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The lateral upper arm free flap for intraoral reconstruction
Int. Z OralMaxillofac. Surg. 2000; 29:104-111 Printed in Denmark. All rights reserved
Copyright©Munksgaard2000 InternationalJournalof
Oral& MaxillofaciaISurgay ISSN 0901-5027
Oncology
The lateral upper arm free flap for intraoral reconstruction
N.-C. Gellrich ~, T. G. Kwon 2, G. Lauer ~, O. Fakler ~, R. Gutwald ~, J,-E. Otten ~, R. Schmelzeisen ~ 1Department of Oral and Maxillofacial Surgery, Albert-Ludwigs University Freiburg, Germany; 2Department of Oral and Maxillofacial Surgery, College of Dentistry, Kyungpook National University, Taegu, Korea
N.-C. Gellrich, T. G. Kwon, G. Lauer, O. Fakler, R. Gutwald, J.-E. Otten, R. Schmelzeisen: The lateral upper arm free flap for intraoral reconstruction. Int. J. Oral Maxillofac. Surg. 2000; 29: 104-111. © Munksgaard, 2000 Abstract. Twenty-three consecutive patients who were reconstructed with a lateral upper arm free flap ( L U F F ) 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 L U F F 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 L U F F were comparable to the results of 14 cases in which radial forearm free flaps ( R F F F ) were used. Although the length of the pedicle and the diameter of the vessels in L U F F 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 R F F E L U F F is, therefore, the flap of choice for intraoral soft tissue reconstruction and it is advised to reserve R F F F for cases in which L U F F fails.
Reconstruction of lost parts of the oral and maxillofacial area is difficult because this area is composed of various kinds of hard and soft tissues. The latter are supposed to maintain a maximum of mobility. Reconstruction without ensuring mobility of the tongue or the remaining muscles often results in severe swallowing or speech problems 7,22. Thin and pliable free flaps like the fasciocutaneous radial forearm free flap ( R F F F ) have, therefore, been regarded as superior to reconstruct lost parts of the oral cavity9"19'22'24'26, however, postoperative donor site morbidity is considered to be one of the problems of R F F F a9,25.
The lateral upper arm free flap (LUFF), first described by SONG et a l Y , is thought to give rise to less donor site morbidity 32. L U F F is a thin and pliable flap with consistent anatomy and a high success rate. It is also claimed that there is no risk of vascular compromise to the arm 2,2s. MATLOUB et al. a5 first reported successful intraoral reconstruction with L U F F with additional sensory nerve repair in six cases2,s,2°. KATSAROS et al. a2 reported 150 cases and STOBER27, HARPF et al. 9 reported an extended indication of this flap. It can be used as a pure fascia1 flap2s or as a tendo-fasciocutaneous flap I1. Some surgeons reported the in-
Key words: lateral upper arm free flap (LUFF); intraoral reconstruction; radial forearm free flap (RFFF); oral cancer; microsurgery. Accepted for publication 3 December 1999
clusion of the cortex of the humerus so that an osteocutaneous flap can be harvested2,12,2°. Application of L U F F for the head and neck area has recently become popular 2'18'21'28'31. L U F F is thought to be a reliable alternative to R F F F for intraoral soft tissue reconstruction 18,2547. Limited pedicle length and sensory deficit of the proximal forearm have, however, been reported as disadvantages 5,8,26. The purpose of this study was to evaluate the esthetic and functional results of patients treated with L U F F and to assess postoperative morbidity, as compared to the use of R F F F over the same period.
Lateral upper arm free flap
105
Fig. 1. LUFF was designed to slightly extend onto the forearm area passing over the lateral epicondyle 2 cm distally. The width should not exceed 6 cm in order to allow for primary wound closure.
Fig. 2. Dissected right LUFF before removal. The ruler lies parallel to the transplant vessels; "T" marks the long head of the triceps muscle (Fig. 2a). The radial nerve (RN) could be easily dissected from the pedicle; a pointer directs to the RN in Fig. 2b.
