The Volar V-Y Advancement (Atasoy or Kleinart) Flap

This flap is used for distal fingertip defects oriented in a dorsal oblique or transverse fashion, measuring <1 cm, usually with exposed bone. The volar triangular flap is oriented with the apex at the distal interphalangeal crease ( Fig. 20.1 ). The skin is incised full thickness. Blunt dissection with spreading of the tissue in the direction of vascular inflow into the flap is performed until the tissue advances to cover the defect. The donor site is sutured to provide a V-Y, tension free closure ( Fig. 20.2 ). Flap length is 1.5–2 times the width, and width is limited to that of the nail bed to prevent tip flattening. This flap provides durable, glabrous, sensate skin for coverage. The flap is limited to cover smaller defects usually <1.5 cm in size. Potential complications include cold intolerance, scarring, and sensory changes.

Fingertip defect reconstructed with a volar V-Y flap. The flap is designed broadly at the distal end and peaks at the distal interphalangeal joint crease. The dissection preserves the vascularity that arises from each digital vessel on the ulnar and radial side of the digit.

The defect in the fingertip is seen following reconstruction with a volar V-Y flap. The donor site is closed primarily.

Lateral V-Y Advancement (Kutler) Flaps

Transverse and dorsal oblique defects of the fingertip can occasionally be closed with a laterally based V-Y advancement with the apex at the DIP joint ( Fig. 20.3 ). It is oriented to be at least 2–3 mm from the nail folds dorsally, with a more thorough dorsal dissection to release the fibrous septae, while preserving the more volar neurovascular contributions. This again provides vascularized, sensate coverage but is severely limited in advancement to about 0.5–0.75 cm.

(A,B) Fingertip defect reconstructed with bilateral lateral V-Y flaps raised in a similar fashion to the volar V-Y flap but because of fibrous septae, limited advancement is achieved.

The Volar Advancement (Moberg) Flap

This flap is most often used for the thumb. Radial and ulnar midaxial incisions are made on either side of the thumb. The flap is elevated in the plane above the tendon sheath incorporating both the neurovascular bundles in the fasciocutaneous flap. The Moberg flap offers up to 2 cm of advancement to cover distal thumb defects. Occasionally the interphalangeal joint needs to be flexed to allow the flap to be inset into the remaining nailbed. The interphalangeal joint extends over time, stretching the flap as it does so. The Moberg advancement flap provides well-vascularized, glabrous, sensate coverage ( Fig. 20.4 ). There has been a number of modifications of the Moberg that are employed to provide a little more length to the advancement. The flap can be advanced as a V-Y flap where the apex is at the volar, proximal thumb crease. Alternatively, a transverse incision can be made in the skin at the proximal thumb, the tissue spread to release the tension from the more proximal palmar skin. A skin graft is then used to close to proximal donor defect as the flap advances distally. The Moberg, volar advancement flap as described is not typically used for other digits of the hand as it may cause flexion contractures of the finger.

(A–C) Tip of thumb defect reconstructed with a Moberg V-Y flap. The flap is elevated at the skeletal plane just above the flexor pollicis longus tendon and sheath. The distal phalanx is flexed to accommodate greater advancement.

The Cross Finger Flap

The cross for your flap offers a two-stage approach to reconstruction of the volar and dorsal aspect of digits including the fingertip. The classic cross finger flap utilizes the skin and subcutaneous tissue on the dorsum of the adjacent finger at level of the middle phalanx. It is based on the dorsally migrating vessels that arise from the volar digital arteries. The venae comitantes and other superficial veins are left within the flap. Occasionally, sensory nerves can also be incorporated in the flap to provide sensation. The flap is elevated at the level of the paratenon which must be kept intact for a skin graft to be utilized over the donor site once the flap is inset. Just as in a page of a book, the flap is folded over to cover the volar defect of the adjacent finger ( Fig. 20.5 ). The flap will remain attached to the donor and the recipient fingers for 2–3 weeks, when the flap is divided and inset. The donor site is covered with a split thickness skin graft and the bolster dressing applied for the first week to provide adequate engraftment.

(A–C) Mangled fingertip of the index finger closed with a cross finger flap from the dorsum of the adjacent finger.

The reverse cross finger flap is used to cover dorsal defects on the adjacent finger. The flap is outlined on the dorsum of the donor finger but is de-epithelialized before it is transposed to the adjacent finger. A split thickness skin graft is used to cover the undersurface of the exposed flap as well as the donor site. The flap is divided and inset at 2–3 weeks.

