Vạt Da Và Phẫu Thuật Tái Tạo (Flaps and Reconstructive Surgery)

e172
PART 4 — CONVENTIONAL WORKHORSE FLAPS
A 55-year-old paraplegic patient presented with a large sacral
decubitus sore. The defect was treated by surgical debridement
and bilateral GM musculocutaneous flaps. The flaps were
sutured to each other in the midline (pressure area) and the
wounds were closed via V-Y advancement (Fig. 44.15).
CASE 44.1  Sacral Defect Reconstructed with Bilateral Gluteus Maximus Advancement Flaps
Figure 44.15  (A) A clinical case of a paraplegic patient with a sacral bed sore. (B) The defect after debridement. (C) The defect was
closed by bilateral V-Y GM musculocutaneous flaps.
A
C
B
A similar patient with a long-standing sacral bed sore. The cover-
age was done using a unilateral SGAP pedicled flap. The GM
muscle was left intact and the flap was transposed into the defect
(Fig. 44.16). Note that the midline (pressure area) is free from
suture lines.
CASE 44.2  Sacral Ulcer Reconstructed with Bilateral Pedicled SGAP Flaps
Figure 44.16  (A) A paraplegic patient with a sacral bed sore with a planned SGAP flap. (B) The defect after debridement and transfer of
the SGAP, based on one perforator. (C) Wound closure.
A
B
C

CHAPTER 44 — Gluteus Flap
e173
A 48-year-old patient sustained a chronic wound breakdown and
recurrent fistula after spinal vertebral surgery with use of osteo-
syntheses. The wound was debrided and closed primarily twice
by the orthopedic surgeon. An extended SGAP was planned. A
compound flap (perforator skin flap with a segment of GM
muscle based on a muscle branch) was transposed successfully
to cover the defect and fill the dead space (Fig. 44.17).
CASE 44.3  Lower Spinal Defect Reconstructed with an Extended Pedicled Chimeric SGAP
Flap with a Piece of Gluteus Muscle
Figure 44.17  (A) A chronic fistula and infected osteosynthesis after vertebral surgery. (B) A planned extended SGAP flap. (C) The com­
pound flap was transferred based on one perforator and a segment of the GM muscle to cover the defect. (D) Wound closure.
A
B
C
D

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
A 55-year-old patient who underwent left mastectomy. She had
had an abdominoplasty in the past, which prohibited the use of
abdominal flaps. Breast reconstruction with a SGAP flap was
performed together with contralateral breast remodeling in
order to obtain adequate breast symmetry (Fig. 44.18).
CASE 44.4  Left Mastectomy Defect Reconstructed with a Free SGAP Flap
Figure 44.18  A 55-year-old patient, who had had an abdominoplasty, underwent a secondary left breast reconstruction with right breast
remodeling. (A,B) Preoperative and postoperative views. (C) Design of SGAP flap over the left buttock. (D) The scar on the donor site.
A
B
C
D

CHAPTER 44 — Gluteus Flap
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REFERENCES
1. Fujino T, Harashina T, Aoyagi F. Reconstruction for aplasia of the
breast and pectoral region by microvascular transfer of a free flap
from the buttock. Plast Reconstr Surg 1975;56:178–81.
2. Le Quang C. Two new flaps developed from aesthetic surgery. II.
The inferior gluteal flap. Aesthetic Plast Surg 1980;4:159.
3. Koshima I, Moriguchi T, Soeda S, et al. Gluteal perforator-based flap
for repair of sacral pressure sores. Plast Reconstr Surg 1993;91:
678–83.
4. Allen RJ, Tucker C. Superior gluteal artery perforator free flap for
breast reconstruction. Plast Reconstr Surg 1995;95:1207–12.
5. Mathes JM, Nahai F, editors. Clinical applications for muscle and
musculocutaneous flaps. St Louis: Mosby; 1982. p. 426–32.
FURTHER READING
Blondeel PN. The sensate free superior gluteal artery perforator
(S-GAP) flap: a valuable alternative in autologous breast reconstruc­
tion. Br J Plast Surg 1999;52:185–93.
Blondeel PN, Van Landuyt K, Hamdi M, et al. Soft tissue reconstruction
with the superior gluteal artery perforator flap. Clin Plast Surg
2003;30(3):371–82.
Borman H, Maral T. The gluteal fasciocutaneous rotation-advancement
flap with V-Y closure in the management of sacral pressure sores.
Plast Reconstr Surg 2002;109(7):2325–9.
Evans GR, Dufresne CR, Manson PN. Surgical correction of pressure
ulcers in an urban center: is it efficacious? Adv Wound Care 1994;
7(1):40–6.
Fade G, Gobel F, Pele E, et al. Anatomical basis of the lateral superior
gluteal artery perforator (LSGAP) flap and role in bilateral breast
reconstruction. J Plast Reconstr Aesthet Surg 2013;66(6):756–62.
Foster RD, Anthony JP, Mathes SJ, et al. Ischial pressure sore coverage:
a rationale for flap selection. Br J Plast Surg 1997;50(5):374–9.
Ger R, Levine SA. The management of decubitus ulcers by muscle trans­
position. An 8-year review. Plast Reconstr Surg 1976;58(4):419–28.
Guerra AB, Metzinger SE, Bidros RS, et al. Breast reconstruction with
gluteal artery perforator (GAP) flaps: a critical analysis of 142 cases.
Ann Plast Surg 2004;52(2):118–25.
Hamdi M, Blondeel P, Van Landuyt K, et al. Bilateral autogenous breast
reconstruction using perforator free flaps: a single center’s experi­
ence. Plast Reconstr Surg 2004;114(1):83–9.
Hamdi M, Van Landuyt K, Van Hedent E, et al. Advances in autogenous
breast reconstruction: the role of preoperative perforator mapping.
Ann Plast Surg 2007;58(1):18–26.
Higgins JP, Orlando GS, Blondeel PN. Ischial pressure sore reconstruc­
tion using an inferior gluteal artery perforator (IGAP) flap. Br J Plast
Surg 2002;55:83–5.
Kierney PC, Engrav LH, Isik FF, et al. Results of 268 pressure sores in
158 patients managed jointly by plastic surgery and rehabilitation
medicine. Plast Reconstr Surg 1998;102(3):765–72.
Kroll SS. The superior gluteal free flap for breast reconstruction. In:
Schusterman MA, editor. Microsurgical reconstruction of the cancer
patient. Philadelphia: Lippincott-Raven; 1997. p. 178–89.
Lin CT, Chang SC, Chen SG, et al. Modification of the superior gluteal
artery perforator flap for reconstruction of sacral sores. J Plast Recon­
str Aesthet Surg 2014;67(4):526–32.
Masia J, Clavero JA, Larrañaga JR, et al. Multidetector-row computed
tomography in the planning of abdominal perforator flaps. J Plast
Reconstr Aesthet Surg 2006;59(6):594–9.
Nahai F. Gluteus maximus musculocutaneous flap for breast recon­
struction. Perspect Plast Surg 1992;6:65.
Parry SW, Mathes SJ. Bilateral gluteus maximus myocutaneous advance­
ment flaps: sacral coverage for ambulatory patients. Ann Plast Surg
1982;8(6):443–5.
Ramirez OM. The distal gluteus maximus advancement musculocuta­
neous flap for coverage of trochanteric pressure sores. Ann Plast
Surg 1987;18(4):295–302.
Ramirez OM, Orlando JC, Hurwitz DJ. The sliding gluteus maximus
myocutaneous flap: its relevance in ambulatory patients. Plast Recon­
str Surg 1984;74(1):68–75.
Scheflan M, Nahai F, Bostwick J 3rd. Gluteus maximus island musculo­
cutaneous flap for closure of sacral and ischial ulcers. Plast Reconstr
Surg 1981;68(4):533–8.
Shaw WW. Microvascular free flap breast reconstruction. Clin Plast Surg
1984;11(2):333–41.
Stallings JO, Delgado JP, Converse JM. Turnover island flap of gluteus
maximus muscle for the repair of sacral decubitus ulcer. Plast Recon­
str Surg 1974;54(1):52–4.
Verpaele AM, Blondeel PN, Van Landuyt K, et al. The superior gluteal
artery perforator flap: an additional tool in the treatment of pressure
sores. Br J Plast Surg 1999;52:385–91.

491
Pedicled Flaps of the Hand
James P. Higgins  |  Ryan D. Katz
45 
INTRODUCTION
This chapter covers a selection of pedicled flaps commonly
used for soft tissue coverage of the hand. Several are based
on primary vessel pedicles (Moberg flap, posterior interos­
seous artery flap, and homodigital island flaps), whereas
others are based on secondary cutaneous branches of larger
primary structures (ulnar artery perforator flap, cross finger
flap). These provide a less complex and rapid means of
achieving wound closure as compared with free tissue trans­
fer, and often with very low donor site morbidity. As a result,
these have become “workhorse” flaps for the reconstructive
hand surgeon.
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION F  —  LOCAL AND FREE FLAPS IN THE UPPER EXTREMITY
Dorsal digital branches
of dorsal branch
of ulnar nerve
Superficial branch
of radial nerve
Dorsal sensory
branches of
radial nerve
First dorsal
metacarpal
artery
Flap
Extensor carpi radialis
longus tendon
Extensor pollicis
brevis tendon
Extensor pollicis
longus tendon
Extensor digitorum
tendons
Dorsal digital branches
of superficial branch
of radial nerve
Dorsal
metacarpal
arteries
Dorsal branch
of ulnar nerve
Radial artery
Extensor retinaculum
Extensor carpi radialis
brevis tendon
Extensor
indicis tendon
Extensor digiti
minimi tendon
Extensor carpi
ulnaris tendon
Dorsal carpal
arterial arch
Figure 45.1  First dorsal metacarpal artery flap.

492
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Secondary:  branch(es) of the cephalic venous system
Length: range 3–6 cm
Diameter: range 1–2 mm
Larger caliber superficial branches of the cephalic system
can be harvested to be included in the vascular leash if they
course appropriately to the skin segment and can be mobi­
lized adequately. This may provide additional drainage if
desired.
FLAP INNERVATION (Fig. 45.1 and See
Figs 12.20, 12.22)
Sensory nerve branches from the dorsal sensory radial nerve
will typically be included in this flap, particularly if volar
thumb coverage is desired. There is a reliably located branch
that will mimic the course of the FDMA, although it is
located more superficially. This can be elevated and mobi­
lized with the flap to provide immediate sensation of the
reconstruction.
FLAP COMPONENTS: SKIN AND
SUBCUTANEOUS TISSUE
Advantages
• Reliable anatomy
• Ease and speed of harvest
• Sensate thin pliable tissue
• Low donor site functional morbidity
Disadvantages
• Donor site requires skin graft
• Donor site visibly conspicuous
FLAP DESIGN (Cases 45.1, 45.2)
The skin segment of the flap may encompass the entire
dorsal skin of the proximal phalanx of the index finger.
Although typically described as a rectangular flap, the
authors routinely make two modifications on this design.
First, the proximal ulnar margin of the flap may be rounded
to avoid incisions violating the second web space in order
to avoid scar contractures in this region of unique tissue.
Second, the proximal radial margin can be harvested with
a tapering V-shaped tongue of skin. This tapered edge will
allow ease of inset of the flap in its destination by relieving
the tension of the skin margin on the distal tunnel.
As with most fasciocutaneous flap harvest techniques, the
flap is generally harvested slightly larger than the measured
soft tissue defect to ensure tension-free closure. Regardless
of size of the harvest, the donor site will require skin graft
coverage and cannot be primarily closed.
Particular care should be made to design the radial
margin at the glabrous margin of the index finger radial
midaxis. Designing this margin more dorsally may risk com­
promising the pedicle connections to the skin segment.
After outlining the skin segment as described, a longitu­
dinal incision is then extended from the proximal margin
of the skin flap to the palpable interval between the thumb
and index metacarpal bases.
Prior to tourniquet inflation, the surgeon may elect to
discern the pathway of the FDMA with a handheld Doppler.
FIRST DORSAL METACARPAL
ARTERY FLAP
FLAP ANATOMY (Fig. 45.1 and See
Figs 12.20, 12.21, 12.22)
The dorsal carpal arch originates from the dorsal branch
of the radial artery as it courses through the anatomic
snuffbox. The arch gives rise to a series of dorsal metacar­
pal arteries that travel distally in the intermetacarpal
spaces. These vessels are numbered sequentially from
radial to ulnar (first, second, third, etc.). The vessel that
has been referred to as the first dorsal metacarpal artery
(FDMA) will often arise independently from the radial
artery rather than as a branch of the dorsal arch itself.
This vessel runs along the surface of the first dorsal inter­
osseous muscle to ultimately provide perfusion to the skin
overlying the dorsal aspect of the index finger proximal
phalanx.
Dominant Pedicle:  first dorsal metacarpal artery
Length: 3–6 cm
Diameter: 0.5–1.0 mm
The vascular pedicle is often clearly visible proximal near
the pedicle origin in the snuffbox, whereas its terminal
branches are often difficult to discern. These branches pass
between the extensor tendon and the radial mid-axis of the
index finger. Wide harvest of this entire fibrofatty leash to
include all tissue immediately subdermal down to, but not
including, the sagittal fibers of the extensor mechanism is
performed to safely include these small vessels. From the
metacarpophalangeal (MCP) joint to the proximal inter­
phalangeal (PIP) joint, the skin paddle is harvested with all
of the subcutaneous fat and vessels, leaving only the thin
paratenon covering the extensor mechanism.
Minor Pedicle:  communicating perforators from palmar
arterial system
The first dorsal metacarpal artery communicates with the
palmar arterial systems through a communicating branch
reliably located at the level of the metaphyseal flare of the
index finger metacarpal neck. This vessel is routinely ligated
in the elevation of the antegrade FDMA flap, but may be
used as a pivot point for a retrograde distally based FDMA
flap (utilized if coverage is needed for the proximal phalanx
or PIP joint).
VENOUS DRAINAGE (See Figs 12.18 and 12.22)
Primary:  venous comitantes of the FDMA system
Length: 3–6 cm
Diameter: 0.2–0.3 mm
These vessels are particularly difficult to identify. The
pedicle is harvested with a wide fibrofatty leash that encom­
passes the subcutaneous fat, vessels, and fascia overlying the
first dorsal interosseous muscle. This wide margin of harvest
will ensure adequate drainage to the skin segment.

CHAPTER 45 — Pedicled Flaps of the Hand
493
The skin flaps at the metacarpal level are elevated in
the subdermal plane in both a radial and ulnar direction.
Once adequate exposure is obtained, the subcutaneous
tissue is incised sharply along the radial margin of the
index metacarpal to the subfascial plane of the first dorsal
interosseous muscle. On the radial margin of the dissection
the subcutaneous tissue is incised sharply down to the
subfascial plane of the adductor pollicis muscle. All inter­
vening tissue between these parallel boundaries is then
elevated distal to proximal, exposing the two muscles
subfascially.
At the level of the index metacarpal neck the communi­
cating branch to the volar arterial systems is identified and
ligated, permitting further elevation of the leash proximally.
The FDMA can now be visibly identified on the undersur­
face of the muscle fascia as the elevation continues to the
level of the snuffbox. The origin of the vessel can usually be
clearly identified emanating from the radial artery.
On the superficial surface of the leash the superficial
veins and sensory nerve branch from the radial sensory
nerve can be identified. These structures can be dissected
to further enable further mobilization of the pedicle. At no
point is the arterial pedicle skeletonized in order to avoid
venous compromise of the flap.
At this point, it is wise to release the tourniquet and
confirm viability of the flap as assessed by subdermal bleed­
ing at the distal flap margins. This can provide the surgeon
This is not required and the authors do not routinely
perform this evaluation. Even in the absence of an audible
Doppler signal in this region, the flap may be successfully
harvested.
FLAP DIMENSIONS
Length: 3 cm (range 2–5 cm)
Width: 2 cm (range 1.5–3 cm)
Thickness: the thickness of the dorsum of the hand
Anesthetic Considerations:  local anesthesia with tourniquet
and some sedation can be used.
TECHNIQUE OF HARVEST
After exsanguination and tourniquet inflation, the preop­
erative markings described above are incised. The flap may
be elevated from distally to proximally. The skin segment is
elevated immediately above the paratenon of the extensor
tendon on all margins except the proximal margin that
contains the pedicle. On the radial margin the subcutane­
ous tissue is harvested to include all tissue immediately
dorsal to the radial digital artery and nerve of the index
finger. As the MCP joint is approached, the dissection cau­
tiously proceeds immediately superficial to the sagittal
bands, taking great care not to disrupt the vascular leash.
A 45-year-old man with a draining wound over the interphalan-
geal (IP) joint flexion crease of the thumb after failed attempts
at debridement and delayed primary closure. FDMA is harvested
with markings as described in text. Wound is debrided with
proximal extension created to permit ease of inset and passage
of pedicle through subcutaneous tunnel. Skin graft shown cover-
ing donor site of index finger (Fig. 45.2).
CASE 45.1  Defect Over IP Joint Reconstructed with a Pedicled FDMA Flap
Figure 45.2  (A) preoperative image showing the wound over the IP joint of the thumb. (B) FDMA flap harvested marked (C) flap elevated
and pedicled toward the defect. (D and E) Skin graft shown covering donor site of index finger.
A
B
C
D
E

494
PART 4 — CONVENTIONAL WORKHORSE FLAPS
POSTOPERATIVE CARE AND OUTCOMES
The donor site may be covered with a bolster dressing or
bulky secure soft dressing and a splint for 7–10 days to
ensure skin graft survival. Thereafter, splinting may be aban­
doned and motion-enhancing exercises commenced. The
skin graft usually survives without difficulty in this location,
and stiffness of the donor index finger is very rare in this
procedure.
The skin-grafted donor site will display a contour defect
initially due to the thin nature of the skin graft. With time
and scar maturation the contour remarkably normalizes,
but the color differences between the skin graft and the
dorsal finger remain noticeable. The donor site typically
becomes pain free and full motion is usually regained (see
Cases 45.1, 45.2).
CROSS FINGER FLAP
FLAP ANATOMY (Fig. 45.1 and See
Figs 12.20, 12.21, 12.22)
Cross finger flaps are designed for coverage of soft tissue
defects on the volar aspect of the digits. The cross finger
with reassurance to proceed with wound preparation and
creation of a tunnel for passage of the flap.
With the tourniquet reinflated, the wound is now widely
debrided and a subcutaneous tunnel is created to gener­
ously accommodate the neurovascular leash. When cover­
ing a dorsal or volar thumb defect (most common indications
for this flap), the wound may be extended with a 1–2 cm
incision along the apex of the tunnel to diminish the pres­
sure on the pedicle near the flap inset. In this extension of
the wound, the proximal V-shaped flap margin (see above)
may provide tension-free coverage and inset closure. Alter­
natively, the entire tunnel may be opened to allow ease of
inset and closure.
DONOR SITE CLOSURE
The donor site incision over the dorsal metacarpal region
may be easily closed primarily. The defect over the proximal
phalanx is then skin grafted from the surgeon’s preferred
donor site. The authors will typically harvest from the thin
pliable skin of the visibly inconspicuous medial brachium.
Indications:  distal dorsal and volar thumb defects
Small wounds over the MCP joints or first web space
where it has adequate pedicle length to reach the MCP
joints of the middle finger and thumb.
A 51-year-old man with dorsal degloving of thumb distal phalanx
with loss of distal phalangeal bone stock and bulk. Preoperative
image is shown after patient had healed by secondary intention
with a tight soft tissue envelope, loss of nail components, and
diminished palmar bulk (Fig. 45.3A and B). A dorsal incision
was used to open the soft tissue envelope and elevate the tissue
off the underlying bone, and FDMA tissue was inset dorsally to
provide bulk and pliability (Fig. 45.3C). Final outcome is shown
in Figure 45.3D–F.
CASE 45.2  Thumb Distal Phalanx Defect Following Degloving Injury Reconstructed with a
Pedicled FDMA Flap
Figure 45.3 
A
B
C
D
E
F

