Surgical Highlights

The lateral aspect of the nondominant arm is prepped and draped and the flap is outlined (Fig. 65). The surface landmarks for the lateral intermuscular septum are the lateral epicondyle of the humerus and the deltoid insertion. The skin paddle must be centered on the septum and is generally designed as a simple ellipse to facilitate donor site closure. The skin paddle and the underlying fascia are raised off the underlying muscle posteriorly and anteriorly towards the intermuscular septum. The sensory nerve is found posteriorly on line with the posterior border of the deltoid muscle. It can be dissected and cut proximally early. The vascular pedicle is identified emanating from the lateral intermuscular septum. It is dissected posteriorly along the spiral groove on the posterior aspect of the humerus. Care must

Figure 65 The lateral arm free flap is depicted. The solid line represents the lateral intermuscular septum and the skin flap is centered along this line. The landmarks for the septum are the lateral epicondyle of the humerus and the deltoid insertion.

Figure 66 Lateral arm flap pedicled on its feeding vessels: the posterior radial collateral artery and vein.

be taken not to injure the radial nerve since it runs with the vascular pedicle within the groove. An additional skin incision is made from the apex of the skin ellipse to the deltoid insertion to facilitate separation of the musculature and dissection of the pedicle. Further superior extension of the incision along the posterior border of the deltoid allows separation of the lateral head of the triceps and the deltoid muscle (Fig. 66). To gain additional length on the pedicle, the insertion of the lateral head of the triceps is sharply incised and the radial collateral artery is seen joining the profunda brachii artery. The profunda brachii vessels are then dissected to the brachial artery and vein where they are divided to release the flap. Finally, a layered closure of the donor site over a large suction drain is performed.

The extended lateral arm flap includes an ellipse of skin over the lateral epicon-dyle and upper lateral forearm. The flap is raised in an identical fashion; however, the posterior cutaneous nerve of the forearm, which accompanies the vascular pedicle, can be used for sensory reinnervation of the flap since this nerve inserts into the skin of the upper lateral forearm (71).

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