The Extended Segmiiller Flap Karen L. Smith, F.R.CS., and David Elliot, M.A., F.R. Chelmsford, England A modification of the homodigital lateral VY advance- ‘ment flaps described by Segmilller in 1976 for the treat- ‘ment of fingertip injuries is described. The extended flap used in this series makes this flap more versatile in the treatment of injuries with considerable soft-tissue loss from the volar aspect of the fingertip. The Segmialler flap, technique, its applications, and the results of 100 flaps are reported and discussed. (Plast. Reconstr. Surg. 105: 1334, 2000.) The amputated digit with exposure of bone challenges the hand surgeon to reconstruct a sensate, pain-free tip in a fully mobile digit of the maximum possible length. Homodigital ad- vancement flaps are of particular value with respect to their ability to replace the missing tip with similar and innervated soft tissues while retaining digital length at or near to that, of the level of amputation. The lateral V-Y flap based on the small vessels of the distal digital pulp tissue was first described as a unilateral flap by Geissendérfer (1943)! and was later used bilaterally by Kutler (1947)! and others. These are still described in most textbooks, and they continue to disappoint with their fa ure to advance as much as is shown in line drawings. The minor modification described by Shepard (1983)” is only a little better. The less well-known lateral V-Y flap based on the neurovascular bundle, which was first de- scribed in German by Segmiiller (1976)* and again, independently, by Biddulph in 1979° is, very much more useful, being more mobile and capable of greater advancement. Both Segmiiller and Biddulph used small flaps that were largely confined to the terminal segment of the finger and so still had limited potential for advancement. Lanzetta et al. (1995)"" reported the use of longer Segmiiller From St, Andrew's Center for P Presented atthe 1998 British Society for Surgery of the Hand in London, England, Surgery. Received for ps ternational Fede flaps in five cases with good results. Indepen- dently, over the past 5 years, we have also de- veloped the use of longer flaps based on the Segmiiller principle but extending proximally into the middle, and even the proximal, seg- ment of the digit. We have found these larger flaps to be capable of greater advancement and to have greater versatility. They are of particu- lar use in treating extensive volarsloping de- fects of the tips of the digits, for which’ the shorter bipedicle flaps are inappropriate.!! This article reviews the long-term function of a hundred Segmiiller flaps, ‘96 of which were extended flaps. PATIENTS AND METHODS Patients Over a 4year period, 133 Segmiiller flaps were used to reconstruct 110 digital tip losses in 102 patients in whom there was bone expo- sure at the amputation site. The group i cluded 86 male and 16 female patients, with a male to female ratio of 5 to 1, ranging in age from 1 to 83 years (mean, 39 years). Eight children under 16 and 4 patients over 70 years old were treated. Fortyseven percent of the injuries were to the dominant and 53 percent to the nondominant hand. Five thumbs, 33 index, 34 middle, 22 ring, and 16 little fingertips were reconstructed. Six- ty-ive percent of the injuries affected the tips of the thumb, index, or middle finger, so the reconstruction was significant with regard to pinch activities. Seventy:six percent of the dig- its had suffered crush or avulsion injuries, 22 percent having been considered unsuitable for replantation. “Clean” amputations constituted ication October 6, 1998; revised August 23, 1900, ion of Societies for Surgery ofthe Hand in Vanconver, Canada, and the 1998 MeetingVol. 105, No. 4 / THE EXTENDED SEGMULLER FLAP only 24 percent of the total. The injury was to a single digit in 78 patients, with 57 of these requiring a single flap and 21 requiring bilat- ral flaps (Fig. 1). In the other 24 patients, the y was multidigital or included injury to other parts of the hand. This group of patients had a total of 32 digital tip injuries. Bight pa- tients had two fingers treated with Segmiiller flaps, one patient having had two flaps to each finger. In three digits, the flap was used in combination with other flaps to cover large defects (one case) or defects extending onto the dorsum of the finger and/or nail bed (two cases) (Fig. 2). Operative Technique The Geissendérfer/Kutler flap was designed as a triangle on the lateral aspect of the finger, with the apex of the triangle proximal and the flap raised on the microcirculation of the tip subcutaneous pulp tissue. Segmiiller increased the size of the triangle, taking the apex back to the distal interphalangeal joint crease and is- landing the flap on the neurovascular pedicle. Our extension of