Sometimes patients with a psychoneurological impairment present with a traumatic injury that requires either microsurgical replantation or free-tissue transfer. We reviewed 38 patients undergoing 40 microvascular operations; the patients included 26 patients with psychological impairment (group 1), 3 with mental disability (group 2), and 9 with an acquired head injury and consciousness disturbance (Glasgow Coma Scale score < or =14) (group 3). Patients with a psychological impairment, especially those with a self-inflicted injury, are often uncooperative and do not recognize the necessity of restorative procedures. A multidisciplinary approach by the trauma surgeon, plastic surgeon, psychiatrist, and neurosurgeon, with coordinated assistance from the physician, nurse, therapist, and family, is required for treatment. In our study the success rate of replantation was 77.8 percent (14 of 18); for free tissue transfer the success rate was 95.5 percent (21 of 22). The overall success rate of microsurgical procedures (87.5 percent, 35 of 40) was similar to that in the population at large. Patients with psychological impairment tend to be lost during follow-up; therefore, their functional results may be poorer than expected. Nonetheless, patients with psychological impairment should not be deprived of the benefits of restorative surgery.