Urethral reconstruction using the radial forearm free flap: experience in oncologic cases and gender reassignment

OBJECTIVES: Urethra reconstruction in men remains a complex problem, particularly in patients who have had previous amputation for penile tumour or who have undergone gender reassignment. Many reconstructive techniques currently in use recreate the urethra but are prone to recurrent stricture formation and fail to achieve micturition with a good stream when standing. The authors propose using the radial forearm fasciocutaneous free flap as a single-stage technique of male urethral reconstruction. METHODS: During 1999-2004, nine patients underwent microsurgical reconstruction of the male urethra using the radial forearm fasciocutaneous free flap. Three patients underwent urethral reconstruction following previous subcutaneous penectomy for penile cancer. Another six patients had urethral reconstruction performed after failure of primary urethra construction as part of their gender reassignment surgery. RESULTS: The average age at the time of surgery was 35.1 yr (range: 22-55 yr) and average follow-up time was 41.8 mo (range: 13-55 mo). Flap reconstruction was successful in all cases, with no instances of free flap failure; however, two patients developed significant stenosis requiring revision, and no patients had postoperative fistula formation. Therefore, the success rate for urethral reconstruction after the first operation was seven of nine. Two patients with stenosis were treated operatively to release strictures with local flaps. Uroflowmetry demonstrated that these patients had satisfactory flow rates. CONCLUSION: Patient satisfaction and objective studies have demonstrated that urethral reconstruction with the use of radial forearm free flap is a good reconstructive procedure particularly when the patients need an extensive and long urethral reconstruction.     

The role of fabricated chimeric free flaps in reconstruction of devastating hand and forearm injuries

Devastating hand and forearm injuries almost exclusively need free flap transfer if reconstruction is attempted. Early active and passive motion is only possible with aggressive, early, and comprehensive reconstruction. Despite recent advances in compound flaps, in selected cases it might be wise to harvest several smaller flaps and microsurgically combine them to one "chain-linked" flap "system." Four microsurgically fabricated chimeric free flaps were used in four patients for complex hand and forearm injuries. The combinations were sensate anterolateral thigh (ALT) flap plus sensate extended lateral arm flap (2x), ALT plus free fibula, and ALT plus functional musculocutaneous gracilis muscle. All flaps survived completely. Functional rehabilitation was possible immediately after flap transfer. There were no donor-site complications except two widened scars. The microsurgical fabrication of chimeric free flaps, as well established in head and neck reconstruction, can be successfully adapted to massive hand injuries as well. Individual placement of selected tissue components, early comprehensive reconstruction, and reduction of the number of operations are beneficial in cases that need more than one free flap.     

Usefulness of free sensate osteofasciocutaneous forearm and fibula flaps for neophallus construction

Female-to-male transsexuals have been treated by the authors since the 1970's, using different operative methods. Since 1981, these patients have received neophallus construction with free sensate osteofasciocutaneous forearm flaps and, since 1993, with free sensate osteofasciocutaneous fibula flaps. In order to evaluate the usefulness of these flaps, the authors performed, in 24 patients (12 with forearm and 12 with fibula flaps), the following examinations: clinical and radiologic evaluations of the neophallus and its donor site, as well as patient questionnaires. In all patients, subjective findings and clinical examinations showed no significant variations in neophallus size and form. Patients with fibula flaps had better sexual intercourse, although their neophallus sensibility was minor, when compared to the forearm flap patients. Donor-site morbidity was moderate in both groups. On radiologic examination, robust, calcified bone structure, and no fracture of the neophallus bone and its donor site, as well as no instability of the ankle joint (in the fibula flap patients) were found. These findings further support the use of these free sensate osteofasciocutaneous flaps for neophallus construction. In the authors' opinion, it is the patient who must decide which method should be used for neophallus construction.     

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.     

