Upper limb traumatic injuries: A concise overview of reconstructive options

Abstract

Different options for upper limb reconstruction are described in literature: advancement or rotation flaps, regional flaps and free flaps are the most common. Local and regional flaps can represent the reconstructive options for small defects while large wounds require the use of free flaps or distant pedicled flaps. In case of large wound, the use of free flaps rather than distant pedicle flaps is usually preferred. To choose the best reconstructive option, it is essential for the surgeon to have a general overview about the different methods.
In this review the Authors will refer to the most commonly used methods to cover soft tissues injuries affecting the dorsum and the palm of the hand and the forearm (excluding fingers). The aim is to show all flap reconstructive options so as to support the inexperienced surgeon during the management of traumatic injuries of the upper limb.

Full text

Annals of Medicine and Surgery 66 (2021) 102418
Available online 27 May 2021
2049-0801/© 2021 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
Review
Upper limb traumatic injuries: A concise overview of reconstructive options
Marta Starnoni
a
,
b
,
*
, Elisa Benanti
a
, Andrea Leti Acciaro
c
, Giorgio De Santis
a
a
Department of Medical and Surgical Sciences, Division of Plastic Surgery, University of Modena and Reggio Emilia, Policlinico of Modena, Largo Pozzo 71, 41124,
Modena, Italy
b
Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
c
Department of Orthopaedics and Traumatology, Division of Hand Surgery and Microsurgery, University of Modena and Reggio Emilia, Policlinico of Modena, Largo
Pozzo 71, 41124, Modena, Italy
ARTICLE INFO
Keywords:
Upper limb reconstruction
Free ap
Pedicle aps
Dermal substitutes
Upper limb traumas
ABSTRACT
Different options for upper limb reconstruction are described in literature: advancement or rotation aps,
regional aps and free aps are the most common. Local and regional aps can represent the reconstructive
options for small defects while large wounds require the use of free aps or distant pedicled aps. In case of large
wound, the use of free aps rather than distant pedicle aps is usually preferred. To choose the best recon-
structive option, it is essential for the surgeon to have a general overview about the different methods.
In this review the Authors will refer to the most commonly used methods to cover soft tissues injuries affecting
the dorsum and the palm of the hand and the forearm (excluding ngers). The aim is to show all ap recon-
structive options so as to support the inexperienced surgeon during the management of traumatic injuries of the
upper limb.
1. Introduction
The management of upper limb traumas may be challenging due to
the involvement of several structures such as skin, bone, tendons,
nerves, arteries and veins. A functional impairment of the limb can be
reported. The most common causes of complex wound are road trafc
and work-related accidents, as well as domestic injuries, burns, rearm
accidents, etc. [1,2].
The hand and plastic surgeon have to provide a functional coverage
of the wound with a good joint excursion. The coverage needs to be
stable and long lasting allowing patient return to work as well as
aesthetically pleasant [3]. The most challenging wounds may require
amputation when is not possible to obtain a functional restoration
because of wide and severe tissue damage. The age of the patient such as
the characteristics of trauma, wound and surrounding tissue inuence
the reconstructive technique. Advancement or rotation aps, regional
aps and free ap are the most common reconstructive options [4].
Defects can be classied according to anatomical location. In 2015,
Rehim et al. modied the functional cutaneous units’ concept of Tubiana
and introduced the functional aesthetic units and subunits of the hand
that consider the principles of visual perception and anatomical aspects
[5]. Ono et al. modied this concept by classifying dorsal and palmar
soft tissues defects based on their characteristics: small (defect of a single
surface of a metacarpal bone), medium (defect of two surfaces of a
metacarpal bone or two adjacent surfaces of two metacarpal bones) and
large (more than two metacarpal bone surfaces or non-contiguous de-
fects) [6].
In this review we will refer to the most commonly used methods to
cover defects on dorsum, on palm of the hand and on forearm.
2. Reconstruction by area
The Authors reviewed the available literature on wound coverage of
dorsum and palm of the hand and of the forearm analyzing all the
reconstructive options for each area. The aim is to provide a general
overview of the coverage of hand wound in order to support the inex-
perienced surgeon in the management of damaged area reconstruction.
