Radial Forearm Free Flap Research Articles

Is Brachytherapy Feasible After Head and Neck Cancer Reconstructive Surgery? Preliminary Report

The purpose of the study was to evaluate the influence of interstitial postoperative brachytherapy for the vitality and quality of flaps used for reconstruction of tissue defects after head and neck cancer salvage resection. We aimed at presenting six consecutive patients with recurrent squamous cell carcinoma in head and neck region who underwent salvage surgery and tissue reconstruction with a regional or free flap followed by brachytherapy. Reconstruction was performed with a free radial forearm flap in 2 cases, with a free thigh flap in 2 cases, and with a myocutaneous lateral upper arm flap in the next 2 cases. In all patients, pulsed-dose-rate brachytherapy was used with a median value of 0.7 Gy (range 0.6–0.8 Gy) per pulse and a median total dose of 20 Gy (range 20–40 Gy). In the analyzed group, there were no serious wound and flap complications after brachytherapy. In one case, peripheral skin necrosis was noticed. No revision surgery was needed but only surgical debridement of the necrotic margins. All wounds healed within 14 days after surgery as well as donor sites which healed within 4 weeks. Based upon our data, pulsed-dose-rate brachytherapy seems to be a safe option that can be performed at the site of reconstruction in immediate postoperative period with minimal wound complications and with no impact on flap survival. Further clinical study based on larger patient series is needed to present statistically proven results.

Microsurgical penile reconstruction in case of intersexuality and after penis carcinoma

The goals of penile reconstruction and phalloplasty include aesthetics as natural as possible and the ability of patients to void while standing and to have sexual intercourse. This article presents two more rare indications and techniques, the phalloplasty using free radial forearm flapin case of intersexuality and after penectomy due to penis carcinoma. In transsexual individuals numerous phalloplasties in Gottlieb and Levine`s technique, by means phalloplasty of free radial forearm-flap of the non-dominant forearm, were performed in our department over the last few years. However, this technique also has its significance for phalloplasty in non-transgender persons.Two patients are considered in detail with regard to indication and surgical technique and were followed up in a multimodal setting.Patient 1 is genetically male, thirty-five years old with a micropenis in the case of pseudohermaphroditism masculine and androgen resistance.Patient 2 is a fifty-one-year old genetically male and as a result of a penis carcinoma his penis had to be amputated at the level of penis root. After absence of recurrence for 1,5 years, the penile reconstruction took place after complete resection of the remaining residual penile stump and corpora cavernosa. Both patients underwent multimodal follow-up 15 months postoperatively with regard to phalloplasty sensors and donor-site restrictions. An aesthetic and functional acceptable result could be obtained for both patients. Both patients are able to void while standing. The multimodal follow-up 15 months postoperatively revealed relevant differences in the sensory findings of both patients, which are due to the different anatomy of reinnervation. In microsurgical experienced departments, the technique of A. radialis phalloplasty can also be used successfully in more rare indications, as shown here, a satisfying result can be achieved in terms of function and aesthetics. The complications shown here do not differ from those using phalloplasty in transgender persons.

Endoscopic Adipofascial Radial Forearm Free Flap Reconstruction of the Skull Base: A Technical Update.

Objective While most defects after endoscopic endonasal resections can be closed with local or locoregional options, rare cases require free tissue transfer. In this setting, while minimally invasive techniques have been described, the essential procedural details are lacking. The objective of this report is to describe several key technical modifications to free flap harvest and endoscopic-assisted inset which decrease morbidity and improve reliability and efficiency. Methods A retrospective chart review was performed of consecutive patients treated at Washington University in St. Louis with endoscopic free flap reconstruction through a Caldwell-Luc/transbuccal approach between January 2016 and September 2019. Results A total of six patients underwent adipofascial radial forearm free flap with this technique, five for recalcitrant cerebrospinal fluid leak or pneumocephalus and one for osteoradionecrosis. All flaps survived and there were no flap-related complications. Five patients (83%) achieved successful healing and separation of the sinonasal cavity and intracranial space. One patient developed recurrent pneumocephalus. Three key technical modifications were identified that improve efficiency and reliability of flap delivery and inset: (1) use of an adipofascial radial forearm flap, without skin paddle; (2) wide resection of the anterior and lateral maxillary face to facilitate flap delivery; and (3) precise defect measurement and flap contouring prior to inset to prevent any need to debulk the flap in situ. Conclusion Endoscopic adipofascial radial forearm free flap delivered to the skull base through a Caldwell-Luc/transbuccal corridor is a feasible option with a high success rate and low morbidity when other reconstructive attempts have failed.

