Donor site morbidity of the prelaminated fasciomucosal and fasciocutaneous radial forearm flap: a comparative study

In order to reconstruct intraoral lining defects after radical tumor resection, mucosal prelamination of the fascia of the distal radial forearm flap was performed in ten patients. By this method a physiologic reconstruction with mucus-producing tissue could be achieved. Preservation of skin and subcutaneous tissue enabled primary closure of the donor site. The exposed median nerve and flexor tendons could be covered by well-vascularized tissue with, hopefully, less donor site morbidity. To investigate this, eight prelamination patients were compared to five patients in whom conventional fasciocutaneous distal radial forearm flaps were harvested. Follow-up was 6–25 months (mean 12.8 months). All patients with prelaminated forearm flaps revealed excellent functional and cosmetic results. Restricted hand function and a poor cosmetic result were found in 40% of the fasciocutaneous flap patients. Subjective cold intolerance could be objectified using thermography, but could not be confirmed, using rheography and photoplethysmography. Received: 9 March 1998 / Accepted: 16 November 1998     

The use of integra artificial dermis to minimize donor-site morbidity after suprafascial dissection of the radial forearm flap

In an effort to minimize the radial forearm flap donor-site morbidity, the flap was elevated using the suprafascial dissection technique, in six patients with various facial defects. The donor site was covered primarily with Integra artificial skin and secondarily with an ultrathin split-thickness skin graft. The mean time to wound healing of the forearm donor site was 24 days. There were no flap failures, and all flaps healed uneventfully. At the end of the follow-up, all patients showed normal range of motion of the wrist and the fingers, normal power grip, and power pinch. All patients evaluated the esthetic appearance of the forearm donor site as very good. In conclusion, suprafascial dissection of the forearm flap creates a superior graft recipient site, and the use of Integra artificial dermis is a valuable advancement to further minimize the donor-site morbidity, resulting in excellent functional and aesthetic outcomes.     

Ulnar fasciocutaneous flap of the wrist

An ulnar fasciocutaneous flap has been developed to provide skin cover of the donor defect after elevating radial forearm flaps and used for that purpose in 55 patients. A case is reported in which the same type of flap was used to cover a traumatic skin defect on the front of the wrist.     

Evaluation of the donor site in patients who underwent reconstruction with a free radial forearm flap

A major disadvantage of free radial forearm flaps is the conspicuous donor site. However, there have been few studies on donor scars. The authors evaluated the donor site in patients who underwent oral-floor reconstruction with a free radial forearm flap. The subjects were 23 patients (19 males and four females) who underwent reconstruction with a free radial forearm flap following resection of a malignant oral tumor, and were followed for 1 year or longer. The fasciocutaneous flap collection site was closed by full-thickness skin graft (FTSG) from the groin with tie-over dressing. All grafts took perfectly. At the scar at the donor site, five items (pigmentation, scar width, depression, wrist mobility, and sensory abnormalities) were evaluated. Depression and pigmentation were often observed, but patient dissatisfaction was slight. While their main postoperative concern was the oral reconstruction site, after about 1 year, the donor site became more important to patients. However, the results were good. A 100 percent take of the FTSG at the donor site should produce good results. Surgeons should pay adequate attention not only to the outcome at the reconstruction site, but also to the closure of the donor site.     

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.     

Forearm flap in orthopaedic and hand surgery.

This study was undertaken in order to evaluate the usefulness of the forearm flap in reconstruction of severe injuries of the upper and lower extremities. A total of 34 patients with extensive skin defects of the upper and lower extremities were treated using radial forearm flaps during the last 4 years. Twenty-four patients had lower extremity injuries, while the remaining ten had upper extremity reconstruction. In two patients, the radial forearm flap was used as an island flap in retrograde direction for coverage of skin defects of the dorsum of the hand. In two patients, the palmaris longus tendon was included in the flap to reconstruct the extensor tendon of the index finger. In one patient, it was used as an innervated flap to cover a skin neurotrophic defect of the sole of the foot. None of the patients had the bony portion of the radius included. Of the 34 flaps, 29 survived. Of the remaining 5, 3 failed totally and 2 partially. The 2 partially failed flaps required reoperation and revision of the venous anastomosis, which was found to be occluded. The patients, eight women and twenty-six men, were examined and questioned regarding the cosmetic appearance of the donor site. The final cosmetic appearance was acceptable to all patients. We conclude that the radial forearm flap is a useful, easily elevated flap, suitable for skin defects of upper and lower extremities. Major advantages of the flap are its ability to be used as an island flap and that the surgery can be performed under axillary block anaesthesia.     

