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SURGICAL TECHNIQUE

Radial Artery Perforator Flap

AndrewM. Ho, MD, PhD, James Chang, MD

Soft tissue defects in the hand and wrist can be challenging problems for the hand surgeon.The retrograde radial forearm fasciocutaneous flap has emerged in recent years as theworkhorse flap to cover many hand and wrist defects. However, recognition of the intrinsiclimitations of this flap has led to the development of other alternative flaps to provide softtissue coverage for this region. The radial artery perforator flap has many of the benefits ofthe radial forearm flap but minimizes the disadvantages, such as the need to sacrifice theradial artery, color and bulk mismatch of the flap and recipient tissues, and donor siteappearance. In this article, we will review the indications for using the radial artery perforatorflap to cover hand and wrist soft tissue defects. We will discuss the surgical anatomy,indications, operating technique, rehabilitation protocol, potential complications, and pearlsand pitfalls for use of this flap for upper-extremity defects. (J Hand Surg 2010;35A:308–311.Copyright © 2010 by the American Society for Surgery of the Hand. All rights reserved.)

Key words Flap, hand, perforator, radial artery, reconstruction.

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OFT TISSUE DEFECTS of the hand and wrist canresult from trauma, burn, infection, ischemia, orneoplasm. In recent years, the volar radial fore-

rm fasciocutaneous pedicled flap has been used exten-ively to cover large areas of hand and wrist defects.his radial forearm flap uses the retrograde flow of the

adial artery to provide a robust blood supply to the flapnd can be raised in a single-stage procedure withouticrovascular surgery to cover defects in the hand andrist.With routine use of the retrograde radial forearm flap

ome drawbacks to this flap have become apparent. Theeed to sacrifice the radial artery during the harvest ofhe flap has precluded its use in patients with aberrantnd incomplete distal radial artery–ulnar artery connec-ions. The donor skin and fascia from the volar forearmffer poor matches in color and contour to the thinnernd more delicate tissue of the hand, especially the

From the Robert A. Chase Hand and Upper Limb Center and the Division of Plastic and ReconstructiveSurgery, Stanford University School of Medicine, Stanford, CA.

Received for publication April 12, 2009; accepted in revised form November 18, 2009.

No benefits in any form have been received or will be received related directly or indirectly to thesubject of this article.

Corresponding author: James Chang, MD, Division of Plastic and Reconstructive Surgery, Stan-ford University School of Medicine, 770 Welch Road, Suite 400, Stanford, CA 94304; e-mail:changhand@aol.com.

0363-5023/10/35A02-0025$36.00/0

pdoi:10.1016/j.jhsa.2009.11.015

08 � © ASSH � Published by Elsevier, Inc. All rights reserved.

orsum. In addition, donor site morbidities such as poorkin graft take, delayed wound healing, and conspicu-us donor scarring also limit use of this flap in someatients.

These limitations of the radial forearm flap and fur-her understanding of the vasculature of the forearmave led to the development of other pedicled forearmaps based on the posterior interosseous artery, dorsallnar artery, and branches of the radial artery.1 In 1988,hang described a technique that takes advantage of theeptocutaneous perforators arising from the distal radialrtery to supply a retrograde radial forearm flap.2 Sincehen, application of the radial artery perforator flap haseen described for coverage of hand and forearm de-ects resulting from various traumas3 and burn injuries.4

NDICATIONS

he radial artery perforator flap can be used to coveroderate-sized defects (�8 cm � 18 cm) of the dorsal

r palmar hand as distal as the base of the proximalhalanges of the digits, as well as the distal forearm2

Fig. 1). As the radial artery is not violated during thelevation of this flap, the patient does not need toemonstrate a competent distal ulnar–radial arterialnastomosis, and a preoperative Allen’s test is not re-uired. However, patency of the radial artery and itsenae comitantes at the wrist is vital to the retrograde

erfusion of the flap.

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CONTRAINDICATIONSBecause the radial artery perforator flap is dependent onretrograde flow of a plexus rather than a major vascularaxis, the maximum dimensions of the flap that can betransferred reliably are smaller and the reach of the flapmore proximal than that for traditional axial flaps. Thus,this flap is not suitable for patients with large defects(greater than 10 cm � 20 cm) or with defects distal tothe metacarpophalangeal joints in the hand. Alternativeflaps should also be considered in patients at risk formicrovascular arterial disease, such as smokers or dia-betics, or in those with a history of venous insufficiencyor thrombosis in the affected limb. This is because theflap depends on the delicate septal perforators that mayor may not be present in these patients. Patients withtrauma to the volar forearm that may have damaged theperforators are also unsuitable candidates for this flap.

