The distally based radial forearm fasciosubcutaneous flap with preservation of the radial artery: an anatomic and clinical approach.

The axial-pattern reverse radial forearm fasciocutaneous flap has become one of the primary flaps for reconstruction of soft-tissue defects of the hand. The two main disadvantages of this flap are (1) sacrifice of a major artery that may possibly jeopardize hand viability and (2) morbidity and appearance of the donor site. In an effort to overcome these drawbacks, an anatomic study of a distally based radial forearm fasciosubcutaneous flap with preservation of the radial artery was conducted. Seventeen fresh cadaver forearms were dissected to investigate the contribution of the distal radial artery and its superficial and deep branches to the fasciosubcutaneous plexus of the forearm. The blood supply to the radial forearm fasciosubcutaneous tissue was found to emanate from 6 to 10 septocutaneous perforators of the distal radial artery in the vicinity of the anatomic snuff box that "fan out" at the level of the deep fascia to form a rich plexus supplying the forearm fascia, subcutaneous tissue, and skin. There appeared to be a definite directional component, with the arterioles running longitudinally along the intermuscular septum. The deep fascia and subcutaneous tissue were found to have their own venous system accompanying the small perforating arterioles. Encouraged by these findings, we proceeded to utilize this fasciosubcutaneous flap for coverage of the thumb-index web space (three patients), the dorsum of the hand (two patients), and both the palmar and dorsal aspects of the hand (one patient). Five flaps had almost complete survival. The largest flap in our series suffered significant loss. Minor skin-graft loss occurred in a few cases, and we now delay skin grafting for several days. The distally based radial forearm fasciosubcutaneous flap with preservation of the radial artery can be a very useful and reliable alternative for repairing soft-tissue defects of the hand, obviating the need for the classic fasciocutaneous flap or even a free flap. This flap not only preserves the radial artery, which is essential in cases where only the radial artery is functioning, such as following severe hand injuries, but also provides a more acceptable donor site.