CLINICAL PAPER
A Comparison Between Proximal Lateral Leg Flap and Radial Forearm Flap for Intraoral Reconstruction Jiunn-Tat Lee, MD,*Þ Peir-Rong Chen, MD,Þþ Li-Fu Cheng, MD,*Þ Chien-Hsing Wang, MD,* Meng-Si Wu, MD,* Chieh-Chi Huang, MD,Þ§ Sou-Hsin Chien, MD,Þ|| and Honda Hsu, MBChBÞ§ Abstract: Free flaps have become a popular option for the reconstruction of intraoral defects. The radial forearm f lap used to be the workhorse f lap for small and thin defects, but was associated with numerous donor-site morbidities. The proximal lateral leg flap can provide a thin and pliable tissue similar to the radial forearm flap but without the related donor-site morbidities. We compared the differences between these 2 flaps. Thirty-four patients with intraoral defects from September 2005 to October 2011 were reconstructed, using the radial forearm flap in 23 cases, and the proximal lateral leg flap in 11 cases. The radial forearm flap group had a success rate of 95.6%. The flap survival rate was 100% in the proximal lateral leg flap group. However, the difference was statistically insignificant. Skin graft was required in 22 of the 23 cases for the donor site of the radial forearm flap. Partial loss of the skin graft occurred in 5/22 (23%) of the patients, with exposure of tendons in 3/22 (14%). Delay in healing of the donor sites occurred in 6/23 (26%) of the patients. The donor sites of the proximal lateral leg flap were all closed primarily. One case developed wound dehiscence and this healed by conservative treatment. Long-term follow-up showed functional impairment of the donor forearm (reduced extension or grip strength) in 17% of the patients. Thirty percent of the patients developed sensory disturbance and 48% complained of poor outcome of the donor forearms. In the proximal lateral leg flap group, no motor or sensory functional deficits were seen. No patients complained of poor outcome of the donor legs. Primary closure of the donor site of the proximal lateral leg f lap could be performed if the flap width was less than 6 cm. This flap is useful for patients with small and thin intraoral defects and is associated with minimal donor-site morbidity when compared to the radial forearm flap. Key Words: radial forearm flap, proximal lateral leg flap, free perforator flap (Ann Plast Surg 2013;71: S43YS47)
F
ree flap transfer has become the primary choice of reconstruction in patients with head and neck cancer. Common conventional flaps that are used for soft tissue defects include the radial forearm flap,1,2 rectus abdominis flap,3 latissimus dorsi flap,4 free peroneal flap,5,6 among others, all with their advantages and disadvantages. With the wide variety of flaps available, the attention of the reconstructive surgeon is now focusing on the functional and aesthetic deficits of the flap’s donor sites. The radial forearm flap is ideal for small and thin defects in head and neck reconstruction cancer. It offers many advantages such as a constant surgical anatomy and a long vascular pedicle
Received October 3, 2013, and accepted for publication, after revision, October 6, 2013. From the *Division of Plastic Surgery, Tzu Chi Hualien General Hospital; †School of Medicine, Tzu Chi University; ‡Department of Otolaryngology, Buddhist Tzu Chi General Hospital, Hualien; §Division of Plastic Surgery, Tzu Chi Dalin General Hospital, Dalin; and ||Division of Plastic Surgery, Tzu Chi Taichung General Hospital, Taichung, Taiwan. Conflicts of interest and sources of funding: none declared. Reprints: Honda Hsu, MBChB, Division of Plastic Surgery, Tzu Chi Dalin General Hospital, Tzu Chi University, 2 Min-Sheng Rd, Dalin, Taiwan. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0148-7043/13/7101-S043 DOI: 10.1097/SAP.0000000000000047
Annals of Plastic Surgery
with large caliber vessels; however, the radial artery has to be sacrificed. It is also associated with a higher donor-site morbidity.7Y11 The introduction of perforator flaps has allowed the reconstructive surgeon to harvest flaps without the need to sacrifice muscle and major vasculature. Many surgeons now favor perforator flaps over myocutaneous flaps. Yajima et al12 introduced the proximal lateral leg f lap in 1994. They found that there were usually 1 or 2 perforators located at the distal portion of the proximal third of the lower lateral leg along the posterior margin of the fibula. These were usually the major nutrient arteries to the lateral half of the soleus muscle. This flap is based on these perforator vessels. If a thin and pliable flap is required in intraoral reconstruction, the proximal lateral leg flap will do as well as the radial forearm flap, but is associated with minimal donor-site morbidity. In this retrospective study, we analyzed and compared reliability, complications, and the donor-site morbidity between radial forearm flap and proximal lateral leg flap.
PATIENTS AND METHODS A retrospective study of medical records was performed. From September 2005 to October 2011, 34 patients (31 men and 3 women) with various intraoral defects after cancer ablation were reconstructed using, in 23 cases, a radial forearm flap and, in 11 cases, a proximal lateral leg flap. Patients who had undergone previous surgery or radiotherapy were excluded from this study. Only patients requiring soft tissue reconstruction without bone reconstruction were included for evaluation. A positive Allen test was a prerequisite for patients undergoing a radial forearm flap. For patients undergoing proximal lateral leg f lap, a handheld Doppler f lowmeter was used to localize the perforators preoperatively. The patient’s age, sex, tumor location, histology, stage, size of defect, flap size, flap dissection time, type of donor-site closure, complications, and flap failure rates were recorded. Function and cosmesis of the donor sites were followed up at the outpatient clinic. Functional evaluation of the donor limb (hand or leg) including ankle motility for the proximal lateral leg f lap and range of motion of the wrist and grip power for the radial forearm flap was done. Sensory disturbance at the area of the superficial radial nerve distribution distal to the flap donor site as well as cold intolerance of the hand and foot was also recorded. Each patient was evaluated for the cosmesis of the scar. All the linear scars, skin grafted areas, and scars of the skin graft donor thigh were assessed for width, height, vascularity, presence of suture/staple marks, pliability, and pigmentation. Finally, the patients were asked to self-evaluate the cosmesis and function of the donor site subjectively.
Surgical Procedure of Proximal Lateral Leg Perforator Flap The operative procedure was described in previous literature.12 We described it with some important modifications. The patient was placed in a supine position with the hip and knee f lexed to allow easy access to the lateral lower leg. The outline of the fibula bone was marked out, with the perforator at the distal portion of the proximal third of the lateral leg located with a handheld Doppler f lowmeter.
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FIGURE 1. A, Preoperative marking of proximal lateral leg f lap: 1 or 2 perforators could be located at the distal portion of the proximal third of the lateral leg. B, The f lap was elevated based on the septocutaneous perforator. C, A 7 4-cm2 defect in the left retromolar area with mandibular bone exposure. D, Proximal lateral leg f lap was used to reconstruct the defect.