2.1. Dorsum of the hand
In soft tissue coverage of the dorsum, tendons sliding must be pre-
served [7,8]. Several options are described including reverse radial
forearm adipofascial, fasciocutaneous or fascial ap (Fig. 1), the poste-
rior interosseous artery ap (PIA), groin ap or other abdominal
* Corresponding author. Modena University Hospital, Largo Pozzo 71, 41124, Modena, Italy.
E-mail address: martastarn@gmail.com (M. Starnoni).
Contents lists available at ScienceDirect
Annals of Medicine and Surgery
journal homepage: www.elsevier.com/locate/amsu
https://doi.org/10.1016/j.amsu.2021.102418
Received 1 May 2021; Accepted 17 May 2021

Annals of Medicine and Surgery 66 (2021) 102418
2
pedicled aps, dermal substitutes/skin graft or free aps. For small
dorsal defects, direct closure or local aps are optimal. For
medium-sized defects, the radial artery perforating ap (RAP), the ulnar
artery perforator (UAP) or the PIA are usually used, whereas for large
defects free aps such as dorsalis pedis, anterolateral thigh ap (ALT) or
abdominal distant aps are preferred [6]. In the absence of a vascular
injury to the same extremity, the most used method is the reverse pedicle
radial forearm ap that can be also raised as a free ap thanks to its thin
and pliable conformation which guarantees an adequate tendon sliding
[9]. However, especially in middle-aged women with signicant thick-
ness of subcutaneous fat, it is better to harvest it as a pure fascial ap
covered then by a skin graft [10]. Concerning the distant pedicled aps,
dorsal defects of the hand are covered with inferiorly pedicled base
aps: the supercial circumex iliac artery ap (SCIA) and the super-
cial inferior epigastric artery ap (SIEA) [11]. The use of dermal sub-
stitutes followed by skin grafting is another option to consider for
defects of the dorsum in selected cases.
2.2. Palm of the hand
A coverage with sturdy tissues that guarantee a good grip and sup-
port is essential for reconstruction of the palm. For small palmar defects
it is possible to use conventional local aps or conservative treatments
such as articial dermis. When deep vital structures are not exposed,
palm has a high potential for second intention healing, whereas for
medium-sized defects, forearm aps such as the pedicled perforator
aps should be considered [6]. The groin ap is an excellent option if
web space or nger stumps need to be covered. It brings copious tissues
which can be useful in case of further procedures such as osteoplastic
reconstruction of the thumb and toe transfer [12]. The serratus anterior
ap can be used to cover the dorsum of the hand as well as the palm or
the rst webspace. Of note, the medialis pedis ap is able to restore the
weightbearing of the palm [6].
2.3. Forearm
Free aps or pedicled distant aps are generally required to cover
large wounds of the forearm. The ALT is a workhorse in the
reconstruction of the upper limb thanks to its long pedicle, simple
dissection, possibility of thinning up to 3 mm, and minimum morbidity
of the donor site. A sensate ap as well as a composite ap with muscle
or fascia can be harvested. Two equips, both in the donor and recipient
site, can simultaneously work with the patient in a supine position [13].
The lateral arm ap (Fig. 2), supplied by the posterior collateral radial
artery, has to be mentioned for forearm reconstruction. It can be used
both as pedicled or free ap and it can be raised as a sensate ap with the
posterior brachial cutaneous nerve reinnervation [14]. Among the
distant pedicled aps the paraumbilical perforator (PUP) is the best
choice for forearm wounds, due to patient comfort during the
post-operative time before division [15].
3. Discussion
Small defects are covered by local and regional aps while large
wounds need the use of free aps or distant pedicled aps [16]. Limits of
local aps for coverage of large defects are represented by the poor
expandability of the donor site, the reduced ap’s range of motion and
the frequent damage of the surrounding tissue with possible compro-
mising of transfer vitality [13]. In case of large wounds, the use of free
aps rather than distant pedicle aps is the choice [16]. In order to
choose the best reconstructive option, several algorithms have been
proposed [16]. Chim et al. proposes an algorithm based on the specic
characteristics of patient and wound, taking into consideration the
preparation of wound bed, the area of injury and the replacement like to
like [16].
