Anat Clin (1984) 6:171-176
9 Springer-Verlag 1984
Anatomy of the radial forearm flap
AC Masquelet
Service de Chirurgie Orthop6dique et R6paratrice, H6pital Avicenne, F-93000 Bobigny, France
Summary. The anatomy of the radial forearm flap
initially described by Chinese authors was studied in 25
dissections. The reliability of this flap, regardless of the
incisional sites used, was demonstrated by the constant
presence of several arterioles supplying the cutaneous
tissue. The comparison of clinical experience and
anatomical data led to the identification of the different
methods and the advantages and disadvantages of the
Chinese forearm flap.
Bases anatomiques du lambeau radial
de l'avant-bras
R6sum6. Vingt-cinq dissections ont prdcis6 les bases
anatomiques du lambeau de l'avant-bras ddcrit par des
auteurs chinois. L'existence constante de plusieurs
art6rioles ~ destinde cutande montre la fiabilit6 de ce
lambeau quel que soit le si6ge de son trac6. L'exp6-
rience clinique confrontde aux donn6es anatomiques,
permet de ddgager les divers modes d'utilisation du
lambeau chinois mais aussi ses avantages et ses inconvd-
nients.
Key words : Forearm flap - Free flap - Microsurgery -
Radial artery
Over the last several years the radial forearm flap, also
known as the Chinese forearm flap, has been widely
used in plastic surgery. Initially described by Yang-
Guofang [10], a military surgeon from the city of
Sunyang, the Chinese forearm flap was fully revealed
outside China by Ruyao Song [6] and by the teams of
Western surgeons [1, 2] who visited its inventors in the
early 1980's.
Material and methods
The work presented in this paper is largely based on the
author's experience [4] acquired during a 5 month stay
in the team of plastic surgeons headed by Professor
Tchang Ti Sheng at People's Hospital n ~ 9 in Shangai.
The post mortem investigations described herein were
done by study of 10 fresh anatomical specimens injected
with neoprene latex dye or a mixture of gelatin and India
ink. Additional study was done on 15 unprepared
preserved forearms. The clinical experience referred to
in this paper was a series of 17 Chinese forearm flaps
made between Jan. 1982 and Dec. 1983.
Results
The Chinese forearm flap is vascularized by the radial
artery. This artery usually arises from the division of the
brachial artery in the elbow region. The posterior
relations of the radial artery are the brachialis, biceps
tendon, supinatoL pronator teres, flexor digitorum
superficialis, flexor pollicis longus and pronator quadra-
tus. The upper part of the artery lies deep to the muscle
belly of the brachioradialis. This muscle blends into its
tendon in the middle third of the forearm. In its
downward course, the radial artery progressively leaves
the deep surface of the brachioradialis to finally come to
lie immediately beneath the fascial tissue. The lower
part of the artery runs in the pulse groove between the
tendons of the brachioradialis and the flexor carpi
radialis. The radial artery gives off many collateral
branches which supply the neighboring muscles and the
integumentum of the anterolateral region of the forearm.
Cutaneous branches of the radial arter)'
A large arteriole (0.5-1.0 mm in diameter) was seen to
arise in 15 of the 25 dissections from the radial artery
172 AC Masquelet : Anatomy of the radial forearm flap

near its origin (at a point about l cm on average distal to

the bifurcation of the brachial artery). This arteriole
contributes to the vascular supply of the anterior surface
of the forearm. This arteriole was constantly present, but
in some cases was seen to arise from the recurrent radial
artery. The arteriole is the anatomical substrate of the
antecubital fasciocutaneous forearm flap described by
Lamberty and Cormack [3] and which is distinct from
the chinese forearm flap.
In the upper third of the forearm, two to four
arterioles arise from the segment of the radial artery
lying deep to the supinator. The largest diameter
arteriole (usually the most proximal one) is accompanied
by an anastomotic vein connecting the superficial venous
Fig. 1
network to the venae comitantes. Latex injection of a post mortem specimen. The vascular networks
A significant cutaneous branch of the radial artery, from the radial artery to the skin and muscle have been dissected.
also accompanied by an anastomotic vein (Fig. 1), is a * Fleshy belly of the supinator muscle. ~ indicates a constantly
consistent finding at the point of junction of the middle present arteriole located at the junction of the middle and lower thirds
of the forearm. The arteriole is accompanied by an anastomotic vein
and lower thirds of the forearm.
connecting the superficial veins to the valveless radial veins. Note the
In the distal third of the forearm there are numerous abundant vascular supply to the neighboring muscles
small arterioles and at least one anastomotic vein.
