Radial Forearm Fasciocutaneous Flap Research Articles

Reconstructive surgery and adjuvant radiotherapy for the multimodal approach in oral cancer: a single cancer centre experience

Introduction and importance: Ablative surgery for oral cancer, irrespective of the histological subtype, causes large tissue defects, functional and aesthetic damage. Microsurgical free flaps have been widely used in reconstruction after resection, with satisfactory success rates in conjunction with adjuvant radiotherapy (RT). This study aims to describe our clinical institutional experience based on the multimodal treatment performed in four cases diagnosed with oral squamous cell carcinoma with the use of different microvascular free flaps and RT. Case series presentation: Four patients underwent reconstructive microsurgery after surgical resection of oral cancer, using three types of free flap: radial forearm fasciocutaneous, osteomyocutaneous fibular, and anterolateral thigh musculocutaneous flaps; RT was performed in Case 2 and Case 3. In the period of 3 years after microsurgical reconstruction and RT, flaps remain clinically stable without failure signs in full patients submitted to multimodal treatment. Clinical discussion: After resection of oral carcinomas, extensive tissue defects can be successfully treated with reconstructive microsurgery using different types of microvascular free flaps. RT for locoregional control is a feasible option and did not seem to interfere with the survival of flaps. Conclusion: An enhance long-term follow-up to assess overall and disease-free survival rates and quality of life must be carried out; however, cohort studies would be necessary for better understanding of the role of each treatment in the multimodal scheme.

Repair of Surgical Defect by Pectoralis Major Flap Versus Free Radial Forearm Flap in Buccal Carcinoma: Assessment of Quality of Life

Background: Soft tissue reconstruction of the oral cavity is the most critical factor in achieving a successful functional result. Malignant lesions occurring in the buccal area are usually treated with primary surgical and/or radiotherapy of the head and neck region. Depending on the location and size of the buccal tumor, radical surgical treatment often affects all oral function such as speech, swallowing, chewing, oral rehabilitation, nutrition and appearance. To maximize postoperative function, flap repair is currently the preferred method for reconstruction of buccal defects after major surgery. Among the flaps most commonly used are pedicle pectoralis major myocutaneous flap and the free radial forearm fasciocutaneous flap. The choice of the best reconstructive option is still controversial. Objective: To find out the quality of life after repair of surgical defect by pectoralis major flap versus free radial forearm flap in buccal carcinoma. Methods: This prospective study was conducted in the department Otolaryngology- Head & Neck Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka from September 2017 to August 2019. A total number of 44 cases of buccal carcinoma patient who had the inclusion criteria were enrolled as a study sample. These subjects were selected from the Department of Otolaryngology-Head & Neck Surgery, Department of Oral & Maxillofacial Surgery, Bangabandhu Sheikh Mujib Medical University, Shahbag, National Institute of ENT, Tejgaon, Dhaka. Comparison of nominal or ordinal variables between patients who have undergone surgery with either the RFFF or PMMF were analyzed using a chi-square test. The UW-QOL scores were compared for each domain using the nonparametric Mann-Whitney test. P-value < .05 was accepted as the level of significance. Results: In this study 40 out of 44 patients were completed UW-QOL questionnaires. The median age was 52 (range 40-65years), the male-female ratio was 1.44:1. All were habituated in either smoking or betel leaf/ nut or alcohol. Most of them were illiterate to the primary level of education and suffering from stage- iii tumor. All these variables were statistically insignificant except gender. Patients reconstructed with RFFF felt better in shoulder domains than PMMF but felt worse appearance domains and these were statistically significant in both 3 months and 6 months postoperatively. Conclusion: The study result had shown that reconstruction of the defect after buccal cancer resection using either RFFF or PMMF significantly influences patient’s quality of life. This study will provide valuable information for surgeons who will decide reconstruction modalities for buccal cancer and also will help the patients getting a better outcome. Bangladesh J Otorhinolaryngol 2023; 29(1): 32-38

Sentinel flaps correlate with pro-inflammatory and immunoregulatory mediators of human face transplantation rejection

