Fingertip Reconstruction Using a

Volar Flap Based on the Transverse

Palmar Branch of the Digital Artery
Kwang Seog Kim, MD, PhD
Sung In Yoo, MD
Dae Young Kim, MD, PhD
Sam Yong Lee, MD, PhD
Bek Hyun Cho, MD, PhD

A new homodigital neurovascular island flap for fingertip recon- struction, but prolonged immobilization can lead
struction, called a volar digital island flap, is described. The flap to stiffness of the injured digits. Several ho-
is perfused from the proper digital artery through the transverse
modigital island or subcutaneous pedicle flaps
palmar branch, and is drained through the tiny venules and
capillaries contained in the perivascular soft tissue. Between have been developed to avoid the disadvantages
1997 and 2000, 25 fingers from 23 patients with defects of the of local, regional, and distant flaps, but even
middle and distal phalangeal areas were reconstructed using this these have some disadvantages. In an attempt to
flap. All flaps survived well. Patient age ranged from 17 to 65
resolve these problems, volar digital island flaps
years (average age, 32.5 years). Long-term follow-up for more
than 6 months was possible in 15 fingers from 14 patients. Light
based on the transverse palmar branches of the
touch and temperature sensation could be detected in all the proper digital artery from the adjacent volar re-
flaps evaluated. The mean value of the static two-point discrim- gion were developed. We present this technique
ination test was 4.2 mm. Although this flap requires the sacrifice and our results, along with a brief literature
of important volar skin, it provides excellent padding and sensa-
review.
tion for fingertip reconstruction. The authors think that this new
flap is an alternative choice for coverage of fingertip defects.

Kim KS, Yoo SI, Kim DY, et al. Fingertip reconstruction using a volar flap
based on the transverse palmar branch of the digital artery. Ann Plast Surg
Surgical Anatomy
2001;47:263–268
According to Strauch and De Moura,6 there are
From the Department of Plastic and Reconstructive Surgery, Chonnam three major transverse palmar branches in each
National University Medical School, Kwangju, Korea.
digit: the proximal, middle, and distal transverse
Received Dec 12, 2000, and in revised form Mar 7, 2001. Accepted for
publication Mar 7, 2001. palmar branches. The locations of these branches
Address correspondence and reprint requests to Dr Kwang Seog Kim, are constant. The proximal and middle transverse
Department of Plastic and Reconstructive Surgery, Chonnam National branches are always in association with the limbs
University Medical School, 8 Hak-dong, Dong-gu, Kwangju, 501-757,
Korea. of the proximal and distal cruciate ligaments. The
distal transverse palmar branch lies just distal to
the insertion of the profundus tendon (Fig 1A). The
middle transverse branch is approximately 1.5
times larger than the proximal transverse palmar
Fingertip amputation represents a common type branch. The distal transverse palmar branch is
of upper extremity injury. Reattachment of the approximately the same size as the middle branch.
severed part is the best method of preserving the There is an average of four palmar branches of the
length and normal anatomy of the nail complex. proper digital arteries from each side at the level of
However, if this is not possible, there are many the proximal and middle phalanges. Many small
surgical techniques using flaps to resurface the branches from the proper digital arteries and the
defect. Local advancement flaps1,2 provide soft- transverse palmar branches are connected to the
tissue coverage of similar quality to that of nor- volar arterial network.
mal glabrous skin. However, this is not always Many hand surgeons have reported that the ve-
possible because of the limitations to the distance nae comitantes running with the proper digital
that the flaps can be advanced. Regional3,4 and artery cannot be found.7–9 In fact, the perivascular
distant flaps5 provide enough tissue for recon- cuff tissue of the proper digital artery contains the

