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Kurzstreckige Trachealstenosen werden oftmals mittels segmentarer Resektion und End-zu-End-Anastomosen behandelt. Manche langerstreckigen Stenosen konnen mittels Dilatation, Lasertherapie, bronchoskopischer Stenteinlage oder segmentarer Resektion und Rekonstruktion behandelt werden. Eine besondere Herausforderung stellen langstreckige narbige Restenosen nach erfolgter Resektion dar. In solchen Fallen konnen suffizient vaskularisierte Transplantate die Ultima ratio darstellen. Wir berichten uber eine 37-jahrige Patientin, die aufgrund einer funktionell wirksamen subglottischen Trachealstenose (5,5 cm) auf dem Boden einer traumatischen Trachea- und Larynxtrummerfraktur und nachfolgender Langzeitbeatmung erfolgreich mit einem schleimhautuberzogenen Radialisfaszienlappen behandelt wurde. Nach longitudinaler, anteriorer Trachearesektion 1 cm ober- und unterhalb der Stenose erfolgte die Einlage eines Dumon®-Stents. Zeitgleich wurde ein Radialisfaszienlappen gehoben sowie bukkale Schleimhaut beidseits entnommen und an die belassene subkutane Fettschicht des Lappens genaht. Diese wurde auf den anterioren Trachealdefekt von kaudal beginnend luftdicht aufgenaht, mit der lumenwarts gerichteten Mukosa. Es folgte die End-zu-End-Anastomose der Lappengefaβe mit den Halsgefaβen. Die Patientin wurde nach 24 h extubiert und nach 5 Tagen entlassen. Computertomographisch war die Stentlage optimal bei suffizientem Erhalt von Sprache und Atmung. Der Stent wurde 6 Wochen postoperativ bronchoskopisch entfernt. Im Nachbeobachtungszeitraum von 6 Monaten blieb der Durchmesser des rekonstruierten Luftwegs erhalten und die Patientin beschwerdefrei.

Since the introduction of the osteocutaneous radial forearm flap in 1983, fractures of the radius have been reported to occur in approximately 30% of cases. Fracture of the donor forearm has been the cause of the most significant morbidity, and the difficulty in management of these fractures has been reported. We report our experience in managing three fractures involving the donor forearm. Optimum results can be achieved by early stabilization with external fixation and vascularized bone grafting. Excessive resection of the radius should be avoided and alternative sources of vascularized bone used to avoid mutilation of the forearm.

Restoration of oral cavity and pharyngeal function following ablative surgery remains an elusive goal. Conventional reconstructive methods often achieve satisfactory wound healing, but the introduction of a dynamic anesthetic and bulky flaps into the oral cavity can interfere with the function of the residual soft tissues. This article examines the anatomy, harvest technique, and applicability of neurosensory radial forearm flaps to head and neck reconstruction with special attention to the attributes of this donor site which, at present, make the radial forearm flap the flap of choice for the reconstruction of a variety of oral cavity and pharyngeal defects.

Soft-tissue injuries of the hand often require flap coverage to achieve primary wound closure and a good functional result. The use of the reverse radial forearm fasciocutaneous flap in the reconstruction of the hand is discussed. This flap offers thin, pliable, hairless skin and has proved very reliable because of its excellent vascular supply. The anatomy and vascular basis of this flap are presented along with its application in three patients.

The keel-shaped modification for harvest of the radial forearm osteocutaneous flap has been used to reconstruct 19 oromandibular defects in 18 patients. Fourteen men and 4 women ranging in age from 22 to 72 years have undergone composite mandibular reconstruction, with follow-up ranging from 3 to 36 months. Sixteen patients (17 reconstructions) had resection of advanced malignancies, and 2 patients sustained shotgun wounds. Twelve symphyseal and 7 lateral or posterior defects were reconstructed with donor radius bone ranging in length from 5 to 13.5 cm. Double osteotomies were performed in 7 patients. Two skin paddles were used in 4 patients to provide simultaneous intraoral lining and external skin coverage. The radial forearm osteocutaneous flap is still an excellent choice for oromandibular reconstruction. Anterior and lateral composite mandibular defects were satisfactorily reconstructed both aesthetically and functionally using the keel-shaped modification of the radial forearm flap. Donor-site problems were uncommon and minor, and long-term forearm function was minimally affected. Radius fracture occurred in only 1 patient.

