HAND/PERIPHERAL NERVE

Pedicled and Free Radial Forearm Flaps for

Reconstruction of the Elbow, Wrist, and Hand
Neil F. Jones, M.D.
Reza Jarrahy, M.D.
Matthew R. Kaufman, M.D.
Los Angeles, Calif.
Background: A single surgeons experience with 67 pedicled and free radial
forearm flaps for reconstruction of the elbow, wrist, and hand was analyzed
retrospectively.
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
hand, wrist, and elbow can be accomplished
using skin grafts, local flaps, regional or dis-
tant pedicled flaps, and free flaps. The groin flap
based on the superficial circumflex iliac artery axis
has been the most commonly used distant pedi-
cled flap.17 Although the axial pattern of the
groin flap provides an area of reliable skin, its
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
the radial forearm flap,8 26 the ulnar forearm
flap,2733 and the posterior interosseous flap34 43
From the UCLA Hand Center, Division of Plastic and Re-
constructive Surgery, and Department of Orthopedic Surgery,
University of California, Los Angeles, School of Medicine.
Received for publication November 27, 2006; accepted Au-
gust 10, 2007.
Copyright 2008 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000299924.69019.57
based on the radial artery, ulnar artery, and pos-
terior interosseous artery, respectively. These fas-
ciocutaneous flaps can be based on proximal ar-
terial inflow for elbow coverage or based distally
on reverse flow for coverage of the wrist and hand.
All three flaps can also be harvested and trans-
ferred as free flaps.8,14,21,22,26 28,40,44,45 The ulnar
forearm flap and posterior interosseous artery flap
Disclosure: None of the authors received funding,
grants, or in-kind support in support of the research
or preparation of the article. No author has an
association or financial involvement (i.e., consul-
tancies/advisory board, stock ownerships/options,
equity interest, patents received or pending, or roy-
alties/honorary) with any organization or commer-
cial entity having a financial interest in or finan-
cial conflict with the subject matter or research
presented in the article.

