Radial Forearm Flap Reconstruction Research Articles

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

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

Free radial forearm flapversuspectoralis major myocutaneous flap reconstruction of oral and oropharyngeal defects: a cost analysis

The free radial forearm flap has replaced the pedicled pectoralis major myocutaneous flap and it has become the 'workhorse flap' used by many head and neck reconstructive surgeons for soft tissue reconstructions. Cost implications of radial forearm flap reconstruction within the context of the overall health care in a particular system need to be investigated particularly before it is labelled as 'costly only'. Forty patients who underwent immediate free radial forearm flap reconstruction for oral or oropharyngeal soft tissue defects were matched with patients who underwent pectoralis major myocutaneous flap reconstruction for similar defects. The 2 years of which the overall management costs according to the hospital perspective were calculated were divided into four periods: operative period, the postoperative phase, follow-up during first year and follow-up during second year after discharge. The total costs within the first 2 years were comparable at approximately 50,000 Euros. The lower costs of hospital admission (24 days versus 28 days; P = 0.005) in the postoperative phase outweighed the higher costs of the surgical procedure (692 min versus 462 min; P < 0.005) in radial forearm flap patients when compared with pectoralis major flap patients. Oral and oropharyngeal reconstruction with radial forearm flap is not more costly than pectoralis major flap reconstruction. Given the better functional outcome and the present cost analysis, reconstruction of oral and oropharyngeal defects is preferably performed using free tissue transfer.

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

The use of the free radial forearm flap for reconstruction of pharyngoesophageal defects has been proven to be ideal in previous studies. However, how to monitor flap viability, when the flap is buried underneath the skin in head and neck surgery, still poses technical difficulties. A new method for monitoring the buried free radial forearm flap by using the distal radial vessel stump elevated over the skin was presented.

Proximal Forearm Flap Based on a Septocutaneous Vessel from the Radial Artery

The radial forearm flap has been a workhorse flap for soft-tissue or coverage reconstruction in the head and neck area. Although it has several major advantages, it requires sacrifice of the radial artery. In this article, the authors present their modification of harvesting a forearm flap based on a large septocutaneous branch of the radial artery in the proximal forearm with or without sacrificing the main radial artery. They name it the proximal radial forearm flap. From September of 2003 to March of 2004, a total of 14 free proximal radial forearm flaps were used for head and neck reconstruction in 12 patients. There was one female patient and 11 male patients. Their ages ranged from 32 to 85 years. The skin flap size ranged from 2.0 x 6.0 cm to 4.5 x 18 cm. All free proximal radial forearm flap reconstructions had immediate success. There were one delayed flap loss caused by wound infection and one death attributable to advanced medical disease. Six flaps were harvested with preservation of the radial artery trunk. Six of the eight radial arteries that were killed during flap harvest were repaired with a short segment (3 to 4 cm) of vein graft. The average diameter and length of the septocutaneous vessel of the proximal radial forearm flap was 0.73 mm and 3.3 cm, respectively. Two flaps were harvested in conjunction with the conventional free radial forearm flaps. Nine donor sites were closed primarily and five donor sites required skin grafts. The proximal radial forearm flap can be used successfully in head and neck reconstruction with the advantages of moving the donor site to the proximal forearm for better scar concealment and possible preservation of the radial artery trunk. The disadvantages of this flap are short pedicle length and small pedicle diameter when the radial artery is to be preserved.

Single free radial forearm flap for reconstruction of simultaneous head and neck cancers

Reconstructions of complex massive, especially separate defects are still challenges for plastic surgeons. Many authors have used multiple free flaps to reconstruct composite defects. In this report, we describe a simple technique to reconstruct two simultaneous but anatomically separate defects with one bipaddle free radial forearm flap with the vascular pedicle passing through a mandibular osteotomy.

Versatility and Reliability of Radial Forearm Flaps for Upper Extremity Reconstruction

The purpose of this study was to analyze the indications for the radial forearm flap in reconstruction of the upper extremity and to document any complications with the flap or donor site.

