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Flaps and Grafts

Hand reconstruction: flap and graft options for soft tissue defects, bone loss, and complex trauma—local to free flaps.

Overview

Soft tissue coverage of the hand and upper extremity requires a structured framework for assessing defects and selecting the most appropriate reconstructive option [3]. Long-term patient-reported and objective outcomes for fingertip coverage with a homodigital unipedicle neurovascular island flap are satisfactory, establishing the procedure as safe and reliable [1]. Experience over the past decade confirms that free-style flaps can be raised reliably and safely [4].

For complex soft tissue hand reconstructions where locoregional flaps would result in unacceptable cosmetic deformity, the anterolateral thigh free flap is encouraged [10]. The heterodigital reversed flow neurovascular island flap serves as an alternative to microsurgical reconstruction for extensive pulp defects in fingers where other flaps are unsuitable [23]. A radial-based pedicled flap from the index finger provides a simple yet favorable alternative for extensive thumb pulp defects, offering thick, durable tissue with minimal dissection and donor side morbidity [14].

Salvage of complete degloved digits using a reversed vascularized pedicled forearm flap provides adequate soft tissue and good functional outcomes compared with other salvage procedures [5]. A modified reverse flow shunt restricted arterialized venous free flap technique has demonstrated high survival rates and satisfactory functional outcomes in clinical series [2]. The fascia-only reverse posterior interosseous artery flap offers major advantages, including confinement of the donor site to the ipsilateral extremity, no requirement for microsurgery, and improved cosmesis due to primary closure without a skin graft [48].

Donor site complications occur at similar rates among patients undergoing osteocutaneous and fasciocutaneous radial forearm free flap harvest [8]. Hand transplantation and prosthetic reconstruction should not be viewed as competing options for upper extremity limb loss functional restoration [9].

Anatomy & Pathophysiology

Composite Tissue and Reconstruction Principles

Hand transplantation represents the most common form of modern composite tissue allotransplantation [16]. Success relies on proper patient selection, technical execution, rehabilitation, and immunotherapy protocols that prevent rejection while minimizing morbidity [16]. Despite these protocols, the transplanted hand remains functionally inferior to a mechanical prosthesis and fails to integrate into the patient's body image [54].

For severe injuries with substantial phalangeal bone loss, nonvascularized autogenous bone grafts are capable of restoring good hand function [17]. Reconstruction is generally preferred over prosthesis fitting for mutilated hands, offering the ability to perform secondary procedures and increased hand use over time [22]. Specifically, functional results of thumb reconstruction via second toe transfer and dorsalis pedis flap far exceed those obtainable with a prosthetic device [49]. Microsurgical techniques remain feasible for restoring partial hand function even in cases of extensive tissue destruction [45].

Diagnostic and Surgical Management

Accurate diagnosis and management of hand and carpal fractures and dislocations require a thorough physical examination and appropriate imaging to limit joint stiffness while preserving mobility and function [29]. Hand surgery principles emphasize balancing the restoration of function with the maintenance of aesthetic appearance [41]. Injuries to the thumb and index finger are more likely to undergo unplanned reoperation, a factor that should guide initial treatment decision-making and postoperative follow-up [56].

Pediatric and Specific Deformity Considerations

Reverse neurocutaneous flaps based on the dorsal branch of the ulnar artery facilitate functional hand development through adequate progressive growth and sensory recovery in children [50]. In mirror hand deformity, thumb reconstruction without formal pollicization requires comparison of objective measurements, particularly pinch strength and power grip, with the pollicization technique [60].

Soft Tissue Pathology

Closed degloving of the thumb is a rare condition caused by crushing and elongation forces that detach soft tissues without skin disruption [58].

Classification

Woo et al.: Proposed as an alternative to Chen’s classification, which lacks utility for type III flaps and renders the term 'venous flap' misleading [27]. This system offers a better clinical description and design framework for venous flaps.

Banff Working Classification: Provides a standardized grading scheme for acute rejection in composite tissue allografts [40].

