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

P.717
P.718
P.719
transfer is possible (Fig. 265.1A). The circulation is checked, the pedicle length is measured, and the
corresponding lengths of dorsalis pedis artery and dorsal vein are harvested.
Prior to the harvest, the recipient site in the hand is prepared (Fig. 265.1C). Scar tissue is excised, the bone
ends are freshened, tendons are mobilized, and the recipient vessels are identified.
The transfer is performed by first stabilizing the bone with interosseous wiring and a bone peg taken from the
anterior tibia (Fig. 265.1D). A longitudinal Kirschner wire also may be used. A bone peg graft is used to fuse the
toe joint in the foot (Fig. 265.1E). In our experience, end-to-side arterial anastomosis has been the most useful
method of reconstruction, especially if a vessel size mismatch occurs (Fig. 265.1F). Two veins are anastomosed.
Both the superficial system and the venae comitantes (deep system) can be used. Postoperative temperature
and color are monitored in the skin island and are indicators of a viable transfer.
In the double joint transfer, the second toe, including the MTP joint, is harvested together with a skin paddle from
the tibial aspect of the big toe (Fig. 265.2A). The medial (tibial) digital artery is mobilized by dividing metaphyseal
and articular branches to the PIP joint. The articular and metaphyseal branches over the lateral (tibial) side of the
MTP joint are divided to free the fibular digital vessel. The distal commissural vessels at the distal phalanx are
preserved to maintain vascular continuity (Fig. 265.2B). The mobilization of the digital vessels in this manner
increases the interjoint pedicle length. This allows the reconstruction of two adjacent MCP joints based on a
single pedicle (Fig. 265.2C and D).

FIGURE 265.1 A: Lateral view of the completely mobilized proximal interphalangeal joint of the second toe. B:
Osteotomized proximal interphalangeal joint attached by skin island. C: Recipient site prepared for the free joint
transfer. D: Lateral view of stabilized free joint transfer. Kirschner wire and interosseous wire fixation. E: Fusion
of donor site using bone peg graft. F: Dorsal view of the completed transfer. (From Tsai et al., ref. 5, with
permission.)

FIGURE 265.2 A: Vascularity of the second toe and the blood supply to the lateral aspect of the big toe on which
the skin paddle for monitoring is based. B: Mobilization of the medial vascular branches to the PIP joint and
lateral vascular branches at the MTP joint, with preservation of the distal commissural branches. C: Transfer of
the PIP joint of the second toe to reconstruct the second MCP joint and the MTP joint to reconstruct the first
MCP joint (case 1). D: Transfer of the PIP joint and MTP joint of the second toe to reconstruct the third and
fourth MCP joint of the left hand, respectively.
CLINICAL RESULTS
Possible complications include (1) arterial or venous failure resulting in loss of the vascularized advantage,
with the joint acting merely as an elaborate arthrodesis; (2) delayed union; and (3) malposition and
misalignment.
To 1993, all of our 10 transfers have been successful, followed from 1 to 3 years. Our mean operative time
was 8 hours, and the mean hospital stay 9 days. The articular space was preserved in all cases. The mean
ranges of motion were 22.1° to 54.9° active and 7.3° to 64.1° passive. All joints transferred were free of

pain, and all but one have stable union. In two patients with open epiphyses there was radiological
evidence of longitudinal growth. Additional required operations included extensor and flexor tenolysis in two
cases, reconstruction of a radial collateral ligament in one patient, and a transposition skin flap in one
patient.
Recently we had two cases that required a double joint transfer. The PIP joint and the MTP joint of the
second toe were used to reconstruct two adjacent MCP joints in the hand based on a single vascular
pedicle. In both cases at 6 months and 4 months follow-up the joint architecture and spaces were
maintained, and sound union of the joint transferred was achieved. The first case will require further staged
reconstruction because of the complexity of the injury. In the second case, at 4 months' follow-up the active
range of motion of the transferred PIP joint to the long MCP joint is 3° and the passive range of motion is
30°. The MCP joint to the ring has an active range of motion of 26° and 37° of passive motion. We have
seen no evidence of functional deficit in the donor foot in any of the single or double joint transfers.
SUMMARY
Transfer of a microvascular toe phalangeal joint can be used for traumatic finger joint loss or for a juvenile
with epiphyseal damage and joint arrest. In multiple joint loss, it is possible to reconstruct two joints with a
single toe and a single vascular pedicle.
References
1. Erdelyi R. Experimental auto-transplantation of small joints. Plast Reconstr Surg 1963;31:129.
2. Hurwitz PH. Experimental transplantation of small joints by microvascular anastomoses. Plast Reconstr
Surg 1979;64:221.
3. Snowdy HA, Omer GE, Sherman FC. Longitudinal growth of a free toe phalanx transplant to a finger. J
Hand Surg [Br] 1980;5:71.
4. Tsai TM, Ogden L, Jaeger SH, Okubo K. Experimental vascularized total joint autografts: a primate study.
J Hand Surg [Br] 1982;7:140.
5. Tsai TM, Jupiter J, Kutz JE, Kleinert HE. Vascularized autogenous whole joint transfer: a clinical study. J
Hand Surg [Br] 1982;7:335.
6. Tsai TM, Lim BH. Single toe double joint transfer using a vascular pedicle. Proceedings of the 12th
Symposium of International Society of Reconstructive Microsurgery, 1996.
7. Tsai TM, Lim BH. Free vascularized transfer of the metatarsophalangeal and proximal interphalangeal
joints of the second toe for reconstruction of the metacarpophalangeal joints of the thumb and index finger
using a single vascular pedicle: a case report. Plast Reconstr Surg 1996; 98(6):1080.

Chapter 266
Volar Thumb Advancement Skin Flap
M. A. POSNER
EDITORIAL COMMENT
This is an excellent flap for resurfacing the tip of the thumb for short lengths. If a longer length is required,
see Chapter 267.
The objectives in the treatment of thumb tip injuries are to preserve length, restore normal sensibility, maintain
joint mobility, and provide a tip that is well padded and free from tender scars. Advancement of a volar skin flap
will satisfy these objectives in the primary and secondary treatment of many injuries involving the distal segment
of the thumb (1, 2, 3, 4).
INDICATIONS
The procedure is particularly applicable to avulsion injuries of the volar pulp tissue or to resurfacing a
scarred, tender thumb tip where most of the distal phalanx remains intact.
ANATOMY
Both neurovascular bundles remain with the volar flap, thereby retaining its sensibility and blood supply
regardless of its length. The dorsal strip of skin remains viable, since it receives its circulation from the first
dorsal metacarpal artery arising from the dorsal carpal arch that is formed by dorsal branches of the radial and
ulnar artery (5). This pattern of circulation to the dorsal skin is different in fingers where the dorsal skin
(particularly at the level of the distal segment) is dependent on the volar digital vessels. The risk of dorsal skin
necrosis is therefore far greater following a volar advancement flap in a finger than in a thumb (see Chapter
236).
OPERATIVE TECHNIQUE
Midaxial incisions are made on the radial and ulnar sides of the thumb (Fig. 266.1A and B). The volar skin with
its subcutaneous tissue and both neurovascular bundles are elevated from the underlying tendon sheath of the
flexor pollicis longus (Fig. 266.1C).
Advancement of the flap is obtained primarily by interphalangeal joint flexion. Flexion of the interphalangeal joint
will permit the flap to be advanced up to 1.5 to 2 cm, if it is elevated to the flexion crease of the
metacarpophalangeal joint (Fig. 266.1D).
With amputations through the distal phalanx, the bone should be contoured. Similarly, the end of the
advancement skin flap itself should be contoured to approximate it closely to the dorsal skin. Postoperatively a
dorsal plaster splint is applied, immobilizing the wrist in neutral position and the thumb in slight flexion, to relieve
any tension on the skin sutures. Active thumb flexion can be instituted immediately postoperatively and active
extension exercises encouraged when the splint is discontinued in 7 to 10 days.

P.721
P.722
CLINICAL RESULTS
Necrosis of the dorsal skin or flexion contractures of the interphalangeal joint have not been encountered in
any case treated with this procedure. The ability to hyperextend the interphalangeal joint is sometimes lost
postoperatively, but this has no clinical significance (Fig. 266.2).
SUMMARY
Restoration of padding with skin of normal sensibility is the predictable outcome for the primary or
secondary treatment of thumb tip injuries.
FIGURE 266.1 A,B: Midaxial incisions are made on the radial and ulnar aspects of the thumb to the
metacarpophalangeal flexion crease. C: The entire volar skin flap with both neurovascular bundles (arrows)
is elevated from the underlying flexor tendon sheath. D: Advancement of the flap is primarily obtained by
flexion of the interphalangeal joint. (From Posner and Smith, ref. 2, with permission.)

FIGURE 266.2 A: This patient had an area of hypersensitivity over the distal 1.5 cm of the thumb tip after a
crushing injury. B,C: The volar skin flap was elevated from the underlying tendon sheath and was easily
advanced by flexion of the interphalangeal joint. D: Immediately postoperatively, after the area of
hypersensitive skin was excised and the volar flap advanced. The distal portion of the flap was trimmed to
follow the contour of the nail. E,F: Several months postoperatively, the patient had a painless thumb tip with
normal padding and sensibility. Interphalangeal flexion was not limited and extension was to the neutral
position. (From Posner and Smith, ref. 2, with permission.)
References
1. Moberg E. Aspects of sensation in reconstructive surgery of the upper limb. J Bone Joint Surg
1964;46(A):817.
2. Posner MA, Smith RJ. The advancement pedicle flap for thumb injuries. J Bone Joint Surg
1971;53(A):1618.
3. Keim HA, Grantham SA. Volar-flap advancement for thumb and finger tip injuries. Clin Orthop
1969;66:109.
4. Millender LH, Albin RE, Nalebuff EA. Delayed volar advancement flap for thumb tip injuries. Plast Reconstr
Surg 1973;52:635.
5. Macht SD, Watson HK. The Moberg volar advancement flap for digital reconstructions. J Hand Surg
1980;5:372.

