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SURGICAL TECHNIQUE
Radial Artery Perforator FlaphD,
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With routine use of the retrograde radial forearm flapsome
drawbacks to this flap have become apparent. Thene
thean
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doskou
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thehaflaulnZhseptocutaneous perforators arising from the distal
radialartery to supply a retrograde radial forearm flap.2 Since
FrSu
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SurgicalTechnique
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:[email protected].
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
SurgicalTechn
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
-
ciswe
POCowina
pefom
tra
CLThres
se
fofla(Fco
4)
The flap healed with no apparent complications, and thepatient
noted a marked decrease in median nerve sen-sitivity after flap
coverage.
PE
RE1.
2.
3.
4.
5.
6.
7.
8.
9.
FIGartthaFC
RADIAL ARTERY PERFORATOR FLAP 311
SurgicalTechn
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