Abstract Early diagnosis and treatment of immune rejection is critical for face transplants (vascularized composite allografts, VCA). VCA rejection is diagnosed by histologic evaluation of skin biopsies, yet repeated biopsies are a considerable aesthetic problem. Sentinel flaps, fasciocutaneous radial forearm flaps, have been used for remote-site rejection monitoring, but the concordance between tissues during rejection remains unclear. With access to the world’s largest cohort of VCA patients at a single center worldwide, we studied 14 paired skin biopsies from sentinel flaps (SF) and facial allografts (FA) during rejection and non-rejection. We previously identified 15 pro-inflammatory genes (including GZMB, HLA-DPB1, IFNG) and 15 immunoregulatory genes (including SOCS1, CTLA4, IDO1) upregulated in VCA rejection. SF and FA had an average correlation coefficient of 0.88 and 0.76 for pro- and anti-inflammatory gene sets, respectively. During rejection, there was no significant difference in expression of the 15 pro-inflammatory genes between tissue type (SF versus FA), and only one immunoregulatory gene (PDCD1) was significantly different. Across all samples, there were 64 differentially expressed genes (DEG) between rejection and non-rejection, 13 DEG between tissue types, and only 2 DEG when statistically accounting for differences in tissue type driven by rejection status (log2FC>1, p<0.05). High throughput sequencing (HTS) of the CDR3 of TCR-β genes from 4 matched pairs during rejection identified a mean of 9.5 expanded shared T cell clones, indicating that shared antigens drove rejection in both tissues. Together, these data indicate that SF could serve as effective remote-site monitoring for face transplant rejection. NIH T32 Training Grant 2T32AR007098-47 Dept. of Dermatology, Harvard Medical School RT170025 (P.I. Rachael A. Clark) Department of Defense - congressionally Directed Medical Research Programs; "T cells and Rejection in Vascularized Composite Allografts).

Usefulness of Reverse Radial Forearm Flaps in Covering Soft Tissue Defects of Hand and Wrist

Aim: To emphasize on the importance of reverse radial forearm flap (RRF flap) in the coverage of soft tissue defects of hand and wrist. Study design: This is a descriptive experimental study. Study place and duration: Study was comprised on the period of six months from January 2022 to June 2022. It was conducted in the plastic surgery department of Allama Iqbal Memorial Teaching Hospital Sialkot Methodology: Patients with the soft tissue defects of hand and wrist due to road traffic accidents, industrial or mechanical trauma and firearm injury were admitted to the plastic surgery ward. After achieving healthy wound with wound debridement, soft tissue coverage was done using reverse radial fasciocutaneous forearm flap. Patients with amputation of thumb and those with partial or complete bone loss were excluded from the study. Ages of the patients were 17-50 years with mean age of 31.42±5.3 years. Donor site of the flap was covered with split thickness skin graft and follow-up of the patients was done for at least three months. Results: 20 cases were included in this study including 16(80%) male and 04(20%) female cases. 15(75%) cases had soft tissue defect on the dorsum of hand, 04(20%) cases had palmar defect and in 01(5%) case there was amputation at transmetacarpal level and flap coverage of the stump was done. Partial loss of the flap happened in one 01(5%) case and it was treated with debridement and skin coverage. In one case superficial epidermolysis was found and managed conservatively. Practical implication Conclusion: Reverse radial forearm fasciocutaneous flap is an excellent option for the coverage of soft tissue defects of hand and wrist due to its greater arc of rotation which makes it easy to apply to the recipient site. Key words: Hand trauma, Soft tissue defects of hand, Reverse Radial Forearm Flap, Flap Coverage of Hand

The arterialised saphenous venous flow-through flap for managing the radial forearm free flap donor site.

BackgroundThe radial forearm fasciocutaneous flap (RFFF) is a workhorse flap, however concerns with donor site morbidity include tendon exposure, delayed wound healing, impaired sensitivity, and poor cosmesis, have seen it fall out of favor. We present a method of using an arterialised saphenous flow through flap to reconstruct the RFFF donor site.MethodA cohort study of six patients (five male, one female; mean age 59 [range 19–90]) who had their RFFF donor site reconstructed with an arterialised saphenous flow through flap is presented. The use of multiple peripheral efferent venous anastomoses, flap rotation 180 degrees prior to inset, and the ligation of intra‐flap connecting veins were three modifications employed. Primary outcomes include complication rates. Secondary outcomes were patient reported outcome measures via the Michigan Hand Outcomes Questionnaire, and patency and flow through the flap.ResultsIn all six cases, there was flap survival. RFFF dimensions ranging from lengths of 6–15 cm (mean 11.5 cm) and widths of 4–6 cm (mean 5.3 cm), with an average flap area of 58 cm2 (range 24–90). There were no total flap losses, one partial superficial flap loss and one minor donor site delayed healing, over a mean follow‐up of 6 months (4–24 months). The average overall patient satisfaction was 91 on Michigan Hand Outcomes Questionnaire. Pain was well tolerated with a low average pain score of 15.ConclusionThe modified arterialised saphenous flow through flap is a useful option for reconstructing the soft tissue defect and reconstituting the radial artery after RFFF harvest.

