Authors of section

Authors

Brian Burkey, Neal Futran

Executive Editors

Gregorio Sánchez Aniceto, Marcelo Figari

General Editor

Daniel Buchbinder

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Radial forearm fasciocutaneous free flap

1. Introduction

These defects are typically small volume and do not have a dental alveolar component. An oral nasal fistula is usually present. The main goal is to cover and/or to obliterate the defect.

Reconstruction of midface Brown I defect - Palate: Radial forearm free flap

2. Choice of flap

The radial forearm free flap is the most appropriate tissue source utilized for palatal repair, as it has a thin soft tissue and a long vascular pedicle.

Reconstruction of midface Brown I defect - Palate: Radial forearm free flap

3. Resection

Marking of the osteotomy lines

The proposed osteotomy lines are marked on the palate (eg. with a Bovie cautery). Care is taken to resect at least 1 cm of normal tissue around the tumor.

Reconstruction of midface Brown I defect - Palate

Incision of the palate

An incision is made in the palate with either a #15 blade or a Bovie cautery to minimize blood loss. A 1 cm margin should be maintained around the tumor.

Reconstruction of midface Brown I defect - Palate

Osteotomies

Utilizing either sagittal or reciprocating saws, an osteotomy is made in the palatal bone around the tumor. Osteotomes can be used to complete the bony cuts (separate the nasal septum from the maxillary crest with an osteotome if necessary) and the segment is mobilized.

Reconstruction of midface Brown I defect - Palate

Tumor delivery

The remaining soft tissues are incised with electrocautery and the tumor is delivered.

The nasal mucosa can either be preserved or excised depending on the tumor invasion.

The specimen is submitted en bloc for permanent pathological examination.

Surgical margins are now checked with frozen sections to ensure the adequacy of the tumor resection.

Reconstruction of midface Brown I defect - Palate

4. Reconstruction

Flap harvest

The radial forearm free flap is harvested in the standard fashion with the following considerations:

  • An adequate sized flap should be harvested to fill the defect and overlap the maxillary and nasal floor
  • The vascular pedicle should be followed to its origin to obtain maximal pedicle length
Reconstruction of midface Brown I defect - Palate: Radial forearm free flap

Insetting of the flap

The flap is placed into its preplanned position to seal the palate with care not to create undue torsion or tension within the pedicle. No specific attempt is necessary to suture the flap to the nasal side of the defect. This area will normally mucosalize.

The vascular pedicle passes either trans-antrally and exits through a bony window that is made in the lateral maxillary wall before entering the cheek tunnel.

Reconstruction of midface Brown I defect - Palate: Radial forearm free flap

Alternatively an incision can be made around the tuberosity and the pedicle passed in the trough to reach the cheek tunnel.

Reconstruction of midface Brown I defect - Palate: Radial forearm free flap

The vascular pedicle is positioned to pass through a tunnel in the pterygoid region to anastomose to the vessels in the neck. The use of a silicon tube could be helpful in order to protect and avoid pedicle rotation during the passing.

Reconstruction of midface Brown I defect - Palate: Radial forearm free flap

The flap is sutured to the cut edge of the palate circumferentially with resorbable suture to create a water tight seal.

Reconstruction of midface Brown I defect - Palate: Radial forearm free flap

5. Revascularization of flap

The detailed procedure for the revascularization is outside the scope of this surgery reference. However, in short the procedure consists of the following steps:

  • A neck incision is made and the appropriate recipient vessels are selected in the neck and dissected so as to be available for anastomosis
  • Creation of a tunnel from the ptyerigoid region to the neck incision lateral to the mandible of adequate size for the passing of the vascular pedicle
  • The recipient and the donor vessels adventitia are cleaned under a microscope
  • Appropriate vessel geometry is assured and the vessels are placed into a microvascular clamp and anastomosis carried out, eg. using 9-0 nylon sutures
  • Vascularization is restored after both arterial and venous anastomoses are completed
  • For adequate vessel length to create the anastomoses (without tension), vein grafts are sometimes necessary
Reconstruction of midface Brown I defect - Palate: Radial forearm free flap

6. Rehabilitation following midface resection and reconstruction

Medication

The use of the following perioperative medication is controversial. There is little evidence to make strong recommendations for postoperative medications.

