The radial forearm free flap: a review of microsurgical options

[Choice of flaps for phalloplasty: what is the contemporary standard? Consensus Statement of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels]

The ever-expanding number of transmen as well as their surgeons share an increasing interest in the construction of a neophallus. While the indication for surgery and the positive effect of a phalloplasty on the quality of life, mental health and sexual function has already been thoroughly analysed, there is a lack of data comparing and evaluating the surgical steps. During the consensus conference on the "choice of flaps for phalloplasty" at the annual meeting of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels, the current literature was discussed and a consensus on the surgical technique of a phalloplasty was reached. This manuscript publishes jointly developed recommendations on the following topics: choice of flaps for phalloplasty, preoperative diagnostic tests before phalloplasty, urethral construction in the radial forearm flap and anterior lateral thigh flap, preformation of the urethra at the forearm or thigh, venous drainage of the radial forearm flap, innervation of the phallus, staged phalloplasty, coronaplasty and managing the donor site of a radial forearm flap.

The Central Facial Defect Reconstruction Using a Radial Forearm Free Flap after Malignant Cutaneous Tumor Ablation

PURPOSE

Acquired defects of the central face pose significant challenges in achieving acceptable cosmetic and functional outcomes. The site, size, and depth of tissue loss often render local tissues inadequate for the repair of major nasal defects. In this article, we aim to demonstrate the efficacy of radial forearm-free flaps as an ideal choice for various central facial unit reconstructions.

METHODS

This study encompassed patients treated between 2020 and 2022 who underwent facial reconstruction using radial forearm flaps. These flaps were employed in eleven patients with defects involving the lower lid, nose, upper lip, and lower lip. Additionally, we used osteocutaneous flaps in one patient to reconstruct a right nasal bone defect. In three patients requiring medial and lateral canthal tendon reconstruction in one case and oral sphincter reconstruction in two cases, the palmaris longus tendon was included with the flap.

RESULTS

In the majority of cases, we achieved good to excellent aesthetic and functional results. Notably, there were no instances of flap failure or partial necrosis in this series. All patients experienced uneventful healing at the donor site.

CONCLUSIONS

The radial forearm-free flap stands as an ideal and reliable method for reconstructing various facial defects. It offers efficient and thin-conforming skin coverage.

Versatility and outcomes of lateral arm free flap in head and neck reconstruction: a retrospective case series study of our experiences and innovations

OBJECTIVES

The Lateral Arm Free Flap (LAFF) offers advantageous features like variable thickness and minimal hair growth. LAFF is primarily used in orofacial and pharyngeal reconstructions, with limited reports on tracheal/esophageal applications. Also, the psychological prognosis and quality of life in patients with LAFF reconstruction are lacking.

METHODS

This retrospective case series presents outcomes of LAFF reconstruction for head and neck surgical defects which included 19 patients. The disease type, location of reconstruction, TNM staging, tumor size, chemoradiation status, anxiety, depression, quality of life and detailed perioperative information of the LAFF reconstruction surgery were presented in a descriptive pattern. Subgroup analysis was conducted using Mann-Whitney U and Pearson r test.

RESULTS

All 19 patients (100%) had a viable flap after surgery with 5 (26.3%) of them developed flap-related complication. Patients with oropharyngeal reconstruction were more likely to have lower anxiety and depression score and higher quality of life than those with below-oropharyngeal reconstruction. However, no significant p-value was generated in any subgroup comparison or correlation test. And the application of LAFF in esophageal and tracheal reconstruction was proved to be successful.

CONCLUSIONS

The lateral arm free flap exhibits remarkable versatility and multifunctionality, providing advantageous outcomes in head and neck reconstruction.

LEVEL OF EVIDENCE

Level 4 according to OCEBM.

