Free forearm skin flap with microvascular anastomosis for oral cavity reconstruction

Free forearm skin-fascia flap was used in 8 patients for intraoral reconstruction. Tissue defect was located in anterior part of the oral cavity in three patients and in lateral part in 5 patients. In the first three patients microvascular anastomosis was performed first and the flap was sutured in the oral cavity later on. In one of these patients the whole flap and in two patients about half of the flap necrotised. In the next 5 patients oral defect was closed first and then microanastomosis was done with good result in all the patients. We advise the last type of reconstruction. Free forearm skin-fascia flap provides good anatomical and functional result of reconstruction in the oral cavity.     

Radial forearm free flap pharyngoesophageal reconstruction

OBJECTIVES: This study evaluates the outcome of pharyngoesophageal reconstruction using radial forearm free flaps with regard to primary wound healing, speech, and swallowing in patients requiring laryngopharyngectomy. STUDY DESIGN: Retrospective review in the setting of a tertiary, referral, and academic center. PATIENTS AND METHODS: Twenty patients underwent reconstruction of the pharyngoesophageal segment using fasciocutaneous radial forearm free flaps. RESULTS: All free flap transfers were successful. An oral diet was resumed in 85% of the patients after surgery. Postoperative pharyngocutaneous fistulas occurred in 4 patients (20%) with 3 resolving spontaneously. Distal strictures also occurred in 20% of the patients. Five patients who underwent tracheoesophageal puncture achieved useful speech. CONCLUSIONS: Advantages of radial forearm free flaps for microvascular pharyngoesophageal function include high flap reliability, limited donor site morbidity, larger vascular pedicle caliber, and the ability to achieve good quality tracheoesophageal speech. The swallowing outcome is similar to that achieved after jejunal flap pharyngoesophageal reconstruction. The main disadvantage of this technique relates to a moderately high incidence of pharyngocutaneous fistulas, which contributes to delayed oral intake in affected patients.     

Free forearm skin flaps with microvascular anastomosis for pharyngeal reconstruction

Free forearm skin flap with microvascular anastomosis was used for tissue defect reconstruction in 4 patients after resection of the oropharynx, base of the tongue and ramus of the mandible. The vascular pedicle of the flap contained the radial artery and the cephalic vein. For microvascular anastomosis the facial artery was used in all the patients, the facial vein in 2 patients, the internal jugular vein in one patient and the external jugular vein in the other one. Good healing of the graft was obtained in 3 patients. In one patient partial necrosis developed. No patient had fistula.     

Orbital exenteration reconstruction with rectus abdominis microvascular free flap

OBJECTIVES: To determine the course of reconstructive treatment and outcomes with use of the rectus abdominis free flap after orbital exenteration with or without total maxillectomy. STUDY DESIGN: Retrospective chart review of treatment and outcomes of patients who had rectus abdominis free-tissue transfer for orbital exenteration with or without total maxillectomy at the Mayo Clinic between 1994 and 2004. METHODS: Charts of patients who had rectus abdominis free flap reconstruction after orbital exenteration were retrospectively reviewed and the surgical technique evaluated. An explanation of the surgical technique for rectus abdominis free-tissue transfer to the orbital cavity is provided, along with a discussion of the advantages and disadvantages of this reconstructive method. RESULTS: Twelve of 13 patients who underwent reconstruction with rectus abdominis free-tissue transfer had a successful outcome (flap viability 92%). Cosmetic results were acceptable both to patients and to surgeons. CONCLUSIONS: Rectus abdominis microvascular free-tissue transfer for repair of orbital exenteration defects is a safe and reliable alternative to the use of the temporalis or the pectoralis major muscle as a pedicle flap; it provides a larger volume of well-vascularized tissue and greater placement flexibility without associated orientation problems; and the long vascular pedicle facilitates the use of multiple donor vessels within the head and neck, which is an advantage in previously irradiated patients. Postoperative care and the donor site defect are well tolerated. The flap allows reliable obturation of the oral maxillectomy defect, and it negates the need for cavity care in these patients.     

