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9 The Radial Forearm Free Flap
131
– Preoperative history and physical is paramount to optimizing vessel selection
and minimizing postoperative complications.
– It is generally easier, and safer, to take a suprafascial approach until critical struc-
tures are identied, although some surgeons will pursue subfascial dissection
due to experience, ease, and time efciency.
– It is recommended to preserve both venous systems (i.e., both venae comitans
and cephalic/basilic veins), even when not planned, due to unforeseen difculties
and to have “bailout” options.
References
1. Song R, Gao Y, Song Y, Yu Y, Song Y.The forearm ap. Clin Plast Surg. 1982;9(1):21–6.
2. Soutar DS, Scheker LR, Tanner NS, McGregor IA.The radial forearm ap: a versatile method
for intra-oral reconstruction. Br J Plast Surg. 1983;36(1):1–8.
3. Chicarilli ZN, Price GJ.Complete plantar foot coverage with the free neurosensory radial
forearm ap. Plast Reconstr Surg. 1986;78(1):94–101.
4. Kelly KE, Anthony JP, Singer M. Pharyngoesophageal reconstruction using the radial
forearm fasciocutaneous free ap: preliminary results. Otolaryngol Head Neck Surg.
1994;111(1):16–24.
5. Calhoun KH.Radial forearm free ap for head and neck reconstruction. Facial Plast Surg.
1996;12(1):29–33.
6. Harris PA, Butler PE, Takushima A.Radial forearm osteocutaneous ap for mandibular reconstruction. Plast Reconstr Surg. 2002;110(4):1196; author reply 1196.
7. Timmons MJ. The vascular basis of the radial forearm ap. Plast Reconstr Surg.
1986;77(1):80–92.
8. Petrolati M, Delaria G, Abbiati G, Tremolada C.Observations on the use of radial forearm
(Chinese) and posterior interosseous reverse pedicled island aps in hand surgery. Plast
Reconstr Surg. 1991;88(1):175–7.
9. Moscoso JF, Urken ML.Radial forearm aps. Otolaryngol Clin N Am. 1994;27(6):1119–40.
10. Demirkan F, Wei FC, Lutz BS, Cher TS, Chen IH.Reliability of the venae comitantes in
venous drainage of the free radial forearm aps. Plast Reconstr Surg. 1998;102(5):1544–8.
11. Chin KY. Dominant radial artery perforator in the proximal forearm. Plast Reconstr Surg.
2011;127(2):1013.
12. Chang EI, Liu J.Prospective comparison of donor-site morbidity following radial forearm and
ulnar artery perforator ap harvest. Plast Reconstr Surg. 2020;145(5):1267–74.
13. Brown JM, Yablon CM, Morag Y, Brandon CJ, Jacobson JA.US of the peripheral nerves of the
upper extremity: a landmark approach. Radiographics. 2016;36(2):452–63.
14. Anderson TB, Bordoni B.Anatomy, shoulder and upper limb, forearm nerves. In: StatPearls.
Treasure Island: StatPearls Publishing; 2022.
15. Patel M, Varacallo M.Anatomy, shoulder and upper limb, arm nerves. In: StatPearls. Treasure
Island: StatPearls Publishing; 2022.
16. Okwumabua E, Thompson JH.Anatomy, shoulder and upper limb, nerves. In: StatPearls.
Treasure Island: StatPearls Publishing; 2022.
17. Yajima H, Tamai S, Yamauchi T, Mizumoto S.Osteocutaneous radial forearm ap for hand
reconstruction. J Hand Surg Am. 1999;24(3):594–603.
18. Koshima I, Tsutsui T, Nanba Y, Takahashi Y, Akisada K.Free radial forearm osteocutaneous perforator ap for reconstruction of total nasal defects. J Reconstr Microsurg. 2002;18(7):585–8;
discussion 589–90.
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132
19. Villaret DB, Futran NA.The indications and outcomes in the use of osteocutaneous radial
forearm free ap. Head Neck. 2003;25(6):475–81.
20. Arganbright JM, Tsue TT, Girod DA, etal. Outcomes of the osteocutaneous radial forearm free
ap for mandibular reconstruction. JAMA Otolaryngol Head Neck Surg. 2013;139(2):168–72.
21. Dediol E, Uglesic V, Knezevic P, Lemac D.Donor-site outcomes for the osteocutaneous radial
forearm free ap. J Reconstr Microsurg. 2017;33(8):e3–4.
22. Ciria-Llorens G, Gomez-Cia T, Talegon-Melendez A. Analysis of ow changes in forearm
arteries after raising the radial forearm ap: a prospective study using colour duplex imaging.
