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The reverse lateral arm flap, based on the interosseous recurrent artery, for cubital fossa burns
Brimh 0
Journal
o/ Plastic
1994 The British
Surger?
Association
(1994), 47. 341-345 of Plastic
Surgeons
The reverse lateral arm flap, based on the interosseous recurrent artery, for cubital fossa burns C.-S. Lai, S.-D. Lin, C.-K. Chou and C.-C. Tsai Division of Plastic and Reconstructive Surgery, Chung-Ho Memorial Hospital, Kaohsiung Medical College, Kaohsiung, Taiwan SUMMARY. The reverse lateral arm flap based on the interosseous recurrent artery was used successfully to reconstruct cubital fossa defects caused by high voltage electric burn in two cases. The flap is nourished by the septocutaneous perforators of the posterior radial collateral artery which anastomoses around the lateral epicondyle with the interosseous recurrent artery. The primary benefits of this flap are that it is an easy and rapid one-stage procedure, with no necessity of sacrificing a main artery or local muscle, and it requires no immobilisation of the involved joint.
the insertion of the lateral intermuscular septum into the humerus; it is exposed along its entire length from the deltoid insertion to the lateral epicondyle. The artery can be easily located with a Doppler probe preoperatively if confirmation is required. The PRCA sends several septal perforating vessels that supply the skin over the lateral arm, and they should be meticulously preserved. Two cutaneous nerves are encountered during dissection, the posterior cutaneous nerve of the arm and forearm. Both arise from the radial nerve in the spiral groove, and pass superficially within the intermuscular septum. They are frequently sacrificed during dissection, although sparing of the nerves is possible with caution. Care should be taken to avoid injury to the radial nerve, which lies just anterior to the PRCA for a short distance prior to entering the space between the brachialis and brachioradialis muscles. The vascular pedicle and cutaneous nerve branches are dissected out and separated from the radial nerve, and the skin is then incised along the anterior border of the flap. Here sharp dissection is necessary to divide the brachialis and brachioradialis fibres from the lateral intermuscular septum, and any muscle branches and periosteal branches of the PRCA are divided or coagulated with bipolar cautery. The vascular pedicle is transected proximally and the flap is elevated in a proximal to distal direction, ensuring inclusion of the vessels and perforators lying within the septum. The PRCA anastomoses with the interosseous recurrent artery around the lateral epicondyle, and a sufficient amount of the adipose tissue and its underlying fascia should be included with the distal vascular pedicle for the purpose of protection and enhancement of the arterial input and venous drainage of the flap. The skin bridge between the donor site and the recipient wound is incised, and the distally-based island flap is then transposed to resurface the defects. The donor wound is closed primarily.
Although many surgical techniques are available for reconstruction of soft tissue defects of the elbow, onestage local island flaps are preferred to multi-stage regional or distant flaps because of less cost, shorter hospitalisation and avoidance of immobilisation of the involved elbow. The lateral arm flap was first developed by Song et al. in 1982.’ Katsaros et al2 further reported anatomical details and clinical applications of the flap in 1984, and it subsequently gained popularity in the West. This septocutaneous flap based on the posterior radial collateral artery (PRCA) has been mostly used as a free flap for various reconstructions. We present here two patients with cubital fossa defects caused by high voltage electric burns which were successfully reconstructed by a reverse lateral arm island flap based on the PRCA and the interosseous recurrent artery, a branch of the posterior interosseous artery. Surgical technique The anatomy of the lateral arm flap has been well described elsewhere.3-7 The central axis of the reverse lateral arm flap is designed on a line drawn from the deltoid insertion near the midpoint of the humerus to the lateral epicondyle, which corresponds to the lateral intermuscular septum. The flap outline is marked with its upper edge close to the deltoid insertion according to the size of the defect. The patient is placed in a supine position with the arm lying across the chest and the elbow in flexion. The incision is carried out first along the posterior margin of the flap down to the fascia, and continued in a subfascial plane towards the lateral intermuscular septum. The deep fascia is easier to approach from this direction since there are no triceps muscle fibres taking origin from the posterior aspect of the lateral intermuscular septum, while fibres of the brachioradialis arise directly from its anterior aspect. During dissection the PRCA is visualised close to 341
