HAND/PERIPHERAL NERVE

Pedicled and Free Radial Forearm Flaps for
Reconstruction of the Elbow, Wrist, and Hand
Neil F. Jones, M.D.
Background: A single surgeon’s experience with 67 pedicled and free radial
Reza Jarrahy, M.D. forearm flaps for reconstruction of the elbow, wrist, and hand was analyzed
Matthew R. Kaufman, M.D. retrospectively.
Los Angeles, Calif. Methods: Fifty-seven pedicled (43 reverse and 14 antegrade flow) and 10 free
radial forearm flaps were performed in 66 patients, including seven fascial flaps
and one osteocutaneous flap. Indications involved soft-tissue coverage of the
elbow (n ⫽ 11), dorsal wrist and hand (n ⫽ 24), palmar wrist and hand (n ⫽
12), and thumb amputations (n ⫽ 5); after release of thumb-index finger web
space contractures (n ⫽ 6) and radioulnar synostosis (n ⫽ 2); before toe-to-
thumb transfers (n ⫽ 3); for reconstruction following tumor excision (n ⫽ 13);
and for wrapping of the median, ulnar, and radial nerves for traction neuritis
(n ⫽ 5).
Results: Primary healing of the soft-tissue defect of the elbow, wrist, and hand
was successful in 95 percent of patients. There was one flap dehiscence, partial
loss of two reverse radial forearm flaps, and complete loss of one free radial
forearm flap. Eleven donor sites were closed primarily and 56 were covered with
a split-thickness skin graft. No patients complained specifically of cold intoler-
ance of the hand or dysesthesias in the superficial radial nerve or lateral ante-
brachial nerve distribution.
Conclusions: This is the largest reported series of radial forearm flaps for
reconstruction of the upper extremity. The authors believe the antegrade pedi-
cled radial forearm flap is the optimal flap for coverage of defects around the
elbow, and the reverse radial forearm flap is the optimal choice for coverage of
moderate-sized defects of the wrist and hand. (Plast. Reconstr. Surg. 121: 887,
2008.)

S
oft-tissue coverage of defects affecting the based on the radial artery, ulnar artery, and pos-
hand, wrist, and elbow can be accomplished terior interosseous artery, respectively. These fas-
using skin grafts, local flaps, regional or dis- ciocutaneous flaps can be based on proximal ar-
tant pedicled flaps, and free flaps. The groin flap terial inflow for elbow coverage or based distally
based on the superficial circumflex iliac artery axis on reverse flow for coverage of the wrist and hand.
has been the most commonly used distant pedi- All three flaps can also be harvested and trans-
cled flap.1–7 Although the axial pattern of the ferred as free flaps.8,14,21,22,26 –28,40,44,45 The ulnar
groin flap provides an area of reliable skin, its forearm flap and posterior interosseous artery flap
disadvantage is that it requires attachment of the
upper extremity to the trunk followed by delay,
division, and insetting of the flap. The three op-
tions for regional pedicled flap coverage include Disclosure: None of the authors received funding,
the radial forearm flap,8 –26 the ulnar forearm grants, or in-kind support in support of the research
flap,27–33 and the posterior interosseous flap34 – 43 or preparation of the article. No author has an
association or financial involvement (i.e., consul-
From the UCLA Hand Center, Division of Plastic and Re- tancies/advisory board, stock ownerships/options,
constructive Surgery, and Department of Orthopedic Surgery, equity interest, patents received or pending, or roy-
University of California, Los Angeles, School of Medicine. alties/honorary) with any organization or commer-
Received for publication November 27, 2006; accepted Au- cial entity having a financial interest in or finan-
gust 10, 2007. cial conflict with the subject matter or research
Copyright ©2008 by the American Society of Plastic Surgeons presented in the article.
DOI: 10.1097/01.prs.0000299924.69019.57

www.PRSJournal.com 887

for burns. coverage of the palmar wrist and hand dial forearm flaps used for reconstruction of the (n ⫽ 12) (Fig. The donor site was usually covered with a dial forearm flaps and 10 were free flaps. subjective assessment of the series. Total 57 Free radial forearm flaps ally harvested as a skin flap. full- sex of the patient. Seven flaps were elevated as fascial flaps and one surgery. with a mean flap size of 8 ⫻ 6 Eleven patients subsequently underwent further cm. duration of release of radioulnar synostosis (n ⫽ 2). lized in a palmar plaster of paris splint for 7 days. 10 for primary or secondary reconstruction donor-site scar. complications of the toe-to-thumb transfers (n ⫽ 3) (Fig. Vascular Supply of Radial Forearm Flaps as the radial forearm flap with hand surgeons in (n ⴝ 67) the United States.46 – 49 or purely as Ipsilateral 2 a fascial flap50 –56 and may incorporate the palmaris Total 10 longus tendon as a vascularized tendon graft. 4). and superficial radial neuritis (n ⫽ 5). ferential wrapping of the median (n ⫽ 3). and proximal forearm. Of the pedicled ra. diagnosis. it may also be har. Inclusion struction after radical resection of malignant tumors criteria were patients who had undergone emer. A carpal tunnel syndrome (Fig. 1). location and size of thickness soft-tissue infections (n ⫽ 6) (Fig.58 The radial forearm flap has often been criticized because of the appearance of the donor site59 – 66 and because of concerns of harvesting the radial artery. in 25 patients. after release of thumb-index finger elbow.57. 