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HAND/PERIPHERAL NERVE

Pedicled and Free Radial Forearm Flaps for Reconstruction of the Elbow, Wrist, and Hand

Neil F. Jones, M.D. Reza Jarrahy, M.D. Matthew R. Kaufman, M.D.

Los Angeles, Calif.

Background: A single surgeon’s experience with 67 pedicled and free radial forearm flaps for reconstruction of the elbow, wrist, and hand was analyzed retrospectively. Methods: Fifty-seven pedicled (43 reverse and 14 antegrade flow) and 10 free

radial forearm flaps were performed in 66 patients, including seven fascial flaps and one osteocutaneous flap. Indications involved soft-tissue coverage of the elbow (n 11), dorsal wrist and hand (n 24), palmar wrist and hand (n 12), and thumb amputations (n 5); after release of thumb-index finger web space contractures (n 6) and radioulnar synostosis (n 2); before toe-to- thumb transfers (n 3); for reconstruction following tumor excision (n 13); and for wrapping of the median, ulnar, and radial nerves for traction neuritis

( n 5).

Results: Primary healing of the soft-tissue defect of the elbow, wrist, and hand was successful in 95 percent of patients. There was one flap dehiscence, partial loss of two reverse radial forearm flaps, and complete loss of one free radial forearm flap. Eleven donor sites were closed primarily and 56 were covered with a split-thickness skin graft. No patients complained specifically of cold intoler- ance of the hand or dysesthesias in the superficial radial nerve or lateral ante- brachial nerve distribution. Conclusions: This is the largest reported series of radial forearm flaps for reconstruction of the upper extremity. The authors believe the antegrade pedi- cled radial forearm flap is the optimal flap for coverage of defects around the elbow, and the reverse radial forearm flap is the optimal choice for coverage of moderate-sized defects of the wrist and hand. (Plast. Reconstr. Surg. 121: 887,

2008.)

S oft-tissue coverage of defects affecting the hand, wrist, and elbow can be accomplished using skin grafts, local flaps, regional or dis-

tant pedicled flaps, and free flaps. The groin flap based on the superficial circumflex iliac artery axis has been the most commonly used distant pedi- cled flap. 17 Although the axial pattern of the groin flap provides an area of reliable skin, its disadvantage is that it requires attachment of the upper extremity to the trunk followed by delay, division, and insetting of the flap. The three op- tions for regional pedicled flap coverage include the radial forearm flap, 8 26 the ulnar forearm flap, 2733 and the posterior interosseous flap 34 43

From the UCLA Hand Center, Division of Plastic and Re- constructive Surgery, and Department of Orthopedic Surgery, University of California, Los Angeles, School of Medicine. Received for publication November 27, 2006; accepted Au- gust 10, 2007. Copyright ©2008 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000299924.69019.57

based on the radial artery, ulnar artery, and pos- terior interosseous artery, respectively. These fas- ciocutaneous flaps can be based on proximal ar- terial inflow for elbow coverage or based distally on reverse flow for coverage of the wrist and hand. All three flaps can also be harvested and trans- ferred as free flaps. 8,14,21,22,26 –28,40,44,45 The ulnar forearm flap and posterior interosseous artery flap

–28,40,44,45 T h e u l n a r forearm flap and posterior interosseous artery flap

www.PRSJournal.com

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–28,40,44,45 T h e u l n a r forearm flap and posterior interosseous artery flap

have not achieved the same degree of popularity as the radial forearm flap with hand surgeons in the United States, because of concerns of harvest- ing the more dominant ulnar artery in the case of the ulnar forearm flap and because of concerns of reliability of the posterior interosseous artery

flap. 42 Even though the radial forearm flap is usu- ally harvested as a skin flap, it may also be har- vested as an osteocutaneous flap 26,46 49 or purely as

a fascial flap 50 56 and may incorporate the palmaris longus tendon as a vascularized tendon graft. 26,57,58 The radial forearm flap has often been criticized because of the appearance of the donor site 59 66 and because of concerns of harvesting the radial artery, which can be the dominant arterial supply to the hand. 6770 The purpose of this study was to analyze the indications and results of pedicled and free ra- dial forearm flaps used for reconstruction of the elbow, wrist, and hand in a large series performed by

a single surgeon and to document any complications with the flap or with the donor site.

