Fingertip Replantation at or Distal to the Nail Base: Use of the Technique of Artery-Only Anastomosis

Abstract

The authors describe the functional and aesthetic results of microsurgical replantation of 21 fingertip amputations at or distal to the nail base-namely, zone I amputations. There were 15 male and 6 female patients, with an average age of 26 years (age range, 1-41 years). Replantations were performed using the anastomosis of the artery-only technique, with neither vein nor nerve repair. Venous drainage was provided by an external bleeding method with a fish-mouth incision in "distal" zone I amputations for approximately 7 days, and by the use of leeches in more "proximal" zone I amputations for 10 to 12 days. Results indicated that the overall survival rate was 76%, with 16 of 21 digits surviving. Sensory evaluation at an average follow-up of 12 months (range, 6-18 months) revealed an average static two-point discrimination of 6.1 mm (range, 2.0-8.0 mm). Considering the unfavorable results and the donor site morbidity of various fingertip reconstructions, a microsurgical fingertip replantation should always be considered except in extremely distal, clean-cut, pediatric cases, in which case a composite graft is a possibility. The results of this series indicate that an amputated fingertip in zone I can be salvaged successfully by microvascular anastomosis of the artery only, with a nonmicrosurgical method of venous drainage. Furthermore, acceptable sensory recovery can be expected without any nerve coaptation.

Our Strategy for Fingertip Amputation

“…Reported success rates of fingertip replantation ranges are from 70 to 90% [4][5][6][7]. The degree of tissue damage and technical aspects influence these numbers, but we have achieved a replantation rate similar or better to that of these reports.…”

Vein grafting in fingertip replantations

“…Good sensory recovery was reported even in those cases without nerve repair in previous studies. 37,43,45,50 In this study, of the 67 patients with a follow-up period greater than 1 year, about 90% patients achieved protective sensation, while only 10% of the replants presented with diminished cold tolerance and only about 15% with pulp atrophy.…”

“…Thus, bone shortening possibly results in poor functional and cosmetic recovery in the replant. Although dissection of a vascular pedicle may preserve the length for vascular repair and some authors performed replantations by dissecting the vessels extensively and using the so-called central branch by transposition to gain the length for direct anastomosis, 20,37,[41][42][43] these methods showed limited reliability. In this series, we compared the survival rate, complications, functional and cosmetic outcomes between fingertip replantations with vein grafting and without vein grafting.…”

Reimplante e revascularização da ponta do dedo: revisão de literatura e relato de caso de amputação da ponta do dedo mínimo na criança de um ano de idade

“…Kim et al 2 described a technique of arterial microanastomosis with venous drainage supplied by suturing the deepithelized extremity into the deep abdominal fascia, which has considerably greater vascularization than does the subcutaneous tissue, and reported a high rate of success. Akyürek et al 7 reported distal replantations at zone I by arterial anastomosis alone, with venous drainage by bleeding through an incision in the shape of a "fish mouth" for 7 days or by leech application for 10 to 12 days, with 76% success. Many authors consider leeches to be the best non-surgical treatment for venous insufficiency; however, this technique is not commonly used in Brazil.…”