Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 876e882

The reverse posterior interosseous flap and

its composite flap: Experience with 201 flaps
Lai-jin Lu, Xu Gong a,*, Xin-min Lu b, Ke-li Wang a

a
Department of Hand Surgery, The First Hospital of Ji Lin University, No. 1, Xin Min Street,
Chang Chun, Ji Lin 130021, PR China
b
Department of Hand Surgery, The Third People’s Hospital of Yang Quan City, Shan Xin 045000

Received 27 March 2006; accepted 29 November 2006

KEYWORDS Summary Objective: To introduce our experiences of using the reverse posterior inteross-
Reverse; eous flap and its composite flap.
Posterior interosseous Methods: In the series of 201 cases, the fasciocutaneous flap was used to cover skin defects
artery; over the distal 1/3rd forearm, wrist and hand in 174 cases. The composite flap with the
Flap; vascularised ulna bone graft was used to reconstruct the thumbs in 11 cases, and with the
Vascularised vascularised tendon graft was used to repair tendon defects with skin defects in 16 cases.
The size of the ulna graft was 3e6 cm in length and 1e2 cm in width. The 4e7 cm tendon graft
was obtained from the extensor digiti quinti or extensor carpi ulnaris. The size of the flaps
ranged from 5 cm  4 cm to 16 cm  10 cm.
Results: One flap failed completely. Of the other 200 flaps which survived 16 cases had ve-
nous congestion and had partial necrosis at the distal end. The size of the necrotic area
ranged from 1 to 4 cm in length. Ninety-three patients were followed up for at least 6
months, and included 10 patients with composite flaps. Generally, the flap matched the
surrounding skin. But 10 cases had a lipectomy. The sensibility did not recover or achieved
S1 within 6 months. For the extensor tendon defect, the function of finger extension was
nearly normal and tenolysis was not required. In contrast, tenolysis was required after
the flexor tendon reconstruction. However, these patients refused surgery. The bone grafts
were healed in 3 months. The reconstructed thumb looked abnormal and lacked normal
sensibility, although the patients used them. The linear scar line was conspicuous over
the dorsum of the forearm.
Conclusion: The reverse posterior interosseous flap is a reliable method to cover skin de-
fects over the distal 1/3rd of the forearm, the wrist and hand. The composite flap with
a vascularised tendon graft is an optimal reconstructive option for any extensor tendon
loss (III zone) associated with a skin defect. Using the composite flap with a vascularised

* Corresponding author. Tel.: þ86 0431 4863906.

E-mail address: gongxu1973@yahoo.com.cn (X. Gong).

1748-6815/$ - see front matter ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2006.11.024
The reverse posterior interosseous flap and its composite flap 877

bone graft or combined with the digital neurovascular flap is another way to reconstruct
the thumb.
ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.