PATIENTS AND METHODS

Approval for this study was obtained from the Institutional Review Board at the University of Cal- ifornia, Los Angeles School of Medicine. Inclusion criteria were patients who had undergone emer- gency or elective reconstruction of their upper extremity using a pedicled or free radial forearm flap with a minimum follow-up of 1 year. Sixty- seven consecutive radial forearm flaps for recon- struction of the upper extremity were performed by a single surgeon between 1993 and 2005. A retrospective chart review evaluated the age and sex of the patient, diagnosis, location and size of the defect, method of reconstruction, duration of hospitalization, flap survival, complications of the flap or donor site, objective assessment of func- tional improvement, subjective assessment of the donor-site scar, and any postoperative neurologic or vascular symptoms in the donor extremity. Sixty-seven radial forearm flaps were per- formed in 66 patients; 42 were men and 24 were women, with a mean age of 45 years (range, 2 to 87 years). Reconstruction was performed emer- gently in 41 patients and as an elective procedure in 25 patients. Fifty-seven flaps were pedicled ra- dial forearm flaps and 10 were free flaps, from either the contralateral extremity (n 8) or the ipsilateral extremity (n 2). Of the pedicled ra- dial forearm flaps, 43 were designed on reverse flow in the radial artery and 14 were based on antegrade flow (Table 1). The size of the flap ranged from 4 2 cm to 15 10 cm, with a mean flap size of 8 6 cm. Seven flaps were elevated as fascial flaps and one

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Plastic and Reconstructive Surgery March 2008

Table 1. Vascular Supply of Radial Forearm Flaps (n 67)

 

No.

Pedicled radial forearm flaps Reverse flow Antegrade flow Total Free radial forearm flaps Contralateral Ipsilateral Total

43

14

57

8

2

10

was elevated as an osteocutaneous flap. Indications included soft-tissue coverage of the elbow (n 11)

(Fig. 1), coverage of the dorsal wrist and hand (n 24) (Fig. 2), coverage of the palmar wrist and hand

(n 12) (Fig. 3), after release of thumb-index finger

web space contractures (n 6) (Fig. 4), and for coverage of thumb amputations (n 5) (Fig. 5).

Thirty-five patients had sustained traumatic injury to their upper extremities, 28 because of avulsion or crush injuries and seven resulting in amputations. Five patients underwent secondary reconstruction for burns. Radial forearm flaps were used for recon- struction after radical resection of malignant tumors of the forearm, wrist, and hand in 13 patients, the most common diagnosis being squamous cell carci- noma (n 4) or malignant fibrous histiocytoma

(n 4). More esoteric indications included circum-

ferential wrapping of the median (n 3), ulnar

(n 1), and radial nerves (n 1) for recalcitrant

carpal tunnel syndrome (Fig. 6), cubital tunnel syn- drome. and superficial radial neuritis (n 5); full- thickness soft-tissue infections (n 6) (Fig. 7); after release of radioulnar synostosis (n 2); and before toe-to-thumb transfers (n 3) (Fig. 8). Fourteen proximal-based radial forearm flaps were used in this series, 10 for primary or secondary reconstruction after trauma or burns. Three proximal-based radial forearm fascial flaps were transposed to the elbow and proximal forearm, two for interposition after radical release of radioulnar synostosis 71 and one for

circumferential wrapping of the ulnar nerve for trac- tion neuritis after multiple operations for cubital tunnel syndrome 72 (Table 2). The donor site was usually covered with a 0.017-inch split-thickness skin graft, preferably nonmeshed. The wrist and fingers were immobi- lized in a palmar plaster of paris splint for 7 days, with the wrist in 20 degrees of extension, the meta- carpophalangeal joints in 50 degrees of flexion, and the interphalangeal joints in extension. Eleven patients subsequently underwent further surgery, three involving the radial forearm flap

Volume 121, Number 3 Radial Forearm Flaps

Volume 121, Number 3 • Radial Forearm Flaps Fig. 1. ( Above , left )This 67-year-oldwoman

Fig. 1. ( Above, left)This 67-year-oldwoman underwent radical resection ofaliposarcoma of the posterioraspect of the right elbow. The triceps tendon was reconstructed with a fascia lata graft. (Below, left) An antegrade pedicled radial forearm flap was elevated with dissection of the radial artery and cephalic vein all the way to the antecubital fossa. (Right) She regained elbow motion of 20/130 degrees.

itself and eight who required secondary proce- dures unrelated to the flap. Over the same time period, 12 groin flaps and four reverse posterior interosseous artery flaps were performed by the same surgeon for recon- struction of the upper extremity in a separate group of 16 patients. Pedicled groin flaps were indicated for soft-tissue coverage of the palmar surface of the wrist and hand (n 5), the dorsal surface of the wrist and hand (n 4), and thumb amputations or after release of contractures of the thumb–index finger web space (n 3). All four reverse posterior interosseous artery flaps were indicated for soft-tissue coverage of dorsal defects of the wrist and hand.

