Osteocutaneous Radial Forearm Flap Free Tissue Transfer

Reconstruction after head and neck cancer extirpative surgery frequently requires the replacement of bone and soft tissue to provide the most optimal functional and aesthetic result. Microvascular free flaps have the advantage of providing healthy, vascularized, non-irradiated tissue for recipient sites that may have been compromised by surgery, radiation, chemotherapy, or a combination of the three.[1]

The fasciocutaneous radial forearm free flap (FCRFFF) is the most common free flap used in head and neck reconstruction. Previous attempts to use an osteocutaneous radial forearm free flap (OCRFFF) for head and neck reconstruction have been associated with unacceptable donor site morbidity, most commonly fracture of the radius.[2] This morbidity has severely limited forearm function and affected the patient’s quality of life.

This article focuses on the OCRFFF procedure and techniques that minimize donor site morbidity to levels near that of the FCRFFF procedure. When donor site morbidity is reduced, this free flap is a useful alternative to other currently used osteocutaneous free flaps for head and neck reconstruction.

Since its introduction by Yang et al. in 1978, the radial forearm free flap (RFFF) has become a workhorse flap in head and neck reconstruction.[3] The RFFF's popularity has stemmed from its superior soft tissue characteristics, which offer a large amount of thin, pliable skin that conforms well to the native contours of the recipient site. The flap is relatively easy to harvest and can be dissected at the same time as the extirpative procedure. It has a long vascular pedicle with large-caliber vessels, predictable innervation for re-establishing sensory function in the oral cavity and oropharynx, and minimal donor site morbidity. It is particularly useful in the oral cavity.

Although the RFFF is most commonly harvested as a fasciocutaneous flap, perforators to the radius allow it to be developed as an osteocutaneous flap. Two issues have been largely to blame for limiting surgeons' consideration of the osteocutaneous radial forearm free flap (OCRFFF) as an option for single-stage reconstruction of composite defects in the head and neck: the inadequacy of available bone and the potential for radial bone fracture.

The bone available as part of the flap is limited in length and caliber. Most reports describe that the optimal length of the harvested radial bone segment is 6-12 cm.[4] Significantly longer segments can be transplanted as part of the fibular osteocutaneous free flap. The thickness of the bone graft is limited to 33-50% of the cross-sectional area of the radius, which is typically inadequate to support osseointegrated dental implants. Secondly, the donor site morbidity from iatrogenic fracture of the radius can be significant. One early series reported post-harvest radius fracture rates of up to 67%. These patients' arms required treatments that ranged from prolonged immobilization to forearm reconstruction with an additional revascularized bone graft.

A defect in the head and neck that involves a large amount of soft tissue and a long segment of bone increases the functional impact on speech and swallowing. In this setting, the reconstructive surgeon must prioritize the various defect components to choose the best reconstructive option. In some instances, the surgeon may need to compromise on either the soft tissue or the bony component of the reconstruction.

For limited defects, choices are more straightforward. If, predominantly, bone is missing, accompanied by only a small soft tissue defect in which sensation and mobility are not likely an issue, the use of an iliac crest or fibular flap may be the best reconstructive option. If the soft tissue defect is more critical, the use of a fasciocutaneous free flap with a mandibular reconstruction plate is an option; however, this has been associated with significant short- and long-term postoperative morbidity. The RFFF is frequently used as the soft tissue component in this situation.

For the most difficult situation, which is a significant defect of both components, one option is to use 2 free flaps, such as a sensate RFFF for the soft tissue and an iliac crest free flap for the bone. This approach carries the obvious disadvantages of increased operative time, morbidity, and cost compared with the use of one donor site. Furthermore, additional anastomoses increase the likelihood of vascular pedicle thrombosis.

The authors believe that a better option is a single microvascular procedure, which has ideal soft tissue characteristics and provides enough bone to reconstruct the mandible and minimize complications. Although the capacity to support osseointegrated implants is desirable, many patients are partially or completely edentulous prior to their cancer surgery and are not interested in undergoing dental restoration. Regardless of interest, this option is not readily available to many patients because of current insurance reimbursement issues.

Frequency

More than 50,000 new head and neck malignancies are diagnosed each year. Many of these cancers arise in the oral cavity and frequently involve the mandibular and/or maxillary alveolus. Bony invasion by squamous cell carcinomas (SCCs) necessitates segmental bone resection. These defects require reconstruction with the same type of tissue (eg, bone, skin), for which the OCRFFF procedure is an attractive and safe option. In the maxilla, use of a prosthetic obturator is another alternative.

