SURGICAL TECHNIQUE

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With routine use of the retrograde radial forearm flapsome drawbacks to this flap have become apparent. Thene

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30ed to sacrifice the radial artery during the harvest offlap has precluded its use in patients with aberrant

d incomplete distal radial arteryulnar artery connec-ns. The donor skin and fascia from the volar forearmer poor matches in color and contour to the thinnerd more delicate tissue of the hand, especially the

then, application of the radial artery perforator flap hasbeen described for coverage of hand and forearm de-fects resulting from various traumas3 and burn injuries.4

INDICATIONS

The radial artery perforator flap can be used to covermoderate-sized defects (8 cm 18 cm) of the dorsalor palmar hand as distal as the base of the proximalphalanges of the digits, as well as the distal forearm2(Fig. 1). As the radial artery is not violated during theelevation of this flap, the patient does not need todemonstrate a competent distal ulnarradial arterialanastomosis, and a preoperative Allens test is not re-quired. However, patency of the radial artery and itsvenae comitantes at the wrist is vital to the retrogradeperfusion of the flap.

om theRobert A. ChaseHandandUpper LimbCenter and theDivision of Plastic andReconstructivergery, StanfordUniversity School ofMedicine, Stanford, CA.

ceived for publicationApril 12, 2009; accepted in revised formNovember 18, 2009.

o benefits in any form have been received or will be received related directly or indirectly to thebject of this article.

rrespondingauthor: James Chang,MD, Division of Plastic and Reconstructive Surgery, Stan-rd University School of Medicine, 770 Welch Road, Suite 400, Stanford, CA 94304; e-mail:anghand@aol.com.

63-5023/10/35A02-0025$36.00/0i:10.1016/j.jhsa.2009.11.015

8 ASSH Published by Elsevier, Inc. All rights reserved.AndrewM. Ho, MD, P

Soft tissue defects in the hand and wrist can bThe retrograde radial forearm fasciocutaneoworkhorse flap to cover many hand and wristlimitations of this flap has led to the developmtissue coverage for this region. The radial artethe radial forearm flap but minimizes the disradial artery, color and bulk mismatch of thappearance. In this article, we will review the inflap to cover hand and wrist soft tissue defindications, operating technique, rehabilitationand pitfalls for use of this flap for upper-extremCopyright 2010 by the American Society foKey words Flap, hand, perforator, radial artery,

OFT TISSUE DEFECTS of the hand and wrist canresult from trauma, burn, infection, ischemia, orneoplasm. In recent years, the volar radial fore-

fasciocutaneous pedicled flap has been used exten-ely to cover large areas of hand and wrist defects.is radial forearm flap uses the retrograde flow of theial artery to provide a robust blood supply to the flap

d can be raised in a single-stage procedure withoutcrovascular surgery to cover defects in the hand andist.James Chang, MD

allenging problems for the hand surgeon.ap has emerged in recent years as thects. However, recognition of the intrinsicof other alternative flaps to provide soft

erforator flap has many of the benefits ofntages, such as the need to sacrifice theap and recipient tissues, and donor siteations for using the radial artery perforator

We will discuss the surgical anatomy,tocol, potential complications, and pearlsefects. (J Hand Surg 2010;35A:308311.rgery of the Hand. All rights reserved.)nstruction.

rsum. In addition, donor site morbidities such as poorin graft take, delayed wound healing, and conspicu-s donor scarring also limit use of this flap in sometients.These limitations of the radial forearm flap and fur-r understanding of the vasculature of the forearm

ve led to the development of other pedicled forearmps based on the posterior interosseous artery, dorsalar artery, and branches of the radial artery.1 In 1988,ang described a technique that takes advantage of the

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RADIAL ARTERY PERFORATOR FLAP 309

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iqueNTRAINDICATIONScause the radial artery perforator flap is dependent onrograde flow of a plexus rather than a major vascularis, the maximum dimensions of the flap that can bensferred reliably are smaller and the reach of the flapore proximal than that for traditional axial flaps. Thus,s flap is not suitable for patients with large defectsreater than 10 cm 20 cm) or with defects distal to

metacarpophalangeal joints in the hand. Alternativeps should also be considered in patients at risk foricrovascular arterial disease, such as smokers or dia-tics, or in those with a history of venous insufficiencythrombosis in the affected limb. This is because thep depends on the delicate septal perforators that maymay not be present in these patients. Patients withuma to the volar forearm that may have damaged therforators are also unsuitable candidates for this flap.

