Grabb’s Encyclopedia of Flaps Upper Extremities, Torso, Pelvis, and Lower Extremities

FIGURE 314.1 A 25-year-old man with a severe adduction contracture of the right hand after an avulsion
injury. A: Preoperative view. The salvaged thumb and index finger were highly contracted. After complete
excision of the scar tissue and release of the adduction contracture of the first web space, a 9 × 20-cm
groin flap was transferred, with vascularization to the ulnar artery and the cutaneous vein. B: Recipient
defect (arrow shows ulnar artery). C,D: Four months postoperatively. The flap survived well and the patient
obtained a useful hand. (From Harii et al., ref. 2, with permission.)
References
1. Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular anastomoses. Plast Reconstr
Surg 1973;52:111.
2. Harii K, Ohmori K, Torii K, et al. Free groin skin flaps. Br J Plast Surg 1975;28:225.
3. Sharzer IA, Barker DT, Adamson JE. Free composite tissue transfer in the upper extremity: a comparison
with existing methods. In: Serafin D, Buncke HJ, eds. Microsurgical composite tissue transplantation. St.
Louis: Mosby, 1979;626.

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Chapter 315
Microvascular Free Transfer of A Dorsalis Pedis Skin Flap With
Extensor Tendons
G. I. TAYLOR
R. J. CORLETT
The combined loss of skin and tendon on the dorsum of the hand, seen especially after avulsion or degloving
injuries, is a challenging problem. When the defect is large, the conventional repair of such a wound usually
requires a distant abdominal flap, with tendon grafting or transfer done as a secondary procedure. These
multistage procedures impose a protracted convalescence and difficult assessment of accurate tendon graft
length, due to retraction of the involved muscle bellies.
INDICATIONS
In carefully selected cases, a composite free flap with attached vascularized tendon grafts offers an
immediate one-stage solution to this problem as a primary procedure (1). Several donor sites are now
available, including the radial or ulnar forearm flaps with attached segments of the forearm flexor tendons,
the groin flap and the tensor fasciae latae flap with vascularized strips of the external oblique aponeurosis
and the fascia lata, respectively, and the dorsalis pedis flap with attached extensor tendons. The latter flap
is ideally suited for the repair of skin and tendon defects on the dorsum of the hand, as the anatomy of
these two areas bears a close resemblance.
ANATOMY
The dorsalis pedis artery has been shown to nourish the extensor hallucis longus and brevis tendons, together
with the long and short extensors of the other toes as they fan across the dorsum of the foot. When combined
with the overlying dorsal skin, this unit provides a very thin skin flap with a mobile complex of one or more
extensor tendons. The effectiveness of this composite flap as a free transfer is well shown in the illustrations.
OPERATIVE TECHNIQUE
Figure 315.1; see Chapter 548.
CLINICAL RESULTS
In the patient shown, the dominant hand was involved and the composite free flap provided an excellent
result. Not only was there a deficiency of skin and tendon, but the metacarpal bones were also involved—a
situation where conventional tendon grafts would have been prone to adhesion. This was not the case with
the vascularized tendon grafts. Presumably, they did not adhere along their length, because of an intact
intrinsic and extrinsic blood supply and the gliding paratenon, which was transferred with the tendons.
The composite dorsalis pedis free flap with attached tendon grafts can be expanded to include a nerve
supply
and the second metatarsal bone. However, in general, the dorsum of the foot cannot be regarded as a

donor site without problems. Hypertrophic unstable scars are not uncommon, and it is therefore essential
that cases be carefully selected.
FIGURE 315.1 A: A 19-year-old salesman sustained a heavily contaminated degloving abrading injury to
the dorsum of his dominant left hand when his automobile overturned. An 8 × 5-cm area of skin was
missing, together with 4-cm defects in the extensor tendons of the index and middle fingers. The dorsal
cortices of the second and third metacarpals were also missing. The wound was debrided and then
reconstructed as a delayed primary procedure 48 hours later. A pattern of the defect was outlined on the
dorsum of his ipsilateral foot. B: A composite free flap, with attached vascularized segments of the extensor
hallucis brevis to the big toe and the extensor digitorum longus to the second toe, was isolated on the
dorsalis pedis vessels. The dissection commenced distally, and a long vascular pedicle was obtained by a
dissection of the vessels to the level of the ankle joint. C: The flap was detached and revascularized by
anastomosis to the radial vessels and the cephalic vein on the dorsum of the wrist joint. D: The
revascularized flap with tendon grafts in position. The vascular paratenon is marked with an arrow. E:
Bright red bleeding was noted from the tendon grafts; the tendon grafts were then sutured in position and
the skin defect was closed. The donor site on the dorsum of the foot was covered with a split-thickness skin
graft. The hand was immobilized in a volar slab with the wrist in extension and the metacarpophalangeal
joints in flexion. Three weeks later, the plaster was removed and mobilization of the fingers commenced.
After a further 3 weeks, the patient returned to work, at which time the range of movement of the fingers
was almost normal. (Continued)

FIGURE 315.1 (Continued) F-I. By 2 months, a full range of flexion and extension was evident, and no
further surgery has been required. The follow-up period has been 6 years and, to date, the donor site has
presented no problems. (From Taylor and Townsend, ref. 1, with permission.)
SUMMARY
The free dorsalis pedis skin flap with attached vascularized tendons can be used effectively to provide
coverage for hand defects that include segmental tendon loss.
Reference
1. Taylor GI, Townsend PLG. Composite free flap and tendon transfer: an anatomical study and a clinical
technique. Br J Plast Surg 1979;32:170.

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Chapter 316
Microvascular and Microneurovascular Free Transfer of A Dorsalis
Pedis Flap
R. K. DANIEL
EDITORIAL COMMENT
The recent description of harvesting this flap purely as a fascial flap significantly extends its usefulness (see
Chapter 549).
The dorsalis pedis free flap, when first developed (1), had several advantages when used in covering hand
defects. It was much thinner than the groin flap (2). Although there were some minor problems with donor site
morbidity, it was extended and expanded to provide an innervated free flap as well (3, 4).
INDICATIONS
The first web space free flap (see Chapter 335) (5, 6, 7) and various toe free flaps (see Chapters 240, 241,
243, 244, and 266) can be used instead of or in addition to the dorsalis pedis free flap.
The dorsalis pedis free flap, although somewhat tedious to dissect, has a reliable arterial supply and
venous drainage. It is innervated by an expendable cutaneous sensory nerve. It has an acceptable two-
point discrimination, approaching 10 mm in its most medial distribution. The addition of a first web space or
toe flap can provide improved sensibility. It is an extremely thin flap, having a minimal amount of
subcutaneous tissue. A long neurovascular stalk can be adapted to various recipient site requirements. The
donor site, although causing some minor problems, is inconspicuous.
ANATOMY
When used as a neurovascular free flap, the innervation of the superficial peroneal nerve must be carefully
documented. This can be done preoperatively by using selective local anesthetic blocks. By anesthetizing the
sural, the saphenous, and medial and lateral plantar nerves, one is left with the maximum area of sensory
distribution for the superficial branch of the peroneal nerve. The quality of two-point discrimination ranges from
10 to 20 mm, being lowest in the area medial to the extensor hallucis longus.
FLAP DESIGN AND DIMENSIONS
Initially the flap was felt to be restricted to 10 × 8 cm. With the addition of the first web space and toe flaps, the
size of the flap can be expanded significantly. This consequently increases the amount of donor site morbidity.
OPERATIVE TECHNIQUE
The innervation of the dorsalis pedis flap can be mapped out intraoperatively using electrophysiologic
techniques (Fig. 316.1). The superficial peroneal nerve is carefully dissected proximally for about 10 cm, to
ensure fusion of its medial and intermediate branches. It is then transected. Under high magnification, the cross-
sectional anatomic topography of the nerve is outlined. There are usually
nine fascicles that can be isolated. After assessing the viability of each fascicle by electrical stimulation, the area

of skin innervated by each fascicle can be determined. Using electrophysiologic techniques, the skin on the
dorsum of the foot is mechanically stimulated and the corresponding fascicle determined. The appropriate
fascicles can then be sutured to the appropriate branches of the median and/or ulnar nerves in the recipient site
(Fig. 316.2). For details of flap elevation see Chapter 548.
FIGURE 316.1 Sensory skin mapping completed on the donor site with the electrophysiologic recording setup
shown at the level of the ankle.
FIGURE 316.2 A: Isolation of the dorsalis pedis neurovascular free flap. B: The neurovascular free flap ready
for microsurgical anastomoses in the recipient hand. C: The flap at 5 months. The extent of reinnervation at this
time is indicated by hatch marks.
SUMMARY
The dorsalis pedis free flap dramatically altered the approach to reconstructive surgery of the hand. It was
further expanded into a neurovascular free flap, which improved both function and cover. Electrophysiologic
techniques refined the approach to restoring sensation. These techniques are mandatory when the nerve
distribution far exceeds the size of the flap required, or when mixed nerves of sensorimotor composition are
used.
References

1. McCraw JB, Furlow LT. The dorsalis pedis arterialized flap: a clinical study. Plast Reconstr Surg
1975;55:177.
2. Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular anastomoses. Plast Reconstr
Surg 1973;52:111.
3. Daniel RK, Terzis J, Schwartz G. Neurovascular free flaps: a preliminary report. Plast Reconstr Surg
1975;56:13.
4. Gilbert A. Composite tissue transfers from the foot: anatomic basis and surgical technique. In: Daniller AT,
Strauch B, eds. Symposium on microsurgery. St. Louis: Mosby, 1976.
5. May JW Jr, Chait LA, Cohen BE, O'Brien BM. Free neurovascular flap from the first web of the foot in hand
reconstruction. J Hand Surg 1977;2:387.
6. Morrison WA, O'Brien BM, MacLeod AM, Gilbert A. Neurovascular free flaps from the foot for innervation
of the hand. J Hand Surg 1978;3:235.
7. Strauch B, Tsur H. Restoration of sensation to the hand by free neurovascular flap from the first web
space of the foot. Plast Reconstr Surg 1978; 62:361.

