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

Planning for the flap is done with the use of a pattern made to fit the defect. The flap, situated over the dorsum of
the middle phalanx, is generally based on the lateral border of the digit, but may be distally based if that seems to
offer a better fit.
OPERATIVE TECHNIQUE
After cleaning and appropriate debridement of the injured fingertip, an adjacent digit is chosen as the cross-
finger flap donor. The middle finger is generally used for resurfacing thumb injuries (Fig. 243.2).
The sensory nerve to the flap is first sought with the aid of loupe magnification through an oblique incision over
its course in the donor finger (Fig. 243.2A and B). Generally there is a thin layer of subcutaneous fat and fascia
overlying the nerve. The nerve is traced to the edge of the planned flap; it is sectioned proximally so that a 2-cm
“tail” may be reflected with the flap. The flap is then cut and elevated in the plane of the extensor tendon
paratenon with the nerve in continuity (Fig. 243.2C).
FIGURE 243.2 Operative technique. The steps in the surgical procedure are outlined. See text for details. (From
Cohen and Cronin, ref. 2, with permission.)
In the injured finger, on the side opposite the flap donor finger, a short linear incision is made over the digital
nerve. The digital nerve is identified proximal to the injury and traced into the traumatic wound (Fig. 243.2D).
Branches to intact tissue are preserved while branches (or, in more proximal injuries, the main nerve trunk) to
amputated areas are isolated for nerve junction with the flap sensory nerve.
The flap is transposed to the defect and sutured loosely in place. The operating microscope is then used to
perform the neurorrhaphy between the digital nerve (or branch) in the injured finger and the sensory nerve to the
flap (Fig. 243.2E). Careful preparation of the nerve ends prevents occlusion of the axons by overlapping
epineurium. A few 9-0 nylon sutures in the epineurium suffice for the nerve junction. The joined nerves are
placed in the underlying wound, which is then closed. The remainder of the flap is inset and the flap donor site is
grafted (Fig. 243.2F). The dressing, after-care, and flap division proceed as for a standard cross-finger flap. The
nerve junction is opposite the flap base and therefore not in jeopardy at the time of flap division.

CLINICAL RESULTS
In two series almost all fingertips reconstructed with innervated cross-finger flaps gained good sensation
and had a better functional result than those reconstructed with standard cross-finger flaps (1, 2). In smaller
wounds, in which no part of the flap is very distant from well-innervated surrounding tissue, this difference is
probably less substantial.
SUMMARY
The innervated cross-finger flap provides cover and good sensation to a fingertip with minimal donor site
morbidity.
References
1. Berger A, Meissl, G. Innvervated skin grafts and flaps for restoration of sensation to anesthetic areas. Chir
Plast [Berlin] 1975;3:33.
2. Cohen BE, Cronin ED. An innervated cross-finger flap for fingertip reconstruction. Plast Reconstr Surg
1983;72:688.

Chapter 244
Neurovascular Island Skin Flap to The Finger Amputation Stump
R. K. SRIVASTAVA
J. B. KAHL
EDITORIAL COMMENT
The editors believe that the indications for this procedure are extremely limited. An amputation and closure
of the wound would be a simpler procedure and just as efficacious. A ray amputation should also be
considered as an alternative.
Once a patient presents with a stiff, nonfunctional, and painful finger, the decision to amputate will often be
made. As with all mutilating hand injuries, the philosophy of salvaging any useful tissue from the amputated part
of the hand is important.
INDICATIONS
The use of this flap is limited to salvaging the special tactile fingertip skin in case of finger amputation, as
long as there are no other digits that need localized sensation. If the amputation is proximal to the PIP joint,
the hand may be more functional with a ray amputation. If the amputation is at, or distal to, the PIP joint, a
neurovascular island flap from the distal phalanx can be used to provide good cover and sensation to the
stump (1).
If one neurovascular bundle has been damaged during the original injury, the half volar and lateral skin flap
based on a single neurovascular bundle is equally good for tactile reception.
ANATOMY
This neurovascular island skin flap is based on one or both neurovascular bundles of the injured finger. The
surgically isolated composite bundle should include sufficient areolar tissue to assure independent venous return
for the isolated skin flap (2).
FLAP DESIGN AND DIMENSIONS
The area of salvageable volar and lateral skin of the fingertip is outlined (Fig. 244.1A). The marking is extended
proximally for the elevation of standard triangular flaps.
OPERATIVE TECHNIQUE
Beginning proximally at the level of the proposed amputation, the neurovascular bundle or bundles are isolated
along with some vein-bearing areolar tissue. The island flap includes the full thickness of skin and padding.
After the amputation is completed, the stump is covered by the island flap without any twisting. It is then sutured
in place without any undue pressure on the redundant neurovascular bundle (Fig. 244.1C).
In the postoperative period, some congestion of the flap may occur, which should clear gradually in 4 to 5 days,
as long as the hand is kept constantly elevated.

CLINICAL RESULTS
As long as there is no twisting or kinking of the neurovascular pedicle, and as long as the skin island is
large enough to cover the amputated stump loosely, there should be no problem with flap necrosis.
Since the nerve is not sectioned, there is no problem with neuroma formation.
After the flap heals, sensibility in the transferred skin is felt to originate from the tip of the amputated finger,
but with time and use (in about 6 to 8 weeks), central nervous system adaptability allows a change in
allegiance to the reconstructed unit (Fig. 244.2).
SUMMARY
The special tactile area of the finger can be preserved as a neurovascular island flap to cover the stump to
elective finger amputations.
FIGURE 244.1 A: The outline of the volar neurovascular island skin flap and the proximal triangular flaps
on the finger that is to be amputated. B: The neurovascular bundles are then isolated and the amputation
performed. C: The neurovascular island flap is then sutured loosely into place on the amputation stump. It is
essential to avoid any twisting, kinking, or pressure on the pedicle. (From Srivastava and Kahl, ref. 1, with
permission.)

FIGURE 244.2 Postoperative result in a 34-year-old man who had an industrial injury to his non-dominant
left hand. (The injury in the thumb was repaired with a volar V-Y advancement flap.) Despite extensive
physiotherapy for 3 months, the index finger was still stiff and painful. After discussion of the alternatives,
his finger was amputated at the proximal interphalangeal joint level and the stump was covered by a
neurovascular island flap. He did very well after the procedure and returned to work. The sensation over
the stump was excellent and central nervous system orientation was achieved in about 6 weeks. (From
Srivastava and Kahl, ref. 1, with permission.)
References
1. Srivastava RK, Kahl JB. Shifting neurovascular island flap for the reconstruction of amputated digital
stump. Plast Reconstr Surg 1980;66:301.
2. Eaton RG. The digital neurovascular bundle: a microanatomic study of its contents. Clin Orthop
1968;61:176.

Chapter 245
Transposition Skin Flap From The Side of A Finger
D. P. GREEN
A transposition flap consists of a rectangular segment of skin and subcutaneous tissue that is turned on its pivot
point to reach the defect to be closed. The side of the proximal phalanx of a finger is an ideal donor site for such
a flap because of the redundant skin present there, an observation easily verified by pinching the skin distal to
the web. This consistent anatomic feature allows a skin flap 12 to 15 mm wide to be taken from this area and the
donor site to be closed primarily without the need for a skin graft (1, 2, 3, 4, 5, 6, 7, 8, 9, 10) (Fig. 245.1).
INDICATIONS
The ideal indication for this flap is an isolated, broad scar crossing the volar aspect of the MP joint (Figs.
245.1A and 245.2), but it can also be used, in conjunction with Z-plasties, to deal with more extensive scars
involving the entire digit. When the flap is used for more extensive scars, however, careful planning of the
extended incisions is necessary, to protect the blood supply of the flaps.
The flap is also useful in patients with Dupuytren's contracture in whom the distance between the volar MP
and PIP flexion creases is significantly decreased (Fig. 245.3) or there is severe skin involvement (dimpling)
at the MP level.
FLAP DESIGN AND DIMENSIONS
The flap is drawn on the finger, extending from a point level with the most proximal volar MP crease to the PIP
joint (Fig. 245.1B), a distance of 2.0 to 2.5 cm in the average adult hand. The ulnar side of the finger is preferred
as the donor site (10), although if the scar to be released lies more to the radial aspect of the MP flexion crease,
the radial side of the finger should be used as the donor site. The proximal half of the flap is 12 to 15 mm in
width, gradually tapering to a blunt angle at the distal end. The volar margin of the flap forms a right angle with a
relaxing incision in the volar MP crease that is now made across the full width of the finger to allow it to be
straightened (Fig. 245.1B). Of course, care must be taken to protect the neurovascular bundle.
The ideal width-to-length ratio of the flap is 1:1.5 (11), although 1:2 is generally safe. Exceeding this 1:2 ratio is
likely to lead to necrosis of the tip of the flap.
OPERATIVE TECHNIQUE
After the scar contracture is released through a transverse volar incision, an elliptical defect remains across the
base of the finger (Fig. 245.1C).
The flap is raised along a plane between the superficial and deep fascia (Fig. 245.1C), and the base is mobilized
sufficiently to allow it to be rotated 90° to cover the elliptical defect. It is not necessary to bring the tip of the flap
completely across the base of the finger; in fact, care should be taken to avoid excessive tension on the flap. A
longitudinal suture line across the MP crease is avoided by the tapered configuration of the tip of the flap.
The donor site is closed primarily by advancing the volar and dorsolateral skin margins toward each other,
leaving the suture line in the desirable midlateral position (Fig. 245.1D). The use of a skin graft to cover the
donor site is not necessary. In some cases it is desirable to leave a triangular defect measuring 2 to 3 mm on
each side at the proximal junction where the distal edge of the rotated flap joins the midlateral incision. It is

