Radial Forearm Flaps for Reconstruction of the Elbow, Wrist, and Hand (2008)

Sir: Dr. Jones et al.1 reported a large series of pedicled or free radial forearm flaps for reconstruction of the upper extremity. They reported 24 dorsal and 12 palmar soft-tissue defects of the wrist that were covered with radial forearm flaps, but they did not present any postoperative photographs of donor sites. They also reported that nine pedicled groin flaps were used to cover wrist defects. However, we were disappointed that they did not comment or provide references concerning radial adipofascial flaps with radial artery preservation in their latest article (though they did previously report a case of a pedicled adipofascial flap for radioulnar synostosis2). Surgeons are aware that upper extremity reconstruction should be accomplished using the simplest means possible, and thus we consider that radial adipofascial turnover flaps with radial artery preservation should not be overlooked in terms of wrist defect reconstruction. As Dr. Jones wrote in a previous article,2 radial adipofascial flaps are straightforward and less time-consuming, and the one-stage operative procedure involved allows early physical rehabilitation.3 Moreover, as compared with other flaps, adipofascial flaps are thinner and introduce less bulk to the recipient site, and thus, their use is associated with minimal aesthetic sequelae at donor sites. In this regard, although pedicled or free radial forearm flaps are optimal under some conditions where functional problems are a concern, we consider that radial artery preservation should also be considered, because the adipofascial flaps, in appropriate cases, can provide pliable soft tissue coverage with a reliable blood supply without sacrificing the radial artery. Many authors4–9 have reported good results, and have described important anatomical and surgical pitfalls for about radial adipofascial flap and the preservation of the radial artery. Here, we present an unusual case treated with radial adipofascial turn-over flaps with radial artery preservation for the reconstruction of bilateral, high-voltage electrical burn wounds of the forearms (Fig. 1).Fig. 1.: Photograph obtained preoperatively.A 34-year-old patient with a high-voltage (22,900-V) electrical burn was referred by the department of orthopedic surgery after midline fasciotomies of the forearms, local skin flap, and skin grafting. He also had a fever of unknown origin, atelectasis, and pneumonic infiltration. The patient showed severe allergic dermatologic reactions to most antibiotics, and experienced frequent epilepsy fits despite antiepileptic medication. The function of both hands was impaired and most of the vital structures of both wrists were exposed. Bilateral median and ulnar neuropathies were identified by electromyography. Immediate flap coverage for both arms was required. During the first-stage treatment, tenolysis and bilateral carpal tunnel releases with neurolysis were performed under brachial plexus blocking anesthesia. During the second stage, both forearm wounds were covered with bilateral adipofascial flaps with radial artery preservation and a split-thickness skin graft. Flaps were easily elevated and applied to the wounds. No serious complication occurred, though minor revisional surgery was needed because of partial necrosis of the skin flap around the previous midline fasciotomy scars. Simultaneous early rehabilitation enabled tendons to glide freely under flaps. No secondary adjuvant procedure, such as tenolysis, was required (Fig. 2).Fig. 2.: Photograph obtained at 8 months postoperatively.Yong-il Yoon, M.D. Seung Chul Rhee, M.D., Ph.D. Dong Lark Lee, M.D., Ph.D. Jung Seok Yoo, M.D. Department of Plastic and Reconstructive Surgery Hanil General Hospital Korea Electric Power Corporation Medical Foundation Seoul, Korea