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Page 4 of 9 Lies et al. Plast Aesthet Res 2019;6:18 I http://dx.doi.org/10.20517/2347-9264.2019.27

Figure 2. Flap choice for reconstruction of composite dorsal hand wound with tendinous defect, immediate vs. staged. ALT: anterolateral
thigh flap

the patients tended to have a greater percentage of returning to work 88% vs. 43% (P < 0.04). Unplanned
return to operating room for immediate reconstruction occurred in 20% whereas reoperation in addition
to planned second stage occurred in ten of eleven staged reconstructions. Flap debulking was not reported
as a complication in this review. Immediate reconstruction had significantly higher complication rate 36%
(P < 0.001). Complications included: partial donor site graft loss, flap venous occlusion, tendon adhesions
and joint contracture requiring tenolysis and capsulectomy.

Staged reconstruction resulted in significantly more operations 5.2 vs. 1.5 (P < 0.001), longer days to
maximum ROM 551 vs. 214 (P < 0.001), and less percentage returning to work 43% vs. 88% (P < 0.04). The
staged approach nonetheless resulted in acceptable functional outcomes with no significant difference in
total active motion 61 vs. 57 degrees (P < 0.3) or grip strength 50% vs. 57% (P < 0.3), and no significant
complications reported.

Of the immediate single surgery group, 39 were free flaps and 11 were pedicled. In the staged group, 6 were
free and 5 were pedicled. When comparing the pedicled vs. free flap surgeries, the pedicled group had a
significantly higher metacarpophalangeal total active motion 75 vs. 55 (P < 0.007). Differences in the days
to maximum ROM, complication rate, and number of operations were not significant however, and there
was not enough data to compare grip strength or percent of patients who returned to work in these groups.

DISCUSSION
Our results are concordant with Sundine and Scheker [24] who found that immediate reconstruction
allowed for faster return to maximum ROM, fewer operations, and a greater chance of adequate recovery
[6]
for vocation. Taylor and Townsend used a vascularized single-stage reconstruction utilizing a dorsalis
pedis free flap, which allows for a one-stage reconstruction for most dorsal hand extensor injuries. The
proposed benefit of this technique is transferring tendons with an intact vascular supply and within
their tendon sheath which may facilitate faster tendon repair healing, thus allowing for rehabilitation