Systematic review and pooled analysis of survival rates, success, and outcomes of osseointegrated implants in a variety of composite free flaps.

The aim of this review was to provide an update on survival rates of osseointegrated implants into common composite free flaps used for maxillary and mandibular reconstructions and identify factors affecting outcomes. PubMed, Medline, Embase, and Cochrane databases were searched. Included studies reported implant survival by flap type. Results were pooled and survival was estimated with the Kaplan-Meier method. Variables affecting survival were assessed using Cox regression. Thirty-two of the 2631 articles retrieved were included, totaling 2626 implants placed into fibula, iliac crest, scapula, and radial forearm free flaps. Pooled survival showed 94% 5-year survival of implants in fibula and iliac crest with no difference between groups (P = .3). Factors effecting survival included radiotherapy (HR 2.3, 95% CI 1.2-4.6, P = .027) and malignant disease (HR 2.2, 95%CI 1.6-3.1, P < .001). Implant survival appears adequate across common flap types; however, there are limited numbers reported in less common flaps.

Factors associated with skin graft take in fibula and radial forearm free flap donor sites.

Identify factors associated with skin graft take in fibula free flaps (FFF) and radial forearm free flaps (RFFF) donor sites. To determine which factors are associated with decreased skin graft take at the donor site in FFF and RFFF in head and neck patients. Retrospective Chart Review Case Series. Multicenter Tertiary Care. A multicenter retrospective review was performed at three institutions identifying patients who underwent free tissue transfer, specifically either FFF or RFFF, between 2007 and 2017. Patient demographics, medical history, and social history were examined including age, gender, BMI, smoking status, diabetes and preoperative anticoagulation use. Preoperative, intraoperative data, and postoperative data were also examined including tourniquet use, type of flap, area of skin graft, if the skin graft had a donor site or if it was taken from the flap, wound NPWT use, cast use, use of physical therapy, DVT prophylaxis, limb ischemia, heparin drip, and postoperative aspirin use. Statistical analysis was used to determine which factors were significantly associated with skin graft take. 1415 patients underwent a forearm or fibula flap and 938 patients underwent split-thickness skin graft. Of these, 592 patients had sufficient information and were included in the final analysis. There were 371 males and 220 females. The average age was 55.7. Complete skin graft take was seen in 480 patients (81.1%). On univariate analysis, patients with diabetes (p=.003), type of flap (fibula p<.001), skin graft area (p=.006), tourniquet use (p=.003), DVT prophylaxis (p=.008) and casting (p=.003) were significantly associated with decreased skin graft take rate. In a multivariate analysis, diabetes (OR 2.17 (95%CI 1.16-3.98)), fibula flaps (OR 2.86 (95%CI 1.79-4.76)), an increase in skin graft area (OR 1.01 (95%CI 1.01-1.01)), post-operative aspirin (OR 2.63 (95%CI 1.15-5.88), and casting (OR 2.94 (95%CI 1.22-7.14)) were associated with poor rates of skin graft take. Several factors affect skin graft take rate and should be considered when performing a skin graft for a donor site defect.

Penile Reconstruction: Current Thoughts, Techniques, and Outcomes

Phalloplasty has matured considerably over the last decades in reconstructive options and technical refinements, thanks to increasing recognition of gender dysphoria. The primary goals of performing a phalloplasty are to facilitate sexual penetration, protective sensation, orgasm, standing micturition, and natural aesthetic, ideally in few stages and with minimal morbidity. Radial forearm free flap, anterolateral flap, and metoidioplasty are the most common options, each with a unique profile of complications, aesthetic, and functional outcomes. Choices for reconstruction must be tailored to the individual patient’s goals and available tissue characteristics.