(Trang không có chữ)

Chapter 267
Rotation Advancement Skin Flap to The Thumb Tip
R. V. ARGAMASO
The thumb has a greater range of motion than any other finger and is indispensable to the prehensile function of
the hand. Because the thumb is endowed with only two phalanges, the complete loss of the distal phalanx
compromises its ability to encompass large objects with the opposing fingers. Conserving length should be the
formost objective in selecting methods of wound closure in cases involving amputation injuries distal to the
interphalangeal joint.
INDICATIONS
The treatment of choice should be to use the amputated segment if it is replantable. However, this course is
not always possible in many injuries. The distal phalanx, even when projecting beyond the level of soft-
tissue loss, should not be sacrificed simply to achieve direct skin suture. Rather, as much bone stock as
can possibly be covered with a skin flap should be preserved.
An ideal flap is one that closely resembles palmar digital skin in appearance and texture. More important, it
should possess good tactile sensation. Direct advancement of a volar skin flap with both neurovascular
bundles satisfies these criteria (1). Stretching the volar skin, however, is limited to a few millimeters. Often a
successful coverage by this method is accomplished only in conjunction with flexion of the thumb at both
metaphalangeal (MP) and interphalangeal (IP) joints (2). There is a risk of causing a flexion contracture in
older patients.
Flexion contraction may be overcome by transferring an island skin flap with a neurovascular pedicle from
one side of a finger to the thumb tip (3). Obviously a skin graft is needed to resurface the donor defect. In
this instance, there is loss of sensation at the donor site, and the sensation at the thumb tip needs to be
reoriented at a cortical level.
A method is described for rotating the entire volar skin of the thumb, keeping its innervation intact (4, 5). A
second flap from the first web on the dorsum of the hand is transposed, to close the secondary defect at the
base of the thumb. This method offers several functional and aesthetic advantages: discriminative
sensibility and texture quality of the skin remain the same, the scar lines are in a location away from the
tactile surface of the thumb, and full-range joint motions are not compromised.
The technique described here is ideal for sharp or guillotine- type amputations of the thumb tip, but is also
suitable for crushing injuries in which the soft tissues of the stump are not seriously damaged.
ANATOMY
The flap is elevated on the ulnar side of the thumb and then back-cut along the volar surface at the MP crease.
Both neurovascular bundles are dissected to allow rotation and advancement of the flap, but they are preserved.
In this way the thumb retains good sensation that is correctly represented on the cerebral cortex.
FLAP DESIGN AND DIMENSIONS
The flap is based on the radial side of the thumb, but the blood supply comes through both neurovascular
bundles. The flap is elevated from the defect just dorsal to the midaxial line of the ulnar side of the thumb. At the
level of the MP crease, a backcut is made to allow the flap to rotate and advance into the defect (Fig. 267.1).

P.724
The pivot point of the flap is at the radial side of the MP crease.
Once the flap is inset, a triangular-shaped defect is created at the base of the thumb. The open area may be
resurfaced by a skin flap transposed from the dorsal skin of the first web. This triangular flap (Fig. 267.1) is
planned slightly larger in dimension than the secondary defect on the volar surface of the thumb. One side of the
flap is an extension of the midaxial thumb incision. It runs almost parallel to the fold of the web skin, and its apex
is at the lateral side of the index finger, where it turns back parallel to the index metacarpal. The flap can be 2 cm
in width.
OPERATIVE TECHNIQUE
If necessary, any small remnants of nail matrix should be removed. Tiny residues of fingernail regenerating in an
abnormal fashion can cause discomfort.
FIGURE 267.1 Volar thumb and dorsal web skin flaps elevated and inset. (From Argamaso, ref. 4, with
permission.)

P.725
FIGURE 267.2 A: Crush-type amputation across the middle of the distal phalanx. The neurovascular bundles
are elevated with the flap. B: Postoperative radial abduction and extension of interphalangeal and
metacarpophalangeal joints. C: Postoperative flexion of interphalangeal and metacarpophalangeal joints. (From
Argamaso, ref. 4, with permission.)
FIGURE 267.3 The postoperative position of the flaps is outlined with ink. Note that the scars are away from
areas of contact during pinch or grasp. (From Argamaso, ref. 4, with permission.)
Once the incision from the defect to the MP crease has been made, a gradual back-cut is done. The digital
neurovascular bundles are identified and kept intact. The proper digital nerves and arteries are found proximally
on the palmar side of the flap. They move toward the midaxial planes as they course distally. The neurovascular
bundles are raised carefully with the volar skin flap (Fig. 267.2A). It may be necessary to dissect these bundles in
the palm, to allow the skin flaps more mobility to rotate and stretch over the stump.
Once the triangular flap is transposed into the defect left by the rotation advancement flap, the defect on the side
of the index finger is closed by direct skin approximation. For more distally located tip injuries, where only a short
distance of volar skin advancement is required, the secondary defect at the thumb base is usually amenable to
simple direct closure by mobilizing the loose dorsal and palmar skin.

The thumb is kept in palmar abduction for about 10 to 14 days. Thereafter active exercises are started.
CLINICAL RESULTS
Tender scars have not been observed in the cases presented in this report. In general, scars on contact
areas, such as the web skin and opposing sides of the thumb and index finger, should be avoided (Fig.
267.3). The pigmented dorsal web skin that is transposed to the volar side of the thumb has not caused any
aesthetic problems.
SUMMARY
A volar rotation advancement flap can be used to close thumb tip injuries. Good cover and normal sensation
are provided and the donor defect can be easily closed with a transposition flap from the index finger.
References
1. Moberg E. Aspects of sensation in reconstructive surgery of the upper limb. J Bone Joint Surg
1964;46(A):817.
2. Posner MS, Smith RJ. The advancement pedicle flap for thumb injuries. J Bone Joint Surg
1971;53(a):1618.
3. Littler JW. In: Converse JM, ed. Reconstructive plastic surgery. Philadelphia: Saunders, 1964;1638-1639.
4. Argamaso RV. Rotation-transposition method for soft tissue replacement on the distal segment of the
thumb. Plast Reconstr Surg 1974;54:366.
5. Joshi BB. One-stage repair for distal amputation of the thumb. Plast Reconstr Surg 1970;45:613.

Chapter 268
Extended Palmar Advancement Flap
A. L. DELLON
Provision of a palmar surface with normal sensibility is the prime requisite of thumb reconstruction. The extended
palmar advancement flap provides an increased supply of local, normally innervated tissue to resurface
extensive distal palmar thumb defects.
INDICATIONS
For loss of up to 15 mm of palmar surface, if flap reconstruction is chosen, the palmar advancement flap first
described in 1964 (1) and then independently in 1967 (2) should be the procedure of choice. This flap uses
local tissue, leaves acceptable donor site scarring and, most important, provides normally innervated tissue.
These observations have been corroborated in several series (3, 4, 5, 6).
ANATOMY
The relative excess of soft tissue over the thumb metacarpophalangeal joint and the thenar eminence is
incorporated into a long palmar advancement flap by extending the classic midlateral incisions onto the thenar
eminence in such a way that both neurovascular bundles are contained within the flap. The incisions stop
approximately 1 cm distal to the thenar crease. Care must be taken during flap elevation on the ulnar side, since
the exact entrance of the princeps pollicis artery is variable. Mobilization of the radial digital artery may be
required also, because its entrance into the flap may vary.
FLAP DESIGN AND DIMENSIONS
It is possible to modify the original thenar advancement flap to provide a palmar advancement flap for the thumb
that allows a defect of up to 30 mm to be resurfaced without resulting joint contracture (7). This extensive
resurfacing can be accomplished by extending the flap proximally onto the thenar eminence and closing the
defects of the donor site of the flaps by additional rotation flaps. Flap width over the thenar eminence is not
critical because width is neither needed for flap survival in this axial pattern flap nor critical to donor site closure
(Fig. 268.1).
This long thin flap is reliable because of its axial pattern blood supply. The increased dissection required for its
elevation and the additional surgery required to fill the lateral donor site defects of the flap with adjacent flaps are
justified to preserve thumb length and sensibility.
OPERATIVE TECHNIQUE
The flap is elevated superficial to the tendon pulley system distally and to the thenar muscle fascia proximally.
The flap tip is then sutured to the distal end of the thumb defect. It will become apparent that, if the thumb is to
be extendable, additional soft tissue must be brought in to fill the triangular space created over both sides of the
metacarpophalangeal joint. If the sides of the flap were simply sutured to the radial and ulnar border of the dorsal
skin, significant flexion contractures of the interphalangeal and metacarpophalangeal joints would result. By the
use of two more adjacent local rotation flaps these defects can be closed.
On the radial side, the midlateral incision is continued to the base of the first metacarpal with a palmar back-cut,
if needed. The flap formed thereby is elevated at the muscle fascia level, rotated toward the radial defect, and

sutured into place.
On the ulnar side, the midlateral incision is continued across the thumb-index web toward the head of the second
metacarpal, then continued onto the palm along the thenar crease extension. This flap is elevated to include all
subcutaneous tissue, with attention being paid to the radial digital nerve to the index finger. The flap is rotated as
needed to fill the palmar and radial defect left by advancing the extended palmar flap onto the thumb. The donor
defects of these two lateral flaps are closed primarily (Fig. 268.1).
The distal tip of the extended palmar advancement flap should be tailored to give a nicely rounded, or contoured,
profile to the thumb. Any subcutaneous tissue appearing extraneous at the tip of the flap can be preserved as a
pedicle and sutured to provide support for the nail matrix or padding over the distal bone. For reconstruction of
an avulsed distal thumb segment, the advanced palmar flap is sutured to the dorsal skin to provide a well-
innervated thumb tip, allowing preservation of as much remaining phalanx as possible.
CLINICAL RESULTS
In almost all cases there is recovery of normal moving (8) and of static two-point discrimination by 1 year
postoperatively. Use of the palmar advancement flap in the fingers has been associated with dorsal skin
blistering (2) and dorsal skin loss (9), reportedly due to interruption of the dorsal branches of the digital
arteries. A small area of dorsal marginal necrosis on the radial side of the thumb (not the flap) occurred in
one of my patients, and this responded to local wound care, with secondary healing over a period of 2
weeks. The small dorsal skin loss observed in one of my four thumb reconstruction patients was probably
related to disruption of some dorsal circulation, although the dorsal aspect of the thumb usually has its own
independent arterial supply. A variation of this procedure, designed to preserve dorsal digital circulation,
has been reported (10).

