Osteocutanous Radial Forearm Free Flap for Head and Neck reconstruction
Intorduction:
The osteocutaneous radial forearm free flap (OCRFFF) was a popular choice for maxillomandibular reconstruction in the 1980s and early 1990s. It then fell out of favor for reasons such as inadequate bone stock (length and quality) and donor site morbidity such as radius fracture. While, the fibular free flap (FFF) continues to be the workhorse for mandibular reconstruction it routinely results in up to 3 months of antalgic gait and can cripple the elderly population. Additionally, its use can be limited by peripheral vascular disease. This is not the case in OCRFFF, which makes it a good choice in certain patient populations. Here we will discuss our experience with OCRFFF including indications and outcomes of its use in our patient population. Additionally, we will show that with proper treatment planning it is possible to successfully place endosseous dental implants in this bony flap for oral rehabilitation.
Method:
This is a retrospective chart review of all the OCRFFF reconstructive procedures performed from January 2010 to December 2014 at Oregon Health and Science University, a tertiary referral academic hospital. Total of 24 cases were identified.
Results:
24 cases were reviewed, 16 males (67%) and 8 females (33%) with ages raging between 41-94 years. OCRFFF was used in 8 patients (33%) for maxillary reconstruction, 15 patients (63%) for mandibular reconstruction and 1 patient (4%) for clavicle reconstruction. Most common indications were: Small bony defects less than 5cm in 13 patients (54%), presence of peripheral vascular disease or lower extremity DVT in 7 patients (29%), previous complete or partially failed fibula flaps in 7 patients (29%), and patient preference in 2 patients (8%). Flap complications included 3 with exposed hardware (12.5%), and one flap failure (4%). All patients received prophylactic plating on the donor site. Donor site morbidity included: minimal wrist weakness and stiffness in 5 patients, minimal tendon exposure in 3 patients, one patient with infected hardware, and one with sensory neuropathy, no radial fractures observed. One patient was able to successfully receive multiple endosseous dental implants in this flap.
Conclusion:
With prophylactic plating of the radius and proper treatment planning, this flap provides a reliable reconstruction with a long pedicle which can be used in ipsilateral or contralateral neck with a very high success rate. It also provides excellent soft tissue with thin, pliable skin for oral cavity reconstruction. Additionally, the OCRFFF is less challenging to harvest compared to other free flaps. Data from this and other reports suggest OCRFFF is particularly useful for midfacial and short segment mandibular reconstruction with a vey high success rate. Most common donor site morbidities include wrist weakness and stiffness, these do not impede with activities of daily living and, in our study, resolved in all patients with physical therapy.
References:
Kim, J. H., Rosenthal, E. L., Ellis, T., & Wax, M. K. (2005). Radial forearm osteocutaneous free flap in maxillofacial and oromandibular reconstructions. The Laryngoscope, 115(9), 1697–701.
Militsakh, O. N., Werle, A., Mohyuddin, N., Toby, E. B., Kriet, J. D., Wallace, D. I., … Tsue, T. T. (2005). Comparison of radial forearm with fibula and scapula osteocutaneous free flaps for oromandibular reconstruction. Archives of Otolaryngology--Head & Neck Surgery, 131(7), 571–5.
Sinclair, C. F., Gleysteen, J. P., Zimmermann, T. M., Wax, M. K., Givi, B., Schneider, D., & Rosenthal, E. L. (2012). ASSESSMENT OF DONOR SITE MORBIDITY FOR FREE RADIAL FOREARM OSTEOCUTANEOUS FLAPS. doi:10.1002/micr
Villaret, D. B., & Futran, N. a. (2003). The indications and outcomes in the use of osteocutaneous radial forearm free flap.Head & Neck, 25(6), 475–81.