presented with fingertip traumatic injury, with tendon or bone exposure; reconstruction with GTP flap, without nerve reconstruction, was performed by the first author (L.T.) from May 2019 to October 2021.Results:All 37 flaps survived completely. Due to COVID restrictions‚ we had to send the tests and PROMs to our patients; 28 of them replied. Cold intolerance was reported by 12 patients (moderate in two cases and mild in ten cases). No pain was complained about either in hand or donor site (Visual Analog Score 0, at rest and at movement). Complete range of motion was achieved in 22 of 28 patients. All flaps recovered protective sensitivity. In every section of the Michigan Hand Outcome Questionnaire, all patients expressed a high level of satisfaction based on the reconstruction’s function and aesthetics. Regarding the donor site morbidity, no patient complained about gait disturbance.Conclusions:This study showed that the GTP flap is the optimal choice for fingertip reconstruction, providing excellent functional and aesthetic results with durable and glabrous skin, satisfactory pulp contour, and sensory restoration. These results could be achieved with no need for nerve suture, especially in defects with no injuries proximal to the loss of substance.

Repair of finger pulp defects using a free second toe pulp flap anastomosed with the palmar vein

PurposeTo evaluate the clinical utility of surgical reconstruction of finger pulp defects using a plantar flap derived from the toes, with vascular anastomosis of the toe-finger artery and the plantar-palmar vein of the finger.MethodsBetween April 2018 and November 2020, 29 patients with finger pulp defects underwent treatment via the transplantation of pulp tissue from the second toe, with the plantar vein of the toe and the palmar vein of the finger being anastomosed during this procedure. In addition, an anastomosis of the toe and finger artery and nerve was conducted, with a flap size of 1.0 cm * 0.8 cm–2.3 cm * 4.0 cm being used for such repair. Donor tissue sites were closed without introducing deformities or other complications.ResultsIn all patients in the present study, flap tissues survived and did not exhibit evidence of vascular crisis over a mean 16.8-month follow-up period (range 8–24 months). After successful skin flap grafting, they exhibited good elasticity and a soft texture. At three months post-surgery, some patients reported partial recovery of touch sensation in the transplanted tissue, while pain recovery was evident in some patients at 4–6 months post-surgery. No deformities or other complications were observed at the donor site, and the ability of patients to walk normally was not impaired.ConclusionThe anastomosis of toe plantar flaps with the palmar vein can facilitate the repair of finger pulp injuries without the need to dissect the dorsal vein of the toe, allowing for the suturing of donor tissue sites without causing any deformities or other complications. This surgical approach can easily be conducted with satisfactory clinical outcomes.

Full-Thickness Skin Grafts for Coverage of the Pedicle in Partial Second Toe Pulp Free Flap

Pedicle coverage during free flap reconstruction of the digit commonly presents complicated issues. As the finger is a cylindrical unit with small volume, it is difficult to secure ample soft tissue for relaxed coverage of the pedicle. We have applied full-thickness skin grafts (FTSGs) to loosely cover the pedicle of the free flap of the fingertip and report preliminary results. Seven patients who received free toe pulp flap and FTSG for soft tissue coverage of the pedicle were analyzed. Intraoperative parameters collected were defect, flap and graft area size and donor site. Patients were observed postoperatively for up to 2 months for graft take, necrosis, digit contour, and donor site complications. The average area of the free flap was 2.39±1.03 cm&lt;sup&gt;2&lt;/sup&gt; and the average graft area was 1.37±1.06 cm&lt;sup&gt;2&lt;/sup&gt;. The FTSG survived without sloughing or necrosis in six patients. Early epithelial sloughing with dermis take was noted in one patient who healed with dressings. The pedicle and graft portion showed bulging immediately after the operation but decreased to normal contour by 4 weeks. FTSG is an option that can be safely used as a method of pedicle coverage during free flap reconstruction of digits.

