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Ciclamini et al. Plast Aesthet Res 2023;10:62 https://dx.doi.org/10.20517/2347-9264.2022.132 Page 3 of 10

general guideline that is still a standard for degloving injuries of fingers: the replantation, when possible,
[3-7]
gives the best results . The original tissue of the patient is a wealth that, once lost, can never be achieved
[8]
again. Toe transfer is a second option, especially for thumb reconstruction. Wrap-around (CIT) or
trimmed-toe (CIT) flaps can also be a valuable option for some cases of amputated or degloved fingers,
[9]
allowing excellent coverage with fewer donor site morbidity, since the P1 of the toe is preserved. Flaps with
the best "like with like" principles are the last resource for multiple long fingers degloving. In the case of
fingers, when possible, the best "like with like" always comes with a local flap from the hand or adjacent
fingers. A pedicled reverse flow dorsal intermetacarpal artery propeller flap, even of considerable size, is a
good option and relatively respects the "like with like" principle. Reverse dorsal digital island adipofascial
flaps, like those described by Del Bene , with or without split-thickness skin grafts (STSG), are ideal for
[10]
slight palmar loss of the substance of fingers. When finding a local flap is impossible, a functional flap is the
island pedicled reverse flow radial forearm flap, even though it is already a significant compromise for both
the functional and the aesthetic aspects. Small free flaps or arterialized venous free flaps harvested from the
volar part of the forearm, especially in thin patients, are suitable for volar reconstructions of fingers [11]
[Figures 1, 2 and 3]. They can also provide sensory function when a superficial cutaneous nerve branches in
the flap. In degloving finger injuries, it is virtually impossible to restore the sensibility. The avulsion of nerve
pedicles sometimes results in the absence of innervation. In the case of the presence of nerve pedicles, even
a primary nerve repair gives poor results, mainly out of the mechanism of injury and the different
innervation of the transferred tissues.

The skin of the hand palm is thick, sensible and adherent, but fortunately, its shape is more straightforward
to retrieve, and sensibility is less necessary compared to fingertips. Furthermore, in superficial injuries, a
well-vascularized palm bed makes the reconstruction relatively simple since a full-thickness skin graft gives
optimal results regarding adherence, proper thickness, and flexibility CIT. Tubiana, in 1996, described the
[12]
[13]
functional cutaneous units of the palm : the mobile units and the adherent ones, thus guiding the search
for the best-replacing tissue. He also defined the units of tactile gnosis, distinguishing between primary,
secondary, and tertiary regions of touch. Consequently, he prioritized the areas where the surgeon must
restore the best sensibility from those areas of the palm where a lighter sensation is enough. However, in
more profound and more extensive injuries, when tendons, vessels and nerves need to be covered, free
muscle flaps with STSG are a valuable option. The gracilis free flap with STSG is optimal, with fast
dissection time and minimal donor site morbidity. The initial bulkiness of muscle flaps does not represent a
limit since denervated muscles get thinner over a short time. Unfortunately, sensibility remains an issue in
free muscle flap reconstructions. The most extensive and complete palm loss of substance can benefit from
the best "like with like" reconstruction of the palm. The medial plantar free flap is the gold standard to
restore a perfect palm, with skin entirely similar to the palm skin and excellent sensibility thanks to the
[15]
medial plantar nerve. Adani et al. and Ono et al. (CIT) summarized a clear reconstructive ladder of
[14]
hand tissues with its major aims [Tables 1 and 2].
It is challenging to achieve functional and aesthetic results in extensive degloving injuries of the whole palm
and fingers, and the main goal remains the savage of the limb. In eastern people, the free anterolateral thigh
(ALT) perforator flap is an advantageous choice due to the inherent thin tissue characteristics of individuals
in this region. On the other hand, the distal inferior epigastric perforator flap (DIEP flap) is more of an
opportunity in Western people since it can be harvested over the Scarpa fascia, giving a thinner flap
compared to the ALT. The superficial circumflex iliac artery flap (SCIP), the lateral arm flap (LAF), and the
dorsalis pedis flap (DPF) are an option. The profunda artery perforator (PAP) flap can also be a very good
alternative for large coverage of the hand, minimizing aesthetic damage, especially in young females, since
sometimes the scars left by the ALT flaps are fairly acceptable . (CIT) Syndactyly of all fingers is often
[16]