Accepted Manuscript Reconstruction of a Large Soft-tissue Defect in the Single Finger Using the Modified Cross Finger Flap Chao Chen, MD. PhD., Peifu Tang, MD. PhD., Lihai Zhang, MD. PhD. PII:
S1748-6815(15)00175-8
DOI:
10.1016/j.bjps.2015.03.033
Reference:
PRAS 4585
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 18 November 2014 Accepted Date: 30 March 2015
Please cite this article as: Chen C, Tang P, Zhang L, Reconstruction of a Large Soft-tissue Defect in the Single Finger Using the Modified Cross Finger Flap, British Journal of Plastic Surgery (2015), doi: 10.1016/j.bjps.2015.03.033. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
Reconstruction of a Large Soft-tissue Defect in the Single Finger Using the Modified Cross
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Finger Flap
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Chao Chen, MD. PhD., a Peifu Tang, MD. PhD.,a Lihai Zhang, MD. PhD.
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Authors’ institution
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a
The department of Orthopedics, Chinese PLA General Hospital, Beijing, 100853, P.R. China
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b
Hand Surgery Department, the Second Hospital of Tangshan, Tangshan, 063000, Hebei,
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P.R. China
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Contact information for the first author
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Chao Chen, MD. PhD.,
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The department of Orthopedics,
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Chinese PLA General Hospital,
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Beijing, 100853,
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P.R. China
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(+86) – 13700350471 (Mobile Phone)
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[email protected] (email)
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Corresponding author:
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Peifu Tang, MD. PhD.,
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The department of Orthopedics,
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Chinese PLA General Hospital,
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Beijing, 100853,
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P.R. China
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(+86) – 13801379901 (Mobile Phone)
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[email protected] (email)
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Reconstruction of a Large Soft-tissue Defect in the Single Finger Using the Modified Cross
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Finger Flap
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Key words: Soft-tissue defects; dorsal branch of the digital artery; dorsal branch of the digital
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nerve; cross-finger flap.
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Abstract
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Background: Providing soft tissue coverage for a large defect in the single finger
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presents marked functional and aesthetic challenges. This article describes the reconstruction
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of such injuries using a modified cross-finger flap and reports the results of the use of the flap. Methods: Over five years, a retrospective study was conducted with 22 patients who had
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a large defect in the single finger. The mean size of soft tissue defects was 4.3 cm ± 0.4 in
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length and 1.8 cm ± 0.4 in width. The defects were reconstructed with a modified cross-finger
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flap.
Results: Full flap survival was achieved in 20 fingers. Partial distal flap necrosis
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occurred in 2 fingers, which healed without surgical intervention. We collected the data of the
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sensory restoration in 20 flaps where sensory return was considered important. Based on the
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modified American Society for Surgery of the Hand guidelines for stratification of 2PD, 17
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(85 %) flaps achieved excellent and good results and only 3 (15 %) flap obtained fair result.
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No significant difference was found in joint motion between the donor finger and the
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contralateral side. According to the Michigan Hand Outcomes Questionnaire, 11 patients
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were satisfied, 9 were somewhat satisfied and 2 were neither satisfied nor dissatisfied with
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functional recovery of the reconstructed finger. Conclusions: The modified cross-finger flap is versatile and useful for coverage of the relatively large defect in the single fingers, especially when sensory reconstruction is needed.
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Type of study/level of evidence: Therapeutic
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INTRODUCTION
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There is a wide range of options for reconstructing small to moderate soft-tissue defects of the finger allowing the use of a specific flap for each reconstructive situation 1. But for a
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large defect in the single finger, the injury condition is often complex and severe, which limits
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the choice of reconstructive alternative. The article introduces the reconstruction of these
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defects using a modified cross-finger flap 2 and reports the results of the use of the flap.
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As described in previous anatomical studies, the distribution of the dorsal branches of the 3
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digital artery is relatively constant
and these branches could be selected as the vascular
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pedicles of the flaps harvested from the dorsum of the finger 4. Based on this anatomical
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structure, a large size cross-finger flap can receive sufficient blood supply from 1 or 2 dorsal
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branches through a narrow pedicle. In this manner, covering a large defect of the single finger
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is practicable.
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The purpose of this study was to report reconstruction of a large defect in the single
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finger using a modified cross-finger flap and to evaluate the efficacy of their application in
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such specific situation.
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PATIENTS AND METHODS
The study was approved by the institutional review boards of the participating hospitals.
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Informed consent and Health Insurance Portability and Accountability Act consents were
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obtained from each patient.
