British Journal of Plastic Surgery (1991). 44.60-61 0 1991 The T&tees of B&h Assckation of Plastic Surgeons
Case Report Survival of a free radial forearm flap without venous return C. M. Erer, N. CerkeS and C. Ersezen Department of Plastic Surgery, Medical Faculty, University of Istanbul, Turkey SUMMARY. The radial forearm free flap is an ideal transfer for intraoral reconstruction because of its large vessels and pliable nature. In the case presented, a proximally-based forearm flap was transferred for reconstruction of an intraoral defect in the buccal and retromolar region after carcinoma resection, but there was no venous flow from either cephalic vein or venae comitantes following completion of the arterial anastomosis. In order to reduce the congestion in the flap, an end-to-end anastomosis between the distal end of the radial artery and the ipsilateral Lingual vein was performed. Despite the absence of venous return, flap survival was complete.
Case report
period the flap was congested and venous return was still absent. In order to reduce the pressure in the flap the ligature on the distal stump of the radial artery was removed and it was anastomosed to the ipsilateral lingual vein against the direction of normal venous drainage, as a salvage procedure. Although there was still no venous return, the cephalic vein was anastomosed to the external jugular vein in an end-toend fashion and the operation was concluded (Fig. 2). On the first postoperative day, 16 hours after the operation, the patient was taken to the operating room to check the venous return. Under local anaesthesia the skin stitches were removed and the anastomoses checked. Venous flow was not present and there were no signs of thrombosis at the anastomotic sites. Both anastomoses of the radial artery, proximal and distal, were patent. For the first and second days there was moderate congestion in the flap but this subsided gradually and disappeared at the end of the first week. Doppler examinations of the distal anastomosis of the radial artery revealed its patency during the hospital stay. The flap survival was complete and the patient was discharged on the 13th postoperative day. Routine periodic controls revealed complete flap survival without any CVS symptoms due to the created A-V shunt (Fig. 3).
The patient (Fig. 1) was a 44-year-old male who had a left radical neck dissection and hemimandibulectomy with en bloc resection of a squamous carcinoma of the retromolar region. There were no clinically enlarged nodes. Reconstruction witha free radial forearm flap was planned and the facial artery, anterior jugular vein and external jugular vein were prepared as recipient vessels during the radical neck dissection. A 6 x 9 cm proximally-based radial forearm Aap centred along the radial artery was raised on the left distal forearm. Before dividing the vessels of the flap, we observed that there was no venous return although there was bleeding from the edges of the flap indicating a sufficient arterial supply. Thinking that this was due to venous spasm, we ligated and cut the vessels and carried the flap to the defect. An end-to-end anastomosis between the facial artery and the radial artery was performed with 10/O nylon sutures under the operating microscope. Opening the arterial clamp started bleeding from the flap but again there was no venous return from either deep or superficial veins. Although venous spasm was not observed, topical antispasmodic drugs and hot compresses were applied. At the end of a 3-hour waiting
Fig. 1
Fig. 2
Fig. 3
Figure l-Preoperative
view of the patient. Figure Z-Preoperative view after the anastomoses were performed. A = anastomosis between radial artery and facial artery; V=anastomosis between cephalic vein and external jugular vein; A-V=anastomosis between the radial artery and sublingual
vein. Figure 3-Postoperative
view of the patient,
60
30 days after the operation.
61
Case Report Discussion
The vascular anatomy of the radial forearm flap has been discussed by several authors (Yang et al., 1981; Foucher er al., 1984; Soutar et al., 1983; Timmons, 1986). This fasciocutaneous flap is supplied by branches of the radial artery which pass between muscles and tendons in the forearm. There are two venous systems in the forearm flap: the superficial venous system (the cephalic and the basilic vein) and the deep venous system (paired venae comitantes). Timmons found one to three veins linking the large superficial veins to the venae comitantes in the distal third of the forearm, between the flexor carpi radialis and brachioradialis tendons. The radial forearm flap can be designed as proximally or distally pedicled. When the radial forearm ilap is proximally based the venous return is in an antegrade direction via subcutaneous veins and venae comitantes. Either of these venous systems is normally sufficient to drain the flap. In a review of the literature we have not found any report about a venous return problem in an antegrade direction. We could not find a satisfactory explanation to account for the absence of venous return in our flap but we think it was due to an anatomical variation in the venous pattern. The aim of the salvage procedure, anastomosing the distal end of the radial artery with the ipsilateral sublingual vein, was to reduce the arterial pressure and decrease congestion in the flap. The pressure in the sublingual vein was relatively higher because of radical neck dissection and the direction of the flow, which is against the normal drainage of the vein. Thus, a critical equilibrium of pressure was accomplished so that it did not permit all the arterial blood
to drain to the sublingual vein but reduced the arterial pressure in the flap. We suggest that this unusual A-V shunt helped the survival of the flap in the critical period until venous connections between the flap and the recipient bed developed. We accept that this explanation remains controversial and open to discussion.
