Radial Forearm Fasciocutaneous Flap Research Articles

Evaluation of Donor Site Function and Morbidity of the Fasciocutaneous Radial Forearm Flap

To assess the results of the use of the free radial forearm flap in terms of objective morbidity and subjective patient response. The donor sites were examined from 37 patients who underwent reconstruction with a free fasciocutaneous radial forearm flap in the head and neck after ablative tumor surgery. Patients were asked to fill in a written questionnaire. The following additional tests were performed: resting skin temperature of digits I and V, temperature after submersion in iced water, grip and pinch tests, and goniometry. Resting skin temperature was slightly decreased for donor hands 0.69 degrees C (P < .001) and 0.31 degrees C (P = .048) for digits I and V, respectively, but recovery after submersion in iced water showed no differences. The strength tests and goniometry revealed no statistically significant findings between donor and control sides. On the questionnaire, 9 patients (24%) reported slightly impaired function, 14 (38%) could not wear their watch or bracelet, 17 (46%) reported numbness, 5 (14%) reported soreness, 5 (14%) reported itching, 6 (16%) reported cold intolerance, 5 (14%) reported bad cosmetic appearance, and 9 (24%) expressed the opinion that they were insufficiently counseled. There is a negligible objective morbidity of a free radial forearm flap harvest procedure, but a number of patients have subjective complaints when asked. Elaborate presurgical counseling can probably reduce these complaints.

Anatomical study of perforator arteries in the distally based radial forearm fasciosubcutaneous flap

We investigated the anatomical vascular basis of the forearm fasciosubcutaneous flap (FSC-F), fed by the distal perforator arteries of the fascia. This type of flap was proposed, in hand reconstructive surgery, to avoid the disadvantages caused by axial-pattern reverse radial forearm fasciocutaneous flap, based on ligation and rotation of the radial artery (RA). In eight fresh cadaveric forearms, the RA was injected slowly with acrylic resin and the superficial flexor compartment was dissected. Then the FSC-F was raised from the lateral margins of the sample to the median RA axis, and the collaterals of the RA (number, interval of origin, and caliber) were evaluated. The fascial branches of RA (mean number +/- SD: 20 +/- 3) originated mainly from the radial and ulnar sides of the RA. In the distal forearm the vessels were more numerous (mean value = 11.3 vs. 8.9; Student's t-test, P < 0.05) but smaller in diameter (mean value = 0.45 mm vs. 0.63 mm; Student's t-test, P < 0.05). The perforator arteries forked in a T-shape following the main axis of the forearm and anastomosed in the fascial plane, forming longitudinal fan-shaped arterial chains giving rise to the vascular epifascial network. Histological (hematoxylin-eosin, azan-Mallory, Weigert) and immunohistochemical (anti-von Willebrand factor) study of the FSC-F at different levels of sampling was also carried out. The epifascial branches of distal sections were smaller in diameter (78.3 +/- 35.5 microm) than those of intermediate (105.7 +/- 28.7 microm; Newman-Keuls test, P < 0.01) and proximal (116.8 +/- 31.2 microm; Newman-Keuls test, P < 0.001) sections. Our findings indicate that the perforator arteries and epifascial branches are smaller in the distal forearm, so that during surgical dissection, the safety distance from the radial styloid should take into account that also in the presence of a sufficient number of vessels in the distal forearm their caliber could be inadequate to the hemodynamic request of the flap. Thus, rather than on a theoretic distance from the radial styloid, the length of the flap should be based on an accurate evaluation of the individual vascularization of the forearm case by case.

Swallowing function and tracheotomy dependence after combined-modality treatment including free tissue transfer for advanced-stage oropharyngeal cancer.

There are many treatments available for advanced oropharyngeal cancer. Organ-sparing protocols reserve surgery for salvage and are thought to provide adequate rehabilitation. Surgical resection with free tissue transfer may also provide adequate functional rehabilitation. The objective was to describe swallowing status and time to decannulation in a series of patients treated with combined-modality therapy that included free flap reconstruction. Retrospective chart review. Patient data were obtained from medical records of 20 patients with stage III or IV oropharyngeal carcinoma, who were consecutively treated with surgical tumor extirpation, free flap reconstruction, and postoperative irradiation at a tertiary academic center from 1985 to 2002. The following variables were identified: patient and tumor characteristics, free flap type, irradiation data, and airway and swallowing status before and after treatment. One patient underwent total laryngopharyngectomy, and the remaining 19 patients underwent tracheotomy at the time of definitive surgery. Free flap reconstructions included 1 ulnar and 15 radial forearm fasciocutaneous flaps and 4 fibula osteocutaneous flaps. Postoperatively, all 19 tracheotomized patients had successful decannulation. Average time to decannulation was 15 days (range, 3-42 d). After surgery and before irradiation, 13 patients initiated oral intake, on average, at 19.5 days (range, 7-28 d); 6 patients required no additional supplementation. By 4 months after surgery, having completed radiation therapy, 10 patients were consuming all nutrition orally; the other 10 patients still required tube-feed supplementation, although 6 of these patients were also eating by mouth. Combined-modality treatment that includes free flap reconstruction for advanced-stage oropharyngeal cancer may provide reasonable functional rehabilitation with respect to postoperative airway and swallowing.

