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A safe and simple technique using the distal

pedicled reversed upper arm flap to cover large
elbow defects
Article in Journal of Plastic Reconstructive & Aesthetic Surgery February 2008
Impact Factor: 1.42 DOI: 10.1016/j.bjps.2007.05.015 Source: PubMed

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Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) xx, 1e7

A safe and simple technique using the distal

pedicled reversed upper arm flap to cover
large elbow defects
L. Prantl a,*, S. Schreml a, H. Schwarze a, M. Eisenmann-Klein a,
chtmeier b
M. Nerlich b, P. Angele b, M. Jung c, B. Fu
a

Department of Plastic Surgery, University Hospital, Regensburg, Germany

Department of Trauma Surgery, University Hospital, Regensburg, Germany
c
Department of Radiology, University Hospital, Regensburg, Germany
b

Received 21 July 2006; accepted 22 May 2007

KEYWORDS
Elbow defect;
Upper arm flap;
Distal pedicled flap;
Early mobilisation

Summary The reconstruction of large soft-tissue defects at the elbow is hard to achieve by
conventional techniques and is complicated by the difficulty of transferring sufficient tissue
with adequate elasticity and sensate skin. Surgical treatment should permit early mobilisation
to avoid permanent functional impairment.
Clinical experience with the distal pedicled reversed upper arm flap in 10 patients suffering
from large elbow defects is presented (seven male, three female; age 40e70 years). The patient sample included six patients with chronic ulcer, two with tissue defects due to excision of
a histiocytoma, and one patient with burn contracture. In the two cases of histiocytoma, defect closure of the elbows ulnar area was achieved by using a recurrent medial upper arm flap.
In the eight other patients we used a flap from the lateral upper arm with a flap rotation of
180 . Average wound size ranged from 4 to 10 cm, average wound area from 30 to 80 cm2. Flap
dimensions ranged from 15  8 cm for the lateral upper arm flap to 29  8 cm for the medial
upper arm flap. The inferior posterior radial and ulnar collateral arteries are the major nutrient vessels of the reversed lateral and medial upper arm flaps. Perforating vessels are identified preoperatively using colour Doppler ultrasonography.
Flap failure did not occur. Secondary wound closure became necessary due to initial wound
healing difficulties in one patient. Mean operation time was 1.5 h and mean follow-up period
12 months. Good defect coverage with tension-free wound closure was achieved in all cases.
Stable defect coverage led to long-term wound stability without any restriction of elbow movement.

* Corresponding author. Address: Department of Plastic Surgery, University of Regensburg, Franz-Josef-Strau-Allee 11, DE-93042 Regensburg, Germany. Tel.: 499419446947; fax: 499419446805.
E-mail address: lukas.prantl@klinik.uni-regensburg.de (L. Prantl).
1748-6815/$ - see front matter 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2007.05.015

Please cite this article in press as: Prantl L 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 (2007), doi:10.1016/j.bjps.2007.05.015

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L. Prantl et al.
The lateral and medial upper arm flaps represent a safe and reliable surgical treatment
option for large elbow defects. The surgical technique is comparatively simple and quick.
2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published
by Elsevier Ltd. All rights reserved.

For defects in the area of the elbow, regardless of their size

and depth, any treatment that allows early mobilisation
and early functional rehabilitation should be considered to
achieve defect closure and avoid the risk of functional
degeneration. This is especially important in older and
paraplegic patients who habitually support themselves on
their elbows. In these patients the high compression forces
acting at the elbow turn this region into a vulnerable
anatomical area. Therefore, elbow defects require good
soft tissue coverage with sufficient restoration of sensitivity.1 To re-establish full elbow mobility, or at least the maximum possible, the tissue cover must possess excellent
elastic properties. For this reason, the principle of selecting
the simplest coverage procedure (for instance, meshed
skin grafts) does not apply. Selection of appropriate wound
cover requires an understanding of the functional aspects
of the donor and recipient sites as well as a full evaluation
of local wound conditions, patient blood circulation, and
donor site morbidity.
The aetiology of elbow defects includes inflammatory
processes such as acute or chronic bursitis, deep burn
injuries and tumours, trauma injuries, and post-surgical
wound dehiscence with exposure of bone implants after the
treatment of elbow fractures. A review of the literature
reveals numerous treatment options ranging from local
flaps to free microvascular tissue transfer.1e5 In this study,
we report our experience with the distal pedicled reversed
lateral and medial upper arm flaps for covering mediumsized defects in the elbow region.