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ACCEPTED MANUSCRIPT From Jul 2007 to Sep 2012, a retrospective study was conducted with 22 patients who
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had a relatively large defect in one finger treated with our technique. Our series included 17
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male and 5 female patients, with mean age of 33 years (range, 21–56 years). The mechanisms
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of injury were avulsion (n = 8), crush (n = 6), and degloving (n = 8). There were 22 soft tissue
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defects in 22 fingers. The fingers requiring resurfacing included 6 index, 7 long, 5 ring, and 4
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little fingers. The injuries included soft-tissue defect in 7 cases and fingertip degloving injury
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involved the entire nail bed in 15 cases. The mean size of soft tissue defects was 4.3 cm ± 0.4
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in length and 1.8 cm ± 0.4 in width. The defects were reconstructed with the dual- (n=16),
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single- (n=4) and non- (n=2) innervated modified cross-finger flaps. Emergency surgery was
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conducted in 17 patients, whereas elective surgery was noted in 5 patients.
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Patients were selected on the basis of the following: (1) a patient who had a large defect in one finger; (2) the defect 4 cm in length and (3) a patient between 15 and 60 years of age.
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Patients were excluded when they had one of the following: (1) concomitant injuries to the
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dorsum of adjacent finger that precluded its use as donor site; (2) a defect < 4 cm in length
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and (3) the defect of the thumb.
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Surgical technique
The operation was performed under axillary block with the aid of tourniquet control. The
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flap was designed on the dorsum of adjacent finger between the distal half of the proximal
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phalanx and the distal interphalangeal joint. The pattern of the flap was based on the pattern
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of the defect.
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An incision was made through the flap outline and the flap was elevated above the
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ACCEPTED MANUSCRIPT tenosynovium. The pedicle was selected at the level of the distal interphalangeal joint or the
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base of the middle phalanx, at which digital artery sent off dorsal branches. One or two dorsal
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branches were included in the 1-cm-wide pedicle. The pedicle was dissected to the original
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site of the dorsal branch, and thus the maximal pedicle length was achieved. For a defect
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where return of sensation was important, one or two dorsal branches of the digital nerves
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could be harvested with the flap to restore neurosensory function. Thereafter, the injured
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finger was flexed and placed in a position to receive the cross-finger flap. The flap was
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transferred to the injured finger and the defect was covered. At last, the donor defect was
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resurfaced with a full-thickness skin graft and tie-over dressing.
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Postoperative management
A splint was used to maintain a tension-free pedicle. The pedicle was divided after a
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mean time of 20 days (range, 19–24 days). After that, the patient started active range of
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motion exercises with the help of a physical therapist.
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Evaluation of outcomes
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At final follow-up, sensation of the flaps was assessed using static two-point
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discrimination (2PD) 5. The modified American Society for Surgery of the Hand guidelines
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were used to stratify the 2PD measurements (excellent, < 6 mm; good, 6–10 mm; fair, 11–15
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mm; poor, > 15 mm) 6. The range of motion (ROM) of the proximal and distal interphalangeal
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joints of the donor finger was measured by a goniometer. Patients reported their satisfaction
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with functional recovery of the injured finger according to the Michigan Hand Outcomes
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Questionnaire that was based on a 5-point response scale 7.
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RESULTS
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Full flap survival was observed in 20 fingers. Partial distal flap necrosis occurred in 2 fingers, which ranged from 10% to 15% of the original flaps and healed without surgical
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intervention. No wound infection was observed. The follow-up period ranged from 20 to 24
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months (mean, 22 months).
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Sensory Recovery
We collected the data of the flap sensibility in the fingers where sensory return was
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considered important. These anatomical regions included the fingertip and the volar aspect of
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the finger. Reconstructive techniques included the dual- (n=16) and single-innervated (n=4)
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cross-finger flaps. At the final follow-up, the mean static 2PD was 7.2 mm (range, 5 to 11 mm)
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and 9.0 mm (range, 7 to 12mm), respectively. Based on the modified American Society for
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Surgery of the Hand guidelines for stratification of 2PD, 17 (85 %) flaps achieved excellent
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and good results and only 3 (15 %) flap obtained fair result.
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Joint Motion
Of the donor fingers, the ROM of the proximal and distal interphalangeal joints were 99°
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(range, 85° to 110°) and 72° (range, 40° to 90°), respectively. The measurements of the
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contralateral side were 101° (range, 90° to 110°) and 73° (range, 45° to 90°), respectively. No
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significant difference was found between the donor finger and the contralateral side.