The Thenar Crease Flap

The thenar crease flap employs the skin from the volar aspect of the thumb at the level of the metacarpal phalangeal joint. The flap is based on the radial aspect of the thumb and can measure 1.5 cm in width and up to 2 cm in length ( Fig. 20.6 ). The digit with the fingertip defect is flexed down towards the elevated flap which is sutured in place. The base of the flap is divided in 2–3 weeks. The thenar crease flap is insensate and may result in flexion contractures to the recipient finger if used in adults.

(A,B) Third fingertip defect reconstructed with a thenar crease flap. The flap is based on the radial volar aspect of the metacarpophalangeal joint of the thumb.

Homodigital and Heterodigital Flaps

Homodigital and heterodigital flaps are usually axial flaps that are elevated in and antegrade or retrograde fashion, based on the digital artery ( Figs 20.7 , 20.8 ). Care must be taken to preserve the digital nerves so that sensation to the distal aspect of the donor finger is not compromised.

(A–C) Dorsal defect over PIP joint reconstructed with a heterodigital flap. The flap is raised on the digital artery and moved as a transposition or an island flap. The digital nerve is left in situ.

(A,B) Distal 2nd and 3rd finger defects reconstructed with small heterodigital flaps.

The Thoraco-Epigastric Flap

It is very uncommon in current surgical practice to apply the principles of the thoraco-epigastric flaps for closure fingertip injuries. Small flaps are raised on the trunk to allow the fingertips to be sutured to them ( Fig. 20.9 ). The patient must hold their arm in the position shown for 2–3 weeks until the flap is divided; these flaps are often bulky and remain insensate.

(A–C) Thumb defect reconstructed with a pedicled thoracoepigastric flap. Debulking is performed to achieve a good contour.

The Free Toe Pulp Flap

The free toe pulp flap utilizes the lateral aspect of the great toe but incorporates the glamorous skin, subcutaneous tissue, and neurovascular bundle. The flap is harvested as a free tissue transfer ( Fig. 20.10 ). Although this flap replaces the defect in the finger with like tissue, it does involve greater technical skills of fine microsurgery. Potential pitfalls include complete loss of the flop due to thrombosis in the anastomosed vessels, poor sensibility recovery, or neuroma formation. Patients may also need to be hospitalized for 5–7 days until the fate of the flap is fully known.

(A–C) Volar thumb defect reconstructed with a free toe pulp flap. The nerves and vessels are anastomosed in the anatomic snuffbox.

(Courtesy SIU photo archives.)

The Dorsal Metacarpal Artery Flap

The first dorsal metacarpal artery flap is used primarily to provide durable sensate tissue to the volar aspect of the thumb. The flap incorporates the first dorsal metacarpal artery that lies within the fascia of the first dorsal interosseous muscle ( Fig. 20.11 ). The artery and superficial veins provide the inflow and venous drainage of the fasciocutaneous portion of the flap which is taken from the dorsal aspect of the proximal phalanx on the index finger. The pedicle is dissected proximally to a point where the flap can be transposed either through a tunnel or through open access to the volar thumb. The arc of rotation of the flap makes it extremely versatile to cover not only the volar thumb but also dorsal aspect of the thumb and hand. Sensation is provided by branches of the superficial radial nerve.

(A–D) A volar thumb defect reconstructed with a dorsal metacarpal artery flap.

The reverse dorsal metacarpal artery flap can also be utilized to cover defects on the dorsal or volar aspect of the digits and even fingertip. The flap is based at the level of the metacarpal phalangeal joint in the web space, where perforating vessels from the Palmer vasculature communicate with the dorsal metacarpal artery system. The flap is therefore a distally based flap ( Fig. 20.12 ). The superficial veins must be incorporated in the flap to provide adequate venous outflow. The skin paddle is taken from the proximal aspect of the dorsum of the hand in between the metacarpals. A 1 cm wide strip is fashioned that includes the dorsal metacarpal artery must be taken to prevent vascular compromise to the flap. A Doppler must be used to identify the dorsal metacarpal artery prior to elevation of the flap. The more ulnar the dorsal metacarpal artery the less reliable its presence is within the fascia. The reverse dorsal metacarpal artery flap may be prone to venous congestion because the venous blood is forced to drain retrograde. Loose closure of the flap may help the flap until it redirects the outflow. Alternatively, a superficial dorsal vein could be anastomosed in the digit.

(A–C) Distal dorsal 4th finger defect reconstructed with a reverse dorsal metacarpal artery flap. The other two defects were reconstructed with skin grafts.