BACKGROUND: Complex defects of the forearm and hand are associated with the loss of important structures. Single-stage reconstruction of these defects requires composite tissue transplantations. The subscapular region offers various components for the coverage of complex defects. The scapular and the parascapular flaps can be used each as cutaneous, fasciocutaneous and osteocutaneous or as a combined flap as well. The purpose of this study was to present our experience with the combined scapular-parascapular free flap for defect coverage of the forearm and hand in 13 patients. PATIENTS AND METHOD: Evaluation of 12 patients who underwent coverage of forearm and hand defects with the combined scapular-parascapular free flap during a five-year period. Other treatment options are discussed. RESULTS: Average age of the patients was 39 years, there were ten male and two female patients. Average follow-up was 20 months. Eleven patients suffered from massive trauma, one patient from severe infection of the forearm and hand. The defect size varied from 12 x 8 cm to 45 x 20 cm. In nine cases, a cutaneous and/or fasciocutaneous scapular-parascapular flap was used, two patients underwent defect coverage with an osteocutaneous scapular-parascapular flap, and in one patient, a "four-flap-mega-flap" was transplanted. One flap developed a partial necrosis. Eight patients developed a good or very good functional outcome with their hand and forearm, two patients have a moderate degree of disability. Two patients can use their hand as a supporting hand. CONCLUSION: This study demonstrates that the combined scapular-parascapular free flap is a reliable treatment choice for early coverage of defects of the forearm and hand. The advantages are the long, large and consistent vascular pedicle, the possibility of combination with other flaps and "custom-tailoring", including whatever component is necessary to close the particular defect.