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Page 2 of 8 Battiston et al. Plast Aesthet Res 2023;10:25 https://dx.doi.org/10.20517/2347-9264.2022.130

intact osteoarticular structure depend not only on the skin coverage but also on the maintained function of
tendons, vessels, and nerves. The new achievements in the research of skin blood supply, biological repair,
[5,6]
and tissue bioengineering , together with the advances in reconstructive surgery, allowed the finding of a
vast armamentarium of methods to solve this kind of defect. The skin of the palmar region differs from the
dorsal one in thickness and flexibility and is important for the coverage of noble structures. Additionally,
the dorsal skin is characterized by high mobility with respect to the underlying tissues, allowing complete
flexion and extension of the fingers . The accurate reconstruction of the involved tissues and early
[7,8]
mobilization are the cornerstones for restoring proper function. One of the aspects, which still sparks a lot
of discussions, is the right timing for the reconstruction [9,10] : immediate or delayed, one or two stages. If a
staged approach is deemed to be the best for the patient, the primary reconstruction should enhance and in
no way compromise the secondary procedures.

This issue will focus on the type of defects (site, size, involved tissues), the timing of reconstruction, and the
possible methods to be used, always considering the patient's profile with their general clinical conditions.

ETIOLOGY
Soft tissue defects of the hand may result from trauma or may follow surgery as it happens in oncological
procedures or after debridement of severe infections. A systematic and correct anamnesis, together with the
first clinical evaluation of the patient and the lesion, may help to determine the nature of problem and then
the etiology. The anamnestic data are essential to understand the etiology and focus on possible factors
[11]
influencing the treatment and prognosis, defining possible complications and eventual final disabilities: age,
sex, diabetes or other systemic diseases, vascular problems, conjoint drug assumption, smoking, and alcohol
dependency. However, sometimes this might be difficult, i.e., when facing a traumatic defect in polytrauma
or unconscious or non-cooperative patients. Then, laboratory and instrumental exams will follow to guide
the surgeon to the right treatment plan.

Traumatic defects
The nature of the trauma responsible for the loss of substance must be taken into consideration, as well as
the causing agent and the mechanism of injury, the energy of the trauma, the timing of the accident, the site,
dimensions, and characteristics of the lesion, as those pieces of information can guide to plan the extent of
trimming, to predict the risk of edema and its consequences and, possibly, to guide the choice of a
therapeutic option. The most common types of trauma leading to loss of substance are :
[12]
● Abrasion: abrasion lesions mainly concern the dorsal surface of the hand and fingers and may be
accompanied by tendon and joint lesions. The classic "door hand" is encountered during road accidents and
results from violent abrasion of the dorsal side of the hand and fingers against the road pavement. Tendon
lesions and osteoarticular apparatus may be associated.

● Avulsion: cutaneous avulsions occur on the dorsal or palmar surface, often in continuity with the avulsion
of the digital skin. These injuries are usually caused by industrial machines with driving rollers; underlying
osteoarticular lesions by crushing can be observed .
[13]

● Crushing: those injuries are caused by industrial machinery such as a pneumatic press or power hammer;
the articular lesions are often complex and comminuted, and it is sometimes difficult to appreciate the
importance of the cutaneous trimming to carry out in urgency. In this context of crushing, one must fear
the occurrence of significant postoperative edema [14,15] .