If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Skin defects on the finger tip, are commonly treated with skin grafts or flaps. Hidden areas are usually preferred as donor sites.
In this study, skin over the dorsal aspect of the base of the injured finger or another finger in the same area is used as a donor site. Since the donor area can be hidden beneath a ring, it was named as the ‘ring graft’. The skin elasticity over this area, allows a fairly large graft. This method was performed in defects of 27 patients involving 32 fingers. Donor sites were closed primarily without any tension.
Results on follow-ups of the patients were satisfactory concerning colour and texture match of the graft. We recommend the ‘ring graft’ as a hidden alternative donor site for resurfacing of a finger in selected cases.
It is important to preserve function and appearance during repair of skin defects on the hand and fingers treated with skin grafts. Ideal conditions for the donor site depend on skin colour, texture, durability, and size. Typical donor sites include the inguinal fold, peri-clavicular area, the peri-auricular area, the prepuce, the anterior axillary fold and the antecubital fossa.
In this paper we report a hidden donor site to resurface relatively small skin defects on the digits. The base of the injured finger, or other fingers are used as a graft donor site. Since, the donor site can be hidden beneath a ring, it was named the ‘ring graft’.
2. Materials and operative technique
Skin graft harvesting from the dorsal aspect of the base of the digits was performed from 32 fingers of 27 patients. The youngest patient was 15-year old and the oldest was 73 (mean age: 39) and the patient group consisting of 19 male and eight female patients (Table 1) . The defect was on the digital pulp in 11 cases, on the finger tip in 15 cases and on the dorsal surface of the distal finger in six cases (Fig. 1, Fig. 2) . The mean size of the skin defects was 17×17 mm and there was no exposed bone, joint, or tendon. This procedure was applied on seven granulating wound sites and on 25 fresh wounds.
Table 1Allocation of patients and their defect characteristics
Fig. 1(A) Showing peri-ungual pyogenic granuloma and the ring on the third finger. (B) The preparation of the ‘ring graft’ under penrose finger-tourniquet in the same region. (C) The skin defect on the dorsal aspect of the finger due to surgical excision is grafted with the ‘ring graft’, harvested from the same finger. (D) Early postoperative appearance of both surgical areas with satisfactory healing.
Fig. 2(A) The skin defect on the thrd finger of the right hand due to trauma. (B) The preparation of ‘ring graft’. (C) The site is grafted with the ‘ring graft’. (D) Early postoperative view of imperceptible scar of the donor area.
Operative technique. Under local anaesthesia, and with finger tourniquet, an appropriate area of skin was outlined elliptically on the dorsal aspect of the base of the finger (Fig. 1, Fig. 2). If the patient was using a ring on the injured finger, the same finger was used as the donor site. If the patient did not use a ring on the injured finger, the fourth finger (ring finger) was usually preferred. The largest graft was 40×13 mm in dimensions. The maximum length of the defects was 40 mm and the width was 21 mm. The graft was applied over the defect and covered with a tie-over dressing (Fig. 1, Fig. 2). Some grafts were used in two, three pieces in order to fit the defect. By carefully thinning the skin grafts taken from the hear-bearing areas, the hair roots were excised. The wound edges of the donor area were undermined, facilitating closure without any undue tension. The sutures were removed at postoperative eighth day.
3. Results
Follow-up has ranged between 6 and 18 months. All the patients had an unremarkable postoperative course and were discharged from hospital in the same day. There was no graft loss. The donor site was closed primarily, and the resulting scar was satisfactory in the early postoperative period (Fig. 1, Fig. 2). If local hyperemia or hypertrophy persists after postoperative 6 months, local steroid cream (Kenokort® triamcinolone asetonid for 2 months) was applied (Fig. 3(A)) . The patients were advised to use their rings (Fig. 3(B)) and the donor site was protected from the sun. All grafts were successfully adapted to the recipient site (Fig. 3(B) and (D)). One patient developed local infection of the donor area that required antibiotic treatment. In 9 months follow-up, the resulting scars of the donor sites were evaluated to be acceptable (Fig. 3(C)). The overall results indicate that this method to be quite successful and useful, especially in older patients using rings.
Fig. 3(A) Postoperative 9 month appearance of the acceptable scar on the base of the finger. (B) View of the finger at postoperative 9 months, showing healed peri-ungual area and hidden donor site by the ring. (C) Postoperative appearance of the donor area of third finger after 9 months. (D) Postoperative appearance of the grafted area after 9 months in the same finger.
The fundamental principle of reconstruction is to replace the lost tissue with similar tissue. The ideal donor site for full-thickness skin grafts to the nonhair-bearing areas of the fingers is the glabrous skin of other fingers. Various techniques for reconstruction of finger or finger tip defects have been described in the literature.
However, the quality of grafts from those previously described sites such as peri-auricular or inguinal folds are often inadequate for the hand and fingers.
In an attempt to avoid unsatisfactory results, use of several other donor sites has been advocated. Webster described a procedure using full-thickness skin grafts taken from the plantar area.
described the use of skin taken from ulnar aspect of the wrist.
The dorsal surface of the finger is an excellent donor site for skin graft coverage of defects on the fingers. The defect of the donor site is closed primarily, depending on the graft size and laxity of the skin. The use of these sites is usually restricted because of the limited amount of skin available and the donor site morbidity. The base of the finger (ring area) is limited by its size and usually can provide no more than 15–40 mm of tissue. Additionally, the fact that these sites can be quite hairy restricts the universal use of these grafts especially in males.
In our series, skin grafting was successfully applied in all patients, and satisfactory results were obtained. All scars on the donor site of the finger were acceptable. The colour and texture match, graft sensation, and functional ability were excellent. The injured site and the donor site being in the same operative field is another advantage of this method.
The fact that the donor area scar could be hidden beneath the ring is an advantage in selected cases. The suture line is protected both from the sun and from unintentional trauma, and silicone sheet may be used beneath the ring. Hairy skin on the dorsal proximal phalanx in some patients could be a problem for the finger tip.
We suggest that this donor area may be used in the treatment of skin wounds of the fingers, if the graft proves to be appropriate, in selected cases.
References
Cheng S.T
Wu C.S
Yu H.S
et al.
Surgical pearl: the first dorsal web of the hand as a graft donor site for the defects on the hand and digits.
00359-X&id=gr1.jpg){kind=link}
00359-X&id=gr2.jpg){kind=link}
00359-X&id=gr3.jpg){kind=link}