FIGURE 268.1 The various steps involved in creating the extended palmar advancement flap (see text for
details). (From Dellon, ref. 7, with permission.)
Although no central (cortical) relearning is required for this flap, as it is with the transfer of a neurovascular
island flap to the thumb, I did find that sensory reeducation (11) facilitated functional recovery.
SUMMARY
In the procedure described here the adjacent flaps are designed to conceal the final scars along the normal
discontinuity of palmar and dorsal skin and along skin creases. The use of these flaps to close the
advancement flap donor site enables full thumb-web space extension and prevents flexion contractures of
the MP and IP joints.
References
1. Moberg E. Aspects of sensation in reconstruction surgery of the upper limb. J Bone Joint Surg [Am]
1964;46:817.
2. Snow JW. The use of volar flap for fingertip amputations. Plast Reconstr Surg 1967;40:163.
3. Keim HA, Grantham SA. Volar-flap advancement for thumb and fingertip injuries. Clin Orthop 1969;66:109.
4. Posner MA, Smith RJ. The advancement pedicle flap for thumb injuries. J Bone Joint Surg [Am]
1971;53:1618.
5. Moberg E. Useful surgical arrangement of skin with normal sensibility to mutilated hand. In: Clarke R, ed.
Modern trends in accident surgery and medicine. London: Butterworth, 1970;159.
6. Snow JW. Volar flap repair of fingertip amputations. In: Grabb WC, Myers MB (Eds.). Skin Flaps. Boston:
Little, Brown, 1975;482-486.
7. Dellon AL. The extended palmar advancement flap. J Hand Surg 1983; 8:190.
8. Dellon AL. The moving two-point discrimination test: clinical evaluation of the quickly-adapting
fiber/receptor system. J Hand Surg 1978;3:474.
9. Shaw MH. Neurovascular island pedicled flaps for terminal digital scars: a hazard. Br J Plast Surg
1971;24:161.
10. Macht SD, Watson BK. The Moberg volar advancement flap for digital reconstruction. J Hand Surg [Am]
1980;5:372.
11. Dellon AL. Evaluation of sensibility and re-education of sensation in the hand. Baltimore: Williams &
Wilkins, 1981; chap. 12.

(Trang không có chữ)

Chapter 269
Volar Cross-Finger Flaps
R. W. BEASLEY
B. W. EDGERTON
Maintenance of maximum length is axiomatic in the treatment of thumb amputations. Whenever possible, wound
closure without shortening should be accomplished with local tissues or those from an adjacent digit. The volar
cross-finger flap has several advantages for repair of distal thumb amputations (1, 2). Positioning is much easier
than with a dorsal cross-finger flap from the index finger, and the donor site is hidden on the volar side of the
finger. Local tissue of near-perfect match with the ability to recover an excellent degree of sensibility is used,
adequate padding is restored, and there is minimal donor site morbidity.
INDICATIONS
The volar cross-finger flap is an excellent method of reconstruction for dorsal oblique, guillotine, or volar
amputations of the distal thumb. The volar advancement flap (3) is a good alternative to this flap for dorsal
oblique amputations; but the volar cross-finger flap is a better alternative for major volar losses, because it
provides excellent tissue replacement without any traction on the vessels or nerves of the thumb that may
result in dysesthesia. The volar cross-finger flap also provides sufficient skin and subcutaneous tissue
under no tension for support of the fingernail and for proper tip contour (Fig. 269.1).
FIGURE 269.1 A: The volar cross-finger skin flap. Note that the neurovascular bundle is left attached to the
base of the pedicle. A formal dissection of the neurovascular bundle is required when the flap is divided.
The flap is dissected in a plane just superficial to the tendon sheath, thereby preserving an adequate bed
for skin grafting. B: Volar flap prepared for transfer. C: Flap in place on the amputated thumb tip. (From
Beasley, ref. 2, with permission.)
ANATOMY
The volar skin of the digits has a vertically oriented blood supply with only short horizontal interconnections. This
differs from the dorsal skin, which has a longitudinal orientation of vessels. This difference must be respected
and there is a limit to the size of volar flaps that can be safely elevated. During the elevation of the flap, the
neurovascular bundle must not be dissected free from the pedicle (Fig. 269.1A), in contrast to dorsal cross-finger

P.727
flaps, because this will seriously jeopardize the blood supply to the flap. A formal dissection of the neurovascular
bundle in a bloodless field is necessary at the time of pedicle division. These flaps are direct flaps, in that the
defect is positioned directly under the open surface of the flap.
FLAP DESIGN AND DIMENSIONS
The thumb is placed in opposition to the volar surface of the long finger, and a decision is made whether to use
the proximal or middle phalanx and whether to base the flap on the radial or ulnar border of the finger. If the
tissue has been lost only on the volar surface of the thumb, the volar cross-finger flap should be based ulnarly.
Most cases of guillotine or dorsal oblique thumb amputations are more suitably handled by a flap based
on the radial side of the finger (Fig. 269.1B). Positioning is more favorable with respect to the joints when tissues
overlying the middle phalanx are used, but a flap overlying the proximal phalanx will provide a greater bulk of
subcutaneous tissue. A maximum-sized flap of 2 × 2 cm may be raised from the volar surface of either the
proximal or the middle phalanx of the long finger.
FIGURE 269.2 A: Dorsal oblique amputation of the thumb tip. B: Dissection of the flap, leaving the
neurovascular bundle attached to the base of the flap. C: The flap in place. The donor site is covered with a full-
thickness skin graft. D: Postoperative appearance. Note that thumb length has been preserved.
A pattern of the defect is created and placed on the donor surface. The flap is outlined to include extra length of
the base, and the margins are carried to lines of neutral skin tension just as with elective incisions, even if part of
the flap must be discarded. Care should be taken to minimize flexion of the proximal interphalangeal joint (Fig.
269.1C). All flaps should be measured twice before cutting.
OPERATIVE TECHNIQUE
The flap is elevated in a plane just superficial to the tendon sheath, which preserves an adequate bed for skin
grafting (Fig. 269.2A and B). The flap must be dissected free from the opposite underlying neurovascular bundle,
but the neurovascular bundle at the base of the flap must not be dissected from the pedicle. After obtaining
meticulous hemostasis, a full-thickness skin graft is sutured into the volar defect and the flap is then sutured to
the thumb (Fig. 269.2C). A carefully fitted compressive dressing is placed over the skin graft and the thumb and

P.728
finger are secured together with tape before applying a light plaster shell with a window to allow inspection.
With progressive healing, the pedicle of the flap may be divided in 10 to 14 days as a formal operative
procedure. Care must be taken not to injure the neurovascular bundle in the pedicle when the base of the flap is
severed. Sutures may be used gently to approximate the donor site after division and for hemostasis, but the flap
should not be sutured or inset further at the time of severance. The flap tolerates handling or any tension poorly
at this stage. A noncompressive dressing is applied and mobilization of joints is begun at once. The wound is
allowed to epithelialize and a secondary revision is required for an occasional patient.
CLINICAL RESULTS
Volar cross-finger flaps have been used on our service in 20 cases (Fig. 269.2D). No instances of flap loss,
infection, or donor site complications have occurred.
SUMMARY
The volar cross-finger flap is an excellent reconstructive method for dealing with major distal amputations of
the thumb, whether dorsal oblique, guillotine, or volar oblique. The flap furnishes well-padded volar skin of
near-perfect tissue match to preserve maximum thumb length and support of the nailbed.
References
1. Beasley RW. Principles of managing acute hand injuries. In: Converse JM, ed. Reconstructive plastic
surgery. Philadelphia: Saunders, 1977; 3027.
2. Beasley RW. Hand injuries. Philadelphia: Saunders, 1981.
3. Moberg E. Aspects of sensation in reconstructive surgery of the upper extremity. J Bone Joint Surg [Am]
1964;46:817.

