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Fig. 27.1 Latex infused picture demonstrating the anatomy of the
blood supply and arches of the nger and hand. (Picture courtery of G
Patanis, D Song, Z Yumao, see chapter 51 Cadaveric Flap Anatomy
section)
1mm proximally to 0.5mm at the level of the distal interphalangeal joint (DIPJ). Lai’s line (which is the junction of
the darker dorsal skin and the volar lighter skin on the digit)
is a useful surface landmark for the digital artery.
Interconnections between the radial and ulnar digital
arteries form the anatomic basis and feasibility of many digital aps (as seen in Fig.27.1). Transverse palmar arches connect the digital arteries at relatively constant locations, deep
to the exor tendons:
1. Proximal arch: C1 pulley
2. Middle arch: C3 pulley
3. Distal arch: just distal to the FDP insertion
The middle and distal arches are larger in caliber than the
proximal and facilitate retrograde vascular ow into distally
based aps. Multiple small palmar branches arise from each
digital artery, usually laterally, and run in the subcutaneous
tissue. These provide the perfusion to the palmar skin islands
mobilized in some homodigital aps. Three dorsal branches
arise from each digital artery to supply the dorsal digital skin
and anastomose with their contralateral counterparts to form
arcades on the dorsum of the nger. There is also a rich network of vessels arising from the distal transverse arch at the
ngertip.
The supercial palmar arch gives rise to three common
digital arteries, which anastomose with corresponding palmar metacarpal branches from the deep palmar arch. Around
the level of the metacarpophalangeal joint, each common
S. Rinko et al.
digital artery bifurcates into the proper digital arteries, which
run into adjacent digits (from the ulnar aspect of the index to
the radial aspect of the little nger). The border digits have
more variable vascular anatomy, but usually the radial digital
artery of the index nger (radialis indicis) arises from the
radial artery as it becomes the deep palmar arch. The ulnar
digital artery to the little nger usually arises from the supercial palmar arch directly. The heterodigital island ap can
be mobilized as proximally as the origin of the supplying
vessel from the supercial palmar arch, and this enables their
transposition to defects that may lie further than just an adjacent digit.
Venous drainage of the nger is via dorsal and palmar
systems. The dorsal system is dominant, with a more constant arrangement of longitudinal subcutaneous veins and
numerous interconnections. The palmar longitudinal veins
are venae comitantes accompanying the digital arteries;
these form the venous drainage of most homodigital island
aps.
The digital nerve can be differentiated from the artery
by its pearly white consistency and the presence of Pacinian
corpuscles. A dorsal branch arises which may run either
deep or supercial to the digital artery and in most cases
arises proximal to the proximal digital exion crease Lai
etal. [7]. It courses obliquely to innervate the lateral skin
over the proximal phalanx (from which the reverse
homodigital island ap is fashioned) and the dorsal skin
over the middle phalanx. The skin overlying the metacarpophalangeal joint (MCPJ) which is included in an
extended reverse homodigital ap is supplied by the supercial sensory branch from the corresponding radial or ulnar
nerve.
In Littler’s original description of the heterodigital
island ap, the digital nerve on the donor nger was transected and incorporated into pedicle of the ap.
Modications of this have been described. Rose etal. [8]
recommended preserving the nerve in the donor digit. To
eliminate double sensibility, coapting the transected nerve
has been suggested; however, the problem of the loss of the
digital nerve in the donor digit remains. To avoid this, Lee
etal. [1] described a lateral middle phalangeal nger ap
where the proper digital nerve (PDN) for the donor digit
was left intact. They dissected fascicles from branches of
the PDN and the dorsal branch of the PDN (DBPDN) and
coapted these to the nerve stumps of PDNs at the recipient
nger. This can be visualized in Fig.27.2; in image c the
heterodigital island ap is raised on the digital artery with
the DBPDN, and in image d this has been coapted to the
ulnar digital nerve stump of the thumb. More recently,
Wang etal. [9] suggested including the PDN and DBPDN
in the ap and bridging the donor nerve defect with a nerve
graft taken from the remaining proximal portion of the
DBPDN.