RESULTS

Primary healing of the soft-tissue defect of the elbow, wrist, and hand was successful in 95 percent of patients. There was partial peripheral loss of one reverse radial forearm flap, probably because

of venous problems in a patient with necrotizing fasciitis and generalized epidermolysis of a reverse radial forearm flap in an elderly, confused patient. There was complete loss of one contralateral free radial forearm flap in a patient who had been heavily irradiated and who had very inadequate recipient veins. Three reverse radial forearm flaps required leech therapy because of transient post- operative venous congestion. Eleven donor sites were closed primarily, 54 were covered with a nonmeshed split-thickness skin graft, and two were covered with a meshed split-thickness skin graft. There was 100 percent take of the split-thickness skin graft in all 56 pa- tients. Patients were hospitalized from 1 to 11 days (mean, 4 days). At follow-up, no patients complained of cold intolerance of the hand on direct questioning. None were dissatisfied with the appearance of the donor site, nor did any patient complain of any altered sensibility or dysesthesias within the dis-

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Plastic and Reconstructive Surgery March 2008

Plastic and Reconstructive Surgery • March 2008 Fig. 2. ( Above , left ) This 27-year-old

Fig. 2. ( Above, left) This 27-year-old man sustained a degloving injury of the dorsal aspect of his left hand down to the exposed extensor tendons, which was debrided radically.

( Above, right) Schematic representation of the anatomy and dissection of a reverse radial

forearm flapfor coverage ofadorsaldefect of the hand.(Below, left)A reverse radialforearm flapwas elevatedand transposed througha connectingincision between the dorsal defect

and the anteriorforearm dissection. (Below, right) Excellent healing of the flap allowingfull extension of the middle, ring, and small fingers.

tribution of the superficial radial nerve or lateral antebrachial cutaneous nerve of the forearm. All the patients who had normal elbow flexion and extension and normal pronation and supina-

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tion of the forearm before coverage using the antegrade pedicled radial forearm flap main- tained normal elbow flexion and extension and forearm pronation and supination postopera-

Volume 121, Number 3 Radial Forearm Flaps

Volume 121, Number 3 • Radial Forearm Flaps Fig. 3. ( Left ) This 24-year-old man

Fig. 3. (Left) This 24-year-old man developed a severe scar contracture of his left thumb and fingers following a hot press injury to the palm of his left hand.(Right) The palm of his left hand was resurfaced with a reverse radial forearm flap; excellent correction of the scar contracture of the thumb and fingers was obtained.

tively. Those patients who underwent release of elbow flexion contractures gained an average of 75 degrees of extension after the elbow release procedure and reconstruction with an antegrade pedicled radial forearm flap. All the patients who underwent a reverse radial forearm flap regained full flexion and extension of their fingers, and those patients who had normal wrist flexion and extension and normal forearm pronation and supination be- fore the reverse radial forearm flap regained full wrist flexion and extension and full forearm prona- tion and supination postoperatively without the need for any postoperative hand therapy. All 12 groin flaps were successful. One poste- rior interosseous artery flap failed.

DISCUSSION

Although the radial forearm flap was originally described by Song et al. 8 as a free flap after release of burn scar contractures of the neck, it was quickly recognized that a radial forearm flap could be har- vested as a proximal-based pedicled flap based on antegrade flow through the radial artery for cover- age of defects around the elbow and proximal forearm, 15,19,20 or as a distal-based pedicled flap for coverage of the wrist and hand. 9 14,16 18,2126 The basis for successful transfer of a reverse radial fore- arm flap is retrograde flow through the radial artery from the ulnar artery and palmar arches after liga-