For a large, complex, soft tissue defect accompanied by a moderate, limited, mandibular segmental defect, many head and neck reconstructive surgeons choose to compromise in favor of the soft tissue reconstruction. The authors believe that using a revascularized radius bone graft is better than using a fasciocutaneous flap to cover a mandibular reconstruction plate. Schusterman showed that bridging of the anterior mandibular defects with a reconstruction plate without a vascularized bone graft carries a 67% risk of surgical failure.[5] Furthermore, Arden demonstrated that the surgical complication rate increases significantly for large defects (>5 cm) reconstructed by plate bridging alone.[6]

Despite the limited bone stock that is available with the osteocutaneous radial forearm free flap (OCRFFF), the procedure has been successfully used for oromandibular reconstruction, with few complications. In lateral or anterior mandibular defects, the radius bone graft can support a tissue-borne prosthesis (denture). Posterior mandibular defects (eg, retromolar trigone, ramus and subcondylar defects) can also be reconstructed successfully, restoring adequate integrity of bony structure with enough soft tissue for multi-dimensional intraoral reconstruction. A thin, pliable skin paddle of the radial forearm proves especially useful in re-creating 3-dimensional soft tissue lining of the floor of the mouth and lower alveolar ridge, and facilitates subsequent denture placement.

The large soft tissue paddle is especially useful for through-and-through defects of the oral cavity because the mid-portion of the fasciocutaneous paddle can be deepithelialized and buried. The color match is generally poor in white patients, but can be quite good in patients of African or Asian descent. The fasciocutaneous paddle size is usually not a limitation because the flap can be extended dorsally onto the ulnar side of the forearm. The OCRFFF does not provide bulky soft tissue, but the volume can be increased by burying deepithelialized portions of the flap.

The OCRFFF is useful for midfacial reconstruction of the maxillary alveolus or the malar eminence.[7] Such reconstructions can obviate the need for a prosthetic obturator after maxillectomy. Reconstruction of maxillofacial defects is a challenging problem because of the complex 3-dimensional, esthetic, and functional roles of the midfacial structures. Cordeiro and Santamaria presented a classification of maxillofacial defects and suggested an algorithm for their reconstruction.[8] Type I defects (limited maxillectomy) include resection of 1 or 2 maxillary walls, excluding the palate. Type II defects (subtotal maxillectomy) include resection of the lower 5 walls including the palate, with preservation of the orbital floor. These are the defects amenable to reconstruction by OCRFF.

A combination of a large skin paddle to line the palatal mucosal surface, a small volume of the soft tissue, and a moderate vascularized bone stock are the requirements that are fulfilled very well by a reconstruction with a OCRFF. A radial forearm free flap is an ideal solution to the most problematic aspect of choosing the flap for a midfacial reconstruction: a need for a long, 10-13 cm pedicle, to span the distance between the midface and cervical vessels. Using an OCRFF eliminates the need for vein grafts, which shortens operative time and improves the success of the reconstruction.

Chepeha and colleagues expanded the use of OCRFF for maxillectomy defects with infraorbital rim involvement in 10 patients.[9] They advocate the choice of OCRFF in total maxillectomy defects, with or without the orbital exenteration, that involve less than 40% of the orbital floor. Rather than using the vascularized bone to reconstruct malar alveolar ridge, the authors employed osteotomized radial bone to recontour the infraorbital rim and to provide support for the orbital contents when preserved. Dental rehabilitation was achieved using palatal obturator and denture.

OCRFF has been shown to be an effective tool when used to reconstruct mandibular defects in the setting of osteoradionecrosis.[10]

The radius bone has also been used to provide vascularized skeletal support for laryngotracheal airway reconstructions.

Harvest of the fasciocutaneous radial forearm free flap (RFFF) and osteocutaneous radial forearm free flap (OCRFFF) depends on the anatomy of the volar forearm. Both flaps depend on perforators from the radial artery and its 2 venae comitantes. The radial artery arises from the brachial artery in the antecubital fossa. The other arterial branch, the ulnar artery, travels medially in the forearm to the hand. After RFFF harvest, the ulnar pedicle supplies the hand, provided an intact palmar arch network exists (see Workup). The ulnar arterial pedicle is covered by the flexor carpi ulnaris tendon but can run superficial distally near the wrist crease.

