Fasciocutaneous and jejunal free flaps for circumferential hypopharyngeal defect reconstruction: A 22-year multicenter cohort study

BACKGROUND

It remains unclear whether a tubed fasciocutaneous or jejunal free flap (FCFF and JFF) is preferable for reconstruction of circumferential pharyngolaryngoesophageal defects.

METHODS

All consecutive patients with circumferential pharyngolaryngoesophageal defects reconstructed with an FCFF or JFF between 2000 and 2022 were included. Outcomes of interest were rates of fistulas, strictures, and donor-site complications.

RESULTS

In total, 112 patients were included (35 FCFFs and 77 JFFs). Fistula and stricture rates were significantly lower following JFF compared to FCFF reconstructions, with 12% versus 34% (p = 0.008) and 29% versus 49% (p = 0.04), respectively. Severe donor-site complications leading to surgical intervention or ICU admittance only occurred after JFF reconstructions (18%, p = 0.007).

CONCLUSIONS

The high fistula and stricture rates in FCFF reconstructions and the rate of severe abdominal complications in JFF reconstructions illustrate inherent procedure-specific advantages and disadvantages. Relative pros and cons should be carefully weighed when tailoring treatments to the individual needs of patients.

Full-Thickness Skin Graft Versus Split-Thickness Skin Graft for Radial Forearm Free Flap Transfer in Oral Cavity Reconstruction: A Systematic Review and Meta-Analysis

The radial forearm free flap (RFFF) is a surgical technique for addressing intraoral reconstruction. However, with the limitation of an unavoidable defect at the RFFF donor site, split-thickness skin grafts (STSGs) have been a solution for repairing these defects, but they are not without challenges. This study aimed to evaluate an approach using full-thickness skin grafts (FTSGs), comparing their effectiveness in terms of aesthetics, pain, complications, and scarring. A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies comparing FTSG with STSG for RFFF donor site repair in head and neck cancer patients were included. Primary outcomes measured were appearance and pain at the RFFF site, and secondary outcomes were infection, tendon exposure, graft loss, and scar assessment. A meta-analysis and systematic review of eight studies demonstrated that FTSG provided a superior aesthetic appearance at the RFFF donor site compared to STSG (p = 0.001), with low heterogeneity among the studies. The analysis found no significant difference in donor site pain between techniques. There were no significant differences in infection, tendon exposure, or skin graft loss between the two graft methods. This study suggests that FTSG is comparable to STSG in terms of donor site pain, scarring, and infection while offering superior aesthetic outcomes.

Medial Sural Artery Perforator Flap: A Middle Ground Between Anterolateral Thigh and Radial Forearm Flaps

OBJECTIVE

The medial sural artery perforator (MSAP) flap has gained popularity in head and neck reconstruction primarily as a less morbid alternative to the radial forearm free flap (RFFF). However, no direct comparison of thickness exists among the MSAP, RFFF, and anterolateral thigh (ALT) flaps, which together represent the commonly utilized nonosseus-free flaps in head and neck reconstruction. Thus, this study aimed to compare these flap sites and identify predictors of thickness that will aid in reconstructive surgical planning.

STUDY DESIGN

Cross-sectional study.

SETTING

Tertiary referral hospital.

METHODS

The thickness of skin and subcutaneous tissue at the RFFF, MSAP, and ALT donor sites were measured in 54 adult patients using Doppler ultrasound. General linear models were generated to identify predictors of flap thickness.

RESULTS

The mean thickness of the RFFF, MSAP, and ALT flaps was 3.8 ± 2.2 mm, 7.4 ± 3.8 mm, and 9.6 ± 4.7 mm. Body mass index (BMI) was the only statistically significant contributing factor (p < .0001, coefficient: 0.15) for the RFFF. MSAP was affected by age (p = .006, coefficient = 0.06), female gender (p < .0001, coefficient = 3.2), and BMI (p < .001, coefficient = 0.25), while the ALT was affected by female gender (p = .0005, coefficient = 3.3) and BMI (p < .0001, coefficient = 0.35). Thus, the ratio of increase for flap thickness with respect to BMI is 3:5:7 for the RFFF, MSAP, and ALT flaps, respectively.

CONCLUSION

The MSAP is about twice the thickness of the RFFF and 2 mm thinner than the ALT; however, 22% of patients had thicker MSAP than ALT flaps. As the strongest predictors of flap thickness, female gender, and BMI may be taken into consideration during surgical planning for reconstruction.

Comparison of Different Reconstruction Flap for Maxillofacial Region: An Original Research

Introduction

Large chunks of the tissue are sacrificed during the surgical procedures for the treatment if oral cancers. Our goal was to assess the viability of "Buccal reconstruction using the anterolateral thigh (ALT) flaps, platysma myocutaneous (PM), and radial forearm free (RFF)".

Material and Methods

Sixty subjects were included in this investigation, and they were divided into 3 groups. The follow-up as accompanied for six months. Comparisons were made for the time for the operations, reduction in the width of the mouth opening and the survival rates of the flaps. The data that was collected for the above two parameters and compared for the significance using the ANOVA, keeping P < 0.05 as significant.