tion of the proximal radial artery. 67 Lin et al. 73 de- scribed venous outflow from a reverse radial forearm flap based on a “crossover pattern” and a “bypass pattern” between the venae comitantes and com- munication between the cephalic vein and deep ve- nous system. The reverse radial forearm flap is especially indicated for moderate-sized defects of the palmar and dorsal aspect of the wrist and hand out to the level of the proximal interphalangeal joints. In this series, 43 reverse radial forearm flaps (64 per- cent) were used to reconstruct 24 dorsal wrist and hand (Fig. 2) and 12 palmar wrist and hand de- fects (Fig. 3). Several previous reports have sug- gested that the reverse radial forearm flap is spe- cifically suited for coverage of dorsal wrist and hand defects because the flap consists of similar thin, supple skin. 9 14,16 18,2126 However, occasion- ally, especially in middle-aged women, the fore- arm skin may have significant thickness of subcu- taneous fat. In such individuals, the thickness of the flap on the dorsum of the wrist and hand can be reduced by harvesting a pure fascial flap 50 56 and covering it with a full-thickness or split-thickness skin graft. Similarly, in some men, the palmar aspect of the forearm is excessively hairy, and if a reverse radial forearm flap is used in these individuals to cover a palmar defect, it may require the use of depilatory creams or laser treatment postoperatively.

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Plastic and Reconstructive Surgery March 2008

Plastic and Reconstructive Surgery • March 2008 Fig. 4. ( Above , left ) This 53-year-old

Fig. 4. ( Above, left) This 53-year-old woman developed an adduction contracture of her right thumb–index finger web space followinga severe crush injury to her right dominantforearm.The original injury requiredfasciotomies,vein graft revascularization of the radial artery, and split-thickness skin grafting of the anterior forearm. (Above, right) After radical release of the thumb–index finger web space contracture, reconstruction with a reverse radial forearm flap was not an option because of the previous injury to the right forearm. (Below, left) A contralateral left free radial forearm flap was used. (Below, right) Pliable skin for the released thumb–index finger web space was provided.

The most distal pivot point of a reverse radial forearm flap is the radial styloid, where the radial artery passes deep to the tendons of the first dorsal extensor tendon compartment. The distance from the radial styloid to the proximal margin of the dorsal or palmar defect is measured and this dis- tance transposed proximally up the anterior sur- face of the forearm, where a template of the defect cut from an Esmarch bandage may be orientated either longitudinally or transversely, but should not extend any farther radially than the radial border of the forearm. If the flap has to reach more distally, the skin flap has to be designed more proximally over the junction of the middle and proximal thirds of the forearm. However, in these circumstances, the surgeon has to be metic- ulous in carefully preserving the fragile lateral in- termuscular septum containing the perforators, because the radial artery and venae comitantes

892

diverge more deeply away from the overlying skin island. For dorsal defects, either the flap can be passed through a very wide subcutaneous tunnel into the dorsal defect (Fig. 2, above, right) or an incision may be made connecting the dorsal de- fect with the forearm donor-site incision (Fig. 2, below, left). It is essential that the pedicle is not twisted, kinked, or compressed; otherwise, venous outflow can be compromised. Despite the hypoth- esis that a “crossover” or “bypass” pattern allows venous egress from a reverse radial forearm flap, 73 many of these flaps remain temporarily swollen for several days. If there is any suggestion of venous congestion of a reverse radial forearm flap, leeches can be applied for a few days (three of 43 in this series), and it has even been suggested that a superficial vein in the flap be anastomosed mi- crosurgically to a superficial vein in the vicinity of the defect 47 or that a valvulotomy be performed in

Volume 121, Number 3 Radial Forearm Flaps

Volume 121, Number 3 • Radial Forearm Flaps Fig. 5. ( Above left, and right )

Fig. 5. ( Above left, and right) This 7-year-old boy sustained a pipe bomb injury to his left hand, with amputation of the thumb, index, and middle fingers. A reverse radial forearm flap was used to cover the remaining thumb metacarpalinpreparationfora secondary toe-to-thumb transfer.(Below, left)Satisfactorycoverage of the thumb metacarpal, which was sufficiently functional that his family did not proceed with a secondary toe-to-thumb transfer.