The volar fasciocutaneous paddle receives vascular supply from septocutaneous perforators in the lateral intermuscular septum. Periosteal perforators from the radial artery pedicle travel deep through the flexor pollicis longus muscle to vascularize the periosteum of the radius. The vascular pedicle travels between the brachioradialis and flexor carpi radialis muscles and lies superficial to the flexor digitorum superficialis muscle. The pronator teres muscle inserts into the mid radius and approximates the proximal radius bone-graft harvest margin. Distally, the brachioradialis tendon inserts into the radius and delineates the safe distal margin for the radius bone graft. This margin lies 2-2.5 cm proximal to the radius styloid process.

The lateral and medial antebrachial cutaneous nerves that innervate the fasciocutaneous paddle can be followed into the antecubital fossa. These branches can provide sensory innervation to the OCRFFF, if desired. Frequently, the ulnar-bias used during harvest of the OCRFFF fasciocutaneous paddle does not allow inclusion of the lateral nerve. The superficial radial nerve pierces the brachioradialis tendon and runs distally on this tendon. The subfascial dissection of the fasciocutaneous paddle must preserve this nerve in its entirety to ensure preservation of dorsoradial hand sensation. A superficial venous network runs subcutaneously in the fasciocutaneous paddle. The cephalic vein is one of the main branches that receive this superficial venous drainage and travels radially to the antecubital fossa. This superficial system is quite variable but can provide venous drainage to the OCRFFF in lieu of, or in addition to the venae comitantes.

The radius bone lies laterally in the forearm; its caliber increases distally until it protrudes the styloid process in the wrist region.

General contraindications to microvascular free tissue transfer also apply to the osteocutaneous radial forearm free flap (OCRFFF) procedure, including coagulopathic states, significant peripheral vascular disease, and severe diabetes mellitus with impaired healing. Physical signs and symptoms of poor peripheral digit perfusion or healing contraindicate harvest of the radial artery pedicle. Patients who are in poor general medical condition and cannot tolerate prolonged anesthesia are not appropriate candidates for OCRFFF reconstruction.

Participation in occupational and recreational activities that place significant demands on the forearm can be a relative contraindication to the OCRFFF procedure. Use of the dominant arm or the only remaining functional arm as a donor site can also be a relative contraindication. Previous surgery or trauma to the proposed donor arm must be closely investigated, especially by means of radiography, to ensure normal and intact vascular and musculoskeletal anatomy. A similar workup applies to obvious congenital deformities.

An incomplete palmar arch system (deep and superficial) becomes apparent preoperatively by performing an Allen test. An incomplete palmar arch precludes radial artery pedicle harvest because inadequate blood supply to the lateral digits results when only the ulnar artery perfuses the hand. Radial artery thrombosis or compromise is also apparent on a preoperative Allen test. Evaluate equivocal Allen tests with objective Doppler photoplethysmography. This test can sometimes confirm adequate ulnar artery perfusion to the hand, which then allows safe harvest of the radial artery and use of the OCRFFF. If ulnar perfusion is inadequate, an alternate flap must be used.

When bony defects larger than about 10 cm are anticipated, reconstruction may require more bone than is safely available using the OCRFFF procedure, depending somewhat on the patient's stature. The recipient site must also have acceptable arterial and venous vasculature for anastomosis.

See the list below:

• Order electrolyte panel tests. Profound diabetes mellitus or renal failure may affect the success of free tissue transfer.

• Obtain a complete blood cell count. Polycythemia and extreme anemia can affect flap success.

• Measure the prothrombin time and/or activated partial thromboplastin time. The presence of coagulopathies may be a contraindication to using a free flap.

• Order liver function tests. Liver failure is a contraindication to using a free flap. Unexplained abnormalities warrant a more extensive metastatic workup.

See the list below:

• Plain radiographs of the forearm are required in cases of congenital deformities or when previous surgery or trauma of the forearm has occurred.

• Angiography of the forearm to determine adequate vascular anatomy has been replaced by noninvasive studies, such as Doppler photoplethysmography, which is used when Allen test results are equivocal or routinely for all patients at some institutions.