Thermal injuries are characterized by varying degrees of damage to the skin and underlying structures. In the vast majority of patients, the initial thermal injury is limited to the skin and subcutaneous fat. The underlying fascia and its vasculature usually are spared. Flaps are required to cover nongraftable wounds (exposed tendon, bone, joints, and so on) and also are used to release joint and web space contractures. Contrary to frequent opinion, previously burned skin or skin-grafted fascia can safely be used as fasciocutaneous flaps when necessary. We present our series of burned patients in whom local flaps originating from within the burned area were used, avoiding the need for more distant or free flaps to accomplish appropriate wound coverage. This series consists of 40 fasciocutaneous flaps in 22 patients. The flaps included lateral arm (4), posterior interosseous (7), radial forearm (4), ulnar forearm (2), metacarpal (3), and digital (20).

During 1998, 69 patients underwent eitherfasciocutaneous or osteofasciocutaneous radial forearm free-tissue transfers at our institution. Three of these patients (4.3%), who had undergone a total of four transfers, had Raynaud's phenomenon. Three of the four transfers survived without perioperative incident. The one flap that failed had been well vascularized until postoperative day 3. Then, coincident with a decrease in ambient room temperature, the patient's extremities and his flap became cyanotic. A salvage procedure was unsuccessful. In this article, we discuss the perioperative course, proposed pathophysiology, and treatment strategies aimed at optimizing hand and flap outcomes in patients with Raynaud's phenomenon.

Objective: 1) Assess donor site morbidity following harvest of osteocutaneous radial forearm free flaps (OCRFF). 2), Evaluate patient perceived upper limb disability for osteocutaneous vs fasciocutaneous radial forearm free flapsMethod: Retrospective cross-institutional review of OCRFF performed between 2001 and 2010. There were 218 included patients. The primary outcome measure was forearm donor site morbidity. The Disability of the Arm, Shoulder and Hand (DASH) questionnaire was used to compare patient perceived arm disability for osteocutaneous vs fasciocutaneous radial forearm flaps.Results: Mean patient age was 63 years with a male predominance (63%). The left arm was the donor site in 86%. Median bone length harvested was 8 cm (range, 3-12 cm). Following harvest, the radius was plated in 99% of patients. Recipient sites primarily included the mandible (62%) and maxilla (34%). Donor site morbidity included fracture (2 patients, 0.9%) and sensory neuropathy (5 patients, 2%). Fractures were treated wit...

To compare outcomes following osteocutaneous radial forearm and fibula free flap reconstruction of lateral mandibular defects.Retrospective case-controlled study.Historical cohort study.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.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.The osteocutaneous radial forearm and fibula free flap provide equivalent wound healing and functional outcomes in patients undergoing lateral mandibular defect reconstruction.

We performed a single-stage operation to reconstruct a large defect of the lips and commissure using a composite radial forearm-palmaris longus free flap. To obtain cranial traction and a voluntary smile, independently from any jaw movement, traction was achieved by using a lengthening temporalis myoplasty. The tendon attached to the coronoid process was fixed to the palmaris longus tendon, recreating a new commissure and a "neo-modiolus." Physical therapy was started on the 21st postoperative day to facilitate progress from a "mandibular smile," to ideally a spontaneous and symmetric smile after 3 months of therapy. This procedure was able to obtain good oral continence and a good commissural movement during smile which has not previously been mentioned in the published literature.

