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. 2017 Nov 27;9(4):372–379. doi: 10.1111/os.12350

A Novel Approach for Reconstruction of Finger Neurocutaneous Defect: A Sensory Reverse Dorsal Digital Artery Flap from the Neighboring Digit

Shi‐ming Feng 1,2,✉, Qing‐qing Sun 1,2, Jian Cheng 1, Ai‐guo Wang 1,2
PMCID: PMC6584124  PMID: 29178311

Abstract

Objective

Providing soft tissue coverage for finger neurocutaneous defects presents aesthetic and sensory challenges. A common source for reconstruction of soft tissue defects of the fingers is the same finger. However, when the donor areas are damaged by concomitant injuries, this option is not available. The present study aims to reconstruct finger neurocutaneous defects using a sensory reverse dorsal digital artery flap from the neighboring digit and to evaluate the efficacy of this technique.

Methods

The study included 16 patients, with an average age of 34.9 years (range, 20–53 years) at the time of surgery, from May 2010 to June 2013. The sensory reverse dorsal digital artery flap was used in all 16 patients, who had a combination of soft tissue and digital nerve defects. The mean size of the soft tissue defects was 3.1 cm × 2.0 cm, and the mean flap size was 3.3 cm × 2.2 cm. The length of the nerve defects ranged from 1.3 to 2.5 cm (mean, 2.0 cm), which were reconstructed with dorsal branches of the proper digital nerve transfer. The active motion of the fingers (injured and donor) and the flap sensibility (static two‐point discrimination) were measured. The appearance and functional recovery of the injured finger and the donor site were assessed using the Michigan Hand Outcomes Questionnaire.

Results

All flaps survived completely. No complications were reported, and no further flap debulking procedure was required. At the mean follow‐up period of 24 months (range, 18–30 months), the mean static two‐point discrimination was 6.5 mm (range, 5–10 mm) of the reconstructed area; the mean ranges of motions of the injured finger and the opposite finger at the proximal interphalangeal and distal interphalangeal joints were 102.2° and 103.5°, and 70.3° and 76.5°, respectively. The average ranges of motions of the metacarpophalangeal and proximal interphalangeal joints of the donor fingers were 90° and 103.4°, respectively. Based on the Michigan Hand Outcomes Questionnaire, 10 patients were strongly satisfied and 6 were satisfied with the functional recovery of the injured finger; however, 13 patients were strongly satisfied and 3 were satisfied with the appearance of the injured finger.

Conclusion

The sensory reverse dorsal digital artery flap from the neighboring digit, based on the dorsal branch of the digital artery, is an effective and additional option for finger neurocutaneous defect reconstruction when use of the local and regional flaps is not feasible.

Keywords: Dorsal digital nerve, Finger neurocutaneous defect, Reverse dorsal digital artery flap

Introduction

Reconstructing finger neurocutaneous defects is a real challenge for hand surgeons1, 2. In some cases, finger pulp sensation is lost due to a combination of soft tissue and digital nerve defects. Common sources for reconstruction of soft tissue defects of fingers are either the same finger or the adjacent finger.

Some reconstructive techniques have been described in the literature. Homodigital and heterodigital artery island flaps, dorsal homodigital island flap, dorsal metacarpal artery flap and little flap may be available options. Homodigital and heterodigital artery island flaps have good blood supply and minimal morbidities, but major artery sacrifice is a disadvantage should be taken into consideration3, 4. The dorsal homodigital island flap and dorsal metacarpal artery flap are the most commonly used flaps in reconstruction for neurocutaneous defects in a finger5, 6. The donor site is similar to the recipient site in cutaneous color, texture, and thickness, ensuring favorable gross appearance postoperatively. Operating time is significantly shorter using this simple procedure compared with free flap grafting. However, when the donor areas of the above flaps are damaged by concomitant injuries, these options may not be available. A Littler flap based on the heterodigital neurovascular bundle has good blood supply and skin texture, but deterioration of fingertip sensibility and the loss of one of the digital arteries are major disadvantages7. A distally‐based pedicled flap or reverse‐flow arterial island flap is also acceptable and has been widely accepted as an effective modality for the repair of digital defects, but subsequent compromise of blood flow, the restriction of digital extension and flexion, and the adverse effects on proper digital nerve are drawbacks8.