Perform the subjective Allen test in both forearms. This test ensures adequate hand perfusion by the ulnar artery and detects radial artery thrombosis. If results of the subjective Allen test are equivocal, use an objective Allen test. This technique uses Doppler photoplethysmography to detect digit perfusion under radial and ulnar artery compression scenarios. This study is most useful in showing adequate hand and digit perfusion when subjective Allen test findings are equivocal, but also used routinely for all patients at some institutions.

Discuss the rigors of extensive surgery and potential complications with each patient. The patient must be prepared to remain in the hospital for 7-10 days after the operation.

Once the donor arm is chosen, avoid all future venipunctures, arterial line, and blood pressure cuff placements. Shave the donor forearm and lay the arm on an arm board. Usually, position the arm 30-45° from the body until harvest. At this time, move the arm approximately 90° from the body so that 2 surgeons can operate on either side of it. Place an appropriately-sized tourniquet on the upper arm and check the cuff's function. Use of a tourniquet is optional but helpful, especially during radius bone harvest. Because the patient is usually placed in a supine position, the volar aspect of the forearm remains pointing superiorly.

Then, prepare the arm and drape it in a sterile fashion, in separate limb drapes while the arm is wrapped in a stockinette. Complete these steps before preparing the clean-contaminated head and neck region. Also, prepare and drape the upper thigh to allow split-thickness skin graft (STSG) harvest for coverage of the forearm donor site. Until the harvest is initiated, cover the leg and arm with sterile drapes to prevent cross-contamination from the head and neck. A separate operating room (OR) instrument table and scrub nurse should be available during harvest of the flap, so that harvest can occur concurrently with the extirpative procedure, to minimize anesthetic and operative time.

Anesthetize and monitor the patient as indicated for the long procedure. To allow for intraoperative nerve stimulation, avoidance of muscle relaxants is preferred. Administer IV antibiotics, systemic steroids, and histamine-2 receptor antagonists.

Osteocutaneous radial forearm free flap harvest

Sterilely uncover the surgical donor site of the arm and draw the skin paddle on the volar aspect of the forearm, as shown below. The size and shape of the paddle depend on the needs of the head and neck defect. The paddle is proximally biased about 2 cm proximal to the wrist crease. The paddle is also ulnarly biased but insufficient to disrupt the perforators in the lateral intermuscular septum to the skin. These 2 positional biases aid in cutaneous coverage of the internal fixation plate hardware of the donor radius described below.

Next, exsanguinate the arm with elastic dressing and elevate it while the tourniquet cuff is inflated to well above arterial pressure (ie, 250 mm Hg). Remove the elastic bandage.

Perform the medial longitudinal skin incision first. Make this incision (as all skin incisions) with a number 15 scalpel. Then, perform subfascial dissection medially to laterally using tenotomy scissors, as shown in the image below. Make the proximal and distal incisions after confirming the defect size in the head and neck recipient site. Take care proximally to avoid the medial antebrachial cutaneous nerve traveling in the muscular fascia. Distally, exercise caution lateral to the flexor carpi ulnaris tendon to avoid damage to a superficially running ulnar artery pedicle. As dissection proceeds laterally, subfascial dissection occurs over the palmaris longus tendon (if present) and the flexor carpi radialis tendon. Maintain the paratenon on these tendons to assist with STSG take during wound closure.

Make the radial longitudinal skin incision and perform lateral-to-medial subfascial dissection over the large brachioradialis (BR) tendon, shown below. Take care to preserve the dorsal radial nerve. The radial artery pedicle can run close to the BR tendon medial margin; use exceptional caution in separating the lateral intermuscular septum from the medial border of this tendon. Next, widely undermine the BR tendon and retract it laterally. Distally, dissect the radial artery pedicle and place a vessel loop around it. Because of the ulnar-biasing, the cephalic vein and lateral antebrachial nerve are not frequently included in the harvest but can be, depending on need. The fasciocutaneous paddle should now be pedicled by only the lateral intermuscular septum and the radial artery pedicle.

