Case 9: Adipofascial Turnover Flap for Reconstruction of a Dorsal Finger Defect Following SCC Excision

A digital nerve block was administered using 5 mL of local anesthesia (LA) without adrenaline, targeting all nerve supplies to the right fourth finger, just distal to the metacarpophalangeal joint (MTP). The surgical site was cleansed with an antiseptic solution to achieve sterile conditions. A sterile finger tourniquet was fashioned from a cut surgical glove to maintain hemostasis during the procedure.

Timeout and starting from the ulnar side, incision and dissection were performed with careful visualization and preservation of nerves and vessels, proceeding to the extensor peritendon, which was exposed after tumor elevation (Figure, left). The peritendon was found to be intact, with no evidence of macroscopic tumor infiltration (Figure, center). Dissection continued within this plane toward the radial side, extending across the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joint capsules. On the radial side, the dorsal digital nerve and artery were assessed adherent to the tumor and resected with the tumor specimen, which was orientation-marked and submitted for expedited hematoxylin and eosin (H&E) pathology evaluation. The macroscopically clear defect (Figure, right) was dressed in Jelonet, gauze, and a finger bandage. Follow-up and control were planned accordingly.

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The patient was evaluated for wound care in the outpatient clinic 5 days after the first stage surgery. No signs of infection were observed, and the patient reported minimal pain, which was managed effectively with over-the-counter analgesics. Sensory deficits in radial, dorsal, the distal part of the finger was noticed as expected.

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Eleven days after tumor excision, radical tumor removal was confirmed microscopically. Twenty days post-excision, secondary stage with closure of the defect, now measuring 40 × 40 mm, was performed.

During operative preparation, dressing removal and cleansing of the defect revealed degeneration and weakening of the extensor tendon in the distal part of the defect, resulting in partial mallet finger deformity. This was addressed during the procedure. Preoperative Doppler examination identified signal from the dorsal aspect of a. digitalis palmaris propria proximal to the defect, including signal dorsally, confirming adequate perforator flow for reconstruction.

Under sterile conditions and local anesthesia as previously, but without tourniquet, the procedure was performed following time-out. The extensor tendon was repaired using a 4-0 Prolene Kessler suture technique, restoring the tendon to its normal position.

An incision was made over the radial-dorsal aspect of the skin proximal to the defect, extending distally over the dorsum of the metacarpophalangeal joint (MTP). The skin flap was elevated with respect for the underlying structures on an ulnar base (Figure, left).

Perioperative Doppler confirmed perforator flow from the dorsal segment of the a. digitalis palmaris propria at A7, with the strongest signal originating from the radial side perforator. The adipofascial layer was mobilized from the ulnar side toward the proximal part and radially, with regards to preserving the perforator. The flap was divided longitudinally to ensure complete coverage of the tendon across the defect (Figure center) and was fixed distally with 4-0 Vicryl simple inverted sutures.

A 2.5 × 5 cm split-thickness skin graft (STSG) was harvested from the right cubit, with primary closure of the donor site. The graft was manually meshed and secured over the APFT using 4-0 Nylon interrupted sutures, ensuring preservation of the vascular supply to the underlying flap (Figure right). The wound was dressed with Jelonet, foam, a custom splint, and a finger bandage. Postoperatively, the patient was scheduled for bolus dressing removal in the outpatient clinic seven days after surgery.

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The patient was evaluated in the outpatient clinic seven days after the second stage surgery for dressing removal. Moderate to significant swelling of the finger was observed, with normal vascular conditions distal to the surgical site. The skin graft appeared fragile with only partial take (Figure, top left), but provided adequate coverage of the APFT (which itself provided cover to the extensor tendon). In consultation with the patient, a decision was made to proceed with conservative healing. The patient was referred to ergonomical therapy and the reconstruction was subsequently evaluated at 30 days (Figure, top right), 48 days (Figure, bottom left), and 106 days (Figure, bottom right) postoperatively, demonstrating progressive improvement.

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