Review of the radial free flap: is it still evolving, or is it facing extinction? Part one: soft-tissue radial flap

Medial sural artery perforator free flap versus radial forearm free flap in oral cavity reconstruction and donor site morbidity

OBJECTIVE

Radial Forearm Free flap (RFFF) is widely used in head and neck reconstruction, yet its donor site defect remains a significant drawback. The Medial Sural Artery Perforator Free Flap (MSAPFF) is considered an alternative flap to RFFF. This study aims to comprehensively analyze their characteristics, outcomes, and their impact on patient quality of life.

METHODS

All patients who underwent oral cavity reconstruction using RFFF and MSAPFF between February 2017 and April 2023 were included in this study. Flap characteristics, outcomes and post-operative complications were recorded and compared. Subjective donor site morbidity, aesthetic and functional results, and quality of life were also analyzed.

RESULTS

The study included 76 patients: 37 underwent reconstruction with RFFF, and 39 with MSAPFF. There was no significance difference between the RFFF and MSAPFF regarding the success rate (97.2% vs 97.4%), flap size (4.8 × 8.8 cm2 vs 5 × 9.8 cm2), hospital of stay (15.5 days vs 13.5 days) and recipient site complications (P > 0.05). However, MSAPFF showed larger flap thickness (P = 0.001), smaller arterial caliber (P = 0.008), shorter pedicle length (P = 0.001), and longer harvesting time (P < 0.001). No significant difference was observed between the pre-and postoperative ranges of wrist and ankle movements or in recipient site complications. MSAPFF showed a significant difference in donor site morbidity (P < 0.05).

CONCLUSION

The MSAPFF is an excellent alternative to the RFFF for repairing oral cavity defects, with additional advantage of a well-hidden scar on the posterior calf, a larger flap thickness, accepted pedicle length and arterial caliber. However, one should consider the harvesting time and surgical skills required in comparison to the RFFF.

CLINICAL RELEVANCE

The study highlights the importance of the MSAPFF as an alternative option for RFFF with less donor site morbidity and high success rate in oral cavity reconstruction and improved patient Quality of life after ablative surgery.

Reconstruction of Head and Neck Defects Using Medial Sural Artery Perforator Free Flap

AIM

To study the use of medial sural artery perforator (MSAP) free flap in head and neck reconstruction.

MATERIAL AND METHOD

This was a prospective study. The patients with cancers of head and neck underwent excision of tumor along with neck dissection, and MSAP free flap was used for reconstruction.

RESULTS

The free MSAP flaps were used in 30 patients to reconstruct head and neck soft tissue defects. There were sixteen male and six female patients with the median age of 40 years. The most common site of tumor resection was the tongue (14 cases), followed by buccal mucosa (12 cases), neck skin(2 cases), skin over parotid(1 case) and lip(1 case). Average flap size was 56 cm2. Thickness of the flap ranged from 4 to 8 mm. The length of the vascular pedicle ranged from 8 to 14 cm (12 cm mean) which provides sufficient length during vessel anastomosis. Arterial diameter ranged from 1.0 to 1.5 mm(Average - 1.25 mm) and venous diameter of both veins in pedicle ranged from 1.5 to 2.5 mm(Average - 2 mm) in size. Most flaps were based on two perforators. Primary closure was attained in 11 cases whereas 19 patients required split thickness skin graft(STSG). The average flap harvesting time was 45 min. Flap was failed in two cases.

CONCLUSION

MSAP is good alternative to FRAFF in the reconstruction of defect after resection of head and neck cancer.

Donor Site Defect Coverage of the Forearm with Dermal Substitute After Harvesting Radial Forearm Free Flap for Phalloplasty: Is MatriDerm® Worth the Effort?

An aesthetically and functionally pleasing phalloplasty is most commonly performed by a free radial forearm flap. However, the problem with donor site morbidity on the forearm remains unsolved. The aim of this study was to evaluate if the use of a dermal template such as MatriDerm® on the donor site significantly decreases the incidence of complications based on the Clavien–Dindo classification, such as wound healing disorders and reoperation rate, and if it could shortens the duration of hospital stay. A case series analysis was conducted at our institution. A total of 21 patients divided into two groups undergoing the phallic construction after the Gottlieb and Levine design in a single center underwent the donor site defect coverage either by MatriDerm® and split-thickness skin graft from the thigh or by full-thickness skin graft from the groin area. The use of MatriDerm® and split-thickness skin graft showed to have a statistically significant impact on the rate of complications (p = 0.008). Complications that were treated conservatively as well as that require surgical revision were significantly lower in the MatriDerm® group than in the full-thickness skin graft group (p = 0.002). Complications occurred not only at the forearm but also at the groin, where the full-thickness skin graft was harvested. The large dimension of the free radial forearm flap used for phalloplasty resulted in a significant donor site morbidity, leading to wound healing disorders, reoperations, and extended length of hospital stay. Therefore, we consider the use of dermal templates such as MatriDerm® as worth the additional effort and costs in this patient collective.