preferable to leave this small area open, rather than to create excessive tension on the flap by attempting perfect
closure of the wound. The small defect is usually completely healed by the time the sutures are removed at 10 to
14 days.
No postoperative immobilization is required; active range of motion of the finger is started on the first or second
day, after the initial dressing is changed.
CLINICAL RESULTS
In my experience complications have been very infrequent with the proper use of this flap. The donor site
heals as a linear scar that does not produce a contracture, since it lies very nearly in the midaxial line of the
digit. Necrosis of the tip of the flap may result from excessive tension in closing the donor site and, as noted
previously, it is preferable to leave open a small triangular defect at the junction of the flap and the donor
site closure, rather than to try to achieve complete skin apposition. Minimal necrosis of the tip of the flap has
occurred in a few patients, but these small areas heal by secondary intention. In no patient has a resulting
scar contracture across the volar aspect of the MP joint been seen, and in no patient was a subsequent
skin graft required.
FIGURE 245.1 A: A scar contracture across the volar aspect of the metacarpophalangeal flexion crease. B:
The flap is outlined on the side of the digit, its volar limb forming a right angle with a transverse incision
across the metacarpophalangeal flexion crease. The flap itself should be approximately 12 to 15 mm in
width. C: The flap is mobilized on a plane between the deep and superficial fascia. The subcutaneous fat is
left attached to the skin flap, and the neurovascular bundle is identified and protected. D: The flap is rotated
90° into the elliptical defect created by release of the flexion contracture, and the donor site is closed
primarily. No skin graft is required. (From Green and Dominguez, ref. 9, with permission.)

FIGURE 245.2 A: The ideal indication for this flap is a scar across the volar aspect of the
metacarpophalangeal flexion crease, as seen in this patient's long finger. The scar in the index finger
extends beyond the proximal interphalangeal joint and is too extreme to be corrected with a transposition
flap. B: The scar in the long finger has been corrected with a transposition flap from the radial side of the
finger. A full-thickness skin graft was used to correct the more extensive scar contracture in the index finger.
FIGURE 245.3 A: Transposition flaps were used in the ring and small fingers of this patient with
Dupuytren's contracture. Note the marked decrease in skin distance between the metacarpophalangeal and
proximal interphalangeal creases. B: The volar aspects of the metacarpophalangeal creases were covered
with transposition flaps from the ulnar side of the small finger and the radial side of the ring finger. The
palmar wound was treated with the open technique.
SUMMARY
A transposition skin flap can be used from the side of the finger to release a volar skin contracture. The
donor site can be closed primarily.
References

1. Tanzer RC. Correction of interdigital burn contractures of the hand. Plast Reconstr Surg 1948;3:434.
2. Lewin ML. Digital flaps. Plast Reconstr Surg 1951;7:46.
3. Burian, F. The plastic surgery atlas. New York: Macmillan, 1968;177.
4. Joshi BB. Dorsolateral flap from the same finger to relieve flexion contracture. Plast Reconstr Surg
1972;49:186.
5. Dean RK, Kelleher JC, Sullivan JG, Baibak GJ. Reconstruction of the dorsal and palmar surfaces of the
hand with local skin flaps. In: Grabb WC, Myers MB, eds. Skinflaps. Boston: Little, Brown, 1975;489-491.
6. MacDougal B, Wray RC, Weeks, PM. Lateral-volar finger flap for the treatment of burn syndactyly. Plast
Reconstr Surg 1976;57:167.
7. Brinkman JF. Local rotation flap. American Society for Surgery of the hand correspondence club
newsletter. No. 39, 1978.
8. Howard LD. Rotational flaps. American Academy of Orthopedic Surgeons, Instructional Course Lecture,
unpublished.
9. Green DP, Dominguez OJ. A transpositional flap for release of volar contractures of a finger at the MP
joint. Plast Reconstr Surg 1979;64:516.
10. Russell RC, Van Beek AL, Wavak P, Zook EG. Alternative hand flaps for amputations and digital defects.
J Hand Surg 1981;6:399.
11. Thompson RVS. Closure of skin defects near the proximal interphalangeal joint, with special reference to
the patterns of finger circulation. Plast Reconstr Surg 1977;59:77.

Chapter 246
Lateral Finger Rotation Skin Flap
H. W. LUEDERS
The lateral finger rotation skin flap is used primarily to interrupt a scar on the dorsal surface of the finger, thereby
providing the joint surface with good mobile skin (1).
INDICATIONS
The lateral finger rotation flap can be used to reconstruct both the volar and the dorsal surfaces of the
finger. Primary uses for the dorsally placed flap are for reconstruction of the fingers after a heavy burn
eschar has been excised, for traumatic avulsion of skin over the PIP joint and tendon, and for covering the
burned hand early over the PIP joint to prevent the granulomatous rupture of the extensor tendon and hood
(2, 3, 4, 5, 6, 7).
An advantage of the flap is that it simulates the original skin over the dorsum of the joint and retains some of
the inherent qualities of resistance to trauma and of elasticity of motion. It often has sensation. The direction
of the rotated flap breaks up the longitudinal scar on the dorsum of the finger.
ANATOMY
The circulation of the flap is derived principally from the dorsal digital vessel complex, with minimal contributions
from the volar complex.
FLAP DESIGN AND DIMENSIONS
After resection of the burn scar bridle on the dorsum of the hand and finger, the flaps are designed and elevated
(Fig. 246.1). The flaps are proximally based and extend on the lateral side from the proximal interphalangeal joint
to or beyond the distal interphalangeal joint. The length of the flap is determined by the width of the finger over
the proximal interphalangeal joint, from the midlateral line on the opposite side to the volar line on the flap side.
The point of rotation is just proximal to the proximal interphalangeal joint. The width of the flap is from the volar
line to the dorsal scar excision.
OPERATIVE TECHNIQUE
With the finger flexed, the flap is rotated over the dorsum of the proximal interphalangeal joint, in such a position
as to protect the joint from trauma. The flaps are tested in flexion and extension to see that they do not restrict
motion, and then they are sutured.
The donor defect and dorsum are covered with a thick split-thickness skin graft. For the traumatic avulsion injury,
a full-thickness graft is preferred. Pressure on the graft is secured by a tie-over bolster dressing, but placing tie-
over sutures in the flap should be avoided. The finger is bandaged in the neutral position for 4 to 5 days. The
grafts and flaps are examined and, if the grafts are dry, the tie-over dressings are kept in place for another 5
days. If the grafts are stable and the flaps adherent, passive to active motion is allowed.
CLINICAL RESULTS
A disadvantage of this flap is that it requires that the skin on the side of the finger be relatively undamaged.

To cover the joint from one side to another, a flap of great length is necessary. The use of a short radial
and ulnar side flap of equal or unequal length could be substituted, but it reintroduces a vertical scar over
the dorsal joint surface.
Flap loss has not occurred, and flap morbidity is related to the condition and amount of injury to the lateral
skin. Postoperative follow-up shows the flaps to be able to withstand considerable trauma occurring with
manual labor, or even with exposure to chemicals. The dog-ear on the proximal side is useful as additional
skin, which is necessary for flexion of the finger. After a time the flaps develop transverse wrinkles, just like
normal skin, and the hands are left cosmetically acceptable. The most vexing postoperative problem is
associated with the skin graft at the junction of the thinner split-thickness graft and the thicker volar palmar
skin. The skin graft is intolerant of additional trauma and the junction may crack and become irritated. The
callous capability of the skin graft is different and leaves very rough skin that is difficult to clean.
SUMMARY
The lateral finger rotation skin flap is used to cover defects in the dorsum of the finger. It is especially useful
for covering the PIP joint in burned hands.
FIGURE 246.1 Flaps are designed over the lateral surfaces of the middle phalanges. Note that the flap
includes only undamaged skin. After the dorsal scar is excised, the flap is rotated to cover the proximal
interphalangeal adjacent joint. The remaining raw areas are covered with split-thickness skin grafts. (From
Lueders and Shapiro, ref. 1, with permission.)
References
1. Lueders HW, Shapiro RL. Reconstruction of burned hands. Plast Reconstr Surg 1971;47:176.
2. Flynn JE. Burned and traumatic hands. Arch Surg 1947;54:249.
3. Tanzer RC. Reconstruction of the burned hand. N Engl J Med 1948; 238:687.
4. Braithwaite F, Watson J. Some observations on the treatment of the dorsal burn of the hand. Br J Plast
Surg 1949;2:21.
5. Lewin ML. Digital flaps. Plast Reconstr Surg 1951;7:46.

6. Peacock EE. Management of the burned hand. South Med J 1963;56:1094.
7. Maisels DO. Middle slip or boutonniere deformity in burned hands. Br J Plast Surg 1965;18:117.