The perforator is usually 7 to 15 cm from the fibula head. The outline of the flap was then designed to include the marked out spot (Fig. 1A). The anterior incision was made first and deepened until the deep fascia. A subfascial dissection was performed. Once the presence of the perforator was confirmed visually, the f lap was then elevated from the posterior border. The perforator vessel was then dissected intramuscularly with ligation of the muscular branches if it was found to be traversing the soleus muscle. If the perforator was found to be septocutaneous, then the dissection was straightforward. If more than 1 perforator is seen, then the larger perforator or the septocutaneous perforator was chosen. The soleus muscle was partially detached from the fibula, and the bifurcation of the perforator vessels from the main artery was located. The perforator was skeletonized at this time (Fig. 1B). One should note that due to the small caliber of the perforator vessels, vessel spasm can occur and one should allow some time for the spasm to pass. Before detaching the flap, flow in the flap should be confirmed, the flap was then ligated at the perforator vessel level and thus the major vessels are spared. The flap is then insetted with microsurgical anastomosis using 10-0 nylon (Fig. 1C, D). The donor site was closed primarily in all our cases.
RESULTS The radial forearm flap group consisted of 21 men and 2 women. Their mean age was 51 years (range, 34Y71 years). There were 10 men and 1 woman in the proximal lateral leg flap group. The mean age of this group was 55 years (range, 30Y68 years). The final pathology for all the patients was squamous cell carcinoma. The patients’ data are shown in Table 1. The mean time of flap harvesting for the S44
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radial forearm flap was 52 minutes (range, 40Y75 minutes). The flap had a mean size of 36 cm2 (range, 24Y60 cm2). The mean diameter of the radial artery pedicle was 2.3 mm (range, 1.5Y3.2 mm) and the mean length of the vascular pedicle was 9.5 cm (range, 6Y12 cm). The diameter of the vena comitante ranged from 1.2 to 2.5 mm (mean, 2.0 mm). In all cases of radial forearm f lap, 2 venous anastomoses (2 venae comitantes or 1 vena comitante and the cephalic vein) were performed. There were 1 arterial thrombosis and 1 venous thrombosis
TABLE 1. Patients Characteristics Group Sex Male Female Mean age, y Defect location Buccal Retromolar Tongue Mouth floor Soft palate Gingiva Mean follow-up, mo
PLLF Group
RFF Group
10 1 55
21 2 51
4 1 2 2 0 2 16
2 2 5 3 1 0 25
PLLF indicates proximal lateral leg f lap; RFF, radial forearm f lap.
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in this group. The flap with arterial thrombosis could not be salvaged due to delay in detection. This group had a success rate of 95.6% with 1 flap loss. Split-thickness skin grafting was required in 22 of the 23 cases for donor-site closure. Partial loss of the skin graft occurred in 5/22 (23%) of the patients, with exposure of tendons in 3/22 (14%) (Fig. 2A). One donor wound was closed primarily under tension. A 3 2-cm area of skin necrosis developed and this healed by conservative treatment. Delays in healing of the donor sites (skin-grafted or primarily closed) developed in 6/23 (26%) of the patients. No ischemic changes of the hand were seen (Table 2). The mean flap harvesting time for the proximal lateral leg f lap was 60 minutes (range, 48Y80 minutes). The mean f lap size was 32 cm2 (range, 4 6 to 6 8 cm2). The mean distance of the perforator
Proximal Lateral Leg Flap and Radial Forearm Flap
TABLE 2. Flaps Characteristics Group
PLLF Group
RFF Group
60 32 1.5 2.1 6.5 100
52 36 2.3 2.7 9.5 95.6
V V 9% (1/11)
23% (5/22) 14% (3/22) 26% (6/23)
Mean harvest time, min Mean flap size, cm2 Artery diameter, mm Venae comitantes diameter, mm Pedicle length, cm Flap survival rate, % Donor site Loss of skin graft Exposure of tendon Delayed healing
from the fibula head was 9.2 cm (range, 7Y15 cm). The mean diameter of the perforator artery was 1.5 mm (range, 0.8Y2.0 mm) and the mean length of the vascular pedicle was 6.5 cm (range, 5Y8 cm). Three flaps had only a single vein and 8 flaps had 2 veins. The diameter of the vena comitante ranged from 1.2 to 2.8 mm (mean, 2.1 mm). Clinically, in 45% (5/11) of the cases, we used the septocutaneous perforators; and in 55% of the cases, we used the musculocutaneous perforators. One venous thrombosis developed in this group and this was successfully rescued. The flap survival rate was 100% in this group. There was no statistical significance when comparing the survival rate between the 2 groups (P = 0.999). The donor sites were closed primarily in all 11 cases and no immobilization was required. One case developed wound dehiscence and this healed with conservative treatment. No peroneal nerve injury or other postoperative complications at the donor sites were seen in this group (Table 2). The mean follow-up time was 25 months for the radial forearm f lap group and 16 months for the proximal lateral leg flap group. The functional results at the intraoral recipient site were satisfactory in both groups. No secondary debulking procedures were required in both groups. In the radial forearm flap group, functional impairment of the donor forearm (reduced extension or grip strength) occurred in 4 (17%) patients. Seven (30%) patients complained of sensory disturbance (Fig. 2B). No cold intolerance was noted in this series. Six patients had hypertrophic scar of the forearm and 3 patients over the thigh. All patients had hyperpigmentation of the grafted skin over the forearm (Fig. 2B) and 16 patients of the donor thighs (Fig. 2C) (Table 3). In total, 11 (48%) patients complained of poor outcome (either functional deficit or poor cosmesis) of the donor forearm. In the proximal lateral leg f lap group, 2 (18%) patients had hypertrophic scar with pruritis and 2 (18%) had hyperpigmentation of the scar of the donor leg. Because no significant amount of soleus muscle was injured or removed, even in the presence of a musculocutaneous perforator, the motor function of the leg was not affected. Similarly, the peroneal nerve was also not disturbed and so no sensory deficit was seen. As no major vessels were sacrificed, none of the patients complained of circulatory or cold intolerance problems. In total, 83% patients had excellent
TABLE 3. Objective Assessment Group
FIGURE 2. A, Partial loss of skin graft at the donor site with tendon exposure. B, Poor cosmetic scar and sensory disturbance at the donor forearm. C, Hyperpigmented and hypertrophic scar of the donor thigh after harvesting of skin graft. * 2013 Lippincott Williams & Wilkins
PLLF Group
RFF Group
Hypertrophic scar
2/11 (18%)
Pigmentation
2/11 (18%)
Sensory loss Function impairment
0/11 (0%) 0/11 (0%)
6/23 (26%, forearm), 3/22 (14%, thigh) 23/23 (100%, forearm), 16/22 (73%, thigh) 7/23 (30%) 4/23 (17%)
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or good outcome of the donor leg (Fig. 3). Table 4 shows the summary of the subjective cosmetic and functional assessment by the patients.