Oropharyngeal reconstruction with radial forearm free flap: functional results

OBJECTIVE: The aim of this retrospective study is to evaluate functional results of oral and oropharyngeal reconstructions with radial forearm free flap. MATERIAL AND METHODS: We present our experience with radial forearm free flap for reconstructing oral and oropharyngeal defect between 2000 and 2004. A total of 96 patients were included in this study. We analysed functional results (alimentation, elocution, mouth opening and cosmetic appearance) and researched the potentialy predictive factors of these results (age, comorbidity, preoperative irradiation...; Chi 2 test). RESULTS: The rate of free flap success was 97.9%. Good functional results (normal or quasi normal function) were obtained for alimentation, elocution, mouth opening and cosmetic appearance in respectively 92.6%, 64.9%, 81.9% and 84.1% of cases. Age (p = 0.05), preoperative irradiation (p = 0.005) and T stage (p = 0,02) had a negative effect on elocution, free flap failure on mouth opening (p = 0.03), preoperative irradiation (p = 0.05) and free flap failure (p = 0,02) on cosmetic appearance. CONCLUSION: Radial forearm free flap is considered as the flap of choice for oral and oropharyngeal reconstructions and allows excellent functional results.     

喉全切除前臂桡侧游离皮瓣发音重建

喉全切除后发音重建一直是临床研究的重要课题之一，目前国内外已有众多方法，术后疗效亦各不相同。前臂皮瓣由杨果凡等于1979年8月创用，目前已广泛用于头颈部软组织缺损的修复，成为头颈缺损修复重建应用最多的游离组织瓣。我们将该皮瓣用于喉全切除后发音重建，自2001年10月-2003年1月共完成5例手术，本文对此手术效果、手术操作及一些有关问题进行回顾性分析。     

Oral and pharyngeal reconstruction using the free forearm flap

Recent progress in myocutaneous and free flaps has facilitated the primary closure of various complex defects resulting from ablative surgery of head and neck cancers. The musculocutaneous flap (such as the pectoralis major flap or the latissimus dorsi flap) has in particular proved its greater versatility. The forearm free flap for intraoral defects can provide thin and pliable skin and has great potential in the reconstruction of oropharyngeal defects. Between November 1982 and August 1985, we achieved 74 free forearm flap transfers for patients with head and neck cancers. Herein we present several clinical applications of the free forearm flap and discuss its advantages and disadvantages, especially hand morbidity after flap elevation.     

Oral cavity reconstruction using the free radial forearm flap

While a number of flaps are available that can "plug the hole" created by the resection of an oral cavity malignancy, the final functional and cosmetic result is often far from satisfactory. The ideal flap for this area should provide a one-stage, reliable reconstruction (regardless of previous surgery or irradiation) with the options of thin pliable skin and/or vascularized bone. Donor-site morbidity must be acceptable. In our experience, the free radial forearm flap best approaches these ideals. Unfortunately, it has received relatively little attention in the otolaryngology literature. The results of using 15 of these flaps to reconstruct 14 oral cavity defects are reported here. Despite the fact that most of the reconstructions were performed in older patients who had undergone irradiation (nine of 14) and previous surgical treatment (ten of 14), there were no flap failures. Hospital stays were short (less than two weeks), cosmetic results were good, and all but one patient had resumed oral intake by the time of hospital discharge. The specific applications and limitations of this flap are emphasized so that the reader can better understand its role in head and neck reconstructive surgery.     

Functional outcomes following palatal reconstruction with a folded radial forearm free flap

