COMBINED IPSILATERAL AND CONTRALATERAL SECOND TOE FLAPS FOR REPAIR OF FINGER DEGLOVING INJURY GUANGLIANG ZHANG, M.S., JIHUI JU, M.B., QIANG ZHAO, M.B., XIANGJUN LI, M.B., GUANGZHE JIN, M.B., LINFENG TANG, M.S., and RUIXING HOU, M.D.*
Purpose: The purpose of this report was to retrospectively review the results of treatment of degloving injury of the finger by use of combined ipsilateral second dorsal nail-skin flap and contralateral medial second toe flap. Methods: From 2010 to 2012, seven fingers in seven patients with complete degloving injuries from the level of middle or distal phalanx were reconstructed with combined ipsilateral second dorsal nail-skin flap and contralateral medial second toe flap. The injured fingers included the index finger in four cases, and middle finger in three cases. The nerves of both the flaps were sutured to the bilateral common digital nerves. The donor site of second toe flap was covered with a full-thickness skin graft. Results: All transferred flaps survived after surgery, and all postoperative courses were uneventful. During the follow-up period (mean of 15 months; ranging 6–20 months), the appearance of the reconstructed fingers was comparable with normal ones. The range of motion of the distal interphalangeal joint averaged 55 6 5.8 degrees. The two point discrimination of the pulp ranged from 8 to > 15 mm (average, 11.3 mm). All the patients were able to walk without difficulty. The MHQ score averaged 59 6 4.2 points and Maryland foot rating score averaged 92 6 4.2 points. Conclusion: The ipsilateral second toe dorsal nail-skin flap combined with contralateral medial second toe flap may provide an alternative for the reconstruction of completely degloved fingers at the middle C 2014 Wiley Periodicals, Inc. Microsurgery 34:540–546, 2014. and the distal phalangeal level, with satisfactory functional and cosmetic results. V
Resurfacing after a total degloving injury to the finger is one of the most difficult problems to manage in hand surgery.1 Replantation can result in good function and appearance in selected patients,2 but the surgeon should verify whether the degloved part is replantable, and only when the degloved skin is deemed non-replantable should some form of flap coverage be considered. Conventional methods such as skin grafts or local or tubed pedicled flaps cannot always ensure satisfactory coverage of such defects. The ultimate goal is not only the survival of the injured fingers but also a favorable functional recovery and appearance. Toes and fingers have a similar structure, so partial toe tissues transplantation can meet the above needs. In 1980, Morrison et al.3 reported the use of a free hallux toe wrap-around flap and an iliac crest bone graft to reconstruct the thumb and achieved satisfactory results. Hou et al.4 used a free wrap-around flap from the second toe to reconstruct a complete degloving injury of the finger at the middle and the distal phalangeal level with a satisfactory result. However, the method requires sacrifice of the second toe.5 To avoid sacrificing the toe, Rui et al.6 designed a free wrap-around flap from the hallux toe combined with a flap from the medial side of the second toe for the reconstruction of the degloved fingers and has reported satisfactory functional and cosmetic results. However, the donor site morbidity is not insignifDepartment of Hand Surgery, Ruihua Affiliated Hospital of Soochow University, Suzhou 215104, China *Correspondence to: Ruixing Hou. E-mail: [email protected] Received 24 March 2013; Revision accepted 11 March 2014; Accepted 14 March 2014 Published online 1 April 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22253 Ó 2014 Wiley Periodicals, Inc.
icant and the reconstructed finger is dissimilar to the contralateral normal finger. To further decrease the donor site morbidity of foot and improve the appearance of the reconstructed finger, based on Rui’s6 technique, we design a free dorsal nailskin flap from ipsilateral second toe combined with a flap from the medial side of contralateral second toe for the reconstruction of the degloved fingers. In this report, we present our experience on seven patients of seven fingers reconstructed with the combined flaps. PATIENTS AND METHODS
From 2010 to 2012, seven fingers in seven patients with complete degloving injuries were reconstructed with combined ipsilateral second toe dorsal nail-skin flap and contralateral medial second toe flap. There were four males and three females with an average age of 20 years (range, 17–27 years). The cause of injury was an industrial machine injury in six cases, and wringer injury was in one case. The skin was avulsed from the middle phalangeal level in six cases, and from the distal phalangeal level in one case. Patient demographic and surgical data are summarized in Table 1. Indications for the procedure were only one finger required to be repaired and the necessity of preserving finger length and restoring aesthetic appearance. Patients with systemic diseases such as diabetes mellitus, vascular disease, and heavy smoking histories and those with multiple degloved fingers were excluded from the surgery. Operative Techniques
Brachial plexus block and epidural anesthesia were used in all cases. After a tourniquet was placed on the
97 56 10
18/F
21/F
27/M
18/M
19/F
17/M
2
3
4
5
6
7
M: Men; F: Female; ROM: Range of motion; 2PD: two-point discrimination; MHQ: Michigan Hand outcome Questionnaire.