A comparison of the donor-site morbidity after using the prelaminated fasciomucosal flap and the fasciocutaneous radial forearm flap for intraoral reconstruction

Since 1996 we have performed mucosal prelamination of the distal radial forearm flap for functional reconstruction of defects of the intraoral lining. This study was undertaken to demonstrate that the prelaminated fasciomucosal radial forearm flap can provide physiological oropharyngeal reconstruction with mucus-producing tissue, while avoiding the donor-site complications of the fasciocutaneous radial forearm flap. We examined the donor hand at least 6 months postoperatively in 20 patients after using a prelaminated fasciomucosal radial forearm flap and in 15 patients after harvesting a classical fasciocutaneous radial forearm flap. The evaluation of hand function included range of motion, grip power, pinch power, sensibility and vascular analysis in both hands. The patients were asked about cold intolerance, pain and any restrictions in daily life, and the cosmetic appearance of the donor hand was noted. In the prelaminated-flap group (n 20), two patients had decreased wrist extension, and one of these patients also had reduced strength and mild hypaesthesia in the donor hand. In the classical-fasciocutaneous-flap group (n 15), six patients had decreased wrist extension, five patients had reduced strength and four patients had diminished sensibility in the donor hand. Painful neuromas were found only after fasciocutaneous flaps (three cases). Subjective assessment revealed restricted hand function in one patient in the prelaminated-flap group, and in five patients who had undergone fasciocutaneous flap transfer. The results of this study show that using the prelaminated fasciomucosal radial forearm flap minimises the donor-site morbidity. Furthermore, we were able to improve the cosmetic appearance of this very exposed region.

Radial forearm free flap pharyngoesophageal reconstruction.

This study evaluates the outcome of pharyngoesophageal reconstruction using radial forearm free flaps with regard to primary wound healing, speech, and swallowing in patients requiring laryngopharyngectomy. Retrospective review in the setting of a tertiary, referral, and academic center. Twenty patients underwent reconstruction of the pharyngoesophageal segment using fasciocutaneous radial forearm free flaps. All free flap transfers were successful. An oral diet was resumed in 85% of the patients after surgery. Postoperative pharyngocutaneous fistulas occurred in 4 patients (20%) with 3 resolving spontaneously. Distal strictures also occurred in 20% of the patients. Five patients who underwent tracheoesophageal puncture achieved useful speech. Advantages of radial forearm free flaps for microvascular pharyngoesophageal function include high flap reliability, limited donor site morbidity, larger vascular pedicle caliber, and the ability to achieve good quality tracheoesophageal speech. The swallowing outcome is similar to that achieved after jejunal flap pharyngoesophageal reconstruction. The main disadvantage of this technique relates to a moderately high incidence of pharyngocutaneous fistulas, which contributes to delayed oral intake in affected patients.

A method for minimizing donor site complications of the radial forearm flap.

The great advantages of the radial forearm fasciocutaneous flap are offset by the dilemmas associated with its donor site. The most commonly encountered problems are the functional and cosmetic sequelae of skin graft loss with consequent exposure of volar forearm tendons, the superficial sensory branch of the radial nerve, and the radius. Techniques that minimize donor site morbidity are those that provide a well-vascularized bed for the protection of exposed tendon, nerve, and bone, and for the acceptance of skin grafts. A technique involving the mobilization of the flexor pollicis longus muscle belly in conjunction with the abductor pollicis longus with approximation to the flexor digitorum superficialis muscle belly provides stable, well-vascularized coverage of the radial forearm flap donor site, with reliable skin graft acceptance and no functional sequelae.

