Original Article: WSRM 2015 Scientific Paper
Expanding the Utilization of the Osteocutaneous Radial Forearm Free Flap beyond Mandibular Reconstruction Dustin A. Silverman, BA1 Wojciech H. Przylecki, MD1 Yelizaveta Shnayder, MD, FACS2 Terance T. Tsue, MD, FACS2 Douglas A. Girod, MD, FACS2 Brian T. Andrews, MD, MA1,2
Kansas City, Kansas 2 Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
Address for correspondence Brian T. Andrews, MD, MA, Department of Plastic Surgery, University of Kansas Medical Center, 3901 Rainbow Blvd, MS 3051, Kansas City, KS 66160 (e-mail: [email protected]).
J Reconstr Microsurg
Abstract
Keywords
► osteocutaneous radial forearm free flap reconstruction ► aesthetic units ► complications
Background The osteocutaneous radial forearm free flap (OCRFFF) for mandibular reconstruction has been well described. Despite this flap’s utility in the repair of such defects, the indications for the OCRFFF have continued to expand in recent years. The advantages of the OCRFFF allow for a high degree of versatility in the reconstruction of the various anatomical and aesthetic units of the head and neck. In this review, the authors aim to explore the successful utilization of the OCRFFF beyond the reconstruction of composite mandibular defects. Methods A retrospective chart review was performed. All subjects who underwent OCRFFF reconstruction at a tertiary academic center between January 2004 and December 2014 were identified. A total of six patients undergoing this procedure for indications other than composite mandibular defects of the head and neck were included. Results A total of six patients underwent OCRFFF reconstruction for correction of nonmandibular defects. Flap success was experienced in six of six cases (100%). Indications included midface maxillary reconstruction (N ¼ 2), orbit reconstruction (N ¼ 1), frontal sinus and forehead reconstruction (N ¼ 2), and subglottic stenosis reconstruction (N ¼ 1). There were no immediate perioperative complications. On long-term follow-up, one subject developed a nasocutaneous fistula following radiation and eventually required maxillary hardware removal. Conclusion As a result of its growing role and versatility, the OCRFFF should be incorporated as a multipurpose tool in the armamentarium of reconstructive microvascular surgeons in the repair of composite head and neck defects beyond the mandible.
The reconstruction of head and neck defects presents a unique challenge to today’s microvascular surgeons. Given the wide variety of microvascular free tissues available for transfer and the complexity of head and neck defects, the selection of the appropriate flap is of particular importance. To address this issue, several authors have developed classifi-
cation schemes in an attempt to simplify and standardize the numerous reconstructive approaches.1–6 Despite these novel algorithms, a universal methodology has yet to be adopted. The osteocutaneous radial forearm free flap (OCRFFF) represents a versatile reconstructive option for the modern head and neck surgeon, yet its use is often overlooked and
received September 27, 2015 accepted November 28, 2015
Copyright © by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0035-1571251. ISSN 0743-684X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
1 Department of Plastic Surgery, University of Kansas Medical Center,
Expanding the Utilization of the Osteocutaneous Radial Forearm Free Flap
Methods A retrospective review was completed for all subjects who underwent OCRFFF reconstruction at a tertiary academic center between January 2004 and December 2014. Of the 193 patients identified over the 10-year period, a total of 6 individuals requiring OCRFFF head and neck microvascular reconstruction for indications other than mandibular defects were included in the final analysis. Data collected encompassed basic patient demographics (e.g., age, sex, race and ethnicity, smoking and alcohol abuse/dependence, and prior radiation), the etiology and location of the primary tumor, clinic notes, operative logs, and inpatient hospital records. Outcome measures included flap success, recipient-site morbidity, and donor-site morbidity. Surgical complications during both the perioperative and long-term follow-up periods were also tabulated for each patient. Due to the limited sample size of the population, only basic descriptive statistics and frequencies were calculated; univariate and multivariate analyses were not attempted.
Surgical Technique The technique for OCRFFF harvest has been well described throughout the literature.10–14 To confirm adequate circulation and aid in the appropriate selection of the donor arm, a standard subjective and objective Allen test is performed on both forearms and reviewed prior to surgery. The respective surgical techniques for insetting of the vascularized radius bone and skin paddle vary depending on the location of the anatomical defect within the head and neck. As such, the number and type of arterial and venous anastomoses, length of bone, and rigid fixation of the vascularized bone to surrounding osseous structures were largely variable; such decisions are determined intraoperatively.
