Grabb’s Encyclopedia of Flaps Upper Extremities, Torso, Pelvis, and Lower Extremities

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FIGURE 230.4 A-C: Amputation of the dorsal oblique left long fingertip, reconstructed with a triangular volar
skin flap. D-F: Appearance 4 months postoperatively. (From Atasoy et al., ref. 2, with permission.)
One functionally and aesthetically disturbing late complication is the hook-nail deformity, seen several
weeks after the procedure. This deformity results from excessive tension on the flap, which causes the
nailbed to curve volarly. The deformity can be corrected by the “antenna” procedure (4).
SUMMARY
A triangular volar skin flap can be used to reconstruct transverse or dorsal oblique fingertip amputations.
References
1. Kleinert HE. Fingertip injuries and their management. Am Surg 1959;25:41.

2. Atasoy E, Ioakimidis E, Kasdan M, et al. Reconstruction of the amputated finger tip with triangular volar
flap. J Bone Joint Surg [Am] 1970;52:921.
3. Frandsen PA. V-Y plasty as treatment of finger tip amputations. Acta Orthop Scand 1978;49:255.
4. Atasoy E, Godfrey A, Kalisman M. The “antenna” procedure for the “hook nail” deformity. J Hand Surg
1983;8:55.

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Chapter 231
Triangular Lateral (Kutler) Skin Flaps to The Fingertip
A. Freiberg
EDITORIAL COMMENT
Both this and the previous chapter on the volar sliding skin flap demonstrate excellent methods for covering
an amputated fingertip where bone is in excess of soft tissue. These procedures have received bad
publicity, primarily because the wounds, incorrectly, are completely closed under tension. The diagrams
both in this chapter and in the previous one show all the wounds closed completely. This can be a
fundamental error. The two flaps should be readjusted over the distal end and closed loosely, unless they
fall together. Secondary contraction will slowly draw the wounds together and provide full-thickness
sensible coverage for the tip of the finger.
Partial amputation of the fingertip is one of the most common conditions seen in hand trauma. A paradox of this
injury is the magnitude of the potential disability in the context of a relatively small area of the body.
INDICATIONS
Although many methods of repair have been advocated, most fingertip amputations can be treated
successfully by allowing the area to heal by secondary intention, or by applying a thin split-thickness skin
graft. These are simple methods that allow the surrounding normal fingertip skin to be drawn toward the
center of the defect. If a secondary procedure is necessary, the resulting defect may be up to 50% of the
original size.
The bilateral V-Y advancement flap method, as originally described by Kutler in 1947 (1), is at present
rarely indicated for primary repair of the amputated tip. It is, however, a useful method in highly selected
situations and a valuable procedure in secondary tip revisions (2, 3, 4, 5, 6).
Because of the generally excellent aesthetic appearance (Fig. 231.2) and relatively good sensation, the
procedure should be considered for the patient with a true transverse guillotine amputation. Dorsal oblique
amputations are, however, better managed by bone shortening and closure, skin grafting, or the triangular
volar skin flap. Volar oblique amputations without exposure of bone are best treated by dressings or by thin
split-thickness skin grafts.
Bilateral Kutler-type flaps can also be used for more proximal transverse amputations, where further
shortening of the digit is not indicated.
Because this procedure uses bilateral, midlateral fingertip tissue, it is ideal for secondary stump revisions
with a broad, unsightly tip. The level of revision can be either at the level of the distal phalanx, with or
without a nail remnant, or through the distal interphalangeal (DIP) or proximal interphalangeal (PIP) joints,
with protruding tissues covering the condyles of the respective phalanges.

FIGURE 231.1 Typical transverse amputation with exposed bone. A: The defect. B: The fibrous bands
between skin and bone are transected. One must make sure that the neurovascular structures are left
intact. C: The flaps are advanced over the defect. D: The flaps are sutured in the midline and to the nail
matrix. E: The donor site is closed in a V-Y fashion. (From Freiberg and Manktelow, ref. 3, with permission.)
ANATOMY
The neurovascular supply courses through the subcutaneous tissue and must be protected during dissection
and advancement of the flap. The fibrous septa that connect the skin with the periosteum must be carefully
divided. Shepard (7) has pointed out that most of the neurovascular structures are volar, thus allowing the dorsal
side to be completely transected.
FLAP DESIGN AND DIMENSIONS
The triangle is based laterally along the edge of the wound. The width of the base will depend on the size of the
defect to be covered. The triangle should be about one-half inch long, from the base to the apex.
FIGURE 231.2 Postoperative appearance after Kutler repair of a transverse amputation through the level of the
middle third of the nailbed. (From Freiberg and Manktelow, ref. 3, with permission.)

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OPERATIVE TECHNIQUE
After appropriate trimming and debridement, two identical triangular flaps are outlined, and only the skin is
incised. By means of a skin hook and gentle distal traction, the fibrous bands between skin and bone are
transected. One must make sure that the neurovascular structures are left intact (magnification at this point is
often helpful) (Fig. 231.1B).
As the fibrous bands are severed, the triangles are gradually advanced over the tip of the finger (Fig. 231.1C).
Further
debridement of bone might be required at this stage, to allow for a comfortable tension-free closure. The flaps
are sutured in the midline and to the nailbed.
The donor site is closed in a V-Y fashion (Fig. 231.1E).
Modifications
Occasionally, and especially in the more proximal amputations, the digital neurovascular bundles may be clearly
identified at the apex of the triangular flaps. In these cases, the small segmental blood vessels and nerves can
be divided completely, and the flaps transferred as true neurovascular islands (see Chapter 235).
Another modification has recently been described that provides greater mobility of the flaps. Shepard (7), using
anatomical dissections, has shown that the major nerve and blood supply to these flaps comes from the volar
side, therefore rendering the dorsal pedicle redundant. By preserving the pedicle on the volar side only, greater
mobility can be achieved (up to 10 mm). Closure is therefore easier, and the need for two flaps can sometimes
be eliminated.
CLINICAL RESULTS
These flaps are technically difficult to perform. If the surgeon does not have sufficient expertise, fine
instruments, and a good light source, he or she may run the risk of developing flap necrosis.
Occasionally the parrot-beak nail deformity can occur. This is due to suture of the flaps to the sterile matrix
and is common to other methods as well.
SUMMARY
Triangular lateral (Kutler) skin flaps are useful mainly for secondary revisions of fingertip amputations. They
are indicated only in selected cases for primary repair. A major contribution to this procedure has been the
modification proposed by Shepard (see Chapter 232).
References
1. Kutler W. New method for fingertip amputation. JAMA 1947;133:29.
2. Fisher RH. The Kutler method of repair of finger tip amputations. J Bone Joint Surg [Am] 1967;49(A):317.
3. Freiberg A, Manktelow R. The Kutler repair for fingertip amputations. Blast Reconstr Surg 1972;50:371.

4. Weston PAM, Wallace WA. The use of locally based triangular skin flaps for the repair of finger tip injuries.
Hand 1976;8:54.
5. Gaber M. Kutler repair for the amputated finger tip. Am Coll Surg Engl 1979;61:298.
6. Roberts AHM. Kutler repairs for amputated finger tips. Ann Coll Surg Engl 1980;62:75.
7. Shepard GH. The use of lateral V-Y advancement flaps for fingertip reconstruction. J Hand Surg
1983;8:254.

Chapter 232
Modified Triangular Lateral Skin Flaps to The Fingertip
G. H. Shepard
The Kutler method of lateral V-Y advancement skin flaps to repair fingertip amputations is well known (1). The
procedure has not been widely used because of limitations in the distance that the flaps could be advanced. An
analysis of the blood supply to this flap has shown that the dorsal pedicle can be incised completely, thus
providing much greater mobility to the flap (2, 3, 4).
INDICATIONS
This flap is not used as a primary procedure to replace the triangular volar skin flap when the latter is
indicated (see Chapter 230). Triangular lateral skin flaps are best used for volar oblique amputations or
transverse oblique amputations (5). In the former situation there is not enough skin for a volar advancement
flap, and in the latter the volar flap creates an asymmetric finger.
As a secondary procedure, this flap is excellent for remodeling a fingertip that is too broad or that has
developed a spoon shape with curvature of the nail.
ANATOMY
Fibrous bands connect the dermis of the distal phalanx to the periosteum. These bands extend outward from the
periosteum, separating the pulp into lobules of adipose cells. The fibrous septa function to prevent gliding of the
skin. Cross sections of both monkey and human fingertips show that these bands are considerably thicker
laterally and dorsally than the relatively thin bands on the volar pad.
FIGURE 232.1 Cross section of a human finger at the level of the midproximal nail fold. Dense fibrous connective
bands are present dorsally and laterally. The neurovascular bundles are abundant in the palmar pulp space.
(From Shepard, ref. 4, with permission.)
An important observation (Fig. 232.1) is that the neurovascular bundles are abundant on the volar aspect of the
finger and are sparse on the lateral and dorsal areas.
The standard Kutler flaps are greatly restricted dorsally, but the volar side of the flap can be readily elongated.
Since the blood supply and cutaneous innervation to the flap are volar structures, preservation of the dorsal

