Anatomical Study and Clinical Application of the Pedicled Distal Palm Mini- kiss Flap

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Methods A total of 20 cadaveric hand specimens were dissected to classify three distinct neurovascular anatomical types. Between 2008 and 2024, 18 distal finger defects in patients were reconstructed with the sensate pedicled distal palm mini-kiss flap. Patient demographics, injury details, defect information, defect dimensions and anatomical location, sources of pedicle vessels, donor and recipient nerve branches used for innervation, as well as clinical outcomes during follow-up were recorded. Results Three anatomical neurovascular subtypes were found. The distances between the two cutaneous flap branches ranged from 4 to 10 mm. A total of 18 distal finger defects were reconstructed using 10 oblique flaps and 8 transverse pedicled distal palm mini-kiss flaps. The mean area of soft tissue defect was quantified at 5.76 ± 2.31cm 2 . Nerve coaptation was achieved in 16 cases. Donor sites had no major complications, and only 2 cases had small blisters measuring between 1-2mm that resulted in epidermolysis at the distal edge of the flaps. The average follow-up was 14 months, and the two-point discrimination tests indicated an average measurement of (5.9 ± 0.7) mm. Conclusion The pedicled distal palm mini-kiss flap has been proven to be an effective and safe option for reconstructing defects of the distal finger. The classification system and technical considerations enhance its potential for this reconstructive approach to achieve optimal functional and aesthetic outcomes. Type of study/ level of evidence Level IV, retrospective case series pedicled distal palm mini-kiss flap distal finger defects neurovascular anatomical types Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Volar finger defects are common in hand trauma and are typically associated with exposure of tendons or bones [ 1 ] . The optimal goals for the reconstruction of volar finger defects should encompass a painless, cosmetically acceptable, sensate distal fingertip with robust skin coverage [ 2 , 3 ] . Options for tissue coverage adhere to the traditional reconstructive ladder and include healing by secondary intention, split-thickness skin grafting, local-regional flaps, or free tissue transfer in a like-to-like manner [ 4 ] . In our experience, donor sites that provide small glabrous skin paddle yield favorable cosmetic outcomes and can present a robust reconstruction option characterized by like-to-like properties when coupled with innervation [ 5 ] . Previous studies utilizing small free flaps from the palmar surface of the hand demonstrate that glabrous skin flaps facilitate primary closure while offering durable wound coverage without compromising hand function when the donor site can be primarily closed [ 6 ] . The pedicled distal palm mini-kiss flap, a small, bilobed skin paddle design based on the “kiss flap” principle [ 7 ] , where adjacent flaps are perfused by a common digital neurovascular bundle, could be meticulously designed at the level of the distal palmar crease, situated distally to the palmar arch and in proximity to the origin of the common digital bundles [ 8 – 10 ] . The anatomical surgical surface markings are defined by the mid-palmar and proximal finger creases. This region exhibits excess and thickened skin, along with bulkier underlined subcutaneous fat pads, while having a sparse palmar aponeurosis. Notably, the common digital artery and the proper digital bundle as it travels towards the fingers give a very rich blood supply to the distal palmar fat pads and overlying skin. It has been reported that a substantial number of arterial cutaneous branches originating from the common and proper digital arteries, typically ranging from 5 to 8 branches, with diameters varying between 0.1 and 0.5 mm [ 9 , 11 ] . The branches contribute to the formation of a rich network within the distal fat pad network within the cutis, supplying the subdermal. Additionally, sensory cutaneous branches derived from the common digital nerve also follow these corresponding arteries. Their length varies from 10 to 20 mm, and their diameter is equivalent and consistent with that of the accompanying arteries (Fig. 1 ). The phalangeal arterial anatomy was investigated clinically to establish the anastomotic branches that facilitate consistent communications between the first and second phalangeal skin paddles [ 12 ] . In their study, Gellman H and Strauch B have demonstrated the regular and repetitive distribution of four dorsal branches originating from the paired digital arteries in each phalanx: condylar vessel, metaphyseal vessel, dorsal skin vessel, and transverse palmar arch. This finding confirmed the consistency of the three major palmar arches (proximal, middle, and distal transverse) and enhanced our understanding of the distribution and location of cutaneous arterial branches that provide the anatomical basis of this study design. The objective of this study is to further elucidate the anatomical foundation and clinical applications of the pedicled distal palm mini-kiss flap for reconstructing traumatic soft tissue defects in the distal finger. Materials and Methods This study utilizing donated cadavers was approved by the Ethics Committee of Affiliated Hospital of Chengde Medical University. All patients agreed to participate and gave their written informed consent. Cadaveric Dissections Distal palm mini kiss flap blood supply In this study, cadaveric hand specimens were prepared and infused with liquid latex ( blue for the veins and red for the arteries). The dissection procedure was conducted by the senior surgeons to document the intricate neurovascular anatomy of both common and proper digital bundles. The neural and arterial supplies, as well as the native anastomotic branches supplying the cutaneous tissue and pedicled distal palm mini-kiss flap skin paddle, were thoroughly documented and analyzed to establish anatomical categorization. Clinical Applications Patients’ selection Between 2008 and 2024, a total of 18 cases (12 males and 6 females) with a mean age of 36 years (range: 19–45) underwent distal finger reconstruction using the pedicled distal palm mini-kiss flap. Patient demographics, mechanism of injury, size and site of wound defect, presence of underlying bone or tendon exposure, flap size and type, as well as recipient vessels were meticulously recorded. Volar distal finger defects involving either bone or tendon exposure were observed in all 18 cases. Among these, 14 cases resulted from crush injuries, 2 cases from laceration injuries, and 2 cases from wringer injuries. Specifically, there were 11 index finger injuries, 4 middle finger injuries, and 3 ring finger injuries. All 18 cases involved distal phalanx injury, with 5 cases exhibiting combined middle and distal phalanx injuries. In 6 cases, there was an associated injury to the digital arteries, while transection of the digital nerve occurred in 16 cases. The mean area of soft tissue defect was measured at (5.76 ± 2.31) cm 2 . Immediate reconstruction was performed in 11 cases, whereas 7 cases required semi-emergency admissions (Table 1 ). All the flaps were pedicled distal palm mini kiss flaps designed on the far side of the palm, and the digital artery was used as the pedicle for retrograde transfer repair. There were 10 oblique flaps and 8 transverse flaps. Overall, the digital nerve at the stump of the finger wound was anastomosed with the cutaneous branch nerve of the retrograde flap in 16 cases. All donor sites were primarily closed, and the average duration of the operation was about 1 hours. No instances of partial or complete flap failures were observed. In 2 cases, blisters measuring 1-2mm resulted in epidermolysis at the distal edge of the flaps, which healed without further intervention (Table 2 ). Complications and functional outcomes were also documented during long-term follow-up. Table 1 Clinical applications of pedicled distal palm mini kiss flaps No Age (Years)(Sex) Etiology Injury Size of Defect (L x W) (mm) Nerve coaptation 1 22M Crushing LMF P3 35 × 22 Yes 2 21M Crushing RMF P3 22 × 15 No 3 28M Laceration LIF P3 23 × 17 Yes 4 45M Crushing RRF P2 - P3 43 × 23 No 5 19F Wringer crash RIF P2 - P3 35 × 21 Yes 6 20F Crushing LIF P3 29 × 15 Yes 7 31M Crushing RMF P2 + P3 42 × 23 Yes 8 22M Wringer crash RIF P3 26 × 16 Yes 9 21F Crushing LRF P3 27 × 15 Yes 10 30M Crushing LRF P3 22 × 16 Yes 11 22F Laceration RIF P2 + P3 35 × 21 Yes 12 30F Crushing RIF P3 28 ×18 Yes 13 27F Crushing RIF P2 + P3 38 × 22 Yes 14 30M Crushing RIF P3 30 × 15 Yes 15 22M Crushing LIF P3 24 × 15 Yes 16 29M Crushing LMF P3 + P3 40 × 20 Yes 17 25M Crushing LIF P3 27 × 17 Yes 18 24M Crushing LIF P3 28 × 16 Yes M, male; F, female; LMF, Left middle finger; RMF, Right middle finger; LIF, Left index finger; RRF, Right ring finger; RIF, Right index finger; LRF, Left ring finger; P1, Proximal phalanx; P2, Middle Phalanx; P3, Distal phalanx Table 2 Flap survival, Complications and Clinical Outcomes at follow-up Outpatient Appointment No. Flap survival Complication Flap type S-2PD Test (mm) Follow-up (months) 1 Complete — II 7.1 8 2 Complete Blister II 5.2 48 3 Complete — I 5.5 9 4 Complete — IIIa 6.0 15 5 Complete — I 7.3 20 6 Complete Blister IIIb 5.5 11 7 Complete — I 5.9 10 8 Complete — II 6.1 10 9 Complete — I 5.2 14 10 Complete — I 5.3 20 11 Complete — II 5.3 11 12 13 Complete Complete — — I I 7.0 5.3 12 16 14 Complete — I 6.5 12 15 Complete — II 5.4 12 16 Complete — IIIa 6.2 12 17 Complete — II 5.8 6 18 Complete — IIIa 5.6 6 S-2PD Test, Sensory-2 Point discrimination ; Type I, reverse homodigital pedicled flap ; Type II flap cutaneous branches arise either radial or ulnar digital arteries distal to the level of the bifurcation of the common digital artery ; Type III (a&b), at least one of the branches arise proximal to the bifurcation of the common digital arter. Preoperative planning Preoperatively, the distal palm donor area was examined for any previous scars or history of traumatic injuries. The Allen test was conducted to clinically evaluate the adequacy of the communicating anastomosis of the digital artery on both sides of the injured finger. Hand-held Doppler ultrasound was used to locate the proper digital artery and the cutaneous branch of the donor site, because the recognition of the skin branch and axial blood vessel signals by hand-held Doppler depends on the pattern of the spectrum and the change of the sound, and the difference is obvious. Regional anesthetic via brachial plexus block or peripheral nerve block was administered in all cases. Surgical Technique The pedicled distal palm mini-Kiss flap was based on the ipsilateral digital artery supplying the finger defect. Thorough debridement, washout, and assessment of the extent of the soft tissue injury were performed under pneumatic tourniquet ischemia to facilitate exposure of deeper structures. The digital nerve or terminal nerve branches within the wound defect were identified and marked with an 8/0 or 9/0 Nylon micro-suture. The location and dimensions of the wound defect were documented to assist in designing either a 3:1 or 4:1 elliptical oblique flap between the mid-palmar and the proximal finger crease. The skin over the pedicle was incised with a curvilinear incision (avoiding the risk of skin necrosis at the angles associated with Z-plasty while reducing the technical difficulty of wound closure compared to straight-line incisions), and the digital artery on the ipsilateral side of the defect was dissected under microscopic magnification to serve as the vascular pedicle for the mini-kiss flap. The pedicled digital artery was sharply and bluntly dissected while maintaining the surrounding distal palmar fat pad around it to ensure the preservation of microscopic dermal branches supplying the mini-kiss flap skin paddles. Larger arterial branches identified in proximity to the fat pad or flap paddles were conserved. The cutaneous sensory nerve branch, located at the level of the common digital nerve, was preserved as it entered the underlying flap fat pad. The most distal pedicle pivot point for rotation of the pedicle was consistently positioned at the level of the finger’s middle crease. Once isolated, the tourniquet pressure was released to establish satisfactory dermal physiological bleeding from the flap. The feasibility of distal perfusion was assessed by applying a micro-clamp to the proximal pedicle, followed by ligation of the proximal digital artery. In cases where anatomy necessitates the transection of the common digital artery, a proximal-to-distal end-to-end arterial micro-anastomosis must be performed. Excess adipose tissue at the flap edges is primarily thinned under higher microscopic magnification (x15-25), while ensuring preservation of flap blood supply. Clockwise or counterclockwise rotation of the islanded pedicled flap in a 90°fashion allows for tension-free inset. The sensory cutaneous nerve and digital nerve in the flap were anastomosed. Flap inset is facilitated using tension-free absorbable interrupted sutures. Postoperative management Hospitalization averaged about 5 days. Thus, during the inpatient period, color and capillary refill time were conducted for the first 48 hours (at least once per hour), followed by bi-hourly observations for the subsequent 3 days to ensure the flap survival. If vascular compromise occurs within 48 hours, the sutures will be removed and vasodilators will be administered concurrently to alleviate the condition. Additionally, early hand physiotherapy was initiated on day 7 post-procedure (therapeutic and rehabilitative protocols were maintained throughout scheduled outpatient follow-ups), and topical silicone gel massage was applied on the scar twice daily following complete wound healing. Three weeks post-operation, sensory training was implemented by referring to the Dellon and Jabaley method [ 13 ] . Results Cadaveric dissection The dissection of 20 cadaveric hand specimens revealed that the intricate neurovascular anatomy of the common and proper digital bundles highlights consistent patterns in the neural and arterial supply to the cutaneous tissue. A comprehensive classification of three anatomical neurovascular types was documented (Types I-III), as illustrated in Fig. 2 . The distances between the two cutaneous flap branches ranged from 4 to 10 millimeters. Minimal arteriolysis, not more than 10 millimeters proximal and distal to the transected bifurcation of the common digital artery, allowed tension-free approximation of the arterial stumps when resection of the junction was necessary (types II and III). Type I anatomy avoided such resection requirements. Classification of distal palm mini kiss flap neurovascular anatomy The three anatomical neurovascular sub-types identified in this study are as follows: Type I (8 cases) – the flap cutaneous branches arise from both the homodigital artery of the injured finger (reverse homodigital flap). Type II (6 cases) – the flap cutaneous branches arise from either radial or ulnar digital arteries distal to the level of the bifurcation of the common digital artery. Type III (a: b – 3:1 cases) – the flap cutaneous branches are categorized as follows: (a) one distal (ulnar) and one proximal, and (b) one distal (radial) and one proximal, originating from the level of bifurcation of the common digital artery. Several additional branches emerge directly or more proximally to this bifurcation of the common digital artery at the level of the distal palmar crease; however, these would not be routinely utilized for supplying the mini-kiss flaps (Fig. 2 ). Clinical applications All 18 cases had an average follow-up duration of 14 months (range: 6–48 months) with complete flap survival. All flaps and donor sites demonstrated successful healing at the time of follow-up. Sensory recovery of the flap reached S3+, and the two-point discrimination test yielded a mean value of (5.9 ± 0.7) mm. Referring to the evaluation standards for total active range of motion/passive range of motion in joints, excellent outcomes were achieved in all cases [ 14 ] . A representative case is illustrated in Figs. 3 and 4 . A 30-year-old male sustained a right index finger (RIF) pulp crushing injury. The wound defect was sized 2cm×3cm, infected, and associated with nail injury and partial loss of nail bed matrix. Under brachial plexus anaesthesia, the pedicled distal palm mini kiss flap (Type I) of the right index finger was transferred and combined to repair the defect of the finger pulp. During the operation, the digital artery was used as the pedicle for retrograde repair, and the sensory nerve in the flap was anastomosed with the digital nerve on both sides. The donor area was sutured directly. The flap survived, and the donor and recipient wound areas healed in the first stage. Two-point discrimination of the flap was 6.5mm. The evaluation standard of the total active range of motion / passive range of motion of the injured finger joint was superior. Discussion Reconstruction of distal finger soft tissue defects remains a formidable challenge due to the imperative for optimal functional and aesthetic outcomes [ 15 ] . This surgical scheme breaks through the traditional concept of fingertip defect repair and innovatively proposes a new flap donor site scheme, which provides a new idea for clinical treatment of fingertip defects. While secondary intention healing remains an important standard for simple fingertip injuries, our cohort specifically addressed defects with exposed tendons or bones where flap coverage is bio-mechanically superior. Evidence demonstrated that secondary intention achieves (5.2 ± 1.1) mm 2PD in pulp defects without bone exposure, comparable to our flap results (5.9 ± 0.7) mm [ 16 ] . However, in cases with structural exposure (e.g., crushing injuries), flap reconstruction reduced median time to wound closure from 6 weeks (secondary intention) to 2 weeks in our series, enabling earlier rehabilitation [ 17 , 18 ] . Future randomized trials should directly compare these modalities in matched defect types. The skin tissue in the distal palm region presents numerous advantages as an ideal donor site for repairing palmar-side soft tissue defects. However, due to its pivotal