ORIGINAL ARTICLE

Dorsal V-Y advancement flap for amputations of the fingertips

MURAT T. OZYIGIT, TAYFUN TURKASLAN & ZAFER OZSOY

Department of Plastic and Reconstructive Surgery, Vakif Gureba Training and Research Hospital, Istanbul, Turkey

AbstractAmputations of the fingertip are the most common injuries to the upper limbs, and they cause greatest socioeconomiclosses. The first choice of the technique of repair should be the simplest and fastest, with rapid restoration of function and anacceptable aesthetic appearance, and should return the worker to his job rapidly to prevent economic loss. Volar V-Yadvancement flaps should therefore be considered first, but unless the dorsal loss is greater than the volar, this first choice offlap cannot be used because of the inadequate donor area. We present here a method for amputations that are proximal tothe matrix of the nail. Seven volar oblique or transverse amputations were treated with dorsal V-Yadvancement flaps with orwithout volar V-Y advancement flaps. All flaps survived. The procedure is simple, versatile, and a reliable way ofreconstructing amputations of the fingertip that are proximal to the nailbed.

Key Words: Amputation, dorsal V-Y advancement flap, fingertip

Introduction

Reconstruction of tissue loss at the fingertip with

exposure of tendons, bone, or joints, is a challenge.

Skin grafts applied to a soft tissue defect over an

exposed tendon, bone, or joint are usually unsuc-

cessful or not durable. Cover of such injuries with a

flap is preferable, and many flaps have been de-

scribed to cover composite digital defects [1�3].

Most procedures that have been described for the

repair of such defects attest to the lack of consensus

on an ideal technique [4].

When replantation is not feasible, the technique of

a local advancement dorsal flap alone or with a

palmar V-Y advancement flap preserves the length.

For defects between the distal phalanx proximal to

the matrix of the nail and the middle part of the

middle phalanx, both volar and dorsal oblique and

transverse amputations can be repaired in this way

(Figure 1). The aim of this study is to simplify the

treatment algorithm for the transverse or slight

oblique amputations proximal to the matrix of the

nail.

Patients and methods

Seven patients with transverse or volar oblique

(including both slight radial or ulnar oblique) digital

amputations between the distal phalanx proximal to

the matrix and the middle of the middle phalanx

were separated into two groups according to the type

of the defect. For the first type (who had volar

oblique amputations) a dorsal V-Y advancement flap

alone was prepared, and the second type (who had

transverse or dorsal oblique amputations) had the

defects reconstructed with combined volar and

dorsal advancement flaps (Table I). All patients

had sustained acute injuries, and were operated on

as emergencies under local anaesthesia.

Operative technique

A regional block was used. Blood is removed from

the finger and a Penrose drain applied to the base of

the finger as a tourniquet. Initially, the sharp end of

the bone is trimmed minimally without shortening

the finger.

For the dorsal oblique and transverse amputations

a straight palmar V-Y advancement flap is prepared

and to minimise the tension at the touching surface,

This study was presented as a poster at the 26th Congress of Turkish

Plastic, Reconstructive and Aesthetic Surgery, at the Bilkent Hotel, Ankara,

Turkey.

Correspondence: Murat T. Ozyigit, MD, Sinanoba 1.kisim A4-22 Blok D:1, BuyukCekmece, TR-34590 Istanbul, Turkey. Tel: �90(212)534-69-00/1661.

Fax: �90(212)621-75-80. E-mail: turkerozyigit@yahoo.com

Scand J Plast Reconstr Surg Hand Surg, 2007; 41: 315�319

(Accepted 26 April 2007)

ISSN 0284-4311 print/ISSN 1651-2073 online # 2007 Taylor & Francis

DOI: 10.1080/02844310701463357

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a dorsal V-Y advancement flap is prepared in the

same manner. For the volar oblique amputations

without extensive tension, a single dorsal V-Y

advancement flap was planned, both flaps being

planned at the distal phalanx if the amputation was

at the level of the matrix. If the distal phalanx was

totally amputated the flaps were planned at the

middle phalanx.