The Medial Sural Artery Perforator Flap versus Other Free Flaps in Head and Neck Reconstruction: A Systematic Review

The medial sural artery perforator (MSAP) flap is a versatile fasciocutaneous flap, and yet is less commonly utilized than other free flaps in microvascular reconstructions of the head and neck. The aim is to conduct a high-quality Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)- and Assessment of Multiple Systematic Reviews 2 (AMSTAR 2)-compliant systematic review comparing the use of the MSAP flap to other microvascular free flaps in the head and neck. Medline, Embase, and Web of Science databases were searched to identify all original comparative studies comparing patients undergoing head and neck reconstruction with an MSAP flap to the radial forearm free flap (RFFF) or anterolateral thigh (ALT) flap from inception to February 2021. Outcome studied were the recipient-site and donor-site morbidities as well as speech and swallow function. A total of 473 articles were identified from title and abstract review. Four studies met the inclusion criteria. Compared with the RFFF and the ALT flaps, the MSAP flap had more recipient-site complications (6.0 vs 10.4%) but less donor-site complications (20.2 vs 7.8%). The MSAP flap demonstrated better overall donor-site appearance and function than the RFFF and ALT flaps ( p  = 0.0006) but no statistical difference in speech and swallowing function following reconstruction ( p  = 0.28). Although higher quality studies reviewing the use of the MSAP flap to other free flaps are needed, the MSAP flap provides a viable and effective reconstructive option and should be strongly considered for reconstruction of head and neck defects.

Robot-assisted radial forearm free flap harvesting: a propensity score-matched case-control study

Although some surgeons prefer anterolateral thigh and latissimus dorsi flap for soft tissue reconstruction in the head and neck area because it minimizes donor site complications, the radial forearm flap remains the workhorse for soft tissue reconstruction due to its reliability. To reduce donor site morbidity, the authors developed a novel technique for radial forearm flap harvesting using a robotic device. 42 radial forearm free flap reconstruction cases were studied, consisting of 31 conventional and 11 robot-assisted cases. 1:1 propensity score matching was done according to age, sex, previous and postoperative radiation therapy history and method used for vein anastomosis. There was no significant difference in flap outcome, which was 100% vitality in the robot-assisted group and 90.9% vitality in the conventional group. The robot-assisted group showed significantly longer mean harvesting time than did the conventional group, being 107.2 min and 67.0 min, respectively. Robot-assisted radial forearm flap harvesting can reduce donor site complications by minimizing incision. When more surgical experience is gained under appropriate case selection, we expect our robot-assisted method will yield a harvesting time similar to that of the conventional method and thus become more reliable and feasible.

"DO ONE, GET TWO": dual venous drainage of the radial forearm free flap by a single venous anastomosis

PURPOSE

The radial forearm free flap (RFFF) remains a workhorse in microsurgical reconstruction. Its failure is primarily due to problems with venous drainage; for this reason, controversy on venous anastomosis patterns still exists. This manuscript describes our experience in using a communicating vein to overcome the complications of venous drainage of the RFFF.

METHODS

Following a review of the vascular anatomy of the RFFF, we retrospectively review the use of the communicating vein and report our results, with the aim of overcoming the dichotomy "superficial versus deep venous system" and "single versus double anastomosis" and discussing the evidence of advantages in using a single microanastomosis with a communicating vein.

RESULTS

Our retrospective review included a total of 123 patients in which a RFFF was performed to reconstruct intraoral defects, performed with a single venous anastomosis using the communicating vein. Four patients (3.25%) required a return to theatre for revision of the venous anastomosis and one case resulted in flap failure due to arterial insufficiency (0.81%).

CONCLUSIONS

Our series highlights the constant presence of the communicating vein, although with variations of origin and course that did not preclude the possibility to correctly perform the anastomosis. Advantages of a single microanastomosis with the communicating vein include ease, speed, reliability and versatility in planning the anastomosis. Based on our results, the use of the communicating vein showed comparable and, in some cases, more favourable results when compared to venous anastomotic complications reported in the literature.

Superficial versus deep system single venous anastomosis in the radial forearm free flap: a meta-analysis

The selection of the superficial or deep drainage system for use with the radial forearm free flap (RFFF) remains controversial. The aim of this study was to identify the optimal drainage system for single venous anastomosis. A systematic review and cumulative meta-analysis was performed to assess superficial and deep system single venous anastomosis for use with the RFFF in postoperative reconstruction of the head and neck. This study included 1073 flaps (495 superficial system-based flaps, 578 deep system-based flaps) reported in six studies. The outcomes assessed in the studies selected for this meta-analysis included venous compromise, flap failure, and the salvage success rate. Venous compromise was more common in the superficial system group (odds ratio (OR) 2.29, 95% confidence interval (CI) 1.36-3.86, P=0.002). The rate of successful salvage was higher with the superficial system (OR 8.19, 95% CI 1.75-38.3, P=0.008). The rate of flap failure was lower in the superficial system group (OR 0.30, 95% CI 0.04-2.48, P=0.27). Although the deep system showed a lower risk of venous compromise, the evidence provided by the meta-analysis was insufficient to determine which type of drainage system is more suitable for single venous anastomosis in RFFF. All included studies were cohort studies; therefore, findings must be interpreted with caution.

