Neurocutaneous Soft Tissue Reconstruction in the Fingers: Tibial Neurocataneous Second Toe Free Flap

Most digital nerve defects can be reconstructed by means of non-vascularized nerve grafts, artificial tubes, or the like. However, when the bed is poor, the defect is long, or there is a concomitant soft tissue loss, a vascularized nerve graft may be the best indication. The authors presented their experience in reconstructing major neurocuatenous defects in the fingers by means of a vascularized neurocutaneous flap from the toe.

Six patients had a combined soft tissue and digital nerve defect reconstructed by a vascularized nerve graft taken from the second toe. In five cases, a tibial neurocutaneous second toe flap was used to reconstruct the radial digital nerve of the index (2 cases), the ulnar digital nerve of the small finger (2 cases) and the radial digital nerve of the small finger (1 case); the other patient had a complex defect that required a combined first web double vascularized nerve graft. Two cases were acute posttraumatic nerve defects averaging 3.0 cm. Three had an iatrogenic defect of 6 cm after surgery for Dupuytren's disease. One had a similar length defect after two previous attempts of treating a skin defect and a neuroma of the small finger, and a final one had anaesthetic-scarred fingers after a saw injury 8 months previously. All chronic cases had dystrophic pain and were under the care of pain specialists. Limited range of motion because of pain was present in all.

The proper or intermetatarsal arteries were joined to the corresponding artery at the digit with full survival of all the flaps and without complications. Nerves were repaired with standard microsurgical technique. At the latest follow-up (average 2,2 years), s2PD varied from 9 to 13 mm. Limited range of motion improved substantially in chronic cases and dystrophic pain disappeared in the chronic group. One Dupuytren's recurred. Donor site sequelae were negligible.

The tibial neurocutaneous second toe flap is ideally suited for combined soft tissue and nerve defects in the digits. It permits reconstruction of major digital nerve and soft tissue defects with minimal donor-site morbidity.