Bilateral V-Y advancements flaps described by Kutler in 1947 are useful for transverse or dorsal fingertip injuries. These flaps are cut from the sides of the injured fingers and then advanced to the tip by dividing the fibrous septa. Volar advancement flaps are used for transverse or dorsal oblique finger-tip amputations or resections [8]. The entire volar surface of an injured digit can be advanced distally to reconstruct an injured finger-tip using the volar neurovascular advancement flap (Moberg flap) [9]. This flap is often indicated in the treatment of volar oblique and transverse defects of the thumb [9].

Cross finger flaps are the commonest used flap to repair more complex digital defects. A rectangular segment of the tissue from the dorsum of the adjacent digit is dissected, elevated and then inserted over the defect [10]. Two weeks later the pedicle will be divided. Reverse cross finger flaps are a modification of the standard cross finger flap and can also be used for coverage of dorsal digital injuries [11]. A traditional cross finger flap is designed and then de-epithelised [11]. The resulting flap is then rotated 10 degrees to cover a dorsal defect of the adjacent finger [11]. The donor defect will need to be covered by a skin graft [11].

Some useful local flaps to restore the digit and hand defects are from the dorsal side of the hand. The kite flap or first dorsal metacarpal artery (FDMA) flap was described first bydescribed by Hilgenfeldt, refined by Hollevich and modified as a pure island flap by Foucher. It is used to restore the thumb and dorsal soft tissue injuries [12, 13]. The flap is drawn on the dorsum of the index proximal phalanx from the MCPJ to the PIPJ [12, 13]. The pedicle is dissected to include the interosseous fascia with the three branches of the FDMA with the inclusion of superficial veins, radial nerve and radial artery [12, 13]. After the pedicle is raised the flap is transferred into the defect. The arc of the FDMA flap can achieve 7 cm in the adult allowing it to reach the thumb tip [14].

The radial forearm flap has shown to be an excellent flap for injured hands and is the most reliable and versatile flap for upper limb soft tissue reconstruction [15, 16]. The radial forearm flap can be used as a free flap or pedicled flap [15]. The flap is based on the radial artery and the accompanying venaecomitans. Medial and lateral antebrachial cutaneous nerves can also be included to provide sensation in the flap. The radial forearm flap can be used to cover the dorsum of the hand [17]. The advantages of the flap includes the provision of up to 8 x 10 cm of thin, pliable and hairless skin and ease of harvest [17]. Unfortunately, the radial artery is sacrificed and there is potential bulkiness and often poor donor site morbidity with this flap [17]. An Allen’s test should always be performed prior to undertaking this flap, with a deficient palmar arch circulation, indicating this flap option is unsuitable for patients. However, the sacrifice of the radial artery has shown not to have a detrimental effect on the circulation of the hand [18]. Ulnar artery forearm flaps have been used but are less preferred.

The posterior interosessous artery flap, a classic septocutanous fasciocutaneous flap is a very useful for coverage of the dorsum of the hand [19]. This flap can provide thin and pliable coverage, which is ideal for the back of the hand without compromising the two main arteries in the hand [19]. The flap is usually designed on the emergence of the artery in the posterior compartment of the proximal forearm [20]. The limits of the flap are distally 3-4 cm above the wrist crease, medially not to extend subcutaneous border of the ulnar and radially not extend 3-4 cm beyond the epicondylar-ulnar line [20]. The flap pivot point is usually proximal to the level of the inferior radioulnar joint [20].

Similar local flaps available for the elbow and arm when local skin is healthy and viable including advancement flaps and Z-plasties [21]. Rhomboid flaps are useful around the elbow when the defect is small and the defect can be excised in a triangular shape [22]. Small elbow and arm defects can be covered using a proximal based radial forearm [23].

Forearm defects can be approached similar to the hand defects with radial or ulnar forearm regional flaps providing good soft tissue coverage [30]. Retrograde ulnar forearm flaps are also useful to repair distal forearm wounds [30].

As highlighted earlier the radial forearm flap has been considered theworkhouse flap of soft tissue coverage in the upper limb. With a long pedicle of large calibre, being a thin flap and the option to be harvested as a composite flap, this flap technique is a very preferable method among microsurgeons [32]. The major disadvantage of this flap includes donor site morbidity which can be lessened with suprafascial flap harvest and full thickness grafting to the donor site [33, 34].

Technique: After a preoperative Allen’s test is performed a skin incision is performed, which is either straight, curvilinear or zig-zag to begin dissection of the flap [32]. The flap is usually designed over the volar aspect of the forearm and may extend over the radial and ulnar aspect of the forearm if required [32]. The radial edge of the forearm is avoided to avoid damage to the radial cutaneous nerve branches [32]. The skin flaps are elevated and the fascia is then incised to fit the shape and size of the desired defect. The fascia is then elevated directly off until the osseocutaneous septum is reached to find the radial artery and its accompanying veins between the flexor carpi radialis and bradioradialis [32]. The radial artery is then ligated and divided distally for elbow coverage and proximally for hand coverage [32]. The flap is then elevated with fascia and subcutaneous tissue [32].

The groin flap is based on the superficial circumflex iliac artery, which is supplied from the superficial femoral artery at the level of the inguinal ligament and drains into the saphenous system [34, 35]. The groin flap has several advantages including adequate skin thickness and minimal donor site morbidity, making it the most useable free flap for soft tissue coverage of the hand and forearm [34, 35]. The disadvantages of the flap include the short pedicle and that the artery size can be small [34, 35]. The groin flap was the first successful skin and soft tissue free flap, described by McGregor and Jackson in 1972 [34, 35].