SURGICAL ANATOMYBlood supply to the skin of the forearm is provided bycutaneous branches of the brachial artery and musculo-cutaneous and septocutaneous perforators of the radial

FIGURE 1: The radial artery perforator flap provides volarcoverage of the forearm and hand proximal to the distal palmarcrease (pink) and dorsal coverage of the radial two-thirds of theforearm and hand proximal to the metacarpophalangeal joints(green). The pivot point of the flap is 2 to 4 cm proximal to theradial styloid process (red circle).

and ulnar arteries. These vessels anastomose around the

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deep fascia of the forearm to form vascular plexusesthat supply the overlying skin.

The radial artery at the distal forearm emerges su-perficially in the septum between the brachioradialisand the flexor carpi radialis tendons to give off about 10small perforating vessels (0.3 to 0.5 mm in diameter)about 2 to 4 cm proximal to the radial styloid process5

(Fig. 2). These septocutaneous perforators form a lon-gitudinal chain-linked vascular plexus along the courseof the artery that can be developed as an adipofascialpedicle for distal forearm flaps. Venous return from thedeep fascia is accomplished via the profunda venaecomitantes through the perforating veins of the fore-arm.6 Sensate flaps can be raised using the lateral an-tebrachial cutaneous nerve.

Several studies have investigated the role of preop-erative imaging of the perforator vessels to assess thevascular anatomy and to facilitate flap design. Imagingmodalities studied include magnetic resonance angio-gram, computed tomography angiography, subtractionangiography, color duplex ultrasound, and radionuclideimaging.7 However, most studies revealed that limita-tions in the image resolution render the reliable delin-eation of the small perforators that originate from fore-arm vessels a difficult task. Thus, preoperative imagingis deemed low-yield and not cost-effective and is notroutinely obtained. Intraoperative exploration remainsthe only reliable method to accurately determine thelocation of the radial perforators.7

SURGICAL TECHNIQUEThe patient is placed supine on the operating table. Thesurgical hand is placed on a well-padded arm board,

FIGURE 2: The radial artery (RA) travels in the septum betweenthe brachioradialis (BR) and flexor carpi radialis (FCR) tendonsin the distal forearm. It gives off several septocutaneousperforators (P) about 2 to 4 cm proximal to the radial styloid tosupply the radial artery perforator flap (RAPF).

and a brachial tourniquet is applied. After appropriate

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debridement of the soft tissue wound, the size andlocation of the defect are noted.

To raise an adipofascial flap, a curvilinear skin inci-sion along the axis of the radial artery is made over thevolar forearm, and the skin is elevated off the underly-ing fat and fascia. Next, a 3- to 4-cm-wide adipofascialflap that includes the deep fascia, antebrachial nerve,and cephalic vein is raised from a proximal to distaldirection as far as the distal pivot point, leaving theradial artery intact. The perforator vessels in the prox-imal forearm can be ligated as needed to allow anadequate arc of rotation of the flap. To avoid injury, thedistal perforating vessels used to supply the flap are notisolated or skeletonized. Care is taken to preserve theintegrity of the superficial radial nerve and its branches.

To raise an adipofasciocutaneous flap, a skin islandis marked over the proximal volar forearm, with thepivot point about 2 to 4 cm proximal to the radialstyloid. A curvilinear incision is designed between theisland and the pivot point that will allow elevation ofthin skin flaps to expose the adipofascial pedicle. Next,the island flap is raised from proximal to distal on a 3-to 4-cm-wide pedicle similar to that described above,leaving the radial artery intact. If a sensate flap isdesired, neurotization of the flap can be performed byidentifying a length of the lateral antebrachial cutaneousnerve and elevating it along with the flap. After neu-rorrhaphy and rotation of the flap, the transected end ofthe antebrachial nerve is sutured to a suitable sensorynerve recipient using microsurgical technique.

Controversy exists as to whether the cephalic veinshould be ligated at the base of the pedicle. Proponentsargue that there is ongoing net venous inflow to the flapfrom the large subcutaneous veins that may exceed theoutflow capacity of the smaller valveless venous chan-nels that communicate with the venae comitantes of theradial artery, resulting in venous congestion.5 In addi-tion, it has been shown that there is no positive role ofthe cephalic vein in the venous drainage of this flap.5

Others maintained that the vascular plexus accompany-ing the cephalic vein contributes to the flap perfusionand should not be sacrificed.8

After the pedicle is raised, the proximal end of theflap is transected, and the flap is transposed and insetalong similar lines to the retrograde radial forearmfascial flap. While the flap can be passed through asubcutaneous tunnel to the distal defect, given the wideadipofascial pedicle that must be raised with this flapalong with the lower arterial perfusion pressures, it isgenerally safer to incise the skin between the pivot pointand the recipient site and to place skin graft over the

bulky pedicle.

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The flap is then inset into the defect. The forearmdonor site can be closed primarily if the width of thedefect is less than 3 cm or skin grafted if the donordefect is larger. An intraoperative Doppler examinationis performed, and the location on the skin where aDoppler signal can be obtained is marked to facilitatepostoperative monitoring. Moist noncompressive dress-ing is applied to the donor and recipient sites, and awell-padded short-arm splint is applied for tissue stabi-lization.