functional role in hand mechanics, the palm is typically excluded as a viable option for vascular pedicle flap transfer. This study elucidates the anatomical basis and clinical applications of the pedicled distal palm mini-kiss flap as the preferred approach for reconstructing traumatic distal finger soft tissue defects. Three anatomical neurovascular subtypes of the pedicled distal palm mini-kiss flap (Figs. 2 ) have been identified based on the anatomical location of the flap’s cutaneous branches relative to the bifurcation of the common digital artery. This flap offers several potential advantages, including excellent skin texture, reliable blood supply, customizable shape design, and potential restoration of sensation in the recipient area. Primary suturing is recommended for donor site closure without requiring skin grafting. Microvascular anastomosis is required when harvesting flaps that involve the transection of the common digital artery (Types II and III ). Furthermore, for larger skin paddles, tight closure at the level of the distal palmar may affect flexion and extension of metacarpophalangeal joints, necessitating early physiotherapy immediately following complete wound healing. Several reconstructive modalities and flaps indicated for similar defects described in this case series, however, fail to achieve satisfactory results due to potential risks associated with the donor site or the suboptimal, like-to-like nature of the skin flap. The pedicled distal palm mini-kiss flap adheres to the principles of homo-digital flap reconstructions. Despite being designed on the main digital artery proximal to the wound defect, this technique has proven reliable and robust in clinical practice. Han et al. reported that scar contractures are commonly observed at the donor site of reverse digital artery flaps following split or full-thickness skin grafting, which can significantly impact overall outcomes to varying degrees [ 19 , 20 ] . Similarly, reports have noted the use of digital artery perforator flaps or fascia-pedicled flaps where the main digital pedicle was not harvested [ 21 ] ; however, based on our experience, we found that the donor site is inferior to distal palm primary wound closure, as in extremes it may expose segments of the digital pedicle or nerve and even cause finger contracture and hyper-pigmentation [ 22–24 ] . Although pedicled flaps based on the lateral cutaneous branch of the digital artery do not compromise the integrity of the digital artery, there is a higher likelihood of requiring skin grafting in the donor area of these flaps [ 25 ] . Moreover, alternative traditional island pedicled flaps with digital artery for reconstruction of homo-digital soft tissue defects, also do not harvest the digital artery; however, their applicability is limited to more proximal defects and may necessitate skin grafting when used distally. Since Zancolli et al. [ 26 ] reported on the digital artery distal palmar skin island flap for finger pulp defect reconstruction, controversies have arisen regarding lumbrical muscle exposure as well as pedicle and nerve exposure at the donor site, even with a skin graft, which has diminished the favorability of this flap [ 27 ] . In an attempt to minimize complications at the donor site, a modification involving advancement of the flap with a wavy incision was proposed [ 28 , 29 ] . However, subsequent experiences have rendered this reconstructive option less favorable unless the wound defect size permits primary closure without tension while preserving hand function and optimizing the final scar outcome. The pedicled distal palm mini-kiss flap can be reliably transferred and tailored to meet the specific requirements, facilitating the repair of wounds with diverse shapes. Primary closure of the donor area in the initial stage ensures optimal functional and aesthetic outcomes for the fingertip or palmar finger defects while minimally impacting the functionality of the injured palm-finger donor area. This technique is suitable for reconstructing volar soft tissue defects of the fingertip or loss of volar skin on fingers. Moreover, it can be utilized retrogradely to address skin defects in the mid-palmar region, particularly when multiple defects are present. We propose that the mini distal kiss flap represents a more appropriate option for isolated injuries distal to the middle phalanx, as it generally preserves the common digital artery; furthermore, it serves as an efficient surgical approach for patients with systemic contraindications to free flap reconstructions involving plantar skin from toes or feet. This study has several limitations. Preoperatively, the Allen test must be performed on both the affected digit and the adjacent digit to assess collateral circulation, as the procedure may compromise one digital artery in either finger, potentially increasing the risk of ischemic necrosis. Furthermore, the extensive surgical field inevitably involves dissection across the metacarpophalangeal and interphalangeal joints, which carries a potential risk of scar contracture and subsequent limitation of joint mobility. Additionally, if transection of the common digital artery is required, vascular graft reconstruction becomes necessary, thereby increasing the procedural complexity. Abbreviations LIF Left index finger LRF Left ring finger LMF Left middle finger NCB Nerve cutaneous branches PPDA Proximal proper digital artery RIF Right index finger RRF Right ring finger RMF Right middle finger S-2PD Sensory two-point discrimination Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of Affiliated Hospital of Chengde Medical University (CYFYLL2024081). The research reported in this paper was performed in compliance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Writen informed consent was obtained from the immediate family members of the deceased for educational and scientifc research purposes. Consent for publication Each of the authors have approved the contents of this paper and have agreed to the journal's submission policies. Competing Interest The authors declare no conflict of interest. Acknoledgments The authors acknowledged the patient in this report for permitting us to present his clinical information. Funding This study was supported by: the Medical Science Research Project of Hebei Provincial Health Commission (20240811 and 20241909). Author Contribution Yunfeng Gao(YFG) wrote the main manuscript text. YFG and Youmao Zheng(YMZ) prepared for all the figures. YMZ and YFG were responsible for editing and reviewing the manuscript. and all authors have read and approved the final manuscript. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Abdellatif HA, El Aziz Maaly MA, Soltan BSHI, Abduallah MS. Role of magnetic resonance imaging on fingers in diagnosis of post-traumatic tendon and ligament injuries. Egypt J Radiol Nuclear Med. 2021;52(1):279. Kawakatsu M. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8190600","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":567194987,"identity":"5adc6444-2648-4b47-a289-416e50d5719a","order_by":0,"name":"Yunfeng Gao","email":"","orcid":"","institution":"the Affiliated Hospital of Chengde Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yunfeng","middleName":"","lastName":"Gao","suffix":""},{"id":567194988,"identity":"8f264e3e-14f3-4e96-bd71-b24fd3296c7c","order_by":1,"name":"Youmao Zheng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIiWNgGAWjYDACCQST8TGETiBeC7MxyVrYpInSIj+7+djDr202iWvbDx+rLsyxY+BnzzFg+LkDtxbGOcfSjWXb0hK3nUlLuz1zWzKDZM8bA8beM7i1MEvkmElLth1O3HYgx+w277YDDAY3cgyYGdtwa2GTyP8G0XL+jVkxSIs9IS08Ejlskh9BWm7kmDGDbZEgoEVCIs1MmuFcmvG2G8+SpXm3JfNInHlWcLAXjxb5GcnPJH+U2chuO5988DPvNjs5/vbkjQ9+4tECDgJeNiSXgogD+DUAA/rHH0JKRsEoGAWjYEQDAE9wT5YvlbkeAAAAAElFTkSuQmCC","orcid":"","institution":"Zhejiang Provincial People's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Youmao","middleName":"","lastName":"Zheng","suffix":""}],"badges":[],"createdAt":"2025-11-24 07:53:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8190600/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8190600/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":99287282,"identity":"b608af5c-3af2-4bc2-b672-3c7c9623a875","added_by":"auto","created_at":"2025-12-31 09:35:55","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":4751109,"visible":true,"origin":"","legend":"","description":"","filename":"manuscriptBMCSURGERY.docx","url":"https://assets-eu.researchsquare.com/files/rs-8190600/v1/43aee511683c823fe50fd3d1.docx"},{"id":99287278,"identity":"d80b0fde-8fb7-423c-a3ef-5576323574e4","added_by":"auto","created_at":"2025-12-31 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09:35:55","extension":"xml","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":92807,"visible":true,"origin":"","legend":"","description":"","filename":"311ae031f8d247ff8d66a348d4c27ff01structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8190600/v1/b54c1b26b0cf332807568144.xml"},{"id":99320225,"identity":"75a09052-2e9c-4628-af90-b1dd48a97556","added_by":"auto","created_at":"2025-12-31 16:38:24","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":104492,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8190600/v1/488b449cff5765a02b254289.html"},{"id":99321290,"identity":"5aaa169c-b93c-40d4-bcc9-383d502f7049","added_by":"auto","created_at":"2025-12-31 16:39:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":572923,"visible":true,"origin":"","legend":"\u003cp\u003eArterial anastomosing network of the distal palm area [cadaveric hand specimen infused with red (artery) and blue (vein) liquid latex].