Chapter 270
Side Finger Skin Flap to The Thumb Tip
R. C. RUSSELL
E. G. ZOOK
EDITORIAL COMMENT
Although this flap is valuable for thumb tip reconstruction, the extreme flexion of the finger while it is
attached to the flap may result in significant residual stiffness of the finger.
A cross-finger flap can be elevated from the side of the proximal phalanx to cover thumb tip amputations (1). This
flap has certain advantages over previously described techniques for this difficult problem (2, 3, 4, 5, 6, 7, 8, 9,
10, 11, 12, 13, 14, 15, 16).
INDICATIONS
A side finger flap elevated from the index or long finger will easily reach thumb tip amputations distal to the
interphalangeal joint in all age groups. More proximal amputations may be difficult to reach in less supplely
working hands.
FLAP DESIGN AND DIMENSIONS
The flap is proximally based and centered dorsal to the midaxial line over the proximal phalanx of the donor
finger. It can extend slightly beyond the proximal interphalangeal joint flexion crease distally, and may be as wide
as 2 cm, depending on the circumference of the donor digit. Elevation from the ulnar side of the finger is best, to
decrease donor site deformity. The ulnar sides of the digits are hidden from view during most hand use and at
rest.
The injured thumb tip is first manipulated next to the proposed donor site to assess ease of positioning. With the
fingers flexed, the midaxial line is next marked along the top of the interphalangeal joint flexion creases. The flap
is then outlined with the finger extended, so that two-thirds of the flap lies dorsal to the midaxial line (Fig.
270.1A).
OPERATIVE TECHNIQUE
Elevation is begun dorsally, by incision through the skin and subcutaneous tissue to the underlying extensor
tendon mechanism. The flap is dissected in a volar direction preserving the peritenon, until the neurovascular
bundle is identified.
The distal and volar skin incisions are then completed to a level superficial to the underlying digital artery and
nerve. The flap is then elevated proximally to the volar metacarpophalangeal joint flexion crease.
The dorsal incision may be extended further into the interphalangeal web space, to permit greater flap mobility.
Large dorsal veins seen entering the base of the flap should be preserved by gentle scissor dissection, dividing
only persistent fibrous tissue.
If the donor defect is to be closed primarily, the dorsal and, to a lesser degree, volar skin edges are undermined

P.729
and approximated toward the base of the flap (Fig. 270.1). Care should be taken to avoid excessive tension of
the soft tissue at the base of the flap. Larger donor defects are closed with a
full-thickness skin graft from the inguinal flexion crease, using a stent dressing. The flap is then rotated 90°
volarly or dorsally over the thumb (Fig. 270.1C).
FIGURE 270.1 A side finger flap from the ulnar side of the donor finger is centered above the midaxial line (A)
and can be rotated 90° volarly to cover an amputated thumb tip (B,C). The side finger may be rotated to cover an
amputated fingertip (D-F). (From Russell et al., ref. 1, with permission.)
Postoperatively, the injured and donor digits should be immobilized, to facilitate neovascular ingrowth into the
flap and, when necessary, the take of the skin graft. Flaps are divided in 12 to 18 days, followed by immediate
active and passive range of motion exercises.
CLINICAL RESULTS
Side finger flap donor sites form fine scars away from the grasping surface of the digit, and these scars
have been uniformly nontender. Skin-grafted donor sites may remain depressed or become hyperpigmented
with time. However, when placed on the ulnar side of the finger, the deformity is much less visible and is
cosmetically superior to that seen following standard dorsal cross-finger flaps.
Residual stiffness of the injured or donor digits has not occurred in our patients, and all flaps have provided
stable cover.

P.730
SUMMARY
The side finger skin flap is an excellent choice for thumb tip amputations, when a more cosmetically
acceptable donor site is desired.
References
1. Russell RC, Van Beck AL, Wavak P, Zook EG. Alternative hand flaps for amputations and digital defects. J
Hand Surg [Am] 1981;6:399.
2. Atasoy E, Ioakimidis E, Kasdan ML, Kutz JE, Kleinert HE. Reconstruction of the amputated finger tip with a
triangular volar flap: a new surgical procedure. J Bone Joint Surg [Am] 1970;52:921.
3. Barton NJ. A modified thenar flap. Hand 1975;7:150.
4. Bennett JE. Fingertip avulsions. J Trauma 1966;6:249.
5. Flatt AE. The thenar flap. J Bone Joint Surg [Br] 1957;39:80.
6. Gatewood. A plastic repair of finger defects without hospitalization. JAMA 1926;87:1479.
7. Hoskins HD. The versatile cross-finger pedicle flap: a report of twenty-six cases. J Bone Joint Surg [Am]
1960;42:261.
8. Kutler W. A new method for finger-tip amputation. JAMA 1947;133:29.
9. Littler JW. Principles of reconstructive surgery of the hand. In: Converse JM, ed., Reconstructive plastic
surgery. Philadelphia: Saunders, 1964; 1612-1673.
10. Miller AJ. Single fingertip injuries treated by thenar flap. Hand 1974;6:311.
11. O'Brien BM. Neurovascular island pedicle flaps for terminal amputations and digital scars. Br J Plast Surg
1968;21:258.
12. O'Brien BM. Neurovascular pedicle transfers in the hand. Aust N Z J Surg 1965;35:2.
13. Robins RHE. Fingertip injuries. Hand 1970;2:119.
14. Smith RJ, Albin R. Thenar “H-flap” for fingertip injuries. J Trauma 1976;16:778.
15. Tempest MN. Cross-finger flaps in the treatment of injuries to the fingertip. Plast Reconstr Surg
1952;9:205.

16. Woolf RM, Broadbent TR. Injuries to the fingertips: treatment with cross-finger flaps. Rocky Mt Med J
1967;35:1195.

P.731
Chapter 271
Cocked Hat (Gillies) Thumb Skin Flap
D. A. CAMPBELL REID
The cocked hat flap was first suggested by Gillies (1) in 1946 as a possible technique for lengthening the
partially amputated thumb.
INDICATIONS
This flap is usually used for lengthening a thumb amputated in the region of the metacarpophalangeal joint
(2, 3, 4). It may be used only as a reconstructive procedure. By the time this is undertaken, scarring
following primary surgery for the amputated thumb will have matured and softened.
The cocked hat flap can be used when all four fingers are intact if it is not considered justifiable to pollicize
a finger. It can also be used in the mutilated hand if no suitable digit is available for pollicization.
ANATOMY
This is a distally based flap. The blood supply is from the vessels that are distributed to the thumb, the radial
side of the index finger, and the adjoining web. The princeps pollicis artery arises from the deep palmar arch and
divides into the two proper digital arteries to supply the volar aspect of the thumb.
The first dorsal metacarpal artery arises from the radial artery just before it passes between the two heads of the
first dorsal interosseous muscle, and divides almost immediately into the two branches that supply the back of
the thumb and the adjacent side of the index finger. Branches of the radialis indicis artery will also supply the
flap. This vessel arises either from the deep palmar arch or from the princeps pollicis artery. There is a
considerable anastomotic network between these various component vessels to supply the skin of the
thumb/index web.
Veins accompany these arteries, and it is these that are responsible for the venous drainage of the flap, since
the superficial veins on the dorsal aspect of the hand must be divided when raising the flap.
FLAP DESIGN AND DIMENSIONS
In the average-sized adult hand, the width of the flap at its base measures 7 to 8 cm. The length of the flap from
base to apex measures 5 to 6 cm. The pivot of the flap is the radial side of the index finger, where it joins the first
web space (Fig. 271.1).
A U-shaped flap is marked out, commencing on the dorsal aspect opposite the neck of the second metacarpal
and curving around the base of the thumb over the carpometacarpal joint onto the thenar region of the palm. The
palmar part of the flap
then extends distally, parallel to, and about 1 cm on the radial side of, the thenar crease, ending at a point
corresponding to the beginning of the flap on the dorsum.

FIGURE 271.1 Outline of the cocked hat flap on the thumb stump. (From Campbell Reid, ref. 4, with permission.)
OPERATIVE TECHNIQUE
Dissection of the flap starts on the dorsal aspect and at the level of the deep fascia. Superficial veins
encountered in the dissection are ligated or coagulated. As the end of the stump is reached, great care must be
taken not to damage the skin, which will almost certainly be adherent to the stump. Dissection is made directly on
the bone, thus freeing the skin.
Further dissection is then extended onto the palmar aspect, until the flap is completely free and may be displaced
over the end of the stump (Fig. 271.2A and B). Branches of the median nerve to the stump are preserved. Radial
nerve branches on the dorsum must be sacrificed, and the proximal ends are coagulated with bipolar diathermy,
in an attempt to prevent neuroma formation.
The thumb stump is then cleared of soft tissue and, if the thumb has been amputated through the
metacarpophalangeal joint, the cartilage is removed from the metacarpal head. Otherwise, sclerotic bone is cut
away to leave a healthy bone surface. Once the tourniquet is released, the flap may initially appear somewhat
congested.
The bone graft is taken as a 5-cm segment from the full thickness of the iliac crest. The proximal 2.5 cm of graft
is made into a peg using the cortical bone, while the remaining part is shaped to size (Fig. 271.2B). The bone on
the dorsal aspect will be cortical, continuous with the peg, while the rest will be cancellous, providing the
necessary bulk. The cortical bone gives the graft its strength. The metacarpal is then reamed out to receive the
peg, which is securely inserted for its full length (Fig. 271.2E). No other fixation is required.
The skin flap is then draped over the bone graft, which must not be of such bulk or length as to imperil the blood
supply of the flap. If that part of the flap overlying the end of the graft remains blanched, then the bone graft is
either too long or too bulky. The bone graft in that case must be removed, further reduced, and rounded off.
The flap must completely cover the bone graft. The resultant defect is skin-grafted. The first dressing is changed
about 10 days later. Early use is encouraged, as this appears to hasten consolidation of the bone graft.
CLINICAL RESULTS
The author has had no failures due to loss of the skin flap. Initially the flap may be a little congested and the
surface may blister, but with elevation for 2 to 3 days it soon settles.
Complications occasionally occur, but these are related to the bone graft. Resorption has occurred in one