60 Complete None 3.0 3 2.5 3.0 3 2.0 Machine injury
87 65 >15 55 Complete None 2.5 3 2.0 3.0 3 2.0 Machine injury
94 62 14 60 Complete None 2.5 3 2.0 2.5 3 2.0
3.5 3 2.5 3.0 3 2.0 Wringer injury
Machine injury
94 59 11 50
88 56 9 55
Complete Debulky procedure Complete None 3.5 3 2.5 3.0 3 2.0 Machine injury
89 63 12 45 Complete None 3.5 3 2.0 3.0 3 2.0 Machine injury
97 54 8 60 Complete None 3.5 3 2.5 3.0 3 2.0 Machine injury
Left small finger/middle phalangeal Left middle finger/ middle phalangeal Right index finger/ middle phalangeal Right index finger/ middle phalangeal Left index finger/distal phalangeal Right index finger/ middle phalangeal Right middle finger/ middle phalangeal 19/M 1
Complications/ ROM 2PD MHQ Maryland foot reoperation (Degrees) (mm) (points) rating score (points) Flap survival Ipsilateral second toe Contralateral medial dorsal nail-skin flap second toe flap Cause Injured digit/level Case Age/Sex
Flap dimension (cm 3 cm)
Table 1. Patient Demographic, Surgical Data, and Surgical Outcomes
Digital recovery
Ipsilateral and Contralateral Second Toe Flaps
541
upper arm, the injured finger was debrided (Fig. 1A), the digital arteries and nerves were isolated and trimmed sparingly down to the level of healthy fascicles, and then tagged with 6/0 black silk sutures. Two or three subcutaneous veins on the dorsal proximal part of the injured finger were identified. The dorsal and volar defects were both measured. The contralateral medial second toe flap was designed to fill in the defect of the volar portion of the finger. The length and width of the flap from medial side of the second toe were designed 0.5 cm longer than the volar defect. The ipsilateral second toe dorsal nail-skin flap was designed to fill in the defect of the dorsal portion of the finger, and the length and width of the flap from dorsal side of the second toe were designed 0.3 cm longer than the dorsal defect of the finger. Proximally, the flap was designed in a teardrop shape, with a zigzag incision extending to the medial plantar surface of the toe for vessel harvest. The skin flap on the dorsum of ipsilateral second toe was designed according to the pattern of the dorsal defect of the injured finger (Fig. 1B). The dorsal skin was incised along the margins of the design, and the dorsal second toe and dorsal metatarsal veins as well as the dorsal branch of deep peroneal nerve were cut. Next, the dorsal digital artery was dissected along the medial side of the second toe to first dorsal metatarsal artery in the opposite direction to make sure the dorsal digital artery was long enough. Dorsal nail-skin flap was raised (Fig. 1C). Besides the donor site in one case was covered by a hallux toe lateral flap, the reminder was covered by a full-thickness skin graft and then covered with pressure dressings. The skin flap at medial side of the contralateral second toe was designed according to the pattern of the volar defect of the injured finger (Fig. 1D); the proximal medial side of the pattern was located to the proximal medial side of the flap. Attention was paid such that the plantar digital nerve and artery of the medial side of the second toe were involved in the flap. The skin was incised and subcutaneous vein in the proximal plantar incision was carefully dissected to its proximal end. Care was taken to be certain the vein was long enough and its continuity maintained. Next, the plantar digital nerve and artery, and first dorsal or plantar metatarsal artery of the toe were dissected. The flap was then lifted, and all tissues were freed except for the neurovascular pedicle (Fig. 1E). Medial flap was raised, and the donor site was covered with a full-thickness skin graft and pressure dressings were applied. In the flaps transferred to the injured fingers (Fig. 1F), the nail and the medial second toe flaps were loosely sutured to each other and wrapped around the finger (Fig. 1G). The flaps were then sutured to the Microsurgery DOI 10.1002/micr
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Figure 1. A: The second toe dorsal nail-skin flap was designed on the dorsum of the ipsilateral second toe according to the pattern of the dorsal defect of the injured finger. B: The second toe dorsal nail-skin flap was elevated. C: The medial second toe flap was designed on medial side of the contralateral second toe according to the pattern of the volar defect of the injured finger. D: The medial second toe flap was elevated. E: The nail and the medial second toe flaps were harvested. F: The nail and the medial second toe flaps were sutured loosely with each other and wrapped around the finger. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
proximal edge of the finger skin. The composite flap was fixed with a Kirschner wire drilled longitudinally through the distal phalanx. The medial plantar digital nerves and arteries of the dorsal nail-skin flap and medial flap were sutured to the bilateral common digital nerves and arteries, respectively. The deep peroneal nerve of the second toe flap was sutured to the common digital nerve, while the vein of the flap was anastomosed with the dorsal recipient vein. The skin edge was trimmed and loosely sutured (Figs. 1H and 1I). Postoperative Treatment
All patients remained at bed rest for 7–10 days. The repaired finger usually was positioned with the hand at heart level, and a plaster splint was applied to the dorsal surface to support the fingers, hand and wrist. Dipyridamole, 25 mg three times daily, combined with acetylsaliMicrosurgery DOI 10.1002/micr
cylic acid, 25 mg three times daily, was routinely administered for 5 days postoperatively. No dextran was used. Anisodamine, 10 mg once a day for 3 days and Papaverine, 30 mg four times daily for 7 days were routinely used. Antibiotics were administered routinely for 1 week after surgery. A compression bandage was left on the donor feet, and the feet were kept elevated for 7 to 10 days to allow sufficient healing of the skin graft. When the wound healed, about 2 weeks after surgery, progressive rehabilitation of the hand could begin. In the feet, when healing had occurred and edema was resolving, a gradually progressive program of walking was followed. Evaluation of Outcomes
A senior hand surgeon who did not attend the surgical cases performed all assessments. At follow-up, we
Ipsilateral and Contralateral Second Toe Flaps
measured active motion of the distal interphalangeal joint of the injured fingers using a goniometer. We used static two point discrimination (2PD) to measure sensibility of the flaps. Subjective criteria using patient-centered questionnaires, MHQ (Michigan Hand outcome Questionnaire)7 and Maryland foot rating score,8 was used to evaluate overall outcomes of the repaired hand and the donor sites after operation.
543
tively. Rehabilitation began 2 weeks after reconstruction, and 4 months after surgery satisfactory aesthetic results were noted (Figs. 2G–2I). However, a second surgery was required to reduce the bulky finger pulp. The active ROM of the distal interphalangeal joint was 55 degrees (Figs. 2J–2L), and 2PD was 9 mm. The MHQ score was 56 points and Maryland foot rating score was 88 points. DISCUSSION
RESULTS
The index finger was repaired in four cases and middle finger in three cases. All cases were treated as immediately after injury. The average design area of second toe dorsal nail-skin flap was 2.9 cm 3 2.0 cm (range, 2.5 cm 3 2.0 cm to 3.0 cm 3 2.0 cm). The average design area of second toe medial flap was 3.2 cm 3 2.3 cm (range, 2.5 cm 3 2.0 cm to 3.5 cm 3 2.5 cm). Among them, one case had a small defect of the distal phalanx and the bone, joints, and tendons were intact in the other cases. All contralateral medial second toe flaps and ipsilateral second toe dorsal nail-skin flaps survived completely. All postoperative courses were uneventful. Patients were followed for an average of 15 months (range, 6 months to 20 months). The appearance of the reconstructed fingers was comparable to normal ones, except for one which required debulking. The appearance of the nail was satisfactory without deformity. The ROM of the distal interphalangeal joint averaged 55 6 5.8 degrees, although it was slightly reduced in two patients. The 2PD of the pulp averaged 11.3 mm (range, 8 to > 15 mm). The dorsal nail-skin flap in all cases recovered a protective sensory response. All the patients were able to walk without difficulty. The MHQ score averaged 59 6 4.2 points and Maryland foot rating score averaged 92 6 4.2 points. Case Report