Results

In the subjects with the PM, the width of the mouth opening reduced comparatively greater than that of the subjects who received other two flaps. The reduction in the mouth opening in the PM was significantly greater compared to that of the ALT and RFF. Survival was greater for the groups ALT and RFF compared to PM. Time of the surgery was the greatest for the ALT and least for the PF.

Conclusion

The observations point to the fact that the PF requires more time than that of the other two flaps. The survival was however better for the ALT and RFF. Further research is suggested for suggesting an appropriative flap design.

Orbital Exenteration and Reconstruction Using a Free Radial Forearm Flap in Conjunctival Melanoma: Old but Gold

Conjunctival melanoma is a rare and potentially deadly tumor. Therefore, adequate oncological resection is essential, commonly leading to total orbital exenteration, which causes patients' extensive functional and cosmetic impairment. As a result, it is essential to reconstruct the orbital region post-exenteration to obliterate the cavity, provide adequate and pliable cutaneous covering, and restore a stable vascularized tissue that can withstand adjuvant radiotherapy. In recent years, the techniques used for orbital reconstruction have included the transorbital temporoparietal fascial flap, the anterolateral thigh flap, and local flaps, such as the paramedian forehead flap. A free radial forearm flap is currently not commonly used for orbital reconstruction due to potential donor site morbidity and cosmetic issues. In our case, we report a free radial forearm fasciocutaneous flap that has been utilized with promising surgical outcomes to reconstruct the orbital region following orbital exenteration.

Free microvascular bone flaps used for cavity reconstruction in the head and neck area

The authors would like to present the possibilities of reconstructive surgery using free microvascular flaps with bone elements in the treatment of cavities in the head and neck area. The cavities in the presented article resulted both from resection of tumors in the head and neck area as well as congenital defects and radiation damage. The authors would like to discuss the difficulties that may arise during the postoperative period, including the maintenance of the graft&apos;s viability, the healing of the donor site and systemic problems. The article presents 33 reconstruction surgeries performed on 31 patients using different flaps, briefly describing their advantages and technical difficulties that may arise during the microvascular anastomoses. The authors emphasise the importance of a well-conducted qualification for the surgery as well as the need to discuss the course of the surgery and recovery and other possible treatment options with patients and their families. The complications that happened in the presented group and how they were treated are described. The authors discuss in details the 3 cases with different types of reconstructive procedures and draw attention to the importance of postoperative care consisting of the constant monitoring of the viability of the graft carried out by qualified personnel of the Otolaryngology Department and appropriately conducted anticoagulant therapy.

A Comparison of Skin Graft Techniques with and without Plaster Back Slab Dressing in Reducing Donor Site Morbidity in Radial Forearm Free Flap Surgery - A Retrospective Study

Introduction

The radial forearm free flap (RFFF) is a commonly used free flap for the reconstruction of orofacial defects because of its versatility and reliability. The donor site is closed with either split or full-thickness skin graft, and one of the common donor site morbidities is skin graft failure. Various techniques to minimise skin graft failure were reported, and we compared the skin graft techniques with and without plaster back slab dressing in the radial forearm donor site.

Materials and Methods

This is a retrospective study of 75 patients who had RFFF for reconstruction of oral cavity cancer at two different tertiary teaching hospitals in the United Kingdom between April 2015 and March 2020. Thirty-nine patients from Hospital one had volar back slap, bolster dressing and crepe bandage. In contrast, 36 patients from Hospital two had only pressure dressing without a back slab.

Results

The mean age of the study population was 60.65 (P = 0.274). In both groups, two patients had donor site complications. However, there was no significant difference in the donor site skin graft complications with a P = 0.662.

Discussion

There was no evidence in the literature to support an ideal bandage for skin graft at the RFFF donor site. Our comparison of two techniques of skin graft dressings with and without back slap did not show any difference in the skin graft take, and the volar back slab did not add any additional benefits. The simple use of foam as a bolster dressing without a back slab is ideal for the radial forearm free flap donor site.

A Novel design for Local Full-Thickness Skin Graft: Optimizing donor sites of Radial Forearm Free Flap

OBJECTIVE

Donor site deformities remain the primary issues after radial forearm free flap (RFFF) translocations. This study introduced a local full-thickness skin graft (FTSG) from an adjacent cutaneous area to manage RFFF donor sites and evaluated the aesthetic and functional outcomes postoperatively.

PATIENTS AND METHODS

This was a retrospective study among patients undergoing ablative surgery for head and neck tumors followed by defect reconstruction using a RFFF. The RFFF donor site defects were covered by local FTSGs from the adjacent skins whose harvesting was assisted by a forearm model or traditional FTSGs from abdomen. The color matching degree, surgical scars, ranges of wrist movement, and grip strengths in donor forearms were assessed in two groups at twelve months after surgery.

RESULTS

Patients undergoing local FTSGs recovery exhibited better color matching than those repaired by traditional FTSGs from the abdomen. In forearm model, the local FTSGs width should be less than 22% of the forearm circumference located 5 cm away from the center of Fossia cubitalis. All the local FTSGs transplanted with this technique showed primary or secondary healing.