Patients and methods

Ten patients (seven men, three women) with elbow defects
were operated on over a 2-year period. All procedures were
carried out by the same surgeon. The average age of the
patients was 55 years (40e70 years) and the average body
mass index was 22.7 kg/m2 (15.6e29.5 kg/m2). Two patients had diabetes mellitus type II and one patient was
paraplegic. Six patients suffered from chronic ulcers in
the elbow area (pressure ulcer degree IV, chronic osteomyelitis, septic bursitis, chronic bursitis (n Z 3), one patient
had a scar contracture after burn injury with meshed skin
grafting, and in two patients a histiocytoma had been excised. The size of the soft-tissue defects ranged from 4 to
10 cm, and the average defect area from 30 to 80 cm2.
The follow-up period was 1 year. In all patients the preand postoperative range of motion (ROM) of the elbow joint
was measured by means of a goniometer. The healing process after surgery was well documented, including any
complications of wound healing, as well as partial or complete treatment failure with flap loss. Elbow mobilisation
commenced as soon as possible after surgery (usually 7th
postoperative day), together with regular monitoring of
flap sensitivity.

Preoperative planning and surgical technique

Preoperatively, a bacterial wound swab was taken and
radiological examination was performed for all patients to
rule out bone lesions. If necessary, we performed radical
wound decontamination with vacuum sealing. Repeated
surgical debridements and antibiotic therapy were necessary in one patient with wound infection and Pseudomonas
aeruginosa to achieve clean wound conditions. Bacterial invasion with Staphylococcus aureus did not represent an
obstacle to flap coverage. In the two patients with histiocytoma, the wound was not closed until the final histological
result had been obtained.
In all patients, angiographic documentation of the deep
brachial artery and of the radial and ulnar recurrent
arteries was carried out prior to surgery. Furthermore,
evaluation of vessel diameter, flow velocity, flow direction,
and identification and marking of the septocutaneous
perforator vessels was performed using colour Doppler
ultrasonography (7e12 MHz linear transducer). This offered
additional preoperative information about suitable perforators which would have to serve as pivots in the case of flap
rotation.

Flap description
Distal pedicled reversed lateral upper arm flap6e9
The vessel supplying the flap is the posterior radial
collateral artery (PRCA), which forms a vascular arcade in
the lateral intermuscular septum (between the brachialis,
brachioradialis muscles anteriorly and the lateral head of
the triceps muscle posteriorly) with the posterior descending branch of the deep brachial artery (Fig. 1). Several septocutaneous perforator vessels derive from it. The largest
perforator, often measuring 1 mm in external diameter,
can be detected 10 cm proximal to the lateral epicondyle.
The pivot (up to 180 rotation) is located above the lateral
epicondyle (Fig. 2). Depending on the skin elasticity of the
exterior upper arm region, the flap size may measure up to
8  15 cm. Attention must be paid to two nerves during dissection: a small nerve, the lower lateral cutaneous nerve of
the arm, which derives directly from the radial nerve and
supplies the flap area; and the posterior cutaneous nerve
of the forearm, which passes through the deep fascia somewhat proximal to the lateral epicondyle and supplies the
proximal postero-lateral surface of the arm. If possible
the latter nerve should be preserved (Fig. 3). The flap
axis corresponds to an imaginary line from the acromion
to the lateral epicondyle of the humerus. Flap harvesting
begins at the posterior aspect, whereby the skin is incised
and harvested together with the fascia of the triceps muscle until the lateral intermuscular septum is encountered.