Hand perfusion following radial or ulnar forearm free flap harvest for oral cavity reconstruction: A prospective study

The radial forearm free flap (RFFF) and ulnar forearm free flap (UFFF) are used in head and neck reconstruction because they provide a thin and pliable skin paddle as well as a long vascular pedicle. However, in spite of several studies showing the safety of the UFFF, the RFFF is more popular among reconstructive surgeons based on concerns about hand ischaemia. A prospective study was designed in which 10 UFFF and 11 RFFF surgeries were performed in 20 patients undergoing oral cavity reconstruction between January 2017 and July 2018. Hand vascular parameters were evaluated preoperatively and postoperatively using Doppler ultrasound and plethysmography. The preoperative and postoperative diameters of the radial and ulnar arteries, and the flow velocities through the remainder of the forearm artery were measured preoperatively and at 3 months postoperative. Additionally, a comparison was performed between the preoperative and postoperative fingertip perfusion values according to impedance plethysmography. The preoperative mean diameter of the radial artery (2.89±0.47mm) was significantly greater than that of the ulnar artery (2.35±0.48mm) at the level of the wrist; however, 3 months after the surgery, the mean diameters of the two arteries did not differ significantly. There were no differences in digital perfusion when a UFFF was used compared with an RFFF.

Comparison of Clinical Results and Quality-of-Life in Tongue Cancer Patients Undergoing Submental Island Flap and Radial Forearm Free Flap Reconstruction

Our goal was to compare the clinical results and quality-of-life (QoL) in tongue cancer patients undergoing submental island pedicled (SIP) flap and radial forearm free (RFF) flap reconstruction. Patients undergoing SIP or RFF flap reconstruction for primary tongue squamous cell carcinoma were prospectively enrolled and were asked to complete the University of Washington Quality-of-Life (UW-QOL) questionnaire, version 4, at 12months after the operation. The study's main interest was QoL as well as locoregional recurrence control. A total of 190 patients were enrolled for analysis, and the SIP and RFF groups showed significant differences in patient age, American Society of Anesthesiologists classification, and hospital cost. In the survival analysis, locoregional recurrence occurred in 35 patients in the SIP group and 48 patients in the RFF group; the difference was not significant (P=.440). In the QoL analysis, compared with patients in the SIP group, those in the RFF group had higher scores in the domains of activity and recreation. No significant differences were found with respect to the other domains. The SIP flap and RFF flap have comparable survival control in tongue squamous cell carcinoma patients. The RFF flap might lead to better QoL, but the SIP flap imposes fewer limitations on patients' health status and is associated with lower hospital cost.

Full cheek defect reconstruction using ALTF versus RFF: Comparison of quality of life, clinical results, and donor site morbidity.

This study aimed to compare the quality of life (QOL) of patients, clinical results of the recipient site, and morbidities of the donor site between the use of free anterolateral thigh flaps (ALTFs) and radial forearm flaps (RFFs) for reconstruction of full cheek defects following tumor resection. We retrospectively reviewed 52 patients who underwent reconstruction of full cheek defects using free ALTFs and free RFFs following tumor ablation at our center. The range of mouth opening, speech, swallowing, facial appearance, donor site complications, and subjective symptoms based on the University of Washington Quality of Life (UW-QOL) questionnaire findings were assessed in the ALTF and RFF groups at 3, 12, and 36months after surgery. Quality of life, range of mouth opening, facial appearance, mood and anxiety, donor site appearance, subjective feeling, and functional impairment were better in the ALTF group than in the RFF group based on the physical examination findings and questionnaire scores. This study found better QOL and better functional results at the recipient site and minor morbidities at the donor site with the use of free ALTFs in the reconstruction of full cheek defects.

Shifting Paradigms in Head and Neck Reconstructive Surgery During the COVID-19 Crisis.

Shifting Paradigms in Head and Neck Reconstructive Surgery During the COVID-19 Crisis.

Three-Dimensional Magnetic Resonance Imaging Volumetry of Radial Forearm Flap Reconstructions After Craniomaxillofacial Tumor Resection.

