Reconstruction of the replanted hand with latissimus dorsi muscle and serratus anterior fascia combined flap

Reconstruction with the latissimus dorsi muscle flap, combined with the serratus anterior fascia flap, was performed to cover two large and separate palmar and dorsal forearm skin defects in a patient, whose hand had been replanted 20 days earlier after traumatic amputation at the distal forearm level. As a result, a total forearm amputation was salvaged by microsurgical replantation and a free combined flap of the subscapular system. This new application of the combined flap allowed the reconstruction of large and separate wounds of the replanted hand, and provided gliding surfaces for tendons.     

Two modifications of the radial forearm flap for reconstruction of complex facial defects

The free radial forearm flap has been one of the most common free flaps of recent decades. This flap is employed predominantly in head and neck reconstruction. The possibility of combining bone, muscle, and nerves with the fasciocutaneous flap greatly enhanced reconstructive options. However, the frequently unsightly donor site and the development of other readily available free flaps have led to a decline in the use of the radial forearm flap. Nevertheless, for reconstruction in head and neck surgery, with the need for thin, pliable tissues and a long vascular pedicle, the radial forearm flap still remains a prime choice. Two modifications of the standard forearm flap are presented. The first patient had two large defects at the nose and mental area after radical resection of a basal-cell carcinoma. Soft-tissue reconstruction was achieved with a conventional forearm flap and a second additional skin island based on a perforator vessel originating proximally from the pedicle. Both skin islands were independently mobile and could be sutured tension-free into the defects after tunneling through the cheek, with vascular anastomosis to the facial vessels. The second patient required additional volume to fill the orbital cavity after enucleation of the eye due to an ulcerating basal-cell carcinoma. In this case, the body of the flexor carpi radialis muscle was included in the skin flap to fill the defect. The skin island was used to reconstruct the major soft-tissue defect.     

骨间前动脉桡侧骨皮支皮瓣的临床应用

目的：研究应用骨间前动脉桡侧骨皮支皮瓣的方法和疗效。方法：利用骨间前动脉桡侧骨皮支与肌皮支恒定吻合,供养前臂背侧较大区域皮肤的解剖学基础,形成前臂背侧桡侧皮瓣,修复虎口部皮肤缺损4例。结果：皮瓣全部成活,术后随访外形功能良好。结论：骨间前动脉桡侧皮支皮瓣具有切取简便,血供可靠,创伤小的特点,是临床较为理想的选择。     

Radial forearm free-flap reconstruction following radiotherapy and total laryngectomy

The authors' experience with six patients who underwent radial forearm free-flap reconstruction following radiotherapy and total laryngectomy is presented. All patients had undergone previous irradiation of 57.8 Gy on average as primary treatment for laryngeal cancer. A patch graft of the radial forearm free flap was used for pharyngoesophageal wall reconstruction in three patients, a radial forearm free flap for cervical soft tissue in one patient, and a double-folded radial forearm free flap for simultaneous pharyngoesophageal wall and cervical soft tissue in two patients. The free-flap transfers were successful in all patients. There was one patient who developed a small pharyngocutaneous fistula, which closed spontaneously. The radial forearm free flap is demonstrated to be a versatile technique for reconstruction of a moderate-sized defect in the treatment of laryngeal cancer.     

Free flap closure in complex congenital and acquired defects of the palate

Extensive palatal defects cause substantial morbidity, including nasal regurgitation, poor oral hygiene, loose-fitting obturators, and difficulty with speech. Microvascular techniques allow the surgeon to repair these complex defects with a one-stage reconstruction, in contrast to possible multistage local or regional flap reconstruction. In this retrospective review, the authors present their 5-year experience with free flap coverage of extensive palatal defects. From 1993 to 1998, 6 patients underwent free flap coverage of large palatal defects. The etiology of the large palatal defects included trauma (N = 1), neoplasm (N = 4), and a recurrent congenital cleft palatal fistula (N = 1). Three patients underwent osteocutaneous radial forearm flaps and 1 patient underwent a fasciocutaneous radial forearm flap. The remaining 2 patients underwent rectus abdominis muscle flaps. The ipsilateral facial artery and vein were used as the recipient vessels in all patients. There were no intraoperative complications (surgical or anesthetic). Postoperatively, 2 patients had surgical evacuation of small flap hematomas. One patient underwent revision of the fasciocutaneous flap. All flaps survived. In our experience, the benefits of free flap reconstruction of complex palatal fistulas seem to outweigh the risks of the operation, with reliable long-term results.     