Br J Plast Surg. 1999;52(6):440–4.
23. Shuck J, Chang EI, Mericli AF, etal. Free lateral forearm ap in head and neck reconstruction:
an attractive alternative to the radial forearm ap. Plast Reconstr Surg. 2020;146(4):446e–50e.
24. Chicarilli ZN, Ariyan S, Cuono CB.Single-stage repair of complex scalp and cranial defects
with the free radial forearm ap. Plast Reconstr Surg. 1986;77(4):577–85.
25. McGregor AD.The free radial forearm ap—the management of the secondary defect. Br J
Plast Surg. 1987;40(1):83–5.
26. Davidson J, Boyd B, Gullane P, etal. A comparison of the results following oromandibular
reconstruction using a radial forearm ap with either radial bone or a reconstruction plate.
Plast Reconstr Surg. 1991;88(2):201–8.
27. Cordeiro PG, Mastorakos DP, Shaha AR.The radial forearm fasciocutaneous free-tissue transfer for tracheostomy reconstruction. Plast Reconstr Surg. 1996;98(2):354–7.
28. Watanabe T, Furuta S, Hataya Y, Yuzuriha S, Otsuka Y.Reconstruction of the eyelids and nose
after a burn injury using a radial forearm ap. Burns. 1997;23(4):360–5.
29. Zhou K, Luong JK, Clark JR, Ch’ng S.Coned radial forearm free ap for improved retention
of orbital prosthesis following orbital exenteration. Plast Reconstr Surg. 2018;142(5):818e–9e.
30. Sokoya M, Bahrami A, Cohn J, Sahwney R, Kohlert S, Ducic Y.The radial forearm free ap for
scalp and forehead reconstruction: a 20-year experience. Clin Otolaryngol. 2018;43(6):1611–3.
31. Salibian AH, Menick FJ, Talley J.Microvascular reconstruction of the nose with the radial
forearm ap: a 17-year experience in 47 patients. Plast Reconstr Surg. 2019;144(1):199–210.
32. Sokoya M, Vincent A, Cohn JE, Kadakia S, Kohlert S, Ducic Y.Comparison of radial forearm free ap and gastric pull-up in pharyngo-oesophageal reconstruction. Clin Otolaryngol.
2019;44(3):405–7.
33. Kiehn M, Brooks D, Lee C, Kind G, Buntic R, Buncke G.Patency of radial arteries reconstructed after radial forearm ap harvest. J Reconstr Microsurg. 2007;23(6):347–9.
34. Knobloch K, Vogt PM.On “patency of radial arteries reconstructed after radial forearm ap
harvest (J Reconstr Microsurg 2007;23:347–350)”. J Reconstr Microsurg. 2009;25(1):77–8;
author reply 79–80.
35. Kamienski RW, Barnes RW.Critique of the Allen test for continuity of the palmar arch assessed
by Doppler ultrasound. Surg Gynecol Obstet. 1976;142(6):861–4.
36. Kaplanoglu H, Beton O.Evaluation of anatomy and variations of supercial palmar arch and
upper extremity arteries with CT angiography. Surg Radiol Anat. 2017;39(4):419–26.
37. Krassnig R, Hohenberger GM, Schwarz AM, etal. The important relationship between the
radial artery’s course and the radius during Henry’s anterior forearm surgical exposure. Clin
Anat. 2020;33(7):983–7.
38. Deleyiannis FW, Sacks JM, McLean KM, Russavage JM.Patient self-report of disability of
the upper extremity following osteocutaneous radial forearm free ap harvest. Plast Reconstr
Surg. 2008;122(5):1479–84.
S. Othman and J. Cohn
t.me/Dr_Mouayyad_AlbtousH
Cervicodeltopectoral Flap
10
NimaVahidi, KevinQuinn, CherylYu, SeungLee,
andThomasS.Lee
Introduction
The deltopectoral fasciocutaneous (DP) ap, also known as the Bakamjian ap, has
been a widely used and described reconstructive option for head and neck surgery.