342
British Journal of Plastic Surgery
Fig. 1
Figure l-(A)
High voltage electric burn caused soft tissue defect over the right cubital fossa. The involved forearm was amputated below the elbow, bone exposure was noted over the amputation stump. (B) Angiography performed 6 weeks after burn showed patent PRCA with abundant anastomoses with the vessels around the lateral epicondyle in spite of discontinuity of the radial and ulnar arteries. (C) A reverse lateral arm flao measuring 9 x 5 cm in size was marked with its uooer marain near the deltoid insertion. (D) The flau was transoosed distallv into the cubital fossa defect, and the donor site was closed primarily witch placement of a drain tube. (E) Follow’-up at 4 months showed durable cover of the defect. I
II
Case reports Case 1 A 30-year-old man had a 11,000 volt burn involving his right upper and lower extremities. The right forearm had to be amputated below the elbow, but bone exposure over the distal end of the amputation stump and a soft tissue defect over the cubital fossa remained. The exposed bone was shortened and the stump was primarily closed. Angiography of the involved arm performed 6 weeks after burn revealed a
patent PRCA anastomosing well with the vessels around the lateral epicondyle in spite of the discontinuity of the radial and ulnar arteries near the bifurcation of the brachial artery. Reconstruction of the cubital fossa defect was achieved using a reverse lateral arm flap measuring 5 x 9 cm in size, which survived completely. Follow-up at 4 months revealed an inconspicuous donor site scare and durable coverage of the defect (Fig. 1).
The Reverse Lateral Arm Flap for Cubital Fossa Bums
343
Fig. 2 Figure 2-(A) A soft tissue defect resulting from high voltage electric burn is shown over the left cubital fossa. The required flap measuring 7 x 5 cm in size was marked on the lateral aspect of the arm. (B) The distally based lateral arm flap with continuity of the subcutaneous tissue around the vascular pedicle (upper arrow) was elevated, and the injured radial nerve was repaired with nerve graft (lower arrow) taken from the transected posterior cutaneous nerve. (C) Uneventful wound healing was shown 5 months after surgery. (D) Range of motion of the involved elbow joint restored to normal.
Case 2 A 17-year-old male sustained a high voltage (11,000 V) electric burn with resultant necrosis of the soft tissue over his left cubital fossa. Wrist drop and sensory loss over the lateral two-thirds of the posterior surface of his left hand were noted on admission. Electromyogram and nerve conduction velocity test revealed dysfunction of his left radial nerve. The deep burn was debrided revealing a soft tissue defect and partial loss of the radial nerve. A reverse lateral arm flap measuring 5 x 7 cm in size was raised and transposed distally to cover the cubital fossa defect and repair of the radial nerve
was achieved by a nerve graft taken from the transected posterior cutaneous nerve. The postoperative course was uneventful and the flap survived completely (Fig. 2). The patient attended for rehabilitation regularly, and postoperative follow-up at 7 months revealed normal wrist dorsiflexion of the involved hand. Discussion
Wound problems around the elbow have been a major challenge to reconstructive surgeons. Few versatile
British Journal of Plastic Surgery
344 local flaps are available. Skin grafts are inappropriate when nerve, tendon or bone are exposed. Local fasciocutaneous flaps have been widely used, but an unsightly donor contour defect is the main shortcoming. When local muscle flaps with or without overlying skin are used, one must consider the functional loss of the donor muscle. Local adipofascial turnover flaps are ideal for coverage of periolecranon defects,’ but they are too thin for deep wounds of the cubital fossa. Distant pedicle flaps may be suitable in providing adequate tissue cover ; however, they require a two-stage procedure and long periods of immobilisation of the involved elbow joint. Free flaps not only require suitable recipient vessels, but also microvascular expertise and facilities. The lateral arm flap based on septocutaneous perforators of the PRCA has been mostly used as a free tissue transfer which may include bone, muscle, tendon, nerve, fascia and skin.