The author presents several case studies of alternative therapy for large and small dorsal hand and finger defects. These alternatives avoid the need for a lengthy free flap procedure, avoid the meticulous dissection required by the posterior interosseous flap, and avoid the loss of radial artery required by the reverse radial forearm flap. Distally based hand and forearm adipofascial flaps consist of the subcutaneous fat and fascia of the hand and/or forearm. They are easy to elevate, with operative times typically less than 2 hours, and can cover surfaces ranging from an individual finger to the entire dorsum of the hand. The blood supply is based on the rich profusion of perforators that exist in the hand and wrist. If desired, a skin paddle can be included with these flaps. These techniques are an important addition to the plastic and hand surgeon's armamentarium.