The prolonged pedicle reverse dorsal digital artery flap from the neighboring digit, including a nerve transfer raised from the dorsal branches of the proper digital nerve (PDN), can be tried as an alternative method to cover the defect and restore the sensation.

The reverse dorsal digital artery flap raised from the dorsum of the proximal phalanx of the digit was first reported by Massimo et al. in 19949. This one‐step procedure, preserving the collateral nerve and artery to the fingertip, proved valuable in salvaging the severely injured digits of nine patients. In 1998, Kayikçioğlu et al. modified the technique by arterialized the flap venous10. The vascularity of the reverse dorsal digital island flap was augmented by performing an arteriovenous anastomosis between a dorsal vein in the flap and one of the proper digital arteries at the fingertip. However, the major disadvantage was the necessity of performing microvascular surgery. Takeishi et al. 11 describe an innervated reverse dorsal digital island flap for fingertip reconstruction applied to nine patients. The dorsal branches of the PDN and the dorsal digital nerve were elevated with the flap, which was anastomosed to the distal end of the digital nerve, to restore the flap sensation11. They obtained a mean two‐point discrimination (2PD) on the reconstructed fingertip of 4 mm (ranged from 3 to 5 mm). The flap was not suitable for reconstructing the adjacent finger neurocutaneous defect, although this sensory flap was subsequently shown to be appropriate for resurfacing finger defects.

In the cadaver study by Yu et al. 12, it was found that the dorsal surface of the proximal phalanges of the index and middle fingers can receive the blood supply of the second dorsal metacarpal artery branches, and these branches are called dorsal digital arteries. The blood supply for the proximal dorsum derives mainly from the terminal branches of the dorsal metacarpal artery. The blood supply of the reverse dorsal digital artery flap derives mainly from: the dorsal branches of the proper digital artery, the branches from the deep nominate artery, and the vascular network from the fascial pedicle. An interlacing vascular network exists between the dorsal digital artery and the dorsal branch of the proper digital artery (PDA, Fig. 1).

Figure 1.

Figure 1

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The diagram shows that the dorsal metacarpal artery (DMA) is divided into fingerweb artery (FWA) and dorsal digital artery (DDA). Constant vascular networks are present between dorsal branches of the proper digital artery (DBPDA) and DDA. Constant DBPDA are also seen around the proximal of the middle phalanx. The dorsal branches of the proper digital nerves (DBPDN) originate from the proper digital nerves (PDN), and innervate the dorsum of the distal third of the proximal phalanx and the middle phalanx. DIP, distal interphalangeal; PIP, proximal interphalangeal.

Based on this anatomic study, the reverse dorsal digital artery flap technique was modified in the present study. In this study, the arterial system encouraged the researchers to raise a reverse dorsal digital artery flap supplied by the vascular network between the dorsal digital artery and the dorsal branch of the PDA.

In this study, the reverse dorsal digital artery flap from the proximal phalange of the adjacent finger was used, which was supplied by the vascular network between the dorsal digital artery and the dorsal branch of the PDA of the injured finger, for sensory and motion reconstructions for neurocutaneous defects in fingers. The sensibility and motor function of the reconstructed fingers were assessed in the follow‐up period.

To sum up, the purpose of the present study is not only to investigate the therapeutic effect of reconstructing finger neurocutaneous defects using a sensory reverse dorsal digital artery flap from the neighboring digit, but also to summarize the indications and contraindications, so as to better understand this novel approach for construction for neurocutaneous defects of the finger.

Materials and Methods

This study was approved by the institutional review boards of our hospital. Informed consent and Health Insurance Portability and Accountability Act consents were obtained from each patient. All operations were performed by the same surgical team, who were blind to the measurement results within the study period.

