Laboratory Studies
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.
Imaging Studies
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Angiography of the forearm to determine adequate vascular anatomy has been replaced by noninvasive studies, such as Doppler photoplethysmography, which is used when Allen test results are equivocal or routinely for all patients at some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.
Other Tests
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.
-
Planned fasciocutaneous paddle drawn with a surgical pen on the volar aspect of the donor forearm. Note the ulnar bias to the skin paddle with the palpated radial artery (RA) and ulnar artery (UA) marked.
-
Subfascial dissection is performed under the fasciocutaneous paddle in the medial to lateral direction. The flexor carpi radialis, palmaris longus, and flexor carpi radialis tendons are preserved as the surgeon moves medial to lateral. The pedicle is preserved just lateral to the flexor carpi radialis tendon. Care is taken to protect the sometimes superficial ulnar pedicle just lateral to the flexor carpi ulnaris tendon distally.
-
Subfascial dissection is performed in a lateral-to-medial direction under the fasciocutaneous paddle. The superficial radial nerve is shown with the vessel loop and is preserved. Care is taken near the medial border of the brachioradialis tendon to preserve the radial artery pedicle. The proximal linear incision from the fasciocutaneous paddle to the antebrachial fossa has been elevated.
-
The horizontal osteotomy is performed using the oscillating saw. Fifty percent of the radius circumference is harvested proximally to distally.
-
An oscillating saw is used to make the concave beveled edges on both ends of the harvested radius bone graft. This step is performed on the medial side of the intermuscular septum. This photograph shows the proximal osteotomy. In order to maintain the donor radius strength, past-pointing the horizontal incision is prevented by placing a metal ruler in the previously made osteotomy.
-
Model of proper prophylactic plating of the donor radius arm. The arrows point to the concave beveled edges' osteotomies. Note that the plate is placed partially over the defect and partially over the remaining radius bone. Usually, 2 bicortical screws are placed distally, while 3 bicortical screws are placed proximally.
-
The plate is placed on the dorsal aspect of the donor radius, and bicortical screws are placed both distally and proximally. The brachioradialis tendon can be retracted to facilitate screw and plate placement.
