Sanford Dubner and Keith S. Heller
REINNERVATED RADIAL FOREARM FREE FLAPS IN HEAD AND NECK RECONSTRUCTION ABSTRACT
The loss of both motor and sensory function of the tongue, following major ablative oncologic surgery, may have devastating consequences for postoperative oral rehabilitation. Although there is currently no technique to restore motor function of the tongue following partial glossectomy, the use of neurotized cutaneous flaps has been shown to help restore intraoral sensibility.12 This prompted us to use the reinnervated radial forearm free flap to help achieve postoperative intraoral sensibility.
PATIENTS AND METHODS The radial forearm free flap was used in the reconstruction of three patients following extensive resection of the floor of mouth and tongue. In all three patients, more than half of the tongue was resected; the minimum flap area was 45 cm2. Following revascularization of each free flap, the lateral antebrachial cutaneous nerve was sutured to the stump of the transected lingual nerve. All three patients were treated with 6000 cGy of postoperative external-beam adjuvant radiation therapy. All flaps were tested for protective sensibility and sensory reinnervation, as defined by two-point discrimination at 1-month inter-
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The radial forearm flap has proved to be a reliable free flap for intraoral reconstruction after major head and neck ablative surgery for cancer. In contrast to the myocutaneous flap, it is thin and flexible, and as a result, it is better suited to conforming to the irregular surface which remains over an intact or restored mandible. A criticism of both techniques however, is that while the flap effectively fills the defect, it serves as an insensate reservoir in which food and saliva can collect. A modification of the reinnervated radial forearm free flap is presented, with discussion of its use in three patients, following extensive resection of the floor of the mouth and tongue.
vals postoperatively. An equal number of patients who underwent pectoralis major myocutaneous flap reconstruction for intraoral defects following major head and neck ablative surgery, with subsequent postoperative radiation therapy, were also tested identically.
RESULTS Restoration of sensation was achieved in all three forearm free flaps within 4 months. Not only was there protective sensibility in all regions of the flaps, but two-point discrimination of 4 mm was achieved in most regions of the flap, including the central portion and most of the periphery. The patients were not tested for heat and cold discrimination within the flaps. Protective sensibility was achieved in one of the pectoralis major myocutaneous flaps, but fine sensation and twopoint discrimination could not be identified. All three patients with reinnervated forearm free flaps reported an improved ability in clearing saliva and food boluses from the oral cavity as sensation improved, as well as a subjective feeling that the anesthesia of the absent portion of tongue had recovered, a finding which, once again, could not be confirmed in the patients who underwent pedicled flap reconstruc-
Long Island Jewish Medical Center, Affiliate of the Albert Einstein College of Medicine, New Hyde Park, NY Materials in this paper were presented at the Northeastern Plastic Surgical Society Annual Meeting, September 14,1991 Reprint requests-. Dr. Dubner, 200 Middle Neck Rd., Great Neck, NY 11021 Accepted for publication May 25,1992 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
467
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 6
NOVEMBER 1992
is a simple modification which is easily applied in intraoral reconstruction following major ablative oncologic surgery. It is reliable, having achieved fine twopoint discrimination in all of our cases, and is apparently unaffected by the use of therapeutic doses of DISCUSSION adjuvant radiation therapy. Perioperative morbidity is not increased, and operative time is not significantly Although there are many reports in the literature increased either. Apparently, a feedback mechanism is regarding patterns of recovery of sensibility in free achieved through the lingual nerve which helps to flaps,3-6 the majority are about flap application in soft- initiate the swallowing mechanism, and which patissue coverage of extremity defects. There are very few tients report assists in clearing saliva and food boluses reports relating to the use of reinnervated free flaps in from the oral cavity. head and neck, reconstruction. Matloub, Larson, Kuhn, Although these data are preliminary, this relaet al.2 employed the neurotized lateral arm free flap in tively simple modification of a well-established reconsix patients who were analyzed postoperatively by a structive technique may improve the functional results speech pathologist, documenting patient progress in