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The posterior interosseous artery (PIA) flap is one of the options for hand and upper extremity reconstruction. It does not sacrifice the main arteries of the hand, the radial and ulnar arteries and could be used even when either artery was damaged. The PIA is a branch of the common interosseous artery and runs down longitudinally in the intermuscular septum between the extensor carpi ulnaris and extensor digiti minimi. PIA appears to be relatively constant in position, and provides a reliable blood supply in the posterior aspect of the forearm. The PIA flap is reliable in its designs, even to making it possible to close the donor site primarily. It provides not only a thin, pliable coverage of the hand and upper extremity, but also a neurosensory flap. Technically, the dissection of the PIA pedicle along its course needs a high learning curve, because it might present the risk of venous congestion, ischemic flap necrosis, and injury to the PIN. Although the flap dissection seems to be difficult, it still offers increased versatility in reconstructions of the hand, foot, and upper extremity. Its popularity has increased, becoming a valuable flap due to its arc of rotation, due to its safety and low morbidity. [ABSTRACT FROM AUTHOR]