The reverse posterior interosseous flap was first reported in
1986 by Lu et al.1 and Penteado et al.2 It has since evoked
universal interest among plastic surgeons and hand sur-
geons.3e15 It has been considered the workhorse for cover-
ing any skin defect over the distal forearm, wrist and hand,
because it does not compromise the dominant hand arteries
and has a reliable blood supply.
From 1985 to December 2005, we performed the reverse
posterior interosseous flap and its composite variant in 201
patients, which included 27 cases of composite flaps. We
present our experience of the reverse posterior interosseous
flap and its composite flap, with respect to its indication, range
of coverage, manipulative caveats, and its therapeutic results.
Materials and methods
General conditions
The 201 patients consisted of 132 males and 69 females.
Their age ranged from 6 years to 58 years (Table 1). The
size of the flaps ranged from 5 cm  4 cm to 16 cm  10 cm.
The donor site was closed directly in 75 cases and by split
graft in 125 cases. In one case, the donor site was left
open due to an anaesthetic event.
The fasciocutaneous flap was used to cover skin defects
over the hand and wrist (Fig. 1). The composite flap was
used to reconstruct the thumb or cover a skin defect with
flexor or extensor tendon defects (Table 2). The composite
flap was composed of the reverse posterior interosseous
fasciocutaneous flap and a vascularised ulna bone graft or
a vascularised extensor tendon graft, which was also sup-
plied by the posterior interosseous artery (PIA). The size
of the vascularised ulna graft was 3e6 cm in length and
1e2 cm in width. The source of the vascularised tendon
graft was the extensor digiti quinti (EDQ) or the extensor
carpi ulnaris (ECU), which was 4e7 cm in length.
into the dorsum of the forearm. It courses distally
underneath the superficial extensor muscles, accompany-
ing two venae comitantes and the posterior interosseous
nerve (PIN). Its projection is the distal 2/3rd of the line
from the lateral epicondyle of the humerus to the radial
edge of the ulnar head under the neutral position of the
forearm. Along its course, the PIA gives out osseous,
muscular, tendinous and septocutaneous branches. Near
the proximal edge of the interosseous membrane, the PIA
gives off the interosseous recurrent artery, which courses
proximally along the postero-lateral edge of the proximal
ulna and gives off osseous branches supplying the ulna.
Along its course, the PIA gives out muscular and tendious
branches, which form a vascular network over the
extensors. There are between five and 13 septocutaneous
branches arising from the PIA, supplying the dorsum of
the forearm. The anatomic basis of the reverse flap is the
anastomosis arc between the PIA and dorsal branch of
the anterior interosseous artery (AIA), which lies 2.5 cm
proximal to the radial edge of ulnar head (Table 3).
This anastomotic arc was deficient in two out of 60 ca-
daveric specimens and one out of the 201 patients. This
demonstrates that the anastomosis arc is consistent, but
very rarely may be deficient.

Surgical anatomy

The PIA arises from the common interosseous artery, and

penetrates the interosseous membrane at its upper edge

Table 1 Cause of injury

Cause No.
Machine crush 61
Skin avulsion 36
Electric burn 6
Explosive injury 17
Burns 29
Lacerations 48
Malignant tumour 1
Gunshot injury 2
Iatrogenic injury 1 Figure 1 Skin defect over the dorsum of left hand. (A) Preop-
erative view. (B) Postoperative view.
878 L.-J. Lu et al.

Table 2 Summary of cases (n Z 201)