Copyright © 2001 by Lippincott Williams & Wilkins, Inc. 263

Annals of Plastic Surgery Volume 47 / Number 3 / September 2001

Fig 1. (A–D) Schematic drawing of the surgical anatomy (A) and operative technique (B–D). a ⫽ distal transverse
palmar branch; b ⫽ middle transverse palmar branch; c ⫽ proximal transverse palmar branch; d ⫽ insertion site of
the profundus tendon; e ⫽ distal cruciate ligament; f ⫽ proximal cruciate ligament; g ⫽ pulp defect; h ⫽ flap design;
i ⫽ elevated flap; j ⫽ transposed flap; k ⫽ skin graft to the donor defect.

tiny venules, but not the venae comitantes.10 In our their entrance into the flap. As the dissection
experience, no vein or venae comitantes running proceeds toward the proper digital artery and
with the proper digital artery have been found. nerve, it is essential to divide the Grayson’s
Therefore, our volar digital island flap is per- ligament, but the Cleland’s ligament can be pre-
fused from the proper digital artery through the served. To avoid kinking and to reduce tension
transverse palmar branch, and is drained through on the vascular pedicle, the fibrous septae should
the tiny venules and capillaries contained in the be freed by scissors dissection from the underly-
perivascular soft tissue. ing bone and tendon sheath. To enable free range
of flap transposition, the pedicle can be dissected
safely to the proximal level of the point where the
Operative Technique transverse palmar branch derives from the proper
digital artery. During dissection, a generous cuff
This operation can be performed in the operating of subcutaneous tissue is maintained around the
room with the patient under a digital nerve block. vascular pedicle to preserve the tiny perivascular
After minimal debridement of the wound, the venules (Fig 1C). The raised flap is then trans-
skin island flap can be designed at the distal, posed and sutured to the defect loosely, and the
middle, or proximal phalangeal area of the long donor site is covered with a split-thickness skin
fingers according to the patterns of the amputated graft from the hypothenar area. A tie-over bolster
stump and the pulp defect. The transverse palmar dressing is not applied, to prevent direct com-
branch is placed carefully in the distal region of pression of the pedicle (Fig 1D).
the flap, and the flap is based on the proximal The hand is elevated to minimize postoperative
side of the wound (Fig 1B). After a tourniquet is venous congestion, and anticoagulants are not
applied to the base of the finger, a skin incision is used. The finger is splinted for 1 week to ensure the
made from the side opposite the vascular pedicle. success of the graft, after which both passive and
The flap is elevated carefully, with the aid of a active mobilization can begin carefully, and a light
operating microscope, to leave the paratenon in protective dressing is worn for approximately 2
situ to ensure the take of the skin graft. The weeks. Most patients can return to work and their
transverse palmar branch is first identified, and is normal routine 3 to 4 weeks after the operation.
then ligated and divided at the distal mid portion
of the flap. The neurovascular pedicle can be best
found where the transverse palmar branch de- Clinical Experience
rives from the proper digital artery of the side
opposite the vascular pedicle. The transverse Volar digital island flaps based on the transverse
palmar branch and the branch of the proper palmar branches of the proper digital artery were
digital nerve in the pedicle area are dissected to used for fingertip reconstruction in 25 fingers