this technique involves use of a larger triangular flap, also raised as an island on the neurovascular pedicle, but with the apex of the flap usually in the middle segment of the finger and often nearer the proximal interphalangeal joint than the distal interpha- langeal joint crease. The length of the flap can be increased into the proximal segment of the finger safely if greater advancement is required to reconstruct a very oblique volar sloping de- fect of the tip of the digit (Fig. 3) ‘The boundaries of the flap are illustrated in Figure 4, The flap extends only to the midline of the finger and differs in this respect from a Venkataswami flap, which is taken right across the volar aspect of the finger to the other mid-ateral line, Because of the volar sloping nature of the tip injuries for which these flaps are commonly used, the proximal edge of the tip defect often includes several millimeters of subcutaneous tissue without skin. This tissue is ncluded in the flap to increase its length and reduce the distance by which it must be ad- vanced to the end of the digit. Consequently, the bone at the tip of the finger may be cov- ered only by denuded pulp tissue after flap advancement and not by pulp and skin. When this is the case, the tip is treated with moist antiseptic dressings for several weeks until reepithelialization completes tip cover. When raising the flap, the skin incision begins down 13: the midateral line and dissection is continued medially and proximally from the lateral cor- ner of the base of the flap in the plane imme- diately superficial to the periosteum laterally and the tendon sheath more medially. By using this approach, the neurovascular bundle is im- mediately identified from its deep surface on the underside of the flap and, thereafter, is protected. All of the fibrous septa that connect the dermis to the periosteum and tendon sheath and those fibers immediately deep to the dermis, particularly at the apex of the flap, are divided to mobilize the flap. Freeing these tissues is sometimes enough to allow adequate mobilization to cover small tip defects. How- ever, in most cases, this is not adequate and it is necessary to completely island the flap on the neurovascular pedicle with a cuff of fat around the palmar surface of the artery and nerve to maintain venous drainage. The flap is then advanced without tension and loosely sutured to cover the bone of the digit tip. Commonly, part or all of the mid-lateral margin of the flap is left unsutured to avoid tension from postop- erative edema. This wound subsequently heals by secondary epithelialization under moist an- tiseptic dressings. A single flap is usually raised on the blind side of the finger unless the par- ticular shape of the tip defect determines oth- erwise. In some injuries, a single flap provides sufficient tissue to reconstruct the digital tip but, in others, two flaps are necessary and a second flap is raised on the other neurovascu- lar bundle and advanced. The finger is splinted dorsally, with the proximal interphalangeal joint slightly flexed for the first 72 hours to take tension off the pedicle. However, this po- sition is not maintained after this time because of the risk of volar plate contracture of the proximal interphalangeal joint after use of all ‘of the longer advancement flaps. After 72 hours, specific measures are taken by the ther- apists to avoid this, extension exercises and/or splinting sometimes being necessary for several weeks or, occasionally, months. Assessment The records of all 102 patients were re- viewed. Each operation record included a drawing and many patients had intraoperative photographs, allowing detailed analysis of the lip injuries. The injury was classified according to the slope of the tip defect and the level of amputation. The slope of the tip defect was described as transverse, coronal oblique (pal-1336 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 Fic. 1. (Abou, kf) Crush amputation of the tip of the left middle finger of a teenage boy showing a palmar-facing coronal oblique amputation with a moderate degree of obliquity exposing the distal phalanx. (Above, righ) Preoperative marking of this, finger with medium-length Segmiller flaps. (Center, lf) Intraoperative view alter mobilization of the flaps on their neurovascular pedicles. (Center, right) Intraoperative view after advancing the flaps to the tip of the finger. (Beloa) Late views of the healed Fingertip.Fic, 2. (Above, lef) Ana 1337 bed injury with greater than 50 percent loss of the nail bed; (above right and belo, lef) intraoperative lateral and dorsal views of the same injury after abl jon of the remaining nail bed and germinal matrix and mobilization of a short Segmiiler flap; (below, right) intraoperative view of the Segmiiller flap