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Repair and

Reconstruction of Thumb
a n d Fi n g e r Ti p I n j u r i e s
A Global View
Jin Bo Tang, MDa,*, David Elliot, MA, FRCSb,
Roberto Adani, MDc, Michel Saint-Cyr, MDd,
Felix Stang, MDe
KEYWORDS
 Thumb tip  Fingertip  Digital amputation  Homodigital pedicle flap  Innervated flap
 Free vascularized flap  Fingertip regeneration  Sensibility

KEY POINTS
 The pulp defect, or distal thumb or finger amputation, often requires cover with flaps from the same
digit, or from other parts of the hand or body.
 Sensate, homodigital flaps pedicled anterogradely on a digital artery are used often for fingertip.
 The Moberg and V-Y advancement flaps are commonly used for distal soft tissue loss with bone
exposure. Modification of the Moberg flaps and an extended version of the Segmuller flap help flaps
to reach the tip of the digit.
 Reverse homodigital flaps for finger pulp or tip defect are used less frequently than a decade ago.
 Free vascularized toe pulps, wrap-around big toe flaps and partial toe transfers are in common use.
 First-line surgical options and surgeons preferences vary globally. Asian surgeons do challenging
replantations of the thumb and fingertips. European surgeons do more modifications and innovations of the homodigital flaps. Surgeons use the classical cross-finger flap less and less.

The distal part of the thumb or the finger is called


the finger or thumb tip. In this article, we discuss
treatment of the structures distal to the insertion
of the flexor digitorum superficialis tendon (FDS)
in the finger, or the interphalangeal joint of the
thumb. From the viewpoint of repair, any structures
around or distal to the distal interphalangeal (DIP)

joint of the finger, especially those distal to the middle of the distal phalanx, are considered as
fingertip. The thumb tip, that is, the part of the
thumb distal to the interphalangeal joint, is usually
discussed separately from the fingertip, as the
thumb and fingers are considered distinct anatomically. Pulp defects are common and are discussed.
Nail and nail bed injuries are considered to be a specific category of trauma, which is not covered here.

a
Department of Hand Surgery, The Hand Surgery Research Center, Affiliated Hospital of Nantong University,
Nantong University, 20 West Temple Road, Nantong, Jiangsu 226001, China; b Hand Surgery Department,
St Andrews Centre for Plastic Surgery, Broomfield Hospital, Chelmsford, Essex CM1 7ET, UK; c Department
of Hand Surgery and Microsurgery, University Hospital of Verona Policlinico GB Rossi, Piazzale LA Scuro 10,
Verona 37126, Italy; d Division of Plastic Surgery, Department of Surgery, Mayo Clinic, 200 First Street
Southwest, Rochester, MN 55905, USA; e Plastic Surgery, Hand Surgery, and Burns Unit, University Hospital
Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, Luebeck 23538, Germany
* Corresponding author.
E-mail address: jinbotang@yahoo.com

Clin Plastic Surg 41 (2014) 325359


http://dx.doi.org/10.1016/j.cps.2014.04.004
0094-1298/14/$ see front matter 2014 Elsevier Inc. All rights reserved.

plasticsurgery.theclinics.com

DEFINITIONS

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Fig. 1. Arterial supply of the structures distal to the midpart of the middle phalanx. The dorsal arteries are small. Volar
arteries are larger. There are 3 sets of palmar arterial arches in fingertip: 2 are at the distal phalanx and one proximal
to the DIP joint. The fourth volar artery arch of the finger locates proximal to the proximal interphalangeal joint.

ANATOMY AND CLASSIFICATIONS


The distal phalanx is the back bone of the thumb
tip and fingertip. However, the very distal tip
includes only the soft tissues of the pulp and the
nail edge. The arterial supply of the thumb or

fingertip consists of multiple small branches of


the digital arteries and the network of their terminal
branches (Fig. 1). The terminal parts of the digital
arteries are located around the DIP joint level and
the proximal half of the distal phalanges. The digital arteries run along the sides of the digit, they

Fig. 2. Nerve supplies of the palmar and dorsal aspect of the finger and their relation with the arteries (A). Note the
communicating branches between the dorsal and volar digital nerves mostly are at the proximal phalanx level. A to F
show the variations and incidence (%) of different connections between the palmar and volar digital nerves in the
hand.

Reconstruction of Thumb and Finger Tip Injuries


have a diameter of 1 to 1.5 mm, which is sufficient
for microsurgical anastomosis. The arterial network beyond the middle of the distal phalanx is
small and difficult to suture. The main draining
veins of the tip run as a network on the dorsum
of the digit. The digital arteries do not have venae
comitantes but there is a venous plexus in the subcutaneous tissue surrounding each artery. Therefore, any flap based on a digital artery must
include 2 to 4 mm of subcutaneous tissues around
the artery and venous return is through the venous
plexus around the artery. The flexor tendons terminate on the palmar aspect of the distal phalanx,
and the digital nerves sent off terminal branches
to form the transverse arch in the palmar subcutaneous tissue of the pulp (Fig. 2). The branches
of the digital nerves distal to the DIP joint are multiple and are difficult, or impossible, to repair
surgically.
Thumb and fingertip injuries can be transverse
or oblique. The resultant defects of the latter can
slope anteroposteriorly or laterally (Fig. 3). The
injury can be classified in terms of severity, as
clean cut or crush injuries, or by the tissues
involved; that is, the injury can include a pulp tissue defect, a complete amputation, fracture of
the distal phalanx, and/or nail and nail bed damage. The authors propose a unified zone division
and classification of fingertip injury (see Fig. 3).
Clinically, when we treat thumb or fingertip injuries, the size of the pulp tissue defect, the obliquity of the amputation, and whether the injury is
a clean-cut or a crush injury are the major concerns. Hence, these are the focus of discussion
in deciding treatment.

BASIC REQUIREMENTS: THUMB AND


FINGERTIP REPAIR
The essential goals of repair of thumb and fingertips are the following:
1. Maintaining length
2. Restoring sensation
3. Appearance
An additional goal is to restore active range of
motion at the distal joint. The length and appearance of the digits is a basic concern, constituting
about 50% of the goal of repair or reconstruction.
With respect to appearance, preserving the nail
complex is very important. Sensibility constitutes
another 40% and is the most important single factor in thumb or fingertip repair and reconstruction.
By contrast, active range of motion of the finger
DIP joint and the thumb interphalangeal (IP) joint
are, relatively, less important, constituting the
other 10% of the goal of repair and reconstruction.
With normally functioning proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints,
active motion of the DIP joint contributes only 15%
of finger motion (Table 1).
The authors consider the different importance of
each structure or function of the thumb or finger tip
(Table 2). Small decreases in either the length or
sensation may not be a great concern for the patients. A shortening of less than 0.5 cm, a mild
decrease in sensation rather than loss of the
sensation, and a loss of DIP joint motion of about
20 , usually cause little functional or cosmetic
impairment. The optimal repairs are (1) to maintain
as much length as possible, with the intention of

Fig. 3. The divisions for the digital tip injury are shown on the left, proposed by the lead author (J.B.T.), to unify
those used in digital tip repair, replantation, and tendon injury. The zones 1A, B, and C are based on existing
flexor tendon zoning. The tip distal to the digital flexor tendon insertion is termed zone 0, which is further
divided into zone 0A (nail root intact), and 0B (nail root absent). The right panel shows our proposed classification of digital tip injury by structures and obliquity. For example, a digital tip injury can be recorded as
zone 0B-C injury when it results in nail root loss and is transverse.

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Table 1
Our consideration on percentage goal of the repair and reconstruction of the thumb or finger tips
Structures

Percent Goal (%)

Reasons

Length and appearance

50

Sensibility/Sensation

40

DIP joint motion (finger) or


IP joint motion (thumb)

10

 Length is the basis of hand action


 Appearance of the tip affects overall perception
of the hand
 Sensation is particularly important and necessary
for the fingertip area
 Less important compared with sensation and
length/appearance
 Responsible for 15% finger/thumb motion

limiting shortening to less than 0.5 to 1 cm; (2) to


recover sensation to grade 31 (S31) or more,
best with static two-point discrimination (2PD)
less than 5 or 6 mm; and (3) to restore an active
range of DIP joint motion or thumb IP joint motion
of 40 to 50 , or greater.

REPLANTATION OR SIMPLE SUTURE OF THE


AMPUTATED DISTAL PART
A clean and tidy amputated tip can be replanted
or sutured back directly as a composite graft. A
positive decision should be made to do one or
the other. Technically, replantation of a clean-cut
digital tip amputation is possible, and replantation
around the DIP joint is a routine in many established hand units (Fig. 4). However, such replantation bears a greater risk of failure and a replanted
digit may become partially, or entirely, necrotic.
The success rate varies, depending on the operating theater setup, the surgical team, and the
experience of the individual surgeons.
Replanting the severed finger around or beyond
the DIP joint level should be attempted routinely
when the cut is clean and tidy but not necessarily
after crush injuries to the digit. If the amputation
site is not clean, untidy, or in children (whose vessels are tiny), this is usually not indicated though
highly experienced team may attempt to replant
these cases. Severe crushing or contamination of

Table 2
Relative importance of each structure or
function to a thumb or finger tip
Structures/function

Importance (%)

Pulp sensation
Pulp and nail cosmetics
Length
DIP (or thumb IP) joint
motion

40
30
20
10

the amputated part is a contraindication to replantation surgery. The digit tip amputated through the
distal phalangeal shaft may be sutured back
directly and may survive, but usually in less than
30% of the cases. After direct suturing back to
the stump, success is more likely in children and
if the tip is replaced within 5 hours; thus, it is
more encouraged.
The surgeon should explain to the patient the
benefits and risks of suturing back the severed
distal part or, alternatively, transferring a flap to
cover the tip. The former is risky of necrosis, but
offers some chance of tip survival, including the
nail complex, which is vital to the appearance of
the digit and, also, to fine pinch function. Flap
reconstruction gives more immediate and reliable
soft tissue coverage but usually at the expense
of loss of the nail complex.

