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

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

Osteocutaneous radial forearm free flap: Its use without significant donor site morbidity ANDREAS H. WERLE, MD, TERANCE T. TSUE, MD, E. BRUCE TOBY, MD...

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Osteocutaneous radial forearm free flap: Its use without significant donor site morbidity ANDREAS H. WERLE, MD, TERANCE T. TSUE, MD, E. BRUCE TOBY, MD, and DOUGLAS A. GIROD, MD, Kansas City, Kansas, and

Kansas City, Missouri

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.)

Microvascular free tissue transfer has become a mainstay in the reconstruction of extirpative defects of the head and neck. In comparison with regional pedicled flaps such as the pectoralis major myocutaneous and deltopectoral fasciocutaneous flaps, free flaps provide a From the Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center (Drs Werle, Tsue, and Girod); Veterans Affairs Medical Center (Drs Tsue and Girod); Division of Orthopedic Surgery, Department of Surgery, University of Kansas Medical Center (Dr Toby). Presented at the annual meeting of the American Academy of Otolaryngology–Head and Neck Surgery, New Orleans, LA, September 27, 1999. Reprint requests: Terance T. Tsue, MD, Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160. Copyright © 2000 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/2000/$12.00 + 0 23/1/110865 doi:10.1067/mhn.2000.110865

number of advantages, including the ability to choose the characteristics of the tissue to be used for reconstruction. One of the most valuable options available with certain free flaps is vascularized bone to replace that resected from the mandible or midface. Chief among the commonly used osteocutaneous free flaps are the iliac crest, scapula, and fibula free flaps. Because they provide a means by which composite defects of the head and neck can be reconstructed in one stage with excellent results—at both the recipient and donor sites—these flaps are currently in widespread use. At one time, the radial forearm free flap was also considered a promising osteocutaneous flap.1-6 Along with a segment of radius bone, this flap’s soft tissue component includes an abundant supply of thin, pliable, sensate skin that is superior to that provided by the other commonly used osteocutaneous free flaps. Use of the osteocutaneous radial forearm free flap (ORFFF) essentially ceased, however, when several series were published noting an excessive rate of pathologic donor radius fracture.1,2,4-13 In an effort to reduce this donor site morbidity and therefore safely make use of the superior soft tissue characteristics of the volar forearm, we began to prophylactically plate the donor radius after graft harvest. This practice was based on biomechanical studies conducted at our institution demonstrating greatly improved strength when ostectomized radii are plated.14,15 Thus far, 54 patients have undergone ORFFF harvest for head and neck reconstruction at our institution, with 52 of them undergoing prophylactic internal fixation of their donor radii at the time of surgery. This study details our experience with this technique, which is notable for the absence of any significant donor site morbidity in plated patients. METHODS AND PATIENTS Retrospective chart reviews were completed of the first 54 patients undergoing ORFFF reconstruction of the head and neck at the University of Kansas Medical Center. Cases were completed between September 1994 and June 1999. Charts were reviewed for demographic information, patient handedness, history and physical examination at the time of presentation, medical history including conditions influencing the quality of the donor site, and results of subjective and objec711

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FLAP HARVEST TECHNIQUE

Fig 1. ORFFF on the back table. Note the long vascular pedicle (small arrow) and the bone graft (large arrow), which is pedicled on the radial artery via the intermuscular septum. Medial antebrachial cutaneous nerve is also shown (open arrow).

