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Radial Forearm Flap

ShahriarRajZaman, QadirKhan, JeremyM.Rawlins, AllanPonniah, andDariushNikkhah

28.1 Introduction

The radial forearm free ap (RFFF) was rst described in 1978in China at the Shenyang Military Hospital and then subsequently in a 1981 case series of 60 patients for resurfacing predominantly the neck for burn contractures [1, 2]. It has been described as a Mathes and Nahai type B fasciocutaneous ap [3]. Traditionally it has been utilized as a fasciocutaneous ap that includes volar forearm skin, fascia and the radial artery; however the ap may also include bone, cutaneous nerves, exor tendons and even the brachioradialis muscle. As such, it has become known for its versatility, reliability and its ease of harvest. The ap can also be pedicled to cover elbow defects or applied as a reverse radial forearm ap for hand/thumb defects [3]. Perforator-based and adipofascial aps have also been described for dorsal hand injuries [4]. For a period of time following its development, it became the workhorse fasciocutaneous ap for those defects requiring soft, thin and pliable reconstructions with long pedicles. Its use now is predominantly, but not limited to, in head and neck cancer reconstruction for intra-oral lining and glossectomy defects [5]. The less than optimal aesthetic donor site morbidity has led to other fasciocutaneous aps such as the anterolateral thigh (ALT) or the medial sural artery perforator (MSAP) ap being utilized now more frequently [6]. Nevertheless, the RFFF represents a reliable choice in situations where others are not feasible.

S. R. Zaman · J. M. Rawlins Royal Perth Hospital, Perth, WA, Australia

Q. Khan Fiona Stanley Hospital, Murdoch, WA, Australia

A. Ponniah · D. Nikkhah (*) Royal Free Hospital, London, UK e-mail: allan.ponniah@nhs.net; d.nikkhah@nhs.net

28.2 Anatomy

The RFFF can be designed off the whole volar forearm, but traditionally the distal radial forearm is harvested due to its slender composition at this level. The arterial supply is based on the septocutaneous branches of the radial artery, which traverses proximally in the septum between the brachioradialis (BR) and pronator teres (PT) and distally between the BR and exor carpi radialis (FCR). In the proximal third, there is a constellation of perforators (4, range 0–10) that are large and well-spaced, whereas in the distal third, they are more numerous and smaller in size (9, range 4–14) [1]. The radial artery is accompanied by venae comitantes throughout its course in a ladder-like conguration whereby the valves can be bypassed by the frequent interconnections and thus permitting retrograde drainage [1, 3]. Supercial venous drainage is traditionally provided by the nearby large cephalic vein which ascends on the radial volar forearm and can be dissected as far proximally as the deltopectoral groove. A sensate ap can be raised based on the lateral cutaneous nerve of the forearm which supplies the radial volar forearm, and if ulnar enough, the medial cutaneous nerve of the forearm could also be harvested. For an osteocutaneous ap, a segment of radius up to 10–12cm in length and 40% in cross section is able to be harvested through periosteal branches that lter down from deep fascia in the intermuscular septum [1, 3]. The concept of subfascial and suprafascial aps has also been explored and will be discussed further below.

With regard to anatomical variations, McCormack found both the radial and ulnar arteries to be present 100% of the time in their 750 dissections [7]. Subsequent work by Coleman and Anson found an absence of branches from the supercial palmar arch to the thumb and index nger in over 10% of dissections [8]. In 50% of dissections, the deep arch from the radial artery did not communicate with the ulnar artery [8]. In such a combination, the thumb would completely be dependent on the radial artery, and so a RFFF would necessitate a vein graft to ensure thumb vascularity.

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S. R. Zaman et al.

28.3 Preoperative Investigation

Preoperatively, an Allen’s test must be performed to ensure adequate vascularity to the hand if the radial artery were to be ligated. In the Allen’s test, both the radial and ulnar arteries are occluded through nger pressure at the wrist whilst asking the patient to make a st a few times to allow venous exsanguination of the hand. The patient then opens their hand, and pressure off the ulnar artery is released whilst maintaining occlusion of the radial artery. A hand colour that returns to pink within several seconds is one where the RFFF will be safe to use. A thorough surgical history is paramount to ascertain any previous injuries including fractures (especially if an osteocutaneous ap is planned) or vascular injuries. If harvesting an osteocutaneous ap, an x-ray aids in planning and assessing for previous fractures. Caution also must be taken particularly in the elderly or vasculopaths whereby unknown atheroma may increase the risk of failure or complications. In such cases, a CT angiogram would be recommended. Once a side is chosen for harvest, the radial artery can be palpated at the level of the volar wrist and traced proximally with a handheld Doppler up to the level of cubital fossa depending on the length of pedicle needed.

