Reconstruction

of the Triangular
A
NEW

Amputated Volar
SURGICAL
M.D.t, M.D4, M.D.t,

Finger Flap

Tip

with

PROCEDURE*
EVANGELOS JOSEPH E. LOUISVILLE, IOAKIMIDtS, KUTZ, M.D4, AND

BY

EISDOGAN MORTON HAROLD L. E.

ATASOY, KASDAN, KLEINERT,

M.D.t,
KENTUCKY

Fi-oni

1/nc Department

of Surgery,

University

of Louisville

School

of Mc(licine,

Lou

isnillc

Amputatious
reconstn-uctions

of the
is nseeded

flnsger procedure
skins

tip

is a common maximum

insjury funsctioni

ssusd good ansd

judgmeust

its surgical loss of time

to preserve with

to miusimize

frons usually

svonk.

The
well

ideal
I)added

sisould
nsormal

mainstaiti
senisatiots.

letsgtis without

anid normal

cover

the

defect

witis Evets

nsons-tensder,

Previously

described

ussethods

provide

good

paddinsg

ansd coverage unscommots

but

seussatioui14. or abseist

with Icutlers its the smaller

procedure, it is tsot lateral triansgles.

to fitid

diminished

seussatioti

Transverse

Oblique

Oblique

Dorsal
FIG.

Palmar
amputations.

1 of finger-tip

Three

commonest

types

The for

procedure

we whets

describe the tlse distal platse

here,

called

the

triansgular

volar ansd thse

flap, bonse

was
is

developed

reconsstructious

phalanx

is amputated

cats
loss

be applied
is extenisive

to most
and

finger-tip

amputations,
of amputatious

except
is

those
iticlinsed

exposed. ins whsichs the soft-tissue

volarward-an oblique

It

palnian anisputatiots be shsortened

(Fig. 1). Occasionsally,

the remainsitsg

part of the ihsalansx has to

a few- millimeters

in order phalatsx
of

to facilitate can be treated

provides
Society for

the
good

procedure. by this method

constour
of the

Amputatiotss
ins order ansd
hand,

through
maiustain
*

the
Head

middle
at the
Alinnnal

or proximal
leusgth. The
Meeting

to

maximum 17,
of

procedure
the
American

paddinig
Chicago,

Surgery \ledicine School

Illinois,January t Depaitment
40202.
Former

1971). utgems ill Surgery

Unstvetsnt
of

of Lout
to l)r.

ville

School
of

of

Louisville of Medicine.

Kentuck Lotuisville, 921

Reprint Kentucky
VOL. 52-A.

Fellow requests 40202.

5, JULY

the 1-land, University

directed Ata.soy,

should

be

Louisville 1001

1)octors

Building,

NO.

i970

922

ERDOGAN

ATASOY

ANI)

ASSOCIATES

FIG,

2
of

Fnu. triangular flap. Advaticemenst

3 flap.

Skits

ilicisioli

atid

mobilization

of triangular

FIG.

4 atid (-losure of (lefect, \-Y techtiique.

Suture

base

of

triangular

flap

to

nail

bed

withs

less
Transverse

scarring
and (Fig. 1).

of the dorsal

finger oblique

tip

and,

most

importaust nure the

(pad) to

of

all,

l)ueseries

normal

sensations.

amputatiouss
oblique of the triatsgle

niost

suitable
the matrix.

ouses
exposed

for this
boise to

procedure permit

In cases
by some of the

of volar
other base

aniputatiouss, thse nail

shsould be covered approximations

method

utsless the bonse is shortetsed

sufficiently

Technique Metacarpal
performed small thse triansgle at before Petsrose is the least block wound cut the ausesthiesia, using preparatious. 1 per ceust plaits lidocaiuse hsydroclsioride, is exsansguiusated from tise finsger ausd is a

Blood

drains is applied edge same of

to the
skits w-idtls

base
where

of the

fiusger

as a tournsiquet.

Thse

base

of

should be ansputatiots

is through

the

distal

tise amputations has occurred. This base as the amputated edge of usail niatrix. If the phsalanix, thse apex of the triangle sisould be placed
THE JOURNAL OF BONE AND JOINT SURGERY

RECONSTRUCTION

OF

THE

AMPUTATED

FINGER

TIP

923

FIG.

5-A

FIG.

5-B

A
1,

FIG.

5-C

FIG.

5-D

FIG.

5-E

FIG.

5-F

at

tIm

(listal

flexious

crease,

sitice

it is easier

to

advance thiroughs

a lonsger the

flap.