following resection of tumors of the mouth and orospeech and swallowing. One report7 describes the use pharynx. of the superficial branch of the radial nerve as a vascularized nerve graft, to bridge a facial-nerve defect following parotidectomy. In the same article, the use of REFERENCES the reinnervated forearm flap was also detailed in the reconstruction of a pharyngeal mucosal defect. Waris T: Innervation of the skin, skin transplants, flaps, and scars. Many techniques have been employed to repair Acta Chirurg Scand 485:1, 1978 Matloub HS, Larson DL, Kuhn JC, et al: Lateral arm free flap in intraoral defects. Nevertheless, the major criticism is oral cavity reconstruction: A functional evaluation. Head that these various flaps persist as insensate reservoirs Neck 11:205, 1989 in which food and saliva may collect. This is particSwanson E, Boyd JB, Manktelow RT: The radial forearm flap: Reconstructive applications and donor-site defects in 35 ularly important, as gravity and atrophy (in the case of consecutive patients. Plast Reconstr Surg 85:258, 1990 pedicled flaps) place them in a dependent position. Brown CJ, Mackinnon SE, Dellon AL, Bain JR: The sensory potenMost patients can learn to overcome this obvious functial of free flap donor sites. Ann Plast Surg 23:135, 1989 tional deficit with appropriate rehabilitative efforts, Rautio I: Patterns of recovery of sensibility in free flaps transferred to the foot: A prospective study. 1 Reconstr Microsurg but there is the occasional patient who must rely on 6:37, 1990 other means of alimentation, because of an inability to Hermanson A, Dalsgaard CJ, Arnander C, Lindblom U: Sensisense food intraorally and thus to initiate the complex bility and cutaneous reinnervation in free flaps. Plast Reconstr Surg 79:422, 1987 mechanism required for swallowing. Urken ML, Weinberg H, Vickery C, Biller HF: The neurofascioAlthough protective sensibility may be achieved cutaneous radial forearm flap in head and neck reconstrucwith time in myocutaneous flaps, as noted in one tion: A preliminary report. Laryngoscope 100:161, 1990 Hoppenreijs TJ, Freihofer HP, Brouns, et al: Sensibility and cutareport,8 it is not reliably achieved in all flaps, and is neous reinnervation of pectoralis major myocutaneous isclosely related to the sensibility present in the surland flaps: A preliminary clinical report. J Craniomaxillofac Surg 18:237, 1990 rounding tissue. Reinnervation of the forearm free flap
468
Downloaded by: Universite Laval. Copyrighted material.
tion. Residual tongue function in each patient varied, but was at best "fair," since the minimum of a hemiglossectomy had been performed in each patient.
REINNERVATED RADIAL FOREARM FREE FLAPS IN HEAD AND NECK RECONSTRUCTION ABSTRACT
The loss of both motor and sensory function of the tongue, following major ablative oncologic surgery, may have devastating consequences for postoperative oral rehabilitation. Although there is currently no technique to restore motor function of the tongue following partial glossectomy, the use of neurotized cutaneous flaps has been shown to help restore intraoral sensibility.12 This prompted us to use the reinnervated radial forearm free flap to help achieve postoperative intraoral sensibility.
PATIENTS AND METHODS The radial forearm free flap was used in the reconstruction of three patients following extensive resection of the floor of mouth and tongue. In all three patients, more than half of the tongue was resected; the minimum flap area was 45 cm2. Following revascularization of each free flap, the lateral antebrachial cutaneous nerve was sutured to the stump of the transected lingual nerve. All three patients were treated with 6000 cGy of postoperative external-beam adjuvant radiation therapy. All flaps were tested for protective sensibility and sensory reinnervation, as defined by two-point discrimination at 1-month inter-
Downloaded by: Universite Laval. Copyrighted material.
The radial forearm flap has proved to be a reliable free flap for intraoral reconstruction after major head and neck ablative surgery for cancer. In contrast to the myocutaneous flap, it is thin and flexible, and as a result, it is better suited to conforming to the irregular surface which remains over an intact or restored mandible. A criticism of both techniques however, is that while the flap effectively fills the defect, it serves as an insensate reservoir in which food and saliva can collect. A modification of the reinnervated radial forearm free flap is presented, with discussion of its use in three patients, following extensive resection of the floor of the mouth and tongue.
vals postoperatively. An equal number of patients who underwent pectoralis major myocutaneous flap reconstruction for intraoral defects following major head and neck ablative surgery, with subsequent postoperative radiation therapy, were also tested identically.
