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Anatomical variations in forearm vascular anatomy
Journal of Cranio-Maxillo-Facial Surgery (2010) 38, 244 Ó 2009 European Association for Cranio-Maxillo-Facial Surgery doi:10.1016/j.jcms.2009.09.003, available online at http://www.sciencedirect.com
Letter to the Editor Anatomical variations in forearm vascular anatomy
Sir, I recently reported a case of aberrant forearm vascular anatomy with a brief review of the literature on anomalies and variations of the radial artery (Bhatt et al., 2009). A year further into my training, I have encountered a further case of anatomical aberrance, this time of the ulnar vessels. Perhaps the incidence of anomalies of forearm vasculature is higher than reported. CASE REPORT A 51 year old gentleman underwent reconstruction of the cutaneous component of the left lower lip and chin following Moh’s chemosurgery for a T2N0 adnexal carcinoma with a free forearm flap. Preoperative Allen’s test determined good collateral flow. Harvesting of the flap was commenced from the ulnar aspect as standard. No sooner had the incision been made when a very superficial artery accompanied by venae commitantes was encountered. The tourniquet was released and vascular clamps and intraoperative Doppler examinations confirmed this vessel to be the ulnar artery running superficially just below the fascia and between the flexor carpi ulnaris and flexor digitorum superficialis tendons. Further careful dissection revealed that this vessel was the dominant supply of the skin paddle and the flap was therefore raised based on the ulnar artery (Fig. 1). The radial vessel was found in its normal position and was left undisturbed.
Fig. 1 e Forearm fasciocutaneous flap raised on the superficial ulnar vessel.
This case highlights once again the need for reconstructive surgeons to remain particularly vigilant when harvesting a forearm flap. References Bhatt V, Green J, Grew N: Dealing with aberrant vessels in radial forearm flaps e report of a case and review of literature. J Craniomaxillofac Surg 37(2): 87e90, 2009 Mar Devansh S: Superficial ulnar artery flap. Plast Reconstr Surg 97(2): 420e426, 1996 Feb Fatah MF, Nancarrow JD, Murray DS: Raising the radial artery forearm flap: the superficial ulnar artery ‘‘trap’’. Br J Plast Surg 38(3): 394e395, 1985 Jul Sieg P, Jacobsen HC, Hakim SG, Hermes D: Superficial ulnar artery: curse or blessing in harvesting fasciocutaneous forearm flaps. Head Neck 2006 Thoma A, Young JE: The superficial ulnar artery ‘‘trap’’ and the free forearm flap. Ann Plast Surg 28(4): 370e372, 1992
DISCUSSION Superficial ulnar artery is a known abnormality. It replaces the normal ulnar artery and has a superficial course. Its accidental division during the raising of the radial forearm flap can seriously jeopardize hand circulation. Anomalies of the ulnar artery have been previously reported (Fatah et al., 1985; Thoma and Young, 1992; Devansh, 1996). In cadaver dissections the incidence is reported to be 9.3%. Free flaps raised on such a vessel have also been reported (Devansh, 1996; Sieg et al., 2006). This variation is probably encountered in clinical practice more commonly, but it is not recognized. Identification of this anomalous artery is facilitated by elevating but not exsanguinating the forearm prior to harvesting the flap.
Vyomesh Bhatt* 86 Presthope Road, Birminghman B29 4NL, United Kingdom * Tel.: +44 78 0392 2649; Fax: +44 12 1475 1165 E-mail: [email protected] Paper received 21 February 2009 Accepted 9 September 2009
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Letter to the Editor Anatomical variations in forearm vascular anatomy
Sir, I recently reported a case of aberrant forearm vascular anatomy with a brief review of the literature on anomalies and variations of the radial artery (Bhatt et al., 2009). A year further into my training, I have encountered a further case of anatomical aberrance, this time of the ulnar vessels. Perhaps the incidence of anomalies of forearm vasculature is higher than reported. CASE REPORT A 51 year old gentleman underwent reconstruction of the cutaneous component of the left lower lip and chin following Moh’s chemosurgery for a T2N0 adnexal carcinoma with a free forearm flap. Preoperative Allen’s test determined good collateral flow. Harvesting of the flap was commenced from the ulnar aspect as standard. No sooner had the incision been made when a very superficial artery accompanied by venae commitantes was encountered. The tourniquet was released and vascular clamps and intraoperative Doppler examinations confirmed this vessel to be the ulnar artery running superficially just below the fascia and between the flexor carpi ulnaris and flexor digitorum superficialis tendons. Further careful dissection revealed that this vessel was the dominant supply of the skin paddle and the flap was therefore raised based on the ulnar artery (Fig. 1). The radial vessel was found in its normal position and was left undisturbed.
Fig. 1 e Forearm fasciocutaneous flap raised on the superficial ulnar vessel.
This case highlights once again the need for reconstructive surgeons to remain particularly vigilant when harvesting a forearm flap. References Bhatt V, Green J, Grew N: Dealing with aberrant vessels in radial forearm flaps e report of a case and review of literature. J Craniomaxillofac Surg 37(2): 87e90, 2009 Mar Devansh S: Superficial ulnar artery flap. Plast Reconstr Surg 97(2): 420e426, 1996 Feb Fatah MF, Nancarrow JD, Murray DS: Raising the radial artery forearm flap: the superficial ulnar artery ‘‘trap’’. Br J Plast Surg 38(3): 394e395, 1985 Jul Sieg P, Jacobsen HC, Hakim SG, Hermes D: Superficial ulnar artery: curse or blessing in harvesting fasciocutaneous forearm flaps. Head Neck 2006 Thoma A, Young JE: The superficial ulnar artery ‘‘trap’’ and the free forearm flap. Ann Plast Surg 28(4): 370e372, 1992
DISCUSSION Superficial ulnar artery is a known abnormality. It replaces the normal ulnar artery and has a superficial course. Its accidental division during the raising of the radial forearm flap can seriously jeopardize hand circulation. Anomalies of the ulnar artery have been previously reported (Fatah et al., 1985; Thoma and Young, 1992; Devansh, 1996). In cadaver dissections the incidence is reported to be 9.3%. Free flaps raised on such a vessel have also been reported (Devansh, 1996; Sieg et al., 2006). This variation is probably encountered in clinical practice more commonly, but it is not recognized. Identification of this anomalous artery is facilitated by elevating but not exsanguinating the forearm prior to harvesting the flap.
Vyomesh Bhatt* 86 Presthope Road, Birminghman B29 4NL, United Kingdom * Tel.: +44 78 0392 2649; Fax: +44 12 1475 1165 E-mail: [email protected] Paper received 21 February 2009 Accepted 9 September 2009
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