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

Chapter 254
Tendocutaneous Dorsal Finger Flap
B. B. JOSHI
EDITORIAL COMMENT
The blood supply to the tendinous portion of the flap is extremely tenuous and the editors believe that there
is a significant likelihood of losing circulation to the tendon.
The cylindrical shape of the fingers usually confines destruction of tissue on the dorsum, such as that caused by
friction injury or contact burn, to a central strip of tissue including the central slip of the extensor mechanism. The
lateral bands and the overlying skin are often spared. These unaffected lateral bands, along with the overlying
skin with neurovascular connection, are readily available for transfer en masse as a composite flap, not only to
cover dorsal defects over the fingers, but also to allow lateral band plasty to achieve active extension of the PIP
joint in a single maneuver (1, 2, 3, 4).
INDICATIONS
The main clinical use of this flap is salvaging active extension at the PIP joints. It can also be used to
provide cover over open PIP joints, since the vascularity of this flap helps in the resolution of infection and
joint destruction. In addition, I have used this flap for providing skin cover to heal chronic ulcers over the
dorsum of the middle phalanx due to osteomyelitis.
ANATOMY
The dorsal digital branch of the volar digital vessel enters the base of the flap and runs between the skin and the
tendon. The skin flap is thus supplied by perforating branches. The transverse and oblique retinacular ligaments
arising from the flexor tendon sheath cover these vessels. In this type of pathology, these ligaments are in a
contracted state and need to be cut, to allow the dorsal displacement of the lateral bands and exposure of the
volar neurovascular bundles. Careful blunt dissection along the flexor digital sheath will make the neurovascular
bundle lax enough for lateral displacement along with the flap, and any tension on these delicate branches when
the flap is being transferred dorsally will be avoided.
The venous drainage of the flap accompanies the main vessel supplying the flap. It enters at the base of the flap
and needs careful dissection. The vascularity of the flap is very good, because the perforating vessels remain
undisturbed.
FLAP DESIGN AND DIMENSIONS
The usual measurement of such a flap is about 1 ×3.5 cm. The volar boundary is the anterolateral border of the
finger. The dorsal boundary is the junction of healthy skin with scar, and distally it can reach as far as the distal
IP joint area.
OPERATIVE TECHNIQUE
An appropriate area of scar tissue to be excised is marked on the dorsum of the finger. A similar area is marked

for transfer of the flap from the adjacent skin of the relatively unaffected lateral side of the finger. The volar limit
of this flap is the anterolateral joint line; dorsally it starts where scar tissue ends.
The oblique and transverse retinacular ligaments are divided in the long axis of the finger and the lateral band is
freed at the distal end of the flap without separating the skin over it. A composite flap of skin and lateral band
with the neurovascular connection is thus raised.
The vessels and nerves entering the flap are protected by mobilizing the volar neurovascular bundle and by
displacing it laterally, to avoid tension on these delicate structures when the flap is transferred dorsally.
The bed is then prepared by excising the scar tissue and the composite flap is transferred over this defect on the
dorsum of the finger. The free distal end of the lateral band in the flap is sutured to the lateral band on the
opposite side of the finger, after mobilizing it dorsally from its volarly displaced position (Fig. 254.1).
The donor site of the composite flap is resurfaced by a split-thickness skin graft with darts on the anterolateral
border of the finger, to avoid flexion contracture of the finger from a linear scar.
FIGURE 254.1 Line drawing of the procedure. (From Joshi, ref. 1, with permission.)
CLINICAL RESULTS
The tendocutaneous flap has thus far been without vascular problems. A linear scar contracture at the
anterolateral border of the finger can be avoided if the donor site is darted at the volar flexion creases and
is covered by a thick split-thickness skin graft or a full-thickness skin graft (Fig. 254.2).
In 28 fingers in which I used the tendocutaneous flap, restoration of healthy skin cover has been achieved
in all cases. In cases where the active extensor mechanism could not be restored, the flap improved the
condition for future restoration of extension by a tendon transfer or graft. The flap provides a vascularized
bed for the grafted tendon.

FIGURE 254.2 A: Friction burns over the index and middle fingers with loss of active extension. B: Full
flexion of proximal interphalangeal joints. C: Full passive extension of proximal interphalangeal joints. D,E:
Postoperative extension and flexion.
SUMMARY
The tendocutaneous flap can be used not only to cover the dorsum of the PIP joint, but also to restore
active extension.
References
1. Joshi BB. A salvage procedure in the treatment of boutonniere deformity caused by contact burn and
friction injury. Hand 1982;14:33.
2. Flint MH, Harrison SH. A local neurovascular flap to repair loss of the digital pulp. Br J Plast Surg
1965;18:156.
3. Littler JW. Neurovascular pedicle transfer of tissue in reconstructive surgery of the hand. J Bone Joint
Surg 1956;38(A):917.
4. Joshi BB. A local dorsolateral island flap restoration of sensation after avulsion injury of fingertip pulp.
Plast Reconstr Surg 1974;54:175.

Chapter 255
Dorsal Cross-Finger Flaps
B. W. EDGERTON
R. W. BEASLEY
The repair of major soft-tissue losses of the digits should be accomplished with local tissues whenever practical.
At least 30 authors have made significant contributions to the literature about the clinical applications of cross-
finger flaps, comprising experiences with more than 500 cases (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16,
17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31).
INDICATIONS
The cross-finger flap is a sturdy, versatile flap that can be used in the following general situations.
Loss of Volar Finger Tissues (see Fig. 255.2)
Significant loss of volar tissue that requires flap coverage is the prime indication for a laterally based cross-
finger flap. In acute traumatic injuries, this will provide necessary coverage of tendons, bones, and joints, to
assure primary healing; it will also provide good coverage for secondary reconstruction of the deeper
structures. Tumor excisions or the release of posttraumatic, congenital, or Dupuytren's contractures also
may expose structures that cannot be covered with local tissues or a skin graft, in which case a laterally
based cross-finger flap may offer the best solution.
Loss of Dorsal Finger Tissue (see Fig. 255.3)
Dorsal tissue loss with exposed tendons or joints has been treated traditionally with distant flaps. When
feasible, local flaps are clearly superior. A cross-finger flap, distally based, or in some cases even proximally
based, or a “flag flap” with its mobile narrow pedicle (21, 22), often can be used for closure of dorsal finger
wounds. Occasionally, a deepithelialized cross-finger flap is an alternative to close these wounds (19, 23,
24).
Major Fingertip Amputations (see Fig. 255.4)
Many methods have been advocated to treat fingertip amputations, but major amputations with exposed
bone (dorsal oblique or guillotine) may be treated with distally based cross-finger flaps. Thenar flaps are
generally the best solution for these injuries, but a cross-finger flap may be more practicable in special
circumstances. Examples are when the amputation is proximal, when joint stiffness exists, or when there are
multiple amputations.
ANATOMY
Dorsal finger skin is basically vascularized by a network of longitudinally oriented vessels that permit a wide
latitude of flap design with safety. The proximally based flaps are especially sturdy, because they are based on
the axial system of the two dorsal branches of the digital neurovascular bundles. The efficiency of this system is
impressively demonstrated by the “flag flap,” with which a large block of dorsal tissue is reliably supported by
only one of these dorsal branches passing through a very narrow pedicle (see Chapter 238).
This longitudinal orientation of vessels provides excellent retrograde flow, permitting long flaps to be based
distally, as is usually required for closure of fingertip amputations. Experience has shown that the vascular
network of dorsal skin also permits the flaps to be based laterally (Fig. 255.1). In laterally based flaps where both

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axial dorsal branches are divided, circulation is maintained principally through the rich dermal and subdermal
plexuses. This blood supply allows the tissue to be de-epithelialized for use as a “reverse dermis” flap (23, 24)
(see Chapter 256).
FLAP DESIGN AND DIMENSIONS
Dorsal cross-finger flaps are direct flaps, in that the defect is positioned directly under the open surface of the
flap (Fig. 255.2). Distally based flaps up to an approximate size of 3 cm in length by 2 cm in width may be raised
from the dorsum of the middle phalanx (Fig. 255.3). Usually an effort is made not to cross the proximal
interphalangeal joint, but it
has been demonstrated that this can be done, when necessary, without serious consequences (7). Laterally
based flaps can be designed over to the midaxial line opposite the pedicle, giving in the large adult dimensions of
up to about 3 cm in length and 6 cm in width. As previously discussed, the axial blood supply of proximally based
flaps allows the elevation of almost the entire dorsal surface of a finger as a flap.
FIGURE 255.1 Level of dissection of a dorsal cross-finger flap. Note that the paratenon is left intact on the donor
site. (From Beasley, ref. 20, with permission.)
FIGURE 255.2 A: Laterally based cross-finger flap used to cover a volar defect. B: Flap in position.
Initially the defect to be repaired should be adjusted to a shape that avoids a round scar or longitudinal scars