CHAPTER 45 — Pedicled Flaps of the Hand
495
• Conventional flap is insensate if nerve coaptation is not
feasible
• Donor site skin graft is visibly conspicuous
PREOPERATIVE PREPARATION
If the donor finger is uninjured, no preoperative testing is
necessary. If the donor finger is also injured, a surface
Doppler examination is recommended to ensure that the
digital artery on the adjacent side of the donor finger is
patent and uninjured.
FLAP DESIGN (Cases 45.3, 45.4)
Flap design is dictated by the location of the wound and the
ease of reach of the tissue on the adjacent digits. The most
common applications are for coverage of fingertip wounds,
or wounds over the DIP joint flexion crease. Due to the
distal location of these wounds the longer of the adjacent
digits is usually selected to provide the greatest reach of the
flap without tension. For this reason, the middle finger
often serves as the donor for wounds on either the index or
ring fingers. Alternatively, wounds on the middle and small
fingers are usually covered by flaps harvested from the ring
finger.
The index finger may serve as a donor for thumb wounds,
although this is not commonly performed because the
variety of other better options for volar thumb coverage
(FDMA flap and Moberg flap), and the morbidity of immo­
bilizing a traumatized hand with the thumb maximally
adducted (first web space contracture).
Although commonly described as a rectangular flap har­
vested by outlining the skin on the dorsal aspect of the
proximal phalanx, the authors routinely design this flap in
a trapezoidal fashion. This is achieved by creating two paral­
lel incisions for the proximal and distal margins of the flap.
These are created to migrate distally as they cross the dorsal
aspect of the donor finger and are ultimately joined by a
midaxial incision on the contralateral aspect of the donor
digit. This design harvests tissue more distally than the con­
ventional rectangular design, including some skin over the
DIP joint extension crease. The eponychial fold is not dis­
turbed. This design modification may be used particularly
effectively when distal reach of the flap is required, such as
for fingertip coverage or on DIP joint flexion crease wounds
on the middle finger.
FLAP DIMENSIONS
Length: 3–4 cm
Width: 1.5–2.5 cm
Thickness: 1.5–3 mm
FLAP MARKINGS
After selecting the adjacent donor digit, the markings start
at a point on the adjacent midaxis of the digit at the level
of the PIP joint. An oblique line is then created moving
distally as it approaches the contralateral midaxis. Here a
longitudinal line is drawn to the level of the base of the distal
phalanx (proximal to the eponychial fold, but distal to the
DIP joint extension crease). The third side of the flap is
flap is an interpolated flap; it is raised as a pedicled skin flap
on the dorsal aspect of a finger adjacent to the digit requir­
ing coverage, inset by temporary attachment of the two
fingers, and divided weeks later when perfusion to the trans­
ferred skin is capable of being supported by the recipient
finger. Unlike the other flaps described in this section, the
cross finger flap always requires a second-stage procedure
for division of the pedicle.
The donor site is the dorsal aspect of the digit distal to
the PIP joint. This angiosome is perfused by dorsal branches
of the digital artery. These very small vessels pass from the
volar aspect of the finger through Cleland’s ligament into
the dorsal skin. The flap is not designed to be harvested as
an island flap nor is the pedicle skeletonized. As a pedicled
flap the size of the elevated skin segment dictates the reach
of the flap; pedicle length and caliber are neither defined
nor relevant to harvest.
Dominant Pedicle:  dorsal skin branches of the donor
digital artery
These branches course dorsally at the level of the proxi­
mal portion of the middle phalanx within the subcutaneous
tissue.
The flap is designed to incorporate a wide base of the
entire length of the middle phalanx in an effort to avoid
injury to these vessels.
VENOUS DRAINAGE (See Figs 12.16, 12.22)
Venous drainage of the flap is provided by the small venous
comitantes of these dorsal arterial branches and is incorpo­
rated within the flap harvest.
FLAP INNERVATION
This flap is most frequently transferred as an insensate flap.
However, dorsal sensory branches of the ipsilateral digital
nerve may be dissected proximally on the donor finger,
transected, and coapted to the digital nerve on the recipient
finger in an effort to provide sensate reconstruction.
FLAP COMPONENTS
This flap is most commonly harvested as a skin flap for volar
adjacent digital coverage. A modification, the “reversed
cross finger flap,” may be harvested as a layer of subcutane­
ous fibrofatty tissue only. This would be designed to provide
coverage of dorsal wounds on adjacent fingers.
In the conventional cross finger flap, the donor site
requires skin graft coverage. In the “reversed cross finger
flap,” the donor site skin layer is closed primarily and the
recipient site requires skin graft coverage over the flap.
Advantages
• Ease of harvest
• Reliable anatomy and durability
• Thin pliable tissue
• Possibility for sensation if nerve coaptation performed
Disadvantages
• Requires two operative stages
• Immobilization period risks stiffness of both recipient
and donor digits

496
PART 4 — CONVENTIONAL WORKHORSE FLAPS
A 23-year-old man sustained an avulsion of the soft tissue at the
DIP joint flexion crease of the ring finger. A trapezoidal shaped
cross finger flap was harvested from the adjacent middle finger
to obtain adequate tension free-inset. The donor site was skin
grafted with a full-thickness skin graft from above the brachium.
Note the shape and design of the flap and the postoperative
appearance and range of motion of the donor finger (Fig. 45.4).
CASE 45.3  DIP Joint Flexion Crease Ring Finger Defect Reconstructed with a Cross Finger
Flap from the Middle Finger
Figure 45.4  Post operative photographs showing the DIP joint flexsion crease defect after reconstruction showing healed wounds and
good function of the hand.
A
B
C
then drawn retreating to the ipsilateral midaxis of the donor
digit, running parallel to the oblique proximal flap margin.
The starting point of this drawing is made just dorsal to the
midaxis in an effort to avoid compromising the passage of
the dorsal vascular branches of the digital artery that supply
the flap. The endpoint of the flap drawing is positioned
volar to the midaxis in an effort to make the flap base less
kinked upon inset to the adducted recipient finger.
ANESTHETIC CONSIDERATIONS
This flap can be performed under local anesthesia with
sedation routinely. However, it may also be easily performed
without sedation using a local digital block for the donor
and recipient fingers and a field block for the skin graft
preferred harvest site. The authors will typically harvest
from the thin pliable skin of the visibly inconspicuous
medial brachium.
TECHNIQUE OF HARVEST
The authors will typically harvest this flap using a forearm
tourniquet under local anesthesia. According to surgeon’s
preference, however, the flap may be harvested without
tourniquet, or with tourniquet applied at a different loca­
tion. The forearm level tourniquet is easily tolerated by the
awake patient for the brief duration of the procedure. Lido­
caine with epinephrine may be used for skin graft harvest
above the tourniquet at the medial brachium. If the surgeon
prefers donor sites distal to the tourniquet, epinephrine
may not be required.
After inflation of the tourniquet and successful local
blocks, the wound is debrided to healthy margins. The
attention is then turned to the donor digit. The flap is
designed as described above. Incisions on all three sides are
made to the depth immediately above the filmy paratenon
of the extensor mechanism. The flap is mobilized and
unfurled to provide coverage of the adjacent volar digital
wound.
The authors will typically harvest and inset the skin graft
on the paratenon of the donor wound first using dissolvable
suture. The flap is then inset and sutured to the adjacent
digit with as minimal tension as possible. Attempts are made
to inset thoroughly on three sides so that there is as much
linear contact area for vessel ingrowth as possible prior to
subsequent division.
Tension-free inset may require flexion of the recipient
digit PIP joint if the wound is very distal. This should be
minimized as much as possible.
FLAP HANDLING
The flap and skin graft sites are covered with a protective
splint to protect the attached digits during and prior to
the next surgery. The period between flap inset and divi­
sion is tailored to the patient and situation. While it may
typically be divided as early as 2 weeks after inset, longer
periods (i.e., 3 weeks) may be desirable if the patient is a
smoker or has subnormal perfusion of the recipient digit.
Alternatively, shorter periods are more desirable in patients
with higher risk of digital stiffness (osteoarthritic or elderly
patients).
Flap division is performed under local anesthesia. No
preoperative testing is required. The base of the flap may
be sharply divided and then inset on both the donor and
recipient fingers quite rapidly. The digits may then be mobi­
lized immediately unless other traumatic requirements limit
motion (i.e., fractures and tendon repairs).

CHAPTER 45 — Pedicled Flaps of the Hand
497
FLAP MODIFICATION
The reversed cross finger flap modification as described
above is harvested similarly with the goal of covering dorsal
wounds on adjacent digits. The design for this flap is con­
ventionally rectangular, rather than trapezoidal. The skin is
elevated on three sides in the subdermal plane to be mobi­
lized away from the injured digit. The fibrofatty tissue is
then elevated on three sides in the opposite direction to
unfold onto the injured digit. Once inset, the donor skin is
then returned to its native position to cover the donor site,
and the skin graft is applied to the recipient digit on top of
the flap tissue.
OUTCOMES
The cross finger flap has been a conventional workhorse
flap because of its reliability and ease of harvest. The skin
will shape and mature to the contour of the digit effectively.
The donor site skin graft reliably survives without difficulty
if the paratenon is carefully preserved during harvest.
A 42-year-old craftsman amputated the volar tissue and hypo-
nychium of the ring finger. The defect was debrided and a
trapezoidal shaped flap was designed on the dorsum of the
middle finger and rotated to reconstruct the defect. the patient
regained excellent function post operatively.
CASE 45.4  Trapezoidal-Shaped Flap to Reconstruct Amputated Volar Tissue and
Hyponychium of the Ring Finger
A
B
C
D
Figure 45.5  A trapezoidal-shaped flap was designed on the adjacent middle finger. Unfurled, the flap provided excellent coverage
to the tip without requiring PIP flexion of the ring finger (Fig. 45.5A,B). Note the postoperative appearance of the donor and recipi­
ent digits 3 weeks after division and inset (Fig. 45.5C,D).
One of the drawbacks of the flap is the lack of sensation,
particularly for fingertip reconstruction. The dorsal digital
nerve may be coapted to the recipient digital nerve; however,
this may not be feasible depending on the condition of the
recipient digit tissue. This technique also requires the time
and inconsistency of digital nerve regeneration. The second
major drawback is the risk of stiffness in both the injured
and donor fingers during required immobilization, particu­
larly in the elderly or arthritic population. For these two
reasons, the authors have preferred the advantages of the
homodigital island flap for fingertip reconstruction when
feasible (see Cases 45.3, 45.4).
MOBERG FLAP
FLAP ANATOMY (See Figs 12.17 and 21.22)
The thumb neurovascular volar advancement flap, or
Moberg flap, is designed to provide immediately sensate,
single-stage glabrous skin coverage for soft tissue defects of

498
PART 4 — CONVENTIONAL WORKHORSE FLAPS
• Single stage procedure
• Immediately sensate coverage
• Reliable and durable flap
• Ease and speed of harvest
Disadvantages
• Limited ability to cover larger defects of volar pad
(>2 cm).
PREOPERATIVE PREPARATION
No preoperative testing is required. If the thumb has sus­
tained a second, more proximal laceration, the condition
of the digital vessels should be assessed with a surface
Doppler to ensure safety of harvest.
FLAP DESIGN (Cases 45.5, 45.6)
The flap is designed by making two parallel markings on the
midaxes of the thumb extending from the wound to the
MCP flexion crease. These markings should reliably be
dorsal to the pathway of the neurovascular bundles.
This flap has been described as a pedicled flap performed
without additional incisions. It has been described as a
V-Y advancement flap that requires a tapered proximal
“V-shaped” incision connecting the midaxial incisions. It has
the volar pulp of the thumb. The flap is harvested with both
the radial and ulnar digital neurovascular bundles and
advanced distally to reconstruct digital tip injuries. The flap
may be reliably performed only on the thumb due to the
thumb’s robust dorsal blood supply that enables the skin to
survive despite harvest of both volar neurovascular bundles
with the flap.
Dominant Arterial Pedicle:  radial and ulnar digital arteries
of the thumb
Length: 1–2 cm advancement with island design
Diameter: 1–1.5 mm
Venous Drainage (See Fig. 12.10):  venous comitantes of
the radial and ulnar digital arteries
Innervation (See Fig. 12.10):  immediate sensation to the
flap is provided by the radial and ulnar digital nerves that
are carefully included in the flap elevation
Advantages
• Glabrous soft tissue of appropriate thickness and quality
for tip reconstruction
A 29-year-old man sustained an amputation of his thumb tip
in a wood splitter and the part was deemed not replantable
(Fig. 45.6A,B). In order to preserve length, a Moberg flap
was performed as an island advancement as described above
(Fig. 45.6C,D). Dissection of the vascular island pedicle permit-
ted significant advancement. Skin grafting was performed at the
donor site of the flap.
CASE 45.5  Thumb Tip Amputation Reconstructed with an Island Advancement Moberg Flap
Figure 45.6  (A–D) Thumb tip amputation reconstructed with an island advancement Moberg flap.
A
B
C
D

CHAPTER 45 — Pedicled Flaps of the Hand
499
authors will typically harvest from the thin pliable skin of
the visibly inconspicuous medial brachium.
TECHNIQUE OF HARVEST
The authors will typically harvest this flap using a proximal
bicep tourniquet under local anesthesia with sedation.
According to surgeon’s preference, however, the flap may
be harvested without tourniquet, or with forearm level tour­
niquet with only local anesthetic utilized. The forearm level
tourniquet is easily tolerated by the awake patient for the
brief duration of the procedure. Lidocaine with epineph­
rine may be used for skin graft harvest above the tourniquet
at the medial brachium in this circumstance.
After inflation of the tourniquet, the wound is debrided
to healthy margins. Attention is then turned to the flap
elevation. Two midaxial incisions are created and dissection
continues dorsal to the neurovascular bundles and volar to
the flexor tendon sheath. This continues to the level of the
MCP flexion crease.
At this point, the flap can be manually advanced to deter­
mine if further dissection is necessary. Flexion of the IP joint
been described as an island flap that requires a transverse
incision at the MCP flexion crease with the goal of advanc­
ing the flap and skin grafting the donor defect at the flexion
crease. The technique is selected by surgeon’s preference.
The authors routinely perform the last of these choices
because they find it enables the greatest advancement and
tension-free closure of the donor site.
FLAP DIMENSIONS
The skin island includes the entire glabrous volar surface
of the thumb. It may be 2–3 cm wide and its length varies
with the side of the length of the digit and the size of the
tissue lost. The proximal border of the flap is the MCP
flexion crease.
ANESTHESIA CONSIDERATIONS
This flap can be performed under local anesthesia with
sedation routinely. However, it may also be easily performed
without sedation using a local thumb digital block and a
field block for the skin graft preferred harvest site. The
A 35-year-old man avulsed the volar tissue of the thumb and
hyponychium. An island flap reconstruction with skin graft
at the MCP joint crease was utilized. After Moberg flap
reconstruction, the flap typically contours well to provide an
excellent functional and aesthetic result (Fig. 45.7).
CASE 45.6  Avulsion of Volar Tissue of the Thumb Reconstructed with an Islanded
Moberg Flap
Figure 45.7  (A–D) Avulsion of volar tissue of the thumb reconstructed with an islanded Moberg flap.
B
C
D
A

500
PART 4 — CONVENTIONAL WORKHORSE FLAPS
of the thumb in order to achieve distal reach of the flap has
been shown to be well tolerated without subsequent devel­
opment of flexion contractures.1
The advancement is often inadequate without perform­
ing a proximal incision and mobilization. If this is required,
it may be performed in a tapered “V-shape” to permit V-Y
closure of the donor site with flap advancement. Alterna­
tively, the proximal incision can be performed transversely
at the MCP flexion crease and a skin graft can be used for
coverage of the defect created by flap advancement.
Skeletonization of the digital bundles should not be per­
formed. This is avoided to protect the venous comitantes
and minimize the risk of flap congestion. However, mobili­
zation of this neurovascular leash should be performed in
two planes to maximize advancement. The first is in the
immediately subdermal plane proximal to the flap on the
volar thenar eminence. This liberates the subcutaneous
tissue from the less pliable thenar skin. The second plane is
immediately above the flexor sheath and muscle fascia prox­
imal to the flap. This is done with extreme care to avoid
injury to the neurovascular structures. These two dissection
planes will maximally mobilize the intervening layer and
gain maximal tissue advancement.
FLAP HANDLING
Once elevated, the flap is inset on the radial and ulnar
margins first, using each suture to advance the flap distally.
The pulp is then able to be inset in a tension-free manner
with maximal advancement achieved. Sutures should not be
placed into the distal nailbed so that tension does not result
in a hook-nail deformity. If enough advancement is achieved
the two distal corners of the flap may be sutured approxi­
mated together to create a convex prominence of the distal
tissue to re-create the volar pad of the thumb.
DONOR SITE CLOSURE
The skin graft is inset into the donor defect with dissolvable
suture. A bulky dressing and thumb spica splint are used to
immobilize the reconstruction for 7–10 days. Motion may
thereafter commence unless concomitant injuries prohibit
movement (i.e., fractures, tendon repairs).
OUTCOMES
This flap is a workhorse flap for volar thumb defects because
it is a hardy and reliable flap that routinely provides imme­
diately sensate tissue on the critically important thumb pad.
The reconstruction tends to contour and mature into an
excellent functional and aesthetic outcome routinely. Flex­
ion contractures of the IP joint are rare, even if IP joint
flexion is used to enable flap advancement.1 Skin graft adher­
ence and survival is routine, and the lack of sensation at the
skin graft site is well tolerated in the MCP joint flexion crease.
A common risk is hook-nail deformity and can be avoided
if sutures are not placed in the nailbed during flap insetting.
Additionally, if any portion of the distal phalangeal bone
has been lost, the nailbed should be trimmed to the level
of the bone. Preservation of nailbed without osseous support
will increase the risk of hook-nail deformity (see Cases 45.5,
45.6).
THE HOMODIGITAL ISLAND FLAP
FLAP ANATOMY (See Figs 12.17, 12.20,
12.21, 12.22)
This adipocutaneous neurovascular island flap can be raised
from the distal volar radial or volar ulnar aspect of the digit.
The flap is designed so that a portion of it lies directly over
either the radial or ulnar neurovascular bundle. The arterial
supply to the flap is the proper digital artery. As there is
rarely a sizeable vein running with the artery, the venous
drainage of the flap is likely a fine network of perivascular
veins. The flap contains within it either the proper radial or
ulnar digital nerve. As such, it provides immediate sensibil­
ity to the reconstructed digit.
Dominant Pedicle:  proper radial digital artery or proper
ulnar digital artery
Length: 3–6 cm
Diameter: 1.0–1.5 mm
Identification of the digital neurovascular bundle can be
achieved through either a Bruner or midlateral incision.
The proper digital artery and nerve will be encountered by
releasing Grayson’s and Cleland’s ligaments. Care should be
taken to minimize disruption of the fine perivascular venous
network by not skeletonizing the neurovascular bundle and
by avoiding separation of the artery from the nerve. Small
dorsal arterial and nerve branches identified at the level of
the middle phalanx and distal aspect of the proximal
phalanx should be liberated with a microbipolar cautery as
they could tether the flap and ultimately limit advancement.
If possible the large dorsal arterial and nerve branches that
often arise at the proximal aspect of proximal phalanx
should be preserved.
Minor Pedicle:  transverse digital palmar arch.
Three separate transverse digital palmar arches provide
vascular communications between the radial and ulnar
digital arteries. These arches are named the proximal,
middle, and distal transverse digital palmar arch, corre­
sponding to their location in the finger.2 The small vascular
interconnections of the middle and distal arches can support
a retrograde homodigital island flap that can be raised
without the corresponding digital nerve (the benefits of
harvesting a digital nerve or dorsal nerve branch with the
retrograde flap are debated).3 The location of middle arch
at the distal cruciate pulley provides a favorable pivot point
that allows a flap raised from the volar proximal phalanx to
often reach the distal phalanx without the need to flex the
interphalangeal joints. The vessels of the arch are quite
small and could be easily injured if direct visualization or
skeletonization were attempted. To avoid injury to the
middle arch vessel when raising the retrograde homodigital
island flap, dissection should stop 5 mm proximal to the
distal interphalangeal joint.
VENOUS DRAINAGE (See Fig. 12.22)
Primary:  fine perivascular venous network
Length: 3–6 cm
Diameter: Submillimeter (not often visible)