Local Immunosuppression for Vascularized Composite Allografts: Application of Topical FK506-TyroSpheres in a Nonhuman Primate Model.

Transplantation of vascularized composite allografts (VCAs) provides a means of restoring complex anatomical and functional units following burns and other disfigurement otherwise not amenable to conventional autologous reconstructive surgery. While short- to intermediate-term VCA survival is largely dependent on patient compliance with medication, the myriad of side effects resulting from lifelong systemic immunosuppression continue to pose a significant challenge. Topical immunosuppression is therefore a logical and attractive alternative for VCA. Current formulations are limited though, by poor skin penetration but this may be mitigated by conjugation of immunosuppressive drugs to TyroSpheres for enhanced delivery. Therefore, we investigated the topical application of FK506-TyroSpheres (in the form of a gel dressing) in a clinically relevant nonhuman primate VCA model to determine if allograft survival could be prolonged at reduced levels of maintenance systemic immunosuppression. Six Major Histocompatibility Complex (MHC)-mismatched cynomolgus macaques (Macaca fascicularis) served as reciprocal donors and recipients of radial forearm fasciocutaneous flaps. Standard Bacitracin ointment and FK506-TyroSpheres were applied every other day to the VCAs of animals in groups 1 (controls, n = 2) and 2 (experimental, n = 4), respectively, before gradual taper of systemic FK506. Clinical features of VCA rejection still developed when systemic FK506 fell below 10 ng/ml despite application of FK506-TyroSpheres and prolonged VCA survival was not achieved. However, unwanted systemic FK506 absorption was avoided with TyroSphere technology. Further refinement to optimize local drug delivery profiles to achieve and maintain therapeutic delivery of FK506 with TyroSpheres is underway, leveraging significant experience in controlled drug delivery to mitigate acute rejection of VCAs.

Usage of Reversed Radial Forearm Flap for Reconstruction of Hand and Wrist Defects

Objectives: To highlight the usefulness of reverse radialforearm fasciocutaneous flap in covering various soft tissuedefects of hand and wrist.Study Design: Descriptive, experimental study.Setting: Department of Plastic & Reconstructive Surgery,Tanta University Hospitals.Material and Methods: A total of 15 reverse radial forearmflaps were utilized to cover various soft tissue defects of handand wrist from various etiologies including road traffic accidents,mechanical trauma, and industrial trauma and fireworksinjuries were included. Patients with segmental bone loss andthose patients having partial of complete amputation of thumbwere excluded. The age ranged from 22-43 (mean 22.5) years.Soft tissue defects of dorsum were covered with this flap in7 cases, 3 cases on palmer aspect and 5 cases for 1st webspace and the index finger defects each. Patients were followedfor at least three months post-operatively.Results: We had partial loss of flap in two cases that wasmanaged with debridement and skin grafting. Superficialepidermolysis was found in one case and managed conservatively.Donor site was skin grafted in 13 cases, which washealed uneventfully and quite acceptable to the patients indue course of time and direct clousure in 2 cases.Conclusion: Reverse radial artery flap has a quite longarc of rotation, which brings it great ease to cover the softtissue defects of various areas of hand like palm, dorsum,first web space.