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Chapter 247
Bipedicle Strap Flaps of The Finger
N. W. YII
D. ELLIOT
EDITORIAL COMMENT
These flaps are particularly useful in longitudinal dorsal defects. Particular attention should be paid to
critical aspects of the border digits; flaps should be elevated on the opposite side of the digit first, to avoid
potential sensory deficits and painful scars.
Dorsal skin defects in which the loss of integument is longitudinal in shape are not uncommon after injury by
rotating machinery and by glass shearing along the length of the digit. This shape of the defect is difficult to
reconstruct with commonly used flaps but lends itself to reconstruction by the use of longitudinal bipedicle strap
flaps moved across the dorsum of the finger from lateral to medial (1).
INDICATIONS
The procedure is recommended for longitudinal defects on the dorsum of the fingers and thumbs.
ANATOMY
Recent anatomic studies (2, 3, 4, 5) have confirmed earlier work by Levame et al. (6), demonstrating that there is
an arterial network similar to that of the veins in the dorsal subcutaneous tissue of the digits, with multiple
feeding arteries from the palmar digital arteries linking into the dorsal network around the lateral borders of the
digit. Although the dorsum does not have such an immediately obvious arterial structure as the palmar aspect of
the digits, this network is extensive, explaining the excellent vascularity of longitudinal bipedicle strap flaps.
FLAP DESIGN AND DIMENSIONS
Because the dorsum of the digit is a convex surface, and the injuring object presents a flat surface to this
convexity, the deep structures are exposed only along and immediately adjacent to the midline, with the wound
becoming progressively shallower laterally (Fig. 247.1). Adjacent to the central zone of complete loss of the
integument is a zone of variable width, in which the subcutaneous fat is preserved with skin loss only. The
extreme dorsolateral integument commonly is uninjured. Although portions of the dorsolateral tissues over which
the skin is preserved are, by themselves, often too narrow to create bipedicle flaps that can be fabricated
successfully in the midline, inclusion of the intermediate zone of the dorsolateral soft tissue, over which only the
skin has been lost, makes the longitudinal bipedicle flaps wider, the central defect smaller, and the technique
more applicable.
OPERATIVE TECHNIQUE
Dorsal bipedicle strap flaps may be raised on any part of the digit. They may be raised safely to any length,
although it is unusual to require reconstructing defects longer than two phalanges in length. A midlateral incision
is first made on one side of the digit, and Cleland's ligaments are divided to allow one lateral strap of

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subcutaneous tissue and skin to move medially (Fig. 247.2). When possible, we select the “concealed” side of
the digit as the donor site of the first flap, although the midlateral incisions heal so well that this is probably an
unnecessary precaution. In releasing Cleland's ligaments, care is taken to preserve the dorsal branches of the
digital nerve, which provide innervation of the flap. It is not necessary to preserve the dorsal branches of the
digital artery if they impede the medial movement of the flap. Through the midline of the dorsal wound, the
integument is mobilized in the plane between the extensor paratenon and the undersurface of the subcutaneous
fat. If one flap is not sufficient to close the central defect, the other lateral flap is raised in the same manner. The
subcutaneous tissue is sutured with an absorbable suture in the midline.
FIGURE 247.1 Transverse section of the finger to illustrate the injury: a - a' is the central part of the dorsal
wound down to extensor tendon; b - b' indicates the width of the skin loss exposing tendon centrally but only
subcutaneous fat laterally; c and c' are the lateral incisions made at surgery, with the dotted lines c - a and c' - a'
indicating the plane of dissection under the bipedicle flaps.
Skin defects, whether on the dorsal or lateral aspects of the digits, are dressed with moist, antiseptic dressings
until epithelialization is complete (Fig. 247.3). This does not impede immediate mobilization of the digits. Another
advantage of the open lateral wounds has been the rapid elimination of the edema that always accompanies
digital injuries and that is usually retained after reconstruction with flaps in which there is complete skin closure.
Complete epithelialization of the dorsal wounds usually takes between 2 and 6 weeks, with the lateral wounds
healing within 2 to 4 weeks.
CLINICAL RESULTS
In a series of 28 longitudinal dorsal digital defects, a single flap was used in 9 digits (32%), and both flaps
were mobilized in 19 digits (68%) (1). There were no flap failures, complete or partial, and none of the flaps
exhibited any feature of circulatory difficulty at any time. The patients were followed up for a mean of 8.4
months (range: 2 to 25 months). All wounds healed uneventfully.
SUMMARY
Dorsal skin defects in which the loss of integument is longitudinal in shape are difficult to reconstruct with
commonly used flaps but lend themselves to reconstruction by the use
of longitudinal bipedicle strap flaps moved across the dorsum of the finger from lateral to medial. Bipedicle
strap flaps are simple and rapid to raise. They add very little time to the procedure, which is useful when

reconstruction of the deeper structures has been complex and time-consuming.
FIGURE 247.2 The same section showing the tissues after movement of the bipedicled flaps medially to
allow suture of the subcutaneous fat (a a') over the exposed tendon.
FIGURE 247.3 A: A single radial bipedicle flap raised and mobilized to cover the exposed extensor tendon
dorsally. B: The finger several days after reconstruction. The central skin defect dorsally and the lateral
wound are dressed three times daily with moist antiseptic dressings, which are removed to allow vigorous
mobilization after cleaning. C: Late lateral view to show healed wound.
Because mobilization is possible from the first postoperative day, the reconstruction contributes little to the
functional morbidity of the injury and to surgery. Furthermore, the use of local tissue adjacent to the primary
defect, in conjunction with the technique of skin healing by secondary intention on both the dorsal and
lateral aspects of the digit, honor the principle of reconstructing “like with like” to a greater degree than with
the use of flaps taken from elsewhere, and achieve a good cosmetic result with minimal donor-site scarring.

This also obviates the need to disfigure the dorsum of the digits with the bulky and shapeless flaps that
have been the hallmark of larger reconstructions of this region in the past.
References
1. Yii NW, Elliot D. Bipedicle strap flaps in reconstruction of longitudinal dorsal skin defects of the digits.
Plast Reconstr Surg 1999;103:1205.
2. Endo T, Kojima T, Hirase Y. Vascular anatomy of the finger dorsum and new idea for coverage of the
finger pulp defect that restores sensation. J Hand Surg (Am) 1992;17:927.
3. Del Bene M, Petrolate M, Raimondi P, et al. Reverse dorsal digital island flap. Plast Reconstr Surg
1994;93:552.
4. Tremolada C, Abbiate G, Del Bene M, Blandini D. The subcutaneous laterodigital reverse flap. Plast
Reconstr Surg 1998;101:1070.
5. Strauch B, de Moura W. Arterial system of the fingers. J Hand Surg (Am) 1990;15:148.
6. Levame JH, Otero C, Berdugo G. Vascularisation arterielle des teguments de la face dorsale de la main et
des doigts. Ann Chir Plast 1967;12:316.

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Chapter 248
The Dorsal Bipedicle Flap for Proximal Interphalangeal
Arthrodesis in Systemic Scleroderma
CHARLES P. MELONE JR.
EREZ DAYAN
EDITORIAL COMMENT
A valuable addition in treatment of the PIP flexion deformity in patients with scleroderma. By taking
advantage of the consistent lateral and dorsal vasculature, this pedicle is made possible.
INTRODUCTION
Systemic scleroderma is a multifarious autoimmune connective tissue disease. It is characterized by an intrinsic
fibro-occlusive vascular disorder, exacerbated by the invariably coexistent Raynaud vasospastic syndrome. This
pervasive circulatory disturbance results in diffuse systemic ischemia and extensive tissue sclerosis, notably
prominent in the skin. The disease is categorized into two basic subsets, namely, diffuse and limited, both of
which include varying components of CREST syndrome. Regardless of the type, classic hand deformities are a
hallmark feature of the process and constitute a major source of painful dysfunction and disfigurement (1, 2, 3, 4,
5). Typically, the hands demonstrate flexion contractures of the proximal interphalangeal (PIP) joints, extension
contractures of the metacarpophalangeal (MP) joints, and adduction contractures of the thumb (Fig. 248.1).
Foremost among these deformities are progressive flexion contractures of the PIP joints, often exceeding 90
degrees. This excessive hyperflexion creates inordinate tension on the overlying dorsal skin with a predictable
sequence of increasing attenuation, atrophy, and, inevitably, painful ulceration. Moreover, with unabated PIP
contracture, the dorsum of the digit is subjected to continuous vascular compromise with a serious reduction in
the dermal capillary bed that is apt to decrease perfusion by as much as 80% over the dorsal aspect of the PIP
joints (5, 6, 7, 8). This extreme paucity of circulation poses a grave threat to digital viability and an ominous
setting for soft-tissue coverage of PIP joint arthrodesis. In the authors' experience for these highly complex
cases, the dorsal bipedicle flap is a consistently successful method of tension-free resurfacing.
INDICATIONS
For the disabling PIP joint flexion contractures of scleroderma, an increasing consensus exists that optimal
treatment comprises arthrodesis of the deformed joint in a more extended position, thereby promoting dorsal
circulation, enhancing functional grasping and pinch, and considerably improving aesthetics (1, 2, 3, 4, 5).
Concurrently, the devitalized dorsal soft tissues are excised and the reconstructed joints are
resurfaced with more amply perfused skin. For these cases in which uncomplicated wound healing is a
primary, but formidable objective, the dorsal bipedicle flap with its consistent vascular network (9) has
proved a reliable method of coverage and is the authors' preference for resurfacing.