Peroneal flap: How to harvest and clinical appraisal for head and neck reconstruction

BACKGROUND

A peroneal flap, the boneless version of fibula flap, is considered as the equivalent of radial forearm flap of the lower leg. Because it is thinner than an anterolateral thigh (ALT) flap, the use of a peroneal flap is a viable option for the repair of soft tissue defects when a thin flap could bring about better functional and cosmetic outcomes. In this article, we describe the details of peroneal flap harvest and present our experience with the use of peroneal flaps for head and neck reconstruction.

MATERIALS AND METHODS

Between 1996 and 2017, a total of 265 peroneal flaps were used to reconstruct a variety of head and neck defects. With the same vascular anatomy and slight modifications to the harvesting technique of a fibula flap, a peroneal flap can be harvested within 1-2 h. All medical records were retrospectively reviewed.

RESULTS

A peroneal flap can be harvested as different types of chimeric flaps to fit a variety of head and neck defects. The peroneal flap failure rate was 3.4% and the postoperative complication rate was 12.8%.

CONCLUSION

A peroneal flap might be an alternative option for the reconstruction of head and neck defects.

Shape-modified radial forearm free tissue transfer in oral cavity reconstruction: Technique and a prospective comparison with the conventional technique

BACKGROUND

Donor site morbidity is a significant drawback of the radial forearm flap. The purpose of this study is to describe a new shape-modified technique. The donor site morbidity was compared to that of the conventional technique, in terms of the esthetic, functional outcomes, and quality of life (QOL).

METHODS

This is a prospective study of 30 patients with oral cancer who underwent reconstruction using radial forearm flaps, in two groups.

RESULTS

Regarding the donor site characteristics, the differences in the time for healing (P = .006), the scar score (P < .0001), and the QOL score (P < .0001) were significant. The number of patients with sensory deficit was 11 in the conventional group and 3 in the shape-modified group (P = .009).

CONCLUSIONS

The functional and esthetic outcomes of the donor site were better for the shape-modified technique. It is best suited for small defects. Compromise of the pedicle length is a limitation.

Free extended posterior tibial artery perforator flap with the neurovascular plexus of a saphenous nerve branch for large soft tissue and sensory reconstruction: Anatomic study and clinical application

BACKGROUND

The posterior tibial artery perforator (PTAP) flap is a useful tool for reconstruction of soft tissue defects in the leg. However, the size and reliability of the flap largely depends on the quality of the perforator by which the flap is supplied, and the sensory recovery of the flap is limited. In this study, the anatomy of the saphenous nerve branches and their accompanying vessels was investigated, and a free extended PTAP flap with the neurovascular plexus of a saphenous nerve branch was designed for large soft tissue and sensory reconstruction in a series of clinical cases.

METHODS

Sixteen adult cadaveric legs perfused with red latex in the femoral artery were dissected. The number and location of the saphenous nerve branches and the features of their accompanying vessels were dissected and studied. From January 2016 to December 2017, six patients with soft tissue defects ranged from 8 × 2.5 cm to 21 × 4 cm were repaired by the free extended PTAP flap. The patients' average age was 48 years. The causes of the defects included machine injuries in three patients and traffic injuries in the other three. The defects located at the hand in three cases, foot in two cases, and ankle in one case. The flap was designed based on the perforators of the posterior tibial artery and included a branch of saphenous nerve. The perforator pedicle and the nerve branch were connected to the vessels and nerve in the recipient site, respectively.