A 21-year-old female experienced an industrial machine injury to the right index finger. The skin and soft tissue were avulsed from the middle phalangeal level with exposure of the bone and flexor tendon (Fig. 2A). Reconstruction was performed using ipsilateral second toe dorsal nail-skin flap and contralateral medial second toe flap (Figs. 2B–2D). The area of the dorsal nail-skin flap was 3.0 cm 3 2.0 cm, and the medial flap was 3.5 cm 3 2.5 cm. The donor site of second toe dorsal nailskin flap was covered by a lateral hallux toe flap (Fig. 2E), and the donor sites of the lateral hallux toe flap and the medial second toe flap were covered with full thickness skin grafts (Figs. 2E and 2F). All flaps and skin grafts survived, and the suture was removed after 14 days. Walking was permitted after 3 weeks postopera-
Degloving injuries of the hand and fingers are extremely challenging to repair. Due to a lack of appropriate tissues that can be used to cover denuded tendons, phalangeal bones, and joint capsules, the injury can be difficult to manage and an operation of choice has yet to be found.9 The selection of the repair methods for degloving injuries of the finger at the middle and the distal phalangeal level depends on the integrity of the distal avulsed tissues. If distal avulsed tissues are intact, the best surgical option is always replantation.10 Replacing the degloved part and vascularizing it by microvascular anastomosis provides adequate coverage with patient skin and a soft tissue. Replantation of degloved parts can result in good function and appearance.11–13 However, in most cases, the avulsed tissues and the vascular supplies are usually so damaged that replantation is not feasible. When a skin defect leaves deep structures exposed, a split-thickness or full-thickness skin graft is insufficient coverage for nerves, tendons, and cortical bone. As a result, a ray amputation is usually considered.14,15 Although revision amputations may be the most expedient treatment option, painful neuromas can occur, and the aesthetic appearance associated with the amputation stumps can be quite bothersome.16,17 A composite tissue must be found to cover the denuded tendons, pulleys, and phalangeal bones. The tissue must be thin, pliable, and sensitive and should be readily harvestable. Thickened tissue limits the joint movement and sensory recovery. Numerous composite tissues18–27 have been described for covering soft tissue defects of the digits, but most of them have drawbacks when the defects are large and located distally. The reverse dorsal metacarpal flap, based on the dorsal metacarpal vascular pedicle, is a useful flap for covering dorsal digital defects, but presents a limited arc of rotation and cannot easily reach defects that are beyond the proximal interphalangeal joints.28 To reconstruct large distal skin defects of the long digits, Demiri et al.29 designed a modified reverse digitometacarpal skin flap that was raised on the vascular axis of the adjacent finger, and Hashem30 reported covering the volar surface of a degloving injury with a heterodigital island flap from the adjacent finger, while a full thickness graft was applied to the dorsum. Although finger reconstruction Microsurgery DOI 10.1002/micr
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Figure 2. A: Preoperative defect proximal to the middle part of the middle phalanx in the right index finger. B: Ipsilateral second toe dorsal nail-skin flap and contralateral medial second toe flap were designed. C: The nail and the medial second toe flaps were harvested. D: The defect was covered and reconstructed with the combined second toe dorsal nail-skin flap and contralateral medial second toe flap. E: The donor site of second toe dorsal nail-skin flap was covered by a hallux toe fibular flap, and the donor sites of the hallux toe fibular flap were covered with full-thickness skin grafts. F: The medial second toe flap was covered with full-thickness skin grafts. G, I: Four months after surgery satisfactory aesthetic results of the volar flap was noted. H, J: Satisfactory aesthetic results of the dorsal flap was noted. K, L, M: The patient showed reasonable opposition and pinch ability. N: Donor sites were also acceptable. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Microsurgery DOI 10.1002/micr
Ipsilateral and Contralateral Second Toe Flaps
using a flap with a vascular pedicle is relatively simple and there can be good circulation and sensory recovery, the reconstructed finger will have a dissatisfactory shape without a nail. Furthermore, scar contracture can affect the function of the fingers. Although groin and abdominal flaps can provide sufficient skin to cover the wide defects that result from avulsion of skin, and the donor sites are concealed, these distant pedicle flaps suffer a number of disadvantages such as hand attachment to another part of the body for 3 weeks, edema secondary to the dependent position, a delay in starting hand rehabilitation program, and multiple-stage procedures.31,32 The movement of the joints are often limited, and both sensory recovery and cosmetic appearance of the reconstructed digit are seldom satisfactory.33,34 With the advent of microvascular composite-tissue transfer, the transfer of composite tissues to resurface the digits became possible. The use of skin from the toe fashioned as a wrap-around flap4,35 fulfills the requirements for reconstruction of the fingers after a degloving injury. Khouri and Diehl36 reported the first case of a degloving injury of the finger successfully repaired with a second toe wrap-around flap. Second toe wrap-around transplantation is the ideal surgical method to cure the injury of the thumb or fingers.37,38 However, this method requires the sacrifice of a toe, and the reconstructed finger pulp is bulky. To avoid the need to sacrifice a toe, a free wraparound flap from the hallux toe combined with a small flap from the medial side of the second toe was designed for the reconstruction of degloved fingers. In our experience, however, some patients who receive this operation have difficulty walking, and deformity of the nail. We considered that the wrap-around flap was divided into a toe pulp flap and a toe dorsal nail-skin flap, and that the pulp flap and dorsal nail-skin flap could be harvested from different feet. The donor site of the second toe pulp flap is important to the function of the foot, so a medial second toe flap was used instead of a pulp flap. As a result, we found that satisfactory function and appearance of the reconstructed fingers could be achieved with minimal donor site morbidity. There were a number of key points for the successful reconstruction of a degloved finger with combined ipsilateral second toe dorsal nail-skin flap and contralateral medial second toe flap. Care should be taken when stripping the nail bed. The flap must be stripped between the nail bed and periosteum such that the periosteal integrity on the bone was maintained. If the periosteum was injured, the full-thickness skin graft for the donor site would not survive. If the nail matrix was damaged, the appearance of the nail would not be satisfactory. A plantar digital artery island flap from fibular side of great toe was designed to cover the donor defect of the dorsal nail-skin flap.
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There are a number of advantages of this technique. 1) The procedure is a one-stage surgery, thus shortening the whole treatment course and reducing the pain and economic burden of multiple surgeries.39 2) The reconstructed finger has a nail of appropriate shape and length. 3) The donor site is concealed, a toe is not sacrificed, and function of the donor foot is not altered. There are, however, some shortcomings of this technique. 1) Only one finger can be reconstructed in multiple finger avulsion injuries because the flaps are harvested from both feet. 2) The procedure is too complicated and there are some risks of failure.40 Indications were fingers that had degloving injuries of skin and subcutaneous tissue. The level of injury was at the middle phalanx. Both flexor and extensor tendons were intact. Although the use of combined ipsilateral second dorsal nail-skin flap and contralateral medial second toe flap provided a satisfaction to both the surgeon and the patient, the psychological stress from the risk of operative failure may be intense. The patient should have a strong desire for finger reconstruction, coupled with a good physical condition to sustain prolonged anesthesia. Other factors include the age of patient, associated medical problems, a smoking habit, and the state of systemic coagulopathy. Because the appearance and nail of hallux toe is more similar to the thumb’s, we preferred to use free great toe wrap-around flap and second toe medial flap to repair the degloved thumb. In cases requiring only one finger reconstruction, we recommend this technique for Finger degloving injuriy, if replantation is impossible. In conclusions, the ipsilateral second toe dorsal nailskin flap combined with contralateral medial second toe flap may provide a valuable alternative for the reconstruction of completely degloved fingers at the middle and the distal phalangeal level. The procedure achieves satisfactory functional and cosmetic results.