RGICAL ANATOMYood supply to the skin of the forearm is provided bytaneous branches of the brachial artery and musculo-taneous and septocutaneous perforators of the radiald ulnar arteries. These vessels anastomose around the

URE 1: The radial artery perforator flap provides volarerage of the forearm and hand proximal to the distal palmarase (pink) and dorsal coverage of the radial two-thirds of theearm and hand proximal to the metacarpophalangeal jointseen). The pivot point of the flap is 2 to 4 cm proximal to theial styloid process (red circle).JHS Vol A, Febrep fascia of the forearm to form vascular plexusest supply the overlying skin.The radial artery at the distal forearm emerges su-rficially in the septum between the brachioradialisd the flexor carpi radialis tendons to give off about 10all perforating vessels (0.3 to 0.5 mm in diameter)out 2 to 4 cm proximal to the radial styloid process5ig. 2). These septocutaneous perforators form a lon-udinal chain-linked vascular plexus along the coursethe artery that can be developed as an adipofascialdicle for distal forearm flaps. Venous return from theep fascia is accomplished via the profunda venaemitantes through the perforating veins of the fore-

.6 Sensate flaps can be raised using the lateral an-rachial cutaneous nerve.Several studies have investigated the role of preop-tive imaging of the perforator vessels to assess the

scular anatomy and to facilitate flap design. Imagingodalities studied include magnetic resonance angio-am, computed tomography angiography, subtractiongiography, color duplex ultrasound, and radionuclideaging.7 However, most studies revealed that limita-ns in the image resolution render the reliable delin-tion of the small perforators that originate from fore-

vessels a difficult task. Thus, preoperative imagingdeemed low-yield and not cost-effective and is notutinely obtained. Intraoperative exploration remains

only reliable method to accurately determine theation of the radial perforators.7

RGICAL TECHNIQUEe patient is placed supine on the operating table. Thergical hand is placed on a well-padded arm board,d a brachial tourniquet is applied. After appropriate

URE 2: The radial artery (RA) travels in the septum betweenbrachioradialis (BR) and flexor carpi radialis (FCR) tendonsthe distal forearm. It gives off several septocutaneous

rforators (P) about 2 to 4 cm proximal to the radial styloid toply the radial artery perforator flap (RAPF).uary

debridement of the soft tissue wound, the size andloc

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310 RADIAL ARTERY PERFORATOR FLAP

SurgicalTechniqueation of the defect are noted.To raise an adipofascial flap, a curvilinear skin inci-n along the axis of the radial artery is made over thelar forearm, and the skin is elevated off the underly-

fat and fascia. Next, a 3- to 4-cm-wide adipofascialp that includes the deep fascia, antebrachial nerve,d cephalic vein is raised from a proximal to distalection as far as the distal pivot point, leaving theial artery intact. The perforator vessels in the prox-al forearm can be ligated as needed to allow anequate arc of rotation of the flap. To avoid injury, thetal perforating vessels used to supply the flap are notlated or skeletonized. Care is taken to preserve theegrity of the superficial radial nerve and its branches.To raise an adipofasciocutaneous flap, a skin islandmarked over the proximal volar forearm, with theot point about 2 to 4 cm proximal to the radialloid. A curvilinear incision is designed between theand and the pivot point that will allow elevation ofn skin flaps to expose the adipofascial pedicle. Next,island flap is raised from proximal to distal on a 3-

4-cm-wide pedicle similar to that described above,ving the radial artery intact. If a sensate flap issired, neurotization of the flap can be performed byntifying a length of the lateral antebrachial cutaneous

rve and elevating it along with the flap. After neu-rrhaphy and rotation of the flap, the transected end of

antebrachial nerve is sutured to a suitable sensoryrve recipient using microsurgical technique.Controversy exists as to whether the cephalic veinould be ligated at the base of the pedicle. Proponentsue that there is ongoing net venous inflow to the flapm the large subcutaneous veins that may exceed thetflow capacity of the smaller valveless venous chan-ls that communicate with the venae comitantes of theial artery, resulting in venous congestion.5 In addi-n, it has been shown that there is no positive role of

cephalic vein in the venous drainage of this flap.5hers maintained that the vascular plexus accompany-

the cephalic vein contributes to the flap perfusiond should not be sacrificed.8After the pedicle is raised, the proximal end of thep is transected, and the flap is transposed and insetng similar lines to the retrograde radial forearmcial flap. While the flap can be passed through a

bcutaneous tunnel to the distal defect, given the wideipofascial pedicle that must be raised with this flapng with the lower arterial perfusion pressures, it is

nerally safer to incise the skin between the pivot pointd the recipient site and to place skin graft over thelky pedicle.JHS Vol A, FebrThe flap is then inset into the defect. The forearmnor site can be closed primarily if the width of thefect is less than 3 cm or skin grafted if the donorfect is larger. An intraoperative Doppler examinationperformed, and the location on the skin where appler signal can be obtained is marked to facilitatestoperative monitoring. Moist noncompressive dress-

is applied to the donor and recipient sites, and all-padded short-arm splint is applied for tissue stabi-ation.

