Syndactyly Repair: Comparison of Skin Graft and No Skin Graft Techniques
Condition: Congenital Hand Deformities
MeSH terms: Syndactyly; Hand Deformities; Hand Deformities, Congenital
Study type: Observational

Summary: 
      Syndactyly is a relatively common congenital abnormality of the hand occurring approximately
      1 out of 2500 live births (1). It can be simple, meaning only skin and soft tissues are
      shared, or complex, meaning the bone or nail parts are shared. In any case, it is a fact that
      there is not enough skin surrounding the two finger segment to be utilized to cover two
      separate fingers. This can also be proven by simple geometry. Therefore, it has always been
      taught to residents and explained to numerous patients' families that addition of skin graft
      is required for a proper syndactyly release. Without it, skin flaps would be too tight,
      causing some necrosis and significant scarring along the finger and particularly in the web
      space, causing an unsatisfactory functional and cosmetic result requiring revision.
    

Detailed description: 
      Syndactyly is a relatively common congenital abnormality of the hand occurring approximately
      1 out of 2500 live births (1). It can be simple, meaning only skin and soft tissues are
      shared, or complex, meaning the bone or nail parts are shared. In any case, it is a fact that
      there is not enough skin surrounding the two finger segment to be utilized to cover two
      separate fingers. This can also be proven by simple geometry. Therefore, it has always been
      taught to residents and explained to numerous patients' families that addition of skin graft
      is required for a proper syndactyly release. Without it, skin flaps would be too tight,
      causing some necrosis and significant scarring along the finger and particularly in the web
      space, causing an unsatisfactory functional and cosmetic result requiring revision.

      Full thickness skin grafts (FTSG) are usually utilized for this procedure and come at some
      cost. An additional incision, and therefore scar, is made in the groin or on the arm or hand
      itself. The skin graft itself usually has a slightly different color and further
      hyperpigments (2, 3, 4, 5) when placed on the hand and can have hair growth that would not
      normally be present between fingers. These create cosmetic issues as the patient gets older.
      In addition, skin graft is quite cumbersome to utilize in these tight areas and small fingers
      of small children. It definitely adds to the time under anesthesia because no method other
      than sewing with small sutures has been shown to be efficacious. Whereas the release of a
      simple syndactyly may take 30-60 minutes, the suturing of skin graft and the skin flaps
      usually takes one and half times that long in addition. Further, skin grafts require
      immobilization and special bandaging techniques to avoid graft loss. One final disadvantage
      of full thickness skin grafts is that they have been implicated in the occurrence of web
      creep, which is a post-operative scarring between fingers that decreases the amount of web
      space originally obtained (4,6). These will often require further surgical procedures
      (Percival & Sykes).

      Over the last 20 years, there has been resurgence in attempts to treat syndactyly without
      skin grafts (8, 9, 10, 11, 12, 3, 6). All techniques include a significant defatting of the
      subcutaneous tissues all the way back to the web space in an effect to decrease circumference
      of the digits. Different dorsal metacarpal flaps have been described as well, including local
      island pedicle flaps that can be used for the web commissure (3, 9, 10, 11). In addition, it
      has been shown that leaving flaps slightly open, up to 2mm, for secondary intention healing
      creates good scars in children and no increased sign of web creep or flexion contracture (5).
      Combining all three of these techniques leads to the technical ability of syndactyly release
      without the need for skin grafts. Proven benefits have been the lack of the donor scar, lack
      of pigmented or hairy graft sites, and decreased operative time. However, the incidences of
      web creep, flexion or lateral contractures, reoperation rate and the final cosmetic result
      have not been proven to be better or worse, as no one has compared similar patients. All
      studies to date have been instead a review of results using their particular technique that
      does not require skin graft. If any comparisons have been made, it has been using historical
      data already published.
    

Observational model: Case-Control
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        Syndactyly is a relatively common congenital abnormality of the hand occurring
        approximately 1 out of 2500 live births. We will utilize children under the age of 6 years
        and over the age of 6 months. Most will likely be less than 2.5 years of age. This surgery
        is usually performed when the patient is still a child.
      
Keywords: syndactyly