241
Fig. 8.6 Procedure 6: A large amount of peripheral fat is attached to
the vascular pedicle of the fl ap, which is elevated as a thick pedicle
Fig. 8.7 Procedure 7: A long length of vascular pedicle is detached
down to the base of the fi nger
Fig. 8.8 Procedure 8: The tourniquet is released and the circulation of
the blood fl ow is confi rmed. The skin fl ap is rotated and advanced to
distal to cover the fi nger tip. The skin fl ap is fi xed in place using a
Kirschner wire inserted into the fi ngertip. From this procedure, the neu-
rovascular pedicle has been transferred from its original path to the
volar center
Oblique Triangular Flap Modifi cation (Level of Diffi culty: 3)
242
Fig. 8.9 Procedure 9: The skin fl ap is sutured to the surrounding area
Fig. 8.10 Procedure 10: By rotating and transferring the fl ap, it is pos-
sible to form suffi cient bulge in the volar fi ngertip. The incision line
does not cross the DIP or PIP crease so there is no new scar contracture.
(Part of photos reproduced from Hirase, Y.: Treatment of nail and fi n-
gertip injuries (6) using free fl aps. MB Orthop 20:81–87, 2007)
8 Reconstruction of Fingertip
243
Tips
Use a fi nger extensor device at 2 weeks following surgery to prevent fl exion contracture
In order to prevent fl exion contracture of the IP or PIP joint following fl ap surgery, a fi nger extensor device should
be fi tted at 2 weeks following surgery
Oblique Triangular Flap Modifi cation (Level of Diffi culty: 3)
244
Graft-on Flap Method by Oblique Triangular Flap (Level of Diffi culty: 3)
Information
Indication Cases involving fi nger amputation at the nail bed level where re-attachment is considered diffi cult
Advantage Short operating time, and surgical technique is comparatively simple.
Caution The transplant tissue mustn’t become dry. Early stage debridement is not performed.
8 Reconstruction of Fingertip
245
Fig. 8.12 Procedure 2: Amputated section of fi nger includes part of the
distal phalanx
Fig. 8.11 Procedure 1: Case of complete amputation of the nail area of
the fi nger
Operation Procedures
Graft-on Flap Method by Oblique Triangular Flap (Level of Diffi culty: 3)
246
Fig. 8.14 Procedure 4: An oblique triangular fl ap is elevated
Fig. 8.13 Procedure 3: An oblique triangular fl ap is designed
Refer to Section of “Reconstruction of fi ngertip/Oblique triangular
fl ap modifi cation” in Chap. 8
8 Reconstruction of Fingertip
247
Fig. 8.16 Procedure 6: Appearance of the dorsal fi ngertip after recon-
structing the fi ngertip using the fl ap
Fig. 8.15 Procedure 5: Flap is used to reconstruct the palmar side of
the fi ngertip
Graft-on Flap Method by Oblique Triangular Flap (Level of Diffi culty: 3)
248
Fig. 8.18 Procedure 8: The bone is fi xed in place with a thin wire
(0.7 mm), and the nail bed is sewn in place with careful alignment using
an absorbable suture. The surrounding skin is also sutured
Fig. 8.17 Procedure 7: Only the bone and the nail bed are harvested as
a single entity from the amputated section of the fi ngers
Note If a large amount of soft tissue is included in the tissue trans-
planted from the amputated fi nger, the take ratio is decreased. It is
important that when conducting a transplant like a skin graft that the
tissue is as thin as possible, and that soft tissue other than the nail bed is
decreased as much as possible. For that reason, it is necessary to create
a graft with suffi cient size on the palmar side for conducting the
reconstruction.
