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Radial Forearm Flap and Posterior Interosseous Flap: Indications and Technical Pearls
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Radial Forearm Flap and Posterior Interosseous Flap: Indications and Technical Pearls
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Language: EN.
Segment:0 .
DURETTI FUFA: All right. Welcome back, guys. Dr. Dan Osei and I, my partner at HSS, we're going to go through two useful flaps that can be used in the upper extremity for coverage of the hand as well as the elbow and then also as a free flap. I'm going to talk quickly through some of the background and steps for the radial forearm flap.
DURETTI FUFA: Dan will talk about the posterior interosseous flap and then we'll go down and demo both of them. The radial forearm flap is an incredibly useful workhorse flap. I think that it's probably one of the key ones that that is a part of any any reconstructive surgeons toolbox. And it's also a great one, for course, like this, because its anatomy is really, really reliable and it's a very good starter kind of a flap for some of the techniques we're talking about.
DURETTI FUFA: The available tissue here is our skin and adiposfascial tissue. The blood supply is obviously the radial artery. We can use it as a free flap, but what we'll do is raise it as pedicled flaps. When you raise it in an anterograde fashion at the level of the wrist crease, you can use it for elbow coverage. And then when you use it in a retrograde fashion, you can use it for coverage of the hand.
DURETTI FUFA: Some of the advantages I mentioned already. It's a very easy harvest. The vascular anatomy of the radial artery is consistent and we're all familiar with it. It also provides very thin skin, which is as hand surgeons oftentimes this type of skin that we're trying to reconstruct. It can also be harvested with bone or with tendon in some variations to make it a chimeric flap.
DURETTI FUFA: Some of the disadvantages are that we are sacrificing a major terminal vessel in the upper limb, and as hand surgeons, we often don't like to do that in order to avoid any terminal vascular compromise to the hand, we want to always perform a digital Allen test to be sure that there's good supply both from the radial and ulnar artery in advance of harvesting the radial artery. In addition, the donor site is rather unattractive cosmetically, covering this with a full thickness skin graft can mitigate that, as can raising it in a suprafacial fashion
DURETTI FUFA: but we're going to practice raising it with traditional subfascial techniques today. The other thing to be aware of is that as hand surgeons, since we are managing oftentimes wounds in a more mangled or traumatic setting, the arch must be complete if you're going to use the flap in a retrograde fashion to use it for hand coverage. And sometimes it's not really an option
DURETTI FUFA: if your patient may have had trauma to the middle of the palm. The surgical technique, which we'll go through live here, we want to follow the vascular course of the radial artery, which you can palpate or Doppler. Skin markings for the anterograde style pedicled flap, which could then be used for coverage of the elbow is raised. I usually try to bias it a little bit more on the radial aspect, and that's because the tendons that are at the central portion of the wrist may have a little bit more trouble accepting your skin graft afterwards
DURETTI FUFA: so if you can bias it a little bit more in the radial direction, that often makes it a little bit easier for your skin graft to take. I like to start the dissection at the distal extent of the flap, just distal to where you think your skin paddle is going to be and identify the radial artery between the brachioradialis and the flexor carpi radialis, so that's what's looped with the vessiloop there.
DURETTI FUFA: Next we'll come from the radial aspect. You'll often encounter radial sensory nerves there that you're going to want to leave protected. You know that these radial sensory nerves like to develop neuromas, so we try not to traumatize those in our harvest. The key plain here is that once we identify the brachioradialis tendon, we keep the perrotine on on the brachioradialis and then dive deep below the level of the radial artery, keeping the radial artery approximated to the skin above.
DURETTI FUFA: This can be facilitated by putting a suture at the level of the peri arterial fat to the level of your skin so that you're sure that you won't shear that skin off. As we proceed then from the ulnar direction, our plane is between the flexor carpi radialis ulnarly and the brachioradialis radially. Similarly, we want to preserve the peritenon over the FCR and as soon as we get just radial to the FCR,
DURETTI FUFA: dive deep with your scalpel to make sure that we're shelling out the radial artery along with the skin paddle. This is progressing then in the distal to proximal direction where that vascular pedicle is sort of at the junction where that start is and you can see the FCR tendon centrally there, the BR tendon more deep in the shadows, and you're keeping everything connected between the radial artery and the skin.
DURETTI FUFA: One sort of, you see that once we've taken the flap out, there can be some bits of tendon that are exposed without your peritenon. Sometimes you can just mobilize and put an extra suture layer to cover some of that tendon there to make it a little bit more receptive to your skin graft. Using integra could also be an alternative if it's really stripped bare somehow.
DURETTI FUFA: Some tips and tricks and then I'll go. Then we'll switch over to Dan. Is he around? Then we'll switch over. So, as I mentioned, make sure that you're familiar with the vascular anatomy in your patient's hand. They have to have a patent radial artery and an arch if you're going to use this flap for hand coverage.
