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

2. Reisman N, Dellon AL. The abductor digiti minimi muscle flap: a salvage technique for palmar wrist pain.
Plast Reconstr Surg 1983;72:859.
3. McGregor IA. Flap reconstruction in hand surgery: the evolution of presently used methods. J Hand Surg
1979;4:1.
4. Mackinnon SE, Weiland AJ, Godina M. Immediate forearm reconstruction with a functional latissimus dorsi
island pedicle myocutaneous flap. Plast Reconstr Surg 1983;71:706.
5. Wray CR, Wise DM, Young VI. The groin flap in severe hand injuries. Ann Plast Surg 1982;9:459.
6. Dellon AL, Mackinnon SE, Pestronk A. Implantation of sensory nerve into muscle: preliminary clinical and
experimental observations on neuroma formation. Ann Plast Surg 1984;12:30.
7. Mackinnon SE, Dellon AL, Hunter D, Hudson A. Alteration of neuroma formation produced by manipulation
of neural environment in primates. Presented at the Annual Meeting of the American Society of Plastic and
Reconstructive Surgery, Dallas, TX, 1983.
8. Dellon AL, Mackinnon SE. Terminal branch of anterior interosseous nerve as source of wrist pain. J Hand
Surg 1984;9B:316.
9. Lister GD. Personal communication, 1983.

Chapter 299
Radial Forearm Fascial Flap
P. H. GROSSMAN
A. M. MAJIDIAN
M. BRONES
M. YOUNG
A. R. GROSSMAN
EDITORIAL COMMENT
This is an extremely useful flap in that the overlying skin is left intact, and the donor defect is almost
imperceptible, except for the straight line scar closure. This is a useful covering flap for any area that is left
bare from surgery or trauma. It requires cover over the top of the flap, but this can be anything from a split-
thickness skin graft to a local flap, such as a scalp flap. The flap may be accomplished with perforators
alone, if the radial artery cannot be sacrificed.
The radial forearm flap is a workhorse for coverage of soft-tissue defects of the hand, when distally based; it can
be based proximally to cover defects in the elbow region. A disadvantage of the fasciocutaneous flap is the
aesthetically displeasing donor site. The radial forearm fascial flap, without inclusion of overlying skin, avoids
donor-site morbidity and provides a pliable and thin coverage for the recipient defect (1, 2, 3, 4).
INDICATIONS
The radial forearm fascial flap is ideally suited for reconstruction of soft-tissue defects of the hand, when
thin, pliable coverage is needed and long periods of immobilization are contraindicated. The flap is thin
enough to have proven very satisfactory for resurfacing the thumb. A complete palmar arch with good
retrograde flow into the radial artery is a prerequisite for the distally based flap. If necessary, bone and
tendon repairs may be performed at the same sitting.
The proximally based flap can be used for coverage of exposed bone or tendon in the elbow territory. Both
radial and ulnar arteries must be patent, and the hand must be well perfused by the ulnar artery alone.
ANATOMY
The radial artery and its accompanying veins lie deep within the volar forearm between the flexor carpi radialis
and the brachioradialis. The vessels run within the lateral intermuscular septum, which is continuous with the
investing fascia of the forearm musculature. Venous drainage of the fascial flap is entirely via the venae
comitantes.
FLAP DESIGN AND DIMENSIONS
The flap is designed over the volar aspect of the forearm and, if necessary, may extend over the radial and ulnar
aspects of the forearm. In general, it is prudent to avoid the radial edge of the forearm, when possible, to
minimize injury to the radial cutaneous nerve branches. The flap may be easily and reliably elevated; the distal
forearm need not be avoided, as with

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the fasciocutaneous flap, since the underlying tendons will not require skin grafting (Figs. 299.1 and 299.2).
FIGURE 299.1 Diagram illustrating distally based radial forearm fascial flap for coverage of hands and digits.
OPERATIVE TECHNIQUE
When planning a proximally based flap, a preoperative Allen's test is performed to establish patency in both
arteries, and to ensure good perfusion of the hand by the ulnar artery alone. For a distally based flap, a safe and
easy method of ensuring a complete arch and adequate retrograde flow through the radial artery is the following:
With a Doppler flowmeter, the radial artery is located at the wrist. Next, the radial artery is occluded proximal to
the probe, and the ulnar artery is occluded at the wrist. There should then be no Doppler signal distal to the
occlusion. The ulnar artery occlusion is released, and a signal should then be heard over the radial artery, just
distal to the point of continued radial- artery occlusion. If there is no signal, reevaluation of the surgical options
may be indicated.
The skin incision may be straight, curvilinear, or zigzag. The skin flaps are elevated, with care taken to leave
some subcutaneous tissue on the underlying fascia investing the superficial musculotendinous layer of the
forearm. The fascia is sharply incised in the shape and with the dimensions desired for the particular defect. The
fascia is then elevated directly off the underlying muscles from the radial and ulnar directions, until the
osseocutaneous septum is reached. Here, the radial artery and its accompanying veins run between the flexor
carpi radialis and the brachioradialis. Sensory nerves are spared whenever possible.
The vessels are ligated and appropriately divided (distally for elbow coverage, proximally for hand coverage),
and elevated along with the overlying fascia and subcutaneous tissue. For the distally based flap in particular, it
is important to avoid skeletonizing the venae comitantes, as bridging vessels within the surrounding cuff of tissue
contribute to retrograde venous flow (5).

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FIGURE 299.2 Diagram illustrating proximally based flap for coverage of elbow.
The flap is skin-grafted after insetting. The donor site is closed directly (Figs. 299.3 and 299.4).
CLINICAL RESULTS
This flap has proved clinically reliable and useful for coverage of upper-extremity defects, as described. The
most serious complications of hand ischemia or flap loss can be avoided entirely by careful preoperative
evaluation of the arterial supply and appropriate dissection of the flap vessels. Inclusion of a thin layer of
subcutaneous tissue with the fascia adds some padding—especially important for the elbow—and provides
a good bed for skin-graft application. Injury to significant segments of the radial sensory nerve may lead to
neuroma or dysesthesia.
SUMMARY
The radial forearm fascial flap can be used with minimal donor defect for upper-extremity defects, when thin
tissue is desirable. The flap is reliable and can be elevated relatively rapidly, avoiding the need for
microvascular anastomoses. The flap is versatile enough to be used as a free flap, as well (6, 7).

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FIGURE 299.3 Case 1. A: Patient with defect on dorsal aspect of hand with exposed tendon. B: Distally
based fascial flap elevated with radial artery and accompanying veins. C: Flap inset on dorsal aspect of
hand. D-F: Early postoperative views.
FIGURE 299.4 Case 2. A: Insetting of flap for coverage of elbow defect. B: Late postoperative view.
References

1. Jin Y, Guan W, Shi T, et al. Reversed island forearm fascial flap in hand surgery. Ann Plast Surg
1985;15:340.
2. Reyes FA, Burkhalter WE. The fascial radial arm flap. J Hand Surg 1988; 13A:432.
3. Cheruup LL, Zachary LS, Gottlieb II, Petti CA. The radial forearm skin graft-fascial flap. Plast Reconstr
Surg 1990;85:898.
4. Weinzweig N, Chen L, Chen Z. The distally based radial forearm fasciosubcutaneous flap with
preservation of the radial artery: an anatomic and clinical approach. Plast Reconstr Surg 1994;94:675.
5. Lin S, Lai C, Chiu C. Venous drainage in the reverse forearm flap. Plast Reconstr Surg 1984;74:508.
6. Batchelor AG, Palmer JH. A novel method of closing a palatal fistula: the free fascial flap. Br J Plast Surg
1990;43:359.
7. Khouri RK, Ozbek MR, Hruza GJ, Young VL. Facial reconstruction with prefabricated induced expanded
(PIE) supraclavicular skin flaps. Plast Reconstr Surg 1995;95:1007.

Chapter 300
Pedicled Radial Forearm Fasciosubcutaneous Flap for Hand
Reconstruction
N. WEINZWEIG
EDITORIAL COMMENT
This is an extremely clever variation of the radial forearm flap, utilizing perforating vessels alone. This
allows for salvage of the radial artery itself. In a single-vessel forearm, this would be very critical.
The distally based radial forearm fasciosubcutaneous flap with preservation of the radial artery is a useful and
reliable method for repairing soft-tissue defects of the hand. This flap avoids sacrificing a major artery, and
militates against morbidity and a poor cosmetic appearance at the donor site (1, 2, 3, 4, 5, 6, 7, 8, 9, 10). The
flap is especially useful in traumatized and thermally injured hands, as well as in cases in which only the radial
artery is functioning.
INDICATIONS
This flap is a safe, simple, and effective one-stage procedure that incorporates the thin, pliable, richly
vascularized subcutaneous tissue and fascia of the forearm, vital to preserve exposed and/or damaged
structures such as bone, joint, or tendon. It can be readily employed for coverage of the thumb-index web
space, the palm, and the dorsum of the hand. The flap is easy to contour, making it an excellent choice for
the tetrahedral first web space. It can also be used in the situation following tendon grafting or tenolysis,
providing a smooth gliding surface. Previous burns to the forearm, with injury to the superficial venous
system, do not prohibit use of the flap; instead, it is often the primary option in reconstructive surgery of the
burned hand. In cases where bone is required, in addition to soft tissue, the classic osteofasciocutaneous
flap should be employed.
Both donor and recipient sites are located within the same operative field. The donor-site skin is closed
primarily, surviving on its dermal vascular network, with no underlying subcutaneous support, thus
minimizing the cosmetic deformity. There is minimal discomfort postoperatively, facilitating early mobilization
and rehabilitation.
ANATOMY
The pedicled radial forearm flap for hand reconstruction has been widely described in its many forms (2, 3, 4, 5,
11, 12, 13, 14, 15, 16, 17, 18, 19, 20), based on the radial artery and its venae comitantes or with preservation of
these vessels. The pedicled radial forearm fasciosubcutaneous flap described here is based on the perforating
vessels of the distal radial artery. The blood supply emanates from 6 to 10 septocutaneous perforators in the
vicinity of the anatomic “snuff box.” These vessels fan out at the level of the deep fascia to form a rich plexus
supplying the forearm fascia and subcutaneous tissue.
Perforators originate approximately 1.5 cm proximal to the radial styloid and recur proximally at 0.4- to 1.5-cm
intervals, arising from both the radial and ulnar aspects of the radial artery, and measuring between 0.3 and 0.8
mm in external diameter (Fig. 300.1). There appears to be a definite directional component, with the arterioles

