Mandibular reconstruction using osteocutaneous radial forearm flap

Objective: To describe the use of radial forearm osteocutaneous free flap in complex mandibular reconstruction. Study Design: A case series. Place and Duration of Study: Combined Military Hospital, Rawalpindi, from January 1998 to January 2008. Methodology: Patients having a small bony component and a large soft tissue mandibular defect requiring reconstruction were selected. These defects include composite through-and-through defects of the cheek in the retromolar trigone, small lateral bony defects with large intra and extra oral soft tissue defects and small central bony defects with large extra oral tissue loss. Radial forearm osteocutaneous free flap was employed. Complications and graft acceptance were determined at follow-up. Results: Patients were followed-up for an average period of 28 months. Complications occurred in 8 patients. Wound infection and partial wound dehiscence were the most common complication observed in 3 patients. Non-union at recipient site was seen in 2 patients. Flap donor site healed uneventfully in all patients with no fractures at the donor site. Conclusion: The radial forearm osteocutaneous flap covers oromandibular defects with large intra-oral and extra oral soft tissue losses. Lateral and anterior mandibular defects were reconstructed satisfactorily in our series.     

Nonmicrosurgical transfer of the radial forearm flap for head and neck reconstruction

In this article I present a nonmicrosurgical technique for transferring the radial forearm flap for reconstruction of defects in the head and neck. The technique is described briefly and experience with 7 patients is presented. The advantages of this method are discussed.     

Eye socket reconstruction with free radial forearm flap

Deformity of the orbital region and contraction of the eye socket were encountered in 3 patients who in their infancy underwent exenteration of the orbit and postoperative irradiation for the treatment of retinoblastoma. These major problems were attributed to the less-vascularized cicatricial conjunctiva left in place. To solve these disadvantages, a microvascular technique using a free radial forearm flap was adopted. A large permanent eye socket was achieved and depression deformity of the orbital region was corrected in a one-stage operation. This is, to our knowledge, the first report on the use of a free vascularized skin flap for "malignant contracture" of an anophthalmic eye socket. The excellent cosmetic results of this method are demonstrated.     

Osteocutaneous radial forearm flap for hand reconstruction.

We treated 5 patients (4 men and 1 woman) with bone and soft tissue defects or total thumb loss using an osteocutaneous radial forearm flap. Their ages at the time of surgery ranged from 27 to 65 years (mean, 53 years). Preoperative conditions were traumatic loss of the thumb in 3 cases and severe injuries with soft tissue and bone defects in 2. The length of the donated radius ranged from 2 to 7 cm (mean, 4.7 cm). In 4 patients the radial forearm flap was transposed, including the lateral antebrachial cutaneous nerve as a sensory flap. Simultaneous iliac bone grafting to the donor site was also performed in 4 of the cases. The follow-up period ranged from 44 to 87 months (mean, 64 months). All flaps survived over their full extent. Radiographic bone union was attained after 2 to 3 months (mean, 2.5 months). Two-point discrimination over the 4 sensory flaps ranged from 8 to 15 mm (mean, 10.8 mm). No radius fractures occurred. No patients showed signs of vascular insufficiency from sacrifice of the radial artery. The radial forearm flap provides thin skin of good texture together with bone for a 1-stage reconstruction. For patients with skin and bone defects of the hand, a radial forearm osteocutaneous flap is recommended. This flap is also recommended for patients with traumatic thumb loss, if the dorsalis pedis artery is absent, or if the patient declines using tissue from the foot.     

The radial forearm island flap in upper limb reconstruction

The radial forearm island flap may be used for resurfacing areas of skin in the upper limb. It allows a safe one stage reconstruction of skin loss providing thin, pliable and innervated skin cover. We present five cases which demonstrate the versatility of the flap.     

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.     

Fail-safe drainage procedure in free radial forearm flap transfer

The reliability of the free radial forearm flap is widely accepted; however, postoperative venous thrombosis still occurs occasionally. Thus, establishment of a fail-safe drainage system has been a challenging frontier. A total of 405 consecutive free radial forearm flap transfers, carried out in the authors' department between 1987 to 2002, were reviewed retrospectively. The most reliable drainage method comprised the dual flap drainage veins of the superficial venous system (the cutaneous vein) and the deep system (the radial vena comitans), including their connecting cubital perforating vein, and the two neck recipient veins of the internal jugular and the external jugular venous systems. None of the flaps transferred by this method incurred venous failure, regardless of the surgeons conducting the operation. This study on the venous network in drainage systems of the free radial forearm flap demonstrated that the described method functions in a self-sustaining manner, and contributes to protection against venous catastrophe.     

Evaluation of moving and static two point discriminations of volar forearm skin before and after transfer as a sensate radial forearm island flap in reconstruction of degloving injury of the thumb.

