The Radial Forearm Fasciocutaneous Free Flap for Head and Neck Reconstruction

Abstract

Sir:FigureFree tissue transfer is a mainstay in head and neck reconstruction following surgical oncologic tumor resection. Perhaps one of the most versatile free flaps that exists for head and neck reconstruction is the radial forearm fasciocutaneous flap, which allows for a thin, pliable piece of tissue to be transferred on a long vascular pedicle with a reliable blood supply.1,2 The reasons for this versatility lie in the aforementioned features, specifically, a long vascular pedicle that allows anastomosis to be performed outside of the zone of resection that may involve irradiated tissues. After obtaining institutional review board approval, a retrospective review of all cases of radial forearm fasciocutaneous free flaps for reconstruction of oncologic head and neck defects performed by the senior author (R.O.D.) between 2001 and 2010 was conducted. The retrospective review returned 55 patients. Of this, 15 (27 percent) were women and 40 (73 percent) were men. The average age of the patients was 58 years (range, 31 to 80 years). The average size of the oncologic defect was 63.1 cm2 (range, 30 to 120 cm2). In total, there were three flap failures (5.5 percent). There were 25 other complications noted in addition to the flap failures. There were 12 complications related to the recipient site other than flap failures. Of the 55 patients, 23 (42 percent) underwent preoperative radiation therapy. A two-sample t test revealed no relationship between the size of the defect and whether or not there was a complication of any nature (p = 0.32) or a complication at the recipient site (p = 0.23). A relationship approaching significance was noted between preoperative radiation therapy and complications at the recipient site (p = 0.052) (Fig. 1).Fig. 1: Comparison of complication rates between those with and without preoperative radiation therapy.The management of oral and airway malignancies is controversial, with radiation therapy and surgery being the favored options. In general, lower grade malignancies are regarded as better treated through radiation therapy alone, whereas higher grade malignancies are treated with surgery. This paradigm presents a problem when surgery is indicated following either failed radiation therapy or recurrent disease after radiation therapy. The competency of the vasculature in the region of the defect is often of concern following radiation therapy. Free flaps to the head and neck have been shown to be adversely affected by radiation therapy.3 Interestingly, in our review, there was no relationship found between preoperative radiation and the occurrence of complications. This may be explained by the extremely long pedicle that is possible with the radial forearm flap that provides the opportunity to bring the site of anastomosis for both the vein and artery away from the field of preoperative radiation and oncologic resection. In general, the vessels outside of this area are likely to be healthier and more suitable for microvascular anastomosis. This is especially important given that this patient population tends to be advanced in age and may suffer from concomitant peripheral vascular disease. Varying degrees of atherosclerosis were noted in each patient in this series. The radial forearm fasciocutaneous free flap remains a reliable and relatively easy flap to use for reconstruction of head and neck oncologic defects. Preoperative radiation therapy does not appear to affect the rate of complications following reconstruction with this flap. The flap's long pedicle allows for the site of anastomosis to be placed outside the area of tissue damage. Ian C. Hoppe, B.A. Priti P. Patel, M.D. Ramazi O. Datiashvili, M.D. Department of Surgery, Division of Plastic Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, N.J. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No outside funding was received.