pedicle is not only redundant but unnecessarily restricting.
FLAP DESIGN AND DIMENSIONS
The dorsal limb of the flap extends parallel to the bone, from the distal interphalangeal crease to the point at
which the lateral margin of the nail emerges from the cover of the lateral nail fold (Fig. 232.2). The distal width of
the flap varies with the level of the amputation, but at the level of the lateral nail fold the flap would be ideally
about 7 mm. The length of the dorsal incision should be 2 to 2.5 cm. Therefore in more proximal amputations the
apex of the flap may extend into the middle phalanx.
FIGURE 232.2 Cross-sectional diagram. The dotted lines indicate depth of incisions for the bilateral flap. (From
Shepard, ref. 4, with permission.)
Kutler originally designed a much smaller flap, with the dorsal limb angulated volarly instead of extending parallel
to the bone. This modified flap is larger and a great deal more versatile in reconstruction.
OPERATIVE TECHNIQUE
The dorsal incision is made to the depth of the collateral ligament proximally and to the periosteum distally (Fig.
232.3). The volar incision is made through skin only. The entire underside of the flap is mobilized from the dorsal
incision at the periosteal level. From the underside of the flap, the thickened lateral bands are cut deep to the
palmar skin incision. The subcutaneous tissue with its nerves and blood vessels is left intact.
Next the volar aspect of the incision is dissected carefully, by gently cutting the radial bands with the very tips of
the scissors. Distal retraction of the flap with a skin hook helps to identify those bands restricting advancement.
This dissection is best done with the aid of magnification, in order to preserve the neurovascular structures.
Each flap can easily be mobilized up to 10 mm. When the situation demands, the flap can be elongated to 14 mm
by meticulous dissection of the fibrous bands, while preserving the remainder of the pulp. The flaps are
advanced to fit the defect. With transverse oblique flaps, the flap on the long side may be advanced a greater
distance than the opposite flap, to contour the fingertip into a natural configuration.
The flaps are sutured to each other and the nailbed. The donor site is closed in a V-Y fashion.
FIGURE 232.3 The dorsal incision mobilizes the flap at the periosteal level. (From Shepard, ref. 4, with
permission.)

CLINICAL RESULTS
Since 1975, 68 of these procedures have been performed. Fifty-two were for traumatic indications and 18
were for elective remodeling of the fingertip. The shaping of the fingertip has been excellent. None of the
fingertips has developed the spooning deformity that is occasionally seen with volar V-Y advancement flaps.
Irregular pointing with oblique amputations has been eliminated. Sensation has been good in all flaps, and
there have been no reoperations for neuroma formation.
There has been one loss of a solitary flap, a unilateral-lateral V-Y advancement flap for an irregular fingertip
injury, in which an attempt was made to advance it too far. There have been no other flap losses. In 68
cases, most of them involving bilateral flaps, this represents only one complication in 116 flaps.
SUMMARY
A modification has been made in the triangular lateral skin flap, which allows more flap mobility than the
standard Kutler flap. The dorsal pedicle is completely incised, since there is little neurovascular supply
dorsally and numerous thick fibrous bands that restrict advancement. This flap is superior to the volar
triangular skin flap for volar oblique amputations and for asymmetric transverse oblique amputations.
References
1. Kutler W. A new method for fingertip amputation. JAMA 1947;133:29.
2. Wilkerson JL. The anatomy of an oblique proximal septum of the pulp space. Br J Surg 1950-1951;38:454.
3. Riordan DC. Functional anatomy of the hand and forearm. Orthop Clin North Am 1974;5:199.
4. Shepard GH. The use of lateral V-Y advancement flaps for fingertip reconstruction. J Hand Surg
1983;8:254.
5. Atasoy E, Ioakinidis E, Kasdau M, et al. Reconstruction of the amputated fingertip with a triangular volar
flap. J Bone Joint Surg [Am] 1970; 52(A):921.

Chapter 233
Triangular Lateral Neurovascular Island Skin Flap to The Fingertip
S. L. Biddulph
Of the industrial accidents reported annually in developed countries, about a third affect the hand, and in the
majority of cases only the fingertips are involved. Terminal amputation can leave the digit with a major skin
defect and exposed bone (Fig. 233.1). The triangular lateral neurovascular island flap is a procedure that
provides durable skin with normal sensibility in a one-stage operation.
INDICATIONS
Although fingertip lesions are sometimes regarded as minor injuries, they often result in disturbed sensibility
and consequent loss of function. For this reason it is justifiable to go to great lengths to preserve as much of
the sensitive pulp area and overlying skin as possible.
With a more proximal amputation, the bone can usually be shortened another 0.5 cm to obtain more skin,
without further sacrificing function of the digital stump. In fact, it can be stated as a general principle that a
shorter stump with good skin cover is preferable to a longer stump with disturbed sensibility.
FIGURE 233.1 A,B: An oblique amputation with bone exposed. (From Biddulph, ref. 5, with permission.)
Various techniques have been devised to provide skin cover for the injured fingertip without shortening the
digit. The simplest of these is the split-thickness skin graft. If, however, the area to be covered is large, this
often results in a hypersensitive and fragile area that is adherent to bone.
Flaps from the palm, neighboring digits, or more distant sites (1, 2, 3) require at least two procedures and
immobilize the digit in a position that may result in a permanent loss of extension. The flaps may regain
some sensation, but this falls well short of what is required in the critical fingertip area (4). The triangular
lateral neurovascular island skin flap provides the fingertip with good cover and good sensation, and can be
performed in a single stage (5).
ANATOMY
This is an island flap based on one of the digital neurovascular bundles.

FIGURE 233.2 A: A triangular area ABC is mapped out on the ulnar side of the digit or on the side with the
longer skin flap. AB corresponds to the width of the defect. C lies on the midlateral line 3 cm proximally. The
neurovascular bundle is identified through an incision CD that is 1.5 cm in length. B: The triangular island of
skin, together with its full complement of subcutaneous tissue and the neurovascular bundle, is completely
mobilized. (From Biddulph, ref. 5, with permission.)
FLAP DESIGN AND DIMENSIONS
A triangular area ABC (Fig. 233.2A) is mapped out on the lateral surface of the finger, just volar to the nail fold,
preferably on the ulnar side of the digit. In oblique amputations, the side with the longer flap is chosen (Fig.
233.2B).
The base of the triangle is along the edge of the wound. Its width is dictated by the size of the defect. The length
of the flap varies, but usually it extends to the midpoint of the middle phalanx.
OPERATIVE TECHNIQUE
To identify the neurovascular bundle, an incision CD (Fig. 233.2A and B) is made from the apex of the triangle in
the midlateral line, extending more proximally for another 1.5 cm. Through this proximal incision the
neurovascular bundle is mobilized distally as far as the apex of the triangular skin flap. Great care is taken to
preserve the venules that are found in the tissues surrounding the neurovascular bundle. They provide the only
means of venous drainage from the flap.
FIGURE 233.3 The flap can be advanced to cover the whole width of the digit. (From Biddulph, ref. 5, with
permission.)
The triangular island is then dissected free down to bone, with its full complement of subcutaneous tissue. The

mobility of this flap is sufficient to allow advancement distally for a distance of about 1.5 cm, which usually
corresponds to the full width of the tip of the digit. The donor site is closed (Fig. 233.3) in V-Y fashion (Fig.
233.4).
Should it still be impossible to achieve full skin cover, the remaining small defect can be covered with a split-
thickness skin graft.
The involved digit alone is immobilized until wound healing is complete (usually in about 10 days). Thereafter,
movement is encouraged to regain full interphalangeal joint function. Normal activities are regained by the third
or fourth postoperative week.
CLINICAL RESULTS
This procedure has been carried out on 60 patients, ranging in age from 2 to 60 years. They have been
followed for periods of 1 to 5 years.
All adult patients returned to their previous occupations and none complained of tenderness in the operated
area. Thirty patients were tested for two-point discrimination. This was found to be normal in every case,
when compared with that of the other fingers. None of the patients complained of altered sensation in the
flap area, and this did not change with time.
FIGURE 233.4 A,B: The donor site is closed in a V-Y fashion, requiring no skin graft. (From Biddulph, ref.
5, with permission.)
FIGURE 233.5 Healing takes about 10 days and usually leaves a linear scar. (From Biddulph, ref. 5, with

