Eur J Plast Surg (2001) 24:275–281
DOI 10.1007/s002380100300
INVITED CONTRIBUTION
P. Loréa · B. C. Coessens
Evolution of surgical techniques for skin releases in the treatment
of simple congenital syndactyly: a review
Received: 12 March 2001 / Accepted: 19 July 2001 / Published online: 11 October 2001
© Springer-Verlag 2001
Abstract Since the first publications in the early nine-
teenth century on surgical techniques for releasing con-
genital syndactyly, this pathology has received constant
interest in the medical literature. Current techniques for
separating syndactylized digits include three major steps
that are discussed separately: commissure reconstruction,
digital incision and ways to overcome the lack of skin.
The use of the recently described commissural flaps –
usually larger and more proximally-raised than conven-
tional flaps – that allow for closure without a skin graft
is discussed, based on the personal experience of the
authors.
Keywords Syndactyly · Surgery · Skin graft ·
Commissural flap
Introduction
Since the first publications in the early nineteenth centu-
ry on surgical techniques to release congenital syndacty-
ly, this pathology has received constant interest in the
medical literature. More than 500 articles on syndactyly
have been published on Medline over the past 5 years,
and many of these focus on new or modified surgical
techniques. This clearly indicates that the quest for an
optimal treatment is still ongoing. The goal of this paper
is to review how the techniques for skin release have
evolved and to emphasize the most important recent
advances.
Syndactyly results from of a failure of digital rays to
separate from one another during the 5th to 8th week of
intrauterine life by programmed cell death [13]. This
condition is thus classified with arthrogryposis, campto-
dactyly, trigger thumb and other malformations in part II
(failure of differentiation or separation of parts) of the
IFSSH classification [45]. Acrosyndactyly that occurs in
P. Loréa · B.C. Coessens (✉)
Hôpital Universitaire Brugmann, Service de Chirurgie Plastique,
4, Pl. Van Gehuchten, 1020 Bruxelles, Belgium
Fax: +32-2-477-2161
the constriction band syndrome, in which digital rays are
fused only distally with a proximal skin-lined fistula, is a
different entity of unknown mechanism that is classified
in group VI with “intrauterine” amputations.
Syndactyly is together with polydactyly one of the
most common congenital malformations of the hand, and
the most common in Western countries. This condition is
encountered in one in 2000 [23, 25, 27]. Half of the cases
are bilateral, males are more commonly affected, and it
occurs more frequently in Caucasians. It accounts for
9%–50% of hand malformations in various surgical series
[27, 28, 38]. The true incidence is difficult to evaluate be-
cause of variations among racial groups, different patient
referral patterns and the lack of uniform classification for
complex cases. Indeed, the frequent association of syndac-
tyly with short fingers (symbrachydactyly), polydactyly,
oligodactyly or cleft hands may raise a problem in classi-
fication [28]. In syndactyly without associated malforma-
tion, the third web is the most commonly affected (57%),
followed by the fourth (27%), the second (14%) and the
first (3%) [17, 40]. The low frequency of first web in-
volvement is explained by the fact that the thumb–index