BACKGROUND Osteomyelitis of the lower limb, associated with soft-tissue defects, is a reconstructive challenge. Microvascular free-tissue reconstruction is an important surgical option with the superiority of free muscle and myocutaneous flaps being explored by various publications. Muscle flaps provide good quality vascularized tissue which can be contoured into defects, but their bulk can often lead to the reconstruction having a suboptimal aesthetic outcome. This result is usually most evident in the lower third of the tibia. We present our series of free radial forearm fasciocutaneous flaps for reconstruction of distal third tibial soft-tissue defects following debridement of osteomyelitic foci and bony stabilization. METHODS A retrospective case-note review of 20 patients treated with free radial forearm fasciocutaneous flap reconstruction of distal third tibial soft-tissue defects following excision of osteomyelitis and adjacent scar tissue, and bony stabilization between January 1999 and December 2006 was conducted. RESULTS There were 20 patients who had established osteomyelitis of the distal third of tibia following previous open fractures. The mean size of the soft-tissue defect at the time of the free fasciocutaneous flap procedure was 72.3 cm(2) and the mean bony defect was 3.4 cm. The mean duration of the procedure was 417 minutes and flap ischemia time did not extend beyond 60 minutes in any of the cases. Overall flap survival was 100% and all patients had radiologic bony union at a mean of 5.73 months. The average period of follow-up was 22.5 (range, 19-36) months, and none of the patients had a recurrence of the disease during the follow-up period. CONCLUSION Free fasciocutaneous flap reconstruction for soft-tissue defects of the lower limb in our series was seen to be safe, reliable, and provided an aesthetic outcome with high patient satisfaction rates. We advocate the use of free fasciocutaneous flaps for small-to-moderate sized defects of the distal third of the tibia after debridement for chronic osteomyelitis. Although we have used radial forearm flaps in our series, more modern free fasciocutaneous flaps with less donor-site morbidity may be preferred.

The purpose of this study was to analyse the causes of venous compromise and flap failure in radial forearm free flap (RFFF) surgery for intraoral reconstruction. One hundred seventy-eight RFFF reconstructions were reviewed retrospectively for intraoral defects. Of the 13 flaps with venous obstruction, 9 flaps were salvaged, and 4 were lost, with a salvage rate of 69.2%. Eleven venous occlusions occurred within the first 72h. The main reasons for venous failure were mechanical obstruction or technical errors due to inadequate pedicle length and geometry, inadequate venous drainage, compression and kinking of the vein. The main cause of failure for oropharynx reconstruction was unrecognized vascular events due to the lack of reliable monitoring for buried flap. Oozing of dusky blood from the flap margin may be directly related to venous congestion in the early postoperative period and a late indication of a change in skin colour. In conclusion, a thorough operative plan, including carefully selected drainage vein for the flap and recipient vessels, adequate pedicle length and geometry, precise surgical technique, avoidance of haematoma, and expert monitoring of buried flaps may improve the success rate of RFFF transfer in intraoral reconstruction.

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.

Summary The goal of this study was to evaluate changes in radial forearm free flap (RFFF) volumes after 5 years of follow-up after ablative tumor surgery in the head and neck. Eighteen patients underwent RFFF reconstruction. Flap volumes were measured by computerized segmentation of CT or MR images. Average postoperative 3 months, and 1, 3, and 5 years flap volumes were 167.4, 129.0, 104.9, and 88.7 cm 3 , respectively. Average percentage changes between 3 months and 1-year, 3 months and 3-years, and 3 months and 5-years scans were 20.4, 30.3, and 42.7%, respectively. A significant relation was found between postoperative irradiation and RFFF volume changes from 3 months to 5 years ( p = 0.046). Overcorrection with a 40% greater RFFF volume is recommended for the reconstruction of tumor-related defects in the head and neck.

Background This study presents an alternative in reconstruction, using free skin flaps in combination with pedicled mandible bone flaps for complex lateral mandibular defects. Methods In all, 13 patients were included in this prospective study. Pedicled mandible myo-osseous flaps were used for reconstruction of bone defects of the lateral mandible in combination with free skin flaps, including radial forearm flaps (n = 3), anterolateral thigh (ALT) flaps (n = 9), and local tongue flap (n = 1). Postoperatively, a 99mTc-methyl diphosphonate bone scan was performed to assess bone flap viability. Results All patients had acceptably contoured mandibles. The major complications consisted of 1 failed ALT flap and 2 nonviable bone flaps. The bone scan confirmed viable bone flaps in 11 cases. Ten patients (77%) were able to resume soft to full diets. Conclusions For complex lateral mandibular defects (≤6 cm), a combination of the pedicled mandible myo-osseous flaps and free skin flaps is an alternative in reconstruction. © 2011 Wiley Periodicals, Inc. Head Neck, 2012

