4. Aims
• The treatment objectives in
fingertip reconstruction are
to:
• close the wound
• maximize sensory return
• preserve length
• maintain joint function
• obtain a satisfactory cosmetic
appearance
5. Epidemiology
• Of all traumatic injuries, one third affect the
hands, with the fingertips being the most
frequently injured portion of the hand
(Kelsey, 1980).
• 24% of surgical hand trauma
• Ages 4-30 most common
• 75% of patients-male
6. Fingertip anatomy
• The fingertip is the portion
of the digit distal to the
insertion of the flexor and
extensor tendons on the
distal phalanx.
• From the periosteum of the
distal phalanx, fibrous
septae anchor the skin and
palmar pulp to the bone.
• The volar surface of the
fingertips contains grooves
and ridges, uniquely
patterned for each
individual, termed
fingerprints.
7. Anatomy
• The volar pulp is also
stabilized by the Grayson
and Cleland ligaments,
extending from the flexor
sheath and distal phalanx
volar and dorsal to the
neurovascular bundles,
respectively.
8.
9. Arterial supply of the fingertip
• The digital arteries
and nerves arborize
or trifurcate near the
distal
interphalangeal
joint.
• The proper digital
artery crosses the
distal
interphalangeal
joint, sending a
branch to the nail
fold, nail bed, and
finger pad
11. Innervation of the
fingertip
• Each digital nerve trifurcates near
the distal interphalangeal joint,
sending branches to the
perionychium, fingertip, and volar
pad.
• The digital nerves lie volar to the
digital arteries near the fingertip.
• The fingertip is the organ of
touch and feel and is abundantly
supplied with sensory receptors,
including Pacinian and Meissner
corpuscles and Merkel cell neurite
complexes.
12. Nail Physiology and anatomy
• The dorsal surface of the fingertip
comprises the nail fold, nail bed, and
nail plate (= perionychium).
• The perionychium includes the entire
nail bed and paronychium complex.
• The paronychium is the skin
surrounding the nail plate radially and
ulnarly.
• The eponychium is the epidermal
shelf at the base of the nail.
• The lunula is the white semicircle at
the base of the nail bed. The
fingernail is a specialized epidermal
structure, like hair.
13.
14. Nailbed production
• The proximal one third of the nailbed,
from the nail fold to the edge of the
lunula, is the germinal matrix. It has two
components, the dorsal and
intermediate nail. The two thirds of the
nailbed distal to the lunula is the sterile
matrix or ventral nail.
• Fingernail production occurs in 3 areas
of the nailbed, the dorsal nail and
intermediate nail of the germinal matrix
and the ventral nail of the sterile matrix.
Of these areas the intermediate
germinal matrix produces 90% of nail
volume. The remainder of the nail
substance is produced by dorsal nail of
the germinal matrix and ventral nail of
the sterile matrix.
15. Nail growth rates
• The dorsal roof of the germinal matrix deposits
cells on the nail surface.
• The two thirds of the nail bed distal to the lunula,
the ventral nail or sterile matrix, acts as a
conveyor belt for the advancing nail and adds
squamous cells to the nail, making it thicker and
stronger (Zook, 1994).
• The nail is not merely attached to the bed but
rather is a continuum of a single structure from
basilar cells in the nail bed.
• Nail growth occurs at a rate of 3-4 mm a month.
It takes 3-4 months for growth to full nail length
and 1 year for the nail to achieve maximal pre-
injury smoothness.
16. Fingertip injury assessment
Level of injury
Mechanism
Depth of loss
Exposed bone/tendon
Nailbed support
Contamination
Patient factors
17. Healing by secondary intention
• If the skin loss is no larger
than about 1.5 cm2
• wound may be allowed to
granulate and heal
spontaneously.
• This type of treatment is
especially well suited to
children and the elderly.
