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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4479_Библиотеки_им_академика_М_И_Перельмана.pdf
Pubic symphysis
8 Free Rectus Flap Reconstruction
Fig. 8.1 Rectus free ap
initial markings
Linea alba
Umbilicus
117
Inferior
ribs
ASIS
Thus, if making a 6×6-cm ap centered at the umbilicus, the perforating
vessels will be in the center.
3. Incise along all markings; the authors prefer to make initial incisions with a
#15, then carry incisions deeper with spatula-tipped insulated Bovie to the anterior surface of the anterior rectus sheath. Dissection should be carried deeply
perpendicular to the anterior surface of the anterior rectus sheath. Of note, if the
dissection drifts away from the perpendicular, it may risk damage to perforating
arteries.
4. Laterally, dissection should extend along the supercial surface of the anterior
rectus sheath until the rectus line is identied. This dissection can be completed
rapidly with bovie, as it is not near any vascular structures of note.
5. Secure the skin paddle to the underlying anterior rectus sheath along the edges
of the ap with multiple 3-0 vicryl sutures. This step is performed to prevent
accidental shear of the skin paddle off the underlying muscle with future manipulation of the ap. Of note, if the ap is going to end up in the mouth or pharynx, then the sutures do not have to be buried. If the ap will end up on the skin,
then the sutures should be buried.
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A. G. Vincent and S. R. Anderson
6. Incise the anterior rectus fascia and rectus muscle at the lateral edge of the ap.
If necessary for visualization, the superior cut can also be made, but the inferior
aspect of the ap should be left along to preserve the pedicle. Extend this incision deeply through the rectus muscle until the posterior rectus sheath is
encountered. Again, be mindful of dissection perpendicular to the abdominal
fascia. If the incision drifts medially, then injury to the ap perforators can
occur. If the incision drifts laterally, the rectus line may be encountered and the
posterior fascia perforated. If a small perforation in the posterior fascia is created, repair it with 3-0 vicryl and oversew with 2-0 PDS.
7. Using a kitner, gently separate the posterior surface of the rectus muscle to be
included in the ap from the posterior rectus sheath. Of note, the vascular pedicle vessels run along the posterior surface of the muscle, so it is important to
be precise in separating the muscle from the fascia. Leaving muscular fascia
down risks damage to the pedicle, whereas lifting posterior sheath into the ap
risks sheath perforation and herniation of abdominal contents.
(a) A kitner is a useful tool for sweeping along the face of the posterior sheath;
it can neatly reveal the appropriate tissue plane, will not accidentally perforate the posterior sheath, and will not damage the pedicle vessels if it
bumps them.
8. Visualize the pedicle vessels along the deep surface of the ap.
9. Complete incisions through the rectus muscle around all sides of the ap, tak-
ing care to preserve the vascular pedicle as it travels inferiorly and taking care
not to separate the pedicle from the ap itself. Superiorly, the ap can be efciently released by using monopolar cautery to cut through rectus muscle onto
the surgeon’s underlying nger. Take care medially not to enter the umbilicus.
Inferior to the ap, the pedicle can be bluntly dissected away from overlying
muscle with Metzenbaum scissors (in a cold fashion without cautery), then protected with a nger placed between the vessels and the overlying muscle while
Bovie is used to rapidly separate that muscle.
(a) A nger is a useful insulating tool in this dissection, as it will not conduct
heat energy to the vessels. Monopolar cautery should be used cautiously or
not at all when in close proximity to the ap vessels, as aberrant heat spread
can injure vessels and compromise ap survival.
(b) Metzenbaum scissors are useful for releasing the ap vessels from overly-
ing muscle given their blunt tips. Appropriate spread will break weak, natural fascial attachments surrounding the vessels before breaking vessel walls
or causing excessive muscular bleeding. Dissection with sharper scissors
risks damage to vascular walls or bleeding from muscular tissue.
10. Dissect out the length of the pedicle inferiorly. Again, cold dissection with met-
zenbaum scissors allows efcient separation of tissue to proceed safely. After a
sufcient length of the pedicle is achieved, the pedicle and ap can be separated. The authors prefer ligating the inferior aspect of the vessels with surgical
clips, free silk ties, or a combination of the two. The pedicle vessels themselves
8 Free Rectus Flap Reconstruction
119
do not require clips or ties, and use of such may compromise the tip ends at the
time of reanastomosis. The authors do not advocate the use of any cautery near
the site of pedicle ligation, as it can cause vascular injury that may compromise
ap survival. Figure8.2 depicts a harvested ARFF before inset, and Fig.8.3
depicts a total glossectomy wound (a) reconstructed with an ARFF (b).
