Radial Forearm Free

Flap
Dr. Wakil Muhammad
PGR, Oral & Maxillofacial
Surgery

Flap and Graft
“A graft or a flap may comprise of the same
tissue type, that is, it can be skin, fat, tendon,
bone, nerve, etc. The key difference is that a
flap has its own blood supply but a graft does
not”

Flap Types
Local (Pedicled) Flap:
Tissue is freed and rotated or moved from an
adjacent area to cover the defect, yet remains
attached to the body at its base and has blood
vessels that enter into the flap from the donor
site.
Free Flap:
Tissue from the donor site is detached and
transplanted to the recipient site and the
blood supply is surgically reconnected to the
blood vessels in recipient site.

Reconstructive Applications
 Floor of mouth, tongue, pharynx and

oesophagus.
Lips, Orbits.
External skin defects.
Incorporating part of radius as

osteocutaneous flap for maxillary, nasal, and
mandibular defects.

Advantages
Good pliability and contourability.
Multiple skin islands can be used.
Skin can be innervated by including the

medial or lateral antebrachial cutaneous
nerve.
Can incorporate radius bone or tendon.
 Excellent vascularisation (Artery; 10-18 cm

long, 2mm dia).

.Disadvantages Possible poor Cosmetic outcome of the donor site. (Unsightly scar formation) Donor site morbidity (loss of skin graft and tendon exposure) Possibility of radial bone fracture.

Any coagulopathy. Any peripheral vascular disease. Uncontrolled diabetes. Poor or slow wound healing.Preoperative Assessment Patient is asked for having a history of. .

 before harvesting the radial forearm free flap” .Allen’s test “A clinical test used to evaluate Ulnar and  Radial Artery Patency which make the deep and superficial palmar arterial arch system.

Performing Allen’s Test .

.Arterial anatomy of the hand with direction of blood flow with manual occlusion of the Radial Artery.

.Arterial anatomy of the hand with direction of blood flow with manual occlusion of the Ulnar Artery.

Surgical anatomy of forearm Arterial system of forearm .

Venous system of forearm .

Cutaneous Nerves encounter during graft harvesting .

Biceps brachi Brachioradia lis Biceps brachi tendon Pronator teres Flexor carpi radialis Palmaris longus Flexor carpi ulnaris Flexor digitorum longus Muscles relevant to RFFF .

Radial Artery Relation of Radial Artery with Brachioradialis and Pronator teres muscles .

Types of Radial Forearm Free Flap The most commonly used radial forearm free flaps in the reconstruction of oral and maxillofacial region are: Radial forearm fasciocutaneous free flap (RFFF) Osteocutaneous radial forearm free flap (OCRFFF) .

The course of the superficial veins is drawn.Surgical Technique Surface markings for RFFF Palpate and mark the radial artery at the wrist between the brachioradialis and flexor carpi radialis tendons. . Mark the flap design on the forearm according to the size of the defect. Shave the intended harvesting area.

Tourniquet Application Apply a tourniquet to the upper arm and inflate it to above the patient's systolic blood pressure (usually set at 250 mmHg). . Record the tourniquet time (maximum time of 90 minutes permitted).

Subfascial RFFF Elevation Technique Flap designed to include radial artery and superficial vein .

with two skin hooks anchoring the skin lateral to the flap Skin incision along lateral aspect of .Subfascial RFFF Elevation Technique  Start dissection laterally.

 Elevate the flap from laterally in a deep subcutaneous plane until the cephalic vein becomes visible. Cephalic vein .

This nerve is elevated with the cephalic vein if innervated flap is planned. Lateral antebrachial cutaneous nerve . The lateral antebrachial cutaneous nerve is located in the same plane along the cephalic vein.

Scalpel points to the Radial Nerve . Identify the superficial branch of the radial nerve which is lateral to the brachioradialis.

Scalpel points to the brachioradialis tendon . Extend the dissection medially over the epitenon covering the radial nerve and tendon of brachioradialis.

