Radial Forearm Fasciocutaneous Free Flap Research Articles

Double Free-Flap Reconstruction

To investigate the increasing use of double free flaps in the reconstruction of large head and neck defects. A 5-year retrospective medical record review in a large tertiary care head and neck oncology program. Prospectively collected functional data were also analyzed. Academic research. A consecutive series of 35 patients (24 men and 11 women; mean age, 57.7 years). The use of double free flaps in the reconstruction of large head and neck defects and prospective functional outcomes. The most common indication for surgery (n = 25 [71.4%]) was squamous cell carcinoma. The most common double free-flap combination (n = 22 [62.9%]) included an osteocutaneous fibular free flap with a fasciocutaneous radial forearm free flap. Objective evaluation by naive listeners demonstrated a mean single-word intelligibility score of 66.2% and a mean sentence intelligibility score of 84.8% in this group of patients. Modified barium swallow study results revealed no evidence of laryngeal penetration for swallowing liquid consistencies in 21 patients (60.0%), pudding consistencies in 30 patients (85.7%), and cookie consistencies in 32 patients (91.4%). With proper patient selection and planning and the use of 2 surgical teams, the length of surgery and complication rates are not significantly increased in double free-flap reconstruction. Furthermore, by using 2 free flaps, the best osseous and soft-tissue elements may be independently selected, yielding appropriate tissue characteristics for ideal defect reconstruction.

Application of radial forearm free flap in extraoral soft tissue head and neck reconstruction

Radial forearm free flap, highly regarded in head and neck reconstructive surgery, is known to be one of the most reliable and versatile flaps. The aim of this study was to illustrate the versatility and reliability of a radial forearm flap in reconstruction of a variety of extraoral head and neck defects. During a period 2001-2007 at the Clinic for Maxillofacial Surgery, Faculty of Dentistry and the Center for Burns, Plastic and Reconstructive Surgery in Belgrade, 19 patients underwent microsurgical reconstructions after extraoral tumor ablation in the head and neck region, using fasciocutaneous radial forearm free flap. The overall flap survival rate was 89.5%. The complications that appeared were one partial necrosis and one venous thrombosis that in spite of reanastomosis resulted in a complete flap failure. The donor site healed uneventfully in all patients, except one, who had a partial skin graft failure, that ended in a secondary skin grafting. For reconstruction in head and neck surgery, with the need for thin, pliable tissues and a long vascular pedicle, radial forearm flap still remains a primary choice. Because of their multiple advantages, free flaps from the radial forearm is a safe method for reconstruction of a variety of extensive extraoral soft tissue defects in the head and neck region.

Free radial forearm adiposo-fascial flap for inferior maxillectomy defect reconstruction

A free radial forearm fascial flap has been described for intraoral reconstruction. Adiposo-fascial flap harvesting involves few technical modifications from the conventional radial forearm fascio-cutaneous free flap harvesting. We report a case of inferior maxillectomy defect reconstruction in a 42-year-old male with a free radial forearm adiposo-fascial flap with good aesthetic and functional outcome with minimal primary and donor site morbidity. The technique of raising the flap and closing the donor site needs to be meticulous in order to achieve good cosmetic and functional outcome.

Free radial forearm adiposo-fascial flap for inferior maxillectomy defect reconstruction

ABSTRACTA free radial forearm fascial flap has been described for intraoral reconstruction. Adiposo-fascial flap harvesting involves few technical modifications from the conventional radial forearm fascio-cutaneous free flap harvesting. We report a case of inferior maxillectomy defect reconstruction in a 42-year-old male with a free radial forearm adiposo-fascial flap with good aesthetic and functional outcome with minimal primary and donor site morbidity. The technique of raising the flap and closing the donor site needs to be meticulous in order to achieve good cosmetic and functional outcome.