Fig. 4. One year follow-up result after reconstruction of left retromolar zone, pharyngeal wall, posterior floor of mouth and buccal mucosa with LUFF. LUFF allows for good reconstruction of concave and convex surfaces.
Fig. 5. Reconstruction of 2]3 of the right tongue and anterior floor of mouth with LUFF. Good flap margin at the tongue. Fig. 6. Reconstruction of right floor of mouth, glossoalveolar sulcus with LUFF. The pliable flap allows for good reconstruction of form. Fig. 7. Minimal donor site morbidity on the left arm with no functional impairment (Fig. 7a). Close view of the donor site (Fig. 7b) three months postoperatively with a linear scar.
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Table 1. Location and type of tumor in patients reconstructed with LUFF (lateral upper arm free flap) Radiation
Case 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Age/Sex 58/M 61/M 47/F 59/M 68/M 43/M 54/M 70/M 48lM 54/M 58/M 69/M 58/M 63/F 47/M 56/M 65/M 55lM 53/M 51/F 47/M 57/F 70/M
Location of tumor
Type of tumor
Neck dissection
therapy
Left floor of mouth Left cheek Right floor of mouth Left floor of mouth Anterior floor of mouth Anterior floor of mouth Right floor of mouth Right floor of mouth & gingiva Right soft palate Anterior floor of mouth & tongue Tongue base, soft palate & epiglottis Left floor of mouth Right cheek Right floor of mouth Left floor of mouth Larynx Left tonsil Right floor of mouth Right tonsil Left floor of mouth (Osteoradionecrosis) Anterior floor of mouth Right retromolar region Right anterior floor of mouth
SCC (T4 N2) SCC (T2 NO) SCC (T2 NO) SCC (T1 NO) SCC (T4 NO) SCC (T4 N2) SCC (T1 NO) SCC (T2 NO) SCC (T1 NO) SCC (T1 NO) SCC (T3 N2) SCC (T2 NO) SCC (T2 NO) SCC (T2 NO) SCC (T2 NO) SCC, Secondary SCC (T4 Nx) SCC (T4 N2) SCC (T3 Nx) SCC, Secondary SCC (T3 NO) SCC (T2 NO) SCC (T2 NO)
Rt. SOND, Lt. FND Lt. FND Rt. FND, Lt. SOND Rt. SOND, Lt. FND Rt. RND, Lt. SOND Rt. + Lt. SOND Rt. FND, Lt. SOND Rt. FND, Lt. SOND Lt. SOND Rt. + Lt. SOND Rt. SOND, Lt. FND Rt. SOND, Lt. FND Rt. SOND Rt. FND, Lt. SOND Rt. SOND, Lt. FND
IORT 25 Gy IORT 20 Gy Post op 60 Gy Post op 6 Gy Post op 66 Gy
Post op 60 Gy Pre op 60 Gy Post op 66 Gy
Post op 60 Gy
Rt.+Lt. FND Rt. FND, Lt. SOND Rt. FND, Lt.SOND Rt. FND, Lt. SOND Rt. SOND Rt. FND, Lt. SOND
SCC: squamous cell carcinoma, SOND: supraomohyoid neck dissection, FND: functional neck dissection, IORT: intraoperative radiation therapy.
