Fingertip soft tissue defects present a challenging clinical problem, particularly in the elderly population. These injuries occur frequently due to a combination of age-related physical decline and lifestyle factors. Older adults often experience reduced visual acuity, slower reflexes, and diminished proprioception, increasing their susceptibility to hand trauma. Many elderly individuals remain active through hobbies or part-time work involving manual labor—such as woodworking or home repairs—where power tools like grinders and chainsaws are frequently used. These high-energy mechanisms often result in complex fingertip injuries requiring thoughtful reconstructive planning.

Treating such injuries in elderly patients poses unique difficulties. Compared with younger individuals, older adults have reduced tissue elasticity, slower wound healing, and compromised vascular integrity. These limitations are often compounded by common comorbidities such as hypertension, diabetes mellitus, and cardiovascular disease. As a result, reconstructive options are narrower, complication risks are higher, and recovery can be slower, prompting more cautious and conservative treatment decisions.

Traditional local flaps, such as the cross-finger flap [1,2] and thenar flap [2-4], are widely used for fingertip reconstruction. However, these techniques require prolonged immobilization, which can lead to joint stiffness and functional limitations—especially problematic in older adults with preexisting reduced range of motion. These flaps may also yield less satisfactory sensory and aesthetic outcomes compared with advanced microsurgical techniques.

Microsurgical reconstruction using a partial toe-pulp free flap offers several advantages, including durable coverage, restoration of sensation, and glabrous skin closely matching fingertip texture [5,6]. Despite these benefits, many surgeons hesitate to perform free flaps in elderly patients due to concerns about poor vascular condition, longer operative times, and higher perceived risk of failure. Underlying thrombotic or atherosclerotic changes can elevate the risk of anastomotic complications, reinforcing such hesitancy.

However, emerging evidence indicates that with careful patient selection and proper technique, free flaps can be performed safely even in older populations [7]. The partial toe-pulp free flap, in particular, has shown consistently high success rates and low donor-site morbidity.

The surgical technique followed the method described by Lee et al. [5]. In brief, a partial second-toe pulp flap was harvested under loupe magnification, including the plantar digital artery, a single plantar cutaneous vein, and the proper digital nerve. One artery, one vein, and one nerve were anastomosed in all cases in an end-to-end fashion. In elderly patients, recipient vessels often exhibited atherosclerotic changes or reduced elasticity; meticulous dissection to a healthy segment was therefore performed, with careful handling to prevent intimal injury. Toe-pulp free flaps generally have a low incidence of venous congestion; no such cases occurred in this series. If congestion were to develop, it could be relieved with a small pit incision as previously described [5]. No vein grafts were required, although a volar forearm vein was prepared as a contingency for tension-free anastomosis.

Postoperatively, patients remained on absolute bed rest for 7 days with a hand splint for protection. Standard ward care was provided, with intravenous prostaglandin E1 (PGE1) and first-generation cephalosporins administered. No routine systemic anticoagulants were used, and protocolized delirium screening and routine venous thromboembolism (VTE) surveillance were not performed.

The aim of this study was to evaluate the clinical outcomes and feasibility of partial toe-pulp free flap reconstruction in patients aged ≥65 years, a threshold aligned with widely accepted definitions of the elderly in clinical and public health literature. By focusing on this group—often considered high-risk or undertreated in fingertip reconstruction—we sought to assess whether age and common comorbidities should be considered barriers to microsurgical reconstruction. Our analysis included flap survival, donor-site morbidity, and patient-reported satisfaction. This study specifically addresses feasibility in this age group rather than re-comparing age cohorts or alternative flap types, which have been reported elsewhere.

This retrospective, multi-institutional series included consecutive patients aged ≥65 years who underwent partial second-toe pulp free flap reconstruction between 2020 and 2024. Non-operated candidates were not systematically recorded at all sites; therefore, a total screened denominator was unavailable.

Patients were eligible if they required reconstruction for fingertip soft tissue defects and received partial toe-pulp free flaps because of joint immobility (e.g., stiffness) or personal preference to avoid local flap procedures. Exclusion criteria included incomplete medical records or previous reconstructive surgery at the same injury site.

Donor selection followed a uniform protocol: the second-toe pulp from the foot ipsilateral to the injured finger was used. The great toe was avoided to reduce donor-site morbidity and footwear problems; contralateral harvest was reserved for ipsilateral contraindications.

