ORIGINAL ARTICLES

CUTANEOUS VASCULAR TERRITORIES OF THE

FOREARM AND HAND

Costache Chertif1, Alexandru V. Georgescu2

REZUMAT
Pentru gsirea celor mai bune metode de acoperire a defectelor de substan, de foarte mare importan este o bun cunoatere a vascularizaiei
cutanate. Zece membre superioare de la cadavre proaspete au fost injectate cu oxid de plumb-gelatin i au fost disecate, cu efectuarea unei hri
generale a perforantelor la nivelul antebraului i minii. Interpretarea rezultatelor s-a fcut prin radiografii individuale ale fiecrei zone, fotografierea
digital, apoi desenarea manual i scanarea imaginilor pentru Windows, calculnd prin msurtori directe ariile teritoriilor vasculare. n diseciile noastre
am identificat la nivelul antebraului i minii nou teritorii vasculare cu o medie de 25 9 perforante. Diametrul perforantelor la nivelul antebraului
i minii a fost n medie de 0,6 0,1 mm, vasculariznd o zon de aproximativ 30 cm2. Perforantele musculo-cutanate sunt mai numeroase la nivelul
1/3 superioare a antebraului, cu o medie de 7:3, iar cele septocutanate predomin la nivelul 1/3 distale a antebraului i la nivelul minii, cu un raport
mediu de 4:3. Fiecare teritoriu vascular este irigat de o surs arterial din care ia natere un numr variabil de perforante cutanate. Localizarea precis i
numrul perforantelor n fiecare teritoriu sunt variabile. n ciuda acestei variabiliti ntre perforante, ariile vasculare, mpreun cu sursa vascular, au fost
relativ uniforme. Aceste date sunt de foarte mare ajutor n practicarea lambourilor perforante locale/regionale la nivelul antebraului i minii.
Cuvinte cheie: vascularizaia antebraului i minii, lambouri perforante, tehnica injectrii cu oxid de plumb gelatin

ABSTRACT
In finding the best method of tissue defects coverage, a good knowledge of the cutaneous vascularization is extremely important. Ten upper extremities
obtained from fresh cadavers were injected with lead oxide-gelatin and were dissected, and an overall map of perforators in the forearm and hand was
created. The interpretation of the data has included individual X-ray photographs for each zone, digital photographs, then manual drawing and scanning
images for Windows, calculating the areas of the vascular territories by direct measurements. In our dissections, we have identified at the level of the
forearm and hand nine vascular territories with an average of 25 9 perforators. The diameter of the perforators at the level of the forearm and hand
was found to have an average of 0.6 0.1 mm, by vascularizing a zone of about 30 cm2. The musculo-cutaneous perforators are more numerous in the
proximal 1/3 of the forearm, with an average ratio of 7:3, while the septo-cutaneous perforators prevail in the distal 1/3 of the forearm and in the hand,
with an average ratio of 4:3. Each vascular territory is fed by an arterial source from which appear a variable number of cutaneous perforators. The precise
localization and the number of the perforators in each territory are variable. In spite of this variability between the perforators, the vascular areas together
with the vascular source have been relatively uniform. All these data are helpful in the design of local/regional perforator flaps in the forearm and hand.
Key Words: forearm and hand blood supply, perforator flaps, technique of injecting lead oxide gelatin