sutured into the nail bed. mar-facing), coronal oblique (dorsal-facing), sagittal oblique, or segmental (Fig. evel of amputation was assessed by using the Ishikawa classification," used originally to in- dicate the level of replantations. Oblique am- putations cross from one Ishikawa level to an- other, and the number of Ishikawa levels crossed by each amputation from its distal edge to its proximal edge was recorded for each injury (Fig. 6) to illustrate the size of the tissue loss and, by implication, the amount of ad- vancement necessary. Flap length was classified as short, medium length, and long according to whether the flap apex was positioned in the1338 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 Fic. 3. (Abou, left) An adult ring finger with a more severe sagittal oblique amputation on the ¥ king of this finger with a long radial Segui Y reconstruction of proximal defects of the volar aspect of the digits. Br. J. Plast. Surg. 47:3 center) preoperati N,,and Eliot, D. Palmar V toallow access to the proximal n of the long Segmiller on a net also requ view of the short Segmiller flap at the end of th postoperative period, distal, middl digi A questionnaire assessing pain, sensation, cold intolerance, movement, grip strength, pinch strength (where relevant), and patient satisfaction on scales of 0 to 10 was mailed to all of the patients. Patients were asked about their use, lack of use, and/or avoidance of use of the reconstructed digit(s). OF the 75 patients (74 , or proximal segment of the ovascular bundle; (above, righ) the finger at the end of the operation and ‘ovascular pedicle mobilized back to the common digital artery through the palmar VY flap, but 1g an additional short Segmiiller flap from the other side ofthe finger to complete the tip closure; (below, lf) lateral operation; (Irlow, righ) lateral view of the long Sey lial side of the finger; (above, Ve¥advancement flap (from Moiemen, 1994) ler flap and a pal ster ad niller flap during the eatly percent) who responded to the questionnaire, 58 (57 percent) were seen for review by the first author (K.S.), who had not been involved in the original treatments. For these patients, objective assessment consisted of measurement of joint ranges of movement, sensation by static and moving two-point discriminatory test, grip, and (for thumb, index, and middle finger in- juries) pinch strength. The results of the lightVol. 105, No. 4 / THE EXTENDED SEGMULLER FLAP. Rao ) ea Fc. 4. Ilustration of the preoperative marking of the boundaries of the Segmiiller flap, ‘Transverse ‘Coronal oblique (palmar facing) Coronal oblique (dorsal facing) Sagittal oblique (medial or lateral facing) 4, AY i A fl Fic, 5, Direction of the injuries to the tips of the digits (n= 110). touch assessments were expressed as the abso- Tute loss in millimeters in the injured digit when compared with the contralateral equiv lent digit. In digits with unilateral flaps, sensa- tion on the side of the finger that was not advanced as a flap was also measured at its most distal part. Grip and pinch strengths were me: sured with a Jamar dynamometer at three set- tings (1,3, and 5) which correspond to grip- ping a thin (3-cm), a medium (5.5-cm), and a large (8-cm) diameter pipe, respectively, and the loss of strength relative to that of the con- 1339 tralateral hand recorded. For each particular modality of this assessment, it was necessary to exclude small numbers of patients reviewed when age, rthritis, and/or associ: ated or old injury negated the validity of the measurement. Because the resulting cohort varied slightly in size for each part of the as- sessment, the results were recorded as percent- ages. At review, patients were also asked about their use or avoidance of use of the finger. For patients who were not seen for review, addi- tional information on outcome was gained, when possible, from the hospital records. Specific complications of the surgery were sought in the questionnaire and at review and were available in the hospital records. Time to healing was taken from the hospital records, but because many patients applied their own dressings at home from a very early stage in treatment there were ofien long time gaps be tween clinic visits, and these times are most probably a considerable overestimate. Informa- tion on employment, employment changes, and time off work was sought in the question- naires. infirmi ‘Transverse (levels of amputation after Ishikawa, 1990) Coronal Oblique (palmar) we A Sagittal Oblique & Ph Fic, 6, Slope of the injuries to the tips of the digits, a ee1340 RESULTS, Of the 102 patients who had 133 Segmiller flap reconstructions of 110 digits, 75 patients, (74 percent) with 100 flaps (75 percent) re- sponded to the questionnaire and 58 (57 7 per- cent) with 83 flaps (62 percent) were seen for review. Twenty-seven patients were lost to fol low-up. For those patients who responded to the questionnaire, the minimum follow-up was 6 months, the maximum 62 months, with an average of 28 months. Figure 5 summarizes the number of injured digits with each type of slope of defect. Only one dorsalfacing coronal oblique injury was reconstructed with this flap, because these de- fects are usually reconstructed with the Tran- quilli-Leali type of flap."