The Reverse Radial Forearm Flap in Reconstruction of the Hand

Abstract

Sir: We read with great interest the article “Soft-Tissue Coverage of the Hand following Sarcoma Resection” by Talbot et al.1 published recently in the Journal. Dr. Talbot and colleagues should be congratulated for focusing attention on this very difficult area for reconstruction. One of the flaps most commonly used in their series was the reverse radial forearm flap (20 percent of cases). We have used the reverse radial forearm flap in various reconstructive problems of the hand2 and would like to offer our thoughts on the subject and interest the readers in this very interesting flap. The reverse radial forearm flap has been proven to be a very reliable solution for reconstruction of the hand without necessitating the use of a microvascular flap. When the forearm flap is used as an island flap pedicled distally, its blood supply is based on a retrograde flow from the ulnar artery through the deep palmar arch. One could argue that ligating the radial artery could compromise the hand’s blood supply. It has been established, however, that the main blood supply of the hand comes through the ulnar artery and the deep palmar arch, whereas the radial and interosseous arteries are potential nutrient arteries of the hand. Provided that the ulnar artery is intact and well functioning, there are no functional or vascular consequences to the hand. Venous return has also been established to be retrograde through the venae comitantes. These have numerous valves, which are often at the same level between the two comitantes. This raises the unavoidable question of how immediate reverse flow through the veins can occur. There are three factors that make this backflow possible: When a distally based radial forearm flap is raised, the deep veins are denervated. Venous pressure in these veins is increased after ligation of their proximal ends. The veins are kept filled by blood from the wrist and hand. Each of these three factors alone, or even two of them together, would not be sufficient to allow backflow, but if all three factors are present simultaneously, as in a distally based radial forearm flap, immediate reverse flow through a venous valve can occur. This finely balanced combination of three necessary factors may explain why some distally based flaps become edematous or even require additional venous drainage. George J. Zambacos, M.D. Apostolos D. Mandrekas, M.D., Ph.D. Artion Plastic Surgery Center Athens, Greece