Journal List > J Korean Soc Surg Hand > v.21(2) > 1106550

J Korean Soc Surg Hand. 2016 Jun;21(2):70-76. English.
Published online June 24, 2016.  https://doi.org/10.12790/jkssh.2016.21.2.70
Copyright © 2016. The Korean Society for Surgery of the Hand
Reverse Digital Island Flap with Skin Strip Retention to Prevent Flap Congestion
Jin Yong Shin, Mun-Young An, Si-Gyun Roh, Nae-Ho Lee, and Kyung-Moo Yang
Department of Plastic and Reconstructive Surgery, Chonbuk National University Hospital, Jeonju, Korea.

Correspondence to: Nae-Ho Lee. Department of Plastic and Reconstructive Surgery, Chonbuk National University Hospital, 20 Geonji-ro, Deokjin-gu, Jeonju 54907, Korea. TEL: +82-63-250-1860, FAX: +82-63-250-1866, Email: psjyshin@gmail.com
Received April 04, 2016; Revised June 06, 2016; Accepted June 07, 2016.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


Abstract

Purpose

The reverse digital island flap is useful for the repair of various fingertip injuries. We present a modified surgical technique with skin strip elevation for the prevention of postoperative congestion.

Methods

From January 2005 to October 2015, we performed 31 reconstructive procedures for finger injury using a reverse digital artery island flap with and without skin strip retention. Patients' clinical characteristics, surgical outcomes, and complications were investigated.

Results

All flaps survived and there were no donor site problems. The mean follow-up time was 5 months (range, 3–8 months). In skin strip retention group, mild venous congestion was observed in 1 case, although it resolved spontaneously. Another case retained flexion contracture, and 2 patients had stiffness at the distal interphalangeal joint. Whereas, in no retention group, venous congestion was observed in 3 cases, 1 patient had partial flap necrosis and 2 patient suffer in flexion contracture at metacarpophalangeal joint.

Conclusion

The reverse digital island flap procedure produces consistent results and is reliable for the treatment of fingertip injury. Our modified surgical technique of elevating the flap accompanied by skin strip retention helps prevent postoperative congestion.

Keywords: Fingertip injury; Reverse digital island flap; Prevention of congestion

INTRODUCTION

Fingertip injury is a commonly encountered and challenging problem for hand surgeons. Various treatment modalities have been reported depending on the types of injury1, 2, 3, 4, 5. In the case of amputation, composite graft or microsurgery is possible. Without amputation there are various possible treatment modalities, such as secondary intention, simple shortening, local flap, regional flap, or free flap6, 7, 8. Among these methods various local flaps have been effective for the treatment of fingertip injury, although volar oblique injury or large defects cannot be covered by a local finger flap9, 10.

In this circumstance, the most frequently considered flap is the reverse digital island flap (RDIF), which has been used widely over previous decades because it can cover large defects of the fingertip in single-stage surgery11, 12. It is also reported to be an excellent choice for fingertip injury because of its safety, reliability, postoperative cosmetic appearance, and favorable sensibility13, 14. Despite these advantages, vascular complications may arise such as venous congestion or partial flap loss. Many reports have been published about modifications of surgical techniques to improve surgical integrity and prevent complications. However, there are few reports of modified surgical techniques for the prevention of postoperative congestion. In a previous study, more than 20% of patients experienced venous congestion or subsequent flap necrosis15.

We designed a modified surgical technique for elevation of the flap to prevent congestion. Here we report our surgical outcomes using skin strip retention and discuss how to ensure flap success without congestion.

MATERIALS AND METHODS

Between January 2005 and October 2015, we performed 31 reconstructive procedures for finger injury using RDIF, with skin strip retention in 20 cases and without skin strip in 11 cases. The patients included 22 males and 9 females, with an average age of 44.87 years (range, 10–84 years). Types of injury were amputation (n=18), crushing (n=5), necrosis (n=4), and defect (n=4). The injured digits included 6 thumbs, 6 index, 5 middle, 9 ring, 4 little fingers, and 1 case of injured thumb and index finger. The donor digits included the index (n=4), middle (n=16), ring (n=9) fingers, and little (n=1) with 1 case of index and middle fingers. We selected patients on the basis of the following criteria: age 10 years or older; 1 or 2 finger defects; island flap 1 to 2 cm in length; skin strip thickness 2 to 3 mm. The size of the defects ranged from 0.5 to 3.0 cm long and 0.7 to 7.5 cm wide. The flaps ranged in size from 0.7×1.0 to 2.5×3.0 cm2 (mean, 3.00 cm2). All cases were in general anesthesia and tourniquet was applied in all cases.

We selected patients on the basis of following: age 10 years or greater; volar soft tissue defect involving the middle phalanx, distal third of the proximal phalanx, or both. Patients were excluded for the following reasons: patient age under 10 years; occurrence of the defect in a region the flap is unable to reach; and pulp defect.

We compared the outcome of with and without skin strip retention groups in all 31 patients. And we analyzed the complications arising from them.

