Grabb’s Encyclopedia of Flaps Head and Neck

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References
1. Baudet J. Reconstruction of the pharyngeal wall by free transfer of the greater omentum and stomach. Int
J Microsurg 1979;1:53.
2. Baudet J, Guimberteau JC, Laisne D, et al. La révascularisation par microchirurgie d'un transfert mixte
gastro-épiploïque: technique et indications. Presented at the Société Chirurgie Bordeaux et SudOuest, April
20, 1978.
3. Ohtsuka H, Kamiishi H, Saito H, et al. Successful free-flap transfers with diseased recipient vessels. Br J
Plast Surg 1976;29:5.
4. Germain M, Gremillet C, Patricio J. Replacement of the esophagus by a jejunal loop revascularized by
vascular microanastomoses. Int J Microsurg 1979;1:60.
5. Germain M, Gremillet C, Morales-Chavez, et al. Replacement of the cervical esophagus and pharynx by
transplantation and microsurgical revascularization of a free digestive graft. Int J Microsurg 1980;2:23.
6. Katsaros J, Tan E. Free bowel transfer for pharyngoesophageal reconstruction: an experimental and
clinical study. Br J Plast Surg 1982;35:268.
7. Robinson DW, MacLeod A. Microvascular free jejunum transfer. Br J Plast Surg 1982;35:358.
8. Nakayama K, Tamiya T, Yamamoto K, Akimoto S. A simple new apparatus for small-vessel anastomosis
(free autograft of sigmoid included). Surgery 1962;52:918.
9. Maillet P, et al. Cancer de l'oesophage cervical: rétablissement du transit par transplant sigmoïdien
révascularisé. Lyon Chir 1965;61:420.
10. Ancona E, Cusumano A, Frasson P, et al. Notiva in campo di microchirurgia clinica: la sostituzione del
esofago cervicale medianto auto trapiante di ans intestinale. Terapia 1976;61:203.
11. Baudet J, Traissac JL, Laisne D, et al. Reconstruction de l'oesophage cervical après pharyngo-
laryngectomie circulaire par anse sigmoïde transplantée avec micro-suture vasculaire. Rev Laryngol
1977;98:481.
12. Baudet J, Guimberteau JC, Traissac JL, et al. La reconstruction du pharynx et de l'oesophage cervical
par transfert libre d'intestin et d'estomac. Chirurgie 1978;504:873.
13. Hiebert CA, Cummings GO, Jr. Successful replacement of cervical esophagus by transplantation and
revascularization of a free graft of gastric antrum. Ann Surg 1961;154:103.
14. Bourgeon A, Tran DD, Abbes M, et al. Etude de la revascularisation du grand épiploon: applications

chirurgicales. Bull Assoc Anat (Nancy) 1973;57:59.
15. Papachristou D, Fortner JC. Experimental use of a gastric flap on an omental pedicle to close defects in
the trachea, pharynx, or cervical esophagus. Plast Reconstr Surg 1977;59:382.

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Chapter 228
Microvascular Transfer of The Dorsalis Pedis Skin Flap for
Hypopharyngeal Reconstruction
R. M. ZUKER
R. T. MANKTELOW
The dorsalis pedis skin flap can be used for lining in most areas of the head and neck, but it is particularly useful
for areas of difficult access (1, 2, 3, 4). The pharyngoesophageal area is often difficult to reconstruct with
conventional pedicle flaps, but it poses no problem when a free flap is used (5, 6, 7).
INDICATIONS
The dorsalis pedis skin flap is useful in the smaller hypopharyngeal defects, particularly when a tube is not
needed because the defect is not circumferential. The flap is especially useful when the more commonly
used flaps, such as the pectoralis major or deltopectoral, have already been used. This flap provides ease
of access, thin pliable tissue for mucosal resurfacing, a long pedicle, and a remote site (nonradiated tissue).
ANATOMY
See Chapter 548 (8, 9).
FLAP DESIGN AND DIMENSIONS
The procedure should be planned in reverse, even though the extent of the defect is not precisely known. One
should know, however, whether a portion of the anterior or posterior wall can be preserved. The more likely side
of available recipient vessels is chosen, and then the more appropriate foot is selected. (For example, with a
hypopharyngeal defect with a residual posterior wall and vessels likely on the right, select the left foot.)
The flap can extend distally to the interdigital web spaces (10). Its proximal extent is to the distal portion of the
extensor retinaculum. Its lateral boundaries are 1 cm medial to the extensor hallucis longis tendon and 1 cm
lateral to the extensor digiti quinti tendon (Fig. 228.1B).
OPERATIVE TECHNIQUE
The procedure is carried out in three stages. The recipient site is prepared following resection of the lesion, and
a suitable artery and vein are found (Fig. 228.1A). We have used virtually all vessels in the head and neck and,
for the hypopharynx, have found the transverse cervical and inferior thyroid most useful. Meticulous hemostasis
is mandatory.
Donor Site
The dissection begins at the web space between the first and second toes. Here the first dorsal metatarsal artery
is identified
as it lies in the interosseous musculature, usually at a superficial level. The vessel is doubly ligated and divided.
The flap then is carefully elevated from distal to proximal below the level of the first dorsal metatarsal artery,
including it in the flap. The flap must be elevated above the paratenon of all extensor tendons and must leave a
suitable bed for split-thickness skin grafting.

