Dynamic anatomical study of the posterior brachial artery perforator flap: Aesthetic refinement and clinical results

Abstract

Background: Reconstruction of the axillary fossa represents a surgical challenge given the functional implications for mobility of the upper limb. The posterior brachial flap is a solution of choice for this indication, providing fine and functional local reconstruction, but little is known about its perforasome. This study aimed to identify the location of the perforator, analyze perfusion flow, and link vessel distribution, and propose an aesthetic refinement to the surgical technique by medializing the skin paddle to conceal aesthetic scarring at the donor site.

Methods: Fifteen fresh cadavers were harvested and dissected. Twenty-six arms were injected with methylene blue. Two arms were injected with radiopaque dye. A dynamic (4-dimensional) computed tomographic angiography was performed to complete the analysis.

Results: The perforasome was centered on the posterior axis of the arm with a perfusion area ranging from 82.2 to 142.9 cm², with a median of 112.7 (96.7-125.6) cm². The median length of the pedicle was 83 mm on an average (65-91 mm). Its caliber at the emergence of the source vessel had a mean diameter of 1.43 mm (1.27-1.61 mm). The distal limit of the paddle was located on an average 10.7 cm from the olecranon (7.8-12.2 cm). The scans showed direct linking vessels toward the perforasomes on the medial side of the arm, suggesting that it is possible to medialize the cutaneous paddle.

Conclusion: The posterior brachial flap presents with a constant perforasome. It can be harvested more medially than previously described to improve the aesthetic results, while maintaining reproducibility and satisfactory vascular reliability.

Keywords: Axillary reconstruction; Perforator flap; Upper extremity; Upper limb.