DURETTI FUFA: Maintain your dissection superficial, overlying the tendon of the FCR and the BR, but then dive deep immediately as you come central to either one of those. Full thickness skin graft can be used for better cosmesis and then if you're harvesting, so I've just shown the dissection for an anterograde flap using it to bring pedicle to the proximal direction,
DURETTI FUFA: but I've also, will also go through in the cadaver the dissection, using it in a in a fashion to bring for hand coverage. But on that dissection I like to start over the brachioradialis tendon muscle belly in order to help that find the septum in in between BR and FCR in order to capture the radial artery. This flap can also be used as a perforator propeller flap at the table.
DURETTI FUFA: If we have time, we can try to identify some of those small vessels if they exist. All right, Dan, you ready? Questions about the radial forearm flap? Uses?
DANIEL OSEI: ok. We'll try to get through this quickly since we have two flaps to go through before you guys start.
DANIEL OSEI: OK so the posterior interosseous flap is definitely another good example of a fascia cutaneous perforator flap and it's been described for a long time. This is one of the historical papers talking about the blood supply and again, this is a flap that gets its blood flow retrograde from the posterior interosseous artery via an anastomosis with the anterior interosseous artery. And what happens in the mid dorsal forearm is that there are superficial septal cutaneous perforators that will provide blood flow to the flap
DANIEL OSEI: and we'll kind of go through this a little bit. Why do I like this flap? It does allow for preservation of the large axial blood vessels to the hand and forearm, the both radial and ulnar artery and so it's always nice to not have to de-vascularize any portion of the blood supply of the hand. The arc of rotation is such that it makes it a very practical flap.
DANIEL OSEI: Most of the dorsal hand coverage that you would need, this is a wonderful flap for this. I really learned a lot of principles from Raja Sabapathy, who's really championed this flap. It doesn't require microsurgery, which is not necessarily good or bad, but particularly in a group like this and if you're not sure whether you're going to do a lot of micro, this is certainly something that allows you to harvest the flap in a more time expedient manner.
DANIEL OSEI: I've had some issues with it, and this is one of the things that people oftentimes will talk about with this flap. The dissection can be a bit challenging, the blood supply from the PIA to the skin becomes more random, meaning that as you get further and further distal, the reliability of that axial blood vessel becomes less. And this was a diabetic patient that I had harvested a PIA flap and it actually survived deep
DANIEL OSEI: and I ended up skin grafting but this can be an issue and people have been worried about this issue. A quick illustrative case here, and I'll probably skip some of this and you can look at some of the slides later. But here's a patient that had a tablesaw injury, a common injury at 2am over a bottle of bourbon in Saint Louis.
DANIEL OSEI: Harvested the flap here and this will go through a little bit of the applied surgical anatomy. So the pivot point is going to be 2cm proximal to the distal radioulnar joint. That is the point at which the anterior interosseous artery anastomoses with the posterior interosseous artery and that's where the tipping point will be. I like the use of this 1cm racket handle,
DANIEL OSEI: and what that does is it makes sure that you don't end up separating out some of the tiny septocutaneous perforators that are going to be important for your pedicle. The critical perforator, again, from deep to the superficial portion of the flap is going to be at the midpoint of the axis between the lateral epicondyle and the DRUJ. I like to harvest from posterior,
DANIEL OSEI: that's because I tend to be able to identify the extensor carpi ulnaris a little bit easier and the perforators are going to lay in between the sixth and fifth dorsal compartments. So here we've elevated again from more ulnar and I've elevated down to the fascia, I've opened up the fascia and then I've elevated all the way to the edge of the ECU and at that point you get to the septum here a little septic cutaneous perforators that are coming again between the sixth and fifth dorsal compartment.
DANIEL OSEI: After I've identified the septum, I'll go to again the more radial side and I'll dissect down in a similar manner over the extensor digitorum communis again going from radial to ulnar up until the edge of the muscle and then I'll go deep, so this is the same kind of technique that Duretti talked about with identifying your interval between the the two compartments that you're trying to preserve the septum in between.
DANIEL OSEI: From there, again, the little caricature in the top right corner sort of demonstrates what's going on there. A number of perforators again, I usually try to maintain the critical perforator and then once you've gone underneath the septum, the rest of the dissection is quite simple. And so here it's been rotated into place, a Penrose drain in position. If you harvest, usually for me, more than 6cm, I end up skin grafting just because it's a bit tight.