permission.)
Parrot-beaking of the nail was seen in a few patients and was usually associated with greater bone loss.
In some cases where the flap technique was performed on both sides, necrosis of the intervening volar
bridge of skin occurred. This procedure is no longer recommended. With a unilateral flap any residual
shortcoming in skin is best treated with a split-thickness skin graft, which is usually so small that healing
occurs by a linear scar (Fig. 233.5).
SUMMARY
Fingertip amputations can be closed in a single stage with the triangular lateral neurovascular island skin
flap. This procedure provides stable cover with normal sensation.
References
1. Flint MH, Harrison SH. A local neurovascular flap to repair loss of the digital pulp. Br J Plast Surg
1965;18:156.
2. Hueston J. The extended neurovascular island flap. Br J Plast Surg 1965;18:304.
3. Moberg E. Aspects of sensation in reconstructive surgery of the upper extremity. J Bone Joint Surg [Am]
1964;46(A):817.
4. Krag C, Rasmussen KB. The neurovascular island flap for defective sensibility of the thumb. J Bone Joint
Surg [Br] 1975;57(B):495.
5. Biddulph SL. The neurovascular flap in fingertip injuries. Hand 1979;11:59.

Chapter 234
Rectangular Lateral Neurovascular Island Skin Flap to The
Fingertip
N. G. Poy
The neurovascular island pedicle flap can be used to restore tactile gnosis and durable cutaneous tip coverage
to the dominant portions of the affected fingertip (1, 2, 3, 4, 5). A neurovascular island flap can be raised from the
affected digit itself, using the nondominant portion of the pulp (6).
INDICATIONS
This is a safe, single-stage procedure, requiring minimal immobilization of the affected finger, and it is
adaptable to most configurations of tip amputation. The composite nature of the flap actually augments the
length of the amputated tip.
The flap can be used for primary coverage of partially amputated digital tips, particularly those involving
dominant fingers. As a secondary procedure, the flap is good for coverage of previously scarred,
anaesthetic, or painful amputation stumps.
This neurovascular island flap should not be used if there has been a crushing injury to contiguous tissue or
a history of previous neurovascular disease or trauma. It is not suitable for use in amputations proximal to
the cuticular border of the terminal phalanx.
ANATOMY
The flap is based on one of the neurovascular bundles of the finger.
FIGURE 234.1 A,B: Diagram showing the rectangular flap based on one hemipulp (usually on the nondominant
side). The proximal edge of the skin flap should be 2 to 3 mm proximal to the DIP joint crease.
FLAP DESIGN AND DIMENSIONS
This rectangular-shaped flap is based on the hemipulp of the nondominant portion of the affected digit. The
proximal edge of the cutaneous flap should be 2 to 3 mm proximal to the DIP crease (Figs. 234.1 and 234.2). A
midlateral extension of the flap incision is made to dissect out the neurovascular bundle.
With appropriate dissection and liberation of the neurovascular bundle, advancement of the hemipulp of up to 1.5
mm or slightly beyond is possible. The donor site is subsequently skin-grafted.

OPERATIVE TECHNIQUE
After the skin incisions are made around the flap, an extension is made along the midlateral line of the finger (Fig.
234.3). Subcutaneous soft-tissue dissection is initially carried out deep to the neurovascular bundle. The
hemipulp is then elevated off the periosteum of the terminal phalanx.
Next the subcutaneous dissection along the midlateral line is carried out superficial to the neurovascular bundle.
To protect the pedicle, the flap is released while retaining some soft-tissue elements (Fig. 234.4). Further
dissection proximally can be done to advance the flap as necessary (Fig. 234.5).
FIGURE 234.2 The flap outlined on the ulnar side of the long finger.
The defect is covered with a split-thickness skin graft. Any soft-tissue or skin revisions to round out the contour
are carried out on the flap.
CLINICAL RESULTS
The flap retains good two-point discrimination and actually adds length to the amputated fingertip (Fig.
234.6). Nailbed support is good, without the tendency toward soft-tissue contracture that can lead to parrot
beak nail deformities. Posttraumatic hyperesthesia and stiffness are minimal. The average time away from
work is approximately 1 month from the date of surgery.
FIGURE 234.3 The incision is extended along the midlateral line, in order to identify and dissect the
neurovascular bundle. The hemipulp is elevated off the periosteum of the terminal phalanx.

FIGURE 234.4 The flap is totally detached and reflected, showing the abundant retained soft tissue that
protects the neurovascular pedicle.
SUMMARY
The attributes of the neurovascular island, including its ability to retain good sensation and to provide well-
padded, robust cutaneous cover, make it a good flap to cover partially amputated fingertips. It can be used
as a single-stage procedure for either primary or secondary closure.
FIGURE 234.5 The neurovascular island flap is advanced distally over the revised terminal phalangeal
bone.

FIGURE 234.6 Twelve weeks postoperatively. Well-healed pedicle, with good nail growth and nailbed
support. Note the darker area on the ulnar border of the finger where the donor site was skin-grafted.
References
1. Moberg E. Transfer of sensation. J Bone Joint Surg [Am] 1953;36(A):305.
2. Littler W. Neurovascular skin island transfer in reconstructive hand surgery. In: Wallace AB, ed.,
Transactions of the second congress of the international society of plastic surgeons, London, 1959. London:
E&S Livingstone, 1960;175.
3. Tubiana R, Duparc J. Restoration of sensibility in the hand by neurovascular skin island transfer. J Bone
Joint Surg [Br] 1961;43(B):474.
4. O'Brien BMc. Neurovascular pedicle transfers in the hand. Aust N ZJ Surg 1965;3:1.
5. Bunnell S. Reconstructive surgery of the hand. Surg Gynecol Obstet 1924;39:259.
6. Poy NG. In: Transactions of the fifth international congress of plastic and reconstructive surgery.
Melbourne: Butterworths, 1971;542.

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Chapter 235
Oblique Triangular Skin Flap to The Fingertip
R. Venkataswami
It is well known that adjacent skin can be the best cover for fingertip amputations. In the method described here,
an obliquely placed flap is mobilized on the digital neurovascular pedicle while retaining innervation from both
sides (1).
INDICATIONS
This flap is suitable only for oblique amputations of fingertips and thumb tips and for proximal areas in the
fingers where further shortening is not advisable.
ANATOMY
The flap consists of the palmar skin and the subcutaneous tissues superficial to the fibrous flexor sheath. The
main blood supply to the flap is the neurovascular bundle on the side of the finger, opposite the site of the major
portion of the amputation. The flap also receives blood from some branches of the digital vessel on the oblique
side. The nerve supply is from both digital nerves.
In some cases one may have to divide the fine branches of the blood vessels from the nerve twigs on the oblique
side, thereby converting this flap into a true island flap based on one neurovascular bundle.
FLAP DESIGN AND DIMENSIONS
An oblique triangle is marked, with the base equal to the width of the amputated tip and with one side longer than
the other (Fig. 235.1A). The “vertical” side of the triangle is along the midlateral line of the finger. In most cases
the flap length, which depends on the amount of advancement necessary, is 1½ to 2 times the base of the
triangle. Where the amputation is sloped toward the dorsum, the flap will need to be advanced more than if it is
sloped toward the volar surface.
This triangular flap does not move in a V-Y fashion, although its appearance may give that impression. The main
advancement occurs because the flap is freed completely from the fibrous flexor sheath and the restricting
fibrous bands in the subcutaneous tissue.
OPERATIVE TECHNIQUE
The skin should be incised just enough to expose the globules of subcutaneous fat. With two hooks applied to
the base, blunt-pointed straight scissors are used to separate the flap from the fibrous flexor sheath for the whole
length of the flap.

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FIGURE 235.1 A,B: An oblique amputation of the radial side of the index finger. The oblique triangular flap is
marked out over the ulnar side of the finger. Both digital nerves are included in the flap. C: The “vertical” side of
the triangle extends along the midlateral line of the finger. D: The neurovascular bundle on the ulnar side of the
finger is included with the flap. As much as possible of the radial neurovascular bundle is also preserved. E-G.
The flap is advanced and sutured to the nailbed. (From Venkataswami and Subramanian, ref. 1, with
permission.)
On the “vertical” side of the triangle, the incision is deepened just dorsal to the neurovascular bundle, which is
then included in the flap. When one reaches the apex, the neurovascular bundle is freed by gentle dissection to
permit adequate flap mobility.
The minute branches of the neurovascular bundle that enter the flap on the oblique side are carefully dissected,
and the fibrous strands are divided. Finally the apex of the flap is lifted, and the fibrous strands holding it are
divided. Immediately one can appreciate the free mobility of the flap.
The flap is then advanced and sutured to the nail or the nailbed (Fig. 235.2).
CLINICAL RESULTS
This procedure has been performed on 78 patients over a 4-year period. The wounds heal in about 10
days, and the majority of patients return to their normal work in approximately 3 weeks. The contour of the
fingertip is full and improves with
time. There may be some shortening, depending on the extent of the amputation.