Other Considerations: Homodigital unipedicle neurovascular island flap: Long-term patient-reported outcome measures and objective outcomes of fingertip coverage are satisfactory, and the flap is considered safe and reliable [1]. Modified reverse flow shunt restricted arterialized venous free flap: Resulted in high flap survival rates and satisfactory functional outcomes in a clinical series of 9 cases [2]. Arterialized venous free flaps: Using 2 parallel veins simplifies the technique for finger soft tissue reconstruction [12]. Free-style flaps: Can reliably and safely be raised based on 10 years of experience [4]. Local pedicle flap: Suggested rather than a free flap for the treatment of painful median nerve neuromas [11]. End-of-skin flap: Allows adequate creation of a new web space and primary closure of separated fingers without skin grafts in syndactyly release [43]. Free thoracodorsal artery perforator (TDAP) flap: Versatile for reconstructing different kinds of soft tissue defects of the extremities, allowing individualized defect reconstruction, minimized donor site morbidities, and aesthetic appearance through five types of advanced applications [44]. Composite anterolateral thigh (ALT) perforator flaps: Reliable and flexible for reconstruction of complex hand injuries because the ability to use different tissue components based on individual perforators allows customization [51]. Pedicled rotational medial and lateral gastrocnemius flaps: Useful, robust options for reconstructing many types of defects about the knee with good functional results, although complications can occur [25]. Microsurgical reconstruction: Should always be undertaken for ring avulsion injury with rupture of both digital arteries despite a completely intact skin envelope to ensure excellent survival and good functional outcome [62]. Framework for assessment: Provides a framework for assessing defects and selecting the best-suited reconstructive option using representative flaps and case examples for soft tissue coverage of the hand and upper extremity [3].

Clinical Presentation

The clinical assessment of hand and upper extremity defects requires a structured framework to evaluate the injury and select the optimal reconstructive option [3]. This process involves assessing the defect characteristics to determine whether locoregional flaps, free flaps, or transplantation are appropriate. For complex soft tissue defects where locoregional options would cause unacceptable cosmetic deformity, the anterolateral thigh free flap is considered [10]. In cases of complete digit degloving, salvage with a reversed vascularized pedicled forearm flap provides adequate soft tissue and good functional outcomes compared with other salvage procedures [5].

Fingertip and Digital Reconstruction

For fingertip coverage, the homodigital unipedicle neurovascular island flap is a safe and reliable option, yielding satisfactory long-term patient-reported and objective outcomes [1]. When selecting between an oblique triangular neurovascular advancement flap and a reverse digital artery island flap for homodigital reconstruction, the decision should be based on expected post-operative complications, scarring, and patient background rather than neurological requirements [30]. However, clinicians must note that sensory disturbance in the fingertip does not subside if the oblique triangular flap is advanced more than 12 mm [13].

For large volar digital defects, the free thenar flap serves as a preferred alternative due to its constant vascular pedicle, good texture match, low donor site morbidity, and ability to achieve primary donor site closure [28]. Extensive thumb pulp defects can be reconstructed using a radial-based pedicled flap from the index finger, which offers thick, durable tissue with minimum dissection and donor side morbidity [14]. In revision of residual deformities after primary surgery for Wassel-Flatt IV-D thumb duplication, microsurgical free lateral great toe flaps survived in all cases, providing satisfactory appearance at 8–12 months follow-up [6].

Free Flap and Perforator Options

Free-style flaps can be raised reliably and safely, supported by ten years of experience [4]. The palmar intermetacarpal perforator flap is vascularized by two perforators arising from adjacent true digital arteries and may be raised on either one [15]. For small defects on the dorsum of the hands, harvesting the first dorsal metacarpal artery-based fascial flap through the border of the defect avoids an additional scar at the donor site [31]. Regarding sensation in this flap, there are no differences at two years in postoperative clinical outcomes whether dorsal digital nerves are used to reconstruct flap sensation regardless of preservation of the dorsal branches of the proper digital nerves [32].

A modified reverse flow shunt restricted arterialized venous free flap technique resulted in high flap survival rates and satisfactory functional outcomes in a clinical series of nine cases [2]. Donor site complications occur at similar rates among patients undergoing osteocutaneous and fasciocutaneous radial forearm free flap harvest [8].

Bone Grafting and Transplantation

Nonvascularized iliac crest bone grafting is supported for metacarpal bone defects when soft tissues are preserved or as a second stage after flap reconstruction and bone temporizing measures [7]. Hand transplantation is the most common form of modern composite tissue allotransplantation, with success depending on proper patient selection, technical success, rehabilitation, and immunotherapy protocols that prevent rejection while minimizing morbidity [16]. It is a valuable treatment option for patients with complex tissue injuries where conventional reconstruction is not feasible, though long-term high-dose immunosuppression remains a limiting obstacle [33].

Hand transplantation and prosthetic reconstruction should not be viewed as competing options for upper extremity limb loss functional restoration [9]. Significant progress has been made in upper extremity transplantation over the past 20 years, although challenges remain including how to best document and share outcome measures, optimize immunosuppression, and diagnose and treat rejection [35].

Investigations

Preoperative Planning and Imaging: Computed Tomography Angiography (CTA) and Color Doppler Sonography (CDS): These are accurate methods for assessing flap location and course for free superficial circumflex iliac artery perforator flaps with a single-pedicle bilobed design in pediatric multi-digit defect reconstruction [67]. Magnetic Resonance Imaging (MRI): Indicates that the donor site for autologous osteochondral mosaicplasty for cartilaginous lesions of the elbow joint is resurfaced with fibrous tissue [61].