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 reverse posterior interosseous flap and its composite flap: experience with 201 flaps.

OBJECTIVE: To introduce our experiences of using the reverse posterior interosseous flap and its composite flap. METHODS: In the series of 201 cases, the fasciocutaneous flap was used to cover skin defects over the distal 1/3rd forearm, wrist and hand in 174 cases. The composite flap with the vascularised ulna bone graft was used to reconstruct the thumbs in 11 cases, and with the vascularised tendon graft was used to repair tendon defects with skin defects in 16 cases. The size of the ulna graft was 3-6cm in length and 1-2cm in width. The 4-7cm tendon graft was obtained from the extensor digiti quinti or extensor carpi ulnaris. The size of the flaps ranged from 5cmx4cm to 16cmx10cm. RESULTS: One flap failed completely. Of the other 200 flaps which survived 16 cases had venous congestion and had partial necrosis at the distal end. The size of the necrotic area ranged from 1 to 4cm in length. Ninety-three patients were followed up for at least 6 months, and included 10 patients with composite flaps. Generally, the flap matched the surrounding skin. But 10 cases had a lipectomy. The sensibility did not recover or achieved S1 within 6 months. For the extensor tendon defect, the function of finger extension was nearly normal and tenolysis was not required. In contrast, tenolysis was required after the flexor tendon reconstruction. However, these patients refused surgery. The bone grafts were healed in 3 months. The reconstructed thumb looked abnormal and lacked normal sensibility, although the patients used them. The linear scar line was conspicuous over the dorsum of the forearm. CONCLUSION: The reverse posterior interosseous flap is a reliable method to cover skin defects over the distal 1/3rd of the forearm, the wrist and hand. The composite flap with a vascularised tendon graft is an optimal reconstructive option for any extensor tendon loss (III zone) associated with a skin defect. Using the composite flap with a vascularised bone graft or combined with the digital neurovascular flap is another way to reconstruct the thumb.     

Deepithelialized reverse pedicled forearm flap: a technical modification useful in hand and wrist reconstruction

Reverse pedicled forearm flap is a reliable and easy option for hand and wrist reconstruction. Between 2000 and 2009, eight patients underwent elective reconstruction of an upper extremity using a pedicled reverse radial forearm flap with a modified technique; a retrospective chart review of the results is presented. The surgically modified procedure is described. The flap donor area is deepithelialized with a dermatome and the split-thickness skin graft obtained is left on the donor site pedicled proximally; the deepithelialized flap is then elevated and rotated with the standard technique and the forearm donor site is covered by repositioning and suturing the skin previously harvested with the dermatome. This useful and easy technical modification allows prevention of post-operative pain and long-term dyschromia in the split-thickness skin graft donor site, making the reverse pedicled forearm flap an even better option in hand and wrist reconstruction.     

Radial forearm flap surgery—evaluation of donor site morbidity

The free radial forearm flap is an excellent method for reconstruction of defects in the head and neck region. In the literature, there is still disagreement about the best surgical treatment of the forearm defect to avoid functional and cosmetic drawbacks. There is a debate about using full-thickness skin graft or better split thickness skin graft. To evaluate our own results after radial forearm flap surgery, a follow-up examination and standardized interview of 25 patients was performed. For closure of the donor site, a full skin graft from the groin was used in 17 cases and split skin graft from the thigh in eight cases. All patients were satisfied with postoperative results and hand function for everyday use. Subjective complaints were more common in the split skin graft group, especially related to loss of sensibility. Because of severe wound healing failure with tendon exposure in one case after split skin grafting, there was the necessity for surgical revision. During the medical examination, we documented more functional impairments in the split skin graft group than in patients after full skin grafting. Only the development of hypertrophic scars dominated in the full skin graft group. According to the trend to fewer complications, we prefer full-thickness skin grafts for the closure of the donor site after radial forearm flap surgery. This study was presented at the International Forum: Plastic and Reconstructive Surgery of the Head and Neck, Annual Meeting of the German Academy of Otorhinolaryngology—Head and Neck Surgery Foundation, May 16–20 2007, Munich, Germany.     