Comparative study on sensory recovery after oral cavity reconstruction by free flaps: preliminary results

Anatomical restoration was once the only goal of reconstructive surgery, but now it represents only one step in the complete functional recovery process to allow resumption of physiological activity. Soft tissue and nerves play important roles in functional recovery, but the potential of these structures is not yet well known. Rehabilitation after oral cavity reconstruction by free flaps needs an interdisciplinary diagnostic and therapeutic approach, in which neurosensory recovery of transferred tissue is an important aspect.Previous studies have used clinical assessment to evaluate sensory recovery after oral reconstruction with free flaps, but these results have been subjective and not quantifiable. The aim of the present study is to evaluate the sensory recovery using objective and standardized electrophysiological data by recording the masseter inhibitory reflexes (MIR) following mental and lingual electrical stimulation.A group of 14 patients who underwent oral cavity reconstruction by transplantation of either forearm (9) or jejunal (5) noninnervated free flaps were investigated. We found that sensory recovery of fasciocutaneous radial forearm free flaps was better than that of jejunal free flaps. This could represent the starting point for further studies about sensory recovery of reconstructed anatomical structures based on standardized and objective electrophysiological data.

Challenges in midface reconstruction.

Defects of the midface and maxilla are often the most challenging problems faced by the reconstructive surgeon. Resections that involve critical structures of the face such as the nose, eyelids, and lips in conjunction with the maxilla can be particularly difficult to reconstruct. The algorithm for reconstruction of these defects is usually based on the extent of maxilla that is resected. A classification system for maxillectomy defects is the most useful way to approach these reconstructions. A vast majority of extensive defects involving the maxilla and midface require free flap reconstructions. The type of flap selected is based on the extent of skin, soft tissue, and bone that is resected. Smaller volume defects with large skin surface requirements are best reconstructed with the radial forearm fasciocutaneous or osteocutaneous flaps. Larger soft-tissue volume and skin surface can be provided by the rectus abdominus myocutaneous flap. Critical structures such as lips, eyelids, and nose should be reconstructed separately, using local flaps if at all possible. The free tissue transfer should ideally not be incorporated into these structures. Most patients with even the largest resections can be restored to fairly good function by following this algorithm. Semin. Surg. Oncol. 19:218-225, 2000.

Donor site morbidity of the prelaminated fasciomucosal and fasciocutaneous radial forearm flap: a comparative study

In order to reconstruct intraoral lining defects after radical tumor resection, mucosal prelamination of the fascia of the distal radial forearm flap was performed in ten patients. By this method a physiologic reconstruction with mucus-producing tissue could be achieved. Preservation of skin and subcutaneous tissue enabled primary closure of the donor site. The exposed median nerve and flexor tendons could be covered by well-vascularized tissue with, hopefully, less donor site morbidity. To investigate this, eight prelamination patients were compared to five patients in whom conventional fasciocutaneous distal radial forearm flaps were harvested. Follow-up was 6–25 months (mean 12.8 months). All patients with prelaminated forearm flaps revealed excellent functional and cosmetic results. Restricted hand function and a poor cosmetic result were found in 40% of the fasciocutaneous flap patients. Subjective cold intolerance could be objectified using thermography, but could not be confirmed, using rheography and photoplethysmography.

Efficacy of microsurgical free-tissue transfer in chronic osteomyelitis of the leg and foot: review of 22 cases.

The efficacy of free composite tissue transfer for the treatment of chronic osteomyelitis of the leg and foot was evaluated in a retrospective study. Twenty-two patients, operated on at the American University of Beirut between January, 1992 and December, 1996, were identified. Infection involved the heel (8), ankle (1), foot (5), and tibia (8). All patients had multiple debridement and prolonged antibiotic treatment prior to presentation. The mean duration of disease was 4.8 years (range: 1 to 25 years). There were five cases of infected tibial non-union and one case of an infected tibial bone defect measuring 15 cm. Following radical debridement, microvascular free-tissue transfer was immediately performed. One latissimus dorsi and 13 rectus abdominis muscle flaps, as well as eight radial forearm fasciocutaneous flaps were used. At a mean follow-up of 3.8 years, there was one rectus abdominis free-flap failure in a Gustilo IIIC tibial fracture, which necessitated secondary amputation; there was no evidence of recurrence of osteomyelitis in the remaining 21 patients during the study period. The patients with tibial nonunion and bone defect healed following resection and bone transport utilizing a callus distraction technique. The results show that free-tissue transfer is a safe and viable treatment option in chronic osteomyelitis of the leg and foot. A brief discussion of the history of microvascular free-tissue transfers, as well as their value in modern reconstructive surgery, is also presented.

