SURGICAL TECHNIQUE

Radial Artery Perforator Flap

Andrew M. Ho, MD, PhD, James Chang, MD

Surgical Technique

Soft tissue defects in the hand and wrist can be challenging problems for the hand surgeon.
The retrograde radial forearm fasciocutaneous flap has emerged in recent years as the
workhorse flap to cover many hand and wrist defects. However, recognition of the intrinsic
limitations of this flap has led to the development of other alternative flaps to provide soft
tissue coverage for this region. The radial artery perforator flap has many of the benefits of
the radial forearm flap but minimizes the disadvantages, such as the need to sacrifice the
radial artery, color and bulk mismatch of the flap and recipient tissues, and donor site
appearance. In this article, we will review the indications for using the radial artery perforator
flap to cover hand and wrist soft tissue defects. We will discuss the surgical anatomy,
indications, operating technique, rehabilitation protocol, potential complications, and pearls
and pitfalls for use of this flap for upper-extremity defects. (J Hand Surg 2010;35A:308311.
Copyright 2010 by the American Society for Surgery of the Hand. All rights reserved.)
Key words Flap, hand, perforator, radial artery, reconstruction.

of the hand and wrist can

result from trauma, burn, infection, ischemia, or
neoplasm. In recent years, the volar radial forearm fasciocutaneous pedicled flap has been used extensively to cover large areas of hand and wrist defects.
This radial forearm flap uses the retrograde flow of the
radial artery to provide a robust blood supply to the flap
and can be raised in a single-stage procedure without
microvascular surgery to cover defects in the hand and
wrist.
With routine use of the retrograde radial forearm flap
some drawbacks to this flap have become apparent. The
need to sacrifice the radial artery during the harvest of
the flap has precluded its use in patients with aberrant
and incomplete distal radial artery ulnar artery connections. The donor skin and fascia from the volar forearm
offer poor matches in color and contour to the thinner
and more delicate tissue of the hand, especially the

OFT TISSUE DEFECTS

From the Robert A. Chase Hand and Upper Limb Center and the Division of Plastic and Reconstructive
Surgery, Stanford University School of Medicine, Stanford, CA.
Received for publication April 12, 2009; accepted in revised form November 18, 2009.
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.
Corresponding author: James Chang, MD, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road, Suite 400, Stanford, CA 94304; e-mail:
changhand@aol.com.
0363-5023/10/35A02-0025$36.00/0
doi:10.1016/j.jhsa.2009.11.015

308 ASSH Published by Elsevier, Inc. All rights reserved.

dorsum. In addition, donor site morbidities such as poor

skin graft take, delayed wound healing, and conspicuous donor scarring also limit use of this flap in some
patients.
These limitations of the radial forearm flap and further understanding of the vasculature of the forearm
have led to the development of other pedicled forearm
flaps based on the posterior interosseous artery, dorsal
ulnar artery, and branches of the radial artery.1 In 1988,
Zhang described a technique that takes advantage of the
septocutaneous perforators arising from the distal radial
artery to supply a retrograde radial forearm flap.2 Since
then, application of the radial artery perforator flap has
been described for coverage of hand and forearm defects resulting from various traumas3 and burn injuries.4
INDICATIONS
The radial artery perforator flap can be used to cover
moderate-sized defects (8 cm 18 cm) of the dorsal
or palmar hand as distal as the base of the proximal
phalanges of the digits, as well as the distal forearm2
(Fig. 1). As the radial artery is not violated during the
elevation of this flap, the patient does not need to
demonstrate a competent distal ulnarradial arterial
anastomosis, and a preoperative Allens test is not required. However, patency of the radial artery and its
venae comitantes at the wrist is vital to the retrograde
perfusion of the flap.

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FIGURE 2: The radial artery (RA) travels in the septum between

the brachioradialis (BR) and flexor carpi radialis (FCR) tendons
in the distal forearm. It gives off several septocutaneous
perforators (P) about 2 to 4 cm proximal to the radial styloid to
supply the radial artery perforator flap (RAPF).

FIGURE 1: The radial artery perforator flap provides volar

coverage of the forearm and hand proximal to the distal palmar
crease (pink) and dorsal coverage of the radial two-thirds of the
forearm and hand proximal to the metacarpophalangeal joints
(green). The pivot point of the flap is 2 to 4 cm proximal to the
radial styloid process (red circle).