web separates at a different and earlier stage.
Genetic origin is well demonstrated in the pathogene-
sis of isolated syndactyly. Inheritance is under the auto-
somal dominant mode [46, 50]. However, the genes are
of reduced penetrance and variable expression, meaning
that the abnormality is rarely found in each generation.
Syndactyly also occurs as a part of 48 different syn-
dromes [12, 19]. The most common syndromes associat-
ed with syndactyly are craniosynostoses and, of these,
Apert’s syndrome is the best known, followed by Poland,
Fanconi, Moebius and Pierre Robin syndromes. Identify-
ing a syndrome is of prime importance to treat associated
anomalies. Indeed, in these cases, syndactyly is often the
least important but the most easily treatable pathology of
the child. An excellent index of syndromes associated
with syndactyly and other hand malformations is provid-
ed in Flatt’s textbook [17].
Of surgical interest, the clinical and radiological
evaluation allows syndactyly to be classified into four
276
Fig. 1 Radiologic appearance of a complicated syndactyly
groups. If the web extends to the tip of the digit, the syn-
dactyly is termed complete, in contrast with incomplete
for a syndactyly that does not involve the full length of
the finger. If radiological evaluation shows bone fusion,
the syndactyly is called complex. If the web is formed by
skin and connective tissue only, the syndactyly is classi-
fied as simple. The degree of complexity may vary from
bone fusion at the end of the distal phalanx to complex
skeletal anomalies. Some authors further classify com-
plex cases introducing the notion of complicated syn-
dactylies for cases involving more than side-to-side bone
fusion (Fig. 1). The treatment of complicated syndacty-
lies or syndactylies with associated hand malformations
(polydactyly, symbrachydactyly, etc.) is beyond the
scope of this paper because it is more often conditioned
by associated anomalies or by the bone fusion than by a
problem of skin release.
The optimal age for correction remains controversial
[33]. Patterns of hand function usually develop before
24 months of age [20, 21], so there is a consensus that
complex cases in which function is impaired should be
treated relatively early. When webbed fingers are of
different growth potential, early correction will prevent
Fig. 2 Web creep 2 years after the release of a syndactyly of the
fourth web using two triangular flaps for the commissure and a
zigzag incision
flexion contracture and lateral deviation of the longer
finger that increases with age. So thumb-index and ring-
little finger syndactylies should be operated on early
(during the second 6 months). Other parameters are
related to the surgeon’s experience and the technique
used for separation. They will be discussed later.
Surgical options
The goals of surgery should be the separation of inde-
pendent digits to create an anatomic and aesthetic web,
ideally in one operative stage that avoids impaired func-
tion, scar contracture, web creep and operative complica-
tions. The newly created web should look as closely as
possible like a normal one. Although some minor varia-
tions exist, the anatomy of normal webs is quite con-
stant. The dorsal aspect of a commissure slopes normally
from proximal and dorsal to distal and palmar to form an
angle of 45 degrees with the palmar aspect. The apex of
the commissure is longitudinally located at the middle of

