eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Reconstructive Surgery

Free Tissue Transfer, Osteocutaneous Radial Forearm Flap: Follow-up

Author: Terance (Terry) Ted Tsue, MD, Vice-Chairman for Administrative Affairs, Professor, Residency Program Director, Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine
Coauthor(s): Yelizaveta (Lisa) Shnayder, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, University of Kansas Medical Center; Douglas A Girod, MD, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine; Professor, Department of Hearing and Speech, School of Allied Health, University of Kansas; Oleg N Militsakh, MD, Fellow, Oncologic Head and Neck and Microvascular Reconstructive Surgery, Clinical Instructor, Department of Otolaryngology Head and Neck Surgery, Medical University of South Carolina
Contributor Information and Disclosures

Updated: Jan 7, 2008

Outcome and Prognosis

As was shown in the authors' recent review, when compared with other commonly used osteocutaneous free flaps in head and neck reconstruction, patients with osteocutaneous radial forearm free flap (OCRFFF) had significantly fewer problems with wound infections, breakdown, and postoperative fistulae at the primary site. Also, at the authors' institution, OCRFFF patients had a shorter postoperative rehabilitation time as demonstrated by the length of ICU and total hospital stay. A similar percentage of patients were rehabilitated with tissue-borne dental prostheses in the OCRFFF group to the percentage for other osteocutaneous free flap groups without any problems with mandibular or bone graft fractures. When the prophylactic internal fixation technique is performed, as described in the previous section, donor site morbidity of the OCRFFF procedure is similar to that seen in the fasciocutaneous free flap procedure.

In a review by Clark et al, nonplated donor radii were shown to have sustained an unacceptably high fracture rate (18% among males and 32% among females).8 In addition, patients with nonplated donor radii had been wearing immobilizing splints for 6-8 weeks, whereas patients with prophylactically plated donor radii had their casts removed on postoperative day 5 and had been encouraged to resume normal activity thereafter.

Reconstitution and remodeling, which are both evidence of bone healing, are observable radiographically by 5 months postoperatively, with bony remodeling seen as early as 3 months postoperatively.

The soft tissue characteristics of the fasciocutaneous paddle are nearly ideal for intraoral reconstruction and yield improved function compared with the pectoralis major myocutaneous flap. The available bone is adequate for small-to-medium segmental mandibular defects, with the primary disadvantage being its inability to support osseointegrated implants. As previously mentioned, because of insurance and cost restrictions, the percentage of the authors' patients who are able to afford this type of rehabilitation is low.

Even in the setting of heavily radiated tissues, such as when treating patients with advanced mandibular osteoradionecrosis, reconstruction using OCRFFF achieves excellent functional results.

Future and Controversies

The possible integration of osseointegrated implants into the osteocutaneous radial forearm free flap (OCRFFF) radius bone graft would make it an even more desirable flap. The OCRFFF can readily tolerate a tissue-borne prosthesis and help rehabilitate mastication to a certain extent.

Hatoko et al described the use of calcium phosphate cement to fill the radius bone defect after harvesting radial forearm osteocutaneous flap in 5 patients.9 The maximum size of harvested radius was 10x50 mm, and the maximum volume required was 3-4 mL. No plating was used, but postoperative fixation of the forearm continued for 14 days. Postoperative radiographs revealed a uniform high-density mass that filled the bone defect, with only a 5% volume reduction at 5 months, suggesting the need for overfilling the defect.

However, further studies of bone replacement that compare the use of calcium phosphate cement with internal fixation of the radius bone are necessary before adopting the technique because of the success and paucity of symptoms associated with the use of prophylactic internal fixation alone.

The authors' goal is to reintroduce this useful and versatile flap as a viable reconstructive option to the head and neck surgery community. Because of the orthopedic technology and principles that currently exist, the flap's stigmatization because of unacceptable donor site morbidity should be only historical. Future applications should become evident as the OCRFFF regains popularity.

 


More on Free Tissue Transfer, Osteocutaneous Radial Forearm Flap

Overview: Free Tissue Transfer, Osteocutaneous Radial Forearm Flap
Workup: Free Tissue Transfer, Osteocutaneous Radial Forearm Flap
Treatment: Free Tissue Transfer, Osteocutaneous Radial Forearm Flap
Follow-up: Free Tissue Transfer, Osteocutaneous Radial Forearm Flap
Multimedia: Free Tissue Transfer, Osteocutaneous Radial Forearm Flap
References
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References

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  2. Kim JH, Rosenthal EL, Ellis T, Wax MK. Radial forearm osteocutaneous free flap in maxillofacial and oromandibular reconstructions. Laryngoscope. Sep 2005;115(9):1697-701. [Medline].

