INCISIONS FOR PLASTIC A N D R E C O N S T R U C T I V E

(NON-SEPTIC) SURGERY OF THE H A N D

By J. M. BRUNER,M.D.
Des Moines, Iowa, U.S.A.

A CORRECTLY placed incision is of great importance in all fields of surgery, b u t

there is perhaps no region in which the exact delineation of a surgical incision
is so critical as in the hand. The surface of the hand is an etching composed
of interlacing lines whose pattern is the result of the movements peculiar to the
human hand through countless centuries. An incision must not deface this
pattern. The interior of the hand is a complex mechanism motivated by myriad
structures of small size and fragile form. An incision must not injure these
structures. There is therefore very little margin for error in gaining surgical
access to the hand.
In I9r4 Kanavel published his monograph, " Infections of the Hand," based
on injection experiments of the tendon sheaths and fascial spaces and on clinical
observations. Although much was already known of the surgical anatomy of hand
infections, Kanavel established our present concept of the synovial and fascial
spaces and gave specific directions as to incisions to be used for their drainage.
Since that time many articles have appeared in the literature dealing with the
problem of where best to incise the infected hand. An excellent recapitulation
of this subject is to be found in Handfield-Jones's textbook published in i94 o.
Until about that year, surgeons were preoccupied with the devastating effects o f
bacterial invasion of the hand, which not only crippled many hands beyond repair
but often thwarted efforts at reconstruction.
To-day, thanks to the antibiotics, but especially to penicillin, serious hand
infections are rarely seen, even in large urban centres where they were common ten
years ago. However, in spite of the virtual disappearance of major hand infections,
the scope of surgery of the hand has actually increased. The mounting incidence
of mechanical and thermal injuries is bringing to surgery large numbers of hands
which, with the aid of penicillin, are being restored to useful function b y
reconstructive and plastic surgery.
Whereas much has been written conceriaing incisions for septic surgery of the
hand, little has been said about proper incisions for non-septic surgery. T h e
subject has never been discussed with the completeness which it deserves, nor
have the reasons for certain controversial points been presented.
The purpose of this paper is to review current ideas on incisions for
reconstructive and plastic surgery of the hand. This field includes the surgery o f
tendons, nerves, bones, and joints in the hand, the removal oftumours, cysts, ganglia,
and foreign bodies, operations for the relief of Dupuytren's and other contractures,
and plastic procedures to restore the normal continuity of the skin itself. The
blue-printing of areas for the application of free grafts and pedicles is a closely
allied subject. The margins of all grafts on the hand are subject to the same l;ules
as primary incisions.
The incisions employed for the drainage of infected tendon sheaths and
fascial spaces are only partially applicable for use in clean cases. In septic cases
48
 PLASTIC AND RECONSTRUCTIVE SURGERY OF THE HAND 49