CONCLUSIONS

This study demonstrated using this innovatively designed local FTSGs to close RFFF donor sites was more advantageous than traditional methods.

Radial Forearm Free Flap Reconstruction of Glossectomy Defects Without Tracheostomy

OBJECTIVES

To assess the feasibility of radial forearm free flap (RFFF) reconstruction of glossectomy defects without tracheostomy tube (TT).

METHODS

Retrospective review of patients with at least oral tongue defects who underwent RFFF reconstruction. Pre- and intra-operative factors were documented. Post-operative respiratory complications included inability to extubate, pneumonia, or need for re-intubation or TT within 30 days.

RESULTS

Twenty-one patients underwent RFFF reconstruction without TT, and 36 patients with TT. The average hospital length of stay was 1.5 days shorter in those without TT (P < .01). Two patients who underwent TT placement experienced a respiratory complication (P = .27). There were no respiratory complications among those without TT. After multivariate analyses, large tongue base defect (>25% resection, P < .001) and bilateral neck dissection (P < .001) were independently associated with TT placement.

CONCLUSIONS

In our experience, RFFF reconstruction of glossectomy defects is feasible without TT among selected patients with small tongue base defects (≤25% resection) and unilateral neck dissection.

Multimodal evaluation of donor site morbidity in transgender individuals after phalloplasty with a free radial forearm flap: a case-control study

BACKGROUND

In phalloplasty, there is a lack of standardized follow-up examinations of motor function and strength after harvesting oversized radial forearm free flaps (RFFF).

METHODS

We evaluated the donor site of 20 transmen after phalloplasty, using a multimodal, standardized approach, assessing the following parameters: opposition of the thumb, composite range of motion of the finger joints, grip strength, mobility of the wrist, lesion of the superficial branch of the radial nerve, the dorsal branch of the ulnar nerve, the sensation of pain, and cold intolerance. The contralateral, nonoperated forearm was used as a control.

RESULTS

No impairment of the mobility of the thumb (Kapandji score median 10, range 5-10) or fingers (all fingers at both sides pulp-to-palm 0 cm, nail-to-table 0 cm) were detected. Grip strength (median 36,3kg, p=0.629) and wrist extension (62.5°vs.70°, p=0.357), flexion (70°vs.70°, p=0.535), pronation (90°vs.90°), supination (90°vs.90°), radial (30°vs.30°, p=0.195), and ulnar deviation (40°vs.50°, p=0.125) did not statistically differ between donor and control hand. Injury of the dorsal branch of the ulnar nerve was uncommon (0% hypoesthesia, 10% positive Tinel's sign). We did not observe any persistent pain of the donor forearm (NRS median 0, range 0-9). We did observe irritation of the superficial branch of the radial nerve (hypoesthesia 40%, neuroma 45%).

CONCLUSION

The harvest of an oversized RFFF for phalloplasty does not cause any significant difference in motor function or strength between the donor and nonoperated hand. A potential risk of injuring the radial nerve branch is to be avoided. An aesthetic impairment could be addressed in future studies.

Is Hyperspectral Imaging Suitable for Assessing Collateral Circulation Prior Radial Forearm Free Flap Harvesting? Comparison of Hyperspectral Imaging and Conventional Allen's Test

(1) Background: This cross-sectional study aims to compare a new and non-invasive approach using hyperspectral imaging (HSI) with the conventional modified Allen’s test (MAT) for the assessment of collateral perfusion prior to radial forearm free flap harvest in healthy adults. (2) HSI of the right hand of 114 patients was recorded. Here, three recordings were carried out: (I) basic status (perfusion), (II) after occlusion of ulnar and radial artery (occlusion) and (III) after releasing the ulnar artery (reperfusion). At all recordings, tissue oxygenation/superficial perfusion (StO₂ (0–100%); 0–1 mm depth), tissue hemoglobin index (THI (0–100)) and near infrared perfusion index/deep perfusion (NIR (0–100); 0–4 mm depth) were assessed. A modified Allen’s test (control) was conducted and compared with the HSI-results. (3) Results: Statistically significant differences between perfusion (I) and artery occlusion (II) and between artery occlusion (II) and reperfusion (III) could be observed within the population with a non-pathological MAT (each <0.001). Significant correlations were observed for the difference between perfusion and reperfusion in THI and the height of the MAT (p < 0.05). Within the population with a MAT >8 s, an impairment in reperfusion was shown (each p < 0.05) and the difference between perfusion and reperfusion exhibited a strong correlation to the height of the MAT (each p < 0.01). (4) Conclusions: The results indicate a reliable differentiation between perfusion and occlusion by HSI. Therefore, HSI could be a useful tool for verification of the correct performance of the MAT as well as to confirm the final diagnosis, as it provides an objective, reproducible method whose results strongly correlate with those obtained by MAT. What is more, it can be easily applied by non-medical personnel.

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.

