Arch Hand Microsurg.  2019 Mar;24(1):79-86. 10.12790/ahm.2019.24.1.79.

Volar Open V-Y Flap for Distal Toe Injury

• Lee YH
• Lee YH
• Kim MB
• Lee CH
• Baek GH

• KMID: 2440616
• DOI: http://doi.org/10.12790/ahm.2019.24.1.79

Abstract

PURPOSE
Soft tissue construction of the toe is challenging because there are low blood supply and lack of available soft tissue around the defect. The purpose of this study is to evaluate the therapeutic effect of an open V-Y flap in toe-tip amputations.
METHODS
Among the cases that involved treatment with Open V-Y flap for the reconstruction of soft tissue defects of great toe between January 2012 to December 2015, only those cases encountered more than six months ago were evaluated. A total of five patients were enrolled between the ages of 24 and 54. The results were assessed by a flap survival, residual pain and complications such as hook nail deformity at last day of follow-up.
RESULTS
In all of five cases, flaps were entirely survived without complications. All patients can walk without disability after three weeks from surgery. More than 80% of sensory recovery was reported subjectively compared to the intact side six months after the surgery without residual pain. No partial flap necrosis, recurrence of skin defects or ulcers were observed. The 4 cases survived without hook nail deformity except for 1 case that was a complete loss of nail at the initial injury.
CONCLUSION
The volar open V-Y flap in toe-tip amputation has a simple procedure, low complications, minimal donor site morbidity, and excellent sensory recovery. Therefore, it is considered one of the proper treatments for toe-tip amputations.

Keyword

Foot injuries; Toes; Surgical flap; Malformed nails

MeSH Terms

Amputation
Congenital Abnormalities
Follow-Up Studies
Foot Injuries
Humans
Nails, Malformed
Necrosis
Recurrence
Skin
Surgical Flaps
Tissue Donors
Toes*
Ulcer

Figure

• 

  Fig. 1 A 36-year-old male presenting soft tissue defect one week after crushing injury at right big toe. (A, B) Dorsal oblique type 2.8×1.7 cm-sized soft tissue defect after debridement. (C, D) Volar triangular shaped flap design was made from the edge of the defect. (E) A flap was elevated and advanced at subcutaneous level. (F, G) The flap was sutured with eversion of the end by Horizontal transverse suture. (H) Skin defect of the donor site was remained open with exposure of subcutaneous tissue and managed by an occlusive dressing. (I, J) A crust was made on the defect of the donor site, and stitch was removed after two weeks from surgery. (K, L) The nail was recovered as near-normal appearance without hook nail deformity, and scar became faded compare to surrounding tissue at 14-month after (informed consent was taken).

Reference

1. Governa M, Barisoni D. Distally based dorsalis pedis island flap for a distal lateral electric burn of the big toe. Burns. 1996; 22:641–643.

2. Dogra BB, Priyadarshi S, Nagare K, Sunkara R, Kandari A, Rana KS. Reconstruction of soft tissue defects around the ankle and foot. Med J Dr DY Patil Univ. 2014; 7:603–607.

3. Berceli SA, Brown JE, Irwin PB, Ozaki CK. Clinical outcomes after closed, staged, and open forefoot amputations. J Vasc Surg. 2006; 44:347–351. discussion 352.

4. Bharathi RR, Jerome JT, Kalson NS, Sabapathy SR. V-Y advancement flap coverage of toe-tip injuries. J Foot Ankle Surg. 2009; 48:368–371.

5. Lin CH, Wei FC, Chen HC. Filleted toe flap for chronic forefoot ulcer reconstruction. Ann Plast Surg. 2000; 44:412–416.

6. Hamilton RB, O'Brien BM, Morrison WA. The cross toe flap. Br J Plast Surg. 1979; 32:213–216.

7. Balakrishnan C, Chang YJ, Balakrishnan A, Careaga D. Reversed dorsal metatarsal artery flap for reconstruction of a soft tissue defect of the big toe. Can J Plast Surg. 2009; 17:e11–e12.

8. Bharathwaj VS, Quaba AA. The distally based islanded dorsal foot flap. Br J Plast Surg. 1997; 50:284–287.

9. Butler CE, Chevray P. Retrograde-flow medial plantar island flap reconstruction of distal forefoot, toe, and webspace defects. Ann Plast Surg. 2002; 49:196–201.