‘-14 Anatomically the PRCA is fairly consistent in comparison to the superior ulnar collateral artery supplying the medial arm flap. Dissection of the reverse lateral arm flap is straightforward and it can usually be raised in less than one hour. The donor site can be closed primarily, if it is under 6 cm in diameter. Preoperative tissue expansion of a larger donor site may also allow its direct closure,l’ otherwise a skin graft may be needed. The advantages of the reverse lateral arm flap for elbow coverage include its relative thinness in comparison to musculocutaneous flaps, the ease of dissection, skin colour match with the area in the elbow, no necessity to sacrifice a major artery (in comparison to a forearm flap), and the location of the donor site in a relatively inconspicuous area. Early mobilisation and rehabilitation of the involved elbow joint is possible. Raising the flap usually involves transection of the posterior cutaneous nerves of the arm and forearm, which results in an area of numbness over the lateral aspect of the elbow and dorsolateral forearm. Although this sensory deficit usually goes unnoticed by the patient and has been reported to get smaller with time, Graham et ~1.‘~ reported that numbness in this area was unchanged in 59 % of patients after longterm follow-up. However, this sole disadvantage is outweighed in clinical usage by the advantages of the reverse lateral arm flap. Anatomically the radial collateral artery anastomoses with the radial recurrent artery in front of the lateral epicondyle, while the PRCA joins the interosseous recurrent artery behind the lateral epicondyle. The reverse lateral arm flap may be based on the radial collateral artery and radial recurrent artery as reported by Maruyama and Takeuchi,l’ or it can be based on the PRCA and interosseous recurrent artery as described by Chang et aZ.l* and Culbertson and Mutimer.l’ Hayashi and Maruyama2’ reported that the interosseous recurrent artery exhibited less welldefined communications (precapillary arteriolar anastomoses) with PRCA, and suggested the flap should be raised with a wide pedicle to obtain additional arterial input from the rete cubiti. There is
no further report of these flaps since these, though Lazarou and Kaplan’l described a distally based lateral arm flap with resultant blistering and partial tissue loss. We also emphasise that a sufficient amount of the subcutaneous tissue and fascia should be attached around the distal vascular pedicle, not only to contain enough arterial input but also to improve venous drainage of the flap. We encountered no venous drainage problem with the distally based flap in the presented cases. In our 2 cases, this flap, with its long and wide vascular pedicle, was an easy and reliable option for one-stage reconstruction of the cubital fossa defects. References 1. Song R, Song Y, Yu Y, Song Y. The upper arm free flap. Clin Plast Surg 1982; 9: 27-35. 2. Katsaros J, Schusterman M, Beppu M, Banis JC, Acland RD. The lateral upper arm flap: anatomy and clinical applications. Ann Plast Surg 1984; 12: 489-500. 3. Cormack GC, Lamberty BGH. Fasciocutaneous vessels in the upper arm: application to the design of new fasciocutaneous flaps. Plast Reconstr Surg 1984; 74: 244-9. 4. Rivet D, Buffet M, Martin D et nl. The lateral arm flap: an anatomic study. J Reconstr Microsurg 1987; 3: 121-32. 5. Yousif NJ. Warren R. Matloub HS. Sanuer JR. The lateral arm fascial free flap: its’anatomy and’use & reconstruction. Plast Reconstr Surg 1990; 86: 113845. 6. Kuek LBK, Chuan TL. The extended lateral arm flap: a new modification. J Reconstr Microsurg 1991; 7: 167-73. 7. Gosain AK, Matloub HS, Yousif NJ, Sanger JR. The composite lateral arm free flap: vascular relationship to triceps tendon and muscle. Ann Plast Surg 1992; 29: 496507. 8. Lai CS. Lin SD, Yang CC, Chou CK. The adipofascial turnover flap for elbow coverage. Ann Plast Surg 1992; 28: 19&4 9. Scheker LR, Kleinert HE, Hanel DP. Lateral arm composite tissue transfer to ipsilateral hand defects. Hand Surg 1987; 12A: 665-72. 10. Scheker LR, Lister GD, Wolff TW. The lateral arm free flap in releasing severe contracture of the first web space. J Hand Surg 1988; 13B: 14650. 11. Matloub HS, Larson DL, Kuhn JC, Yousif J, Sanger JR. Lateral arm free flap in oral cavity reconstruction: a functional evaluation. Head Neck 1989; 11: 205-l 1. 12. Waterhouse N, Healy C. The versatility of the lateral arm flap. Br J Plast Surg 1990; 43: 398402. 