From November 2008 to March 2015, we performed fingertip reconstructions on 78 fingers (excluding the thumb) of 72 patients using the oblique triangular flap in 29 fingers of 26 patients, volar advancement flap in 8 fingers of 8 patients, reverse digital artery island flap in 16 fingers of 16 patients, thenar flap in 8 fingers of 8 patients, free flap in 7 fingers of 6 patients, and other flaps in 10 fingers of 8 patients. In homodigital flap (oblique triangular flap, volar advancement flap and reverse digital artery island flap) reconstruction, postoperative appearances were excellent in color and texture match; sensory recoveries were favorable. However, postoperative scars and slight joint contractures were sometimes seen on the flap donor sites. In contract, distant flaps (thenar flap) and short pedicle free flaps (posterior interosseous artery perforator flap) showed no postoperative scars in the middle and proximal phalanges levels, and postoperative sensory disturbance (numbness, tingling or hypersensitivity) rarely occurred. Several procedures use flaps for fingertip reconstruction. Thus, one must choose the most appropriate treatment that is tailored to each patient while taking postoperative appearance and flap donor site morbidity into consideration.
Fingertip reconstruction must be carried out from the standpoint of function as well as cosmesis. In order to maintain the length of the finger, the flap must be carefully selected and applied depending on the size, shape and the location of the defect. There are several options for optimum flap selection. In this report, our surgical methods are demonstrated and we discuss such clinical issues as the indication and limit of the flaps often introduced for the fingertip reconstruction. Oblique triangular flap and reverse vascular pedicle digital island flap were the flaps most frequently used for our fingertip reconstructions. Wrap-around flap was specifically indicated for reconstruction of the nail. Fingertip reconstruction was previously planned based upon the order of “reconstruction ladder”. In fingertip reconstruction, it is also necessary to be familiar with local flaps. With recent technical advancements in microsurgery, reconstruction procedures have become less invasive with minimal sacrifice of the donor site. The concept of the “reconstructive elevator” using recent microsurgical innovation is beginning to make it possible to repair the fingertip with wider options of flaps in a less invasive and more tailored manner.
The fingernails are important not only aesthetically but also to maintain a pinch. With the development of finger reconstruction by partial toe transfer, partial distal finger defects can be reconstructed by using a skin-nail flap. We reconstructed seven amputated fingers (three 1st toes, one 2nd toe, one 3rd toe, one 4th toe, and one 5th toe) by using a free wrap-around flap (two cases), partial toe transfer (four cases), and fourth toe transfer (one case). Closure of the donor site on the leg was performed by using a peroneal perforator flap (three cases), cross-toe flap (three cases), and full-thickness skin graft (one case). All the transplanted flaps survived. The DASH scores were good, with an average of 9.75 points in our cases, which we further investigated. In the four cases, the mean moving-2PD was 10 mm, and the mean Semmes-Weinstein test score was 4.25. The clinical results were satisfactory both cosmetically and functionally.
Post-traumatic vessel disease (PTVD) is known to affect vessels well beyond the “zone of injury”. These vessels are often immersed in a thick fibrous atmosphere whose dissection frequently leads to refractory and irreversible spasm (IS). We examined 72 recipient vessels and incidences of IS in free flap surgery for fresh severe limb injuries. IS occurred in 8/72 (11.1 %) vessels if the flap surgeries were significantly delayed (p=0.047), regardless of their continuity especially in four lower limbs. If the outflow of the recipient vessels was poor after dissection and their spasms were irreversible, we have to anastomose more proximally or choose another vessel as the recipient.
A pedicled groin flap has to be connected for a long period of time to the trunk and upper limbs. Conventionally, it has been fixed by taping, band and body cast, but such fixation is weak, and fine adjustment of the limb position is difficult. We have applied an external fixator, devising upper limb pelvic external fixation for fixing to a metacarpal and radius of the upper limbs and iliac of the pelvis to the penetration by two half pins. Upper limb pelvic external fixation as a fixed pedicled groin flap seem to be useful ; it is minimally invasive and simple, can be strongly fixed to the optimal limb position for circulation maintenance of flap, can be fine-tuned any number of times, and observation and wound treatment is also easy to do. Walking, rehabilitation and ability to use a shower bath can also after excellent QOL.
We performed fingertip reconstructions using a local flap or a graft on flap method in un-replantated fingertips as seen in severe crush amputation cases. Local flaps were performed on 2 thumbs and 4 fingers using 4 oblique triangular flaps, 1 palmar advanced flap and 1 reversed island flap. According to the Ishikawa classification of fingertip amputations, subzone I was in 1, subzone II in 2, subzone III in 2 and subzone IV in 1. Graft on flap was performed on 6 thumbs and 5 fingers using 10 palmar advancement flaps and 1 oblique triangular flap. Four fingers were subzone II, 5 fingers were subzone III, and 2 fingers were subzone IV. The patient age range at surgery was 23 to 68 years (mean 45.3 years) and the follow-up range was from 3 to 18 months (mean 8 months). All flaps survived. Complications after surgery were fingertip numbness in 7 fingers, joint contracture in 10, nail deformity in 6, infection in 4 and nail bed ulcers in 4 after engraftment of graft on flap. Nail bed ulcer cases were healed (3 : by bone shortening, 1 : by medieated bath).