A buried reversed radial forearm flap in pharyngeal reconstruction: refinements and monitoring

Pharyngeal reconstruction can be accomplished in a variety of ways, from pedicled to free revascularized tissue transfers. The use of an extra skin paddle combined with a buried radial forearm flap, which permits long-term postoperative monitoring under direct vision, has been described before. In this study, we monitored nine patients who had undergone pharyngeal reconstruction with a buried reversed radial forearm flap. Our modified technique gave better coverage of the large vessels and a better postoperative neck contour, prevented esophageal leakage and facilitated continuous postoperative patient monitoring, without any significant additional donor site morbidity. Received: 18 January 2000 / Accepted: 14 February 2000     

Paraumbilical perforator-based pedicled abdominal flap for extensive soft-tissue deficiencies of the forearm and hand

A new paraumbilical-based pedicled abdominal flap was used in 11 patients with extensive soft-tissue defects of the forearm and hand. With a relatively narrow pedicle, large flaps up to 5- x 14-cm can be raised. Another advantage of this flap is the comfortable position of the hand and forearm for the patient. The main disadvantage is the conspicuous abdominal scars like the other pedicled abdominal flaps.     

Fibula free flap phalloplasty: Modifications and recommendations

Radial forearm flap phalloplasty should be regarded as the gold standard. The large forearm donor site scar, however, has led to the search for other donor areas. We present our modifications and recommendations for addressing the ideal goals of phalloplasty better when applying the fibula free flap. We recommend preconstruction and secondary anastomosis of the neo-urethra. Preoperative infiltration of the cutaneous nerve is recommended for planning of the sensate flap. The osseous part of the flap should be long enough to be fixed to the tunica albuginea. We recommend a longitudinal, rather than a transverse, design for the flap. For aesthetic reasons, the flap should include two triangular tongues. Even so, secondary surgery will be needed. The patient may be left with functional loss in the donor region. A case report illustrates all of these points. We conclude that the sensate fibula free flap has a place in phalloplasty in case the patient refuses a forearm scar. © 1997 Wiley-Liss, Inc. MICROSURGERY 17:358–365 1996     

Construction of penis with two free flaps

A case of penis construction using two free flaps is presented. The urethra is constructed with an ulnar forearm flap and external coverage is provided with deltoid flap. The biggest disadvantage with radial forearm flap, which is considered to be the most ideal donor flap for penile construction, is its large and unsightly donor scar. The authors have been using deltoid flap for penile construction because its donor scar is concealed under the half-sleeve shirt; however, its biggest disadvantage is its thickness. With the method presented here, an appropriate-size penis can be constructed even in an obese individual whose deltoid flap is thick. Donor scar is almost inconspicuous when the patient is wearing a half-sleeve shirt, because the donor scar on the forearm is 3-cm wide and located on the ulnar side.     

Full-thickness cheek and lip reconstruction with the radial forearm free flap

The radial forearm free flap has proven versatility in head and neck reconstruction. It is superior to regional alternatives such as the pectoralis flap because it is thin, pliable, and predominantly hairless. A more recent application is the use of the folded forearm flap to replace both the skin and inner lining, simultaneously, in full-thickness cheek and lip defects. Nine such cases are presented in this report. Each patient had a recurrent lesion that had been reconstructed previously with local flaps, and all but one were treated with postoperative radiation therapy. The average size of the external defects after resection was 27 cm2, and of the intraoral defects, 18 cm2. All free flaps survived completely. The folded forearm flap solved the reconstructive problem for each patient in a single-stage procedure, providing good contour and a reasonable color match. The flap is easy to raise, has a long pedicle with large-diameter vessels, and has an acceptable donor site defect not associated with long-term morbidity.     

