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The neurovascular tranquilli-leali flap
THE N E U R O V A S C U L A R
TRANQUILLI-LEALI
FLAP
D. ELLIOT, N. S. MOIEMEN and V. S. JIGJINNI
From the North-East Thames Regional Plastic Surgery Unit, St Andrew's Hospital, Billericay, Essex, UK A modification of the flap first described in 1935 by Tranquilli-Leali and described again by Atasoy et al (1970) is presented. The relative indications for use of the original and the modified flap are examined in the fight of our experience of 116 flaps over a period of 4 years. Journal of Hand Surgery (British and European Volume, 1995) 20B." 6." 815-823
tations by ablation of the germinal matrix of the nail and slight shortening of the bone. To overcome these limitations, a larger flap was designed with the flap extending proximal to the DIP palmar crease and vascularized directly by the neurovascular bundles (Fig 2), which we called the "neurovascular Tranquilli-Leali flap". Our experience with more than 100 original and modified flaps is presented, and indications for the use of each are suggested.
The flap described by Tranquilli-Leali in 1935, described again by Atasoy et al (1970), and translated into English more recently (Lister, 1991) is an advancement of palmar skin and pulp tissue to cover exposed bone at the digital tip. Because the flap is vascularized by the small vessels of the subcutaneous pulp tissue lateral to its edges and distal to the trifurcation of the digital arteries, its use must be limited to amputations distal to the nail fold (Ishikawa Classification Types 1 and 2) (Fig 1; Ishikawa et al, 1990). Lister also pointed out that it can only provide adequate bone cover if the amputation is transverse or dorsal-facing (Lister, 1984). We have found use of this flap to be further restricted in that it is only adequate for transverse amputations at or distal to the mid-nail level (Ishikawa Type 1). Proximal to this level, the flap bulk is too small and does not advance far enough to provide good tip cover, except in those transverse amputations just distal to the nail fold, which can be converted to dorsal-facing ampu-
MATERIALS AND METHODS The technique of designing, raising and advancing the original flap is well known and has been clearly described and illustrated in previous publications (TranquilliLeali, 1935; Atasoy et al, 1970; Verdan and Egloff, 1981; Lister, 1984; 1991). The modified flap is designed so that the proximal part of the "V" extends onto the middle phalangeal segment (Fig 2a). The flap is mobilized in the same manner as the original flap, except that it is vascularized more proximally, and directly by the neurovascular bundles. These are sought and visualized on the underside of the flap as it is turned back from the palmar surface of the distal phalanx and the flexor tendon sheath (Fig 2b). We have described this flap as a modification of the Tranquilli-Leali flap, and it was as such that it was conceived. Previously, we have used another flap which advances to the fingertip on both neurovascular pedicles, leaving a proximal defect which requires a skin graft (Fig 3). Although we have been unable to trace the origins of this flap in the literature it came to this unit from SOS Main, Strasbourg. The new flap described above could equally be considered a variant of this flap by the addition of a proximal tail, to allow use of the V-to-Y principle of closure and avoid a donor site skin graft. Both flaps are "bipedicled neurovascular island flaps" in the classification proposed by Schuind et al (1985). Because the neurovascular flap is not based on the small blood vessels beyond the arterial trifurcation but on the actual neurovascular bundles, it can provide tip cover following amputations of the fingertip proximal to the level of the nail fold. It can also be used to
Tranquilli-Leafi Flaps
Neumvascular Design
Original
Design Angle of Amputation
Dorsal Transverse Palmar Facing Facing
Dorsal Transverse
Facing
Palmar Facing
Levelof Amputation • d
I
t~
....
19
"18
12
4
32 3
7
III
1
W --DIP -.
5 3
--PIP -2
Fig 1
Diagram and Table summarizing the 116 cases in this series, classified by level and angulation of amputation. * Levels of amputation after Ishikawa (1990). 815
816
Fig 2
THE JOURNAL OF HAND SURGERY VOL. 20B No. 6 DECEMBER 1995
(a) Pre-operative views of a transverse amputation at nail fold level showing the neurovascular Tranquilli-Leali flap markings. (b) Left: flap dissected, only attached to the finger by the neurovascular bundles, visible on the underside of the flap. Right: flap advanced, showing unadjusted leading edge which is too broad. (c) Inset: flap sutured after narrowing of the leading edge by excision of a central "V". Main: fingertip after completion of epithelialization.
