Innervated Digital Artery Perforator Flap

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SCIENTIFIC ARTICLE

Innervated Digital Artery Perforator Flap

Haluk Ozcanli, MD, Osman Koray Coskunfirat, MD, Gamze Bektas, MD, Ali Cavit, MD

Purpose To describe a technique for covering defects of the fingertips: the innervated digitalartery perforator (IDAP) flap.

Methods A total of 17 patients were treated with an IDAP flap. The size of the flaps variedbetween 2 �1 cm and 3.5 � 2 cm. Postoperative evaluation of the patients consisted of theSemmes-Weinstein Monofilament test, static 2-point discrimination, patient satisfaction,extension loss, and an investigation into complications.

Results All IDAP flaps survived completely, and no patients required secondary interventions.The mean follow-up period was 7 months (range, 6–10 mo). The Semmes-Weinstein monofil-ament test results ranged from 3.22 to 3.84. The static 2-point discrimination in the flaps rangedfrom 2 mm to 4 mm (mean, 3.4 mm) compared with a range of 2 mm to 3 mm (mean, 2.7 mm)on the contralateral hand. There were no joint contractures in the reconstructed fingertips,although 2 patients developed mild hook nail deformity. One patient experienced mild coldintolerance, and 1 patient exhibited mild postoperative hypersensitivity.

Conclusions The advantages of the IDAP flap include minimally invasive surgery; a reliable,versatile flap; and the ease of the technique for different-sized fingertip defect reconstructionswith few complications. The IDAP flap may be useful in fingertip amputations when theamputated part is not suitable for replantation. (J Hand Surg 2013;38A:350–356. Copyright© 2013 by the American Society for Surgery of the Hand. All rights reserved.)

Type of study/level of evidence Therapeutic IV.

Key words Pulp reconstruction, neurovascular island flap, digital artery, perforator flap.

o(nd

SOFT TISSUE DEFECTS OF THE fingertip are one of themost common types of injury encountered inacute hand surgery. Distal replantations are the

est way to restore finger length and offer the bestosmetic results.1 Although microsurgical develop-

ments and techniques have enabled the replantation ofeven extreme distal tip amputations, replantation maynot be feasible for distal pulp crush injuries.1 Severaltreatment options are available, including closure with

From Department of Orthopedics, and the Department of Plastic and Reconstructive Surgery, AkdenizUniversity Faculty of Medicine, Antalya, Turkey.

Received for publication July 7, 2012; accepted in revised form October 11, 2012.

This study was supported by grants from the Akdeniz University scientific research projects man-agements unit, Antalya, Turkey.

No benefits in any form have been received or will be received related directly or indirectly to thesubject of this article.

Corresponding author: Haluk Ozcanli, MD, Akdeniz University School of Medicine, Departmentof Orthopaedics, 07059, Antalya, Turkey; e-mail: [email protected].

0363-5023/13/38A02-0018$36.00/0

thttp://dx.doi.org/10.1016/j.jhsa.2012.10.019

350 � © ASSH � Published by Elsevier, Inc. All rights reserved.

shortening, simple skin grafting, composite grafting,transposition flaps, advancement flaps, antegrade-retrograde flow flaps, perforator flaps, and freeflaps.2–13 The decision as to which method of recon-struction should be used depends on the localization,the geometry of the defect, and the exposed structures(bone, tendon, and nerve).2,3,13,14 The advantages anddisadvantages of each technique depend on the diffi-culty and reliability of the procedure, donor site morbidity,and the recovery of sensation, all of which have to becarefully considered when choosing the best technique forthe patient. Various techniques have been reviewed in theliterature; however, the optimal treatment for fingertip am-putations remains controversial.2–14

Described herein is a technique for covering defectsf fingertips, the innervated digital artery perforatorIDAP) flap. The IDAP flap is a proximally basedeurovascular island flap that can be rotated into theefect and provide sensate reconstruction for defects of
he fingertip.
mailto:[email protected]

http://dx.doi.org/10.1016/j.jhsa.2012.10.019

INNERVATED DIGITAL ARTERY PERFORATOR FLAP 351

MATERIALS AND METHODSBetween August and December of 2011, 17 patients(15 men, 2 women) with a mean age of 36 (range,19–65 y) were operated on using the IDAP flap. Ap-proval from the ethics committee and informed consentfrom all patients in this study were obtained. All 17patients were acute cases. The mechanism of the inju-ries was 3 sharp and 14 crush amputations, 13 of whichwere sustained at work. Two injuries were volar obliqueamputations, while the remaining ones were transverse.With the exception of 1 case, all flaps were elevatedfrom the ulnar part of the fingertip in accordance withthe crush type of injury on the ulnar side of the digit.

