Reconstruction of Hand Soft-Tissue

Defects: Alternatives to the

Radial Forearm Fasciocutaneous Flap

Rohan Page, MBBS, James Chang, MD

From the Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA.

Soft-tissue defects of the hand and wrist are not an uncommon problem confronting the hand
surgeon. Over the past 20 years the retrograde radial forearm fasciocutaneous flap has gained
widespread acceptance in reconstruction of these defects. Appreciation of the inherent
limitations of this workhorse flap and increased understanding of the blood supply of the
upper extremity have prompted the development of several alternative pedicled forearm
flaps. Aspects of surgical technique, specific limitations, and indications for the radial forearm
fascial flap, the posterior interosseous artery flap, the retrograde radial artery perforator flap,
and the dorsal ulnar artery flap are discussed and a reconstructive algorithm for flap selection
is presented. (J Hand Surg 2006;31A:847– 856. Copyright © 2006 by the American Society
for Surgery of the Hand.)
Key words: Flap, hand injuries, posterior interosseous artery, radial artery, reconstruction,
ulnar artery.

oft-tissue defects of the hand and wrist com- dient soft-tissue coverage is required. Local flaps

S monly occur in the context of high-energy

trauma. Less commonly they may be an end
point of extirpation of infected or neoplastic tissue, or
have limited application because there is a paucity
of expendable donor tissue in the hand, flap mo-
bility is restricted, and sublethal injury to adjacent
burn injuries. Borderline vascularity of the adjacent tissues in the case of trauma may impair their
tissues, contamination or frank infection, and associated viability for transfer. Distant pedicled flaps from the
defects in the underlying bones, tendons, or neurovas- groin, trunk, or contralateral arm were traditionally the
cular structures may complicate reconstructive efforts. mainstay of reconstruction in these situations but they
A clean noninfected wound, a viable extremity, skel- provide a bulky reconstruction that requires at least 2
etal stability, an adequately resuscitated patient, and stages with an intervening period of immobilization and
suitable expertise and equipment all are prerequisites dependency. The development of microvascular tech-
for successful soft-tissue reconstruction in these niques for free tissue transfer in the 1970s addressed
cases. many of these shortcomings at the expense of increased
Standard reconstructive paradigms serve as a procedural complexity, duration, and demand on re-
broad guide to planning that can be tailored to the sources.
demands of the situation. Simpler reconstructive op- The radial forearm fasciocutaneous flap was de-
tions such as secondary intention healing, delayed scribed initially as a free flap by Yang et al2 in 1981
primary closure, or skin grafting have a role in and only later as a retrograde-flow pedicled flap for
smaller defects or where tissue loss has not left hand reconstruction by Lu et al3 in 1982. Recogni-
important or relatively poorly vascularized tissues tion of the potential for retrograde flow in distally
exposed. Topical negative pressure dressings (VAC, pedicled radial forearm flaps was a notable contribu-
Kinetic Concepts Inc., San Antonio, TX) have ex- tion to hand surgery because large areas of relatively
tended the situations in which these simpler recon- thin skin and fascia with a robust blood supply now
structive procedures can be applied.1 could be harvested from within the same surgical
Frequently, however, a more durable and expe- field and transferred without the need for microvascular

The Journal of Hand Surgery 847

848 The Journal of Hand Surgery / Vol. 31A No. 5 May–June 2006

technique in a single-stage procedure that facilitated Radial Forearm Fascial Flap

postoperative elevation and early mobilization. In 1985 Jin et al4 described their experience with
Several drawbacks to the radial forearm flap have harvesting large areas of the volar forearm fascia
become apparent with collective experience. Sacri- pedicled distally on the radial artery and its venae
fice of the radial artery is rarely of consequence in the comitantes to reconstruct hand defects. Up to two
appropriately selected patient but on occasion may thirds of the volar, lateral, and dorsal circumference
require vein graft reconstruction. More importantly of the forearm fascia (10 –12 cm width ⫻ 20 –30 cm
this precludes its use in patients with clinically ab- length) can be elevated through a curvilinear forearm
sent/questionable distal ulnar–radial vascular com- incision and transferred to cover the entire dorsal or
munications. The abundant skin and fascia that can palmar surface of the hand, extending distally to the
be transferred in the flap is durable and pliable but level of the midproximal phalanx. A split-thickness
often a poor match in terms of bulk and color for skin graft is required to cover the flap after inset, but
tissue replacement in the hand (Fig. 1A). Additional the technique allows for primary closure of the fore-
shortcomings relate to the conspicuous donor site; arm donor site in most instances.
which can be subject to poor skin graft take and
delayed healing, particularly in the distal third of the Technique
forearm (Fig. 1B). These limitations together with A preoperative Allen’s test is essential to confirm
advances in knowledge of the blood supply of the adequate perfusion of the hand by the ulnar artery. A
forearm have driven the development of alternative cut-to-fit template is made of the defect and the
distally based pedicled forearm flaps that form the required pedicle length is measured from the pivot
basis of the following discussion. point at the radial styloid. Consideration should be