CHAPTER 45 — Pedicled Flaps of the Hand
501
These vessels are rarely visible. Care should be taken to
minimize disruption of the fine perivascular venous network
by not skeletonizing the neurovascular bundle and by avoid­
ing separation of the artery from the nerve.
Secondary:  none
Length: none
Diameter: none
FLAP INNERVATION (See Figs 12.21 and 12.22)
The anterograde flap contains within it a proper digital
nerve and is immediately sensate.
Advantages
• Single-stage operation
• Reliable anatomy
• Ease of harvest
• Delivery of sensate glabrous tissue
• Low donor site morbidity
• Well-hidden scars if harvested from the ulnar aspect of
the digit
Disadvantages
• Donor site requires skin graft
• Possibility of proximal interphalangeal joint contracture
FLAP DIMENSIONS
SKIN ISLAND DIMENSIONS
As the maximum size of this flap has not yet been studied,
these measurements reflect the authors’ experience.
Length: Average 1.5 cm (range 1.0–2.0 cm), primary closure
not recommended
Width: Average 1.0 cm (range 0.5–1.5 cm), primary closure
not recommended
Thickness: Average 1 cm (range 0.5–1.5 cm)
FLAP MARKINGS
A template of the defect is made and the dimensions of the
flap measured (Fig. 45.8). The template is transposed over
intact skin just proximal to defect. The template should be
positioned over the course of either the radial or ulnar
digital neurovascular bundles. The long axis of the template
should be oriented in the same direction of the long axis of
the defect to minimize rotation or twisting upon inset after
advancement.
The selection of either a radial or ulnar artery based flap
is based primarily on the design that would require the least
amount of flap advancement. Thus, if a finger has been
amputated obliquely, the flap will often be designed on the
side of the digit with the most distally preserved skin. In the
setting of a transverse amputation or an amputation with
minimal obliquity, harvest from the ulnar aspect of the digit
is preferable as it often results in a very favorable, minimally
visible scar. If possible, consideration should be given to not
harvesting the flap based on either the ulnar neurovascular
bundle of the small finger or the radial neurovascular
bundle of the index finger as these are important contact
surfaces of the hand.
PATIENT POSITIONING
The best position for flap harvest is with the patient in a
supine position with the forearm supinated. A lead hand
should be available.
Prior to tourniquet inflation, the surgeon may elect to
perform a digital Doppler Allen’s test to ensure patency of
the vessel selected to support the flap. This is not required
and the authors do not routinely perform this evaluation.
ANESTHETIC CONSIDERATIONS
The authors prefer to raise this flap with the patient under
general anesthesia. This ensures comfort during the tourni­
quet time. The flap can also be raised with the patient
anesthetized via a regional block. A bupivacaine digital
block is placed at the end of the case for long-lasting post­
operative pain control. To prevent vasospasm, epinephrine
is not used in the local digital block.
TECHNIQUE OF FLAP HARVEST
Note: As the flap can be raised from either the radial or ulnar
aspect of the digit, the terms “central” and “lateral” will
sometimes be used in this guide as substitutes to clarify the
direction of dissection.
We use the surgical technique previously described by
Katz.4 The patient is placed supine on a well-padded table
with the arm extended on a well-padded hand table. The
procedure is performed under tourniquet control after
exsanguination with an elastic bandage. At least ×2.5
loupe magnification is recommended for optimal visualiza­
tion. After thorough debridement of devitalized tissues,
the dimensions of the defect are measured. A flap with the
premeasured dimensions is then drawn over either the
distal ulnar or radial aspect of the finger centered over
the neurovascular bundle.
A midlateral incision is then made proximal to the out­
lined flap. The neurovascular bundle is dissected free of
surrounding tissue in a circumferential fashion. This involves
completely releasing the pedicle from any potential tether­
ing structures, including Cleland and Grayson ligaments as
well as small arterial side branches. The artery and nerve
Figure 45.8  Flap markings.

502
PART 4 — CONVENTIONAL WORKHORSE FLAPS
previous embolic phenomenon, or severe vasospasm. The
flap should also not be used in patients who cannot tolerate
a postoperative period of splinting and therapy or will not
tolerate the possibility of a joint flexion contracture.
An avulsive mechanism may be a relative contraindication
because it can place the proximal vessels within a zone
of injury. This can be assessed preoperatively with a hand­
held Doppler and a digital Allen test. The author would
proceed with the flap if, during the digital Allen test, the
selected flap vessel is patent and generates a signal over the
designed flap.
SPECIAL INSTRUMENTS
Microvascular instruments are recommended for handling
the flap pedicle. A microbipolar cautery is recommended
for takedown of small dorsal arterial branches. A lead hand
is recommended to maintain the hand in supination and
keep the uninjured digits outside of the surgeon’s field
of view.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES AND
AVOID COMPLICATIONS
The following technical tips have been previously described
by Katz.4 It is of paramount importance to confirm that the
neurovascular bundle travels into the designed flap before
incising the flap itself. For this reason, the midlateral inci­
sion should be made first and the pedicle identified before
flap incision. In addition to allowing the surgeon to reori­
ent the flap over the pedicle if needed, this pearl also
allows the surgeon to clinically inspect the suitability of the
pedicle. If during pedicle inspection the digital artery
appears diminutive or diseased, the tourniquet should be
released and a digital Allen test performed before flap
incision. This can be done with a pencil Doppler held over
the proposed flap as manual pressure is applied to the
contralateral digital artery. If a Doppler signal exists within
the proposed flap initially but disappears with pressure
on the contralateral artery, the flap should not be incised
and an alternative means of digital coverage should be
considered.
Even if designed with a template, the flap will often cover
most but not the entire wound. The bulk of the flap should
be used to cover the portion of the finger deemed most
important. This should either be the central pulp or areas
of exposed bone, tendon, or hardware. Any peripheral areas
not covered directly by the flap will heal rapidly as the flap
incorporates into the surrounding tissues.
When possible, harvest of the flap from the ulnar side of
the digit will place the skin grafted donor site and midlateral
incision on an aspect of the hand that is well concealed.
Harvest from the ulnar aspect of the digit is not mandatory,
however, and the author recommends using whichever side
of the digit harbors the best available tissue requiring the
least amount of advancement.
The pedicle should always be dissected proximal to the
PIP joint. This will optimize flap advancement by allowing
the surgeon to completely free the pedicle from Grayson
and Cleland ligaments and take down potential tethering,
small vascular or nerve branches. This has the added advan­
tage of contributing to flap advancement via slight flexion
of the interphalangeal joints as needed. If the flap is
are kept together and skeletonization is avoided to preserve
the fine perivascular tissue that likely provides venous
outflow to the flap. Atraumatic manipulation of the pedicle
is aided by use of microvascular instruments and a microbi­
polar cautery is recommended to take down any tethering
vascular branches. Once the neurovascular bundle has been
isolated, it is traced distally toward the base of the flap. The
course of the pedicle must be confirmed as running into
the skin flap before incising the flap. Observing the course
of the pedicle before flap incision allows the surgeon to
re-draw the boundaries of the flap to situate it directly over
the pedicle if needed. Once the flap is confirmed directly
over the pedicle, the central/volar aspect of the flap is then
incised and dissected down to the flexor tendon sheath.
Dissection proceeds under the flap in a central to lateral
fashion, freeing the flap off the flexor tendon sheath. Direct
visualization of the underside of the flap reveals the pedicle.
This allows the surgeon one last opportunity to make flap
alterations before committing to the lateral/dorsal incision.
The lateral/dorsal incision is then safely made and carried
down to the level of the phalanx. The flap is then com­
pletely raised off the underlying flexor tendon sheath. Visu­
alization of the pedicle on the underside of the flap allows
protection of the neurovascular bundle throughout this
portion of the case. Toward the proximal portion of the flap,
great care is taken to preserve a cuff of fat around the
pedicle to minimize injury to the pedicle. The flap is then
dissected in a distal to proximal fashion, completely isolat­
ing it on the previously dissected neurovascular bundle. In
addition to the mobilization gained by complete dissection
of the neurovascular bundle, slight interphalangeal joint
flexion facilitates advancement of the flap into the defect.
If greater advancement is needed, the pedicle can be dis­
sected proximal to the MCP joint. This takes further advan­
tage of the intrinsic pedicle elasticity and allows slight
flexion of this joint as well. The flap is inset using 4-0 and
5-0 chromic suture. The tourniquet is then released and
viability of the flap is assessed. If there is any question as to
flap viability or undue tension on the flap, the pedicle and
inset should be critically examined. Although rare, issues
with flap vascularity can likely be corrected by further mobi­
lization of the pedicle, further flexion of the digit, or re-inset
of the flap.
When possible, harvesting the flap from the ulnar aspect
of the finger is preferable from an aesthetic standpoint
because ulnar-sided incisions and scar are difficult to see
with the hand in repose and normal use.
FLAP MODIFICATION/FLAP HANDLING
The classic indication for this one-stage immediately sensate
flap is soft tissue coverage of distal finger injuries. The flap
can be used to cover exposed bone, tendon, and/or exposed
hardware. It can also be used to resurface lost pulp or pre­
serve digital length. In the author’s experience, the best
aesthetic outcomes are obtained when at least 50% of the
distal phalanx and overlying nailbed remain. This ensures
enough nail support to minimize the chance of a hook-nail
deformity.
As noted by Katz,4 use of this flap is contraindicated in
patients with a known history of prior injury to the digital
vessels, peripheral vascular disease, small vessel vasculitis,

CHAPTER 45 — Pedicled Flaps of the Hand
503
A 27-year-old man sustained an amputation of his non-dominant
index finger at the middle phalanx level and an amputation of
the distal aspect of his middle phalanx while operating a saw.
The index finger wound could not be closed primarily without
further shortening the bone. To allow possible future key pinch
by preserving length at the proximal interphalangeal joint, a
homodigital island flap was employed. The middle finger volar
defect was resurfaced with a separate homodigital flap. The
patient’s wounds healed without complication or contracture.
His key pinch was preserved (Fig. 45.9).
CASE 45.7  Index and Middle Finger Distal Amputations Reconstructed with Two
Homodigital Island Flaps
Figure 45.9  (A–I) Index and middle finger distal amputations reconstructed with two homodigital island flaps.
A
D
G
H
I
E
F
B
C

504
PART 4 — CONVENTIONAL WORKHORSE FLAPS
INDICATIONS FOR USE OF THIS FLAP
Although this flap is primarily used for distal fingertip
reconstruction, it can also be used for partial pulp recon­
struction, total pulp reconstruction, resurfacing a painful
fingertip in the setting of painful scar, and preservation of
digital length in the setting of a proximal amputation. The
flap can also be positioned on either the volar or dorsal
aspect of the digit depending on the reconstructive needs.
POSTOPERATIVE CARE AND OUTCOMES
The patient is sent home in a dorsal blocking splint and is
advised to perform flexion and extension exercises within
the confines of the splint over the first postoperative week.
At the 1-week appointment, the patient receives a removable
forearm-based dorsal blocking splint and visits a hand thera­
pist for “out-of-splint” exercise instruction. These include
active and passive flexion exercises as well as active exten­
sion exercises toward a goal of neutral. This is achieved by
placing the dorsum of the patient’s hand flat on a tabletop
and asking the patient to “touch the table with the back of
your fingers.” These exercises are performed for 30 min at
least 5 times a day. After 3 weeks, splint usage is
harvested from the middle phalanx or distal, excessive
flexion of the interphalangeal joints can be avoided.
Early range of motion exercises may be the key to mini­
mizing interphalangeal joint contractures. These exercises
(described below) are initiated in the immediate postopera­
tive period.
DONOR SITE CLOSURE
The midlateral incision is closed with dissolving sutures of
4-0 chromic. The flap donor defect is treated with a full-
thickness skin graft harvested from the medial brachium (or
donor site of preference). The graft is inset using inter­
rupted chromic sutures (4-0 or 5-0) and dressed with only
a bulky dressing of mineral oil–soaked cotton, and the
patient is placed in a dorsal blocking splint. Avoidance of
circumferential dressings around the digit is critical. The
full-thickness skin graft can be closed primarily in a layered
fashion with a 3-0 and 4-0 monofilament suture.
FLAP USAGE
This flap is primarily used for distal fingertip soft tissue
coverage in the setting of preserved length.
A 30-year-old man sustained near total pulp loss over his non-
dominant ring finger distal phalanx while operating a machine.
He had preservation of digital length and dorsal nail elements.
He underwent a pulp reconstruction with a homodigital island
flap harvested from the ulnar aspect of the digit. He healed
without complication or contracture (Fig. 45.10).
CASE 45.8  Distal Finger Pulp Defect Reconstructed with a Homodigital Island Flap
Figure 45.10  (A–G) Distal finger pulp defect reconstructed with a homodigital island flap.
A
D
E
F
G
B
C

CHAPTER 45 — Pedicled Flaps of the Hand
505
identification of the ECU muscle and tendon. The ECU
fascia is incised and a retractor used to gently pull the
muscle ulnarly. This maneuver exposes the septum between
the ECU and EDQ. Within this septum, the PIA and drain­
ing venae will be visible. The common interosseous artery,
having branched from the ulnar artery is the proximal
source of the PIA and can be located as piercing the interos­
seous membrane approximately 6 cm distal to the lateral
epicondyle. Multiple septal perforators can usually be seen
traveling to the skin of the designed flap. Once the septum
is identified, the radial incision can be made.10
VENOUS DRAINAGE
Primary:  venae comitantes
Length: 14.5 cm
Diameter: not reported
The artery and veins can lose caliber as they travel from
proximal to distal. To avoid iatrogenic injury, the vessels
should be kept within their septum and raised directly off
of the interosseous membrane. The surgeon is encouraged
not to skeletonize the vessels.
Secondary:  extra adipofascial and subcutaneous tissue
raised along with the pedicle is thought to augment venous
outflow
Length: none
Diameter: none
FLAP INNERVATION
Motor branches of the PIN should be spared while raising
this flap. The sensory portion of the PIN provides no cutane­
ous sensibility to the flap.
FLAP COMPONENTS
The PIA flap is primarily an adipocutaneous flap. Use of the
flap with a portion of ulna has also been described.11
Advantages
• Single-stage operation
• Minimal donor site morbidity
• Ease of harvest
• Thin flap rarely requires debulking
• Good color match
• Does not require microsurgery
Disadvantages
• Unpredictable anatomy
• Donor site often requires skin graft
• Hair-bearing skin in men
• Pedicled nature limits distal advancement
PREOPERATIVE PREPARATION
Though no formal studies are needed, a CT angiogram can
be obtained if, in the setting of trauma, there is concern for
injury to the distal AIA/PIA anastomosis.12 The use of ultra­
sound has also been described to confirm the presence and
patency of the distal AIA/PIA anastomosis.13
Pearl
Though most often used as a distally based flap for
coverage or resurfacing of hand defects, it can also be
used as a proximally based flap for coverage or resur-
facing of the elbow. When used as a proximally based
flap, the PIA is still the dominant artery and the venae
comitantes provide flap venous drainage.
discontinued and passive extension exercises are added to
the regimen. The patient wears a nighttime extension splint
(if needed) to correct any residual extensor lag or early
flexion contracture (see Cases 45.7, 45.8).4
THE POSTERIOR INTEROSSEOUS
ARTERY FLAP
FLAP ANATOMY (See Figs 12.5, 12.14 and 12.22)
This adipocutaneous island flap is typically raised in a
“reverse fashion” and depends on retrograde arterial flow
through the posterior interosseous artery (PIA) for survival.
The source of this retrograde flow is most often (90%) a
distal communication between the PIA and the anterior
interosseous artery (AIA). Rarely (10%), the PIA can be a
direct branch off of the ulnar artery. The PIA pierces the
interosseous membrane approximately 6 cm distal to the
lateral epicondyle and can be clinically located just caudal
to the supinator muscle and deep in the interval between
the extensor carpi ulnaris (ECU) and the extensor digiti
quinti (EDQ) muscles. The course of the PIA roughly cor­
responds to a line drawn between the lateral epicondyle and
the distal radioulnar joint (DRUJ). Though proximally the
artery originates deep, it becomes more superficial distally.
In the middle and distal forearm the PIA is actually quite
superficial (just beneath the superficial antebrachial fascia)
and does not run along the interosseous membrane as one
might otherwise expect given its name. Approximately 2 cm
proximal to the DRUJ exists an anastomosis between the
distal anterior interosseous artery (AIA) and the distal PIA.
This anastomosis should exist and be patent to optimize
survival of a pedicled “reverse” PIA flap.
PIA anatomic variability can be as frequent as 20% and
can include either absent communication with the AIA dis­
tally or a hypoplastic distal artery unable to perfuse the flap.9
The venous drainage to the flap is retrograde via venae
comitantes accompanying the PIA.
Dominant:  posterior interosseous artery
Length (variable and depends on flap design): 14.5 cm
(range 12.1–17 cm)
Diameter (proximal): 1.7 mm (range 1.2–2.6 mm)
Diameter (middle forearm): 0.45 mm (range 0.3–0.6 mm)
Diameter (distal communicating branch): 0.95 mm (range
0.8–1.4 mm)
The proximal PIA is located in the interval between the
ECU and EDQ muscles. This interval is easily defined by
making the ulnar incision first. This allows for rapid