P.732
case. In another case a bone graft extruded, but this was in an early case where the graft was taken from
the upper end of the ulna. It is not possible to obtain a graft of adequate bulk from this site, and the bone is
almost entirely cortical. The rather narrow bone graft ulcerated through the end of the thumb flap, became
infected, and had to be removed. Subsequently, the grafts were all taken from the iliac crest, as has been
described, with satisfactory results.
The secondary defect covered with a thick split-thickness skin graft heals well, with no functional deficit.
There have been no problems with neuromata where the radial nerve fibers have been severed.
This operation does displace the thumb/index web distally, but, should it be required, the web may
subsequently be deepened by a Z-plasty.
SUMMARY
Thumb lengthening can be achieved by covering a bone graft with the Gillies cocked hat flap.
FIGURE 271.2 A: Thumb loss just distal to an immobile metacarpophalangeal joint. B: Cocked hat flap
raised and displaced over the metacarpal head, with iliac bone graft about to be inserted. C,D:

Postoperative result with donor site skin-grafted. The thumb was lengthened 2.5 to 3 cm, and good
sensation was present over the tactile surface. E: X-ray demonstrates incorporation of bone graft 6 months
later. (From Campbell Reid, ref. 4, with permission.)
References
1. Gillies H. “Cocked hat thumb flap.” Paper presented at the Annual Meeting of the British Association of
Plastic Surgeons, 1946.
2. Hughes NC, Moore FT. A preliminary report on the use of a local flap and peg bone graft for lengthening a
short thumb. Br J Plast Surg 1950;3:34.
3. Campbell Reid DA. In: Pulvertaft RG, ed., Operative surgery: the hand. 3d Ed. London: Butterworths,
1977.
4. Campbell Reid DA. The Gillies' thumb lengthening operation. Hand 1980;12:123.

Chapter 272
Thumb Pulp Neurovascular Island Flap
R. W. H. PHO
The thumb pulp flap is a local neurovascular island flap based on the volar radial digital neurovascular bundle of
the thumb, to resurface extensive pulp loss of the thumb when tendon and bone are exposed. The flap offers
excellent skin coverage with adequate soft-tissue padding and near-normal sensibility (1, 2, 3) (see Chapter
274).
INDICATIONS
This flap can be used to preserve thumb length in cases of traumatic amputation. It is also excellent for
replacing either pulp or skin loss on the volar surface of the thumb (Figs. 272.1 and 272.2) or of the first
web space.
The thumb pulp flap is a flexible flap that is not technically difficult. The preservation of the dorsal skin
bridge to retain its alternative blood supply is a method of salvaging the flap if the vascular pedicle is
accidentally damaged, thrombosed, or congenitally absent. The flap can then be replaced in its original bed
or converted into a transposition flap with the dorsal skin bridge as its base.
There is an added advantage in that the flap retains relatively normal sensibility. There is none of the
sensory disorientation that is seen in the neurovascular island flap that is taken from other digits.
ANATOMY
The skin over the dorsoradial side of the thumb receives sensory innervation from both the radial nerve and the
volar digital nerve (Fig. 272.1A and B) (4, 5, 6). The volar digital nerve on the radial side normally sends its
minute dorsal branches distal to the interphalangeal joint.
The main trunk is accompanied by the volar digital artery, which has a relatively constant location just distal to
the first metacarpophalangeal joint. The artery is invariably dorsal and deep to the digital nerve and lies just
superficial to the fibrous flexor sheath. It normally sends a branch dorsally at the level of the neck of the proximal
phalanx and forms a cross-anastomosis with the ulnar digital artery.
FLAP DESIGN AND DIMENSIONS
An island flap based on the volar digital neurovascular bundle can be raised from the metacarpophalangeal joint
proximally to within 3 mm of the nail fold distally. Similarly, the flap can be extended across the midline dorsally.
However, the sensory innervation provided by the radial volar digital nerve to the skin proximally and across the
midline is limited (Fig. 272.1).
The island flap to be raised is outlined with methylene blue, corresponding to the size of the defect to be
resurfaced.
OPERATIVE TECHNIQUE
A preliminary identification of the volar radial neurovascular bundle is made by a midlateral incision at the level of
the metacarpophalangeal joint. The bundle should be raised with the surrounding fatty tissue (Fig. 272.2A). The
plane of dissection should be superficial to the fibrous flexor sheath.

P.734
The neurovascular bundle together with the skin flap is raised, leaving only a midline skin bridge connecting it to
the surrounding dorsal skin as its base, to obtain its alternative blood supply (Fig. 272.2A). The neurovascular
bundle is traced as far proximally in the palm as is necessary to obtain adequate length for advancement.
A digital tourniquet is then placed around the thumb, excluding the isolated neurovascular bundle. The main arm
tourniquet is then released.
If the pedicle has been raised successfully, there will be initial bleeding confined to the wound edges of the
raised flap. Subsequently, due to cross anastomosis along the intact dorsal skin bridge, the remaining thumb will
become pink. Once this is confirmed, one can safely divide the dorsal skin bridge and convert the flap into an
island flap (Fig. 272.2B), advancing it distally to cover the pulp defect (Fig. 272.2C).
The donor area should always be resurfaced with a full-thickness skin graft, to provide a cosmetically stable
scar. The loss of sensation over the donor area is not significant, because it is not the critical area where precise
prehension is required.
A dorsal plaster slab is used in the first 2 weeks, with the metacarpophalangeal joint and the interphalangeal joint
flexed to avoid undue stretching of the pedicle.
CLINICAL RESULTS
This technique was used in six thumbs with extensive pulp loss. Three cases were done as primary
procedures; three cases were done as secondary procedures for residual tender scarring on the pulp that
affected pinch strength (Figs. 272.3 and 272.4).
FIGURE 272.1 A: Outline of the flap. Note the proximal extension used to isolate the neurovascular bundle.
B: The flap has been raised, but with the dorsal skin bridge left intact. A digital tourniquet has been applied,
excluding the isolated neurovascular bundle. C: The dorsal skin bridge has been divided. The island flap is
then advanced distally and the donor defect covered with a full-thickness skin graft. (From Pho, ref. 3, with
permission.)

P.735
FIGURE 272.2 A: The flap is raised with an intact neurovascular bundle (N) and with the dorsal skin bridge
still intact. B: After division of the dorsal skin bridge, the island flap has been raised, showing the donor
defect (which is skin-grafted). C: The island flap is advanced to cover the pulp defect. (From Pho, ref. 3,
with permission.)
FIGURE 272.3 A,B: Pulp loss with unhealthy tender scar. (From Pho, ref. 3, with permission.)
In five cases the flap was raised successfully. In one case, done as an elective procedure and as my
second attempt at using this technique, the flap showed no evidence of circulation before division of the
dorsal skin bridge. It was decided that it would be too risky to convert it into an island flap. Instead it was
used as a rotation flap to narrow the gap that had to be closed.
All five patients in whom flaps were converted into island flaps successfully achieved primary wound healing
within 2 weeks. Each was able to return to his or her original work within 6 weeks.
The results were assessed 9 to 40 months after operation. None of the patients experienced hyperesthesia,
pain, or autonomic disturbance such as cold sensitivity or excessive sweating in the flap or donor area. The
flap was supple with no induration along the margins.
Sensibility was evaluated by light touch, two-point discrimination, and ninhydrin printing. All patients

P.736
responded well to light touch with cotton wool, but they seemed to have delayed responses to pin pricks, as
compared with the response in the surrounding digits.
FIGURE 272.4 A,B: Postoperative result showing the donor area and the newly reconstructed pulp. (From
Pho, ref. 3, with permission.)
The two-point discrimination test was recorded as varying from 3 to 6 mm. One patient had an initial record
of 15 mm at 2 weeks after the operation, but improved to 6 mm by 9 months later. In all of the other patients,
there was no alteration of two-point discrimination from the initial recording immediately after operation to
that measured several months later.
Two patients, in whom strength of pulp-to-pinch was assessed before and after operation, showed
significant improvement in pinch strength.
SUMMARY
The thumb pulp flap is a neurovascular island flap that is useful for covering defects of the thumb tip with
well padded sensory skin.
References
1. Joshi BB. Local dorso-lateral island flap for restoration of sensation after avulsion injury of the finger tip.
Plast Reconstr Surg 1974;54:175.
2. Pho RWH. Restoration of sensation using a local neurovascular island flap as a primary procedure in
extensive pulp loss of the finger tip. Injury 1976;8:20.
3. Pho RWH. Local composite neurovascular island flap for skin cover in pulp loss of the thumb. J Hand Surg
1979;4:11.
4. Coleman SS, Anson BJ. Arterial patterns in the hand based upon a study of 650 specimens. Surg Gynecol
Obstet 1961;113:409.
5. Wallace WA, Coupland RE. Variation in the nerves of thumb and index finger. J Bone Joint Surg [Am]

1975;57:491.
6. Parks BJ, Abelaez J. Medical and surgical importance of the arterial blood supply of the thumb. J Hand
Surg 1978;3:383.