Classification Recipient No.
Fasciocutaneous 174
First web space 36
Palm of distal 1/3rd 52
forearm, wrist or hand
Dorsum of hand 72
Dorsum of hand 14
and finger Figure 2 The axis and pivot point of the reverse posterior
Composite 27 interosseous flap. (1) The lateral epicondyle of the humerus;
Reconstruction of thumb 11 (2) the radial edge of the ulnar head; (3) pivot point.
Repair of tendon defect 16
Dissection of the flap
First, incise the radial edge of the flap into the epimysium
of the EDC. Dissect ulnarly towards the intermuscular
Operative technique
septum between the EDQ and ECU, along the plane
between the fascia and epimysium. During the dissection,
Surface marking the fascia to the skin paddle is secured with interrupted
The axis of a flap is the line drawn from the lateral sutures. Then, incise the ulnar edge and dissect radially
epicondyle of the humerus to the radial edge of the ulnar towards the septum, also along the plane between the
head under the neutral position of the forearm. The pivot fascia and epimysium.
point is at 2.5 cm proximal to the radial edge of the ulnar
head. The length of the pedicle depends on the distance
Harvesting of the flap
from the pivot point to the proximal edge of the recipient
First, dissect carefully the PIN from the PIA and its venae
site. The flap is designed along its axis (Fig. 2).
comitantes. During dissection, avoid injuring the venae
comitantes. The intermuscular septum between the EDQ
Dissection of the pedicle and ECU is the landmark of dissection, along which the PIA
Because of the possibility of a deficient anastomosis, we and its venae comitantes course distally. After completing
prefer to dissect the pedicle and expose the anastomosis the dissection of the PIN, detach the intermuscular septum
arc first. Incise the skin and undermine bilaterally. The from the ulna. The pedicle of the flap consists of the PIA,
plane of dissection is between the skin and the antebrachial venae comitantes and intermuscular septum between the
fascia. Through the fascia, confirm the tendons of the EDQ and ECU. Finally incise and ligate the origin of the PIA
extensor digitorum communis (EDC) and extensor carpi and complete the harvest of the flap.
ulnaris (ECU). Then, incise the fascia over the tendons of
the EDC and ECU. Reflect the fascia radially or ulnarly, the Harvesting of the composite flap with the vascularised
PIA can be observed, which courses along the intermuscular tendon graft
septum between the extensor digiti quinti (EDQ) and the As the PIA courses distally along the septum between the
ECU. At the pivot point, observe the anastomosis arc, if it EDQ and ECU and gives off branches supplying the tendons
exists, and continue the operation. of the EDQ and ECU, we prefer to choose the tendons of the
EDQ and ECU as the tendon graft. Based on the distance
Table 3 The anatomical parameters of the posterior from the proximal end of the recipient tendon defect to the
interosseous artery (specimens Z 60) pivot point, design the location of the distal end of the
graft along the course of the ECU or EDQ. Then depending
Parameter Results
on the length of the tendon defect, design the length of the
Length (cm) 13.74  0.8 tendon graft along the course of the ECU in a distal to
Diameter of PIA (mm)a proximal direction. This tendon graft usually lies under-
Original 1.44  0.2 neath the skin paddle.
Terminal 0.70  0.1 Like the steps of dissection of the fasciocutaneous flap,
we first dissect the pedicle and pivot. During the dissection
No. of branches
of the pedicle, we confirm the course of ECU and EDQ.
Osseous 6e10
After completing the dissection of the pedicle, reflect the
Tendinous and muscular 13e19
skin paddle radially or ulnarly to expose the course of the
Proximal cutaneous 3e9
ECU or EDQ completely. According to preoperative design,
Distal cutaneous 2e5
observe whether there is a tendinous branch to the ECU or
Diameter of anastomosis 0.84  0.1
EDQ. Generally, there are one or two tendinous branches,
arc (mm)b
which run along the paratenon. If such a branch is absent at
a
PIA: posterior interosseous artery. the site of the designed graft, the donor site of the tendon
b
Anastomosis arc between the posterior interosseous artery graft should be moved proximally. After confirming the
and the dorsal branch of the anterior interosseous artery was
existence of the tendinous branch over the paratenon, split
present in 58 of 60 specimens.
the tendon of the ECU longitudinally. Choose the half
The reverse posterior interosseous flap and its composite flap 879

adjacent to the pedicle as the graft. As to the EDQ, the

whole tendon can be chosen as graft. During harvesting,
keep the paratenon attached to the tendon graft (Fig. 3).

Harvesting of the composite flap with the vascularised

bone graft
We prefer to choose the proximal ulna as the donor, which
is supplied by the interosseous recurrent artery.
After completing the dissection of the flap and before
detachment of the pedicle from the proximal ulna,
observe the course of the interosseous recurrent artery
at the origin of the PIA from the radial side of the
intermuscular septum between ECU and EDQ. The inter-
osseous recurrent artery, along the intermuscular septum
between the ECU and EDQ, runs proximally along the
posterolateral edge of the proximal ulna, so we choose
the posterolateral potion of the proximal ulna as the
source of the vascularized bone graft. The bone graft can
be harvested from the ulnar side of the intermuscular
septum. During resection of the bone graft, protect the
periosteum and interosseous recurrent vessels (Figs. 4
and 5). The bone graft is connected with the PIA through
the periosteum, septum between the ECU and EDQ and
interosseous recurrent vessels.

