An Overview Algorithm for Perforator Free Flap Coverage of all Zones of the Mangled Upper Extremity

A truly mangled upper extremity will undoubtedly need composite tissue rearrangement to ensure adequate wound healing; but often also the replacement of missing parts, always with the goal of maximizing functional rehabilitation. Whatever the approach, restoration of the cutaneous envelope surrounding the underlying repaired musculoskeletal system will be mandatory. Vascularized tissues as flaps frequently will be essential to accomplish this goal; however, intrinsic local donor sites not only may not be available due to the injury itself or if chosen would contribute to further injury. Instead, microvascular tissue transfers will play an important role. In this regard, the perforator free flap today has gained prominence as "like can replace like," sensibility is restored, secondary procedures are more simply approached, and donor site morbidity is reduced since no muscle needs to be sacrificed, maximizing function preservation. However, perforator flap donor sites are highly variable, providing another attribute that, on selection, may best meet the requirements for the involved zone of the upper extremity.