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236
15 Reconstruction ofFinger Pulp Defects
15.5 Proper Digital Artery Island Flap
Anastomosed withDorsal Digital
Nerve
Without sacricing the main trunk of the proper digital nerve,
but the branch of dorsal digital never is cut while the ap is
removed, which anastomosed with the proper digital nerve of
the nger stump and form the reverse proper digital artery
island ap to reconstruct nger pulp. The incisional method:
The trafc branches of the two proper digital arteries are anastomosed with each other, so the lateral digital ap can be
designed at the proximal end, and the distal proper digital
artery can be the pedicle to form a reverse digital artery island
ap to repair the soft tissue defect of the nger tip. According
to the size of the wound, the ap should be designed on the
lateral and dorsal sides of the proximal and distal ends of the
middle segment. The long axis of the ap is perpendicular to
the proper digital artery, or slightly oblique to the proximal
end. The pedicle of the ap is designed into an arc or triangle,
including the proper digital artery and nerve bundle which is
about 1cm long. Most of the ap is located on the dorsal side,
and should be designed to the distal nger as far as possible.
The ap is dissociated from the distal to the proximal in the
supercial layer of the aponeurosis of the extensor digitorum
tendon. At the proximal end of the ap, the dorsal branch of
proper digital nerve is dissociated for 1cm to the proximal end
and cut off. The ap is rotated to the distal end to reconstruct
the nger pulp, and the dorsal branch of proper digital nerve of
the ap is sutured with the proper digital nerve on the other
side of the nger tip. The donor site can be covered by fullthickness skin graft (Figs.15.11, 15.12, 15.13, and 15.14).
Postoperative Treatment
After the operation, lie in bed for 7 days, continued lamp
irradiation, the blood supply of the reconstructed nger pulp
should be observed, routine treatment of “three anti” therapy,
dressing change every 2–3 days, and suture removal 2 weeks
after the operation.
15.5.1 Operation Characteristics
(a) The digital artery island ap with proper palmar artery
and nerve pedicle (mainly using ulnar ap of middle and
ring nger) to repair the defect of thumb and index nger can restore the sensory function of the two ngers,
and the color, texture, and appearance of the repaired
ap are also better.
(b) The vascular pedicle of the donor site is constant and
convenient.
(c) The operation is simple and safe without anastomosis of
blood vessels.
(d) The appearance of the reconstructed nger pulp is not
bloated, the texture is similar, the appearance is realistic,
and the better feeling can be restored.
(e) It aggravated the hand trauma and affected the hand
aesthetics.
15.5.2 Announcements
(a) This method should be used with caution in patients
with damage to one side of the proper digital artery.
Fig. 15.11 Proper digital artery Island ap anastomosed with dorsal
digital nerve
Fig. 15.12 Design of proper digital artery Island ap
Fig. 15.13 Dissociation of proper digital artery Island ap
Fig. 15.14 The appearance after the operation
15.5 Proper Digital Artery Island Flap Anastomosed withDorsal Digital Nerve
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237
(b) Noninvasive procedures should be performed to sharply
dissociate the vascular bundle and prevent the separation
of the blood vessel from the ap so as not to interfere
with blood supply.
(c) When dissociating the main trunk of the proper palmar
digital nerve, to try to retain the soft tissue around the artery,
in order to prevent injury with the accompanying veins.
(d) The vascular pedicle of the reconstructed nger pulp
should be long enough to prevent pulling, crimping or
compression during rotation and transposition.
(e) The subcutaneous tunnel should be loose, and the tunnel
can be cut open if the ap is difcult to pass through, and
then suture after the ap is transferred.
(f) Postoperative environment of patients should pay atten-
tion to heat preservation, keep quiet, strictly smoke-free
environment, and patients absolutely lie in bed for a week.
(g) The blood supply of reconstructed nger pulp should be
observed closely after the operation.
(h) Postoperative dressing change should be gentle, and
attention should be paid to the use of warm disinfectant
for disinfection and clean scab.
15.5.3 Case Description
Case 1 A 35-year-old male patient was admitted to hospital
for two hours due to pain and bleeding of the right rst to
fth ngers caused by punch injury. Physical examination:
He was in good general condition, with stable vital signs.
