NJCA
  • Users Online: 413
  • Print this page
  • Email this page
  • Email this page
  • Facebook
  • Twitter


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 3  |  Page : 136-142

Perforators of the arm to provide anatomical basis to skin flaps: A cadaveric study


1 Assistant Professor, Department of Anatomy, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India
2 Assistant Professor, Department of Anatomy, Shri Shankaracharya Institute of Medical Sciences, Bhilai, Chhattisgarh, India
3 Assistant Professor, Department of Anatomy, Autonomous State Medical College, Hardoi, Uttar Pradesh, India
4 Professor, Department of Anatomy, King George's Medical University, Lucknow, Uttar Pradesh, India
5 Additional Professor, Department of Anatomy, King George's Medical University, Lucknow, Uttar Pradesh, India
6 Professor and HOD, Department of Anatomy, School of Medical Sciences & Research, Sharda University, Greater Noida, Uttar Pradesh, India

Date of Submission04-May-2022
Date of Decision25-Jun-2022
Date of Acceptance30-Jun-2022
Date of Web Publication12-Aug-2022

Correspondence Address:
Ritu Singh
Department of Anatomy, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJCA.NJCA_89_22

Rights and Permissions
  Abstract 


Introduction: The upper extremity is commonly involved in severe soft tissue defects that can be challenging functionally and cosmetically. Anatomical studies on skin vascularization provide developmental base for the flap nourished by perforating arteries. Perforator flaps reduce donor site morbidity and recovery time. Therefore, in case of cosmetic surgery of soft tissue defect of the arm, it is mandatory for reconstructive surgeons to have beforehand knowledge of vascular anatomy of cutaneous perforators of the arm. Hence, a study was done to evaluate the total number of perforators, distribution from bony landmarks, and pedicle length from source vessels on the medial, lateral, and posterior aspects of the arm. Methodology: The study was undertaken at the Department of Anatomy, King George's Medical University, Lucknow, on 15 upper limbs of fresh cadavers of both the sexes of adult age group. Methylene blue dye was injected into the arterial system of the arm. After one hour, perforators were visualized by incising the margins of the stained arm skin. Results: We observed that maximum numbers of perforators were contributed by direct branch of the brachial artery (49.7%), followed by superior ulnar collateral artery. Numbers of perforators on the medial aspect of the arm were maximum (52.0%), followed by lateral aspect and posterior aspect of the upper arm. Perforators supplying the posterior and lateral aspects of the arm had the maximum mean length. Conclusion: Thus, a detail understanding of position, length, and numbers of perforators of the arm helps surgeons to predefine the appropriate perforator flaps for reconstructive surgeries.

Keywords: Brachial artery, Cutaneous perforators, forearm, flaps, superior ulnar collateral artery


How to cite this article:
Singh R, Singh P, Kori D, Kumar N, Pankaj AK, Gupta N. Perforators of the arm to provide anatomical basis to skin flaps: A cadaveric study. Natl J Clin Anat 2022;11:136-42

How to cite this URL:
Singh R, Singh P, Kori D, Kumar N, Pankaj AK, Gupta N. Perforators of the arm to provide anatomical basis to skin flaps: A cadaveric study. Natl J Clin Anat [serial online] 2022 [cited 2022 Oct 6];11:136-42. Available from: http://www.njca.info/text.asp?2022/11/3/136/353723




  Introduction Top


The upper extremity is commonly involved in severe soft tissue defects that can be due to trauma, burn, chronic infection, pressure sore, chronic ulcer, and after oncological excision. Since these defects are challenging functionally and cosmetically, a variety of surgical techniques have been developed to repair the soft tissue defect cosmetically using tissue transfer. Advances in the design of skin flaps, from the refinement of local flap transfer to the use of regional, distant, free, and now perforator flaps, have successively benefitted the surgeons to transfer tissue of desirable qualities and to decrease morbidity at the donor site.[1] During the last decade, anatomical studies on skin vascularization provided the base for the development of flap nourished by perforating arteries and preserving major vascular axis.[2] Perforator flaps are perfectly consummate in reconstructing the areas where further surgery required or to cover areas with massive wounds with remarkable soft tissue defects.[3] Perforator flaps of the arm like deltoid flaps and medial and lateral arm flaps are based on perforators and were used in repair of soft tissue defects of the upper extremities, especially of axilla, forearm, and hand, as well as in elbow contracture. Now, it is understood that any skin flap can be harvested if it is incorporated with a perforator vessel.

