الفهرس 
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Abstract
Soft-tissue reconstruction of the hand poses a formidable challenge to the plastic and reconstructive surgeons. Durable and stable coverage of soft-tissue defects of hands with a cutaneous flap seems to be an ideal solution. The paucity of local or regional flaps that are thin, pliable, and large enough forces the surgeon to perform incomplete excisions and use skin grafts with their inherent drawbacks and suboptimal outcomes.
For reconstruction of hand defects with substantial skin loss resulting from trauma, deep burns, infections or after tumor resection, a single-stage procedure that can provide well-vascularized flap coverage offers the best possible functional results with reduction in fibrosis, scarring, and hospital stay.
The distally based radial artery forearm flap is considered the workhorse for covering large hand defects. Its advantages are a large skin paddle with reliable reversed perfusion. However, this flap should not be used in badly mutilated hands where the additional loss of the radial artery could compromise hand viability, although some authors have recommended that the flap can be raised in such cases if the pivot point is kept 5 cm proximal to the wrist crease.
The ulnar artery-based flap is based on the major arterial supply to the hand, but it damages the ulnar artery, which is the major disadvantage of this flap. The dorsoulnar flap, based on the ascending branch of the dorsoulnar artery, is a distally based flap but has a short pedicle with limited rotation. Only defects on the ulnar–dorsal side of the hand and proximal palm can be reached.
The posterior interosseous vessels offer a reliable blood supply to the skin of the posterior aspect of the forearm, and damage to this vessel is not detrimental to hand vascularity. Another advantage is the anatomical basis of the retrograde flow of this flap by the anastomosis between the posterior and anterior interosseous arteries, and thus even with damage of radial or ulnar arteries or palmar arches this flap can still be used.
The distally pedicled PIA flap is suitable for providing vascular skin to the dorsal region of the hand as far as the proximal phalanx of the thumb and the first webspace. It can also be raised as an osteofasciocutaneous unit, including a vascularized bone segment from the ulna for thumb reconstruction.
CONCLUSION
The reverse-flow posterior interosseous artery flap is a reliable and versatile flap for resurfacing of mild to moderate size defects on the dorsum and palmar aspect of the hand up to the MPJ, first web space and thumb up to the IP joint.
Thorough attention to the technical details, including performing a proximo-distal flap dissection with the deep fascia, avoiding dissection of the anastomotic arc between posterior and anterior interosseous artery, and avoiding its tunnelling for inset, will contribute to survival of the flap.
The PIA flap does not affect hand function. DASH score in the studied patients ranged from 30 – 60 with a mean of 38.7 ± 11.25. Also, neuropraxia of the PIN developed in only 1 patient (6.7%) and resolved during follow up.
The aesthetic appearance of both the flap and donor site was acceptable by most patients. Subjective scar assessment was good in 12 (80%) patients and fair in 3 (20%) patients.
The PIA flap does not cause serious donor site problems or complications. Only 2 (13%) patients had cold intolerance and numbness at the donor site. Regarding the incidence of complications, there were 1 (7%) patient had distal flap necrosis and 1 (7%) had venous congestion; both flaps healed well with follow-up.
At the end of this study, we can conclude that the PIA flap is good as regard hand function, aesthetic appearance and donor site morbidity for reconstruction of hand soft tissue defects.