Reversed forearm island flap supplied by the septocutaneous perforator of the radial artery: anatomical basis and clinical applications

The cutaneous perforators of the radial artery adjacent to the superficial branch of the radial nerve and the lateral antebrachial cutaneous nerve were investigated, and the vascular anatomical features of the reversed forearm island flap supplied by those accompanying perforators were documented. Ten fresh cadavers were systemically injected with lead oxide, gelatin, and water. Twenty forearms were then dissected, and an overall map of the cutaneous vasculature and source vessels was constructed. The accompanying arteries were observed to lie along the lateral antebrachial cutaneous nerve and the superficial branch of the radial nerve and to nourish the skin through cutaneous branches. Vascular communication among these cutaneous vessels was evaluated, to determine the cutaneous vascular territory of the radial forearm flap. This anatomical information facilitates flap design in the forearm region. Clinical experience regarding the usefulness of the reversed forearm island flap for hand reconstruction for a series of five patients is presented.     

“Sensory Switching” in Elbow Reconstruction

In the treatment of the soft tissue defect of the elbow, flap reconstruction is necessitated in many cases because of thinness of soft tissue at this region. In addition, reacquirement of tactile sensation is desirable because of the anatomical and specific functions of the elbow. Of three cases treated for elbow defects, one was reconstructed with a pedicled island forearm flap containing the lateral cutaneous nerve of the forearm, another was reconstructed with a venoneuro-accompanying artery fasciocutaneous flap (VNAF flap) containing the basilic vein, and the third with the VNAF flap containing the cephalic vein. The three cases demonstrated a sudden change of sensory territory 4 to 6 months after surgery, which was confirmed by touching the reconstructed region with patients'' eye-closed: from its original territory to the elbow in a “switching”-like action. Here we describe and discuss the concept of “sensory switching.”     

The lower trapezius musculocutaneous flap from pedicled to free flap: anatomical basis and clinical applications based on the dorsal scapular artery

The pedicled lower trapezius musculocutaneous flap is a standard flap in head and neck reconstruction. A review of the literature showed that there is no uniform nomenclature for the branches of the subclavian artery and the vessels supplying the trapezius muscle and that the different opinions on the vessels supplying this flap lead to confusion and technical problems when this flap is harvested. This article attempts to clarify the anatomical nomenclature, to describe exactly how the flap is planned and harvested, and to discuss the clinical relevance of this flap as an island or free flap. The authors dissected both sides of the neck in 124 cadavers to examine the variations of the subclavian artery and its branches, the vessel diameter at different levels, the course of the pedicle, the arc of rotation, and the variation of the segmental intercostal branches to the lower part of the trapezius muscle. Clinically, the flap was used in five cases as an island skin and island muscle flap and once as a free flap. The anatomical findings and clinical applications proved that there is a constant and dependable blood supply through the dorsal scapular artery (synonym for the deep branch of the transverse cervical artery in the case of a common trunk with the superficial cervical artery) as the main vessel. Harvesting an island flap or a free flap is technically demanding but possible. Planning the skin island far distally permitted a very long pedicle and wide arc of rotation. The lower part of the trapezius muscle alone could be classified as a type V muscle according to Mathes and Nahai because of its potential use as a turnover flap supplied by segmental intercostal perforators. The lower trapezius flap is a thin and pliable musculocutaneous flap with a very long constant pedicle and minor donor-site morbidity, permitting safe flap elevation and the possibility of free-tissue transfer.     

Reappraisal of island modifications of lateral calcaneal artery skin flap

Reconstruction of soft-tissue defects of the calcaneal region and the heel is very demanding and necessitates, as a rule, a sensate and thin flap. The ideal characteristics of a sensate and thin layer of flap should be combined with a reliable blood supply and minimal morbidity at the donor site. The authors report an updated review of their experience with the use of island modifications of the lateral calcaneal artery skin flap-the lateral calcaneal island flap, the lateral calcaneal V-Y advancement flap, and the bilobed-shaped lateral calcaneal island advancement flap-for the reconstruction of small and medium-sized tissue defects over the exposed calcaneal tendons and calcaneal bones of 18 patients. All of the procedures were performed under spinal or epidural anesthesia. There were no problems associated with flap viability, but the authors have seen necrosis of undermined skin between the lateral malleolus and calcaneal tendon in two cases and a partial loss of skin graft in one case. In this article, the authors discuss some advantages and disadvantages of the use of a lateral calcaneal island flap and its modifications.     

