Fig. 8.1. Lateral arm flap comitantes of the radial artery but the flap can include the cephalic vein, the basilic vein or both. The flap can contain the lateral antebrachial cutaneous nerve or the medial antebrachial cutaneous nerve and serve as a neurosensory flap. The size of the flap can be 10 x 40 cm2. A portion of the radius can be included as a vascularized bone with this flap.16 The advantages of this flap are: a long pedicle, and potential sensory inervation. The quality of the bone from the radius is mainly cortical and not of any substantial volume.17 Including the bone in the radial forearm flap may lead to stress fractures.
Preliminary tissue expansion will increase the flap dimensions and more importantly, it will allow direct closure of the donor defect18 (Fig. 8.2).
The patient is positioned supine with arm on a hand table. Preoperatively evaluate the vascular supply to the hand by an Allen test and a Doppler and confirm the circulation through the ulnar artery. A line drawn from the center of the antecubital fossa to the radial border of the wrist where the radial pulse is palpable represents the course of the radial artery. Mark the flap centered over the course of the vessels. The more distal the flap design, the longer the pedicle. Make the skin incision and continue a sub-fascial dissection towards the vessels. On the distal part of the flap, identify the brachio-radialis and flexor carpi radialis tendon. The radial artery and venae comitantes will lie along the ulnar side of the bracioradialis and along the radial side of the flexor carpi radialis tendon. The cephalic vein will lie radial to the bracioradialis. Dissect under the pedicle and isolate the pedicle distally. Raise flaps from distal to proximal and isolate the vessels proximally. The dissection is done deep to the deep fascia elevating the flap from the underlying muscle. Combined flaps can include tendons and segments of the radius.
If the radius is harvested as vascularized bone, less than 40% of the cross section of the radius should be harvested, and the wrist and forearm should then be put in a cast for 3-4 weeks. Maximum attention should be focused during harvesting the flap since injury to the paritenon covering the tendons of the flexor carpii radialis, brachioradialis, and finger flexors can lead to skin graft failure and even loss of the tendons.
In most of the cases the donor site requires a skin graft for closure leaving a scar in a visible place.
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