# Proximal toe wrap-around: a coverage technique for circumferential skin defects of the fingers

Germain Pomares, Amandine Ledoux, Christophe Duysens, Thomas Jager, Alban Fouasson-Chailloux

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Germain Pomares, Amandine Ledoux, Christophe Duysens, Thomas Jager, Alban Fouasson-Chailloux. Proximal toe wrap-around: a coverage technique for circumferential skin defects of the fingers. Hand Surgery and Rehabilitation, 2024, 43 (2), pp.101673. 10.1016/j.hansur.2024.101673. hal-04995061

HAL Id: hal-04995061

https://nantes-universite.hal.science/hal-04995061v1

Submitted on 18 Mar 2025

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Surgical technique

# Proximal toe wrap-around: a coverage technique for circumferential skin defects of the fingers

<figure><img src="image_3.png" /></figure>

Germain Pomares<sup>a,b</sup>, Amandine Ledoux<sup>a</sup>, Christophe Duysens<sup>a</sup>, Thomas Jager<sup>a,b</sup>, Alban Fouasson-Chailloux<sup>a,b,c,d,*</sup>

ARTICLE INFO

Article history:
Available online 1 March 2024

Keywords:
Microsurgery
Hand
Flap
Hallux

A B S T R A C T

Circumferential skin defects of the fingers are a technical challenge. Although rare, their management should respect tissue organization and functional abilities. We report two cases of circumferential skin defect. Management used individually tailored "wrap-around" flaps taken from the hallux. The sample concerned the proximal cutaneous sheath of the first toe and the neurovascular pedicle of the first inter-metatarsal space. Nail and toe pad were spared. Both cases had complex circumferential skin defect of the finger, involving the neuro-vascular pedicle. Postoperative results were favorable, without functional limitation. The wrap-around technique provided skin coverage and also neurovascular pedicle reconstruction. Donor site damage was limited, with no functional consequences. This technique is a valuable option for management of circumferential skin defect of the finger.

© 2024 SFCM. Published by Elsevier Masson SAS. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).

Introduction

Circumferential skin defect (CSD) of the fingers is a technical
challenge. Functional capacities must be conserved. The usual local
procedures are insufficient, whether performed as two-stage
surgery with tissue transfer from the adjacent fingers or by
techniques of lesser quality, allowing only incomplete coverage of
the CSD [1]. Del Piñal et al. described reconstruction of complex
distal skin defects, but with no circumferential reconstruction
[2]. We describe a wrap-around reconstruction technique for
finger CSD, with two case reports.

Technique and cases

Surgical technique

An individually tailored flap is taken from the hallux according
to principles close to those of Morrison et al. [3]. The flap concerns
the cutaneous sheath of the hallux 1st phalanx and the
neurovascular pedicle of the first inter-metatarsal space (Fig. 1),

according to Gilbert's description [4]. The nail and the toe pad are
preserved. The flap should be drawn on the patient's toe according
to the size of the CSD. The flap anastomosis site must be assessed in
advance to determine which foot the flap should be taken from.
The flap is approximatively quadrangular, surrounding the 1st toe,
beginning at the first inter-metatarsal space. A medial cutaneous
bridge should always be preserved. Complete skin removal of the
1st toe is prohibited. This cutaneous bridge allows the venous
return, but also a more resistant cutaneous quilting than a skin
graft for walking and wearing shoes.

Harvesting begins by an incision centered on the dorsal side of the first inter-metatarsal space. The skin is reclined and the veins from the first toe are identified and individualized. The dorsal interosseous artery of the 1st space is identified [4]. The second toe artery is clipped between two ligatures, after its bifurcation from the dorsal interosseous artery. The first toe artery and its perforating arteries communicating with the digital plantar artery are identified. The dorsal periphery of the flap is only incised after identification and protection of the neurovascular units. The incision comes in contact with the peri-tendon of the extensor apparatus, including venous elements inside the flap. The dissection goes as far as the 1st commissure, taking care to include the pedicle. The nerve should be left in place if its removal is not necessary. The plantar periphery of the flap is then incised.

