Extended vertical trapezius myocutaneous flap in head and neck reconstruction as a salvage procedure

In surgical treatment of head and neck cancer, when local tumor recurrence or failure of the previous reconstruction method occurs, reoperation for reconstruction of complicated soft-tissue defects can become a challenge for the plastic surgeon. This article describes the authors' experience with the extended vertical trapezius myocutaneous flap for head and neck complicated soft-tissue defects in nine patients ranging in age from 17 to 72 years. The causes of the defects were squamous cell carcinoma of the external ear (n = 2), lip (n = 2), larynx (n = 1), and oral cavity floor (n = 1); congenital hemifacial atrophy-temporomandibular joint ankylosis (n = 1); synovial sarcoma at the mandibular ramus (n = 1); and malignant fibrous histiocytoma at the posterior cranial fossa (n = 1). Eight of the nine patients had previously been operated on using other flap procedures, including free flaps and/or distant pedicled flaps (pectoralis major and deltopectoral flaps). One patient had been operated on using a graft procedure. After failure of the previous flap procedures in four patients and tumor recurrence in five patients, the extended vertical trapezius myocutaneous pedicled flap was used as a salvage procedure. The mean flap size was 7 x 34 cm. The flap was based solely on the transverse cervical artery. Superior muscle fibers of the trapezius were preserved and the caudal end of the flap was extended from 10 to 13 cm beyond the caudal end of the trapezius muscle. Three weeks postoperatively, the pedicle was separated. No flap failure occurred. The donor sites were closed primarily. There were no disabilities with regard to shoulder motion. Tumor recurrence was observed in two patients. In conclusion, for complicated soft-tissue defects of the head and neck, the extended vertical trapezius flap can be preferred as a salvage procedure because it is a simple, reliable, large flap that is located far enough from the damaged area.     

The vascular supply of the extended tensor fasciae latae flap: how far can the skin paddle extend?

The vascular supply of the tensor fasciae latae flap and of the lateral thigh skin was studied in 10 cadavers to evaluate whether the lateral thigh skin toward the knee could be incorporated into an extended tensor fasciae latae flap. Within each cadaver, vascular injection of radiopaque material preceded flap elevation in one limb and followed flap elevation in the contralateral limb. Flaps raised after vascular injection were examined radiographically to evaluate the vascular anatomy of the lateral thigh skin independent of flap elevation. When vascular injection was made into the profunda femoris, the upper two-thirds of the flaps was better visualized than the distal third. When the injection was made into the popliteal artery, the vasculature of the distal third of the flaps was better visualized. Flaps raised before vascular injection were examined radiographically to delineate the anatomical territory of the vascular pedicle that had been injected. In these flaps, consistent cutaneous vascular supply was only seen in the skin overlying the tensor fasciae latae muscle, confirming that musculocutaneous perforators are the predominant means by which the pedicle of the tensor fasciae latae flap supplies the skin of the lateral thigh. Extended tensor fasciae latae flaps were elevated bilaterally in one cadaver, and selective methylene blue injections were made into the lateral circumflex femoral artery on one side and into the superior lateral genicular artery on the contralateral side. Methylene blue was observed in the proximal and distal thirds of the skin paddles, respectively, leaving unstained midzones. The vascular network of the lateral thigh skin could be divided into three zones. The lateral circumflex femoral artery and the third perforating branches of the profunda femoris artery perfuse the proximal and middle zones of the lateral thigh skin, respectively. The superior lateral genicular artery branch of the popliteal artery perfuses the distal zone. The middle and distal zones meet 8 to 10 cm above the knee joint, where the skin paddle of the tensor fasciae latae flap becomes unreliable. These data indicate that if the aim is to incorporate the skin over the distal thigh in an extended tensor fasciae latae flap without resorting to free-tissue transfer, then either a carefully planned delay procedure or an additional anastomosis to the superior lateral genicular artery is required.     

