Injury, Int. J.

Care Injured 40 (2009) 1346–1350

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Reconstruction of finger-pulp defect with a homodigital laterodorsal

fasciocutaneous flap distally based on the dorsal branches
of the proper palmar digital artery
Meng Xianyu, Chen Lei *, Lu Laijin *, Liu Zhigang
Department of Hand Surgery, The First Hospital, Jilin University, 1 Xinmin Street, Changchun 130021, PR China

A R T I C L E I N F O A B S T R A C T

Article history: Objective: The purpose of our study was to introduce the surgical procedure and long-term follow-up of
Accepted 17 July 2009 finger-pulp defect treated with the homodigital laterodorsal fasciocutaneous flap, which is based on the
dorsal branches of the proper palmar digital artery.
Keywords: Methods: Seven cases with finger-pulp defect, which were treated by the homodigital laterodorsal
Fasciocutaneous flap fasciocutaneous flap based on the dorsal branches of the proper palmar digital artery, were involved in
Finger-pulp defect this study. The defect size ranged from 14.5 mm  14.5 mm to 24.5 mm  16.5 mm. Average duration of
Microsurgery
follow-up was 12 months (range, 10–36 months). Standardised assessment of outcome in terms of the
defect size of finger-pulp, survival size of the flap, the static and moving two-point discrimination, time
of returning to work and subjective assessment (satisfactory, good and very good) was completed.
Results: All flaps in this series survived uneventfully. No loss of the flap in this series was noted. The
average size of the flaps was 18.43 mm  15.28 mm. The flaps had a good appearance, texture and blood
circulation. The average static two-point discrimination and moving two-point discrimination of the
flaps were 4.5 mm (range, 4–6 mm) and 4.3 mm (range, 3–6 mm). All patients were content with the
aesthetic and functional outcome of the surgery, and returned to their original job after an average of 4
weeks (range, 3–8 weeks) postoperatively.
Conclusion: The homodigital laterodorsal fasciocutaneous flap based on the dorsal branch of the proper
palmar digital artery is an ideal alternative to reconstruct the finger-pulp for single-stage reconstruction
without sacrificing the proper palmar digital artery and nerve.
ß 2009 Elsevier Ltd. All rights reserved.

Introduction
Finger-pulp injuries represent the most common type of
injuries seen in the upper extremity. Some finger-pulp injuries
involve with pulp defect, bone, joint, tendon or nerve exposure; in
these cases, flap coverage is necessary. Flap selection remains a
challenge for surgeons, who must select the appropriate donor: (1)
to provide sensate soft tissue covering, (2) to preserve the length of
finger injured, (3) to complete in one-stage reconstruction, (4) to
prevent adjacent joint contracture, and (5) to minimise the
aesthetic loss.12 Management of the injury is functionally and
aesthetically important but at the same time very controversial.
The flaps commonly used include the V–Y flap,7 digital
advancement flaps,16 cross-finger flap,19 thenar flap,17 cross-arm
flap,4 pedicled abdominal flap20 and various kinds of free flaps.10,11
* Corresponding authors. Tel.: +86 431 84808259; fax: +86 431 84808259.
E-mail addresses: xianyu1973@163.com (M. Xianyu), mengdan2876@163.com
(C. Lei), 834391482@qq.com (L. Laijin).
However, the V–Y flap or digital advancement flap cannot cover a
wide defect. The cross-finger flap, thenar flap, cross-brachial flap or
pedicled abdominal flap all need 2 or 3 weeks of uncomfortable
immobilisation, a necessary two-stage operation procedure and a
prolonged period of sensory recovery. The free flaps inevitably
demand complicated, time-consuming operative procedures and
have larger failure risks as compared with local or regional options.
Thus, such options for finger-pulp defect reconstruction may not
be ideal.
Nowadays, reverse dorsal digital flap is commonly used.1–
3,9,8,15,18
However, it is prone to congestion during the post-
operative 5 days, and usually results in a bulky pedicle, abnormal
sensation and interphalangeal joints contracture; the major
disadvantage of this flap is that it sacrifices the proper palmar
digital artery and nerve. Hirase et al. improved the reverse dorsal
digital flap and used this flap that embraced a vascular pedicle of
the digital artery and the dorsal branch of digital nerve, and
followed-up seven patients of a group of eight patients for longer
than 6 months.6 Surgery in three cases of innervated reverse island
flap based on the end-dorsal branch of the digital artery was

