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Free ulnar artery forearm flap: a modification
356
British Journal of Plastic Surgery
British Journal of Plastic Surgery (2002) 9 2002 The British Association of Plastic Surgeons doi: 10.1054/bjps.2002.3837
Free ulnar artery forearm flap: a modification P. M. Arnstein and J. S. Lewis
Department of Plastic and Reconstructive Surgery, The Queen Victoria Hospital, East Grinstead, UK SUMMARY.
We describe a modification of the free ulnar artery forearm flap that has the benefit of the anastomosis of large-calibre vessels and the reassurance of a reconstructed ulnar artery for perfusion of the donor hand. 9 2002 The British Association of Plastic Surgeons
Keywords: free flap, ulnar artery, modification.
In certain patients where only a small free flap with a short pedicle is required, the modification of the free ulnar artery forearm flap presented here is technically straightforward and quick to perform. The free ulnar artery forearm flap was first described by Lovie et al in 1984,1 and continues to be hailed as a reliable, versatile and convenient fasciocutaneous flap. 2'3 The donor site can usually be easily closed directly or with a skin graft. Flaps based on the medial aspect of the forearm are thin, pliable and virtually hail"less, and the donor site is less obvious than its radial counterpart. The ulnar artery forearm flap is a flap of skin and fascia with the potential to include muscle or bone. It is based on the segment of the ulnar artery distal to the common interosseous branch. There are two to four skin perforators linked to the main pedicle through the fascia; these lie 15-25 m m apart. The venous drainage is via the venae comitantes of the ulnar artery or via the superficial system of veins. The cutaneous component can include a very small area overlying any of the cutaneous pedicles or almost the entire aspect of the forearm passing onto the ulnar border. In our modified flap, a 1 cm segment of ulnar artery is raised with the septocutaneous perforator, which supplies the fasciocutaneous flap.
the hand via the radial artery is verified. The flap is raised after reinflation of the tourniquet.
Case report A 34-year-old man presented with an ulcer on the posterior aspect of his heel, which had been present for 8 months. The Achilles tendon was exposed in the base of the wound. The posterior tibial, peroneal and dorsalis pedis arterial pulses were palpable. After debridement of the ulcer, the defect measured 9 cm x 5 cm. A free fasciocutaneous flap based on a septocutaneous perforator of the ulnar artery and the accompanying venae comitantes, 8 cm proximal to the pisiform, was raised together with a 1 cm segment of the ulnar artery (Figs 1 and 2). The ends of the donor ulnar artery were anastomosed to restore continuity of the vessel. At the recipient site, the flap was inset into the defect. The posterior tibial artery and a superficial vein were identified as recipient vessels. The posterior tibial artery was transected, and the segment of ulnar artery was interposed between the ends. The larger of the venae comitantes of the ulnar artery was anastomosed end-to-side to the superficial vein at the recipient site. The flap healed uneventfully. At 17 months, an Allen's test showed that the reconstructed donor-site ulnar artery at the wrist was patent, as was the radial artery. There was no sensory deficit in the donor hand, wrist or forearm, and the patient had returned to his previous job as a builder.
Surgical technique An Allen's test is used to assess the vascularity of the hand. The courses of the ulnar artery and a nearby cutaneous vein are marked on the skin. An arm tourniquet is inflated following elevation of the upper limb. The flap is planned to overlie the perforator situated 8-10 cm from the pisiform. The first incision is on the ulnar side of the flap. Dissection is carried out in the subfascial plane in order to identify both the septum between the flexor carpi ulnaris and the flexor digitornm superficialis, and a suitable skin perforator within it. If a perforator is not found, the dorsal branch of the ulnar artery, which is situated in the fascial septum between the flexor carpi ulnaris and the ulna more posteriorly, is located and the flap is based on this vessel instead. After identification of the perforator and the ulnar artery, a microvascular clamp is applied to the ulnar artery and the adequacy of the blood flow to
Figure 1 The free ulnar artery forearm flap. Note the clamps on the ulnar artery on either side of the perforator supplyingthe flap.
Free ulnar artery forearm flap
357 donor site (as compared with the radial artery forearm flap), simplicity, reliability and versatility. While there is the potential disadvantage of turbulent flow and thrombosis resulting from two anastomoses very close to each other (1 cm apart), it was not found to be a problem in this case. The anastomoses of the large-calibre ulnar artery to the posterior tibial artery at the recipient site provided an ideal size match and through-flow for the posterior tibial artery.
Acknowledgements We are grateful to the Photographic Departmentat The Queen Victoria Hospital for the illustrations,and to Alison Davies for her secretarial support.