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crossing flexion creases, even if the excision of normal tissue is necessary. The finger is always positioned to
minimize proximal interphalangeal joint flexion. A pattern of the defect is cut and pressed against the proposed
location of the flap pedicle.
The flap must be larger than the defect, and allowance must be made for the length of the pedicle bridge, to
avoid tension when it is sutured into place. The base of the flap may be oriented obliquely, to minimize twisting of
the pedicle in distally or proximally based flaps. Fingertip injuries require a flap approximately 1½ times the width
of the finger, to restore a round contour. All flaps should be measured twice before cutting.
FIGURE 255.3 Distally based cross-finger flap used to cover a dorsal defect.
OPERATIVE TECHNIQUE
Dorsal cross-finger flaps should be elevated just superficial to the paratenon overlying the extensor tendon (Fig.
255.1), which preserves an adequately vascularized bed for skin grafting and minimizes damage to the network
of vessels in the flap. When a long laterally based flap is needed, Cleland's ligaments can be divided and the
neurovascular bundle dissected free from the base of the flap (Fig. 255.4). This not only lengthens the pedicle
and adds mobility, but also facilitates safe subsequent flap division. A full-thickness skin graft is used to repair
the donor site. When feasible, the graft should also cover the raw surface of the pedicle extending across to the
recipient finger.
Immobilization is accomplished with a dressing that provides gentle compression on the skin graft, dry gauze
under and around the fingers to prevent maceration, and tape to maintain the carefully selected position. The
dressing is covered with a plaster shell in which a window is cut for ongoing inspection. Use of a Kirschner wire
to hold the optimal position has been advocated (25) but it has not been necessary in our experience, unless it is
required for management of some concomitant problem.
If healing is uncomplicated, the pedicle may usually be divided in 10 to 14 days postoperatively as an office
procedure. The donor finger may be compressed with a proximal tourniquet and the vascularity of the flap
assessed before division. Flap tissues are intolerant of tension or handling immediately after pedicle division and
generally should not be inset at that time. The common exception is in small children who require an anesthetic
for pedicle division, and for these patients division is usually deferred until about 21 days. Wounds resulting from
division of the pedicle are allowed to epithelialize, as prompt and vigorous efforts are directed to achieve full joint
remobilization. When needed, a secondary revision is done several months later.

FIGURE 255.4 A: Volar fingertip defect. B: Elevation of a laterally based dorsal cross-finger flap. Note flap
thickness and paratenon left intact on donor site. C: Donor site covered with a full-thickness skin graft. D: Flap
sutured into position.
CLINICAL RESULTS
Of 546 cross-finger flaps reported in the English-language literature, only seven have had any necrosis
(usually partial), for a survival rate of 98.7%. Reported complications are infrequent, with authors reporting
47 patients (8.6%) with any joint stiffness (most mild); 31 with dysesthesia (5.7%) (most of a minimal
degree); 6 (1.1%) with loss of the graft; and 4 (0.7%) with infection. Restoration of well-functioning volar
padded skin was almost always achieved. An important parameter of success is the return of sensibility,
which generally requires at least 6 months. Seven authors who have carefully evaluated the return of two-
point discrimination have found that 80% to 90% of patients have 8 mm or less of static two-point
discrimination, which is roughly twice that of a normal finger pulp, but refined enough to be useful to the
patient (26, 27, 28, 29, 30, 31). These flaps can be used in children with excellent results and in older
adults, but every effort to avoid joint stiffness should be made, especially with older patients (27, 30).
Limitations of dorsal cross-finger flaps relate to the lack of substantial subcutaneous tissue, the limitations
of size, the presence of a dorsal donor site that may be disturbing to some patients, and the occasional
presence of hair in the flap, which is unaesthetic when transferred to the volar surface of the hand.
SUMMARY
Cross-finger flaps are valuable procedures and have withstood the tests of time and wide experience. Many
variations have been devised by imaginative surgeons to cover volar tissue losses, dorsal tissue losses,
and major digital amputations.

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References
1. Cronin TD. The cross finger flap in hand surgery. Ann Surg 1957;145:650.
2. Gurdin M, Pangman WJ. The repair of surface defects of fingers by trans-digital flaps. Plast Reconstr Surg
1950;5:368.
3. Horn JS. The use of full thickness hand skin flaps in the reconstruction of injured fingers. Plast Reconstr
Surg 1951;7:463.
4. Tempest MN. Cross finger flaps in the treatment of injuries to the fingertip. Plast Reconstr Surg
1952;9:205.
5. Barclay TL. The late results of fingertip injuries. Br J Plast Surg 1955-6;8:38.
6. Campbell Reid DA. Experience of a hand surgery service. Br J Plast Surg 1956;9:11.
7. Curtis RM. Cross finger flap in hand surgery. Ann Surg 1957;145:650.
8. Kleinert HE. Fingertip injuries and their management. Am Surg 1959;25:41.
9. Brody GS, Cloutier AM, Woolhouse FM. The fingertip injury: an assessment of management. Plast
Reconstr Surg 1960;26:80.
10. Hoskins HD. The versatile cross finger pedicle flap. J Bone Joint Surg. [Am.] 1960;42:261.
11. Gottlieb O, Mathiesen FR. Thenar flaps and cross finger flaps. Acta Chir Scand 1961;122:166.
12. Sturman MJ, Duran RJ. Late results of fingertip injuries. J Bone Joint Surg [Am] 1963;45:289.
13. Woolf RM, Broadbent TR. Injuries to the fingertips: treatment with cross finger flaps. Rocky Mt Med J
1967;8:35.
14. Wood RW. Multiple cross finger flaps: “piggy back” technique. Plast Reconstr Surg 1968;41:54.
15. Beasley RW. Local flaps for surgery of the hand. Orthop Clin North Am 1970;1:219.
16. Artz TD, Posch JL. Use of cross finger flap for treatment of congenital broad constricting bands of the
fingers. Plast Reconstr Surg 1973;52:645.
17. Wickstrom OW, Bromberg BE. Finger flaps. Plast Reconstr Surg 1973; 13:481.
18. Kisner WH. Cross finger flaps. Am Fam Phys 1979;19:157.

19. Russell RC, Van Beek AL, Wavak P, Zook E. Alternative hand flaps for amputations and digital defects. J
Hand Surg 1981;6:399.
20. Beasley RW. Hand injuries. Philadelphia: Saunders, 1981.
21. Iselin F. The flag flap. Plast Reconstr Surg 1973;51:374.
22. Vilain R, Dupuis JF. Use of the flag flap for coverage of a small area on a finger or the palm. Plast
Reconstr Surg 1973;51:397.
23. Pakiam AI. The reversed dermis flap. Br J Plast Surg 1978;31:131.
24. Atasoy E. Reversed cross-finger subcutaneous flap. J Hand Surg 1982;7:481.
25. Kislov R, Kelly AP. Cross finger flaps in digital injuries, with notes on Kirschner wire fixation. Plast
Reconstr Surg 1960;25:312.
26. Smith JR, Bom AF. An evaluation of fingertip reconstruction by cross finger and palmar pedicle flap. Plast
Reconstr Surg 1965;35:409.
27. Thomson HG, Sorokolit WT. The cross finger flap in children: a follow-up study. Plast Reconstr Surg
1967;39:482.
28. Porter RW. Functional assessment of transplanted skin in volar defects of the digits. J Bone Joint Surg
[Am] 1968;50:955.
29. Johnson RK, Iverson RE. Cross finger pedicle flaps in the hand. J Bone Joint Surg [Am] 1971;53:913.
30. Kleinert HE, MacDonald CJ, Kutz JE. A critical evaluation of cross finger flaps. J Trauma 1974;14:756.
31. Gelles M, Pool R. Two-point discrimination distances in the normal hand and forearm. Plast Reconstr
Surg 1977;59:57.

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Chapter 256
Reversed Cross-Finger Subcutaneous Tissue Flap
E. ATASOY
EDITORIAL COMMENT
This elegant chapter is, in reality, using a fasciocutaneous flap principle. In elevating the flap, care must be
taken to maintain the integrity of the subdermal plexus.
The principle of the deepithelialized reversed cross-finger subcutaneous tissue flap from the dorsum of one
finger can be widely applied to hand surgery (1, 2, 3, 4). It can be used successfully to cover large nailbed
defects with exposed distal phalanx, and full-thickness skin defects with exposed tendon and bone.
INDICATIONS
This flap can be used for reconstruction of an avulsed eponychial skin fold and for coverage of exposed
tendon near the distal interphalangeal joint (Fig. 256.1). It can also be used for reconstruction of large full-
thickness sterile matrix nailbed defects with exposed bare distal phalanx (Fig. 256.2), with or without skin
loss.
Any contused, repaired, or grafted extensor tendon denuded of peritenon can be covered with this flap, as
can a boutonniere deformity with poor quality skin over the proximal interphalangeal joint.
FLAP DESIGN AND DIMENSIONS
The best donor site for this flap is the dorsum of the middle and proximal phalanges. The area over the distal
interphalangeal and proximal interphalangeal joints should be avoided because of the thinness of the
subcutaneous tissue in these areas.
The skin is marked on the dorsum of the middle phalanx of the adjacent finger approximately 3 to 4 mm larger
than the defect (Fig. 256.1A).