Free aps provide the best coverage in cases of severe injury of upper
limb. The microvascular aps bring good skin coverage and can be
combined with fascia, muscle, bone, and tendons, providing healthy
tissues and facilitating vascular growth from the surrounding tissues
[17]. The blood supply has the advantage of improving bone healing and
resistance to infections [13]. Moreover, these aps have the advantage
of requiring few days of hospitalization and patients don’t have the
discomfort of the attached limb to the abdomen. Complete reconstruc-
tion in a single stage allows early mobilization, reduces brosis and
avoids stiffness [18]. Of note, mobilization should begin as soon as
possible to prevent joint stiffness, tendon adhesion and soft tissue
contracture which can compromise long-term outcomes [19].
Fig. 1. Reverse radial fascio-cutaneous forearm ap. Fig. 1aTraumatic injury of
the dorsum of the hand. Fig. 1bFlap harvest. Fig. 1cFlap inset and coverage of
the donor site with skin graft. Fig. 1dPost-operative result. e Tendons and joint
function restoration.
Fig. 2. Lateral arm free ap. Fig. 2a. Defect of the volar region of the forearm.
Fig. 2b. Preoperative ap mark. Fig. 2c. Flap harvest. Fig. 2d. Microvascular
anastomosis. Fig. 2e. Post-operative result.
M. Starnoni et al.

Annals of Medicine and Surgery 66 (2021) 102418
3
Fasciocutaneous aps have a better color match and a greater choice of
the donor area compared to muscular aps. In selected cases, perforator
aps can be an alternative good option because of the lower morbidity of
the donor site and the less bulky aspect [16].
In the 1970s and 80s the distant pedicled aps such as groin and
abdominal aps were the workhorses for hand and forearm recon-
struction. These aps have well-known disadvantages such as the need
of ap division, the patient discomfort and emotional stress, an
increased hospitalization with higher costs, the need of a debulking, as
well as joints stiffness and long physiotherapy sessions. Furthermore,
their use is limited by the rotation arc, the extension and the position of
the injury [11,13]. Nevertheless, when well executed distant pedicled
aps can be even better than free aps in long-term outcomes [20],
especially in patients with comorbidities. They are fast and easy to raise
and in obese patients they are certainly thinner than other aps [21].
Abdominal aps are versatile and do not require technical skills or
microsurgical instruments. They can be cost effective but proper tech-
nical renements should be performed. A narrow base allows a good
inset without bunching and unevenness of the ap. In order to have a
more comfortable position it is mandatory to keep an adequate length of
the pedicle allowing mobility. A dedicate and prompt post-operative
rehabilitations therapy is fundamental. The vascularization of the
injured limb is not potentially compromised because there is not vessels
manipulation in comparison with free ap. Moreover, they can be
thinned during the second surgical step almost up to the subdermal level
[21,22]. The training period, the attention to details and the ability to
perform are certainly lower than the microsurgical ones and give the
surgeon a greater level of condence when facing with a complex defect
[20]. Pedicled aps should always be considered because they can allow
further reconstructive options. In case of large injuries with bone loss
and a single vessel limb, the pedicled ap can be used to cover the soft
tissue defect allowing a future bone reconstruction with a free ap [20].
