Donor site deficit of the osteocutaneous radial forearm flap

Case report of substantial reconstruction of second ray segment by osteo-tendo-cutaneous pedicled radial forearm flap

Introduction and importance: The hand is one of the most vital organ that the surgeon aims to preserve its function and natural appearance. Gunshot injuries are common, especially in a war zone, and unfortunately, they create complex wounds that are hard to reconstruct and infection is very common. In this article, we report rebuilding segment of index finger with a pedicled osteo-tendo-cutaneous radial forearm flap. Case presentation: A 50-year-old man-African with no past medical comorbidities, sustained trauma to his left index finger by high-velocity injury that led to composite tissue loss including metacarpal and proximal phalanx. After applying the initial irrigation and dressing to the wound, his hand was supported by a volar cast then he was referred to the hospital. The hand was examined at the operation room and the index finger was found to be hanged with a medial skin pedicle with necrotic and exposed bone and tendon. He underwent a session of debridement followed by reconstruction using a pedicled osteo-cutaneous radial forearm flap accompanied with metacarpophalangeal joint arthrodesis. Clinical discussion: A significant number of war-related hand injuries resulted in amputations because there were not enough facilities or doctors. While they are alternatives to free flap, abdominal and regional flaps won't yield the same outcomes. The second ray of the hand is reshaped using a radial flap, producing an acceptable result. Conclusion: The Radial forearm flap was used to reconstruct segment of index finger and fulfill our requirements, which include bone, tendon, and skin cover. Additionally, this is a simple and single stage procedure and micro-surgical equipment is not necessary.

Oral Cavity Reconstruction

This summary provides a concise overview of oral cavity reconstruction to optimize functional outcomes in the modern era. Soft tissue and osseous reconstruction options for a wide range of oral cavity sites including lip, oral tongue, floor of mouth, buccal, hard palate, and composite oromandibular resections are reviewed. The appropriate applications of primary closure, secondary intention, skin grafts, and dermal substitute grafts are included. Anatomic considerations, indications, contraindications, and complications of local, regional, and free flaps in oral cavity reconstruction are discussed. Specific defects and the appropriate options for reconstruction of those defects are delineated.

Prospective Comparison of Donor-Site Morbidity following Radial Forearm and Ulnar Artery Perforator Flap Harvest

BACKGROUND

The forearm is a common donor site, providing thin, pliable workhorse flaps for head and neck reconstruction. There are no prospective studies comparing the donor-site morbidity of the radial forearm flap to the ulnar artery perforator flap.

METHODS

All patients undergoing forearm free flaps were included for analysis and followed for a minimum of 1 year. Grip strength, sensation to light touch, temperature sensation, and wound healing were assessed.

RESULTS

A total of 98 patients were enrolled (radial forearm flap, n = 50; ulnar artery perforator flap, n = 48). There were three osteocutaneous radial forearm flaps performed. The donor site was closed primarily in one radial forearm flap patient and four ulnar artery perforator flap patients. The majority of donor sites were resurfaced with full-thickness skin grafts (radial forearm flap, n = 40; ulnar artery perforator flap, n = 44), and the remaining were closed with split-thickness skin grafts. Average grip strength compared to baseline measured at 1, 3, 6, and 12 months after surgery demonstrated no significant differences. All patients returned to baseline sensation to light touch with no long-term sensory deficits at 1 year. No patients suffered significant changes in temperature sensation or cold intolerance. Seven patients suffered partial skin graft loss (radial forearm flap, n = 5; ulnar artery perforator flap, n = 2); all of them healed secondarily with local wound care. There were no flap losses in the study.