Early Use of a Mechanical Stretching Device to Improve Mandibular Mobility After Composite Resection: A Pilot Study

Cohen EG, Deschler DG, Walsh K, Hayden RE. Early use of a mechanical stretching device to improve mandibular mobility after composite resection: a pilot study. Objective To evaluate the use of a mechanical stretching device, the Therabite, for the early postoperative management of trismus in select patients. Design Prospective series of consecutive head and neck cancer patients. Setting Academic, tertiary referral center. Participants Seven patients with oropharyngeal carcinoma who underwent resection and radial forearm flap reconstruction. Five had midline mandibulotomy procedures for exposure. Six had radiation therapy (2 pre, 4 post). Interventions Patients were given a Therabite mechanical jaw mobilization device, were instructed in its proper use, and began using it within 6 weeks postoperatively. Main Outcome Measures Maximal interincisor opening (MIO) was measured at the beginning of use and at the most recent postoperative visit. A 5-question self-assessment telephone survey was administered on study completion. Results The average MIO was 30mm (range, 21–38mm) at the beginning of the study and 40mm (range, 30–57mm) at the last visit. Average gain in MIO was 10mm (range, 1–21mm). Four of 5 assessable patients had minimal or no limitation on overall quality of life relative to jaw opening. No complications were associated with use of the device. Two patients could not be located for follow-up. Conclusions The Therabite mechanical stretching device is effective and safe for the management of trismus in a select group of head and neck cancer patients after extensive ablation and complex reconstruction. Specifically, there were no adverse effects in the 5 patients who had undergone midline mandibulotomy.

Comparison of deltopectoralis flap and free radial forearm flap in reconstruction after oral cancer ablation

Defects in the head and neck resulting from ablation of oral cancer frequently lead to disabling functional and cosmetic deformities. Rehabilitation of patients with oral cancer can be an emotionally and technically challenging endeavor. Selection of the donor tissue is clearly dependent upon the defect that is to be reconstructed. The donor tissue should be of sufficient bulk and pliability to facilitate reestablishing contour and function. Regional flap and free flap have been the mainstays of reconstruction for surgical defects after ablation of oral cancer. The records of 77 patients in whom 49 deltopectoral (DP) flaps and 28 free radial forearm flaps (FRFF) were used were analyzed. The success rate of the DP flap was 89.8% and of the FRFF was 96.4%. The minor complication rate at the transplant site (fistula, dehiscence, hematoma) for the DP flaps was 22.4% and for the FRFFs was 14.3%. Overall complication rate at the transplant site for DP flaps was 32.7% and for the FRFFs was 17.9%. The incidence of partial loss of the donor-site skin graft was 4.1% for the DP flaps and 10.7% for the FRFFs. Overall complication rate at the donor site for DP flaps was 10.2% and for the FRFFs was 39.3%. DP flaps had better aesthetic and functional results at the donor site, than FRFFs. However, the DP flap is a staged procedure and results in prolonged hospitalization. In contrast to FRFF, performing a DP flap avoids the difficult technique of microanastomosis, and therefore reduces the donor-site complication rate and the operation time. Therefore, free flaps can not be routinely substituted for regional flaps, but they represent better reconstructive alternatives for specific and selected patients.

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.

Radial forearm flaps for reconstruction in hand surgery.

Thirty-seven patients were treated using distally-based island radial forearm flaps. There were 31 men and six women. Reconstructed sites involved the dorsum of the hand (n = 17), the thumb (n = 11), the fingers (n = 5), the first web (n = 3), and the palm (n = 1). Sensory flaps were transferred in 15 cases, osteocutaneous flaps in six, and tendocutaneous flaps in eight. All the flaps survived. There were five donor-site complications, but no functional disturbances. Three patients had symptoms of cold intolerance. There were no radial fractures. In the six cases with osteocutaneous flaps, a mean of 2.6 months (range 2-3) was needed to obtain bony union. Among the eight cases with tendocutaneous flaps, postoperative tenolysis was required in two cases, and finally seven achieved a satisfactory outcome. The mean moving 2-point discrimination of the sensory flaps was 13 mm.

The radial forearm flap as a carrier for the osteocutaneous fibula graft in mandibular reconstruction

According to the concept of a free flap carrier we transferred an osteocutaneous fibula graft after microanastomosis to a pedicled radial forearm flap for reconstruction of the lower face in a patient with a total occlusion of the left and a subtotal occlusion of the right common carotid artery. The fibula was osteotomized in three segments to form the new mandible, and the skin paddle was placed extraorally. An external fixation device was connected to the radial bone, and a halo frame was fixed to the skull, and the forearm was thus stabilized rigidly in a suitable position. After 2 weeks, serial occlusion of the pedicle was begun twice daily. Blood flow and haemoglobin oxygenation of the skin paddle were measured by laser Doppler flowmetry and photometry. At the 14th day of ischaemic preconditioning, the flap could tolerate 3h of occlusion. Then the carrier vessels and the forearm flap were excised. The flap survived completely based on neovascularization from the recipient site.