The cutaneous perforators can be traced back to source vessel, and this property found useful in searching recipient vessels adjacent to soft tissue defects.[2] Perforator flap of medial distal arm is considered as a potential donor site due to its excellent skin color, fine texture, and ideal thickness.[4]

The other merits of using perforator flaps are reduced donor site morbidity, reduced recovery time, suitable flap for specific defects, and importantly, improved aesthetic outcome. The size, distribution, and variability of cutaneous perforators of human body play pivotal role in designing and enactment of successful perforator flap surgery;[5] therefore, in case of cosmetic surgery of soft tissue defect of the upper extremities, it is mandatory for reconstructive surgeons to have details of vascular anatomy of cutaneous perforators of the arm for performing better perforator flap surgery. Large number of perforators of the upper arm were discovered and discussed till date; however, their distribution on the lateral, posterior, and medial sides of the upper arm as whole with emphasis on constant perforators with their length, respective to the side of the upper arm, has not been discussed. Hence, a study was done to evaluate the total number of perforators, distribution from bony landmarks, and pedicle length from source vessels on the medial, lateral, and posterior aspects of the upper arm.


  Materials and Methods Top


The study was undertaken at the Department of Anatomy, in collaboration with the Department of Forensic Medicine, King George's Medical University, UP, Lucknow, and the Department of Plastic and Reconstructive Surgery, King George's Medical University, UP, Lucknow, from April 2015 to June 2016. In the present study, 15 upper limbs of fresh cadavers of both the sexes of adult age group were dissected to define perforators after obtaining Institutional Ethics Committee approval for the study protocol (75th ECM II-B Thesis/P18).

Study material

Methylene blue dye, camera, scalpel vein set, 10-ml syringe, scalpel, toothed and plain forceps, artery forceps, and measuring scale.

Method

For delineating the perforators, the arm was abducted to right angle and longitudinal incision was made at the junction of anterior one-third and posterior two-third of the lateral wall of the axilla. Axillary artery was identified and was exposed, the vessel was closed tightly proximally with the help of artery forceps, while through distal part scalp vein set was introduced into the lumen of axillary artery A 10-ml syringe filled with methylene blue dye was connected to the scalp vein set, and slowly, methylene blue dye was injected into the arterial system of the arm and forearm until skin staining become evident over skin of the upper arm and forearm. One hour after instilling the dye, flaps were raised by incising the margins of the stained skin to visualize the stained perforators of the arm. Once precise locations of perforators were identified in arm, their distances were measured from corresponding bony landmarks. Bony landmarks for medial, lateral and posterior perforators were medial epicondyle, lateral epicondyle and midpoint of distance between olecranon process and medial epicondyle respectively. After measuring distances of perforators from corresponding bony landmarks, they were traced retrograde to their source vessels. The total length of each perforator was measured from source vessels to the level of superficial fascia. Finally, the total number of perforators of individual source artery was counted and noted down.

Results

In the present study we observed a total of 167 perforators of brachial artery in the arm of 15 upper limb of fresh cadavers, out of which maximum number were contributed by Direct branch of brachial artery (DBBA) followed by Superior Ulnar Collateral Artery (SUCA) and least by Inferior Ulnar Collateral Artery(IUCA). [Table 1] Number of perforators on medial side of arm were maximum [Figure 1] followed by on lateral side and on posterior side of arm. Mean length of perforators supplying arm from DBBA is maximum followed by RCA, SUCA and IUCA.
Figure 1: Perforators (black arrows) of the brachial artery proximal to medial epicondyle (yellow dot) of humerus

Click here to view
Table 1: Total number of perforators of the brachial artery supplying 15 arm

Click here to view


Perforators supplying the medial aspect of the arm

We observed that skin on medial aspect of the arm was supplied mainly by perforators of DBBA, followed by SUCA, and IUCA [[Table 2] and [Figure 2].
Table 2: Total number of perforators supplying the medial, lateral and posterior side of the 15 arm

Click here to view
Figure 2: Origin of superior ulnar collateral artery (red arrow), perforators of direct branch of the brachial artery (black arrows) and superior ulnar collateral artery (yellow arrow) supplying medial aspect of the arm proximal to medial epicondyle

