Considerations in Flap Selection for Soft Tissue Coverage of the Hand and Digits

Abstract

Background/Objectives: The goal of reconstructive hand surgery is to achieve both functional and aesthetic restoration. The primary aim of this study is to perform a detailed, practice-oriented evaluation of perforator-based and local flaps for soft-tissue reconstruction of the hand and digits, focusing specifically on their functional reliability, anatomical consistency, complication profile, and aesthetic integration in a real-world, high-complexity referral population. Methods: This retrospective single-center study included 37 patients with soft tissue defects of the hand that required flap coverage between September 2021 and September 2024. The study assessed patient demographics, defect characteristics, flap selection, surgical techniques, and outcomes including satisfactory soft tissue coverage, functional results and occurrence of complications. Various perforator flaps were analyzed, including the dorsal metacarpal artery flap, reverse radial forearm flap, reverse posterior interosseous artery flap, reverse homodigital and heterodigital island flaps, and the thenar flap. Results: Satisfactory soft tissue coverage was achieved in 35 out of 37 patients. One case involved partial distal flap necrosis, and another presented with Foucher flap failure. The remaining flaps demonstrated stable integration, preserved perfusion, and durable soft-tissue coverage with satisfactory contour and pliability. Functional outcomes were favorable, with restoration of joint mobility and absence of secondary deformities. Conclusions: This study supports the continued use of perforator and local flaps in upper extremity reconstruction, emphasizing the need for individualized planning to optimize the outcomes.

Keywords: perforator flaps; reconstruction; thenar flap; upper limb.

Figure 1

(a) A 26-year-old male with contracting scarring of the first webspace due to thermal burn. (b) PIA flap design; (c) Early post-operative effect; (d) Result 3 months after surgery.

Figure 1

(a) A 26-year-old male with contracting scarring of the first webspace due to thermal burn. (b) PIA flap design; (c) Early post-operative effect; (d) Result 3 months after surgery.

Figure 2

(a) A 56-year-old man presented with thumb infection with soft tissue necrosis in course of untreated diabetes; (b) Foucher flap design; (c) Flap raising; (d) Insetting of the flap (e,f) Results 6 weeks post-surgery.

Figure 2

(a) A 56-year-old man presented with thumb infection with soft tissue necrosis in course of untreated diabetes; (b) Foucher flap design; (c) Flap raising; (d) Insetting of the flap (e,f) Results 6 weeks post-surgery.

Figure 3

(a) A 44-year-old male presented with PIP 2 and PIP 4 defects due to industrial injury resulting in third digit amputation; (b) DMCA flap design; (c) Flap raising; (d) Early post-operative outcome (e) Post-operative outcome 12 weeks after surgery.

Figure 3

(a) A 44-year-old male presented with PIP 2 and PIP 4 defects due to industrial injury resulting in third digit amputation; (b) DMCA flap design; (c) Flap raising; (d) Early post-operative outcome (e) Post-operative outcome 12 weeks after surgery.

Figure 4

(a) A 76-year-old female suffered chemical burn which resulted in dorsal hand defect exposing extension tendons; (b) Reverse radial artery flap raising; (c) Immediate post-operative result; (d) Donor site covered with split-thickness skin graft; (e) Post-operative outcome 8 weeks after surgery; (f) Donor site 8 weeks after surgery.

Figure 5

(a) A 37-year-old male with dorsal IV finger DIP joint defect with a fistula due to open fracture; (b) Flap design; (c) Island finger reverse artery flap raising; (d) Early post-operative outcome.

Figure 6

(a) A 53-year-old male sustained fingertip amputation of the fourth digit due to mechanical injury; (b) Early post-operative outcome of covering the defect with thenar flap; (c) Outcome 6 weeks after surgery; (d) Outcome 3 months after surgery.

Figure 6

(a) A 53-year-old male sustained fingertip amputation of the fourth digit due to mechanical injury; (b) Early post-operative outcome of covering the defect with thenar flap; (c) Outcome 6 weeks after surgery; (d) Outcome 3 months after surgery.