13. Katsaros J, Tan E, Zoltie N, Barton M. Venugopalsrinivasan Dr, Venkataramakrishnan Dr. Further experience with the lateral arm free flap. Plast Reconstr Surg 1991; 87: 902-10. 14. Moffett TR. Madison SA, Derr JW. Acland RD. An extended approach for the vascular pedicle of the lateral arm free flap. Plast Reconstr Surg 1991; 89: 259-67. 15. Shenaq SM. Pretransfer expansion of a sensate lateral arm free flap. Ann Plast Surg 1987; 19: 558-62. 16. Graham B. Adkins P. Scheker LR. Complications and morbidity of the donor and recipient sites in 123 lateral arm flaps. J Hand Surg 1992; 17B: 182-92. 17. Maruyama Y. Takeuchi S. The radial recurrent fasciocutaneous flap: reverseupper arm flap. BrJPlast Surg 1986;39:458861. 18. Chang CC, Maruyama Y. Onishi K, Iwahira Y, Fujita R, Shimizu K. Fasciocutaneous flap of the upper arm (abstract). J Jpn Plast Reconstr Surg 1987; 6: 550. 19. Culbertson JH, Mutimer K. The reverse lateral upper arm flap for elbow coverage. Ann Plast Surg 1987; 18: 62-8. 20. Hayashi A, Maruyama Y. Anatomical study of the recurrent flaps of the upper arm. Br J Plast Surg 1990; 43 : 300-6. 21. Lazarou SA. Kaplan IB. The lateral arm flap for elbow coverage. Plast Reconstr Surg 1993; 91: 1349954.
The Reverse Lateral Arm Flap for Cubital Fossa Burns
Kaohsiung Medical College, 100 Shih-Chuan 1st Road. Kaohsiung, Taiwan.
The Authors Chung-Sheng Lai, MD, Associate Professor. Sin-D& Lii, MD, Professor and Chief. Chih-Kang Chou, MD, Assistant Professor. Chih-Cheng Tsai, MD, Attending Plastic Surgeon. Division of Plastic Surgery, Chung-Ho Memorial
25
345
Requests for reprints to Dr C.-S. Lai. Hospital,
Paper received 3 December 1993. Accepted 2.5 February 1994. after revision
BPS 47
Journal
o/ Plastic
1994 The British
Surger?
Association
(1994), 47. 341-345 of Plastic
Surgeons
The reverse lateral arm flap, based on the interosseous recurrent artery, for cubital fossa burns C.-S. Lai, S.-D. Lin, C.-K. Chou and C.-C. Tsai Division of Plastic and Reconstructive Surgery, Chung-Ho Memorial Hospital, Kaohsiung Medical College, Kaohsiung, Taiwan SUMMARY. The reverse lateral arm flap based on the interosseous recurrent artery was used successfully to reconstruct cubital fossa defects caused by high voltage electric burn in two cases. The flap is nourished by the septocutaneous perforators of the posterior radial collateral artery which anastomoses around the lateral epicondyle with the interosseous recurrent artery. The primary benefits of this flap are that it is an easy and rapid one-stage procedure, with no necessity of sacrificing a main artery or local muscle, and it requires no immobilisation of the involved joint.
the insertion of the lateral intermuscular septum into the humerus; it is exposed along its entire length from the deltoid insertion to the lateral epicondyle. The artery can be easily located with a Doppler probe preoperatively if confirmation is required. The PRCA sends several septal perforating vessels that supply the skin over the lateral arm, and they should be meticulously preserved. Two cutaneous nerves are encountered during dissection, the posterior cutaneous nerve of the arm and forearm. Both arise from the radial nerve in the spiral groove, and pass superficially within the intermuscular septum. They are frequently sacrificed during dissection, although sparing of the nerves is possible with caution. Care should be taken to avoid injury to the radial nerve, which lies just anterior to the PRCA for a short distance prior to entering the space between the brachialis and brachioradialis muscles. The vascular pedicle and cutaneous nerve branches are dissected out and separated from the radial nerve, and the skin is then incised along the anterior border of the flap. Here sharp dissection is necessary to divide the brachialis and brachioradialis fibres from the lateral intermuscular septum, and any muscle branches and periosteal branches of the PRCA are divided or coagulated with bipolar cautery. The vascular pedicle is transected proximally and the flap is elevated in a proximal to distal direction, ensuring inclusion of the vessels and perforators lying within the septum. The PRCA anastomoses with the interosseous recurrent artery around the lateral epicondyle, and a sufficient amount of the adipose tissue and its underlying fascia should be included with the distal vascular pedicle for the purpose of protection and enhancement of the arterial input and venous drainage of the flap. The skin bridge between the donor site and the recipient wound is incised, and the distally-based island flap is then transposed to resurface the defects. The donor wound is closed primarily.