In 1917, Aymard rst described the use of the fasciocutaneous DP ap in a tubed
fashion for staged nasal reconstruction. However, wide popularization of the DP
ap did not come until the 1960s, when Bakamjian described the use of a mediallybased DP ap for the reconstruction of laryngopharyngectomy defects and resurfacing of mucocutaneous defects of the head and neck [1]. A more recent modication
to the original DP ap is the cervicodeltopectoral (CDP) ap which includes the
cervical extension of the DP ap. The CDP ap is a pedicled fasciocutaneous ap
that is based off of the rst, second, and third internal mammary arteries. Along with
its associated cervical skin and platysma, the CDP ap can be utilized to cover large
anterolateral facial and neck skin defects. The CDP ap’s unreliability with salivary
exposure limits its usage in cases of intraoral mucosal and pharyngeal defects with
extensive salivary exposure. Although it has been used successfully by Ducic and
Smith to provide buccal mucosal lining as well as external cheek skin defect (by
turning the skin ap on to itself and de-epithelializing the portion that will be buried), whenever it is being used around the oral cavity, it is imperative to avoid salivary exposure to the subdermal layers of the CDP ap as it will likely lead to skin
ap infection and failure [2].
N. Vahidi · K. Quinn · C. Yu · S. Lee · T. S. Lee (*)
Department of Otolaryngology, Virginia Commonwealth University Hospital,
Richmond, VA, USA
e-mail: Nima.vahidi@vcuhealth.org; Kevin.quinn@vcuhealth.org; Cheryl.yu@vcuhealth.org;
Seung.lee@vcu.edu; Thomas.Lee@vcuhealth.org
© 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_10
t.me/Dr_Mouayyad_AlbtousH
133
134
Internal mammary
phalic
N. Vahidi et al.
Anatomy
The CDP ap includes superior extension of the fasciocutaneous DP ap that incorporates cervical skin and platysma located inferior to the site of the defect and
anterior to the trapezius muscle. The CDP ap also includes the inferior neck and
upper chest skin located medial to the cephalic vein and superior to the third intercostal space.
Neurovascular Supply
The internal mammary artery (IMA), also known as the internal thoracic artery, is a
branch of the subclavian artery that runs inferiorly along the inside of the rib cage,
1cm lateral to the sternum (Fig.10.1). The bilateral, paired arteries course deep to
Fig. 10.1 Trapezius muscle, deltoid muscle, pectoralis major muscle, deltopectoral groove,
cephalic vein, internal mammary artery, clavicle, 1–4 intercostal space, and the area of blood supply where the skin ap should be left down
artery & veins
Trapezius
muscle
Deltoid
1
2
3
muscle
Ce
vein
t.me/Dr_Mouayyad_AlbtousH
10 Cervicodeltopectoral Flap
135
the clavicle but supercial to the pleura as they descend in the chest, providing perforating arteries through the intercostal spaces to supply the skin of the chest wall.
Both the DP and CDP aps are based on the rst four perforators from the IMA,
with the primary blood supply coming from the second and third perforators. These
perforators run in a plane supercial to the pectoralis major fascia and deltoid
muscles.
Understanding the angiosome model is essential in performing the ap harvest.
The primary region and rst angiosome supplied by the internal mammary perforators includes the skin from the sternum to the deltopectoral groove (medial to the
cephalic vein). As one moves lateral to the cephalic vein and into the deltoid skin
region, the risk of ischemia and tissue necrosis increases. In the context of the
angiosome model, the DP is typically described as two distinct areas: a medial,
arterial-based ap and a lateral, random cutaneous-based ap.
The CDP ap is a modication of the DP ap which includes cervical skin and
platysma extending superiorly into the lower neck. As such, the primary blood supply remains based on the perforating branches of the IMAs. The original CDP ap
illustrated by Ducic & Smith describes the skin ap being raised in subcutaneous
tissue plane. However, the senior author (TL) recommends incorporating the platysma with the neck skin to further optimize blood supply to the skin and to provide
additional tissue bulk, especially in situations where the donor neck skin was previous radiated. By raising in the subplatysmal plane, the skin ap has been noted to be
more reliable, especially in radiated patients. The neck skin located anterior to the
trapezius muscle and medial and superior to the cephalic vein are included to center
around the third intercostal space.
The venous drainage of both the DP ap and CDP aps is based on the venae
comitantes that accompany the arteries in the region. These drain to the internal
mammary vein (IMV), which can accompany the IMA as either a single or double
vessel. The most common pattern is to have a single IMV that lies medial to the IMA.
The nerve supply to the deltopectoral skin arises from the supraclavicular nerves
(C3 and C4) and the anterolateral intercostal nerves (T2, T3, and T4). The supraclavicular nerves of the cervical plexus supply the skin over the sternoclavicular joint
to the upper deltoid muscle. The intercostal nerves supply the skin of the anterior
chest wall and provide both sensory and motor function.
Cervicodeltopectoral Flap Advantages
– Relatively easy ap to harvest and offers signicant skin ap volume.
– Can be performed as a single-stage reconstruction.