A hitchhiking approach to reconstruct the finger pulp and the subsequent 1st toe hemi-pulp donor site defect

The free 1st toe hemi-pulp transfer for finger pulp reconstruction was acknowledged as the optimal one. However, the treatment of the 1st toe donor defect, owning to the impossibility of primary closure, was frequently oversimplified. This study presented a "hitchhiking" approach to resurface finger pulp and the subsequent 1st toe donor site defect in a one-stage procedure. From 2014 to 2019, finger pulp amputations (13 digits in 12 patients) were reconstructed with free 1st toe pulp flaps, and the donor site was resurfaced by the 2nd toe pedicled flap with the 2nd toe's primary closure. Therapeutic evaluation of repaired fingers and toes was based on cold intolerance, two-point discrimination (2PD), and gait disturbance. All finger and toe pulp flaps survived uneventfully. The average size of free 1st toe and pedicled 2nd toe flap was 3.1cm×2.0cm (3.5cm×1.4cm to 4.2cm×2.5cm) and 3.0cm×1.1cm (2.0cm×0.9cm to 3.8cm×1.5cm), respectively. The regained average static 2PD on the finger and 1st toe pulps was 6mm (ranged 5-10mm) and 4mm (ranged 2-6mm), respectively. All reconstructed 1st toe pulps were qualified for normal gait. One patient complained the mild cold intolerance, and hammer-toe deformities were involved in two cases. To fulfill donor site care and cost-effective rule, the toe-to-finger pulp reconstruction can't underestimate the morbidity on 1st toe donor site due to inappropriate intervention. Equally importantly, the hitchhiking pedicled 2nd toe flap should be recruited in the reconstructive scheme.

Partial second toe pulp free flaps in early childhood.

BackgroundThe introduction of the partial second toe pulp free flap has enabled superior aesthetic and functional results for fingertip reconstruction in adults. Children undergoing fingertip amputation for various reasons have limited options for reconstruction. Conventional treatment could shorten the finger, leading to poor cosmesis and function. We report 18 years of our experiences with fingertip reconstruction using partial second toe pulp free flaps in patients in early childhood.MethodsMedical charts of children who had undergone fingertip reconstruction using partial second toe pulp free flaps from 2001 to 2018 were retrospectively reviewed. The surgical procedures were identical to those for adults, except for the usage of 11-0 nylon sutures. Patients’ demographic data, vessel size, flap dimensions, length of the distal phalanx, and functional outcomes over the course of long-term follow-up were documented. The statistical analysis was performed with the Student t-test, the Mann-Whitney U test, and Pearson correlation analysis.ResultsEighteen toe pulp flaps in 17 patients (mean age, 3.0 years) were identified. All the flaps survived without any major complications. In long-term follow-up, the flap-covered distal phalanges showed growth in line with regular development. There was no donor-site morbidity, and all children adapted to daily life without any problems. In two-point discrimination tests, the fingertip sensation recovered to almost the same level as that in the contralateral finger.ConclusionsPartial second toe pulp free flaps are an excellent option for fingertip reconstruction in young children, as well as in adults.

Bilateral Free 2nd Toe Pulp Flap for Reconstruction of Soft Tissue Defect in Traumatic Finger Injuries

Finger reconstruction involves paramount significance of both functional and aesthetic aspects, due to its great impact on quality of life. The options range from primary closure, skin grafts, local flaps, pedicled flaps, and free flaps. The optimal method should consider various circumstances of the patient and surgeon. We would like to report a case of a young woman who initially presented with cellulitis and necrosis of the left second finger-tip who underwent reconstruction with bilateral toe pulp free flap. The patient could successfully return to her job that involves keyboard typing and playing the piano, with acceptable donor site morbidity.

Ulnar Thumb Pulp Reconstruction Using the Anterograde Homodigital Neurovascular Island Flap.

The thumb ulnar pulp is a critical component of key pinch and precision manipulation. Injuries to this area should be reconstructed with robust, sensate tissue that restores bulk and contour. The existing reconstructive options, however, have substantial risks and drawbacks. We describe an anterograde homodigital neurovascular island flap that provides both sensate and durable coverage of the ulnar thumb pulp. The flap uses innervated glabrous tissue, limits donor site morbidity to the thumb and first web space, and does not require microvascular anastomoses or nerve coaptation. The flap has been previously described for nonthumb fingertip injuries, but it has not been applied to the thumb. We discuss several important technical modifications that are essential to raising and insetting this flap in the thumb, review potential pitfalls, and highlight key steps to ensuring judicious intraoperative decision making and success.