The base of the flap is the cut edge of the skin where

it has been amputated. If the bases of the flaps are

made much wider a square fingertip results, rather

than the normal round shape. If the amputation is at

the level of the nailbed, the apex of the triangle should

be placed at the distal flexion crease, and if the

amputation is at the level of the distal phalanx, the

apex of the triangle should be placed at the proximal

flexion crease, because a longer flap is easier to

advance. The side arms of the triangle are not straight,

but are drawn as two gently curving lines to the apex.

The flap is developed by cutting through the skin

completely, but leaving the paratenon intact. The flap

is then mobilised and advanced distally, and is

sutured to the edge of the volar flap or to the skin

edges with 4/0 nylon. The rest of the closure is done in

a V-Y fashion, starting with the proximal end of the

incision (Figure 2). It must be closed without tension.

If there is any tension a volar V-Yadvancement flap is

added to the dorsal one. The finger is immobilised for

a week and then active range of movement is begun.

Results

Five dorsal V-Y advancement and two volar plus

dorsal advancement flaps were done for six adult

male and one female patients (aged 25 to 46).

Follow-up was from 12 to 24 months (mean 18).

The mean operating time was 32 minutes. All flaps

survived completely and a full range of movement

was retained in the affected digit. All patients were

satisfied and used their digits without difficulty. The

mean static two-point discrimination was differed at

both sides of the finger, but was satisfactory on both

sides (Table I). The fingertips looked excellent, and

Table I. Patient data.

Case No.

Age

(years) Sex

Affected

digit

Type and

location

of defect

Two-point

discrimination at 12

months (mm)

1 25 M Right ring Proximal distal phalanx 5

2 26 M Left middle Distal interphalangeal 5

3 28 M Right ring Proximal distal phalanx 4

4 33 M Left index Midline of middle

phalanx

5

5 37 M Right index Distal interphalangeal 5

6 38 M Right ring Proximal distal phalanx Dorsal 5, Volar 6

7 46 F Left ring Proximal distal phalanx Dorsal 4, Volar 6

A dorsal V-Y flap was used in each case, together with a volar V-Y flap in cases 6 and 7.

Figure 2. The dorsal V-Y advancement flap is raised with slightly

curved side arms shown on the left. It is closed in a V-Y fashion

shown on the right.

Figure 1. Left to right: Transverse amputation, dorsal oblique

amputation, volar oblique amputation. All three types of amputa-

tion can be repaired with our treatment protocol.

316 M. T. Ozyigit et al.

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no patient had any pain. All patients returned to

work by the 21st day (Figures 3 and 4). No

dysaesthesia or hyperaesthesia was seen in any

patient. Two patients were intolerant to cold post-

operatively on the volar side, but not on the dorsal

side.

Discussion

The ideal reconstruction of fingertip injuries should

maintain length, and should cover the defect with

non-tender, well-padded skin that has normal or

near-normal sensation with no pain during activities

of daily living [5,6]. However, the technique should

minimise the time to return to work and economic

losses, and should ideally be a short one-stage

procedure.

Conventional methods, including the cross-finger

and thenar flaps, require an extended period to gain

sensitivity and have the disadvantage of being two-

stage operations. They need a period of immobilisa-

tion between procedures that can lead to stiffness of

the injured or donor digit, adding to time lost from

work [6].

The reconstructive algorithm for such amputa-

tions should begin from the simplest to the most

complex one, so free tissue transfer should be

preferred only if there are two or more adjacent

injured fingers, because they have many disadvan-

tages: a long period of immobilisation; scars at the

donor site; two-stage operations, lost time and

money; a long stay in hospital; inadequate sensory

return; long duration of unemployment; difficult

dissection; and risk of failure [7,8].

a b

c

Figure 3. (a) This patient had a transverse

amputation at the distal interphalangeal

level of the long finger; after debridement,

a volar V-Y advancement flap was raised. (b)

To reduce tension and to add bulk to the

stump, a dorsal V-Y advancement flap was

combined with the volar one. (c) The donor

area of the dorsal V-Y advancement flap was

closed in a V-Y fashion.

Dorsal V-Y flap for fingertip amputations 317

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Local flaps not only provide the best tissues for

reconstruction but also avoid cumbersome attach-

ments of the hand to distant donor sites and

minimise the required period of hospital care [9].