Material and methods In an 18-month period, intraoral reconstruction with LUFF was used in 23 patients (19 men, 4 women) out of a total of 52 cases of microvascular reconstruction involving soft tissue defects of the head and neck region. All intraoral tumors were diagnosed as squamous cell carcinoma. The average age of the patients was 54.7 years (range: 43 to 71). The location and type of tumor are listed in Table 1. In all but two cases, the operations were for primary reconstruction after ablative tumor surgery. In one case secondary reconstruction was carried out after osteoradionecrosis and in one case oesophageal reconstruction was carried out after extensive laryngeal carcinoma resection. The preoperative assessment consisted of clinical examination of the donor site, but neither a special clinical testing nor a preoperative angiography was performed to study LUFF's vascular supply. Tumor excision and flap harvesting were performed by separate teams in order to reduce operating time. LUFF was designed to extend onto the proximal forearm area passing over the lateral epicondyle, 2 cm distally (Fig. 1). The average flap size was 6×8.5 cm2. The average pedicle length was 8.8 cm. The distal portion of the flap was usually thinner than the proximal one. Flap adaption to the intraoral defect was usually done by taking into account the different thicknesses. The anastomosing vessel of LUFF was the posterior radial collateral artery (PRCA) and vein (Fig. 2a,b). PRCA (diameter: ranging between 1.5-2.2 mm) is smaller than the radial artery
but shows a consistent anatomy. The superior thyroid artery and vein were the preferred recipient vessels. In some cases the facial artery and vein were used, depending on the diameter of the artery and pedicle length. Arterial anastomosis was in all cases end-toend, whereas venous anastomosis was in 15 cases end-to-end, and in eight cases end-toside with the internal jugular vein. In three cases, the pedicle of LUFF was connected to contralateral cervical vessels. LUFF was used only as a fasciocutaneous flap. Marginal resections of the mandible were done in 11 cases; continuity resections (n= 10) of the mandible were bridged by a Unilock-plate (Stratec Medical, Oberdorf, Switzerland). Bony reconstruction is usually performed in our institution after one year when no recurrence has presented. An elastic dressing on the lateral upper arm was applied in all patients and was usually removed after two days. For five days 2 g cefotiam® i.v. were administered twice daily, while a low dose heparin (0.4 mg clexane ® s.c.) was given prophylactically. If postoperative radiotherapy had to be given, it was started after completion of wound healing after approximately two weeks. Eight patients (35%) received postoperative radiotherapy. Intraoperative radiotherapy (IORT) with a linear accelerator as a single shot procedure to the tumor area was performed in two patients. The patients with LUFF reconstruction were divided into three groups (Fig. 3) according to the area of reconstruction, using the classification of JACOBSON et al.l°. Group I patients (Cases 1, 2, 3, 4, 7, 8, 12, 13, 14, 15,
18, 20) had resection and reconstruction including the floor of the mouth and the lateral tongue; intraoral cheek mucosa excision was also included in this group. Group II (Cases 5, 6, 10, 21, 23) included resection and reconstruction of the anterior tongue or anterior floor of the mouth. Group III patients (Cases 9, 11, 17, 19, 22) had resection and reconstruction of the oropharynx, including the tonsilar region and soft palate. Case 16, a laryngeal cancer patient, could not be included in this classification. To evaluate swallowing function, we used a swallowing index from 0 to 3 based on the patient's subjective judgement. Speech ability was scored from 1 to 3 according to the patient's ability to communicate. Average scores were compared between groups. Four patients were lost to follow-up, so that their postsurgical function could not be included. Nearly half of the patients (n= 10) had systemic disease such as diabetes mellitus (n=4), coronary heart disease (n=3), COPD (n=3) or liver cirrhosis (n=l), which might have influenced the vascular condition of the recipient site. The choice of R F F F or LUFF for reconstruction of defects was based on selection criteria. All patients who should be reconstructed with a fasciocutaneous flap were scheduled to receive LUFE except that patients with positive Allen test and no former injuries to the forearm or hand and few hairs at the forearm were chosen for reconstruction with RFFF (n=7); defects which required grafts with long pedicles were also chosen for reconstruction with R F F F (n=7). The 14 R F F F patients (six men, eight women) had an average age of 62.0 years
Lateral upper arm free flap Group L"Reconstructionincludingfloor of mouth & ventral tongue or cheek [
Case
1, 14
Case 7, 8, 18, 20
107
Group II: Reconstructionincludinganteriortongue or anteriorfloor of mouth ]
Case 4, I5 Case 5, 10
Case 6, 21, 23
Group III: Reconstructionincludinglateralpharyngealwall & soft palate ]
Case 3, 12
Case 2
Case 13
Case 9
Case
11, 17
Case 19, 22
Fig. 3. Classification of the area of reconstruction in patients with LUFF, according to JACOBSONet al. (1995) l°.
(ranging from 45 to 85). Except for two patients with basal cell carcinoma and one with sclerosing duct carcinoma, all other patients had squamous cell carcinoma (Table 2). Most received radiotherapy (n=9) and 3 patients suffered from systemic disease. All RFFFs were fasciocutaneous flaps. The average size w a s 7x5 cm 2. The average pedicle length was 10.5 cm. All patients passed the Allen test preoperatively. In two patients, a reconstruction plate (Unilock system) was used after mandibular continuity resection. The donor site defect was covered by a split thickness skin graft from the anterior thigh. Seven days of tie-over dressings on the forearm and additional dressings on the lateral thigh were needed for RFFE Donor site complications of LUFF and
R F F F were evaluated with respect to wound healing, take of skin graft (only in RFFF), tendon exposures motor dysfunction (radial nerve) and quality [hypo-, par-, hyperesthesia] and extent of sensory deficits directly at and distally to the flap harvesting area. The recipient sites were assessed with particular reference to wound healing, graft take, presence of fistula and intraoral hair growth.
Results Functional evaluation of recipient site of I.UFF
Examples of intraoral reconstruction with L U F F are s h o w n in Figs. ~ 6 . T h e
results o f the evaluation o f p o s t o p e r a tive f u n c t i o n at the recipient site are presented in Table 3. F l o o r o f m o u t h excisions - included in p a t i e n t s o f g r o u p I r e c o n s t r u c t i o n s - were usually a c c o m p a n i e d by removal o f lingual att a c h e d gingiva; buccal m u c o s a excisions often included labial a t t a c h e d gingiva. T h e r e was a s m o o t h t r a n s i t i o n f r o m the flap to the n e i g h b o u r i n g oral m u c o s a a n d t o n g u e (Figs. 4-6). This g r o u p h a d good postoperative swallowing capability a n d speech (Table 3). M o s t o f t h e m could m a i n t a i n a n o r m a l diet, b u t some needed water to wash o u t the f o o d debris after they h a d swallowed.
Table 2. Location and type of tumor in patients reconstructed with R F F F (radial forearm free flap) Case
Age/Sex
Location of tumor
Type of tumor
Neck dissection
1 2 3 4
73/M 45/F 56/M 67/M
Hard palate & nasal cavity Right maxillary sinus Left anterior floor of mouth Left anterior floor of mouth & tongue
SCC SCC SCC SCC
Rt. Rt. Rt. Rt.
5 6 7 8 9 10 11 12 13 14
75/M 48lM 71/F 70/F 49/M 85/F 57/F 57/F 48/M 67/F
Left medial orbit & frontal bone Maxillary sinus & skull base Right maxillary & frontal sinus Left upper lip Right retromolar & cheek Left orbit & frontal bone Right posterior floor of mouth Left floor of mouth & tonsil Right tongue & floor of mouth Anterior floor of mouth
(T4 (T4 (T2 (T2
N2) N1) N2) N0)
FND, Lt. SOND FND SOND, Lt. FND SOND, Lt. FND
Basal cell carcinoma Adenocarcinoma (T2 N0) Rt. SOND SCC (T4 N0) Lt. SOND Sclerosing duct carcinoma (T2 N0) Lt. SOND SCC (T2 NO) Rt. FND, Lt. SOND Basal cell carcinoma SCC (T2 N0) Rt. FND, Lt. SOND SCC (T2 N1) Rt. SOND, Lt. RND SCC (T1 N2) Rt. FND, Lt. SOND SCC (T2 Nx) Rt. + Lt. SOND
Radiation therapy Post op 62 Gy Post op 64 Gy Post op 64 Gy IORT 12 Gy & Post op 50 Gy Post op 50 Gy Pre op 60 Gy Post op 60 Gy Post op 60 Gy
Post op 60 Gy
SCC: squamous cell carcinoma, SOND: supraomohyoid neck dissection, FND: functional neck dissection, IORT: intraoperative radiation therapy.