CONTRAINDICATIONS
Because the radial artery perforator flap is dependent on
retrograde flow of a plexus rather than a major vascular
axis, the maximum dimensions of the flap that can be
transferred reliably are smaller and the reach of the flap
more proximal than that for traditional axial flaps. Thus,
this flap is not suitable for patients with large defects
(greater than 10 cm 20 cm) or with defects distal to
the metacarpophalangeal joints in the hand. Alternative
flaps should also be considered in patients at risk for
microvascular arterial disease, such as smokers or diabetics, or in those with a history of venous insufficiency
or thrombosis in the affected limb. This is because the
flap depends on the delicate septal perforators that may
or may not be present in these patients. Patients with
trauma to the volar forearm that may have damaged the
perforators are also unsuitable candidates for this flap.
SURGICAL ANATOMY
Blood supply to the skin of the forearm is provided by
cutaneous branches of the brachial artery and musculocutaneous and septocutaneous perforators of the radial
and ulnar arteries. These vessels anastomose around the

deep fascia of the forearm to form vascular plexuses

that supply the overlying skin.
The radial artery at the distal forearm emerges superficially in the septum between the brachioradialis
and the flexor carpi radialis tendons to give off about 10
small perforating vessels (0.3 to 0.5 mm in diameter)
about 2 to 4 cm proximal to the radial styloid process5
(Fig. 2). These septocutaneous perforators form a longitudinal chain-linked vascular plexus along the course
of the artery that can be developed as an adipofascial
pedicle for distal forearm flaps. Venous return from the
deep fascia is accomplished via the profunda venae
comitantes through the perforating veins of the forearm.6 Sensate flaps can be raised using the lateral antebrachial cutaneous nerve.
Several studies have investigated the role of preoperative imaging of the perforator vessels to assess the
vascular anatomy and to facilitate flap design. Imaging
modalities studied include magnetic resonance angiogram, computed tomography angiography, subtraction
angiography, color duplex ultrasound, and radionuclide
imaging.7 However, most studies revealed that limitations in the image resolution render the reliable delineation of the small perforators that originate from forearm vessels a difficult task. Thus, preoperative imaging
is deemed low-yield and not cost-effective and is not
routinely obtained. Intraoperative exploration remains
the only reliable method to accurately determine the
location of the radial perforators.7
SURGICAL TECHNIQUE
The patient is placed supine on the operating table. The
surgical hand is placed on a well-padded arm board,
and a brachial tourniquet is applied. After appropriate

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RADIAL ARTERY PERFORATOR FLAP

Surgical Technique

debridement of the soft tissue wound, the size and

location of the defect are noted.
To raise an adipofascial flap, a curvilinear skin incision along the axis of the radial artery is made over the
volar forearm, and the skin is elevated off the underlying fat and fascia. Next, a 3- to 4-cm-wide adipofascial
flap that includes the deep fascia, antebrachial nerve,
and cephalic vein is raised from a proximal to distal
direction as far as the distal pivot point, leaving the
radial artery intact. The perforator vessels in the proximal forearm can be ligated as needed to allow an
adequate arc of rotation of the flap. To avoid injury, the
distal perforating vessels used to supply the flap are not
isolated or skeletonized. Care is taken to preserve the
integrity of the superficial radial nerve and its branches.
To raise an adipofasciocutaneous flap, a skin island
is marked over the proximal volar forearm, with the
pivot point about 2 to 4 cm proximal to the radial
styloid. A curvilinear incision is designed between the
island and the pivot point that will allow elevation of
thin skin flaps to expose the adipofascial pedicle. Next,
the island flap is raised from proximal to distal on a 3to 4-cm-wide pedicle similar to that described above,
leaving the radial artery intact. If a sensate flap is
desired, neurotization of the flap can be performed by
identifying a length of the lateral antebrachial cutaneous
nerve and elevating it along with the flap. After neurorrhaphy and rotation of the flap, the transected end of
the antebrachial nerve is sutured to a suitable sensory
nerve recipient using microsurgical technique.
Controversy exists as to whether the cephalic vein
should be ligated at the base of the pedicle. Proponents
argue that there is ongoing net venous inflow to the flap
from the large subcutaneous veins that may exceed the
outflow capacity of the smaller valveless venous channels that communicate with the venae comitantes of the
radial artery, resulting in venous congestion.5 In addition, it has been shown that there is no positive role of
the cephalic vein in the venous drainage of this flap.5
Others maintained that the vascular plexus accompanying the cephalic vein contributes to the flap perfusion
and should not be sacrificed.8
After the pedicle is raised, the proximal end of the
flap is transected, and the flap is transposed and inset
along similar lines to the retrograde radial forearm
fascial flap. While the flap can be passed through a
subcutaneous tunnel to the distal defect, given the wide
adipofascial pedicle that must be raised with this flap
along with the lower arterial perfusion pressures, it is
generally safer to incise the skin between the pivot point
and the recipient site and to place skin graft over the
bulky pedicle.

FIGURE 3: A radial artery perforator fascial flap (RAPF) was

raised in a proximal to distal fashion to cover a defect over the
median nerve (M) without sacrificing the radial artery (RA).
FCR, flexor carpi radialis.