tive Allen’s testing. Surgical information reviewed included donor arm side, size of the soft tissue and bony components harvested, and type of plating used on the donor radius. The immediate postoperative treatment of the donor arm was noted. Follow-up data collected included the timing and nature of complications and significant events documented during follow-up at our institution and those related to us through correspondence from outside physicians. Status of the donor site was documented at the most recent follow-up date, based on history and physical examination as well as x-rays when available. For 24 patients, postoperative objective assessment of the donor arm was performed. Grip strength was tested with a Jamar gripper (Lafayette Instrument Company, Lafayette, IN). Pinch strength was tested with a pinch gripper (B&L Engineering, Santa Fe Springs, CA). Range of motion on supination, pronation, radial deviation, ulnar deviation, palmar flexion, and dorsiflexion were also measured. All of these measurements were made on both the donor and unoperated arms. Of note, data collected on these patients did not always include the entire complement of tests. Forty-seven patients underwent forearm radiography of their donor sites postoperatively. Eleven of these patients had x-rays within the first 10 postoperative days only. The remaining 36 patients underwent their most recent x-rays between 1 and 34 months postoperatively, with a mean of 7.6 months. These x-rays were reviewed with attention to size and type of reconstruction plate used, number of bicortical screws placed distal and proximal to the bone graft defect, and number of monocortical screws placed in the defect. The presence of fractures was also noted. Each patient’s most recent x-rays were used to make qualitative assessments of the degrees of localized osteopenia, remodeling, and reconstitution were made.

The radial forearm free flap, as first described by Yang Guofan, Chen Baoqui, and Gao Yuzhi in 1978, is based on the radial artery, which branches from the brachial artery in the antecubital fossa.3 Its venous drainage is provided by the paired venae comitans, which run with the radial artery, and the superficial venous system, which contains the cephalic and basilic veins. The lateral intermuscular septum, which contains perforators from the radial artery supplying the periosteum of the radius, passes between the flexor carpi radialis and the brachioradialis muscles and must be preserved. Sensation of the flap is provided by the lateral and medial antebrachial cutaneous nerves. Preoperatively, we perform both subjective and objective Allen’s tests to confirm adequate circulation to the hand via the ulnar artery and to assist in the selection of the donor arm.16 At surgery, the radial artery and cephalic vein are marked, along with the proposed skin paddle. The skin paddle is positioned at least two centimeters proximal to the wrist crease and with an ulnar bias. This ensures adequate skin coverage of the internal fixation plate. The soft tissue component of the flap is raised in the standard fashion, with care taken to preserve the lateral intermuscular septum. The bone is harvested between the pronator teres and brachioradialis tendon insertions. The flexor digitorum superficialis is released from the radius, allowing visualization of the flexor pollicis longus. This muscle belly is split over the midline of the volar surface of the radius using a scalpel. The required length of bone is marked. The distal cut must be made at least 2.5 cm from the radial styloid to allow later fixation of the radius. Proximally, the bone can be cut even beyond the pronator teres insertion; however, the pronator teres tendon will require reinsertion. An oscillating saw with a fine blade is used to make a longitudinal cut in the radius through its midportion. This cut is placed to allow harvest of approximately 50% of the radius circumference. A metal ruler is placed in the longitudinal cut of the radius to act as a stop to prevent past-cutting during the proximal and distal cuts, which are slightly beveled. The periosteum is then incised dorsally, completing the bone graft harvest. The flap is then left to perfuse on its pedicle, which is divided proximally and distally just before transfer of the flap to the recipient site (Fig 1). Prophylactic fixation of the radius, as developed by one of the authors (E.B.T.), is begun by exposing the dorsal aspect of the radius proximally and distally. An appropriately sized plate is positioned over the radius and bent to the contour of the bone. Eight to 14 hole plates have been used, including reconstruction plates, dynamic compression plates (DCPs), and low-contact

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Fig 2. Current donor radius fixation method. Bicortical screws are placed proximally and distally. No monocortical screws are placed into the bone graft defect.

dynamic compression plates (LC-DCPs, all plates AO Synthes, Davos, Switzerland). The LC-DCP is now our preferred fixation device. Distally, the radial wrist extensors are retracted and standard bicortical screws are placed. Proximally, the supinator is visualized. Great care is taken to protect the posterior interosseus nerve, which passes through the supinator but is not usually adjacent to the fixation area. When a large bone graft has been harvested, the supinator is elevated in a subperiosteal plane and the plate placed beneath it. Standard bicortical screws are placed proximally. Early in our series, intermittent monocortical screws were placed in the defect area. The procedure has since evolved such that we no longer place screws in the defect area in order to eliminate the risk of additional stress risers (areas of stress concentration at transitions between supported and unsupported bone) with these screws (Fig 2). After standard closure of the forearm defect, including split thickness skin grafting, the arm is placed in a rigid ulnar gutter splint for approximately 7 days, at which time the splint is removed and the wound inspected. The patient is then encouraged to resume full activity of the wrist and fingers, including weight bearing and rotation, with the donor arm protected with a soft dressing until the wound has healed. RESULTS Patient Demographics and Surgical Variables