28.5 Flap Raise/Elevation: AStep-by-Step Guide

Step 1 Position and Incision

With the patient supine, the arm is on an arm table extended to 90 degrees. The arm is elevated for exsanguination, tourniquet applied and the forearm supinated. Make an incision on the ulnar border of the ap down through subcutaneous tissue until forearm fascia is reached. The fascia is incised proximally over the muscle and down to the paratenon of the exor carpi ulnaris (FCU) tendon distally.

Step 2 Ulnar to Radial Subfascial Raise: Standard Method

Elevation at this subfascial level proceeds ulnar to radially supercial to the underlying muscles/tendons with haemostasis along the way. It’s important to preserve the paratenon of all the tendons. As the dissection is subfascial, the volar forearm veins and the lateral and medial cutaneous nerves (depending on how ulnar the ap is) will be already within the ap (Fig.28.2). The nerves and veins will be encountered at the proximal edge of the ap, and so prepare whatever is necessary for the reconstruction. Proceed radially till edge of previously marked FCR.

28.4 Flap Design andMarkings

Begin by marking the course of the radial artery and cephalic vein from the wrist to the cubital fossa. Coarsely this is represented by a line 1cm inferior to the centre of the antecubital fossa to the scaphoid tubercle but can be more accurately traced with a handheld Doppler. Mark the BR and FCR tendons by palpating them distally on the wrist. The axis of the ap will be slightly ulnar to this line in order to avoid the hairier dorsal wrist. The dimensions of the ap for marking are determined by the defect for reconstruction and generally are made over the distal third of the forearm (Fig.28.1).

Fig. 28.1 Flap design and markings

Step 3 Pedicle Dissection Proximally

Whilst waiting for recipient site preparation, dissection of the radial artery and its venae proximally can be performed (Fig.28.3). This can be aided with a self-retainer retractor in the septum between FCR and BR to expose the vascular pedicle (Fig.28.4). Take care to apply micro-haemostatic clips to the small muscle branches off the radial artery. Free the pedicle circumferentially proximally to the skin paddle (Fig.28.5). If the cephalic vein is also going to be included in the ap, then its dissection can also be performed at this point.

Step 4 Radial Incision

The radial border of the ap is then incised 1cm radial to the artery. Care must be taken to identify and protect the supercial radial nerve and its branches (Fig.28.6). Clip and divide the cephalic vein at the distal edge of the ap if it is to be included. The free border of BR muscle and its tendon is seen and retracted radially. The radial artery and its venae will be seen along the ulnar side of the BR tendon and the radial border of FCR tendon. Dissect along BR muscle edge, ensuring the intermuscular fascia is not breached as the vascular pedicle is within.

28 Radial Forearm Flap

Fig. 28.2 Subfascial ulnar to radial raise with the distal radial neurovascular bundle ligaclipped

273

Manipulate the flap with its pedicle for exposure but be mindful to not apply over traction

Side branches should be secure with ligaclips

Prevent desiccation of the donor site by keeping it moist with damp gauze.

Fig. 28.5 Meticulous ligaclipping of the side branches with gentle traction

Fig. 28.3 Distal to proximal raise of the RFFF

Fig. 28.4 Careful dissection of the pedicle between BR and FCR

Step 5 Divide Radial Artery and Venae Distally

At the distal edge of the ap, isolate and divide the radial artery and its venae. At this point the vascular pedicle of the ap should be the only attachment remaining to the

Fig. 28.6 Care must be taken around the radial border of the ap to avoid injury to the supercial branch of the radial nerve

underlying tissues as the rest of the ap has been raised already. Proceed then to create a plane under the pedicle from distal to proximal along its length ensuring haemostasis of any small branches. Once free of all its attachments, release the tourniquet and assess circulation of the ap.