FIGURE 256.1 A: Reconstruction of the eponychium and coverage of the nail root and extensor tendon with
deepithelialized reverse cross-finger subcutaneous flap. The small area of preserved skin, after reversing, forms
the inner surface of the eponychium. B: A flap composed of the full thickness of skin alone is elevated and based
along the opposite side of the finger. A subcutaneous flap is elevated and based on the side of the finger next to
the defect. Note that the portion of intact skin, once reversed, will form the lining of the eponychial fold. C: The
subcutaneous flap is reversed onto the defect and then covered with a full-thickness skin graft. The full-
thickness skin flap that was elevated off the donor site is then replaced over the intact paratenon and held with a
tie-over dressing. D: Postoperative result at 1 year. Full nail growth with little deformity. (From Atasoy, ref. 4, with
permission.)
OPERATIVE TECHNIQUE
A thin full-thickness skin flap is elevated under magnification and left attached to the donor finger along the
opposite side from the injured finger. Then a full-thickness subcutaneous flap, excluding peritenon, is raised in
the opposite direction by placing the base next to the recipient finger (Fig. 256.1A).
Following meticulous hemostasis, the flap is reversed and sutured to the dermis of the recipient finger. The
donor defect is covered with the previously elevated thin full-thickness skin, and a tie-over dressing is applied. A
free thin full-thickness skin graft is used to surface the reversed side of the subcutaneous flap, which is covered
with a soft dressing, so that there will be no pressure on the flap.
After 2 weeks of immobilization the flap is divided and inset, and gentle mobilization is begun.
For reconstruction of the eponychial skin fold, an area of skin, appropriately sized and shaped to fit the defect, is
preserved along the distal portion of the flap (Fig. 256.1B). This preserved skin forms the inner surface of the
reconstructed eponychial skin fold after the reversing and suturing of the flap to the margins of the defect.
When the procedure is used to cover large nailbed defects with exposed distal phalanx and intact germinal
matrix, in which there is a good chance for the nail to grow, the reversed flap should not be covered with a skin
graft as a permanent procedure. Rather it should be allowed to epithelialize by remaining nailbed. By doing so,
the growing nail will have a better chance to adhere to its new bed (Fig. 256.2).

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However, in a case of complete avulsion of the nailbed, germinal matrix, and surrounding skin with exposed bone
and extensor tendon, the reversed side of the flap should be covered with a skin graft as a permanent
procedure, since there is no chance for the nail to grow.
FIGURE 256.2 A: Coverage of exposed distal phalanx and reconstruction of large nailbed defect. Defect on
small finger and preparation of flap on ring finger. B: Reversed subcutaneous flap covering the nailbed defect
without skin coverage. Tie-over dressing on the donor site. C,D: Six months postoperatively, showing
satisfactory nail growth.
FIGURE 256.3 A: Full-thickness skin loss with exposed, lacerated extensor tendon denuded of peritenon of
index finger. Elevated full-thickness skin and mobilized flap on the middle finger. B: Reversed flap covering the
defect and previously elevated full-thickness skin laid down on the donor site. C: Six months postoperatively.

CLINICAL RESULTS
Complications are very rare if the procedure is done properly and according to the rules of ordinary cross-
finger flaps (Fig. 256.3). Epithelial cyst formation from the reversed dermal elements is rare. These skin
elements usually disappear after a few weeks (5). In this series there was no evidence of cyst formation in
the several cases that were followed 1 to 3 years postoperatively.
SUMMARY
The reversed cross-finger subcutaneous flap can be widely applied to hand defects, especially to dorsal
finger injuries with nailbed defects or with exposed tendon, bone, or joint.
References
1. Clodius L, Shamel J. The reversed dermal fat flap: a case report. Plast Reconstr Surg 1973;52:85.
2. Pakiam AJ. The reversed dermis flap. Br J Plast Surg 1978;31:131.
3. Russell RC, Van Beek AL, Wavak P, Zook EC. Alternative hand flaps for amputations and digital defects. J
Hand Surg 1981;6:399.
4. Atasoy E. The reversed cross-finger subcutaneous flap. J Hand Surg 1982;7:481.
5. Peer LS, Paddock R. Histologic studies on the fate of deeply implanted dermal grafts. Arch Surg
1937;37:268.

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Chapter 257
Dorsal Branch of The Digital Nerve Innervated Cross-Finger Flap
B. B. JOSHI
EDITORIAL COMMENT
Use of the dorsal branch allows transfer of innervated tissue from one finger to the other without sacrificing
sensibility to the volar aspects of the tip of the finger.
For full-thickness skin loss over the volar surface of a finger, an ideal repair replaces the tactile surface with skin
that has an intact nerve supply and that also produces a satisfactory cosmetic result. The long-term results of
cross-finger flaps are generally considered satisfactory. However, after the pedicle is divided from the donor
finger, the flap becomes insensitive.
Subsequent restoration of sensation can occur only by reinnervation from the bed and the periphery of the
grafted area. The functional quality of these flaps has been questioned. Sensation can be improved by isolating
and transposing the dorsal cutaneous branch of the volar digital nerve along with the flap (1).
INDICATIONS
This method is yet another alternative for providing sensibility in repair over the volar aspect of the distal
segment of the index finger, which is next in importance to the thumb. The results obtained are comparable
to those of the radially innervated cross-finger flaps used for the thumb (see Chapter 281).
I reserve this method for restoring sensibility only in those cases where local neurovascular island flaps are
not feasible or where a neurovascular island flap from the other finger is not desired.
ANATOMY
On the radial side of the index and long fingers and on the ulnar side of the small finger, a dorsal branch of the
volar digital nerve is well defined (Fig. 257.1). This dorsal branch on the radial aspect of the long finger arises
opposite the base of the proximal phalanx. It accompanies the main volar neurovascular pedicle for about 1 cm,
and then it gradually branches off to run obliquely distally and dorsally to supply the dorsal aspect of the
middle segment of the long finger. In cases where the nerve does not branch off near the base of the phalanx it
can still be seen as a separate fascicle in the volar digital nerve sheath.

FIGURE 257.1 A: The flap is elevated over the middle phalanx of the long finger. Care is taken to ensure that
the dorsal branch of the volar digital nerve is preserved and included in the flap. Loose areolar tissue should be
abundant to protect the nerve fibers. B: The flap is set into the defect of the index finger. C: The incisions are
marked for the second stage, which is performed approximately 3 weeks later. D: The dorsal branch of the volar
digital nerve, which usually arises opposite the base of the proximal phalanx, is dissected proximally. E: The
nerve branch is then transposed to the index finger. F: The donor site may need a skin graft. (From Joshi, ref. 1,
with permission.)
OPERATIVE TECHNIQUE
First Stage
To cover a volar defect over the index finger, a radially based cross-finger flap is marked on the middle segment
of the long finger. The flap is raised, preserving the dorsal volar nerve branch with its terminal arborizing fibers
and with an abundance of areolar tissue protecting the nerve and its fibers (Fig. 257.1A). The flap is set into the
defect of the index finger in the usual fashion (Fig. 257.1B).
The dorsal digital nerve branch would be seen entering this flap just proximal to the PIP joint. The incision is then
carried to sever the oblique fascial bands that attach the skin to the extensor tendon and to the periosteum along
the side of the finger. A skin graft is then applied to the donor site.
Second Stage
After 3 weeks or so (depending on the healing at the recipient site) a zigzag incision is made to expose the volar
digital neurovascular bundle on the radial aspect of the long finger up to the distal palmar crease. This incision is
extended to the index finger in a zigzag fashion, to raise the flap to cover the transposed dorsal branch of the
cross-finger flap.
This branch is dissected out, isolated, and transposed onto the index finger along with the detached cross-finger
flap (Fig. 257.2). The length of the dorsal nerve branch is made sufficiently lax by loosening it proximally, to
permit this transposition without tension. After closing the skin incision, a small skin graft may be needed on the
anterolateral aspect of the long finger.
The nerve may branch away from the main bundle more distally than expected, thus requiring fascicular
dissection to isolate and separate it proximally for transposition. This may cause a temporary neurapraxia, which
recovers within 3 weeks.