Data were collected on a total of 54 patients undergoing ORFFF reconstruction. Thirty (56%) patients were male, and 24 (44%) were female. Ages ranged from 16 to 89 years with a mean of 62 years. Follow-up averaged 16 months, with a range of 0 to 45 months. All patients underwent preoperative upper extremity vascular assessment, both in the clinic (subjective Allen’s test) as well as in the vascular laboratory with Doppler ultrasonography (objective Allen’s test).16 One patient additionally underwent upper extremity arteriography. The nondominant hand was chosen as the donor site in

most cases. Three (6%) patients underwent flap harvest from their dominant arms when the preoperative workup revealed an unsuitable vascular supply to their nondominant hands. The radial artery was reconstructed with a saphenous vein graft in 1 patient for concerns of inadequate ulnar flow to the hand. Fifty-two donor radii were internally fixated after graft harvest; the first 2 flaps performed were treated postoperatively with a period of immobilization without plating of the donor bone. Fifty-three donor sites were covered with split thickness skin grafts, while the remaining patient had her donor site closed primarily. Radius bone grafts harvested ranged in length from 5.5 to 12 cm with a mean of 7.6 cm (±1.3, SD). In all cases, approximately 50% of the radius circumference was harvested. The accompanying soft tissue paddle ranged in length from 4 to 15 cm with a mean of 10.4 cm (±2.8, SD). Skin paddle width ranged from 3 to 10 cm with a mean of 6.6 cm (±1.5, SD). Total skin paddle surface area ranged from 12 to 130 cm2 with a mean of 71 cm2 (±29.8, SD). Donor Site Complications

Complications involving the donor arm are summarized in Table 1. The most common complication at the forearm donor site has been flexor carpi radialis tendon exposure due to incomplete take of the split thickness skin graft. This has occurred in 23 (43%) patients. All except 1 healed uneventfully with local wound care. The 1 patient whose arm was closed primarily developed necrosis around the incision requiring subsequent debridement and skin grafting. None of the patients had hardware loosening or exposure at the donor site, and no hardware required removal. Postoperative donor radius fracture occurred in 1 (50%) of the 2 patients who did not undergo internal fixation of the radius. No clinically significant radius bone fractures were seen in the 52 patients treated with prophylactic plate fixation. There were 5 (10%)

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Table 2. Donor arm function compared with unoperated side

Parameter

Fig 3. Postostectomy radius fracture. Note that the fracture occurred at the site of a monocortical screw within the bone graft defect (arrow).

Mean (% of unoperated side)

Range (% of unoperated side)

Number of patients tested

84 90 90 102 101 87 100 100

51-110 63-110 43-133 40-167 67-200 50-110 100 100

22 21 16 16 22 22 18 18

Grip strength Pinch strength Radial deviation Ulnar deviation Dorsiflexion Palmar flexion Pronation Supination

Table 1. Donor arm complications Complication

Tendon exposure Healed with local wound care Operative treatment Donor radius fracture Plated patients Clinical fracture Radiographic fracture Unplated patients

Number of patients (% of 54)

23 (43) 22 1 6 (11) 0 5 1

fractures; all were asymptomatic, discovered radiographically, and required no treatment at all. Interestingly, 1 patient fell on an outstretched donor arm on postoperative day 7 and suffered a fracture of the humerus on the donor side; the ostectomized and plated radius was not fractured. All 5 plated patients with donor radius fracture had their fractures discovered on their first postoperative forearm x-rays. These x-rays were taken 3 days to 3 months postoperatively (mean, 62 days). Follow-up on these 5 patients has averaged 17 months, with a range of 2 to 33 months. No cosmetic or functional sequelae have resulted from their fractures. Each of these patients had intermittent monocortical screws placed in their bone graft defects. Four of the fractures occurred at these screw sites and are felt to have occurred intraoperatively (Fig 3). Due to this experience and the risk of introducing stress risers at these screw sites, the use of monocortical screws in the bone graft defect ceased in April 1998. We have seen no further fractures in the 23 patients surgically treated since this practice was discontinued. Donor Arm Function