INTRODUCTION

Initially used almost exclusively as free flaps, the

1
Plastic Surgery Center Cosmedica, Baia Mare, 2 Department of Plastic
Surgery and Reconstructive Microsurgery, Rehabilitation Clinical
Hospital, Iuliu Hatieganu Faculty of Medicine and Pharmacy, Cluj Napoca
Correspondence to:
C. Chertif, MD, Clinica Cosmedica, Str. G. Cobuc 50B, Baia Mare, Tel.
+40-262-219521.
Email: chertif@yahoo.com
Received for publication: Sep. 11, 2009. Revised: Dec. 02, 2009.
perforator flaps have been also used in the last years as
local transposition or regional pedicled flaps. However,
the use of the perforator flaps has been improved
after the description and the understanding of the
cutaneous vascularization.
One of the first complete descriptions of the
blood supply of the skin was done by Manchot,
who described the source vessels and their branches
coursing through the muscles to reach the skin,
but the first describing also the finer framework of
anastomosing vessels within the skin was Salmon, who
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Costache Chertif et al 241
used the lead oxide injection technique.1,2
Despite the numerous studies regarding the blood
supply of the skin in various regions of the human
body, this is still incompletely understood, necessitating
a new development nowadays.3-11
A lot of regional or local flaps are used nowadays
in hand and forearm reconstructive surgery, especially
as perforator flaps, but the data regarding the overall
architecture of arterial cutaneous perforators are still
insufficient.12-16 Many studies were done in the attempt
to find the main perforators able to sustain such
flaps, but the method of injecting lead oxide-gelatin
described by Salmon and modified by Rees and Taylor
seems to be the most reliable.2,3,5,6,17,18,19
The goal of our study was to find the main
perforators in the hand and forearm through a series
of ten upper extremities from fresh cadavers, injected
with lead oxide-gelatin, and to document the number
of perforators of sufficient caliber to sustain local/
regional perforator flaps.
MATERIALS AND METHODS
We have dissected and studied the cutaneous
vascularization at the level of the upper limb in 10
fresh human cadavers segments injected with lead
oxide and gelatin. (Fig. 1)
Figure1. Angiogram of the skin of the upper extremity: general aspect.
The Ethics Committee of the Emergency County
Hospital from Baia Mare, together with the Department
of Pathological Anatomy, approved this study.
The cadavers with peripheral vascular diseases,
poly-traumas of the upper limb or with metastasis at
the level of the upper limb were eliminated from the
study.
In the first stage, the axillary vascular pedicle
was dissected, then the axillary artery was incised
longitudinally and a Foley catheter was introduced
in its proximal part. A cannula was introduced into
the axillary vein. The axillary artery was flushed
abundantly with 5-10 l water in carbonated solution
(9% KCl), with continuous pressure until a clear liquid
was obtained in the axillary vein.17-20 Immediately
afterwards the segment was introduced into warm
water at 38C in order to maintain the mixture of lead
oxide gelatin in liquid state, allowing its spreading
throughout the whole vascular system of the segment,
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242 TMJ 2009, Vol. 59, No. 3-4
without solidifying.21-23 After injection, the segment was
refrigerated for 24 hours at 4C, and then was X-rayed
after the important anatomic osseous landmarks were
positioned. The areas intended to be studied were
X-rayed before dissection in order to have a general
image of the respective vascular anatomy. (Figs. 1-3)
One must take into account the fact that the angiograms
obtained can be confusing to analyze, because of the
tri-dimensional overlapping of the multiple vessels
visualized. During the dissection that followed, X-ray
photographs and sequential digital photographs were
taken in order to increase the degree of pointing out
the tissue areas to be studied. (Fig. 4) The parameters
observed during the study were: the number of
perforators, the length and the diameter of the pedicle
at the level of the deep fascia, the area vascularized by
each perforator, the ratio between muscle-cutaneous
and septocutaneous perforators.
Figure 2. Angiogram of the upper extremity showing cutaneous branches
of the ulnar and radial artery.
Figure 3. Angiogram of the forearm showing cutaneous branches of the
posterior interosseous artery .
Figure 4. The perforators during dissections, sequential digital pictures
are being taken. The arrow indicates one of the perforators.
RESULTS
The length of the superficial pedicle of each
perforator was measured directly during the dissection,
and the vascular territories were measured directly on
the X-ray images by calculating the average value. The
diameter of the vascular pedicle was measured directly
during the dissection at the level of the deep fascia.
 As a result of the study carried out, we have
found at the level of the forearm and of the hand
nine vascular territories with an average number of
perforators of 25 + 9, with a diameter of 0.6 +0.1
mm, generally vascularizing a cutaneous area of about
30 cm2. It was evident that the perforators became
smaller from proximal to distal.
The septo-cutaneous perforators occur predo-
minantly at the elbow level, in the inferior third of the
Table 1. Vascular territories of the forearm.
forearm and in the hand, with a ratio of 4:1, while
the muscle-cutaneous ones prevail in the proximal
third of the forearm, with a ratio of 7:3. A detailed
presentation of the data obtained can be found in
Table 1. We compared our results with those obtained
by Geddes and al.24 The results are presented in the
Tables 2- 7.
The great majority of perforators emerging from
the same source artery anastomoses longitudinally with

