Osteocutaneous Radial Forearm Free Flap Research Articles

Comparing the Outcomes of Osteocutaneous Radial Forearm and Fibula Free Flaps in the Reconstruction of Mandibular Osteoradionecrosis.

This study compares the outcomes of osteocutaneous radial forearm free flap (OC-RFFF) and fibula free flap (FFF) reconstruction of mandibular osteoradionecrosis (ORN). Retrospective review of patients undergoing OC-RFFF/FFF reconstruction for mandible ORN between 2005 and 2020 at a tertiary center. Patient characteristics, postoperative complications, and functional outcomes were evaluated using chi-squared and logistic regression analysis. Fifty-six patients were included (OC-RFFF: 38; FFF: 18). Significantly more OC-RFFF patients had lateral mandible defects (94% vs. 61%, p = 0.0014). There were significantly more patients with exposed intraoral bone in the OC-RFFF group (23% vs. 0% p = 0.02), but no significant differences in hardware complications or flap failure. Donor site partial skin graft loss was more common in the FFF group (22% vs. 2.6%, p = 0.016), but no other significant differences in donor site morbidity were seen. Bivariable analysis showed no impact of flap type, tobacco/alcohol use, diabetes, or hypothyroidism on postoperative complications. Sixty percent of OC-RFFF, and 67% of FFF, patients resumed an oral diet after surgery. Oral diet was not impacted by flap type (OR = 0.769, 95% CI = 0.201-2.706, p = 0.688). The OC-RFFF is an acceptable option in the reconstruction of ORN involving the lateral mandible, though there is increased risk of bone exposure. These findings can help guide surgeon selection of microvascular free flap donor sites and appropriate patient counseling.

Recurrent Axis Chordoma after Carbon ion Therapy Necessitating Reconstructive Surgery with Osteocutaneous Radial Forearm Free Flap: A Case Report

AbstractChordomas originate from remnant tissue of the notochord during embryonic development, with a relatively low incidence rate. Furthermore, chordomas, being resistant to radiotherapy, are primarily treated by resection; however, in some cases, particularly in those that involve the skull base or upper cervical spine, chordomas are unresectable. In recent years, carbon ion/proton beam therapy has shown significant efficacy in such cases. However, it is not sufficiently curative and is commonly associated with recurrence. Moreover, there is no consensus regarding the treatment of recurrent cases, resulting in several uncertainties pertaining to it. Here, we present the case of a 55-year-old male patient with axial chordoma who experienced recurrence after carbon ion therapy and underwent tumor reduction surgery for a longer life span. Two months postoperatively, dehiscence was found in the posterior pharyngeal wall, probably due to heavy ion therapy. Salvage surgery was performed using an osteocutaneous radial forearm free flap, and the patient's postoperative course was uneventful.

The Complications of Osseous Reconstruction in the Head and Neck: A Systematic Review and Meta-analysis.

To compare the postoperative complications of the fibular free flap (FFF), scapula free flap (SFF), and osteocutaneous radial forearm free flap (OCRFFF) following osseous reconstruction in the head and neck. PUBMED, EMBASE, Cochrane. A literature search and systematic review were performed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. A meta-analysis of proportions was conducted using a random effects model to compare operative time and postoperative complications. The systematic review identified 26 studies comparing at least 1 variable of interest. The odds ratio estimates favored reduced rates of flap failure with the OCRFFF when compared to FFF (0.7, confidence interval [CI]: 0.29-1.11, P < .001), while FFF and SFF were similar. The mean difference estimates for operative time significantly favored FFF over SFF (-51.04 minutes, CI: -92.73 to -9.35, P = .016) and OCRFFF over FFF (66.77 minutes, CI: 52.74-80.8, P < .001). The FFF was more prone to hardware exposure, longer hospital stays, and donor site complications. Recipient wound complications and fistula rates were similar for all flap types. Depending on the clinical context, the OCRFFF, FFF, and SFF are all robust options for reconstruction in the head and neck. The OCRFFF is associated with a reduced rate of flap failure and shorter operative times. The SFF requires longer operative times, although significant variation was observed between institutions. The FFF has broad reconstructive indications but is associated with more perioperative and long-term complications.