Injection au latex d'une pi6ce anatomique. Dissection ~ l'avant-bras de
la vascularisation cutande et musculaire issue de l'art~re radiale.
General anatomic pattern * Corps charnu du long supinateur. ~ Art6riole cutande constante
of the radial artery situde 'a l'union du 1/3 moyen et du 1/3 infdrieur de l'avant-bras. Elle
est accompagnde d'une veine anastomotique reliant le r6seau super-
Over its entire course through the forearm, the radial ficiel et les veines radiales ddpourvues de valvules. Noter l'abondante
vascularisation destinde aux muscles voisins
artery and its cutaneous branches are contained within
an areolar septum. The upper third of this septum is a
very loose, fine structure lying between the muscle
bellies of the supinator and flexor carpi radialis
(Fig. 2). In the middle third of the forearm, this septum
is a more consistent structure lying between the
tendinous parts of the two above muscles and distally it
becomes a veritable lamina with lateral walls in the
region of the pulse groove 9
The cutaneous branches of the radial artery perforate
the antebrachial fascia and then give rise to a horizontal
suprafascial network. From the latter arise fine ascend-
ing arterioles which constitute a second arterial network
beneath the dermis9
The above described vascular pattern accounts for
the different terms used to describe the forearm flap.
The Chinese authors [6] refer to it as a septocutaneous
flap, thereby emphasizing that the main artery of the flap
lies in an intermuscular or intertendinous areolar septum
between the fascial layers9 The English speaking authors Fig. 2
Schematic illustration of a section made through the junction of the
[3, 7, 8] use the term fasciocutaneous flap to underline upper and middle thirds of the forearm. The illustration shows the
the fact that the fascia must also be removed when upper end of the cut forearm. The Chinese forearm flap is made by
constructing the flap. removal en bloc of the skin, subcutaneous areolar tissue, superficial
Aside from its cutaneous branches, the radial artery antebrachial fascia, intermuscular areolar septum and radial arterial
axis
gives off numerous muscular branches beneath the
fascia. Sch6ma d'une coupe 5 l'union du 1/3 supdrieur et du 1/3 moyen de
l'avant-bras. Segment sup6rieur de la coupe. Prdl~vement d'un
The radial artery also consistently gives rise to fine lambeau chinois qui comporte en bloc, la peau, le tissu cellulaire
arterioles (usually two) supplying the periosteum of the sous-cutan6, l'apon6vrose antdbrachiale superficielle, le septum cellu-
distal part of the radius lying above its styloid process. leux intermusculaire et l'axe art6riel radial
AC Masquelet : Anatomy of the radial forearm flap
These arterioles approach the radius lateral to the
insertion of the pronator quadratus.
The tendons of the flexor carpi radialis and supinator
muscles, and the neural rami emanating from the
anterior branch of the radial and musculocutaneous
nerves are supplied by a vascular network originating
from the radial artery.
Size of the Chinese forearm flap
Owing to the existence of numerous anastomoses
between the suprafascial arterial networks, it is theoreti-
cally possible to remove all of the skin of the forearm
along with the radial artery to construct the forearm flap.
However, in surgical practice the flap should be limited
to the anterolateral zone extending from the cubital
margin of the forearm, medially, to the vertical line
running in the middle of the posterior aspect of the
forearm.
Discussion
Anatomical variations of the radial artery [9]
The radial artery very rarely arises distal to the elbow.
