Local flaps to the hand

In choosing which flap to employ for a particular defect, the surgeon should think again about areas of skin availability. Where insufficient skin is present for a flap design that permits no skin graft, such as a rotation or a rhomboid flap, then a simple transposition flap with a graft on the secondary defect may serve admirably. In planning a local flap, the inexperienced surgeon should always think of an elegant escape should this plan not work--the experienced one always does. In raising the flap, the surgeon should remain aware that he is challenging its blood supply and thereby rendering it more vulnerable to injury; he should take care that he not inflict that injury during dissection. The skin hook and the knife are more precise and less damaging than the forceps and the scissors and should be used in preference. By rendering tissues tense with judicious hook traction, natural planes are revealed. By pursuing such planes much less trauma is inflicted than in creating planes where none exist. The design and execution of a local flap is an intellectual and elegant pursuit worthy of any surgeon. If the surgeon, in turn, is worthy, he or she will appreciate that fact and gain much satisfaction from the practice.