Finger detipping and soft tissue defects

Detipping

 

DetippingDetipping xray

 

Definition

 

Distal to insertion of flexor and extensor tendons

 

Anatomy

 

Thick skin

- fibrofatty tissue

- fibrous septa from dermis to periosteum

 

Tissue involved

 

Pulp only

Nail bed

Bone

 

Goals

 

1.  Preserve functional length 

2.  Preserve useful sensibility

3.  Prevent neuromas

4.  Prevent joint contractures

5.  Short morbidity with early return to work

 

Options

 

Detip 1Detip 2Detip 3

 

1.  Primary suture and healing

 

2.  Secondary healing (< 1 cm2 area)

 

4.  Formalization

 

5.  Flaps

 

Local flaps / VY flaps

Regional Flaps (Cross-finger / Thenar flap)

 

Formalization

 

Finger formalisation 1Finger formalization 2

 

Technique

 

Remove nail bed in full (bilateral eponychial incisions)

Take bone to level distal to extensor / flexor tendons

Close using fishmouth flaps or volar flap

 

Local Flaps

 

Indications

 

Small defects < 1 cm2

Transverse or volar based defects

 

Results

 

Chakraborty et al World J Plast Surg 2021

- systematic review of 13 articles

- mean 2 point discrimination of 5 mm (c.f. 3 mm contralateral)

- minimal loss of ROM

- some cold intolerance

- risk of hook nail

 

1.  Unilateral VY flap - Atasoy

 

Atasoy 1Atasoy 2Atasoy 3

 

Volar VY Advancement flap

 

Technique

- nibble bone back

- incise skin in V

- ensure vase of flap is as wide as nail bed

- must release all fibrous septa to mobilize flap

- attempt to leave small vessels

- advance and suture to nail bed

- close in Y fashion

 

Surgical technique article

 

2.  Bilateral VY flap - Kutler's

 

 

Kutler 1Kutler 2

 

Technique

- triangular skin flaps on both sides of digit

- advanced to close transverse skin defect

- closed in Y patter

 

Surgical technique article

 

Regional Flaps

 

Advantages

 

Good quality skin

Good sensory outcome

 

Disadvantages

 

2 stage procedure 

Longer period of recovery

Potential donor site morbidity

 

1.  Cross finger flap

 

Indications

 

Volar based skin defects

 

de-puplped finger injury

 

Technique

 

Cross finger 1Cross finger 2

 

 

Rectangle of donor skin from dorsum of adjacent digit middle phalanx

- hinge is mid-axial line

- must preserve paratenon over extensor tendon to ensure take of the subsequent skin graft

- flap crossed onto distal finger pulp

 

Full-thickness skin graft to donor site from forearm

- must remove all fat from FT graft

- graft sutured 75% onto dorsum of donor finger

 

Divide flap under GA 3 weeks later

 

Surgical technique article

 

2.  Reverse cross finger flap

 

Dorsal skin loss

 

Indication

 

Dorsal based skin defects

Complete nail bed defects

 

Surgical technique article

 

3.  Thenar flap

 

Indications

 

2 cm2 defect of index / middle / ring finger pulp

Difficult to oppose little finger

 

Technique

 

Thenar flap

 

Most important point is site of flap

- if too distal and over webspace can endanger NV bundle to thumb

- needs to be over thenar eminence

 

Flex finger to identify donor site

- create distally based rhomboid flap

- suture to finger defect

 

Flap division 2 - 3 weeks later

- primary closure of thenar defect

 

Surgical technique article

 

3.  Abdominal Flap

 

Suture finger to border between chest / abdomen

- release 3 weeks later

- primary closure of chest wound