18. Grafting- Composite grafting
Reattach part
• Outcome
unpredictable
• Younger do better
• 2 years or less
• Can be done in adults
However, when the
amputated part is crushed
and macerated, this should
not be used as a graft.
19. • As composite tip grafts must initially survive
by plasmatic imbibition until
neovascularization, revascularization is not
reliable for adults and tip grafts should not
be reapplied for adults
20. Skin grafting
• Skin graft application is considered for distally
located and volarly directed fingertip wounds
without exposed bone or tendon.
• Glabrous or non-glabrous skin
• Controversy exists as to whether split- or full-
thickness grafts are better.
• split skin grafts take earlier and more reliable
and wounds contract more, resulting in a
smaller defect
• full-thickness offer earlier re-innervation and
more reliable, durable coverage (Hutchison,
1949; Napier, 1952; Ponten, 1960; Porter,
1968).
21. What’s the difference?
• Glabrous skin provides a
better aesthetic appearance
and match of texture and
color.
• Glabrous skin can be
harvested from the
hypothenar eminence or
thigh (Patten, 1968).
• Nonglabrous skin can be
obtained from the wrist
crease, forearm, medial
upper arm, or groin.
22. Local flap options for fingertips
• When bone or tendon is exposed at the base of a
fingertip wound, a local flap is required.
• The various local flaps used to reconstruct
fingertips include volar V-Y, bilateral V-Y flaps,
cross-finger flap, thenar flap, and island flaps.
• Flap choice depends on orientation and
configuration of the wound, injured finger, and sex
of the patient.
• Surgeons can optimize the reliability of these local
flaps by avoiding tension on the suture line and
preserving the traversing sub-dermal blood vessels
into the flap
23. Volar V-Y flap
• Though frequently termed the Atasoy
flap, Tranquilli-Leali first described the
volar V-Y flap in 1935 (Tranquili-Leali,
1935; Atasoy, 1970).
• The volar V-Y flap is a triangular-
shaped volar advancement flap
outlined with its tip at the distal
interphalangeal crease.
• The local flap is most applicable for
transverse and dorsal avulsions when
a relative abundance of pulp skin is
present
• Then the V is scored through the
dermis only to avoid injuring the
traversing vessels into the triangular-
shaped flap
24. Bilateral V-Y flaps
• In 1947 Kutler described the
bilateral V-Y flaps for fingertip
injuries.
• Best applied for volar and
transverse avulsions with exposed
bone when excess lateral skin is
present.
• These flaps are designed along the
midlateral line and should not
extend proximal to the distal
interphalangeal joint.
• In raising these flaps the incisions
are performed through the dermis
only to preserve arborizing vessels.
• The flaps are mobilized for distal •The disadvantages of Kutler flaps include
advancement by dissecting fibrous partial or complete flap necrosis, risk for
septae from the distal phalanx. pincher nail deformity, and excess scar on
fingertip risking hypersensitivity. These
disadvantages are increased compared to
other flaps.
25. The Cross Finger Flap
• Originally termed the
transdigital flap by Gurdin and
Pangman in 1950, the cross-
finger flap is commonly used
for volar-directed tip injuries
with exposed bone or tendon
when insufficient pulp for the
volar V-Y flap is present.
• Requires two operations and a
skin graft.
• Moreover, the fingers become
stiff during the delay between
these two stages.
26. Cross finger flap technique
• The flap is elevated from the adjacent finger dorsum in
the plane above the peritenon to allow for grafting of
the donor site.
• A full-thickness graft can be taken to close the donor
finger dorsum.
• The flap is opened like a book cover, turned 180°, and
inset into the fingertip defect. The fingers may be
sutured together or even pinned to prevent flap
dehiscence.
• During the delay, gentle active range-of-motion
exercises are critical to prevent joint stiffness of both
fingers.
• At 2-3 weeks the flap is divided and inset and more
aggressive active and passive range-of-motion exercises
are begun.