Outcomes of Single Anastomoses for Superficial and Deep-System Venous Drainage of Radial Forearm Free Flaps

Objective

Venous insufficiency occurs in radial forearm free flaps (RFFFs) when either the deep venous system (DVS) or superficial venous system (SVS) is used as the venous outlet. We report our experience using the antecubital perforating vein (APV) in a single-vessel anastomosis to the median-cubital or cephalic vein to drain both systems.

Study Design

Retrospective review.

Setting

Single, academic, tertiary care center.

Methods

Data were collected from 72 patients who underwent RFFF from October 2009 to January 2017. In all cases, DVS and SVS were dissected, and an APV single-vessel anastomosis was attempted.

Results

Anatomical variations precluded single-vessel anastomosis in 11 (15.3%) cases. In 61 (84.7%) cases, single-vessel anastomosis produced unobstructed drainage for DVS and SVS without intrinsic venous insufficiency. Venous thrombosis and total loss occurred in 2 (3.3%) and 1 (1.6%) patients, respectively. Proximal dissection of the cephalic vein addressed a vessel-depleted neck in 3 cases.

Conclusion

The antecubital perforating vein is present and functional in most patients, allowing for single anastomosis techniques for RFFF. Antecubital perforators capture DVS and SVS outflow through a single, extended venous pedicle, eliminating the risk of venous insufficiency and need for vein grafts.

Magnitude of radial forearm free flaps and factors associated with loss of volume in oral cancer reconstructive surgery: Prospective study

BACKGROUND

Adequate flap volume is key to maintaining oral function after oral cancer surgery. This study aimed to evaluate changes in radial forearm free flap (RFFF) volumes after 1 year of follow-up following ablative tumor surgery in the head and neck.

METHODS

A prospective study that recorded the clinical data of 20 patients with head and neck cancer who underwent RFFF reconstruction. Magnetic resonance (MR) and Mimics Research 19.0 software were used to measure the RFFF volumes at 1, 3, 6, and 12 postoperative months.

RESULTS

Compared with one postoperative month, the RFFF volume decreased by 15.5%, 29.4%, and 42.0% at 3, 6, and 12 months, respectively, after surgery. A significant positive correlation between postoperative radiotherapy and RFFF volume changes was detected.

CONCLUSION

The volume of RFFF decreases with time. It is recommended to use overcorrection, with a 40% increase in RFFF volume, to reconstruct head and neck tumor-related defects.

[Use of radial forearm free flap for the reconstruction of hard and soft palate]

OBJECTIVE

Improvement functional and aesthetic results of treatment patients with defects of the hard and soft palate after resections for malignant tumors.

MATERIALS AND METHODS

During the period from 2014 to 2020, 30 patients underwent microsurgical reconstruction of hard and soft palate defects using a radial forearm free flap. For the primary tumor process, surgery was performed in 21 patients (70%), for relapse after chemotherapy, combined or complex treatment - in 9 patients (30%). The majority of patients at the time of surgery had a locally advanced process of the T2 category (12 patients - 40%), T3 (2 patients - 7%) and T4 - 2 patients (7%). Localized stage T1 process was diagnosed in 5 patients (17%).

RESULTS

Total flap necrosis was noted in 3 cases (10%) due to venous thrombosis on the 2nd and 3rd days after surgery and arterial thrombosis on the 2nd day. In one observation, on the 2nd day after surgery, a tense hematoma was diagnosed in the zone of formation of microanastomoses without signs of impaired flap perfusion, which required an emergency surgical intervention. All patients returned to their normal meals. No rhinolalia was observed in any of the cases. In one case, a patient with a defect in the anterior part of the hard palate obtained an unsatisfactory aesthetic result deformity of the midface; in all other cases, an excellent aesthetic result was obtained.

CONCLUSION

For defects of the hard palate of posterior localization and minimal or no defect of the alveolar edge of the maxilla (class I, a, b according to Braun, class Ia, Ib according to Okay, class V according to Armany), as well as for the defects of the soft palate, the method of choice is radial forearm free flap. The size of the skin area of the flap can reach 6X8 cm, which makes it possible to replace the combined defects of the hard and soft palate, the lateral wall of the oropharynx, and the retromolar region. The plasticity of the flap makes it possible to reconstruct the total defects of the soft palate by forming it in the form of a duplication.

Long-term donor site morbidity after radial forearm flap elevation for tongue reconstruction: Prospective observational study

BACKGROUND

To assess long-term donor site morbidity after radial forearm free (RFF) flap harvesting.

METHODS

Enrolled patients were asked to complete the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and undergo wrist motion and hand strength examinations at different time points. The data were prospectively collected and retrospectively analyzed.

RESULTS

The postoperative DASH score did not return to normal until 24 months after the operation. The mean postoperative wrist motion degree of flexion was significantly decreased compared to the preoperative level and returned to normal at 12 months after the operation. Similar trends were noted regarding extension, radial abduction, and ulnar abduction. The mean postoperative grip strength was significantly decreased compared to the preoperative level and remained dysfunctional at 24 months after the operation. A similar trend was also noted with regard to tip pinch and key pinch.

CONCLUSION

The long-term negative effect on hand strength is sustained.