® The levels of ampu- tation of the various types of injury are recorded in Figure 6, which also illustrates the various degrees of obliquity of the coronal and sagittal injuries. Twenty-three (70 percent) of the palmar-facing coronal and 18 (67 percent) of the sagittal oblique injuries had a severe loss, of tissue, with the amputation crossing two or more Ishikawa levels, indicating an obliquity of greater than 45 degrees. Four percent of the flaps used were the short flaps originally de- scribed by Segmiiller and 96 percent were ex- tended flaps, of which 61 percent were of me- dium length and 35 percent of long length. OF those patients who answered the ques- tionnaire, few had pain in the digit at rest or in the operative scars (Fig. 7). Slightly more had pain or tenderness in the digital tip when tapped or inadvertently bumped, but 34 pa- tients (45 percent) described this as 5 or less out of 10 in severity and 33 digits (42 percent) were reported as having no pressure pain at all. Fifteen digits (19 percent) were reported as having tip pain on pressure that was greater than 5 out of 10. Cold intolerance was greater than 5 out of 10 in 39 digits (49 percent), with only 21 (27 percent) reported as having no cold sensitivity. Most patients perceived their digit tips to have some numbness, and only 17 tips (22 percent) had normal sensation. How- ever, 53 percent of the digital tips were re- ported as having sensation within 70 percent of normal and only 19 percent had a more severe sensory loss. Generally, patients were pleased with the end result, but a small number were not. Ten patients (13 percent) reported that the digit was ignored in normal use, but of PLASTIC A D RECONSTRUCTIVE SURGERY, April 2000 these, only six graded themselves or poor sensation or s Table I records the light touch assessment in the 58 patients who were seen for review. Flaps had normal static owo-point discrimination in 45 percent and normal moving two-point dis- crimination in 50 percent of cases. There was Joss of sensation of between 5 and 10 mm in 22 percent of flaps by static and 13 percent of flaps by moving two-point assessment. In the 2 digits with unilateral flaps, the side of the digit tip that had no surgery generally suffered less loss of sensation than the side advanced as a flap. Nevertheless, 56 percent of these digits had a mean loss of sensation of 2 mm by static two-point measurement, and of 1.5 mm by moving two-point measurement, on the side that was not advanced as a flap. Of those injuries that involved fingertips in the 58 patients reviewed, joint range of motion was generally well preserved. At the distal in- terphalangeal joint, 78 percent had normal extension with 22 percent having lost 3 to 50 (mean 15) degrees of extension; 74 percent had normal flexion with 26 percent having lost 5 to 70 (mean 26) degrees of flexion. At the proximal interphalangeal joint, extension was normal in 83 percent with 17 percent having lost of 5 to 30 (mean 14) degrees of extension; flexion was normal in 86 percent with 14 per- cent having lost 5 to 45 (mean 19) degrees of flexion. Table II indicates the range and mean loss of grip and pinch strengths in cases with single-digit injuries expressed as a percentage of the grip strength of the opposite hand, with correction for hand dominance of 10 percent The grip strength of the injured hands was normal in 49, 49, and 57 percent of cases at Jamar settings of 1, 3, and 5, respectively. Of injuries to the thumb, index, and middle fir gers, pinch strength was normal in 41 percent. The overall losses of both grip and pinch strengths were small (Table II) Healing time averaged 5 weeks with a range from 2 to 9 weeks. There were few specific complications of the surgery. There were four superficial infections, one partial flap necrosis (which healed by secondary intention with dressings), one inclusion dermoid cyst, one carly reflex. sympathetic dystrophy, and five neuromas, four of which were on the flap side of fingertips treated with a single flap. OF the latter, only one required treatment and four were moderately satisfied with their outcome despite this problem. Seventy-seven percent of as having fairVol. 