Chapter 317
Biceps Femoris Per Forator Free Flap for Upper-Extremity
Reconstruction
P. C. CAVADAS
J. R. RAMÓN SANZ
L. LANDIN
EDITORIAL COMMENT
A useful flap but not first choice.
Perforator flaps are now being widely recognized as useful adjuncts to reduce donor morbidity in reconstructive
microsurgery. The anatomy of the musculocutaneous perforating vessels of the short head of the biceps femoris
muscle is described as a source for free-tissue transfer for upper-extremity reconstruction. The vascular anatomy
is relatively constant. Flap dissection is straightforward under tourniquet control; donor morbidity is low, if primary
closure is possible; and pedicle size is appropriate for repair. When a moderately sized (up to 20 × 7 cm),
moderately thick, medium-sized pedicle, far from the recipient area (double-team approach) free flap is needed,
the biceps femoris perforator (BiFeP) flap can be considered among possible alternatives.
INDICATIONS
The BiFeP flap can be harvested as a fasciocutaneous flap for soft-tissue coverage of medium-sized
defects of the upper extremity. If it is harvested as a fasciosubcutaneous flap, BiFeP flap size matches that
of small defects and first web-space contracture release. As with other perforator flaps of the thigh, the
BiFeP flap can be used for postoncologic head and neck reconstruction (1, 2, 3, 4, 5, 6). A few publications
have reported the use of lateral thigh flaps in the reconstruction of the Achilles tendon (7).
The BiFeP flap should be preferably used in thin patients; otherwise, debulking procedures will be
necessary. Color matching will be much better if the flap is used to reconstruct the lower extremity, rather
than the upper extremity, and this issue should be stressed before surgery in dark-skinned patients.
ANATOMY
The posterolateral region of the thigh was described as a donor area for free-tissue transfer by Baek in 1983, in
a paper reporting an anatomic study and a single clinical case (8). The BiFeP flap is closely related to the “lower
posterolateral thigh flap” described by Laitung (9) in 1989 and clearly different from the lateral-posterolateral flap
described by Baek and later widely reported in the head and neck literature (1, 2, 3, 4, 5, 6). Reports by Hayashi
and Maruyama (10) have focused on describing the superior lateral genicular artery (SLGA) flap, and more
recently, they have reported on an anatomic study of the lateral intermuscular septum of the thigh and the short
head of the biceps femoris muscle (BFsh) (11), in which the importance of the SLGA in the vascularization of the
distal BFsh was stressed. An attempt at clarifying the anatomic confusion regarding lateral-thigh skin
vascularization is also made in the present chapter.
The skin of the lateral thigh is vascularized by different vessels. The profunda femoris artery provides the classic
“perforating” branches that run along the septum between the vastus lateralis muscle and the BFsh, named the

lateral intermuscular septum, to emerge through the fascia lata and to irrigate the proximal two thirds of the
lateral thigh. The distal third of the thigh skin may vary in its vascular nourishment.
We studied the distal-third vascularization of the thigh. In our cadaver study, three sizable BFsh perforators
(more than 0.5 mm external diameter) were consistently found in all specimens (Fig. 317.1). Their location was
also constant. The lower perforator was located at 6 cm from the knee-joint line (range: 5 to 6.5 cm), and was a
branch off the SLGA in all cases. This artery was a branch from the popliteal artery that runs close to the bone
and sends out several muscular branches and one musculocutaneous branch. The middle perforator was
located at 11.6 cm from the joint line (range: 10 to 14 cm). It was a direct branch off the first portion of the
popliteal artery in 60% of the cases (Fig. 317.2), and off the “classic” perforating branch of the profunda femoris
artery (probably the third) in 40% of the cases (Fig. 317.2). The upper perforator was located at 15.3 cm from the
joint line (range: 14 to 17 cm) and was usually the least substantial of the three vessels. Its course was variable,
it being a true perforator in 80% of the cases and piercing the lateral intermuscular septum in the remaining 20%.
In all cases, it had a common intramuscular origin with the middle perforating vessel. Other less substantial
musculocutaneous perforators were distributed over the BFsh.
FIGURE 317.1 Anatomy of the musculocutaneous perforators over the short head of the biceps femoris in a
fresh human specimen. Left thigh, supine position, ruler indicating the distance in centimeters from the knee-joint
line. Left margin is distal, up is ventral in the figure. There are three main perforators located about 6, 12, and 25
cm, respectively, from the joint line. DP, distal perforator; MP, middle perforator; PP, proximal perforator; FL,
fascia lata overlying the vastus lateralis muscle; BFsh, biceps femoris short head; SLGA, superior lateral
genicular artery.
The flap described herein as the BiFeP flap is more distally located than the “posterolateral thigh flap” based on
the third perforator of the profunda femoris artery, described by Baek (8) and widely reported by other authors for
head and neck cancer surgery. The branch of these previously reported flaps is located about the midpoint of
the line connecting the greater trochanter and the lateral femoral condyle, septal or musculocutaneous,
depending on the description, whereas the BiFeP flap is based on a BFsh perforator located well below this
point, 11 cm above the knee joint. The flap described by Laitung (9) as the “lower posterolateral thigh flap” is
closely related to the BiFeP flap and could well be the same flap, although Laitung only suggested the possibility
of freely transferring this flap. The lateral genicular flap of Hayashi and Maruyama (10) is based on the SLGA,
the distal BFsh perforator in our anatomic study.
OPERATIVE TECHNIQUE
The BiFeP flap can be elevated in supine, midlateral, or lateral position, although supine is preferred. The knee
is flexed, the hip is flexed and internally rotated, and a sandbag is placed below the ipsilateral buttock. The
interval between the vastus lateralis-iliotibial tract and the long head of biceps femoris muscle is easily palpated

in the lower half of the thigh. (Knee extension for tensioning the iliotibial tract may be necessary for accurate
palpation in overweight patients.) The predicted positions of perforating vessels are plotted with a directional
Doppler probe, although they can reliably be found at 10 to 14 cm from the knee joint line. A flap up to 20 × 7 cm
can be elevated under tourniquet control with partial exsanguination.
The anterior edge of the flap is elevated first, proceeding in the loose areolar plane above the iliotibial tract and
the thick fascia lata posteriorly. Once the BFsh is reached, the exact position of the perforators is determined.
There are usually three sizable vessels and some additional minor ones. The branch located 11.6 cm (10 to 14
cm) proximal to the knee-joint line (middle perforator) is selected as the pedicle of the flap, although any of the
perforating vessels could be. This vessel is traced back intramuscularly for several centimeters to meet the
required length and caliber of the particular case. The skin island is best oriented proximally so that the
perforator enters its distal end. In this way, the thinner upper portion of the skin is used, and the scar is kept
away from the knee joint.
Once the desired pedicle length and size are dissected, the posterior border of the flap is incised and quickly
elevated. The maximal length of the pedicle depends on the origin of the middle perforator. When it comes from
the popliteal vessels, up to 7 to 8 cm can be obtained. When it is a branch of the profunda femoris, longer
pedicles can be obtained, although the dissection below the femur can be very tedious. Donor areas are directly
closed.
CLINICAL RESULTS
In our series of 10 patients, there were 7 acute skin losses and 3 delayed reconstructions (releases of
adduction retraction of the thumb). All 10 flaps were based on the middle musculocutaneous perforator.
Two of the flaps were subcutaneous free flaps. Nine free flaps healed without any complication. One flap
developed arterial ischemia on postoperative day 2. The flap was reexplored, but partial distal necrosis
developed, probably because of the undue secondary ischemia time. Donor areas were directly closed in
every case, although there were two wound dehiscences that required revision. Four of the flaps required a
debulking procedure at a second stage.
The BiFeP flap is based on a constant anatomy and can be elevated under tourniquet control, which are
definite advantages over other perforator flaps. The pedicle is of moderate size in terms of length (up to 7 to
8 cm) and caliber (artery up to 2 to 2.5 mm, vein 3 to 4 mm), and it is a rather thick flap, which somewhat
limits its applications. When a thin flap with a long or large-caliber pedicle is required, other free flaps are a
better choice. The donor area of the BiFeP flap is relatively well hidden and inconspicuous if direct closure
is possible. If direct closure is not possible (pinch test), then skin grafting would be necessary, and other
options should take preference over a BiFeP flap. The use of the subcutaneous version of this flap partially
avoids the donor morbidity of large flaps.
Because the BiFeP flap is a genuine perforator flap, surgical injury to the BFsh should be minimal, and no
functional disability is to be expected from its harvest, although this was not specifically addressed in the
clinical series presented here. A relatively high incidence of donor-site complications, especially
dehiscence, seroma formation, and delayed healing, has been reported in the head and neck literature, and
was also found in the present series. More attention to technical detail in wound closure and postoperative
knee immobilization might reduce this incidence. The use of quilting sutures can also reduce the incidence
of seroma.

FIGURE 317.2 Anatomic origin of the musculocutaneous perforators over the short head of the biceps
femoris muscle. A: PFA, profunda femoris artery; 3pPFA, third classic perforator off the profunda femoris
artery; LIMS, lateral intermuscular septum; PA, popliteal artery. (Modified from Hayashi A, Maruyama Y.
Plast Reconstr Surg 2001;108:1646.) B: Left thigh, supine position. Left margin is distal, and up is ventral in
the figure. The distal perforator is always a branch from the superior lateral genicular artery. The middle
perforator is a direct branch from the popliteal artery in 60% of the cases. The proximal perforator is a
branch off the middle perforator. DP, distal perforator; MP, middle perforator; PP, proximal perforator; FL,
fascia lata overlying the vastus lateralis muscle; BFsh, biceps femoris short head; BFlh, biceps femoris long
head; SLGA, superior lateral genicular artery; P, popliteal vessels; DPA, direct branch from the popliteal
artery. C: Left margin is distal, up is ventral in the figure. The middle perforator is a branch off the profunda
femoris artery in 40% of the cases (presumably its third perforating branch, although not explicitly
determined in the present anatomic study). MP, middle perforator; FL, fascia lata overlying the vastus
lateralis muscle; BFsh, biceps femoris short head; 3pPFA, third perforator of the profunda femoris artery.
In our experience, the flaps were rather small, although a 20 × 7-cm flap survived completely. The maximal
dimensions of the BiFeP flap are yet to be defined, but based on the vast clinical experience with the
anterolateral thigh flap, larger skin islands are likely to survive completely based on a single perforator. The
skin over the distal lateral thigh is thinner anteriorly than it is posteriorly, and a substantial thickness of fat is
present at the angle between the vastus lateralis and the BFsh muscles. The skin island is oriented
proximally, with the perforating vessel entering about its distal end, to keep the scar far from the knee joint
and to take advantage of the thinner, more proximal skin. The distal perforator (SLGA) is not used as the
pedicle of the BiFeP flap, to avoid scars in the lateral knee region.