Results A total of six patients underwent OCRFFF head and neck microvascular reconstruction for indications other than segmental mandibular defects. The study population comprised four males (66.7%) and two females (33.3%). Patient ages ranged from 20 to 78 years, with a median age of 73 years. Three of six patients (50.0%) carried a previous smoking history while none endorsed any history of alcohol abuse or dependence. Two of six (33.3%) patients had undergone prior irradiation therapy. One of these previously radiated patients had previously undergone multiple resections of an olfactory groove meningioma followed by adjuvant radiation therapy. The second patient had been treated with radiation therapy in addition to multiple surgical interventions for recurrent squamous cell carcinoma of the eyelid. These results are displayed in ►Table 1. Indications for OCRFFF reconstruction varied in their etiologies and respective anatomical locations within the head and neck region (►Table 1). The locations of the defects necessitating surgical repair were as follows: maxilla (two patients), orbit (one patient), frontal sinus and forehead (two patients), and cricoid/trachea (one patient). Of the six patients included in this series, two subjects required midface maxillary reconstructions. The first individual presented with a naso-oral fistula following prior rhinectomy and maxillectomy for squamous cell carcinoma of the nasal septal
Table 1 Patient demographics, etiology, and location of defect necessitating OCRFFF reconstruction Gender
Age (y)
Etiology
Location
Male
69
Naso-oral fistula
Female
20
Osteomyelitis
Maxilla
No
No
No
No
Male
78
Squamous cell carcinoma
Eyelid, cheek, orbit
No
No
No
No
Female
68
Bilateral frontal sinocutaneous fistulas/ exposed implant
Medial canthus, skull base
No
No
Yes
No
Male
77
Pott puffy tumor
Forehead
Yes
No
No
No
Male
78
Subglottic stenosis
Cricoid/trachea
Yes
No
Yes
No
Maxilla
Abbreviation: OCRFFF, osteocutaneous radial forearm free flap. Journal of Reconstructive Microsurgery
History of: Smoking
Alcohol abuse/ dependence
Prior radiation
Prior chemotherapy
Yes
No
No
No
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
underutilized. The utility of this specific flap has been widely published throughout the literature and improvements in surgical technique, namely, prophylactic plating of the donor radius, have reduced the incidence of perioperative complications in recent years.7–11 While the OCRFFF has traditionally been used to reconstruct complex mandibular defects, the indications for the OCRFFF have expanded to all areas of the head and neck as well as cricotracheal abnormalities. Advantages associated with the use of this specific flap are its pliable skin paddle, long vascular pedicle, and availability of vascularized cortical bone. These characteristics translate well across the various anatomical subsites of the head and neck region and allow the aesthetic qualities of the native tissues to be accurately reproduced. In select instances, the OCRFFF is well suited to meet the respective demands of these subsites and leads to high rates of clinical success, with minimal postoperative complications. The authors present a small series of patients who underwent OCRFFF head and neck reconstruction for various indications excluding those used to reconstruct the mandibular defects.
Silverman et al.
lip and primary palate. A second patient with Down syndrome was found to have developed osteomyelitis and loss of a Le Fort maxillary advancement flap for severe sleep apnea as a child. A single subject required orbit reconstruction following multiple recurrences of left eyelid squamous cell carcinoma with involvement of the cheek and orbit at the time of presentation (►Fig. 1). Two subjects required bony reconstruction of their forehead and frontal sinus; the first subject had bilateral frontal sinocutaneous fistulas and an exposed Medpor implant used previously to reconstruct the skull base following resection of a recurrent olfactory groove meningioma. The second patient had a Pott puffy tumor—a subperiosteal abscess with concomitant osteomyelitis—of the right frontal bone secondary to chronic sinusitis (►Fig. 2). The last of six patients underwent OCRFFF reconstruction to repair severe subglottic stenosis with an accompanying tracheoesophageal fistula following a traumatic intubation. OCRFFF flap survival was experienced in six of six subjects (100%). There were no recipient-site complications during the immediate perioperative period. During long-term follow-up, one patient developed a nasocutaneous fistula ultimately leading to maxillary hardware removal to allow for spontaneous closure of the fistula. Aesthetic outcomes were determined to be appropriate in all cases with restoration of native tissue contours.
Discussion Over the past two decades, a number of composite and noncomposite microvascular free tissue transfers have become increasingly available to head and neck surgeons.15,16 Several
Silverman et al.
authors have proposed novel algorithms to further classify defects of the head and neck and aid in selection of the donor site.1–6 Despite these classification schemes, no single reconstructive technique has been universally adopted as the mainstay of treatment for a given aesthetic deficit. Defects involving the maxilla and/or orbit remain difficult areas for modern facial reconstruction as a result of the threedimensional relationship of the midface skeleton and overlying soft tissues. To accurately reproduce the natural bony and soft tissue contours of the midface region, the versatility and unique characteristics of the OCRFFF make it a particularly amenable tool in addressing these challenges. At many institutions, the fibula flap remains the workhorse for midface microvascular reconstruction, yet its bulky and tethered skin paddle often results in suboptimal fasciocutaneous reconstructions and requires multiple revisions. Given the highly variable nature of anterior maxillary defects, surgeons Cordeiro and Santamaria introduced a classification system based on the extent of midface structures and surrounding tissues including palate and orbital floor contents that are resected.1,2 The authors of this series recognize the utility of this system and tend to preferentially select the fibula flap in cases involving dental rehabilitation; however, when rehabilitation is determined to neither be warranted or possible, surgeons at our institution prefer the OCRFFF as the first-line reconstructive option. Chepeha et al demonstrated flap success in a series of 10 patients with maxillectomy defects in which the entire infraorbital rim was reconstructed with an OCRFFF.17 The results indicated flap success in all patients and favorable aesthetic and functional outcomes. In a similar
Fig. 1 Recurrent squamous cell carcinoma of left eyelid with lateral orbit involvement. (A) Preoperative left lateral orbit squamous cell carcinoma. (B) Intraoperative flap inset. (C) Postoperative result prior to ocular prosthesis.
