1/39. replantation of fingertip amputation by using the pocket principle in adults.There are several treatment modalities for zone 1 or zone 2 fingertip amputations that cannot be replanted by using microsurgical techniques, such as delayed secondary healing, stump revision, skin graft, local flaps, distant flaps, and composite graft. Among these, composite graft of the amputated digit tip is the only possible means of achieving a full-length digit with a normal nail complex. The pocket principle can provide an extra blood supply for survival of the composite graft of the amputated finger by enlarging the area of vascular contact. The surgery was performed in two stages. The amputated digit was debrided, deepithelialized, and reattached to the proximal stump. The reattached finger was inserted into the abdominal pocket. About 3 weeks later, the finger was removed from the pocket and covered with a skin graft. We have consecutively replanted 29 fingers in 25 adult patients with fingertip amputations by using the pocket principle. All were complete amputations with crushing or avulsion injuries. Average age was 33.64 years, and men were predominant. The right hand, the dominant one, was more frequently injured, with the middle finger being the most commonly injured. Of the 29 fingers, 16 (55.2 percent) survived completely and 10 (34.5 percent) had partial necrosis less than one-quarter of the length of the amputated part. The results of the above 26 fingers were satisfactory from both functional and cosmetic aspects. Twenty of the 29 fingers, which had been followed up for more than 6 months (an average of 16 months), were included in a sensory evaluation. Fifteen of these 20 fingers (75 percent) were classified as "good" (static two-point discrimination of less than 8 mm and normal use). From the overall results and our experience, we suggest that the pocket principle is a safe and valuable method in replantation of zone 1 or zone 2 fingertip amputation, an alternative to microvascular replantation, even in adults.- - - - - - - - - - ranking = 1keywords = discrimination (Clic here for more details about this article) |
2/39. thumb reconstruction with a wrap-around free flap according to the level of amputation.In 1980, Morrison and O'Brien reported their experiences with the reconstruction of an amputated thumb using a wrap-around neurovascular free flap from the great toe, but its indication has been limited distal to the metacarpophalangeal (MP) joint (Morrison et al., J Hand Surg 5:575-583, 1980). We have performed 37 wrap-around free flaps from the great toe for the reconstruction of thumbs amputated at distal or proximal to the MP joint and investigated their functional results according to the level of amputation. The amputation was distal and proximal to the MP joint in 25 and 12 cases, respectively. Pinching and grasping power, two-point discrimination, and the amount of opposition to the other fingers were compared to the uninjured hand. Pinching and grasping power were not significantly different according to the level of amputation but the results of two-point discrimination was better in the cases amputated proximal to the MP joint. The opposition of reconstructed thumb to the other fingers was completely possible in all cases amputated distal to the MP joint. In the 12 cases amputated proximal to the MP joint of the thumb, opposition was completely possible in 6 cases in which the iliac bone block was fixated in the position of 30 degrees flexion and 45 degrees internal rotation. However, in the other six cases in the fixation of 30 degrees flexion and 30 degrees internal rotation, the opposition of the reconstructed thumb to the ring and little fingers was impossible in five cases and only to the little finger in one case. In this study, we concluded that amputation proximal to the MP joint is not an absolute contraindication to the wrap-around free flap procedure for thumb reconstruction. However, for a better functional outcome, we recommend iliac bone block fixation in the position of 30 degrees flexion and 45 degrees internal rotation.- - - - - - - - - - ranking = 2keywords = discrimination (Clic here for more details about this article) |
3/39. Fingertip reconstructions using partial-toe transfers.Fifty-six partial toes were transferred to reconstruct fingertip deficits. The transfers from the big toe mainly consisted of 3 trimmed big toetips, 3 vascularized nail grafts, 3 onychocutaneous flaps, 19 thin osteo-onychocutaneous flaps, and 2 hemipulp flaps. The transfers from the second toe mainly consisted of 8 trimmed second toetips, 5 reduced second toes, and 9 whole distal phalanges. The average values of postoperative sensory recovery of the osteo-onychocutaneous flaps including the vascularized nail grafts were 3.1 (Semmes-Weinstein test) and 6.3 mm (moving two-point discrimination) at 2.6 years after the transfer; those of the thin osteo-onychocutaneous flaps were 3.1 and 7.2 mm at 2.0 years after surgery; those of the trimmed big toe tip transfers were 3.61 and 6.5 mm at 1.8 years after surgery; and those of the trimmed second toetip transfers were 3.37 and 6.3 mm at 2.6 years after transfer. Those of the distal phalanx of the second toe were 3.41 and 7.9 mm at 1.2 years after surgery, and those of the reduced second toe were 3.2 and 6.7 mm at 10.6 months after surgery.- - - - - - - - - - ranking = 1keywords = discrimination (Clic here for more details about this article) |
