Closure of Hand Wounds with Tissue Loss in Ankara, Turkey

Closure of hand wounds with tissue loss is the process of surgically repairing skin, muscle, or tendon defects that occur after trauma, tumor excision, infection, or burns. The goal is to preserve hand function while ensuring aesthetic integrity.

In small tissue losses, primary closure or skin grafting may be applied. However, if the tendon, nerve, or bone tissue is exposed, flap surgery is required. Missing tissue is covered using local, regional, or free flaps, providing reconstruction with living tissue.

In flap selection, the size, depth, location, and circulatory status of the wound are taken into account. Especially in areas such as the dorsum of the hand where tendons are superficial, thin flaps with good vascularity are preferred. Microsurgical techniques are used in free flap procedures.

In the postoperative period, wound care, infection control, and physical therapy are important. Early movement and rehabilitation should be initiated to preserve hand functions. With appropriate technique and timing, functional and aesthetic results can be achieved successfully.

What Is Closure of Hand Wounds with Tissue Loss?

Closure of hand wounds with tissue loss refers to reconstructive surgical procedures aimed at repairing skin and soft-tissue deficiencies that occur after trauma, infection, or surgery. Depending on the size and depth of the wound, primary closure, skin grafting, or local or free flap procedures may be preferred. The goal is to preserve hand function, reduce infection risk, and achieve an aesthetically appropriate healing outcome.

What is the initial assessment process like in hand injuries?

In a patient presenting with tissue loss, the first thing we look at is the mechanism of injury. How the injury occurred can change the entire course of treatment. There is a huge difference between a clean knife cut and a crush injury caused by being caught in a press machine. In clean cuts, the borders are clear and we can see exactly which tissue is intact. However, crush injuries are always more challenging for surgeons.

In crush injuries, the area we call the “zone of injury” can extend far beyond the wound that is visible to the naked eye. A piece of skin that appears intact at first glance may lose viability within a few days due to impaired circulation. Therefore, in such cases, rather than acting hastily, sometimes the best strategy is to wait for tissue boundaries to become clear. At this stage, the procedure we call “debridement” comes into play. Debridement is the removal of dead or nonviable tissues and is vital for preventing infection.

It is also necessary to mention some incorrect practices performed during emergency intervention. In particular, applying a tourniquet by tightening the upper arm to stop bleeding is a procedure that must be done very carefully. If there is no major vessel laceration and there is no life-threatening situation, we avoid prolonged tourniquet use. Because keeping tissues without blood supply for a long time can cause additional damage called “reperfusion injury” when blood flow is restored.

In this assessment process, there are some critical factors we consider:

These factors include:

• Time of injury
• Degree of wound contamination
• Bone integrity
• Status of vascular circulation
• Presence of nerve injury
• Tendon functions

How should a severed part or limb be transported?

The most dramatic presentation of hand injuries is undoubtedly amputations. In the case of a complete amputation of a finger or hand, the first aid performed by the patient and relatives is one of the most important factors that determines whether the part can be replanted. Unfortunately, some incorrect methods commonly known among the public can cause the loss of a salvageable part.

The most common mistake is placing the amputated part directly into ice. Tissue that comes into direct contact with ice freezes. In medicine, this is called “frostbite.” The cellular structure of frozen tissue is damaged and vessels are injured. In such a case, replantation with microsurgery becomes impossible. Cooling is necessary, but it must be indirect.

The steps to follow when transporting the amputated part to the hospital are very clear.

These steps are:

• Sterile gauze moistened with normal saline
• A clean, waterproof bag
• A container filled with an ice-water mixture
• Rapid transfer

First, the amputated part should be wrapped in sterile gauze lightly moistened (not soaking wet) with normal saline. If normal saline is not available, a clean, damp cloth may also be used. This wrapped part should be placed into a waterproof bag and the bag should be sealed tightly. Then, this bag should be placed into another container containing a mixture of ice and water. The aim is to keep the part cold without direct contact with ice. With this method, tissue metabolism slows down and tolerance to lack of oxygen is prolonged.

In treatment planning, should we use the reconstructive ladder or the elevator?

In plastic surgery training, there is a classic concept taught from residency onward: the “Reconstructive Ladder.” According to this principle, when closing a wound, one should always start with the simplest method. First, the wound is left to heal on its own; if not possible, suturing is performed; if that is not sufficient, a skin graft is considered; and if bone is exposed, more complex flap methods are used. However, hand surgery does not always accept such a strict, step-by-step hierarchy. Because the function and aesthetics of the hand cannot always be achieved with simple methods.

In modern hand surgery practice, we adopt the “Reconstructive Elevator” approach. This approach means going directly to the method that will provide the ideal result for the patient, rather than climbing the ladder step by step. Sometimes, if the most complex method—free tissue transfer (microsurgery)—will provide the fastest recovery and the best function for the patient, we skip the simpler steps and choose that method directly.