The concept of fillet flaps: classification, indications, and analysis of their clinical value

Tissue of amputated or nonsalvageable limbs may be used for reconstruction of complex defects resulting from tumor and trauma. This is the "spare parts" concept.By definition, fillet flaps are axial-pattern flaps that can function as composite-tissue transfers. They can be used as pedicled or free flaps and are a beneficial reconstruction strategy for major defects, provided there is tissue available adjacent to these defects.From 1988 to 1999, 104 fillet flap procedures were performed on 94 patients (50 pedicled finger and toe fillets, 36 pedicled limb fillets, and 18 free microsurgical fillet flaps).Nineteen pedicled finger fillets were used for defects of the dorsum or volar aspect of the hand, and 14 digital defects and 11 defects of the forefoot were covered with pedicled fillets from adjacent toes and fingers. The average size of the defects was 23 cm2. Fourteen fingers were salvaged. Eleven ray amputations, two extended procedures for coverage of the hand, and nine forefoot amputations were prevented. In four cases, a partial or total necrosis of a fillet flap occurred (one patient with diabetic vascular disease, one with Dupuytren's contracture, and two with high-voltage electrical injuries).Thirty-six pedicled limb fillet flaps were used in 35 cases. In 12 cases, salvage of above-knee or below-knee amputated stumps was achieved with a plantar neurovascular island pedicled flap. In seven other cases, sacral, pelvic, groin, hip, abdominal wall, or lumbar defects were reconstructed with fillet-of-thigh or entire-limb fillet flaps. In five cases, defects of shoulder, head, neck, and thoracic wall were covered with upper-arm fillet flaps. In nine cases, defects of the forefoot were covered by adjacent dorsal or plantar fillet flaps. In two other cases, defects of the upper arm or the proximal forearm were reconstructed with a forearm fillet. The average size of these defects was 512 cm2. Thirteen major joints were salvaged, three stumps were lengthened, and nine foot or forefoot amputations were prevented. One partial flap necrosis occurred in a patient with a fillet-of-sole flap. In another case, wound infection required revision and above-knee amputation with removal of the flap.Nine free plantar fillet flaps were performed-five for coverage of amputation stumps and four for sacral pressure sores. Seven free forearm fillet flaps, one free flap of forearm and hand, and one forearm and distal upper-arm fillet flap were performed for defect coverage of the shoulder and neck area. The average size of these defects was 432 cm2. Four knee joints were salvaged and one above-knee stump was lengthened. No flap necrosis was observed. One patient died of acute respiratory distress syndrome 6 days after surgery.Major complications were predominantly encountered in small finger and toe fillet flaps. Overall complication rate, including wound dehiscence and secondary grafting, was 18 percent. This complication rate seems acceptable. Major complications such as flap loss, flap revision, or severe infection occurred in only 7.5 percent of cases. The majority of our cases resulted from severe trauma with infected and necrotic soft tissues, disseminated tumor disease, or ulcers in elderly, multimorbid patients.On the basis of these data, a classification was developed that facilitates multicenter comparison of procedures and their clinical success. Fillet flaps facilitate reconstruction in difficult and complex cases. The spare part concept should be integrated into each trauma algorithm to avoid additional donor-site morbidity and facilitate stump-length preservation or limb salvage.     

Posterior interosseous free flap with extended pedicle for hand reconstruction

The anatomy of the posterior interosseous vessels makes them suitable as a donor area of free flap. The skin island can be designed on the perforating vessels of the distal third of the forearm, up to the dorsal wrist crease, to increase the pedicle length (7 to 9 cm). A series of nine flaps transferred to reconstruct hand defects is presented. All flaps were designed over the dorsal distal forearm, and dimensions permitted direct closure of the donor site (up to 4 to 5 cm wide). Apart from a linear scar, donor morbidity was negligible. All transfers were successful. Although its dissection is somewhat tedious, the anatomy of the vascular pedicle is suitable for microanastomosis and the skin island is thin, although hairy. The posterior interosseous free flap with extended pedicle may be a good choice when limited amounts of thin skin and a long vascular pedicle are needed.     