264
 Kim et al: Volar Digital Island Flap

Table 1. Injured Digits and Flap Pedicles branch of the proper digital nerve in the pedicle,
Transverse Palmar Branch the flap was transposed and sutured to the result-
Used as Flap Pedicle, N ing defect. The donor defect was covered with a
Injured Digit No. of Digits Proximal Middle Distal split-thickness skin graft from the left hypothenar
Index 12 1 6 6 area. Five days after the operation, the transposed
Middle 9 1 3 5 flap had a static two-point discrimination of less
Ring 3 0 1 2
than 5 mm. The flap survived completely and the
Little 1 0 1 0
graft healed uneventfully. Three months after the
operation, the flap had the ability to detect light
from 23 patients (16 men and 7 women; average touch, sharp from dull stimuli, and hot from cold
age, 32.5 years; age range, 17– 65 years) between stimuli. Seven months after the operation, static
1997 and 2000. All defects were caused by two-point discrimination was 3 mm (Fig 2).
trauma. Twenty fingers from 18 patients were
operated as primary cases, whereas 5 fingers from Patient 2
5 patients were covered secondarily to resolve A 42-year-old man sustained a complete amputa-
necrosis that occurred after composite grafting, tion of the distal part of the right middle finger.
replantation, and so on. There were 12 index, 9 The amputated fingertip was missing and the
middle, 3 ring, and 1 little finger that underwent patient did not want to have the finger shortened
operation (Table 1). All flaps survived well. The further. Local advancement flaps were not con-
width and length of the flaps ranged from 0.8 to sidered because of the large volar skin and pulp
2.2 cm and from 1.7 to 4 cm respectively. The loss. A 1.8 ⫻ 2.5-cm volar digital island flap
maximum flap size used in this series was 2.2 ⫻ based on the distal transverse palmar branch of
4 cm. Long-term follow-up for more than 6 the proper digital artery was raised in the manner
months was possible in 15 fingers from 14 pa- described earlier from the distal and middle
tients. Light touch, sharp stimuli, and tempera- phalangeal areas to cover the stump. The flap
ture could be detected in all flaps evaluated. The survived perfectly and the graft took without loss.
mean value of the static two-point discrimination Two months after the operation, the transposed
test was 4.2 mm (Table 2). In two fingers, the skin flap was slightly hypersensitive. However, 10
graft failed to take, partially as a result of subgraft months after the operation, the flap demonstrated
hematomas. However, scar contracture in most good sensibility, and static two-point discrimina-
flap donor sites was minimal. tion was 5 mm (Fig 3).

Patient Reports Disscussion

Patient 1 Various homodigital island flaps have been de-

A 28-year-old man with a complete amputation veloped or modified for fingertip reconstruction
of the left index fingertip was referred to us. because they can provide reconstruction in a
Using composite grafting, the amputated fingertip single operation and simultaneous good skin cov-
was reattached. Postoperatively, the reattached erage without immobilizing the injured and do-
fingertip survived completely. However, 3 nor digits. These flaps can be classified into three
months after the operation, partial necrosis of the groups.
fingertip occurred as a result of minor trauma. The first group of homodigital island flaps are
The devitalized tissue was debrided under a distally based flaps raised from the lateral aspect
digital nerve block. Local advancement flaps of the finger. Lai and colleagues10 and Kojima and
were not considered because of the poor vascu- associates11 described a reverse vascular pedicle
larity of the grafted fingertip. A 0.8 ⫻ 3-cm volar digital island flap to reconstruct a fingertip. This
digital island flap based on the middle transverse flap was raised from the lateral aspect of the
palmar branch of the proper digital artery was proximal phalangeal area, keeping the proper
designed. After elevation of the flap containing a digital artery within the flap. This is in contrast to

265
Annals of Plastic Surgery Volume 47 / Number 3 / September 2001

Table 2. Sensory Recovery for Flap Sizes

Static Two-Point
Discrimination, mm
Flap Size, Contralateral
Patient No. Age, yr Sex Follow-up, mo cm Flap Fingertip
1a 28 M 7 0.8 ⫻ 3.0 3 3
2a 42 M 10 1.8 ⫻ 2.5 5 3
3 17 M 22 1.6 ⫻ 2.5 3 2
4 32 F 14 1.6 ⫻ 2.5 3 3
5 56 M 9 1.8 ⫻ 2.2 5 3
6 23 F 10 1.6 ⫻ 2.0 4 2
7 45 M 8 1.6 ⫻ 2.2 3 3
8 26 M 17 2.2 ⫻ 4.0 5 3
9 18 M 9 1.6 ⫻ 2.5 3 3
10 37 F 12 1.6 ⫻ 2.5 3 3
11 23 M 15 1.8 ⫻ 2.8 3 2
12 52 F 16 1.8 ⫻ 2.2 6 3
13 63 M 6 1.8 ⫻ 3.2 8 5
14 41 M 9 2.0 ⫻ 3.4 4 3
15 41 M 9 1.8 ⫻ 2.5 5 3

Mean 36.2 11.5 1.7 ⫻ 2.7 4.2 2.9

a
These patients are described in the text.
M ⫽ male; F ⫽ female.