Preoperative evaluation did not include routine Allen’s testing, perforator Doppler mapping, or computed tomography (CT) angiography. Because the flap is axial rather than perforator-based, handheld Doppler mapping was not applicable, and CT angiography was not routinely obtained given its limited ability to visualize very distal vessels in this context. Bedside perfusion was assessed clinically, and recipient vessel quality was confirmed intraoperatively. If a diseased or short segment was encountered, more proximal dissection to a healthy vessel was performed; interposition vein grafting using a volar forearm vein was available to ensure a tension-free anastomosis.

Procedures were performed under regional anesthesia: brachial plexus block with spinal anesthesia before 2021, and brachial plexus block with popliteal sciatic nerve block thereafter [8]. Across centers, skin-to-skin operative time was not uniformly recorded; based on scheduling records and operative notes, the typical duration was approximately 120 to 150 minutes.

Data were collected retrospectively from surgical and inpatient records, including age, sex, injured finger and side, mechanism of injury (crushing injury, incomplete amputation, or complete amputation), comorbidities (hypertension, diabetes mellitus, cardiovascular disease), smoking status, anesthesia method, and defect size. Comorbidities were abstracted as binary variables (present/absent) from the electronic medical record, and smoking status was recorded as current smoker: yes/no. No severity indices (American Society of Anesthesiologists physical status classification, hemoglobin A1c, estimated glomerular filtration rate, pack-years) were collected.

Outcome measures included flap survival (complete, partial, or failure), donor-site morbidity, and patient satisfaction (categorized as very satisfied, somewhat satisfied, or not satisfied).

A partial toe-pulp flap was harvested from the second toe under loupe magnification. The fingertip defect was debrided, followed by microsurgical anastomosis to the appropriate digital vessels. All donor sites were closed primarily.

Postoperatively, patients remained on absolute bed rest for 7 days. A hand splint was applied for 1 week, after which ambulation and hand mobilization were initiated. First-generation cephalosporins and PGE1 were administered intravenously. No systemic anticoagulants (e.g., heparin) were used.

Follow-up was defined as the interval from surgery to the last documented outpatient or telemedicine contact. Timing of follow-up was not uniformly recorded across centers. Patient satisfaction was recorded on a 3-point Likert scale; reasons for ratings were not collected.

A total of 21 consecutive elderly patients met the inclusion criteria and underwent reconstruction; these cases comprise the analytic cohort. Patients frequently declined surgery when they were unable or unwilling to comply with 7-day absolute bed rest or preferred faster wound closure with less intensive postoperative care. All flaps were harvested from the second toe; laterality matched the injured hand in all cases. No contralateral harvests were required.

Comorbidity frequencies are summarized in Table 1. Fourteen patients (66.7%) were smokers, and 12 patients (57.1%) had at least one underlying condition: hypertension (n=10), diabetes mellitus (n=5), and cardiovascular disease (n=1). The most common mechanism of injury was crushing injury (n=12), followed by incomplete amputation (n=7) and complete amputation (n=2). Anesthesia was administered as a brachial plexus block plus spinal anesthesia in 14 cases before 2021, and as a brachial plexus block plus popliteal sciatic nerve block in the remaining seven cases.

No donor-site morbidity occurred, and all flaps survived. No wound complications were documented; however, structured donor-site symptom surveys were not performed, so minor symptoms may have been under-detected. Follow-up was typically 3 to 4 months; precise dates were inconsistently available. Patient satisfaction was “very satisfied” in 13 cases (61.9%), “somewhat satisfied” in four (19.0%), and “not satisfied” in four (19.0%). Reasons for dissatisfaction were not systematically recorded. No cases of delirium or deep-vein thrombosis/pulmonary embolism was documented during hospitalization; these complications were not assessed systematically.

Fingertip soft tissue defects in elderly patients present a unique reconstructive challenge due to age-related physiological changes and comorbidities. Historically, free flaps in this population were often avoided because of concerns regarding poor outcomes. Our data suggest that, in carefully selected elderly patients with stable systemic conditions, partial second-toe pulp free flaps can be a reasonable option when performed with meticulous planning and technique.

Local flap techniques such as cross-finger or thenar flaps are often avoided in elderly patients due to prolonged immobilization, multiple procedures, and increased risk of stiffness. Delayed rehabilitation can further compromise hand function [9,10].

While local flaps require less specialized equipment and are technically less demanding, all procedures in this series were performed by surgeons with microsurgical competence, rendering the technical demands comparable to fingertip replantation. In our series, all procedures were performed by surgeons who had already acquired microsurgical competence through digital replantation, typically within 1–2 years after board certification.

The partial toe-pulp free flap closely matches the glabrous tissue of the fingertip in texture and durability, providing superior cosmetic and functional outcomes. In our 21 patients aged ≥65 years, flap survival was 100%, with no donor-site morbidity and high satisfaction rates.