"Components separation" method for closure of abdominal-wall defects: an anatomic and clinical study

Closure of large abdominal-wall defects usually requires the transposition of remote myocutaneous flaps or free-tissue transfers. The purpose of this study was to determine if separation of the muscle components of the abdominal wall would allow mobilization of each unit over a greater distance than possible by mobilization of the entire abdominal wall as a block. The abdominal walls of 10 fresh cadavers were dissected. This demonstrated that the external oblique muscle can be separated from the internal oblique in a relatively avascular plane. The rectus muscle with its overlying rectus fascia can be elevated from the posterior rectus sheath. The compound flap of the rectus muscle, with its attached internal oblique-transversus abdominis muscle, can be advanced 10 cm around the waistline. The external oblique has limited advancement. These findings were utilized clinically in the reconstruction of abdominal-wall defects in 11 patients, ranging in size from 4 x 4 to 18 x 35 cm. This study suggests that large abdominal-wall defects can be reconstructed with functional transfer of abdominal-wall components without the need for resorting to distant transposition of free-muscle flaps.     

Double-paddle peroneal tissue transfer for oromandibular reconstruction

The double-paddle peroneal tissue transfer is a useful technique for reconstructing the extensive and complex defect that results after ablative surgery for oral cancer. It can facilitate the design and inset of the skin paddle and avoid the need for a second free flap. The two skin paddles can be based on either two cutaneous perforators of the peroneal vessels or two branches of a single cutaneous perforator. The authors report their experience with double-paddle peroneal tissue flaps (10 fasciocutaneous and five osteocutaneous) in 15 patients. The largest double paddle used was (16 x 9) (15 x 6) cm, and the smallest one was (7 x 5.5) (4.5 x 4) cm. All flaps were used for both intraoral and extraoral defect reconstruction. There was one single skin paddle necrosis caused by erroneous manipulation of the flap 1 week after the operation; however, the skin paddle had survived completely before the manipulation. All other flaps survived completely, with a good to excellent appearance, and no patient had a significant gait disturbance after the operation.     

Primary closure of radial forearm flap donor defects with a bilobed flap based on the fasciocutaneous perforator of the ulnar artery

To primarily repair a series of radial forearm flap donor defects, a total of 10 bilobed flaps based on the fasciocutaneous perforator of the ulnar artery were designed at the Chang Gung Memorial Hospital in Kaohsiung in the period from January of 2002 to January of 2003. All patients were male, with ages ranging from 36 to 67 years. The forearm donor defects ranged in size from 5 x 6 cm to 8 x 8 cm, with the average defect being 47 cm. One to three sizable perforators from the ulnar artery were consistently observed in the distal forearm and were most frequently located 8 cm proximal to the pisiform, which could be used as a pivot point for the bilobed flap. The bilobed flap consisted of two lobes, one large lobe and one small lobe. With elevation and rotation of the bilobed flap, the large lobe of the flap was used to repair the radial forearm donor defect and the small lobe was used to close the resultant defect from the large lobe. All bilobed flaps survived completely, without major complications, and no skin grafting was necessary. Compared with conventional methods for reconstruction of radial forearm donor defects, such as split-thickness skin grafting, the major advantage of this technique is its ability to reconstruct the donor defect with adjacent tissue in a one-stage operation. Forearm donor-site morbidity can be minimized with earlier hand motion, and better cosmetic results can be obtained. Furthermore, because a skin graft is not used, no additional donor area is necessary. However, this flap is suitable for closure of only small or medium-size donor defects. A lengthy postoperative scar is its major disadvantage.     

Reconstruction of composite through-and-through mandibular defects with a double-skin paddle fibular osteocutaneous flap

Microsurgical reconstruction of composite through-and-through defects of the oral cavity involving mucosa, bone, and external skin has often required two free flaps or double-skin paddle scapular or radial forearm flaps for successful functional and aesthetic outcomes. A safe, reliable technique using a double-skin paddle fibular osteocutaneous flap to restore the intraoral lining, mandibular bone, and external skin is described. A large elliptical or rectangular skin paddle is designed 90 degrees to the longitudinal axis of the fibula, over the junction of the middle and distal thirds of the lower leg, based only on the posterolateral septocutaneous perforators. This skin flap can be draped anteriorly and posteriorly over the fibular bone to reconstruct both the intraoral defect and the external skin defect. The area between the two skin islands of the intraoral flap and the external flap is deepithelialized and left as a dermal bridge between the two skin islands, as opposed to the creation of two separate vertical skin paddles, each based on a septocutaneous perforator. The transverse dimension of the flap can be as great as 14 cm, extending to within 1 to 2 cm of the tibial crest anteriorly and as far as the midline posteriorly, and with a length of up to 26 cm, this flap should be more than sufficient for reconstruction of most through-and-through defects. This technique has allowed the successful reconstruction of large composite defects, with missing intraoral lining, mandibular bone, and external skin, for 16 patients, with 100 percent survival of both skin islands in all cases and without the development of any orocutaneous fistulae.     