REVERSE RADIAL FOREARM FLAP

Objectives: To highlight the usefulness of reverse radial forearm fasciocutaneous flap in covering various soft tissue defects of hand and wrist. Study Design: Descriptive, experimental study. Setting: Department of Plastic & Reconstructive Surgery, Dow University of Health Sciences & Dr Ruth KM Pfau Civil Hospital Karachi. Period: December 2016 to January 2018. Material & Methods: A total of 16 reverse radial forearm flaps were utilizedto cover various soft tissue defects of hand and wrist from various etiologies including road traffic accidents, mechanical trauma, and industrial trauma and fireworks injuries were included. Patients with segmental bone loss and those patients having partial of complete amputation of thumb were excluded. The age ranged from 18 – 45 (mean 29.25) years. Soft tissue defects of dorsum were covered with this flap in 8 cases, 4 cases on palmer aspect and 2 cases for transmetacarpal level and 1st web space defects each. Donor site was covered with split skin graft in all cases. Patients were followed for at least three months postoperatively. Results: We had partial loss of flap in two cases which was managed with debridement and skin grafting. Superficial epidermolysis was found in one case and managed conservatively. Donor site was skin grafted in all cases which was healed uneventfully and quite acceptable to the patients in due course of time. Conclusion: Reverse radial artery flap has a quite long arc of rotation, which brings it great ease to cover the soft tissue defects of various areas of hand like palm, dorsum and first web space.

Prevention and management of bacterial infections of the donor site of flaps raised for reconstruction in head and neck surgery

PurposeIn the field of reconstructive head and neck surgery, surgical site infections (SSI) are commonly investigated for the recipient site of various reconstructive procedures. Data about SSI of the donor site of different flaps raised for reconstruction are rare. Material and MethodsWith regard to the bacterial donor site infections, we retrospectively investigated the medical data, surgical reports and wound management protocols of 267 patients who received reconstruction of the head and neck after ablative surgery. All patients underwent reconstruction with one of the following flaps: free fasciocutaneous radial forearm flap (RFFF), free fasciocutaneous anterolateral thigh flap (ALTFF), pedicled myocutaneous latissimus dorsi flap (PLDF), pedicled myocutaneous pectoralis major flap (PPMF), free osteocutaneous fibula flap (FFF). Follow-up was conducted for 12 months. ResultsThe lowest detection ratio (DR: number of infected sites/flaps raised from the respective donor site) was calculated for the radial forearm, 0.087. Pedicled flaps presented a moderate DR (PLDF: 0.27, PMMF:0.35). Donor sites of the leg possessed the highest DR (ALTFF:0.61, FFF: 045). Mainly gram-positive facultative anaerobic bacteria (n = 41) were detected and gram-negative bacteria (aerobe/anaerobe) were present in 27 cases. The most frequently detected bacteria were Staphylococcus spp., Viridans Streptococci, Pseudomonas aeruginosa and Escheria coli. Continuous wound management for in-hospital patients was able to prevent any local spreading or a prolonged length of in-hospital stay. ConclusionOverall, gram-positive facultative anaerobic bacteria, mainly Staphylococcus spp., are the predominant bacteria detected in donor site wounds. For wound care management, an infection with gram-negative pathogens should not be neglected.

The Reverse-flow Radial Forearm Flap for Soft Tissue Reconstruction of the Wrist and Hand

Soft-tissue injuries of the hand and wrist regions are quiet common casualty. Flap coverage is often required to achieve primary wound closure and to achievea good functional result. The use of the reversed flow radial forearm fasciocutaneous flap in the reconstruction of the hand and wrist soft tissue defectshas been described by many authors to be an easy-to-learn and very versatile technique in hand injuries and reconstruction.In this report, the anatomy and vascular basis of the reversed flow radial forearm flap are presented along with the evaluation of its application in twenty patients with different hand and wrist soft tissue defects.

Combined Direct and Indirect Cerebral Revascularization Using Local and Flow-Through Flaps.