CHAPTER 45 — Pedicled Flaps of the Hand 505.e1
DISTAL ULNAR ARTERY PERFORATOR FLAP
FLAP ANATOMY (See Figs 12.9, 12.10 and 12,22)
Originally described by Becker and Gilbert in 1988,5 the
distal ulnar artery perforator flap is designed based on the
angiosome of the dorsal cutaneous branch of the ulnar
artery that travels alongside the dorsal sensory branch of the
ulnar nerve. This vessel arises from the ulnar artery on the
ulnar margin of the flexor carpi ulnaris muscle and bifur­
cates into a descending branch and ascending branch. The
descending branch travels distally to the dorsal hand along
with the dorsal ulnar sensory nerve. The pedicle of the flap
is the proximally directed ascending branch.
Dominant Pedicle: 
Length: 1.0–2.0 cm
Diameter: 1.0–1.3 mm
This perforator can be located 2–4 cm proximal to the
pisiform on the ulnar border of the flexor carpi ulnaris
muscle. This is conventionally designed as a pedicled flap
for rotation into defects in more distal wounds. Its pedicle
is short but the flap can provide a significant arc of rotation
due to the length of its angiosome on the ulnar aspect of
the forearm.
Venous drainage (See Fig. 12.22):  provided by the venous
comitantes of the arterial system.
Sensory innervation (See Fig. 12.22):  may be provided by
harvest of branches of the medial antebrachial cutaneous
nerve and performing micro-neurorrhaphy to appropriate
nerves at the recipient site. The larger dorsal sensory nerve
branch of the ulnar nerve is not harvested with this flap.
This nerve is identified and preserved as it courses distally
with the descending branch of the perforator that serves as
the origin of the flap pedicle.
Advantages
• Thin pliable often hairless tissue
• Harvest does not require sacrifice of major forearm
vessel
• Speed and ease of harvest
• Donor site is usually closed primarily
• Single stage procedure
• Inconspicuous donor site scar on ulnar border of
forearm
Disadvantages
• Short vascular pedicle
• Limitations of arc of rotation
PREOPERATIVE PREPARATION
Unlike the conventional radial forearm or ulnar forearm
flap harvests, the ulnar artery perforator flap does not
depend on the presence of a complete vascular arch of the
hand nor does it pose a risk of perfusion to the hand. There­
fore a preoperative Allen test is not required. However,
patency of the ulnar artery would need to be confirmed
preoperatively. Surgeons may elect to assess ulnar artery
patency by surface Doppler exam or Allen test.
FLAP DESIGN
The long axis of the flap follows the pathway of the ascend­
ing branch of the dorsal ulnar artery perforator. This can
be estimated by drawing a line between the medial epicon­
dyle and the ulnar border of the pisiform. Alternatively, the
surgeon may estimate by palpating the ulnar border of the
FCU muscle belly. The pivot point is located at the perfora­
tor that arises 2–4 cm proximal to the pisiform along that
axis. The flap is designed to measure slightly larger than the
prepared wound, and additional length is incorporated into
the design to minimize tension at the pivot during inset.
The potential area of harvest includes the distal aspect
of the ulnar forearm with boundaries of the extensor digiti
quinti (EDQ) dorsally, the palmaris longus (PL) volarly, and
the proximal margin can be up to 20 cm proximal to the
perforator.
The flap width is usually 5–9 cm, with the goal of primary
closure of the donor site typically achieved. The flap can be
used to reach wounds on the ulnar aspect of the hand, the
wrist flexion crease and extension crease. It has also been
described for use as a fascia coverage of the median nerves
after neurolysis for adhesive neuritis. The limited arc of
rotation is not typically used for defects distal to the MCP
joints.
FLAP DIMENSIONS
SKIN ISLAND DIMENSIONS
Length: 10–20 cm
Width: 5–9 cm
Thickness: 1–3 cm
TECHNIQUE OF HARVEST
This flap is usually harvested under general or regional
block anesthesia using tourniquet control. The axis of the
flap is marked as a longitudinal ellipse centered on the axis
created by a line drawn between the medial epicondyle and
the ulnar aspect of the pisiform. After debridement of the
wound, a template may be created and the distance to the
pivot point (see above) is measured. The template is used
to outline the flap design, locating it proximal to the pivot
point at a distance equal to the required arc of rotation,
with added 1–3 cm to ease the tension of rotation on the
vascular pedicle.
The width of the flap should not exceed 9 cm and should
be limited roughly by the boundaries of the PL tendon
volarly and the EDQ tendon dorsally.
The flap is usually harvested with a long skin component
that encompasses the length of the pedicle and the skin over
the pivot point. This is rotated with the inset of the flap and
does not require tunneling of the flap. Alternatively, the
portion of the pedicle that is not within the templated flap
skin may be elevated as a wide perivascular fibrofatty leash
and be inset under a skin tunnel between the pivot point
and the wound
The flap may be safely dissected in a subfascial plane from
the volar aspect first. After elevating to the FCU muscle the

505.e2 PART 4 — CONVENTIONAL WORKHORSE FLAPS
ulnar margin of the muscle is slowly approached and the
perforator may be visualized 2–4 cm proximal to the pisi­
form. This will indicate the axis of rotation. Once this is
confirmed the flap can be rapidly harvested from distal to
proximal providing a generous protective cuff of tissue sur­
rounding the arterial and venous pedicle.
During dissection at or distal to the pivot point, the
surgeon will identify and protect the dorsal sensory branch
of the ulnar nerve coursing with the descending arterial
branch of the perforator. If a sensate flap is desired, smaller
sensory nerve branches of the medial antebrachial cutane­
ous nerve may be located along the proximal ulnar aspect
of the flap for harvest with the flap.
During rotation of the flap caution is taken to avoid exces­
sive torsion or kinking of the pedicle. Incomplete rotation
may leave a prominent mound of tissue near the pivot point
that could require excision in a subsequent surgery after the
wound heals.
DONOR SITE CLOSURE
Attempts are made to harvest this flap with the goal of
primary closure of the donor site. In wider flaps, skin graft­
ing may be performed to facilitate closure. A bulky dressing
and an ulnar gutter splint are used to immobilize the recon­
struction for 7–10 days. Motion may thereafter commence
unless concomitant injuries prohibit movement (i.e., frac­
tures, tendon repairs).
ATYPICAL INDICATIONS FOR THIS FLAP
This flap has been described as a free flap for very small
defects of the fingers because of its thin pliable charac­
teristics. In this report, the flaps were centered over the
described perforator and measured from 1 × 3–3 × 4 cm in
size. The authors closed all donor defects primarily and
would perform the arterial anastomosis with supermicrosur­
gical technique and recommended use of superficial veins
for drainage because of the small size of the perforator veins.6
OUTCOMES
In small series of use of these flaps, no flap loss or partial
loss was reported in nine patients.7 In a second series, 2
of 12 flaps experienced partial necrosis.8 The flap is low
morbidity and patient-reported complaints are related to
transient donor site paresthesias and scar appearance (see
Case 45.9).
A young man sustained a crush injury to the hand and resultant
dorsoulnar wound. A distally based ulnar artery perforator flap
was raised to rotate into the defect (Fig. 45.11A,B). The donor
site in this case required skin graft coverage. The dorsal hand
wound healed uneventfully with good color match and contour
(Fig. 45.11C,D).
CASE 45.9  Dorsoulnar Hand Wound Secondary to Crush Injury Reconstructed with a
Distally Based Ulnar Artery Perforator Flap
A
B
C
D
Figure 45.11  (A–C) Dorsal-ulnar hand wound secondary to crush injury reconstructed with a distally based ulnar artery perforator flap.
D, postoperative image.
(Case images courtesy of Günter Germann, MD, Heidelberg, Germany.)

506
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Figure 45.12  Flap design. Point A represents the approximate loca­
tion of the PIA as it perforates the interosseous membrane and enters
the posterior forearm. Point B represents the location of the AIA/PIA
anastomosis upon which the flap will pivot. Point C represents the
most distal portion of the wound needed to be covered by the flap.
The distance between point C and point B is measured. This distance
(X) is transposed proximal to point B along the course of the PIA. The
proximal point (X1) determined by transposing the distance between
C and B represents the minimum acceptable proximal margin of the
flap (see text for details).
FLAP DESIGN
A line is drawn from the lateral epicondyle to the DRUJ.
This represents the approximate course of the PIA. The
long axis of the flap should be designed along this line
(Fig. 45.12).
A point (A) is marked along this line 6 cm distal to the
lateral epicondyle. This represents the approximate loca­
tion of the PIA as it perforates the interosseous membrane
and enters the posterior forearm. The majority of the flap
should be designed distal to this point.
A point (B) is marked 2 cm proximal to the DRUJ along
this line. This represents the location of the AIA/PIA anas­
tomosis upon which the flap will pivot.
A point (C) is marked at the distal margin of the defect.
This represents the most distal portion of the wound needed
to be covered by the flap.
The distance between point C and point B is measured.
This distance (X) is transposed proximal to point B along
the course of the PIA. The proximal point (X1) determined
by transposing the distance between C and B represents the
minimum acceptable proximal margin of the flap. Though
the proximal margin of the flap can be placed proximal to
this point, placing the proximal margin of the flap distal to
this point may not allow the flap to reach the distal aspect
of the wound.
The size of the flap should be the size of the defect and
can be determined by measuring the largest dimensions of
the defect or using a template.
FLAP DIMENSIONS
SKIN ISLAND DIMENSIONS
The following measurements are derived from averages of
five case series spanning 1991–2013.
Length: Average 12 cm (range 7.5–19 cm)
Width: Average 5.74 cm (range 3.2–7.5 cm), primary closure
not recommended
Thickness: depends on thickness of the forearm
FLAP MARKINGS
The long axis of the flap should be oriented along a line
drawn from the lateral epicondyle to the DRUJ. Along this
line, a mark is made 6 cm distal to the lateral epicondyle.
This represents the approximate point where the PIA
emerges through the interosseous membrane dorsally. The
pivot point (PP) of the flap is marked 2 cm proximal to the
DRUJ. This corresponds to the naturally occurring anasto­
mosis between the AIA and PIA.
Once the size of the defect has been determined, the
distance between the distal-most portion of the defect and
the PP is measured. This distance is then transposed from
the PP proximally along the premarked axis (with some
distance added to allow for correction of tissue elasticity and
primary skin contraction). The proximal-most aspect of this
distance represents the proximal-most aspect of the flap.
The remaining flap dimensions are drawn to represent the
dimensions of the wound.
PATIENT POSITIONING
The patient is positioned in the supine position on a well-
padded table with the arm extended on a well-padded hand
table. A pneumatic tourniquet should be placed on the
upper arm and inflated prior to flap elevation. As dissection
of the ulnar border of the flap is recommended by the
authors, exposure is facilitated by having either the arm
maximally pronated or the elbow flexed, allowing the hand
to rest on the patient’s draped chest.
ANESTHETIC CONSIDERATIONS
The authors prefer to raise this flap with the patient under
general anesthesia. This ensures comfort during the tourni­
quet time. The flap can also be raised with the patient
anesthetized via a regional block.
TECHNIQUE OF FLAP HARVEST
The patient is placed on a well-padded table with the arm
extended on a well-padded hand table. The procedure is
performed under tourniquet control after exsanguination
with an elastic bandage. At least ×2.5 loupe magnification is
recommended for optimal visualization. After thorough
debridement of devitalized tissues, the dimensions of the
defect are measured. The flap is drawn over the proximal
dorsal forearm as described above.
It is preferable to incise the ulnar border of the flap
first. Doing so, and extending the incision distally along
the premarked line from the lateral epicondyle to the
DRUJ, facilitates identification of the ECU muscle belly
and tendon and helps protect the surgeon from missing
the interval between the ECU and EDQ. Once the ECU
muscle has been identified, the ECU fascia is incised and
the muscle retracted ulnarly. This provides visualization
of the septum between the ECU and EDQ. Running along
the septum, close to the interosseous membrane in the
proximal forearm, the PIA can be visualized. Multiple per­
forators from the PIA to the dorsal skin and adjacent
muscles will also be seen. The muscle perforators should
be
ligated
with
microclips
or
coagulated
with
a

CHAPTER 45 — Pedicled Flaps of the Hand
507
microbipolar cautery. Once the appropriate interval has
been identified, the radial border of the flap is incised.
Dissection proceeds down to the EDQ muscle fascia, which
is incised allowing this muscle to be retracted radially. A
self-retaining retractor can then be placed within the
wound and used to further define the interval between the
ECU and EDQ muscles. Care should be taken to preserve
any visible motor branches of the posterior interosseus
nerve.
The proximal origin of the PIA is then ligated and
the septum between the ECU and EDQ is raised directly
off of the interosseous membrane. Dissection proceeds
in a proximal to distal fashion up to a point roughly
2  cm proximal to the DRUJ. This point represents the
location where the AIA volarly and the PIA dorsally com­
municate. This vascular anastomosis represents the pivot
point of the flap.
The flap can then be passed through a wide subcutaneous
tunnel and gently guided to the defect. Tension on the flap
can be relieved by extending the wrist. Doing so, shortens
the distance the flap has to travel to reach the defect and
minimizes skin tension that would otherwise be experienced
with the wrist in neutral or flexion.
FLAP MODIFICATION/FLAP HANDLING
This adipocutaneous flap is primarily used for coverage of
dorsal hand defects or to provide tissue to the first web space
after contracture release. If needed for volar coverage, the
flap can extend around the ulna or can be passed through
the interosseous membrane. When insetting the flap, great
care is needed to avoid undue tension or compression on
the pedicle. If concerned about the pedicle, the wrist can
be extended and/or the pedicle can be exteriorized and
allowed to “bowstring.” Both maneuvers effectively shorten
the distance between the flap and the defect. These maneu­
vers have also been described as a means of allowing the
flap to cover digital defects as distal as the DIP joints.13
If the pedicle is exteriorized, covering it with either split-
thickness skin graft or allograft can prevent desiccation and
promote wound hygiene. In the setting of an exteriorized
pedicle, division and excision of the pedicle should be safe
at 3 weeks (the time when an analogous flap such as a
pedicled groin flap could be divided).
Including a wide adipofascial leash with the pedicle has
been cited as a maneuver that can possibly improve flap reli­
ability and minimize the risk of partial or complete flap loss.
Similar to the radial forearm flap, modifications of the
PIA flap such as using it as an osteocutaneous or adipofas­
cial flap have been reported.
Though the flap is typically used in a distally based fashion
for coverage of hand defects, it can also be used as a proxi­
mally based flap for elbow coverage. In either case, patency
of the PIA and some communication between the PIA and
the volar forearm vasculature is a prerequisite. Thus a rela­
tive contraindication to raising the flap is known vascular
disease. A strict contraindication to raising this flap includes
absence of a communication between the PIA and volar
forearm such as could be seen in the setting of trauma to
the distal AIA/PIA anastomosis, trauma to the volar forearm
and disruption of the common interosseous artery, or a
preoperative imaging study demonstrating loss of integrity
of the PIA throughout its length. Communication between
the PIA and the AIA can be confirmed with a preoperative
vascular duplex.13
SPECIAL INSTRUMENTS
Self-retaining retractors are recommended to help define
the interval between the ECU and EDQ muscles. Microclips
and a microbipolar cautery are recommended for takedown
of small dorsal arterial branches. A small hemoclip can help
take down the proximal PIA, which can be too large to be
coagulated with the bipolar. A large blunt clamp is used to
create the dorsal subcutaneous tunnel.
DONOR SITE CLOSURE
The flap is loosely inset into the defect using a suture of the
surgeon’s choosing (we prefer dissolvable sutures of either
4-0 chromic or 3-0 Monocryl). If the wound was large,
friable, or if there is concern for postoperative oozing, a
drain is placed under the flap and subcutaneous tunnel. If
there is concern that the subcutaneous tunnel is too tight,
the tunnel should be aborted and the skin split between the
defect and flap pivot point.
The donor site is often too wide to be closed primarily.
The donor site is treated with a split-thickness skin graft
harvested from either the ipsilateral medial brachium or the
ipsilateral upper outer thigh. If skin graft donor site aesthet­
ics are a patient concern, a skin graft can be harvested from
the groin.
The skin graft is inset using dissolvable sutures (we prefer
4-0 chromic), and dressed with a bolster dressing of Vaseline
gauze and mineral oil – soaked cotton. The skin graft can
also be managed with a negative pressure dressing.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES AND
AVOID COMPLICATIONS
This flap carries with it a reputation of having unreliable
or unfavorable anatomy. Multiple case reports describe
instances of venous congestion, partial necrosis, or even
complete flap loss. Techniques designed to minimize these
risks include excluding unfavorable vascular anatomy with
a preoperative vascular duplex or CT angiogram, minimiz­
ing venous congestion by including with the pedicle a large
swath of adipofascial tissue (a so-called “septofasciosubcuta­
neous pedicle”),13 or minimizing venous congestion by per­
forming a microvascular venous anastomosis from a flap
vein to a dorsal hand vein.14
The reconstructive surgeon is advised to err on making
the flap larger rather than smaller. Though a smaller flap
may allow a primary donor site closure, it places the surgeon
at risk for designing the flap outside of the interval between
the ECU and EDQ tendons. As the septum between these
muscles carries the PIA perforators, capturing this interval
is imperative.
Beginning flap harvest from the ulnar aspect of the
flap will also protect the surgeon from missing the ECU/
EDQ interval by allowing rapid identification of the ECU
musculotendinous origin. The ECU represents the ulnar-
most border of the flap. The radial border of the flap
should only be incised after the ECU ulnar border has been
defined.

