The Littler flap has been widely used to repair large pulp defects of the thumb; however, several complications have occurred frequently. In order to reduce these issues, the modified Littler flap innervated by the dorsal branch of the proper digital nerve and the proper digital nerve from the ulnar aspect of the middle finger or the radial aspect of the ring finger were devised in 16 consecutive cases. At the donor site, the defect of the proper digital nerve was repaired with a nerve graft from the proximal portion of the ipsilateral dorsal branch of the proper digital nerve. At the final follow-up, the scores for the static two-point discrimination test, Semmes–Weinstein monofilament test and total active motions in both recipient and donor fingers were nearly normal. This modified Littler flap provides a simple and reliable alternative for treatment of large defects of the thumb pulp with low donor-site morbidity.
AdaniRPancaldiGCastagnettiCZanasiSSquarzinaPB. Neurovascular island flap by the disconnecting-reconnecting technique. J Hand Surg Br. 1990, 15: 62–5.
2.
AdaniRSquarzinaPBCastagnettiCLaganáAPancaldiGCaroliA. A comparative study of the heterodigital neurovascular island flap in thumb reconstruction, with and without nerve reconnection. J Hand Surg Br. 1994, 19: 552–9.
3.
AtasoyEIoakimidisEKasdanMLKutzJEKleinertHE. Reconstruction of the amputated finger tip with a triangularvolar flap: a new surgical procedure. J Bone Joint Surg Am. 1970, 52: 921–6.
4.
BaumeisterSMenkeHWittemannMGermannG. Functional outcome after the Moberg advancement flap in the thumb. J Hand Surg Am. 2002, 27: 105–14.
5.
ChenCTangPZhangX. The dorsal homodigital island flap based on the dorsal branch of the digital artery: a review of 166 cases. Plast Reconstr Surg. 2014, 133: 519e–29e.
6.
ChenCTangPZhangX. A comparison of the dorsal digital island flap with the dorsal branch of the digital nerve versus the dorsal digital nerve for fingertip and finger pulp reconstruction. Plast Reconstr Surg. 2014, 133: 165e–73e.
7.
ChungKCPillsburyMSWaltersMRHaywardRA. Reliability and validity testing of the Michigan Hand Outcomes Questionnaire. J Hand Surg Am. 1998, 23: 575–87.
8.
ChungKCHamillJBWaltersMRHaywardRA. The Michigan Hand Outcomes Questionnaire (MHQ): assessment of responsiveness to clinical change. Ann Plast Surg. 1999, 42: 619–22.
9.
DelikonstantinouIPGrawanisAIDimitriouVZogogiannisIDoumaATsoutsosDA. Foucher first dorsal metacarpal artery flap versus littler heterodigital neurovascular flap in resurfacing thumb pulp loss defects. Ann Plast Surg. 2011, 67: 119–22.
10.
DellonALKallmanCH. Evaluation of functional sensation in the hand. J Hand Surg Am. 1983, 8: 865–70.
11.
HastingsH. Dual innervated index to thumb cross finger or island flap reconstruction. Microsurgery. 1987, 8: 168–72.
12.
HrabowskiMKloetersOGermannG. Reverse homodigital dorsoradial flap for thumb soft tissue reconstruction: surgical technique. J Hand Surg Am. 2010, 35: 659–62.
13.
ImaiHTajimaTNatsumaY. Interpretation of cutaneous pressure threshold (Semmes-Weinstein monofilament measurement) following median nerve repair and sensory reeducation in the adult. Microsurgery. 1989, 10: 142–4.
14.
IrwinMSGilbertSETerenghiGSmithRWGreenCJ. Cold intolerance following peripheral nerve injury. Natural history and factors predicting severity of symptoms. J Hand Surg Br. 1997, 22: 308–16.
15.
LanzettaMMastropasquaBCholletABriseboisN. Versatility of the homodigital triangular neurovascular island flap in fingertip reconstruction. J Hand Surg Br. 1995, 20: 824–9.
16.
LeeYHBaekGHGongHSLeeSMChungMS. Innervated lateral middle phalangeal finger flap for a large pulp defect by bilateral neurorrhaphy. Plast Reconstr Surg. 2006, 118: 1185–93.
17.