NEUROVASCULARTRANQUILLI-LEALI FLAP
Fig 3
Bipedicled homodigital advancement flap with split skin graft reconstruction of the proximal donor site.
achieve stump closure, without shortening, in more proximal amputations at any level of the finger (Figs 1 and 4). Because it is bigger and only attached by the neurovascular bundles, it is capable of greater advancement than the original flap. This makes it possible to use this flap not only for transverse and dorsal-facing amputations, but after palmar-facing amputations up to an angle of 30 ° to 35 ° (Fig 5). However, with more shelving amputations than this, lateral advancement flaps based on a single neurovascular bundle (SegmOller, 1976; Venkataswami and Subramanian, 1980; Evans and Martin, 1988) provide more tissue bulk and are more suitable reconstructions. The neurovascular flap has been modified at its leading edge to improve the appearance of the reconstructed fingertip. The original Tranquilli-Leali flap was designed with the lateral incisions well away from the lateral nail folds. As a consequence of scar shortening in length, these scars sometimes heal with indentations, as shown in Figure 6. This appearance, which is permanent, is also seen in the illustrations of previous authors. It gives the fingertip an unattractive and unusual appearance, not unlike that of a circumcised penis. Where the flap is particularly narrow it may heal with not only this scar indentation but with retention of oedema both in the flap and in the lateral parts of the fingertip between the scars and the lateral nail folds, giving the fingertip an ugly,
817
spatulate appearance (Fig 6). We have designed the modified flap so that the lateral incisions come close to, although preserving, the lateral nail folds (Figs 2, 4 and 5). After advancement, the flap is then too wide (Figs 2b and 5b). If the flap is sutured without modification, the fingertip is too broad and appears shovel-like. Initially, we narrowed the fingertip by excising a central "V" from the leading edge of the flap. As this technique did not gi~e the desired rounding of the fingertip and sometimes left a central notch (Fig 2c), we now shape the tip by excising the comers of the leading edge of the flap. The corners are then allowed to epithelialize under moist antiseptic dressings to give a rounded and more natural appearance (Figs 4c and 5c, d). We have used 116 original and modified flaps to reconstruct amputations of the fingers over a period of 4 years. In order to increase the size of these flaps and so increase their potential for advancement they have all been advanced to cover the exposed bone with pulp tissue only, with the tip then re-epithelializing under moist antiseptic dressings, except where suture to the nail or dorsal skin could be achieved easily. This is only usually the case with dorsal-facing amputations. Although this technique only achieves a difference of 1 mm to 3 mm in flap size and advancement, it allows a significant widening of the circumstances in which these flaps can be used and allows cover of the fingertip with less tension. Re-epithelialization in this way also appears to achieve more rounded fingertips. The proximal " V " of exposed pulp tissue following flap advancement has not been closed as a " Y " in most cases, but is also re-epithelialized under moist dressings. Closure of the " Y " often narrows the finger proximal to the flap (Fig 7) with the risk of post-operative flap congestion. There have been no flap deaths in the series. The original flap was designed such that the lateral incisions remained on the distal phalangeal segment and did not cross the DIP joint crease. Although the incisions of the neurovascular flap cross this crease, they do so obliquely and have caused no problems of scar contracture, despite initial concern. We have used 53 original flaps in 53 patients and 63 neurovascular flaps in 62 patients. One patient had an original flap to one fingertip and a neurovascular flap to another. Figure 1 shows the levels of amputation and the slope of amputation of the fingers. The Ishikawa level 2 amputations included nine transverse amputations close to the nail fold which were converted to dorsal-facing amputations by ablation of the germinal matrix of the nail and slight bone shortening to allow use of the original flap. These cases are included in Figure 1 as Ishikawa level 2 dorsal-facing amputations. The original flap has been used mainly in transverse and dorsal-facing amputations at the distal nail level and in dorsal-facing amputations at the more proximal nail level, after nail matrix ablation. The neurovascular flap has been used for all three angulations of fingertip amputation and also for more proximal finger loss.
818
Fig4
THE JOURNAL OF HAND SURGERY VOL. 20B No. 6 DECEMBER 1995
(a) Pre-operative views of transverse amputation just beyond the DIP joint showing the markings of the modified flap, including the corners of the leading edge of the flap which will be excised to narrow the flap after advancement. (b) Main: flap advanced. Inset: flap sutured in after narrowing of the leading edge by excision of the corners. (c) Late views of fingertip.
NE UROVASCULAR TRANQUILLI-LEALI FLAP
Fig 5
819
(a) Pre-operative views of palmar-facing amputation at nail fold level showing the marking of the modified flap. This finger represents the extreme of palmar-facing defect for which the neurovascular Tranquilli-Leali flap can be used. (b) Flap advanced, with the corners of the leading edge marked prior to excision of the corners and suturing. (c) Fingertip after completion of epithelialization. (d) Late view: the middle finger is reconstructed with a modified Tranquilli-Leali flap. The ring finger suffered a more oblique palmar-facing amputation and is reconstructed with 2 Segm~ller flaps (Segmttller, 1976; both fingers show mild hook nail deformity on lateral view at this late stage).
820
Fig 6
THE JOURNAL OF HAND SURGERY VOL. 20B No. 6 DECEMBER 1995
Late views of original Tranquilli-Leali flap. Left: with lateral incisions, as routinely described, showing indentation of scars, resulting in an appearance like a circumcised penis. Right: with very narrow flap and oedema of the fingertip lateral to flap, resulting in a spatulate fingertip.