Fig 2. Patient 1. (A) Preoperative view of the defect and flap design. (B) Postoperative view at 7 months. (C) Elevation
of the volar digital island flap based on the middle transverse palmar branch. (D) Immediate postoperative view of
the flap transposed to the defect and the skin graft applied to the donor defect.

the use of dorsal skin branches along with the transposition. However, these flaps have a poten-
proper digital artery described by Niranjan and tial risk of venous insufficiency and may cause
Amstrong.12 In an effort to provide sensibility, Lai problems in an already traumatized finger.
and colleagues13,14 developed reverse digital ar- The second group of flaps are distally based
tery flaps innervated by unilateral or bilateral flaps raised from the dorsal aspect of the finger.
neurorrhaphy using the cut ends of the digital Lai and colleagues15 introduced a dorsal adipo-
nerve at the injured site, the dorsal branch of the fascial turnover flap that provided a vascularized
proper digital nerve, and the superficial sensory surface, which allows an immediate skin graft.
branch of the radial or ulnar nerve. These flaps However, the reality of this flap emphasizes the
were thin, flexible, and durable, and had a long, importance of random subcutaneous circulation.
distally based vascular pedicle with a wide arc of Del Bene and coworkers16 described fingertip

266
 Kim et al: Volar Digital Island Flap

Fig 3. Patient 2. (A) Preoperative view of the defect and flap design. (B) Postoperative view at 5 months. (C) Elevation
of the volar digital island flap based on the distal transverse palmar branch. (D) Immediate postoperative view of the
flap transposed to the defect and the skin graft applied to the donor defect.

reconstruction using a subcutaneous pedicle, dis- flaps of this type supply similar skin with near-
tally based dorsal skin flap, called a reverse normal sensibility and do not require extensive
dorsal digital island flap. This flap is nourished soft-tissue dissection. However, there are limita-
by the reversed arterial flow through the dorsal tions in the distance they can reach, such as local
branches of the intact digital arteries, and is advancement flaps.
drained by the subcutaneous venous flow. In an The volar digital island flap, based on the
attempt to augment the reverse dorsal digital transverse palmar branches of the proper digital
island flap blood supply, Kayıkçıoğlu and col- artery, offers the advantages of both proximally
leagues17 anastomosed the proximal end of the and distally based homodigital island flaps.
dorsal vein in the flap to the cut end of the proper These include a constant and reliable blood sup-
digital artery at the fingertip. This created the ply without sacrificing a major artery, excellent
so-called arterialized venous dorsal digital island sensory recovery because of the digital nerve
flap. A main advantage of these flaps is that the branches contained in this flap, coverage of the
proper digital artery is totally spared. However, volar defect with skin that has similar qualities in
the grafted donor area of these flaps is on the a single operative field, no venous congestion
relatively conspicuous dorsal surface, and the because of the proximally based flap, a one-stage
pedicle needs to be thinned considerably before procedure for both functional and aesthetic pres-
it can be rotated 180 deg to reach the wound. ervation of the fingertip, and the avoidance of
The third group is the proximally based flap long hospitalization and immobilization of the
raised from the neighboring tissue of the wound. hand. This procedure is also versatile because it
Joshi18 covered the pulp defect using an island can be used on any transverse palmar branch of
flap based on the proper digital vessels and their the proper digital artery, and is easy to plan
dorsal branches from the dorsolateral surface. because it can reach the wound by means of
The oblique triangular flap used by Ven- rotating the adjacent volar tissue. However, there
kataswami and Subramanian19 and the step-ad- are some disadvantages. The main disadvantage
vancement island flap developed by Evans and is the volar scar contracture resulting from the
Martin20 have also been described. Tasi and sacrifice of volar skin. The skin graft loss may
Yuen21 developed a sickle-shaped island flap to aggravate the volar scar because a tie-over bolster
manage a partial amputation of the fingertip or dressing is not applied to prevent direct compres-
volar skin defects less than 1.5 cm in length. The sion of the pedicle. When a transverse palmar
advancement and transposition of local skin as branch is located on a rim of tissue adjacent to the
an island flap effects a physiological reconstruc- wound, the flap based on the branch may not be
tion when the fingertip pulp has been lost. The raised because of vascular injury.