DANIEL OSEI: But again, nice fit in terms of the thinness as well as kind of the likeness of the dorsum of the hand relative to the dorsum of the forearm. So I kind of want to end there because again, this is a little bit of a long dissection here between the two but again, start posteriorly, I do think it's easier for you guys. One trick I used to use a lot is if you start your dissection further distal, you'll be able to actually identify the ECU tendon and that will give you greater confidence that you're actually in the right interval there
DANIEL OSEI: and I do like this racket handle technique to preserve the adipofascial perforators within the pedicle. So I'll stop there. Thanks. [APPLAUSE]
DURETTI FUFA: OK. Can you guys hear me? So we're going to come now to do some of the pro section that we did on the radial artery forearm flap, and then we'll wrap up with Dan doing it before we give you guys a chance to go at it.
DURETTI FUFA: The radial artery forearm flap, like I said, is the anatomy is something that us hand surgeons are all really comfortable with, so I'll just go through again some of those points that I'd highlighted in the PowerPoint. So if we're going to use the flap for elbow coverage or oftentimes as a free flap, we'll base it distal on the forearm here so the blood flow is coming in in an antegrade fashion.
DURETTI FUFA: As I mentioned, we know the vascular anatomy of the radial artery and I try to bias my skin paddle a little bit more in the radial direction to try not to leave as many of the ulnar tendons exposed. My first incision is distal to the skin paddle where we're going to identify the radial artery and loop it with a vessiloop.
DURETTI FUFA: OK? We at the same time, we can start to identify our interval, which is going to be between the flexor carpi radialis and the brachioradialis tendon there. Some superficial veins that we can take down, as I mentioned. You'll often encounter superficial radial sensory nerves. Things dried out a little bit since my pro section, which we will free up and here over the BR tendon,
DURETTI FUFA: I'm going to try to keep that peritenon intact. CR, BR keeping peritenon on intact but as soon as I'm to the ulnar aspect of the brachioradialis, think it's coming out OK in the, did you go?
DANIEL OSEI: We come over the top a little bit more? Is that possible?
DURETTI FUFA: And as soon as I'm radial to the flexor carpi radialis, I'm really going to start shelling deep here. Now, once I've defined my borders, radial and ulnar, I am going to place a suture between the skin edge here and the fat not as big of a suture as this, of course, so that we don't shear the skin, paddle off the blood vessel.
DURETTI FUFA: And at this point, we can then decide that we're going to sacrifice the radial artery. Prior to doing that, if you have any concern about the vascular supply, a good step to do would be to put a microvascular clamp on the radial artery that's identified here, take the tourniquet down and make sure that you have good perfusion in the hand. So we've confirmed that we have good blood flow through the ulnar artery only, and we can sacrifice the radial artery here and now the dissection can move in the distal to proximal direction relatively expediently.
DURETTI FUFA: Dan's holding the FCR tendon to the side, I'm taking the artery out. We've got our dorsal branch of the radial artery coming off underneath there, and now I'm just working in this crevice between the two, keep making sure that I keep everything between the skin and this radial artery intact. This dorsal branch is massive.
DURETTI FUFA: Again, making sure that on the side here I'm identifying and protecting our radial sensory nerve. I may have more of my volar branch here. So we're going to take a little bit more of this, more main portion of the radial artery with our flap here.
DURETTI FUFA: So nothing untoward has happened yet. All still nicely connected and we'll take this portion to the dorsal branch there. Here again, I'm going to try to keep the peritenon intact over the FCR and not dive deep until I've gotten just radial to it.
DURETTI FUFA: Bipolars can help this dissection be expedient, as can small haema clips like gem clips. OK. So then once we get to the proximal extent of the flap, we'll have just identified the radial artery and we can island the artery
DURETTI FUFA: to carry it as proximal as we need for the elbow coverage or as long of a pedicle as we need if we're using it as a free flap. Here we have our artery here
DURETTI FUFA: OK and we can carry that as proximal as we need to go in order to reach the elbow. I just want to spend a moment to show you the start of the dissection of when it's going to be based proximal such that we would use it for hand coverage. So again, doppling the course of the radial artery and the plane between the flexor carpi radialis and the brachioradialis, I like to begin the dissection on this radial aspect.
DURETTI FUFA: When I came down here, I encountered almost immediately a radial sensory nerve that we protect, and the muscle that we're on here is a brachioradialis and what I just want to show in this step is that when you incise that fascia of the brachioradialis, this is a very similar step that we did for the fibular flap that you'll do for the PIA flap as well. We incise also for the dorsal metacarpal artery we've got the fouchet flap, incise that fascia and then use that to fall into the septum between the FCR
DURETTI FUFA: and the brachioradialis. The proximal flap is, it's easier to lose that septum between the radial artery and your flap here so finding the artery and that septum is not quite as easily defined as it is distally. So if you have the time, which we may not, if you have the time, I would recommend taking that step to just try to see that you can identify the plane between brachioradialis and flexor carpi radialis and keep that vessel in that sheath there.
DURETTI FUFA: OK? We'll switch over to Dan for posterior interosseous and then can get you guys on your dissection. Give me the microphone.
