Complications of skin grafts and pedicle flaps

Skin coverage complications of hand wounds can be divided into two categories: those associated with problems of the wound bed itself and those associated with failure of the skin graft or flap coverage. Wound problems generally are the result of inadequate preparation, infection, or excess scarring due to a long interval between injury and time of coverage. If the wound is adequately debrided, removing all devitalized tissue or tissue colonized with bacteria, coverage can usually be undertaken no later than 3 days after injury. Injuries that result in loss of skin only are best treated with skin grafts. If the bed is well vascularized, complications generally are only mechanical ones, either establishment of a barrier such as hematoma between the bed and the graft, or shearing forces tearing the graft from the bed. Skin flaps carry their own blood supply so they are not generally subject to those kinds of complications; but they are dependent upon continuation of adequate circulation until vascularization takes place. Because they are much thicker than grafts, this is a slower process, and the flap is vulnerable to problems of kinking or tension of the base. Careful attention must be paid to prevention of these problems, especially in the first few days. Axial flaps are preferable to random ones, but any flap must be carefully planned in order to assure adequate vascular perfusion and minimal tension.