A review of the patients' notes was carried out. The notes of 46 patients with 46 original flaps and 55 patients with 56 neurovascular flaps were available for review. The average follow-up of all patients was 25 weeks, with those patients with original flaps having an average follow-up of 20 weeks and those with modified flaps having an average follow-up of 30 weeks. The two groups were well matched for age, with five original flap and two neurovascular flap patients being under 5 years, six original flap and seven neurovascular flap patients being between 6 and 15 years, 25 original flap and 35 neurovascular flap patients being between 16 and 50 years, and ten original flap and 11 neurovascular flap patients being over 50 years old. The distribution of injured digits was also well matched, with seven of each group having thumb injuries and 13 of the original flap and ten of the neurovascular flap patients having index finger injuries. 16 original flap and 20 neurovascular flap patients sustained middle finger injuries, six original flap and nine neurovascular flap patients had ring finger injuries and four original flap and ten neurovascular flap patients had suffered little finger injuries. Cold intolerance was reported by six (13%) of the original flap patients and seven (13%) of the neurovascular flap patients. Only one patient, who had had a neurovascular flap with pulp skin to nail suture, developed early post-
Fig 7
Modified flap sutured in with closure of the proximal "Y", resulting in narrowing of the finger proximal to the flap.
operative infection requiring re-exploration and removal of necrotic bone. The low incidence of infection in both groups probably reflects the policy of aiming to achieve pulp cover of the bone at the tip of the digit, then using antiseptic dressings to regain skin cover, as opposed to trying to achieve primary skin closure. Of the original flap patients, one (2%) complained of nail tenderness, two (4%) of bone tenderness at the tip of the digit and two (4%) of tenderness of the tip scar. Two (4%) more patients complained of problems of bone tenderness, tip scar sensitivity and also hypersensitivity of the proximal "V" scar. One of these two patients also developed a digital neuroma and had two fingertip revisions, the first of which involved relocation of the neuroma into the middle phalanx. One other patient in this group is scheduled to have a revision of a tender tip scar. Of the neurovascular flap patients, four (7%) complained of bone tenderness at the tip of the digit, three (5%) of tenderness of the tip scar and one (2%) patient complained of a minor degree of bone tenderness, tip scar sensitivity and also hypersensitivity of the proximal "V" scar. Two of these patients had revision amputations with shortening, one for bone tenderness and one for a very sensitive tip scar. One patient who sustained four fingertip amputations of the fingers of one hand which were treated by a neurovascular Tranquilli-Leali flap (index), direct suture (little) and
NEUROVASCULARTRANQUILLI-LEALIFLAP
Fig 8
821
(a) Very distal, dorsal-facing amputation. Inset: illustration of the difficulty encountered on simply approximating the leading skin edge to the nail. The pulp bulk is excessive. (b) Original Tranquilli-Leali flap. Left: designed. Right: advanced, facilitating approximation of the leading skin edge and the nail. (c) Fingertip after completion of epithelialization.
two Segmuller flaps to each of two digits (middle and ring), developed hyperaesthesia of all four fingertips, but continues to work. One other patient in the neurovascular flap group required excision of an inclusion dermoid cyst from the tip scar. This group, which includes more proximal injuries, also included two patients with nail problems requiring secondary surgery: one developed a nail bed infection which was opened 1 week after primary surgery, and one required removal of a nail spicule after previous ablation of the nail matrix. Four (9%) of the original flap and five (9%) of the neurovascular flap patients had hook nails, with one of the latter developing mild hooking of both of two neurovascular flap reconstructions. All of these were mild in degree, reflecting the operative policy of never leaving nail bed unsupported by bone. Only four (9%) of the original flap and two (4%) of the neurovascular flap patients complained of loss of sensation at the digit tip.
DISCUSSION Both the original and the modified Tranquilli-Leali flaps are used in fingertip injuries in which there is bone exposure. Where the bone is not exposed it is our policy, as it is that of others, to simply dress the fingertip and await re-epithelialization followed by full skin formation. If this policy is used after significant loss of pulp and when bone is exposed, then the end result is poor cover of the bone by pulp which may give rise to bone tenderness on applying pressure to the fingertip. A secondary effect of this is that the loss of bulk of the pulp on the palmar aspect of the fingertip is apparent. This is evident on examination of some of the illustrations in recent publications in which a policy of dressings only has been applied to all fingertip injuries (Mennen and Wiese, 1993; Lee et al, 1995). While these papers seem to confirm that the nail bed has powers of regeneration, as suggested by Ogo in 1987, this power
THE JOURNALOF HANDSURGERYVOL.20B No. 6 DECEMBER1995
822
Fig 9
Dorsal-facing amputation at mid-nail level simply closed by suture of the leading skin edge to the nail, resulting in a shovel-like fingertip.