A new surgical procedure for phallic reconstruction: Istanbul flap

A new surgical procedure is described for phallic reconstruction, which still remains a great challenge in reconstructive surgery. In this procedure, an osteocutaneous radial forearm flap is combined with a radial recurrent fasciocutaneous flap from the anterolateral aspect of the upper arm. While keeping a fasciovascular connection between them, both flaps are elevated as a combined free flap based on the radial artery. The forearm skin island is used solely to construct the outer skin cover of the phallic shaft, and the neourethra is created by using the radial recurrent flap. Over the past 4 years, this surgical procedure, termed the Istanbul flap, has been used successfully for complete phallic reconstruction in five patients. Although more clinical experience with this new technique is needed, it seems to be a useful alternative in phallic reconstruction. It remarkably minimizes the donor-site scar without sacrificing the length of the neopenis. In addition, this technique reduces the risk of a hairy urethra.     

From the "charretera" to the supraclavicular fascial island flap: revisitation and further evolution of a controversial flap

Wide tissue defects located on the face and neck area often require distant flaps or free flaps to achieve a tension-free reconstruction together with an acceptable aesthetic result. The supraclavicular island flap surely represents a versatile and useful flap that can be used in case of large tissue losses. Because of its wide arc of rotation, which ensures a 180-degree mobilization anteriorly and posteriorly, the flap can reach distant sites when harvested as a pure island flap. The main vascular supply of the flap, the supraclavicular artery, a branch of the transverse cervical artery or, less frequently, of the suprascapular artery, though reliable, is not a very large vessel. In some particular cases, when too much tension or angles that are too tight are present, the vascular supply of the flap can be difficult and special care must be taken to avoid flap failure. To avoid this problem, the authors started harvesting the flap not as a pure island flap but with a fascial pedicle, thin and resistant, which ensures good reliability; also, when a higher tension rate is present, it avoids the risk of excessive traction or kinking of the vessels. Twenty-five consecutive patients with various defects located on the head, neck, and thorax area were treated in the past 2 years using the modified supraclavicular island flap. There was no flap loss or distant necrosis of the flap, and there was marginal skin deepithelialization in only two cases, which only required minor surgery. Postoperative morbidity was low, similar to the classic supraclavicular island flap, with primarily closed donor sites, except for one case, and tension-free scars. The authors show how the modified supraclavicular island flap is a reliable and safe flap that gives a good aesthetic result with low risk concerning the viability of the transferred skin. The technique, similar to supraclavicular island flap harvesting, is easy to perform and is attractive in patients at risk for poor or delayed healing such as smokers or patients with complex medical histories.     

Primary closure of radial forearm flap donor defects with a bilobed flap based on the fasciocutaneous perforator of the ulnar artery

To primarily repair a series of radial forearm flap donor defects, a total of 10 bilobed flaps based on the fasciocutaneous perforator of the ulnar artery were designed at the Chang Gung Memorial Hospital in Kaohsiung in the period from January of 2002 to January of 2003. All patients were male, with ages ranging from 36 to 67 years. The forearm donor defects ranged in size from 5 x 6 cm to 8 x 8 cm, with the average defect being 47 cm. One to three sizable perforators from the ulnar artery were consistently observed in the distal forearm and were most frequently located 8 cm proximal to the pisiform, which could be used as a pivot point for the bilobed flap. The bilobed flap consisted of two lobes, one large lobe and one small lobe. With elevation and rotation of the bilobed flap, the large lobe of the flap was used to repair the radial forearm donor defect and the small lobe was used to close the resultant defect from the large lobe. All bilobed flaps survived completely, without major complications, and no skin grafting was necessary. Compared with conventional methods for reconstruction of radial forearm donor defects, such as split-thickness skin grafting, the major advantage of this technique is its ability to reconstruct the donor defect with adjacent tissue in a one-stage operation. Forearm donor-site morbidity can be minimized with earlier hand motion, and better cosmetic results can be obtained. Furthermore, because a skin graft is not used, no additional donor area is necessary. However, this flap is suitable for closure of only small or medium-size donor defects. A lengthy postoperative scar is its major disadvantage.     

Distally based dorsal forearm fasciosubcutaneous flap

Use of a local flap is often required for the reconstruction of a skin defect on the dorsum of the hand. For this purpose, a distally based dorsal forearm fasciosubcutaneous flap based on the perforators of the posterior interosseous artery was developed. From 1997 until 2002, this flap was used to reconstruct skin defects on the dorsum of the hand in nine patients at Chonnam National University Medical School. The sizes of these flaps ranged from 10 to 14 cm in length and from 5 to 7 cm in width. The flaps survived in all patients. Marginal loss over the distal edge of the flap was noted in one patient. Three flaps that developed minimal skin-graft loss were treated successfully with a subsequent split-thickness skin graft. The long-term follow-up showed good flap durability and elasticity. The distally based dorsal forearm fasciosubcutaneous flap is a convenient and reliable alternative for reconstructing skin defects of the dorsum of the hand involving vital structure exposure. It obviates the need for more complicated and time-consuming procedures.     