Radiation necrosis of the pharyngeal soft tissue: Unique clinical entity reconstructed with a previously unreported composite brachioradialis and flexor digitorum superficialis radial forearm flap

BACKGROUND

The radial forearm free flap (RFFF) is a versatile flap commonly used in head and neck reconstructive surgery. We describe the use of a composite RFFF that includes muscle for reconstruction of a hostile wound of the posterior pharyngeal wall.

METHODS

A 54-year-old male with a history of recurrent right palatine tonsil HPV+ squamous cell carcinoma developed severe soft tissue necrosis of the posterior pharyngeal wall secondary to reirradiation. The defect was reconstructed with a composite RFFF that included the brachioradialis (BR) muscle and the flexor digitorum superficialis (FDS) muscle.

RESULTS

Restoration of this complex defect was successfully accomplished with minimal donor site functional deficits and satisfactory functional outcomes including decannulation and resumption of oral intake.

CONCLUSION

This composite RFFF can be effectively used to reconstruct a hostile wound of the posterior pharyngeal wall. Incorporation of muscle in the reconstruction of complex wounds with soft tissue necrosis is beneficial.

Predictors of Free Flap Volume Loss in Nonosseous Reconstruction of Head and Neck Oncologic Defects

OBJECTIVES

Free tissue reconstruction of the head and neck must be initially overcorrected due to expected postoperative free flap volume loss, which can be accelerated by adjuvant radiation therapy. In this study, we aim to identify patient and treatment-specific factors that may significantly contribute to this phenomenon and translate these characteristics into a predictive model for expected percent free flap volume loss in a given patient.

METHODS

Patients with a history of oral cavity and/or oropharyngeal cancer who underwent nonosseous free flap reconstruction were reviewed between January 2009 and November 2018 at a tertiary care center. Demographics/characteristics, total radiation dose, radiation fractionation (RF), and pre/postradiation free flap volume as evaluated by computed tomography imaging were collected. Free flap volume was measured by a fellowship-trained neuroradiologist in all cases. Only patients receiving adjuvant radiotherapy with available pre/postradiation imaging were included. Multivariable linear regression modeling for prediction of free flap volume loss was performed with optimization via stepwise elimination.

RESULTS

Thirty patients were included for analysis. Mean flap volume loss was 42.7% ± 17.4%. The model predicted flap volume loss in a significant fashion (P = .004, R² = 0.49) with a mean magnitude of error of 9.8% ± 7.5%. Age (β = 0.01, P = .003) and RF (β = -0.01, P = .009) were individual predictors of flap volume loss.

CONCLUSIONS

Our model predicts percent free flap volume loss in a significant fashion. Age and RF are individual predictors of free flap volume loss, the latter being a novel finding that is also modifiable through hyperfractionation radiotherapy schedules.

Predicting length of stay in head and neck patients who undergo free flap reconstruction

OBJECTIVE

Understanding factors that affect postoperative length of stay (LOS) may improve patient recovery, hasten postoperative discharge, and minimize institutional costs. This study sought to (a) describe LOS among head and neck patients undergoing free flap reconstruction and (b) identify factors that predict increased LOS.

METHODS

A retrospective cohort was performed of 282 head and neck patients with free flap reconstruction for oncologic resection between 2011 and 2013 at a tertiary academic medical center. Patient demographics, tumor characteristics, and surgical and infectious complications were characterized. Multivariable regression identified predictors of increased LOS.

RESULTS

A total of 282 patients were included. Mean age was 64.7 years (SD = 12.2) and 40% were female. Most tumors were located in the oral cavity (53.9% of patients), and most patients underwent radial forearm free flap (RFFF) reconstruction (RFFF-73.8%, anterolateral thigh flap-11.3%, and fibula free flap-14.9%). Intraoperative complications were rare. The most common postoperative complications included nonwound infection (pneumonia [PNA] or urinary tract infection [UTI]) (15.6%) and wound breakdown/fistula (15.2%). Mean and median LOS were 13 days (SD = 7.7) and 10 days (interquartile range = 7), respectively. Statistically significant predictors of increased LOS included flap take back (Beta coefficient [C] = +4.26, P < .0001), in-hospital PNA or UTI (C = +2.52, P = .037), wound breakdown or fistula (C = +5.0, P < .0001), surgical site infection (C = +3.54, P = .017), and prior radiation therapy (C = +2.59, P = .004).

CONCLUSION

Several perioperative factors are associated with increased LOS. These findings may help with perioperative planning, including the need for vigilant wound care, optimization of antibiotics prophylaxis, and institution-level protocols for postoperative care and disposition of free flap patients.

LEVEL OF EVIDENCE

2b; retrospective cohort.

The Anomalous Radial Artery: A Rare Vascular Variant and Its Implications in Radial Forearm Free Tissue Transfer

The radial forearm free flap (RFFF) has become a workhorse for soft tissue reconstruction following surgical ablation of head and neck cancer. Given the popularity of the RFFF, it is important to understand potential variants of upper extremity vascular anatomy and the effects of these findings on pre- and intraoperative planning. The purpose of this series is to synthesize the existing literature to raise awareness for potential radial artery aberrations during planned reconstruction.