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running longitudinally along the intermuscular septum, and the fascial perforators
passing transversely from these arterioles. Multiple transverse anastomoses occur between these vessels.
FIGURE 300.1 At least seven septocutaneous perforators emanate from the radial aspect of the distal radial
artery at 0.4- to 1.5-cm intervals, to nourish the forearm fascia.
Venous drainage is from both the superficial and deep systems. There are multiple anastomoses between these
venous channels. One or both venae comitantes ordinarily follow each of the fascial arterial perforators, with
communicating branches between the venae comitantes allowing reverse flow via both crossover and bypass
patterns. Sufficient reverse flow venous drainage occurs to ensure flap survival.
The reverse-flow fasciocutaneous flap is pedicled on the distal fascia and subcutaneous tissue and the
fasciosubcutaneous vascular network described. It is a random-pattern flap, as there is no axial artery in the
pedicle. However, incorporation of sizable perforating vessels and a well-developed longitudinal vascular
network within the subcutaneous tissue provide significant vascularity to the flap.
FIGURE 300.2 A-C: Cadaver dissection. The radial forearm fascial flap is based solely on the distal perforators
of the radial artery. The pivot point is located 5 to 8 cm above the radial styloid along the dorsoradial aspect of
the hand. Care must be taken to identify and preserve the superficial radial nerve as it emerges between the
brachioradialis and extensor carpi radialis longus tendons 8 to 11 cm above the radial styloid. The arc of rotation
of this flap facilitates coverage of the dorsum of the hand (A), the palm (B), and the thumb-index web space (C).
FLAP DESIGN AND DIMENSIONS
The flap can be utilized for coverage of the dorsum of the hand, the palm, and the thumb-index web space (Fig.
300.2). It is designed based on the distal perforating vessels of the radial artery and its venae comitantes. The

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flap should measure at least 6 cm in width, so as to include as much of the longitudinal plexus of vessels as
possible; its longitudinal axis is centralized directly over the radial vessels. The pivot point is situated at least 5 to
8 cm above the radial styloid. This is the usual site of the most proximal perforating vessel of the distal zone of
perforators of the radial artery.
The flap is planned in reverse using a template, with its distal edge placed at the pivot point. The maximal
dimensions are not yet known. Flaps with surface areas of up to 96 cm2 have been reliably harvested; however,
larger flaps, incorporating much of the forearm fasciosubcutaneous tissue, can probably be safely elevated and
transferred. The flap is designed slightly larger than the measured defect, including as many of the distal
perforating vessels as possible, and accounting for variation in the location of the most proximal of the distal
perforating vessels. This will ensure maximum flap vascularity.
OPERATIVE TECHNIQUE
Following elevation exsanguination of the upper extremity, dissection proceeds under tourniquet control. A
curvilinear or S-shaped incision, oriented along the central axis of the proposed flap directly over the radial
vessels, is carried through skin and down to the relatively avascular plane just beneath the hair follicles and
dermis.
Using loupe magnification, skin undermining proceeds radially and ulnarly in this plane to the margins of the
proposed flap. The lateral antebrachial cutaneous nerve is identified coursing superficially through the
subcutaneous tissue.
The superficial radial nerve is identified as it emerges between the brachioradialis and extensor carpi radialis
longus tendons, and preserved.
The incision is deepened along the margins of the flap, to incorporate the deep fascia overlying the muscle
bellies of the flexor carpi ulnaris, palmaris longus, flexor digitorum superficialis, and flexor carpi radialis.
Subfascial dissection then proceeds expeditiously over the muscle bellies proximally and the tendons distally.
Sparse proximal and middle zone perforators are serially ligated. Flap transfer should be attempted before the
first distal zone perforator is visualized, if possible. Sacrifice of the distal perforating vessels should be avoided,
unless absolutely necessary to cover the defect. The fasciosubcutaneous flap can be transferred to cover the
defect either through a subcutaneous tunnel or turned over distally 180°.
The redundant edges of the forearm cutaneous flaps, supplied by the dermal vascular plexus, can be
conservatively trimmed back for several millimeters, so as to maximize their vascularity; however, closure must
be accomplished without any tension whatsoever. Suction drains are placed beneath the flap and the donor skin
flaps. Biobrane, a sterile dressing, and a short-arm plaster splint are applied. Delayed skin grafting is performed
on the third or fourth postoperative day, after flap edema has subsided.

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FIGURE 300.3 A 15-year-old male patient who sustained a severe crush-avulsion injury to the dorsum of the
hand. A: Following debridement, a retinacular flap is used to cover the exposed carpus, and the extensor
tendons are repaired. B: During elevation of the fasciosubcutaneous flap in a proximal-to-distal fashion, the
sparse middle-zone perforators (on background) of the radial artery (arrow) are identified and serially ligated.
The superficial branch of the radial nerve is encircled with a vessel loop and protected as it is carefully dissected
away from the flap. C: The radial forearm fasciosubcutaneous flap is elevated. Note that the radial artery and
venae comitantes are left intact. D: The flap is tunneled subcutaneously to cover the dorsal defect.
CLINICAL RESULTS
During the past 4 years, eight flaps were utilized in seven patients. Flaps were employed for coverage of
the thumbindex web space (three cases), the dorsum of the hand (four cases) (Fig. 300.3), and both the
palm and dorsum of the hand (one case). Soft-tissue coverage was undertaken following reconstructive
procedures such as tendon grafting, tenolysis, and bone grafting, in patients sustaining crush-avulsion
injuries, severe infections, shotgun blasts, and thermal insults. Flap sizes ranged from 30 cm2 to 286 cm2
(mean: 106.2 cm2).
Flap survival was excellent in seven of the eight cases. Minor flap loss was limited to the peripheral margin
and most distal portion of the flap. Only the largest flap in the series, incorporating virtually the entire
forearm fasciosubcutaneous tissue and measuring 286 cm2, suffered significant loss. This was most likely
due to the intricate method of flap transfer, which folded the flap upon itself several times in order to achieve
coverage of both the palm and dorsum of the hand.
Despite the excellent vascularity observed following release of the tourniquet, several flaps in the series
suffered minor skin-graft loss for unexplained reasons. Moderate flap edema, with an apparent decrease in
flap vascularity, was observed

for 3 to 4 days postoperatively, followed by dramatic spontaneous improvement in flap perfusion, probably
related to gradual flap accommodation to the reverse-pattern venous flow. Of interest, others have
observed this same phenomenon following the immediate skin grafting of fascial flaps, with no obvious
explanation. Skin grafting is now delayed until flap edema subsides, to avoid this potential problem.
Donor sites healed uneventfully, except for a narrow margin of the forearm skin edges in two cases, which
healed secondarily without problem. Functionally, results were related to the extent of the original injury and
to the patient's compliance with occupational therapy. Even in the one patient who had previously sustained
a thermal burn to his midvolar forearm, there were no problems with the vascularity of either the
fasciosubcutaneous or donor skin flaps.
SUMMARY
The distally based radial forearm fasciosubcutaneous flap, based on the perforating vessels of the distal
radial artery, can be a very useful and reliable procedure in hand reconstruction, and obviates the need for
the classic fasciocutaneous flap or even a free flap. Not only is the radial artery preserved, which is
essential in cases where only this vessel is functioning after severe trauma, but a more acceptable donor
site is also provided.
References
1. Weinzweig N, Chen L, Chen Z-W. The distally based radial forearm fasciosubcutaneous flap with
preservation of the radial artery: an anatomic and clinical approach. Plast Reconstr Surg 1994;94:675.
2. Stock W, Muhlhauer W, Biemer E. Der neurovaskulare Unterarm-Insel- Lappen. Z Plast Chir 1981;5:158.
3. Lu KH, Zhong DC, Chen B, Luo JW. The clinical applications of the reverse forearm island flap. Chin J
Surg 1982;20:695.
4. Reid D, Moss ALH. One-stage repair with vascularized tendon grafts in a dorsal hand injury using the
“Chinese” forearm flap. Br J Plast Surg 1983; 36:473.
5. Soutar DS, Tanner NSB. The radial forearm flap in the management of soft tissue injuries of the hand. Br J
Plast Surg 1984;37:18.
6. Yang G, Yang C, Chen B, et al. Forearm free skin flap transplantation. Natl Med J China 1978;61:139.
7. Song R, Gao Y, Song Y, et al. The forearm flap. Clin Plast Surg 1982;9:21.
8. Timmons MJ, Missotten FEM, Poole MD, Davies DM. Complications of radial forearm flap donor sites. Br J
Plast Surg 1986;39:176.
9. Boorman G, Brown JA, Sykes PJ. Morbidity in the forearm flap donor arm. Br J Plast Surg 1987;40:207.
10. Brenner P, Berger A, Caspary L. Angiologic observations following autologous vein grafting and free

radial artery flap elevation. J Reconstr Microsurg 1988;4:297.
11. Biemer E, Stock W. Total thumb reconstruction: a one-stage reconstruction using an osteocutaneous
forearm flap. Br J Plast Surg 1983;36:52.
12. Foucher B, van Genechten F, Merle N, Michon J. A compound radial artery forearm flap in hand surgery:
an original modification of the Chinese forearm flap. Br J Plast Surg 1984;37:139.
13. Jin Y-T, Guan W-X, Shi T-M, et al. Reversed island forearm fascial flap in hand surgery. Ann Plast Surg
1985;15:340.
14. Reyes FA, Burkhalter WE. The fascial radial flap. J Hand Surg 1988; 13A:432.
15. Chang YT, Wang XF, et al. The reversed forearm fasciocutaneous flap in hand reconstruction: ten
successful cases. Chin J Plast Surg Burns 1988;4:41.
16. Marty FM, Montandon D, Gumener R, Zbrodowski A. The use of subcutaneous tissue flaps in the repair
of soft tissue defects of the forearm and hand: an experimental and clinical study of a new technique. Br J
Plast Surg 1984;37:95.
17. Lai C-S, Lin S-D, Chou C-K, Tsai C-W. Clinical application of adipofascial turn-over flaps for burn
wounds. Burns 1993;19:73.
18. Yang J-Y, Noordhoff MS. Early adipofascial flap coverage of deep electrical burn wounds of upper
extremities. Plast Reconstr Surg 1993;91:819.
19. Lamberty BGH, Cormack GC. The forearm angiotomes. Br J Plast Surg 1982;35:420.
20. Timmons MJ. The vascular basis of the radial forearm flap. Plast Reconstr Surg 1986;77:80.