This

distally

based The the

triangular neives flap

tissue

flap

is developed vessels
from periosteum

by cuttinsg of the

onsly

full

thicktsess

of skits. of

ansd blood

subcutanseous

flap are preserved. ansd flexor tensdon (smootlsitsg

Separations of tise fibrofatty slseaths aids mobilizations of tlse sharp edges is sutured
of the distal

(Fig. 2). After miusinsuns

d#{233}bridemetst

of tIm stump

of the to

boise etid), the flap is advausced over bonse and the base of thse triatsgle the nsail bed with 6-0 nsylors sutures. The V incision oti the palmar aspect plsalanLx cans be defatted is thsens closed covered with to cover the by convertinsg a Wolfe graft defect.
it to a Y (Figs.

or

occasionsally

3 and 4). The densuded nail bed a portion of the flap can be

Illustrative
F.T.N.,
VOL. 52-A, NO. a thirtv-seven-yeal--old 5, JULY 1970 male machine

Cases
operator, sustaimsed an amputatioti

of the

tip

of

924

ERDOGAN

ATASOY

ANt)

ASSOCIATES

Fit;.

6-A

Fn(;. 6.B

LML1

Fme.

6.C

Fue. 6-I)

Fie.
TIlE JOURNAL OF BONE AN!) JOINT SURGERY

RECONSTRUCTION

OF
on

THE

AMPUTATED

FINGER

TIP of

923 the distal

volar pisalnuix. flap pro-

the left long

Under

finger

by block
ims

a shear

machine

August

20, 1968,
recotistructed

amid lost otse-third

with the

metacarpal
Selisation

anesthesia,

the

tip

was

triamigular

cedure.
through C.si: fingers comistructed through

the

finger

tip amid the

cosmetic

result

at follow-up

were

excellent

(Figs.

5-A

5-F). 2. 1). K., ims ut door by 6-F). at usilsg a thsree-year-old home the on August triatsgular girl, 5, amputated 1969. Umider the procedure. distal one-third block The result of the anesthesia, was right the excellent long tips and
were

ring
re-

axillary

volar-flap

(Figs.

6-A

Material From amputationss

tise onse middle Unsiversity September 1967 Louisville to October 1969, sixty-otse patiensts affiliated w-itls hospitals. sixty-four flisger at youtsgest

at differetst
of

levels

had
Medical

their
Center

finsgers
and

reconsstructed years phalanx

phalatsx five

by this old. fifty-four

times.

procedure
The

j)atienst
nsale

was

fourteens
sevensteens

nsonsths
female

atsd

tise oldest
patients.

eighty-five distal

Thsere

were times,

fortyots the

ansd I)hsalai5

The

procedure
five

was
times,

performed
atsd

ons the
ots thse proximal

Results
Fifty-six of

tise

sixtv-otse except to returned

I)atiensts for isearly two

were nsormal. Two

available finger All

for patiensts had

evaluatiots

at was

follow-up.

All but

isad later Tlsere

tsormal gradually is-crc

senssations

its whom

setsatiots isad

itsitiahly
motions

lost
atsd

tsormal

tise ficial sonic

to

appearansce skits necrosis sympathetic

Not included method

of the

flusger

was

excellenst. patietstt a small

tso serious

complicatiotss.

at the edge dystrophy

treatmenst ins this cases, the atsd study ensd

of the flap which with hypersenssitivity

withins are result cases old a few in which

later
weeks the

epithelized. of tue flnsger

the hsyperesthesia

area of superThree patietsts had tip. Thsis responsded

had was finger-tip subsided. utilized amputa-

cotsservative

V-V

procedure painsful

as

ans elective tionis.

of recotsstructinsg

unsatisfactory also excelletit.

Its tisese

was

Advantages

of the V-Y procedure

is mitsimum
Cosmetically,

It is simple
directly over the

tt)

perform.
cud of thse

Scar
fitiger.

ansd less
the

paitiful
result

sitice

it is tiot
with

locatcd
good

is excelletit

finger-tip sensation
out Metacarpal tournsiquet.

coistour of the
block

ansd finsger
as

padditsg. tip. Otsly

its other

Most a simple
flaps is adequate

important, finger
atid grafts, anid

the dressinsg
thereby a small

procedure atsd guard

lessensinsg Petsrose

preserves is required
joitit draits suffices

nsormal withstifftsess. as a

immobilizatiots

atsesthiesia

Summary

A
amputated with distally

triatsgular finsger based

volar tips. soft-tissue triatsgular It

flap cats loss flap, botse it to

has
be ots

beets
applied the

used
to volar prepared

successfully
most side of with to finsger the the instact

for

the

recotistructioti
except fitsger atid blood The tip. those The supply, V itscisions

of

amputatiotis amputated tserve matrix. nsail

extetssive over

carefully ansd a V.

is advatsced is closed

exposed

approximated

by consvertinsg

References T. L.: The Late Results H. %V.: Reconstructiomi 44: 349-352, 1969. 3. CIS0NIN, T. 1).: The Cross Filigel 1951.
1. 2.
BARCLAY, BFasLl:Y, VOL. 52-A, NO. 5. JULY 1970

of Finger-Tip
of Amputated

Injuries.
Finger

Britisis
Tips.