Other Considerations: Soft Tissue Coverage Framework: A framework for assessing defects and selecting the best-suited reconstructive option using representative flaps and case examples is provided for soft tissue coverage of the hand and upper extremity [3]. Fingertip Reconstruction: Long-term patient-reported outcome measures and objective outcomes for fingertip coverage with a homodigital unipedicle neurovascular island flap are satisfactory, indicating it is a safe and reliable flap [1]. Reconstruction with available flaps generally yields satisfactory results for fingertip amputations with bone exposure and nail matrix involvement [72]. Complex Defects: The anterolateral thigh free flap is encouraged for complex soft tissue hand defects where locoregional flaps would result in unacceptable cosmetic deformity [10]. A free groin flap to reconstruct a dorsal hand skin defect in the replantation of multi-finger amputations satisfies the reconstructive demands of these patients very adequately [71]. Salvage Procedures: Salvage of complete degloved digits with a reversed vascularized pedicled forearm flap provides adequate soft tissue and good functional outcomes compared with other salvage procedures [5]. Vessel transfers from the middle finger appear to be the most reliable solution for replantation of ring avulsion amputations, demonstrating that replantation should be attempted [75]. Thumb Duplication: Revision of residual deformities after primary surgery for Wassel-Flatt IV-D thumb duplication using a microsurgical free lateral great toe flap resulted in all flaps surviving and satisfactory appearance of the reconstructed thumbs at 8–12 months follow-up [6]. Use of an axial flap increases the volume and girth of Wassel IV thumb reconstructions, with clinical and radiological measurements showing efficacy [24]. Neuroma Management: Local pedicle flaps are suggested over free flaps for the treatment of painful median nerve neuromas using radial and ulnar artery perforator adipofascial flaps [11]. Bone Reconstruction: Nonvascularized iliac crest bone grafting is supported for metacarpal bone defects when soft tissues are preserved or as a second stage after flap reconstruction and bone temporizing measures [7]. Free vascularised fibular grafting is a successful form of treatment for large bony defects [69]. A one-stage combined reconstruction of an amputated thumb with application of a free neurovascular flap and an iliac-bone graft has been reported [77]. To prevent hernias through donor sites for iliac-bone grafts, full-thickness iliac-crest bone grafts should be taken from the anterior or posterior portion of the crest rather than the middle [76]. Functional Restoration: Hand transplantation and prosthetic reconstruction should not be viewed as competing options for upper extremity limb loss functional restoration [9]. Reconstruction is a better option than prosthesis fitting for the management of a mutilated hand due to the ability to perform secondary procedures and increased hand use over time [22]. Bypass Surgery: There appears to be a benefit of utilizing arterial versus venous conduits for distal upper extremity bypass surgery, although this may need further examination given the small number of arterial reconstructions reported [74]. Alternative Techniques: A modified reverse flow shunt restricted arterialized venous free flap technique resulted in high flap survival rates and satisfactory functional outcomes in a clinical series of 9 cases [2].

Treatment

Operative

Indications: The anterolateral thigh free flap is indicated for complex soft tissue hand defects where locoregional flaps would result in unacceptable cosmetic deformity [10]. The heterodigital reversed flow neurovascular island flap is indicated for extensive pulp defects in fingers where reconstruction cannot be done using other flaps and serves as an alternative to microsurgical reconstruction [23]. Bilateral hand transplantation is justified in cases of bilateral amputations with strict indications, while transplantation for the loss of one hand is not indicated [34].

Surgical Approach / Technique: Long-term patient-reported outcome measures and objective outcomes of fingertip coverage with a homodigital unipedicle neurovascular island flap are satisfactory, and the flap is considered safe and reliable [1]. The parallelogram flap is a better choice than the homodigital island flap for the reconstruction of fingertip injury with bone exposure in a prospective controlled study [21]. A modified reverse flow shunt restricted arterialized venous free flap technique resulted in high flap survival rates and satisfactory functional outcomes in a clinical series of 9 cases [2]. Free-style flaps can be raised reliably and safely based on 10 years of experience [4]. Salvage of complete degloved digits with a reversed vascularized pedicled forearm flap provides adequate soft tissue and good functional outcomes compared with other salvage procedures [5]. Revision of residual deformities after primary surgery for Wassel-Flatt IV-D thumb duplication using a microsurgical free lateral great toe flap resulted in 100% flap survival and satisfactory appearance of the reconstructed thumbs at 8–12 months follow-up [6]. Microsurgical reconstruction of partial thumb defects achieved 100% flap survival and functional improvement with near-normal appearance [20]. Pedicled rotational medial and lateral gastrocnemius flaps are useful, robust options for reconstructing many types of defects about the knee with good functional results, although complications can occur [25]. Coverage with a fasciocutaneous transposition flap for lower extremity defects proved to be safe and simple [37]. Different flap techniques can obtain better clinical efficacy in repairing diabetic foot defects according to local conditions [38]. Muscle pedicle bone flap transplantation for treating femoral neck fracture in adults provides promising results with low rates of avascular necrosis and nonunion, although further controlled studies are required to ascertain its effectiveness [39]. Pinch reconstruction by hand-to-hand finger transfer associated with hallux transfer after severe frostbite injury provided a satisfactory functional result in a very active patient who refused any cosmetic prosthesis [68]. A combined rib-latissimus dorsi flap is a useful option for composite defects of the upper extremity requiring elbow arthrodesis and soft-tissue coverage for the practicing non-microvascular orthopaedic surgeon [70].