The right thumb and index nger were damaged from proximal segment, most of the soft tissue of the nger pulp of the
middle nger was contused and defect, and the distal segment of the ring nger was damaged. After complete emergency debridement, the rst and second ngers were
performed stump repair, the third nger was reconstructed
by dorsal metacarpal ap and the fourth nger pulp was
reconstructed by digital artery island ap. The operation was
successful, and routine reconstruction treatment was given
after the operation. Three months’ regular follow-up was
conducted to guide functional exercise. The appearance and
function of the reconstructed nger were satisfactory
(Fig.15.15).
a
d
Fig. 15.15 Reconstruction of the left ring nger pulp defect by transposition of the digital artery island ap. (a) Preoperative palmar view of
the nger defect. (b) Preoperative dorsal view of the nger defect. (c)
The palmar view of the reconstructed ngers 1 week after the operation.
b
e
c
f
(d) The dorsal view of the reconstructed ngers 1 week after the operation. (e) The palmar view of the reconstructed ngers 3 months after the
operation. (f) The dorsal view of the reconstructed ngers 3 months
after the operation
238
15 Reconstruction ofFinger Pulp Defects
15.6 Reconstruction ofFinger Pulp Defect
by Great Toe Pulp Flap Transposition
The ap is pedicled with the blood vessel and nerve of the
bular plantar of the great toe, including the ap on the bular side of the great toe. The bular plantar artery of the great
toe originates from the rst plantar metatarsal artery, which
anastomoses with the medial plantar artery in an X-shaped
intersection at the plantar side of the rst metatarsal bone.
The rst metatarsal artery is anastomosed with the deep
plantar branch of the dorsal foot artery at the proximal plane
of the rst and second metatarsal bones, which has important
clinical value. Clinically, the reconstruction of the nger
pulp defect by free great toe pulp ap is satisfactory. The
reconstructed nger pulp is similar to the original one, with
full appearance and ribbed, and can also restore sensation.
15.6.1 Surgical Design
The ap is designed in the middle or slightly dorsal side of
the bular side of the great toe, the distal end is slightly
upward from the anterior middle, the tibial side is slightly
upward from the middle or super middle of the plantar side
of the great toe, and the proximal side is made an oval mark
at the toe crease of the great toe.
15.6.2 Surgical Method
The Thumb Pulp Defect
(a) Anesthesia: It is performed under general anesthesia or
combined brachial plexus epidural anesthesia.
(b) The recipient site: In emergency cases, the wound sur-
face of the injured thumb nger should be debrided thoroughly, and the contaminated and destroyed tissues are
removed. In selected cases, the scar or dry necrotic tissue of the afxed bone should be removed to eliminate
the hook nail deformity, and the skin is separated from
the surrounding dermal margin. The obviously depressed
skin is removed and the dermal margin is trimmed. Two
thick subcutaneous veins could be carefully searched at
the proximal nger pulp and marked. An oblique incision could also be made at the radial dorsal side of the
proximal segment of the thumb to expose the dorsal
digital vein. The recipient vein should be prepared in
two ways: it can be found either in the palmar side or the
dorsal side. If no anastomotic vein can be found in the
palmar side, a thicker vein that can be anastomosed must
be found in the dorsal side. An extended incision could
be made to proximal on the ulnar side of the wound
margin to separate the normal ulnar digital artery or the
main artery of the thumb.
(c) The donor site: The ap should be designed according
to cloth pattern on the bular side of the ipsilateral great
toe. The bular plantar digital artery and nerve of the
great toe are included in the ap. After cutting open the
skin, the thick subdermal vein of the plantar side should
be carefully searched and dissociated in the proximal
incision of the plantar side, which should be dissociated
to proximal for a certain length to maintain vein continuity and network structure. If a suitable vein could not be
found on the plantar side, an extended incision could be
made along the proximal edge of the ap to the bular
dorsal side, and the small veins in the ap are carefully
dissociated to converge to the bular dorsal side to form
thicker veins. The above operation can be completed
under the naked eye, that can also be done under a magnifying glass or surgical microscope if with problems.