References Foucher, C., Gene&ten, F. van, Merle, N. and Michon, J. A. (1984). A compound radial artery forearm flap in hand surgery: an
original modification of the Chinese forearm flap. British Journal of Plastic Surgery, 37, 139. Soutar, D. S., Scbeker, L. R., Tanner, N. S. B. and McGregor, I. A. (1983). The radial forearm flap: a versatile method for intraoral reconstruction. British Journal of Plastic Surgery, 36, 1. Tiimons, M. J. (1986). The vascular basis of the radial forearm flap. Plastic and Reconstructive Surgery, 77,80. Yang, G., Cben, B., Gao, Y., Lin, X., Li, J., Jiang, S. and He, S. (198 1). Forearm free skin flap transplantation. National Medical Journalof China, 61,139.
The Authors C. M. Erer, MD, Professor in Plastic Surgery N. Cerkes, MD, Resident in Plastic Surgery C. Erseaett, MD, Resident in Plastic Surgery Department of Plastic Surgery, Istanbul Medical Faculty, University of Istanbul, Turkey. Requests for reprints to: Prof. Dr C. M. Erer, Istanbul Universitesi, Istanbul Tin Fakilltesi. Plastik ve Rekonstrilktif Cerrahi ABD Capa, Istanbul 34390, Turkey. Paper received 24 April 1990. Accepted 12 June 1990.
Case Report Survival of a free radial forearm flap without venous return C. M. Erer, N. CerkeS and C. Ersezen Department of Plastic Surgery, Medical Faculty, University of Istanbul, Turkey SUMMARY. The radial forearm free flap is an ideal transfer for intraoral reconstruction because of its large vessels and pliable nature. In the case presented, a proximally-based forearm flap was transferred for reconstruction of an intraoral defect in the buccal and retromolar region after carcinoma resection, but there was no venous flow from either cephalic vein or venae comitantes following completion of the arterial anastomosis. In order to reduce the congestion in the flap, an end-to-end anastomosis between the distal end of the radial artery and the ipsilateral Lingual vein was performed. Despite the absence of venous return, flap survival was complete.
Case report
period the flap was congested and venous return was still absent. In order to reduce the pressure in the flap the ligature on the distal stump of the radial artery was removed and it was anastomosed to the ipsilateral lingual vein against the direction of normal venous drainage, as a salvage procedure. Although there was still no venous return, the cephalic vein was anastomosed to the external jugular vein in an end-toend fashion and the operation was concluded (Fig. 2). On the first postoperative day, 16 hours after the operation, the patient was taken to the operating room to check the venous return. Under local anaesthesia the skin stitches were removed and the anastomoses checked. Venous flow was not present and there were no signs of thrombosis at the anastomotic sites. Both anastomoses of the radial artery, proximal and distal, were patent. For the first and second days there was moderate congestion in the flap but this subsided gradually and disappeared at the end of the first week. Doppler examinations of the distal anastomosis of the radial artery revealed its patency during the hospital stay. The flap survival was complete and the patient was discharged on the 13th postoperative day. Routine periodic controls revealed complete flap survival without any CVS symptoms due to the created A-V shunt (Fig. 3).
