Patency of radial arteries reconstructed after radial forearm flap harvest

Poor patency is cited as a reason to not perform radial artery reconstruction after the harvest of the radial forearm flap. The need for a long vein graft and the presence of a patent ulnar artery are offered as explanations for thrombosis of the reconstruction in this setting. Similar arguments have been made regarding radial artery reconstruction in the trauma setting. In this study, the patency rate for patients undergoing radial forearm flap harvest with immediate reconstruction with reversed interposition vein grafting was evaluated. The mean follow-up time was 24 months, and all seven patients had patent reconstructions. Ultrasound examination revealed slightly larger diameters of the vein grafts compared with native arteries. No areas of stenosis were detected. No complications resulted from harvest of the vein. From these data, we conclude that radial artery reconstruction can be performed with the expectation of patency.     

The radial forearm flap

Described in 1981 by the Chinese authors Yang Kuofan et al. [1] as a free flap, then in 1982 by Lu et al. [2] as a retrograde flow pedicle flap, this fasciocutaneous flap is designed at the level of the anterior and external faces of the forearm, and vascularized by the radial artery via a network of septal arteries. Prior to utilization it must be reversed on its distal pedicle. This flap allows repairing cutaneous substance loss of the whole hand and fingers. The emergence of the Chinese flap in the 1980’s resulted in a regression of the Mac Gregor groin flap that was widely used at this time [3,4]. Nevertheless, other forearm flaps, less “expensive” in terms of vascular involvement [5–9] have reduced its indications. The Chinese flap however keeps two essential indications: the multi-finger important defect that no other forearmflapmay cover; and composite substance loss of the thumb (despite the fact that the Chinese flap shares these indications with interosseous artery composite flaps).     

Reestablished circulation after free radial forearm flap transfer

New circulation in the free flap reestablished at the recipient site is the key to successful microvascular reconstructive surgery. This study is the first evaluation of long-term circulatory changes in nine free radial forearm flap transfers. Postoperatively, color Doppler studies revealed that the flow volume through the arterial pedicle increased rapidly during the first 3 days, gradually increased until day 14 (exceeding flow volume through the facial artery of the unoperated contralateral side), then decreased slightly until the sixth month. The pulsatility index, representing vascular resistance downstream, decreased successively. Ohm's law explains that this flow increase is caused by reduced vascular resistance downstream, attributed to changes in the vascularity of the transferred flap and in the recipient bed. The authors believe the circulatory changes are determinants of the clinical properties of the flap. This study addresses the importance of clarifying the events that transpire at the macroscopic circulatory level in the transferred free flap.     

The shamrock flap: a three-paddle radial forearm flap

The radial forearm flap has been well described for reconstruction of the oral cavity. The flap is most commonly used as a single-paddle flap with or without a segment of vascularised radius. Double-paddle radial flaps may be required to reconstruct defects of intraoral lining and overlying skin following excision of extensive tumours. We wish to report the first described case of reconstruction using a triple-paddle radial forearm flap including a segment of vascularised radius.     

Oblique radial forearm reverse-flow flap

A modifed design for the distally-based radial forearm flap is presented, in an oblique direction rather than longitudinally, based on the existence of skin laxity in the proximal forearm region. The skin paddle of the flap is designed in an oblique fashion pedicled on one of the proximal-row septocutaneous perforators, and elevated in the usual manner supplied by the distal radial artery. The oblique radial forearm flap thus created was successfully utilized for reconstruction of seven dorsal hand defects. Results showed that all the flaps could easily be transposed to the defect through a wide arc of rotation and all survived totally, with direct closure of the donor site in five cases, and significant reduction in size in the remaining two cases. It was concluded that the oblique design for the skin island of the reverse radial forearm flap could allow creation of a flap that has a smaller donor defect and yet presents a longer pedicle length, with a wider arc of rotation and better adaptation to a dorsal hand defect, than a conventional longitudinal-design radial forearm flap.     

Longitudinally-split radial forearm flap.

