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31 Free Thenar Flap
303
a b
Fig. 31.9 (a) Volar oblique amputation of thumb, with free thenar ap marked to resurface thumb pulp (b) early result at 2 months with minimal
donor site morbidity and a well padded glabrous reconstruction of the thumb
31.8 Pearls andPitfalls
Pearls
• Perform the arterial anastomosis rst, so that the
vein can ll with prominent backow to assist the
handsewn venous anastomosis [6].
• Perform the venous anastomosis to the proximal
dorsal digital or distal dorsal hand veins in order to
improve the size match and ow [6].
• Inset the ap loosely– use a split skin graft from the
hypothenar eminence over the loose fatty areolar
tissue covering the pedicle if required to avoid
potential compression from direct closure [6].
• Design the ap obliquely and centrally located over
the mid-palmar crease [6].
• It is possible to base the ap on a subcutaneous vein
only and used as an arterialized venous owthrough ap, with arterial inow and outow to
revascularize the digit and also provide skin coverage of the digit [1].
• Avoid long-term pain at the site of nerve division,
by carefully dissecting and burying the nerve ends
to avoid neuroma formation [5].
• The free thenar ap may also be used for recon-
struction of intraoral defects following excision of
oral SCC or other small-medium-sized defects in
the hard palate, for example [17].
Pitfalls
• If a ap of width larger than 2cm is raised, this may
require the use of a skin graft for donor site closure,
which will signicantly compromise donor site
morbidity [2, 6].
• Avoid injury to the recurrent motor branch of the
median nerve, which may pass through or distal to
the transverse carpal ligament (Types I–III) [18].
• Avoid the pedicle being too short by measuring the
length required and ensuring this is less than 2cm.
• If the ap appears too bulky after inset, allow this to
settle before performing a debulking procedure several months postoperatively [6].
• Avoid poor postoperative outcome, but ensuring the
patient attends for adequate hand therapy and complies with this [6].
31.9 Selected Readings
• Tsai TM, Sabapathy SR, Martin D.Revascularisation of a
nger with a thenar mini-free ap. J Hand Surg Am
1991;16 (4):604e6.
Summary: This is the rst case report of the use of a free
ap from the thenar region. This was performed for a
patient with a devascularized left index nger with a soft
tissue defect on the volar side. The thenar mini-free ap
304
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D. Reissis et al.
was raised at the level of the MCPJ of the thumb, based
on the radial digital artery of the thumb that was anastomosed to the ulnar digital artery of the index nger. A
volar vein was also harvested with the ap and anastomosed to a dorsal vein. The arterial anastomosis clotted
off postoperatively, but ow was restored with revision of
the anastomosis, and no further complications were
encountered. The donor site was noted to be minimal with
good range of motion of the thumb.
• Kamei K, Ide Y, Kimura T, A new free thenar ap. Plast
Reconstr Surg 1993;92 (7):1380e4.
Summary: This was the rst description of the free thenar
ap based on the supercial palmar branch of the radial
artery. The authors report two cases of traumatic volar
defects of the ngers, for which local/pedicled aps would
not have been large enough and cross-nger aps were
deemed unsatisfactory due to stiffness caused postoperatively. Both aps survived uneventfully and successfully
reconstructed the defects with some sensory recovery. The
anatomy of the SUPBRA is described clearly along with
the main advantages of the ap, including requiring only
one operative eld, providing a sensory ap with good
tissue match and minimal donor site morbidity, compared
with other options such as a cross-nger ap or a partial
toe transfer.
• Omokawa S, Ryu J, Tang JB, Han J.Vascular and neural
anatomy of the thenar area of the hand: its surgical applications. Plast Reconstr Surg. 1997;99 (1):116–121.
doi:10.1097/00006534-199701000-00018
Summary: This anatomical study investigated the vascular and neural supplies of the thenar region in 30 fresh
cadavers. The supercial palmar branch of the radial
artery was found in all hands. It had an average diameter
of 1.4mm (0.8–3.0mm). The constant area supplied by
the SUPBRA was 4x3cm over the proximal part of the
abductor pollicis brevis and opponens pollicis muscles.
