Radial Forearm Flap

Flap	Pedicle or free flap; distal or proximal pedicle
Tissue	Potentially innervated fasciocutaneous flap with little hair; also possible as a fascial flap
Course of the vessels	At the bottom of a fascial septum along the brachioradialis muscle as the leading structure
Dimensions	Maximum 8 × 20 cm
Extensions and combinations	Can be combined with a strip of brachioradialis or palmaris longus tendon, a bony segment of the radius, or a second proximal skin island based on a perforator vessel
Anatomy
Neurovascular pedicle	—
Artery	Radial artery
Veins	Two concomitant veins or the cephalic system
Length and arc of rotation	Depends on flap location on the forearm; up to 15 cm
Diameter	Artery, 3–4 mm; veins, 3–5 mm (in the case of a free flap)
Nerve	Lateral antebrachial cutaneous nerve
Surgical technique
Preoperative examination and markings	Identify the course of the radial artery by Doppler examination; Allen test
Patient position	Supine position with arm on arm board
Dissection	Mark the flap centered over the course of the vessel; incise the skin and make a subfascial dissection cuff toward the vessel; stay under the vessels and isolate the pedicle distally; include a cuff of subcutaneous fat and a subcutaneous vein if the flap is raised as a distal pedicle flapFor experienced surgeons, create a suprafascial dissection and a possible pedicle flap: raise flap from distal to proximal; isolate the vessels proximally; put a vessel clamp on the proximal pedicle; check for perfusion or signs of venous congestion; wait for 15 minutes; leave a subcutaneous vein long; ligate the proximal vessels and rotate the flap to the distal site; check again for perfusion and venous congestion; if the area is congested, connect the vein to a forearm vein (turbocharging)Proximal pedicle: put a vessel clamp on the distal pedicle after isolating the flap; check perfusion; ligate the distal vessels
Advantages
Vascular pedicle	A long, reliable pedicle with large-caliber vessels; atherosclerosis is rare; can be used as a “flow-through” flap when used as a free flap
Flap size and shape	Large flap; can be raised as a multi-island flap with strips of de-epithelialized subcutaneous tissue and fascia between the skin islands; many shapes possible; usually thin and pliable, even in obese patients
Combinations	Can be combined with extensions or second skin islands based on perforators, strips of tendons, and bony segments of the radius
Dissection	Donor and recipient sites can be dissected simultaneously
Disadvantages
Donor site morbidity	Very conspicuous donor site with potential impairment of tendon function; indication has to be carefully weighed, especially in women; graft take can be impaired distally
Pedicle	Sacrifice of a major forearm artery
Pearls and pitfalls
Dissection	Avoid separating the fascial septum from the vessels
Extensions and combinations	Maintain connections to bone and tendons when combined flaps are raised
Contouring and correction	Flap has only a little tendency to sag; contour corrections are rarely required
Clinical applications	Defects where flat, thin, and supple flaps are indicated; forearm, dorsum of the hand, and donor site appearance can be improved with suprafascial dissection