Distal, dorsal superior extremity plasty.

Multiple deep wrinkles and redundant skin over the dorsal hand, wrist, and forearm develop and become of cosmetic importance to some patients as they age. Distal, dorsal superior extremity plasty was performed in selected patients by excising redundant skin and wrinkles from the dorsal hands, wrists, and forearms. The area of skin to be excised is elliptical, with the long axis of the ellipse centered over the wrinkles on the dorsal wrist. The amount of skin to be excised (i.e., the short axis of the ellipse) is determined by grasping the dorsal wrist skin, hence advancing the dorsal forearm and hand skin, while the patient flexes the wrist. This maneuver is performed to avoid excessive excision of dorsal wrist skin, which would cause decreased wrist flexion. The surgical procedure is performed with use of magnification to avoid sensory nerve injury. A relatively large volume of lidocaine is injected subcutaneously to increase the distance between the skin and nerves and therefore decrease the risk of nerve injury. The skin edges are undermined for 1 to 1(1/2) cm, and the wound is closed in two layers. The wrist is splinted in 30 to 45 degrees of extension to decrease wound tension. The procedure produces long-lasting, good to excellent cosmetic improvement and patient satisfaction. The dorsal wrist, hand, and forearm appear smoother and more youthful, and scars are relatively inconspicuous. Potential significant complications include injury to the superficial branch of the radial nerve and dorsal branch of the ulnar nerve, wound dehiscence, and decreased range of motion of the wrist. Use of magnification, a bloodless field, injection of a relatively large volume of local anesthetic (10 to 12 cc), knowledge of regional anatomy, and careful surgical technique decrease the risk of nerve injury. Avoidance of injury to the superficial sensory branches of the radial and ulnar nerves is absolutely necessary for patient satisfaction. Avoidance of injury to the wound edges with good surgical technique, postoperative immobilization with the wrist in an extended position, and subsequent advancement of the wrist to a neutral position for several weeks decrease the risk of wound dehiscence. Avoidance of excessive skin excision and prolonged wrist immobilization lowers the risk of decreasing range of motion. There have been no complications in patients who underwent this procedure.