<footnote><sup>a</sup> Institut Européen de la Main, Luxembourg, L-2540, Luxembourg</footnote>

<footnote><sup>b</sup> Medical Training Center, Hôpital Kirchberg, Luxembourg L-2540, Luxembourg</footnote>

<footnote><sup>c</sup> Service de MPR Locomotrice et Respiratoire, Nantes Université, CHU Nantes, 44093 Nantes, France</footnote>

<footnote><sup>d</sup> Institut Régional de Médecine du Sport (IRMS), Hôpital St Jacques, 44093 Nantes, France</footnote>

<footnote>* Corresponding author.</footnote>

<footnote>E-mail address: alban.fouassonchailloux@chu-nantes.fr
(A. Fouasson-Chailloux).</footnote>
<figure><img src="image_4.png" /><figcaption>**Fig. 1.** (A) Drawing of the flap incisions; (B) Flap with its neurovascular pedicle; (C) Donor site covered on its plantar side by a cross-toe flap from the dorsal side of the 2nd toe.</figcaption></figure>

<figure><img src="image_5.png" /><figcaption>**Fig. 2.** Case 1. (A, B) Almost circumferential skin necrosis of the 3rd finger; (C) Skin, neurovascular and bone defects; (D, E) Immediate postoperative results.</figcaption></figure>
The medial digital plantar pedicle of the first toe is respected. The incision comes in contact with the flexor sheath as far as the previously created detachment plane. The flap is then isolated with its pedicle. It is secondarily weaned after ligation of its pedicle. The donor site is covered on its plantar side by a cross-toe flap from the dorsal side of the 2nd toe. Coverage of the dorsal side of the 1st and 2nd toes is performed with a skin graft taken from the leg.

## First case

A 27-year-old man had a CSD of the 2nd phalanx of the 3rd finger of the right hand after a crush injury (Fig. 2). Initially he was managed in another center by internal fixation with K-wires and skin repositioning. Surgical trimming disclosed a 5 × 3 cm CSD with residual thin skin bridge on the ulnar side. The second phalanx needed bone trimming of the diaphysis and a cement spacer. The radial proper palmar digital pedicle had a 2 cm defect. The flap was taken from the left 1st toe. A Gilbert stage 1a vascular pattern was identified. The lateral proper plantar digital nerve was included into the flap to allow reconstruction of the radial proper palmar digital nerve. After positioning the flap on the CSD, the flap artery allowed bridging with the radial proper palmar digital artery. Two venous end-to-end anastomoses were performed on the dorsal side of the 3rd metacarpophalangeal joint, with reconstruction of the digital nerve on the radial side of the 3rd digit (with the nerve included in the flap). No postoperative complications occurred. Full healing of the toe was obtained within 6 weeks, and the cross-toe flap was freed at 3 weeks. At 2 months, the cement spacer was removed, and iliac bone graft was performed.

## Second case

A 29-year-old man had an electric burn under a metal ring on the 4th finger of the right hand. Incisions and trimming of the 3rd degree burn areas left a 7 × 3 cm CSD on the 1st phalanx

associated with a lesion on the radial side of the 4th finger neurovascular pedicle. The ulnar neurovascular pedicle and the flexor sheath were exposed, without lesions (Fig. 3). The flap was taken from the left 1st toe. A Gilbert stage-3 vascular pattern was identified. After harvesting, the flap was positioned on the CSD. The flap artery allowed bridging by end-to-side arterial anastomosis on the 3rd common palmar digital artery, and then end-to-end anastomosis on the distal end of the radial proper digital artery of the 4th finger. The flap nerve allowed grafting to the digital nerve on the radial side of the 4th digit. Two end-to-end venous t anastomoses were made on the dorsal side of the hand. There were no postoperative complications. Full healing of the toe was obtained within 5 weeks, and the cross-toe flap was freed at 3 weeks.

## Progression

Progression was favorable for both patients at 6 months, with perfect integration of the wrap-around flaps (Fig. 4). The patients reported no problems in standing, walking or wearing shoes. A sensory deficit of the fibular hemi-pulp of the 1st toes was present in both cases. The esthetic aspect was considered satisfactory, and there was no cold intolerance. Both patients returned to their previous jobs.

## Discussion

This technical option respects tissue organization and functional capacity by early mobilization in case of complex finger CSD. It also allows pedicle reconstruction. Contiguous management is of no interest in this situation, except in case of contraindications to microsurgical procedures. Homo-digital solutions do not provide complete skin coverage, and only displace the problem. Hetero-digital solutions such as cross-finger flap [5] do not respect tissue organization, and cause stiffness in the traumatized finger

<figure><img src="image_6.png" /><figcaption>**Fig. 3.** Case 2. (A, B) Circumferential skin defects of the 4th finger; (C, D) Immediate postoperative results.</figcaption></figure>
<figure><img src="image_7.png" /><figcaption>Fig. 4. (A, B) Case 1 at 6 months; (C, D) Case 2 at 6 months.</figcaption></figure>

[6]. Moreover, hetero-digital techniques cannot be used in lateral fingers, and a double cross-finger flap does not allow circumferential coverage [7].

