Upper Arm (Tagliacozzi) Skin Flap
B. C. MENDELSON
J. K. MASSON
This is a classic plastic surgery flap; although it has been supplanted by a host of other options, the advantage of having medial arm skin which is a reasonable color and texture match for this location still remains. However, the use of a free flap is probably a preferable choice.
The Tagliacozzi flap serves as a symbol in the tradition of plastic surgery. Tagliacozzi’s portrait is on the logo of the American Board of Plastic Surgery, and his flap is centered in the emblem of the American Association of Plastic Surgeons. The only major advance in the use of this flap since it was first reported by Gaspare Tagliacozzi in 1597 (1, 2) has been the introduction of anesthesia. Several variations of this pedicled arm flap have been described (3, 4, 5, 6, 7, 8).
In current practice, pedicle flaps from the arm have limited application in nasal reconstruction. The skin color is often a poor match with facial skin, certainly less satisfactory than that of forehead and clavicular skin flaps. The texture of the hairless skin of the anteromedial surface is too fine and the dermis too thin for effective total nasal reconstruction without the provision of additional support at a subsequent operation. The thinness of the skin, however, can be an advantage for coverage of an exposed nasal skeleton. The immobilization required is a most trying position for the patient and can result in permanent stiffness of the shoulder (9). The major advantage of the flap is that less time is required for a nasal reconstruction than with any of the other distant pedicle flaps, e.g., clavicular. Also, further facial scarring associated with forehead flaps can be avoided.
The Tagliacozzi flap is still the preferred flap in several situations (8). This flap should be used for total nasal reconstruction in children, preserving the forehead for definitive rhinoplasty later in life. It is also preferred for those in whom the forehead is not available, either because of a low hairline or because of the unacceptable aesthetic result of a skin graft on the residual forehead donor site. This is a real factor in darker-skinned patients (African-American, Latino, Indian), in whom hyperpigmentation of the graft is anticipated.
There is an arterial axis in the upper arm between the deltoid branches of the thoracoacromial artery and the recurrent branches of the radial and ulnar arteries of the elbow (10). On this basis, the Tagliacozzi flap may be partly an arterialized rather than a true random-pattern tubed pedicle flap. This may account for its good vascularity compared to other distant pedicle flaps, e.g., clavicular. The classically located flap ignores the adjacent arterialized skin of the lateral arm used in the cervicohumeral flap (see Chapter 134).