The dissociation of the ap is the key to the success of
this operation, and the injury must be prevented. After
dissociation of the vein, the plantar digital nerve, the
plantar digital artery, and their continuation that is dorsal
(plantar) metatarsal artery are dissociated along the
proximal bular incision of the ap to a sufcient length,
and then the ap is lifted along the incision, and at this
time the skin ap is completely dissociated except for
the nerves and vessels. The tourniquets should be relaxed
to observe the blood supply of the ap.
(d) Repair by transplantation: When the recipient site is
ready and the bleeding has been completely stopped, the
great toe pulp ap is moved to the recipient site. The position of the ap should be adjusted according to the position
of the blood vessel and nerve pedicle, and the 3-0 suture is
used to suture the skin margin of the recipient site, and the
ribbing should be aligned. The ulnar digital nerve should
be rst repaired, and then the veins and arteries are sutured
to rebuild blood supply under the microscope. The wound
is cleaned and the skin is sutured, and then the operation is
completed (Figs.15.16, 15.17, and 15.18).
The Finger Pulp Defect
(a) Anesthesia: It is performed under general anesthesia or
combined brachial plexus epidural anesthesia.
(b) The recipient site: The preparation of the wound is
basically the same as the surgical preparation of the
recipient site for the thumb defect, and the preparation of
the blood vessels in the recipient site is determined
according to the different ngers. In the case of the index
nger pulp defect, the dorsal digital vein can choose the
radial side, and the artery should be the ulnar side. On
the ring nger, the opposite choice is true. While the
middle nger is in the middle, the choice of arteries and
veins is not special.
(c) The donor site: The method of dissociation and trans-
plantation of toe aps is the same as above.
15.6 Reconstruction ofFinger Pulp Defect by Great Toe Pulp Flap Transposition
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Fig. 15.16 Flap design
Fig. 15.17 Defects of the
nger
239
Fig. 15.18 Reconstruction of
nger pulp defect by great toe
pulp ap transposition
240
15 Reconstruction ofFinger Pulp Defects
15.6.3 Operation Characteristics
(a) The length and sensory function of the nger can be
retained while it is reconstructed by the great toe ap.
The skin on the palm of the nger is dense, and the nger pulp is plump and wear resistant after the operation.
(b) The operation is complicated and good small vessel
anastomosis technique is needed.
(c) It will increase the trauma to the foot.
15.6.4 Announcements
(a) This operation is to reconstruct the nger pulp defect by
anastomosis of the digital artery and vein to rebuild
blood circulation. High microsurgical technique is
required.
(b) In the case of elective repair, since the proximal digital
artery in the nger pulp has been contracted, in order to
select the normal artery, a prolonged incision should be
made proximally to expose the normal artery for anastomosis under microscope.
(c) The key to the success of toe ap transplantation is to cut
the donor vein. The best choice is to cut the vein pedicle
that extends between the plantar side of the toe and the
dorsum of the toe to facilitate anastomosis on the dorsum of the nger. To ensure continuity and quality, it is
necessary to cut under the microscope.
(d) The feeling of the reconstructed nger pulp can be
recovered normally with ribbed and satisfactory
appearance.
(e) Vascular and nerve repair is key operation.
(f) The thicker digital artery should be chosen in the recipi-
ent site, the thumb should choose the ulnar or the main
artery, the index nger should choose the ulnar digital
artery, and the middle and ring ngers should choose the
radial digital artery.
(g) Too long vascular pedicle through the subcutaneous tun-
nel of the nger body is easy to lead to the occurrence of
postoperative crisis.
(h) Postoperative environment of patients should pay atten-
tion to heat preservation, keep quiet, strictly smoke-free
environment, patients absolutely lie in bed for a week.
15.6.5 Case Description
given, and surgical contraindications were excluded. The
thumb was performed complete debridement and repaired by
avulsed ap replantation under brachial plexus anesthesia in
emergency. The operation was successful, but the thumb
pulp was gradually black and necrotic after the operation.
After the patient’s condition is stable, the right hand debridement and free bular great toe ap transplantation of the
right foot were performed at a selected time. The operation
was successful, after the tourniquet relaxed, the reconstructed nger was ruddy with moderate tension, wrapped
with the sterile cotton, bulked, and stuffed with the broken
cotton gauze around, and he returned to the ward safely with
plaster external xation. Routine reconstruction treatment
was given after the operation. Two weeks after the operation,
the reconstructed nger survived successfully. Regular follow- up was conducted to guide functional exercise. The
appearance and function of the reconstructed nger were satisfactory. The donor site healed in the rst stage, and the
patient was satised with the appearance and function
(Fig.15.19).