Inclusion and Exclusion Criteria

Patients were selected on the basis of the following criteria: (i) index, middle, ring, or little finger injury with exposed tendon or bone; (ii) single or double digital nerve defect of 1–2.5 cm in length; (iii) defect located on the middle and distal phalanges; (iv) normal local pedicled flaps not available, such as the traditional reverse dorsal digital artery flap, flaps based on the dorsal branch of the PDA, and reverse dorsal metacarpal artery; (v) proximal phalange tissue of adjacent fingers uninjured; (vi) defect of the injured finger no more than the adjacent proximal phalange in length; and (vii) necessity of repairing the soft tissue and nerve defects. Patients were excluded when they had any of the following criteria: (i) normal local pedicled flap available; (ii) nerve defect less than 1.0 cm or more than 2.5 cm in length; (iii) defect of the injured finger longer than the adjacent proximal phalange in length; (iv) refuse to preserve finger length or restore aesthetic appearance; and (v) injuries in the flap donor finger or the dorsal digital artery.

General Information

From May 2012 to June 2014, a reverse dorsal digital artery flap supplied by the vascular network between the dorsal digital artery and the dorsal branch of the PDA was designed in 16 patients. This study included 10 male and 6 female patients, with an average age of 34.9 years (range, 20–53 years) at the time of the surgery. The mechanisms of injury included avulsion (n = 9), crushing (n = 6), and electrical burn (n = 1). The injured fingers requiring reconstruction included 7 index, 3 middle, 4 ring, and 2 little fingers (Table 1). Internal fixation of the phalanx fracture was performed in 1 patient (case 4 in Table 1).

Table 1.

Patient demographics

Case Age (years) Sex Cause Side Injury finger Donor finger Defect Size (cm × cm) Flap Size (cm × cm) Pedicle length (cm)
1 24 F Avulsion R Middle Ring 2.1 × 1.7 2.3 × 2.0 5.5
2 29 M Crush R Index Middle 3.9 × 2.3 4.2 × 2.5 5.8
3 37 M Crush L Ring Middle 3.7 × 2.0 3.9 × 2.2 5.0
4 53 F Avulsion R Index Middle 4.0 × 2.0 4.2 × 2.2 5.3
5 36 M Avulsion L Index Middle 2.5 × 1.8 2.7 × 2.0 5.6
6 20 M Crush R Little Ring 3.8 × 2.4 4.0 × 2.6 5.1
7 31 F Avulsion L Middle Ring 2.2 × 1.9 2.5 × 2.1 5.5
8 48 M Electrical burn R Index Middle 2.9 × 2.5 3.2 × 2.6 5.0
9 43 M Crush L Index Middle 2.6 × 2.2 2.8 × 2.4 6.0
10 36 F Avulsion L Middle Ring 3.2 × 1.5 3.4 × 1.6 5.4
11 20 M Avulsion R Ring Middle 4.0 × 2.5 4.2 × 2.6 5.5
12 45 F Crush R Index Middle 2.8 × 1.6 3.0 × 1.8 5.9
13 26 M Avulsion R Ring Middle 2.7 × 2.3 2.9 × 2.5 5.3
14 50 F Avulsion R Index Middle 3.3 × 1.9 3.5 × 2.2 5.2
15 32 M Crush L Little Ring 2.0 × 1.6 2.2 × 1.8 5.8
16 28 M Avulsion R Ring Middle 3.4 × 2.0 3.6 × 2.2 5.0
Mean 34.9 3.1 × 2.0 3.3 × 2.2 5.4
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F, female; M, male.

The size of the soft tissue defects ranged from 2.0 to 4.0 cm long and 1.5 to 2.5 cm wide (mean, 3.1 cm × 2.0 cm). The flaps ranged in size from 2.2 cm × 1.8 cm to 4.2 cm × 2.6 cm (mean, 3.3 cm × 2.2 cm). The length of the nerve defects ranged from 1.3 to 2.5 cm (mean, 2.0 cm). The mean length of the nerve grafts was 2.2 cm. The pedicle length ranged from 5.0 to 6.0 cm (mean, 5.4 cm). In this study, flap transfer was performed in the primary stage with a mean time delay of 1.2 h (range, 1.5–7.0 h) after injury in 15 cases and 2 weeks after injury in 1 case (electrical burn case).

