Radial forearm free flap

Radial forearm free flap

Oral Maxillofacial Surg Clin N Am 15 (2003) 577 – 591 Radial forearm free f lap Neal D. Futran, MD, DMD*, T.J. Gal, MD, D. Gregory Farwell, MD Depart...

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Oral Maxillofacial Surg Clin N Am 15 (2003) 577 – 591

Radial forearm free f lap Neal D. Futran, MD, DMD*, T.J. Gal, MD, D. Gregory Farwell, MD Department of Otolaryngology – Head and Neck Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356515, Seattle, WA 98195-6515, USA

The radial forearm free flap was developed in 1978 as a fasciocutaneous flap in the People’s Republic of China. It was first reported in the literature in 1981 by Yang et al [1] who used the flap to provide soft pliable tissue to resurface the neck and release postburn contractures. Soutar and colleagues [2 – 4] from Scotland popularized the technique for intraoral reconstruction with several publications starting in 1983. Because of its ability to transfer reliable, well-vascularized, and moldable tissue, along with the potential to incorporate bone, tendon, and nerve, this flap has a key role in head and neck reconstruction. Similar to widespread use of the pectoralis major pedicled myocutaneous flap for intraoral reconstruction in the 1980s and early 1990s, the radial forearm free flap has become the workhorse flap for intraoral reconstruction in the late 1990s and early 2000s. This flap is based on the radial artery. Because it has a unique dual venous system, it may be drained using either the cephalic vein or the venae comitantes [5]. It is generally harvested as a fasciocutaneous flap that includes the volar forearm skin, the underlying antebrachial fascia, and the intermuscular fascia, which contains the vascular pedicle (Fig. 1). It is versatile in that it also may be transferred as a sensory flap incorporating the medial or lateral antebrachial cutaneous nerve [6,7], or a composite bone flap using vascularized radius [4,8,9]. It also may include vascularized tendon [10] and brachioradialis muscle [11]. Because of the ability to harvest the entire skin of the volar forearm, which is thin and pliable, it has great application for the restoration of oral mucosal defects

* Corresponding author. E-mail address: [email protected] (N.D. Futran).

after ablative oncologic surgery. It has been used in all areas of the oral cavity, particularly for anterolateral tongue and floor of mouth defects; tonsillar, pharyngeal, and hard or soft palate defects; and reconstruction of the hypopharynx, cervical esophagus, and skull base.

Vascular anatomy Almost the entire radial artery from its origin at the brachial artery to the wrist can be transferred with the flap (Fig. 2a and b)[12]. Its reliable course under the brachioradialis muscle and 2- to 3-mm diameter make it a favorable vessel for harvest and anastomosis. In fact, after giving out the radial recurrent artery and the inferior cubital artery near the antecubital fossa, no named branches exist until the wrist. At this point, a superficial palmar branch and palmar carpal branch occur. In the course of the forearm, multiple cutaneous muscular and periosteal branches allow this artery to support skin and bone for free tissue transfer [13]. Distally, the radial artery turns laterally to wind around the wrist and gives rise to the deep palmar arch. Harvest of this flap requires complete interruption of the radial artery, but, in almost all patients, the ulnar artery provides the dominant blood supply to the hand through the superficial palmar arch and will usually supply the entire hand. McCormick et al [14] performed 750 arm dissections and found that the radial and ulnar arteries were present 100% of the time. In 650 anatomic dissections of the forearm, Coleman and Anson [15] found there were no branches of the superficial palmar arch to the thumb and index finger in 10% of cases. In 50% of dissections, the deep arch did not connect to the ulnar artery. If both of these variations are present, the thumb and index finger

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Fig. 1. A typical flap is outlined on the forearm. The superficial venous drainage is marked, as is the position of the radial bone. The design for restoration of the defect is drawn on the distal aspect of the volar surface of the forearm, with the incision line drawn to the antecubital fossa. To monitor the vitality of the flap, a small portion of proximal tissue (MON) is incorporated with the flap and sutured into the neck.