Conversely, in some cases the artery is present in the
upper arm or the axilla, in which case it runs through the
forearm superficial to the fascia. In certain cases the
radial artery can be very slender, partially missing distal
to the wrist or even entirely absent. In such cases,
addition vascular supply is afforded by the anterior
interosseous or cubital arteries or the artery of the
median nerve. In the hand, the deep branch of the radial
artery gives rise to the a. princeps pollicis. Owing to the
commonly predominant ulnar arterial system and the
existence of numerous anastomoses between it and the
radial arterial network, ligation of the radial artery at the
wrist does not compromise the blood supply to the
thumb. However, in rare cases the radial artery is the
source of vascularization o f the thumb and other main
sources of blood supply are lacking since the anatomoses
are limited to the first interosseous space.
Surgical removal of the Chinese forearm flap
Two investigative procedures are necessary prior to
removal of the flap. First, the course of the radial artery
should be identified. Doppler ultrasonography is the best
technique for this purpose. Second, Allen's test * is
* This clinical test is designed to evaluate separately the blood flow to
the hand originating from the radial and ulnar arteries. The first step of
the test is to drain the venous blood by elevating the upper limb. Next,
the two arteries are occluded by manual compression. The functional
significance of each artery is then assessed by observing the time
required and the territory of superficial blood return to the hand when
each of the arterial axes is decompressed.
173
Fig. 3
The shape and size of the Chinese forearm flap can be made to
precisely correspond to the defect to bc repaired. Thc main technical
feature is that the flap must be centered on the radial vascular axis.
Two different-shaped flaps are shown
La forme et les dimensions du lambeau chinois peuvent 6tre 6tablies
avec pr6cision en fonction des pertes de substance g recouvrir.
L'essentiel est de rester centr~ sur I'axe vasculaire radial. Dessin de
deux lambeaux de morphologie diff6rente
done to study the vascularization of the hand and especially
the thumb when the radial artery is compressed. The
standard Chinese forearm flap is centered on the lower
two-thirds of the anterolateral surface of the forearm
(Fig. 3). The sequence described below should be
followed as the forearm flap is constructed from the
cubital margin to the radial margin and from the distal
end to the proximal end of the forearm. First, the
incision is made through the skin and fascia. Next,
dissection is carried out in a horizontal plane deep to the
fascia and flush with the muscles and tendons. The
peritendinous tissue is preserved in this step. After
ligation of the radial al~ery at the wrist, the artery and
the areolar septum are removed en bloc in the region
between the tendons of the flexor carpi radialis and the
supinator. In this region, the dissection is done flush
with the pronator quadratus and flexor pollicis longus
(Fig. 4). Care must be taken not to damage the sensory
branches of the radial nerve along the lateral margin of
the flap. The cephalic vein should be included in the
flap. In the area facing the fleshy belly o f the supinator,
the dissection should also include removal of the fine
aponeurotic tissue covering the muscle. The purpose o f
this procedure is to protect the arterial branches which
arise along the medial margin of the supinator. Finally,
subsequent to approximation of the muscles and ten-
dons, the forearm defect is repaired by a thick or full
thickness skin graft.
Variations of the Chinese forearm flap
The Chinese forearm flap can be used as a simple or
compound flap in several different ways :
a) simple cutaneous flap eventually with sensory
innervation when the sensory rami of the musculocu-
taneous nerve are included in it;
174 AC Masquelet : Anatomy of the radial forearm flap

Fig. 4
Isolation of the Chinese forearm flap on its proximal pedicle. Facing
the flap, the septum has been removed along with the segment of the
radial artery lying between the tendons of the flexor carpi radialis and
supinator muscles
lsolement du lambeau chinois sur son ptdicute proximal. En regard du
lambeau le septum a 6t~ prdlev6 avec l'art~re entre les tendons du
grand palmaire et du long supinateur
b) fascial flap. Subdermal dissection is done to
include the subcutaneous areolar tissue and fascia in the
flap. This type of flap, which is small in size in order to
avoid necrosis of the skin, has the advantage o f not
requiring an o v e r l y i n g graft [5];
c) cutaneous flap including the tendons o f the
supinator and flexor carpi radialis (Fig. 5) [1].
