The superficial ulnar artery "trap" and the free forearm flap.

A superficial ulnar artery identified during the elevation of a free forearm flap is reported. This is the second case appearing in the English literature. The free forearm flap is increasingly popular among plastic surgeons, and it is therefore imperative that this anomaly be well recognized because inadvertent injury of this anomalous artery may devascularize the hand. In cadaver dissections, the incidence of this anomaly has been reported to be 3.1%. This variation is probably encountered in clinical practice more commonly, but it is not recognized. Identification of this anomalous artery is facilitated by elevating but not exsanguinating the forearm prior to harvesting the flap.     

Superficial ulnar artery: curse or blessing in harvesting fasciocutaneous forearm flaps

BACKGROUND: Superficial ulnar artery is a well-known vascular anomaly that may cause special risks because of possible impairment of the vessel by mistake during harvesting fasciocutaneous forearm flaps. METHODS: The charts of patients who had undergone forearm flap transfer were reviewed for vascular anomalies. When a superficial ulnar artery was present, a superficial ulnar artery flap was raised and arteriography was performed postoperatively to figure out the vascular pattern in the contralateral arm. RESULTS: Four superficial ulnar arteries were found during dissection of ulnar forearm flaps (n = 107). We were unable to identify any superficial ulnar artery when preparing the radial pendant (n = 27), and we did not notice any impairment of such an artery. The four superficial ulnar artery flaps healed uneventfully. Postoperative arteriography revealed a bilateral vascular anomaly in one of the four cases. CONCLUSION: The superficial ulnar artery is a calculable anatomic variation as long as its possible presence is considered during flap harvesting. In these cases, the use of the superficial ulnar artery flap was found to be an easy and safe alternative.     

Anomalous superficial ulnar artery based flap

Upper limb shows a large number of arterial variations. This case report describes the presence of additional superficial ulnar artery which was used to raise a pedicle flap to cover an arm defect thus avoided using the main vessel of the forearm - radial or ulnar artery. Vascular anomalies occurring in the arm and forearm tend to increase the likelihood of damaging the superficial anomalous arteries during surgery. Superficial ulnar or radial arteries have been described to originate from the upper third of the brachial artery; here we report the origin of the anomalous superficial ulnar artery originating from the brachial artery at the level of elbow with the concomitant presence of normal deep radial and ulnar arteries.KEY WORDS: Anomalous artery based flap, arterial variations of the forearm, superficial ulnar artery based flap     

The ulnar artery forearm free flap

The ulnar artery forearm flap is a reliable, versatile and convenient fasciocutaneous flap. Based on the ulnar artery distal to the common interosseous branch it may include muscle (FCU) tendon (PL) and bone (ulna). The arterial and venous anatomy allow a flow-through capability and a reversal of flow which permits its use as a distally pedicled island flap. Many of its properties are shared with the radial flap, but the ulnar flap has further advantages. The donor site is virtually hairless, easily closed even when bone is taken, and is less obvious as it lies on the proximal ulnar aspect of the forearm. The ulnar artery is not reconstituted and in 11 cases there has been no clinical evidence of any circulatory, sensory or motor impairment of the hand. The flap is especially useful in intra-oral reconstruction and has been valuable in the lower leg where it may restore deficient distal circulation.     

Free ulnar artery forearm flap: a modification.

We describe a modification of the free ulnar artery forearm flap that has the benefit of the anastomosis of large-calibre vessels and the reassurance of a reconstructed ulnar artery for perfusion of the donor hand.     

Distally based ulnar artery island forearm flap for the large defect of the ulnar side of the hand

After wide excision of the squamous cell carcinoma, the large defect of the ulnar side of the left hand was treated successfully by a distally based ulnar artery island forearm flap. The flap has excellent circulation and can cover the wide defect of the hand.     