Oral cancer is a common and life threatening disease that requires interdisciplinary treatment and often necessitates complex facial reconstruction. Standard care includes tumor resection, while reconstruction is routinely performed with free radial forearm flaps. As esthetic results are crucial for quality of life, flap size, flap volume, and flap composition have to be considered. To date no standardized measurement of flap volume and shrinkage has been established for routine use. The purpose of this study was therefore to evaluate the transplant volume of radial forearm flaps in craniomaxillofacial reconstruction using magnetic resonance imaging (MRI) volumetry. Ten postoperative MR sequences of 5 patients were included. All patients had received transplantation of radial forearm flaps after tumor resection and radiation therapy. Evaluated parameters were: sex, age, type of flap, flap volume. Two different observers (1 surgeon and 1 radiologist) segmented transplant volume at three different time points in a postoperative MRI independently and in consensus, using both axial and coronal slices. A nonfat saturated T1 spin echo sequence was used. Mean transplant volume was calculated. A total of 90 volumetric measurements were included. Overall Tvolm was 24.83 cm from axial sections and 27.25 cm from coronal sections. Measurements for axial and coronal orientations differed significantly. Results showed excellent intra- and inter-rater correlation, coefficient for rater A and rater B were 0.91 (axial) and 0.96 (coronal). MRI volumetry is a noninvasive reproducible method to quantify volume of free radial forearm flaps in situ but should follow specific considerations for best results.

Free radial forearm flap for reconstruction of postoperative defects in combined and complex treatment of patients with locally-advanced squamous cell carcinoma of the oral cavity

The study objectiveis to assess immediate and long-term results of replacing complex defects with a free radial forearm flap in the multimodal treatment of patients with locally advanced oral cavity squamous cell carcinoma.Materials and methods.Twenty eight patients (20 women and 8 men aged 23 to 71 years) with locally advanced oral cavity squamous cell carcinoma (including 10 buccal cancers, 8 carcinomas of tongue, 6 carcinomas of the floor of the mouth, 2 retromolar area carcinomas, 1 carcinoma of the hard palate and 1 carcinoma of alveolar region of the lower jaw) underwent tumor surgery with simultaneous plastic reconstruction of the defect using radial forearm free flap at the department of head and neck tumors of N. N. Blokhin National Medical Research Center of Oncology within 2010–2018. Primary tumors were detected in 2 patients and 11 patients had residual (n = 7) or recurrent (n = 4) tumors after radiotherapy or chemoradiotherapy.Results.An overall success rate was 96.4 %. Postoperative histology revealed that there were no tumor cells at the resection edges. Postoperative complications included: complete flap necrosis in 1 patient with severe concomitant diseases, marginal flap necrosis in 2 patients (in both cases after the necrotic tissue had rejected, wounds were healed by secondary intention), sural veins thrombosis in 1 patient, acute peptic ulcer bleeding on the 6th day after surgery in 1 patient treated with emergency endoscopic hemostasis. No lethal outcomes were reported. Postoperative period lasted in average 14 days. Upon subsequent observation tumor relapse in the oral cavity occurred in 4 (14.3 %) patients, relapses of regional metastases – in 2 (7.1 %). Good aesthetic and functional results were noted. Adequate restoration of breathing, chewing, swallowing and speaking resulted in a full patients’ rehabilitation. In all cases, the radial flap adapted well to the oral cavity organs and corresponded to the surrounding tissues in thickness and consistency.Conclusion.Use of a radial forearm free flap makes it possible to successfully reconstruct extensive and complex defects after surgery of locally advanced primary and recurrent forms of oral cavity squamous cell cancer of various locations. Due to flap’s high regenerative capabilities, preoperative radiation therapy does not affect the frequency of local complications. It allows restoring vital functions of the oral cavity and achieving good aesthetic and functional results.

