Preoperative Management

• Patient is usually brought at emergency. Patient's vitals are taken and any other injury if present is examined and managed.
• Hand is thoroughly examined any fractures or infection is ruled out
• Wound is cleaned and irrigated thoroughly.
• Vascularity is assessed using capillary refill, pin prick and color of fingertips.
• Digital Xray of the finger/hand is done to rule out any bony injury.
• All pre operative investigations are done and the finger is immobilized.

Technique of reconstructions

Soft tissue reconstruction depends on size, shape, location and characteristics of the tissue lost. Efficient wound closure becomes a higher priority to prevent finger stiffness and maximize hand function.

Secondary healing (with only dressing and no sutures)

Only small wounds should be allowed to heal by re-epithelialization and closure may take 4-6 weeks. Healing by Secondary intention provides disadvantages of contour deformity, sensation loss and lack of donor site morbidity.

Skin grafting

Skin grafting is the transfer of thin skin sheet, usually taken from thigh, to cover the raw areas of the hand. Once the wound is healthy, skin grafting may be done if defect is not much deep and vitals structures are embedded in granulation tissue. In such cases, dressing is done every alternate day after surgery. Patient may be discharged after 5-6 days, and regular follow-up is required. The area gradually heals and need compression garment later to avoid hypertrophy of scars and to reduce the swelling.

Local flaps

Local flap is the transfer of flap of skin from the surrounding areas to the defect site. It is done when defect is deep and surrounding area is normal and sufficient enough to cover the defect. If not, or local flap fails, then a distant free flap is used to cover the defect through microvascular reconstruction. There are variety of options available to reconstruct THE HAND.

The reverse radial artery flap from the front of forearm and posterior interosseus artery flap from back of forearm are very versatile flap which can be used to resurface the hand in a very effective and efficient way with very less morbidity to the hand with the most natural result possible. It follows the principle of like replaces like and give hand the same skin which was there before the accident or trauma.

Flaps from Groin/Abdomen and chest-

Flaps from groin, abdomen and chestare very versatile flap which can resurface the hands. In this technique, the flaps from the groin, abdomen and chestare used to resurface the defect while remaining attached via skin pedicle. This is a 2 stage procedure. In the first stage, flap is harvested from the selected areaand the raw area is covered by Skin graft. In the second stage after 2-3 weeks when the flap has restored its blood supply over the defect, it is detached from the abdomen or chest. Some amount of cosmetic deformity of the grafted abdomen or chest(area of the harvested flap) should be acceptable to the patient.

Microvascular free flaps-

If defect is deep, any vital structures are visible, like blood vessels, nerve, bone or tendons exposed and no local tissue is available or patient does not want 2 stage procedure or any flap harvest from the abdomen groin and chest region, then transfer of skin flap, muscle flap from a distant area as a free flap is done to cover the defect using microsurgical techniques. It needs surgical expertise and a good working team. Dr Amit Agarwal specializes in microsurgical reconstruction and has saved innumerable hands from amputation. Flaps harvested from the outer aspect of the thigh, back and leg region are used commonly by Dr Amit Agarwal. He also harvests flap from the inner aspect of the foot (medial plantar artery flap) and transfer it to the palmer aspect of the defect to exactly match the kind of tissue loss.

The flap should be monitored frequently post-surgery. Hospital stay is increased, with respect to skin grafting or local flap procedures, but it is the best modality to cover the defects in patients who want a single stage procedure. Dressing is done every alternate day and patient is admitted for at least 7-8 days and discharged once the flap is settled

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