This supported the fact that a fasciocutaneous ap could
be reliably harvested from the thenar region, based on the
SUPBRA. In 63% of the hands dissected, the SUPBRA
was connected to other arteries in the palm, suggesting
that the ap can also be transferred as a reverse-pedicled
island ap in these cases. The predominant sensory innervation of the ap was found to be from a branch of the
supercial radial nerve.
• Iwuagwu, F.C., Orkar, S.K. and Siddiqui,
A.Reconstruction of volar skin and soft tissue defects of
the digits including the pulp: experience with the free
SUPBRA ap. Journal of Plastic, Reconstructive &
Aesthetic Surgery, 2015, 68 (1), pp.26–34.
Summary: Following an initial publication in 2011 by the
same authors, in which the term “SUPBRA” ap was rst
coined, this article presents a case series of 13 patients
for whom a range of traumatic digital defects were reconstructed using a free SUPBRA ap. Flap dimensions
ranged from 2x5cm to 2x10cm. They reported no ap fail-
ures and good functional outcomes with ideal tissue
match, minimal donor site morbidity, and return of protective sensation despite no neurorrhaphy performed
except in one patient. They conclude that the free SUPBRA
ap has many advantages, approaching the ideal replacement for the volar tissue of the ngers.
References
1. Tsai TM, Sabapathy SR, Martin D.Revascularisation of a nger
with a thenar mini-free ap. J Hand Surg Am. 1991;16(4):604e6.
2. Kamei K, Ide Y, Kimura T.A new free thenar ap. Plast Reconstr
Surg. 1993;92(7):1380e4.
3. Omokawa S, Ryu J, Tang JB, Han J. Vascular and neural
anatomy of the thenar area of the hand: its surgical applications. Plast Reconstr Surg. 1997;99(1):116–21. https://doi.
org/10.1097/00006534- 199701000- 00018.
4. Iwuagwu Fortune C, Orkar Sam K, Aftab S.Free supercial palmar
branch of the radial artery ap for the reconstruction of defects of
the volar surface of the digits, including the pulp. Plast Reconstr
Surg. 2013;131(2):308ee9e.
5. Garg R, Fung BK, Chow SP, Yuk Ip W.A free thenar ap–a case
report. J Orthop Surg Res. 2007;2(1):1–3.
6. Iwuagwu FC, Orkar SK, Siddiqui A.Reconstruction of volar skin
and soft tissue defects of the digits including the pulp: experience with the free SUPBRA ap. J Plast Reconstr Aesthet Surg.
2015;68(1):26–34.
7. Mabvuure NT, Pinto-Lopes R, Iwuagwu FC, Sierakowski A. A
systematic review of outcomes following hand reconstruction
using aps from the supercial palmar branch of the radial artery
(SUPBRA) system. J Plast Reconstr Aesthet Surg. 2020;
8. Yang JW, Kim JS, Lee DC, Ki SH, Roh SY, Abdullah S, Tien
HY. The radial artery supercial palmar branch ap: a modied
free thenar ap with constant innervation. J Reconstr Microsurg.
2010;26(08):529–38.
9. Omokawa S, Mizumoto S, Iwai M, etal. Innervated radial thenar
ap for sensory reconstruction of the ngers. J Hand Surg Am
1996;21:373e80, 373.
10. Mackinnon SE, Dellon AL.The overlap pattern of the lateral antebrachial cutaneous nerve and the supercial branch of the radial
nerve. J Hand Surg [Am]. 1985;10:522–6.
11. Sassu P, Lin CH, Lin YT, Lin CH. Fourteen cases of free thenar
ap: a rare indication in digital reconstruction. Ann Plast Surg.
2008;60(3):260–6. https://doi.org/10.1097/SAP.0b013e31806ab39f.
12. Sakai S. Free ap from the exor aspect of the wrist for resurfacing defects of the hand and ngers. Plast Reconstr Surg.
2003;111:1412–20. discussion 1421–1422
13. Melone CP Jr, Beasely RW, Carstens JH Jr. The thenar ap: an
analysis of its use in 150 cases. J Hand Surg. 1982;7:291e7.
14. Kim KS, Kim ES, Hwang JH, Lee SY.Thumb reconstruction using
the radial midpalmar (perforator based) island ap (distal thenar
perforator based island ap). Plast Reconstr Surg. 2010;125:601e8.