A clinical experience with perforator flaps in the coverage of extensive defects of the upper extremity

Traditional skin free flaps, such as radial arm, lateral arm, and scapular flaps, are rarely sufficient to cover large skin defects of the upper extremity because of the limitation of primary closure at the donor site. Muscle or musculocutaneous flaps have been used more for these defects. However, they preclude a sacrifice of a large amount of muscle tissue with the subsequent donor-site morbidity. Perforator or combined flaps are better alternatives to cover large defects. The use of a muscle as part of a combined flap is limited to very specific indications, and the amount of muscle required is restricted to the minimum to decrease the donor-site morbidity. The authors present a series of 12 patients with extensive defects of the upper extremity who were treated between December of 1999 and March of 2002. The mean defect was 21 x 11 cm in size. Perforator flaps (five thoracodorsal artery perforator flaps and four deep inferior epigastric perforator flaps) were used in seven patients. Combined flaps, which were a combination of two different types of tissue based on a single pedicle, were needed in five patients (scapular skin flap with a thoracodorsal artery perforator flap in one patient and a thoracodorsal artery perforator flap with a split latissimus dorsi muscle in four patients). In one case, immediate surgical defatting of a deep inferior epigastric perforator flap on a wrist was performed to immediately achieve thin coverage. The average operative time was 5 hours 20 minutes (range, 3 to 7 hours). All but one flap, in which the cutaneous part of a combined flap necrosed because of a postoperative hematoma, survived completely. Adequate coverage and complete wound healing were obtained in all cases. Perforator flaps can be used successfully to cover a large defect in an extremity with minimal donor-site morbidity. Combined flaps provide a large amount of tissue, a wide range of mobility, and easy shaping, modeling, and defatting.     

Free proximal gracilis muscle and its skin paddle compound flap transplantation for complex facial paralysis

Gracilis functioning free-muscle transplantation for the correction of pure facial paralysis has been a preferred method used by many reconstructive microsurgeons. However, for complex facial paralysis, the deficits include facial paralysis along with soft-tissue, mucosa, and/or skin defects. No adequate solution has been proposed. Treatment requests in those patients are not only for facial reanimation but also for correction of the defects. Of 161 patients with facial paralysis treated with gracilis functioning free-muscle transplantation from 1986 to 2002, eight patients (5 percent) presented with complex deficits requiring not only facial reanimation but also aesthetic correction of tissue defects. The tissue defects included an intraoral defect created following contracture release (one patient), infra-auricular radiation dermatitis with contour depression (one patient), temporal depression following a temporalis muscle-fascia transfer (one patient), ear deformity (two patients), and infra-auricular atrophic tissue with contour depression (three patients). A compound flap, consisting of a gracilis muscle with its overlying skin paddle separated into two components, was transferred for simultaneous correction of both problems. The blood supply to the gracilis and to the skin paddle originated from the same source vessel and therefore required the anastomosis of only one set of vessels. The versatility of this compound flap allows for a wide arc of rotation of the skin paddle around the muscle. All flaps were transferred successfully without complications. Satisfactory results of facial reanimation were recorded in five patients after all stages were completed. The remaining three patients are undergoing physical therapy and waiting for revision of the skin paddle.     

Free-flap reconstruction of large defects of the scalp and calvarium

Beyond a certain size, full-thickness defects of scalp are not amenable to local flap repair. Staged distant flaps have now been virtually eliminated by free-flap reconstruction. The authors present 12 patients in whom full-thickness scalp defects with an average area of 275 cm2 were reconstructed utilizing free flaps. Nine patients had corresponding large calvarial defects. Ten patients had reconstruction with free latissimus dorsi muscle flaps and overlying skin grafts, and one patient had reconstruction with a scapular free flap. Of the 12 patients, 8 had extirpative surgery for tumor with immediate reconstruction and the remaining 4 had reconstruction for chronic radionecrosis of the scalp, usually associated with infected osteoradionecrosis of the calvarium. Of this latter group, 2 patients underwent simultaneous acrylic cranioplasty. The technique and results are discussed.     