Source Artery Average Number of Superficial Diameter Total area Musculocutaneous/

Perforators with Length mm cm2 septocutaneous
Diameter 0.5 mm mm
IUCA 2 282 0.70.1 455 2/6
RRA 2 251 0.60.1 4710 3/1
RA 43 286 0.6 1156 4/3
UA 6 201 0.4 1353 3/3
PIOA 31 72 0.5 762 3/1
AIOA 2 15 0.4 15 1/1

IUCA inferior ulnar collateral artery, RRA radial recurent artery, RA radial artery, UA ulnar artery, PIOA posterior interosseous artery, AIOA
anterior interosseous artery.

Table 2. Inferior ulnar collateral artery teritory.

Nr. of Pedicle superficial Diameter Total area Ratio musculocutaneous/

perforators length (mm) mm cm2 septocutaneous
Present study 2 282 0.70.1 455 2/6
Geddes et al24 21 3812 0.80.2 6320 3/7

Table 3. Radial recurrent artery territory.

Nr. of Pedicle superficial Diameter Total area Ratio musculocutaneous/

perforators length (mm) mm cm2 septocutaneous
Present study 2 251 0.60.1 4710 3/1
Geddes et al24 21 3718 0.70.3 5527 4/1

Table 4. Radial artery territory.

Nr. of Pedicle superficial Diameter Total area Ratio musculocutaneous/

perforators length (mm) mm cm2 septocutaneous
Present study 43 286 0.6 1156 4/3
Geddes et al 24
55 3225 0.60.2 18068 7/3

Table 5. Ulnar artery territory.

Nr. of Pedicle superficial Diameter Total area Ratio musculocutaneous/

perforators length (mm) mm cm2 septocutaneous
Present study 6 201 0.4 1353 3/3
Geddes et al24 72 2714 0.60.2 18658 3/2

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Costache Chertif et al 243
Table 6. Posterior interosseous artery territory.

Nr. of Pedicle superficial Diameter Total area Ratio musculocutaneous/

perforators length mm cm2 septocutaneous
mm
Our research 31 72 0.5 762 3/1
Geddes, et al24
52 2111 0.50.1 11643 9/1

Table 7. Anterior interosseous artery territory.

Nr. of Pedicle Diameter Total area Ratio musculocutaneous/

perforators superficial length mm cm2 septocutaneous
mm
Our research 2 15 0.4 15 1/1
Geddes, et al24 31 2110 0.50.1 2712 4/1

each other, and some others anastomose transversely

with perforators emerging from other source arteries;
this fact is especially true for the radial and ulnar
arteries. (Figs. 2, 3)
In the proximal part of the forearm we found
mainly perforator branches from the inferior collateral
ulnar artery and the radial recurrent artery. (Fig. 5)

Figure 6. Angiogram showing the dorsal carpal arch.

Figure 5. Angiogram of the forearms and hands. In the square: a big

perforator of the radial artery; black star-perforators from the radial
recurrent artery; white star-perforators from the inferior collateral ulnar
artery.