Radial forearm flaps were first reported by Yang et al. [1] in 1978 and are one of the most reliable conventional types of flaps. To overcome the donor-site morbidity associated with this flap, which includes problems due to major artery sacrifice, numbness of the dorsal hand, and the development of unfavorable scars, many modifications of the radial forearm flap method have been reported. These modifications have resulted in the expanded flap [2], the distally based flap [3], and the perforator-based flap/perforator flap [4–6] methods. In a further modification, we developed the “shape-modified radial artery perforator flap method” [7–9].

Treatment of cancer of the cervical aerodigestive tract is challenging due in part to the difficulty in reestablishment of pharyngoesophageal continuity after resection of the involved tract. From May 1989 to August 1990, six patients underwent immediate reconstruction utilizing microvascular transfer of free radial forearm flaps following resection of pharyngoesophageal neoplasms. A small island flap connected to the radial vascular pedicle by fasciocutaneous branch was used to monitor the vascular condition of the hidden fabricated free forearm flap. Stricture is the most troublesome complication of esophageal reconstruction using a conventional free forearm flap. Two small triangular flaps were designed and inserted bilaterally in the distal anastomosis of both lateral esophageal walls to prevent circular contracture. The outer layer sutures were anchored to surrounding rigid structures to withstand shrinkage and circular contraction. The problem of stricture was solved by these procedures. This one-stage, easily monitored operation for pharyngoesophageal reconstruction is considered to be as useful as a free jejunal transfer.

Radial forearm free flaps (RFFFs) are safe, but critical ischaemia of the hand has been described and is catastrophic. Every effort should therefore be made to improve the safety margin even further. Colour flow duplex ultrasound (US) is a simple, non-invasive and effective assessment tool. We compared it with Allen's test to identify serious vascular anomalies. We studied 121 patients who were listed to have a RFFF harvested, all of whom had both duplex US assessment and Allen's testing of the selected arm. The significance of differences in proportions was assessed using McNemar's test. Five of the 121 patients had an alternative flap selected as a consequence of the duplex assessment. A single flap failed. There were no ischaemic vascular complications that affected the hand.

We carried out a retrospective study of fracture morbidity of radial forearm osteocutaneous donor sites. During a period of three-and-a-half years, 12 patients had had composite flaps taken, and 5 of them had subsequently fractured the radius. We then elected to plate the radius prophylactically and found that over a period of just over two years, none of the 8 patients who had had prophylactic plating at the original harvesting operation had subsequently fractured the radius.

Reconstruction was performed on the back of a hand following a poorly managed septic hand injury leading to skin and extensor apparatus necrosis using a reverse radial forearm fasciocutaneous flap and a bilayer artificial skin substitute.Authors report on the first Hungarian case using Integra dermal regeneration template. Integra was placed on the back of the hand on an area left uncovered by the reverse radial forearm fasciocutaneous flap as well as on the flap harvest area. After biointegration of the regeneration template, the outer silicon layer was removed and a split thickness skin graft was applied.The take-rate on the donor area was 100% for Integra and 99% for the skin graft, and 90% for both Integra and the skin graft on the back of the hand, providing a good functional and aesthetic result.

Objectives1. Assess speech outcomes for patients undergoing primary tracheoesophageal puncture (TEP) following total laryngectomy (TL) with patch free flap reconstruction. 2. Evaluate risk of fistulization following primary TEP vs. no TEP in patch free flap TL reconstruction.MethodsPatients undergoing reconstruction with patch free-flaps following TL were studied retrospectively. Demographic data, surgical procedures, speech outcomes, and postoperative complications were collected. Patients were divided in 2 groups depending on whether TEP was performed at the time of ablation (primary TEP). Voice outcomes were assessed by a speech therapist.Results77 patients underwent TL, mean age of 63 years. Glottis (60%), followed by hypopharynx (18%), and supraglottis (17%) were the most common tumor sites. Most patients had T3 and T4 disease (71%) on initial presentation, and there were 57% undergoing salvage total laryngectomy. The radial forearm fascioucutaneous free flap was used in 90% of the cases. Primary TEP...