10. Jyoshid RB, Vardhan H, Anto F. Free medial plantar artery flap for the reconstruction of great toe pulp. J Plast Reconstr Aesthet Surg. 2014; 67:863–865.

11. Wang X, Mei J, Pan J, Chen H, Zhang W, Tang M. Reconstruction of distal limb defects with the free medial sural artery perforator flap. Plast Reconstr Surg. 2013; 131:95–105.

12. Lin CH, Lin CH, Sassu P, Hsu CC, Lin YT, Wei FC. Replantation of the great toe: review of 20 cases. Plast Reconstr Surg. 2008; 122:806–812.

13. Tranquilli-Leali E. Ricostruzione dell' apice delle falangi ungueali mediante autoplastica volare peduncolata per scorrimento. Infort Traum Lavoro. 1935; 1:186–193.

14. Atasoy E, Ioakimidis E, Kasdan ML, Kutz JE, Kleinert HE. Reconstruction of the amputated finger tip with a triangular volar flap. A new surgical procedure. J Bone Joint Surg Am. 1970; 52:921–926.

15. Bickel KD, Dosanjh A. Fingertip reconstruction. J Hand Surg Am. 2008; 33:1417–1419.

16. Peterson SL, Peterson EL, Wheatley MJ. Management of fingertip amputations. J Hand Surg Am. 2014; 39:2093–2101.

17. Panattoni JB, De Ona IR, Ahmed MM. Reconstruction of fingertip injuries: surgical tips and avoiding complications. J Hand Surg Am. 2015; 40:1016–1024.

18. Thoma A, Vartija LK. Making the V-Y advancement flap safer in fingertip amputations. Can J Plast Surg. 2010; 18:e47–e49.

19. Niranjan NS, Vanstralen P. Homodigital reverse pedicle island flap for reconstruction of the great toe. Br J Plast Surg. 2000; 53:499–502.

20. Reiffel RS, McCarthy JG. Coverage of heel and sole defects: a new subfascial arterialized flap. Plast Reconstr Surg. 1980; 66:250–260.

21. Baker GL, Newton ED, Franklin JD. Fasciocutaneous island flap based on the medial plantar artery: clinical applications for leg, ankle, and forefoot. Plast Reconstr Surg. 1990; 85:47–58. discussion 59-60.

22. Hauck RM, Camp L, Ehrlich HP, Saggers GC, Banducci DR, Graham WP. Pulp nonfiction: microscopic anatomy of the digital pulp space. Plast Reconstr Surg. 2004; 113:536–539.

23. Banis JC. Glabrous skin grafts for plantar defects. Foot Ankle Clin. 2001; 6:827–837. viii

24. Thorne C, Chung KC, Gosain A, Guntner GC, Mehrara BJ. Grabb and Smith's plastic surgery. 7th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health;2014.

25. Demirtas Y, Ayhan S, Latifoglu O, Atabay K, Celebi C. Homodigital reverse flow island flap for reconstruction of neuropathic great toe ulcers in diabetic patients. Br J Plast Surg. 2005; 58:717–719.

26. Cheng MH, Ulusal BG, Wei FC. Reverse first dorsal metatarsal artery flap for reconstruction of traumatic defects of dorsal great toe. J Trauma. 2006; 60:1138–1141.

27. Hwang JC, Chung DW. Homodigital reverse pedicle island flap for reconstruction of the great toe - a case report -. J Korean Soc Microsurg. 2011; 20:64–67.

28. Chung DW, Lee JH. The reconstruction of foot using medial plantar flap. J Korean Soc Microsurg. 2002; 11:153–161.

29. Tupper J, Miller G. Sensitivity following volar V-Y plasty for fingertip amputations. J Hand Surg Br. 1985; 10:183–184.

30. Krishnan KG. Sensory recovery after reconstruction of defects of long fingertips using the pedicled V flap. Br J Plast Surg. 2001; 54:523–527.

31. Foucher G, Dallaserra M, Tilquin B, Lenoble E, Sammut D. The Hueston flap in reconstruction of fingertip skin loss: results in a series of 41 patients. J Hand Surg Am. 1994; 19:508–515.

32. Kets CM, Van Leerdam ME, Van Brakel WH, Deville W, Bertelsmann FW. Reference values for touch sensibility thresholds in healthy Nepalese volunteers. Lepr Rev. 1996; 67:28–38.

33. Kumar VP, Satku K. Treatment and prevention of “hook nail” deformity with anatomic correlation. J Hand Surg Am. 1993; 18:617–620.