The patient (Fig. 1) was a 44-year-old male who had a left radical neck dissection and hemimandibulectomy with en bloc resection of a squamous carcinoma of the retromolar region. There were no clinically enlarged nodes. Reconstruction witha free radial forearm flap was planned and the facial artery, anterior jugular vein and external jugular vein were prepared as recipient vessels during the radical neck dissection. A 6 x 9 cm proximally-based radial forearm Aap centred along the radial artery was raised on the left distal forearm. Before dividing the vessels of the flap, we observed that there was no venous return although there was bleeding from the edges of the flap indicating a sufficient arterial supply. Thinking that this was due to venous spasm, we ligated and cut the vessels and carried the flap to the defect. An end-to-end anastomosis between the facial artery and the radial artery was performed with 10/O nylon sutures under the operating microscope. Opening the arterial clamp started bleeding from the flap but again there was no venous return from either deep or superficial veins. Although venous spasm was not observed, topical antispasmodic drugs and hot compresses were applied. At the end of a 3-hour waiting
Fig. 1
Fig. 2
Fig. 3
Figure l-Preoperative
view of the patient. Figure Z-Preoperative view after the anastomoses were performed. A = anastomosis between radial artery and facial artery; V=anastomosis between cephalic vein and external jugular vein; A-V=anastomosis between the radial artery and sublingual
vein. Figure 3-Postoperative
view of the patient,
60
30 days after the operation.
61
Case Report Discussion
The vascular anatomy of the radial forearm flap has been discussed by several authors (Yang et al., 1981; Foucher er al., 1984; Soutar et al., 1983; Timmons, 1986). This fasciocutaneous flap is supplied by branches of the radial artery which pass between muscles and tendons in the forearm. There are two venous systems in the forearm flap: the superficial venous system (the cephalic and the basilic vein) and the deep venous system (paired venae comitantes). Timmons found one to three veins linking the large superficial veins to the venae comitantes in the distal third of the forearm, between the flexor carpi radialis and brachioradialis tendons. The radial forearm flap can be designed as proximally or distally pedicled. When the radial forearm ilap is proximally based the venous return is in an antegrade direction via subcutaneous veins and venae comitantes. Either of these venous systems is normally sufficient to drain the flap. In a review of the literature we have not found any report about a venous return problem in an antegrade direction. We could not find a satisfactory explanation to account for the absence of venous return in our flap but we think it was due to an anatomical variation in the venous pattern. The aim of the salvage procedure, anastomosing the distal end of the radial artery with the ipsilateral sublingual vein, was to reduce the arterial pressure and decrease congestion in the flap. The pressure in the sublingual vein was relatively higher because of radical neck dissection and the direction of the flow, which is against the normal drainage of the vein. Thus, a critical equilibrium of pressure was accomplished so that it did not permit all the arterial blood
to drain to the sublingual vein but reduced the arterial pressure in the flap. We suggest that this unusual A-V shunt helped the survival of the flap in the critical period until venous connections between the flap and the recipient bed developed. We accept that this explanation remains controversial and open to discussion.
References Foucher, C., Gene&ten, F. van, Merle, N. and Michon, J. A. (1984). A compound radial artery forearm flap in hand surgery: an
original modification of the Chinese forearm flap. British Journal of Plastic Surgery, 37, 139. Soutar, D. S., Scbeker, L. R., Tanner, N. S. B. and McGregor, I. A. (1983). The radial forearm flap: a versatile method for intraoral reconstruction. British Journal of Plastic Surgery, 36, 1. Tiimons, M. J. (1986). The vascular basis of the radial forearm flap. Plastic and Reconstructive Surgery, 77,80. Yang, G., Cben, B., Gao, Y., Lin, X., Li, J., Jiang, S. and He, S. (198 1). Forearm free skin flap transplantation. National Medical Journalof China, 61,139.
The Authors C. M. Erer, MD, Professor in Plastic Surgery N. Cerkes, MD, Resident in Plastic Surgery C. Erseaett, MD, Resident in Plastic Surgery Department of Plastic Surgery, Istanbul Medical Faculty, University of Istanbul, Turkey. Requests for reprints to: Prof. Dr C. M. Erer, Istanbul Universitesi, Istanbul Tin Fakilltesi. Plastik ve Rekonstrilktif Cerrahi ABD Capa, Istanbul 34390, Turkey. Paper received 24 April 1990. Accepted 12 June 1990.