appears to be present to a lesser degree in the pulp tissue o f the fingertip. A l t h o u g h Figure 1 reflects the policy o f differential use o f the two flaps described above, the modified flap is so m u c h m o r e flexible in its application that we have tended to use it with increasing frequency in situations in which we would previously have used the original flap. The modified flap has become our technique o f choice even for transverse amputations at Ishikawa level 1 and we n o w use the original flap only for very distal transverse amputations and dorsal facing a m p u tations b e y o n d the mid-nail level (Fig 8). It is clear f r o m the illustrations o f Tranquilli-Leali's original article that he described this flap for just such amputations (Tranquilli-Leali, 1935; Lister, 1984). Even amputations at this level are difficult to close directly without creating a shovel-like fingertip (Figs 8a inset and 9) and the original flap remains useful for such cases. The results o f the late analysis o f the patients are included with reservation as they are based on note review, it having p r o v e d impossible to bring the actual patients back for review. The follow-up is also short as
m a n y patients were o f working age and reluctant to continue follow-up b e y o n d the m i n i m u m essential, as clinic visits entail loss o f earnings. 12 (26%) o f the original flap g r o u p and ten (18%) o f the neurovascular flap group attended clinic for 4 or fewer weeks f r o m injury, so can have barely healed their fingertips before taking self-discharge. The above results tend to indicate a small n u m b e r of problems with b o t h types of Tranquilli-Leali flap. Cold intolerance is a problem c o m m o n to all fingertip injuries in the British Isles. The incidence is p r o b a b l y low in this review, as this problem is not routinely sought after in follow-up clinics, the figures representing spontaneous c o m m e n t by the patients. By comparison, sensory problems o f loss o f sensitivity o f the fingertip or tenderness/hypersensitivity are b o t h volunteered by patients and sought in the clinics, and are m o r e likely to be related to the technique o f reconstruction. The follow-up is too short to represent the long-term situation, as fingertips are often still tender 6 m o n t h s after injury. The concern with all reconstructions o f the fingertip is to provide adequate pulp cover o f the bone, to avoid bone tip tenderness and to avoid loss o f sensitivity as a result o f the reconstruction. In respect o f the latter, homodigital advancement flaps have an advantage over reconstruction with flaps with no innervation and those with nerve anastomosis. Nevertheless, the risk they do carry in maintaining digital length is that o f neuropraxia as a result o f nerve stretching. The incidence o f this problem has never been analyzed. A problem o f presentation o f end results o f new techniques o f fingertip reconstruction is that this has rarely been done in the past. This is a fault which has been and is difficult to rectify as patients are discharged or take self-discharge early after fingertip reconstruction. It makes comparison o f the merits o f different techniques impossible and tends to load opinion against those few techniques which are presented with long-term analysis. References
ATASOY, E., IOAKIMIDIS,E., KASDAN, M. L., KUTZ, J. E. and KLEINERT,H. E. (I 970). Reconstructionof the amputatedfingertip with a triangularvolarflap. Journal of Bone and Joint Surgery,52A:5:921-926. EVANS,D. M. and MARTIN,D. L. (1988). Step-advancementisland flap for fingertip reconstruction. British Journal of Plastic Surgery,41:2:105-1l 1. ISHIKAWA,K., OGAWA,Y., SOEDA,H. and YOSHIDA,Y. (1990). A new classificationof the amputatedlevelfor the distal part of the finger. Journal of the Japan Societyof ReconstructiveMicrosurgery,3: 54. LEE, L. P., LAU, P. Y. and CHAN, C. W. (1995). A simple and efficient treatment for fingertip injuries. British Journal of Hand Surgery, 20B: 1: 63 71. LISTER, G. The Hand." Diagnosis and Indications. Edinburgh, Churchill Livingstone, 1984:85 87; 120 123.(includingillustrations fromTranquilliLeali's originalpaper.) LISTER, G, V-Y Advancementflaps. In: Foucher, G. (Ed.): Fingertip and Nailbed Injuries'. Edinburgh, ChurchillLivingstone,1991:52-61. (including a completetranslation of Tranquilli-Leali'soriginalpaper into English). MENNEN, U. and WIESE, E. (1993). Fingertip injuries management with semiocclusivedressings. Journal of Hand Surgery, 18B:4:416-422. OGO, K. (1987). Doesthe nail bed reallyregenerate?Plasticand Reconstructive Surgery, 80:3:445-447. (seealso letter pertainingto this paper Plasticand ReconstructiveSurgery,June 1988.) SCHUIND, F., VAN GENECHTEN, F., DENUIT, P., MERLE, M. and FOUCHER, G. (1985). Le lambeauen riot homodactyleen chirurgiede la
NEUROVASCULAR TRANQUILLI-LEALI FLAP main: A p r o p o s de soixante cas. Annales de Chirurgie de la Main, 4:4: 306-316. SEGMULLER, VON G. (1976). Modifikation des Kutler-Lappens: Neurovaskul/ire Stielung. Handchirurgie, 8: 75-76. TRANQUILLI-LEALI, E. (1935). Ricostruzione dell'apice delle falangi ungueali ruediante autoplastica volare peduncolata per scorrimento. Infort. Traum. Lavaro, 1: 186-193. VENKATASWAMI, R. and SUBRAMANIAN, N. (1980). Oblique triangular flap: A new method of repair for oblique amputations of the fingertip and thumb. Plastic and Reconstructive Surgery, 66:2: 296-300.
