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Outcomes of the Skin Graftless Dorsal Metacarpal Island VY Advancement Flap vs. Dorsal Rectangular Flap with Skin Grafting in Simple Syndactyly Reconstruction
Emily M. Graham, BSN1; Shaun D. Mendenhall, MD2; Zoe E. Belardo, BA2; Anchith Kota, BA3; Elizabeth B. Card, MD4; Apurva S. Shah, MD MBA3; Benjamin Chang, MD4
1University of Utah, Salt Lake City, UT; 2The Children's Hospital of Philadelphia, Philadelphia, PA; 3Children's Hospital of Philadelphia, Philadelphia, PA; 4University of Pennsylvania, Philadelphia, PA

Introduction: Traditional reconstructive approaches for congenital hand syndactyly utilize skin grafting; however, recent studies suggest that graftless techniques may mitigate postoperative complications and reduce operative time. We hypothesized that patients who underwent reconstruction with a skin graftless dorsal metacarpal island VY advancement flap would have fewer postoperative complications compared to those released with a dorsal rectangular flap with skin grafts.
Methods: Patients 0-17 years of age presenting for primary reconstruction of simple syndactyly from 2007-2022 were retrospectively analyzed at a large, tertiary referral pediatric hospital. Outcomes included early postoperative complications and long-term web creep and pathologic scar formation. Group comparisons were made with chi-square tests, Fisher’s exact test, Mann-Whitney U tests, student t-tests, and multivariate regression analyses.
Results: In total, 213 syndactyly reconstructions from 153 patients (rectangular=94 webspaces, 58 patients; VY island=119 webspaces, 95 patients; Table 1) with a mean age of 1.1 ± 0.3 years were analyzed. The average post-operative follow-up intervals were 1.8 and 1.3 years for rectangular and VY island groups respectively (p=0.26). Syndactyly reconstruction with the VY island flap required significantly less time than the rectangular technique with skin grafting (67.0 vs. 85.5 minutes, p=0.004, Table 2). The rectangular group had a significantly higher rate of 30-day postoperative complications including dehiscence and infection (Table 2). The rectangular group also had significantly higher incidences of web creep (19.3% vs 1.8%, p<0.001) and hypertrophic scarring (19.1% vs 5.9%, p=0.003). On regression analysis, the rectangular flap with skin grafting was the only variable predictive of web creep and hypertrophic scar formation (p<0.001 and p=0.004, respectively). Subgroup analyses of nonsyndromic and incomplete syndactyly cases mirrored overall cohort results.
Conclusions: This 15-year retrospective comparative study suggests that a skin graftless dorsal metacarpal island VY advancement flap produces fewer postoperative complications and lower rates of webcreep and hypertrophic scar formation compared to a dorsal rectangular flap with skin grafting. Additionally, most VY island flaps reduce operative time by 20% compared to techniques requiring skin grafting. Further prospective studies are needed to increase the quality of evidence available to hand surgeons managing syndactyly.


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