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Patient satisfaction According to the Michigan Hand Outcomes Questionnaire, 11 patients were satisfied
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(score 5), 9 were somewhat satisfied (score 4) and 2 were neither satisfied nor dissatisfied
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with functional recovery of the reconstructed finger.
CASE REPORTS
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Case 1
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A 22-year-old worker sustained a degloving injury to his left ring, resulting in a projecting tip of the distal phalanx and a soft tissue defect with 4.3×1.8 cm in size (Fig. 1). A
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modified cross-finger flap was harvested from the dorsum of the middle finger. The size of
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the flap was 4.4×2.0 cm. Double dorsal branches of the digital nerves were harvested with
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the flap for sensory reconstruction of the pulp (Fig. 2 and 3). The flaps survived completely.
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Four months after surgery, almost full range of motion was attained to the donor finger (Fig.
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4). The static 2PD on the reconstructed pulp was 8 mm at 22 months postoperatively.
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Case 2
A 35-year-old male worker had a crushing injury in the right hand, resulting in a large
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volar defect in the little finger with 4.2×1.6 cm in size (Fig. 5). Although the ring finger had
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a fingertip defect, its dorsal skin on the proximal and middle phalanxes was uninjured and
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could be used as a donor site. A single-innervated cross-finger flap was harvested from the
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dorsum of the ring finger (Fig. 6). The flap survived completely and the graft healed
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uneventfully (Fig. 7). No loss of joint motion occurred in the donor finger 3 months after
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surgery. The static 2PD was 10 mm on the flap at 23 months postoperatively.
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DISCUSSION
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Providing soft tissue coverage for a large defect in the single finger often presents
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marked functional and aesthetic challenges 9. The article introduces the use of a modified
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cross-finger flap 2, which can be an optional solution.
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Some reconstructive techniques have been described in the literature. A volar V-Y flap10 can result in a good sensory recovery, but the flap cannot be used to cover a defect longer
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than 1.5 cm. The neurovascular island pedicle advancement flap11, dorsal homodigital island
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flap based on the digital artery12 or its dorsal branch13 are available options for tissue coverage
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of the small to moderate defects. But for a large defect in the single finger, none of these
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options can afford to provide sufficient or reasonable coverage. The abdominal or forearm
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random-pattern flap is technically easy for repairing these injuries14. However, the overstaffed
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form and poor sensory recovery are major disadvantages of these technique15. The reverse
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dorsal metacarpal artery flap or its modified technique can be used as alternatives but have a
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limited pedicle length to reach the defects distal to the distal interphalangeal joint16. A Littler
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flap17 based on the heterodigital neurovascular bundle provides relatively large tissue
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coverage and achieves sufficient sensory restoration, but it is characterised by several major
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drawbacks such as the loss of the digital artery and deterioration of the pulp sensibility and
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ACCEPTED MANUSCRIPT hyperaesthesia of the donor finger 18. Transferring a free flap, such as venous flow through
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flap19, free groin20 or toe flap21, can be used as an alternative and is associated with minimal
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donor site morbidities. However, these techniques usually require a two-team approach,
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microsurgical technique, long operating time and carry a risk of anastomotic failure 22.
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The conventional cross-finger flap is an alternative for repairing the large regular defects, but for the irregular defect or fingertip degloving injury, the wide pedicle restricts its
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application 23. We modified this technique to improve its flexibility by means of a narrow
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pedicle containing the dorsal branch of the digital artery. Moreover, the entire dorsum of the
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middle or proximal phalanx can be used as the donor. The important features of the modified
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flap makes it more versatile for reconstructing a large soft-tissue defect, especially for the
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fingertip degloving injury.
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Fingertip degloving injury is a special type tissue defect involved the pulp and nail bed,
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and is often associated with transected digital nerves in both sides 24. Therefore, restoration
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of pulp sensation and reduction of complications are difficult. Double dorsal branches of the
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digital nerves can be harvested with the flap to restore neurosensory function and reduce the
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recurrence of the painful digital neuroma 25. It may become one valuable option as sensory
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recovery and pain prevention in fingertip reconstruction.
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When the modified cross-finger flap can not provide sufficient coverage or can not reach
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the distal portion of the defect, a combinative reconstruction with the two flaps may be an
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alternative. However, more scars along the dorsum of the hand is its major disadvantage.
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Therefore, this technique is only an additional option for coverage of the large soft-tissue
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defects.
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Finger stiffness may be the major concern in terms of joint motion when the modified cross-finger flap extends proximally beyond the proximal interphalangeal joint. However,
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early rehabilitation can lower stiffness incidence and render the skin graft less prone to
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contraction. In addition, early rehabilitation can prevent the development of extensor tendon
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adhesion 26.