Severe atherosclerosis of the radial artery in a free radial forearm flap precluding its use

The free radial forearm flap is the most frequently used free flap for head and neck reconstructions. Survival of free flaps is dependent on adequate blood supply. A 69-year old woman was scheduled for excision of a T3N0M0 oropharyngeal carcinoma, neck dissections and reconstruction with a free vascularized radial forearm flap. During the operation it appeared that the entire radial artery was almost completely obstructed by atherosclerotic plaques precluding microvascular anastomosis. Despite systemic risk factors certain artery types are more prone to develop clinically manifest atherosclerosis. There are no reports on the pathology of the radial artery in free flap reconstructions. In head and neck cancer patients severe atherosclerosis of the radial artery is very rare, but if present makes free radial forearm flap reconstruction impossible. Therefore, in patients with risk factors for peripheral vascular disease screening for radial artery stenosis should be considered.

Primary closure versus radial forearm flap reconstruction after hemiglossectomy: functional assessment of swallowing and speech.

The authors compared the postoperative speech and swallowing function of six patients who underwent free radial forearm flap reconstruction after hemiglossectomy with that of six control patients who underwent primary closure of the defect. Clinical speech pathologic evaluations included the Fletcher time-to-time maximum repetition rate of syllables, multiple rhyme test, and overall quality and intelligibility of the patients' speech. Evaluation of swallowing included the duration of deglutition, bolus volume, and ingestion rate. Speech quality, including intelligibility and articulation, was better in patients with primary closure. However, the bolus volume and ingestion rate in deglutition were better in those with flap reconstruction. These results suggest that the flap adds bulk, thus improving pharyngeal clearance by maintaining the tongue-to-mouth roof contact that is necessary in the swallowing process. The nonfunctional flap, however, hinders articulation by restricting the mobility of the remaining portion of the normal tongue.

Videofluoroscopic Study of Swallowing Function in Hemiglossectomized Patients-Comparison of Primary Closure and Free Radial Forearm Flap Reconstruction

The swallowing function of patients who had undergone hemiglossectomy with either primary closure of the defect or radial forearm flap reconstruction were studied with videofluoroscopy. Patients with primary closure were unable to lift the tongue tip, had poor tongue-to-palate contact on initiating swallowing, premature spilling of the bolus into the pharynx, a large amount of barium stasis on the floor of the mouth, and prolonged oral transit time. With flap reconstruction, patients could easily lift the tongue and make good contact with the entire palate. They were able to seal the posterior pharyngeal sphincter by elevation of the reconstructed tongue, approximating it to the soft palate, so that premature spilling of the bolus rarely happened. Their swallowing pattern was nearly normal. Although the reconstructed flap is nonfunctional, it provides bulk and helps the remaining tongue to complete the swallow. Compared with primary closure of the tongue defect, free radial forearm flap reconstruction provides better swallowing function when more than 50% of the tongue is resected.

Do intraoral radial forearm free flaps re-mucosalise and is candida infection relevant?

Eleven patients, with a mean age of 57 years, who had undergone radial forearm flap reconstruction following the excision of intraoral carcinoma, underwent flap biopsy at a mean of 45 months postoperatively. Seven of the patients had received postoperative radiotherapy. In eight patients the clinical appearance of the flap was similar in colour to that of adjacent normal oral mucosa; the remaining flaps retained the appearance of normal volar forearm skin. Histological examination of the flaps showed varying degrees of telangiectasia and mild chronic inflammation. In only two patients was superficial infection by candida hyphae identified. Intraoral free flaps, although clinically resembling oral mucosa, retain histological features of skin, at least within the period under study. The erythematous clinical appearance was not correlated with the presence of chronic fungal infection, but reflected the presence of vascular repair tissue, telangiectasia and mild residual chronic inflammation.