www.PRSJournal.com 887

have not achieved the same degree of popularity
as the radial forearm flap with hand surgeons in
the United States, because of concerns of harvest-
ing the more dominant ulnar artery in the case of
the ulnar forearm flap and because of concerns of
reliability of the posterior interosseous artery
flap.42 Even though the radial forearm flap is usu-
ally harvested as a skin flap, it may also be har-
vested as an osteocutaneous flap26,46 49 or purely as
a fascial flap50 56 and may incorporate the palmaris
longus tendon as a vascularized tendon graft.26,57,58
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,
which can be the dominant arterial supply to the
hand.6770 The purpose of this study was to analyze
the indications and results of pedicled and free ra-
dial forearm flaps used for reconstruction of the
elbow, wrist, and hand in a large series performed by
a single surgeon and to document any complications
with the flap or with the donor site.
PATIENTS AND METHODS
Approval for this study was obtained from the
Institutional Review Board at the University of Cal-
ifornia, Los Angeles School of Medicine. Inclusion
criteria were patients who had undergone emer-
gency or elective reconstruction of their upper
extremity using a pedicled or free radial forearm
flap with a minimum follow-up of 1 year. Sixty-
seven consecutive radial forearm flaps for recon-
struction of the upper extremity were performed
by a single surgeon between 1993 and 2005. A
retrospective chart review evaluated the age and
sex of the patient, diagnosis, location and size of
the defect, method of reconstruction, duration of
hospitalization, flap survival, complications of the
flap or donor site, objective assessment of func-
tional improvement, subjective assessment of the
donor-site scar, and any postoperative neurologic
or vascular symptoms in the donor extremity.
Sixty-seven radial forearm flaps were per-
formed in 66 patients; 42 were men and 24 were
women, with a mean age of 45 years (range, 2 to
87 years). Reconstruction was performed emer-
gently in 41 patients and as an elective procedure
in 25 patients. Fifty-seven flaps were pedicled ra-
dial forearm flaps and 10 were free flaps, from
either the contralateral extremity (n 8) or the
ipsilateral extremity (n 2). Of the pedicled ra-
dial forearm flaps, 43 were designed on reverse flow
in the radial artery and 14 were based on antegrade
flow (Table 1). The size of the flap ranged from 4
2 cm to 15 10 cm, with a mean flap size of 8 6
cm. Seven flaps were elevated as fascial flaps and one
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Plastic and Reconstructive Surgery March 2008
Table 1. Vascular Supply of Radial Forearm Flaps
(n 67)
No.
Pedicled radial forearm flaps
Reverse flow 43
Antegrade flow 14
Total 57
Free radial forearm flaps
Contralateral 8
Ipsilateral 2
Total 10
was elevated as an osteocutaneous flap. Indications
included soft-tissue coverage of the elbow (n 11)
(Fig. 1), coverage of the dorsal wrist and hand (n
24) (Fig. 2), coverage of the palmar wrist and hand
(n 12) (Fig. 3), after release of thumb-index finger
web space contractures (n 6) (Fig. 4), and for
coverage of thumb amputations (n 5) (Fig. 5).
Thirty-five patients had sustained traumatic injury to
their upper extremities, 28 because of avulsion or
crush injuries and seven resulting in amputations.
Five patients underwent secondary reconstruction
for burns. Radial forearm flaps were used for recon-
struction after radical resection of malignant tumors
of the forearm, wrist, and hand in 13 patients, the
most common diagnosis being squamous cell carci-
noma (n 4) or malignant fibrous histiocytoma
(n 4). More esoteric indications included circum-
ferential wrapping of the median (n 3), ulnar
(n 1), and radial nerves (n 1) for recalcitrant
carpal tunnel syndrome (Fig. 6), cubital tunnel syn-
drome. and superficial radial neuritis (n 5); full-
thickness soft-tissue infections (n 6) (Fig. 7); after
release of radioulnar synostosis (n 2); and before
toe-to-thumb transfers (n 3) (Fig. 8). Fourteen
proximal-based radial forearm flaps were used in this
series, 10 for primary or secondary reconstruction
after trauma or burns. Three proximal-based radial
forearm fascial flaps were transposed to the elbow
and proximal forearm, two for interposition after
radical release of radioulnar synostosis71 and one for
circumferential wrapping of the ulnar nerve for trac-
tion neuritis after multiple operations for cubital
tunnel syndrome72 (Table 2).
The donor site was usually covered with a
0.017-inch split-thickness skin graft, preferably
nonmeshed. The wrist and fingers were immobi-
lized in a palmar plaster of paris splint for 7 days,
with the wrist in 20 degrees of extension, the meta-
carpophalangeal joints in 50 degrees of flexion,
and the interphalangeal joints in extension.
Eleven patients subsequently underwent further
surgery, three involving the radial forearm flap
Volume 121, Number 3 Radial Forearm Flaps

Fig. 1. (Above, left) This 67-year-old woman underwent radical resection of a liposarcoma of the posterior aspect
of the right elbow. The triceps tendon was reconstructed with a fascia lata graft. (Below, 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. (Right) She regained elbow motion of 20/130 degrees.

itself and eight who required secondary proce-
dures unrelated to the flap.
Over the same time period, 12 groin flaps and
four reverse posterior interosseous artery flaps
were performed by the same surgeon for recon-
struction of the upper extremity in a separate
group of 16 patients. Pedicled groin flaps were
indicated for soft-tissue coverage of the palmar
surface of the wrist and hand (n 5), the dorsal
surface of the wrist and hand (n 4), and thumb
amputations or after release of contractures of the
thumbindex finger web space (n 3). All four
reverse posterior interosseous artery flaps were
indicated for soft-tissue coverage of dorsal defects
of the wrist and hand.
RESULTS
Primary healing of the soft-tissue defect of the
elbow, wrist, and hand was successful in 95 percent
of patients. There was partial peripheral loss of
one reverse radial forearm flap, probably because
of venous problems in a patient with necrotizing
fasciitis and generalized epidermolysis of a reverse
radial forearm flap in an elderly, confused patient.
There was complete loss of one contralateral free
radial forearm flap in a patient who had been
heavily irradiated and who had very inadequate
recipient veins. Three reverse radial forearm flaps
required leech therapy because of transient post-
operative venous congestion.
Eleven donor sites were closed primarily, 54
were covered with a nonmeshed split-thickness
skin graft, and two were covered with a meshed
split-thickness skin graft. There was 100 percent
take of the split-thickness skin graft in all 56 pa-
tients. Patients were hospitalized from 1 to 11 days
(mean, 4 days).
At follow-up, no patients complained of cold
intolerance of the hand on direct questioning.
None were dissatisfied with the appearance of the
donor site, nor did any patient complain of any
altered sensibility or dysesthesias within the dis-