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FIGURE 228.1 A: Recipient-site preparation. Arrow denotes extent of hypopharyngeal defect (posterior wall). B:
Dorsalis pedis flap isolated on vascular pedicle. C: Healed donor site. D: Flap tacked in place and
revascularized. E: Flap sutured in position, closing hypopharyngeal defect.
As the dissection proceeds more proximally, the extensor hallucis brevis tendon is encountered. Because this
structure passes between the first dorsal metatarsal artery and the skin, it must be maintained in the flap. It is
divided, and the dissection proceeds beneath it. Also, on the medial side of the flap, care is taken to maintain the
continuity of the long saphenous vein and the flap. Toward the base of the second metatarsal, a critical point in
the dissection is reached. Here the first dorsal metatarsal artery originates from the dorsalis pedis artery as it
passes over the second cuneiform bone and plunges down to the plantar arch. It is imperative to maintain
communication between the dorsalis pedis artery and the first dorsal metatarsal artery.
The perforating vessel is doubly ligated and divided deep to the takeoff of the first dorsal metatarsal artery. Flap
elevation
then proceeds proximally, maintaining the dorsalis pedis artery in the flap. The venae comitantes of this vessel
are preserved, along with the long saphenous vein. At the termination of flap elevation, the decision will be made
as to which vein will be used.
Proceeding further proximally, the superficial peroneal nerve is encountered when the proximal skin incision is

made. (This flap does have the potential for innervation.) After the proximal skin incision is made, the extensor
retinaculum is divided to facilitate the dissection of the dorsalis pedis vessels and, more proximally, the anterior
tibial vessels. At this point, the flap is isolated on the long saphenous vein and the anterior tibial artery and its
venae comitantes (Fig. 228.1B). A long pedicle can be dissected out for this flap, but in our experience, this has
not been necessary for the hypopharyngeal region. The flap is then completely divided from the foot.
Donor-site closure must be carried out with extreme care. Any rents in the paratenon are carefully closed with
absorbable sutures. A vascularized bed must be present for grafting. We prefer to use a medium-thickness split-
thickness graft, which is gently held in place with a tie-over bolus dressing. The ankle is maintained in neutral
position with a posterior slab. This dressing is not changed for 10 days, and strict bed rest with foot elevation is
maintained. If a longer flap is necessary, such that the interdigital web space is transgressed, then
hyperkeratosis may ensue. This is a difficult problem, and it is best to restrict the flap to the area just proximal to
the interdigital web spaces (Fig. 228.1C).
Recipient Site
The site of the recipient vessels will determine in which direction the flap is situated, since the pedicle will go
toward the recipient vessels. The flap is loosely tacked in place, and vessel length is adjusted. Usually, the long
saphenous vein is used. This has a relatively thick wall compared to the veins of the head and neck. The venous
anastomosis is done first, and then the arterial anastomosis is done (Fig. 228.1D). The flap is then sutured
definitively into place with a watertight closure of interrupted mattress sutures (Fig. 228.1E). The neck flaps that
were used for access to the hypopharyngeal region are then returned to their original position.
CLINICAL RESULTS
Donor-site healing problems will occur if vascularized paratenon is not preserved. Also, this flap is difficult to
elevate.
SUMMARY
The dorsalis pedis skin flap can be used for smaller noncircumferential mucosal defects in the hypopharynx,
particularly when the conventional pedicle flaps about the head and neck have been previously exhausted.
Access is not a problem, and thin pliable tissue is provided; however, this is a difficult flap to elevate, and
unless care is taken, donor-site healing problems can occur.
References
1. Gilbert A. Composite tissue transfers from the foot: anatomic basis and surgical technique. In: Daniller AI,
Strauch B, eds. Symposium on microsurgery. St. Louis: Mosby, 1976;230.
2. Morrison WA, O'Brien BM, MacLeod AM. The foot as a donor site in reconstructive microsurgery. World J
Surg 1979;3:43.
3. Robinson DW. Dorsalis pedis flap. In: Serafin D, Buncke HJ, eds. Microsurgical composite tissue
transplantation, Part II, Section 1. St. Louis: Mosby, 1979;257-284.

