Injury, Int. J.

Care Injured 45 (2014) 20252028

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

The medial arm pedicled perforator ap: Application of phenomenon

of one perforator perfusing multiple perforator angiosomes
Xu Gong, Jian Li Cui, Lai Jin Lu *
Department of Hand Surgery, The First Hospital of Ji Lin University, Chang Chun, Ji Lin 130021, China

A R T I C L E I N F O

A B S T R A C T

Article history:
Accepted 7 September 2014

Background: The medial arm is an optimal potential donor site for treating skin defects around the elbow.
However, whether a reliable pedicled perforator ap could be harvested from the medial arm remains
unanswered. The purpose of this study was to report the technique and our results using the medial arm
pedicled perforator aps.
Methods: A total of eight aps in seven patients underwent the medial arm pedicled perforator aps to
treat skin defects around the elbow. The ap was pedicled on one perforator 1.3  0.3 mm in diameter
within 3 cm above the medial epicondyle. The ap size varied between 10 and 20 cm in length and between 6
and 10 cm in width.
Results: Of the eight aps in seven patients, seven aps survived uneventfully except that one suffered
venous insufciency. Six patients were followed up for 1 month to 2 years. One patient was lost to
follow-up after 7 days. The wounds in all patients healed satisfactorily. No deep wound infection and
wound dehiscence developed. No revision surgery was performed in the survived aps.
Conclusions: The survival of the medial arm pedicled perforator ap conrms the phenomenon of one
perforator perfusing multiple perforator angiosomes in the medial arm, although this study has the
retrospective clinical nature and limited number of the patients. The medial arm pedicled perforator ap
is a useful tool to treat skin defects around the elbow.
2014 Elsevier Ltd. All rights reserved.

Keywords:
Perforator angiosomes
Elbow
Medial arm ap
Pedicled
Skin defects

Introduction
Skin defects around the elbow pose a unique challenge for the
reconstructive surgeon [1,2]. With regard to the skin texture,
colour, and thickness, the medial arm is an optimal potential donor
site for treating skin defects around the elbow. However, whether a
reliable pedicled perforator ap could be harvested from the
medial arm remains unanswered.
Maruyama et al. [3] rst utilized the medial arm as a reverse
ap to cover skin defects around the elbow based on the posterior
ulnar recurrent artery (PURA). Through the anastomotic connection between the PURA and superior ulnar collateral artery (SUCA),
the PURA can reliably perfuse the medial arm skin via one or two
cutaneous perforators arising from the SUCA [3]. Anatomic studies
have demonstrated that there exists a row of ve or six cutaneous
perforator arteries along the medial intermuscular septum in the

* Corresponding author. Tel.: +86 13756661203.

E-mail addresses: 13944099151@163.com (X. Gong), richsp@126.com (J.L. Cui),
lulaijin@hotmail.com (L.J. Lu).
http://dx.doi.org/10.1016/j.injury.2014.09.005
00201383/ 2014 Elsevier Ltd. All rights reserved.

medial arm [47]. Based on the work of Maruyama et al., we

postulate that there exists the phenomenon of one perforator
artery perfusing multiple perforator angiosomes in the medial arm.
The concept of a perforator angiosome is dened as the
anatomic skin territory of each cutaneous perforator artery [8,9].
Each perforator angiosome connects with neighbours via either
reduced calibre choke arteries or true anastomoses without a
change in calibre [9]. According to the reports of Taylor et al. [10], if
the anastomotic connections between the perforator angiosomes
are by the choke anastomoses, one cutaneous perforator can safely
perfuse one adjacent perforator angiosome in any direction when a
ap is raised on one perforator and necrosis occurs at the next
choke zone in sequence. However, if the anastomotic connections
are by true anastomoses, then one perforator could perfuse
multiple perforator angiosomes, such as in the distally based sural
ap in the leg [10].
Based on the aforementioned evidences, we hypothesize that
the anastomotic connections between the perforator angiosomes
in the medial arm are by true anastomoses, and one perforator
artery can perfuse multiple perforator angiosomes. If there exists a
constant perforator >1 mm in diameter around the medial

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epicondyle, a pedicled perforator ap can be harvested from the

medial arm. In our previous anatomic study in 22 specimens, we
already noticed a constant perforator >1 mm in diameter existing
behind the medial intermuscular septum [11]. Based on this
perforator artery, we designed a medial arm pedicled perforator
ap and performed eight aps in seven patients with skin defects
around the elbow. The purpose of this study was to report the
technique and our results using the medial arm pedicled perforator
aps in the treatment of skin defects around the elbow.

