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Bertolini et al. Plast Aesthet Res 2023;10:34 https://dx.doi.org/10.20517/2347-9264.2022.121 Page 11 of 25

Composite venous flap and palmaris longus (PL) tendon might be useful to reconstruct soft tissue defects
along with tendon loss. This technique requires microsurgical reconstruction, arterializing one vein of the
flap with an anastomosis with the digital artery and connecting another vein with the finger venous
system [92,93] .

Zone 2
The management of zone 2 extensor tendon defects employs the same technique described in relation to
zone 1, considering particularly local tendon flap and interposition tendon graft (palmaris longus tendon) .
[1]

Regarding local tendon flap, the defect is bridged with a tendon graft harvested from the proximal portions
of the extensor tendon and flipped distally to fill the gap [Figure 4] .
[64]

Zone 3
Due to the unique anatomy of the extensor tendon in zone 3 and the different structures that could be
involved, various reconstructive procedures could be performed [66,70] .

If the lateral bands are intact, they may be divided longitudinally, centered over the proximal
interphalangeal (PIP) joint and sutured to each other . If the proximal portion of the extensor tendon is
[59]
intact, a distally based tendon flap may be harvested from this tendon portion and flipped over distally to
overcome the gap [Figures 5 and 6] .
[94]
If the lateral bands and the proximal portion of the extensor tendon are damaged, interposition tendon
grafting or, in case of associated soft tissue injuries, composite tissue grafting should be considered [59,61] .

Zone 3 extensor tendon defects should be managed carefully, proposing a reconstruction that manages to
[59]
overcome the gap as well as to prevent the development of boutonnière deformity .

Zone 4
Since in zone 4, extensor tendons gradually show more girth than in the previous zones, tendon gap
restoration may be more simple [59,61,72] . Again, two main reconstructive methods should be taken into
consideration: local tendon flaps and interpositional tendon reconstructions .
[72]
Zone 5
Compared to zone 4, the treatment of defects in zone 5 also includes the use of tendon lengthening
[75]
techniques .
Zone 6, 7 and 8
The extensor tendons in zone 6-8 are characterized by a parallel course and a greater degree of excursion. In
cases of single extensor tendon defect, with adjacent tendons in continuity, a straightforward method to
overcome the gap is to suture the injured tendon to a close tendon using a side-to-side suture. However, this
new pattern is biomechanically inefficient, altering the alignment of tendons and creating overloading on
the donor tendon; this might lead to early tendon ruptures [95,96] . Accordingly, even in zone 6-8, tendon
lengthening procedures and interposition tendon grafts should be considered when planning the
reconstruction . Among tendon lengthening procedures, Cerovac and Miranda described the tendon
[73]
turnover technique, where the tendon ends are L-shaped cut and flipped over to reconstruct the gap .
[75]
Another surgical option suitable for significant tissue and tendon loss is the two-stage extensor tendon
reconstruction employing a silicone rod [65,83,97] .