4. Ben-Hur N. Reconstruction of the floor of the mouth by a free dorsalis pedis flap with microvascular
anastomosis. J Maxillofac Surg 1980;8:73.
5. Zuker RM, Manktelow RT, Palmer JA, Rosen IB. Head and neck reconstruction following resection of
carcinoma using microvascular free flaps. Surgery 1980;88:461.
6. Zuker RM, Rosen IB, Palmer J, et al. Microvascular free flaps in head and neck reconstruction. Can J Surg
1980;23:157.
7. Zuker RM, Manktelow RT. The dorsalis pedis flap: technique of elevation, foot closure, and flap
application. Plast Reconstr Surg 1986;77:93.
8. McCraw JB, Furlow LT. The dorsalis pedis arterialized flap. Plast Reconstr Surg 1975;55:177.
9. Ohtsuka H. Angiographic analysis of the first metatarsal artery. Ann Plast Surg 1981;7:2.
10. May JW, Chait LA, Cohen BE, O'Brien BM. Free neurovascular flap from the first web of the foot in hand
reconstruction. J Hand Surg 1977;2:387.

Chapter 229
Radial Forearm Cutaneous Flap for Hypopharyngeal
Reconstruction
J. B. BOYD
EDITORIAL COMMENT
This flap has significant advantages, in that the blood supply to the flap is quite vigorous. It avoids the
intraperitoneal approach; however, the donor disability in the forearm is its biggest drawback.
The radial forearm flap (1) is extremely versatile because of its thin, supple nature; its ease of elevation; its large
vessels and long pedicle; and its capacity to be sensate (2, 3, 4). To these advantages must be added the
possibility of simultaneous dissection in two-team head and neck surgery and the ease of tubing the flap for
pharyngeal reconstruction (5, 6). The donor defect is cosmetic rather than functional, but the patient must endure
2 weeks of immobilization to allow the skin graft to take.
INDICATIONS
The radial forearm flap may be used as a patch for noncircumferential defects, or it may be tubed when a
complete section of the hypopharynx has been removed. A patch is indicated when at least one third of the
circumference remains following resection of the tumor. If less than a third remains, the remanent may just
as well be discarded, for its only contribution would be to impose a second longitudinal suture line on the
repair (7).
Many would argue that the radial forearm flap is second choice to free jejunum for circumferential
pharyngeal and hypopharyngeal defects. The jejunum, being tubular, requires only superior and inferior
enteric anastomoses; the radial forearm flap has a longitudinal seam as well. The potential for leakage and
fistula development is correspondingly greater. It should be noted that swallowing is often quite slow with a
jejunal graft, even though peristalsis is orthodromic (8). The tubed radial flap, although only a passive
conduit, seems to offer less delay. Furthermore, there are circumstances in which the radial forearm flap
might be preferred over enteric substitutes. For example, multiple previous abdominal surgeries or active
Crohn disease would make the necessary laparotomy excessively risky.
When a patch repair is required, however, the jejunum has no advantages over the forearm. In fact, the long
pedicle of this flap, its capacity for reinnervation, and its more accessible donor site give it the edge. When
the larynx is still present, reinnervation may help prevent aspiration (2). Patch repair is indicated following a
pharyngectomy or pharyngolaryngectomy when there is insufficient pharyngeal wall for a tension-free
closure. The closure of such defects without a patch may lead to dehiscence and a pharyngocutaneous
fistula. Such fistulas, when large, are themselves another indication for patch repair using a radial forearm
flap. In this case, there is a requirement for a two-layer closure. The radial forearm flap can bear two skin
paddles, but it is probably more effective to use a single paddle for the inner layer and to cover the repair
with pectoralis muscle (Fig. 229.1), which has the ability to overlap, adhere to, and seal the anastomotic
suture line (7).