4/39. Sixty-four cases of thumb and finger reconstruction using transplantation of the big toe skin-nail flap combined with the second toe or the second and third toes.The purpose of this article is to introduce the results of thumb and finger reconstruction using transplantation of the big toe wraparound flap combined with the second toe or the second and third toes. Between August of 1981 and December of 1998, in a series of 64 cases involving 58 patients with digitless hands, either (1) the thumb and index fingers were reconstructed by transplantation of a big toe wraparound flap combined with the adjacent second toe harvested from the ipsilateral foot; or (2) the thumb, index, and long fingers were reconstructed by transplantation of an ipsilateral big toe wraparound flap combined with the adjacent second and third toes. The phalanx of the new thumb was usually an iliac block. The success rate of this series was 92.2 percent. At long-term follow-up, the average static 2-point discrimination was less than 10 mm. The distance between the tip of the new thumb and the new index finger ranged from 6 to 10 cm (average, 8 cm). Opposition action was nimble and forceful. The patients could lift a 6- to 12-kg weight with their reconstructed digits. All patients were satisfied with their new hands and were able to use them in their daily activities. The transplants for reconstructing the thumb and fingers are harvested from the same foot in a procedure known as one-foot donation. Function of the bilateral digitless hand can be recovered with this procedure.- - - - - - - - - - ranking = 1keywords = discrimination (Clic here for more details about this article) |
5/39. A reverse ulnar hypothenar flap for finger reconstruction.A reverse-flow island flap from the hypothenar eminence of the hand was applied in 11 patients to treat palmar skin defects, amputation injuries, or flexion contractures of the little finger. There were three female and eight male patients, and their ages at the time of surgery averaged 46 years. A 3 x 1.5 to 5 X 2 cm fasciocutaneous flap from the ulnar aspect of the hypothenar eminence, which was located over the abductor digiti minimi muscle, was designed and transferred in a retrograde fashion to cover the skin and soft-tissue defects of the little finger. The flap was based on the ulnar palmar digital artery of the little finger and in three patients was sensated by the dorsal branch of the ulnar nerve or by branches of the ulnar palmar digital nerve of the little finger. Follow-up periods averaged 42 months. The postoperative course was uneventful for all patients, and all of the flaps survived without complications. The donor site was closed primarily in all cases, and no patient complained of significant donor-site problems. Satisfactory sensory reinnervation was achieved in patients who underwent sensory flap transfer, as indicated by 5 mm of moving two-point discrimination. A reverse island flap from the hypothenar eminence is easily elevated, contains durable fasciocutaneous structures, and has a good color and texture match to the finger pulp. This flap is a good alternative for reconstruction of palmar skin and soft-tissue defects of the little finger.- - - - - - - - - - ranking = 1keywords = discrimination (Clic here for more details about this article) |
6/39. Reconstruction of pulp defect using a free finger-pulp flap from an excised extra digit.We present a case of a post-traumatic finger-pulp reconstruction in which we used a free finger-pulp flap elevated from the excised extra digit in a patient with coincidental polydactyly of the thumb that had not been previously corrected. It resulted in satisfactory reconstruction of the defect with a well-padded, sensitive fingertip (static two-point discrimination of 3 mm) and excellent cosmetic appearance with the simultaneous correction of the polydactyly.- - - - - - - - - - ranking = 1keywords = discrimination (Clic here for more details about this article) |
7/39. Reversed dorsal digital and metacarpal island flaps supplied by the dorsal cutaneous branches of the palmar digital artery.The dorsal digital and metacarpal island flaps have been described for use in a variety of clinical situations. On the basis of the authors' previous angiographic studies, these two skin flaps were planned on the dorsum of the proximal phalanx or intermetacarpal space based on the vascular anastomoses between the proximal dorsal cutaneous branches of the palmar digital artery and the dorsal digital branches of the dorsal metacarpal artery at the level of the proximal phalanx. The authors present a series of 13 patients using these flaps. To reconstruct the injured finger pulp, the reverse dorsal digital flap was used in 5 patients, and the reverse dorsal metacarpal flap was used in 8 patients. Most of the 13 patients sustained a work-related injury. Associated injuries of bone, joint, or tendon occurred in most patients. In all patients, the skin defect was located distal to the proximal interphalangeal joint. The skin paddle was taken from the dorsal aspect of the middle and ring fingers or the first, second, third, and fourth metacarpal area. All flaps survived completely. Two patients who had the dorsal branch of the sensitive radial nerve anastomosed to the digital nerve recovered 6-mm two-point discrimination in the reverse dorsal digital flap. The results of this anatomic study and the authors' clinical experience confirm the reliability of the dorsal digital and metacarpal island flaps.