15. Iwuagwu F, Siddiqui A. Pedicled (antegrade) SUPBRA ap for
wound cover on volar aspect of thumb. J Plast Reconstr Aesthet
Surg. 2012;65(5):678e80.
16. Omokawa S, Takaoka T, Shigematsu K, etal. Reverse-ow island
ap from the thenar area of the hand. J Reconstr Microsurg.
2002;18:659–63.
17. Gaggl A, Bürger H, Brandtner C, Singh D, Hachleitner J. The
microvascular thenar ap as a new possibility for super-thin soft
tissue reconstruction in the oral cavity—initial clinical results. Br J
Oral Maxillofac Surg. 2012;50(8):721–5.
18. Kozin SH. The anatomy of the recurrent branch of the median
nerve. J Hand Surg Am. 1998;23(5):852–8. https://doi.org/10.1016/
S0363- 5023(98)80162- 7.
Medial and Lateral Arm
Fasciocutaneous Flaps
KaterinaKyprianou, GeorgiosPatanis, DajiangSong,
andYoumaoZhen
32
32.1 Introduction
32.1.1 First Description, Origin andEvolution
ofMedial Arm Flap Vascularity
The medial arm ap was rst described by Tagliacozzi in
1597. In 1975, Daniel etal. described the medial arm with its
associated medial brachial cutaneous nerve, where the arterial supply was thought to be a cutaneous branch arising
from the superior ulnar collateral artery (SUCA). Similarly,
Kaplan and Pearl (1980) described an axial pattern ap supplied by SUCA and vein. Subsequently, Dolmans et al.
(1979) dissected the medial arm ap and reported the SUCA
was absent in 20% of the dissections, with Matoub et al.
(1981) reporting ve arterial variations supplying the ap. In
1982, Song etal. indicated that the medial arm was supplied
by a branch from the SUCA and described variations in
terms of the SUCA being absent and sometimes too small for
free ap transfer.
K. Kyprianou
Department of Plastic Surgery and Burns, Chelsea and
Westminster Hospital, London, UK
G. Patanis (*)
London Reconstructive Microsurgery Unit (LRMU), Department
of Plastic Surgery, Emergency Care and Trauma Division (ECAT).
The Royal London Hospital, Barts Health NHS Trust & University
College Hospital London (UCLH), London, UK
e-mail: g.patanis@qmul.ac.uk
D. Song
Department of Oncology Plastic Surgery, Hunan Province Cancer
Hospital, Changsha, Hunan, China
Y. Zhen
Department of Hand and Foot Surgery, Enze Hospital of Taizhou,
Enze Medical Center, Taizhou, Zhejiang, China
32.1.2 Medial Arm Flap Characteristics
The medial arm ap is a fasciocutaneous ap with a Type
B pattern of circulation according to Mathes and Nahai
classication. The standard ap is based on the upper segmental subcutaneous perforator and the ap can reach and
cover up to the axilla. Reverse or distally based aps are
designed on the lower segmental perforators. Those are
useful for staged transfer such as in nasal reconstruction
(Tagliacozzi ap). Additionally, a ap based on the posterior ulnar collateral vessels can be elevated as a distally
based ap.
32.1.3 Common Indications
The medial arm ap can be used both as a pedicled and free
ap. As a pedicled ap, it can be used for coverage for the
nose, axilla, antecubital fossa and breast reconstruction. As
a free ap, it can be used for distant coverage for the head
and neck area, as well as both upper and lower
extremities.
The following ap modications of the medial arm ap
exist:
1. Segmental transposition: Achievable due to the segmental nature of blood supply to this ap. Distally based
transposition is also feasible by basing the ap on the
subcutaneous vessels, particularly useful for staged distant transfer as in nasal reconstruction.
2. Innervated ap: Microvascular transplantation of a neural
sensory ap based on intercostobrachial or medial cutaneous nerve of the arm can be performed.
3. Reverse ap: A reverse island ap based on the ulnar
recurrent vessel can be used for coverage of the antecubital fossa. This is the reverse medial arm ap or the ulnar
recurrent fasciocutaneous ap.
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_32
305
306
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K. Kyprianou et al.
