It is common for the Atasoy flap to appear blanched immediately postoperatively. This subsides unless there is excessive tension or irreversible vascular damage. The nail plate is not replaced as this may lead to infection. Antibiotics active against Staphylococcus aureus should be prescribed for 7–10 days, with coverage for Gram-negative organisms recommended for food industry workers and landscapers, or when injuries occur in bodies of water. The prevalence of methicillin-resistant S. aureus should be considered, with a dressing change at 48 hours. Elevation of the extremity should always be stressed. Hydrogen peroxide is useful for release of an adherent surgical dressing. Nonabsorbable sutures should be removed after 10–14 days.
PEARLS AND PITFALLS
A digital block using plain lidocaine 1% or 2% mixed 50:50 with plain bupivacaine 0.25% has been found to be efficacious. If circumstances permit, intravenous sedation is recommended. Note that bupivacaine is not recommended for use in children under 12 years old. Removing the nail plate and nail remnants removes contamination and allows the surgeon to see any previously unvisualized nail bed injuries. Curved iris “supercut” scissors are ideal for dissection. Sculpting of the volar phalanx with rongeurs helps prevent the dysesthesias occasionally seen with Atasoy flaps. The nail bed should extend to, but not beyond the bone. When closing skin, it is preferable to leave gaps with protruding fat between sutures than to create suture line tension. Dividing the V-Y flap transversely is not necessary and should be avoided, as this maneuver may endanger the original flap. The sensibility of these secondary flaps is routinely poor.1
It is essential to divide the fibrous septa after the skin incision is made. The technique presented here recommends closure of the donor defect as the stem of the “Y” allowing for primary wound healing. Dissection should not end when subcutaneous fat is visible, as this will not allow tension-free advancement. The solution is not to leave an open donor defect requiring dressing changes by the patient.6
The incision for the V-Y flap should extend to the DIP joint crease. This procedure should not be attempted by family physicians or other nonspecialists.8
Careful preservation of the distal neurovascular elements of the Atasoy flap is critical for maintaining the blood supply and sensibility of the flap. The digital arteries must never be ligated as described by Tranquilli-Leali.2
The flap technique described herein is superior to the V-Y ‘‘cup’’ flap because it creates equal advancement without the need for additional, potentially risky, dissection to the level of the PIP joint crease.9 Note that the distal corners of the V-Y flap cannot be rotated medially, as this will not only create a bilateral skin defects but also will create a dog-ear deformity centrally. The base (distal edge) of the flap does not need to be wider than the distal nail bed edge and in fact may be even 2–3 mm narrower with the technique described here.10
The flap described by Moberg,11 so useful for thumb injuries, is not advisable in the fingers because flexion of the IP joints is necessary for primary closure.12 This can lead to unacceptable permanent flexion deformities.
Persistent tip tenderness is usually due to a prominent distal phalanx, which may require revision after soft-tissue healing is complete. Paresthesia or poor sensibility may be due to the traumatic injury or to iatrogenic injury to digital nerve branches. Frequently, however, it can be due to tension from inadequate flap mobilization. Flap necrosis is, fortunately, rare. It may be caused by iatrogenic injury to digital vessels or, more commonly, by unrecognized crush injury. During surgery, if unsure of circulation, one should release the tourniquet before insetting the flap; the tissue should bleed healthily. The nemesis, tension, must always be reduced or eliminated. When flap edge necrosis is seen, one should suspect tobacco smoke, directly or through second hand exposure. It may also be seen in the patient using nicotine replacement therapy or electronic cigarettes.
If the flap fails, all necrotic tissue must be sharply debrided regardless of its location. Nonviable bone must also be debrided. All exposed viable tissues should be treated with dressing changes until healing by secondary intent occurs, or until granulation tissue can be closed with a split thickness skin graft.
A 12-year-old right-handed Haitian girl was brought to my office by her father. She sustained a traumatic amputation of her left ring finger tip at home while using a sharp kitchen knife. X-rays demonstrated a transverse amputation of the distal one-third of the left ring finger distal phalanx. Medical history was unremarkable.
Examination revealed a transverse amputation of the left ring finger tip with slightly greater volar than dorsal loss. The remaining volar pad had good sensibility and circulation with 2-point discrimination of 5 mm radial and ulnar. The remaining nail plate was intact, with preservation of the proximal one-half of the nail bed.
After obtaining proper surgical consent, an Atasoy flap reconstruction was performed as described above. The distal aspect of the remaining volar phalanx was sculpted with small rongeurs to create a gently sloping surface. After dividing the ligamentous fibrous septa on either side of the flap, easy, tension-free advancement was obtained. Generous irrigation with normal saline was performed.
