Free digital artery flap: an ideal flap for large finger defects in situations where local flaps are precluded.

The heterodigital arterialized flap is increasingly accepted as a flap of choice for reconstruction of large finger wounds. However, in situations where the adjacent fingers sustained concomitant injuries, the use of this flap as a local flap is precluded. This paper describes our experience with the free digital artery flap as an evolution of the heterodigital arterialized flap. Four patients with large finger wounds were reconstructed with free digital artery flap. Our indications for digital artery free flap were concomitant injuries to adjacent fingers that precluded their use as donor sites. The arterial supply of the flap was from the digital artery and the venous drainage was from the dominant dorsal vein of the finger. The flap was harvested from the ulnar side of the finger. The digital nerve was left in situ to minimize donor morbidity. The donor site was covered with a full-thickness skin graft and secured with bolster dressings. Early intensive mobilization was implemented for all patients. All flaps survived. No venous congestion was noted and primary healing was achieved in all flaps. In addition to providing well-vascularized tissue for coverage of vital structures, the digital artery was also used as a flow-through flap for finger revascularization in one patient. Donor-site morbidity was minimal, with all fingers retaining protective pulp sensation and the distal and proximal interphalangeal joints retaining full ranges of motion. In conclusion, the free digital artery flap is a versatile flap that is ideal for coverage of large-sized finger defects in situations where local flaps are unavailable. Donor-site morbidity can be minimized by preservation of the digital nerve, firmly securing the skin graft with bolster dressings, and early mobilization of the donor finger.

The spiral flap for fingertip resurfacing: short-term and long-term results.

PURPOSE: We describe a homodigital neurovascular island flap for reconstructing large pulp defects of the fingertips and review the short-term and long-term appearance and function of the reconstructed fingertips. METHODS: The spiral flap is a homodigital neurovascular island flap with a unique spiral advancement and transposition design that allows pulp reconstruction using sensate glabrous skin while restricting donor morbidity to the injured digit. Thirty-two fingertips were resurfaced using this flap. All had large pulp defects averaging 1.2 cm wide x 2.0 cm long (1.0-2.0 cm x 1.5-2.5 cm). Short-term results (<18 months) for all patients at a minimum of 6 months and long-term results (>5 years) for 10 patients with a mean follow-up of 13 years were reviewed. Objective outcome measures included static 2-point discrimination, degree of nail deformity (beaking), total active motion, and hypersensitivity or cold intolerance. Subjective outcome measures included patient satisfaction with function and aesthetics, using a visual analog scale. RESULTS: All flaps achieved primary healing with no complications. There was initially mild extension deficit in the proximal interphalangeal and distal interphalangeal joints, which improved to full range of motion in the long term. Sensory recovery was excellent, with an average 2-point discrimination of 5 mm initially, improving to 4 mm in the long term. Nail beaking was minimal initially but increased significantly in the long term. These results may be explained by soft tissue remodeling. All patients on long-term follow-up were highly satisfied with both aesthetic and functional outcome. There was no hypersensitivity or cold intolerance at either the short-term or long-term follow-up assessments. CONCLUSIONS: The spiral advancement-transposition flap is suitable for resurfacing large pulp defects with excellent short-term and long-term functional and aesthetic results and high patient satisfaction. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Extending the reach of the heterodigital arterialized flap by cross-finger transfer.

BACKGROUND: The heterodigital arterialized island flap is a versatile flap providing robust, vascularized, nonsensate soft-tissue cover for the reconstruction of sizable digital defects. Routine inclusion of a dorsal vein augments venous drainage and minimizes postoperative congestion. To extend the reach and versatility of the flap in resurfacing larger digital defects and defects in awkward areas such as the dorsal surface, distal fingertip, and far sides of border digits or thumb, a modification is proposed. METHODS: The authors' experience with this technique in 12 patients with digital soft-tissue defects is reviewed. Defect sizes ranged from 2.0 to 4.5 cm in length and from 1.0 to 2.5 cm in width. By positioning the finger defect to the flap and creating a temporary bridging tissue pocket at the base of the fingers to site the flap pedicle, the flap is applied to defects of adjacent digits in a cross-finger fashion. Division and inset of the flap are performed 3 weeks later. RESULTS: Complete survival and primary healing was achieved in all the flaps, without evidence of venous congestion. Donor morbidity was acceptable. All donor fingers retained normal fingertip sensation and had minimal stiffness, with return of excellent to good total active interphalangeal joint motion. CONCLUSIONS: The cross-finger modification of the heterodigital arterialized flap extends the reach of the flap and versatility of application, delivering a good cosmetic result while minimizing the amount of proximal dissection required, and has minimal donor morbidity.