24) (Fig. More esoteric indications included circum- seven consecutive radial forearm flaps for recon. with the flap or with the donor site. and before hospitalization. proximal-based radial forearm flaps were used in this tional improvement. ing the more dominant ulnar artery in the case of Pedicled radial forearm flaps the ulnar forearm flap and because of concerns of Reverse flow 43 reliability of the posterior interosseous artery Antegrade flow 14 flap. after the defect. was elevated as an osteocutaneous flap. 6). the meta- in the radial artery and 14 were based on antegrade carpophalangeal joints in 50 degrees of flexion.26. and hand in a large series performed by web space contractures (n ⫽ 6) (Fig. and for a single surgeon and to document any complications coverage of thumb amputations (n ⫽ 5) (Fig. Contralateral 8 vested as an osteocutaneous flap26. three involving the radial forearm flap 888 . The wrist and fingers were immobi- ipsilateral extremity (n ⫽ 2). of the forearm. flow (Table 1). No. forearm fascial flaps were transposed to the elbow Sixty-seven radial forearm flaps were per. dial forearm flaps. ulnar struction of the upper extremity were performed (n ⫽ 1). 3). Los Angeles School of Medicine. Indications which can be the dominant arterial supply to the included soft-tissue coverage of the elbow (n ⫽ 11) hand. wrist. and radial nerves (n ⫽ 1) for recalcitrant by a single surgeon between 1993 and 2005. and hand in 13 patients. Sixty. (n ⫽ 4). 8). two for interposition after formed in 66 patients. 2 cm to 15 ⫻ 10 cm. objective assessment of func. with a mean age of 45 years (range. 42 were men and 24 were radical release of radioulnar synostosis71 and one for women. 5). Fourteen flap or donor site. the gency or elective reconstruction of their upper most common diagnosis being squamous cell carci- extremity using a pedicled or free radial forearm noma (n ⫽ 4) or malignant fibrous histiocytoma flap with a minimum follow-up of 1 year. The size of the flap ranged from 4 ⫻ and the interphalangeal joints in extension. because of concerns of harvest. 2). 28 because of avulsion or PATIENTS AND METHODS crush injuries and seven resulting in amputations. preferably either the contralateral extremity (n ⫽ 8) or the nonmeshed. cubital tunnel syn- retrospective chart review evaluated the age and drome. Reconstruction was performed emer.42 Even though the radial forearm flap is usu. Radial forearm flaps were used for recon- ifornia. 43 were designed on reverse flow with the wrist in 20 degrees of extension. method of reconstruction. coverage of the dorsal wrist and hand (n ⫽ the indications and results of pedicled and free ra. Thirty-five patients had sustained traumatic injury to their upper extremities. Plastic and Reconstructive Surgery • March 2008 have not achieved the same degree of popularity Table 1. Approval for this study was obtained from the Five patients underwent secondary reconstruction Institutional Review Board at the University of Cal. flap survival. Fifty-seven flaps were pedicled ra. and any postoperative neurologic after trauma or burns. Three proximal-based radial or vascular symptoms in the donor extremity. tion neuritis after multiple operations for cubital gently in 41 patients and as an elective procedure tunnel syndrome72 (Table 2). 2 to circumferential wrapping of the ulnar nerve for trac- 87 years).017-inch split-thickness skin graft. from 0. 7). wrist.67–70 The purpose of this study was to analyze (Fig.

surface of the wrist and hand (n ⫽ 4). All four skin graft. and hand was successful in 95 percent None were dissatisfied with the appearance of the of patients. Patients were hospitalized from 1 to 11 days (mean. probably because altered sensibility or dysesthesias within the dis- 889 . tients. fasciitis and generalized epidermolysis of a reverse Over the same time period.Volume 121. the dorsal operative venous congestion. of venous problems in a patient with necrotizing dures unrelated to the flap. 54 amputations or after release of contractures of the were covered with a nonmeshed split-thickness thumb–index finger web space (n ⫽ 3). radial forearm flap in a patient who had been struction of the upper extremity in a separate heavily irradiated and who had very inadequate group of 16 patients. and two were covered with a meshed reverse posterior interosseous artery flaps were split-thickness skin graft. Number 3 • Radial Forearm Flaps Fig. nor did any patient complain of any one reverse radial forearm flap. and thumb Eleven donor sites were closed primarily. confused patient. 4 days). (Above. (Below. left) This 67-year-old woman underwent radical resection of a liposarcoma of the posterior aspect of the right elbow. no patients complained of cold Primary healing of the soft-tissue defect of the intolerance of the hand on direct questioning. (Right) She regained elbow motion of 20/130 degrees. There was partial peripheral loss of donor site. wrist. The triceps tendon was reconstructed with a fascia lata graft. 1. itself and eight who required secondary proce. four reverse posterior interosseous artery flaps There was complete loss of one contralateral free were performed by the same surgeon for recon. 12 groin flaps and radial forearm flap in an elderly. Pedicled groin flaps were recipient veins. elbow. RESULTS At follow-up. left) An antegrade pedicled radial forearm flap was elevated with dissection of the radial artery and cephalic vein all the way to the antecubital fossa. Three reverse radial forearm flaps indicated for soft-tissue coverage of the palmar required leech therapy because of transient post- surface of the wrist and hand (n ⫽ 5). There was 100 percent indicated for soft-tissue coverage of dorsal defects take of the split-thickness skin graft in all 56 pa- of the wrist and hand.

