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Bertolini et al. Plast Aesthet Res 2023;10:34 https://dx.doi.org/10.20517/2347-9264.2022.121 Page 9 of 25

Surgical techniques
If the extensor tendon primary repair is not possible due to tendon loss, a number of procedures have been
developed to repair the extensor system. Particularly, the main surgical techniques employed are tendon
lengthening, tendon graft, and tendon transfer [61,66,67,72] .

Lengthening of the tendon may be done to achieve additional length in a small to moderate extensor tendon
gap, especially in more proximal lacerations where the extensor tendons have more thickness [58,66] . The
modified Baker technique (U-T plasty) and Z-plasties are recommended because of their simple technique,
[73]
favorable biomechanical characteristics, and early rehabilitation .

There are also reconstructive techniques for chronic lesions of the extensor pollicis longus (EPL). One
example is the L-lengthening local tendon flap described by Lobo-Escolar et al., which avoids the use of
tendon graft or tendon transfer .
[74]

Another extensor tendon reconstructive option is the use of local or distant tendon flaps. Both these
techniques are anatomically feasible and technically quick to perform, but local tendon flap harvesting
avoids distant donor site morbidity and provides morphologically similar donor tendon that is readily
accessible [72,75] .

When local procedures cannot adequately resolve significant tendon gaps, tendon grafting offers a relevant
surgical solution [76,77] . The palmaris longus (PL) or strip of the flexor carpi radialis (FCR) are useful as
donors for small defects, whereas the plantaris tendon is suitable for large gaps or when multiple grafts are
required . Other examples include extensor digitorum longus of the middle and small toe, extensor
[71]
proprius indicis, extensor digiti minimi, abductor pollicis longus and accessory abductor pollicis longus
[59]
tendons .
In cases of multiple finger injury, if one finger requires amputation or joint fusion, tendon grafts could be
harvested from this finger and employed to reconstruct tendon gaps in another finger .
[78]

Adequate tendon length is crucial for a functional outcome. When placing the tendon graft, care must be
given to determine the graft length to reconstruct the extension mechanism and ensure complete flexion in
[72]
wrist and hand joints .

The suture technique introduced by Pulvertaft in 1956 is one of the most reliable suturing methods for
[77]
joining the tendon ends .

The maintenance of the anatomic axis of tendon function and the minimal donor site morbidity are two of
the main benefits of tendon grafts with respect to tendon transfers .
[79]

In cases of extensive trauma of the dorsum of the hand with severe soft tissue damage, previous surgical
approaches may not be sufficient to guarantee a functional clinical outcome. Usually, these large defect
treatments require both stable skin replacement and tendon repair, using microsurgical reconstruction, in a
single-stage procedure or, more frequently, in a multiple-stage procedure [59,66] . Fasciocutaneous flaps and
free-functioning muscle transfer, with or without the application of silicon rods and followed by delayed
tendons transfers graft, as well as free composite tissue flap (tendons and soft tissue flap, especially from the
lower extremity, e.g., dorsalis pedis flap with extensor tendons of the toes) can help to re-establish hand
function [62,80-82] .