The extended trapezius musculocutaneous flap for cranio-orbital facial reconstruction

The use of the extended posterior trapezius muscle skin flap for cranio-orbital facial reconstruction is presented. Its enormous arc of rotation allows it to reliably reconstruct massive defects of the upper face with the orbit at the center of the defect; i.e., this flap will reach well beyond the supraorbital rim and across the midline. Its application for the immediate reconstruction of massive deformities following resection of tumors of the orbit and cranial base appears justified and helps avoid the major morbidity normally associated with such resections.     

Free split-cutaneous perforator flaps procured using a three-dimensional harvest technique for the reconstruction of postburn contracture defects

With recent advances in free-tissue transfer, microsurgical techniques have been used more frequently for the reconstruction of postburn contracture defects. Traditional methods, including full-thickness skin grafts and local flaps, often result in a good outcome; however, multiple operative procedures, long periods of splinting, and physical rehabilitation are often required. Free split-cutaneous perforator flaps, consisting of one large cutaneous paddle with two perforating vessels split into two separate skin regions, were used for two kinds of postburn contractures: rectangular and spatially separate defects. From September of 2000 to October of 2002, seven patients underwent this method of reconstruction at Chang Gung Memorial Hospital in Taiwan. A three-dimensional flap harvest method, in which the skin paddle is circumferentially elevated early in the harvest, was used. Postburn scar contractures had resulted from flame burns in six cases and an electric burn in one case. The reconstructive regions included the neck in two patients, the breast in one patient, and the hand in four patients. There were six male patients and one female patient, with a mean age of 34.8 years (range, 25 to 49 years). The size of the excised scar ranged from 120 cm2 to 308 cm2 (mean, 162.3 cm2). The size of the unsplit flaps ranged from 144 cm2 to 337.5 cm2 (mean, 192.1 cm2). The average time for flap harvest using this three-dimensional harvest technique was 39.1 minutes. The average total operative time was 4.3 hours. The average total hospital stay was 7.3 days (range, 6 to 11 days). All flaps survived without major complications. The donor site was closed primarily in all cases. At a mean follow-up time of 9 months, the functional and aesthetic outcomes showed significant improvement as compared with the preoperative condition. In this study, a new method of flap harvest using a three-dimensional technique is introduced, and its application in the reconstruction of postburn contractures is evaluated.     

Use of an adipofascial flap based on the proximal perforators of the ulnar artery to correct contracture of elbow burn scars: an anatomic and clinical approach.

Different techniques can be used to repair contracture of burn scars on the elbow, including local or distant pedicle flaps, muscle or myocutaneous flaps, free flaps, and tissue expanders. Among these, a pedicled adipofascial flap based on the most proximal two to four perforators of the ulnar artery (located 1 to 5 cm from the origin of the artery) can be anastomosed to form a sort of axially patterned blood supply within the fascia and subcutaneous fat. Therefore, no major vessel in the forearm need ever be severed. In addition, use of this type of flap preserves muscle function. The pedicled adipofascial flap described in this article allows for early rehabilitation because the flap is thin and pliable. Additional advantages are the easy and quick dissection and completion of the procedure in one stage. A detailed anatomic dissection of the flap was performed on 16 upper extremities from fresh cadavers; an injection study was also performed to determine the location and dimensions of the pedicle flap and its area of reach around the elbow. In the past 3 years, 14 flaps were used in 13 patients to repair elbow defects after release of burn scar contractures. Flap dimensions ranged from 4 x 7 cm to 6 x 14 cm (mean flap size, 74 cm). The results were very satisfactory.     

The descending branch of the superficial circumflex artery supplying anteromedial thigh skin

This report presents an extended groin flap design that consists of a conventional skin paddle in the groin region and a vertical extension in the anteromedial thigh region, based on the superficial iliac circumflex artery and an unnamed descending branch, respectively. The inferior branch of the superficial iliac circumflex artery that supplies the thigh extension of the flap, spanning approximately the upper half of the thigh region, was found to originate approximately 2 cm from the origin of the superficial iliac circumflex artery. A total of six free and four local flaps were used in 10 patients with ages ranging from 10 to 60 years (average, 45 years). There were six male and four female patients. The free flaps were required for total facial resurfacing, through-and-through cheek defect, and burn scar contractures and traumatic defects of the lower extremity. The local flaps were used for reconstruction of scrotum defect, trochanteric decubitus ulcer, and lower abdominal skin and fascia defects. All 10 flaps survived completely. The groin flap with anteromedial thigh extension offers the following advantages: (1) it is very easy and quick to elevate; (2) a significantly increased volume of tissue is available for reconstruction, based on one axial vessel and being completely reliable; (3) the flap offers two skin paddles that are independently mobile; (4) there is no need for positional change and a two-team approach is possible; and (5) it can be raised as a vertical skin island only. The authors conclude that the groin flap with anteromedial thigh extension is a useful modification for reconstruction of both distant and local defects.     

