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Van Hove et al. Plast Aesthet Res 2023;10:8 https://dx.doi.org/10.20517/2347-9264.2022.59 Page 3 of 14

[6]
Figure 1. Areas of thumb loss considered (© Dr. Piñal 2020) .
Small soft tissue defects that require less than 5 mm of advancement can be covered readily by local
advancement with palmar V-Y plasty, bilateral V-Y plasty, or modifications thereof [14-16] . The choice is based
on the preference and experience of the surgeon, as all flaps are equally effective.

Moberg volar advancement flap
Moberg described a flap based on proper neurovascular bundles for coverage of palmar defects of the
pulp [Figure 2]. The flap permits covering moderate-size defects and provides sensitive skin
[17]
simultaneously. If good coverage of the pulp requires more than 45º of interphalangeal (IP)-joint flexion,
transforming the flap into a true island or combining the advancement with a V-Y flap ,or Z-plasty can
[19]
[18]
[20]
provide some extra length .
Defects up to 2 cm (about half the pulp length) can be covered with this flap; however, this benefit comes at
the price of causing a flexion contracture of the IP joint that can result in a painful thumb and a beaked nail
deformity. Problems ensue when asking too much of the flap [Figure 3].

Larger than 50% of the pulp surface
Dorso-ulnar homodigital flap (Brunelli)
Brunelli et al. studied the arteries’ layout on the thumb’s dorsal surface [7,21] . The constant disposition and
anastomoses permitted raising a distally-based flap safely from the dorso-ulnar region of the
metacarpophalangeal joint [22,23] .

This flap is based on the ulnar dorsal digital artery of the thumb, which (like its radial counterpart) has a
peculiar anatomy [Figure 4]. During its short course, it has two constant anastomoses that allow this flap to
rotate in two locations. The first pivot point is located at the neck of the proximal phalanx (2.5 cm proximal
to the cuticle), reaching dorsal thumb defects; the second is located at the level of the nail fold arcade (0.9 to
1 cm proximal to the cuticle), providing the possibility to cover the nail and the pulp.