Figure 1. (A) The retrograde radial forearm fasciocutaneous flap may be a poor color and contour match for the dorsum of the
hand and (B) produce a conspicuous donor scar in the forearm.
 Page and Chang / Reconstruction of Hand Soft-Tissue Defects 849

given to the extra pedicle length that is required to Perfusion of the hand and retrograde perfusion of the
allow for pedicle rotation without tension or kinking. flap is ensured before formal ligation and division of
The flap and the pedicle are marked out on the the proximal artery and venae comitantes. Failure
forearm over the course of the radial artery. will mandate either the use of an alternative soft-
Through a curvilinear incision over the course of tissue reconstruction or vein graft reconstruction of
the artery thin skin flaps are raised to expose the the radial artery.
forearm fascia to be harvested and the pedicle itself The islanded fascial flap is transposed carefully to
(Fig. 2A). Fascia then is incised and raised from avoid tension or kinking of the pedicle. Various
radial and ulnar directions until it is isolated on the factors (skin laxity, swelling, thickness of the pedi-
lateral intermuscular septum. Septocutaneous perfo- cle) will dictate whether it is advisable to pass the
rators running from the radial artery in the lateral flap through a subcutaneous tunnel or to lay open the
intermuscular septum between the flexor carpi radi- intervening skin bridge between the defect and the
alis and the brachioradialis supply the adipofascial pivot point and subsequently close the skin or lay a
tissue in the flap. The radial artery and venae comi- split-skin graft over the pedicle. In general we prefer
tantes are dissected free from the adjacent tissues in the latter approach because there is less risk for
their course through the flap and distally to the pivot superficial radial nerve injury, improved hemostasis
point. Care is taken to identify and ligate any small in the intervening tract, and less chance of pedicle
side branches, preserve a perivascular cuff of adven- compression caused by local bleeding or swelling in
titial tissue, and identify and preserve the superficial the postoperative period. A zigzag incision in the
radial nerve. The lateral antebrachial cutaneous nerve intervening skin will allow partial closure in a V to Y
usually is sacrificed. fashion with minimal risk for pedicle compression.
A vascular clamp is applied to the radial artery The remaining area is covered with a split-skin graft.
proximal to the flap and the tourniquet is released. The donor site is closed primarily and the fascial

Figure 2. (A) Radial forearm fascial flap raised through a curvilinear incision on the volar forearm that can be closed directly.
(B) The fascial flap is rotated, inset, and covered with a split-thickness skin graft.
850 The Journal of Hand Surgery / Vol. 31A No. 5 May–June 2006

