Soft tissue reconstruction of the upper extremity requires strict adherence to standard surgical principles. In keeping with the reconstructive ladder, options for coverage include primary closure, skin grafting, local flaps, regional flaps, and free tissue transfer. Goals include restoration of a functional, sensate, and aesthetically acceptable hand. In addition, stable coverage of vessels, nerves, tendons, and joints throughout the forearm and arm is required. Primary wound healing is also a fundamental goal as it reduces scar formation and joint stiffness. Among the considerations involved in selecting the proper techniques are the components involved, the size of the defect, the mechanism of injury, and the cleanliness of the wound. Patient factors including handedness, occupation, age, sex, and overall health are also considered.

Classic teaching dictates that soft tissue reconstruction follows skeletal stabilization in the traumatized extremity. After bony fixation, stable soft coverage facilitates wound healing, reduces contracture, decreases infection, and improves outcomes for secondary skeletal operations such as bone grafting or distraction. The attempt to achieve a stable soft tissue envelope begins immediately following injury, as Godina espoused for lower extremity injuries.1 Although definitive soft tissue coverage may not be immediately possible, wound debridement is always performed initially. Early debridement of nonviable tissue reduces the opportunity for local inflammatory response and infection. Serial debridement is performed as many times as necessary to ensure viability of all remaining tissues. Definitive coverage is then performed once the wound is adequately debrided.

When planning definitive coverage, local tissue options are considered. Uninvolved soft tissue of the upper extremity is often superior to more distant tissue, as it offers similar sensibility and tissue match. Unfortunately, there is often a paucity of donor tissue in the upper extremity, especially following significant injuries or extirpative surgery. In such cases, distant tissue options are explored.

Basic wound care principles are as essential as the various grafts and flaps available. These principles allow the crafting of a safe and effective reconstructive plan for the upper extremity. This chapter outlines reconstructive options ranging from simple skin grafts to complex free tissue transfer. There are many instances in upper extremity soft tissue reconstruction where “less is more”—an example being the healing of a fingertip injury by secondary intention, when more complex solutions would prolong impairment. The surgeon must be comfortable with all rungs of the reconstructive ladder if the appropriate reconstruction is to be performed in a wide range of clinical scenarios.

The use of negative pressure dressings has revolutionized the care of complex wounds. Although some controversy exists regarding its effect on time to heal, there is no debate over the degree of convenience that it has introduced for both the patient and the surgeon. Wounds of the upper extremity requiring serial debridement do well with negative pressure dressings between procedures provided no neurovascular structures are exposed. Thus, negative pressure dressings serve as a bridge to definitive coverage. In addition to the convenience and cleanliness of the dressings, negative pressure has been shown to promote wound contraction, improve local tissue perfusion, and promote the formation of granulation tissue—effects that make definitive reconstruction easier to achieve.2

The goal of upper extremity soft tissue reconstruction is primary wound healing. Healing by secondary intention is occasionally appropriate such as in certain fingertip injuries. As one of the main goals of fingertip reconstruction is the restoration of protective sensibility, this method is helpful in small, superficial tip defects. In such defects, sensation is maintained in the healed tissue as sensate skin is drawn into the defect.3

This is especially helpful for defects in both children and the elderly. Wounds heal more rapidly in children than in adults because of enhanced wound contraction. In the elderly, healing by secondary intention avoids some of the pitfalls of sensate local flaps: prolonged postoperative immobility and resultant joint stiffness, and the avoidance of necessary cortical reinnervation.

Apart from these defects, healing by secondary intention is of little use for soft tissue resurfacing elsewhere in the upper extremity because of the functional limitations from the resultant contracture.

Similar to healing by secondary intention, revision amputation is best suited for specific cases of fingertip injuries in select patients. This is often advantageous in those patients eager to return to work, and those with multiple comorbidities or clinically unstable pictures.

Although those injuries of the remainder of the extremity with large amounts of devitalized tissue may also benefit from some degree of select amputation, it is rarely indicated as the primary method for definitive treatment of upper extremity injuries.

Stable skin and soft tissue coverage of the hand is essential for hand function. Volar and dorsal surfaces should be considered separate entities when considering coverage. The dorsal hand skin is thin, mobile, and has the primary function of allowing flexion, while maintaining nonadherent coverage of tendons and joints. Split-thickness skin grafts are appropriate for large defects of the upper extremity that have no vital structures exposed. In addition to improved “take” relative to full-thickness skin grafts, split grafts also offer the advantage of greater secondary contraction of the wound, and resultant reduction in the size of the grafted area. The presence of paratenon greatly enhances the survival of the graft and improves postoperative tendon gliding. The ideal thickness for skin grafts to the hand ranges between 0.012 and 0.014 inches. Meshing of the graft can be performed to increase graft surface area, and allow egress of underlying fluid.

When resurfacing the dorsal surface of the hand, tendon adhesion to the overlying skin graft may occur, and subsequent tenolysis is often required. The authors have found that large dorsal defects with exposed tendon do well with coverage by Integra Dermal Regeneration Template, followed by split-thickness skin grafting (Figure 73.1). Other biologic templates may also be comparable and should provide the benefits of improved coverage and reduced adherence to underlying gliding tendons. Though not appropriate for all wounds, elderly patients or those with significant comorbidities precluding free tissue transfer can be reconstructed using this method.

The glabrous skin on the volar surface of the hand carries a highly specialized tactile sensory function. Because of the mechanical demand placed on the working palm, the volar skin is thick and densely adherent to the underlying fascial system, through a series of vertical ligaments. For defects involving the volar hand, primary options for resurfacing include full-thickness glabrous skin grafts from either the hypothenar eminence or the non-weight-bearing region of the plantar foot. This offers the advantage of also providing specialized nerve endings, similar to those encapsulated nerve endings in the injured volar skin, and donor sites that may be closed primarily. If necessary, full-thickness grafts for such defects may also be obtained from other areas of the upper extremity. Given that the native volar skin is devoid of pilosebaceous structures, every effort should be taken to harvest the grafts from similarly hairless areas, such as the volar wrist, or the skin just proximal to the medial epicondyle of the elbow.

Skin grafting of forearm and proximal arm defects follows a similar algorithm to dorsal hand grafting. The majority of defects can be adequately covered with meshed split-thickness grafts. Skin grafting is also an option for fingertip defects. While full-thickness skin grafts are sometimes useful for tip coverage, they are rarely a preferred primary method due to poor recovery of sensibility. In most cases, a sensate flap is a better option, as it retains the important protective sensibility of the fingertip.