0020–1383/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2009.07.067
 M. Xianyu et al. / Injury, Int. J. Care Injured 40 (2009) 1346–1350
Fig. 1. (A and B) Schematic diagram illustrating the homodigital laterodorsal fasciocutaneous flap. (A) The artery and nerve network of laterodorsal digital. (B) The
homodigital laterodorsal digital fasciocutaneous flap based on the dorsal branch of the proper palmar digital artery, which arises at distal 1/3 of proximal digit. (1) Proper
palmar digital artery; (2) dorsal digital artery; (3abc) dorsal branches of proper palmar digital artery; (4) proper palmar digital nerve; (5) dorsal branch of the proper palmar
digital nerve.
proposed by Li et al.,13 which was harvested from the dorsum of
the middle phalanx. However, the dorsum of the middle phalanx of
the finger is so easily contractured as to affect the aesthetic
appearance of the finger, and the flap is too small to cover the
defect zone. Application of the dorsal branches can help to avoid
sacrifice of the proper palmar digital artery and nerve; meanwhile,
the laterodorsal digit skin is an ideal donor site for the coverage of
finger-pulp defect because it is characterised by a similar texture as
the pulp, has a rich blood supply as well as cutaneous nerves
(Fig. 1). To the best of our knowledge, there are limited reports
about clinical application of the homodigital laterodorsal digital
fasciocutaneous flap based on the dorsal branch of the proper
palmar digital artery.6,13 The purpose of our study was to introduce
the surgical procedure and present the results of long-term follow-
up of finger-pulp defect treated with the homodigital laterodorsal
fasciocutaneous flap, which is based on the dorsal branches of the
proper palmar digital artery.
Patients and methods
We retrospectively identified seven outpatients with finger-pulp
defects caused by cutting, avulsion and crushing injury from 2000 to
2007; the work complied with the principles laid down in the
Declaration of Helsinki has been approved by the ethical committees
of the Jilin University in which the subjects gave informed consent to
the surgical procedure. Three patients were females and four were
males; the age of the patients ranged from 36 to 59 years (mean, 52
years), most of whom were involved in a manual activity (cutting,
three cases; avulsion, one case and crushing, three cases).
The involved fingers were L2, L4, R1, R2, R3 (one case each) and
L3, two cases. The defect size ranged from 14.5 mm  11.5 mm to
24.5 mm  16.5 mm (mean 17.93 mm  14.35 mm). In all cases,
reconstruction was achieved using the homodigital laterodorsal
fasciocutaneous flap based on the dorsal branch of the proper palmar
digital artery. All operations were performed by two surgeons, and
the examiner was not the surgeon. All seven patients were invited
for clinical review at an outpatient’s clinic. All patients (seven flaps)
attended follow-up. Written records and photographic docu-
mentation of all seven patients were performed. Standardised
assessment of outcome in terms of the defect size and survival
size of the flap, the static and moving two-point discrimination, time
of returning to work and subjective assessment (satisfactory, good
and very good) was completed.
1347
Surgical technique
The operation is carried out under regional anaesthesia, and a
tourniquet is applied. After wound debridement, the size and
shape of the defect is measured (Fig. 2A and B). The flap is
designed over the laterodorsal side of the digital according to
the size and shape of the finger-pulp defect. Either the radial or
the ulnar neurovascular branch of the proper palmar digital
neurovascular branch can be used; the ulnar side of the index
finger and radial side of the ring or small finger is preferred. The
pedicle of flap is designed and marked on the digit according to
the size and shape of flap (Fig. 2C). The length of the donor site is
between the metacarpophalangeal joint and the distal inter-
phalangeal joint of the homodigit. The distal end of the flap
should be more than 5 mm away from the nail base to avoid nail
injury. When the skin incision is made, care should be taken not
to injure the cutaneous vein of the pedicle. All the layers up to
the paratenon over the extensor tendon (keep the paratenon
intact) were incised along the margin of this flap except the
pedicle corner, where the incision depth is limited to the skin
alone (Fig. 2D). The rotation degree of the pedicle is 808 to 1608
with the mid-lateral line. The dorsal branch of proper palmar
digital nerve is identified and dissected, and then epineurium
suture is performed to the proximal nerve stump of the injured
finger-pulp with 11/0 nylon suture under the microscope. The
vascular pedicle (ranging from 4 mm to 6 mm) should be
transferred through an opened tunnel to avoid pedicle compres-
sion and benefit the venous drainage, which is always one of the
most important factors for postoperative venous crisis (Fig. 2E).
Haemostasis is performed completely after tourniquet release.
The flap is then sutured loosely over the finger-pulp defect and
the donor site is covered with a full-thickness skin grafting
from the upper arm using tie-over dressing (Fig. 2F and G).
Sensory re-education of the finger is instituted, both active and
passive mobilisations begin after removing the stitches 2 weeks
postoperatively (Fig. 2H).
Results
Within 2 weeks after operation, all flaps and skin grafts
survived, and primary healing was achieved. No loss of the flap
was noted in this series. The average size of the flaps ranged
from 15 mm  12 mm to 25 mm  17 mm (mean, 18.43 mm 
1348 M. Xianyu et al. / Injury, Int. J. Care Injured 40 (2009) 1346–1350