Defects of the soft palate often occur after extirpative procedures are performed to treat oropharyngeal cancers. These defects usually result in velopharyngeal insufficiency and an alteration in speech and deglutition. Palatal prostheses have been used to circumvent this problem in the past. Recently, however, folded radial forearmfreeflaps have been introduced for reconstruction of the soft palate to eliminate velopharyngeal insufficiency and the need for a prosthesis. We conducted a study to evaluate pharyngeal and palatal functions following reconstruction of soft-palate defects with radial forearm free flaps in 16 patients who had undergone resection of the soft palate for squamous cell carcinoma. Nine patients had partial soft-palate defects and 7 had total defects. All patients had lateral pharyngeal-wall defects. In addition, 14 patients had defects of the base of the tongue. Patients were followed for 3 to 40 months. Outcome measures were determined according to several parameters, including postoperative complications, resumption of diet, intelligibility of speech, and decannulation. All patients were evaluated by a speech pathologist and an otolaryngologist with a bedside swallowing evaluation and flexible nasopharyngoscopy. Twelve patients underwent videofluoroscopic studies. There was no incidence of flap failure. One patient developed a transient salivary fistula, which resolved with conservative management. Four patients without dysphagia resumed oral intake 2 weeks after surgery. The 12 patients with dysphagia underwent swallowing therapy. Ten of them responded and were able to resume oral intake, while the other 2 required a palatal prosthesis. Overall, 10 patients resumed a normal diet and 4 tolerated a soft diet within 6 weeks. The 2 patients who required a palatal prosthesis were able to take purees. All patients were decannulated, and all were able to speak intelligibly. Speech was hypernasal in 2 patients and hyponasal in 3. We conclude that the folded radial forearm free flap procedure is a useful alternative for reconstruction of palatal and pharyngeal defects. It is safe and effective, and it results in excellent functional outcomes.     

Functional outcome after partial glossectomy with reconstruction using radial forearm free flap

Objective

The purpose of this study was to investigate the relationship between the radial forearm free flap (RFFF) volume changes and speech and swallowing outcomes.

Methods

The study included 18 subjects with squamous cell carcinoma of the oral tongue.

Results

Average percentage changes in flap volume between 3 and 12 months was 19.2%. Postoperative free flap volume changes were significantly and negatively correlated with the word and sentence intelligibility (Y = −0.338X + 43.641, r² = 0.383, p = 0.006 and Y = −0.246X + 34.322, r² = 0.321, p = 0.014, respectively). A significant positive correlation was also found between word and sentence intelligibility and floor of mouth resected, postoperative irradiation. Postoperative flap volume changes between 3 and 12 months were correlated with reduced posterior bolus movement by tongue (p = 0.002), reduced tongue base to posterior pharyngeal wall contact (p = 0.002), reduced laryngeal elevation (p = 0.005), increased aspiration (p = 0.005), delayed oral (p = 0.010) and pharyngeal transit time (p = 0.011). Floor of mouth resected, tongue base resected, and postoperative irradiation also influenced the swallowing outcomes.

Conclusions

This study shows that postoperative flap volume changes are significantly related to speech and swallowing outcomes in patients undergoing partial glossectomy reconstructed with RFFF.     

A retrospective analysis of temporomandibular joint reconstruction with free fibula microvascular flap

OBJECTIVES: The temporomandibular joint is occasionally encountered in extirpative surgery of the head and neck. It presents a difficult management issue. Little has been reported on functional outcomes after resection and reconstruction of the temporomandibular joint. DESIGN: A retrospective analysis consisting of chart reviews and phone interviews was performed on 17 patients who underwent fibular free flap reconstruction of the temporomandibular joint from 1993 to 1998. RESULTS: Mean follow-up in surviving patients (10) was 41.3 months. Mean age of the group was 62; male-to-female ratio was 11:6. Average hospital stay was 11.6 days. Four patients had no radiation therapy, 2 had preoperative and 11 had postoperative treatment. Five patients had one osteotomy, seven had two, one had three, and one had four. Ten patients could chew, one could not, and none were recorded for the remaining. Diet consisted of regular food for two patients, soft food for seven, full liquids for four, and tube feeds for four. Cosmesis was judged as excellent by eight patients, acceptable by two, and unacceptable by two. Five patients did not describe cosmesis. Most patients stated that bony contour was excellent, but that the soft tissue defect was noticeable. Speech was judged as intelligible by seven and moderately understandable by one. Nine patients did not describe speech. Two patients had postoperative displacement of the fibular head out of the fossa. CONCLUSION: Primary reconstruction of the temporomandibular joint with microvascular fibular flaps is a viable and effective means of restoring function. The majority of patients are able to resume oral feeds, obtain excellent or pleasing cosmetic results, and maintain intelligible speech.     