8 Reconstruction of Fingertip
249
a
b
Fig. 8.19 ( a , b ) Procedure 9: Appearance immediately after surgery
Note It took 92 min to reattach the three fi ngers.
a
b
Fig. 8.20 ( a , b ) Procedure 10: Appearance of nails 1 year later. Healthy nail growth can be seen. The bulge on the palmar side of the fi ngertip has
been accurately recreated. Return of sensory function is also recognized
Liberal amounts of ointment are continually applied to the transplanted nail bed to prevent it from drying out, and the scab is not removed
for 2 weeks.
Graft-on Flap Method by Oblique Triangular Flap (Level of Diffi culty: 3)
250
Fig. 8.21 Procedure 11: X-ray image 1 year after surgery. No bone
absorption in the fi nger tip. (Some photos reproduced from Hirase, Y.,
et al.: A new reattachment procedure for fi ngers amputated at the nail
bed level. Journal of Japanese Society for Surgery of the Hand 20:501–
504, 2003)
Tips
Concept of graft-on fl ap method
The basic concept of the graft-on fl ap method is reconstructing the palmar side of the fi nger using a fl ap, and trans-
planting the nail bed onto that. Therefore, the requirement is that even though the nail bed is lost, the nail matrix still
remains. In emergency amputation cases, the nail bed is harvested from the amputated fi ngers, but for mature amputa-
tion cases or fi ngertip deformation cases the nail bed is harvested from the nail bed of the great toe.
8 Reconstruction of Fingertip
251
Extended Palmar Flap Advancement with V-Y and Z Plasty (Level of Diffi culty: 2)
Information
Vascular pedicle Digital artery
Size The fl ap is designed from the palmar side of the thumb to the thenar.
In order to obtain a greater transfer distance, the design of the fl ap is extended to the proximal thenar. V-Y plasty is
conducted in the proximal area of the fl ap.
Indication Digital arteries to the thumb is inserting from the ulnar side at the mid- point of the ulnar side of thenar region.
Therefore, if the fl ap is designed extending to the thenar region over the insertion of digital arteries, the digital arteries are
not pulled by moving the fl ap, but the fl ap is rotated without tension of digital arteries as the pivot point. It is possible to
create a complete island fl ap by dissecting the fl ap from the tendon sheath, the fl ap can be moved more than 2 cm
Caution When creating an advanced thenar fl ap, several Z plasties should be conducted to prevent a new contracture
from occurring on the margins of the fl ap.
Extended Palmar Flap Advancement with V-Y and Z Plasty (Level of Diffi culty: 2)
252
Operation Procedures
Fig. 8.23 Procedure 2: An incision is made in the fl ap margin, and the
fl ap is detached above the tendon sheath, however as far as possible, the
dorsal branch from the digital artery is retained
Fig. 8.22 Procedure 1: Case of skin defect on palmar thumb tip. A
thumb palmar advancement fl ap that extends to the proximal thenar is
designed, and a Z plasty is planned for the margin in line with the fi nger
crease, following movement of the fl ap. The entire proximal area of the
fl ap is to be closed using a V-Y plasty, and a Z plasty is added to the tip
Note The solid line in the fl ap shown in the photo is to be moved to the
dotted line following movement of the fl ap, and a Z plasty is conducted
here (solid line outside the fl ap).
Note For the thumb, even if all of the dorsal branch of the digital artery
is severed, necrosis of the skin on the dorsum of the fi nger does not
occur. But for other than the thumb, if the entire dorsal branch is sev-
ered, then this can cause skin necrosis on the dorsal side of the distal
phalanx.
8 Reconstruction of Fingertip
253
Fig. 8.25 Procedure 4: After the skin fl ap is moved distally, V-Y plasty
is conducted to the proximal end and Z plasty conducted to the margins
to close the wound
Fig. 8.24 Procedure 3: The fl ap is completely detached from above the
tendon sheath, creating a complete island fl ap elevated with only the
digital nerve and vascular pedicle
Note The fl ap tip is not only advanced, but the skin of both sides at the
fl ap tip are rotated and sutured to create a dog ear in the center of the
fi ngertip.
