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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 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.

In three patients with long-standing vascular malformations of the face and scalp, radial forearm free flaps were transferred after a near-total excision of the lesion. All patients had typical high-flow malformations with thrill and bruit. The onset and progression of the malformations were analyzed through clinical and histologic studies. After free flap transfer, the vascular malformations were followed up grossly and histologically for between 4 and 9 years. There was no recurrence of arteriovenous malformation after free flap transfer. The portion of the residual lesion adjacent to the transferred free flap disappeared, and the remaining discoloration also vanished grossly. Histologic comparison of immediate postoperative and 4-month postoperative specimens from the margin and residual lesion using Victoria blue staining showed that the typical preoperative findings for arteriovenous malformation-an intermingling of thick-walled vessels with abundant elastic fibers and thin-walled vessels without elastic fibers-had undergone change, resulting in the disappearance of the thick-walled vessels and leaving only homogeneous, thin-walled vasculature. The highly vascularized free flap, which does not contain abnormal fistulas, impacted the histologic change of the arteriovenous malformation by blocking the vicious cycle of ischemia and anatomic replacement of disfigured skin and subcutaneous tissues.

Simultaneous primary tumors (tumors found at the same time or within 1 month of each other) are not uncommon in head and neck cancer. Most frequently, one lesion is small relative to the other; however, this is not always the case When two anatomically separate simultaneous primary tumors are large, a challenge for the reconstructive surgeon exists. The authors present a case of simultaneous primary tumors arising along the left and right mandibular gingiva. Following extirpation of the tumors, the defects were reconstructed with bilateral free radial forearm flaps. They conclude that this procedure is an excellent option for reconstruction of anatomically separate simultaneous defects of the head and neck region. This reconstruction provides an excellent tissue match for the intraoral region, and can be accomplished with minimal morbidity in a relatively short operative time.

A patient with tuberculous infection of the hand and wrist developed a recurrent draining wound of the right forearm. After recurrent failure of surgical débridement and wound closure under antituberculous therapy, wound closure was established by means of a radial forearm fascial flap with an excellent functional and cosmetic result. Extra-pulmonary tuberculosis must be kept in mind in the diagnosis of slowly growing tumours and chronic wounds in the upper extremity.

An anatomic and statistical analysis was performed on the distribution of cutaneous perforators that perfuse the scapular, radial forearm, and lateral arm cutaneous flaps. Perforators were categorized as direct, terminal, and intransitive, depending upon perforator origin and termination site relative to the source artery. Statistical cluster analysis of perforator distributions was performed to determine the regions in which cutaneous perforators are consistently found. The scapular and radial forearm flaps could be divided into up to three well-perfused segments. The analysis predicted the possibility of dividing the lateral arm flap into as many as seven segments while maintaining perfusion. Clinical applications of this method for preoperative flap design and elevation as well as final results are shown.

Delayed donor-site healing remains one of the most significant disadvantages of the radial forearm free flap. In an effort to decrease morbidity at the donor site, the authors adopted a closure technique that utilized the flexor digitorum sublimis (FDS) and flexor pollicis longus (FPL) muscle bellies to cover the flexor carpi radialis (FCR) tendon prior to placement of a split-thickness skin graft. While this approach eliminated tendon exposure, two patients with postoperative median-nerve compression forced a modification of this technique. The authors now detach the radial attachment of the FDS muscle and mobilize the median nerve away from the underside of the muscle, to prevent kinking of the nerve when the FDS and FPL muscle bellies are sewn together. With these modifications, the technique retains its efficacy, but with an improved margin of safety for the median nerve.

Free-tissue transfer in the elderly has received increasing attention in the literature. Existing reports are limited by small samples or inadequate definition of the term elderly. This study reviewed 5 years' experience with free-tissue transfer in a geriatric population (mean age 75 years, range 70 to 83 years). Forty-nine free flaps were performed in 42 patients between 1986 and 1991. This review focuses on the 39 flaps undertaken in 33 head and neck cancer patients, the main indication being reconstruction after tumor resection (80 percent). In the head and neck cancer group, donor sites included the radial forearm (20), rectus abdominis (6), jejunum (5), and others (8). Thirty-four flaps (87 percent) were primarily successful. Reexploration was required in 10 patients (26 percent) for compromised flaps (5) and bleeding (5). Three of the compromised flaps were salvaged, giving an overall flap success rate of 95 percent. One patient (3 percent) died within 30 days of surgery. These results compare favorably with other published series in elderly patients, as well as with larger cohorts of younger subjects. Free flaps are safe in the elderly. Chronologic age alone should not be an exclusion criterion when selecting patients for free-tissue transfer.