REFERENCES 1. Henry M. Degloving combined with structural trauma at the digital level: Functional coverage with fascial free flaps. J Reconstr Microsurg 2007;23:59–62. 2. Beris AE, Lykissas MG, Korompilias AV, Mitsionis GI, Vekris MD, Kostas-Agnantis IP. Digit and hand replantation. Arch Orthop Trauma Surg 2010;130:1141–1147. 3. Morrison WA, O’Brien BM, MacLeod AM. Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. J Hand Surg Am 1980;5:575–583. 4. Hou R, Feng L, Wang H, Guo D, Chen X, Huang X, Shi L, Lu Z. Transplantation of nail skin flap from the second toe for repair of degloving injury of the fingers. Chin J Hand Surg 1999;15:240–241. 5. Lee JI, Park JH, Park JH, Kim YJ, Park JW. Thumb reconstruction with a wrap-around free flap in hand radiation injury. Microsurgery 2012;32:401–405.
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6. Rui Y, Mi J, Shi H, Zhang Z, Yan H. Free great toe wrap-around flap combined with second toe medial flap for reconstruction of completely degloved fingers. Microsurgery 2010;30:449–456. 7. Chung KC, Pillsbury MS, Walters MR, Hayward RA. Reliability and validity testing of Michigan Hand Outcomes Questionaire. J Hand Surg (Am) 1998;23:575–587. 8. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res 1993;290:87–95. 9. Nazerani S, Motamedi MH, Nazerani T, Bidarmaghz B. Treatment of traumatic degloving injuries of the fingers and hand: Introducing the “compartmented abdominal flap.” Tech Hand Up Extrem Surg 2011;15:151–155. 10. Adani R, Castagnetti C, Landi A. Degloving injuries of the hand and fingers. Clin Orthop Relat Res 1995;314:19–25. 11. Davis Sears E, Chung KC. Replantation of finger avulsion injuries: A systematic review of survival and functional outcomes. J Hand Surg Am 2011;36:686–694. 12. Lefe`vre Y, Mallet C, Ilharreborde B, Jehanno P, Frajmann JM, Pennec¸ot GF, Mazda K, Fitoussi F. Digital avulsion with compromised vascularization: Study of 23 cases in children. J Pediatr Orthop 2011;31:259–265. 13. Krishnamoorthy R, Karthikeyan G. Degloving injuries of the hand. Indian J Plast Surg 2011;44:227–236. 14. Pederson WC. Replantation. Plast Reconstr Surg 2001;107:823–841. 15. Chung KC. Invited discussion: Long-term results of replantation for complete ring avulsion amputations. Ann Plast Surg 2003;51:569. 16. Holm A, Zachariae, L. Fingertip lesions: An evaluation of conservative treatment versus free skin grafting. Acta Orthop Scand 1974;45: 382–392. 17. Rose EH, Norris MS, Kowalski TA. Microsurgical management of complex fingertip injuries: Comparison to conventional skin grafting. J Reconstr Microsurg 1988;4:89–98. 18. Senarath-Yapa K, Bell DR. “Front and back” flaps for multiple dorsal and palmar digital skin loss. J Hand Surg Eur Vol 2010;35:721– 724. 19. Yan H, Fan C, Gao W, Chen Z, Li Z, Chi Z. Finger pulp reconstruction with free flaps from the upper extremity. Microsurgery 2012;32: 406–414. 20. Gu JH, Jeong SH. Radical resection of a venous malformation in middle finger and immediate reconstruction using medial plantar artery perforator flap: A case report. Microsurgery 2012;32:148–152. 21. Ki SH, Hwang K, Kim DH, Hwang S, Han SH. A toenail flap based on the fibro-osseous hiatus branch for fingernail reconstruction. Microsurgery 2011;31:371–375. 22. Senda H, Muro H, Terada S, Okamoto H. A case of degloving injury of the whole hand reconstructed by a combination of distant flaps comprising an anterolateral thigh flap and a groin flap. J Reconstr Microsurg 2011;27:299–302.
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23. El-Sabbagh AH, Zeina AA, El-Hadidy AM, El-Din AB. Reversed posterior interosseous flap: Safe and easy method for hand reconstruction. J Hand Microsurg 2011;3:66–72. 24. Wong M, Tay SC, Teoh LC. Versatility of the turn-around technique of the lateral arm flap for hand reconstruction. Ann Plast Surg 2012; 69:265–270. 25. Ulrich D, Fuchs P, Bozkurt A, Pallua N. Free serratus anterior fascia flap for reconstruction of hand and finger defects. Arch Orthop Trauma Surg 2010;130:217–222. 26. Deal DN, Barnwell J, Li Z. Soft-tissue coverage of complex dorsal hand and finger defects using the turnover adipofascial flap. J Reconstr Microsurg 2011;27:133–138. 27. Hammouda AA, El-Khatib HA, Al-Hetmi T. Extended stepadvancement flap for avulsed amputated fingertip—A new technique to preserve finger length: Case series. J Hand Surg Am 2011;36:129–134. 28. Zhang X, Shao X, Ren C, Wen S, Zhu H, Sun J. Coverage of dorsal-ulnar hand wounds with a reverse second dorsal metacarpal artery flap. J Reconstr Microsurg 2012;28:167–173. 29. Demiri EC, Dionyssiou DD, Biskiniotis I, Papadimitriou D. Reconstruction of a degloved finger with a heterodigital reverse dorsal digitometacarpal flap. Scand J Plast Reconstr Surg Hand Surg 2007;41:42–44. 30. Hashem AM. Salvage of degloved digits with heterodigital flaps and full thickness skin grafts. Ann Plast Surg 2010; 64:155–158. 31. Giessler GA, Erdmann D, Germann G. Soft tissue coverage in devastating hand injuries. Hand Clin 2003;19:63–71. 32. Heitmann C, Levin LS. Alternatives to thumb replantation. Plast Reconstr Surg 2002;110:1492–1503. 33. Van der Horst CM, Hovius SE, van der Meulen JC. Results of treatment of 48 ring avulsion injuries. Ann Plast Surg 1989;22:9–13. 34. Kleinman WB, Dustman JA. Preservation of function following complete degloving injuries to the hand: Use of simultaneous groin flap, random abdominal flap, and partial thickness skin graft. J Hand Surg 1981;6:82–89. 35. Wei FC, Chen HC, Chuang DC, Chen S, Noordhoff MS. Second toe wrap-around flap. Plast Reconstr Surg 1991;88:837–843. 36. Khouri RK, Diehl GJ. Salvage in a case of ring avulsion injury with an immediate second-toe wrap-around flap. J Hand Surg 1992;17A: 714–718. 37. Guoliang C. Replantation and Reconstruction of Fingers. People’s Medical Publishing House: Beijing, China; 2008. p 561. 38. Kitidumrongsook P, Patradul A, Pataradool K. Resurfacing the degloved thumb up to the interphalangeal joint level with twin extended neurovascular island flaps. J Hand Surg Br 2006;31:562–565. 39. Lee DC, Kim JS, Ki SH. Partial second toe pulp free flap for fingertip reconstruction. Plast Reconstr Surg 2008;121:899–907. 40. Fatemi MJ, Jalilimanesh M, Dini MT. Evaluation of moving and static two point discriminations of volar forearm skin before and after transfer as a sensate radial forearm island flap in reconstruction of degloving injury of the thumb. J Plast Reconstr Aesthet Surg 2007;60:356–359.
