Radial forearm flap

Step 1 · Mark

Mark the flap and expose the artery

Allen’s test, then mark the radial artery by its pulse, design the paddle with its radial edge over the artery, and open the distal end to find the vessels.

• Allen’s test first: the hand must perfuse through the ulnar artery and palmar arch once the radial artery is taken.
• The radial artery is palpable in the distal forearm; follow the pulse proximally and mark its course to the antecubital fossa.
• Design the paddle with its radial border over the artery, extending ulnarward onto the less hair-bearing skin; size it from a template of the defect.
• Shoulder abducted to 90° on an arm board, padded tourniquet proximally, and the distal end of the flap is opened first.

Hotspots in this step

• 1Radial artery at the wrist — Palpable between flexor carpi radialis and brachioradialis — the first structure found when the distal end of the flap is opened. Allen’s test before anything else.
• 2Venae comitantes — Paired veins with the artery; they can be small, which is why the cephalic vein is often taken as well.
• 3Skin paddle — Radial edge over the artery, extended ulnarward as needed; the paddle can be folded or split for three-dimensional defects.
• 4Pedicle marking — The course of the radial artery marked proximally — the pedicle can be dissected to its origin just distal to the antecubital fossa.
• 5Tourniquet — A padded tourniquet proximally; previous arterial or intravenous lines in this forearm compromise the flap and should be asked about.