We reconstructed a right middle fingertip using a twisted wrap around flap. A 20-year-old female injured her right middle fingertip while using a heat press machine for sealing plastic bags. The right middle finger survived by a conservative treatment. However, nail was lost, and atrophy and hypersensitivity of finger pulp remained. She requested reconstruction of the middle finger with sensitive pulp and nail. Eight months after the injury, we reconstructed the middle finger with a twisted wrap around flap. We eventually covered the donor site with a full thickness skin graft at 5 weeks after an artificial dermis graft. After primary surgery, she was self-conscious of the bulkiness of her right finger and had hidden her right middle finger by wearing a glove. She was satisfied after 3 cosmetic surgeries and she stopped wearing the glove. A twisted wrap around flap has the potential to avoid the toe pain when walking because the flap is harvested from non-weight bearing areas of the 1st and 2nd toes.
The replantation of an amputated fingertip is difficult, because a suitable vein is rarely available. Fingertip replantation using the palmar plexus salvage procedure for venous drainage was reported by Tanabe et al. in 2006. This is an alternative salvage procedure for fingertip replantation in cases with no suitable vein. We used this procedure for 6 distal phalangeal replantations in 4 patients with venous congestion between October 2010 and March 2012. According to the Ishikawa classification, the amputation levels were subzone 2 in 2 cases, subzone 3 in 3 cases, and subzone 4 in 1 case. Of the 6 replanted fingertips, 5 survived, and 1 with amputation at subzone 4 demonstrated partial necrosis. The palmar plexus salvage procedure is easy to perform and can provide satisfactory finger function. However, the use of this procedure may be limited for fingers amputated at the proximal part as we experienced a complication of partial necrosis in a case of amputation at subzone 4.
If a patient has a nonunion but is asymptomatic, no treatment is needed. However, if the patient remains in pain and radiography shows no union after three months, surgical intervention may be necessary. The nonunion rate for radial head fractures is low and there are a few reports that describe various treatments for nonunion of the radial head, including radial head excision, internal fixation with bone graft and radial head replacement. However, there have been no reports in which nonunion of the radial head was treated with a pedicled vascularized bone graft. We describe the case of a 73-year-old female with nonunion of the radial head, that was treated with a pedicled reverse-flow osteocutaneous lateral arm flap transfer. The flap successfully survived and bone union was obtained at an early stage, so we conclude that pedicled reverse-flow osteocutaneous lateral arm flap transfer is a useful option for treatment of nonunion of the radial head.
Flap failure rates may be increased with the reversed artery flap, particularly among patients with risk factors such as advanced age, peripheral artery disease, venous insufficiency, diabetes mellitus, and smoking. This case report describes the use of a delay procedure to avoid flap necrosis in a potentially high-risk heavy smoker. A 70-year-old man sustained an injury to the right hand, resulting in the loss of a 6 cm × 7 cm area of skin and soft tissue from the first web. A reversed posterior interosseous artery flap was used. After elevating the flap, the proximal vascular pedicle was clamped. The pale elevated flap was then re-sutured to its original location. Three days later, the flap was re-elevated and clamped again at the proximal vascular pedicle. The ruddy-colored flap was rotated into the defect. The donor site was covered with grafted skin. The wound healed with no necrosis, and the patient returned to his previous work. This delay procedure appears useful as a treatment modality for patients with risk factors jeopardizing the reversed artery flap.
The free rectus abdominis musculocutaneous (RAMC) flap is one of the most favored flaps for reconstructive surgeries because of fewer anatomical variations and easy and safe flap elevation. A vertically-designed RAMC flap is usually harvested with a pair of inferior epigastric artery and vein for head and neck reconstruction. Congestive complications of an RAMC flap are rarely seen with the ordinal method of flap harvest. We have experienced three cases of flap congestion during flap elevation in the last nine years. In case 1, the elevated RAMC flap with engorgement of the superficial inferior epigastric vein was salvaged with super drainage venous anastomosis. In case 2, the flap could not be salvaged and required replacement with an anterolateral thigh flap. In case 3, although the flap was transferred without additional procedure, partial necrosis of the flap developed postoperatively. Flap congestion can develop even in one of the safest flaps for various reasons. It is important to take occasional RAMC flap congestion into consideration to avoid further complications.
A 59 year old man with long term hemodialysis suffered from left critical limb ischemia. The limb was preserved by revascularization using a bypass graft. One year after limb rescue, skin ulcer occurred on the left knee and progressed to suppurative arthritis of the knee. This knee was treated with arthrodesis. The soft tissue did not heal by skin closure following debridement of the ulcer. A free latissimus dorsi musculocutaneous flap was performed. As the recipient artery, we selected the former femoral artery that had been obstructed at the popliteal region for protection of the bypass graft. This elaboration of the anastomosis technique allowed the flap to survive. Microsurgical reconstruction of soft tissue is important even in chronic dialysis patients to avoid the need for amputation.
In recent years, numerous studies have reported the good therapeutic effect of early vascularized free tissue transplantation for a severe open fracture of the lower extremity with soft tissue damage. Reconstruction using a free latissimus dorsi flap was performed for severe open fracture of a lower extremity injured in a marine environment. Although a good result was obtained eventually, we found that a relatively long period was required until bone union and full load bearing. A 65-year-old man was injured when he entangled his lower leg in the net of a fishing boat. On the day of injury, debridement, external fixation, and wound closure were performed. Seven days after the injury, infection caused by marine environment-specific bacteria was observed; therefore, debridement, and negative pressure wound therapy were performed. One month after the injury, reconstruction using a free latissimus dorsi flap was performed. At 4.5 months after the injury, non-vascularized free iliac cancellous bone grafting and internal fixation were performed. Thirteen months after the injury, the bone union was confirmed. Sixteen months after the injury, the patient could walk without a crutch, and he returned to work on a fishing boat.