RESULTS Restoration of sensation was achieved in all three forearm free flaps within 4 months. Not only was there protective sensibility in all regions of the flaps, but two-point discrimination of 4 mm was achieved in most regions of the flap, including the central portion and most of the periphery. The patients were not tested for heat and cold discrimination within the flaps. Protective sensibility was achieved in one of the pectoralis major myocutaneous flaps, but fine sensation and twopoint discrimination could not be identified. All three patients with reinnervated forearm free flaps reported an improved ability in clearing saliva and food boluses from the oral cavity as sensation improved, as well as a subjective feeling that the anesthesia of the absent portion of tongue had recovered, a finding which, once again, could not be confirmed in the patients who underwent pedicled flap reconstruc-
Long Island Jewish Medical Center, Affiliate of the Albert Einstein College of Medicine, New Hyde Park, NY Materials in this paper were presented at the Northeastern Plastic Surgical Society Annual Meeting, September 14,1991 Reprint requests-. Dr. Dubner, 200 Middle Neck Rd., Great Neck, NY 11021 Accepted for publication May 25,1992 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
467
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 6
NOVEMBER 1992
is a simple modification which is easily applied in intraoral reconstruction following major ablative oncologic surgery. It is reliable, having achieved fine twopoint discrimination in all of our cases, and is apparently unaffected by the use of therapeutic doses of DISCUSSION adjuvant radiation therapy. Perioperative morbidity is not increased, and operative time is not significantly Although there are many reports in the literature increased either. Apparently, a feedback mechanism is regarding patterns of recovery of sensibility in free achieved through the lingual nerve which helps to flaps,3-6 the majority are about flap application in soft- initiate the swallowing mechanism, and which patissue coverage of extremity defects. There are very few tients report assists in clearing saliva and food boluses reports relating to the use of reinnervated free flaps in from the oral cavity. head and neck, reconstruction. Matloub, Larson, Kuhn, Although these data are preliminary, this relaet al.2 employed the neurotized lateral arm free flap in tively simple modification of a well-established reconsix patients who were analyzed postoperatively by a structive technique may improve the functional results speech pathologist, documenting patient progress in following resection of tumors of the mouth and orospeech and swallowing. One report7 describes the use pharynx. of the superficial branch of the radial nerve as a vascularized nerve graft, to bridge a facial-nerve defect following parotidectomy. In the same article, the use of REFERENCES the reinnervated forearm flap was also detailed in the reconstruction of a pharyngeal mucosal defect. Waris T: Innervation of the skin, skin transplants, flaps, and scars. Many techniques have been employed to repair Acta Chirurg Scand 485:1, 1978 Matloub HS, Larson DL, Kuhn JC, et al: Lateral arm free flap in intraoral defects. Nevertheless, the major criticism is oral cavity reconstruction: A functional evaluation. Head that these various flaps persist as insensate reservoirs Neck 11:205, 1989 in which food and saliva may collect. This is particSwanson E, Boyd JB, Manktelow RT: The radial forearm flap: Reconstructive applications and donor-site defects in 35 ularly important, as gravity and atrophy (in the case of consecutive patients. Plast Reconstr Surg 85:258, 1990 pedicled flaps) place them in a dependent position. Brown CJ, Mackinnon SE, Dellon AL, Bain JR: The sensory potenMost patients can learn to overcome this obvious functial of free flap donor sites. Ann Plast Surg 23:135, 1989 tional deficit with appropriate rehabilitative efforts, Rautio I: Patterns of recovery of sensibility in free flaps transferred to the foot: A prospective study. 1 Reconstr Microsurg but there is the occasional patient who must rely on 6:37, 1990 other means of alimentation, because of an inability to Hermanson A, Dalsgaard CJ, Arnander C, Lindblom U: Sensisense food intraorally and thus to initiate the complex bility and cutaneous reinnervation in free flaps. Plast Reconstr Surg 79:422, 1987 mechanism required for swallowing. Urken ML, Weinberg H, Vickery C, Biller HF: The neurofascioAlthough protective sensibility may be achieved cutaneous radial forearm flap in head and neck reconstrucwith time in myocutaneous flaps, as noted in one tion: A preliminary report. Laryngoscope 100:161, 1990 Hoppenreijs TJ, Freihofer HP, Brouns, et al: Sensibility and cutareport,8 it is not reliably achieved in all flaps, and is neous reinnervation of pectoralis major myocutaneous isclosely related to the sensibility present in the surland flaps: A preliminary clinical report. J Craniomaxillofac Surg 18:237, 1990 rounding tissue. Reinnervation of the forearm free flap
468
Downloaded by: Universite Laval. Copyrighted material.
tion. Residual tongue function in each patient varied, but was at best "fair," since the minimum of a hemiglossectomy had been performed in each patient.
![[Free radial forearm flap in head and neck: our experience].](/assets/img/hold.png)