Implant Selection: Nonvascularized iliac crest bone grafting is supported for metacarpal bone defects when soft tissues are preserved or as a second stage after flap reconstruction and bone temporizing measures [7]. Nonvascularized autogenous bone grafting is capable of restoring good hand function in severe injuries with substantial phalangeal bone loss [17]. Pedicle bone grafts united to the recipient bed earlier than non-pedicle bone grafts, and the rate of non-union of pedicle bone grafts was lower than that of non-pedicle grafts in an experimental study in dogs [73]. The continued incorporation of 4- to 5-mm-diameter large-caliber processed nerve allografts into repair algorithms for upper extremity nerve injuries is acceptable and reasonable based on overall success rates [36].

Other Considerations: Hand transplantation and prosthetic reconstruction should not be viewed as competing options for upper extremity limb loss functional restoration [9]. While microsurgery has made replantation a routine procedure with reliable viability rates, achieving a satisfactory functional result is difficult and depends on a variety of factors [18]. Different microsurgical transfer techniques offer great freedom of surgical choices for thumb repair and reconstruction, but choices are considerably restricted if all functional and cosmetic requirements are to be met [42]. Local pedicle flaps are suggested over free flaps for the treatment of painful median nerve neuromas [11]. A framework for assessing defects and selecting the best-suited reconstructive option using representative flaps and case examples is provided for soft tissue coverage of the hand and upper extremity [3].

Complications

Donor site complications: Occur at similar rates for osteocutaneous and fasciocutaneous radial forearm free flap harvest [8].

Wound complications: Sensory disturbance of the fingertip occurred and did not subside when an oblique triangular flap was advanced more than 12 mm [13].

Other Considerations: Free vascularized fibular graft reconstruction has a high complication rate [52].

Recovery

Light activity (weeks): Evidence does not specify a distinct week range for light activity or desk work return.

Full activity (months): Evidence does not specify a distinct month range for manual work or full ROM/strength return.

Complete recovery / outcome plateau (months): Outcomes stabilize at 1 year for single-stage osteo-onychocutaneous island flap reconstruction of finger macrodactyly [80]. Final aesthetic and functional outcomes for microsurgical free lateral great toe flap reconstruction of thumb duplication are assessed at 8–12 months follow-up [6].

Rehabilitation protocol: Specific rehabilitation protocols, including PT phasing, immobilisation duration, and brace removal timing, are not detailed in the provided evidence.

Functional milestones: Long-term patient-reported outcome measures and objective outcomes for fingertip coverage with a homodigital unipedicle neurovascular island flap are satisfactory [1]. A modified reverse flow shunt restricted arterialized venous free flap technique resulted in high flap survival rates and satisfactory functional outcomes in a clinical series of 9 cases [2]. Salvage of complete degloved digits with a reversed vascularized pedicled forearm flap provides adequate soft tissue and good functional outcomes compared with other salvage procedures [5]. Microsurgical reconstruction of partial thumb defects achieved 100% flap survival and functional improvement with near-normal appearance [20]. The majority of zone I replantations without vein repair led to satisfactory function on follow-up assessments [46]. Intermediate-term outcomes for arterial grafts in upper extremity vascular reconstruction are promising, with patency rates up to 100% reported [19].

Other Considerations: While microsurgery has made replantation a routine procedure with reliable viability rates, achieving a satisfactory functional result is difficult and depends on a variety of factors [18]. Delayed and suspended replantations for complete amputation of digits and hands demonstrate results comparable to immediate replantation regarding graft survival and clinical outcome [78]. Following revascularization, skin from a completely degloved finger survives in approximately two out of three cases [79]. Reconstructive surgery was required in 15% of patients during a 10-year follow-up period after hand burns [63]. Two-point discrimination (2-PD) data for flaps in digit-tips in the previous 6 years in English literature is generally considered insufficiently reliable [26]. Free-style flaps can be raised reliably and safely based on 10 years of experience [4]. Finger soft tissue reconstruction using arterialized venous free flaps with 2 parallel veins simplifies the technique of arterialized venous flaps [12]. Nonvascularized iliac crest bone grafts are supported for metacarpal bone defects when soft tissues are preserved or as a second stage after flap reconstruction and bone temporizing measures [7]. Donor site complications occurred at similar rates between patients undergoing osteocutaneous and fasciocutaneous radial forearm free flap harvest [8].