tribution of the superficial radial nerve or lateral tion of the forearm before coverage using the antebrachial cutaneous nerve of the forearm. left) A reverse radial forearm flap was elevated and transposed through a connecting incision between the dorsal defect and the anterior forearm dissection. which was debrided radically. right) Excellent healing of the flap allowing full extension of the middle. right) Schematic representation of the anatomy and dissection of a reverse radial forearm flap for coverage of a dorsal defect of the hand. (Above. left) This 27-year-old man sustained a degloving injury of the dorsal aspect of his left hand down to the exposed extensor tendons. antegrade pedicled radial forearm flap main- All the patients who had normal elbow flexion tained normal elbow flexion and extension and and extension and normal pronation and supina. (Below. (Above. and small fingers. ring. Plastic and Reconstructive Surgery • March 2008 Fig. 2. (Below. forearm pronation and supination postopera- 890 .

16 –18. 891 .21–26 However. occasion- described by Song et al. and dorsal aspect of the wrist and hand out to the fore the reverse radial forearm flap regained full level of the proximal interphalangeal joints.8 as a free flap after release ally. tively. Number 3 • Radial Forearm Flaps Fig. the fore- of burn scar contractures of the neck.15. full flexion and extension of their fingers. taneous fat. and if a reverse basis for successful transfer of a reverse radial fore. In such individuals.20 or as a distal-based pedicled flap for skin graft. the palmar aspect coverage of the wrist and hand. 2) and 12 palmar wrist and hand de- All 12 groin flaps were successful.Volume 121. the thickness of vested as a proximal-based pedicled flap based on the flap on the dorsum of the wrist and hand can antegrade flow through the radial artery for cover. Those patients who underwent release of tion of the proximal radial artery. supple skin.16 –18. Several previous reports have sug- rior interosseous artery flap failed. especially in middle-aged women. in some men. this series. hand (Fig. All the patients who munication between the cephalic vein and deep ve- underwent a reverse radial forearm flap regained nous system. be reduced by harvesting a pure fascial flap50 –56 age of defects around the elbow and proximal and covering it with a full-thickness or split-thickness forearm. and those The reverse radial forearm flap is especially patients who had normal wrist flexion and extension indicated for moderate-sized defects of the palmar and normal forearm pronation and supination be.9 –14. 3.73 de- elbow flexion contractures gained an average of scribed venous outflow from a reverse radial forearm 75 degrees of extension after the elbow release flap based on a “crossover pattern” and a “bypass procedure and reconstruction with an antegrade pattern” between the venae comitantes and com- pedicled radial forearm flap. radial forearm flap is used in these individuals to arm flap is retrograde flow through the radial artery cover a palmar defect. In wrist flexion and extension and full forearm prona. One poste- fects (Fig. excellent correction of the scar contracture of the thumb and fingers was obtained. depilatory creams or laser treatment postoperatively. (Right) The palm of his left hand was resurfaced with a reverse radial forearm flap.21–26 The of the forearm is excessively hairy. gested that the reverse radial forearm flap is spe- cifically suited for coverage of dorsal wrist and DISCUSSION hand defects because the flap consists of similar Although the radial forearm flap was originally thin. 43 reverse radial forearm flaps (64 per- tion and supination postoperatively without the cent) were used to reconstruct 24 dorsal wrist and need for any postoperative hand therapy. 3). 9 –14.19.67 Lin et al. (Left) This 24-year-old man developed a severe scar contracture of his left thumb and fingers following a hot press injury to the palm of his left hand. it may require the use of from the ulnar artery and palmar arches after liga. it was quickly arm skin may have significant thickness of subcu- recognized that a radial forearm flap could be har. Similarly.

tance transposed proximally up the anterior sur. a superficial vein in the flap be anastomosed mi- termuscular septum containing the perforators. venous cut from an Esmarch bandage may be orientated outflow can be compromised. 2. left). the skin flap has to be designed several days. and it has even been suggested that ulous in carefully preserving the fragile lateral in. the surgeon has to be metic. 2. The original injury required fasciotomies. in leeches can be applied for a few days (three of 43 these circumstances. below. left) A contralateral left free radial forearm flap was used. kinked. left) This 53-year-old woman developed an adduction contracture of her right thumb–index finger web space following a severe crush injury to her right dominant forearm. The distance from into the dorsal defect (Fig. vein graft revascularization of the radial artery. The most distal pivot point of a reverse radial diverge more deeply away from the overlying skin forearm flap is the radial styloid. either the flap can be artery passes deep to the tendons of the first dorsal passed through a very wide subcutaneous tunnel extensor tendon compartment. If there is any suggestion of venous more proximally over the junction of the middle congestion of a reverse radial forearm flap. If the flap has to reach many of these flaps remain temporarily swollen for more distally. (Above. (Above. right) or an the radial styloid to the proximal margin of the incision may be made connecting the dorsal de- dorsal or palmar defect is measured and this dis. Plastic and Reconstructive Surgery • March 2008 Fig. 4. Despite the hypoth- either longitudinally or transversely. where the radial island. It is essential that the pedicle is not face of the forearm. and split-thickness skin grafting of the anterior forearm. right) Pliable skin for the released thumb–index finger web space was provided. reconstruction with a reverse radial forearm flap was not an option because of the previous injury to the right forearm. (Below.73 border of the forearm. but should esis that a “crossover” or “bypass” pattern allows not extend any farther radially than the radial venous egress from a reverse radial forearm flap. otherwise. above. right) After radical release of the thumb–index finger web space contracture. (Below. and proximal thirds of the forearm. in this series). or compressed. For dorsal defects. where a template of the defect twisted. However. fect with the forearm donor-site incision (Fig. crosurgically to a superficial vein in the vicinity of because the radial artery and venae comitantes the defect47 or that a valvulotomy be performed in 892 .

