Page 82 - Read Online

Artiaco et al. Plast Aesthet Res 2023;10:57 https://dx.doi.org/10.20517/2347-9264.2022.145 Page 7 of 11

Skin grafting and synthetic skin substitutes
After initial debridement and appropriate antibiotic treatment of infected lesions, skin graft and dermal
substitutes can be a valuable solution for superficial STL of the hand, provided that no signs of infection are
present.

Skin grafts of variable thickness may be used to cover STL areas, provided that the vascularization of the soft
tissue bed is healthy. This type of graft is ideally applied when the defect does not require volume
restoration and when deep structures are not exposed. Notably, in complex STL, due to complicated wound
infection, scarring and fibrosis with non-optimal wounds are often observed, representing a potential cause
of skin graft failure .
[28]

Full and split-thickness skin grafts may be harvested for soft tissue coverage, but split-thickness is the most
commonly used. Split-thickness skin graft does not require donor site coverage, and it can be easily adapted
to the area of tissue loss. Furthermore, it can mesh to cover a larger surface area, allowing eventual drainage
[28]
for blood and serum .
Flaps
Flaps are the most reliable solution for covering medium to large infected STL of the hand. They are
reserved for severe hand injuries that involve deep structures such as tendons, nerves, and blood vessels in
which the defect can be covered by reconstructing tendons and bones in a single surgical procedure if
needed .
[26]

Flaps are classified into cutaneous, fasciocutaneous, fascial, adipofascial, and composite (including bones
and tendons) according to composition, and into the rotation, advancement, and transposition flaps
according to transfer method. Flaps are further classified into local, regional, and distant flaps depending on
their position regarding STL to restore .
[25]

Pedicle flaps
Local flaps

Local flaps consist of skin and subcutaneous tissue that originate close to the primary defects, and that is
mobilized into the wound bed . Local flaps, derived from tissue surrounding the hand injured area, offer
[29]
many clinical advantages such as few days of hospitalization, early mobilization, and reduced stiffness
[27]
risk .
Local flaps require several evaluations before being performed. First, the receiver area should be prepared
with appropriate debridement to optimize flap positioning. Furthermore, the donor site may be evaluated
before sampling through a Doppler ultrasound or angiography to assess the vascularization [25,29] .

Local flaps are differentiated into random and axial pattern flaps . Random pattern flaps have no
[3]
established supply vessels and are characterized by subdermal vasculature with a random distribution
pattern. Due to the restricted perfusion pressure, the flap size is limited to a 1:1 ratio. Rhomboidal, rotation
and transposition flaps are random pattern flaps examples . Instead, axial pattern flaps are based on a
[25]
specific artery termed angiosome, which directly supplies the skin and subcutaneous tissues. Furthermore,
interconnections between branches of adjacent axial vessels connect contiguous cutaneous territories.
Consequently, axial flap size may be more extensive than random pattern ones due to the greater perfusion
area provided by axial vessels. Axial pattern flaps examples are the first dorsal metacarpal artery (FDMA)