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 Plastic and Reconstructive Surgery March 2008

Fig. 2. (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, which was debrided radically.
(Above, right) Schematic representation of the anatomy and dissection of a reverse radial
forearm flap for coverage of a dorsal defect of the hand. (Below, left) A reverse radial forearm
flap was elevated and transposed through a connecting incision between the dorsal defect
and the anterior forearm dissection. (Below, right) Excellent healing of the flap allowing full
extension of the middle, ring, and small fingers.

tribution of the superficial radial nerve or lateral tion of the forearm before coverage using the
antebrachial cutaneous nerve of the forearm. 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- forearm pronation and supination postopera-

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Volume 121, Number 3 Radial Forearm Flaps
Fig. 3. (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. (Right) The palm of his left hand was resurfaced with a reverse radial
forearm flap; excellent correction of the scar contracture of the thumb and fingers was obtained.
tively. Those patients who underwent release of
elbow flexion contractures gained an average of
75 degrees of extension after the elbow release
procedure and reconstruction with an antegrade
pedicled radial forearm flap. All the patients who
underwent a reverse radial forearm flap regained
full flexion and extension of their fingers, and those
patients who had normal wrist flexion and extension
and normal forearm pronation and supination be-
fore the reverse radial forearm flap regained full
wrist flexion and extension and full forearm prona-
tion and supination postoperatively without the
need for any postoperative hand therapy.
All 12 groin flaps were successful. One poste-
rior interosseous artery flap failed.
DISCUSSION
Although the radial forearm flap was originally
described by Song et al.8 as a free flap after release
of burn scar contractures of the neck, it was quickly
recognized that a radial forearm flap could be har-
vested as a proximal-based pedicled flap based on
antegrade flow through the radial artery for cover-
age of defects around the elbow and proximal
forearm,15,19,20 or as a distal-based pedicled flap for
coverage of the wrist and hand. 9 14,16 18,2126 The
basis for successful transfer of a reverse radial fore-
arm flap is retrograde flow through the radial artery
from the ulnar artery and palmar arches after liga-
tion of the proximal radial artery.67 Lin et al.73 de-
scribed venous outflow from a reverse radial forearm
flap based on a crossover pattern and a bypass
pattern between the venae comitantes and com-
munication between the cephalic vein and deep ve-
nous system.
The reverse radial forearm flap is especially
indicated for moderate-sized defects of the palmar
and dorsal aspect of the wrist and hand out to the
level of the proximal interphalangeal joints. In
this series, 43 reverse radial forearm flaps (64 per-
cent) were used to reconstruct 24 dorsal wrist and
hand (Fig. 2) and 12 palmar wrist and hand de-
fects (Fig. 3). Several previous reports have sug-
gested that the reverse radial forearm flap is spe-
cifically suited for coverage of dorsal wrist and
hand defects because the flap consists of similar
thin, supple skin.9 14,16 18,2126 However, occasion-
ally, especially in middle-aged women, the fore-
arm skin may have significant thickness of subcu-
taneous fat. In such individuals, the thickness of
the flap on the dorsum of the wrist and hand can
be reduced by harvesting a pure fascial flap50 56
and covering it with a full-thickness or split-thickness
skin graft. Similarly, in some men, the palmar aspect
of the forearm is excessively hairy, and if a reverse
radial forearm flap is used in these individuals to
cover a palmar defect, it may require the use of
depilatory creams or laser treatment postoperatively.
891
 Plastic and Reconstructive Surgery March 2008

Fig. 4. (Above, left) This 53-year-old woman developed an adduction contracture of her right thumbindex finger web space
following a severe crush injury to her right dominant forearm. The original injury required fasciotomies, vein graft revascularization
of the radial artery, and split-thickness skin grafting of the anterior forearm. (Above, right) After radical release of the thumbindex
finger web space contracture, reconstruction with a reverse radial forearm flap was not an option because of the previous injury
to the right forearm. (Below, left) A contralateral left free radial forearm flap was used. (Below, right) Pliable skin for the released
thumbindex finger web space was provided.