Extended Palmar Flap Advancement with V-Y and Z Plasty (Level of Diffi culty: 2)
254
Fig. 8.26 Procedure 5: A suitable bulge in the fi ngertip is created by
the creation of the dog ear. (Some photos reproduced from Hirase, Y.:
Standard surgical procedures for skin defects on 10 fi ngers and fi nger-
tips. Plastic Surgery 50 : S111–S117, 2007)
Tips
Application example of graft-on fl ap: Palmar Flap Advancement + Nail bed graft
1. Case example: Case of thumb tip amputation example accompanying loss of the nail bed.
2. The palmar side was reconstructed using a palmar advancement fl ap.
3. A nail bed split-thickness graft was conducted from the great toe to the nail bed defect area.
4. Appearance after reconstruction. Good growth of nail was seen on thumb. Suffi cient bulge was reconstructed in the
thenar and thumb tip using the palmar fl ap. No deformity was seen in the nail from which the nail bed was
harvested.
(Some photos reproduced from Hirase, Y.: Reconstruction of the fi ngertips using the graft-on fl ap method. The Japanese
Journal of Plastic Surgery 50:743–748, 2007 & Hirase, Y.: Fingertip injuries including the nail: Plastic Surgery for
Injuries (edited by Anze, M.) pp 115–120, Kokuseido, Tokyo, 2007)
8 Reconstruction of Fingertip
255
Extended Palmar Flap Advancement with V-Y and Z Plasty (Level of Diffi culty: 2)
256
Heterodigital Finger Island Flap (Modifi ed Littler Method) (Level of Diffi culty: 4)
Information
Vascular pedicle Digital artery
Size About 15 × 30 mm
Caution The Littler fl ap (1956) was used for reconstructing the thumb and index fi nger using a neurovascular pedicled
island fl ap from the ulnar side of the middle fi nger or ring fi nger. This was the fi rst report of a sensory island fl ap used
in the hand. However, the sensory function of the reconstructed fi nger was still the same as that of the donor area for
the fl ap, so problems remained with regard to actual use of the fi nger. Therefore in this method, as a modifi cation of
the Littler method, the digital nerve is severed and transferred and then re-sutured with the digital nerve of the recipient
site to reconstruct sensory function.
Disadvantage Sensory function of the fi ngertip from the harvested fi nger is lost. Therefore, the fi rst choice for the
harvest area is the ulnar side of the ring fi nger which is comparatively less important in terms of sensory function.
8 Reconstruction of Fingertip
257
Operation Procedures
Fig. 8.27 Procedure 1: An island arterial fl ap is designed on the ulnar
side of the ring fi nger with respect to defect tissue on the ulnar side of
the thumb. A zig-zag incision is made in line with the crease of the palm
between the ring fi nger and the thumb
Heterodigital Finger Island Flap (Modifi ed Littler Method) (Level of Diffi culty: 4)
258
Fig. 8.28 Procedure 2: The fl ap including the digital artery is elevated
from the ulnar side of the intermediate phalanx area of the ring fi nger.
The digital nerve is severed and attached to the fl ap. A small amount of
fat is included in the area surrounding the vascular pedicle, and a
slightly thick pedicle is dissected
Fig. 8.29 Procedure 3: The vascular pedicle is dissected up to the arte-
rial arch. The digital artery to the little fi nger is ligated and separated.