Twenty-four patients underwent objective assessment of donor arm function at various stages of their

follow-up. Testing occurred at 2 to 34 months postoperatively, with a mean of 12 months. Results are summarized in Table 2. Data were collected on both arms, with the untreated arms serving as controls. Donor arms were noted to perform at 84% and 90% of unoperated arms on grip and pinch strength testing, respectively. Range of motion results indicated that donor arms functioned between 87% and 102% as well as controls. It is important to note again that donor arms were nondominant in the vast majority of cases. Radiographic Data

Forty-seven patients underwent multiple-view forearm x-rays postoperatively (Table 3). Forty-six of these patients had undergone prophylactic internal fixation of their donor radii. The number of fractures found on this review was noted previously. Eleven patients had their most recent x-rays completed within the first 10 postoperative days. The remaining 36 patients had x-rays completed between 1 and 34 months from surgery (mean, 7.6 months), with 35 of these patients having undergone internal radius fixation. The vast majority of patients had 3 bicortical screws placed proximal to their bone harvest sites and 2 bicortical screws placed distally. Low contact dynamic compression plates were used in the majority of patients. For the patients who underwent forearm plating and on whom forearm x-rays were obtained, the most recent radiographs were also reviewed to evaluate for evidence of localized osteopenia due to plating of the radius, bony reconstitution, and bony remodeling (Table 4). Reconstitution is manifested by an increased bone mass within the area of the defect (ie, increased thickness). Remodeling is seen at the margins of the defect, where the square edges resulting at surgery become rounded and the defect becomes boat-shaped. Reconstitution and remodeling are evidence of bone healing. Both are seen

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Table 3. Fixation features Internal fixation choice

Plate type LC-DCP DCP Reconstruction Plate size 8-hole 9-hole 10-hole 11-hole 12-hole Screw placement 1 proximal 2 proximal 3 proximal 1 distal 2 distal 3 distal

Number of patients (% of 46)

40 (87) 5 (11) 1 (2)

A

1 (2) 4 (8) 23 (5) 9 (20) 9 (20) 1 (2) 4 (9) 41 (89) 0 44 (96) 2 (4)

in the vast majority of patients in our series by 5 months after surgery, with remodeling present in most patients by 3 months (Fig 4). There has been no evidence of localized osteopenia. DISCUSSION

Since its introduction in 1978 by Yang Guofan et al, the radial forearm free flap has gained increasing popularity in head and neck reconstruction.3 This is based on its superior soft tissue characteristics, notably its abundant supply of thin, pliable, sensate skin and its long, reliable, vascular pedicle. In addition to soft tissue reconstruction, early use of the flap commonly included the harvest of radius bone, generally for mandibular reconstruction. This technique made possible the 1stage reconstruction of composite defects with both vascularized bone and excellent soft tissue. Because the radial forearm also has the advantage of being relatively easy to harvest concurrently during head and neck procedures, the osteocutaneous radial forearm free flap seemed to have a promising future in head and neck reconstruction. Early published series of patients undergoing osteocutaneous radial forearm flap harvest, however, demonstrated serious donor site morbidity in the form of radius bone fracture. Ranging from 8% to 67%, the combined incidence of donor radius fracture in these early series averaged 24%.1,2,4-13 A recent article by Thoma et al17 reported the largest series of ORFFF reconstructions to date (60 patients), with a fracture incidence of 15%. Often, the donor arms in these series were prophylactically immobilized postoperatively.

B Fig 4. A, Donor forearm radiograph obtained 1 month postoperatively. This patient did not undergo placement of screws within the bone graft defect. B, Radiograph of the same donor arm at 10 months postoperatively. Significant bony reconstitution and remodeling are evident.

