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Lateral Arm Free Flap in Head and Neck Reconstruction
Abstract
The lateral arm fasciocutaneous free flap is a versatile donor site of sensate soft tissue for reconstruction and augmentation of the head and neck. The lateral arm flap can be quickly harvested without interference to the head and neck team and with minimal morbidity to the patient. For these reasons, this flap has become our soft-tissue flap of choice.
... 15,16 It is also claimed that there is no risk of vascular compromise to the arm. 13,17 This flap has been widely used for intraoral recon- struction, 13,14,[17][18][19][20] but to the best of our knowledge, there are no reports of its use in reconstruction of tubular structures such as the hypopharynx and the PES. Encouraged by the results of the group of oral and maxillofacial surgeons at the University of Freiburg who used the LUFF for reconstructive surgery following tumor ablation in the oral cavity, 19 we decided to use this flap for reconstruction of the pharynx. ...
... 15,16 It is also claimed that there is no risk of vascular compromise to the arm. 13,17 This flap has been widely used for intraoral recon- struction, 13,14,[17][18][19][20] but to the best of our knowledge, there are no reports of its use in reconstruction of tubular structures such as the hypopharynx and the PES. Encouraged by the results of the group of oral and maxillofacial surgeons at the University of Freiburg who used the LUFF for reconstructive surgery following tumor ablation in the oral cavity, 19 we decided to use this flap for reconstruction of the pharynx. ...
... Although the diameter of the artery in the LUFF is smaller than that in the RFFF, this difference does not appear to be a problem. 18,19,[35][36][37] Although there is a certain degree of risk of radial nerve damage, 13,14,38 there has been no report of permanent radial nerve palsy after LUFF harvesting. There is the possibility of anastomosing the posterior cutaneous nerve of the forearm (nervus cutaneus antebrachii posterior) with the inferior branch of the hypoglossal nerve to ensure sensory feeling in the area of the flap and improve the swallowing function. ...
Free microvascular flaps are an established method for soft tissue reconstruction following ablative oncological surgery in the head and neck. Functional reconstructions of the hypopharynx and the pharyngoesophageal segment (PES) are of particular relevance, as they are highly demanding surgical procedures. So far, the radial forearm free flap (RFFF) and the free jejunal transfer have been the transplants predominantly used for this purpose. The lateral upper arm free flap (LUFF) presents an alternative method for the fasciocutaneous tissue transfer. We report on our experience with the LUFF in a 56-year-old male patient with a pT3pN0M0 squamous cell carcinoma of the hypopharynx. A pharyngocutaneous fistula developed 5 days after pharyngolaryngectomy with bilateral neck dissection. The fistula was localized between the pharyngeal constrictor muscle and the esophagus and was closed with an LUFF from the left arm. Excellent flap adaptation to the remaining pharyngeal mucosa was observed. Although the length of the vascular pedicle and the diameter of the vessels in the LUFF are smaller than those in the RFFF, neither pedicle length nor vessel diameter proved to be a problem. The LUFF can be recommended as a well-vascularized, relatively safe and reliable flap for reconstruction of tubular structures such as the hypopharynx and the PES after tumor ablation and as an alternative to the RFFF. The flexibility of the LUFF allows surgeons to reconstruct the anatomy of the lost soft tissues as adequately as possible.
... For this reason, the lateral arm flap is considered a more suitable alternative. It has a constant vascular anatomy, and there is no damage to the vascular supply of the hand because the flap contains a non-essential terminal branch of the profunda brachii artery [21,22]. The lateral arm is a donor site with better color matching than the radial, fibula, thigh, and latissimus regions. ...
Background and Objectives: The lateral arm flap has been a very useful choice for the reconstruction of small to medium-sized defects, such as in the hands, extremities, and oral head and neck area. Its versatile characteristics and surgical feasibility allow this flap to be widely applied, but its reconstructive potential in the facial subunit after tumor ablation procedures has never been reported. In this study, we aimed to utilize the advantages of this flap to carry out facial temple subunit defect reconstruction. Materials and Methods: Between 2020 and 2023, 12 patients underwent temple reconstruction with lateral arm free flaps after wide malignant tumor excisions. There were seven women and five men, and the mean patient age was 60.6 years. Among the patients with cancer, six had squamous cell carcinoma, five had basal cell carcinoma, and one had myxofibrosarcoma. All flaps were elevated under general anesthesia. Alprostadil (PGE1, Eglandin®, Mitsubishi Tanabe Korea, Seoul, Republic of Korea) was administered postoperatively. Results: All flaps were the fasciocutaneous type, with sizes that varied from 3 cm × 4 cm to 5 cm × 7 cm (average size: 22.7 cm2). The average pedicle length was 6.1 cm. The versatility of the lateral arm flap enabled successful coverage in all cases, with no specific complications. Good functional outcomes and good ranges of motion in the donor arms were observed after surgery. Conclusions: The authors successfully verified the advantages of lateral arm flaps in the treatment of medium-sized facial temple subunit defects.