Mucosal prelamination of a radial forearm flap for intraoral reconstruction

Until now the microvascular fasciocutaneous radial forearm flap has been one of several methods favoured for reconstruction of intraoral soft tissue defects after radical resection of squamous cell carcinoma. Mucosal reconstruction and lining has been performed by a skin island, this is epidermis and cannot produce mucus. In order to provide mucosal properties and allow mucus production, a distal radial forarm flap has been successfully prelaminated with buccal mucosa in five patients. By this method thin, pliable and resistant flaps have been produced. Due to mucosal spreading, the mucosa lined area was 30–50% larger than the originally inserted mucosal grafts. Preservation of skin and subcutaneous tisssue lowered donor site morbidity. This technique has also been performed in axial pattern flaps; two osteofasciomucosal fibulae and three myomucosal pectoralis major flaps.

Mucosal prelamination of a radial forearm flap for intraoral reconstruction.

For reconstruction of intraoral soft-tissue defects after radical resection of squamous-cell carcinomas, the microvascular jejunal patch has been a reconstructive graft option of first choice. in addition to other advantages, these jejunal grafts are able to produce mucus. In cases in which the use of jejunal grafts is contraindicated, the fasciocutaneous radial forearm flap has enlarged the spectrum of reconstructive options. A disadvantage is that mucus production will be absent, because mucosal and lining reconstruction is performed with tissue lacking mucus-providing qualities. The authors successfully prelaminated a distal radial forearm flap with buccal mucosa in five patients. Mucosal prelamination of the distal radial forearm flap enables a physiologic reconstruction with resultant mucus production, in combination with the provision of thin, pliable, and resistant flaps. The technique lowers donor-site morbidity because of the preservation of skin and subcutaneous tissue. Reconstruction with fasciomucosal, osteomyomucosal, and myomucosal flaps by this method seems feasible.

The fasciocutaneous radial forearm flap in orofacial reconstructive surgery: Clinical results of 50 consecutive cases

The fasciocutaneous radial forearm flap in orofacial reconstructive surgery: Clinical results of 50 consecutive cases

Emergency free tissue transfer

The authors report the use of acute free flaps in head, upper and lower limb injuries. The series includes 9 clinical cases, 2 latissimus dorsi muscle and 2 fasciocutaneous radial forearm flaps for coverage and 1 flow-through cephalic antebrachial dermal venous flap for coverage and venous drainage and 4 flow-through fasciocutaneous radial mid-forearm flaps for coverage and revascularisation of the ischaemia extremities. There were no postoperative infections and no failures, confirming the reliability of this concept.

The distally based lateral arm flap for intraoral soft tissue reconstruction.

The radial forearm flap is probably the most frequently used among free flaps for intraoral soft tissue reconstruction. However, this flap is not always available. The other fasciocutaneous flaps may be too bulky or less pliable or may have a short vascular pedicle; their use is therefore less than ideal. We present a variant of the lateral arm flap located distally to the lateral epicondyle and having the same advantages as the radial forearm flap. Vascular study (dissection and radiography) was previously undertaken to determine the vascular anastomotic network in the epicondylar area, between the posterior radial collateral artery and recurrent arteries running in front of the lateral epicondyle. This demonstrated the possibility of taking a skin paddle on and below the lateral epicondyle, based on the proximal pedicle. We used this flap on three patients for intraoral soft tissue reconstruction (tonsil, floor of the mouth, and piriform sinus). No complication with the flap itself was encountered. In all cases, direct closure of the donor site was possible, with no local complication. The distal lateral arm flap (LAF) represents an interesting and reliable alternative to the fasciocutaneous radial forearm flap. The positioning of the skin paddle over the lateral epicondyle and the proximal third of the lateral aspect of the forearm increases pedicle length, thus avoiding the use of vein grafts. Dissection is straightforward with a reliable vascular anatomy. Moreover, in this area, the limited amount of subcutaneous fatty tissue ensures easier placement and more pliability when compared with the standard LAF.