CONCLUSIONS

The radial forearm and ulnar artery perforator flaps are equivalent in terms of success and donor-site morbidity. Selection of flap should be based on need for pedicle length, flap bulk, concerns with radial or ulnar dominance, and surgeon comfort.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Review of surgical resection and reconstruction in head and neck cancer. Traditional versus current concepts

This review summarizes the development of head and neck cancer resection and reconstruction. The developments in the treatment of cancer patients are reflected in their surgical outcomes, in addition to functional and aesthetic improvements. New technologies, such as surgical simulation and planning, minimally invasive surgery, and microsurgery have been added to the field to improve surgical resection of the tumor and reconstruction. The field is still growing to optimize the management of head and neck cancer.

Ulnar forearm osteocutaneous flap harvesting using Kapandji procedure for pre-existing complicated fibular flap on mandible reconstruction--cadaveric and clinical study

It is not uncommon that after using a fibular flap for lower gum cancer reconstruction, nonunion, chronic osteomyelitis, or fibular bone exposure occurs, which requires a composite bone and soft tissue reconstruction. Radial forearm osteocutaneous flap possesses the risk of stress fracture. Ulnar forearm osteocutaneous flap can be another option for small bone defect reconstruction.

PATIENTS AND METHOD

Six patients who had undergone fibular flap for mandible reconstructions and sustained either bone exposure (3 patients), chronic osteomyelitis (1 patient), malocclusion (1 patient), or osteoradionecrosis (1 patient) underwent ulnar forearm osteocutaneous flap with 3-cm ulnar bone for touch-up procedure. The distal radioulnar joints were fused with a screw. Six ulnar forearm osteocutaneous flap dissections were also performed on 4 fresh frozen cadavers to clarify the anatomic distribution of the distal ulnar artery.

RESULT

All 6 ulnar forearm osteocutaneous flaps survived with one re-exploration for venous occlusion. All presented bone union. Comparable to the clinical dissection, the cadaveric distal ulnar artery demonstrates a periosteal branch that runs between the proper ulnar nerve and dorsal sensory nerve. This periosteal branch comes out of an ulnar artery approximately 3 cm proximal to the wrist joint.

CONCLUSION

Ulnar forearm osteocutaneous flap can provide a secondary flap of wide skin paddle and small segment bone for specific mandibular defect after a fibular flap transfer.

[Cost effectiveness of a free forearm flap in reconstruction of the oral cavity and pharynx--the donor site complications]

PURPOSE

Evaluation of the donor site efficiency in patients after reconstructive surgery with use of free forearm flap. All patients were treated for oral cavity and larynx cancer.

MATERIALS AND METHODS

a group of 21 patients (16 men and 5 women) treated in 2007-2011. The retrospective analysis was conducted on the anamnesis, operating protocols, physical examination and a questionnaire, there was completed by patients during a routine ENT follow up examination. The PRWE (Patient Rated Wrist Evaluation) subjective questionnaire was used to estimate the rate of pain severity and wrist mobility.

RESULTS

In 59% of patients the wrist was healed primary, in 36% of patients by granulation. In all patients the wound was healed satisfactory in follow up examination, but 60% of patients revealed extensive scars formation. 62% of patients showed no local pain at rest, while in 38% of them worsening of symptoms was noticed--average 0.5/10 (median 1.0). Pain was more intense in patients who did basic motor activity of hands approximately 1/10 and lifting weights averaging 2.1/10. Dysfunction of the wrist was at the level of the average value of 4.2/50.

CONCLUSIONS

Surgical reconstruction with a use of the free forearm flap is associated with the formation of extensive wrist scars. The risk of local complications is low while preserving the qualification protocol, postoperative care and proper surgical management. Reconstructive surgery based on the free forearm flaps gives satisfactory functional results of the donor site. However, it requires surgical experience and practical knowledge of anatomy.

Free flap reconstruction of lateral mandibular defects: indications and outcomes

OBJECTIVE

To compare outcomes following osteocutaneous radial forearm and fibula free flap reconstruction of lateral mandibular defects.

STUDY DESIGN

Retrospective case-controlled study.

SETTING

Historical cohort study.