Steps ofClosure
1. Irrigate the wound with copious amounts of saline. This is an important step
before the closure of all surgical wounds, as it can greatly decrease the risk of
surgical wound infections.
2. Dissect laterally along the anterior rectus sheath to allow primary closure of
the wound.
3. Reapproximate the anterior rectus sheath. 2-0pds can be used in a running fashion for this reapproximation. A wide ribbon retractor (3–4cm width) should be
placed over the posterior rectus sheath, beneath the anterior rectus fascia, during
reapproximation to prevent accidental needle-violation of the posterior sheath.
4. Close the skin and subcutaneous tissue in layers. The skin can be tailored superiorly and inferiorly to where the ap was harvested to facilitate a straight-line
closure.
(a) The authors typically place two bulb-suction fully perforated 10F at drains
in the wound bed, to be removed 1 to 2weeks postoperatively. At minimum,
two layers of suture should be used.
(b) The authors prefer closure of subcutaneous tissues with multiple 3-0 inter-
rupted vicryl sutures, then skin closure with a running prolene as this allows
efcient and cosmetically acceptable wound closure.
5. Cover the wound with antibacterial ointment, telfa, and an abdominal binder.
Fig. 8.2 Harvested rectus
free ap
120
Fig. 8.3 Glossectomy defect before and after rectus inset
A. G. Vincent and S. R. Anderson
Postoperative Care andComplications
Rectus aps should be monitored in a similar fashion to other free tissue transfers;
aps should be monitored very closely for vascular compromise in the initial 72h
after surgery, then closely but less intensively over the next 96h. Drains are commonly left in the harvest site for one to 2weeks, until the output is serous in quality
and stable in quantity. Patients should wear an abdominal binder for 1month after
surgery and avoid abdominal exercise for 3months. If permanent sutures are placed
for skin closure, they should be removed 7 to 10days after placement to avoid cosmetically unfavorable “train track” markings from forming. Light walking is acceptable the day after surgery and, if patients are capable, is encouraged to prevent
venous thromboses.
Pearls
1. Quick and easy harvest with no need for patient repositioning when combined
with extirpation of the majority of head and neck cancers. Ultrasound identication of perforators is not necessary when muscle is harvested with appropriate
initial markings.
2. Two-team approach (concurrent excision and ap harvest).
3. Reliable vascular pedicle anatomy, more so than from anterolateral thigh aps,
with a moderate vascular length. Some texts report that a vascular pedicle length
of up to 15cm can be harvested. The authors have observed a harvest length of
7cm or so to be more typical, meaning, for a total glossectomy defect, the donor
vessels in the neck need to be nearby (facial vessels, lingual artery, external
carotid terminus, etc.) or vein grafts will be necessary to complete anastomosis.
4. Option for perforator ap harvest that does not include muscle and has less bulk
and less recovery time.
5. Primary closure of the harvest site is standard.
6. If a small perforation of the posterior fascia is made, it can be repaired primarily
with 3-0 vicryl, and the repair oversewn with 2-0 PDS.If this happens, surgeons
should code for a hernia repair.
8 Free Rectus Flap Reconstruction
121
Conclusion
The ARFF is an advantageous ap that can be employed in a diverse array of head
and neck-based defects requiring skin, soft tissue bulk, and muscle. However, for a
successful outcome, the prospective patient should be closely evaluated in effort to
determine candidacy for an ARFF-based operation. Morbid obesity and prior
abdominal procedures may preclude a patient from undergoing this specic ap
procedure. For those patients who are candidates, the ARFF offers the opportunity
for a two-team approach at both the donor and the recipient site, leading to overall
operative efciency. The ARFF technique displays consistent anatomy, ease of ap
elevation, and vessel size similar to that of neck vessels without signicant size to
size mismatch. Additionally, pending patient body habitus, the ARFF provides a
large cutaneous surface area in conjunction with fatty bulk and muscle not seen in
other ap alternatives making this ap ideal for large, complex head and neck defect
reconstruction. The ARFF is an established workhorse ap secondary to proven
reproducible reliability and versatility and should be considered an effective tool
within the reconstructive head and neck surgeon’s armamentarium.
References
1. Basaran B, Ünsaler S, Kesimli M, Aslan Î. Free ap reconstruction of the head and neck
region: a series of 127 aps performed by otolaryngologists. Turk Arch Otorhinolaryngol.
2021;59(2):103–10.
2. Low H, Lindsay A, Clark J, Chai F, Lewis R.Reconstruction of maxillary defect with musculo-
adipose rectus free ap. Microsurgery. 2017;37:137–41.
3. Kozusko S, Liu X, Riccio C, etal. Selecting a free ap for soft tissue coverage in lower extrem-
ity reconstruction. Injury. 2019;50(S5):S32–9.