\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8190600/v1/f59b51b7ea89c6c8a30fe9c1.png"},{"id":99287275,"identity":"30d147de-33f7-4772-bd2c-8e21f016fa06","added_by":"auto","created_at":"2025-12-31 09:35:54","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":961790,"visible":true,"origin":"","legend":"\u003cp\u003eThe three anatomical neurovascular sub-types for the mini kiss flap design: Type I: the flap cutaneous branches arise both from the homodigital artery of the injured finger, Type II: the flap cutaneous branches arise from either radial or ulnar digital arteries distal to the level of the bifurcation of the common digital artery, and Type III: the flap cutaneous branches arise from a dual blood supply comprising both digital arteries and the common digital artery, and are further subdivided into two subtypes: (a) One distal branch (from the ipsilateral digital artery of the injured finger) and the common digital artery. (b) One distal branch (from the contralateral digital artery) and the common digital artery.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8190600/v1/f79b6a478fbb3b9976426c6f.png"},{"id":99320751,"identity":"43e60fa8-602d-4bec-a250-3a728e78042e","added_by":"auto","created_at":"2025-12-31 16:38:53","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":506740,"visible":true,"origin":"","legend":"\u003cp\u003eA 30-year-old male with a right index finger pulp crushing injury:\u003c/p\u003e\n\u003cp\u003e(A) Crushing injury of the right index finger; exploration, debridement, assessment, and design of a mini Kiss flap\u003c/p\u003e\n\u003cp\u003e(B) Flap elevation;\u003c/p\u003e\n\u003cp\u003e(C\u0026amp;D) Flap elevation, Proximal Proper Digital Artery (PPDA) dissection, and Nerve Cutaneous Branches (NCB) dissected and identified;\u003c/p\u003e\n\u003cp\u003e(E) Donor site primary closure and flap inset.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8190600/v1/72ae13e478e222b1762179d2.png"},{"id":99287276,"identity":"761cb40c-fe27-42f5-a735-56988bf9491b","added_by":"auto","created_at":"2025-12-31 09:35:54","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":259163,"visible":true,"origin":"","legend":"\u003cp\u003ePost-operative clinical outcome at 12 months (volar, lateral, and dorsal view)\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8190600/v1/3e121f4cf06926c9e8ae0e2e.png"},{"id":99788347,"identity":"d906b28d-8967-4bce-923a-332a135371a6","added_by":"auto","created_at":"2026-01-08 12:46:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3968832,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8190600/v1/1ab902fd-2766-4123-8ab5-39c340d04ff0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Anatomical Study and Clinical Application of the Pedicled Distal Palm Mini- kiss Flap","fulltext":[{"header":"Introduction","content":"\u003cp\u003eVolar finger defects are common in hand trauma and are typically associated with exposure of tendons or bones\u003csup\u003e[\u003c/sup\u003e1\u003csup\u003e]\u003c/sup\u003e. The optimal goals for the reconstruction of volar finger defects should encompass a painless, cosmetically acceptable, sensate distal fingertip with robust skin coverage\u003csup\u003e[\u003c/sup\u003e2\u003csup\u003e,\u003c/sup\u003e 3\u003csup\u003e]\u003c/sup\u003e. Options for tissue coverage adhere to the traditional reconstructive ladder and include healing by secondary intention, split-thickness skin grafting, local-regional flaps, or free tissue transfer in a like-to-like manner\u003csup\u003e[\u003c/sup\u003e4\u003csup\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn our experience, donor sites that provide small glabrous skin paddle yield favorable cosmetic outcomes and can present a robust reconstruction option characterized by like-to-like properties when coupled with innervation\u003csup\u003e[\u003c/sup\u003e5\u003csup\u003e]\u003c/sup\u003e. Previous studies utilizing small free flaps from the palmar surface of the hand demonstrate that glabrous skin flaps facilitate primary closure while offering durable wound coverage without compromising hand function when the donor site can be primarily closed\u003csup\u003e[\u003c/sup\u003e6\u003csup\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe pedicled distal palm mini-kiss flap, a small, bilobed skin paddle design based on the \u0026ldquo;kiss flap\u0026rdquo; principle\u003csup\u003e[\u003c/sup\u003e7\u003csup\u003e]\u003c/sup\u003e, where adjacent flaps are perfused by a common digital neurovascular bundle, could be meticulously designed at the level of the distal palmar crease, situated distally to the palmar arch and in proximity to the origin of the common digital bundles\u003csup\u003e[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. The anatomical surgical surface markings are defined by the mid-palmar and proximal finger creases. This region exhibits excess and thickened skin, along with bulkier underlined subcutaneous fat pads, while having a sparse palmar aponeurosis. Notably, the common digital artery and the proper digital bundle as it travels towards the fingers give a very rich blood supply to the distal palmar fat pads and overlying skin. It has been reported that a substantial number of arterial cutaneous branches originating from the common and proper digital arteries, typically ranging from 5 to 8 branches, with diameters varying between 0.1 and 0.5 mm\u003csup\u003e[\u003c/sup\u003e9\u003csup\u003e,\u003c/sup\u003e 11\u003csup\u003e]\u003c/sup\u003e. The branches contribute to the formation of a rich network within the distal fat pad network within the cutis, supplying the subdermal. Additionally, sensory cutaneous branches derived from the common digital nerve also follow these corresponding arteries. Their length varies from 10 to 20 mm, and their diameter is equivalent and consistent with that of the accompanying arteries (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe phalangeal arterial anatomy was investigated clinically to establish the anastomotic branches that facilitate consistent communications between the first and second phalangeal skin paddles\u003csup\u003e[\u003c/sup\u003e12\u003csup\u003e]\u003c/sup\u003e. In their study, Gellman H and Strauch B have demonstrated the regular and repetitive distribution of four dorsal branches originating from the paired digital arteries in each phalanx: condylar vessel, metaphyseal vessel, dorsal skin vessel, and transverse palmar arch. This finding confirmed the consistency of the three major palmar arches (proximal, middle, and distal transverse) and enhanced our understanding of the distribution and location of cutaneous arterial branches that provide the anatomical basis of this study design.\u003c/p\u003e \u003cp\u003eThe objective of this study is to further elucidate the anatomical foundation and clinical applications of the pedicled distal palm mini-kiss flap for reconstructing traumatic soft tissue defects in the distal finger.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e This study utilizing donated cadavers was approved by the Ethics Committee of Affiliated Hospital of Chengde Medical University. All patients agreed to participate and gave their written informed consent.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eCadaveric Dissections\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eDistal palm mini kiss flap blood supply\u003c/h2\u003e \u003cp\u003eIn this study, cadaveric hand specimens were prepared and infused with liquid latex (\u003cem\u003eblue\u003c/em\u003e for the veins and \u003cem\u003ered\u003c/em\u003e for the arteries). The dissection procedure was conducted by the senior surgeons to document the intricate neurovascular anatomy of both common and proper digital bundles. The neural and arterial supplies, as well as the native anastomotic branches supplying the cutaneous tissue and pedicled distal palm mini-kiss flap skin paddle, were thoroughly documented and analyzed to establish anatomical categorization.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eClinical Applications\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u0026rsquo; selection\u003c/h2\u003e \u003cp\u003eBetween 2008 and 2024, a total of 18 cases (12 males and 6 females) with a mean age of 36 years (range: 19\u0026ndash;45) underwent distal finger reconstruction using the pedicled distal palm mini-kiss flap. Patient demographics, mechanism of injury, size and site of wound defect, presence of underlying bone or tendon exposure, flap size and type, as well as recipient vessels were meticulously recorded.