SUMMARY
The BiFeP flap is a low-morbidity, genuine perforator free flap, based on musculocutaneous perforators
located distally over the BFsh, that can be quickly elevated under tourniquet control and that should
probably be within the group of first-choice flaps when a moderately pedicled and relatively thin free flap is
needed. The amount of skin required is within the range that permits direct closure. Its usefulness in upper-
extremity reconstruction has been demonstrated, and it would also probably be a good choice in lower-
extremity reconstruction as a regional free flap. Attention must be paid to ensure color matching and desired
thickness.
References
1. Hayden RE. A new technique in pharyngoesophageal reconstruction. In: Bloom HJG, ed., Head and neck
oncology. New York: Raven Press, 1986.
2. Hayden RE. Lateral cutaneous thigh flap. In: Baker S, ed., Microsurgical reconstruction of the head and
neck. New York: Churchill Livingstone, 1989.
3. Hayden RE. Lateral thigh flap. Otolaryngol Clin North Am 1994;27:1171.
4. Hayden RE, Deschler DG. Lateral thigh free flap for head and neck reconstruction. Laryngoscope
1999;109:1490.
5. Truelson JM, Leach JL. Lateral thigh flap reconstruction in the head and neck. Otolaryngol Head Neck
Surg 1998;118:203.
6. Miller MJ, Reece GP, Marchi M, Baldwin BJ. Lateral thigh free flaps in head and neck reconstruction.
Plast Reconstr Surg 1995;96:334.
7. Inoue T, Tanaka K, Imai K, Hatoko M. Reconstruction of Achilles tendon using vascularized fascia lata with
free lateral thigh flap. Br J Plast Surg 1990;43:727.
8. Baek SM. Two cutaneous free flaps: the medial and lateral thigh flap. Plast Reconstr Surg 1983;71:354.
9. Laitung JKG. The lower posterolateral thigh flap. Br J Plast Surg 1989; 42:133.
10. Hayashi A, Maruyama Y. The lateral genicular artery flap. Ann Plast Surg 1990;24:310.
11. Hayashi A, Maruyama Y. Lateral intermuscular septum of the thigh and short head of the biceps femoris
muscle: an anatomical investigation with new clinical applications. Plast Reconstr Surg 2001;108:1646.

Chapter 318
Free Parietotemporalis Fascial Flap
J. UPTON
C. RODGERS
EDITORIAL COMMENT
This was the first clinically significant fascial flap and still continues to be an excellent flap.
The parietotemporalis fascia, which lies between the skin and the temporalis muscle fascia, has been used by
the reconstructive surgeon as a pedicle flap for eyebrow, eyelid, facial, and ear reconstructions (1, 2, 3).
Recently, as a free tissue transfer, it has been used to cover burn wounds on the dorsum of the hand (4, 5) and
indolent wounds on the lower extremities (5, 6) (see Chapter 572).
INDICATIONS
The potential use as a distant tissue transfer is almost as versatile as its use as a pedicle flap (Fig. 318.1).
Our most common use has been to provide stable coverage with minimal bulk over localized defects in the
extremities, in difficult regions such as the Achilles tendon, pretibial surface, and dorsum of the foot. The
use of these tissues as a free transfer has been reserved for problems where a minimally bulky flap, with or
without potential gliding properties, has been desired.
FIGURE 318.1 Many uses of the parietotemporalis fascia as a free tissue transfer include (clockwise):
transfer of hair-bearing scalp; provision of internal nasal cavity lining (with split-thickness skin graft);
coverage of difficult wounds over the distal tibia, dorsum of foot, Achilles tendon, dorsum of hand, and ear
frames; and finally as a vascularized bone graft.
In the hand, the flap has been used for resurfacing the metacarpal region, for resurfacing digit and/or
thumb, and for wrist retinacular and/or dorsal capsule reconstruction.
The advantages of using this tissue as a vascularized tendon, retinaculum, and bone graft have not been

proven in experimental models over conventional, nonvascularized counterparts.
FIGURE 318.2 A coronal section through the temporal fossa region demonstrates the relationship of the
parietotemporalis fascia to the overlying skin and the underlying temporalis muscle. Note the areolar plane
beneath the fascia. Vessels are carried above the fascia.
ANATOMY
This fascial layer has been poorly understood and has been given many names: superficial temporalis fascia,
parietotemporalis fascia, superficial layer of temporalis fascia, cervicocephalic fascia, and cephalic extension of
the superficial musculo- aponeurotic system (7, 8). This tissue layer is not the fascial investment of the
temporalis muscle (Fig. 318.2). It represents a separate tissue layer between this muscle and the skin. The
areolar plane between the muscle and the fascia enhances the mobility of the scalp and forehead skin; hence,
the term musculo-aponeurotic system. We prefer the descriptive term parietotemporalis fascia.
FIGURE 318.3 The anatomic relationship of the sensory auriculotemporal nerve and the motor facial (VIIth)
nerve is shown. (Central inset) The facial nerve is deep to the parietotemporalis fascia (stippled) and is quite
vulnerable to injury above the zygoma and lateral to the eye.

Fascia
The parietotemporalis fascia is the cephalic extension of the superficial musculo-aponeurotic system. It is
continuous with the platysma in the lower face, muscles of facial expression anteriorly, and acts as a distributor
of muscular contractions to skin (7, 8). Part of the subcutaneous fascia of the head, it is continuous with the
frontalis anteriorly, the occipitalis muscle posteriorly, and the galea aponeurotica above the crest of the temporal
fossa. The fascia, quite thick and dense in the preauricular and temporal region, thins out peripherally toward its
muscular investments and behind the ear. In the pretragal area, the parietotemporalis fascia is adherent to the
dense parotid fascia. Fascial thickness varies. It is not unusual to find thin, areolar fascia in pediatric and elderly
patients, in contrast with thick, muscular structures in young adults.
Surfaces
The outer or external surface is not mobile and is connected to the dermis of the overlying skin/scalp by fibrous
septa. In the upper scalp, this fascia is almost continuous with dermis (Fig. 318.2). In contrast, the inner or deep
layer borders a mobile areolar plane over the fascial investment of the temporalis muscle.
FIGURE 318.4 The superficial temporal artery is the terminal branch of the external carotid system. Five
branching patterns are depicted with the most common in the center. A large zygomaticomalar branch is
consistently found anterior to the ear. The posterior auricular and greater occipital branches are also carried
above the fascial plane. [After dissection of 26 facial halves and after Eustathianos (9).]
Nerves
In the preauricular region, the facial (VIIth) nerve is either within the parotid gland or deep to the thick parotid
fascia, well below the superficial musculo-aponeurotic system. Important motor nerves are always deep to this
fascia. A danger zone exists above the zygoma where branches of the nerve to both frontalis and orbicularis
oculi muscles lie directly below or within the fascia and can be damaged easily. In the temporal region, only the
auriculotemporal sensory nerve lies above or external to this fascia (Fig. 318.3).
Vessels
The axial vessel carried by the fascia is the superficial temporal artery, which is always located above the
parietotemporalis fascia. At the level of the zygomatic arch, the arterial diameter is consistently 1.5 to 1.7 mm in
adults and 0.5 to 0.9 mm in children. The accompanying vein usually lies anteriorly and its diameter is equal to or
larger than the artery. As one extends cephalically, the vessels carried by the fascia become more superficial. At

the crest of the temporal fossa, these vessels with their abundant anastomotic network are subdermal.
Dissection is difficult.
FIGURE 318.5 (Left) Incision. (Right) After skin and scalp flap elevation, the fascial flap is raised in a retrograde
fashion. Elevation of skin flaps is initially difficult, in contrast to the retrograde fascial flap elevation, which is
easily accomplished in an areolar plane.
Five major variations of the superficial temporal artery are found (9) (Fig. 318.4). In the most common (80%), the
axial vessel bifurcates with its major anterior and posterior branches above the zygoma. The important
zygomaticomalar branch is found below the zygoma and must be differentiated from the anterior temporal
bifurcation in the pretragal region where the vessels lie in a subcutaneous fat plane. Tortuous S-shaped
redundancies of the vessels are common (10). The superficial temporal artery may be absent or hypoplastic in
type III hemifacial microsomia, hemifacial atrophy (Romberg's disease), congenital absence of scalp and skull,
and temporal arteritis.
FIGURE 318.6 Vessel identification and skin flap elevation is facilitated in the preauricular region (heavily
stippled). More peripherally, dissection is more difficult, as the fat plane thins out and the fascia is closer to the
dermis (lightly stippled). Abundant vascular anastomoses are present between all major axial scalp vessels.
Skin
In the preauricular and lower temporal region, a generous fat plane is found between the dermis and the
parietotemporalis fascia. More peripherally, over muscle groups and beneath the eyebrows, this fat thins out and
dense fibrous connections between dermis and fascia become more abundant. In these cephalad areas, the
fascia is directly beneath, and sometimes continuous with, the deep layer of dermis. In the upper temporal and
occipital scalp regions, hair follicles extend almost to the fascial levels (Fig. 318.3). Septal connections to the
skin may be thin and attenuated in the elderly.

FIGURE 318.7 A: Ulcerating squamous cell lesions of the hand and forearm. B: After excision of hand lesions,
leaving denuded tendons, exposed periosteum, and dorsal interosseous muscles. C: Four weeks following
excision and coverage with vascularized flap plus skin graft on the hand and skin graft alone on the forearm.
Vascular anastomoses of the axial vessels were performed, using the princeps pollicis artery and one vein as
donor vessels. Postoperatively, the patient had no problems. Active and passive range of motion exercises were
started on the fifth postoperative day. No refinement surgery has been necessary. An extensor lag to the long
finger exists. This could be reconstructed with an extensor tendon graft. (From Brent et al., ref. 5, with
permission.)
FLAP DESIGN AND DIMENSIONS
Only the anticipated amount of fascia should be removed. The risk of injury to the motor nerves anteriorly to
ensure “extra tissue” may not be justified. In adults, a fascia fan measuring 12 to 14 cm in length and 8 to 9 cm in
maximum width is obtained easily. This is sufficient to resurface the dorsal metacarpal region of a hand or small
localized regions on lower extremities. If large extensions of hair-bearing scalp are carried with the flap, the initial
incisions must be modified.
OPERATIVE TECHNIQUE
A rhytidectomy-type incision, with appropriate modification for male and female patients, is made in the
preauricular region, with T extension at the upper border of the temporal fossa (Fig. 318.5). The superficial
temporal artery and vein and the auriculotemporal nerve are first identified within subcutaneous fat in the
pretragal region. Scalp and skin flaps are raised anteriorly and posteriorly. Fat is left on the skin flaps (Fig.
318.3).
As one proceeds distally, the dissection becomes more difficult because the subcutaneous fat plane thins out
and the parietotemporalis fascia, with its septa to skin, is closer to the dermis. Hair follicles should not be
damaged (Fig. 318.6). Meticulous hemostasis, using either bipolar or battery-containing cauteries, facilitates flap
elevation. If the skin flaps are first raised in a retrograde fashion, the fascial layer may remain inadvertently
attached to the scalp flaps. Along the zygoma and in the frontal region, a nerve stimulator is used to localize
vulnerable motor nerves. The auriculotemporal sensory nerve in the pretragal region is sacrificed with the fascial