  3. Schusterman MA, Reece GP, Kroll SS, Weldon ME. Use of the AO plate for immediate mandibular reconstruction in cancer patients. Plast Reconstr Surg. Oct 1991;88(4):588-93. [Medline].

  4. Arden RL, Rachel JD, Marks SC, Dang K. Volume-length impact of lateral jaw resections on complication rates. Arch Otolaryngol Head Neck Surg. Jan 1999;125(1):68-72. [Medline].

  5. Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg. Jun 2000;105(7):2331-46; discussion 2347-8. [Medline].

  6. Chepeha DB, Moyer JS, Bradford CR, Prince ME, Marentette L, Teknos TN. Osseocutaneous radial forearm free tissue transfer for repair of complex midfacial defects. Arch Otolaryngol Head Neck Surg. Jun 2005;131(6):513-7. [Medline].

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  8. Clark S, Greenwood M, Banks RJ, Parker R. Fracture of the radial donor site after composite free flap harvest: a ten-year review. Surgeon. Oct 2004;2(5):281-6. [Medline].

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  12. Militsakh ON, Wallace DI, Kriet JD, Tsue TT, Girod DA. The role of the osteocutaneous radial forearm free flap in the treatment of mandibular osteoradionecrosis. Otolaryngol Head Neck Surg. Jul 2005;133(1):80-3. [Medline].

  13. Militsakh ON, Werle A, Mohyuddin N, Toby EB, Kriet JD, Wallace DI, et al. Comparison of radial forearm with fibula and scapula osteocutaneous free flaps for oromandibular reconstruction. Arch Otolaryngol Head Neck Surg. Jul 2005;131(7):571-5. [Medline].

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  18. Tsue TT, Desyatnikova SS, Deleyiannis FW, Futran ND, Stack BC Jr, Weymuller EA Jr. Comparison of cost and function in reconstruction of the posterior oral cavity and oropharynx. Free vs pedicled soft tissue transfer. Arch Otolaryngol Head Neck Surg. Jul 1997;123(7):731-7. [Medline].

  19. Urken ML, Weinberg H, Vickery C, Aviv JE, Buchbinder D, Lawson W, et al. The combined sensate radical forearm and iliac crest free flaps for reconstruction of significant glossectomy-mandibulectomy defects. Laryngoscope. May 1992;102(5):543-58. [Medline].

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Further Reading

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Keywords

osteocutaneous radial forearm flap, radial forearm osteocutaneous free flap, radial forearm osteocutaneous microvascular flap, osteocutaneous radial forearm free tissue transfer, fasciocutaneous radial forearm free flap, FCRFFF, RFFF, OCRFFF, head and neck reconstruction, head and neck surgery, head and neck reconstructive surgery, head and neck cancer, head and neck extirpative surgery

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Contributor Information and Disclosures

Author

Terance (Terry) Ted Tsue, MD, Vice-Chairman for Administrative Affairs, Professor, Residency Program Director, Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine
Terance (Terry) Ted Tsue, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, Association for Research in Otolaryngology, Johns Hopkins Medical and Surgical Association, Missouri State Medical Association, Phi Beta Kappa, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Yelizaveta (Lisa) Shnayder, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, University of Kansas Medical Center
Yelizaveta (Lisa) Shnayder, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

Douglas A Girod, MD, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine; Professor, Department of Hearing and Speech, School of Allied Health, University of Kansas
Douglas A Girod, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, Society of University Otolaryngologists-Head and Neck Surgeons, and Southwestern Oncology Group
Disclosure: Nothing to disclose.

Oleg N Militsakh, MD, Fellow, Oncologic Head and Neck and Microvascular Reconstructive Surgery, Clinical Instructor, Department of Otolaryngology Head and Neck Surgery, Medical University of South Carolina
Oleg N Militsakh, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and American Rhinologic Society
Disclosure: Nothing to disclose.

Medical Editor

Anthony P Sclafani, MD, Director of Facial Plastic Surgery, The New York Eye and Ear Infirmary; Professor of Otolaryngology, New York Medical College
Anthony P Sclafani, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American College of Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

David W Stepnick, MD, Associate Professor, Departments of Plastic Surgery and Otolaryngology-Head and Neck Surgery, Case Western Reserve University School of Medicine, University Hospitals of Cleveland Case Medical Center
David W Stepnick, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Advanced Headache Intervention Consulting fee Consulting; Covidien Corp Consulting fee Consulting

 
 
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