REHABILITATION AND POSTOPERATIVE CAREOur routine postoperative protocol for flap reconstruc-tion includes core warming and adequate hydration ofthe patient to minimize vascular spasm, intravenousantibiotics, appropriate pain control measures includingregional nerve blocks and patient-controlled analgesicdevices, and prophylaxis against deep venous thrombo-sis. Sequential clinical examinations of the flap forarterial insufficiency and venous congestion as well asDoppler examinations are diligently performed. Thepatient typically stays in the hospital for 2 to 3 days

FIGURE 3: A radial artery perforator fascial flap (RAPF) wasraised in a proximal to distal fashion to cover a defect over themedian nerve (M) without sacrificing the radial artery (RA).FCR, flexor carpi radialis.

before being discharged. Gentle range of motion exer-

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cises can be initiated once the flap is stable, about 2weeks after reconstruction.

POTENTIAL COMPLICATIONSComplications with perforator flaps may be higher thanwith traditional axial flaps, secondary to the delicatenature of the perforator vessels and the weaker plexusperfusion. In a retrospective review of 68 forearm per-forator flaps, Matei et al. reported partial flap epider-molysis in 12% of cases, which the authors attributed totransitory venous congestion.9

CLINICAL CASEThis patient had median nerve exploration and tumorresection and required coverage of a superficial andsensitive median nerve. Soft tissue coverage was per-formed using a radial artery perforator fascial flap. Theflap was elevated from a proximal to distal fashion(Fig. 3) until the fascial flap could be transposed tocover the defect over the exposed median nerve (Fig.

FIGURE 4: One of several perforators (P) from the radialartery (RA) supplying the radial artery perforator flap (RAPF)that was transposed to cover a defect at the carpal tunnel.FCR, flexor carpi radialis.

4). The radial artery was preserved during the harvest.

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The flap healed with no apparent complications, and thepatient noted a marked decrease in median nerve sen-sitivity after flap coverage.

PEARLS AND PITFALLS

● The radial artery perforator flap is an alternative tothe radial forearm flap that can be used to coverhand and forearm soft tissue defects.

● No preoperative Allen’s test is required, althoughpatency of the radial artery at the wrist is necessary.

● The plexus-driven blood supply makes this a suit-able flap for covering medium-sized defects in theforearm and hand proximal to the metacarpopha-langeal joints.

● The perforating vessels need not be dissected whenraising the flap.

● More proximal perforators can be sacrificed andligated as needed to allow adequate arc of rotationof the flap.

● Subcutaneous tunneling of the flap under an intactskin bridge may compromise the vascularity of theflap. We recommend incising the skin between thepivot point and the recipient site and skin graftingthe transferred pedicle if needed.

● Sensate flaps can be accomplished using the lateralantebrachial cutaneous nerve.

REFERENCES1. Page R, Chang J. Reconstruction of hand soft-tissue defects: alterna-

tives to the radial forearm fasciocutaneous flap. J Hand Surg 2006;31A:847–856.

2. Zhang YT. The use of reversed forearm pedicled fascio-cutaneous flapin the treatment of hand trauma and deformity (report of 10 cases).Chin J Plast Surg Burns 1988;4:41–42.

3. Georgescu AV, Matei I, Ardelean F, Capota I. Microsurgical nonmi-crovascular flaps in forearm and hand reconstruction. Microsurgery2007;27:384–394.

4. Martin JP, Chambers JA, Long JN. Use of radial artery perforator flapfrom burn-injured tissues. J Burn Care Res 2008;29:1009–1011.

5. Chang SM, Hou CL, Zhang F, Lineaweaver WC, Chen ZW, Gu YD.Distally based radial forearm flap with preservation of the radialartery: anatomic, experimental, and clinical studies. Microsurgery2003;23:328–337.

6. Tiengo C, Macchi V, Porzionato A, Bassetto F, Mazzoleni F, De CaroR. Anatomical study of perforator arteries in the distally based radialforearm fasciosubcutaneous flap. Clin Anat 2004;17:636–642.

7. Lee GK. Invited discussion: harvesting of forearm perforator flapsbased on intraoperative vascular exploration: clinical experiences andliterature review. Microsurgery 2008;28:331–332.

8. Nakajima H, Imanishi N, Fukuzumi S, Minabe T, Aiso S, Fujino T.Accompanying arteries of the cutaneous veins and cutaneous nervesin the extremities: anatomical study and a concept of the venoadipo-fascial and/or neuroadipofascial pedicled fasciocutaneous flap. PlastReconstr Surg 1998;102:779–791.

9. Matei I, Georgescu A, Chiroiu B, Capota I, Ardelean F. Harvesting offorearm perforator flaps based on intraoperative vascular exploration: clinical

experiences and literature review. Microsurgery 2008;28:321–330.

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