Results Figure 4 The composite flap with the vascularised ulna bone
graft.
To analyse the results, the follow-up time was divided into
short term (within 3 weeks) in 201 patients and long term
(at least 6 months) in 93 patients. Short-term follow up

In the series of 201 patients, one flap failed completely due

to vascular deficiency, and all other cases survived. In the
200 survived cases, 16 had venous congestion and partial
necrosis at the distal end of the flap, which ranged from 1
to 4 cm in length. The flap healed with the surrounding tis-
sue within 3 weeks, usually by 2 weeks.

Long-term follow up

Ninety-three patients were followed up for at least 6

Figure 3 The composite flap with the vascularised tendon
grafts, which are from the tendons of the extensor carpi ulnaris
(ECU) and the extensor digiti quinti (EDQ).
months. These included 10 patients with composite flaps.
Generally, the flap matched the surrounding skin over the
hand and wrist. Ten cases had a lipectomy for a fatty skin
paddle. The sensibility did not recover or achieved S1
within 6 months. The linear scar line was conspicuous over
the dorsum of the forearm. This influenced the cosmetic
result of the forearm, especially in women.
Six cases of composite flaps with the vascularised tendon
graft were followed up for 6 months; in these no tenolysis was
performed. For the extensor tendon defect, the function of
finger extension was nearly normal after repair without the
need to perform tendon release. In contrast, for flexor
tendon defect, the outcome was suboptimal and needed
tenolysis, but these patients refused further surgery.
Four cases of reconstructed thumbs were followed up.
The vascularised bone graft healed within 3 months. The
shape of the reconstructed thumb was not aesthetic and
lacked normal sensibility but patients did accept it.
However, in cases of the reverse posterior interosseous
composite flap combined with a digital neurovascular flap,
880
Figure 5 Thumb defect of the left hand; the thumb was
reconstructed by the reverse posterior interosseous composite
flap (with the vascularised ulna bone graft) combined with
the digital neurovascular flap. (A) Preoperative view. (B) Intra-
operative view. (C) Postoperative view. (D) Functional view.
L.-J. Lu et al.
the sensibility of the reconstructed thumb was S3eS3þ
(Fig. 5).
Discussion
Indication of the reverse posterior interosseous
flap and its composite variant
Based on the application in 201 cases, we suggest the
reverse posterior interosseous flap should be the first
choice to cover any skin defect over the distal forearm,
wrist, hand and fingers. The range of coverage is as follows:
the dorsum and palm of the hand, the first web space, the
proximal phalanges of the finger, and the palm of the wrist
and distal 1/3rd of the forearm. In addition, the composite
flap can be an alternative to reconstruct the thumb,
although its cosmesis and sensibility are poor compared
with the wrap-round flap.
Choosing the donor
Based on a review of 87 cases, Akinci et al.16 concluded
that the reverse posterior interosseous flap was reliable
if it included the septocutaneous perforators in the distal
third of the forearm.16 They suggest that to cover distal
defects reliably by a flap with a long pedicle, the flap
should extend up to the distal third of the forearm to in-
clude a piece of skin with numerous perforators. Based on
our anatomic study of 60 specimens, we consider the sep-
tocutaneous branches can be divided into two groups,
namely the proximal and distal groups, which is partly
in accordance with the work of Costa.13 There are be-
tween three and nine septocutaneous branches at the
proximal half of the forearm; in contrast, only two to
five branches in the distal half. So we prefer to choose
the proximal half as the donor, especially the middle
1/3rd of the forearm.
In our series, we seldom identify how many septocuta-
neous branches enter the flap. We feel that even if one
septocutaneous branch enters the skin paddle, the survival
of the flap can be ensured. The key is to increase the
numbers of septocutaneous branches into the fascia. By
choosing the proximal half as the donor, there is usually at
least one branch entering the skin paddle. We prefer to
increase the width of the pedicle to increase the numbers
of septocutaneous branches into the pedicle. As the
septocutaneous branches of the PIA form a vascular net-