Fig. 2 Pott’s puffy tumor with involvement of forehead secondary to chronic sinusitis. (A) Preoperative frontal sinus cutaneous fistula. (B) Intraoperative flap positioning. (C) Postoperative results. Journal of Reconstructive Microsurgery
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Expanding the Utilization of the Osteocutaneous Radial Forearm Free Flap
manner, other authors specifically endorse its effectiveness in treating anterior maxillectomy defects citing the close approximation of radial bone stock to that of the maxilla and conformability of the forearm soft tissue to the palate and naso-oral cavities.14 The present study mirrors these findings. The use of the OCRFFF as a “sandwich” free flap has also been described for the reconstruction of larger, bilateral subtotal maxillectomy defects.18 While the maxillectomy patients in our series experienced a lesser degree of soft tissue and bony structural loss, neither the “sandwich” flap nor adoption of a standardized classification system has been implemented at our institution. In contrast, others support the use of the fibula osteocutaneous free flap, particularly for lower maxillary defects involving the alveolar and palatal surfaces.19 In a retrospective review, Futran et al described success of the fibula flap in 26 of 27 patients with limited perioperative complications. While their series notes the fibula’s utility to reconstruct a variety of maxillary defects, they argue that the flap becomes limited in its ability to offer full orbitozygomatic support as the complexity of defects increases. The authors concur with this assessment and prefer the use of the OCRFFF for more complicated reconstructions, particularly in cases with undermining of orbital and zygomaticomaxillary buttress structures and when dental rehabilitation is neither indicated nor desired by the patient.20 Within our series, a single patient with recurrent left eyelid squamous cell carcinoma involving the cheek and orbit had operative success with restoration of the lateral and infraorbital rim. Following postoperative radiation, this individual elected for placement of an ocular prosthesis as previous epicanthal cancer had necessitated the sacrifice of his left eye; excellent aesthetic results were obtained without complication (►Fig. 1). While midface repairs predominate, the OCRFFF may also be utilized for the correction of frontal sinus and skull base defects. Within our series, a total of two patients underwent upper face reconstruction. In the patient presenting with bilateral frontal sinocutaneous fistulas following multiple resections of a recurrent olfactory groove meningioma, the OCRFFF was used to recreate the frontal bar and provide supraorbital support after frontal sinus obliteration, removal of prior hardware, and debridement of nonviable soft tissue and bone. As Pott puffy tumor is relatively uncommon clinically, literature surrounding this entity and subsequent surgical treatment is largely limited to case reports and small series.21–23 Less commonly, Pott puffy tumor may arise secondary to trauma, namely, fractures of the frontal sinus. A study of two such cases by Bluebond-Langner et al described a novel technique utilizing the fibula free flap for bony reconstruction of the horizontal buttress in a singlestaged approach following obliteration of the frontal sinus.24 While the fibula flap offers larger bone stock available for harvest, the bony mismatch is problematic based upon the thinner nature of the frontal bone and surrounding structures. As such, the OCRFFF may represent a more suitable alternative with respect to bone quality in cases involving limited frontal sinus defects. Additionally, the malleable skin paddle is easy to work with and can be manipulated once the Journal of Reconstructive Microsurgery
Silverman et al.
OCRFFF bone is fixated. The skin paddle can be used to reconstruct the forehead skin externally or be de-epithelialized to fill and obliterate the frontal sinus or repair a skull base injury if needed and both were done in this study. To date, there has been limited experience with the surgical correction of partial cricotracheal defects.25–28 Our experience includes a single case involving the reconstruction of severe subglottic stenosis with a concomitant tracheoesophageal fistula, which developed secondary to a traumatic intubation. Before presenting to our institution, surgical management included laryngotracheoplasty with failure of the nasal septal cartilage graft resulting in chronic prolapse of the esophagus into the trachea. By utilizing the OCRFFF, the surgical goal of correcting the patient’s subglottic stenosis was ultimately achieved. As the use of the OCRFFF for partial cricotracheal abnormalities represents a recent advancement in this field, more experience is clearly needed. Nonetheless, utilization of the OCRFFF for the reconstruction of partial cricotracheal defects represents a promising new area for improvement in head and neck surgery.
Conclusion This small series illustrates the versatility of the OCRFFF and demonstrates its utility in the repair of nonmandible defects containing both soft tissue and bony components with minimal postsurgical complications. As a result of its growing role and efficacy as a reconstructive option, the OCRFFF should be considered an optimal choice in the repair of composite head and neck defects beyond the mandible.
