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Reverse Radial Artery Perforator Flap: Technique Description And Case Series
Justin Davis, BS1,1, Anna Meade, BS1,1, Corrine Wong, MD2, Andrew Y. Zhang, MD1,1, Douglas Sammer, MD1,1.
1UT Southwestern, Dallas, TX, USA, 2University of Colorodo, Denver, CO, USA.

Purpose
The reverse radial artery forearm flap is a large, reliable flap used for soft tissue coverage of the hand. However, this flap cannot be used in patients with an incomplete palmar arch. The reverse radial artery perforator flap is an alternative pedicled flap that can be used when the arch is incomplete, and which does not require sacrifice of the radial artery. Some studies suggest that the vascular territory and distal reach of this flap are substantially smaller than those of the standard reverse radial artery forearm flap, which limits its use to coverage of small proximal hand defects. The purpose of this study is to review the size, distal reach, and reliability of the reverse radial artery perforator flap.
Methods
After obtaining Institution Board Review approval, a retrospective review of all reverse radial artery perforator flaps performed by a single surgeon during a four-year period from 2015 to 2019 was performed. Flap dimensions, the location of the proximal margin of the flap, the location of the pivot point, and distal reach of the flap were recorded. Clinical outcomes including flap survival rate and complications such as venous congestion and partial necrosis were recorded. A detailed technique description is included.
Results
Seven reverse radial artery perforator flaps were identified and included in the study. The transverse dimension of the flap ranged from 2 cm to 16 cm, and the longitudinal dimension ranged from 4 cm to 23 cm. The proximal margin of the flap was raised at the antecubital fossa in all cases, and the mean pivot point was 4 cm proximal to the radial styloid in five of the cases, 3 cm and 6 cm in the other two. The flap reliably reached to the metacarpal heads, and to the thumb tip. One flap was complicated by partial necrosis that required minor debridement, and one flap was compromised by hematoma. There was one case of post-operative venous congestion that resolved after bedside ligation of the cephalic vein which had been included in the flap.
Conclusion
The vascular territory and dimensions of the reverse radial artery perforator flap are similar to those of the standard reverse radial artery forearm flap. Although the distal reach of the perforator flap is decreased due to a more proximal pivot point, the flap reliably reaches the metacarpal heads and the distal thumb. Careful attention to maintaining a wide pedicle, routine ligation of the cephalic vein, and avoiding kinking or pressure during inset can reduce post-operative complications.


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