4. Pryor S, Moore E, Kasperbauer J.Orbital exenteration reconstruction with rectus abdominis
microvascular free ap. Laryngoscope. 2005;115:1912–6.
5. Chung T, Wilson K, Patil Y. Double deep inferior epigastric arteries encountered during
vertical rectus abdominis ap harvest: a case report and literature review. Ear Nose Throat
J. 2013;92(6):E34–7.
6. Lee S, You H, Kim D.Dual vascular free transverse rectus abdominis myocutaneous ap for
hemifacial reconstruction in a vessel-depleted neck. Arch Plast Surg. 2020;47:88–91.
Part III
Fasciocutaneous Flaps
The Radial Forearm Free Flap
SammyOthman andJasonCohn
Introduction/History
In 1970s, a concern for ap harvest involving reliable, thin, pliable skin became one
of the forefront endeavors in regard to free tissue transfer. Subsequently, Song etal.,
a group hailing from China, described the earliest documented utilization of the
radial forearm ap to address these concerns [1]. Subsequently, the radial forearm
ap has become a workhorse as a pedicled, reverse-ow pedicled, and free ap for
a variety of defects and lesions from head to toe [2–6]. The head and neck regions
in particular have found great success in the re-surfacing of defects using various
iterations of the radial forearm ap, with various components including fasciocutaneous, fascial, osteocutaneous, and neurotized aps with several unique ap designs,
owning to its consistent anatomy that allows for versatile tissue architecture [7–9].
9
Anatomy
The radial forearm ap (RFF) is harvested as an axial ap based on the radial artery,
which supplies the perforators to the radial forearm. The origin of the radial artery,
stemming as a terminal branch of the brachial artery, can be palpated through the
antecubital fossa, giving a large pedicle length between 15 and 22cm, dependent on
patient anatomy [2, 5, 7, 9–11]. The radial artery is accompanied by pairs of venae
comitans, or alternatively, the cephalic or basilic veins can be harvested when larger
source anastomoses are desired or when multiple venous anastomoses are desired.
S. Othman
Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwell Health,
New York, NY, USA
J. Cohn (*)
Cohn Plastic Surgery, PC, Smithtown, NY, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
F. Sokoya, A. G. Vincent (eds.), Manual of Head and Neck Reconstruction,
https://doi.org/10.1007/978-3-031-65999-7_9
125
126
S. Othman and J. Cohn
The perforators of the radial artery to this region are fasciocutaneous, piercing
through the antebrachial fascia of the forearm. Rarely, the ap is raised as a perforator ap, and even more rarely in the context of free tissue transfer [11, 12]. Distally,
the pedicle and radial artery runs just deep to the intermuscular septum between the
brachioradialis and exor capri radialis muscles.
The nerve supply to this region includes both the lateral and medial antecubital
nerves, depending on desired dimensions of the ap and specic ap design [3, 7,
10]. Briey, the lateral antecubital nerve is a branch of the musculocutaneous nerve,
beginning near the antecubital fossa, and travels intimately with the cephalic vein
where it divides into volar and dorsal branches. It is the volar branch that can be
harvested for a sensate ap utilization. The medial antecubital nerve is a direct trunk
from the branchial plexus, where in the middle third of the upper arm, descending
along the ulnar half of the forearm distally [13–16].
When an osseous component is desired, a section of radius may be harvested.
The exact dimensions are varied, but typically this ranges from the insertion of the
pronator teres to proximal to the radial styloid, one-third in width or smaller, and up
to 14cm [6, 17–21].
Owning to this diversity in anatomy, this can be raised as fasciocutaenous ap
(most common), fascial-only ap, or variations of osseous ap based on the radius.
If desired, it can also include tendon and neurotization options [8, 22, 23]. There are
many well-established ap designs, outlining the popularity and heterogeneity
afforded by the radial forearm.
Indication/Contraindications
The RFF is a versatile ap owning to its thin, pliable texture, ability to raise with or
without hair, consistent blood supply, and options in raising fascial and osseous
components. As such, it can be used for a range of defects for the head and neck,
including nasal reconstruction, lip reconstruction, intraoral resurfacing, including
tongue and buccal defects, ear reconstruction, scalp reconstruction, pharyngeal
resurfacing, and neck resurfacing [2, 5, 8, 24–32].
Relative contraindications to harvest include general health concerns for major
reconstruction and concerns for vascular compromise to the donor site. This includes
poor perfusion to the digits and history or suspected clinical peripheral artery disease. If necessary, the radial artery may be reconstructed, most often with a saphenous vein graft, or an intact remaining cephalic and basilic vein, to keep an intact
inow to the palmar arch [33–37]. Furthermore, caution should be taken when considering an osseous component in the elderly or those prone to osteoporosis or other
bony disease, given the donor site morbidity of radial bone harvest.