In many parts of the world, distant pedicled aps are still workhorse in
the management of upper limb reconstruction and are unlikely to be
displaced by free aps [23]. Free aps are used only when other options
are not available and when the defect cannot be covered otherwise. Free
aps provide coverage in a single stage; however, they require experi-
ence, a long operating time, facilities, a learning curve and they have a
potential for failure [4,24,25]. Distant pedicled aps can be considered a
good coverage option and preferred to free aps in specic situations of
large wounds that cannot be covered by loco-regional aps. Common
indications are represented by poor receiving vessels, extended scars,
and severe comorbidities. The demanding of a toe transfer as a second
surgical time may require a pedicle ap for prevention of contractures,
preservation of a stump and recipient vessels for a second microsurgical
step [26]. In case of electrical burns injuries, recipient vessels are often
damaged. The use of free aps can lead to hand ischemia if thrombosis
occurs [11]. However, some authors prefer the use of free aps because a
burned hand is prone to stiffness and free aps allow an early mobili-
zation [27]. The coverage of metacarpal heads is another described
indication [28]. Nevertheless, all these indications can be disproved and
reviewed in favor of microsurgery, although free aps can have a greater
number of postoperative complications in the hand of unskilled surgeon.
Certainly, pedicled abdominal aps nd their main indications in cases
in which the patient’s health is critical (as in polytrauma), the vessels are
damaged, if other surgical procedures are planned such as toe transfer or
bula ap or when the general anesthesia and long surgeries are con-
traindicated (pregnancy), as well as in case of microsurgical ap failure
and in the setting of limited economic and technical resources [20,21].
A possible approach to upper limb wounds could be the initial
application of dermal substitutes or vacuum therapy and wait for
granulation to occur. This can be performed in all situations in which the
defect is not so small to be covered with local aps and not so large to
need a free ap or a distant pedicled ap. Bioengineering products are a
valid option to consider in patients who are not suitable for aps
reconstruction. In 1981 Burke et al. described articial dermal
substitutes composed by a layer of silicone epidermis and a dermis of
porous collagen chondroitin 6-sulfate brillar, used for extensive burns
treatment [29]. Dermal substitutes are a heterogeneous group of wound
coverage materials that help in closing wounds and replace skin func-
tions, sometimes temporarily, sometimes permanently depending on
their characteristics [30]. These substitutes provide many biological and
physiological properties of human dermis, can promote tissue growth
and optimize healing conditions [31]. Dermal substitutes can be used in
the hand to cover critical structures such as tendons without paratenon,
cartilage without perichondrium and bone without periosteum. The
complete bio-integration requires a well vascularized wound bed free
from infections [32]. Therefore, the use of dermal substitutes should be
considered as an additional option, especially if local tissues are
damaged or unavailable. In case of soft tissue damage with exposed
tendon and absent paratenon, skin substitute can be considered a
convenient and efcient option for immediate tendon coverage in terms
of tendon function restoration and good cosmetic results [33]. For small
wounds the use of free ap is not convenient as it brings additional costs
and resources, and surrounding tissues are often unavailable: in these
cases, dermal substitutes can be a valid alternative [34]. The simplicity
of the procedure and a minor donor site morbidity are the most
important advantages. Moreover, favorable cosmetic and functional
outcomes have been reported with the use of dermal substitutes for deep
defects of the hand after burns, tumors excision and injuries of ngers
that cannot be covered with local aps [35]. Certainly, the high initial
cost of dermal substitutes could be a disincentive to use them limiting
their availability. This is true in developing countries, while more
economically advanced countries are likely to buy dermal substitutes. In
our knowledge, there is only one study on the cost analysis that com-
pares the total costs derived from the use of dermal substitutes vs. total
skin graft costs for small burns treatment: the costs of dermal substitutes
were higher, but not statistically signicant; indirect costs such as the
duration of hospitalization and overheads have been the most important
factors in inuencing the total cost of treatment [32]. The potential use
of dermal substitutes in difcult wounds with deep structures exposure
leaves an open chapter that could avoid more complex procedures and
cause less morbidity to patients [36].
Of note, the surgical background can signicantly interfere with the
surgeon’s choices in traumatic emergencies as well as in elective pro-
cedures both in hand and plastic surgery [37]. Different surgical aspects
have to be taken into considerations when facing with the patient:
- detailed knowledge of the topic and all surgical solutions [38];
- technical possibilities according to hospital class (hub or spoke
center) and epidemiologic challenges such as emerging COVID-19
pandemic [39–42];
- required instruments to perform microsurgery [43–47];
- use of new technologies, innovative surgical methods and uncon-
ventional devices [48–52];
- possibility to refer to skilled consultants;
- possibility to work in multi-equip with different specialists [53–58];
- selection of high-risk surgical wound complications patients
throughout available scores [59,60];
- the help of skilled health professionals able to early detect possible
complications and promptly start proper care and close follow-up
[61,62].