References 1 Cordeiro
2
3
4
5
6
7
8
PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg 2000;105(7):2331–2346, discussion 2347–2348 Santamaria E, Cordeiro PG. Reconstruction of maxillectomy and midfacial defects with free tissue transfer. J Surg Oncol 2006;94(6): 522–531 Muresan C, Hui-Chou HG, Dorafshar AH, Manson PN, Rodriguez ED. Forehead reconstruction with microvascular flaps: utility of aesthetic subunits. J Reconstr Microsurg 2012;28(5):319–326 Hicks DL, Watson D. Soft tissue reconstruction of the forehead and temple. Facial Plast Surg Clin North Am 2005;13(2): 243–251, vi Singh DJ, Bartlett SP. Aesthetic considerations in nasal reconstruction and the role of modified nasal subunits. Plast Reconstr Surg 2003;111(2):639–648, discussion 649–651 Rahman M, Jefferson N, Stewart DA, Oliver R, Walsh WR, Gianoutsos MP. The histology of facial aesthetic subunits: implications for common nasal reconstructive procedures. J Plast Reconstr Aesthet Surg 2010;63(5):753–756 Arganbright JM, Tsue TT, Girod DA, et al. Outcomes of the osteocutaneous radial forearm free flap for mandibular reconstruction. JAMA Otolaryngol Head Neck Surg 2013;139(2):168–172 Silverman DA, Przylecki WH, Arganbright JM, et al. Evaluation of bone length and number of osteotomies utilizing the osteocutaneous radial forearm free flap for mandible reconstruction: An 8-year review of complications and flap survival. Head Neck 2014 (e-pub ahead of print). doi:10.1002/hed.23919
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Expanding the Utilization of the Osteocutaneous Radial Forearm Free Flap
9 Militsakh ON, Werle A, Mohyuddin N, et al. Comparison of radial
10
11
12
13
14
15
16
17
18
forearm with fibula and scapula osteocutaneous free flaps for oromandibular reconstruction. Arch Otolaryngol Head Neck Surg 2005;131(7):571–575 Bowers KW, Edmonds JL, Girod DA, Jayaraman G, Chua CP, Toby EB. Osteocutaneous radial forearm free flaps. The necessity of internal fixation of the donor-site defect to prevent pathological fracture. J Bone Joint Surg Am 2000;82(5):694–704 Werle AH, Tsue TT, Toby EB, Girod DA. Osteocutaneous radial forearm free flap: its use without significant donor site morbidity. Otolaryngol Head Neck Surg 2000;123(6):711–717 Shnayder Y, Tsue TT, Toby EB, Werle AH, Girod DA. Safe osteocutaneous radial forearm flap harvest with prophylactic internal fixation. Craniomaxillofac Trauma Reconstr 2011;4(3):129–136 Avery CM. Review of the radial free flap: still evolving or facing extinction? Part two: osteocutaneous radial free flap. Br J Oral Maxillofac Surg 2010;48(4):253–260 Villaret DB, Futran NA. The indications and outcomes in the use of osteocutaneous radial forearm free flap. Head Neck 2003;25(6): 475–481 Urken ML. Composite free flaps in oromandibular reconstruction. Review of the literature. Arch Otolaryngol Head Neck Surg 1991; 117(7):724–732 Frederick JW, Sweeny L, Carroll WR, Peters GE, Rosenthal EL. Outcomes in head and neck reconstruction by surgical site and donor site. Laryngoscope 2013;123(7):1612–1617 Chepeha DB, Moyer JS, Bradford CR, Prince ME, Marentette L, Teknos TN. Osseocutaneous radial forearm free tissue transfer for repair of complex midfacial defects. Arch Otolaryngol Head Neck Surg 2005;131(6):513–517 Cordeiro PG, Bacilious N, Schantz S, Spiro R. The radial forearm osteocutaneous “sandwich” free flap for reconstruction of the
19
20
21 22
23
24
25
26
27
28
Silverman et al.
bilateral subtotal maxillectomy defect. Ann Plast Surg 1998;40(4): 397–402 Futran ND, Wadsworth JT, Villaret D, Farwell DG. Midface reconstruction with the fibula free flap. Arch Otolaryngol Head Neck Surg 2002;128(2):161–166 Andrades P, Rosenthal EL, Carroll WR, Baranano CF, Peters GE. Zygomatic-maxillary buttress reconstruction of midface defects with the osteocutaneous radial forearm free flap. Head Neck 2008; 30(10):1295–1302 Sullivan CD, Poetker DM. Anterior table remodeling after treatment for Pott’s puffy tumor. Am J Otolaryngol 2013;34(3):265–267 Shin JW, Choi IG, Jung SN, Kwon H, Shon WI, Moon SH. Pott puffy tumor appearing with a frontocutaneous fistula. J Craniofac Surg 2012;23(2):e158–e160 Akiyama K, Karaki M, Mori N. Evaluation of adult Pott’s puffy tumor: our five cases and 27 literature cases. Laryngoscope 2012; 122(11):2382–2388 Bluebond-Langner R, Jackowe D, Rodriguez ED. Simultaneous obliteration and treatment of infected frontal sinus fractures: novel use of the fibula flap. J Craniofac Surg 2007;18(3):680–683 Al-Khudari S, Sharma S, Young W, Stapp R, Ghanem TA. Osteocutaneous radial forearm reconstruction of large partial cricotracheal defects. Head Neck 2013;35(8):E254–E257 Fujiwara T, Nishino K, Numajiri T. Tracheal reconstruction with a prefabricated and double-folded radial forearm free flap. J Plast Reconstr Aesthet Surg 2009;62(6):790–794 Teng MS, Malkin BD, Urken ML. Prefabricated composite free flaps for tracheal reconstruction: a new technique. Ann Otol Rhinol Laryngol 2005;114(11):822–826 Yu P, Clayman GL, Walsh GL. Human tracheal reconstruction with a composite radial forearm free flap and prosthesis. Ann Thorac Surg 2006;81(2):714–716
Journal of Reconstructive Microsurgery
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Expanding the Utilization of the Osteocutaneous Radial Forearm Free Flap
Expanding the Utilization of the Osteocutaneous Radial Forearm Free Flap beyond Mandibular Reconstruction Dustin A. Silverman, BA1 Wojciech H. Przylecki, MD1 Yelizaveta Shnayder, MD, FACS2 Terance T. Tsue, MD, FACS2 Douglas A. Girod, MD, FACS2 Brian T. Andrews, MD, MA1,2
Kansas City, Kansas 2 Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
Address for correspondence Brian T. Andrews, MD, MA, Department of Plastic Surgery, University of Kansas Medical Center, 3901 Rainbow Blvd, MS 3051, Kansas City, KS 66160 (e-mail: [email protected]).