Case 2 A 26-year-old male patient was admitted to hospital
in emergency for 2 h due to pain, bleeding, and movement
limitation of the right index nger caused by the machine.
Physical examination: Traumatic loss of the radial half side
of the middle and distal segment of the right index nger,
irregular skin of the stump, exposed bone and tendons, active
bleeding, moderate pollution, movement limitation, and the
blood supply for the ulnar side was normal. Complete
debridement of the right index nger was performed in emergency. Antibiotics, change dressing, and relieve pain were
performed after the operation. One week after the operation,
the wound was fresh and there was no infection. The right
index nger was reconstructed by free great toe nail ap
transplantation of the left foot, and the donor foot was
repaired by anterolateral thigh ap at a selected time. The
operation was successful, after the tourniquet relaxed, the
reconstructed nger was ruddy with moderate tension,
wrapped with the sterile cotton, bulked, and stuffed with the
broken cotton gauze around, and he returned to the ward
safely with plaster external xation. Routine reconstruction
treatment was given after the operation. Regular follow-up
was conducted to guide functional exercise. The appearance
and function of the reconstructed nger were satisfactory.
The donor site healed in the rst stage, and the patient was
satised with the appearance and function (Fig.15.20).
Case 1 A 26-year-old male patient was admitted to hospital
due to reversed avulsion of the right thumb. After admission,
routine preoperative preparation for reconstruction was
Case 3 A 27-year-old male patient was admitted to hospital in emergency for 1 h due to pain, bleeding, and bone
exposure of the left index nger caused by planer injury.
15.6 Reconstruction ofFinger Pulp Defect by Great Toe Pulp Flap Transposition
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abc
def
ghi
241
j k l
Fig. 15.19 Reconstruction of the right thumb pulp defect by free bular great toe ap transplantation. (a) Preoperative dorsal view of the
nger defect. (b) Preoperative palmar view of the nger defect. (c) The
dorsal view of the replanted thumb 10 days after the operation. (d) The
dorsal view of the replanted thumb 10 days after the operation. (e)
Preoperative design (dorsal side). (f) Preoperative design (plantar side).
Physical examination: He was in good general condition,
with stable vital signs, traumatic loss of nger pulp, irregular wound, exposed bone, and seriously polluted. After
admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were
excluded. The nger pulp was reconstructed by bular
great toe ap transplantation of the right foot under general
anesthesia in emergency, and the donor site was covered by
(g) Dissociation of the ap. (h) The palmar view of the reconstructed
nger 10 days after the operation. (i) The dorsal view of the reconstructed nger 10 days after the operation. (j) The dorsal view of the
reconstructed nger 3 weeks after the operation. (k) The palmar view of
the reconstructed nger 3 weeks after the operation. (l) The view of the
donor foot
free full-thickness skin graft. The operation was successful,
after the tourniquet relaxed, the reconstructed nger was
ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze
around, and he returned to the ward safely. Routine reconstruction treatment was given after the operation, and the
reconstructed nger survived successfully. The efcacy
was satisfactory (Fig.15.21).
242
abc
def
ghi
15 Reconstruction ofFinger Pulp Defects
j k l
Fig. 15.20 Reconstruction of the right index nger defect by free left
great toe ap transplantation. (a) Preoperative dorsal condition of nger
defect. (b) Preoperative palmar condition of nger defect. (c) The condition of nger defect after debridement. (d) Preoperative X-ray. (e)
Preoperative design of great toe nail ap. (f) Dissociation of the ap. (g)
Dissociation of the ap. (h) The dissociated great toe nail ap. (i)
Preoperative design of anterolateral thigh ap. (j) The dissociated
anterolateral thigh ap. (k) Thinning of the ap. (l) The situation of the
donor site after the operation. (m) The palmar view of the reconstructed
nger after the operation. (n) The dorsal view of the reconstructed nger after the operation. (o) The lateral view of the reconstructed nger
after the operation. (p) The local view of the reconstructed nger after
the operation. (q) The appearance of the reconstructed nger 6 months
after the operation. (r) The function of the reconstructed nger 6
months after the operation. (s) The appearance of the donor foot 6
months after the operation. (t) The function of the donor foot 6 months
after the operation
15.6 Reconstruction ofFinger Pulp Defect by Great Toe Pulp Flap Transposition
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243
m
n
pqr
st
o
Fig. 15.20 (continued)
244
abc
def
ghi
15 Reconstruction ofFinger Pulp Defects
jkl
Fig. 15.21 Reconstruction of the left index nger pulp defect by bular great toe ap transplantation of the right foot. (a) Preoperative dorsal condition of nger defect. (b) Preoperative palmar condition of
nger defect. (c) Preoperative design (dorsal side). (d) Preoperative
design (bular side of great toe). (e) Dissociation of the ap. (f) The
blood supply of the ap before cutting. (g) Transplantation of the ap.