and infec- in the anatomical snuffbox. this confirms that a re- The reverse radial forearm flap may be used verse radial forearm flap can be reliably per- for coverage of moderate-sized defects of the pal. and one because of generalized epidermolysis in The tourniquet is then deflated. the cephalic vein. left) Satisfactory coverage of the thumb metacarpal. and middle fingers. requires that the defect has not interrupted the The majority of reverse radial forearm flaps in connection between the ulnar and radial arteries this series were performed for primary or second- through the deep palmar arch or the radial artery ary reconstruction after trauma. (Above left. burns. 5. index. but obviously this ulnar artery and the radial artery. one because of venous outflow to isolate the radial artery just proximal to the compromise in a patient with necrotizing fasciitis radial styloid and apply a microvascular clamp. ideally. 5) that are unsuitable for replantation. a tions and for immediate reconstruction after tu- preoperative Allen test should be performed on mor resection. Although. microvascular clamp. a preoperative angiogram may be tures of the thumb–index finger web space (Fig. and if a pulse an elderly confused patient who was unable to can be heard with a Doppler probe distal to the maintain her hand in an elevated position. The 893 . A reverse radial forearm flap was used to cover the remaining thumb metacarpal in preparation for a secondary toe-to-thumb transfer. The reverse radial forearm flap is every patient being considered for reverse radial also especially indicated after release of contrac- forearm flap. with amputation of the thumb. Another way to document the integrity of in the 43 reverse radial forearm flaps in this series flow from the ulnar artery to the radial artery is (4. Number 3 • Radial Forearm Flaps Fig. formed on the intact connections between the mar aspect of the wrist and hand. which was sufficiently functional that his family did not proceed with a secondary toe-to-thumb transfer.Volume 121.65 percent). 4) indicated in those patients being considered for and for coverage of amputations of the thumb reverse radial forearm flap coverage of a palmar (Fig.74 There were two partial failures defect. (Below. and right) This 7-year-old boy sustained a pipe bomb injury to his left hand.

in our opinion.26. Allen test is positive or an angiogram shows no tial wrapping of the median nerve in cases of recal.21. Four small series have previously described the use of the antegrade Fig.20 neurolysis of the median nerve under the operating microscope. ulnar. A reverse radial forearm fascial tomical snuffbox and either the preoperative flap may occasionally be indicated for circumferen.34 and subsequently by Costa and Soutar35 and Zancolli and Angrigiani. Plastic and Reconstructive Surgery • March 2008 them to stiffness of the shoulder. originally described by Penteado et al.46 – 49 flap to provide soft-tissue coverage of the anterior Even though the groin flap popularized by aspect of the forearm and to simultaneously re- McGregor and Jackson1 provides a large segment construct a segmental defect of either the radial or of skin based on the superficial circumflex iliac ulnar artery in the forearm.22. citrant carpal tunnel syndrome (Fig. She underwent defects.36 may be designed as a reverse flow flap based on the anas- tomotic connections between the anterior and posterior interosseous arteries and has been advo- cated as an alternative to the reverse radial forearm flap.19. 4). with the majority being forearm fascial flap. The indications for a contralateral free radial fore- arm flap are if the soft-tissue defect involves the proximal stump of the radial artery within the anterior aspect of the middle and distal thirds of reverse radial forearm flap can then be used to pro.47 When har- artery. 7). the trunk in a semidependent position and requires radial artery can be dissected all the way to its two or three stages. and in very young children. Very occasionally.76 A reverse radial forearm osteocutaneous be reliably covered with a reverse radial forearm flap can be considered for reconstruction of thumb flap.45. 1). the forearm. it mandates attachment of the hand to the vesting a contralateral free radial forearm flap. (Above) This 64-year-old woman had undergone three pedicled radial forearm flap for coverage of elbow previous operations on her left carpal tunnel.44.55. Ten free radial forearm flaps were performed (Below) The median nerve was then wrapped with a reverse radial in this series (15 percent).15. if the soft-tissue defect involves the vide arterial inflow to a subsequent toe-to-thumb palmar aspect of the wrist and hand or the ana- transfer75 (Fig. 8). a contralateral free radial amputations if the patient is unwilling to undergo a forearm flap may be indicated as a flow-through toe-to-thumb transfer (Fig.37– 43 Proponents of the posterior interosseous artery flap argue that it preserves both the radial and ulnar arterial supply to the hand and that the donor defect is less conspicuous. because it may predispose phalic vein and the two venae comitantes can be 894 . it has not gained popularity in the United States because of concerns regarding its reliability. harvested from the contralateral forearm (Fig.42 The radial forearm flap may also be designed on the proximal radial artery and accompanying venae comitantes and cephalic vein. Because of the thin. continuity between the radial and ulnar arteries. However.2–7 It is usually contraindicated bifurcation from the brachial artery. and if the soft-tissue defect is more ulnar and distal ritis of the superficial branch of the radial to the metacarpophalangeal joints and could not nerve.9. and the ce- in elderly patients. compared with the more re- stricted rotation of a pedicled reverse lateral arm flap77– 82 or various muscle flaps. 6. because of difficulties cooperating with immobilization. The pedicled poste- rior interosseous artery flap. The groin flap seems to have been superseded by the pedicled radial forearm and posterior interosseous flaps.16. 6) or for neu.72. anterior. and posterior aspects of the elbow (Fig. supple skin of the forearm and the long pedicle. it is probably the optimal flap for coverage of moderate-sized defects over the radial.