Purpose: The purpose of this report was to retrospectively review the results of treatment of degloving injury of the finger by use of combined ipsilateral second dorsal nail-skin flap and contralateral medial second toe flap. Methods: From 2010 to 2012, seven fingers in seven patients with complete degloving injuries from the level of middle or distal phalanx were reconstructed with combined ipsilateral second dorsal nail-skin flap and contralateral medial second toe flap. The injured fingers included the index finger in four cases, and middle finger in three cases. The nerves of both the flaps were sutured to the bilateral common digital nerves. The donor site of second toe flap was covered with a full-thickness skin graft. Results: All transferred flaps survived after surgery, and all postoperative courses were uneventful. During the follow-up period (mean of 15 months; ranging 6–20 months), the appearance of the reconstructed fingers was comparable with normal ones. The range of motion of the distal interphalangeal joint averaged 55 6 5.8 degrees. The two point discrimination of the pulp ranged from 8 to > 15 mm (average, 11.3 mm). All the patients were able to walk without difficulty. The MHQ score averaged 59 6 4.2 points and Maryland foot rating score averaged 92 6 4.2 points. Conclusion: The ipsilateral second toe dorsal nail-skin flap combined with contralateral medial second toe flap may provide an alternative for the reconstruction of completely degloved fingers at the middle C 2014 Wiley Periodicals, Inc. Microsurgery 34:540–546, 2014. and the distal phalangeal level, with satisfactory functional and cosmetic results. V
Resurfacing after a total degloving injury to the finger is one of the most difficult problems to manage in hand surgery.1 Replantation can result in good function and appearance in selected patients,2 but the surgeon should verify whether the degloved part is replantable, and only when the degloved skin is deemed non-replantable should some form of flap coverage be considered. Conventional methods such as skin grafts or local or tubed pedicled flaps cannot always ensure satisfactory coverage of such defects. The ultimate goal is not only the survival of the injured fingers but also a favorable functional recovery and appearance. Toes and fingers have a similar structure, so partial toe tissues transplantation can meet the above needs. In 1980, Morrison et al.3 reported the use of a free hallux toe wrap-around flap and an iliac crest bone graft to reconstruct the thumb and achieved satisfactory results. Hou et al.4 used a free wrap-around flap from the second toe to reconstruct a complete degloving injury of the finger at the middle and the distal phalangeal level with a satisfactory result. However, the method requires sacrifice of the second toe.5 To avoid sacrificing the toe, Rui et al.6 designed a free wrap-around flap from the hallux toe combined with a flap from the medial side of the second toe for the reconstruction of the degloved fingers and has reported satisfactory functional and cosmetic results. However, the donor site morbidity is not insignifDepartment of Hand Surgery, Ruihua Affiliated Hospital of Soochow University, Suzhou 215104, China *Correspondence to: Ruixing Hou. E-mail: [email protected] Received 24 March 2013; Revision accepted 11 March 2014; Accepted 14 March 2014 Published online 1 April 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22253 Ó 2014 Wiley Periodicals, Inc.
icant and the reconstructed finger is dissimilar to the contralateral normal finger. To further decrease the donor site morbidity of foot and improve the appearance of the reconstructed finger, based on Rui’s6 technique, we design a free dorsal nailskin flap from ipsilateral second toe combined with a flap from the medial side of contralateral second toe for the reconstruction of the degloved fingers. In this report, we present our experience on seven patients of seven fingers reconstructed with the combined flaps. PATIENTS AND METHODS
From 2010 to 2012, seven fingers in seven patients with complete degloving injuries were reconstructed with combined ipsilateral second toe dorsal nail-skin flap and contralateral medial second toe flap. There were four males and three females with an average age of 20 years (range, 17–27 years). The cause of injury was an industrial machine injury in six cases, and wringer injury was in one case. The skin was avulsed from the middle phalangeal level in six cases, and from the distal phalangeal level in one case. Patient demographic and surgical data are summarized in Table 1. Indications for the procedure were only one finger required to be repaired and the necessity of preserving finger length and restoring aesthetic appearance. Patients with systemic diseases such as diabetes mellitus, vascular disease, and heavy smoking histories and those with multiple degloved fingers were excluded from the surgery. Operative Techniques
Brachial plexus block and epidural anesthesia were used in all cases. After a tourniquet was placed on the
97 56 10
18/F
21/F
27/M
18/M
19/F
17/M
2
3
4
5
6
7
M: Men; F: Female; ROM: Range of motion; 2PD: two-point discrimination; MHQ: Michigan Hand outcome Questionnaire.