DISCUSSION In the era before free tissue transfer, various pedicled f laps are available for the reconstruction of head and neck defects. Since the 1980s, free tissue transfer has provided the reconstructive surgeon with an alternative treatment option. Free f lap survival rate is now around 95%13Y16 due to advances in microsurgical equipment and techniques. It has now become the treatment of choice over the pedicled f lap. The rectus abdominis myocutaneous f lap and the radial forearm f lap were commonly used before the year 2000 at our center. However, with the introduction of perforator flaps, the anterolateral thigh flaps together with the radial forearm flap have become the workhorse flaps in the past decade. The anterolateral thigh f lap was especially useful when a larger and thicker flap was required. However, it is sometimes too bulky in some intraoral defects, and so thinning or secondary debulking of the f lap was required. Numerous studies have confirmed that the flap can be thinned primarily until a thickness of 3 to 5 mm.17Y19 But in our experience and as reported in other studies, this was at running the risk of damaging the subdermal plexus with resultant partial flap necrosis.20,21 Although a number of perforator flaps have been described in the literature, thin perforator flaps are still uncommon. In our center as well as in others, radial forearm f lap is still the favored f lap for small and thin intraoral defects. However, donorsite morbidity and complications remains a major issue for this f lap. Complications of the donor site can be divided mainly into functional and aesthetic problems. Commonly, split-thickness skin graft (STSG) was necessary for the donor-site defects. Richardson et al, in one of the largest studies of the radial forearm f lap donor sites, found that partial loss of the skin graft occurred in 16% of the patients, with exposure of tendons in 13%; delay in healing of the STSG in 22%.7 Lutz et al22 achieved a 98.4% take of the STSG after with a suprafascial
FIGURE 3. Uniformly good linear scar of the donor lateral leg, after the proximal lateral leg f lap was harvested. S46
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TABLE 4. Donor-Site Morbidity: Subjective Cosmetic and Functional Assessment Group Excellent Good Acceptable Poor
PLLF Group, n = 11, n (%)
RFF Group, n = 23, n (%)
2 (18) 6 (55) 3 (27) 0 (0)
0 (0) 2 (9) 10 (43) 11 (48)
elevation of the radial forearm flap. In our series, we used subfascial dissection technique for harvesting and this resulted in partial loss of the skin graft in 5 (23%) patients, with exposure of tendons in 3 (14%) patients. Delayed wound healing developed in 6 (27%) of our patients. Other methods of donor-site closure included pre-expansion with a tissue expander.23 Some has used full-thickness skin grafts (FTSGs),24 but studies have found no statistical difference between using STSG and FTSG with regard to incidence of tendon exposure and time to healing.25 Still others have used acellular dermal matrix26 or acellular dermal matrix together with STSG or FTSG for reconstruction of the donor site. Local f laps, according to Swanson et al27 produced a better aesthetic result and should be attempted whenever possible. Various local f laps had been described. These include a f lap based on a single ulnar artery perforator,28 local hatchet f lap,29 VYY advancement f lap islanded on a single ulnar artery perforator,30 and local Z-plasty31 are a few of the different local f laps described. But in all these different types of wound closure, they were aesthetically superior to STSG, but were still associated with functional problems. The incidence of functional deficits as a result of harvesting the radial forearm f lap varied. Richardson et al found significant reduced wrist extension and pinch and grip strength. They further found superficial radial nerve sensation was reduced in 24 (32%) patients at 1 year. Ten (14%) patients reported cold intolerance, and 21 (28%) patients complained of poor aesthetic result.7 Timmons et al8 described a high incidence of reduced hand or wrist strength (40%), persistent wrist stiffness (27%), and decreased sensation over the radial nerve distribution (47%). However, Lutz et al,22 in a very comprehensive study in 1999, found that there was no significant difference in range of motion, as well as grip power and pulp-to-pulp pinch power in 90% of the patients whose skin graft healed without complications. In 10% of the patients who developed delayed wound healing, they developed a significant decrease in wrist flexion as well as a decrease in grip power. They did notice 54% of the patients developed numbness in the area innervated by the superficial radial nerve, but these dysesthesias improved with time. We found that reduced extension or grip strength occurred in 4 (17%) of our patients. Seven (30%) patients complained of paresthesia over the superficial radial nerve distribution. No cold intolerance was noted in our patients and in Lutz series, as this maybe because we live in a country with warm subtropical climate. In our series, cosmesis of the donor forearm remained a major issue too. In total, 11 (48%) patients complained of either functional deficit or poor cosmesis of the donor forearm. Some patients wore long-sleeved shirts to hide the unsightly donor forearm scar the whole year round, even in extremely hot weather. Previous studies showed that there were many perforators in lateral leg.32 Yoshimura et al33 introduced the peroneal f lap in 1984. This f lap can be harvested with the fibular bone as an osteocutaneous f lap or with the underlying soleus muscle as a musculocutaneous f lap. The pedicle, which is the peroneal artery, is sacrificed in the harvesting of this flap. With the introduction of the concept of perforator f laps, Yajima et al12 used the proximal lateral leg flap based on its perforators, thus preserving the peroneal artery. Wolff et al34 used perforator flaps from the lateral lower leg for intraoral reconstruction. * 2013 Lippincott Williams & Wilkins
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In this series, we used the proximal lateral leg flap in 11 selected primary case patients. All the flaps in our 11 patients survived well. Due to the short pedicle of this flap, we chose the lingual vessels and the facial vessels or their branches as their recipient vessels. The small diameter of pedicle vessels was the main challenge for anastomosis. The size of the perforator arteries may at times be less than 1.0 mm. Venous thrombosis was seen in 5 (28%) of 18 flaps in the series of Kawamura et al.35 They noted that the venous walls of these perforator flaps were very thin and this could be related to the high complication rate seen. In our series, 1 venous thrombosis developed and was successfully rescued. Due to the small diameter of the vessels, a high degree of microsurgical skills is required. It should be undertaken by skilled experienced microsurgeons. When vessel spasm occurs, one should give the vessel some time, f lush with lidocaine or prostaglandin E1 and wait for the spasm to pass. Donor-site morbidities have become an important factor in the selection of flaps. The donor site of proximal lateral leg flap can usually be closed primarily when the width of this flap was less than 6 cm. Only a linear scar was seen. We usually perform a pinch test to determine if the donor site can be closed primarily. There were no motor or sensory functional disturbances. The main vessels of the leg were preserved, so further flap harvesting, like the fibula osteocutaneous flap, from the same limb are still a possibility. Distal circulation and cold intolerance was not a problem as there were no disturbances to the blood supply of the foot. However, the proximal lateral leg flap has a shorter pedicle when compared to the radial forearm flap. In patients undergoing excision of secondary or recurrent head and neck tumors as well as in patients who has undergone prior irradiation, the shorter pedicle of the flap increases the difficulty with anastomosis and ultimately may increase the risk of flap failure. Whereas the radial forearm flap has a longer pedicle to allow for anastomosis on the contralateral side of the neck if there is depletion of vessels for anastomosis on the ipsilateral neck and close to the anastomosis site. We suggest that this flap can be used for reconstruction of small intraoral defects in selected primary cases. In conclusion, although there is a general reluctance to use perforator-based f laps on the assumption that the pedicle is short with small caliber vessels, perforator-based f laps only cause minimal donor-site morbidity. This study shows that the f lap failure rate of using proximal lateral leg f lap was no higher when compared to radial forearm f lap used. But due to small number of proximal lateral leg f lap in this series, a larger series is required to allow for adequate comparison of f lap survival.
