The medial arm pedicled perforator flap: application of phenomenon of one perforator perfusing multiple perforator angiosomes

Anatomy, surgical techniques, and clinical outcomes for the medial arm flap: A systematic review

BACKGROUND

The medial arm flap (MAF) has been used as a pedicle flap and free flap to reconstruct various deformities, including those of the head and neck, axilla, elbow, chest, and hand. This study reviews the anatomy of the flap, the technique of flap harvest, its clinical applications, and a systematic review of the current published literature.

METHODS

An online systematic review of MEDLINE, EMBASE, PubMed, and The Cochrane Library from inception to September 30, 2023, was completed. Studies that investigate the anatomy, technique or clinical outcomes of medial arm flaps were included. Clinical data extracted includes patient, defect, flap characteristics, complications, and take-back procedures. Anatomic data extracted includes anatomical variations, and vascular characteristics and patterns.

RESULTS

Between 1980 and 2023, 50 papers were published outlining the medial arm flap. Anatomic studies detail the anatomy of 384 medial arms, and outcomes are reported for 283 MAFs (75 free flaps and 208 pedicle flaps). The superior ulnar collateral artery is most commonly cited as the dominant arterial supply to the middle third of the medial arm. The majority of patients required reconstruction post-burn (39.2%), trauma (17.7%), and tumor excision (12.4%). MAFs were mostly used to reconstruct defects of the head and neck (41.7%), the hand and wrist (21.9%), and the elbow (16.3%). Eleven flaps (4.1%) suffered partial flap failure, and two flaps (0.7%) suffered total flap failure.

CONCLUSION

This manuscript demonstrates that the MAF is a reliable and underutilized flap option with a well-hidden donor scar and a low complication rate.

Clinical Effectiveness of Free Upper Arm Medial Flap in Repairing Skin and Soft Tissue Defects of the Dorsum of the Hand

Objective

To study the effectiveness of medial upper arm free flap in repairing skin and soft tissue (SST) defects of the dorsum of the hand.

Methods

10 patients with SST defects on the dorsum of the hand who underwent free upper arm medial flap repair in our hospital from March 2017 to August 2018 were included in the study. Hand function, flap survival rate, wound healing, donor wound recovery, and the level of pain in the injured area were recorded before the operation, 1 month, and 6 months postoperatively.

Results

The highest score in hand function was seen at the 6-month postoperative interval, followed by that at the 1-month postoperative interval. The lowest score in hand function was the preoperative score (P < 0.05). All flaps were still surviving 6 months postoperatively. Recovery of the function of the donor muscle, the elbow joint, as well as wound healing, all progressed well. 6 months postoperatively, 3 patients developed numbness and stiffness of the hand, but the symptoms were relieved following treatment. Compared to the preoperative scores, the visual analogue scale (VAS) scores at the injured site 1 month and 6 months postoperatively were significantly decreased, with the 6-month postoperative score being lower than the 1-month postoperative score (P < 0.05).

Conclusion

The free upper arm medial flap is a good alternative for repairing skin and soft tissue defects of the dorsum of the hand with exposed phalanges, an approach that merits widespread promotion and clinical application.

Procurement of Extended Vascularized Skin Flaps from the Donor Enables Hand Transplantation in Severe Upper Extremity Burns: An Anatomical Study

BACKGROUND

Hand transplantation in patients with severe upper extremity burns can be associated with an increased risk of exposure of vessels, tendons, and nerves because of extensive skin and soft-tissue deficit. This study evaluated how to reliably transfer additional extended skin flaps with a standard hand allograft.

METHODS

Twenty-five upper extremities were used. Sixteen were injected with latex to map the perforating branches of the brachial, superior ulnar collateral, radial, ulnar, and posterior interosseous arteries. Nine hand allografts were procured, injected with blue ink through the brachial artery to assess the perfusion of the skin flaps, and then mock transplanted.

RESULTS

Sizable perforators from the brachial, superior ulnar collateral, radial, ulnar, and posterior interosseous arteries were used to augment the vascularization of the skin flaps. The average stained area of the medial arm flap was between 85.7 and 93.9 percent. The stained area of the volar forearm flap was the smallest when based on perforators within 6 cm from the wrist crease (51.22 percent). The dorsal forearm flap showed the least amount of staining (34.7 to 46.1 percent). The average time to repair tendons, nerves, and vessels was longer when a single volar forearm-arm flap was harvested (171.6 minutes). Harvest of the allograft associated with a distally based forearm flap and islanded arm flap was the fastest (181.6 ± 17.55 minutes).

CONCLUSION

Extended skin flaps, based on perforators of the main axial vessels, can be reliably transplanted with a standard hand allograft based on the brachial or axillary vascular pedicle.