Reply to a Letter to the Editor: Anatomical Study of the Fingertip Artery in Tamai Zone I: Clinical Significance in Fingertip Replantation

Anatomical Study of the Fingertip Artery in Tamai Zone I: Clinical Significance in Fingertip Replantation

Letter to the Editor: Anatomical Study of the Fingertip Artery in Tamai Zone I: Clinical Significance in Fingertip Replantation

I thank Drs. Wang, Wei, and Wei for the interest in our article titled “Anatomical study of the fingertip artery in Tamai zone I: Clinical significance in fingertip replantation.”[1] I agree with the vein issue that they mentioned. However, the purpose of the study was not to examine venous anatomy but instead to precisely define the arterial system. The previous anatomical data regarding the arteries were scarce and discrepant. For beginners and those with little replantation experience, it is difficult to locate the artery, and impossible to take a step forward without finding the artery.

I am aware that it is important to identify the venous pattern in Tamai zone I for use in clinical practice. However, since the vein is located superficially and adjacent to the dermis, it is possible to identify its course by direct observation just before or during the operation. Therefore, an anatomical description of the vein is less useful than that of the artery, and experienced surgeons are more likely to have the practical know-how to find veins. Moreover, even if venous patterns can be determined with anatomical information, the veins are often difficult to connect because of crushing-wound conditions or technical problems.

What I provided in the Discussion section were suggestions for various options if the attempt to find the vein fails. This was not meant to imply that it is not necessary to connect the veins. As I stated in the article, based on the anatomical study, an additional artery can be used for venous drainage by adaptation of reverse flow.[1] In addition, it is possible to use the intramedullary space for venous drainage, although Wang et al may disagree. Recent articles have described intramedullary venous drainage.[2] [3] Drilling was used to create a route in the medullary space and a fenestrated needle was used to increase the amount of venous drainage.[2] Chen et al[3] also demonstrated the possibility of intramedullary drainage with artery-only replantation and achieved a >90% success rate. Good results were even obtained without bone fixation because the medullary space of the bone in an amputated finger is often open.

If the vein cannot be connected, various options can be tried. Keep in mind, however, that all these possibilities regarding the veins depend on connecting the arteries.

• References

• 1 Nam YS, Jun YJ, Kim IB, Cho SH, Han HH. Anatomical study of the fingertip artery in Tamai zone I: clinical significance in fingertip replantation. J Reconstr Microsurg 2017; 33 (01) 45-48
• 2 Purisa H, Ozturk MB, Kabakas F, Mersa B, Ozcelik IB, Sezer I. Intramedullary venous drainage system for distal fingertip replantations. Ann Plast Surg 2017; 79 (02) 166-173
• 3 Chen KK, Hsieh TY, Chang KP. Tamai zone I fingertip replantation: is external bleeding obligatory for survival of artery anastomosis-only replanted digits?. Microsurgery 2014; 34 (07) 535-539