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Chapter 301
Posterior Interosseous Artery Flap
C. R. GSCHWIND
M. A. TONKIN
EDITORIAL COMMENT
This can serve as a very useful flap for resurfacing defects in the hand. Dissection is not easy, but once
mastered, a good and serviceable flap can be provided.
The posterior interosseous artery (PIA) flap does not compromise the two principal arteries of the forearm (1). It
is generally raised as a distally based pedicle flap with reversed blood flow, to cover small to medium-sized
defects on the dorsum of the hand and proximal phalanges, or defects in the first web space and on the thumb.
INDICATIONS
Defects on the dorsum of the hand require coverage with a thin, pliable flap, and flap sensation is usually
not of primary importance. If flap sensation is required, the posterior antebrachial cutaneous nerve can be
identified and connected with an
appropriate recipient nerve (2, 3). Using a distally based pedicle PIA flap, even when the pedicle is raised to
its maximal length, the flap cannot be extended beyond the proximal interphalangeal joint of the fingers. It is
therefore most suitable for small or medium-sized dorsal hand or thumb web defects. Hair growth and
pedicle length make the PIA flap less optimal for coverage of palmar defects.
Small or moderate-sized defects around the elbow can be covered by a proximally based PIA flap with
anterograde blood flow (2, 3, 4, 5, 6, 7, 8). Use as a fasciocutaneous flap, a fascial flap, an
osteomyocutaneous flap (9), and a free flap (10) has been reported. To avoid an unsightly donor area and
possible donorsite morbidity, direct closure of the defect is desirable; however, this limits the width of a
fasciocutaneous flap to 4 to 5 cm.
ANATOMY
At the level of the radial tuberosity, the common interosseous artery arises from the ulnar artery and divides into
posterior and anterior interosseous branches. The PIA passes through the chorda obliqua and the interosseous
membrane deep to the supinator, and enters the posterior compartment of the forearm (Fig. 301.1). The artery
lies ulnar-dorsal to the posterior interosseous nerve. The surface marking for the point of entry into the posterior
compartment is located at the junction of the middle and proximal thirds on a line drawn between the lateral
epicondyle and the inferior radioulnar joint (Fig. 301.2). The artery and nerve then pass under the fibrous arcade
of the extensor muscles of the fingers, to enter the septum between the extensor digiti minimi laterally and the
extensor carpi ulnaris medially.
Further distally, the artery lies between the long abductor and long extensor muscles of the thumb, and then
under the extensor indicis muscle. Along its course within the septum, the artery gives off between 7 and 13
cutaneous branches and 13 to 22 muscular and periosteal branches. The septocutaneous branches anastomose

in the superficial layer of the deep fascia, and form arcades with longitudinal anastomoses. Three patterns of
distribution have been described for the fasciocutaneous perforators (5). Most commonly, there is a perforator
every 1 to 2 cm. The largest one is the most proximal perforator, which often originates from the common
interosseous artery or the recurrent branch of the PIA. The constancy of a large cutaneous perforator, 1 to 2 cm
distal to the midpoint of the epicondylar-ulnar line, has been demonstrated (8). Cadaver studies have shown that
the PIA narrows in the middle third of the forearm. In 5% of clinical cases and anatomic dissections, the PIA
terminates at mid-forearm level.
FIGURE 301.1 Outline of the posterior interosseous artery, septum, and fasciocutaneous territory.
FIGURE 301.2 Surface markings and flap design. (From Tubiana et al., ref. 12, with permission.)
Near the wrist joint, the artery communicates with the anterior interosseous artery, the dorsal carpal network, and
the ulnar artery. Absence of any distal communication is rare, but well described (1, 3, 7, 11). The transverse
branch between the PIA and the dorsal branch of the anterior interosseous artery is the most consistent and
important anastomosis, and lies under the extensor indicis proprius tendon, about 1 to 2 cm proximal to the
inferior radioulnar joint. This represents the pivot point of the distally based PIA pedicle flap.
At the point of entry into the dorsal compartment, the caliber of the artery varies from 0.9 to 2.7 mm. At the level
of the communication with the anterior interosseous artery, the caliber varies between 0.2 and 1.2 mm. A small
caliber of the vessel can be responsible for flap failure, when retrograde flow through the pedicle cannot perfuse
the proximally based flap adequately. Venous drainage of the distally based flap depends on reversed blood flow
through the venae comitantes.
The relationship between the PIA and the posterior interosseous nerve may pose significant problems in flap
dissection. At the entrance into the dorsal compartment, the nerve gives off branches to the epicondylar muscles,

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i.e., the extensor carpi ulnaris, extensor digiti minimi, and extensor digitorum communis. The artery is commonly
crossed over by the posterior interosseous nerve branch to the extensor carpi ulnaris. In some cases, the branch
crosses over the PIA and the most proximal significant septocutaneous perforator. In the septum, the posterior
interosseous nerve is found deep and radial to the artery, but often within a distance of only 1 to 3 mm. The
nerve gives off five branches to the abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, and
extensor indicis proprius, from proximal to distal. After supplying the extensor indicis proprius muscle, the nerve is
sensory for the wrist capsule.
The dorsal ulnar skin of the forearm is innervated proximally by the posterior antebrachial cutaneous nerve, and
distally by branches of the medial and lateral antebrachial cutaneous nerves. The posterior antebrachial
cutaneous nerve can be identified and used to make the flap sensate.
The cutaneous territory of the PIA flap extends from 2 to 3 cm below the elbow crease to the wrist. The ulnar
margin is defined by the subcutaneous border of the ulna. Medially, the territory extends to the radial border of
the radius, i.e., a line drawn from the lateral epicondyle to the radial styloid.
FLAP DESIGN AND DIMENSIONS
Classically, the flap is centered on the emergence of the artery in the posterior compartment in the proximal
forearm. Small flaps should be designed distally to the point of emergence of the PIA, in order to include the
septocutaneous perforator in the lower two-thirds of the forearm. In a large series (8), the authors recommend
keeping the flap design distal to the proximal quarter of the epicondylar-ulnar line, in order to avoid proximal flap
necrosis. More proximal extension of the flap depends on random- pattern perfusion, which may be variable,
according to the distance to the most proximal septocutaneous perforator.
Distally, the cutaneous radial nerve and dorsal cutaneous branch of the ulnar nerve can be damaged in flap
dissection. The distal limit should be about 3 to 4 cm above the wrist joint. Medially, the flap should not extend
beyond the subcutaneous border of the ulna. The radial margin should not extend more than 3 to 4 cm from the
epicondylar-ulnar line. It is possible to raise a flap of 10 cm in width; however, skin grafting is necessary for
defects greater than 4 to 5 cm.
The pivot point of the pedicle is just proximal to the level of the inferior radioulnar joint, i.e., the anastomosis with
the anterior interosseous artery. As this connection is occasionally absent, a preoperative Doppler evaluation is
recommended.
For a proximally based flap, the skin territory is designed on the lower third of the forearm. The first medium-
sized perforator is placed about 7.5 cm above the wrist joint. Flap design should not go more distally, in order to
avoid damage to the radial and ulnar sensory nerve branches. The pivot point of the pedicle is at the emergence
of the PIA, at the junction of the upper and mid-third of the forearm. A fibrous band deep to the extensor digiti
minimi indicates a level at which the pedicle is long enough to reach the anterior aspect of the elbow or the
olecranon.
OPERATIVE TECHNIQUE
Distally Based Pedicle Flap
The elbow is positioned in full pronation and 90° of flexion. Surface markings indicate the lateral epicondyle and
inferior radioulnar joint. The point at the junction between the proximal and middle third marks the emergence of
the PIA in the dorsal extensor compartment; this is 7.5 to 9.5 cm distal to the lateral epicondyle. Flap design
should not extend more than 3 cm proximal to this point. Small flaps should be centered on the midpoint of the
epicondylar-ulnar line.

P.814
The flap is outlined, depending on the size of the defect (Fig. 301.2). For flap siting, it is wise to continue the
distal margin of the design beyond the midpoint of the epicondylar-ulnar line, to include the constant perforator
previously described (8). The distal incision is extended just to the level of the deep fascia (Fig. 301.3). The
septum between the extensor carpi ulnaris and the extensor digiti minimi is identified, and the fascia incised on
either side of the septum. The PIA is identified, and the communication with the anterior interosseous artery, after
retraction of the extensor indicis proprius tendon, is verified (Figs. 301.4 and 301.5).
FIGURE 301.3 The septum is identified and the flap is raised on the radial side first. 1: cutaneous pedicle within
the septum. 2: aponeurosis. 3: extensor digitorum communis. (From Tubiana et al., ref. 12, with permission.)
The septum containing the artery and its perforators is dissected proximally to the skin paddle, by retracting the
extensor carpi ulnaris medially and the extensor digiti minimi and extensor indicis proprius to the radial side (Fig.
301.6). The skin-paddle incision is carried through the level of the fascia, and an extra 1 cm of fascia is included
circumferentially. To avoid shearing forces between the skin and the fascia, fine absorbable stitches are used to
fix the fascia to the skin. The skin paddle itself is then raised with the fascia, beginning with dissection on the
radial side over the wrist extensors, and more ulnarly over the common finger extensors.
The deep arch of the extensor digitorum communis has to be incised to obtain a clear view of the artery as it
emerges
from underneath the supinator. At this point, the posterior artery gives off its recurrent branch, which runs toward
the elbow and gives off several musculocutaneous branches. This recurrent branch of the PIA can occasionally
also give origin to the first significant fasciocutaneous perforator, in which case part of it may be included in the
dissection. Inclusion of this perforator is mandatory only when there is no main perforator present farther distally.
FIGURE 301.4 The deep arch of the extensor digitorum communis is incised to obtain a view of the artery

emerging from underneath the supinator muscle. 1: extensor carpi ulnaris. 2: posterior interosseous artery with
venae comitantes. (From Tubiana et al., ref. 12, with permission.)
FIGURE 301.5 The posterior interosseous artery is dissected proximally and ligated distal to the nerve branch to
the extensor carpi ulnaris. 1: proximal ligature of the posterior interosseous artery. 2: extensor carpi ulnaris. 3:
extensor indicis proprius. 4: abductor pollicis longus. 5: extensor digiti minimi. 6: posterior interosseous nerve. 7:
supinator. (From Tubiana et al., ref. 12, with permission.)
Under magnification, the PIA is also isolated from the branches of the posterior interosseous nerve. The motor
branch to the extensor carpi ulnaris crosses superficial to the interosseous recurrent artery when it arises
proximally, or crosses the PIA when it arises distal to the supinator. When this motor branch is found to cross the
posterior interosseous vessel, the vessel should be ligated distal to the nerve (Fig. 301.5). The ulnar side of the
skin paddle is then raised, and the pedicle itself is dissected off the ulnar shaft (Fig. 301.6).
If there is any doubt about the presence or size of the distal anastomosis between the PIA and the anterior
interosseous artery, the PIA is temporarily occluded with a small artery clamp at its most proximal point. The
tourniquet is let down, and the adequacy of the retrograde flow is verified. It is at this point that a decision may
be made to resort to a freeflap transfer (Fig. 301.7), if the distal anastomosis is too small and the retrograde flow
insufficient for flap survival. The PIA may be dissected proximally and the flap transferred as a free flap, or the
dissection is abandoned and the flap returned to its original site.
FIGURE 301.6 After raising the ulnar side of the skin paddle, the pedicle is dissected off the ulnar shaft. 1: ulnar
shaft. (From Tubiana et al., ref. 12, with permission.)