Fig. 2. a, The course, relationship, and branches of the radial artery. Many small branches pass superficially and deeply in the intermuscular septum to supply the skin and the radius. b, The radial artery lies between the two layers of the intermuscular septum. The lateral layer lies on the brachial radialis and wrist extensors, and the medial layer lies on the flexor carpi radialis and sublimus. The heavy line in the illustration indicates the plane of flap dissection, which is deep to the antebrachial fascia and incorporates this fascia in intermuscular septum in the flap. In this way, the radial artery with its vessels to the skin is included in the flap. (From Manktelow RT, Zuker RM, Finch K. Microvascular reconstruction: anatomy, applications, and surgical technique. English Book viii. Berlin; New York: Springer-Verlag; p. 221; with permission.)

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depend on the radial artery for their perfusion, and sacrifice of that vessel could cause ischemia; therefore, during the preoperative assessment of patients undergoing use of this flap, an Allen test should be performed [16]. Proper performance of this test requires simultaneous compression of the ulnar and radial arteries by the examiner while the hand is alternately opened and closed. This pumping action causes the hand to become pale as a result of mechanical exsanguination. The hand is then opened to a relaxed position, and the ulnar artery is released. While the radial artery is compressed, the normal finding on examination is a blush of the hand within 15 to 20 seconds. A delay beyond this time should raise concern about the ability of the ulnar circulation to perfuse the hand. A color flow Doppler examination can be performed in these instances to determine the integrity of the palmar arch. If the ulnar circulation cannot sustain the thumb and index finger, an alternate flap should be chosen. In the authors’ clinical experience of 362 radial forearm free flaps, 19 patients were found to have abnormal findings on the Allen test in one or both arms. Subsequent color flow Doppler examination of these 19 patients revealed an incomplete palmar arch in one arm in two patients. The forearm flap has excellent venous drainage from the deep venae comitantes (1 – 2 mm) or the superficial cephalic vein (3 – 4 mm). The venae comitantes are paired around the radial artery along its length. The cephalic vein runs superficially. Multiple connections exist between these two systems, allowing either to be used alone. The two systems can also be combined and drained as a single system based on the cephalic vein if the median cubital vein connecting the two systems near the antecubital fossa is incorporated in the dissection [17]. The branching patterns of these two systems are variable. In 1994, Thoma et al [18] described five different patterns, the most common of which is type II. In that pattern (43%), a wide communication exists through the anastomotic vein between the superficial and deep systems. The type I pattern, which occurs 20% of the time, is similar to type II except that the median cubital vein splits into two branches. In the type III pattern (18%), the two venae comitantes come together in a sizeable trunk, but there is no major communication with the cephalic vein to form a median cubital vein. The type IV and V patterns have large venae comitantes but no communicating vein. If necessary, the cephalic vein can be traced into the upper arm to lengthen the vascular pedicle, particularly in skull base reconstruction to avoid the need for vein grafts. Although some surgeons [1,18] have advocated the need for routinely anastomosing the deep and superficial venous systems

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to vessels in the neck for flap success, a meta-analysis by Stack and Futran [17] showed that a single venous system was sufficient for flap survival. The most common structure additionally harvested with this flap is the lateral antebrachial cutaneous nerve, which supplies sensation to the volar forearm skin [19]. This large nerve is reliably identified deep to the cephalic vein in the proximal dissection and can be dissected distally for 10 to 15 cm. Incorporation of a segment of the radius is also possible but is limited proximally by the insertion of the pronator teres and distally by the insertion of the brachioradialis [4]. Bone stock is approximately 40% of the circumference of the radius and is generally not greater than 10 cm in length. Early enthusiasm for use of radial bone in the 1980s was tempered by the fact that, even after placing patients in a long arm splint for 8 weeks, as many as 20% of patients sustained radius fractures [20]. More recently, prophylactic plating of the osteotomized radius has been described, with an early return to function and near elimination of the risk for radius fractures [8,9]. This flap has also shown versatility owing to the ability to incorporate the palmaris longus tendon, which can be used as a sling in lip reconstruction and facial reanimation procedures [21]. The thickness of the cutaneous portion of this flap varies among different individuals and across different areas of the forearm. The layer of subcutaneous fat tends to be thicker in female patients and in patients with a greater fat-to-muscle ratio. The flap also tends to be thinner on the distal aspect of the volar forearm in all patients. These variations affect the design of the flap depending on the defect to be reconstructed. In addition, the degree and pattern of hair-bearing skin vary among individuals. If the recipient bed will be irradiated, the hair will be lost. Other patients may require laser ablation of the hair follicles in the postoperative setting.