The most distal pivot point of a reverse radial
forearm flap is the radial styloid, where the radial
artery passes deep to the tendons of the first dorsal
extensor tendon compartment. The distance from
the radial styloid to the proximal margin of the
dorsal or palmar defect is measured and this dis-
tance transposed proximally up the anterior sur-
face of the forearm, where a template of the defect
cut from an Esmarch bandage may be orientated
either longitudinally or transversely, but should
not extend any farther radially than the radial
border of the forearm. If the flap has to reach
more distally, the skin flap has to be designed
more proximally over the junction of the middle
and proximal thirds of the forearm. However, in
these circumstances, the surgeon has to be metic-
ulous in carefully preserving the fragile lateral in-
termuscular septum containing the perforators,
because the radial artery and venae comitantes
diverge more deeply away from the overlying skin
island. For dorsal defects, either the flap can be
passed through a very wide subcutaneous tunnel
into the dorsal defect (Fig. 2, above, right) or an
incision may be made connecting the dorsal de-
fect with the forearm donor-site incision (Fig. 2,
below, left). It is essential that the pedicle is not
twisted, kinked, or compressed; otherwise, venous
outflow can be compromised. Despite the hypoth-
esis that a crossover or bypass pattern allows
venous egress from a reverse radial forearm flap,73
many of these flaps remain temporarily swollen for
several days. If there is any suggestion of venous
congestion of a reverse radial forearm flap,
leeches can be applied for a few days (three of 43
in this series), and it has even been suggested that
a superficial vein in the flap be anastomosed mi-
crosurgically to a superficial vein in the vicinity of
the defect47 or that a valvulotomy be performed in

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Volume 121, Number 3 Radial Forearm Flaps

Fig. 5. (Above left, and right) This 7-year-old boy sustained a pipe bomb injury to his left hand, with amputation
of the thumb, index, and middle fingers. A reverse radial forearm flap was used to cover the remaining thumb
metacarpal in preparation for a secondary toe-to-thumb transfer. (Below, left) Satisfactory coverage of the thumb
metacarpal, which was sufficiently functional that his family did not proceed with a secondary toe-to-thumb
transfer.

the cephalic vein.74 There were two partial failures
in the 43 reverse radial forearm flaps in this series
(4.65 percent), one because of venous outflow
compromise in a patient with necrotizing fasciitis
and one because of generalized epidermolysis in
an elderly confused patient who was unable to
maintain her hand in an elevated position.
The reverse radial forearm flap may be used
for coverage of moderate-sized defects of the pal-
mar aspect of the wrist and hand, but obviously this
requires that the defect has not interrupted the
connection between the ulnar and radial arteries
through the deep palmar arch or the radial artery
in the anatomical snuffbox. Although, ideally, a
preoperative Allen test should be performed on
every patient being considered for reverse radial
forearm flap, a preoperative angiogram may be
indicated in those patients being considered for
reverse radial forearm flap coverage of a palmar
defect. Another way to document the integrity of
flow from the ulnar artery to the radial artery is
to isolate the radial artery just proximal to the
radial styloid and apply a microvascular clamp.
The tourniquet is then deflated, and if a pulse
can be heard with a Doppler probe distal to the
microvascular clamp, this confirms that a re-
verse radial forearm flap can be reliably per-
formed on the intact connections between the
ulnar artery and the radial artery.
The majority of reverse radial forearm flaps in
this series were performed for primary or second-
ary reconstruction after trauma, burns, and infec-
tions and for immediate reconstruction after tu-
mor resection. The reverse radial forearm flap is
also especially indicated after release of contrac-
tures of the thumbindex finger web space (Fig. 4)
and for coverage of amputations of the thumb
(Fig. 5) that are unsuitable for replantation. The