The submental flap for head and neck reconstruction: Comparison of outcomes to the radial forearm free flap

OBJECTIVES

To compare intraoperative, postoperative, functional, and oncologic outcomes of the submental island pedicled flap (SIPF) to the radial forearm free flap (RFFF).

STUDY DESIGN

Retrospective review; comparison with statistical analysis.

METHODS

A retrospective review was performed on patients at two tertiary care academic hospitals by a single surgeon. Consecutive patients who underwent cancer resection and reconstruction with SIPF or RFFF between 2004 and 2016 were included. Cancer staging, surgical procedure, hospital stay, complications, and functional and oncologic results were extracted.

RESULTS

The study included 146 patients (57 SIPF; 89 RFFF). The most prevalent primary site was oral cavity, with a minority in the oropharynx, paranasal sinuses, or external face. Mean area of the SIPF was smaller at 28 cm² compared to 48 cm² for the RFFF. Operative time for SIPF was shorter at 6.5 hours compared to 9 hours for RFFF. Hospital stay was 8.0 days for SIPF patients and 10.0 days for RFFF patients. Multivariate analysis confirmed these differences were significant. Functional outcomes of speech quality and gastrostomy feeding tube dependence were similar between the SIPF and RFFF groups. There was no difference in local recurrence rate for SIPF (16%) and RFFF (19%), and there was no difference in overall recurrence. Kaplan-Meier curves showed no difference in recurrence between both groups, and multivariate logistic regression demonstrated no association between SIPF and local recurrence.

CONCLUSION

Operative time and hospital stay are both significantly reduced with the SIPF. Functional and oncologic results are similar with no contraindication to the SIPF. The SIPF is a good first-line choice for head and neck reconstruction.

LEVEL OF EVIDENCE

3 Laryngoscope, 130:S1-S10, 2020.

A novel radial forearm free flap design to treat pharyngoesophageal stenosis in combination with the posterior wall of the trachea

Pharyngoesophageal stenosis (PES) is a common and serious complication of head and neck cancer treatments such as radiation therapy, chemotherapy, tracheoesophageal puncture placement, and total laryngectomy surgery. Dilation-resistant stenosis requires surgical reconstruction, often with a radial forearm free flap (RFFF). With the present technique, the authors refine their previous bipaddled free flap design used to reconstruct a persistent tracheoesophageal fistulae (TEF) in combination with PES. Accordingly, we present a novel bipaddled triangular RFFF design ideally suited to address the shape of the defect in the posterior tracheal wall that results when the TEF is opened and the esophageal and tracheal components are restored.

Radial Forearm Free Tissue Transfer to Clival Defect

Introduction  Reconstruction of craniocervical junction (CCJ) defects after endoscopic endonasal skull base surgery (ESBS) remains challenging, despite advancements in vascularized intranasal and regional flaps. Microvascular free tissue transfers have revolutionized reconstruction in open skull base surgery but have been utilized rarely in ESBS. We describe the use of a radial forearm free flap (RFFF) for reconstruction of a recalcitrant CCJ defect after resection of a clival chordoma.

Case Report  A 54-year-old female who underwent ESBS for a clival chordoma complicated by a C1–C2 epidural abscess after proton beam therapy presented with pneumocephalus 4 years after her resection ( Fig. 1 ). At the CCJ, she developed a 1-cm skull-base defect. An occult cerebrospinal fluid (CSF) leak persisted despite an extracranial pericranial flap and a lateral nasal wall flap. Her definite reconstruction was a RFFF inset through a transmaxillary approach. Using a maxillary vestibular incision, anterior, lateral, and medial maxillotomies allowed the introduction of the flap into the nasal cavity and the passage of the RFFF pedicle across the posterior maxillary wall, into the premassateric space and to the facial vessels at the mandible. An endonasal inset supplemented with transoral suturing of the distal end of the flap to the posterior oropharynx halted further CSF egress. Vascularization of the flap was confirmed with intraoperative indocyanine green angiography and postoperative computed tomography (CT) angiography and magnetic resonance imaging (MRI).

Conclusion  A RFFF inset through a transmaxillary approach to the facial vessels has an adequate reconstructive surface and pedicle to cover the central and posterior fossa skull base after ESBS ( Fig. 2 ).

The link to the video can be found at: https://youtu.be/rQ5vJKyD5qg .

Closure of radial forearm free flap donor site: A comparative study between keystone flap and skin graft

BACKGROUND

The aim was to investigate the feasibility of radial forearm free flap (RFFF) donor site closure by keystone flap (KF) and compare its outcomes to those of skin graft (SG) closure.

METHODS

One hundred and one patients who underwent RFFF for head and neck reconstruction were included (35 KF closure and 65 SG closure). Duration of wound healing and donor site complications was collected. After a minimal follow-up of 1 year, patients were questioned about functional and esthetic impairment.

RESULTS

Coverage of donor site by KF was successful in all cases. The duration of wound healing was longer after SG than after KF (32 days vs 18 days, P < .001). Healing complications, esthetic and functional results were not statistically different.