– Offers a thin skin ap with ideal color match for face and neck skin
reconstruction.
– Can be harvested even if the patient had a previous pectoralis myocutaneous ap,
as long as the blood supply to the skin ap (medial chest along second and third
intercostal space) has not been disrupted.
t.me/Dr_Mouayyad_AlbtousH
136
N. Vahidi et al.
Cervicodeltopectoral Flap Disadvantages
– May be raised in patients with previous radiation therapy (at least 6months after
radiation therapy) but there likely is an increased risk of poor wound healing.
Radiated patients with neck skin that does not slide from underlying soft tissue
(i.e., woody neck) is not a good candidate for CDP ap.
– Not as reliable for intraoral mucosal defects or pharyngeal mucosal defects
where signicant salivary exposure can occur.
– Less reliable in scenarios where the skin ap tents up from excess tension.
Draping the CDP skin ap by following the underlying the contour of the facial
and neck soft tissues without tension will optimize vascular ingrowth from the
underlying wound bed, leading to highest chance of ap success.
– If the skin ap is closed with excessive tension that results in excess dead space
between the CDP ap and the underlying soft tissue, there is an increased risk of
poor wound healing or partial skin ap necrosis, especially in those who have
undergone previous radiation to the area.
– Results in an unsightly donor site defect, particularly if skin grafting is required.
Although the donor site defect can usually be closed primarily with undermining
and mobilization of the posterior neck/deltoid skin and the lateral chest/axillary
skin towards each other, skin grafting may be required near the deltopectoral
groove or along the site of trifurcation in case of excess tissue tension (see
Fig.10.6).
– In women, distortions to breast symmetry and nipple positioning may occur.
Preoperative Evaluation
Preoperative evaluation includes a thorough history and physical examination.
Particular emphasis is placed on the history of prior head and neck surgeries and/or
radiation therapy. The surgical site is evaluated for the presence of any scars or
defects that may interfere with ap harvest. If the patient has had a previous pectoralis myocutaneous ap, the blood supply to the CDP ap may have been disturbed.
Typically, additional imaging or vascular studies are not needed prior to surgical
intervention. The patient’s sex should be taken into consideration, as males may
have excess chest hair which could compromise reconstruction where excess hair is
less desirable while females are at risk for breast and nipple position asymmetry.
Flap Harvest
1. The patient is placed in a supine position and the chest is prepped from the mid-
line to the posterior neck and deltoid. The thigh is prepped and draped for potential skin grafting. Surgical landmarks are trapezius muscle, clavicle, sternum,
and the second and third intercostal spaces.
t.me/Dr_Mouayyad_AlbtousH
10 Cervicodeltopectoral Flap
137
2. One can think of the CDP ap with two large limbs similar to a large bilobed
ap. One limb will be centered around the posterior neck extending into the
deltoid while the second limb will be centered from the superolateral chest skin
(located superolateral to the second and third intercostal spaces). The rst limb
will rotate to reconstruct the cervicofacial neck skin defect while the second
limb will rotate to ll the donor site defect along the deltoid/posterior neck region.
(a) From the deltopectoral groove, an incision is marked to include the posterior
neck skin staying along the anterior border of the trapezius muscle and
extending superiorly to reach the inferior aspect of the tissue defect located
in the face or the neck. This will make up the rst limb.
(b) Next, the second limb is designed to ll the defect from the rst limb. The
second and third intercostal spaces are marked immediately lateral to the
sternum, with the latter marking the inferomedial aspect of the CDP ap.
The incision is made around 2–3cm lateral to the sternal border in the third
intercoastal space and extends obliquely toward the deltopectoral groove.
This oblique, curvilinear line from the third intercostal space to the deltopectoral groove marks the inferior margin of the CDP ap. While designing
the CDP ap, avoid including the skin ap region that would typically be
included for a pectoralis myocutaneous ap (Figs.10.2 and 10.3). In addition, while raising the skin ap, it is important to avoid raising the skin ap
2–3cm lateral to the sternum in the second and third intercostal spaces to
avoid injury to the CDP ap blood supply.
3. The size and anticipated reach of the ap are veried using an imaginary line
extending from the inferoposterior aspect of the defect to second intercostal
space. This line marks the axis of rotation required to reach the supero-anterior
most aspect of the skin defect (Fig.10.4).
4. The neck skin ap is raised in the subplatysmal tissue plane following the ante-
rior border of the trapezius. Along the inferior border of the mandible, one should
be mindful to avoid injury to the marginal mandibular nerve and resulting lower
lip paralysis. The platysma is left attached to the skin ap as dissection is carried
medially towards midline. It is important to remain supercial to the sternocleidomastoid muscle and leave the adjacent external jugular vein and greater auricular nerve down in the wound bed.