Microsurgical Phalloplasty in Nontranssexual Patients – Considerations After a Retrospective Single-center Analysis of 23 Cases

ObjectiveTo evaluate the outcome of a single-center series of penile reconstruction using the radial free forearm flap in rare indications. Materials and MethodsFrom April 1993 until September 2016, 23 nontranssexual patients underwent phallic reconstruction by the use of a neuromicrovascular free radial forearm flap in our clinic. Patient-specific characteristics, surgical techniques, complications, and outcomes were retrospectively evaluated and interpreted. ResultsThe indications for surgery were: disorders of sex development (34.8%), reconstruction after oncologic surgery (34.8%), automutilation (8.7%), iatrogenic (8.7%), microphallus (8.7%), and 1 case of priapism (4.3%). Two patients (8.7%) had a total flap necrosis and 2 patients (8.7%) had a partial flap necrosis; 3 out of these 4 patients were heavy smokers. Urinary fistulae and strictures were frequent but were successfully managed by urologists in all cases. There was no statistically significant correlation between smoking, comorbidities, number of venous anastomoses, and complications. ConclusionIn departments experienced in microsurgery, the goals of penile reconstruction could also be achieved in patients with rare indications by the use of the neuromicrovascular free radial forearm flap. Despite the high rate of postoperative complications, penile reconstruction with the free radial forearm flap yields satisfying results. An intensive cooperation between the plastic-reconstructive team and the urological team is a prerequisite to achieve the best surgical result.

How to Harvest The Radial Forearm Free Flap

Summary: Radial forearm flap is fasciocutaneous flap from the volar aspect of the forearm that based on the perforator of radial artery. Radial forearm free flap (RFFF) has several advantages and disadvantages. It has unique characteristic of thin and pliable tissue. It may be indicated when a defect requires a thin flap with little bulk of soft tissue or multiple skin islands are needed to be provided. Physical signs and symptoms of poor peripheral digit perfusion or healing contraindicate the harvest of the radial artery pedicle. Preparations for RFFF procedure include history taking, physical examinations and supporting examinations. Several steps of intraoperative preparations should also be conducted.

The Anomalous Radial Artery: A Rare Vascular Variant and Its Implications in Radial Forearm Free Tissue Transfer.

The radial forearm free flap (RFFF) has become a workhorse for soft tissue reconstruction following surgical ablation of head and neck cancer. Given the popularity of the RFFF, it is important to understand potential variants of upper extremity vascular anatomy and the effects of these findings on pre- and intraoperative planning. The purpose of this series is to synthesize the existing literature to raise awareness for potential radial artery aberrations during planned reconstruction.

PD46-11 TECHNIQUES THAT REDUCE PARS FIXA AND PARS PENDULANS URETHRAL ANASTOMOTIC COMPLICATIONS DURING RADIAL FOREARM FREE FLAP PHALLOPLASTY

INTRODUCTION AND OBJECTIVE: Transmasculine individuals interested in radial forearm free flap (RFFF) phalloplasty with full length urethroplasty are counseled on high urethral complication rates. The most common site for a postoperative urethral complication is the pars fixa (PF) and pars pendulans (PP) urethral anastomosis, which reportedly occurs in 40% to 50% of patients. Distal pars fixa urethral complications are rare; therefore, maximization of blood flow to the proximal PP urethral component of the RFFF may decrease urethral fistula and stricture formation. We describe our experience with flap harvest techniques that preserve blood flow to this region of the RFFF. METHODS: PF urethral reconstruction utilized labia minora flaps without use of any vaginal wall flaps. PP urethral reconstruction involved the volar portion of the RFFF with a 1-2cm proximal extension for the urethral component of the flap. Blood flow to and from this portion of the RFFF was maximized using the following techniques: 1) preservation of direct arterial perforators, when present; 2) keeping a dermal skin bridge to the proximal PP urethra; 3) wide dissection of an adipofascial layer; 4) preservation of a “urethral” vein. The added benefit of the adipofascial layer around the proximal PP urethra is tissue coverage over the PF-PP anastomosis. We retrospectively reviewed the outcomes of RFFF phalloplasty patients who underwent urethral reconstruction. RESULTS: From Oct 2017 to Oct 2019, 79 patients underwent RFFF phalloplasty with full-length urethroplasty. Mean followup is 12 months (range 0-23 months). Urethrocutaneous fistulas and/or urethral strictures developed at the PF-PP anastomosis in 27 (34%) patients: 7 patients had a PF-PP urethral stricture and fistula, 5 had an isolated anastomotic stricture, and 15 patients had a fistula with 11 patients spontaneously healing the fistula by 6 weeks. The total urethral revision rate for patients with a non-healing fistula and/or stricture at the PF-PP urethral anastomosis was 14% (11 patients). There are two patients with mild strictures and three with a fistula who are still being monitored and have not yet had urethral reconstruction. CONCLUSIONS: Techniques directed towards preservation of blood flow to the proximal urethral component of a RFFF phallourethroplasty reduces risk of urethral complications. More than half of the fistulas healed spontaneously, and most strictures required urethroplasty. Source of Funding: none