Surgical Technique

Surgery was performed using brachial plexus anesthesia with the aid of pneumatic tourniquet control, loupe magnification, and a surgical microscope. The middle finger was used as the donor site when resurfacing the index or the ring finger. The ring finger served as the donor site when reconstructing the middle or the little finger. The flap was marked on the dorsum of the proximal phalange between the midlateral lines, and was designed in a rectangle style according to the size of the defect.

The proximal nerve ends were evaluated and trimmed to normal neural tissue after debridement of the injured finger. The incision of the flap was initiated along the margin of the flap design line. The pivot point of the flap was located just around the midportion of the midlateral line of the middle phalanx in the injured finger, where the constant dorsal branch (located within 5–7 mm distal to the proximal interphalangeal joint line) originating from the PDA could be identified predictably. To safely preserve the arterial pedicle of the flap, the flap was harvested carefully with the aid of loupe magnification. The perforators and the fingerweb artery were ligated toward the dorsal digital artery. A 0.5‐cm‐wide subcutaneous tissue cuff was maintained around the flap pedicle to avoid vasospasm. The dorsal branches of the PDN of the donor finger were harvested with the flap. With the constant dorsal branch of the injured finger used as the pivot point, the flap was then turned to cover the defect (Fig. 2). The dorsal branches of PDN of the flap were coapted with the located nerves of the degloved finger in an end‐to‐end fashion. The donor site was resurfaced with a full‐thickness skin graft taken from the inner aspect of the forearm.

Figure 2.

Figure 2

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The diagram shows that the sensory reverse dorsal digital artery (DDA) flap from the neighboring digit, including two dorsal branches of the proper digital nerves (DBPDN), is raised based on the constant dorsal branches of the proper digital artery (DBPDA) that are located within 4–5.5 mm distal to the proximal interphalangeal joint line. DMA, dorsal metacarpal artery.

Postoperative Management

After the surgery, the injured hand was placed above the heart level to reduce possible flap venous congestion. Visual inspection of the flap color and capillary refilling was used to monitor the flap circulation for at least 24 h after surgery. Two weeks after the surgery, an active range of motion exercises were encouraged with the help of a physical therapist, and supervised rehabilitation was commenced thereafter with a mean time of 55 days (range, 45–85 days).

Evaluation of Outcomes

At the final follow‐up, one senior hand surgeon performed all assessments. The active motion of the injured and donor fingers was measured by a goniometer, and the flap sensibility was measured using the static 2PD test. The active motion of the donor fingers was compared with that of the opposite side. The appearance and functional recovery of the injured finger and the donor site were assessed using the Michigan Hand Outcomes Questionnaire13, 14. A 10‐cm‐line visual analogue scale (VAS), which was categorized into mild (0–3 cm), moderate (4–6 cm), and severe (7–10 cm), was used to evaluate pain sensations of the injured and donor fingers. Cold intolerance of the injured finger was assessed with the self‐administered Cold Intolerance Severity Score (CISS)15 questionnaire. The scores were categorized into four degrees (mild, moderate, severe, and extremely severe) corresponding to four ranges (0–25, 26–50, 51–75, and 76–100), respectively.

Results

General Results

All flaps survived completely, without insufficient blood supply or venous congestion. Two weeks after the surgery, the surviving flaps displayed warmth, good capillary refill, and pink color. Patient follow‐up lasted from 18 to 30 months (mean, 24 months), no complication was reported, and no further flap debulking procedure was required.

Clinical Outcomes

At the final follow‐up, the mean ranges of motions of the injured finger and the opposite finger at the proximal interphalangeal and distal interphalangeal joints were 102.2° and 103.5°, and 70.3° and 76.5°, respectively. The average ranges of motions of the metacarpophalangeal and proximal interphalangeal joints of the donor fingers were 90° and 103.4°, respectively, and those of the opposite sites measured 90° and 102.9°, respectively. At the final examination, the average score of the static 2PD of the flap was 6.5 mm (range, 5–10 mm), and that of the opposite sides was 3.9 mm (range, 3–5 mm).