These aspects are crucial to dene the context of the patient treat-
ment. Technical surroundings are extremely different from one care
center to another. The healthcare background is fundamental when
choosing among different surgical options. The best surgical solution
available in a hospital could be the worst if performed in another health
center [2,63,64]. Despite several studies and innovative techniques, we
have not yet reached a scientic conclusion on the best type of coverage
[65]. Beyond the possible indications of different centers, variables that
play an important role in the decision are patient related and surgeon
M. Starnoni et al.

Annals of Medicine and Surgery 66 (2021) 102418
4
dependent as well as depending on the economic possibilities and fa-
cilities of the different hospitals [66]. The patient’s age, employment,
other injuries and future plans are factors to consider: in the planning of
reconstruction it is good to have in mind from the beginning all the
possible surgical steps [67]. Concerning the patient age there are con-
icting opinions between those who prefer distant aps because of the
patients comorbidities and those who prefer free aps for the lower risk
of joints stiffness: the groin ap is generally contraindicated in elderly
patients because it could predispose to shoulder stiffness, and in young
children because of the difcult cooperation [10]. A decision-making
algorithm for selecting an ideal ap for a particular hand defect re-
quires experimental considerations on functional outcome, aesthetic
appearance, donor site morbidity and patient satisfaction. To select the
best and most appropriate ap, more studies are needed with scientic
evidence that can compare the different outcomes [6].
4. Conclusion
In order to choose the best reconstructive option of the upper limb,
several algorithms have been proposed, but it seems that surgeon
experience can represent a useful help. Thoughts gleaned from the wide
experience of a surgeon represent important evidence-based advice that
can be essential for the decision-making process.
Author contribution
Marta Starnoni: study concept, data interpretation, writing the
paper. Elisa Benanti: study concept, data interpretation, writing the
paper. Andrea Leti Acciaro: data collection. Giorgio De Santis: study
concept, data interpretation, writing the paper.
Guarantor
Marta Starnoni, Elisa Benanti; Andrea Leti Acciaro; Giorgio De
Santis.
Trial registry number
Nothing to declare.
Ethical approval
Nothing to declare.
Sources of funding
Nothing to declare.
Provenance and peer review
Not commissioned, externally peer reviewed.
Declaration of competing interest
The authors declares that there is no conict of interest regarding the
publication of this paper.
References
[1] M. Giustini, et al., Incidence estimates of hand and upper extremity injuries in
Italy, Ann. Ist. Super Sanita 51 (4) (2015) 305–312.
[2] B. Battiston, A. LetiAcciaro, A. DeLeo, The role of the FESSH hand trauma
committee in europe, Handchir. Mikrochir. Plast. Chir. 45 (6) (2013) 326–331.
[3] C.K. Alphonsus, Principles in the management of a mangled hand, Indian J. Plast.
Surg. 44 (2) (2011) 219–226.
[4] M.M. Bashir, M. Sohail, H.B. Shami, Traumatic wounds of the upper extremity:
coverage strategies, Hand Clin. 34 (1) (2018) 61–74.
[5] S.A. Rehim, E. Kowalski, K.C. Chung, Enhancing aesthetic outcomes of soft-tissue
coverage of the hand, Plast. Reconstr. Surg. 135 (2) (2015) 413e–428e.
[6] S. Ono, et al., Microsurgical aps in repair and reconstruction of the hand, Hand
Clin. 33 (3) (2017) 425–441.
[7] A. Leti Acciaro, et al., A new sign allowing diagnosis in the pathologies of the
extensor tendons of the hand, Injury 49 (6) (2018) 1119–1125.