flap.
After skin elevation, a full-thickness fascial incision is made through the parietotemporalis fascia, which then is
raised in a retrograde fashion. The areolar plane on the underside of the fascia facilitates the dissection. Then
the flap is isolated as a vascular island. Additional pedicle length may be obtained by proximal dissection within
the parotid gland. The flap is ready for transfer (Fig. 318.7).
CLINICAL RESULTS
Most complications—alopecia, VIIth nerve damage, or insufficient tissue—relate to the critical flap elevation
and/or poor preoperative planning. The loss of this tissue does not significantly affect the mobility of parietal
or frontal scalp or skin. Loss of the auriculotemporal sensory nerve has been tolerated well by our patients.
SUMMARY
Among other uses, the free parietotemporalis fascial flap can be used to provide thin cover for the hand.
References
1. Ohmori S. Reconstruction of microtia using the Silastic frame. Clin Plast Surg 1978;5:379.
2. Byrd HS. The use of subcutaneous axial fascial flaps in reconstruction of the hand. Ann Plast Surg
1980;4:191.
3. Brent B. Ear reconstruction. Presented at the Annual Meeting of the American Society of Plastic and
Reconstructive Surgeons, Honolulu, Hawaii, October, 1982.
4. Chang TC. Recent advances in plastic surgery in China. Presented as Plastic Surgery Educational
Foundation Maliniac Lecture at the Annual Meeting of the American Society of Plastic and Reconstructive
Surgeons, Honolulu, Hawaii, October 12, 1982.
5. Brent B, Upton J, Acland RD, et al. Experience with the temporoparietal fascial free flap. Plast Reconstr
Surg 1985;76:177.
6. Smith RA. The free fascial scalp flap. Plast Reconstr Surg 1980;66:204.
7. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area.
Plast Reconstr Surg 1976;58:80.
8. Couly G, Hureau J, Valliant JM. Le fascia superficialis cephalique. Ann Chir Plast 1975;20:171.
9. Eustathianos N. Etude anatomique sur les artères temporales superficielles. Ann Anat Pathol 1932;9:678.
10. Ricbourg B, Mitz V, Lassau JP. Artère temporale superficielle: etude anatomique et déductions pratiques.
Ann Chir Plast 1975;20: 197.

(Trang không có chữ)

Chapter 319
Microvascular Free Transfer of The Lateral Arm Fasciocutaneous
Flap
L. SCHEKER
G. LISTER
The lateral arm flap is especially useful in hand reconstruction, where the thinness, color, and texture of the flap
give not only a good functional result, but also a pleasing cosmetic match.
INDICATIONS
Like any other thin, fasciocutaneous flap, the lateral arm flap can be used for many defects; however, its
use for intraoral reconstruction may be limited by the amount of hair that is often present. It is an excellent
flap for hand reconstruction in both elective and emergency situations, for it is possible to elevate small
areas of skin in almost any orientation. If only a segment of vascularized subcutaneous tissue is required, a
fascial flap alone can be harvested.
Because the lateral arm flap, like the radial and ulnar forearm flaps, has through-flow characteristics (1, 2),
structures distal to the flap can be revascularized with the distal end of the pedicle.
This flap can also be divided transversely so as to cover two defects, for example on the palm and dorsum,
provided only that the intermuscular septum is maintained.
ANATOMY
The profunda brachii artery is the first branch of the brachial artery. After giving origin to some muscular
branches in the medial aspect of the arm, it winds behind the humerus in company with the radial nerve in the
spiral groove. The two terminal branches of the profunda brachii artery, the middle collateral and the radial
collateral arteries, originate here.
The middle collateral is usually larger than the radial collateral. It enters the substance of the long and medial
heads of the triceps, descends along the posterior aspect of the humerus, and disappears deep to the aconeus.
The radial collateral artery, appearing laterally in front of the triceps, divides into two terminal branches, the
anterior radial collateral and the posterior radial collateral artery. The anterior radial collateral runs between
brachialis and brachioradialis accompanying the radial nerve.
The posterior radial collateral artery—the pedicle of the lateral arm flap—enters the lateral intermuscular septum
close to the insertion of the deltoid muscle, between the brachioradialis muscle anteriorly and the triceps muscle
posteriorly. The artery remains in the lateral intermuscular septum close to the humerus, giving off several
periosteal and muscular branches. It continues close to the lateral epicondyle and ends by supplying the skin of
the forearm over the radial head. In its course, the posterior radial collateral artery gives origin to two or three
septal branches that pass to the deep fascia and irrigate the skin. The most proximal of these branches is closely
related to the posterior cutaneous nerve of the forearm.
The venous return of this flap is through two systems, the superficial veins that are tributaries of the cephalic
vein and the deep venae comitantes. Either system is satisfactory as a flap pedicle, but in practice we prefer the
venae comitantes.

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The pedicle is constant and its length varies according to the design of the flap, ranging from 4 to 8 cm. The
caliber of the artery in our practice has always been greater than 1.2 mm and the venae comitantes larger than
2.0 mm.
The posterior cutaneous nerve of the arm innervates this flap. The posterior cutaneous nerve of the forearm runs
through the deep tissues with the posterior radial collateral artery, and has to be sacrificed in most cases.
FIGURE 319.1 A: The dissection of the lateral arm flap has commenced posteriorly. In this clinical photograph,
the dotted marks on the skin at the lower side of the photograph represent the extent of the fascia that was taken
with the flap. The fascia has been dissected sharply off the underlying triceps muscle, which is shown in the
wound. The posterior radial collateral artery can be seen running in the lateral intermuscular septum. The lower
vessel of the two at the bifurcation is the one that can be used for through-flow in replantation or
revascularization. B: The anterior dissection in the same patient shows that fascia has been taken from over the
brachialis muscle at the upper left and the brachioradialis muscle at the upper right. C: The anterior dissection
has been completed, and the flap has been raised by incising the lateral intermuscular septum. The radial nerve
is clearly seen passing anteriorly between the brachialis and brachioradialis muscles, and so out of the field of
dissection. Its accompanying vessel, the anterior radial collateral artery, can be divided to give greater pedicle
length. D: The flap has been raised completely. Note that a pedicle of at least 6 cm can be obtained while still
working in a bloodless field. The sterile tourniquet is seen at the upper left of the photograph. In this photograph
the triceps tendon can be seen running along the lower margin of the wound.
FLAP DESIGN AND DIMENSIONS
The lateral arm flap is based on the posterior radial collateral artery, a terminal branch of the profunda brachii
system. It may be raised purely as a fascial flap, or with bone, or with overlying skin, with or without innervation.
The flap consists of the skin of the distal half of the lateral aspect of the arm and the proximal fifth of the forearm,
centered on a line running from the insertion of the deltoid to the lateral epicondyle, with the extremity extended.
The estimated width of skin that can be harvested with this flap varies from 10 to 14 cm (3, 4, 5, 6), but this large

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donor site defect may prove troublesome. We prefer to restrict the width of the skin flap to 6 cm, facilitating
primary closure of the donor defect. The area of fascia that may be taken, either alone or with skin is, of course,
much larger, to a practical maximum of 20 × 14 cm.
The insertion of the deltoid and the lateral epicondyle is marked with the elbow extended. A dotted line is drawn
between these two structures. The pattern of the primary defect is centered on the dotted line that corresponds
to the lateral intermuscular septum. A sterile tourniquet is positioned as high as possible on the arm and inflated.
OPERATIVE TECHNIQUE
The skin is incised posteriorly and distally first, and the dissection continues until the deep fascia is encountered.
Two additional centimeters of fascia are included in the posterior extent of the flap. The deep fascia is incised
and the dissection is continued in a subfascial plane. Elevation can be facilitated by suturing the fascial and skin
margins together.
At the anterior border of the triceps, the deep fascia turns down toward the humerus, forming the lateral
intermuscular septum. By coagulating the small vessels that enter the triceps, the pedicle can be visualized in its
entire course from the insertion of the deltoid to the lateral epicondyle lying within the septum in its distal two-
thirds (Fig. 319.1A).
The skin is then incised at its anterior border, the deep fascia is again found, and two extra centimeters are
included. Elevation of the deep fascia here requires sharp dissection, as the brachioradialis muscle has fibers
originating from the lateral septum (Fig. 319.1B). Once the vascular pedicle is again seen, the lateral septum can
be elevated from the humerus starting distally. Because the pedicle is seen from both sides, it can readily be
protected during the rest of the dissection.
Care is needed proximally where the pedicle leaves the lateral intermuscular septum. Here the vessel of the flap
arises from the common radial collateral artery. Both this vessel and its anterior branch lie very close to the radial
nerve (Fig. 319.1C). The anterior branch must be divided to give a longer pedicle for the flap (Fig. 319.1D). Up to
a point some 4 cm proximal to the division, the dissection can be done in a bloodless field. If a longer pedicle is
needed, the tourniquet has to be removed. In most cases we stop at this point and, after separating and ligating
the vessels, divide the flap and release the tourniquet.
CLINICAL RESULTS
A longitudinal scar and an area of anesthesia in the posterior aspect of the forearm are the only sequelae of
this flap (Fig. 319.1). Patients have been satisfied with the results when the donor site has been closed
directly. If a larger flap is required, and the donor site cannot be closed primarily, every effort should be
made to cover the lateral epicondyle with subcutaneous tissue, because a split-thickness skin graft over the
epicondyle may produce later problems.
SUMMARY
The lateral arm flap is a fasciocutaneous free flap that can be used, with minimal donor site morbidity, to
cover various hand and forearm defects.
References

1. Song R, Gao Y, Song Y, et al. The forearm flap. Clin Plast Surg 1982;9:21.
2. Scheker L, Lister G. Variations in the use of the radial flap. In: Williams HB, ed., Transactions of the VIII
International Congress of Plastic and Reconstructive Surgery, 1983;725.
3. Song R, Song Y, Yu Y, Song Y. The upper arm free flap. Clin Plast Surg 1982;9:27.
4. Shusterman M, Acland RD, Banis JC, Beppu M. The lateral arm flap: an experimental and clinical study.
In: Williams HB, ed., Transactions of the VIII International Congress of Plastic and Reconstructive Surgery,
1983;725.
5. Katsaros J, Schusterman M, Beppu M, et al. The lateral arm flap: anatomy and clinical applications. Ann
Plast Surg 1984;12:489.
6. Matloub HS, Sanger JR, Godina M. The lateral arm neurosensory flap. In: Williams HB, ed. Transactions
of the VIII International Congress of Plastic and Reconstructive Surgery, 1983;125.

