Journal of Clinical and Diagnostic Research. 2018 Feb, Vol-12(2): AC14-AC18 14 14 DOI: 10.7860/JCDR/2018/26498.11216 Original Article Anatomical and Clinical Perspective of Medial Arm Region Perforators-A Potential Flap for Reconstructive Surgeries Anatomy Section INTRODUCTION Owing to advances in microsurgical techniques and anatomical studies on perforators, it is widely accepted that septocutaneous and direct cutaneous perforators can prove to be quite useful for a variety of flap options in conventional donor regions. Understanding of anatomic territories of individual perforator supplying skin and their crucial role in flap design and survival has thus become the need of hour. Though many studies have been conducted in the past related to perforators of various regions [1-2], still medial arm region is least explored with regard to its vascularity and anatomical details. Small defects of hand and forearm can usually be managed by local flaps. However, for larger defects, alternate donor site needs to be explored. Such a flap, should have some important properties like cosmetically acceptable, easy to nurse and must not hamper the daily routine of the patient. Medial arm perforator can serve as best option during flap surgeries with desired qualities of hidden scar and cosmetically acceptable [3-5]. Perignon D et al., also suggested medial arm flap to be ideal choice for elbow and head and neck surgeries [6]. Major advantage of using medial arm region flap in local reconstructive surgeries is that it does not sacrifice the major vessel. Its main requirement is pedicle of suitable length and diameter. However, the anatomical details of the medial arm perforators like their main source vessel, its location, its branching pattern, course and number of perforators varies from one individual to another. Due to these reasons, medial arm region is not very popular among surgeons for flap surgeries. In this article, the role of cadaveric study have been highlighted for better understanding of vascular anatomy of medial arm region. It was aimed to provide the reliable data regarding vascular supply of medial arm region along with relevant morphometric data regarding vessels, their branches and perforators supplying medial arm region. MATERIALS AND METHODS Present cadaveric study was conducted in Department of Anatomy, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh in collaboration with Department of Plastic and Reconstructive surgery, PGIMER, Chandigarh, India. Duration of study was January 2015–December 2015. 30 upper limbs of 15 fresh adult cadavers (11 males, 4 females) with mean age of 79±3 years were studied. All these cadavers were donated to department of Anatomy, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh. Cadavers with any visible limb deformity or any kind of pathology were excluded from the study. During dissection of upper limb, the arm was placed at 90º abduction and laterally rotated. Through a minimal axilla incision, axillary artery was located and injected with colored latex dye (10–15 mL) with the help of feeding tube. Dye was injected slowly, so as to avoid any vascular injury. Dissections were performed 24 hours after inserting the dye. The approach was a longitudinal incision over the lateral aspect of arm, across a vertical line perpendicular to medial epicondyle, extending along the long axis of arm upto the point midway between anterior and posterior pillar of axilla (X axis). Horizontally line extended between the medial and lateral epicondyles (Y axis). Dissections were performed in suprafascial plane from lateral to medial aspect. Then the individual perforators were identified, their location was projected over the skin with the help of a needle and traced on the transparent sheet. Distance of each perforator from X and Y axis was recorded. Then each individual perforator was followed upto its source vessel [Table/Fig-1]. RICHA GUPTA 1 , TULIKA GUPTA 2 , SUNIL GABA 3 , ANJALI AGGARWAL 4 , KAUR HARJEET 5 , DAISY SAHNI 6 Keywords: Brachial artery, Cadavers, Plastic surgery, Superior ulnar collateral artery, Vascularity ABSTRACT Introduction: The medial arm region can be a potential donor site for the flap surgeries because of its excellent colour and ideal thickness. It is an excellent choice for coverage of elbow, axilla, distant microvascular transfer, as the free posterior brachial fascial flap or the superficial circumflex iliac artery perforator flap, to head and neck, upper and lower extremities. Aim: To locate a consistent site and dimensions of perforators in medial arm region so as to make it easier for surgeons to design medial arm perforator flaps for various surgeries. Materials and Methods: 30 upper limbs of 15 fresh adult cadavers with mean age of 79±3 years were studied. Dimensions, total number, location and source vessel of individual perforators were determined. Also, brachial artery, its branches and course along with variations, if any were studied. Results: Consistent location was found to be 9.32±0.46 cm proximal and 4.4±1.72 cm medial to the medial epicondyle. Total number of perforators was 192. Brachial artery was the main source vessel in 67% (128) of cases, followed by superior ulnar collateral artery in 28% (54) of the cases. 56% (107) of the perforators had diameter more than 0.5 mm, while 33% (64) had diameter more than 1 mm. Mean length of perforators was found to be 33.76±0.52 mm. Conclusion: Larger the diameter of the perforator lesser is the chances of necrosis of the flap due to better vascularisation. As 89% (171) of perforators in the medial arm region had diameter more than 0.5 mm, there are higher chances of successful flap surgeries. Knowledge of consistent position of perforators can help in designing of flaps accordingly.