Reconstruction of Complicated Skull Base Defects Utilizing Free Tissue Transfer

We managed five patients with large skull base defects complicated by complex infections with microvascular free tissue transfer. The first patient developed an infection, cerebrospinal fluid (CSF) leak, and meningitis after undergoing a translabyrinthine resection of an acoustic neuroma. The second patient had a history of a gunshot wound to the temporal bone, with a large defect and an infected cholesteatoma that caused several episodes of meningitis. The third through the fifth patients had persistent CSF leakage and infection refractory to conventional therapy. In all cases prior attempts of closure with fat grafts or regional flaps had failed. Rectus abdominis myofascial free flap, radial forearm free flap or a gracilis muscle free flap was used after debridement of the infected cavities. The CSF leaks, local infections, and meningitis were controlled within a week. In our experience, microvascular free tissue provides the necessary bulk of viable, well-vascularized tissue, which not only assures a mechanical seal but also helps clear the local infection.     

Tongue reconstruction with a combined brachioradialis-radial forearm flap

Total glossectomy adversely affects speech and swallowing, and subsequent reconstruction results in limited functional return. The radial forearm flap has been reliably used to resurface glossectomy defects, but has limited bulk with which to aid in palatoglossal contact for speech. The authors have modified the forearm flap by incorporating a segment of brachioradialis muscle, to increase bulk posteriorly and to aid in speech. Sufficient muscle perforators arise from the proximal brachial artery and enter the brachioradialis to permit transfer of the muscle with the fasciocutaneous forearm flap as a single free-flap unit. The muscle is folded onto itself and enclosed within the forearm flap skin to create a neotongue. Coaptation of the antebrachial cutaneous nerves can provide a senate flap. Successful transfer of the combined brachioradialis/forearm flap in a patient who had undergone total glossectomy resulted in a neotongue good shape. Speech was rated good by a speech pathologist, and palatoglossal contact was observed on cineoradiograph. No functional loss at the donor site occurred. Inclusion of the brachioradialis muscle with the radial forearm flap as a combined unit results in a neotongue with good form and increased bulk posteriorly at the base, compared to a standard fasciocutaneous flap alone. This is a useful variation of the forearm flap. Sensory return is possible if the medial and/or lateral antebrachial cutaneous nerves of the flap are coapted to the lingual nerve.     

Use of the radial forearm free tissue flap to treat persistent stricture after esophagogastrectomy.

BACKGROUND: Persistent stricturing or anastomotic leakage at the cervical esophagogastric anastomosis can be a troublesome complication of gastric pull-up procedures. When the stricture is the result of ischemia of the stomach, the strictures are long and often not responsive to dilatation and require large operations such as jejunal interposition or replacement with colonic pull-up. In this report we describe the use of a radial forearm flap to patch strictures. METHODS: The radial forearm flap is a fascia cutaneous flap taken from the forearm and based on the radial artery and its venae comitantes. The advantages of this flap are that it is thin and pliable, conforms easily, has excellent reliability due to the size of the feeding vessels, and has a relatively long pedicle. The vascular anastomosis can be made to several arteries and veins within the neck. The epithelial component can be made in sizes up to 10 by 20 cm. RESULTS: We have used the radial forearm flap to patch strictures in 6 patients with persistent complex strictures in the cervical region after esophagectomy. Results were excellent in 4 patients (able to eat liquids and solids without problems) and good in 1 patient (liquids okay, some problem with solids), and 1 patient died postoperatively. Follow-up is 4 months to 7 years. CONCLUSIONS: The radial forearm flap is an excellent option for handling persistent stricture after esophagogastrectomy. In many instances, this flap can be used in lieu of a jejunal interposition flap and obviates a laparotomy to harvest jejunum. The flap fits easily into the neck and conforms to the space.     