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ANATOMY
The skin of the anterior forearm receives a significant blood supply from the radial artery via perforating
septocutaneous vessels passing to the skin along the vascular septum between the brachioradialis and the
flexor carpi radialis muscles (Fig. 229.2). These perforators are plentiful in the distal third
of the forearm; proximally, where tendons give way to muscle bellies, they become sparser. Nevertheless, it is
probably safe to raise a septum-based skin flap anywhere along the course of the radial artery. In this way, two
skin islands may be raised, one proximal and one distal, thereby facilitating two-layer closure of a large
pharyngeal fistula.
FIGURE 229.1 Diagram showing how pectoralis muscle overlaps the mucosal anastomosis in the radial forearm
flap and fills the dead space laterally. This is believed to contribute to the reliability of the repair.
FIGURE 229.2 Diagrammatic section of distal forearm showing disposition of radial artery in respect to vascular
septum, brachioradialis, and flexor carpi radialis. The skin paddle extends over the dorsoradial aspect of the
wrist to encompass the cephalic vein. This improves vessel access in the neck but is admittedly detrimental to
the cosmetic result at the wrist.
After emerging from the septum, the vessels branch laterally and medially, piercing the deep fascia and quickly
passing to the subdermal plexus to supply the skin. Contrary to previous teaching, these vessels do not travel on
the surface of the deep fascia for any significant distance. As a result, little of the deep fascia needs to be
harvested with the flap.
Practically the whole anterior forearm skin can be safely taken. Limits extend from the antecubital fossa to the
transverse wrist crease, and from the ulnar border of the forearm to the posterolateral aspect of the radial border.
Raising a flap of such dimensions would require preservation of the entire vascular septum. The “base” of any
radial forearm skin flap is that portion in direct contact with the vascular septum. Like any flap, if the base is
small, the surviving length is accordingly reduced. Length-to-width ratios of 2 or more should be avoided.
The brachial artery bifurcates into radial and ulnar arteries a few centimeters distal to the antecubital fossa. The

