How is the tissue moved?
Tissue is completely separated from another body area and transferred to the arm or hand.
Using microsurgery, the surgeon joins small arteries and veins to restore blood flow to the transferred tissue.
Hand, Wrist & Upper Extremity
Free Flap Reconstruction – Upper Extremity
Upper-extremity free flap reconstruction transfers living tissue and reconnects its blood vessels to repair complex wounds of the hand, wrist, or arm.
Is this the same as a skin graft?
No. A free flap brings its own blood vessels; a skin graft depends on the wound underneath for nourishment.
A flap may cover exposed tendon, bone, nerves, or hardware where a skin graft alone may not survive.
Will it restore movement?
It may support recovery, but coverage alone does not restore every injured structure.
Tendon, nerve, bone, or joint injuries may need separate repair and hand therapy. Suitability and likely function depend on a surgeon's assessment.
01 · Overview
Rebuilding coverage and protecting function
A free flap moves skin, fat, muscle, bone, or a combination of tissues from a donor site to a wound. Its small blood vessels are connected to vessels near the wound so the tissue can remain alive in its new location. [1]
In the upper extremity, the aim may be to cover exposed structures, replace missing tissue, protect a repair, or help preserve the limb. Wound cleaning, infection treatment, and stabilization of bone or other structures may be needed before or during reconstruction. [1]
Unlike a local or pedicled flap, a free flap is detached from its original blood supply and reconnected at the destination. Unlike a skin graft, it carries a blood supply with it. The best approach depends on the wound, available vessels, donor-site effects, and your priorities. [2]
- Main purpose
- Reconstruct complex tissue loss
- Key technique
- Microsurgical blood-vessel connections
- Anesthesia
- Usually general anesthesia
- Recovery needs
- Hospital monitoring and individualized rehabilitation
Why might simpler coverage not be enough?
A skin graft needs a wound surface with adequate blood flow. Exposed structures or large, deep wounds may need living tissue with its own circulation. A nearby flap may be an option if surrounding tissue and vessels are healthy.
Can a free flap replace muscle or bone?
Yes, selected flaps can transfer muscle or bone as well as soft tissue. A functioning muscle transfer also requires nerve connections and rehabilitation. These are specialized plans, not features of every free flap reconstruction.
02 · Concerns & Goals
What reconstruction may address
A serious injury, infection, or tumor removal can leave a wound that needs more than skin coverage. Your surgeon will assess what tissue is missing and what function may be recoverable.
An open or complex wound
Tissue loss can leave tendons, bone, nerves, or hardware exposed. A flap may provide coverage when the wound cannot be closed safely.
Loss of useful tissue
Some injuries require replacement of more than skin. Your surgeon will consider the depth, size, and type of tissue needed.
Movement and sensation
Stiffness, weakness, or numbness may come from the original injury. Reconstruction may support rehabilitation without fully reversing these changes.
Effects on another body area
The donor site also needs to heal. Its scar, appearance, strength, and sensation are part of the decision.
03 · Options
How the approaches differ
These are tissue-transfer approaches, not interchangeable choices. Your surgeon will match the flap to the wound and discuss both the recipient site and donor site.
Skin-and-fascia free flap
Transfers skin, underlying fat, and sometimes fascia, the tissue covering muscle.
How it worksThe tissue is moved with its vessels and connected to circulation near the wound.
May suitSelected defects needing flexible coverage and a surface that can be monitored.
Main tradeoffThickness, color, and hair growth may differ from the surrounding skin; later contour adjustment may be considered.
Muscle free flap
Transfers muscle to fill a deeper defect or provide coverage.
How it worksThe muscle's vessels are reconnected; a skin graft may be placed over it.
May suitSelected wounds with deeper tissue loss or spaces that need filling.
Main tradeoffDonor-site weakness and contour changes are possible. A coverage flap does not automatically provide active movement.
Bone-containing free flap
Transfers living bone, sometimes together with skin or muscle.
How it worksThe bone is secured into the defect and its blood supply is reconnected.
May suitSelected complex bone defects requiring vascularized bone reconstruction.
Main tradeoffBone healing, fixation, and donor-site recovery add complexity and may require further surgery.
Functional muscle transfer
Transfers muscle with the goal of restoring a specific movement.
How it worksThe surgeon connects vessels, attaches the muscle to appropriate structures, and connects a nerve when feasible.
May suitSelected patients with major muscle loss or paralysis after specialized assessment.
