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The medial head of triceps brachii: A muscular flap
Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, e263ee264
CORRESPONDENCE AND COMMUNICATION The medial head of triceps brachii: A muscular flap* Sir, Optimal reconstruction of soft tissues in the shoulder or elbow regions1e3 may sometimes require a small muscular pedicled flap. Moreover, a small muscular free flap is suitable for reanimation in selected cases, including sequelae of thenar eminence post-traumatic injury. The vascular anatomical features of the posterior lodge of the arm4 allow harvesting the lateral arm flap, based on the radial (RC) collateral vessels, but also the medial head of triceps brachii flap, based on the medial collateral (MC) vessels.5 We performed the medial head of triceps brachii (MHTB) reverse pedicled flap on two patients in October, 2008 and in June, 2009. The first patient, 72-year old, had had an accidental trauma of the upper limb, with open fracture of the right elbow and wrist, soft tissue deficit in the medial and anterior elbow region. The second patient, 77-year old, had a cystic lymphangioma of the posterior elbow region, complicated by infection, loss of substance and exposed olecranon. The arm was abducted at 90 and the forearm flexed at 90 . The depression between the lateral and long head of the triceps brachii muscle was identified and a longitudinal incision was performed up to the loss of substance. The tendinous part of the triceps muscle was directly exposed and incised along its medial border, separating the long and lateral heads and exposing the medial head. MC vessels were identified and sectioned at their origin from the deep brachial vessels. The motor branch of radial nerve for the medial head was also sectioned. The medial head was cleaved from periosteal insertions and harvested with a distal muscular pedicle, based on the reverse blood flow into the MC artery via the anastomotic circle of the elbow (Figure 1). The flap was positioned in the recipient site after debridement (Figure 2) and covered by a partial thickness skin graft. No early complications occurred. Patients were reviewed in February, 2012 (mean follow up: 3 years). No muscular * The work was partially presented at: MegaHand Congress, 30th of September, 2011, Paris.
Figure 1 Patient #1. After debridement, a loss of substance resulted on the proximal third of the forearm.
Figure 2 Patient #1. The medial head of triceps brachii (MHTB) muscle flap is positioned to cover the loss of substance.
1748-6815/$ - see front matter ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2012.02.023
e264 strength impairment of the triceps brachii occurred. Soft tissue coverage and reconstruction was excellent. Indications of the MHTB flap include radial or ulnar nerve injury, shoulder or elbow defects, muscular reanimation. The MHTB can be harvested as a pedicled muscular flap, based on the MC vessels, an osteomuscular flap, a free flap for muscular reanimation, a chimeric flap with the fasciocutaneous lateral arm flap, or a reverse pedicled flap, based on the anastomotic circle of the elbow. The latter procedure could be useful for defects of the elbow or the proximal third of the forearm, as an alternative option to local cutaneous flaps such as the “extreme” lateral arm flap when muscular tissue is required.
Conflict of interest We disclose all conflict of interest.
Funding No funding supporting this study.
References 1. Choudry UH, Moran SL, Li S, Khan S. Soft-tissue coverage of the elbow: an outcome analysis and reconstructive algorithm. Plast Reconstr Surg 2007;119(6):1852e7. 2. Prantl L, Schreml S, Schwarze H, et al. A safe and simple technique using the distal pedicled reversed upper arm flap to cover large elbow defects. J Plast Reconstr Aesthet Surg 2008; 61(5):546e51. 3. Reece EM, Oishi SN, Ezaki M. Brachioradialis flap for coverage after elbow flexion contracture release. Tech Hand Up Extrem Surg 2010;14(2):125e8.
Correspondence and Communication 4. Casoli V, Kostopoulos E, Pe ´lissier P, Caix P, Martin D, Baudet J. The middle collateral artery: anatomic basis for the "extreme" lateral arm flap. Surg Radiol Anat 2004;26(3):172e7. 5. Piquilloud G, Villani F, Casoli V. The medial head of the triceps brachii. Anatomy and blood supply of a new muscular free flap: the medial triceps free flap. Surg Radiol Anat 2010 Oct 26 [Epub ahead of print] PMID:20976453.