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Limitation of the study is the lack of comparison and control. Future studies ideally will
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be prospective, randomized, and blinded to better ascertain the efficacy of our reconstructive
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technique.
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CONCLUSION
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The modified cross-finger flap is versatile and useful for coverage of the relatively large
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defect in the single fingers, especially when sensory reconstruction is needed.
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Funding: None
Conflicts of interest: None declared Ethical approval: Not required
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REFERENCES
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1. Yang D, Morris SF. Reversed dorsal digital and metacarpal island flaps supplied by the
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dorsal cutaneous branches of the palmar digital artery. Ann Plast Surg. 2001;46:444–449.
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2. Chen C, Tang P, Zhang L, Wang B. Treatment of fingertip degloving injury using the
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bilaterally innervated sensory cross-finger flap. Ann Plast Surg. 2013; June; 6.
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3. Strauch B, Moura W. Arterial system of the fingers. J Hand Surg Am. 1990;1:148–154.
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4. Li YF, Cui SS. Innervated reverse island flap based on the end dorsal branch of the digital
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artery: surgical technique. J Hand Surg Am. 2005;30:1305–1309.
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5. Chen C, Tang P, Zhang L. Reconstruction of a soft tissue defect in the finger using the
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heterodigital neurocutaneous island flap. Injury. 2013,44: 1607–1614.
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6. Crosby PM, Dellon AL. Comparison of two-point discrimination testing devices.
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Microsurgery. 1989;10:134–137.
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7. Dellon AL, Kallman CH. Evaluation of functional sensation in the hand. J Hand Surg Am.
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1983;8:865–870.
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8. Chung KC, Hamill JB, Walters MR, Hayward RA. The Michigan Hand Outcomes
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Questionnaire (MHQ): assessment of responsiveness to clinical change. Ann Plast Surg.
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1999;42:619–622.
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9. Teoh LC, Tay SC, Yong FC, Tan SH, Khoo DB. Heterodigital arterialized flaps for large finger
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wounds: results and indications. Plast Reconstr Surg. 2003;111:1905–1913.
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10. Tupper J, Miller G. Sensitivity following volar V-Y plasty for fingertip amputations. J Hand
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Surg Br. 1985;10:183–184.
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ACCEPTED MANUSCRIPT 11. Snow JW. Volar advancement skin flap to the fingertip. Hand Clin. 1985;1:685–688.
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12. Han SK, Lee BI, Kim WK. The reverse digital artery island flap: an update. Plast Reconstr
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Surg. 2004;113:1753–1755.
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13. Chen C, Tang P, Zhang X. Sensory reconstruction of a finger pulp defect using a dorsal
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homodigital island flap. Plast Reconstr Surg. 2012 ;130:1077–1086.
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14. Senarath-Yapa K, Bell DR. 'Front and back' flaps for multiple dorsal and palmar digital
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skin loss. J Hand Surg Br. 2010;35:721–724.
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15. Cohen BE, Cronin ED. An innervated cross-finger flap for fingertip reconstruction. Plast
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Reconstr Surg. 1983;72:688–697.
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16. Yoon SW, Rebecca AM, Smith AA, Mazaheri MK, Casey WJ. Reverse second dorsal
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metacarpal artery flap for reconstruction of fourth-degree burn wounds of the hand. J Burn
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Care Res. 2007;28:521–523.
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17. Littler JW. The neurovascular pedicle method of digital transposition for reconstruction of
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the thumb. Plast Reconstr Surg 1953;12:303–19.
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18. Adani R, Squarzina PB, Castagnetti C, Lagana
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study of the heterodigital neurovascular island flap in thumb reconstruction, with and without
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nerve reconnection. J Hand Surg Br 1994;19:552–9.
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19. Brooks D, Buntic RF, Taylor C. Use of the venous flap for salvage of difficult ring
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avulsion injuries. Microsurgery. 2008;28:397–402.
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20. Collins D, Sebire NJ, Barnacle A, Ramakrishnan V, Kangesu L. 'Mini' free groin flap for
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treatment of a tufted angioma of the finger. J Plast Reconstr Aesthet Surg. 2011;64:128–131.
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21. Deglise B, Botta Y. Microsurgical free toe pulp transfer for digital reconstruction. Ann
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Plast Surg. 1991;26:341–346.