Technique: The flap is raised in its entirety [36]. The first incision divides the superficial circumflex iliac arteriovenous system, raising the flap in a plane deep to these vessels until the lateral border of the sartorius is reached [36]. The fascia covering the muscle is then incised and included in the flap [36]. The flap is then elevated medially until muscle fibres are seen passing into the underlying muscles at the medial border of the sartorius muscle [36]. The secondary site of both groin flaps can be closed directly but may require split thickness grafts [36]. The pedicle of the flap is commonly tubed by suturing loosely to itself for attachment of the flap to the hand or forearm wound [36]. The arm is then placed in ‘the hand in pocket’ position to suture the flap to the wound site [36]. Gradually the flap will develop a growth of circulations from the new site and after no less than 3 weeks the surgeon will begin to divide the pedicle [36]. By 5 weeks the surgeon is able to divide the flap completely from the pedicle [36].

Originally described by Shaw, the hypogastric flap based on the superficial inferior epigastric artery can also be used for coverage of hand wounds, particular dorsal defects [37, 38]. It is based just proximal to the ipsilateral inguinal ligament and centred on the femoral artery and vein [37, 38]. This flap is useful has it provides minimal hair and thin flap [37-40]. The groin flap is now more commonly used than the hypogastric flap for hand reconstruction due to the concealed donor scar and better skin texture from the groin flap [39].

Technique: The flap is raised at the deep fascia proximally and superficially to the scarpa fascia proximally [37-40]. The base of the flap is tubed in the direction of the chosen resting hand position [37-40]. Movement of the shoulder, elbow, wrist and fingers will continue [37-40]. At three weeks the flap is usually divided [37-40].

This fasciocutaneous flap based on the circumflex scapular artery (CSA) [41]. This flap causes minimal donor site morbidity, which can often be closed primarily [42]. This flap is useful because it offers the opportunity for a flap with muscle latissimus or serratusmuscle) or bone (scapular) [43]. However, the flap does needs to be harvested with the patient in the prone position or lateral position, meaning the patient will need to be turned during the operation [44].

Technique: The harvest is started by identifying the muscular triangular space and localising the CSA within it by confirming using a doppler probe [41-45]. The scapular flap will be designed along the horizontal plane which is perpendicular to the lateral border of the scapula [41-45]. The superior limit is the scapular spine and the inferior limit is the tip of the scapula [41-45]. Flap elevation must proceed from medial to lateral in the plane just superficial to the facia of the infraspinatus, rhomboid and trapezius muscles with dissection in the subfascial plane [41-45]. The resulting skin flap is then inset according to the wound site with anastomosis carried out before or after the insetting of the flap [41-45]. Primary closure of the donor site is usually possible with split thickness skin grafts in the area being less desirable for use [41-44].

This flap is based on the lateral femoral circumflex artery and has become a preferred flap as it has a long pedicle, provides a large skin paddle and minimal donor site morbidity [45]. It is commonly used in hand reconstruction. It can be used to provide skin fat and fascia or thinned as necessary, providing to be a very versatile flap. With the lateral femoral cutaneous nerves of the thigh it can be used to provide innervation to the wound site [46-49]. The disadvantages of the flap are that the anatomy of the perforator vessels can be variable with perforator dissection difficult for inexperience surgeons [46-49]. Adani et al. illustrated that the anterolateral thigh flap provided soft tissue of the hand covering for nine patients suffering from severe scar contracture, burn and crushing injuries. All flaps survived and the donor site was closely directly in seven patients [46].

Technique: After the patient is placed in the supine position, a line is drawn from the ASIS to the lateral patella [46-49]. The hand-held doppler firstly maps out the descending branch of the lateral circumflex femoral artery starting from the midpoint to the drawn line. The perforators within 3-4 cm usually cluster anterolateral to the midpoint [46-49]. The flap is usually cantered around the perforators and can extend up to 15-16 cm in length. Dissection begins with incising down to the fascia overlying the rectus femoris muscle [46-49]. Medial dissection starts first continuing lateral until the skin perforators are identified [46-49]. Once the main pedicle is identified, the flap is dissected from its lateral border [46-49]. After transection of the vessels, the flap is brought to the defect with anastomosis to recipient vessel and insetting of the flap after successful re-perfusion [46-49]. Anastomosis can be completed for arterial using 9.0 nylon accompanied by anastomosis of two veins [46-49]. Closure of the donor site can be closed primarily or with a skin graft in large defects [46-49].

A microvascular free transfer of the lateral arm fasciocutaneous flap is especially useful in hand reconstruction as the thinness, colour and texture of the flap provides an excellent functional result [50, 51]. Similar to the radial and ulnar forearm flaps, it has flow through characteristics, which means the structures distal to the flap can be vascularised with the distal part of the pedicle [50, 51]. The estimated length of skin transferred is approximately 10-14 cm and the width is restricted to around 6 cm, allowing primary closure of the donor defect [50].

Technique: The flap based on the posterior radial collateral artery, can be raised as a facial flap, with bone, the overlying skin and with/without innervation [50]. To design the flap the insertion of the deltoid and the lateral epicondyle is marked with the elbow extended [50]. A line is drawn between these two structures and the defect is placed in the centre [50]. The skin is usually excised posteriorly and distally until deep fascia is reached. Usually 2 cm of facia are included in the posterior extent of the flap before the deep fascia is incised [50]. The deep fascia forms the lateral intermusulcar septum at the anterior border of the triceps [50]. The pedicle is then visualised from the insertion of the deltoid to the lateral epicondyle with the septum in the distal two thirds. Small muscular perforators are encountered which can be coagulated [50]. The skin is incised at the anterior border of the triceps where the deep fascia is found and another 2 cm are included [50]. The deep fascia is this area requires further sharp dissection [50]. Once the vascular pedicle is found the lateral septum is elevated from the humerus starting distally [50]. Careful dissection is required at the level where the pedicle leaves the lateral intermuscular septum [50].