REGENERATION POTENTIALS OF DIGIT TIPS


Subcutaneous Soft Tissues at the Tip
Before discussing complex surgical repairs and
reconstruction, one phenomenon is worthy of consideration: a digit tip amputation with loss of length
of less than, or approximately, 1 cm may regenerate without any surgery. Cover of the amputation
wound with moist dressings for 1 to 2 months (or
more) allows soft tissue regeneration and ingrowth
to cover the exposed phalanx, then reepithelialization. If the patient is willing to wait for 2 months,
self-regeneration is an acceptable option of treatment and some patients do choose to wait.
Acceptable appearance can be expected of such
digit tip regeneration (Fig. 5). Such regeneration
can occur over a small area of subcutaneous tissue defect over exposed tendon in the digit as
well (Fig. 6). A small wound with exposed tendons
can be covered in this way. If the distal phalanx is
exposed, the lost bone does not regenerate, only
growth of the soft tissue over the end of the
bone. Such regeneration does not work as well
for large defects, may not work well in all patients,

Reconstruction of Thumb and Finger Tip Injuries

Fig. 4. Thumb and finger tip replantations. (AC) Thumb tip replantation and postoperative recovery. (DF)
Replantation of the little finger tip. (Courtesy of Dr Bin Wang and Dr Jian Hui Gu, Department of Hand Surgery,
Affiliated Hospital of Nantong University, Nantong, China). (G) Preoperative view of the amputated fingertip,
before replantation at DIP joint level of a finger after crush avulsion injury, and (H, I) postoperative recovery.
(Courtesy of Department of Hand Surgery, Nantong University, Nantong, China, and Plastic Surgery, The Alpert
Medical School of Brown University, Providence, RI, USA.)

and sensory recovery is very limited in some


cases. In reality, most patients and surgeons
choose not to wait, and prefer surgical interventions for a quick and possibly more predictable recovery. In some countries, surgeons often use this
treatment before proceeding with any flap surgery.

tip of the digit. In transfer of flaps, such as a


homodigital flap, we cover the bone at the tip of
the finger with subcutaneous tissue, which is
then covered by skin regeneration under moist
antiseptic dressings. This way of using flaps with
the distal end not covered by skin is common for
any oblique pulp defects.

Skin
Any localized loss of skin alone of 1.0 to 1.5 cm
can be covered with moist dressings and will
heal by dermal regeneration, or reepithelialization,
over 2 to 3 weeks. Any dressings that are not a
desiccant can work well, as it is the regenerative
potential of the digit tip that works to cover the
defect, rather than any particular dressing initiating
this process. This treatment allows early and rapid
mobilization of the digit with the patient carrying
out a simple dressing regime once or twice daily
at home.
We routinely use dressings for treating tip skin
loss. It works for larger areas of skin than just the

THUMB TIP REPAIR AND RECONSTRUCTION


Moberg Advancement Flap
The Moberg advancement flap is the most useful
flap for thumb tip reconstruction. The advantages
include restoration of almost normal sensation
and maintenance of length of the thumb. This is
a classical flap, and it covers a defect of an axial
length of approximately 1.0 to 1.5 cm or less.1
The disadvantage of the flap, as originally described by Moberg, is its likelihood of permanent
flexion contracture of the IP joint, limiting thumb
extension. This IP flexion contracture cannot be
relieved by therapy and splinting at a later date,

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Fig. 5. Regeneration of fingertip after moist dressing coverage and dressing changes. (AC) A finger tip wound
with bone exposure. (DF) Recovery by self-regeneration. Ideal recovery can be expected in a considerable percentage of the patient with tip trauma even with bone exposure. This treatment is popular in some countries.
(Courtesy of Dr Felix Stang, University Hospital Schleswig-Holstein, Luebeck, Germany.)

for which reason the original flap is not recommended by some surgeons.
This problem can be avoided if the flap is made
as an island advancement flap (Fig. 7), by
dividing it proximally with a transverse skin incision at the thumb base, but preserving the neurovascular bundles.2 This modification, described
by OBrien,2 allows flap advancement as a bipedicled island. The defect created proximal to
the flap is covered by a full-thickness skin graft.
Alternatively, this flap can be designed with a
V tail extending onto the thenar eminence as

Fig. 6. A soft tissue defect in a finger with exposed


flexor tendon of a 60-year-old man. He was treated
with twice daily antiseptic dressings. The wound was
fully healed at 6 weeks with full finger flexion and
extension. (Courtesy of Dr David Elloit, St Andrews
Center for Plastic Surgery, Chelmsford, UK.)

far as a line drawn proximally from the midline


of the middle finger (see Fig. 7).3

V-Y Advancement Flaps: Traquilli-Leali


(Atasoy), Segmuller, and Venkataswami Flaps
Three types of V-Y advancement flaps, TraquilliLeali (Atasoy), Segmuller, and Venkataswami
flaps, and their recent variants413 are used for
thumb tip reconstruction. They can be used for
thumbs, but they are used more often in fingertips.
Therefore, detailed descriptions are given under
the section on fingertips later.
The variants of the Moberg advancement flap
are more popular in reconstruction of the thumb.
By contrast, the Moberg flap is rarely used in
fingertip repair. Conversely, the other V-Y flaps
mentioned later in this article are less effective in
thumb tip reconstruction, partly because the
more fibrous nature of the subcutaneous tissue
of the thumb, as compared with the palmar soft
tissues of the finger, makes mobilization less,
and partly because the greater anteroposterior
diameter of the thumb accentuates this difficulty
in reaching the nail distally.

Flag Flap from the Dorsum of the Middle


Phalanx of the Index Finger
Although the flag flap (with the flap being the
flag and the vascular pedicle with skin being
the flagpole) was originally described for reconstructions within the same finger by Iselin and

Reconstruction of Thumb and Finger Tip Injuries

Fig. 7. (A) A typical volar sloping loss of the thumb tip after a crush avulsion injury. The bone was exposed only in
the distal third of the defect. More proximally, the bone was covered with subcutaneous tissue. The distal edge of
the subcutaneous tissue becomes the leading edge of the flap. (B) The flap incisions must lie along the midlines of
the thumb to avoid scar contracture and the V proximally is taken out onto the thenar eminence so the tip of the
V lies in line with the middle finger. (C) The flap was raised completely from the skeleton of the thumb on the
neurovascular bundles and advanced to cover the bone of the thumb tip with soft tissue, reducing the tip defect
to a skin loss, which can be reepithelialized under moist antiseptic dressings over a period of 2 to 3 weeks. The
proximal V was closed as a Y. (D) A week after surgery. (E) Four months after surgery, good skin cover of the
thumb tip, with the typical tapering of the digital tip, which was achieved through reepithelialization. (Courtesy
of Dr David Elliot, St Andrews Center for Plastic Surgery, Chelmsford, UK.)

Gosse in France many years ago,14 with both the


flag and the flagpole entirely within the dorsum of
the finger (Fig. 8), these flaps are now rarely used.
The most useful variant of these flag flaps in current use was described by Holevich in 1963,15 a
prototype of later named kite flaps, to provide
soft tissue cover to the thumb tip and pulp by using a flag portion of the flap, which is raised from
the distal dorsum or the dorsal radial surface of
the proximal phalanx of the index finger with the
flag pole being raised over the second

metacarpal. Because the flap is based on a long


pedicle, or flagpole, this flap can cover defects
of the thumb tip and shaft of varying sizes and locations. The feeding arteries are the dorsal digital
arteries, which are branches of the first dorsal
metacarpal artery (FDMA), are harvested under
the skin of the flagpole, with a wide surround
of subcutaneous tissue to allow venous return.
However, this flap restores sensation only if the
appropriate branches of the superficial radial
nerve are included in the flagpole and flag. The

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flap. It is not particularly suitable for soft tissue defects after transverse distal amputations of the
thumb (for which the variants of the Moberg flap
are best suited), partly because the flaps have
the poor sensation of the dorsum of the fingers
and partly because it reaches the tip of thumb
only if harvested from the dorsum of the distal
part of the proximal phalanx. It is an option for
larger soft tissue defects, such as a palmar defect
extending from the tip to the base of the thumb.
The size of this flap can be large but it is a narrow
flap and at the donor site the defect needs skin
graft, leaving an obvious cosmetic defect.

Fig. 8. Flag flap.

donor site is closed directly or with a skin graft.


The flap can be transferred to the thumb in 1
stage, but can be transferred in 2 stages as an island, with the pedicle being severed 2 weeks
later. Two-stage transfer is almost not used now.

The First Dorsal Metacarpal Artery Flap (the


Kite Flap)
The kite flap was popularized by Foucher and
Braun in 197916 as an island pedicle flap based
on the FDMA. These investigators first used it to
reconstruct the dorsum of the thumb IP joint, for
which it is ideally suited. The branches of the radial
sensory nerve can be included to create a sensate

1. An S-shaped or a longitudinal incision is made


over the first dorsal web space (Fig. 9). An incision is made outlining the flap over the dorsum
of the proximal phalanx of the index finger.
2. The flap is raised superficial to the extensor
paratenon in a distal to proximal and an ulnar
to radial direction. The flap is raised on the ulnar
branch of the FDMA and FDMA (see Fig. 9).
However, there is no need to dissect out the
arterial supply and perivascular fat. A pedicle
including perivascular fat is recommended.
3. Often the flap may take about 20 minutes to
pick up after release of the tourniquet. An infrequent complication is flap ischemia.
4. The flap is transferred to the thumb. The donor
site is closed directly or with a skin graft.
Surgical Notes: The first dorsal interosseous fascia must be raised to avoid violating the feeding
vessels, which normally lie on the fascia adjacent
to the radial border of the index, or second,

Fig. 9. (A) Design of the skin territory of the FDMA flap. (B) Vascular anatomy and location of the FDMA. The
ulnar branch of the FDMA is the nutrient artery of this flap.

Reconstruction of Thumb and Finger Tip Injuries


metacarpal. Occasionally, the vessel lies at a
deeper level within in the muscle and should be
found and dissected. The veins remain in the fat
superficial to the fascia. The vessels are sometimes
too small to provide sufficient blood supply.
Both a flag flap and a kite flap use the branches
of the FDMA as the feeding vessel; some surgeons
use flag and kite flaps interchangeably. The flag
flap harvests a narrower and more distal flap distal
to the PIP joint level with a skin pedicle, whereas
the kite flap is usually raised more proximally and
larger, over the proximal phalanx often without
skin in the pedicle. The kite flap can be harvested
as a free flap17,18 and as a reverse-flow pedicle
flap.19

Free Vascularized Toe Pulp Flap


A free vascularized flap from the toe provides
excellent tissue cover to replace the thumb pulp.
Many microsurgeons favor this flap and, cosmetically, this flap is ideal for the thumb pulp
(Fig. 10).20 Sensory restoration is possible through

Fig. 10. Free toe pulp flap for thumb pulp repair.

a nerve repair to the digital nerve, but the need for


nerve suture makes this reconstruction less effective compared with a Moberg flap from a sensory
point of view. It also takes longer to transfer and
carries an inherent risk of failure of the vessel
anastomoses. For these various reasons, and
because of the availability of local flaps, many surgeons tend to choose a local flap instead of a free
toe flap.