508
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Extending the wrist facilitates flap advancement and min­
imizes pedicle tension. Though this maneuver has an associ­
ated risk of wrist stiffness, wrist stiffness and extension
contractures are not often seen.
FLAP USAGE
This flap is primarily used for coverage of dorsal hand
defects or treatment of first web space soft tissue defects
after contracture release. The flap can also be used in
a proximal-based fashion to resurface elbow soft tissue
defects.
ATYPICAL INDICATIONS FOR USE OF THIS FLAP
While this flap is primarily used as an adipocutaneous flap
for dorsal hand coverage or resurfacing the first web space
after contracture release, it has been also used as an osteo­
cutaneous flap in which a portion of proximal ulna was
harvested with the flap for metacarpal reconstruction.11 The
A 30-year-old man with a crush injury to the right hand with
metacarpal fractures and a 7 × 4 cm wound on the dorsoradial
aspect of the hand (Fig. 45.13A). A reversed pedicle posterior
interosseous artery flap is elevated with dissection of the vessel
and fascia between the ECU and EDQ muscles (Fig. 45.13B).
The flap provides good contour of the reconstruction and a skin
graft provides coverage of the donor site (Fig. 45.13C,D)
CASE 45.10  Dorsal Hand Soft Tissue Defect Reconstructed with a Distally Based Posterior
Interosseous Flap
Figure 45.13  (A–D) Dorsal hand soft tissue defect reconstructed with a distally based posterior Interosseous flap.
A
B
C
D

CHAPTER 45 — Pedicled Flaps of the Hand
509
A 43-year-old woman with a non-healing wound over the olecra-
non (Fig. 45.14A). An antegrade pedicled posterior interosseous
artery flap is designed (Fig. 45.14B) and elevated over the ECU/
EDQ interval (Fig. 45.14C). The PIA septal perforator is clearly
demonstrated in Figure 45.14D. Successful wound coverage is
achieved and the donor site is covered with a skin graft (Fig.
45.14E).
CASE 45.11  Chronic Wound Over Olecranon Reconstructed with a Proximally Based
Posterior Interosseous Flap
A
B
C
D
E
Figure 45.14  (A–E) Chronic wound over olecranon reconstructed with a proximally based posterior interosseous flap.
flap can also be used as an adipofascial flap or as a proxi­
mally based pedicled flap for elbow coverage.
POSTOPERATIVE CARE AND OUTCOMES
Care is taken to ensure no undue tension or pressure on
the flap pedicle. If tension is an issue, the wrist should be
extended. Some authors have described allowing the pedicle
to “bowstring” above the wrist to facilitate the flap reaching
the defect.13 In this setting, or when the pedicle is not passed
through a subcutaneous tunnel, the pedicle can be managed
by either allograft skin or split-thickness autograft. The
pedicle can then be divided and completely excised in a
second-stage procedure at 3 weeks if needed.
Though small donor sites (<3–4 cm in width) can some­
times be closed primarily, larger flaps should be skin grafted.
The skin graft can be full or split thickness and should be
applied to the donor wound with the aid of a bolster dress­
ing, which will minimize shear and subgraft fluid
collection.
To minimize inadvertent tension on the pedicle in the
postoperative setting, a splint should be applied to the wrist
that maintains it in an extended position for a 3-week period
of time. At 3 weeks, the splint can be removed and, if a
secondary procedure is not needed, physical therapy can
commence (see Cases 45.10, 45.11).
CONCLUSION
The above described flaps are among the more popular
pedicled flaps for soft tissue reconstruction of the digits.
Each has relative advantages and disadvantages related to
arc of rotation, size of angiosome, soft tissue characteristics,
donor site morbidity, etc. They all provide non-microsurgical
alternatives to upper extremity reconstruction that make
them a valuable part of the reconstructive hand surgeon’s
armamentarium.

510
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Access Figure 45.11, as well as case example 9
and further reading online at http://
expertconsult.inkling.com
REFERENCES
1. Foucher G, Braun JB. A new island flap transfer from the dorsum
of the index to the thumb. Plast Reconstr Surg 1979;63:344–9.
2. Strauch B, Vasconez LO, Hall-Findlay EJ. Grabb’s encyclopedia of
flaps. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 1990.
3. Thorne CH, Bartlett SP, Beasley RW, et al., editors. Grabb and
Smith’s plastic surgery. 6th ed. London: Lippincott Williams &
Wilkins; 2006.
4. Katz RD. The anterograde homodigital neurovascular island flap.
J Hand Surg [Am] 2013;38(6):1226–33.
5. Becker C, Gilbert A. [The ulnar flap]. Handchir Mikrochir Plast
Chir 1988;20(4):180–3.
6. Inada Y, Tamai S, Kawanishi K, et al. Free dorsoulnar perforator
flap transfers for the reconstruction of severely injured digits. Plast
Reconstr Surg 2004;114(2):411–20.
7. Unal C, Ozdemir J, Hasdemir M. Clinical application of distal ulnar
artery perforator flap in hand trauma. J Reconstr Microsurg 2011;
27:559–66.
8. Ignatiadis IA, Mavrogenis AF, Avram AM, et al. Treatment of
complex hand trauma using the distal ulnar and radial artery
perforator-based flaps. Injury 2008;39(Suppl. 3):S116–24.
9. Büchler U, Frey HP. Retrograde posterior interosseous flap. J Hand
Surg [Am] 1991;16(2):283–92.
10. Hsu C, Chang J. The posterior interosseous artery flap revisited.
Oper Tech Plast Reconstr Surg 2002;9(4):173–80.
11. 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(1):28–33.
12. Rozen WM, Hong MK, Ashton MW, et al. Imaging the posterior
interosseous artery with computed tomographic angiography:
report of a rare anomaly and implications for hand reconstruction.
Ann Plast Surg 2010;65(3):300–1.
13. 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(12):1331–7.
14. Chen HC, Cheng MH, Schneeberger AG, et al. Posterior interos­
seous flap and its variations for coverage of hand wounds. J Trauma
1998;45(3):570–4.
Expert Commentary 
Don Lalonde BSc, MSc, MD, FRCSC
Drs Higgins and Katz are extremely well respected hand sur-
geons who have written this excellent chapter. It is a great
guide for all hand surgeons. You are lucky to have it!
To flap or not to flap? This is often a more important
question than. Which flap?
This is particularly true in the fingertip. All fingertip amputations
will heal in 2–8 weeks if the raw tissues are kept clean (daily
showering) and greasy (petrolatum jelly or ointment) so exposed
fat, bone, and joint do not dry and die. The glabrous skin will
always bring fat, nerves, and blood vessels over the exposed
bone, tendons, and joint as the wound contracts. Most patients
can return to work with Coban tape and Vaseline covering a
raw fingertip, long before it is healed.
Surgeons must remember that every time they cut finger skin
and fat to create a flap, they kill fat, nerves, and blood vessels.
This causes more numbness, cold intolerance, stiffness, and
an additional cosmetic defect. The cure should never be worse
than the disease. A surgeon should never flap a finger that he
would let heal secondarily if it were his own finger. It is unlikely
that I would ever consent to having a Moberg flap cover my
thumb tip without first letting it heal and seeing what functional
impairment I suffered.
To have patients asleep or under local to perform a
flap is another question
Most hand surgery can now be performed awake with lidocaine
and epinephrine instead of sedated with traditional tourniquet
surgery. This includes hand flap surgery.
Epinephrine 1 : 100,000 mixed with lidocaine will not kill the
flaps that are raised under local. However, the epinephrine may
make the flap pale until the vasoconstriction has resolved. This
may take more than a couple of hours in some cases. Clearly
this can be disconcerting to a surgeon who wants to see a pink
flap before he leaves the patient. The process can be acceler-
ated by injecting or bathing the area with 1 mg of phentolamine
in 1–10 cc of saline.
For many years, epinephrine flaps on noses and ears have
been pale for hours and then have “pinked” up. The same will
occur with fingers.

CHAPTER 45 — Pedicled Flaps of the Hand 510.e1
FURTHER READING
First Dorsal Metacarpal Artery Flap
Pistre V, Pelissier P, Martin D, et al. Vascular blood supply of the dorsal
side of the thumb, first web and the index finger: anatomical study.
J Hand Surg [Br] 2001;26:98–104.
Sherif MM. First dorsal metacarpal artery flap in hand reconstruction.
I. Anatomical study. J Hand Surg [Am] 1994;19(1):26–31.
Sherif MM. First dorsal metacarpal artery flap in hand reconstruction.
II. Clinical application. J Hand Surg [Am] 1994;19(1):32–8.
Tränkle M, Sauerbier M, Heitmann C, et al. Restoration of thumb
sensibility with the innervated first dorsal metacarpal artery island
flap. J Hand Surg [Am] 2003;28(5):758–66.
Cross Finger Flap
Al-Qattan MN. The cross-digital dorsal adipofascial flap. Ann Plast Surg
2008;60:150–3.
Megerle K, Palm-Bröking K, Germann G. The cross finger flap. Oper
Orthop Traumatol 2008;20:97–102.
Moberg Flap
Baumeister S, Menke H, Wittemann M, et al. Functional outcome after
the Moberg advancement flap in the thumb. J Hand Surg [Am]
2002;27(1):105–14.
Eliot D, Wilson Y. V-Y advancement of the entire volar soft tissue of the
thumb in distal reconstruction. J Hand Surg [Br] 1993;18(3):
399–402.
Foucher G, Delaere O, Citron N, et al. Long-term outcome of neuro­
vascular palmar advancement flaps in distal thumb injuries. Br J Plast
Surg 1999;52:64–8.
Macht SD, Watson HK. The Moberg volar advancement flap for digital
reconstruction. J Hand Surg [Am] 1980;5:372–6.
The Homodigital Island Flap
Adani R, Marcoccio I, Tarallo L, et al. The reverse heterodigital neuro­
vascular island flap for digital pulp reconstruction. Techn Hand
Upper Extrem Surg 2005;9(2):91–5.
Bickel KD, Dosanjh A. Fingertip reconstruction. J Hand Surg [Am]
2008;33(8):1417–19.
Braga-Silva J, Gehlen D, Bervian F, et al. Randomized prospective study
comparing reverse and direct flow island flaps in digital pulp recon­
struction of the fingers. Plast Reconstr Surg 2009;124(6):2012–18.
Fassler PR. Fingertip injuries: evaluation and treatment. J Am Acad
Ortho Surg 1996;4(1):84–92.
Henry M, Stutz C. Homodigital antegrade-flow neurovascular pedicle
flaps for sensate reconstruction of fingertip amputation injuries.
J Hand Surg [Am] 2006;31(7):1220–5.
Huang Y-C, Liu Y, Chen T-H. Use of homodigital reverse island flaps
for distal digital reconstruction. J Trauma 2010;68(2):429–33.
Kayalar M, Bal E, Toros T, et al. The outcome of direct-flow neurovas­
cular island flaps in pulp defects. Acta Orthop Traumatol Turc
2011;45(3):175–84.
Lachica RD. Randomized prospective study comparing reverse and
direct flow island flaps in digital pulp reconstruction of the fingers.
Plast Reconstr Surg 2011;127(5):2129–32.
Varitimidis SE, Dailiana ZH, Zibis AH, et al. Restoration of function
and sensitivity utilizing a homodigital neurovascular island flap after
amputation injuries of the fingertip. J Hand Surg [Br] 2005;30(4):
338–42.
Wang B, Chen L, Lu L, et al. The homodigital neurovascular antegrade
island flap for fingertip reconstruction in children. Acta Orthop Belg
2011;77(5):598–602.
Yazar M, Aydın A, Yazar SK, et al. Sensory recovery of the reverse
homodigital island flap in fingertip reconstruction: a review of 66
cases. Acta Orthop Traumatol Turc 2010;44(5):345–51.
Distal Ulnar Artery Perforator Flap
Page R, Chang J. Reconstruction of hand soft-tissue defects: alternatives
to the radial forearm fasciocutaneous flap. J Hand Surg 2006;31A:
847–56.
The Posterior Interosseous Artery Flap
Acharya AM, Bhat AK, Bhaskaranand K. The reverse posterior interos­
seous artery flap: technical considerations in raising an easier and
more reliable flap. J Hand Surg [Am] 2012;37(3):575–82.
Angrigiani C, Grilli D, Dominikow D, et al. Posterior interosseous
reverse forearm flap: experience with 80 consecutive cases. Plast
Reconstr Surg 1993;92(2):285–93.
Balakrishnan G, Kumar BS, Hussain SA. Reverse-flow posterior interos­
seous artery flap revisited. Plast Reconstr Surg 2003;111(7):2364–9.
Gavaskar AS. Posterior interosseous artery flap for resurfacing post­
traumatic soft tissue defects of the hand. Hand 2010;5(4):397–402.
Lim Y-J, Sebastin SJ, Fong PL, et al. Extending the reverse posterior
interosseous artery flap using a de-epithelialised bridge segment.
J Plast Reconstr Aesth Surg 2010;63(1):e111–13.
Neuwirth M, Hubmer M, Koch H. The posterior interosseous artery
flap: clinical results with special emphasis on donor site morbidity.
J Plast Reconstr Aesth Surg 2013;66(5):623–8.
Tonkin M, Stern H. The posterior interosseous artery free flap. J Hand
Surg 1989;14(2):215–17.
Zancolli E, Angrigiani C. Posterior interosseous island forearm flap.
J Hand Surg [Br] 1988;13(2):130–5.

511
INTRODUCTION
The lateral arm flap (LAF) is a reliable septofasciocutaneous
flap for local and free tissue transfer. Song et al. in 1982,1
Cormack and Lamberty in 1983,2 and Katsaros et al. in 19843
first reported the advantages of the conventional LAF. In
its original design, the flap extends from the insertion of
the deltoid muscle to the lateral epicondyle. Katsaros et al.4
and Kuek and Chuan5 were first to report the clinical use of
an “extended” lateral arm flap (ELAF) in 1991. The ELAF
is a LAF that includes an extension over and beyond the
lateral epicondyle. The LAF/ELAF presents numerous
advantages including a constant vascular anatomy, based on
a terminal branch of the profunda brachii artery, minimal
donor site morbidity, and a great variability in design. The
LAF/ELAF can be employed for reconstruction in the lower
and upper extremities and especially in the head and neck
region.
FLAP ANATOMY (see Fig. 46.1 and Figs 12.4,
12.5, 12.22 and 12.23)
ARTERIAL AND VENOUS SUPPLY OF THE FLAP
(Fig. 46.1 and Figs 12.4 and 12.5)
Dominant:  radial collateral artery (RCA) of the profunda
brachii artery (PBA)
Length: 6 cm (range 4–8 cm)
Diameter: 1.5 mm (range 1–3 mm)
The main branch of the RCA that supplies the flap is the
PRCA. This posterior branch arises from the RCA at the
anterolateral border of the triceps muscle and runs distally
through the lateral intermuscular septum between the
triceps posteriorly and the brachialis and brachioradialis
anteriorly. It supplies the overlying flap skin by four or five
Lateral Arm Flap
Milomir Ninković  |  Ulf Dornseifer 46 
Figure 46.1  Lateral arm flap.
Deltoid
Profunda brachii
artery
Radial
collateral
artery
Lateral intermuscular
septum
Long head of triceps brachii
Middle branch of
radial collateral artery
Anterior branch of
radial collateral artery
Posterior antebrachial
cutaneous nerve
Posterior branch of
radial collateral artery
Lower lateral brachial
cutaneous nerve
Biceps
Brachialis
Brachial artery
Brachioradialis
Externsor carpi radialis longus
Lower lateral brachial
cutaneous nerve
Radial nerve
Radial recurrent artery
Lateral head of triceps brachii
Radial artery
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION F  —  LOCAL AND FREE FLAPS IN THE UPPER EXTREMITY

512
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Advantages
• The LAF/ELAF is a reliable fasciocutaneous flap for local
and free tissue transfer with constant vascular anatomy.
• In the elevation of the LAF/ELAF, there is no risk to the
vascular supply of the hand, because the LAF/ELAF con­
tains a terminal branch of the PBA.
• Dissection is easy with the patient in supine as well as in
prone position.
• There is only minimal donor site morbidity with generally
direct closure up to a width of 8 cm in elderly patients.
• The unique vascular plexus in the elbow region allows
great variability in design.
• Using the ELAF, there is increased skin availability and
pliability of thin proximal forearm skin, but, above all, a
long vascular pedicle can be obtained. Therefore, the
ELAF is one of the best alternatives for the radial fore­
arm flap.
• The variability in fasciocutaneous thickness (i.e., upper
arm – thick; proximal forearm – thin) enables the use of
this flap in two different regions according to defect
requirements. In addition, the versatility of this flap is
enlarged by the potential inclusion of vascularized
osseous, nerve, or musculotendinous tissue.
Disadvantages
• Transection of the LBCN and PACN will result in a sensory
deficit in the posterolateral side of the arm and forearm.
This area of hyposensibility is significantly reduced after
6 months because of ingrowth of the surrounding cutane­
ous nerve.
• Donor site complications are described, including lateral
epicondylar pain, hyperesthesia of the proximal lateral
forearm skin caused by damage to the posterior cutaneous
nerve of the forearm during raising of the flap, temporary
radial nerve palsy, and a decreased range of motion.
• The radial nerve, coursing deep to the PBA in the region
of the spiral groove, is endangered during proximal dis­
section of the vascular pedicle.
• Using the LAF/ELAF as a free flap, the small diameter of
the flap’s vessels, especially the veins, is disadvantageous,
particularly when the pedicle is ligated distally from the
branching of the ARCA.
• The reverse flap requires retrograde flow, which can
result in inadequate flap perfusion. A 180° flap rotation
may additionally lead to venous insufficiency.
• Hair growth in the skin territory of the ELAF in some
male patients may also be a problem, especially for head
and neck reconstruction.
• The flap, especially the LAF, is thick in overweight indi­
viduals. However, the ELAF is always thin and pliable.
PREOPERATIVE PREPARATION
Preoperatively, the surgeon has to ensure that there has
been no prior trauma or operative intervention at the donor
region that could endanger the vascular supply of the LAF/
ELAF. In cases of trauma, consideration should be given to
performing a Doppler sonography or in very rare situations,
an angiogram (CT angiogram) to determine the blood
supply. Extended local scarring can necessitate the choice
septocutaneous perforators along the intermuscular septum,
and empties into the epicondylar and olecranon plexus.
The most distal septocutaneous perforator typically branches
off at approximately 4 cm proximal to that prominence.
The use of the ELAF, including the proximal forearm
region, enables a lengthening of the pedicle up to 16 cm as
compared with the conventional LAF (6 cm). It is important
to include the distal septocutaneous perforator above the
lateral epicondyle, harvesting the ELAF.
Minor:  anterior radial collateral artery (ARCA)
Length: 3 cm (range 2–6 cm)
Diameter: 0.8 mm (range 0.5–1.5 mm)
Minor:  interosseous recurrent artery (IRA) and recurrent
radial artery (RRA) (important for distally pedicled flap)
Length: 3 cm (range 2–6 cm)
Diameter: 0.8 mm (range 0.5–1.5 mm)
VENOUS DRAINAGE OF THE FLAP
Primary:  venae comitantes of the radial collateral artery
and its posterior branch
Length: 6 cm (range 4–8 cm)
Diameter: 2.5 mm (range 1.5–3 mm)
Venous drainage is supplied by two (75%) and less fre­
quently by one (25%) venae comitantes.
Secondary:  cephalic vein
Length: 20 cm (range 15–25 cm)
Diameter: 6 mm (range 4–10 mm)
The cephalic vein itself or smaller braches can be included
in the anterior part of the flap during dissection to provide
augmented drainage.
FLAP INNERVATION (Figs 12.22 and 12.23)
Sensory:  the lower brachial cutaneous nerve (LBCN) is
a primary sensory branch of the standard skin territory of
the LAF
The posterior antebrachial cutaneous nerve (PACN) sup­
plies a more distal skin territory, inferior to the lateral epi­
condyle, used for the ELAF.
Motor:  this is a septofasciocutaneous flap
FLAP COMPONENTS
The LAF/ELAF is generally harvested as a septofasciocuta­
neous flap, but it can also be elevated as a pure fascial flap.
In addition, it can include a fragment of the posterolateral
distal humerus as an osseofasciocutaneous flap. It is possible
to integrate a segment of the lateral head of the triceps
muscle and also a segment of vascularized triceps tendon.
Enclosing the ARCA also enables integration of a segment
of brachialis or brachioradialis muscle. The inclusion of the
LBCN or PACN enables the design of a neurosensory flap.