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Chapter 320
Free Deltoid Skin Flap
J. D. FRANKLIN
R. D. GOLDSTEIN
EDITORIAL COMMENT
This is an excellent flap with reliable blood supply, as well as innervation. The limiting factor is that there is
usually a very poor aesthetic result at the donor site.
The neurovascular territory designated for the deltoid flap comprises the skin and subcutaneous tissue over the
deltoid muscle and the posterior superior aspect of the upper arm. This is a fasciocutaneous neurosensory free
flap receiving its blood supply from the cutaneous branch of the posterior circumflex humeral artery, and its
innervation from a branch of the axillary nerve, the upper lateral cutaneous nerve of the arm (1, 2).
INDICATIONS
Among the advantages of this neurovascular free flap is its ability to provide thin, pliable, fasciocutaneous
tissue, with the added provision of sensation. Primary indications would be for those areas where a thin,
fasciocutaneous flap would
be advantageous and for weight-bearing and pressure areas where protective sensation would be of
benefit. Its greatest use has been in head and neck reconstruction, where an excellent color and texture
match is provided, and as a sensory flap on the upper extremity and foot.
ANATOMY
The third portion of the axillary artery that extends from the lower border of the pectoralis minor to the distal
border of the tendon of the teres major gives off the posterior humeral circumflex artery, just distal to the
subscapular artery (3, 4). The posterior humeral circumflex artery runs dorsally with the axillary nerve through the
quadrilateral space (bounded by the subscapularis and teres minor proximally, the teres major distally, the long
head of the triceps medially, and the surgical head of the humerus laterally). The majority of its branches supply
the deltoid muscle.
The artery continues to wind around the neck of the humerus and as it exits the quadrilateral space it
anastomoses with the anterior humeral circumflex and the profunda brachii. Other branches supply the skin and
subcutaneous tissue of the deltoid region and posterior aspect of the arm.
A cutaneous branch of the distal posterior circumflex artery, about 1 mm in diameter at its origin, lies in the
areolar tissue underneath the deltoid, overlying the lateral head of the triceps. This artery, accompanied by two
venae comitantes, and the sensory nerve, emerge from the deltoid-triceps groove, to swing up over the muscle
above the fascia and supply the tissue over the deltoid muscle. Some small branches of the vascular pedicle
also supply the skin beneath the deltoid-triceps groove.
The axillary nerve is derived from the posterior cord off the brachial plexus. It passes through the quadrilateral

space with the posterior humeral circumflex artery and, after giving off motor branches, sends out a cutaneous
branch, the upper lateral cutaneous nerve of the arm. The lateral brachial cutaneous nerve, originating from the
inferior division of the axillary nerve, accompanies the cutaneous artery and veins lateral to the pedicle. This
sensory nerve innervates the skin over the posterior inferior two-thirds of the deltoid muscle and the upper
portion of the triceps, an area ranging from 10 to 15 cm in diameter.
A vessel 2 to 4 mm in diameter is obtained by the division of the posterior circumflex humeral artery proximal to
the origin of the cutaneous artery supplying the flap. The accompanying posterior circumflex humeral vein is 1.5
to 2.0 times the size of the artery. A neurovascular pedicle some 6 to 8 cm may be obtained when elevating this
flap (Figs. 320.1, 320.2, 320.3, 320.4).
FLAP DESIGN AND DIMENSIONS
In designing the deltoid flap, the surgeon must determine the approximate entry of the neurovascular bundle.
This is accomplished by drawing a line from the acromion to the medial epicondyle; another line is drawn over
the deltoid-triceps groove. The pedicle usually emerges from beneath the deltoid muscle at the point of
intersection of the two lines. A more precise entry of the artery may be determined using the Doppler probe.
The flap to be elevated is designed so that the neurovascular bundle, in most instances, enters at one flap end
or edge. The pedicle emerges from beneath the deltoid muscle at a point 2 to 4 cm posterior to the intersection
of the lines along the deltoid-triceps groove. The flap can extend two-thirds or more its length over the deltoid
proximally (can actually go past the deltoid superiorly), and one-third over the triceps distally. It can extend for a
variable length along the axis of the arm. Its distal limit is not exactly known. The neurovascular pedicle can be
anywhere from 6 to 8 cm in length, with a vessel diameter of 2 to 4 mm possible, by taking the posterior
circumflex humeral artery proximal to the origin of the cutaneous artery.
FIGURE 320.1 The usual position of the neurovascular bundle is about 2 to 3 cm posterior to lines intersecting
from the acromion to the olecranon and deltoid triceps groove.

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FIGURE 320.2 Elevation of the deltoid flap showing anatomic landmarks.
FIGURE 320.3 Arrow demonstrates on an angiogram the cutaneous branch of the posterior circumflex humeral
artery.

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FIGURE 320.4 A: Elevation of the deltoid flap. B: Deltoid elevated with the neurovascular bundle lying deep in
the areolar tissue on the triceps muscle. C: Deltoid flap has been elevated and detached.
FIGURE 320.5 Deltoid donor site that is closed, a portion of it primarily and the remainder with a skin graft.
Flaps as large as 15 × 27 cm have been elevated, supplied by the single neurovascular pedicle. The area best
supplied by the artery is that portion over the posterior lateral aspect of the deltoid muscle; however, tissue
overlying the entire deltoid muscle, as well as a portion overlying the triceps and up onto the shoulder almost to
the midline, may be safely elevated.
OPERATIVE TECHNIQUE
After the flap has been outlined, it may be elevated in one of two ways: a dome-shaped incision can be made
around the proposed flap, making no incision over the deltoid triceps groove; or an incision may be made along
the posterior lateral aspect of the flap and over the deltoid-triceps groove.
If a dome-shaped incision is used, the flap is elevated down to and including the fascia. Dissection proceeds
toward the posterior lateral aspect of the deltoid muscle. During this elevation, the surgeon must observe through
the fascia for evidence of the neurovascular pedicle entering the flap. Occasionally, a pseudogroove is
encountered in the deltoid muscle that contains no vessels and may be confused with the deltoid-triceps groove;
this is easily recognized because the muscle fibers above and below the groove run in the same direction (Fig.
320.1).

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FIGURE 320.6 A: Insensate skin graft amputation stump of an elbow. B: Sensate deltoid flap on the elbow
stump.
As soon as the groove between the deltoid and triceps muscles is identified, the neurovascular pedicle can be
approached from a medial or lateral direction. The deltoid muscle is elevated superiorly. With blunt dissection,
the neurovascular bundle, containing one artery, two veins, and the nerve, is easily dissected. On most
occasions this is a single structure; however, in approximately 5% to 10% of cases, the pedicle may divide
prematurely, resulting in two smaller pedicles supplying the flap.
The neurovascular bundle is dissected out in the plane between the deltoid above and the triceps below. The
vessels are easily traced to the larger arteries and veins. Arterial and venous branches to the deltoid muscle are
doubly clamped and transected. The posterior circumflex artery and vein are divided in the quadrilateral space.
While the vessels are still intact, flap viability can be demonstrated by bleeding from the underlying dermis. The
artery measures 2 to 4 mm in this area, with an accompanying single vein of adequate diameter. The sensory
nerve is divided last, since it lies beneath the vessels.
If the deltoid-triceps groove is opened first, the neurovascular pedicle is identified first, and the flap is then
appropriately designed and elevated to meet the particular needs of the reconstruction.
Although the artery can be taken for some distance to its origin from the axillary artery, the nerve pedicle is
limited to its point of origin from the axillary nerve, to prevent the sacrifice of motor supply to the deltoid and the
teres minor. The donor site is closed either primarily or with a skin graft, as required by the dimensions of the
harvested flap.
In men the thinnest flaps are best elevated from the more anterior aspect of the shoulder; the flap tends to be
thicker in women. The donor site is more easily closed primarily when the flap is raised more toward the posterior
lateral aspect of the deltoid muscle and onto the back. An example of a donor site closed with skin graft and
primarily is demonstrated in Figure 320.5.

FIGURE 320.7 A: A 24-year-old woman with a mangled hand. B: The hand reconstructed primarily with a deltoid
flap.
CLINICAL RESULTS
We have had experience with over 40 free deltoid flaps, 20 of which have been used to reconstruct upper
extremity, foot, and ankle defects. Only four flaps have been used in the upper extremity (Figs. 320.6 and
320.7), all of which survived. To date, no functional deficit has been demonstrated, such as denervation of
the deltoid muscle or restriction of activity from skin grafting or the tightness of primary closure.
Complications and compromise have been primarily associated with the recipient vessels and the
extremities, and not with those vessels supplying the flap. On only one occasion has a deltoid flap been
elevated in which no vascular pedicle supplying the area could be demonstrated: the pedicle has indeed
been demonstrated to be consistent; it contains a large vein, artery, and sensory nerve supplying the fascia,
subcutaneous tissue, and skin overlying the deltoid muscle.
The greatest problems with the flap have been in the donor area. Two patients who had donor sites closed
primarily developed a pseudo-bursa that needed to be revised and closed secondarily. If flaps greater than
7 to 9 cm in diameter are used, the defect usually needs to be at least partially closed with a split-thickness
skin graft.
Although the donor site may be hidden by clothing, since it is on the posterior lateral aspect of the arm and
shoulder, the result is less than ideal. Those donor sites that have been closed primarily tend to form fairly
large hypertrophic thickened scars on the shoulder and posterior arm. In selected cases, tissue expanders
to close these sites with less tension should be considered.
SUMMARY
The deltoid flap is a fasciocutaneous neurosensory free flap, supplied by the posterior circumflex humeral
artery and by a nerve from a branch of the axillary nerve. It is especially useful when a thin fasciocutaneous
flap is needed, especially in weight-bearing and pressure areas requiring protective sensibility, and in the
head and neck.
References

1. Serafin D, Voci VE. Reconstruction of the lower extremity: microsurgical composite tissue transplantation.
Clin Plast Surg 1983; 10(1):55.
2. Franklin JD. The deltoid flap: anatomy and clinical applications. In: Buncke HJ, Furnas DW, eds.
Symposium on clinical frontiers in reconstructive microsurgery, Vol. 24. St. Louis: Mosby, 1984;63-70.
3. Goss CM, ed. Gray's anatomy of the human body, 29th Ed. Philadelphia: Lea & Febiger, 1973;454-455,
610-614, 960-968.
4. Grant JCB, ed. An atlas of anatomy, 6th Ed. Baltimore: Williams and Wilkins, 1972; Figs. 14-34.