尺动脉腕上皮支上下行支为蒂的前臂逆行岛状皮瓣修复手部缺损

目的介绍一种修复手部创面的皮瓣设计。方法尺动脉腕上皮支下行支与腕背动脉弓交通,形成尺动脉腕上皮支上下行支为蒂的前臂逆行岛状皮瓣修复手部缺损。结果2000年4月～2003年10月于临床应用8例,其中修复手背和指背创面3例、手掌创面2例、第1指间隙创面3例。所有皮瓣均成活,伤口一期愈合,外形满意。结论该皮瓣血管蒂长、供区隐蔽,为手部深度创面修复提供了一种新的方法     

Perforator anatomy of the ulnar forearm fasciocutaneous flap

The ulnar forearm fasciocutaneous flap (UFFF) is a favourable alternative to the radial forearm flap when thin and pliable tissue is required. The precise anatomy of the cutaneous perforators of UFFF has not been previously reported. The position of cutaneous perforators>0.5 mm was recorded while raising 52 consecutive free UFFFs in 51 patients at our Centre. Three (6%) UFFFs in two patients demonstrated direct cutaneous supply through a superficial ulnar artery, a known anatomic variance. There was no cutaneous perforator>0.5 mm in one flap. Among the remaining 48 dissections, an average of 3 (range, 1-6) cutaneous perforators were identified. Ninety-four percent of these forearms demonstrated at least one perforator>0.5 mm within 3 cm, and all had at least one perforator within 6 cm of the midpoint of the forearm. Proximal perforators were more likely to be musculo-cutaneous through the edge of flexor carpi ulnaris or flexor digitorum superficialis, while mid- to distal perforators were septo-cutaneous. UFFF skin paddle designed to overlie an area within 3 cm of the midpoint between the medial epicondyle and the pisiform is most likely to include at least one cutaneous perforator from the ulnar artery, without a need for intra-operative skin island adjustment. This novel anatomic finding and other practical generalisations are discussed to facilitate successful elevation of UFFF.     

Intraoperative confirmation of ulnar collateral blood flow during radial artery harvesting using the "squirt test"

Hand ischemia is a major concern after radial artery harvesting for coronary revascularization. Although a number of preoperative tests have been described to assess the adequacy of ulnar collateral blood flow, many of them are subjective and unreliable. In addition, the presence of arterial connections between the radial and ulnar systems in the elbow and forearm and variability in forearm angiology imply that assessment of alternative blood supply to the hand can only be made once collateral branches of the radial artery have been divided. We describe a technique for intraoperative assessment of ulnar collateral blood flow after mobilization and division of collateral branches of the radial artery.     

游离尺动脉腕上皮支皮瓣修复手指创面

目的探讨尺动脉腕上皮支皮瓣修复手指创面的手术方法及效果。方法对11例手指皮肤软组织缺损合并肌腱或骨外露者,采用游离尺动脉腕上皮支皮瓣进行修复。其中8例面积为2．5cm×1．0cm-5．2cm×2．2cm的皮瓣．在腕上皮支下行支轴线上切取：3例面积为5．5cm×3．0cm×6．2cm×3．8cm的皮瓣,在腕上皮支下行支及上行支轴线上切取。皮瓣切取后,8例下行支皮瓣内腕上皮支主干均直接与受区指动脉吻合,3例合并有上行支的皮瓣均移植了前臂静脉与受区的指动脉吻合,皮瓣内的皮下静脉或伴行静脉分别与近端指掌侧或指背侧2-3根静脉吻合,将皮瓣内携带的1条尺神经手背支与指固有神经接合。结果术后11例皮瓣全部成活．并获得4～17个月随访。皮肤弹性、色泽、质地良好,外形满意。两点辨别觉9-12mm。结论游离尺动脉腕上皮支皮瓣供区隐蔽,血管穿支位置恒定,不损伤主干血管,供区损伤小,切取简单。修复手指缺损外观满意,可携带神经恢复皮瓣感觉,是修复手指创面的一种理想选择。     

Analysis of flow changes in forearm arteries after raising the radial forearm flap: a prospective study using colour duplex imaging.

The purpose of this study is to assess the changes in flow patterns of forearm arteries produced by excision of the radial artery when harvesting the radial forearm flap, in order to clarify its vascular morbidity rationally. Eleven patients with elective surgery using the radial flap were included in this investigation. A prospective study was designed using colour duplex imaging for quantitative flow measurement in two stages: a few days before the operation, a first colour duplex scanning examination was done recording flow velocity and vessel section area from the radial, ulnar, posterior interosseous and anterior interosseous arteries around the wrist. Volumetric parameters and relative blood flow percentages were calculated and compared to those obtained from a second similar vascular investigation accomplished in the same limb 4-5 months after the operation. Statistical analysis was done using the Wilcoxon matched pairs test. After raising the radial forearm flap there was a trend for increased overall forearm flow (from 162 to 215 ml/min, P = 0.09 N.S.), the ulnar (P = 0.04), the posterior interosseous (P = 0.004) and the anterior interosseous (P = 0.003) arteries being responsible for this tendency. The anterior interosseous artery showed the greatest increase in blood (from 8.2 to 67.7 ml/min), reaching a relative flow percentage (33%) close to that of the radial artery before its excision (39%). Results of this study indicate that another 'major vascular axis' based on the anterior interosseous artery develops after sacrificing the radial artery and that global arterial inflow to the hand is not impaired.     

