Soft tissue defects of the upper extremity must be carefully assessed to determine the most appropriate method of coverage. Direct closure and local flaps represent the most basic techniques on the reconstructive ladder; however, they are inadequate for large or complex defects. Split thickness skin grafts are appropriate for granulating wounds with a bed of vascularized tissue; however, if there is an exposed joint or bone devoid of periosteum or tendon devoid of paratenon, there will be insufficient neovascularization, and the graft will inevitably fail. The reconstructive hand surgeon must then pursue more complicated techniques for wound coverage based upon knowledge of the available pedicled and free flaps. The reverse radial forearm flap potentially offers thin, mobile skin with similar characteristics to the skin over the dorsum of the hand. This flap is more versatile than the groin flap and probably more reliable than the posterior interosseous artery flap for coverage of moderate-sized defects of the dorsal or palmar wrist and hand and is specifically indicated for coverage of degloving injuries of the dorsal wrist and hand, after release of thumb-index finger web space, and for coverage of amputations of the thumb in preparation for toe-to-thumb transfer.