9 The Radial Forearm Free Flap
127
Preoperative Planning
A commonly cited disadvantage of the RFF is what is often sacrice of a major
axial vessel in the radial artery. Clinically, this, along with the ulnar artery, is a main
contributor to the palmer arch and subsequently blood supply to the hand. It is
important to inquire about prior manipulation of the vessels, such as history of arterial lines, arteriovenous stula formation, and intravenous catheters, particularly in
the situation of cephalic vein harvest for venous egress. As such, evaluation of an
intact palmer arch must be elucidated with the Allen’s Test. At times, this exam may
be equivocal, or patient history may dictate a requirement for further or more objective testing. This can necessitate computer tomography angiography (CTA) or ultrasound with an experienced sonographer [35–37].
Patients must also be counseled on donor site morbidity, as sensation may be lost
the area. Additionally, an unsightly scar will be present in anatomically exposed
area, particularly when a longer pedicle is required. When a bony component is
planned, there will be a longer recovery period and a signicantly increased risk of
fracture, even patients are adherent to rehabilitation planning [12, 17, 19–21, 38].
This all includes the likelihood of requiring a skin graft to secondarily cover the
donor site, which is always at risk and leads to skin mismatch, both at the skin graft
donor and recipient site [12, 21]. Finally, the process of recovery after skin graft
harvest is sometimes painful, and this should be discussed prior to the operation.
Instrumentation
Standard operative instrumentation and microsurgical instrumentation are required.
These include major plastic surgery/otolaryngology trays and biceps forceps trays.
Specically, necessary instruments include dissecting scissors, such as Stevens and
Metzenbaum, hemoclip appliers, and nylon sutures. Additionally, Browns, Addisonbrowns, and jeweler forceps are also helpful during dissection. Iris and double skin
hooks, Army-Navy, and Senn retractors all have a role in exposure. Finally, bovie
cautery and various blade sizes are necessary for dissection dependent on surgeon
preference and experience. The specic details of tool vary by surgeon preference
and institutional tray setup. In most cases, a dermatome will be required for skin
graft harvest, and a pneumatic tourniquet cuff will be utilized during ap dissection.
Flap Design andSurgical Technique
Flap Design andPreparation
The patient is placed in a supine position with the arm extended in anatomic volar up positioning, prepped widely passed the antecubital fossa. Using a template for
the defect to be reconstructed, this is traced over the volar distal forearm centered
upon the radial artery with preference to the underlying cephalic vein. These
128
S. Othman and J. Cohn
markings can be extended ulnarly to the ulnar bone and radially to the lateral axial
portion of the radius as necessary, and with desire to capture or spare hair-bearing
regions as necessary. Length-wise, the ap can extend to near the takeoff the radial
artery, resulting in a ap size of up to 30×15cm2, again dependent on patient habitus, though more commonly, signicantly smaller ap dimensions are required.
From the tip of skin paddle to the antecubital fossa, a lazy-S marking is created to
minimize axial scar burden, contracture, and wound healing (Fig.9.1). A pneumatic
torniquet is placed proximal to the elbow joint and, when ready, elevated to
250mmHg for up to 90min. Only light exsanguination is recommended to facilitate
identication of the vasculature during dissection.
Dissection andElevation
There are numerous described methods for approaches to dissection, including distal to proximal, proximal to distal, ulnar to radial, radial to ulnar, and combinations
therein. One common approach involves dissecting in the ulnar to radial direction at
the distal end of the ap. In this pattern, dissection begins from the ulnar border of
the ap marking, elevating down to the deep fascia to reveal the palmaris longus
tendon. Depending on ap design and goal, this can be left or dissected out to
include within the ap. Dissection then continues until identication exor capri
radialis tendon. Supercial veins can be ligated throughout the process to prevent
egress bleeding during dissection and later elevation. From the radial aspect of dissection, there is care to preserve two critical structures in the cephalic vein and
supercial branch of the radial nerve, both of which run radial to the brachioradialis
tendon. At this juncture, the supercial branch of the radial nerve, which runs
closely to the cephalic vein and anteriorly to the brachioradialis tendon, is identied
and protected to preserve sensation to distal dorsal forearm and hand. Additionally,
the cephalic vein, which runs in the deep subcutaneous plane, should be protected if
intended for harvest. Once adequate exposure is achieved, the deep fascia and
Fig. 9.1 Preoperative
markings for incision and
ap design, with the
presumptive pedicle path
traced