Number 3 • Radial Forearm Flaps Fig.Volume 121. and the most recent radial artery and cephalic vein by interposition prospective study by Richardson et al. whom there was discontinuity of the palmar arches corporate the small connection between the venae because of a previous thermal burn. so Harvesting a free radial forearm flap is tech- that the large cephalic or basilic vein at the elbow nically easier than harvesting a free lateral arm can be used for the venous anastomosis. right) The flap healed primarily without infection and with very satisfactory thumb function. 7.63– 66 to improve the appear- position of the flap by elongation of the proximal ance of the donor site.83 hand so that there is insufficient flow from the Finally. Several tips have been learned from carpophalangeal joints and in one patient in this large series of radial forearm flaps to im- 895 . Several case reports have proposed radial forearm flap involves a more distal trans. various options59 – 61. carefully dissected all the way to the elbow to in. (Below. the morbidity of the donor site has ulnar artery through the palmar arches to the been criticized by opponents of the radial fore- distal radial artery. right and below. By harvesting the radial arm flap are very specific: if a soft-tissue defect is artery up to the bifurcation from the brachial ar- more ulnar and distal to the metacarpophalangeal tery and the basilic or cephalic vein at the elbow. left) This 29-year-old construction worker with diabetes developed necrotizing fasciitis of his dominant right thumb. anterolateral thigh flap. (Above. or if the soft-tissue larger and longer than the pedicle of a free lateral defect involves the palmar aspect of the wrist and arm flap or free posterior interosseous flap. arm flap.62 con- vein grafts. comitantes and the superficial venous system. Only two ipsilateral free radial forearm cluded that there was a low incidence of long- flaps were indicated in this series: in one patient term morbidity associated with the radial fore- with a soft-tissue palmar defect distal to the meta. Essentially. he underwent reconstruction of his right thumb with a reverse radial forearm osteocutaneous flap. left) Because a toe-to-thumb transfer was felt to be contraindicated. an ipsilateral free arm flap. joints and therefore beyond the arc of rotation of the pedicle of a free radial forearm flap is much a reverse radial forearm flap.83 flap or free posterior interosseous flap or free Indications for an ipsilateral free radial fore. (Above.

Fig. The margins of the donor site are sutured to the flexor muscles with absorb- able sutures. Using this protocol. Most importantly. Preferably. In this series. split-thickness skin graft is then applied with a few fenestrations to allow the egress of any seroma and the wrist and fingers are immobilized in a plaster of paris splint for only 7 days. just like debridement. This 3-year-old boy with a metacarpal hand underwent a but the donor site could also be closed primarily reverse radial forearm flap to provide both soft-tissue coverage in three reverse radial forearm flaps and one and arterial inflow to a second toe-to-thumb transfer. However. 8. 0.70 and at follow-up on direct question- No. despite the beyond the radial border of the forearm if at all fact that hyperpigmentation or hypertrophy of possible. but in fact should be the responsibility of the most senior surgeon. the skin was closed primarily in the seven radial forearm fascial flaps in this series. and free radial forearm flaps for reconstruction of 896 . no patients have specifically complained of Dorsal wrist and hand coverage 24 cold intolerance in the 59 hands undergoing Palmar wrist and hand coverage 12 pedicled radial forearm or ipsilateral free radial Elbow coverage 11 forearm flaps or in the eight donor hands un- Thumb–index finger web space 6 Thumb amputations 5 dergoing a contralateral free radial forearm Tumor excision 13 flap.66 Table 2. First.017-inch-thick. which may help diminish postoperative symptoms. because this makes the donor site very the donor site is more likely in Hispanic and obvious. Moreover. there has been 100 percent take of the split-thickness skin graft in all 56 donor sites. if the radial mar- gin of the flap is confined within the radial CONCLUSIONS border of the forearm. the tients have expressed dissatisfaction with the radial border of the flap should not be extended overall appearance of the donor site. where symptoms of Nerve wrapping for traction neuritis 5 Prior to toe-to-thumb transfers 3 cold intolerance may be less of a problem than Release of radioulnar synostosis 2 in colder climates. ing. the superficial branch of This is the largest reported series of pedicled the radial nerve can always be covered by fore. great care is taken to preserve any cutaneous nerves during the dissection if possible. both to advance the skin margins and decrease the overall area of the donor site and to convert the donor site to a very shallow surface. a nonmeshed. and the flexor carpi radialis tendon has never been exposed. closure of the radial forearm flap donor site should not be relegated to the most junior surgeon. Indications for Radial Forearm Flap The radial artery was reconstructed in only one Reconstruction patient. it should be acknowledged that Burn scar contractures 5 all patients live in California. The flexor digitorum sublimis muscle is imbricated over the flexor carpi radialis tendon to prevent exposure of this tendon. contralateral free radial forearm flap because the width of the flap did not exceed 2 to 3 cm. Plastic and Reconstructive Surgery • March 2008 arm skin and not lie immediately beneath the skin graft covering the donor site. no pa- prove the outcome of the donor site. even when the forearm is held neutral African American patients. or in pronation. none of the 66 patients in this series had any symptoms of dysesthesias within the distribution of the superficial branch of the radial nerve. On direct questioning at long-term postoperative follow- up. Obviously. Furthermore.