CONCLUSION

Forearm donor site closure by KF is a feasible alternative to the traditional SG. Its main advantages are the reduced wound healing time and the avoidance of a second donor site.

Free flap salvage from venous thrombosis by creation of a venocutaneous fistula: Case report and review of the literature

BACKGROUND

Venous congestion is the most frequently reported complication of free flap tissue transfer in head and neck patient with cancer. Numerous methods are utilized and prompt correction is necessary to prevent flap failure.

METHODS

A 77-year-old woman underwent oral cavity resection and neck dissection for squamous cell carcinoma followed by radial forearm free flap for reconstruction. Three days later, the flap became congested and surgical exploration revealed extensive venous thrombosis throughout the free flap venous system and internal jugular vein. The flap vein was evacuated and flowing, and a venocutaneous fistula was created thereafter.

RESULTS

Venocutaneous fistula resulted in flap decongestion and successful salvage. The patient was discharged from the hospital with no further flap or surgical complications.

CONCLUSION

When anatomical revision of the venous anastomosis is not feasible in a venous-congested free flap, the creation of a venocutaneous fistula should be considered as a viable option for salvage.

Extended adipofascial wrap around radial forearm flap for hard palate reconstruction

Background

While using radial forearm free flap in palate reconstruction, the pedicle lies in the nasal floor, constantly exposed to the nasal secretions and turbulent air current. To overcome this problem, we have designed a procedure which utilises the adipofascial extension to wrap the pedicle and nasal side of the flap.

Materials and Methods

The study was done during 2017 and 2018, 2 years' period. Totally 13 consecutive patients with defect in the palate status post-oncological resection and those in whom local flaps were not enough to cover the defect were included into the study. These patients were divided into two groups. First group in whom adipofascial extension was not used to cover the pedicle and second group in whom adipofascial extension was used to cover the pedicle. The incidence of nasal crusting, secondary haemorrage, blow out and flap necrosis were analysed and compared.

Results

In Group 1, we had 2 among 6 (33%) patients with secondary haemorrage. One patient had partial flap loss. On exploring, we noticed thrombosis of cephalic vein. We did not had any incidence of blow out of the pedicle. In Group 2, none of the patients had any secondary haemorrage. All flaps healed well. On doing nasal endoscopy at 6 months of follow-up, all flaps showed complete mucosalisation at the nasal side.

Conclusion

Use of adipofascial extension while planning a radial forearm free flap to cover the nasal side of the flap and pedicle in the nasal floor helps to reduce the nasal crusting and secondary haemorrhage.

Osteocutaneous radial forearm free flap in nonmandible head and neck reconstruction

BACKGROUND

The osteocutaneous radial forearm free flap (RFFF) is a versatile flap primarily used to reconstruct composite defects involving the mandible. The purpose of this study was to describe our experience with this flap for nonmandible reconstruction.

METHODS

All patients undergoing nonmandible osseous reconstruction with free-tissue transfer were reviewed. Patients with osteocutaneous RFFF reconstructions were evaluated. The retrospective review of all osteocutaneous RFFFs was performed from 1998 to 2014.

RESULTS

One hundred forty-two nonmandible osseous reconstructions were performed. Twenty-five patients underwent nonmandible osteocutaneous RFFF reconstruction. Eleven patients failed previous nonmicrovascular reconstruction. Reconstruction was for defects of the: palatomaxillary complex (n = 15), orbitomaxillary complex (n = 4), nasomaxillary complex (n = 4), larynx (n = 1), and clavicle (n = 1). There were no flap compromises. Postoperative complications included: 2 partial intraoral dehiscences; 1 recipient-site infection; and 1 seroma. Eight reconstructions required secondary procedures to improve functional and/or cosmetic outcomes.

CONCLUSION

The osteocutaneous RFFF is a robust flap that can be used to reconstruct composite defects involving bone and soft-tissue beyond the mandible.

Local Intraluminal Irrigation With Argatroban During Free Flap Repair in a Patient With Heparin-Induced Thrombocytopenia

OBJECTIVE

This study describes a case of a successful free flap repair using argatroban for local intraluminal irrigation as a substitute to heparin in a patient with heparin-induced thrombocytopenia.

METHODS

Case report and review of literature.

RESULTS

The patient had an uneventful postoperative course, and the free flap survived without complications.

CONCLUSIONS

The use of argatroban during microvascular surgery is likely to be safe and simple and may be effective in preventing micro-thrombotic complications during microvascular surgery, and it should be considered as an alternative to heparinized saline for local intraluminal irrigation.