When making this decision, we do not look only at the size of the wound. The patient’s social and physical characteristics are among the most important parts of the equation.

The criteria we evaluate include:

• The patient’s age
• Occupational expectations
• Dominant hand use
• Smoking
• Systemic diseases
• Social support status

For example, the treatment of a tissue loss on the fingertip of a pianist cannot be the same as that of a laborer doing heavy work. While touch sensation and fingertip bulk are vital for the pianist, early return to work and durability may be priorities for the laborer. Therefore, the treatment plan must be tailored individually for each patient.

In which situations is a skin graft used?

Skin grafts, commonly referred to as “skin patches,” are among the most frequently used methods to cover large and superficial tissue losses in the hand. However, not every wound can be closed with a skin graft. For a graft to take, the blood supply of the recipient bed must be good. If avascular structures such as bone, tendon, or cartilage are directly exposed after the injury, a skin graft cannot survive over these areas. In such cases, instead of a graft, we prefer tissue transfers (flaps) that have their own blood supply.

Because the hand is a mobile organ, the quality of the skin transferred here is very important. We generally prefer “full-thickness skin grafts.” This is because thin grafts tend to shrink (contract) during the healing process. This shrinkage can restrict finger movements and impair hand function. Full-thickness skin grafts are more durable, contract less, and adapt better to the aesthetic structure of the hand.

The donor site from which the graft is taken must also be chosen carefully.

Donor site options include:

• Inner surface of the wrist
• Inner elbow crease
• Behind the ear
• Groin area
• Inner upper arm

In particular, grafts taken from the wrist provide excellent color and texture match with the hand. The key to success in grafting is ensuring that the graft adheres firmly to the wound bed. For this, we use a special dressing technique called a “tie-over.” We apply pressure to the area by tying sutures at the wound edges over a cotton- or sponge-like material placed on top of the graft.

There are some main reasons why a graft may fail to take:

The reasons for failure include:

• Inadequate fixation
• Hematoma formation
• Development of infection
• Smoking
• Early movement

Smoking, in particular, constricts capillaries, impairs graft perfusion, and is one of the most important causes of failure.

Which flap methods are preferred in fingertip injuries?

Fingertips are the areas where we make the most intense contact with the outside world, recognize objects, and perform the finest tasks. In tissue loss in this region, our main goal is not only to close the open wound. At the same time, we aim to preserve finger length, support the nail bed, and most importantly, create a “sensate” fingertip. A fingertip without sensation is functionally like a blind spot, and the patient avoids using that finger.

There are several basic flap techniques we frequently use in fingertip injuries. The first is V-Y advancement flaps. Especially when there are clean cuts at the fingertip, we advance the healthy skin just below the wound upward while preserving the vascular and nerve structures. With this technique, finger length is not shortened and sensation is preserved. Aesthetic results are usually very good.

Another method is the cross-finger flap. If there is a large tissue loss on the volar surface of the injured finger and bone is exposed, we borrow skin from the dorsum of the adjacent finger. We suture the injured finger to the healthy finger. This may sound somewhat intimidating, but the results are quite successful.

In this process, the points that require attention are:

• Immobilization of the fingers
• Dressing follow-up
• Need for a second stage
• Joint movements

The fingers remain attached to each other for about 2–3 weeks. At the end of this period, once the transferred skin establishes its own blood supply in the new location, we separate the fingers with a minor procedure. This method provides a durable and strong coverage for the fingertip.

A third option is the thenar flap. Especially in defects at the fingertips of the index and middle fingers, we flex the finger and suture it to the padded area at the base of the thumb in the palm. The finger remains flexed for a while and tissue transfer is achieved from that region. This method provides an excellent cushioning tissue for the fingertip. However, keeping the finger flexed for a long time may cause joint stiffness, especially in older patients, so we select patients very carefully.

What are the regional or distant flap options in large tissue losses?

When the injury extends beyond the fingertip and becomes large enough to involve the dorsum of the hand or the palm, the finger’s own tissues or simple skin grafts are insufficient. In this case, we need to transfer tissue from other parts of the body together with its own vascular system.

One of the methods we use most frequently in this context is the radial forearm flap. We elevate the skin from the inner surface of the forearm together with its vessel and place it into the defect on the hand by turning it over without cutting the vessel. With its thin, flexible, and relatively hairless structure, it adapts very well to the hand. This tissue can even be transferred together with its nerves to provide sensory function. Its only disadvantage is that it leaves a noticeable scar in the area where the skin is taken from the forearm, which may bother some patients aesthetically.