27 Digital Artery Flaps: Homodigital and Heterodigital Island Flaps
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261
Fig. 27.2 (a–d) Illustrate a
heterodigital island ap
neurotized with the DBPDN
for thumb reconstuction
(illustration by Julia Ruston)
ab
cd
27.3 Preoperative Investigation
side of the digit. The patency of both digital vessels can be
conrmed with a digital Allen’s test. For a heterodigital
The digital artery can be identied through palpation or the
aid of a ne Doppler probe. As this ap requires you to sacrice one of the digital arteries, it is important to check there
has been no injury to the digital artery on the contralateral
island ap, the adjacent digit should also be assessed, as the
donor digital artery may need to be dissected proximally to
its origin from the supercial palmar arch, and this necessitates ligation of the digital artery to the adjacent nger (at the
262
bifurcation of the common digital artery). To perform a digital Allen’s test, ask the patient to ex and extend their nger
repeatedly while the digital arteries are compressed to
achieve blanching of the nger; blanching of the nger will
persist while compression is maintained on the digital arteries. Testing both ulnar and radial digital arteries separately,
release of compression on one digital artery should cause the
nger to become pink if the artery is patent; however if it is
occluded, the nger will remain blanched.
27.4 Flap Design andMarkings
27.4.1 Reverse Homodigital Island Flap
Lai’s line can be used to mark the location of the digital
artery preoperatively. The defect is templated and mapped on
to the lateral aspect (radial or ulnar) of the proximal phalanx
of the affected digit. Either a zigzag or a midaxial skin incision over the lateral border of the nger can be used, and this
is marked preoperatively, between the ap and the defect (as
in Fig.27.3).
For the middle and ring ngers, the ap is usually elevated from the same side as the defect of the involved digit.
This allows less stretching of the pedicle during transposition. For the index and little nger, the preference is the ulnar
side and radial side of the proximal phalanx, respectively.
S. Rinko et al.
Fig. 27.4 Skin markings for a heterodigital island ap to thumb defect
27.4.2 Heterodigital Island Flap
Lee etal. described a heterodigital island ap known as the
mid-lateral phalangeal ap. They suggested basing the ap
on the lateral ulnar side of the middle phalanx of the middle
nger for a thumb defect and on the lateral ulnar side of the
ring nger for a little nger defect, according to the size and
shape of the pulp defect. The ap is centered on the mid-
Fig. 27.3 Demonstrates a volar oblique amputation of the RMF pulp
lateral line of the donor nger and extends from the middorsal line to the mid-palmar line and from the proximal
interphalangeal joint to the distal interphalangeal joint.
A palmar zigzag incision is drawn, to allow dissection of
the pedicle to the level of the common digital artery or to the
supercial palmar arch (as in this case).
Figure 27.4 shows the skin markings for a heterodigital
island ap to thumb defect. The ap is marked on the lateral
ulnar aspect of the middle phalanx, and a zigzag excision
extends on the lateral border of the digit to meet the palmar
incision.
27.5 Flap Raise/Elevation: AStep-by-Step
Guide
27.5.1 Reverse Homodigital Island Flap
Dissection of reverse homodigital island ap
(Fig.27.5)
1. Skin is incised along the markings and skin aps raised
in the subcutaneous plane, to facilitate exposure of the
neurovascular bundle. The ap, overlying the lateral
border of the proximal phalanx, is incised and the neurovascular bundle is identied rst proximally.
27 Digital Artery Flaps: Homodigital and Heterodigital Island Flaps
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Fig. 27.5 Dissection of a
reverse homodigital island
ap
2. The nerve and artery are carefully separated, and the
nerve is retracted in the palmar direction Fig 27.5, to
preserve it. The dorsal branch of the digital nerve can
be preserved, but may also be raised with the ap and
subsequently coapted with a digital nerve distally in
the defect using 9.0 Nylon (a neurotized homodigital
island ap).
3. The digital artery is ligated proximally and divided.
4. Dissection deep to the artery allows gradual elevation
and mobilization of the ap and the pedicle. As dissection progresses distally, deep and dorsal branches of
the artery are divided, and a cuff of adipofascial tissue
is maintained around the pedicle to preserve venous
drainage. The artery itself is not well visualized in the
dissection (rather just tethering branches as they are
encountered) to avoid skeletonizing the vessel.
5. Caution should be taken in the vicinity of the transverse arches, as these form the pivot point for the ap
and must not be injured. The middle or distal can be
used depending on the length of pedicle required for
the ap to reach the defect—dissection to the most distal arch results in a longer pedicle.
6. Once pedicle length is adequate to rotate 180° into the
defect without tension, stop dissection (there is no need
to dissect all the way to the distal arch if the pedicle
length is adequate; this minimizes risk of inadvertent
damage).
