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DOI: https://doi.org/10.5999/aps.2017.01501    [Accepted]
Published online October 27, 2017.
Modified Toe Pulp Fillet Flap Coverage: Better Wound Healing and Satisfactory Length Preservation
Sang Oon Baek, Hyo Wan Suh, Jun Yong Lee
Department of Plastic and Reconstructive Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
Correspondence:  Jun Yong Lee, Tel: +82-32-280-5184, Fax: +82-32-280-5556, 
Email: ps.jylee@catholic.ac.kr
Received: 1 October 2017   • Revised: 1 October 2017   • Accepted: 20 October 2017
Abstract
Background
Amputation is commonly performed for toe necrosis secondary to peripheral vascular diseases, such as diabetes mellitus. When amputating a necrotic toe, preservation of the bony structure is important for preventing the collapse of adjacent digits into the amputated space. However, in the popular terminal Syme’s amputation technique, partial amputation of the distal phalanx could cause increased tension on the wound margin. Herein, we introduce a new way to resect sufficient bony structure while maintaining the normal length, based on a morphological analysis of the toes.

Methods

Unlike the pulp of the finger in the distal phalanx, the toe has abundant tear-drop--shaped pulp tissue. The ratio of the vertical length to the longitudinal length in the distal phalanx was compared between the toes and fingers. Amputation was performed at the proximal interphalangeal joint level. Then, a mobilizable pulp flap was rotated 90 degrees cephalad to replace the distal soft tissue. This modified toe fillet flap was performed in 5 patients.

Results

The toe pulp was found to have a vertically oriented morphology compared to that of the fingers, enabling length preservation through cephalad rotation. All defects were successfully covered without marginal ischemia.

Conclusions

While conventional toe fillet flap coverage focuses on the principle of length preservation as the first priority, our modified method takes both wound healing and length into account. The fattiest part of the pulp is advanced to the toe tip, providing a cushioning effect and enough length to substitute for phalangeal bone loss. Our modified method led to satisfactory functional and aesthetic outcomes.
Keywords: Diabetic Foot ; Amputation; Surgical Flaps; Wound Healing
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