Fingertip Injuries
Soft tissue defects of hand
Fat to Fit
Always remember Liposuction is not primarily a weight loss surgery but is a body contouring surgery.
Fingertip injuries and nail bed injuries are the most common injuries of the hand. Finger tip provides sense of touch. With nails providing aesthetic appearance to the fingers and fingertips providing sense of touch constitute important function for the hand. These injuries are quite common in children and mostly crushing in nature due to slamming of the door against it. The fingertip can get amputated or lacerated or crushed attached with the small narrow pedicle.
Reconstructing defects on the fingers requires thorough knowledge of a variety of coverage options.
To obtain definitive closure- function, contour and cosmesis is also integrated.
PREOPERATIVE MANAGEMENT
- Patient is usually brought at emergency. Patient's vitals are taken and any other injury if present is examined and managed.
- Fingertip injury is examined and assessed according to Allen's classification.Allen classification:
Type 1= pulp injury
Type2= pulp + nail bed injury
Type3= concomitant fractureof distal phalanx
Type4= involvement of lunula
- Hand is thoroughly examined any fractures are ruled out
- Wound is cleaned and irrigated thoroughly.
- Vascularity is assessed using capillary refill, pin prick and color of fingertips.
- Digital Xray of the finger/ hand is done to rule out any bony injury.
- All pre operative investigations are done and the finger is immobilized.
RECONSTRUCTIVE PRINCIPLES
- Irrigation
- Debridement
- Restoration of vascularityIf there is no blood flow in the injured part. If the fingertip is brought amputated, reimplantation should be thought of.
- Stabilization of fractures- usually with a k wire or needle
- Repair of nerve and tendon if required
- Soft tissue cover if distal part is lost or damaged
Reimplantation of cut fingertips-
Reimplantation of cut fingertips is possible if the amputated part is brought in well preserved manner to us within the acceptable time frame after the accident which is usually between 4 to 6 hours but can extend up to 10 hours also in case of fingertip injuries as there is no muscle mass.
Reimplantation of cut fingertips is a very technically demanding and challenging procedure which needs to be done as early as possible once the patient is received and it needsa lot of patience and understanding on the part of the patient and the attendants also.
It is generally believed among general publicthat the reimplantation of cut fingertips should bevery easy but actually it's the opposite.It is more technically challenging then reimplantation done at proximal joints like hand, forearmas the size of vessels in the fingertip is even much less than one millimetre. The success rate of such digital re-implants is around50 to 60%. I believe this success rate is quite good in fingertip reconstructions as most of the fingertip injuries are not sharp cuts which yields better results but are crush injuries in which the cut amputated part does not have viable vessel to anastomose.
Patient is admitted in the hospital for quite a long time after reimplantation (for 8- 10 days) for proper monitoring and medication. If the reimplanted part show sign of withering or blocked blood circulationafter 2 to 3 days then that part is removed and appropriate flap reconstruction is done.
In few cases, counselling is done for the patient and the attendants and specially when children are the patients. Sometimes, results of a flap reconstruction are much better than preferring undergoing a surgery which islengthy and with unpredictable outcome under anaesthesia.
Technique of fingertip reconstructions
Soft tissue reconstruction depends on size, shape, locationand characteristics of the tissue lost.
Efficient wound closure becomes a higher priority to prevent finger stiffness and maximize hand function.
Secondary healing (with only dressing and no sutures
Only small wounds should be allowed to heal by re-epithelialization and closure may take 4-6 weeks. Healing by Secondary intention provides disadvantages ofcontour deformity, sensation loss and lack of donor site morbidity.
Skin grafting
When the extent of defect is limited to skin, a split or full thickness skin graft may be used for coverage of a well vascularized bed.
The amputated part may be replaced as a composite graft after defatting called as a cap graft.
Local flaps from the adjacent part of the finger
There are variety of options available to reconstruct the pulp of the finger. The most commonly used flaps by DrAmit Agarwal are
Volar V-Y advancement flap (Atasoy, Kleinert)
-Fingertip defects less than 1 cm and oriented in a dorsal oblique or transverse fashion
-0.75-1 cm of length can be obtained
Lateral V-Y advancement flap (Kutler)
-Transverse and lateral oblique defects
-0.75-1 cm of length can be obtained
Cross finger flap
Cross finger flap is also a very versatile flap which can resurface the fingertips. In this technique, the dorsal skin (skin on the back of the finger) of the adjacent finger is used to resurface the defect while remaining attached via skin pedicle. Cross finger flap is a 2 stage procedure. In the first stage, flap is harvested from the back of the finger and the raw area is covered bySkin graft. In the second stage after 2- 3weeks when the flap has restored its blood supply over the defect, it is detached from the adjacentfinger. Some amount of cosmetic deformity of the grafted back of finger (area of the harvested cross finger flap)should be acceptable to the patient.
Thenar flap
The thenar flap is a very versatile flap which can be used to resurface the fingertips in a very effective and efficient way with very less morbidity to the hand with the most natural result possible. It follows the principle of like replaces like and give fingertips the same glabrous skin which was there before the accident or trauma. But thenar flap is a 2 stage surgery. In the first stage, flap is harvested from the skin of the palm and inset over the defect and in second stage after 2-3 weeks, flap is detached and exercised started.
Technique of soft tissue defects of hand-
POST OPERATIVE MANAGEMENT
- Vascularity of flap is assessed for 48 hours
- IV antibiotics are given for 1 days
- Immobilization is done till sutures get mature
- Sutures are removed after 2 weeks
- Patient is discharged on 2thday
- Limb elevation is given
- If thenar flap and cross finger flap are used then a second stage surgery is performed after 2 to 3 weeks. The patient is discharged next day after the first stage surgery and comes for the regular dressings and is readmitted again on the day of second stage surgery and is discharged on the same day.
- Rehabilitation and physical therapy after 2 weeks with massage over the flap after 4 weeks.
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Best plastic surgeon, Dr. Amit Agarwal is an American Board Certified, extensively trained, and best Plastic & Aesthetic surgeon in Lucknow. He is the Chief Plastic Surgeon heading the Department of Plastic, Microvascular, and Craniofacial surgery at Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, U.P, India. He maintains a busy practice at Avadh and Nishat Hospital and his own center - Kayakriti Plastic Surgery & Dental Center. He was formerly a Consultant in the Department of Plastic Surgery and Burns at the prestigious SGPGI, Lucknow.
MS, DNB (General Surgery) MCh, DNB (Plastic Surgery),
MNAMS, FACS, FICS, FRCS (Edinburgh, UK)
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Frequently Asked Questions
If you have flat or small breast and you want to improve your breast and hip contour ratio then you are a good candidate for it. The answer will be best provided after the first consultation with Dr Amit Agarwal.
Acute pain will be there for almost a week which gradually reduces and there will be soreness and swelling which may take up to 3 weeks to subside.
You can join your work and daily routines after a week of the procedure and can start exercising after 3 weeks of it.
Yes, you have to wear it round the clock unless we suggest you to remove it.
This surgery does not affect the ducts or the areas of the breast involved in milk production. Thus, it does not affect the breast feeding.
This surgery does not affect the ducts or the areas of the breast involved in milk production. Thus, it does not affect the breast feeding.
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