Surgical augmentation of skin blood flow and viability in a pig musculocutaneous flap model

A porcine rectus abdominis musculocutaneous (TRAM) flap model was designed and validated in nine pigs. This TRAM flap was based on the deep inferior epigastric (DIE) vessels with an 8 x 18 cm transverse skin paddle at the superior end of the rectus abdominis muscle. The model was subsequently used to test our hypothesis of surgical augmentation of flap viability by vascular territory expansion. Specifically, we observed that ligation of the superior epigastric (SE) vessels at 4, 7, 14, and 28 days (N = 6 to 8) prior to raising the TRAM flaps significantly increased (p less than 0.05) the length and area of the viable skin in the transverse skin paddles of the treatment flaps compared with the contralateral shammanipulated control flaps. This significant increase in skin viability was seen to be accompanied by a significant increase (p less than 0.05) in skin and muscle capillary blood flow in the treatment TRAM flaps compared with the controls (N = 9). The mechanism of vascular territory expansion is unclear. We postulate that hypoxia resulting from the ligation of the superior epigastric vessels prior to the flap surgery may play a role in the triggering of the deep inferior epigastric artery to take over some of the territory previously perfused by the superior epigastric artery. This would then increase the skin and muscle capillary blood flow in the transverse paddle when the TRAM flap was raised on the deep inferior epigastric vascular pedicle.     

Reconstruction of concomitant lip and cheek through-and-through defects with combined free flap and an advancement flap from the remaining lip

Massive facial defects involving the oral sphincter are challenging to the reconstructive surgeon. This study presents the authors' approach to simultaneous reconstruction of complex defects with an advancement flap from the remaining lip and free flaps. From January of 1997 to December of 2001, 22 patients were studied following ablative oral cancer surgery. Their ages ranged from 32 to 66 years. Nineteen patients had buccal cancer, two patients had tongue cancer, and one patient had lip cancer. In all cases, the disease was advanced squamous cell carcinoma. Nine patients underwent composite resection of tumor with segmental mandibulectomy, and seven patients underwent marginal mandibulectomy. Cheek defects ranged from 15 x 12 cm to 4 x 3 cm, and intraoral defects ranged from 14 x 8 cm to 5 x 4 cm in size. One third of the lower lip was excised in nine patients, both the upper and lower lips were excised in 10 patients, and only commissure defects were excised in three patients. An advancement flap from the remaining upper lip was used for reconstruction of the oral commissure and oral sphincter. Then, the composite through-and-through defect of the cheek was reconstructed with radial forearm flaps in 13 patients, fibula osteocutaneous flaps in five patients, double flaps in three patients, and an anterolateral thigh flap in one patient. The free flap survival rate was 96 percent, and only one flap failed. With regard to complications, there were two patients with cheek hematoma, six patients with orocutaneous fistula or neck infection, and one patient with osteomyelitis of the mandible. All but one patient had adequate oral competence. All patients had an adequate oral stoma and could eat a regular or soft diet; two patients could eat only a liquid diet. For moderate lip defects, immediate reconstruction of complex defects took place using an advancement flap from the remaining lip to obtain a normal and functional oral sphincter; the free flap can be used to reconstruct through-and-through defects. This simple procedure can provide patients with a useful oral stoma and acceptable cosmesis.     

