Being a sensory organ, a functional and cosmetic unit, fingertip reconstruction is a challenge in achieving volume with good quality sensation and cosmetic nail. This study is a comparison between unilateral neurovascular islanded (UNI) flaps and Total pulp advancement cup (TPAC) flaps.
27 Fingers with transverse or volar oblique traumatic amputations of fingertips with 50% or less remaining nail were included.
After debridement (unilateral / bilateral / extended / modified) Kuttler, Segmuller or Unilateral homodigital islanded TPAC flap reconstructions were performed. The latter is a cup flap, designed incorporating whole remaining pulp down to DIPJ crease and based on one neurovascular pedicle around which the flap is mobilized in V-Y fashion down to PIPJ crease after dividing the Cleland’s and Grayson's ligaments and periosteal branches.
Flap healing was assessed up to 4 weeks and up to 1 year for sensory, cosmetic and functional outcome.
Mean flap advancement for laterally based UNI flaps(n=16) was 7.25mm(6mm-10mm) whereas in TPAC flaps(n=15) it is 9.14mm(7-12mm) (p<0.005). Three got nail bed grafts. Two partial epidermal losses were managed conservatively. Patients regained quality sensation over entire flap within 8-12 weeks. Hooked nail deformity wasn’t observed. With the pressure and scar therapy all patients regained excellent cosmetic pulp and good quality nail. TPAC flap yielded the best pulp volume and contour.
When the total pulp is advanced, with a great volume advancement as well as the excellent liner advancement, there’re more pulp tissues to make a comfortable cup closure to achieve a good contoured tip. There’re minimal pulp scars compared to most other liner advancement flaps.
Unipedicled islanded TPAC flaps are promising in fingertip reconstructions but need long-term follow-up for better comparison.
Achieving the volume with good quality sensation and good nail are realistic goals with neurovascular islanded TPAC flaps.