267
Annals of Plastic Surgery Volume 47 / Number 3 / September 2001

The fingertip is the most important tactile area 8 Lucas GL. The pattern of venous drainage of the digits.
J Hand Surg [Am] 1964;9A:448 – 450
and makes a great contribution to finger power.
9 Cormack GC, Lamberty BGH. The arterial anatomy of skin
Although the flap reported in the current study flaps. London: Churchill Livingston, 1986:186 –193.
requires the sacrifice of important volar skin, it 10 Lai CS, Lin SD, Yang CC. The reverse digital artery flap for
fingertip reconstruction. Ann Plast Surg 1989;22:495–500
provides excellent padding and sensation for 11 Kojima T, Tsuchida Y, Hirase Y, et al. Reverse vascular
fingertip reconstruction. Therefore, despite some pedicle digital island flap. Br J Plast Surg 1990;43:290–295
troubles, it appears to be suitable for fingertip 12 Niranjan NS, Armstrong JR. A homodigital reverse pedicle
island flap in soft tissue reconstruction of the finger and
reconstruction. In particular, it is indicated for the thumb. J Hand Surg [Br] 1994;19B:135–141
use in patients who sustain a large volar defect of 13 Lai CS, Lin SD, Chou CK, et al. A versatile method for
reconstruction of finger defects: reverse digital artery flap.
the fingertip.
Br J Plast Surg 1992;45:443– 453
14 Lai CS, Lin SD, Chou CK, et al. Innervated reverse digital
artery flap through bilateral neurorrhaphy for pulp defect.
References Br J Plast Surg 1993;46:483– 488
15 Lai CS, Lin CC, Yang CC, et al. The adipofascial turn-over
flap for complicated dorsal skin defects of the hand and
1 Kutler W. A new method for fingertip amputation. JAMA finger. Br J Plast Surg 1991;44:165–169
1947;133:29 –30 16 Del Bene M, Petrolati M, Raimondi P, et al. Reverse dorsal
2 Atasoy E, Ioakimidis E, Kasdan ML, et al. Reconstruction digital island flap. Plast Reconstr Surg 1994;93:552–557
of the amputated fingertip with a triangular volar flap—a 17 Kayıkçıoğlu A, Akyürek M, Safak T, et al. Arterialized
new surgical procedure. J Bone Joint Surg Am 1970;52A: venous dorsal digital island flap for fingertip reconstruc-
921–926 tion. Plast Reconstr Surg 1998;102:2368 –2373
3 Tempest MN. Cross-finger flaps in the treatment of injuries 18 Joshi BB. A local dorsolateral island flap for restoration of
to the finger tip. Plast Reconstr Surg 1952;9:205–222 sensation after avulsion injury of fingertip pulp. Plast
4 Miller AJ. Single fingertip injuries treated by thenar flap. Reconstr Surg 1974;54:175–182
Hand 1974;6:311–314 19 Venkataswami R, Subramanian N. Oblique triangular flap:
5 McGregor IA, Jackson IT. The groin flap. Br J Plast Surg a new method of repair for oblique amputations of the
1972;25:3–16 fingertip and thumb. Plast Reconstr Surg 1980;66:296 –300
6 Strauch B, De Moura W. Arterial system of the fingers. 20 Evans DM, Martin DL. Step-advancement island flap for
J Hand Surg [Am] 1990;15A:148 –154 fingertip reconstruction. Br J Plast Surg 1988;41:105–111
7 Eaton RG. The digital neurovascular bundle: a microana- 21 Tsai TM, Yuen YC. A neurovascular island flap for volar–
tomic study of its contents. Clin Orthop Rel Res 1968;61: oblique fingertip amputations. J Hand Surg [Br] 1996;21B:
176 –185 94 –98

268