Aesthetic and sensate reconstruction of the fingertip defect with pivot flaps【推荐论文】 .doc

精品论文Aesthetic and sensate reconstruction of the fingertip defect with pivot flapsNi Feng, Chen Bo, Wang Bin5(Department of Plastic and Reconstructive Surgery, Shanghai 9th Peoples Hospital, ShanghaiJiaotong University School of Medicine, ShangHai 200011)Abstract: Purpose Sensate reconstruction with glabrous skin is critical for resurfacing the fingertip or pulp defects. Based on the segmental blood supply from the digital artery to the palmar skin and subcutaneous tissue of the digit with accompanied proper digital innervation, the pivot flap was10advocated to reconstruct the fingertip defect. Methods From Feb. 2007, 21 patients with fingertip or pulp defects were repaired by pivot flaps in our department. The flap size ranged from 1.8×1.5cm to2.6×2.2cm. The range of motion of the injured digits was measured. Semmes-Weinstein monofilament test, static and moving 2-point discrimination test was also performed to evaluate the sensory of theflap. Michigan Hand Outcomes Questionnaire (MHQ) was used to investigate the Patients satisfaction15with the appearance of the hand, pain, cold intolerance and percussion tenderness of the repaired fingertip was also examined. Results All flaps survived completely. Full motion was maintained at the distal and proximal interphalangeal joints. The mean values of Semmes-Weinstein score was 3.92 g. The mean values of moving and static 2-point discrimination were 3.9 mm and 4.7 mm, respectively. All patients were satisfied with appearance of the fingertips. No painful tips could be found. All flaps20have mild cold intolerance and only 1 of the patients complained of mild tenderness with percussion of the fingertip.Conclusions The pivot flap can provide sensate, glabrous skin and is useful for resurfacingfingertip and pulp defects with an aesthetic and functional outcomes.Keywords: Fingertip; reconstruction; sensory flap; soft tissue25Finger tip defects are common injuries of the hand. Few doctors choose full-thickness skin graft for finger tip coverage because of the unsatisfactary pulp view and bad abradability. Different flaps have been advocated to cover finger tip defects. However, reverse dorsal digital island flap can not supply firm skin texture, pedicled abdominent flaps are usually fat and clumsy1,2. Cross-finger flap will inevitably injury the adjacent finger3. Although reversed digital30artery flap can offer glabrous skin, sacrificing one side of main digital artery may not be avoided4.Simple V-Y advancement flap are still in wide use with little or no modifications for limited finger tip defect5. In order to expend the covering area, Evans and Martin first reported the step-advancement flap in 13 patients in 19886. Hammoud further extended step advancement flap using the stepladder principle which can wrap around the projecting tip of the distal phalanx7.35However, too much advancement of the flap (>12mm) may lead to sensory disturbance of the fingertip which did not subside8. To reconstruct the finger tip with sensate and glabrous skin is still challenging.Yam described a “palmar pivot flap” based on the digital artery on the injured side of the digit. This flap relies on the segmental blood supply to the palmar skin and subcutaneous tissue of40the digit. The author applied this flap to cover palmarlateral defects at or distal to the proximal interphalangeal joint. We have used this flap for finger tip coverage from 2007 and found it is really an easy approach to reconstruct a sensate and well padded tip which also achieve the aesthetic appearance. Here we presented our experience on this flap mainly focused on itsapplication for finger tip defect9.45Materials and MethodsFrom February 2007 to October 2010, 21 patients with fingertip or pulp defects were repairedFoundations: 博士点新教师基金（20090073120097）Brief author introduction:Ni Feng, Male, Attending Surgeon, Hand Surgery.Correspondance author: Wang Bin,（1971）, Male, Associate Professor, Hand Surgery. E-mail:wangbin1766- 7 -by palmar pivot flaps in our department. 