... The glabrous moderately thick flap with the prospectus for neurotization and the ease of harvest without the need of change in position makes it a flap of choice in head and neck reconstruction. 8,[14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] The donor site can be closed primarily and the scar, being hidden in clothing, is aesthetically acceptable. Moderate subcutaneous arm tissue provides bulk to obliterate the hemiglossectomy defects. ...
Introduction and Methods The glabrous, thin, and pliable texture of lateral arm flap with no loss of any axial vessel of the limb renders it a good choice for hemiglossectomy defect reconstruction. The main caveat of this flap harvest is the loss of sensation in the distribution of posterior antebrachial cutaneous nerve (PABCN). In this article, we present two strategic sites and techniques to preserve the integrity of PABCN and at the same time harvesting lateral arm flap with a lengthy lower lateral cutaneous nerve of arm for the neurotization. The outcome of this function-preserving neurotized lateral arm free flap in the reconstruction of hemiglossectomy defects is analyzed and presented in this article.
Results Ninety percent of the patients attained grade 3 score in objective assessment, leading to a significant p-value of 0.02 with this technique. All had preservation of sensation in the distribution of PABCN.
Conclusion Our technique of harvest and neurotization has brought good functional recovery of the oral cavity with preservation of PABCN.
... An adequate soft tissue coverage at the forearm and hand requires careful planning. The planned tissue transplantation has to provide Subsequently, an ideal flap should be variable regarding its tissue complexity [16,21,25,27,29] and provide the option of being planned either as a fascia-only flap [3,5,8,11,26,28] and osteocutaneous flap [7,13,15,20,23] including a tendon component as a tendon replacement or with the possibility of sensory nerval connection. The flap should be variable in its size and provide a good substitute tissue quality, e.g., equal skin thickness, hairiness, texture, and pigmentation, and an adequate overall thickness of the different components of the flap. ...
This retrospective study was performed to verify the advantages and disadvantages of the free lateral arm flap for defect reconstruction of the forearm and hand.
Between 2001 and 2010, 21 patients underwent defect coverage of the forearm and hand with the free lateral arm flap. The mean patient age was 48 years (17-78). The results concerning defect origin, flap size, pedicle length, operative time, revisions of the anastomoses or other complications, donor site morbidity, and length of hospital stay were evaluated.
The majority of defects were caused by infections or chronic wounds. The defects were localized at the forearm in 6 cases and at the hand in 15 cases. The flap width ranged from 3 to 8 cm, and the length was from 5 to 20 cm. All flaps survived. Only in one case, a revision of the anastomosis was necessary. Primary closure of the donor site was possible in all patients. No complications occurred during the healing procedure. The majority of the patients were satisfied with the aesthetic result at the recipient site as well as at the donor site.
The free lateral arm flap is a very reliable option for defect coverage at the forearm and hand for small and medium size defects. A satisfactory aesthetic appearance, an excellent tissue quality, and frequent primary donor site closure are great advantages for selecting this flap.
... For the intraoral lining, the thinner forearm flaps are preferred because it is easier to drape them over the contours of the mouth. 17,18 The lateral arm flap, when used in this situation, always requires debulking. Sanger and Campbell 19 described a useful variation of the forearm flap that incorporates a segment of the brachioradialis muscle to increase the bulk. ...
The radial forearm flap has been one of the most popular flaps used to reconstruct defects after oral cancer ablation. However, it sometimes may not provide sufficient soft tissue to obliterate the dead space after tumor excision and lymph node dissection, which can result in deep wound infection of the neck or even orocervical fistula. The authors modified the radial forearm flap with a sheet of adipofascial tissue extension to prevent such postoperative complications. From January 1997 to December 2000, 52 patients who underwent ablative oral cancer surgery were studied. A total of 29 patients (group I) underwent reconstruction with the traditional radial forearm flap retrospectively, and 23 patients (group II) underwent reconstruction with the radial forearm flap along with a sheet of adipofascial tissue extension. The radial forearm flap was designed on the axis of the radial artery, was 8 x 4 to 12 x 10 cm in size, and was sufficient to resurface the intraoral defect. In group II, the radial forearm skin flap along with a sheet of adipofascial tissue 8 x 8 to 12 x 10 cm was used to obliterate the dead space of the oral floor and neck. The donor site of both groups was resurfaced with a split-thickness skin graft. In group II, the skin flap of the adipofascial tissue was resutured to its original site. Two flaps in group I failed because of arterial occlusion and required other skin flaps for reconstruction. Postoperative hematoma, which required surgical treatment for drainage, developed in five patients in group I. None of the patients in group II had hematoma formation. Nine patients in group I had a neck wound infection compared with only 2 patients in group II (a significant difference). The average volume of drainage and days of hospitalization were similar in both groups. The morbidity of the donor site of both groups was not significant. The advantages of this modification include 1) suitable soft tissue available for dead space obliteration to decrease the chance of postoperative hematoma; 2) the important vessels in the neck can be protected; 3) there is a decrease in neck wound infections; and 4) donor site morbidity is similar to the traditional group.