LeupinPWeilJBüchlerU. The dorsal middle phalangeal finger flap Mid-term results of 43 cases. J Hand Surg Br. 1997, 22: 362–71.
18.
LinCHLinYTSassuPLinCHWeiFC. Functional assessment of the reconstructed fingertips after free toe pulp transfer. Plast Reconstr Surg. 2007, 120: 1315–21.
19.
LittlerJW. The neurovascular pedicle method of digital transposition for reconstruction of the thumb. Plast Reconstr Surg. 1953, 12: 303–19.
20.
LiuJZhengH. Free distal ulnar artery perforator flaps for the reconstruction of a volar defect in fingers. J Plast Reconstr Aesthet Surg. 2014, 67: 1557–63.
21.
MuyldermansTHiernerR. First dorsal metacarpal artery flap for thumb reconstruction: a retrospective clinical study. Strategies Trauma Limb Reconstr. 2009, 4: 27–33.
22.
NiFAppletonSEChenBWangB. Aesthetic and functional reconstruction of fingertip and pulp defects with pivot flaps. J Hand Surg Am. 2012, 37: 1806–11.
23.
NovakCBMackinnonSEWilliamsJIKellyL. Establishment of reliability in the evaluation of hand sensibility. Plast Reconstr Surg. 1993, 92: 311–22.
24.
PelzerMSauerbierMGermannGTränkleM. Free “kite” flap: a new flap for reconstruction of small hand defects. J Reconstr Microsurg. 2004, 20: 367–72.
25.
SanoKOzekiSKimuraKHyakusokuH. Relationship between sensory recovery and advancement distance of oblique triangular flap for fingertip reconstruction. J Hand Surg Am. 2008, 33: 1088–92.
26.
SatishCNemaS. First dorsal metacarpal artery islanded flap: A useful flap for reconstruction of thumb pulp defects. Indian J Plast Surg. 2009, 42: 32–5.
27.
SilvaJBPiresFKTeixeiraLF. The pulp switch flap: An option for the treatment of loss of the dominant half of the digital pulp. J Hand Surg Eur. 2013, 38: 948–51.
28.
SongDDengXChenYXieSZhouX. Thinned chimeric radial collateral artery perforator flap in complex distal thumb reconstruction. Arch Orthop Trauma Surg. 2015, 135: 1623–31.
29.
TanHLuoXYangKJiangJWeiPZhaoJ. Repair of minor tissue defect in hand by transfer of free tissue flap from the toe. Arch Bone Jt Surg. 2014, 2: 11–6.
30.
TangJBElliotDAdaniRSaint-CyrMStangF. Repair and reconstruction of thumb and finger tip injuries: a global view. Clin Plast Surg. 2014, 41: 325–59.
31.
TangJBGiddinsG. Why and how to report surgeons’ levels of expertise. J Hand Surg Eur. 2016, 41: 365–6.
32.
TelliogluA TSensözO. The dorsal branch of the digital nerve: an anatomic study and clinical applications. Ann Plast Surg. 1998, 40: 145–8.
33.
TeohLCTaySCYongFCTanSHKhooDB. Heterodigital arterialized flaps for large finger wounds: results and indications. Plast Reconstr Surg. 2003, 111: 1905–13.
34.
TeránPCarneroSMirandaRTrilloEEstefaníaM. Refinements in dorsoulnar flap of the thumb: 15 cases. J Hand Surg Am. 2010, 35: 1356–9.
35.
ThomaAVartijaLK. Making the VY advancement flap safer in fingertip amputations. Can J Plast Surg. 2010, 18: e47–9.
36.
WoonCYLeeJYTeohLC. Resurfacing hemipulp losses of the thumb: the cross finger flap revisited: indications, technical refinements, outcomes, and long-term neurosensory recovery. Ann Plast Surg. 2008, 61: 385–91.
37.
XarchasKCTilkeridisKEPelekasSIKazakosKJKakagiaDDVerettasDA. Littler’s flap revisited: an anatomic study, literature review, and clinical experience in the reconstruction of large thumb-pulp defects. Med Sci Monit. 2008, 14: 568–73.
38.
ZhangXShaoXRenCZhangZWenSSunJ. Reconstruction of thumb pulp defects using a modified kite flap. J Hand Surg Am. 2011, 36: 1597–603.
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