Free toe pulp flap for finger pulp and volar defect reconstruction.

Background:Fingertip injury requiring flap cover is very common in the modern era. The ideal cover should fulfill both functional and aesthetic improvement.Materials and Methods:From June 2015 to April 2016, we performed seven free toe pulp flaps for finger defect reconstruction. All patients were males. Five flaps were done in emergency post-traumatic cases, and two were done in elective set up. The cases included reconstruction of three thumbs, one index and one ring finger in an emergency set up and two ring fingers in the elective. Thumb reconstruction was done with great toe lateral pulp and the other digits reconstructed with second toe pulp flap. Follow-up evaluation included both functional and aesthetic assessment.Results:Five flaps survived completely, one suffered partial loss, and one flap failed completely. The median follow-up period was 9 months. The median duration of surgery was 255 min (range 210 to 300 min). The median two-point discrimination was 6.5 mm (range 4–8 mm). There was the return of temperature sensation in all patients; two had cold intolerance. The Semmes-Weinstein monofilament score varied from 3.61 to 5.07 (median filament index value 4.31/pressure value of 2 g/mm2). Three patients had delayed donor site wound healing.Conclusions:The free toe pulp flap is an efficient choice for fingertip and volar finger defects reconstruction with an excellent tissue match.

Donor-Site Morbidity after Partial Second Toe Pulp Free Flap for Fingertip Reconstruction.

BackgroundIn this study, we characterize the morbidity at the donor-site of partial second toe pulp free flaps in terms of wound management as well as long-term outcomes.MethodsA single-institutional retrospective review was performed for patients who had undergone partial second toe pulp free flap transfer to the fingertip. Patient charts were reviewed for infection, skin necrosis, wound dehiscence, and hematoma for the donor site. Additionally, a questionnaire survey was given to patients who had a follow-up of longer than 1 year to characterize long-term postoperative pain and appearance.ResultsThe review identified a total of 246 cases. Early wound complications were significant for wound dehiscence (n=8) and hematoma (n=5) for a wound complication rate of 5.3%. The questionnaire was distributed to 109 patients, and 54 patients completed the survey. Out of these 54 patients, 15 patients continued to have donor-site pain (28%) at a mean follow-up period of 32.4 months. However, the pain intensity was relatively low in the range between 2 to 5, on a 0–10 scale. None of these patients felt this donor-site pain interfered significantly with daily activity, nor did any patient require pain medications of any type. Donor-site appearance was satisfactory to most patients.ConclusionsThe partial second toe pulp flap was associated with low rates of wound complications and favorable long-term outcomes. Given the functional and aesthetic gain in the recipient finger, donor-site morbidities appear acceptable in this patient population. This study can be helpful in counseling patients regarding donor-site morbidity during the informed consent process.

Free lateral great toe flap for the reconstruction of finger pulp defects.

The aim of this study was to evaluate the esthetic and sensory outcomes after reconstruction of finger pulp defects with free toe flaps from the lateral aspect of the great toe. From June 2006 to October 2011, we performed 48 free toe pulp transfers for finger pulp reconstruction in 43 patients; 18 male and 25 female patients with a mean age of 31.8 years (range, 16-47 years). Six patients suffered multiple digital pulp defects and five received two synchronous pulp transfers. The defects involved 20 thumbs, 15 index fingers, 10 long fingers, and 4 ring fingers, and flap size ranged from 24 × 18 to 55 × 30 mm. Follow-up evaluation included the functional and esthetic outcomes of the reconstructed pulps and donor toes. All but one flap survived completely. Overall, 32 cases (35 pulp flaps) were followed for more than 1 year (range, 12-48 months; average, 22.8 months). The Semmes-Weinstein sensitivity score was 2.83 to 4.74 at the flaps and the mean static two-point discrimination was 6.17 mm (range, 3-10 mm). A total of 13 patients (40.6%) experienced mild (10 cases) to moderate (3 cases) cold intolerance, and 1 patient (3.1%) suffered severe cold intolerance. According to the Michigan Hand Outcome Questionnaire the mean esthetic appearance score was 16 (range, 12-19). The free neurovascular great toe pulp flap is an efficient and reliable flap for the reconstruction of finger pulp defects.

