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Radial Free Forearm Flap - RFFF - Surgical Technique PDF
Radial Free Forearm Flap - RFFF - Surgical Technique PDF
RADIAL FREE FOREARM FLAP (RFFF): SURGICAL TECHNIQUE Ottie van Zyl
The radial free forearm flap (RFFF) was • Large distal size of vessel allows it to
one of the first free tissue transfer flaps to be used as a "flow-through-flap" for an
be described. It has since become a work- additional flap to be attached distally
horse for soft tissue replacement in head
and neck cancer surgery, being commonly Caveats
used to replace external skin and internal
mucosal linings. It is an extremely versa- • Potentially poor skin quality: in certain
tile flap allowing intricate folding of the individuals the flap may be quite
skin, using two or more skin paddles/ bulky, especially proximally; this can
islands, and incorporating vascularised compromise certain reconstructions
tendon and/or bone (osteocutaneous flap). • Donor site morbidity: loss of skin graft
and tendon exposure; visible donor site
Common reconstructive applications and possible poor cosmetic result
• Vascular: atherosclerosis (seldomly);
• Floor of mouth, tongue, soft and hard postoperative vascular compromise of
palate, buccal mucosa, pharynx and hand (rarely)
oesophagus
• Lips Surgical anatomy of volar forearm
• Orbit
• External skin defects The skin of the volar (anterior) surface of
• Incorporating part of radius as osteocu- the forearm is usually thin and pliable,
taneous flap for premaxillary, maxil- especially the distal half. It is however
lary, nasal, and selected mandibular unfortunately hair-bearing skin, especially
defects on the proximal and lateral sides of the
• Incorporating palmaris longus tendon forearm; consequently, one might have
sling to support lower lip reconstruct- hair growth e.g. in the oral cavity. The
tion subcutaneous fat is thin, especially over
the distal third of the forearm. However,
Advantages overweight patients and even some normal
individuals may have a disproportionate
• Very pliable, thin skin, especially at amount of fat in this distal area.
distal forearm (one of thinnest skin
flaps) Venous system
• Usually very little soft tissue bulk
• Large flap may be harvested (30 x In the subcutaneous tissues lie the small
15cm) venous tributaries of the main superficial
• Multiple skin islands can be used venous drainage system of the forearm,
i.e. the cephalic and basilic veins, which
• Sensory innervation possible
lie deep to the fatty layer (Figure 1).
• Can incorporate radius bone or tendon
• Easy flap elevation The cephalic vein is the most commonly
• Large, reliable, constant vessels used single vein for venous drainage of
• Long pedicle usually available RFFFs (Figure 1). It is a large, thick-
• Distant location of donor site from walled vein and is found in a relatively
head and neck resection permits simul- constant location deep beneath the subcu-
taneous harvesting and resection taneous fat. Unfortunately, due to its size
nerve (Figure 1). The superficial branch of
the radial nerve lies in close proximity to
the vein in the distal third of the lateral
forearm and over the "snuffbox” area up to
Cephalic vein
the lateral aspect of the dorsum of the
hand.
Basilic vein
The basilic vein runs towards the lateral
cubital fossa along the medial side of the
Lateral
Vena mediana forearm and is located deep beneath the
cubiti
antebrachial
cutaneous nerve
subcutaneous fat.
2
between the flexor carpi radialis and
palmaris longus tendons. The palmar
cutaneous branch of the median nerve
arises just above the flexor retinaculum at
the wrist and becomes cutaneous between
Venae comitantes the tendons of palmaris longus and flexor
of branchial artery
carpi radialis. Elevation of a very distal
skin flap may injure the latter branch and
cause sensory loss of the proximal mid-
palm.
Muscles
Interosseous
Where the radial artery enters the forearm
veins it lies superficial to the supinator (Figure
3), pronator teres and flexor digitorum
Radial deep
veins superficialis (FDS) muscles in the proxi-
Ulnar deep mal third of the forearm, and superficial to
veins the flexor pollicis longus (FPL) and
pronator quadratus muscles in the distal
Figure 2: Venous anatomy at right cubital third (Figure 4).
fossa
The radial artery runs in the lateral inter-
after supplying the flexors of the upper muscular septum which separates the flex-
arm, pierces the deep fascia just proximal or and extensor compartments of the fore-
to the cubital fossa. The anterior branch arm. Medially are the flexor carpi radialis
of the antebrachial nerve then accompa- (FCR) and the other forearm flexor mus-
nies the cephalic vein distally (Figure 1) cles (Figures 5, 6). Laterally is the exten-
and supplies sensation to the anterolateral sor compartment.