Salvage of fibular osteocutaneous flap with creation of arteriovenous fistula

In utilizing free-tissue transfers to reconstruct complex wounds, occasionally a mismatch exists between the donor-flap inflow and the recipient vessel outflow. This occurs more often with fasciocutaneous flaps as opposed to muscle flaps due to their higher resistance. The result of this may be microvascular thrombosis within the system and ultimately flap failure. The creation of an arteriovenous fistula at the distal aspect of the flap may improve the flow dynamics and ultimately salvage the flap. We submit a case of a free osteocutaneous fibular flap used for reconstruction of an ulnar forearm defect. Due to intraoperative thrombosis as a result of flow mismatch, we were able to salvage the flap using a distal arteriovenous fistula. This fistula improved the flow dynamics of the flap by bypassing the high intraflap resistance. An arteriovenous fistula should be kept in the repertoire of the microvascular surgeon as a potential option for flap salvage.     

The folded double paddled free flap for oral cavity reconstruction

Summary Six radial forearm flaps, two transverse rectus abdominis flaps and one latissimus dorsi myocutaneous flap were used in a bipaddled fashion for full thickness defects of the cheek and the floor of the mouth resulting from cancer resection. The flaps provided both intraoral lining and skin cover in all cases. Immediate reconstruction was carried out following tumor resection in six cases. In three patients who presented with large full thickness defects due to failure of primary reconstruction, late reconstruction with double paddled free flaps was performed. All transfers were successful, in the latissimus dorsi transfer a minimal area of necrosis occurred at the tip of the flap. A salivary fistula developed in two cases, both healed spontaneously up to three weeks postoperatively. The average operating time was 5.5 h; the average hospital stay was 13.4 days.     

Urethroplasty in female-to-male transsexuals

OBJECTIVE: Female-to-male transformation includes total phallic reconstruction. Construction of a neourethra is necessary to achieve the goal of voiding while standing; however urethral fistula and stricture formation occur in a significant percentage of patients. METHODS: 25 patients with primary female transsexualism underwent phalloplasty with a free radial forearm flap, vaginectomy and urethroplasty in a one-stage procedure. In 16 of these patients the fixed part of the neourethra ("bulbar urethra") was constructed from a vaginal flap. In 9 patients flaps of the labia minora (5 patients) or the "urethral plate" (4 patients) were used. RESULTS: In 14 (58%) patients fistulas and/or strictures in the newly constructed urethra occurred. 11 (69%) of 16 patients in whom the "bulbar urethra" was constructed from a vaginal flap experienced fistulas and/or stricture formation. Fistulas and/or strictures occurred in 3 of 5 patients with labia minora flaps and none of 4 patients with the urethral plate procedure. Repair of fistula and strictures was performed by primary closure of fistulas, staged urethroplasty with local pedicle flaps or distant tissue grafts using buccal mucosa (2-6 procedures). CONCLUSION: One-stage total phalloplasty and urethroplasty is associated with a significant rate of fistulas and strictures. However, these complications can be corrected by the techniques used in modern urethral surgery.     

Scrotal septocutaneous island flap for the reconstruction of the urethral fistula

We report the reconstruction of the urethral fistula using a scrotal septocutaneous island flap. A scrotal septocutaneous island flap is supplied by vascular networks in the scrotal septum area from both perineal arteries and posterior scrotal arteries. This flap is divided into two flaps, one for urethral lining and the other for the skin defect. We found it to be a simple, useful, and reliable alternative to other local flaps. However, hairless skin of the scrotum must be used for the urethral lining. The musculocutaneous flap is also reliable. However, use of the scrotal septocutaneous island flap can save the musculocutaneous flap for secondary procedures.     

Long-term follow-up of coverage of weight bearing surface of the foot with free muscular flap in a pediatric population