Although many surgical techniques are available for reconstruction of soft tissue defects of the elbow, onestage local island flaps are preferred to multi-stage regional or distant flaps because of less cost, shorter hospitalisation and avoidance of immobilisation of the involved elbow. The lateral arm flap was first developed by Song et al. in 1982.’ Katsaros et al2 further reported anatomical details and clinical applications of the flap in 1984, and it subsequently gained popularity in the West. This septocutaneous flap based on the posterior radial collateral artery (PRCA) has been mostly used as a free flap for various reconstructions. We present here two patients with cubital fossa defects caused by high voltage electric burns which were successfully reconstructed by a reverse lateral arm island flap based on the PRCA and the interosseous recurrent artery, a branch of the posterior interosseous artery. Surgical technique The anatomy of the lateral arm flap has been well described elsewhere.3-7 The central axis of the reverse lateral arm flap is designed on a line drawn from the deltoid insertion near the midpoint of the humerus to the lateral epicondyle, which corresponds to the lateral intermuscular septum. The flap outline is marked with its upper edge close to the deltoid insertion according to the size of the defect. The patient is placed in a supine position with the arm lying across the chest and the elbow in flexion. The incision is carried out first along the posterior margin of the flap down to the fascia, and continued in a subfascial plane towards the lateral intermuscular septum. The deep fascia is easier to approach from this direction since there are no triceps muscle fibres taking origin from the posterior aspect of the lateral intermuscular septum, while fibres of the brachioradialis arise directly from its anterior aspect. During dissection the PRCA is visualised close to 341
342
British Journal of Plastic Surgery
Fig. 1
Figure l-(A)
High voltage electric burn caused soft tissue defect over the right cubital fossa. The involved forearm was amputated below the elbow, bone exposure was noted over the amputation stump. (B) Angiography performed 6 weeks after burn showed patent PRCA with abundant anastomoses with the vessels around the lateral epicondyle in spite of discontinuity of the radial and ulnar arteries. (C) A reverse lateral arm flao measuring 9 x 5 cm in size was marked with its uooer marain near the deltoid insertion. (D) The flau was transoosed distallv into the cubital fossa defect, and the donor site was closed primarily witch placement of a drain tube. (E) Follow’-up at 4 months showed durable cover of the defect. I
II
Case reports Case 1 A 30-year-old man had a 11,000 volt burn involving his right upper and lower extremities. The right forearm had to be amputated below the elbow, but bone exposure over the distal end of the amputation stump and a soft tissue defect over the cubital fossa remained. The exposed bone was shortened and the stump was primarily closed. Angiography of the involved arm performed 6 weeks after burn revealed a
patent PRCA anastomosing well with the vessels around the lateral epicondyle in spite of the discontinuity of the radial and ulnar arteries near the bifurcation of the brachial artery. Reconstruction of the cubital fossa defect was achieved using a reverse lateral arm flap measuring 5 x 9 cm in size, which survived completely. Follow-up at 4 months revealed an inconspicuous donor site scare and durable coverage of the defect (Fig. 1).
The Reverse Lateral Arm Flap for Cubital Fossa Bums
343
Fig. 2 Figure 2-(A) A soft tissue defect resulting from high voltage electric burn is shown over the left cubital fossa. The required flap measuring 7 x 5 cm in size was marked on the lateral aspect of the arm. (B) The distally based lateral arm flap with continuity of the subcutaneous tissue around the vascular pedicle (upper arrow) was elevated, and the injured radial nerve was repaired with nerve graft (lower arrow) taken from the transected posterior cutaneous nerve. (C) Uneventful wound healing was shown 5 months after surgery. (D) Range of motion of the involved elbow joint restored to normal.