P.737
Chapter 273
Dorsal to Volar Transposition Skin Flap of The Finger
S. H. HARRISON
D. H. HARRISON
The dorsal skin flap is designed to provide neurovascular cover to the dynamic sensory areas of the hand (1):
the ulnar side of the thumb pulp, the radial side of the index and middle pulps, and the ulnar side of the pulp of
the little finger.
INDICATIONS
The area to be covered is greater than that treatable by small local flaps and would normally qualify for a
cross-finger or neurovascular island flap (2). A disadvantage of the crossfinger flap is the lack of sensation.
With the neurovascular island flap the patient can have difficulties with cortical sensory representation. The
dorsal to volar transposition flap has been further developed by converting it into an island on the same
neurovascular pedicle (3). It can then cover the whole of the terminal pulp in length and three-quarters of
the width.
ANATOMY
The blood supply of the terminal segment is shown in Figure 273.1 (4), demonstrating how large vessels arise
from the digital artery in the middle segment of the finger to supply the dorsal skin. A rich anastomosis occurs
around the nailbed. Distally there is free communication between the dorsal vessels and the vessels of the pulp.
The blood supply will permit the elevation of a long and fairly narrow flap based on the main dorsal branch of the
digital artery that arises in the middle segment of the finger. This artery arises from the volar digital artery, within
the neurovascular tunnel created by Grayson's ligament anteriorly and Cleland's cutaneous ligament posteriorly
(Fig. 273.2). The dorsal branch of the digital nerve accompanies the dorsal branch of the digital artery.
FLAP DESIGN AND DIMENSIONS
The incision along the side of the dorsum curves just proximal to the proximal interphalangeal joint crease, and
the length is therefore the distance between the proximal interphalangeal joint crease and the nail fold (see Fig.
273.3B). The width of the flap is the entire dorsum of the finger. The nailbed is not at risk from ischemia,
because of the excellent anastomosis around the nailbed.
OPERATIVE TECHNIQUE
As the dissection proceeds toward the base of the flap, it is essential to divide Grayson's ligament (Fig. 273.2).
This will allow the dorsal branch and the main digital vessel to turn toward the midline of the finger, to avoid
kinking and to reduce tension on the main vascular pedicle. It is important to elevate the flap at a critical level
between the vascular field and the paratenon and, at the same time, to free the dorsal branch and the main
digital branch from the fascial compartment, in order to prevent kinking of the main artery (Fig. 273.3B).
To offset the effect of crush and to allow the vascular tree to recover, a delayed primary repair can be performed
on the fifth day, after a primary toilet and debridement.

P.738
FIGURE 273.1 Vascular supply to the finger. (From Flint and Harrison, ref. 1, with permission.)
CLINICAL RESULTS
The success of this flap depends on careful anatomic dissection and design, supplemented by
magnification. If there has been an element of crush in the primary injury (as distinguished from a slicing
injury), it is desirable to defer primary repair for delayed primary or secondary, using a split-thickness skin
graft for physiologic cover.
The complications of all such flaps are ischemia and infection. If there is any doubt about the viability of the
flap it should be replaced. If it survives it can be used as a delayed flap.
FIGURE 273.2 Drawing showing the anatomy of Cleland's ligament, which lies dorsal to the neurovascular
bundle, and Grayson's ligament, which lies volar. Release of these ligaments will avoid kinking and excess
tension on the vessels. (From Flint and Harrison, ref. 1, with permission.)
A functional deficit is the loss of sensation in the skingrafted donor site on the dorsum of the finger.
SUMMARY
The dorsal neurovascular skin flap can provide both cover and sensation to volar pulp losses.

FIGURE 273.3 A: Pulp defect suitable for a dorsal transposition flap. There is almost a total loss of the
terminal pulp skin and subcutaneous tissue. B: The flap elevated from the dorsum of the finger. The
dissection lies in the critical area between the paratenon and the neurovascular plateau. C: The flap
adequately covers the defect. D,E: Postoperative result. A split-thickness skin graft is used to cover the
donor site. (From Flint and Harrison, ref. 1, with permission.)
References
1. Flint MH, Harrison SH. A local neurovascular flap to repair loss of the digital pulp. Br J Plast Surg
1965;18:156.
2. Littler JW. Neurovascular pedicle transfer of tissue in reconstructive surgery of the hand. J Bone Joint
Surg 1956;38(A):917.
3. Joshi BB. A local dorsolateral island flap restoration of sensation after avulsion injury of fingertip pulp.
Plast Reconstr Surg 1974;54:175.

4. Flint MH. Some observations on the vascular supply of the nailbed and terminal segments of the finger. Br
J Plast Surg 1955;8:186.

Chapter 274
Dorsolateral Island Skin Flap to The Fingertip and Thumb Tip
B. B. JOSHI
EDITORIAL COMMENT
Retention of the dorsal vein is most likely unnecessary and probably limits the mobility of the flap. The
neurovascular bundle itself will provide sufficient venous drainage for the flap. This operation is still an
extremely useful procedure. It is one of the better nonmicrovascular reconstructions of the thumb that
provides a very useful and functional digit (see Chapter 272).
The fingertip can be reconstructed by using a flap from the dorsolateral surface of the finger (1). This flap is
based on the volar digital vessels and their dorsal branches, thus providing good sensory tissue to cover pulp
loss.
INDICATIONS
The dorsolateral island flap is suitable for repair of those defects that are too large to be covered by such
procedures as the volar advancement flap or the volar V-Y advancement flap.
The dorsolateral island flap does not have the problem of cortical reorientation, and is therefore preferred
over an island flap transfer from another finger (2, 3). It has better sensibility than palmar flaps or cross-
finger flaps, as the latter are essentially insensitive flaps that depend on subsequent innervation from the
bed and periphery of the grafted area.
Since the donor site is dorsolateral, the functional deficit is minimal. Volar skin is left essentially undisturbed,
and there is no danger of producing a flexion contracture.
The only contraindication would be thrombosis of the digital artery.
ANATOMY
The skin over the distal two phalanges of the finger is supplied mainly by segmental branches of the volar digital
arteries and nerves, with many anastomoses among the dorsal and volar branches.
Small island flaps that contain only distal phalangeal skin do not have good circulation. Subsequently the island
flaps are extended to include the skin over two distal segments; one must be careful to include both the most
proximal dorsal branch of the volar digital vessels and a vein over the dorsum of the finger. The accompanying
nerves are also included in the pedicle.
The flap can be taken from either side of the finger or thumb. The dorsal branches of the radial artery and nerve
are usually quite separate from the volar branches in the thumb. Vessels and nerves need to be preserved and
dissected proximally, as do the branches of the volar digital neurovascular bundles.
FLAP DESIGN AND DIMENSIONS
The flap is extended proximally in an oblique direction, from the edge of the defect to the midlateral border of the
finger at the level of the proximal interphalangeal joint crease. Distally, the flap extends along the margin of the

P.740
P.741
defect to the tip, and then turns dorsally, leaving a border of skin measuring 2 to 5 mm next to the nail. The flap
extends proximally along the midline of the dorsum of the finger, and then turns obliquely to join the midlateral
line at the proximal interphalangeal joint crease (Fig. 274.1).
This flap will usually cover the full length of the defect and about three-quarters of the width of the pulp.
OPERATIVE TECHNIQUE
An incision is made along the midlateral line proximal to the flap outline. The volar digital vessels and the nerves
in the
pedicle area are dissected to their entrance into the flap. Care must be taken to preserve the branches of the
neurovascular bundle that arise at the proximal interphalangeal joint level. The pedicle must be dissected
sufficiently to allow adequate advancement of the flap. This may involve extending the incision proximally into the
palm (Fig. 274.1A).
FIGURE 274.1 A: The flap outline extends proximally in an oblique direction from the edge of the defect to the
junction of the proximal interphalangeal joint crease and the midlateral line. B: The flap outline extends distally
along the edge of the defect. A border of skin of about 2 to 5 mm should be left along the margin of the nail. The
incision then runs proximally down the midline of the dorsum of the finger and then turns obliquely to join the
midlateral line at the level of the proximal interphalangeal joint crease. C: The neurovascular bundle is dissected
proximally to allow advancement of the flap into the defect. D: A dorsal vein and the branches of the
neurovascular bundle, as they cross dorsally at the proximal interphalangeal joint, are included with the flap. E:
The flap is advanced into the defect. F: The dorsolateral donor site is skin-grafted. (From Joshi, ref. 1, with
permission.)

FIGURE 274.2 A: Fingertip injuries of the index, long, and ring fingers had been previously covered with cross-
arm flaps that were bulky and lacked sensation. B,C: Volar and lateral views of the flap advanced and inset over
the defect. D,E: Postoperative views, showing complete extension and flexion.
FIGURE 274.3 A: Dorsolateral island flap after transposition and advancement to the thumb. B: Final result.
The flap as outlined above is raised from the volar aspect initially. The neurovascular bundle and its branches
are preserved within the flap (Fig. 274.1C). Before the dorsal incisions are made, the tourniquet should be
released and the circulation checked. A dorsal vein should be included with the flap as the incisions are
completed (Fig. 274.1D). If there is a separate dorsal neurovascular bundle, as in the thumb, it should also be
dissected and preserved.
After the flap is advanced into the defect, the donor site is covered with a skin graft (Fig. 274.1E and F). The
finger is immobilized for 2 weeks with partial flexion at the metacarpophalangeal joint (Figs. 274.2 and 274.3).
CLINICAL RESULTS
Partial necrosis occurred in two early cases, when small island flaps were raised. Once the flap was
enlarged to cover both the middle and distal phalanges and to include the neurovascular branches as they
cross dorsally at the proximal interphalangeal joint, flap circulation has not been a problem.

More than 200 dorsolateral island flaps have been done at my center. The sensation obtained in these
island flaps has been excellent, with a two-point discrimination of 3 to 4 mm (Fig. 274.2).
SUMMARY
Fingertip or thumb tip injuries can be repaired with an island flap based on one of the dorsolateral surfaces
of the same digit. This leaves a minimal donor site defect and provides good padding and sensation to the
volar pulp.
References
1. Joshi BB. A local dorsolateral island flap restoration of sensation after avulsion injury of finger tip pulp.
Plast Reconstr Surg 1974;54:175.
2. Littler JW. Neurovascular pedicle transfer of tissue in reconstructive surgery of the hand. J Bone Joint
Surg 1956;38A:917.
3. Flint MH, Harrison SH. A local neurovascular flap to repair loss of the digital pulp. Br J Plast Surg
1965;18:156.