Main tradeoffNerve recovery and muscle retraining take time, and useful movement is not assured.
Flap selection depends on tissue needs, blood-vessel quality, overall health, and what can be taken safely from the donor site. Not every technique is suitable for every wound. [1] [2].
How is the donor site chosen?
The surgeon considers tissue size and thickness, vessel anatomy, previous operations, and the effect on everyday function. Possible donor areas include the thigh, back, or lower leg, depending on the tissue required.
Could reconstruction require several operations?
Yes. Wound cleaning, temporary coverage, definitive reconstruction, and later tendon, nerve, or contour procedures may occur in stages. An urgent operation may also be necessary if blood flow to the flap becomes compromised.
04 · Results
What may improve and what may remain
Wound coverage
The main goal is living tissue that heals over the defect.
- Early success depends on adequate circulation and wound healing.
- Infection, damaged vessels, and the original injury can affect the result.
Everyday function
Function depends on more than flap survival.
- Tendon, nerve, bone, and joint damage influence movement and sensation.
- Hand therapy, additional repairs, and adaptive strategies may be part of recovery.
Appearance and donor-site effects
Both surgical sites may look and feel different afterward.
- Scars, bulk, color differences, and altered sensation can persist.
- Later contour surgery may be considered once healing and circulation are established.
A surviving flap does not guarantee normal strength, sensation, appearance, or freedom from further surgery. Ask your surgeon to separate coverage goals from functional goals. [1]
05 · Recovery
Planning your recovery
Recovery at a glance
- Stay after surgery
- Determined by Your Surgeon
- Initial recovery at home
- Varies by Individual
- Return to desk work
- Varies by Procedure and Work Activity
- Light daily activities
- Based on Individual Recovery
- Strenuous exercise
- Based on Surgeon Clearance
Returning to work does not mean fully healed. Follow your surgeon’s instructions; strenuous activity requires clearance.
Recovery involves protecting the transferred tissue, watching its circulation, and rehabilitating the injured limb without disrupting repairs. Your plan must also account for the donor site.
Step 1 · Surgery and immediate recovery
Treatment day
The team prepares the wound, transfers the tissue, and reconnects its vessels. After surgery, staff assess the flap's circulation and manage pain, dressings, and any splint or drains.
Step 2 · Early hospital recovery
Close monitoring
Frequent flap checks look for circulation problems that may require urgent surgery. Positioning and movement restrictions are tailored to the flap, vessel connections, and other repairs.
Step 3 · After discharge
Healing at both sites
Follow-up checks address the wound, donor site, dressings, and any drains or sutures. Hand therapy begins or progresses only as the surgical team allows.
Step 4 · Following weeks and months
Rehabilitation and reassessment
Strength, movement, and daily activities are advanced gradually. Nerve or functional muscle recovery may take longer, and some limitations may remain.
Planning everyday activities
ActivityGeneral planning contextWhat affects the plan
Work and schoolPlanning context: Timing depends on hand use, pain medicines, wound care, and the donor site.What affects it: Desk duties may be possible before manual work; returning does not mean healing is complete.
DrivingPlanning context: Wait for clearance and the ability to control the vehicle safely without impairing medicines.What affects it: Splints, weakness, limited grip, or a leg donor site may prevent safe driving.
Lifting and exercisePlanning context: Limits depend on vessel connections and any tendon, bone, or muscle repair.What affects it: Loading too soon can disrupt healing; therapy exercises require a specific plan.
Bathing and wound carePlanning context: Ask how to protect each surgical site and when showering or soaking is allowed. [2]What affects it: Dressings, grafts, drains, and open areas may need different care.
Follow your surgical team's instructions rather than a general recovery timeline. Ask your surgical team whether compresses are appropriate and exactly how to use them.
Before your procedure
- Discuss the goals of reconstruction and which functions may remain limited.
- Share your medicines, supplements, allergies, and previous anesthesia problems.
- Ask for a personalized plan for blood thinners and other medicines; do not change them on your own.
- Discuss nicotine use and support for stopping, since nicotine can impair circulation and healing.
- Arrange help with transportation, meals, personal care, and care of both surgical sites.
- Confirm fasting instructions, the expected hospital stay, therapy arrangements, and urgent contact numbers.
Why are flap checks so frequent?
A clot or other circulation problem can threaten transferred tissue. Staff may check color, temperature, and blood-flow signals. Early recognition can allow urgent treatment, although the flap cannot always be saved.
When should I start moving my hand?