REFERENCES 1. Yang GF, Chen PJ, Gao YZ, et al. Forearm free skin flap transplantation: a report of 56 cases, 1981. Br J Plast Surg. 1997;50:162Y165. 2. Soutar DS, Scheker LR, Tanner SB, et al. The radial forearm flap: a versatile method for intra-oral reconstruction. Br J Plast Surg. 1983;36:1Y8. 3. Kroll SS, Baldwin BJ. Head and neck reconstruction with the rectus abdominis free flap. Clin Plast Surg. 1994;21:97Y105. 4. Chowdhury CR, McLean NR, Harrop-Griffiths K, et al. The repair of defects in the head and neck region with the latissimus dorsi myocutaneous flap. J Laryngol Otol. 1988;102:1127Y1132. 5. Saito H, Yoshimura M, Tsuda G, et al. Free peroneal and its composite flap: a distant donor for head and neck reconstruction. Auris Nasus Larynx. 1993;20:63Y71. 6. Saito H, Kimura Y, Tsuda G, et al. Free peroneal skin flap for oropharyngeal reconstruction. Scand J Plast Reconstr Surg Hand Surg. 1999;33:41Y45. 7. Richardson D, Fisher SE, Vaughan ED, et al. Radial forearm flap donor-site complications and morbidity: a prospective study. Plast Reconstr Surg. 1997; 99:109Y115. 8. Timmons MJ, Missotten FE, Poole MD, et al. Complications of radial forearm flap donor sites. Br J Plast Surg. 1986;39:176Y178.
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9. Sardesai MG, Fung K, Yoo JH, et al. Donor-site morbidity following radial forearm free tissue transfer in head and neck surgery. J Otolaryngol Head Neck Surg. 2008;37:411Y416. 10. Kao HK, Chang KP, Wei FC, et al. Comparison of the medial sural artery perforator flap with the radial forearm flap for head and neck reconstructions. Plast Reconstr Surg. 2009;124:1125Y1132. 11. Loreti A, Di Lella G, Vetrano S, et al. Thinned anterolateral thigh cutaneous flap and radial fasciocutaneous forearm flap for reconstruction of oral defects: comparison of donor site morbidity. J Oral Maxillofac Surg. 2008;66:1093Y1098. 12. Yajima H, Ishida H, Tamai S. Proximal lateral leg flap transfer utilizing major nutrient vessels to the soleus muscle. Plast Reconstr Surg. 1994;93:1442Y1448. 13. Suh JD, Sercarz JA, Abemayor E, et al. Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 2004;130:962Y966. 14. Bianchi B, Copelli C, Ferrari S, et al. Free flaps: outcomes and complications in head and neck reconstructions. J Craniomaxillofac Surg. 2009;37:438Y442. 15. Simpson KH, Murphy PG, Hopkins PM, et al. Prediction of outcomes in 150 patients having microvascular free tissue transfers to the head and neck. Br J Plast Surg. 1996;49:267Y273. 16. Eckardt A, Fokas K. Microsurgical reconstruction in the head and neck region: an 18-year experience with 500 consecutive cases. J Craniomaxillofac Surg. 2003;31:197Y201. 17. Rajacic N, Gang RK, Krishnan J, et al. Thin anterolateral thigh free flap. Ann Plast Surg. 2002;48:252Y257. 18. Yang WG, Chiang YC, Wei FC, et al. Thin anterolateral thigh perforator flap using a modified perforator microdissection technique and its clinical application for foot resurfacing. Plast Reconstr Surg. 2006;117:1004Y1008. 19. Kimura, N, Satoh, K, Hasumi, T, et al. Clinical application of the free thin anterolateral thigh flap in 31 consecutive patients. Plast Reconstr Surg. 2001;108:1197Y1208. 20. Sharabi SE, Hatef DA, Koshy JC, et al. Is primary thinning of the anterolateral thigh flap recommended? Ann Plast Surg. 2010;65:555Y559. 21. Ross GL, Dunn R, Kirkpatrick J, et al. To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects. Br J Plast Surg. 2003;56:409Y413. 22. Lutz BS, Wei FC, Chang SC, et al. Donor site morbidity after suprafascial elevation of the radial forearm flap: a prospective study in 95 consecutive cases. Plast Reconstr Surg. 1999;103:132Y137. 23. Bonaparte JP, Corsten MJ, Allen M. Cosmetic and functional outcomes after preoperative tissue expansion of radial forearm free flap donor sites: a cohort study. J Otolaryngol Head Neck Surg. 2011;40:427Y435. 24. Kaltman JM, McClure SA, Lopez EA, et al. Closure of the radial forearm free flap donor site with a full-thickness skin graft from the inner arm: a preferred technique. J Oral Maxillofac Surg. 2012;70:1459Y1463. 25. Davis WJ 3rd, Wu C, Sieber D, et al. A comparison of full and split thickness skin grafts in radial forearm donor sites. J Hand Microsurg. 2011;3:18Y24. 26. Rowe NM, Morris L, Delacure MD. Acellular dermal composite allografts for reconstruction of the radial forearm donor site. Ann Plast Surg. 2006;57:305Y311. 27. Swanson E, Boyd JB, Manktelow RT. The radial forearm flap: reconstructive applications and donor-site defects in 35 consecutive patients. Plast Reconstr Surg. 1990;85:258Y266. 28. Hsieh CH, Kuo YR, Yao SF, et al. Primary closure of radial forearm flap donor defects with a bilobed flap based on the fasciocutaneous perforator of the ulnar artery. Plast Reconstr Surg. 2004;113:1355Y1360. 29. Lane JC, Swan MC, Cassell OC. Closure of the radial forearm donor site using a local hatchet flap: analysis of 45 consecutive cases. Ann Plast Surg. 2013; 70:308Y312. 30. Shoaib T, Van Niekerk WJ, Morley S, et al. The ulnar artery perforator based islanded V-Y flap closure of the radial forearm flap donor site. J Plast Reconstr Aesthet Surg. 2009;62:421Y423. 31. Bashir MA, Fung V, Kernohan MD. ‘‘Z-plasty’’ modification of ulnar-based fasciocutaneous flap for closure of the radial forearm flap donor defect. Ann Plast Surg. 2010;64:22Y23. 32. Chen YL, Zheng BG, Zhu JM, et al. Microsurgical anatomy of the lateral skin flap of the leg. Ann Plast Surg. 1985;15:313Y318. 33. Yoshimura M, Imura S, Shimamura K, et al. Peroneal flap for reconstruction in the extremity: preliminary report. Plast Reconstr Surg. 1984;74:402Y409. 34. Wolff KD, Holzle F, Nolte D. Perforator flaps from the lateral lower leg for intraoral reconstruction. Plast Reconstr Surg. 2004;113:107Y113. 35. Kawamura K, Yajima H, Kobata Y, et al. Clinical applications of free soleus and peroneal perforator flaps. Plast Reconstr Surg. 2005;115:114Y119.