Score Outcomes

Based on the Michigan Hand Outcomes Questionnaire, 10 patients were strongly satisfied (score 5) and 6 were satisfied with the functional recovery of the injured finger (score 4); 13 patients were strongly satisfied (score 5) and 3 were satisfied with the appearance of the injured finger (score 4). The average score of the patient satisfaction of donor site appearance based on the Michigan Hand Outcomes Questionnaire was 4.8. According to the VAS, apart from 1 patient (Patient 5) who reported mild pain in the injured finger, all the other patients reported no pain. According to the CISS questionnaire, 6 patients reported mild cold intolerance and 10 patients reported no cold intolerance, and all the reconstructed fingers scored less than 25.

Case Reports

Case 8

A 48‐year‐old man suffered from an electrical burn to his right hand for 12 days. Normal local pedicled flaps were not available. Dorsal aspect soft tissue defect on the middle phalanx of the index finger was observed (Fig. 3A). The defect was 2.9 cm × 2.5 cm in size. A reverse dorsal digital artery flap of 3.2 cm × 2.6 cm in size, based on the dorsal branch of PDA at the middle phalanx, was harvested from the proximal dorsum of the middle finger to resurface the defect (Fig. 3B). The donor site was resurfaced with a full‐thickness skin graft (Fig. 3C). At the 21‐month follow‐up evaluation, good finger function and satisfactory appearance were obtained (Fig. 3D). The static 2PD of the flap was 6.8 mm. The ranges of motion of the injured finger at the proximal interphalangeal and distal interphalangeal joints were 103° and 72°, respectively. The ranges of motion of the metacarpophalangeal and proximal interphalangeal joints of the donor fingers were 91° and 104°, respectively. This patient returned to his original occupation and activities.

Figure 3.

Figure 3

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Case 8: (A) A 48‐year‐old man presented with a dorsal aspect soft tissue defect on the middle phalanx of the index finger. (B, C) A sensory reverse dorsal digital artery flap, based on the dorsal branch of proper digital artery at the middle phalanx, was harvested from the proximal dorsum of the middle finger to resurface the defect. (D) Postoperative view of the flap and finger appearance 21 months after surgery.

Case 10

A 36‐year‐old woman sustained an avulsion injury to her left middle finger and opisthenar. A left middle fingertip defect was observed. Normal local pedicled flaps were not available. The defect was 3.2 cm × 1.5 cm in size (Fig. 4A). A reverse dorsal digital artery flap, sized 3.4 cm × 1.6 cm, was taken from the proximal dorsum of the ring finger to reconstruct the defect (Fig. 4B, C). The donor site was resurfaced with a full‐thickness skin graft (Fig. 4D). Clinical evaluation at 19‐month follow‐up showed that the static 2PD of the injured finger pulp was 5.5 mm. The range of motion of the injured finger at the distal interphalangeal joint was 82°. The ranges of motion of the metacarpophalangeal and proximal interphalangeal joints of the donor fingers were 90° and 110°, respectively (Fig. 4E, F).

Figure 4.

Figure 4

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Case 10: (A) A 36‐year‐old woman presented with a left middle fingertip defect. (B–D) A sensory reverse dorsal digital artery flap, based on the dorsal branch of proper digital artery at the middle phalanx, was taken from the proximal dorsum of the ring finger to reconstruct the defect. (E, F) Postoperative views of the flap and finger function at 19‐month follow‐up.

Case 15

A 32‐year‐old man sustained a crushing injury to his left little finger and opisthenar. A left little finger pulp defect was observed. The defect was 2.0 cm × 1.6 cm in size (Fig. 5A). A reverse dorsal digital artery flap, sized 2.2 cm × 1.8 cm, was taken from the proximal dorsum of the ring finger to reconstruct the defect (Fig. 5B). The donor site was resurfaced with a full‐thickness skin graft. Clinical evaluation at 28‐month follow‐up showed that the static 2PD of the injured finger pulp was 5.8 mm. The range of motion of the injured finger at the distal interphalangeal joint was 86°. The ranges of motion of the metacarpophalangeal and proximal interphalangeal joints of the donor fingers were 90° and 101°, respectively (Fig. 5C, D).

Figure 5.