Please cite this article in press as: Prantl L 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 (2007), doi:10.1016/j.bjps.2007.05.015

ARTICLE IN PRESS
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Safe and simple technique using the distal pedicled reversed upper arm

Figure 1 Fine-needle angiography with demonstration of the

important vessels for flap harvesting (brachial artery with origin of the deep brachial artery). PRCA Z posterior radial collateral artery, RRA Z radial recurrent artery, SUCA Z superior
ulnar collateral artery, URA Z ulnar recurrent artery.

The flap is removed from the anterior aspect, whereby the

underlying fascia is harvested from the brachialis and
brachioradialis muscle.
The distal perforators are well visible within the septum
and have to be preserved. One of the two perforators is

Figure 3 Flap harvesting. Representation of the radial

nerve: the lower lateral cutaneous nerve of the arm runs into
the flap and has to be transected. If possible the posterior cutaneous nerve of the forearm should be preserved. The vascular bundle, one artery (descending branch of the deep brachial
artery, continuing as PRCA) and usually two accompanying
nerves have to be transected proximally and ligated.

sufficient to ensure adequate perfusion of the skin island.

Proximally, the descending branch of the deep brachial
artery is ligated. The two nerves mentioned above are
usually exposed and transected. The lateral intermuscular
septum is dissected closely from the humerus, carefully
preserving the attached axial vessel, which originates from
the posterior radial recurrent artery. At this point, the flap
can be rotated in an anterior or posterior direction, as
required, to cover the defect.

Distal pedicled medial upper arm flap6,10,11

Figure 2 Flap design (distally pedicled lateral upper arm

flap): The pivot of the flap is located above the lateral epicondyle; the largest perforator is located approx. 10 cm proximally
of the lateral epicondyle in the palpable lateral intermuscular
septum.

The vessel supplying the flap is the posterior ulnar recurrent

artery (PURA) which runs directly behind the medial epicondyle and posterior to the ulnar nerve within the medial
intermuscular septum. The PURA forms a vascular arcade
with the superior ulnar collateral artery (SUCA), which arises
proximally from the brachial artery. Five to seven perforators radiate into the skin from this anastomosis. The largest
perforator is generally located 10 cm proximal to the medial
epicondyle (Fig. 4). The pivot (up to 180 rotation) is located
above the medial epicondyle. The flap can be as much as
29  8 cm in size depending on skin elasticity. It is the flap
size which determines whether the medial brachial cutaneous nerve can be preserved or whether it has to be transected. The flap axis corresponds to an imaginary line from
the medial epicondyle of the humerus to the posterior axillary line between the brachialis and biceps brachii muscles
and the triceps muscle. The flap is incised from the anterior
aspect and the fascia with corresponding skin area is detached from the biceps brachii. The medial intermuscular
septum is exposed and the perforators are identified. The axial vessel, i.e. the SUCA, is separated from the ulnar nerve
and ligated at the proximal outlet of the brachial artery.
The medial intermuscular septum is detached from the

Please cite this article in press as: Prantl L 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 (2007), doi:10.1016/j.bjps.2007.05.015

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L. Prantl et al.

Figure 4 Flap design (distally pedicled medial upper arm

flap). The flap pivot is located above the medial epicondyle;
the largest perforator is located approx. 10 cm proximally of
the medial epicondyle in the palpable medial intermuscular
septum.

humerus under careful protection of the axial vessel which

originates from the posterior radial recurrent artery. The
flap can now be rotated in an anterior or posterior direction
to cover the defect.

Results
In nine out of 10 patients intra- and postoperative flap
perfusion was excellent. Only in one case did difficulties of
venous drainage occur 24 h after surgery leading to middlesized venous congestion in the distal lower third of the flap
(patient 2: Table 1). Definite and clearly visible supply
from the collateral vessels of the distal and proximal arteries
as investigated by preoperative angiography is a precondition for successful surgery. Good flow in the axial vessels
and the presence of at least one large septocutaneous

Table 1

Figure 5 Colour-coded duplex sonography. Representation

of the lateral intermuscular septum with the axial vessel (the
PRCA forms an arcade with the posterior descending branch
of the deep brachial artery). The axial vessel shows a flow of
50 cm/s and flow volume of 4 ml/min.

perforator are also important conditions. The distal pedicled

reversed lateral upper arm flap required a flow velocity of
approx. 50 cm/s, and a flow volume of 4 ml/min (Fig. 5).