The flap is then inset into the defect. The forearm

donor site can be closed primarily if the width of the
defect is less than 3 cm or skin grafted if the donor
defect is larger. An intraoperative Doppler examination
is performed, and the location on the skin where a
Doppler signal can be obtained is marked to facilitate
postoperative monitoring. Moist noncompressive dressing is applied to the donor and recipient sites, and a
well-padded short-arm splint is applied for tissue stabilization.
REHABILITATION AND POSTOPERATIVE CARE
Our routine postoperative protocol for flap reconstruction includes core warming and adequate hydration of
the patient to minimize vascular spasm, intravenous
antibiotics, appropriate pain control measures including
regional nerve blocks and patient-controlled analgesic
devices, and prophylaxis against deep venous thrombosis. Sequential clinical examinations of the flap for
arterial insufficiency and venous congestion as well as
Doppler examinations are diligently performed. The
patient typically stays in the hospital for 2 to 3 days
before being discharged. Gentle range of motion exer-

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The flap healed with no apparent complications, and the

patient noted a marked decrease in median nerve sensitivity after flap coverage.

FIGURE 4: One of several perforators (P) from the radial

artery (RA) supplying the radial artery perforator flap (RAPF)
that was transposed to cover a defect at the carpal tunnel.
FCR, flexor carpi radialis.

cises can be initiated once the flap is stable, about 2

weeks after reconstruction.
POTENTIAL COMPLICATIONS
Complications with perforator flaps may be higher than
with traditional axial flaps, secondary to the delicate
nature of the perforator vessels and the weaker plexus
perfusion. In a retrospective review of 68 forearm perforator flaps, Matei et al. reported partial flap epidermolysis in 12% of cases, which the authors attributed to
transitory venous congestion.9
CLINICAL CASE
This patient had median nerve exploration and tumor
resection and required coverage of a superficial and
sensitive median nerve. Soft tissue coverage was performed using a radial artery perforator fascial flap. The
flap was elevated from a proximal to distal fashion
(Fig. 3) until the fascial flap could be transposed to
cover the defect over the exposed median nerve (Fig.
4). The radial artery was preserved during the harvest.

The radial artery perforator flap is an alternative to

the radial forearm flap that can be used to cover
hand and forearm soft tissue defects.
No preoperative Allens test is required, although
patency of the radial artery at the wrist is necessary.
The plexus-driven blood supply makes this a suitable flap for covering medium-sized defects in the
forearm and hand proximal to the metacarpophalangeal joints.
The perforating vessels need not be dissected when
raising the flap.
More proximal perforators can be sacrificed and
ligated as needed to allow adequate arc of rotation
of the flap.
Subcutaneous tunneling of the flap under an intact
skin bridge may compromise the vascularity of the
flap. We recommend incising the skin between the
pivot point and the recipient site and skin grafting
the transferred pedicle if needed.
Sensate flaps can be accomplished using the lateral
antebrachial cutaneous nerve.

REFERENCES
1. Page R, Chang J. Reconstruction of hand soft-tissue defects: alternatives to the radial forearm fasciocutaneous flap. J Hand Surg 2006;
31A:847 856.
2. Zhang YT. The use of reversed forearm pedicled fascio-cutaneous flap
in the treatment of hand trauma and deformity (report of 10 cases).
Chin J Plast Surg Burns 1988;4:41 42.
3. Georgescu AV, Matei I, Ardelean F, Capota I. Microsurgical nonmicrovascular flaps in forearm and hand reconstruction. Microsurgery
2007;27:384 394.
4. Martin JP, Chambers JA, Long JN. Use of radial artery perforator flap
from burn-injured tissues. J Burn Care Res 2008;29:1009 1011.
5. Chang SM, Hou CL, Zhang F, Lineaweaver WC, Chen ZW, Gu YD.
Distally based radial forearm flap with preservation of the radial
artery: anatomic, experimental, and clinical studies. Microsurgery
2003;23:328 337.
6. Tiengo C, Macchi V, Porzionato A, Bassetto F, Mazzoleni F, De Caro
R. Anatomical study of perforator arteries in the distally based radial
forearm fasciosubcutaneous flap. Clin Anat 2004;17:636 642.
7. Lee GK. Invited discussion: harvesting of forearm perforator flaps
based on intraoperative vascular exploration: clinical experiences and
literature review. Microsurgery 2008;28:331332.
8. Nakajima H, Imanishi N, Fukuzumi S, Minabe T, Aiso S, Fujino T.
Accompanying arteries of the cutaneous veins and cutaneous nerves
in the extremities: anatomical study and a concept of the venoadipofascial and/or neuroadipofascial pedicled fasciocutaneous flap. Plast
Reconstr Surg 1998;102:779 791.
9. Matei I, Georgescu A, Chiroiu B, Capota I, Ardelean F. Harvesting of
forearm perforator flaps based on intraoperative vascular exploration: clinical
experiences and literature review. Microsurgery 2008;28:321330.

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Surgical Technique

PEARLS AND PITFALLS