FIGURE 235.2 A: An oblique amputation of the tip of the right index finger. B: The oblique triangular flap
elevated. The flap is advanced and sutured over the defect. C: Postoperative appearance after 1 year.
(From Venkataswami and Subramanian, ref. 1, with permission.)
Sensation becomes normal within a few weeks, and the initial hyperesthesia that is seen in some instances
passes. Marginal flap necrosis occurred in four patients, and some dehiscence at the suture line was seen
in three patients. These minor complications were therefore present in 11% to 12% of cases.
SUMMARY
The oblique triangular skin flap is a good method of closing oblique fingertip amputations.
Reference
1. Venkataswami R, Subramanian N. Oblique triangular flap: a new method of repair for oblique amputations
of the finger tip and thumb. Plast Reconstr Surg 1980;66:296.

Chapter 236
Volar Advancement Skin Flap to The Fingertip
J. W. Snow
EDITORIAL COMMENT
The color advancement flap was originally described for resurfacing the end of the thumb. The thumb,
however, has an independent circulation to the dorsum when the entire volar flap is divided. In trying to use
this procedure for the finger, the surgeon should be extremely careful to retain the circulation coming from
the molar surface to the dorsal surface, so that the dorsal surface is not devascularized, especially over the
distal portion of the finger. In addition, prolonged flexion of the interphalangeal (IP) joints may cause
permanent contractures.
Amputation of the fingertips through a portion of the distal phalanx can be repaired by elevation and
advancement of a volar flap.
INDICATIONS
This is a good way to resurface a volar oblique amputation of the fingers, particularly of the index and
thumb in adults and of all digits in children (1, 2, 3, 4, 5, 6). It also affords a good method for repair of a
guillotine amputation.
ANATOMY
Some authors have felt that dorsal necrosis would occur over the middle phalanx, since both neurovascular
bundles are carried with the flap. This does not occur, however, if the dorsal branch of the neurovascular bundle
is preserved at the proximal interphalangeal joint level. This vessel crosses obliquely to supply the skin over the
dorsum of the middle phalanx. It is imperative to preserve this vessel, which is less than 1 mm in diameter, on at
least one side of the proximal interphalangeal (PIP) joint.
FLAP DESIGN AND DIMENSIONS
The incision is outlined in the neutral, or midaxial, zone on the radial and ulnar sides of the involved digit. The
incision is carried no further than 1 cm proximal to the proximal interphalangeal joint.
OPERATIVE TECHNIQUE
The flap is elevated off the finger, just volar to the flexor tendon sheath. The neurovascular bundles are
contained in the flap, and care is taken to preserve intact at least one of the branches at the PIP joint that supply
the dorsum of the finger (Figs. 236.1 and 236.3).
Oblique Amputations
When one is using the volar advancement flap to reconstruct the volar oblique amputation of a finger, the
triangles of tissue forming the margins of the avulsion must be preserved for purposes of flap length (Figs. 236.1
and 236.2). One cannot advance the most proximal level of a volar oblique amputation all the way to the tip of
the finger.

If the lateral triangles of tissue are maintained when the flap is elevated, a V-shaped defect will be created. (I do
not make this V-shaped defect, as some have incorrectly stated. It is secondary to the injury.) The V is sutured
together in the midline, forming a cup that preserves the length of the flap (Fig. 236.1) and that creates a suitable
contour around the terminal portion of the finger.
Guillotine Amputations
In the case of a guillotine amputation the incision need only go to the proximal interphalangeal joint axis, and it
can easily be advanced to resurface the tip. The initial suture is usually placed through the central portion of the
distal aspect of the flap and the midsagittal line of the nail, allowing the interphalangeal joint to flex as the suture
is tied down (Fig. 236.4).
FIGURE 236.1 A volar oblique amputation of an index finger, showing the midaxial incision to 1 cm proximal to
the PIP joint. The injury leaves a V-shaped defect with two triangular areas (shaded) that are retained and
sutured together as shown. Note the dorsal branch of the neurovascular bundle at the level of the PIP joint. This
must be preserved on one side at least, in order to avoid dorsal skin necrosis.
The excess skin and subcutaneous tissue are trimmed while one approaches the sides, so that they fit well into
the recipient site. This gives a smooth, well-contoured fingertip without volar scarring. The less lengthy biaxial
incisions give better assurance of preserving the dorsal branch of the neurovascular bundle at the proximal
interphalangeal joint level.
FIGURE 236.2 Slightly angulated volar oblique amputations of the tips of the index and long fingers.

FIGURE 236.3 A: Volar flaps elevated and the dorsal branch of the neurovascular bundle demonstrated. Note
the V-shaped defect of the index finger. B: Note that the dorsal branch has been dissected and preserved to
retain the blood supply to the dorsal skin.
Modification
A technique has been described that may make it easier for some surgeons to dissect out the flap without
damaging the neurovascular bundle and the important dorsal branches. The midaxial incisions are made through
the skin alone. The subcutaneous tissue is not incised, but it is carefully dissected up, so that the flap can be
advanced and the dorsal branch of the neurovascular bundle at the interphalangeal level can be preserved.
CLINICAL RESULTS
There has not been a single instance of dorsal necrosis in my personal series of 55 cases, because at least
one of the branches of the neurovascular bundle that pass dorsally at the level of the PIP joint has been
preserved.
FIGURE 236.4 The flap is advanced, after suturing the V-shaped defect together and allowing the
interphalangeal joints to flex. Sutures are inserted in the midaxial incision, so that the flap is advanced from
its base.

FIGURE 236.5 A: Postoperative result. B: Note the lack of complete extension of the PIP joint. C: Full
flexion of the fingers.
In an oblique amputation the two lateral “triangles” created by the injury are sutured together. This creates
a midline scar that fortunately has not been particularly troublesome to patients. This repair has been used
to resurface a previously grafted fingertip in a blind patient who needed 2- to 3-mm two-point discrimination
in order to read Braille (7). After the grafting procedure the patient's ability to read Braille was lost, but it was
regained when a volar advancement flap on the index and long fingers was performed.
Physiotherapy is an essential part of this procedure, to avoid flexion contractures at the PIP joint (Fig.
236.5B).
I do not think it is necessary in most cases to graft the defect and then to do the operation on a healed
wound, since infection has not occurred in this series of 55 fingers. It has been my experience that delayed
primary repair seems to work best.
SUMMARY
A volar advancement flap can be used to cover thumb tip and other fingertip amputations.
References
1. Moberg E. Aspects of sensation in reconstructive surgery of the upper extremity. J Bone Joint Surg [Am]
1964;46(A):817.
2. Snow JW. The use of a volar flap for repair of fingertip amputations: a preliminary report. Plast Reconstr
Surg 1967;40:163.
3. Posner MA, Smith RJ. The advancement pedicle flap for thumb injuries. J Bone Joint Surg [Am]
1971;53(A):1615.
4. Snow JW. Follow-up clinic: the use of a volar flap for repair of fingertip amputations—preliminary report.
Plast Reconstr Surg 1973;52:299.
5. Kamal MS, et al. Volar advancement flap in fingertip repair. Egypt J Plast Reconstr Surg 1979;3:41.

6. Macht SD, Watson HK. The Moberg volar advancement flap for digital reconstruction. J Hand Surg
1980;5:372.
7. Joshi BB, Orth MS. Problem of sensory loss in fingertip injuries in the blind. Br J Plast Surg 1970;23:283.