1. Surgical technique

The flap was designed on the finger adjacent to the injured site or injured finger. The flap was easily found at the distal third of the proximal phalanx, and was designed according to the size and shape of the defect. The subcutaneous pedicle and skin strip of the flap were elevated on the lateral middle line of the proximal phalanx adjacent to the injured finger (Fig. 1), and maximum pedicle length was achieved. We included subcutaneous tissue of at least 0.5 cm width in the pedicle. A 2- or 3-mm-thick skin strip should be retained to preserve blood supply. After the digital artery was ligated at the proximal base, the flap was turned 180° on the pivot point to reach the fingertip defect. No neurorrhaphy was performed. We covered the flap donor site with a full-thickness skin graft. No difficulties from inflammation or adhesion were encountered when harvesting these flaps, even after failed fingertip replantations.


Fig. 1
A 61-year-old-male with posttraumatic amputation, the defect size was about 1.5×2.0 cm over the left thumb. (A) Reverse-flow heterodigital island flap with skin strip was elevated from index finger. (B) The flap with skin strip was transferred into the defect. (C) Five months after the operation, the flap circulation was intact.
Click for larger image

RESULTS

All flaps with or without skin strip survived and there were no donor site problems. In all cases, the operation was performed to maintain as far as possible the original length of the injured fingers. All defects were successfully covered by the flap. We cannot find either digital tip ischemia or revascularization failure on injured fingers. The mean follow-up time was 5 months (range, 3–8 months). In no skin strip retention group, venous congestion was observed in 3 patients, 1 patient had partial flap necrosis (Fig. 2) and 2 patients suffer in flexion contracture at metacarpophalangeal joint (Tables 1, 2). Whereas, in skin strip retention group, mild venous congestion was observed in 1 patient, which resolved spontaneously. Total active range of motion of the affected fingers was 180° to 260°. Flexion contracture persisted on PIP joint in 1 patient, while stiffness at the distal interphalangeal joint was apparent in 2 cases (Table 3, 4). The venous congestion incidence was about 27% in no skin strip retention group and about 5% in skin strip retention group, however, there is not significant difference (p=0.077).


Fig. 2
Partial flap necrosis of reverse digital island flap in no skin retention group.
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Table 1
Patient data of the reverse digital island flap without skin strip retention
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Table 2
Patient data of postoperative complications without skin strip retention
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Table 3
Patient data of the reverse digital island flap with skin strip retention
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Table 4
Patient data of postoperative complications with skin strip retention
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DISCUSSION

Well-performed reconstruction of the fingertip demands preservation of the finger length and provision of a sensate and durable flap. Selection of treatment approach should consider defect size, nail presence, donor site morbidity, and level of amputation16. In addition, reconstruction should be achieved in a single session. Numerous treatment modalities such as conservative treatment17, and local, regional, and distal flaps have been proposed for the reconstruction of fingertip injuries.

Among the various treatment approaches, several regional or distant flaps can be considered when the defect size is too large for conservative treatment or local flap coverage. The RDIF is our first considered option when a local flap is insufficient. The abundant vascular communication between the radial and ulnar digital arteries enables the RDIF to achieve normal blood supply by retrograde flow. Moreover, it does not require a 2-stage operation and long immobilization time. The wide arc of rotation of this flap in relation to the fingertip is also an advantage.

Of course the RDIF also has drawbacks, which may be overcome by modifications in surgical technique. Cold intolerance or hypersensitivity has been discussed as a possible complication. Elevation of the sensate flap at the beginning of surgery has been attempted to overcome this sensory problem13. However, several studies reported that there are no significant sensory differences between sensate and insensate flaps9, 14. Following publication of updated clinical outcomes, sensory problems with the RDIF are no longer recognized as a postoperative complication. Possible hypersensitivity after RDIF due to re-innervation of the nerve has been investigated, which is reported to be temporary until recovery is complete. Although full sensory recovery after RDIF surgery is usually possible after about 1 year, efforts to achieve earlier recovery are ongoing8, 18. Donor site morbidity is another frequently mentioned complication of RDIF. A donor site proximal to the phalanx can lead to irreversible depressed scar or motor limitations. To prevent such morbidity, a previous study introduced adipofascial flap elevation without skin19.

Postoperative flap congestion is also a commonly encountered complication of RDIF. Some studies reported postoperative venous congestion in more than 10% and partial flap loss in more than 20% of cases15. Several studies reporting the use of specific procedures have underlined the need to resolve the problem of congestion8, 18, 20. While it is recommended that patients be monitored carefully for postoperative congestion, few studies have investigated its prevention.

We used a modified surgical technique of elevated pedicle with skin strip for the prevention of postoperative congestion. An en bloc elevation of the subcutaneous venous network has been also introduced for the same purpose10. Similarly to this technique, our skin strip retention also can overcome venous congestion by elevation of the skin and subcutaneous venous network. We assumed that skin strip over the pedicle could be helpful for vascular supply by enhancing the subdermal vascular network21. In addition, the skin strip serves a protective role for the pedicle in that it prevents venous congestion by twisting or compressing the pedicle, and also easy handling can be possible22. Using flap elevation with skin strip retention, vascular problems such as congestion decreased than not using skin strip and we can reduce the need for postoperative monitoring.

CONCLUSION

In conclusion, although the RDIF produces consistent results and reliable flaps for the treatment of fingertip injury, several complications can occur. We suggest modified surgical technique of elevated flap with skin strip retention for prevention of postoperative congestion.

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