Step 6 Division of Pedicle for Transfer

Once the recipient site is ready for transfer, the pedicle is prepared for division (Fig. 28.7). At the proximal pedicle end, carefully separate the venae from the radial artery to allow adequate length for anastomoses. Beginning with the venae, double clip the side that will remain and divide distal to this. Do the same for the artery. This will now render the ap ischaemic.

Step 7 Donor Site Closure

For a sizeable RFFF that isn’t amenable for a hatchet ap, a skin graft is used. The FCR and BR muscle bellies are approximated with absorbable sutures, ensuring the paratenon isn’t injured. Apply a skin graft, a bulky dressing and a resting volar plaster of Paris.

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Fig. 28.7 Flap islanded and pedicle dissected out as far proximally as required

28.6 Core Surgical Techniques inFlap Dissection

S. R. Zaman et al.

thus its use is rare. Available bone is from distal to pronator teres insertion to the distal styloid which gives approximately 10–12cm length of boat-shaped bone segment in an adult [1]. The wrist and forearm is then placed into a plaster of Paris for 3–4weeks to prevent a radius fracture; some surgeons plate the donor site for further rigid stability [1, 3].

28.6.4 Flap Dissection andInstrumentation

Dissection with a blade is generally the standard but can also be done with ne bipolar cautery at low settings especially near the pedicle. DeBakey forceps are used when handling vessels, and micro-ligaclips for clipping off the numerous side branches of the radial artery are recommended.

28.6.1 Skin Paddle Design

The cutaneous design is open to great variation depending on what is required. The standard RFFF is designed over the distal volar third of the forearm. The design for the reverse RFF is with the skin paddle in the proximal forearm, and the pivot point is the palpable radial pulse at the level of the wrist. The skin island is designed centrally along the radial artery axis (illustrated in case scenario B). The ap can also be split into several skin islands based on the septocutaneous perforators.

28.6.2 Ulnar toRadial Approach

The subfascial ap elevation technique is the standard method; however a suprafascial ap harvest can also be performed. It was hypothesized that the subfascial ap improved ap vascularity by way of preserving the subfascial vascular plexus. The suprafascial ap on the other hand was thought to leave a more suitable donor site for graft take and tendon excursion which was subsequently conrmed by Chang etal. [9]. A decade later, a denitive anatomical study found that the deep fascia did not contribute to the perfusion of the RFFF as was initially thought [10].

28.6.3 Osteocutaneous Flap

RFFF as an osteocutaneous ap has fallen out of favour due to better donor sites such as the free bula ap and

28.6.5 Tendon Inclusion

Depending on what the requirements of the reconstruction are, vascularized tendon can be transferred with the ap. The palmaris longus can be used if a fascial sling is required in cases of angle of mouth or lower lip reconstruction [1]. The BR tendon can also be utilized in pedicled reverse RFF for extensor defects.

28.6.6 Vein Harvest

For the free ap, harvesting a supercial vein (usually cephalic vein) is always worthwhile, even though the ap will generally be ne with venous drainage via the deep venae system. This applies also for the reverse pedicled ap for the hand defects [11].

28.6.7 Donor Site

The donor site morbidity represents the most unappealing feature of this ap, particularly if grafting is required. Fullthickness grafts from lateral groin (hairless) are preferred to split-thickness grafts for cosmesis, and suprafascial aps have been found to improve graft take [9]. The ulnar transposition ap (“hatchet ap”) was popularized by the Canniesburn group in the late 1980s and is applicable for the small donor site defects [12]. Acellular dermal matrices such as Integra or Matriderm have also shown promising results as staged constructions of the donor site.

28 Radial Forearm Flap

275

28.7 Clinical Scenario

28.7.1 Clinical Scenario A: Surgeons Jeremy Rawlins and Qadir Khan

A 58-year-old female patient with a left nasal alar invasive BCC (Fig. 28.8). Staged excision and reconstruction was planned due to the extent and inconspicuous clinical borders

of the tumour. Anatomical subunits were marked using the contralateral side as the template. A subfascial RFFF from the non-dominant forearm was raised (Figs.28.9 and 28.10). The RFFF was folded for nasal lining and along with a cheek advancement ap for the medial cheek defect (Fig.28.11). The fascial side of the ap was temporarily split skin grafted whilst awaiting the next stage (Figs.28.12 and 28.13). The donor was closed with a full-thickness skin graft.