32.2 Anatomy
The vascular supply of the medial arm ap has been described
as variable septocutaneous blood supply, and perhaps this is
one of the major reasons why this ap has not been widely
popularised. It’s primarily characterised by a dominant pedicle, the SUCA, and a minor pedicle that mostly originates
from the brachial artery, with their interconnected collateral
anastomotic cutaneous networks.
32.2.1 Vascular Supply: Superior Ulnar
Collateral Artery (SUCA)
The vascular anatomy of the arm originates from the axial
artery, renamed as brachial artery as it enters the proximal
arm region. The brachial artery crosses through the septum
between triceps and biceps and gives off the profunda brachii artery that supplies the triceps muscle and the posterior
fasciocutaneous region of the arm via multiple small
branches.
The SUCA is considered the main supply to the medial
arm, with 1–2cm length and calibre of up to 2mm. Direct
cutaneous branches of the brachial artery, septocutaneous
perforators provide signicant blood supply to the medial
arm skin. It is an axial cutaneous artery approximately
5cm below the pectoralis major muscle and coursing in the
subcutaneous planes approximately 10 cm beyond. The
nomenclature of the SUCA is characterised by three anatomical variations: (1) originating from the profunda
(~60%), (2) originating directly from the brachial artery
(~20%) and (3) originating from both profunda and brachial arterial branches (~20%). The calibre of the SUCA is
adequate for dissection of free ap in the case of (1) or (2);
however, in the case of (3), the arterial pedicle calibre
requires the ability for submillimetre microvascular anastomosis or could be utilised as a pedicled ap. Extra care
should be taken as the biceps musculocutaneous blood supply also arises in very close proximity (~7cm) below the
pectoralis major muscle and through the muscle supplies
the anterior arm skin via more than two musculocutaneous
perforators.
Posteriorly, the ulnar collateral artery which is an axial
cutaneous vessel can be found 7cm from the elbow and
occasionally forms branches that connect the SUCA cutaneous network to the elbow. Posteriorly, the ulnar collateral artery, a larger in calibre vessel, travels between the
proximal heads of the exor carpi ulnaris to gives its muscle branches and courses us and posterior to the medial
condyle along with the ulnar nerve, to be anastomosed
with the SUCA.
32.2.2 Nerve Supply
The medial cutaneous nerve of the arm offers sensory innervation to the skin paddle of the medial arm ap. The superior
region is primarily innervated by the intercostobrachial nerve
and the inferior region by the medial cutaneous nerve of the
arm (C8-T1).
32.2.2.1 Anatomical Studies (Vasculature or
Angiosomes)
In the medial ap territory, the major blood supply is provided by the septocutaneous perforators, which arise from
the brachial artery, SUCA, inferior ulnar collateral artery or
supercial brachial artery if present. Hwang etal. found that
a constant perforator could be found within a circle of diameter 2.89cm, centred 8.9cm above and 1.2cm medial to the
medial epicondyle. Perignon etal. reported the same but for
a circle of radius 2.4cm, centred at 7.5cm above and 0.5cm
medial to the medial epicondyle. Finally, Tinhofer et al.
reported the same but for a circle of radius 3cm, centred at
8cm above and 1cm medial to the medial epicondyle. Xue
et al. reported that an average of 4.5 perforators can be found
along the medial intermuscular septum of the arm, which is
consistent with previous observations. According to the
angiosome theory, elevating a medial arm ap with full
length should be based on at least 1.5 perforator angiosomes
connected by true anastomoses, as medial arm aps based on
a single perforator have less favourable survival.
32.3 Preoperative Investigation
Preoperative planning of the ap includes identication of
the SUCA using the handheld Doppler and marking of the
large subcutaneous veins, to include at least one large supercial vein. The dominant SUCA could be also identied in a
computerised tomography as usually has larger calibre than
2mm, along the course of the brachial artery.
32.4 Flap Design andMarkings
The patient is positioned supine, and a line drawn from the
anterior axillary fold or coracoid process to the medial epicondyle of the humerus, which is the main landmark. The
skin island lies along the medial inner aspect of the arm and
can be centred along the distal third of the line drawn above.
