Christopher M. Harris¹ and Remy H. Blanchaert²

¹Department of Oral and Maxillofacial Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA

²Private Practice, Oral and Maxillofacial Surgery Associates, Wichita, Kansas, USA

A means of obtaining free tissue transfer for the replacement of moderate to large soft tissue defects associated with ablative wounds.

Indications

1. Utilized for the reconstruction of moderate to large soft tissue defects related to traumatic, congenital, and benign or malignant defects
2. Most commonly utilized for the replacement of oral and oropharyngeal soft tissues due to ablative treatment of malignancies

Contraindications

1. Vascular anatomy disruption due to prior surgical procedures or trauma in the area of interest
2. Anatomical variants precluding the use of a radial forearm flap: aberrant or no radial artery, absent branching from the superficial arch to the index finger and thumb, and lack of connections between the superficial and palmar arches
3. Hereditary or acquired coagulopathy, which may lead to flap loss
4. Inability of the patient to medically tolerate anesthesia and a prolonged surgical procedure

Anatomy

• Vascular supply: The radial artery supplies the arterial flow to the flap. The radial artery runs the length of the arm and terminates in the deep palmar arch. The ulnar artery supplies the superficial palmar arch. Anastomoses occur between the two that supply collateral circulation to the hand. The radial artery gives off multiple perforating branches to the skin, subcutaneous tissue, muscles, and radius bone of the volar forearm. The lateral intermuscular septal perforators are found between the flexor carpi radialis and the brachioradialis muscles. Venous drainage of the flap is from the deep radial veins and the superficial system. The superficial system allows for better anastomosis due to a larger caliber, but it may be unreliable with small flaps. The arterial vessel caliber (2–3 mm) and vein caliber (1–4 mm) allow for easier anastamosis. A long vascular pedicle is available for most oral cancer defect reconstructions.

Radial Forearm Flap Landmarks

1. Proximal wrist crease
2. Antecubital fossa
3. Superficial veins (cephalic)
4. Flexor carpi radialis tendon
5. Brachioradialis muscle
6. Flexor carpi ulnaris
7. Palmaris longus tendon (when present)

Radial Forearm Flap Layers

1. Skin
2. Subcutaneous tissue
3. Antebracial fascia
4. Superficial veins
5. Radial artery and venae comitantes; lateral intermuscular septum
6. Paratenon
7. Forearm tendons

Radial Forearm Flap Technique

1. Preoperatively, a history of wrist surgery or trauma needs to be ascertained, as certain conditions may restrict safe flap harvest. An Allen’s test is performed to verify collateral circulation from the ulnar artery. Questionable findings dictate that other vascular studies (e.g., color Doppler) be performed to verify adequate circulation prior to performing the procedure. Inadequate circulation between the superficial and deep palmar arches increases the risk of vascular insufficiency to the hand and thumb if the flap is harvested. Preoperatively, the patient is instructed to not allow intravenous attempts or venipuncture in the chosen arm. This is also recorded as an order within the patient’s medical record.
2. The flap design is drawn on the volar forearm with a surgical skin marker. Superficial veins and the radial artery are also marked for identification. The distal margin is 2–3 cm proximal to the wrist crease. The ulnar margin is typically the flexor carpi ulnaris. The radial margin is typically the brachioradialis muscle, but can extend over to the dorsal surface. The proximal extent is dependent on the size of flap needed for the reconstruction. The entire volar surface skin can be harvested if needed.
3. Surgical prep and draping are performed. A sterile tourniquet is applied to the upper arm.
4. The limb is exsanguinated with an elastic wrap, and the tourniquet is inflated to 250 mmHg. The tourniquet “uptime” is recorded. The dorsal wrist has a rolled lap sponge placed underneath, and an open lap sponge across the palm is secured with clamps to the arm board./>
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