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Page 6 of 11 Artiaco et al. Plast Aesthet Res 2023;10:57 https://dx.doi.org/10.20517/2347-9264.2022.145

Figure 4. Control after 10 days of NPWT with a clean wound bed.

on NPWTi-d recommended its application with the instillation of saline solution, hypochlorous acid
solution, sodium hypochlorite solution, acetic acid solution, and biguanides . The superiority of one
[21]
solution over the others has not been demonstrated, and it has been suggested that the instillation is the
determining factor for the outcome of treatment. The antibiotics topical instillation is not currently
recommended or supported by a clinical high level of evidence studies [20,21] .

In summary, NPWT is highly important as it provides the necessary substrate to structures, such as bones
or tendons, that would otherwise be unsuitable for covering with grafts through granulation tissue
stimulation and formation.

TREATMENT OPTIONS FOR SOFT TISSUE RECONSTRUCTION
Adequate tissue coverage is necessary to restore hand function and reduce stiffness risk and disability.
Infected wound debridement could leave a large STL, which may be treated with various strategies. The
reconstructive procedures should be evaluated case-by-case according to several factors. They include
wound size and location, injury complexity, structure exposure, surrounding tissue conditions, and patient
comorbidities, such as diabetes and vascular disease, which may predispose to severe infections and surgical
procedure failures . In hand reconstruction, fundamental principles such as function restoration, donor
[1]
tissue accurate assessment, and sensitivity and motility preservation should always be considered .
[22]

Early studies in the literature suggested an early coverage of STL to prevent flap failure because fibrosis and
scarring may cause vascular impairment [1,10] . Recent studies have demonstrated that delayed coverage is
effective and safe, reporting no differences in flap outcome based on reconstruction timing [11,23] .
Furthermore, delayed coverage may positively affect flap viability due to multiple debridement and NPWT,
which could optimize the wound bed and reduce the infectious risk before final soft tissue coverage [24-26] .

The STL coverage should be delayed until the infection is solved. Clinically, oedema reduction, absence of
purulent material, and adequate granulation tissue formation may be observed. At the same time, blood
parameters should demonstrate a progressive trend toward inflammatory resolution. When these
conditions are obtained, several coverage options can be adopted, varying from local skin substitutes in the
case of a minor STL to flaps for more extensive lesions . As a general rule, a progressive approach
[27]
according to the reconstructive ladder should be followed, using the simplest possible procedure for soft
tissue coverage. The risk-benefit balance has to be considered, especially in the most complex procedures,
evaluating the expected result and discussing with the patient his functional requests.