Free Tissue Failure Is Not an All-or-None Phenomenon

A common misconception among microsurgeons is that free tissue failure is an "all-or-none" phenomenon. In other words, there is an instantaneous cessation of blood flow to a flap primarily due to thrombosis at the arterial or venous anastomotic site (primary thrombosis) with complete flap loss as a result. Contrary to this belief, we have found that free tissue transfers occasionally "die" a slow, progressive, and partial death. This most likely is due to gradual "shutting down" of the microcirculation by the showering of microemboli downstream from the arterial anastomosis (secondary thrombosis). We discuss our clinical experience during the past 6 years with 10 patients in whom free flap failure was not an all-or-none phenomenon and describe the expectant management of these failing free flaps. Microvascular reconstruction of the lower extremities was performed for recalcitrant sickle cell ulceration, chronic venous stasis ulceration in a patient with anti-thrombin III deficiency, dry gangrene of the plantar surface of the foot and toes secondary to posterior tibial artery injection in an intravenous drug abuser, Gustillo type IIIc injury requiring reconstitution of the femoropopliteal artery after an automobile bumper injury, Gustillo type IIIb injury resulting from gunshot wounds, an open ankle joint in a patient with severe peripheral vascular disease, and osteomyelitis. Other cases included cheek soft tissue reconstruction after wide resection of a recurrent dermatofibrosarcoma protuberans of the parotid gland, chest wall coverage after claviculectomy for osteoradionecrosis, and thumb replantation complicated by refractory vasospasm. Latissimus dorsi (four patients), rectus abdominis (three patients), scapular (one patient), and radial forearm fasciocutaneous (one patient) flaps were used. Flap compromise was detected between 4 hours and 6 weeks after surgery. Salvage attempts included Fogarty thrombectomy (four patients), anastomotic revision (two patients), streptokinase instillation (one patient), and leech application (one patient). Failing free flaps were managed expectantly with the use of daily dressing changes. This allowed for the survival of sufficient soft tissue to effect coverage of exposed bone, tendon, or joint. Hyperbaric oxygen was not administered. Tangenital excision of the eschar was performed between 6 and 51 days after free tissue transfer. Skin grafting was delayed for 15 to 80 days. In all cases, a successful outcome was achieved ultimately by either a single skin-grafting procedure (seven patients) or groin flap coverage (one patient). Follow-up ranged from 2 to 35 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Large Doses of Topical Lidocaine during Microvascular Surgery Are Not Associated with Toxic Blood Concentrations

Large Doses of Topical Lidocaine during Microvascular Surgery Are Not Associated with Toxic Blood Concentrations

Microvascular free flaps in head and neck surgery.

This study is a retrospective review of 60 patients who had microvascular free flap reconstructions in the head and neck region. They were all performed over a 10-year period by a single surgeon. The series includes a wide range of flap types and analyses pre-operative risk factors for flap failure as well as complications and outcome. Smoking and advanced age did not appear to prejudice flap survival but peripheral vascular disease, cardiac disease and alcohol withdrawal were found to increase the likelihood of flap failure. The most frequent complications encountered were thrombosis of one of the anastomosis and haematoma. The most successful flap in terms of survival and function was the fasciocutaneous radial forearm flap. The literature is reviewed in relation to the general principles of microvascular free flap surgery and the results of this series are placed in context.

Reverse-Flow Radial Forearm Flap for Reconstruction of the Hand

Soft-tissue injuries of the hand often require flap coverage to achieve primary wound closure and a good functional result. The use of the reverse radial forearm fasciocutaneous flap in the reconstruction of the hand is discussed. This flap offers thin, pliable, hairless skin and has proved very reliable because of its excellent vascular supply. The anatomy and vascular basis of this flap are presented along with its application in three patients.

The Distally Based Radial Forearm Fasciosubcutaneous Flap with Preservation of the Radial Artery

The axial-pattern reverse radial forearm fasciocutaneous flap has become one of the primary flaps for reconstruction of soft-tissue defects of the hand. The two main disadvantages of this flap are (1) sacrifice of a major artery that may possibly jeopardize hand viability and (2) morbidity and appearance of the donor site. In an effort to overcome these drawbacks, an anatomic study of a distally based radial forearm fasciosubcutaneous flap with preservation of the radial artery was conducted. Seventeen fresh cadaver forearms were dissected to investigate the contribution of the distal radial artery and its superficial and deep branches to the fasciosubcutaneous plexus of the forearm. The blood supply to the radial forearm fasciosubcutaneous tissue was found to emanate from 6 to 10 septocutaneous perforators of the distal radial artery in the vicinity of the anatomic snuff box that "fan out" at the level of the deep fascia to form a rich plexus supplying the forearm fascia, subcutaneous tissue, and skin. There appeared to be a definite directional component, with the arterioles running longitudinally along the intermuscular septum. The deep fascia and subcutaneous tissue were found to have their own venous system accompanying the small perforating arterioles. Encouraged by these findings, we proceeded to utilize this fasciosubcutaneous flap for coverage of the thumb-index web space (three patients), the dorsum of the hand (two patients), and both the palmar and dorsal aspects of the hand (one patient). Five flaps had almost complete survival. The largest flap in our series suffered significant loss. Minor skin-graft loss occurred in a few cases, and we now delay skin grafting for several days. The distally based radial forearm fasciosubcutaneous flap with preservation of the radial artery can be a very useful and reliable alternative for repairing soft-tissue defects of the hand, obviating the need for the classic fasciocutaneous flap or even a free flap. This flap not only preserves the radial artery, which is essential in cases where only the radial artery is functioning, such as following severe hand injuries, but also provides a more acceptable donor site.