Free Vascularized Partial Toe Transfer


This is a common option for surgeons who like,
and are skillful in, microsurgical tissue transfer.
This surgery restores a good appearance to the
thumb or fingers, but at the cost of partial loss of
a toe.21 The partial toe is harvested with a vascular
pedicle extending proximally to the base of the toe
web. Exceptionally confident microsurgeons may
harvest the needed part from a toe as a primary
procedure and connect it to the amputated thumb
or finger in the fashion of a digital replantation
(Fig. 11). This surgery is not advisable in older

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Fig. 11. Partial toe transfer can reconstruct the lost fingertip. A partial toe harvested for this purpose is shown
here.

patients and is better undertaken in children at an


older age.

Neurovascular Pedicle Flaps from the Fingers


For thumb reconstructions, we do not encourage
the use of flaps from the tip or the palmar surface
of the fingers. Such procedures need extensive
incisions, leave scarring of the donor finger
and, inevitably, damage the sensation. The Littler
flap22 is such a classical method described in
many textbooks. This flap is occasionally useful
for thumb reconstructions and also for heterodigital transfer between fingers, but it is usually carried
out sparing the tissue of the tip of the donor finger,
or even using a skin paddle from the dorsolateral
surface of the donor finger innervated by the dorsal branch of the digital nerve. However, there
are other better reconstructions of the thumb tip
with respect to the sensibility achieved, the incisions required, and donor site morbidity. The
Moberg and other V-Y flaps are more appropriate
and microvascular free flap transfers are another
good alternative, particularly in the young.
The following are several flaps that we do not
use commonly, and do not recommend to general
plastic surgeons, for reconstruction of the tip of
the thumb:
1. Neurovascular pedicle flaps from the fingers: for
reasons stated previously, it is used only occasionally. Two of the authors (D.E. and R.A.) use
it occasionally for defects that are too big to

cover with V-Y Moberg advancement flap and


in patients who are too old to get good sensation from a toe pulp transfer with digital nerve
sutures. They also can be useful to reconstruct
more extensive finger palmar surface losses.
2. Venous flaps: Plastic surgeons turned their
back on the original presentations of the
venous flap 20 years ago, as the risk of loss
was higher than with flaps vascularized by an
artery. More recently, following reassessment
of the method of vessel connections within
the venous flap, this flap has become safer. In
the opinion of one of us (D.E.), this flap, harvested from the thin skin and subcutaneous
tissues of the volar aspect of the wrist,23 has
become a safe and excellent microsurgical
reconstructive option for digital tip and palmar
surface reconstruction that can be innervated
and avoids harvesting from the foot.
3. Flaps that are technically possible but difficult
or less reliable, for example, the free vascularized thenar flap: The vascular anatomy of this
flap is less commonly known and most surgeons are not familiar with it. With numerous
known and more reliable flaps available, and
without more personal experience of these
less well-known flaps, we cannot recommend
them yet, although surgeons experienced with
these particular flaps may prefer them. These
methods are used occasionally by us, or our
colleagues, with satisfactory outcomes, but
they are not a routine or first-line choice.

Reconstruction of Thumb and Finger Tip Injuries


Fillet Flaps
Where a recognized flap can be harvested from a
finger that cannot be salvaged, this can be used
to advantage without donor site morbidity. This is
called a fillet flap, and is often available in multiple digital injuries.

FINGERTIP REPAIR AND RECONSTRUCTION


V-Y Advancement Flaps
The newer generation of larger V-Y flaps are more
easily mobilized in the fingers and, so, better
suited for use here than in the thumb. Selection
depends on the size and direction of the tip loss.
The palmar V-Y advancement flap (ie, TraquilliLeali or Atasoy flap)
This flap was first described by Tranquilli-Leali4 in
1935 and Atasoy and colleagues5 in 1970. It is
used for distal fingertip pulp defects beyond the
mid part of the nail bed. A triangular flap is designed with the base at the edge of the amputation
and the apex at the DIP joint crease of the finger
(Fig. 12). Its blood supply relies on the small arterial branches of the digital arteries beyond the
trifurcation of the digital nerves, with the neurovascular bundles being preserved and not dissected.
The fibrous septa that anchor the skin to deeper
structures, including the palmar surface of the
distal phalanx, are gently divided.
The skin flap is then advanced over the exposed
bone. The base of the triangle is sutured to the nail
bed, and the V-shaped donor site defect is closed
as a Y (see Fig. 12). The advancement of this flap is
limited by its distal blood supply and the small size
of the flap and its sensation may be reduced, as

advancement is achieved only with some tension


on the flap.
It can be made much more useful by enlarging
the flap, so the proximal V extends back to the
middle of the middle phalanx, and mobilizing it
on the 2 neurovascular bundles. This neurovascular Tranquilli-Leali flap will cover distal tip defects as far proximally as the nail fold and with a
30 palmar slope of the amputation angle. This
flap also can be used at any level of amputation
of the finger as far proximally as the proximal phalanx (Fig. 13).6
Lateral V-Y flaps
These are divided into unilateral V-Y flaps, bilateral
V-Y flaps, and lateral pedicled V-Y flaps. The unilateral V-Y flap, based on the same small vessels
as the Tranquilli-Leali flap was first described by
Geissendorf in 19437 but used for a rather small
defect, as it has little cover potential. Bilateral
V-Y flaps, described soon after by Kutler in
1947,8 are also harvested without dissection of
the vascular pedicles. Although the 2 flaps can
be pulled toward the midline of the tip defect
with slightly greater ease, this reconstruction is
limited in its use by the small size of the flaps
and the limited advancement possible. It has
largely been superceded by the more substantial
lateral pedicled V-Y flaps, described by Segmuller
in 19769 and by Biddulph in 1979,10 which are harvested from the lateral sides of the digit proximally
to the DIP joint crease with dissection of their neurovascular pedicles to help flap advancement to
cover the tip defect. Lanzetta and colleagues11
and Smith and Elliot12 extended the pedicled flap
proximally to the PIP joint crease of the finger to

Fig. 12. (A) Atasoy flap. Suitable for volar sloping defects up to a slope of 30 . Typically, these oblique tissue losses
leave only the distal portion of the distal phalanx exposed, with the more proximal loss of the subcutaneous tissue being less than full-thickness. The subcutaneous tissue without skin becomes the leading edge of the flap and
this, not skin, is sutured to the distal edge of the nail. (B) The neurovascular Atasoy flap is much larger than the
original Tranquilli-Leali flap, with the V extending across the crease of the DIP joint (albeit with both incisions
crossing this crease at an angle so not creating the potential to cause scar contracture). This flap is raised in the
same way as the original flap, but is based on the digital bundles, not their terminal branches.

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Fig. 13. (AD) An example of a true Tranquilli-Leali flap or Atasoy flap suitable for transverse or distal sloping
defects of the fingertip at the level of the mid-nail and beyond. (A) Traumatic fingertip defect. (B) Flap design
and skin incision. The flap is moving distally to cover the defect. (C) The skin defect proximal to the flap is left
for reepithelialization to fill. (D) Postoperative result. (EH) An example of the neurovascular Atasoy flap. (E)
Flap design. (F) Flap lifting. (G) Defect coverage. (H) Postoperative result.

further increase its size and the ease of advancement, so improving its usefulness further (Fig. 14).
Oblique V-Y flap (Venkataswami flap)
A long oblique V-Y flap is harvested with the apex
proximal to the PIP joint over one neurovascular
bundle of the digit.13 The entire flap is advanced
to cover the defect of the fingertip or thumb tip,
the proximal incision is closed in a Y shape
(Fig. 15).
The advantages of V-Y advancement flaps are
the preservation of sensation and durable soft tissue coverage. Tension is the primary problem
encountered with the smaller versions of this
flap, such as the original Tranquilli-Leali and Kutler
flaps, especially if expected to cover larger defects. If a tension-free closure is not achieved,
the flap is at risk for necrosis and likely to have

poor sensation from tension on the small nerves.


In addition, the distal nail bed may be pulled in a
volar direction, creating a hook nail deformity. To
allow for a tension-free closure, the proximal incision can be left unclosed, or closed very loosely
(and will heal by dermal regeneration). These
problems are not seen routinely with the newer
generation of larger V-Y flaps (eg, OBrien and
V-Y Moberg, neurovascular Tranquilli-Leali, Venkataswami,13 and extended Segmuller flaps).12
The Moberg advancement flap is used less
often in the fingers, as raising this flap over the
entire finger risks flexion contracture and risks
loss of the skin of the dorsum of the finger.24
The bipedicled neurovascular Tranquilli-Leali
flap can be considered as a V-Y flap raised only
over the distal part of the finger for fingertip
reconstruction.

Reconstruction of Thumb and Finger Tip Injuries

Fig. 14. The extended Segmuller flap. This flap is suited for volar sloping tip defects greater than 30 . (A) The V is
taken to the PIP joint crease, with the posterior incision running down the mid-lateral line and the sloping volar
incision reaching the midline of the finger. (B) Volar view of flap design. (C) The flap is raised from distal to proximal, with the artery being easily followed down the deep surface of the flap. (D) The incision is taken down the
mid-lateral line proximal to the V of the flap so the neurovascular bundle can be visualized proximally to make
dissection. (E) In this case, 2 flaps have been drawn but only one was needed to cover the exposed bone of the
fingertip with subcutaneous tissue. The tip is then reepithelialized under moist antiseptic dressings. (F) Postoperative outcomes. (G) Bilateral flaps are raised in another case. (H) Coverage of the tip with 2 flaps. Note the tip is
covered with subcutaneous tissue and is then reepithelialized under moist antiseptic dressings. (I) Postoperative
outcomes.

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Fig. 15. (A) Injury to the tip of the index finger. A Venkataswami flap, based on the ulnar digital artery, was
raised. This flap is raised as the Segmuller, the only difference being that the flap is taken right across the volar
aspect of the finger, not to the midline. The flap is dissected more proximally to gain more advancement by
further freeing the neurovascular bundle proximally in the finger and palm. (B) Volar view of the flap. (C)
Completion of the flap transfer. The very distal part was left uncovered with skin, which healed later through
reepithelialization process. The sight corner insert is the volar view of the skin defect on the tip.