Patient Characteristics

Patient No.

Age (years)

Diagnosis

Operation

Time between
injury and flap
coverage

Complications

Flap dimension
(cm2)

1
2

40
52

Burns contracture
Chronic osteomyelitis

Lat.upper arm flap

Lat.upper arm flap

24 months
7 months

80
35

3
4
5
6
7
8
9
10

55
56
60
62
62
68
69
70

Pressure ulcer grade IV

Septic bursitis
Chronic bursitis
Chronic bursitis
Chronic bursitis
Chronic bursitis
Histiocytoma
Histiocytoma

Lat.upper arm flap

Lat.upper arm flap
Lat.upper arm flap
Lat.upper arm flap
Lat.upper arm flap
Lat.upper arm flap
Med.upper arm flap
Med.upper arm flap

1
3
2
1
2
3
3
5

None
Wound
breakdown
None
None
None
None
None
None
None
None

month
months
months
month
months
months
daysa
daysa

55
60
40
50
50
30
66
72

Lat. Z lateral, Med. Z medial.

a
Period until receipt of final histology result.

Please cite this article in press as: Prantl L 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 (2007), doi:10.1016/j.bjps.2007.05.015

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Safe and simple technique using the distal pedicled reversed upper arm
The medial flap required a flow velocity of approx. 30 cm/s
and a flow volume of 1 ml/min. The diameter of the axial
vessel ranged from 1.0 to 1.5 mm; the diameter of the largest perforator ranged from 0.5 to 1 mm. The average duration of surgery was 2 h.
In the case of venous congestion, early use of leeches
preserved the flap, and complete defect closure was
achieved 5 weeks after surgery. Wound healing was uneventful at all donor sites. Early mobilisation generally commenced on the 7th postoperative day depending on wound
conditions. Pre- and postoperative range of motion of the
upper arm and the elbow joint was the same in nine patients
(Tables 2 and 3). Although full elbow movement could not be
achieved in the case of scar contracture after burn injury,
a significant improvement of mobility and elbow movement
was recorded (patient 1: Table 2 and Fig. 6). The follow-up
examination after 12 months demonstrated stable conditions with good soft-tissue coverage and skin elasticity in
all patients (Fig. 7). All flap areas showed excellent recovery
of sensitivity.

Discussion
Defect covering of the elbow area should take into account
the need for rapid restoration of joint movement and early
mobilisation. The covering tissue should offer sufficient
thickness, good elasticity and good sensitivity. Generally,
the elbow area consists of very well vascularised tissue
layers. For smaller defects, local flaps (random pattern
flaps), harvested as rotation, transposition or advancement
flaps, represent suitable treatment options for wound
closure. Mostly, these local flaps demonstrate good skin
sensitivity.2,3,12 Furthermore, the length to width ratio of

Table 3 Pre- and postoperative comparison of movement

range of elbow
Preoperative (degrees) Postoperative (degrees)
Extension 12.8  3.6
Flexion
126.7  11.2
Pronation 68.3  9.0
Supination 71.1  12.4

12.8  2.6
126.7  12.3
66.7  8.7
70.0  14.1

Values are medians  SD.

