Table 1.

Indications and aesthetic considerations of various reconstructive methods.

Tissue type	Indications	Aesthetic considerations
Skin grafts	Superficial wounds with a graftable bed Burn injuries Coverage of donor-site defects	Inadequate volume replacement especially with full thickness defects that may result an unsightly contour defect Color mismatch (e.g. hyper-pigmentation of the palm). Skin grafted sites sometimes result in a color mismatch with adjacent tissue Split thickness skin grafts have a high potential for developing scar contractures and ulcerations. Moreover, meshed skin grafts leave permanent unsightly skin marks
Local flaps	Medium-size full thickness defects of the hand with exposed tendons or bones (e.g. V-Y advancement flap for fingertip injuries) In severe trauma the use of local flaps may be limited because of damage or ischemia of the donor area	An ideal tissue replacement, replaces ‘like-with-like’ that provide an excellent color, texture, hair and volume match
Regional pedicled flaps	Moderate to large sized defects that cannot be covered with a local flap Lack of microsurgical expertise for a free flap reconstruction Several useful flaps are available especially ‘perforator flaps’ that do not sacrifice a major blood supply to the hand e.g. Radial forearm perforator artery flap and Ulnar forearm perforator artery flap or Posterior interosseous artery flap	The major aesthetic drawback of regional flaps is a highly visible and unsightly donor-site that is usually covered with a meshed split thickness skin graft
Free flaps	Large extensive soft-tissue defects Compound wounds that may involve loss of the underlying tendons or bones (e.g. chimeric flaps). When regional flaps cannot be harvested due to damage of vascular pedicle within the zone of injury	In terms of aesthetics consideration, free flaps are the second best option after local flaps. When local flaps are not indicated, free flaps should be considered as the first line of treatment, if no contraindications exist Free flaps can be harvested from several regions of the body with almost any shape or size that can be tailored to the defect Muscle flaps often yield less donor site scars than fasciocutaneous flaps that in many cases can’t be closed primarily and need skin graftcoverage