Midface microvascular reconstruction after maxillary complex tumor resection: A retrospective study

The study purpose is to review the surgical approach and evaluate the results in managing patients with advanced midface and maxillary complex tumors.The most common anatomical site of the primary tumor was the maxilla, sometimes with extension to the orbit and anterior fossa, parotid and middle ear or even the lip. Surgical resection included maxillectomy in the majority of cases, combined with orbital exenteration or orbitectomy and anterior fossa resection. Parotidectomy and mastoidectomy/core petrosectomy were also performed. Reconstruction was performed with radial forearm osteocutaneous free flap, latissimus dorsi myocutaneous flap with scapular bone flap, lengthening temporalis myoplasty, rectus abdominis free flap, anterolateral thigh flap, in combination with temporalis and vastus lateralis, as well as pectoralis major myocutaneous flap.A total of 36 midface tumor excisions were performed, followed by the appropriate reconstruction. The average follow-up period was 15 years. To date, 23 patients are disease free, while 6 patients presented disease recurrence and 7 patients died during the 15-year follow-up period.Surgical resection remains the gold standard for midface tumors management. When safely performed, combined with microvascular and dynamic face reconstruction, surgery can offer improvement in quality of life and prolong the overall survival.

Comparing donor site morbidity in osteocutaneous radial forearm versus fibula free flap for mandibular reconstruction

PurposeThe osteocutaneous radial forearm free flap has gained popularity as a less morbid option for oromandibular reconstruction compared to the fibular free flap. However, there is a paucity of data regarding direct outcome comparison between these techniques. MethodsRetrospective chart review of 94 patients who underwent maxillomandibular reconstruction intervened from July 2012–October 2020 at the University of Arkansas for Medical Sciences. All other bony free flaps were excluded. Endpoints retrieved encompassed demographics, surgical outcomes, perioperative data, and donor site morbidity. Continuous data points were analyzed using independent sample t-Tests. Qualitative data was analyzed using Chi-Square tests to determine significance. Ordinal variables were tested using the Mann-Whitney U test. ResultsThe cohort was equally male and female, with a mean age of 62.6 years. There were 21 and 73 patients in the osteocutaneous radial forearm free flap and fibular free flap cohorts, respectively. Excluding age, the groups were otherwise comparable, including tobacco use, and ASA classification. Bony defect (OC-RFFF = 7.9 cm, FFF = 9.4 cm, p = 0.021) and skin paddle (OC-RFFF = 54.6 cm2, FFF = 72.21 cm2, p = 0.045) size were larger in the fibular free flap group. However, no significant difference was found between cohorts with respect to skin graft. There was no statistically significant difference between cohorts regarding the rate of donor site infection, tourniquet time, ischemia time, total operative time, blood transfusion, or length of hospital stay. ConclusionsNo significant difference in perioperative donor site morbidity was found between patients undergoing fibular forearm free flap and osteocutaneous radial forearm flap for maxillomandibular reconstruction. Osteocutaneous radial forearm flap performance was associated with significantly older age, which may represent a selection bias.

Comparison of patient-reported upper extremity disability following free flaps in head and neck reconstruction: A systematic review and meta-analysis.

Comparisons of patient-reported donor site morbidity based on the Disabilities in Arm, Shoulder, and Hand (DASH) instrument across upper trunk free flaps in head and neck surgery, including radial forearm (RFFF), osteocutaneous radial forearm (OCRFF), scapular tip (STFF), and serratus anterior (SAFF) free flaps, may help inform donor tissue selection. In this meta-analysis, 12 studies were included and the primary outcome was average DASH score. The pooled DASH scores were 12.14 (95% CI: 7.40-16.88) for RFFF (5 studies), 17.99 (11.87-24.12) for OCRFF (2 studies), 12.19 (8.74-15.64) for STFF (3 studies), and 16.49 (5.92-27.05) for SAFF (2 studies) and were not significantly different. Results suggest that patients generally function well, with minimal to mild donor site morbidity, when assessed at an average of 20 months after flap harvest. These results are based on few effects from primarily retrospective studies of fair quality, and further research is needed.