In larger and deeper injuries, especially in “degloving” injuries where the skin of the hand is completely stripped, the groin flap can be lifesaving. In this method, the hand is tunneled and sutured under the groin skin in the lower abdomen. The hand remains attached to the groin for about 3 weeks, as if it were in a pocket. This period can be challenging for the patient in terms of comfort. Shoulder and elbow pain and difficulties with personal care may occur. However, it is a reliable option for closing very large soft-tissue defects.

In modern surgery, we now frequently perform microsurgical free tissue transfers that eliminate this prolonged period of attachment. Tissue taken from the groin, leg, or back region is completely detached from the body together with its vessels and then anastomosed to the vessels in the hand under a microscope. This is a “single-stage” procedure.

The advantages of free flaps include:

• Early mobilization
• Patient comfort
• Less joint stiffness
• Shorter hospital stay

From the moment the patient leaves the operating room, they can move the hand and do not have to keep it attached to the abdomen for 3 weeks. This accelerates the rehabilitation process tremendously.

How does negative-pressure wound therapy (VAC) speed up healing?

Technology has greatly strengthened our capabilities in the preoperative preparation process. Negative-pressure wound therapy (VAC), commonly known as “vacuum dressing,” creates revolutionary results in complex wounds. In this system, a special porous sponge is placed over the wound, sealed in an airtight manner, and connected to a device that applies controlled suction.

The biological effects of this system are numerous. First, by drawing out edema and excess fluid from the wound, it relieves tissue circulation. Tissue with improved blood flow heals faster. In addition, the vacuum effect significantly reduces the bacterial load on the wound surface. One of its most important effects is accelerating the formation of “granulation tissue,” which is the red, viable tissue with high healing potential, in the wound bed.

The benefits provided by VAC therapy include:

• Edema control
• Reduced infection
• Wound size reduction
• Increased perfusion
• Improved flap success

Especially in crush injuries where tissue viability is borderline, or when we want to support the bed of a skin graft we performed, VAC therapy is a reliable aid. Studies show that applying vacuum intermittently (e.g., running for 5 minutes and stopping for 2 minutes) rather than continuously stimulates tissue formation more.

What is the role of tissue engineering and artificial skin?

In recent years, developments in tissue engineering have added new options to our surgical armamentarium. We can now use materials called “dermal substitutes,” which replace the dermis or act as a scaffold for dermal healing. Products such as Matriderm and Integra are advanced-technology materials produced from biological substances such as bovine collagen and elastin.

Normally, placing only a thin skin graft over a deep wound—especially if it is over bone or tendon—does not yield good results. The graft adheres to the area, collapses, and prevents tendon gliding. However, when we use these artificial dermal scaffolds, the situation changes. When these materials are placed over the wound, the body sends its own cells and vessels into the scaffold. Over time, as the material is absorbed by the body, it leaves behind a thicker and more flexible tissue that is much closer to normal skin.

The areas of use for these materials include:

• Wounds over tendons
• Joint regions
• Burn contractures
• Defects over bone

When used especially in mobile areas of the hand, they significantly increase the hand’s range of motion (ROM) and enable a more aesthetic scar outcome. Matriderm can often be applied in a single session together with a skin graft, whereas Integra usually requires a two-stage surgery.

Why is postoperative physical therapy and rehabilitation important?

There is a reality we always tell our patients: “If 50% of a successful outcome is the work done in the operating room, the other 50% is postoperative rehabilitation.” Even if we perform the best microsurgery in the world and place the most perfect flap, if the hand is not moved correctly and on time after surgery, the result can be disappointing. The hand is an organ that has no tolerance for immobility. In an immobilized hand, joints stiffen quickly, tendons adhere, and edema becomes permanent.

The healing and rehabilitation process is examined in three main phases. The first phase, the Acute Phase (0–5 days), is the protection period. In this period, to protect the surgical site, reduce edema, and control pain, the hand is usually rested in a splint (static splint). However, this rest period should never be kept longer than necessary.

The second phase is the Proliferative Phase (2–6 weeks). In this phase, controlled movement begins. If a tendon repair was performed, special exercises are done that are gentle enough not to allow tendon rupture but effective enough to prevent adhesions. In this phase, the harmony between the patient and the physiotherapist is very important.

The third phase is the Maturation Phase (after week 6). Tissues have healed, and it is time to strengthen.

The practices applied in this phase include:

• Scar massage
• Resisted exercises
• Stretching movements
• Return to daily activities
• Sensory re-education

Here, the concept of “Sensory Re-education” deserves special attention. Even if nerves heal, the brain may initially be unable to recognize signals coming from that area. Touching different textures with eyes closed and trying to recognize objects helps the patient use brain plasticity to “relearn” how to feel the hand. This process is just as important as motor movement.