Twelve right and 5 left hand injuries were evaluated.The distribution of injuries according to fingers in-cluded 9 middle, 5 index, and 3 ring fingers (Table 1).The mean follow-up period was 7 months (range, 6–10mo). The size of the flaps was between 2 �1 cm and 3.5� 2 cm. The Semmes-Weinstein monofilament test(SWM), static 2-point discrimination test (s2PD), pa-tient satisfaction, extension loss, and early and latecomplications were investigated after surgery.

Surgical technique

All flap dissections were performed under �4.5 loupe

TABLE 1. Patient Details

Age,Gender Side

DefectType Mechanism

Size(cm)

54, male Left 2nd Transverse Sharp 2 � 1.5

52, female Right 4th Transverse Crush 2 � 1

39, male Right 2nd Transverse Crush 2.5 � 1

51, male Right 2nd Volaroblique

Crush 3.5 � 2

29, male Left 2nd Transverse Crush 2 � 1

23, male Right 3rd Transverse Crush 2 � 1.5



19, male Right 4th Transverse Crush 2 � 1.5

23, male Left 4th Transverse Crush 2 � 1


43, male Left 3rd Transverse Crush 2 � 1.5

23, male Left 3rd Transverse Crush 2 � 1

65, male Right 3rd Volaroblique

Crush 3 � 1.5


53, female Right 2nd Transverse Sharp 2 � 1.5

19, male Right 3rd Transverse Sharp 2 � 1.5

magnification with digital block anesthesia. The surgi-

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cal technique is depicted in Figure 1. The configurationof the flap is either triangular or custom-shaped accord-ing to the defect size. The flap is designed on themidlateral line distally, and the long axis is slightlydorsal and oblique to the midlateral line. The distal partof the flap starts at the edge of the wound, with theproximal portion possibly extending to the dorsal partof the middle phalanx. The distal aspect of the flapshould be designed volar to the level of the midlateralline. If necessary, the flap can be enlarged to the dorsalpart of the middle phalanx. The paratenon of the exten-sor system should be left intact to serve as a glidingplane between the tendon and the skin graft. Largerflaps are necessary when covering volar obliquedefects. The IDAP flap may be elevated from eitherside of the digit, but elevated from the ulnar side ofthe index, middle, and ring fingers and from theradial side of the small finger. After tourniquet place-ment at the base of the finger, the incision starts at thedorsal part of the flap, and the subcutaneous tissuesshould be dissected from the periosteum of the phalanx.The Cleland ligament is divided to identify the neuro-vascular bundle. Then, the palmar incision is meticu-lously dissected up to the periosteum. The distal end ofthe neurovascular bundle had already been cut, and theflap is mobilized as a digital artery island flap. TheIDAP flap is elevated with the skeletonized neurovas-cular bundle for better mobilization. The flap pedicleincludes the digital nerve, the terminal digital artery,the perforators, and the subcutaneous veins. TheIDAP flap allows a wide arc of transposition.

According to defect size and configuration, the is-land flap, with its neurovascular perforator, is rotated90° to 180°. The donor site of the flap is covered witha full-thickness skin graft from the ulnar side of thewrist crease. Elevation of the hand in the early postop-erative period prevents venous congestion. Splint andanticoagulant therapy are not used. Patients are encour-aged to undertake active motion exercises beginning 3days after surgery.

Case 1A 65-year-old heavy laborer had the right middle fingeramputated in an industrial crush injury. The volaroblique amputation was reconstructed with a 3 � 1.5cm IDAP flap (Fig. 2). The reconstructed fingertipsurvived completely without any complications or do-nor site morbidity. There were no early complications.A mild hook nail deformity was noted in the finalfollow-up. The patient was highly satisfied with theresult of the reconstruction. The SWM test result was3.84 (contralateral, 3.61), and the s2PD was 4 mm
(contralateral, 3 mm) 6 months after surgery.
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352 INNERVATED DIGITAL ARTERY PERFORATOR FLAP

Case 2A 23-year-old man’s left ring finger was transverselyamputated in an industrial crush injury. The amputatedpart of the fingertip was not available for replantation.Reconstruction with an IDAP flap was performed fromthe ulnar site of the fingertip (Fig. 3). The reconstructedfingertip survived completely without any complica-tions, either early or late. The patient was highly satis-fied with the result of the reconstruction. The SWM testresult was 3.22 (contralateral, 2.83), and the s2PD was3 mm (contralateral, 2 mm) 8 months after surgery.