MP29-20 METOIDIOPLASTY FOLLOWED BY SECONDARY PHALLOPLASTY

INTRODUCTION AND OBJECTIVE: Metoidioplasty can be a definitive reconstruction option in transmen, but can also be an intermediate step towards phalloplasty. During the metoidioplasty, the vagina is excised (in most cases), scrotum and perineal are reconstructed, and the urethra is lengthened. As these steps have already been performed in case of prior metoidioplasty, staged phalloplasty might be associated with less urethral and flap-related complications compared to immediate (all-in-one) phalloplasty. This hypothesis was evaluated in this retrospective study. METHODS: Between 2006 and 2019, 27 patients underwent phalloplasty after prior metoidioplasty (staged phalloplasty). These patients were matched for type of flap and time period with a cohort of 27 patients who underwent immediate phalloplasty (group 2). Phalloplasty was performed with a radial forearm free flap and pedicled anterolateral thigh flap in 36 and 18 patients respectively. There were no significant differences for age, body mass index and smoking habits between both groups. Vaginectomy was performed in 23 (85%) and 20 patients (74%) in the staged and immediate phalloplasty group, respectively (p=0.31). In case of staged phalloplasty, the phalloplasty was performed after a median of 11 months (range: 4-42) after metoidioplasty. RESULTS: Median follow-up after phalloplasty was respectively 32 and 33 months for staged and immediate phalloplasty (p=0.99).For staged phalloplasty, metoidioplasty required a median operation time of 125 minutes, a median hospital stay of 5 days (range: 3-12) and a median catheter stay of 16 days. Respectively 1 (3.7%) and 2 patients (7.4%) required subsequent surgery because of respectively a perineal fistula and stricture before phalloplasty.For staged and immediate phalloplasty, median operation time was 396 and 410 minutes (p=0.6), median hospital stay was 16 and 17 days (p=0.5) with a median catheter stay of 19 and 20 days (p=0.9), respectively. In both groups, 16 patients (59%) needed at least one additional surgical procedure for postoperative complications, urethral complications (stricture, fistula) and/or flap-related complications (partial/total flap necrosis). For staged phalloplasty, additional surgery was needed because of urethral complications only, flap-related complications only, both urethral and flap-related complications, postoperative hematoma and combined urethral complications with postoperative hematoma in respectively 4 (15%), 1(3.7%), 8 (30%), 2 (7.4%) and 1 patients (3.7%), whereas this was respectively the case in 5 (19%), 3 (11%), 6 (22%), 2 (7.4%) and 0 patients who underwent immediate phalloplasty (p=0.9). CONCLUSIONS: Postoperative complications are not reduced in case metoidioplasty has been performed prior to phalloplasty. In case metoidioplasty is considered as a step towards phalloplasty, the separate morbidity of metoidioplasty must be taken into account. Source of Funding: none

Iatrogenic Damage of the Pedicle of Radial Forearm Free Flap Repaired with Super-Microsurgery Techniques: A Case Report

Introduction: Accidental Iatrogenic damage of the pedicle or perforators has been frequently reported as a cause of failure of free flaps. Free radial forearm flap helps to cover defects that are not possible to cover with local flaps or skin graft.Case Presentation: A 91 years old patient with Bowen Disease had multiple actinic keratosis and a history of squamous cell carcinoma over the forehead, which was removed 4 years before. The recurrent tumor was detected and wide excision of the tumor was done. It resulted in a large defect of 8 x 5.5 cm2 in diameter at the forehead with exposure of bone, therefore, a free radial forearm flap was performed for reconstruction with right superficial temporal artery and vein as recipient’s vessel. We observed leakage of blood through the radial artery near to the anastomosis due to iatrogenic damage during flap harvesting.Conclusions: Nowadays, repairing iatrogenic damage through the main pedicle or perforators of the pedicle is possible with super-microsurgery technique due to the improvement of the skills and smaller sutures avoiding the obstruction of the lumen of the pedicle or perforator. This is considered a salvage procedure instead of harvesting new free flaps and can be useful for all kinds of free flaps.