17men and 4 women were involved in our case serious with ages ranging from 18 to 77 years (mean, 40 years). The mechanisms of injury included avulsion (n = 12) and crush (n=9). There were 6 index finger, 5 middle finger,10 ring finger and 150little finger injuries.Patients were selected mainly as the following issues: （1）small oblique or transverse fingertip defect with or without bone exposure; （2）defects > 1.5 cm in length; （3）no concomitant fracture of the middle phalanx.Contraindication included (1) concomitant injuries, especially fractures proximal to the55affected sites; (2) injury to one side of the proper digital artery; (3) defect <1.5 cm in length; (4) the length of the fingertip or pulp loss exceeding the transverse distance between the lateral midline of the finger.Patients with Dupuytrens contracture, diabetes and Raynauds disease or other vascular disorders were relatively contraindicated.60The flap size ranged from 1.8 ×1.5cm to 2.6 ×2.2cm. All the flaps were transferredemergently with time delay less than 8 hours after injury.Surgical TechniqueThe palmar pivot flap is based on the transverse branches of the digital artery. Each segment of the digit artery usually has 4-7 transverse branches which arborize with similar branches from65the contralateral digital artery. The drainage is via small veins accompany with these branches which terminally drain into palmar venous system11. With concomitant nerve branches, the transverse palmar part of the digit has the most similar tissue texture to the tip and pulp. This unique structure feature makes the palmar pivot flap to be a neurovascular island flap especially suitable for resurfacing the defect in fingertip or pulp area.70The maximum length of the flap is determined by the midlateral distance of the digital segment proximal to the affected area (L1). This length should be equal to or longer than the distance between distal margin of the fingertip defect and the proximal transverse dissection line(L2)（Fig.1）. One side of the digital neurovascular bundle is chosen as a pivoted pedicle. The flapis marked according to the width and length of the defect. Dissecting the skin to the subcutaneous75tissue opposite to the pivoted side is first initiated. The opposite side of the neurovascular bundle is kept intact. Then the transverse parts of the flap are incised to the tendon sheath level. The skin and subcutaneous tissues are dissected off the tendon sheath and all the fibrous attachment to the sheath is isolated. At the pivoted side, digital neurovascular bundle should be carefully protected and remained in the flap. Both Clelands and Graysons ligaments are divided. So the flap could80be pivoted freely on the bundle.859095100105110FIGURE 1 The maximum length of the flap is determined by the midlateral distance of the digital segmentproximal to the affected area (L1). This length should be equal to or longer than the distance between distal margin of the fingertip defect and the proximal transverse dissection line (L2).The flap is usually pivoted 90o on the bundle to cover the fingertip or pulp defect. The suture between the distal part of the flap and nail bed is first accomplished to secure the coverage of the bone without tension. To prevent hook nail deformity, a small sterile pin can be inserted 1mm away from the distal margin of the flap to the remnant of the bone for 3 weeks when necessary. Then the dominant and proximal sides of the flap are closed. There is usually small patch of skin defect at the non-dominant site which can be resurfaced with a full-thickness skin graft from the inner aspect of the upper arm or the palmar skin crease area of the wrist.Postoperative treatmentAfter surgery, a light splint was used for 2 weeks to control the DIP joint flexed at 15 o to reduce the tension of the pedicle. Tissue color and capillary refill were regularly monitored every2 hours for the first 3 days. The splint was removed after 2 weeks and the patient was encouraged to extend and flex the finger actively.Evaluation of outcomesThe active range of motion (ROM) of the proximal interphalangeal (PIP) joint and the distal interphalangeal (DIP) joint of the injured and donor digits were measured by a goniometry at the final follow-up. Semmes-Weinstein monofilament test, static and moving 2-point discrimination test was also performed to evaluate the sensory of the flap. Michigan Hand Outcomes Questionnaire (MHQ) was used to investigate the Patients satisfaction with the appearance of thehand12. Pain sensations of the injured digits were also reported by the patients with the 5-pointresponse scale. The cold intolerance of the flap was measured with the self-administered Cold Intolerance Severity Score (CISS) questionnaire13. Percussion tenderness of the fingertip was examined by gentle percussion of the fingertip area of the flap. Students t test was performed to compare the data between the injured and unaffected fingers. p<0.05 was regarded as the difference having statistical significance.ResultsGood capillary refill could be observed immediately after the surgery in all the flaps. The115120125130135color of the flap usually turned normally within 5 to 7 days. Mild venous congestion in the distal part of the flap was noticed in 3 cases and relieved in 5 days without additional management. All the flaps