Reverse Radial Forearm Fascial Flap With Radial Artery Preservation

The reverse radial forearm fascial (RRFF) flap is widely used in soft-tissue reconstruction of the hand. The traditional RRFF flap incorporates the radial artery from the forearm and is perfused by retrograde flow through the palmar arch. In patients with an abnormal Allen test because of an incomplete palmar arch, the traditional RRFF flap is contraindicated unless a vein graft is used to reconstruct the radial artery. A simpler alternative approach for hand reconstruction in such patients is a distally based RRFF flap based on radial artery perforators, which preserves the radial artery. We used RRFF flaps based on radial artery perforators in five patients who had palmar or dorsal soft-tissue loss. All five recovered full hand function, and only one had any complications (full-thickness skin graft loss at recipient site). The RRFF flap based on distal radial artery perforators is suitable for thin coverage of soft-tissue defects in hands with either a complete or an incomplete palmar arch.     

Perforator-based forearm and hand adipofascial flaps for the coverage of difficult dorsal hand wounds

The author presents several case studies of alternative therapy for large and small dorsal hand and finger defects. These alternatives avoid the need for a lengthy free flap procedure, avoid the meticulous dissection required by the posterior interosseous flap, and avoid the loss of radial artery required by the reverse radial forearm flap. Distally based hand and forearm adipofascial flaps consist of the subcutaneous fat and fascia of the hand and/or forearm. They are easy to elevate, with operative times typically less than 2 hours, and can cover surfaces ranging from an individual finger to the entire dorsum of the hand. The blood supply is based on the rich profusion of perforators that exist in the hand and wrist. If desired, a skin paddle can be included with these flaps. These techniques are an important addition to the plastic and hand surgeon's armamentarium.     

Distally based radial forearm flap with preservation of the radial artery: anatomic,experimental, and clinical studies

In this article we report on the anatomical, experimental, and clinical investigations of the distally adipofascial pedicled radial forearm flap based on the small perforators around the radial styloid process. There are about 10 small perforators (0.3-0.5 mm in diameter) from the distal radial artery around the radial styloid process. The longitudinal chain-linked vascular plexuses (suprafascial, paraneural, and perivenous) formed by the forearm ascending and descending branches of septofasciocutaneous perforators meet and cross over with the transverse carpal vascular plexuses around the radial styloid region. Based on these directional-oriented plexuses, distally based adipofascial pedicled radial forearm fasciocutaneous and adipofascial flaps were designed and successfully applied in 34 clinical cases. The pivot point was located at 1-2 cm above the radial styloid. The skin island plus adipofascial pedicle measured between 9-18 cm in length, with the adipofascial pedicle 3-4 cm in width. The length-to-width ratio is 3-5:1. The venous drainage of this distally based flap was investigated anatomically and experimentally. The cephalic vein has no positive role for venous drainage in distally based flaps. The difference between distally based flaps and reverse-flow flaps, clinical selection of fasciocutaneous and adipofascial flaps, advantages and disadvantages, and technical tips for operative success are discussed.     

前臂远端复合血管网带蒂皮瓣的血供特点及应用

目的探讨前臂远端蒂复合血管网皮瓣的血供特点及临床疗效。方法应用包含深筋膜、皮神经及浅静脉的前臂远端蒂复合血管网皮瓣修复手、腕部创面26例,皮瓣面积5cm×6cm～6cm×12cm。结果本组随访3～8个月,26例皮瓣完全成活,皮瓣不臃肿、耐磨、质地优良。结论皮神经、浅静脉营养血管网与真皮下及深筋膜血管网经穿动脉相互联系,构成三维、立体、轴向的血供构筑,是皮瓣存活的解剖基础,蒂部远端的主干血管穿支是皮瓣的血供来源,皮瓣操作安全,成活率高。     

前臂外侧皮神经营养血管远端蒂皮瓣的临床应用

目的报道前臂外侧皮神经营养血管远端蒂皮瓣的临床应用疗效。方法根据前臂外侧皮神经营养血管皮瓣血供来源及其与前臂筋膜皮肤血供的相互关系，在前臂外侧设计皮神经营养血管远端蒂皮瓣，转位修复手部、腕部及前臂远端软组织缺损19例。结果术后皮瓣完全成活，创面一期愈合，经3～30个月随访，皮瓣外形与手部功能恢复满意。结论前臂外侧皮神经营养血管远端蒂皮瓣解剖位置恒定，血液供应良好，手术方法简单，适用于修复手部、前臂软组织的缺损。     