Functional outcomes after hemiglossectomy and reconstruction with a bilobed radial forearm free flap

OBJECTIVE: This study examines prospectively the functional outcomes of a cohort of patients who had undergone hemiglossectomy and reconstruction with a bilobed radial forearm free flap (RFFF) for oral tongue squamous cell carcinoma. METHODS: Speech and swallowing data were compiled for patients treated for oral tongue cancer with hemiglossectomy and and reconstruction with a bilobed RFFF. The three evaluation periods were preoperative, postoperatively, and postradiation therapy. RESULTS: Eleven patients were included in the study. A significant difference between preoperative and postoperative single-word intelligibility scores was observed. There was no significant difference across any of the evaluation times for sentence intelligibility. Swallowing analysis revealed fewer instances of laryngeal penetration with liquids postoperatively. No significant differences were found in laryngeal penetration with either the pudding or cookie consistencies across any of the evaluation times. There was no incidence of aspiration at any of the evaluation times. There were no significant differences in the number of problems with the oral or oral preparatory phases across any of the evaluation times. The neurotization status of the RFFF had no significant effect on any of the observed speech or swallowing parameters. CONCLUSIONS: The bilobed RFFF provides functional speech and excellent swallowing outcomes in the reconstruction of hemiglossectomy defects.     

Fistula analysis after radial forearm free flap reconstruction of hypopharyngeal defects

Objective/Hypothesis: To evaluate risk factors and management options for fistula formation after hypopharyngeal reconstruction using the radial forearm free flap reconstruction. Study Design: Retrospective cohort study. Methods: Patients undergoing radial forearm free flap for hypopharyngeal reconstruction were retrospectively reviewed. A total of 104 patients underwent this procedure between 2001 and 2007. Fistulas were classified as mild or severe depending on the response to conservative management. Demographics, operative details, pathology, and postoperative course were recorded as the prognostic variables. Univariate analysis and a logistic regression model were used to identify associated factors. Results: Pharyngocutaneous fistula developed in 30 (28.8%) patients. Recurrence, cancer stage, cancer location, type of ablative surgery, and the addition of other oncologic procedures were identified as significant predictors of fistula formation. Fistula significantly increases hospital stay and recipient site complications such as flap survival, infection, and bleeding. Functional results such as diet, deformity, and socialization were also negatively affected by fistula development. One third of the cases responded to conservative management, and 20 cases required a surgical procedure to definitively close the fistulous track. Conclusions: Fistula formation remains a significant cause of morbidity associated with hypopharyngealreconstruction. Postoperative course and successful preventive strategies are discussed.     

Functional long-term results following hemipharyngo-hemilaryngectomy and microvascular reconstruction using the radial forearm flap

BACKGROUND: The surgical treatment of advanced hypopharyngeal carcinomas with infiltration of the laryngeal skeleton often includes total laryngectomy for functional reasons, although tumor infiltration is limited to only one half of the larynx. When not only the infiltrated half of the thyroid cartilage but also the cricoid cartilage of the involved side has to be removed, in spite of adequate reconstruction using local or pedicled flaps (f. e. pectoralis major flap) persistent dysphagia and aspiration prevent oral food intake and closure of the tracheostoma. These functional disturbances are increased by the negative effects of postoperative radiotherapy, which has to be applied in most of the cases for oncological reasons. The routine use of free, microvascularly anastomosed flaps for reconstruction of defects following removal of extended carcinomas of the mouth, the tongue or the oropharynx as well as in total pharyngolaryngectomy led to considerable improvements in functional rehabilitation of swallowing and speech. An improved functional outcome is also reported following partial resections of the hypopharynx and reconstruction by means of these thin and pliable transplants (f. e. replacement of the entire posterior hypopharyngeal wall). METHOD: Since 1991 in 30 patients with a T3 or T4 squamous cell carcinoma of the piriform sinus a complete hemipharyngo-hemilaryngectomy including resection of the involved thyroid and cricoid cartilage was carried out. For reconstruction a radial forearm flap was dissected with two separate epithelial islands: The smaller island was used to create an epithelialized endolarynx, which allows complete closure of the glottis by the healthy vocal chord. With the bigger second island the hypopharynx was replaced, creating a highly mobile, adaptable neo-piriform-sinus, which was suspended to the ipsilateral half of the hyoid bone. Parts of the both islands were sutured together to create a new aryepiglottic fold. The laryngeal skeleton intentionally was not reconstructed. RESULTS: One year evaluation revealed 25 of the 30 patients swallowing normal diet and being decannulated. 4 patients could take up a soft diet, 1 patient with a severe stricture at the entrance to the esophagus however had to be laryngectomized for functional reasons. Most of the patients judged their postoperative voice as satisfactory, although there was a different impairment of the voice (quite normal up to a marked hoarseness). During follow-up (up to 10 years) 4 patients developed a local recurrence, in 3 cases a secondary metastasis after neck dissection occurred. In 3 patients a second primary was detected (oropharynx 2, esophagus 1), 3 patients died with lung metastases. CONCLUSION: Rehabilitation of normal swallowing and a satisfying voice restoration without a permanent tracheostoma following complete hemipharyngo-hemilaryngectomy can obviously be improved by the use of microvascular transplants (here radial forearm flap) in comparison to other surgical techniques. The necessary radical extirpation of these extended carcinomas also is guaranteed like in total laryngectomy, so that in spite of the advanced tumor stage an organ preserving surgery can be offered. A prolonged course of swallowing rehabilitation however has to be taken into consideration.     