RESULTS

The saphenous nerve gave off 5.8 ± 1.1 branches, with a relatively constant one issuing 8.1 ± 0.7 cm distal to the medial femoral condyle. Every nerve branch had an accompanying vessel, which connected with the PTAPs and supplied the skin. The size of the flap ranged from 10 × 3.5 cm to 23 × 5 cm. All of the flaps survived completely without complications. Follow-up varied from 6 to 12 months. All the patients obtained cold/hot sensation and pain sensation. The results of Semmes-Weinstein monofilament test ranged from 4.31(2 g) to 5.46 (26 g), and the 2-point discrimination test varied from 20 to 35 mm.

CONCLUSION

The free extended PTAP flap, containing the saphenous nerve branch and its accompanying vessels, may be an alternative for large soft tissue reconstruction with improved sensation recovery.

Reconstructing the Face of War

Introduction

Ongoing combat operations in Iraq, Afghanistan, and other theaters have led to an increase in high energy craniomaxillofacial (CMF) wounds. These challenging injuries are typically associated with complex tissue deficiencies, evolving areas of necrosis, and bony comminution with bone and ballistic fragment sequestrum. Restoring form and function in these combat-sustained CMF injuries is challenging, and frequently requires local and distant tissue transfers. War injuries are different than the isolated trauma seen in the civilian sector. Donor sites are limited on patients with blast injuries and they may have preferences or functional reasons for the decisions to choose flaps from the available donor sites.

Methods

A case series of patients who sustained severe combat-related CMF injury and were treated at Walter Reed National Military Medical Center (WRNMMC) is presented. Our study was exempt from Institutional Review Board review, and appropriate written consent was obtained from all patients included in the study for the use of representative clinical images.

Results

Four patients treated by the CMF team at Walter Reed National Military Medical Center are presented. In this study, we highlight their surgical management by the CMF team at WRNMMC, detail their postoperative course, and illustrate the outcomes achieved using representative patient clinical images. We also supplement this case series demonstrating military approaches to complex CMF injuries with CMF reconstructive algorithms utilized by the senior author (EDR) in the management of civilian complex avulsive injuries of the upper, mid, and lower face are thoroughly reviewed.

Conclusion

While the epidemiology and characteristics of military CMF injuries have been well described, their management remains poorly defined and creates an opportunity for reconstructive principles proven in the civilian sector to be applied in the care of severely wounded service members. The War on Terror marks the first time that microsurgery has been used extensively to reconstruct combat sustained wounds of the CMF region. Our manuscript reviews various options to reconstruct these devastating CMF injuries and emphasizes the need for steady communication between the civilian and military surgical communities to establish the best care for these complex patients.

Middle and Lower Face Soft Tissue Reconstruction: A 10-Year Retrospective Study

Retrospectively analyze the reconstruction methods and surgical outcomes of patients with middle and lower face soft tissue defects treated at our hospital over the past 10 years. 200 patients with middle and lower face soft tissue defects were surgically reconstructed at our hospital. Medical charts were retrospectively reviewed and analyzed to abstract the pertinent information. The lesion was mainly at the eyelid, lips, chin and nasal-cheek region. There were 41 (63.08 %) men and 24 (36.92 %) women. In our study, male to female ratio = 1.7:1. We used direct closure for night patients, local flap for 141 patients, free flap for 38 patients, combined flap for 12 patients involving extensive mid face and lower face defects. Most patients had their tumor resected and reconstructed in single stage procedure mostly with local advancement flap, and no flap failure was presented post-operatively. Middle and lower face soft tissue defects can be successfully treated with local flap in a single stage approach and step-by-step approach.

[Free radial forearm flap in head and neck: our experience]

INTRODUCTION

Oncologic surgery leads to important defects and sequelae, as well as notable cosmetic and functional alterations. In this aspect reconstructive surgery has an essential role, allowing more radical excision and lower associated functional and cosmetic morbidities. The aim of this study was to present and evaluate the experience and results of the reconstructive microsurgery unit in our centre's ENT department.

METHODS

Retrospective study of procedures performed between 2006 and 2012.

RESULTS

A total of 36 cases were reviewed. The primary tumour was found in the oropharynx (58%) in the majority of cases. In 5 cases the procedure was performed for reconstruction and fistula closure (4 pharyngostoma and 1 tracheoesophageal fistula). Failure from total necrosis was 16% (6/36). No associated mortality has been reported. The most common postoperative complications were wound dehiscence in 5 patients and pharyngostoma (fistula) in 5 cases. Prior radiotherapy significantly influenced the increase in the overall incidence of complications (P<05).