FIGURE 248.1 Classic deformity of a scleroderma hand most prominently resulting in severe PIP flexion
contracture with dorsal softtissue attenuation and ulceration.
FIGURE 248.2 Bipedicle H-shape flaps designed over dorsum of PIP joints with ellipses marked for excision
of attenuated soft tissues. As shown here, for the contracted index finger, the ellipse is excised, the pedicles
are elevated, and the deformed joint is exposed.
A long-standing apprehension that the ischemic, sclerotic tissues of scleroderma would impede, if not
prevent, digital wound healing has been decidedly lessened with increasing surgical experience. This
previously foreboding outlook has been supplanted by a heightened awareness that the vast majority of
elective wounds, especially those with local vascularized flaps, consistently heal without complication and
with an enriched quality of life for the afflicted patients (3, 7, 10).
Previously, the senior author (CPM) emphasized the frequent need and efficacy of PIP joint arthrodesis in
the treatment of systemic scleroderma (3). Also accentuated was the need for careful case selection as the
critical prerequisite for successful surgery. Only patients in optimal medical condition were considered
candidates for arthrodesis, whereas for those with unremitting disease and a deteriorating health status,
elective hand surgery was fundamentally contraindicated.
In our initial experience of 70 medically stable patients requiring 272 hand surgical procedures, PIP
arthrodesis accounted for 211 or 78% of the cases and was uniformly successful. Moreover, for this group,
dorsal advancement flaps were first employed and considerably enhanced primary wound closure.
Subsequently, the dorsal bipedicle advancement flap was devised and has been used exclusively for
resurfacing the ischemic arthrodesis site (Fig. 248.2).
Presently, for medically stable patients, the authors recommend arthrodesis and resurfacing with the dorsal

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bipedicle advancement flap for progressive PIP joint contractures exceeding 60 degrees of flexion. At this
stage of deformity, the joints become increasingly painful and dysfunctional, as rising tension of the
overlying soft tissues intensifies ischemic attrition and dorsal ulceration of the digits (Fig. 248.3A). With
timely operative intervention, surgical procedures are facilitated and patient morbidity is considerably
lessened.
ANATOMY
Numerous investigators have confirmed a consistent and symmetrical arterial blood supply to the dorsal surface
of the PIP joint arising from the dorsal cutaneous arterial branches (DCABs) of the radial and ulnar proper digital
arteries (PDAs)
(9, 11, 12, 13, 14). This PIP arterial system is further enriched by a contribution from the dorsal metacarpal
arterial network that extends distally over the dorsal surface of the proximal phalanx (15). Braga-Silva more
precisely elucidated this vascular anatomy by demonstrating the constant presence of two DCABs emerging from
each side, both proximally and distally, of the PIP joint and located at specific distances from the articular surface
(Fig. 248.3B) (9). Clearly, these studies substantiate a reliable and relatively generous arterial network
nourishing the dorsum of the PIP joint. Sufficient venous drainage of the area is provided by adjacent venae
comitantes as well as the more replete palmar venous system of the digit (16, 17).
FIGURE 248.3 A: Chronic PIP flexion contractures of scleroderma resulting in ischemic attenuation and
ulceration of dorsal soft tissues. B: Consistent vascular anatomy of the dorsal bipedicle flap. Each pedicle is
based on dorsal cutaneous arterial branches of the proper digital artery arising at predictable distances from the
PIP joint. (Continued)

FIGURE 248.3 (Continued) C: Dorsal bipedicle flap design and dimension with basic 2:0.5 to 1 width-to-length
flap ratio. The ellipses with devitalized skin and soft tissue are excised and the joint is exposed. Following
arthrodesis, the site is resurfaced by advancing the dual pedicles. D: Flap incision and elevation with
preservation of dorsal vascular network, and preparation of the arthrodesis site with contoured cancellous bone.
E: Firmly coapted arthrodeses sites secured with percutaneous K-wires and resurfaced with the bipedicle flaps
that achieve a tension-free wound closure.
The consistent and ample vascular system of the dorsal surface of the PIP joint, coupled with successful clinical
application of the DCAB-based adipofascial flap for traumatic dorsal tissue loss, strongly supports the utility of
the DCAB vascularized bipedicle flap for resurfacing the frequently reconstructed PIP joints in scleroderma (14).
A variety of alternative flaps have been proposed for resurfacing soft-tissue deficits on the dorsum of the fingers
but none have addressed the demanding requirements of the scleroderma hand, and all are prone to
compromise vascular tissues essential to viability of the scleroderma finger (18, 19, 20). The diffuse fibro-
occlusive, vasospastic vascular disorder characteristic of the disease creates unique and perilous donor and
recipient site conditions seldom encountered with other causes of soft-tissue loss.
In contrast to the other methods, the DCAB-based bipedicle flap has been designed specifically for coverage of
the reconstructed PIP joints in scleroderma. The symmetrical vascularity of the dual pedicles has proved
consistently sufficient to offset the characteristic digital ischemia and promote uncomplicated soft-tissue healing.
For patients afflicted with the inherent vascular deficiency of scleroderma, the dorsal bipedicle flap has provided

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a reliable method of exposing and resurfacing the devitalized arthrodesis site.
FLAP DESIGN AND DIMENSIONS
The DCAB-based bipedicle flap is used exclusively by the authors for coverage of PIP joint arthrodesis in
systemic scleroderma. The flap is designed in an H-shaped configuration with a central transverse limb directly
over the joint and bilateral vertical limbs extending across the lateral aspect of the joint from the proximal phalanx
to the middle phalanx, creating two pedicles, each with a basic 2:0.5 to 1 width to length ratio (Fig. 248.3C). This
design facilitates comprehensive exposure with minimal flap undermining, ease of flap advancement, tension-free
closure, and preservation of the DCAB vascular plexus.
An ellipse is initially marked directly over the dorsal aspect of the PIP joint for thorough excision of established or
impending ulcers and is subsequently contoured into the transversally oriented central limb of the flap. This
central limb extends the full width of the dorsal aspect of the joint and usually measures 12 to 14 mm in diameter.
The lateral limbs are longitudinally oriented in the midlateral plane of the phalanges with lengths determined by
the well-documented location of the DCABs at their predictable distances from the PIP joint (9). Bilateral limbs
measuring 4 to 5 mm proximally and 6 to 8 mm distally secure preservation of the critical dorsal arterial plexus
and, after judicious incision and elevation, provide unobstructed exposure for joint reconstruction (Fig. 248.3D).
In cases with relatively large dorsal ulcers and severe flexion contractures, the proximal lateral limbs may require
an extension of several millimeters to gain the necessary exposure for thorough soft-tissue debridement and
precise joint reconstruction. In these instances, although the arterial branches nearest the proximal joint surfaces
are unavoidably jeopardized, the intricate configuration of the plexus remains intact and provides sufficient
vascularity for flap survival. Notably, distinct advantages of the bipedicle flap are its multiple, bilateral arterial
basis and the additional perfusion to the proximal pedicle received from the dorsal metacarpal arterial network.
OPERATIVE TECHNIQUE
Under tourniquet control, the dorsal ellipses are incised and the ulcerated tissues excised. The bipedicle H-
shaped flaps are then contoured, incised, and judiciously elevated and reflected, with minimal flap undermining,
thereby avoiding compromise of the critical subdermal plexus. The deformed, eburnated joint is then exposed
and prepared for arthrodesis. Overlying fibrotic tissues, including remnants of the extensor mechanism and the
collateral ligaments, are thoroughly debrided, the sclerotic articular surfaces are completely excised, and the
contracture is corrected. With sufficient, but relatively minor, bony shortening, the vascular juxta-articular
cancellous bone, essential for fusion, is accessed and contoured. The apposing cancellous surfaces are then
firmly coapted in a snug-fit, pencil-in-cup configuration of increased extension and securely transfixed with
crossed Kirschner wires that exit and are left protruding through the dorsal skin of the proximal phalanx. Both the
bony shortening and the increased digital extension at the arthrodesis site serve to alleviate tension and improve
perfusion of the flaps, considerably facilitating flap advancement and tension-free closure (Fig. 248.3E). In the
vast majority of cases, these techniques have secured a solid arthrodesis with superior soft-tissue coverage.

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FIGURE 248.4 A: Preoperative radiograph of classic scleroderma hand deformity showing severe flexion
contractures of the PIP joints (above); Postoperative radiograph demonstrating arthrodeses of PIP joints in more
extended positions (below). B: Radiograph of solidly fused PIP joint 7 weeks postoperatively.
The position of arthrodesis is individualized and is contingent on the extent of pre-existing deformity, the quantity
of available cancellous bone, and specific patient requirements. In the majority of cases, a more extended
posture ranging from 40 to 50 degrees of flexion is selected, ultimately resulting in a marked improvement in
function and aesthetics.
CLINICAL RESULTS
A series of 60 consecutive PIP joint arthrodeses in 16 patients with evaluation ranging from 1 to 5 years
after surgery consistently demonstrated (a) uncomplicated primary wound healing; (b) solid radiographic
union of 58 (97%) of the arthrodeses within 8 weeks of surgery; (c) complete eradication of dorsal ulcers;
(d) marked alleviation of pain, (e) substantial functional and aesthetic improvement; and (f) high levels of
patient satisfaction with enriched quality of life (Figs. 248.4A and B, 248.5). Radiographic pseudoarthroses
occurred in two cases but both were painless and did not require further surgery. For this group of patients,
which is inherently prone to surgical risk, infection, ischemic tissue loss, or ulcer recurrence was not
encountered and none of the cases required healing by secondary intention or secondary would closure.
The
consistently uncomplicated primary wound healing in conjunction with the high and rapid rate of bony fusion
suggests that the dorsally vascularized bipedicle flap increases vascularity not only to the skin margins but
also to the underlying fusion site, promoting both soft-tissue and skeletal healing.

FIGURE 248.5 A. Preoperatively, severe PIP joint flexion contractures resulting in painful, dorsal soft tissue
attrition and obscured finger nails. B. Postoperatively, arthrodeses of PIP joints in more extended positions
results in substantial improvement in digital alignment and function, as well as aesthetics, as demonstrated
by inconspicuous dorsal scarring and clearly visible nails.
The favorable outcome of this group, comparable to previous reports by other clinicians, (1, 2, 3, 4, 5) can
be attributed to precise coaptation of cancellous bone surfaces at the fusion site, secure Kirschner wire
fixation, and a tension-free, vascularized wound closure afforded by the dorsal bipedicle flap. Undoubtedly,
the key prerequisite for success was the optimal medical condition of this group of patients as determined
by comprehensive presurgical evaluation.
SUMMARY
With careful case selection, arthrodeses with uncomplicated primary wound healing for the classic PIP joint
flexion deformities of scleroderma have been consistently achieved with employment of the dorsal bipedicle
advancement flap. This vascularized flap, based on the dorsal cutaneous branches of the PDAs, has
reliably facilitated thorough operative exposure and tension-free wound closure essential for successful PIP
articular and soft-tissue reconstruction. In these cases, the expectant outcome has been alleviation of pain
and substantial improvement in function and aesthetics.
ACKNOWLEDGMENTS
The authors express sincere gratitude to Courtney A. McKenna, CMI, for her original artwork. Special
appreciation is also extended to Maria Cecilia Bolitsky of the Mount Sinai Beth Israel Hand Surgery Center for
her invaluable assistance in the preparation of this chapter.
References
1. Lipscomb PR, Simons GW, Winkelmann RK. Surgery for sclerodactylia of the hand. J Bone Joint Surg Am
1969A;51:112-117.
2. Jones NF, Imbriglia JE, Steen VD, et al. Surgery for scleroderma of the hand. J Hand Surg 1987;12A:391-
400.
3. Melone CP Jr, Mcloughlin JC, Beldner S. Surgical management of the hand in scleroderma. Curr Opin
Rheumatol 1999;11:514-520.
4. Nalebuff EA. Surgery in patients with systemic sclerosis of the hand. Clin Orthop Relat Res 1999;366:19-
97.
5. Gilbart MK, Jolles BM, Lee P, et al. Surgery of the hand in severe systemic sclerosis. J Hand Surg
2004;29B:599-683.
6. Henriksen O, Kristensen K. Reduced systolic blood pressure in fingers of patients with generalized
scleroderma (acrosclerosis). Acta Derm Venereol 1981;61:531-534.