Figure 2--The harvested flap, with a segmentof ulnar artery. References Discussion Flaps based on the ulnar artery have been widely used as pedicled, islanded or free flaps, and can be based proximally or distally. 1'4-8 It is possible to include a combination of fascia and skin, muscle, bone or nerve. The ulnar artery forearm flap is versatile, and has been used in upper and lower limb, penile, and head and neck reconstruction. Yii and Niranjan used pedicled fascial flaps based on a single fascial feeding vessel or 'perforator' arising from the ulnar artery to reconstruct 13 donor defects resulting from the harvesting of free radial forearm flaps. 5 They consistently found one or two fascial feeders 8 - 1 0 c m from the pisiform. Although there are other perforators along the length of the ulnar artery, the dissection is easier distally, where the artery is more superficial. Although Becker and Gilbert mentioned the possibility of raising a segment of the ulnar artery with the dorsal ulnar artery flap, 9 we have not heard of this procedure being used with a direct septocutaneous perforator from the ulnar artery. In about 10% of cases, t~ the course of the ulnar artery may be superficial. In these cases, the artery usually arises high up in the arm or at the intercondylar line of the humerus. It lies superficial to all the forearm flexor muscles, and gives off an average of four good-sized fasciocutaneous vessels before passing deep to the palmaris longus muscle if this is present. We would consider such an anomaly to be advantageous, as it would facilitate the dissection of the flap, even though it has been referred to as a 'trap' for the unwary. 11'12 Tonks et al have shown that the dominant blood supply to the hand is from the radial artery. 13 Despite this, routine vein grafting of the radial artery following elevation of a radial forearm flap is unnecessary, and only 59% of vein-grafted radial arteries remain patent. 14 One of the major advantages of the ulnar artery flap is that the major blood supply to the hand is left intact. In summary, therefore, this modification of the ulnar artery forearm free flap has the advantages of a preferable
1. Lovie MJ, DuncanGM, GlassonDW. The ulnar artery forearm free flap. Br J Plast Surg 1984; 37: 486-92. 2. KoshimaI, Iino T, Fukuda H, Soeda S. The free ulnar forearm flap. Ann Plast Surg 1987; 18: 24--9. 3. GrobbelaarAO, HarrisonDH. The distallybased ulnar artery island flap in hand reconstruction.J Hand Surg 1997; 22B: 204-11. 4. Li Z, Liu K, Cao Y. The reverse flow ulnar artery island flap: 42 clinicalcases. Br J Plast Surg 1989; 43: 256-9. 5. Yii NW, NiranjanNS. Fascial flaps based on perforators for reconstruction of defects in the distal forearm. Br J Plast Surg 1999; 52: 534--40. 6. GlassonDW, Lovie MJ. The ulnar island flap in hand and forearm reconstruction.Br J Plast Surg 1988;41: 349-53. 7. GuimberteauJC, Goin JL, PanconiB, SchuhmacherB. The reverse ulnar artery forearm island flap in hand surgery: 54 cases. Plast Reconstr Surg 1988; 81: 925-32. 8. Christie DRH, Duncan GM, Glasson DW. The ulnar artery free flap: the first 7 years. Plast Reconstr Surg 1994; 93:547-51. 9. Becker C, GilbertA. The ulnar flap - descriptionand applications. Eur J Plast Surg 1988; 11: 79-82. 10. Devansh. Superficialulnar artery flap. Plast Reconstr Surg 1996; 97: 420-6. i 1. Fatah MF, Nancarrow JD, Murray DS. Raising the radial artery forearm flap: the superficial ulnar artery 'trap'. Br J Plast Surg 1985; 38: 394-5. 12. Thoma A, Young JEM. The superficial ulnar artery 'trap' and the free forearm flap. Ann Plast Surg 1992; 28: 370-2. 13. TonksAM, Lawrence J, Lovie MJ. Comparisonof ulnar and radial arterial blood-flowat the wrist. J Hand Surg 1995; 20B: 240--2. 14. Boorman JG, Brown JA, Sykes PJ. Morbidity in the forearm flap donor arm. Br J Plast Surg 1987;40: 207-12.
The Authors Peter Michael Arnstein FRCS, Consultant Plastic Surgeon Jacqueline Saw Lewis FRCS (Plast), SpecialistRegistrar in Plastic Surgery The QueenVictoriaHospital, HoltyeRoad, East Grinstead, West Sussex RH19 3DZ, UK. Correspondenceto Mr P. M. Arnstein. Paper received 10 October 2001. Accepted 8 March 2002, after revision.
