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Battiston et al. Plast Aesthet Res 2023;10:25 https://dx.doi.org/10.20517/2347-9264.2022.130 Page 3 of 8

● Burn: splashes of molten metal or lesions due to heating presses can cause deep third-degree burns,
sometimes concerning both the palmar and dorsal sides of the hand. Again, the occurrence of significant
postoperative edema should be feared. Several successive trimming times are often necessary, given the
difficulty of urgently assessing the exact extent of the burn [16,17] .

● Gun wounds often cause stereotypical lesions with an inconspicuous entry portal and an extremely
dilapidated exit orifice. Regarding penetrating wounds, the lesions are usually mixed: vascular, tendinous,
osteoarticular, and cutaneous .
[18]

The involved structures (skin, muscles, tendons, bone and joints, vessels, nerves) are finally the elements to
be examined individually for precise evaluation and classification of the lesion. After an accurate inspection
of the defect, a functional exam is mandatory to check distal vascularization through the presence of
peripheral pulses, lack of function due to muscle-tendon damage or nerve lesions, looking not only for the
motor but also for sensory deficits .
[19]

[20]
Instrumental exams should complete the clinical evaluation . Even if the lesion mainly involves soft
tissues, an X-ray examination may help identify underlying bone and joint problems or foreign bodies.
Echography [21,22] is a rapid and non-invasive system to evaluate soft tissues, even dynamically if necessary,
completed by an echo-Doppler if the vascular system needs to be assessed. Second-level exams may be MRI
and angiography or angio TC when required.

The clinical exam of a severe lesion with tissue loss is often better performed in the operating room, in
sterile conditions, and with good illumination. The lesion should preferably be documented even with
photos. The debridement and gradual exam of the lesion, going from superficial to deep, should give data
on vascular perfusion through the color of the structures, turgor, bleeding, and capillary refill. Particularly,
[23]
the muscle evaluation should follow the four C's rule : Color, Contractility through mechanical or
electrical stimulation, Consistence, and bleeding Capacity. Tendon and nerve continuity is finally assessed.

Defects from surgical procedures
The technical issue of reconstructing a tissue loss from the surgical excision of a tumor or severely infected
tissues may be similar. In both situations, the surgeon performing the excision of the involved tissues should
do it widely to avoid recurrences of the pathology, eventually leaving tissue loss but with healthy margins.
As for the traumatic defects, the treatment plan should consider the site, dimensions, and characteristics of
the defect together with the involved structures.

Tumors
The current multimodal approaches, combining wide surgical resection with radiotherapy and/or
chemotherapy, allow limb preservation in 90%-95% of patients [24,25] . The excision plan is generally performed
after the pre-operative clinical and instrumental data acquisition, allowing the reconstructive surgeon to
program the best anatomical and functional repair option. Ultrasound and MRI are helpful diagnostic
tools [26,27] . Surgical margins are the essential factor associated with local tumor control [28-30] , but obtaining
good oncological margins can result in extensive or critical loss of bone and soft-tissue components [31-33]
which could then need an appropriate plan of reconstruction which is generally to be performed after the
tumor resection in the same surgical act.

Malignant tumors of the hand needing extended resections with a risk of soft tissue defects are uncommon,
though it is important to know them . Among the bone tumors of the hand are described high-grade
[34]