Lateral Arm Free Flap Harvest - Standard (Feat. Dr. Pet)

SURGICAL PROCEDURE Lateral Arm Free Flap Harvest Authors: Pet, MA1, Yee A1 Published: September 4, 2020 Author Information 1 - Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, Missouri Standard Edition () ABSTRACT The lateral arm free flap is a fasciocutaneous flap, which can also be modified to include muscle and/or bone. This flap is based upon the posterior radial collateral vessels within the lateral intermuscular septum between the triceps posteriorly, and the brachioradialis and brachialis anteriorly. The axis of the flap is marked on a line between the deltoid insertion and the lateral epicondyle. In this case, a traditional lateral arm flap is harvested, but it should be noted that extension of the cutaneous paddle across the lateral epicondyle and onto the proximal third of the forearm is reliable, and often useful. The patient in this video presented with a recurrent sarcoma in the right forearm with a previously radiated bed. After re-resection, there was a 6 x 12 cm wound overlying the ulnar border with exposed ulnar neurovascular bundle and ulna. This instructional video details the harvest of a lateral arm fasciocutaneous free flap for coverage of this defect. KEYWORDS free flap, posterior radial collateral artery, lateral intermuscular septum, radial nerve, lateral arm flap POSITION Supine. INCISION The axis of the flap is marked along the line between the deltoid insertion and the lateral epicondyle on the posterolateral aspect of the arm. The presence of perforating vessels along this axis is confirmed using a handheld doppler, and an elliptical flap is marked along this axis to incorporate the perforating vessels. TABLE OF CONTENTS (Standard) 00:00 Introduction 00:10 Case Presentation 00:37 Orientation 00:50 Surface Markings for Incision 02:05 Incision 02:31 Posterior Dissection of the Flap 03:04 Exposure and Identification of Tendon of the Triceps Brachii 03:14 Identifying the Longitudinal Perforator Vessel and Plane of Dissection 03:41 Dissecting the Flap from the Triceps Brachii 04:55 Following the Longitudinal Perforator Vessel Proximally 05:17 Identifying the Radial Collateral Vessels Supplying the Flap 05:22 Resecting the Triceps Muscle from the Lateral Intermuscular Septum 05:41 Extending the Incision Proximally for Additional Exposure 06:21 Dividing the Lateral Intermuscular Septum 06:38 Identifying the Posterior Brachial Cutaneous Nerve 07:27 Further Release of the Triceps Muscle from the Flap 08:54 Critical View of the Radial Nerve and Radial Collateral Artery and Vessels 09:08 Identifying the Vascular Branch to the Triceps 09:43 Anterior Dissection of the Flap 10:06 Identifying of the Brachioradialis an Brachialis 11:29 Elevating the Flap from Brachioradialis an Brachialis 12:29 Identifying the Longitudinal Perforator Vessel 13:23 Exposure the Humeral Attachment Posteriorly 14:04 Incising the Humeral Attachment 14:27 Elevating the Flap Distally from the Humerus 15:24 Dividing the Anterior Branch of the Radial Collateral Vessels from the Radial Nerve 16:11 Dividing the Vascular Branch to the Triceps 16:26 Further Exposure of the Vascular Pedicle to the Flap 16:37 Dividing the Posterior Brachial Cutaneous Nerve 17:04 Identifying the Venous and Arterial Component of the Pedicle 17:42 Take Down of Tourniquet and Checking Perfusion of Flap 18:12 Dividing an Accessory Pedicle and Checking Perfusion of Flap 18:34 Clipping and Dividing the Radial Colleterial Artery and Vein to Mobilize the Flap 18:55 Post-Operative Results 19:11 Credits