Microvascular Reconstruction of the Upper Extremity Iain Whitaker 1,2 , Ian C. Josty 2 , Vera C. van-Aalst Jr. 1 , Joseph C. Banis 1 , John H. Barker 1 Abstract Background: Upper extremity composite tissue de- fects may result from trauma, tumor resection, infec- tion, or congenital malformations. When reconstructing these defects the ultimate objectives are to provide adequate soft tissue protection of vital structures, and to provide optimal functional and es- thetic outcomes. The development of clinical micro- surgery has added a large number of treatment options to the trauma surgeon’s armamentarium – primarily replantation of amputated tissues and transplantation of vascularized tissues from distant donor sites. Since the early 1970s, considerable refinement in microsurgical tools and techniques to- gether with a better understanding of the anatomy and physiology of microcirculatory tissue perfusion led to the introduction of a variety of thin, pliable and versatile-free flap designs. Methods: Sources for this manuscript include a com- prehensive literature search using the PUBMED and EMBASE databases along with relevant text books, Selected Readings in Plastic Surgery Ò , and personal experiences of upper extremity reconstruction and microsurgery. Results: In this manuscript, we describe the primary microsurgical techniques used to reconstruct upper extremity tissue defects and discuss the basis for selecting one technique over another. Conclusion: Where possible, the best results may be achieved by reattaching the amputated original tis- sues (microsurgical replantation). In noninfected, uncontaminated traumatic injuries resulting in com- posite soft tissue defects, Early free flap reconstruction of the upper extremities has important advantages over delayed (72 h–3 months) or late wound closure (3 months–2 years). In recent years, thin, pliable, and versatile fasciocutaneous flaps such as the antero- lateral thigh (ALT) and lateral arm (LA) free flaps have been increasingly used with great success to recon- struct the upper extremity. The use of ‘‘spare parts’’ and functional reconstructions using osteomyocuta- neous free flaps or toe to thumb transfers complete the armamentarium of the upper limb reconstructive microsurgeon. Key Words Upper extremity Æ Reconstruction Æ Microvascular reconstruction Eur J Trauma Emerg Surg 2007;33:14–23 DOI 10.1007/s00068-007-7022-8 Introduction ‘‘As the problem is composite, the surgeon must also be .... The surgeon must face the situation and equip himself to handle any and all of the tissues of the limb ...’’ [1]. Upper extremity composite tissue defects may result from trauma, tumor resection, infection [2], or con- genital malformations [3]. When reconstructing these defects, the ultimate objectives are to provide ade- quate soft tissue protection of vital structures, and to provide optimal functional and esthetic outcomes [4]. These objectives are best achieved in selected trauma cases where the amputated tissues are recovered and can be replanted. In most cases the tissue is damaged beyond repair by trauma or disease (e.g., tumor resection) and the defect must be repaired using local, regional and/or free-tissue transfers from a suitable 1 Plastic Surgery Research Laboratory, University of Louisville, Louisville, KY, USA, 2 Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, UK. Received: February 1, 2007; revision accepted: February 4, 2007; Published Online: February 27, 2007 European Journal of Trauma and Emergency Surgery Focus on Reconstructive Surgery 14 Eur J Trauma Emerg Surg 2007 Æ No. 1 Ó URBAN &VOGEL