Syndactyly Release and Reconstruction

YEAR

2025

 

CLIENT

Cory Sandone, MA, CMI

Dr. Scott Lifchez, MD

Johns Hopkins Department of Plastic and Reconstructive Surgery

 

MEDIA

Graphite  |  Photoshop

 

DESCRIPTION

Syndactyly is a congenital condition in which two or more fingers do not fully separate during development, leaving them fused. Surgical release is typically performed between 12 and 18 months of age to support normal growth and function. The patient observed was 5 years old and presented with bilateral complete complex syndactyly of the fourth and fifth digits or ring and small finger. This means fusion extended to the fingertips involving a bony connection. The patient also had simple incomplete syndactyly between the third and fourth digits. Due to the length disparity between the ring and small fingers, their separation is prioritized to prevent progressive angular deformity and soft-tissue tension. Release of the middle and ring fingers will be planned for a future procedure.

 

For this illustration, I rendered a few of the key reconstruction steps beginning with an orientation of the planned incisions for flap creation. I chose to render in grayscale and rely on contrast and shading for clear visualization of flap design and tissue planes which I thought color would distract from.

SKETCHES

1A Dorsal planned incisions including division of the shared nail plate, creation of interdigital flaps, and design of a rectangular web hood for web-space reconstruction. 1B The palmar view demonstrates the planned paronychial flaps which are the V shaped incisions at the finger tip that will form the skin fold bordering the divided nail plate. Also detailed are interdigitating flaps, and a reverse T-shaped incision which is placed more proximally than than the native web space to account for postoperative web creep.
2A Beginning distally, an incision is made to mobilize the paronychial skin flaps followed by separation of the nail plate at the junction of the ring and small finger. 2A Skin flaps are elevated and retracted with care to preserve the epidermis, dermis, and sufficient subcutaneous fat to maintain flap viability. Interdigital flaps are raised distal to proximal on the dorsal side, followed by elevation of the palmar flaps.
Again here we appreciate the disparity in finger length. 3A indicates synostosis between the distal ring and small phalanx which is transected using bone cutters, then smoothed with a bone rasp to restore proper alignment and contour.
4A Using blunt dissection, the digits are separated with care taken to identify and preserve the proper digital arteries and nerves. 4B shows the completed separation.
5 The dorsal rectangular hood is advanced and inset to the reverse T-shaped incision for webspace reconstruction.
6A Interdigital flaps are advanced to their respective side of each digit, avoiding tension or vascular compromise. 6BParonychial flaps are inset and sutured forming the paronychial folds which border the nail plate.
7 A full thickness skin graft harvested from the patient’s right lateral groin is divided and placed to resurface exposed aspects of the created web space.
8 The completed reconstruction shows fully separated digits with restored web spaces. Areas of gaping are closed with simple interrupted sutures. Complete skin coverage is confirmed and fingertip perfusion is assessed.