Fingertip defects coverage using reverse-flow homodigital island flaps

BACKGROUND: The hand has always been a highly organized tool in humans daily and professional activity. Distal phalanges are most commonly exposed to trauma, which often cause defects that need to be covered through plastic surgery. One of the most reliable and universal methods for fingertip reconstruction is the reverse-flow homodigital island flap. CLINICAL CASES: This series of clinical cases describe three children aged 7, 8, and 11 years who underwent coverage of fingertip defects with the reverse-flow homodigital island flap. In all cases, mechanisms of injury were associated with crushing and rupture of soft tissues. All children underwent coverage of fingertip defects with the reverse-flow homodigital island flap. In the first case, evaluation results at 6 months after surgery revealed 4 mm in the Webers test and phalanx length deficit of 2 mm. In the second case, the assessment performed 1 month after surgery revealed 5 mm in the Webers test and the length of the operated phalanx corresponds to the contralateral one. In the third case, results of the 2-month observation period revealed 4 mm in the Webers test and lengths of the operated and contralateral phalanges were the same. DISCUSSION: The reverse-flow homodigital island flaps have irrefragable advantages among methods of surgical reconstruction of soft tissues of distal phalanges. These are single-stage reconstruction techniques that can possibly replenish sufficient amounts of soft tissues to the defect. A literature data analysis of the outcomes of the fingertip reconstruction through the reverse-flow homodigital island flaps revealed good and satisfactory results. CONCLUSIONS: The method of the reverse-flow homodigital island flap has potential to take a significant place in pediatric traumatology and reconstructive surgery.

Clinical Outcomes and Complications of Primary Fingertip Reconstruction Using a Reverse Homodigital Island Flap: A Systematic Review

Background Reverse homodigital island flaps (RHIFs) are increasingly used to reconstruct traumatic fingertip injuries, but there is limited evidence on the efficacy of this technique. We performed a systematic review of the literature to establish the safety and functional outcomes of RHIF for traumatic fingertip injuries. Methods Electronic searches were performed using 3 databases (PubMed, Ovid Medline, Cochrane CENTRAL) from their date of inception to April 2020. Relevant studies were required to report on complications and functional outcomes for patients undergoing RHIF for primary fingertip reconstruction. Data were extracted from included studies and analyzed. Results Sixteen studies were included, which produced a total cohort of 459 patients with 495 fingertip injuries. The index and middle fingers were involved most frequently (34.6% and 34.1%, respectively), followed by the ring finger (22%), the little finger (6.7%), and the thumb (2.6%). The mean postoperative static and moving 2-point discrimination was 7.2 and 6.7 mm, respectively. The mean time to return to work was 8.4 weeks. The mean survivorship was 98.4%, with the pooled complication rate being 28%. The pooled complication rate of complete flap necrosis was 3.6%, of partial flap necrosis was 10.3%, of venous congestion was 14.6%, of pain or hypersensitivity was 11.5%, of wound infection was 7.2%, of flexion contractures was 6.3%, and of cold intolerance was 17.7%. Conclusions Reverse homodigital island flaps can be performed safely with excellent outcomes. To minimize complications, care is taken during dissection and insetting, with extensive rehabilitation adhered to postoperatively. Prospective studies assessing outcomes of RHIF compared with other reconstruction techniques would be beneficial.

Kirschner Wire Fixation for Immobilization of the Thenar Flap in an Uncooperative Pediatric Patient: A Case Report

Thenar flap is a commonly used operational method in fingertip reconstruction. It should be maintained for two to three weeks before flap division until the neovascularization is established from the fingertip to the flap. However, immobilization between two stages of operation is challenging especially in uncooperative pediatric patients. A 47-month-old female with a ring fingertip amputation underwent soft tissue reconstruction with thenar flap. Two days postoperatively, the flap’s proximal margin was found disrupted. Flap revision was performed, followed by applying a trans-phalangeal Kirschner wire (K-wire) between the thumb proximal phalanx and ring finger middle phalanx. The flap was successfully divided two weeks after the original operation. The result was aesthetically pleasing, and no complication was observed, including dehiscence, necrosis, limitation of range of motion, and visible scar of the pinning sites. In conclusion, K-wire fixation is a safe and effective method to immobilize thenar flap in uncooperative pediatric patients.

Fingertip Reconstruction with Subcutaneous Island Flap and Composite Graft: A Case Report

Reconstruction of amputated fingertips is extremely challenging when the amputee is very small and severely crushed. Moreover, there are not many options if distal phalanx is exposed due to defects of soft tissue. We report a case of successful fingertip reconstruction in a 10-month-old girl using a subcutaneous island flap with a composite graft. Her fingertip of the right little finger was amputated stuck by the air purifier. Some soft tissue was lost from the stump and the bone was exposed. There was a very small amputee, and soft tissue was extremely little inside. Replantation was not possible because of the soft tissue defect. The composite graft was inadequate due to the exposure of distal phalanx and defect of soft tissue. Soft tissue island flap based terminal branch of the digital artery was transposed to cover the distal phalanx. After then, the amputee was grafted over the flap. After debridement, most of the soft tissue survived and 0.2×0.2 cm of skin defect was found, which was healed through secondary intention.

Partial second toe pulp free flaps in early childhood

Background The introduction of the partial second toe pulp free flap has enabled superior aesthetic and functional results for fingertip reconstruction in adults. Children undergoing fingertip amputation for various reasons have limited options for reconstruction. Conventional treatment could shorten the finger, leading to poor cosmesis and function. We report 18 years of our experiences with fingertip reconstruction using partial second toe pulp free flaps in patients in early childhood.Methods Medical charts of children who had undergone fingertip reconstruction using partial second toe pulp free flaps from 2001 to 2018 were retrospectively reviewed. The surgical procedures were identical to those for adults, except for the usage of 11-0 nylon sutures. Patients’ demographic data, vessel size, flap dimensions, length of the distal phalanx, and functional outcomes over the course of long-term follow-up were documented. The statistical analysis was performed with the Student t-test, the Mann-Whitney U test, and Pearson correlation analysis.Results Eighteen toe pulp flaps in 17 patients (mean age, 3.0 years) were identified. All the flaps survived without any major complications. In long-term follow-up, the flap-covered distal phalanges showed growth in line with regular development. There was no donor-site morbidity, and all children adapted to daily life without any problems. In two-point discrimination tests, the fingertip sensation recovered to almost the same level as that in the contralateral finger.Conclusions Partial second toe pulp free flaps are an excellent option for fingertip reconstruction in young children, as well as in adults.