radial artery passes distally along the radial side of the pronator teres, initially lying between the biceps tendon
and the bicipital aponeurosis. It crosses anterior to the pronator teres just proximal to that muscle's insertion into
its tubercle on the lateral surface of the radius. On entering the distal third of the forearm, it first overlies the
flexor pollicis longus and finally the pronator quadratus. Septocutaneous branches from the radial artery pass
along the vascular septum between the brachioradialis and flexor carpi radialis muscles to supply the skin (see
Fig. 229.2).
The radial artery is accompanied by two venae comitantes. These vessels are constant but of variable diameter.
Often, they are inconveniently small for microvascular anastomosis. In the region of the bifurcation of the brachial
artery, there is a confluence of veins. Here, the venae comitantes of both ulnar and radial arteries communicate
with each other as well as with one or more of the large subcutaneous veins of the forearm.
Classically, there are three major subcutaneous veins in the anterior forearm: the cephalic, the median, and the
basilic. In the distal forearm, the cephalic vein lies on the dorsoradial, and the basilic on the dorsosulnar aspect
of the wrist. They pass around their respective borders at the midforearm level and then proceed proximally on
the radial and ulnar sides of the anterior forearm. The median vein lies in the midline of the anterior forearm. Just
distal to the antecubital fossa, it bifurcates into two: the median cephalic and the median basilic; the former
angles radially to join the cephalic, the latter ulnarly to join the basilic. The cephalic and basilic veins then pass
up the arm on either side of the biceps muscle, although there are significant variations on this basic pattern.
Perforating veins connect the superficial veins to the deep system at various points. Of most interest here is the
communication at the level of the brachial artery bifurcation. This communication may be single or multiple and
from any of the superficial veins (commonly, the median).
Both the venae comitantes and the large subcutaneous veins of the forearm are capable of draining the flap
alone. The superficial veins are often preferred because of their greater diameter and their independence from
the arterial pedicle. Care should be taken to ensure that the superficial veins have not previously been canalized
and not undergone partial or complete thrombosis.
The median antebrachial cutaneous nerve (C8,T1) enters the forearm in the company of the basilic vein. It soon
gives off a number of large anterior branches that pass down the radial side of the basilic vein and supply the
ulnar half of the anterior forearm as far as the wrist. An ulnar branch supplies the ulnar border of the forearm.
The lateral antebrachial cutaneous nerve (C5,C6) is the forearm continuation of the musculocutaneous nerve. It
enters the forearm on the ulnar side of the cephalic vein and via multiple branches supplies the radial half of the
forearm as far as the wrist as well as the dorsoradial aspect of the forearm.
FLAP DESIGN AND DIMENSIONS
The skin flap usually is positioned over the anterior or anterolateral aspect of the distal wrist. Here the
subcutaneous tissue is thinnest and the pedicle length maximized. It is advantageous to position the flap
anterolaterally in such a way that part of it overlies the cephalic vein (see Figs. 229.1 and 229.3). This vessel
then can be used for venous drainage. In hirsute patients, the flap may be positioned purely on the anterior
aspect of the distal wrist where the skin is less hairy. Unfortunately, the median vein is often quite small at the
distal wrist. Furthermore, it is a favorite target for the frustrated phlebotomist. If an innervated flap is required, it
should be noted that the watershed between the neurosomes of the lateral and medial antebrachial cutaneous
nerves lies down the midline of the anterior forearm. It follows that flaps positioned over the cephalic vein and
extending to the midline need only the lateral antebrachial cutaneous nerve for full reinnervation. Those
positioned centrally, and straddling two neurosomes, require both superficial nerves (4).
The flap may be of almost any dimension so long as a significant portion of it overlies the vascular septum. For
tubular pharyngeal reconstruction, a quadrangular flap is required (see Fig. 229.3). To produce a 3-cm tube, the
flap must be 9.4 cm long (π × 3). Its width is governed by the length of the pharyngeal gap. By making the flap

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trapezoidal in shape, allowance may be made for the discrepancy in diameter between the narrow esophagus
and the wider base of the tongue. On the other
hand, making it a perfect rectangle retains flexibility in the final orientation. The dimensions of patch
reconstructions are determined by the size and shape of the defect.
FIGURE 229.3 Preoperative markings for a tubular reconstruction, approximately 3 cm in diameter.
OPERATIVE TECHNIQUE
A preoperative Allen's test should always be done, but its meaning is open to question. Only in a severe
arteriopathy would grafting of the radial artery be necessary. In many cases, the flap was elevated in the
presence of an unfavorable Allen's test, with no adverse sequelae. One possible cause for an ischemic hand
after this surgery is the inadvertent ligation or division of a superficial ulnar artery, which can lie in the superficial
tissues along the medial border of the flap. With the tourniquet up, this may take the appearance of a large vein.
Such a vessel is at most risk with skin paddles that intrude onto the ulnar border of the wrist.
A tourniquet is placed around the upper arm. The arm is incompletely exsanguinated using an Esmarch or an
Ace bandage before dissection commences. Totally empty vessels are difficult to identify.
The skin flap is incised around its periphery, and dissection is carried down to the underlying muscle fascia.
Care is taken at the proximal margin of the flap to identify and preserve the cephalic vein or any other superficial
veins that may be recruited for venous drainage. A whole network of veins may be selected. An incision is made
from the proximal edge of the flap incision straight up the forearm toward the antecubital fossa. Dissection is
carried through the subcutaneous tissue and the selected venous system traced proximally. If an innervated flap
is desired, all the subcutaneous nerves entering the flap should be preserved in a sheath of fascia. They tend to
lie just superficial to the deep fascia; however, they are extremely delicate and somewhat difficult to locate at this
level. Precise identification of the nerves is best made in the proximal forearm, where they are large and located
next to the cephalic and basilic veins. These nerves and their relevant branches then can be traced distally into
the proximal margin of the flap.
The ulnar side of the flap then is elevated at a level just superficial to the deep fascia, working toward the
intermuscular septum between the brachioradialis and the flexor carpi radialis (see Fig. 229.1). About 1 cm on
the ulnar side of this septum, the deep fascia is incised and dissection then proceeds under it. Preservation of
the deep fascia in this way facilitates skin grafting of the donor site. Dissection proceeds over the surface of the

