Radial forearm free flap - Fasciocutaneous

Considerations

Preparation

Procedure

Sample operative report

The patient was already on the OR table. The resection was previously completed and will be noted separately. A safety check was previously performed.

The *** forearm and *** lateral thigh were prepared in standard sterile fashion at the beginning of the case. The Webril was placed around the upper arm followed by the sterile tourniquet and it was connected to the tourniquet. The arm was then exsanguinated with the Esmarch bandage. 

The skin paddle was designed at the distal aspect of the forearm, centered on the radial artery. Its dimensions were *** cm by *** cm, shaped as a ***.

The incision was made first on the ulnar aspect through the skin down to the level of the paratenon and then over the paratenon from the ulnar aspect. The radial portion of the incision was made through skin down to the level of the muscle fascia. The flap was rolled onto the brachioradialis tendon to include the cephalic vein in its lateral (radial) aspect. The flap was elevated over the brachioradialis. The radial artery and venae comitantes were clamped, divided, and ligated with #3-0 silk ties. The flap was elevated from distal to proximal direction; Perforating vessels were clamped, divided, and ligated with #3-0 silk ties or ligated with hemoclips and divided. 

The incision was made through the skin from the antecubital fossa to the proximal portion of the flap. The soft tissue was elevated off the soft tissue of the flap so that the cephalic vein would be included in the flap itself. The soft tissue was divided on both sides of the vein down to the level of the musculature and then reflected medially. The brachioradialis tendon was elevated away from the underlying vessels, and this was traced superiorly. Again, any perforating vessels were clamped, divided, and ligated with #3-0 silk ties or ligated with hemoclips and divided. The communicating branch from the deep system to the antecubital vein was identified and preserved. The venae comitantes were then divided superior to the connection to the communicating vein, such that the communicating vein remained intact and drained into the antecubital vein.

The radial artery was identified and dissected until it exited from the brachial artery. The tourniquet was then let down. The total tourniquet time was *** minutes. The flap was seen to be bleeding well at this point in time. Any bleeding was controlled with bipolar cautery or ligation with #3-0 silk ties or hemoclips. After *** minutes, the flap was then disconnected from the arm. The antecubital vein and radial artery were clamped, divided, and ligated. The vessels were irrigated with heparinized saline until the effluent through the vein ran clear.

The forearm defect was irrigated was saline and Bacitracin irrigant. The proximal portion of the incision was closed in two layers using buried interrupted #3-0 Polysorb in the deep layer and running subcuticular #5-0 Biosyn to approximate the skin. 

A split-thickness skin graft was harvested from the *** lateral thigh with a deduct of 16/1000 inch. The lateral thigh was dressed with *** Benzoin and Tegaderm.

The STSG was placed into the forearm defect in the arm and inset with simple #5-0 Fast absorbing gut.  Once the peripheral edges were sutured into place on the arm, small "pie crust" incisions were completed on the STSG over the muscle aspect, while leaving STSG over the paratenon intact. Quilting stitches were placed into the underlying muscles. *** Xeroform was then made into little rolls and placed between the tendons followed by a big bolster dressing. The arm was then placed into a splint in a safe position and wrapped with *** Kerlix followed by an ACE wrap. *** Doppler refill on the thumb was less than 2 seconds at the end of release of the tourniquet.

Meanwhile the flap was brought into the head and neck. It was inserted into place into the defect using #3-0 Polysorb in a vertical mattress fashion. 

The vessels were then brought down into the neck. The *** vein and the *** artery were selected as the recipient vessels. The adventitial tissue was cleaned on the donor and recipient vessels. The recipient artery was approximated to the radial artery and then anastomosed using simple interrupted #9-0 Nylon on the MV100 needle. *** The recipient vein was approximated to the antecubital vein and sutured in a running fashion using #9-0 Nylon on the MV100 needle. The vessels were released. Excellent flow to the flap was visualized. The flap was pink and bleeding well on skin scratch.

*** drains were placed into the neck. The *** drain was loosely sutured to keep it off the vessels and flap. These were secured to the skin using #3-0 Nylon. 

The neck was irrigated with a copious amount of saline. No further bleeding was encountered. No evidence of a chyle leak was seen.

The flaps were then replaced. The *** lip was repaired with 3-0 Polysorb deeply and on the lip mucosa, 5-0 Chromic on the vermillion and 5-0 Surgipro on the skin. The platysma and the subcutaneous tissue layers were closed using #3-0 Polysorb and the skin was closed using #5-0 Surgipro. 

The NG tube was placed through the nasal cavity into the stomach. It was then sutured to the membranous nasal septum using a #3-0 Nylon. The patient's mouth was then suctioned. The endotracheal tube was then removed and a *** #6 LPC Shiley tracheostomy tube was inserted and sutured to the skin at four points using *** #3-0 Nylon. 

The patient was cleaned and transferred to the Intensive Care Unit in satisfactory condition. No complications were encountered. Final needle and sponge counts were correct.

Post-op

Pearls & Pitfalls

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