105, No, 4 / THE EXTENDED SEGMULLER FLAP & Rest pain Number of Digs tanauasansl Pressure pain Number of Digits easasasnsaeaes o123 4567 89 10 None Severe «s 6 ae zg 335 330 o1za4 567 8 9 0 Normal Absent 1341 ‘Scar pain ensaunsesagsss O12 34567890 None Severe Cold intolerance Number of Digte oosauneesaeass orzo e567 89 0 Patient satisfaction Number of Digits onsauusesnensa 4234 6 6 7 8,8 10 cba Poor Fic, 7. Subjective (patient) assessment of function of the healed digital tips the patients who answered the questionnaire were employed at the time of injury, and 88 percent of these were manually skilled work requiring power or precision hand use for their work, The remaining 12 percent were employed in a clerical or supervisory capacity. Students, retired persons, and unemployed people constituted 23 percent of the patients. Of the employed patients, time off work ranged from 0 to 28 weeks with a mean of 7 weeks, and only two of those with simple digital tip injuries changed jobs as a result of the injury Discussion The extended Segmiiller flap provides a good, but not perfect, reconstruction of the tip Of the digit from both an aesthetic and a func- tional point of view. In the final analysis, this technique must be compared with the alterna- tives. Both epithelialization under dressings and skin grafting provide insufficient padding of the exposed bone to be useful for the type of injuries being treated in this series. Local slid- ing flaps of the Tranquilli-Leali type and Kutler flaps are also too small to provide sufficient1342 TABLE I Objective Assessment of Digital Tip Function: Loss of Sensation, Fp Not ort mm 74 2.3.4 mm 2% 5.6.7 mm 65. ° 8.9, 10 mm. 65, ° replacement of the missing soft tissues for more extensive tip losses of soft tissue." At one extreme of possible treatments is skeletal short ening and terminalization. This is simple but, leaves a shortened finger, frequently with an oversensitive or numb tip that often cannot be involved in activities of the digital tips.!°"! In- termediate in sophistication are the flaps— cross-finger, thenar, and reverse neurovascular homodigital—which will maintain the length of the digit but with no or reduced tip sensa- tion. Previous studies of fingertip reconstruc tion have largely concentrated on the sensory function of the crossfinger flap. Although ear- lier authors often considered sensory return to be “adequate,” the objective evidence suggests that these flaps are likely to leave the digit unable to participate in finer activities such as tip pinching.""""" At the other end of the reconstructive spectrum is microvascular free toe pulp transfer, which is an elegant option but is not available to all surgeons and is seen as “overkill” by most. When offered, this ap- proach is almost universally dismissed immedi- ately by our patients. A more objective criticism of this reconstruction is that it involves nerve anastomosis with inevitable loss of sensation in middle-aged persons. It also carries a signifi- cant risk, in northern climates, of cold intoler ance in two extremities instead of one. PLASTIC D RECONSTRUCTIVE SURGERY, April 2000 Flaps pedicled on the neurovascular bun- dle(s) offer much in terms of avoiding short- ening, maintaining nerve integrity, and provid- ing good soft tissue cover of the tip. We agree with Foucher et al."° that violation of normal, adjacent digits should be avoided whenever possible, making homodigital preferable to heterodigital flaps. The latter also suffer prob- lems of cortical reorientation and sensory loss.*-" Bipedicled flaps based on those de- scribed by Tranquilli-Leali'® are useful but are applicable only to less oblique defects." The longer bipedicle flaps based on the principle of the Moberg flap’ are an alternative to single pedicle lateral V-Y flaps (such as the Segmiiller flap) not only for more severe oblique ampu- tations of the tip of the thumb, but also for similar injuries to the fingertip when used in the manner recently described by Kojima et al Although similar in its uses to the Ven- kataswami flap, extended Segmiiller flaps are more likely to create a al tip with better innervation inasmuch as the leading edge of the Venkataswami flap furthest from the pedi- cle is denervated on elevation of the flap. From a practical point of view, reconstruction with two smaller flaps, each on its own pedicle, is more versatile. Although we have used approx- imately the same number of Venkataswami flaps over the past 5 years, we prefer the ex- tended Segmiiller. Itis useful to be able to raise one flap and then assess the need for a second before incising and scarring the other side of the finger. This benefit is seen particularly when reconstructing the borders of the hand. We find both the Segmiiller and Venkataswami flaps to be more adaptable intraoperatively than the Evans flap” (the ultimate position of which is largely predetermined at the design stage) and to be