The Use of Radial Vessel Stump in Free Radial Forearm Flap as Flap Monitor in Head and Neck Reconstruction

Abstract

The versatile use of the free radial forearm flap for the reconstruction of pharyngoesophageal defects has been proven ideal in previous studies. However, the monitoring of flap viability when buried underneath the skin in head and neck surgery still posed technical difficulties. An innovative monitoring method for the buried free radial forearm flap by using distal radial vessel stump elevated over the skin is to be presented here. Eighteen patients received free radial forearm flap reconstruction for their pharyngoesophageal defects after tumor ablation during June 2003 to March 2005. All patients were males; ages ranged from 36 to 71 years, averaging 53.2 years old. Fourteen skin tubing and patches were designed for the defects. The pharyngoesophageal defects ranged from 6 to 12 cm in length, averaging 8.5 cm. The free radial forearm flap was designed to allow a distal radial vessel stump about 3 cm long, which was then elevated above the skin in the neck region after insetting to act as a monitor for the viability of the buried flap. The flap viability can be easily demonstrated simply by observing continuous pulsation coming from the distal radial vessel stump with naked eyes. The monitoring stump was then ligated and resected at bedside after the viability of the buried flap was insured 2 weeks postoperatively. All free flap transfers were successful. One case was found with kinking of artery during the operation and it was corrected immediately. One case with venous insufficiency was detected 13 hours after the operation and the flap was salvaged successfully by thrombectomy and venous reanastomosis. Three patients developed temporary fistula and healed spontaneously after conservative treatment. Deep neck infections were found in patients, and recovered after aggressive antibiotic treatment. Two patients had esophagocutaneous fistula and needed secondary surgical intervention. The use of distal radial vessel stump as a monitor for the buried flap is a reliable method in head and neck surgery. It not only allows easy monitoring, no further donor site morbidity, but it also eliminates the need for special monitoring device.