Chapter 321
Scapular and Para Scapular Flaps
J. BAUDET
T. NASSIF
J. L. BOVET
B. PANCONI
EDITORIAL COMMENT
Dr. Baudet's original description of these flaps has continued to maintain its usefulness and popularity.
Today, these flaps are used for many different applications, as described in several of the following
chapters.
These flaps (1, 2, 3, 4, 5, 6, 7, 8, 9) offer a satisfactory solution for coverage of any skin defect, whether small,
medium, or large, in any part of the body: the head and neck area and especially the face, with a good color
match (see Chapter 142); the upper extremity and especially the hand, thanks to relative thinness; and finally,
the lower extremity, where their use in resurfacing weight-bearing areas proves reliable (see Chapters 573 and
575).
INDICATIONS
The combination of the parascapular flap and latissimus dorsi muscle provides a great potential for
coverage that has been achieved until recently only by tensor fasciae latae flaps (10) or a combination of
latissimus dorsi and groin flaps (11). Inclusion of ribs in the transfer is useful in difficult cases of complex
reconstruction, especially for one-stage reconstruction of the mandible.
These flaps are easily accessible and their dissection only moderately difficult. The vascular system is
constant and the pedicle is long (up to 14 mm) and large (up to 4.5 mm at the origin of the scapular artery).
The intradermal network is rich, the skin hairless, and the flap contains a reasonable amount of
subcutaneous tissue. The operative position (lateral) allows a two-team approach and easy access to any
recipient site. The flaps have no functional morbidity and leave the muscular anatomy of the area
undisturbed. The donor site is closed primarily, even for large flaps, a procedure that works best for
parascapular flaps.
ANATOMY
The circumflex scapular artery, the first major branch of the subscapular artery, emerges at about 4 cm from the
origin of the subscapular artery from the axillary artery (Figs. 321.1 and 321.2). It divides into one infrascapular
branch that runs horizontally toward the subscapularis muscle, and one descending branch that runs backward
and emerges posteriorly from the omotricipital space right at the edge of the lateral border of the scapula (Figs.
321.1 and 321.3).
The descending branch divides into a cutaneous “scapular” artery that runs horizontally over the posterior
aspect of the scapula, and a cutaneous “parascapular” artery that proceeds to the tip of the scapula,

overreaching it (Fig. 321.3). These arteries are almost always accompanied by two venae comitantes of unequal
diameter.
According to surgical requirements, the course of the circumflex scapular artery can be transected at different
levels, allowing us to describe three principal types of procedures: type A with only the descending branch; type
B including the entire circumflex scapular artery; and type C with the scapular artery (Fig. 321.1). According to
the level of artery transection, the diameter of the artery ranges from 1.5 to 4.5 mm and the diameter of the vein
from 2 to 5 mm. In clinical situations that require a long pedicle, it is possible to extend the dissection more
proximally up to the axillary artery.
There is no distinct sensory nerve supply to this area of skin, and it is not possible to include innervated muscle
in the transfer. However, a compound transfer from this area has been successfully performed (2) and included
skin and lateral border of the scapula with a small cuff of infraspinatus, teres minor, and teres major muscles left
attached in order not to injure the vessels.
FLAP DESIGN AND DIMENSIONS
Methods of designing the flap vary according to its orientation, its particular anatomic type, and the personal
preference of the surgeon. A unanimously accepted landmark is the point of emergence of the pedicle from the
omotricipital space and the lateral edge of the scapula. This space, limited by the teres minor above, teres major
below, and long head of the triceps laterally, is felt as a depressed area with finger palpation. Otherwise, the
following procedure may be used for measurement. The omotricipital triangle is usually located at distance D1
from the middle part of the spine of the scapula, given by the formula D1 = (D − 1)/2, where D is the distance
between the middle part of the spine and the tip of the scapula (Fig. 321.4).
FIGURE 321.1 Schematic diagram of the thoracodorsal and circumflex scapular arteries and the nutrient pedicle
of the scapular and parascapular flaps (in the frame).
Then the main axis of the flap is outlined either horizontally (scapular flap) or vertically (parascapular flap). For a
scapular flap, the main axis is located midway between the spine of the scapula and its inferior angle. Some
authors (7) have proposed the “rule of twos,” i.e., medial border 2 cm lateral from the spinous process, lateral
border 2 cm superior to the posterior axillary crease, upper border 2 cm inferior to the spine of the scapula, and
inferior border 2 cm superior to the inferior edge of the scapula. In fact, this rule is an approximate guideline for
outlining a horizontal elliptical flap consistent with direct skin closure (maximum width about 10 cm).

FIGURE 321.2 Cadaver dissection showing the axillary artery (AX) giving origin to the subscapular artery (SUB),
the thoracodorsal artery (TH), and finally the circumflex scapular artery (CI) with its descending branch (D.CI).
FIGURE 321.3 Dorsal aspect of the scapular area showing the relationships of the circumflex scapular artery
with the muscles delimiting the omotricipital triangle and its dividing branches (horizontal and vertical ones, the
last supplying the parascapular flap).
The rich vascular anastomotic network of the area and the two dividing branches of the circumflex scapular
artery allow flaps of almost any shape and size to be designed, providing that they remain located over the lower
two-thirds of the scapula.
FIGURE 321.4 Determination of the emergence of the pedicle by the distance D1 and D and outlining of the
parascapular flap on the cutaneous parascapular artery.

For parascapular flaps that are larger in size, allow easier wound closure, and leave less conspicuous scarring,
the upper edge of the flap is outlined at the same level as the emergence of the pedicle, the lower edge as far as
25 to 30 cm from the upper edge. The main axis is constituted by the lateral border of the scapula. The width of
this flap that proved consistent with direct closure of the donor defect is about 15 cm (minimal width 6 cm,
maximum width 20 cm, in our experience) (Fig. 321.5).
FIGURE 321.5 Representation of the main types of cutaneous flaps from the scapular area: scapular flap,
parascapular flap, combination of both in an inverted L-shape, or the whole area.
COMBINED FLAPS
According to the vascular pattern of the donor area, with two main dividing branches of the circumflex scapular
artery and a rich anastomotic network, it is possible to design a large-sized flap extending over the scapular and
parascapular zones or, in some instances, to outline an L-shaped flap centered over the two main vascular axes
(Fig. 321.5). Either cutaneous flap (scapular or parascapular) can be combined with a latissimus dorsi flap (1,
12), muscular or musculocutaneous. Or only one flap can be combined, preferably the parascapular, for easier
closure of the donor defect.
One or several ribs can be included in the transfer. Such a transfer is revascularized through a single arterial or
venous anastomosis at the origin of the subscapular artery.
Several possibilities for transfer exist. First, the cutaneous parascapular flap and the latissimus dorsi can be
transferred in a unibloc fashion (Fig. 321.6). This flap is divided into three adjacent cutaneous territories with
discrete blood supplies: proximally, the vascularization depends on scapular and parascapular vessels; medially,
on the parascapular vessels and the perforating branches of the thoracodorsal vessels; and distally, solely on
the thoracodorsal vessels (Fig. 321.7). Second, for even greater versatility, a side-by-side transfer can be
considered (latissimus dorsi muscle and scapular or parascapular flap) (Fig. 321.8).
OPERATIVE TECHNIQUE
The patient is placed in a prone position or, sometimes even better, in a lateral decubitus position, the arm
abducted at 90° for better access to the axilla for the dissection of the extended pedicle. A lateral position is more
convenient for procedures in the head and neck area, anterolateral aspect of the lower extremity (ipsilateral
donor site), and anterior and anterolateral aspect of the upper extremity (contralateral donor site). The prone
position is preferable for exposure and transfer to the posterior aspect of the trunk, upper, and lower extremities.
The first step in any dissection of a scapular or parascapular flap is identifying the pedicle in the omotricipital
triangle. An incision is made, following the upper lateral portion of the elliptical flap outline and allowing adequate
exposure of the posterior aspect of the deltoid muscle that is retracted superiorly. The inferior border of the teres

minor is then visualized limiting the upper border of the omotricipital triangle, where the pedicle of the circumflex
scapular artery is identified and dissected deeply between the muscles. To free the pedicle, the infrascapular
branch of the circumflex scapular artery is ligated, as well as other numerous collateral minor muscular vessels.
In this way a pedicle from 5 to 7 cm is obtained (Fig. 321.9). If a longer pedicle is required, the incision must be
extended horizontally across the axilla in an S-shaped prolongation that allows control and further dissection of
the pedicle. At this point the thoracodorsal artery is seen and care should be taken not to damage the nerves to
the teres major, latissimus dorsi, and serratus anterior muscles. Then further incision is carried out around the
whole flap, starting distally and proceeding toward the pedicle in an avascular plane between the subcutaneous
tissue and the muscular aponeurosis. The flap is then totally freed and ready for transfer (Figs. 321.10 and
321.11).
FIGURE 321.6 Cadaver dissection of a combined unibloc transfer of parascapular flap and latissimus dorsi
muscle. Note the single pedicle (subscapular artery) supplying the whole transfer.
FIGURE 321.7 A unibloc transfer (parascapular flap and latissimus dorsi muscle) with three different skin
territories (A, B, C) under different blood supplies. A, circumflex scapular artery; B, circumflex scapular artery and
thoracodorsal arteries; C, thoracodorsal artery alone.

FIGURE 321.8 A combined “side-by-side” parascapular flap and latissimus dorsi muscle, allowing potential for
large coverage. Ribs can be inserted in the transfer for complex reconstructions.
CLINICAL RESULTS
Resultant scarring is rather conspicuous and has some tendency to spread, especially with the use of the
scapular flap. These cosmetic sequelae might limit its use in women, in whom an alternative flap such as
the groin flap might be considered. The only contraindication to the use of a combined flap is a preoperative
finding that the circumflex scapular artery originates independently from the axillary artery, a situation that
occurs in 4% of cases (13).
FIGURE 321.9 Intraoperative view of a small parascapular flap isolated on its pedicle.

FIGURE 321.10 A: Severe web space contracture. B: Outlining of a 14 × 6-cm parascapular flap. C:
Intraoperative view of the transfer. D: Excellent functional and cosmetic result.
SUMMARY
The scapular and parascapular flaps depend on direct cutaneous arteries, horizontal or vertical branches of
the circumflex scapular artery. These flaps fulfill most of the requirements for a free flap transfer: full
reliability, adequate thickness, potential for extensive coverage, no functional morbidity at the donor site,
and acceptable cosmetic results in males. Including latissimi dorsi muscle and ribs in the transfer, with
several anatomic possibilities, provides even greater versatility.