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Gellrich et al.
Only one patient (Case 8) in this group complained of severe speech difficulty, another patient had a mild dysarthria which did not preclude speech. G r o u p II patients revealed a mild degree of dysphagia and dysarthria. Speech intelligibility, however, had decreased significantly. In group III patients, swallowing ability and speech intelligibility were markedly decreased. U n d e r videofluoroscopy, some aspiration of contrast
medium during swallowing was observed in one patient. Recipient site morbidity: LUFF
vs
RFFF
The results of the evaluation of recipient site morbidity of L U F F and R F F F are summarized in Table 4. There was one case of complete and one case of incomplete flap necrosis using L U F E N o flap necrosis occurred with R F F E The one total and one partial flap ne-
Table 3. Evaluation of postoperative function of patients reconstructed with LUFF*
Classification
Case No.
Swallowing Index
Speech Index
Group I
Case 1 Case 2 Case 3 Case 4 Case 7 Case 8 Case 12 Case 13 Case 14 Case 15 Case 18 Case 20
3 2 3 3 3 2 3 3 2 3 flap failure -
3 2 3 3 2 1 3 3 3 3 flap failure -
Group II
Group III
Mean
2.7
2.6
Case 5 Case 6 Case 10 Case 21 Case 23
2 3 3 2
2 2 2 2
Mean
2.5
2.0
Case Case Case Case Case
9 11 17 19 22
1 1 2 1 (partial flap failure) 2
Mean
2 2 1
1 (partial flap failure) 3
1.4
1.8
Swallowing Index: 3 - No problem in swallowing, near normal 2 - Difficult to swallow hard or dry food 1 - Difficult to swallow liquid food 0 - Impossible to swallow Speech Index: 3 - Good speech intelligibility 2 - Moderate speech intelligibility 1 - Poor speech intelligibility (-): impossible to access long term follow-up data * Laryngeal cancer patient (Case 16) was impossible to evaluate.
Table 4. Recipient site complications
Total flap loss Partial flap loss Partial dehiscence of margin Infection Cutaneous fistula Iutraoral hair
LUFF (n=23)
RFFF (n = 14)
1 (4.3%) 1 (4.3%) 2 (8.6%) 0 1 (4.3%) 3 (13.0%)
0 0 3 (21.4%) 2 (14.2%) 1 (7.1%) 1 (7.1%)
crosis were attributed to general vascular insufficiency of the patient - even though there was no systemic disease present and the ischemic time was not longer as compared to other cases. In both cases, P R C A and vein were successfully harvested without difficulty, but there was arterial circulatory impairment of the recipient site artery (superior thyroid, facial and - later on external carotid artery). With the use of R F F F , three cases of wound dehiscence and two cases of infection occurred. L U F F had excellent flap margin integration to the recipient site. There was only a small a m o u n t of hair on the intraorally positioned flap in four patients but none of them complained about this. The proportion of hair-bearing skin was higher in L U F F than in R F F F , which was probably due to the higher male:female ratio in L U F F (19:4) compared to R F F F (7:7). Donor site morbidity: LUFF
vs
RFFF
Functional and esthetic problems of the donor site were evaluated and are listed in Table 5. The most c o m m o n problem of L U F F was a sensory deficit in the lateral proximal forearm area. D u r i n g the flap harvesting procedure, the posterior cutaneous nerve of the forearm (PCNF) was cut in most cases, but injury of P C N F did not fully coincide with the postoperative sensory deficit. The area of sensory disturbance ranged from 5 x 9 cm 2 to 5.5×16.5 cm 2. Most patients did n o t complain about their cutaneous sensory disturbance, but one patient had pain on pressure around the lateral epicondyle of the humerus. The hypoesthesia (n=6) did not improve before 3 to 6 m o n t h s after surgery, however, patients with paresthesia (n=2) or hyperesthesia (n=2) improved over time. There was one case of 5th digit adduction difficulty due to temporary ulnar nerve compression probably caused by incorrect positioning of the elbow during operation. The wound healing was uneventful after surgery except for one case of donor site infection in a poorly controlled diabetic woman. In five patients with R F F F , paresthesia on the proximal t h u m b area was noted but there was no functional disturbance. Paresthesia persisted during the period of follow-up 6 to 12 months after surgery. The flexor carpi radialis tendon was exposed in two cases, followed by partial loss of the