Chapter 237
Volar V-Y “Cup” Flap
L. T. Furlow JR.
The V-Y “cup” flap (1) is a volar V-Y neurovascular flap that provides coverage of fingertip amputations by
advancing skin from the volar surface of the distal and middle segments of the digit. The V-Y advancement is
done between the distal interphalangeal and proximal interphalangeal flexion creases. The distal end of the flap
is cupped to reproduce the contour of the amputated fingertip, a technique first illustrated by Snow (2) (see
Chapter 236). The fingertip is reconstructed from volar finger skin that retains its sensation.
INDICATIONS
The volar V-Y “cup” flap is especially useful in cases where the amputation has left the digit shorter volarly
than dorsally and the tissue for an Atasoy triangular volar fingertip flap (3) has been amputated. It can also
be used for reconstructing the fingertip with insufficient padding, or with beaking of the fingernail.
ANATOMY
The flap is elevated as an island on both digital neurovascular bundles from the underlying distal phalanx and
the flexor tendon sheath. The dorsal branches of the digital arteries that arise at the middle phalanx level should
be protected, because the distal phalanx and dorsal soft tissues depend on them and may not survive if they are
divided.
FLAP DESIGN AND DIMENSIONS
The flap incisions begin distally at the amputation a millimeter or so volar to the lateral nailbed margin, run to the
distal interphalangeal (DIP) joint level at or a millimeter volar to the midlateral line, then head directly for the
midline of the finger to meet at the PIP flexion crease (Fig. 237.1A and B; see also Fig. 237.3A and B).
After elevation on its two neurovascular bundles, the distal end of the flap is cupped by bringing the two distal
points of the flap together to form the distal end of the flap into a fingertip shape (Fig. 237.1C; see also Fig.
237.3C and D).
OPERATIVE TECHNIQUE
The incisions distal to the DIP joint are made completely through subcutaneous tissue (Figs. 237.2A and 237.3A
and B). Over the middle phalanx the incisions are initially made just through dermis to protect the neurovascular
bundles. Beginning distally the flap is elevated from the distal phalanx and the flexor tendon sheath (Fig.
237.3C). The middle phalanx “V” portion of the incisions crosses the neurovascular bundles, which are identified
through these incisions and from beneath. Cleland's and Grayson's ligaments, just above and below the
neurovascular bundles, are divided at that level, and the attachments of the flap medial and proximal to the
neurovascular bundles, in the apex of the “V,” are divided to leave the flap attached by only the neurovascular
bundles. The flap will now move distally a centimeter or more (Fig. 237.2B).
The two distal lateral points of the flap are brought together to cup the end of the flap (Figs. 237.2C and 237.3C
and D). If the amputation removed more skin volarly, suturing the end of the “cup” will produce a fingertip
contour. If the amputation was more transverse, a portion of the volar dog-ear that results from forming the cup
may have to be trimmed.

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With only slight or no flexion of the PIP and DIP joints the flap is pulled distally and its cupped end brought up
and over the transected end of the phalanx and nail. The flap is then sutured in its advanced V-Y position. This
part of the closure is nearly always loose, with considerable “gaposis,” and the closure of the cup may also be
loose
(Figs. 237.2D and 237.3E). The gaps close very well as the wound heals (Fig. 237.3F and G).
FIGURE 237.1 A,B: Skin incisions. C: Cupping the distal end of the flap makes it unnecessary for the volar skin
edge to advance to the nail margin. (From Furlow, Jr., ref. 1, with permission.)
FIGURE 237.2 A,B: Flap elevated from the flexor tendon sheath. C: The end of the flap is cupped. D: V-Y
advancement. E,F: It is important that the flap project above the nail edge. Wound contraction will pull the skin to
the nailbed margin, contouring the tip. Adequate skin and soft tissue prevent beaking. (From Furlow, Jr., ref. 1,
with permission.)
It is very important that the cup edge of the flap be held dorsal to the nail edge, with the soft tissue of the cup
covering bone and nail to prevent beaking of the nail. One or several nylon sutures are passed through the
dorsal surface of the nail, then through the distal end of the flap and back to hold the flap up (Fig. 237.2E and F).
As healing progresses the skin margin of the cup of the flap is pulled under the nail end to complete the
contouring of the fingertip (Fig. 237.3F and G).

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CLINICAL RESULTS
Since little or no joint flexion is necessary to position the flap, flexion contractures have not been a problem.
The cupping method of closure requires the flap to advance no more than 1.0 to 1.5 cm, regardless of the
volar skin deficit. The vertical scar from the cupping closure has healed extremely well and has not been
sensitive. The dorsal branches of the digital vessels are preserved, maintaining blood supply to the distal
phalanx, nailbed, and dorsal tissues.
SUMMARY
The volar V-Y “cup” flap is especially useful for closure of fingertip amputations in cases where the tissue
used in the standard Atasoy volar V-Y flap has been amputated. It uses volar skin and preserves sensation
—distinct advantages over a cross-finger flap or thenar flap. The donor defect is closed simply, by V-Y
advancement.

FIGURE 237.3 A,B: Amputation and flap incisions. C: Flap elevated. Hooks in corners are to be apposed to
cup the end of the flap. D: Flap cupped. E: Flap advanced; V-Y closure. F,G: Fingertip 11 months later: full
range of motion, normal two-point discrimination, nontender. Note old and new distal interphalangeal flexion
creases; less than 1 cm of advancement was necessary. (From Furlow, Jr., with permission.)
References
1. Furlow LT, Jr. V-Y “cup” flap for volar oblique amputations of fingers. J Hand Surg 1984;9(B):253.
2. Snow JW. The use of a volar flap for repair of fingertip amputations—a preliminary report. Plast Reconstr
Surg 1967;40:163.
3. Atasoy E, Ioakimidis E, Kasdan M, et al. Reconstruction of the amputated finger tip with a triangular volar
flap. J Bone Joint Surg 1970;52(A):921.

Chapter 238
Flag Skin Flap to The Finger
F. Iselin
G. PRADET
EDITORIAL COMMENT
The narrowness of the pedicle of the flag flap makes the circulation to the flap a variable one.
A flag flap is a square or rectangular flap that originates from the dorsal aspect of a finger. It has a long narrow
pedicle that can be twisted, thus proving uniquely versatile for coverage of many nearby defects. It has the
appearance of a flag at the top of a flagpole (1, 2, 3, 4) (Fig. 238.1).
INDICATIONS
The length of the pedicle allows the flap to be transferred either to the donor or to an adjacent finger.
Because the pedicle can be twisted, the flag flap can be used to cover both dorsal and volar defects.
There are three main indications for this flap (Fig. 238.2). First, the flap can be used to cover volar defects
on the same finger (5, 6, 7). Other flaps, such as cross-finger flaps, may be contraindicated, or one may not
wish to damage an adjacent digit, especially if ultimate salvage of the injured finger is questionable.
Second, the flap can be used to cover distal digital amputations (5, 8, 9). It is especially useful, however, for
coverage either of thumb amputations (proximal to the nailbed) or of osteoplastic reconstructions. Nerve
branches that provide some sensation can be carried with the flap. Since the sensation is less sophisticated
than that of volar skin, it can more easily be retrained to be interpreted as coming from the thumb.
FIGURE 238.1 The flag flap can be designed either distally or more proximally over the dorsum of the donor
finger.
Third, this flap is very useful for dorsal defects, especially over the PIP and metaphalangeal (MP) joints.
This is probably its best indication, since both local and volar flaps are inadequate. Whenever the skin
quality is not ideal, we routinely use the flap to cover tendon reconstructions in zone 3 (boutonnieres) and
resection implant arthroplasties. We have noted that most failures can be attributed to inadequate skin
conditions.
The flag flap should not be used unless both volar digital arteries are intact. Otherwise there is some risk of

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necrosis of the more distal dorsal skin.
ANATOMY
The blood supply of the dorsal aspect of the hand and fingers has been studied (10) by angiography and
selective dissection. It has been observed that the dorsal skin of the hand is vascularized by vertical perforating
branches originating from the dorsal interosseous arteries. Each vertical ray splits into diverging horizontal
branches that have the appearance of vascular stars. The horizontal branches are interconnected through three
to four layers of a dermal capillary network.
There are four patterns of blood supply to the fingers. At the level of the web space, some of the horizontal
branches from the dorsum of the hand reach the proximal portion of the finger. The area over the rest of the
proximal phalanx is vascularized by two commissural arteries originating from the volar digital artery. The middle
phalanx is vascularized only by a few small metameric branches originating from the volar digital artery. The
distal phalanx is vascularized through the subungual network, which originates from the volar vessels.
There are at least two longitudinal veins with transverse anastomoses that are most prominent over the joints.
It can therefore be seen that any flaps raised from the dorsal aspect of the fingers have a random-pattern blood
supply. In standard cross-finger flaps, the longitudinal venous drainage is transected, thus making a wide pedicle
necessary. In the flag flap, however, the longitudinal veins are preserved. It is well accepted that good venous
drainage is essential to flap survival. Therefore a flap with a long narrow pedicle, even if it is twisted, can survive
without ischemia.
FIGURE 238.2 The flag flap can be used to cover: A: The dorsal surface of an adjacent digit. B: The volar
surface of an adjacent digit. C: The volar surface of the donor finger. D: The tip of the donor finger. E: The tip of
an adjacent digit.
A sensory nerve branch can be found beside the longitudinal vein. This should always be preserved with the flap
to retain sensation.

