Comparison of Bilateral V-Y Rotation Advancement Flap, Homodigital Island Flap and Cross Finger Flap for Reconstruction of Fingertip Amputations: A Prospective Interventional Study

1. Associate Professor, Department of Burns, Plastic and Maxillofacial Surgery, VMMC and Safdarjung Hospital, New Delhi, India. 2. Assistant Professor, Department of Plastic and Reconstructive Surgery, AIIMS New Delhi, New Delhi, India. 3. Associate Professor, Department of Burns, Plastic and Maxillofacial Surgery, VMMC and Safdarjung Hospital, New Delhi, India. 4. Professor, Department of Burns, Plastic and Maxillofacial Surgery, VMMC and Safdarjung Hospital, New Delhi, India.

Abstract

Introduction: The aim of reconstruction for fingertip amputations is to provide stable soft-tissue coverage while preserving length, preventing joint stiffness, minimising neuromas, restoring normal sensation and achieving an acceptable cosmetic outcome. Cross-Finger (CRF) flaps and Homodigital Island (HDI) flaps have been workhorse flaps for fingertip amputation reconstruction for decades.

Aim: To assess the long-term functional and aesthetic outcomes of the Bilateral V-Y Rotation Advancement (BV-YRA) flap compared to CRF and HDI flaps.

Materials and Methods: This was a prospective interventional study conducted over a period of two years in the Department of Burns, Plastic and Maxillofacial Surgery, Vardhman Mahavir Medical College (VMMC) and Safdarjung Hospitals, New Delhi, India, involving patients presenting with fingertip amputations. A total of 39 patients presenting with Allen zone II and III amputations were included in the study. A total of 13 patients underwent BV-YRA Flap, 13 patients underwent HDI Flap and 13 patients had CRF Flap for fingertip amputation reconstruction. The authors compared the BV-YRA Flap, the HDI Flap and the CRF Flap for fingertip reconstruction. The final outcome was assessed at 12 months. Assessments were done for sensory recovery by the 2-Point Discrimination (2-PD), cold intolerance by Cold Intolerance Symptom Severity (CISS), Range Of Motion (ROM) of the Distal Interphalangeal (DIP) joint by goniometer, aesthetic outcome by self-evaluation score and time-off work in days. Comparisons were performed using appropriate statistical parametric or non parametric tests. After four patients lost to follow-up postsurgery, 35 patients presenting with Allen zone II and III amputations were included in the study. A total of 13 patients underwent BV-YRA Flap, 12 patients underwent HDI Flap and 10 patients had CRF Flap for fingertip amputation reconstruction.

Results: The demographics of patients in the three groups were comparable. All the flaps survived. The 2-PD was significantly lower in the BV-YRA group than in the other two groups (p<0.05). Only two patients in the BV-YRA flap group reported cold intolerance, whereas all patients in the HDI and CRF groups reported mild cold intolerance. The BV-YRA flap group demonstrated significantly greater DIP and PIP joint mobility than the HDI and CRF flap groups (p<0.05). The aesthetic satisfaction score was significantly better in the BV-YRA group (3.6±0.6) compared to the HDI (1.9±0.79) and CRF (1.0±0.82) groups (p<0.05). The mean time-off work for patients in the BV-YRA, HDI and CRF groups was 20, 33.5 and 51.5 days, the difference was statistically significant (p<0.05).

Conclusion: The authors found that fingertip amputations treated with the BV-YRA flap had significantly better functional and aesthetic outcomes than those treated with HDI and CRF flaps.

Allen zone, Fingertip injury, Fingertip reconstruction, Hand injury

Fingertips are the most distal points of our body that interact with the environment, making them highly susceptible to injury during daily activities (1). Amputation of the fingertip involves a composite injury affecting the pulp, nail bed and/or distal phalanx beyond the DIP joint (2). Inadequate management of fingertip amputations can lead to chronic pain, paraesthesia, tip rotation, hook nail deformity, sinus formation, decreased mobility and diminished quality of life (3).

In India, the middle finger is the most commonly affected, accounting for 30% of fingertip injuries (4). Children under five years of age are more prone to these injuries, with door crush incidents being the leading cause. In adults, injuries due to bike chain crushes are the most frequent (5).

The choice of reconstruction depends on the severity of the injury, available tissue and, most importantly, the patient’s vocational and functional requirements. Various reconstructive options exist based on the reconstructive ladder (6),(7). Healing by secondary intention is ideal for small fingertip injuries (less than 1 cm²) without exposed bone or nail matrix, as it ensures good sensory recovery (8). However, in larger defects, the risk of desiccation and osteomyelitis necessitates soft-tissue coverage (9). Secondary healing may also lead to prolonged recovery, repeated dressings, shortened finger length, impaired fine motor skills and reduced pinch strength (10).