. therefore the angle of the scalpel blade is changed to a horizontal plane to avoid cutting the artery. the radial artery generally lies immediately below the tendon. Sharply dissect and elevate the tendon superiorly up to its musculotendinous junction.

 Incise the fascia overlying the brachioradialis muscle lateral to the vascular pedicle. .

Radial Artery . the radial artery becomes visible and the chances of injuring the perforators are much less. Once the brachioradialis muscle has been mobilised.

 Ligate and divide larger muscle perforators with Liga clips and coagulate small ones with bipolar forceps. .

preserving the epitenon.Next. . elevate the medial side of the flap by dissecting the deep fascia over the tendons of wrist flexor muscles.

 Incise the fascia over the radial artery then isolate. Radial Artery . ligate and transect the artery.

 Radial artery has been transected .

. Dissection now proceeds from distal-to- proximal.

 Carefully divide the side-branches arising from the radial artery until enough vessel length is achieved Radial Artery Cephalic Vein Radial Artery perforators .

Transfer of Flap Now deflate the tourniquet to reperfuse the flap vasculature. Control bleeding from the side-branches on the pedicle and on the flap before disconnecting the flap from its blood supply. . Transfer the flap to reconstruction site after preparing the recipient vessels for anastomotic suturing.

and the ability to use the flap for structural bone and soft tissue reconstruction” . vascularised bone which is not bulky.Osteocutaneous RFFF “It incaporates a long pedicle and thin. pliable skin.

Up to 40% of the thickness of radius bone may be harvested. The distal 10–12 cm of the radius (26. .42 cm) can be harvested as an osteocutaneous RFFF.Harvesting Osteocutaneous RFFF The available bone lies between the insertion of the Pronator teres and Brachioradialis muscle. Periosteal perforators provide blood supply to the bone.

Perforator s Perforators to the bone are identified and protected .Care should be taken to avoid injury to periosteal perforators which is the only blood supply to the harvesting bone.

Start cutting from proximally while leaving 2.5 cm bone at the proximal end. About 10–12 cm of the radius can be harvested. . A high speed oscillating saw is used to cut the bone longitudinally.Mark the length of bone required.

Divide both cortices longitudinally and place a metal plate on the dorsolateral side to protect the radial nerve and the laterally placed tendons. .

Bevel the proximal and distal osteotomies at an angle of about 50o to avoid a weak (stress) point (which would occur if it was to be cut at 90 o). Beveled ends of bone .

Vascular pedicle Bone segment Osteocutaneous radial forearm free flap appearance immediately after harvest .

Maintain epitenon over tendons. Keep the donor arm elevated.Donor site Closure & Care Try to advance skin to cover the exposed tendons. When placing a skin graft. . Always fix and immobilize skin graft with sutures and appropriate dressings. Use volar splint to restrict movement of flexor tendons.

. Persantin) 75 mg orally per day for 14 days.9% sodium chloride injection) for 5 days at 20 ml/hr. 2004 .Post-operative Medications Dextran-40 (in 0. Kruavit et al. Dipyridamole (Tab. Aspirin 150 mg orally per day for 14 days.

Examples of Reconstruction with Radial Forearm Free Flap .

1 Incision for resection and neck dissection outlined (recurrent sweat gland carcinoma of the skin). The surgical specimen. .Case No.

Surgical defect after removal of the lesion .

The outline of a radial forearm free flap. .

The radial forearm fasciocutaneous free flap. .

A postoperative .

Case No. 2 A 24-year-old man suffered from burn scar contracture at neck and lower lip causing leakage of the saliva. Unable to close his eyes when the neck was fully extended. .

Following complete release of the burn scar contracture and reconstruction with a large radial forearm free flap. . all facial deformities were corrected and the cervicomental angle was maintained.

Donor site of the radial forearm free flap before skin grafting procedure. and the hand function . the noticeable grafted skin at the donor site was accepted by the patient. Three months after the operation.