Indications for free soft-tissue flap transfer to the upper limb and the role of alternative procedures.

The aim of soft-tissue replacement to the upper limb is twofold. The first is to restore as much functional tissue as possible, and the second is to achieve this in the shortest possible time. Of lesser consideration is the desire to achieve a good cosmetic result. In any given clinical situation, no single reconstructive procedure will maximally satisfy these aims. The personal philosophy expounded in this article exposes disadvantages as well as advantages of the many operations available to the upper limb surgeon. Each clinical problem is different from any other, so no blueprint or computer program is available to help the surgeon select an operation. It takes judgment based on knowledge and experience on the part of the surgeon to make the most appropriate selection. During the last two decades, free vascularized transfers have superseded some of the conventional pedicled flap operations, and this has been acclaimed quite rightly as a significant advance. By the same token, indications for the "older" techniques should remain in the armamentarium of the surgeon because in certain situations these may yet offer the best solution. A spin-off of the microsurgical era is the reverse forearm island flap, and in my view, this has become a new "star" in the recent era. It is fitting that it should have prominence in the reconstructive arena because it straddles the border between microsurgical and nonmicrosurgical techniques. It is a modern reminder that there are many ways to treat defects of the upper limb and that the responsibility of the surgeon is to be both imaginative and wise in securing the best possible result for the patient.