Flap harvest If possible, the nondominant arm is chosen for flap harvest. Many patients undergoing this type of reconstruction require a tracheotomy, and it is useful for postoperative communication to have the patient maintain the ability to write messages. An accurate Allen test determines the suitability of that arm for flap harvest. All personnel, particularly nursing and anesthesia staff, should be notified of the use of this arm for the flap to prevent arterial or venopunctures in this limb. The patient also should be instructed to warn all personnel of that issue. The authors lightly wrap the arm with gauze to minimize this risk before surgery.

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Even if the superficial veins are inadvertently traumatized, the venae comitantes are usually not affected. The course of the radial artery and superficial veins should be marked. The latter can be identified easily by briefly inflating the tourniquet to engorge the veins. The design and shape of the flap are dictated by the particular defect to be reconstructed (see Fig. 1). They can usually be determined by examination and manual palpation of the tumor to be resected, but it is prudent to wait to harvest the flap until clear margins have been achieved by frozen section. The flap axis is slightly medial to the course of the radial artery and is positioned in a suitable location on the arm depending on the thickness of tissue required and the need to avoid hair-bearing skin. At the proximal portion of the pattern, the incision extends along the volar aspect of the forearm to the antecubital fossa in a lazy ‘‘S’’ design. The arm is then exsanguinated with an elastic wrap or Esmarch bandage, and a previously placed tourniquet on the upper arm is inflated to 250 mm Hg. The incision is made through the skin and subcutaneous tissue along the outline of the entire flap. To obtain additional tissue to drape in the neck to replace bulk lost by the performance of a neck dissection, the proximal skin flaps can be elevated medially and laterally to maintain extra subcutaneous tissue with the flap. On the radial side, dissection is continued down to the fascia over the brachioradialis muscle, taking care to identify the cephalic vein and cutting just laterally to it. In the lower forearm, a major branch frequently extends more radially to the dorsum of the hand and can be ligated. The main vein sends off branches medially to the flap; these branches should be

preserved. All venous branches at the distal portion of the flap can be ligated. The flap is then elevated in a subfascial plane over the brachioradialis muscle to the level of the lateral intermuscular septum marked by the border of this muscle (Fig. 2a and b). It is critical to identify and preserve the superficial branches of the radial nerve to maintain sensation to the dorsum of the hand. These branches are easily identified when elevating the flap toward the vascular pedicle. On the ulnar side of the flap, dissection is continued down to the fascia overlying the flexor carpi radialis muscle and palmaris longus tendon. Again, dissection is continued toward the intermuscular septum and vascular pedicle in the subfascial plane. It is critical to maintain the integrity of the paratenon to provide an adequate bed for the latter skin graft. Several small veins encountered during the dissection should be ligated with hemoclips and divided. The radial artery and venae comitantes are then identified between the brachioradialis and flexor carpi radialis muscles distally. They are clamped, cut, and ligated with 2-0 silk sutures. At this point, the dissection can begin from a distal to proximal direction as the vascular pedicle needs to be elevated from between the flexor carpi radialis and brachioradialis muscles. A plane of dissection can be developed under the radial artery, elevating it off the flexor pollicis longus muscle. Multiple small branches extend to this muscle and require ligation with hemoclips and division, or the use of bipolar cautery. By keeping the dissection between the muscles and the intermuscular fascia, a longitudinal curtain of fascia hanging between the two muscles and connecting the skin to the radial artery becomes

Fig. 3. The vascular pedicle is dissected at the antecubital fossa. Usually, a communicating vein exists between the venae comitantes and cephalic vein, and the radial artery passes medially to this.