保留桡神经浅支的血管筋膜蒂皮瓣的临床研究

目的 观察保留桡神经浅支的血管筋膜蒂皮瓣进行转位修复手部创面的可行性及临床效果.方法 临床应用前臂远端保留桡神经浅支的血管筋膜蒂皮瓣修复手腕部软组织缺损7例,皮瓣切取面积7 cm×4 cm～12 cm×7 cm.结果 7例皮瓣中4例完全成活,3例出现静脉回流障碍,其中1例表皮脱落,皮瓣全部成活,质地良好；1例远端皮肤有宽约1.5cm坏死区,经植皮愈合;另1例皮瓣远端有3 cm×2 cm斑片状坏死,经换药瘢痕愈合.术后5例桡神经浅支支配区皮肤感觉正常；2例有麻木感,术后4周恢复正常.经术后3～20个月随访,7例患者对皮瓣修复效果均表示满意,2例对皮瓣部分坏死后的局限性瘢痕及前臂植皮瘢痕有整形愿望.结论 保留桡神经浅支的血管筋膜蒂皮瓣对保留手部皮肤感觉有实用价值,进一步改善静脉回流是防止皮瓣部分坏死的关键因素.     

Aesthetic improvements of radial forearm flap donor site by autologous fat transplantation

Despite its reliability, radial forearm (RF) flap is still affected by high donor site morbidity with poor cosmetic and functional outcomes after coverage with skin grafts. Having fat grafting demonstrated promising and effective filling and rejuvenating properties, we considered and tested it as a valuable alternative to dermal substitutes for the aesthetic improvement of RF flap donor site. Thirty-three patients with previous RF free flap reconstruction and poor donor site outcomes after full-thickness skin grafting to RF region were evaluated for secondary fat injection to improve outcomes. Objective and subjective assessments of results with standardized ultrasonographic soft tissue thickness measurements, cutaneous sensibility tests with the pressure-specified sensory device and scar assessment scale (POSAS) have been performed. Bivariate statistical analyses were performed comparing outcomes with contralateral healthy forearm. All cases showed significant improvement in soft tissue thickness (p< 0.031), cutaneous sensibility and scar appearance, with improved patient’s and observers’ scar assessment scores (<0.001). In conclusion, fat transplantation is an effective procedure that provided us with an adjunctive autologous layer in-between skin graft and underlying fascia, as well as a rejuvenating effect on skin and scars.     

Osteocutaneous radial forearm free flap: Its use without significant donor site morbidity

While the fasciocutaneous radial forearm free flap has gained increasing popularity, the osteocutaneous radial forearm free flap has been condemned because of a high rate of pathologic donor radius fracture. On the basis of studies that demonstrated increased strength in ostectomized radii after dynamic compression plating, we believed that internal fixation at the time of graft harvest would significantly reduce the incidence of donor radius fracture. This is a retrospective review of the first 54 patients undergoing osteocutaneous radial forearm free flap reconstruction of the head and neck at our institution; 52 underwent prophylactic plating of their donor radii. No clinically significant donor radius fractures have occurred in plated patients. Five asymptomatic fractures were discovered on routine radiographs and required no treatment. Objective evaluation of forearm range of motion and strength after graft harvest demonstrated excellent function compared with unoperated arms. Serial radiographs have shown remodeling and reconstitution of donor radii without localized osteopenia.     

Free radial forearm flap with adipofascial tissue extension for reconstruction of oral cancer defect

The radial forearm flap has been one of the most popular flaps used to reconstruct defects after oral cancer ablation. However, it sometimes may not provide sufficient soft tissue to obliterate the dead space after tumor excision and lymph node dissection, which can result in deep wound infection of the neck or even orocervical fistula. The authors modified the radial forearm flap with a sheet of adipofascial tissue extension to prevent such postoperative complications. From January 1997 to December 2000, 52 patients who underwent ablative oral cancer surgery were studied. A total of 29 patients (group I) underwent reconstruction with the traditional radial forearm flap retrospectively, and 23 patients (group II) underwent reconstruction with the radial forearm flap along with a sheet of adipofascial tissue extension. The radial forearm flap was designed on the axis of the radial artery, was 8 x 4 to 12 x 10 cm in size, and was sufficient to resurface the intraoral defect. In group II, the radial forearm skin flap along with a sheet of adipofascial tissue 8 x 8 to 12 x 10 cm was used to obliterate the dead space of the oral floor and neck. The donor site of both groups was resurfaced with a split-thickness skin graft. In group II, the skin flap of the adipofascial tissue was resutured to its original site. Two flaps in group I failed because of arterial occlusion and required other skin flaps for reconstruction. Postoperative hematoma, which required surgical treatment for drainage, developed in five patients in group I. None of the patients in group II had hematoma formation. Nine patients in group I had a neck wound infection compared with only 2 patients in group II (a significant difference). The average volume of drainage and days of hospitalization were similar in both groups. The morbidity of the donor site of both groups was not significant. The advantages of this modification include 1) suitable soft tissue available for dead space obliteration to decrease the chance of postoperative hematoma; 2) the important vessels in the neck can be protected; 3) there is a decrease in neck wound infections; and 4) donor site morbidity is similar to the traditional group.     