A, Pancaldi G, Caroli A. A comparative
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ACCEPTED MANUSCRIPT 22. Yao J, Li J, Shen X, Chen Q, Jing S. Clinical application of free digital artery flap of the
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hand. Plast Reconstr Surg. 1999;103:980–983.
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23. Lee JY, Teoh LC, Seah VW. Extending the reach of the heterodigital arterialized flap by
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cross-finger transfer. Plast Reconstr Surg. 2006;117:2320–1328.
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24. Kazufumi S, Shinpo A, Sachiko K, et al. Delayed extended “midthenar” flap for
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reconstruction of total fingertip avulsion injury and a proposal of ideal postoperative
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immobilization for a palmar flap. Ann Plast Surg. 2007;58: 116–119.
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25. Chen C, Tang P, Zhang X. The dorsal homodigital island flap based on the dorsal branch
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of the digital artery: a review of 166 cases. Plast Reconstr Surg. 2014,133:519–529.
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26. Shao X, Chen C, Zhang X, Yu Y, Ren D, Lu L. Coverage of fingertip defect using a
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dorsal island pedicle flap including both dorsal digital nerves. J Hand Surg Am.
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2009;34:1474–1481.
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Figure 1: A fingertip degloving injury involved the entire nail bed.
Figure 2: The modified cross-finger flap was harvested from the dorsum of adjacent middle
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finger. The 2 dorsal nerve branches were elevated with the flap (arrows).
Figure 4: At 3 months after surgery, the contour of the finger pulp was restored.
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Figure 5: A soft-tissue defect of the little finger involving entire volar aspect.
Figure 6: A cross-finger flap was harvested from the dorsum of the ring finger. One dorsal
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branch of the digital nerve was harvested with the flap.
Figure 7: (Left) Transposition of the flap. (right) the appearance of the reconstructed finger at 5 weeks after surgery.
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S1748-6815(15)00175-8
DOI:
10.1016/j.bjps.2015.03.033
Reference:
PRAS 4585
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 18 November 2014 Accepted Date: 30 March 2015
Please cite this article as: Chen C, Tang P, Zhang L, Reconstruction of a Large Soft-tissue Defect in the Single Finger Using the Modified Cross Finger Flap, British Journal of Plastic Surgery (2015), doi: 10.1016/j.bjps.2015.03.033. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
Reconstruction of a Large Soft-tissue Defect in the Single Finger Using the Modified Cross
2
Finger Flap
3 a, b
Chao Chen, MD. PhD., a Peifu Tang, MD. PhD.,a Lihai Zhang, MD. PhD.
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Authors’ institution
7
a
The department of Orthopedics, Chinese PLA General Hospital, Beijing, 100853, P.R. China
8
b
Hand Surgery Department, the Second Hospital of Tangshan, Tangshan, 063000, Hebei,
9
P.R. China
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10
Contact information for the first author
12
Chao Chen, MD. PhD.,
13
The department of Orthopedics,
14
Chinese PLA General Hospital,
15
Beijing, 100853,
16
P.R. China
17
(+86) – 13700350471 (Mobile Phone)
18
[email protected] (email)
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Corresponding author:
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Peifu Tang, MD. PhD.,
22
The department of Orthopedics,
1
23
Chinese PLA General Hospital,
24
Beijing, 100853,
25
P.R. China
26
(+86) – 13801379901 (Mobile Phone)
27
[email protected] (email)
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Reconstruction of a Large Soft-tissue Defect in the Single Finger Using the Modified Cross
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Finger Flap
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Key words: Soft-tissue defects; dorsal branch of the digital artery; dorsal branch of the digital
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nerve; cross-finger flap.
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50
Abstract
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Background: Providing soft tissue coverage for a large defect in the single finger
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presents marked functional and aesthetic challenges. This article describes the reconstruction
54
of such injuries using a modified cross-finger flap and reports the results of the use of the flap. Methods: Over five years, a retrospective study was conducted with 22 patients who had
55
a large defect in the single finger. The mean size of soft tissue defects was 4.3 cm ± 0.4 in
57
length and 1.8 cm ± 0.4 in width. The defects were reconstructed with a modified cross-finger
58
flap.
Results: Full flap survival was achieved in 20 fingers. Partial distal flap necrosis
EP
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occurred in 2 fingers, which healed without surgical intervention. We collected the data of the
61
sensory restoration in 20 flaps where sensory return was considered important. Based on the
62
modified American Society for Surgery of the Hand guidelines for stratification of 2PD, 17
63
(85 %) flaps achieved excellent and good results and only 3 (15 %) flap obtained fair result.