J. Plast. Surg., 8: 38-43, Plast. and Ilecomistruct. Am. Surgeon., 17:

1956. Surg., 419-425,

Flap: A New

Method

of Repair.

926 4.
1)EJ0NGH, EDwIN:

ERDOGAN

ATASOY

AND

ASSOCIATES

A Simple
Tissue Pad. The Kutler

Plastic

Procedure

Forming

5. FmsHEu,
Surg.,

a Soft H. H,:

Am. J. Surg., 57 Method of Repair

: 346

of Fingers for 347, 1942.

Corssel-ving

Bony J. Boise

Tissue and

and Joint

of Fitsger-Tip

Ansputatiolis.

49-A:

6. FL.srr,
7. S.
(UmunmN,

A. E.:

317-321, Mar. 1967. The Thenar Flap. J. Bone and Joitit Surg., 39-B : 80-85, Feb. 1957. MICHAEL, atsd PANGMAN, W. J.: The Repair of Surface Defects of Fingets

by Trans-

9.
10.

11. 12. 13. 14.

digital Flaps. Plast. and Reconstruct. Surg., 5 : 368-371, 1950. IIADDAD, H. J., Jis.: The Kutler Repair of Fingertip Amputation. Southerts Met!. J., 61 1264-1267, 1968. lI0LMES, J. L.: Repair of Traumatic Finger Tip Amputations. U. S. Armed Forces Med. J., 4: 877-882, 1953. K:msi, II. A., and (iRANTHAM, S. A.: Volar-Flap Advancemetit for Thumb and Fimiger Tip Injuries. Clin. Orthop., 66: 109-112, 1969. KLEINERT, H. E.: Finger Tip Injuries and Their Maniagensent, Am. Surgeon, 25 : 41-51, 1959. KLEINERT, H. E. ; DESIMONE, KENNETH; GASPAR, H. E. ; ARNOLD, R. E. ; and KASDAN, M. L.:

Regionial
KUTLER,

Atsesthesia
WILLIAM:

for Upper

Extremity
for Finger

Surgery.
Tip for Repair 40 : 163-168,

J. Trauma,
Amputation. of Fingertip 1967.

3 : 3-12,
J. Ans. Amptttatiolss:

1963.
Med. Assn., 133 : 29-30, A Pieliminary

New

Method

1947. SNOW,
Report.

J.

W.: Plast.

The and

Use of a Volar Flap Reconstruct. Surg.,

DISCUSSION
1)R. another WILLIAM METCALF, BRONX,

NEw surgery which at one

YoRK: of the of Dr. he of our

Dr. well Kutlers described meetings

Ata.soy knowns bilateral

and

his

associates tried of years

have

demonstrated its plastic having Medical the

useful
It basic They

applicatiots
imagitsative ansd atsd 1947 treated

to hatsd applicatiots discussed a sizeable

ansd well Journal a few

presented

V-Y
the ago.

prinsciple
repair, American

surgery. same Association

is an principle in have

adaptation

triangular-flap

ins the just

have

ly, atsd with

clear

and the follow-up well substantiated

advaistage not stated

the series briefly, succinctdiagrams and photographs. The local complication rate ha.s beens at a minimum results are eminently satisfactory. The advatstages claimed by the authors are by their results, have been clearly stated, ansd do not need repetitiots. A major
series of cases,

and

they

by the

authors

is that

the

method

obviates

the

need

for

split-graft

coverage

of residual the authors,

lateral loss or incisions

skin
is

defects required the inapplicability

oblique losses.

by other methods of repair. One disadvantage, of the method to volar oblique loss of tissue,

freely
atid,

admitted
add,

by
to

I might

medial

like to indicate methods of using local tissue to repair such defects. For volar oblique in each paronychial sulcus allow the two resulting flaps to be ilsterdigitat.ed covering the bone end and reconstituting the finger tip ; the small proximal residual skin defect, about one centimeter its diameter, is covered with a split graft. For the dorsal oblique tissue loss, shortening of the boise by only three to five millimeters allows direct approximation to the msail base and this method may be as effective as the one presented by the authors. For the lateral oblique tissue loss including part of the nail, the V-Y procedure again is not applicable. Here an ilicisiOni ins the sulcus opposite the injury allows development of a flap to cover the bone (after trimming the little spike) atsd a small graft completes the repair.
In a crushing injury, resulting in the loss of the nail, the pitlp, nail base, alsd
weeks

I would

the

bone

tuft,

careful d#{233}bridement resulted in two flaps nail base. A split graft covered the small regrown nail and nicely contoured finger

which were interdigitated and supported residual defect. The result about ten tip.

the remaining later was

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY