General Principles of Upper Extremity Reconstruction

Reconstructive surgery of the upper extremity as it relates to trauma, tumor, and sepsis has progressed significantly over the past 50 years. The introduction of microsurgical techniques—including a wide variety of new flaps, functional free muscle transfer, nerve conduits, motor nerve transfers and allografts, and even hand transplantation—complements the vast array of sophisticated treatment concepts, which now include vascularized composite allotransplantation. These additions have greatly expanded the number of options available to the reconstructive surgeon.

The current philosophy of treatment in combination with early functional rehabilitation represents a significant evolution; historically, treatment was much more limited and sequential. It involved multiple-stage interventions that simply covered defects, with functional restoration not being considered until later in the process. More recently, surgeons have demonstrated the ability to perform “one-stage” multiphase reconstructions with the use of precisely tailored composite flaps of skin, tendons, nerves, vessels, and, often, vascularized bone for the earliest possible definitive and appropriate repair.

Today, the reconstructive surgery plan may be fully executed during the initial operative exploration (i.e., replantation) or after a “second-look” procedure and definitive wound closure. Definitive reconstruction during the primary injury period saves time, shortens the postinjury morbidity interval, and allows for earlier rehabilitation intervention, thereby maximizing functional outcomes.