Key Evidence

  • [L4] At a long-term follow-up, the patient-reported outcome measures and objective outcomes of this flap are satisfactory and it is a safe and reliable flap. (10.1177/17531934231172081)
  • [L4] In this clinical series of 9 cases, the modified technique resulted in high flap survival rates with satisfactory functional outcomes. (10.1016/j.jhsa.2018.02.023)
  • [L5] This review provides a framework for assessing defects and selecting the best-suited reconstructive option using representative flaps and case examples. (10.1016/j.jhsa.2016.04.020)
  • [Paper] Experience over the past 10 years has consistently demonstrated that free-style flaps can reliably and safely be raised. (10.1016/j.injury.2008.05.020)
  • [L4] This flap provides adequate soft tissue and good functional outcome compared with other salvage procedures. (10.1016/j.jhsa.2012.01.032)
  • [L4] All flaps survived and patients were followed up for 8–12 months with satisfactory appearance of the reconstructed thumbs. (10.1177/17531934231222400)
  • [L4] The report supports the use of a nonvascularized iliac crest bone graft when soft tissues are preserved or as a second stage after flap reconstruction and bone temporizing measures. (10.1177/1753193420970162)
  • [L3] Donor site complications occurred at similar rates among patients undergoing osteocutaneous and fasciocutaneous flap harvest. (10.1016/j.jhsa.2016.07.027)
  • [L5] Hand transplantation and prosthetic reconstruction should not be viewed as competing options. (10.1016/j.jht.2013.10.007)
  • [L4] The authors encourage hand surgeons to consider this flap for defects where locoregional flaps would result in unacceptable cosmetic deformity. (10.1054/jhsb.2002.0863)
  • [L4] The authors suggest using a local pedicle flap rather than a free flap. (10.1016/j.jhsa.2014.01.007)
  • [L4] By using these flaps, the authors were able to simplify the technique of arterialized venous flaps. (10.1016/j.jhsa.2008.08.001)
  • [L3] In cases where the flap was advanced more than 12 mm, sensory disturbance of the fingertip occurred and did not subside. (10.1016/j.jhsa.2008.02.022)
  • [L4] The presented flap provided a simple yet favourable alternative for reconstruction of the thumb tip, with thick and durable tissue requiring minimum dissection and donor side morbidity. (10.1177/1753193418778447)
  • [L5] The flap is vascularised by two perforators arising from the adjacent true digital arteries and may be raised on either one. (10.1177/1753193408095353)
  • [L4] Hand transplantation is the most common form of modern composite tissue allotransplantation, with success depending on proper patient selection, technical success, rehabilitation, and immunotherapy protocols that prevent rejection while minimizing morbidity. (10.1016/j.jhsa.2011.09.001)
  • [Case_report] The technique is capable of restoring good hand function in severe injuries with substantial phalangeal bone loss. (10.1016/j.jhsa.2008.04.025)
  • [L5] While microsurgery has made replantation a routine procedure with reliable viability rates, achieving a satisfactory functional result is difficult and depends on a variety of factors. (10.5435/00124635-199803000-00004)
  • [L4] Intermediate-term outcomes for arterial grafts in upper extremity vascular reconstruction are promising, with patency rates up to 100% reported, though no long-term outcomes studies exist. (10.1016/j.jhsa.2012.12.009)
  • [L4] Flap survival was 100% and functional improvement with near normal appearance was obtained in the reconstructed thumbs. (10.1054/jhsb.1998.0176)
  • [L2] This method is a better choice for reconstruction of fingertip injury. (10.1186/s13018-022-03214-1)
  • [L5] Reconstruction is a better option than prosthesis fitting due to the ability to perform secondary procedures and increased hand use over time. (10.1177/17531934211047760)
  • [L4] This new procedure is indicated for extensive pulp defects in fingers in which reconstruction cannot be done using other flaps and as an alternative to microsurgical reconstruction. (10.1054/jhsb.1999.0164)
  • [L4] Clinical and radiological measurements showed the efficacy of this reconstruction in increasing the volume and girth of the reconstructed thumb. (10.1016/j.jhsa.2015.02.032)
  • [L5] Gastrocnemius flaps are useful, robust flaps for reconstructing many types of defects about the knee with good functional results, though complications can occur. (10.5435/jaaos-d-15-00722)
  • [L4] The 2-PD data of flaps in digit-tips in the previous 6 years in English literature should be generally considered insufficiently reliable. (10.1177/17531934211017047)
  • [Letter] The authors comment on the terminology and classification of venous flaps, arguing that the term 'venous flap' is misleading and that Chen's classification lacks utility for type III flaps, proposing instead the Woo et al. classification for better clinical description and design. (10.1177/1753193417730524)
  • [Case_report] The free thenar flap is a fasciocutaneous sensate flap with a constant vascular pedicle that offers low donor site morbidity, good texture match, and primary closure of the donor site, making it a preferred alternative for large volar digital defects. (10.1186/1749-799x-2-4)
  • [L3] The selection of these flaps should be based on various factors such as expected post-operative complications, scar, and patient background, but not neurological requirement. (10.1177/1753193413515134)
  • [L4] Flap harvesting through the border of the defect avoided an additional scar at the donor site. (10.1016/j.jhsa.2019.02.013)
  • [L3] There are no differences at 2 years in postoperative clinical outcomes when dorsal digital nerves are used to reconstruct flap sensation regardless of preservation of the dorsal branches of the proper digital nerves in the first dorsal metacarpal artery flap. (10.1186/s13018-021-02838-z)
  • [L5] Hand transplantation is a valuable treatment option for patients with complex tissue injuries where conventional reconstruction is not feasible, though long-term high-dose immunosuppression remains a limiting obstacle. (10.1016/j.hcl.2011.08.009)
  • [L5] Bilateral hand transplantation is justified in cases of bilateral amputations with strict indications, while transplantation for the loss of one hand is not indicated. (10.1054/jhsb.2001.0674)