893

Fig. 6. (Above) This 64-year-old woman had undergone three
previous operations on her left carpal tunnel. She underwent
neurolysis of the median nerve under the operating microscope.
(Below) The median nerve was then wrapped with a reverse radial
forearm fascial flap.
proximal stump of the radial artery within the
reverse radial forearm flap can then be used to pro-
vide arterial inflow to a subsequent toe-to-thumb
transfer75 (Fig. 8). A reverse radial forearm fascial
flap may occasionally be indicated for circumferen-
tial wrapping of the median nerve in cases of recal-
citrant carpal tunnel syndrome (Fig. 6) or for neu-
ritis of the superficial branch of the radial
nerve.55,72,76 A reverse radial forearm osteocutaneous
flap can be considered for reconstruction of thumb
amputations if the patient is unwilling to undergo a
toe-to-thumb transfer (Fig. 7).26,46 49
Even though the groin flap popularized by
McGregor and Jackson1 provides a large segment
of skin based on the superficial circumflex iliac
artery, it mandates attachment of the hand to the
trunk in a semidependent position and requires
two or three stages.27 It is usually contraindicated
in elderly patients, because it may predispose
894
Plastic and Reconstructive Surgery March 2008
them to stiffness of the shoulder, and in very young
children, because of difficulties cooperating with
immobilization. The groin flap seems to have been
superseded by the pedicled radial forearm and
posterior interosseous flaps. The pedicled poste-
rior interosseous artery flap, originally described
by Penteado et al.34 and subsequently by Costa and
Soutar35 and Zancolli and Angrigiani,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.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. However, it has not gained
popularity in the United States because of concerns
regarding its reliability.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, supple skin of the forearm and the long
pedicle, in our opinion, it is probably the optimal
flap for coverage of moderate-sized defects over
the radial, ulnar, anterior, and posterior aspects of
the elbow (Fig. 1), compared with the more re-
stricted rotation of a pedicled reverse lateral arm
flap77 82 or various muscle flaps. Four small series
have previously described the use of the antegrade
pedicled radial forearm flap for coverage of elbow
defects.15,16,19,20
Ten free radial forearm flaps were performed
in this series (15 percent), with the majority being
harvested from the contralateral forearm (Fig. 4).
The indications for a contralateral free radial fore-
arm flap are if the soft-tissue defect involves the
anterior aspect of the middle and distal thirds of
the forearm; if the soft-tissue defect involves the
palmar aspect of the wrist and hand or the ana-
tomical snuffbox and either the preoperative
Allen test is positive or an angiogram shows no
continuity between the radial and ulnar arteries;
and if the soft-tissue defect is more ulnar and distal
to the metacarpophalangeal joints and could not
be reliably covered with a reverse radial forearm
flap. Very occasionally, a contralateral free radial
forearm flap may be indicated as a flow-through
flap to provide soft-tissue coverage of the anterior
aspect of the forearm and to simultaneously re-
construct a segmental defect of either the radial or
ulnar artery in the forearm.9,21,22,44,45,47 When har-
vesting a contralateral free radial forearm flap, the
radial artery can be dissected all the way to its
bifurcation from the brachial artery, and the ce-
phalic vein and the two venae comitantes can be
Volume 121, Number 3 Radial Forearm Flaps

Fig. 7. (Above, left) This 29-year-old construction worker with diabetes developed necrotizing fasciitis of his dominant right
thumb. (Above, right and below, left) Because a toe-to-thumb transfer was felt to be contraindicated, he underwent reconstruction
of his right thumb with a reverse radial forearm osteocutaneous flap. (Below, right) The flap healed primarily without infection and
with very satisfactory thumb function.

carefully dissected all the way to the elbow to in-
corporate the small connection between the venae
comitantes and the superficial venous system, so
that the large cephalic or basilic vein at the elbow
can be used for the venous anastomosis.83
Indications for an ipsilateral free radial fore-
arm flap are very specific: if a soft-tissue defect is
more ulnar and distal to the metacarpophalangeal
joints and therefore beyond the arc of rotation of
a reverse radial forearm flap; or if the soft-tissue
defect involves the palmar aspect of the wrist and
hand so that there is insufficient flow from the
ulnar artery through the palmar arches to the
distal radial artery. Essentially, an ipsilateral free
radial forearm flap involves a more distal trans-
position of the flap by elongation of the proximal
radial artery and cephalic vein by interposition
vein grafts. Only two ipsilateral free radial forearm
flaps were indicated in this series: in one patient
with a soft-tissue palmar defect distal to the meta-
carpophalangeal joints and in one patient in
whom there was discontinuity of the palmar arches
because of a previous thermal burn.
Harvesting a free radial forearm flap is tech-
nically easier than harvesting a free lateral arm
flap or free posterior interosseous flap or free
anterolateral thigh flap. By harvesting the radial
artery up to the bifurcation from the brachial ar-
tery and the basilic or cephalic vein at the elbow,
the pedicle of a free radial forearm flap is much
larger and longer than the pedicle of a free lateral
arm flap or free posterior interosseous flap.83
Finally, the morbidity of the donor site has
been criticized by opponents of the radial fore-
arm flap. Several case reports have proposed
various options59 61,63 66 to improve the appear-
ance of the donor site, and the most recent
prospective study by Richardson et al.62 con-
cluded that there was a low incidence of long-
term morbidity associated with the radial fore-
arm flap. Several tips have been learned from
this large series of radial forearm flaps to im-

