Second toe microsurgical free-flap for aesthetic and sensory reconstruction of palmar soft tissue defects of fingers

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Summary

Objectives

To illustrate the surgical methods and clinical efficacy of microsurgical free-flaps obtained from second toe for the reconstruction of palmar soft-tissue defect of fingers.

Methods

We enrolled 22 patients (13 men and 9 women), who received second toe free-flap for 22 finger defects between August 2007 and July 2013. The average age was 35 years (range, 18–62 years). The average size of flap was 2.7 cm × 2.0 cm (range, 1.5 cm × 1.5 cm–3.5 cm × 2.5 cm).

Results

All flaps survived well without any complications. Follow-up period ranged from 8 to 30 months (mean 15 months). The Visual Analog Scale for flap appearance (VAS flap) was ranged from 8 to 10 (average, 9.5). Based on the CISS questionnaires, 6 cases had mild cold intolerance. The average value of Michigan Hand Outcome Questionnaire (MHOQ) scoring for overall hand function was 8 (range, 5–13). The sensibility outcomes in 10 patients who underwent nerve repair were satisfactory. Average value of static two point discrimination (2PD) was 6.4 mm (range, 4–10 mm) and SWM test was 3.45 (range 2.83–4.12).

Conclusions

Second toe free micro-flap is a very useful and reliable alternative for the reconstruction of palmer soft-tissue defect of fingers.

Level of Evidence: IV.

Introduction

Palmar soft-tissue defects of the finger are very common in clinical practice. If left untreated, these defects may result in severe functional disability. Several techniques, ranging from skin grafting to free tissue transfer, have been described for resurfacing these defects.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 However, none have yielded entirely satisfactory results.

Second toe microsurgical free-flap has been found to be very useful in reconstructing palmar soft-tissue defects of fingers.14, 15, 16, 17, 18, 19 This flap is harvested from the medial aspect of second toe and offers glabrous tissue with histological similarity to finger soft-tissue. This flap is probably the best alternative for cases in which local flaps are not feasible. However, most previous studies suffer from small sample size and lack rigorous analysis of outcomes to support the indication of this reliable flap. Therefore, in this study, we report our experience of finger soft-tissue defects reconstruction using second toe free-flap. In addition, we analyze aesthetic, sensory and functional outcomes of reconstruction.

Section snippets

Patients and methods

We reviewed clinical data records of patients who received second toe free-flaps in our hospital. Patients with palmar soft-tissue defect of fingers were included and patients with thumb defects were excluded. For each of the patients, the following data were recorded: age, sex, mechanism of injury, sites of the defect, injury to operation time, size of the flap, donor site coverage and duration of follow-up.

We enrolled 22 patients (13 men and 9 women), who received second toe free-flap for 22

Surgical technique

Patients were explained thoroughly about the risks and benefits of the procedure and written informed consent were obtained. Patency of the donor toe's arterial systems was confirmed by Doppler ultrasonography. We performed all surgeries under general anesthesia aided by pneumatic tourniquet control, loupe magnification and surgical microscope. Meticulous debridement was done to remove non-viable tissues. The pattern of the flap was designed at medial aspect of ipsilateral second toe according

Postoperative regime and follow-up outcome evaluations

Postoperatively, the perfusion of the transplant was intensively monitored and viability was assessed by color, capillary refill, and temperature. Patients were treated with adequate dosage of antibiotics (broad spectrum cephalosporin), anti-coagulants (heparin SC injection, 4000 IU once-daily) and spasmolytics (papaverine, 30 mg every 8 h). The reconstructed finger was kept in extension splint for 5–7 days and rehabilitation was started.

At final follow-up visit, sensory outcomes were evaluated

Results

All flaps survived well without any complications and no operative revision was required. Follow-up period ranged from 8 to 30 months (mean 15 months). At final examination, all patients were satisfied with their recovery in terms of finger strength and function, and returned to their normal work. The Visual Analog Scale for flap appearance (VAS flap) was ranged from 8 to 10 (average, 9.5). Based on the CISS questionnaires, 6 cases had mild cold intolerance. The average Michigan Hand Outcome

Discussion

Aesthetic and sensory reconstruction of the finger soft tissue defects remains a consistent challenge for hand surgeons. The choice of the flap depends on several factors such as defect sizes, skin characteristics, donor site morbidity and facilitation of rehabilitations. Small superficial defects can be treated with full thickness skin grafts, but larger defects or those with exposed vital structures require flap coverage.1, 2

Local advancement and transposition flaps are ideal choice, but are

Conflict of interest

N/A.

Funding

N/A.

References (21)

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These authors contributed to this article equally.

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Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.