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 Table of Contents  
CASE SERIES
Year : 2021  |  Volume : 18  |  Issue : 2  |  Page : 76-78

The esthetic reverse adipofascial cross-finger flap for nail bed and pulp defects


Department of Plastic and Hand Surgery, Baby Memorial Hospital, Kozhikode, Kerala, India

Date of Submission20-Oct-2021
Date of Acceptance24-Oct-2021
Date of Web Publication27-Jan-2022

Correspondence Address:
Subin Joseph
Department of Plastic and Hand Surgery, Baby Memorial Hospital, Kozhikode, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joasis.joasis_25_21

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  Abstract 


Introduction: Unlike volar or pulp defects of fingers, nail bed loss or defects are challenging for plastic and hand surgeons. It is difficult to achieve the best esthetic fingernails following nail bed defects. The reverse adipofascial cross-finger flap is a promising option for reconstructing more natural-looking fingernails. Materials and Methods: Twelve patients who underwent reverse adipofascial cross-finger flap for nail and pulp defects were reviewed. Results: All patients were satisfied with the esthetic appearance of their nail plate and color. Overall, 83.3% of patients graded their finger as excellent and good, compared to the normal finger on the opposite hand.

Keywords: Cross-finger flap, reverse cross-finger flap, adipofascial flap, nail, fingertip injury


How to cite this article:
Joseph S, Samantaray SA, Shet SM, Koyappathody HM, Kalathingal K. The esthetic reverse adipofascial cross-finger flap for nail bed and pulp defects. J Orthop Assoc South Indian States 2021;18:76-8

How to cite this URL:
Joseph S, Samantaray SA, Shet SM, Koyappathody HM, Kalathingal K. The esthetic reverse adipofascial cross-finger flap for nail bed and pulp defects. J Orthop Assoc South Indian States [serial online] 2021 [cited 2022 May 26];18:76-8. Available from: https://www.joasis.org/text.asp?2021/18/2/76/336655




  Introduction Top


Unlike volar or pulp defects of fingers, nail bed loss or defects are challenging for plastic and hand surgeons. It is difficult to achieve a more esthetic fingernails following nail bed defects. The reverse adipofascial cross-finger flap is a promising option for reconstructing natural-looking fingernails. The reverse adipofascial flap was explained by Al Pakiam in 1978 and by Atasoy in 1982.[1],[2] Since it is cumbersome and time-consuming, surgeons rarely attempt this flap.


  Materials and Methods Top


In our tertiary care center, we reviewed our 12 cases of reverse adipofascial cross-finger flap for nail and pulp defects last year. All patients had partial nail bed loss and hyponychium loss with intact germinal matrix and exposed distal phalanx. All underwent reverse adipofascial cross-finger flap in a single stage.

Surgical technique

After adequate debridement, the defect is defined and markings for reverse adipofascial cross-finger flap are planned on the dorsum of middle or proximal phalanx of adjacent donor finger [Figure 1].
Figure 1: Marking for adipofascial flap

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Full-thickness skin epidermis with dermis elevated laterally away from the injured finger starting from the proposed pivot point of adipofascial flap going upto the distal end of flap marking. Adipofascial flap is elevated towards the injured finger and flipped to cover the nail bed or pulp defects or combined nail bed and pulp defects and secured [Figure 2].
Figure 2: Elevated full-thickness skin away from the injured finger and elevated adipofascial flap towards the injured little finger

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Full-thickness skin raised initially is now kept back to cover the donor defect [Figure 3] and secured with bolster dressing. We usually never keep any skin graft over the flap to avoid compression. We can put hypothenar area skin grafts over the volar aspect. Sterile, soft, and noncompressing paraffin gauze moist dressings are applied.
Figure 3: Flap inset and replaced full thickness skin graft