64
No significant difference was found in joint motion between the donor finger and the
65
contralateral side. According to the Michigan Hand Outcomes Questionnaire, 11 patients
66
were satisfied, 9 were somewhat satisfied and 2 were neither satisfied nor dissatisfied with
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60
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functional recovery of the reconstructed finger. Conclusions: The modified cross-finger flap is versatile and useful for coverage of the relatively large defect in the single fingers, especially when sensory reconstruction is needed.
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Type of study/level of evidence: Therapeutic
.
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INTRODUCTION
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There is a wide range of options for reconstructing small to moderate soft-tissue defects of the finger allowing the use of a specific flap for each reconstructive situation 1. But for a
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large defect in the single finger, the injury condition is often complex and severe, which limits
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the choice of reconstructive alternative. The article introduces the reconstruction of these
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defects using a modified cross-finger flap 2 and reports the results of the use of the flap.
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As described in previous anatomical studies, the distribution of the dorsal branches of the 3
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digital artery is relatively constant
and these branches could be selected as the vascular
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pedicles of the flaps harvested from the dorsum of the finger 4. Based on this anatomical
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structure, a large size cross-finger flap can receive sufficient blood supply from 1 or 2 dorsal
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branches through a narrow pedicle. In this manner, covering a large defect of the single finger
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is practicable.
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The purpose of this study was to report reconstruction of a large defect in the single
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finger using a modified cross-finger flap and to evaluate the efficacy of their application in
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such specific situation.
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PATIENTS AND METHODS
The study was approved by the institutional review boards of the participating hospitals.
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Informed consent and Health Insurance Portability and Accountability Act consents were
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obtained from each patient.
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ACCEPTED MANUSCRIPT From Jul 2007 to Sep 2012, a retrospective study was conducted with 22 patients who
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had a relatively large defect in one finger treated with our technique. Our series included 17
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male and 5 female patients, with mean age of 33 years (range, 21–56 years). The mechanisms
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of injury were avulsion (n = 8), crush (n = 6), and degloving (n = 8). There were 22 soft tissue
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defects in 22 fingers. The fingers requiring resurfacing included 6 index, 7 long, 5 ring, and 4
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little fingers. The injuries included soft-tissue defect in 7 cases and fingertip degloving injury
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involved the entire nail bed in 15 cases. The mean size of soft tissue defects was 4.3 cm ± 0.4
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in length and 1.8 cm ± 0.4 in width. The defects were reconstructed with the dual- (n=16),
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single- (n=4) and non- (n=2) innervated modified cross-finger flaps. Emergency surgery was
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conducted in 17 patients, whereas elective surgery was noted in 5 patients.
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Patients were selected on the basis of the following: (1) a patient who had a large defect in one finger; (2) the defect 4 cm in length and (3) a patient between 15 and 60 years of age.
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Patients were excluded when they had one of the following: (1) concomitant injuries to the
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dorsum of adjacent finger that precluded its use as donor site; (2) a defect < 4 cm in length
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and (3) the defect of the thumb.
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Surgical technique
The operation was performed under axillary block with the aid of tourniquet control. The
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flap was designed on the dorsum of adjacent finger between the distal half of the proximal
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phalanx and the distal interphalangeal joint. The pattern of the flap was based on the pattern
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of the defect.
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An incision was made through the flap outline and the flap was elevated above the
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ACCEPTED MANUSCRIPT tenosynovium. The pedicle was selected at the level of the distal interphalangeal joint or the
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base of the middle phalanx, at which digital artery sent off dorsal branches. One or two dorsal
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branches were included in the 1-cm-wide pedicle. The pedicle was dissected to the original
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site of the dorsal branch, and thus the maximal pedicle length was achieved. For a defect
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where return of sensation was important, one or two dorsal branches of the digital nerves
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could be harvested with the flap to restore neurosensory function. Thereafter, the injured
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finger was flexed and placed in a position to receive the cross-finger flap. The flap was
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transferred to the injured finger and the defect was covered. At last, the donor defect was
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resurfaced with a full-thickness skin graft and tie-over dressing.
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Postoperative management
A splint was used to maintain a tension-free pedicle. The pedicle was divided after a
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mean time of 20 days (range, 19–24 days). After that, the patient started active range of
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motion exercises with the help of a physical therapist.