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flexor carpi radialis tendon, leaving paratenon behind. It then extends around the radial edge of the tendon into
the space beneath. Usually, the radial artery and its venae comitantes are now visible. This step completes
dissection on the ulnar side.
The radial dissection is similar to that on the ulnar side. It passes immediately superficial to the deep fascia until
a point is reached 1 cm lateral to the intermuscular septum, where the deep fascia is divided; dissection then
proceeds at this deeper level. The brachioradialis tendon is seen, and the dissection hugs this tendon in the
same way as the ulnar dissection hugged that of the flexor carpi radialis. Paratenon is preserved.
The radial artery and its venae comitantes are easily identified at the distal margin of the flap. These are ligated
and divided. The cephalic vein is ligated and divided distally, as are other small veins in this region.
It should be noted that the superficial branch of the radial nerve passes through the deep portion of the flap and
is visible during the radial dissection. This nerve is not to be used for innervation purposes because it passes
right through the flap and out the other side. Furthermore, its loss may give rise to a painful neuroma, as well as
sensory loss, on the dorsum of the hand. The nerve can be easily dissected from the undersurface of the flap,
and it is virtually never necessary to sacrifice it.
The proximal portion of the intermuscular septum between the brachioradialis and the flexor carpi radialis then is
entered and communicated with the more distal dissection. The radial artery and its venae comitantes are
immediately visible between these muscles. Proximal to the skin island, it is not necessary to maintain any skin
perforators, septal or otherwise.
The vascular leash is dissected free of surrounding tissues and, together with its attached skin island, lifted clear
of the forearm. This involves bipolar coagulation and the clipping or ligation of numerous small muscular
branches. It can be stripped all the way up to the origin of the radial artery from the brachial artery just distal to
the antecubital fossa. The superficial venous system communicates with the deep system of veins just distal to
this point. This communication may even be preserved as part of a combined venous pedicle (9). Both cephalic
vein and superficial nerves may be dissected into the upper arm to obtain greater length.
It is to be hoped that the dissection will take less than 2 hours of tourniquet time. The tourniquet is released and
hemostasis is established by the usual means. Perfusion of the hand by the ulnar artery should be assessed at
this stage. With proper preoperative assessment, there should be no surprises. Nevertheless, the surgeon
should be prepared to graft the radial artery when faced with obvious arterial insufficiency. In practice, this is
extremely rare. Perfusion of the flap also is assessed. To save ischemia time, the flap may be tubed in situ with a
single mattress layer of 3-0 polyglycolic acid tied internally. When required, the vascular pedicles are divided
between ligatures and the preformed neopharynx transferred to the head and neck region.
To facilitate wound closure, the palmaris longus tendon usually is removed and discarded. The proximal portion
of the wound closes directly. Although the paratenons of the flexor carpi radialis and the brachioradialis have
been preserved and would probably accept a skin graft, it is often better to bury the tendons among the fibers of
the flexor digitorum superficialis muscle. Soft tissues are sutured over the exposed tendon using 4-0 chromic
catgut. By whatever means, a flat, well-vascularized bed is produced to receive an unmeshed skin graft, held in
place by a meticulous tie-over dressing. The graft remains unmeshed to maximize the bridging phenomenon,
which may help avoid tendon exposure. The wrist, including the thumb, then is mobilized in a palmar splint that is
generally not removed for 7 days. When it is removed, the graft is inspected. If the take is less than 100%, further
splinting and dressings are required.