S110 – Free Tissue Transfer Reconstruction of Fistula after ACDF

Objectives Pharyngeal injury post-anterior cervical disc fusion (ACDF) repair is a well-recognized postoperative complication. It can lead to abscess formation, pharyngocutaneous fistula, and esophageal diverticulum. Various reconstructive procedures have been proposed, including primary repair or pedicled muscle flaps. In recalcitant cases, free tissue transfer can be used. We review our experience with patients undergoing free tissue transfer for repair of pharyngeal defects. Methods Retrospective data review from January 2002 to February 2008 of patients undergoing pharyngeal repair following ACDF surgery. Results 5 patients were identified for total of 6 reconstruction procedures. Presentation of the pharyngeal leak occurred from 8 days to 3 years after the ACDF procedure. 3 patients presented acutely with cervical abscesses requiring incision and drainage. 2 patients underwent hardware removal at the time of incision and drainage. 2 patients presented with dysphagia and a contained esophageal diverticulum. 4 of the patients underwent radial forearm fasciocutaneous free flap reconstruction, and 1 underwent anterolateral thigh musculocutaneous free flap reconstruction. One patient had a revision surgery for recurrent fistula formation after radial forearm free flap with rectus free flap reconstruction. There were no immediate postoperative leaks; however, on 1–51 months follow-up, 4 out of 6 cases developed a diverticulum, with one of them developing a second fistula. 3 out of 5 patients had no evidence of diverticulum or fistula at last follow-up, for a success rate of 60%. Conclusions Pharyngo-esophageal perforation following an ACDF approach is difficult to repair even with free tissue transfer.

Radial Fasciocutaneous Free Flap “Wrap-Around” Iliac Bone Graft for Hard Palate–Premaxilla–Nasal Septum Reconstruction

Sir: A 48-year-old healthy man presented with an advanced squamous cell carcinoma at the maxillary labial sulcus, expanding into the premaxilla and palate. There was no neck or distant metastasis. Surgery was staged over 2 consecutive days. Tracheostomy and extirpation of the tumor were performed first. Excision included the premaxillary alveolus, the hard palate and the adjacent labial sulcus mucosa, the nasal septum, and the lateral nasal walls, leaving a skeletal and soft-tissue defect measuring 5 × 5 × 3 cm (Fig. 1). The next day, the patient underwent bilateral supra-omohyoid neck dissections and reconstruction of the defect.Fig. 1.: The defect after bilateral subtotal maxillectomy.An en bloc segment of the iliac crest and the adjacent gluteal surface of the ilium were harvested as a nonvascularized bone graft. The ilium was burred down to a thin sheet of cortical bone to replace the bony hard palate. The iliac crest component was to become the alveolar process. A separate bone fragment, also from the crest, was fashioned to imitate the vomer component of the septum. This new “septum” was stabilized to the new “hard palate” using metal wires. This iliac bone graft was wrapped in a radial forearm fasciocutaneous free flap and oriented so the fascia of the flap would become the nasal lining and the skin paddle would replace the oral mucosa of the palate. This composite flap-graft was inset using wires (Fig. 2). The radial artery and cephalic vein were anastomosed with the facial artery and vein using 9-0 nylon.Fig. 2.: Design of the radial fasciocutaneous free flap wrapped around the reconstructed hard palate and nasal septum.Postoperative recovery was uncomplicated (Fig. 3). The final staging was a T4N1M0 premaxillary squamous cell carcinoma. Six months postoperatively, the patient developed a recurrence and is presently undergoing palliative chemotherapy.Fig. 3.: View of the patient 3 weeks postoperatively, before radiotherapy.Palatal reconstruction is challenging. Traditionally, obturators are the mainstay of reconstruction. Autologous tissues are preferred and result in better cosmetic and functional outcomes. Local flaps and regional flaps are frequently inadequate and multistaged, and leave poor secondary defects.1 Hatoko et al. first described the use of the radial forearm free flap for palatal reconstruction.2 Other free flaps are available, but all are too bulky.3–5 We found no example of simultaneous palatal and nasal septum reconstruction in the literature. Our technique is a good option for a large premaxilla, hard palate, and nasal septum defect. The forearm skin is a reasonable oral lining. The fascia is thin, provides revascularization of the bone graft, and becomes mucosalized. The “wrap-around” technique improves the bone graft’s take. Septum reconstruction is important to prevent nasal deformity. The iliac crest has sufficient bulk to support dental prostheses or implants. The relative ease of molding and shaping of this technique provides flexibility in design. Good oral function was achieved with no early fistulas; speech was intelligible and aesthetically excellent. The disadvantages are long operative time and high personnel demand. In summary, we were able to reconstruct the premaxilla, hard palate, and nasal septum simultaneously using a radial forearm fasciocutaneous free flap wrapped around a composite nonvascularized iliac bone. We believe that this is a good option to meet the structural, functional, and aesthetic needs of this complex defect. Tam Dieu, F.R.A.C.S. Ram Silfen, M.D. Laura Chin-Lenn, M.B., B.S. Michael Schenberg, F.R.A.C.D.S., F.D.S.R.C.S. James Leong, F.R.A.C.S. Department of Plastic and Reconstructive Surgery and Hand Surgery Southern Health Melbourne, Victoria, Australia