survived completely and the incisions healed with inconspicuous scars. The mean follow up time of the patients was 11 months (range, 912 mo) after surgery. Most of the patients regain sensation less than 2 weeks postoperatively and none of the patients experienced hypersensitivity at the reconstructed area. The mean range of motion of the PIP and DIP joints of the injured fingerwas 81.3o and 96.7o, respectively , which do not have significant difference from that of thecorresponded normal finger(83.2o and 98.6o, respectively, p>0.05). Thus, all 21 patients had near-normal range of motion of the joints of the injured digits . Semmes-Weinstein Monofilament Test displayed the mean sensitivity of the reconstructed fingertip area was 3.92 (range, 2.834.56), while that of the corresponded unaffected area was 2.55 (range, 2.362.83 ). The moving 2-point discrimination ranged from 3 to 5 mm (mean, 3.9 mm) and the static 2-point discrimination 3 to 6 mm (mean, 4.7 mm) of the flap in the pulp, respectively.According to MHQ, 20 patients were strongly satisfied with the appearance of the fingertips (score 5). Only 1 patient was evaluated as being satisfied with the appearance (score 4). No painful tips could be found. All flaps have mild cold intolerance based on the CISS (scored <25 ) and only 1 of the patients complained of mild tenderness with percussion of the fingertip . Thus, the flap provided a good tissue pad with similar color and texture and there was no donor site morbidity. All patients returned to normal daily activity or work approximately 8 weeks after surgery (Fig.2-4).FIGURE 2: A Tissue defect in the tip and pulp of the ring finger (case 4 in Tables 13). B Dissection line from the midlateral part of the ring finger. C Dissection line at the midlateral part of the opposite side. D Elevated flap with the dominant digital neurovascular bundle. E Arrow showed the rotation direction of the flap. F The flap was pivoted 90o on the bundle to cover the fingertip defect. G Skin defect at the non-dominant site was resurfaced with a full-thickness skin graft. H Glabrous skin appearance 3 month postoperatively. I Full range of flexion could be achieved 3 month postoperatively.140145150155160165170FIGURE 3: A Tissue defect in the tip and pulp of the index, middle and ring finger (case 17 in Tables 13). BFingertip and pulp defects of the index and middle finger were resurfaced with pivot flap. C Aesthetic appearance3 month postoperatively.FIGURE 4: A Tissue defect in the tip and pulp of the ring and little finger (case 18 in Tables 13). B Fingertip and pulp defects of the ring finger were resurfaced with pivot flap. C Well-padded and glabrous fingertip and pulp was achieved at 3 month postoperatively.DiscussionFingertip defects are usually accompanied with bone exposure and composite soft tissue loss. Flap or partial toe transplantation is often needed. However, the reconstruction of fingertip or pulp defect requires not only soft tissue coverage but also epicritic sensory recovery and aesthetic appearance. Flaps from dorsal part of the fingers and trunk may not have good tissue match, and most of them can only achieve protective sense recovery1-3. Partial toe transplantation requires microsurgery techniques and donor site morbidity can not be avoided. V-Y advancement flap can offer glabrous skin for limited fingertip defect. Although modification of step or stepladderprinciples may expend the coverage distance, too much advancement of the flap (>1.2cm) still lead to unrecoverable sensory disturbance of the fingertip5-8. Based on the segmental blood supply from the digital artery to the palmar skin and subcutaneous tissue of the digit with accompanied proper digital innervation, the palmar pivot flap proved to be the most suitable flap to resurface the fingertip and pulp defect11. From our study, the flap is easy to perform with quick epicritic sensory recovery, the recipient site was glabrous and well-padded, the joint motion was also not interfered. No compression necrosis and severe flap congestion was observed. The revision for bulky pedicle was also avoided. Moreover, the operation can be accomplished underlocal anesthesia.The Semmes-Weinstein values of normal fingertip or pulp ranged from 1.65 to 2.83 , the scores in our cases was 3.90. Although it was greater than that of the opposite side or normal range, it was superior to those reported flaps for fingertip coverage14-16. The moving 2- point discrimination was measured as 3.9mm and the static 2- point discrimination reached 4.7mm, both of them were less than 6mm, indicating the epicritic sensory recovery17. This is due to the direct proper digital innervation and less advancement of the neurovascular