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Artiaco et al. Plast Aesthet Res 2023;10:57 https://dx.doi.org/10.20517/2347-9264.2022.145 Page 9 of 11

Figure 5. Soft tissue and tendon reconstruction with ALT free flap.

Free flaps for dorsal skin

STL on the dorsal aspect of the hand can be treated with several types of free flaps. They include radial
forearm flap (RFF), lateral arm flap (LAF), extreme lateral arm flap (ELAF), anterolateral thigh (ALT) flap,
medial sural artery perforator (MSAP) flap, and dorsalis pedis flap . All these flaps provide a skinny and
[3]
pliable tissue ideal for hand reconstruction. Some of them, such as RFF and dorsalis pedis and MSAP flaps,
are of limited use due to the size of the defect that must be covered. ELAF can be proposed as an alternative
for large hand defects; it is supplied by terminal branches of the deep brachial artery (middle collateral
[37]
artery and posterior radial collateral artery) . ALT flap is probably the most versatile one, enabling the
coverage of a large STL with minimal donor site morbidity [Figure 5].

Muscular fascia harvested with the flap may also be sutured and used to reconstruct extensor tendon.
Nonetheless, especially in the female sex, liposuction or debulking in multiple stages may be necessary due
to the flap thickness [3,30] .

Free flaps for palmar skin

Glabrous skin is rare in body distribution. The foot plantar aspect is the only site other than the hand, where
glabrous skin is available and could be used as a free flap to cover small and medium-sized palmar and
digital defects. Larger flaps usually require skin graft addition, probably related to the unavoidable shear
forces and the wetness of the donor site. The short arterial pedicle is another problem, which makes
harvesting technically more challenging .
[3]

CONCLUSION
Infected hand STL management still represents a challenge for the orthoplastic surgeon. Treatment is
controversial, but some cornerstones may be defined. It is essential to identify and eradicate the cause of
infection with the support of antibiotic therapy and aggressive debridement. NPWT is essential in keeping
the wound bed hydrated and promoting healing. Finally, several strategies may be considered to treat STL,
including skin grafting and synthetic skin substitutes, local, distant, and free flaps.