Heterodigital Adipofascial Turnover Flap - Systematic Review of Indications, Techniques and Outcomes

1. Purpose:

The Heterodigital adipofascial turnover flap, also known as the reverse cross-finger flap was first described in 1978¹. This flap has been used for soft tissue coverage of a variety of dorsal digital defects² including nail bed injuries, extensor tendon injuries and open fractures³. The purpose of this study is to systematically review the specific indications, surgical techniques and common reported outcomes to guide clinical management.

 

2. Materials and Methods:

This review was constructed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A comprehensive literature review of articles indexed to PubMed was performed using the keywords “turn-over”, “reversed”, “hinged”, “open book”, “cross finger”, “transdigital”, “heterodigital”, “adipofascial”, “dermal”, “de-epithelialized” and “flap”. Two independent reviewers screened the abstracts with regards to exclusion criteria which consisted of non-digital flaps, homo-digital flaps, classical cross finger and non-adipofascial flaps. Selected manuscripts were analyzed in full text with regards to references and citations in order to expand the number of relevant articles. Independent data extraction was performed by two reviewers utilizing pre-determined study characteristics and outcomes. These characteristics included, patient demographics, defect characteristics, clinical diagnosis, surgical technique, duration of follow-up, post-operative protocol such as immobilization, time of flap division, and methods for adipofascial flap and donor site coverage. The prevalence of these characteristics was calculated to summarize indications, surgical techniques and common reported outcomes.

 

3. Results:

Our search in PubMed using the above-mentioned keywords resulted in 266 articles. 23 of these articles met the inclusion criteria, yielding 163 patients treated with the heterodigital adipofascial turnover flap. Traumatic injury was the most common indication for treatment (n=144). This flap was commonly used from the adjacent digit from extensor zone 2 or 4 (n=95). In 62 cases, the flap was de-epithelialized. 23 cases involved the nail bed, with 17 left to epithelialize and 6 cases covered with a toe nail bed graft. Post-operatively, digits were most commonly immobilized with a splint (n=88). The mean follow up time was 6 months. Complications included, cold intolerance (n=14), incomplete graft take (n=12), stiffness (n=8), infection (n=6), epidermal inclusion cyst (n=3), tendon adherence (n=1) and complete flap necrosis (n=1).

 

4. Conclusion:

The Heterodigital adipofascial turnover flap is an excellent option for coverage of a variety of dorsal digital defects. The surgical technique utilizes an adipofascial turnover flap most commonly from zone 2 or 4 of adjacent finger. This method has a variety of applications for both traumatic and non-traumatic injuries⁴. Donor site morbidity is rare and functional outcomes are promising. The Most common complications are cold intolerance and incomplete graft take.

 

References

 

1.Pakiam AI. The reversed dermis flap. British Journal of Plastic Surgery. 1978;31(2):131-135.

2. Al-Qattan MM. The Cross-Digital Dorsal Adipofascial Flap. Annals of Plastic Surgery. 2008;60(2):150-153.

 

3. Atasoy ECF. The Reverse Cross Finger Flap. The Journal of Hand Surgery. 2016;41(1):122-128. 

 

4. Al-Qattan MM. De-epithelialized Cross-Finger Flaps Versus Adipofascial Turnover Flaps for the Reconstruction of Small Complex Dorsal Digital Defects: A Comparative Analysis. The Journal of Hand Surgery. 2005;30(3):549-557.