FIGURE 321.11 A: Extensive skin loss of the anterior aspect of the forearm, with tendon exposure and
fractures of radius and ulna treated by an external fixator. B: Outlining of a large parascapular flap (25 × 15
cm), with primary closure of the donor site. C: Late postoperative result, with recovery of satisfactory flexion
of fingers. D: Acceptable scar at the donor site.
References
1. Baudet J, Guimberteau JC, Nascimento E. Successful clinical transfer of two free thoraco-dorsal axillary
flaps. Plast Reconstr Surg 1976;58:680.
2. Teot L, Bosse JP, Moufarrege R, et al. The scapular crest pedicled bone graft. Int J Microsurg
1981;3:257.
3. Hamilton SGL, Morrison WA. The scapular free flap. Br J Plast Surg 1982;35:2.
4. Mayou BJ, Whitby D, Jones BM. The scapular flap: an anatomical and clinical study. Br J Plast Surg
1982;35:8.

5. Nassif TM, Vidal L, Bovet JL, Baudet J. The parascapular flap: a new cutaneous microsurgical free flap.
Plast Reconstr Surg 1982;69:591.
6. Gilbert A, Teot L. The free scapular flap. Plast Reconstr Surg 1982; 69:601.
7. Urbaniak JR, Koman LA, Goldner RD, et al. The vascularized cutaneous scapular flap. Plast Reconstr
Surg 1982;69:772.
8. Barwick WJ, Goodkind DJ, Serafin D. The free scapular flap. Plast Reconstr Surg 1982;69:779.
9. dos Santos LF. Retallro escapular: um novo retallro livre microcirurgico. Rev Bras Cir 1980;70:133.
10. Hill HL, Nahai F, Vasconez LO. The tensor fascia lata myocutaneous free flap. Plast Reconstr Surg
1978;61:517.
11. Harii K. Personal communication to authors at the Course in Microvascular and Peripheral
Microneurosurgery. New York, October 5-9, 1980.
12. Maxwell GP, Stueber K, Hoopes JE. A free latissimus dorsi myocutaneous flap: case report. Plast
Reconstr Surg 1978;62:462.
13. Bartlett SP, May JW Jr, Yaremchuk MJ. The latissimus dorsi muscle: a fresh cadaver study of the primary
neurovascular pedicle. Plast Reconstr Surg 1981;67:631.

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Chapter 322
Medial Upper Arm Fasciocutaneous Flap for Palmar Defects of
The Hand and Distal Forearm
S. BHATTACHARYA
S. P. BHAGIA
S. K. BHATNAGAR
S. D. PANDEY
R. CHANDRA
EDITORIAL COMMENT
The skin of the medial upper arm can be used, based on any one of the intermuscular branches from the
brachial artery. It is most useful if it is based on the most proximal intermuscular branch, in which case the
flap can be outlined with greater length.
The medial upper arm fasciocutaneous flap, based either distally or proximally, appears to be a solution for large
cutaneous defects on the palmar aspect of the hand and distal forearm, especially in acute injuries where other
alternatives are not possible. This flap protects and preserves functional nerves and tendons, and is uniformly
dependable and cosmetically acceptable.
INDICATIONS
Palmar defects of the hand and distal forearm, often seen in accident victims, are best covered by split-
thickness skin grafts. However, if the recipient area contains tendons without paratenon or exposed bones
without periosteum, or if future bone or tendon surgery is contemplated, full-thickness skin coverage is
required. Traditional flaps used to cover the dorsum of the hand (1, 2, 3, 4, 5) necessitate a painful and
poorly tolerated supination of the recipient arm. The medial surface of the contralateral upper arm remains a
site from which a flap will allow the recipient arm to lie comfortably in a midprone position across the chest,
leaving the elbow and forearm of the donor limb relatively free (6).
ANATOMY
The flap is a type B fasciocutaneous flap (7) centered along the medial intermuscular septum, which lies
between the biceps muscle anteriorly and the triceps muscle posteriorly. According to early cadaveric studies (8),
three fasciocutaneous perforators originating in the medial intermuscular septum can be used as the basis for
this flap: (1) One of the bicipital arteries gives off a fasciocutaneous perforator lateral to the brachial artery
(unnamed, but frequent and large). (2) Infrequent fasciocutaneous perforators go directly from the axillary or
brachial artery. (3) There is a not infrequent fasciocutaneous branch of the superior ulnar collateral artery medial
to the brachial artery.

FIGURE 322.1 Anatomic dissection of the medial upper arm showing the medial intermuscular septum (sp) into
which the superior ulnar collateral artery (S) enters. This arises from the brachial artery (B), which, along with the
median nerve (M), runs lateral to the intermuscular septum. The ulnar nerve (U) is seen running medial to the
septum. (From Bhattacharya et al., ref. 6, with permission.)
The fasciocutaneous branch of the superior ulnar collateral artery has been reported further (9, 10). This artery
is marked arising from the brachial artery at the middle of the upper arm, where it is accompanied by the ulnar
nerve. It pierces the medial intermuscular system to course on its posterior surface, and then descends between
the medial epicondyle and olecranon. Keeping this artery along a central axis, a fasciocutaneous flap with a
length-to-width ratio of 3:1 can be safely raised.
The medial intermuscular septum is quite thick, tough, and cord-like. The brachial artery and median nerve
closely follow the course of the septum anteriorly, while the ulnar nerve does so posteriorly. These structures are
identified and preserved while harvesting the flap (Fig. 322.1).
FLAP DESIGN AND DIMENSIONS
The course of the brachial artery is marked on the skin; it can be palpated in the axilla. From there, it courses
along the anterior surface of the medial intermuscular septum, covered by the coracobrachialis and biceps
muscles, and then takes a slightly spiral course, to appear at the elbow midway between the humeral
epicondyles. The superior ulnar collateral artery is marked arising from the middle of the upper arm and coursing
between the biceps anteriorly and triceps posteriorly, toward the midpoint between the medial epicondyle and
olecranon. Keeping this artery as the axis, both proximally and distally based flaps can be fashioned (Fig. 322.2A
and B).
The proximally based flap should have its base designed as high as the insertion of the pectoralis major, but
extension beyond this, although possible, should be avoided. The apex of this flap can descend to the level of
the elbow. The flap can be extended anteriorly and posteriorly to the midanterior and midposterior lines of the
upper arm. The superior limit of the retrograde flap is at the level of the origin of the superior ulnar collateral
artery; its base is slightly above the level of the medial epicondyle. Anterior and posterior limits remain the same.

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FIGURE 322.2 Flap design. A: Surface markings of proximally based medial upper arm fasciocutaneous flap. B:
Surface markings of distally based medial upper arm fasciocutaneous flap.
OPERATIVE TECHNIQUE
The anterior incision is made first, and the deep fascia is divided 0.5 cm from the skin and sutured to the skin
with 3-0 catgut. The flap is raised at the subfasical level until the medial intermuscular septum is reached. The
brachial artery and median nerve are identified as they run close to the septum, and these structures are gently
dissected off the septum (Fig. 322.3). The posterior incision is now made, and the fascia over the triceps (which
is thicker than that over the biceps) is incised 0.5 cm from the skin and sutured to the skin with catgut. The flap is
now elevated at the subfascial level until the ulnar nerve is identified running close to the medial intermuscular
septum. The nerve is separated from the septum, and the two incisions, anterior and posterior, are joined in an
arc.
The flap is elevated both anteriorly and posteriorly, and the media intermuscular septum (now resembling a thick,
cord-like structure) is divided along with multiple perforators, as close to the bone as possible, to preserve the
anastomosis between the perforators (Fig. 322.4). Flap elevation takes about 30 minutes.
The donor site can be closed primarily with wide undermining up to the lateral intermuscular septum anteriorly,
and posteriorly with lateral fasciotomies. The process of flap elevation and donor-site closure may cause edema
in the distal arm. When a relatively wide flap has been harvested, the donor area
can be reduced in size and a split-thickness skin graft can be utilized.

FIGURE 322.3 The superior ulnar collateral artery (S) is seen entering the flap from the brachial artery (B). The
median (M) and ulnar (U) nerves are also seen.
CLINICAL RESULTS
Ten patients with palmar defects on the distal forearm, hand, and fingers were treated with the medial upper
arm fasciocutaneous flap. Two retrograde and eight antegrade type B flaps were used. Of the latter eight,
five were based on the main trunk of the superior ulnar collateral artery, and three on its main cutaneous
branch. The donor area in four patients was closed primarily after wide undermining and internal
fasciotomy. In the remaining six patients, the donor defect was reduced in size and a split-thickness skin
graft was applied. Immobilization was achieved with Elastoplast strapping, so that the elbow of the donor
arm could be kept free for use, and the flap could be observed with the patient raising both arms above the
head (Figs. 322.5 and 322.6). The flap pedicle was divided by a selective delay (palpating the medial
intermuscular septum and its vessel) 21 days after flap transfer, and flap division was done 5 to 7 days after
the delay.
FIGURE 322.4 The flap has been elevated by dividing the medial intermuscular septum close to the bone
(Aa, Bb, Cc), in order to incorporate the superior ulnar collateral artery.
FIGURE 322.5 Proximally based medial upper arm flap used to cover a palmar defect on the distal forearm,

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postexcision of a desmoid tumor. Note comfortable position for case management.
All flaps survived completely with no evidence of necrosis, infection, or hematoma formation. The donor arm
developed edema in three patients, in two of whom the donor area had been closed primarily. This was
managed by Elastoplast strapping, limb elevation, and physiotherapy for 3 to 4 days. One patient showed
evidence of ulnar-nerve paresis, which subsided within 1 week. The donor area in all patients was
cosmetically satisfactory and well concealed. All patients returned to their original work.
The flap provides an excellent color match for the forearm, but not for the palm. It is usually nonhirsute, but
in one patient hair growing in the palm proved embarrassing.
SUMMARY
The medial upper arm fasciocutaneous flap has a clinical place in the management of palmar defects.
However, the flap is used by necessity, rather than by election, for those defects that cannot support free
skin grafting.
FIGURE 322.6 Distally based medial upper arm flap used to cover a palmar defect on the ulnar two fingers
of the contralateral hand, following release of severe postburn contracture.
References
1. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg 1972;25:3.
2. Stranc MF, Sanders R. Abdominal wall skin flaps. In: Grabb WC, Myers BM, eds. Skin flaps. Boston: Little,
Brown, 1968;419-426.
3. Dias AD, Thatte RL, Patil UA, et al. The use of the SEPA flap in the repair of defects in the hands and
fingers. Br J Plast Surg 1987;40:340.
4. Chandra R, Kumar P, Abdi SHM. The subaxillary pedicled flap. Br J Plast Surg 1988;42:169.
5. Bhattacharya S, Pandey SD, Chandra R, Bhatnagar SK. Lateral chest wall fasciocutaneous flaps in the
management of burn contractures on the dorsum of the hand. Eur J Plast Surg 1988;11:8.
6. Bhattacharya S, Bhagia SP, Bhatnagar SK, et al. The medial upper arm fasciocutaneous flap. J Hand

Surg 1991;16B:342.
7. Cormack GC, Lamberty BGH. A classification of fasciocutaneous flaps according to their patterns of
vascularization. Br J Plast Surg 1984; 37:80.
8. Song RY, Song YG, Yu YS, Song YL. The upper arm free flap. Clin Plast Surg 1982;9:27.
9. Cormack GC, Lamberty BGH. Fasciocutaneous vessels in the upper arm: application to the design of new
fasciocutaneous flaps. Plast Reconstr Surg 1984;74:244.
10. Kaplan EN, Pearl RM. An arterial medial arm flap: vascular anatomy and clinical applications. Ann Plast
Surg 1980;4:205.