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A Comparison Between Proximal Lateral Leg Flap and Radial Forearm Flap for Intraoral Reconstruction Jiunn-Tat Lee, MD,*Þ Peir-Rong Chen, MD,Þþ Li-Fu Cheng, MD,*Þ Chien-Hsing Wang, MD,* Meng-Si Wu, MD,* Chieh-Chi Huang, MD,Þ§ Sou-Hsin Chien, MD,Þ|| and Honda Hsu, MBChBÞ§ Abstract: Free flaps have become a popular option for the reconstruction of intraoral defects. The radial forearm f lap used to be the workhorse f lap for small and thin defects, but was associated with numerous donor-site morbidities. The proximal lateral leg flap can provide a thin and pliable tissue similar to the radial forearm flap but without the related donor-site morbidities. We compared the differences between these 2 flaps. Thirty-four patients with intraoral defects from September 2005 to October 2011 were reconstructed, using the radial forearm flap in 23 cases, and the proximal lateral leg flap in 11 cases. The radial forearm flap group had a success rate of 95.6%. The flap survival rate was 100% in the proximal lateral leg flap group. However, the difference was statistically insignificant. Skin graft was required in 22 of the 23 cases for the donor site of the radial forearm flap. Partial loss of the skin graft occurred in 5/22 (23%) of the patients, with exposure of tendons in 3/22 (14%). Delay in healing of the donor sites occurred in 6/23 (26%) of the patients. The donor sites of the proximal lateral leg flap were all closed primarily. One case developed wound dehiscence and this healed by conservative treatment. Long-term follow-up showed functional impairment of the donor forearm (reduced extension or grip strength) in 17% of the patients. Thirty percent of the patients developed sensory disturbance and 48% complained of poor outcome of the donor forearms. In the proximal lateral leg flap group, no motor or sensory functional deficits were seen. No patients complained of poor outcome of the donor legs. Primary closure of the donor site of the proximal lateral leg f lap could be performed if the flap width was less than 6 cm. This flap is useful for patients with small and thin intraoral defects and is associated with minimal donor-site morbidity when compared to the radial forearm flap. Key Words: radial forearm flap, proximal lateral leg flap, free perforator flap (Ann Plast Surg 2013;71: S43YS47)
F
ree flap transfer has become the primary choice of reconstruction in patients with head and neck cancer. Common conventional flaps that are used for soft tissue defects include the radial forearm flap,1,2 rectus abdominis flap,3 latissimus dorsi flap,4 free peroneal flap,5,6 among others, all with their advantages and disadvantages. With the wide variety of flaps available, the attention of the reconstructive surgeon is now focusing on the functional and aesthetic deficits of the flap’s donor sites. The radial forearm flap is ideal for small and thin defects in head and neck reconstruction cancer. It offers many advantages such as a constant surgical anatomy and a long vascular pedicle
Received October 3, 2013, and accepted for publication, after revision, October 6, 2013. From the *Division of Plastic Surgery, Tzu Chi Hualien General Hospital; †School of Medicine, Tzu Chi University; ‡Department of Otolaryngology, Buddhist Tzu Chi General Hospital, Hualien; §Division of Plastic Surgery, Tzu Chi Dalin General Hospital, Dalin; and ||Division of Plastic Surgery, Tzu Chi Taichung General Hospital, Taichung, Taiwan. Conflicts of interest and sources of funding: none declared. Reprints: Honda Hsu, MBChB, Division of Plastic Surgery, Tzu Chi Dalin General Hospital, Tzu Chi University, 2 Min-Sheng Rd, Dalin, Taiwan. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0148-7043/13/7101-S043 DOI: 10.1097/SAP.0000000000000047
Annals of Plastic Surgery
with large caliber vessels; however, the radial artery has to be sacrificed. It is also associated with a higher donor-site morbidity.7Y11 The introduction of perforator flaps has allowed the reconstructive surgeon to harvest flaps without the need to sacrifice muscle and major vasculature. Many surgeons now favor perforator flaps over myocutaneous flaps. Yajima et al12 introduced the proximal lateral leg f lap in 1994. They found that there were usually 1 or 2 perforators located at the distal portion of the proximal third of the lower lateral leg along the posterior margin of the fibula. These were usually the major nutrient arteries to the lateral half of the soleus muscle. This flap is based on these perforator vessels. If a thin and pliable flap is required in intraoral reconstruction, the proximal lateral leg flap will do as well as the radial forearm flap, but is associated with minimal donor-site morbidity. In this retrospective study, we analyzed and compared reliability, complications, and the donor-site morbidity between radial forearm flap and proximal lateral leg flap.
PATIENTS AND METHODS A retrospective study of medical records was performed. From September 2005 to October 2011, 34 patients (31 men and 3 women) with various intraoral defects after cancer ablation were reconstructed using, in 23 cases, a radial forearm flap and, in 11 cases, a proximal lateral leg flap. Patients who had undergone previous surgery or radiotherapy were excluded from this study. Only patients requiring soft tissue reconstruction without bone reconstruction were included for evaluation. A positive Allen test was a prerequisite for patients undergoing a radial forearm flap. For patients undergoing proximal lateral leg f lap, a handheld Doppler f lowmeter was used to localize the perforators preoperatively. The patient’s age, sex, tumor location, histology, stage, size of defect, flap size, flap dissection time, type of donor-site closure, complications, and flap failure rates were recorded. Function and cosmesis of the donor sites were followed up at the outpatient clinic. Functional evaluation of the donor limb (hand or leg) including ankle motility for the proximal lateral leg f lap and range of motion of the wrist and grip power for the radial forearm flap was done. Sensory disturbance at the area of the superficial radial nerve distribution distal to the flap donor site as well as cold intolerance of the hand and foot was also recorded. Each patient was evaluated for the cosmesis of the scar. All the linear scars, skin grafted areas, and scars of the skin graft donor thigh were assessed for width, height, vascularity, presence of suture/staple marks, pliability, and pigmentation. Finally, the patients were asked to self-evaluate the cosmesis and function of the donor site subjectively.
Surgical Procedure of Proximal Lateral Leg Perforator Flap The operative procedure was described in previous literature.12 We described it with some important modifications. The patient was placed in a supine position with the hip and knee f lexed to allow easy access to the lateral lower leg. The outline of the fibula bone was marked out, with the perforator at the distal portion of the proximal third of the lateral leg located with a handheld Doppler f lowmeter.
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FIGURE 1. A, Preoperative marking of proximal lateral leg f lap: 1 or 2 perforators could be located at the distal portion of the proximal third of the lateral leg. B, The f lap was elevated based on the septocutaneous perforator. C, A 7 4-cm2 defect in the left retromolar area with mandibular bone exposure. D, Proximal lateral leg f lap was used to reconstruct the defect.
