A 25-Year Systematic Review of Flaps for Coverage of the Dorsal Hand

PURPOSE: Soft-tissue coverage of the dorsal hand poses unique reconstructive challenges, requiring pliable yet durable tissue overlying critical tendon structures. This systematic review aimed to evaluate different options in flap selection for dorsal hand reconstruction. MATERIALS AND METHODS: Following PRISMA guidelines, a comprehensive search of PubMed, Embase, and Web of Science was conducted for studies published between January 2000 and December 2024. Adult patients who underwent dorsal hand reconstruction with pedicled or free flaps were included. Data regarding flap composition, complications, debulking procedures, and donor-site morbidity were extracted. Statistical analyses were performed using the Fisher exact test, multivariate logistic regression, and the Mann-Kendall test to evaluate temporal trends. RESULTS: Out of 1258 identified studies, 29 met the inclusion criteria, encompassing 372 flaps. Trauma (65.6%) and burn contracture release (25.8%) were the most common indications. Partial and total flap loss rates of 5.64% and 1.07%, respectively. Free flaps (52.7%) and pedicled flaps (47.3%) demonstrated similar complication profiles. Free fasciocutaneous and free muscle flaps were significantly associated with secondary debulking (P<0.001), whereas pedicled flaps showed increased donor-site necrosis (P=0.049). No significant temporal trends in flap selection were observed from 2000 to 2024. CONCLUSIONS: Both free and pedicled flaps remain reliable options for dorsal hand reconstruction, demonstrating high success rates. While there is considerable heterogeneity in flap choices, our results suggest free flaps may necessitate additional contouring procedures, while pedicled flaps may carry slightly higher donor-site morbidity. Flap selection continues to reflect surgeon preference and patient-specific considerations rather than evolving trends.