Fig. 5
Schematic illustration of a section through the lower third of the
forearm. A compound osteocutaneous Chinese forearm flap has been
made. The plane of dissection is extended deep to the septum and
down to the bone of which a fragment has been removed. Note also
the removal of a segment of the pronator quadratus and flexor polticis
longus
Schtma d'une coupe au 1/3 inftrieur de l'avant-bras. Pr616vement
d'un lambeau chinois composite ostto-cutan& Le plan de dissection
est prolong6 en profondeur au-del~ du septum, jusqu'~ l'os dont on
dttache une baguette externe. Au passage, une portion du carr6
pronateur et du long fltchisseur du pouce est 6galement prtlevte

T h e Chinese forearm flap is also highly versatile

regarding the w a y s in which it can be used. Indeed, it
can be used as a free flap with an antegrade or
retrograde pedicle, according to whether the flap is
m a d e f r o m the distal or proximal part o f the forearm. In
o t h e r cases, it can be used as an islet flap with a
proximal or distal pedicle. In the latter case, the radial
artery is ligated proximally and the flap turned around
180 ~ (Fig. 6). The vascular supply is ensured by the
anastomoses b e t w e e n the ulnar and radial arterial
systems. V e n o u s return is in a counter current direction
via the valveless radial veins [3] draining the cutaneous
bed through the anastomotic veins.
T h e Chinese forearm flap has m a n y obvious advan- Fig. 6
tages. Its clinical reliability is based on the f o l l o w i n g Operative dissection of a Chinese forearm islet flap with a distal
factors : dissection is easily carried out, the pedicle is pedicle. Subsequent to proximal ligation and division of the radial
long, the vessels included in the flap are o f large arterY, the flap is turned 180~ around the radial artery axis. In this
case, the flap was used to repair a defect on the dorsal surface of the
d i a m e t e r and blood f l o w is directed to the skin thereby
hand
leading to hypervascularization of the flap (Fig. 7b). It
Dissection optratoire d'un lambeau chinois en ~lot h pEdicule distal. Le
should also be pointed out that an interrupted arterial lambeau est retoum6 h 180~ sur l'axe radial apr~s ligature et section
axis in the defect to be repaired can be by-passed using proximales de l'artbre. Dans ce cas, le lambeau est destin6 h couvrir
the two ends o f the radial artery. O w i n g to the quality o f une perte de substance du dos de la main
AC Masquelet : Anatomy of the radial forearm flap
Fig. 7
Clinical case. A free Chinese forearm flap was used for reconstructive
surgery of the face. a Preoperative status. The defect resulted from
excision of rhabdomyosarcoma. Surgical repair was very difficult
the forearm skin and the thinness of its adipose
panniculus, the flap is ideal for resurfacing.
However, the Chinese forearm flap does have some
disadvantages. First, the ligation of the radial artery m a y
lead to disturbances resulting from hypovascutarization
of the hand. In order to overcome this potential
problem, m a n y authors have proposed that a vein patch
be used to repair the surgical defects of the artery.
Nevertheless, a significant decrease in muscular blood
supply always occurs and this m a y lead to altered
function of certain forearm muscles. Second, thick or
full thickness grafting of the forearm defect does not
always yield a good final cosmetic result. Third,
abundant pitosity, which is more frequent in C a u c a s i a n
than Asiatic races, m a y render this flap inappropriate in
certain indications. Fourth, the superficial forearm veins
that ensure venous return from the flap m a y be affected
by sclerosis due to previous venous puncture in the
elbow or forearm region. Finally, there is a risk of
neuroma in the course of dissection of the anterior
branches of the radial nerve.
175
owing to the marked adhesion of the skin graft to the bone.
