Radial Forearm Free Flap

Radial Forearm Free
Flap
Dr. Wakil Muhammad
PGR, Oral & Maxillofacial
Surgery
Flap and Graft

A graft or a flap may comprise of the same
tissue type, that is, it can be skin, fat, tendon,
bone, nerve, etc. The key difference is that a
flap has its own blood supply but a graft does
not
Flap Types
Local (Pedicled) Flap:
Tissue is freed and rotated or moved from an
adjacent area to cover the defect, yet remains
attached to the body at its base and has blood
vessels that enter into the flap from the donor
site.
Free Flap:
Tissue from the donor site is detached and
transplanted to the recipient site and the
blood supply is surgically reconnected to the
blood vessels in recipient site.
Reconstructive Applications
Floor of mouth, tongue, pharynx and
oesophagus.
Lips, Orbits.
External skin defects.
Incorporating part of radius as
osteocutaneous flap for maxillary, nasal, and

mandibular defects.
Advantages
Good pliability and contourability.
Multiple skin islands can be used.
Skin can be innervated by including the
medial or lateral antebrachial cutaneous

nerve.
Can incorporate radius bone or tendon.
Excellent vascularisation (Artery; 10-18 cm
long, 2mm dia).
Disadvantages
Possible poor Cosmetic outcome of the donor
site. (Unsightly scar formation)

Donor site morbidity (loss of skin graft and
tendon exposure)
Possibility of radial bone fracture.
Preoperative
Assessment
Patient is asked for having a history of;
Any peripheral vascular disease.
Uncontrolled diabetes.
Poor or slow wound healing.
Any coagulopathy.
Allens test
AclinicaltestusedtoevaluateUlnar and Radial
Artery Patency which make the deep and
superficial palmar arterial arch system,before
harvesting the radial forearm free flap
Performing Allens Test
Arterial anatomy of the hand with direction of blood

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

flow with manual occlusion of the Ulnar Artery.
Surgical anatomy of forearm
Arterial system of forearm
Venous system of forearm
Cutaneous Nerves encounter during graft

harvesting
Biceps
brachi
Brachioradia
lis
Biceps brachi
tendon
Pronator teres
Flexor carpi
radialis
Palmaris longus
Flexor carpi
ulnaris
Flexor digitorum
longus
Muscles relevant to RFFF
Radial Artery
Relation of Radial Artery with

Brachioradialis and Pronator teres
muscles
Types of Radial Forearm

Free Flap
The most commonly used radial forearm free
flaps in the reconstruction of oral and
maxillofacial region are:
Radial forearm fasciocutaneous free flap
(RFFF)
Osteocutaneous radial forearm free flap
(OCRFFF)
Surgical Technique
Surface markings for
RFFF
Palpate and mark the radial artery at the
wrist between the brachioradialis and flexor

carpi radialis tendons.
The course of the superficial veins is
drawn.
Mark the flap design on the forearm
according to the size of the defect.
Shave the intended harvesting area.
Tourniquet
Application
Apply a tourniquet to the upper arm and
inflate it to above the patient's systolic blood

pressure (usually set at 250 mmHg).
Record the tourniquet time (maximum time of
90 minutes permitted).
Subfascial RFFF Elevation

Technique
Flap designed to include radial artery and

superficial vein
Subfascial RFFF Elevation

Technique
Start dissection laterally, with two skin hooks
anchoring the skin lateral to the flap
Skin incision along lateral aspect of
Elevate the flap from laterally in a deep
subcutaneous plane until the cephalic vein

becomes visible.
Cephalic
vein
The lateral antebrachial cutaneous nerve is
located in the same plane along the cephalic

vein. This nerve is elevated with the cephalic
vein if innervated flap is planned.
Lateral antebrachial
cutaneous nerve
Identify the superficial branch of the radial
nerve which is lateral to the brachioradialis.

Scalpel points to
the Radial Nerve
Extend the dissection medially over the
epitenon covering the radial nerve and tendon

of brachioradialis.
Scalpel points to
the
brachioradialis
tendon
Sharply dissect and elevate the tendon superiorly up
to its musculotendinous junction; the radial artery

generally lies immediately below the tendon;
therefore the angle of the scalpel blade is changed to
a horizontal plane to avoid cutting the artery.
Incise the fascia overlying the brachioradialis
muscle lateral to the vascular pedicle.
Once the brachioradialis muscle has been
mobilised, the radial artery becomes visible and

the chances of injuring the perforators are much
less.
Radial
Artery
Ligate and divide larger muscle perforators with Liga
clips and coagulate small ones with bipolar forceps.
Next, elevate the medial side of the flap
by dissecting the deep fascia over the

tendons of wrist flexor muscles, preserving
the epitenon.
Incise the fascia over the radial artery then
isolate, ligate and transect the artery.
Radial
Artery
Radial artery has been transected
Dissection now proceeds from distal-to-
proximal.
Carefully divide the side-branches arising from the
radial artery until enough vessel length is achieved
Radial
Artery
Cephalic
Vein
Radial Artery
perforators
Transfer of
Flap
Now deflate the tourniquet to reperfuse the flap
vasculature.
Control bleeding from the side-branches on the
pedicle and on the flap before disconnecting the

