Microvascular soft tissue reconstruction of the digits

Composite tissue loss to digits following trauma may require flap coverage. Local reconstruction techniques are popular but can result in a functional limitation at the donor site. Small free flaps though complex, may provide a superior alternative.

We retrospectively reviewed the case-notes of all patients who had a small free flap to a digit following trauma. The time period was 4 years (2000-2004). Sixteen patients with 18 digital free flaps were identified. These comprised of 10 venous flow-through flaps, one lateral arm flap, one great toe to thumb pulp transfer, three first web space flaps from the foot, one medial plantar flap and two free posterior interosseous flaps. All 16 patients were invited for clinical review at an out-patients clinic. Ten patients (11 flaps) attended follow-up. Standardised assessment of outcome in terms of scar quality at both the recipient and donor sites, sensibility, range of motion and function of the hand was completed.

Overall the average follow-up period was 14 months, with 16 out of 18 flaps surviving. Of the patients that attended for clinical review, the majority recovered excellent function of the hand (quick-DASH--av. 5.7) with satisfactory aesthetics, minimal pain or limitations in range of motion. The flaps were all soft and durable. Ten flaps recovered protective but not discriminative sensation (only one flap was innervated). The three patients whose donor site was the first-web space of the foot developed significant hypertrophic scarring.

Small free flaps provide an acceptable method of reconstructing digital defects. Venous flow-through flaps provided the best overall results in this series. The donor site for first-web space flaps is probably unacceptable.