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Fig. 4. A, A 58-year-old woman with squamous cell carcinoma of the anterior floor of mouth abutting the mandibular alveolus. B, The tumor is resected with an anterior marginal mandibulectomy. C, A radial forearm free flap reconstructs the floor of mouth (FOM). Additional subcutaneous tissue was harvested proximally to fill in the dissected neck. D, The flap is inset into the floor of mouth. E, Five-year follow-up with the tongue at rest. F, Five-year follow-up exhibiting normal tongue protrusion and mobility.

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apparent and maintains the integrity of the flap. Although the radial artery and venae comitantes can be traced all the way to the brachial artery, this is usually not necessary, and the dissection can be adjusted to the appropriate pedicle length. When dissection is performed to the level of antecubital fossa, the communicating vein between the deep and superficial systems

can be maintained, and the flap can drain based on both systems by a single vessel (Fig. 3). At the takeoff of the communicating branch, multiple small venous branches require ligation. This communicating branch anastomoses with the cephalic vein, which can be skeletonized to serve as the large draining vessel. Just deep to the cephalic vein lies the lateral antebrachial

Fig. 5. A, An 18-year-old man with a T3NoMo squamous cell carcinoma of the right side of the lateral tongue. B, The tumor is exposed fully via a pull-through approach. C, A hemiglossectomy has been completed to resect the tumor. D, A bilobed radial forearm free flap is harvested so that the tongue portion can be separated from the floor of mouth (FOM) to maximize tongue mobility. The medial antebrachial cutaneous nerve can be dissected for ease of anastomosis to the lingual nerve. E, The flap is inset into the floor of mouth and tongue. F, Three-year follow-up revealing maintenance of tongue bulk and form.

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cutaneous nerve. This nerve can be ligated proximally and dissected toward the flap to create a sensory flap. Once the harvest is completed, the tourniquet is released, and appropriate hemostasis is achieved. The radial artery and draining veins are ligated proximally and divided, and the flap is sent to the head and neck region. The hand is assessed for proper vascularity, and a closed suction drain is placed in the proximal portion of the wound. The forearm incision can be closed in layers with resorbable suture and skin staples, leaving a distal defect that usually requires a skin graft. A split-thickness skin graft is taken from the thigh at 0.015-in thickness and sutured circumferentially in the defect with 4-0 chromic suture. Fenestrations are made in the skin graft to prevent hematoma formation. A nonadhering sterile dressing is placed over the wound, and the arm is wrapped in gauze and padded with Webril. A volar plaster splint extending from the fingers to the antecubital fossa is placed and fixed with an elastic bandage. Immobilization of the forearm for 7 days is imperative to allow the skin graft to become revascularized and to maintain its integrity. The forearm is elevated to reduce edema. The splint is taken down on the seventh postoperative day. The skin graft is generally covered with a dry dressing and protective soft splint to minimize rubbing the skin graft off the tendons and to reduce the risk for wound breakdown. When the palmaris longus tendon is incorporated into the flap, it is easily maintained by sectioning it distally and proximally to the flap design, keeping the dissection just deep to the tendon until the flexor carpal radialis is reached. If bone is used when the dissection is continued on the radial side of the flap, the brachioradialis muscle is retracted laterally and dissection continued sharply down to the lateral border of the radius from

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the wrist to the insertion of the pronator teres muscle. Osteotomies are then made in the bone with an oscillating saw and copious irrigation at approximately 40% thickness of the radius. The distal and proximal cuts are made slightly obliquely in a boat-shaped fashion. The beveled bone cut may reduce the concentration of the stress at corners of the right-angle cuts. Once these cuts are made, the overlying flexor pollicis longus muscle is incorporated with the flap harvest to maintain the blood supply to the bone. The proximal dissection is continued as described previously. After the flap is harvested, the dorsal radius is exposed proximally and distally to allow room for at least two screw holes. A low-contact dynamic compression plate is applied over the radius and bent to the contour of the bone. Distally, the radial wrist extensors are retracted; proximally, the supinator muscle is elevated to allow for subperiosteal placement of the plate. Two to three bicortical screws are placed proximally and distally. No screws are placed in the defect cavity to avoid the creation of additional stress risers. The flexor pollicis longus remnant is then sutured over the radius defect and plate using absorbable sutures. The flexor digitorum superficialis muscle can also be brought over the flexor carpi radialis tendon to the radial skinage. This muscle can provide a second layer over the bony donor site and can help the skin graft take over the tendon. The procedure is continued as previously described. Care must be taken to minimize problems at the donor site intraoperatively and postoperatively to achieve 100% take of the skin graft. The paratenon over the flexor tendons should be preserved and the hand adequately immobilized to prevent shearing forces of the underlying muscles. Although infection of the forearm donor site is uncommon, the surgeon

Fig. 5 (continued).