Lateral Switch Flap


This is an easy and effective method of reconstructing a finger or thumb hemi-pulp defect,
where the missing pulp has significance to pinch.
The opposite pulp of the same digit can be transferred, or switched, across from one side of the
digit to the other as an island,25,26 or as a pedicle
flap.27,28 The defect on the other side of the digit
is then covered with a full-thickness skin graft

(Fig. 16). This flap switches the defect from the


palmar aspect to its lateral aspect, which is thus
called a switch flap (Fig. 17).

Volar or Dorsal Rotational Flaps (Visor Flap,


Modified Souquet Flap and Pivot Flap)
The volar or dorsal rotational flaps can be harvested close to the fingertip amputation site to
cover the tip defect. Visor flap and Modified

Fig. 16. The lateral switch flap can be used to reconstruct the radial half of the index fingertip and the ulnar half of
the thumb tip after either irreversible nerve injury or hemi-pulp loss and reconstitute the sensation and appropriate
subcutaneous and cutaneous tissues of these 2 parts, vital to fine pinch. (AC) A 55-year-old man with a previous
ulnar digital nerve injury of the left thumb, who had a primary nerve repair and, subsequently, a nerve graft but
had recovered no sensation. (A) The numb area as shaded. This area of skin was excised. A flap based on the radial
neurovascular bundle was designed, elevated, and transposed. The donor defect was grafted with full-thickness
skin. (B, C) The results. (Courtesy of Dr David Elliot., St Andrews Center for Plastic Surgery, Chelmsford, UK.)

Reconstruction of Thumb and Finger Tip Injuries

Fig. 17. Switch flap and rotational flaps: (A) Surgical procedure of a switch flap. The normal half of the pulp is
harvested based on neurovascular bundle of one side and is transferred to the other side. The defect in the donor
site is covered with a skin graft. (B) Modified Souquet flap, made with rotation of a flap after dissecting out the
neurovascular pedicle of one side. (C) Visor flap, made with rotation of a dorsal or volar flap based on an intact
wide skin pedicle. (D) Pivot flap is based on a digital neurovascular pedicle after its dissection and flap rotated for
90 degrees to cover the tip defect.

Souquet flap can be harvested as shown in


Fig. 17. In addition, a flap (called a pivot flap)
can be harvested from midline to midline of the
volar aspect of the finger just proximal to the
pulp defect. The flap is elevated on one digital

artery and its transverse branches (Fig. 17), leaving at least 2 mm of soft tissue intact over the arterial pedicle for venous drainage, and pivoted
through 90 on the neurovascular bundle so that
one lateral border of the flap is sutured to the

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Tang et al
proximal margin of the defect and the other lateral
border is sutured to the nail distally.29 The contralateral neurovascular bundle is not included in the
flap. A small skin defect is seen on the contralateral side, which requires a full-thickness skin graft.

Homodigital Reverse Pedicle Digital Artery


Flap
A reverse pedicle flap, originally described by Glicenstein in France carrying a skin island harvested
from the web space,30 is now most often harvested with the skin paddle from the proximal
lateral aspect of the finger,31 or from the distal
palm overlying the common digital bundle and its
bifurcation.32
1. The flap is outlined at the base of the finger
proximal to the PIP joint. The flap size can be
up to 2.0  1.5 cm centered by the digital
artery.
2. One digital artery is ligated proximal to the
proximal flap border. The perivascular soft tissue (24 mm in width) containing the venous
network must be retained with the artery.
3. At this time, the digital nerve is usually kept
intact, by dissecting it out from the flap so not
to affect sensation. The vascular pedicle is
dissected out along the course of the digital
artery and elevated retrogradely distal to the
DIP joint, where it receives arterial input from
vessels passing transversely across the palmar
aspect of the joint (and supplying both the joint
and the vinculae of the flexor tendons) from the
other digital artery of this finger.
4. The flap is reversed to reach the fingertip, and is
sutured. The circulation is checked to ensure
the suture is not too tight to compress the
vascular pedicle.
5. The donor site is covered by a skin graft.
Surgical Notes: The digital nerve, or its dorsal
branches, may be retained with the flap and the
nerve end under the proximal part of the skin paddle sutured at the fingertip to the contralateral
digital nerve of the finger to innervate the flap; however, this involves nerve suture. Sacrifice of a digital artery in an already traumatized finger is another
concern.

Classical Thenar and Cross-Finger Flaps


These two classical flaps require placing the patients fingers in uncomfortable positions, occasionally resulting in permanent limitations of joint
motions. They also suffer the problems of routinely
requiring a second operation, being insensate
flaps and delaying mobilization. The pedicled
thenar flap is useful in children and in areas of

the world in which the population has mobile fingers and, technically, the reconstruction is less
demanding. The flap is raised from the thenar
area to cover the fingertip. Because of the great
elasticity of skin in the donor area, direct closure
is always possible. The pedicle is divided 2 weeks
after initial surgery and most fingers do not
develop flexion contracture. In the thick fingers
of working North European men, PIP joint contracture is quite possible after even 2 weeks in this
flexed position and this flap should be avoided in
this population. The thenar flap is, otherwise, a
simple, yet fine, flap.
The cross-finger flap is included in many textbooks. The lack of innervation of the flap, need
of donor site skin graft on the visible dorsum of
the donor finger, and immobilization of 2 fingers
(with the potential of affecting motion of 2 fingers)
make it a less favored option now for many surgeons. Therefore, this flap is currently a rare
choice. In fact, some surgeons, including 3 of
the authors, no longer, or rarely, use this flap
except when the defect to be reconstructed
covers one and half to 2 segments of the volar
surface of a finger, when homodigital flaps are
too small, the cross-finger flap is a simple solution. When the defect involves the proximal and
middle segments of the finger, the lack of sensibility of the cross-finger flap has no relevance.
These flaps are by no means out of date.
Nevertheless, they do require tissue harvest from
outside the injured finger(s) and the patient is
required to place the hand in uncomfortable positions, for which reason, many surgeons seek to
avoid them.

Terminalization or Finger Shortening


A variety of reasons can lead surgeons to decide,
albeit reluctantly, to shorten fingers. The patient
may not wish to go through complex surgery, the
patients general condition does not allow such
surgery, the fingertip is severely infected, contaminated, or crushed, or the patient may reject
complex treatment for economic reasons. Terminalization offers a short operation and a quick recovery with reasonable function, but it is not a
good choice in terms of cosmetics or finesse of
function. Loss of length will be a permanent
concern and the stump is covered by skin from
the digital shaft, so is less sensate than that of
the original tip.

Creating a Protected Environment to Favor


Regeneration
As stated earlier, a practical, but less often used
(and in some countries sometimes neglected)

Reconstruction of Thumb and Finger Tip Injuries


option is to create an ideal tissue growth environment to the totally amputated or crushed fingertip
stump with moist antiseptic dressings, with no
reparative surgical procedures, following thorough
washing and wound debridement. Dressings
change vary from twice daily to every 3 to 4 days
or weekly (see Figs. 5 and 6). Such self-regeneration achieves a shortened but well-covered fingertip after about 2 months; some sensation may
also return.
This same regimen of moist antiseptic dressings
will allow the subcutaneous tissues to grow over
exposed bone at the tip or flexor tendons more
proximally. If the vital structure exposure is more
extensive, a dermal template (such as Integra,
Upper Saddle River, NJ, USA) can be used to
cover the exposed tendons after wound cleaning
and debridement and the template maintained
for about 2 weeks in the same moist antiseptic
environment. The subcutaneous tissue will regenerate to converge over the tendons, ending with a
much narrowed skin defect area, which will either
grow skin under the same dressing regimen for a
little longer or require only a secondary skin graft.
This option is good for those patients who are
willing to wait and appreciate that there may be a
need of secondary grafting. This regimen has the
advantage of allowing the patient to mobilize
immediately and regain a full range of motion of
the digit while carrying out the dressing regimen.

PRACTICE ACROSS THE WORLD: PREFERRED


OR UNIQUE METHODS
In this section we summarize current global views
of preferred, sometimes unique, methods of
thumb and fingertip repair and reconstruction.
The information presented here is offered by the
authors in their respective countries/regions.

China and Asia


In Nantong University, China, the hand and upper
extremity surgery team is composed of 14 surgeons with 100 hospital beds with an annual operating load of approximately 4000 cases. The team
regularly reviews and updates the centers treatment guidelines. We recognize the self-repairing
capability of the skin under moist antiseptic dressings and use this for defects smaller than 1 cm.
Guidelines for treatment of more extensive injuries
have evolved continuously.
The Moberg-type and V-Y flaps: essential
options for a small to moderate tip defect
In this unit, the Moberg-type advancement in the
thumb and the palmar or lateral V-Y advancement
flaps in the finger are commonly used for those

defects that cannot be closed directly but do not


exceed 50% to 60% of the pulp area.
Homodigital digital artery dorsal branch flaps
or anterograde digital artery pedicle flaps: for a
moderate fingertip or pulp defect
If the loss of finger pulp is the major concern and is
large (involving >60%70% area of the pulp distal
to the DIP joint), a flap based on the dorsal
branches of the digital artery (containing the
branches of the digital nerve that innervate a small
area of the flap close to the pedicle) is often used
(Fig. 18). Alternatively, a homodigital anterograde
digital artery pedicle flap that contains the digital
nerve is used. A reverse pedicle digital artery
flap, although reliable, was used often 5 to 10 years
ago (Fig. 19); however, this flap is being used less
frequently now, mainly because it sacrifices a digital artery and the donor site creates a permanent
cosmetic concern on the proximal part of the
finger.
In contrast, the digital artery dorsal branch flap
harvested from the dorsal aspect of the middle
phalanx of a size upto 1.5  2 cm can be transferred more easily with a shorter incision and
dissection. This is a quick and easy way to repair
the tip or the pulp. This is attractive to the patient
in that both the injury and donor sites are confined
to the distal part of the finger. This achieves high
patient satisfaction. The drawback is the need to
skin graft the donor defect. This drawback is outweighed by the ease of the surgery and the fact
that the injury and donor site are close. We recorded some recovery of sensibility of this flap
6 months after surgery, but whether greater sensory recovery is possible needs longer follow-up.
The homodigital anterograde digital artery
pedicle flap restores excellent sensation to the
fingertip, and finger flexion contracture is rare.
However, it needs incision and dissection to, or
nearly to, the base of the finger; these long incisions sometimes cause scarring problems, such
as joint, or web space, contractures.
Dorsal radial or ulnar artery flaps of the thumb:
for a moderate thumb tip or pulp defect
This team often uses reverse dorsal radial or ulnar
artery flaps of the thumb, because these flaps are
harvested locally and do not risk flexion contracture of the thumb, and the donor site does not
need a skin graft (Fig. 20). The ulnar collateral artery flap of the thumb was harvested as Brunelli
and colleagues33 described in 1999. The surgery
is easier than the flag, or kite, flaps; however, as
with the flag and kite flaps, poor sensory recovery
is a concern.