Coverage of Tendon Exposure after Radial Forearm Free Flap by the Dorsoulnar Artery Perforator Flap

Objective This study was designed to assess the effectiveness of an alternative technique using a perforator flap to manage secondary tendon exposure after a radial forearm free flap in head and neck oncologic surgery. Study Design Prospective cohort study. Setting Plastic Reconstructive Surgery Unit, Nice University Hospital, Pasteur 2 Hospital, France. Subjects and Methods Despite its numerous advantages, the radial forearm free flap is associated with significant donor site morbidity and the risk of secondary tendon exposure. Conventional skin grafts for secondary tendon exposure can lead to diminished wrist range of motion and grip strength, with residual pain and cold intolerance. Between 2012 and 2015, we prospectively studied 20 patients with secondary tendon exposure after a forearm radial free flap for head and neck reconstruction. Two techniques of secondary coverage were compared: a reference technique with a secondary full skin graft (10 patients) and a dorsoulnar artery perforator (DUAP) flap (10 patients). Results Maximum wrist extension (100%) was observed for the DUAP group compared with only 87% for the skin graft (SG) group ( P = .001). An improvement in grip strength (+14 kg) ( P = .028) and a decrease in pain or cold intolerance ( P = .002) were also observed in the DUAP group, in addition to a better aesthetic appearance. Conclusion The perforator flap procedure is an interesting tool in reconstructive surgery. The DUAP flap is a reliable, useful flap for secondary tendon exposure coverage after a radial forearm free flap. Level of Evidence III (case-control analytic studies of 1 center).

Suprafascial Harvest of the Radial Forearm Free Flap Decreases the Risk of Postoperative Tendon Exposure

OBJECTIVE

To determine if suprafascial harvest of the radial forearm free flap improves postoperative donor site outcomes compared to subfascial harvest.

METHODS

Retrospective chart review.

RESULTS

Forty-six patients underwent reconstruction of a head and neck defect with a radial forearm free flap (RFFF). Subfascial harvest of the RFFF was performed in 25 (53%) patients and suprafascial harvest performed in 22 (47%) patients. All donor sites were covered with a split thickness skin graft and a bolster that remained in place for 6 days. Postoperative tendon exposure at the donor site occurred in 5 (20%) of the patients in the subfascial group and in 0 (0%) of the patients in the suprafascial group ( P = .05; Fisher's exact test). Average tourniquet time was 117 minutes in the subfascial group and 102 minutes in the suprafascial group. Hematoma formation occurred at the donor site in 2 (8%) and 1 (5%) patients in the subfascial and suprafascial groups, respectively. There were no complete or partial flap losses in either group.

CONCLUSIONS

Suprafascial harvest of the RFFF decreases the risk of postoperative tendon exposure. The suprafascial harvest technique does not increase harvest time or donor site complications, nor does it negatively impact flap vascularity.

Comparison of quality-of-life in tongue cancer patients undergoing tongue reconstruction with lateral upper arm free flap and radial forearm free flap

Surgery entails radical resection, neck dissection and tongue reconstruction has been commonly used in treatment of T2 and T3 tongue squamous cell carcinoma. Although lateral upper arm free flap (LUFF) and radial forearm free flap (RFFF) are similar in texture and thickness, significant differences can be noticed in the donor-site function and surgical demands. In the treatment of T2 and T3 tongue cancer, the choice of either LUFF or RFFF is still not defined.We aim to investigatethe long-term QOL of patients with moderate tongue defect and reconstruction with LUFF or RFFF, based on which to provide clinical suggestion for tongue reconstructions.Sixty-five patients (T2 or T3 stage, 42 underwent tongue reconstruction with RFFF and 23 with LUFF) treated at the Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Sun Yat-Sen University from January 2005 to June 2009 were included. The QOL of each patient was determined using the questionnaire designed based on the University of Washington Quality-of-Life (UW-QOL, version 4). The questionnaire was accomplished by a qualified medical staff blinded to the study after telephone communication with each patient. Statistical analysis showed that no significant difference was noticed in the long-term QOL of patients with tongue cancer after tongue reconstruction using LUFF or RFFF, respectively, indicating that similar QOLs were obtained in the long-term follow-up of patients with tongue cancer (T2 or T3 stages) using LUFF and RFFF for reconstruction.

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.

Angioembolization of a leaking radial artery pseudoaneurysm in a radial forearm free flap

BACKGROUND

A radial forearm free flap (RFFF) is used frequently in oral and pharyngeal reconstruction. Pseudoaneurysms within RFFFs and their management have not been previously reported.

METHODS AND RESULTS

In the present case, a patient with chemoradiation failure of the right base of the tongue clear cell carcinoma underwent salvage resection and failed reconstruction with pectoralis major muscle flap. He subsequently underwent RFFF reconstruction with delayed development of a radial artery pseudoaneurysm at the site of a previous arterial line within the RFFF, which was not present perioperatively. A rupture of this pseudoaneurysm manifested with recurrent bleeding. Angiography with embolization successfully arrested the bleeding without compromising the flap.

CONCLUSION

Ruptured pseudoaneurysm of the radial artery within the RFFF is a rare and life-threatening complication, which in the posterior oral cavity and pharynx can be effectively managed with angioembolization.

Esophagus and hypopharyngeal reconstruction

This article reviews the literature on esophageal reconstruction. The most common methods used are gastric pull-up, pectoralis major flap, colon interposition, fasciocutaneous flaps (radial forearm free flap or anterolateral thigh flap), and free jejunum and colon flaps. The stricture rates, fistula rates, morbidity, and mortality of each flap are reviewed.