Arch Hand Microsurg.  2021 Jun;26(2):125-130. 10.12790/ahm.21.0085.

Simultaneous Volar Pulp and Nail Bed Reconstruction with the Second Toe Onychocutaneous Free Flap

• Lee KJ
• Park I
• Roh SY
• Koh SH
• Kim JS
• Hong MK

• KMID: 2516157
• DOI: http://doi.org/10.12790/ahm.21.0085

Abstract

Fingertip injury is one of the most common hand injuries. Although several types of advancement and cross-finger flaps exist, they would not be essential for nail bed defects. The authors present a simultaneous volar pulp and nail bed reconstructive technique that uses a second toe onychocutaneous free flap. Four patients without amputees underwent fingertip amputation reconstruction between 2011 and 2019. After thorough debridement, the defect size was estimated, and the digital arteries, nerves, and veins of the recipient were evaluated. The flap, composed of pulp tissue and nail bed, was harvested with continuity from the second toe. Additional split-thickness skin grafts were performed in two cases. All flaps survived without considerable complications. We evaluated the scar and contour, and nail growth was reported over Zook’s criteria grade B. The second toe onychocutaneous free flap provides a reliable option for fingertip defects that involve pulp tissue and nail bed without further amputation.

Keyword

Fingertip; Nail bed; Free flap

Figure

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  Fig. 1. A 48-year-old female patient who injured her right middle finger visited our department without amputee. (A) Nail bed defect (dotted round) and bone exposure (arrow). (B) Volar pulp defect (dotted round) and bone exposure (arrow).

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  Fig. 2. Intraoperative photographs. (A) After dermal dissection, a digital artery (red arrow) and a subcutaneous vein (blue arrow) are seen at the med-level flap. (B) The flap is elevated on the anteromedial second toe tip, including nail bed and alongside the tibial side of the second toe. (C) The radial digital artery (red arrow) and a volar subcutaneous vein (blue arrow) are anastomosed at the middle phalanx level of the recipient finger. The radial digital nerve is anastomosed under the subcutaneous fat tissue.

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  Fig. 3. Schematic diagram of flap harvesting. (A) The harvested flap from the second toe (red, artery; yellow, nerve; blue, vein). (B) Cross section view of the harvested flap. A red dotted line represents the cross section level in Fig. 3A.

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  Fig. 4. Long-term follow-up photographs. (A) Case 1, excellent. (B) Case 2, very good.

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