SUBJECTS AND METHODS

All patients who underwent free flap reconstruction of lateral mandibular defects from 1999 to 2010 were included in this study. Patients were classified into 2 groups based on type of reconstruction: (1) osteocutaneous radial forearm (n = 73) and (2) fibula free flap reconstruction (n = 51). Patient characteristics, length of hospital stay, recipient and donor site complications, and long-term outcomes including postoperative diet were evaluated.

RESULTS

Most patients were male (68%) and presented with advanced T-stage (71%) squamous cell carcinoma (94%) involving the alveolus (21%), retromolar trigone (23%), or oral tongue (21%). Median length of hospital stay was 8 days (range, 4-22 days). The recipient site complication rate approached 27% and included infection (n = 11), mandibular malunion (n = 9), exposed bone or mandibular plates (n = 9), and flap failure (n = 5). Most patients demonstrated little to no trismus following reconstruction (94%) and were able to resume a regular or edentulous diet (73%). No difference in complication rates or postoperative outcomes was seen between osteocutaneous radial forearm and fibula free flap groups (P > .05). One patient underwent dental implantation following osteocutaneous radial forearm free flap reconstruction. No patients from the fibula free flap group underwent dental implantation.

CONCLUSION

The osteocutaneous radial forearm and fibula free flap provide equivalent wound healing and functional outcomes in patients undergoing lateral mandibular defect reconstruction.

Osteocutaneous radial forearm free flaps: prophylactic fixation of donor site using locking plate augmented with mineral cement

Prophylactic plating of donor site in osteocutaneous radial forearm free flaps have demonstrated improvement in fracture rates. Previous series used conventional plating systems which rely on plate-bone friction forces to generate stability and can result in iatrogenic fractures if not accurately contoured. Locking plates have superior stability and do not require contouring. This retrospective series reports our experience using locking plate fixation augmented with calcium phosphate mineral cement. Twenty patients' records were reviewed; 13 were alive and reviewed clinically. Mean radiological follow-up was 28.2 months. Two deceased patients had donor site fractures diagnosed on the first postoperative radiograph. These fractures were related to technical fixation errors and failure to apply correct locking fixation principles. None of the other patients with proper locking fixation had fractures or metalwork related complications. We believe that locking fixation augmented with mineral cement can provide more biological stability and enhance restoration of bone structural strength.

Closure of radial forearm free flap donor site defect with a local meshed full-thickness skin graft: a retrospective study of an original technique

INTRODUCTION

Closure of the radial free flap donor site remains a problem. Donor site morbidity is related to poor skin graft taking, inaesthetic appearance and hand sensory dysfunction.

PATIENTS AND METHODS

From January 1998 to December 2002, 41 radial free flaps were harvested. The donor site closure technique consisted of a combination of: flexor tendons coverage, purse string and local meshed full-thickness skin graft.

RESULTS

The mean time of wound healing of the donor site was 4.68 weeks. Four patients (16%) developed a partial necrosis of the skin graft. Nine patients (36%) showed a definitive hypoaesthesia in the dorsal region of the thumb. Neither total necrosis of the skin graft nor exposure of flexor carpi radialis tendon was noted. The average visual analogue scale of the aesthetics was 6 (patients), 4.18 (students) and 7.2 (first author) out of 10.

CONCLUSION

This technique for closing a small-to-medium sized radial donor site defect is recommended.

Comparison of Clinical and Functional Outcomes and Hospital Costs following Pharyngoesophageal Reconstruction with the Anterolateral Thigh Free Flap versus the Jejunal Flap

BACKGROUND

Pharyngoesophageal defects are commonly reconstructed with free jejunal or fasciocutaneous flaps, with various outcomes, and a direct comparison is lacking.

METHODS

Fifty-seven circumferential pharyngoesophageal reconstructions with an anterolateral thigh flap (n = 26 patients) performed by a single surgeon or jejunal flap (n = 31 patients) performed by six experienced surgeons between 1998 and 2004 were reviewed and outcomes were compared.

