Division of the transverse carpal ligament as primary treatment of carpal tunnel syndrome is effective, but can have complications. PURPOSE: We undertook a prospective study to evaluate limited incision release outcomes and compared these results to limited incision releases done with an easily fashioned fascia flap as primary treatment for EMG documented chronic carpal tunnel syndrome. MATERIALS AND METHODS: We prospectively studied 50 consecutive carpal tunnel releases done through a one-cm limited incision and evaluated outcomes with a minimum six month follow-up. Then, we prospectively studied 100 limited incision carpal tunnel releases performed with a hpothenar fascia flap as part of the primary procedure and evaluated outcomes with a minimum six month follow-up. RESULTS: With the flap, the complication rate (subjective + objective) was only 6% as compared to 32% without the flap (power = 90%, p<0.025, chi-squared statistical analysis). With subjective complaints removed, the complication rates were 2% with the flap versus 10% without the flap. CONCLUSIONS: Limited incision carpal tunnel release with a hypothenar fascia flap as primary treatment for EMG documented chronic carpal tunnel syndrome significantly improves outcome without increasing morbidity.