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Evaluation of outcomes
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At final follow-up, sensation of the flaps was assessed using static two-point
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discrimination (2PD) 5. The modified American Society for Surgery of the Hand guidelines
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were used to stratify the 2PD measurements (excellent, < 6 mm; good, 6–10 mm; fair, 11–15
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mm; poor, > 15 mm) 6. The range of motion (ROM) of the proximal and distal interphalangeal
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joints of the donor finger was measured by a goniometer. Patients reported their satisfaction
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with functional recovery of the injured finger according to the Michigan Hand Outcomes
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Questionnaire that was based on a 5-point response scale 7.
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RESULTS
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Full flap survival was observed in 20 fingers. Partial distal flap necrosis occurred in 2 fingers, which ranged from 10% to 15% of the original flaps and healed without surgical
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intervention. No wound infection was observed. The follow-up period ranged from 20 to 24
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months (mean, 22 months).
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Sensory Recovery
We collected the data of the flap sensibility in the fingers where sensory return was
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considered important. These anatomical regions included the fingertip and the volar aspect of
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the finger. Reconstructive techniques included the dual- (n=16) and single-innervated (n=4)
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cross-finger flaps. At the final follow-up, the mean static 2PD was 7.2 mm (range, 5 to 11 mm)
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and 9.0 mm (range, 7 to 12mm), respectively. Based on the modified American Society for
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Surgery of the Hand guidelines for stratification of 2PD, 17 (85 %) flaps achieved excellent
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and good results and only 3 (15 %) flap obtained fair result.
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Joint Motion
Of the donor fingers, the ROM of the proximal and distal interphalangeal joints were 99°
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(range, 85° to 110°) and 72° (range, 40° to 90°), respectively. The measurements of the
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contralateral side were 101° (range, 90° to 110°) and 73° (range, 45° to 90°), respectively. No
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significant difference was found between the donor finger and the contralateral side.
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Patient satisfaction According to the Michigan Hand Outcomes Questionnaire, 11 patients were satisfied
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(score 5), 9 were somewhat satisfied (score 4) and 2 were neither satisfied nor dissatisfied
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with functional recovery of the reconstructed finger.
CASE REPORTS
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Case 1
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A 22-year-old worker sustained a degloving injury to his left ring, resulting in a projecting tip of the distal phalanx and a soft tissue defect with 4.3×1.8 cm in size (Fig. 1). A
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modified cross-finger flap was harvested from the dorsum of the middle finger. The size of
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the flap was 4.4×2.0 cm. Double dorsal branches of the digital nerves were harvested with
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the flap for sensory reconstruction of the pulp (Fig. 2 and 3). The flaps survived completely.
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Four months after surgery, almost full range of motion was attained to the donor finger (Fig.
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4). The static 2PD on the reconstructed pulp was 8 mm at 22 months postoperatively.
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Case 2
A 35-year-old male worker had a crushing injury in the right hand, resulting in a large
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volar defect in the little finger with 4.2×1.6 cm in size (Fig. 5). Although the ring finger had
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a fingertip defect, its dorsal skin on the proximal and middle phalanxes was uninjured and
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could be used as a donor site. A single-innervated cross-finger flap was harvested from the
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dorsum of the ring finger (Fig. 6). The flap survived completely and the graft healed
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uneventfully (Fig. 7). No loss of joint motion occurred in the donor finger 3 months after
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surgery. The static 2PD was 10 mm on the flap at 23 months postoperatively.
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DISCUSSION
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Providing soft tissue coverage for a large defect in the single finger often presents
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marked functional and aesthetic challenges 9. The article introduces the use of a modified
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cross-finger flap 2, which can be an optional solution.
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Some reconstructive techniques have been described in the literature. A volar V-Y flap10 can result in a good sensory recovery, but the flap cannot be used to cover a defect longer
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than 1.5 cm. The neurovascular island pedicle advancement flap11, dorsal homodigital island
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flap based on the digital artery12 or its dorsal branch13 are available options for tissue coverage
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of the small to moderate defects. But for a large defect in the single finger, none of these
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options can afford to provide sufficient or reasonable coverage. The abdominal or forearm
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random-pattern flap is technically easy for repairing these injuries14. However, the overstaffed
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form and poor sensory recovery are major disadvantages of these technique15. The reverse
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dorsal metacarpal artery flap or its modified technique can be used as alternatives but have a
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limited pedicle length to reach the defects distal to the distal interphalangeal joint16. A Littler
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flap17 based on the heterodigital neurovascular bundle provides relatively large tissue
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coverage and achieves sufficient sensory restoration, but it is characterised by several major
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drawbacks such as the loss of the digital artery and deterioration of the pulp sensibility and
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flap19, free groin20 or toe flap21, can be used as an alternative and is associated with minimal
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donor site morbidities. However, these techniques usually require a two-team approach,
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microsurgical technique, long operating time and carry a risk of anastomotic failure 22.