flap is inset and skin grafted. It has been our experience its use in some patients, and rarely will demand
that a fenestrated sheet graft gives a superior final vein graft reconstruction of the radial artery for
aesthetic result to a meshed split-skin graft (Fig. 2B). A acute or chronic hand ischemia. There is a small
volar resting splint is worn and the hand is elevated risk for superficial radial nerve injury with either
after surgery. Rehabilitation is commenced after 1 of these flaps.
week in most cases.
Retrograde Posterior Interosseous Artery
Discussion Flap
Improved donor site aesthetics is the main benefit of Since Zancolli and Angrigiani5,6 first described this
this flap over the more conventional retrograde radial flap in 1985 widespread experience has shown its
forearm fasciocutaneous flap. Donor site healing usu- reliability and versatility.7–9 Fascia and skin up to 12
ally is not problematic and leaves a more acceptable to 15 cm in length and 8 to 10 cm in width can be
curvilinear scar. Large areas can be covered with thin based proximally or distally on the posterior in-
vascular tissue, which in comparison contour partic- terosseous artery (PIA) as it courses between the
ularly well to the dorsum of the hand. The distal extensor digiti minimi and the extensor carpi ulnaris.
reach of this fascial flap is similar to the retrograde Distally pedicled flaps will reach to the dorsum of the
radial forearm fasciocutaneous variant and generally metacarpophalangeal joints, the first web space, and
is superior to the alternative pedicled forearm flaps the proximal and ulnar part of the palm. Retrograde
that are discussed later. perfusion is dependent on an intact distal communi-
Because of its thinness a split-skin grafted fascial cating artery between the anterior and posterior in-
flap, however, may provide a less favorable environ- terosseous arteries just proximal to the distal radio-
ment for secondary procedures such as staged tendon ulnar joint. In approximately 5% of forearms this
grafting. Furthermore the retrograde radial forearm distal communication is absent; therefore when pre-
fascial flap does not contain the cutaneous sensory operative radiologic confirmation of its presence is
end organs required for potential neurotization via the not available it is necessary to explore the pedicle
lateral antebrachial cutaneous nerve. When these addi- before flap elevation.
tional procedures are planned consideration should be
given to a fasciocutaneous flap. Technique
Similar to its fasciocutaneous counterpart the The required flap dimensions are determined using a
retrograde radial forearm fascial flap involves the cut-to-fit template of the defect and the required
sacrifice of a major limb vessel that will preclude pedicle length is measured from the pivot point 2 cm

Figure 3. (A) Incision planning for a posterior interosseous artery flap. (B) Elevation of the posterior interosseous artery flap and
closure of a larger fasciocutaneous donor site with a split-thickness skin graft. (C) Rotation of the posterior interosseous artery flap
to reconstruct a moderate-sized ulnar palmar defect.
 Page and Chang / Reconstruction of Hand Soft-Tissue Defects 851

proximal to the distal radioulnar joint with due con- retrograde flow the flap can be islanded on the distal
sideration to avoid kinking or tension in the pedicle pedicle and rotated and inset into the defect (Figs 3B,
after rotation. The axis of the flap is planned along a 3C).
line joining the lateral epicondyle and the distal ra-
dioulnar joint (Fig. 3A). At approximately the mid- Discussion
point of this axis is the middle (median) perforator of The main advantage of this flap over the previously
the PIA, which should be included in the flap design; described retrograde radial artery flaps is that it does
its location can be confirmed by intraoperative Dopp- not require the sacrifice of a major limb vessel. The
ler sonography. The reliable proximal limit of the rare complications of acute or chronic arterial insuf-
flap is 6 cm distal to the lateral epicondyle based on ficiency after radial artery harvest are therefore
this vessel. A more proximal perforator is present avoided, the requirement for intact distal ulnar–radial
consistently but this vessel variably (30%) may orig- arterial communication to raise a distally based radial
inate from the recurrent interosseous branch of the forearm flap no longer applies.
PIA and has a variable relationship to the main motor Skin color and contour from the dorsal forearm are
branch to the extensor carpi ulnaris that necessitates a closer match for the dorsal hand than volar forearm
division and subsequent repair of the nerve if the flaps and the flap can be neurotized by including a
vessel is included with the flap.10 According to the proximal length of posterior antebrachial cutaneous
experience of Zancolli and Angrigiani6 it seems to nerve for microneurorrhaphy to a suitable donor
add little to the viable length of flap that can be nerve. Smaller fasciocutaneous flap donor sites up to
raised. For all of these reasons we do not include it 3 to 4 cm in width can be closed primarily but larger
routinely with our pedicle. defects will require skin grafting. Although skin graft
Flap elevation begins with exploration of the pedi- healing is rarely problematic on the well-vascular-
cle through a curvilinear incision along the marked ized muscle bed at the donor site, one of the main
axis between the pivot point and the planned distal disadvantages of this flap is that the resultant scar is
border of the flap. The vessels are identified on the particularly conspicuous if a skin graft is required for
interosseous membrane in the base of the septum closure.
between the extensor digiti minimi and the extensor Additional criticism of the PIA flap has centered
carpi ulnaris tendons. If the distal PIA is absent and on the anatomic variation and size of the pedicle
distal arterial communication with the anterior in- vessels. Familiarity with these variations, a meticu-
terosseous artery is absent then the procedure can be lous dissection technique, and a viable contingency
abandoned at this point and an alternative flap con- plan is required to elevate this flap safely.
sidered. A distal to proximal dissection of the pedicle Finally, the flap has a limited reach to the distal and
from the adjacent tissues, preserving a perivascular cuff radial parts of the palm. Alternative flap options should
of tissue, will avoid injuring the fine venae comitantes. be considered for defects that extend to these areas.
The planned ulnar border of the flap is incised next
and elevated in a subfascial plane toward the septum. Retrograde Radial Artery Perforator Flap
Retracting the extensor carpi ulnaris muscle in an In a further effort to preserve radial arterial flow to
ulnar direction facilitates further development of the the hand Chang et al11 in 1988 described the first
septum and visualization of the pedicle and the sep- clinical series using a retrograde radial forearm flap
tocutaneous perforators. Radial incisions then are with an arterial inflow based only on the septocuta-
made and that part of the flap is elevated in a sub- neous perforators arising from the distal radial artery.
fascial plane off of the extensor digiti minimi muscle Subsequent anatomic studies and limited published
toward the intermuscular septum. Dissection of the clinical experience have shown the reliability of ret-
septum and pedicle with ligation or cautery of mus- rograde flow to and from perforating vessels arising
cular branches continues until the flap is attached from 1 to 3 cm proximal to the radial styloid along a
only by the septum containing the intact PIA. Ap- longitudinally oriented adipofascial plexus in the dis-
plying an atraumatic clamp to the artery proximal to tal forearm adipofascial layer that forms the vascular
the flap and releasing the tourniquet allows assessment pedicle for these flaps.12–15 Because retrograde flow
of adequate retrograde flow. Inadequate retrograde flow is dependent on a plexus rather than a major vascular
would necessitate either a microvascular free transfer of axis, the maximum dimensions of the flap that can be
the flap based on antegrade vessels or selection of an transferred reliably (8 –12 cm width ⫻ 15–20 cm
alternate flap reconstruction. After confirming adequate length) are smaller and the maximum reach more
852 The Journal of Hand Surgery / Vol. 31A No. 5 May–June 2006

