The role of donor site angiography before mandibular reconstruction utilizing free flap

This study was initiated to establish a treatment algorithm for preoperative evaluation of donor sites prior to the harvest of free osteocutaneous flaps, in the setting of complex mandibulofacial reconstruction. A total of 29 consecutive patients were treated between 1999 and 2003 in a university-based setting. Reconstructions were completed using either a free fibula osteocutaneous flap or a radial forearm free flap. Functional and aesthetic results were determined by completing a thorough patient physical examination postoperatively. We hypothesized that a routine preoperative angiogram at the donor site was unnecessary. The Allen's test was the only preoperative evaluation completed in the 13 patients undergoing the free radial forearm reconstruction. In the remaining 16 patients undergoing free fibula reconstruction, a thorough physical examination was completed, along with noninvasive Doppler examinations. No angiograms were obtained. Using this systematic approach, no ischemic complications were observed at the donor site. Only two complete flap losses were seen, one in each group, due to microvascular thrombosis. We conclude that preoperative assessment of the donor site(s) with only an Allen's test in the free radial forearm group and a thorough pulse exam and a noninvasive Doppler in the free fibula group appear adequate. Routine preoperative angiogram of the donor extremity may be unnecessary and place the patient at additional risk for associated complications.     

Reconstruction of hand soft-tissue defects: alternatives to the radial forearm fasciocutaneous flap

Soft-tissue defects of the hand and wrist are not an uncommon problem confronting the hand surgeon. Over the past 20 years the retrograde radial forearm fasciocutaneous flap has gained widespread acceptance in reconstruction of these defects. Appreciation of the inherent limitations of this workhorse flap and increased understanding of the blood supply of the upper extremity have prompted the development of several alternative pedicled forearm flaps. Aspects of surgical technique, specific limitations, and indications for the radial forearm fascial flap, the posterior interosseous artery flap, the retrograde radial artery perforator flap, and the dorsal ulnar artery flap are discussed and a reconstructive algorithm for flap selection is presented.     

A forearm free flap based on an occluded radial artery: its salvage and avoidance

The salvage of a radial forearm free flap based on an occluded radial artery is reported. Circulation to the flap was restored by resection and reconstruction of the nonpatent arterial segment within the flap. A simple test is recommended for preoperative assessment of forearm radial artery patency in which proximal pulsation is felt after distal compression of the radial artery at the wrist.     

Reverse Radial Forearm Fascial Flap With Radial Artery Preservation

The reverse radial forearm fascial (RRFF) flap is widely used in soft-tissue reconstruction of the hand. The traditional RRFF flap incorporates the radial artery from the forearm and is perfused by retrograde flow through the palmar arch. In patients with an abnormal Allen test because of an incomplete palmar arch, the traditional RRFF flap is contraindicated unless a vein graft is used to reconstruct the radial artery. A simpler alternative approach for hand reconstruction in such patients is a distally based RRFF flap based on radial artery perforators, which preserves the radial artery. We used RRFF flaps based on radial artery perforators in five patients who had palmar or dorsal soft-tissue loss. All five recovered full hand function, and only one had any complications (full-thickness skin graft loss at recipient site). The RRFF flap based on distal radial artery perforators is suitable for thin coverage of soft-tissue defects in hands with either a complete or an incomplete palmar arch.     

The radial (Chinese) flap in hand surgery

The radial (Chinese) flap is an fascio-cutaneous flap raised on the volar aspect of the forearm based on the radial pedicle axis which can be used either pedicled or by microsurgical free transfer. In hand and thumb reconstruction, it is used as an island flap vascularized by a reverse flow from the ulnar artery via the palmar arch, keeping the pivot point at the snuff box level. The possibility to raise a composite flap with vascularized bone or tendons make the chinese flap very useful in hand reconstruction. Of the 35 cases presented, there were 30 pedicled and 5 free flaps from the opposite forearm. The island flaps were reverse flow in 30 cases and with proximal pedicle in 5. In 4 cases the flap contained flexor carpi radialis longus tendon, and in 2 cases a bone graft from the radius. The five free radial flaps transferred from the contralateral side were used as flow-through flap. There were no vascular complications. The advantages and disadvantages of the methods are discussed.     

A compound radial artery forearm flap in hand surgery: an original modification of the Chinese forearm flap

The Chinese forearm flap based on the radial artery is extremely versatile. It can be used as an island-skin flap, a free flap or as a compound forearm flap including vascularised nerve, bone or tendons. This paper describes and discusses some of these applications and is based on a series of 17 patients who presented with problems of reconstruction in the hand.     