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Fig. 18. Digital artery dorsal branch flap. (A) This flap is raised based on the dorsal branches of the digital artery
with a broad pedicle. (B) Release of the tourniquet to confirm good blood supply. (C) It can be rotated to reach
the palmar pulp defect, or (D) cover the pulp loss of one side (small arrow). (C, D) The pictures show postoperative
views at 3 months. (D) Views of the donor site on the dorsum of the middle phalanx are shown by big arrows.

Fig. 19. Homodigital reverse digital artery flap. (A) Fingertip defect and design of the flap on the proximal lateral
aspect of the finger. (B) Ligation of the digital artery proximal to the flap margin. (C) Harvesting the flap, leaving
the digital artery intact. (D) Extension of the incision distally and dissection out the pedicle. Keep a wider pedicle
to ensure venous return. The vascular pedicle should not be dissected at or beyond the DIP joint level. This is the
point where this flap obtains blood supply through transverse vascular network. (E) Rotation of the flap to reach
the fingertip defect. (F) Skin graft to the donor site.

Reconstruction of Thumb and Finger Tip Injuries

Fig. 20. Dorsal radial or ulnar artery flaps of the thumb. (A, B) A flap based on dorsal radial artery of the thumb.
(C) The flap has been transferred to the thumb tip and pulp. The donor site can be closely directly. (D) A flap
based on dorsal ulnar artery of the thumb. (E, F) The vascular pedicle of this flap. The pedicle usually is kept wider,
as shown in (E). It is dissected thinner if blood supply is confirmed. Dissection at this point should be without tourniquet. (G) The flap is transferred to the thumb tip. (H) Anatomy of the dorsal radial artery. The flap is harvested
based on this artery with the rotation point proximal to the connection with the palmar artery. (I) Anatomy of the
dorsal ulnar artery and the rotation point is a little distal to the thumb MCP joint. A: artery.

Cross-finger digital artery flaps, performed by


one (R.G. Xie) in the team, are occasionally used
for repair of neighboring fingers when no homodigital flaps are feasible (Fig. 21).
A FDMA pedicle flap or a free flap transfer are
used for extensive defect involving the thumb tip.
Method selection
 Moberg-type and modified V-Y flaps for
young, active patients whose defect is relatively small, who wish to restore tip sensation
and can go through physical therapy to regain
thumb joint motion. The dorsal radial or ulnar
artery flap of the thumb are used often for
thumb tip defect. The FDMA flap (ie, the kite
flap) is used for more extensive volar or dorsal
tissue defects.
 No surgeons in the team currently perform
vascularized heterodigital pedicle flaps (Littler
flap) for a thumb pulp defect.

 Two flaps (eg, 2 neurovascular flaps, from


middle and ring fingers based on one common digital artery), or a wrap-around big toe
flap, or a kite flap or a free vascularized flap,
are used for degloving injuries of the thumb.
 Classical cross-finger and thenar flaps are
used rarely, and are not a first-line treatment
of this team.
 Free vascularized flap transfer from various
sites is often used for more extensive defects.
Free vascularized toe pulps restore a nice
appearance to the thumb, but have been
used in only a small number of patients to
date, because most patients want a simpler
procedure and, in an emergency setting,
most surgeons are not equipped for emergency microsurgical transfer. The surgeons
also feel they have plenty of local options, so
prefer to cover the defect by other means.
Consequently, few patients elect to have
free vascularized toe pulp flap transfers.

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Fig. 21. Digital artery cross-finger flap when no homodigital flaps are feasible. (A) Defects in the index and middle fingertips. Flaps were outlined on the lateral aspects of the middle and ring fingers. (B) Flaps elevated to
cover the tips of the index and middle fingers. (C) Follow up results. (Courtesy of Dr Ren Guo Xie, Department
of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, China.)

Many modifications and variants can be made. Examples are shown in Fig. 22.
Opinions on the choices of flaps differ considerably among surgeons throughout China. Some surgeons do not like flaps based on the dorsal aspect
of the hand (including the flag and kite flaps), and
some prefer to use transfers and flaps from the
foot. Some consider free vascularized flaps as the
best options for thumb or finger pulp repairs.
Microsurgical free flap transfers are frequent
and much more common in this country than in
many Western countries. Venous flaps were reported by some groups, but they are not a popular
option in general. Compound, or degloving,
fingertip defects are reconstructed with compound flap designs; for example, a cross-finger
flap with a composite tissue flap from the dorsal
aspect of the second toe, or transfer of twin
flaps.34
Japanese and Korean hand surgeons use
microsurgical tissue transfer to the finger or thumb
tip often as well. A few Korean teams favor venous
flaps. Japanese surgeons with a strong microsurgical background use free tissue transfers
more often, whereas classically trained, often
older, hand surgeons tend to use more classical
methods. Fine outcome studies are also reported
from these countries. Usami and colleagues35 reported follow-up of oblique triangular neurovascular advancement flaps in 17 digits and insensate
reverse digital artery island flaps in 14 digits. Sensory recovery had equilibrated at 12 months after
surgery, with no significant difference in static or
moving 2PD between the two procedures. Of
note, insensate small flaps to the digital pulp are
reinnervated. This mirrors the finding that sensation in fingertip replantations recovers without
digital nerve repair,36 indicating at least some recovery of sensibility at the fingertip without surgical nerve repair. Reinnervation of insensate

small flaps explains why surgeons use them in


fingertip repair.
We must further point out that in all regions,
such as mainland China, Taiwan, Japan, Korea,
and Singapore, fingertip or thumb tip replantation
is frequently reported and discussed. These surgeons challenge themselves to salvage those usually considered impossible, or unnecessary, by
others and elsewhere globally.37 Replantation at
around the DIP joint level is not considered a
contraindication but a conventional and wellaccepted surgical routine, with a fairly high survival
rate. This practice has greatly changed digital tip
treatment: cases with a clean, tidy (or even untidy)
amputation at the DIP joint level or distal to it are
first considered for replantation, rather than
covered with a flap.

Italy, Germany, and Mainland Europe


The following are the treatment methods and
guidelines in University Hospital of Verona, Italy.
Fingertip losses
In most cases, the pulp is reconstructed using
simple advancement flaps, such as Kutler or
Tranquilli-Leali flaps; however, when a greater
part of the pulp is involved (>1 cm), the surgeons
prefer to use a larger and more mobile flap. Anterograde homodigital neurovascular island flaps are
our first choice. This concept was initially popularized by Venkataswami and Subramanian13 with
the introduction of an oblique triangular flap to
treat pulp defects. Its drawback lies in the short
proximal incision limiting the dissection of the
pedicle and therefore its advancement. For these
reasons, we modified the original technique by using a more proximal incision to obtain significant
advancement (Fig. 23).38
The flap reported by Mouchet and Gilbert39
for pulp reconstruction is a variant of the

Reconstruction of Thumb and Finger Tip Injuries

Fig. 22. A few methods that are used by hand surgeons. (A) Two flaps harvested from the dorsal aspect of a
finger, based on dorsal branches of the digital artery, for coverage of a fingertip. (B) Two flaps, one from the
distal dorsal aspect and the other from the lateral aspect of the finger, cover a fingertip. (C) Rotation of a flap
can cover a distal lateral tip defect. (D) A digital artery flap is advanced to cover a fingertip.

Venkataswami flap. The ideal indication for its use


is a tangential loss of the pulp with bone exposure.
We have been using this technique since 1991,40
implementing some technical tips (Fig. 24):
1. The flap is designed as an oval island proximal
to the skin defect, including part of the dorsal
skin.
2. A hemi-Bruner incision is used instead of a longitudinal midlateral incision to avoid the risk of
scar contracture.
3. The neurovascular bundle of the flap is protected under the skin flaps so that the skin graft
is not placed directly on the pedicle.
4. Gentle traction on the pedicle is used to
advance the flap by 1.5 to 2.2 cm.

5. The apex of the flap should be fixed into the


distal phalanx by using a needle to avoid traction on the nail.
The main disadvantages of this procedure are
mild cold sensitivity and, occasionally, flexion
contracture of the PIP joint. To prevent the latter
complication, it is advisable to use the anterograde homodigital island flap for digital pulp loss
up to 2  2 cm. In this way, flexion of the MCP
or PIP joint is unnecessary; the flap dissected
back to the MCP joint can easily reach the pulp
defect. The recovery of static 2PD of 3 to 9 mm
and good skin quality of these homodigital flaps
led us to consider this type of flap40 as the first
choice in patients with pulp defects smaller than
2 cm (see Fig. 24).

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Tang et al

Fig. 23. Anterograde homodigital neurovascular island flap. (A) The fingertip necrosis after trauma (upper) and
postoperative outcomes (lower). (B) Bruner incision to expose the pedicle and flap elevation. (C) Flap coverage of
the fingertip. These pictures show modification of the original method using a more proximal incision to obtain a
significant advancement.