Chapter 275
Digital Neurovascular Island Skin Flap
J. W. LITTLER
J. M. MARKLEY
EDITORIAL COMMENT
This is the “classic” procedure described by Littler in the late 1950s. Its use both as an island transfer and,
more recently, as a free transfer, provides sensibility to another part of the hand. If it is transferred as a
pedicle, it requires reeducation, which may be difficult for some patients.
The anatomic specificities of various regions allow particular reconstructive techniques. The spoke-like digital
neurovascular bundles that radiate from the central palm into the fingers allow the lateral transfer of an
innervated and well-perfused composite skin island to a critical site deprived of special coverage.
INDICATIONS
The finger neurovascular composite skin island can provide durable corniferous glabrous skin with excellent
perfusion and functional sensibility (1, 2, 3). It is particularly useful for resurfacing defects in the critical
functional contact areas of the thumb or index finger after loss of their terminal surfaces, in various
reconstructions of the thumb by osteoplastic methods, or to enhance a reunited amputated part.
Although usually used as a secondary procedure after initial healing with a free skin graft or distant flap,
primary reconstruction with a digital neurovascular island flap may be advantageous in carefully selected
cases (4). Use of the neurovascular island flap for relief of a chronically painful digit with inadequate skin
and soft tissue and poor sensibility should be undertaken with caution, because disabling dysesthesia
persists with distressing frequency in such cases despite technically good and well-healed flaps (5).
The neurovascular island transfer of composite tissue is adaptable to reconstructive problems when part or
all of a digit is to be discarded. For example, when the index, due to injury or disuse, could serve better as a
source of composite tissue, it may be removed with transfer of its tactile corniferous skin as a neurovascular
island, to resurface the thumb web or other area in need of durable cover.
Microsurgical techniques make possible potentially useful variations on the neurovascular island transfer of
digital skin. In cases of replantation or revascularization of digits in which insufficient length of vessel or
nerve is available, the deficiency may be met by transfer, without skin, of artery and nerve from a donor site
of lesser advantage (6). Also, the problem of reorientation of localization of sensibility may be partially
solved by vascular island transfer with division of the donor nerve and microsurgical fascicular anastomosis
with a remaining recipient site sensory nerve. The latter maneuver demands careful management of the
proximal stump of the donor digital nerve to reduce the possibility of painful neuroma.
ANATOMY
The radial arrangement of the digital arteries and nerves from the central palm to the digits is the basic anatomic
feature permitting transfer of a neurovascular island between any two digits (Fig. 275.1). The center of the arc of
transfer of this flap is thus a small midpalmar zone approximated by the points of intersection of the palmar

P.743
midline axes of the fully extended and abducted digits. Variations in vessel and nerve anatomy occur, obligating
the surgeon to be aware of potential anatomic pitfalls (7). Preoperative wrist and digital Allen's tests and Doppler
tracing of the digital vessels are sufficient to identify cases where a technically troublesome anomaly may be
present. In such cases, comprising 2% to 3% of hands, angiography may be indicated (8). The flap depends on
multiple small veins in the soft tissues adjacent to the artery and nerve for venous drainage (9).
FLAP DESIGN AND DIMENSIONS
The ulnar aspects of long or ring fingers are the usual donor areas. Selection is based on surface area required,
vascular integrity, preexisting digital injury or affliction, and choice between median and ulnar innervated skin.
Patterns of innervation may be checked preoperatively by selective local anesthetic nerve blocks. A digital Allen's
test is used to confirm perfusion of the finger adjacent to the donor finger by the contralateral digital artery that
will not be divided in dissection of the flap.
FIGURE 275.1 The radial arrangement of the volar digital arteries and nerves from the central palm to the digits
is the basic anatomic feature permitting transfer of a neurovascular composite island.
The flap should include the skin of the distal segment of the donor finger nearly to the hyponychial ridge, in order
both to transfer the domain of critical sensibility and to avoid occurrence of a painful neuroma at the distal end of
a too proximally based flap. The most volar edge of the flap should be the digital volar midline, with darts at the
interphalangeal flexion creases (Fig. 275.2A). The most dorsal edge of the flap should be determined by flap size
requirements and may extend to the dorsal digital midline, without darts. Generally, the maximum width flap is
desirable; this requires preservation of the dorsal branch of the digital nerve in the flap. The proximal limit of the
flap is determined by the dimensions of the recipient defect.
OPERATIVE TECHNIQUE
It is advisable to defer definitive preparation of the recipient area until after the flap dissection if this involves
creation of an open defect not already present. The configuration of the donor composite tissue determines that
of the recipient site.
The palmar incisions radiate in zigzag fashion from the central palm to the bases of the flap and recipient sites.
The neurovascular leash should be transferred entirely through open incisions without tunneling (Fig. 275.2B).

Dissection begins in the palm. The common digital artery and nerve to the flap are identified. At the bifurcation to
proper digital arteries, the proper artery to the adjacent finger is isolated. Care must be taken to avoid denuding
the digital artery and nerve of the small vein-bearing soft tissue loosely attached to them.
After the initial palmar dissection has verified suitability of the neurovascular anatomy for transfer, the margins of
the flap are incised. The flap is elevated by sharp dissection from its distal end proximally, leaving the thin
areolar layer over the extensor tendons and the flexor sheath. It will be necessary to isolate, divide, and ligate
the transverse-oblique vincular and articular branches of the digital artery at each interphalangeal joint. The
dorsal branch of the proper volar digital nerve is preserved with the flap.
On reaching the proximal end of the flap, the nerve-vessel pedicle is dissected into the palm, preserving the
adherent fatty areolar tissue. The identity of the proper digital artery to the adjacent finger is reconfirmed, and
this vessel is then severed and ligated, freeing the common digital artery. Slightly more proximally, the dorsal
interosseous branch of the common digital artery must also be divided, as well as several small arterial
branches. The proper digital nerve is carefully separated from the common nerve by epineural incision using
loupe magnification. The digital nerve and artery with their attendant areolar investment are thus mobilized to the
central palmar rotation point from the superficial arterial arch.
The incision from rotation point to recipient bed is opened. Beneath the zigzag flaps, a straight subcutaneous
course at least 1 cm in width is prepared for the neurovascular pedicle. The flap is transferred to the recipient
site. If any tension, torsion, or kinking of the pedicle occurs, it must be corrected. The recipient defect is then
prepared. The flap is sutured in place. The palmar and digital incisions are closed, taking care to ensure that the
neurovascular pedicle is not compressed or kinked. The donor defect is resurfaced with a free graft. This may
later be replaced with a corniferous graft from the pedal instep, if desired. A nonconstricting longitudinally
oriented dressing with plaster shell or splint support is applied.
Attention to specific details of design and transfer of the digital neurovascular composite skin island seems to
enhance the preservation of sensibility (10). The surgical technique and variations in technical details may
account for the differing results cited. We feel that the essential surgical features are:
1. The flap should always encompass the specific sensory area of the proper volar digital nerve, including the
territory of its dorsal branch. It should extend to the tip of the digital phalanx to avoid the painful neuromata
that may occur if the nerve is severed more proximally.
2. As much soft tissue as possible should be left with the neurovascular pedicle, avoiding separation of vessels
from nerves.
3. Tension and compression of the neurovascular bundle should be avoided, as these are known to interfere
with nerve function, causing neurapraxia, and may be responsible for cases of gradual loss of two-point
discrimination (11). This may be prevented by open exposure of the final path of the neurovascular bundle,
rather than transfer by subcutaneous tunneling.
4. Incisions, especially the donor area margins, must be designed to avoid secondary interphalangeal joint
contracture deformity.
5. Such procedures should be done only by surgeons experienced in reconstructive surgery of the hand and well
versed in the details of hand anatomy. Loupe magnification is recommended.
CLINICAL RESULTS
With proper attention paid to careful dissection and handling, this is a sturdy, highly reliable flap. We are
unaware of any occurrences of necrosis of the digital neurovascular island skin flap.

P.744
Flexion contracture of the donor digit may result if the volar line of union of skin graft with normal skin is not
adequately
broken by darts at the interphalangeal joint creases. The donor finger should be mobilized rapidly, as soon
as the reparative graft has taken. Dynamic splinting may occasionally be needed if flexion contracture
develops.
FIGURE 275.2 A: The distal and volar margins of this donor area skin graft outline the correct incisional
configuration. An even broader base for the interphalangeal dart may be desirable. B: Use of open incisions
without tunneling assists transfer of the neurovascular leash without torsion, tension, or kinking. C: The
completed flap in a case of traumatic loss of distal phalanx and denudation of proximal phalanx of thumb.
Early preservation of two-point sensibility. D: One year postoperatively.
Nearly all surgeons with experience in digital neurovascular island skin composite transfer state that
durable skin, sensibility, and improved circulation can reliably be provided. The question concerning
maintenance of discriminatory touch is controversial. Widely varying results are reported, including
preservation of normal static two-point discrimination (10, 12, 13, 14), complete loss of two-point
discrimination (5, 15), and early preservation with later decrease in two-point sensibility below critical levels
(16, 17). Present neurophysiologic information suggests that moving touch is of great significance to normal
tactile perception. Our experience continues to suggest that attention to the details of design and execution
of this flap as discussed above will lead in most cases to preservation of useful functional sensibility in the