E. Khouri. I. K. V. and Ly. 41: 221. The groin flap.. S.. J.. M. J. and Lovie. Merle. The radial author’s (N. C. J. 1982. Chir. Ann.. A. T. Surg. The proximally pedicled osteocutaneous flaps are infrequently indicated arteria radialis forearm flap in the treatment of soft tissue de- for thumb reconstruction if the patient refuses a fects of the dorsal elbow. and Glasson. island forearm flap. W. C. H. Reconstr. E. (Br. Soucacos.) 9: 234. Br... C. B. J.. G. 1986. Plast. J. 1984. (Am. and radial nerves for Microsurgery 12: 155. Hand Surg. Plast.. Braun. S. Surg. W. N. and radial forearm 20. R.. McGregor. and Shojima. 34. occasionally indicated for circumferential wrap... Ann. Poole. S. 23: 266. Gang. Surg. Hentz. Masquelet. and Surg. Plast. E. Surg. M. L. Godfrey. S. The radial forearm flap for re- contralateral free radial forearm flaps are more construction of the upper extremity. Koshima. H. Los Angeles School of Medicine with reverse flaps: A review of 52 patients with emphasis on 10945 Le Conte Avenue. (Br..F. Lovie. Panconi. Forearm flap in orthopaedic and hand Neil F. M. D. 1990. Zancolli.. Foucher. 49: 41. recalcitrant traction neuritis. Y. H. C. Surg. Merle. Malizos. Clin. S. and Angrigiani. et al. Ann. Jones. Kostakoglu. Surg. May. M. and Bartlett. 102: 400. Kobata. Plast. Reconstr. H.. W. Y. F. D. J. B.. Goin. flap design and versatility. Br. Br. Chen. M. Surg. Reconstr. S. 10. P. The Chinese forearm flap in reconstruction of than the posterior interosseous flap for coverage the hand.) 6: 163. Plast. Based on the senior 14.ucla. A.. J.. Swanson. Sanner. and Soutar. D. J. 1972. Plast. 37: 493. Fatah. T. I. W.. M. 28. Surg. D. J.. Jr. 1988. 1988. 42: 256. Br. Ding.. J. Groin flap artery forearm free flap. Surg. P. and Schuhmacher. (Br.. The 11.. 8: 209.. S. J. Surg. Hand Surg. Small. pedicled radial forearm flap has become the flap 15. 1. 29. 22: 126. C.) 13: 435. artery flap for reconstruction around the elbow. Radial forearm flap cover of the of choice for coverage of moderate-sized defects elbow joint. Ann. F. F. Br. 32. 2. J. Herndl. application. M... P. The island sensate ulnar Plast. F. Y. I. R. J. Br. Fukuda. Plast. F. The reverse ulnar artery forearm island flap in hand surgery: present role of the groin flap in hand trauma in the light of 54 cases. 19. K. N. N. Microsurg. and Wei.. Groin flap: 42 clinical cases.) 15: 84. Posterior interosseous to close a complicated excisional wrist defect in a nonage.. J. W. 1990. and Rohrich. M.. Song. struction of the pediatric hand. and Harrison. H. A. Ann. 1972.. 27. 17.. 1984. Scand. 1988.. T. Reconstr. R. 1989. Tizian. et al. J. Reconstr. I. Duncan. 1994.) experience.D. Soeda.. M. Surg. M. D. Plast. Surg. Plast. The forearm flap. G. R. O. Plast.. Colony. The ulnar 3. 1988. ulnar forearm flap.J... R. and Jackson. 37: 486. 1992. Lister. Hoang. Van Genechten. J.. D. Boyd. I. Penteado. Z. and Department of Orthopedic Surgery 23.. 1988.. and Millar. R. and hand. A. Surg. M. ulnar. J. interosseous artery. Pearl. upper limb reconstruction. V. Local transposition of a distally-based island forearm flap 36. D.. D.. Distally based 8. 41: 349. and Cao. Gao. (Br. Plast. 9: 459. S... I. Accid.. G. The radial fore- aspect of the wrist and hand following trauma or arm flap: Reconstructive applications and donor-site defects tumor resection. J. C. Hand Surg. Young. 1989. J. M.. ulnar side of the hand.. 1991. 18: 24. Plast. J. Soutar.. in hand injuries. Surg. and Manktelow. 84: 100. 35. 90095 24. W. Calif. Surg. Ann. Surg. Shigematsu. Reconstr. H. P. of moderate-sized defects of the dorsal or palmar 18. Van Genechten. 1987. 1997. J.. M. J.. 33. 1982. wrist. Freelander. Grossman. The forearm flap. 1989. 38: 112. Plast. Surg. P. and Chevrel. P. Plast. McGregor. Smith.. and Berger. McGregor. and Wood. Plast.. 21. 1981.. 1998. (Br. Anatomical basis of dorsal Plast. M. J. C. Dickson. Surg. M. around the elbow. 37: 18. S. Br. J. and Wei. The and forearm reconstruction.edu in hand reconstruction. A. omy of skin territory of posterior forearm and its clinical Main 4: 85. 1984. Br. N. and Soeda. S. B. F. 9: 21.. K. R. Reconstr. 1973. 19: 287. Muhlbauer. D. Song. A... A. Kawate. Injury 4: 229... toe-to-thumb transfer. 25: 3. The free 4. J. Staged groin flap in recon.) 9: 245.. Xenakis.. Hand 13. 1985. T. Ann. Y. The radial forearm flap anatomic basis of the fasciocutaneous flap of the posterior in the management of soft tissue injuries of the hand. The distally based island poste- 12. Y. Radial forearm flaps for reconstruction in REFERENCES hand surgery. S. and Michon.. and Touliatos. ulnar artery island forearm flap for the large defect of the Surg. C. G. and Pho. C. The radial forearm flap in Surg. F. W. 1982. 