DANIEL OSEI: Welcome here. Good. All right. So switching gears to the dorsum of the forearm has desiccated a little bit. So, again, just landmarks. I've marked out the radial, the radius and the ulnar DRUJ. Again, that's going to be our pivot point and then lateral epicondyle so the critical perforator again is usually at the midpoint.
DANIEL OSEI: There are multiple perforators, perhaps a little bit proximal to that and so usually when I base a PIA flap, I tend to be in this region as the proximal extent. As you get further out here, you can raise the PIA flap further. There are multiple people that have described this, but again, it does become slightly more unreliable in terms of the distal blood supply. So as I was saying in my talk, I usually will start again on the ulnar side of the flap.
DANIEL OSEI: I'm just going to open up the area that we've already done a little bit of pre-dissection and what I would typically do is leave the apex of the flap intact as I start the dissection looking for that septum again between the sixth and the fifth dorsal compartment. So I would make my incision down through dermis as well as finding the forearm fascia and then what I would typically do is once I've opened up and confirmed that I was in the sixth dorsal compartment over the ECU, which I don't know if you can see here, is back here,
DANIEL OSEI: I would elevate from ulnar to radial and this, as I was telling one of the tables, is sort of a classic technique with any kind of perforator flap surgery. And then once I got to the edge of the ECU, that's when I start to dissect down, just as we were talking about with the radial forearm flap. Here, I don't know if that projects is going to be that critical
DANIEL OSEI: perforator going into your PIA flap. And so once I've seen that, that's when sphincter tone goes down a little bit, you know that you're kind of in the right interval, and once we get underneath, we're going to be OK. From that point on, I would then go on to the radial side, as I was just describing and again, for the sake of expediency,
DANIEL OSEI: we've already done a little bit of pre-dissection here. And using a similar technique again on the more radial side down through skin dermis, subcutaneous tissues onto the fascia, open up the fascia over the fourth dorsal compartment so the extensor digitorum and again, in a similar manner, I would be using my knife to slowly elevate up the fascia and this is again the fascia carefully until we get to that interval between the fourth and the fifth dorsal compartments.
DANIEL OSEI: So what we're really trying to see again is this septum on that side here. So once I've done that and I've elevated on both sides from here, I would go ahead and come back down to where we were on the ulnar side. And as I'm looking at the interval, I'm going to start trying to get underneath. You can actually see small perforators going into the extensor carpi ulnaris over here.
DANIEL OSEI: And so as I'm trying to elevate all the way down, trying to make sure we're not disconnecting blood supply from the flap, the skin, we get all the way get underneath this interval here. And so again, what I'm really doing and I think I described this again to one of the other tables, is that what you're trying to do is dissect the ECU away from the flap rather than dissecting the flap tissue, if that makes sense.
DANIEL OSEI: You really want to keep the flap tissue intact. So I'm just again dissecting the ECU away.
DANIEL OSEI: And so now that we have our septum up and I'm looking at the perforators here, what we would end up doing is dissecting and then just releasing some of the septum up here, and I'm still just following these blood vessels all the way down into this area here.
DANIEL OSEI: Yep. And so what you can see here, I don't know if this projects at all, but there's a blush of that posterior interosseous artery right there, so I'm just carefully dissecting some of the septal tissue off of
DANIEL OSEI: the vessel here. And you see that projector, right? OK, good. So again, trying to make sure that our vessel stays with the tissue and once I see that I'm underneath it and here it is over here, I can be a little bit more expedient with my time and again, this is all
DANIEL OSEI: fascial tissue that I'm dissecting again, away from the blood vessel and elevating that up. Here's the vessel again over here. So here's another perforator that I see here and that's a good place to kind of truncate because again, this is retrograde flow. So I do this with some kind of Liga clips or Gem clips and I'm underneath.
DANIEL OSEI: Again vessel here. We can come back to the other side. Again trying to leave the EDC alone. Getting down to the bottom of the septum, again, not wanting to separate blood vessel away.
DANIEL OSEI: Fat typically represents a good plain for blood vessels and nerves and so we found it there and so we'll go back again, and I think for the sake of time, I'm just going to go ahead and make sure that I'm underneath our vessel, which we've confirmed time and time again with our extremely sharp
DANIEL OSEI: tenotomies here. We'll go ahead and go underneath the flap. Again, vessel sort of talking through mental steps that I'll take where I'm constantly looking, where is the vessel? Confirming again, seeing the vessel again, and then coming up. So we'll stop there.
DANIEL OSEI: We can definitely continue all the way down again to the pivot point all the way over here and that will allow you to kind of come all the way there. But the big thing again, is going to be finding the interval between fifth and sixth on the ulnar side and then fourth and fifth on the radial side. OK so we were behind.
DANIEL OSEI: So what we'll do, why don't we guys go ahead and get started. At 10.30, if you guys want, there will be coffee outside, but we'll please try to be back in here if you are going to take a break at 10.45 because we're going to have the live demo for the lateral arm flap.