Reconstructive options include skin grafts, composite grafts, local flaps, distant flaps and free flaps. Local flaps, utilising adjacent tissue, are preferred because they provide optimal replacement with similar tissue and maintain stability for fine motor functions (11). The CRF and HDI flaps have been mainstays in fingertip reconstruction, though they come with complications such as joint stiffness, skin mismatch, cold intolerance and venous congestion (7),(12),(13). In 2012, Sungur N et al., introduced the BV-YRA flap, offering superior cosmetic and functional outcomes (14).

The present study aimed to evaluate the long-term functional and aesthetic outcomes of the BV-YRA flap compared to CRF and HDI flaps. To the authors’ knowledge, no prior study has compared the functional and aesthetic outcomes of these three flaps, BV-YRA, HDI and CRF for fingertip amputation reconstruction in a single prospective study.

Material and Methods

A prospective interventional study was conducted in the Department of Burns, Plastic and Maxillofacial Surgery, Vardhman Mahavir Medical College (VMMC) and Safdarjung Hospitals, New Delhi, India, from January 2018 to December 2019. During this period, 39 patients with fingertip amputations (13 per group) were enrolled according to the study’s inclusion and exclusion criteria. Ethical approval has been obtained from the Institutional Ethics Committee (Ref:IEC/MMc/SJH/Project/February/2018).

Inclusion criteria: Only patients with Allen Zone II and III fingertip amputations were included.

Exclusion criteria: Patients with Allen Zone I injuries were excluded, as they are better managed through secondary healing.

• Allen Zone IV injuries were also excluded since amputations close to the DIP joint could bias Range Of Motion (ROM) measurements and lacked sufficient residual pulp for reconstruction.

• Patients with severe crush injuries, life-threatening conditions, chronic smoking habits, or underlying vascular and metabolic pathologies, such as Diabetes Mellitus, were also excluded.

To ensure comparability, patients with similar injury levels and amputation characteristics were selected across all three groups and random allocation was performed using an identical blind-envelope method.

The defects were classified using Allen’s classification (2): Type-I involved only the pulp, Type-II included the pulp and nail bed, Type-III involved partial loss of the distal phalanx and Type-IV extended proximal to the lunula (Table/Fig 1). While this classification does not consider the obliquity of the amputation, it remains the most widely used and was adopted for the present study.

Study Procedure

Demographic details, injury type, defect characteristics, nail bed involvement, co-morbid conditions and surgical interventions were documented. Patients were followed until wound healing and reassessed at one and six months, with the final evaluation at 12 months. Four patients were lost to follow-up after surgery, leaving 35 for analysis.
Assessment included sensory recovery, cold intolerance, ROM, aesthetic outcomes and time-off work.

a. Objective sensory recovery was done by the static 2-point discrimination test (2-PD). The area to be tested was blinded to the patient (Baseline-12-1492-2, disc Discrim-A-Gon, China). A 2-point discriminator set was used. The smallest distance between two points that results in the perception of two distinct stimuli was recorded as the patient’s two-point threshold.

b. Cold intolerance was assessed by the Cold Intolerance (CISS) questionnaire developed by Irwin (15).

c. Range Of Motion (ROM): Both active and passive ROM of DIP, PIP, Metacarpo-Phalangeal (MCP) joints and Total Active Motion (TAM) and Total Passive Motion (TPM) were assessed by finger goniometer (Indo Surgicals®, New Delhi, India).

d. Aesthetic outcome by self-evaluation score with 0 being poor, 1-Dissatisfied, 2- Satisfied, 3-Highly satisfied and 4-Perfect.

e. Time-off work is defined as the total number of workdays lost due to injury, encompassing periods of medical treatment, rehabilitation and recovery until return to gainful employment.

Surgical techniques: The CRF Flap (3) and HDI Flap were raised in the standard fashion (16).

The ROM exercises were initiated on postoperative (POD) day 2 following the flap division in the CRF flap and on POD 8 for the HDI flap.

Bilateral V-Y Rotation Advancement (BV-YRA) Flap- The flaps were marked laterally at the base, equal to half the defect’s width. A longitudinal line was drawn from the midpoint of the defect to three-quarters of the remaining pulp. From this point, two V’s were marked, with the apex at the DIP joint crease and the lateral limb ending at the flap’s base. Under digital block and a tourniquet, dissection was performed under loupe magnification. Full-thickness flaps were raised just above the periosteum, preserving the digital neurovascular bundles. The flaps were advanced and rotated into the defect, with distal medial corners sutured to the dorsal skin or nail and distal edges secured. The inferomedial edges were sutured together using a three-point suture. For large defects, small triangular gaps were left for secondary healing. The fingertip was dressed with Neosporin-absorbed paraffin gauze. No splint was applied and ROM exercises began on POD 2 (Table/Fig 2).