Purpose of review:
The aim of this study was to review the recent literature on the utilization of the lateral arm free flap use in head and neck reconstruction.
Recent findings:
The lateral arm free flap provides a reliable fasciocutaneous free tissue transfer option ideally suited for reconstruction of the oral cavity, pharynx and parotid. Primary donor site closure, compartmentalized fat and excellent colour match make it an excellent option for head and neck reconstruction. Donor site morbidity is low, and the primary limitation is the short and narrow vascular pedicle.
Summary:
The lateral arm free flap should be considered in cases of oral cavity and skin reconstruction, particularly in cases wherein pedicle length is not restrictive.
While the lateral arm free flap has been well described, there is a relative paucity in its use compared to other free flaps and regional flaps. The lateral arm free flap is a unique soft tissue free flap that provides several reconstructive advantages in head and neck reconstruction: excellent contour and color match to facial skin, well compartmentalized fat, donor nerves for nerve grafting, and the ability to two-team harvest and close the donor site without a skin graft. A detailed anatomic and harvest technique is described, along with indications and advantages of using lateral free flap for head and neck reconstruction. A scoping literature review was also conducted to tabulate indications, overall success and complications of the flap. The lateral arm flap is a primary option for defects requiring soft tissue reconstruction in the head and neck.
Introduction. The availability of easily pliable skin has allowed the functional reconstruction of oral cavity defects. Although the radial forearm free flap is the most frequently used flap for the reconstruction of surface defects of the oral cavity, the lateral arm free flap may be preferable in some situations. Objectives. The aim of the present paper is to show the advantages and disadvantages and our indications and results for the lateral arm flap in intraoral reconstruction. Material and methods. This is a prospective work on the use of the lateral arm free flap for the reconstruction of oral cavity defects after ablative surgery. The parameters that have been evaluated are: flap viability, morbidity in the donor site, length of the pedicle, selection of recipient vessels, complications and functional results in the reconstructed area. Results. The lateral arm flap has been used in primary reconstruction after ablative surgery for squamous cell carcinoma of the oral cavity in ten patients. One flap was lost because of venous thrombosis. The donor site was repaired by direct closure in 8 cases and a split thickness skin graft had to be used in 2 cases. Mean pedicle length was 8.75 cm. In 9 cases a favorable functional result was achieved. Conclusions. Fasciocutaneous lateral arm flap allows the reconstruction of oral cavity defects achieving good functional results. Morbidity in the donor site is minimal and, in most cases, direct closure permits the repair of the donor site.
The forearm part of the extended lateral arm flap may be separately raised on the most distal septocutaneous perforator of the posterior collateral radial artery. This truly distal lateral arm flap shares most of the advantages of the radial forearm flap and is associated with less donor site morbidity. From April 2000 to March 2004, we used 30 such flaps as the fasciocutaneous free flap of choice, mostly for reconstructions in the head and neck region. The eventful postoperative course observed in 5 of these flaps motivated us to evaluate the rationale and risk factors of this procedure. We prospectively analyzed the influence on the incidence of partial or complete flap loss of 19 patient-related or procedure-related characteristics that may have acted as risk factors. None were found to be of statistical significance. We found the distal lateral arm flap to have a less robust vascular anatomy than the radial forearm flap, resulting in the need for advanced surgical expertise to raise and handle it. As we recognized the difficulty of this flap to be associated predominantly with this anatomy of its vascular pedicle, we now take a more liberal stand toward the possibility of intraoperative conversion to the use of a radial forearm flap.
The lateral upper arm flap (LUAF) was initially described by in 1982 by Song et al. as a simple skin flap, addressing the availability of cutaneous nerves for anastomoses. Katsaros et al., reported the use of a lateral upper arm skin flap, but also considered using it as a composite graft. The LUAF for the oral and maxillofacial reconstruction has several advantages over other flaps, such as constant anatomy, good color match and texture, thin design and plasticity. There is no functional limitation in the donor arm, such as strength and extension, and donor defects can be closed primarily with a linear scar, even when a flap of up to 8 cm in width is taken. For a better understanding of LUAF as a routine reconstructive option in moderate defect of maxillofacial region, the constant anatomical findings must be learned and memorized by young doctors during the specialized training course for the Korean national board of oral and maxillofacial surgery. This article review the anatomical basis of LUAF with Korean language.
