47: Lateral Arm Flap for Upper Limb Coverage

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Last modified 22/04/2025

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Procedure 47 Lateral Arm Flap for Upper Limb Coverage

Indications

image Procedure is used for soft tissue defects of the hand and wrist. These defects range from a medium size of 3 × 5 cm to a large size of 15 × 20 cm and can include the following:

image These skin defects are from loss of the full thickness of the dermis and the entire thickness of the subcutaneous tissues. The deeper tendons and neurovascular bundle could also be lacerated or could have suffered a segmental loss. The underlying bone could also be fractured. These defects include the following:

image Location of these soft tissue defects could be further classified as follows:

Palmar defect (Fig. 47-1 shows a 10 × 10 cm degloving injury over the palm and thumb in a 35-year-old male fitter.)

image Free-flap version of the lateral arm flap is always preferred for the resurfacing. The flap is usually harvested from the ipsilateral side. The pedicled version of the flap is harvested from the contralateral side. The pedicled flap is chosen for the following indications:

The recipient vessels for anastomosis are not available. (Fig. 47-2 shows a 22 × 4.5 cm circumferential skin defect, following skin necrosis of a transmetacarpal replant in a 25-year-old carpenter.)

Surgical Anatomy

image The flap is from the lateral arm region with extension distal to the lateral humeral epicondyle down the lateral side of the forearm. The vascular pedicle is the posterior radial collateral artery (PRCA), a branch of the profunda brachii artery. One to two veins accompany the PRCA artery. The size of the artery is 1.5 to 2 mm in diameter, and the vein 2 to 3 mm in diameter. The vascular pedicle runs in the lateral intermuscular septum accompanied by the posterior antebrachial cutaneous nerve. Three to four septocutaneous perforators supply the lateral arm skin. The most distal branch of the septal vessel is 3 to 5 cm proximal to the lateral epicondyle. There are also three to four small branches of vessels running deep providing periosteal blood supply to the distal lateral humeral bone. The pedicle length of the flap ranges from 5 to 10 cm depending on the design of the flap (Fig. 47-3).

image The flap extends from the deltoid tuberosity to the lateral humeral epicondyle, a length of about 20 cm. The flap can be further extended distally down the lateral aspect of the forearm another 15 cm. The skin over the lateral forearm is thinner than the skin over the lateral arm. The width of the skin flap is limited to 6 cm to allow direct closure of the donor site. Centering the flap over the lateral humeral epicondyle has the advantage of having the thinner distal skin and a longer vascular pedicle.

image In a free-flap version, the ipsilateral flap is preferred. This gives the advantage of confining the wound to the same upper limb. In a pedicled flap version, the flap has to come from the contralateral arm.

Design of Free Lateral Arm Flap

Procedure

Step 9: Harvesting the Pedicled Flap

Evidence

Akinci M, Ay S, Kamiloglu S, Ercetin O. Lateral arm free flaps in the defects of the upper limbs—a review of 72 cases. Hand Surg. 2005;10:177-185.

Seventy-four free lateral arm flap procedures were performed in 72 patients. Five were performed as emergencies, 12 within 72 hours of injury, and 57 as elective surgery. The size of skin defects ranged from 6 × 4 cm to 20 × 9 cm. There was 7% flap failure rate. One flap dissection was abandoned owing to very thin pedicle and obesity. (Level V evidence)

Katsaros J, Tan E, Zoltie N. The use of lateral arm flap I upper limb surgery. J Hand Surg [Am]. 1991;16:598-604.

The lateral-arm free microvascular flap was used for upper limb reconstruction in 20 patients. The size of the flap, modifications to the flap, and complications were documented. There was one flap failure, and nine flaps required surgical thinning at a second procedure. This sole disadvantage was outweighed in clinical use by the advantages and versatility of the lateral arm flap. (Level V evidence)

Ng SW, Teoh LC, Lee YL, Seah WT. Contralateral pedicled lateral arm flap for hand reconstruction. Ann Plast Surg. 2010;64:159-163.

Contralateral pedicled lateral arm flaps were used in 22 consecutive patients between 6 and 70 years of age (18 males and 4 females) with hand defects from trauma, infection, burn, and complications of free flap. The flap size ranged from 18 cm2 to 127.5 cm2. Eighteen reconstructions were fasciocutaneous, and 4 were osteofasciocutaneous. The flap was divided in 3 weeks. All the flaps survived, with no wound infection. There was no significant shoulder or elbow joint stiffness. (Level V evidence)

Scheker LR, Kleinert HE, Hanel DP. Lateral arm composite tissue transfer to ipsilateral hand defects. J Hand Surg [Am]. 1987;12:665-672.

The ipsilateral lateral arm free flap was presented in 29 patients for hand reconstruction. The flap was used in both elective and emergency reconstruction with a success rate of 96.5%. This flap is elevated from the same limb as the injured hand, permitting the entire operative procedure to be performed with the patient under a single regional block anesthesia, both flap and recipient sites being prepared synchronously in a bloodless field. (Level V evidence)