b Construction of a Chinese forearm flap from the lower third of the
forearm designed to fill the orbital cavity. The venous and arterial axes
have been isolated. The flap showed hypervascularization when the
tourniquet was removed, c Appearance of the repair on the 15th
postoperative day. Microsurgical anastomoses were made with the
temporal vessels. Note the healthy aspect of the flap. Owing to the
filling of the orbital defect, future cosmetic repair can be done
Cas clinique. Utilisation d'un lambeau libre de l'avant-bras en
chirurgie reconstructive de la face. a Etat prE-opEratoire. II s'agissait
~l'origine d'un rhabdomyosarcome excisE. La greffe de peau tr~s
adhErente ~ l'os interdit toute chirurgie rEparatrice, b PrElEvement
d'un lambeau chinois au 1/3 infErieur de l'avant-bras destine ~ remplir
la cavitE orbitaire. Isolement des axes veineux et artEriel. Hypervascu-
larisation du lambeau au l~chage du garrot, c Etat post-op~ratoire au
15~jour. Les anastomoses microchirurgicales ont EtE rEalisEes sur les
vaisseaux temporaux. Bonne vitalit6 du lambeau. Le comblement de
l'orbite permettra ultErieurement une chirurgie rEparatrice ~ visEe
esthEtique
Clinical applications
The indications of the Chinese forearm flap are n u m e r -
ous. Its use as an islet flap with a distal pedicle is an
essential procedure in reconstructive surgery o f the
hand. In an e m e r g e n c y setting or at the stage o f sequelae
the flap can be used to repair a skin defect which is
b e y o n d repair by a dermo-epidermal graft. As a
c o m p o u n d flap, the Chinese forearm flap can be used for
tendinous or osseous repair [1, 2]. Furthermore, since
the flap can be fashioned to precise shape and size it is
ideal for use in reconstructive surgery. Stuctures such as
the nose or penis can be repaired by a one-staged
procedure using a free flap with microsurgical anasto-
moses. O w i n g to the fineness and elasticity o f the
forearm skin, the Chinese forearm flap is also helpful in
reconstructive surgery of the face [7] (Fig. 7abc).
Results
W h e n used as a free flap, the Chinese forearm flap
seems to offer greater reliability than other flaps that
176
h a v e b e e n d e s c r i b e d . In a p e r s o n a l series o f 17 free or
p e d i c l e C h i n e s e f o r e a r m flaps, partial n e c r o s i s (not
requiring surgical r e i n t e r v e n t i o n ) was seen in only 2 o f
the free flaps.
Conclusion
T h e use o f the C h i n e s e f o r e a r m flap is l i m i t e d b y the
nature o f the d o n o r site. W h e n u s e d as a free flap, the
C h i n e s e f o r e a r m flap is m o r e a p p r o p r i a t e for r e s u r f a c i n g
than for filling o f the d e f e c t . Finally, a l t h o u g h its use in
h a n d repair as a flap with a distal p e d i c l e is a very
appealing t e c h n i q u e , s i m p l e r m e t h o d s can be u s e d in
m a n y cases.
References
1. Biermer R, Stock W (1983) Total thumb reconstruction : a one
Stage reconstruction using an osteo cutaneous forearm flap. Br J
Plast Surg 36:52-55
AC Masquelet : Anatomy of the radial forearm flap
2. Foucher G, Van Genechten F, Merle M, Michon J (1984) A
compound radial artery forcarm flap in hand surgery : an original
modification of the chinese forearm flap. Br J Plast Surg 37 :
139-148
3. Lamberty BGH, Cormack GC (1983) The antecubital fascio
cutaneous flap. Br J Plast Surg 36 : 428-433
4. Masquelet AC (1984) R6alit6s de la microchirurgie et de la
chirurgie r6paratrice en R6publique populaire de Chine. Encycl
Med Chit (Instantan6s m6dicaux) 2:43-44
5. Schools M, Bienfait B, Calteux N, Dachy Ch, Vandermaeren
CA, De Coninck A (1983) Le lambeau apon6vrotique de
l'avant-bras. Ann Clair Main 3 : 197-201
6. Song Ruyao, Gao Yuzhi, Song Yegnang, Yu Yureng, Song
Yeliang (1982) The forearm flap. Clin Plast Surg 9 : 21
7. Soutar DS, Scheker LR, Tanner NSB, Mac Gregor JA (1983) The
radial forearm flap : a versatile method for intraoral reconstruc-
tion. Br J Plast Surg 36 : 1-8
8. Soutar DS, Tanner NSB (1984) The radial forearm flap in the
management of soft tissue injuries of the hand. Br J Plast Surg 37 :
18-26
9. Testut L (1981) Trait6 d'anatomie humaine. Tome II, Ang6iologie
114-118, Doin, Paris
10. Yang Guofan (1981) Forearm free skin flap transplantation. Ntl
Med J China 61 : 139