flap from its blood supply.
Transfer the flap to reconstruction site after
preparing the recipient vessels for anastomotic

suturing.
Osteocutaneous RFFF
It incaporates a long pedicle and thin,
pliable skin, vascularised bone which is
not bulky; and the ability to use the flap for
structural bone and soft tissue
reconstruction
Harvesting Osteocutaneous
RFFF
The available bone lies between the insertion
of the Pronator teres and Brachioradialis

muscle.
The distal 1012 cm of the radius (26.42 cm)
can be harvested as an osteocutaneous RFFF.
Up to 40% of the thickness of radius bone
may be harvested.
Periosteal perforators provide blood supply to
the bone.
Care should be taken to avoid injury to
periosteal perforators which is the only blood

supply to the harvesting bone.
Perforator
s
Perforators to the bone are identified and

protected
Mark the length of bone required.

Start cutting from proximally while leaving 2.5
cm bone at the proximal end.

A high speed oscillating saw is used to cut the
bone longitudinally.
About 1012 cm of the radius can be
harvested.
Divide both cortices longitudinally and place a
metal plate on the dorsolateral side to protect

the radial nerve and the laterally placed
tendons.
Bevel the proximal and distal osteotomies at an
angle of about 50o to avoid a weak (stress) point

(which would occur if it was to be cut at 90 o).
Beveled ends of
bone
Vascular
pedicle
Bone
segment
Osteocutaneous radial forearm free

flap appearance immediately after
harvest
Donor site Closure & Care

Try to advance skin to cover the exposed
tendons.
When placing a skin graft;
Maintain epitenon over tendons.
Always fix and immobilize skin graft with sutures
and appropriate dressings.
Keep the donor arm elevated.

Use volar splint to restrict movement of flexor
tendons.
Post-operative
Medications
Dextran-40 (in 0.9% sodium chloride
injection) for 5 days at 20 ml/hr.

Aspirin 150 mg orally per day for 14 days.
Dipyridamole (Tab. Persantin) 75 mg orally per
day for 14 days.
Kruavit et al.,
2004
Examples of Reconstruction
with Radial Forearm Free Flap
Case No. 1
Incision for resection and neck

dissection outlined (recurrent sweat
gland carcinoma of the skin).
The surgical
specimen.
Surgical defect after removal of the

lesion
The outline of a radial forearm free

flap.
The radial forearm fasciocutaneous free

flap.
A postoperative
Case No. 2
A 24-year-old man suffered from burn scar contracture at

neck and lower lip causing leakage of the saliva. Unable to
close his eyes when the neck was fully extended.
Following complete release of the burn scar contracture and

reconstruction with a large radial forearm free flap, all facial
deformities were corrected and the cervicomental angle was
maintained.
Donor site of the radial

forearm free flap before
skin grafting procedure.
Three months after the operation,

the
noticeable grafted skin at the
donor site was accepted by the
patient, and the hand function

Radial Forearm Free Flap

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What are the different types of flaps discussed?

What are the different types of flaps discussed?

What are some reconstructive applications of radial forearm free flaps?

What are some reconstructive applications of radial forearm free flaps?

Radial Forearm Free

Flap and Graft

osteocutaneous flap for maxillary, nasal, and

medial or lateral antebrachial cutaneous

long, 2mm dia).

site. (Unsightly scar formation)

Performing Allens Test

Arterial anatomy of the hand with direction of blood

Arterial anatomy of the hand with direction of blood

Surgical anatomy of forearm

Arterial system of forearm

Venous system of forearm

Cutaneous Nerves encounter during graft

Muscles relevant to RFFF

Relation of Radial Artery with

Types of Radial Forearm

Palpate and mark the radial artery at the

wrist between the brachioradialis and flexor

inflate it to above the patient's systolic blood

Subfascial RFFF Elevation

Flap designed to include radial artery and

Subfascial RFFF Elevation

anchoring the skin lateral to the flap

Skin incision along lateral aspect of

Elevate the flap from laterally in a deep

subcutaneous plane until the cephalic vein

The lateral antebrachial cutaneous nerve is

located in the same plane along the cephalic

Identify the superficial branch of the radial

nerve which is lateral to the brachioradialis.

Extend the dissection medially over the

epitenon covering the radial nerve and tendon

Sharply dissect and elevate the tendon superiorly up

to its musculotendinous junction; the radial artery

Incise the fascia overlying the brachioradialis

muscle lateral to the vascular pedicle.

Once the brachioradialis muscle has been

mobilised, the radial artery becomes visible and

Ligate and divide larger muscle perforators with Liga

clips and coagulate small ones with bipolar forceps.

Next, elevate the medial side of the flap

by dissecting the deep fascia over the

Incise the fascia over the radial artery then

isolate, ligate and transect the artery.

Radial artery has been transected

Dissection now proceeds from distal-to-

Carefully divide the side-branches arising from the

radial artery until enough vessel length is achieved

pedicle and on the flap before disconnecting the

preparing the recipient vessels for anastomotic

of the Pronator teres and Brachioradialis

Care should be taken to avoid injury to

periosteal perforators which is the only blood

Perforators to the bone are identified and

Mark the length of bone required.

cm bone at the proximal end.