The surgeon and hand therapist should give you a specific plan. Some repairs benefit from carefully controlled early motion, while others need protection. Do not assume that a well-healed skin surface means deeper repairs can tolerate loading.
06 · Safety
Risks and what your clinician assesses
Pain, swelling, bruising, scars, and temporary activity limits are expected at one or both surgical sites. Numbness and stiffness may reflect both surgery and the original injury. Symptoms should be reviewed if they worsen rather than gradually settle.
Blood-flow problems and flap loss
Clotting, vessel compression, or poor circulation can cause partial or complete tissue loss. Urgent surgery or another reconstruction may be needed.
Bleeding or fluid collection
Bleeding, a blood collection, or fluid buildup may require drainage, transfusion, or another operation.
Infection or delayed healing
Either site can develop infection, wound separation, or slow healing. Existing contamination, infection, or damaged tissue can complicate recovery.
Donor-site problems
Possible effects include weakness, pain, numbness, contour changes, prominent scars, or trouble healing.
Persistent functional limitations
Stiffness, altered sensation, chronic pain, or limited movement may remain. Further procedures may be needed, and limb preservation is not always possible.
Anesthesia and general surgical complications
Serious complications can include reactions to anesthesia, heart or lung problems, and blood clots in the legs or lungs.
Discuss these risks and your individual health history with your surgeon. [1]
What your clinician assesses
- Wound size, tissue loss, contamination, infection, and damage to nearby structures
- Blood flow and suitable vessels at the recipient and donor sites
- Overall health, diabetes, nicotine use, nutrition, and clotting or bleeding history
- Donor-site function, rehabilitation needs, daily demands, and realistic goals
07 · Costs
What makes up the Total Procedure & Care Cost
Compare written estimates for the same planned scope, including the flap, donor-site care, hospital stay, and any staged procedures. Insurance coverage and your share of costs depend on your plan and the care required.
Surgeon
Surgical care
Surgeon services, microsurgical reconstruction, and any planned wound preparation or associated repairs.
Ask your surgeonAsk which surgeons and procedures are included and how unplanned or later operations are billed.
Facility
Anesthesia and facility
Anesthesia, operating-room services, hospital care, and postoperative monitoring.
Ask your surgeonConfirm network status and how a longer admission or additional surgery could affect charges.
Supplies
Supplies and follow-up
Potential charges for dressings, splints, medicines, follow-up visits, and hand therapy.
Ask your surgeonAsk which items are included and whether therapy or home nursing requires separate authorization.
TRC
Patient Services
Any separately listed care-coordination or administrative services.
Ask TRCAsk whether these services apply, what they include, and whether they are optional or billed separately.
Your written estimate should explain the services included, any separate charges, and payment terms.
08 · Questions
Common questions
Will the flap have normal feeling?
Not necessarily. Sensation depends on the flap, the injury, and whether nerve reconstruction is possible. Reduced or altered feeling may persist, so the team may teach ways to protect the area from unnoticed injury.
Will I have two wounds?
Yes. The recipient site and donor site both need care. The donor site may be closed directly or may need a skin graft, depending on the tissue taken.
Can reconstruction be done in an infected wound?
Sometimes, but infection treatment and removal of unhealthy tissue are central to planning. A flap does not replace wound cleaning or antibiotics when those are needed.
What happens if the flap fails?
The team may attempt urgent surgery to restore circulation. If tissue cannot be saved, options can include another flap, another form of coverage, or a different reconstruction goal based on the limb's condition and your health.
0 consultation questions in your plan
View in My TRC workspaceMy Aesthetic Plan
Prepare for your consultation
Bring these to help your consultation:
- Understand the planned flap, donor site, alternatives, and possible additional procedures.
- Have written site-specific care instructions, activity limits, and urgent contact details.
- Confirm follow-up, therapy, home support, and financial responsibilities.
View My Aesthetic Plan
Choices stay in this visit until saving to your account completes. Nothing is sent to a clinician.
Sources
- [1]Cleveland Clinic — surgical reconstruction and flap surgery educationGeneral flap reconstruction principles, transferred tissue types, microsurgical blood supply, donor-site considerations, flap monitoring, and surgical complications.
- [2]MedlinePlus — Skin flaps and grafts: self-careDifferences between flaps and grafts, individualized wound care and activity precautions, and warning signs including changes in tissue color, temperature, pain, swelling, and drainage.
Photographs are illustrative scenes, not patients, staff, facilities or outcomes. This information does not replace a personal assessment by your treating clinician.