The island fl ap is transferred to the thumb
8 Reconstruction of Fingertip
259
Fig. 8.30 Procedure 4: After the fl ap is sutured to the transferred
thumb, the digital nerve that was attached to the fl ap is sutured to the
digital nerve of the thumb
Fig. 8.31 Procedure 5: A skin graft is conducted on the donor site
Heterodigital Finger Island Flap (Modifi ed Littler Method) (Level of Diffi culty: 4)
260
Fig. 8.32 Procedure 6: Appearance of the reconstructed thumb
8 Reconstruction of Fingertip
261
Modifi ed Heuston Flap (Level of Diffi culty: 1)
Information
Vascular pedicle Unilateral digital artery
Size The entire skin surface on the palmar side of the fi nger is moved. This is indicated in cases of transverse amputa-
tion of the fi nger
Caution In the original Heuston method (1966), the skin of the palmar side of the fi nger is cut in an L shape, and the
entire fl ap is moved distally, with a skin graft used for the donor site. In the modifi cation, using the stretch of the fl ap,
the fl ap is used as a rotation fl ap and the wound closed using a V-Y plasty of the proximal area
Modifi ed Heuston Flap (Level of Diffi culty: 1)
262
Operation Procedures
Fig. 8.33 Procedure 1: A transverse amputation at the DIP joint of the
middle fi nger
Fig. 8.34 Procedure 2: A diagonal incision is made from the lateral
center line of the fi nger to the base of the fi nger so as not to cut across
the PIP crease
8 Reconstruction of Fingertip
263
Fig. 8.35 Procedure 3: The fl ap is dissected above the tendon sheath
with the unilateral digital artery as the pedicle
Fig. 8.36 Procedure 4: The entire fl ap is moved distally to cover the
amputation stump of the fi nger, and suturing conducted from the distal
end downward
Modifi ed Heuston Flap (Level of Diffi culty: 1)
264
Fig. 8.37 Procedure 5: Appearance of the dorsum of the fi ngertip
4 months after surgery
8 Reconstruction of Fingertip
265
Reverse Flow Digital Arterial Flap (Level of Diffi culty: 4)
Information
Vascular pedicle Reverse fl ow circulation via the proximal palmar arterial arch of the digital artery
Size Can be created from the ulnar side of the fi ngertip to the fi nger web space
Advantage Possible to transfer suffi cient amount of tissue to the fi nger tip
Disadvantage Requires a skin graft to cover the donor site
Caution Congestion can occur, so it is important to attach fat around the vascular pedicle and not to close the wound
too tightly. There is also a method of transferring the fl ap with a thin skin pedicle attached in order to avoid congestion
and twisting of the vascular pedicle (See photo top center).
Reverse Flow Digital Arterial Flap (Level of Diffi culty: 4)
266
Operation Procedures
Fig. 8.39 Procedure 2: A line is drawn along the mid-lateral of the
fi nger, and fi rstly, the position of the proximal palmar arterial arch is
marked (center of middle phalanx). The proximal palmar arch is the
pivot point of the fl ap for circulation, however there are less problems if
the actual pivot point is moved 2 mm proximal of the commissure
branch, so the mark is moved to here. The distance from that point to
the skin defect area of the fi ngertip is measured, and the skin fl ap is
designed the same distance proximally. The skin fl ap is designed to a
size that is 15 % greater than the actual area of the skin defect. A small
triangular fl ap is attached to the distal fl ap
Fig. 8.38 Procedure 1: Skin defect is recognized on the palmar side of
the fi ngertip
8 Reconstruction of Fingertip
267
Fig. 8.40 Procedure 3: The digital neurovascular pedicle is confi rmed
in the proximal area of the fl ap, and only the nerve is dissected and
separated. The digital artery is ligated proximally and the fl ap is dis-
sected distally with the vascular pedicle included. It is dissected with a
small amount of fat surrounding the vascular pedicle
Note The dissection area of the vascular pedicle mustn’t exceed the
pivot point.
In the case that there is concern for the circulation of the fl ap, after
the vascular pedicle is dissected, the digital artery is clamped at the
proximal position of the fl ap, and confi rmation is made of suffi cient
circulation prior to ligation.
Fig. 8.41 Procedure 4: The fl ap is transferred and sutured to the fi nger-
tip. Tight suturing can cause congestion, so the fl ap is sutured loosely.
