Successful soft tissue reconstruction of the upper extremity with free flaps must be approached with the goals of not only providing stable coverage but most importantly restoring function. Whereas delayed reconstruction is tolerated in the lower extremity, the hand is poorly tolerant of prolonged immobilization, which predictably results in joint stiffness and tendon adhesions. If delayed reconstruction is selected or necessary, then all joints must be actively or passively mobilized to maintain motion and prevent joint contractures and tendon adhesions. Radical debridement followed by restoration of all missing tissue components at the time of wound coverage can be followed by early mobilization. Other advantages of early reconstruction include primary wound closure, a shorter hospitalization course, the avoidance of multiple procedures and multiple painful wound dressing changes, and early rehabilitation. The advantages of using free flaps for soft tissue reconstruction of the upper extremity are numerous. These include versatility in flap design, the ability to appropriately match color and texture of the recipient site, a long vascular pedicle allowing micro-anastomoses outside the zone of injury, and no additional morbidity at the injury site. Free flaps can provide obliteration of dead space in complex three-dimensional defects with restoration of normal contour and coverage of exposed vital structures, while providing a smooth tendon gliding surface. Multi-component reconstruction can also be achieved, including skin, fascia, muscle, vascularized bone, and vascularized tendon, with minimal donor site morbidity and aesthetically acceptable scar locations. The multitude of flap options available to the reconstructive surgeon enables the choice of flap to be tailored specifically based on the individual characteristics of the donor site and recipient site.
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