RESULTS

Total flap loss occurred in one (4 percent) and two (6 percent) patients, fistula rates were 8 percent and 3 percent, and stricture rates were 15 percent and 19 percent in the anterolateral thigh and jejunal flap groups, respectively (p > 0.5). A completely oral diet was achieved in 95 percent and 65 percent, and fluent tracheoesophageal speech was achieved in 89 percent and 22 percent of patients with the anterolateral thigh and jejunal flaps, respectively (p < 0.01). The mean lengths of postoperative ventilator support, intensive care unit stay, and hospital stay were 1.0 +/- 0.2, 1.7 +/- 1.0, and 8.0 +/- 3.7 days for the anterolateral thigh flap group and 2.2 +/- 3.0, 3.0 +/- 3.2, and 12.6 +/- 7.9 days for the jejunal flap group (p < 0.001 for all), respectively. Mean hospital charges per patient were $8694 and $12,651 for the anterolateral thigh and jejunal flap groups, respectively (p = 0.02).

CONCLUSIONS

With the limitations of comparing a single surgeon's results with those of multiple surgeons, the anterolateral thigh flap appears to offer better speech and swallowing functions and quicker recovery and to be more cost-effective than the jejunal flap for pharyngoesophageal reconstruction. The complication rates were similar.

Pharyngoesophageal Reconstruction with the Anterolateral Thigh Flap: A Clinical and Functional Outcomes Study

BACKGROUND

Functional outcomes and morbidities of pharyngoesophageal reconstruction have not been satisfactory. The purpose of the present study was to evaluate such outcomes following pharyngoesophageal reconstruction with the anterolateral thigh flap.

METHODS

Reconstruction of pharyngoesophageal defects was performed in 41 consecutive patients with the anterolateral thigh flap. There were 31 circumferential and 10 near-circumferential defects. In the initial nine patients, a portion of the flap was externalized for monitoring by deepithelializing a strip of skin at the distal anastomosis. This technique resulted in a 33-percent fistula rate and was thus modified for the subsequent 32 patients, in whom a true end-to-end, spatulated anastomosis was performed.

RESULTS

Total flap loss occurred in one patient, and one patient had partial flap necrosis due to ischemic bowel and sepsis. The mean hospital stay was 6.7 +/- 1.9 days. With the modified technique, fistulas occurred in two out of 25 patients (8 percent) and two out of seven patients (29 percent) with circumferential and near-circumferential defects, respectively, for an overall fistula rate of 13 percent. Strictures occurred in three out of 25 (12 percent) of patients with circumferential defects only. Fluent speech was achieved in all 13 patients who had successful tracheoesophageal prosthesis placement. Among the 34 patients available for diet assessment, two patients (6 percent) required partial tube feeding owing to extensive tongue resection; all other patients tolerated a regular (88 percent) or pureed (6 percent) diet.

CONCLUSION

The anterolateral thigh flap offers comparable complication rates, superior speech and swallowing functions, minimal donor-site morbidity, a quick recovery, and a short hospital stay.

The indications and outcomes in the use of osteocutaneous radial forearm free flap

INTRODUCTION

Whether secondary to cancer surgery ablation or trauma, surgeons are faced with defects of the mandible or maxilla that would be best reconstructed with a thin, pliable soft tissue component and vascularized bone. A subset of these challenging wounds do not require the bicortical bone necessary to reestablish structural integrity or to retain a dental prosthesis, because the soft tissue needs are more critical than the bony needs. It is this niche that the radial forearm osteofaciocutaneous free flap (RFOFF) fulfills well. In the past, potential and real donor site morbidity has precluded the routine use of this flap. New methods to reduce this morbidity have rekindled our use of this flap. PROCEDURES USED: A retrospective review of patients with defects of the mandible or maxilla treated with the RFOFF from July 1, 1997, to December 31, 2000, was performed. After flap harvest, the donor site was rigidly fixated. A skin graft was placed, and a volar splint was applied for 7 days. The arm was then fully mobilized. Parameters examined were defect location, donor site complications, flap survival, fistula occurrence, plate fracture, and/or extrusion.