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FLAP DESIGN AND DIMENSIONS
The dimensions of the flap are more or less determined by the size of the defect to be covered. To place suture
lines in neutral areas, the flap width will almost always be that of the finger. The length of the flap will vary with
the defect (4, 6).
A template should always be made first, in order to establish the best position of the flap and of the pedicle. The
flap should reach the defect easily, with no more than a 90° twist to the pedicle. The “pole” or pedicle width is
half the width of the finger and is located on either side, according to the site the flap must reach.
When both the donor site and the defect are on the same finger (Fig. 238.2C and D), the flap should be
designed with a long enough pedicle to avoid excessive flexion and consequent joint stiffness (7).
If the flap is to be used to cover an amputation tip directly (Fig. 238.2D and E), care must be taken to avoid
including any nail matrix with the flap. If this is not possible, some other form of flap cover should be used. When
used for an amputation at the tip of the same finger, this flap does have the advantage of preserving intact the
volar skin with its special sensitivity (Fig. 238.2D). This procedure is used more often in the thumb than in the
long fingers.
When the flap is used for dorsal defects, it is outlined on the skin of the adjacent finger, just distal to the joint to
be covered. In other words, the flap is taken from the middle phalanx to cover the PIP joint, and from the proximal
phalanx to cover the MP joint. The pedicle is situated on the side of the finger next to the recipient digit (Fig.
238.2A).
OPERATIVE TECHNIQUE
Both the flap and the pedicle are elevated at the level of the extensor tendons, and one must be very careful to
leave the paratenon intact, so that it can accept a skin graft. The length of the pole is limited proximally by the
longitudinal veins when they merge with the vascular “stars” over the web space. Care is taken to include both
the longitudinal vein and the sensory nerve branch in the pedicle (Fig. 238.3).
When the flag flap is to be transferred to the thumb to cover an amputation, to cover an osteoplastic
reconstruction, or to restore sensation after pulp avulsion, both the flag and the pole are shifted radially. A
longitudinal incision is made over the dorsum of the thumb, which is widened like a trench to accommodate the
pedicle (Fig. 238.4B). In this case the pedicle is not divided, so that the sensory nerve is retained.
CLINICAL RESULTS
Survival of the transposed flag flap has been achieved in all 50 cases that we have performed. Normal
healing is complete within 20 days. In some cases early blistering and marginal crusting have occurred, but
there have been no instances of ischemic necrosis.
Provided that the recipient site has been properly prepared, so that the scars lie in neutral zones, the
cosmetic result is
good. Functional results are more difficult to evaluate, since they depend on the underlying lesion.

FIGURE 238.3 A,B: The flag flap is transferred to cover a dorsal defect on an adjacent finger. The donor
site is skin-grafted. C,D: Postoperative result.
FIGURE 238.4 A: The flag flap is used to provide both pulp and sensation to the volar aspect of the thumb.
B: Note that the pedicle of the flap, which is taken from the index finger, is incorporated into the dorsum of
the thumb, so that the sensory nerve can be preserved with the flap. (From Iselin, ref. 4, with permission.)
The flag flap has been used in 20 cases of fingertip amputation, in two thumb reconstructions, and in eight
cases where sensation and coverage were required for the distal thumb. It has been used to cover the volar
surface of eight fingers and the dorsal surface of 12 fingers.

SUMMARY
A skin flap that looks like a flag on a flagpole can be taken from the dorsum of a finger to cover fingertips,
thumbs, and defects on both the dorsal and the volar surfaces of fingers. By including a dorsal sensory
nerve in the flap, sensation can be provided to the thumb.
References
1. Vilain R. Technique élémentaire de réparation des pertes de substance cutanées des doigts. Sem Hop
Paris 1952;29:1.
2. Iselin M, Gosse L. Lelambeau en drapeau, son emploi systématique dans le comblement des pertes de
substance limitées des doigts. Ann Chir Plast 1962;8:1.
3. Vilain R, Dupuy JF. Use of the flag flap for coverage of a small area on a finger of the palm. Plast Reconstr
Surg 1973;51:397.
4. Iselin F. The flag flap. Plast Reconstr Surg 1973;52:374.
5. Kuhn H. Traitement des amputations en coup de hache des phalanges distales. Rev Chir Orthop
1967;53:469.
6. Iselin M, Iselin F. In: Atlas de technique opératoire de chirurgie de la main. Paris: Ed. Med. Flammarion,
1971;62-68.
7. Mitz V, Senly G. A propos de l'utilisation du lambeau en drapeau clans la couverture des pertes de
substance de is troisième phalange. Ann Chir Plast 1975;20:337.
8. Holevich J. A new method of restoring sensibility to the thumb. J Bone Joint Surg [Br] 1963;45(B):496.
9. Iselin F, Sedel L, Thevenin R. Resensibilisation du pouce par lambeau de Kuhn et Holevich. Ann Chir
Plast 1971;16:295.
10. Levame J, Otero C, Berdugo G. Vascularisation arterielle des teguments de la face dorsale de la main et
des doigts. Ann Chir Plast 1967;12:316.

Chapter 239
on-Top-Plasty Skin Flap of The Finger
G. J. BAIBAK
EDITORIAL COMMENT
The need for this procedure has been dramatically reduced by the advent of microsurgical toe transfers.
The term on-top plasty was coined (1) to describe a technique for transferring a flap from a severely injured digit
to a more useful location on the hand as an island vascular flap.
INDICATIONS
The technique of digit migration on neurovascular pedicles is not intended to replace pedicled flaps, bone
grafts, or free flap digit reconstruction for hand injuries.
My series has used all fingers of the hand for transfer, the concept being that an injured part is used to
increase function of other injured parts (2). If a usable injured finger is available, a normal finger need not
be sacrificed for “spare parts.”
FLAP DESIGN AND DIMENSIONS
Complete or partial digit migration into the thumb position is quite easily accomplished, even if the distal portion
is damaged. The finger segment is moved along an arc, based at the proximal palmar crease, into the receptor or
thumb position. The on-top plasty digit migration concept for gaining length is dependent on MP joint function,
i.e., on active and passive flexion and extension (Fig. 239.1).
Tendons and neurovascular bundles that may have been shortened at the time of migration to a flexed phalanx
can gradually be straightened or extended over a period of time. In essence, one gradually stretches the tendons
and the neurovascular bundle beyond the initial hook-up length, thus increasing the length and span of grasp of
the injured hand (Fig. 239.2).
OPERATIVE TECHNIQUE
It is assumed that the reader is familiar with the technique of developing and using neurovascular pedicles within
the hand (3, 4).
The dissection is started in the proximal palm, lest a neurovascular anomaly exist that might preclude transfer. (I
have encountered three anomalies in approximately 50 neurovascular islands in the hand). A W-type of incision
is used both about the recipient stump and in the donor area, to give good exposure and to prevent linear
contractures in the incision and circular contractures around the transposed digit.
The neurovascular pedicles are dissected to include the loose investing areolar tissue. The palmar aponeurosis
and the septa extending down to the metacarpals are released from about the neurovascular pedicle of the
donor finger and the base of the recipient digit. This release allows for increased freedom of the palmar skin
overlying the transplanted neurovascular bundle and reduces the likelihood of vascular constriction to the
transposed digit in the subaponeurotic space.

At the time of migration to a finger, the recipient digit is held in 90° flexion while the base of the proximal phalanx
of the donor digit is placed “on-top” of the sharpened end of the proximal phalanx of the recipient finger. The
thumb, because of its recessed position, need not be flexed for a successful on-top plasty. When one is using
the index finger, the first dorsal interosseous muscle is attached to the proximal phalanx of the long finger via a
drill hole, in order to reinforce key pinch.
Skin closure is usually accomplished with local skin flaps and/or grafts, as determined by the preexisting defect.
At 5 to 6 weeks, when the healing of skin and bone is adequate, the digit is gradually straightened and brought
into the fully extended position. Such a period of time allows the nerves and blood vessels to gain length without
loss of function (Figs. 239.3 and 239.4).
FIGURE 239.1 Migration of index stump to thumb stump. Any other shortened digit may be used in a similar
fashion. The long finger stump may be sacrificed to increase the span of grasp in multiple amputations.

FIGURE 239.2 Migration of the index to long finger stump, illustrating the technique and the increased span of
grasp.
FIGURE 239.3 Index to thumb “on-top plasty,” showing increased function.
FIGURE 239.4 Index to long “on-top plasty,” illustrating neurovascular pedicles and increased function.
CLINICAL RESULTS
This procedure has been used on ten patients over the past few years. There has been no loss of the
migrated digits, nor have there been any significant complications. Sensation of the transposed digits has
been maintained at the preoperative level, as measured by two-point tactile discrimination testing. There
have been no nonunions requiring secondary procedures at the synostosis.