Chapter 323
Ulnar Artery Free Flap
D. R. H. CHRISTIE
G. M. DUNCAN
D. W. GLASSON
EDITORIAL COMMENT
This is, in essence, a flap similar to the radial artery forearm flap but based on the ulnar artery. It gives the
surgeon a wider latitude in choice; otherwise, there is no serious difference in advantages between the two.
The ulnar artery free flap is described for situations in which small to medium amounts of composite tissue are
required. This flap is best suited for reconstruction after cancer surgery in the head and neck, especially for oral
cancers. It is also an appropriate method of repair of distal limb defects, usually in the ankle, foot, wrist, and
hand.
INDICATIONS
Radial and ulnar artery flaps share some important advantages (1, 2, 3, 4, 5, 6). Both are relatively thin
fasciocutaneous flaps that may include skin, muscle, bone, and tendons for the reconstruction of small to
medium-sized tissue defects. Both have sensory potential. In each flap, the large-caliber vessels and long
vascular pedicles allow easy inset and anastomosis. The arterial architecture permits flow through,
maintaining circulation distal to the flap. The remote donor site enables two surgical teams to work
simultaneously, reducing operating time.
The flaps share some significant disadvantages. Fracture of the donor bone is common to both, the risk
being similar for the radius and the ulna (7). In our experience, all patients in whom bone is harvested have
been immobilized in an above-elbow cast for 6 weeks. The risk of encountering abnormal vascular anatomy
is also common to both flaps. Both the radial and ulnar arteries demonstrate anatomic variations in a small
percentage of patients. These may render the arm unsuitable for a safe raising of the flap. However, the
presence of a superficial ulnar artery has not been a contraindication to using an ulnar artery free flap and
may, in fact, facilitate the raising of this flap.
The ulnar artery free flap confers three important additional advantages. The first of these is ease of donor-
site healing and repair. Considerable difficulty has been encountered with repair of the radial donor site;
indeed, a method of repairing that donor defect using an ulnar flap has been proposed (8). The ulnar donor
site is easily repaired, often by primary closure, and donor-site healing is usually rapid. No long-term
complaints or objective disabilities have been noted.
The second advantage is cosmetic acceptability. The scar from the ulnar donor site lies more proximally
along the ulnar border, and is therefore less obvious during normal daily activity.
The third advantage, relative hairlessness, is important for those undergoing intraoral reconstruction. Hair
on the intraoral surface can be irritating and is difficult to remove. The relative hairlessness of the ulnar side
of the forearm makes this site preferable for intraoral reconstruction, particularly in Caucasians, who
commonly have hair along the radial side of the forearm.

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ANATOMY AND FLAP DESIGN
The flap is based on the ulnar artery distal to the common interosseous branch. Vascular pedicles pass from the
artery to adjacent muscles and to the skin of the ulnar border of the
forearm, running in the fascial septum between the flexor carpi ulnaris and the flexor digitorum superficialis. Small
nutrient vessels also pass directly to the ulnar nerve. The fascia of the flap is continuous with the periosteum of
the subcutaneous border of the ulna (Fig. 323.1).
FIGURE 323.1 Diagram showing vascular pedicles passing from the ulnar artery to the adjacent muscles and
skin. (From Glasson et al., ref. 3, with permission.)
Dual venous drainage is provided by the superficial forearm veins, usually the basilic and the venae comitantes.
The medial cutaneous nerve of the forearm may be taken with the flap, if sensory reconstruction is planned.
The skin island is designed on the ulnar palmar aspect of the forearm. There is a reasonable degree of freedom,
providing that fascial continuity is maintained with the septum between the flexor carpi ulnaris and the flexor
digitorum superficialis.
The final position of the flap is often determined by the pattern of the superficial veins. Any minor adjustment to
the skin island can be made after the radial side of the flap is elevated and the position of the septal pedicles is
determined. This adjustment may be reassuring, if a very small flap is used.
OPERATIVE TECHNIQUE
An Allen's test is performed prior to surgery. The operation is begun distal to the flap, where the ulnar artery and
vein are identified. Depending on flap design, the artery may be dissected as far as the wrist. This will allow
sufficient distal arterial length for revascularization by reverse flow. The incision is continued proximally along the
radial border of the flap, which is easily separated from the underlying belly of the flexor digitorum superficialis.
This plane is developed, with radial retraction of the flexor digitorum superficialis, allowing clear identification of
the ulnar nerve, the ulnar artery, and the vascular pedicles (usually, two or more) passing from it (Fig. 323.2).
Should the planning of the flap not coincide with the position of the pedicles, the ulnar side margin can be
altered.
The ulnar margin is then incised, and the flap is raised subfascially from the flexor carpi ulnaris. The draining
superficial vein is dissected, and an extended length can be taken by continuing this dissection above the elbow,
if required. The medial cutaneous nerve of the forearm accompanying the basilic vein, is easily identified.
The ulnar artery is divided distally, and the flap is dissected free from the ulnar nerve, coagulating or clipping
pedicles to other destinations (nerve or muscles).
The palmaris longus may be included in the flap, as may the flexor carpi ulnaris, depending on reconstructive
requirements (e.g., extensor tendon reconstruction, muscle to fill a bony cavity, or provision of bulk in the floor of
the mouth).

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FIGURE 323.2 Initial incision exposing major vessels and nerves. (From Christie et al., ref. 4, with permission.)
To include a length of hemiulna, a fascial extension is designed in continuity with the bone segment. This can be
done by including a large component of the flexor carpi ulnaris, or by dissecting a thin superficial lamina of
muscle that is attached to bone. In female nondominant arms, this attachment to the ulna can be flimsy. Limited
subperiosteal stripping of extensor compartment muscles allows a clear view for longitudinal osteotomy and
preserves the fascioperiosteal attachment on the palmar aspect of the bone. The bone is thin in the middle and
distal portions, and care must be taken to preserve adequate metaphysis. Bone segments of 16 cm are not
difficult to harvest.
The surgeon must always be aware of the possible need to reconstruct the ulnar artery; however, this is not
routinely required (no cases in our series). The donor sites of smaller flaps may be closed directly. Where
primary closure is not possible, a skin graft is applied to the exposed muscle bellies. Tendons are usually not
exposed by the forearm defect. If the flexor carpi ulnaris has been included in the flap, exposing the ulnar nerve,
the flexor digitorum superficialis should be sutured over the nerve, to prevent the skin graft from being applied
directly to it. If bone has been taken, the arm is immobilized in an above-elbow cast for 6 weeks.
CLINICAL RESULTS
All 56 patients treated by the authors were analyzed by retrospective review of the medical records (4). The
presenting diagnoses fell into two major categories: neoplasia of the head and neck, usually in the mouth,
and trauma, in most cases resulting from motor-vehicle accidents involving tissue loss in the lower limbs.
The flap included bone in 21 patients, all of whom had oral cancers.
Direct closure of the donor site was used in 25 patients (45%), with the remaining 31 requiring split-
thickness skin grafts applied over exposed muscle bellies; no graft failures occurred. Two significant
problems were identified regarding donor-site morbidity. Transient paresthesias of the ulnar nerve occurred
in 18 patients (32%), but were always mild and resolved completely within 2 weeks. In 21 patients, bone
had been included in the flap, and 6 patients (29%) sustained fractures in the remaining length of hemiulna.
One fracture occurred intraoperatively and was fixed internally. Five fractures occurred postoperatively and
were managed conservatively. No deformity was evident following any of the fractures, and none of the
complications affected the long-term outcome in any of the cases reviewed.
Of the 56 cases, two were abandoned intraoperatively, and two failed following transfer. In two patients, an
abnormal vascular pattern was noted during raising of the flap. No perforators from the ulnar artery to the
skin could be identified in the fascia, and the skin circulation was noted to be severely compromised prior to
flap separation. The procedure was abandoned, and the flap was reset. In one patient, 50% of the flap
subsequently necrosed. In the two other patients, the flap necrosed within 48 hours following venous
congestion. Both of these cases were early in our series and involved grade IV lower-limb trauma. Limited

proximal vascular resection was carried out, and anastomoses were performed within the area of tissue
damage. Salvage was not attempted. Both failures were attributed to lack of experience.
SUMMARY
The ulnar artery free flap is highly versatile and reliable in the reconstruction of a variety of defects, where
small to medium amounts of composite tissue are required. The main indication has been intraoral
reconstruction after ablative cancer surgery. The flap has also been used to repair other head and neck
defects and soft-tissue defects of the lower limb.
References
1. Song R, Gao Y, Song Y, et al. The forearm flap. Clin Plast Surg 1982;9:21.
2. Lovie MJ, Duncan GM, Glasson DW. The ulnar artery forearm free flap. Br J Plast Surg 1984;37:486.
3. Glasson DW, Lovie MJ, Duncan GM. The ulnar forearm free flap in penile reconstruction. Aust N Z J Surg
1986;56:477.
4. Christie DRH, Duncan GM, Glasson DW. The ulnar artery free flap: the first seven years. Plast Reconstr
Surg 1994;93:547.
5. Glasson DW, Lovie MJ. The ulnar island flap in hand and forearm reconstruction. Br J Plast Surg
1988;41:349.
6. Soutar DS, McGregor A. The radial forearm flap in intraoral reconstruction: the experience of 60
consecutive cases. Plast Reconstr Surg 1986;78:1.
7. Boorman JG, Brown JA, Sykes PJ. Morbidity in the forearm flap donor arm. Br J Plast Surg 1987;40:207.
8. Elliot D, Bardsley AF, Batchelor AG, Soutar DS. Direct closure of the radial forearm flap donor defect. Br J
Plast Surg 1988;41:358.