Flap decisions and options in soft tissue coverage of the upper limb

Soft tissue deficiency in the upper limb is a common presentation following trauma, burns infection and tumour removal. Soft tissue coverage of the upper limb is a challenging problem for reconstructive surgeons to manage. The ultimate choice of soft tissue coverage will depend on the size and site of the wound, complexity of the injury, status of surrounding tissue, exposure of the vital structures and health status of the patient. There are several local cutaneous flaps that provide adequate soft tissue coverage for small sized defects of the hand, forearm and arm. When these flaps are limited in their mobility regional flaps and free flaps can be utilised. Free tissue transfer provides vascularised soft tissue coverage in addition to the transfer of bone, nerve and tendons. Careful consideration of free flap choice, meticulous intraoperative dissection and elevation accompanied by post-operative physiotherapy are required for successful outcomes for the patient. Several free flaps are available for reconstruction in the upper limb including the groin flap, anterolateral flap, radial forearm flap, lateral arm flap and scapular flap. In this review we will provide local, regional and free flap choice options for upper limb reconstruction, highlighting the benefits and challenges of different approaches.