Segment:0 .
DURETTI FUFA: All right. Welcome back, guys. Dr. Dan Osei and I, my partner at HSS, we're going to go through two useful flaps that can be used in the upper extremity for coverage of the hand as well as the elbow and then also as a free flap. I'm going to talk quickly through some of the background and steps for the radial forearm flap.
DURETTI FUFA: Dan will talk about the posterior interosseous flap and then we'll go down and demo both of them. The radial forearm flap is an incredibly useful workhorse flap. I think that it's probably one of the key ones that that is a part of any any reconstructive surgeons toolbox. And it's also a great one, for course, like this, because its anatomy is really, really reliable and it's a very good starter kind of a flap for some of the techniques we're talking about.
DURETTI FUFA: The available tissue here is our skin and adiposfascial tissue. The blood supply is obviously the radial artery. We can use it as a free flap, but what we'll do is raise it as pedicled flaps. When you raise it in an anterograde fashion at the level of the wrist crease, you can use it for elbow coverage. And then when you use it in a retrograde fashion, you can use it for coverage of the hand.
DURETTI FUFA: Some of the advantages I mentioned already. It's a very easy harvest. The vascular anatomy of the radial artery is consistent and we're all familiar with it. It also provides very thin skin, which is as hand surgeons oftentimes this type of skin that we're trying to reconstruct. It can also be harvested with bone or with tendon in some variations to make it a chimeric flap.
DURETTI FUFA: Some of the disadvantages are that we are sacrificing a major terminal vessel in the upper limb, and as hand surgeons, we often don't like to do that in order to avoid any terminal vascular compromise to the hand, we want to always perform a digital Allen test to be sure that there's good supply both from the radial and ulnar artery in advance of harvesting the radial artery. In addition, the donor site is rather unattractive cosmetically, covering this with a full thickness skin graft can mitigate that, as can raising it in a suprafacial fashion
DURETTI FUFA: but we're going to practice raising it with traditional subfascial techniques today. The other thing to be aware of is that as hand surgeons, since we are managing oftentimes wounds in a more mangled or traumatic setting, the arch must be complete if you're going to use the flap in a retrograde fashion to use it for hand coverage. And sometimes it's not really an option
DURETTI FUFA: if your patient may have had trauma to the middle of the palm. The surgical technique, which we'll go through live here, we want to follow the vascular course of the radial artery, which you can palpate or Doppler. Skin markings for the anterograde style pedicled flap, which could then be used for coverage of the elbow is raised. I usually try to bias it a little bit more on the radial aspect, and that's because the tendons that are at the central portion of the wrist may have a little bit more trouble accepting your skin graft afterwards
DURETTI FUFA: so if you can bias it a little bit more in the radial direction, that often makes it a little bit easier for your skin graft to take. I like to start the dissection at the distal extent of the flap, just distal to where you think your skin paddle is going to be and identify the radial artery between the brachioradialis and the flexor carpi radialis, so that's what's looped with the vessiloop there.
DURETTI FUFA: Next we'll come from the radial aspect. You'll often encounter radial sensory nerves there that you're going to want to leave protected. You know that these radial sensory nerves like to develop neuromas, so we try not to traumatize those in our harvest. The key plain here is that once we identify the brachioradialis tendon, we keep the perrotine on on the brachioradialis and then dive deep below the level of the radial artery, keeping the radial artery approximated to the skin above.
DURETTI FUFA: This can be facilitated by putting a suture at the level of the peri arterial fat to the level of your skin so that you're sure that you won't shear that skin off. As we proceed then from the ulnar direction, our plane is between the flexor carpi radialis ulnarly and the brachioradialis radially. Similarly, we want to preserve the peritenon over the FCR and as soon as we get just radial to the FCR,
DURETTI FUFA: dive deep with your scalpel to make sure that we're shelling out the radial artery along with the skin paddle. This is progressing then in the distal to proximal direction where that vascular pedicle is sort of at the junction where that start is and you can see the FCR tendon centrally there, the BR tendon more deep in the shadows, and you're keeping everything connected between the radial artery and the skin.
DURETTI FUFA: One sort of, you see that once we've taken the flap out, there can be some bits of tendon that are exposed without your peritenon. Sometimes you can just mobilize and put an extra suture layer to cover some of that tendon there to make it a little bit more receptive to your skin graft. Using integra could also be an alternative if it's really stripped bare somehow.
DURETTI FUFA: Some tips and tricks and then I'll go. Then we'll switch over to Dan. Is he around? Then we'll switch over. So, as I mentioned, make sure that you're familiar with the vascular anatomy in your patient's hand. They have to have a patent radial artery and an arch if you're going to use this flap for hand coverage.