Patient-specific Prosthetic Appliance for Interim Management of Chronic Orocutaneous Fistula in the Irradiated and Vessel-depleted Head and Neck Patient – A Case Report and Technical Note

The formation and persistence of an orocutaneous fistula as a sequela of major head and neck surgery followed by microvascular reconstructive surgery and adjuvant radiation therapy is a common and frustrating challenge to address. When reconstructive surgical options are exhausted, limited, or with high risk for failure, the fabrication of an oral appliance can provide a temporary to long-term treatment option for the patient. In this case report, an oral appliance was fabricated to decrease salivary incontinence, improve intelligibility, and deglutition in a 60-year-old patient who underwent a subtotal glossectomy with radical mandibulectomy followed by reconstruction with an osteocutaneous radial forearm free flap who developed a chronic orocutaneous fistula following completion of radiation therapy.

Systematic Review of Donor Site Morbidity of the Osteocutaneous Radial Forearm Free Flap and the Role of Bone Grafting

Systematic Review of Donor Site Morbidity of the Osteocutaneous Radial Forearm Free Flap and the Role of Bone Grafting

Perioperative Outcomes in Patients Who Underwent Fibula, Osteocutaneous Radial Forearm, and Scapula Free Flaps

Studies comparing perioperative outcomes of fibula free flaps (FFFs), osteocutaneous radial forearm free flaps (OCRFFFs), and scapula free flaps (SFFs) have been limited by insufficient sample size. To compare the perioperative outcomes of patients who underwent FFFs, OCRFFFs, and SFFs. This cohort study assessed the outcomes of 1022 patients who underwent FFFs, OCRFFFs, or SFFs for head and neck reconstruction performed at 1 of 6 academic medical centers between January 2005 and December 2019. Data were analyzed from September 17, 2021, to June 9, 2022. Patients were stratified based on the flap performed. Evaluated perioperative outcomes included complications (overall acute wound complications, acute surgical site infection [SSI], fistula, hematoma, and flap failure), 30-day readmissions, operative time, and prolonged hospital length of stay (75th percentile, &gt;13 days). Patients were excluded if data on flap type or clinical demographic characteristics were missing. Associations between flap type and perioperative outcomes were analyzed using logistic regression, after controlling for other clinically relevant variables. Adjusted odds ratios (aORs) with 95% CIs were generated. Perioperative outcomes of 1022 patients (mean [SD] age, 60.7 [14.5] years; 676 [66.1%] men) who underwent major osseous head and neck reconstruction were analyzed; 510 FFFs (49.9%), 376 OCRFFFs (36.8%), and 136 SFFs (13.3%) were performed. Median (IQR) operative time differed among flap types (OCRFFF, 527 [467-591] minutes; FFF, 592 [507-714] minutes; SFF, 691 [610-816] minutes). When controlling for SSI, FFFs (aOR, 2.47; 95% CI, 1.36-4.51) and SFFs (aOR, 2.95; 95% CI, 1.37-6.34) were associated with a higher risk of flap loss than OCRFFFs. Compared with OCRFFFs, FFFs (aOR, 1.77; 95% CI, 1.07-2.91) were associated with a greater risk of fistula after controlling for the number of bone segments and SSI. Both FFFs (aOR, 1.77; 95% CI, 1.27-2.46) and SFFs (aOR, 1.68; 95% CI, 1.05-2.69) were associated with an increased risk of 30-day readmission compared with OCRFFFs after controlling for Charlson-Deyo comorbidity score and acute wound complications. Compared with OCRFFFs, FFFs (aOR, 1.78; 95% CI, 1.25-2.54) and SFFs (aOR, 1.96; 95% CI, 1.22-3.13) were associated with a higher risk of prolonged hospital length of stay after controlling for age and flap loss. Findings of this cohort study suggest that perioperative outcomes associated with OCRFFFs compare favorably with those of FFFs and SFFs, with shorter operative times and lower rates of flap loss, 30-day readmissions, and prolonged hospital length of stay. However, patients undergoing SFFs represented a more medically and surgically complex population than those undergoing OCRFFFs or FFFs.

Bone Union of Osseous Microvascular Free Tissue Transfer in Mandibular Reconstruction.