Fascial flaps based on perforators for reconstruction of defects in the distal forearm.

Twenty fascial flaps were used in the reconstruction of defects in the distal forearm, wrist and hand in 18 patients over a 2-year period. In 16 patients the fascial flaps were based on a single fascial feeding vessel or 'perforator' arising from the anterior interosseous artery and/or ulnar artery when the radial artery had been used as the donor vessel in free flap reconstruction elsewhere in the body. There was no loss of any fascial flap in the study. The use of fascial flaps based on fascial feeders of the anterior interosseous and ulnar arteries extends the range of fascial flaps that can be raised in the forearm for reconstruction of defects in the distal forearm, wrist and hand.     

Aberrant branch of the radial artery encountered during elevation of the radial forearm free flap

Although the radial arterial system is fairly consistent in structure, rare anomalies have been encountered. During the elevation of a radial forearm free flap for floor of mouth reconstruction, the authors have encountered an accessory branch of the radial artery arising from the main radial artery at the level of the mid forearm, extending laterally over the brachioradialis muscle, and descending into the dorsal wrist in the subcutaneous plane. This artery, named as the superficial radial artery, is a very rare vascular anomaly of the radial arterial system in the forearm. The reconstructive surgery literature is relatively silent about this particular variant. Knowledge of possible anatomic anomalies and careful identification of vessels are important to prevent damage to the arterial system and enable optimal flap harvest.     

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.     

The Evolution of the Pedicled Radial Forearm Flap

Because of the thin skin envelope of the hand, especially at the dorsum, flaps are frequently required for defect reconstruction in the hand. The pedicled radial forearm flap is a time proven procedure that offers reliable coverage in this area without the need of advanced microsurgical expertise. Despite several alternatives and an increasing acceptance of free tissue transfers, the pedicled radial forearm flap can still be the procedure of choice under special circumstances. Variations of the original technique address the two main disadvantages, the conspicuous donor site and the sacrifice of the radial artery. Indications, anatomy, surgical technique, and limitations of this classic workhorse flap are presented.     

Toe transfer to the vessels of the reversed forearm flap

A 23-year-old man had a severe degloving injury of his hand, amputation of multiple fingers, and devascularization of the thumb. Primary care consisted of successful revascularization of the thumb and skin grafting of the hand. Secondary soft tissue reconstruction of the hand was done with a reverse forearm flap. This was followed by second-toe transfer to the hand, with the recipient vessels, the radial artery, and the venae comitantes of the reverse forearm flap.     

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.     

A rare variant of the radial artery: clinical considerations in raising a radial forearm flap.

A rare vascular anomaly of the radial artery encountered during elevation of a radial forearm free flap is reported in this paper. We discovered a superficial radial artery which bifurcated from the deep radial artery 4 cm below the antecubital fossa. The blood supply to the proximal radial forearm flap was thought to be from the superficial radial artery, and to the distal forearm flap from both arteries. Ascertaining the course of the radial artery pre- and intraoperatively and careful dissection of the artery are essential to minimise problems of flap transfer.     

Arterialized venous flow-through flap for simultaneous reconstruction of a radial artery defect and palmar forearm soft-tissue loss from sarcoma resection

A 50-year-old right-handed male presented with a previously incompletely excised low-grade fibrous histiocytoma on his distal radial palmar forearm. Reoperative wide resection resulted in a segmental defect of the radial artery and a large soft-tissue defect with exposed tendons denuded of paratenon. An arterialized venous fasciocutaneous flow-through flap, measuring 8 x 3 cm, was harvested from the dorsal ipsilateral hand and used to reconstruct both the soft-tissue and the segmental radial-artery defects. A full-thickness skin graft was harvested from the ipsilateral groin to cover the dorsal hand wound. Moderate venous congestion was noted in the flap on postoperative day 1 and treated with four days of leeches. Approximately 10 percent of the flap was lost due to the venous congestion. The flap healed well without further complications. At 33 months the flap remained well-perfused, with excellent flow through the reconstructed radial artery evidenced by both clinical examination and by color vascular Doppler exam. The patient had full range of motion in his right hand despite initial postoperative stiffness and reported no cold intolerance in the right hand. There has been no local recurrence of the sarcoma. The authors believe that this is the largest arterialized venous flow-through flap currently reported to have survived, as well as the first reported case of its use for the simultaneous reconstruction of a radial artery defect and an associated soft-tissue loss.     