\u003c/p\u003e \u003cp\u003eVolar distal finger defects involving either bone or tendon exposure were observed in all 18 cases. Among these, 14 cases resulted from crush injuries, 2 cases from laceration injuries, and 2 cases from wringer injuries. Specifically, there were 11 index finger injuries, 4 middle finger injuries, and 3 ring finger injuries. All 18 cases involved distal phalanx injury, with 5 cases exhibiting combined middle and distal phalanx injuries. In 6 cases, there was an associated injury to the digital arteries, while transection of the digital nerve occurred in 16 cases. The mean area of soft tissue defect was measured at (5.76\u0026thinsp;\u0026plusmn;\u0026thinsp;2.31) cm\u003csup\u003e2\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eImmediate reconstruction was performed in 11 cases, whereas 7 cases required semi-emergency admissions (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). All the flaps were pedicled distal palm mini kiss flaps designed on the far side of the palm, and the digital artery was used as the pedicle for retrograde transfer repair. There were 10 oblique flaps and 8 transverse flaps. Overall, the digital nerve at the stump of the finger wound was anastomosed with the cutaneous branch nerve of the retrograde flap in 16 cases. All donor sites were primarily closed, and the average duration of the operation was about 1 hours. No instances of partial or complete flap failures were observed. In 2 cases, blisters measuring 1-2mm resulted in epidermolysis at the distal edge of the flaps, which healed without further intervention (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Complications and functional outcomes were also documented during long-term follow-up.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical applications of pedicled distal palm mini kiss flaps\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026times;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003e(Years)(Sex)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEtiology\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInjury\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSize of Defect\u003c/p\u003e \u003cp\u003e(L x W) (mm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNerve coaptation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrushing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLMF P3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e35 \u0026times; 22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrushing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRMF P3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e22 \u0026times; 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLaceration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLIF P3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e23 \u0026times; 17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrushing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRRF P2 - P3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e43 \u0026times; 23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19F\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWringer crash\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRIF P2 - P3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e35 \u0026times; 21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20F\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrushing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLIF P3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e29 \u0026times; 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrushing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRMF P2\u0026thinsp;+\u0026thinsp;P3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e42 \u0026times; 23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWringer crash\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRIF P3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e26 \u0026times; 16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21F\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrushing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLRF P3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e27 \u0026times; 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e10\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrushing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLRF P3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e22 \u0026times; 16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e11\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22F\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLaceration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRIF P2\u0026thinsp;+\u0026thinsp;P3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e35 \u0026times; 21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e12\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30F\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrushing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRIF P3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e28 \u0026times;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e13\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27F\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrushing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRIF P2\u0026thinsp;+\u0026thinsp;P3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e38 \u0026times; 22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e14\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrushing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRIF P3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e30 \u0026times; 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e15\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrushing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLIF P3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e24 \u0026times; 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e16\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrushing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLMF P3\u0026thinsp;+\u0026thinsp;P3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e40 \u0026times; 20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e17\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrushing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLIF P3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e27 \u0026times; 17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e18\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrushing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLIF P3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e28 \u0026times; 16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eM, male; F, female; LMF, Left middle finger; RMF, Right middle finger; LIF, Left index finger; RRF, Right ring finger; RIF, Right index finger; LRF, Left ring finger; P1, Proximal phalanx; P2, Middle Phalanx; P3, Distal phalanx\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFlap survival, Complications and Clinical Outcomes at follow-up Outpatient Appointment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFlap\u003c/p\u003e \u003cp\u003esurvival\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComplication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFlap type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eS-2PD\u003c/p\u003e \u003cp\u003eTest (mm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFollow-up\u003c/p\u003e \u003cp\u003e(months)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBlister\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIIIa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBlister\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIIIb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e10\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e11\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e12\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e13\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI\u003c/p\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e14\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e15\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e16\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIIIa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e17\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e18\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIIIa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eS-2PD Test, Sensory-2 Point discrimination ; Type I, reverse homodigital pedicled flap ; Type II flap cutaneous branches arise either radial or ulnar digital arteries distal to the level of the bifurcation of the common digital artery ; Type III (a\u0026amp;b), at least one of the branches arise proximal to the bifurcation of the common digital arter.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePreoperative planning\u003c/h3\u003e\n\u003cp\u003ePreoperatively, the distal palm donor area was examined for any previous scars or history of traumatic injuries. The Allen test was conducted to clinically evaluate the adequacy of the communicating anastomosis of the digital artery on both sides of the injured finger. Hand-held Doppler ultrasound was used to locate the proper digital artery and the cutaneous branch of the donor site, because the recognition of the skin branch and axial blood vessel signals by hand-held Doppler depends on the pattern of the spectrum and the change of the sound, and the difference is obvious. Regional anesthetic via brachial plexus block or peripheral nerve block was administered in all cases.