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.     

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.     

尺动脉腕上皮动脉升支皮瓣修复手部皮肤缺损的临床应用

目的 报道应用尺动脉腕上皮动脉升支皮瓣修复手部皮肤缺损的临床效果。方法 自1992年起，应用尺动脉腕上皮动脉升支皮瓣转位修复各种原因所致的手部皮肤缺损25例。结果 25例手部皮肤缺损，手术后得满意的修复效果，没有出现手部及指端缺血情况。结论 应用尺动脉腕上皮动脉升支皮瓣在不用牺牲前臂主要血管的前提下转位修复手部缺损，是一种较理想的方法，值得推广。     

A rare variant of the radial artery: clinical considerations in raising a radial forearm flap.

A rare vascular anomaly of the radial artery encountered during elevation of a radial forearm free flap is reported in this paper. We discovered a superficial radial artery which bifurcated from the deep radial artery 4 cm below the antecubital fossa. The blood supply to the proximal radial forearm flap was thought to be from the superficial radial artery, and to the distal forearm flap from both arteries. Ascertaining the course of the radial artery pre- and intraoperatively and careful dissection of the artery are essential to minimise problems of flap transfer.     

The effect of radial artery reconstruction on the radial forearm donor site: a prospective study

The purpose of this study was to evaluate the effect of radial artery reconstruction after radial forearm flap elevation and to study whether a vein graft can stay patent in this position. Ten consecutive oral cancer patients were included in the study. Pre-operative Allen's test was performed, and the flow velocity of both radial and ulnar arteries was recorded using colour Doppler ultrasonography. After flap elevation, the radial artery was reconstructed using the cephalic vein of the donor forearm as a free vein graft. The reconstructed artery was completely covered with surrounding skin, while the actual donor defect was covered with a split thickness skin graft. Colour Doppler ultrasonography was performed at 1–2 weeks and at 6–12 months post-operatively to record long-term patency. Radial artery reconstruction did not prolong the operations. All donor sites healed uneventfully. All of the reconstructed arteries were patent at the post-operative controls. In one patient, graft flow was missing on the first post-operative day but normal in the follow-up. A vein graft can remain patent with a very high success rate after radial artery reconstruction. A negative Allen’s test is not an absolute contraindication of a radial forearm flap as radial artery reconstruction can be performed.     

The island sensate ulnar artery flap for reconstruction around the elbow

Elbow joint prostheses have now become reliable and provide stable movement. Some do have rather sharp edges on the ulnar component which, particularly in the rheumatoid arthritics and the elderly, may erode the skin, leading to exposure. Various flaps will provide cover to this area but do tend to re-ulcerate, probably due to inability to appreciate excess pressure. The ulnar artery flap, including the medial cutaneous nerve of the forearm, provides durable and sensitive cover, preventing re-exposure. Its successful use in two cases is described.     

应用数字减影血管造影术指导皮瓣选择修复严重手外伤创面

目的本文探讨数字减影血管造影术(Digital subtraction angiography,DSA)在严重手外伤治疗中,对皮瓣选择的指导作用。方法回顾性分析我科治疗的6例手外伤患者,创面均有肌腱和(或)骨外露,所有患者均行DSA检查,明确前臂和手的血供情况,包括桡动脉、尺动脉的走行及其穿支动脉、掌深弓掌浅弓的存在与否等。根据造影结果,综合评价血管损伤情况和邻近的软组织条件,并据此选择逆行前臂岛状皮瓣或远位游离皮瓣修复创面。结果 4例患者前臂及手掌部主干血管无损伤,选择逆行前臂轴型皮瓣修复。2例患者因前臂桡动脉断裂、掌深弓掌浅弓完整性缺失而选择游离轴型皮瓣修复创面,术后皮瓣均存活。结论 DSA造影可以清晰显示患侧前臂和手的血管网,发现可能存在的血管损伤,能有效地指导皮瓣的选择,提高皮瓣选择的合理性和皮瓣移植的成功率。     

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.