In degloving injury of the thumb the large skin defect needs cover with sensate, glabrous and pliable skin. Although coverage of this defect with a sensate free flap from the foot is the best choice, most commonly, cover is achieved using a non-sensate distant pedicle flap. Between 2001 and 2003, degloving injuries of the thumb in eight patients were reconstructed using a sensate radial forearm flap in the sensory territory of the lateral ante-brachial nerve of the forearm which was repaired to the digital nerve of the thumb (six cases) or to a branch of the sensory radial nerve (two cases). Follow-up period ranged from 17 to 41 months (mean: 29.9 months). Sensory evaluation was performed using the moving two point discrimination (M-2PD) and static two point discrimination (S-2PD) of the volar forearm skin. These altered significantly after transfer and their values approached those of the contra-lateral thumb but never reached normal sensation (p<0.01). Sensate radial forearm island flap is a reliable option to cover a large defect of the thumb such as degloving injury and the sensation produced is acceptable.     

Reversed radial forearm flap: an ad hoc flap for hand reconstruction

Complex wounds of the hand and vital structures are important to reconstruct. They should be covered as soon as possible in order to maintain the function of the hand. The reversed radial forearm flap is a versatile option for hand reconstruction. Reversed radial forearm flaps were harvested in 15 cases. Doppler ultrasound was used in all cases to evaluate the vascular status of the flap. No complications were observed in this series. All skin grafts healed well. The reversed radial forearm flap is a workhorse tool for the coverage of the hand.     

Free radial forearm adiposo-fascial flap for inferior maxillectomy defect reconstruction

A free radial forearm fascial flap has been described for intraoral reconstruction. Adiposo-fascial flap harvesting involves few technical modifications from the conventional radial forearm fascio-cutaneous free flap harvesting. We report a case of inferior maxillectomy defect reconstruction in a 42-year-old male with a free radial forearm adiposo-fascial flap with good aesthetic and functional outcome with minimal primary and donor site morbidity. The technique of raising the flap and closing the donor site needs to be meticulous in order to achieve good cosmetic and functional outcome.     

Phalloplasty for female transsexuals with sensate free forearm flap

One of the primary goals of phalloplasty on female to male transsexuals is to void while standing. However, achieving competence of the neourethra, sensation, and rigidity of the neophallus still present a challenge. Over a 5 year period (1988–1993), 56 phalloplasties using sensate free forearm flaps were performed for 56 primary female transsexuals. The urethrocutaneous fistula rate was 38/56 and one flap totally necrosed. However, when the flap was prefabricated with a tubed graft of vaginal mucosa for the 28 cases (the later part of the series), there were less complications and a lower fistula rate within this portion of the neourethra. Although the whole procedure was time consuming, it was worthwhile and patient satisfaction was high. © 1994 Wiley-Liss, Inc.     

Digital reconstruction using the distally based osteofasciocutaneous radial forearm flap

The Chinese forearm flap is a versatile flap in hand reconstruction. Five cases are reported. The mechanism and reliability of retrograde venous return is discussed.     

Burned ear reconstruction using a prefabricated free radial forearm flap

Postauricular skin, postauricular fascia, temporoparietal fascia (pedicle or free), the free radial forearm flap (fascial or fasciocutaneous), and free lateral arm fascial flap, have been used for burned ear reconstruction reported in the literature. Patients who did not have normal tissue around the ear region, because of severe thermal injuries to the external ear, are not available for draping the costal cartilage framework; these patients require free flaps. The author reports a burned ear reconstruction, using a prefabricated free radial forearm fasciocutaneous flap, included an autogenous costal cartilage framework. In this case, the front and back of the cartilage framework were covered with the skin of the forearm flap. This is the main difference from other techniques in the literature. This flap is valuable for burned ear reconstruction, when local tissue and other free flaps are not available.     

Mucosal prelamination of a radial forearm flap for intraoral reconstruction

Until now the microvascular fasciocutaneous radial forearm flap has been one of several methods favoured for reconstruction of intraoral soft tissue defects after radical resection of squamous cell carcinoma. Mucosal reconstruction and lining has been performed by a skin island, this is epidermis and cannot produce mucus. In order to provide mucosal properties and allow mucus production, a distal radial forarm flap has been successfully prelaminated with buccal mucosa in five patients. By this method thin, pliable and resistant flaps have been produced. Due to mucosal spreading, the mucosa lined area was 30–50% larger than the originally inserted mucosal grafts. Preservation of skin and subcutaneous tisssue lowered donor site morbidity. This technique has also been performed in axial pattern flaps; two osteofasciomucosal fibulae and three myomucosal pectoralis major flaps. Received: 17 July 1997 / Accepted: 15 October 1997     

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).     

Microsurgical penile reconstruction with a sensitive radial forearm free flap

A series of six consecutive cases of total penile reconstruction with a sensitive forearm free flap based on the radial artery is presented. A simple, reliable, and easily reproducible technique with an acceptable aesthetic appearance is described. No partial or complete flap losses were found. The only complication found in three patients was a urinary fistula on the distal third of the flap, which was repaired successfully with a secondary surgical procedure. The aesthetic and functional outcome was satisfactory to the patient and surgical team in all cases. A sensitive radial forearm free flap is a good choice of treatment for total penile reconstruction.