Figure 4. (A, B) Planning, elevation, and inset of the radial artery perforator flap. An adipofascial flap is shown in this case.

proximal than for the true axial flaps previously injury the perforating vessels are not isolated. Care is
described. Both islanded fasciocutaneous and turn- taken to preserve the integrity of the superficial radial
over adipofascial flap variants of this flap have been nerve and its branches. It remains contentious
described. whether or not the cephalic vein should be ligated at
the base of the pedicle. Proponents argue that valvu-
Technique
lar competency in large subcutaneous veins is re-
A preoperative Allen’s test is not required. The radial
tained in these flaps and that there is ongoing net
artery is not harvested with the flap, however, its
venous inflow to the flap from the limb periphery that
patency at the wrist is essential for flap perfusion.
may exceed the capacity of the smaller valveless
The defect size and required pedicle length is deter-
venous channels that communicate with the venae
mined as described previously for the retrograde
radial artery fascial flap. The pivot point is taken at 3 comitantes of the radial artery, resulting in venous
cm proximal to the radial styloid and the flap is congestion. Chang et al15 reported their clinical ex-
marked on the proximal volar forearm over the perience with experimental evidence in a canine
course of the radial artery. A curvilinear incision is model in support of this practice. Others13 have
planned between the flap and pivot point that will maintained that the vascular plexus accompanying
allow elevation of thin skin flaps to expose the adi- the cephalic vein makes a contribution to flap perfu-
pofascial pedicle (Fig. 4A). An adipofascial turnover sion that should not be sacrificed. The presence of
or fasciocutaneous island flap is raised from proximal venous congestion with a tense engorged cephalic
to distal on a 3- to 4-cm wide adipofascial pedicle vein after tourniquet release is a useful indicator
that includes deep fascia, antebrachial nerve, and whether careful dissection and ligation of the vein at
cephalic vein as far as the distal pivot point. To avoid the base of the flap is required. The flap is rotated and
 Page and Chang / Reconstruction of Hand Soft-Tissue Defects 853