simpler than the flap de- scribed by Foucher et al.,!" which involves skin TABLE IL Objective Assessment of Digital Tip Function: Loss of Strength Paints with Lose "ot Neca ‘of Normal Dynamometer Seng of Seng (0) seg) Ssrengi" (6) 51 11053 2 3 (55cm) 51 Lio s 5 (sem) 8 110.50 8 Pinch strength (w= 48) 59 Lo 66 8 Tn howe patents who had any low of arength,Vol. 105, No. 4 / THEE SEGMULLER FLAP. Fic. 8. (Above, lf) Multiple palm: ing coronal oblique fin right) The same fingers after tip reconstruction without shortening using bilateral sho ons. (Abou, Seg: stip amput miller flaps to the index and middle fingers, a neurovascular Tranquill-Leali flap to the ring i P 1% and direct closure of the litte ge grafting with the additional problems of a graft and its donor site. Despite our enthusiasm for the extended Segmiiller flap, certain features of this study warrant critical discussion. Advancement flaps, in general, have been criticized previously as postopera + with opportunist flaps from the ragged soft tissue remnants at the amputation site. (Below) Late tive views of the same Fingertips suffering altered sensation, although the cause of this has never been analyzed." Concern about this was a precipitating reason for this study, which sought to determine whether this flap risks trading maintenance of finger length for loss of sensitivity of the digital tip. However,1344, alternative reconstructions that maintain func- tional digital length after injuries of the degree described in this article require the use of flaps that are subject to at least as great a risk of sensory loss. Because many plastic and hand surgeons consider the crossfinger flap to be the workhorse for flap reconstruction of the tips of digits, it is appropriate to use this flap as the standard for comparison. Fortunately, al- though few reports of flap reconstructions of > fingertip provide measurements of late sen- sory function, the most thoroughly investigated has been the crossfinger flap. Our study shows that the Segmiiller flap has better sensation than that reported for the crossfinger flap in most adult studies2***" although this finding is not invariable.” Nevertheless the Segmiiller flaps in this study did suffer measurable loss of sensation, albeit small in most digits. Although traction on the digital nerve as the flap is ad- vanced may be involved, this study shows that part of the loss of sensitivity isa consequence of the injury. The injury was other than a clean- cut amputation in 76 percent of our cases, so neuropraxia injury of both digital nerves adja- cent to the amputation stump would be ex- pected. In the 35 digits with unilateral flaps that were reviewed, there was sensory loss on the “nonflap” side of the digital tip in 56 per- cent of reconstructed tips, which averaged mm for static and 1.5 mm for moving two-point, discrimination. Replacement of the tip s with less sensate skin from an area more prox- imally on the palmar surface of the digit is another inevitable factor in all advancement procedures, Subjectively, patient satisfaction in our study was higher than might be expected from the objective measurements, which is in keeping with the recognized dissociation be- tween sensory testing and actual sensory fune- tion and makes interpretation of objective data in studies of this kind difficult and, often, un- duly pessimistic. Loss of full extension of the distal interpha- langeal joints occurred in 22 percent of fin- gers, and loss of full flexion occurred in 26 percent of fingers, in our study. However, the degrees of loss of distal interphalangeal joint, range of movement recorded are likely after any digital tip injuries, whatever the method of reconstruction. There was loss of full extension of the proximal interphalangeal joints, ranging from 5 to 30 (mean, 14) degrees, in 17 percent of fingers and loss of full flexion, ranging from 5 to 45 (mean, 19) degrees, in 14 percent of PLASTIG AND RECONSTRUCTIVE SURGERY, April 2000 fingers. Although these losses were mostly small, use of these flaps creates a very definite need for skilled hand therapy and, in particu lar, postoperative extension splinting of the proximal interphalangeal joint. Grip strength was usually slightly reduced, with a greater loss of strength when gripping small diameter ob- jects. The loss of pinch strength in those with injury to the radial digits was of similar degree. Itis impossible to say how much of these losses resulted from the original injury and how much resulted from the reconstruction. Cold intolerance was a significant problem in our patients, and others! have reported a similar prevalence. However, this is not specific to any one treatment of digital amputations,!