A simple splint for the radial forearm donor site is described. It can be constructed preoperatively and provides for unlimited re-applications and has been used successfully in 15 consecutive cases.

Wide resection of parastomal tissues after stomal recurrence significantly benefits patient survival. The defect thus created often requires coverage with a flap that provides (1) well-vascularized skin and soft tissue for uncomplicated wound closure and (2) pliable skin that can be inset easily around the often-shortened tracheal remnant. The radial forearm fasciocutaneous flap is ideal for these types of reconstructive problems. It should therefore be included on the reconstructive ladder for tracheostomy reconstruction both as a first choice and as a backup flap.

A basic disadvantage of radial forearm flaps is the removal of skin from a functionally important and cosmetically exposed region. To minimize the donor-site morbidity of the radial forearm flap, we have thus far used a two-phase procedure for intraoral defect coverage in five patients: In a first step, a split-thickness skin graft is transplanted to the forearm fascia, which "takes" there over a period of 2 weeks. In step two, the prefabricated fascial-split-thickness skin flap can be raised with complete preservation of the forearm skin and microsurgically transplanted like a conventional radial flap. Performing this procedure, we have obtained the following results: (1) All skin grafts "took" completely on the forearm fascia. (2) Prefabricated fascial-split-thickness skin flaps could be raised without any problems, like conventional radial forearm flaps. (3) All flaps were excellently suited for defect coverage in the oral cavity as very thin and moldable grafts and "took" without any complications. (4) Tension-free primary closure of all forearm donor sites was achieved with only slight cosmetic and functional impairment.

The additional use of the palmaris longus tendon is presented with the composite radial forearmpalmaris longus free flap, as useful for improving the final cosmetic appearance. This flap has the additional advantage of avoiding gravitational descent, which is a common problem encountered with many free flaps in head and neck reconstructions. A clinical case is also presented as an example of this approach.

The surgical management of anterior neck contractures, related to burn injuries, is a challenging problem for reconstructive surgeons. The use of sensate expanded radial forearm fasciocutaneous free flaps in two patients suffering from anterior burn contractures of the neck is presented as an alternative method of surgical management. The advantages of employing sensate expanded radial forearm free flaps to reconstruct anterior neck contractures are also discussed in this paper.

Reconstruction of the lower and upper lips, commissure, and full-thickness cheek defects using a composite radial forearm palmaris longus free flap with secondary commissuroplasty is described. This flap is useful for reconstruction of the total lower lip as well as larger defects that include full-thickness cheek and the commissure.

The authors present a ten-year series of consecutive one-stage reconstructions of defects following excision of malignant disease and of traumatic defects, using the radial forearm flap. Of the 155 radial forearm flaps performed, 144 were free flaps and 11 were pedicled flaps; 55 of the 144 free flaps were osteofasciocutaneous. Microvascular reconstructions with this versatile flap had a 98 percent success rate in this series.

The first 100 consecutive free radial forearm flaps used in reconstruction for oral and pharyngeal cancer were investigated. Seven re-operations took place due to circulatory impairment of the flap. Two flaps underwent partial, and four total necrosis, one of those patients died of massive haemorrhage. Post-operative infection was significantly correlated to increased time between the last radiotherapy session and surgery. All but eight patients had post-operative impairment of swallowing and all but five patients had impairment of speech articulation or hypernasality. Post-operative time spent in hospital was a range of 12-122 days (mean 37 days). The 2-year survival rate was 70% and the 5-year survival rate was 45%.

We report the clinical use of the free radial forearm-lateral arm mega flap to cover a large degloving injury of the leg with a compound fracture of the fibula.

