The bottom-up approach to the suprafascial harvest of the radial forearm flap.

Suprafascial radial forearm flaps cause far less donor morbidity compared with the conventional method of including the deep fascia. Here we describe our technique of harvesting the flap with a bottom-up approach, which simplifies flap elevation and is safe and expedient. The radial artery pedicle is ligated distally and secured to the flap. Gentle traction on the pedicle presents the inferior surface of the pedicle, facilitating dissection. The superficial layer of the deep fascia is taken with the flap, together with a generous cuff of subcutaneous tissue above the pedicle in which vessels nourishing the flap are located. It is crucial to preserve the conjoin of the deep layer of the deep fascia to the fascia covering the brachioradialis laterally and flexor carpi radialis medially. This fascial layer prevents bow-stringing of the tendons during wrist and finger flexion and allows the use of a full-thickness skin graft to close the donor site. The latter delivers superior cosmetic results than can be achieved with a split-thickness skin graft.