The aim of this article is to compare the superficial venous drainage system versus dual venous drainage system of radial forearm free flaps (RFFF) and its impact on flap survival. A total of 136 consecutive patients undergoing RFFF reconstruction for oral and maxillofacial surgical defects were reviewed retrospectively. In group l, both the superficial and deep veins were anastomosed to the neck recipient veins. In group 2, only the superficial vein was used for anastomosis. There were no statistical differences in venous problems between two groups (6/68 in group 1 vs. 5/68 in group 2, P = 0.75). The flap survival rate was 98.5% (66/68 in group 1 vs. 68/68 in group 2, P = 0.15). Although there are many theoretical advantages to dual venous drainage system anastomoses, they seem not to impact on flap survival in our experience.

A single surgeon's experience with 67 pedicled and free radial forearm flaps for reconstruction of the elbow, wrist, and hand was analyzed retrospectively.Fifty-seven pedicled (43 reverse and 14 antegrade flow) and 10 free radial forearm flaps were performed in 66 patients, including seven fascial flaps and one osteocutaneous flap. Indications involved soft-tissue coverage of the elbow (n = 11), dorsal wrist and hand (n = 24), palmar wrist and hand (n = 12), and thumb amputations (n = 5); after release of thumb-index finger web space contractures (n = 6) and radioulnar synostosis (n = 2); before toe-to-thumb transfers (n = 3); for reconstruction following tumor excision (n = 13); and for wrapping of the median, ulnar, and radial nerves for traction neuritis (n = 5).Primary healing of the soft-tissue defect of the elbow, wrist, and hand was successful in 95 percent of patients. There was one flap dehiscence, partial loss of two reverse radial forearm flaps, and complete loss of one free radial forearm flap. Eleven donor sites were closed primarily and 56 were covered with a split-thickness skin graft. No patients complained specifically of cold intolerance of the hand or dysesthesias in the superficial radial nerve or lateral antebrachial nerve distribution.This is the largest reported series of radial forearm flaps for reconstruction of the upper extremity. The authors believe the antegrade pedicled radial forearm flap is the optimal flap for coverage of defects around the elbow, and the reverse radial forearm flap is the optimal choice for coverage of moderate-sized defects of the wrist and hand.

PubMedID: 18788053 We present the first free flap operation to our knowledge for a patient with squamous cell carcinoma on a lesion of discoid lupus erythematosus. Although the disease affects the skin, the defect was reconstructed successfully with a free radial forearm fasciocutaneous flap. © 2008 Informa UK Ltd. (Informa Healthcare, Taylor & Francis As).

The radial forearm flap, owing to its good-caliber arteries of long length and equally well distributed venous system, has proved very reliable. It has not only earned its place and recognition in reconstructive hand surgery, but also has emerged as a workhorse for the microvascular surgeon. We have used 14 radial forearm flaps for upper extremity reconstruction, and we present herein our experience. The technique of extracorporeal tissue transfer, which has been published elsewhere, was used in two patients and is detailed. Four representative patients are presented.

Eleven patients had scalp tumours with full thickness calvarial invasion excised and reconstructed with free flap transfer as a primary procedure. Latissimus dorsi or radial forearm flaps were used, with split rib calvarial reconstruction. One flap was lost peroperatively and another necrosed at 8 days following pedicle compression against an acrylic "skull". Only six patients presently survive, two being treated for recurrence. Long-term follow-up indicates that poor prognostic factors are advanced local invasion, squamous or anaplastic tumours, and advanced age. However, palliative treatment has a role.