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSurgical Technique\u003c/h2\u003e \u003cp\u003eThe pedicled distal palm mini-Kiss flap was based on the ipsilateral digital artery supplying the finger defect. Thorough debridement, washout, and assessment of the extent of the soft tissue injury were performed under pneumatic tourniquet ischemia to facilitate exposure of deeper structures. The digital nerve or terminal nerve branches within the wound defect were identified and marked with an 8/0 or 9/0 Nylon micro-suture. The location and dimensions of the wound defect were documented to assist in designing either a 3:1 or 4:1 elliptical oblique flap between the mid-palmar and the proximal finger crease. The skin over the pedicle was incised with a curvilinear incision (avoiding the risk of skin necrosis at the angles associated with Z-plasty while reducing the technical difficulty of wound closure compared to straight-line incisions), and the digital artery on the ipsilateral side of the defect was dissected under microscopic magnification to serve as the vascular pedicle for the mini-kiss flap. The pedicled digital artery was sharply and bluntly dissected while maintaining the surrounding distal palmar fat pad around it to ensure the preservation of microscopic dermal branches supplying the mini-kiss flap skin paddles. Larger arterial branches identified in proximity to the fat pad or flap paddles were conserved. The cutaneous sensory nerve branch, located at the level of the common digital nerve, was preserved as it entered the underlying flap fat pad. The most distal pedicle pivot point for rotation of the pedicle was consistently positioned at the level of the finger\u0026rsquo;s middle crease. Once isolated, the tourniquet pressure was released to establish satisfactory dermal physiological bleeding from the flap.\u003c/p\u003e \u003cp\u003eThe feasibility of distal perfusion was assessed by applying a micro-clamp to the proximal pedicle, followed by ligation of the proximal digital artery. In cases where anatomy necessitates the transection of the common digital artery, a proximal-to-distal end-to-end arterial micro-anastomosis must be performed. Excess adipose tissue at the flap edges is primarily thinned under higher microscopic magnification (x15-25), while ensuring preservation of flap blood supply. Clockwise or counterclockwise rotation of the islanded pedicled flap in a 90\u0026deg;fashion allows for tension-free inset. The sensory cutaneous nerve and digital nerve in the flap were anastomosed. Flap inset is facilitated using tension-free absorbable interrupted sutures.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePostoperative management\u003c/h3\u003e\n\u003cp\u003eHospitalization averaged about 5 days. Thus, during the inpatient period, color and capillary refill time were conducted for the first 48 hours (at least once per hour), followed by bi-hourly observations for the subsequent 3 days to ensure the flap survival. If vascular compromise occurs within 48 hours, the sutures will be removed and vasodilators will be administered concurrently to alleviate the condition. Additionally, early hand physiotherapy was initiated on day 7 post-procedure (therapeutic and rehabilitative protocols were maintained throughout scheduled outpatient follow-ups), and topical silicone gel massage was applied on the scar twice daily following complete wound healing. Three weeks post-operation, sensory training was implemented by referring to the Dellon and Jabaley method \u003csup\u003e[\u003c/sup\u003e13\u003csup\u003e]\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n\u003ch2\u003eCadaveric dissection\u003c/h2\u003e\n\u003cp\u003eThe dissection of 20 cadaveric hand specimens revealed that the intricate neurovascular anatomy of the common and proper digital bundles highlights consistent patterns in the neural and arterial supply to the cutaneous tissue. A comprehensive classification of three anatomical neurovascular types was documented (Types I-III), as illustrated in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003eThe distances between the two cutaneous flap branches ranged from 4 to 10 millimeters. Minimal arteriolysis, not more than 10 millimeters proximal and distal to the transected bifurcation of the common digital artery, allowed tension-free approximation of the arterial stumps when resection of the junction was necessary (types II and III). Type I anatomy avoided such resection requirements.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n\u003ch2\u003eClassification of distal palm mini kiss flap neurovascular anatomy\u003c/h2\u003e\n\u003cp\u003eThe three anatomical neurovascular sub-types identified in this study are as follows: \u003cem\u003eType I\u003c/em\u003e (8 cases) \u0026ndash; the flap cutaneous branches arise from both the homodigital artery of the injured finger (reverse homodigital flap). \u003cem\u003eType II\u003c/em\u003e (6 cases) \u0026ndash; the flap cutaneous branches arise from either radial or ulnar digital arteries distal to the level of the bifurcation of the common digital artery. \u003cem\u003eType III\u003c/em\u003e (a: b \u0026ndash; 3:1 cases) \u0026ndash; the flap cutaneous branches are categorized as follows: (a) one distal (ulnar) and one proximal, and (b) one distal (radial) and one proximal, originating from the level of bifurcation of the common digital artery. Several additional branches emerge directly or more proximally to this bifurcation of the common digital artery at the level of the distal palmar crease; however, these would not be routinely utilized for supplying the mini-kiss flaps (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n\u003ch2\u003eClinical applications\u003c/h2\u003e\n\u003cp\u003eAll 18 cases had an average follow-up duration of 14 months (range: 6\u0026ndash;48 months) with complete flap survival. All flaps and donor sites demonstrated successful healing at the time of follow-up. Sensory recovery of the flap reached S3+, and the two-point discrimination test yielded a mean value of (5.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7) mm. Referring to the evaluation standards for total active range of motion/passive range of motion in joints, excellent outcomes were achieved in all cases\u003csup\u003e[\u003c/sup\u003e14\u003csup\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eA representative case is illustrated in Figs.\u0026nbsp;3 and \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA 30-year-old male sustained a right index finger (RIF) pulp crushing injury. The wound defect was sized 2cm\u0026times;3cm, infected, and associated with nail injury and partial loss of nail bed matrix. Under brachial plexus anaesthesia, the pedicled distal palm mini kiss flap (Type I) of the right index finger was transferred and combined to repair the defect of the finger pulp. During the operation, the digital artery was used as the pedicle for retrograde repair, and the sensory nerve in the flap was anastomosed with the digital nerve on both sides. The donor area was sutured directly. The flap survived, and the donor and recipient wound areas healed in the first stage.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo-point discrimination of the flap was 6.5mm. The evaluation standard of the total active range of motion / passive range of motion of the injured finger joint was superior.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eReconstruction of distal finger soft tissue defects remains a formidable challenge due to the imperative for optimal functional and aesthetic outcomes\u003csup\u003e[\u003c/sup\u003e15\u003csup\u003e]\u003c/sup\u003e. This surgical scheme breaks through the traditional concept of fingertip defect repair and innovatively proposes a new flap donor site scheme, which provides a new idea for clinical treatment of fingertip defects. While secondary intention healing remains an important standard for simple fingertip injuries, our cohort specifically addressed defects with exposed tendons or bones where flap coverage is bio-mechanically superior. Evidence demonstrated that secondary intention achieves (5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1) mm 2PD in pulp defects without bone exposure, comparable to our flap results (5.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7) mm\u003csup\u003e[\u003c/sup\u003e16\u003csup\u003e]\u003c/sup\u003e. However, in cases with structural exposure (e.g., crushing injuries), flap reconstruction reduced median time to wound closure from 6 weeks (secondary intention) to 2 weeks in our series, enabling earlier rehabilitation\u003csup\u003e[\u003c/sup\u003e17\u003csup\u003e,\u003c/sup\u003e 18\u003csup\u003e]\u003c/sup\u003e. Future randomized trials should directly compare these modalities in matched defect types.