The size of skin island can be up to 20x8cm. The anterior
border of the ap is incised rst to identify the biceps and
dissection continues to the intermuscular septum. The pedicle (SUCA) enters the ap on the deep surface through the
32 Medial and Lateral Arm Fasciocutaneous Flaps
medial intermuscular septum of the arm. The point where the
pedicle enters the ap is at the midpoint of the key landmark
line from the coracoid process to the medial epicondyle.
Proximally, the SUCA is closely involved with the ulnar
nerve.
32.5 Flap Raise/Elevation: AStep-by-Step
Guide
1. Anterior incision from the ap design required is made
and the deep fascia is divided (Fig.32.1).
2. Flap is elevated carefully at subfascial plane until the
medial intermuscular septum is seen and the brachial
artery and median nerve are identied and dissected
(Fig.32.2).
307
Fig. 32.3 Flap is islanded on its pedicle
Fig. 32.1 Flap design
Fig. 32.2 Flap is elevated at the subfascial plane until the medial inter-
muscular septum is seen
Fig. 32.4 The anterior and posterior incisions are undermined and dissected to allow identication of a subcutaneous vein in proximity or
overlying the muscular fascia and SUCA pedicle
3. The posterior incision is made at the fascia over the triceps and the ap can be islanded on its pedicle (Fig.32.3).
4. If the ap is elevated up to the mid- to distal third of the
inner arm at the subfascial level, the ulnar nerve must be
identied and separated from the intermuscular septum
(Fig.32.4).
5. The anterior and posterior incisions are undermined and
dissected to allow identication of a subcutaneous vein in
proximity or overlying the muscular fascia and SUCA
pedicle (Fig.32.4).
6. The ap could be harvested for free tissue transfer
(Fig.32.5).
7. If the reverse ap has been chosen, the collateral distal
arm connections should be identied to allow safe rotation to cover the defect around the elbow joint.
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Fig. 32.5 The ap harvested for free tissue transfer
Fig. 32.6 The donor site can be closed primarily
8. For the small aps, the donor site can be closed primarily.
Larger aps may require split thickness skin graft of the
donor site; however, that is not advisable since there are
other numerous alternative aps that can be used for
larger fasciocutaneous skin paddles (Fig.32.6).
K. Kyprianou et al.
process to the medial epicondyle of the humerus. The
distal extent of the ap is 3 cm above the medial
epicondyle.
2. The anterior incision is made rst and dissection is continued through the skin and subcutaneous tissues to the
deep fascia.
3. The deep fascia is elevated off the biceps muscle, and
dissection continues from lateral to medial towards the
medial intermuscular septum.
4. As the medial intermuscular septum is approached, the
septocutaneous branches are easily identied. These are
usually branches of the SUCA.
5. At this stage the posteromedial half of the incision is made,
and the posteromedial half of the ap is elevated from
medial to lateral. The dissection starts over the triceps muscle, continues over the exposed ulnar nerve and extends
across the brachialis to the medial intermuscular septum.
6. The deep plane of elevation includes the areolar fascia to
protect the superior brachial collateral artery. Care is
taken to avoid the intermuscular septum that contains the
ulnar and median nerves and the brachia/artery.
Protection is facilitated by marking the brachial artery
course between the biceps and triceps. Proximal to the
point where the superior ulnar collateral artery penetrates the skin, the dissection requires more care, so as
not to transect this direct cutaneous artery as it exits the
intermuscular septum.
7. The medial cutaneous nerve of the arm and the basilic
vein or a branch are divided and included in the ap.
8. Once the medial and lateral halves of the dissection meet
the intermuscular septum, the SUCA is traced proximally to its origin from the brachial artery. In its proximal course, the ulnar nerve is intimately involved with
the SUCA.
9. Proximal dissection of the SUCA to its origin will yield
a pedicle length of up to 3cm.
10. At this stage the ap is ready for transfer as a free ap or
transposition.
32.6.2 Reverse Flap
The reverse medial arm ap is based on the posterior ulnar
32.6 Core Surgical Techniques inFlap
Dissection
collateral vessels. The design of the ap is the same as the
standard ap. The vascular bases of the ap, the posterior
ulnar collateral vessels, run deep to the ulnar nerve along the
32.6.1 Standard Flap
anterior border of the triceps muscle coursing diagonally
from the medial epicondyle to the midline of the upper arm:
The standard ap is based proximally on the SUCA and is
elevated either for free tissue transfer or local transposition.