43: 698. A. Endo. 1984. 10: 403. The distally based forearm island flap njones@mednet. and Sharma. Bayon. Liu. 86: versatile than the groin flap and more reliable 920. M.. 70: 336. (Br. K. forearm flap: Based on posterior interosseous vessels. The reverse radial forearm and 16. J. and Stock. T. R. UCLA Hand Center 22. ping of the median. 2004. 30. Sakai. Costa. Plast. Reconstr. 26: 40. The vascular microanat- in hand surgery: A report of thirty-three cases. Meland. 81: 925. Clinkscales. The reverse flow ulnar artery island 7.. Plast. and Davies. Hand Surg. 1990. L. 19: 485. Wray. J.. T. Br. Jeng. a long-term review. Glasson. Y.. groin flap in severe hand injuries. Sun. Radiol. 9. C.. J.. Los Angeles. Ann. K. D. Surg. narian: Some anatomical and clinical considerations. A. K. Number 3 • Radial Forearm Flaps the elbow. 26. Foucher. G.. A.Volume 121. and Tanner. and Weeks.. Hand Surg. Li. V. Foley.. Govila. B. 6. S.. L.. 1984. 25. and Jackson. Surg. Upper limb reconstruction University of California. Reconstr. J. island flap. surgery. 37. 1998. H. Plast. Beris. C. A. Surg. The Single stage thumb reconstruction by a composite forearm anatomical basis of the groin flap. Yajima. 31. Plast. Anat. Microsurgery 13: 170. F. D. Plast. Radial forearm fascial flaps are in 35 consecutive patients. Surg. Surg. and Jackson. Lu. 1990. B. Plast. E. and Kecik. and Tamai. A. A. The radial forearm flap: A reconstructive cha- Division of Plastic and Reconstructive Surgery meleon. the proximal-based forearm flap: A versatile source of composite tissue. 897 .. Wise.. D.. R. K. Surg.. P. A. 1986. M.) 13: 130.. The ulnar island flap in hand 5. R. Hand Surg. rior interosseous flap.. Rowsell. A. Pedicled radial forearm flaps for recalcitrant defects about the elbow. I. N.. Iino. J.. 1989. Plast. B. Hand Surg. 85: 258. 1991. and McGrouther. Chuang. A.) 11: 187. Technique and indications of the forearm flap 38. Guimberteau. 39: 381. E. Kawamura. 1987. The B. Jawad. R. Suite 3355 flap selection.

Timmons. 1989. and Hartman. Micro. 15: 19. Microsurgery 10: 155. Ann.. Liao.. 61. Y. patterns of venous drainage of the free forearm flap in head and Plast. S. Surg. J. Singapore 11: 236. J. C.) 22: 51.. W.. L. 2003. Orthop. and Schorr. and Lee. and De Mey. A. Langer. Plast. Lai. B. and Lille. 82. G. technique. 37: 139. 1997.. flap. The radial 67.. M... Wang. Hemodynamic changes 47. Wechselberger. Kolker. Plast. Reconstr.. 76. Plast. S. 92: 1133. J. 37: 61. Br. Gottlieb. W. Esmail. B. Otto. Br. S... Kubota. Mahoney.. S. Plast.. et al. Morbidity in the pedicled lateral arm flap for reconstruction of posterior soft forearm flap donor arm. and Katz. J. (Am. 2003. 1984. B. (Am.. G. Core. I. M. 34: 190. B. K. C. Brunelli. O. A method for 43. S. one-stage reconstruction using an osteocutaneous forearm Surg.. and Buchler. B.) 12: 62. A. M. Ann. A. flap. G. 1986. Reconstr. McLean. W. The radial forearm skin graft-fascial flap. How reliable is the of the donor defect of the radial forearm free flap.. Plast. S. Pode.. Inada. 63. Surg. 1994. Hand Surg. D. T. Guan.... 99: parison of free and reversed pedicled posterior interosseous 109. Mikrochir. Plast. Rechnic. Clinical experience vascularised tendon grafts in a dorsal hand injury using the with the reverse lateral arm flap in soft-tissue coverage of the “Chinese” forearm flap. D. Surg.. Zhang. and Naiberg. 38: 635. and Kaplan. Ann. Br. 1991. based radial fasciosubcutaneous flap for soft tissue cover of Plast. R. J.. Occhialini. C. Tamai. M.. and Batchelor. and Burkhalter. Ismail. Akyurek. Missotten. J. A. Fang. Jones. 71. C. (in German).. 83. plications of radial forearm donor sites. and Mutimer. Surgical Reducing morbidity in the radial forearm flap donor site. Hand Surg. J. 1990. and O’Brien. T. and Mizumoto. Acute ischaemia of the hand 46. Y. F. R.. 43: 140. Vico.. Plast. 1990. Plast. and Petti.. 73. J. Vogelin. S. Surg. K. 75. Ann. Pederson. The retrograde radial fascial forearm flap: Surgical cutaneous forearm flaps are effective in treating incapaci- rationale. Reconstr. S.. Scand. forearm flap: A reconstructive chameleon. 1984. 70. J.) 16: 283.. Hand Surg. R. H. Plast. 47: 25. 38: 396. 1986. E. and Young. 40: 207. Reconstr. R. neck reconstruction. L. Tung. Reconstr. Timmons. Plast. 2002. Coessens. The lateral 56. Total thumb reconstruction: A resulting from elevation of a radial forearm flap. Beppu. and Black. Jones. J. 1987. A. Lai. L. Brown.. L. U. Numata. Eades. Surg. 123: 323. Arch. et al. 74: 508. J. Shaw. 1997. Treatment of radio- 49. I.. G. et al. and Michon. 