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Variations in Technique
The dorsal sensory branch can be transferred along with the flap during the first stage, as shown in Figure
257.2. The second stage will then include only division and insetting of the flap.
CLINICAL RESULTS
In 17 fingers repaired with this method, the sensation has been considerably better than that expected in
standard cross-finger flaps. In 14 fingers the two-point discrimination reached a level of 7.1 to 11 mm. The
functional quality of the sensation could not be considered good in the other three fingers, as the two-point
discrimination was 13, 15, and 17 mm, respectively.
FIGURE 257.2 A: The cross-finger flap has been elevated from the donor site. In this case the dorsal
branch of the volar digital nerve has been dissected proximally for transfer to the index finger in the first
stage. B: The cross-finger flap is inset and will be divided in approximately 3 weeks. The donor site is skin-
grafted.
SUMMARY
The sensory cross-finger flap, based on the dorsal branch of the volar digital nerve, is worth considering for
restoring sensibility whenever a cross-finger flap is scheduled for primary coverage of the index finger. It is
an alternative to the volar neurovascular island flap from the other fingers (2, 3).
References
1. Joshi BB. A sensory cross-finger flap for use on the index finger. Plast Reconstr Surg 1976;58:210.
2. Littler JW. Neurovascular skin island transfer in reconstructive hand surgery. In: Transactions of the
second international congress of plastic surgeons. Edinburgh: Livingstone, 1960;175.
3. Tubiana R, Du Parc J. Restoration of the sensibility in the hand by neurovascular skin island transfer. J
Bone Joint Surg 1961;43(B):474.

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Chapter 258
Cross-Forearm Skin Flap
D. S. EASTWOOD
EDITORIAL COMMENT
The use of the forearm for fingertip resurfacing not only limits the hand that is attached to the forearm, but
also significantly limits the use of the contralateral free hand.
The cross-forearm flap is used to resurface skin defects on the hand, particularly on the fingers (1, 2, 3, 4). It has
a random blood supply.
FLAP DESIGN AND DIMENSIONS
The flaps are usually more or less rectangular and based on one of the long sides (Fig. 258.1, flap A), but they
may also be based on the narrow end (Fig. 258.1, flap B). In the latter case a length to width ratio of 1.5:1 should
rarely be exceeded. When one is tubing the flap to provide circumferential cover for a digit, the shape is roughly
square. When defects on the adjacent surfaces of two fingers are to be covered, as when separating syndactyly
with bony fusion, flaps based opposite each other may be required (Fig. 258.2). Exceptionally, a finger may be
inserted into a tunnel under a bipedicled bridge flap.
The use of cloth or paper patterns is advised in planning, especially when more than one flap is to be used. (It is
surprising how long a flap may need to be when required to reach up and over a finger.) Further, the flaps should
always be made wider (by about 1 to 1.5 cm) than the defect, because they retract when raised.
The best donor site, from a cosmetic viewpoint, is the region of the ulnar border of the forearm; from this site a
flap goes well onto either the flexor or the extensor aspect of the fingers (Fig. 258.3). The flexor aspect of the
upper portion of the forearm has the most sensitive skin and is perhaps the easiest site to use. It certainly allows
maximum mobility for personal hygiene and other purposes (Fig. 258.4).
Where several fingers have to be covered, the whole of the forearm is available. One advantage of the forearm
is that, being fusiform, the fingers can be spread around it and flaps can be obtained for awkward defects for
several fingers at one time (Figs. 258.5, 258.6, 258.7). The softer and more adaptable skin of the upper portion
of the flexor aspect of the forearm is preferred for this purpose, although the outer aspect is also available. The
latter is particularly relevant when skin cover is required for both hands at one time (Fig. 258.5).
OPERATIVE TECHNIQUE
The portion of the flap intended for the defect on the fingers should be raised at a thickness corresponding to
approximately the midpoint of the subcutaneous fat. Cautious thinning with scissors may be required to adapt it
to the defect (5, 6). As soon as the intermediate, carrying portion of the flap is reached, dissection should be
deepened to the fascia, and any further raising of the flap necessary to enable it to reach into the defect should
be continued in this plane.
When the flap is to be tubed, it is helpful to close most of the defect directly, because this helps in the tubing.
Under other circumstances the temptation to close the defect directly at the time of raising should be avoided,
the secondary defect being grafted with a thin split-thickness skin graft that extends across the pedicle to the
margin of the finger defect. If a bridge type of flap is used, the floor of the tunnel must be grafted.

If more than one flap is needed, it is recommended that they should be tentatively planned preoperatively, with
the patient conscious. Only one flap is raised at a time and fitted into the defect; the next flap is then raised,
because a need for modification may become evident during the procedure.
These flaps are often somewhat inaccessible, and it may be helpful to hold the arms in a raised position by
attaching them to the transverse bar of an anesthetic screen that is adjustable for height. This gives good access
to what at operation is, in fact, the undersurface of the forearm.
Postoperatively, the arms are immobilized by strapping along the forearms and around the elbows, to hold them
in a longitudinal direction, and around the wrists and hand in the other direction (Fig. 258.5). The tips of
individual fingers may be stabilized by sutures through the nails to the skin of the donor arm; superglue may also
be used; in children, plaster of Paris slabs may be required. In the recovery room it is helpful to keep the weight
of the arms off the abdomen by means of a supporting bridge of Kramer wire; this also helps to maintain the
position at this awkward stage. Two or 3 days postoperatively, the amount of strapping may be markedly
reduced to free one hand for feeding and toilet procedures.
FIGURE 258.1 Basic types of flap.
FIGURE 258.2 Flaps with opposed bases used in complex syndactyly with bony fusion.

FIGURE 258.3 A,B: Positioning for flexor and extensor aspects of finger along ulnar border donor site.
FIGURE 258.4 Use of flexor aspect of forearm. Note position of hand of donor arm.
The flaps are usually separated at 14 days postoperatively. It is often convenient to do this simply under local
infiltration anesthesia and to delay formal setting in of the flaps for 48 hours. This acts as a delay tactic and,
when practicable, this opportunity may also be used to remove the graft on the secondary defect and to close it
directly. Bridge flaps are separated in stages: two-thirds of each pedicle is divided at 10 days, and the rest at 21
days.
In dealing with flexion contractures of the fingers following burn, it is often practical to deal with each finger
serially, thus confining the secondary scarring to a linear area along the subcutaneous border of the ulna. When
the flaps are placed on the flexor aspect of the fingers, thinning is not usually required, because the movement of
the fingers appears to reduce the subcutaneous fat. On the lateral and dorsal aspects of the fingers thinning is
often required.
Neurocutaneous Flaps
It is possible to incorporate a cutaneous nerve in a cross-forearm flap, anastomosing its proximal end to the
relevant sensory nerve. The superficial branch of the radial nerve becomes subcutaneous some 8 cm proximal to
the radial styloid process. It may be incorporated in a proximally based flap taken from just above the wrist (7).
The medial cutaneous nerve of the forearm runs with the basilic vein and may be identified at the elbow and
incorporated in a proximally based flap (8).

FIGURE 258.5 Flaps for two hands simultaneously. Note spreading of right fingers for multiple flaps.
FIGURE 258.6 Serial flaps to ring and middle fingers (burn contracture). (From Eastwood, ref. 4, with
permission.)
There are obvious problems of size and orientation in these flaps. Great care must be taken to ensure that the
small branches to the skin itself that arise proximally are not divided. Use of these flaps should be reserved for
pulp replacement, where they may be worth the difficulties involved.
CLINICAL RESULTS
Loss of flaps due to deficient circulation is very uncommon. The principal problem is one of separation due
to inadequate immobilization and, above all, to faulty planning in multiple flaps when digits are placed in a
position that results in tension on the flap bases. Children up to the age of 3 years present a special
problem, because of their tendency to curl their fingers into flexion. Under these circumstances a bridge
type of flap is indicated.
The main practical problems are those associated with nursing patients with limited or absent use of both
hands (incidentally an excellent practical cure for smoking). Children tolerate the procedure well, being used
to intimate attention and being capable of playing with their feet. Adults are prone to shoulder stiffness; the
joints must be put through as full a range of movement as possible while the arms are joined, preferably
under the direction of a physiotherapist who will also supervise recovery of movement after separation.

FIGURE 258.7 Flaps for all five digits of one hand (hot press burn).
SUMMARY
The forearm is a good donor site for flap coverage of one or more fingers. It can be modified to become a
sensory flap, when indicated.
References
1. Campell Reid DA. Experience of a hand surgery service. Br J Plast Surg 1956;9:11.
2. McCash CR. Cross-arm bridge flaps in the repair of flexion contractures of the fingers. Br J Plast Surg
1956;9:25.
3. Teich-Alasia S, Barberis ML. The value of the cross-arm flap in reconstructive surgery of the hand. Chir
Plast [Berlin] 1972;1:134.
4. Eastwood DS. Cross-forearm flaps. Hand 1974;6:62.
5. Thomas CV. Thin flaps. Plast Reconstr Surg 1980;65:747.
6. Colson P, Janvier H. Primary total defatting of flaps. Ann Chir Plast 1966;11:11.
7. Dolich BH, Olshansky J, Babar AH. Use of cross-forearm neurocutaneous flap to provide sensation and
coverage in hand reconstruction. Plast Reconstr Surg 1978;62:550.
8. Paneva-Holevich E. Sensory cross-forearm neurocutaneous flap. Acta Chir Plast [Prague] 1980;22:86.