A skin graft is conducted on the donor site, and a tie-over bolster dress-
ing applied
Reverse Flow Digital Arterial Flap (Level of Diffi culty: 4)
268
a
b
Fig. 8.42 ( a , b ) Procedure 5: Appearance of the dorsum of the fi nger after surgery. No deformation of the nail. A healthy-shaped fi ngertip has
been reproduced. (Part of photos reproduced from Hirase Y. Treatment of nail and fi ngertip injuries (6) Reconstruction by fl aps. MB Orthop
20:81–87, 2007)
8 Reconstruction of Fingertip
269
Tips
Make the incision line exactly along the mid-lateral line of the fi nger
If the incision line is not completely along the mid- lateral line of the fi nger, new scar contracture can occur.
Reverse Flow Digital Arterial Flap (Level of Diffi culty: 4)
270
Tips
In bone defect cases, combine skin fl ap and grafting bone with periosteum attached
For bone defect cases, bone chip with periosteum attached harvested from the distal phalanx of the second toe is
transplanted to the affected site. This can be done at the same time as fl ap transfer or performed secondarily, however
outcome is better when performed secondarily. There is little bone resorption when grafting bone with periosteum
attached.
8 Reconstruction of Fingertip
271
Reverse Flow Digital Arterial Flap with Adipose Flap Attached (Level of Diffi culty: 4)
Information
Even if the palmar side of the fi ngertip is reconstructed using a reverse fl ow fl ap, if there is exposure of the bone on the
dorsal side, it is not possible to perform a nail bed graft on the exposed bone. If a reverse fl ow digital arterial fl ap with
adipose fl ap attached is elevated, and the adipose fl ap transferred to the dorsal side to cover the exposed bone area, it
is possible to conduct a nail graft on top of that.
Reverse Flow Digital Arterial Flap with Adipose Flap Attached (Level of Diffi culty: 4)
272
Operation Procedures
Fig. 8.43 Procedure 1: A reverse fl ow digital arterial fl ap with adipose
fl ap attached is designed in the surrounding area
Fig. 8.44 Procedure 2: The reverse fl ow fl ap with adipose fl ap attached
is elevated
8 Reconstruction of Fingertip
273
Fig. 8.45 Procedure 3: The fl ap is transferred to the fi ngertip. The adi-
pose fl ap is brought around to the dorsal side and used to cover the
exposed bone area
Fig. 8.46 Procedure 4: A split-thickness nail bed is harvested from the
great toe
Refer to Section of “Reconstruction of the Nail/Split- thickness Nail
Bed Graft” in Chap. 10
Reverse Flow Digital Arterial Flap with Adipose Flap Attached (Level of Diffi culty: 4)
274
Fig. 8.48 Procedure 6: The nail bed is transplanted onto the adipose
fl ap. A tie-over bolster dressing is applied
Fig. 8.47 Procedure 5: The nail is put back and bandaged in place for
2 weeks
8 Reconstruction of Fingertip
275
a
b
Fig. 8.49 ( a , b ) Procedure 7: Appearance after 6 months. A healthy nail has regenerated
Reverse Flow Digital Arterial Flap with Adipose Flap Attached (Level of Diffi culty: 4)
276
Reverse Flow Digital Artery Cross Finger Flap (Level of Diffi culty: 4)
Information
Vascular pedicle Digital artery
Indication Cases involving reconstruction of the fi nger tip where there is a possibility of rupturing of the proximal
palmar arterial arch and it is not possible to create a reverse fl ow digital arterial fl ap on the same fi nger. Or in cases
where there is a large skin defect exceeding the distal phalanx area, that cannot be covered using a reverse fl ow fl ap
from the same fi nger. Uses reverse blood fl ow via the proximal or distal palmar arterial arch of the digital artery.
Caution A narrow skin fl ap is created above the blood vessel to protect the vascular pedicle and prevent it from
twisting.