Incidence of donor site skin graft loss requiring surgical intervention with the radial forearm free flap

Many methods of managing the fasciocutaneous radial forearm free flap (RFFF) donor site have been described. Ideal management would be technically easy to perform, reliable, cost-effective, and prevent further complications. The clinical records of 54 consecutive patients undergoing RFFF surgery by the senior author were reviewed. Records were reviewed to identify donor sites with significant breakdown that required intervention. Fifty-four patients were identified. Only 1 patient had significant tendon exposure. A V to Y closure was performed. The site healed well following this procedure and no further intervention was required. No other donor site complications were noted in this group. The incidence of wound breakdown requiring surgical intervention at the RFFF donor site is less than 2% utilizing a simple technique of split thickness skin grafting, bolster, and short-term splinting. This study demonstrates the low donor site morbidity of the RFFF.

Urethral Reconstruction Using the Radial Forearm Free Flap: Experience in Oncologic Cases and Gender Reassignment

ObjectivesUrethra reconstruction in men remains a complex problem, particularly in patients who have had previous amputation for penile tumour or who have undergone gender reassignment. Many reconstructive techniques currently in use recreate the urethra but are prone to recurrent stricture formation and fail to achieve micturition with a good stream when standing. The authors propose using the radial forearm fasciocutaneous free flap as a single-stage technique of male urethral reconstruction. MethodsDuring 1999–2004, nine patients underwent microsurgical reconstruction of the male urethra using the radial forearm fasciocutaneous free flap. Three patients underwent urethral reconstruction following previous subcutaneous penectomy for penile cancer. Another six patients had urethral reconstruction performed after failure of primary urethra construction as part of their gender reassignment surgery. ResultsThe average age at the time of surgery was 35.1 yr (range: 22–55 yr) and average follow-up time was 41.8 mo (range: 13–55 mo). Flap reconstruction was successful in all cases, with no instances of free flap failure; however, two patients developed significant stenosis requiring revision, and no patients had postoperative fistula formation. Therefore, the success rate for urethral reconstruction after the first operation was seven of nine. Two patients with stenosis were treated operatively to release strictures with local flaps. Uroflowmetry demonstrated that these patients had satisfactory flow rates. ConclusionPatient satisfaction and objective studies have demonstrated that urethral reconstruction with the use of radial forearm free flap is a good reconstructive procedure particularly when the patients need an extensive and long urethral reconstruction.

Rectourethral fistula associated with two short segment urethral strictures in the anterior and posterior urethra: Single-stage reconstruction using buccal mucosa and a radial forearm fasciocutaneous free flap

Introduction We report a novel surgical technique used to repair a rectourethral fistula associated with two short-segment urethral strictures located in the anterior and posterior segments of the urethra in a patient with prior unsuccessful repairs. Technical Considerations The anterior urethral stricture was reconstructed with a ventral onlay of buccal mucosa in the exaggerated lithotomy position. In a modified prone position, the rectourethral fistula was repaired using the transrectal transsphincteric (York-Mason) technique and the posterior urethral stricture with a radial forearm fasciocutaneous free flap which was anastomosed to the inferior gluteal artery and vein. The coexistence of a rectourethral fistula and distal urethral stricture requires simultaneous repair, because the urethral pressure from the distal obstruction may compromise fistula closure. Reconstructive efforts should be tailored to minimize disruption of the urethral blood supply in patients with previous pelvic trauma. Rectal and urethral repairs should be separated by well-vascularized tissue to prevent fistula recurrence. Conclusions The radial fasciocutaneous flap may offer the reconstructive surgeon another surgical option for complex urethral stricture and rectourethral fistula reconstruction when the local blood supply is in question. Longer follow-up and more cases are needed to further evaluate the continued use of this technique.

Resurfacing the nasomaxillary cavity for management of epistaxis in Osler–Rendu–Weber disease

Recurrent massive epistaxes due to heriditary haemorrhagic telangectasia were managed in two patients by ablation of the mucosa of the nasal and maxillary cavities and resurfacing with radial forearm fasciocutaneous free flaps. Both patients had undergone multiple procedures attempting to control the epistaxes prior to the definitive procedures described. Both patients remained epistaxis free postoperatively and retained their nasal airways. Olfactory function was preserved in the second patient due to preservation of the superior turbinate and cribriform olfactory mucosa.