Between 1985 and 1991, 13 muscular free flaps with split thickness skin grafts (10 latissimus dorsi, 2 rectus abdominis, and 1 gracilis) were done in 12 patients to cover the weight bearing surface of the foot. Four open wounds were closed primarily and nine unstable scars were replaced with a free flap. A retrospective analysis shows that over the short term the flaps provided a complete coverage of wounds, with a 100% survival of flaps, and permitted normal weight bearing ambulation starting at 1 month postoperatively. Long-term results show deep pressure sensation but no light touch sensation. All patients are able to wear normal shoes. Six patients (seven flaps) required further surgery to close subsequent wounds on the flaps: Three hypertrophic scars with recurrent ulcerations needed scar revisions, one child presented a fistula through the flap due to underlying osteomyelitis, and one patient presented a friction wound on the lateral malleolus requiring thinning of the flap. Two flaps presented an area of pressure necrosis through the full thickness of the flap and had to be replaced with another free flap (fasciocutaneous sensate flap) over the heel area. In conclusion, it seems that in the pediatric population, skin-grafted muscular coverage of the weight bearing surface of the foot is a good alternative, even if more problems with hypertrophic scarring around the grafts have been found than in the adult population. In two cases, the flaps had to be replaced because of pressure necrosis over the calcaneus. Long-term follow-up of the sensate fasciocutaneous flaps will be needed to find out if they provide a better alternative for foot coverage. © 1994 Wiley-Liss, Inc.     

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.     

Functional outcomes of sensate versus insensate free flap reconstruction in oral and oropharyngeal reconstruction: A systematic review

The purposes of this article were to review the literature regarding subjective outcomes, objective functional outcomes, and objective sensation return after sensate and/or insensate free flap reconstruction of the oral cavity and oropharynx. Sensate radial forearm and anterolateral thigh free flaps tend to have better static 2‐point discrimination and pressure threshold sensitivity than insensate flaps. There is insufficient evidence to draw conclusions on whether sensate flaps improve functional speech and swallowing outcomes measured by videofluoroscopic swallowing studies and percentage of word intelligibility by a listener blinded to the study. These data highlight the complexity and number of variables affecting functional outcomes in patients who have undergone reconstructive surgery after oral and oropharyngeal cancer ablative operations. A prospective randomized multicenter study that properly and rigidly stratifies patients by defect, flap and recipient nerve choice, adjuvant therapies, and uses widely agreed upon pretreatment and posttreatment evaluation tools could help to answer this important question. © 2016 Wiley Periodicals, Inc. Head Neck 38 : 1708–1716, 2016     

Sensory reconstruction in sensate radial forearm flap transfer

The authors treated 14 patients (13 men and one woman), using a sensate radial forearm flap. Their ages at operation ranged from 27 to 67 years (mean: 52 years). Preoperative conditions were amputations in 10 cases, degloving injury in three, and crush injury in one. Reconstructive sites involved the thumb in nine cases, the mitten-like hand in two, the index finger in one, the ring and small finger in one, and the palm in one. In all cases, the radial forearm flap, including the lateral antebrachial cutaneous nerve, was harvested. Sensory evaluation was performed using the moving two-point discrimination test (m-2PD). Sensation in the mid-palmar area of 50 forearms was examined in 25 healthy adult volunteers as a control group. Follow-up periods ranged from 12 to 87 months (mean: 39.6 months). The mean m-2PD of the 14 sensory flaps was 13.2 mm, and the mean of 50 forearms in the control group was 18.08 mm. A statistically significant difference was demonstrated between the sensory flaps and the 50 forearms of the control group. The mean m-2PD was much more sensitive in the innervated radial forearm flaps than in the donor forearm. The results suggested that sensory return in the innervated flaps is influenced not by the donor nerve in the flaps, but by the recipient digital nerve.     

Targeted sensory restoration to the upper aerodigestive tract with physiologic implications

BACKGROUND: Sensory restoration through sensate flaps placed into critical areas of the upper aerodigestive tract is an attractive reconstructive goal to achieve optimal post-therapy function. The question that has remained unanswered is whether sensory recovery takes place through the newly established neural pathway or through ingrowth of sensory nerves from the periphery of the defect. METHODS: Three patients with squamous cell cancer underwent resection and primary reconstruction of the laryngopharynx with a sensate radial forearm flap. The flaps were designed with a smaller, proximal paddle to serve as a monitor. Reneurotization of the flaps was carried out to the superior laryngeal nerve. RESULTS: All three patients were followed for a minimum of 12 months. Each of these patients reported the development of a cough that resulted from stimulation of the external monitor. This phenomenon was easily duplicated by light stimulation of the monitor, which not only produced the cough but was consistently perceived by the patient as arising from inside their throat. CONCLUSIONS: This series conclusively demonstrates that sensory feedback can be restored in a targeted fashion through neural anastomoses and that a physiologic response that helps in airway protection can be produced through the use of sensate flaps with a strategically selected recipient nerve.     