The perforator is usually 7 to 15 cm from the fibula head. The outline of the flap was then designed to include the marked out spot (Fig. 1A). The anterior incision was made first and deepened until the deep fascia. A subfascial dissection was performed. Once the presence of the perforator was confirmed visually, the f lap was then elevated from the posterior border. The perforator vessel was then dissected intramuscularly with ligation of the muscular branches if it was found to be traversing the soleus muscle. If the perforator was found to be septocutaneous, then the dissection was straightforward. If more than 1 perforator is seen, then the larger perforator or the septocutaneous perforator was chosen. The soleus muscle was partially detached from the fibula, and the bifurcation of the perforator vessels from the main artery was located. The perforator was skeletonized at this time (Fig. 1B). One should note that due to the small caliber of the perforator vessels, vessel spasm can occur and one should allow some time for the spasm to pass. Before detaching the flap, flow in the flap should be confirmed, the flap was then ligated at the perforator vessel level and thus the major vessels are spared. The flap is then insetted with microsurgical anastomosis using 10-0 nylon (Fig. 1C, D). The donor site was closed primarily in all our cases.
RESULTS The radial forearm flap group consisted of 21 men and 2 women. Their mean age was 51 years (range, 34Y71 years). There were 10 men and 1 woman in the proximal lateral leg flap group. The mean age of this group was 55 years (range, 30Y68 years). The final pathology for all the patients was squamous cell carcinoma. The patients’ data are shown in Table 1. The mean time of flap harvesting for the S44
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radial forearm flap was 52 minutes (range, 40Y75 minutes). The flap had a mean size of 36 cm2 (range, 24Y60 cm2). The mean diameter of the radial artery pedicle was 2.3 mm (range, 1.5Y3.2 mm) and the mean length of the vascular pedicle was 9.5 cm (range, 6Y12 cm). The diameter of the vena comitante ranged from 1.2 to 2.5 mm (mean, 2.0 mm). In all cases of radial forearm f lap, 2 venous anastomoses (2 venae comitantes or 1 vena comitante and the cephalic vein) were performed. There were 1 arterial thrombosis and 1 venous thrombosis
TABLE 1. Patients Characteristics Group Sex Male Female Mean age, y Defect location Buccal Retromolar Tongue Mouth floor Soft palate Gingiva Mean follow-up, mo
PLLF Group
RFF Group
10 1 55
21 2 51
4 1 2 2 0 2 16
2 2 5 3 1 0 25
PLLF indicates proximal lateral leg f lap; RFF, radial forearm f lap.
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in this group. The flap with arterial thrombosis could not be salvaged due to delay in detection. This group had a success rate of 95.6% with 1 flap loss. Split-thickness skin grafting was required in 22 of the 23 cases for donor-site closure. Partial loss of the skin graft occurred in 5/22 (23%) of the patients, with exposure of tendons in 3/22 (14%) (Fig. 2A). One donor wound was closed primarily under tension. A 3 2-cm area of skin necrosis developed and this healed by conservative treatment. Delays in healing of the donor sites (skin-grafted or primarily closed) developed in 6/23 (26%) of the patients. No ischemic changes of the hand were seen (Table 2). The mean flap harvesting time for the proximal lateral leg f lap was 60 minutes (range, 48Y80 minutes). The mean f lap size was 32 cm2 (range, 4 6 to 6 8 cm2). The mean distance of the perforator
Proximal Lateral Leg Flap and Radial Forearm Flap
TABLE 2. Flaps Characteristics Group
PLLF Group
RFF Group
60 32 1.5 2.1 6.5 100
52 36 2.3 2.7 9.5 95.6
V V 9% (1/11)
23% (5/22) 14% (3/22) 26% (6/23)
Mean harvest time, min Mean flap size, cm2 Artery diameter, mm Venae comitantes diameter, mm Pedicle length, cm Flap survival rate, % Donor site Loss of skin graft Exposure of tendon Delayed healing
from the fibula head was 9.2 cm (range, 7Y15 cm). The mean diameter of the perforator artery was 1.5 mm (range, 0.8Y2.0 mm) and the mean length of the vascular pedicle was 6.5 cm (range, 5Y8 cm). Three flaps had only a single vein and 8 flaps had 2 veins. The diameter of the vena comitante ranged from 1.2 to 2.8 mm (mean, 2.1 mm). Clinically, in 45% (5/11) of the cases, we used the septocutaneous perforators; and in 55% of the cases, we used the musculocutaneous perforators. One venous thrombosis developed in this group and this was successfully rescued. The flap survival rate was 100% in this group. There was no statistical significance when comparing the survival rate between the 2 groups (P = 0.999). The donor sites were closed primarily in all 11 cases and no immobilization was required. One case developed wound dehiscence and this healed with conservative treatment. No peroneal nerve injury or other postoperative complications at the donor sites were seen in this group (Table 2). The mean follow-up time was 25 months for the radial forearm f lap group and 16 months for the proximal lateral leg flap group. The functional results at the intraoral recipient site were satisfactory in both groups. No secondary debulking procedures were required in both groups. In the radial forearm flap group, functional impairment of the donor forearm (reduced extension or grip strength) occurred in 4 (17%) patients. Seven (30%) patients complained of sensory disturbance (Fig. 2B). No cold intolerance was noted in this series. Six patients had hypertrophic scar of the forearm and 3 patients over the thigh. All patients had hyperpigmentation of the grafted skin over the forearm (Fig. 2B) and 16 patients of the donor thighs (Fig. 2C) (Table 3). In total, 11 (48%) patients complained of poor outcome (either functional deficit or poor cosmesis) of the donor forearm. In the proximal lateral leg f lap group, 2 (18%) patients had hypertrophic scar with pruritis and 2 (18%) had hyperpigmentation of the scar of the donor leg. Because no significant amount of soleus muscle was injured or removed, even in the presence of a musculocutaneous perforator, the motor function of the leg was not affected. Similarly, the peroneal nerve was also not disturbed and so no sensory deficit was seen. As no major vessels were sacrificed, none of the patients complained of circulatory or cold intolerance problems. In total, 83% patients had excellent
TABLE 3. Objective Assessment Group
FIGURE 2. A, Partial loss of skin graft at the donor site with tendon exposure. B, Poor cosmetic scar and sensory disturbance at the donor forearm. C, Hyperpigmented and hypertrophic scar of the donor thigh after harvesting of skin graft. * 2013 Lippincott Williams & Wilkins
PLLF Group
RFF Group
Hypertrophic scar
2/11 (18%)
Pigmentation
2/11 (18%)
Sensory loss Function impairment
0/11 (0%) 0/11 (0%)
6/23 (26%, forearm), 3/22 (14%, thigh) 23/23 (100%, forearm), 16/22 (73%, thigh) 7/23 (30%) 4/23 (17%)
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or good outcome of the donor leg (Fig. 3). Table 4 shows the summary of the subjective cosmetic and functional assessment by the patients.