CHAPTER 46 — Lateral Arm Flap
513
epicondyle (ELAF). The distal extension of the ELAF can
reach up to 15 cm beyond the epicondyle. The combination
of LAF and ELAF can result in flap dimensions of about
35 cm length. Finally, the possible length of the flap depends
on the patient’s age, body size, and local tissue situation.
The surgeon can use the thicker fasciocutaneous tissue of
the upper arm, the thinner extended part of the ELAF, or
both, according to the defect requirements. Generally, it is
sufficient to raise only the extended part of the ELAF, par­
ticularly as the ELAF provides a thinner and more pliable
skin paddle than the LAF. In addition, the extension of the
LAF provides a longer pedicle of the flap.
Width generally should not exceed 6 cm to allow for
primary closure of the donor defect. In combination with
Z-plasties, donor defects up to 8 cm can be closed directly.
SPECIAL CONSIDERATIONS
HEAD AND NECK RECONSTRUCTION
In 3-dimensional defects with loss of bone, muscle, or nerve
tissue, the LAF/ELAF enables the inclusion of vascularized
bone, muscle, or nerve tissue (see below). Compared with
the radial forearm flap, the ELAF, with its very long pedicle
and its thin, pliable skin, is perfectly indicated for intraoral
reconstruction. Sometimes laser hair removal has to be per­
formed before this ELAF application.
EXTREMITY RECONSTRUCTION
• Soft tissue defect with a bone defect: a vascularized
segment of the distal humerus may be included.
• Soft tissue defect with a 3-dimensional defect: a vascular­
ized segment of the lateral head of the triceps, brachialis,
or brachioradialis muscle may be included.
• Soft tissue defect with a peripheral nerve defect: the
PACN can be harvested with the flap as a vascularized
nerve graft.
of another donor site. The hair at the operative field, espe­
cially at the male forearm region, has to be trimmed or
removed by laser. There is no size or age limitation of the
patients. In elderly patients, with relaxed arm skin, the
donor site can even be closed directly up to 8 cm. While
the upper arm and forearm territory provide one of the
thinnest flaps available, in obese individuals it can still be
bulky. However, a thin fascia flap covered with split-thickness
skin graft can be raised in even the most obese individuals.
If operability is ensured and there is no evidence for vascu­
lopathy, preventing microsurgical intervention, no contra­
indication for the surgery exists.
FLAP DESIGN
ANATOMIC LANDMARKS (Fig. 46.2)
The bifurcation of the PBA is visualized at the level of the
deltoid insertion beneath the lateral caput of the triceps
muscle. Marginally distal, the RCA, as the pedicle’s basis,
divides into PRCA and ARCA before appearing at the
anterolateral aspect of the triceps. The pedicle’s axis passes
along the lateral intermuscular septum, which is located
between the brachialis and brachioradialis muscle on the
anterior side and the lateral head of the triceps muscle on
the posterior side. The skin island of the conventional LAF
is located between the insertion of the deltoid muscle and
the lateral epicondyle. The axis of the skin island of the
ELAF at the forearm is centered on a line between the
lateral epicondyle and the processus styloideus radii.
GENERAL THOUGHTS ABOUT FLAP DESIGN
The flap design depends on the defect that has to be
covered. According to the size of the defect, the dimensions
of the LAF can be extended over and beyond the lateral
Figure 46.2  Anatomic landmarks. 1. Anatomic snuffbox. 2. Brachioradialis. 3. Deltoid. 4. Acromion. 5. Trapezius. 6. Latissimus dorsi.
7. Triceps. 8. Olecranon process. 9. Common extensor muscle group. 10. Extensor carpi ulnaris. (With permission from Standring et al., editors.
Gray’s anatomy. 39th ed. Elsevier, Churchill Livingstone; 2005.)
1
2
3
4
5
6
7
8
9
10

514
PART 4 — CONVENTIONAL WORKHORSE FLAPS
BONE DIMENSIONS
HUMERUS
Length: Average 6 cm (range 2–15 cm)
Width: Average 1 cm (range 0.5–1.5 cm)
Thickness: Average 1 cm (range 0.5–1.5 cm)
The inclusion of a bone fragment necessitates immobili­
zation for 2–3 weeks to avoid fracture of the distal humerus.
TENDON DIMENSIONS
TRICEPS TENDON
Length: Average 6 cm (range 3–10 cm)
Width: Average 1 cm (range 0.5–2.5 cm)
NERVE DIMENSIONS
LOWER BRACHIAL CUTANEOUS NERVE/POSTERIOR
ANTEBRACHIAL CUTANEOUS NERVE
Length: Average 14 cm (range 12–16 cm)
The flap can include a vascularized nerve graft in combi­
nation with soft tissue reconstruction. The nerve graft on
its own does not have a pedicle; therefore, it has to be
harvested as a composite flap with the main pedicle of the
LAF/ELAF.
FLAP MARKINGS (Fig. 46.3)
The skin island’s axis of the conventional LAF is centered
over a line between the mid-deltoid to the lateral epicon­
dyle. The insertions of the deltoid muscle and the lateral
epicondyle mark the proximal and distal edge. The proxi­
mal edge of the conventional LAF flap could be prolonged
over the deltoid muscle. However, this area is difficult to
close primarily and hypertrophic scar formation is usual.
The ELAF is an LAF that includes an extension of the
flap’s skin area over and beyond the lateral epicondyle. In
our experience, the maximal distal extension can reach
12–15 cm beyond the lateral epicondyle at the radial proxi­
mal forearm region without problems with blood supply. If
only the forearm skin of the ELAF is used, the skin island
ends proximal at the level of the lateral epicondyle. The skin
island positioned over the lateral epicondyle is also a
common design. The width is planned in accordance with
the requirements of the defect’s dimensions.
PATIENT POSITIONING
The LAF can be best elevated with the patient in supine
position, the arm flexed in place on the abdominal wall.
However, this flap can be elevated with the patient in prone
position, the arm abducted and flexed in place on a rest.
ANESTHETIC CONSIDERATIONS
The LAF/ELAF is usually harvested under general anesthe­
sia. In case of ipsilateral upper extremity defects, the pedi­
cled or free flap may be elevated under axillary block.
• Soft tissue defect with substantial loss of a tendon: for
tendon grafting, a vascularized part of the triceps tendon
may be integrated with the segmental muscle flap.
DIFFERENCE IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
Generally there is no difference in design when performing
the flap as pedicled or free. Only the design of the
reverse LAF differs, because of its other pedicle, as described
below.
FLAP DIMENSIONS
SKIN ISLAND DIMENSIONS
LATERAL ARM FLAP
Length: average 12 cm (range 5–20 cm),
Width: average 6 cm (range 3–12 cm), maximum to close
primarily: 8 cm
Thickness: average 10 mm (range 5–35 mm)
Widths up to 8 cm can be closed primarily in elderly
patients. The thickness of the flap varies with the donor site
(proximal thick fat layer vs distal thin fat layer).
EXTENDED LATERAL ARM FLAP
Length: Average 12 cm (range 5–35 cm),
Width: Average 5 cm (range 2–10 cm),
Thickness: Average 5 mm (range 5–15 mm)
The use of the ELAF as an extension of the LAF to the
antebrachial region allows the elongation of the skin island
and the harvest of thinner skin tissue in comparison to the
brachial area. According to the defect requirements, the
surgeon can also use the thinner and more pliable skin
paddle of the ELAF alone.
MUSCLE DIMENSIONS
TRICEPS MUSCLE
Length: Average 10 cm
Width: Average 2.5 cm
Thickness: Average 1 cm
BRACHIALIS MUSCLE
Length: Average 4 cm
Width: Average 2 cm
Thickness: Average 2 cm
BRACHIORADIALIS MUSCLE
Length: Average 6 cm
Width: Average 2 cm
Thickness: Average 2 cm
This flap is mainly a fasciocutaneous flap but part of the
triceps muscle and small parts of the brachialis or brachio­
radialis muscle could be included, as filling material for
deep defects. The dimension of the harvested muscle tissue
especially depends on the patient’s constitution. Using the
larger part of these muscles will produce significant donor
site morbidity.

CHAPTER 46 — Lateral Arm Flap
515
edge of the skin island. Proximal dissection of this nerve is
required for adequate nerve length to design a neurosensory
flap. After identifying the PRCA entering the intermuscular
septum, it is exposed in the proximal direction by dissection
until the ARCA and radial nerve are exposed. The radial
nerve is dissected anteriorly and distally from the ARCA.
Then the ARCA is ligated distally from the bifurcation of the
RCA, and further dissection of the RCA is completed proxi­
mally from the branching of the ARCA and PRCA.
EXTENDED LATERAL ARM FLAP
The use of the ELAF enables lengthening of the pedicle.
Planning of the ELAF includes extension of the skin island
either to the epicondylar region or to the radial proximal
forearm. The main axis of the forearm skin island proceeds
between the lateral epicondyle and the processus styloideus
radii, including the distal extension of the PRCA and its most
distal septocutaneous perforators, which can be detected by
a handheld Doppler in advance. After the flap is outlined,
dissection is begun in a bloodless field distally at the radial
forearm region and then posteriorly in the triceps region.
Skin and deep fascia are dissected from the muscles, includ­
ing the PACN in the forearm region, until the lateral epicon­
dyle is reached distally and the intermuscular septum
becomes visible posteriorly. The PACN is left intact, if sensory
nerve preservation or a vascularized nerve graft is planned,
and has to be dissected with the vascular pedicle proximally.
When the forearm part of the flap is raised with the deep
fascia from the muscles, effort is made to dissect the terminal
part of the PRCA with septocutaneous perforators from the
lateral epicondyle. Entrainment of the deep fascia in the
forearm region is not absolutely necessary, but permits a
safer dissection. Dissection of the upper arm portion of the
flap and its pedicle is then performed as described above
(LAF). The dimension of the upper arm fasciocutaneous
island depends on the demands of the defect.
If the flap (LAF/ELAF) is planned as a pedicled flap, the
pedicle should be exposed up to the deep brachial artery
(DBA). Depending on the required arc of rotation, the dis­
section can be continued in a proximal direction to include
a part of the DBA.
When the flap is harvested as a free flap, the RCA and
venae comitantes are dissected proximally to the branching
of the ARCA and PRCA. This is a very important step to
increase vessel diameter, especially vein diameter.
If only the forearm skin of the extended LAF is used, the
intermuscular septum, including the septocutaneous perfo­
rators, is also exposed by incision of the distal and posterior
deep fascia. The muscular fascia of the forearm is raised with
the flap to preserve the vascular plexus superficial to this
fascia, and at least 3 cm of the intermuscular septum proxi­
mal to the lateral epicondyle has to be harvested to include
the most distal septocutaneous perforators in the flap.
FLAP MODIFICATION/FLAP HANDLING
REVERSE FLAP
Coverage of elbow defects can be achieved with a reverse
LAF. The vascular supply of this flap is based on the epicon­
dylar and olecranon plexi, which are supplied by the IRA
TECHNIQUE OF FLAP HARVEST
LATERAL ARM FLAP
After the flap is outlined, the dissection is begun in a blood­
less field (use the sterile tourniquet applied very proximal
and posteriorly to achieve better access to the vascular
pedicle) postero-proximally (Fig. 46.4). The incision will be
performed posterior to the lateral intermuscular septum
over the lateral head of the triceps muscle. After exposure
and incision of the deep fascia, the flap is elevated on the
muscular level until the intermuscular septum with the sep­
tocutaneous perforators becomes visible, exposing the
lateral head of the triceps muscle. The overlying fascia is
fixed with two stitches to the skin to avoid a separation of
skin and fat layer. After that, dissection proceeds anteriorly
until the intermuscular septum is reached, exposing the
brachialis and brachioradialis muscles. The septocutaneous
perforators are visualized superficial to the deep fascia.
Afterward, the distal fascia is incised to the level of humeral
periosteum and the intermuscular septum is now separated,
with periosteum, from the humerus proximally to the level
of deltoid insertion.
The LBCN enters the cutaneous territory of the flap at the
level of deltoid insertion and is visualized at the proximal
Figure 46.3  Flap markings. LAF, lateral arm flap; ELAF, extended
lateral arm flap.
LAF
ELAF
Combination

516
PART 4 — CONVENTIONAL WORKHORSE FLAPS
kind of flap can also be harvested with a small skin island,
which could be removed and used as a full-thickness skin
graft, making flap dissection easier. The maximal dimen­
sions of the fascia flap should not exceed 8 cm by 15 cm.
This flap can be split and each segment can be based on
one or two perforators.
OSSEOFASCIOCUTANEOUS FLAP
The PRCA has 1–2 branches, supplying the bone directly
and constantly between 2 cm and 7 cm proximal to the
lateral epicondyle. Therefore, the LAF/ELAF can be har­
vested with a vascularized bone fragment of the distal
humerus. Initial flap dissection is similar to the standard
flap description. Instead of elevating the intermuscular
septum from the distal humerus, an osseous segment 1.5 cm
in width and up to 15 cm in length is elevated in continuity
with the intermuscular septum connected with periosteum.
To ensure blood supply, harvesting of the bone fragment
between 3 cm and 6 cm above the lateral epicondyle is
recommended.
COMBINED MUSCULOTENDINOUS AND
FASCIOCUTANEOUS FLAP
The PRCA has vascular connections to the lateral head
of the triceps muscle. Therefore, the LAF/ELAF can be
harvested with a segment of the muscle for increased flap
bulk. In addition, a segment of vascularized triceps tendon
may be included for tendon grafting. Initial flap dissection
is similar to the standard flap description. After visualization
of the distal lateral head of the triceps muscle with the
triceps tendon, a 10 × 2 cm lateral segment of tendon with
muscular tissue is elevated. Therefore, the muscle portion
and the RRA. It is nearly impossible to dissect the flap on
the pedicles (IRA and RRA). Therefore, it is better to leave
a fasciocutaneous flap base about 2 cm to gain blood supply
by both arteries. Preoperatively, a Doppler examination is
advisable to determine the pedicle’s anatomy.
The beginning of surgery is comparable with dissection
of the LAF. After the intermuscular septum is exposed as
described above (LAF), the PRCA is ligated and dissected
at the level of the deltoid insertion. Subsequently, the proxi­
mal fascia is incised to the level of the humeral periosteum
and the intermuscular septum is now separated from the
humerus distally to the level of the lateral epicondyle. It is
important to include muscle fascia to preserve the distally
based pedicles. Stopping the dissection 2 cm before reach­
ing the lateral epicondyle can make the procedure safer.
However, extending the dissection to the level of the lateral
epicondyle or 1–2 cm distal to the epicondyle can expand
mobility. Then the pedicled reverse LAF can be transferred
to the elbow region.
FASCIA AND ADIPOFASCIA FLAP
The fascial LAF/ELAF provides thin and pliable tissue, con­
forming well to the contour of the fingers, and its undersur­
face creates a gliding surface for tendons. Following a
curvilinear skin incision overlying the axis of the lateral
intermuscular septum of the upper arm or proximal
forearm, skin flaps are elevated above the fascia. A thin fat
layer over the fascia should always be left, raising the flap as
a fascia flap. Additionally, the amount of fat to be included
with the flap is determined in accordance with the require­
ment at the recipient site. The fascia flap is harvested in a
similar manner to the previously described techniques for
LAF/ELAF flap harvest, generally without a skin island. This
Figure 46.4  (A) Incision of the skin and exposure of the intermuscular septum including the pedicle. (B) Release of the flap up to the lateral
epicondyle. (C) Release of the intermuscular septum including the pedicle. (D) Preparation of the pedicle (radial collateral artery) and exposure
of the posterior antebrachial cutaneous nerve. (E) Removed flap with pedicle and posterior antebrachial cutaneous nerve.
A
B
C
D
E

CHAPTER 46 — Lateral Arm Flap
517
Before closing the defect primarily, one drain (12 mm)
is placed subcutaneously to the brachial area.
The primarily closed defect is dressed with Steri-Strips.
The skin graft needs a moist coverage in the form of a fat-
gauze dressing and compression.
The use of an adipofacial LAF allows a tension-free skin
closure even in larger flap dimensions, as the skin is only
incised to raise the fascia beneath.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
The diameter of the flap’s vessels is very small. Therefore,
the pedicle has to be dissected proximal to the branching
of the PRCA and ARCA, following the radial nerve and RCA.
Dissection has to be performed proximally to the branching
of the ARCA and PRCA to achieve an appropriate diameter
of the vessel and easier manipulation under a microscope.
For beginners it is very important to mark the artery
before cutting the pedicle, because, under a microscope
is separated from its attachments to the humerus and dis­
sected together with the intermuscular septum, keeping
vascular supply intact. If more muscle bulk is needed, part
of the brachial and/or brachioradial muscle together with
the ARCA can be included. However, if more muscle bulk
is needed, it is better to harvest other myocutaneous flaps
(e.g., gracilis flap).
NEUROSENSORY FLAP
The PACN and the LBCN may be included with the flap for
a neurosensory flap design. The LBCN enters the cutaneous
territory of the flap at the level of the deltoid insertion and
is visualized at the proximal edge of the skin island. Proxi­
mal dissection of this nerve is required for adequate nerve
length to design a neurosensory flap. The PACN pierces the
deep fascia slightly anterior to the intermuscular septum in
the distal third of the upper arm and courses superficial to
the brachioradialis muscle. Generally, this nerve is divided
during elevation of the inferior portion of the intermuscu­
lar septum. Inclusion of the nerve will allow a neurosensory
ELAF design. Otherwise, the nerve can be used as vascular­
ized nerve graft. The nerve is dissected proximally parallel
to the pedicle to the deltoid insertion. The PACN joins the
radial nerve at the level of bifurcation of the PBA. At this
junction the nerve is divided. It is possible to harvest a
12–16 cm vascularized nerve graft.
EXTENDED PEDICLE FLAP
See Flap Usage/Pedicled LAF/ELAF.
FLOW-THROUGH FLAP FOR DISTAL
REVASCULARIZATION
This technique is not practical because of the terminal
branching of the RCA.
SPLIT CUTANEOUS FLAP
This modification can be applied if the distal extended part
with two perforators is separated from the proximal part
with perforators on its own.
SPECIAL INSTRUMENTS
There is no need for special instruments.
DONOR SITE CLOSURE
AND MANAGEMENT
The donor site defect of the LAF/ELAF can be closed pri­
marily up to a width of 6 cm or 8 cm in elderly patients. For
larger dimensions, the donor site defect is closed by a skin
graft, after reduction of the defect size by closing the proxi­
mal and distal ends primarily. The scar of the skin graft can
be corrected later, using serial excisions.
In some situations the closure will be easier if the tech­
nique of Z-plasty is used to avoid a straight scar on the lateral
aspect of the elbow joint (Fig. 46.5).
Figure 46.5  Skin closure by Z-plasty.