27. Cross finger flap results
• The advantages of the cross-finger flap include a
reliable and large flap that can even be innervated
(Cohen, 1983). However, several reports describe
very good 2-point discrimination (2PD) without
innervating the cross-finger flap (Kleinert, 1974;
Sturman, 1963; Johnson, 1971).
• The disadvantage to the cross-finger flap is the
need for a second operation and the delay that
results in stiffness.
• Accordingly, this flap is contraindicated for older
patients (>40 y) or those with Dupuytren
syndrome or rheumatoid arthritis.
28. Thenar flap
• The classic description of the thenar
flap by Gatewood in 1926 was
proximally based (Gatewood, 1926).
• Later, Smith and Albin (1976) described
the H-shaped modification of the
thenar flap.
• A 2 cm x 4 cm thenar flap can be
harvested from the MCP crease and still
allow primary closure of the donor site
with thumb flexion.
• Care must be exercised in harvesting
this thenar flap at the MCP crease to
avoid injury to the neurovascular
bundles and flexor pollicis longus
tendon (Russell, 1981).
29. Laterally based pedicled flaps
• An alternative way to increase the
pulp advancement for more
oblique palmar sloping defects is to
use single pedicle lateral flaps. The
earliest of these lateral flaps was
described by Geissendörfer in
1943. This flap was subsequently
popularised by Kutler .
• It is vascularised by the small
vessels beyond the trifurcation of
the digital arteries. These flaps only
ever move significantly in the
drawings in textbooks
30. Segmüller & Venkataswami flaps
• More useful is the lateral flap described by
Segmüller G. Modifikation des Kutler-Lappens:
Neuro-vaskuläre Stielung. Handchirurgie
1976;8:75-6
• Each lateral flap is raised as an island on its
own neurovascular bundle and has a much
bigger volume and reconstructive potential
than the Geissendörfer /Kutler flaps.
• Originally, Segmüller raised the flaps only as
far proximally as the DIP joint crease.
Lanzetta et al described the use of a
modification in which the flap is extended
back to the PIP joint.
31. Difference between them?
• The Segmüller flap can
also be bilateral and
carries its own
innervation while the
advancing edge of the
Venkataswami flap
furthest from the pedicle
is denervated.
32. Reverse digital island flap
• Lai 1989
• The reverse digital flap is
an arterialized homodigital
flap described by which
replaces injured tissue with
like tissue from the same
digit in a single stage.
• The flap is harvested from
the lateral aspect of the
proximal phalanx of the
same finger, preferably the
nonopposition side.
33. Reverse digital island flap dissection
• The pedicle is harvested with a cuff of soft tissue to include the digital artery
venae comitante.
• The digital nerve can be preserved.
• The pedicle is harvested to 5 mm proximal to the distal interphalangeal joint
to capture crossover vessels from the contralateral digital artery.
• If doubt exists concerning reverse blood supply to the flap, the proximal
digital artery can be temporarily clamped to evaluate retrograde flow to the
skin island. The donor site usually requires a skin graft
34. Local Flaps for the Thumb
• Rectangular volar advancement flap
• Though often termed the Moberg flap, the
volar advancement flap was first described
by Littler in 1956 before being popularized
by Moberg in 1964.
• This is a rectangular volar flap based on
both neurovascular bundles.
• The flap is undermined in the distal to
proximal direction to the MCP crease
superficial to the flexor pollicis sheath and
advanced in the distal direction. This flap can
usually be advanced 1.5 cm distally.
35. Complications for fingertip reconstructions
• Major ones are hypersensitivity and
cold intolerance,
• The rates of hypersensitivity and cold
intolerance approximate 50%
regardless of the treatment, including
healing by secondary intention, skin
grafting, and local flap reconstruction.
• This hypersensitivity and cold
intolerance is self-limited and almost
always resolves after 1-2 years. Initial
treatment includes scar massage,
desensitization, and edema control.