60 Complete None 3.0 3 2.5 3.0 3 2.0 Machine injury
87 65 >15 55 Complete None 2.5 3 2.0 3.0 3 2.0 Machine injury
94 62 14 60 Complete None 2.5 3 2.0 2.5 3 2.0
3.5 3 2.5 3.0 3 2.0 Wringer injury
Machine injury
94 59 11 50
88 56 9 55
Complete Debulky procedure Complete None 3.5 3 2.5 3.0 3 2.0 Machine injury
89 63 12 45 Complete None 3.5 3 2.0 3.0 3 2.0 Machine injury
97 54 8 60 Complete None 3.5 3 2.5 3.0 3 2.0 Machine injury
Left small finger/middle phalangeal Left middle finger/ middle phalangeal Right index finger/ middle phalangeal Right index finger/ middle phalangeal Left index finger/distal phalangeal Right index finger/ middle phalangeal Right middle finger/ middle phalangeal 19/M 1
Complications/ ROM 2PD MHQ Maryland foot reoperation (Degrees) (mm) (points) rating score (points) Flap survival Ipsilateral second toe Contralateral medial dorsal nail-skin flap second toe flap Cause Injured digit/level Case Age/Sex
Flap dimension (cm 3 cm)
Table 1. Patient Demographic, Surgical Data, and Surgical Outcomes
Digital recovery
Ipsilateral and Contralateral Second Toe Flaps
541
upper arm, the injured finger was debrided (Fig. 1A), the digital arteries and nerves were isolated and trimmed sparingly down to the level of healthy fascicles, and then tagged with 6/0 black silk sutures. Two or three subcutaneous veins on the dorsal proximal part of the injured finger were identified. The dorsal and volar defects were both measured. The contralateral medial second toe flap was designed to fill in the defect of the volar portion of the finger. The length and width of the flap from medial side of the second toe were designed 0.5 cm longer than the volar defect. The ipsilateral second toe dorsal nail-skin flap was designed to fill in the defect of the dorsal portion of the finger, and the length and width of the flap from dorsal side of the second toe were designed 0.3 cm longer than the dorsal defect of the finger. Proximally, the flap was designed in a teardrop shape, with a zigzag incision extending to the medial plantar surface of the toe for vessel harvest. The skin flap on the dorsum of ipsilateral second toe was designed according to the pattern of the dorsal defect of the injured finger (Fig. 1B). The dorsal skin was incised along the margins of the design, and the dorsal second toe and dorsal metatarsal veins as well as the dorsal branch of deep peroneal nerve were cut. Next, the dorsal digital artery was dissected along the medial side of the second toe to first dorsal metatarsal artery in the opposite direction to make sure the dorsal digital artery was long enough. Dorsal nail-skin flap was raised (Fig. 1C). Besides the donor site in one case was covered by a hallux toe lateral flap, the reminder was covered by a full-thickness skin graft and then covered with pressure dressings. The skin flap at medial side of the contralateral second toe was designed according to the pattern of the volar defect of the injured finger (Fig. 1D); the proximal medial side of the pattern was located to the proximal medial side of the flap. Attention was paid such that the plantar digital nerve and artery of the medial side of the second toe were involved in the flap. The skin was incised and subcutaneous vein in the proximal plantar incision was carefully dissected to its proximal end. Care was taken to be certain the vein was long enough and its continuity maintained. Next, the plantar digital nerve and artery, and first dorsal or plantar metatarsal artery of the toe were dissected. The flap was then lifted, and all tissues were freed except for the neurovascular pedicle (Fig. 1E). Medial flap was raised, and the donor site was covered with a full-thickness skin graft and pressure dressings were applied. In the flaps transferred to the injured fingers (Fig. 1F), the nail and the medial second toe flaps were loosely sutured to each other and wrapped around the finger (Fig. 1G). The flaps were then sutured to the Microsurgery DOI 10.1002/micr
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Figure 1. A: The second toe dorsal nail-skin flap was designed on the dorsum of the ipsilateral second toe according to the pattern of the dorsal defect of the injured finger. B: The second toe dorsal nail-skin flap was elevated. C: The medial second toe flap was designed on medial side of the contralateral second toe according to the pattern of the volar defect of the injured finger. D: The medial second toe flap was elevated. E: The nail and the medial second toe flaps were harvested. F: The nail and the medial second toe flaps were sutured loosely with each other and wrapped around the finger. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
proximal edge of the finger skin. The composite flap was fixed with a Kirschner wire drilled longitudinally through the distal phalanx. The medial plantar digital nerves and arteries of the dorsal nail-skin flap and medial flap were sutured to the bilateral common digital nerves and arteries, respectively. The deep peroneal nerve of the second toe flap was sutured to the common digital nerve, while the vein of the flap was anastomosed with the dorsal recipient vein. The skin edge was trimmed and loosely sutured (Figs. 1H and 1I). Postoperative Treatment
All patients remained at bed rest for 7–10 days. The repaired finger usually was positioned with the hand at heart level, and a plaster splint was applied to the dorsal surface to support the fingers, hand and wrist. Dipyridamole, 25 mg three times daily, combined with acetylsaliMicrosurgery DOI 10.1002/micr
cylic acid, 25 mg three times daily, was routinely administered for 5 days postoperatively. No dextran was used. Anisodamine, 10 mg once a day for 3 days and Papaverine, 30 mg four times daily for 7 days were routinely used. Antibiotics were administered routinely for 1 week after surgery. A compression bandage was left on the donor feet, and the feet were kept elevated for 7 to 10 days to allow sufficient healing of the skin graft. When the wound healed, about 2 weeks after surgery, progressive rehabilitation of the hand could begin. In the feet, when healing had occurred and edema was resolving, a gradually progressive program of walking was followed. Evaluation of Outcomes
A senior hand surgeon who did not attend the surgical cases performed all assessments. At follow-up, we
Ipsilateral and Contralateral Second Toe Flaps
measured active motion of the distal interphalangeal joint of the injured fingers using a goniometer. We used static two point discrimination (2PD) to measure sensibility of the flaps. Subjective criteria using patient-centered questionnaires, MHQ (Michigan Hand outcome Questionnaire)7 and Maryland foot rating score,8 was used to evaluate overall outcomes of the repaired hand and the donor sites after operation.
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tively. Rehabilitation began 2 weeks after reconstruction, and 4 months after surgery satisfactory aesthetic results were noted (Figs. 2G–2I). However, a second surgery was required to reduce the bulky finger pulp. The active ROM of the distal interphalangeal joint was 55 degrees (Figs. 2J–2L), and 2PD was 9 mm. The MHQ score was 56 points and Maryland foot rating score was 88 points. DISCUSSION
RESULTS
The index finger was repaired in four cases and middle finger in three cases. All cases were treated as immediately after injury. The average design area of second toe dorsal nail-skin flap was 2.9 cm 3 2.0 cm (range, 2.5 cm 3 2.0 cm to 3.0 cm 3 2.0 cm). The average design area of second toe medial flap was 3.2 cm 3 2.3 cm (range, 2.5 cm 3 2.0 cm to 3.5 cm 3 2.5 cm). Among them, one case had a small defect of the distal phalanx and the bone, joints, and tendons were intact in the other cases. All contralateral medial second toe flaps and ipsilateral second toe dorsal nail-skin flaps survived completely. All postoperative courses were uneventful. Patients were followed for an average of 15 months (range, 6 months to 20 months). The appearance of the reconstructed fingers was comparable to normal ones, except for one which required debulking. The appearance of the nail was satisfactory without deformity. The ROM of the distal interphalangeal joint averaged 55 6 5.8 degrees, although it was slightly reduced in two patients. The 2PD of the pulp averaged 11.3 mm (range, 8 to > 15 mm). The dorsal nail-skin flap in all cases recovered a protective sensory response. All the patients were able to walk without difficulty. The MHQ score averaged 59 6 4.2 points and Maryland foot rating score averaged 92 6 4.2 points. Case Report