5. While dissecting over the deltoid and pectoralis major muscles, the CDP ap is
raised immediately on top of the underlying deltoid and pectoralis muscle fascia.
It is important to remain in a subplatysmal tissue plane as one dissects inferomedially over the clavicle as thinning the skin ap over the clavicular region may
compromise blood supply. The ap is elevated medially up to a point 2–3cm
lateral to the sternum along the rst, second and third intercostal spaces. This
avoids injury to the perforating vessels of the IMA (Fig.10.2).
6. Once the skin ap is raised, it is rotated superomedially to reach the site of the
defect. After it is appropriately positioned, ap perfusion can be checked by
making a supercial cut at the distal skin edges or by nicking the skin ap with
a needle. While positioning, it is important to allow the skin ap to drape along
t.me/Dr_Mouayyad_AlbtousH
138
av
N. Vahidi et al.
CDP flap
incision
Minimize skin
dissection to
oid injury to
flap vessels
Fig. 10.2 CDP ap incision is designed around second and third intercostal spaces. It is important
to avoid injury to these ap vessels by minimizing dissection 2–3cm immediately lateral to the
sternal border within the second and third intercoastal spaces. In addition, in case of future reconstruction needs, avoid disturbing the skin that may be used for future pectoralis muscle ap which
border the inferior aspect of the CDP ap design. Axis of rotation from posteroinferior corner of
the defect to the second intercostal space that can rotate superomedially to meet the superoanterior
aspect of the defect. Two limbs of the CDP ap
2
3
Potential
pectoralis flap
harvest site
the contour of the underlying soft tissue of the neck and avoid tenting which can
compromise perfusion and inhibit neovascularization.
7. Once the CDP ap is positioned into the desired location without tension, clo-
sure of the donor site is performed by advancing the surrounding local tissue.
Two skin aps are mobilized to achieve this (Figs.10.5 and 10.6). The skin over-
lying the trapezius and deltoid muscles is raised immediately on top of the
underlying muscle fascia towards the direction of the scapula, allowing for anterior mobilization of the posterior neck and posterior deltoid skin. At the same
time, a secondary skin ap is raised along the superolateral chest, axilla, and
anterior deltoid skin located lateral to the deltopectoral groove. The skin ap is
t.me/Dr_Mouayyad_AlbtousH
10 Cervicodeltopectoral Flap
Fig. 10.3 CDP ap is
highlighted in light blue
incision. Purple incision
marks the expected skin
defect after cancer
resection. The CDP ap
can be based on second
and third intercoastal
spaces (located inferior to
the corresponding rib).
139
raised supercial to the pectoralis major muscle fascia and the deltoid muscle
fascia, while paying attention to avoid sacricing the pectoralis muscle skin ap
in case the ap is needed in the future (skin medial and inferior to the nipple is
left undisturbed). The superolateral chest, axilla, and anterior deltoid skin are
recruited as a skin ap is then mobilized superiorly to meet the posterior neck/
deltoid skin ap. Towel clamps can be used to help oppose the two skin ap
edges that typically end up in a horizontal orientation near the clavicle. However,
it is best to avoid placing the incision directly over the clavicle to minimize the
risk of bone exposure. If there is excessive tension that prohibits primary closure, typically near the deltopectoral groove or at the site of skin ap trifurcation,
either a split thickness or full thickness skin graft may be employed.
8. Two Jackson Pratt (JP) drains are placed into the neck. One JP drain is placed
from the posterior neck/deltoid skin ap to sit along the posterior neck/inferior
neck gutter. A second JP drain is placed through the superolateral chest/axilla/
deltoid skin ap or from the opposite neck skin ap to sit along the anterior neck/
inferior neck gutter. It is best to avoid placing any drain through the CDP ap as
it can negatively affect the blood supply.
t.me/Dr_Mouayyad_AlbtousH
140
Fig. 10.4 Ensure adequate
ap reach by checking
from the posteroinferior
corner of the defect (A) to
the second intercoastal
space and attempting to
reach the superoanterior
most point of
reconstruction (A′). This
line marks the axis of
rotation from
posteroinferior corner of
the defect to meet the
superoanterior aspect of
the defect. The second
limb of the CDP ap
(marked as point C) allows
closure of the donor defect
with local tissue
advancement in vast
majority of cases
N. Vahidi et al.
t.me/Dr_Mouayyad_AlbtousH
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