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Page 2 of 10 Ciclamini et al. Plast Aesthet Res 2023;10:62 https://dx.doi.org/10.20517/2347-9264.2022.132

INTRODUCTION
The management and reconstruction of soft tissue defects of the hand require a proper "mental approach",
like that of an experienced handicraftsman. Experience, art, ability with your hands, a sense of beauty, and a
sense of usefulness come together to help accomplish the task. This surgery aims to get both a functional
and an aesthetical repair of tissue losses. The "like with like" principle summarizes unifying functional and
aesthetic aspects. Unfortunately, the characteristics of the skin of the hand are particular, meaning that the
function of the hand is very advanced and specific. As a fact, few other tissues around can replace the hand
tissues without impairing function and at the same time mimicking its aesthetic properly. Therefore, thin
flaps are always a prerequisite in hand repair. Given that a thin flap is not always the first choice for multiple
reasons, the "flap thinning" technique helps optimize the transferred tissue to mimic and shape the hand
skin.

AESTHETIC AND FUNCTION
The aesthetic of the hand is well-known, depending mainly on its proportions, as described by
[1]
Jakubietz et al. . Painting of ancient artists such as Michelangelo, Leonardo Da Vinci, and others depicted
wonderfully the correct proportions of the hand. The soft tissue envelope with a valid quantity of
subcutaneous fat creates visible grooves, concavities, and prominences. The palmar skin is clear, hairless,
sensible, thick and fixed, adherent to the palmar fascia, thus allowing the grip of the objects. On the opposite
side, the dorsal skin is darker, partially hairy, less based on refined sensibility, relatively thin, pliable and
extensible, allowing for movements of flexion and extensions, and tends to get even thinner with aging.

The function of the hand is always the main issue, typically not questioned when it comes to reconstruction.
Del Pinal has described how to get a correct functional reconstruction of the hand for bone and soft
tissues . He also primarily affirms that a patient will use a mutilated/reconstructed hand only if it is
[2]
tolerable to him/her, thus strongly connecting the functional results to the aesthetic aspects. In a reasonable
prospect, the soft tissue reconstruction should allow the correct functioning of the bone (residual finger,
hand cascade, tripodal hand, amputated rays and stumps) and mobile structures (free or fused joints,
residual flexor and extensor tendons). It should also apport the necessary sensibility, mainly in the fingers
and palm. Flaps should also respect the main characteristics of palmar (thickness, fixed) and dorsal
(thinness, elasticity) skin when possible.

LIKE WITH LIKE
Considering these principles, trading function for a better appearance is not an option. Nevertheless, good
cosmetic is often associated with good function because the complex attempt to get a proper aesthetic
always traduces itself into a better functional reconstruction. Here is where "like with like" comes in handy.

Palmar aspect
The surgeon must finalize the reconstruction of the palm and the palmar skin of the fingers to enable a
pain-free grip, prevent adherence, and restore sensibility. At the same time, he should avoid loose skin,
bulkiness, and complete numbness. Fasciocutaneous flaps with an excessive layer of fatty tissue, causing the
"savonnage" effect (a French word meaning slipping or gliding) and looseness of the grip, should be
avoided.

The skin of the fingers is the most difficult to reproduce because it perfectly wraps the shape of the fingers,
giving adherence but also flexibility. There is no source of similar tissue in the body apart from the toes. As
such, degloving injuries of fingers are the most difficult to repair, whereas amputated fingers can be
replaced with toe transfers, thus obtaining a more cosmetic and functional hand. Adani et al. defined a clear