823 VERDAN, C.-E. and EGLOFF, D.-V. (1981). Fingertip injuries. Surgical Clinics of North America, 61:2: 237-266.
Accepted: 23 February 1995 David Elliot FRCS, Regional Plastic Surgery Unit, St Andrew's Hospital, Billericay,Essex, UK. © 1995 The British Society for Surgery of the Hand
TRANQUILLI-LEALI
FLAP
D. ELLIOT, N. S. MOIEMEN and V. S. JIGJINNI
From the North-East Thames Regional Plastic Surgery Unit, St Andrew's Hospital, Billericay, Essex, UK A modification of the flap first described in 1935 by Tranquilli-Leali and described again by Atasoy et al (1970) is presented. The relative indications for use of the original and the modified flap are examined in the fight of our experience of 116 flaps over a period of 4 years. Journal of Hand Surgery (British and European Volume, 1995) 20B." 6." 815-823
tations by ablation of the germinal matrix of the nail and slight shortening of the bone. To overcome these limitations, a larger flap was designed with the flap extending proximal to the DIP palmar crease and vascularized directly by the neurovascular bundles (Fig 2), which we called the "neurovascular Tranquilli-Leali flap". Our experience with more than 100 original and modified flaps is presented, and indications for the use of each are suggested.
The flap described by Tranquilli-Leali in 1935, described again by Atasoy et al (1970), and translated into English more recently (Lister, 1991) is an advancement of palmar skin and pulp tissue to cover exposed bone at the digital tip. Because the flap is vascularized by the small vessels of the subcutaneous pulp tissue lateral to its edges and distal to the trifurcation of the digital arteries, its use must be limited to amputations distal to the nail fold (Ishikawa Classification Types 1 and 2) (Fig 1; Ishikawa et al, 1990). Lister also pointed out that it can only provide adequate bone cover if the amputation is transverse or dorsal-facing (Lister, 1984). We have found use of this flap to be further restricted in that it is only adequate for transverse amputations at or distal to the mid-nail level (Ishikawa Type 1). Proximal to this level, the flap bulk is too small and does not advance far enough to provide good tip cover, except in those transverse amputations just distal to the nail fold, which can be converted to dorsal-facing ampu-
MATERIALS AND METHODS The technique of designing, raising and advancing the original flap is well known and has been clearly described and illustrated in previous publications (TranquilliLeali, 1935; Atasoy et al, 1970; Verdan and Egloff, 1981; Lister, 1984; 1991). The modified flap is designed so that the proximal part of the "V" extends onto the middle phalangeal segment (Fig 2a). The flap is mobilized in the same manner as the original flap, except that it is vascularized more proximally, and directly by the neurovascular bundles. These are sought and visualized on the underside of the flap as it is turned back from the palmar surface of the distal phalanx and the flexor tendon sheath (Fig 2b). We have described this flap as a modification of the Tranquilli-Leali flap, and it was as such that it was conceived. Previously, we have used another flap which advances to the fingertip on both neurovascular pedicles, leaving a proximal defect which requires a skin graft (Fig 3). Although we have been unable to trace the origins of this flap in the literature it came to this unit from SOS Main, Strasbourg. The new flap described above could equally be considered a variant of this flap by the addition of a proximal tail, to allow use of the V-to-Y principle of closure and avoid a donor site skin graft. Both flaps are "bipedicled neurovascular island flaps" in the classification proposed by Schuind et al (1985). Because the neurovascular flap is not based on the small blood vessels beyond the arterial trifurcation but on the actual neurovascular bundles, it can provide tip cover following amputations of the fingertip proximal to the level of the nail fold. It can also be used to
Tranquilli-Leafi Flaps
Neumvascular Design
Original
Design Angle of Amputation
Dorsal Transverse Palmar Facing Facing
Dorsal Transverse
Facing
Palmar Facing
Levelof Amputation • d
I
t~
....
19
"18
12
4
32 3
7
III
1
W --DIP -.
5 3
--PIP -2
Fig 1
Diagram and Table summarizing the 116 cases in this series, classified by level and angulation of amputation. * Levels of amputation after Ishikawa (1990). 815
816
Fig 2
THE JOURNAL OF HAND SURGERY VOL. 20B No. 6 DECEMBER 1995
(a) Pre-operative views of a transverse amputation at nail fold level showing the neurovascular Tranquilli-Leali flap markings. (b) Left: flap dissected, only attached to the finger by the neurovascular bundles, visible on the underside of the flap. Right: flap advanced, showing unadjusted leading edge which is too broad. (c) Inset: flap sutured after narrowing of the leading edge by excision of a central "V". Main: fingertip after completion of epithelialization.
NEUROVASCULARTRANQUILLI-LEALI FLAP
Fig 3
Bipedicled homodigital advancement flap with split skin graft reconstruction of the proximal donor site.
