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V-Y Local Advancement Flaps

- See:
      - Nail Bed Injuries
      - Finger Tip Injuries:

- Discussion:
    - may be used for finger tip amputations which have more dorsal soft tissue loss than palmar loss);
    - advancement flaps from same finger provide advantage of rapid healing, limited morbidity, and critical sensibility if executed properly;
    - w/ sufficient tissue present, the V-Y flap can be advanced about 1 cm over end of bone w/ minimal tension, good coverage will occur;
          - smaller nail will result but usually is not a problem;
    - the goal is to disrupt all of the septae anchoring the skin to bone, while leaving intact the nerves and vessels;
          - this allows a tension free flap advancement;
    - indications:
          - amputations at or distal to the midportion of the nail, w/ more palmar tissue remaining that dosral tissue;
    - contraindications:
          - if bone is not exposed then a skin graft will suffice;
          - half the nail bed must be remaining, otherwise consider ablating the nail bed and revising the amputation;
          - if more palmar tissue is lost than dorsal tissue, the palmar flap will not provide adequate coverage;

- Technique:
    - loupe magnification;
    - outline a palmar triangular flap
    - shorten bone so that it is even with the nail bed;
    - incision:
         - flap width: must equal width of nail bed;
         - flap length: apex of the "V flap" based at DIP joint flexion crease (the flap can be made even more proximally);
         - disally at base of triangle, incise full thickness flap thru skin, subQ, and periosteum (all periosteal attachments are divided);
    - divide septae:
         - using tenotomy scissors, separate deep surface of flap from the distal phalangeal periosteum and terminal flexor tendon;
         - with small fine scissors separate the V limbs of the triangle to identify and divide fibrous septae;
         - differentiate sepatae from vessels and nerve by examination under loupe magnification;
               - note: vessels and nerves are elastic, which fibrous septae are inelastic;
               - also note that in the distal digit, veins and arteries lie at distal levels;
         - divide upto level of apex of triangle (all resistant septae must be transected);
    - advance flap;
         - most common mistake is to have inadequate mobilization of flaps;
         - flaps should advance into place w/ no tension;
         - if flap will not advance sufficiently, sutue flap down as far as possible and apply STSG to remaining defect;
         - alternatively, insert a small K wire into the distal phalanx and secure the flap to the K wire to aleviate tension;
         - note that a hooked nail deformity may follow dorsal dissection and flap creation under the nail bed;
    - avoid excessive tension:
          - when a lot of tension is used, the nail will "hook" over the end of finger, nail matrix will stretch w/ tender coverage over the bone, &
                  coverage will not be satisfactory;
          - excessive tension will cause vascular compromise of the flap, leading to loss of at least some of tissue and subsequent poor coverage;
          - excess tension may also cause a "hook" nail deformity due to stretch of the nail matrix over the bone;
    - flap closure:
          - suture flap starting at apex, which turns the inverted V into an inverted Y

The use of lateral V-Y advancement flaps for fingertip reconstruction.

Sensitivity following volar V-Y plasty for fingertip amputations.

Palmar advancement flap with V-Y closure for thumb tip injuries.

Reconstruction of the amputated finger tip with a triangular volar flap. A new surgical procedure.

V-Y plasty as treatment of finger tip amputations.

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