Reverse flow flap use in upper extremity burn contractures

Upper extremity contractures still happen and constitute one of the most trying challenges in burn patients. This series comprised of 4 radial forearm flaps, 14 dorsoulnar artery flaps, and 4 medial arm flaps, all of which were used in a reverse pattern for upper extremity postburn contractures. The reverse flow radial forearm flap (RRFF) was chosen for reconstruction of extensive palmar contractures after burn. The reverse flow dorsoulnar flap (RDUF) was used particularly for reconstruction of the hypothenar aspect of the hand which requires moderate size tissue transfer. The reverse medial arm flap (RMAF) was used for elbow contractures after burn. In the first RMAF, venous congestion occured and was finaly resolved with minimal flap loss, which was managed with STSG later. In the following 3 cases the flap was supercharged with anastomosis of the brachial vein into the antebrachial vein. Both RRFF and RDUF may provide a smooth and efficient solution. However, RMAF has a significant venous problem, which may result in flap loss, therefore, this flap should not be considered as a first option in the elbow area.     

Indirect revascularization of the lower extremity by means of microvascular free-muscle flap--a preliminary report

We describe the treatment of a patient with end-stage peripheral vascular disease and ischemic ulceration of the lower extremity in whom an obliteration of the distal arterial bed precluded conventional arterial reconstruction. A nonhealing dorsal foot ulcer was debrided, and soft tissue reconstruction was accomplished by the free microsurgical transfer of a muscle flap to the distal lower extremity. Arterial inflow to this free flap was provided by a contralateral reversed saphenous vein graft from the proximal arterial tree of the leg. This procedure resulted in a healed wound, stable coverage, and limb salvage. The patient also noted complete relief of rest pain and improvement in his claudication symptoms. A follow-up arteriogram was done 2 months after surgery. Contrast injection directly into the artery of this flap showed new blood vessel growth from the muscle flap into the foot with anastomoses of these "new vessels" to the patient's native circulation. This experience suggests that limb salvage may be possible by the free microvascular transplantation of a muscle flap onto the limb in selected patients whose limbs are deemed "nonreconstructible."     

Acute ligation of the radial and ulnar arteries: A case report and review of literature

Isolated injury to the radial or ulnar artery results in no significant complications in patients who undergo repair or ligation of the injured artery. However, ligation of both infrabrachial vessels of the upper extremity is associated with limb loss from ischemia due to lack of collateral circulation. A rare case of acute ligation of both the radial and ulnar arteries in a drug abuser where collateral vessels preserved the circulation to the hand is reported.     

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.     

Creating two independent fasciocutaneous free flaps from a single radial forearm donor site

The authors describe the creation of two independent fasciocutaneous free flap units from a single radial forearm donor site. After the radial forearm flap is elevated in the standard manner, based on the entire length of the radial artery, the individual flap units are developed as island flaps based on the proximal and the distal radial artery respectively by transecting the radial artery, its accompanying veins, and the cephalic vein. Thus, two independent radial forearm free flaps are created from a single donor site: The proximal one has antegrade flow and the distal one has retrograde flow. The individual free flap units were transferred, and microvascular anastomoses were performed simultaneously by two surgical teams. This technique was used in 2 patients presenting with bilateral foot defects that required reconstruction with a thin, reliable flap such as the radial forearm flap.     

Upper extremity salvage with a flow-through free flap

In complex extremity injuries, which include composite tissue lost with devascularization caused by segmental vascular damage, simultaneous coverage of the defects with revascularizations should be required. One-stage reconstruction of both soft tissue coverage and vascular damage can be performed by a flow-through-type free flap. In this series, 5 patients between 13 and 36 years of age with wide composite tissue defects in the cubital region and segmental defects in brachial arteries were operated at our clinic between 1996 and 2003. With the aim of reconstructing the wide tissue defects in the cubital region as well as that of the brachial artery, a radial arterial flow-through flap was applied. The radial artery of the flow-through flap was anastomosed to the proximal ends of the brachial and ulnar arteries in an end-to-end fashion. In 4 of the patients, the radial arterial flow-through flap was prepared from the distal aspect of the wounded forearm and in 1 patient from the contralateral forearm. In the postoperative period, no complications related to the anastomosis were encountered in the flap with all anastomoses found to be patent, and distal circulation was restored. The radial arterial flow-through flap is very useful in the clinical field of major trauma of the cubital region with brachial artery damage with numerous advantages that include the opportunity to work in one single surgical area, shorter dissection times resulting from simple and fixed anatomy, perfect color and tissue adaptation, and the suitability of the vessel caliber and length.