895

Fig. 8. This 3-year-old boy with a metacarpal hand underwent a
reverse radial forearm flap to provide both soft-tissue coverage
and arterial inflow to a second toe-to-thumb transfer.
Table 2. Indications for Radial Forearm Flap
Reconstruction
No.
Dorsal wrist and hand coverage
Palmar wrist and hand coverage
Elbow coverage
Thumbindex finger web space
Thumb amputations
Tumor excision
Burn scar contractures
Nerve wrapping for traction neuritis
Prior to toe-to-thumb transfers
Release of radioulnar synostosis
prove the outcome of the donor site. First, the
radial border of the flap should not be extended
beyond the radial border of the forearm if at all
possible, because this makes the donor site very
obvious, even when the forearm is held neutral
or in pronation. Furthermore, if the radial mar-
gin of the flap is confined within the radial
border of the forearm, the superficial branch of
the radial nerve can always be covered by fore-
896
Plastic and Reconstructive Surgery March 2008
arm skin and not lie immediately beneath the
skin graft covering the donor site. On direct
questioning at long-term postoperative follow-
up, none of the 66 patients in this series had any
symptoms of dysesthesias within the distribution
of the superficial branch of the radial nerve.
Most importantly, just like debridement, closure
of the radial forearm flap donor site should not
be relegated to the most junior surgeon, but in
fact should be the responsibility of the most
senior surgeon. The margins of the donor site
are sutured to the flexor muscles with absorb-
able sutures, 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. The flexor digitorum sublimis muscle is
imbricated over the flexor carpi radialis tendon
to prevent exposure of this tendon. Preferably,
a nonmeshed, 0.017-inch-thick, 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. Using this protocol, there
has been 100 percent take of the split-thickness
skin graft in all 56 donor sites, and the flexor
carpi radialis tendon has never been exposed.
Obviously, the skin was closed primarily in the
seven radial forearm fascial flaps in this series,
but the donor site could also be closed primarily
in three reverse radial forearm flaps and one
contralateral free radial forearm flap because
the width of the flap did not exceed 2 to 3 cm.66
The radial artery was reconstructed in only one
patient,70 and at follow-up on direct question-
ing, no patients have specifically complained of
24 cold intolerance in the 59 hands undergoing
12 pedicled radial forearm or ipsilateral free radial
11 forearm flaps or in the eight donor hands un-
6
5 dergoing a contralateral free radial forearm
13 flap. However, it should be acknowledged that
5 all patients live in California, where symptoms of
5
3 cold intolerance may be less of a problem than
2 in colder climates. Moreover, great care is taken
to preserve any cutaneous nerves during the
dissection if possible, which may help diminish
postoperative symptoms. In this series, no pa-
tients have expressed dissatisfaction with the
overall appearance of the donor site, despite the
fact that hyperpigmentation or hypertrophy of
the donor site is more likely in Hispanic and
African American patients.
CONCLUSIONS
This is the largest reported series of pedicled
and free radial forearm flaps for reconstruction of
Volume 121, Number 3 Radial Forearm Flaps
the elbow, wrist, and hand. Based on the senior
authors (N.F.J.) experience, the proximal-based
pedicled radial forearm flap has become the flap
of choice for coverage of moderate-sized defects
around the elbow. The reverse radial forearm and
contralateral free radial forearm flaps are more
versatile than the groin flap and more reliable
than the posterior interosseous flap for coverage
of moderate-sized defects of the dorsal or palmar
aspect of the wrist and hand following trauma or
tumor resection. Radial forearm fascial flaps are
occasionally indicated for circumferential wrap-
ping of the median, ulnar, and radial nerves for
recalcitrant traction neuritis, and radial forearm
osteocutaneous flaps are infrequently indicated
for thumb reconstruction if the patient refuses a
toe-to-thumb transfer.
Neil F. Jones, M.D.
UCLA Hand Center
Division of Plastic and Reconstructive Surgery
and Department of Orthopedic Surgery
University of California, Los Angeles School of Medicine
10945 Le Conte Avenue, Suite 3355
Los Angeles, Calif. 90095
njones@mednet.ucla.edu
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