Radial forearm and fibula free flap reconstruction after radical resection of head and neck malignancies

The incidence of head and neck cancer has been rapidly increasing in Hungary during the last decade. Most of these tumors are discovered in advanced stage, consequently, surgical removal of the tumor results in large complex defects in the soft tisses and bone elements of the face and neck. For optimal anatomical and functional reconstruction we perform free flap transfer in increasing number of cases. Between December 1993 and March 2001 in the Head and Neck Surgery Department of the National Institute of Oncology the defects after resection of head and neck tumors were reconstructed with free flaps in 85 cases. Radial forearm flap in 64 cases, fibula osteoseptocutaneous flap in 14 cases were used. In 87% of the patients the postoperative period was uneventful, the surgical complications were not more numerous than following traditional reconstructions. The average duration of operations became shorter by 2.5 hours during the last two years than before. In most of the cases we achieved good functional and esthetic results. The quality of life of the patients was excellent in 14%, almost normal in 73% and bad with serious problems of social life in 13%. It is surprising that there was no significant difference between the survival of neck node positive and negative patients. In our practice the replacement of large defects in the head and neck region with free flaps is a reliable and useful method for reconstruction.

頬部に原発したメルケル細胞癌を遊離皮弁で再建した１例

We recently treated case of Merkel cell carcinoma of the right cheek. The patient, an 83-year old japanese woman, complained of a nodule on her left cheek measuring 40×40×10mm. The tumor was a cutaneous nodule with reddish-purple overlying skin. Histologically, the tumor invaded the dermis and subcutaneous tissue and did not exend into the epidermis. The tumor cells were small sized and showed a monotonously uniform appearance. They had round nuclei and scant cytoplasm. We performed wide local excision, radical neck dissection and used the radial forearm flap for reconstruction of the right cheek.

Radial forearm flap donor-site complications and morbidity: a prospective study.

One-hundred patients undergoing radial forearm flap reconstruction in the head and neck over a 2-year period were followed prospectively to assess complications and morbidity associated with the radial flap donor site. Eighty-six patients were available follow-up at 3 months and 74 at 1 year (49 fasciocutaneous, 25 composite). Partial loss of the donor-site skin graft occurred in 14 patients (16 percent), with exposure of tendons in 11 patients (13 percent). Delay in healing of the split-thickness skin graft at the donor site occurred in 19 patients (22 percent). Fracture of the radius occurred in 6 of 35 patients with composite flaps (17 percent). Superficial radial nerve sensation was reduced in 24 patients (32 percent) at 1 year. Ten patients (14 percent) reported cold intolerance, and 21 patients (28 percent) complained of poor aesthetic result. Function of the donor arm was restricted in 8 patients (16 percent) in the fasciocutaneous group, in 7 patients (36 percent) in the composite group without fracture, and in all patients who had a fracture of the radius following harvesting of composite flaps. Detailed measurements of forearm circumference, grip strength, pinch strength, and wrist movements showed greater reduction in these parameters in patients reporting restricted function compared with those reporting normal function. It is concluded that there is a low incidence of long-term morbidity associated with fasciocutaneous flaps and a higher incidence with composite flaps. Fracture of the radius results in reduced function in all cases.

Application of free radial forearm flap in reconstruction of the face and oral cavity.

Application of free radial forearm flap in reconstruction of the face and oral cavity.

Free forearm flap in oral reconstruction. Functional outcome.

To examine functional outcome associated with free radical forearm flap reconstruction of oral cavity and oropharyngeal defects. Case series obtained from a head and neck clinic conducted at a regional cancer center. Patients underwent surgery at the associated tertiary care center. Thirty consecutive patients treated for oral and oropharyngeal malignant neoplasms staged from T1 to T4 were studied. Subjects were assigned to five groups based on the site and extent of their surgical resections, as specified on a resection template. All patients had undergone free radial forearm flap reconstruction of their surgical defects. Ten factors reflecting functional properties and processes of the upper aerodigestive tract were evaluated clinically or with videofluoroscopy or both. Near-normal and fair oral and oropharyngeal function wholly characterized the sample. Patients who underwent reconstruction of unilateral tongue, floor of mouth-ventral tongue, and retromolar trigone-buccal defects functioned well on most measures; the function of patients with anterior tongue-jaw and tongue base-tonsil defects varied. Functional outcome with free radial forearm flap reconstruction was favorable for three of five subgroups of oral and oropharyngeal cancer patients. Qualitatively different functional profiles emerged for subgroups based on resection site. Methodologic issues for research on surgical reconstruction and functional outcome include the need for a meaningful, reliable system of classifying oral and oropharyngeal resections, and the development of standardized procedures for evaluating functional outcome.