J Reconstr Microsurg
Abstract
Keywords
► osteocutaneous radial forearm free flap reconstruction ► aesthetic units ► complications
Background The osteocutaneous radial forearm free flap (OCRFFF) for mandibular reconstruction has been well described. Despite this flap’s utility in the repair of such defects, the indications for the OCRFFF have continued to expand in recent years. The advantages of the OCRFFF allow for a high degree of versatility in the reconstruction of the various anatomical and aesthetic units of the head and neck. In this review, the authors aim to explore the successful utilization of the OCRFFF beyond the reconstruction of composite mandibular defects. Methods A retrospective chart review was performed. All subjects who underwent OCRFFF reconstruction at a tertiary academic center between January 2004 and December 2014 were identified. A total of six patients undergoing this procedure for indications other than composite mandibular defects of the head and neck were included. Results A total of six patients underwent OCRFFF reconstruction for correction of nonmandibular defects. Flap success was experienced in six of six cases (100%). Indications included midface maxillary reconstruction (N ¼ 2), orbit reconstruction (N ¼ 1), frontal sinus and forehead reconstruction (N ¼ 2), and subglottic stenosis reconstruction (N ¼ 1). There were no immediate perioperative complications. On long-term follow-up, one subject developed a nasocutaneous fistula following radiation and eventually required maxillary hardware removal. Conclusion As a result of its growing role and versatility, the OCRFFF should be incorporated as a multipurpose tool in the armamentarium of reconstructive microvascular surgeons in the repair of composite head and neck defects beyond the mandible.
The reconstruction of head and neck defects presents a unique challenge to today’s microvascular surgeons. Given the wide variety of microvascular free tissues available for transfer and the complexity of head and neck defects, the selection of the appropriate flap is of particular importance. To address this issue, several authors have developed classifi-
cation schemes in an attempt to simplify and standardize the numerous reconstructive approaches.1–6 Despite these novel algorithms, a universal methodology has yet to be adopted. The osteocutaneous radial forearm free flap (OCRFFF) represents a versatile reconstructive option for the modern head and neck surgeon, yet its use is often overlooked and
received September 27, 2015 accepted November 28, 2015
Copyright © by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0035-1571251. ISSN 0743-684X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
1 Department of Plastic Surgery, University of Kansas Medical Center,
Expanding the Utilization of the Osteocutaneous Radial Forearm Free Flap
Methods A retrospective review was completed for all subjects who underwent OCRFFF reconstruction at a tertiary academic center between January 2004 and December 2014. Of the 193 patients identified over the 10-year period, a total of 6 individuals requiring OCRFFF head and neck microvascular reconstruction for indications other than mandibular defects were included in the final analysis. Data collected encompassed basic patient demographics (e.g., age, sex, race and ethnicity, smoking and alcohol abuse/dependence, and prior radiation), the etiology and location of the primary tumor, clinic notes, operative logs, and inpatient hospital records. Outcome measures included flap success, recipient-site morbidity, and donor-site morbidity. Surgical complications during both the perioperative and long-term follow-up periods were also tabulated for each patient. Due to the limited sample size of the population, only basic descriptive statistics and frequencies were calculated; univariate and multivariate analyses were not attempted.
Surgical Technique The technique for OCRFFF harvest has been well described throughout the literature.10–14 To confirm adequate circulation and aid in the appropriate selection of the donor arm, a standard subjective and objective Allen test is performed on both forearms and reviewed prior to surgery. The respective surgical techniques for insetting of the vascularized radius bone and skin paddle vary depending on the location of the anatomical defect within the head and neck. As such, the number and type of arterial and venous anastomoses, length of bone, and rigid fixation of the vascularized bone to surrounding osseous structures were largely variable; such decisions are determined intraoperatively.