Functional and biomechanical assessment of the hand following ulnar forearm free flap transfer: Prospective self-controlled study

BACKGROUND

There is a shortage of well-designed self-controlled studies evaluating hand biomechanics following ulnar forearm flap (UFF) harvest. This study was conducted to evaluate objective and subjective functional outcomes of the donor's hand following UFF harvest.

METHODS

All patients undergoing UFF were included for analysis. Grip strength, wrist movement, forearm supination and pronation, pinch strengths, sensation to light touch and temperature, and hand dexterity were assessed preoperatively and at 1, 3, and 6 months postoperatively. In addition, DASH score (disabilities of the arm, shoulder, and hand score) and Patient and Observer Scar Assessment Scale (POSAS) were analyzed.

RESULTS

A total of 18 patients were enrolled. A significant reduction in grip strength for donor's hand was observed between preoperative and postoperative 1 and 3 months (mean difference = 14 kg, 7.38 kg, respectively, p = 0.000 for all). A similar trend was observed for pinch strength and range of motion (p < 0.05). Three months after surgery, there is still a significant reduction in tip pinch, tripod pinch, wrist extension, and supination. All biomechanics outcomes returned to preoperative baseline at 6 months after surgery. No patients suffered significant changes in sensation to light touch, temperature, and numbness by 6 months. There was a significant increase in DASH score by 3.37 points 6 months after operation (p = 0.000). The POSAS score indicates satisfaction with the appearance of the donor site.

CONCLUSIONS

UFF is a safe and reliable option for oral cavity reconstruction with minimum donor site morbidities, mainly when cosmesis is paramount. Furthermore, objective hand biomechanics ultimately returns to its preoperative state within 6 months after surgery.

Comparison Between Radial Forearm Free Flap and Pectoralis Major Myocutaneous Flap for Reconstruction in Oral Cavity Cancer Patients: Assessment of the Quality of Life

ABSTRACT

We aimed to evaluate the quality of life of Chinese patients after immediate reconstruction surgery on individuals with oral cavity cancer. In addition, we compared the differences between radial forearm free flap and pectoralis major myocutaneous flap. Using the University of Washington quality of life v4 questionnaire, 1:1 matched research was performed on patients received PMM or RFF flap. Chi-square test was used to analyze the variables. One hundred twenty four of 179 questionnaires were returned (69.3%). Age, N stage, and postoperative radiotherapy were similar for both groups. However, there were significant differences between two groups in gender, T stage, operation duration, and complication rate. Oral cavity cancer patients reconstructed with radial forearm free flap had better shoulder and speech functions but worse appearance domains. The results of our research provide important information for patients and physicians during their discussion of treatment programs for oral cavity cancers.

Negative-pressure wound therapy for donor-site closure in radial forearm free flap: A systematic review and meta-analysis

Negative‐pressure wound therapy (NPWT) is often used for skin graft site dressing, and several studies have reported that its use improves skin graft failure in the forearm flap donor site. The present systematic review aimed to evaluate the efficacy of NPWT with skin graft for donor‐site closure in radial forearm free flap (RFFF) reconstruction. A systematic search in PubMed, Web of Science, and Cochrane Library databases was conducted. The search terms used for PubMed were ([radial forearm]) AND ([donor]) AND ([negative pressure or vacuum]). This review was registered in the International Prospective Register of Systematic Reviews and performed in accordance with the preferred reporting items for systematic reviews and meta‐analyses statement. Three prospective randomised controlled trials and three retrospective comparative studies were included. Compared with conventional bolster dressing, the use of NPWT dressing did not lead to significant improvements in partial skin graft loss, tendon exposure, and other complications. NPWT improved hand functionality earlier; nonetheless, the cost of the device and dressings was a disadvantage. The use of NPWT for skin graft fixation in the RFFF donor site is not generally recommended.

Donor Site Wound Healing in Radial Forearm Flap: A Comparative Study Between Dermal Substitute and Split-Thickness Skin Graft Versus Full-Thickness Skin Graft Primary Coverage

ABSTRACT

Radial forearm flap (RFF) is one of the most used flaps in reconstructive surgery. Despite its versatility and effectiveness, the donor site is affected by aesthetic and functional issues. In the group of techniques described to improve the donor site morbidity, dermal substitutes offer a valid approach in the wound management. A bilayered bioresorbable dermal substitute (Hyalomatrix) was used to provide the primary coverage of the RFF harvest site followed after 3 weeks by a split-thickness skin graft placement. In this study, 37 patients underwent RFF donor site reconstruction and subjected to a minimum follow-up of 1 year. The dermal substitute was applied on 15 patients, and their outcomes were compared with the data achieved by 22 patients submitted to immediate reconstruction with autologous full-thickness skin graft. Results were documented by digital photographs, the visual analog scale, the Vancouver Scar Scale, and the Disabilities of the Arm, Shoulder, and Hand questionnaire. Data were analyzed and compared through statistical analysis. Total wound coverage was achieved in 4 to 6 weeks, and no tendon impairments were reported in the dermal substitute group. In our experience, the use of the dermal substitute is a valuable mean to minimize RFF donor site morbidity with excellent functional and aesthetic outcomes.