DURETTI FUFA: Maintain your dissection superficial, overlying the tendon of the FCR and the BR, but then dive deep immediately as you come central to either one of those. Full thickness skin graft can be used for better cosmesis and then if you're harvesting, so I've just shown the dissection for an anterograde flap using it to bring pedicle to the proximal direction,
DURETTI FUFA: but I've also, will also go through in the cadaver the dissection, using it in a in a fashion to bring for hand coverage. But on that dissection I like to start over the brachioradialis tendon muscle belly in order to help that find the septum in in between BR and FCR in order to capture the radial artery. This flap can also be used as a perforator propeller flap at the table.
DURETTI FUFA: If we have time, we can try to identify some of those small vessels if they exist. All right, Dan, you ready? Questions about the radial forearm flap? Uses?
DANIEL OSEI: ok. We'll try to get through this quickly since we have two flaps to go through before you guys start.
DANIEL OSEI: OK so the posterior interosseous flap is definitely another good example of a fascia cutaneous perforator flap and it's been described for a long time. This is one of the historical papers talking about the blood supply and again, this is a flap that gets its blood flow retrograde from the posterior interosseous artery via an anastomosis with the anterior interosseous artery. And what happens in the mid dorsal forearm is that there are superficial septal cutaneous perforators that will provide blood flow to the flap
DANIEL OSEI: and we'll kind of go through this a little bit. Why do I like this flap? It does allow for preservation of the large axial blood vessels to the hand and forearm, the both radial and ulnar artery and so it's always nice to not have to de-vascularize any portion of the blood supply of the hand. The arc of rotation is such that it makes it a very practical flap.
DANIEL OSEI: Most of the dorsal hand coverage that you would need, this is a wonderful flap for this. I really learned a lot of principles from Raja Sabapathy, who's really championed this flap. It doesn't require microsurgery, which is not necessarily good or bad, but particularly in a group like this and if you're not sure whether you're going to do a lot of micro, this is certainly something that allows you to harvest the flap in a more time expedient manner.
DANIEL OSEI: I've had some issues with it, and this is one of the things that people oftentimes will talk about with this flap. The dissection can be a bit challenging, the blood supply from the PIA to the skin becomes more random, meaning that as you get further and further distal, the reliability of that axial blood vessel becomes less. And this was a diabetic patient that I had harvested a PIA flap and it actually survived deep
DANIEL OSEI: and I ended up skin grafting but this can be an issue and people have been worried about this issue. A quick illustrative case here, and I'll probably skip some of this and you can look at some of the slides later. But here's a patient that had a tablesaw injury, a common injury at 2am over a bottle of bourbon in Saint Louis.
DANIEL OSEI: Harvested the flap here and this will go through a little bit of the applied surgical anatomy. So the pivot point is going to be 2cm proximal to the distal radioulnar joint. That is the point at which the anterior interosseous artery anastomoses with the posterior interosseous artery and that's where the tipping point will be. I like the use of this 1cm racket handle,
DANIEL OSEI: and what that does is it makes sure that you don't end up separating out some of the tiny septocutaneous perforators that are going to be important for your pedicle. The critical perforator, again, from deep to the superficial portion of the flap is going to be at the midpoint of the axis between the lateral epicondyle and the DRUJ. I like to harvest from posterior,
DANIEL OSEI: that's because I tend to be able to identify the extensor carpi ulnaris a little bit easier and the perforators are going to lay in between the sixth and fifth dorsal compartments. So here we've elevated again from more ulnar and I've elevated down to the fascia, I've opened up the fascia and then I've elevated all the way to the edge of the ECU and at that point you get to the septum here a little septic cutaneous perforators that are coming again between the sixth and fifth dorsal compartment.
DANIEL OSEI: After I've identified the septum, I'll go to again the more radial side and I'll dissect down in a similar manner over the extensor digitorum communis again going from radial to ulnar up until the edge of the muscle and then I'll go deep, so this is the same kind of technique that Duretti talked about with identifying your interval between the the two compartments that you're trying to preserve the septum in between.
DANIEL OSEI: From there, again, the little caricature in the top right corner sort of demonstrates what's going on there. A number of perforators again, I usually try to maintain the critical perforator and then once you've gone underneath the septum, the rest of the dissection is quite simple. And so here it's been rotated into place, a Penrose drain in position. If you harvest, usually for me, more than 6cm, I end up skin grafting just because it's a bit tight.
DANIEL OSEI: But again, nice fit in terms of the thinness as well as kind of the likeness of the dorsum of the hand relative to the dorsum of the forearm. So I kind of want to end there because again, this is a little bit of a long dissection here between the two but again, start posteriorly, I do think it's easier for you guys. One trick I used to use a lot is if you start your dissection further distal, you'll be able to actually identify the ECU tendon and that will give you greater confidence that you're actually in the right interval there
DANIEL OSEI: and I do like this racket handle technique to preserve the adipofascial perforators within the pedicle. So I'll stop there. Thanks. [APPLAUSE]
DURETTI FUFA: OK. Can you guys hear me? So we're going to come now to do some of the pro section that we did on the radial artery forearm flap, and then we'll wrap up with Dan doing it before we give you guys a chance to go at it.