马来酸桂哌齐特与腹部带蒂皮瓣对上肢烧伤组织缺损的修复效果

目的：探讨马来酸桂哌齐特联合腹部带蒂皮瓣治疗手及前臂皮肤软组织烧伤缺损的临床效果。方法：选取我院2011 年2 月 -2013 年2 月收治的68 例手及前臂皮肤软组织烧伤缺损患者作为观察组,行马来酸桂哌齐特结合腹部带蒂皮瓣治疗,另选择同 期接受股前外侧皮瓣修复治疗的50 例患者为对照组。观察并比较两组患者皮瓣修复效果以及神经功能烧伤缺损评分。结果：观 察组患者皮瓣存活率高于对照组,差异具有统计学意义(P<0.05);观察组皮瓣感染率低于对照组,差异具有统计学意义(P<0.05); 观察组皮瓣断蒂时间及神经功能烧伤缺损评分均低于对照组,差异具有统计学意义(P<0.05)。结论：马来酸桂哌齐特结合腹部带 蒂皮瓣治疗具有皮瓣存活率高、神经功能恢复良好,术后恢复快等特点,值得临床推广应用。     

Reverse-flow island flap: clinical report and venous drainage

Twenty-two reverse-flow island flaps were transferred. These included peroneal, forearm, anterior tibial, and temporal flaps. Sixteen of 22 flaps survived completely. We encountered partial necrosis in 4 flaps and total necrosis in only 2 flaps. We credit this success to the reliability and availability of the peroneal, forearm, and temporal flaps; but we do not encourage use of the anterior tibial flap. The flaps that survived well did not show any signs of venous congestion. The advantage of the reverse-flow island flap is that it can be transferred from a proximal to a distal location. Using cadavers and fresh amputated limbs, studies on venous drainage of the reverse-flow island flap were performed. The venae comitantes had numerous venous valves and communicating branches, but more than sufficient reflux of the venous blood occurred through the valves at pressures of 90 to 105 cmH2O. We believe that the venous drainage of the reverse-flow island flap occurs as a result of reflux actions at the valve, communicating branches between the venae comitantes, and bypass vessels around the valves.     

The radial forearm skin graft-fascial flap

The radial forearm flap has become a versatile flap for upper extremity reconstruction. The use of the forearm flap for hand reconstruction in the patient with previously burned forearms has not been widely appreciated. In those patients whose forearms have been previously split-thickness skin-grafted on fascia, we have employed the reverse radial forearm flap as a skin graft-fascial flap for hand reconstruction and have obtained excellent functional results. Three patients at various intervals postburn are presented to demonstrate use of this flap for wrist contracture release, coverage of arthroplasties, first web space contracture release, and acute salvage of phalanges and tendons. Assessment of the hand's vascular anatomy and careful treatment of the donor area have contributed to no added morbidity and an excellent aesthetic result at the donor site.     