518
PART 4 — CONVENTIONAL WORKHORSE FLAPS
defect is the basic prerequisite for successful reconstruction.
In a second step, the requirements of the defect must be
precisely analyzed. This enables an accurate decision con­
cerning the choice of LAF or ELAF type, with or without
modification (innervated, composite flap).
Therefore, the required dimension and volume have to
be analyzed initially to achieve an appropriate closure of the
defect according to the reconstructive requirements. The
thick subcutaneous tissue on the upper arm (LAF) gives this
flap enough volume to fill a large 3-dimensional defect, or
allows it to be used for contour reconstruction. The thin,
pliable skin of the lower arm (ELAF) is ideal for superficial
defects and locations with no need for bulky tissue (e.g.,
head and neck, intraoral region, esophagus, hand, foot).
The variability in fasciocutaneous thickness (upper arm –
thick; proximal forearm – thin) enables the use of this flap
in two different regions.
Depending on the specific localization (see below), the
available recipient vessels have to be planned. Their posi­
tion in relation to the defect determines the necessary
length of the pedicle. If a long distance has to be bridged,
the pedicle could be elongated, choosing the ELAF instead
of the conventional LAF (see above).
Additional requirements, such as the need for nerve
grafts, bone, tendon, or muscle tissue, have to be evaluated.
These tissues can be subsequently included in the compos­
ite flap, as described above.
This procedure affords a functional as well as an aesthetic
reconstruction.
PEDICLED LAF/ELAF
SOFT TISSUE DEFECTS OF THE SHOULDER
AND AXILLA
Concerning its arc of rotation, the pedicled LAF/ELAF can
be moved anteriorly or posteriorly toward the shoulder or
axilla. Indeed, the posterior way is shorter, because of the
anatomic course of the PRCA. The arc of rotation of the
pedicled LAF/ELAF can be maximized by extended dissec­
tion of the vascular pedicle. The pedicle of the flap can be
dissected proximally to the junction of the profunda brachii
artery and the brachial artery. This can be reached by sepa­
rating the lateral and long heads of the triceps or by partial
release of the triceps muscle fibers from their humeral
attachment. Then, a retrograde dissection of the PRCA to
the profunda brachii in the spiral groove can be done all
the way up to its takeoff from the brachial artery. This dis­
section will add approximately 7–8 cm to the pedicle’s
length. The use of the ELAF, providing a longer pedicle,
further extends the arc of rotation.
SOFT TISSUE DEFECTS OF THE ELBOW REGION
The reverse LAF can be moved in a radial or ulnar direction
to the elbow region. However, its arc of rotation is limited
because of the fasciocutaneous bridge, saving the blood
supply of the flap (see above).
The pedicled ELAF can also be used as a propeller flap
for elbow coverage. In this case the flap is rotated on the
distal perforator (usually 4 cm proximal to the lateral epi­
condyle), that has to be dissected free to prevent any venous
congestion.
later on, it is sometimes difficult to distinguish between the
artery and vein.
When designing the ELAF without inclusion of lateral
arm skin, it is important for the perfusion of the flap to
include distal septocutaneous perforating vessels 3 cm prox­
imal to the lateral epicondyle.
FLAP USAGE
PEDICLED LAF/ELAF
Soft tissue defects of the shoulder and the axilla. The
pedicled ELAF can be also used for elbow defects as a pro­
peller flap.
REVERSE LAF
Soft tissue defects of the elbow region.
FREE LAF/ELAF
• Head and neck: defects after radical resection of tumors,
post-burn or unstable scars, full-thickness defects of the
buccal region, all kind of intraoral defects, substantial
defect of the orbital space after enucleation, incomplete
non-circumferential hypopharyngeal or upper esopha­
geal defects, and contour deformity defects (acquired or
congenital)
• Trunk: penile reconstruction
• Upper extremity: defects after radical resection of tumors,
post-burn or unstable scars, defects with larger dimen­
sions or complex post-traumatic defects that additionally
need vascularized nerve, tendon, or bone grafts, particu­
lar defects at the dorsal and palmar side of the hand,
interdigital space as well as the fingers (also in combina­
tion with defects of palmar/digital nerves or bones)
• Lower extremity: defects after radical resection of tumors,
ulcers, post-burn or unstable scars, particular soft tissue
defects at the foot (especially Achilles tendon region and
dorsum of the foot), defects with larger dimensions or
complex post-traumatic defects that additionally need vas­
cularized nerve, tendon, or bone grafts.
TYPICAL INDICATIONS FOR THE USE OF THIS FLAP
The LAF/ELAF is indicated when coverage with a local flap
or a skin graft is not possible because of the defect’s require­
ments. The versatility of the free LAF/ELAF enables complex
reconstructions and makes it the most adaptable free fascio­
cutaneous flap not only in head and neck but also in upper
and lower extremity reconstruction.
Indications could be 3-dimensional defects, defects with
exposed anatomic structures (e.g., bone, tendon, nerve)
after radical resection of tumors, ulcers, post-burn or unsta­
ble scars, and the requirement for a shifting layer for suffi­
cient coverage. The LAF/ELAF is also useful for defects with
larger dimensions or complex post-traumatic defects that
additionally need vascularized nerve, tendon, or bone grafts.
It is obvious that the ELAF can replace the radial forearm
flap (RFF) in all indications with significantly less donor site
morbidity compared with the RFF.
The procedure of the reconstruction should always be
performed in a standardized manner, irrespective of the
defect’s localization. Sufficient radical debridement of the

CHAPTER 46 — Lateral Arm Flap
519
according to the general condition of the patient and
treated problem.
The postoperative monitoring for pedicled flaps does not
need to be as extensive as it is for free flaps. The distal part
of the pedicled flap should be observed twice a day for the
first 2 days. Additional fluid substitution is not necessary
but it is important to avoid circular dressings for this kind
of flap.
RECIPIENT SITE
The flap needs only a slack protective or Steri-Strip dressing.
Splinting is necessary when the flap is used in a joint region.
DONOR SITE
The primarily closed donor site should be dressed dry (e.g.,
Steri-Strips). In cases of closure with a split-thickness skin
graft, the donor site needs a moist coverage by fat-gauze and
compression.
OUTCOMES
EXPECTED OUTCOMES
SHORT-TERM OUTCOMES
Recipient Site
The LAF/ELAF is a reliable fasciocutaneous (septocutane­
ous) flap for local and free tissue transfer. Defect-adjusted
flap design results in an optimal aesthetic outcome at the
recipient site. However, this flap is the most useful for
appropriate indications in the head and neck region and
upper extremity, and less for lower extremity reconstruc­
tion, with excellent outcomes concerning the reconstructed
area.
Donor Site
The donor site of the LAF/ELAF can generally be closed
primarily. This scar is usually inconspicuous and causes no
functional restriction except for some sensibility discomfort.
LONG-TERM OUTCOMES
Recipient Site
There are no effects on growth at the recipient site. Follow­
ing integration, the transposed flap growth is adapted to the
surrounding tissue.
Coaptation of the posterior cutaneous nerve of the arm
to an appropriate recipient sensory nerve should provide
sensation. However, the benefit of a neurosensory flap has
not really been proven. In our experience, the sensory effect
of nerve coaptation is generally satisfactory in reconstruc­
tion on the hand, because of appropriate recipient nerves.
Protective sensation was attained in many patients without
nerve coaptation.
Donor Site
The donor site of the LAF/ELAF shows an excellent aes­
thetic and functional long-term outcome. Split-thickness
skin graft coverage could be improved by serial excision.
Possible areas of hypoesthesia of the skin adjacent to the
FREE LAF/ELAF
HEAD AND NECK
In the head and neck region, this flap is also useful for
reconstruction of incomplete non-circumferential hypopha­
ryngeal or upper esophageal defects and contour deformity
defects (acquired or congenital), as well as all kinds of intra­
oral defects. Especially in this localization, the versatility of
this flap can be excellently utilized. For example, the proxi­
mal part can be used to fill orbital space after enucleation
with simultaneous nasal reconstruction, using the distal thin
part of the ELAF. The middle part of the flap can be
de-epithelialized and the distal part of the flap can be pulled
out for full-thickness reconstruction of the buccal region.
In addition, a vascularized bone segment or a vascularized
nerve graft included in the flap may be used to fill bone
defects or to bridge larger nerve gaps.
UPPER AND LOWER EXTREMITY
Similar to the head and neck region, the reconstruction is
performed in the way described above. Considering the
typical defects in this region, bone, muscle, tendon, or
nerve tissue might need to be included more often.
ATYPICAL INDICATIONS FOR THE USE OF THIS FLAP
Penile Reconstruction with a Free
Fasciocutaneous LAF/ELAF
In this reconstruction, the planning of the urethra is the
most important part and should be done centrally and lon­
gitudinally above the septocutaneous pedicle. A 3 cm wide
longitudinal bar serves as a lining for the urethra. At both
sides next to this bar, a narrow area is de-epithelialized. Both
de-epithelialized areas are sutured together, forming an epi­
thelialized tube. Then the tissue lateral to the de-epithelialized
areas is wrapped around the neo-urethra and forms the
penis. The shaped LAF is transferred to the perineum and
anchored to the periosteum of the pubic symphysis. The
neo-urethra is connected to the existing urethral stump, the
PACN and LBCN are coapted to the erogenous branches of
the internal pudendal nerve, and the pedicle is anasto­
mosed end-to-end to the deep inferior epigastric vessels or
end-to-side to the femoral vessels. The biggest disadvantage
of this procedure is a large donor area that has to be covered
with a split-thickness skin graft, and causes aesthetic and
sometimes functional disturbance.
POSTOPERATIVE CARE AND
EXPECTED OUTCOMES
GENERAL
The free flap is monitored hourly, clinically, and by use
of handheld Doppler, for the first 24 h and every 3–4 h for
the next 48 h. According to their general condition, the
patient should be given 2000 mL per 46 h of Ringer’s solu­
tion, thrombosis prophylaxis (low (1–3) molecular weight
heparin), prophylactic antibiosis for post-traumatic cases,
and postoperative analgesics in the first 5 postoperative
days. Circular dressings should be avoided. The average
length of hospital stay is between 5 days and 3 weeks,

520
PART 4 — CONVENTIONAL WORKHORSE FLAPS
caused by damage to the PACN during raising of the flap,
have been seen seldom in our clinical practice. The hypo­
esthesia of the proximal lateral forearm skin may be ignored,
as most of the skin innervated by this nerve is included in
the ELAF. Lateral epicondylar pain may be related to tight
wound closure or the use of skin grafts for donor defects
over 6–8 cm in width.
CONCLUSION
Easy and quick dissection under tourniquet, design and
thickness variability, as well as potential sensory innervation
and possibility of use as a composite flap (muscle, tendon,
bone, nerve) make the LAF/ELAF superior to other fascio­
cutaneous flaps. The ELAF provides the same quality of a
pliable, thin fasciocutaneous tissue and a longer pedicle,
like the RFF, without raising the main hand artery. In con­
trast to the RFF, the donor site can be closed primarily and
heals with an acceptable scar without any functional deficit.
A defect-adjusted flap design results in an optimal aesthetic
outcome at the recipient site, without any increased disad­
vantage at the donor site. Therefore, the LAF/ELAF should
be considered among the best choices of all possible fascio­
cutaneous flaps for head and neck reconstruction. It can
also be successfully used in the reconstruction of various soft
tissue and composite defects of the extremities.
donor area are significantly reduced by reinnervation from
surrounding cutaneous nerves and do not provide consider­
able problems to the patient. The function of the elbow has
not been affected at all. In cases where the donor site passes
laterally over and beyond the epicondyle, Z-plasty could be
used for skin closure (Fig. 46.5).
UNTOWARD OUTCOMES
RECIPIENT SITE
The intensive postoperative monitoring of the flap enables
fast intervention in case of perfusion failure of the flap.
Partial necrosis can happen only if the flap is sutured under
significant tension, requiring partial necrosectomy and sec­
ondary wound closure. We have observed this condition in
two cases among 115 free LAFs.
Heavy hair growth in some male patients, especially at the
proximal radial forearm region, may be a problem when
this territory is included in the flap, particularly when the
flap is transferred to the head and neck region for enoral
or mucosal replacement. Given the fact that the lateral
upper arm region is less haired, the flap has to be planned
more proximally as a conventional LAF. Another alternative
is the use of the RFF, because the distal RFF region is always
hairless even in men with a strong hair growth; a groin flap
could be another option. Furthermore, the scapula flap
(SF) and anterolateral thigh flap are alternatives for those
patients with hair-bearing LAF regions and large recipient
defects.
DONOR SITE
Donor site complications, including lateral epicondylar
pain and hypoesthesia of the proximal lateral forearm skin

CHAPTER 46 — Lateral Arm Flap
521
An 80-year-old man presented with wound healing disorders fol-
lowing orthopedic bursectomy and multiple revision surgeries in
case of a chronically infected olecranon bursitis. As the chronic
infection also involved the humeral bone, radical debridement
was performed including sequestra and necrotic bone tissue,
resulting in an osteocutaneous defect. The defect was covered
after further debridement using a reverse pedicled musculocu-
taneous LAF. A triceps muscle cuff, perfused by a separate
branch at the mid of the pedicle, was included and plugged into
the bony defect. The radical debridement and reconstruction
with healthy, well-perfused tissue resulted in an immediate
healing of the chronic infection (Fig. 46.6).
CASE 46.1  Chronically Infected Olecranon Bursitis Reconstructed with a Pedicled
Chimeric Lateral Arm Flap Including a Segment of Muscle
Figure 46.6  (A) Osteocutaneous defect following chronic olecranon bursitis, orthopedic bursectomy, and multiple revision surgeries
including cortical windowing of the humeral bone. (B) Dissection of a reversed pedicled LAF including a triceps muscle cuff to fill the
post-infectious bone defect. (C) Proximal planning of the skin island allows to dissect a sufficient length of the distal pedicle and therefore
to increase the arc of rotation. (D) Postoperative result 1 year following reconstruction. The treatment has not led to a decreased range
of motion of the elbow, nor to a reduced elbow extension strength. (E) Donor site of the reverse pedicled osteomyocutaneous LAF.
A
B
D
E
C

522
PART 4 — CONVENTIONAL WORKHORSE FLAPS
A 24-year-old man presented with an amputation of the first and
second toe in addition with a massive crush injury of the dorsal
and plantar soft tissue of the right foot. The injury was caused
by the weight of a truck, rolling over the foot. Destruction of the
affected toes did not allow their replantation. Following radical
debridement and fluorescence perfusion control of the remain-
ing tissue, defect closure was achieved by a free sensate ELAF.
Whereas the LAF part of the flap covered the plantar defect, the
extended part was turned over to reconstruct the dorsum. The
flap was anastomosed to the medial plantar vessels. This recon-
struction offered to keep the length of the first metatarsal bone
and to provide sensibility at the plantar weight-bearing zone by
the coaptation of the lateral brachial cutaneous nerve to a
branch of the medial plantar nerve. Following this reconstruc-
tion, the patient was not considerably limited in playing football,
skiing, and mountain climbing. Sensibility of the plantar recon-
struction also contributes to preventing pressure ulcer formation
(Fig. 46.7).
CASE 46.2  Amputation and Crush Injury of the Foot Reconstructed with a Free
Sensate ELAF
Figure 46.7  (A) Amputation injury of the first and second toe including massive plantar and dorsal soft tissue damage. (B) Planning of
a 30 × 6 cm sensate fasciocutaneous ELAF at the right arm. (C) Postoperative result 3 years after surgery. (D) Postoperative result 3 years
after surgery. The skin of the flap has gotten more robust at the metatarsal head due to the pressure load of this region.
A
B
C
D

CHAPTER 46 — Lateral Arm Flap
523
A 52-year-old man presented with insufficient soft tissue coverage
at the forearm following a gunshot injury. He suffered from a
painful neuroma formation of the dorsal branch of the ulnar
nerve directly beneath the skin graft that also adhered to the
underlying tendons. The scar tissue and the neuroma were com-
pletely resected. Soft tissue coverage of the tendons was achieved
by a free LAF and nerve reconstruction was performed with a
vascularized nerve graft (lateral brachial cutaneous nerve),
included in the flap. The patient had no pain immediately after
this reconstruction and achieved adequate sensibility at the ter-
ritory of the reconstructed nerve (Fig. 46.8).
CASE 46.3  Insufficient Soft Tissue Coverage and Neuroma Formation After Gunshot
Injury Reconstructed with a Free LAF and Vascularized Nerve Graft
Figure 46.8  (A) Insufficient soft tissue coverage following gunshot injury resulting in painful neuroma formation directly beneath the skin
graft that also adhered to the underlying tendons. (B) Planning of a 14 × 6 cm LAF, including a vascularized nerve graft. (C) Defect after
complete resection of the skin graft scar and the neuroma of the dorsal branch of the ulnar nerve. The LAF is inserted in the defect and
anastomosed end-to-side to the ulnar artery. The proximal and distal stumps of the included vascularized nerve graft and the dorsal
branch of the ulnar nerve are marked by foils and coapted afterward. (D) Postoperative result, 2 years after reconstruction. (E) Donor site
of the LAF, 2 years after reconstruction.
A
B
C
D
E

524
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Access Figures 46.9, 46.10, 46.11, and 46.12,
as well as case examples 4, 5, 6, and 7 and
further reading online at
.inkling.com
REFERENCES
1. Song R, Song Y, Yu Y, et al. The upper arm free flap. Clin Plast Surg
1982;9:27.
2. Cormack GC, Lamberty BGH. Fasciocutaneous vessels in the upper
arm: application to the design of new fasciocutaneous flaps. Plast
Reconstr Surg 1983;74:244.
3. Katsaros J, Schusterman M, Beppu M, et al. The lateral upper arm
flap: anatomy and clinical applications. Ann Plast Surg 1984;12:489.
4. Katsaros J, Tan E, Zoltie N, et al. Further experience with the lateral
arm free flap. Plast Reconstr Surg 1991;87:902.
5. Kuek LBK, Chuan TL. The extended lateral arm flap: a new modi­
fication. J Reconstr Microsurg 1991;7:167.
Expert Commentary
Yu-Te Lin, MD, and Chih-Hung Lin, MD
The lateral arm flap is a reliable fasciocutaneous flap and can
be transferred with different components, including triceps
muscle, tendon, and humeral bone. Nonetheless, these com-
ponents at the donor site are not totally expendable and
should be transferred with caution. For example, when the
distal humerus is included in the flap transfer, prophylactic
plating of the humerus has been used to prevent fracture. If
volume of tissues is required, donor sites other than the
lateral arm flap, will be recommended.
As a pedicled flap based on the radial collateral artery, it
can reach the shoulder proximally; and to cover an elbow
defect, the flap can be transferred with a retrograde flow.
The pedicle length with “Y-V” technique was further
extended. Middle collateral artery (MCA) branches either
from profunda brachii artery (PBA) or from posterior radial
collateral artery (PRCA). With controlling the PBA, the extra
pedicle length gained from the MCA was around 5 cm in
average. The technique made coverage of the distal forearm
attainable.
For dorsal hand reconstruction, a thin flap is usually pre-
ferred. The thickness of the lateral arm flap is much thinner
at the proximal forearm than at the upper arm. The distally
planned lateral arm flap (or the truly distal lateral arm flap) is
suggested for this purpose. The distally planned flap is based
on the terminal branches of the PRCA. This distally planned
lateral arm flap gives longer pedicles to reach the recipient
vessels out of the injury zone or the irradiated recipient site.
The medial sural artery perforator flap is an alternative option
for thin flaps, and also provides a lengthy pedicle. The dif-
ference is, the lengthy pedicle of distally planned lateral arm
flap is from PRCA, of which the diameter is about 1.5–2 mm,
but the medial sural artery perforator flap is based on a
long perforator vessel, of which the diameter is <1 mm,
before branching from medial sural artery. When a shorter
pedicle is required, we still can trim the pedicle of the distally
placed lateral arm flap and repair with sizeable donor vessels.
As for the medial sural artery perforator flap, the trimmed
perforator vessels may not be comfortable for microsurgical
anastomosis.