Results A total of six patients underwent OCRFFF head and neck microvascular reconstruction for indications other than segmental mandibular defects. The study population comprised four males (66.7%) and two females (33.3%). Patient ages ranged from 20 to 78 years, with a median age of 73 years. Three of six patients (50.0%) carried a previous smoking history while none endorsed any history of alcohol abuse or dependence. Two of six (33.3%) patients had undergone prior irradiation therapy. One of these previously radiated patients had previously undergone multiple resections of an olfactory groove meningioma followed by adjuvant radiation therapy. The second patient had been treated with radiation therapy in addition to multiple surgical interventions for recurrent squamous cell carcinoma of the eyelid. These results are displayed in ►Table 1. Indications for OCRFFF reconstruction varied in their etiologies and respective anatomical locations within the head and neck region (►Table 1). The locations of the defects necessitating surgical repair were as follows: maxilla (two patients), orbit (one patient), frontal sinus and forehead (two patients), and cricoid/trachea (one patient). Of the six patients included in this series, two subjects required midface maxillary reconstructions. The first individual presented with a naso-oral fistula following prior rhinectomy and maxillectomy for squamous cell carcinoma of the nasal septal
Table 1 Patient demographics, etiology, and location of defect necessitating OCRFFF reconstruction Gender
Age (y)
Etiology
Location
Male
69
Naso-oral fistula
Female
20
Osteomyelitis
Maxilla
No
No
No
No
Male
78
Squamous cell carcinoma
Eyelid, cheek, orbit
No
No
No
No
Female
68
Bilateral frontal sinocutaneous fistulas/ exposed implant
Medial canthus, skull base
No
No
Yes
No
Male
77
Pott puffy tumor
Forehead
Yes
No
No
No
Male
78
Subglottic stenosis
Cricoid/trachea
Yes
No
Yes
No
Maxilla
Abbreviation: OCRFFF, osteocutaneous radial forearm free flap. Journal of Reconstructive Microsurgery
History of: Smoking
Alcohol abuse/ dependence
Prior radiation
Prior chemotherapy
Yes
No
No
No
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
underutilized. The utility of this specific flap has been widely published throughout the literature and improvements in surgical technique, namely, prophylactic plating of the donor radius, have reduced the incidence of perioperative complications in recent years.7–11 While the OCRFFF has traditionally been used to reconstruct complex mandibular defects, the indications for the OCRFFF have expanded to all areas of the head and neck as well as cricotracheal abnormalities. Advantages associated with the use of this specific flap are its pliable skin paddle, long vascular pedicle, and availability of vascularized cortical bone. These characteristics translate well across the various anatomical subsites of the head and neck region and allow the aesthetic qualities of the native tissues to be accurately reproduced. In select instances, the OCRFFF is well suited to meet the respective demands of these subsites and leads to high rates of clinical success, with minimal postoperative complications. The authors present a small series of patients who underwent OCRFFF head and neck reconstruction for various indications excluding those used to reconstruct the mandibular defects.
Silverman et al.
lip and primary palate. A second patient with Down syndrome was found to have developed osteomyelitis and loss of a Le Fort maxillary advancement flap for severe sleep apnea as a child. A single subject required orbit reconstruction following multiple recurrences of left eyelid squamous cell carcinoma with involvement of the cheek and orbit at the time of presentation (►Fig. 1). Two subjects required bony reconstruction of their forehead and frontal sinus; the first subject had bilateral frontal sinocutaneous fistulas and an exposed Medpor implant used previously to reconstruct the skull base following resection of a recurrent olfactory groove meningioma. The second patient had a Pott puffy tumor—a subperiosteal abscess with concomitant osteomyelitis—of the right frontal bone secondary to chronic sinusitis (►Fig. 2). The last of six patients underwent OCRFFF reconstruction to repair severe subglottic stenosis with an accompanying tracheoesophageal fistula following a traumatic intubation. OCRFFF flap survival was experienced in six of six subjects (100%). There were no recipient-site complications during the immediate perioperative period. During long-term follow-up, one patient developed a nasocutaneous fistula ultimately leading to maxillary hardware removal to allow for spontaneous closure of the fistula. Aesthetic outcomes were determined to be appropriate in all cases with restoration of native tissue contours.
Discussion Over the past two decades, a number of composite and noncomposite microvascular free tissue transfers have become increasingly available to head and neck surgeons.15,16 Several
Silverman et al.
authors have proposed novel algorithms to further classify defects of the head and neck and aid in selection of the donor site.1–6 Despite these classification schemes, no single reconstructive technique has been universally adopted as the mainstay of treatment for a given aesthetic deficit. Defects involving the maxilla and/or orbit remain difficult areas for modern facial reconstruction as a result of the threedimensional relationship of the midface skeleton and overlying soft tissues. To accurately reproduce the natural bony and soft tissue contours of the midface region, the versatility and unique characteristics of the OCRFFF make it a particularly amenable tool in addressing these challenges. At many institutions, the fibula flap remains the workhorse for midface microvascular reconstruction, yet its bulky and tethered skin paddle often results in suboptimal fasciocutaneous reconstructions and requires multiple revisions. Given the highly variable nature of anterior maxillary defects, surgeons Cordeiro and Santamaria introduced a classification system based on the extent of midface structures and surrounding tissues including palate and orbital floor contents that are resected.1,2 The authors of this series recognize the utility of this system and tend to preferentially select the fibula flap in cases involving dental rehabilitation; however, when rehabilitation is determined to neither be warranted or possible, surgeons at our institution prefer the OCRFFF as the first-line reconstructive option. Chepeha et al demonstrated flap success in a series of 10 patients with maxillectomy defects in which the entire infraorbital rim was reconstructed with an OCRFFF.17 The results indicated flap success in all patients and favorable aesthetic and functional outcomes. In a similar
Fig. 1 Recurrent squamous cell carcinoma of left eyelid with lateral orbit involvement. (A) Preoperative left lateral orbit squamous cell carcinoma. (B) Intraoperative flap inset. (C) Postoperative result prior to ocular prosthesis.