A Novel Design of V-shaped Radial Forearm Free Flap Facilitates the Direct Closure of Donor Site Wound

ABSTRACT

The radial forearm free flap (RFFF) is one of the commonly used flaps in the repair of head and neck soft tissue defects, especially small and medium-sized defects. The free skin grafts from abdomen are usually used to repair the RFFF donor site wound. This study aims to design a novel V-shaped RFFF, hoping that it might facilitate the direct closure of the forearm donor site wound. From August to December in 2019, 20 patients with oral cancers received radical surgeries, and V-shaped RFFFs were designed to repair the soft defects and the forearm donor site wound was directly closed. The patients were followed up for 6 months to assess the final outcome of repair. The results showed that the pre-designed V-shaped RFFF met the needs of soft tissue defect repair, with the size ranging from 24 cm2 to 30 cm2. Fifteen patients with tongue cancers and four with buccal cancers had satisfactory repair results, and only one patient with buccal cancer had mild limitation of mouth opening. There were 3 patients with a small area of ischemia. The mean postoperative hospital stay was 13.85 ± 1.09 days. In 5 patients, wrist tilt motility decreased compared with that before surgery. The postoperative influence score of wrist exercise on daily life was 2.75 ± 0.44 points. In conclusion, the V-shaped RFFF can meet the needs of small and medium-sized defect repair. This novel design can directly close the forearm donor site wound, which avoids surgical trauma to secondary donor site, and significantly reduces related complications.

The profunda artery perforator free flap for lower extremity reconstruction

BACKGROUND

The profunda artery perforator (PAP) flap has been reported in several types of reconstructions. This report aims to evaluate the usefulness and the clinical outcome of patients who underwent the PAP free flap for lower limb reconstruction.

METHODS

Between February 2018 and February 2020, nine patients with injury at lower third of the leg, foot dorsum or foot plant (eight acute injuries and one chronic ulcer) were selected. Mean wound size was 12.5 × 6.3 cm (9 × 5-14.5 × 6.5). Inclusion criteria consisted in patient's request to hide the donor site scar and the absence of previous traumas or surgery in the donor site. Patients considered unable to bear prolonged surgery were excluded. Patients underwent preoperative CT angiography and peri-operative Doopler, for perforator selection. All flaps were designed with pinch test, in elliptical shape. Microvascular anastomosis was performed to the tibialis anterior/posterior or medial plantar vessels. Outcomes were evaluated in terms of wound coverage success and patient's quality of life through Lower Extremity Functional Scale (LEFS) questionnaire.

RESULTS

The mean size of the harvested skin paddle was 13.5 × 7.4 cm (9 × 6-15 × 8) and mean pedicle length was 8.5 cm. Mean flap harvest time was 43.5 min (35-55). Flap survival rate was 100%, with one re-exploration with minimal partial flap loss. Mean follow-up was 13.5 months . Reconstructive results were successful in wound coverage and function. All patients reported satisfaction with their result by LEFS questionnaire (score:64.7).

CONCLUSION

With proper patient selection, there was 100% flap survival rate with no major complication. According to our data, the PAP free flap could be a valuable option for lower extremity reconstruction.

Selecting a free flap for soft tissue coverage in lower extremity reconstruction

BACKGROUND

Goals of lower extremity microvascular reconstruction (LEMR) include the restoration of function, prevention of infection, and optimal cosmesis. Indications for LEMR include large defects that are not amenable to pedicled options, a large zone of injury, and large complex defects. The novice microsurgeon should first master a handful of free flaps to develop an armamentarium of options for addressing such defects. The scope of this review is to provide free flap options for LEMR in any of the thirds of the lower leg. After reading this article, the reader will understand variations, advantages, disadvantages, indications, and tips for raising each of these flaps.

METHODS

Six most commonly used free flaps for LEMR are described in this paper, including the anterolateral thigh flap (ALT) and its variations, the radial forearm flap (RFFF), the lateral arm flap (LAF), the gracilis muscle flap, the rectus abdominis flap (RAF) and the latissimus dorsi flap and its variations. Indications, advantages, disadvantages and technique tips are discussed for each flap. Moreover, selection of the recipient vessels, preoperative management along with an algorithm are also provided.

CONCLUSIONS

The ALT flap is a workhorse in covering defects of the leg, foot, and ankle. It's the flap of choice at our institution, especially given the number of traumatic wounds seen as a result of motor vehicles, all-terrain vehicles (ATV), lawnmowers, and gunshot wounds (GSW). At times, the lower extremity zone of injury requires a distant donor site. The RAF can also provide coverage for large soft tissue defects but donor-site morbidity remains its main drawback. The LAF and RFFF provide two pliable options, one that provides pliable soft tissue with minimal donor site morbidity and another that provides a long pedicle. The free gracilis flap is an excellent choice for crossing the ankle joint. Lastly, the free latissimus dorsi is indicated for large defects of the lower extremity independently of the location.

