The Forgotten Healer: The Role of Adipose Tissue in Spontaneous Healing After Free Flap Finger Reconstruction

Background: Digital pulp reconstruction with toe based flaps reliably restores sensibility, durability, and contour, one aspect that has received little attention is the healing be-havior of viable digital fat. This study evaluates outcomes from a large series of free toe flaps with specific attention to the healing behavior of preserved subcutaneous fat and its contribution to contour refinements. Methods: We retrospectively reviewed consecutive digital reconstructions performed with free toe flaps and several variations (pulp toe flap, chimeric pulp toe flap, trimmed great toe flap and chimeric pulp+ trimmed great toe). Particular attention was given to healthy subcutaneous fat deliberately maintained or exposed to help shape the final contour. All patients were followed clinically and pho-tographically until complete healing occurred. Results: A total of 133 patients underwent a finger reconstruction with a with free toe flaps and several variations. The preserved fat layer was intentionally left exposed to promote healthy granulation and spontaneous epithelialization, contributing favorably to the final contour of the distal pulp as the nail advanced. All wounds healed within three to four weeks without the need for skin grafts. All patients achieved good to excellent functional and aesthetic outcomes with minimal donor-site morbidity .Conclusion: This large retrospective series confirms the reliability of healthy flap to help in the shape of the digital reconstruction, highlighting the re-generative potential of viable digital fat. Incorporating this concept into flap design may reduce the need for grafting, minimize donor-site morbidity, and enhance reconstructive outcomes in hand surgery.