This paper reports on 29 patients treated for soft-tissue defects of the fingers using heterodigital arterialized flaps from adjacent digits. All defects were proximal to the DIP joint. Wound etiology was infection (14), trauma (6), replantation defects (6), electrical burn (1), and high- pressure injection (1). Flaps were harvested from the midaxial line preferably central and adjacent to the defect to be reconstructed. The flap arterial supply was based on the digital artery, which was carefully dissected off of the overlying nerve to preserve sensation in the distal pulp, which was not harvested in the flap. Venous drainage was provided by incorporation of a longitudinal dorsal vein, rather than relying on venae comitantes from the digital artery. The dorsal dissection was performed superficial to the paratenon of the extensor mechanism, and the donor sites were replaced with full-thickness skin grafts. Average flap dimensions were 4.1 cm x 2.1 cm. There were no partial flap losses, and all survived. The authors assessed both donor morbidity and reconstructive results by means of Strickland criteria. Donor fingers were assessed as: excellent in 83%, good in 14%, and one fair result due to RSD. Donor sensation was normal in 28/29 fingertips, with an average 2pt discrimination of 3.6mm. Of 22 reconstructed fingers assessed, results were excellent in 32%, good in 14%, fair in 32%, and poor in 23%. Flexion contractures were present in 8 fingers, with and average total active range of motion for the series of 106 degrees.
This is a large series of heterodigital island flaps, considering the relative rare indication for this technique. The authors present a very careful outline of the technical aspects and apply the flap to excellent use in a number of challenging scenarios. Their critical analysis of the results reveals that, despite excellent technique in experienced hands, these complex large soft tissue defects in the fingers still resulted in only fair or poor results in over 50% of the cases. The important modifications of the original heterodigital island flap, namely, preservation of the digital nerve within the donor finger while maintaining intact pulp to maximize functional sensation, and incorporation of a large longitudinal dorsal vein in the flap to prevent venous congestion, have made this a more useful and reliable option. Still despite their excellent donor site results, the finger remains a controversial donor site for another injured finger. With an ever-increasing number of local flaps being described, such as the reliable and very mobile dorsal metacarpal artery flap, the trade-off of a significant donor site complication or even cosmetic deficit in an adjacent finger with an already significant finger injury in the hand becomes harder to justify. Still, there are times when replacing "like with like" is the most important consideration. For those cases, this paper sets the foundation for reliable and effective use of this technique.
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Plastic & Reconstructive Surgery