Chapter 259
Cross-Hand Hypothenar Skin Flap to The Finger
C. ARRUNÁTEGUI
EDITORIAL COMMENT
The very early division of the pedicle, in from 2 to 5 days postoperatively, would indicate faster
revascularization, perhaps due to a wider inset of the flap. On the other hand, the possibility that this thin
flap “took” as a full-thickness graft should he considered.
The hypothenar flap can be used effectively to cover denuded fingertips on the opposite hand (1). The flap
provides skin similar to that which is lost, while resulting in minimal donor site morbidity. One of the main
advantages of this flap is that the pedicle can be divided in 3 to 5 days.
INDICATIONS
The advantages of this technique are (1) the procedure is easy to perform; (2) there is a minimal period of
immobilization; (3) the cosmetic and functional results are excellent; and (4) the donor site is hidden and an
insignificant scar results. Among the disadvantages are that only about 5 to 6 mm2 of donor area can be
used, on average, to avoid problems in the donor hand, and that both hands are simultaneously
immobilized.
ANATOMY
There is a clear line of demarcation between the palmar and the dorsal skin over the hypothenar eminence (2).
The palmar skin is used for the flap. The subcutaneous tissue is divided into compartments that cushion the
area. The trabeculae that run between the dermis and the fascia overlying the hypothenar muscles help to resist
friction. These are all characteristics that make the flap ideal for fingertip coverage.
On both sides of the ulnar border are branches of the ulnar nerve to the little finger. In the distal and proximal
parts of the hypothenar skin there are two natural creases that limit the surgical field.
The fingertips have an interconnecting dermal-subdermal plexus containing arteriovenous shunts, similar to
hypothenar skin. This rich anastomotic network on both sides allows circulation into the flap from the fingertip to
be established quickly. It is for this reason that the pedicle can be divided as early as 2 to 3 days.
FLAP DESIGN AND DIMENSIONS
The flap must be designed preoperatively so that the hands lie in a comfortable position. Care must be taken to
orient the flap so that the pedicle can lie over the remaining nailbed. In this way, after division of the pedicle, the
raw area will be at the level of the nailbed and secondary healing will enhance the fixation of the nail as it grows.
The flap should be designed larger than the recipient area and should be situated as much as possible over the
palmar skin. Depending on the requirements, flaps can be designed to cover two fingertips simultaneously (Fig.
259.1E).

OPERATIVE TECHNIQUE
Once the hands are positioned comfortably and the flap sutured into place, the hands may be held together by
dressings or even sutures.
The pedicle was initially divided at only 2 days, with excellent results. Currently I feel it is safer to divide the
pedicle at 3 days in most cases. It may be better to wait 4 days in laborers who have a thick keratin layer. In
those patients with a poor bed with exposed tendons and bone, the pedicle should not be divided for 5 days.
The pedicle is not inset, but secondary healing is allowed to take place. This produces a better cosmetic result
than would follow grafting (Figs. 259.2 and 259.3).
FIGURE 259.1 Different forms of hypothenar skin flaps. (From Arrunátegui, ref. 1, with permission.)
CLINICAL RESULTS
After flap integration and complete healing have occurred, all properties and characteristics of the
transferred skin are surprisingly recovered. The color match, texture, and all tests of sensitivity of the new
fingertip are positive after 2 to 6 months. In some patients, it can even be difficult to identify the injured
finger 1 year later.
SUMMARY
A cross-hand hypothenar skin flap can be used to cover fingertip defects on the opposite hand.

FIGURE 259.2 A 26-year-old man with large loss of pulp and nail. A: Twenty-five days after injury. The
fingertip has already undergone both a skin graft and a local flap. B: Elevation of the flap. C: Immediately
after application of hypothenar skin flap. The pedicle was divided after 2 days. D: Forty-five days
postoperatively. Dorsal side. E: Forty-five days postoperatively. Palmar side. (From Arrunátegui, ref. 1, with
permission.)

FIGURE 259.3 A 14-year-old girl with necrosis produced after a glass injury. A: Fifteen days after injury. B:
The necrotic tissue, including the deep flexor tendon, was removed. C: Immediately after application of a
large hypothenar skin flap. The pedicle was divided after 4 days. D: One year postoperatively. (From
Arrunátegui, ref. 1, with permission.)
References
1. Arrunátegui C. El colgajo hipotenar. Revista de cirugía estética 1976;1:67.
2. Bargmann W. Histologia y anatomia microscopica humans. Spanish translation of the 3d German edition.
São Paolo, Brazil: Labor S. A., 1961; 675-690.

Chapter 260
Cross-Hand, Cross-Finger Neurovascular Skin Flap
M. R. WEXLER
I. J. PELED
EDITORIAL COMMENT
This complex procedure would have limited applications. Since other microsurgical techniques are
available, the same objective perhaps can be accomplished in a more expeditious manner.
Restoration of sensation of the finger pulp in hand trauma is important for hand function. This is especially
important in reconstruction of the thumb and index finger.
INDICATIONS
In cases of subtotal loss of the volar aspect of the fingers, for instance following deep burns, coverage is
initially undertaken using skin flaps. The best flap for this purpose is the cross-arm flap that supplies good
skin coverage with a supple, delicate layer of subcutis. The cross-hand, cross-finger neurovascular island
flap can be used when the volar aspect of all the fingers is lost (1).
To restore sensation, continuity of the sensory nerves and organs is needed, the density of which is
relatively higher in digits and the tips of digits than elsewhere. For this reason neurovascular flaps from the
fingers or toes are superior to most other neurovascular flaps for restoring sensibility.
Restoration of sensation is important along the radial side of the index and middle fingers and along the
ulnar side of the thumb, enabling two-finger and three-finger pinch. The whole length of the donor finger
should be included in the neurovascular island flap (2); this increases the amount of sensitive skin in the
recipient finger along its whole length (Fig. 260.1).
OPERATIVE TECHNIQUE
The injured fingers have previously been covered with a crossarm flap. The donor site is usually the ulnar side of
the ring finger: the flap is outlined along the midlateral ulnar line (1), using the end of the interphalangeal creases
as a landmark (Fig. 260.2).
The skin is incised along with Cleland's ligament down to the areolar plane over the tendon sheath. The recipient
index finger, covered previously with a flap taken from the arm, is incised along its midlateral radial side under
the flap to the middle of the finger all along its length. The two hands are then brought together, the donor flap is
sutured to the recipient finger along its radial aspect, and the primary covering flap is crossed over to the donor
finger along its ulnar side. The hands are bandaged together with light Elastoplast and left in this position for 12
to 14 days.
In a second operation the neurovascular island is dissected, consisting of half of the finger width. It is advised to
take it in a zigzag fashion to prevent flexion contracture. Care should be taken to leave the neurovascular bundle
attached to the skin and to leave its surrounding fatty tissue attached to it. At the web space care must also be
taken to avoid damage to the arteries where the common digital artery branches into the two proper digital

arteries. The branch of the neighboring finger is dissected, ligated, and cut. The artery is then dissected further
proximally to the superficial palmar arch, where it is ligated and severed.
The digital nerve is dissected by separating the common digital nerve as proximally as needed. It is then sharply
severed and the proximal end of the nerve is buried into muscle or bone. At this stage the neurovascular island
flap is connected all along the ulnar side of the recipient finger. The flap that was taken from the injured finger
and is now connected all along the ulnar side of the donor finger is severed in a zigzag fashion from the volar
aspect of the recipient finger. The two hands are thus separated, each having a longitudinal flap that was
originally on the other finger.
The palm of the recipient finger is then opened to the proximal palmar crease, and further if needed. The artery
is sutured to any available artery with an end-to-end anastomosis or to the superficial palmar arch in an end-to-
side anastomosis, using microvascular technique. The artery could be elongated by interposing a vein graft, if
necessary. The digital nerve is sutured to its corresponding proximal severed nerve.
It should be mentioned that this crossed-over island neurovascular flap can survive as a random flap without this
microvascular anastomosis, but the enhanced perfusion can decrease any symptoms related to vascular
insufficiency.
FIGURE 260.1 A: Sensory loss of the volar aspect of the index and middle fingers of the left hand after mangle
injury. The right hand was covered with a cross-arm flap. The planned cross-hand, cross-finger neurovascular

flap to be taken from the ulnar side of the right ring finger is outlined. B: A flap based on the ulnar side of the left
index finger is raised to cover the ulnar defect of the right ring finger. Note neurovascular island flap still based
on its vascular supply and the whole length of the radial side of this finger, before crossing it over to cover the
radial side of the left index finger. C: The two hands are “glued” together through the two crossed-over flaps.
One is a neurovascular flap from the right ring finger, sutured to the radial aspect of the left index finger. This is
hidden behind another flap taken from the left index finger to the right ring finger donor site. D: The two flaps
after separation. At this stage, microsurgery was used for arterial anastomosis and digital neurorrhaphy (see
text).
FIGURE 260.2 A: Injured hand with index and long fingers covered with a thin cross-arm flap. There was no
sensation in these fingers. The area to be covered with a cross-hand, cross-finger neurovascular island flap is
outlined. B: A cross-hand, cross-finger neurovascular island flap. The recipient is the left index finger and the
donor is the volar aspect of the right ring finger. To avoid injury to the distal phalanx of the donor finger, it is
recommended that only half the volar aspect be used, i.e., one neurovascular bundle and its skin as island flap.
(From Wexler and Neuman, ref. 1, with permission.) C: The neurovascular island flap following its separation,
marked with criss-cross lines.
CLINICAL RESULTS
Circulatory difficulties of neurovascular island flaps are almost always due to venous insufficiency (3).
Sensation does spread eventually beyond the island flap. A cross-hand, cross-finger neurovascular skin
flap can provide durable integument with maximal sensation, without impairment of sensory pathways (1).
Because of the anatomy of the human finger, in which most of the arteries are on the volar aspect and most
of the veins are in the dorsum, the usual neurovascular island flap is difficult to use as a free flap, because
veins for drainage may be lacking. At least one neurovascular bundle should be left at the donor finger, to
avoid damage to this finger.
SUMMARY
The cross-hand, cross-finger neurovascular skin flap can be used to provide sensation, with correct cortical
orientation to the fingers. It is especially useful when most or all of the volar aspect of the fingers of one
hand has been damaged.