Digital Pulp Reconstruction with Free Neurovascular Toe Flaps

Finger pulp defects are commonly encountered in clinical settings and their treatment remains a consistent challenge for plastic and hand surgeons. Reconstruction should restore, as much as possible, the contour of the pulp as well as discriminating sensibility. Following the prime reconstructive principle of replacing "like with like," the free neurovascular toe pulp flap seems to be the optimal choice for digital pulp reconstruction because of the natural similarity of the digital pulp both anatomically and physically. However, after about 30 years of experience with this procedure, it is still controversial because it is technically demanding, involves donor site morbidity, and its reliability is questionable. With other small free flaps available, the application of this flap has been challenged and reconsidered. In this review we specifically focus on the reconstruction of soft tissue defects of digital pulp using the free neurovascular toe flap, aiming to investigate its advantages and drawbacks and obtain a comprehensive understanding of this procedure. The latest reconstruction concerns and technical refinements are also discussed. This journal requires that authors assign a level of evidence to each article.

Multiple flaps based on one pedicle from the foot to repair multiple skin defects of the hand

Objective To introduce the clinical outcomes of using multiple flaps based on one pedicle from the foot for repairing multiple skin defects of the hand.Methods Eight cases with a total of 19 wounds of the hand were treated with multiple flaps based on one pedicle from the foot.The lateral flaps from the first and second toes based on first plantar metatarsal artery were used to repair 12 wounds in 5 cases.Lateral tarsal flap and the first and second toes lateral flaps based on dorsalis pedis artery were transferred to repair 3 wounds in 1 case.Foot dorsum flap and big toe pulp flap pedicled on dorsalis pedis artery were used to repair 4 wounds in 2cases.Results All 19 flaps in 8 cases survived.Postoperative follow-up periods ranged from 3 to 36 months.Flap appearance was lifelike.Two-point discrimination was 5 to 11 mm.Sweat function recovered.Primary healing of skin grafts was achieved at the donor sites. Conclusion Transfer of multiple flaps based on one pedicle from the foot is an ideal method to repair multiple defects of the hand.It simplifies the surgical procedure and shortens the operation time.Flap selection should be based on the type and area of the injury. Key words: Surgical flaps; Microsurgery; Hand injuries

Communicating Branch of Toe Web Veins as a Venous Return Pathway in Free Toe Pulp Flaps

Communicating Branch of Toe Web Veins as a Venous Return Pathway in Free Toe Pulp Flaps

Toe pulp free flap to repair defects in the clinical application of the fingers

Objective To evaluate the toe flap repair of finger pulp defect of the clinical effects.Methods Of finger pulp defect using the first or second toe in 25 cases of free flaps, the flaps were cut size of 2.0 cm x 3.0 cm-3.5 cm x 4.5 cm, to toe at the end of artery-means the artery, subcutaneous veins-ve-nous anastomosis reconstruction of dorsal skin flap blood circulation, plantar digital nerve-refers to the inherent sensory nerve reconstruction.Results Twenty-five patients with flaps all survived, after vascular crisis occurred in 2 cases,surgical exploration and re-anastomosis of vascular survival, 3 months after flap reconstructive surgery in 12 cases.All patients were followed up for 2 months to 2 years, an average of 10 months,the fingers were satisfied with function and appearance, pulp full, two- point discrimination was 4-6 mm.Conclusion The toe plantar free flap repair of finger pulp defect may be a better clinical effects. Key words: Finger pulp; Toe pulp flaps; Transplantation; Microsurgery