Severe orbital soft-tissue loss and contracted eye sockets often present in patients who have had enucleation, exenteration, or other ocular diseases. In this article, the authors report a novel contracted eye socket reconstruction technique using lateral upper arm free flaps and review the surgical outcome in patients with severe orbital soft-tissue loss and contracted eye sockets.
Twenty-four patients with severe orbital soft-tissue loss and contracted eye sockets were included in this study. A free flap from the lateral upper arm of the patient was inserted into the eye socket, with the artery and vein of the flap pedicle attached to the ipsilateral superficial temporal artery and vein, respectively. Eye socket reconstruction was performed 2 weeks after the first operation. Patients were fitted with a piece of prosthesis 3 months later. Most patients needed a second operation for eyelid and eye socket reconstruction, including lower eyelid laxity and retraction correction, medial and lateral canthoplasty, and upper or lower fornix reconstruction.
Postoperative improvement in appearance was evaluated, including texture and color of the flaps, sensation and mobility of the forearm and elbow, and visibility of the surgical scar. All 24 patients were followed up for 6 months to 5 years. Donor sites healed with linear scars, and no sensory or movement loss was found in any of the patients. The reconstructed area appeared good, patients were satisfied with recovering results, and the prosthesis fit well.
The skin from the lateral upper arm has consistent blood vessels and suitable thickness to serve as a source for orbital soft-tissue and contracted eye socket reconstruction, with good cosmetic outcomes.
Therapeutic, IV.
Los colgajos libres constituyen en la actualidad un gran aporte y son una técnica indispensable en cirugía reconstructiva cervicofacial. Sus principales indicaciones se encuentran en las cirugías de exéresis oncológica de la cabeza y del cuello, causantes de pérdidas de sustancia complejas y, a menudo, extensas. El dominio de las distintas técnicas de extracción de los colgajos y la realización de las microanastomosis vasculares requieren un aprendizaje riguroso. La vigilancia postoperatoria, con especial atención a la vitalidad del colgajo, constituye uno de los puntos clave del éxito de este tipo de cirugía. El colgajo fasciocutáneo antebraquial de pedículo radial (colgajo chino) es el colgajo libre más utilizado en la actualidad para las reparaciones de las pérdidas de sustancia mucosa de la cavidad bucofaríngea y de la hipofaringe. En la reparación ósea mandibular se recurre sobre todo al colgajo de peroné.
I lembi liberi costituiscono oggi un apporto fondamentale e indispensabile nella chirurgia ricostruttiva cervicofacciale. Le loro principali indicazioni consistono nelle tecniche chirurgiche di exeresi neoplastica della testa e del collo, che comportano perdite di sostanza complesse e spesso estese. La padronanza delle differenti tecniche di prelievo dei lembi e l’esecuzione di microanastomosi vascolari richiedono una preparazione rigorosa. Il controllo postoperatorio, particolarmente mirato alla vitalità del lembo, rappresenta uno dei punti chiave del successo di questo approccio chirurgico. Il lembo fasciocutaneo antibrachiale a peduncolo radiale (lembo cinese) è il lembo libero attualmente più utilizzato per le riparazioni delle perdita di sostanza mucosa della cavità orofaringea e dell’ipofaringe. La riparazione ossea sottomandibolare fa appello principalmente al lembo del perone (fibula).
An anatomic and topographic study of the lateral upper arm free flap for the clinical use in reconstruction.
Defects of the laryngopharynx and the oral cavity after cancer ablation are increasingly reconstructed by free microvascular anastomosed tissue transfer. Besides the jejunum transplant we use the free radial forearm flap frequently. This flap is suitable for restoring intraoral and pharyngeal integrity. Major disadvantages are the requirement of a skin graft to obtain wound closure and the cosmetic deformity. The lateral upper arm free flap is intended as alternative method for the fasciocutaneus tissue transfer. Based on our dissection of ten cadavers we demonstrate the anatomy of the flap, the harvesting technique, and present data of vascular pedicle length, vessel calibers, and flap size. The vessel calibers of the profund brachial artery (X̄= 2,5 mm) and its terminal branch, the posterior radial collateral artery (X̄=l,8mm), are comparable to the radial artery. The pedicle length can be extended up to 13 cm by using a lateral approach. The subcutaneous tissue volume was 1,3 cm in average, and compared to the radial flap rather thick. Because of his bulky and strong fascia the lateral arm flap seems to be useful as a fascia-fat flap in facial augmentation or as a fascia flap in soft tissue reconstruction.