achieve stump closure, without shortening, in more proximal amputations at any level of the finger (Figs 1 and 4). Because it is bigger and only attached by the neurovascular bundles, it is capable of greater advancement than the original flap. This makes it possible to use this flap not only for transverse and dorsal-facing amputations, but after palmar-facing amputations up to an angle of 30 ° to 35 ° (Fig 5). However, with more shelving amputations than this, lateral advancement flaps based on a single neurovascular bundle (SegmOller, 1976; Venkataswami and Subramanian, 1980; Evans and Martin, 1988) provide more tissue bulk and are more suitable reconstructions. The neurovascular flap has been modified at its leading edge to improve the appearance of the reconstructed fingertip. The original Tranquilli-Leali flap was designed with the lateral incisions well away from the lateral nail folds. As a consequence of scar shortening in length, these scars sometimes heal with indentations, as shown in Figure 6. This appearance, which is permanent, is also seen in the illustrations of previous authors. It gives the fingertip an unattractive and unusual appearance, not unlike that of a circumcised penis. Where the flap is particularly narrow it may heal with not only this scar indentation but with retention of oedema both in the flap and in the lateral parts of the fingertip between the scars and the lateral nail folds, giving the fingertip an ugly,
817
spatulate appearance (Fig 6). We have designed the modified flap so that the lateral incisions come close to, although preserving, the lateral nail folds (Figs 2, 4 and 5). After advancement, the flap is then too wide (Figs 2b and 5b). If the flap is sutured without modification, the fingertip is too broad and appears shovel-like. Initially, we narrowed the fingertip by excising a central "V" from the leading edge of the flap. As this technique did not gi~e the desired rounding of the fingertip and sometimes left a central notch (Fig 2c), we now shape the tip by excising the comers of the leading edge of the flap. The corners are then allowed to epithelialize under moist antiseptic dressings to give a rounded and more natural appearance (Figs 4c and 5c, d). We have used 116 original and modified flaps to reconstruct amputations of the fingers over a period of 4 years. In order to increase the size of these flaps and so increase their potential for advancement they have all been advanced to cover the exposed bone with pulp tissue only, with the tip then re-epithelializing under moist antiseptic dressings, except where suture to the nail or dorsal skin could be achieved easily. This is only usually the case with dorsal-facing amputations. Although this technique only achieves a difference of 1 mm to 3 mm in flap size and advancement, it allows a significant widening of the circumstances in which these flaps can be used and allows cover of the fingertip with less tension. Re-epithelialization in this way also appears to achieve more rounded fingertips. The proximal " V " of exposed pulp tissue following flap advancement has not been closed as a " Y " in most cases, but is also re-epithelialized under moist dressings. Closure of the " Y " often narrows the finger proximal to the flap (Fig 7) with the risk of post-operative flap congestion. There have been no flap deaths in the series. The original flap was designed such that the lateral incisions remained on the distal phalangeal segment and did not cross the DIP joint crease. Although the incisions of the neurovascular flap cross this crease, they do so obliquely and have caused no problems of scar contracture, despite initial concern. We have used 53 original flaps in 53 patients and 63 neurovascular flaps in 62 patients. One patient had an original flap to one fingertip and a neurovascular flap to another. Figure 1 shows the levels of amputation and the slope of amputation of the fingers. The Ishikawa level 2 amputations included nine transverse amputations close to the nail fold which were converted to dorsal-facing amputations by ablation of the germinal matrix of the nail and slight bone shortening to allow use of the original flap. These cases are included in Figure 1 as Ishikawa level 2 dorsal-facing amputations. The original flap has been used mainly in transverse and dorsal-facing amputations at the distal nail level and in dorsal-facing amputations at the more proximal nail level, after nail matrix ablation. The neurovascular flap has been used for all three angulations of fingertip amputation and also for more proximal finger loss.
818
Fig4
THE JOURNAL OF HAND SURGERY VOL. 20B No. 6 DECEMBER 1995
(a) Pre-operative views of transverse amputation just beyond the DIP joint showing the markings of the modified flap, including the corners of the leading edge of the flap which will be excised to narrow the flap after advancement. (b) Main: flap advanced. Inset: flap sutured in after narrowing of the leading edge by excision of the corners. (c) Late views of fingertip.
NE UROVASCULAR TRANQUILLI-LEALI FLAP
Fig 5
819
(a) Pre-operative views of palmar-facing amputation at nail fold level showing the marking of the modified flap. This finger represents the extreme of palmar-facing defect for which the neurovascular Tranquilli-Leali flap can be used. (b) Flap advanced, with the corners of the leading edge marked prior to excision of the corners and suturing. (c) Fingertip after completion of epithelialization. (d) Late view: the middle finger is reconstructed with a modified Tranquilli-Leali flap. The ring finger suffered a more oblique palmar-facing amputation and is reconstructed with 2 Segm~ller flaps (Segmttller, 1976; both fingers show mild hook nail deformity on lateral view at this late stage).
820
Fig 6
THE JOURNAL OF HAND SURGERY VOL. 20B No. 6 DECEMBER 1995
Late views of original Tranquilli-Leali flap. Left: with lateral incisions, as routinely described, showing indentation of scars, resulting in an appearance like a circumcised penis. Right: with very narrow flap and oedema of the fingertip lateral to flap, resulting in a spatulate fingertip.