Factors associated with skin graft take in fibula and radial forearm free flap donor sites

Learning objectivesIdentify factors associated with skin graft take in fibula free flaps (FFF) and radial forearm free flaps (RFFF) donor sites.Study objectivesTo determine which factors are associated with decreased skin graft take at the donor site in FFF and RFFF in head and neck patients.DesignRetrospective Chart Review Case Series.SettingMulticenter Tertiary Care.MethodsA multicenter retrospective review was performed at three institutions identifying patients who underwent free tissue transfer, specifically either FFF or RFFF, between 2007 and 2017. Patient demographics, medical history, and social history were examined including age, gender, BMI, smoking status, diabetes and preoperative anticoagulation use. Preoperative, intraoperative data, and postoperative data were also examined including tourniquet use, type of flap, area of skin graft, if the skin graft had a donor site or if it was taken from the flap, wound NPWT use, cast use, use of physical therapy, DVT prophylaxis, limb ischemia, heparin drip, and postoperative aspirin use. Statistical analysis was used to determine which factors were significantly associated with skin graft take.Results1415 patients underwent a forearm or fibula flap and 938 patients underwent split-thickness skin graft. Of these, 592 patients had sufficient information and were included in the final analysis. There were 371 males and 220 females. The average age was 55.7. Complete skin graft take was seen in 480 patients (81.1%). On univariate analysis, patients with diabetes (p = .003), type of flap (fibula p < .001), skin graft area (p = .006), tourniquet use (p = .003), DVT prophylaxis (p = .008) and casting (p = .003) were significantly associated with decreased skin graft take rate. In a multivariate analysis, diabetes (OR 2.17 (95%CI 1.16–3.98)), fibula flaps (OR 2.86 (95%CI 1.79–4.76)), an increase in skin graft area (OR 1.01 (95%CI 1.01–1.01)), post-operative aspirin (OR 2.63 (95%CI 1.15–5.88), and casting (OR 2.94 (95%CI 1.22–7.14)) were associated with poor rates of skin graft take.ConclusionSeveral factors affect skin graft take rate and should be considered when performing a skin graft for a donor site defect.     

游离前臂皮瓣对口腔颌面部肿瘤术后缺损修复

目的总结游离前臂皮瓣在口腔颌面部肿瘤术后缺损修复中的应用体会。方法回顾分析2000年1月至2001年7月完成的11例游离前臂皮瓣在口腔颌面部肿瘤术后缺损修复中应用的临床效果。结果本组11例术后组织瓣全部存活,外形及功能主客观评价均较为满意。本组病人全部随访3年以上,1年生存率100.0%,3年生存率90.9%,1例存活17个月因癌复发全身转移死亡。结论游离前臂皮瓣是口腔颌面部软组织缺损修复较理想方法。