Disadvantageous are the difficult dissection technique and the loss of sensitivity on the lateral aspect of the forearm. Where a fasciocutaneous flap is indicated, we prefer the radial forearm flap.
Introduction. The availability of easily pliable skin has allowed the functional reconstruction of oral cavity defects. Although the radial forearm free flap is the most frequently used flap for the reconstruction of surface defects of the oral cavity, the lateral arm free flap may be preferable in some situations. Objectives. The aim of the present paper is to show the advantages and disadvantages and our indications and results for the lateral arm flap in intraoral reconstruction. Material and methods. This is a prospective work on the use of the lateral arm free flap for the reconstruction of oral cavity defects after ablative surgery. The parameters that have been evaluated are: flap viability, morbidity in the donor site, length of the pedicle, selection of recipient vessels, complications and functional results in the reconstructed area. Results. The lateral arm flap has been used in primary reconstruction after ablative surgery for squamous cell carcinoma of the oral cavity in ten patients. One flap was lost because of venous thrombosis. The donor site was repaired by direct closure in 8 cases and a split thickness skin graft had to be used in 2 cases. Mean pedicle length was 8.75 cm. In 9 cases a favorable functional result was achieved. Conclusions. Fasciocutaneous lateral arm flap allows the reconstruction of oral cavity defects achieving good functional results. Morbidity in the donor site is minimal and, in most cases, direct closure permits the repair of the donor site.
Post-maxillectomy defects may be restored either by surgical reconstruction or by protheses and there is continuing controversy about the most appropriate method of rehabilitation in any particular case. A questionnaire was designed to assess the current practices of oral and maxillofacial surgeons in the UK after resection of the maxilla for malignant disease.Maxillectomies were carried out by 83% of surgeons; most surgeons do 1–5 cases a year; 38% of surgeons do reconstruct surgically, but only in 10% of cases. Only 65% of surgeons have access to the services of a restorative dentist; this did influence 19% of surgeons' decision about whether to reconstruct surgically or restore by prosthetic means.
Background
The purpose of this retrospective study was to verify the advantages and disadvantages of the free lateral arm flap for defect reconstruction of the forearm and hand.
Patients and methods
The data of 21 patients who underwent defect coverage of the forearm and hand with the free lateral arm flap between 2002 and 2010 were analyzed. The mean patient age was 48 years (range 17–78 years). The results concerning defect origin, flap size, pedicle length, operative time, revision of the anastomosis or other complications, donor site morbidity and length of hospital stay were evaluated.
Results
In 6 cases the defect was on the forearm and in 15 on the hand. The majority of defects were infections or chronic wounds. The overage flap width ranged from 3 to 8 cm and the length from 5 to 20 cm. Revision of the anastomosis was only necessary in one case and flap survival rate was 100%. In all patients primary closure of the donor site was possible without complications during the healing procedure.
Conclusion
The results underline the good reliability of the free lateral arm flap with a satisfactory aesthetic appearance excellent tissue quality and frequent primary donor site closure.
Wir berichten ber den notfallmigen Einsatz einer mikrovaskulren Lappenplastik zum Verschluss eines hohen Pharynxdefektes, entstanden 3Wochen nach radikaler Hals-Lymphknoten-Dissektion, Laserresektion und adjuvanter Therapie eines Tonsillenkarzinoms, kompliziert durch akute intraorale Arrosionsblutung aus der A.carotis. Durch uere Einflsse hervorgerufen kam es nach einer Woche zur Ischmie und nachfolgenden Totalnekrose dieses Oberarmlappens, bis zu diesem Zeitpunkt erfllte das transplantierte Gewebe jedoch die Aufgabe des wasserdichten Verschlusses gegenber bakterieller Kontamination und der agressiv digestiven Wirkung des Speichels. In einem elektiven Eingriff wurde dieser sekundr avaskulre Lappen erfolgreich durch einen myokutanen Latissimus-dorsi-Lappen ersetzt, es traten keine weiteren Komplikationen auf.We report on a case of an emergency free flap cover of a pharyngeal defect which was made necessary by aggressive digestive salivatory and radiation effects 3weeks after neck-dissection and laser ablation of an epidermoid left tonsil carcinoma. Life threatening intraoral bleeding resulted from the erosion of branches of the external carotid artery. After management of the bleeding, massive blood transfusions and restoration of the patient's general condition, a sandwich patch cover of the transmural pharyngeal defect was achieved using a microvascular lateral arm flap. This aimed at preventing further digestive effects and bacterial colonisation of the neurovascular structures at the carotid triangle. Unfortunately, due to external mechanical forces, the flap became avascular and thus necrotic at the eighth postoperative day; however, until the successful replacement by a myocutaneous latissimus dorsi flap it remained water-tight and fulfilled its sealing task.