Partial Second Toe Pulp Free Flap for Fingertip Reconstruction

The authors present their clinical experience and surgical methods of fingertip coverage using a short-pedicle partial medial second toe pulp free flap. The surgical steps for reducing surgical time and donor-site morbidity are described. Between April of 1999 and September of 2006, 929 partial second toe pulp free flaps were performed in 854 patients. The indications for this flap were preservation of digital length to cover exposed bone and replacement of skin over unstable fingertip scars. A total of 156 patients were assessed more than 1 year postoperatively with the two-point discrimination test. The mean patient age was 34 years (range, 20 months to 72 years); 747 of 854 were male. The overall survival rate was 99.7 percent. Fifty-seven patients had two fingertip defects covered with bilateral second toe pulp flaps and nine had three defects covered with bilateral second toe pulp flaps and a third toe pulp flap. Donor-site complications occurred in 59 cases (hematoma, n = 39; wound separation, n = 20). No gait disturbance or painful toes were observed at the donor site. Static two-point discrimination averaged 8 mm (range, 4 to 15 mm). A total of 264 patients required additional surgical procedures, including skin grafting at the recipient site (n = 154) and secondary flap revision (n = 110). The shorter pedicle and smaller flap can reduce the surgical time and morbidity associated with this procedure. This flap is the authors' first line of treatment for covering fingertip wounds by transferring similar pulp tissue from the toe to the finger.

Digital reconstruction and donor site resurfacing: A two‐flap technique

Use of a great toe pulp flap is one of the methods to repair partial soft-tissue defect of the thumb or other digits. However, the conventional application of free skin grafts to close the donor site may bring donor-site morbidity. The authors present a two-flap technique that a reverse first dorsal metatarsal artery (FDMA) flap resurfaces the defect of the free great toe pulp flap. Six patients with soft-tissue defects of the thumbs or fingers were treated with this technique. Both the pulp and reverse flaps survived uneventfully after reconstruction of the thumbs and fingers. The reverse flap to resurface the donor site on the great toe was sensate and durable. Satisfactory appearance and function were gained in all patients. Results revealed that this technique can be accepted as an alternative method when treating soft tissue defect of the thumb or finger.

Resurfacing of the donor defect with a second toe plantar flag flap after free first toe pulp flap

A second toe plantar flap was attached to the donor site after a free first toe pulp flap. Twenty-two days postoperatively, the wound had almost healed. Although the whole defect is impossible to cover with this flap, partial resurfacing will reduce the healing time and morbidity from recurrent ulceration.

Free Toe Pulp Transfer for Digital Reconstruction

The problem of loss pulp substance of the fingers during an unanticipated event such as trauma, represents not only the deprivation of tactile perception, but also the loss of a solid, well-cushioned covering. The ultimate goals for the reconstruction of finger pulp are to maintain the original digital length, provide adequate soft tissue padding and to obtain near-normal sensations. Anatomically and functional speaking, the most suitable source for finger pulp reconstruction will be the toe pulp. A total of 15 free toe pulp transfers were done for finger pulp reconstruction between 1992 and 2001 which included 11 thumbs, 1 index finger, 2 middle fingers, and 1 ring finger. The pulp size varied from 2.5×2 cm^2 to 4.5×2.5 cm^2. All patients were followed-up for an average of 28 months (range: 10 to 64 months). All the toe donor sites were closed with split thickness skin grafts. The survival rate of the transferred toe pulp flap was 100% in all of the 15 flaps. Partial loss of skin graft in the donor site was noted in 2 of the 15 flaps, but secondary healing was accomplished later. No discomfort was identified during maneuvers such as walking. Satisfactory functional and cosmetic results were reported in 13 of the 15 flaps. One patient had complained about the bulkiness of the transferred pulp flap. Cold intolerance of the injured digit was noted in 2 patients and two complains were about hypoesthesia of the transferred pulps. S2-PD ranged from 6 to 15 mm with an average of 9.9 mm. We believe that the free toe pulp transfer is an excellent option for the finger pulp reconstruction with minimal donor site morbidity.