® but rather it appears to be a complication that is unavoidable in colder climates or in those with a significant winter season. The literature contains few comprehensive reviews of flap reconstructions of the di tips, and many authors describe their “excellent,” “satisfactory,” and so forth without definition of these terms and with insuffi follow-up data to allow independent opinion. Therefore, outcome data to compare with our study are limited. Of those studies reporting Segmiillertype flaps, that of Segmiiller® in- cluded 15 cases with one flap failure, which was terminalized, and 13 (87 percent) * ry" results, Foucher et al. and Schiund et al.*" used a flap closely resembling the Segmiller flap but without a V tail, so skin grafting of the donor defect was required. Of 37 reviewed pa- tients, 84 percent had static two-point values between 3 and 7 mm, a result that equates to our measured loss of static two-point discrimi- nation of 0 to 4 mm in 78 percent of digits. Lanzetta et al." reported five extended Seg- miiller flaps in a series of 25 cases of various lateral V-Y island flap reconstructions of finger- tips. Unfortunately, these authors did not ex- amine the results of the extended Segmiiller subgroup separately, but they reported data for all of the VY island flaps as a group. One flap in the whole series was lost and one patient was dissatisfied with the appearance, but it is not stated which flaps were involved in these two cases, The remainder of the flaps were aesthet- ically acceptable to the patients, although 28 percent had a flexion contracture of the prox- imal interphalangeal joint and extension splinting was generally needed postoperatively. The finding of 92 percent of patients having static two-point measurements equal to thoseVe |. 105, No. 4 / THE EXTENDED SEGMULLER FLAP of the contralateral equivalent digital tips at 8 weeks postoperatively, with values ranging from 3 to 6 mm, is considerably better than the more long-term results for lateral VY island advancements in our series or those of Foucher et al.!® These authors include the extended Segmiiller flaps in a grouping of “extremely satisfactory” in terms of good padding and pulp tissue stability. In this study, we did not specifically examine these features, which are a fundamental reason for the use of any flap in digital tip reconstruction. However, we agree that these flaps provided such qualities when. advanced without tension and with sufficient bulk of subcutaneous pulp to the very tip of the digit. Commendable features of the extended Se miiller flap are its versatility, ease of use, and reliability. It is a single-stage reconstruction that borrows from no other part than the al- ready injured recipient digit. Although the procedure demands careful technique, it re- ‘es no microsurgical expertise and is well within the capabilities of most hand surgeons. It can be used to treat digital tip defects of variable size, shape, and slope, as illustrated by the wide range of injuries treated in this study. The flap is suitable for any transverse or oblique loss of the distal segment, however steeply sloping the latter, with the length of the flap being tailored to the size of the tissue loss. When one flap provides insufficient tissue bulk at the tip after advancement, a second can be brought into use (Fig. 3). Like all homodigital flaps, this flap is useful in multidigital injuries in which adjacent digits are not available as a source of flaps (Fig. 8). It can also be used alone to reconstruct nail bed loss (Fig. 2) or in combination with other flaps for more com- plex reconstruction of combined tip and dor- sal injuries." The extended Segmiiller flap has become our workhorse for reconstruction of digital tips whose loss of soft tissue places them beyond the capabilities of the neurovascular Tranquilli-Leali flap.” David Elliot, M.A., FRCS. St. Andrew's Center for Plastic Surgery Broomfield Hospital Court Road, Broomfield Chelmsford, Essex CMI 7ET United Kingdom info@davidelliot.co.uk u. 18, 19. 20, 23. 1345, REFERENCES, Geissendorfer, H. Beitrag. 2ur Fingerkuppenplastik Zentralblatt fir Chirurgie 70: 1107, 1943, Kautler, W. A new method for finger tip amputation, JAMA, 138: 29, 1947. Fisher, R-H. The Kutler method of repair of fingersip ‘amputations. J. Bone Joint Surg. 494: 317, 1967. Frandsen, P. A.” VEY plasty as treatment of finger tp ‘amputations, Acta Orthop. Scand. 