Flap inset and closure (Fig.27.6)
7. The ap is inset at the ngertip with loose sutures to
minimize compromise from postoperative swelling of
the skin paddle.
8. A full-thickness skin graft is inset to the donor defect
proximally, and the skin incision is closed.
9. The pedicle can be covered with remaining skin graft
or left open (closure of the skin is usually not possible
over the pedicle, without compression). As healing
263
Fig. 27.6 Reverse homodigital island ap inset and closure
occurs, this contracts with time. In Fig. 27.6 a jelonet
tie-over dressing is used to bolster the graft and
Kaltostat covers the graft donor site.
27.5.2 Heterodigital Island Flap
Dissection of the ap (Fig.27.7)
1. The ap is dissected from the exor sheath/periosteum
of the middle phalanx and the digital artery is divided
distally. Care is taken to preserve the proper digital
nerve (as pictured).
Dissection of the DBPDN and the pedicle
(Fig.27.8)
2. The dorsal branch of the proper digital nerve is taken
with the ap; this allows it to be coapted to the digital
nerve at the recipient site. The digital artery is dissected to the supercial palmar arch– with ligation of
the radial digital artery to the ring nger in this case, at
its origin from the common digital artery.
264
S. Rinko et al.
Length of the pedicle is tested (Fig.27.9)
3. The length of the pedicle is tested to check it can reach
the recipient site without tension at the thumb tip.
The ap is passed under a tunnel of skin to the
thumb tip (Fig.27.10)
4. A silk suture is used to aid the passage of the ap
through a subcutaneous tunnel to the thumb
Perfusion of the ap is checked (Fig.27.11)
5. The tourniquet is released so that perfusion of the ap
can be checked and haemostasis performed.
The ap is secured in place and a FTSG sutured to
donor site (Fig.27.12)
6. The ap is secured in place, a full-thickness skin graft
inset into the donor site and the remaining skin incisions sutured.
Fig. 27.7 Dissection of the heterodigital island ap
Fig. 27.8 Dissection of the DBPDN and the pedicle for heterodigital
island ap Fig. 27.9 Pedicle length is tested for a heterodigital island ap
27 Digital Artery Flaps: Homodigital and Heterodigital Island Flaps
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265
Fig. 27.10 The heterodigital island ap is passed under a tunnel of
skin to the thumb tip
Fig. 27.11 Perfusion of the heterodigital island ap is checked
Fig. 27.12 Heterodigital island ap is secured in place
27.6 Core Surgical Techniques
27.6.1 Reverse Homodigital Island Flap :
Surgeon Dariush Nikkhah
This ap is most easily raised using an arm tourniquet and
loupe magnication under regional or general anesthesia.
The wound is thoroughly cleaned and debrided. The skin
markings are incised. Firstly, the ap over the lateral border
of the proximal phalanx and the skin incisions on the lateral
border of the digit are extended distally to the defect.
The main digital nerve is identied as can be seen in
Fig.27.5 and preserved. The ap is dissected free preserving
a cuff of soft tissue around the artery, preserving venous
drainage of the ap. The senior author uses ne microsurgical
instrumentation for dissection of the nerve away from the
digital artery, including microscissors and ne-handled tenotomies. For vessel side branches, one can use bipolar with heat
sinking technique or microligaclips to avoid thermal injury to
the main digital artery. Once the ap is dissected, the digital
artery is ligated and divided proximally. The ap can then be
raised on the pedicle and inset into the defect.
266
Fig. 27.13 Six-month post-op outcome for a heterodigital island ap
S. Rinko et al.
The arc of rotation is centered on the distal transverse palmar arch at the distal interphalangeal joint, giving the ap a
wide reach in a variety of clinical situations. The ap can be
sensate if the dorsal sensory branch is included in the skin
paddle. In Fig.27.6 you can see the ap inset at the ngertip;
a skin graft has been harvested from over the hypothenar
eminence and has been inset over the ap donor site. The
skin graft can be harvested from other sites but if using the
groin, avoid taking hair-bearing skin.
27.6.2 Heterodigital Island Flap : Surgeon
Dariush Nikkhah
This procedure should be done under general or regional
anesthesia with tourniquet control. In this example which
demonstrates a mid-lateral phalangeal ap, the ap is raised
from the ulnar side of the middle nger (donor) over the
middle phalanx.