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The conventional cross-finger flap is an alternative for repairing the large regular defects, but for the irregular defect or fingertip degloving injury, the wide pedicle restricts its
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application 23. We modified this technique to improve its flexibility by means of a narrow
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pedicle containing the dorsal branch of the digital artery. Moreover, the entire dorsum of the
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middle or proximal phalanx can be used as the donor. The important features of the modified
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flap makes it more versatile for reconstructing a large soft-tissue defect, especially for the
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fingertip degloving injury.
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Fingertip degloving injury is a special type tissue defect involved the pulp and nail bed,
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and is often associated with transected digital nerves in both sides 24. Therefore, restoration
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of pulp sensation and reduction of complications are difficult. Double dorsal branches of the
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digital nerves can be harvested with the flap to restore neurosensory function and reduce the
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recurrence of the painful digital neuroma 25. It may become one valuable option as sensory
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recovery and pain prevention in fingertip reconstruction.
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When the modified cross-finger flap can not provide sufficient coverage or can not reach
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the distal portion of the defect, a combinative reconstruction with the two flaps may be an
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alternative. However, more scars along the dorsum of the hand is its major disadvantage.
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Therefore, this technique is only an additional option for coverage of the large soft-tissue
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defects.
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Finger stiffness may be the major concern in terms of joint motion when the modified cross-finger flap extends proximally beyond the proximal interphalangeal joint. However,
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early rehabilitation can lower stiffness incidence and render the skin graft less prone to
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contraction. In addition, early rehabilitation can prevent the development of extensor tendon
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adhesion 26.
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Limitation of the study is the lack of comparison and control. Future studies ideally will
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be prospective, randomized, and blinded to better ascertain the efficacy of our reconstructive
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technique.
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CONCLUSION
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The modified cross-finger flap is versatile and useful for coverage of the relatively large
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defect in the single fingers, especially when sensory reconstruction is needed.
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Funding: None
Conflicts of interest: None declared Ethical approval: Not required
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REFERENCES
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1. Yang D, Morris SF. Reversed dorsal digital and metacarpal island flaps supplied by the
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dorsal cutaneous branches of the palmar digital artery. Ann Plast Surg. 2001;46:444–449.
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2. Chen C, Tang P, Zhang L, Wang B. Treatment of fingertip degloving injury using the
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bilaterally innervated sensory cross-finger flap. Ann Plast Surg. 2013; June; 6.
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3. Strauch B, Moura W. Arterial system of the fingers. J Hand Surg Am. 1990;1:148–154.
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4. Li YF, Cui SS. Innervated reverse island flap based on the end dorsal branch of the digital
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artery: surgical technique. J Hand Surg Am. 2005;30:1305–1309.
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6. Crosby PM, Dellon AL. Comparison of two-point discrimination testing devices.
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Surg. 2004;113:1753–1755.
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13. Chen C, Tang P, Zhang X. Sensory reconstruction of a finger pulp defect using a dorsal
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14. Senarath-Yapa K, Bell DR. 'Front and back' flaps for multiple dorsal and palmar digital
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skin loss. J Hand Surg Br. 2010;35:721–724.
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16. Yoon SW, Rebecca AM, Smith AA, Mazaheri MK, Casey WJ. Reverse second dorsal
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17. Littler JW. The neurovascular pedicle method of digital transposition for reconstruction of
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the thumb. Plast Reconstr Surg 1953;12:303–19.
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18. Adani R, Squarzina PB, Castagnetti C, Lagana
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nerve reconnection. J Hand Surg Br 1994;19:552–9.
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19. Brooks D, Buntic RF, Taylor C. Use of the venous flap for salvage of difficult ring
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25. Chen C, Tang P, Zhang X. The dorsal homodigital island flap based on the dorsal branch
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Figure 1: A fingertip degloving injury involved the entire nail bed.
Figure 2: The modified cross-finger flap was harvested from the dorsum of adjacent middle
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Figure 3: The flap was transferred to the recipient site.
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finger. The 2 dorsal nerve branches were elevated with the flap (arrows).
Figure 4: At 3 months after surgery, the contour of the finger pulp was restored.
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Figure 5: A soft-tissue defect of the little finger involving entire volar aspect.
Figure 6: A cross-finger flap was harvested from the dorsum of the ring finger. One dorsal
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branch of the digital nerve was harvested with the flap.
Figure 7: (Left) Transposition of the flap. (right) the appearance of the reconstructed finger at 5 weeks after surgery.
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