References
1. Wexler MR, Neuman Z. Cross hand, cross finger neurovascular flap: a preliminary report. Br J Plast Surg
1975;28:216.
2. Milford L. Neurovascular island grafts. In: Grenshaw AH, ed. Campbell's operative orthopaedics. St. Louis:
Mosby, 1971;81-82.
3. Peacock EE. Island pedical gymnastics. In: Cramer LM, Chase RA, eds. Symposium on the Hand. St.
Louis: Mosby, 1971;209-221.

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Chapter 261
Louvre Skin Flap
A. J. J. EMMETT
This is a multiple broad dermal-thickness flap for the resurfacing of finger defects (1, 2, 3). Skin loss from the
surface of a number of adjacent fingers will involve a wider area than could be provided by resurfacing with a
continuous single flap (Fig. 261.1A). In order that a greater surface area of cover can be provided for a number
of adjacent digits, separately based flaps are simultaneously raised and placed on the defects (Fig. 261.1B).
INDICATIONS
Full-thickness burns with loss of cover over the extensors are suitable for this type of repair. I have used it
similarly on the flexor surface as well. The donor sites have been the abdomen or the opposite arm, or
flexor or extensor surface of the upper arm. The cross-arm flap on the lateral surface of the upper arm is
suitable when the fingers have some degree of fixed flexion, which then fits that contour.
ANATOMY
The flaps have a random pattern blood supply, depending on the dermal, subdermal, and subcutaneous vascular
plexus.
FLAP DESIGN AND DIMENSIONS
After excision of the finger burn or scar, the extent of skin replacement required can be determined. This total
area can be measured and the required area projected to the proposed donor site.
The spread of skin required will be wider than the possible span of the fingerbreadth, and it is planned that the
donor site will extend beyond each finger progressively (Fig. 261.2B). The natural elastic recoil of each finger
tends to pull it back into each pedicle base, helping with the snug fit of flap to finger. The flaps are initially all
raised together, and the donor sites are skin grafted primarily.
The fingers must fit comfortably into the flap or there will be too much tension on the stitch line and poor healing.
In planning the flap situation and the hand position to be maintained for 2 to 3 weeks, it is wise to have the
patient's agreement to that position.
OPERATIVE TECHNIQUE
The flaps are raised as thinly as possible; this is reasonably safe because they have such a broad base in
relation to their length. Atraumatic sharp dissection is used to raise the flap with skin hooks and scalpel blade. I
avoid using vasoconstrictors and diathermy on the flaps: they always ooze, to a degree.
Tapering an increasing thickness of subcutaneous tissue into the flap pedicle as the flap is raised makes for a
better blood supply and produces an even fit around the side of the finger. Keep in mind that this subcutaneous
tissue then must be thinned when the flap is divided and inset, so that it should be thicker mainly at the base. A
two-thirds healed inset is needed for safe insetting of the remaining one-third of the base at the time of flap
division (Fig. 261.2). In general, I have left the flap attached for 3 weeks before dividing it, because an extra
week
has produced better healing and blood supply, allowing me to do more insetting safely at the time of flap division.

FIGURE 261.1 A: The curved surface of the fingers in a cross section required more skin than a flat application
could provide. B: Lower abdominal wall plan for the flap, planned for an area where the hand can rest
comfortably. Fingers are spread apart to a width that will provide the area of skin required for each finger flap.
This is then marked on the abdominal wall. These are broadly based thin flaps. C: The dermal-thickness flaps
with subcutaneous tissue pedicle are each raised from what is the base of the preceding flap. Since only dermis
is raised, the circulation is left to support the pedicle of the next flap. The pedicle thickens toward the base of
each flap, and the subcutaneous thickness is drawn up on the side of the finger as the flap is sutured on. It helps
if the finger is supple and can rotate a little. (From Emmett, ref. 3, with permission.)
The flap is divided at 3 weeks, the subcutaneous tissue is trimmed from the base of the pedicle, and the pedicle
inset to the side of the finger to produce an even contour (Fig. 261.2C). This involves a little undermining of the
flap, which is safe only if there is a well-healed primary attachment of two-thirds to three-quarters of the flap. If
delayed healing occurs with the flap initially, the pedicle base only is best divided and left to inset itself, with a
secondary recontouring later.
Some months later, when the flaps are supple and the joints have been restored to as much movement as can
be achieved with active therapy, a secondary repair is carried out, as necessary (Fig. 261.2D). Some excess of
flap always seems to develop, and this needs to be removed.
CLINICAL RESULTS
The scar left at the donor site is rather unsightly initially, but it fades and flattens and is acceptable to
patients who have had adequate explanation prior to the operation.

P.704
SUMMARY
Skin flaps from the abdomen or the arm can be used to cover either the flexor or the extensor surfaces of
the fingers. Louvre skin flaps are elevated to cover each finger separately and simultaneously. This
provides more tissue than a single skin flap.
FIGURE 261.2 A: Full-thickness hot press burns of the dorsum of the fingers with loss of the skin,
subcutaneous tissue, extensor tendons, and nailbeds, as well as burn of dorsal joint capsules. B: The
dorsal joint capsules were preserved to be vascularized by the flap. Primary repair was by louvre flap only.
At 4 days, the bread-thin louvre flaps were sewed on each finger after excision of deep burn. Donor sites
were skin-grafted. Fingers were rotated a little to shorten the flap pedicle. Note that the flap for the index
finger was taken wide of the position in which the finger can sit, and the finger then lay back into the flap
pedicle. This applied to each other finger to a lesser degree, least with the little finger. C: One week after
flap division from the abdomen. The thicker subcutaneous tissue in the pedicle base of each flap was
thinned out before insetting that base. The broad attachment and close coaption of flap to finger gave a
blood supply adequate to allow this thinning at the time of inset. The flap had been attached 3 weeks. D:
Secondary later reconstruction. A zigzag side incision along each finger side allowed excess skin to be

removed, and extensor tendons have been inserted as grafts. Nailbed folds were made with flap underlap,
and artificial nails were used to stent these folds. One joint arthrodesis was held with Kirschner wire. E:
Flexed hands showing quite good proximal interphalangeal joint movement. Distal interphalangeal joint
movement is limited, and the distal interphalangeal joint of the middle finger is fused. Nail folds can be seen.
Extensor grafts are pulling through well. Fine abdominal hairs are showing. (From Emmett, ref. 3, with
permission.)
References
1. Barron JN, Emmett AJJ. Subcutaneous pedicle flaps. Br J Plast Surg 1965;18:51.
2. Colson P, Houot R, Gangolphe M, et al. Utilisation des lambeaux degraisses (lambeaux greffes) en
chirurgie reparatrice de la main. Ann Chir Plast 1967;12:298.
3. Emmett AJJ. Finger resurfacing by the multiple subcutaneous pedicle or louvre flaps. Br J Plast Surg
1974;27:370.

Chapter 262
Dermo-Epidermal Flap
P. COLSON
H. JANVIER
EDITORIAL COMMENT
The use of thin flaps for resurfacing the dorsum of the hand or fingers is a valuable objective. However, to
ensure the blood supply to the overlying skin, the subdermal plexus should be preserved; this may mean
that the flap would be 1 or 2 mm thicker than the authors indicate.
The dermo-epidermal flap was developed to solve two basic problems in coverage of hand defects (1, 2, 3, 4):
Coverage needs to be thick enough to retain normal elasticity, so that fingers can pass through their full range of
motion. At the same time, coverage needs to be thin enough to avoid bulkiness (5).
ANATOMY
The flap is completely separated from the subdermal fat. It is therefore nourished only by the most superficial
portion of the dermal-subdermal plexus. However, the flap is thick enough to retain nerve endings and most of
the sensory organs (6, 7).
FLAP DESIGN AND DIMENSIONS
With such a tenuous random vascular supply, one would assume that the flap would be limited to only small
defects. However, whole hand defects can be covered by using either a single or a bipedicled flap.
The flap should not be longer than it is wide (base). To cover one or two fingers, the flap does not need to be
longer than 8 to 10 cm. A bipedicle flap can be as large as 15 to 18 cm (Figs. 262.1 and 262.2).
It is unwise to use the inside of the arm to cover the volar surface of the fingers, since pressure on the chest wall
may interfere with circulation to the flap. If several fingers are to be covered, they should be widely spaced, so
that there is enough tissue at the time of division to cover the lateral surfaces of the fingers (Fig. 262.3).
OPERATIVE TECHNIQUE
The flap is elevated just below the dermis and it must be securely fixed to the defect. Although joint mobilization
can be preserved, especially with the cross-arm position, shearing forces must be avoided (Fig. 262.4).
Otherwise, in-growth of vessels may be prevented, resulting in loss of the flap.