Proximally, make a linear or curvilinear incision from the skin paddle to the antecubital fossa. Then, perform subcutaneous dissection to elevate skin flaps medially and laterally. The medial antebrachial cutaneous nerve can then be followed to the antecubital fossa prior to harvest. Also, follow the radial artery pedicle to the antecubital fossa using microclips or bipolar cautery on small vascular branches between the pedicle and underlying musculature. Those branches lying deep to the skin paddle must be preserved because they feed the underlying radius periosteum. Typically, clean the pedicle and follow it proximally to the radial artery's takeoff from the brachial artery. The paired venae comitantes frequently coalesce into a single larger vein near the antecubital fossa. If a superficial vein is preserved from the fasciocutaneous paddle, it can be followed into the antecubital fossa. These veins frequently connect to the deeper venous network as well.

Next, release the flexor digitorum superficialis (FDS) from the distal medial radius and retract it medially to visualize the flexor pollicis longus (FPL). Using a scalpel, split the FPL and periosteum over the longitudinal midline of the volar radial surface (on the ulnar side of the lateral intermuscular septum). Determine this midline by means of palpation, remembering that the radius enlarges distally.

Next, accurately determine the required length of radius bone from the head and neck defect and measure along the exposed radius. Generally, harvest the vascularized bone graft between the pronator teres (PT) and BR tendon insertions, remembering that the distal osteotomy must be made at least 2.5 cm proximal to the radius styloid process to allow insertion of at least 2 bicortical screws during internal fixation. Proximally, the bone can be harvested beyond the PT insertion, but the PT tendon must be reinserted to the remaining radius bone and/or fixation plate. (Using this technique, as much as 12 cm of radius bone has been harvested.) Mark the proximal and distal osteotomies by sharply incising the periosteum in a beveled fashion, so that the resulting bony defect is beveled somewhat concavely.

Use a fine-blade oscillating saw to make the longitudinal radius cut, as in the image below. Irrigate copiously with antibiotic-containing saline irrigation. The longitudinal radius cut is placed to allow harvest of approximately 50% of the radius circumference. Usually, cutting is started proximally. Because of the curvature of the radius and increased radius circumference distally, the frequency of harvesting too much of the radial circumference proximally is minimized. Next, make the proximal and distal beveled osteotomies with the saw, as shown below. Avoid past-cutting because this can weaken the remaining radius bone. Incise the dorsal periosteum lateral to the intermuscular septum and under or lateral to the retracted BR tendon, completing the bone-graft harvest.

Release the tourniquet and allow the OCRFFF to perfuse on its pedicle until its transfer to the recipient site. Bleeders are managed with bipolar cautery or hemoclips. Confirm adequate perfusion of the entire flap. First, clamp the distal arterial pedicle and again confirm hand perfusion before actual pedicle sacrifice. Use silk ties and/or medium hemoclips during pedicle sacrifice, both proximally and distally. Then, transfer the OCRFFF to the head and neck recipient site for inset and microvascular anastomoses. Up to 2 osteotomies have been performed subperiosteally in the radius graft without vascular compromise to the bone graft.

Prophylactic internal fixation of donor radius and wound closure

Prophylactic internal fixation can be performed most efficiently after reinflating the arm tourniquet. Expose the dorsal radius proximally and distally. Position an appropriately sized 3.5-mm low-contact dynamic compression plate (AO Synthes, Davos, Switzerland) over the radius and bend it to the contour of the bone, as depicted in the image below. Typically, 12- to 14-hole plates are required, depending on the length of the harvested radius graft. Distally, retract the radial wrist extensors (ie, abductor pollicis longus, extensor pollicis brevis, extensor carpi radialis longus, extensor carpi radialis brevis) laterally and place at least 2 standard bicortical screws.

Proximally, visualize the supinator (S). With long-bone harvests, elevate this muscle subperiosteally and place the plate beneath it. Take care to protect the posterior interosseous nerve, a branch of the deep radial nerve that pierces the S. Place 3 bicortical screws proximally. To avoid the creation of additional stress risers, do not place screws in the defect cavity. See the image below.

Using a dermatome, harvest a STSG (0.015-in thickness) from the prepared thigh. Bring the STSG up to the donor arm. Dress the leg with Xeroform gauze (Sherwood Medical, St Louis, Mo) or an occlusive dressing.

Reinsert the PT tendon into the remaining radius or fixation plate with sutures as necessary. Using absorbable sutures, suture the FPL remnant over the radius defect and plate. The FDS can usually be brought over the flexor carpi radialis (FCR) tendon to the radial skin edge. This method provides a second muscular layer over the bony donor site and helps the STSG take on the FCR tendon. Then, cover the defect with the STSG and cut a few "pie-crusting" holes in the STSG, avoiding tendons underneath. Cover the forearm donor site with Xeroform gauze, cotton balls, and a gauze wrap. Finally, apply a rigid plaster ulnar-gutter splint and wrap with an elastic bandage.