forearm, (which is also the main area of a
distal RFFF). The posterior branch sup-
plies sensation to the posterolateral fore- The key muscle when elevating a RFFF is
arm. the brachioradialis muscle and its tendon
(Figures 4, 5, 6). The muscle overlies the
The medial antebrachial nerve runs with anterolateral side of the artery (Figures 5,
the basilic vein; they pierce the deep fascia 6). It is supplied by the radial nerve of the
in the medial part of the mid-upper arm. It extensor compartment, even though it is an
too, has an anterior branch supplying elbow flexor. This bulky muscle belly lies
sensation to the anteromedial forearm and anterior to, and covers, the radial artery
a posterior branch to the posteromedial in the proximal half of the forearm
forearm. (Figure 5). In the distal forearm the muscle
be-comes a flat tendon. It is important to
Deeper nerves include the median, ulnar know that the tendon commonly covers
nerves. These are usually not at risk when the artery either partially or completely.
elevating the flap. The median nerve lies The significance of this will become appa-
3
a
c
Supinator
d
b
Figure 3: Dorsal view of right forearm Figure 4: Volar view of right forearm: a:
demonstrating the supinator muscle biceps brachii; b: brachioradialis; c: bi-
ceps brachii tendon d: pronator teres; e:
rent during flap elevation and protection of flexor carpi radialis; f: palmaris longus; g:
the perforators. At the wrist the radial ar- flexor carpi ulnaris; flexor digitorum lon-
tery lies between the brachioradialis and gus
flexi carpi radialis tendons (Figure 5).
Radial artery and its branches
The palmaris longus tendon (Figures 4, 5)
can be sacrificed without causing a func- The brachial artery bifurcates into ulnar
tional deficit. It is absent in ca. 13% of and radial arteries (Figures 5, 6). The ra-
individuals. Its tendon and muscle can be dial artery starts in the medial cubital fos-
incorporated in a forearm flap for various sa, 1cm distal to the elbow crease, just me-
reconstructive possibilities and it may dial to the biceps tendon (Figures 5, 6). It
therefore be an extremely valuable adjunct then courses down the forearm in the
in complex reconstructions. lateral intermuscular septum which sepa-
rates the flexor and extensor compart-
4
Radial recurrent
Radial recurrent
Dorsal
interosseous
Muscular
Extensor
pollicis Volar radial carpal
brevis Superficial volar
Superficial
volar
5
ments of the forearm to the (palpable)
radial pulse, just medial to the tip of the
styloid process of the radius. Branches in
the forearm include the radial recurrent
artery close to its origin (Figures 5, 6);
and distally, the palmar carpal branch
(Figure 6), the superficial palmar branch
and the continuation of the artery, the
dorsal carpal branch. Along its course in
the forearm it gives off muscular bran-
ches (Figures 5, 6).
6
• Ask the patient to release the hand into prophylactic pressure garment to avoid it;
a relaxed, slightly flexed position delayed wound healing and possible loss
• Check whether the palm and fingers of a skin graft. Mention should also be
have blanched; if not, then occlusion of made of possible temporary or permanent
the vessels is inadequate, and the test is variable sensory loss over the radial thenar
repeated region, the metacarpal region of the dor-
• Release pressure from the ulnar artery sum of the thumb or less commonly, of the
• With a positive Allen Test the hand dorsal hand; as well as claudication.