Delayed Reconstruction of Palatomaxillary Defect Using Fibula Free Flap.

Introduction. The objective of this study was to evaluate a surgical technique and to present the results of delayed reconstruction of palatomaxillary defects using fibula free flap (FFF). Methods. A review was conducted for nine patients who underwent palatomaxillary reconstruction using FFF. Primary disease, type of reconstruction, defect area, fibula segment length and number of osteotomies, radiotherapy, and implant installation after FFF reconstruction were analyzed. Results. All nine patients underwent delayed reconstruction. The fibula shaft was osteotomized into two segments in seven patients and three segments in one patient with bilateral Brown’s revised classification IV/d defect. One case was planned by using a computer-aided design computer-aided manufacturing (CAD/CAM) system with a navigation system. The mean length of the grafted fibula bone was 68.06 mm. Dental implant treatment was performed in six patients. Six patients received radiation therapy, and there were no specific complications related to the radiation therapy. In one case, the defect was reconstructed with FFF flow-through from a radial forearm free flap. Conclusion. This clinical study demonstrated that the fibula flap is an ideal donor-free flap in a palatomaxillary defect. Delayed reconstruction using an FFF can reduce the complication and failure rates.

Multimodal Evaluation of Functional Nerve Regeneration in Transgender Individuals After Phalloplasty With a Free Radial Forearm Flap

BackgroundConstructing a sensitive phallus is a key objective in sex affirmation surgery, but still there is a major lack of evidence in outcome analysis of postoperative sensibility of the newly constructed body part. AimTo evaluate the innervation and sensibility of a forearm free-flap neophallus with nerve coaptation by a broad-spectrum follow-up. MethodsThe phallic sensibility of 20 transgender individuals who underwent phalloplasty with a free radial forearm flap was evaluated by a standardized multimodal approach, examining 5 main sensory modalities. Measurements were performed in defined areas at the phallus and at the unoperated forearm as a control area. Additionally, all patients were asked to complete a questionnaire about their subjective quality of life and ability to orgasm. OutcomeThis study evaluated the following parameters: perception of pressure (Semmes-Weinstein monofilaments) and vibration (C64 Hz tuning fork), static two-point discrimination, sharp-blunt and hot-cold discrimination at the phallus and the forearm, sum score of calculated life satisfaction, and ability to orgasm. ResultsMost of the patients (n = 14) were able to perceive 2 or more sensory modalities tested at the newly constructed phallus. 2 patients did not develop any sensibility. Interestingly, the median values for vibration perception were similar for the phallus and the unoperated forearm. Pressure sensibility was present at the phallus, but less than at the forearm. Moreover, sharp-blunt sensibility was present in 11 patients. In contrast, clear cold-warm discrimination could not be achieved, although the majority of patients detected the cold stimulus. A two-point discrimination of up to 23 mm could not be detected in either body part. 15 patients experienced orgasms without difficulty after 23 months (n = 20 after 54 months). Clinical ImplicationsWe observed successful recovery of sensibility at the phalli for the majority of patients, including the preservation of orgasm. Strengths & LimitationsOur institution is one of the few centers regularly performing phalloplasties in transgender patients, especially preferring the technique of Gottlieb and Levine. This study contributes to the few studies that perform sensory testing at the phallus and is unique in its kind in that it uses a multimodal approach. A limitation of this study is the limited number of cases and the limited validity of vibratory testing. ConclusionConfirming a promising tactile sensibility after phalloplasty with a neurovascular radial forearm flap, the next step would be to identify whether this reinnervation effectively develops due to nerve coaptation or spontaneous sprouting.Küenzlen L, Nasim S, van Neerven S, et al. Multimodal Evaluation of Functional Nerve Regeneration in Transgender Individuals After Phalloplasty With a Free Radial Forearm Flap. J Sex Med 2020;17:1012–1024.