Experiences with the flow‐through radial forearm flap as a bridge in lower extremity reconstruction

Various techniques have been proposed in order to overcome recipient vessel problems in microsurgery. In cases with no suitable recipient vessels close to the defect, the flow‐through flap is a valuable and reliable alternative for accessing healthy recipient vessels in a single stage. We describe our experiences with combined flaps and discuss the advantages of the flow‐through radial forearm flap as a bridge. Between 2003 and 2009, eight combined flaps were used to reconstruct soft‐tissue defects of lower extremities. Seven patients had acute or subacute wound with exposed bone and vascular injury caused by trauma, one had a chronic nonhealing wound. The flow‐through radial forearm flap was used as a bridge flap with combined a cover flap in all cases. Radial forearm flaps provided recipient vessel lengthening. In one patient, the distal ALT flap failed and replaced with latissimus dorsi flap. Other postoperative courses were uneventful and all of flaps survived. In one patient although the flaps were healthy, sepsis developed and the extremity was amputated. Recovery and ambulation were achieved in the remaining patients. Combined flaps with the flow‐through radial forearm flap are an appropriate technique for overcoming recipient vessel problems. Although the technique involves a more complicated procedure and increases the number of microvascular anastomoses, it is a valuable, safe and comfortable alternative in selected cases. © 2015 Wiley Periodicals, Inc. Microsurgery 36:128–133, 2016.     

A comparison of the donor-site morbidity after using the prelaminated fasciomucosal flap and the fasciocutaneous radial forearm flap for intraoral reconstruction.

Since 1996 we have performed mucosal prelamination of the distal radial forearm flap for functional reconstruction of defects of the intraoral lining. This study was undertaken to demonstrate that the prelaminated fasciomucosal radial forearm flap can provide physiological oropharyngeal reconstruction with mucus-producing tissue, while avoiding the donor-site complications of the fasciocutaneous radial forearm flap. We examined the donor hand at least 6 months postoperatively in 20 patients after using a prelaminated fasciomucosal radial forearm flap and in 15 patients after harvesting a classical fasciocutaneous radial forearm flap. The evaluation of hand function included range of motion, grip power, pinch power, sensibility and vascular analysis in both hands. The patients were asked about cold intolerance, pain and any restrictions in daily life, and the cosmetic appearance of the donor hand was noted. In the prelaminated-flap group (n 20), two patients had decreased wrist extension, and one of these patients also had reduced strength and mild hypaesthesia in the donor hand. In the classical-fasciocutaneous-flap group (n 15), six patients had decreased wrist extension, five patients had reduced strength and four patients had diminished sensibility in the donor hand. Painful neuromas were found only after fasciocutaneous flaps (three cases). Subjective assessment revealed restricted hand function in one patient in the prelaminated-flap group, and in five patients who had undergone fasciocutaneous flap transfer. The results of this study show that using the prelaminated fasciomucosal radial forearm flap minimises the donor-site morbidity. Furthermore, we were able to improve the cosmetic appearance of this very exposed region.     

Latissimus dorsi musculocutaneous free flap transplantation to salvage below-elbow amputation in an emergency operation: A case report

We used a free latissimus dorsi musculocutaneous flap (LD m-c flap) to cover a large skin defect at the stump of a forearm in an emergency operation. The patient we discuss is a 52-year-old man. Amputation at the distal one third of the left forearm occurred after catching his hand and wrist in a machine. The amputated left hand was severely damaged and there were wide skin defects. The function of the elbow joint was well preserved. Both the radius and ulna were cut 7 cm distal from the elbow joint. A 20 × 8 cm square of LD m-c flap was transplanted to the stump of the forearm. The flap survived without incident. The range of motion of the elbow joint was from 20° to 85°. The prosthesis was well fitted to the stump, and the patient returned to his workshop 9 months after injury. © 1996 Wiley-Liss, Inc.     