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FIGURE 301.7 A,B: Posterior interosseous artery flap after release of first web contracture. Retrograde flow was
insufficient, and the flap was transferred as a free flap. (From Tonkin and Stern, ref. 10, with permission.)
After mobilization of the pedicle, the flap can then be inset on the dorsum or the palm of the hand (Figs. 301.7
and 301.8). The donor defect can be closed primarily, when flap width does not exceed 4 to 5 cm. Otherwise, a
split-thickness skin graft is necessary.
Proximally Based Pedicle Flap
The skin flap is outlined on the distal aspect of the forearm. The distal flap limit should be at least 3 cm above
the inferior radioulnar joint. The tendons of the extensor digiti minimi and extensor carpi ulnaris are retracted
after their fascia has been incised, and raised en bloc with the septum. The pedicle is followed proximally, and
care is taken to separate the nerve
from the artery. The artery is followed as far as the fibrous band deep to the extensor digiti minimi. This usually
provides sufficient length to cover defects on the anterior aspect of the elbow or over the olecranon.
FIGURE 301.8 A,B: Distally pedicled flap used for coverage of a defect on the lateral aspect of the hand, after
traumatic amputation of the little finger and revascularization of the ring finger.
ALTERNATIVE TECHNIQUES
Elevation as a Fascial Flap
The technique is the same as previously described, but after the skin incision only the fascia is raised. It is
important to leave a thin layer of fatty tissue on the dorsal surface of the fascia, in order to preserve the
supraaponeurotic vascular plexus.
Elevation as an Osteomyocutaneous Flap
Dissection is the same as for the distally based pedicle flap. After dissection of the posterior interosseous nerve
from the artery, the extensor pollicis longus muscle deep to the extensor carpi ulnaris and ulnar to the abductor
pollicis longus is identified. The extensor pollicis longus overlies the radial border of the ulna. The interosseous

membrane, which lies volar to the extensor pollicis longus muscle, is incised along the required length of bone. A
cuff of extensor pollicis longus is then raised with the underlying bone. The bone segment is cut using a power
saw.
Elevation with Sensory Nerve
Dissection is the same as for the distally based pedicle flap. When dissecting the proximo-ulnar aspect of the
flap, special care is taken to identify branches of the posterior cutaneous nerve of the forearm (usually one or
two). The nerve lies deep in the fatty tissue just above the fascia.
CLINICAL RESULTS
Two cases of partial necrosis in a series of 21 patients were reported (6). In a series of 36 patients, seven
instances of partial necrosis occurred (3), and four flap losses were reported in another series of 80
patients (8). Apart from partial or total flap necrosis, complications involving branches of the posterior
interosseous nerve are documented; the results of flap innervation have been poor (3).
SUMMARY
Although several alternative flap designs are possible, the PIA flap is used mainly as a retrograde pedicle
flap. It is suitable for coverage of small to medium-sized defects on the hand, and interference with the two
main arteries of the forearm is avoided. However, flap dissection is difficult, and the vascular anatomy may
be variable.
References
1. Penteado CV, Masquelet AC, Chevrel JP. The anatomic basis of the fascio-cutaneous flap of the posterior
interosseous artery. Surg Radiol Anat 1986;8:209.
2. Bayon P, Pho RWH. Anatomical basis of the dorsal forearm flap. J Hand Surg 1988;13B:435.
3. Buechler U, Frey HP. Retrograde posterior interosseous flap. J Hand Surg 1991;16A:283.
4. Masquelet AC, Penteado CV. Le lambeau interosseux posterieur. Ann Chirurg Main 1987;6:131.
5. Costa H, Soutar DS. The distally based island posterior interosseous flap. Br J Plast Surg 1988;41:221.
6. Costa H, Comba S, Martins A, et al. Further experience with the posterior interosseous flap. Br J Plast
Surg 1991;44:449.
7. Landi A, Luchetti R, Soragni O, et al. The distally based posterior interosseous island flap for the coverage
of skin loss of the hand. Ann Plast Surg 1991;27:527.
8. Angrigiani C, Grilli D, Dominikow D. Posterior interosseous reverse forearm flap: experience with 80
consecutive cases. Plast Reconstr Surg 1992;92:285.

9. Costa H, Smith R, McGrouther DA. Thumb reconstruction by the posterior interosseous osteocutaneous
flap. Br J Plast Surg 1988;41:228.
10. Tonkin MA, Stem H. The posterior interosseous artery free flap. J Hand Surg 1989;14B:215.
11. Dadalt LG, Ulson HJR, Penteado CV. Absence of the anastomosis between the anterior and posterior
interosseous arteries in a posterior interosseous flap: a case report. J Hand Surg 1994;19A:22.
12. Tubiana R, McCullough CJ, Masquelet AC. Atlas of surgical exposures of the upper extremity. London:
Martin Dunitz, 1990.

Chapter 302
The Reverse Bipaddle Posterior Interosseous Artery Perforator
Flap
YIXIN ZHANG
DAVIDE LAZZERI
HE-PING ZHENG
EDITORIAL COMMENT
A versatile flap for coverage of hand defects. The donor site is long, and the scar may hypertrophy.
INDICATIONS
The reverse posterior interosseous artery (PIA) perforator flap has become the workhorse for early wound
coverage of any defect over the distal forearm, wrist, and hand due to its versatility, easy single-stage
harvesting, and reliable blood supply (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21,
22, 23, 24, 25, 26). This flap provides thin, soft, and pliable tissue that matches the color and texture of the
skin surrounding the defect and restricts the deformity to the ipsilateral extremity, allowing for early
postoperative mobilization without sacrificing any major blood vessels of the forearm (1, 2, 15, 18, 19, 20).
The major drawbacks of the PIA perforator flap include a short vascular pedicle and a proximal axis of
rotation that limits the distal reach of the flap to the metacarpophalangeal (MP) joint on the dorsum of the
hand and the first web space, a technically demanding dissection of the pedicle, and risks of ischemic flap
necrosis and venous congestion (1, 2, 15, 17, 18, 19, 21, 22, 23, 24). Several modifications of the flap to
overcome these shortcomings have been reported and include the extended flap, tunneling or splitting of
the skin bridge between the pivot point and the defect (1, 2), reverse flap with an exteriorized pedicle (16,
19), composite flap with a vascularized tendon graft or bone (24), free extended pedicle flap (15), and the
“tennis racquet”- or “teardrop”-shaped distally based flap (1, 20).
The bipaddle PIA perforator flap allows for reconstruction of two different hand subunits at the same time
(type A, chain-link flap). Alternatively, the flap's flexible shape can be altered to match the shape of the
recipient site and resurface a single large defect while achieving primary donor site closure (type B, kiss
flap).
ANATOMY
The PIA arises from the common interosseous artery and passes backward between the oblique cord and the
upper border of the interosseous membrane. It runs down the dorsal aspect of the forearm between the
superficial and deep layers of muscles. In the distal third of the forearm, the PIA anastomoses with the anterior
interosseous artery (AIA) and with the dorsal carpal network. Near its origin, the PIA gives rise to the
interosseous recurrent artery that anastomoses with the radial collateral branch of the profunda brachii artery
and the posterior ulnar recurrent and the inferior ulnar collateral arteries. During its course, the PIA distributes
septocutaneous branches spreading out on the deep fascia to form longitudinal fascial arcades. In the distal
third, the PIA gives rise to some direct ulnar septoperiosteal branches.

P.817
The absence of the distal anastomosis of PIA with the dorsal branch of the AIA has only been described in two
patients (4, 11), and the narrowing of the PIA in the middle third of the forearm has also been reported only in
nine cases (4, 11, 23, 25, 26).
FLAP DESIGN AND DIMENSIONS
The axis of the flap is a line drawn from the lateral epicondyle of the humerus to the ulnar styloid with the forearm
in neutral position. The pivot point is marked as conventionally between 1 and 1.5 cm proximal to the radial edge
of the ulnar head. The length of the pedicle is calculated depending on the distance from the pivot point to the
proximal edge of the recipient site and the type of modification chosen. The same distance is then reported from
the pivot point along the axis of the flap to identify the most distal margin of the flap. Starting from this margin,
with the help of a paper template, the exact size of the defect(s) is reproduced. The modified PIA perforator flap
is designed along the axis of the flap as a skin island composed by two individual skin paddles nourished by two
independent perforators. Preoperative Doppler is never used because, according to the previous studies and
series (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24) and in our experience, a
consistent presence of perforators along the flap axis is always found.
OPERATIVE TECHNIQUE
The proximal dissection of the flap is initiated with the incision of its radial edge deep into the epimysium of the
extensor digitorum communis (EDC). By entering the plane between the overlying fascia and the underlying
muscle, dissection moves ulnarly until the intermuscular septum that divides the extensor digiti quinti (EDQ) and
the extensor carpi ulnaris is intercepted. At least two perforators, one proximal and one distal, are identified as
nourishing the skin area to be included in the flap, which is planned to be split into two with each separate skin
paddle supplied by a separate perforator. In particular, the proximal paddle is nourished by the perforator arising
from the recurrent branch of the PIA and the distal paddle is supplied by the dominant distal cutaneous perforator
of the same source artery. After the posterior interosseous nerve (PIN) is preserved, dissecting it away from the
vascular bundle, the PIA and its two venae comitantes are followed along their distal course in the intermuscular
septum between the EDQ and ECU until the pivot point to ascertain the presence of distal PIA communication
with the AIA. Then, the ulnar edge is approached and dissected radially toward the septum along the same
subfascial plane. Finally, the origin of the PIA is ligated proximally to complete the elevation of the flap.

