Visual subunits of the hand: proposed guidelines for revision surgery after flap reconstruction of the traumatized hand

The posttraumatic hand deformity remains a difficult challenge for reconstructive surgeons. Much has been written about the relative benefits of fasciocutaneous, fascial, and muscle flap reconstruction; however, the literature is devoid of guidelines for secondary surgery after flap reconstruction to improve the appearance of the hand. We introduce the concept of visual subunits of the hand in an effort to better guide restoration of natural hand form; thenar, hypothenar, midpalm, distal palm, dorsal hand, volar forearm, and dorsal forearm subunits are proposed. The visual subunit principle has been implemented in reconstruction of posttraumatic hand deformities. Management initially focused on reestablishment of hand function and provision of soft tissue coverage via local and free tissue transfer. Secondary procedures involved partial flap elevation, targeted debulking, and redefining topographic regions where possible. By designing asymmetric skin excision patterns, the resultant length and width discrepancies can be used to purposefully enhance topographic features while re-creating the appearance of natural crease lines bordering adjacent subterritories. No complications related to partial or complete flap loss were encountered.