Since its description in the 1970s, the radial forearm free flap has earned a clearly defined role in the armamentarium of reconstructive head and neck surgery. Three decades later, the donor site remains an intrinsic drawback primarily due to its esthetic impact, although functional morbidity is significant in a minority. These points do not outweigh significant advantages but are occasionally reasons for the choice of alternative flaps. Modifications evolved in an effort to improve these undesirable features include primary closure, rotation-advancement, proximal paddle placement, full-thickness skin graft (FTSG) and suprafascial dissection. We describe a novel technique of engineering a composite graft of cadaveric acellular dermal matrix and autologous split-thickness skin graft (STSG) for a better donor-site closure.From December 1995 to August 2003, 23 patients underwent radial forearm reconstruction of head and neck defects. Control patients (Group I; n = 5) had donor sites closed by conventional STSG technique (0.014-0.016 inch). In 18 patients (Group II), the donor site was closed with a composite technique (dermal allograft, 0.020-0.030 inch, and an ultrathin STSG, 0.0080 inch). Both groups of patients were retrospectively studied for comparative defects. Contralateral upper extremities also served as controls. All patients underwent a standardized functional examination of the donor and contralateral extremities, as well as an outcome questionnaire. All extremities were photographed for visual comparison by the author.Three of the 5 group I patients were available for follow-up, which averaged 64 months (60-72 months). Thirty-three percent had a decrease in functional parameters and 67% complained of paresthesia. Patient satisfaction was 3.5/5. Six of the 18 patients were excluded from Group II due to insufficient follow-up or inability to follow. Follow-up averaged 8 months (1-24 months). Functional parameters in all patients were comparable to the contralateral extremity, except in 1 patient. In this case, a 0.030-inch allograft was used which never revascularized, inhibiting wrist motion. Other patients exhibited excellent range of motion of the wrist and fingers. This was the only patient in this group that exhibited paresthesia of the donor site. Patient satisfaction was 4.6/5. Esthetic results were extremely gratifying as judged by the author. Esthetic results were better than those observed in Group I.Composite grafting with acellular dermal matrix and STSG provides a comparable (trending to superior) result with traditional STSG for the treatment of radial forearm graft donor sites. Even if functionally equivalent, it is esthetically superior and therefore a technique warranting further investigation.

Flaps have long been recognized as an essential tool for soft-tissue reconstruction. Flaps range in complexity from local to free and perforator flaps and can include a variety of composite tissues. The concept of a flow-through flap, in which both the proximal and the distal ends of the vascular pedicle of a free flap are anastamosed to provide blood flow to distal tissues, was first described by Soutar et al. in 1983. An uninterrupted arterial flow was established by Soutar et al. between the external carotid and distal facial artery via a radial forearm flap for head and neck reconstruction (Soutar et al., Br J Plast Surg 1983;36:1-8). Shortly thereafter, Foucher et al. were the first to report the reconstruction of an extremity with a simultaneous vascular defect by utilizing a radial forearm flow-through flap (Foucher et al., Br J Plast Surg 1984;37:139-148). The utility of the flow-through flap is now well established, and its indications for use continue to grow. The principle advantage of this flap is that it provides the opportunity for a single stage composite reconstruction of both soft tissue and vascular defects, making it particularly useful in the reconstruction of ischemic extremities and defects from oncologic ablations. Improvements in microsurgical equipment and techniques are making early difficulties with these flaps irrelevant, giving plastic surgeons opportunities to become more creative in the choices and uses of flow-through flaps. The literature consists mostly of case reports and series. The nomenclature used to describe the types of flow-through flaps is confusing and inconsistent. The purpose of this article is to provide an organized review of flow-through flaps and to classify these flaps based on their inflow, outflow, and the nature of their vascular conduit. Additionally, we have included a discussion on the physiology of these flaps, reviewed the current literature, and summarized the various types of flow-through flaps in a reference guide that can aid in flap selection.

The upper lip was totally reconstructed with a radial forearm sensory flap and vermilionplasty using medical tattooing after resection of a malignant melanoma. Three courses of chemotherapy (dacarbazine, nimustine, and vincristine) were given postoperatively. The reconstructed lip had good contour, colour, and sensory recovery.

The use of a free vascularised fascio-cutaneous radial forearm flap in combination with a cranially based pharyngeal flap for soft palate reconstruction has not been previously reported. We present the technique and illustrate its use in two cases of total and one case of subtotal soft palate reconstruction. The functional outcome is discussed with particular reference to nasal airway patency, speech and swallowing.