One-stage coverage of multi-digital pulp defects with sensate flaps from the foot

BackgroundThe reconstruction of the digital pulp defects was a mix of the sensation, function, and aesthetics. As the conventional flaps became out of date, the sensate flaps were increasingly utilized in covering such defects. In this report, we present our experience with some novel flaps design, located on the foot.MethodFrom April 2015 to September 2018, nine patients received the free sensate flaps to resurface soft tissue defects in the multi-digital pulps. And all flaps were harvested from each aspect of the foot, which dimensions were tailored to the defects. The cutaneous nerve was preserved within the flap. Standardized assessment of outcome in terms of sensory, functional, and esthetic scores of the reconstructed pulps was completed.ResultsNineteen flaps survived completely without significant complications, and mild venous congestion was observed in one flap. The free sensate flaps were performed for digital pulp reconstruction in 9 patients: 6 male and 3 female patients with a mean age of 49 years (ranged, 16 to 72 years). The defects involved 3 thumbs, 6 index fingers, 5 long fingers, 3 ring fingers, and 2 little fingers. All flaps were available for a mean follow-up of 30 months (ranged, 24 to 36 months). The functional and esthetic outcomes were satisfied for all flaps, as well as the sensory restoration.ConclusionThe sensate flap from the foot is a remarkable alternative for digital pulp reconstruction with less morbidity and better outcomes. Furthermore, the foot region presents a sensitive, glabrous skin with the proper bulkiness and allows for easy dissection.     

Penile reconstruction by the free scapular flap and malleable penis prosthesis

BACKGROUND:: Penile reconstruction has always been a challenging problem for plastic surgeons while facing patients with severe congenital deformities and gender dysphoria and those who have suffered penile loss because of trauma, self-amputation, malignancy, and so on. Since 1936, when Bogoras first constructed a total penis, attempts have been made by different techniques, including skin flaps or myocutaneous flaps. And with development of free tissue transfer and microsurgical techniques, various free skin flaps, such as the radial free forearm flap, the superficial inferior epigastric artery flap, the superficial circumflex iliac artery flap, have been attempted for phallic construction, with the goal of functional (including a competent neourethra that allows voiding while standing and sexual intercourse) and cosmetic result. The purpose of our study was to evaluate the scapular free flap and implantation of malleable penile prosthesis for penile reconstruction. PATIENTS AND METHODS:: Since March 2000, 20 patients with penile loss were reconstructed in a 1-stage procedure by transferring scapular flap and implantation of a malleable penile prosthesis. The age of the patients ranged between 21 and 36 years old. Of these patients, 12 had penile amputation resulting from an electric accident; the other 8 were self-amputated. RESULTS:: All the flaps remained 100% viable postoperatively. Follow-up ranged from 1 to 5 years. There were no cases of urethral fistula, urethral stenosis, prosthesis extrusion, or infection. The reconstructed penis yielded satisfactory function and esthetic appearance. CONCLUSION:: The scapular free flap is an ideal flap that achieves satisfactory function and esthetic appearance for penile reconstruction because of its adequate amount of tissue, reliable vascularity, acceptable donor-site morbidity, and reliable blood supply.     

LONG-TERM RESULTS WITH THE PROXIMALLY-BASED NEUROVASCULAR LATERAL CALCANEAL FLAP

From 1995 to 1997, the proximally-based neurovascular lateral calcaneal flap was used in eight patients to cover defects in the Achilles tendon area or the lateral malleolar region. The mean postoperative follow-up was 40 months (range 29-51). The outcome of the operation was investigated both clinically and using a questionnaire sent to patients. All flaps healed uneventfully within a mean of 33 days. Revisional operations were required in two cases because of pain at the donor site. No flaps had broken down up to the follow-up, which was between three and five years. Two of the patients operated on were paraplegic, and the other six patients had sensate flaps. Five of the six patients with sensate flaps were able to wear normal shoes and one patient needed a shoe elevated by about 7.5 &#114 cm because of a disease independent of the flap. All but two patients were satisfied with the functional and aesthetic results. The proximally-based neurovascular lateral calcaneal flap proved to be safe and can be recommended as a good option to cover tissue defects in the Achilles tendon area or the lateral malleolar region.     