FIGURE 302.1 Above: Severe postburn deep contracture of the palm and the first web space. Below: After
scar excision. (From Zhang YX, et al. Reverse bipaddle posterior interosseous artery perforator flap. Plast
Reconstr Surg 2013;131(4):552e-562e, with permission.)
FIGURE 302.2 Each paddle of the modified flap was planned to have the same size and shape as the two
defects to be resurfaced in two different units or functional areas of the hand (type A, chainlink variant of the
flap). (From Zhang YX, et al. Reverse bipaddle posterior interosseous artery perforator flap. Plast Reconstr Surg
2013;131(4):552e-562e, with permission.)
FIGURE 302.3 Perforators for each paddle were found and the original design was eventually moved slightly
proximally or distally, depending on the exact location of the perforators (black arrow, posterior interosseous
nerve; asterisk, posterior interosseous artery; open arrow, recurrent branch and its perforator; white arrow, distal

P.818
perforator). (From Zhang YX, et al. Reverse bipaddle posterior interosseous artery perforator flap. Plast
Reconstr Surg 2013;131(4):552e-562e, with permission.)
Type A
The skin paddle is split into two separate paddles, each supplied by independent perforators arising from a
common vascular supply (PIA) with an adequate intervening bridge of PIA vessel between them. Each paddle
has the same size and shape of the two defects to be resurfaced in two different units or functional areas of the
hand (“chain-link” variant of the flap; Figs. 302.1, 302.2, 302.3, 302.4, 302.5).
FIGURE 302.4 The flap (above) was raised and inset (below); the proximal skin paddle was rotated 180
degrees as a perforator-pedicled propeller flap to gain additional length, almost reaching the first distal
interphalangeal joint crease in a single step. The donor site was skin grafted. (From Zhang YX, et al. Reverse
bipaddle posterior interosseous artery perforator flap. Plast Reconstr Surg 2013;131(4):552e-562e, with
permission.)

FIGURE 302.5 Postoperative view at (above) 3 and (center and below) 14 months, with excellent functional
and cosmetic results. (From Zhang YX, et al. Reverse bipaddle posterior interosseous artery perforator flap.
Plast Reconstr Surg 2013;131(4):552e-562e, with permission.)
Type B
Once the two perforators arising from the same source vessel (PIA) are identified as nourishing each island of
the skin paddle, they are split and placed side by side “kissing” together (“kiss” variant of the flap), effectively
doubling the width of the flap (Figs. 302.6, 302.7, 302.8, 302.9, 302.10, 302.11, 302.12). The two paddles with a
width never larger than 4 cm are stacked side by side or rotated around each other, providing wound coverage
for large defects while maintaining primary closure of the donor site.
FIGURE 302.6 Dorsal hand defect following resection of a squamous cell carcinoma measuring 6 × 5 cm. The
design of the type B “kiss” variant-modified posterior interosseous artery perforator flap was planned so that the

P.819
sum of the areas of the skin paddles should match the area of the defect and, because of the adaptability of the
shape, it should be molded to match exactly the shape of the recipient site. In this case, a circular 6 × 5 cm
defect can be filled using our design with two 6 × 2.5 cm skin paddles that are divided and stacked side by side
and placed on the recipient site. (From Zhang YX, et al. Reverse bipaddle posterior interosseous artery
perforator flap. Plast Reconstr Surg 2013;131(4):552e-562e, with permission.)
In both types of flaps, the pedicle is completely skeletonized, and the inset of the flap is provided by tunneling or
splitting the skin bridge between the pivot point and the defect for the transfer of the pedicle, depending on the
pliability and the tension provided by the intervening skin. To prevent venous congestion, only a small cuff of
intermuscular septum from the distal forearm pedicle dissection is incorporated, which is
the part of the pedicle that, after rotation, is inset either in the subcutaneous tunnel or under the sutured
intervening split skin. To avoid any tension on the pedicle, a plaster cast immobilizing the wrist and the MP joint
in overextended posture is applied for 3 days after the operation.
FIGURE 302.7 Above: Through a radial approach, dissection moved ulnarly to identify perforators as nourishing
each island of the bilobed skin paddle. Below: The pedicle was skeletonized and dissection was carried out.
The two 6 × 2.5 cm skin paddles were divided, stacked side by side, and placed on the recipient site, “kissing”
together, allowing for the resurfacing of a single but large defect while maintaining primary closure of the donor
site. (From Zhang YX, et al. Reverse bipaddle posterior interosseous artery perforator flap. Plast Reconstr Surg
2013;131(4):552e-562e, with permission.)

P.820
FIGURE 302.8 Photographs obtained 12 months postoperatively, showing functional recovery. (From Zhang YX,
et al. Reverse bipaddle posterior interosseous artery perforator flap. Plast Reconstr Surg 2013r;131(4):552e-
562e, with permission.)
CLINICAL RESULTS
In our series, the bipaddle PIA perforator flap was used to treat successfully 11 patients (6 postburn
contractures, 2 tumor excisions, and 3 posttraumatic injuries). The mean age of the patients was 30 years,
ranging from 16 to 55 years. The location of the defects varied and included the first web space, proximal
thumb, dorsum of the hand, palm, wrist, and the radial or ulnar half of the hand (Figs. 302.1, 302.2, 302.3,
302.4, 302.5, 302.6, 302.7, 302.8, 302.9, 302.10, 302.11, 302.12).
In seven cases, the type A modification was used to cover defects involving two different units of the hand.
Donor sites
were skin grafted in four cases, whereas primary closure was achieved in the three remaining cases in
which the flap width was less than 4 cm. In four patients, the type B pattern was required to resurface a
large defect of a single unit of the hand. In these cases, the donor site was closed directly.
FIGURE 302.9 Excisional debridement of keloid-scarred tissue following trauma. (From Zhang YX, et al.
Reverse bipaddle posterior interosseous artery perforator flap. Plast Reconstr Surg 2013;131(4):552e-
562e, with permission).

FIGURE 302.10 Design (above) and harvesting (below) of the splitskin paddle distally based kiss posterior
interosseous artery perforator flap. The donor site was closed primarily. (From Zhang YX, et al. Reverse
bipaddle posterior interosseous artery perforator flap. Plast Reconstr Surg 2013;131(4):552e-562e, with
permission.)
FIGURE 302.11 Follow-up at 7 months. (From Zhang YX, et al. Reverse bipaddle posterior interosseous
artery perforator flap. Plast Reconstr Surg 2013;131(4):552e-562e, with permission.)
FIGURE 302.12 Follow-up at 7 months. (From Zhang YX, et al. Reverse bipaddle posterior interosseous

artery perforator flap. Plast Reconstr Surg 2013;131(4):552e-562e, with permission.)
All the modified flaps were transferred successfully and healed uneventfully with no major complications
such as flap failure or distal partial flap necrosis at 12 months of follow-up with excellent functional and
aesthetic outcomes.
SUMMARY
The reverse PIA perforator flap is useful for covering defects over the distal forearm, wrist, and hand, but
some of its major limitations include a short vascular pedicle, inadequate distal reach, difficult pedicle
dissection, and risk of venous congestion. Although some of these drawbacks have been overcome with
refinements over the years, the problems of donor site morbidity and the inability to reconstruct multiple
subunits of the hand in a single stage remain.
The reverse bipaddle PIA perforator flap is a variant of the original flap designed to extend its applications
while minimizing donor site morbidity. Eleven patients were successfully treated with no major complications
at 12 months of follow- up in our series. The bipaddle PIA perforator flap is an excellent method for
reconstruction of two different hand subunits at the same time (type A, chain-link flap) or to resurface a
single large defect while achieving primary donor site closure (type B, kiss flap).
References
1. Acharya AM, Bhat AK, Bhaskaranand K. The posterior interosseous artery flap: technical considerations in
raising an easier and more reliable flap. J Hand Surg Am 2012;37:575-582.
2. Puri V, Mahendru S, Rana R. Posterior interosseous artery flap, fasciosubcutaneous pedicle technique: a
study of 25 cases. J Plast Reconstr Aesthet Surg 2007;60:1331-1337.
3. Lu LJ, Wang SF, Yang J, et al. The posterior interosseous flap: a report of 6 cases. The Second
Symposium of the Chinese Association of Hand Surgery (Qing Dao city), 1986:187-191.
4. Penteado CV, Masquelet AC, Chevrel JP. The anatomic basis of the fasciocutaneous flap of the posterior
interosseous artery. Surg Radiol Anat 1986;8:209-215.
5. Zancolli EA, Angrigiani C. Posterior interosseous island forearm flap. J Hand Surg 1988;13B:130-135.
6. Masquelet AC, Penteado CV. The posterior interosseous flap. Ann Chir Main 1987;6:131-139.
7. Costa H, Soutar DS. The distally based island posterior interosseous flap. Br J Plast Surg 1988;41:221-
227.
8. Bayon P, Pho RW. Anatomical basis of dorsal forearm flap. Based on posterior interosseous vessels. J
Hand Surg (Br) 1988;13:435-439.
9. Landi A, Luchetti R, Soragni O, et al. The distally based posterior interosseous island flap for the coverage

of skin loss of the hand. Ann Plast Surg 1991;27:527-536
10. Costa H, Comba S, Martins A, et al. Further experience with the posterior interosseous flap. Br J Plast
Surg 1991;44:449-455.
11. Angrigiani C, Grilli D, Dominikow D, et al. Posterior interosseous forearm flap: experience with 80
consecutive cases. Plast Reconstr Surg 1993;92:285-293.
12. Mazzer N, Barbieri CH, Cortez M. The posterior interosseous forearm island flap for skin defects in the
hand and elbow. A prospective study of 51 cases. J Hand Surg (Br) 1996;21:237-243.
13. Martin D, Bakhach J, Casoli V, et al. Reconstruction of hand with forearm island flaps. Clin Plast Surg
1997;24:36-41.
14. Shibata M, Iwabuchi Y, Kubota S, et al. Comparison of free and pedicled posterior interosseous
cutaneous flaps. Plast Reconstr Surg 1997;99:791-802.
15. Chen HC, Cheng MH, Schneeberger AG, et al. Posterior interosseous flap and its variations for coverage
of hand wounds. J Trauma 1998;45:570-574.
16. Brunelli F, Giele H, Perrotta R. Posterior interosseous flap based on an exteriorized pedicle to cover
digital skin defects. J Hand Surg [Br] 2000;25:296-299.
17. Cavadas PC. Posterior interosseous free flap with extended pedicle for hand reconstruction. Plast
Reconstr Surg 2001;108:897-901.
18. Costa H, Gracia ML, Vranchx J, et al. The posterior interosseous flap: a review of 81 clinical cases and
100 anatomical dissections--assessment of its indications in reconstruction of hand defects. Br J Plast Surg
2001;54:28-33.
19. Brunelli F, Valenti P, Dumontier C, et al. The posterior interosseous flap: experience with 113 flaps. Ann
Plast Surg 2001;47:25-30.
20. Balakrishnan G, Kumar S, Hussain SA. Reverse-flow posterior interosseous artery flap revisited. Plast
Reconstr Surg 2003;111:2364-2369.
21. Hubmer MG, Fasching T, Haas F, et al. The posterior interosseous artery in the distal part of the
forearm. Is the term “recurrent branch of the anterior interosseous artery” justified? J Plast Reconstr Aesthet
Surg 2004;57:638-644.
22. Akinci M, Ay S, Kamiloglu S, et al. The posterior interosseous flap: a solution for flap necrosis based on a
review of 87 cases. J Plast Reconstr Aesthet Surg 2006;59:148-152.
23. Costa H, Pinto A, Zenha H. The posterior interosseous flap—a prime technique in hand reconstruction.
The experience of 100 anatomical dissections and 102 clinical cases. J Plast Reconstr Aesthet Surg