Fig. 2 Pott’s puffy tumor with involvement of forehead secondary to chronic sinusitis. (A) Preoperative frontal sinus cutaneous fistula. (B) Intraoperative flap positioning. (C) Postoperative results. Journal of Reconstructive Microsurgery
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Expanding the Utilization of the Osteocutaneous Radial Forearm Free Flap
manner, other authors specifically endorse its effectiveness in treating anterior maxillectomy defects citing the close approximation of radial bone stock to that of the maxilla and conformability of the forearm soft tissue to the palate and naso-oral cavities.14 The present study mirrors these findings. The use of the OCRFFF as a “sandwich” free flap has also been described for the reconstruction of larger, bilateral subtotal maxillectomy defects.18 While the maxillectomy patients in our series experienced a lesser degree of soft tissue and bony structural loss, neither the “sandwich” flap nor adoption of a standardized classification system has been implemented at our institution. In contrast, others support the use of the fibula osteocutaneous free flap, particularly for lower maxillary defects involving the alveolar and palatal surfaces.19 In a retrospective review, Futran et al described success of the fibula flap in 26 of 27 patients with limited perioperative complications. While their series notes the fibula’s utility to reconstruct a variety of maxillary defects, they argue that the flap becomes limited in its ability to offer full orbitozygomatic support as the complexity of defects increases. The authors concur with this assessment and prefer the use of the OCRFFF for more complicated reconstructions, particularly in cases with undermining of orbital and zygomaticomaxillary buttress structures and when dental rehabilitation is neither indicated nor desired by the patient.20 Within our series, a single patient with recurrent left eyelid squamous cell carcinoma involving the cheek and orbit had operative success with restoration of the lateral and infraorbital rim. Following postoperative radiation, this individual elected for placement of an ocular prosthesis as previous epicanthal cancer had necessitated the sacrifice of his left eye; excellent aesthetic results were obtained without complication (►Fig. 1). While midface repairs predominate, the OCRFFF may also be utilized for the correction of frontal sinus and skull base defects. Within our series, a total of two patients underwent upper face reconstruction. In the patient presenting with bilateral frontal sinocutaneous fistulas following multiple resections of a recurrent olfactory groove meningioma, the OCRFFF was used to recreate the frontal bar and provide supraorbital support after frontal sinus obliteration, removal of prior hardware, and debridement of nonviable soft tissue and bone. As Pott puffy tumor is relatively uncommon clinically, literature surrounding this entity and subsequent surgical treatment is largely limited to case reports and small series.21–23 Less commonly, Pott puffy tumor may arise secondary to trauma, namely, fractures of the frontal sinus. A study of two such cases by Bluebond-Langner et al described a novel technique utilizing the fibula free flap for bony reconstruction of the horizontal buttress in a singlestaged approach following obliteration of the frontal sinus.24 While the fibula flap offers larger bone stock available for harvest, the bony mismatch is problematic based upon the thinner nature of the frontal bone and surrounding structures. As such, the OCRFFF may represent a more suitable alternative with respect to bone quality in cases involving limited frontal sinus defects. Additionally, the malleable skin paddle is easy to work with and can be manipulated once the Journal of Reconstructive Microsurgery
Silverman et al.
OCRFFF bone is fixated. The skin paddle can be used to reconstruct the forehead skin externally or be de-epithelialized to fill and obliterate the frontal sinus or repair a skull base injury if needed and both were done in this study. To date, there has been limited experience with the surgical correction of partial cricotracheal defects.25–28 Our experience includes a single case involving the reconstruction of severe subglottic stenosis with a concomitant tracheoesophageal fistula, which developed secondary to a traumatic intubation. Before presenting to our institution, surgical management included laryngotracheoplasty with failure of the nasal septal cartilage graft resulting in chronic prolapse of the esophagus into the trachea. By utilizing the OCRFFF, the surgical goal of correcting the patient’s subglottic stenosis was ultimately achieved. As the use of the OCRFFF for partial cricotracheal abnormalities represents a recent advancement in this field, more experience is clearly needed. Nonetheless, utilization of the OCRFFF for the reconstruction of partial cricotracheal defects represents a promising new area for improvement in head and neck surgery.
Conclusion This small series illustrates the versatility of the OCRFFF and demonstrates its utility in the repair of nonmandible defects containing both soft tissue and bony components with minimal postsurgical complications. As a result of its growing role and efficacy as a reconstructive option, the OCRFFF should be considered an optimal choice in the repair of composite head and neck defects beyond the mandible.