8 Reconstruction of Fingertip
277
Operation Procedures
Fig. 8.50 Procedure 1: A reverse fl ow digital arterial fl ap is designed
at the base of the middle fi nger for a comparatively large skin defect at
the distal phalanx of the index fi nger tip. A skin fl ap of around 2–3 mm
width is attached above the vascular pedicle
Fig. 8.51 Procedure 2: If digital dorsal nerve on the dorsal side of the
fl ap can be secured, it is possible to create a sensory fl ap. The digital
nerve is dissected and separated from the vascular pedicle on the palmar
side of the fi nger and the fl ap elevated
Reverse Flow Digital Artery Cross Finger Flap (Level of Diffi culty: 4)
278
Fig. 8.53 Procedure 4: The fi nger tip of the index fi nger is covered
using the fl ap from the middle fi nger
Fig. 8.52 Procedure 3: A reverse fl ow digital arterial fl ap with the digi-
tal dorsal nerve included in the dorsal side of the fl ap, is created
Note The skin pedicle is dissected only to the distance required for a
cross fi nger fl ap.
If the pivot point is made on the distal palmar arterial arch of the
fi nger tip instead of the proximal palmar arterial arch, then it is possible
to make a longer skin fl ap.
Note If the nerve in the fl ap can be sutured to the distal nerve end in
the fi ngertip of the index fi nger, it is possible to also carry out a recon-
struction of sensory function.
8 Reconstruction of Fingertip
279
Fig. 8.54 Procedure 5: Appearance of the sutured fl ap. A tie-over bol-
ster dressing is applied to the donor site. A dorsal plaster splint is used
to fi x the index and middle fi ngers in place
Note A wet dressing for the soft tissue is applied to the reverse side of
the fl ap pedicle.
Fig. 8.55 Procedure 6: Appearance 2 weeks later. The fl ap pedicle is
separated
Reverse Flow Digital Artery Cross Finger Flap (Level of Diffi culty: 4)
280
a
b
Fig. 8.56 ( a , b ) Procedure 7:
The fi ngertip has been
reconstructed with suffi cient
tissue volume
8 Reconstruction of Fingertip
281
Thenar Flap / van der Biezen Method (Palm Flap) (Level of Diffi culty: 2)
Information
Vascular pedicle Vascular plexus of the palm
Size Designed in line with the skin defect of the fi ngertip. A slightly large skin fl ap is elevated with full thickness skin.
In most cases the donor site can be closed.
Caution The donor area for the thenar fl ap method is created on the thenar, and the skin pedicle can be created on the
ulnar side/radial side/proximally/distally depending on the position and form of the skin defect area.
The double opposing palmar fl ap for syndacty is created slightly proximal in the center of the palm.
Care must be taken with all methods that the fl ap doesn’t fold over on itself.
Advantage Rich subcutaneous tissue. Donor site is not obvious. Similar tissue is used to the fi ngertip, and good sen-
sory function can be expected.
Disadvantage Surgery is carried out in two stages. Contracture of the fi nger joint can occur.
Thenar Flap / van der Biezen Method (Palm Flap) (Level of Diffi culty: 2)
282
Operation Procedures
Fig. 8.58 Procedure 2: Two palm fl aps are designed back to back on
the center proximal palm with a 1 cm gap between
Fig. 8.57 Procedure 1: Cleft hand. Osseous syndactyly present
between middle and ring fi ngers
8 Reconstruction of Fingertip
283
Fig. 8.59 Procedure 3: The osseous syndactyly is separated, and a
slightly large palm fl ap is elevated with the full thickness of the skin
(above the palmar fascia)
Fig. 8.60 Procedure 4: After suturing closed the donor site, the skin
fl ap is sutured to the skin defect area
Note In this case example, a tissue expander is inserted into the dorsal
side of the proximal phalanx area of the middle and ring fi nger in prepa-
ration for the next syndactyly operation.
Thenar Flap / van der Biezen Method (Palm Flap) (Level of Diffi culty: 2)
284
Fig. 8.61 Procedure 5: Taking care not to bend the fl ap pedicle, the
sutured fl ap is bandaged, while being careful to avoid applying tension
to the sutured fl ap area
Fig. 8.62 Procedure 6: The fl ap is separated 2 weeks later
Note The osseous syndactyly area is separated with a suffi cient
amount of tissue.