RESULTS

Thirty-four patients were reconstructed with the RFOFF with a follow-up of 10-54 months. Seven patients had an anterior maxillectomy defect, and 27 patients had a lateral mandibulectomy defect with associated tongue/tonsillar fossa and/or palate defect. There were no cases of flap failure or donor site radius fracture. During the follow-up period, there were no plate fractures or intraoral exposures as evidenced by clinical and radiographic evaluation. Fistulas occurred in five patients; all healed without surgical intervention.

CONCLUSION

With rigid fixation of the residual radius, donor site morbidity has been minimized, and indications for this flap have expanded. Specifically the anterior maxillary arch and the ascending ramus, angle, and posterior body of the mandible (nontooth-bearing areas) are the sites most amenable to the thin bony stock of the harvested radius. The pliable forearm skin is ideal for the soft tissue defects. We believe that the RFOFF with bone has a definite role in the reconstruction of select head and neck defects.

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

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

Pursestring closure of radial forearm fasciocutaneous donor sites

BACKGROUND

The radial forearm fasciocutaneous free flap has become one of the most common methods of reconstructing defects after head and neck ablative surgery. The fasciocutaneous flap is an excellent replacement for the tissue that has been removed. Unfortunately, donor site morbidity remains a problem. Donor site morbidity is primarily related to poor skin graft take, cosmesis, and neural dysfunction. Decreasing the size of the donor site defect may allow for improved cosmesis with decreased morbidity.

MATERIAL AND METHODS

Prospective evaluation of a pursestring closure of radial forearm fasciocutaneous donor sites over a 16-month period.

RESULTS

Seventy-one radial forearm free flaps were used. Sixty-seven had a pursestring closure of the donor site. After flap elevation the mean size of the defect was 61 cm2 (range, 28-140 cm2). Pursestring closure decreased the mean of the defect to 34 cm2 (range, 10-104 cm2) (P <.0001). Defect size was decreased by a mean of 44.5% (range, 24.5%-66.7%) (P <.0001).

COMPLICATIONS

The rate of skin graft loss (>25%) (9% of patients) was less than that reported in the literature. No patient required a second surgical procedure. Neural morbidity was equal in both groups. Cosmesis was much improved.

CONCLUSIONS

Pursestring closure allowed for a significantly decreased donor defect, associated with better cosmesis and less skin graft loss.

Donor site morbidity of radial forearm flaps. A clinical and ultrasonographic evaluation

Harvesting of a forearm flap based on the radial artery has been thought to cause functional or circulatory problems in the donor hand. Eighteen patients were examined three to 24 months after a radial forearm flap had been raised. The function of both hands was studied for grip strength, mobility of the wrist and elbow joints, and sensitivity of the area served by the superficial radial nerve. The patients were interviewed and the cosmetic result was evaluated. Duplex ultrasonography and colour Doppler ultrasonography of both ulnar arteries were done, and the brachial arteries were measured as controls. Angle-corrected peak flow velocity (cm/s) in the ulnar artery of the donor forearm was significantly increased at the level of the wrist compared with the control forearm (100.9 compared with 73.1 cm/s, p = 0.017), as was the ulnar: brachial peak flow velocity ratio (1.18 compared with 0.76, p = 0.001). The grip strength of the donor hand was weaker by 11.9% (86.5 compared with 72.2 Kp), 10 (56%) had areas of sensory loss over the radial nerve distribution, and seven of the 18 patients complained of cold intolerance. Four patients considered the donor site result so bad that they would not have chosen the operation had they known what the result would look like. The radial forearm flap donor site is not without problems, and the patients must be carefully selected and properly informed preoperatively.