  • [L5] Over the past 20 years, significant progress has been made in upper extremity transplantation although a number of challenges remain including how to best document and share outcome measures, optimize immunosuppression, and diagnose/treat rejection. (10.1177/1558944718790579)
  • [L4] The overall success rate suggests that the continued incorporation of 4- to 5-mm-diameter allografts into repair algorithms is acceptable and reasonable. (10.1177/1558944716646782)
  • [L4] Coverage with a fasciocutaneous transposition flap proved to be safe and simple. (10.2106/00004623-198971070-00005)
  • [L3] Different flap techniques can obtain better clinical efficacy in repairing DFD wounds. (10.1186/s13018-024-05122-y)
  • [L4] Muscle pedicle bone flap transplantation provides promising results with low rates of avascular necrosis and nonunion, although further controlled studies are required to ascertain its effectiveness. (10.1186/s13018-021-02448-9)
  • [L5] The Banff Working Classification provides a standardized grading scheme for acute rejection in composite tissue allografts. (10.1016/j.hcl.2011.08.006)
  • [L4] Different microsurgical transfer techniques suggest a great freedom of surgical choices, but choices are considerably restricted if all functional and cosmetic requirements are to be met. (10.1177/1753193417723310)
  • [L4] The new flap allows adequate creation of a new web space and primary closure of separated fingers without skin grafts. (10.1007/s11552-008-9134-y)
  • [L4] The free TDAP flap, with five types of advanced applications, makes it versatile for reconstructing different kinds of soft tissue defects of the extremities that can be used to achieve individualized defect reconstruction, minimize donor site morbidities, and an aesthetic appearance. (10.1186/s13018-023-04480-3)
  • [L4] The study highlights the feasibility of restoring partial hand function even in cases of extensive tissue destruction. (10.1186/s12891-025-09441-x)
  • [L4] Follow-up assessments show that the majority of zone I replantations led to satisfactory function. (10.1016/j.jhsa.2008.05.005)
  • [L4] Major advantages include confinement of the donor site to the ipsilateral extremity, no requirement for microsurgery, and improved cosmesis due to primary closure without a skin graft. (10.1016/j.jhsa.2018.06.012)
  • [L4] The functional results of the thumb reconstruction were far better than could be obtained by a prosthetic device. (10.1177/1753193412449580)
  • [L4] The flap facilitates functional hand development through adequate progressive growth and sensory recovery. (10.1016/j.jhsa.2022.09.001)
  • [L4] The ability to use different tissue components based on individual perforators allows the ALT flap to be a reliable and flexible composite flap in reconstruction of complex hand injuries. (10.1177/1753193411427648)
  • [L4] The transplanted hand was functionally inferior to a mechanical prosthesis and never integrated into the patient's body image. (10.1054/jhsb.2001.0697)
  • [L3] Injuries sustained in the thumb and index finger were more likely to undergo unplanned reoperation, which may guide initial treatment decision-making and postoperative follow-up. (10.1177/15589447221109635)
  • [L4] Closed degloving of the thumb is a rare condition caused by crushing and elongation forces that detaches soft tissues without skin disruption. (10.1016/j.jhsa.2007.06.016)
  • [L4] However, objective measurements, especially with regards to pinch strength and power grip, need to be compared with the pollicization technique. (10.1177/1753193412475129)
  • [L4] However, magnetic resonance imaging indicates that the donor site is resurfaced with fibrous tissue. (10.1177/0363546507306465)
  • [L4] Microsurgical reconstruction should always be undertaken regardless of the class of injury to ensure excellent survival and good functional outcome. (10.1177/1753193408089052)
  • [L4] Reconstructive surgery was required in 15% of patients during the 10-year follow-up period after hand burns. (10.1016/j.jhsa.2017.02.006)
  • [L4] Preoperative CTA and CDS are accurate methods for assessing the flap location and course. (10.1186/s13018-020-01733-3)
  • [L4] The reconstruction procedure provided a satisfactory functional result in a very active patient who refused any cosmetic prosthesis, demonstrating the usefulness of combining salvage microsurgical procedures with non-microsurgical methods. (10.1054/jhsb.1999.0225)
  • [L3] Free vascularised fibular grafting is a successful form of treatment for large bony defects. (10.1302/0301-620x.99b1.bjj-2016-0160.r1)
  • [L4] In composite defects of the upper extremity, it is a useful option for the practicing non-microvascular orthopaedic surgeon. (10.1016/j.jse.2010.08.010)
  • [L4] The described method of reconstruction satisfies very adequately the reconstructive demands of these patients. (10.1177/1753193418805854)
  • [L5] For fingertip amputations with bone exposure and nail matrix involvement, reconstruction with available flaps generally yields satisfactory results. (10.1016/j.jhsa.2008.07.001)
  • [L3] There appears to be a benefit of utilizing arterial versus venous conduits, although this may need further examination given the small number of arterial reconstructions reported in the literature. (10.1016/s0363-5023(12)60049-5)
  • [L4] Vessel transfers from the middle finger appear to be the most reliable solution, and the outcome of the cases demonstrates that replantation should be attempted. (10.1016/j.jhsa.2013.02.014)
  • [L4] To prevent this rare complication, full-thickness iliac-crest bone grafts should be taken from the anterior or posterior portion of the crest rather than the middle. (10.2106/00004623-198365070-00022)
  • [Case_report] This is the first report of a one-stage combined reconstruction of an amputated thumb with application of a free neurovascular flap and an iliac-bone graft in the English literature. (10.2106/00004623-197961080-00024)
  • [L4] Delayed and suspended replantations demonstrate results comparable to immediate replantation regarding graft survival and clinical outcome. (10.1016/j.jhsa.2015.01.006)
  • [L4] Following revascularization, the skin from a completely degloved finger will survive in approximately two cases out of three. (10.1177/1753193417724680)
  • [L4] The presented single-stage technique using a pedicled osteo-onychocutaneous island flap combined with growth-limiting procedures achieved satisfactory aesthetic and functional outcomes at 1 year. (10.1016/j.jhsa.2021.04.021)