Resurfacing the nasomaxillary cavity for management of epistaxis in Osler–Rendu–Weber disease

Recurrent massive epistaxes due to heriditary haemorrhagic telangectasia were managed in two patients by ablation of the mucosa of the nasal and maxillary cavities and resurfacing with radial forearm fasciocutaneous free flaps. Both patients had undergone multiple procedures attempting to control the epistaxes prior to the definitive procedures described. Both patients remained epistaxis free postoperatively and retained their nasal airways. Olfactory function was preserved in the second patient due to preservation of the superior turbinate and cribriform olfactory mucosa.

Microvascular radial forearm fasciocutaneous free flap in hard palate reconstruction

The aim of this studyTo report the reconstruction of palatal defects by microvascular radial forearm fasciocutaneous free flap (RFFF) and to report patient's quality of life outcomes after this procedure. Material and methodsDuring the period 1990–2002, 30 cases of palatal defects were reconstructed using RFFF in our institution. RFFF allowed restoration of a vestibular sulcus to maintain dental prostheses. Outcome measurements included post-operative assessment of speech, swallowing and diet evaluation 6 months, 1 year and 2 years after reconstruction. Quality of life outcomes were measured 1 and 2 years post-reconstruction. ResultsRFFF surgery was successful in 28 cases. Six months after resection 28 patients reported satisfactory speech and swallowing. Two years after surgery, 92% (n=26) of patients resumed a normal diet. All patients underwent dental evaluation and 68% (n=19) of patients required dental rehabilitation over a post-operative period of 3–18 months. Patients self assessed their quality of life on a scale of 0–2. First year post-operatively, 21 patients reported a good quality of life (score=2). After the second year, 26 patients reported a good quality of life and the remaining two patients reported an intermediate quality of life (score=1) because they did not resume a normal diet. ConclusionRFFF for palatal reconstruction is a reliable technique and provides a definitive separation between oral and sinusonasal cavities. Furthermore, it improves quality of life by improving speech, swallowing and chewing. It should be considered an integral component of head and neck cancer therapy and rehabilitation.

Speech and swallowing following radial forearm flap reconstruction of major soft palate defects

Velopharyngeal function is often compromised by the resection and reconstruction of oropharyngeal and palatal tumours. While free tissue transfer has improved the outcomes of head and neck reconstruction. In general, palatal reconstruction remains a challenge. Velopharyngeal function was analysed in eight patients following microsurgical reconstruction of defects of between 50 and 100% of the soft palate. The radial forearm fasciocutaneous free flap was used in all cases. The outcome of reconstruction was analysed by patient questionnaire and with standardised tests of speech and swallowing function. Velopharyngeal function post-operatively ranged from poor to near normal. Poor function appeared due to the loss of active elevation and contracture of the reconstructed palate producing failure of velopharyngeal closure during swallowing and speech. The results emphasise the limitations of reconstruction of a dynamic structure such as the soft palate with the static fold of skin and soft tissue produced by a fasciocutaneous flap. The relatively poor results obtained suggest that an anatomical approach to soft palate reconstruction is inadequate and reduction of the calibre of the velopharyngeal aperture is required to compensate for the lack of mobility in the reconstructed palate.

Short-term functional donor site morbidity after radial forearm fasciocutaneous free flap harvest.

The existing literature on postoperative donor extremity function describes a spectrum of morbidity in the long term (>3 mo after surgery). However, the consensus is that there is minimal to no impact of flap harvest on patients' activities of daily living. No previous reports have examined functional donor site morbidity in the early postoperative period; such may affect patients' overall perioperative progress, especially with respect to donor extremity dominance. The authors' objective was to quantify functional morbidity of the donor site in radial forearm fasciocutaneous free flaps during the early postoperative period. Retrospective case series review. Patient data were obtained from hospital records of 12 consecutive patients who underwent head and neck reconstruction with radial forearm fasciocutaneous free tissue transfer over a 6-month period at a tertiary academic medical center. Functional results of each patient's donor extremity obtained preoperatively and at 5 to 8 days after surgery were determined by quantifying forearm supination and pronation, wrist flexion and extension, and sharp and dull hand sensations in radial, median, and ulnar nerve distributions. Mean patient age was 57 years (age range, 42-71 y). The nondominant extremity was the donor site in 9 of 12 patients. Using the paired two-tailed t test, statistically significant differences were demonstrated in preoperative versus postoperative forearm supination (P <.032), pronation (P <.006), wrist flexion (P <.000), and wrist extension (P <.000). Three of 12 patients demonstrated diminished sharp sensation in the "anatomical snuffbox" distribution. The authors describe statistically significant functional forearm and wrist range-of-motion morbidity associated with the harvest of a radial forearm fasciocutaneous free flap in the early postoperative period.

