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Page 2 of 9 Lies et al. Plast Aesthet Res 2019;6:18 I http://dx.doi.org/10.20517/2347-9264.2019.27

Conclusion: Immediate cutaneous tendinous flaps have clear advantages over staged approaches for reconstruction of
composite dorsal hand wounds. Benefits include less operations, faster time to maximum ROM, and higher percent of
patients returning to work; however, significantly more flap related complications were seen. Immediate pedicled radial
forearm provided the best total active motion with least complications. When patient circumstances dictate, a fascial
perforator free flap offers a suitable environment for staged tendon grafts with good functional outcomes reported
albeit longer time to achieve them.

Keywords: Composite dorsal hand wound flap extensor tendon reconstruction

INTRODUCTION
Complex dorsal hand wounds present a challenging problem for hand and reconstructive surgeons.
[1]
The proximity to the surface makes open injury to extensor tendons relatively common . The surgical
timing and flap choice for composite dorsal hand wounds are debated. Traditional management focuses
on debridement, skeletal fixation, and soft tissue coverage. There is limited evidence on optimal extensor
tendon reconstruction in a wound with tendinous defect. These injuries have been approached with a
multitude of techniques with varying degrees of success.

[2]
The goal of extensor tendon treatment is to restore function while minimizing disability . Restoration of
thin, pliable tissue with reliable vascularity and a gliding surface facilitates motion . Analysis of treatment
[3]
options begins with assessment of the wound. The paratenon provides a well-vascularized compartment
that minimizes adhesion to surrounding tissue. If paratenon is intact, skin graft or substitute matrix are
viable options. When there is denuded tendon or exposed bone, reconstruction typically elevates to flap
selection [Figure 1]. Numerous coverage options are available for these types of defects and are determined
based on the extent of zone of injury and tissue match. An Allen’s test is vital to ascertain competence of
the palmar arch for deciding upon a reverse radial forearm flap with retrograde flow or an appropriate
recipient for anastomosis. A decision must be made whether immediate or staged tendon reconstruction is
preferable and which fairs best with the least complications.

Single-staged procedures include either composite pedicle forearm flaps or free tissue transfers with
accompanying vascularized tendon graft. Alternatively, primary reconstruction with nonvascularized
tendon grafts may be performed in conjunction with conventional flap coverage . Staged approaches include
[4]
initial flap coverage and subsequent delayed tendon reconstruction with grafts or transfer [Figure 2]. Reid [5]
reported success using a multiple-staged approach with a primary abdominal flap and delayed tendon
[6]
grafts to restore function in the hand. Taylor and Townsend described the single-stage dorsalis pedis
cutaneotendinous free flap with positive results withstanding donor site morbidity. The dorsalis pedis flap
[12]
can provide up to four vascularized tendons [7-11] . Reid and Moss performed a one-stage flap repair using
radial forearm flap containing palmaris longus and brachioradialis tendon. Modifications can provide
palmaris longus, flexor carpi radialis, and/or brachioradialis with paddle location dependent on desired
orientation when transposed [13,14] . Pedicle flaps obviate the need for microsurgery when it is relatively
[15]
contraindicated due to patient factors and status. Other flap choices including ulnar island , posterior
interosseous [16,17] , lateral arm [18,19] , and free anterolateral thigh [20-22] have been described to incorporate
strips of tendon or fascia for reconstitution. Latissimus, serratus, and gracilis are common muscle flaps.
Consideration of positioning and availability of a two-team approach to expedite harvest and inset is
warranted.

The goals of reconstruction are to provide adequate soft tissue coverage, enable tendons to glide with
[23]
excursion, and provide adequate power for pull through . To determine whether a specific technique for
management of cutaneous-tendinous hand defects provides superior outcomes, we performed a systematic