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Scoring system

We devised a scoring system to assess the outcome of our study similar to the one used by Wang.[3] The outcomes measured were scored 0, 1, and 2 as described in the [Table 1]. The patient assessment included a patient satisfaction visual analog scale. The assessor evaluates all other parameters. The final outcome of surgery is classified as Excellent (for scores of 12 to 14), Good (for scores of 8 to 11), Fair (for scores of 4 to7), and Poor (for scores below 4).
Table 1: Scoring system for outcome assessment of nail bed and pulp defects

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  Results Top


All patients were satisfied with their postoperative appearance after 3 months when compared with the corresponding finger of opposite hand in terms of appearance, color, and nail plate shape. Satisfactory length (>75%) was preserved in all patients. Nail plate roughness was obvious in five patients, slight in four patients, and none in three patients. Lustre was found normal in eight patients (66.6%). Translucency was normally present in 4 (33.3%) patients and found less in four patients (33.3%). Eight patients (66.6%) were completely satisfied and none were unsatisfied. In overall appearance, nail dehiscence or growth failure was not found in nine patients (75%) and found only in three patients (25%). Cuticle appearance was found normal in 11 patients (91.6%). Results were graded as excellent in five patients (41.6%), good in five patients (41.6%), and fair in two patients (16.6%). Poor results were not graded by any of the patients. Overall, 83.3% of patients were graded their finger as excellent and good, compared to their normal finger on opposite hand. Results were most evident earliest by 3–4 months. [Figure 4], [Figure 5] and [Figure 6] shows the preoperative and postoperative images of three patients
Figure 4: Preoperative and postoperative picture of patient one

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Figure 5: Preoperative and postoperative picture of patient two

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Figure 6: Preoperative and postoperative picture of patient three

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  Discussion Top


Fingertip and nail esthetics are more demanding nowadays. When we do a conventional cross-finger flap for this combined nail bed and pulp defects, the dark-colored dorsal skin will replace the nail area and pulp. Hence, the esthetics of fingertips and nails would become compromised even though the reconstruction aspect is fulfilled. Especially young patients will be reluctant to show such fingertips in public. Other options for nail bed defects are nail bed grafting and secondary healing. Nail bed grafting is associated with graft loss and donor finger morbidity. Secondary healing will result in scarring, distorted nail plate due to poor adhesion between nail plate and nail bed.

The reverse adipofascial cross-finger flap is difficult and time-consuming surgery to perform.[4] This procedure requires loupe magnification and utmost precision to retain the flap thickness throughout and to prevent its vascular compromise. Most flaps will get epithelialized completely within 3 to 4 weeks. Volar pulp defects will get their natural-looking skin color. In nail bed defects covered with adipofascial flap, germinal matrix epithelium grows over the flap. When the nail plate grows above it, the anatomy is restored in color and congruity with good esthesis. In some cases, we may need to trim the hypergranulation over the flap surface to make sure a smooth nail bed and nail plate growth, and hence the shape and esthetics. Moreover, there is no need for extra skin graft harvest for flap donor site coverage, and thus unnecessary scars can be avoided. Disadvantages associated with this flap are, it involves two stages and if the flap fails, it will again lead to bone exposure. We had one partial flap failure which healed by secondary intention.


  Conclusion Top


The reverse adipofascial cross-finger flap is an alternative to conventional cross-finger flap in terms of better esthetics and more natural-looking nail and pulp. Although time-consuming and difficult to perform, the results are satisfactory for both patients and surgeons.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pakiam AI. The reversed dermis flap. Br J Plast Surg 1978;31:131-5.  Back to cited text no. 1
    
2.
Atasoy E. Reversed cross-finger subcutaneous flap. J Hand Surg Am 1982;7:481-3.  Back to cited text no. 2
    
3.
Wang A, Gao W, Wu L, Li Z, Chen X, Li X. Nail fusion plasty. Ann Plast Surg 2015;75:290-4.  Back to cited text no. 3
    
4.
Atasoy E. The reverse cross finger flap. J Hand Surg Am 2016;41:122-8.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1]



 

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Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
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