No significant association was found between comorbidities or smoking status and flap survival, although this likely reflects selection bias. In our clinical practice, patients with severe or uncontrolled systemic conditions—such as poorly managed diabetes or unstable cardiovascular disease—were informed of the increased surgical risk. Consequently, some high-risk individuals declined surgery, while others were excluded during preoperative assessment. Moreover, Arterial anastomosis requires absolute bed rest for 7 days, which can be a considerable burden for elderly patients. While none of our patients experienced complications due to this protocol, discomfort, poor compliance, or the risk of delirium must be considered. Patient selection should therefore account not only for vascular and systemic health but also for functional and cognitive capacity to comply with postoperative care.

In contrast to common microsurgical protocols that use PGE1 and systemic heparinization, we administered PGE1 alone due to concerns about bleeding risk in elderly patients [11,12]. This adjustment proved both safe and effective in our series.

Unlike protocols using PGE1 with systemic heparinization, we used PGE1 alone, minimizing bleeding risk without adverse outcomes [11,12]. Technical considerations in elderly patients include avoiding diseased vessel segments, harvesting the plantar digital artery to maximum length, and using vein grafts when necessary to prevent tension. Attempting an anastomosis under tension increases the risk of thrombosis and should be avoided.

In the past, free flap reconstruction was often avoided in elderly patients due to concerns about suboptimal outcomes and higher perceived risks. Our findings suggest that, in carefully selected elderly patients with stable systemic conditions, partial toe-pulp free flaps can be considered a reasonable reconstructive option when performed with meticulous planning and surgical technique.

As summarized in our prior report [10], the partial second-toe pulp flap offers native glabrous pulp with volume/texture match and typically allows primary donor closure, whereas the radial artery superficial palmar branch flap provides a long pedicle with a forearm/hand donor scar; operative complexity is comparable for surgeons experienced in digital replantation. Those comparative data provide context for reconstructive choice, and the current series complements them by addressing elderly feasibility.

As reported previously by our group [13], among 246 partial second-toe pulp flaps, early donor-site wound complications occurred in 5.3%, and 28% of long-term respondents reported low-intensity donor-site pain not limiting daily activity, with overall satisfactory appearance, suggesting low but non-zero donor-site morbidity in routine practice.

This study has several limitations. First, the sample size was relatively small, and all patients were treated at specialized centers by experienced microsurgeons, which may limit the generalizability of the results. Second, objective severity indices were not collected, precluding dose–response analyses and limiting generalizability; findings should be interpreted within a cohort defined only by binary comorbidity coding. Granular timing data (total operation time, microanastomosis time) were not systematically captured across institutions, precluding analyses of factors influencing operative duration. Donor-site symptoms were not captured with a validated patient-reported outcome measure in the current cohort; therefore, mild discomfort or sensitivity could have been missed. Reasons for satisfaction ratings were not captured, so specific drivers of dissatisfaction could not be analyzed.

Moreover, patients with severe or uncontrolled comorbidities were either excluded during preoperative assessment or declined surgery after counseling, introducing a selection bias toward healthier individuals. Because non-operative cases were not systematically logged, selection bias cannot be quantified; accordingly, we present descriptive feasibility data and avoid causal “no association” claims. Therefore, our conclusions should be interpreted within the context of this carefully selected cohort, and further studies with larger, more diverse populations are needed to validate these findings. Lastly, follow-up capture was incomplete and non-uniform, precluding formal assessment of long-term outcomes (e.g., quantitative sensibility, cold intolerance). Findings should be interpreted as early/short-term results.

Future studies comparing long-term sensory recovery, cold intolerance, and fine motor performance between free flaps and local flaps in the elderly may further clarify indications. The absence of protocolized delirium/VTE surveillance may have led to under-detection; future studies should assess earlier mobilization under formal monitoring protocols.

Partial toe-pulp free flap reconstruction is a safe and effective option for fingertip soft tissue defects in elderly patients. Despite common concerns about vascular fragility, comorbidities, and recovery tolerance, all 21 flaps in this series survived completely without donor-site morbidity. These findings support feasibility in selected elderly patients; broader claims will require prospective, comparative studies. Patient satisfaction was high, and no correlation was observed between chronic disease or smoking status and clinical outcome.

With careful patient selection and appropriate microsurgical technique, age and underlying medical conditions should not be considered contraindications. When functional and aesthetic restoration is a priority, the partial toe-pulp free flap should be regarded as a reliable first-line option—even in patients aged 65 years and older.