Click here to view


Number of perforators

An average of 3.5, 1.5, and 0.73 numbers of perforators per arm was contributed by DBBA, SUCA, and IUCA, respectively [Table 3]. Perforators from DBBA were found to be scattered all over the medial side of arm proximal to medial epicondyle while perforators of SUCA were found from 10cm to 16 cm proximal to medial epicondyle.
Table 3: Perforators on the medial aspect of the arm proximal to medial epicondyle

Click here to view


Range of supply

Perforators of DBBA supplied within the range of 4 cm to 21 cm proximal and anterior to medial epicondyle.Those perforators founded to be clustered at about 8–9.5 cm and 14–18 cm, proximal and anterior to medial epicondyle. SUCA perforators supplied medial aspect of the arm within the range of 10 cm to 16 cm proximal to medial epicondyle, while perforators of IUCA supplied 0–3 cm proximal to medial epicondyle [Graph 1].



Length of perforators

The perforators found within range of 15 cm – 20 cm proximal to medialepicondyle were longest and were mainly contributed by DBBA. [Graph 1] Perforator from DBBA had an average length of 4.3 cm, with a range of 6.5cm - 2.2 cm per arm. Perforators from SUCA show an average length of 4.36 cm length and from IUCA an average length of 3.15 cm.

Perforators supplying the lateral aspect of the arm

In the present study 65.1% skin over lateral side of arm was observed to be supplied mainly by perforators ofRCAfollowed by DBBA in arm [Table 2] and [Figure 3] and [Figure 4].
Figure 3: Perforators (arrow) of direct branch of the brachial artery proximal to lateral epicondyle of humerus

Click here to view
Figure 4: Perforators (arrow) of radial Collateral Artery proximal to lateral epicondyle, emerging from lateral intermuscular septum of the arm

Click here to view


Number of perforators

An average of 1.0 and 1.9 numbers of perforators per upper arm was contributed by DBBA and RCA, respectively [Table 4].
Table 4: Perforators on the lateral aspect of the arm proximal to lateral epicondyle

Click here to view


Range of supply

Constant perforators of DBBA found at about 9.5–16 cm proximal and anterior to lateral epicondyle. RCA perforators supply lateral aspect of the arm within the range of 2–13.5 cm proximal to lateral epicondyle, but found to be clustered at about 2–3.8 cm and 9–12 cm proximal and anterior to lateral epicondyle [Graph 2].



Length of perforators

Perforator from DBBA had an average length of 5.09 cm, with range of 6.0cm - 4.5 cm per arm. Perforators from RCA show an average of 4.4cm length, with range of 6.5 - 2.0 cm per arm [Table 4] and [Graph 2].

Perforators of RCA emerged from lateral intermuscular septum proximal and anterior to lateral epicondyle [Figure 4]. Perforators of the brachial artery originated as DBBA and run in-between biceps brachii and brachialis muscle to reach lateral side of the arm proximal and anterior to lateral epicondyle of humerus [Figure 3].

Perforators supplying the posterior aspect of the arm

In the current study, we observed that posterior-superior aspect of the arm was supplied by DBBA, 40.5% [Figure 5], while posterior-inferior aspect of the arm was supplied by perforator of SUCA, 59.5% [Table 5] and [Figure 6].
Figure 5: Perforators of direct branch of the brachial artery on posterior superior aspect of the arm proximal to midpoint of distance between olecranon process (yellow dot) and medial epicondyle

Click here to view
Table 5: Perforators on the posterior aspect of the arm proximal to midpoint of olecranon process and medial epicondyle

Click here to view
Figure 6: Perforator (arrow) of superior ulnar collateral artery on the posterior inferior aspect of the arm proximal to midpoint of distance between olecranon process and medial epicondyle (yellow dot)

Click here to view


Number of perforators

An average of 1.0 and 1.46 numbers of perforators per arm was contributed by DBBA and SUCA, respectively [Table 5].

Range of supply

The constant perforators of DBBA were found at about 12 cm to 20 cm proximal to midpoint of distance between olecranon process and medial epicondyle. SUCA perforators supply posterior inferior of the arm at about 2 cm to 7 cm proximal to midpoint of distance between olecranon process and medial epicondyle [Graph 3].



Length of perforators

Perforator from DBBA had an average length of 5.18 cm, with maximum being 6.8 cm and minimum 4.0 cm/arm. Perforators from SUCA showed an average of 2.8 cm length, with maximum being 3.4 cm and minimum 2.0 cm/arm. Perforator from DBBA is longer than that of SUCA [Table 5 and Graph 3].