the cephalic vein. 74 There were two partial failures in the 43 reverse radial forearm flaps in this series (4.65 percent), one because of venous outflow compromise in a patient with necrotizing fasciitis and one because of generalized epidermolysis in an elderly confused patient who was unable to maintain her hand in an elevated position. The reverse radial forearm flap may be used for coverage of moderate-sized defects of the pal- mar aspect of the wrist and hand, but obviously this requires that the defect has not interrupted the connection between the ulnar and radial arteries through the deep palmar arch or the radial artery in the anatomical snuffbox. Although, ideally, a preoperative Allen test should be performed on every patient being considered for reverse radial forearm flap, a preoperative angiogram may be indicated in those patients being considered for reverse radial forearm flap coverage of a palmar

defect. Another way to document the integrity of flow from the ulnar artery to the radial artery is to isolate the radial artery just proximal to the radial styloid and apply a microvascular clamp. The tourniquet is then deflated, and if a pulse can be heard with a Doppler probe distal to the microvascular clamp, this confirms that a re- verse radial forearm flap can be reliably per- formed on the intact connections between the ulnar artery and the radial artery. The majority of reverse radial forearm flaps in this series were performed for primary or second- ary reconstruction after trauma, burns, and infec- tions and for immediate reconstruction after tu- mor resection. The reverse radial forearm flap is also especially indicated after release of contrac- tures of the thumb–index finger web space (Fig. 4) and for coverage of amputations of the thumb (Fig. 5) that are unsuitable for replantation. The

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Fig. 6. ( Above ) This 64-year-old woman had undergone three previous operations on her

Fig. 6. ( Above) This 64-year-old woman had undergone three previous operations on her left carpal tunnel. She underwent

neurolysis of the median nerve under the operating microscope.

( Below)Themedian nervewas thenwrappedwitha reverse radial forearm fascial flap.

proximal stump of the radial artery within the reverse radial forearm flap can then be used to pro- vide arterial inflow to a subsequent toe-to-thumb transfer 75 (Fig. 8). A reverse radial forearm fascial flap may occasionally be indicated for circumferen- tial wrapping of the median nerve in cases of recal- citrant carpal tunnel syndrome (Fig. 6) or for neu- ritis of the superficial branch of the radial nerve. 55,72,76 A reverse radial forearm osteocutaneous flap can be considered for reconstruction of thumb amputations if the patient is unwilling to undergo a toe-to-thumb transfer (Fig. 7). 26,46 49 Even though the groin flap popularized by McGregor and Jackson 1 provides a large segment of skin based on the superficial circumflex iliac artery, it mandates attachment of the hand to the trunk in a semidependent position and requires two or three stages. 27 It is usually contraindicated in elderly patients, because it may predispose

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Plastic and Reconstructive Surgery March 2008

them to stiffness of the shoulder, and in very young children, because of difficulties cooperating with immobilization. The groin flap seems to have been superseded by the pedicled radial forearm and posterior interosseous flaps. The pedicled poste- rior interosseous artery flap, originally described by Penteado et al. 34 and subsequently by Costa and Soutar 35 and Zancolli and Angrigiani, 36 may be designed as a reverse flow flap based on the anas- tomotic connections between the anterior and posterior interosseous arteries and has been advo- cated as an alternative to the reverse radial forearm flap. 3743 Proponents of the posterior interosseous artery flap argue that it preserves both the radial and ulnar arterial supply to the hand and that the donor defect is less conspicuous. However, it has not gained popularity in the United States because of concerns regarding its reliability. 42 The radial forearm flap may also be designed on the proximal radial artery and accompanying venae comitantes and cephalic vein. Because of the thin, supple skin of the forearm and the long pedicle, in our opinion, it is probably the optimal flap for coverage of moderate-sized defects over the radial, ulnar, anterior, and posterior aspects of the elbow (Fig. 1), compared with the more re- stricted rotation of a pedicled reverse lateral arm flap 77 82 or various muscle flaps. Four small series have previously described the use of the antegrade pedicled radial forearm flap for coverage of elbow

defects. 15,16,19,20

Ten free radial forearm flaps were performed in this series (15 percent), with the majority being harvested from the contralateral forearm (Fig. 4). The indications for a contralateral free radial fore- arm flap are if the soft-tissue defect involves the anterior aspect of the middle and distal thirds of the forearm; if the soft-tissue defect involves the palmar aspect of the wrist and hand or the ana- tomical snuffbox and either the preoperative Allen test is positive or an angiogram shows no continuity between the radial and ulnar arteries; and if the soft-tissue defect is more ulnar and distal to the metacarpophalangeal joints and could not be reliably covered with a reverse radial forearm flap. Very occasionally, a contralateral free radial forearm flap may be indicated as a flow-through flap to provide soft-tissue coverage of the anterior aspect of the forearm and to simultaneously re- construct a segmental defect of either the radial or ulnar artery in the forearm. 9,21,22,44,45,47 When har- vesting a contralateral free radial forearm flap, the radial artery can be dissected all the way to its bifurcation from the brachial artery, and the ce- phalic vein and the two venae comitantes can be