See Also

References

[1] Long-term patient-reported outcome measures of fingertip coverage with a homodigital unipedicle neurovascular island flap. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231172081

[2] Reverse Flow Shunt Restricted Arterialized Venous Free Flap. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.02.023

[3] Soft Tissue Coverage of the Hand and Upper Extremity: The Reconstructive Elevator. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.04.020

[4] Free-style free flap. Injury. 2008. DOI: 10.1016/j.injury.2008.05.020

[5] Salvage of Complete Degloved Digits With Reversed Vascularized Pedicled Forearm Flap: A New Technique. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.01.032

[6] Revision of residual deformities after primary surgery for Wassel-Flatt IV-D thumb duplication using a microsurgical free lateral great toe flap. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934231222400

[7] Iliac crest bone grafting for metacarpal bone defects using bridging bone block. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420970162

[8] Donor Site Outcomes with Osteocutaneous versus Fasciocutaneous Radial Forearm Free Flap Harvest. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.07.027

[9] Upper extremity limb loss: Functional restoration from prosthesis and targeted reinnervation to transplantation. Journal of Hand Therapy. 2014. DOI: 10.1016/j.jht.2013.10.007

[10] Anterolateral Thigh Free Flap for Complex Soft Tissue Hand Reconstructions. Journal of Hand Surgery. 2003. DOI: 10.1054/jhsb.2002.0863

[11] Treatment of Painful Median Nerve Neuromas With Radial and Ulnar Artery Perforator Adipofascial Flaps. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.01.007

[12] Finger Soft Tissue Reconstruction Using Arterialized Venous Free Flaps Having 2 Parallel Veins. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.08.001