Some authors proposed venous flow-through flaps to treat CSD in conditions similar to those described here [8]. However, these venous flaps were taken from the palmar side of the forearm, which prevents the restitution of digital tissue organization, and were usually complicated by early venous congestion [9].

Del Pinal et al. [2] described a reconstruction technique for complex tissue defects of the fingers, using a composite flap from the 2nd toe. The main limitation is the smaller circumference of the 2nd toe compared to those of the hallux. The present wrap-around technique, on the other hand, allows coverage of large and even circumferential skin defects.

Acellular dermal matrices could also be considered for soft tissue reconstruction, but, in our own practice, indications for artificial dermal matrices are limited to covering hand and finger skin defects without associated lesions. If bone, tendon and/or pedicle repair is associated, this is for us a formal indication for an individually tailored flap. Taras et al. and Maruccia et al. also argued that artificial dermal matrices are a last-ditch solution in circumferential skin defects of the fingers [10,11]. In addition, skin grafts on artificial dermal matrices never completely restore the elasticity of the skin, especially when the graft is circular.

Our technique has some limitations, due to the risk of failure linked to microsurgery and due to operating time. Another limit could be that harvesting from the toe might cause cold intolerance [12]. However, these flaps without bone graft seem well-tolerated after full healing [12].

## Conclusion

The technique of individually tailored flaps taken from the proximal part of the hallux is a suitable solution for circumferential skin defects of the proximal or intermediate segments of the

fingers or the thumb. However, it requires a surgeon well trained in microsurgical techniques.

## Conflict of interest

The authors declare that they have no conflicts of interest.

## References

[1] Merle M, Dautel G. Perte de substance digital et de la main. Main Traumatique, 4th ed., Paris: Masson; 2016. p. 175-307.

[2] del Piñal F, García-Bernal FJ, Regalado J, Studer A, Cagigal L, Ayala H. The tibial second toe vascularized neurocutaneous free flap for major digital nerve defects. J Hand Surg 2007;32:209-17. http://dx.doi.org/10.1016/j.jhsa.2006.11.006.

[3] Morrison WA, O'Brien BM, MacLeod AM. Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. J Hand Surg 1980;5:575-83. http://dx.doi.org/10.1016/s0363-5023(80)80110-9.

[4] Gilbert A. Vascular anatomy of the first web space of the foot. Reconstr. Thumb. London: Chapman & Hall; 1989. p. 199.

[5] Cronin TD. The cross finger flap: a new method of repair. Am Surg 1951;17:419-25.

[6] Koch H, Kielnhofer A, Hubmer M, Scharnagl E. Donor site morbidity in cross-finger flaps. Br J Plast Surg 2005;58:1131-5. http://dx.doi.org/10.1016/j.bjps.2005.04.047.

[7] Breton A, Jager T, Dederichs A, Dautel G. Le lambeau portefeuille : une technique pour la couverture palmaire et dorsale du segment digital moyen. Chir Main 2012;472-8.

[8] Chia J, Lim A, Peng YP. Use of an arterialized venous flap for resurfacing a circumferential soft tissue defect of a digit. Microsurgery 2001;21:374-8. http://dx.doi.org/10.1002/micr.21805.

[9] Kong BS, Kim YJ, Suh YS, Jawa A, Nazzal A, Lee SG. Finger soft tissue reconstruction using arterialized venous free flaps having 2 parallel veins. J Hand Surg 2008;33:1802-6. http://dx.doi.org/10.1016/j.jhsa.2008.08.001.

[10] Taras JS, Sapienza A, Roach JB, Taras JP. Acellular dermal regeneration template for soft tissue reconstruction of the digits. J Hand Surg 2010;35:415-21. http://dx.doi.org/10.1016/j.jhsa.2009.12.008.

[11] Maruccia M, Marannino PC, Elia R, Ribatti D, Tamma R, Nacchiero E, et al. Treatment of finger degloving injury with acellular dermal matrices: functional and aesthetic results. J Plast Reconstr Aesthetic Surg JPRAS 2019;72:1509-17. http://dx.doi.org/10.1016/j.jbps.2019.05.029.

[12] Barbary S. La reconstruction du pouce traumatique par transfert d'orteil : à propos de 98 cas. Faculté de Médecine de Nancy 2004.