Use of amniotic membrane for radial forearm free flap donor site coverage: clinical, functional and cosmetic outcomes

Objective

To evaluate the clinical, functional and aesthetic outcomes for radial forearm free flap (RFFF) donor sites covered with amniotic membrane (AM).

Material and methods

The healing process of patients with RFFF donor sites covered with AM was prospectively followed for 1 year. Additionally at the 12-month evaluation, objective scoring systems were used to assess the aesthetic (Vancouver scar scale, VSS: range 1–13) and functional outcome (skin sensibility, hand/wrist functionality [goniometer], grip strength [score 1 = excellent, 5 = poor]). By using a subjective rating system (score 1 = excellent, 5 = poor), the patient-reported aesthetic and functionality outcome was correlated with objective data analysis.

Results

Twenty-one out of 23 patients were followed for 12 months (dropout: 2 patients at 3 months). In 17/23 (73.9%) patients RFFF defect covered with AM showed an uneventful healing period (< 3 months). Prolonged healing periods (> 3 months < 6) for 6 patients (26.1%) were attributed to wound infections (4×), seroma (1×) and inflammation (1×). At the 1-year evaluation, there was a significant (p < 0.01) correlation between subjective (2.0 ± 0.71) and objective aesthetic scores (VVS 3.74 ± 2.18), and a successful grip strength (score 1.67 ± 0.86); however, thumb hyposensibility in 76.2% was seen. A high body mass index (BMI) was in conjunction with a negative (p = 0.012) and the use of antihypertensive medications provided positive effects (p = 0.041) on the aesthetic outcome.

Conclusion

RFFF donor site defects covered using AM show excellent clinical, aesthetic and functional outcome representing patient comorbidities (BMI, antihypertensive drugs) might affect the aesthetic outcome.

Clinical relevance

In relation to the excellent outcomes found, the use of AM offers an alternative treatment procedure for RFFF defect covering.

Comparative Analysis of Radial Forearm Free Flap and Anterolateral Thigh Flap in Tongue Reconstruction after Radical Resection of Tongue Cancer

BACKGROUND

Surgery is still the preferred treatment for tongue cancer. Reconstruction should be performed immediately after extensive resection of the tumor. The purpose of this study was to investigate the clinical effect, advantages, and disadvantages of radial forearm free (RFF) flap and anterolateral thigh (ALT) flap in tongue reconstruction after radical resection of tongue cancer.

METHODS

Thirty-nine cases of tongue reconstruction with RFF flap or ALT flap from 2014 to 2018 were analyzed. The survival of the flap, the functional status after repair, and the influence on the donor area were examined, in addition to the advantages and disadvantages of the flap and the critical points of the technique.

RESULTS

Twenty-one cases with RFF flaps and 18 cases with ALT flaps showed complete flap survival. Among them, 1 case involved a venous vessel crisis after an ALT operation, and the flap survived after reoperation after thrombus removal and anastomosis. The recovery of tongue function was as follows: 41.0% patients exhibited normal speech, 43.6% patients exhibited near-normal speech, 12.8% patients exhibited vague speech, and 2.6% patients could not speak. There was no significant difference between the 2 groups (p = 0.134). The recovery of tongue flexibility was as follows: 41.0% of the patients had normal postoperative tongue flexibility, 43.6% of the patients had slightly limited tongue flexibility, 12.8% of the patients had severely limited tongue flexibility, and 2.6% of the patients were completely limited. The difference between the 2 groups was statistically significant (p = 0.045). The postoperative diet of patients was as follows: 51.3% of patients had a regular diet, 33.3% of patients had soft foods, 12.8% of patients received a fluid diet, and 2.6% of patients could not eat after the operation. There was no significant difference between the 2 groups (p = 0.209). The satisfaction of donor area was as follows: 46.2% of the patients were satisfied with the donor area, 51.3% of the patients were basically satisfied with the donor area satisfaction, and 2.6% of the patients were not satisfied with the donor area satisfaction. There was no significant difference between the 2 groups (p = 0.809).

CONCLUSION

The RFF flap is the most widely used technique in tongue reconstruction, especially in patients with tongue defects less than half of tongue tissue. However, for a large number of tissue defects caused by radical resection of advanced tongue cancer, the ALT flaps can provide a sufficient tissue volume, conceal scars after the operation, cause fewer complications in the donor area, and facilitate tongue function and aesthetic quality.

Donor site morbidity following radial forearm free flap reconstruction with split thickness skin grafts using negative pressure wound therapy

Background

Donor site complications secondary to radial forearm free flap (RFFF) reconstruction can limit recovery. Optimizing hand and wrist function in the post-operative period may allow more efficient self-care and return to activities of daily living. Negative pressure wound dressings (NPD) may increase blood flow and perfusion as compared to static pressure dressings (SPD) designed to minimize shear forces during the healing period. This study aims to compare subjective and objective hand and wrist functional outcomes following RFFF reconstruction with split thickness skin grafts (STSG) in patients treated with NPD and SPD.