inset along similar lines to the retrograde radial fore- a history of venous insufficiency or thrombosis in the
arm fascial flap. Neurotization of fasciocutaneous affected limb.
island flaps can be performed if a proximal length of
lateral antebrachial cutaneous nerve is elevated with Dorsal Ulnar Artery Flap
the flap and a suitable sensory nerve stump is avail- Becker and Gilbert16 described a fasciocutaneous
able. flap in 1988 based on this branch of the ulnar artery
arising 2 to 4 cm proximal to the pisiform bone. The
Discussion 1- to 2-mm dorsal ulnar artery (DUA) and accompa-
Similar to the posterior interosseous flap, elevating nying venae comitantes pass deep to the musculoten-
this flap does not sacrifice a major limb vessel and is dinous junction of the flexor carpi ulnaris muscle
not dependent on intact distal ulnar–radial arterial with the dorsal branch of the ulnar nerve. After
communication. Provided there is an intact radial giving off branches to the pisiform and flexor carpi
artery and venae comitantes to the wrist the distally ulnaris muscle the artery divides into ascending and
based perforator flap can be used to cover moderate- descending branches that supply the ulnar border of
sized defects of the dorsum or palm of the hand as far the forearm, wrist, and hand. The ascending branch
as the base of the proximal digital phalanges. forms the vascular basis for a distally pedicled island
Donor site healing usually is not problematic in the or peninsula flap up to 5 to 9 cm in width and 10 to
proximal forearm, although a skin graft will be re- 20 cm in length with potential to reach to the defects
quired for donor site defects larger than 3 or 4 cm in over the dorsum of the hand, the ulnar half of the
width. With the wide adipofascial pedicle that must palm, and the dorsal and volar wrist.
be raised with this flap along with the lower arterial
perfusion pressures it generally is safer to incise the Technique
skin between the pivot point and the recipient site A preoperative Allen’s test is not required for this
and skin graft the bulky pedicle rather than attempt- flap, however, the patency of the distal ulnar artery
ing to tunnel it beneath an intact skin bridge. should be confirmed. Tissue requirements are deter-
The vascularity of this flap is not as good as the mined using a cut-to-fit template of the defect. The
aforementioned radial artery flap and the defect size required pedicle length is measured from the proxi-
and distal extent will preclude its use in some clinical mal edge of the defect to the pivot point just ulnar to
scenarios. Alternative flaps probably should be con- the flexor carpi ulnaris tendon 2 to 4 cm proximal to
sidered in patients at risk for microvascular arterial the pisiform, with allowance made for tension-free
disease, such as smokers or diabetics, or in those with pedicle rotation. The flap is marked along an axis

Figure 5. (A) Planning, (B) elevation, and (C) inset of the dorsal ulnar artery flap.
854 The Journal of Hand Surgery / Vol. 31A No. 5 May–June 2006

