Case 23 2026: “Minimally Invasive Finger Amputation Using a Volar ‘Toilet seat’ Flap for Invasive Squamous Cell Carcinoma”
Claes Hannibal Killerich, Nikolaj Warming
Abstract
Keywords: Squamous cell carcinoma; finger amputation; volar flap; local reconstruction; traction neurectomy; hand surgery. Authors: Claes Hannibal Killerich, Nikolaj Warming Abstract A 93-year-old woman presented with a chronic non-healing dorsal finger wound initially diagnosed as actinic keratosis. Repeat biopsy revealed invasive squamous cell carcinoma with joint and bone involvement. Due to the extent of invasion, distal amputation of the third finger was required. Reconstruction was performed using a volar “toilet seat” flap under digital nerve block to minimize surgical burden. The procedure achieved clear margins, preserved stump length, and avoided donor-site morbidity. This case highlights the importance of early re-biopsy of non-healing lesions and adapting surgical strategy to patient age, function, and comorbidity. Patient medical history A 93-year-old woman presented with a wound on the dorsal aspect of the proximal phalanx of the left third finger. A primary biopsy revealed actinic keratosis, and the lesion was treated several times with curettage and electrodesiccation by a private dermatologist. Despite repeated treatments under professional supervision, the wound failed to heal.Due to the persistent non-healing nature of the lesion, a repeat biopsy was performed, confirming the diagnosis of squamous cell carcinoma (SCC). The patient was referred to the Department of Plastic Surgery, Aalborg University Hospital, where a primary excision was performed with a 7 mm surgical margin. Histopathological examination demonstrated invasive tumor growth involving both joint and bone. The defect was subsequently reconstructed using a full-thickness skin graft. Before and After Patient examination The left third finger showed a healed full-thickness skin graft on the dorsal aspect of the proximal phalanx, covering the proximal interphalangeal (PIP) joint. There was no visible residual tumor, and no palpable lymphadenopathy in the left cubital fossa or axillary re
BeforeAfterA 93-year-old woman presented with a wound on the dorsal aspect of the proximal phalanx of the left third finger. A primary biopsy revealed actinic keratosis, and the lesion was treated several times with curettage and electrodesiccation by a private dermatologist. Despite repeated treatments under professional supervision, the wound failed to heal.Due to the persistent non-healing nature of the lesion, a repeat biopsy was performed, confirming the diagnosis of squamous cell carcinoma (SCC). The patient was referred to the Department of Plastic Surgery, Aalborg University Hospital, where a primary excision was performed with a 7 mm surgical margin. Histopathological examination demonstrated invasive tumor growth involving both joint and bone. The defect was subsequently reconstructed using a full-thickness skin graft.
The finger was excised with a 5 mm safety margin. Dissection of the digital nerve bundles allowed for bilateral traction neurectomy, enabling the nerve ends to retract proximally into healthy tissue.
Dissection of the flexor tendons prior to proximal tenotomy.
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Amputation of the finger was performed distal to the metacarpophalangeal (MCP) joint, exposing the remaining base of the proximal phalanx along with the adjacent soft tissues. A needle was placed in the MCP joint to visualize the length of the preserved finger stump. The bony edges were smoothed with a rongeur.
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The volar “toilet seat” flap sutured into the defect using interrupted flap sutures
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Removal of flap sutures seven days postoperatively.
How to cite this article
Claes Hannibal Killerich, Nikolaj Warming. Case 23 2026: “Minimally Invasive Finger Amputation Using a Volar ‘Toilet seat’ Flap for Invasive Squamous Cell Carcinoma”. Journal of Plastic, Breast & Reconstructive Surgery. 2026.
Open access. © 2026 The Author(s). Published by the Journal of Plastic, Breast & Reconstructive Surgery. Copyright to this case is shared between the author(s) and the journal; authors may reuse their own case for education, presentations and social media.
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