Methods

Adult patients undergoing RFFF with STSG were identified preoperatively and randomized to receive NPD or SPD following their RFFF reconstruction. NPD involved a single-use, portable device capable of applying 80 mmHg of negative pressure to the forearm donor site. SPD involved a volar splint. Dressings were left in place for seven days with subjective and objective function assessed at seven days, one month and three months postoperatively. The primary outcome was self-reported hand function as measured with the function subscale of the Michigan Hand Questionnaire (MHQ). Secondary outcomes included hand and wrist strength, range of motion, sensation, scar aesthetics, and skin graft complications.

Results

Twenty-four patients undergoing RFFF were randomized to NPD or SPD. Patients treated with NPD had improved MHQ self-reported functional scores as compared to those treated with SPD at seven days postoperatively (P = 0.016). Flexion at seven days was improved in NPD group (P = 0.031); however, all other strength and range of motion outcomes were similar between groups. There were no differences in rates of graft complications, scar aesthetics, or sensation.

Conclusions

In the immediate post-operative period, NPD was associated with improved patient-reported hand and wrist function. Wound care to optimize hand and wrist function could allow for improved patient outcomes in the immediate postoperative period.

Appraisal of the Free Ulnar Flap Versatility in Craniofacial Soft-tissue Reconstruction

The unique anatomical characteristics of the forearm region make it especially popular as a free flap donor site for craniofacial soft-tissue reconstruction. The free ulnar forearm flap is less hirsute and allows for better concealment of donor site scar as compared with its radial counterpart. Despite these factors, the free radial forearm flap remains more popular among reconstructive surgeons. Through the presented case series, we hope to emphasize the versatile nature of the free ulnar forearm flap in addressing various craniofacial soft-tissue defects. Following institutional review board approval, a retrospective review of the senior authors' clinical experience performing microvascular free ulnar forearm flap reconstruction of craniofacial soft-tissue defects was performed. A total of 10 patients were identified through our review. Soft-tissue defect locations included lower eyelid (n = 2), tongue and floor of mouth (n = 2), lower lip (n = 2), palatopharyngeal area (n = 1), nose (n = 1), and palate (n = 1). Trauma was the most common defect etiology (n = 5), followed by malignancy (n = 4), and iatrogenic injury in 1 case. All patients demonstrated good aesthetic and functional outcomes related to vision, speech, and oral intake at follow-up when applicable. The free ulnar forearm flap is a versatile reconstructive option that can be used to address a wide spectrum of craniofacial soft-tissue defects and offers numerous advantages over its radial counterpart.

An algorithm to improve outcomes of radial forearm flap donor site

Abstarct Background: Due to the high rate of donor site complications the Radial Forearm Flap (RFF) has lost ground in favor of the Antero-lateral tight flap (ALT) and other flaps. We have designed a reconstruction algorithm for reconstruction of its donor site. The goal of this study was to retrospectively evaluate the impact of this algorithm on RFF donor site complication rates.

METHODS

The authors analyzed retrospectively 31 patients who underwent free radial forearm flap reconstruction between November 2009 and May 2013. Donor site complications were compared with data from patients treated before introdutction of the algorithm. Within the group were compared patients in which the flap was harvested suprafascial with those in which the flap was harvested as subfascial.

RESULTS

Before application of the algorithm, there was a 23.3% complication rate at the RFF donor site, in our experience. After introduction of the algorithm, complication rate has dropped to 3.2%, consisting in a partial skin graft necrosis treated by local wound-care and healed without further intervention.

CONCLUSIONS

Application of the algorithm described has led to a significant reduction in RFF donor site complication rates. This demonstrates that if flap donor sites are analyzed and tailor treated in the same way as primary defects are, instead of being given secondary importance and just grafted, outcomes improve.

Medial Sural Artery Perforator Flap for Head and Neck Reconstruction

Aim:

The aim is to study the assessment of feasibility of medial sural artery perforator (MSAP) free flap for head and neck reconstruction at our center.

Materials and Methods:

Oral cancer patients with squamous cell carcinoma of the tongue, buccal mucosa, and floor of mouth cancer attending our center were reconstructed using MSAP flap after oncologic resection. Handheld 8 MHz Doppler was used to identify the perforator preoperatively.

Results:

We reconstructed 10 patients using MSAP flap. The flap was designed according to defect and donor site was primarily closed in all cases. Excellent results were seen in nine patients reconstructed with MSAP flap without any postoperative complication. Flap failure occurred in one patient due to venous thrombosis. The thickness of flap ranged from 4 to 8 mm. The vascular pedicle length ranged from 9 to 13 cm.

Conclusion:

The MSAP flap is appropriate for medium-sized oral defect reconstruction, with a long pedicle of matching caliber, adequate tissue volume, and minimal donor-site morbidity which makes it comparable to other microvascular free flaps such as radial artery free flap (RAFF) and anterolateral thigh flap.