ObjectivesOsseous microvascular free tissue transfer (MFTT) is the gold standard for reconstruction for most segmental mandibulectomy defects. The most common osseous MFTT utilized in reconstruction is the fibular, scapular, and osteocutaneous radial forearm (OCRF) free flap. We evaluated postoperative bone union as well as clinical complications following MFTT and the impact of various patient and reconstructive characteristics, including type of osseous MFTT.Study DesignRetrospective cohort study.SettingTertiary care academic hospital.MethodsThis study examined patients who underwent osseous MFTT for mandibular defects from January 2017 to January 2019.ResultsAn overall 144 osteotomies in 58 patients were evaluated. Of the 144 junctions, 28 (19.4%) showed radiographic nonunion. Patients who underwent preoperative (odds ratio [OR] = 0.30, P = .027) and postoperative (OR = 0.28, P = .003) radiation had a significantly lower bone union score. Time from surgery to postoperative imaging was associated with higher bone union scores (OR = 1.07, P = .024). When bone union scores were compared among types of MFTT, fibular (OR = 5.62, P = .008) and scapular (OR = 4.69, P = .043) MFTT had significantly higher scores than OCRF MFTT. Twelve (20.7%) patients had postoperative complications. There was no statistically significant correlation between clinical complications and various variables, including type of osseous MFTT.ConclusionPre- and postoperative radiation and time from surgery have an impact on bone union. Regarding the type of MFTT, fibular and scapular MFTT appeared to have higher bone union when compared with OCRF. There was no impact of bone union or type of osseous MFTT on clinical complications.

Rates of bone reabsorption and union in mandibular reconstruction using the osteocutaneous radial forearm free flap.

Historical concerns over bone resorption and malunion of the osteocutaneous radial forearm free flap (OCRFFF) limited its widespread adoption for head and neck reconstruction, despite lack of outcomes data evaluating this notion. A retrospective cohort study was performed including patients 18 years or older who underwent reconstruction of the mandible using an OCRFFF. Linear modeling and logistic regression were used to evaluate the change in bone volume and union over time. One hundred and twenty-one patients were included in the study. A mixed effects linear model incorporating age, sex, treatment type, and number of bone segments did not demonstrate a significant loss of bone volume over time. A logistic regression model identified lack of adjuvant treatment and time to be significantly associated with complete union. This study supports that the OCRFFF is a stable form of osseus reconstruction for defects of the head and neck.

Complications in oncologic mandible reconstruction: A comparative study between the osteocutaneous radial forearm and fibula free flap.

The osteocutaneous radial forearm free flap (OC-RFFF) has been proposed as a safe and reliable free flap for head and neck reconstruction with low donor site morbidity. The purpose of this study is to compare the late complications (>30 days) associated with using the OC-RFFF versus the free fibula flap (FFF) for mandibular reconstruction following oncologic segmental resection. We conducted a single-institution, retrospective study composed of patients who underwent oncologic microvascular composite mandibular reconstruction with either the OC-RFFF or FFF. The primary predictor variable was the type of free flap used. The outcome variable was late complication postoperatively (>30 days). A total of 93 patients (28, OC-RFFF and 65, FFF) were analyzed. The majority of patients were male (62%) and with AJCC stage T4a disease (72%). Mean hospital length of stay was comparable between the two flap groups (p= .50). OC-RFFF was associated with more late complications (p= .03) compared to FFF. Nonunion occurred in 10.7% of OC-RFFF and 0% of FFF. Partial or complete flap failure was seen in 7.1% and 0% in the OC-RFFF and FFF, respectively. Two-year disease-free survival was comparable in both groups (p> .05). The results of this study suggest that the rate of nonunion and odds of having a late complication were significantly greater in the OC-RFFF compared to the FFF following oncologic mandibular reconstruction. However, flap success, early complications (<30 days), and length of hospital stay were comparable between the two flaps.

Outcomes and Utility of Intracranial Free Tissue Transfer.

Complications associated with intracranial vault compromise can be neurologically and systemically devastating. Primary and secondary repair of these deficits require an air and watertight barrier between the intracranial and extracranial environments. This study evaluated the outcomes and utility of using intracranial free tissue transfer as both primary and salvage surgical repair of reconstruction. A retrospective review was performed of all subjects who underwent intracranial free tissue transfer as primary or salvage repair. A total of 13 intracranial free tissue transfers were performed on 11 subjects: osteocutaneous radial forearm free flaps (n = 6), partial myofascial rectus abdominis flaps (n = 5), temporoparietal fascia flap (n = 1), and serratus anterior myofascial flap (n = 1). Primary reconstruction was performed on 4 subjects with the remaining being salvage repair. Indications for surgery included neoplasm (n = 6 of 11), ballistic trauma (n = 3 of 11), motor vehicle accident (n = 1 of 11), and infection (n = 1 of 11). Three subjects required additional surgical repair for CSF leak and pneumocephalus, with 2 subjects requiring an additional free tissue transfer at a different site. In our experience, free tissue transfer is an effective primary and salvage surgical technique in the reconstruction of complex intracranial problems.

