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Page 8 of 11 Artiaco et al. Plast Aesthet Res 2023;10:57 https://dx.doi.org/10.20517/2347-9264.2022.145

flap, the dorsal metacarpal artery perforator flap (DMAP), and the advancement flap from the same thumb
[25]
(Moberg type) .
Regional flaps

Regional flaps are obtained from an adjacent uninjured finger or hand region. The donor site is not adjacent
to the wound, and a specific pedicle is recognized. The flaps may be moved to the STL area, and
vascularization is provided by the pedicle, which remains anchored at the origin site.

Several regional flaps are described in the literature [30,31] . The posterior interosseous artery (PIA) flap, the
radial artery perforator (RAP) flap, and the ulnar artery perforator (UAP) flap are the most widely used in
hand STL.

PIA flap consists of the skin and subcutaneous tissue area sampled from the posterior aspect of the forearm.
This flap is typically used to cover defects in the hand dorsal or volar region; at the same time, it is not
suitable for treating STL distal to the proximal interphalangeal joint [30,31] . The anastomosis between the
anterior and posterior interosseous arteries represents the pedicle; the major forearm arteries are not
sacrificed.

RAP flap originates from the radial volar forearm at the distal base. It is vascularized by the deep palmar
arch, which has retrograded flow. The flap must sacrifice one of the main axial arteries; therefore, a
preoperative Allen test must be performed to ensure that ulnar artery vascularization compensates for the
radial artery absence [26,32] . RAP flap is widely used to reconstruct hand and elbow STL. The flap is robust and
[33]
versatile, although donor site scarring is a disadvantage [Figure 5].
UAP flap is based on a dorsal branch of the ulnar artery, whose course is deep to the flexor carpi ulnaris
(FCU) muscle. This flap is suitable for small to medium-sized defects involving the hand and wrist ulnar
side. The advantages of the UAP flap over the RAP flap are a more hidden incision and relatively hairless
skin in this forearm area .
[34]

Distant flaps

In the lower abdomen, several arteries branching off the external iliac artery and the superficial femoral
[3]
artery may be reliably used to treat hand STL . Among them, the most important is the circumflex
superficial iliac artery (SCIA).

SCIA flaps do not require high microsurgical skills or major artery sacrifice; the main disadvantage is that
the hand is tied to the trunk for two to three weeks in a dependent position with delayed rehabilitation.
SCIA is indicated in young children's hand defects, high-voltage electrical burns with questionable major
[35]
arterial patency, and multiple digital defects .

Free flaps
Free flaps are used when the size of infected STL after debridement is too large or too complex to be treated
with local flaps. As most regional flaps, they are technically demanding, requiring careful planning and
rigorous surgical technique. Flap selection is a fundamental step that must consider multiple factors,
including the characteristics of the defect, patient’s health status, functional expectations, and surgeon’s
skill . Moreover, in hand surgery, aesthetic and functional factors play a major role in surgical choice .
[3]
[36]