flushes and the colour changes from
pallor to rubor within 5 - 15 seconds; it Operating room setup
can be concluded that there is good
crossflow from the ulnar artery • Resect the primary tumour and elevate
• With a negative Allen Test the circu- the RFFF simultaneously as a 2-team
lation is considered inadequate and it is approach to minimise the length of sur-
a relative contraindication to proceed- gery (Figure 8)
ing with a RFFF
• Even though there is controversy
about the reliability of the Modified
Allen Test, the author routinely does
the test; in equivocal cases when there
is some delay in the "flush", he has
always continued with the RFFF and
has never encountered symptomatic
vascular compromise or ischaemia in
more than 700 RFFFs
Choice of arm
Figure 8: Two-team setup: RFFF being
It is not as critical as with free fibular flaps harvested (foreground); head & neck re-
what side to use. Although it is preferable section (background); anaesthetics (right)
to have the operating arm table on the con-
tralateral side to the resection to create • Create working space around the head
enough space for two surgical teams to and torso by placing anaesthetic and
work simultaneously, it is not that difficult other equipment at the foot of the bed
to work on the same side of the patient. with extensions for intravenous lines
Previous intravenous lines, surgery, injury, and anaesthetic tubes (Figure 8)
scars, skin deformities, fractures or vascu- • Two bipolar and monopolar electrocau-
lar compromise may necessitate one to use tery systems are required
a specific arm. The patient's preference is • Place the arm on an arm table
also taken into account. • Avoid hyperextending or hyperabduc-
ting the shoulder
Preoperative counselling • Shave the forearm
• Apply a tourniquet to the upper arm
Patients are properly counselled about the • Adjust the operating table and/or the
outcomes following flap harvest, particu- chairs so that the reconstructive sur-
larly visibility of the scar or skin graft, a geon and assistant are seated
(possibly) poor cosmetic result, the possi-
bility of hypertrophic scarring and using a
7
Surface markings for RFFF • Do not extend the flap too far over the
lateral aspect of the forearm, because
• Palpate and mark the radial artery at the cosmetic outcome of donor site will
the wrist between the brachioradialis be worse. Sensitivity of the superficial
and flexor carpi radialis tendons radial nerve is also avoided if skin pro-
• Palpate the vessel proximally and mark tection can be achieved over the nerve
its course on the skin up to the mid- • A risk of placing the flap too medially
medial cubital fossa is that the cephalic vein may be posi-
• Draw the superficial venous vessels in tioned too laterally to be safely used as
the mid- and lateral forearm the draining vein. However, this is gen-
• Inflating the tourniquet to just above erally not the case; and the lateral part
diastolic pressure may help delineate of the skin flap does not need to extend
the superficial veins fully to the cephalic vein, as long as the
• Especially with fat arms, the cephalic intervening subdermal tissue between
vein may not be visible; use your the skin flap and vein is preserved
anatomical knowledge to mark its
probable course Tourniquet
• Before shaving the arm, note the hair-
growth in the intended harvesting area • Elevate the arm without exsanguina-
of the RFFF, in case the flap can be ting it and inflate the tourniquet to at
positioned more medially in the distal least 100mmHg above the patient's sys-
forearm where there is less hair (most tolic blood pressure. (Usually set at
flaps undergo radiation with loss of 250 mmHg)
hair growth) • Record the tourniquet time (maximum
• Assess the fatty layer of the arm and time of 90 minutes permitted)
reposition the flap if necessary
• Mark the flap design on the forearm Elevating the RFFF
• Consider which side of the flap the
vascular pedicle is to exit from: Many methods have been described. Some
o Which side of the neck will be used advocate elevating the flap from distal-to-
for the vascular anastomoses? proximal in its entirety; others elevate the
o What is the most favourable posi- flap medially, then laterally, then distal-to-
tion for the pedicle at the recon- proximal. The author has done >700
structtion site to avoid kinking the RFFFs and describes his preferred meth-
pedicle? od.
o Determine the pedicle length re-
quired and draw the flap as distal as Critical points
necessary
o Let the pedicle exit the flap on the • Careful flap and template design
edge closest to the anastomosis site • Flap design on the forearm to include
• Generally, the flap is centered over the the lateral intermuscular septum as
radial artery well as a superficial vein (usually ceph-
• The flap may be placed more medially alic)
if an osteocutaneous flap is to be used • Elevate medial and lateral fasciocuta-
to provide more skin and soft tissue neous parts of the flap and dissect to-