work over the dorsal fascia of the forearm, the flap can
survive with sufficient blood supply.
Caveats of manipulation
Although the operative manipulation of this flap is easy
and safe, some precautions are required. First, how can
the deficient anastomotic arc be avoided? Our method is
to dissect the pedicle first, and confirm the existence of
the anastomosis arc 2.5 cm proximal to the radial edge of
the ulnar head.
Second, how can postoperative venous congestion be
avoided or managed? Venous congestion occurs frequently
in reverse flaps and is usually the main cause of failure.
The reverse posterior interosseous flap and its composite flap
Based on our experience, the venous congestion of the
reverse posterior interosseous flap is due to two causes: the
width of the pedicle and the narrowness of the subcutane-
ous tunnel. Because the venae comitantes in the pedicle
are thin and subject to inadvertent injury and external
pressure, we prefer to keep a 2-cm-wide fascial strip
attached to it. This not only avoids the inadvertent injury
to vessels, but also increases the numbers of septocuta-
neous branches entering the skin. During dissection of the
pedicle, we incise the fascia over the tendons of ECU and
EDC to form a 2-cm-wide fascial strip. Also, we detach the
septum from the ulna in contrast to mobilising the vessels
from the septum. So, in our series, the vascular pedicle not
only includes the PIA and its venae comitantes, but also
includes both a 2 cm fascial strip and the septum between
the EDQ and ECU (Fig. 6). We also pay attention to the
width of the subcutaneous tunnel, which is another impor-
tant factor causing postoperative venous congestion. Some-
times, although the width of the tunnel is enough
intraoperatively, the postoperative bleeding within the tun-
nel and swelling can cause external compression to the
pedicle within the tunnel, which leads to venous congestion
during the first 2 days. In order to avoid the external
compression within the subcutaneous tunnel, we usually re-
lease the tourniquet to observe the condition of bleeding
and make the tunnel at least two fingers wide. Sometimes,
even after careful formation of the subcutaneous tunnel,
postoperative venous congestion occurs. In our series, ve-
nous congestion occurred in 16 patients. Our method of re-
lieving venous congestion is to allow the flap to bleed at the
distal. The venous congestion is usually relieved within
72 h. As postoperative swelling usually decreases after
72 h, the external compression of the pedicle can be
relieved.
Therapeutic results of the composite flap
Based on the outcomes of 27 composite flaps, we confirm
that the reverse posterior interosseous flap can be har-
vested as a composite flap with a vascularised tendon graft
Figure 6 The pedicle of the reverse posterior interosseous
flap consists of the posterior interosseous artery and its vena
comitantes, intermuscular septum between the tendons of
extensor carpi ulnaris (ECU) and extensor digiti quinti (EDQ),
and a 2-cm-wide strip of antebrachial fascia.
881
or bone graft. As a composite flap with a vascularised
tendon graft, it proved a single-stage procedure for any
extensor tendon defect (III zone) with a skin defect. But for
flexor tendon defects, postoperative adhesion is likely. A
posterior interosseous flap with a vascularised bone graft
singly or combined with a digital neurovascular flap can
reconstruct the thumb. This avoids the long period of
immobilisation required after the traditional flap with iliac
bone graft. Although its shape and sensibility is poor
compared with the wrap-round flap, its manipulation is
local, easier and safer, and no microsurgical anastomosis is
necessary.
In general, the reverse posterior interosseous flap is
a reliable fasciocutaneous flap for skin defects over the
distal forearm, wrist and hand. It should be the first choice
to cover skin defects with exposure of bone or tendon. The
composite flap with a vascularised tendon graft can repair
an extensor tendon defect (III zone) with a skin defect. The
composite flap with a vascularised bone graft or combined
with a digital neurovascular flap can reconstruct the
thumb.
Acknowledgement
The authors thank Mr. J.J. Dias, Consultant Orthopaedic
and Hand Surgeon, Department of Orthopaedic Surgery,
Glenfield Hospital, University Hospitals of Leicester, UK for
his corrections and revision.
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