7. Jones NF, Raynor SC, Medsger TA. Microsurgical revascularization of the hand in scleroderma. Br J Plast
Surg 1987;40:264-269.
8. Jones NF. Acute and chronic ischemia of the hand: pathophysiology, treatment, and prognosis. J Hand
Surg 1991;16:1074-1083.
9. Braga-Silva J, Kyuven CR, Fallopa F, et al. An anatomical study of the dorsal cutaneous branches of the
digital arteries. J Hand Surg 2002;27:577-579.
10. Tagil M, Dieterich J, Kopylov P. Wound healing after hand surgery in patients with systemic sclerosis—a
retrospective analysis of 41 operations in 19 patients. J Hand Surg 2007;32:316-319.
11. Levame JH, Otero C, Berdugo G. Vascularization arterielle des teguments de la face dorsale de la main
et des doigts. Ann Chir Plast 1967;12:316-324.
12. Yousif NJ, Cunningham MW, Sanger JR, et al. The vascular supply to the PIP joint. J Hand Surg
1985;10A:852-861.
13. Strauch B, Moura W. Arterial system of the fingers. J Hand Surg 1990;15A:148-154.
14. Braga-Silva J. Anatomic basis of dorsal finger skin cover. Tech Hand Up Extrem Surg 2005;9:1-8.
15. Valenti P, Masquelet AC, Begue T. Anatomic basis of a dorso-commissural flap from the 2nd, 3rd and 4th
intermetacarpal spaces. Surg Radiol Anat 1990;12:235-239.
16. Lucas GL. The pattern of venous drainage of the digits. J Hand Surg 1984;9A:448-450.
17. Nystrom A, von Drasek-Ascher G, Friden J, et al. The palmar digital venous anatomy. Scand J Plast
Reconstr Surg Hand Surg 1990;24:113-119.
18. Pakian AI. The reversed dermis flap. Br J Plast Surg 1978;31;131-135.
19. Earley MJ. The second dorsal metacarpal artery neurovascular island flap. J Hand Surg 1989;14:434-
440.
20. Rose EH. Local arterialized island flap coverage of difficult hand defects preserving donor digit
sensibility. Plast Reconstr Surg 1983;72:848-858.

Chapter 249
Axial Flag Skin Flap
G. D. LISTER
EDITORIAL COMMENT
Lengthening the flap pole would maintain the axial vascularity of the flap and, at the same time, would
facilitate the transposition and increase the versatility of the flap.
Since the axial flag flap can be rotated like any other island flap through a full circle, it can be brought to cover
defects not only over the dorsum of the proximal phalanx or metacarpophalangeal joint of either finger forming
the web, but also over the palmar surface of the same structures (see Fig. 249.3A and B). A standard cross-
finger flap will cover only one of these eight surfaces, namely the palmar aspect of the proximal phalanx of the
adjacent finger (1).
INDICATIONS
The axial flap is of particular value in covering combined lateral and palmar defects (see Fig. 249.4A).
ANATOMY
The axial flag skin flap, as used thus far, consists of the skin of the dorsal aspect of the proximal phalanx of the
finger. The arterial supply comes from the arcade that is formed in the web space by the communication between
the proper digital and the dorsal metacarpal arteries (Fig. 249.1). The dorsal metacarpal arteries arise from the
dorsal carpal arch, which is formed by branches of the radial, ulnar, and anterior interosseous arteries (2). They
run deep to the extensor tendons on the fascia of the interosseous muscles. At the metacarpophalangeal joint
they pass on to the superficial aspect of the extensor hood, where they arborize. One branch passes in a palmar
direction through the web space to anastomose with the proper digital artery (3). The other branches of this
arcade serve the skin of the dorsal proximal phalanx, communicating thereby with the identical system on the
other aspect of the digit. Reliable flow distally goes only as far as the distal extension crease of the proximal
interphalangeal joint (2, 4). The dorsal metacarpal arteries are not always present in all fingers. In order of
decreasing incidence, they appear in the second, first, fourth, and third interspaces. Thus the flap can be raised
most confidently on the middle and index fingers.
FIGURE 249.1 The dorsal metacarpal artery communicates with the proper digital artery by a web space branch,
thereby forming an arcade from which vessels arise to serve the dorsal skin over the proximal phalanx.
The venous drainage follows a similar pattern (Fig. 249.2), the dominant dorsal venous system forming a “bridle”

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vein, which is an arch over the proximal phalanx some 1 to 2 cm distal to the metacarpophalangeal joint. From
this, two dominant veins arise from either end of the arch—that is, on either side of the finger—and pass
proximally between the metacarpophalangeal joints, to gain the dorsum of the hand superficial to the extensor
tendons. Each of these veins is joined by a web space branch coming from the palmar aspect and, under normal
circumstances, carrying flow in that direction (5).
FLAP DESIGN AND DIMENSIONS
With the above anatomic knowledge, an axial flap can be raised, employing the vessels of any web space as the
pedicle. (This pedicle on the radial aspect of the index finger supplies the island skin flap to the thumb described
in Chapter 282 [4].) Since the pedicle is only as wide as the supplying vessels, the flap can be rotated like any
other island flap through a full circle. The selected web space therefore constitutes the pivot point of the axial
flag flap (Fig. 249.3).
The dual palmar and dorsal supply and drainage outlined above offers some security, but before selecting an
axial flag flap for coverage of a proximal wound over either aspect of the metacarpophalangeal joint, care should
be taken to ensure that the proper digital and dorsal metacarpal arteries have not been injured. The flap is, of
course, designed to fit the defect.
The largest flap available extends from midlateral line to midlateral line and from the base of the proximal phalanx
to the proximal extension crease of the proximal interphalangeal
joint, thereby avoiding the use of a free skin graft over the articulations. This yields a flap of maximum
dimensions, 3.5 × 3.5 cm of the middle finger of an 80-kg male. The surgeon should first confirm by reverse
planning with a pattern of suitable material that the flap will reach and cover the defect.
FIGURE 249.2 Here in an injection angiogram the venous drainage of the proximal phalanx can be seen. A
number of veins join to form a “bridle” vein over the junction of proximal and middle thirds of the phalanx, from
which two major branches proceed proximally on either side of the metacarpophalangeal joint.

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FIGURE 249.3 A: The axial flag skin flap can be rotated through 360° on the dorsum, thereby covering the
proximal phalanx of the adjacent finger and the metacarpophalangeal joints both of that finger and of the donor
finger. B: The flap can also be carried down through the web space to cover the palmar aspect of the same four
locations. (From Lister, ref. 1, with permission.)
OPERATIVE TECHNIQUE
The proximal margin of the flap should be incised first, carrying the incision down to the extensor tendon. The
end of the wound that contains the intended pedicle should then be dissected under magnification, if
confirmation of the presence of the requisite artery and vein is desired. Once this has been done, the other three
margins can be raised exactly in the manner employed for a cross-finger flap, that is, leaving the epitenon on the
extensor but taking all veins with the flap. It is safe, from a vascular viewpoint, to incise all four aspects
completely, provided that the pedicle is preserved. This gives maximum mobility and makes the use of the flap a
one-stage procedure (Fig. 249.4A-D).
The pedicle does consist, however, of vessels of relatively small caliber, and there is therefore some merit in
preserving a 2-mm skin attachment to protect it from stretch and torsion. This attachment can be divided in the
office or clinic under local anesthesia and requires no suturing. Once the flap is raised the tourniquet should be
released and perfusion confirmed. The flap can then be inset and a full-thickness skin graft applied to the
secondary defect (Fig. 249.5). As with other axial flaps, motion of adjacent joints can be commenced
immediately, if appropriate.
CLINICAL RESULTS
All such axial flag flaps have survived in their entirety, barring only one in an 83-year-old patient, which
showed superficial necrosis of the distal 20%.
SUMMARY
The axial flag flap consists of the skin on the dorsal aspect of the proximal phalanx of the finger and can be
used to cover defects over both the dorsal and volar surfaces of the proximal phalanx or
metacarpophalangeal joint of the same or the adjacent finger.

FIGURE 249.4 A: In this case a defect with exposure of the proximal interphalangeal joint on the index
finger extends over the lateral and palmar aspects of the index finger. B: An axial flag skin flap has been
raised on the dorsum of the proximal phalanx of the adjacent middle finger. It is elevated on all four sides,
with the exception of a small pedicle at the proximal radial aspect. C: The flap is rotated and transposed to
cover the defect on the adjacent index finger. D: The flap is sutured in position and can here be seen to be
well perfused and to cover adequately the palmar as well as the lateral aspect of the defect. A full-thickness
skin graft is applied to the secondary defect, and healing occurred uneventfully. (From Lister, ref. 1, with
permission.)
FIGURE 249.5 After grade 3 ring avulsion injury a decision was made that replantation should not be
attempted, but maximum length was retained in the amputated digit by employing an axial flag skin flap that
covered all aspects of the exposed bone.