cover over the area of bone harvesting wards the lateral intermuscular septum
and the (probable) area of prophylactic • Brachioradialis muscle is most critical
plating of the radius element of elevating the flap
8
• Start flap elevation at lateral edge over need to be elevated like "opening a
brachioradialis muscle book"
• Progress towards intermuscular septum • The artery and perforators are then vis-
(not always well defined) and down to ible as they run obliquely anteriorly,
the lateral aspect of the artery from lateral-to-medial
• Proceed to medial dissection
• Dissect vessels and elevate flap from Subfascial RFFF elevation technique
distal-to-proximal
This is the preferred technique for less
Author’s reasoning for above sequence experienced surgeons. Readers are referred
to a later description of an alternate supra-
• Refer to the anatomy of the forearm fascial/fascia-sparing elevation technique
(Figure 9)
• Note how the radial artery lies within • Design the flap on the forearm to
the lateral intermuscular septum which include the lateral intermuscular sep-
extends obliquely (anteromedially) to- tum as well as a superficial vein, usual-
wards the skin (Figure 9) ly the cephalic vein; the preferred posi-
tion of the proximal extension is late-
rally between the radial artery and
cephalic vein (Figure 10)
• Start the dissection laterally, with two
skin hooks anchoring the skin lateral to
the flap (Figure 11)
10
where he/she is protected from physi- • Incise the fascia overlying the muscle
cal interference by the resection team lateral to the vascular pedicle (Figure
• While the assistant applies lateral trac- 18)
tion to the muscle with skin hooks, re-
lease the medial edge of the brachiora-
dialis muscle off the (poorly defined)
underlying lateral intermuscular sep-
tum using sharp dissection (Figure 16)
11
Figure 20: Dividing muscle perforators
• Elevate the deep fascia over the ten- Figure 22: Radial artery
dons, but preserve the epitenon cover-
ing the tendons
• Elevate beyond the flexor carpi radia-
lis and incise the deeper muscle fascia
over the flexor digitorum superficialis
muscle (Figure 21)
12
nections may exist between one (or superior thyroid artery or even the trans-
both) branches of the venae comi- verse cervical artery may in some cases be
tantes of the radial artery and, more a better choice.
commonly to the median cubital or
the cephalic veins The author's preference for venous anasto-
o More rarely the deep and superfi- mosis is the internal jugular vein, follow-
cial systems are anastomosed sep- ed by the common facial vein and external
arately, utilising the cephalic and jugular vein.
one of the large cubital veins
o Occasionally a very large domi- If sensory innervation of the flap is
nant median vein of the forearm planned using the lateral antebrachial
can be used nerve, the surgeon should identify and
o Avoid using venae comitantes for mark e.g. the lingual nerve with a suture at
anastomoses if at all possible, due the time of tumour resection, as the nerve
to their small size may be difficult to identify later.
• Deflate the tourniquet
• While awaiting reperfusion of the flap Transfer and inset of flap
vasculature, the surgeon prepares the
recipient vessels in the neck • Only after the recipient area and reci-
• Control bleeding side-branches on the pient vessels have been fully prepared
pedicle and on the flap with bipolar are the flap vessels divided
coagulation and/or Liga clips before • Prepare the vessels for anastomotic
disconnecting the flap from its blood suturing
supply • Ensure that there is no bleeding from
the flap before transferring it to the
Reconstruction site neck
• Refer to chapter: Principles and techni-
Check the reconstruction site for bleeding. que of microvascular anastomosis for
Inspect the neck dissection for bleeding free tissue transfer flaps in head and
and ask the anaesthetist to perform a Val- neck reconstructive surgery
salva manoeuvre to demonstrate bleeders
or lymphatic leaks. Suprafascial RFFF elevation technique
Recipient vessels and nerves The main reason for elevating the RFFF
suprafascially is to reduce the failure rate
The recipient vessels are selected and pre- of the skin graft by maintaining a fascial
pared for anastomosis. The distance be- covering over the exposed tendons. It does
tween the recipient artery and vein must also allow the flap to be thinned in patients
allow the donor vessels to reach both ves- with very thick subcutaneous fat layers
sels comfortably, although this is not a (Extreme care should be taken if the latter
problem when the cephalic vein is used as is attempted).
it is totally separate from the main vascular
pedicle. Only the most lateral and medial parts of
The recipient artery is selected according the flap may be partially thinned of deep
to size; access; and position to avoid kin- fat. More extensive thinning of the flap
king or excessive tension. The facial arte- may interrupt critical blood supply by the
ry is most commonly used, although a perforators.