Reverse homodigital pedicle flaps, with or


without inclusion of the digital nerve,41 require
the integrity of the middle transverse palmar arch
of the finger, which may be damaged in extensive
pulp injuries. We believe that this technique should
be used only when the skin loss is more than 2 
2 cm. Sensory recovery obtained has been less
than our expectations (static 2PD: 915 mm),42
and the results in terms of the appearance and of
the donor site have not always been good. For
these reasons, the reverse homodigital pedicle
flap, which was very popular in this unit during
the 1990s, is now used less frequently.
Free flap transfers (eg, partial free toe transfers)
produce excellent functional and cosmetic results,
but the surgery requires advanced microsurgical
skills. Furthermore, often these injuries are operated on by trainees. So, free toe transfers are
rarely used in our practice for resurfacing digital
pulp defects.
Recently, attention has been drawn to the use of
heterodigital neurovascular island flaps (Littler
flap) to reconstruct extensive finger pulp losses.
A heterodigital flap is transferred from the lateral
surface of a nearby finger, including the digital artery but without the digital nerve, to minimize the
sensory loss in the donor finger (Fig. 25A). To

reduce the donor site morbidity and to achieve a


better sensory recovery, we harvest the donor
skin from the lateral side of the middle phalanx
with the vascular pedicle located on the palmar
side of the flap.43 The grafted donor area is
cosmetically more acceptable because the defect
is over the midlateral line and does not extend palmarly (see Fig. 25B). The dorsal branch of the digital nerve is routinely raised and used to innervate
the flap, with acceptable sensory recovery.42,43
The distal pulp of the donor finger should never
be harvested as part of a heterodigital flap.
If a pulp defect is large, a reverse heterodigital
pedicle flap can be a satisfactory solution.43,44
The surgical procedures are as follows:
1. The flap is outlined and cut from the side of the
donor finger (proximal to the DIP joint, not
including the tip of the donor finger) facing the
injured finger. The digital nerve is kept intact
and dissected away from the flap.
2. The vascular pedicle of the reverse island flap is
dissected proximally to the bifurcation of the
common digital artery in the palm and the common digital artery transected just proximal to its
bifurcation into the 2 proper digital arteries
(Fig. 26A). The digital nerve is dissected out

Reconstruction of Thumb and Finger Tip Injuries

Fig. 24. A variant of the Venkataswami flap (AC) and outcomes are shown (DF). The ideal indication for its use
is a tangential loss of the pulp with bone exposure. We have been using this technique since 1991. The arrow in B
indicates the intact digital nerve. The asterisk indicates the vascular pedicle.

from the pedicle. Retain sufficient amount of


soft tissue around the digital artery to allow
venous return of the flap.
3. The Y-shape vascular connection then turns
into a V shape, as a long pedicle to allow the
flap to reach the defect (see Fig. 26B).
4. Blood to the flap is supplied through the proximal transverse digital palmar arch of the
injured finger, if the middle transverse palmar
arch has been damaged (see Fig. 26C).
5. The donor site is closed with a skin graft.
Traumatic pulp losses from the thumb
Traumatic pulp losses from the thumb are treated
with different flaps, depending on the size of
the pulp defect extension. The palmar advancement flap, initially described by Moberg and

subsequently modified by Elliot and Wilson,3 is


our first choice. The flap is raised and advanced
on both neurovascular bundles, including the
whole palmar aspect of the thumb with a large Vshaped flap from the thenar eminence; the defect
is closed by using the V-to-Y principle (Fig. 27A
D). It enables restoration of the thumb padding
with normal sensibility and glabrous skin (see
Fig. 27E, F).
When the pulp defect is more than 2.0 to 2.5 cm
in length, other reconstructive solutions should be
used. One option includes a neurovascular island
flap raised from the dorsal aspect of the middle
finger supplied by the ulnar digital artery, its venae
comitantes, and by the dorsal branch of the digital
nerve (Fig. 28AC).45 This is a modification of the
technique described by Littler.46 If the modified

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Tang et al

Fig. 25. A heterodigital flap is transferred from the lateral surface of a nearby finger. (A) Surgical procedure. (B)
Follow-up outcome.

technique is skillfully performed, it may result in


sensate and stable skin coverage of the thumb
tip with acceptable donor site morbidity (see
Fig. 28DF). The FDMA pedicle flap is popular,
but we use it only when the defect is located on
the dorsal surface of the thumb or to cover stump
pulp defects, as it has poor sensation. Other techniques used include the dorsal ulnar or dorsal
radial pedicle flaps of the thumb, but we advocate
their use only to cover distal dorsal thumb defects
because, in our hands, they give poor sensory results. Although we dislike using free flaps to cover
fingertip pulp defects, we support the use of great
toe pulp free flaps to resurface very large thumb
pulp defects.
In Germany, it is becoming more and more
popular to treat those injuries using semiocclusive
dressings (eg, Varihesive extra thin, ConvaTec,
Skillman, NJ, USA; or Tegaderm, 3M, St. Paul,
MN, USA), allowing soft tissue regeneration to

cover any exposure of the distal phalanx by


ingrowth of the subcutaneous tissue, then reepithelialization; it works both for skin loss only and
also in cases with larger defects and exposed
bone to provide good esthetic results and sensibility (see Fig. 5). Sensibility of the regenerated
tip is good. Disadvantages are the long treatment
period and the smell if semiocclusive dressings
are used rather than moist antiseptic dressings:
this requires good patient compliance.
In the unit of one of the authors (S.F.), the first
choices for the fingertip injuries are traditional
techniques, such as palmar V-Y or bilateral V-Y
flaps (Tranquilli-Leali, Kutler, and Venkataswami
flaps). With experience, good results are achieved
with these techniques, provided the surgical
dissection leaves nothing intact but the neurovascular bundle; that is, using the more recent versions of these flaps, which are island flaps,6,1013
rather than the original advancement flaps.

Reconstruction of Thumb and Finger Tip Injuries

Fig. 26. A reverse heterodigital island flap. (A) Flap design. (B) Flap pedicle and harvest. (C) Completion of transfer and donor skin graft coverage. (From Adani R, Giesen T, Inguaggiato M. Heterodigital flaps for severe pulp
defects. In: Dubert TP, Georgescu AV, Soucacos PN, editors. Primary care of complex injuries of the hand and wrist.
Athens (Greece): Medical Publication; 2010. p. 320; with permission.)

Methods for coverage of the thumb tip are


decided by localization of the defect. First choice
for a palmar defect is the classical Moberg flap
or one of its modifications, usually as a V-Y flap
described by Epping in 1992.47 We never use a
Tranquilli-Leali flap at the thumb.
Large defects of the pulp, which cannot be
covered by a Moberg advancement flap and
require restoration of sensibility, are a challenge.
They oppose the classical neurovascular flap
transfer from the finger to the thumb described
by Littler, because the donor morbidity and the
damage to the entire hand are too severe. A
sensate kite flap, by including the superficial
cutaneous branch of the radial nerve, is a good
alternative, as Gaul described.48 When the entire
thumb-pulp is missing with intact bone in young
patients, we use a free pulp flap from the first toe.

United Kingdom
There is a regrettable tendency in the United
Kingdom at present, possibly driven by economic factors, to terminalize injuries of the digital
tips. Although sometimes necessary, this contravenes all of the basic principles of tip reconstruction, achieving a short, ugly digit with no nail
complex and poor sensation, which may be
permanently dysfunctional. In St Andrews Center for Plastic Surgery, Broomfield Hospital,
which has approximately the same hand emergency workload as Nantong in China, we avoid

this procedure whenever possible and actively


encourage tip restoration by distal replantation
or composite graft replacement.49,50 As in the
Far East, amputations distal to the DIP joint level
are first considered for replantation, rather than
covered with a flap, and many replantations at,
or close to, the proximal nail fold (occasionally
beyond it) have been performed in the unit.
Where microsurgical venous reconnection is
not possible, leaching is used.
Where the distal parts are not available, we
believe the extraordinary capacity of the digital
skin to regenerate with excellent cosmetic and
functional results should be exploited whenever
possible. We treat all tip injuries with only skin
loss and some degree of subcutaneous tissue
loss, or those converted to this by minimal bone
shortening, with moist antiseptic dressings and
early mobilization. We believe skin grafting is unnecessary, introduces further morbidity, delay of
mobilization, and may leave the tip abnormal in
appearance, poorly sensate, and of inadequate
durability, with splitting in the cold of winter.
If skin can replace itself, operating to achieve
skin cover, per se, is a dubious indication for surgery. However, more extensive tip injuries require
well-vascularized subcutaneous soft tissue for
protection of the underlying bone, to avoid tenderness. The alternative to shortening is flap cover. In
a ragged injury, soft tissues may be adequately
vascularized and of sufficient size to provide
bone cover: these opportunist flaps can be

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Tang et al

Fig. 27. The palmar advancement flap, described by Moberg and subsequently modified by Elliot and Wilson. (A)
The surgical procedure. The flap is raised and advanced on both neurovascular bundles including the whole
palmar aspect of the thumb with a large V-shaped flap from the thenar eminence; the defect is closed using
the V-to-Y principle. (B) Postoperative results.

used to convert the tip into a skin wound that can


be healed with dressings. If flap cover is necessary, by choice we use advancement flaps, rearranging the soft tissues of the same digit and
avoiding any external donor site. As many tip losses of tissue are sloping, most of our advancement
flaps achieve subcutaneous tissue cover of bone
distally, not distal flap skin to nail suture. In other
words, the tip injury is converted to a skin loss
only, then reepithelialized under moist dressings
over 2 to 3 weeks. This extends the length of the
advancement flaps and allows them to cover
longer defects. These flaps allow early and

independent mobilization of each digit and respect


the cosmetic principle of reconstruction of like
with like. They are durable and intrinsically more
likely to restore good sensory function than the
alternatives.
Our choice of homodigital flap is determined by
the length of the digit and the extent and shape of
the defect:
1. Transverse amputations beyond the mid nail
level and dorsal oblique amputations beyond
the proximal nail fold: A Tranquilli-Leali, or Atasoy, flap can achieve the slight advancement

Reconstruction of Thumb and Finger Tip Injuries

Fig. 28. When the pulp defect is more than 2.0 to 2.3 cm in length, a modification of the Littler flap by harvesting
the flap at the base of the finger can result in sensate and stable skin coverage of the thumb tip with acceptable
donor site morbidity. (AC) Surgical procedure of flap transfer. (D, E) Follow-up results.

needed.4,5 With greater losses of finger length


and in palmar oblique injuries, this flap is too
small.
2. Palmar and sagittal oblique amputations that
have a slope of 30 or less: We use the neurovascular Tranquilli-Leali flap.5,51,52 This flap
has the same shape as the original but is larger,
extending across the DIP joint crease proximally. It is islanded on both neurovascular pedicles. It can be used for stump reconstruction of
any length of amputated finger or thumb and is
much more useful than the original TranquilliLeali flap, which it has, in our unit, largely superceded. It will suffice to cover tip defects with a
palmar slope of up to 30 .
3. More sloping palmar oblique defects (>30 ): We
use 2 alternatives to increase the pulp advancement. The first, used on the thumb mainly, is a
longer bipedicle flap: OBriens modification of
the Moberg flap1,2 with the addition of a large
V tail proximally instead of a skin graft (see
Fig. 7).3 An alternative is to use single-pedicle
lateral flaps. The unilateral V-Y flap described
by Geissendorf7 and the bilateral V-Y flaps,
described by Kutler,8 are never used, as we
feel that they have has little advancement or
cover potential. More useful is the larger flap

reaching proximal to the DIP crease, raised as


an island on its own neurovascular bundle,
described by Segmuller9 and by Biddulph10
(and called the Segmuller flap). Lanzetta and
colleagues11 extended this flap to the PIP joint.
We reported the same modification in 100
cases (see Fig. 14).12 During the same period,
we used a similar number of Venkataswami
flaps. This flap is also islanded on one neurovascular bundle but with the leading edge of
the flap extending across the whole palmar surface of the finger.9 We have found the extended
Segmuller flap to be the more adaptable of the
two. In practice, one raises one Segmuller flap
on the blind side of the finger. If this, alone, is
not adequate for the tissue needs of the digital
tip, the second flap is raised.
With respect to the appearance and sensibility of
the tip and the mobility of the digit, 2-stage techniques, such as cross-finger, thenar, groin, and
cross-arm flaps, are undesirable. These flaps are
rarely used by us for fingertip repair. However, neurovascular advancement flaps are inadequate in
size to cover palmar-sloping tip defects that extend
proximal to the DIP/IP crease of the finger or
thumb. These relatively uncommon, 2-segment

