Chapter 6.4: The Hands and Feet

The hands and feet present some novel challenges to wound closure. First, these areas are highly mobile—by their very nature, these locations are under constant stress, so that the dorsal hands are subject to significant stretching when making a fist or grasping an object. Second, these areas are subject to repetitive friction, on the hands when they are put in a pocket or purse and on the feet while wearing shoes. Moreover, since the hands are frequently exposed to bacteria in the course of everyday events and the feet often spend the day occluded and are bathed in a significant bacterial load during showers, these areas also have a theoretically higher risk of postoperative infection.

Due to these considerations, wound repair on the hands and feet is best accomplished by effecting a robust closure with the minimal degree of transepidermal suture placement. As with all anatomic locations, linear closure is generally preferred if at all possible, and the overwhelming majority of defects on the hands and feet may be closed in a linear fashion.

Careful broad undermining is very helpful in these locations where the vasculature is often easily visualized in the subdermal plane. As with all closures, examining the patient throughout their range of motion may be helpful in determining the best axis for closure. Generally, longitudinal closures along the long axis of the hand or foot are favored, both in terms of minimizing tension and mitigating the risk of postoperative lymphedema. That said, individual variations and individual propensities must always be taken into account when designing a closure.

On the hands and feet, 3-0 or 4-0 absorbable suture material is often used as the mainstay of closure. Although the skin in these areas is often under marked tension, smaller needles such as the PS-3 or P-3 needle may be most useful since the defects are generally modest in size and the dermis on the hands, while tougher on younger patients, may become markedly atrophic with age and accumulated solar damage.

For superficial closures, 5-0 absorbable suture may be used for a subcuticular closure, while 5-0 nonabsorbable suture may be used for transepidermal closures. On the feet of younger patients, 4-0 or even 3-0 nonabsorbable suture may also be used when placing interrupted transepidermal sutures.

As in most locations, the set-back dermal suture or buried vertical mattress suture is generally the technique of choice on the hands and feet. Since these wounds are sometimes fairly narrow, percutaneous approaches such as the percutaneous set-back dermal suture, percutaneous buried vertical mattress, or buried horizontal mattress approaches may be useful as well (Figure 6-4).

In wounds under marked tension, the pulley set-back dermal or pulley buried vertical mattress may be useful techniques, particularly when placed toward the center of a wound under tension. The relatively robust dermis on the hands and feet of younger patients means that everting horizontally or obliquely oriented techniques, including the butterfly suture, are viable options as well.

The presence of significantly sized vessels very close to the underside of the dermis means that caution should be exerted when placing transepidermal sutures on the dorsal hands and feet. With wide undermining in the appropriate plane, these larger vessels are easily visualized when placing buried sutures. Transepidermal sutures could easily perforate a superficial vessel, and therefore unless they are necessary it may be best to avoid traditional approaches such as the simple running suture. Instead, utilizing either skin adhesive or a running subcuticular approach may be preferable, especially on the highly vascular dorsal hands. This has the added benefit of minimizing the amount of suture material extruding from the skin that could be caught when placing the hand in a pocket or purse in the postoperative period.

In select cases, purse-string approaches may be useful as well, although the postoperative cosmesis is generally not as appealing as when using linear closures.