\u003c/p\u003e \u003cp\u003eThe skin tissue in the distal palm region presents numerous advantages as an ideal donor site for repairing palmar-side soft tissue defects. However, due to its pivotal functional role in hand mechanics, the palm is typically excluded as a viable option for vascular pedicle flap transfer. This study elucidates the anatomical basis and clinical applications of the pedicled distal palm mini-kiss flap as the preferred approach for reconstructing traumatic distal finger soft tissue defects.\u003c/p\u003e \u003cp\u003eThree anatomical neurovascular subtypes of the pedicled distal palm mini-kiss flap (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) have been identified based on the anatomical location of the flap\u0026rsquo;s cutaneous branches relative to the bifurcation of the common digital artery. This flap offers several potential advantages, including excellent skin texture, reliable blood supply, customizable shape design, and potential restoration of sensation in the recipient area. Primary suturing is recommended for donor site closure without requiring skin grafting. Microvascular anastomosis is required when harvesting flaps that involve the transection of the common digital artery \u003cem\u003e(Types II and III\u003c/em\u003e). Furthermore, for larger skin paddles, tight closure at the level of the distal palmar may affect flexion and extension of metacarpophalangeal joints, necessitating early physiotherapy immediately following complete wound healing.\u003c/p\u003e \u003cp\u003eSeveral reconstructive modalities and flaps indicated for similar defects described in this case series, however, fail to achieve satisfactory results due to potential risks associated with the donor site or the suboptimal, like-to-like nature of the skin flap. The pedicled distal palm mini-kiss flap adheres to the principles of homo-digital flap reconstructions. Despite being designed on the main digital artery proximal to the wound defect, this technique has proven reliable and robust in clinical practice. Han et al. reported that scar contractures are commonly observed at the donor site of reverse digital artery flaps following split or full-thickness skin grafting, which can significantly impact overall outcomes to varying degrees\u003csup\u003e[\u003c/sup\u003e19\u003csup\u003e,\u003c/sup\u003e 20\u003csup\u003e]\u003c/sup\u003e. Similarly, reports have noted the use of digital artery perforator flaps or fascia-pedicled flaps where the main digital pedicle was not harvested\u003csup\u003e[\u003c/sup\u003e21\u003csup\u003e]\u003c/sup\u003e; however, based on our experience, we found that the donor site is inferior to distal palm primary wound closure, as in extremes it may expose segments of the digital pedicle or nerve and even cause finger contracture and hyper-pigmentation\u003csup\u003e[\u003c/sup\u003e22\u0026ndash;24\u003csup\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAlthough pedicled flaps based on the lateral cutaneous branch of the digital artery do not compromise the integrity of the digital artery, there is a higher likelihood of requiring skin grafting in the donor area of these flaps\u003csup\u003e[\u003c/sup\u003e25\u003csup\u003e]\u003c/sup\u003e. Moreover, alternative traditional island pedicled flaps with digital artery for reconstruction of homo-digital soft tissue defects, also do not harvest the digital artery; however, their applicability is limited to more proximal defects and may necessitate skin grafting when used distally. Since Zancolli et al.\u003csup\u003e[\u003c/sup\u003e26\u003csup\u003e]\u003c/sup\u003e reported on the digital artery distal palmar skin island flap for finger pulp defect reconstruction, controversies have arisen regarding lumbrical muscle exposure as well as pedicle and nerve exposure at the donor site, even with a skin graft, which has diminished the favorability of this flap\u003csup\u003e[\u003c/sup\u003e27\u003csup\u003e]\u003c/sup\u003e. In an attempt to minimize complications at the donor site, a modification involving advancement of the flap with a wavy incision was proposed\u003csup\u003e[\u003c/sup\u003e28\u003csup\u003e,\u003c/sup\u003e 29\u003csup\u003e]\u003c/sup\u003e. However, subsequent experiences have rendered this reconstructive option less favorable unless the wound defect size permits primary closure without tension while preserving hand function and optimizing the final scar outcome.\u003c/p\u003e \u003cp\u003eThe pedicled distal palm mini-kiss flap can be reliably transferred and tailored to meet the specific requirements, facilitating the repair of wounds with diverse shapes. Primary closure of the donor area in the initial stage ensures optimal functional and aesthetic outcomes for the fingertip or palmar finger defects while minimally impacting the functionality of the injured palm-finger donor area. This technique is suitable for reconstructing volar soft tissue defects of the fingertip or loss of volar skin on fingers. Moreover, it can be utilized retrogradely to address skin defects in the mid-palmar region, particularly when multiple defects are present. We propose that the mini distal kiss flap represents a more appropriate option for isolated injuries distal to the middle phalanx, as it generally preserves the common digital artery; furthermore, it serves as an efficient surgical approach for patients with systemic contraindications to free flap reconstructions involving plantar skin from toes or feet.\u003c/p\u003e \u003cp\u003eThis study has several limitations. Preoperatively, the Allen test must be performed on both the affected digit and the adjacent digit to assess collateral circulation, as the procedure may compromise one digital artery in either finger, potentially increasing the risk of ischemic necrosis. Furthermore, the extensive surgical field inevitably involves dissection across the metacarpophalangeal and interphalangeal joints, which carries a potential risk of scar contracture and subsequent limitation of joint mobility. Additionally, if transection of the common digital artery is required, vascular graft reconstruction becomes necessary, thereby increasing the procedural complexity.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLIF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLeft index finger\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLRF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLeft ring finger\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLeft middle finger\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNCB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNerve cutaneous branches\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePPDA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProximal proper digital artery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRIF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRight index finger\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRRF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRight ring finger\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRMF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRight middle finger\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eS-2PD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSensory two-point discrimination\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003e This study was approved by the Ethics Committee of Affiliated Hospital of Chengde Medical University (CYFYLL2024081). The research reported in this paper was performed in compliance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Writen informed consent was obtained from the immediate family members of the deceased for educational and scientifc research purposes.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent for publication\u003c/h2\u003e \u003cp\u003e Each of the authors have approved the contents of this paper and have agreed to the journal's submission policies.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting Interest\u003c/h2\u003e \u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eAcknoledgments\u003c/h2\u003e \u003cp\u003eThe authors acknowledged the patient in this report for permitting us to present his clinical information.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study was supported by: the Medical Science Research Project of Hebei Provincial Health Commission (20240811 and 20241909).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eYunfeng Gao(YFG) wrote the main manuscript text. YFG and Youmao Zheng(YMZ) prepared for all the figures. YMZ and YFG were responsible for editing and reviewing the manuscript. and all authors have read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbdellatif HA, El Aziz Maaly MA, Soltan BSHI, Abduallah MS. Role of magnetic resonance imaging on fingers in diagnosis of post-traumatic tendon and ligament injuries. Egypt J Radiol Nuclear Med. 2021;52(1):279.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKawakatsu M. Free medialis pedis venous flap transfer for reconstruction of volar finger defects: Clinical application and esthetic evaluation. J Plast Reconstr Aesthetic Surg. 2019;72(3):459\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYan H, Fan C, Gao W, Chen Z, Li Z, Chi Z. Finger pulp reconstruction with free flaps from the upper extremity. Microsurgery. 