Neurovascular Anatomy

The vascular supply to the lateral arm flap is the posterior radial collateral artery and vein. However, the profunda brachii artery and vein, from which the radial collateral vessels branch, are often used to exploit their greater length and size. The

Figure 63 Surgical anatomy demonstrated in a harvested and pedicled lateral arm flap. Note the positions of the lateral brachial cutaneous and posterior radial collateral vessels. A larger donor vessel diameter is possible if the vascular pedicle is further dissected posteromedially to the deep brachial artery. Although two sensory nerves are associated with this flap—the lateral brachial cutaneous nerve and the posterior cutaneous nerve of the forearm—only the former supplies the skin territory of the flap.

Figure 63 Surgical anatomy demonstrated in a harvested and pedicled lateral arm flap. Note the positions of the lateral brachial cutaneous and posterior radial collateral vessels. A larger donor vessel diameter is possible if the vascular pedicle is further dissected posteromedially to the deep brachial artery. Although two sensory nerves are associated with this flap—the lateral brachial cutaneous nerve and the posterior cutaneous nerve of the forearm—only the former supplies the skin territory of the flap.

profunda brachii artery arises from the posteromedial aspect of the brachial artery, below the lower border of the teres major muscle. Traveling with the radial nerve, the artery passes posteriorly around the humerus between the medial and lateral heads of the triceps muscle. The vascular pedicle is covered by the lateral head of the triceps muscle. On the lateral side of the arm, the artery pierces the lateral intermuscular septum and descends inferiorly between the brachioradialis and brachialis muscles to pass anterior to the lateral epicondyle. The radial collateral artery branches from the profunda brachii artery behind the humerus and descends within the lateral intermuscular septum behind the lateral epicondyle (Fig. 64). The radial collateral artery sends multiple septocutaneous perforating vessels to the lateral arm corresponding to the vascular territory of the lateral arm flap. In addition, the artery sends perforators more inferiorly into the forearm, so the true vascular territory of the artery extends several centimeters beyond the lateral epicondyle (so-called extended lateral arm free flap) (71).

The sensory nerve to the lateral arm flap is the lateral brachial cutaneous nerve. Two sensory nerves are associated with this flap, but only one supplies the skin covering the flap. The posterior cutaneous nerve of the forearm arises from

Figure 64 Further posteromedial dissection of the vascular pedicle of the lateral arm flap will uncover and allow harvest of the larger profunda brachii artery and vein.

the lateral septum 2.5-7.5 cm above the epicondyle and continues into the forearm. It does not serve the flap but may be harvested with the flap and used as a vascularized nerve graft (72). The lateral brachial cutaneous nerve follows the posterior border of the deltoid muscle and supplies the skin of the lateral arm, entering the flap near its proximal posterior border. To facilitate its incorporation into the flap, it is useful to identify this nerve early in the dissection. The extended lateral arm flap incorporates skin supplied by the posterior cutaneous nerve of the forearm and so this nerve can be used for reinnervation when the flap territory extends significantly below the lateral epicondyle.

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