2007;60:740-747.
24. Lu LJ, Gong X, Lu XM, et al. The posterior interosseous flap and its composite flap: experience with 201
flaps. J Plast Reconstr Aesthet Surg 2007;60:876-882.
25. Giunta R, Lukas B. Impossible harvest of the posterior interosseous artery flap: a report of an
individualised salvage procedure. Br J Plast Surg 1998;51:642-645.
26. Büchler U, Frey HP. Retrograde posterior interosseous flap. J Hand Surg Am 1991;16:283-292.

Chapter 303
Proximal Forearm Flap
R. K. KHOURI
Y. J. SHIN
EDITORIAL COMMENT
The authors have allowed extension of the lateral arm flap into the forearm for more distal use of skin.
The proximal forearm flap provides very thin cutaneous coverage and contains less subcutaneous fat than the
lateral arm flap. It is a sensate flap with a long vascular pedicle, causes less donor-site morbidity than the radial
forearm flap, and can be easily raised under tourniquet.
INDICATIONS
This flap is useful when thin fasciocutaneous coverage is required in the hand or foot. When used for
reconstructing hand defects, it can be harvested ipsilaterally. It is ideally suitable for use as a sensate flap
for palmar or heel defects. When utilized as a composite lateral arm/proximal forearm free flap, it can also
provide excellent tissue for penile reconstruction.
ANATOMY
The anatomy of the proximal pedicle is similar to that of the lateral arm flap. The posterior radial collateral artery
proceeds distally in the lateral intermuscular septum between the triceps posteriorly and the brachioradialis
anteriorly. The artery vascularizes the lateral upper arm flap by a series of direct cutaneous branches. Ultimately,
it anastomoses around the lateral epicondyle with an extensive vascular plexus that interconnects the posterior
interosseous artery, the anterior and posterior radial recurrent arteries, and the olecranon anastomosis (Fig.
303.1).
An average length of the posterior radial collateral artery of 8 cm beyond the lateral condyle, and interconnection
with the radial recurrent artery, have previously been described (1, 2). A constant single trunk of the posterior
radial collateral artery extending beyond the condyle has not been demonstrated (3), but the distal vessel
anastomosis with a rich vascular plexus centered around the posterior elbow has been observed. This plexus
lies immediately superficial to the deep muscular fascia and extends well beyond the lateral epicondyle. The
plexus allows the posterior radial collateral vessels to capture the cutaneous territory of the posterior
interosseous artery.
The posterior cutaneous nerve of the arm, arising from the radial nerve in the spiral groove, accompanies the
posterior radial collateral artery and innervates the skin of the distal part of the lateral upper arm. The posterior
cutaneous nerve of the forearm also arises from the radial nerve in the spiral groove, accompanies the posterior
radial collateral artery, and then passes beyond the lateral epicondyle, to innervate the skin of the posterolateral
forearm. Therefore, by using the two nerves that accompany the vascular pedicle of the flap, the distal lateral
arm and the entire proximal posterior forearm can be reinnervated.
FLAP DESIGN AND DIMENSIONS

The skin paddle of the lateral arm flap, as originally described, does not extend distally beyond the lateral
epicondyle into the forearm. The distal extension of the flap was originally believed to be random in nature (4, 5).
We have found (3) that, at the level of the proximal forearm, there is an extensive watershed/vascular plexus
connecting the posterior radial collateral vessels (the axial pedicle of the lateral arm flap) with the posterior
interosseous artery, the olecranon anastomosis, and the anterior and posterior radial recurrent arteries. This
vascular plexus allows the safe transfer of the entire half of the posterior proximal forearm skin as a flap based
on the posterior radial collateral vessels (Fig. 303.1).
The important surface marking is a line that joins the deltoid insertion with the lateral epicondyle. This line marks
the lateral intermuscular septum and the course of the posterior radial collateral artery. The flap is typically
designed like a tennis racket, with the handle along the lateral intermuscular septum. A complex flap pattern can
then be designed over the posterior proximal half of the forearm. Depending on the patient's body habitus and
skin laxity, donor defects of 6 to 8 cm can be closed primarily.
FIGURE 303.1 Diagram of the blood supply of the proximal forearm. The vascular plexus around the lateral
epicondyle connects the posterior radial collateral artery to the olecranon anastomosis, the radial recurrent
vessels, and the posterior interosseous artery.
OPERATIVE TECHNIQUE
Using a sterile tourniquet, the entire flap dissection, including the area of the spiral groove, can be done in a
bloodless field. Flap dissection is begun distally, and the deep muscular fascia is raised with the flap, to ensure
preservation of the vascular plexus immediately superficial to this fascia. Branches of the radial recurrent artery
travel along the intermuscular septa of the forearm extensors, to communicate with the vascular plexus; 1 to 2
mm of the septa should be harvested with the deep fascia. Not all the septa contain communicating branches,
but when such branches are identified, they should be coagulated well away from the plexus deep inside the
groove. Where the septa attach to the lateral epicondyle, the dissection is just superficial to the periosteum.
The posterior cutaneous nerve of the forearm is preserved within the flap, and enough length is retained to allow
repair to a sensory nerve at the recipient site. Above the lateral epicondyle, the dissection continues, as
described for the lateral arm flap (4). If only the forearm skin is to be utilized, a proximal extension of skin
overlying the pedicle is included, resembling a tennis racket, to aid in a tensionless skin closure at the recipient
site. For additional length and pedicle size, the profunda brachii can be traced back to its origin by a separate
medial approach (6).

CLINICAL RESULTS
We have performed 31 proximal forearm flaps on 29 patients. Twenty were for upper-extremity
reconstruction, seven for lower-extremity reconstruction, and four for penile construction. The sizes of the
flaps ranged from 35 × 12 cm to 14 × 5 cm (average: 24 × 10 cm). The flaps extended beyond the lateral
condyle for a distance of 7 to 15 cm (average: 10 cm). The reach of the flap from proximal pedicle to flap tip
ranged from 35 to 14 cm (average: 22 cm). Follow-up ranged from 6 months to 2 years. Results have been
quite acceptable (Fig. 303.2).
SUMMARY
By including the rich vascular plexus that terminates the posterior radial collateral artery and extends well
into the forearm, the pedicle of the lateral arm flap can perfuse the entire posterior proximal half of the
forearm, capturing the cutaneous territory of the posterior interosseous artery. The posterior cutaneous
nerve of the forearm provides constant direct innervation to the proximal forearm flap. The flap can be used
as a pedicled or free flap, depending on the recipient site, and it provides very thin sensate skin, with
minimal donor-site morbidity.
FIGURE 303.2 Clinical case. A: Complex palmar defect following release of severe burn contracture. B:
Design of the bilobed proximal forearm flap. C: Final outcome, flexion.
References
1. Kuek LB, Chuan TL. The extended lateral arm flap: a new modification. J Reconstr Microsurg 1991;7:167.
2. Rivet D, Buffet M, Martin D, et al. The lateral arm flap: an anatomical study. J Reconstr Microsurg

1987;3:121.
3. Brand KE, Khouri RK. The lateral arm/proximal forearm flap. Plast Reconstr Surg 1993;92:1137.
4. Katsaros J, Schusterman M, Beppu M, et al. The lateral upper arm flap: anatomy and clinical applications.
Ann Plast Surg 1984;12:489.
5. Schusterman M, Katsaros J, Beppu M. The lateral arm flap: an experimental and clinical study. In: Williams
HB, ed. Transactions of the VIII International Congress of Plastic Surgery. 1983;132.
6. Acland RD, Madison S, Moffet TR, et al. A long-pedicled extension of the lateral upper arm flap. Presented
at the VIth Annual Meeting of the American Society of Reconstructive Microsurgery, Toronto, Canada, 1990.

Chapter 304
Paired Abdominal Skin Flaps for The Hand
T. MIURA
EDITORIAL COMMENT
When considering local flaps to resurface both surfaces of the hand, this is an excellent design that will
accomplish this objective. To keep the flaps relatively thin, they need only to be deepened just below
Scarpa's fascia.
Promptly covering raw areas on the opened palmar and dorsal surfaces is the key to successful treatment of the
avulsed hand. The raw surface, an unfavorable bed for split-thickness skin grafts, should be covered with flaps
(1, 2, 3, 4, 5, 6).
INDICATIONS
The technique can be used in almost all cases that need flap coverage (Fig. 304.1), and the best
indications are the following.
Circumferentially Degloved Avulsion Injuries
Circumferentially stripped hands and fingers, with circulatory disturbance, constitute an unfavorable bed for
splitthickness skin grafts. Immediately after surgical debridement, the palmar and dorsal surfaces of the raw
hand can be covered in between an inside-to-inside flap, like a sandwich (Fig. 304.2).
Release of Adduction Contractures of the Thumb
In mild adduction contracture, a small local rotation flap of the dorsal skin is available, but in severe cases
adequate dorsal skin is not available. In such cases Littler's method is a desirable one (5). Although this flap
is sufficient to release the dorsal skin contracture, it is not adequate to supplement the palmar skin, and the
interdigital space is too deep.
After complete release of contractures in the first interdigital space with a longitudinal skin incision on the
dorsum and a curved incision around the thenar eminence, the opened interdigital space is sandwiched in
between an inside-to-inside flap. Special care should be taken so that a straight suture line will not cross
the web.
Paired flaps provide broader flaps, to fill in for any palmar and dorsal skin contracture and to make it
possible to prepare the web space in the desired form (4) (Fig. 304.3).
Reconstruction of Congenital Hand Anomalies
Paired abdominal flaps are indicated to correct the so-called Windmühlenflügelstellung (windmill sail
position) and hypotrophic thumb (6).
Congenital Ulnar Deviation Deformities
Following the correction of a congenital flexion deformity, the opened palmar surface can be covered with
split-thickness or full-thickness skin grafts. However, in severe congenital adduction, flexion, and ulnar
deviation deformity of the thumb and fingers, such as arthrogryposis multiplex congenita, digitotalar
dysmorphism, and Freeman-Sheldon syndrome, opened palmar and interdigital raw areas are an
unfavorable bed for split-thickness skin grafts, because of the shortage of subcutaneous tissues. In such