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must use meticulous sterile technique and avoid cross contamination from the head and neck by using a separate set of instruments, operative gowns, and gloves. The function of the hand following proper harvest of the radial forearm free flap is usually normal; however, when bone is taken with the flap, there may be a measurable reduction in grip and chin strength, although, subjectively, this has not been a problem with plating the radius [8]. Stretching or transection of the superficial branches of the radial nerve will lead to decreased sensation of the thumb and thenar eminence of the hand. Neuromas owing to transection of the cutaneous sensory nerves have not been described in the literature, but the potential for painful neuroma is present. The cosmetic deformity that results from a skingrafted arm can be a major disadvantage of the radial

forearm flap [22 – 24]. In the authors’ series of 362 radial forearm free flaps, this has not been a problem recognized by patients. Two different techniques allow primary closure of the forearm defect—an ulnar transposition flap and a V-to-Y closure [25]. Although these techniques can be used for small defects, they are not reliable in larger defects or in patients with muscular arms. Masser [24] described the use of tissue expanders placed preoperatively to allow full-thickness closure of the donor defect; however, these expanders must be placed several weeks before the flap harvest and may disturb the blood supply to the distal flap tissue if not placed properly. More recently, the use of AlloDerm over the donor site has been described [26]. This material results in a prolonged 6- to 8-week course of wound care at increased expense and no objective improvement over a split-thickness skin

Fig. 6. A, A 62-year-old man underwent segmental resection of the lateral mandible, tongue base, tonsil, and soft palate. B, The radial forearm flap contains a soft tissue segment and a bony segment to reconstruct the defect. C, The bone is contoured to restore mandible continuity. D, The soft tissue is inset to restore the palate, pharynx, and tongue base. E, The flap maintains its bulk and contour, allowing optimal speech and swallowing at 2-year follow-up. F, Panoramic radiograph revealing union of the radial bone to the mandibular segments. G, The donor site defect at 2 years with normal hand function. H, Radiograph of the donor site with the reconstruction plate in place.

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graft other than avoiding the skin graft donor site. One can also transfer a fascial flap alone to avoid the problem of the cutaneous donor site defect. Kawashina et al [23] used this flap to reconstruct defects in the upper aerodigestive tract. The flaps were rapidly covered by an epithelial layer in their series but may lead to increased contractures, especially when used in the floor of mouth, which could limit tongue mobility. Although the radial forearm free flap has been used for many diverse reconstructive problems, its greatest application in head and neck reconstruction is in the restoration of upper aerodigestive tract defects follow-

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ing ablative surgery. It is particularly useful in the oral cavity. Defects involving the tongue, floor of mouth, tonsillar fossa, and palate can be restored superbly by this thin pliable tissue with a long vascular pedicle to reach into the neck [2,3,7,9,19,23]. In addition to restoring oral cavity anatomy, one must maximize tongue and tissue mobility to achieve optimal speech and swallowing, particularly when anterior floor of mouth tumors require resection. Although relatively simple techniques, such as the placement of a skin graft and, more recently, cadaveric dermis [27], have been shown to provide healing in this area, scar

Fig. 6 (continued).