Experiences with an arterialized venous flap for intraoral defect reconstruction

This clinical investigation should try out the suitability of arterialized venous forearm flaps for immediate reconstruction of intraoral defects after excision of an oral squamous cell carcinoma. In contrast to the free radial forearm flap there is no need for either sacrificing a peripheral artery or jeopardizing motor nerves. As the exact function of arterialized venous flaps is still unknown we had to take into account the possible loss of the flap. Therefore we used this flap in patients with small or medium sized defects only. All skin fat flaps were raised out of the right forearm using two different flap types. In 34 patient we used a flap with a superficial vein passing through (type I), in 5 patients we took a flap with two parallel proximal veins (type II). After the flap had been sutured into the intraoral defect, in flap type I the original distal end of the vein was anastomosed to an artery and the original proximal end to a vein. In flap type II there was no specific differentiation between the veins both. 18 (46.2%) of the flaps survived completely, 9 (23%) had superficial epithelial loss or some marginal necrosis and 12 (30.8%) became completely necrotic. Areas of partial loss developed slowly and formed stable granulation tissue. The flap donor sites were either closed primarily (n = 19) or were covered with split thickness skin graft (n = 20). There were no functional problems of the donor forearms. These results contrast with the high success rates achieved with orthodox free forearm flaps. Further research into venous flaps is essential.     

Peroneal perforator‐based peroneus longus tendon and sural neurofasciocutaneous composite flap transfer for a large soft‐tissue defect of the forearm: A case report

We describe the use of a composite flap composed of a sural neurofasciocutaneous flap and a vascularized peroneus longus tendon for the reconstruction of severe composite forearm tissue defects in a patient. A 43‐year‐old man had his left arm caught in a conveyor belt resulting in a large soft‐tissue defect of 18 × 11 cm over the dorsum forearm. The extensor carpi radialis, superficial radial nerve, and radial artery were severely damaged. A free neurofasciocutaneous composite flap measuring 16 × 11 cm was outlined on the patient's left lower leg to allow simultaneous skin, tendon, nerve, and artery reconstruction. The flap, which included the peroneus longus tendon, was elevated on the subfascial plane. After the flap was transferred to the recipient site, the peroneal artery was anastomosed to the radial artery in a flow‐through manner. The vascularized tendon graft with 15 cm in length was used to reconstruct the extensor carpi radialis longus tendon defect using an interlacing suture technique. As the skin paddle of the sural neurofasciocutaneous flap and the vascularized peroneus longus tendon graft were linked by the perforator and minimal fascial tissue, the skin paddle was able to rotate and slide with comparative ease. The flap survived completely without any complications. The length of follow‐up was 12 months and was uneventful. Range of motion of his left wrist joint was slightly limited to 75 degrees. This novel composite flap may be useful for reconstructing long tendon defects associated with extensive forearm soft tissue defects.     

Reconstruction of Lateral Skull Base Defects with Radial Forearm Free Flaps: The Double-Layer Technique

Introduction The radial forearm flap has fallen out of favor in lateral skull base reconstruction in recent literature. However, especially when used in a double layer, a radial forearm may be able to provide the thickness of a large flap while taking advantage of the pliability for which the flap is renowned. Objective To report the results of the double-layer technique of radial forearm free flap reconstruction of lateral temporal bone defects. Design A retrospective chart review. Setting A tertiary care institution. Participants All consecutive patients who underwent lateral temporal bone resections and were reconstructed with free flaps from 2006 to 2012. Major Outcome Measures Flap success rate, complications, and rate of revision surgery. Results A total of 17 patients were identified with free flap reconstruction of the lateral skull base. Seven received reconstruction with a double-layer radial forearm flap. Reconstruction-related complications in this group included one case of facial cellulitis. The flap success rate was 100%. These results were comparable with patients who had other flaps. Conclusions The radial forearm free flap may be an effective reconstruction option for lateral temporal bone defects especially when used in the double-layer technique.     

The Radial Forearm Flap: A Report of Two Cases with Antegrade and Retrograde Arterial and Venous Flow

The utility of the radial forearm flap is demonstrated by presenting the flap in two variations, as a free flap and as a reversed pedicled flap. The recipient areas were a large temporo-frontal defect remaining after tumor excision which included the periosteum and a radionecrosis on the radial side of the wrist where a conventional flap had failed.