Table 4. Bone healing in plated patients with forearm x-rays performed 1 or more months postoperatively Postoperative Number Retime of of modeling latest x-ray patients (%)

<10 days 1 month 2 months 3 months 4 months 5 months >5 months

11 8 3 4 2 2 16

0 (0) 0 (0) 1 (33) 3 (75) 1 (50) 2 (100) 15 (94)

Reconstitution (%)

0 (0) 0 (0) 0 (0) 0 (0) 1 (50) 2 (100) 15 (94)

Osteopenia Fracture (%) (%)

0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

1 (9) 1 (12.5) 1 (33) 2 (50) 0 (0) 0 (0) 0 (0)

Fractures were treated with a variety of methods including prolonged immobilization, external fixators, and more complex reconstructions involving both vascularized and nonvascularized bone grafts. In several reports,5,7-9,18 it was noted that arm and hand range of motion and strength were markedly reduced after donor radius fracture. This was in contrast to the normal strength and range of motion demonstrated in patients undergoing fasciocutaneous flap harvest or osteocutaneous flap harvest without subsequent fracture. As a result of the early experience with donor radius fracture, 2 studies were published quantifying the weak-

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ening of the radius that occurs following graft harvest. Swanson et al,19 in 1990, noted that formalin-fixed ostectomized human radii were only 24% as strong as intact radii. In 1992, Meland et al,20 using sheep tibia as a model, found that ostectomized bones were only 15% to 28% as strong as intact bones, depending on the depth of cut. Their conclusion that the radius was an unacceptable bone graft donor site was indicative of widespread sentiment, as the osteocutaneous forearm flap was essentially abandoned. In order to take advantage of the superior soft tissue characteristics of the radial forearm free flap, we hoped to develop a way to minimize the incidence of donor radius fracture. To strengthen the radius, a logical option was prophylactic internal fixation of the ostectomized bone at the time of surgery. Compression plate fixation of radius fractures was introduced in the 1950s and has developed into a widely accepted practice in orthopedics.21 At our institution, initial studies were conducted to establish the value of plate fixation after bone graft harvest. Using matched pairs of fresh human radii, the strength of plated bones after ostectomy was 70% of intact bones on torsional loading and 64% on 4point bending.14,15 These values were a significant improvement over the unplated values of 18% to 24% determined in these studies and 20% to 25% determined by Swanson et al19 and Meland et al.20 Plating therefore seemed likely to reduce the incidence of donor radius fracture. Our clinical experience with this flap has been consistent with these results. Of the 2 flaps harvested without plate fixation of the donor radius, 1 fractured postoperatively. Conversely, the subsequent 52 cases included prophylactic plating of the radius, and there have been no clinically significant fractures in these patients. Five fractures were discovered on routine xrays, with the majority of these likely occurring intraoperatively at screw sites within the bone graft defect. We no longer place these screws. None of the fractures were symptomatic, and no treatment was required. The most common complication at the donor site, tendon exposure resulting from incomplete skin graft take, has occurred at a rate similar to that experienced after fasciocutaneous free flap harvest and has caused little, if any, morbidity. Review of our patients’ donor forearm radiographs has bolstered our confidence in our prophylactic internal fixation technique. None of the plated forearms has undergone hardware loosening or exposure; and no intervention has been required because of complications of the bone or hardware. This is in keeping with the orthopedic experience with these compression plates since the 1950s in the management of radius frac-