Fig. 3 This figure and the next show the evolution of different
patterns for skin release. Dotted lines represent incisions. See text
for details
the proximal phalanx. Active abduction of the long
fingers (more than 35 degrees for each web) is allowed
by transverse redundancy of the skin.
The history of skin release in syndactyly goes back to
the early nineteenth century when surgeons used glass
setons or ligatures to separate the fingers, leaving large
row areas to secondary epithelialization that often led to
severe recurrences [9]. Recurrence of a syndactyly is, in
fact, a scar contracture. In its mildest form it presents
just like tension on a suture line. It evolves as the hand
grows and leads to deformities of the fingers with differ-
ent degrees of severity [47]. Unilateral scar contracture
leads to bone distortion with rotation of the longitudinal
axis during growth. Scar contracture of the web leads to
distal migration of the web, called “web creeping”
(Fig. 2). Upton has pointed out that a 1.0 mm loss of
tissue in an infant translates to a 1.0 cm distraction in the
adult [48].
Current techniques for separation of syndactylized
digits include three major steps that will be discussed
separately: the commissure reconstruction, the digi-
tal incisions and the ways to overcome the lack of
skin.
277
Fig. 4 See Fig. 3
Commissure reconstruction
Zeller, in 1810, was the first to introduce the concept of
a flap for commissure lining. He described a dorsal trian-
gular flap in order to decrease secondary web creep [51]
(Fig. 3a). Norton adapted Zeller’s technique more than
70 years later by using two triangular flaps, one dorsal
and one palmar [35] (Fig. 3b). This technique was devel-
oped and later used by many surgeons [3, 7, 29, 30, 36,
44] and is still preferred by some despite the fact that
children treated by this procedure tend to develop a
narrow V-shaped commissure [17].
Dieffenbach used a large rectangular dorsal flap in
1934 [11] (Fig. 3c) that was later developed by Cogswell
[5], Olfield [37] and Bauer [2]. Bauer et al. [2] recom-
mended using this broad dorsal flap that would pass be-
tween the fingers and join a transverse incision in the
palm to form the commissure. The main advantage of
this broad dorsal flap is that it tends to provide a replica
of the normal anatomy of the commissure [24]. Even
after 50 years, this method is still considered to be the
most satisfactory by many [17].
Moss and Foucher mentioned the possible role that
the palmar junctional scar of the dorsal flap method
plays in the recurrence of webbing [32]. They described
a modification of Ostrowski’s flap in order to break up
this palmar junctional scar, by using a combination of a
rectangular dorsal flap and two palmar laterally-based
triangular flaps (Fig. 3d).
278
Fig. 5 a Cross-section of two syndactylized digits. Traditional
mathematical evaluation of the lack of skin (r=rayon). b Clinical
presentation. The skin available is longer than 2r but still less than
2πr. c Clinical presentation before (right) and after defatting (left).
The width of the finger is diminished, allowing primary closure of
the sides (dotted lines)
During the last decade a new generation of flaps has
been developed to decrease the need for skin grafting [6,
14, 15, 34, 43]. These flaps are usually larger and more
proximally-raised than conventional triangular or rectangu-
lar flaps and allow for closure without skin grafts. These
flaps will be discussed under the section skin grafting.
Digital incisions
The story starts with the use of straight incisions along
the digits that resulted in significant contractures. Didot
was the first to introduce two laterally-based rectangular
flaps. These flaps extended from the base up to the tip of
the web to cover the defects at the sides of the fingers
that break the longitudinal scars on the lateral aspects of
the fingers [10] (Fig. 3e).
The history of the introduction of zigzag incisions is
unclear. Although Cronin [7, 8] is usually reported to be
the first to use the zigzag incision in 1943, a similar idea
was developed earlier by Faniel in 1911 when two large
Z-shaped incisions on the dorsal and palmar surfaces of
the web were used and two triangular flaps on each fin-
ger were created [16] (Fig. 3f). As first described by
Cronin in 1943, zigzag incisions were made only on the
palmar side of the web, conserving a straight incision on
the dorsal aspect. Cronin’s second article in 1956 de-
scribed zigzag incisions on both sides (Fig. 4a). Simulta-
Fig. 6 Long-term appearance of a skin graft
neously, Pieri [39] condemned the use of straight inci-
sions in favour of piano key incisions (Fig. 4b) and
Zachariae [49] extended such incisions to the full width
of the digits (Fig. 4c). A myriad of modifications was
described, including round-shaped modifications of the
zigzag incisions [4, 23, 41], Z plasties [3] and straight in-
cisions broken up with square incisions [36] or triangular
incisions around the joints [44]. Although, at this time,
zigzag incisions are considered to be a standard by most
authors [49], Colville recently still advocated using rect-
angular flaps joined with straight-line incisions between
the joints so as to decrease the need for a skin graft [6].
Skin grafting
Basic geometry (Fig. 5a) indicates that syndactylized
digits offer less skin than needed for separated digits. In
fact, this classically presented mathematical calculation
of the lack of skin overestimates the real difference be-
tween syndactylized and separated digits. Indeed, in the
clinical situation, the skin is placed in a slight concave
curve rather than stretched over the two fingers (Fig. 5b).
 279