Technical considerations for its dissection are detailed:
1. Dissection of the ap is initiated through the medial incision and the ap elevated across the intermuscular septum.
2. The SUCA and its septocutaneous branches are identied
1. The ap is designed as an ellipse centred along the middle to distal third of the key line drawn from the coracoid
and isolated and the SUCA ligated at its origin.
3. The lateral incision is then made.
32 Medial and Lateral Arm Fasciocutaneous Flaps
4. The ap is elevated across to the ulnar nerve.
5. At this stage the posterior ulnar recurrent vessels are
identied, dissected off the ulnar nerve included within
the ap, and the ap dissected from above down towards
the medial epicondyle.
6. The ap is now ready for transposition superiorly into the
antecubital area.
7. The ap is placed in the defect without tension and
sutured.
32.6.3 Free Flap
For free tissue transfer, the ap is based on its dominant
SUCA:
1. The anterior incision is made and the dissection continued
down to biceps and the medial intermuscular septum.
2. The SUCA is identied and the septocutaneous branch is
traced to the ap.
3. Once it has been established that the SUCA is the domi-
nant supply and the vessel is suitable for microvascular
transfer, ap elevation proceeds as described for the standard ap.
309
Fig. 32.7 First webspace reconstruction with a thin and pliable free
fasciocutaneous medial arm ap
32.7 Clinical Scenarios
32.7.1 Medial Arm Flap
A 45-year-old gentleman underwent right foot rst webspace
reconstruction with a thin and pliable fasciocutaneous medial
arm ap. The medial arm ap was raised in the exact dimensions of the defect (3.5×5.5cm). The superior ulnar collateral artery and the basilic vein were used as the dominant
pedicles (Fig. 32.7). Microvascular anastomosis was
achieved with a dorsal incision to identify branch of the dorsalis pedis artery and a cutaneous vein on the medial dorsum
of the foot, overlying the rst webspace. The ap inset along
with primary closure of the dorsal extension incision for the
microvascular arterial and venous anastomosis achieved
excellent webspace reconstruction and coverage of the big
toe lateral wound defect (Figs.32.8 and 32.9).
32.7.2 Lateral Arm Flap
The lateral arm ap, a ap with consistent vascular pedicle,
similar to the medial arm ap can also be used for similar
indications. It is based on the radial collateral artery, a branch
of the brachial artery. The ap is designed in the humerus
axis, posterior to the biceps, brachialis and brachioradialis
sarcomeres. During ap elevation, the pedicle is seen within
the septum between triceps and biceps muscles, along with
Fig. 32.8 Microvascular anastomosis was achieved with a dorsal incision to identify branch of the dorsalis pedis artery and a cutaneous vein
Fig. 32.9 The ap inset achieved primary closure of the foot dorsum
and like-to-like webspace reconstruction of the big toe lateral wound
defect
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Fig. 32.10 Right hand thenar eminence skin, muscle and rst metacarpal bone defect
K. Kyprianou et al.
Fig. 32.12 The chimeric paddles raised en-bloc of two perforators of
the lateral arm ap, along with a small segment of the triceps sarcomere
on the distal pedicle
Fig. 32.11 A chimeric bi-paddle lateral arm ap, along with a small
segment of the triceps sarcomere to obliterate the thenar muscle defect
and a small distal humerus bone component, was designed
multiple small musculocutaneous perforators, that could be
used to harvest small chimeric muscle components for composite reconstructions, i.e. thenar eminence and rst webspace reconstruction.
A 35-year-old gentleman required a composite reconstruction of his right hand thenar eminence skin, muscle
and rst metacarpal bone defect (Fig.32.10). A chimeric
bi- paddle lateral arm ap, along with a small segment of
Fig. 32.13 The small segment of the triceps sarcomere to obliterate
the thenar muscle defect is demonstrated along with the distal humerus
bone segment
the triceps sarcomere to obliterate the thenar muscle defect
and a small distal humerus bone component, was raised
(Fig. 32.11). Figure 32.12 demonstrates the radial collateral artery within the septum with the multiple muscular
branches and the distal humeral branch. The chimeric conguration of the ap dissected allowed the composite
reconstruction of all defect characteristics of the right thenar eminence along with the small 1×1×1cm defect of
the rst metacarpal (Figs.32.13 and 32.14). Figure32.15
shows the complementary pattern of the chimeric free ap
components with the composite defect after the microvascular anastomosis to the radial artery and branch of the
cephalic vein.