tures. Further, we have seen that virtually all radii have undergone significant bony remodeling and reconstitution by 5 months after surgery and none of the donor radii has developed radiographic evidence of localized osteopenia as a result of plating of the bone. Objective assessment of forearm and hand function in prophylactically plated patients has revealed excellent range of motion and strength compared with untreated arms. This finding is in keeping with previously published reports in which the avoidance of donor radius fracture was associated with preservation of function. Collecting data on patients still undergoing follow-up in our clinic, as well as measuring forearm function in future flap recipients, will be an ongoing project at our institution. As a result of prophylactic internal fixation of the donor radius, we have established a reliable method by which the osteocutaneous radial forearm free flap can be safely used. This flap provides adequate bone for many commonly encountered composite defects of the head and neck as well as the superior soft tissue of the fasciocutaneous radial forearm flap. When the radius is plated to avoid postoperative fracture, we feel that this free flap should again be considered an excellent and safe option in head and neck reconstruction. We would like to thank Heather Barnhart, RN, for her help with data collection for this project. REFERENCES 1. Matthews RN, Fatah F, Davies DM, et al. Experience with the radial forearm flap in 14 cases. Scand J Plast Reconstr Surg 1984;18:303-10. 2. O’Brien CJ, Archer DJ, Breach NM, et al. Reconstruction of the mandible with autogenous bone following treatment for squamous carcinoma. Aust NZ J Surg 1986;56:707-15. 3. Song R, Gao Y, Song Y, et al. The forearm flap. Clin Plast Surg 1982;9:21-6. 4. Soutar DS, McGregor IA. The radial forearm flap in intraoral reconstruction: the experience of 60 consecutive cases. Plast Reconstr Surg 1986;78:1-8. 5. Soutar DS, Widdowson WP. Immediate reconstruction of the mandible using a vascularized segment of radius. Head Neck Surg 1986;8:232-46. 6. Vaughan ED. The radial forearm free flap in orofacial reconstruction: personal experience in 120 consecutive cases. J Craniomaxillofac Surg 1990;18:2-7. 7. Bardsley AF, Soutar DS, Elliot D, et al. Reducing morbidity in the radial forearm flap donor site. Plast Reconstr Surg 1990;86: 287-94. 8. Boorman JG, Brown JA, Sykes PJ. Morbidity in the forearm flap donor arm. Br J Plast Surg 1987;40:207-12. 9. Juretic M, Car M, Zambelli M. The radial forearm free flap: our experience in solving donor site problems. J Craniomaxillofac Surg 1992;20:184-6. 10. Muldowney JB, Cohen JI, Porto DP, et al. Oral cavity reconstruction using the free radial forearm flap. Arch Otolaryngol Head Neck Surg 1987;113:1219-24. 11. Smith AA, Bowen CVA, Rabczak T, et al. Donor site deficit of the osteocutaneous radial forearm flap. Ann Plast Surg 1994;32: 372-6.

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12. Swanson E, Boyd JB, Manktelow RT. The radial forearm flap: reconstructive applications and donor-site defects in 35 consecutive patients. Plast Reconstr Surg 1990;85:258-66. 13. Timmons MJ, Missotten FEM, Poole MD, et al. Complications of radial forearm flap donor sites. Br J Plast Surg 1986;39:1768. 14. Edmonds JL, Bowers KW, Toby EB, et al. Torsional strength of the radius following osteofasciocutaneous free flap harvest with and without primary bone plating [abstract]. Otolaryngol Head Neck Surg 1997;117:P161. 15. Bowers KW, Edmonds JL, Girod DA, et al. Prophylactic plate fixation of the radius with osteocutaneous free radial forearm flap. Presented at American Society of Reconstructive Microsurgery, January 1999, Kamuela, Hawaii. 16. Nuckols DA, Toby EB, Tsue TT, et al. Preoperative evaluation of

17. 18. 19. 20. 21.

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radial forearm free flap patient with the objective Allen’s test. Otolaryngol Head Neck Surg 2000;123:553-7. Thoma A, Khadaroo R, Grigenas O, et al. Oromandibular reconstruction with the radial forearm osteocutaneous flap: experience with 60 consecutive cases. Plast Reconstr Surg 1999;104:368-78. Urken ML. Composite free flaps in oromandibular reconstruction. Arch Otolaryngol Head Neck Surg 1991;117:724-32. Swanson E, Boyd JB, Mulholland RS. The radial forearm flap: a biomechanical study of the osteotomized radius. Plast Reconstr Surg 1990;85:267-72. Meland NB, Maki S, Chao EYS, et al. The radial forearm flap: a biomechanical study of donor-site morbidity utilizing sheep tibia. Plast Reconstr Surg 1992;90:763-73. Canale ST, ed. Campbell’s operative orthopedics, 9th ed. St Louis: Mosby–Year Book, Inc; 1998. p. 2336-41.

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