They also provide similar skin colour, texture, and

ease of operating.

Traditionally, the reconstructive algorithm sug-

gests the use of the triangular volar V-Yadvancement

flap as the first choice for the reasonable indications

[10]. The triangular volar skin flap is contraindi-

cated for palmar oblique amputations; those defects

must be covered by another type of local flap

because of the extensive soft tissue lost at the donor

area [5]. However, the other local or regional flaps,

or skin grafts, are unsatisfactory for the reasons given

above. For these cases, elasticity of the intact dorsal

skin is used, which gives an additional 8 mm; and

when combined with volar V-Y advancement flap,

the stump can be closed easily and free of tension

without shortening the length of the finger. The flap

we described can be used only for digital injuries

proximal to the germinal matrix; it is not indicated

for ulnar or radial oblique amputations.

The longitudinal dorsal arterial network on the

dorsum of the finger is cut while incising as far as the

paratenon. However, there are rich dorsal venous

and arterial networks lying in the subcutaneous

plane between the dermis and the paratenons [11].

This random pattern of circulation is safe for our

flaps as all survived completely.

We have therefore simplified the reconstructive

algorithm: if there is dorsal oblique transverse

amputation, it is better to add dorsal V-Y advance-

ment flap to the volar one to cover the bone with

well-padded skin. In the case of a volar oblique

defect, a dorsal V-Yadvancement flap can be used as

a b

c

Figure 4. (a) A crush tip injury of the right

ring finger. (b) A dorsal V-Y advancement

flap was sutured to the volar one, dorsal

view. (c) Postoperative dorsal view of the

ring finger after two years.

318 M. T. Ozyigit et al.

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a single procedure or added to the volar one. For the

cases of transverse amputations, we recommend that

the dorsal V-Y advancement flap is combined with

volar one to reduce the tension at the repair site.

The flap we propose can be used immediately in the

emergency department in a few minutes, with little

equipment, and it does not require the use of adjacent

fingers. The operative technique is easy, even without

loupe magnification, which results in saving time and

resources. It allows defects to be closed in a single

outpatient procedure done under local anaesthesia.

References

[1] Atasoy E. Reversed cross finger subcutaneous flap. J Hand

Surg 1982;/7A:/481�3.

[2] Tempest M. Cross finger flaps in the treatment of injuries to

the finger tip. Plast Reconstr Surg 1952;/9:/205�22.

[3] Iselin F. The flag flap. Plast Reconstr Surg 1973;/52:/374�7.

[4] Grossman JAI, Masson J, Kulber DA. Soft tissue repair and

replacements for the upper limb. In: Aston SJ, Beasley RW,

Thorne CHM, editors. Plastic Surgery. 5th ed. Philadelphia:

Lippincott-Raven; 1997. p 835�47.

[5] Atasoy E. Triangular volar skin flap to the fingertip. In:

Strauch B, Vasconez LO, Hall-Findlay EJ, editors. Encyclo-

pedia of flaps. 1st ed. Boston: Little, Brown and Company;

1990. p 805�8.

[6] Karamursel S, Kayikcioglu A, Aksoy HM, Daycan A, Safak

T, Kecik A. Dorsal visor flap in fingertip reconstruction.

Plast Reconstr Surg 2001;/108:/1014�8.

[7] Unlu RE, Mengi AS, Kocer U, Sensoz O. Dorsal adipofascial

turn-over flap for fingertip amputations. J Hand Surg 1999;/

24B:/525�30.

[8] Ozdemir R, Kilinc H, Sensoz O, Unlu RE, Baran CN.

Innervated dorsal adipofascial flap for fingertip amputations.

Ann Plast Surg 2001;/46:/9�14.

[9] Beasley RW. Reconstruction of amputated fingertips. Plast

Reconstr Surg 1969;/44:/349.

[10] Atasoy E, Loakimidis E, Kasdan ML, Kutz JE, Kleinert HE.

Reconstruction of the amputated fingertip with a volar

triangular flap: a new surgical procedure. J Bone Joint Surg

1970;/52A:/921.

[11] Bene MD. Reverse dorsal digital island flap. Plast Reconstr

Surg 1994;/93:/552�7.

Dorsal V-Y flap for fingertip amputations 319

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