The distal flap edge was secured to the nail bed edge with interrupted simple sutures of 6-0 Vicryl. Skin was secured in Y fashion with interrupted simple sutures of 6-0 nylon.
Following removal of the tourniquet, hemostasis was gently obtained. Dressings and a splint were applied as described above. Duricef 500 mg daily was prescribed. On postoperative day 7, the dressings were changed. The flap demonstrated good color and sensibility. On postoperative day 14, the nylon sutures were removed and absorbable sutures along the distal nail bed left in place. The patient demonstrated full range of motion of her left ring finger and left hand. Two-point discrimination of the flap was 5 mm throughout.
Although there are many well-designed studies demonstrating the efficacy of treatment of fingertip injuries with dressing changes,13,14 the benefits of primary closure should not be overlooked. Some of these advantages are decreased pain, more rapid healing (10 days versus 30 days), better preservation of length, lower risk of dysesthesias, lower risk of cold intolerance, avoidance of hook-nail deformity, and immediate coverage of exposed bone. In the case of a fingertip amputation involving the distal phalanx with transverse, dorsal oblique, or even modest volar oblique orientation, the technique presented here is ideally suited for primary closure.
With the technique modifications and recommendations presented here, the Atasoy flap can be performed with predictably excellent results.
- 1) The original description is for the direction of dissection to be from distal to proximal. Here, the direction of dissection is shifted to be from lateral to medial.
- 2) The plane of dissection is shifted from the flexor tendon sheath and periosteum to the mid flap plane.
- 3) Careful lysis of the fibrous ligamentous septa is emphasized. This dissection allows the Atasoy flap to be advanced further.
- 4) The treatment of the bone is emphasized to prevent dysesthesias and hook-nail deformity.
- 5) Coverage of the nail bed is not recommended.
This flap is an anatomical, single-stage reconstruction with virtually no donor-site morbidity. It can be a workhorse for the treatment of a variety of fingertip injuries, including amputations through the distal phalanx. The disadvantages of this flap are few. The flap may fail. Dysesthesias may occur.
The advantages and disadvantages of primary closure versus healing by secondary intent should be presented to patients when obtaining informed consent. Regardless of one’s preference for the treatment of fingertip injuries, the Atasoy flap should be a part of every surgeon’s armamentarium.
Dr. Viciana wishes to gratefully acknowledge the assistance of Robert W. Beasley, MD, in the preparation of the article.
1. Díaz LC, Vergara-Amador E, Fuentes L, et al. Double V-Y flap to cover the fingertip injury: new technique and cases. In: Techniques in Hand and Upper Extremity Surgery. 2016;20:133–136.
2. Gharb BB, Rampazzo A, Armijo BS, et al. Tranquilli-Leali or Atasoy flap: an anatomical cadaveric study. J Plast Reconstr Aesthet Surg. 2010;63:681–685.
3. Baker TJ. The versatile finger flap. Bull Univ Miami Sch Med Jackson Meml Hosp. 1961;15:50–55.
4. Atasoy EJ. Reconstruction of the amputated fingertip with a triangular volar flap. J Bone and Joint Surg. 1970; 52-A:921–926.
5. Ganchi PA, Lee WP. Stephen J. Hand surgery in Mathes. In: Plastic Surgery. 2006:2nd ed. Philadelphia, Pa.: WB Saunders; 153–170 [context link].
6. Achilleas T, Vartija LK. Making the V-Y advancement flap safer in fingertip amputations. Can J Plast Surg. 2010;18:e47–e49.
7. Beasley RW. In: Hand Injuries. 1981:Philadelphia, Pa.: WB Saunders; 149.
8. Jackson EA. The V-Y plasty in the treatment of fingertip amputations. Am Fam Physician. 2001;64:455–458.
9. Furlow LT Jr.. V-Y “Cup” flap for volar oblique amputation of fingers. J Hand Surg. 1984;9-B:256.
10. Tezel E, Numanoğlu A. A new swing of the atasoy volar V-Y flap. Ann Plast Surg. 2001;47:470–471.
11. Moberg E. Aspects of sensation in reconstructive surgery of the upper extremity. J Bone Joint Surg Am. 1964;46:817–825.
12. Chong JK, Macht S, Watson KH. The Moberg volar advancement flap for digital. Plast Reconstr Surg. 1981;68:654.
13. Lemmon JA, Janis JE, Rohrich RJ. Soft-injuries of the fingertip: methods of evaluation and treatment. An algorithmic approach. Plast Reconstr Surg. 2008;122:105e–117e.
Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
14. Weichman KE, Wilson SC, Samra F, et al. Treatment and outcomes of fingertip injuries at a large metropolitan public hospital. Plast Reconstr Surg. 2013;131:107–112.