the infected spaces must be laid open widely by incisions which sometimes violate
flexion creases roughshod. Such incisions, while admittedly necessary to provide
adequate drainage, often leave the hand a veritable Verdun, heavily scarred by the
partially obliterated trenches representing old surgical incisions. To-day in
non-septic surgery we are hardly satisfied with an incision which does not result
in a fine scar that is inconspicuous among the flexion folds of the finger, hand,
or wrist.
Incisions in the hand may be placed in two categories : firstly, elective hand
incisions, made by the surgeon according to plan ; and secondly, traumatic
incisions inflicted by accident. The utilisation of such traumatic skin lacerations
and their proper elongation to gain needed exposure for tendon or nerve repair
often poses a difficult problem.
The merit of a surgical incision in the hand may be judged by the following
criteria : (I) adequate exposure of the structures undergoing surgery ; (2) minimal
Scarring after healing, with absence of contracture; (3) minimal disturbance of
arterial and nerve supply, venous and lymphatic drainage, tendon gliding, and
joint motion.
The position of an incision is therefore influenced by (i) the skin flexion
creases of the fingers, hand, and wrist, which, with few exceptions, are transverse
in direction ; (2) the geography of underlying arteries, veins, nerves, and tendons
in the locality, which in general are longitudinal in course.
This is the dilemma which confronts the hand surgeon. Incisions must not
cross flexion creases ; to do so invites heavy scars and contractures. But if incisions
conform with flexion folds, they are at odds with anatomical structures, thereby
endangering these and limiting exposure. The difficulty of entering the hand
surgically may be compared to the course of a ray of light which, having been
polarised in one plane by a grid, encounters another grid at right angles to the first.
The problem has four possible solutions, each applicable under different
circumstances: (I) by making incisions in conformity with flexion creases but
with careful regard to the integrity of underlying nerves and blood-vessels;
(2) by staying in neutral territory where " to and fro " movements of the skin are
least active in producing scar tissue (e.g., the mid-lateral lines of the fingers and
thumb and the mid-lateral line of the ulnar border of the hand) ; (3) by making
compromise incisions, curved or diagonal, or those employing the S or Z
principle; (4) by making " non-conformist " incisions which offend skin lines
but pay obeisance to underlying blood-vessels and nerves. These latter should
be regarded as exceptions to the rule, and are indicated only in specific areas.
Incisions in the hand will now be considered from a regienal standpoint.
Fingers.--The volar surfaces of the fingers are marked by the transverse
interphalangeal flexion creases. The distal crease is usually single, the middle
crease double, and the proximal crease double in the ring and middle fingers,
single in the minimus and index. In the intervening areas the skin lines form a
delicate cross-hatching in which the longitudinal lines are somewhat more
prominent. According to Wood-Jones, these latter represent the tension lines of
Langer. Limited incisions conforming with these longitudinal lines are often
useful for the removal of small turnouts, cysts, ganglia, or foreign bodies in the
finger. No trespassing is permissible, however, across the track of the
interphalangeal folds.
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50 BRITISH JOURNAL OF PLASTIC SURGERY

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 PLASTIC AND RECONSTRUCTIVE SURGERY OF THE HAND 51

Illustrations s h o w i n g relation of incisions to skin flexion lines

A, Mid-lateral finger incision, posterior to digital nerve and artery, advocated

by Bunnell for flexor tendon surgery.
B, Antero-lateral finger incision, just anterior to digital nerve, used by Koch
and Mason for flexor tendon surgery.
C, Mid-lateral incision on thumb for exposure of long flexor tendon.
D, Longitudinal incision on dorsum of hand for surgery on metacarpal bones.
E. Incisions for capsulectomy on metacarpo-phalangeal joints.
F, Limited transverse incision on dorsum of wrist for removal of ganglion.
Division of subcutaneous veins and nerves should be avoided.
G, Longitudinal incision over radial styloid with immediate partial Z plasty
for operation to relieve De Quervain's disease.
H, Incision for removal of benign tumour or foreign body in thenar web.
J, Bayonet extensions of traumatic lacerations for exposure to repair severed
extensor tendons.
K, Incision for repair of rupture or avulsion of extensor tendon.
L, L-shaped incisions for access to digital extensions of palmar fascia in
Dupuytren's contracture (Mason).
M, Incisions for excision of skin tumours. If large area of skin must be
excised, the defect should be d o s e d by graft rather than primary
suture (see text).
N, Hockey-stick incision used by Bunnell for flexor tendon work in the
palm ; distal portion of incision used for resection of palmar fascia
in Dupuytren's contracture.
P, Distal palmar crease incision used by Koch, Mason, and McIndoe for
access to palmar fascia in Dupuytren's contracture.
Q, Accessory incision used by Koch and Mason for access to palmar fascia.
R, Incision for exposure of flexor pollicis longus tendon in palm (avoid
injury to motor branch of median nerve).
S, S-shaped incision, crossing joint.
T, Bayonet extensions of traumatic laceration on volar surface of wrist for
access to flexor tendons, median, and ulnar nerves.
V, Limited transverse incision on dorsum of wrist for work on extensor
tendons.
W, Elective incision for work on flexor tendons at wrist level (should be well
above the border of transverse carpal ligament).
X, Incision for relief of snapping thumb (access to flexor pollicis longus
tendon).
Y, Limited longitudinal incision (within finger segment) for removal o f
foreign body or tumour.
Z, Longitudinal incision with immediate Z plasty for access to digital bands
of palmar fascia in Dupuytren's contracture (McIndoe).
52 BRITISH JOURNAL OF PLASTIC SURGERY