- - - - - - - - - - ranking = 1keywords = discrimination (Clic here for more details about this article) |
8/39. Fingertip replantation at or distal to the nail base: use of the technique of artery-only anastomosis.The authors describe the functional and aesthetic results of microsurgical replantation of 21 fingertip amputations at or distal to the nail base-namely, zone I amputations. There were 15 male and 6 female patients, with an average age of 26 years (age range, 1-41 years). Replantations were performed using the anastomosis of the artery-only technique, with neither vein nor nerve repair. Venous drainage was provided by an external bleeding method with a fish-mouth incision in "distal" zone I amputations for approximately 7 days, and by the use of leeches in more "proximal" zone I amputations for 10 to 12 days. Results indicated that the overall survival rate was 76%, with 16 of 21 digits surviving. Sensory evaluation at an average follow-up of 12 months (range, 6-18 months) revealed an average static two-point discrimination of 6.1 mm (range, 2.0-8.0 mm). Considering the unfavorable results and the donor site morbidity of various fingertip reconstructions, a microsurgical fingertip replantation should always be considered except in extremely distal, clean-cut, pediatric cases, in which case a composite graft is a possibility. The results of this series indicate that an amputated fingertip in zone I can be salvaged successfully by microvascular anastomosis of the artery only, with a nonmicrosurgical method of venous drainage. Furthermore, acceptable sensory recovery can be expected without any nerve coaptation.- - - - - - - - - - ranking = 1keywords = discrimination (Clic here for more details about this article) |
9/39. Fingertip reconstruction using a volar flap based on the transverse palmar branch of the digital artery.A new homodigital neurovascular island flap for fingertip reconstruction, called a volar digital island flap, is described. The flap is perfused from the proper digital artery through the transverse palmar branch, and is drained through the tiny venules and capillaries contained in the perivascular soft tissue. Between 1997 and 2000, 25 fingers from 23 patients with defects of the middle and distal phalangeal areas were reconstructed using this flap. All flaps survived well. Patient age ranged from 17 to 65 years (average age, 32.5 years). Long-term follow-up for more than 6 months was possible in 15 fingers from 14 patients. light touch and temperature sensation could be detected in all the flaps evaluated. The mean value of the static two-point discrimination test was 4.2 mm. Although this flap requires the sacrifice of important volar skin, it provides excellent padding and sensation for fingertip reconstruction. The authors think that this new flap is an alternative choice for coverage of fingertip defects.- - - - - - - - - - ranking = 1keywords = discrimination (Clic here for more details about this article) |
10/39. Microsurgical medialis pedis flaps for reconstruction of soft-tissue defects in the hand.The medialis pedis flap (MPF) has been used for the reconstruction of soft-tissue defects in the hand since 1990. From January 1997 through January 2000, 19 patients (15 male, 4 female) with hand injuries underwent microsurgical MDF reconstruction at Chang Gung Memorial Hospital. There were finger injuries in 16 patients and palm defects in 3 patients. The mean patient age was 32.6 years (age range, 16-58 years). Flap size ranged from 4.5 x 2 cm to 7 x 6 cm (mean, 6 x 2.8 cm). Only one flap had partial loss. The donor site was closed primarily in 9 patients, and was closed using a split-thickness skin graft in 9 patients and a full-thickness skin graft in 1 patient. At a mean follow-up of 13 months, the protective sensation was 16 mm using the static two-point discrimination test and was 10 mm using the moving two-point discrimination test. Based on this retrospective study the authors conclude that (1) the MPF has the advantages of thin and glabrous skin, (2) the size of pedicle is compatible with the recipient vessel in the hand, (3) there is low donor site morbidity, and (4) achieving protective sensation is possible.- - - - - - - - - - ranking = 2keywords = discrimination (Clic here for more details about this article) |
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