A 21-year-old female experienced an industrial machine injury to the right index finger. The skin and soft tissue were avulsed from the middle phalangeal level with exposure of the bone and flexor tendon (Fig. 2A). Reconstruction was performed using ipsilateral second toe dorsal nail-skin flap and contralateral medial second toe flap (Figs. 2B–2D). The area of the dorsal nail-skin flap was 3.0 cm 3 2.0 cm, and the medial flap was 3.5 cm 3 2.5 cm. The donor site of second toe dorsal nailskin flap was covered by a lateral hallux toe flap (Fig. 2E), and the donor sites of the lateral hallux toe flap and the medial second toe flap were covered with full thickness skin grafts (Figs. 2E and 2F). All flaps and skin grafts survived, and the suture was removed after 14 days. Walking was permitted after 3 weeks postopera-
Degloving injuries of the hand and fingers are extremely challenging to repair. Due to a lack of appropriate tissues that can be used to cover denuded tendons, phalangeal bones, and joint capsules, the injury can be difficult to manage and an operation of choice has yet to be found.9 The selection of the repair methods for degloving injuries of the finger at the middle and the distal phalangeal level depends on the integrity of the distal avulsed tissues. If distal avulsed tissues are intact, the best surgical option is always replantation.10 Replacing the degloved part and vascularizing it by microvascular anastomosis provides adequate coverage with patient skin and a soft tissue. Replantation of degloved parts can result in good function and appearance.11–13 However, in most cases, the avulsed tissues and the vascular supplies are usually so damaged that replantation is not feasible. When a skin defect leaves deep structures exposed, a split-thickness or full-thickness skin graft is insufficient coverage for nerves, tendons, and cortical bone. As a result, a ray amputation is usually considered.14,15 Although revision amputations may be the most expedient treatment option, painful neuromas can occur, and the aesthetic appearance associated with the amputation stumps can be quite bothersome.16,17 A composite tissue must be found to cover the denuded tendons, pulleys, and phalangeal bones. The tissue must be thin, pliable, and sensitive and should be readily harvestable. Thickened tissue limits the joint movement and sensory recovery. Numerous composite tissues18–27 have been described for covering soft tissue defects of the digits, but most of them have drawbacks when the defects are large and located distally. The reverse dorsal metacarpal flap, based on the dorsal metacarpal vascular pedicle, is a useful flap for covering dorsal digital defects, but presents a limited arc of rotation and cannot easily reach defects that are beyond the proximal interphalangeal joints.28 To reconstruct large distal skin defects of the long digits, Demiri et al.29 designed a modified reverse digitometacarpal skin flap that was raised on the vascular axis of the adjacent finger, and Hashem30 reported covering the volar surface of a degloving injury with a heterodigital island flap from the adjacent finger, while a full thickness graft was applied to the dorsum. Although finger reconstruction Microsurgery DOI 10.1002/micr
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Figure 2. A: Preoperative defect proximal to the middle part of the middle phalanx in the right index finger. B: Ipsilateral second toe dorsal nail-skin flap and contralateral medial second toe flap were designed. C: The nail and the medial second toe flaps were harvested. D: The defect was covered and reconstructed with the combined second toe dorsal nail-skin flap and contralateral medial second toe flap. E: The donor site of second toe dorsal nail-skin flap was covered by a hallux toe fibular flap, and the donor sites of the hallux toe fibular flap were covered with full-thickness skin grafts. F: The medial second toe flap was covered with full-thickness skin grafts. G, I: Four months after surgery satisfactory aesthetic results of the volar flap was noted. H, J: Satisfactory aesthetic results of the dorsal flap was noted. K, L, M: The patient showed reasonable opposition and pinch ability. N: Donor sites were also acceptable. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Microsurgery DOI 10.1002/micr
Ipsilateral and Contralateral Second Toe Flaps
using a flap with a vascular pedicle is relatively simple and there can be good circulation and sensory recovery, the reconstructed finger will have a dissatisfactory shape without a nail. Furthermore, scar contracture can affect the function of the fingers. Although groin and abdominal flaps can provide sufficient skin to cover the wide defects that result from avulsion of skin, and the donor sites are concealed, these distant pedicle flaps suffer a number of disadvantages such as hand attachment to another part of the body for 3 weeks, edema secondary to the dependent position, a delay in starting hand rehabilitation program, and multiple-stage procedures.31,32 The movement of the joints are often limited, and both sensory recovery and cosmetic appearance of the reconstructed digit are seldom satisfactory.33,34 With the advent of microvascular composite-tissue transfer, the transfer of composite tissues to resurface the digits became possible. The use of skin from the toe fashioned as a wrap-around flap4,35 fulfills the requirements for reconstruction of the fingers after a degloving injury. Khouri and Diehl36 reported the first case of a degloving injury of the finger successfully repaired with a second toe wrap-around flap. Second toe wrap-around transplantation is the ideal surgical method to cure the injury of the thumb or fingers.37,38 However, this method requires the sacrifice of a toe, and the reconstructed finger pulp is bulky. To avoid the need to sacrifice a toe, a free wraparound flap from the hallux toe combined with a small flap from the medial side of the second toe was designed for the reconstruction of degloved fingers. In our experience, however, some patients who receive this operation have difficulty walking, and deformity of the nail. We considered that the wrap-around flap was divided into a toe pulp flap and a toe dorsal nail-skin flap, and that the pulp flap and dorsal nail-skin flap could be harvested from different feet. The donor site of the second toe pulp flap is important to the function of the foot, so a medial second toe flap was used instead of a pulp flap. As a result, we found that satisfactory function and appearance of the reconstructed fingers could be achieved with minimal donor site morbidity. There were a number of key points for the successful reconstruction of a degloved finger with combined ipsilateral second toe dorsal nail-skin flap and contralateral medial second toe flap. Care should be taken when stripping the nail bed. The flap must be stripped between the nail bed and periosteum such that the periosteal integrity on the bone was maintained. If the periosteum was injured, the full-thickness skin graft for the donor site would not survive. If the nail matrix was damaged, the appearance of the nail would not be satisfactory. A plantar digital artery island flap from fibular side of great toe was designed to cover the donor defect of the dorsal nail-skin flap.
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There are a number of advantages of this technique. 1) The procedure is a one-stage surgery, thus shortening the whole treatment course and reducing the pain and economic burden of multiple surgeries.39 2) The reconstructed finger has a nail of appropriate shape and length. 3) The donor site is concealed, a toe is not sacrificed, and function of the donor foot is not altered. There are, however, some shortcomings of this technique. 1) Only one finger can be reconstructed in multiple finger avulsion injuries because the flaps are harvested from both feet. 2) The procedure is too complicated and there are some risks of failure.40 Indications were fingers that had degloving injuries of skin and subcutaneous tissue. The level of injury was at the middle phalanx. Both flexor and extensor tendons were intact. Although the use of combined ipsilateral second dorsal nail-skin flap and contralateral medial second toe flap provided a satisfaction to both the surgeon and the patient, the psychological stress from the risk of operative failure may be intense. The patient should have a strong desire for finger reconstruction, coupled with a good physical condition to sustain prolonged anesthesia. Other factors include the age of patient, associated medical problems, a smoking habit, and the state of systemic coagulopathy. Because the appearance and nail of hallux toe is more similar to the thumb’s, we preferred to use free great toe wrap-around flap and second toe medial flap to repair the degloved thumb. In cases requiring only one finger reconstruction, we recommend this technique for Finger degloving injuriy, if replantation is impossible. In conclusions, the ipsilateral second toe dorsal nailskin flap combined with contralateral medial second toe flap may provide a valuable alternative for the reconstruction of completely degloved fingers at the middle and the distal phalangeal level. The procedure achieves satisfactory functional and cosmetic results.