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References
1. Lister GD. The theory of the transposition flap and its practical application in the hand. Clin Plast Surg
1981;8:115.
2. Johnson MK, Cohen MJ. The hand atlas. Springfield: Charles C. Thomas, 1975;55,66.
3. Carlier A, Lister GD. Unpublished data.
4. Foucher G, Braun JB. A new island flap transfer from the dorsum of the index to the thumb. Plast Reconstr
Surg 1979;63:344.
5. Moss S, Lister GD. Unpublished data.

Chapter 250
Use of The Sepa Flap in The Repair of Defects in The Hands and
Fingers
A. D. DIAS
EDITORIAL COMMENT
This is another technique for resurfacing the hand and fingers with a patch pedicle flap. The disadvantage
of this flap is that it still keeps the hand dependent and immobile for a period of time that is probably
unwarranted, if another option is a local flap from the hand or a free flap. However, an advantage is that a
thinner flap can be designed because the superficial external pudendal system runs directly underneath
Scarpa's fascia.
The superficial external pudendal artery (SEPA) flap is an axial-pattern flap based on the superficial external
pudendal arteriovenous system. Its usefulness in reconstructive surgery of the hands and fingers has been
demonstrated, and it can be raised as a unilateral flap or, when more skin is required, as a bilateral flap.
INDICATIONS
The flap is useful for resurfacing the hand in both dorsal and palmar aspects. When there is a simultaneous
loss of both dorsal and palmar skin, the SEPA flap can be used on the dorsum and a flap of the anterior
rectus sheath (with split-thickness skin cover) can be used on the palmar side (1, 2). The anatomic position
of the flap makes it possible to immobilize the hand postoperatively in a more comfortable and natural
position than possible with a groin flap. The length and narrowness of the flap allow the patient to move the
fingers freely, and also provide considerable freedom during the period of immobilization.
The SEPA flap has also been used in the repair of hypospadias, urinary fistulas, epispadias, degloving
injuries of the penis and scrotum, reconstruction of the amputated penis, and following release of groin
contractures.
ANATOMY
The superficial external pudendal artery originates from the medial side of the femoral artery at the level of the
saphenofemoral junction (3, 4, 5). At its origin, the vessel is 2 mm in diameter. It proceeds medially and
horizontally, crossing the femoral vein either above the saphenofemoral junction or, with equal frequency, in the
angle between the long saphenous and the femoral vein (Fig. 250.1). Piercing the femoral sheath and the
cribriform fascia, it proceeds medially and upward toward the pubic tubercle. Here, it gives off penile, scrotal, or
labial branches, and a variable number of small ascending branches toward the superficial inguinal ring. One of
the latter branches occasionally enters the inguinal canal. At this point, the vessel is just superficial to Scarpa's
fascia.
It then continues upward toward the umbilicus, gradually becoming more superficial (Fig. 250.2). There are two
constant sites of well-developed cross circulation, useful in the bilateral flap: they are at one-quarter and one-half
the distance between the symphysis pubis and the umbilicus. Halfway between the symphysis and the umbilicus,
the SEPA rapidly branches out into three to four longitudinal vessels, which arborize to form a subdermal plexus

in the juxta-umbilical region. On the lateral side, the vessel anastomoses freely with branches of the superficial
epigastric artery. The veins follow the arterial pattern, and a pair of venae comitantes accompany the SEPA.
FIGURE 250.1 Origin and early course of the SEPA.
FIGURE 250.2 A,B: Progressive depth of the artery. The vessels become more superficial in their course to the
umbilicus.
FLAP DESIGN AND DIMENSIONS
The anterior superior iliac spine, the pubic tubercle, and the proximal part of the femoral artery are marked; the
full length of the SEPA is marked next (Fig. 250.3). The midline is marked upward from the pubis to just below
the umbilicus. The length of this line can be decreased, according to the requirements of the case. From the

upper end of the midline, a horizontal line is drawn laterally for about 3.8 cm. A vertical line is then dropped from
the lateral end of the horizontal line; this vertical line reaches down to the level of the pubic tubercle, but stays at
least 19 to 25 mm lateral to it. Instead of a horizontal line just described, a sloping line can be outlined for
particular digital defects. Using a bilateral flap, similar markings are made on the contralateral side; a bilateral
flap can also be designed with halves of unequal length, again meeting the requirements of particular digital
defects.
OPERATIVE TECHNIQUE
General anesthesia is commonly used, although local anesthesia has been suitable for unilateral flaps, making it
easier to immobilize the hand postoperatively. The flap is cut according to the design and modifications
described above. With bilateral flaps, the midline incision is omitted. The length of the flap is adjusted to the
requirements of the case; a “cut as you need” approach should be adopted. The thickness of the flap should be
in accordance with the anatomy described. As the flap is prepared, perforating vessels of the inferior epigastric
artery are encountered on their way to the skin; as many as necessary of these vessels can be cut safely. (No
undue postoperative edema has been noted in these flaps, indicating adequate venous and lymphatic drainage.)
The axial vessel is divided on postoperative day 10, and the flap is detached and inset in the third postoperative
week. Flap detachment after 15 days is possible, if the initial inset is almost complete. In those cases where the
axial vessel cannot be sectioned for technical reasons prior to detachment of the flap, no untoward effect has
been noted.
The position of the flap in relation to the hand makes it possible to immobilize the hand postoperatively in a
comfortable position. This is especially so when a unilateral flap is used, as it is long and narrow, and can be
rotated up to 180° on either side, avoiding the need for rigid postoperative immobilization. A bilateral flap
provides a width of about 10 cm. The donor site of a unilateral flap can always be closed by direct suture. With a
bilateral flap, the donor site requires a skin graft, after reducing the raw surface by marginal sutures.
FIGURE 250.3 Design of bilateral SEPA flaps. (From Dias et al., ref. 4, with permission.)

FIGURE 250.4 A-D: Use of unequal bilateral flaps for multiple finger sites. (From Dias et al., ref. 4, with
permission.)
The mobility of the flap makes it possible to use it either on the dorsal or palmar surface of the hand. The flap
can also be deepithelialized and applied, as required, to the palmar surface of the hand and fingers. Although the
presence of hair in the lower part of the flap is a disadvantage, this problem can be decreased, as the upper part
of the flap is utilized most of the time. In extreme cases, the hair-bearing skin can be excised, and a split-
thickness skin graft applied over the subcutaneous fat.
CLINICAL RESULTS
The SEPA flap has been used to cover exposed tendons, phalanges, metacarpals, and
metacarpophalangeal and interphalangeal joints. The unilateral flap is used predominantly on the digits
(Fig. 250.4), while the bilateral flap is used on the hands (Fig. 250.5). The bilateral flap has also been used
as a tubed flap to cover a totally degloved thumb or finger, and for the reconstruction of a new thumb. When
used for multiple fingers, these are syndactylized prior to flap application. The flap has also been utilized in
a wraparound fashion for the finger, when both dorsal and palmar surfaces are exposed. The unilateral flap
has been used to correct adduction contractures between thumb and index fingers.

FIGURE 250.5 A-C: Correction of adduction contracture between thumb and index finger. (From Dias et al.,
ref. 4, with permission.)
The SEPA flap can be used by itself, or combined with a groin flap or a superficial epigastric artery flap, to
cover large avulsion injuries of the thumb, fingers, and hand. Its use with the anterior rectus sheath with
split-thickness skin coverage has been mentioned previously. For old dorsal injuries of the hand, where
extensor tendons are involved in the scar, the skin has been replaced with a SEPA flap, and an anterior
rectus sheath flap as a separate layer has been placed under the tendons.
Early mobilization has been vigorously pursued (2). Functional results have been most encouraging, but
have varied according to the severity of the injury. The quality of the primary skin coverage contributes
greatly to good functional results, and makes any further required reconstructive work on bones or tendons
easier. Subsequent defatting of some flaps has been necessary. In the series reported, three flaps were lost
due to gross infection from contamination at the time of injury.
SUMMARY
The SEPA flap, which is reliable, safe, and versatile, is a useful addition to the repertoire of the
reconstructive surgeon.
References
1. Thatte RL, Patil UA, Dhami LD. The combined use of the superficial external pudendal artery flap with a
flap of the anterior rectus sheath for the simultaneous cover of dorsal and volar defects of the hand. Br J
Plast Surg 1986;39:321.
2. Thatte RL, Patil UA. Flap skin cover in the hand: three new additions. In: Boswick, ed., Upper extremity
surgery and rehabilitation. Rockville: Aspen, 1986.
3. Patil UA, Dias AD, Thatte RL. The anatomical basis of the SEPA flap. Br J Plast Surg 1987;40:342.
4. Dias AD, Thatte RL, Patil UA, et al. The uses of the SEPA flap in the repair of defects of the hands and
fingers. Br J Plast Surg 1987;40:348.