Perforators of DBBA supplied posterior superior aspect of the arm, proximal and anterior to medial epicondyle. This perforator curves downward subcutaneously from anterior aspect of the arm to reach at an average distance of 2.0 ± 0.2 cm posterior to medial epicondyle, finally supplying posterior aspect of the arm [Figure 5]. This perforator was found to be observed in almost all cases.

Perforators of SUCA were clustered at a distance of about 3–5 cm proximal to midpoint of distance between olecranon process and medial epicondyle. While perforators of DBBA were located at about 11cm – 20cm proximal to midpoint of distance between olecranon process and medial epicondyle [Graph 3].


  Discussion Top


The superficial and subdermal plexus are the two vascular plexus that supply the skin.[6] Branches from the subdermal plexus travel for variable distance to supply overlying skin. Its course depends on the proximity of the source artery to under surface ofthe deep fascia.[7] Skin receives its blood supply from so-called perforators.[8],[9] Cutaneous perforators can be defined as any vessel that arises directly from the underlying source vessels or indirectly from branches of those source vessels that supply deep tissues, especially muscles or intermuscular septum, and finally supplying the subcutaneous tissue and skin.[10]

The brachial artery supplies the arm, and it begins at the distal border of the teres major muscle and ends at the level of the neck of the radius. Brachial artery is covered only by skin and superficial and deep fascia. It gives profunda brachii, nutrient, superior ulnar collateral, middle collateral, deltoid, muscular, radial, and ulnar artery. Profunda brachii artery arises from posteromedial aspect of the brachial artery. It divides into terminal radial and middle collateral branches. The radial collateral branch pierces the intermuscular septum to reach the anterior aspect of the epicondyle of the humerus in-between brachioradialis and brachialis. SUCA arises a little distal to midlevel of the arm. IUCA arises approximately 5 cm proximal to the elbow.[11]

In a study on ten upper extremities, it was showed that there were 2.4 ± 0.8 perforators of SUCA having mean length of 55.7 ± 34.4 mm, 6.1 ± 3.5 perforators of brachial artery having mean length of 30.2 ± 14.4 mm, and 2 ± 1.5 perforators of RCA having mean length of 48.7 ± 15.3 mm.[12]

Perforators on medial aspect of the arm

The medial aspect of the arm was supplied by an average of 3.3 ± 0.95 perforators of the brachial artery and an average of 3.0 ± 0.82 perforators of SUCA.[13] Similarly, the other authors observed that both brachial and SUCA supplied the medial arm,[14],[15] while according to others, it was remarked that SUCA was the major arterial source for medial arm.[16],[17]

In other studies, it was observed that brachial artery was the main source vessel in 67% (128) of cases, followed by SUCA in 28% (54) of the cases. The mean length of perforators was found to be 33.76 ± 0.52 mm.[18]

We observed that skin of medial aspect of the arm supplied mainly by perforators of DBBA (53), followed by SUCA (23) and IUCA (11). The mean length and diameter of the distal brachial perforator artery were 3.3 cm and 0.95 mm, respectively.[19]

Perforators from DBBA that were located within 18–20 cm proximal and anterior to medial epicondyle have maximum length; whereas perforators of SUCA have an average length of 4.36 cm and were found at about 10–16 cm proximal and anterior to medial epicondyle.

The skin of medial arm is thin and hairless, thus making it very suitable for coverage of the hand, face, neck, or flexor crease.[20] Being on medial side of the arm, medial arm flaps are cosmetically acceptable, and the presence of medial brachial cutaneous nerve of the arm can give neurosensory flaps.[21]

Perforators on Lateral aspect of the arm

In a study, it was reported that lateral aspect of the arm was supplied by an average of 1 ± 0.47 perforator of the brachial artery and an average of 3 ± 0.47 perforators of the middle collateral artery.[13] The present study showed that an average of 1.0 and 1.9 numbers of perforators per arm were contributed by DBBA and RCA, respectively. The mean length of perforators of DBBR and RCA was 5.09 cm and 4.4 cm, respectively. We observed that the length of the perforators of RCA was increasing as the distance between its origin and bony medial epicondyle increases, proximally.