Results: An ALT flap was explored in 80 of our free flap patients for reconstruction of defects caused by cancers of the head and neck. A total of 71 flaps (89%) were successfully raised without incident. Unilateral ALT exploration using perforators from the descending branches of the lateral circumflex femoral artery (LCFA) was less successful compared to bilateral exploration using both descending LCF and alternative flap perforators (89% v 96%, p=0.02). A total of 18 cases required an alternate flap, most commonly the radial forearm (67%) or the rectus (28%) free flaps. Long-term survival of all ALT flaps was 98.7%.

We present 8 cases of microvascular reconstruction of the pharynx and cervical esophagus using 5 free ileal transfers and 3 radial forearm flaps. One of the skin flaps underwent a delay procedure a month before transfer. All flaps survived, though there were 2 salivary fistulas that healed spontaneously.

The valves of the cephalic, basilic and median cubital veins were investigated in the superficial veins of the left forearm in 9 cadavers, aged 25-95. The radial forearm flaps involving these veins are of special clinicoanatomical importance. The following results were obtained: (1) Valves were most frequently evident at Site G of the cephalic vein. No valves were present in Section A-B, (2) type B valves were located at confluences, junctions and branches and were more frequent (54.7%) than Type A (45.3%) located in the straight trunks of superficial forearm veins, (3) Type 2 valves accounted for most (82.3%), and these were followed by Type 1 and Type 4b (5.9%), Type 4a (4.4%) and Type 3 (1.5%).

A patient sustained a compound fracture of the elbow resulting in a deep soft tissue defect with exposed bone, joint and nerve. The flexor carpi radialis (FCR) muscle was incorporated within the radial forearm island flap to cover the defect. Wrist flexion was not compromised by this procedure. The blood supply and applications of the radial forearm--flexor carpi radialis myocutaneous flap are described.

Summary 50 patients who underwent major surgery for head and neck cancer and reconstructed with radial forearm microvascular free flaps, were assessed with regard to social adaptation, appearance and in particular mouth function. The results were compared with a similar group of patients who underwent reconstruction with either primary repair or pedicled flaps.

There is good evidence of the benefit of transferring vascularized muscle into wounds that are contaminated or have been infected previously. This benefit particularly applies in cavities around bones and joints. We present two patients in whom the inclusion of a portion of muscle in the lateral arm and radial forearm flaps allowed the effective combination of good-quality skin cover with the properties of vascularized muscle.

The coverage of posterior elbow defects after debridement of burns is usually done by skin flaps from adjacent chest or abdomen in a two-stage operation. Other possibilities are local flaps and free-tissue transfer. A proximally based radial forearm flap for the cover of a 5-day-old burn is presented. It is considered to be indicated in large defects of the posterior surface of the elbow, including several centimetres of the triceps tendon.

Between 1986 and 1990, five patients have been treated for full-thickness skin loss proximal to the level of the anterior joint line of the ankle following open reduction and internal fixation of closed C3 (ASIF) pilon fractures. The average delay from injury to the initial open reduction and internal fixation was 4.6 days. Anteromedial and posterolateral incisions were used to expose the fractures, resulting in a bipedicle flap over the anterior aspect of the ankle joint at the time of the initial surgery. The minimum distance between these two incisions for these five patients was 6.0 to 9.0 cm (average of 7.4 cm). Free tissue transfers using the radial forearm flap were effective in providing durable but thin coverage for this difficult problem of soft-tissue coverage in an area requiring a thin flap with a long vascular pedicle. The risk for skin necrosis at the time of surgery may be minimized by spacing the incisions up to 12.0 cm apart in addition to avoiding the period of maximal tissue ischemia occurring 3 to 6 days after the injury.

Purpose: To report the outcome of a reversed osteocutaneous radial forearm flap for a thumb re-construction. Materials and Methods: Five patients who underwent a reversed osteocutaneous radial forearm island flap for a thumb reconstruction between 2001 and 2005 were reviewed retrospectively. They were all males with a mean age at the time of surgery of 45 years. The types of thumb defects, size of the flap, length of the radius harvested, time to union, the range of motion of the thumb, grip and pinch strengths, and complications were analyzed. Results: The mean size of the transferred radial forearm flap was 58.4 . The mean length of the harvested radius was 4.4 cm. All flaps survived completely. The mean interval required to obtain bone union was 2.8 months. The mean ROM of the thumb was . The postoperative mean grip strength was 94 lbs and the mean pinch power was 14.6 lbs. Mean moving two-point discrimination on the flap was 13 mm. There were no complications. All 5 patients were satisfied with the reconstructed new thumb. Conclusion: A reversed osteocutaneous radial forearm island flap is a useful procedure for recon-structing of a combined defect of the thumb.