STATISTICAL ANALYSIS

The statistical analysis was conducted using Predictive Analytics Software (PASW) version 17.0 software (SPSS Inc., Chicago, IL, USA). The Kruskal-Wallis test was used to compare the groups. Subgroup analysis was performed using the Bonferroni test. The Friedman test was applied to assess the differences within each group at various follow-up points. CISS, aesthetic outcome and time-off work were assessed only at the final 12-month follow-up; therefore, within-group longitudinal analysis was not performed for these outcomes. The Mann-Whitney U test was used to compare movement between injured and normal fingers and the Wilcoxon signed-rank test was applied for paired comparisons at 1, 3 and 12 months; however, as this was not a primary outcome, detailed data are not presented.

Results

A total of 39 patients with fingertip amputations (Allen zones II and III) were initially included in the study, but four patients were lost to follow-up. Therefore, the analysis was performed on 35 patients: 13 patients (37%) underwent BV-YRA Flap (Table/Fig 3),(Table/Fig 4),(Table/Fig 5), 12 patients (34%) underwent HDI Flap (Table/Fig 6) and 10 patients (29%) had CRF Flap for fingertip reconstruction (Table/Fig 7).

All patients were operated on within 48 hours of injury. The right hand, being the dominant hand, was most commonly involved in all three groups, with the middle finger and index finger being the most frequently injured digits (Table/Fig 8).

Flap survival was noted in all 35 cases (100%). In the HDI group, temporary venous congestion occurred in 3 cases (25%), which resolved on its own. In the CRF group, one patient experienced flap dehiscence that required re-suturing and two patients had partial graft loss, which was managed conservatively with dressings. In the BV-YRA group, two patients had marginal necrosis at the tip, which healed by secondary healing with regular non adhesive dressings.

Outcome Assessments

a. 2-Point Discrimination-fine touch: Changes in 2-PD within each group over time demonstrated a significant improvement over the 12-month period in all patients, irrespective of the type of surgical procedure performed (p<0.05) (Table/Fig 9). Based on the findings of the present study, sensory recovery at 12 months as assessed by 2-PD was significantly better in patients undergoing BV-YRA, followed by the HDI group (Table/Fig 10).

b. Cold intolerance: Of the 35 fingers assessed, only two patients in the BV-YRA flap group reported cold intolerance, whereas all patients in the HDI flap and CRF flap groups complained of mild cold intolerance. The mean CISS score was 0.77 in the BV-YRA group, 15.92 in the HDI group and 21.80 in the CRF group.

Post-hoc analysis revealed that the BV-YRA flap group had significantly lower CISS scores than both the HDI and CRF groups. Additionally, the HDI group demonstrated significantly lower CISS scores than the CRF group suggesting a graded improvement (BV-YRA > HDI > CRF) (Table/Fig 10),(Table/Fig 11).

c. Range of Motion (ROM): The Bonferroni test for subgroup analysis revealed statistically significant differences in movements (both active and passive) between all groups (p <0.05). Movements were significantly better in the BV-YRA group than in the HDI and CRF groups (p <0.05). However, subgroup analysis comparing the HDI and CRF groups showed that the HDI group was better than the CRF group (p <0.05) (Table/Fig 12),(Table/Fig 13).

d. Aesthetic Outcome: The mean aesthetic satisfaction score for BV-YRA flap patients was 3.6±0.6, for HDI flap patients it was 1.9±0.79 and for CRF flap patients it was 1±0.82. On comparison, the difference was statistically significant, with the aesthetic satisfaction score being better in the BV-YRA group than in the HDI and CRF groups (p<0.05). An intergroup comparison using the Bonferroni test showed that the aesthetic satisfaction score of HDI patients was significantly higher than that of CRF patients (Table/Fig 10),(Table/Fig 14).

e. Time-Off Work: The mean time-off work for patients in the BV-YRA, HDI and CRF groups was 20, 33.5 and 51.5 days, respectively, with the observed differences between groups statistically significant (p<0.05) (Table/Fig 10).

Discussion

The reconstructive approach for fingertip injuries relies on the surgeon’s experience and skills. These decisions are often influenced by the type and severity of the injury as well as patient-specific factors.

The objective of the present research was to assess the outcomes of individuals who underwent BV-YRA flap surgery for fingertip amputation reconstruction and to compare these outcomes with those of individuals who received HDI Flap or CRF Flap. To our knowledge, no prior study has explored this particular aspect of fingertip amputation reconstruction.