HABILITATION AND POSTOPERATIVE CAREr routine postoperative protocol for flap reconstruc-n includes core warming and adequate hydration of

patient to minimize vascular spasm, intravenoustibiotics, appropriate pain control measures includingional nerve blocks and patient-controlled analgesic

vices, and prophylaxis against deep venous thrombo-. Sequential clinical examinations of the flap forerial insufficiency and venous congestion as well asppler examinations are diligently performed. The

tient typically stays in the hospital for 2 to 3 daysfore being discharged. Gentle range of motion exer-

URE 3: A radial artery perforator fascial flap (RAPF) wassed in a proximal to distal fashion to cover a defect over thedian nerve (M) without sacrificing the radial artery (RA).R, flexor carpi radialis.uary

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The flap healed with no apparent complications, and thepatient noted a marked decrease in median nerve sen-sitivity after flap coverage.

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RADIAL ARTERY PERFORATOR FLAP 311

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iquees can be initiated once the flap is stable, about 2eks after reconstruction.

TENTIAL COMPLICATIONSmplications with perforator flaps may be higher thanth traditional axial flaps, secondary to the delicateture of the perforator vessels and the weaker plexusrfusion. In a retrospective review of 68 forearm per-rator flaps, Matei et al. reported partial flap epider-olysis in 12% of cases, which the authors attributed tonsitory venous congestion.9

INICAL CASEis patient had median nerve exploration and tumorection and required coverage of a superficial and

nsitive median nerve. Soft tissue coverage was per-rmed using a radial artery perforator fascial flap. Thep was elevated from a proximal to distal fashionig. 3) until the fascial flap could be transposed tover the defect over the exposed median nerve (Fig.. The radial artery was preserved during the harvest.

URE 4: One of several perforators (P) from the radialery (RA) supplying the radial artery perforator flap (RAPF)t was transposed to cover a defect at the carpal tunnel.R, flexor carpi radialis.JHS Vol A, FebrARLS AND PITFALLS

The radial artery perforator flap is an alternative tothe radial forearm flap that can be used to coverhand and forearm soft tissue defects.No preoperative Allens test is required, althoughpatency of the radial artery at the wrist is necessary.The plexus-driven blood supply makes this a suit-able flap for covering medium-sized defects in theforearm and hand proximal to the metacarpopha-langeal joints.The perforating vessels need not be dissected whenraising the flap.More proximal perforators can be sacrificed andligated as needed to allow adequate arc of rotationof the flap.Subcutaneous tunneling of the flap under an intactskin bridge may compromise the vascularity of theflap. We recommend incising the skin between thepivot point and the recipient site and skin graftingthe transferred pedicle if needed.Sensate flaps can be accomplished using the lateralantebrachial cutaneous nerve.

FERENCESPage R, Chang J. Reconstruction of hand soft-tissue defects: alterna-tives to the radial forearm fasciocutaneous flap. J Hand Surg 2006;31A:847856.Zhang YT. The use of reversed forearm pedicled fascio-cutaneous flapin the treatment of hand trauma and deformity (report of 10 cases).Chin J Plast Surg Burns 1988;4:4142.Georgescu AV, Matei I, Ardelean F, Capota I. Microsurgical nonmi-crovascular flaps in forearm and hand reconstruction. Microsurgery2007;27:384394.Martin JP, Chambers JA, Long JN. Use of radial artery perforator flapfrom burn-injured tissues. J Burn Care Res 2008;29:10091011.Chang SM, Hou CL, Zhang F, Lineaweaver WC, Chen ZW, Gu YD.Distally based radial forearm flap with preservation of the radialartery: anatomic, experimental, and clinical studies. Microsurgery2003;23:328337.Tiengo C, Macchi V, Porzionato A, Bassetto F, Mazzoleni F, De CaroR. Anatomical study of perforator arteries in the distally based radialforearm fasciosubcutaneous flap. Clin Anat 2004;17:636642.Lee GK. Invited discussion: harvesting of forearm perforator flapsbased on intraoperative vascular exploration: clinical experiences andliterature review. Microsurgery 2008;28:331332.Nakajima H, Imanishi N, Fukuzumi S, Minabe T, Aiso S, Fujino T.Accompanying arteries of the cutaneous veins and cutaneous nervesin the extremities: anatomical study and a concept of the venoadipo-fascial and/or neuroadipofascial pedicled fasciocutaneous flap. PlastReconstr Surg 1998;102:779791.Matei I, Georgescu A, Chiroiu B, Capota I, Ardelean F. Harvesting offorearm perforator flaps based on intraoperative vascular exploration: clinicalexperiences and literature review. Microsurgery 2008;28:321330.uary

Radial Artery Perforator FlapINDICATIONSCONTRAINDICATIONSSURGICAL ANATOMYSURGICAL TECHNIQUEREHABILITATION AND POSTOPERATIVE CAREPOTENTIAL COMPLICATIONSCLINICAL CASEPEARLS AND PITFALLSREFERENCES