Patients and methods

This was a retrospective consecutive case series study. We
included all patients who had undergone the medial arm pedicled
perforator aps for the coverage of skin defects around the elbow
from 2005 to 2013. A total of seven patients were included in our
study. The patient age ranged from 22 to 82 years. Of the seven
patients, six were men and one was a woman. In addition, eight
aps in seven patients were performed to cover skin defects
around the elbows (Table 1). The ap size varied between 10 and
20 cm in length and between 6 and 10 cm in width.
Surgical procedure
The patient was positioned supine with the affected extremity
disinfected from the shoulder to the hand. The upper extremity
was brought into a supinated and abducted position. The skin
paddle, usually <10 cm in width, was outlined over the medial arm
from the medial epicondyle along the medial intermuscular
septum, that is, a line drawn from the medial epicondyle to the
axilla (Fig. 1A). The point of pivot was marked at 3 cm above the
medial epicondyle. The length of the ap was determined by the
distance from the pivot point to the distal margin of the recipient.
The ap elevation started from the posterior margin of the skin
paddle, which was incised up the fascia. Then a blunt dissection
was carried out under the fascia towards the medial intermuscular
septum. Along its posterior aspect, a perforator with its vena
comitantes was identied within 3 cm above the medial epicondyle (Fig. 1B). The basilic vein was divided and ligated at the distal
margin of the skin paddle. The medial antebrachial cutaneous
nerve should be meticulously dissected and protected to avoid
painful neuroma. Then, the anterior margin was incised and
undermined subfascially towards the medial intermuscular
septum. The ap was raised by incising the medial intermuscular
septum from the humerus in a retrograde fashion until the origin of
the perforator was reached (Fig. 1C). During the elevation of the
ap, the course of the ulnar nerve should be noticed to avoid

inadvertent injury. The ap elevation was completed and

transposed to the recipient (Fig. 1D). The donor site was closed
primarily.
Results
Of the eight aps in seven patients, seven aps in six patients
survived completely. One ap suffered venous insufciency
leading to partial necrosis (Fig. 2). Six patients were followed up
for 1 month to 2 years. One patient was lost to follow-up after 7
days. The wounds in all patients healed satisfactory. No deep
wound infection and wound dehiscence developed. The sutures
were removed after 2 weeks. No revision surgery was performed in
the surviving aps.
Discussion
Since the monumental report of the perforator angiosomes by
Taylor and Palmer, the survival and necrosis of a ap should be
reappraised by the pattern of the anastomotic connections
between the perforator angiosomes in series [8,9]. In 80% of cases,
one perforator artery as the pedicle of a ap can safely perfuse one
and a half perforator angiosomes because of the frequently existing
choke anastomoses between the perforator angiosomes [10].
However, if the anastomotic connections are by true anastomoses,
the resistance of blood ow between perforator angiosomes is low
compared to those connections by choke anastomoses, which will
produce the phenomenon of one perforator perfusing multiple
(more than two) perforator angiosomes [10].
In the series, based on one perforator artery nearby the medial
epicondyle, seven aps completely survived in eight medial arm
pedicled perforator aps, indicating the phenomenon of one
perforator perfusing multiple perforator angiosomes. Many
studies have demonstrated that there are at least ve to six
septocutaneous and/or myocutaneous perforators in the medial
arm. The perforators arise from different sources, including the
brachial artery and SUCA [37]. After penetrating the fascia, these
perforators further give off branches, forming a longitudinaloriented vascular network along the medial intermuscular septum.
In other words, there exist at least ve to six longitudinal-oriented
perforator angiosomes in the medial arm. In 22 cadaver arm
dissections, we noticed that one perforator artery 1.3  0.3 mm in
diameter constantly existed within 3 cm above the medial epicondyle. [11] It arose from the medial vascular arcade of the elbow, which
was composed of the SUCA, inferior ulnar collateral artery (IUCA), and
PURA. After arising from the medial vascular arcade of the elbow, it
ascended along the posterior aspect of the medial intermuscular

Table 1
Patient characteristics.
Patient

Gender

Site

Cause

Flap size

Result

CS

Post-release of ischaemic contracture

of forearm due to crush injury
Malignant tumour excision

10 cm  6 cm

10 cm  7 cm

CS

Frostbite

10 cm  5 cm

CS

Exposure of plate xing the olecranon

14 cm  9 cm

CS

Animal bites

L: 15 cm  6 cm R: 8 cm  6 cm

CS

Skin necrosis due to crush injury

12 cm  7 cm

CS

Left
Anteromedial aspect of proximal forearm
Right
Medial aspect of the proximal forearm
Right
Anterior aspect of the elbow
Left
Posterior aspect of elbow
Bilateral
Posterior aspect of left elbow
Anterior aspect of right elbow
Left
Anteromedial aspect of forearm
Left
Anteromedial aspect of forearm

Traumatic skin defect

20 cm  10 cm

1/4PN

M, male; F, female; CS, complete survival; PN, partial necrosis.