British Journal of Plastic Surgery
British Journal of Plastic Surgery (2002) 9 2002 The British Association of Plastic Surgeons doi: 10.1054/bjps.2002.3837
Free ulnar artery forearm flap: a modification P. M. Arnstein and J. S. Lewis
Department of Plastic and Reconstructive Surgery, The Queen Victoria Hospital, East Grinstead, UK SUMMARY.
We describe a modification of the free ulnar artery forearm flap that has the benefit of the anastomosis of large-calibre vessels and the reassurance of a reconstructed ulnar artery for perfusion of the donor hand. 9 2002 The British Association of Plastic Surgeons
Keywords: free flap, ulnar artery, modification.
In certain patients where only a small free flap with a short pedicle is required, the modification of the free ulnar artery forearm flap presented here is technically straightforward and quick to perform. The free ulnar artery forearm flap was first described by Lovie et al in 1984,1 and continues to be hailed as a reliable, versatile and convenient fasciocutaneous flap. 2'3 The donor site can usually be easily closed directly or with a skin graft. Flaps based on the medial aspect of the forearm are thin, pliable and virtually hail"less, and the donor site is less obvious than its radial counterpart. The ulnar artery forearm flap is a flap of skin and fascia with the potential to include muscle or bone. It is based on the segment of the ulnar artery distal to the common interosseous branch. There are two to four skin perforators linked to the main pedicle through the fascia; these lie 15-25 m m apart. The venous drainage is via the venae comitantes of the ulnar artery or via the superficial system of veins. The cutaneous component can include a very small area overlying any of the cutaneous pedicles or almost the entire aspect of the forearm passing onto the ulnar border. In our modified flap, a 1 cm segment of ulnar artery is raised with the septocutaneous perforator, which supplies the fasciocutaneous flap.
the hand via the radial artery is verified. The flap is raised after reinflation of the tourniquet.
Case report A 34-year-old man presented with an ulcer on the posterior aspect of his heel, which had been present for 8 months. The Achilles tendon was exposed in the base of the wound. The posterior tibial, peroneal and dorsalis pedis arterial pulses were palpable. After debridement of the ulcer, the defect measured 9 cm x 5 cm. A free fasciocutaneous flap based on a septocutaneous perforator of the ulnar artery and the accompanying venae comitantes, 8 cm proximal to the pisiform, was raised together with a 1 cm segment of the ulnar artery (Figs 1 and 2). The ends of the donor ulnar artery were anastomosed to restore continuity of the vessel. At the recipient site, the flap was inset into the defect. The posterior tibial artery and a superficial vein were identified as recipient vessels. The posterior tibial artery was transected, and the segment of ulnar artery was interposed between the ends. The larger of the venae comitantes of the ulnar artery was anastomosed end-to-side to the superficial vein at the recipient site. The flap healed uneventfully. At 17 months, an Allen's test showed that the reconstructed donor-site ulnar artery at the wrist was patent, as was the radial artery. There was no sensory deficit in the donor hand, wrist or forearm, and the patient had returned to his previous job as a builder.
Surgical technique An Allen's test is used to assess the vascularity of the hand. The courses of the ulnar artery and a nearby cutaneous vein are marked on the skin. An arm tourniquet is inflated following elevation of the upper limb. The flap is planned to overlie the perforator situated 8-10 cm from the pisiform. The first incision is on the ulnar side of the flap. Dissection is carried out in the subfascial plane in order to identify both the septum between the flexor carpi ulnaris and the flexor digitornm superficialis, and a suitable skin perforator within it. If a perforator is not found, the dorsal branch of the ulnar artery, which is situated in the fascial septum between the flexor carpi ulnaris and the ulna more posteriorly, is located and the flap is based on this vessel instead. After identification of the perforator and the ulnar artery, a microvascular clamp is applied to the ulnar artery and the adequacy of the blood flow to
Figure 1 The free ulnar artery forearm flap. Note the clamps on the ulnar artery on either side of the perforator supplyingthe flap.
Free ulnar artery forearm flap
357 donor site (as compared with the radial artery forearm flap), simplicity, reliability and versatility. While there is the potential disadvantage of turbulent flow and thrombosis resulting from two anastomoses very close to each other (1 cm apart), it was not found to be a problem in this case. The anastomoses of the large-calibre ulnar artery to the posterior tibial artery at the recipient site provided an ideal size match and through-flow for the posterior tibial artery.
Acknowledgements We are grateful to the Photographic Departmentat The Queen Victoria Hospital for the illustrations,and to Alison Davies for her secretarial support.