RESULTSAll IDAP flaps survived completely. No patient suf-fered from postoperative infections, and no patient re-quired secondary interventions (debridement or super-charging). The SWM test result ranged from 3.22 to3.84, compared with 2.83 to 3.61 on the contralateralhand (Table 2). The s2PD in the flaps ranged from 2mm to 4 mm (mean, 3.4 mm), compared with 2 mm to3 mm (mean, 2.7 mm) on the contralateral hand. Ex-tension loss or joint contracture was not observed in anypatients. Hook nail deformities were evaluated accord-ing to the Lim et al classification system.15 This systemis based on the percentage of the hook nail deformityand dorsal-to-volar distance of the fingertip. One patienthad a grade 1 deformity, and the other patient had agrade 2 deformity. One patient had mild cold intoler-ance, and another patient experienced minimal postop-

FIGURE 1: Schematic drawing of the innervated digital arteryand the digital nerve. The neurovascular bundle should be prese

erative hypersensitivity of the reconstructed fingertip;

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however, these complaints did not impair function ei-ther at work or in daily life. None of the patients haddonor site morbidity or symptomatic scar contractures.

DISCUSSION

Pulp reconstructions are helpful in cases with soft tissueloss and exposed distal phalanx. The goals of anyfingertip reconstruction are to preserve finger functionand digital length and volume while minimizing aes-thetic loss and covering the defect with sensitiveskin.3,13,14,16 Although composite tip grafts are oftenconsidered for children, successful functional and aes-thetic outcomes have also been reported in adults.5,17,18

The advantages of advancement flaps are the simplicityof the technique and the restoration of sensitivity; how-ever, they have limited size.2–4 The mobility of V-Yadvancement flaps are restricted, and large and volaroblique defects cannot be covered.3,13 The cross-fingerflap has been widely used with volar oblique defects ofthe index and ring fingers.6,13 The advantages of thecross-finger flap are that more tissue is available than inthe advancement flaps, it is a quick and reliable proce-dure, and multiple fingers may be covered simultane-ously.6,13,19 The disadvantages of cross-finger flap areseveral. An innervated cross-finger flap for treatment offingertip injuries has been described, but the procedureis not ideal for the recovery of fingertip sensation. Theprocedure involves prolonged immobilization, the sur-

orator flap. The pedicle includes the digital artery, perforators,at the volar and at the 20% to 25% distal part of the island.

perf

gery occurs in 2 stages, and the cross-finger flap causes

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stiffness. In addition, the donor site may become hy-perpigmented.13,19

Unlike cross-finger flaps, thenar flaps provide dura-ble, glabrous skin as well as sufficient subcutaneoussoft tissue to restore the 3-dimensional structure of the

FIGURE 2: A, B Volar oblique defect of the fingertip. C, D Tdefect was covered with the flap. E–G Final result 6 months aft

fingertip.13,20,21 The thenar flap also has disadvantages.

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The procedure leads to prolonged immobilization; thesurgery occurs in 2 stages; the surgery causes stiffness,flexion contractures, and tenderness; and the donor sitescar is unsightly.13,20,21

Local neurovascular island flaps are another op-

nervated digital artery perforator flap was rotated 90°, and thergery.

he in

tion.8,13,22–25 These flaps have the advantages of being

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single-stage procedures with a reliable antegrade bloodflow that does not sacrifice the digital artery, and ofproducing a sensate flap with limited donor site mor-bidity.8,13,22–25 The limitations of these flaps are that itis rarely possible to advance them more than 2 cm andthere is a risk of proximal interphalangeal (PIP) joint

FIGURE 3: A Transverse defect of the fingertip, flap design. Bneurovascular perforator was rotated 180°, and the defect was c

flexion contractures.8,22–25

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Reverse-flow homodigital island flaps are helpfulwhen there are relatively large defects of the pulp.26–28

The advantages of this flap are the extensive arc ofrotation, a 1-stage procedure. and its reliable vascularpedicle.24,26–28 The disadvantages of this flap are a42% increase in cold intolerance, the necessity of sac-

ation of the innervated digital artery perforator flap. C, D Theed with the flap. E–H Final result 8 months after surgery.