A review of the patients' notes was carried out. The notes of 46 patients with 46 original flaps and 55 patients with 56 neurovascular flaps were available for review. The average follow-up of all patients was 25 weeks, with those patients with original flaps having an average follow-up of 20 weeks and those with modified flaps having an average follow-up of 30 weeks. The two groups were well matched for age, with five original flap and two neurovascular flap patients being under 5 years, six original flap and seven neurovascular flap patients being between 6 and 15 years, 25 original flap and 35 neurovascular flap patients being between 16 and 50 years, and ten original flap and 11 neurovascular flap patients being over 50 years old. The distribution of injured digits was also well matched, with seven of each group having thumb injuries and 13 of the original flap and ten of the neurovascular flap patients having index finger injuries. 16 original flap and 20 neurovascular flap patients sustained middle finger injuries, six original flap and nine neurovascular flap patients had ring finger injuries and four original flap and ten neurovascular flap patients had suffered little finger injuries. Cold intolerance was reported by six (13%) of the original flap patients and seven (13%) of the neurovascular flap patients. Only one patient, who had had a neurovascular flap with pulp skin to nail suture, developed early post-
Fig 7
Modified flap sutured in with closure of the proximal "Y", resulting in narrowing of the finger proximal to the flap.
operative infection requiring re-exploration and removal of necrotic bone. The low incidence of infection in both groups probably reflects the policy of aiming to achieve pulp cover of the bone at the tip of the digit, then using antiseptic dressings to regain skin cover, as opposed to trying to achieve primary skin closure. Of the original flap patients, one (2%) complained of nail tenderness, two (4%) of bone tenderness at the tip of the digit and two (4%) of tenderness of the tip scar. Two (4%) more patients complained of problems of bone tenderness, tip scar sensitivity and also hypersensitivity of the proximal "V" scar. One of these two patients also developed a digital neuroma and had two fingertip revisions, the first of which involved relocation of the neuroma into the middle phalanx. One other patient in this group is scheduled to have a revision of a tender tip scar. Of the neurovascular flap patients, four (7%) complained of bone tenderness at the tip of the digit, three (5%) of tenderness of the tip scar and one (2%) patient complained of a minor degree of bone tenderness, tip scar sensitivity and also hypersensitivity of the proximal "V" scar. Two of these patients had revision amputations with shortening, one for bone tenderness and one for a very sensitive tip scar. One patient who sustained four fingertip amputations of the fingers of one hand which were treated by a neurovascular Tranquilli-Leali flap (index), direct suture (little) and
NEUROVASCULARTRANQUILLI-LEALIFLAP
Fig 8
821
(a) Very distal, dorsal-facing amputation. Inset: illustration of the difficulty encountered on simply approximating the leading skin edge to the nail. The pulp bulk is excessive. (b) Original Tranquilli-Leali flap. Left: designed. Right: advanced, facilitating approximation of the leading skin edge and the nail. (c) Fingertip after completion of epithelialization.
two Segmuller flaps to each of two digits (middle and ring), developed hyperaesthesia of all four fingertips, but continues to work. One other patient in the neurovascular flap group required excision of an inclusion dermoid cyst from the tip scar. This group, which includes more proximal injuries, also included two patients with nail problems requiring secondary surgery: one developed a nail bed infection which was opened 1 week after primary surgery, and one required removal of a nail spicule after previous ablation of the nail matrix. Four (9%) of the original flap and five (9%) of the neurovascular flap patients had hook nails, with one of the latter developing mild hooking of both of two neurovascular flap reconstructions. All of these were mild in degree, reflecting the operative policy of never leaving nail bed unsupported by bone. Only four (9%) of the original flap and two (4%) of the neurovascular flap patients complained of loss of sensation at the digit tip.
DISCUSSION Both the original and the modified Tranquilli-Leali flaps are used in fingertip injuries in which there is bone exposure. Where the bone is not exposed it is our policy, as it is that of others, to simply dress the fingertip and await re-epithelialization followed by full skin formation. If this policy is used after significant loss of pulp and when bone is exposed, then the end result is poor cover of the bone by pulp which may give rise to bone tenderness on applying pressure to the fingertip. A secondary effect of this is that the loss of bulk of the pulp on the palmar aspect of the fingertip is apparent. This is evident on examination of some of the illustrations in recent publications in which a policy of dressings only has been applied to all fingertip injuries (Mennen and Wiese, 1993; Lee et al, 1995). While these papers seem to confirm that the nail bed has powers of regeneration, as suggested by Ogo in 1987, this power
THE JOURNALOF HANDSURGERYVOL.20B No. 6 DECEMBER1995
822
Fig 9
Dorsal-facing amputation at mid-nail level simply closed by suture of the leading skin edge to the nail, resulting in a shovel-like fingertip.
