British Journal of Plastic Surgery (1983) 36.428-433 0 1983 The Trustees of British Association of Plastic Surgeons

The antecubital fascia-cutaneous flap

B. G. H. LAMBERTY and G. C. CORMACK

Department of Plastic Surgery, Addenbrooke’s Hospital, Cambridge and the Department of Anatomy, University of Cambridge

Summary-A clinical case is reported in which a fascia-cutaneous forearm pedicled flap was used. The flap was based on the previously described inferior cubital artery. Anatomical studies suggested that this vessel could be the basis for a fascia-cutaneous free flap possessing an exceptionally long vascular pedicle. This flap is described and its implications flap.

Recent anatomical studies of the vascular terri- tories of the forearm suggested that a significant length to breadth fascia-cutaneous flap could be raised on the inferior cubital artery (Lamberty and Cormack, 1982). This paper demonstrates this flap in clinical use, firstly as a pedicled flap and secondly as a free flap.

Case 1

A 69-year-old man presented with a squamous cell

discussed in relation to the radial forearm (Chinese)

carcinoma on the dorsum of his right forearm, which had failed to respond to radiotherapy.

The tumour was excised including the deep fascia and adjacent muscle. The periosteum over the radius appeared free of tumour and was preserved. The defect was closed with a split skin graft. Despite apparent histological clearance, an ulcerated area persisted over the radius (Fig. 2). This was excised together with the periosteum and histological examination confirmed complete excision of the residual tumour. The defect was closed with a fascia-cutaneous antecubital flap (Figs. l-4). The flap measured 4 x 17 cm and was based on the

Fig. 3 Fig. 4

Figures l-4-A squamous cell carcinoma on the forearm which was excised and for which an antecubital fascia-cutaneous pedicled flap was used as part of the surgical reconstruction (see text for details).

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THE ANTECUBITAL FASCIO-CUTANEOUS FLAP 429

inferior cubital artery. This vessel arises 4 cm below the mid-point of the inter-epicondylar line and its detailed anatomy has already been described (Lamberty and Cormack, 1982).

The flap was drawn on the forearm (Fig. 1) and the skin incision carried down through subcutaneous fat and deep fascia. The flap was raised from its distal and medial sides, to include the deep fascia. The inter- muscular septum between brachioradialis and flexor carpi radialis and flexor digitorum superficialis was divided deep between the muscles from distally to proximally. In the proximal part of the flap, care was taken not to divide the inferior cubital vessel as it coursed through the intermuscular septum from its origin from the radial artery (Fig. 3). The vessel was

visualised by transillumination. The flap was transposed and the secondary defect grafted with split skin.

Case 2 A 66-year-old man presented with a histologically proven squamous cell carcinoma involving the left pinna and external auditory meatus. Excision involved removal of soft tissue, part of the temporal bone, the zygoma and the temporo-mandibular joint. The defect was closed using an antecubital free flap (Figs. S-8).

The flap was raised initially as a standard “Chinese” flap as described by Miihlbauer ef al. (1982) and Soutar et al. (1983) as shown in the intra-operative photographs (Figs. 5 and 6). The distal radial fascial perforators were then divided (Fig. 6) leaving the inferior cubital vessel as

Fig. 5 Fig. 6

Fig. 7 Fig. 8

Figures 5-b--Reconstruction of a facial defect with an antecubital fascia-cutaneous free flap. Note the radial artery (Fig. 7, arrow A) dissected from the distal end of the flap (Fig. 7, arrow B).

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Fig. 9

Figure 9-Cadaver injection of anterior forearm skin. The inferior cubital artery is seen at the top of the radiograph. In the distal half of the specimen the fascia-cutaneous perforators show a marked transverse orientation.

the only artery supplying the skin paddle. The radial end of the divided facial artery to the proximal end of the artery can be seen dissected free from the distal part of radial artery. The distal end of the radial artery was the flap (Fig. 7). looped back to be anastomosed to the distal end of the

The radial artery was divided between arterial clamps facial artery. The cephalic vein was anastomosed to the and the flap finally freed by division of the cephalic and posterior facial vein at a Y junction of each by two basilic veins. venous anastomoses. The flap survived without any

The flap was set in place, anastomosing the proximal complications (Fig. 8).

THE ANTECUBITAL FASCIO-CUTANEOUS FLAP

Anatomical study

A total of 25 preserved cadaver limbs were studied by gross anatomical dissection techniques to in- vestigate whether or not there were valves present in the venae comitantes of the radial artery. In no case were valves found to be present.

A further study was carried out on fresh cadaver limbs, in which barium sulphate suspension was injected after elevation of the antecubital flap as a

Length of pedlcle

The forearm (Chinese) fasclocutaneous free flap

Fig. 10

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vessel. Ideally, the axial line of this flap lies along the cephalic vein, being directed from the origin of the vessel below the mid-inter-epicondylar point to the radial styloid process. In the first example reported here, the midline of the flap was neces- sarily in the mid-forearm line because of the

Long pedlcle

:’

Long flap !I : /

The antecubltal fasclocutaneous free flap

Fig. 11

Figure IO-In the Chinese fascia-cutaneous free flap, as the flap is increased in size from A to B the length of the pedicle decreases fromatob.