The ulnar fasciocutaneous free flap in head and neck reconstruction.

The radial forearm fasciocutaneous free flap has become the reconstructive tissue of choice for the majority of soft tissue defects in the head and neck. The forearm skin has many of the ideal soft tissue characteristics that optimize reconstruction and rehabilitation in these patients. The tissue is malleable, supple, and moldable in three dimensions; has a reliable pedicle; and can be harvested with a two-team approach. In some patients, the radial forearm cannot be used. An alternative is to use the adjacent tissue, which shares identical tissue characteristics. This tissue gets its vascular supply from the ulnar artery. The purpose of the report was to describe the authors' experience with the ulnar fasciocutaneous free flap in head and neck reconstruction. Prospective consecutive case series. Retrospective review of all patients undergoing ulnar fasciocutaneous free tissue transfer by a group of microvascular surgeons was performed. Thirty patients underwent free tissue transfer using the ulnar fasciocutaneous free flap. The male-to-female ratio was 3:1. Defects were located in the oral cavity (14), oropharynx (12), neck skin (1), and soft tissue of the lateral skull (3). The average size of the skin paddle that was transferred was 7 x 10 cm (range, 3 x 5 to 9 x 12 cm). The mean area of tissue that was transferred was 70 cm2 (range, 15-108 cm2). Vessel sizes were somewhat smaller than the comparable radial forearm. One patient had complete loss of the skin graft on the donor site. There were no median nerve or other wound-healing problems. Two flaps were lost in the postoperative period. Indications for use of the ulnar fasciocutaneous free flap were failed Allen's test (23), use of a less hairy part of the forearm (3), and surgical preference (4). The ulnar fasciocutaneous free flap has all of the tissue characteristics of the radial forearm flap. When a radial forearm flap cannot be used and forearm skin is desired, consideration of an ulnar fasciocutaneous free flap should be undertaken.

Management of advanced mandibular osteoradionecrosis with free flap reconstruction.

The purpose of this study was to assess the effectiveness of free tissue transfer for treatment of advanced mandibular osteoradionecrosis (ORN) in head and neck cancer patients. We reviewed 29 patients who were treated for advanced mandibular ORN by radical resection and reconstruction with free flaps at our institution. All patients had either failed to respond to conservative treatment, including hyperbaric oxygen therapy and debridement or had pathological fracture due to ORN. Twenty-four vascularized bone (17 fibula, five iliac, and two scapula), four rectus abdominis myocutaneous, and one radial forearm fasciocutaneous free flaps were used. The complications occurred in 6 of 29 patients (21%). A total of four flaps (14%) were lost. The mean follow-up was 2 years 9 months. All patients had complete resolution of ORN symptoms. No evidence of ORN recurrence was observed in any patient. For advanced osteoradionecrosis of the mandible, radical resection followed by reconstruction using free flap provides a reliable means of obtaining good wound healing with acceptable aesthetic and functional results.

A Prospective Comparison of Scalpel Versus Bipolar Scissors in the Elevation of Radial Forearm Fasciocutaneous Free Flaps

The radial forearm fasciocutaneous free flap has become the workhorse for reconstruction of head and neck ablative defects. A location distal to the head and neck allows this flap to be elevated concurrent with the ablation. Most commonly, the flap is elevated under tourniquet control. This involves a primary ischemic insult with a certain amount of hemorrhage after the tourniquet is released. Bipolar scissors are a new method of dissection. They may allow for a speedier dissection with a concomitant decrease in ischemic time. Their hemostatic properties may control hemorrhage after use of the tourniquet. A prospective study of patients undergoing radial forearm free flaps over a 12-month period at a tertiary care referral center was undertaken. Forty patients were entered into the study, flaps were elevated with scalpel (20) and with bipolar scissors (20). Mean time under tourniquet was 39 minutes (range, 30-56 min) with scalpel compared with 27 minutes (range, 21-31 min) with bipolar scissors (P <.001). Total mean time of elevation (including control of hemostasis and pedicle dissection) for scalpel elevation was 50 minutes (range, 35-61 min) compared with 32 minutes (range, 20-41 min) for bipolar scissors elevation (P <.001). Mean blood loss was 46 mL (range, 15-110 mL) in the scalpel elevation group compared with 14 mL (range, 0-50 mL) in the bipolar scissors elevation group (P <.001). Complications at the donor site were equal between groups. Bipolar scissors are a safe, efficient method for elevating radial forearm free flaps.