P.706
FIGURE 262.1 Various techniques to cover one finger with the dermo- epidermal flap. A: Coverage of a single
outside finger. B: Coverage of a single inside finger should not be done this way. Compression from the outside
finger can lead to necrosis of the flap. C: The outside finger should lie underneath the base of the flap.
FIGURE 262.2 A,B: Various techniques to cover two fingers.

P.707
FIGURE 262.3 A: Coverage of multiple fingers. The donor site is covered first with a split-thickness skin graft.
B,C: The fingers should be spaced widely apart, to have enough tissue at division for covering the lateral aspect
of the fingers.
FIGURE 262.4 Shearing forces should be avoided. One way to fix the finger is to suture it, as shown.
CLINICAL RESULTS
The dermo-epidermal flap looks bright red initially (Fig. 262.5), and then takes on a cyanotic hue. These
variations are felt to be due to changes in the vasomotor system and to short circuits occurring in the
arteriovenous anatomoses in the flap. The cyanosis persists for 4 to 5 days and the skin then takes on a
more reassuring appearance.
The skin cover provided by the dermo-epidermal flap is thicker and more elastic than full-thickness skin
grafts. This extra mobility is of prime importance in covering hand defects (Figs. 262.6 and 262.7).

P.708
FIGURE 262.5 Coverage of two adjacent digits, including the web space.
FIGURE 262.6 The dermo-epidermal flap can provide skin with normal elastic properties that are not
provided with skin grafts.
The donor site must be covered with a split-thickness skin graft. Judicious choice of donor site can minimize
the cosmetic deformity.
SUMMARY
The dermo-epidermal flap can be used to provide thin, durable coverage for hand defects.

FIGURE 262.7 A: Burned hand. B,C: Positioning. D,E: Result of dermo-epidermal flap coverage. F: Result
4 years later.
References
1. Colson P, Janvier H. Le dégraissage primaire et total des lambeaux d'autoplastie à distance. Ann Chir
Plast 1966;11:11.
2. Colson P, Janvier H, Gangolphe M, Laurent J. Brûlures du dos de la main. Problèmes posés par la
réparation secondaire de la région des commissures. Ann Chir Plast 1970;15:14.
3. Kelleher JC, Sullivan JG, Dean RK. Use of a tailored abdominal pedicle flap for surgical reconstruction of
the hand. J Bone Joint Surg 1970; 52(A):1552.
4. Arlon HG. Couverture d'une perte de substance cutanée post traumatique de la jambe par “cross-legs”
utilisant un lambeau dégraissé selon la technique de Colson. Bulletin et memoires de la Societé des

Chirurgiens de Paris 1973;63:167.
5. Ionescu OG, Polovici A, Ciomei G. Valeur du lambeau sous claviculaire dégraissé dans les reconstructions
digitales. Acta Orthop Belg 1975;41:3355.
6. Burton AC. Physiology and biophysics of the circulation. Paris: Masson, 1974;51, fig. 24.
7. Martineaud JP, Seroussi S. Physiologie de la circulation cutaneé. Paris: Masson, 1977;59.

Chapter 263
Supraclavicular Innervated Flap to The Finger
B. C. SOMMERLAD
J. G. BOORMAN
EDITORIAL COMMENT
This is an elegant procedure the surgeon might wish to consider for the totally desensitized hand.
When the hand has sustained significant skin loss, a flap is frequently required to provide sturdy cover and to
allow maximal function. Many innervated flaps have been described for use in the hand (1, 2, 3, 4, 5), but most
provide only a limited quantity of skin with one sensory nerve. The supraclavicular innervated flap (6) provides a
larger area of skin innervated by three or more nerves, thus giving it advantages over other flaps in cases where
larger areas are to be resurfaced. The procedure allows multiple digits to be resurfaced by one flap, but with
separate innervation.
INDICATIONS
The flap is indicated in cases of extensive skin loss, for example, after degloving injuries or severe burns,
when no suitable local flap is available. For smaller areas of loss it may be advisable to use another flap (1,
2, 3, 5), such as those from the foot or the contralateral hand (4), that are thinner and may provide better
sensation. The flap may be used as a primary procedure (in which case the relative simplicity of the first
stage may be advantageous for an emergency operation), or for secondary reconstruction.
ANATOMY
The cervical plexus gives rise to a branch that emerges from behind the sternomastoid muscle and thereafter
divides into the supraclavicular nerves. From a point slightly below the midpoint of the muscle close to the
external jugular vein, these nerves radiate toward the clavicle. They supply the skin area superior to, overlying,
and inferior to the clavicle as far as the second rib, extending from the midline to the point of the shoulder.
We found (6) that although three was the commonest number, up to five distinct and significant branches could
be identified at a level just above the clavicle, any or all of which may be sutured separately to recipient nerves in
the hand. The nerves are 1 to 2 mm in diameter and typically contain two to five bundles. In nonobese subjects
the nerves may be palpated as they cross the clavicle (Fig. 263.1A).
The blood supply of this skin area is from three main sources: (1) the transverse cervical artery (superficial
branch) (7); (2) the internal mammary artery (perforating branches) as is used for the deltopectoral flap (8); and
(3) the thoracoacromial artery. The possibility thus exists of raising these innervated flaps on an axial pattern
blood supply or as free flaps. An innervated deltopectoral flap has been used for pharyngeal reconstruction (9),
but this flap is supraclavicularly innervated only in its upper half.
FLAP DESIGN AND DIMENSIONS
The maximum size of a supraclavicular innervated flap is approximately 20 × 12 cm, depending on the patient's
size. Its thickness is moderate: greater than foot flaps, but less than groin flaps, both these other types being

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alternative sensory flaps for hand resurfacing. The flap is not appropriate in obese subjects.
Flap design is dictated by the orientation of nerves for suture in the recipient hand. In its most useful application
— resurfacing both dorsal and volar surfaces together—it is convenient to base the flap superiorly and to inset it
onto the dorsal surface (Fig. 263.1B-D). At the stage of flap division the nerves are identified and are sutured to
digital nerves as the flap is inset on the palmar aspect of the hand.
OPERATIVE TECHNIQUE
To ensure inclusion of the nerves, the flap should be raised to include the deep fascia, especially in its superior
portion. The nerves are readily identified on the deep surface of the flap.
They pierce the fascia 1 to 2 cm above the clavicle, and then lie between fascia and platysma. To make nerve
suture easier, a length of nerve proximal to the flap may be taken with the flap (Fig. 263.1E and F).
When more than one digit is to be resurfaced, subsequent separation can be safely achieved if the web spaces
have been marked by a short length of rubber tubing (Fig. 263.1F).
CLINICAL RESULTS
The donor site of this flap may be closed directly or, if a larger area of skin is needed, may require grafting.
There is no interference with shoulder movements, and no loss of sensation in the remaining skin has been
detectable. Scarring in this area is less acceptable to women patients. We have used this flap only in men,
who more commonly sustain the type of injury for which the use of this flap is indicated.
SUMMARY
The supraclavicular innervated flap can provide a large area of sensory skin to the hand. The flap can be
used to resurface multiple fingers while providing each with separate innervation.

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FIGURE 263.1 A: Surface anatomy of main supraclavicular nerve branches (broken lines) in relation to
sternomastoid and clavicle. B,C: A 28-year-old laborer with insensitive skin cover of his middle, ring, and
little fingers. The skin broke down frequently with minor trauma, and movements at the
metacarpophalangeal joints were restricted (0° to 45°). This was the result of an accident 7 months earlier,
when his hand had been caught between two heavy rollers, producing a crushing and degloving injury. (B
is reproduced from Sommerlad and Boorman, ref. 6, with permission.) D: A flap measuring 12 × 12 cm
based superiorly was designed and inset onto the dorsal surface of the stumps. ( Continued)
FIGURE 263.1 (Continued) E: The flap was divided 4 weeks later (and 1 week after a preliminary delay). F:
Three nerves were identified and sutured to the digital and common digital nerves (one nerve per finger).
The web spaces had been marked with rubber tubing, and the fingers had subsequently been released and
thinned. G,H: The patient was able to return to his previous employment as a laborer. His
metacarpophalangeal joint range improved to a range of 0° to 90°. He has good light touch and pinprick
sensation and localization. He is also able to detect hot and cold temperatures, which could not be done
previously. He has suffered no further breakdown or ulceration of the skin.
References
1. Daniel RK, Terzis JK, Midgley RD. Restoration of sensation to an anaesthetic hand by a free
neurovascular flap from the foot. Plast Reconstr Surg 1976;57:275.
2. Ohmori K, Harii K. Free dorsalis pedis sensory flap to the hand with microneurovascular anastomoses.
Plast Reconstr Surg 1976;58:546.