A new flap design: neural-island flap

This report introduces the "neural-island flap" concept, which represents a consistent and reliable skin flap design supplied only by the intrinsic vasculature of a cutaneous nerve. In this study, the lateral femoral cutaneous nerve was selected as the pedicle of the neural-island flap, and a standard skin flap, which is the territory of the accompanying vessels (i.e., iliac branches of the iliolumbar artery and vein), was elevated on the lower dorsal region of the rats. In a total of 92 Wistar rats, three experiments were performed. In part I (n = 24), the vascular anatomy of the lateral femoral cutaneous nerve was established by the methods of dissection, microangiography, nerve mapping, perfusion with colored latex and India ink, and histologic analysis. In part II (n = 46), the role of the cutaneous nerve in supporting an acutely elevated skin flap was explored by creating five flap groups as follows: group 1, conventional flap (artery, vein, and nerve intact); group 2, neural island flap (only the nerve intact); group 3, neurocutaneous flap (vein and nerve intact); group 4, denervated flap (artery and vein intact); and group 5, skin graft. In part III (n = 22), the role of a preliminary surgical delay procedure to augment the survival of the neural island flap was investigated. Results of the anatomic studies indicated a consistent perineural vasculature by the accompanying iliolumbar artery. Skin flaps survived totally in groups where the artery and vein were intact, whereas mean survival rates for the neural island flap and the neurocutaneous flap were 38.2 +/- 3.1 percent and 44.5 +/- 3.8 percent, respectively (p > 0.05). Results of part III of the experiment demonstrated a significantly higher survival for the delayed neural island flap (94.5 +/- 5.5 percent) compared with the acutely elevated neural island flap (p < 0.05). The perineural and intraneural vessels were found to be greatly dilated after a delay procedure, demonstrated by direct observation, microangiography, histologic analysis, dye injection study, and scanning electron microscopy. On the basis of this promising series of experiments, a clinical technique was developed using the sural neural-island flap. The flap was used to reconstruct lower extremity defects in four cases. A delay procedure was accomplished in the first stage by elevating a fasciocutaneous flap from the midcalf region based on a posterior skin bridge and the sural nerve. After a 2-week delay period, a sural neural-island flap was created based on the nerve and transposed to the defect. Flap survival was complete in all cases, with a satisfactory result. The authors conclude that this report proves for the first time that a robust and reliable skin flap can be created pedicled only by the intrinsic vasculature of a cutaneous nerve, after a proper surgical delay. The so-created neural-island flap design offers two novel advantages: (1) a very narrow pedicle and (2) a pedicle without any restriction to a specific pivot point, in addition to the previously described unique advantages of preservation of a major artery and avoidance of microvascular anastomoses.     

Comparison of the radial forearm flap and the thinned anterolateral thigh cutaneous flap for reconstruction of tongue defects: an evaluation of donor-site morbidity

The radial forearm flap is commonly used for reconstruction of tongue defects following tumor extirpation. This flap is easy to harvest and offers thin tissue with large-caliber vessels. However, its use leaves behind a conspicuous aesthetic deformity in the forearm and requires the sacrifice of a major artery of that limb, the radial artery. The anterolateral thigh cutaneous flap has found clinical applications in the reconstruction of soft-tissue defects requiring thin tissue. More recently, in a thinned form, the anterolateral thigh flap has been used for reconstructing defects of the tongue with functional results equivalent to that of the radial forearm flap. For the reconstruction of tongue defects, these two flaps could provide similar soft-tissue coverage, but they seem to result in different donor-site appearances. The donor site is closed primarily, leaving only a linear scar that is inconspicuous with normal clothing, and no functional deficit is left behind in the thigh. Thus, for the supply of flaps for tongue defects, a comparison between the radial forearm flap and the anterolateral thigh flap donor sites is provided in this study. Between December of 2000 and August of 2002, 41 patients who underwent reconstruction of defects of the tongue using either a radial forearm flap or an anterolateral thigh flap were evaluated. The focus was on the evaluation of the functional and aesthetic outcome of the donor site after harvesting these flaps for the purpose of reconstructing either total or partial tongue defects. Finally, a comparison was performed between the donor sites of the two flaps. The disadvantages of the radial forearm flap include the conspicuous unattractive scar in the forearm region, pain, numbness, and the sacrifice of a major artery of the limb. In some patients, the donor-site scar of the forearm acted as a social stigma, preventing these patients from leading a normal life. In contrast, the anterolateral thigh cutaneous flap, after thinning, achieved the same results in reconstructing defects of the tongue without the associated donor-site morbidity. Most importantly, the donor site in the thigh could be closed primarily in almost all patients without any functional deficit. The thinned anterolateral thigh cutaneous flap is a viable substitute for the radial forearm flap when reconstructing defects of the tongue. The results achieved are similar to those of the radial forearm flap, and the donor-site morbidity is significantly decreased.     

Heterodigital arterialized flaps for large finger wounds: results and indications