DISCUSSION In the era before free tissue transfer, various pedicled f laps are available for the reconstruction of head and neck defects. Since the 1980s, free tissue transfer has provided the reconstructive surgeon with an alternative treatment option. Free f lap survival rate is now around 95%13Y16 due to advances in microsurgical equipment and techniques. It has now become the treatment of choice over the pedicled f lap. The rectus abdominis myocutaneous f lap and the radial forearm f lap were commonly used before the year 2000 at our center. However, with the introduction of perforator flaps, the anterolateral thigh flaps together with the radial forearm flap have become the workhorse flaps in the past decade. The anterolateral thigh f lap was especially useful when a larger and thicker flap was required. However, it is sometimes too bulky in some intraoral defects, and so thinning or secondary debulking of the f lap was required. Numerous studies have confirmed that the flap can be thinned primarily until a thickness of 3 to 5 mm.17Y19 But in our experience and as reported in other studies, this was at running the risk of damaging the subdermal plexus with resultant partial flap necrosis.20,21 Although a number of perforator flaps have been described in the literature, thin perforator flaps are still uncommon. In our center as well as in others, radial forearm f lap is still the favored f lap for small and thin intraoral defects. However, donorsite morbidity and complications remains a major issue for this f lap. Complications of the donor site can be divided mainly into functional and aesthetic problems. Commonly, split-thickness skin graft (STSG) was necessary for the donor-site defects. Richardson et al, in one of the largest studies of the radial forearm f lap donor sites, found that partial loss of the skin graft occurred in 16% of the patients, with exposure of tendons in 13%; delay in healing of the STSG in 22%.7 Lutz et al22 achieved a 98.4% take of the STSG after with a suprafascial
FIGURE 3. Uniformly good linear scar of the donor lateral leg, after the proximal lateral leg f lap was harvested. S46
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TABLE 4. Donor-Site Morbidity: Subjective Cosmetic and Functional Assessment Group Excellent Good Acceptable Poor
PLLF Group, n = 11, n (%)
RFF Group, n = 23, n (%)
2 (18) 6 (55) 3 (27) 0 (0)
0 (0) 2 (9) 10 (43) 11 (48)
elevation of the radial forearm flap. In our series, we used subfascial dissection technique for harvesting and this resulted in partial loss of the skin graft in 5 (23%) patients, with exposure of tendons in 3 (14%) patients. Delayed wound healing developed in 6 (27%) of our patients. Other methods of donor-site closure included pre-expansion with a tissue expander.23 Some has used full-thickness skin grafts (FTSGs),24 but studies have found no statistical difference between using STSG and FTSG with regard to incidence of tendon exposure and time to healing.25 Still others have used acellular dermal matrix26 or acellular dermal matrix together with STSG or FTSG for reconstruction of the donor site. Local f laps, according to Swanson et al27 produced a better aesthetic result and should be attempted whenever possible. Various local f laps had been described. These include a f lap based on a single ulnar artery perforator,28 local hatchet f lap,29 VYY advancement f lap islanded on a single ulnar artery perforator,30 and local Z-plasty31 are a few of the different local f laps described. But in all these different types of wound closure, they were aesthetically superior to STSG, but were still associated with functional problems. The incidence of functional deficits as a result of harvesting the radial forearm f lap varied. Richardson et al found significant reduced wrist extension and pinch and grip strength. They further found superficial radial nerve sensation was reduced in 24 (32%) patients at 1 year. Ten (14%) patients reported cold intolerance, and 21 (28%) patients complained of poor aesthetic result.7 Timmons et al8 described a high incidence of reduced hand or wrist strength (40%), persistent wrist stiffness (27%), and decreased sensation over the radial nerve distribution (47%). However, Lutz et al,22 in a very comprehensive study in 1999, found that there was no significant difference in range of motion, as well as grip power and pulp-to-pulp pinch power in 90% of the patients whose skin graft healed without complications. In 10% of the patients who developed delayed wound healing, they developed a significant decrease in wrist flexion as well as a decrease in grip power. They did notice 54% of the patients developed numbness in the area innervated by the superficial radial nerve, but these dysesthesias improved with time. We found that reduced extension or grip strength occurred in 4 (17%) of our patients. Seven (30%) patients complained of paresthesia over the superficial radial nerve distribution. No cold intolerance was noted in our patients and in Lutz series, as this maybe because we live in a country with warm subtropical climate. In our series, cosmesis of the donor forearm remained a major issue too. In total, 11 (48%) patients complained of either functional deficit or poor cosmesis of the donor forearm. Some patients wore long-sleeved shirts to hide the unsightly donor forearm scar the whole year round, even in extremely hot weather. Previous studies showed that there were many perforators in lateral leg.32 Yoshimura et al33 introduced the peroneal f lap in 1984. This f lap can be harvested with the fibular bone as an osteocutaneous f lap or with the underlying soleus muscle as a musculocutaneous f lap. The pedicle, which is the peroneal artery, is sacrificed in the harvesting of this flap. With the introduction of the concept of perforator f laps, Yajima et al12 used the proximal lateral leg flap based on its perforators, thus preserving the peroneal artery. Wolff et al34 used perforator flaps from the lateral lower leg for intraoral reconstruction. * 2013 Lippincott Williams & Wilkins
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In this series, we used the proximal lateral leg flap in 11 selected primary case patients. All the flaps in our 11 patients survived well. Due to the short pedicle of this flap, we chose the lingual vessels and the facial vessels or their branches as their recipient vessels. The small diameter of pedicle vessels was the main challenge for anastomosis. The size of the perforator arteries may at times be less than 1.0 mm. Venous thrombosis was seen in 5 (28%) of 18 flaps in the series of Kawamura et al.35 They noted that the venous walls of these perforator flaps were very thin and this could be related to the high complication rate seen. In our series, 1 venous thrombosis developed and was successfully rescued. Due to the small diameter of the vessels, a high degree of microsurgical skills is required. It should be undertaken by skilled experienced microsurgeons. When vessel spasm occurs, one should give the vessel some time, f lush with lidocaine or prostaglandin E1 and wait for the spasm to pass. Donor-site morbidities have become an important factor in the selection of flaps. The donor site of proximal lateral leg flap can usually be closed primarily when the width of this flap was less than 6 cm. Only a linear scar was seen. We usually perform a pinch test to determine if the donor site can be closed primarily. There were no motor or sensory functional disturbances. The main vessels of the leg were preserved, so further flap harvesting, like the fibula osteocutaneous flap, from the same limb are still a possibility. Distal circulation and cold intolerance was not a problem as there were no disturbances to the blood supply of the foot. However, the proximal lateral leg flap has a shorter pedicle when compared to the radial forearm flap. In patients undergoing excision of secondary or recurrent head and neck tumors as well as in patients who has undergone prior irradiation, the shorter pedicle of the flap increases the difficulty with anastomosis and ultimately may increase the risk of flap failure. Whereas the radial forearm flap has a longer pedicle to allow for anastomosis on the contralateral side of the neck if there is depletion of vessels for anastomosis on the ipsilateral neck and close to the anastomosis site. We suggest that this flap can be used for reconstruction of small intraoral defects in selected primary cases. In conclusion, although there is a general reluctance to use perforator-based f laps on the assumption that the pedicle is short with small caliber vessels, perforator-based f laps only cause minimal donor-site morbidity. This study shows that the f lap failure rate of using proximal lateral leg f lap was no higher when compared to radial forearm f lap used. But due to small number of proximal lateral leg f lap in this series, a larger series is required to allow for adequate comparison of f lap survival.