The purpose of this study was to report the effectiveness of the lateral arm free flap (LAFF) in the reconstruction of oral tongue defects, the subsite in which it may have advantage over the other donor sites. This is a retrospective analysis of 48 consecutive cases of LAFF used for the reconstruction of partial glossectomy defects for squamous cell carcinoma of the oral tongue. Primary defect and donor-site morbidity and the functional and aesthetic outcomes were assessed in 37 evaluable patients, with a minimum of 6 months follow-up. Patient-reported Visual Analog Scale score from 0 (minimum satisfaction) to 10 (maximum satisfaction) was used to evaluate the aesthetic outcome. The follow-up was for 6 to 52 months (mean, 24 months). The flap was successful in 45 (93.8%) patients. The commonest observed donor-site morbidity was a broad scar, but it did not cause much patient dissatisfaction because it could be covered with appropriate dressing. Speech was normal or near-normal in all patients. Poor functional outcome was associated with adjuvant postoperative radiotherapy. The visual analog scale score for the aesthetic satisfaction (mean [standard deviation]) was 6.58 (1.82) for primary site and 7.13 (1.99) for the donor site. LAFF is an excellent option for the reconstruction of partial glossectomy defects of oral tongue without significant involvement of the floor of mouth and base of tongue.
The purpose of this retrospective study was to verify the advantages and disadvantages of the free lateral arm flap for defect reconstruction of the forearm and hand.
The data of 21 patients who underwent defect coverage of the forearm and hand with the free lateral arm flap between 2002 and 2010 were analyzed. The mean patient age was 48 years (range 17-78 years). The results concerning defect origin, flap size, pedicle length, operative time, revision of the anastomosis or other complications, donor site morbidity and length of hospital stay were evaluated.
In 6 cases the defect was on the forearm and in 15 on the hand. The majority of defects were infections or chronic wounds. The overage flap width ranged from 3 to 8 cm and the length from 5 to 20 cm. Revision of the anastomosis was only necessary in one case and flap survival rate was 100%. In all patients primary closure of the donor site was possible without complications during the healing procedure.
The results underline the good reliability of the free lateral arm flap with a satisfactory aesthetic appearance excellent tissue quality and frequent primary donor site closure.
A multitude of reconstructive options are possible for the patient afflicted with an intraoral malignancy. The reconstructive technique chosen depends on the stage of the disease and the extent of the soft- and hard-tissue defects after extirpation. A graded approach is applied to reconstruction. If local tissues are not available for reconstruction, the surgeon must look to more distant sites in choosing a reconstructive procedure. Microsurgical transfer of composite tissues have allowed us a high degree of success in effecting immediate one-stage closure of complex three-dimensional wounds.
The lateral arm free flap (LAFF) has been chosen by some head and neck reconstructive microsurgeons to be their fasciocutaneous free flap of choice. The qualities of this flap have been suggested to include its consistent vascular anatomy, its thin and pliable nature, and its reinnervation capabilities, as well as its low donor site morbidity and ease of closure. During the past year we have performed 14 head and neck reconstructions using the extended LAFF (ELAFF). We present our indications for its use and review its shortcomings. Although the ELAFF does have its limitations, including variability in its flap thickness and donor vessel size, it unquestionably is an important flap in head and neck reconstruction and is our flap of choice for soft tissue reconstruction.
To report our results of a study of 28 patients who underwent sequential reconstructions of the head and neck using the lateral arm flap. To discuss the situations where we have found the procedure useful, report the complication rates, and delineate the advantages and disadvantages of using this flap.
A clinical series of patients was followed up prospectively. The swallowing function of a subgroup that underwent oropharyngeal reconstruction was compared with that of a simultaneous control group that underwent reconstruction with the pectoralis major flap.
University medical center.
Patients with malignant neoplasms of the head and neck who underwent resections and reconstruction with the lateral arm flap.
Twenty-eight patients underwent head and neck reconstruction using lateral arm flaps. In 17 patients, the lateral arm flaps were used for pharyngeal and posterior oral cavity defects. Thirteen of these patients underwent reinnervation. Nine combined palatal and midfacial defects were reconstructed, and 1 lateral facial defect was reconstructed. Most cases were advanced malignant neoplasms and represented a selected minority of similar resections performed at our institutions. Three maxillary reconstructions were performed secondarily. All other reconstructions were performed at the time of tumor ablation.
Data were collected regarding flap survival, return of sensation in flaps, complication rates, and the ability to feed orally.