Figure 5

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Case 15: (A) A 32‐year‐old man presented with a left little finger pulp defect. (B) A sensory reverse dorsal digital artery flap taken from the proximal dorsum of the ring finger was raised to fit the defect. (C, D) Postoperative views of the flap and finger function at 28‐month follow‐up.

Discussion

Management of Finger Neurocutaneous Defect

A finger neurocutaneous defect poses a reconstructive challenge. The challenge lies in resurfacing the finger with a good‐quality pliable and sensate skin cover and providing good cosmetic results16, 17. For the closure of a neurocutaneous defect, various options exist. A neurovascular pedicle V‐Y advancement flap has been used to treat small soft tissue defects (no larger than 1.5 cm) with excellent sensory recovery18. Reconstructing finger neurocutaneous defects with abdominal, groin, and forearm pedicle tubes is a simple and reliable technique. However, it requires the fingers to be attached to the donor sites for at least 3 weeks and offers poor functional and cosmetic results19, 20. Although the flap from the great or second toe can be used to reconstruct finger neurocutaneous defects with good aesthetic appearance and satisfactory sensory function, the procedures are cumbersome and carry a relatively high risk of anastomosis failure21, 22, 23, 24. The modified cross‐finger flap has been reported with excellent cosmetic appearance and sensory recovery; however, the requirement of a minimum attachment period of 2 weeks and stages of surgeries are major drawbacks25.

For the closure of a simple finger defect, the aforementioned commonly used flaps may be available options and provide excellent sensory recovery and cosmetic results. However, for complex finger defects, in conditions where none of the normal options can provide reasonable coverage, the sensory reverse dorsal digital artery flap from the neighboring digit can be used as an alternative.

Reverse Dorsal Digital Artery Flap

The reverse dorsal digital artery flap, which has been previously described in reconstructing finger defects, has been reported on for decades26, 27. It is rarely reported for reconstructing finger neurocutaneous defects on the neighboring digit due to its short pedicle. The limited pedicle length restricts using the flap in distal areas or the neighboring digit areas28. The reach of the reverse dorsal digital artery flap could be improved if the pedicle length could be extended. An interlacing vascular network between the dorsal digital artery and the dorsal branch of the PDA is constant in anatomy in this study. The sensory reverse dorsal digital artery flap using the dorsal branch of the PDA as a pedicle could be raised safely from the neighboring uninjured digit in this study. Sixteen sensory reverse dorsal digital artery flaps were harvested with only a 0.5‐cm‐wide pedicle. The long pedicle made it possible to resurface any defect of the injured finger. The present study demonstrated that this procedure is a safe technique for finger neurocutaneous defect reconstruction.

Finger sensation plays an indispensable role in daily activities. It should be restored, if possible, in any finger injury. Neurorrhaphy between the dorsal branch of PDN and PDN is a useful technique that has been used for sensory reconstruction with excellent sensory recovery29, 30. In this study, the mean value of static 2PD in the injured finger pulps was 6.5 mm (range, 5–10 mm), compared with 4 mm (range, 3–5 mm) of the opposite sides. Although finger sensation was not completely restored compared with that of the opposite side, the results in the patients of the present study were superior compared with those that did not contain both dorsal branches of PDN.

Indication and Advantages

The indication for the use of the technique discussed in this study includes finger neurocutaneous defect with no normal local pedicled flaps available. The contraindications are associated injuries to the donor sites or the course of the pedicle that preclude raising the flap, concomitant acute infection, and life‐threatening associated injuries.

The advantages of the technique presented in this study include stable hemodynamics in the flap, extended flap pedicle length, wide arc of flap rotation, satisfactory finger function, satisfactory flap appearance, and excellent sensory recovery. The disadvantages include the requirement for microsurgical neurorrhaphy and the relatively complex procedure.

Nevertheless, the limitations of the present study include a small sample size and absence of a comparison group. However, the technique can benefit selected patients. A prospective, randomized and blinded future study is recommended to better ascertain the effects of this technique.

Conclusions

A sensory reverse dorsal digital artery flap raised from the neighboring digit is an effective and reliable option for reconstructing finger neurocutaneous defects. The technique used in this study has been shown to provide good finger sensation and appearance.

Disclosure: The authors have no conflict of interest to declare.

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