DURETTI FUFA: The radial artery forearm flap, like I said, is the anatomy is something that us hand surgeons are all really comfortable with, so I'll just go through again some of those points that I'd highlighted in the PowerPoint. So if we're going to use the flap for elbow coverage or oftentimes as a free flap, we'll base it distal on the forearm here so the blood flow is coming in in an antegrade fashion.
DURETTI FUFA: As I mentioned, we know the vascular anatomy of the radial artery and I try to bias my skin paddle a little bit more in the radial direction to try not to leave as many of the ulnar tendons exposed. My first incision is distal to the skin paddle where we're going to identify the radial artery and loop it with a vessiloop.
DURETTI FUFA: OK? We at the same time, we can start to identify our interval, which is going to be between the flexor carpi radialis and the brachioradialis tendon there. Some superficial veins that we can take down, as I mentioned. You'll often encounter superficial radial sensory nerves. Things dried out a little bit since my pro section, which we will free up and here over the BR tendon,
DURETTI FUFA: I'm going to try to keep that peritenon intact. CR, BR keeping peritenon on intact but as soon as I'm to the ulnar aspect of the brachioradialis, think it's coming out OK in the, did you go?
DANIEL OSEI: We come over the top a little bit more? Is that possible?
DURETTI FUFA: And as soon as I'm radial to the flexor carpi radialis, I'm really going to start shelling deep here. Now, once I've defined my borders, radial and ulnar, I am going to place a suture between the skin edge here and the fat not as big of a suture as this, of course, so that we don't shear the skin, paddle off the blood vessel.
DURETTI FUFA: And at this point, we can then decide that we're going to sacrifice the radial artery. Prior to doing that, if you have any concern about the vascular supply, a good step to do would be to put a microvascular clamp on the radial artery that's identified here, take the tourniquet down and make sure that you have good perfusion in the hand. So we've confirmed that we have good blood flow through the ulnar artery only, and we can sacrifice the radial artery here and now the dissection can move in the distal to proximal direction relatively expediently.
DURETTI FUFA: Dan's holding the FCR tendon to the side, I'm taking the artery out. We've got our dorsal branch of the radial artery coming off underneath there, and now I'm just working in this crevice between the two, keep making sure that I keep everything between the skin and this radial artery intact. This dorsal branch is massive.
DURETTI FUFA: Again, making sure that on the side here I'm identifying and protecting our radial sensory nerve. I may have more of my volar branch here. So we're going to take a little bit more of this, more main portion of the radial artery with our flap here.
DURETTI FUFA: So nothing untoward has happened yet. All still nicely connected and we'll take this portion to the dorsal branch there. Here again, I'm going to try to keep the peritenon intact over the FCR and not dive deep until I've gotten just radial to it.
DURETTI FUFA: Bipolars can help this dissection be expedient, as can small haema clips like gem clips. OK. So then once we get to the proximal extent of the flap, we'll have just identified the radial artery and we can island the artery
DURETTI FUFA: to carry it as proximal as we need for the elbow coverage or as long of a pedicle as we need if we're using it as a free flap. Here we have our artery here
DURETTI FUFA: OK and we can carry that as proximal as we need to go in order to reach the elbow. I just want to spend a moment to show you the start of the dissection of when it's going to be based proximal such that we would use it for hand coverage. So again, doppling the course of the radial artery and the plane between the flexor carpi radialis and the brachioradialis, I like to begin the dissection on this radial aspect.
DURETTI FUFA: When I came down here, I encountered almost immediately a radial sensory nerve that we protect, and the muscle that we're on here is a brachioradialis and what I just want to show in this step is that when you incise that fascia of the brachioradialis, this is a very similar step that we did for the fibular flap that you'll do for the PIA flap as well. We incise also for the dorsal metacarpal artery we've got the fouchet flap, incise that fascia and then use that to fall into the septum between the FCR
DURETTI FUFA: and the brachioradialis. The proximal flap is, it's easier to lose that septum between the radial artery and your flap here so finding the artery and that septum is not quite as easily defined as it is distally. So if you have the time, which we may not, if you have the time, I would recommend taking that step to just try to see that you can identify the plane between brachioradialis and flexor carpi radialis and keep that vessel in that sheath there.
DURETTI FUFA: OK? We'll switch over to Dan for posterior interosseous and then can get you guys on your dissection. Give me the microphone.