We have applied the split flap concept to a distally-pedicled radial forearm flap to cover separate dorsal defects of the fingers in two cases. The rationale is that there are the vascular plexuses inside and around the sensory nerve that permit surgical splitting of the flap. In the split design, the first segment is supplied by the radial artery itself. The second segment is supplied by the neurocutaneous artery of the medial cutaneous nerve.     

Resurfacing of the nasopharynx after nasopharyngectomy using a free radial forearm flap

BACKGROUND: Nasopharyngectomy is emerging as an important treatment option for salvaging locally recurrent nasopharyngeal carcinoma (NPC). After nasopharyngectomy, resurfacing the nasopharynx and covering the internal carotid artery is important to minimize the risk of infection, osteoradionecrosis, and carotid rupture. Previous authors have advocated the use of free grafts of skin and mucosa for this purpose but have also described significant rates of partial and total graft failure. METHODS: We believe that the best and most reliable way to resurface the nasopharynx is with vascularized tissue, and our preference is for the use of a free radial forearm flap. To illustrate our approach, we present two patients who underwent nasopharyngectomy by means of a maxillary swing approach and who had resurfacing of the surgical defect with a free radial forearm flap. RESULTS: Both patients had complete en bloc resection of tumor followed by the insetting of a free radial forearm flap to reline the surgical defect. Both flaps remained completely viable, and both patients achieved successful resurfacing of the entire nasopharynx. The morbidity of surgery was minimal, and there were no perioperative complications. On assessment 1 year later, the free radial forearm flap continues to reline the entire neonasopharynx, and the long-term functional recovery after surgery is excellent. CONCLUSION: Resurfacing the nasopharynx after nasopharyngectomy with a free radial forearm flap aids healing and minimizes the risk of complications. The morbidity of surgery is minimal and the functional recovery is excellent.     

Hemodynamic changes of the hand after radial forearm flap harvesting

After radial forearm flap harvesting, there is some risk for hand circulatory disorders. To reveal the changes in circulatory dynamics in the hand after harvesting this flap, the authors compared blood pressure and flow by color Doppler ultrasonography in the donor and nondonor hands, and evaluated the long-term changes in these factors in 40 patients undergoing this operation. Blood pressure and flow of the index finger in the donor hands were lower than those in the nondonor hands during the first 2 months postoperatively, but they virtually returned to the level of those in the nondonor hands within 1 year of the operation. These results suggest that after harvesting the radial artery, collateral circulation in the hand developed during a short postoperative period. Therefore, the authors can predict the long-term safety of forearm flap harvesting by evaluating the hemodynamic changes of the digits caused by acute occlusion of the radial artery preoperatively, which would reflect the hemodynamics at an early postoperative stage.     

Hypothenar hammer syndrome after radial forearm flap harvest: a case report

A case of acute hypothenar hammer syndrome (HHS) in a high-risk laborer in whom the radial artery had been surgically removed during a prior radial forearm flap harvest is reported. Studies estimating the true incidence of HHS among laborers are reviewed to define the risk of this complication. Two major risk factors must be considered in the assessment of a patient for radial forearm flap harvest. First, the risk for immediate vascular compromise is determined by using a standard Allen's test to assess ulnar artery contribution to hand perfusion. Second, the risk for future vascular compromise is determined. When patients at high risk for HHS are recognized the surgeon should consider other reconstructive alternatives. If the superficial palmar arch is patent and complete and a radial forearm flap is performed, postoperative activity modification and risk counseling should be provided.     

Haemodynamics of the radial forearm flap

An electromagnetic blood flow meter was used to study blood flow to the radial forearm flap intra-operatively in 20 patients. Blood flow correlated more significantly with surface area than with weight. Both antegrade and retrograde flow were measured and showed no significant difference. Temperature affected blood flow significantly (P less than 0.01) as did sympathetic block (P less than 0.01). The venous drainage of the flap was studied in five cases. Both superficial and deep systems were equally capable of draining the flap.     