CONCLUSIONS

Reconstructive surgery currently plays an important role in surgery for head and neck cancer. The radial forearm flap is a safe, reliable method for reconstruction of most defects in the ENT field. This type of intervention provides greater autonomy and safety in surgical oncology.

Infrahyoid myocutaneous flap for medium-sized head and neck defects: surgical outcome and technique modification

OBJECTIVES

To evaluate the surgical outcomes associated with infrahyoid myocutaneous flaps used in the reconstruction of medium-sized defects following head and neck cancer resection, as well as to discuss a novel technique modification.

STUDY DESIGN

Case series with chart review.

SETTING

University cancer hospital.

SUBJECTS AND METHODS

A total of 20 patients with oral or hypopharyngeal carcinoma who underwent infrahyoid myocutaneous flap reconstruction between June 2005 and December 2011 were retrospectively studied. A novel technical modification of flap harvest, preservation of the cranial portion of the anterior jugular vein, was attempted in 15 flaps and was successful in 13 flaps. Functional evaluation was performed in all patients 3 to 6 months after the operation or postoperative radiation.

RESULTS

Total flap necrosis, marginal skin paddle necrosis, and total skin paddle loss were observed in 1, 2, and 1 patient(s), respectively. Pharyngocutaneous fistula without flap problem occurred in 1 patient. No flap complications occurred in 13 cases where the cranial portion of the anterior jugular vein was successfully preserved. Functional results were excellent in 16 patients, good in 3 patients, and fair in 1 patient.

CONCLUSION

The infrahyoid myocutaneous flap is a reliable and convenient technique that can serve as an alternative to free flaps in the reconstruction of medium-sized defects of the oral cavity or hypopharynx. Preservation of the cranial portion of the anterior jugular vein is a novel technical modification of harvesting this flap, which may result in better venous return of the skin paddle and reduce skin paddle necrosis.

Semi-free radial forearm flap for head and neck reconstruction in vessel-depleted neck after radiotherapy or radical neck dissection

BACKGROUND

Venous thrombosis is the main cause of radial forearm flap failure, especially when recipient vessels are compromised by prior radiation therapy or neck dissection. In such conditions, semi-free radial forearm flap (SF-RFF) can be performed to reduce this risk.

PATIENTS AND METHOD

We reviewed all SF-RFF procedures performed in our institution for head and neck reconstruction. The flap was harvested as a conventional radial forearm flap but the cephalic vein was dissected along the arm up to the deltopectoral crease and used as the sole drainage vein.

RESULT

Seven SF-RFFs were harvested for head and neck reconstructions. The dissection of the cephalic vein lasted less than 25 min in all cases. No flap loss or thrombosis was observed.

CONCLUSION

The SF-RFF is a reliable and versatile procedure for facial, oral, or larynx reconstruction. This hybrid version of the radial forearm free flap is particularly appropriate when no suitable recipient veins are available as a result of radiation or prior surgery.

[Application of radial forearm free flap in extraoral soft tissue head and neck reconstruction]

BACKGROUND/AIM

Radial forearm free flap, highly regarded in head and neck reconstructive surgery, is known to be one of the most reliable and versatile flaps. The aim of this study was to illustrate the versatility and reliability of a radial forearm flap in reconstruction of a variety of extraoral head and neck defects.

METHODS

During a period 2001-2007 at the Clinic for Maxillofacial Surgery, Faculty of Dentistry and the Center for Burns, Plastic and Reconstructive Surgery in Belgrade, 19 patients underwent microsurgical reconstructions after extraoral tumor ablation in the head and neck region, using fasciocutaneous radial forearm free flap.

RESULTS

The overall flap survival rate was 89.5%. The complications that appeared were one partial necrosis and one venous thrombosis that in spite of reanastomosis resulted in a complete flap failure. The donor site healed uneventfully in all patients, except one, who had a partial skin graft failure, that ended in a secondary skin grafting.

CONCLUSION

For reconstruction in head and neck surgery, with the need for thin, pliable tissues and a long vascular pedicle, radial forearm flap still remains a primary choice. Because of their multiple advantages, free flaps from the radial forearm is a safe method for reconstruction of a variety of extensive extraoral soft tissue defects in the head and neck region.