Fig. 2. (A–H) Case illustrating the surgical procedure of finger-pulp defect treated with the homodigital laterodorsal fasciocutaneous flap. (A and B) Size and shape of the
defect; (C) design of flap; (D) keep the proper palmar digital neurovascular bundle intact; (E) the flap is transferred into the defect site through an opened tunnel; (F) sutured
loosely; (G) the donor site is covered with skin grafting; (H) both active and passive mobilisation begin after removing the stitches 2 weeks postoperatively.

15.28 mm). The average duration of follow-up was 12 months
(range, 10–36 months). There were no complications such as flap
congestion, haematoma or infection and no pain from neuroma
was observed. All patients returned to their original jobs on an
average of 4 weeks (range, 3–8 weeks) postoperatively; none of the
patients had to modify their job or leisure activities. No stiffness
developed in the digits in any of these patients. The average static
two-point discrimination and moving two-point discrimination of
the flaps significantly improved to 4.5 mm (range, 4–6 mm) and
4.3 mm (range, 3–6 mm), respectively. The flaps were charac-
terised by rich blood supply, cold resistance, suitable thickness and
good texture. None of these flaps required thinning or any
revisions. All patients were contented with the aesthetic and
functional outcome of the surgery. Subjective assessments to the
postoperative appearance of the finger-pulp and donor site were:
two patients—satisfactory, two patients—good and three patients—
very good. Flap size, complications, time of returning to work,
static and moving two-point discrimination, objective outcome
and subjective outcome of the long-term follow-up are sum-
marised in Table 1.
with the function and appearance of the reconstructed finger-pulp
and returned to his present job after 5 weeks (Fig. 3D).
Case II
A 46-year-old woman presented with right middle finger-pulp
defect involving bone and soft tissue loss with joint disruption
caused by a crush injury, which led to a 15 mm  14 mm skin
defect with exposure of the tendon and distal phalanx (Fig. 4A). A
17 mm  16 mm size flap originating from the laterodorsal region
of the middle phalange, which included the dorsal branch of the
proper palmar digital artery and the dorsal branch of the proper
palmar digital nerve, was then transferred into the pulp defect. The
donor sites were covered with full-thickness skin graft using tie-
over dressings. No flap necrosis was observed, and donor site
morbidity was minimal (Fig. 4B). The patient had no limitations in
the activities of daily life and returned to her previous work 28
days postoperatively (Fig. 4C). Follow-up evaluation at 28 months
postoperatively showed that the static and moving two-point
discriminations were 4 mm and 3 mm, respectively (Fig. 4D).

Case I Discussion

A 40-year-old left-hand-dominant male presented with left
middle finger-pulp defect following an agricultural machine
accident. There was a 14.5 mm  14.5 mm pulp defect with
exposure of the tuberosity of the distal phalanx (Fig. 3A). The
homodigital laterodorsal fasciocutaneous flap was designed with
size of 15 mm  15 mm and then harvested and rotated 1608 to
cover the above defect. The skin defect at the donor site was
covered with a full-thickness skin graft. The wounds healed
uneventfully and the flap survived completely (Fig. 3B). The length
of injured finger was preserved (Fig. 3C). The patient was satisfied
The homodigital laterodorsal fasciocutaneous flap, which is
based on the dorsal branches of the proper palmar digital artery, is
strongly recommended for use in the clinic because no loss of the
flap in this series is noted; further, this flap has the potential for the
treatment of finger-pulp defect recovery in a single-stage
procedure within the scope of the digit injured, reducing cost
and time to return to work and avoiding further surgical
procedures. These factors are based on gradual refinement made
on the reverse digital artery flap. Hirase et al.6 improved the
reverse digital artery flap with the dorsal branch of the proper

Table 1
Objective and subjective assessments of the long-term follow-up.

Case Flap size (mm) Flap outcome Time return Sta-two-discrimination Mov-two-discrimination Subjective assessments
to work (weeks) (mm) (mm)