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Tang et al
injuries can be reconstructed with cross-finger
flaps, which are our first choice, reverse Zancolli
flaps,53 or by free toe to hand transfers. However,
the latter, whether for the tip or for a 2-segment
defect, require nerve suture, which may result in a
poorly sensate digital tip in older patients. The patients also may have donor site problems (eg, difficulty when wearing sandals in hot days and cold
intolerance when wearing rubber boots in winter).
Occasionally, other flaps are useful. We devised
the lateral pulp flap for losses of the lateral surface
of the digital tip with exposure of bone.54 This flap
exploits the excess of pulp in the digital tip. The
flap is raised by opening a fish-mouth incision in
the tip and freeing the pulp attachments to the
bone. The pulp then moves laterally and is lifted
over the bone and sutured to the edge of the
nail. The deep edge of the pulp, not the superficial
edge, is brought up to the nail bed to cover the
bone. The pulp is then epithelialized under moist
antiseptic dressings, to create a digital tip that is
sensate with good function but no lateral nail
fold. Side-to-side homodigital switch flaps, which
reconstruct one side of a tip at the expense of
the other, are useful to resurface areas of pulp sensibility critical for pinch activity (see Fig. 16).26,55

United States and North America


The methods to treat the finger or thumb tips vary
among plastic surgeons on this continent. Many
surgeons consider early digital mobilization paramount to any digital tip or thumb pulp or tip reconstruction. The following are preferred methods of
one of the authors from Mayo Clinic, Rochester,
MN, USA.
Fingertip repair
1. Bone exposure with limited soft tissue loss: If
there is a small portion of bone exposed with
limited soft tissue loss, the bone is shortened
to allow the wound to heal by secondary intention. Skin grafting is rarely used and avoided
whenever possible for reasons previously
mentioned.
2. For pediatric fingertip soft tissue losses, we
favor defatting the tip amputation and using it
as a composite graft whenever possible. We
favor using sensate advancement or island
flaps for fingertip reconstruction.
3. Small to moderate transverse fingertip amputations: These injuries are commonly treated
with V-Y advancement flaps described by Tranquilli-Leali4 and Atasoy and colleagues.5 It is
indicated for transverse and dorsal oblique
fingertip amputations with exposed bone.
Palmar oblique amputations with significant

soft tissue loss are an absolute contraindication. Bilateral V-Y Kutler advancement flaps
are used less often because of the significant
scarring created in the finger tip.
The blood supply of these flaps is through a
subcutaneous tissue pedicle, which includes
terminal branches of the digital arteries. All
fibrous vertical septae that anchor the volar
skin to the underlying distal periosteum and
proximal flexor tendon sheath must be divided
to allow tension-free closure. The base corresponds to the volar margin of the amputation
site, and a rounded, more natural fingertip
appearance is ensured by limiting the maximal
base width to that of the nail matrix and by
making the 2 lateral arms of the flap slightly
convex. Important points in harvest include
advancing the flap slightly above the hyponychial fold, so as to avoid a hook nail deformity
due to wound-healing contracture.
4. More oblique fingertip amputations greater
then 50% of the length of the nail bed: We favor
the oblique triangular neurovascular island flap
described by Venkataswami and Subramanian.13 A volar triangular skin flap is raised
based on the vascular pedicle opposite the major amputation side, with the apex at, or near,
the PIP joint flexion crease, and is advanced
with inclusion of both digital nerves.
We favor a larger flap, which covers the entire
neurovascular pedicle. This has advantages
over using a smaller flap: less secondary flap
atrophy, less risk of arterial vasospasm, and a
greater advancement potential. A modification
described by Evans and Martin56 incorporates
3 triangles of increasing size to avoid potential
flexion contractures and longitudinal scarring.
It is indicated for the coverage of large oblique
fingertip defects and is based on one of the
neurovascular bundles from the least dominant
side, or the side with the longest skin flap.
5. More extensive palmar, or palmar oblique, defects: These defects can be covered with a
cross-finger flap. A laterally based dorsal
cross-finger flap is harvested from the dorsal
skin of the middle phalanx of the finger radial
to the injured digit, with the exception of the index finger, which uses a flap from the middle
finger; in general, the most easily positioned
and least important digit should be used.
6. The innervated cross-finger flap, described by
Cohen and Cronin57 in 1983, is achieved by
incorporating the dorsal branch of the digital
nerve opposite to the hinge of the flap within
the flap. This dorsal digital branch is then sutured to the digital nerve contralateral to the
hinge margin of the wound. Division and flap

Reconstruction of Thumb and Finger Tip Injuries


inset is later performed at 3 to 4 weeks. The
reverse cross-finger flap, described by Pakiam,58 is useful for dorsal digital avulsion injuries of the nail bed and distal phalanx, and
also can be used to restore venous drainage after digital replantation. Following transposition
of the subcutaneous tissue flap into the defect,
this is then skin grafted, and the skin flap of
the donor finger used to resurface the donor

defect. Fig. 29 illustrates a method for dorsal


distal finger defect using a cross-finger flap.
7. Another option used for volar oblique amputations: The dorsolateral island flap described
by Flint and Harrison59 provides sensate skin
from the dorsolateral aspect of the distal phalanx. This flap is based on one of the neurovascular bundles located on the side of the finger
with the greatest amount of remaining volar

Fig. 29. Step-by-step description of a reverse cross-finger flap elevation. Either a thin split-thickness or fullthickness skin graft can be used to cover the wound. (A) The method of transfer. (B) Flap elevation. (C) Fascia
flap transfer. (D) Completion of transfer and donor skin graft. ([A] From Tang JB, Amadio PC, Guimberteau JC,
et al, editors. Tendon surgery of the hand. Philadelphia: Elsevier; 2012. p. 376. Figure 35-2.)

353

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Tang et al
and lateral pulp. The distal volar end of this
sickle-shaped island flap is designed as wide
as the remaining nail bed and it extends
obliquely, from the dorsal DIP joint to the
pulp, in a proximal-dorsal to distal-volar direction. Following advancement and insetting,
the donor defect over the dorsum of the distal
phalanx is covered with a full-thickness skin
graft.
Thumb tip repair
1. We favor using the Moberg flap in most cases.
Additional advancement can be achieved by
converting this flap to an island flap after a
transverse incision is made at the base of the
MCP joint. The lateral laxity of the thumb allows
the use of unilateral or bilateral triangular
pedicle flaps to be used to close the donor
site directly. Other modifications include
cupping the Moberg flap to increase volume
and bulk in the tip; any open areas are left to
heal by secondary intention.
2. For defects that are more extensive and not
amenable to a Moberg-type flap, we prefer to

use an FDMA flap. The arc of rotation of this


flap allows it to reach the thumb volar or dorsal
tip easily. The FDMA originates from the radial
artery or, rarely, the dorsalis superficialis antebrachialis artery, and anastomoses at the level
of the metacarpal neck with dorsal perforating
branches from the palmar metacarpal arteries
of the deep palmar arch, which form the basis
of the reverse-flow FDMA island flap (see
Fig. 9). An extended flap can be harvested by
including skin from the dorsum of the middle
phalanx. Sensory branches of the radial nerve
and one or more subcutaneous veins are identified proximally and included in the pedicle. A
branch of the radial sensory nerve in the
FDMA flap is sutured to one of the thumb digital
nerves. We often harvest this flap with a skin
paddle overlying the pedicle to avoid tight
closure during flap insetting (Fig. 30).
3. When a Moberg, or FDMA, flap is not available,
the dorsal ulnar artery flap of the thumb can be
used for small to moderate defects. This flap incorporates skin from the dorsal ulnar surface of
the MCP joint of the thumb to cover distal
thumb defects. The dorsal ulnar collateral

Fig. 30. Surgical procedure of the FDMA flap. (A) Incision. (B) Pedicle has been dissected out. (C) Elevation and
transfer. (D) Completion of transfer and skin graft on the donor site.

Reconstruction of Thumb and Finger Tip Injuries


artery originates from the princeps pollicis artery and travels longitudinally along the dorsal
ulnar surface of the thumb. The reverse island
flap design is based on 2 distal vascular communications with the dorsal ulnar collateral artery. The flap template is marked over the
dorsal ulnar aspect of the MCP joint and is
centered over the dorsal ulnar collateral artery.
The dorsal ulnar nerve can be used to innervate
the flap by anastomosis to a recipient digital
nerve for pulp reconstruction. The donor site
is either closed primarily or covered with a
full-thickness skin graft.

CURRENT TREATMENT FROM A GLOBAL


PERSPECTIVE
First-line surgical options and surgeons preferences vary greatly globally (Table 3), but most
tend to use homodigital flaps and most prefer
sensate flaps.