Volume 121, Number 3 Radial Forearm Flaps

Volume 121, Number 3 • Radial Forearm Flaps Fig. 7. ( Above , left ) This

Fig. 7. ( Above, left) This 29-year-old construction worker with diabetes developed necrotizing fasciitis of his dominant right thumb. (Above, right and below, left) Because a toe-to-thumb transfer was felt to be contraindicated, he underwent reconstruction of his right thumb with a reverse radial forearm osteocutaneous flap. (Below, right) The flap healed primarily without infection and with very satisfactory thumb function.

carefully dissected all the way to the elbow to in- corporate the small connection between the venae comitantes and the superficial venous system, so that the large cephalic or basilic vein at the elbow can be used for the venous anastomosis. 83 Indications for an ipsilateral free radial fore- arm flap are very specific: if a soft-tissue defect is more ulnar and distal to the metacarpophalangeal joints and therefore beyond the arc of rotation of a reverse radial forearm flap; or if the soft-tissue defect involves the palmar aspect of the wrist and hand so that there is insufficient flow from the ulnar artery through the palmar arches to the distal radial artery. Essentially, an ipsilateral free radial forearm flap involves a more distal trans- position of the flap by elongation of the proximal radial artery and cephalic vein by interposition vein grafts. Only two ipsilateral free radial forearm flaps were indicated in this series: in one patient with a soft-tissue palmar defect distal to the meta- carpophalangeal joints and in one patient in

whom there was discontinuity of the palmar arches because of a previous thermal burn. Harvesting a free radial forearm flap is tech- nically easier than harvesting a free lateral arm flap or free posterior interosseous flap or free anterolateral thigh flap. By harvesting the radial artery up to the bifurcation from the brachial ar- tery and the basilic or cephalic vein at the elbow, the pedicle of a free radial forearm flap is much larger and longer than the pedicle of a free lateral arm flap or free posterior interosseous flap. 83 Finally, the morbidity of the donor site has been criticized by opponents of the radial fore- arm flap. Several case reports have proposed various options 59 61,63 66 to improve the appear- ance of the donor site, and the most recent prospective study by Richardson et al. 62 con- cluded that there was a low incidence of long- term morbidity associated with the radial fore- arm flap. Several tips have been learned from this large series of radial forearm flaps to im-

895

Fig. 8. This 3-year-old boy with a metacarpal hand underwent a reverse radial forearm flap

Fig. 8. This 3-year-old boy with a metacarpal hand underwent a reverse radial forearm flap to provide both soft-tissue coverage and arterial inflow to a second toe-to-thumb transfer.

Table 2. Indications for Radial Forearm Flap Reconstruction

 

No.

Dorsal wrist and hand coverage Palmar wrist and hand coverage Elbow coverage Thumb–index finger web space Thumb amputations Tumor excision Burn scar contractures Nerve wrapping for traction neuritis Prior to toe-to-thumb transfers Release of radioulnar synostosis

24

12

11

6

5

13

5

5

3

2

prove the outcome of the donor site. First, the radial border of the flap should not be extended beyond the radial border of the forearm if at all possible, because this makes the donor site very obvious, even when the forearm is held neutral or in pronation. Furthermore, if the radial mar- gin of the flap is confined within the radial border of the forearm, the superficial branch of the radial nerve can always be covered by fore-

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Plastic and Reconstructive Surgery March 2008

arm skin and not lie immediately beneath the skin graft covering the donor site. On direct questioning at long-term postoperative follow-

up, none of the 66 patients in this series had any symptoms of dysesthesias within the distribution of the superficial branch of the radial nerve. Most importantly, just like debridement, closure of the radial forearm flap donor site should not be relegated to the most junior surgeon, but in fact should be the responsibility of the most senior surgeon. The margins of the donor site are sutured to the flexor muscles with absorb- able sutures, both to advance the skin margins and decrease the overall area of the donor site and to convert the donor site to a very shallow surface. The flexor digitorum sublimis muscle is imbricated over the flexor carpi radialis tendon to prevent exposure of this tendon. Preferably,

a nonmeshed, 0.017-inch-thick, split-thickness

skin graft is then applied with a few fenestrations to allow the egress of any seroma and the wrist and fingers are immobilized in a plaster of paris splint for only 7 days. Using this protocol, there has been 100 percent take of the split-thickness skin graft in all 56 donor sites, and the flexor carpi radialis tendon has never been exposed. Obviously, the skin was closed primarily in the seven radial forearm fascial flaps in this series, but the donor site could also be closed primarily in three reverse radial forearm flaps and one contralateral free radial forearm flap because the width of the flap did not exceed 2 to 3 cm. 66