The proper location of incisions for tendon surgery in the fingers is one of the
most controversial points in surgery of the hand. The two incisions used are the
mid-lateral and the antero-lateral, and each has its proponents. In either case
the proper digital nerve and artery must be protected from injury. The severance
of a digital nerve, if not immediately repaired (and this is not always easy) results
in para~sthesia, anaesthesia, and trophic changes in the finger-tip, for which the
patient is not thankful. The volar digital nerve should be as assiduously avoided
as the sandtrap on a golf course. It is better to stay on the fairway.
The mid-lateral incision is advocated by Bunnell (I949) : " A finger should
be opened by mid-lateral incisions, not antero-lateral as so often pictured, for these
are exactly over the nerves and vessels." The scar resulting from this incision is
neutral with respect to flexion and extension of the finger, and is innocent of
causing contracture. Exposure of the flexor tendon sheath, the pulleys, and the
tendons themselves is possible throughout the entire length of the finger if
necessary. The only disadvantage of this incision seems to be the rather brisk
bleeding often encountered from the dorsal branches of the digital artery. These
branches must be ligated.
The antero-lateral longitudinal incision as used by Koch and Mason also has
wide application in tendon surgery in the finger. " The incision should be made
so that it lies just volar to the vessels and nerves, which may be retracted dorsally
after the skin is divided" (Kanavel and Mason, I939). There is usually less
bleeding with this incision than with the mid-lateral incision, but there is
necessarily some interference with nerve filaments from the digital nerve which
supply the volar surface of the finger. This incision seems a somewhat more
direct approach to the flexor tendon mechanism than the lateral approach. As
used by its advocates, it has wide utility in the surgery of the flexor tendons and
gives excellent results.
Considerable confusion still exists regarding the comparative merit of these
two incisions. If the proper indications for each could be clarified, a great service
would be done to hand surgery. We have used the mid-lateral incision most
frequently, but have found the antero-lateral incision of special advantage in
selected cases.
The median longitudinal incision running the length of the volar surface of
the finger has frequently been made in the past, and is mentioned for its
condemnation. It is nocuous for two reasons : when it goes deeply through the
pulleys it allows luxation of the flexor tendons with bow-stringing ; when it
crosses interphalangeal creases it results in flexion contracture, requiring plastic
correction.
An exception to the rule against the median longitudinal incision is the
limited median incision used by McIndoe for removal of the digital prolongations
of the palmar fascia Jn Dupuytren's contracture. This incision, followed by
immediate Z plasty, gives unequalled exposure for the removal of the offending
fascial bands and plaques, and affords relief of the flexion contracture in the
skin itself.
Transverse traumatic incisions on the volar surface of the finger are often
encountered by the surgeon who is called upon to repair severed tendons. The
exposure of flexor tendons, possible through a simple transverse incision, is ~harply
limited by the digital nerves and vessels on each side ; in the average adult finger
this space is ½ in. or less. It is therefore usually advisable to prolong transverse
 PLASTIC AND RECONSTRUCTIVE SURGERY OF THE HAND 53

