Analysis of 13 cases of venous compromise in 178 radial forearm free flaps for intraoral reconstruction.

The purpose of this study was to analyse the causes of venous compromise and flap failure in radial forearm free flap (RFFF) surgery for intraoral reconstruction. One hundred seventy-eight RFFF reconstructions were reviewed retrospectively for intraoral defects. Of the 13 flaps with venous obstruction, 9 flaps were salvaged, and 4 were lost, with a salvage rate of 69.2%. Eleven venous occlusions occurred within the first 72h. The main reasons for venous failure were mechanical obstruction or technical errors due to inadequate pedicle length and geometry, inadequate venous drainage, compression and kinking of the vein. The main cause of failure for oropharynx reconstruction was unrecognized vascular events due to the lack of reliable monitoring for buried flap. Oozing of dusky blood from the flap margin may be directly related to venous congestion in the early postoperative period and a late indication of a change in skin colour. In conclusion, a thorough operative plan, including carefully selected drainage vein for the flap and recipient vessels, adequate pedicle length and geometry, precise surgical technique, avoidance of haematoma, and expert monitoring of buried flaps may improve the success rate of RFFF transfer in intraoral reconstruction.

[1]  Michael J Miller,et al.  Analysis of 49 cases of flap compromise in 1310 free flaps for head and neck reconstruction , 2009, Head & neck.

[2]  D A Hidalgo,et al.  Efficacy of conventional monitoring techniques in free tissue transfer: an 11-year experience in 750 consecutive cases. , 1999, Plastic and reconstructive surgery.

[3]  S. Jeng,et al.  The Use of Radial Vessel Stump in Free Radial Forearm Flap as Flap Monitor in Head and Neck Reconstruction , 2007, Annals of plastic surgery.

[4]  Frank Hölzle,et al.  Results of monitoring fasciocutaneous, myocutaneous, osteocutaneous and perforator flaps: 4-year experience with 166 cases. , 2010, International journal of oral and maxillofacial surgery.

[5]  G. Evans,et al.  Current Options in Head and Neck Reconstruction , 2006, Plastic and reconstructive surgery.

[6]  Lei Jiang,et al.  Reliability of the superficial venous drainage of the radial forearm free flaps in oral and maxillofacial reconstruction , 2008, Microsurgery.

[7]  Hadi Seikaly,et al.  The implantable Cook-Swartz Doppler probe for postoperative monitoring in head and neck free flap reconstruction. , 2008, Archives of otolaryngology--head & neck surgery.

[8]  S. Hovius,et al.  Long-term functional outcome and satisfaction after radial forearm free flap reconstructions of intraoral malignancy resections. , 2007, Journal of plastic, reconstructive & aesthetic surgery : JPRAS.

[9]  P. Magennis,et al.  Flap monitoring after head and neck reconstruction: evaluating an observation protocol. , 2001, Journal of wound care.

[10]  S. Rogers,et al.  Factors that influence the outcome of salvage in free tissue transfer. , 2003, The British journal of oral & maxillofacial surgery.

[11]  A. Yang,et al.  External monitoring of buried radial forearm free flaps in hypopharyngeal reconstruction , 2011, Acta oto-laryngologica.

[12]  Gregory R. D. Evans,et al.  Timing of Pedicle Thrombosis and Flap Loss after Free‐Tissue Transfer , 1996, Plastic and reconstructive surgery.

[13]  F. Wei,et al.  Reliability of the Venae Comitantes in Venous Drainage of the Free Radial Forearm Flaps , 1998, Plastic and reconstructive surgery.

[14]  J C Yuen,et al.  Monitoring Free Flaps Using the Laser Doppler Flowmeter: Five‐Year Experience , 2000, Plastic and reconstructive surgery.

[15]  S. Yokoo,et al.  Fail-safe drainage procedure in free radial forearm flap transfer. , 2003, Journal of reconstructive microsurgery.

[16]  C. Zeebregts,et al.  Early reintervention of compromised free flaps improves success rate , 2007, Microsurgery.

[17]  I. Whitaker,et al.  The efficacy of clinical assessment in the postoperative monitoring of free flaps: a review of 1140 consecutive cases. , 2010, Plastic and reconstructive surgery.

[18]  Max Heiland,et al.  Outcome and complications of 540 microvascular free flaps: the Hamburg experience , 2007, Clinical Oral Investigations.

[19]  A. Kunselman,et al.  A Prospective Study of Microvascular Free‐Flap Surgery and Outcome , 1998, Plastic and reconstructive surgery.

[20]  R. Tanino,et al.  Salvage operations of free tissue transfer following internal jugular venous thrombosis: A review of 4 cases , 2005, Microsurgery.

[21]  D. Smith,et al.  Free Flap Reexploration: Indications, Treatment, and Outcomes in 1193 Free Flaps , 2009 .

[22]  F. Hölzle,et al.  Reconstructive oral and maxillofacial surgery. , 2008, Deutsches Arzteblatt international.

[23]  L. Levin,et al.  Microsurgery costs and outcome. , 1999, Plastic and reconstructive surgery.

[24]  G. Weinstein,et al.  Internal jugular vein versus external jugular vein anastamosis: Implications for successful free tissue transfer , 2001, Head & neck.

[25]  R. Pellini,et al.  Venous flow-through flap as an external monitor for buried radial forearm free flap in head and neck reconstruction. , 2006, Journal of plastic, reconstructive & aesthetic surgery : JPRAS.