The radial artery was reconstructed in only one patient, 70 and at follow-up on direct question- ing, no patients have specifically complained of cold intolerance in the 59 hands undergoing

pedicled radial forearm or ipsilateral free radial forearm flaps or in the eight donor hands un- dergoing a contralateral free radial forearm flap. However, it should be acknowledged that all patients live in California, where symptoms of cold intolerance may be less of a problem than

in colder climates. Moreover, great care is taken

to preserve any cutaneous nerves during the dissection if possible, which may help diminish postoperative symptoms. In this series, no pa- tients have expressed dissatisfaction with the overall appearance of the donor site, despite the fact that hyperpigmentation or hypertrophy of the donor site is more likely in Hispanic and African American patients.

CONCLUSIONS

This is the largest reported series of pedicled and free radial forearm flaps for reconstruction of

Volume 121, Number 3 Radial Forearm Flaps

the elbow, wrist, and hand. Based on the senior author’s (N.F.J.) experience, the proximal-based pedicled radial forearm flap has become the flap of choice for coverage of moderate-sized defects around the elbow. The reverse radial forearm and contralateral free radial forearm flaps are more versatile than the groin flap and more reliable than the posterior interosseous flap for coverage of moderate-sized defects of the dorsal or palmar aspect of the wrist and hand following trauma or tumor resection. Radial forearm fascial flaps are occasionally indicated for circumferential wrap- ping of the median, ulnar, and radial nerves for recalcitrant traction neuritis, and radial forearm osteocutaneous flaps are infrequently indicated for thumb reconstruction if the patient refuses a toe-to-thumb transfer.

14. Hentz, V. R., Pearl, R. M., Grossman, J., et al. The radial forearm flap: A versatile source of composite tissue. Ann. Plast. Surg. 19: 485, 1987.

15. Small, J. O., and Millar, R. Radial forearm flap cover of the elbow joint. Br. J. Accid. Surg. 19: 287, 1998.

16. Govila, A., and Sharma, D. The radial forearm flap for re- construction of the upper extremity. Plast. Reconstr. Surg. 86:

920, 1990. 17. Gang, R. K. The Chinese forearm flap in reconstruction of the hand. J. Hand Surg. (Br.) 15: 84, 1990. 18. Swanson, E., Boyd, J. B., and Manktelow, R. The radial fore- arm flap: Reconstructive applications and donor-site defects in 35 consecutive patients. Plast. Reconstr. Surg. 85: 258, 1990. 19. Meland, N. B., Clinkscales, C. M., and Wood, M. B. Pedicled radial forearm flaps for recalcitrant defects about the elbow. Microsurgery 12: 155, 1991. 20. Tizian, C., Sanner, F., and Berger, A. The proximally pedicled arteria radialis forearm flap in the treatment of soft tissue de- fects of the dorsal elbow. Ann. Plast. Surg. 26: 40, 1991. Soucacos, P. N., Beris, A. E., Xenakis, T. A., Malizos, K. N., and Touliatos, A. S. Forearm flap in orthopaedic and hand surgery. Microsurgery 13: 170, 1992. Khouri, R. K. The radial forearm flap: A reconstructive cha- meleon. J. Reconstr. Microsurg. 10: 403, 1994. Kostakoglu, N., and Kecik, A. Upper limb reconstruction with reverse flaps: A review of 52 patients with emphasis on flap selection. Ann. Plast. Surg. 39: 381, 1997.

21. 22. 23. 24. 25. 2004.
21.
22.
23.
24.
25.
2004.

Neil F. Jones, M.D. UCLA Hand Center Division of Plastic and Reconstructive Surgery and Department of Orthopedic Surgery University of California, Los Angeles School of Medicine 10945 Le Conte Avenue, Suite 3355 Los Angeles, Calif. 90095 njones@mednet.ucla.edu

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