Extracranial-intracranial bypass is indicated in ischemic disease such as moyamoya, certain intracranial aneurysms, and other complex neurovascular diseases. In this article, we present our series of local and flow-through flaps for cerebral revascularization as an additional tool to provide direct and indirect revascularization and/or soft tissue coverage. A retrospective review of a prospectively maintained database was performed identifying nine patients. Ten direct arterial bypass procedures with nine indirect revascularization and/or soft tissue reconstruction were performed. Indications for arterial bypass included intracranial aneurysm (n = 2) and moyamoya disease (n = 8). Indications for soft tissue transfer included infected cranioplasty (one) and indirect cerebral revascularization (eight). Four flow-through flaps and five pedicled flaps were used including a flow-through radial forearm fasciocutaneous flap (one), flow-through radial forearm fascial flaps (three), and pedicled temporoparietal fascial (TPF) flaps with distal end anastomosis (five). The superficial temporal vessels (seven) and facial vessels (two) were used as the vascular inflow. Arterial bypass was established into the middle cerebral artery (six) and anterior communicating artery (three). There were no intraoperative complications. All flaps survived with no donor-site complications. In one case of flow-through TPF flap, the direct graft failed, but the indirect flap remained vascularized. Local and flow-through flaps can improve combined direct and indirect revascularization and provide soft tissue reconstruction. Minimal morbidity has been encountered in early outcomes though long-term results remain under investigation for these combined neurosurgery and plastic surgery procedures. The level of evidence is IV.

Functional Outcomes and Complications of Robot-Assisted Free Flap Oropharyngeal Reconstruction.

Robotic surgical systems provide a clear, magnified 3-dimensional visualization as well as precise, stable instrumental movement, thereby minimizing technical difficulties that may be encountered in the surgical treatment of oropharyngeal tumors. This study assessed the outcomes of robotic-assisted free flap oropharyngeal reconstruction compared with those of conventional free flap reconstruction. A retrospective review of 47 patients who underwent reconstructive operations using a free radial forearm fasciocutaneous flap for oropharyngeal defects was conducted over a 20-month period (May 2013-December 2014). Complications were evaluated for a robot-assisted reconstruction group and a conventional reconstruction group; postoperative complication rates and revision rates were further evaluated. The Functional Intraoral Glasgow Scale (FIGS) was adopted for functional outcome assessment. This study recruited 47 people who underwent reconstructive operations using a free radial forearm fasciocutaneous flap for oropharyngeal defects (14 robot-assisted and 33 conventional reconstructions). The mean postoperative FIGS score was 10.29 ± 2.02 in the robot-assisted group (P = 0.010) and 8.42 ± 2.29 in the conventional group at 1 month postoperatively. The mean postoperative FIGS score was 12.57 ± 1.91 in the robot-assisted group (P = 0.005) and 9.91 ± 3.09 in the conventional group at 3 months postoperatively. Complication rates between the robot-assisted and conventional groups were similar for flap failure (P = 0.531), partial necrosis, wound infection, hematoma or seroma formation (P = 0.893), wound dehiscence, and fistula formation (P = 0.515). The number of flap revision operations requiring additional surgery (P = 0.627) was comparable between the cohorts. There is no significant difference in complications or revision rates between the robot-assisted and conventional oropharyngeal reconstructions. The functional postoperative outcomes of robot-assisted reconstructions are superior to those of conventional reconstructions. Robotic surgical systems provide a safe option with optimal postoperative oral function for the free flap reconstruction of oropharyngeal defects without lip or mandible splitting.

Comparison of morbidity after reconstruction of tongue defects with an anterolateral thigh cutaneous flap compared with a radial forearm free-flap: a meta-analysis

Currently the radial forearm fasciocutaneous flap and the anterolateral thigh flap are among the most popular free flaps used for reconstruction of oral soft tissue. However, there is controversy about their efficacy after reconstruction of tongue defects because of their respective intrinsic properties, so we have compared them in reconstruction of tongue defects using meta-analysis. We conducted a search in Pubmed, EMBASE, OVID, Science Direct, the Cochrane Library, and Chinese National Knowledge Infrastructure, which covered all papers published before January 2015. Twelve clinical papers, that included 366 patients with 198 radial forearm flaps and 168 anterolateral flaps, met the criteria. Relevant data were extracted and analysed using systematic meta-analyses. The results showed that the incidence of localised numbness at the donor site of the radial forearm flap postoperatively was significantly higher and satisfaction with the appearance of the donor site significantly lower than in the anterolateral thigh group. There were no differences in flap survival, incidence of vascular crises in the flap, complications, satisfaction with the appearance of the tongue, or the postoperative clarity of speech and swallowing ability. Results suggested that the anterolateral thigh flap is the ideal soft tissue flap for reconstructing defects in the tongue, as there was minimal numbness at the donor site and patients were much more satisfied. Further research is needed to address details of the site and the extent of surgical defects as well as the relations between dissection of the radial flap and repair of the skin graft.