2-Point Discrimination

Static 2-PD is one of the most vital outcomes of fingertip reconstruction. The authors found a statistically significant difference among the three groups. This is explained by the fact that BV-YRA flaps have intact neurovascular channels, preserving sensation and obviating the need for cortical relearning (14). Although HDI flaps have intact neurovascular island and provide a durable tactile surface with sensation for gross grip, sensory stimuli are typically poorly localised, resulting in poor 2-PD (17). In contrast, for CRF flaps, recovery of two-point discrimination typically takes 12 to 18 months because dorsal skin is used for coverage (18),(19).

Cold Intolerance

Although the exact aetiology of cold intolerance remains unclear, alterations in neuronal and/or vascular pathways are commonly implicated. Cold intolerance is objectively measured using the CISS score, which ranges from 0 to 100 (15).In the present study, cold intolerance was reported by all patients in the HDI and CRF groups, whereas it was reported by two patients in the BV-YRA flap group. Murray JF et al., noted a high incidence of cold intolerance following HDI flap reconstruction, possibly due to extensive dissection around the pedicle (17). Similarly, Nishikawa H and Smith PJ observed that nearly half of the patients treated with CRF flaps reported increased cold sensitivity (19).

Range of Motion (ROM)

Patients reconstructed with the BV-YRA flap demonstrated considerably better ROM at the PIP and DIP joints compared to those in the HDI and CRF flap groups.

Literature reports extension lag as a known complication following HDI flap reconstruction. Arsalan-Werner A et al., observed mild extension lag of the PIP joint in three patients at a mean follow-up of eight years after homodigital neurovascular island flap reconstruction for Allen Type-III/IV fingertip amputations (20). Another study reported extension lag in the interphalangeal joints in 30% of patients at a mean follow-up of 46 months (21). In the CRF group, Paterson P et al., reported that 50% of patients experienced stiffness of the donor finger along with a reduction in ROM (22).

In contrast, the present study showed superior preservation of joint mobility in the BV-YRA flap group.

Aesthetic Outcome

Patients who underwent the BV-YRA flap scored substantially higher than those who underwent the HDI or CRF flaps and patients with HDI flaps scored higher than those with CRF flaps. This is in line with the results of Sungur N et al’s., who also found that, because the BV-YRA flap employs nearby tissue with the same colour and texture, the aesthetic results of finger reconstruction using this flap are better (14). None of the patients had a hooked nail deformity, despite it being reported as a frequent consequence of the HDI flap, which can compromise the cosmetic result. According to Paterson P et al., problems of the donor finger of the CRF flap include hyperpigmentation of the Full-Thickness Graft (FTG), which results in colour mismatch and contour deformity of the donor finger (22). Studies demonstrating that the donor area’s appearance is frequently inadequate further corroborate this (23),(24).

Time-off Work

After taking about 20 days out from work, patients who had the BV-YRA flap returned to work 13.6 days earlier than those who had HDI flaps and 31.6 days earlier than those who had CRF flaps. The average time-off work in Sungur N et al., study was 1.5–2.5 weeks, which is similar to what we found (14). For patients treated with the HDI flap, Pires reported a 45-day work leave, with a range of 31-62 days (25). Al-Qattan MM reported that patients with CRF in whom early mobilisation was initiated prior to flap division returned to work at a mean of 4.75 weeks, whereas those in whom mobilisation was commenced after flap division returned to work at approximately six weeks (26).

The present study suggests that the BV-YRA flap provides superior functional recovery, sensory outcomes and aesthetic satisfaction with earlier return to work compared to HDI and CRF flaps for Allen zone II and III fingertip amputations.

Limitation(s)

The limitations of the present study include a small sample size, a single-centre design and a lack of randomisation, which may affect generalisability. Future studies with larger, multicentre randomised cohorts and longer follow-up are recommended to validate these findings and refine flap selection algorithms.

Conclusion

The present study revealed that patients with fingertip amputations treated with the BV-YRA flap had superior 2-PD, reduced cold intolerance, better ROM and higher aesthetic satisfaction scores compared to those treated with HDI and CRF flaps. These patients also had a significantly shorter time-off work, reducing the economic burden on them. The HDI flap group, while not as favourable as the BV-YRA group, still showed better functional and aesthetic outcomes compared to the CRF flap group.

DOI and Others

DOI: 10.7860/JCDR/2026/82426.24351

Date of Submission: Jul 30, 2025
Date of Peer Review: Dec 04, 2025
Date of Acceptance: May 20, 2026
Date of Publishing: Sep 01, 2026

Author declaration:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

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EMENDATIONS: 8