Objective Patients who undergo skull base resection after prior surgery or radiation may be at high risk for complications when local flaps alone are used for reconstruction. To determine whether the complication rate could be reduced, fasciocutaneous free tissue transfer was used to reinforce the dural closure in patients who had prior skull base surgery or radiation. Methods This study is a case series of 20 patients (14 males, 6 females, aged 8–79 years of age with a mean of 47.7 years) from 1997 to 2001 who had prior skull base surgery or radiation, and underwent salvage skull base resection without large volume defects. All patients had a radial forearm free tissue transfer to reinforce the dural closure. Six patients had an osseous component to the forearm flap to provide vascularized bone to the orbital rim. Results The overall local complication rate was 35%. Three patients (15%) had major complications including 1 case of meningitis, 1 case of cerebrospinal fluid leak, and 1 case of a flap requiring venous salvage. There were no flap failures, 1 idiopathic median nerve palsy, and no pathologic radius bone fractures. Conclusion Reconstruction with fasciocutaneous free tissue transfer for high-risk patients with low-volume dural defects following skull base resection can minimize the risk of major postoperative complications. EBM rating: C.

Objective Negative-pressure dressings (NPDs) have been reported to improve split-thickness skin graft survival in some settings; we assessed whether NPDs could improve skin graft results in radial forearm donor sites. Methods Between October 2003 and November 2004, 45 radial forearm donor sites underwent split-thickness skin graft immobilization either with conventional bolster dressing and splint or with an NPD. Split-thickness skin graft take was recorded at 1 and 4 weeks postoperatively. Results Overall split-thickness skin graft healing was improved in the NPD group (92%) compared with the case of conventional splinting (81%) at 4 weeks ( P = .10). The rate of major graft loss was less in NPDs (10%) compared with the case of conventional management (28%) after 4 weeks ( P = .06). Conclusions Split-thickness skin graft survival was significantly improved by the use of NPDs. Because the use of NPDs is expensive, we consider their use only in patients with potential wound-healing problems, when there is a need to monitor the hand, or when immediate postoperative hand immobilization might impede the patient’s recovery.

We have reconstructed soft tissue defects in 121 hands with radial forearm flaps. So that the flap perfectly fitted the defect, and to minimise the size of the donor site, we divided the flap into two or three components in each case. We call this the shape-modified radial forearm flap. Of the 118 patients, 113 had complete survival of the flap. The follow-up time was 1 to 15 years. The donor sites were closed primarily in all patients, giving good aesthetic results. The shape-modified radial forearm flap seems to be reliable, and makes it possible to adjust the flap according to the defect. The donor area can be closed primarily in all cases.

Fifty patients undergoing radial forearm free flap reconstruction of head and neck defects were examined to find out the extent of sensory defect at the donor site. Flaps (mean length 6 cm, range 4–9) and mean width 4.7 cm (range 3.5–7) were raised. Of the 50 patients 38 (76%) were aware of some sensory loss over the radial distribution in the donor hand. There was objective evidence of a reduction in at least one sensory function in 32 of these patients (84%). The mean affected area was 44.3 cm 2 (range 6–125). The mean length of the affected area was 11.3 cm (range 4.3–12.1) and the mean width 5.1 cm (range 2.1–8.4). Of the 12 patients (24%) who reported no feeling of sensory loss all modalities of sensation were preserved in 11 (92%).

Thirty-seven patients were treated using distally-based island radial forearm flaps. There were 31 men and six women. Reconstructed sites involved the dorsum of the hand (n = 17), the thumb (n = 11), the fingers (n = 5), the first web (n = 3), and the palm (n = 1). Sensory flaps were transferred in 15 cases, osteocutaneous flaps in six, and tendocutaneous flaps in eight. All the flaps survived. There were five donor-site complications, but no functional disturbances. Three patients had symptoms of cold intolerance. There were no radial fractures. In the six cases with osteocutaneous flaps, a mean of 2.6 months (range 2-3) was needed to obtain bony union. Among the eight cases with tendocutaneous flaps, postoperative tenolysis was required in two cases, and finally seven achieved a satisfactory outcome. The mean moving 2-point discrimination of the sensory flaps was 13 mm.