A zigzag incision is made from the distal margin of the
exor retinaculum in the palm to the nger web, and then a
lateral zigzag incision extends up the digit. The pedicle is
raised carefully in a retrograde fashion, protecting a 5mm
cuff of adipofascial tissue around the artery. This is important (as with homodigital artery aps) for venous drainage
of the ap. Gentle traction on the pedicle allows visualization of nerve and vessel branches to the exor tendon and
joints which are divided. The branch of the common digital
artery to the ring nger is ligated, and the common digital
artery is dissected as far proximally as the supercial palmar arch. This is the pivot point. As with the reverse
homodigital island ap, side branches of the artery can be
clipped with microligaclips, or bipolar with heat sink technique can be used.
A stitch secured to the ap is used to aid its passage
through the subcutaneous tunnel from the donor site to the
recipient site (thumb tip). Once the ap is in place, the pedicle is checked for any evidence of tension or kinking. The
tourniquet is released to check perfusion and perform hemostasis prior to closure. A FTSG from the forearm was sutured
to the defect on the donor nger. A jelonet bolster has been
used to secure the FTSG.
Figure 27.13 shows the outcome at 6months post-op for
this patient. The patient had protective sensation.
27.7 Clinical Scenario
27.7.1 Reverse Homodigital Island Flap :
Surgeon Dariush Nikkhah
An 18-year-old woman sustained a burn to the right index
nger, while cooking. After debridement she was left with a
full-thickness defect over the distal interphalangeal joint
(Fig.27.14).
This was an isolated injury and the patient was otherwise
well and a nonsmoker. A reverse homodigital island ap
from the ulnar border of the proximal index provided robust
and padded soft tissue cover (Fig.27.15).
The wound had healed at 2weeks and the patient had an
uneventful recovery (Fig.27.16).
27.7.2 Heterodigital Island Flap : Surgeon
Dariush Nikkhah
A 50-year-old man required multiple washouts for a exor
sheath infection of his index nger, with resultant skin loss
27 Digital Artery Flaps: Homodigital and Heterodigital Island Flaps
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Fig. 27.14 Injury to the nger with defect over DIPJ
267
Fig. 27.15 Intraoperative view showing reverse homodigital island
ap to defect
over the volar aspect of the middle phalanx. Following resolution of the infection, he had a defect with exor tendon
exposed. Using the principles described previously, a heterodigital island ap was designed based on the radial digital
artery of the middle nger, to cover the defect on the index
Fig. 27.16 Two-week postoperative outcome for reverse homodigital
island ap
Fig. 27.17 Skin markings for heterodigital island ap
nger. The donor site in this case was closed primarily due to
skin laxity.
Figure 27.17 shows the index nger defect, with
exposed tendon and skin markings for a heterodigital
island ap.
Figure 27.18 shows how the ap is raised on the radial
digital artery of the middle nger and is ready to be inset into
the defect (Fig.27.19). The digital nerve from donor nger is
still intact (seen retracted with skin ap).
268
Fig. 27.18 Heterodigital island ap is raised and ready to be inset
Fig. 27.19 Final ap inset to cover index nger, donor site closed
primarily
27.8 Pearls andPitfalls [10–18]
S. Rinko et al.
• If there is concern about the blood supply from
the contralateral digital artery, the ipsilateral digital artery can be initially clamped to check the
blood supply to the digit before it is ligated and
divided.
• When performing a mid-lateral phalangeal ap,
make the subcutaneous tunnel wide, and use a
silk suture to aid passing the ap through the
tunnel.
• For a heterodigital island ap, avoid the need for
sensory reeducation and donor numbness by preserving the main digital nerve on the donor nger
and taking just the dorsal branch.
• Use a thick FTSG skin graft to close the donor site.
Pitfalls
• Avoid skeletonizing the pedicle as this may result in
damage of the venous drainage or vascular supply
of the ap.
• A reverse homodigital island ap needs to be inset
loosely to avoid compression of the pedicle, which
usually leads to venous compromise of the ap.
Leaving the area of the pedicle open or applying a
small split-thickness graft will avoid ap loss.
• If reconstructing the ngertip with a retrograde
homodigital island ap, make sure the distal arch is
intact, and if there is any question that it is compromised, a homodigital ap should not be performed.
• Avoid performing antegrade and retrograde
homodigital aps on infected or vascularly compromised digits as this may compromise the digit
further.
