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Introduction
CHAPTER 45 Reconstruction of the
Hands and Feet
Anna A. Bar Omar Nazir Justin J. Leitenberger
SUMMARY
A thorough appreciation of anatomy is a prerequisite prior to engaging in any
surgery on the hand and foot.
Functional considerations play an important role in closure design.
Closure options run the gamut from secondary intention healing to cross-finger
flaps.
Beginner Tips
Assess laxity and tension by having the patient make a fist and move through a range of
motion.
The atrophic dermis on the dorsal hand lends itself to percutaneous suturing
techniques.
Residual edema is possible, particularly if lymphatics are severed.
Expert Tips
Random pattern flaps are most useful on the proximal hand and fingers.
Fasciocutaneous flaps such as the keystone flap may help preserve vascular supply, but
require a high level of knowledge and comfort with local anatomy to be properly freed and undermined.
Donโt Forget!
Nerve blocks are very useful on the hand and foot, as minimizing local anesthetic
infiltration may reduce background edema and mitigate against anatomic distortion.
Do not aggressively undermine fasciocutaneous flaps, as this may lead to impaired
blood supply.
Pitfalls and Cautions
Both motor and sensory nerve damage may occur with large hand and foot repairs.
Grafts should be adequately immobilized to maximize their chance of survival.
Patient Education Points
Minimizing tension across a healing surgical site is critical; splints may help not
simply by immobilizing the relevant anatomy, but by reminding the patient of the need to minimize activity. Assess patient compliance and motivation before considering a two-stage flap.
For foot reconstruction, the legs should be elevated as much as possible in the
postoperative period.
Billing Pearls
Fasciocutaneous flaps should be coded using the adjacent tissue transfer codes
(14040โ14041).
A cross-finger flap is coded as 15574, and division is coded as 15620.
When repairing a fingertip defect with a cross-finger flap, both flap and graft CPT
codes may be used.
CHAPTER 45 Reconstruction of the