Plastic & Reconstructive Surgery:
Reply: The Radial Artery Pedicle Perforator Flap: Vascular Analysis and Clinical Implications
Saint-Cyr, Michel M.D.
Department of Plastic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, Texas 75390, email@example.com
I would like to thank Dr. Yang and colleague for their interest and comments regarding the article entitled “The Radial Artery Pedicle Perforator Flap: Vascular Analysis and Clinical Implications.”1 The authors ask how the vascular cutaneous territory of the distal radial artery perforator was determined. This was performed as follows: the radial forearm flap was dissected with the entire circumferential forearm skin. The dominant distal perforator, found within 2 cm from the radial styloid, was identified and the radial artery was injected just proximal to the dominant perforator with methylene blue. The section of the radial artery just distal to the dominant perforator was ligated. This allowed for easy injection of the radial artery with only the dominant perforator attached to the radial artery and all other perforators ligated to get an estimate of the distal perforator's vascular cutaneous territory (Figs. 1 and 2). I realize that these results will vary based on the size of the distal perforator injected and also based on the number of perforators used at the base of the flap clinically. The pivot point for this flap, as with many other pedicle perforator flaps, can encompass either a large perforator or a large perforator and other smaller ones. Alternatively, a cluster of smaller perforators, which does not require skeletonization or even identification, can also be used. This flap represents a pedicle “cluster perforator” flap when a generous cuff of subcutaneous tissue is kept intact at the flap pivot point. Peripheral undermining is performed just sufficiently to achieve flap rotation and tension-free inset.
The vascular territory of the flaps injected in the study also underestimates the true probable clinical value for the following reasons. First, injected cadaver cutaneous vascular territories will underestimate true clinical values. Second, the injection studies were based on a single perforator injection, whereas clinically this flap is often harvested with more than one perforator incorporated into its base and pivot point. Because of the superficial location of the radial artery distally, perforators are not audible secondary to the predominance of the radial artery. This was one of the reasons for performing the study. My colleagues and I wanted to determine the location of the distalmost dominant perforators to establish the flap's pivot point. The Doppler probe is used only to confirm perforator flow once the initial incision has been made. I agree with Dr. Yang and colleague that the arterial network of the flap is oriented longitudinally in the forearm.2 Each perforator communicates with adjacent ones by means of linking vessels that are oriented parallel to the radial artery and along the long axis of the forearm. This allows multiple perforators in the forearm to be captured by means of a single perforator source. I prefer to harvest all of the radial forearm flaps (free, pedicle, and perforator pedicle) in a suprafascial plane to minimize donor-site morbidity. The donor site is either closed primarily when possible, or closed with a full-thickness skin graft harvested from the groin, which is closed primarily. This suprafascial harvest plane does not diminish flap perfusion, and I have not found any significant difference in flap vascularity when harvested in a suprafascial versus subfascial plane (Fig. 3).3 The vascular network of the radial forearm flap is predominantly found between the dermis and fascia (Fig. 4). With regard to the size of the radial artery pedicle perforator flap, this will certainly vary based on the size of the selected perforator. For all pedicle perforator flaps, I keep the flap length safely within half the limb's length and try to encompass as many perforators within the pivot point as possible to maximize vascularity and improve venous outflow. I again thank Dr. Yang and colleague for their valuable input and comments regarding the article.
Michel Saint-Cyr, M.D.
Department of Plastic Surgery
University of Texas Southwestern Medical Center
1801 Inwood Road
Dallas, Texas 75390
1. Saint-Cyr M, Mujadzic M, Wong C, Hatef D, Lajoie AS, Rohrich RJ. The radial artery pedicle perforator flap: Vascular analysis and clinical implications. Plast Reconstr Surg.
2. Yang D, Morris SF, Tang M, Geddes CR. Reversed forearm island flap supplied by the septocutaneous perforator of the radial artery: Anatomical basis and clinical applications. Plast Reconstr Surg.
3. Schaverien M, Saint-Cyr M. Suprafascial compared with subfascial harvest of the radial forearm flap: An anatomic study. J Hand Surg Am.
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David H. Song, M.D., M.B.A. is the President-elect of the American Society of Plastic Surgeons (ASPS). He is a consultant with BioMet, Emmi Solutions, LLC, a consortium-member providing senior debt for Brava, and consultant with and investor in HealthEngine.com. He receives author royalties from Elsevier. Scot Glasberg, M.D. is the President of the American Society of Plastic Surgeons (ASPS). He is a consultant with LifeCell Corp and Mentor Corp and an investor with Strathspey Crown. The authors have no sources of funding to report related to the writing or submission of this discussion.
The location and affiliation information should read as follows: Arlington Heights, Ill. From the American Society of Plastic Surgeons/Plastic Surgery Foundation.
David H. Song, M.D., M.B.A., 444 E. Algonquin Rd. Arlington Heights, IL 60005, firstname.lastname@example.org
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