Perfusion of the flap and the hand are closely monitored, as is the motor and sensory neural integrity of the hand and fingers.

Keep the donor arm elevated. Take down the arm splint 5-7 days postoperatively and dress the donor site with a fresh Xeroform gauze and cotton wrap dressing for protection during healing. Remove the arm sutures and/or staples approximately 10 days postoperatively. Encourage the patient to perform normal movements with the donor arm after splint removal.

Monitor the arm and leg wounds during routine postoperative follow-up as dictated by the head and neck problem. Encourage normal wrist activity; physical therapy is needed only if limited range of motion or decreased strength is encountered. Postoperative radiographs of the donor arm are needed only to investigate arm symptoms.

In a study of osseous or osteocutaneous free flaps for mandibular or maxillary reconstruction, Swendseid et al found that over a follow-up period of at least 6 months, 17.3% of 185 patients had suffered at least one long-term complication. The most common among these were wound breakdown, fistula development, and plate extrusion. The tendency toward long-term complications was greater in patients who had previously undergone chemoradiotherapy or in whom maxillary reconstruction was performed.[11]

Microvascular free flaps always carry the risk of ischemia and flap loss. Early detection of vascular compromise and expeditious flap revision is important and can result in overall success rates greater than 95%. As with the fasciocutaneous radial forearm free flap (FCRFFF), the most common donor site complication is poor split-thickness skin graft (STSG) take over the flexor carpi radialis tendon. This problem usually responds readily to wet-to-dry dressings and rarely requires debridement or regrafting.

Complications from the harvest of the radius bone include donor radius fracture, decreased range of motion, and decreased strength. A study by Torina et al indicated that in OCRFFF, the radius can be effectively reconstructed with a combination of iliac crest bone grafting and plating. In the study, which involved 23 patients, those who underwent grafting and plating had a 0% fracture rate, compared with 29% and 14% for, respectively, patients with no reconstruction at the radius donor site and those who had iliac crest bone grafting without plating. This was the case even though the mean cross-sectional diameter (by percentage) and length of radius bone harvested was greater in the grafting/plating patients than in the other two groups.[12]

Werle et al report eliminating radius fractures by using keel-shaped osteotomies and prophylactic plating of the donor radius bone.[13] Their results have been reproduced by other authors. Kim et al. looked at donor and recipient site complications in 52 patients who underwent osteocutaneous radial forearm free flap (OCRFF) for oromandibular and maxillofacial reconstruction.[4] In their series, only one fracture of the donor site occurred, which was subsequently repaired without sequelae. With careful closure of the forearm, paying attention to the muscle coverage of the plate, these authors had no incidences of plate exposure in the forearm.

In more than 100 consecutive cases, the authors experienced no cases of symptomatic radius fractures that required any intervention. Interestingly, one patient fell on an outstretched donor arm on postoperative day 7 and suffered a humerus fracture; the plated radius was uninjured.

The rate of major surgical complications at the donor site was comparable or better for the radius bone harvest compared with a harvest of the fibula and scapula osteocutaneous flaps (7% vs 16%). Only 1 patient (0.9%) required plate removal because of hardware loosening, and 2 patients required another surgical intervention at the donor site. None of the above complications resulted in any further sequelae.

Limitations of wrist range of motion and strength have not been significant. Mean grip and pinch strength were at least 84% of the unoperated, and usually dominant, arm. Wrist range of motion was at least 87% of the control side. Again, operated arms are usually the nondominant arm, which may have decreased values at baseline. Any minimal limitation has generally been overcome with physical therapy. One case of an attritional tear of the extensor pollicis longus tendon tear from the end of a fixation plate placed too ulnarly occurred. This patient required repair and plate removal without sequelae. No instances of infection or loosening of donor arm hardware have occurred.

Thigh STSG donor sites may occasionally become infected and require local wound care and topical antibiotics. However, they usually heal without difficulties.

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., non-plated donor radii were shown to have sustained an unacceptably high fracture rate (18% among males and 32% among females).[14] 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.

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.[15] 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 popularize this useful and versatile flap as a viable reconstructive option within 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.