1:1 can be enlarged due to numerous collateral vessels,

but not indefinitely. This represents the major limiting factor of local flaps and becomes obvious when dealing with
larger wounds. Defect closure with meshed skin grafts at
the elbow should be ruled out due to the grafts tendency
to contracture. In summary, difficulties are more likely to
occur for medium-sized or larger defects.
In our study, coverage with the distal pedicled lateral or
medial upper arm flap has proven its reliability and efficiency despite variations relating to defect localisation.
Successful wound covering starts with good and precise
preoperative planning. This should include good vascular
collateralisation together with identification of the deep
brachial artery and the PRCA. Likewise, visualisation of the
PURA and the SUCA is important when using the medial upper
arm flap. In addition, we believe that identification and
marking of at least one large septocutaneous perforator by
means of colour Doppler ultrasonography can be helpful and
of great importance, especially when flap rotation becomes
necessary and this particular perforator is required to serve

Table 2 Preoperative versus postoperative movement

range of elbow joint
Patient No.

Preoperative
(degrees)

Postoperative
(up to 1 year) (degrees)

E/F:
P/S:
E/F:
P/S:
E/F:
P/S:
E/F:
P/S:
E/F:
P/S:
E/F:
P/S:
E/F:
P/S:
E/F:
P/S:
E/F:
P/S:
E/F:
P/S:

E/F:
P/S:
E/F:
P/S:
E/F:
P/S:
E/F:
P/S:
E/F:
P/S:
E/F:
P/S:
E/F:
P/S:
E/F:
P/S:
E/F:
P/S:
E/F:
P/S:

2
3
4
5
6
7
8
9
10

0e30e50
70e0e75
5e0e120
80e0e80
15e0e140
75e0e80
15e0e120
70e0e80
15e0e135
50e0e70
15e0e105
60e0e40
15e0e135
75e0e75
10e0e135
70e0e75
10e0e120
65e0e70
15e0e130
70e0e70

0e5e130
70e0e80
10e0e120
70e0e75
15e0e140
75e0e80
15e0e125
70e0e80
10e0e130
50e0e65
10e0e100
55e0e35
15e0e135
75e0e80
15e0e135
70e0e75
10e0e120
65e0e70
15e0e135
70e0e70

E/F Z extension/flexion, P/S Z pronation/supination.

Figure 6 Patient with burn contracture. Preoperative marking of distally pedicled lateral upper arm flap (16  5 cm).
Complete mobilisation of the flap with the supplying pedicle,
and rotation of the flap into the defect.

Please cite this article in press as: Prantl L 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 (2007), doi:10.1016/j.bjps.2007.05.015

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L. Prantl et al.
wound closure with the parascapular flap which offers lower
morbidity of the donor site but leaves a scar on the back.
Compared to the parascapular flap, the latissimus dorsi muscle flap is too voluminous and bulky, especially if harvested
together with the corresponding skin area (skin island). Furthermore, seromas of the donor site are common,18,19 and
one of the largest muscles of the human body is sacrificed.
With regard to precise preoperative planning and careful
tissue harvesting, the distal pedicled reversed upper arm
flap represents a safe and reliable treatment option to
achieve adequate, long-term wound closure for mediumsized elbow defects. It has the following advantages.
1. A larger flap can be harvested without the difficulties of
primary closure of the donor site.
2. The shape of the contour and scar of the donor site is
acceptable.
3. The flap can be rotated or turned over to cover larger
areas.
4. The surgical technique is comparatively simple and
quick.

References

Figure 7 Follow up after 1 year. Well settled flap with sufficient and stable closure of the former elbow defect.

as a pivot. The flow velocity in the axial septal vessel for

a distal pedicled lateral upper arm flap should be approx.
50 cm/s whereas 30 cm/s is sufficient for a medial upper arm
flap. Overall, dissection using magnifying glasses is recommended. Careful preservation of the accompanying veins
of the septal vessel is crucial. In cases of postoperative venous congestion, the early use of leeches is recommended.
Treatment with leeches became necessary and facilitated
flap preservation in one case in our patient group.
Lateral and medial upper arm flaps are both fasciocutaneous flaps with a central axial supplying vessel. Flap
thickness is considered sufficient to obtain coverage of
elbow defects. Compared to other local flaps, donor morbidity is low and the site can generally be closed without any
difficulties.3,13,14,18 None of the important vessels supplying
the forearm and hand are damaged or destroyed. In addition,
the contours and scars in the upper arm region are acceptable to the patient. Comparing the upper arm flap with the
radial flap reveals an increased morbidity for the latter.13 After transection of the radial artery, the vascular supply to the
hand region is limited to the ulnar artery. Furthermore, the
defect at the donor site may not close primarily and may require covering with meshed skin grafts. This often leads to
scarring contracture with muscle adhesion. Numerous muscle flaps have been described in the literature as inducing
functional loss of the harvested muscle and/or needing additional skin grafting of the donor site.14,16e18 In the case of
a very large defect, free tissue transfer with microvascular
anastomoses becomes necessary.3,15 In such cases we prefer