The use of the radial styloid in the extended osteocutaneous radial forearm free flap

BACKGROUND

The osteocutaneous radial forearm free flap (OC-RFFF) remains a useful tool in head and neck reconstruction; however, it can be challenging to harvest sufficient bone for large reconstructions. The extended OC-RFFF is a modification that involves harvest of the distal border of the radius to the tip of the styloid. This increases the length of the bone flap by 2 cm to 3 cm, and the inherent contour of the styloid can be used to reconstruct the anterior curvature of the mandible or maxilla without additional osteotomies that may reduce blood supply.

METHODS

The key steps in harvesting the extended OC-RFFF are described. Six patients with mandibular or maxillary defects underwent reconstruction with the extended OC-RFFF. Patient data including demographics, defect features, reconstruction details and outcomes were collected.

RESULTS

Of the six patients who underwent the extended OC-RFFF, four had mandibular reconstruction and two had maxillary reconstruction. Two patients underwent reconstruction for osteoradionecrosis and the remainder for malignant disease. The average patient age at the time of surgery was 64.5 years. The length of radius harvested ranged from 8 cm to 14 cm (mean 9.7 cm). Two of six patients required a single osteotomy of their bone flap. Donor site complications included partial skin graft loss in 50% and a radius fracture in two patients. Recipient site complications included one patient with intraoral plate exposure. There have been no cases of nonunion.

CONCLUSIONS

The extended OC-RFFF was a safe and reliable option for bony reconstruction in the head and neck.

The use of the radial styloid in the extended osteocutaneous radial forearm free flap

Background

The osteocutaneous radial forearm free flap (OC-RFFF) remains a useful tool in head and neck reconstruction; however, it can be challenging to harvest sufficient bone for large reconstructions. The extended OC-RFFF is a modification that involves harvest of the distal border of the radius to the tip of the styloid. This increases the length of the bone flap by 2 cm to 3 cm, and the inherent contour of the styloid can be used to reconstruct the anterior curvature of the mandible or maxilla without additional osteotomies that may reduce blood supply.

Methods

The key steps in harvesting the extended OC-RFFF are described. Six patients with mandibular or maxillary defects underwent reconstruction with the extended OC-RFFF. Patient data including demographics, defect features, reconstruction details and outcomes were collected.

Results

Of the six patients who underwent the extended OC-RFFF, four had mandibular reconstruction and two had maxillary reconstruction. Two patients underwent reconstruction for osteoradionecrosis and the remainder for malignant disease. The average patient age at the time of surgery was 64.5 years. The length of radius harvested ranged from 8 cm to 14 cm (mean 9.7 cm). Two of six patients required a single osteotomy of their bone flap. Donor site complications included partial skin graft loss in 50% and a radius fracture in two patients. Recipient site complications included one patient with intraoral plate exposure. There have been no cases of nonunion.

Conclusions

The extended OC-RFFF was a safe and reliable option for bony reconstruction in the head and neck.

The Allen's test: revisiting the importance of bidirectional testing to determine candidacy and design of radial forearm free flap harvest in the era of trans radial endovascular access procedures

Background

The radial forearm free flap is a workhorse free flap. The radial artery, which supplies it, is increasingly being used for endovascular access. A complication of this is radial artery occlusion. Although often asymptomatic it can compromise future free tissue transfer.

Case Presentation

Two patients who underwent RFFF harvest for head and neck reconstruction are presented; both of who likely had distal radial artery occlusion.

The first patient had failure of flap perfusion, presumed secondary to radial artery occlusion from prior endovascular access at the distal radial artery. In the second case, we used the Allen’s test in reverse to identify the same scenario and successfully redesigned the harvest.

Conclusion

The Allen’s test is a simple bedside test that should be performed bidirectionally to exclude radial artery occlusion, which may compromise flap harvest. Radial artery occlusion will become increasingly common as the radial artery is used more frequently for endovascular access procedures.

Assessment of free microvascular flap perfusion by intraoperative fluorescence angiography in craniomaxillofacial surgery

Microsurgical tissue transfer represents a standard technique for reconstruction in craniomaxillofacial surgery. The transferred tissue is anastomosed to vessels of varying diameters and different physiological conditions. The aim of this study was to evaluate the blood flow in free flaps at their origin and compare this with the flow after reperfusion. In 24 patients undergoing microsurgical procedures (13 radial forearm free flaps (RFFF) and 11 parascapular/scapular free flaps (PSFF)), blood flow was evaluated by intraoperative fluorescence angiography after flap raising and again after reperfusion in the neck area (Flow800, Carl Zeiss AG, Oberkochen, Germany). Flow is expressed by the blood flow index (BFI), maximum intensity (MaxInt) and half-time to MaxInt (t1/2) and was measured in the flap pedicle itself, as well as in the supplying vessels. Following anastomosis of the free flaps in the head and neck area, both the arterial and the venous BFI and MaxInt significantly increased, whereas t1/2 decreased significantly. There was no significant difference in the perfusion parameters between RFFF and PSFF. Intraoperative fluorescence angiography is a reliable method for assessing the perfusion of free microvascular flaps. In the head and neck area, free flaps undergo a significant increase in perfusion but show no differences between varying flap types.