Deep defects of the hand and fingers with an unhealthy bed exposing denuded tendon, bone, joint, or neurovascular structures require flap coverage. However, the location and size of the defects often preclude the use of local flap coverage. Free-flap coverage is often not desirable either, because the recipient vessels may be unhealthy from surrounding infection or trauma. In such situations, a regional pedicled flap is preferable. A solution to this is the heterodigital arterialized flap. This flap is supplied by the digital artery and a dorsal vein of the finger for venous drainage. Unlike the neurovascular island flap, the digital nerve is left in situ in the donor finger, thus avoiding many of the neurologic complications associated with the Littler flap. The digital artery island flap is centered on the midlateral line of the donor finger. It extends from the middorsal line to the midpalmar line. The maximal length of the flap is from the base of the finger to the distal interphalangeal joint. By preserving the pulp and the digital nerve, a sensate pulp on the donor finger remains that reduces donor-finger morbidity and also preserves fingertip cosmesis. Twenty-nine flaps were performed in 29 patients and the outcomes in the donor finger and the reconstructed finger were reviewed. The flap survival was 100 percent. There were no cases of flap ischemia or flap congestion. Good venous drainage of the flap through the additional dorsal vein was helpful in preventing the occurrence of early postoperative venous congestion, which is common in island flaps of the fingers, which depend on only the venae comitantes for drainage. Donor-finger morbidity, measured in terms of range of motion and two-point discrimination in the pulp, was minimal. Ninety-seven percent of the donor fingers achieved excellent or good total active motion according to the criteria of Strickland and Glogovac. Pulp sensation in the donor fingers was normal in 28 of the 29 donor fingers. No cold intolerance of the donor finger or the adjacent finger is reported in this series.     

Oropharyngeal reconstruction using the supraclavicular artery island flap: a new flap alternative

Oropharyngeal reconstruction following head and neck oncologic resection has utilized local, regional, and free tissue transfer flap options. The modality utilized is often guided by the type of defect created as well as the surgeon's preference. In this article, the authors introduce the application of the supraclavicular artery island flap as a reconstructive modality following oropharyngeal oncologic ablation. Five patients underwent head and neck oncologic resection for oropharyngeal squamous cell carcinoma followed by single-stage reconstruction with an ipsilateral supraclavicular artery island flap. There were no flap failures and only one postoperative complication consisting of a postoperative oral-cutaneous fistula that resolved without surgical intervention. There were no donor-site complications. The supraclavicular artery island flap is a viable alternative for oropharyngeal reconstruction following head and neck oncologic resection. It is a regional flap that can be harvested without microsurgical expertise and yields reliable postoperative results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.     

Reconstruction of soft-tissue defect of the posterior heel with a lateral calcaneal artery island flap

We obtained most favorable results in 11 patients with a lateral calcaneal artery island flap. It is a simple, stable, sensate, and yet safe and versatile flap to repair defects around the ankle and heel. We have also used this flap to cover defects around the medial malleolus without any delay (extended lateral calcaneal artery island flap).     

7. The groin flap: a new technique to repair traumatic tissue defects.

Tissue loss from trauma, particularly in the hand and forearm, occasionally requires immediate skin-flap coverage to ensure optimal healing. A consistently safe technique of skin-flap coverage is use of a groin flap. Anatomic studies of this flap have revealed the reliability of blood supply by the superficial circumflex iliac vessels to an area of skin and subcutaneous tissue running paralle to the inguinal ligament lateral to the femoral artery, and the axial relation of the vessels to the flap allows the surgeon to take a longer flap than usual without fear of vascular embarassment. Three case reports illustrate the value of the groin flap in primary soft-tissue closure and in the treatment of acute traumatic injuries.     

Nonmicrosurgical use of the radial forearm flap for penile reconstruction

Although the era of microsurgical techniques has greatly expanded the number of possible solutions for penile reconstruction, additional options are still needed for some unusual situations when microsurgery is not available or not desired. This article describes the first nonmicrosurgical use of the radial forearm flap for penile reconstruction. With this technique, an osteocutaneous radial forearm flap 15 x 20 cm in size is elevated as a reverse-flow island flap and used to create a neopenis in the classic "tube within a tube" fashion. The neopenis is then transferred to the recipient site as a distant flap, without dividing its vascular connection with the forearm. Once a complete healing is ensured after the following 2 to 3 weeks, the pedicle is cut and the penile reconstruction is completed. Since 1995, this technique was used for total penile reconstruction in four patients: two with congenital penile agenesis, one with penile amputation as a result of a high-voltage electrical injury, and one with total loss of the external genitalia as a result of a shotgun injury. The patients have been followed up for 1 to 4 years. Good results were achieved in all patients. In conclusion, non-microsurgical use of the radial forearm flap seems to be a useful alternative to create an innervated functionally and aesthetically acceptable neopenis when microsurgery is not available or not desired. Although it is a multistage procedure, it is easy to perform. Moreover, this technique provides all well-known advantages of the radial forearm flap in penile reconstruction but does not require the sophisticated equipment and expertise of microsurgery. This is a great advantage that enables surgeons without microsurgical skill to use the radial forearm flap for phallic reconstruction. The author believes that the described technique will be extremely useful in developing countries that have limited resources and where microsurgery is difficult to obtain.