volar wounds of the fingers by bayonetic extensions which will afford the
necessary exposure.
On the dorsum of the fingers, incisions should in general be transverse, in
conformity with the multiple flexion folds. Whenever possible, the dorsal venous
network and cutaneous nerves should be spared. The extensor tendon mechanism
may often be exposed by a lateral or dorsi-lateral approach.
Thumb.--Incisions on the thumb follow the same general rules as for the
fingers. For surgery on the long flexor tendon the mid-lateral incision is advisable,
some surgeons preferring the radial, others the ulnar side of the thumb.
Frackelton employs an ulnar mid-lateral incision which is interrupted to leave
a small bridge of skin near the metacarpo-phalangeal joint, then is extended into
the palm somewhat parallel to the thenar crease. The palmar portion of this
incision is often useful for retrieving the proximal end of a severed pollicis longus
tendon which has retracted into the palm. For work on the flexor pollicis longus
tendon incisions on the radial side of the thumb are useful only distal to the
metacarpo-phalangeal joint ; proximal to that level, the long flexor tendon is
inaccessible because of the intervening thenar muscles.
Choice of sides for incision in a finger or thumb depends on several factors.
The radial side of the finger or thumb is usually more convenient for the surgeon
to work upon, but a scar on the radial side of the finger-tips is more subject to
pressure in pinching. Decision as to the best site for incisions on the fingers of
musicians, typists, etc., calls for careful pre-operative consideration.
Webs.--Incisions in the webs should be avoided. It is well known that
transverse web incisions cause contractures which often require plastic relief.
Longitudinal incisions through the web likewise result in an inevitable loss in
web freedom. I f a web space must be entered for the removal of a tumour, cyst,
or foreign body, access should be gained through an incision proximal to the web.
The delicate crescentic plica forming the edge of the web should remain inviolate.
The importance of web laxity applies especially to the thumb, where unrestricted
amplitude of motion is needed.
The Palrn.--The three chief palmar flexion folds, namely, the proximal,
middle, and distal flexion creases, are perhaps more familiar to some as the linea
vitalis, linea cephalica, and linea mensalis of palmistry. Since not even the surgeon
may lightly dismiss the ancient science of cheiromancy, it may not be mere
coincidence that the transgression of these lines is attended by bad luck. It is
obvious that it is unwise to transect the life line or to mar the love line. Hence
it is axiomatic that surgical incisions in the palm st'ould be coincident with or
parallel to those lines. The anatomical structures most vulnerable to injury in
the palm are the common and proper digital nerves, and the superficial palmar
arch and its branches.
Bunnell's palmar incision follows the distal crease to a point about I in.
from the ulnar border of the hand, then turns proximally, describing a broad
hockey-stick curve. The proximal limb of this incision does not violate the rule
against longitudinal incisions, inasmuch as it enters a quiet area in the palm, the
hypothenar area, which is relatively free from the turbulence of skin wrinkling.
When wide access to the palm is needed, as in tendon suture or graft, this incision
gives the required exposure of the sublimis and profundus tendons and of the
54 BRITISH JOURNAL OF PLASTIC SURGERY

lumbrical muscles which are often sutured over the region of tendon juncture to
prevent adhesions.
Bunnell also uses this incision for access to the palmar aponeurosis in
Dupuytren's contracture. Excellent exposure is thereby provided, facilitating
resection of the thickened fascia. In cases where quality and thickness of the
palmar skin is doubtful, we have experienced some trouble at the bend of the
incision, where there may be a tendency of the edge of the palmar flap to undergo
necrosis.
For Dupuytren's contracture we often employ the exposure advocated by
Koch and Mason. One incision is made in the distal palmar crease, and
a supplementary incision in the proximal (thenar) crease, raising a bridge of
skin under which the palmar aponeurosis is resected. Although exposure is
somewhat more restricted, skin healing is more favourable. McIndoe obtains
exposure in the palm for Dupuytren's contracture through an incision in the distal
crease alone, supplemented by digital incisions, as described above.

D o r s u m of Hand.--Incisions on the dorsum of the hand are often needed

for surgery of the extensor tendons, removal of skin tumours, or operations on the
metacarpal bones. The flexion creases on the dorsum of the hand consist of
multiple fine wrinkles which are transverse in disposition except over the thenar
web where they are longitudinal, in relation to adduction and abduction of the
thumb. The general course of the large subcutaneous veins and sensory nerves
is mainly longitudinal.
Unlike palmar incisions, dorsal incisions should usually be longitudinal,
conforming with the underlying structures. While it is admissible to make short
transverse incisions for minor procedures, long transverse incisions on the dorsum
which entail the section and ligation of large veins often lead to protracted cedema,
puffiness, and stiffness of the fingers. Furthermore, if damage is done to the
terminal sensory branches of the radial and ulnar nerves by such incisions, many
patients will complain bitterly of the resulting sensory disturbances which are
more or less permanent.
Skin tumours of the basal and squamous-cell types occur frequently on the
back of the hand. If such growths are excised and the skin edges closed primarily
by a long transverse incision, it will be necessary to bring the metacarpo-phalangeal
joints into full extension to relieve tension on the suture line. The result is a
bad situation, and is frequently followed by cedema of the fingers and stiffening
of the metacarpo-phalangeal joints in the position of full extension. The solution
of this problem is often found in the application of a free graft to the denuded
area, allowing the metacarpo-phalangeal joints to be placed in semi-flexion
post-operatively.
For operations on the metacarpal bones, longitudinal incisions are advisable,
and these generally heal with a remarkably slender scar.