Super sural neurofasciocutaneous flaps in acute traumatic heel reconstructions

Conventional reversed sural flaps have been used to cover heel defects; however, the experience of the authors indicates that the reach of these flaps falls just short of the critical area to be covered. With the limitation being the location of the flap (the middle third of the leg), the authors thought that if the flap territory were extended proximally, they would have a super flap with immense potential. Nevertheless, the critical question remained, "How far?" The massive earthquake in January of 2001 in Gujarat, India, made medical personnel pressed for time, manpower, resources, and other ancillary supports. The authors were forced to make some innovations in their management of extensive heel defects. On the basis of preexisting anatomic studies, they developed the possibility of using distally based neuroskin flaps of huge dimensions that extend well beyond the conventional confines. The versatility of this extended, reversed, neuro-fasciocutaneous flap in regard to its reliability and safety, despite its huge dimensions, is commendable. The hallmarks of this successful extended sural flap, which the authors used to cover large heel defects, were basically accurate understanding of the anatomy and the use of Doppler to map the perforators and the lesser saphenous vein for inclusion in the lie of the pedicle. The authors share their experience of five cases of difficult heel reconstructions salvaged with this flap, which made them attempt to define maximum flap dimensions that can be harvested. The authors learned that the flap can be extended proximally to include the entire upper one-third of the leg posteriorly, drastically improving its reach and size, without compromising safety. The largest flap used measured 17 x 16 cm, far more than ever reported in the literature. The flaps truly deserve the classification of "super," which is usually reserved for Ponten's flaps.     

The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck.

A compound flap is described that utilizes skin from the anterior chest on a narrow segment of pectoralis major muscle, with its underlying axial neurovascular bundle. This flap has been used successfully to reconstruct large defects in 4 consecutive patients. Our experience with this flap suggests that it may be more versatile than the deltopectoral flap.     

Free dorsoulnar perforator flap transfers for the reconstruction of severely injured digits

The aim of this study was to investigate the feasibility of transferring the free dorsoulnar perforator flap nourished by the cutaneous perforator branched dorsoulnar artery to reconstruct severely injured fingers under upper arm anesthesia. Between April of 2001 and April of 2002, 13 free dorsoulnar perforator flaps were used in 13 patients. There were 11 men and two women ranging in age from 18 to 64 years, with an average age of 38 years. The affected fingers were one thumb, four index fingers, five middle fingers, two ring fingers, and one little finger. All cases were performed under upper arm anesthesia combined with intravenous local anesthesia. The operative time ranged from 103 to 140 minutes, with an average time of 120 minutes. The flap size ranged from 1 x 3 to 3 x 4 cm, and was transferred from the same forearm of the injured finger. All donor sites were closed primarily without a skin graft. The aim of reconstruction for fingers was to repair a traumatic defect (five cases), partial necrosis following replantation (two cases), and soft-tissue defects resulting from resection of a scar (three cases) and to revascularize ischemic fingers (three cases). All flaps survived completely. After repair of the flow-through circulation of the common digital artery and ischemic finger, a postoperative angiogram showed the vascular patency and hypervascularity of the reconstructed fingers, and the patients' complaints were reduced. The free dorsoulnar perforator flap under regional anesthesia is first reported; it may become one valuable option as a very small flap for the treatment of repairing intercalated or segmental defects as a flow-through flap for soft-tissue defects and ischemic fingers.     

Upper extremity microsurgery

Learning objectives: After studying this article, the participant should be able to: 1. Understand the indications for free flap coverage of the upper extremity. 2. Know the advantages and disadvantages of the flaps discussed. 3. Have a basic understanding of the anatomy of the flaps discussed. 4. Have a variety of options for free tissue transfer.The application of microsurgical tissue transfer to reconstruction of the upper extremity allows repair of significant bone and soft-tissue defects. Through the years the approach has changed from one of simply getting the wound covered to primary reconstruction to preserve or regain function. A wide variety of free flaps offers the potential to reconstruct nearly any defect of the arm and hand. Vascularized bone transfer can be utilized to repair large bony defects, while innervated free muscle transfer can replace missing muscle function. The total array of flaps and their indications is beyond the scope of a single discussion, but this article focuses on a few flaps that have found application for coverage and functional restoration in the hand and upper extremity.     

Posterior interosseous free flap with extended pedicle for hand reconstruction

The anatomy of the posterior interosseous vessels makes them suitable as a donor area of free flap. The skin island can be designed on the perforating vessels of the distal third of the forearm, up to the dorsal wrist crease, to increase the pedicle length (7 to 9 cm). A series of nine flaps transferred to reconstruct hand defects is presented. All flaps were designed over the dorsal distal forearm, and dimensions permitted direct closure of the donor site (up to 4 to 5 cm wide). Apart from a linear scar, donor morbidity was negligible. All transfers were successful. Although its dissection is somewhat tedious, the anatomy of the vascular pedicle is suitable for microanastomosis and the skin island is thin, although hairy. The posterior interosseous free flap with extended pedicle may be a good choice when limited amounts of thin skin and a long vascular pedicle are needed.