Syndactyly Repair: Comparison of Skin Graft and No Skin Graft Techniques

Syndactyly is a relatively common congenital abnormality of the hand occurring approximately
1 out of 2500 live births (1). It can be simple, meaning only skin and soft tissues are
shared, or complex, meaning the bone or nail parts are shared. In any case, it is a fact that
there is not enough skin surrounding the two finger segment to be utilized to cover two
separate fingers. This can also be proven by simple geometry. Therefore, it has always been
taught to residents and explained to numerous patients' families that addition of skin graft
is required for a proper syndactyly release. Without it, skin flaps would be too tight,
causing some necrosis and significant scarring along the finger and particularly in the web
space, causing an unsatisfactory functional and cosmetic result requiring revision.

Full thickness skin grafts (FTSG) are usually utilized for this procedure and come at some
cost. An additional incision, and therefore scar, is made in the groin or on the arm or hand
itself. The skin graft itself usually has a slightly different color and further
hyperpigments (2, 3, 4, 5) when placed on the hand and can have hair growth that would not
normally be present between fingers. These create cosmetic issues as the patient gets older.
In addition, skin graft is quite cumbersome to utilize in these tight areas and small fingers
of small children. It definitely adds to the time under anesthesia because no method other
than sewing with small sutures has been shown to be efficacious. Whereas the release of a
simple syndactyly may take 30-60 minutes, the suturing of skin graft and the skin flaps
usually takes one and half times that long in addition. Further, skin grafts require
immobilization and special bandaging techniques to avoid graft loss. One final disadvantage
of full thickness skin grafts is that they have been implicated in the occurrence of web
creep, which is a post-operative scarring between fingers that decreases the amount of web
space originally obtained (4,6). These will often require further surgical procedures
(Percival & Sykes).

Over the last 20 years, there has been resurgence in attempts to treat syndactyly without
skin grafts (8, 9, 10, 11, 12, 3, 6). All techniques include a significant defatting of the
subcutaneous tissues all the way back to the web space in an effect to decrease circumference
of the digits. Different dorsal metacarpal flaps have been described as well, including local
island pedicle flaps that can be used for the web commissure (3, 9, 10, 11). In addition, it
has been shown that leaving flaps slightly open, up to 2mm, for secondary intention healing
creates good scars in children and no increased sign of web creep or flexion contracture (5).
Combining all three of these techniques leads to the technical ability of syndactyly release
without the need for skin grafts. Proven benefits have been the lack of the donor scar, lack
of pigmented or hairy graft sites, and decreased operative time. However, the incidences of
web creep, flexion or lateral contractures, reoperation rate and the final cosmetic result
have not been proven to be better or worse, as no one has compared similar patients. All
studies to date have been instead a review of results using their particular technique that
does not require skin graft. If any comparisons have been made, it has been using historical
data already published.

Inclusion Criteria:

- Children ages 6 months to 6 years with simple syndactyly 2nd and/or 3rd web space
without other major congenital hand abnormally syndrome that would affect growth,
function, and appearance of hand.

Exclusion Criteria:

- patients with complex syndactyly, syndactyly of teh first web, patients with
brachysyndactyly and diagnosis of Apert's, poland's and other syndromes that often
include incomplete digital components and subsequent function.