Figure 1 l--In the antecubital fascia-cutaneous free flap, the length of the pedicle is independent of the flap length. Note also that blood flow in the radial artery can be reversed.

free forearm flap based on the radial artery. It was found that diluted micropaque injected into the radial artery penetrated the flap and drained via the cephalic vein.

Discussion

Our recent investigation of the blood supply to forearm skin showed that an undelayed fascio- cutaneous flap of useful length to breadth ratio could theoretically be raised on the inferior cubital

previous skin graft (Fig. 1). Despite the axial flap line not following the known central position of the axial fascial inferior cubital artery, the flap survived on a 4 to 1 length to breadth ratio. The clinical use of this flap bears out the anatomical predictions and supports the validity of post- mortem anatomical studies in the search for new flaps and flap design. This flap has a wide arc of rotation and can be used for local flap cover to the elbow or as a distant flap.

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The use of this flap has wider application in the context of the forearm radial artery free flap or a “Chinese” flap (Yang Guofan et al., 1981). In our anatomical study (Lamberty and Cormack, 1982), we showed that in 37 dissected cadaver arms the inferior cubital vessel arose in 21 instances from the radial artery and in 16 instances from the radial recurrent artery. We predicted, on anatomical grounds, that a free forearm flap based on the inferior cubital artery alone and incorporating also the proximal end of the radial artery and, if necessary a portion of the radial recurrent artery, would be successful.

Venous drainage of such a free forearm flap would be by the cephalic vein and the venous pedicle could be made extremeIy long by proximal

Brachlal

Radial recurrent ii

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versatility in flap orientation at the recipient site. In the excisional defect demonstrated here, through flow in the radial artery could not have been achieved using a Chinese flap without using a vein graft. Through flow (Soutar et al., 1983) appears to make both this flap and the Chinese flap a better physiological entity than a flap with a unipedicled arterial input. We feel that this will significantly reduce circulatory complications.

It should be noted that there is inadequate communication between the superficial veins of the proximal forearm and the venae comitantes of the radial artery. Venous drainage of this flap, is, therefore, advocated via the cephalic vein rather than via reverse flow in the radial venae comi- tantes. We have, however, shown that on ana-

Radial

A. B

Fig. 12

C.

Figure 12-Variations in the manner of origin of the inferior cubital artery. Type C precludes the possibility of raising an antecubital radial artery free flap.

dissection of the cephalic vein right up to the deltopectoral groove.

The current design of a fascia-cutaneous skin flap raised on the radial artery depends for its blood supply on septal perforators. In the proxi- mal one-third of the forearm these lie between brachioradialis and pronator teres and in the distal two-thirds between brachioradialis and flexor carpi radialis or flexor digitorum superficialis. In the distal part of the forearm these perforators are small and their axiality is directed transversely (Fig. 9). In raising the current design of forearm free flap, the length of the arterial pedicle is inversely related to the size of the skin flap (Fig. 10). A flap based on the inferior cubital vessel enables a large skin flap to be used together with a long vascular pedicle (Fig. 11) thereby overcoming one of the constraints of the present design and also, by virtue of the long pedicle, allowing greater

tomical grounds this reverse flow is possible in the Chinese flap.

There are two situations in which this flap would not be feasible. Firstly in the absence of a signifi- cantly sized inferior cubital artery and secondly in the presence of such an artery when it arose from a radial recurrent which had its point of origin from the brachial artery rather than the radial artery (Fig. 12). This is rare. The presence of the inferior cubital vessel can be demonstrated by pre- operative angiography or by direct vision at the time of operation.

Acknowledgements

Wewouldliketo thank Mr R. Overhill, AIMBI, Mr J. Bashford, Mr T. Crane and Mrs R. Cooper for the preparation of the illustrations and Mrs P. Morley for the preparation of the manuscript.

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References The Authors

Lamberty, B. G. H. and Cormack, G. C. (1982). The forearm B. G. H. Lamberty, MA, FRCS, Consultant Plastic Surgeon, angiotomes. British Journal of PIosric Surgery, 35, 4. Addenbrooke’s ffospital, Cambridge.

Miihlbauer, W., Herndl, E. and Stock, W. (1982). The forearm G. C. Cormack, FRCS(Ed), Department of Anatomy, flap. Plastic and Reconstructive Surgery, 70, 336. University of Cambridge, Cambridge.

Soutar, D. S., Scheker, L. R., Tanner, N. S. B. and McGregor, 1. A. (1983). The radial forearm flap: a versatile method of intra-oral reconstruction. British Journal of Plastic Surgery, 36,l. Requests for reprints to: Mr B. G. H. Lamberty, FRCS,

Yang, Guofan et al. (1981). Forearm free skin flap trans- Addenbrooke’s Hospital, Trumpington Street, Cambridge CB2 plantation. NationalMedical Journal of China, 61, 139. 1QE.

This paper forms part of an essay entitled “Fascia-cutaneous Vessels” which was awarded joint First prize in the clinical category for the 1983 Scholarship Contest awarded by the Plastic Surgery Educational Foundation of the United States of America.