When a nerve and/or tendon is injured in association with extensive loss of skin, and it is apparent at the outset that their repair or reconstruction will be required, the management of that aspect of the overall defect has generally to be subordinated to the provision of skin cover.
In order to function properly in the case of a tendon, or for axon regeneration in the case of a nerve, a covering of subcutaneous tissue as well as skin is necessary, and this carries the implication that cover by a flap will be required.
When the skin defect is being reconstructed primarily using a flap, the possibility of carrying out the tendon and/or nerve reconstruction simultaneously theoretically exists, but the decision may well depend on the degree of experience of the surgeon(s) involved. The considerations which would determine such a decision concern the degree of tissue damage and wound contamination present, and whether an adequate primary debridement is possible, whether failure to reconstruct primarily is likely to result in much poorer final function, and whether the posture which may be required of the tendon/nerve reconstruction will preclude the use of the method of providing skin cover considered otherwise appropriate.
The cautious approach is to provide primary flap cover and carry out the tendon/nerve reconstruction as a secondary procedure.
When the initial skin cover has been provided
by a free skin graft, tendon/nerve reconstruction has to await replacement of the graft by a flap. Here again the considerations are essentially the same as those involved in decision making at the acute stage, except that tissue damage and potential contamination are not part of the equation.
A single-stage reconstruction, with the opportunity present for preoperative planning, simultaneous tendon/nerve reconstruction may be a reasonable approach; multi-staged, it is safer to wait until the flap transfer is complete and the flap well settled before carrying out the tendon/ nerve reconstruction.
Sometimes disease or previous injury makes it
necessary to replace the overlying skin to allow surgery of bone, joint or tendon to be carried out.
A flap is then usually required, and the con-siderations involved are similar to those de-scribed for the combined skin-tendon/nerve injury.