Lateral arm flap based on the profunda brachii artery will not endanger the vascular supply to the upper extremity and wound at donor site closes with a linear scar.[22]

Lateral arm flap can be used for large upper extremities defects as well as preferred for the reconstruction of the defects of the hands and fingers.[23] Due to its suppleness, softness and mobility lateral arm flap are preferred for tongue reconstruction.[24]

Perforators on Posterior aspect of the arm

The posterior surface of the arm was supplied by posterior brachial artery originated in 71% dissection from brachial artery and 23.5% from deep brachial artery.[25],[26] Vascularity of posterior arm flap may sometimes rely on branching either from SUCA or IUCA.[27] We observed that posterior superior aspect of the arm was supplied by brachial artery (40.5%), while posterior inferior aspect of the arm was supplied by perforator of SUCA (59.5%). In the current study, there is constant finding of perforators of DBBA at about 12–21 cm proximal to the midpoint of distance between olecranon process and medial epicondyle having an average length of 5.18 cm. Posterior arm flaps based on perforators of the brachial artery should be considered foremost option while planning axillary construction.[28]


  Conclusion Top


Medial aspect of the arm was having the maximum number of perforators, mainly contributed by perforators of DBBA as compared to SUCA and IUCA. Lateral and posterior aspect of arm found to have constant perforators of DBBA. Average length of perforators of SUCA was maximum on medial aspect of arm while average length of perforators of DBBA was maximum on lateral and posterior aspect of arm. Thus, a detail understanding of position, length, and numbers of perforators of the arm helps surgeons predefine the appropriate perforator flaps for reconstructive surgeries.

Acknowledgment

The authors sincerely thank those who donated their bodies to science, so that anatomical research could be performed. Results from such research can potentially increase humankind's overall knowledge that can then improve patient care. Therefore, these donors and their families deserve our highest gratitude.[29]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Morris SF, Taylor GI. Vascular territories. In: Blondeel PN, Morris SF, Hallock GG, Neligan PC, editors. Perforator Flaps: Anatomy, Technique and Clinical Applications. 2nd ed. St. Louis, Missouri: Quality Medical Publishing, Inc.; 2013. p. 25-52.  Back to cited text no. 1
    
2.
Artiaco S, Battiston B, Colzani G, Bianchi P, Scaravilli G, Boux E, et al. Perforator based propeller flaps in limb reconstructive surgery: Clinical application and literature review. Biomed Res Int 2014;2014:690649.  Back to cited text no. 2
    
3.
Appleton SE, Morris SF. Anatomy and physiology of perforator flaps of the upper limb. Hand Clin 2014;30:123-35, v.  Back to cited text no. 3
    
4.
Maruyama Y, Onishi K, Iwahira Y. The ulnar recurrent fasciocutaneous island flap: Reverse medial arm flap. Plast Reconstr Surg 1987;79:381-8.  Back to cited text no. 4
    
5.
Morris SF, Tang M, Almutari K, Geddes C, Yang D. The anatomic basis of perforator flaps. Clin Plast Surg 2010;37:553-70, xi.  Back to cited text no. 5
    
6.
Cormack GC, Lamberty BG, editors. The Different Layers of Integument and Functional Organization of the Microcirculation. New York: Churchill Livingstone; 1994. p. 16-69.  Back to cited text no. 6
    
7.
Taylor GI, Corlett RJ, Ashton MW. The blood supply of the skin and skin flaps. In: Chung KC, Gosain AK, Gurtner GC, Mehrara BC, Rubin JP, et al., editors. Grabb and Smith's Plastic Surgery. 7th ed. Philadelphia (PA): Lippincott Williams & Wilkins, A Wolters Kluwer Business; 2014. p. 29-41.  Back to cited text no. 7
    
8.
Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: Experimental study and clinical applications. Br J Plast Surg 1987;40:113-41.  Back to cited text no. 8
    
9.
El-Mrakby HH, Milner RH. Bimodal distribution of the blood supply to lower abdominal fat: Histological study of the microcirculation of the lower abdominal wall. Ann Plast Surg 2003;50:165-70.  Back to cited text no. 9
    
10.
Morris SF, Taylor GI. Vascular territories of the integument. In: Blondel PN, Morris SF, Hallock GG, Neligen PC, editors. Perforators Flaps. Anatomy, Technique and Clinical Applications. 2nd ed. Philadelphia, Boca Raton, Florida: CRC Press; 2013.  Back to cited text no. 10
    
11.
Standring S. Gray's Anatomy. The Anatomical Basis of Clinical Practice. 41st ed. UK: Elsevier; 2016.  Back to cited text no. 11
    
12.
Chen SH, Xu DC, Tang ML, Ding HM, Sheng WC, Peng TH. Measurement and analysis of the perforator arteries in upper extremity for the flap design. Surg Radiol Anat 2009;31:687-93.  Back to cited text no. 12
    