joining the medial epicondyle and the pisiform and The main disadvantage of the flap is related to its
should lie within the territory bounded by the palmaris shorter pedicle length in comparison with the afore-
longus tendon volarly and the ring finger extensor digi- mentioned flaps. The DUA flap as it is described
torum communis tendon dorsally (Fig. 5A). conventionally will not reach to cover defects on the
Flap elevation commences proximally and pro- radial border of the hand. Peninsula-design DUA
ceeds distally in a subfascial plane toward the pivot flaps have a further restricted arc of rotation and may
point. The flexor carpi ulnaris tendon is retracted radi- require delayed secondary excision of an unsightly
ally as the pivot point is approached and a perivascular standing cone of skin at the base of the pedicle.19
cuff of adipofascial tissue 2 to 3 cm in width is pre-
served to protect the fine vessels in the pedicle (Fig. Discussion
5B). The intervening skin bridge between the pivot Limitations of the retrograde radial forearm fasciocuta-
point and the defect is incised and elevated with care neous flap for soft-tissue reconstruction in the hand
taken to preserve the dorsal branch of the ulnar nerve include the potential vascular morbidity to the hand and
accompanying the descending branch of the DUA. forearm after radial artery harvest, the relatively in-
The elevated flap then is rotated and inset into the ferior color and contour match of proximal volar
defect (Fig. 5C). The donor site and the adipofascial forearm skin particularly for the dorsum of the hand,
pedicle in the case of an island flap then are skin the conspicuous donor site skin graft on the volar
grafted. forearm, and the dependence on intact distal ulnar–
radial arterial communications for flap viability.
Discussion There is only 1 report20 in the literature of acute
This flap shares the advantages of the distal radial ischemia of the hand resulting from the harvest of a
artery perforator flap and the posterior interosseous radial forearm flap. Limited retrospective series have
flap in terms of providing thin, pliable, and poten- identified symptoms in the hand such as cold intol-
tially sensate soft-tissue coverage to the hand without erance, pain, and edema attributed to chronic vascu-
sacrificing a major vascular axis or dependency on lar insufficiency in patients after radial artery forearm
intact distal ulnar–radial arterial communication. In flap harvest.21,22 Confounding these findings is the
general the donor site scar on the ulnar border of the well-recognized occurrence of identical symptoms
forearm is less conspicuous than radial or posterior after extremity trauma/surgery in patients who have
forearm flap donor sites. not had a major arterial injury. Furthermore studies
More recently several investigators have presented using objective measurement techniques (Doppler
limited series describing further variations in dorsal ultrasound, digital thermography, color duplex imag-
ulnar artery flap design: proximally based flaps based ing) have failed to show vascular compromise after
on the descending branch of the DUA, more distally radial artery harvest.23,24 In light of the evidence pub-
based flaps perfused by communications between the lished to date it is difficult to substantiate that harvest of
DUA and the fourth intermetacarpal artery, and com- the radial artery in the appropriately selected patient
posite flaps that include a segment of ulna.17,18 The will cause acute or chronic hand ischemia.
flap potentially can be neurotized by elevating a With a number of alternative regional pedicled
proximal length of the medial antebrachial cutaneous flaps potentially available for skin and soft-tissue
nerve with the flap for microneurorrhaphy to a suit- coverage in the hand and wrist, donor morbidity and
able donor nerve in the hand. aesthetics should be taken into consideration when

Table 1. Algorithm of First and Second Choices for Reconstruction of Hand Soft-Tissue Defects by Defect
Site and Size Preference Using the Flaps Discussed
Dorsal Volar

Extensive Radial Ulnar Extensive Radial Ulnar

First Radial forearm Radial artery Posterior interosseous Distant free Radial forearm Posterior
fascial flap perforator flap artery flap flap fascial flap interosseous
artery flap
Second Radial forearm Posterior interosseous Dorsal ulnar artery Distant Radial artery Dorsal ulnar
fasciocutaneous artery flap flap pedicled perforator artery flap
flap flap flap
 Page and Chang / Reconstruction of Hand Soft-Tissue Defects 855

planning reconstruction. When surgical expertise and hand and wrist. As such it remains the gold standard
the reconstructive requirements of the case allow, against which more recently described regional flaps
alternatives to the retrograde radial forearm flap may must be compared. In patients without an intact distal
provide an equal or superior solution. Inherent limi- communication between ulnar and radial arteries it
tations in each of the alternative flaps in terms of size, clearly is not a safe reconstructive option and those
composition, and reach influences their suitability for flaps described previously that do not sacrifice a
specific indications. An algorithm outlining our first major limb vessel can be useful regional alternatives.
and second choice of flap for particular defects is In patients with less extensive defects these alterna-
presented in Table 1. tive flaps may provide a satisfactory reconstruction
Extensive palmar defects in particular are likely to with less donor morbidity and/or improved aesthet-
require distant pedicled or free tissue transfer be- ics. Familiarity with alternative regional flaps in the
cause distal communications between radial and ul- upper limb allows the surgeon to tailor reconstruction
nar arteries are likely to be compromised and flaps closely to the demands of the situation.
based on these major vessels will be unavailable for
regional reconstruction. Moderate-sized palmar de- No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this
fects still may be reconstructed with alternative re- article.
gional flaps that are not dependent on an intact distal Corresponding author: Dr Rohan Page, Division of Plastic and Recon-
vascular arcade: radial palmar defects can be covered structive Surgery, 770 Welch Rd, Suite 400, Stanford University Medical
Centre, Stanford, CA 94305; e-mail: rohanpage@[Link].
with the retrograde radial perforator flap and ulnar Copyright © 2006 by the American Society for Surgery of the Hand
palmar or proximal palmar defects with the posterior 0363-5023/06/31A05-0026$32.00/0
interosseous or dorsal ulnar artery flaps. We gener- doi:10.1016/[Link].2006.02.024
ally prefer thin fasciocutaneous flaps to adipofascial References
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