[13] Relationship Between Sensory Recovery and Advancement Distance of Oblique Triangular Flap for Fingertip Reconstruction. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.02.022

[14] Reconstruction of extensive pulp defects of the thumb with a radial-based pedicled flap from the index finger. Journal of Hand Surgery (European Volume). 2018. DOI: 10.1177/1753193418778447

[15] Anatomical Study of the Palmar Intermetacarpal Perforator Flap. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193408095353

[16] The Current State of Hand Transplantation. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.09.001

[17] Nonvascularized Autogenous Bone Graft for Extensive Phalangeal Bone Loss: Case Report. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.04.025

[18] Amputations of the Fingers and Hand: Indications for Replantation. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199803000-00004

[19] Arterial Conduits for Distal Upper Extremity Bypass. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.12.009

[20] Microsurgical Reconstruction of Partial Thumb Defects. Journal of Hand Surgery. 1999. DOI: 10.1054/jhsb.1998.0176

[21] Parallelogram flap versus homodigital island flap in the treatment of fingertip defects with bone exposure: a prospective controlled study. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03214-1

[22] Management of a mutilated hand: the current trends. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211047760

[23] The Heterodigital Reversed Flow Neurovascular Island Flap for Fingertip Injuries. Journal of Hand Surgery. 1999. DOI: 10.1054/jhsb.1999.0164

[24] Use of an Axial Flap to Increase the Girth of Wassel IV Thumb Reconstructions. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.02.032

[25] Pedicled Rotational Medial and Lateral Gastrocnemius Flaps: Surgical Technique. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-15-00722

[26] Reported sensory function after digit-tip defect repair with flaps lacks sufficient details. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211017047

[27] Letter about a Published Paper. Journal of Hand Surgery (European Volume). 2018. DOI: 10.1177/1753193417730524

[28] "A Free thenar flap – A case report". Journal of Orthopaedic Surgery and Research. 2007. DOI: 10.1186/1749-799x-2-4

[29] Chapter 29 Hand/Carpal Fractures and Dislocations. 2021.

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[31] Use of the First Dorsal Metacarpal Artery-Based Fascial Flap for Reconstruction of Small Defects on the Dorsum of the Hands. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2019.02.013

[32] First dorsal metacarpal artery flap with dorsal digital nerve with or without dorsal branch of the proper digital nerve produces comparable short-term sensory outcomes. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02838-z

[33] Hand Transplantation. Hand Clinics. 2011. DOI: 10.1016/j.hcl.2011.08.009

[34] Bilateral Hand Transplantation – Indication and Rationale. Journal of Hand Surgery. 2001. DOI: 10.1054/jhsb.2001.0674

[35] Building a Hand and Upper Extremity Transplantation Program: Lessons Learned From the First 20 Years of Vascularized Composite Allotransplantation. HAND. 2018. DOI: 10.1177/1558944718790579

[36] A Preliminary Assessment of the Utility of Large-Caliber Processed Nerve Allografts for the Repair of Upper Extremity Nerve Injuries. HAND. 2016. DOI: 10.1177/1558944716646782

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[38] Clinical effects of different types of flaps selected according to local conditions in the treatment of diabetic foot defects. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05122-y

[39] Muscle pedicle bone flap transplantation for treating femoral neck fracture in adults: a systematic review. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02448-9

[40] Acute and Chronic Rejection in Upper Extremity Transplantation: What Have We Learned?. Hand Clinics. 2011. DOI: 10.1016/j.hcl.2011.08.006

[41] 9. Hand Surgery. 2013.

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[43] End-of-Skin Grafts in Syndactyly Release: Description of a New Flap for Web Space Resurfacing and Primary Closure of Finger Defects. HAND. 2008. DOI: 10.1007/s11552-008-9134-y

[44] The versatile thoracodorsal artery perforator flap for extremity reconstruction: from simple to five types of advanced applications and clinical outcomes. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-04480-3

[45] Application of microsurgical techniques in severe hand injury management: a retrospective analysis of clinical data. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09441-x

[46] Reconstruction of Circulation in the Fingertip Without Vein Repair in Zone I Replantation. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.05.005

[48] The Fascia-Only Reverse Posterior Interosseous Artery Flap. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.06.012

[49] Thumb reconstruction by second toe transfer and dorsalis pedis flap, with the use of a peroneal perforator flap to replace the skin deficit on the foot. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193412449580

[50] Reverse Neurocutaneous Flap Based on the Dorsal Branch of the Ulnar Artery for Palm Coverage in Children: Long-Term Results. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2022.09.001

[51] Composite anterolateral thigh perforator flaps in the management of complex hand injuries. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411427648

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[61] Donor Site Evaluation after Autologous Osteochondral Mosaicplasty for Cartilaginous Lesions of the Elbow Joint. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546507306465

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