1. We see more challenging replantation procedures for finger and thumb tip reconstructions
in Asian countries. They also tend to use classical cross-finger flaps less and less. We see
more modifications and innovations of the
different local homodigital flaps being described in European countries.
2. The pulp defect or distal thumb or finger amputation often requires cover with flaps from
the same digit or from elsewhere. Sensate homodigital anterograde digital artery pedicle
flaps are used often for thumb and fingertip
repair. The Moberg and various V-Y flaps are
commonly used for relatively small composite
tissue losses with bone exposure. Modifications of the Moberg flaps with isolation and
mobilization of the neurovascular bundles proximal to the flap, use of the extended modification of the Segmuller flap, and cover distally
by pulp only then epithelialization under dressings all help these flaps to reach the tip. The

Table 3
Summary of different options of a few hand surgeons from different continents for pulp defect of a
moderate size or coverage of distal thumb or finger amputation
Jin Bo Tang
First-line
Moberg flapa: thumb
V-Y flapsa: fingers,
thumb
Digital A. dorsal branch
flap: fingers
Anterograde digital
A. flapa
Toe pulp flapa
Dorsal radial/ulnar
A. flaps: thumb
Second-line
Thenar flap: finger
Reverse homodigital
A. flap
FDMA flap: thumb
Special case
Cross-finger digital
A. flap
Partial toe transfera
Heterodigital flap:
finger
Rare/not use
Cross-finger flap
The Littler flap: thumb

Roberto Adani

David Elliot

Michel Saint-Cyr

V-Y flapsa: thumb,


fingers
Anterograde
digital A. flapa
(Venkataswami flap,
Mouchet-Gilbert flap
or similar)
Modified Moberg
(V tail)a

Modified Moberg
(V tail)a
Tranquilli-Leali flapa
Extended Segmuller
flapa
Venkataswami flapa

Venkataswami flapa
Tranquilli-Leali flapa
Cross-finger flapa
Moberg islanda: thumb

FDMA flapa: thumb


Dorsal ulnar/radial
A. flapa: thumb
Lateral V-Y Kutler flapa

Anterograde
heterodigital A. flapa
Reverse homodigital
A. flap
Free toe pulp
Reverse heterodigital
A. flapa

Lateral pulp (switch)


flapa

Free toe pulpa


Pulp exchangea

Cross-finger flap
Thenar flap

Cross-finger flap
Thenar flap, groin flap
Cross-arm flap

Reverse homodigital
A. flap
Thenar flap
Abdominal, cross-arm

Abbreviation: A., artery.


a
These flaps contain the digital nerve truck or its branches within the base or pedicle of the flap.

355

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Tang et al
homodigital reversed digital artery pedicle flap
is used, but less favored than in earlier times.
3. Among more recent methods or modifications
are flaps based on the dorsal branches of the
digital artery and dorsal ulnar or radial artery
flaps of the thumb. Free vascularized flaps harvested from the toe pulp and wrap-around flaps
from the big toe are favored by those surgeons
with a preference for microsurgery, although
they are not done commonly in an emergency
setting.
4. All of the authors across the globe recognize
the regenerative potential of the tissues of the
digital tips. Consequently, they remind readers
of such alternatives to a tissue transfer to cover
amputation stumps as moist antiseptic dressings for weeks, or a few months.
The homodigital pedicle flaps have become
dominant in the treatment of tip or pulp defects
worldwide. Unfortunately, many of them are not
included in major textbooks; many texts continue
to describe a few classical flaps that experienced
practitioners choose to use rarely. We suggest
that there is a need for texts to be updated to
contain more about recently developed flaps, to
highlight the best among the currently available
options, and to reflect more modern guidelines
on treatment selection.

EVIDENCE AND DECISION-MAKING: FROM


WAITING FOR SELF-REPAIR TO COMPLEX
MICROSURGERY
Most of our practice is currently experience-based
and personal preferencebased. Although it is not
realistic, or necessary, to have sound evidence to
support each decision we make, evidence is
lacking to answer some key questions; that is,
how a sensate flap compares with an insensate
flap, and how sensation differs between a selfregenerated tip and a tip repaired with a flap
without severance of the digital nerve of the flap
and a tip covered with a flap with a sutured nerve.
Surgical cost and length of time to return to
employment, cold tolerance, and hypersensitivity
of the tip also need to be studied and compared
between different treatments.
Personal preference and social, or cultural,
background also play important roles in decisionmaking. In a recent discussion about the view on
tip repair between the lead author (J.B.T.) and a
prominent microsurgeon (Dr Z.T. Wang), who
tends to reconstruct every case using microsurgery, Dr Wang commented that extension of the
fingers likely is affected to a greater or lesser
extent by skin grafting. Instead, he uses

microsurgical flaps as his first-choice reconstruction of digital soft tissue defects. His view is typical
of a number of microsurgeons who treat most of
their cases with highly demanding microsurgery.
This illustrates the currently diverse preference of
surgical options among surgeons and countries.
As a result, we see those who are keen on, and
skillful in, microvascular surgery use microsurgical
transfers often, whereas others who use classical
flaps claim good results with much simpler, less
costly, and less demanding procedures. We
mostly find those crazy, and perfectly skillful, microsurgeons in Asian countries.

FUTURE CHALLENGE AND PERSPECTIVES


Finally, this review draws the attention of readers
to a few important clinical observations, which
may considerably change their treatment of thumb
and fingertip injuries in subsequent years:
1. Tip loss at the mid-distal phalanx, or beyond,
can be treated successfully with moist antiseptic dressings, to achieve total wound closure
by subcutaneous tissue regeneration over the
exposed distal phalanx, provided a month, or
two, are allowed for this regeneration.
2. Currently, a number of wound cover templates
(eg, Integra Dermal Regeneration Template) are
available. These templates maintain a moist
wound-healing environment that promotes
growth of granulation tissues and subcutaneous cover of the exposed bone over approximately 2 weeks. This first stage of surgery
turns a defect originally requiring a flap transfer
to a defect that requires only a skin graft or,
given a little more time, will regenerate skin
over the new subcutaneous tissue.
3. We have observed successful skin graft take on
the regenerated subcutaneous tissue covering
exposed bone in finger tips, which, conventionally, needed flap transfer.
4. Some insensate local flaps gain a degree of
sensory recovery a year after their transfer to
the tips.
These phenomena lead us to consider future
changes in our currently stagnating approach to
management of this problem. The questions to
be answered are:
1. Do we really need complex surgeries if these
amputated tips will eventually regenerate?
Those patients who do not wish to have complex surgeries and will tolerate waiting for a month
or more, albeit carrying out a strict dressing
regimen, can be candidates for this simpler (but
still orchestrated) treatment. Record of such

Reconstruction of Thumb and Finger Tip Injuries


healing by Galen in the first century AD and in the
Smith papyrus, recording medical activity
10,000 years earlier in ancient Egypt, are testimony to the fact that this is not new! A further
and pertinent question is can we speed up this
biologic regenerative process? If we could speed
up regeneration to make the wound close within 2
to 3 weeks, more patients would prefer this course
of management to a surgical flap (which needs 7
10 days to heal, may also include the healing time
of a skin graft donor site and, because of the delay
in starting mobilization, return finger mobility to
normal more slowly). This may become possible
as biologic therapies advance, especially for tissues that already have the intrinsic ability to regenerate. The current dilemma is how to speed the
process up. Research in this direction would
greatly change our practice.
2. Could cover of a pulp defect (with bony exposure) with a biologic or synthetic template
become the routine of the future?
If so, many of the pulp defects that require flap
reconstruction would require only a skin graft or
a slightly longer period of dressings to allow skin
regeneration. This would be a huge simplification
of surgery and would significantly reduce donor
morbidity. Synthetic and biologic wound cover
templates are now available and are still evolving.
Based on the success of these so far, we foresee a
future paradigm shift in management of thumb and
fingertip injuries.
3. Can some insensate digital flaps be proven to
restore the same, or similar, sensibility to the
fingertip as a sensate flap?
Sensation is the key to high-quality thumb or
fingertip repair. Surgeons have always been concerned about this and, consequently, continue to
struggle to include sensory nerves within flaps.
Although a sensate neurovascular island flap
(without nerve suture) is, intrinsically, the ideal in
this respect, we wonder whether an insensate
flap is any less effective, whether sensation is
achieved to a proper degree by ingrowth of nerves
from the surrounding digital skin. Or whether after
suture of the nerve of the flap to a nerve in the
finger tip sensory recovery is reliable and sufficient. We know that, most digital nerve repairs
produce incomplete sensory recovery. Therefore,
the findings of similar sensibility in an insensate
flap to a flap containing a digital nerve a year later
are surprising.17 The literature on this is currently
inconclusive and further investigations are
required. A flap harvested with no nerve supply
at all or one with its nerves sutured to in situ nerves

could be used more often, if proven equal to an


innervated flap. Struggling to include nerve
branches in flaps may become less demanding,
simplifying the surgery.
Ultimately, we must be realistic and optimistic:
the thumb and fingertips are the most sensitive
parts of the body and any replacements will inevitably be less sensate; however, we look forward to
future biologic means of promoting nerve sprouting from neighboring sensate tissue. Enhancing
nerve sprouting from the adjacent digital tissues
could be an intriguing subject of investigation
and advances in this respect would allow surgeons to use an insensate flap to reconstruct
thumb and fingertips. This may be a reality in the
future.
Any of the previously mentioned advances will
have huge implications by simplifying our treatment and will revolutionize our concepts of thumb
and fingertip repair.

SUMMARY
Sensate homodigital anterograde digital artery
pedicle flaps are very often used, with the Moberg
and various V-Y flaps being most commonly used
for relatively small tissue losses with bone exposure. Modifications of the Moberg flaps by
isolating the neurovascular bundles proximal to
the flap, use of an extended Segmuller flap, and
cover distally by pulp only, then epithelialization
under dressings all help these flaps to reach the
tip. Among more recent flaps or modifications
are homodigital pedicle flaps based on the dorsal
branches of the digital artery of the finger and dorsal ulnar or radial artery of the thumb. Free vascularized toe pulps, wrap-around big toe flaps, and
partial toe transfers are favored by surgeons
with microsurgical enthusiasm, although uncommonly performed in an emergency setting. Firstline surgical options and surgeons preferences
vary greatly globally. We see more challenging
replantation procedures of finger and thumb tips
in Asian countries. They also tend to use the
classic cross-finger flap less and less. We see
more innovations of the homodigital or sensate
flaps from Europe.
Finally, we draw attention to 2 important considerations that may change future treatment of the
thumb and fingertip:
1. Cover of a transverse amputation stump
with moist antiseptic dressings achieves total
wound closure, albeit slowly. Cover of a soft
tissue defect with bone or tendon exposure
with a dermal template for weeks allows more
rapid growth of granulation tissue.

357

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Tang et al
2. Some insensate local flaps gain a degree of
sensation after transfer to the thumb or
fingertips.
Enhancement of either, or both, of these biologic observations would have significant implications to simplifying our future treatment of these
injuries.

18.

19.

20.

REFERENCES
1. Moberg E. Aspects of sensation in reconstructive
surgery of the upper extremity. J Bone Joint Surg
Am 1964;46:81725.
2. OBrien B. Neurovascular island pedicle flaps for
terminal amputations and digital scars. Br J Plast
Surg 1968;21:25861.
3. Elliot D, Wilson Y. V-Y advancement of the entire
volar soft tissue of the thumb in distal reconstruction. J Hand Surg Br 1993;18:399402.
4. Tranquilli-Leali E. Ricostruzione dellapice delle
falangi ungueali mediante autoplastica volare peduncolata per scorrimento. Infort Traumatol Lav
1935;1:18693.
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