The Ideal Upper Extremity Flap for Soft Tissue Defects, Radial Artery Perforator Adipofascial Flap

Purpose: The ideal requirements for soft tissue coverage of the upper extremity are a thin, pliable, durable flap with minimal donor site morbidity that allows early functional rehabilitation and protection.  Common flap options for coverage include the reverse radial artery flap, reverse lateral arm flap, pedicle latissmus and posterior interosseus flap.  Drawbacks of these flaps include sacrifice of the radial or ulnar artery, donor site morbidity, bulky flaps requiring secondary thinning, non-aesthetic donor sites, and inability to provide sensate coverage. We report our series of five adipofascial radial artery perforator flaps for the upper extremity.   A modification to the proximal forearm fascial flap allows the flap to be harvested as a neurosensory flap. The thin, pliable and preservation of the radial and ulnar artery make the adipofascial perforator flap the ideal flap for the upper extremity.

Methods: We present our experience of 5 cases with the adipofascial forearm flap for upper extremity soft tissue defects including dorsal hand or proximally base wounds of the elbow. The proximally based flaps were based 4cm distally to the anticubital fossa while the distally based flap was based 2 cm from the radial styloid. The adipofascial flaps were raised in a retrograde fashion from the pivot point.  The flaps were subsequently skin grafted and the donor sites closed primarily.

Experience: Two patients had traumatic defects of the elbow and these two case represent the first description of the neurosensory proximally based radial artery perforator adipofascial flap.  Three patients were treated for dorsal hand coverage or soft tissue reconstruction from infectious or traumatic defects.  None of the patients needed secondary thinning or flap revisions. 

Summary: The adipofascial forearm flap is an extremely versatile flap for soft tissue coverage of the upper extremity with excellent outcomes. The forearm fascial flap provides coverage of the upper extremity without sacrificing any major arteries to the hand.  Donor site morbidity is minimal as the adipofascial nature of the flap allows primary closure of the donor site.  Further benefits include a shorter operative time, no microsurgery requirements, aesthetically pleasing contour for the hand with out the need for secondary procedures and early range of motion for patients.  

Conclusion: The adipofascial forearm perforator flap has become our choice for coverage of upper extremity soft tissue defects.