cases all the opened raw areas should be covered simultaneously with flaps.
After surgical correction with skin incisions along the two palmar and dorsal creases, the opened interdigital
space and palmar surface are sandwiched in between an inside-to-inside flap (Fig. 304.4).
Hypoplastic or Adducted Thumb
In some cases of hypoplastic and/or adducted thumb, paired abdominal flaps are the indicated procedure.
After sufficient correction of the position of the thumb, opened raw areas that may be on the first interdigital
space are sandwiched in between an inside-to-inside flap.
FIGURE 304.1 A: An S-shaped skin incision is designed on the abdominal wall. B: The vis-à-vis flaps are
raised at the subcutaneous level. C: The two flaps are rotated and joined at the edges, inside-to-inside. D:
The pocket of paired flaps enables one to cover simultaneously both the palmar and the dorsal sides of the
denuded hand. (From Miura and Nakamura, ref. 3, with permission.)

FIGURE 304.2 A: Male patient seen 10 days after a degloving injury to the right hand. The index, middle,
and ring fingers were necrotic. B: The denuded fingers were covered with paired flaps. C: Three weeks
later the pedicles were detached from the abdominal wall. D: Still later, the index, middle, and ring fingers
were separated.
FIGURE 304.3 A: Male patient with severe posttraumatic adduction contracture of the first web space. B:
After complete release of contracture in the first interdigital space, the first metacarpal was fixed with two
Kirschner wires and sandwiched in the paired flaps. C: Three weeks later the pedicles were detached.
FLAP DESIGN AND DIMENSIONS

Two flaps of adequate size are designed on the abdominal wall and are used to cover raw areas on the opened
palmar and dorsal surfaces. A flap for the dorsal surface is designed to have its pedicle on the caudal side, and a
flap to cover the palmar surface has a pedicle on the cephalic side. To avoid a straight line scar across the web
space, one of the two flaps must be designed to put a triangle of tissue on the other side. If possible, the two
flaps are extended 1 to 2 cm, to free the pedicles. The two flaps are joined together at one side, and an S-
shaped skin incision is planned (Fig. 304.1A).
FIGURE 304.4 A: Female child with severe adduction, flexion, and ulnar deviation deformity of the digits. B: The
opened raw areas on the dorsal and volar surfaces were covered with paired flaps.
OPERATIVE TECHNIQUE
The vis-à-vis flaps are raised at the subcutaneous level (Fig. 304.1B). Blood vessels directly under the skin must
be protected and included in the flap. The flaps are joined at the edges to form an inside-to-inside flap (Fig.
304.1C). The raw areas remaining on the abdominal wall can be closed with direct sutures in almost all cases. In
a few cases, a split-thickness skin graft will be required. The denuded surface of the hand is sandwiched in
between the inside-to-inside flap (Fig. 304.1D). Three weeks later the pedicles are detached from the abdominal
wall. Care should be taken to avoid making a straight suture line across the web space.
CLINICAL RESULTS
Since 1970, I have employed “paired abdominal flaps,” a modification of other methods (2, 3) to construct
an adequate flap or flaps to cover the raw surface of the hand. This procedure reduces the fixation period to
3 weeks, provides broader flaps to fill in both palmar and dorsal raw surfaces, permits simultaneous
complete closing of the denuded wound on the palmar and dorsal surfaces, and makes the hand position
freer and the technique easier.
The single disadvantage of this procedure is the necessity of fixation and a period of 3 weeks before
separating the embedded hand from the abdominal wall. Although I have never experienced any
troublesome exudation and necrosis of the flaps, protection of the blood vessels directly under the skin,
meticulous hemostasis and careful bandaging are essential for preventing hematomas and troublesome
complications.
SUMMARY
Paired abdominal flaps can be used to reconstruct the palmar and dorsal surfaces of the injured hand. They
can also be used for many other traumatic and congenital problems of the hand to cover both sides of a
web space.

References
1. Brown JB. Surface repair of compound injuries. J Bone Joint Surg 1944; 26A:448.
2. Tajima T, Uchiyama J, Noto S. The procedure of pedicle skin graft covering the entire surface of the
injured hand or forearm primarily. Jpn J Plast Reconstr Surg 1969;12:87.
3. Miura T, Nakamura R. Use of paired flaps to simultaneously cover the dorsal and volar surfaces of a raw
hand. Plast Reconstr Surg 1974;54:286.
4. Miura T. Use of paired abdominal flaps for release of adduction contractures of the thumb. Plast Reconstr
Surg 1979;63:242.
5. Littler JW. The prevention and correction of adduction contracture of the thumb. Clin Orthop 1959;13:182.
6. Miura T. Use of paired abdominal flaps for congenital hand anomalies. Jpn J Plast Reconstr Surg
1980;23:180.

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Chapter 305
Anterior Chest Wall Skin Flaps to The Forearm and Hand
R. G. KATZ
W. L. WHITE
The application of a skin flap to the forearm or hand may be indicated as part of the initial treatment of an acute
wound involving a loss of skin, or as the first step in later reconstruction of a disabled upper extremity (1). At the
current time in the era of axial pattern flaps and free flaps, random pattern flaps originating from the anterior
chest wall remain an infrequently needed but useful tool in the hand surgeon's armamentarium (2, 3).
INDICATIONS
Cutaneous defects of the upper limb can usually be repaired with skin grafts or with local skin flaps. When
these two modalities are not satisfactory, flaps from a distance are indicated. Chest wall flaps have the
advantage of permitting elevation of the hand at the time of initial application, in distinction to flaps
originating on the abdomen or in the groin that require placement of the extremity in a dependent position.
FLAP DESIGN AND DIMENSIONS
A skin flap from the anterior chest wall originates in the area bounded by the nipple line superiorly, the umbilicus
inferiorly, and the midaxillary line laterally. Considerations in the selection of a flap donor site include the location
and size of the recipient site, the ease of application of the flap to the extremity, the patient's comfort while the
extremity is immobilized, the availability and quality of skin at the tentative donor site, and the resultant cosmetic
deformity at the flap donor site.
Anterolateral Chest Wall Skin Flap
Flaps based laterally on the lower anterolateral chest derive their blood supply from the intercostal and the
thoracoepigastric
vessels. The skin in this area has great mobility, as it normally must move over the flare of the lower ribs during
movements of the thorax (Fig. 305.1). In comparison with the lower abdomen, this skin is more pliable, the
subcutaneous fat layer is thinner, and the surrounding skin is more elastic. These characteristics usually permit
elevation and application of the flap in one stage and closure of the donor defect without resorting to a skin graft.
In addition, the thinner tissue in the anterolateral chest resembles that of the hand and forearm and allows
accurate fitting of the flap, minimizing the need for a secondary defatting of the flap. The fact that there is
generally scant growth of hair in this area is an additional benefit (4).

FIGURE 305.1 The tissue over the flare of the lower ribs is thin, pliable, generally hairless, and well
vascularized. The tissue laxity is such as generally to allow direct closure of the donor defect. (From White, ref.
2, with permission.)
Contralateral Anterolateral Chest Wall Flap
The anterolateral chest opposite to the side of the injured upper extremity is an ideal source of skin flaps not
exceeding approximately 7 to 8 cm in width and approximately 10 to 12 cm in length (length to width ratio of
approximately 1.5:1) for application to the digits, palm, dorsum of the hand, and occasionally to the wrist. These
transversely oriented flaps should not extend across the ventral midline, since the collateral blood supply of the
skin across the midline in this region is poor (Fig. 305.4).
Ipsilateral Anterior Chest Wall Flap
Flaps based on the lower anterolateral chest on the same side as the involved upper extremity are best suited for
coverage about the elbow, forearm, and proximal wrist (4). These flaps may be based laterally, superiorly, or
inferiorly, and if need be, can be extended to the upper abdomen. These flaps have a length to width ratio of
approximately 1.5:1.
FIGURE 305.2 The cross-chest position of the forearm in an obese or emphysematous patient is easily obtained
with the body upright. On reclining, however, the thorax is thrust anteriorly and the shoulders fall posteriorly. This
produces tension on the attached flap. (Upper left and right) Views of the upper extremity position with the
patient standing. (Lower left and right) Views of the upper extremity position with the patient supine. (From
White, ref. 2, with permission.)