more inferiorly placed artery such as the
13
• Elevate the flap laterally, including the Composite flaps
cephalic vein, which lies superficial to
the fascia The palmaris longus muscle and tendon
• Maintain a superficial dissection plane are commonly used for tendon transfers
up to the medial edge of the brachio- and as grafts for tendon or ligament recon-
radialis tendon struction. In the head and neck the tendon
• Incise the deep fascia at the medial is mainly used in total or near-total lower
edge of the tendon, but not beyond lip reconstruction to suspend the lower lip
• Perform the brachioradialis tendon and to the facial muscles at the oral commis-
muscle elevation and mobilisation as sure or to the maxilla. Harvesting the ten-
described previously don or muscle does not cause significant
• Incise the deep fascia on the pronator loss of hand function. The palmaris longus
quadratus, flexor pollicis longus and tendon is identified preoperatively and
flexor digitorum superficialis lateral to easily incorporated in the flap by incising
the vascular pedicle the deep fascia medial to the tendon down
• Suprafascially elevate the medial to the deeper muscles when medially
extent of the flap up to the lateral edge elevating the flap, and including the tendon
of the flexor carpi radialis tendon and in the flap. The palmaris longus muscle
muscle and tendon may be absent in up to 15% of
individuals. In such situations the flexor
• Incise the deep fascia beyond this point
carpi radialis tendon may be incorporated
down to the deeper muscles (flexor
in the flap with minimal functional deficit
pollicis longus and flexor digitorum
of hand and wrist flexion.
superficialis)
• Complete the flap elevation as pre-
Osteocutaneous RFFF
viously described
• Following complete elevation of the
Addition of radius bone to a RFFF has
flap, it is often possible to approximate some major benefits including having a
the two edges of the cut deep fascia to composite flap with a long pedicle and
achieve complete fascial closure thin, pliable skin for soft tissue reconstruc-
(Figure 26). If not, at least the tendons tion; vascularised bone which is not
have a more reliable cover to avoid bulky; and the ability to use the flap for
loss of the skin graft, exposed tendons structural bone and soft tissue reconstruc-
and infection tion without reverting to the use of two
flaps, such as a forearm flap in combina-
tion with a fibula flap (although the latter
combination may still be required).
14
Disadvantages compared to a free fibula
flap include lack of bone stock for osseo-
integrated implants, inadequate bone
strength for reconstruction of areas subjec-
ted to greater force and torque e.g. the
symphysis, parasymphysis and body of the
mandible; limited bone length; and the risk
of subsequent forearm fracture.
The available bone lies between the inser- Figure 27: Perforators to the bone are
tion of the pronator teres muscle on a identified and protected
small area on the mid-lateral radius, and
the insertion of brachioradialis laterally at • Retract the flap and vascular pedicle
the base of the radial styloid. Up to 40% of laterally (distal pedicle not yet divided)
the circumference may be harvested. To • Flexor carpi radialis may need to be
avoid a subsequent fracture, prophylactic retracted medially to expose the flexor
plating is done after the bone has been digitorum superficialis muscle (radial
harvested. head). Muscle perforators enter the
muscle (Figure 28)
• It is preferable to place the flap more
medially on the forearm so that the
area of harvesting and the plate are
covered with intact skin
• This might preclude the use of the
cephalic vein and the lateral ante-
brachial nerve, as they may lie too far
laterally
• Periosteal and musculoperiosteal perfo-
rators provide the blood supply to the
bone. Great care should be taken to Figure 28: Muscle perforators entering the
elevate the brachioradialis tendon by muscle
cutting horizontally underneath the
tendon with a No.15 blade to avoid • Partially release the flexor digitorum
injury to the perforators exiting the superficialis from inferior to superior,
radial artery laterally that supply the enough to expose the flexor pollicis
bone and flexor pollicis longus and longus muscle and its origin from the
pronator quadratus muscles anterior surface of the radius (Figure
• Extend the dissection deep to brachio- 29)
radialis more laterally by widely re- • Retract the cut flexor digitorum super-
tracting the tendon and muscle and ficialis medially while gently retracting
dissecting beneath the superficial radial the lateral intermuscular septum and
nerve vascular pedicle laterally (Figure 29)
• Identify and protect the perforators to The thickness of the radial bone is de-
the bone (Figure 27) termined proximally during the dis-
• Elevate the medial part of the flap section and a longitudinal cut is made
Incise the deep fascia over the pronator through the flexor pollicis longus and
quadratus, flexor pollicis longus and periosteum on the medial surface of the
flexor digitorum superficialis muscles radius with a No. 15 scalpel blade
15
Figure 29: Flexor digitorum superficialis Figure 30: Cutting cortices longitudinally
partially released to expose the flexor while protecting radial nerve and laterally
pollicis longus muscle and the lateral placed tendons with a metal (copper) plate
intermuscular septum and vascular pedicle
• Attempt to advance skin to cover the Figure 33: Soft palate and tonsil fossa
exposed tendons
• Skin grafts
o Maintain epitenon over tendons
o Bury tendons by oversewing with
deeper muscles
17
Figure 34: Hemiglossectomy
18
References Author
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