[8] A. Leti Acciaro, et al., A mini-invasive tenolysis of the exor tendons following
hand fractures: case series, Musculoskelet Surg 102 (1) (2018) 41–45.
[9] A.D. Mih, Pedicle aps for coverage of the wrist and hand, Hand Clin. 13 (2) (1997)
217–229.
[10] N.F. Jones, R. Jarrahy, M.R. Kaufman, Pedicled and free radial forearm aps for
reconstruction of the elbow, wrist, and hand, Plast. Reconstr. Surg. 121 (3) (2008)
887–898.
[11] M.M. Al-Qattan, A.M. Al-Qattan, Dening the indications of pedicled groin and
abdominal aps in hand reconstruction in the current microsurgery era, J Hand
Surg Am 41 (9) (2016) 917–927.
[12] R. Naalla, et al., Reconstruction of post-traumatic upper extremity soft tissue
defects with pedicled aps: an algorithmic approach to clinical decision making,
Chin. J. Traumatol. 21 (6) (2018) 338–351.
[13] F. Herter, M. Ninkovic, Rational ap selection and timing for coverage of complex
upper extremity trauma, J. Plast. Reconstr. Aesthetic Surg. 60 (7) (2007) 760–768.
[14] S. Karamürsel, et al., Versatility of the lateral arm free ap in various anatomic
defect reconstructions, J. Reconstr. Microsurg. 21 (2) (2005) 107–112.
[15] L.G. Gutwein, G.A. Merrell, K.R. Knox, Paraumbilical perforator ap for soft tissue
reconstruction of the forearm, J Hand Surg Am 40 (3) (2015) 586–592.
[16] H. Chim, et al., Soft tissue coverage of the upper extremity: an overview, Hand
Clin. 30 (4) (2014) 459–473, vi.
[17] M. Pappalardo, V.G. Laurence, Y.T. Lin, Chimeric free vascularized
metatarsophalangeal joint with toe llet ap: a technique for reconstruction of the
posttraumatic metacarpophalangeal joint with concomitant soft tissue defect,
J Hand Surg Am 43 (2) (2018) 193.e1–193.e6.
[18] B.S. Lutz, T. Klauke, F.E. Dietrich, Late results after microvascular reconstruction of
severe crush and avulsion injuries of the upper extremity, J. Reconstr. Microsurg.
13 (6) (1997) 423–429.
[19] M. Sundine, L.R. Scheker, A comparison of immediate and staged reconstruction of
the dorsum of the hand, J Hand Surg Br 21 (2) (1996) 216–221.
[20] S.R. Sabapathy, B. Bajantri, Indications, selection, and use of distant pedicled ap
for upper limb reconstruction, Hand Clin. 30 (2) (2014) 185–199, vi.
[21] O. Goertz, et al., The effectiveness of pedicled groin aps in the treatment of hand
defects: results of 49 patients, J Hand Surg Am 37 (10) (2012) 2088–2094.
[22] S.R. Sabapathy, H. Venkatramani, P. Martin Playa, The use of pedicled abdominal
aps for coverage of acute bilateral circumferential degloving injuries of the hand,
Trauma Case Rep 1 (3–4) (2015) 25–31.
[23] J.B. Friedrich, L.I. Katolik, N.B. Vedder, Soft tissue reconstruction of the hand,
J Hand Surg Am 34 (6) (2009) 1148–1155.
[24] N. Panse, P. Sahasrabudhe, Free style perforator based propeller aps: simple
solutions for upper extremity reconstruction!, Indian J. Plast. Surg. 47 (1) (2014)
77–84.
[25] M. Pappalardo, et al., Immunomodulation in vascularized composite
allotransplantation: what is the role for adipose-derived stem cells? Ann. Plast.
Surg. 82 (2) (2019) 245–251.
[26] S.R. Sabapathy, H. Venkatramani, P. Bhardwaj, Reconstruction of the thumb
amputation at the carpometacarpal joint level by groin ap and second toe
transfer, Injury 44 (3) (2013) 370–375.
[27] Z.Y. Ng, et al., Soft tissue reconstruction of complete circumferential defects of the
upper extremity, Arch Plast Surg 44 (2) (2017) 117–123.