DANIEL OSEI: Welcome here. Good. All right. So switching gears to the dorsum of the forearm has desiccated a little bit. So, again, just landmarks. I've marked out the radial, the radius and the ulnar DRUJ. Again, that's going to be our pivot point and then lateral epicondyle so the critical perforator again is usually at the midpoint.
DANIEL OSEI: There are multiple perforators, perhaps a little bit proximal to that and so usually when I base a PIA flap, I tend to be in this region as the proximal extent. As you get further out here, you can raise the PIA flap further. There are multiple people that have described this, but again, it does become slightly more unreliable in terms of the distal blood supply. So as I was saying in my talk, I usually will start again on the ulnar side of the flap.
DANIEL OSEI: I'm just going to open up the area that we've already done a little bit of pre-dissection and what I would typically do is leave the apex of the flap intact as I start the dissection looking for that septum again between the sixth and the fifth dorsal compartment. So I would make my incision down through dermis as well as finding the forearm fascia and then what I would typically do is once I've opened up and confirmed that I was in the sixth dorsal compartment over the ECU, which I don't know if you can see here, is back here,
DANIEL OSEI: I would elevate from ulnar to radial and this, as I was telling one of the tables, is sort of a classic technique with any kind of perforator flap surgery. And then once I got to the edge of the ECU, that's when I start to dissect down, just as we were talking about with the radial forearm flap. Here, I don't know if that projects is going to be that critical
DANIEL OSEI: perforator going into your PIA flap. And so once I've seen that, that's when sphincter tone goes down a little bit, you know that you're kind of in the right interval, and once we get underneath, we're going to be OK. From that point on, I would then go on to the radial side, as I was just describing and again, for the sake of expediency,
DANIEL OSEI: we've already done a little bit of pre-dissection here. And using a similar technique again on the more radial side down through skin dermis, subcutaneous tissues onto the fascia, open up the fascia over the fourth dorsal compartment so the extensor digitorum and again, in a similar manner, I would be using my knife to slowly elevate up the fascia and this is again the fascia carefully until we get to that interval between the fourth and the fifth dorsal compartments.
DANIEL OSEI: So what we're really trying to see again is this septum on that side here. So once I've done that and I've elevated on both sides from here, I would go ahead and come back down to where we were on the ulnar side. And as I'm looking at the interval, I'm going to start trying to get underneath. You can actually see small perforators going into the extensor carpi ulnaris over here.
DANIEL OSEI: And so as I'm trying to elevate all the way down, trying to make sure we're not disconnecting blood supply from the flap, the skin, we get all the way get underneath this interval here. And so again, what I'm really doing and I think I described this again to one of the other tables, is that what you're trying to do is dissect the ECU away from the flap rather than dissecting the flap tissue, if that makes sense.
DANIEL OSEI: You really want to keep the flap tissue intact. So I'm just again dissecting the ECU away.
DANIEL OSEI: And so now that we have our septum up and I'm looking at the perforators here, what we would end up doing is dissecting and then just releasing some of the septum up here, and I'm still just following these blood vessels all the way down into this area here.
DANIEL OSEI: Yep. And so what you can see here, I don't know if this projects at all, but there's a blush of that posterior interosseous artery right there, so I'm just carefully dissecting some of the septal tissue off of
DANIEL OSEI: the vessel here. And you see that projector, right? OK, good. So again, trying to make sure that our vessel stays with the tissue and once I see that I'm underneath it and here it is over here, I can be a little bit more expedient with my time and again, this is all
DANIEL OSEI: fascial tissue that I'm dissecting again, away from the blood vessel and elevating that up. Here's the vessel again over here. So here's another perforator that I see here and that's a good place to kind of truncate because again, this is retrograde flow. So I do this with some kind of Liga clips or Gem clips and I'm underneath.
DANIEL OSEI: Again vessel here. We can come back to the other side. Again trying to leave the EDC alone. Getting down to the bottom of the septum, again, not wanting to separate blood vessel away.
DANIEL OSEI: Fat typically represents a good plain for blood vessels and nerves and so we found it there and so we'll go back again, and I think for the sake of time, I'm just going to go ahead and make sure that I'm underneath our vessel, which we've confirmed time and time again with our extremely sharp
DANIEL OSEI: tenotomies here. We'll go ahead and go underneath the flap. Again, vessel sort of talking through mental steps that I'll take where I'm constantly looking, where is the vessel? Confirming again, seeing the vessel again, and then coming up. So we'll stop there.
DANIEL OSEI: We can definitely continue all the way down again to the pivot point all the way over here and that will allow you to kind of come all the way there. But the big thing again, is going to be finding the interval between fifth and sixth on the ulnar side and then fourth and fifth on the radial side. OK so we were behind.
DANIEL OSEI: So what we'll do, why don't we guys go ahead and get started. At 10.30, if you guys want, there will be coffee outside, but we'll please try to be back in here if you are going to take a break at 10.45 because we're going to have the live demo for the lateral arm flap.
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