P.745
flap.
Recent studies suggest that sensibility should be evaluated by moving two-point discrimination and
vibration (18, 19). To date, no series of digital neurovascular island skin transfers have been evaluated by
this method. Although the successful transfer of normal sensibility is highly desirable, it is not necessarily
tantamount to useful function. The independent thumb resurfaced with durable skin will nearly always be
used to advantage, despite decreased sensibility, as long as it is not dysesthetic.
Furthermore, the change in conscious localization of feeling from the donor to the recipient area is variable,
often difficult, and sometimes fails to occur (18, 20, 21). When attained, it may be temporarily lost by
immobilization of the hand or in moments of severe stress. Distortion of cortical patterns
of sensory events following peripheral nerve repair is known to occur. Conflict between tactile,
proprioceptive, and visual perception may result in such distortions in patients with neurovascular island
flaps. An organized program of sensory reeducation (18, 21) may result in improved quality and
relocalization of sensibility and is recommended postoperatively for patients with digital neurovascular
island skin transfers.
SUMMARY
The digital neurovascular island skin flap in its various forms is a useful technique to restore sensibility and
therefore function to the thumb and the index finger.
References
1. Moberg E. Transfer of sensation. J Bone Joint Surg 1955;37(A):305.
2. Littler JW. Neurovascular island transfer in reconstructive hand surgery. In: Transactions of the second
congress of the international society of plastic surgeons. London: Livingstone, 1960; 175-178.
3. Littler JW. Principles of reconstructive surgery of the hand. In: Converse JM, ed. Reconstructive plastic
surgery. Philadelphia: Saunders, 1964; 1612-1673.
4. Chase RA. Early salvage in acute hand injuries with a primary island flap. Plast Reconstr Surg
1971;48:521.
5. Murray JF, Ord JVR, Gavelin GF. The neurovascular island pedicle flap. J Bone Joint Surg
1967;49(A):1285.
6. Doi K. Replantation of an avulsed thumb, with application of a neurovascular pedicle. Hand 1976;8:258.
7. Lignon J, Le Tenneur J, Ratcliffe H, et at. Lambeau en ilot digital muni de son pedicule vasculo-nerveux.
Ann Chir 1976;30:917.
8. Coleman SS, Anson BJ. Arterial patterns in the hand based upon a study of 650 specimens. Surg Gynecol
Obstet 1961;113:409.

9. Eaton RG. The digital neurovascular bundle: A microanatomic study of its contents. Clin Orthop
1968;61:176.
10. Markley JM Jr. Preservation of two-point sensibility in digital neurovascular island flaps. Plast Reconstr
Surg 1977;59:812.
11. Lundborg G. Structure and function of the intraneural microvessels as related to trauma, edema
formation, and nerve function. J Bone Joint Surg 1975;57(A):938.
12. Chase RA, Iverson RE. Commentary. In: Symposium on the hand, Vol. 3. St. Louis: Mosby, 1971; 221.
13. Tubiana R, Duparc J. Restoration of sensibility in the hand by neurovascular skin island transfer. J Bone
Joint Surg 1961;43(B):474.
14. Stice RC, Wood MB. Neurovascular island skin flaps in the hand: function and sensibility evaluations.
Microsurgery 1987;8:162.
15. Reid CAC. The neurovascular island flap in thumb reconstruction. Br J Plast Surg 1966;19:234.
16. Krag C, Rasmussen KB. The neurovascular island flap for defective sensibility of the thumb. J Bone Joint
Surg 1975;57(B):495.
17. Omer GE, Day DJ, Ratcliffe H, et al. Neurovascular cutaneous island pedicles for deficient median nerve
sensibility. J Bone Joint Surg 1970;52(A): 1181.
18. Dellon AL. Evaluation of sensibility and re-education of sensation in the hand. Baltimore & London:
Williams & Wilkins, 1981.
19. Wall PD. Two transmission systems for skin sensations in sensory communication. In: Rosenblith WA,
ed. Sensory Communication. Cambridge, Mass.: MIT Press, 1961; 475-496.
20. Paul RL, Goodman H, Merzenich M. Alterations in mechanoreceptor input to Brodmann's areas 1 and 3
of the post-central hand area of Macaca mulatta after nerve section and regeneration. Brain Res 1972;39:1.
21. Parry CW, Salter M. Sensory re-education after median nerve lesions. Hand 1976;8:250.

P.746
Chapter 276
Reverse Digital Artery Flap to The Fingertip
S. K. HAN
EDITORIAL COMMENT
It is important that this flap be used only in the reconstruction of defects distal to the distal interphalangeal
(DIP) joint. In addition, although this flap can be designed as a sensate flap, long-term follow-up has shown
minimal benefit and therefore innervation is no longer recommended.
Fingertip injuries represent the most common type of injuries seen in the upper extremity. Their management is
functionally and aesthetically important but, at the same time, controversial. The goals of fingertip reconstruction
are preservation of functional length and sensibility, prevention of symptomatic neuromas and of adjacent joint
contracture, and minimization of aesthetic deformity. The usefulness and postoperative results of the reverse
digital artery flap for fingertip reconstruction are reported. This relatively simple and time-saving procedure is
done in one stage, maintains the finger length with sufficient soft-tissue padding, provides thin and hairless skin,
avoids uncomfortable immobilization, and shortens the hospital stay. Excellent sensory restoration is possible,
the donor-site scar can be hidden, flap size is unlimited, cosmetic results are acceptable, and the flap can be
used in multiple fingertip amputation cases.
INDICATIONS
The distally based arterial island flap was first described in 1973 (1). Since then, several authors have
introduced modifications, including the reverse digital artery flap, which has many advantages over the
more conventional flap (2). The reverse digital artery flap is indicated in any cases with amputations or
tissue defects distal to the DIP joint of the fingers. However, this flap is contraindicated in cases with injuries
proximal to the DIP joint.
ANATOMY
Regarding the digital arterial system, the existence of sufficient arterial anastomoses between the digital arteries
from both sides has long been known (3, 4, 5, 6). According to Strauch and de Moura's findings (6), there are
three transverse digital palmar arches in the fingers and their locations are constant: that is, at the level of the
proximal cruciate ligament, distal cruciate ligament, and just distal to the flexor digitorum profundus insertion.
Therefore, this flap is perfused from the contralateral side proper digital artery through the middle transverse
palmar arch at the level of the distal cruciate ligament, and then from the ipsilateral proper digital artery. In
addition, an abundant number of vascular communications in the pulp of the distal phalanx exist, and these
communications enable the reverse digital artery flap, with a more distally skeletonized pedicle, to gain its
retrograde blood supply without any trouble (Fig. 276.1).
Regarding the venous system, the reverse digital artery flap is drained through the tiny venules and capillaries
contained in the perivascular soft tissue (7).

FLAP DESIGN AND DIMENSIONS
The flap is designed in a stellate shape to avoid scar contracture on the ulnar or radial side of the proximal
phalanx of the finger, with a digital artery as the central axis (according to the size and shape of the defect);
however, the least-used side of the finger is chosen, if possible.
Reviewing the sizes of the flap I have used, the length and width of flaps ranged from 1.6 to 3.2 cm and 1.0 to
2.5 cm, respectively, with a maximum size of 3.2 × 2.5 cm. In extended flaps, the dorsal skin over the
metacarpophalangeal joint, as well as the lateral skin of the proximal phalanx, can be included (8).
OPERATIVE TECHNIQUE
The procedure is carried out under regional block or general anesthesia. After minimal debridement of the
wound, the size and shape of the defect are measured.
After pneumatic tourniquet inflation, a skin incision is made, and the flap is elevated carefully with the aid of
surgical- loupe magnification. The digital artery is first identified, and then separated from the proper digital nerve
to the level of about 5 mm proximal to the DIP joint, to transfer the flap freely but, at the same time, not to injure
the middle transverse digital palmar arch. However, the digital artery may be dissected more distal to the level of
the DIP joint in cases where enough finger pulp remains, to include vascular communications between radial and
ulnar proper digital arteries.
I usually consider the center of the fingerprint as an indicator. If this remains at the recipient site, the digital artery
can be dissected more distally. This maneuver enables the flap to move to the very distal part with ease.
FIGURE 276.1 Digital arterial system of a finger. Three transverse digital palmar arches between digital arteries
and abundant vascular communications in the pulp of a distal phalanx exist. DA, digital artery; P, proximal palmar
arch; M, middle palmar arch; D, distal palmar arch.
A generous cuff of subcutaneous tissue is maintained around the vascular pedicle, to preserve the tiny
perivascular venules. The digital artery at the proximal end of the flap is ligated and divided.
In cases of sensate flaps, the dorsal branch of the digital nerve or the superficial sensory branch of the radial or

P.747
ulnar nerve attached to the flap is identified and dissected, then microanastomosed to the digital nerve at the
defect by an epineurial technique. However, I no longer use sensate flaps, because the long-term results do not
show a significant difference between sensate and insensate flaps, and additional operating time is required for
innervated flaps. Sensory recovery in the insensate flaps comes from collateral sprouting from adjacent intact
nerves and central adapting mechanisms (9).
The flap is transferred and sutured to the defect loosely, so as not to compress the pedicle. A skin graft is
applied to the donor defect. Postoperatively, the operated on hand is elevated, and no anticoagulants are used
(Fig. 276.2).
CLINICAL RESULTS
One hundred forty fingers with defects of the distal phalanx were reconstructed using reverse digital artery
flaps (2, 10). Survival of the flaps was successful in all fingers, except for one. In 20 fingers, postoperative
congestion developed but subsided
spontaneously within 2 to 3 days in all of them (Fig. 276.3). Postoperative sensory recovery in all cases was
excellent. All the evaluated flaps had the ability to detect light touch, temperature, and sharp stimuli.
Regarding scar contracture, no patient required an additional operation for further improvement of the
fingertip shape, although a mild irregularity was seen at the flap edge in three of the patients.
FIGURE 276.2 Diagram of the reverse digital artery island flap. The flap is perfused from a contralateral
side proper digital artery through a middle transverse palmar arch and then an ipsilateral proper digital
artery. F, reverse digital artery island flap; DA, digital artery; DN, digital nerve; P, divided proximal palmar
arch; M, middle palmar arch; D, distal palmar arch.