2012;32(5):406\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScheker LR, Polo FS, Aguilar FJ. Free Tissue Transfer for Fingertip Coverage. In: \u003cem\u003eFingertip Injuries: Diagnosis, Management and Reconstruction.\u003c/em\u003e edn. Edited by Rozmaryn LM. Cham: Springer International Publishing; 2015: 131\u0026ndash;148.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoodfield M. Structure and function of the skin. London: Oxford Textbook of Plastic and Reconstructive Surgery; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDas De S, Sebastin SJ. Considerations in Flap Selection for Soft Tissue Defects of the Hand. Clin Plast Surg. 2019;46(3):393\u0026ndash;406.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang YX, Hayakawa TJ, Levin LS, Hallock GG, Lazzeri D. The Economy in Autologous Tissue Transfer: Part 1. The Kiss Flap Technique. Plast Reconstr Surg. 2016;137(3):1018\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBesmens IS, Guidi M, Frueh FS, Uyulmaz S, Lindenblatt N, Reissner L, Calcagni M. Finger reconstruction with dorsal metacarpal artery perforator flaps and dorsal finger perforator flaps based on the dorsal branches of the palmar digital arteries \u0026ndash; 40 consecutive cases. J Plast Surg Hand Surg. 2020;54(4):248\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOmokawa S, Tanaka Y, Ryu J, Clovis N. Anatomical Consideration of Reverse-Flow Island Flap Transfers from the Midpalm for Finger Reconstruction. Plast Reconstr Surg. 2001;108(7):2020\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZheng Y, Hallock GG, Levin LS, Zhang Y, Min P. Mini-Shaped Kiss Flap Design for Palmar and Digital Soft-Tissue Resurfacing. Plast Reconstr Surg. 2024;153(2):411\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar MSA. The Skin: Techniques in Small Animal Wound Mangement; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGellman H, Botte MJ, Shankwiler J, Gelberman RH. Arterial Patterns of the Deep and Superficial Palmar Arches. Clin Orthop Relat Research\u0026reg; 2001, 383.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDellon AL, Jabaley ME. Reeducation of Sensation in the Hand Following Nerve Suture. \u003cem\u003eClinical Orthopaedics and Related Research (1976\u0026ndash;2007)\u003c/em\u003e 1982, 163.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePorretto-Loehrke A, Schuh C, Szekeres M. Clinical manual assessment of the wrist. J Hand Ther. 2016;29(2):123\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArpaci E, Unlu RE, Altun S, Ertas NM. Super Kutler flap: an alternative technique for reconstruction of fingertip defects. J Hand Surg Eur Vol. 2017;42(6):626\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQiu Y, Gao W, Yang J, Jin Y, Zou Y, Qiao C, Chen H, Lin X. Cable-Stayed Face Lift: An Innovative Short-Scar Lift for Better Correction of Nasolabial Folds in East Asians. Plast Reconstr Surg. 2021;148(3):543\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Ouml;zcanlı H, Bektaş G, Cavit A, Duymaz A, Coşkunfırat OK. Reconstruction of fingertip defects with digital artery perforator flap. Acta Orthop Traumatol Turc. 2015;49(1):18\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArsalan-Werner A, Brui N, Mehling I, Schlageter M, Sauerbier M. Long-term outcome of fingertip reconstruction with the homodigital neurovascular island flap. Arch Orthop Trauma Surg. 2019;139(8):1171\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim DH, Seo KB, Lee SH, Lee H-J, Kang HJ. Reverse digital artery cross-finger flap for reconstruction of failed finger replantation. J Orthop Surg. 2018;27(1):2309499018816773.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHan S-K, Lee B-I, Kim W-K. The Reverse Digital Artery Island Flap: An Update. Plast Reconstr Surg 2004, 113(6).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin Y-T, Loh CYY, Lin C-H. Flaps Based on Perforators of the Digital Artery. Hand Clin. 2020;36(1):57\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhu L, Xu Q, Kou W, Ning B, Jia T. Outcome of free digital artery perforator flap transfer for reconstruction of fingertip defects. Indian J Orthop. 2014;48(6):594\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBene MD, Petrolati M, Raimondi P, Tremolada C, Muset A. Reverse dorsal digital island flap. Plast Reconstr Surg. 1994;93(3):552\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoshima I, Urushibara K, Fukuda N, Ohkochi M, Nagase T, Gonda K, Asato H, Yoshimura K. Digital artery perforator flaps for fingertip reconstructions. Plast Reconstr Surg. 2006;118(7):1579\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Z, Zhu L, Qingjia X, Hao L. Repair of fingertip wound with flap pedicled with lateral vascular chain of cutaneous branch of digital artery. Chin J Microsurgery. 2009;32(4):293\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZancolli E. Colgajo cutaneo en isla del hueco de la palma. Prensa M\u0026eacute;dica Argentina. 1990;77:14\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGermann G. Extensor tendon injuries: Core Procedures in Plastic Surgery. E-Book; 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWoo K, Ayello EA, Sibbald RG. The Edge Effect: Current Therapeutic Options to Advance the Wound Edge. Adv Skin Wound Care 2007, 20(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoiemen N, Elliot D. A modification of the Zancolli reverse digital artery flap. J Hand Surg. 1994;19(2):142\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"pedicled distal palm mini-kiss flap, distal finger defects, neurovascular anatomical types","lastPublishedDoi":"10.21203/rs.3.rs-8190600/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8190600/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo further clarify the anatomical basis and clinical applications of the pedicled distal palm mini-kiss flap for reconstructing traumatic soft tissue defects in distal fingers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 20 cadaveric hand specimens were dissected to classify three distinct neurovascular anatomical types. Between 2008 and 2024, 18 distal finger defects in patients were reconstructed with the sensate pedicled distal palm mini-kiss flap. Patient demographics, injury details, defect information, defect dimensions and anatomical location, sources of pedicle vessels, donor and recipient nerve branches used for innervation, as well as clinical outcomes during follow-up were recorded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree anatomical neurovascular subtypes were found. The distances between the two cutaneous flap branches ranged from 4 to 10 mm. A total of 18 distal finger defects were reconstructed using 10 oblique flaps and 8 transverse pedicled distal palm mini-kiss flaps. The mean area of soft tissue defect was quantified at 5.76 ± 2.31cm\u003csup\u003e2\u003c/sup\u003e. Nerve coaptation was achieved in 16 cases. Donor sites had no major complications, and only 2 cases had small blisters measuring between 1-2mm that resulted in epidermolysis at the distal edge of the flaps. The average follow-up was 14 months, and the two-point discrimination tests indicated an average measurement of (5.9 ± 0.7) mm.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe pedicled distal palm mini-kiss flap has been proven to be an effective and safe option for reconstructing defects of the distal finger. The classification system and technical considerations enhance its potential for this reconstructive approach to achieve optimal functional and aesthetic outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eType of study/ level of evidence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLevel IV, retrospective case series\u003c/p\u003e","manuscriptTitle":"Anatomical Study and Clinical Application of the Pedicled Distal Palm Mini- kiss Flap","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-31 09:35:50","doi":"10.21203/rs.3.rs-8190600/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-01-08T05:21:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"86051698489162434777235020882597880900","date":"2026-01-05T23:26:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"210269831368033059775252791347857687066","date":"2025-12-31T17:28:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"10651575225958817539715397445551853468","date":"2025-12-30T07:14:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-29T10:53:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-22T22:34:48+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-03T06:48:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-03T03:23:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2025-12-03T03:17:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9624ccbf-1d96-4b4f-8d0b-54a3e5db8e36","owner":[],"postedDate":"December 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-31T09:35:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-31 09:35:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8190600","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8190600","identity":"rs-8190600","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}