5. Dias AD. The superficial external pudendal artery (SEPA) axial pattern flap. Br J Plast Surg 1984;37:256.

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Chapter 251
Vascularized Adipofascial Island Flap for Thenar Augmentation in
Pollicization
KEVIN CHEUNG
JANET H. YUEH
AMIR H. TAGHINIA
JOSEPH UPTON
EDITORIAL COMMENT
The use of “spare parts” adds to the appearance of the reconstructed thumb.
INDICATIONS
Blauth types IIIB, IV, and V represent the most severe forms of congenital thumb hypoplasia (1). In these
types, there is a functionless thumb remnant (IIIB and IV) or complete thumb absence (type V). Index finger
pollicization remains the preferred technique for reconstruction of these severe deformities. Good functional
outcomes with excellent longevity have been reported (2, 3, 4, 5, 6). The pollicized index finger, however,
lacks normal pinch strength due to hypoplasia or absence of median
nerve-innervated thenar intrinsic muscles. Furthermore, there is persistent hollowing of the thenar eminence
due to lack of these muscles. Thenar augmentation may be achieved using a vascularized adipofascial
island flap from the discarded thumb remnant in patients with Blauth type IIIB or IV hypoplastic thumbs (7).
Surgical indications for the vascularized adipofascial island flap for thenar augmentation include the
presence of a hypoplastic thumb remnant during index pollicization. The inability to close the palm without
tension is a relative contraindication. Indications and contraindications for index pollicization have been
described previously, but in brief, most patients with severe thumb hypoplasia or absence are candidates
barring significant neurologic, cardiovascular, or hematologic deficiency that would preclude use of the
reconstructed hand or represent serious surgical or anesthetic risk (8).
ANATOMY
The vascularized adipofascial island flap is derived from the hypoplastic thumb remnant that would usually be
discarded. Anatomy of this remnant varies depending on the severity of deformity. The flap, consequently, may
be based on one or two digital arteries and its venae comitantes. These vessels arborize at inconsistent levels
from the common digital artery that courses along the radial aspect of the index finger (Figs. 251.1 and 251.2). In
remnant thumbs with a large dorsal skin bridge, a dorsal vein may be included.
Flap Design and Dimensions
Dimensions of the adipofascial island flap may be designed dependent on the volume of bulk required to
reconstruct the thenar eminence (Fig. 251.3). This volume is limited by the size of the remnant hypoplastic thumb
after excision of rudimentary bone, nail matrix, and extra skin.

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FIGURE 251.1 This type IV thumb demonstrates the axial pedicle arborizing from the radial digital artery to the
index finger. All of the pulp tissue that would normally be discarded was transposed to create a thenar
prominence. (From Upton J, Sharma S, Taghinia AH. Vascularized adipofascial island flap for thenar
augmentation in pollicization. Plast Reconstr Surg 2008;122(4):1089-1094.
doi:10.1097/PRS.0b013e3181858c29, with permission.)
OPERATIVE TECHNIQUE
Index pollicization is performed as previously described (8, 9). A racquet-shaped incision, maximizing use of all
available soft tissue, is designed across the base of the index finger with radial extension towards the palm or
along the radial border of the hand. Volar and dorsal skin and subcutaneous tissue flaps are elevated, permitting
identification and preservation of the vessels to the rudimentary thumb. The thumb is then isolated as a vascular
island with inclusion of a dorsal vein if present. The bone, nail matrix, and extra skin are then excised, creating a
filet flap of the rudimentary thumb. Skin segments may be de-epithelialized for inclusion if additional volume is
required. Palmar skin may also be retained and inset as an adipofasciocutaneous island flap if required.
Pollicization then proceeds with mobilization of the index finger, including division of the A1 pulley, ligation of the
radial digital artery to the long finger, mobilization of the intrinsic muscles, and metacarpal osteotomy and
repositioning. Extensor tendon and intrinsic muscles are then rebalanced and reinserted as appropriate. After
tourniquet deflation, the soft tissue is redraped with the index finger in its new position. The adipofascial island
flap is then positioned in the thenar region to create a natural-appearing bulge of the thenar eminence (Fig.
251.4). Tension-free closure is performed, and a concave web space between the metacarpophalangeal joint of
the pollicized index finger and the long finger is created.

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FIGURE 251.2 A larger type IV hypoplastic thumb with a more proximal branching point. The arterial arch is
incomplete. More tissue was available for transposition to create the appearance of a thenar eminence. (From
Upton J, Sharma S, Taghinia AH. Vascularized adipofascial island flap for thenar augmentation in pollicization.
Plast Reconstr Surg 2008;122(4):1089-1094. doi:10.1097/PRS.0b013e3181858c29, with permission.)
CLINICAL RESULTS
The vascularized adipofascial island flap for thenar augmentation in patients undergoing pollicization has
been described in a case series of 14 children between the ages of 10 months and 5 years (7). Follow-up
ranged from 1 to 26 years. All patients were satisfied with the appearance of their hand. Although more
tissue is available for bulk in larger Blauth type IIIB thumbs, the transfer of pulp tissue from a smaller
remnant still results in an appreciable improvement. Functional outcomes were similar to children
undergoing pollicization without use of the adipofascial island flap. Instead, functional outcomes were more
dependent on the preoperative status (stiffness) of the index finger and the remainder of the hand. Long-
term
follow-up demonstrated maintenance of the reconstructed thenar eminence over time (Figs. 251.5 and
251.6). No cases of flap loss were observed. In one patient, sutures were removed because of early
postoperative swelling and delayed closure was completed 48 hours later without any vascular compromise.

FIGURE 251.3 A larger type IV hypoplastic thumb with a more proximal branching point. The arterial arch is
incomplete. More tissue was available for transposition to create the appearance of a thenar eminence.
(From Upton J, Sharma S, Taghinia AH. Vascularized adipofascial island flap for thenar augmentation in
pollicization. Plast Reconstr Surg 2008;122(4):1089-1094. doi:10.1097/PRS.0b013e3181858c29, with
permission.)

FIGURE 251.4 A functionless type IIIB hypoplastic thumb in a child with previous radialization for radial
longitudinal deficiency and multiple camptodactyly releases (above, left). The thumb tissue is isolated as a
vascularized island (above, right), shown by the black arrow. All of the adipofascial tissue and pulp are
then dissected and transposed into the thenar eminence (below, right), shown by the white arrow.
Improvement in hand contour is seen following pollicization and transposition of the adipofascial flap
(below, left). (From Upton J, Sharma S, Taghinia AH. Vascularized adipofascial island flap for thenar
augmentation in pollicization. Plast Reconstr Surg 2008;122(4):1089-1094.
doi:10.1097/PRS.0b013e3181858c29, with permission.)

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FIGURE 251.5 The left (above, left) and right (above, right) hands of a child with bilateral type IV
hypoplastic thumbs are illustrated. This was the first patient to undergo augmentation of the thenar
eminence with a vascularized adipofascial island flap. The same patient at long-term follow-up, 26 years
later (below). (From Upton J, Sharma S, Taghinia AH. Vascularized adipofascial island flap for thenar
augmentation in pollicization. Plast Reconstr Surg 2008;122(4):1089-1094.
doi:10.1097/PRS.0b013e3181858c29, with permission.)
SUMMARY
In patients with severe thumb hypoplasia, atrophy or complete absence of the median innervated thenar
muscles results in a flat palm and an abnormal appearance (Fig. 251.7). The rudimentary thumb is routinely
discarded during index finger pollicization, and a vascularized adipofascial island flap can be easily
harvested from these remnant tissues and used to augment the thenar area of the hand. This procedure
improves the appearance of the hand while adding no morbidity and requiring very little time to perform.
While aesthetics are often considered secondary to functional parameters, patients still consider this aspect
of reconstruction quite important (10). Patients with a more normal-appearing hand will be less inclined to
hide and more likely to use their reconstructed hand.

FIGURE 251.6 Preoperative and postoperative molds of three patients with type IV hypoplastic thumbs. The
vascular bundle to the rudimentary thumb arborizes at the distal (above), middle (center), and proximal
(below) portions of the index metacarpal, respectively. All of these cases included adipofascial island flap
augmentation of the thenar eminence. (From Upton J, Sharma S, Taghinia AH. Vascularized adipofascial
island flap for thenar augmentation in pollicization. Plast Reconstr Surg 2008;122(4):1089-1094.
doi:10.1097/PRS.0b013e3181858c29, with permission.)
FIGURE 251.7 Example of pollicization without adipofascial island flap augmentation of the thenar
eminence. This patient with type V thumb hypoplasia (absent thumb) underwent pollicization 1 year earlier.
Without extra tissue for augmentation, the thenar area is flat and atrophic. (From Upton J, Sharma S,
Taghinia AH. Vascularized adipofascial island flap for thenar augmentation in pollicization. Plast Reconstr

Surg 2008;122(4):1089-1094. doi:10.1097/PRS.0b013e3181858c29, with permission.)
References
1. Kozin SH. Deformities of the thumb. In: Wolfe SW, Hotchkiss RN, Pederson WC, et al., eds. Green's
Operative Hand Surgery, 6th ed. Philadelphia: Elsevier Health Sciences, 2011;1371-1403.
2. Manske PR, Rotman MB, Dailey LA. Long-term functional results after pollicization for the congenitally
deficient thumb. J Hand Surg 1992;17(6):1064-1072. doi:10.1016/S0363-5023(09)91063-2.
3. Ogino T, Ishii S. Long-term results after pollicization for congenital hand deformities. J Hand Surg
1997;2(2):79. doi:10.1142/S021881049700015X.
4. Staines KG, Majzoub R, Thornby J. Functional outcome for children with thumb aplasia undergoing
pollicization. Plast Reconstr Surg 2005;116(5):1314-1323. doi:10.1097/01.prs.0000181820.36306.a0.
5. Netscher DT, Aliu O, Sandvall BK, et al. Functional outcomes of children with index pollicizations for thumb
deficiency. J Hand Surg Am 2013;38(2):250-257. doi:10.1016/j.jhsa.2012.10.032.
6. Goldfarb CA, Deardorff V, Chia B, et al. Objective features and aesthetic outcome of pollicized digits
compared with normal thumbs. J Hand Surg Am 2007;32(7):1031-1036. doi:10.1016/j.jhsa.2007.05.028.
7. Upton J, Sharma S, Taghinia AH. Vascularized adipofascial island flap for thenar augmentation in
pollicization. Plast Reconstr Surg 2008;122(4):1089-1094. doi:10.1097/PRS.0b013e3181858c29.
8. Upton J. Index pollicization for congenital absence and hypoplasia of the thumb. In: Strickland JW, Graham
TJ, eds. Master Techniques in Orthopedic Surgery, 2nd ed. Philadelphia: Lippincott Williams & Wilkins,
2005:149-170.
9. Taghinia AH, Littler JW, Upton J. Refinements in pollicization. Plast Reconstr Surg 2012;130(3):423e-
433e. doi:10.1097/PRS.0b013e31825dc21f.
10. Giorgio P, Medina J, Khoury R, et al. A plea for improving appearance and function in pollicization for
congenital conditions. J Hand Surg 2003;28(suppl):35.