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3. Stevanovic M, Sharpe F, Itamura JM. Treatment of soft tissue
problems about the elbow. Clin Orthop Relat Res 2000;370:
127e37.
4. Tu
regu
n M, Nisanci M, Duman H, et al. Versatility of the reverse
lateral arm flap in the treatment of post-burn antecubital contractures. Burns 2005;31:212e6.
5. Hayashi A, Maruyama Y, Saze M, et al. Ulnar recurrent adipofascial flap for reconstruction of massive defects around the
elbow and forearm. Br J Plast Surg 2004;57:632e7.
6. Hayashi A, Maruyama Y. Anatomical study of the recurrent
flaps of the upper arm. Br J Plast Surg 1990;43:300e6.
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8. Culbertson JH, Mutimer K. The reverse lateral upper arm flap
for elbow coverage. Ann Plast Surg 1987;18:62e8.
9. Tung TC, Wang KC, Fang CM, et al. Reverse pedicled lateral
arm flap for reconstruction of posterior soft-tissue defects of
the elbow. Ann Plast Surg 1997;38:635e41.
10. Bhattacharya S, Bhagia SP, Bhatnagar SK, et al. The medial upper arm fasciocutaneous flap. An alternative flap to cover palmar defects of hand and distal forearm. J Hand Surg [Br] 1991;
16:342e5.
11. Maruyama Y, Onishi K, Iwahira Y. The ulnar recurrent fasciocutaneous island flap: reverse medial arm flap. Plast Reconstr
Surg 1987;97:381e8.
12. Bishop AT. Soft tissue loss about the elbow. Selecting optimal
coverage. Hand Clin 1994;10:531e42.
13. Meland NB, Clinkscales CM, Wood MB. Pedicled radial forearm
flaps for recalcitrant defects about the elbow. Microsurgery
1991;12:155e9.
14. Hodgkinson DJ, Shepherd GH. Muscle musculocutaneous and
fasciocutaneous flaps in forearm reconstruction. Ann Plast
Surg 1983;10:400e7.
15. Hamdi M, Van Landuyt K, Monstrey S, et al. A clinical experience
with perforator flaps in the coverage of extensive defects of the
upper extremity. Plast Reconstr Surg 2004;113:1175e83.

Please cite this article in press as: Prantl L 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 (2007), doi:10.1016/j.bjps.2007.05.015

ARTICLE IN PRESS
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Safe and simple technique using the distal pedicled reversed upper arm
16. Mordick TG, Britton EN, Brantigan C. Pedicled latissimus dorsi
transfer for immediate soft tissue coverage and elbow flexion.
Plast Reconstr Surg 1996;99:1742e4.
17. Rohrich RJ, Ingram AE. Brachioradialis muscle flap: clinical
anatomy and use in soft-tissue reconstruction of the elbow.
Ann Plast Surg 1995;35:70e6.

18. Stern PJ, Neale HW, Gregory RO, et al. Latissimus dorsi musculocutaneous flap for elbow flexion. J Hand Surg (Am) 1982;7:
25e30.
19. Daltrey I, Thomson H, Hussien M, et al. Randomized clinical
trial of the effect of quilting latissimus dorsi flap donor site
on seroma formation. Br J Surg 2006;93:825e30.

Please cite this article in press as: Prantl L 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 (2007), doi:10.1016/j.bjps.2007.05.015