Elev

rificing a digital artery, a prolonged surgery, venous

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congestion, PIP joint contractures, and an increasedincidence of total or partial loss of the flap.24,29

Kim et al30 described the sensate volar flap involvingthe transverse branch of the digital artery without sac-rificing the digital artery. The main disadvantages ofthis flap are that it causes volar scar contractures and isa technically difficult flap to perform.30

Koshima et al 9 reported on the digital artery perfo-rator (DAP) flap in 2006. Mitsunaga et al16 developedDAP flaps and reported on their experiences and mod-ifications with successful results in a limited numbers ofpatients. The disadvantages of the DAP flaps includelimited flap size without sensation and the sometimescomplicated detection of the perforators.9,16 The advan-tage of the IDAP flap over conventional DAP flaps isthat more perforators are available in larger-sized, reli-able flaps of sensate tissue. In addition, there is no needto isolate the perforator, so vascularity, especially ve-nous drainage, is improved when compared with ourexperience with the DAP flap. Although the surgicalprocedure requires meticulous dissection, elevation ofthe IDAP flap is technically straightforward because theperforator does not need to be isolated. This makes itless technically demanding than the DAP flap.

Various microvascular reconstruction techniques,

TABLE 2. Postoperative Results

Patient SWM SWMc s2PD (mm) s2PDc (mm)

1 3.22 3.22 3 3

2 3.61 3.22 4 3

3 3.61 3.22 4 3

4 3.61 3.22 4 3

5 3.22 3.22 3 3

6 3.61 3.22 3 2

7 3.22 3.22 2 2

8 3.22 3.22 3 3

9 3.61 3.22 4 3

10 3.22 2.83 3 2

11 3.61 3.22 4 3

12 3.84 3.22 4 3

13 3.84 3.22 4 3

14 3.84 3.61 4 3

15 3.22 3.22 4 3

16 3.22 3.22 3 2

17 3.61 2.83 3 2

s2PDc, static 2-point discrimination contralateral; SWM, Semmes-Weinstein monofilament; SWMc, Semmes-Weinstein monofilamentcontralateral.

such as arterialized venous flaps,31 partial toe trans-

JHS �Vol A, Fe

fers,10 and free medial plantar artery perforator flaps,12

have been reported with successful results. However,these techniques are challenging microsurgical proce-dures, and advanced microsurgical skills are needed,each with a steep learning curve.

The IDAP flap is an excellent method for fingertipreconstruction with excellent sensitivity and good aes-thetic results. One of the most important advantages ofthe IDAP flap over conventional reconstruction tech-niques is its low complication rate. In our series, therewere no joint contractures. Although PIP joint exten-sion loss has been reported in antegrade-retrograde flowneurovascular island flaps, this complication is frequentin cross-finger flaps and thenar flaps.6,8,13,19–21,24,29

PIP joint extension loss has been reported at rates of 8%to 29%.6,8,24,29 In our series, cold intolerance was de-tected in only 1 patient, whereas the literature reportsrates at 6% to 42%.8,23,24,29

The IDAP flap has several advantages. It has areliable vascular pedicle; it has an extensive arc ofrotation; the size is expandable; the flap is sensate; andit is a quick, single-stage procedure, performed withdigital block anesthesia. It allows full active fingermotion, and we noted low complication rates and donorsite morbidities. The observable disadvantages of thisflap are the requirements for meticulous dissection anddonor site grafting.

REFERENCES1. Scheker LR, Becker GW. Distal finger replantation. J Hand Surg

Am. 2011;36(3):521–528.2. Kutler W. A new method for finger tip amputation. JAMA. 1947;

133(1):29.3. Atasoy E, Ioakimidis E, Kasdan ML, Kutz JE, Kleinert HE. Recon-

struction of the amputated finger tip with a triangular volar flap. Anew surgical procedure. J Bone Joint Surg Am. 1970;52(5):921–926.

4. Venkataswami R, Subramanian N. Oblique triangular flap: a newmethod of repair for oblique amputations of the fingertip and thumb.Plast Reconstr Surg. 1980;66(2):296–300.

5. Rose EH, Norris MS, Kowalski TA, Lucas A, Fleegler EJ. The “cap”technique: nonmicrosurgical reattachment of fingertip amputations.J Hand Surg Am. 1989;14(3):513–518.

6. Cronin TD. The cross finger flap: a new method of repair. Am Surg.1951;17(5):419–425.

7. Hueston J. Local flap repair of fingertip injuries. Plast Reconstr Surg.1966;37(4):349–350.

8. Varitimidis SE, Dailiana ZH, Zibis AH, Hantes M, Bargiotas K,Malizos KN. Restoration of function and sensitivity utilizing ahomodigital neurovascular island flap after amputation injuries of thefingertip. J Hand Surg Br. 2005;30(4):338–342.