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6. Rui Y, Mi J, Shi H, Zhang Z, Yan H. Free great toe wrap-around flap combined with second toe medial flap for reconstruction of completely degloved fingers. Microsurgery 2010;30:449–456. 7. Chung KC, Pillsbury MS, Walters MR, Hayward RA. Reliability and validity testing of Michigan Hand Outcomes Questionaire. J Hand Surg (Am) 1998;23:575–587. 8. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res 1993;290:87–95. 9. Nazerani S, Motamedi MH, Nazerani T, Bidarmaghz B. Treatment of traumatic degloving injuries of the fingers and hand: Introducing the “compartmented abdominal flap.” Tech Hand Up Extrem Surg 2011;15:151–155. 10. Adani R, Castagnetti C, Landi A. Degloving injuries of the hand and fingers. Clin Orthop Relat Res 1995;314:19–25. 11. Davis Sears E, Chung KC. Replantation of finger avulsion injuries: A systematic review of survival and functional outcomes. J Hand Surg Am 2011;36:686–694. 12. Lefe`vre Y, Mallet C, Ilharreborde B, Jehanno P, Frajmann JM, Pennec¸ot GF, Mazda K, Fitoussi F. Digital avulsion with compromised vascularization: Study of 23 cases in children. J Pediatr Orthop 2011;31:259–265. 13. Krishnamoorthy R, Karthikeyan G. Degloving injuries of the hand. Indian J Plast Surg 2011;44:227–236. 14. Pederson WC. Replantation. Plast Reconstr Surg 2001;107:823–841. 15. Chung KC. Invited discussion: Long-term results of replantation for complete ring avulsion amputations. Ann Plast Surg 2003;51:569. 16. Holm A, Zachariae, L. Fingertip lesions: An evaluation of conservative treatment versus free skin grafting. Acta Orthop Scand 1974;45: 382–392. 17. Rose EH, Norris MS, Kowalski TA. Microsurgical management of complex fingertip injuries: Comparison to conventional skin grafting. J Reconstr Microsurg 1988;4:89–98. 18. Senarath-Yapa K, Bell DR. “Front and back” flaps for multiple dorsal and palmar digital skin loss. J Hand Surg Eur Vol 2010;35:721– 724. 19. Yan H, Fan C, Gao W, Chen Z, Li Z, Chi Z. Finger pulp reconstruction with free flaps from the upper extremity. Microsurgery 2012;32: 406–414. 20. Gu JH, Jeong SH. Radical resection of a venous malformation in middle finger and immediate reconstruction using medial plantar artery perforator flap: A case report. Microsurgery 2012;32:148–152. 21. Ki SH, Hwang K, Kim DH, Hwang S, Han SH. A toenail flap based on the fibro-osseous hiatus branch for fingernail reconstruction. Microsurgery 2011;31:371–375. 22. Senda H, Muro H, Terada S, Okamoto H. A case of degloving injury of the whole hand reconstructed by a combination of distant flaps comprising an anterolateral thigh flap and a groin flap. J Reconstr Microsurg 2011;27:299–302.
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23. El-Sabbagh AH, Zeina AA, El-Hadidy AM, El-Din AB. Reversed posterior interosseous flap: Safe and easy method for hand reconstruction. J Hand Microsurg 2011;3:66–72. 24. Wong M, Tay SC, Teoh LC. Versatility of the turn-around technique of the lateral arm flap for hand reconstruction. Ann Plast Surg 2012; 69:265–270. 25. Ulrich D, Fuchs P, Bozkurt A, Pallua N. Free serratus anterior fascia flap for reconstruction of hand and finger defects. Arch Orthop Trauma Surg 2010;130:217–222. 26. Deal DN, Barnwell J, Li Z. Soft-tissue coverage of complex dorsal hand and finger defects using the turnover adipofascial flap. J Reconstr Microsurg 2011;27:133–138. 27. Hammouda AA, El-Khatib HA, Al-Hetmi T. Extended stepadvancement flap for avulsed amputated fingertip—A new technique to preserve finger length: Case series. J Hand Surg Am 2011;36:129–134. 28. Zhang X, Shao X, Ren C, Wen S, Zhu H, Sun J. Coverage of dorsal-ulnar hand wounds with a reverse second dorsal metacarpal artery flap. J Reconstr Microsurg 2012;28:167–173. 29. Demiri EC, Dionyssiou DD, Biskiniotis I, Papadimitriou D. Reconstruction of a degloved finger with a heterodigital reverse dorsal digitometacarpal flap. Scand J Plast Reconstr Surg Hand Surg 2007;41:42–44. 30. Hashem AM. Salvage of degloved digits with heterodigital flaps and full thickness skin grafts. Ann Plast Surg 2010; 64:155–158. 31. Giessler GA, Erdmann D, Germann G. Soft tissue coverage in devastating hand injuries. Hand Clin 2003;19:63–71. 32. Heitmann C, Levin LS. Alternatives to thumb replantation. Plast Reconstr Surg 2002;110:1492–1503. 33. Van der Horst CM, Hovius SE, van der Meulen JC. Results of treatment of 48 ring avulsion injuries. Ann Plast Surg 1989;22:9–13. 34. Kleinman WB, Dustman JA. Preservation of function following complete degloving injuries to the hand: Use of simultaneous groin flap, random abdominal flap, and partial thickness skin graft. J Hand Surg 1981;6:82–89. 35. Wei FC, Chen HC, Chuang DC, Chen S, Noordhoff MS. Second toe wrap-around flap. Plast Reconstr Surg 1991;88:837–843. 36. Khouri RK, Diehl GJ. Salvage in a case of ring avulsion injury with an immediate second-toe wrap-around flap. J Hand Surg 1992;17A: 714–718. 37. Guoliang C. Replantation and Reconstruction of Fingers. People’s Medical Publishing House: Beijing, China; 2008. p 561. 38. Kitidumrongsook P, Patradul A, Pataradool K. Resurfacing the degloved thumb up to the interphalangeal joint level with twin extended neurovascular island flaps. J Hand Surg Br 2006;31:562–565. 39. Lee DC, Kim JS, Ki SH. Partial second toe pulp free flap for fingertip reconstruction. Plast Reconstr Surg 2008;121:899–907. 40. Fatemi MJ, Jalilimanesh M, Dini MT. Evaluation of moving and static two point discriminations of volar forearm skin before and after transfer as a sensate radial forearm island flap in reconstruction of degloving injury of the thumb. J Plast Reconstr Aesthet Surg 2007;60:356–359.