SUMMARY
Fingers or thumbs that have been shortened by injury and that are useless can be lengthened and made
functional by transferring the ends of other injured fingers to the stumps by means of the on-top plasty
procedure.
References
1. Soiland H. Lengthening a finger with the “on-the-top” method. Acta Chir Scand 1961;122:184.
2. Kelleher JC, Sullivan JG, Baibak GJ, Dean RK. “On top plasty” for amputated fingers. Plast Reconstr Surg
1968;42:242.
3. Littler JW. Proceedings of the American Society for Surgery of the Hand. J Bone Joint Surg
1956;35(A):917.
4. Frackleton WD, Teasley JL. Neurovascular island pedicle extension in usage. J Bone Joint Surg
1962;44(A):1069.

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Chapter 240
Thenar Flap
B. W. EDGERTON
R. W. BEASLEY
EDITORIAL COMMENT
The design of these flaps and the flexion required to the attached finger make one wary of the strong
possibility of fixed flexion contractures postoperatively.
Major distal phalangeal amputations are best treated by a local flap from the hand, whenever practicable. The
thenar flap has the advantages of near-perfect tissue match, excellent recovery of sensibility, adequate
subcutaneous tissue for pulp restoration, and a minimally disfiguring donor site (1, 2, 3, 4, 5, 6). Thenar flaps
must not be confused with palmar flaps, for which the complication rate is so high as to contraindicate their use
(7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18).
INDICATIONS
The major indication for a thenar flap is amputation of the digits distal to the distal interphalangeal joint. No
other graft or flap providing adequate subcutaneous tissue for pulp restoration can provide as good a tissue
match for texture, appearance, and recovery of sensibility (19). Preservation of finger length provides a
functionally and aesthetically superior reconstruction to shortening and closure of the amputation stump,
especially if an acceptable fingernail can be salvaged. For those amputations proximal to the distal
interphalangeal joint for which reattachment is not possible, a thenar flap may be used for wound closure to
preserve length and a functional proximal interphalangeal joint. Positioning becomes more difficult with more
proximal amputations, and a volar or dorsal cross-finger flap may then be preferable (see Chapter 255).
ANATOMY
The thenar flap should be raised from a location high on the thenar eminence. Tenderness has not proved to be
a problem with scars located in this area. With the flap in this location palmar abduction of the thumb minimizes
interphalangeal joint flexion of the injured digit. The distal (or lateral) margin should be placed in the
metacarpophalangeal joint crease.
Because the flap has a random blood supply provided by the dermal and subdermal plexuses, it may be raised in
any direction. Since subcutaneous tissue is desired in pulp reconstruction, the flap is raised in a plane just
superficial to the thenar musculature.
FLAP DESIGN AND DIMENSIONS
The thenar flap may be based in any direction. In most cases of fingertip amputation it is based proximally. The
flap may be considered a direct flap, in that the defect is brought to the open surface of the flap. Flaps of
approximately 2.25 × 2.25 cm in size are usually necessary to resurface an adult fingertip if contour restoration
rather than a flat tip is desired.

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FIGURE 240.1 A: The thenar flap may be based in any direction, but for fingertip amputations it is usually based
proximally. To restore the rounded contour of the normal fingertip, the flap should be at least 1½ times the width
of the finger. A W-shaped extension can be made to avoid a longitudinal scar across the lines of tension. B:
Proximal interphalangeal joint flexion can be a problem with this procedure. Patients should be individually
evaluated before choosing this procedure. Positioning is more difficult for the index finger and becomes less of a
problem with the small finger.
Interphalangeal joint contracture of the injured finger is avoided by maximal finger metacarpophalangeal joint
flexion and by palmar abduction of the thumb to meet the finger. These procedures usually result in proximal
interphalangeal joint flexion of no more than 50° (Fig. 240.1B). Positioning is more difficult for the index finger
and is easier for the more ulnar digits.
A pattern is cut, pressed against the defect, and held against the location of the flap pedicle. A flap to restore
fully the round contour of the fingertip must be at least 1½ times larger than the width of the finger (Fig. 240.1). If
the flap is proximally based and extends into the first web, a W-shaped extension is made to avoid a longitudinal
scar across lines of tension (Fig. 240.1A). All flaps should be measured twice and cut once.
OPERATIVE TECHNIQUE
The flap is elevated from the thenar muscles, taking subcutaneous tissue with it. The only vital structure that may
be injured underneath this flap is the radial digital sensory nerve to the thumb, which courses along the surface
of the flexor pollicis brevis. This nerve should be identified and carefully protected. If the flap is designed distal
on the thenar eminence, the motor branch of the median nerve is not vulnerable to injury.
The donor site of the flap may be closed primarily in cases where the flap is less than 2 cm in width, but usually a
skin graft is required for closure without thumb restriction. The distal volar wrist crease is a convenient location to
obtain a full-thickness, hair-free skin graft of up to 12 mm in width that when divided into two pieces will provide
enough skin to cover the defect.
To prevent a bulbous tip and a downward pull on the distal nailbed, only the lateral margins of the flap are
sutured to the finger. A carefully shaped gauze packing is placed over the skin graft and the finger is then
immobilized with tape to prevent tension on the suture line or flap. A light plaster cast is placed over the hand,
with a replaceable window cut in it to allow inspection and wound care.

FIGURE 240.2 A: Defect of the long fingertip suitable for a thenar flap. Note the position of the flap high up on
the thenar eminence. B: Flap in place. Note proximal interphalangeal flexion. C: Donor site is covered with a skin
graft. D: Postoperative result. Note complete proximal inter-phalangeal extension.
After 10 to 14 days the pedicle is divided. The flap is never inset at the time of pedicle division, because it will
tolerate poorly any handling, tension, or suturing at this time. The wounds are dressed with care not to compress
the flap tissues. The wounds are allowed to heal secondarily, but active extension and intrinsic muscle exercises
are begun immediately to mobilize the interphalangeal joints. A secondary revision may be performed at a later
date for perfection of contour, but it is not required for many cases (Fig. 240.2).
CLINICAL RESULTS
Flaps taken from the palm have justly earned a bad reputation. One series of 21 palmar flaps reported 24%
with tender scars and 38% with stiff joints (12).
A recent careful review of 150 consecutive cases of thenar flaps (18) performed by two surgeons shows
that the poor reputation of thenar flaps is not deserved. There were no losses of the flaps and no infections,
and excellent contour reconstruction was obtained. Only four patients (3%) had any tenderness of the
donor site. Only six patients had any joint stiffness (there was less than 15° loss of extension in four of the
six patients). Recovery of two-point discrimination averaged 7 mm (in agreement with previous authors),
and only one patient having repair of the index finger subsequently favored use of the adjacent middle
finger. Ninety-four percent of the patients returned to work an average of 11 weeks after injury. (The
average was 4.5 weeks in noncompensation cases.) No special difficulties were encountered with children
(nine patients) or with older adults (31 patients over the age of 50). Only one of the patients who
demonstrated joint stiffening was older than 50 years. The skin grafts to the donor site usually developed
some hyperpigmentation, but patients did not find this troublesome.

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SUMMARY
The thenar flap is unsurpassed for restoration of major distal phalangeal and selected middle phalangeal
digital amputations. It provides tissue of excellent match, supplies adequate subcutaneous tissue for pulp
restoration, and has good recovery of sensibility. When the guidelines are carefully followed the procedure
can be performed with minimal morbidity in all age groups.
References
1. Gatewood. A plastic repair of finger defects without hospitalization. JAMA 1926;87:1479.
2. Flatt AE. The thenar flap. J Bone Joint Surg [Br] 1957;39:80.
3. Gottlieb O, Mathiesen FR. Thenar flaps and cross finger flaps. Acta Chir Scand 1961;122:166.
4. Miller AJ. Single fingertip injuries treated by thenar flap. Hand 1974;6:311.
5. Barton NJ. A modified thenar flap. Hand 1975;7:150.
6. Smith RJ, Albin R. Thenar H-flap for fingertip injuries. J Trauma 1976;16:778.
7. Horn JS. The use of full thickness hand skin flaps in the reconstruction of injured fingers. Plast Reconstr
Surg 1951;7:463.
8. Fusco EM. Fingertip reconstruction with palmar skin flaps. Am J Surg 1954;87:608.
9. Barclay TL. The late results of finger tip injuries. Br J Plast Surg 1955-1956;8:38.
10. Campbell Reid DA. Experience of a hand surgery service. Br J Plast Surg 1956;9:11.
11. Kleinert HE. Fingertip injuries and their management. Am Surg 1959;25:41.
12. Sturman MJ, Duran RJ. Late results of fingertip injuries. J Bone Joint Surg [Am] 1963;45:289.
13. Smith JR, Bom AF. An evaluation of fingertip reconstruction by cross-finger and palmar pedicle flap. Plast
Reconstr Surg 1965;3.5:409.
14. Beasley RW. Reconstruction of amputated fingertips. Plant Reconstr Surg 1969;44:349.
15. Beasley RW. Local flaps for surgery of the hand. Orthop Clin North Am 1970;1:219.
16. Russell RC, Van Beek AL, Wavek P, Zook EG. Alternative hand flaps for amputations and digital defects.