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Fig. 7. A, CT scan of a 32-year-old man status post a gunshot wound to the anterior palate with a persistent oronasal and oroantral defect after failed reconstruction. B, Submental view of the collapsed premaxilla. C, The wound is exposed, revealing nonviable bone grafts and necrotic tissue. D, The radial bone is osteotomized to provide the proper contour for the premaxilla. E, The bone is inset to the premaxilla and fixated to the remaining maxilla with 1.5-mm craniofacial titanium plates. F, The soft tissue component of the flap restores the palate. G, At 1-year follow-up, the flap has conformed to the natural shape of the palate and provides a suitable base for a dental prosthesis. H, The patient at 1 year with restored form and function.

contracture may limit mobility of the oral tissues. This problem is enhanced when the tumor involves the mandibular alveolus and a marginal mandibulectomy is required. The radial forearm free flap provides more substantial tissue that will maintain its volume over time

and is ideal in this situation. Figs. 4A to F show a 53-year-old woman with an anterior floor of mouth defect following resection of a squamous cell carcinoma with an anterior marginal mandibulectomy. Reconstruction of this defect with a radial forearm flap maintained excellent tongue mobility through the

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Fig. 7 (continued).

5-year follow-up. In patients with tongue malignancies, surgical resection exacerbates potential problems to a much greater degree. It is critical not only to restore the tongue bulk and preserve its mobility but also to restore sensation in the area to enhance the functional result. Urken and Biller [7] addressed these issues in 1994 when they described a bilobe design for the radial forearm flap. This design provides thin and redundant tissue so that one lobe can be used to resurface the tongue defect; the second lobe is placed in the floor of mouth. Using this technique, the rest of the tongue remains separate from the inner table of the mandible. The same group also described the first successful sensate flap for restoration of a pharyngeal defect [6]. In this procedure, the sensory nerve was anastomosed to the greater auricular nerve, and the patient noticed a sensation when drinking hot and cold liquids that was referred to the ear. The mechanism of the sensory recovery was through the nerve anastomosis. Further work has shown a predictable level of sensory recovery when the antebrachial cutaneous nerve is sutured to the head and neck primary nerve stump. The greatest application of sensate flaps is in anterolateral tongue and tongue base reconstruction

[19]. The antebrachial cutaneous nerve is anastomosed to the lingual nerve to restore topographic hot and cold sensation as well as two-point discrimination. This concept also applies to the pharynx and larynx with anastomoses to the primary sensate nerve. Figs. 5A to F show an 18-year-old man with squamous cell carcinoma of the right side of the lateral tongue. Reconstruction with a bilobed forearm flap maintained tongue bulk and mobility, tolerated the burden of postoperative radiotherapy, and remained stable through 3 years of follow-up. In the anterior oral cavity, a total lower lip reconstruction with this flap harvested with the palmaris longus tendon has been described by Sadove et al [21]. The tendon accompanied with the forearm skin provides support and maintains the height of the lower lip. Additionally, anastomosing the central nerve supply can provide an elegant total lower lip reconstruction. In the resection of buccal mucosal tumors, a relatively thin tissue reconstruction is needed, particularly when the defect is through the external skin. A single tissue source that can provide inner and outer tissue lining is ideal. The radial forearm flap has this ability. It can be divided into two or more epithelial surfaces separated by a de-

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E

Fig. 9. A, A 78-year-old woman status post craniotomy and resection of a posterior fossa tumor. The cranium was reconstructed with acrylic and bone; however, the wound broke down after radiotherapy. The persistent nonhealing wound had chronic infection and exposed dura. B, The poorly vascularized tissue is resected. C, A radial forearm flap provides the proper thickness for the scalp in this area. The distal portion is de-epithelialized to provide a second layer of vascularized tissue folded over the dura. D, The patient has a healed wound with no infection at the 3-month follow-up.

Fig. 8. A, A 71-year-old man with a recurrent postcricoid squamous cell carcinoma after previous radiotherapy and chemotherapy. The larynx and cervical esophagus are elevated off the prevertebral fascia for full-thickness resection. B, The surgical defect from the tongue base to the sternal notch. C, A radial forearm free flap is folded and tubed to restore pharyngeal esophageal continuity. D, Radiograph of a barium swallow showing restoration of the alimentary tract.