Chapter 252
Dorsolateral Neurovascular Skin Flap of The Finger
B. B. JOSHI
Local dorsolateral flaps from either side of the finger can be used for volar defects. The flap provides both cover
and sensation (1, 2, 3). Deficiency of skin from one-half to three-quarters of the proximal or middle segment of
the finger can be replaced by local dorsolateral flaps.
INDICATIONS
This flap can be used in multiple finger contractures and in skin loss over the volar aspect of the digits when
multiple fingers are involved. It has the advantages of being a one-stage procedure, involving only the
injured digit and offering a large and relatively expandable donor area for the reconstruction of the more
important volar surface of the fingers.
If a digital vessel is thrombosed, even on one side, the procedure should not be attempted because it may
jeopardize the circulation of the finger that is already deficient. Proper selection of cases and establishing
the patency of the volar digital vessels are prerequisites for the procedure.
ANATOMY
Adjacent to the base of the proximal phalanx, each collateral volar digital nerve gives off a dorsal branch that
joins the dorsal digital branches of the radial or ulnar nerve and supplies the skin on the dorsal surface of the
fingers. These are accompanied by branches of the digital vessels. Together these make possible a flap based
on a specific neurovascular attachment on either side, over the dorsolateral surface of the finger. This flap can
be shaped and swung volarly to provide a fully innervated prehensile surface for the area deficient in skin. The
venous drainage of the flap is usually excellent, because most of the veins in the fingers are on the dorsal
surface. The vascularity of flaps from the dorsum has already been emphasized by several authors (4, 5).
FLAP DESIGN AND DIMENSIONS
Requirements for the size and shape of the flap would depend on the defect that is created after the release of
the contracture. It is usually 1.5 to 2 cm in width and 2 to 3 cm in length.
A flap is designed on the dorsolateral aspect of the finger with the midlateral incision as its volar boundary and
the dorsal midline as its dorsal boundary. Distally the flap can be extended up to the crease of the distal
interphalangeal joint (Fig. 252.1C).
OPERATIVE TECHNIQUE
Recipient Site
Midlateral incisions are made over either side of the finger, joining the distal interphalangeal and proximal
interphalangeal flexion creases. These may be extended proximally and/or distally, if needed, to expose volar
digital neurovascular bundles in a healthy area. The neurovascular bundles are freed from scar.
An oblique incision is made over the middle segment of the finger, joining the two midlateral incisions to convert
them into an N or its reverse, according to the requirements of the dorsoulnar or dorsoradial flap. The scarred
skin is not excised. The finger is straightened by dissecting the involved structures and by using gentle force to

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overcome the contracture (Fig. 252.2). If a contracture of the flexor sheath needs to be released, the tendon will
be exposed.
Donor Site
The flap is raised along with deep fascia, leaving only flimsy areolar tissue over the extensor expansion to
envelop and protect the dorsal digital vessels and nerves. Special care should be
taken while dissecting near the base of the flap where the vessels and nerves branch off from the volar
neurovascular bundle, by limiting dissection on the volar boundary of the flap.
FIGURE 252.1 A: Design for release of flexion contracture. B: Resulting defect with exposure of underlying
structures. C: Elevation of the dorsolateral flap. D: The flap inset. E: The donor site covered with a split-
thickness skin graft. (From Joshi, ref. 1, with permission.)
The flap is sutured over the volar aspect and the donor site is covered with a free skin graft held by a tie-over
dressing.
The finger is splinted with the interphalangeal joints held in extension and the metacarpophalangeal joint in
flexion, to avoid tension on the digital neurovascular bundles.
CLINICAL RESULTS
Necrosis of the transposed flap can occur in a few instances. This may be due to an accidental injury to the
dorsal branch of the volar neurovascular bundle at the proximal part of the dissection. Poor selection of
cases where dorsal skin has scanty subcutaneous padding can also lead to necrosis of the flap due to
insufficient circulation. This is avoidable if a doubtful flap is delayed before transfer and the operation is
completed as a two-stage procedure. In about 5% of cases, superficial blister or marginal necrosis of the
flap occurs, but these heal subsequently and show some depigmentation of the new skin.
In a series of 156 cases, 95% had satisfactory results following dorsolateral flaps from the same finger,

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either to release flexion contractures or to cover traumatic wounds on the volar surface of the fingers.
SUMMARY
The dorsolateral skin flap can provide sensory coverage to volar defects or release volar skin contractures
over the proximal and middle phalanges of the same finger.
FIGURE 252.2 A: Flexion contractures of right middle and ring fingers before correction. B: Defects on the
volar surfaces created after straightening the fingers. C: Raised dorsolateral flaps. D: The flaps sutured
into the volar defects. E,F: Postoperative results. (From Joshi, ref. 1, with permission.)
References
1. Joshi BB. Dorsolateral flap from the same finger to relieve flexion contracture. Plast Reconstr Surg
1972;49:186.
2. Joshi BB. A local dorsolateral island flap restoration of sensation after avulsion injury of fingertip pulp.
Plast Reconstr Surg 1974;54:175.
3. Joshi BB. Sensory flaps for the degloved, mutilated hand. Hand 1974; 6:247.
4. Flint MH, Harrison, SH. A local neurovascular flap to repair loss of the digital pulp. Br J Plast Surg
1965;18:156.
5. Holevich J. A new method of restoring sensibility to the thumb. Bone Joint Surg 1963;45(B):496.

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Chapter 253
Arterialized Side Finger Flaps for The Proximal Interphalangeal
Joint
R. C. RUSSELL
E. G. ZOOK
Hand burns requiring skin grafts most commonly involve the dorsal surface. Breakdown of a healed split-
thickness skin graft over the proximal interphalangeal joint is a difficult problem to manage. The exposed joint is
prone to infection that can destroy gliding surfaces and produce chronic osteomyelitis and loss of the finger.
Adjacent fingers, when covered with skin grafts, are unavailable as cross-finger flap donor sites. Further skin
grafts over the exposed joint are not feasible.
FIGURE 253.1 A: The arterialized side finger flap is centered over the neurovascular bundle on the
nondominant side of the finger. The volar incision is darted at the interphalangeal joint flexion creases and
angled from the midline distally toward the entry point of the artery into the finger at the metacarpophalangeal
joint flexion crease proximally. B: The digital artery is incorporated into the flap, while the digital nerve is left
undisturbed. C: Excising the intervening skin bridge, the flap is easily rotated dorsally, to cover the exposed
proximal interphalangeal joint.
A proximally based arterialized side finger flap, elevated from the lateral/volar surface of the involved digit, can be

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rotated dorsally to cover the defect, preserving the joint and finger (1).
ANATOMY
Random pattern flaps of a length sufficient to cover the proximal interphalangeal joint would have a marginal
blood supply (2, 3). Inclusion of the digital artery creates an axial pattern flap with excellent vascularity. The
generous flap blood supply aids in the resolution or prevention of infection and helps prevent joint destruction.
FLAP DESIGN AND DIMENSIONS
The flap is centered over the volar digital neurovascular bundle, preferably on the nondominant side of the finger
(Fig. 253.1A). Based proximally and extending 3 to 5 mm past the distal interphalangeal joint flexion crease, the
flap incorporates the digital artery but leaves the digital nerve intact (Fig. 253.1B). Sensation to the fingertip and
to the soft tissue over the distal phalanx is therefore preserved.
OPERATIVE TECHNIQUE
A dorsal incision is first made along the midaxial line, with dissection volarly deep to the neurovascular bundle.
The volar skin incision begins along the midline of the digit distally. It is angled away from the midline proximally
toward the entry point of the digital artery into the finger at the metacarpophalangeal joint flexion crease (Fig.
253.1A).
The digital artery is carefully separated from the nerve and elevated with the flap (Fig. 253.1B). Cleland's and
Grayson's ligaments are divided along the length of the digit. The venous drainage accompanying the artery and
in the base of the flap is carefully preserved by blunt dissection.
The edges of the dorsal defect surrounding the exposed proximal interphalangeal joint are circumferentially
excised, including a bridge of skin between the dorsal defect and the flap donor site. The flap is then rotated
dorsally and easily covers the proximal interphalangeal joint (Fig. 253.1C). The donor site is darted at the distal
and proximal interphalangeal joint flexion creases, to prevent a straight line volar scar (Fig. 253.1A).
The donor defect is covered with a full-thickness skin graft from the inguinal flexion crease and secured with a
stent dressing. The finger is immobilized for 7 to 10 days to facilitate skin graft survival.
CLINICAL RESULTS
The full-thickness skin graft placed over the retained donor site digital nerve becomes reinnervated and
provides stable skin cover. Two-point discrimination to the fingertip on the side of the flap is not affected. In
most cases, a full range of
digital motion is infrequently achieved, due to prior joint damage, stiffness, or extensor tendon scarring
following burn injury. When indicated, reconstruction of the extensor mechanism can be achieved without
difficulty at a later date by reelevation of the flap.