Long-term follow-up of donor site morbidity after defect coverage with Integra following radial forearm flap elevation

Background

The radial forearm flap (RFF) is known for its excellent and reliable results regarding defect coverage though donor site morbidity represents a persisting problem. Integra is widely used in reconstructive surgery. This study aims to assess long-term outcomes regarding functionality and cosmesis after donor site coverage with respect to esthetic appearance, scar quality, and wrist function as well as ability to work after donor site coverage with Integra and split-thickness skin.

Methods

The prospective follow-up exam, after a mean time of 23.8 months, enrolled 13 patients. Identification of patients’ comorbidities and evaluation of the subjective esthetic outcome, sensibility, cold intolerance, and scar instability was assessed by a questionnaire. In clinics, designed Pinch test assessed scar tissue mobility over the flexor tendons. The Vancouver Scar Scale (VSS) was calculated; wrist function and grip strength were determined.

Results

The satisfaction score for the esthetic appearance of the donor site was in average 3.42 ± 0.44. Two patients experienced an unstable scar and cold intolerance. The VSS resulted in a value of 4.2 representing a good result. The pinch test revealed an average scar mobility of 8 mm without any tendon adhesions. Active range of motion of the wrist was equal to the non-operated site as was grip strength. The pinch test showed a significant negative correlation with the VSS making it a reliable tool to measure scar quality.

Conclusion

Long-term results show an esthetic and functional successful defect coverage of the RFF donor site by the use of Integra and split-thickness skin.

Level of Evidence: Level IV, therapeutic study.

Full thickness skin grafts from the groin: donor site morbidity and graft survival rate from 50 cases

Objectives

Full thickness skin grafts (FTSG) offer several advantages; they are esthetically superb, have less postoperative shrinkage, and offer minimal postoperative pain and scar formation at the donor site. As a donor site of FTSG, the groin offers a relatively large area of skin with high elasticity. The aim of this study was to evaluate FTSG from the groin for reconstruction in oral and maxillofacial surgery.

Materials and Methods

In a retrospective study, 50 patients (27 males, 23 females) who received FTSG from the groin were evaluated for their operation records, clinical photography, and medical records.

Results

The width of skin from the groin was distributed from 2-8 cm (mean: 5.1 cm) at the donor site, while the long axis length was distributed from 3-13 cm (mean: 7.4 cm). A high number of patients, 47 patients (94%) out of 50, showed good healing at the donor site. Wound impairment was seen in 3 patients (6%), minor wound dehiscence in 2 patients, and severe wound dehiscence in 1 patient. In the recipient site, delayed healing was observed in 2 patients (4%).

Conclusion

FTSG from the groin to repair soft tissue defects in reconstruction surgery is a good method due to the relatively big size of the graft, decreasing morbidity at the donor site, and higher graft survival rates.

Full length articles published in BJOMS during 2010-11--an analysis by sub-specialty and study type

Full length articles such as prospective and retrospective studies, case series, laboratory-based research and reviews form the majority of papers published in the British Journal of Oral and Maxillofacial Surgery (BJOMS). We were interested to evaluate the breakdown of these types of articles both by sub-specialty and the type of study as well as the proportion that are written by UK colleagues compared to overseas authors over a 2 year period (2010-11). A total of 191 full length articles across all sub-specialties of our discipline were published, with 107 papers (56%) coming from UK authors. There were proportionately more oncology papers arising from the UK than overseas (60 and 30% of total respectively) while the opposite was found for cleft/deformity studies (10% and 22%). There was only one laboratory-based study published from the UK compared with 27 papers from overseas. The number of quality papers being submitted to the Journal continues to increase, and the type of article being published between UK and overseas probably reflects different practices and case-loads amongst colleagues. The relatively few UK laboratory based studies published in BJOMS compared to overseas authors are most likely due to authors seeking the most prestigious journals possible for their work.

Microvascular tissue transfer in cleft palate patients: advocacy of the prelaminated radial free forearm flap

The closure of wide palatal clefts and recurrent oronasal fistulae may be challenging. After repeated failure of conventional techniques, microvascular tissue transfer may be indicated in the closure of such fistulae. Depending on the location and the size of the palatal fistula, different tissues are required to sufficiently close the palatal gaps. A subdivision of common flaps into mucosa, muscular, bony, skin, and fascia flaps was carried out to analyze their suitability for alveolar, hard, and soft palate reconstruction. Furthermore, the bulk of flaps and the length of the vascular pedicle were analyzed to rate the suitability of different flaps for palatal closure. Based on a new classification of oronasal fistulae, all these factors were taken into consideration to introduce a decision guidance of what microvascular flap fits a particular clinical situation. The radial free forearm flap was found to be sufficient in the closure of all classes of oronasal fistulae.

