Reverse Radial Forearm Flap.

Supplemental Digital Content is available in the text.

The reverse radial forearm (RRF) flap can be used to cover moderate-sized defects of the dorsal or volar hand extending to the metacarpophalangeal joints as well as for treatment of median nerve neuromas.[1] For proximal volar defects, a perforator-based variant can be employed, avoiding violation of the radial artery (RA).[2,3] It can be harvested as a fasciocutaneous flap or a fascia-only flap.

AIM

In these videos, we will concentrate on safely elevating the RRF fasciocutaneous flap and the RRF fascia-only flap.

1. Preparation:

a. Step 1: Allen’s test to assess for an intact palmar arch.

b. Step 2: The course of the RA is marked. Distally, the major perforators are marked.

c. Step 3: The length from the defect to the pivot point of the RA is measured to determine the required pedicle length.

METHODS

For steps 1–3, see video, Supplemental Digital Content 1, which discusses the preoperative considerations, including possible alternative reconstructive options, indications for a RRF flap, and Allen’s test, http://links.lww.com/PRSGO/A401.

See video, Supplemental Digital Content 1, which discusses the preoperative considerations, including possible alternative reconstructive options, indications for a RRF flap, and Allen’s test. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A401.

2. Fascia-only flap:

a. Step 1: A curvilinear incision is made, and the skin is elevated from the flexor carpi ulnaris to the brachioradialis.

b. Step 2: The exposed fascia is incised over flexor carpi ulnaris and elevated, proceeding radially to the radial border of the flexor carpi radialis tendon, skeletonizing underlying muscles and tendons to ensure the fascia is not damaged.

c. Step 3: The fascia is raised off the ulnar border of the brachioradialis tendon, without violating the perforators entering the fascia. Care should be taken to identify and preserve the radial sensory nerve.

d. Step 4: The RA is identified and ligated proximally, and the fascia is elevated with the artery from proximal to distal. For proximal volar defects, the fascial flap can be raised on distal radial perforators, in which case the RA is preserved.

e. Step 5: The flap is passed through a subcutaneous tunnel to the defect, taking care to ensure the pedicle is not kinked. After inset, the flap is covered with a skin graft and the donor site closed.

For steps 1–5, see video, Supplemental Digital Content 2, which demonstrates the surgical technique for elevation and inset of a radial forearm fascia-only flap, http://links.lww.com/PRSGO/A402.

See video, Supplemental Digital Content 2, which demonstrates the surgical technique for elevation and inset of a radial forearm fascia-only flap. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A402.

3 Fasciocutaneous flap:

a. Step 1: Fasciocutaneous flaps are marked based on the defect size and pedicle length required to ensure an adequate arc of rotation. One-third of the flap is radial to the RA and two-third is ulnar.

b. Step 2: The skin is incised circumferentially, and the flap is elevated deep to the fascia starting at the ulnar border, as described for the fascia-only flap.

c. Step 3: The fascia of the pedicle is exposed before the radial aspect of the fascia is elevated off the brachioradialis.

d. Step 4: In most instances, a skin graft on the donor site is required. Care should be taken to ensure that the flexor carpi radialis tendon has paratenon and/or soft-tissue cover.

For steps 1–4, see video, Supplemental Digital Content 3, which demonstrates the surgical technique for elevation and inset of a radial forearm fasciocutaneous flap, http://links.lww.com/PRSGO/A403.

See video, Supplemental Digital Content 3, which demonstrates the surgical technique for elevation and inset of a radial forearm fasciocutaneous flap. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A403.

RESULTS

Fasciocutaneous flaps allow for staged tendon reconstruction. Fascia-only flaps provide a good thickness match for the dorsal skin (see video, Supplemental Digital Content 4, which discusses postoperative dressings, flap management, and potential complications, http://links.lww.com/PRSGO/A404).

See video, Supplemental Digital Content 4, which discusses postoperative dressings, flap management, and potential complications. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A404.

CONCLUSION

The RRF flap provides an effective and versatile reconstructive option for upper extremity soft-tissue defects.