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. 2025 Jul 1;410(1):208.
doi: 10.1007/s00423-025-03800-x.

Skin pedicle expansion technique in dorsal nerve fascial Island flap: enhancing viability in repairing digital soft tissue defects

Xun Wang  1 , Rui Yang  2 , Qixiang Yang  2 , Jingdan Lv  3 , Qi Ye  4 , Yaohui Chen  4 , Mingyu Pan  4 , Gaofeng Chen  4 , Lisha Qiu  5   6
Affiliations

Skin pedicle expansion technique in dorsal nerve fascial Island flap: enhancing viability in repairing digital soft tissue defects

Xun Wang et al. Langenbecks Arch Surg. .

Abstract

Purpose: Various flap techniques have been developed for injuries to the middle and distal phalanges, with the dorsal nerve fascial island (DNFI) flap offering distinct advantages. We aimed to elucidate the process of skin pedicle expansion (SPE) during DNFI flap transplantation and its effectiveness in relieving pressure on the fascial pedicle.

Methods: Ninety-two patients with soft tissue defects in the middle and distal phalanges were treated using a DNFI flap from February 2008 to August 2023. Eighty-three patients underwent SPE. The SPE technique involves creating a 3- to 4-mm wide skin strip on the surface of the fascial tissue, which contains a small arterial-venous system along with dorsal nerves, enabling the flap to remain viable. The fascial pedicle reaches the defect area via an incision (the skin channel). The skin pedicle transforms the shape of the channel from triangular to trapezoidal, thereby increasing its capacity. After flap rotation and suturing, the design reduced the pressure of the channel on the fascial pedicle. Theoretically, this should facilitate smoother arterial and venous circulation within the flap, thereby improving survival rates.

Results: All 83 flaps treated using the SPE technique survived. However, one patient experienced flap necrosis, and two patients had partial necrosis in the non-SPE group, with only six patients presenting satisfactory survival outcomes.

Conclusions: SPE may improve the viability of DNFI flaps by alleviating pressure on the fascial pedicle, ensuring adequate blood flow, and enhancing flap viability. SPE has the potential to be a valuable technique in hand-repair surgery.

Level of evidence: Level 4 according to the Oxford Centre for Evidence-Based Medicine (OCEBM).

Keywords: Compression; Dorsal digital nerve; Fascia; Finger; Flap; Skin pedicle expansion.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: This study was approved by the ethics committee of our institution. The skin pedicle technique and dorsal nerve fascial island (DNFI) flap were approved for clinical use by the authors’ institution. All procedures involving human participants performed in this study were in accordance with the ethics standards of the institutional and national research committee and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Written informed consent was obtained from all participants in this study and is stored in the Department of Medical Records at our institution. Competing interests: The authors declare no competing interests. Consent to publish: Not applicable. Authors’ information: XW, Deputy Director, Department of Hand and Foot Surgery, The Third Hospital of Xiamen, The First Affiliated Hospital of Xiamen University (Tongan Branch), Xiamen, Fujian, China. Academic Societies:: Member, Chinese Medical Association Fujian Branch for Microscopic Surgery. Member, Chinese Medical Association Fujian Branch for Tissue Regeneration and Repair. Member, Xiamen Association of the Integration of Traditional and Western Medicine for Trauma. Expert Panel Member, Chinese Medical Association Xiamen Branch for Medical Accident and Medical Damage Identification. Clinical Specializations:: Wound Repair. Foot and Hand Diseases. Nerve and Vessel Repair.

Figures

Fig. 1
Fig. 1
General information on each finger surgery
Fig. 2
Fig. 2
Schematic of the rotation points of the flap. The distal end of the middle phalanx (MPx) (point a) or distal end of the proximal phalanx (PPx) (point A) serves as the rotation point, also known as the outlet point of the dorsal branches of the proper palmar digital artery
Fig. 3
Fig. 3
Schematic of the flap designed at the middle and distal segment of the proximal phalanx
Fig. 4
Fig. 4
Schematic of the flap located adjacent to the metacarpophalangeal joint on the dorsum
Fig. 5
Fig. 5
Schematic of the skin channel. The dermal layers on both sides of the incision are dissected from the subcutaneous tissue, forming a skin channel to accommodate the retrogradely rotated fascial pedicle. The dermal layers (pink and orange areas) act as the lateral walls on both sides, and the fascial tissue acts as the lower wall
Fig. 6
Fig. 6
Management of the fold and uncovered triangular area of the fascial pedicle. (A) The fold and exposed triangular area; a detached skin strip to cover the exposed area (green curved arrow) in the next step is prepared. (B) A partially detached strip measuring 0.5–0.8 cm in length (black circle) is created. (C) The exposed triangular area with the strip is covered. (D) The detached strip with the surrounding integument is sutured
Fig. 7
Fig. 7
Case presentation of the index finger. (A) Pre-operative dorsal side. (B) Pre-operative lateral side. (C) Flap design. (D) Suturing. E and F. Sixteen months postoperatively. (E) Dorsal side. (F) Lateral side
Fig. 8
Fig. 8
Case presentation of the little finger. (A) Pre-operative ventral side. (B) Flap design. (C) Flap cutting. (D) Total length of the flap. (E) Length of the pedicle. (F) Width of the skin pedicle. (G) Width of the fascial pedicle. (H) Skin channel. (I) Donor site suture. (J) One week postoperatively. K. Three weeks postoperatively. L. Six months postoperatively
Fig. 9
Fig. 9
Schematic of the approximate volume calculation of skin channel with and without the skin pedicle expansion (SPE) technique. (A) Skin channel without the SPE technique. (B) Skin channel with the SPE technique
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