A free radial forearm fascial flap has been described for intraoral reconstruction. Adiposo-fascial flap harvesting involves few technical modifications from the conventional radial forearm fascio-cutaneous free flap harvesting. We report a case of inferior maxillectomy defect reconstruction in a 42-year-old male with a free radial forearm adiposo-fascial flap with good aesthetic and functional outcome with minimal primary and donor site morbidity. The technique of raising the flap and closing the donor site needs to be meticulous in order to achieve good cosmetic and functional outcome.

Total and subtotal penile reconstruction represents a major surgical challenge. We present a new method and two illustrative cases using a modified design of the radial forearm free-tissue transfer: the "cricket bat" flap.

A completely avulsed ear cartilage was successfully replanted after being buried under the volar forearm skin as a radial forearm composite free flap.

Chronic, open wounds about the elbow frequently require flap coverage. Skin grafts, local transposition flaps, muscle transposition flaps, and two-staged pedicled flaps from the chest and abdomen as well as free tissue transfers have all been reported. Recalcitrant elbow defects in patients in whom these previous flaps have failed are especially challenging to the upper extremity reconstructive surgeon. We have successfully employed pedicled radial forearm flaps in three patients in whom one or more previous flaps have failed.

Two patients presented with loss of skin in the Achilles tendon region, which is difficult to repair satisfactorily. They were both treated with microvascular flaps, one of which was taken from the lateral arm, and the other from the radial forearm. Both methods gave good functional results.

A microsurgical instrument incorporating a needle holder and scissors was developed and used in 14 operations. The combined instrument was used with #9–0 to #10–0 sutures for hypoglossal facial anastomosis (n=2) and free radial forearm flaps (n=9). Inadvertent cutting of sutures or tissue did not occur. The combined instrument may offer advantages in microscopic neck surgery, especially when assistance is not available.

The radial forearm flap has become a versatile flap for upper extremity reconstruction. The use of the forearm flap for hand reconstruction in the patient with previously burned forearms has not been widely appreciated. In those patients whose forearms have been previously split-thickness skin-grafted on fascia, we have employed the reverse radial forearm flap as a skin graft-fascial flap for hand reconstruction and have obtained excellent functional results. Three patients at various intervals postburn are presented to demonstrate use of this flap for wrist contracture release, coverage of arthroplasties, first web space contracture release, and acute salvage of phalanges and tendons. Assessment of the hand's vascular anatomy and careful treatment of the donor area have contributed to no added morbidity and an excellent aesthetic result at the donor site.

Background: This study compared outcomes of bilateral simultaneous endoscopic carpal tunnel release to staged release using the Levine-Katz outcome instrument and physical measurements. Methods: Seventy-one patients were evaluated preoperatively and at 6 months postoperatively. One group underwent simultaneous releases, a second group underwent staged releases 1 to 3 weeks apart, and a third underwent staged releases more than 3 weeks apart. Preoperative data included age, gender, race, medical history, initial symptom severity score, and body mass index. Preoperative and postoperative data included Semmes-Weinstein testing, grip and pinch strength, Tinel's sign, Phalen's test, Levine-Katz questionnaire, occupational history, postoperative complications, and patient satisfaction. Results: Groups were similar demographically except that the simultaneous group had more men and patients were younger. Level of preoperative symptom severity was similar in all groups. Physical measurements were similar for all groups preoperatively and improved similarly at follow-up. All groups improved Levine-Katz mean symptom severity score and functional status score at follow-up. The groups had no significant difference in number of complications, and patient satisfaction was similar. Conclusions: In selected patients, bilateral simultaneous endoscopic carpal tunnel release has an outcome similar to that for surgery staged weeks apart. However, patients who choose simultaneous surgery may benefit from a shorter postoperative disability period and earlier return to work. (Plast. Reconstr. Surg.