References 1 Cordeiro
2
3
4
5
6
7
8
PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg 2000;105(7):2331–2346, discussion 2347–2348 Santamaria E, Cordeiro PG. Reconstruction of maxillectomy and midfacial defects with free tissue transfer. J Surg Oncol 2006;94(6): 522–531 Muresan C, Hui-Chou HG, Dorafshar AH, Manson PN, Rodriguez ED. Forehead reconstruction with microvascular flaps: utility of aesthetic subunits. J Reconstr Microsurg 2012;28(5):319–326 Hicks DL, Watson D. Soft tissue reconstruction of the forehead and temple. Facial Plast Surg Clin North Am 2005;13(2): 243–251, vi Singh DJ, Bartlett SP. Aesthetic considerations in nasal reconstruction and the role of modified nasal subunits. Plast Reconstr Surg 2003;111(2):639–648, discussion 649–651 Rahman M, Jefferson N, Stewart DA, Oliver R, Walsh WR, Gianoutsos MP. The histology of facial aesthetic subunits: implications for common nasal reconstructive procedures. J Plast Reconstr Aesthet Surg 2010;63(5):753–756 Arganbright JM, Tsue TT, Girod DA, et al. Outcomes of the osteocutaneous radial forearm free flap for mandibular reconstruction. JAMA Otolaryngol Head Neck Surg 2013;139(2):168–172 Silverman DA, Przylecki WH, Arganbright JM, et al. Evaluation of bone length and number of osteotomies utilizing the osteocutaneous radial forearm free flap for mandible reconstruction: An 8-year review of complications and flap survival. Head Neck 2014 (e-pub ahead of print). doi:10.1002/hed.23919
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Expanding the Utilization of the Osteocutaneous Radial Forearm Free Flap
9 Militsakh ON, Werle A, Mohyuddin N, et al. Comparison of radial
10
11
12
13
14
15
16
17
18
forearm with fibula and scapula osteocutaneous free flaps for oromandibular reconstruction. Arch Otolaryngol Head Neck Surg 2005;131(7):571–575 Bowers KW, Edmonds JL, Girod DA, Jayaraman G, Chua CP, Toby EB. Osteocutaneous radial forearm free flaps. The necessity of internal fixation of the donor-site defect to prevent pathological fracture. J Bone Joint Surg Am 2000;82(5):694–704 Werle AH, Tsue TT, Toby EB, Girod DA. Osteocutaneous radial forearm free flap: its use without significant donor site morbidity. Otolaryngol Head Neck Surg 2000;123(6):711–717 Shnayder Y, Tsue TT, Toby EB, Werle AH, Girod DA. Safe osteocutaneous radial forearm flap harvest with prophylactic internal fixation. Craniomaxillofac Trauma Reconstr 2011;4(3):129–136 Avery CM. Review of the radial free flap: still evolving or facing extinction? Part two: osteocutaneous radial free flap. Br J Oral Maxillofac Surg 2010;48(4):253–260 Villaret DB, Futran NA. The indications and outcomes in the use of osteocutaneous radial forearm free flap. Head Neck 2003;25(6): 475–481 Urken ML. Composite free flaps in oromandibular reconstruction. Review of the literature. Arch Otolaryngol Head Neck Surg 1991; 117(7):724–732 Frederick JW, Sweeny L, Carroll WR, Peters GE, Rosenthal EL. Outcomes in head and neck reconstruction by surgical site and donor site. Laryngoscope 2013;123(7):1612–1617 Chepeha DB, Moyer JS, Bradford CR, Prince ME, Marentette L, Teknos TN. Osseocutaneous radial forearm free tissue transfer for repair of complex midfacial defects. Arch Otolaryngol Head Neck Surg 2005;131(6):513–517 Cordeiro PG, Bacilious N, Schantz S, Spiro R. The radial forearm osteocutaneous “sandwich” free flap for reconstruction of the
19
20
21 22
23
24
25
26
27
28
Silverman et al.
bilateral subtotal maxillectomy defect. Ann Plast Surg 1998;40(4): 397–402 Futran ND, Wadsworth JT, Villaret D, Farwell DG. Midface reconstruction with the fibula free flap. Arch Otolaryngol Head Neck Surg 2002;128(2):161–166 Andrades P, Rosenthal EL, Carroll WR, Baranano CF, Peters GE. Zygomatic-maxillary buttress reconstruction of midface defects with the osteocutaneous radial forearm free flap. Head Neck 2008; 30(10):1295–1302 Sullivan CD, Poetker DM. Anterior table remodeling after treatment for Pott’s puffy tumor. Am J Otolaryngol 2013;34(3):265–267 Shin JW, Choi IG, Jung SN, Kwon H, Shon WI, Moon SH. Pott puffy tumor appearing with a frontocutaneous fistula. J Craniofac Surg 2012;23(2):e158–e160 Akiyama K, Karaki M, Mori N. Evaluation of adult Pott’s puffy tumor: our five cases and 27 literature cases. Laryngoscope 2012; 122(11):2382–2388 Bluebond-Langner R, Jackowe D, Rodriguez ED. Simultaneous obliteration and treatment of infected frontal sinus fractures: novel use of the fibula flap. J Craniofac Surg 2007;18(3):680–683 Al-Khudari S, Sharma S, Young W, Stapp R, Ghanem TA. Osteocutaneous radial forearm reconstruction of large partial cricotracheal defects. Head Neck 2013;35(8):E254–E257 Fujiwara T, Nishino K, Numajiri T. Tracheal reconstruction with a prefabricated and double-folded radial forearm free flap. J Plast Reconstr Aesthet Surg 2009;62(6):790–794 Teng MS, Malkin BD, Urken ML. Prefabricated composite free flaps for tracheal reconstruction: a new technique. Ann Otol Rhinol Laryngol 2005;114(11):822–826 Yu P, Clayman GL, Walsh GL. Human tracheal reconstruction with a composite radial forearm free flap and prosthesis. Ann Thorac Surg 2006;81(2):714–716
Journal of Reconstructive Microsurgery
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Expanding the Utilization of the Osteocutaneous Radial Forearm Free Flap