appears to be present to a lesser degree in the pulp tissue o f the fingertip. A l t h o u g h Figure 1 reflects the policy o f differential use o f the two flaps described above, the modified flap is so m u c h m o r e flexible in its application that we have tended to use it with increasing frequency in situations in which we would previously have used the original flap. The modified flap has become our technique o f choice even for transverse amputations at Ishikawa level 1 and we n o w use the original flap only for very distal transverse amputations and dorsal facing a m p u tations b e y o n d the mid-nail level (Fig 8). It is clear f r o m the illustrations o f Tranquilli-Leali's original article that he described this flap for just such amputations (Tranquilli-Leali, 1935; Lister, 1984). Even amputations at this level are difficult to close directly without creating a shovel-like fingertip (Figs 8a inset and 9) and the original flap remains useful for such cases. The results o f the late analysis o f the patients are included with reservation as they are based on note review, it having p r o v e d impossible to bring the actual patients back for review. The follow-up is also short as
m a n y patients were o f working age and reluctant to continue follow-up b e y o n d the m i n i m u m essential, as clinic visits entail loss o f earnings. 12 (26%) o f the original flap g r o u p and ten (18%) o f the neurovascular flap group attended clinic for 4 or fewer weeks f r o m injury, so can have barely healed their fingertips before taking self-discharge. The above results tend to indicate a small n u m b e r of problems with b o t h types of Tranquilli-Leali flap. Cold intolerance is a problem c o m m o n to all fingertip injuries in the British Isles. The incidence is p r o b a b l y low in this review, as this problem is not routinely sought after in follow-up clinics, the figures representing spontaneous c o m m e n t by the patients. By comparison, sensory problems o f loss o f sensitivity o f the fingertip or tenderness/hypersensitivity are b o t h volunteered by patients and sought in the clinics, and are m o r e likely to be related to the technique o f reconstruction. The follow-up is too short to represent the long-term situation, as fingertips are often still tender 6 m o n t h s after injury. The concern with all reconstructions o f the fingertip is to provide adequate pulp cover o f the bone, to avoid bone tip tenderness and to avoid loss o f sensitivity as a result o f the reconstruction. In respect o f the latter, homodigital advancement flaps have an advantage over reconstruction with flaps with no innervation and those with nerve anastomosis. Nevertheless, the risk they do carry in maintaining digital length is that o f neuropraxia as a result o f nerve stretching. The incidence o f this problem has never been analyzed. A problem o f presentation o f end results o f new techniques o f fingertip reconstruction is that this has rarely been done in the past. This is a fault which has been and is difficult to rectify as patients are discharged or take self-discharge early after fingertip reconstruction. It makes comparison o f the merits o f different techniques impossible and tends to load opinion against those few techniques which are presented with long-term analysis. References
ATASOY, E., IOAKIMIDIS,E., KASDAN, M. L., KUTZ, J. E. and KLEINERT,H. E. (I 970). Reconstructionof the amputatedfingertip with a triangularvolarflap. Journal of Bone and Joint Surgery,52A:5:921-926. EVANS,D. M. and MARTIN,D. L. (1988). Step-advancementisland flap for fingertip reconstruction. British Journal of Plastic Surgery,41:2:105-1l 1. ISHIKAWA,K., OGAWA,Y., SOEDA,H. and YOSHIDA,Y. (1990). A new classificationof the amputatedlevelfor the distal part of the finger. Journal of the Japan Societyof ReconstructiveMicrosurgery,3: 54. LEE, L. P., LAU, P. Y. and CHAN, C. W. (1995). A simple and efficient treatment for fingertip injuries. British Journal of Hand Surgery, 20B: 1: 63 71. LISTER, G. The Hand." Diagnosis and Indications. Edinburgh, Churchill Livingstone, 1984:85 87; 120 123.(includingillustrations fromTranquilliLeali's originalpaper.) LISTER, G, V-Y Advancementflaps. In: Foucher, G. (Ed.): Fingertip and Nailbed Injuries'. Edinburgh, ChurchillLivingstone,1991:52-61. (including a completetranslation of Tranquilli-Leali'soriginalpaper into English). MENNEN, U. and WIESE, E. (1993). Fingertip injuries management with semiocclusivedressings. Journal of Hand Surgery, 18B:4:416-422. OGO, K. (1987). Doesthe nail bed reallyregenerate?Plasticand Reconstructive Surgery, 80:3:445-447. (seealso letter pertainingto this paper Plasticand ReconstructiveSurgery,June 1988.) SCHUIND, F., VAN GENECHTEN, F., DENUIT, P., MERLE, M. and FOUCHER, G. (1985). Le lambeauen riot homodactyleen chirurgiede la
NEUROVASCULAR TRANQUILLI-LEALI FLAP main: A p r o p o s de soixante cas. Annales de Chirurgie de la Main, 4:4: 306-316. SEGMULLER, VON G. (1976). Modifikation des Kutler-Lappens: Neurovaskul/ire Stielung. Handchirurgie, 8: 75-76. TRANQUILLI-LEALI, E. (1935). Ricostruzione dell'apice delle falangi ungueali ruediante autoplastica volare peduncolata per scorrimento. Infort. Traum. Lavaro, 1: 186-193. VENKATASWAMI, R. and SUBRAMANIAN, N. (1980). Oblique triangular flap: A new method of repair for oblique amputations of the fingertip and thumb. Plastic and Reconstructive Surgery, 66:2: 296-300.
823 VERDAN, C.-E. and EGLOFF, D.-V. (1981). Fingertip injuries. Surgical Clinics of North America, 61:2: 237-266.
Accepted: 23 February 1995 David Elliot FRCS, Regional Plastic Surgery Unit, St Andrew's Hospital, Billericay,Essex, UK. © 1995 The British Society for Surgery of the Hand