The free ulnar forearm flap

Many flaps have been described based on the septocutaneous perforators; these have many advantages for the coverage of soft tissue defects. The ulnar forearm flap described by Lovie is a septocutaneous flap based on the septocutaneous perforators of the ulnar artery. We report the use of this flap in 2 patients who required soft tissue coverage. The ulnar forearm flap has the advantages of thin and pliable skin, constant and large pedicle, and the technical possibility of combination with the muscles, sensory or motor nerve, and ulna. Comparing it with the radial forearm flap, there is no possibility of exposure of flexor tendons, which usually results in the good take of skin grafts. After skin grafting, the donor scar is unnoticeable because of its position on the forearm. This flap is for the coverage of thin defects that require mobility, such as in the extremities or the intraoral region. It also could be used for the coverage of hand or arm defects as a distally or proximally based island flap, respectively.     

Dorsal forearm adipofascial turnover flap among the elderly

We have assessed the results of soft tissue cover on the back of the hand using an adipofascial turnover flap. From 2004 until 2007, 14 patients (mean age: 62 years) underwent reconstruction of extensive defects in the dorsum of the hand, using a forearm adipofascial turnover flap based on the perforators of the anterior interosseous artery covered with a split skin graft. The pivot point of the flap is typically 4-6?cm proximal to the level of the radial styloid process. In 93% of patients, the reconstruction healed without any problem. The adipofascial turnover flap is a useful and reliable method of reconstruction of the dorsum of the hand even in elderly patients.     

Hand blood supply in radial forearm flap donor extremities: a qualitative analysis using doppler examination

This retrospective study evaluated the contribution of the forearm arteries to the blood supply of the hand after radial forearm flap surgery. Doppler ultrasound examinations of the radial, ulnar, anterior interosseous and posterior interosseous arteries were performed in the distal forearm using a continuous emission directional Doppler and a modified Allen test. Twenty-seven patients were included in this investigation which demonstrated a significant contribution of the anterior interosseous artery to hand vascularity after radial forearm flap surgery.     

Oblique radial forearm reverse-flow flap

A modifed design for the distally-based radial forearm flap is presented, in an oblique direction rather than longitudinally, based on the existence of skin laxity in the proximal forearm region. The skin paddle of the flap is designed in an oblique fashion pedicled on one of the proximal-row septocutaneous perforators, and elevated in the usual manner supplied by the distal radial artery. The oblique radial forearm flap thus created was successfully utilized for reconstruction of seven dorsal hand defects. Results showed that all the flaps could easily be transposed to the defect through a wide arc of rotation and all survived totally, with direct closure of the donor site in five cases, and significant reduction in size in the remaining two cases. It was concluded that the oblique design for the skin island of the reverse radial forearm flap could allow creation of a flap that has a smaller donor defect and yet presents a longer pedicle length, with a wider arc of rotation and better adaptation to a dorsal hand defect, than a conventional longitudinal-design radial forearm flap.     

Reconstruction of hand soft-tissue defects: alternatives to the radial forearm fasciocutaneous flap

Soft-tissue defects of the hand and wrist are not an uncommon problem confronting the hand surgeon. Over the past 20 years the retrograde radial forearm fasciocutaneous flap has gained widespread acceptance in reconstruction of these defects. Appreciation of the inherent limitations of this workhorse flap and increased understanding of the blood supply of the upper extremity have prompted the development of several alternative pedicled forearm flaps. Aspects of surgical technique, specific limitations, and indications for the radial forearm fascial flap, the posterior interosseous artery flap, the retrograde radial artery perforator flap, and the dorsal ulnar artery flap are discussed and a reconstructive algorithm for flap selection is presented.     

The distally based radial forearm fascia-fat flap for treatment of recurrent de Quervain's tendonitis.

A radial fascial flap has been described as a valuable and versatile option to provide appropriate tissue coverage of tendons, nerves, and soft tissues in the forearm and hand. We report the use of this distally based radial forearm fascia-fat flap to create a fascial tube to treat recurrent de Quervain's tendonitis.     

Fascial flaps based on perforators for reconstruction of defects in the distal forearm.

Twenty fascial flaps were used in the reconstruction of defects in the distal forearm, wrist and hand in 18 patients over a 2-year period. In 16 patients the fascial flaps were based on a single fascial feeding vessel or 'perforator' arising from the anterior interosseous artery and/or ulnar artery when the radial artery had been used as the donor vessel in free flap reconstruction elsewhere in the body. There was no loss of any fascial flap in the study. The use of fascial flaps based on fascial feeders of the anterior interosseous and ulnar arteries extends the range of fascial flaps that can be raised in the forearm for reconstruction of defects in the distal forearm, wrist and hand.     