Fig. 7 Planning the incisions for release without skin graft using
the intermetacarpal island flap

In the first separation techniques, large raw areas were

left to secondary epithelialization, with the already de-
scribed problems of contracture and “recurrences”. The
concept of skin grafting these raw areas created after sep-
aration of the fingers was introduced by Lennander [26].
Widespread use of tissue expansion has led to some
publications concerning its use for syndactyly. This tech-
nique has been abandoned in these cases because of the
need for two operative stages and the associated higher
rate of complications [1, 22, 31].
Skin grafting remained the gold standard until recently.
Most commonly, incisions are designed to leave raw areas
on the lateral part of the proximal phalanx of each digits,
but some modifications have been described. For instance,
Bauer advocated entirely covering the dominant digit with
local flaps at the expense of the other that would be skin-
grafted [2] (Fig. 4e). Although the aetiologies of web
creeping are multiple, the loss of a skin graft is one of the
most frequent [38, 43]. The frequency of web creeping is
extremely variable, ranging from 7.5% to 60% in surgical
series [18, 38, 47, 48]. Other drawbacks of skin grafting
are related to hyperpigmentation (about 5%, Fig. 6), hair
growth (11%), donor-site morbidity or hypertrophic scar-
ring at the edges ofthe graft [47]. These complications,
whether they are related to skin grafting or not, lead to
secondary procedures in up to half of all patients to
achieve satisfactory results [47, 38].
Some debate exists concerning the type of graft and the
choice of the donor site. Although most authors prefer us-
ing full-thickness skin grafts [2, 17, 32, 49], some surgeons
advocate using a split-thickness skin graft for a better col-
our match but this type of skin graft seems to have a high
incidence of secondary contracture [47, 38]. Moreover,
split-thickness skin grafts often result in thin and retracted
skin [47, 38]. The inguinal donor site is commonly pre-
ferred over other regions although some authors advocate
using the plantar instep for the best colour match [52].
Related to the drawbacks of skin grafting, new com-
missural flaps were introduced to wrap the web and the
lateral part of the inter-digital space without skin graft-
ing. In 1990, Niranjan described employing an extended
Fig. 8 Symbrachydactyly in Poland syndrome. Preoperative draw-
ings of the commissural VY flap and digital incisions
dorsal trilobed flap [34] in a limited series of five cases
that allowed for primary closure. The central portion is
used to cover the web and lateral arms to cover the proxi-
mal raw areas that are usually skin-grafted (Fig. 4f).
Ekerot used this flap in a larger series and compared
Niranjan’s technique with the traditional skin-grafting
procedure [14, 15]. Decreased operating time and fewer
complications were found in the non-grafted group [15].
Although the follow-up period is short, Ekerot did not
find evidence of an increased incidence of web creeping
and, according to basic principles of plastic surgery,
using flaps instead of skin grafts to cover the raw areas
should decrease the rate of contracture during child
growth and subsequent web creeping. One of the draw-
backs of this flap is that two additional scars are created
on the dorsum of the proximal phalanx. At the same
time, Colville introduced the concept of island commis-
sural flaps. He used a V-Y advancement kite-shaped dorsal
flap to create the web (Fig. 4d). Due to the fact that this
flap brings some additional skin to the web, the size of
the skin graft was reduced [6]. Sherif modified this flap
in 1997 to allow for systematic closure without a skin
280

graft [43]. The design of the flap is centred 1 cm proxi-

Fig. 9 Same case as Fig. 8. View of the VY flap lining the com-
missure
mal to the metacarpal joint (Figs. 7 and 8). The proximal
edge of the flap is V-shaped to allow closure of the donor
area and the distal part is concave to join the palmar con-
vex incision to the web. This palmar concave incision
gives an extra length to the web and pulls the suture line
palmar to the mid-lateral line of the web floor with two
small triangular flaps at the base of the digits (Fig. 9).
Sherif successfully used this technique in 21 webs and
did not report any web creeping during the follow-up pe-
riods of 6 months to 2 years. The main disadvantage of
this flap is the presence of a dorsal scar (Fig. 10).
In our experience, closure without a skin graft is relat-
ed to two factors. Although the use of intermetacarpal
flaps like the island flap described by Sherif is able to
bring more skin to the inter-digital space, we believe that
removing the fatty tissue around the neurovascular pedicle
and along the full length of the finger is the key point for
primary closure. Indeed, drastic defatting decreases the
digital volume and, thus, gives proportionally more skin
for closure (Fig. 5c). Flatt explained how defatting is an
important step in his surgical technique of separation [17].
We recently reviewed 24 syndactylies that had been oper-
ated on using defatting combined with a traditional rectan-
gular dorsal flap or with a VY dorsal flap, and demon-
strated that closure without a skin graft was feasible in all
but one case, even in the group treated with the “tradition-
al” rectangular flap. We noted only one web contracture
due to postoperative infection. Although defatting may ap-
pear deleterious for future digital contour, the appearance
of the separated digits was comparable to the others at a
mean follow-up of 24 months. To benefit from maximal
digital fat fullness in a child, we advocate early division
between 3–6 months of age. Although some authors prefer
to perform division later (mainly for technical reasons),
we are convinced that the size of the neurovascular bundle

Fig. 10 Same case as Fig. 8.

Postoperative appearance
of the web and dorsal scars at
6 months

is sufficient to permit safe dissection at this age for experi-
enced surgeons using optical magnification. Unfortunate-
ly, associated pathologies may preclude this early release.
Conclusion
A plethora of publications about syndactyly release have
appeared during the past two centuries. The main steps
of evolution were the use of commissural flaps to cover
the web and the design of digital zigzag incisions. The
need for skin and the associated drawbacks of skin graft-
ing remain a challenging problem. During the last de-
cade, new dorsal flaps have been developed in order to
bring in new skin and to permit primary closure without
a skin graft. Digital defatting is an important step in the
surgical procedure to decrease the digital volume. Early
results with these flaps are encouraging and need to be
confirmed by longer follow-up.
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