Case 2 A 17-year-old male sustained a high voltage (11,000 V) electric burn with resultant necrosis of the soft tissue over his left cubital fossa. Wrist drop and sensory loss over the lateral two-thirds of the posterior surface of his left hand were noted on admission. Electromyogram and nerve conduction velocity test revealed dysfunction of his left radial nerve. The deep burn was debrided revealing a soft tissue defect and partial loss of the radial nerve. A reverse lateral arm flap measuring 5 x 7 cm in size was raised and transposed distally to cover the cubital fossa defect and repair of the radial nerve
was achieved by a nerve graft taken from the transected posterior cutaneous nerve. The postoperative course was uneventful and the flap survived completely (Fig. 2). The patient attended for rehabilitation regularly, and postoperative follow-up at 7 months revealed normal wrist dorsiflexion of the involved hand. Discussion
Wound problems around the elbow have been a major challenge to reconstructive surgeons. Few versatile
British Journal of Plastic Surgery
344 local flaps are available. Skin grafts are inappropriate when nerve, tendon or bone are exposed. Local fasciocutaneous flaps have been widely used, but an unsightly donor contour defect is the main shortcoming. When local muscle flaps with or without overlying skin are used, one must consider the functional loss of the donor muscle. Local adipofascial turnover flaps are ideal for coverage of periolecranon defects,’ but they are too thin for deep wounds of the cubital fossa. Distant pedicle flaps may be suitable in providing adequate tissue cover ; however, they require a two-stage procedure and long periods of immobilisation of the involved elbow joint. Free flaps not only require suitable recipient vessels, but also microvascular expertise and facilities. The lateral arm flap based on septocutaneous perforators of the PRCA has been mostly used as a free tissue transfer which may include bone, muscle, tendon, nerve, fascia and skin.‘-14 Anatomically the PRCA is fairly consistent in comparison to the superior ulnar collateral artery supplying the medial arm flap. Dissection of the reverse lateral arm flap is straightforward and it can usually be raised in less than one hour. The donor site can be closed primarily, if it is under 6 cm in diameter. Preoperative tissue expansion of a larger donor site may also allow its direct closure,l’ otherwise a skin graft may be needed. The advantages of the reverse lateral arm flap for elbow coverage include its relative thinness in comparison to musculocutaneous flaps, the ease of dissection, skin colour match with the area in the elbow, no necessity to sacrifice a major artery (in comparison to a forearm flap), and the location of the donor site in a relatively inconspicuous area. Early mobilisation and rehabilitation of the involved elbow joint is possible. Raising the flap usually involves transection of the posterior cutaneous nerves of the arm and forearm, which results in an area of numbness over the lateral aspect of the elbow and dorsolateral forearm. Although this sensory deficit usually goes unnoticed by the patient and has been reported to get smaller with time, Graham et ~1.‘~ reported that numbness in this area was unchanged in 59 % of patients after longterm follow-up. However, this sole disadvantage is outweighed in clinical usage by the advantages of the reverse lateral arm flap. Anatomically the radial collateral artery anastomoses with the radial recurrent artery in front of the lateral epicondyle, while the PRCA joins the interosseous recurrent artery behind the lateral epicondyle. The reverse lateral arm flap may be based on the radial collateral artery and radial recurrent artery as reported by Maruyama and Takeuchi,l’ or it can be based on the PRCA and interosseous recurrent artery as described by Chang et aZ.l* and Culbertson and Mutimer.l’ Hayashi and Maruyama2’ reported that the interosseous recurrent artery exhibited less welldefined communications (precapillary arteriolar anastomoses) with PRCA, and suggested the flap should be raised with a wide pedicle to obtain additional arterial input from the rete cubiti. There is