带前臂外侧皮神经营养血管筋膜皮瓣的应用解剖

目的：为带前臂外侧皮神经及其营养血管筋膜皮瓣提供形态学基础。方法：在３２侧成人上肢标本上，观测前臂外侧皮神经营养血管及其周围皮肤的供血情况。结果：前臂外侧皮神经近侧的血供为肱动脉末端和桡动脉起始部的肌皮支，起始处外径分别为１．４ｍｍ、１．１ｍｍ，穿出深筋膜前长为１．９ｃｍ、１．４ｃｍ；远侧主要为桡动脉的粗大皮支，起始处外径为０．８ｍｍ，穿出深筋膜前长０．８ｃｍ；此外，桡动脉的茎突返支及掌浅支的皮支营养其远端。其神经支在神经束间或神经旁相互吻合构成纵向（链式）血管网，并借分支与筋膜皮支所形成的皮下筋膜血管网沟通。结论：可设计带前臂外侧皮神经及其营养血管的筋膜皮瓣，顺行或逆行转位修复邻近部位的软组织缺损。     

Free tensor fascia lata perforator flap as a backup procedure for head and neck reconstruction

Free tissue transfer is an essential part of the head and neck reconstruction. Despite several flap options, free perforator flaps have become very popular for head and neck. Anterolateral thigh perforator flap has multiple advantages among other options and is preferred by most of the reconstructive microsurgeons. Besides its advantages, sometimes it is impossible to harvest an anterolateral thigh perforator flap, and the surgeon has to shift to another option. Between January 2002 and June 2005, 5 tensor fascia lata perforator flaps were used for head and neck reconstruction because anterolateral thigh perforator flap could not be elevated due to absence or insufficient musculocutaneous perforators. Only 1 flap was reexplored and salvaged by redoing the venous anastomosis. All flaps survived without any other problem. Donor sites were covered by split-thickness skin grafts in 4 patients and closed directly in 1 of them. Doppler examination is important in planning of anterolateral thigh perforator; if the signals of the perforators are absent or very weak, the surgeon can shift to another flap. This decision may also be made during the operation when insufficient perforators are seen. Based on our experience, tensor fascia lata perforator flap is a safe alternative when anterolateral thigh perforator harvest is not possible. Tensor fascia lata perforator flap can be harvested from the same anatomic region with almost same morbidity.     

The distally based radial artery/flexor carpi radialis muscle flap for dorsal hand reconstruction: a clinical and cadaver study

Complex soft tissue defects of the hand often require vascularized tissue for protection and coverage of exposed underlying structures. Pedicled local flaps from the forearm are one reconstructive option, but its use is limited by relatively high donor-site problems, including a disagreeable forearm scar and potential division of superficial forearm nerves. We describe a pedicled local flap option--the distally based radial artery/flexor carpi radialis flap, which potentially decreases forearm donor-site morbidity while still providing for coverage of small hand soft tissue defects. Six cadaver forearm dissections were performed to confirm that the vascular supply to the middle and distal portion of the flexor carpi radialis comes off the radial artery. Four clinical cases are presented in which the flexor carpi radialis muscle based on the distal radial artery was used to cover complex wounds of the dorsum of the hand. We believe the lack of damage to the superficial sensory forearm nerves and the ease of flexor carpi radialis muscle flap elevation make this a versatile flap for small, complex, soft tissue defects of the hand.     

Burned ear reconstruction using a prefabricated free radial forearm flap

Postauricular skin, postauricular fascia, temporoparietal fascia (pedicle or free), the free radial forearm flap (fascial or fasciocutaneous), and free lateral arm fascial flap, have been used for burned ear reconstruction reported in the literature. Patients who did not have normal tissue around the ear region, because of severe thermal injuries to the external ear, are not available for draping the costal cartilage framework; these patients require free flaps. The author reports a burned ear reconstruction, using a prefabricated free radial forearm fasciocutaneous flap, included an autogenous costal cartilage framework. In this case, the front and back of the cartilage framework were covered with the skin of the forearm flap. This is the main difference from other techniques in the literature. This flap is valuable for burned ear reconstruction, when local tissue and other free flaps are not available.     

Penis reconstruction using three different operative methods.