Fig. 28.8 Left alar/nasal and medial cheek defect with the anatomical subunits marked out

Fig. 28.9 Subfascial radial forearm ap raise. The cephalic vein was

not included due to the small size of the ap

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Fig. 28.10 The ap divided and placed in the plastic sleeve, ready for tunnelling to the neck vessels for microanastomoses

S. R. Zaman et al.

28.7.2 Clinical Scenario B: Surgeons Dariush Nikkhah and Norbert Kang

A 60-year-old manual worker crushed his hand under heavy machinery. He had an exposed third metacarpal with a unicortical fracture, with tendon and periosteum stripped off the metacarpal (Fig.28.14). A reverse radial forearm ap was performed after debridement (Fig.28.15). He had an uneventful recovery, and at 6months postoperatively, he had full range of movement and declined further debulking surgery (Fig.28.16).

Fig. 28.11 Cheek advancement ap raised for the medial cheek defect

Fig. 28.12 The ap pedicle being tunnelled safely to the neck vessels.

The plastic sleeve safeguards the pedicle from any untoward injury during the tunnelling

Fig. 28.14 Size of dorsal hand defect post denitive debridement and ready for reconstruction

Fig. 28.15 Reverse radial forearm ap raised and islanded

Fig. 28.13 Stage 1 complete. Nasal packs have been inserted to stent

the nostrils open temporarily

28 Radial Forearm Flap

Fig. 28.16 Postoperatively, he had full range of movement with no restrictions

277

28.7.3 Clinical Scenario C: Surgeons Dariush Nikkhah andAllan Ponniah

A 69-year-old woman presented with aggressive recurrent poorly differentiated cutaneous squamous cell carcinoma of the nose. The lesion was xed to the nasal bone, and CT imaging demonstrated extension of the tumour into the upper lateral cartilages and nasal bone—without evidence of lymphadenopathy. A partial rhinectomy was performed, and the upper septum, upper and lower lateral cartilage, nasal bone and nasal side wall were removed en bloc (Fig.28.17). The lesion was narrowly excised at the deep margin, and after MDT discussion due to its aggressive and locally invasive nature, it was felt that immunotherapy with cemiplimab should be given over radiotherapy as this would allow for a better chance for later nasal reconstruction. After assessment at the craniofacial MDT, decision was made to perform a trilaminar reconstruction with internal lining imported as a free tissue transplant. The most suitable donor site was the forearm which was templated intraoperatively; the ap was taken as a suprafascial ap to reduce bulk (Figs.28.18 and 28.19). The advantage of this approach would allow more accurate tailoring of the inner lining, which is not possible with locoregional aps. Free ap reconstruction of the inner lining provides a customised and templated solution which allows for a robust blood supply for cartilage constructs. The radial forearm ap was raised on the nondominant hand, and the donor site was closed primarily with a hatchet ap. Supercial veins were harvested, and an 11 cm pedicle was taken for a tensionless anastomosis with the facial artery and facial vein in the neck with 9.0

Fig. 28.17 Nasal defect post SCC cancer resection

Fig. 28.18 Intraoperative picture demonstrating harvest of a suprafas-

cial radial forearm ap for inner lining

ST.An alar batten graft was taken from the right conchal bowl to recreate the external valve. A full-thickness forehead ap was used to cover the cartilage and inner lining radial forearm ap in the same operation. Two subsequent revision operations which involved forehead ap debulking and pedicle division were performed. The patient had an excellent cosmetic outcome and remains cancer-free at 12months (Fig.28.20).

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Fig. 28.19 Postage stamp size radial forearm ap with cephalic vein and radial artery demonstrated before transplantation

S. R. Zaman et al.

28.8 Pearls andPitfalls [13]

Pearls

1. Proximal pressure above the elbow provides a degree of venous occlusion and thus can help identify more clearly the supercial veins.

2. Avoid the distal most 2 cm of the volar wrist to reduce the risk of tendon exposure from ap elevation.

3. Proximal incision to ap should be designed with the closure of the resultant defect in mind. If an ulnar transposition (hatchet) ap is planned, then plan design with the backcut. Otherwise a “lazy S” incision can be made if a split skin graft is planned for the donor site.

4. To ensure a true subfascial dissection, incise the fascia until the underlying muscle can be clearly seen.

5. To avoid injury to the paratenon and subsequent wound healing and tendon glide problems, utilize a sharp scalpel to dissect above the paratenon.