  • Analgesia as necessary
  • Antibiotics (many surgeons use perioperative antibiotics). There is no clear advantage of any one antibiotic but evidence supports their use for 24h. The spectrum should be according to the existing bacterial flora, especially in the combined intra and extra cranial procedures.
  • Steroids may help with postoperative edema.
  • Regular perioral and oral wound care has to include disinfectant mouth rinse, lip care, etc.
  • Antibiotic ointment is used on the wounds for 72 hours
  • If a free flap is utilized for the reconstruction, 100 mg of aspirin/day is recommended.

Wound care

Remove sutures from skin after approximately 7 days if nonresorbable sutures have been used. If the patient has had previous radiation, the sutures should be left in for 10 – 14 days.
Moisturizing lotion should be used on the skin wounds to minimize excessive scarring after sutures are removed.

Avoid sun exposure and tanning to skin incisions for several months.

Diet

Diet depends on the reconstructive method. For patients who have obturators placed, initial liquid diet followed by a soft diet as tolerated is initiated after surgery.

For patients with free flap reconstruction of the maxilla, a feeding tube is placed during sugery allowing the patient to be kept nil per os for 5-7 days. If issues develop with velopharyngeal insufficiency or dysphagia, assessment by a speech and swallowing rehabilitation specialist may be indicated. When the lateral nasal wall is reconstructed, especially when a bulky soft tissue flap is used, the nasal airway should be stented with gauze packing or a merocel sponge for five days.

Clinical follow-up

Typically the patients are seen in clinical follow-up one week after discharge, and then on a weekly basis until such time the clinician determines that less frequent follow ups are needed.

Oral hygiene

Patients with intraoral incisions and/or wounds must be instructed in appropriate oral hygiene procedures. A soft toothbrush (dipped in warm water to make it softer) should be used to clean the surfaces of the teeth. Chlorhexidine oral rinses should be prescribed and used at least 3 times a day to help sanitize the mouth. For larger debris, a 1:1 mixture of hydrogen peroxide/chlorhexidine can be used. The bubbling action of the hydrogen peroxide helps remove debris.

Reconstruction with obturator

For individuals reconstructed with a maxillary prosthesis, the surgical packing is left for seven to ten days postoperatively. The patient will need to remain on appropriate gram positive antibiotic coverage over that time.

Upon returning to clinic, the patient is seen by the maxillofacial prosthodontist and the obturator and the packing are removed, the cavity is cleaned and inspected and the patient is then started on frequent nasal saline irrigations and home humidification. The obturator is modified as needed and replaced.

Over time, the maxillary prosthesis can be altered to best fit the evolving defect.

Reconstruction with free flap

When a free flap is utilized, it should be regularly monitored to ensure vascular integrity. Physical examination, assessing the flap color, turgidity, and capillary refill should be routine for at least the first 48 hours postoperatively. Hand-held Doppler probes can be used to assess blood flow. In case of doubt of the vitality of the flap, pin-prick assessment with a 25 gauge needle to look for bright red bleeding.. In cases of buried flaps, an implantable Doppler placed just distal to the venous anastomosis can be utilized

Radial forearm free flap
The radial forearm free flap donor site should be closed with a skin graft and a bolster placed over the area. The arm is then cast or placed in a volar splint for 7 days prior to removal to ensure graft take. If bone is taken and the radius plated, appropriate follow-up with an orthopedic or hand specialist should be arranged.

Fibula free flap
After a fibula free flap, the donor lower leg should be cast with the ankle slightly dorsiflexed for 5 days. The patient can touch-down their body weight as tolerated. After the cast is removed they can ambulate and work with physical therapy to optimize leg function. A splint should be placed to keep the foot flexed when in bed.

Scapula free flap
Flaps from the subscapular system require no particular rehabilitation care but closed suction drains should remain until a minimal output is still draining to avoid seroma formation.

Rectus abdominous and iliac crest
Rectus abdominous and iliac crest donor sites require that the patient not strain or lift heavy objects for at least 4 weeks to avoid hernia formation.

Anterolateral thigh
Patients should avoid climbing stairs for 2-4 weeks after surgery. They should also be observed for seroma formation at the wound bed.

Furthermore, patients often need physical therapy to rehabilitate the donor site.