Microvascular Reconstruction in Fingertip Injuries

Although it is seldomly fatal, fingertip injury has the potential of causing long term disability. In performing fingertip reconstruction, several priorities should be bear in mind: restoration of skin cover to protect underlying bone, tendon, and nerve structure; maximize sensibility and nullify pain; preserve the length of the affected digit; and minimize cosmetic defect. In the effort to give a “normal” shape of the digit, microvascular surgery holds an important role. As you may be aware, microvascular surgery is a surgical technique where the surgeon performs the techniques under magnification aided with a surgical microscope to connect small vessels and nerves.

The level of fingertip injury determines whether a replantation can be performed. An amputation injury at the level of proximal nail plate can be managed by replantation. However, replantation is more difficult when the injury is located more distally or only involves volar skin loss. Despite the difficulty in microsurgical reconnection of distal vessels due to their size, the functional results are often superior to more proximal level of replantations.

Replantation by microsurgery is considered an important technique compared to classic alternative techniques. This is due to more displeasing aesthetic results on both the site of injury and the donor area, paresthesia, joint contracture, and the risk of necrosis associated with classic treatments. Replantation means that the surgical procedure is aimed to reconnect the totally amputated body part, including finger tip amputation.

In the event where the pulp of a finger is lost and gives a technically difficult situation, the patient may have an option to get a reconstructive surgery to get the contoured finger pulp back. A small area of the great toe side pulp can be a good donor site to reconstruct finger pulp, leaving minor scar and no functional impairment in the toe. That small pulp tissue is then transferred to the finger by microsurgical technique where the vessels (artery and vein) and the nerve are connected to their counterparts in the finger. The finger gets its normal and natural look and function.

Top left: A 34 year-old male with the skin and soft tissue on the palmar side of the ring finger crushed. Top rigt: A free pulp tissue flap is taken from the great toe. Bottom left: 1 week after the pulp tissue is transferred to the injured ring finger. Bottom right: 4 month after surgery. (with permission from the Journal of Medical Sciences)

Reference: Seswandhana R, Prasetyono TOH, Sukasah C. Microvascular reconstruction for finger tip injuries: case series. J Med Sci Volume 43, No. 2, June 2011:145-149.