9. Koshima I, Urushibara K, Fukuda N, et al. Digital artery perforatorflaps for fingertip reconstructions. Plast Reconstr Surg. 2006;118(7):1579–1584.

10. Koshima I, Inagawa K, Urushibara K, Okumoto K, Moriguchi T.Fingertip reconstructions using partial-toe transfers. Plast ReconstrSurg. 2000;105(5):1666–1674.

11. Lin CH, Lin YT, Sassu P, Lin CH, Wei FC. Functional assessmentof the reconstructed fingertips after free toe pulp transfer. Plast
Reconstr Surg. 2007;120(5):1315–1321.
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12. Huang SH, Wu SH, Lai CH, et al. Free medial plantar arteryperforator flap for finger pulp reconstruction: report of a series of 10cases. Microsurgery. 2010;30(2):118–124.

13. Lemmon JA, Janis JE, Rohrich RJ. Soft-tissue injuries of the finger-tip: methods of evaluation and treatment. An algorithmic approach.Plast Reconstr Surg. 2008;122(3):105–117.

14. Browne EZ Jr. Complications of fingertip injuries. Hand Clin. 1994;10(1):125–137.

15. Lim GJ, Yam AK, Lee JY, Lam-Chuan T. The spiral flap forfingertip resurfacing: short-term and long-term results. J Hand SurgAm. 2008;33(3):340–347.

16. Mitsunaga N, Mihara M, Koshima I, et al. Digital artery perforator(DAP) flaps: modifications for fingertip and finger stump reconstruc-tion. J Plast Reconstr Aesthet Surg. 2010;63(8):1312–1317.

17. Heistein JB, Cook PA. Factors affecting composite graft survival indigital tip amputations. Ann Plast Surg. 2003;50(3):299–303.

18. Uysal A, Kankaya Y, Ulusoy MG, et al. An alternative technique formicrosurgically unreplantable fingertip amputations. Ann Plast Surg.2006;57(5):545–551.

19. Cohen BE, Cronin ED. An innervated cross-finger flap for fingertipreconstruction. Plast Reconstr Surg. 1983;72(5):688–697.

20. Melone CP Jr, Beasley RW, Carstens JH Jr. The thenar flap—ananalysis of its use in 150 cases. J Hand Surg Am. 1982;7(3):291–297.

21. Rinker B. Fingertip reconstruction with the laterally based thenarflap: indications and long-term functional results. Hand (N Y). 2006;1(1):2–8.

22. Evans DM, Martin DL. Step-advancement island flap for fingertip
reconstruction. Br J Plast Surg. 1988;41(2):105–111.
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23. Adani R, Busa R, Castagnetti C, Bathia A, Caroli A. Homodigitalneurovascular island flaps with “direct flow” vascularization. AnnPlast Surg. 1997;38(1):36–40.

24. Kayalar M, Bal E, Toros T, Sügün ST, Özaksar K, Gürbüz Y. Theoutcome of direct-flow neurovascular island flaps in pulp defects.Acta Orthop Traumatol Turc. 2011;45(3):175–184.

25. Hammouda AA, El-Khatib HA, Al-Hetmi T. Extended step-ad-vancement flap for avulsed amputated fingertip—a new technique topreserve finger length: case series. J Hand Surg Am. 2011;36(1):129–134.

26. Kojima T, Tsuchida Y, Hirasé Y, Endo T. Reverse vascular pedicledigital island flap. Br J Plast Surg. 1990;43(3):290–295.

27. Lai CS, Lin SD, Chou CK, Tsai CW. A versatile method forreconstruction of finger defects: reverse digital artery flap. Br J PlastSurg. 1992;45(6):443–453.

28. Han SK, Lee BI, Kim WK. The reverse digital artery island flap:clinical experience in 120 fingers. Plast Reconstr Surg. 1998;101(4):1006–1111.

29. Yildirim S, Avci G, Akan M, Aköz T. Complications of the reversehomodigital island flap in fingertip reconstruction. Ann Plast Surg.2002;48(6):586–592.

30. Kim KS, Yoo SI, Kim DY, Lee SY, Cho BH. Fingertip reconstruc-tion using a volar flap based on the transverse palmar branch of thedigital artery. Ann Plast Surg. 2001;47(3):263–268.

31. Kayikçioglu A, Akyürek M, Safak T, Ozkan O, Keçik A. Arterial-ized venous dorsal digital island flap for fingertip reconstruction.
Plast Reconstr Surg. 1998;102(7):2368–2372.
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Innervated Digital Artery Perforator Flap