What are we reading? A study of downloaded and cited articles from the British Journal of Oral and Maxillofacial Surgery in 2010

A large number of papers related to oral and maxillofacial surgery are published in many specialist journals. With the ever-increasing use of the internet it is easy to download them as part of a journal subscription on a fee per paper basis, or in some cases for free. Online access to the British Journal of Oral and Maxillofacial Surgery (BJOMS) is free to British Association (BAOMS) members with a $30 fee per paper download for non-members. Many colleagues use the online version of the journal, and this provides valuable information about downloading trends. Other data on articles that have been cited in subsequent publications are also readily available, and they form the basis for the calculation of a journal's impact factor. We evaluated the top 50 downloaded papers from the BJOMS website in 2010 to ascertain which articles were being read online. We also obtained data on the number of citations for papers published in 2009-2010 to see whether these papers were similar to the articles being downloaded. In 2010 there were over 360000 downloaded articles. The most popular papers were leading articles, reviews, and full length articles; only one short communication featured in the top 50 downloads. The papers most cited in subsequent publications were full length articles and leading articles or reviews, which represent 80% of the total citations of the 50 papers. Ten papers were in both the top 50 downloaded and most cited lists. We discuss the implications of this study for the journal and our readers.

[Vacuum-assisted closure of head and neck wounds]

OBJECTIVE

Since the early 1990s, vacuum-assisted closure (VAC) therapy has been used to treat acute and chronic wounds in almost all disciplines of surgery in Germany. Taking this into consideration, the use of vacuum therapy in the area of head and neck surgery was examined.

METHODS

A literature review using MEDLINE (with PubMed) and EMBASE as well as a Cochrane search was performed on 15 December 2010. Search terms included "vacuum therapy", "vacuum-assisted closure", "V.A.C.", "VAC", "(topical) negative pressure (wound therapy)".

RESULTS

There were 1,502 peer-reviewed articles about "vacuum therapy" concerning all medical fields in literature. There were a total of 37 publications from the discipline of head and neck surgery (538 patients). Although benefits for the patients are consistently reported, these results are usually presented only in case reports or case series (evidence level IV and V). Positive results are mainly observed for the treatment of lifting defects in reconstructive surgery and for the treatment of acute and chronic soft tissue defects of the neck. Only little experience exists in the vacuum therapy of war wounds in the head and neck region.

CONCLUSION

Due to its advantages (i.e., hygienic temporary wound care with support of the continuous decontamination, wound drainage, promotion of granulation tissue formation, and effective wound conditioning), VAC is an integral and indispensable part of modern wound treatment. Analogous to this general experience, a benefit must also be assumed for head and neck wounds. High-quality and reliable studies on the use of VAC must be performed to verify this observation and the future reimbursement of in- and outpatient wound VAC treatment.

Comparison of sensory recovery at the subfascial and suprafascial donor sites of the free radial flap

The radial flap may be raised using a subfascial or suprafascial approach. The latter donor site is associated with fewer healing complications. We retrospectively evaluated the quality of sensory recovery within two comparable groups of 30 patients with subfascial and suprafascial donor sites. When considering the two groups, two-point discrimination was the modality most commonly reduced, with 97% of patients in both groups having reduced sensation in at least one anatomical zone. Sensation of sharp touch was most often lost; 90% in the subfascial and 83% in the suprafascial groups lost sensation in at least one anatomical zone. Roughly half the patients had reduced perception of light touch (43% and 50%), whilst perception of heat (27% and 17%) and cold (33% and 27%) were lost least often. At least one modality in at least one anatomical zone was lost or reduced in all patients, and roughly two-thirds (73% and 63%) had a reduction in 3 or more. The only significant difference between the donor and non-donor arms was reduced perception of sharp touch in the anterior forearm in both groups (p<0.001). Perception at the two sites (including the anatomical snuff box) was similar except for superior thenar palmar light touch (p=0.015) in the suprafascial group, which may indicate injury to the thenar cutaneous sensory branches during subfascial dissection.

Squamous cell carcinoma arising in a skin flap: case report and review on malignant transformations in skin grafts and microvascular cutaneous flaps

OBJECTIVES

Sufficient closure of intraoral defects can be challenging. Various methods of tissue transfer have been presented in the literature. From skin grafts to microvascular flaps, most techniques used for intraoral reconstruction use skin to line out the oral cavity to guarantee an epithelial surface. Native mucosa tolerates the moist environment of the oral cavity, whereas skin flaps do to just a certain extent. This may lead to chronic inflammation of the flap-skin. Under rare circumstances, these histologic changes can enhance the risk for malignant transformation of the skin graft.

CASE REPORT

We present a case of a patient who derived a squamous cell carcinoma in the skin island of a jump flap raised from the abdominal wall 30 years earlier. The flap was used to close a very wide palatal cleft. The patient had no history of malignancy, smoking, drinking, or other risk factors.

DISCUSSION

To the authors' knowledge, this is the first report on carcinoma in a skin flap in a patient without any history of intraoral malignancy. Although malignant transformations of skin grafts are very rare and usually appear years after the reconstruction, one should be aware that the moist environment can lead to chronic inflammation of the dermis of flap. This fact may increase the risk of malignant transformation in a skin graft.