[28] R. Naalla, et al., Thoracoumbilical ap: anatomy, technique, and clinical
applications in upper limb reconstruction in the era of microvascular surgery,
J Hand Microsurg 10 (1) (2018) 29–36.
[29] J.F. Burke, et al., Successful use of a physiologically acceptable articial skin in the
treatment of extensive burn injury, Ann. Surg. 194 (4) (1981) 413–428.
[30] J.T. Shores, A. Gabriel, S. Gupta, Skin substitutes and alternatives: a review, Adv.
Skin Wound Care 20 (9 Pt 1) (2007) 493–508, quiz 509-10.
[31] M. Starnoni, G. De Santis, M. Pinelli, Dermal matrix xation: a good adhesion to
wound edges without vascularization impairment, Plast Reconstr Surg Glob Open 7
(7) (2019) e2327.
[32] S.A. Rehim, M. Singhal, K.C. Chung, Dermal skin substitutes for upper limb
reconstruction: current status, indications, and contraindications, Hand Clin. 30 (2)
(2014) 239–252, vii.
[33] J.T. Shores, et al., Tendon coverage using an articial skin substitute, J. Plast.
Reconstr. Aesthetic Surg. 65 (11) (2012) 1544–1550.
[34] N.K. Ahuja, R.O. Datiashvili, Biobrane in the management of critical microsurgical
wounds of the upper extremity, Microsurgery 32 (3) (2012) 196–200.
[35] J.S. Taras, et al., Acellular dermal regeneration template for soft tissue
reconstruction of the digits, J Hand Surg Am 35 (3) (2010) 415–421.
[36] I.L. Valerio, et al., Use of a dermal regeneration template wound dressing in the
treatment of combat-related upper extremity soft tissue injuries, J Hand Surg Am
41 (12) (2016) e453–e460.
[37] M. Starnoni, et al., Factors related to delayed treatment: a case report of a huge
cutaneous horn and review of the literature, Ann Med Surg (Lond) 60 (2020)
384–388.
[38] E. Benanti, et al., Soft tissue coverage of the upper limb: a ap reconstruction
overview, Ann Med Surg (Lond) 60 (2020) 338–343.
[39] A. Baccarani, et al., Plastic surgeons in the middle of the coronavirus disease 2019
pandemic storm in Italy, Plast Reconstr Surg Glob Open 8 (5) (2020) e2889.
M. Starnoni et al.

Annals of Medicine and Surgery 66 (2021) 102418
5
[40] G. De Santis, et al., The Telematic solutions in plastic surgery during COVID-19
pandemic, Acta Biomed. 91 (3) (2020) ahead of print.
[41] A. Leti Acciaro, et al., Retrospective study in clinical governance and nancing
system impacts of the COVID-19 pandemic in the hand surgery and microsurgery
HUB center, Musculoskelet Surg (2021).
[42] M. Starnoni, et al., Management of personal protective equipment in plastic
surgery in the era of coronavirus disease, Plast Reconstr Surg Glob Open 8 (5)
(2020) e2879.
[43] A. Baccarani, et al., Obturator nerve split for gracilis free-ap double reinnervation
in facial paralysis, Plast Reconstr Surg Glob Open 7 (6) (2019), e2106.
[44] E. Benanti, et al., Objective selection criteria between ALT and radial forearm ap
in oral soft tissues reconstruction, Indian J. Plast. Surg. 52 (2) (2019) 166–170.
[45] G. De Santis, et al., Tip of the tongue reconstruction with prelaminated
fasciomucosal radial forearm free ap, Plast Reconstr Surg Glob Open 8 (12)
(2020) e3226.
[46] G. De Santis, M. Pinelli, M. Starnoni, Extended and unusual indications in jaw
reconstruction with the bula ap: an overview based on our 30-year experience,
Ann Med Surg (Lond) 62 (2021) 37–42.
[47] A. Spaggiari, et al., Lower lip and chin reconstruction with functional
myocutaneous gracilis ap, Indian J. Plast. Surg. 52 (2) (2019) 242–245.