Radial forearm fasciocutaneous free-tissue transfer in ankle and foot reconstruction: review of 17 cases.

Seventeen patients who underwent soft-tissue reconstruction of various anatomic regions of the foot and ankle, using the radial forearm fasciocutaneous free flap, are reported. The procedures were performed between January, 1992 and December, 1998. Indications for reconstruction included diabetes and/or vascular insufficiency (four patients), soft-tissue defects (six patients), and chronic osteomyelitis (seven patients). The weight-bearing surface of the foot was involved in 16 patients. Defects ranged in size from 35 to 206 cm2 (mean: 86.2 cm2). At a mean follow-up of 3.8 years, the radial forearm flap was successful in all cases (100 percent). Flap complications included superficial infection (three patients), and minor wound dehiscence at the flap-leg-skin interface (two patients). Recurrent ulceration occurred in two patients; both were diabetics with weight-bearing flaps. Donor-site complications included partial skin graft loss with tendon exposure in one patient, which healed with conservative management. Recurrent or persistent osteomyelitis was not demonstrated in any of the patients. Of the 16 patients with weight-bearing flaps, 12 were ambulatory, three had limited ambulation, and one was non-ambulatory. Three patients required modified shoes. No debulking of the transferred flaps was necessary. The radial forearm flap is one of the preferred flaps for reconstruction of moderate-sized ankle and foot defects, for weight-bearing surfaces, and in the treatment of osteomyelitic and diabetic wounds. It meets most of the anatomic prerequisites for an ideal foot coverage; it also facilitates the restoration of normal foot contour, allowing patients to wear ordinary shoes. The flap provides a durable and stable weight-bearing plantar surface during ambulation, and achieves excellent aesthetic results; when used as a neurosensory flap, it permits adequate reinnervation.

Osteocutaneous radial forearm free flap: Its use without significant donor site morbidity

While the fasciocutaneous radial forearm free flap has gained increasing popularity, the osteocutaneous radial forearm free flap has been condemned because of a high rate of pathologic donor radius fracture. On the basis of studies that demonstrated increased strength in ostectomized radii after dynamic compression plating, we believed that internal fixation at the time of graft harvest would significantly reduce the incidence of donor radius fracture. This is a retrospective review of the first 54 patients undergoing osteocutaneous radial forearm free flap reconstruction of the head and neck at our institution; 52 underwent prophylactic plating of their donor radii. No clinically significant donor radius fractures have occurred in plated patients. Five asymptomatic fractures were discovered on routine radiographs and required no treatment. Objective evaluation of forearm range of motion and strength after graft harvest demonstrated excellent function compared with unoperated arms. Serial radiographs have shown remodeling and reconstitution of donor radii without localized osteopenia. (Otolaryngol Head Neck Surg 2000;123:711-7.)

Use of the radial forearm fasciocutaneous free flap and montgomery salivary bypass tube for pharyngoesophageal reconstruction.

Head and neck reconstructive surgeons involved in pharyngoesophageal reconstruction have several options available to repair the defect after partial or total laryngopharyngectomy. There is no uniform agreement among head and neck surgeons as to which of the most frequently used techniques offers the best results. A retrospective study was performed on 20 consecutive patients who had undergone reconstruction of the hypopharynx and cervical esophagus using a radial forearm free flap with Montgomery salivary bypass tube at the Massachusetts Eye and Ear Infirmary in Boston, Massachusetts, and St. Louis University, Department of Otolaryngology-Head and Neck Surgery between 1992 and 1996. This reconstruction was used for primary reconstruction after total or partial laryngopharyngectomy with cervical esophagectomy, partial pharyngectomy sparing the larynx, and for reconstruction of the stenotic neopharynx after laryngectomy. The overall rate of pharyngocutaneous fistula was 20%, and the rate of postoperative stricture was 10%. Of patients reconstructed with this technique, 85% were able to resume oral alimentation, whereas 15% remained G-tube dependent. Of the 18 patients who did not have their larynges remain intact, 6 were able to develop useful tracheoesophageal speech. The results of this study show that the radial forearm fasciocutaneous free flap in combination with the Montgomery salivary bypass tube is extremely useful for reconstruction of partial and circumferential defects of the hypopharynx and cervical esophagus.