A patient had radical excision of type II diaphyseal radioulnar synostosis and interposition of a radial forearm adipofascial flap. Neither adjuvant nonsteroidal anti-inflammatory medications nor radiation therapy were used. Three years after surgery the patient showed 90 degrees of pronation and 90 degrees of supination without any evidence of recurrence.

Twenty-two free flap reconstructions were done by one of both authors as visiting microsurgeons to a hospital a long distance away. The reconstructions were performed in the head and neck (n = 21) and the soft tissue of the lower leg (n = 1). Free flaps included: fibula (n = 8), radial forearm (n = 6), anterolateral thigh (n = 4), iliac crest (n = 1), and musculocutaneous latissimus dorsi flap (n = 3). No pedicle revision was necessary. No flap was lost completely, but one partially. Either of both microsurgeons arrived the day before reconstruction and stayed for about two days postoperatively. Preoperative investigations and postoperative care were done by the local plastic surgeons (who had no microsurgical experience), the ear, nose, and throat surgeons, and the nurses, following the regimen given by the microsurgeon. Microvascular reconstructions, done by a microsurgeon visiting from a long distance away are a reliable and safe option. This may be of advantage in remote areas where no microsurgeon is available locally, to avoid long transports for patients and the associated high costs.

Standard magnification in microsurgery is accomplished with the operating microscope. Loupes are perceived by the microsurgical community as technically less safe. However, after several years of microscope-only microsurgery, most of our microvascular procedures are performed under loupes 3.5-4x. Considering our results using loupes-only microsurgery, which are comparable with those obtained when using the microscope, we suggest that loupe-aided microsurgery might represent a natural progression for the experienced microsurgeon. Microsurgical skills and experience outweigh the importance of the magnification factor. While the microscope is mandatory for replantations distal to the palmary arch, microneurosurgery, and supramicrosurgery, loupes should be used in so-called "macro-microsurgery." One may include in this category replantations down to the palmar arch and free flaps with vessels more than 1.5 mm, such as the latissimus, serratus, (para)scapular, fibula, radial forearm, rectus abdominis, dorsalis pedis, omentum, and jejunum. Before starting loupes-only microsurgery, intensive training under the microscope is crucial. Less magnification does not mean less quality.

The distally-based radial forearm fasciosubcutaneous flap is based on the distal perforators of the radial artery. We used it in a particularly difficult case involving loss of soft tissue at the wrist with exposure of tendons and nerves after an operation to section the transverse carpal ligament for carpal tunnel syndrome complicated by a chronic fistula.

w f o n N d f ercutaneous endoscopic gastrostomy (PEG) has become an ccepted method of providing long term enteral nutritional upport for patients who, it is anticipated, will have their abilty to swallow impaired after serious operations to the head nd neck,1 and in whom simple nasogastric feeding is conraindicated. The tube can be inserted using the pull, push, irect puncture, or Russell method. Radiologically inserted astrostomy (RIG) is another alternative to the surgical (open) astrostomy, but not all techniques are available in all hospials. In patients with active head and neck cancer, use of the ull or push method is associated with a small but definite isk of tumour implantation in the gastrostomy site. Cancer ells that are picked up and implanted into the PEG tract can resent as a metastatic tumour mass at the PEG site between and 16 months after the procedure.2 This is an ominous ign and is associated with extremely poor prognosis; mean urvival is 7 months after diagnosis with one-year survival of %.3 At the Bristol Royal Infirmary, patients with head and neck ancer who have been assessed preoperatively as requiring gastrostomy now have it inserted at the beginning of the peration by an upper gastrointestinal surgeon using an open urgical approach. It is done at the same time as temporary racheostomy, which removes the risks of tumour seeding nd damage to adjacent organs as the trocar is inserted into he stomach under direct vision. It also reduces pressure on

Summary Free radial forearm adipofascial flaps were used for limb reconstruction in four cases. The flaps were harvested through limited skin incisions with the aid of lighted retractors. The mean surface area was 96 cm 2 . The donor sites and the transferred tissue healed satisfactorily in all cases. Although the dissection through limited incisions is slightly awkward and prolongs the operating time, the technique offers significant benefits in terms of donor-site morbidity and aesthetics.