Fig. 28.20 12-month result after reconstruction

Pitfalls

1. Care must be taken to avoid an iatrogenic injury to the supercial branch of the radial nerve with the radial ap incision.

2. Following the radial incision, retract the BR muscle radially to avoid injuring the vascular pedicle.

3. Injuring the paratenon during subfascial dissection can lead to donor site healing issues.

4. A common pitfall with not taking a supercial vein as a lifeboat (usually cephalic) could place the ap at risk of venous congestion.

5. Misplacement of the ap not over the radial artery perforators in reverse pedicled aps can result in ap necrosis.

28 Radial Forearm Flap

279

28.9 Selected Readings

• Wei FC, Mardini, S.Chapter 25 Radial Forearm Flap. In: Flaps and Reconstructive Surgery. Pp 320–338. In: Flaps and Reconstructive surgery.

• A modern encyclopaedia on reconstructive plastic sur-

gery. The chapter is an excellent source on all aspects on the radial forearm ap.

• Manktelow RT. Forearm Flap. In: Microvascular Reconstruction. 1986. pp25–30.

• Foreworded by Professor Ian Taylor himself, this book was a denitive landmark on aps in reconstructive surgery during a time when reconstructive microsurgery was in its teens.

• Mathes S, Nahai F. Radial Forearm Flap. 1997. pp.775–802.

• A succinct summary of the key aspects of a radial forearm

ap raise with good cadaveric pictures. One of the pioneering volumes on reconstructive ap surgery.

• Soutar DS, Mc Gregor IA. The radial forearm ap in intraoral reconstruction: The experience of 60 consecutive cases. Plast Reconstr Surg. 1986; 78(1). pp.1–8.

• From Canniesburn, Scotland, a 60-case review of the util-

ity of the RFFF in intraoral reconstruction at a time when a reliable ap did not appear to be available.

• Timmons MJ, Missotten FEM, Poole MD, Davies DM.Complications of radial forearm ap donor sites. Br J Plast Surg. 1986;39(2):176–8.

• An important paper examining the complications of radial

forearm free aps including skin graft failure, swelling of the hand, stiffness, reduced strength and sensation, coldinduced symptoms and fractures of the radius. Their paper was on 15 patients from across 2 centres.

• Jones NF, Jarrahy R, Kaufman MR.Pedicled and Free Radial Forearm Flaps for Reconstruction of the Elbow, Wrist and Hand. Plast Reconstr Surg. 2008; 121(3). pp.887–898.

• A single surgeon’s experience from California with 67

pedicled and free RFF for reconstruction of the elbow, wrist and hand. The authors recommend the anterograde pedicled ap for elbow coverage and the reverse RFF as the optimal choice for moderate-sized defects of the wrist and hand.

• Chang SCN, Miller G, Halbert CF, Yang KH, Chao WC, Wei FC.Limiting Donor Site Morbidity by Suprafascial

Dissection of the Radial Forearm Flap. Microsurgery.

1996. 17: pp.136–140.

• In response to problems with donor site complications

with subfascial raises, this paper examined the technique of suprafascial ap elevation to prevent donor site problems with considerable value.

• Schaverien M, Saint-Cyr M.Suprafascial Compared With Subfascial Harvest of the Radial Forearm Flap: An Anatomic Study. J Hand Surg Am. 2008; 33(1): pp.97–101.

• An anatomical study examining the difference between

suprafascial and subfascial RFFF raises. Based on radiology, the draining patterns were assessed and deemed that the deep fascia doesn’t contribute to the perfusion of the RFFF for viability.

References

1. Wei FC, Mardini S.Flaps and reconstructive surgery. Flaps and reconstructive. Surgery. 2009

2. Manktelow RT, Manktelow RT. Forearm ap. In: Microvascular reconstruction; 1986.

3. Mathes S, Nahai F. 8J- Radial Forearm Flap. 1997. pp.775–802.

4. Taghinia AH, Carty M, Upton J.Fascial aps for hand reconstruction. J Hand Surg Am [Internet]. 2010;35(8):1351–5. https://doi.

org/10.1016/j.jhsa.2010.05.015.

5. Soutar DS, Mc Gregor IA. The radial forearm ap in intraoral reconstruction: the experience of 60 consecutive cases. Plast Reconstr Surg. 1986;78:1.

