Upper limb replantation remains one of the most challenging — and rewarding — procedures in plastic and reconstructive surgery. From fingertip injuries to major limb salvage, success depends not only on microsurgical skill but also on sound decision-making, efficient technique, and anticipating complications.

In this episode, we break down the essential principles every trainee should know when faced with an amputation on call. We review absolute and relative indications, discuss how to approach very distal fingertip injuries, and highlight pearls for zone 2 replantation, thumb salvage, avulsion injuries, and multi-digit cases. We also touch on more complex scenarios, including transmetacarpal and major limb replantation, and strategies for managing ischemia, venous congestion, and postoperative anticoagulation.

Whether you’re a resident seeing your first replant in the trauma bay, or a fellow refining your operative flow, this episode offers practical guidance to help you prioritize function over length, select the right cases, and master technical details that make the difference between survival and success.

Key takeaways:

• Replantation is always about restoring function, not just tissue.

• Thumb and multi-digit injuries take priority.

• Bone shortening, venous salvage, and nerve repair are central to good outcomes.

• Team efficiency and thoughtful sequencing matter as much as microsurgical precision.

References:Woo SH. Practical Tips to Improve Efficiency and Success in Upper Limb Replantation. Plast Reconstr Surg. 2019;144:87 8e–911e. doi:10.1097/PRS.0000000000006134

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