Association of Virtual Surgical Planning With External Incisions in Complex Maxillectomy Reconstruction

Maxillectomy can commonly be performed through a transoral approach, but maxillectomy defect reconstruction can be difficult to precisely design, contour, and inset through this approach. To evaluate whether the use of virtual surgical planning (VSP) and 3-dimensional (3-D) modeling is associated with a decrease in the requirement of lateral rhinotomy (LR) for patients undergoing total and partial maxillectomy reconstruction. This retrospective cohort study was conducted among patients undergoing subtotal or total maxillectomy with microvascular free flap reconstruction with or without VSP and 3-D modeling at a single tertiary care academic medical center between January 1, 2008, and October 3, 2019. Maxillectomy and free flap reconstruction with or without VSP. Necessity of LR or other external incision for contouring, placement, and fixation of reconstruction as well as surgical complications. Fifteen patients (12 men [80%]; mean age, 64 years) underwent maxillectomy with free flap reconstruction without VSP. Eight patients (53%) in this group underwent total maxillectomy, and 4 patients in this group (27%) underwent partial maxillectomy. Twenty-three patients (18 men [78%]; mean age, 58 years) underwent maxillectomy with free flap reconstruction and VSP and 3-D modeling. Twelve of these patients (52%) underwent total maxillectomy, and 11 (48%) underwent partial maxillectomy. Lateral rhinotomy was necessary for 1 patient (4%) in the VSP group vs 12 patients (80%; 95% CI, 54%-98%) in the pre-VSP group. There were no LR complications in the VSP group vs 6 in the pre-VSP group. Among both groups, 14 patients underwent fibula free flap, 22 patients underwent subscapular system free flap, and 2 patients underwent cutaneous or osteocutaneous radial forearm free flap. There were no flap failures in the LR group and 1 flap failure in the group without LR. This cohort study suggests that the use of VSP and 3-D modeling for maxillectomy reconstruction is associated the a decrease in the need for external incisions without compromising reconstructive flap utility.

Osteocutaneous radial forearm free flap for anterior cranial base reconstruction: Technical note

The reconstruction of anterior skull base defects after carcinologic surgery is challenging. Large defects can require the use of autologous free tissue transfer. Currently, most reconstructions use soft-tissue flaps. We describe the use of an osteocutaneous radial forearm free flap to reconstruct a large defect secondary to a malignant paraganglioma extending into the anterior cranial fossa and both orbits. The surgical resection required endonasal and transcranial approaches. We reconstructed the defect with a free osteocutaneous radial forearm flap. We laid the bone flap across the defect, resting on the orbital roof on each side, and sutured the soft component to the edge of the dura. The pedicle was funnelled from the craniotomy to a prepared cervicotomy and the micro-anastomoses were performed onto the facial artery and two satellite veins. Potential indications and major drawbacks of this technique are briefly discussed. Osteocutaneous radial forearm free flaps can be a valuable reconstructive option for patients with a large defect of the anterior skull base, needing both rigid support and a watertight closure.

A lightweight cast to support the upper limb following osteocutaneous radial forearm free flap harvest: a technical modification

Introduction The osteocutaneous radial forearm free flap remains a valuable option in head and neck reconstructive surgery. It remains a back-up option for composite mandibular defects in cases where the composite fibular free flap is not suitable.

Lightweight cast to support the upper limb after harvest of an osteocutaneous free flap from the radial forearm: a technical modification

The osteocutaneous radial forearm free flap remains a valuable option in reconstructive surgery in the head and neck, and in Class VI midface or segmental mandibular reconstructions, particularly in older patients with multiple comorbidities.1,2

Outcomes and cost implications of microvascular reconstructions of the head and neck.