One-stage reconstruction of the penis using an innervated radial forearm osteocutaneous flap

One-stage reconstruction of the penis using a radial forearm osteocutaneous flap with sensibility, has been used with excellent cosmetic and functional results. The main advantages of this technique are not only the one-stage reconstruction and satisfactory cosmetic and functional solution, but also the possibility of obtaining normal erogenous sensibility.     

Folded free radial forearm flap for reconstruction of full-thickness defects of the cheek

Background. Full thickness defects of the cheek have been conventionally reconstructed using the folded forehead flap, cervical flap, pectoralis major myocutaneous flap, or deltopectoral flap in various combinations. We report a modified technique of folding the radial forearm flap for reconstruction of full-thickness defects of the cheek. Methods. The free radial forearm flap is a type C fasciocutaneous flap based on the radial artery along with its vena commitans and superficial forearm vein. The size and shape of the flap are determined according to the dimensions of the surgical defect. The flap is then lifted off with the fascia of the forearm making it a fasciocutaneous flap, in which the radial artery lies deep to the fascia and gives numerous branches. The flap is disconnected from the donor site only after the recipient vessels have been prepared for anastomosis. Vascular anastomosis is then performed using the operating microscope. This technique was used in 13 patients with carcinoma of the buccal mucosa who underwent full-thickness excision of the cheek. Results. Flap edema was observed in 4 patients in the immediate post-operative period. Necrosis of the outer paddle was seen in 1 patient. Donor site morbidity was seen in 4 patients who required dressings on an outpatient basis for up to 3 weeks. Conclusion. Single-stage reconstruction of full-thickness defects of the cheek with the folded free radial forearm flap is reliable and produces excellent cosmesis with minimal donor site morbidity. © 1995 Jons Wiley & Sons, Inc.     

前臂外侧皮神经营养血管远端蒂皮瓣的临床应用

目的报道前臂外侧皮神经营养血管远端蒂皮瓣的临床应用疗效。方法根据前臂外侧皮神经营养血管皮瓣血供来源及其与前臂筋膜皮肤血供的相互关系，在前臂外侧设计皮神经营养血管远端蒂皮瓣，转位修复手部、腕部及前臂远端软组织缺损19例。结果术后皮瓣完全成活，创面一期愈合，经3～30个月随访，皮瓣外形与手部功能恢复满意。结论前臂外侧皮神经营养血管远端蒂皮瓣解剖位置恒定，血液供应良好，手术方法简单，适用于修复手部、前臂软组织的缺损。     

Free anterolateral thigh flap for reconstruction of head and neck defects: preliminary results and a comparison with the radial forearm flap

BACKGROUND: The authors present their personal preliminary experience with the free anterolateral thigh flap in the reconstruction of head and neck defects and compare these first cases with the radial forearm flaps. METHODS: Seventeen patients undergoing free flap reconstruction between December 1998 and September 2001 have been selected for this retrospective study and evaluated. In fourteeen patients reconstruction was performed with a radial forearm flap. In three patients an anterolateral thigh flap was used. Six dissections on cadavers have also been performed in order to study the anatomical variations of the perforators of the lateral circumflex femoral system. RESULTS: All flaps survived, without any major vascular impairment. CONCLUSIONS: Despite a laborious dissection of the pedicle the anterolateral thigh is a versatile flap, with a minimal morbidity of the donor area. Even if the radial forearm is overall accepted as the gold standard for head and neck reconstruction, the anterolateral thigh flap is suggested as a good and safe surgical option, especially when a large flap is requested or in female patients concerned with the cosmetic result in the forearm donor area.     

Prelaminated free radial forearm flap for a total nasal reconstruction.

A prelaminated osteocutaneous radial forearm flap has previously been described for total nasal reconstruction, but achieving good aesthetics at the dorsum and tip tends to be difficult with a flap that can be too bulky. We present a case of total nasal reconstruction in a burns patient where a tight adherent scar at the forehead precluded the use of a forehead flap, ideal for such reconstructions. We successfully used a prelaminated free radial forearm flap, with a non-vascularised bone graft. The existing scarred skin at the dorsum was turned down as pedicled flaps for the lining. We were able to achieve a successful total nasal reconstruction which was aesthetically pleasing and made a tremendous impact on the quality of life of the patient.     

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.