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FIGURE 305.3 Flaps from the epigastric area may be quite large. If they are based inferiorly, a delay procedure
may be necessary. Because of the poor blood supply in the midline, tissue loss is frequently encountered in this
area (*). The donor site defect should be closed by means of skin grafts. (From White, ref. 2, with permission.)
Anteromedial Chest Wall Flap
Flaps originating on the anterior chest wall can also be based medially. The blood supply to these flaps is
provided by perforating vessels from the internal thoracic artery and/or the superior epigastric artery. By placing
the base of the flap approximately 5 to 6 cm from the midline, the important vascular system nourishing the flap is
maintained. If a flap is of appropriate width, it can extend in length to the region of the anterior axillary line. Such
flaps have previously been described for use in breast reconstruction (5, 6). These flaps are suitable for
application to the hand or distal forearm and are based on the ipsilateral or contralateral side of the chest,
depending on the location of the recipient site (Fig. 305.2).
Epigastric Skin Flap
When the recipient defect is large and is located on the distal forearm and/or the hand, an apron flap based
inferiorly just above the umbilicus provides a great expanse of skin (Fig. 305.3). This flap is most useful in male
patients and makes use of the cross-chest position. The width of these flaps is limited only by the width and
convexity of the torso.
The upper border of these flaps may be placed from the fifth intercostal space to the xyphoid tip. They may be 18
to 20 cm in width and 15 to 18 cm in length. If these flaps are divided and inset in stages, it is possible to
resurface the distal forearm circumferentially. Delay procedures are more often required if the skin is not supple.
Occasionally it is preferable to base these epigastric flaps superiorly in the region of the xyphoid. However,
application of the flap may be technically difficult, as the skin of the upper abdomen is somewhat thicker and less
pliable than that of the lower chest.
Infraclavicular Flap
When small skin flaps are needed for digital cover or for extension of the digits, the area just below the clavicle
on the contralateral side is an excellent source of tissue (7). The skin is thin, the blood supply is excellent, and
the position the patient must maintain is both stable and comfortable. This area is not suitable for larger flaps and
is contraindicated in women because of the unsightly scar. In men there may be a heavy growth of hair present
in this area. With an obese or emphysematous patient, a flap suitable for the extremity without tension on the flap
will be difficult to maintain (Fig. 305.2).
OPERATIVE TECHNIQUE
When applying a flap to the upper extremity, consideration should be given to attempting to obtain a closed
wound in the flap donor site, the flap pedicle, as well as in the recipient site. A closed wound may be achieved by

P.824
combining tubing of the flap pedicle, direct closure of the donor site, and skin-grafting open areas of the donor
site and/or pedicle, as appropriate for the specific situation. This will avoid the undesirable inflammatory effects
of an open wound on the hand and flap, and drainage from such a wound. Still, closure of the open area of a flap
pedicle frequently is not practical and the open wound can be well managed with petrolatum-impregnated fine
mesh gauze dressings.
FIGURE 305.4 The point of the flap reaching across the midline should be removed, as the blood supply across
the midline in this area is poor. (From White, ref. 2, with permission.)
FIGURE 305.5 Demonstrating the rotation of the flap which occurs when the superior (A) or inferior (B) limb of
the donor site incision is extended and the donor site is closed. (From White, ref. 2, with permission.)
Contralateral Anterolateral Flap
Closure of the defect may be facilitated and a dog-ear avoided by giving the flap a temporary extension (tapered
to a point) across the midline. After the flap is elevated, the tissue that was beyond the midline should be
discarded (Fig. 305.4). The ability to close the donor defect directly provides the potential for rotation of the flap
through a range of 180° (Fig. 305.5).
Rotation is accomplished by extending the superior or inferior limb of the initial incision. If the superior incision is
extended laterally for a distance equal to the width of the flap, the flap will be rotated superiorly on closure of the
donor site. Conversely, if the inferior limb of the initial incision is extended laterally, the flap will be rotated

inferiorly. In general, the situation where the flap is ultimately based inferiorly (as shown in Fig. 305.3A) is the
preferred orientation, inasmuch as it minimizes venous congestion and edema formation in the flap by permitting
dependent drainage.
FIGURE 305.6 The cross-chest position permits comfortable movement and independence of the patient. (From
White, ref. 2, with permission.)
If the chest wall skin flap is to be tubed (as in application to a degloved thumb), the base of the flap is not rotated
as discussed above. The margins of the donor defect are simply approximated and the flap is tubed. Since there
is relatively little fat present about the lower chest, this flap may be tubed with minimal thinning. In addition,
because of the excellent vascularity of the area, this flap seldom needs to be delayed.
Using the area above the umbilicus as a donor site for flaps to be applied to the hand and wrist permits the
recipient forearm to be positioned across the lower chest and upper abdomen with the elbow flexed at
approximately 90°. This cross-chest position of the forearm permits the patient significant comfort and mobility
(Fig. 305.6). The arm is held flush with the trunk, preferable to having the elbow protrude, which would occur if
the flap were raised from the ipsilateral chest area. The patient with his forearm fixed in a cross-chest position
can wear street clothes and may be managed as an outpatient approximately 5 to 7 days after flap application.
Early in the postoperative period, with adult patients of slender or average habitus, the operated extremity is
immobilized by dressings and elastic bandages. A light plaster covering added over the bandages ensures more
secure mobilization and is recommended for children and some adults of heavy build.
Ipsilateral Anterior Chest Wall Flap
Depending on the size of the donor defect, direct closure of the donor site may not be possible and a skin graft
may be required to close the donor defect and to cover the open area of the bridging portion of the flap pedicle.
In the case of defects about the proximal forearm, there is usually little choice in regard to other skin flap donor
sites. These flaps offer the same advantages of excellent tissue and ease of forearm positioning as described
above.
Epigastric Skin Flaps
A split-thickness graft is necessary to close the flap donor site. The graft should cover the bridging portion of the
flap as well.
In female patients, small donor defects located in the inframammary region can be closed with minimal deformity.
However, the closure of large donor sites in this area may displace the breasts inferiorly. In those instances in
female patients where a large flap is required, it is preferable to use the lower abdomen as the flap donor site.
Separation of Flaps: Delay Procedures
If the flap has a relatively large area of inset relative to the total area of the flap that is to be transferred, if

P.825
there is no compromise of flap viability, and if the area of flap inset is well healed, then the flap may be
divided 2 weeks after its application. Occasionally the division of a large flap may need to be undertaken in
stages, particularly if an extension of the flap is needed to obtain tissue to wrap around the extremity. A trial
clamping of the base of the flap may be done. The adequacy of the blood supply can be judged clinically by
inspection or by fluorescence.
Occasionally after elevation, a flap will be noted to have poor color and circulation, necessitating returning it
to the donor site and postponing its transfer. Although a delay procedure will improve flap circulation, it will
cause some induration and fibrosis of the flap, making later fitting of the flap to the recipient site somewhat
more difficult.
CLINICAL RESULTS
The application of an anterior chest wall flap to the upper extremity has the disadvantages of requiring
significant immobilization of the shoulder and of producing scarring that is exposed when the patient is
clothed in swimwear or similar attire.
The difficulty most frequently encountered in applying flaps from the anterior chest wall to the upper
extremity is an increased anteroposterior diameter of the chest. This may be secondary to obesity but is
more often caused by pulmonary emphysema. In these barrel-chested individuals, it is relatively easy to
place the forearm across the trunk if the patient is standing or sitting. When the patient is supine, however,
the rib cage is pushed anteriorly and the shoulders fall posteriorly. If this change of relative position of the
chest and shoulders is
not considered when the flap is planned, there will be difficulty achieving satisfactory immobilization of the
extremity and this may result in tension on the flap base (Fig. 305.2). Placing the patient in a semi-sitting
position in bed somewhat alleviates this problem.
SUMMARY
The chest wall can be a good source of skin flap coverage for hand and forearm defects, especially when
other flaps are not available.
References
1. Gillies H. Design of direct pedicle flaps. Br Med J 1932;2:1008.
2. White WL. Cross-chest flap grafts. Am J Surg 1960;99:804.
3. White WL. Anterior chest wall skin flaps for the arm and hand. In: Grabb W, Myers B, eds. Skin flaps.
Boston: Little, Brown, 1975;397.
4. Greeley PW. Practical procedures for correction of scar contractures of hand. Am J Surg 1947;74:622.
5. Cronin TD, Upton J, McDonough TM. Reconstruction of the breast after mastectomy. Plast Reconstr Surg

1977;59:1.
6. Davis WM, McCraw JM, Carraway JH. Use of a direct transverse, thoracoabdominal flap to close difficult
wounds of the thorax and upper extremity. Plast Reconstr Surg 1977;60:526.
7. Chase RA. Atlas of hand surgery. Philadelphia: Saunders, 1973.

Chapter 306
Hand Sandwich
D. W. FURNAS
EDITORIAL COMMENT
As with all major reconstructive efforts, the possibility of amputation combined with a good working
prosthesis should always be considered.
Major tissue losses involving both the volar and the dorsal surfaces of the upper limb present a formidable
reconstructive problem. Paired flaps, forming a hand sandwich, have proved to be a satisfactory solution to this
problem (1, 2).
INDICATIONS
An earlier technique was designed at a time when the only axial flaps described were the deltopectoral flap,
the groin flap, the epigastric flap, and the temporal artery flap. A trial with plastic patterns showed that the
distance between a pair of groin flaps would have been too great for the flaps to reach the hand defect
simultaneously. Thus, random pattern flaps were designed that satisfied the goal of immediate coverage of
the exposed tendons, nerves, and bone.
FLAP DESIGN AND DIMENSIONS
In the original design (1), paired flaps on two separate opposing body surfaces, the chest and the upper arm,
were used to envelop the raw hand (Fig. 306.1). Serial delay incisions on the arm and the chest were used to
outline the tissue destined to resurface the distal parts of the hand. In the final stage, the flaps were elevated, the
arm and chest were separated, and the flaps were closed over the hand. The raw surfaces of the hand and
forearm were repaired with split-thickness skin grafts (Fig. 306.2).
The potential donor sites for “sandwich” coverage of the hand multiplied dramatically with the advent of
musculocutaneous flaps, muscle flaps, and other useful axial flaps. The use of paired axial flaps was developed
for the repair of a degloved hand (2). Ipsilateral groin and tensor fasciae latae flaps were used in an ingenious
design (Figs. 306.3 and 306.4). This flap greatly improved on the original sandwich design by obviating delay
incisions and improving mobility of the shoulder. Other musculocutaneous, muscle, and axial flaps would appear
to have similar applicability.
Among possible candidates as hand sandwiches are (1) groin flap plus epigastric flap, (2) posterior trapezius
musculocutaneous flap plus pectoralis major musculocutaneous flap, (3) latissimus dorsi musculocutaneous flap
plus pectoralis musculocutaneous flap, and (4) paired gracilis flaps.
Certain single flaps could be considered as material for a hand sandwich (more a bun than a sandwich): (1) A
single latissimus dorsi muscle flap, surfaced with a skin graft, could sandwich an entire hand. It could be based
on the thoracodorsal artery or on the collateral arteries (reverse latissimus). It could even be transferred as a
microvascular flap to save the intervening stage and to maintain a permanent arterial pattern. A skin graft would
be needed only on the hand, as the donor site would be closed primarily. (2) The omentum could be used in

similar fashion, and would have the potential of sandwiching each digit individually. The patient could have the
independent use of each finger from the start.
SUMMARY
The “hand sandwich” idea can thus be invoked in any of a multitude of current forms when the urgent need
arises for coverage of the degloved hand.
FIGURE 306.1 Construction of sandwich coverage from arm and chest flaps. A: Posteriorly based flaps are
plotted. (The entire axilla could be included in the flaps, but the axillary skin may have a less dependable
blood supply.) B: The donor area of the arm is joined to the donor area of the chest, making an extended
pocket. C: The raw hand is placed between the flaps. D: The flaps are sutured together, enveloping the
hand. Additional skin can be gained by delay incisions (dashed lines). (From Smith and Furnas, ref. 1, with
permission.)