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epithelialized zone, which can be incised down to the level of the fascia while providing adequate vascularity to the distal skin paddle. Particularly attractive areas for use of the radial forearm flap in oral pharyngeal reconstruction are defects of the tonsil and soft palate. Although two layers of the flap are used for the oral pharyngeal and nasal pharyngeal sides of the defect to optimize velopharyngeal competence, the bulk is minimized in this area owing to the thin nature of the tissues. Frequently, segmental resection of the angle of the mandible is necessary to provide complete clearance of the tumors, and the additional need for the bone provides a unique reconstructive dilemma. Reconstruction of the lateral mandibular defect is a subject of great debate, with recommendations ranging from no reconstruction at all to dual free flap reconstruction. Although placement of a reconstruction plate with a pedicled or free soft tissue flap is widely performed, there is concern regarding late plate fracture and debilitation over time [28,29]. Several bone-containing free flaps are available to restore the mandibular contour in this region; however, the accompanying soft tissue components are usually too bulky or immobile to address adequately the soft tissue needs of the mucosal defect. Although one option is to use two free flaps, such as a sensate radial forearm free flap for the soft tissue and iliac crest or fibula for the bone, this approach carries the obvious disadvantage of increased operative time, two donor sites, and significant potential for morbidity and cost. In operations in which the mandibular defect is in a nontooth-bearing area, the soft tissue needs of the defect clearly outweigh the needs of the bony defect. The radial forearm osteocutaneous free flap is in a unique position in the reconstructive ladder to achieve these needs [9]. Figs. 6A to H show the typical defect after resection of a tonsillar fossa squamous cell carcinoma fixed to bone in a 49-year-old man. The soft tissue is folded and inset to restore the lateral oropharynx and soft palate, and the attached bone restores the angle of the mandible. Function and cosmesis are achieved with a stable long-term result. Hard palate defects may also require a thin lining. Hatoko et al [30] folded a radial forearm flap to reconstruct the oral and nasal lining to achieve a proper seal. Anterior premaxillary defects are suitable for the osteocutaneous flap as described by Futran and Haller [31] and Villaret and Futran [9] (Figs. 7A to H). The hypopharynx is another appropriate anatomic site in which the radial forearm flap can be used for reconstruction. Although the jejunum has been used successfully for free tissue transfer of circumferential pharyngeal and cervical esophageal defects, a laparot-

omy is required, and persistent peristalsis may inhibit swallowing. Harii et al [32] described the tubed radial forearm flap to reconstruct a laryngopharyngectomy defect in 1985. This tissue is more readily tubed than is a thicker musculocutaneous flap, either free or pedicled, and harvest of the flap can occur simultaneously with the resection. Its utility is illustrated in Figs. 8A to D and allows maintenance of a patent hypopharyngeal segment. In larynx-sparing resections for tumor in this area, the forearm flap provides a thin lining to restore this intricate anatomy. In patients who have piriform sinus carcinoma, an extended hemilaryngectomy can be performed with restoration of the circumference of the trachea with a cartilage graft, which is wrapped by a forearm flap to provide a neovocal cord and hypopharyngeal repair [33,34]. The radial forearm flap can provide excellent surface coverage at the skull base to provide a barrier between the brain and sinonasal contents [35]. In the anterior cranial fossa, it can provide external coverage to seal the cerebrospinal fluid. Figs. 9A to D show the utility of having well-vascularized pliable tissue to restore the integrity of the skull base.

Summary The unique attributes of the radial forearm flap for head and neck reconstruction make it a primary choice from the reconstructive ladder. As more surgeons become familiar and comfortable with microvascular techniques and recognize the ease of its harvest, the popularity of this flap will increase. The radial forearm free flap should not be used for every head and neck defect. Flap choice should be dictated by the needs of the patient and those of the site to be reconstructed.

References [1] Yang G, Chen B, Gao Y, et al. Forearm free skin flap transplantation. Natl Med J China 1981;61:139. [2] Soutar DS, McGregor IA. The radial forearm flap in intraoral reconstruction: the experience of 60 consecutive cases. Plast Reconstr Surg 1986;78:1 – 8. [3] Soutar DS, Scheker LR, Tanner NSB, McGregor IA. The radial forearm flap: a versatile method for intraoral reconstruction. Br J Plast Surg 1983;36:1 – 8. [4] Soutar DS, Widdowson WP. Immediate reconstruction of the mandible using a vascularized segment of radius. Head Neck 1986;8:232 – 6.

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