Adipofascial radial forearm flap after failed surgical treatment of lateral epicondylitis

Secondary cases of lateral epicondylitis after failed surgical treatment are a particular therapeutic challenge. Excision of the scar tissue and muscle transposition have been advocated as alternative procedures, although the optimal treatment has yet to be established. We present one desperate case of failed surgical treatment of lateral epicondylitis, where an adipofascial radial forearm flap was used successfully to alleviate the patient's symptoms.     

Closure of the ulnar forearm free flap donor site using a local radial forearm flap.

Thin, pliable cutaneous flaps with large calibre vessels ideal for microsurgical transfers are major attributes of the reliable forearm fasciocutaneous flaps. A major detriment, however, that must always be considered is the management of the residual donor site deformity. Just as this potential morbidity for small radial forearm free flap donor sites may be minimised by the V-Y advancement of a local ulnar forearm flap, the converse, using a local radial forearm flap for closure of the ulnar forearm free flap donor site, may be efficacious.     

Tongue reconstruction with free radial forearm flap after hemiglossectomy: a functional assessment

Thirty-three patients with squamous cell carcinoma of the anteriolateral part of the tongue underwent a 50 percent resection of the tongue. The surgical defect was reconstructed with a microvascular radial forearm flap. All the flaps were especially designed to have a narrow waist, shaped like an omega in cross-section, thus allowing for a free tongue tip, and avoiding suturing the edge of the flap to the soft palate and tongue base. Sixteen patients were evaluated for swallowing and speech function at least 6 months following reconstruction. With this technique, the majority of the patients had nearly normal deglutition, although their speech was still unsatisfactory. However, the speech function in this series was better than that in other reported series.     

Complications of radial forearm flap donor sites

The complications of radial forearm flap donor sites in 15 patients from two centres have been reviewed. The complications included skin graft failure, swelling of the hand, stiffness of joints, reduced strength and sensation, cold-induced symptoms and fractures of the radius. Methods to reduce the incidence of such complications are discussed.     

Neural anatomy of the radial forearm flap

Typically the lateral antebrachial cutaneous nerve alone is used to innervate the radial forearm free flap when a sensate flap is required. The authors desired, by means of fresh cadaveric microdissections and by means of local anesthetic injections in living subjects, to map the sensory nerve territories of this flap. Eight radial forearm flaps were elevated and the medial antebrachial cutaneous nerve (MABC), lateral antebrachial cutaneous nerve (LABC), and superficial radial sensory nerve (SRSN) were dissected with the aid of an operating microscope (2.5-10x) and traced to their dermal insertions. In the injection study, the MABC, LABC, and SRSN in eight forearms of 4 subjects were blocked sequentially with 2% lidocaine injections. The resulting sensory deficit from each injection was mapped on the skin and superimposed on the marked radial forearm flap territory. Distribution of the three dissected nerve regions and the sensory deficit after injection were determined by digital images and computer analysis. During flap dissections, mean nerve distributions of total flap area were as follows: LABC, 61.8% (range, 48.3-71.6%); MABC, 33.8% (range, 30.5-38.9%); and SRSN, 34.6% (range, 26.8-44.1%). After nerve block the mapped sensory areas were as follows: LABC, 62.3% (range, 44.5-88.5%); MABC, 19.6% (range, 8.0-35.8%); and SRSN, 19.5% (range, 9.9-26.3%). At least 40% of the total flap area was not innervated by the LABC as identified both by nerve dissection and sensory local anesthetic blockade. By including the LABC, MABC, and SRSN in the radial forearm flap, both the theoretical and the clinically determined useful sensory innervation of the radial forearm flap potentially would be increased.     

Neophalloplasty using a rectus abdominis muscle flap and a radial forearm free flap

Summary A method for construction of a neopenis in female-to-male transsexual patients is described. The method consisted of inferior transposition of a rectus abdominis island muscle flap with resurfacing using a radial forearm free flap. Excellent internal support and a natural looking appearance was achieved. This technique was considered to be better than any other previously used method of neophalloplasty.