D o r s u m of Wrist.--Incisions on the dorsal surface of the wrist should always

be transverse, in company with the fine skin furrows. The ebb and flow in the
tides of skin tension are very strong here, and keloids or heavy scars often result
from longitudinal incisions. Here, again, great care must be used to protect veins
and nerves from injury. For this reason, operations for the removal of ganglia
which so often occur in this location should be performed only under ideal
 PLASTIC AND RECONSTRUCTIVE SURGERY OF THE HAND 55

conditions of ha~mostasis with the pneumatic tourniquet to ensure identification

o f fine nerves. Transverse incisions over the anatomical snuffbox for the relief
o f De Quervain's disease also require the same meticulous safeguarding o f the
sensory twigs o f the radial nerve.
An alternative plan for access to the stenotic fibrous tunnels in De Quervain's
disease is a longitudinal incision over the radial styloid, followed by immediate
Z plasty in the central part o f the incision. We prefer this incision because there
is less danger o f damage to the terminal branches o f the radial nerve. T h e Z
in the centre o f the incision prevents heavy scar formation, which would otherwise
follow.
Volar S u r f a c e o f W r i s t . - - T h e volar surface o f the wrist is marked by three
flexion f o l d s - - t h e proximal, middle (restricta), and distal (rasceta) creases.
Incisions here should always be transverse, and the severance of superficial veins
is without serious consequences. Only one cutaneous nerve is met here, the palmar
branch of the median nerve, and this is inconstant. For flexor tendon work at the
wrist, the proximal crease marks the best level for incision, being proximal to the
edge o f the transverse carpal ligament.
Traumatic lacerations o f the volar surface of the wrist with severed tendons,
nerves, and arteries are common. T h e proper extension o f these wounds for
necessary surgical exposure is very important. T and X incisions should never
be made ; the angles tend to undergo necrosis. Instead, extensions should be
made at one or both ends o f the laceration, bayonet-wise. I f the radial or ulnar
arteries have been divided by the trauma, the angles o f prolongation must be
quite obtuse, otherwise skin sloughs may occur, threatening the success of
tendon repair.

CONCLUSION
T h e choice o f an incision for non-septic surgery o f the hand must be made
with careful respect to the dynamics of skin motion on the hand, as well as to the
anatomy o f underlying structures. A poorly chosen incision may result in injury
to important nerves or vessels, tendon or joint malfunction, skin necrosis, sensitive
scars, keloids, or contractures. A well-chosen, correctly executed incision is the
sine qua non o f a competent hand surgeon who must be architect as well as artisan
in repairing and rebuilding the human hand.

REFERENCES
BUNNELL,STERLING(1949)- " Surgery of the Hand." S~zond Edition. Philadelphia : Lippincott.
FRACKELTON, W . n . Personal communication.
HANDFIELD-JONES,R. M. (194o). " Surgery of the Hand." Baltimore: Williams & Wilkins.
JONES,FREDERICWOOD(1941). " Anatomy of the Hand." Baltimore : Williams & Wilkins.
KANAVEL,ALLENB. (1914). " Infections of the Hand." Philadelphia: Lea & Febiger.
KANAVEL, ALLEN B., and MASON, M. L. (1939). " Infections of the Hand," reprinted from
"Cyclopedia of Medicine." Philadelphia : F. A. Davis Co.
KOCH, SUMNERL. (1944). Surg. Gynec. Obstet., 78, 9-2z.
MCINDOE, A.H. Personal communication.
MASON,MICHAELL. (1939). Surg. Clin. N. Amer., x9, 227.
Sr~OOG,TORD(1948). Acta chit. scan&, 96, Supplement 139.