Management of recurrent carpal tunnel disease with reverse radial forearm fasciocutaneous flap and external neurolysis

Management of recurrent carpal tunnel disease with reverse radial forearm fasciocutaneous flap and external neurolysis

The Radial Forearm Fasciocutaneous Free Flap for Head and Neck Reconstruction

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.

Autonomization of free flaps in the oral cavity: A prospective clinical study

Controversy exists over how long a free flap is dependent on its pedicle and if neovascularization is different between flap types, recipient sites, and irradiated and nonirradiated patients. An understanding of the timing of this process should optimize the safety of secondary procedures involving the flap. In a prospective clinical study, hemoglobin oxygenation and capillary flow were measured in 50 flaps (25 forearm flaps, 15 osteocutaneous fibula flaps, and 10 anterolateral thigh flaps) 4 and 12 weeks postoperatively. The flaps were located at the floor of the mouth, cheek, or tongue (n = 39) or at the hard or soft palate (n = 11). Measurements were carried out using the O2C monitoring system under temporary digital occlusion of the pedicle. After 4 weeks, 17 free flaps were found to be autonomized indicated by the O2C measurements comparing both values before and after digital compression of the vascular pedicle. After 12 weeks, 41 patients had completion of free flap autonomization, as indicated by the HbO(2) and CF before and after pedicle compression. The location of free flap in the lower jaw (P < 0.0001 after 4 weeks, P = 0.013 after 12 weeks), fasciocutaneous radial forearm flaps after 4 weeks (P < 0.0001), and not irradiated recipient site after 4 weeks (P = 0.014) were found to be positive factors significantly influencing autonomization. In conclusion, free flap autonomization depends on several variables which should be considered before further surgery after free flap reconstruction as the transferred tissue can be still dependent on its pedicle.

Free Radial Forearm Fasciocutaneous Flap in the Treatment of Distal Third Tibial Osteomyelitis

Osteomyelitis of the lower limb, associated with soft-tissue defects, is a reconstructive challenge. Microvascular free-tissue reconstruction is an important surgical option with the superiority of free muscle and myocutaneous flaps being explored by various publications. Muscle flaps provide good quality vascularized tissue which can be contoured into defects, but their bulk can often lead to the reconstruction having a suboptimal aesthetic outcome. This result is usually most evident in the lower third of the tibia. We present our series of free radial forearm fasciocutaneous flaps for reconstruction of distal third tibial soft-tissue defects following debridement of osteomyelitic foci and bony stabilization. A retrospective case-note review of 20 patients treated with free radial forearm fasciocutaneous flap reconstruction of distal third tibial soft-tissue defects following excision of osteomyelitis and adjacent scar tissue, and bony stabilization between January 1999 and December 2006 was conducted. There were 20 patients who had established osteomyelitis of the distal third of tibia following previous open fractures. The mean size of the soft-tissue defect at the time of the free fasciocutaneous flap procedure was 72.3 cm(2) and the mean bony defect was 3.4 cm. The mean duration of the procedure was 417 minutes and flap ischemia time did not extend beyond 60 minutes in any of the cases. Overall flap survival was 100% and all patients had radiologic bony union at a mean of 5.73 months. The average period of follow-up was 22.5 (range, 19-36) months, and none of the patients had a recurrence of the disease during the follow-up period. Free fasciocutaneous flap reconstruction for soft-tissue defects of the lower limb in our series was seen to be safe, reliable, and provided an aesthetic outcome with high patient satisfaction rates. We advocate the use of free fasciocutaneous flaps for small-to-moderate sized defects of the distal third of the tibia after debridement for chronic osteomyelitis. Although we have used radial forearm flaps in our series, more modern free fasciocutaneous flaps with less donor-site morbidity may be preferred.

