Hand & nail unit reconstruction

Dorsal hand defects

• Small superficial defects with a vascular bed: full-thickness skin graft from groin or supraclavicular fossa.
• Larger dorsal defects may still graft well if paratenon / periosteum is intact and tendons glide freely.
• Exposed tendon without paratenon, exposed bone, joint or hardware usually needs vascularised tissue rather than a graft alone.
• Preferred vascularised options are usually local or regional flaps selected for the defect: local rotation / transposition flaps where laxity allows, posterior interosseous flap, reverse radial forearm flap, groin flap or free flap for larger composite defects.
• Dermal regenerative templates are occasional staged adjuncts in selected cases, not routine substitutes for flap cover.

Palmar / fingertip pulp defects

• Full-thickness graft from hypothenar eminence — glabrous match, donor closes primarily.
• V-Y advancement (Atasoy volar, Kutler lateral) for transverse or dorsal-oblique fingertip amputations < 1 cm without significant exposed bone (or after rongeuring back any small bony prominence). With substantial bone exposure, V-Y typically fails — consider cross-finger or thenar flap.
• Cross-finger flap — donor from dorsum of adjacent middle phalanx; two-stage with division at 2 weeks.
• Reverse cross-finger flap — for dorsal fingertip defects.
• Thenar flap — for index/middle fingertip pulp defects in young patients with good range of motion.
• Heterodigital island flap (Littler) — neurovascular island from non-dominant ulnar digit for sensate thumb pulp reconstruction.
• First dorsal metacarpal artery (FDMA, kite) flap from index dorsum to thumb.

Nail unit reconstruction

Wide local excision technique

1. For melanoma in situ, mark an appropriate clinical margin around the involved nail unit and extend proximally to include the germinal matrix at the proximal nail fold.
2. Excise the involved nail unit en bloc — nail plate, nail bed, germinal matrix and overlying skin to the appropriate deep plane.
3. If periosteum is preserved and the bed is vascular, full-thickness skin grafting is usually appropriate.
4. Exposed bone, tendon or joint generally needs revision to a graftable bed or vascularised local / regional flap cover.
5. Full-thickness skin graft from glabrous donor (hypothenar) for pulp surface; non-glabrous (groin) acceptable for dorsal coverage.

Invasive disease

Do not assume that digit preservation is appropriate for invasive subungual melanoma. Management depends on Breslow depth, ulceration, anatomical extent, bone / joint involvement, imaging and MDT assessment. Reconstruction should follow the oncological plan, not drive it.

When to refer to hand surgery

• Any defect crossing a joint.
• Tendon, nerve or bone exposure.
• Subungual melanoma (consider hand surgeon + plastic surgeon joint approach).
• Dominant hand functional surgery.