At the dorsal aspect of the wrist we found a

very nice network-the dorsal carpal arch- formed by
perforators emerging from the main axial arteries of the
forearm, as follows: type 1 formed by the anastomosis
of the dorsal carpal branches of the radial artery with
the anterior and posterior interosseous arteries, in 70%
of the specimens, and type 2 formed of branches of
the ulnar or radial artery, in 30% of the specimens. Figure 7. Angiogram of the hand showing the perforators coming from
(Fig. 6) the network formed between the volar and dorsal system of vessels of the
In the hand we found perforators from the dorsal fingers, and the perforators of the digital arteries.
intermetacarpal arteries, but also more distally, at the
level of commissural spaces and the proximal half of DISCUSSION
the first phalanx, emerging from the arches realized
between the volar and dorsal system of vessels of The aim of this anatomic research was to assess
the fingers. (Fig. 7) Also, more distally, at the level of the cutaneous vascularization of the forearm and of
fingers, we found well developed perforators emerging the hand, with practical applicability in carrying out
from the collateral digital arteries. (Fig. 7) perforator flaps at this level.
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244 TMJ 2009, Vol. 59, No. 3-4
 Compared to other studies, we have found less
perforators at the level of the forearm and with
the superficial length of the vascular pedicle also
smaller.3,8,10,11,24 It is possible that these differences
appear because of the different modality of injecting
the contrast substance, but also probably because
we could not see the perforating vessels having a
diameter less than 0.4 mm during the dissections
despite the fact that the dissections were done with
a magnifying apparatus. Otherwise, the data obtained
overlap those from the literature.
We have found a variable distribution for the
perforators at these levels, but relatively constant for
each one of the main vessels. Regarding the forearm,
other anatomical studies found the same constant
distribution for the main vessels, but with overlapping
of the adjacent territories of these vessels.3,11,25 Similar
to Kanellakos et al, we found that the number and
diameter of the perforators decreases from proximal
to distal, but compared with other studies, we have
noticed differences both regarding the number
of perforators, the length and the diameter of the
vascular pedicle and of the area blood supplied for
each perforator.11,2,24,26 A comparison between our
results and those obtained by Geddes et al is presented
in Tables 2-7.24
Based on these results, we found as in other
previous studies, that the main arteries of the
forearm (i.e., radial, ulnar, posterior and anterior
interosseous arteries) are involved in the blood
supply of the forearm, with a predominance for the
radial artery.12-16,27 More, as Geddes et al have shown,
there are also perforator branches from the inferior
collateral ulnar artery and from the radial recurrent
artery.24 (Figs. 5,6) At the hand level our finding are
similar to other authors: in the proximal half of the
long fingers, there is a well represented anastomotic
network between the dorsal metacarpal arteries and
the palmar common digital arteries and the collateral
digital arteries.28-30 The perforators emerging from
this network give branches which realize longitudinal
anastomoses able to supply blood to the dorsal skin
over the intermetacarpal spaces. At the level of the
fingers, we found well developed perforators emerging
from the collateral digital arteries, both at the level of
the distal phalanx as Koshima et al found, but also
more proximal; these perforators are able to supply
blood to small flaps, very useful in covering small
defects in the fingers.31
Based on these observations, some possible clinical
applications can be described; we consider that in
the forearm the perforator flaps can be used both as
regional and local flaps. The regional flaps, both as
adipofascial or fasciocutaneous flaps are true pedicled
flaps, their pedicle being a proximally or distally based
adipofascial one. Because of their possibly long
pedicle, these flaps can have a very large rotation arch,
which make them very useful in the coverage of hand
defects, especially on the dorsal aspect, and in the
reconstruction of the first web space. More, if only an
adipofascial flap is used, the donor site morbidity can be
much reduced. The local flaps are transposition flaps,
that can be used as rotational or advancement flaps; the
source artery of these flaps can be any one of the four
main arteries of the forearm, their blood supply being
provided through short perforator pedicles. Taking
into consideration that they have to be harvested in
the immediate vicinity of the defect but, because of
the mentioned longitudinal anastomoses exist, they can
have sufficient length for covering large defects. The
main indication of these flaps is in covering small or
medium defects with bone, tendons, vessels or nerves
exposure in the elbow, forearm and hand.
Because the perforators blood supply not only the
skin, but also the anatomic sector spanning between the
skin and bone, these areas are well known as angiotomes
or angiosomes and represent the anatomical base
of composite flaps in the forearm.3,26 In the hand,
in the proximal half of the long fingers, there is a
well represented anastomotic network between the
dorsal metacarpal arteries and the palmar common
digital arteries and the collateral digital arteries. The
perforators emerging from this network give branches
which realize longitudinal anastomoses able to blood
supply the dorsal skin over the intermetacarpal spaces.
Based on these perforators, perforator metacarpal
flaps can be designed, which are similar, as design
and donor area, with the classical metacarpal flap,
but they can be used in covering more distal defects
in both palmar and dorsal aspect of the long fingers,
and allow an early postoperative mobilization, due
to the situation of the vascular pedicle distally to the
metacarpophalangeal joint. It is possible to harvest
two such types of flaps: (1) fasciocutaneous pedicle
flaps and (2) fasciocutaneous transposition flaps. The
first ones are very useful in covering the very distal
defects in the fingers and the second ones in the
reconstruction of the web spaces and first phalanx.
Both of them can be used as composite flaps by
including small vascularised metacarpal segments.
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