13.
Hwang K, Lee WJ, Jung CY, Chung IH. Cutaneous perforators of the upper arm and clinical applications. J Reconstr Microsurg 2005;21:463-9.  Back to cited text no. 13
    
14.
Cormack GC, Lamberty BG. A classification of fascio-cutaneous flaps according to their patterns of vascularisation. Br J Plast Surg 1984;37:80-7.  Back to cited text no. 14
    
15.
Perignon D, Havet E, Sinna R. Perforator arteries of the medial upper arm: Anatomical basis of a new flap donor site. Surg Radiol Anat 2013;35:39-48.  Back to cited text no. 15
    
16.
Gao XS, Mao ZR, Yang ZN, Wang BS. Medial upper arm skin flap: Vascular anatomy and clinical applications. Ann Plast Surg 1985;15:348-51.  Back to cited text no. 16
    
17.
Breidenbach WC, Adamson W, Terzis JK. Medial arm flap revisited. Ann Plast Surg 1987;18:156-63.  Back to cited text no. 17
    
18.
Gupta R, Gupta T, Gaba S, Aggarwal A, Harjeet K, Sahni D. Anatomical and clinical perspective of medial arm region perforators – A potential flap for reconstructive surgeries. JCDR 2018;12:AC14-8.  Back to cited text no. 18
    
19.
Cil Y, KocabΙyΙk N, Ozturk S, Isik S, Ozan H. A new perforator flap from distal medial arm: A cadaveric study. Eplasty 2010;10:e65.  Back to cited text no. 19
    
20.
Carriquiry CE. Superior medial arm flap.In Strauch B, Vasconez LO, Hall-Findlay EJ, editors. Grabb's Encyclopedia of flaps upper extremities. 3rd ed. Philadelphia: Lippincott-Williams & Wilkins; 2009; 2:963-5.  Back to cited text no. 20
    
21.
Karamürsel S, Bağdatli D, Demir Z, Tüccar E, Celebioğlu S. Use of medial arm skin as a free flap. Plast Reconstr Surg 2005;115:2025-31.  Back to cited text no. 21
    
22.
Deleyiannis FW, Gastman BR, Russavage JM. Microvascular reconstruction of the head and neck. In: Myers EN, editor. Operative Otolaryngology: Head and Neck Surgery. 2nd ed. Philadelphia: Saunders Elsevier; 2008. p. 739-52.  Back to cited text no. 22
    
23.
Atzei A, Pignatti M, Udali G, Cugola L, Maranzano M. The distal lateral arm flap for resurfacing of extensive defects of the digits. Microsurgery 2007;27:8-16.  Back to cited text no. 23
    
24.
Yuksel E, Sandeen SN, Weinfeld AB, Shenaq SM, Langstein HN. Reconstruction of the oral cavity. In: Weinzweig J, editor. Plastic Surgery Secrets Plus. 2nd ed. Philadelphia: Mosby Elsevier; 2010.  Back to cited text no. 24
    
25.
Masquelet AC, Rinaldi S. Anatomical basis of the posterior brachial skin flap. Anat Clin 1985;7:155-60.  Back to cited text no. 25
    
26.
Masquelet AC, Rinaldi S, Mouchet A, Gilbert A. The posterior arm free flap. Plast Reconstr Surg 1985;76:908-13.  Back to cited text no. 26
    
27.
Tinhofer IE, Tzou CH, Duscher D, Pollhammer MS, Weninger WJ, Huemer GM, et al. Vascular territories of the medial upper arm-an anatomic study of the vascular basis for individualized flap design. Microsurgery 2017;37:618-23.  Back to cited text no. 27
    
28.
Sirvan SS, Demir IA, Irmak F, Sevim KZ, Dagdelen D, Yazar SK, et al. Posterior arm perforator flap for axillary reconstruction after hidradenitis suppurativa excision. Plast Surg (Oakv) 2019;27:204-10.  Back to cited text no. 28
    
29.
Iwanaga J, Singh V, Ohtsuka A, Hwang Y, Kim HJ, Moryś J, et al. Acknowledging the use of human cadaveric tissues in research papers: Recommendations from anatomical journal editors. Clin Anat 2021;34:2-4.  Back to cited text no. 29
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed566    
    Printed32    
    Emailed0    
    PDF Downloaded269    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]