32 Medial and Lateral Arm Fasciocutaneous Flaps
Fig. 32.14 The chimeric ap raised
311
32.8 Pearls andPitfalls
Pearls
• The basilic vein or a major branch is crucial to be
identied and included within the anterior incision
during ap elevation.
• The arc of rotation in cases when the reverse conguration is chosen must take into consideration the
joint movement to reduce the risks of scar
contracture.
• It is ideal to use the medial arm free ap when
requiring thin pliable fasciocutaneous ap that
could be also innervated via the medial cutaneous
nerve of the arm.
Pitfalls
• Larger-size aps that will require skin graft closure
of the donor site are not advisable since numerous
other alternatives are available.
• This is not a ap of rst choice; however, it offers a
pliable and good-quality skin especially in elderly.
• The septocutaneous perforators are usually branches
of the superior ulnar collateral artery. However, on
occasion these branches may arise directly from the
brachial artery or may not course through the intermuscular septum but through the posteromedial
aspect of the biceps muscle.
Fig. 32.15 The chimeric conguration of the ap dissected allowed
the composite reconstruction of all defect characteristics of the right
thenar eminence along with the small defect of the rst metacarpal
32.9 Selected Readings
• Kaplan EN, Pearl RM.An arterial medial ap– vascular
anatomy and clinical applications. Ann Plast Surg.
1980;4(3):205–15.
• A comprehensive vascular anatomical reference from the
early stages of reconstructive microsurgery, demonstrating the arterial blood supply of the medial arm ap.
Detailed nomenclature, vascular branches and clinical
applications are also revealed.
• Xue B, Zang M, Chen B, Tang M, Zhu S, Li S, Han T, Liu
Y.Septocutaneous perforator mapping and clinical appli-
312
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
K. Kyprianou et al.
cations of the medial arm ap. J Plast Reconstr Aesthet
Surg. 2019;72(4):600–8. doi: 10.1016/j.bjps.2019.01.025.
Epub 2019 Feb 10. PMID: 30808600.
• A retrospective study of 36 patients who underwent recon-
structive surgery using a medial arm ap, aiming to clarify the distribution of septocutaneous perforators and its
relationship with pedicled ap design. Given its rich septocutaneous perforator distribution, the medial arm ap
can be harvested reliably with versatile design and minimal donor site morbidity, thus deserving more attention in
reconstructive surgery.
• Matloub HS, Ye Z, Yousif NJ, Sanger JR.The medial arm
ap. Ann Plastic surg. 1992 Dec 1;29(6):517–22.
• A cadaveric study of 40 fresh cadaver arms, looking at the
vascular supply to the medial side of the arm after latex
injection. This study demonstrated that the superior ulnar
collateral artery was present in 39 of 40 dissections and
was the most consistent prominent blood supply to this
area.
• Gong X, Cui JL, Lu LJ.The medial arm pedicled perforator ap: application of phenomenon of one perforator perfusing multiple perforator angiosomes. Injury. 2014
Dec;45(12):2025–8. doi: 10.1016/j.injury.2014.09.005.
Epub 2014 Sep 21. PMID: 25294118.
• A study of eight aps using the medial arm pedicled per-
forator aps to treat skin defects around the elbow with
seven aps surviving uneventfully. This study conrmed
the phenomenon of one perforator perfusing multiple
perforator angiosomes in the medial arm and showed
that it is a useful tool for skin defects around the elbow.
• Hou C, Chang S, Lin J, Song D.Medial arm perforator ap.
In: Surgical Atlas of Perforator Flaps. Dordrecht: Springer;
2015. https://doi.org/10.1007/978- 94- 017- 9834- 1_9.
• A detailed published literature regarding the medial arm
island ap in a reverse conguration. Special considerations regarding the local fasciocutaneous ap based on
the recurrent ulnar arterial branches are demonstrated
and discussed.
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