3. May JW, Chait LA, Cohen BE, O'Brien BM. Free neurovascular flap from the first web of the foot in hand
reconstruction. J Hand Surg 1977;2:387.
4. Dolich BH, Olshansky KJ, Babar AH. Use of a cross-forearm neurocutaneous flap to provide sensation
and coverage in hand reconstruction. Plast Reconstr Surg 1978;62:550.
5. Strauch B, Tsur H. Restoration of sensation to the hand by a free neurovascular island flap from the first
web space of the foot. Plast Reconstr Surg 1978;62:361.
6. Sommerlad BC, Boorman JG. An innervated flap incorporating supraclavicular nerves for reconstruction of
major hand injuries. Hand 1981;13:5.
7. Lamberty BGH. The supraclavicular axial pattern flap. Br J Plast Surg 1979;32:207.
8. Bakamjian VY. A two stage method for pharyngo-esophageal reconstruction with a primary pectoral skin
flap. Plast Reconstr Surg 1965;36:173.
9. David DJ. Use of an innervated deltopectoral flap for intra-oral reconstruction. Plast Reconstr Surg
1977;60:377.

Chapter 264
Microvascular Transplantation En Bloc of The Second and Third
Toe
E. BIEMER
The second and third toes can be transferred en bloc to the hand (1, 2, 3, 4, 5). Indications are limited to special
cases such as (1) amputation of all fingers, when only a thumb is left, and (2) total hand amputation, where the
procedure is used in combination with single toe transfer for thumb reconstruction.
ANATOMY
Transfer of the second and third toes en bloc depends on an intact dorsalis pedis artery, as does the transfer of
the big toe or of a single second toe. In the region of the tarsometatarsal joints, the dorsalis pedis artery gives
rise to the arcuate artery at the lateral border of the foot. From the arcuate artery arise the dorsal metatarsal
arteries, which divide at the level of the metatarsophalangeal joints into the dorsal digital arteries. These latter, in
turn, divide to supply each side of the neighboring toe.
When the second and third toes are elevated, the second metatarsal artery as well as the first must be included,
in order to have a good blood supply for the third toe. It should be noted, however, that in about 15% of cases
the dorsalis pedis artery is not available.
To attain dorsal sensitivity in the toes, the deep peroneal nerve, which runs parallel to the artery, must be
included. The plantar digital nerves normally run far more superficial to the flexor tendon than do the digital
nerves in the fingers. For venous drainage, the venae comitantes are included and, just to be safe, a superficial
vein from the venous arch of the dorsum of the foot.
OPERATIVE TECHNIQUE
Donor Site
The vascular supply to the donor area should be clarified by palpation, Doppler sonography, or angiography. It is
important to ascertain whether the posterior tibial artery will supply the forefoot after removal of the dorsalis pedis
artery.
In most instances the vascular connection in the recipient hand will be done in the snuffbox area. Therefore,
quite a long vascular pedicle is needed. In addition to marking the course of the artery, the appropriate veins
draining the toe superficially on the dorsum of the foot should be marked and should be elevated with the
transplant, in case there is difficulty preparing the venae comitantes. It should also be decided if incorporation of
the dorsalis pedis flap for soft-tissue coverage of the hand is necessary. The use of a paper model is
recommended for this purpose.
After raising the neurovascular trunk and incorporating the extensor tendons of the toe, an osteotomy is done.
Then, by lifting the toes, the plantar nerves and the flexor tendon are separated and divided. If this preparation is
done from the dorsum of the foot, a scar can be avoided on the plantar side of the foot that extends as far as the
weight-bearing surface of the sole of the foot. The tendons taken with the transplanted toes are always
somewhat longer than initially required.
The donor defect of the foot is closed with the objective of putting the heads of the first and fourth metatarsal as
close together as possible. The ends of the metatarsal bones are carefully covered by local small muscles.
Finally the whole defect is covered with a split-thickness skin graft.

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Recipient Site
At the recipient site, the bones of the stumps (mostly third and fourth metatarsal bone) are exposed by two dorsal
palmar fish-mouth incisions, which are connected by incising through the included web space so that an H-
incision results. In cases where all the metacarpal bone is lost, alterations of the incision depend on the
individual situation. The functional
structures such as tendons and digital nerves are then identified, and the recipient vessels, mostly in the
snuffbox area, are prepared.
The transplantation starts with bone fixation. In most of my cases I use Kirschner wires with transosseous wiring.
This is an almost always stable and applicable procedure. The metatarsophalangeal joints of the toes are fixed
in a slightly flexed position by Kirschner wire, to avoid hyperextension of the new finger. When only the head of
the metatarsal bone is needed, this can also be achieved by a palmar flexion of the metatarsal head of up to 60°.
One can thereby achieve useful flexor function in the metatarsophalangeal joint, or the use of that joint just for
elongation of a new finger.
After tendon repair, the nerves are sutured and finally the arterial and the venous anastomoses are done. The
decision to anastomose either a vena comitans or a superficial vein depends on the best venous reflux after
opening the arterial anastomosis. Occasionally two venous anastomoses are done primarily.
The hand is not elevated as in replantation cases, but placed even somewhat lower than heart level. The donor
foot is put in a light cast that allows both good stabilization of the foot and early mobility after the third or fourth
day. In our experience, it normally takes up to 3 months until the donor area is completely healed.
FIGURE 264.1 A: Condition after an explosion injury of the left hand in a 16-year-old boy. Only the thumb was
left. B,C: Good functional result 2 years after two-toe en bloc transplantation and shortening of the thumb. (From
Biemer and Duspiva, ref. 5, with permission.)
CLINICAL RESULTS
There were no vascular complications in seven cases (Fig. 264.1, 264.2, 264.3). All transplanted toes
survived very well. As to the mobility of the new “fingers,” I found the motivation of these highly
handicapped patients was so immense that in all instances extremely good functional results were

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achieved. The mobility of the second toe was always somewhat greater than that of the third toe. Most of
the flexion and extension occurred in the proximal interphalangeal joint of the toes. Sensitivity steadily
increased up to a two-point discrimination of 6 to 10 mm over 3 years. This is an interesting result, because
two-point discrimination in a normal toe in an adult is 22 to 26 mm. All of the patients were pleased with the
result, and would ask again for the same procedure under the same circumstances. In two cases, a
tenolysis was done as a secondary procedure, to improve hand flexion.
Mobility of the donor foot is comparatively limited. In my experience, patients need a specially made inlay to
support the destroyed transverse arch of the foot, for up to 2 years. After this period, they could all wear
normal shoes without difficulty. There was no breakdown or reulceration in the donor area, but it must be
pointed out that the age of the patients ranged between 16 and 31 years.
FIGURE 264.2 A: Amputation of all four fingers of both hands. B,C: Functional results at 5 months after
finger reconstruction of the right hand by two-toe en bloc transplantation. (From Biemer and Duspiva, ref. 5,
with permission.)

FIGURE 264.3 A: Double hand amputation in a 23-year-old man. B,C: Reconstruction of one hand by three
toes. (From Biemer and Duspiva, ref. 5, with permission.)
An alternative to the procedure discussed is transferring only a single toe (6, 7) and building up only one
long finger. This leads to a lobster hand, and with this grip it is very difficult to stabilize a telephone receiver
or to write—results that are easily achieved with the two-toe en bloc transplantation, which also yields
superior aesthetic results.
SUMMARY
Although there are very limited indications, two-toe en bloc transplantation has its place in reconstructive
hand surgery.
References
1. O'Brien BM, McLeod AM, Sykes PJ, Donahoe S. Hallux-to-hand transfer. Hand 1975;7:128.
2. Biemer E. In: Lie TS ed. Toe transfer for thumb and finger replacement microsurgery, Vol. 17. Amsterdam,
Oxford: Excerpta Medica, 1979.
3. Biemer E, Stock W, Herndl E, Duspiva W. Reconstruction of the hand by free tissue transfer. Int J
Microsurg 1980;2:159.
4. Biemer E. Daumenreconstruction. Hefte zur Unfallheilkunde 1982;158:428.

5. Biemer E, Duspiva W. Reconstructive Microvascular Surgery. New York: Springer, 1982.
6. Ohmori K, Harii K. Transplantation of a toe to an amputated finger. Hand 1975;7:134.
7. Biemer E. Zehentransplantation. Presented at the Third Congress of the European Section of the
International Confederation for Plastic and Reconstructive Surgery, The Hague, May 22-27, 1977.