V-Y Local Advancement Flaps
- Nail Bed Injuries
- Finger Tip Injuries:
- may be used for finger tip amputations which have more dorsal soft tissue loss than palmar loss);
- advancement flaps from same finger provide advantage of rapid healing, limited morbidity, and critical sensibility if executed properly;
- w/ sufficient tissue present, the V-Y flap can be advanced about 1 cm over end of bone w/ minimal tension, good coverage will occur;
- smaller nail will result but usually is not a problem;
- the goal is to disrupt all of the septae anchoring the skin to bone, while leaving intact the nerves and vessels;
- this allows a tension free flap advancement;
- amputations at or distal to the midportion of the nail, w/ more palmar tissue remaining that dosral tissue;
- if bone is not exposed then a skin graft will suffice;
- half the nail bed must be remaining, otherwise consider ablating the nail bed and revising the amputation;
- if more palmar tissue is lost than dorsal tissue, the palmar flap will not provide adequate coverage;
- loupe magnification;
- outline a palmar triangular flap
- shorten bone so that it is even with the nail bed;
- flap width: must equal width of nail bed;
- flap length: apex of the "V flap" based at DIP joint flexion crease (the flap can be made even more proximally);
- disally at base of triangle, incise full thickness flap thru skin, subQ, and periosteum (all periosteal attachments are divided);
- divide septae:
- using tenotomy scissors, separate deep surface of flap from the distal phalangeal periosteum and terminal flexor tendon;
- with small fine scissors separate the V limbs of the triangle to identify and divide fibrous septae;
- differentiate sepatae from vessels and nerve by examination under loupe magnification;
- note: vessels and nerves are elastic, which fibrous septae are inelastic;
- also note that in the distal digit, veins and arteries lie at distal levels;
- divide upto level of apex of triangle (all resistant septae must be transected);
- advance flap;
- most common mistake is to have inadequate mobilization of flaps;
- flaps should advance into place w/ no tension;
- if flap will not advance sufficiently, sutue flap down as far as possible and apply STSG to remaining defect;
- alternatively, insert a small K wire into the distal phalanx and secure the flap to the K wire to aleviate tension;
- note that a hooked nail deformity may follow dorsal dissection and flap creation under the nail bed;
- avoid excessive tension:
- when a lot of tension is used, the nail will "hook" over the end of finger, nail matrix will stretch w/ tender coverage over the bone, &
coverage will not be satisfactory;
- excessive tension will cause vascular compromise of the flap, leading to loss of at least some of tissue and subsequent poor coverage;
- excess tension may also cause a "hook" nail deformity due to stretch of the nail matrix over the bone;
- flap closure:
- suture flap starting at apex, which turns the inverted V into an inverted Y
The use of lateral V-Y advancement flaps for fingertip reconstruction.
Sensitivity following volar V-Y plasty for fingertip amputations.
Palmar advancement flap with V-Y closure for thumb tip injuries.
Reconstruction of the amputated finger tip with a triangular volar flap. A new surgical procedure.
V-Y plasty as treatment of finger tip amputations.
Original Text by Clifford R. Wheeless, III, MD.
Last updated by Data Trace Staff on Tuesday, May 22, 2012 3:33 pm