To identify the relative success rates, including aesthetic success, of three penis reconstruction techniques, we reviewed 44 cases of penis reconstruction carried out over the past 12 years. The three operative methods we surveyed involved: lower abdominal pedicled fascia flaps; paraumbilical island flaps; and free forearm flaps. Reconstructions survived in only half of the patients receiving lower abdominal pedicled fascia flaps, but 100% success rates were obtained with paraumbilical island flaps and free forearm flaps. The paraumbilical island flap is safe in terms of its blood supply, and the operative procedure is relatively simple in that it does not require microsurgery. Although, the flap is thicker than the forearm skin flap, its shape is satisfactory in slim patients; furthermore, it can be defatted secondarily. The free forearm skin flap provides the best shape, but skilled microsurgery is necessary to carry out the procedure, and damage is likely to the forearm. In conclusion, the best methods to repair defects in the penis in our experience are the paraumbilical island flap and free forearm flap. Lower abdominal pedicled fascia flaps are unsuitable for penile reconstruction and should be used less often.     

Reconstruction of the replanted hand with latissimus dorsi muscle and serratus anterior fascia combined flap

Reconstruction with the latissimus dorsi muscle flap, combined with the serratus anterior fascia flap, was performed to cover two large and separate palmar and dorsal forearm skin defects in a patient, whose hand had been replanted 20 days earlier after traumatic amputation at the distal forearm level. As a result, a total forearm amputation was salvaged by microsurgical replantation and a free combined flap of the subscapular system. This new application of the combined flap allowed the reconstruction of large and separate wounds of the replanted hand, and provided gliding surfaces for tendons.     

Anatomic study of distally based pedicle compound flaps with nutrient vessels of the cutaneous nerves and superficial veins of the forearm

The purpose of this study was to describe the anatomic basis for a distally based neurovenovascular pedicle compound flap, with nutrient vessels of the cutaneous nerves and superficial veins of the forearm. In this study, the origins, branches, and anastomoses of nutrient vessels of the cutaneous nerves and superficial veins of the forearm and their relationships with the blood supply of adjacent muscle, bone, and skin were assessed in 96 adult cadavers by perfusion of red gelatin into the superior limb arteries. The results showed that the nutrient vessels of cutaneous nerves and superficial veins of the forearm were found to have multiple origins, consisting of six longitudinal vascular plexuses and one transverse vascular plexus of the forearm, as follows: 1) the anterior-lateral vascular plexus from cutaneous branches of the radial artery; 2) the anterior-medialis vascular plexus from cutaneous branches of the ulnar artery; 3) the dorso-lateral vascular plexus from radial osteal and cutaneous branches; 4) the dorso-medialis vascular plexus from ulnar osteal and cutaneous branches; 5) the radial vascular plexus from osteal and cutaneous branches of the radial artery, cutaneous branches of the radial artery in the upper wrist, recurrent branches of the styloid process of the radius, and the radialis vascular plexus of cutaneous branches of the tabatière anatomique (anatomical snuffbox); and 6) the ulnar lateral vascular plexus from cutaneous branches of the ulnar artery in the upper wrist and osteal and cutaneous branches. The transverse vascular plexus is composed of dorsal branches of the ulnar and radial arteries. These perforating branches give fascial branches, cutaneous branches, periosteal branches, and nutrient vessels of cutaneous nerves and superficial veins. These results suggest that nutrient vessels of the cutaneous nerves and superficial veins of the forearm have the same origins as those of the nutrient vessels of adjacent muscles, bones, and skin of the forearm, which can be designated as five types of distally based pedicle flaps with nutrient vessels of cutaneous nerves and superficial veins of the forearm, whose rotation point is at the wrist joint. This flap can be applied to repair tissues of distal parts of the hand.     

The bottom-up approach to the suprafascial harvest of the radial forearm flap

Suprafascial radial forearm flaps cause far less donor morbidity compared with the conventional method of including the deep fascia. Here we describe our technique of harvesting the flap with a bottom-up approach, which simplifies flap elevation and is safe and expedient. The radial artery pedicle is ligated distally and secured to the flap. Gentle traction on the pedicle presents the inferior surface of the pedicle, facilitating dissection. The superficial layer of the deep fascia is taken with the flap, together with a generous cuff of subcutaneous tissue above the pedicle in which vessels nourishing the flap are located. It is crucial to preserve the conjoin of the deep layer of the deep fascia to the fascia covering the brachioradialis laterally and flexor carpi radialis medially. This fascial layer prevents bow-stringing of the tendons during wrist and finger flexion and allows the use of a full-thickness skin graft to close the donor site. The latter delivers superior cosmetic results than can be achieved with a split-thickness skin graft.