J Hand Surg 1981;6:399.
17. Beasley RW. Hand Injuries. Philadelphia: Saunders, 1981.
18. Melone CP, Beasley RW, Carstens JH. The thenar flap: analysis of its use in 150 cases. J Hand Surg
1982;7:291.
19. Porter RW. Functional assessment of transplanted skin in volar defects of the digits. J Bone Joint Surg
[Am] 1968;50:955.

Chapter 241
Thenar H-Flap
R. J. SMITH
EDITORIAL COMMENT
The only advantage this procedure provides is a completely closed system when cohering the fingertip.
Otherwise a more proximal attachment creates greater flexion constraint than that required in the flap
discussed in Chapter 240.
If the distal phalanx protrudes from the wound after a fingertip injury, skin and subcutaneous tissue are needed
to provide a functional and aesthetic soft-tissue cover. With a thenar H-flap there is a closed system: a graft is
not needed to cover the donor site, and scarring and disability at the donor site are negligible (1, 2).
INDICATIONS
In infants and small children the wound may heal rapidly by secondary intention. Occasionally a composite
graft may survive. For the older child or young adult, however, the thenar flap offers robust and durable skin
and subcutaneous tissue that are readily available for direct flap coverage and that require immobilization
only of the injured finger.
The thenar H-flap is indicated for fingertip injuries with protruding bone and with a defect of 1 to 3 cm. It is
not usually used in older patients with stiff finger joints or with large soft-tissue defects. It is inappropriate for
thumb tip injuries.
FLAP DESIGN AND DIMENSIONS
Regardless of which finger is involved, a palmar flap should always come from the thenar eminence. A
hypothenar flap to the little finger forces this finger to assume an awkward position of pronation and flexion, and
should not be used.
An H-flap of skin and subcutaneous tissue is elevated from the thenar eminence (Fig. 241.1A and B). Each of the
flaps is about 20% larger than the size of the defect.
OPERATIVE TECHNIQUE
Each flap is sutured to the fingertip and to the other flap (Fig. 241.1C). Fourteen days later the proximal flap is
detached from the palm and sutured to the defect. The distal thenar flap is detached from the finger and
advanced to close the donor site (Fig. 241.1C).
The finger is fully extended on an aluminum splint for 2 or 3 days. Range of motion exercises then are performed
for 1 week, during which period the finger is placed in an extension splint at rest.
SUMMARY
The thenar H-flap offers an excellent means of providing aesthetic and functional coverage of deep,
medium-sized fingertip defects in younger patients (Fig. 241.2). One must take care, however, to construct

a closed system when applying the flap, and to prevent contracture after the flap has been detached, by
appropriate postoperative splinting and exercises.
FIGURE 241.1 A: An H is incised in the thenar eminence. Each flap is about 20% larger than the defect,
with the horizontal limb of the H at the spot where the flexed index finger lies most comfortably. The flaps
are elevated down to the thenar fascia. B: Both flaps are sutured to the fingertip and to each other. C: After
2 weeks, the flaps are detached. One remains with the finger; the other remains on the palm to close the
donor site. (From Smith and Albin, ref. 2, with permission.)

FIGURE 241.2 A thenar H-flap is used to cover a fingertip defect in an eight-year-old girl. (From Smith and
Albin, ref. 2, with permission.)
References
1. Smith JR, Bom AF. An evaluation of fingertip reconstruction by cross-finger and palmar pedicle flap. Plast
Reconstr Surg 1965;35:409.
2. Smith RJ, Albin R. Thenar H-flap for fingertip injuries. J Trauma 1976;16:778.

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Chapter 242
Cross Thumb to Index Fingertip Skin Flap
E. ATASOY
EDITORIAL COMMENT
Early division of the flap must be anticipated. Otherwise there is a danger of joint and first web space
contracture. This flap should not be used routinely, but only in the specific situations indicated by the
author.
The dorsum of the thumb is not considered an ideal donor site. It can, however, provide excellent coverage in
certain cases for fingertip amputations where there is exposed bone.
INDICATIONS
The cross thumb to index skin flap is useful for index fingertip amputations in which there is an associated
crushing injury
to the dorsum of the long finger (1). With the use of this flap as an elective procedure an unsatisfactory
index fingertip stump can be improved in the presence of old multiple finger amputations.
FIGURE 242.1 Schematic representation of the operative technique. (From Atasoy, ref. 1, with permission.)

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FIGURE 242.2 A: Severe crushing injury resulting in multiple fingertip amputations. Note the flap outline on
the thumb. B: Cross thumb-index flap covering the index finger, which was amputated just distal to the
proximal interphalangeal joint. Preservation of length is important in order to retain function. A Kirschner
wire is placed across both digits to hold the flap in position, thus avoiding any tension. C,D: Postoperative
flexion and extension at 3 months. Note the lack of contracture at the first web space and at the skin-grafted
donor site. (From Atasoy, ref. 1, with permission.)
When the index finger is amputated just distal to the proximal interphalangeal joint it is essential to maintain
length in order to preserve function. If there are associated amputations of the other fingers at the distal
interphalangeal joint level or above, the amputated index fingertip can be covered with a crossthumb flap,
which actually adds a little length (see Fig. 242.2).
If the long finger is damaged, this flap can be used to cover an index finger in which the complete nailbed
and surrounding skin have been avulsed. Otherwise a reversed cross-finger flap from the long finger would
be used to cover the exposed bone and the extensor tendon insertion (see Chapter 256).
ANATOMY
The cross thumb to index flap has a randomly based circulation, but it includes any dorsal veins that are present.
Care is taken during the dissection to preserve the peritenon over the extensor pollicis longus tendon, to allow
the donor site to be skin grafted. Both dorsal sensory nerves, which should be left intact, run along the edge of
the extensor tendon (Fig. 242.1).
FLAP DESIGN AND DIMENSIONS
A flap that is 3 to 4 mm wider than the defect to be covered is marked on the dorsum of the proximal phalanx of
the thumb. The flap can be made twice as long as it is wide. The base of the flap is placed on the radial side of
the thumb in a slightly oblique direction (Figs. 242.1 and 242.2A).

OPERATIVE TECHNIQUE
A two or three power magnifying loupe is very helpful during this operation. As in ordinary cross-finger pedicles
(2, 3, 4), full-thickness subcutaneous tissue and dorsal veins should be included in the flap, but the peritenon
should be left intact on the extensor tendon.
The defect is covered with a full-thickness skin graft taken from the forearm, upper arm, or groin. The recipient
index finger, when positioned on the thumb, will act as a tie-over dressing.
After placing the index finger in the proper position on the thumb, a 0.028 Kirschner wire is inserted through
these digits, to maintain the flap in the best position for preventing kinking and stretching. Both ends of the
Kirschner wire are bent fairly close to the skin on the thumb and the index finger to prevent migration.
Division of the flap and removal of the Kirschner wire are performed about 2 weeks postoperatively, and gentle
manipulation of the first web space and joints is carried out.
CLINICAL RESULTS
Flap necrosis can be avoided by pinning the index finger to the thumb in the optimal position for preventing
any vascular embarrassment of the flap.
If both dorsal sensory nerves are preserved intact during the dissection, sensory disturbances at the tip of
the thumb should not occur.
First web space contracture and joint stiffness can be prevented by early division of the flap (12 to 14 days
postoperatively), and by gentle joint and first web space manipulation, followed by immediate active and
passive range of motion exercises.
SUMMARY
The cross thumb to index skin flap is a good method for covering index fingertip defects when there is an
associated injury of the long finger that precludes its use as a donor site.
References
1. Atasoy E. The cross thumb to index finger pedicle. J Hand Surg 1980;5:572.
2. Cronin TD. The cross finger flap: a new method of repair. Am Surg 1951;17:419.
3. Flatt AE. The thenar flap. J Bone Joint Surg [Br] 1957;39:80.
4. Kleinert HE. Fingertip injuries and their management. Am Surg 1959;25:41.