All flaps survived in their entirety. Of 7.5 tested flaps acquired sensation. Of 14 patients with large oropharyngeal defects, 8 resumed early oral feeding and all survivors eventually obtained nutrition orally. The ability to swallow was superior to the results obtained in a retrospective analysis of a group reconstructed using pectoralis major flaps.
A unique feature of this flap is that it incorporates both thin skin from the proximal forearm and thicker skin from the upper arm. This is ideal for an oropharyngeal defect, where the thin malleable portion can be used in the posterior oral cavity or pharyngeal wall and the thicker portion in the tongue base. Either portion can be used alone as well. The availability of intermediate tissue bulk can also be advantageous for midfacial reconstruction. Sensation can be reliably reconstituted with this flap. We think that the lateral arm flap is versatile and has particularly low donor-site morbidity.
Twenty-three consecutive patients who were reconstructed with a lateral upper arm free flap (LUFF) were examined especially concerning functional and morphological results at the recipient and donor sites. There were 22 intraoral and one upper oesophageal reconstruction after radical laryngectomy. The LUFF rendered good functional and esthetic results except for one case of complete and one case of incomplete flap necrosis due to vascular insufficiency of the supplying vessel of the neck. There was some sensory deficit of the donor site (n=10), but no radial nerve injury or conspicuous scarring. Recipient site dehiscence occurred in two cases and a temporary orocervical fistula was seen in one case. Oral function was maintained due to the thin and pliable flap. Excellent flap adaptation to the adjacent tissue was obtained in eight cases of complete loss of lingual attached gingiva in the molar region and in four cases of loss of buccal attached gingiva. The success and functional results of LUFF were comparable to the results of 14 cases in which radial forearm free flaps (RFFF) were used. Although the length of the pedicle and the diameter of the vessels in LUFF are smaller than in RFFF, neither pedicle length nor vessel diameter proved to be a problem. Extent of scarring and risk of vascular compromise proved to be less as compared to RFFF. LUFF is, therefore, the flap of choice for intraoral soft tissue reconstruction and it is advised to reserve RFFF for cases in which LUFF fails.
The lateral arm flap, is a fasciocutaneous flap with great versatility, but underused in head and neck reconstruction. Its qualities include a intermediate thickness between the radial forearm flap and the pectoralis major, ideal to reconstruct oropharyngeal defect, a consistent vascular pedicle, a pliable soft tissue and a low donor site morbidity. Use of this flap does not require the sacrificing of a major feeding vessel to the arm. We have chosen this technique to reconstruct four cases with surgical defects in oral cavity and oropharynx. The anatomic and functional results have been satisfactory and the complications rate is comparable to other microvascular techniques. We think that the lateral arm free flap is a useful reconstructive technique in specific areas of head and neck.
The lateral upper arm flap is not widely used yet for intraoral defect reconstruction. Investigation of its morphologic and functional outcome was the objective of this study.
The morphologic and functional results of recipient (swallowing, flap survival, dehiscence of margins, cutaneous fistulas, intraoral hairs) and donor sites (wound healing, scar width and length, sensory and motor disturbance) (n = 44) were checked clinically. Postoperative swallowing was investigated via videofluorography (n = 11).
The lateral upper arm flap showed low donor site morbidity, primary closure was achieved in all but one case. Sensory deficit at the proximal forearm (n = 27) occurred without any case of compromise of radial nerve function. Videofluorography allows for objective evaluation of swallowing function.
The lateral upper arm flap is the reconstruction of first choice for intraoral defects due to its low donor site morbidity.
Soft-tissue defects of the head and neck are often reconstructed with fasciocutaneous free flaps. The radial forearm flap is used most commonly, however the lateral arm flap may be the flap of choice in certain situations. Advantages include flap elevation with simultaneous tumor ablation, avoidance of intraoperative patient position changes, and primary closure of the donor site. After extirpative procedures of the head and neck region, 4 patients were reconstructed with the lateral arm flap. Flap survival was 100%, a vein graft to supplement the short pedicle length was necessary in 1 patient, all donor sites were closed primarily, and secondary procedures to reduce flap bulk were necessary in 2 patients. The lateral arm flap is an excellent alternative to the radial forearm flap and should be included in the armamentarium of the reconstructive head and neck surgeon.
The study goal was to show that the lateral arm flap is a viable reconstructive option for complex parotidectomy defects.Study design and setting We studied a case series at a tertiary care medical center from March 1997 to March 2002. The lateral arm flap was used to reconstruct parotidectomy defects that included a composite resection of adjacent tissue in 30 patients. There were 19 men and 11 women (mean age, 62 years; mean follow-up, 19 months). The mean flap area was 114 cm(2), and the mean flap volume was 172 cm(3). The posterior cutaneous nerve of the forearm (PCNF) was used as a facial nerve cable graft in 14 patients. Facial disability outcomes were measured using the Facial Clinimetric Evaluation scale.