Figure 2--The harvested flap, with a segmentof ulnar artery. References Discussion Flaps based on the ulnar artery have been widely used as pedicled, islanded or free flaps, and can be based proximally or distally. 1'4-8 It is possible to include a combination of fascia and skin, muscle, bone or nerve. The ulnar artery forearm flap is versatile, and has been used in upper and lower limb, penile, and head and neck reconstruction. Yii and Niranjan used pedicled fascial flaps based on a single fascial feeding vessel or 'perforator' arising from the ulnar artery to reconstruct 13 donor defects resulting from the harvesting of free radial forearm flaps. 5 They consistently found one or two fascial feeders 8 - 1 0 c m from the pisiform. Although there are other perforators along the length of the ulnar artery, the dissection is easier distally, where the artery is more superficial. Although Becker and Gilbert mentioned the possibility of raising a segment of the ulnar artery with the dorsal ulnar artery flap, 9 we have not heard of this procedure being used with a direct septocutaneous perforator from the ulnar artery. In about 10% of cases, t~ the course of the ulnar artery may be superficial. In these cases, the artery usually arises high up in the arm or at the intercondylar line of the humerus. It lies superficial to all the forearm flexor muscles, and gives off an average of four good-sized fasciocutaneous vessels before passing deep to the palmaris longus muscle if this is present. We would consider such an anomaly to be advantageous, as it would facilitate the dissection of the flap, even though it has been referred to as a 'trap' for the unwary. 11'12 Tonks et al have shown that the dominant blood supply to the hand is from the radial artery. 13 Despite this, routine vein grafting of the radial artery following elevation of a radial forearm flap is unnecessary, and only 59% of vein-grafted radial arteries remain patent. 14 One of the major advantages of the ulnar artery flap is that the major blood supply to the hand is left intact. In summary, therefore, this modification of the ulnar artery forearm free flap has the advantages of a preferable
1. Lovie MJ, DuncanGM, GlassonDW. The ulnar artery forearm free flap. Br J Plast Surg 1984; 37: 486-92. 2. KoshimaI, Iino T, Fukuda H, Soeda S. The free ulnar forearm flap. Ann Plast Surg 1987; 18: 24--9. 3. GrobbelaarAO, HarrisonDH. The distallybased ulnar artery island flap in hand reconstruction.J Hand Surg 1997; 22B: 204-11. 4. Li Z, Liu K, Cao Y. The reverse flow ulnar artery island flap: 42 clinicalcases. Br J Plast Surg 1989; 43: 256-9. 5. Yii NW, NiranjanNS. Fascial flaps based on perforators for reconstruction of defects in the distal forearm. Br J Plast Surg 1999; 52: 534--40. 6. GlassonDW, Lovie MJ. The ulnar island flap in hand and forearm reconstruction.Br J Plast Surg 1988;41: 349-53. 7. GuimberteauJC, Goin JL, PanconiB, SchuhmacherB. The reverse ulnar artery forearm island flap in hand surgery: 54 cases. Plast Reconstr Surg 1988; 81: 925-32. 8. Christie DRH, Duncan GM, Glasson DW. The ulnar artery free flap: the first 7 years. Plast Reconstr Surg 1994; 93:547-51. 9. Becker C, GilbertA. The ulnar flap - descriptionand applications. Eur J Plast Surg 1988; 11: 79-82. 10. Devansh. Superficialulnar artery flap. Plast Reconstr Surg 1996; 97: 420-6. i 1. Fatah MF, Nancarrow JD, Murray DS. Raising the radial artery forearm flap: the superficial ulnar artery 'trap'. Br J Plast Surg 1985; 38: 394-5. 12. Thoma A, Young JEM. The superficial ulnar artery 'trap' and the free forearm flap. Ann Plast Surg 1992; 28: 370-2. 13. TonksAM, Lawrence J, Lovie MJ. Comparisonof ulnar and radial arterial blood-flowat the wrist. J Hand Surg 1995; 20B: 240--2. 14. Boorman JG, Brown JA, Sykes PJ. Morbidity in the forearm flap donor arm. Br J Plast Surg 1987;40: 207-12.
The Authors Peter Michael Arnstein FRCS, Consultant Plastic Surgeon Jacqueline Saw Lewis FRCS (Plast), SpecialistRegistrar in Plastic Surgery The QueenVictoriaHospital, HoltyeRoad, East Grinstead, West Sussex RH19 3DZ, UK. Correspondenceto Mr P. M. Arnstein. Paper received 10 October 2001. Accepted 8 March 2002, after revision.