REFERENCES 1. Yang GF, Chen PJ, Gao YZ, et al. Forearm free skin flap transplantation: a report of 56 cases, 1981. Br J Plast Surg. 1997;50:162Y165. 2. Soutar DS, Scheker LR, Tanner SB, et al. The radial forearm flap: a versatile method for intra-oral reconstruction. Br J Plast Surg. 1983;36:1Y8. 3. Kroll SS, Baldwin BJ. Head and neck reconstruction with the rectus abdominis free flap. Clin Plast Surg. 1994;21:97Y105. 4. Chowdhury CR, McLean NR, Harrop-Griffiths K, et al. The repair of defects in the head and neck region with the latissimus dorsi myocutaneous flap. J Laryngol Otol. 1988;102:1127Y1132. 5. Saito H, Yoshimura M, Tsuda G, et al. Free peroneal and its composite flap: a distant donor for head and neck reconstruction. Auris Nasus Larynx. 1993;20:63Y71. 6. Saito H, Kimura Y, Tsuda G, et al. Free peroneal skin flap for oropharyngeal reconstruction. Scand J Plast Reconstr Surg Hand Surg. 1999;33:41Y45. 7. Richardson D, Fisher SE, Vaughan ED, et al. Radial forearm flap donor-site complications and morbidity: a prospective study. Plast Reconstr Surg. 1997; 99:109Y115. 8. Timmons MJ, Missotten FE, Poole MD, et al. Complications of radial forearm flap donor sites. Br J Plast Surg. 1986;39:176Y178.
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9. Sardesai MG, Fung K, Yoo JH, et al. Donor-site morbidity following radial forearm free tissue transfer in head and neck surgery. J Otolaryngol Head Neck Surg. 2008;37:411Y416. 10. Kao HK, Chang KP, Wei FC, et al. Comparison of the medial sural artery perforator flap with the radial forearm flap for head and neck reconstructions. Plast Reconstr Surg. 2009;124:1125Y1132. 11. Loreti A, Di Lella G, Vetrano S, et al. Thinned anterolateral thigh cutaneous flap and radial fasciocutaneous forearm flap for reconstruction of oral defects: comparison of donor site morbidity. J Oral Maxillofac Surg. 2008;66:1093Y1098. 12. Yajima H, Ishida H, Tamai S. Proximal lateral leg flap transfer utilizing major nutrient vessels to the soleus muscle. Plast Reconstr Surg. 1994;93:1442Y1448. 13. Suh JD, Sercarz JA, Abemayor E, et al. Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 2004;130:962Y966. 14. Bianchi B, Copelli C, Ferrari S, et al. Free flaps: outcomes and complications in head and neck reconstructions. J Craniomaxillofac Surg. 2009;37:438Y442. 15. Simpson KH, Murphy PG, Hopkins PM, et al. Prediction of outcomes in 150 patients having microvascular free tissue transfers to the head and neck. Br J Plast Surg. 1996;49:267Y273. 16. Eckardt A, Fokas K. Microsurgical reconstruction in the head and neck region: an 18-year experience with 500 consecutive cases. J Craniomaxillofac Surg. 2003;31:197Y201. 17. Rajacic N, Gang RK, Krishnan J, et al. Thin anterolateral thigh free flap. Ann Plast Surg. 2002;48:252Y257. 18. Yang WG, Chiang YC, Wei FC, et al. Thin anterolateral thigh perforator flap using a modified perforator microdissection technique and its clinical application for foot resurfacing. Plast Reconstr Surg. 2006;117:1004Y1008. 19. Kimura, N, Satoh, K, Hasumi, T, et al. Clinical application of the free thin anterolateral thigh flap in 31 consecutive patients. Plast Reconstr Surg. 2001;108:1197Y1208. 20. Sharabi SE, Hatef DA, Koshy JC, et al. Is primary thinning of the anterolateral thigh flap recommended? Ann Plast Surg. 2010;65:555Y559. 21. Ross GL, Dunn R, Kirkpatrick J, et al. To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects. Br J Plast Surg. 2003;56:409Y413. 22. Lutz BS, Wei FC, Chang SC, et al. Donor site morbidity after suprafascial elevation of the radial forearm flap: a prospective study in 95 consecutive cases. Plast Reconstr Surg. 1999;103:132Y137. 23. Bonaparte JP, Corsten MJ, Allen M. Cosmetic and functional outcomes after preoperative tissue expansion of radial forearm free flap donor sites: a cohort study. J Otolaryngol Head Neck Surg. 2011;40:427Y435. 24. Kaltman JM, McClure SA, Lopez EA, et al. Closure of the radial forearm free flap donor site with a full-thickness skin graft from the inner arm: a preferred technique. J Oral Maxillofac Surg. 2012;70:1459Y1463. 25. Davis WJ 3rd, Wu C, Sieber D, et al. A comparison of full and split thickness skin grafts in radial forearm donor sites. J Hand Microsurg. 2011;3:18Y24. 26. Rowe NM, Morris L, Delacure MD. Acellular dermal composite allografts for reconstruction of the radial forearm donor site. Ann Plast Surg. 2006;57:305Y311. 27. Swanson E, Boyd JB, Manktelow RT. The radial forearm flap: reconstructive applications and donor-site defects in 35 consecutive patients. Plast Reconstr Surg. 1990;85:258Y266. 28. Hsieh CH, Kuo YR, Yao SF, et al. Primary closure of radial forearm flap donor defects with a bilobed flap based on the fasciocutaneous perforator of the ulnar artery. Plast Reconstr Surg. 2004;113:1355Y1360. 29. Lane JC, Swan MC, Cassell OC. Closure of the radial forearm donor site using a local hatchet flap: analysis of 45 consecutive cases. Ann Plast Surg. 2013; 70:308Y312. 30. Shoaib T, Van Niekerk WJ, Morley S, et al. The ulnar artery perforator based islanded V-Y flap closure of the radial forearm flap donor site. J Plast Reconstr Aesthet Surg. 2009;62:421Y423. 31. Bashir MA, Fung V, Kernohan MD. ‘‘Z-plasty’’ modification of ulnar-based fasciocutaneous flap for closure of the radial forearm flap donor defect. Ann Plast Surg. 2010;64:22Y23. 32. Chen YL, Zheng BG, Zhu JM, et al. Microsurgical anatomy of the lateral skin flap of the leg. Ann Plast Surg. 1985;15:313Y318. 33. Yoshimura M, Imura S, Shimamura K, et al. Peroneal flap for reconstruction in the extremity: preliminary report. Plast Reconstr Surg. 1984;74:402Y409. 34. Wolff KD, Holzle F, Nolte D. Perforator flaps from the lateral lower leg for intraoral reconstruction. Plast Reconstr Surg. 2004;113:107Y113. 35. Kawamura K, Yajima H, Kobata Y, et al. Clinical applications of free soleus and peroneal perforator flaps. Plast Reconstr Surg. 2005;115:114Y119.
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