49: 255, 1978, Freiberg, A, and Manktelow, R. ‘The Kutler repair for fingertip amputations. Plast. Reconstr. Surg. 50: 371, 1972 Weston, P. A. M.,and Wallace, W. A. The use of locally based triangular skin flaps for the repair of finger tip ties. Hand 8: 54, 1976, Shepard, G.H. The use of lateral advancement flaps for fingertip reconstruction. J. Hand Surg. 88: 254, 1983, von Segmiiller, G. Modifikation des Kutler-Lapper Neurowaskulare Stichung. Handchirurgie 8: 75, 1976. Biddulph, 8. L. The neurovascular flap in finger tip injuries, Hand 11: 59, 1979 Lanzetta, M., Mastropasqua, 1, Chollet, A., and Brise- bois, N. Versatility of the homodigital twiangular neurovascular istand flap. J. Hand Surg. 20B: 824, 1995, Atasoy, E., loakimidis, E., Kasdan, M. L., Kutz, J Eo, and Kleinert, HE, Reconstruction ofthe amputated fin- ger tip with a triangular volar flap. J. Bone Joint Surg, Am. 53: 921, 1970. Elliot, D., Moiemen, N.S. quill and Jigjinni, V.S. The new liflap. J. Hand Surg. 208: 815, rovascular'T 1995 ‘Tranquill-Leali, dell'apice delle falangi ungueali mediante autoplastica volare pedun colata per scorrimento, Infort. Traum. Lavavo 1: 186, 1935. Ishikawa, K., Ogawa, Y., Soeda, H., and Yoshida, YA. ation of the amputated level for the distal ger. J. Jpn. Soc. Reconstr. Microsurg: 8 54, E, Ricostruzione Foucher, G.,S th, D., Pempinello, €., Braun, F. Mand Gitron, N. Homodigital neurovascular flaps for dig tal pulp loss. J. Hand Surg. 14B: 204, 1989. Bojsen-Moller, J. Pers, M., and Schmidt, A. Finger tip injuries: Late results, Acta Chir, Scand. 192: 177, 1961 Brody, G. S,, Cloutier, A. MeL., and Woolhouse, F. M. The finger tip injury: An assessment of ma Plast. Reconstr. Surg. 26: 80, 1960. Elliot, D., Sood, M. K., Flemming, A. F. S., and Swain, B. ‘A comparison of replantation and terminalisati ter distal finger amputation. J. Hand Swg. 1997, Holm, A.,and Zachariae, L. Fingertip lesions: An evat- uation of conservative treatment versus free skin graft ing. Acta Onthop. Scand, 45: 382, 1974 Jones, J. M., Schenck, R. R., and Chesney, RB. Digital replantation and amputation: Comparison of func tion. J. Hand Surg. TA: 183, 1982. Sturman, M.J.,andDuran,R.J. Late results of fingersip injuries, . Bone joint Surg. Am. 45: 289, 1963. Dellon, AL. Evaluation of Sensibility and Reeducation of Sensation in the Hand, Baltimore: Williams & Wilkins, 1981. P, 232, Johnson, R. K,, and Iverson, RE. Crossfinger pedicle flaps in the hand. J. Bone Joint Surg. Am.1346, 24, Kleinert, H. E., McAlister, C. G., MacDonald, G. J., and Kurz, J. E. A critical evaluation of cross finger flaps, J. Trauma 14: 756, 1974. 25. Nicolai, J. P., and Hentenaar, G. finger flaps. Hand 13: 12, 1981 26, Porter, R. W. Functional assessment of transplanted, skin in volar defects of the digits: A comparison be- rneeen free grafts and flaps, J. Bone Joint Surg. Am. 50: 955, 1968. mith, J. R,,and Bom, A. F._An evaluation of finger-tip reconstruction by crossfinger and palmar pedicle flap. Plast. Reconstr. Surg. 36: 409, 1965, 98. Krag, G., and Rasmussen, K. B. The neurovascular is land flap for defective sensibility of the thumb. J. Bone Joint Surg. Br. 57: 495, 1975. Markley, J. M., Jt. The preservation of close two-point discrimination in the interdigital transfer of newro- vascular island flap. Plast. Reconstr. Surg. 59: 812, 1977. 30. Murray, J. F, Ord, J. V. R, and Gavelin, GE. The neurovascular island pedicle flap: An assessment of late results in sixteen cases, J. Bone Joint Sung. Am. 49: 1285, 1967, 31. Omer, G. E., Jr, Day, D. J., Ratliff, H., and Lambert, P. Neurovascular cutaneous iskand pedicles for deficient median-nerve sensibility. J. Bone Joint Surg. Am, 52: 1181, 1970, 32 Reid, D! A.C, ‘The neurovascular island flap in thumb reconstruction. Br. J. Plast. Surg. 19: 234, 1966, 38. Bang, H., Kojima, ., and Hayashi, H. Palmar advance- ment flap with VY closure for thumb tip injuries J. Hand Surg. 7A: 983, 1992, Sensation in cross PLASTIC AND RECONSTRUCTIVE SURGER} , April 2000 34. Elliot, D.,and Wilson,Y. VYadvancement of the entire volar soft tissue of the thumb in distal reconstruction, J. Hand Surg. VSB: 399, 1993, 85. Kojima, ., Kinoshita, ¥., Hirase, Y., Endo, '., and Hae ashi, H. Extended palmar advancement flap with VY closure for finger injuries. Br. J. Plast. Surg. 47: 275, 1994, 36, Moberg, E. Aspects of sensation in reconstructive sur gery of the upper extremity. J. Bone Joint Surg, Am, 46: 817, 1964, - O'Brien, B. Neurovascular island pedicle flaps for ter= minal amputations and digital sears, Br. J. Plast, Surg. 21: 258, 1968, 38. Venkataswami, R., and Subra Oblique trian gular flap: A new method for oblique amputations of the fingertip and thumb, Plast. Reconstr Surg. 66: 296, 1980. 39, Evans, D. M., and Martin, D. L. Stepadvancement is land flap for fingertip reconstruction. Br. J. Plast. Surg. Al: 105, 1988, 40, Tupper, J. and Miller, G. Sensitivity following volar VY plasty for fingertip amputations. j. Hand Surg: 10B: 183, 1985, 41, Schuind, B., Van Genechten, F., Denuit, P., Mette, M. Le lambeat en ilot homodactyle en, chirurgie de la main: A propos de soixante eas. Ann. Chir. Main 4: 306, 1985, N.W.,and Elliot, D. Dorsal VY advancement flaps in digital reconstruction. J. Hand Sug. 19B: 91, 1994, and Foucher G. 42. Yi