First Results of the Free Flap Transfer for the Head and Neck Reconstruction: The Public Hospital Experience

ABSTRACTThe aim of the study is to assess our first results with the free flap transfer. Since October 2006 through April 2012, 58 operations were performed. The upper digestive tract was reconstructed in 46 cases, the soft tissues and skin of the head and neck region—in 12 cases. The primary plasty was performed in all but two cases. Eighteen first cases were performed with 2. 5 and 4x binocular loupes magnification only. The operating microscope was used in 40 cases. Fourty-two radial forearm fasciocutaneous flaps, five latissimus dorsi musculocutaneous flaps, nine anterolateral thigh flaps, one scapular osteocutaneous flap were used with the single case of the visceral flap— the jejunal flap. Death in early postoperative period occurred once. Complete flap loss occurred six times. Five radial and one latissimus dorsi free flaps were lost. The arterial thrombosis is considered as the primary cause of failure in one case, venous thrombosis—in two cases, postoperative infection—in one case with remaining two cases of the unknown primary cause of failure. There were three cases of the revision surgery with the attempts to reperform venous anastomosis, one of them was successful. The overall success rate in this series is 87.9%. Most of the failures occurred early in the series. The main cause of such a low rate of the success is a lack of experience. Even in a so small number of patients the results significantly improved from 72.2 to 94.4%.How to cite this articleKarpenko A, Roman L, Chumanikhina N, Kostyuk I, Sibgatullin R, Belova E, Evdokimova N, Dzhalilov First Results of the Free Flap Transfer for the Head and Neck Reconstruction: The Public Hospital Experience. Int J Head Neck Surg 2012;3(2):66-72.

Assessment of Donor Site Morbidity for Osteocutaneous Radial Forearm Free Flaps

Objective: 1) Assess donor site morbidity following harvest of osteocutaneous radial forearm free flaps (OCRFF). 2), Evaluate patient perceived upper limb disability for osteocutaneous vs fasciocutaneous radial forearm free flaps Method: Retrospective cross-institutional review of OCRFF performed between 2001 and 2010. There were 218 included patients. The primary outcome measure was forearm donor site morbidity. The Disability of the Arm, Shoulder and Hand (DASH) questionnaire was used to compare patient perceived arm disability for osteocutaneous vs fasciocutaneous radial forearm flaps. Results: Mean patient age was 63 years with a male predominance (63%). The left arm was the donor site in 86%. Median bone length harvested was 8 cm (range, 3-12 cm). Following harvest, the radius was plated in 99% of patients. Recipient sites primarily included the mandible (62%) and maxilla (34%). Donor site morbidity included fracture (2 patients, 0.9%) and sensory neuropathy (5 patients, 2%). Fractures were treated with open reduction and internal fixation without functional deficits. Hardware extrusion was the most common complication at the recipient site (29 patients, 13%). Conclusion: Reluctance to perform OCRFF by surgeons usually centers on potential donor site morbidity. However, we identified minimal objective or patient perceived donor site morbidity following harvest of OCRFFs.

Radical Parotidectomy: Reconstruction and Facial Reanimation

Objective: 1) Report a viable reconstructive alternative after parotid gland mucoepidermoid carcinoma resection, rendering a large facial defect and facial nerve paralysis. 2) Demonstrate the combination of temporalis muscle pedicled flap and microvascular fasciocutaneous radial forearm flap, fulfilling 3 purposes: bulk restitution, facial paralysis reanimation, and adequate skin replacement for acceptable aesthetics. Method: Facial defect was left after radical parotidectomy with facial nerve sacrifice, as well as masseter muscle, mandibular periosteum, and skin removal. Reconstruction of the large defect was achieved recurring to temporalis muscle transposition combined with fasciocutaneous radial forearm flap. Facial artery and vein were used for microvascular sutures. Results: The necessity of the head and neck surgeon to make aggressive interventions has enabled the usage of flaps for reconstruction of significant facial defects. Satisfactory results require careful 3-dimensional thought, adequate texture matching as well as functional restoration. The results showed that temporalis muscle transposition was a successful method for bulk restitution and reanimation of permanent facial paralysis in the resting position, including both eyelid and mouth, by tension provided to orbicularis ori and orbicularis oculi muscles. Fasciocutaneous radial forearm flap provided the best possible tissue color and contour restoration of skin due to its thin, pliable tissue. Conclusion: Radial forearm flap and temporalis muscle transposition combined offered a viable reconstructive option after radical parotidectomy resulting in acceptable aesthetic and functional outcomes. Radial forearm flap was a good choice for skin restoration. Temporalis muscle transposition proved to be adequate both for bulk restitution as for reanimation of facial paralysis.