Surgical restoration of key functions of the upper extremity has tremendous potential to increase autonomy, mobility, and self-esteem by resuming critical abilities in patients with tetraplegia. New strategies of surgical reconstruction and postoperative rehabilitation of upper extremity function in tetraplegic patients have been developed, based on basic science and clinical studies. In contrast to traditional hand reconstruction with separate flexors and extensors phases, combining 7 individual procedures provides key pinch and finger flexion together with passive opening of hand in one stage. Further research should aim at combining traditional algorithms with new approaches, such as immediate postoperative activation, combined procedures and nerve transfers.