A comparative study of four types of free flaps from the ipsilateral extremity for finger reconstruction

Abstract

Aim: To compare the outcomes of finger reconstruction using arterialized venous flap (AVF), superficial palmar branch of the radial artery (SPBRA) flap, posterior interosseous perforator flap (PIPF), and ulnar artery perforator free (UAPF) flap harvested from the ipsilateral extremity.

Methods: We retrospectively reviewed the outcomes for 41 free flaps from the ipsilateral extremity in the reconstruction of finger defects in 41 patients with small/moderate skin defects, including 11 AVFs, 10 SPBRA flaps, 10 PIPFs, and 10 UAPF flaps. Standardized assessment of outcomes was performed, including duration of operation, objective sensory recovery, cold intolerance, time of returning to work, active total range of motion (ROM) of the injured fingers, and the cosmetic appearance of the donor/recipient sites.

Results: All flaps survived completely, and the follow-up duration was 13.5 months. The mean duration of the complete surgical procedure for AVFs was distinctly shorter than that of the other flaps (p<0.05). AVFs were employed to reconstruct skin defects and extensor tendon defects using a vascularized palmaris longus graft in 4 fingers. Digital blood supply was reestablished in 4 fingers by flow-through technique when using AVFs. Optimal sensory recovery was better with AVFs and SPBRA flaps as compared with UAPF flaps and PIPFs (p<0.05). No significant differences were noted in ROM or cold intolerance between the 4 groups. Optimal cosmetic satisfaction was noted for the recipient sites of AVFs and the donor sites of SPBRA flaps. The number of second-stage defatting operations required for AVFs was considerably lesser than that for the other flaps.

Conclusion: All 4 types of free flaps from the ipsilateral extremity are a practical choice in finger reconstruction for small/moderate-sized skin defects. AVFs play an important role in such operations due to the wider indications, and better sensory recovery and cosmetic appearance associated with this method.

Figure 1. Finger reconstruction by AVF.

Case 1: A 34-year-old man underwent finger reconstruction by AVF. (A) Preoperative defect of the little finger. (B) The design and elevation of the AVF. This flap contained 2 veins. The relatively smaller vein was used as the afferent vein, while the larger vein was used as the efferent vein. The perfusion pattern employed was the against-valve type. (C) The 4-day postoperative view shows good blood supply in the flap. (D) The 7-day postoperative view indicates the presence of blisters sporadically distributed over the flap, along with slight venous congestion. (E, F) The 10-month postoperative view shows that all the blisters subsided gradually without any special care. The flap completely survived, with excellent contour and texture. The patient’s self-assessments for cosmetic appearance was good on recipient site (9 scores), acceptable on donor site (6 scores).

Figure 2. Finger reconstruction by using the SPBRA flap.

Case 2: A 45-year-old man underwent finger reconstruction using the SPBRA flap. (A) Preoperative defect of the middle finger. (B) The elevation of the SPBRA flap. The green arrow indicates the SPBRA and its concomitant vein. The yellow arrow indicates a subcutaneous vein. The ratio of the artery and veins to be anastomosed was 1∶2. (C) The 5-day postoperative view indicates the presence of blisters distributed over the flap. All the blisters subsided gradually without any special care. (D) The 10-month postoperative volar view. (E) The 10-month postoperative lateral view. (F) The 10-month postoperative donor site and wrist function view. The patient’s self-assessments for cosmetic appearance was acceptable on recipient site (7 scores), good on donor site (9 scores).

Figure 3. Finger reconstruction by using the PIPF and UAPF flap.

Case 3: A 30-year-old man underwent finger reconstruction using the PIPF. (A) Preoperative defect of the index finger. The ulnaris digital artery was intact, whereas a defect of the radialis digital artery was noted. (B) The design of the flap, showing the perforator located at midpoint of Lister's tubercle and humerus epicondyle. The radialis digital artery was anastomosed with the posterior interosseous perforator. The diameter of the accompanying vein was too narrow; therefore, 2 superficial veins were used for ensuring venous return. (C) The 12-month postoperative view. This patient’s self-assessments for cosmetic appearance was good on recipient site (8 scores). Case 4: A 42-year-old man underwent finger reconstruction using the UAPF flap. (D) Preoperative defect of the little finger. (E) The design and elevation of the flap, with the defected ulnar digital artery anastomosed with the ulnar artery perforator, which was located approximately 40 mm proximal to the pisiform bone. The accompanying vein and superficial vein were used for venous return. (F) The 15-month postoperative view. This patient’s self-assessments for cosmetic appearance were acceptable on recipient site (6 scores).