1 15  15
2 17  16
3 20  14
4 25  17
5 18  15
6 17.5  12
7 16.5  14
Survival 5 6 6 Satisfactory
Survival 3 4 3 Very good
Survival 6 5 5 Good
Survival 4 4 4 Very good
Survival 4 6 6 Good
Survival 4 4 4 Satisfactory
Survival 5 4 3 Very good
 M. Xianyu et al. / Injury, Int. J. Care Injured 40 (2009) 1346–1350
Fig. 3. (A–D) Case I—(A) 14.5 mm  14.5 mm left middle finger-pulp defect; (B) the flap survived completely; (C) length preservation of middle finger; (D) the function and
appearance of the reconstructed finger-pulp, 14 months postoperatively.
Fig. 4. (A–D) Case II—(A) 15 mm  14 mm defect of right middle finger-pulp; (B) no complications at the donor site; (C) no limitations in activities of daily life; (D) 28 months
postoperatively, subjective assessment: very good.
digital artery and avoided sacrificing the digital artery. The
innervated reverse island flap based on the end-dorsal branch of
the digital artery was proposed by Li et al.13 However, the donor
site is easily contractured and therefore affects the function of the
interphalangeal joints and aesthetic appearance. The flap is too
small to cover the injury zone. We propose that the homodigital
laterodorsal skin is a convenient and fine-quality donor site for its
texture which is similar to the finger-pulp, rich blood supply and
existence of cutaneous nerves. Meanwhile, the laterodorsal digital
fasciocutaneous flap can be harvested from either the laterodorsal
skin of proximal phalange or the laterodorsal skin of middle
phalange and has an advantage in providing enough durable tissue
without invading the palm or another digit. When properly
designed, the laterodorsal skin of the finger can offer enough
durable tissue to cover almost any size and any degree of finger-
pulp defect. The donor site scar can be well hidden, contrasting
with other methods. This flap minimised aesthetic loss to a large
extent, thus meeting the patient’s aesthetic requirements.
The laterodorsal digital fasciocutaneous flap minimises venous
congestion postoperatively. Arterial blood perfusion of the
laterodorsal digital fasciocutaneous flap is supplied by the dorsal
branches of proper palmar digital artery, which is formed by the
links between proper palmar digital artery and dorsal digital
artery. The dorsal branches of proper palmar digital artery
originate from the proper palmar digital artery and usually have
four gross branches, which arise at the middle and distal one-third
of proximal phalangeal region, middle phalangeal region and
around the distal interphalangeal joint.12,13,2 Venous drainage is
through the cutaneous veins and the surrounding perivascular fat,
associated with the dorsal arterial network.14,5 There was no or
little venous congestion 24 h postoperatively in all seven patients;
maybe, the dorsal branch of proper palmar digital artery in the
pedicle serving as the main perfusion route is weaker than the
artery perfusion of reverse dorsal digital flaps and the cutaneous
veins in the pedicle serving as the main drainage route are more
voluminous than the vein drainage of reverse dorsal digital flaps.
Adequate return of sensitivity to the laterodorsal digital
fasciocutaneous flap makes it an attractive option for finger-pulp
reconstruction. None of the patients in this series had amputation
neuroma. Attention should be paid to preserve the stump of proper
1349
palmar digital nerve during debridement and avoid injuring the
dorsal branch of the proper palmar digital nerve in the flap.
Epineurium suture is performed between the proximal nerve
stump within the injured finger-pulp and the dorsal branch of
proper palmar digital nerve within the flap. Therefore, prophylaxis
to combat painful neuroma formation is achieved. The static two-
point discrimination 4.5 mm (range, 4–6 mm) and moving two-
point discrimination 4.3 mm (range, 3–6 mm) of the lateral–dorsal
digital fasciocutaneous flap in the present series are better than
reported earlier (Hirase, 4.9 mm; Li, 4.6 mm). Finger-pulp obtained
good appearance and sensory recovery with little affect to the
supply area.
In the development of new techniques in finger-pulp recon-
struction, it may be worthwhile to consider the defect size and
degree, the flap texture and blood supply and patient’s age and
requirements. The homodigital laterodorsal fasciocutaneous flap,
which is based on the dorsal branches of the proper palmar digital
artery, cannot be applied to the finger-pulp defect caused by
electric or chemical burns, and in the case of the patients who have
peripheral vascular disease or are heavy smokers living in a
comparatively cold zone.
Conclusion
The homodigital, laterodorsal fasciocutaneous flap has a
reliable blood supply, suitable thickness, good texture, avoiding
the need for sacrificing a major artery, easy and secure dissection,
no functional loss of the involved digit, tiny two-point discrimina-
tion, good finger-pulp appearance, excellent aesthetic results and
high patients’ satisfaction. The homodigital, laterodorsal fascio-
cutaneous flap based on the dorsal branch of the proper palmar
digital artery is an ideal alternative to reconstruct the finger-pulp
for single-stage reconstruction without sacrificing the proper
palmar digital artery and nerve.
Conflict of interest statement
None of the authors have any conflicts of interest. No benefits in
any form have been received or will be received from a commercial
party related directly or indirectly to the subject of this article.
1350 M. Xianyu et al. / Injury, Int. J. Care Injured 40 (2009) 1346–1350

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