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Fig. 1. (A) Preoperative design of the medial arm pedicled perforator ap. (B) Intraoperative view showing the perforator with its venae comitantes located behind the medial
intermuscular septum within 3 cm above the medial epicondyle. (C) An islanded ap of 12 cm  7 cm was elevated pedicled on the perforator within 3 cm above the medial
epicondyle. (D) The ap survived uneventfully and the donor was closed directly.

septum and penetrated the fascia (Fig. 3) [11]. Pedicled on this

perforator, a distally based perforator ap can be harvested from the
medial arm to resurface skin defects around the elbow. In the medial
arm pedicled perforator ap, one perforator artery safely perfused
ve to six perforator angiosomes.
Compared to the reverse medial arm ap of Maruyama et al., the
medial arm pedicled perforator ap is different in two ways. First,
the mechanism of ap survival is different. In the reverse medial
arm ap, the blood supply comes from the PURA. It arises from the
ulnar artery and ascends along the ulnar nerve to anastomose with
the IUCA and SUCA. During its course, the PUCA does not give off
cutaneous perforators; the cutaneous perforators arise from the
SUCA [3]. Thus, the ap gets its blood supply from the cutaneous
perforators arising from the SUCA, which gets its blood supply
from the PUCA via the anastomotic connection between the PURA
and SUCA. In the medial arm pedicled perforator ap, the blood
supply comes from the perforator above the medial epicondyle. Its
survival is dependent on the true anastomoses between perforator
angiosomes in the medial arm, utilizing the phenomenon of one
perforator perfusing multiple perforator angiosomes. Second, the
surgical approach of the ap elevation is different. The harvest of

the reverse medial arm ap needs to dissect the PURA and SUCA
along the ulnar nerve, and the key step is to preserve the
anastomotic connection between the PURA and SUCA. Instead, in
the elevation of the medial arm pedicled perforator ap, the key
step is to identify the constant perforator above the medial
epicondyle. There is no need to dissect the PURA or SUCA.
Although the weakness of our study is the retrospective clinical
nature and limited number of the patients, we conrm that there
exists the phenomenon of one perforator perfusing multiple
perforator angiosomes in the medial arm. We speculate that the
anatomic basis of this phenomenon is the pure true anastomoses
between perforator angiosomes in series in accordance with
Taylors theory. The phenomenon of one perforator perfusing
multiple perforator angiosomes is important for designing and
safely harvesting a pedicled perforator ap, and the key to utilize it
is to identify the true and choke anastomotic connections in the
ap donor preoperatively. Recently, Chubb et al. [12] have realized
the identication and differentiation of the choke and true
anastomotic connections in the donor preoperatively by thermography, which provides a practical tool for utilizing the phenomenon of one perforator perfusing multiple perforator angiosomes.

Fig. 2. In patient 7, the medial arm pedicled perforator ap of 20 cm  10 cm suffered venous congestion, which led to distal 1/4 necrosis. But the survival area was
15 cm  10 cm.

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X. Gong et al. / Injury, Int. J. Care Injured 45 (2014) 20252028

Conict of interest
None.

References

Fig. 3. Anatomic specimen of right side indicating the perforator within 3 cm above
the medial epicondyle (view from the medial side of the right arm).

However, it is still unclear how many perforator angiosomes

connected by true anastomoses could be perfused by one
perforator. Future studies will be needed to further investigate
this question.
Disclosures of funding
None.

[1] Jensen M, Moran SL. Soft tissue coverage of the elbow: a reconstructive
algorithm. Orthop Clin North Am 2008;39(2):25164.
[2] Choudry UH, Moran SL, Li S, Khan S. Soft-tissue coverage of the elbow: an
outcome analysis and reconstructive algorithm. Plast Reconstr Surg
2007;119(6):18527.
[3] Maruyama Y, Onishi K, Iwahira Y. The ulnar recurrent fasciocutaneous
island ap: reverse medial arm ap. Plast Reconstr Surg 1987;79(3):
3818.
[4] Gao XS, Mao ZR, Yang ZN, Wang BS. Medial upper arm skin ap: vascular
anatomy and clinical applications. Ann Plast Surg 1985;15(4):34851.
[5] Breidenbach WC, Adamson W, Terzis JK. Medial arm ap revisited. Ann Plast
Surg 1987;18(2):15663.
[6] Matloub HS, Ye Z, Yousif NJ, et al. The medial arm ap. Ann Plast Surg
1992;29(6):51722.
[7] Karamursel S, Bagdatli D, Demir Z, Tuccar E, Celebioglu S. Use of medial arm
skin as a free ap. Plast Reconstr Surg 2005;115(7):202531.
[8] Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body:
experimental study and clinical applications. Br J Plast Surg 1987;40:
11341.
[9] Taylor GI, Corlett RJ, Dhar SC, et al. The anatomical (angiosome) and clinical
territories of cutaneous perforating arteries: development of the concept and
designing safe aps. Plast Reconstr Surg 2011;127(4):144759.
[10] Taylor GI, Chubb DP, Ashton MW. True choke anastomoses between perforator angiosomes: part I. Anatomical location. Plast Reconstr Surg 2013;132(6):
144756.
[11] Lu LJ, Xuan ZP, Liu B, et al. Retrograde medial brachial cutaneous perforator
island ap: anatomical basis and clinical application. Chin J Hand Surg
2007;23(4):2123.
[12] Chubb DP, Taylor GI, Ashton MW. True choke anastomoses between perforator angiosomes: part II. Dynamic thermographic identication. Plast
Reconstr Surg 2013;132(6):145764.