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An ideal reconstruction is a marriage between science and art. The art lies in achieving a (not always possible) perfect functional and aesthetic result, and in the innovative ability to achieve this.

The most important principle in reconstruction is the reconstructive ladder. The principle involved is to begin planning the reconstruction at the bottom rung of the ladder. If this is not anatomically or functionally possible, planning then moves on to the next rung of the ladder, until an optimal reconstructive option is found.

Our plan in managing patients with major degloving injuries of the hand is to start planning from the simplest option and to move stepwise up the ladder to more complex and difficult reconstruction, if the simpler options are not possible. We aim to achieve a single-stage reconstruction with appropriate flaps, to facilitate early mobilization. Our algorithm is as follows.

REPLANTABLE DEGLOVED PART Evaluate the viability and functional status of the avulsed part. If these are satisfactory, the whole or viable part of the avulsed segment is replanted. The advantage is twofold. No other part of the body is violated, preventing donor-site morbidity. We adhere to the principle that replacing like with like will produce the best functional and cosmetic outcome. No other reconstructive option will give the functional and cosmetic result of replanting a viable avulsed part. In major degloving, the main arteries (radial and ulnar) are not usually involved. But the major veins (cephalic and basilic), being subcutaneously situated, are avulsed off with the degloved segment. So there will not be any major arteries in the degloved portion to replant. This is considered a barrier to replantation. We use the principle of arteriovenous shunting. The proximal artery is anastomosed to either the cephalic or basilic vein, to provide the inflow. The other vein is then anastomosed to its counterpart in the forearm, to provide the outflow. Additional arterial and venous anastomoses are done, as appropriate. Sometimes, additional excision of epidermis, and the use of an abdominal pedicle flap for 3 weeks, can be temporary means for improving viability. If the procedures described above are not possible, we move on to step two.