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FIGURE 229.4 A: Pharyngeal fistula following laryngopharyngectomy, with attempted primary repair of
pharyngeal remnant. Two thirds of the circumference has been lost. B: Final results using radial forearm flap
used as shown in Figure 229.3. C: Barium swallow.
At the recipient site, the flap is anastomosed to the proximal and distal pharynx with a single layer of internally
tied mattress sutures (3-0 polyglycolic acid). Patch reconstructions are sutured directly into the defect using a
similar technique. Arterial microanastomosis is performed to one of the major branches of the external carotid
artery if the defect is high and to the transverse cervical artery if it is low. The external jugular vein, if available,
provides the most convenient venous drainage. Otherwise, alternate vessels may be selected (10). The radial
forearm flap is one of the few in which the arterial and venous pedicles may access opposite sides of the neck
simultaneously. In cases of pharyngeal fistula, where there is a requirement for a two-layer closure, it is
advantageous to use a pectoralis major flap for the outer layer (see Figs. 229.1 and 229.4). The muscle may be
overlapped around the suture line to seal off the anastomosis and minimize the risk of
leakage. If the patient is thin, the skin paddle of the flap can be used for skin closure. If there is too much bulk,
the muscle can simply be skin grafted. In cases where the larynx is still present, the lateral and medial
antebrachial cutaneous nerves may be trimmed and anastomosed to the greater auricular nerve (2).
Postoperative monitoring may be done by transcutaneous Doppler readings taken from the radial artery, which
lies on the outside of the neopharynx in the subcutaneous plane. Alternatively, a small “monitor flap,” supplied by
the radial vessels, may be brought out on the skin surface. Buried laser Doppler probes have also been used.
Patients are mobilized after a few days and usually commence a progressive oral diet at 2 weeks (3 weeks, if

irradiated).
CLINICAL RESULTS
Similar to most free flaps in the head and neck, the radial forearm flap enjoys a 95% success rate in terms
of survival. Specific complications in pharyngeal reconstruction involve fistula and stricture formation. For
tubular reconstructions, the fistula rate approaches 50% and is believed to be significantly higher than that
associated with jejunal reconstruction (6). These fistulas, like those occurring with free jejunal grafts, tend
to close spontaneously with conservative treatment. (Fistulas are thought to be much rarer with patch
repairs, particularly when reinforced by vascularized muscle.)
Swallowing may be superior with the radial forearm flap due to the absence of peristalsis; however,
comparative trials have not been undertaken. Late strictures have been reported in 5% of tubular radial
forearm flap reconstructions (6) and in fewer than 20% of jejunal cases (11). Most respond to endoscopic
dilatation.
Tubular reconstructions usually leave a considerable cosmetic defect on the forearm because a large
amount of skin is harvested. Functional problems are rare, however, and rehabilitation is more rapid than
when abdominal surgery is involved.
Trachoesophageal puncture for the placement of a voice prosthesis may be performed 6 weeks after
laryngopharyngeal reconstruction using a tubed radial forearm flap. The puncture is placed within 1 cm of
the inferior suture line. Voice rehabilitation is reported to be excellent in those patients in whom there is
residual tongue function (6).
SUMMARY
For patients undergoing pharyngolaryngectomy who require reconstruction of part or all of the pharyngeal
circumference, the radial forearm flap may be used either as a patch or as a tube. The graft may be tailored
to fit the defect, accommodating the discrepancy in diameters between the oropharynx and esophagus. Like
the jejunum, the flap tolerates postoperative radiation extremely well, and it is favored in the presence of
intraabdominal pathology and general debility.
References
1. Song R, Gao Y, Yu Y, et al. The forearm flap. Clin Plast Surg 1982;9:21.
2. Urken ML, Weinberg H, Vickery C, et al. The neurofasciocutaneous radial forearm flap in head and neck
reconstruction: a preliminary report. Laryngoscope 1990;100:161.
3. Dubner S, Heller KS. Reinnervated radial forearm free flaps in head and neck reconstruction. J Reconstr
Microsurg 1992;8:467.
4. Boyd B, Mulholland S, Gullane P, et al. Lateral antebrachial cutaneous neurosome flaps in oral
reconstruction: Are we making sense? Plast Reconstr Surg 1994;93:1350.
5. Harii K, Ebihara S, One I, et al. Pharyngoesophageal reconstruction using a fabricated forearm free flap.

Plast Reconstr Surg 1985;75:463.
6. Anthony JP, Singer MI, Mathes SJ. Pharyngoesophageal reconstruction using the tubed free radial
forearm flap. Clin Plast Surg 1994;21:137.
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