1996. Cherup. Rampino. 93: 54. E. Chir. arm flap for elbow coverage. J. M.. phalic vein: A preliminary report. Surg...) 10: 179. S. Acad. M. D. Circumferential 50. J. Reconstr. H. S. 527. H.. 1999. Plast. Com. C. S. 1985. et al. Reconstr. The fascial radial flap. 1993.. Smith.. Yajima. 1988. Neill-Cage. A. E. C. Plast. elbow. The distally- 53. J. 1985. interosseous reverse flap: Experience with 113 flaps. 176. H. B. and Moss. Hand Surg. 62. posterior interosseous artery island flap? A review of 88 patients Microsurg. of the hand after radial forearm flap harvesting. Venous drainage in the 52. C. Radial fore. C. Merle. T. Hand comparative study.. J. Iwabuchi. 1984. C. Handchir. and Shin. Shiba. M. 15: 340... Schoeller. M. Surg. K. E. S. 74. Culbertson.. K. P. 45: 329. Schusterman. Plast. Plast. 57. T. D. Lin. P. The reverse 59. One-stage flap repair with 79. Microsurg. Hand Surg. 1993.. Surg.. A. 36: 473. and Matsuzaki.. Boorman. Surg. 39: 196. 91: 865. 64. Tuncay. surg. and Brown. M. 65. D. Posterior interosseous minimizing donor site complications of the radial forearm artery flap in traumatic injuries. Surg. F. radial forearm fascial flap. Surg. W. and Safak. G.) 20: 915. Surg. and Chiu. Surg. J. M. C... Ege. T. Plast.. M. M. Plast. and Meara. and clinical application. Direct closure of radial forearm 44. A.) 24: 594. Reid.-P. J. Br. Spauwen. P. F.... M. Plast. Bardsley. Shono. Surg. 2000.. 1993. A.. Med. Matev... Ann. Reconstr. based radial forearm free flap with valvulotomy of the ce- 85: 898.. Surg. The radial Surg. J. S. 18: 62. reversed forearm flap. 2002. Plast.. Soutar. 86: 287. Reconstr. M. Surg. The lateral arm flap for arm flap with vascularized tendons for hand reconstruction. Iida.. N. morbidity: A prospective study. J. and Tamai..) 18: 959. Br. reverse forearm flap. 898 . Surg. Ann.. Reconstr. E. Surg. 2001. Tubed radial fascial flap and 1990. Reconstr. upper arm flap: Anatomy and clinical applications. I. C. Reconstr. Surg. Parodi. De Biasio. 49: 156. Tsai. Retrograde posterior interosse. and Frey... F. Ann. Ann. 77. (Am. Reverse fascio- R. Plast. Richardson. Plastic and Reconstructive Surgery • March 2008 39... and Sykes. Foucher.. Hand tating neuromas in the hand... E. Katsaros. C. The free fascial forearm flap. P. Valenti. R. V.. F.. 1993. 91: 1349. Trauma Surg. A. 66. J. The vascular basis of the radial forearm flap. A.. M. Surg. sition flaps: Case report. (Am.. Coombs.. A.) 29: 1143. 2004. 1987. Reyes. J. Surg. Van Genechten. J. Chang. 77: 70. Z-plasty closure 42.-S.. 80. 36: 52.. the flexor aspect of the wrist.. G. Meland. Surg. 18: 33. Surg. E. Shi. Os- ulnar synostosis by radical excision and interposition of a teocutaneous radial forearm flap for hand reconstruction. tissue defects of the elbow. Braun. F. U. T. L. H. Reconstr.. and Lin. M. Surg.. and Stock. E. F. D.. Zachary. P.. D. A compound radial artery forearm flap in hand surgery: An Surg. lateral arm adipofascial flap for elbow coverage. J.. S. Biemer. 39: Surg. J. The distally. Plast. and Lineaweaver. Hui. Radial forearm flap donor-site complications and 40. Reverse 60. N. 12: 489. Y. 1994. Plast. F. T. J. J. 101: 874. J. 1997. S. Yamauchi.. A. (Am. Ann. 1994. 68. The posterior forearm flap donor-site complications and morbidity. Plast. A. Jackson. 1983. Com. 69. B. J. Y. (Am. and Hsu. 55. W. reconstruction of the flexor apparatus in the forearm. Yajima. J. T. Plast. 1997. Surg. Hand Surg. G. Eur. J.. 1987. Y. (Am. cutaneous flaps. 1985. and Davies.. 99: 791.. original modification of the Chinese forearm flap. J.. et al. W. Radial 41. (Br. M... C. C. 1998.. Thoma. D. (Am. C. J. Surg. forearm flap donor site: Should we vein graft the artery? A 48. C. Hand Surg. Plast. and Ross. elbow coverage. 58. 81. A. M. 78. Vaughan. H. 10: 299. Br. 2002. J. 72. E.) 13: 444. J. ous flap. Plast. 45. X. Br. Reconstr. C. N. 1999. and Ercetin. The osteocutaneous pedicle forearm flap. C. The reverse lateral upper Hand Surg. et al. J. S. Niazi. salvage of end-stage traction neuritis. 54. M. Lazarou. D. 1982. K. and Hoverman. Z. C. Plast. 1995. P. Plast. Surg. Reversed island forearm wrapping of a flap around a scarred peripheral nerve for fascial flap in hand surgery. 22: 107. Jin. Reconstr. E. N. Toe transfer to the vessels of the J. Reconstr. Archibald. The free forearm flap: free-flap donor sites by double-opposing rhomboid transpo- A report of 25 cases. Buchler. 98: 328. K. Wang. Jones. Shibata. J.. H. Elliot. Plast. J. 1983. T... 1997. W. C.. W. Fisher. F. Dumontier.-D. T..