(h) The view of the reconstructed nger after the operation. (i) The
dorsal view of the reconstructed nger 6 months after the operation. (j)
The palmar view of the reconstructed nger 6 months after the operation. (k) The function of the reconstructed nger 6 months after the
operation. (l) The appearance of the donor foot 6 months after the
operation
Reconstruction ofDorsal Digital
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Composite Tissue Defects
16
Abstract
Soft tissue defect of hand is common, when it cannot be
treated in time and effectively, they will face nger truncation or late nger body dysfunction, especially composite tissue defect involving the joint. With the development
of microsurgical techniques, there are many methods to
repair soft tissue defects in hand, but functional recovery
in the later stage is still a research topic. Due to the complexity of the anatomical structure and biomechanics of
the nger, the tension imbalance after injury, such as the
long-course disease, can lead to the occurrence of deformity, such as the buttonhole nger, hammer nger, etc.
Emergency repair of the defect and functional reconstruction is of great signicance.
Keywords
Finger reconstruction · Dorsal digital composite tissue
defect
16.1 Indications
Joint is an important functional area of the limb, and its subcutaneous tissue is less, located in the exposed part, so the
application of a free skin graft is not only difcult to survive
but also easy to form scar, affecting the function of the joint;
The application of pedicled chest and abdomen ap can
cover a large area, but the patients need to be xed for 3–4
weeks, which brings great inconvenience and affects the
recovery of joint function;
The application of a perforator ap for transplantation
and repair has also achieved a good effect, but it is limited
due to the complicated operation of some ap transplantation, insufcient pedicle length, bloated recipient site, difcult to close the donor site directly, and the phenomenon of
different degrees of atrophy of the ap in the later stage;
In the treatment of defective wound surface by emergencyfree composite tissue ap transplantation combined with 1/2
extensor digital tendon of toe, can not only repair the wound
surface in the rst stage but also rebuild the function of
extensor nger. The advantages are: (a) The application of
tendon with blood supply and intact peri-tendon tissue, the
suture site of tendon transplantation can heal early and have
a certain strength, patients can take the initiative to exercise
early to reduce adhesion; (b) The ap contains supercial
peroneal nerve and has a good feeling; (c) The skin of the
dorsum of the toe is close to that of the nger, and its texture
and shape are excellent. However, this method is difcult to
operate, there is a certain risk of failure, which requires the
operator to have a more in-depth study of the anatomy, functional characteristics, and main uses of various aps.
16.2 Surgical Design
After debridement, the ap is designed on the dorsal side of
the second foot on the ipsilateral or contralateral side of the
injured hand, with the dorsal metatarsal artery as the axis
(including 1/2 digitorum tendon longus and cutaneous
branch of supercial peroneal nerve). The size and shape of
the ap and whether the tendon is removed depend on the
recipient site.
16.3 Surgical Method
(a) Dissociation of the ap: The ap should be cut accord-
ing to the preoperative design. The proximal ap incision is made rst, and the skin and subcutaneous tissue
are cut from proximal to distal to expose the dorsal
metatarsal artery and vein. After identifying the course
of the dorsal metatarsal artery, a lateral incision is made
to separate the cutaneous branch of the supercial pero-
© Springer Nature Singapore Pte Ltd. 2023
J. Lin et al., Atlas of Finger Reconstruction, https://doi.org/10.1007/978-981-19-9612-2_16
245
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