CHAPTER 46 — Lateral Arm Flap 524.e1
A 62-year-old woman presented with radiation skin necrosis and
bone resorption at the lateral forehead after tumor resection
and radiotherapy of a squamous cell cancer.
Following radical excision of the necrosis, the defect was
reconstructed using a fasciocutaneous LAF anastomosed to the
temporal artery (Fig. 46.9).
CASE 46.4  Radiation Skin Necrosis at the Forehead Reconstructed Using a
Fasciocutaneous LAF
Figure 46.9  (A) Radiation skin necrosis after tumor resection and radiotherapy of squamous cell cancer. (B) Postoperative result after
radical resection and reconstruction with free fasciocutaneous ELAF.
A
B

524.e2 PART 4 — CONVENTIONAL WORKHORSE FLAPS
A 55-year-old woman presented with local recurrence of a carci-
noma of the hypopharynx (T4). After tumor resection, laryngec-
tomy, and bilateral neck dissection, the non-circumferential
defect of the hypopharynx was reconstructed by means of a
fasciocutaneous ELAF (Fig. 46.10).
CASE 46.5  Carcinoma of the Hypopharynx Defect Reconstructed Using a Fasciocutaneous
ELAF
Figure 46.10  (A) Non-circumferential defect of the hypopharynx after local recurrence of a carcinoma of the hypopharynx, tumor resec­
tion, laryngectomy, and bilateral neck dissection. (B) Skin island of the ELAF. (C) Insetting of the ELAF at the hypopharyngeal defect.
(D) Donor site after harvesting of the ELAF. Notice the small Z-plasty at the level of the lateral epicondyle, to avoid straight line closure.
A
B
C
D

CHAPTER 46 — Lateral Arm Flap 524.e3
A 52-year-old man presented with a post-traumatic contracture
of the first interdigital space. Following surgical release of the
muscle and skin contracture, the defect was reconstructed using
a neurosensory fasciocutaneous LAF anastomosed to the radial
vessels in the anatomic snuffbox. The nerve was coapted to one
branch of the superficial radial nerve. The patient achieved full
mobility of the thumb with very good sensitivity of the skin island
(Fig. 46.11).
CASE 46.6  Contracture of the Hand Reconstructed Using a Neurosensory
Fasciocutaneous LAF
Figure 46.11  (A) Post-traumatic muscle and skin contracture of the first interdigital space. (B) Release of the contracture and defect
reconstruction using a neurosensory fasciocutaneous LAF. (C) Donor site of the conventional LAF.
A
B
C
A 42-year-old mountaineer presented with frostbite of both fore-
feet and previous debridement at another hospital. Following
further debridement, both defects were reconstructed using a
neurosensory fasciocutaneous ELAF anastomosed to the dorsalis
pedis artery. The nerve was coapted to the medial terminal
branch of the deep peroneal nerve. The patient achieved excel-
lent soft tissue cover of the stumps with very good sensitivity
(Fig. 46.12).
CASE 46.7  Severe Frostbite of Both Feet Reconstructed Using a Neurosensory
Fasciocutaneous ELAF
Figure 46.12  (A) Bilateral forefeet frostbite after radical debridement. (B) Planning of the fasciocutaneous ELAF at the right arm.
(C) Planning of the fasciocutaneous ELAF at the left arm. (D) Postoperative result at the time of discharge 2 weeks after surgery (frontal
view). (E) Postoperative result at the time of discharge 2 weeks after surgery (plantar view).
A
D
E
B
C

524.e4 PART 4 — CONVENTIONAL WORKHORSE FLAPS
FURTHER READING
Culbertson JH, Mutimer K. The reverse lateral upper arm flap for elbow
coverage. Ann Plast Surg 1987;18:62.
Gosain AK, Matloub HS, Yousif NJ, et al. The composite lateral arm
free flap: vascular relationship to triceps tendon and muscle. Ann
Plast Surg 1992;29(6):496–507.
Graham B, Adkins P. Scheker LR. Complications and morbidity of the
donor and recipient sites in 123 lateral arm flaps. J Hand Surg [Br]
1992;17:189.
Haas F, Rappl T, Koch H, et al. Free osteocutaneous lateral arm flap:
anatomy and clinical applications. Microsurgery 2003;23:87–95.
Hage JJ, Woerdeman LAE, Smeulders MJC. The truly distal lateral arm
flap. Ann Plast Surg 2005;54(2):153–9.
Hamdi M. Coessens BC. Distally planned lateral arm flap. Microsurgery
1996;17:375–9.
Harpf C, Papp C, Ninkovic M, et al. The lateral arm flap: review of 72
cases and technical refinements. J Reconstr Microsurg 1998;14(1):
39–48.
Ninkovic M, Deetjen H, Ohler K, et al. Emergency free tissue transfer
for severe upper extremity injuries. J Hand Surg [Br] 1995;20(1):
53–8.
Ninkovic M, Schwabegger AH, Wechselberger G. Reconstruction of
large palmar defects of the hand using free flaps. J Hand Surg [Br]
1997;22(5):623–30.
Ninkovic M, Harpf C, Gunkel A. One-stage reconstruction of defects
in the hypopharyngeal region with free flaps. Scand J Plast Reconstr
Surg Hand Surg 1999;33(1):31–9.
Ninkovic M, Mooney E, Ninkovic M, et al. A new classification for the
standardization of nomenclature in free flap wound closure. Plast
Reconstr Surg 1999;103(3):903–14.
Ninkovic M, Harpf C, Schwabegger AH, et al. The lateral arm flap. Clin
Plast Surg 2001;28(2):367–73.
Shenaq SM. Pretransfer expansion of a sensate lateral arm free flap.
Ann Plast Surg 1987;19:558.
Tan BK, Lim BH. The lateral forearm flap as a modification of the
lateral arm flap: vascular anatomy and clinical implications. Plast
Reconstr Surg 2000;105:2400–4.

525
INTRODUCTION
Drs. Yang and Gao of the Shenyang Military Hospital ini­
tially introduced the radial forearm flap, often called the
“Chinese flap.” Cadaveric studies performed in 1978 identi­
fied this flap and subsequent clinical series published in the
Chinese literature in 1981 sealed it as a viable reconstructive
option. In 1980, a delegation of German surgeons visiting
China saw this flap and subsequently introduced it to the
Western world.
The initial introduction of this flap was as a free flap in
the original 1981 article. It took another year or so for Lu
and Biemer to independently reintroduce it as a pedicled
flap based on retrograde flow.
Further refinements and delineation of its vascular
anatomy increased the reliability and applicability of this
flap for local, regional, and distant reconstruction of a
variety of defects in the body. The skin is thin and pliable,
the vascular anatomy is consistent, and the donor site mor­
bidity is acceptable. It can be sculpted into a sensate flap,
adipofascial flap, osteofasciocutaneous flap, or flow-through
flap with interposition of vein or artery as a conduit. The
forearm provides an ideal location for prelamination of the
flap prior to transfer. This flap is the most commonly used
fasciocutaneous flap for reconstruction of defects in the
head, neck, and limbs. With these versatile qualities, the
forearm flap has become one of the most frequently used
free tissue transfers.
FLAP ANATOMY (Figs 47.1 and 47.2, See Figs
12.8, 12.9, 12.10, 12.12, 12.19, 12.22, and 12.23)
ARTERIAL SUPPLY OF THE FLAP (Figs 47.1 and 47.2
and Figs 12.8, 12.9 and 12.10)
Dominant (Figs 47.1 and 47.2, See Figs 12.8, 12.9,
12.10):  radial artery
Length: 18.0 cm (range 15.0–22.0 cm) in the adult
Diameter: 3.0 mm (range 2.5–3.5 mm) in the adult
Approximately 12 septocutaneous branches from the
radial artery supply the skin of the forearm. Three to four
of these branches arise in the proximal forearm between
the brachioradialis and the pronator teres muscles (Fig.
47.2). These are large perforators with average diameter
>0.5 mm. They supply a large area of skin 4.0 cm below the
elbow flexion crease. The rest of the fasciocutaneous per­
forators are mostly small branches, densely populated in
the distal third of the forearm between the tendons of the
Radial Forearm Flap
Amir H. Taghinia  |  Joseph Upton 47 
Radial artery
Brachioradialis
(retracted)
Lateral
intermuscular
septum
Bicipital
aponeurosis
Palmaris longus
Ulnar artery
Flexor carpi radialis tendon
Lateral antebrachial
cutaneous nerve
Pronator
teres
Medial
antebrachial
cutaneous
nerve
Radial artery
Brachioradialis
tendon
Palmaris longus tendon
Extensor carpi
radialis longus
tendon
Flexor pollicis longus tendon
Flexor digitorum
superficialis tendon
Superficial
(cutaneous)
branch of
radial nerve
Figure 47.1  Radial forearm flap.
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION F  —  LOCAL AND FREE FLAPS IN THE UPPER EXTREMITY
The authors of this chapter acknowledge the original chapter contribu­
tion by David Soutar.4

526
PART 4 — CONVENTIONAL WORKHORSE FLAPS
brachioradialis and flexor carpi radialis. The middle third
of the forearm has the lowest density of perforators.
The perforators from the radial artery pass superficial to
the deep fascia, and herein, they interconnect to an exten­
sive network of subdermal fascia and vessels (Fig. 47.3).
These allow near circumferential vascular nourishment of
the forearm, sparing only about a 3.0 cm-wide strip on the
ulnar dorsal aspect of the forearm that is not perfused.
VENOUS DRAINAGE OF THE FLAP
(See Figs 12.22, 12.23)
Primary:  venae comitantes of the radial artery
Length: 18.0 cm (range 15.0–22.0 cm) in the adult
Diameter: 1.5 mm (range 1.0–2.0 mm) in the adult
Typically, two venae comitantes follow the radial artery
along its course. Connecting these venae comitantes is a
plexus of veins devoid of valves that surround the radial
artery. Since the venae comitantes contain valves, the con­
nections may be important for drainage of distally based
flaps (Fig. 47.4).
Secondary:  cephalic vein (see Fig. 12.19 for superficial
veins)
Figure 47.2  Cadaveric injection study shows proximal perforators
of radial artery.
Figure 47.3  Radial forearm flap components. (A) Multiple tissue types including tendon and bone can be harvested with flap. (B) Blood
flows via septocutaneous vessels to subdermal plexus.
Septocutaneous vessels
Mesoneurium
Arteria nervosa
Lateral intermuscular
septum
Segment of radius
Superficial vein
Lateral cutaneous nerve
of forearm
Deep fascia
Radial nerve
Radial artery
Venae comitantes
Periosteal feeding vessels
Septocutaneous
perforators
Septocutaneous
vessels
Pedicle vessels
Cutaneous island
Fascial base
A
B

CHAPTER 47 — Radial Forearm Flap
527
• Substantial pedicle length can be obtained, thus the flap
can reach difficult areas such as the palate, the skull base,
pharynx, or interdigital spaces.
• The artery and/or its veins can be used as interpositional
grafts and the flap can be used as a flow-through flap (see
Case 47.4).
• There is flexibility of venous anastomosis due to extensive
redundancy of veins.
• The flap can be free, pedicled, distally based, or
proximally based.
• A combination of tissues can be harvested, including skin,
fat, fascia, nerve, tendon, and bone.
• Very small to very large flaps can be harvested reliably.
• The skin is thin, pliable, and in many individuals,
hairless.
• The flap can be harvested under regional block.
Disadvantages
• The donor site is in a conspicuous location.
• Unless a very small flap is harvested, the donor site usually
requires a skin graft for closure.
• Healing of the skin graft can be delayed if the fascia over
the flexor carpi radialis is taken.
• Secondary fractures may occur when large osseous seg­
ments are harvested, particularly in the elderly.
• The flap requires sacrifice of a major artery of the forearm
and hand (unless revascularized).
PREOPERATIVE PREPARATION
It is common practice to choose the donor site from the
nondominant arm. The ulnar and radial arteries must be
assessed for patency via physical examination. An Allen test
can ensure that the hand will remain well-perfused after
division of the radial artery. Although a traditional Allen test
relies on clinical visualization, a more reliable test uses a
pulse oximeter probe on the thumb. The thumb is the most
distal digit to be perfused by the ulnar artery via a patent
arch. Once pressure on the ulnar artery is relieved (while
holding continued pressure on the radial artery), one
should see return of waveform and strong oximetry signal
within 5 s. A substantial delay in return of the waveform or
a dampened waveform should alert the surgeon about the
possibility of an incomplete arch. In these cases, one option
is to place a clamp on the radial artery and reperfuse the
hand before dividing the radial artery to make sure that the
hand becomes perfused. The other option is to plan a priori
to reconstruct the radial artery defect with a reversed vein
graft, or to avoid the flap altogether. Preoperative vascular
imaging is rarely needed but helpful following extensive
trauma, congenital malformations, electrical and thermal
burns, and conditions such as purpura fulminans.
If the bone is to be taken, preoperative plain films should
be obtained for planning and to ensure that there is no
pathology.
FLAP DESIGN
ANATOMIC LANDMARKS
Although nearly all of the forearm skin can be taken as a
free flap based on the radial artery angiosome, this would
Length: 20.0 cm (range 16.0–24.0 cm) in the adult
Diameter: 3.0 mm (range 2.5–4.0 mm) in the adult
The skin of the forearm flap is drained by a plexus of
unnamed superficial veins, many of which empty into the
cephalic vein. The cephalic vein can be dissected proximally
the whole length of the arm up to the deltopectoral groove.
It can be used as extra venous drainage for the flap, or as a
conduit for reconstructing the radial artery in reverse flow
flaps.
FLAP INNERVATION (see Figs 12.19 and 12.22)
Sensory
• Lateral antebrachial cutaneous nerve: innervates the
lateral (radial) half of the volar surface of the forearm
• Medial antebrachial cutaneous nerve: innervates the
medial (ulnar) half of the volar surface of the forearm
FLAP COMPONENTS
In addition to the skin, fat, and fascia, this septocutaneous
flap can be raised containing vascularized nerve, tendon
(palmaris longus, brachioradialis, flexor carpi radialis), and
bone incorporating a segment of the distal radius (Fig.
47.3). Given the importance of the flexor muscle compart­
ment for the function of the hand, this flap does not typi­
cally incorporate any functional muscle components.
Advantages
• The flap has reliable vascular anatomy.
• The radial artery and its venae comitantes are large in
diameter and microanastomoses are more predictable.
Figure 47.4  Interconnecting veins allow retrograde blood flow
despite valves in the venae comitantes.
Venae comitantes
Communicating branch
Collateral branch
A
B

528
PART 4 — CONVENTIONAL WORKHORSE FLAPS
which are more widely spaced in this area. Antegrade flaps
designed proximally are not typically used because the
pedicle length is shorter, the vascularity less reliable (due to
fewer perforators), and the flap thicker and less pliable.
SPECIAL CONSIDERATIONS
Flaps that will be used as skin tubes need to be broad and
usually incorporate all of the volar aspects of the forearm.
When used for reconstruction of the cervical esophagus,
ideally the upper and lower ends can be angulated, so that
the ends become wide (cone-shaped). Flaps for penile
reconstruction need substantial width due to the need
for creation of a urethra, an area of de-epithelialized skin,
and an area for forming the outer surface of the penis (see
Case 47.3).
If bone is incorporated, only the distal part of the radius
between the pronator teres and the radial styloid is acces­
sible and well-vascularized. The maximum length of bone
that can be harvested in most instances is 12.0 cm. Harvest­
ing more bone, however, is inadvisable because it may result
in the need to provide coverage for the bone, and/or may
weaken the radius substantially and increase the likelihood
of fracture. The authors advise against incorporating the
radius unless a small segment of bone is needed. Alternative
donor sites can provide a substantial amount of well-
vascularized bone with far less morbidity. These include the
medial femoral condyle or the fibular flaps. If a segment of
bone 5 cm or larger is taken from the radius, we recom­
mend bone grating and plate fixation.
DESIGN DIFFERENCES IN FREE VERSUS
PEDICLED FLAPS
Distal flap design is identical for free and pedicled flaps.
Distally designed pedicled flaps are ideal for reconstruction
Figure 47.5  Anatomic landmarks. 1. Acromion. 2. Greater tubercle (tuberosity). 3. Deltoid. 4. Axillary nerve. 5. Biceps brachii. 6. Radial nerve.
7. Cephalic vein. 8. Lateral epicondyle. 9. Head of radius. 10. Brachioradialis. 11. Radial artery. 12. Styloid process of radius. 13. Scaphoid.
14. Thenar eminence. 15. Lunate. 16. Hypothenar eminence. 17. Triquetrum. 18. Styloid process of ulna. 19. Proximal wrist crease. 20. Ulnar
artery. 21. Ulnar nerve. 22. Median cubital vein. 23. Median epicondyle. 24. Basilic vein. 25. Median nerve. 26. Triceps. 27. Brachial artery. 28.
Pectoralis major. The dashed line marks the course of the radial artery from a point 1 cm below the center of the antecubital fossa to the
tubercle of the scaphoid. (With permission from Standring et al., editors. Gray’s anatomy. 39th ed. Elsevier, Churchill Livingstone; 2005.)
1
2
3 4
5 6
7
8
9 10
11
16
20
21
22
23
24
25
26
27
28
17
19
18
121314 15
X
X
be highly morbid because of the disruption of the lymphatic
drainage from the hand. In practice, a strip of skin at least
3.0–5.0 cm in width overlying the posterior extensor com­
partment and the ulnar subcutaneous border should be
kept intact at a minimum.
The path of the radial artery is marked by drawing a line
from 1.0 cm distal to the midline of the elbow flexion crease
to the scaphoid tubercle (see Fig. 47.5). The artery is easily
palpable in the distal forearm and can be followed well into
its middle third with a Doppler probe.
Proximal pressure above the elbow helps to engorge veins
in the forearm and make them visible for marking and
incorporation into the flap design.
GENERAL CONSIDERATIONS
Smaller flaps should be designed in the distal third of the
forearm to ensure proper incorporation of perforators. The
skin and subcutaneous tissue here can be quite thin. A
suprafascial dissection can be performed ulnar and radial
to the artery and then taken deep to the fascia as the artery
is approached (Fig. 47.6). This technique protects the
tendons from exposure, preserves the epitendinous con­
nective tissue, and enhances skin graft take. Very small,
distally situated donor sites can usually be closed with skin
advancement.1
Flaps harvested from the center of the forearm harbor
the fewest perforators. These should be larger flaps to avoid
missing perforators. In these situations, it is advisable to take
a large cuff of fascia to ensure capture of as many perfora­
tors as possible (Fig. 47.7).
Proximally designed flaps are thicker, as they have more
subcutaneous fat. Small flaps designed proximally can be
problematic because there are fewer perforators and there
is risk that a perforator may not be incorporated in the flap.
Subfascial dissection is important to preserve perforators,