Critical review of current head and neck reconstructive practices as related to free flap donor sites and their impact on clinical outcomes and cost. Retrospective multicenter review of free tissue transfer reconstruction of head and neck defects (n = 1315). Variables reviewed: defect, indication, T classification, operative duration, and complications. A convenience sample was selected for analysis of overall (operative and inpatient admission) charges per hospitalization (n = 400). Mean charges of hospitalization by donor tissue: radial forearm free flap (RFFF) $127 636 (n = 183), osteocutaneous RFFF (OCRFFF) $125 456 (n = 70), anterior lateral thigh $133 781 (n = 54), fibula $140 747 (n = 42), latissimus $208 890 (n = 24), rectus $169 637 (n = 18), scapula $128 712 (n = 4), and ulna $110 716 (n = 5; P = .16). Mean operative times for malignant lesions stratified by T classification: 6.9 hours (±25 minutes) for T1, 7.0 hours (±16 minutes) for T2, 7.3 hours (±17 minutes) for T3, and 7.8 hours (±11 minutes) for T4 (P < .0001). Complications correlated with differences in mean charges: minor surgical ($123 720), medical ($216 387), and major surgical ($169 821; P < .001). Operations for advanced malignant lesions had higher mean charges: T1 lesions ($106 506) compared to T2/T3 lesions ($133 080; P = .03) and T4 lesions ($142 183; P = .02). On multivariate analysis, the length of stay, operative duration, and type a postoperative complication were factors affecting overall charges for the hospitalization (P < .018). Conclusion: The RFFF and OCRFFF had the lowest complication rates, length of hospitalization, duration of operation, and mean charges of hospitalization. Advanced stage malignant disease correlated with increased hospitalization length, operative time, and complication rates resulting in higher hospitalization charges.

Classification and Microvascular Flap Selection for Anterior Cranial Fossa Reconstruction.

Microvascular reconstruction of the anterior cranial fossa (ACF) creates difficult challenges. Reconstructive goals and flap selection vary based on the defect location within the ACF. This study evaluates the feasibility and reliability of free tissue transfer for salvage reconstruction of low, middle, and high ACF defects. A retrospective review was performed. Reconstructions were anatomically classified as low (anterior skull base), middle (frontal bar/sinus), and high (frontal bone/soft tissue). Subjects were evaluated based on pathologic indication and goal, type of flap used, and complications observed. Eleven flaps in 10 subjects were identified and anatomic sites included: low (n = 5), middle (n = 3), and high (n = 3). Eight of 11 reconstructions utilized osteocutaneous flaps including the osteocutaneous radial forearm free flap (OCRFFF) (n = 7) and fibula (n = 1). Other reconstructions included a split calvarial graft wrapped within a temporoparietal fascia free flap (n = 1), latissimus myocutaneous flap (n = 1), and rectus abdominis myofascial flap (n = 1). All 11 flaps were successful without microvascular compromise. No complications were observed in the high and middle ACF defect groups. Two of five flaps in the low defect group using OCRFFF flaps failed to achieve surgical goals despite demonstrating healthy flaps upon re-exploration. Complications included persistent cerebrospinal fluid leak (n = 1) and pneumocephalus (n = 1), requiring flap repositioning in one subject and a second microvascular flap in the second subject to achieve surgical goals. In our experience, osteocutaneous flaps (especially the OCRFFF) are preferred for complete autologous reconstruction of high and middle ACF defects. Low skull base defects are more difficult to reconstruct, and consideration of free muscle flaps (no bone) should be weighed as an option in this anatomic area.

Outcomes after free tissue transfer for composite oral cavity resections involving skin.

Resections involving oral cavity mucosa, bone, and skin present a unique challenge. Optimizing outcomes often requires technically demanding reconstruction. The purpose of this study is to evaluate outcomes of several reconstructive approaches for patients with composite through-and-through defects, with a focus on the osteocutaneous radial forearm free flap (RFFF). We conducted a retrospective evaluation of the cohort of patients treated for composite through-and-through defects with cutaneous involvement who underwent free flap reconstruction from August 2012 through October 2015. Seventeen patients received a single flap (12 cases of osteocutaneous RFFF), whereas 10 patients underwent a combination of flaps. Complication rates and functional outcomes were favorable in patients who underwent osteocutaneous RFFFs. The supraclavicular artery island flap (SCAIF) was used as a second flap in 3 cases. The osteocutaneous RFFF provides a valuable reconstructive option for complex composite resection defects involving skin. When 2 flaps are required, the SCAIF is a viable alternative to a second free flap or pectoralis flap.