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.     

应用骨间后动脉单一穿支微型皮瓣修复手指皮肤缺损

目的 应用骨间后动脉单一穿支微型皮瓣对手部较小面积的皮肤软组织缺损进行精确的定点修复。方法 在前臂背侧中部，以骨间后动脉（骨间总动脉尺侧肌皮支）为轴线，用多普勒血流探测仪确定穿支部位后以此设计皮瓣。对24例手指皮肤软组织缺损的患者，应用单一穿支微型皮瓣进行修复，并对皮瓣的设计、切取、吻合、成活特点及治疗效果进行观察和探讨。结果 术后21例皮瓣顺利存活，3例皮瓣术后1—3d出现不同程度的水疱、暗紫、结痂，2例皮瓣脱痂后成活，1例坏死。术后17例获得5—17个月的随访，7例失访。皮瓣外形满意，手指修复后效果良好。3例缝合伴行神经、皮下神经者，Dellon试验达5—6mm。结论 骨间后动脉单一穿支微型皮瓣游离移植可对手部较小的皮肤软组织缺损进行精确的定点修复，并获得了较好的临床效果。     

Neural anatomy of the radial forearm flap

Typically the lateral antebrachial cutaneous nerve alone is used to innervate the radial forearm free flap when a sensate flap is required. The authors desired, by means of fresh cadaveric microdissections and by means of local anesthetic injections in living subjects, to map the sensory nerve territories of this flap. Eight radial forearm flaps were elevated and the medial antebrachial cutaneous nerve (MABC), lateral antebrachial cutaneous nerve (LABC), and superficial radial sensory nerve (SRSN) were dissected with the aid of an operating microscope (2.5-10x) and traced to their dermal insertions. In the injection study, the MABC, LABC, and SRSN in eight forearms of 4 subjects were blocked sequentially with 2% lidocaine injections. The resulting sensory deficit from each injection was mapped on the skin and superimposed on the marked radial forearm flap territory. Distribution of the three dissected nerve regions and the sensory deficit after injection were determined by digital images and computer analysis. During flap dissections, mean nerve distributions of total flap area were as follows: LABC, 61.8% (range, 48.3-71.6%); MABC, 33.8% (range, 30.5-38.9%); and SRSN, 34.6% (range, 26.8-44.1%). After nerve block the mapped sensory areas were as follows: LABC, 62.3% (range, 44.5-88.5%); MABC, 19.6% (range, 8.0-35.8%); and SRSN, 19.5% (range, 9.9-26.3%). At least 40% of the total flap area was not innervated by the LABC as identified both by nerve dissection and sensory local anesthetic blockade. By including the LABC, MABC, and SRSN in the radial forearm flap, both the theoretical and the clinically determined useful sensory innervation of the radial forearm flap potentially would be increased.     

Management of iatrogenic recto‐urethral fistula by transanal rectal flap advancement

Aim Recto‐urethral fistulas are an uncommon, but devastating complication following rectal or urinary tract surgery. Repair is often difficult, and the optimal approach is unclear. We report our recent experience using an endorectal advancement flap. Method A case note review of all patients undergoing repair of recto‐urethral fistula in our institution was undertaken. Data on aetiology of the fistula, patient demographics, operative procedure and outcome both clinically and radiologically were extracted. Results Between 2002 and 2008, six transanal rectal advancement flaps in five patients were carried out. Four had undergone a laparoscopic radical prostatectomy, without any radiotherapy. Two types of fistula (type 1 associated with severe intra‐abdominal sepsis and type 2 associated with localized sepsis) were found, with faecal diversion being less likely with the latter. Four (80%) patients underwent successful primary repair, with one patient requiring a second procedure. Postoperative cystography confirmed closure of the fistula in all five patients, and no recurrence has been observed at a mean follow‐up time of 11 months. Conclusion Rectal advancement flap is a simple, effective technique for iatrogenic recto‐urethral fistula with minimal morbidity.