6. Timmons MJ, Missotten FEM, Poole MD, Davies DM.Complications of radial forearm ap donor sites. Br J Plast Surg. 1986;39(2):176–8.

7. Mccormack LJ, Cauldwell EW, Anson BJ. Brachial and antebrachial arterial patterns; a study of 750 extremities. Surg Gynecol Obstet. 1953;96:43.

8. Coleman SS, Anson BJ.Arterial patterns in the hand based upon a study of 650 specimens. Surg Gynecol Obstet. 1961;113:409.

9. Chang SCN, Miller G, Halbert CF, Yang KH, Chao WC, Wei FC.Limiting donor site morbidity by suprafascial dissection of the radial forearm ap. Microsurgery. 1996;17(3):136–40.

10. Schaverien M, Saint-Cyr M.Suprafascial compared with subfascial harvest of the radial forearm ap: an anatomic study. J Hand Surg Am. 2008;33(1):97–101.

11. Jones NF, Jarrahy R, Kaufman MR.Pedicled and free radial forearm aps for reconstruction of the elbow, wrist, and hand. Plast Reconstr Surg. 2008;121(3):887–98.

12. Elliot D, Bardsley AF, Batchetor AG, Soutar DS. Direct closure of the radial forearm ap donor defect. Br J Plast Surg. 1988;41(4):358–60.

13. Wolff K-D, Hölzle F. Raising of microvascular aps. Springer;

2011.

Posterior Interosseous Artery Flap

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DouglasCopson, DariushNikkhah, andMarkPickford

29.1 Introduction

The PIA ap is a regional fasciocutaneous ap, which can be used to cover small- to medium-sized defects. The anterograde PIA variant is suitable for coverage of elbow defects, and the more common distally based PIA ap for cover of the dorsal hand and rst webspace. Its main benets include its thin pliable nature and avoiding disrupting the two major arteries within the forearm. We the authors see its utility in small non-graftable defects where the donor site may be closed directly or a small skin graft used with minimal morbidity. Large defects may be better served by thin fasciocutaneous free aps, or alternatively the PIA ap may be raised without skin, i.e. as an adipofascial or pure fascial ap, with a view to grafting the ap and directly closing the donor site.

The PIA ap was described around the same time by

Zancolli and Angrigiani as well as Penteado and Masquelet.

At the sixth European Hand Surgery Course in Umea (Sweden) in 1985, Zancolli and Angrigiani described the reverse posterior interosseous artery ap. The ap was published in Spanish literature by Zancolli and Angrigiani 1986 and in the English literature in the Journal of Hand Surgery in 1988 [1]. In this paper the PIA ap was described as an option for coverage of the dorsum of the hand and rst webspace; 25 cases were performed between 1984 and 1987, 21

for rst webspace release, 3 for reconstruction of dorsal hand defects and 1 for a volar wrist defect. In this paper the vascular anatomy and surgical technique are described.

The ap was also described by Penteado and Masquelet in 1986in French literature as well as by Penteado, Masquelet and Chevrel in English literature in 1986 [2]. The latter paper is an early anatomical study/original description of the PIA ap; dissection of 70 cadaveric forearms and the anatomical ndings underlying the ap were described. The authors reported two cases of anterograde PIA aps and ten distally based variants.

Since its rst description, multiple variations of the PIA ap have been described, which include the distally based PIA ap, anterograde PIA ap, extended PIA ap and adipofascial and pure fascia variants.

29.1.1 Characteristics (Types)

29.1.1.1 Distally Based PIA Flap

The distally based PIA ap is the most common variant used today and the original form as it was described. It is based on the distal communication between the anterior interosseous artery and the posterior interosseous artery and allows for coverage of defects of the dorsal hand and rst webspace up to the level of the MCPJ.

29.1.1.2 Anterograde PIA Flap

Supplementary Information The online version contains supplementary material available at [https://doi.org/10.1007/978- 3- 031- 07678- 7_29].

D. Copson (*) Royal Perth Hospital, Perth, WA, Australia

D. Nikkhah Royal Free Hospital , London, UK

M. Pickford Queen Victoria Hospital East Grinstead, East Grinstead, UK

The posterior interosseous artery ap can be designed in an anterograde fashion with a pivot point where the PIA enters the extensor compartment. In this fashion it can be used to cover defects of the elbow and proximal forearm.

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