8 Reconstruction of Fingertip
285
Fig. 8.63 Procedure 7: The cutaneous syndactyly is separated in two
stages. The donor site for the palm fl ap is not obvious
Thenar Flap / van der Biezen Method (Palm Flap) (Level of Diffi culty: 2)
286
Hemi Pulp Transfer (Level of Diffi culty: 4)
Information
Vascular pedicle First dorsal metatarsal artery or plantar digital artery and cutaneous vein. Digital nerve of the toe is
used as the nerve.
Size Medial side of great toe and/or lateral side of second toe.
Indication Indicated for the reconstruction of the palmar side of the fi nger tip, especially skin defects exceeding the
distal phalanx area where reconstruction is diffi cult using a localized skin fl ap. Hemi pulp transfer is the No. 1 choice
in such cases.
Caution If a long vascular pedicle is harvested to the dorsal artery, it is easier for twisting to occur, so a short pedicle
and anastomosis to a digital artery of the fi nger in the recipient site is performed as standard. The cutaneous vein
should be included in the dorsal skin of the fl ap.
8 Reconstruction of Fingertip
287
Operation Procedures
Fig. 8.64 Procedure 1: A skin defect is present on the distal phalanx of
the middle and ring fi ngers
Fig. 8.65 Procedure 2: The anastomotic vessel (digital artery) and
suture nerve (digital nerve) of the recipient site are dissected from the
amputation stump
Hemi Pulp Transfer (Level of Diffi culty: 4)
288
Fig. 8.66 Procedure 3: Two hemi pulp fl aps are designed on the medial
great toe and lateral second toe
Note Part of the dorsal skin is included so that the cutaneous vein is
also included, however the plantar weight bearing area is not included.
Fig. 8.67 Procedure 4: An incision is added to the dorsal side of the
fi rst interdigital area, the fi rst dorsal metatarsal artery is identifi ed and
dissection of the digital arteries of the great toe and second toe is con-
tinued distally. The dorsal metatarsal artery connects to the plantar
artery. When harvesting the fl ap with a short pedicle, it is harvested
with the digital artery of the toe. In cases where a long pedicle is
required, the dorsal metatarsal artery and the plantar artery are com-
pared and the fl ap is elevated by the dominant artery (the one with the
larger diameter)
Note The fi rst to appear subcutaneously is the cutaneous vein. This
cutaneous vein heads toward the second toe, and if only harvesting the
fl ap from the great toe, it will make the surgical procedure easier later if
this is ligated and cut at an early stage. Next to appear is the deep pero-
neal nerve and the fi rst dorsal metatarsal artery.
In the rare case that the fi rst dorsal metatarsal artery is missing, the
fl ap is elevated with the plantar artery.
8 Reconstruction of Fingertip
289
Fig. 8.68 Procedure 5: While confi rming each of the digital arteries,
they are detached from above the periosteum. The hemi pulp fl ap con-
taining the digital artery of the toe, the digital nerve of the toe and the
cutaneous vein is elevated
Fig. 8.69 Procedure 6: The hemi pulp fl ap containing the digital artery
of the toe, the digital nerve of the toe and the cutaneous vein from each
of the great toe and the second toe is harvested with a short pedicle
Hemi Pulp Transfer (Level of Diffi culty: 4)
290
Fig. 8.70 Procedure 7: An artifi cial dermis is placed over the donor
site. A skin graft is conducted 2–3 weeks later under local anesthetic
Fig. 8.71 Procedure 8: Anastomosis is conducted with the digital
artery of the toe to the digital artery of the fi nger, and with the cutaneous
vein of the toe to the cutaneous vein of the fi nger. The digital nerve of
the toe is sutured to the digital nerve of the fi nger
8 Reconstruction of Fingertip