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Page 8 of 10 Ciclamini et al. Plast Aesthet Res 2023;10:62 https://dx.doi.org/10.20517/2347-9264.2022.132

Table 3. Flap classification based on dissection level by Rios et al. [36]
Flap dissection
Subfascial below the deep muscle fascia
Suprafascial above the deep muscle fascia and below the superficial adipose fascia
Thin on the plane of the superficial adipose fascia
Super thin above the superficial adipose fascia
Pure skin perforator flaps only skin and subdermal plexus vessels

and allows thinner flaps with lower donor site morbidity [36-38] . Park underlined two critical concepts in
[39]
thinning procedures: the flap size and the defatting extension. Concerning the first item, he reported results
of various clinical studies from which it emerges that the safe dimension of a thin flap is 17-18 cm . As per
[40]
the defatting extension, the second point has no clear answer in literature [39,41,42] . Many studies reported that
preserving adipose tissue approximately 3 cm from the pedicle could be sufficient to protect intra-adiposal
branches [28,43-45] .

CONCLUSIONS
The "like to like" and the "flap thinning" are two workhorse principles the surgeon must keep in mind to
achieve a functional and cosmetic reconstruction of the hand. In addition, the knowledge of functional
cutaneous units of palm and units of tactile gnosis, together with palmar and dorsal skin characteristics, can
prioritize the reconstruction. When larger-sized substance losses jeopardize the flap choice, knowledge of
the architecture of the different layers of tissue helps to transform bulky flaps into more well-shaped tools.
Remember that no tissue can replace the original one: a mean replantation is often better than a perfect
secondary reconstruction.

DECLARATIONS
Authors’ contributions
Made a substantial contribution to writing different sections of the paper: Ciclamini D, Fissore F, Arioli L
Provided literature research and analysis: Giacalone F, Battiston B
Provided clinical cases and pictures: Ciclamini D, Battiston B
Provided help revising the paper before submission: Fissore F, Ciclamini D

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
The study does not need the review board's approval since no ethical issues are involved. It is a review
paper. Informed consent was obtained from the patients involved in this manuscript.

Consent for publication
The study obtained WRITTEN consent from patients (Figures 1-5). The related files are in the clinical
documentation of our institution and typically can not be copied or sent to editorial boards. Nevertheless,