Small flap coverage of hand and digit defects

Small defects of the hand and digits challenge the surgeon to use innovative methods of composite reconstruction for retention of digital length; aesthetic nail appearance; coverage of joint, implants, and tendons; release of scar contractures; and restoration of sensation in critical tactile surfaces. This article is by no means totally encompassing but an attempt to provide the reader with an insight into the author's select flap choices applying some of the newer microvascular methods. Descriptions include the volar advancement flap, free microvascular pulp transfer from the toe, "kite flap," onycho-osteocutaneous transfer, arterialized toe transposition, wrap-around flap, arterialized island pedicle, venous flow-through flap, and the free temporoparietal fascial flap. Options are influenced by morphological and physiological considerations, specifically in the fingertip, nail complex, volar surface of the digit, and dorsum of the hand.