Surgical Highlights

The design and dimensions of the skin component depend upon the needs at the donor site. A simple rectangular design of appropriate dimensions will suffice in the vast majority of cases. A special design such as a bilobe is useful if a combined floor-of-mouth defect is associated with a hemiglossectomy. If the flap is used for an extensive base of tongue defect, fascia may be harvested in the mid and upper forearm continuous with the proximal aspect of the flap to fold into the defect for increased bulk.

A pneumatic tourniquet around the upper arm may be used but is usually ^

d unnecessary. The radial artery should be marked out at the wrist and the flap must be designed to incorporate this vessel. To incorporate the cephalic vein the flap is designed to extend over the dorsoradial aspect of the wrist (Fig. 47). The initial inci- o sion should be along the wrist and the radial artery identified. A temporary occlusion clamp or suture is placed around the artery and, with the tourniquet deflated, the

Figure 47 Radial forearm free flap designed and incised to include the cephalic vein (arrow).

Allen's test should be repeated. If the test is positive, the pedicle can be divided between clamps and ligated with sutures. The flap may be harvested from lateral to medial, completely releasing the flap to remain pedicled along its superior border. The superficial branch of the radial nerve is identified and preserved and the distal cephalic vein is divided. If needed, the palmaris tendon is easily included by dividing the tendon near the wrist and keeping the tendon with the flap during the subsequent dissection. As the flap is dissected the fascia should be taken with the flap while preserving the fine peritenon. A 10-12 cm segment of radius bone (up to 40% of the circumference) can be harvested starting from 2 to 3 cm behind the styloid process and proceeding proximally. The bone must be kept attached to the overlying vascular pedicle and skin to maintain the integrity of the muscular and septocutaneous perforators. The proximal and distal bone cuts should be directed at a gentle angle into the bone (not perpendicular) to lessen the risk of fracture. Superior to the midupper edge of the flap a gently curved cutaneous incision is made toward the antecubital fossa. Medial and lateral thin skin flaps are created to expose the underlying subcutaneous tissues and fascia.

The lateral antebrachial cutaneous nerve is very superficial and closely associated with the cephalic vein. The cephalic vein is harvested with a cuff of surrounding fascia to prevent kinking at the recipient site. Within this fascial cuff lies the ยป sensory nerve and it may be freed by careful dissection to allow it to be directed away from the cephalic vein. Dissection of the vascular pedicle commences after the cepha-

d lic vein and sensory nerve have been dissected and divided near the antecubital fossa. >3

The vascular pedicle is released superior to the flap within the volar forearm by dividing the numerous muscular perforators. The pedicle is dissected to its junction o with the brachial artery, divided between clamps and suture-ligated, and the flap transferred to the recipient site.

Donor site closure is straightforward, involving primary closure of the incision over the volar forearm and placement of a split-thickness skin graft over the site of flap harvest. To prevent desiccation of the superficial radial nerve it should be covered by medial advancement of the lateral skin. During the initial 7 days postoperatively a temporary palmar splint is placed to allow care of the wound and to accommodate the bolster for the skin graft. If bone is harvested, an above-the-elbow cast is placed after removal of the temporary splint and worn for approximately 2 months.

How To Reduce Acne Scarring

How To Reduce Acne Scarring

Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.

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