no further report of these flaps since these, though Lazarou and Kaplan’l described a distally based lateral arm flap with resultant blistering and partial tissue loss. We also emphasise that a sufficient amount of the subcutaneous tissue and fascia should be attached around the distal vascular pedicle, not only to contain enough arterial input but also to improve venous drainage of the flap. We encountered no venous drainage problem with the distally based flap in the presented cases. In our 2 cases, this flap, with its long and wide vascular pedicle, was an easy and reliable option for one-stage reconstruction of the cubital fossa defects. References 1. Song R, Song Y, Yu Y, Song Y. The upper arm free flap. Clin Plast Surg 1982; 9: 27-35. 2. Katsaros J, Schusterman M, Beppu M, Banis JC, Acland RD. The lateral upper arm flap: anatomy and clinical applications. Ann Plast Surg 1984; 12: 489-500. 3. Cormack GC, Lamberty BGH. Fasciocutaneous vessels in the upper arm: application to the design of new fasciocutaneous flaps. Plast Reconstr Surg 1984; 74: 244-9. 4. Rivet D, Buffet M, Martin D et nl. The lateral arm flap: an anatomic study. J Reconstr Microsurg 1987; 3: 121-32. 5. Yousif NJ. Warren R. Matloub HS. Sanuer JR. The lateral arm fascial free flap: its’anatomy and’use & reconstruction. Plast Reconstr Surg 1990; 86: 113845. 6. Kuek LBK, Chuan TL. The extended lateral arm flap: a new modification. J Reconstr Microsurg 1991; 7: 167-73. 7. Gosain AK, Matloub HS, Yousif NJ, Sanger JR. The composite lateral arm free flap: vascular relationship to triceps tendon and muscle. Ann Plast Surg 1992; 29: 496507. 8. Lai CS. Lin SD, Yang CC, Chou CK. The adipofascial turnover flap for elbow coverage. Ann Plast Surg 1992; 28: 19&4 9. Scheker LR, Kleinert HE, Hanel DP. Lateral arm composite tissue transfer to ipsilateral hand defects. Hand Surg 1987; 12A: 665-72. 10. Scheker LR, Lister GD, Wolff TW. The lateral arm free flap in releasing severe contracture of the first web space. J Hand Surg 1988; 13B: 14650. 11. Matloub HS, Larson DL, Kuhn JC, Yousif J, Sanger JR. Lateral arm free flap in oral cavity reconstruction: a functional evaluation. Head Neck 1989; 11: 205-l 1. 12. Waterhouse N, Healy C. The versatility of the lateral arm flap. Br J Plast Surg 1990; 43: 398402. 13. Katsaros J, Tan E, Zoltie N, Barton M. Venugopalsrinivasan Dr, Venkataramakrishnan Dr. Further experience with the lateral arm free flap. Plast Reconstr Surg 1991; 87: 902-10. 14. Moffett TR. Madison SA, Derr JW. Acland RD. An extended approach for the vascular pedicle of the lateral arm free flap. Plast Reconstr Surg 1991; 89: 259-67. 15. Shenaq SM. Pretransfer expansion of a sensate lateral arm free flap. Ann Plast Surg 1987; 19: 558-62. 16. Graham B. Adkins P. Scheker LR. Complications and morbidity of the donor and recipient sites in 123 lateral arm flaps. J Hand Surg 1992; 17B: 182-92. 17. Maruyama Y. Takeuchi S. The radial recurrent fasciocutaneous flap: reverseupper arm flap. BrJPlast Surg 1986;39:458861. 18. Chang CC, Maruyama Y. Onishi K, Iwahira Y, Fujita R, Shimizu K. Fasciocutaneous flap of the upper arm (abstract). J Jpn Plast Reconstr Surg 1987; 6: 550. 19. Culbertson JH, Mutimer K. The reverse lateral upper arm flap for elbow coverage. Ann Plast Surg 1987; 18: 62-8. 20. Hayashi A, Maruyama Y. Anatomical study of the recurrent flaps of the upper arm. Br J Plast Surg 1990; 43 : 300-6. 21. Lazarou SA. Kaplan IB. The lateral arm flap for elbow coverage. Plast Reconstr Surg 1993; 91: 1349954.
The Reverse Lateral Arm Flap for Cubital Fossa Burns
Kaohsiung Medical College, 100 Shih-Chuan 1st Road. Kaohsiung, Taiwan.
The Authors Chung-Sheng Lai, MD, Associate Professor. Sin-D& Lii, MD, Professor and Chief. Chih-Kang Chou, MD, Assistant Professor. Chih-Cheng Tsai, MD, Attending Plastic Surgeon. Division of Plastic Surgery, Chung-Ho Memorial
25
345
Requests for reprints to Dr C.-S. Lai. Hospital,
Paper received 3 December 1993. Accepted 2.5 February 1994. after revision
BPS 47