• Make sure the patient understands the donor site
from a heterodigital island ap is unsightly, and
offer them microsurgical alternatives (hand or foot).
Pearls
• For a reverse homodigital island ap, identify the
digital nerve rather than the artery rst, and start
proximal to the ap. It is then dissected free from
the adipofascial tissue that surrounds the artery. The
ap can then be raised quicker and without the need
to hunt for the digital artery.
• Elevating the hand postoperatively can help reduce
venous congestion.
27.9 Selected Readings
• Lai etal. The Reverse Digital Artery Flap for Fingertip
Reconstruction. Ann Plast Surg. 1989 Jun;22(6):495–500.
doi: 10.1097/00000637-198906000-00005.
• This is the original paper describing the reverse homodig-
ital island ap. It describes the anatomy and relationship
of the digital artery and nerve. It describes how to raise
27 Digital Artery Flaps: Homodigital and Heterodigital Island Flaps
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269
and inset the ap. It describes a case series of 11 patients
2. Venkataswami R, Subramanian N.Oblique triangular ap: a new
for which this ap was used.
• Lai etal. A Versatile Method for Reconstruction of Finger
3. Lai CS, Lin SD, Yang CC. The reverse digital artery ap for n-
Defects: Reverse Digital Artery Flap. Br J Plast Surg.
Aug-Sep 1992;45(6):443–53. doi:
10.1016/0007-1226(92)90208-f.
4. Kojima T, Tsuchida Y, Hirasé Y, Endo T.Reverse vascular pedicle
• This paper describes in more detail the reverse homodigi-
tal island ap. It includes a cadaveric dissection examin-
5. Koshima I, Urushibara K, Fukuda N, Ohkochi M, Nagase T, Gonda
ing the anatomy of the dorsal sensory nerve. It also
describes an extended ap and an innervated ap.
• Kojima et al. Reverse Vascular Pedicle Digital Island
6. Haerle M, Häfner HM, Schaller HE, Brunelli F.Dominances in
Flap. Br J Plast Surg. 1990 May;43(3):290–5. doi:
10.1016/0007-1226(90)90074-a.
• This paper also describes a reverse homodigital island
7. Lai CS, Lin SD, Chou CK, Tsai CW. A versatile method
ap. It describes eight ngers in which this ap was used.
• Tan R E S & Lahiri A.Vascular Anatomy of the Hand in
Relation to Flaps. Hand Clin 2020 (36) 1–8.
• Detailed review of anatomical studies of vasculature of
the whole hand.
8. Rose EH.Small ap coverage of hand and digit defects. Clin Plast
9. Wang H, Yang X, Chen C, Huo Y, Wang B, Wang W. Modied
• Littler JW. Neurovascular pedicle transfers of tissue in
reconstructive surgery of the hand. J Bone Joint Surg.
1956, 38A: 917.
10. Ashbell TS, Kutz JE, Kleinert HE. The digital Allen
• This is Littler’s original description of elevating an island
ap.
• Lee et al. Innervated Lateral Middle Phalangeal Finger
Flap for a Large Pulp Defect by Bilateral Neurorrhaphy.
Plast Reconstr Surg 2006 Oct;118(5):1185–93; doi:
11. Littler JW.Neurovascular pedicle transfers of tissue in reconstruc-
12. Moberg E. Aspects of sensation in reconstructive surgery of the
13. Moledina J, Reissis D, Nikkhah D. Maneuvers to aid rais-
10.1097/01.prs.0000221002.75057.a4.
• This describes the mid-lateral phalangeal ap demon-
strated in the step-by-step guide in this chapter.
• Wang etal. Modied Heterodigital Neurovascular Island
14. Niranjan NS, Armstrong JR. A homodigital reverse pedi-
Flap for Sensory Reconstruction of Pulp or Volar Soft
Tissue Defect of Digits. J Hand Surg Am 2020
Jan;45(1):67.e1–67.e8. doi: 10.1016/j.jhsa.2019.04.014.
15. Tan RES, Lahiri A.Vascular anatomy of the hand in relation to
Epub 2019 Jun 22.
• This describes the techni\que of using the proximal
DBPDN as a nerve graft for the transected donor PDN.
16. Tubiana R, Duparc J.Restoration of sensibility in the hand by neu-
17. Weeks PM, Wray RC. Management of acute hand injuries. St.
18. Xarchas KC, Tilkeridis KE, Pelekas SI, Kazakos KJ, Kakagia
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