Radial Forearm Flap

Flap type: fasciocutaneous (neurovascular) flap or pure fascial flap of the axial pattern type (see Figs. 1.3 and 1.4).

Flap components: skin, subcutaneous fat, and fascia (may include sensory nerve). Use: microvascular flap.

Vascular pedicle: The flap is based on the radial artery, which is a continuation of the brachial artery. Its caliber is approximately 1-2 mm. The radial artery is accompanied in its distal portion by two venae comitantes (Fig. 14.1, 2), which unite at the elbow to form one vein about 2 mm in diameter. The flap is innervated by the lateral antebrachial cutaneous nerve (Fig. 14.1,9), which runs parallel to the superficial cephalic vein.

Flap size: maximum 5 x 15 cm. Position: supine.

Flap elevation: Before the operation, it is determined whether the hand will survive without radial arterial input. This is done by performing an Allen test (see p.33) or using Doppler ultrasound or angiography to check for adequate collateral flow via the ulnar artery. The flap size is marked on the skin, and an S-shaped incision is made from the elbow to the proximal margin of the flap, dividing the forearm fascia. Next the muscle bellies of flexor carpi radialis and brachioradialis are identified (Fig. 14.1, 4 and 5) and separated from their intermuscular septum. The radial artery and its two venae comitantes lie between these muscle bellies on the fascia of flexor digitorum superficialis. Next the perimeter of the flap is incised, dividing the fascia of flexor digitorum superficialis at the ulnar border. The dissection of the

a Design of the radial forearm flap, a free flap based on the radial artery and two venae comitantes (2) (see text).

a Design of the radial forearm flap, a free flap based on the radial artery and two venae comitantes (2) (see text).

1

Brachial artery

2

Radial artery

3

Pronator teres muscle

4

Flexor carpi radialis

muscle

5

Brachioradialis muscle

6

Flap

7

Flexor pollicis longus

muscle

8

Deep fascia

9

Lateral antebrachial cu

taneous nerve

10

Cephalic vein

11

Radial nerve

b Cross section of the forearm (viewed from above; from Walter 1997).

Venae Comitantes Radial

b Cross section of the forearm (viewed from above; from Walter 1997).

flap and muscular fascia (Fig. 14.1, 8) proceeds from the ulnar to the radial side, avoiding injury to the peritendinous tissue. The flap should not be developed too far distally to preserve the extensor retinaculum. Next the radial artery and its accompanying veins are ligated at the distal margin of the flap. The next step is to dissect the fasciocutaneous tissue from the radial side as far as the abductor pollicis longus and brachioradialis muscles, preserving the superficial branch of the radial nerve. The vascular pedicle is raised with the fascia of flexor digitorum superficialis in a distal to proximal direction, and finally the radial artery and venae comi-tantes (or one deep vein draining into the accompanying veins) are ligated. The donor site is closed by a combination of direct closure and split-skin grafting (Remmert 1995).

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