Federico Villani U.O. Chirurgia Plastica, IRCCS Policlinico San Donato, San Donato Milanese, Milano, Italy Service de Chirurgie Plastique, Reconstructrice, Esthe´tique et Brule´s e CHU Pellegrin e Centre Franc¸ois Xavier Michelet e Bordeaux, France Gael Piquilloud Service de Chirurgie Plastique, Reconstructrice, Esthe´tique et Brule´s e CHU Pellegrin e Centre Franc¸ois Xavier Michelet e Bordeaux, France Laboratoire d’Anatomie Me´dico-Chirurgicale, Faculte´ de Me´decine, Universite´ Victor Segalen Bordeaux 2 e Bordeaux, France Vincent Casoli Service de Chirurgie Plastique, Reconstructrice, Esthe´tique et Brule´s e CHU Pellegrin e Centre Franc¸ois Xavier Michelet e Bordeaux, France Laboratoire d’Anatomie Me´dico-Chirurgicale, Faculte´ de Me´decine, Universite´ Victor Segalen Bordeaux 2 e Bordeaux, France E-mail address: [email protected]
6 February 2012
CORRESPONDENCE AND COMMUNICATION The medial head of triceps brachii: A muscular flap* Sir, Optimal reconstruction of soft tissues in the shoulder or elbow regions1e3 may sometimes require a small muscular pedicled flap. Moreover, a small muscular free flap is suitable for reanimation in selected cases, including sequelae of thenar eminence post-traumatic injury. The vascular anatomical features of the posterior lodge of the arm4 allow harvesting the lateral arm flap, based on the radial (RC) collateral vessels, but also the medial head of triceps brachii flap, based on the medial collateral (MC) vessels.5 We performed the medial head of triceps brachii (MHTB) reverse pedicled flap on two patients in October, 2008 and in June, 2009. The first patient, 72-year old, had had an accidental trauma of the upper limb, with open fracture of the right elbow and wrist, soft tissue deficit in the medial and anterior elbow region. The second patient, 77-year old, had a cystic lymphangioma of the posterior elbow region, complicated by infection, loss of substance and exposed olecranon. The arm was abducted at 90 and the forearm flexed at 90 . The depression between the lateral and long head of the triceps brachii muscle was identified and a longitudinal incision was performed up to the loss of substance. The tendinous part of the triceps muscle was directly exposed and incised along its medial border, separating the long and lateral heads and exposing the medial head. MC vessels were identified and sectioned at their origin from the deep brachial vessels. The motor branch of radial nerve for the medial head was also sectioned. The medial head was cleaved from periosteal insertions and harvested with a distal muscular pedicle, based on the reverse blood flow into the MC artery via the anastomotic circle of the elbow (Figure 1). The flap was positioned in the recipient site after debridement (Figure 2) and covered by a partial thickness skin graft. No early complications occurred. Patients were reviewed in February, 2012 (mean follow up: 3 years). No muscular * The work was partially presented at: MegaHand Congress, 30th of September, 2011, Paris.
Figure 1 Patient #1. After debridement, a loss of substance resulted on the proximal third of the forearm.
Figure 2 Patient #1. The medial head of triceps brachii (MHTB) muscle flap is positioned to cover the loss of substance.
1748-6815/$ - see front matter ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2012.02.023
e264 strength impairment of the triceps brachii occurred. Soft tissue coverage and reconstruction was excellent. Indications of the MHTB flap include radial or ulnar nerve injury, shoulder or elbow defects, muscular reanimation. The MHTB can be harvested as a pedicled muscular flap, based on the MC vessels, an osteomuscular flap, a free flap for muscular reanimation, a chimeric flap with the fasciocutaneous lateral arm flap, or a reverse pedicled flap, based on the anastomotic circle of the elbow. The latter procedure could be useful for defects of the elbow or the proximal third of the forearm, as an alternative option to local cutaneous flaps such as the “extreme” lateral arm flap when muscular tissue is required.
Conflict of interest We disclose all conflict of interest.
Funding No funding supporting this study.
References 1. Choudry UH, Moran SL, Li S, Khan S. Soft-tissue coverage of the elbow: an outcome analysis and reconstructive algorithm. Plast Reconstr Surg 2007;119(6):1852e7. 2. Prantl L, Schreml S, Schwarze H, et al. A safe and simple technique using the distal pedicled reversed upper arm flap to cover large elbow defects. J Plast Reconstr Aesthet Surg 2008; 61(5):546e51. 3. Reece EM, Oishi SN, Ezaki M. Brachioradialis flap for coverage after elbow flexion contracture release. Tech Hand Up Extrem Surg 2010;14(2):125e8.
Correspondence and Communication 4. Casoli V, Kostopoulos E, Pe ´lissier P, Caix P, Martin D, Baudet J. The middle collateral artery: anatomic basis for the "extreme" lateral arm flap. Surg Radiol Anat 2004;26(3):172e7. 5. Piquilloud G, Villani F, Casoli V. The medial head of the triceps brachii. Anatomy and blood supply of a new muscular free flap: the medial triceps free flap. Surg Radiol Anat 2010 Oct 26 [Epub ahead of print] PMID:20976453.
Federico Villani U.O. Chirurgia Plastica, IRCCS Policlinico San Donato, San Donato Milanese, Milano, Italy Service de Chirurgie Plastique, Reconstructrice, Esthe´tique et Brule´s e CHU Pellegrin e Centre Franc¸ois Xavier Michelet e Bordeaux, France Gael Piquilloud Service de Chirurgie Plastique, Reconstructrice, Esthe´tique et Brule´s e CHU Pellegrin e Centre Franc¸ois Xavier Michelet e Bordeaux, France Laboratoire d’Anatomie Me´dico-Chirurgicale, Faculte´ de Me´decine, Universite´ Victor Segalen Bordeaux 2 e Bordeaux, France Vincent Casoli Service de Chirurgie Plastique, Reconstructrice, Esthe´tique et Brule´s e CHU Pellegrin e Centre Franc¸ois Xavier Michelet e Bordeaux, France Laboratoire d’Anatomie Me´dico-Chirurgicale, Faculte´ de Me´decine, Universite´ Victor Segalen Bordeaux 2 e Bordeaux, France E-mail address: [email protected]
6 February 2012