The major and minor complication rates with use of this reconstructive approach were low: 16.7% (5 of 30) and 26.7% (8 of 30), respectively. Donor site morbidity was minimal, with no patient having a major donor site complication and 23.3% (7 of 30) having minor complications. Functional recovery of the facial nerve occurred in 6 of 8 evaluable patients who underwent facial nerve grafting using the PCNF. Controlling for degree of facial nerve paralysis, Facial Clinimetric Evaluation scale scores of our patients were not statistically different than those of a historic population with a facial paralysis and no surgical defect.
The lateral arm free flap effectively restores facial appearance when used for reconstruction of complex parotidectomy defects. The PCNF, a nerve harvested with the lateral arm flap, can be used as a facial nerve cable graft with a high rate of success.
The lateral arm flap is successful as a single donor site for reconstructing facial contour and the facial nerve after major ablative defects in the parotid region.
Reconstruction of the oral cavity is an intricate subject that reflects the complexity of the oral cavity itself. There is no perfect reconstruction. Presented here are the current optimal choices for the various regions within the oral cavity. We are constantly seeking to improve these reconstructions in an effort to restore optimal function to patients unfortunate enough to require surgical excision of this most elaborate of anatomic structures.
The forearm part of the extended lateral arm flap may be separately raised on the most distal septocutaneous perforator of the posterior collateral radial artery. This truly distal lateral arm flap shares most of the advantages of the radial forearm flap and is associated with less donor site morbidity. From April 2000 to March 2004, we used 30 such flaps as the fasciocutaneous free flap of choice, mostly for reconstructions in the head and neck region. The eventful postoperative course observed in 5 of these flaps motivated us to evaluate the rationale and risk factors of this procedure. We prospectively analyzed the influence on the incidence of partial or complete flap loss of 19 patient-related or procedure-related characteristics that may have acted as risk factors. None were found to be of statistical significance. We found the distal lateral arm flap to have a less robust vascular anatomy than the radial forearm flap, resulting in the need for advanced surgical expertise to raise and handle it. As we recognized the difficulty of this flap to be associated predominantly with this anatomy of its vascular pedicle, we now take a more liberal stand toward the possibility of intraoperative conversion to the use of a radial forearm flap.
The free lateral arm flap may be harvested as a fascial, fasciocutaneous, or osteofasciocutaneous flap. Simultaneous flap elevation with preparation of the recipient site, easy dissection, minimal donor-site morbidity, and a constant vascular anatomy with long pedicle are advantages of the flap. In this study, the authors present 18 patients operated on between January, 2002 and August, 2003 in whom 18 free lateral arm flaps were utilized. There were four women and 14 men, and the mean patient age was 40 years. Thirteen fasciocutaneous, three fascial, and two osteofasciocutaneous flaps were used. Flaps were employed for the reconstruction of the lower extremity in five patients, upper extremity in nine patients, and head and neck in four patients. Thirteen flaps were elevated under axillary block and five flaps under general anesthesia. Aspirin, dipirydamol, dextran, and chlorpromazine were administered postoperatively. Venous insufficiency developed in two lower-extremity reconstructions on postoperative day 1. Venous thromboses were detected, anastomoses were re-done, and flaps healed uneventfully. No other postoperative complication was observed in the other patients. The free lateral arm flap may be used in various anatomic defects with various indications. It may be elevated under axillary block for extremity reconstructions.
The aim of this retrospective study is to evaluate functional results of oral and oropharyngeal reconstructions with radial forearm free flap.
We present our experience with radial forearm free flap for reconstructing oral and oropharyngeal defect between 2000 and 2004. A total of 96 patients were included in this study. We analysed functional results (alimentation, elocution, mouth opening and cosmetic appearance) and researched the potentialy predictive factors of these results (age, comorbidity, preoperative irradiation...; Chi 2 test).
The rate of free flap success was 97.9%. Good functional results (normal or quasi normal function) were obtained for alimentation, elocution, mouth opening and cosmetic appearance in respectively 92.6%, 64.9%, 81.9% and 84.1% of cases. Age (p = 0.05), preoperative irradiation (p = 0.005) and T stage (p = 0,02) had a negative effect on elocution, free flap failure on mouth opening (p = 0.03), preoperative irradiation (p = 0.05) and free flap failure (p = 0,02) on cosmetic appearance.
Radial forearm free flap is considered as the flap of choice for oral and oropharyngeal reconstructions and allows excellent functional results.
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