[48] A. Baccarani, M. Starnoni, G. De Santis, Ultrasonic cutting and coagulating device
in implant-based breast reconstruction, Plast Reconstr Surg Glob Open 6 (11)
(2018), e2020.
[49] M. Pinelli, M. Starnoni, G. De Santis, The use of cold atmospheric plasma device in
ap elevation, Plast Reconstr Surg Glob Open 8 (5) (2020), e2815.
[50] M. Starnoni, G. De Santis, M. Pinelli, Fibula free ap elevation without tourniquet:
are harmonic scalpel shears useful? Plast Reconstr Surg Glob Open 7 (9) (2019),
e2409.
[51] M. Starnoni, M. Pinelli, G. De Santis, Setting of helium plasma device (J-Plasma) in
ap elevation, J Vasc Surg Cases Innov Tech 6 (3) (2020) 446.
[52] M. Pinelli, M. Starnoni, G. De Santis, A simplied and practical surgical treatment
for medial ectropion: a case report, Plast Reconstr Surg Glob Open 7 (5) (2019),
e2102.
[53] A. Baccarani, et al., Pectoralis muscle transposition in association with the ravitch
procedure in the management of severe pectus excavatum, Plast Reconstr Surg
Glob Open 7 (9) (2019) e2378.
[54] R. De Vitis, et al., Unusual intranodular collagenase injection: a case of bilateral
ledderhose disease, Plast Reconstr Surg Glob Open 8 (4) (2020), e2754.
[55] B. Manfredini, et al., Can surgery relieve pain and act as rst-line treatment for a
large metastasis of the sternum? Int J Surg Case Rep 63 (2019) 125–128.
[56] C. Reggiani, et al., The "Bat Flap": a ap for reconstruction of large skull skin
defects, J. Plast. Reconstr. Aesthetic Surg. 72 (11) (2019) 1856–1871.
[57] M. Starnoni, et al., Median nerve injury caused by screw malpositioning in
percutaneous scaphoid fracture xation, Plast Reconstr Surg Glob Open 7 (6)
(2019), e2292.
[58] M. Starnoni, et al., Management of locked volar radio-ulnar joint dislocation, Plast
Reconstr Surg Glob Open 7 (10) (2019), e2480.
[59] M. Starnoni, M. Pinelli, G. De Santis, Surgical wound infections in plastic surgery:
simplied, practical, and standardized selection of high-risk patients, Plast
Reconstr Surg Glob Open 7 (4) (2019), e2202.
[60] M. Starnoni, et al., Standardization and selection of high-risk patients for surgical
wound infections in plastic surgery, Plast Reconstr Surg Glob Open 9 (3) (2021),
e3472.
[61] M. Starnoni, et al., A rare case of nipple-areolar complex partial necrosis following
micropigmentation: what to learn? Plast Reconstr Surg Glob Open 7 (11) (2019)
e2494.
[62] M. Starnoni, et al., Tattooing of the nipple-areola complex: what not to do. A case
series, Ann Med Surg (Lond) 55 (2020) 305–307.
[63] A. Leti Acciaro, et al., The carpal tunnel syndrome in children, Musculoskelet Surg
102 (3) (2018) 261–265.
[64] S. Ichihara, et al., External bone remodeling after injectable calcium-phosphate
cement in benign bone tumor: two cases in the hand, Orthop Traumatol Surg Res
101 (8) (2015) 983–986.
[65] K.R. Eberlin, et al., Soft-tissue coverage of the hand: a case-based approach, Plast.
Reconstr. Surg. 133 (1) (2014) 91–101.
[66] J.M. Adkinson, K.C. Chung, Flap reconstruction of the elbow and forearm: a case-
based approach, Hand Clin. 30 (2) (2014) 153–163, v.
[67] W.C. Pederson, Upper extremity microsurgery, Plast. Reconstr. Surg. 107 (6)
(2001) 1524–1537, discussion 1538-9, 1540-3.
M. Starnoni et al.