Lateral upper arm free flap Table 5. Donor site complications
Sensory disturbance Hypoesthesia Paresthesia Hyperesthesia Infection (delayed healing) Poor take of skin graft Tendon exposure
split thickness skin graft on the flap harvesting area. After several weeks of local wound care, the wounds healed by secondary intention. Compared to LUFF, the area of sensory disturbance in cases of R F F F was prone to injury. Average scar length at the lateral upper arm was 20 cm (ranging from 17 cm to 23 cm). In all cases, the donor site was primarily closed without the use of a skin graft, so that this part of the scar, where the tissue had been excised, was 8 cm long and 4 nun wide on average. No conspicuous scars were visible on the whole linear incision of the arm (Fig. 7a,b). Compared to RFFF, in which an average 5×4.5 cm 2 rectangular scar and a 15 cm long conspicuous linear scar were visible, the scar of L U F F was positioned posterolaterally and could be easily covered by a T-shirt. Discussion
Bulky flaps like the pectoralis major or latissimus dorsi myocutaneous flaps were previously used for intraoral reconstruction following ablative tumor surgery. At present, it is known that volume replacement does not necessarily result in good rehabilitation of oral function 23. There are still cases, however, where voluminous flaps are indicated. Thin and pliable fasciocutaneous free flaps are preferred when the aim is to restore delicate oral anatomy, including a concave sulcus 16. The remaining mobile structures are then allowed to move without being fixed by a bulky nonmoving tissue mass. The RFFF, which is easy to harvest, is still the most often used flap to fulfil these requirements 1°,23,26. Donor site morbidity, however, is still a problem, because of the necessity of skin grafting in most cases, while there are also esthetic concerns 3°. Removal of one of the two essential arteries of the hand also implies a certain risk to the vascular supply of
LUFF (n=23)
RFFF (n= 14)
10 (43.4%) .6 2 2 1 (4.3%) 0 ,9
5 (35.7%) 0 5 0 0 2 (14.3%) 2 (14.3%)
the hand. L U F F has many advantages, including relatively simple and reliable anatomy 2,3,32,33 with minimal vascular variation 11'14,2°. According to anatomical studies, complete duplication of the profunda brachii artery is reported in 40/511 to 12% 2o of cases, however this was not noticed in the present series of patients. This figure is comparable to R F F F in which the arterial anomaly rate has been reported to be 10% 29. The diameter of the artery in L U F F is smaller than in R F F E as mentioned by various authors 3,6,21, which does not appear to be a problem. P R C A in L U F F is not essential to the vascular supply of the arm and there is no risk of vascular compromise and no need for preoperative evaluation of the donor site vessel as with R F F E Another advantage of L U F F is that the donor site region can be closed directly if the graft does not exceed 6 cm in width 17,31. The flap length can be over 15 cm if the flap is extended distally to the lateral epicondylelA3,TM. In the patient group presented, all intraoral defects could be covered with an average flap of 6× 8 cm 2 without any tension. Recent modification includes extension of L U F F more distally to extend the pedicle length 1,13,14,21. A too distally positioned LUFF, however, may leave a conspicuous scar behind as with the R F F F in the proximal forearm area. We extended the flap 2 cm distal to the lateral epicondyle to achieve additional pedicle length and to extend the thinner part of the flap. This was found sufficient to guarantee primary closure, while sufficient extension of the flap was achieved to close large intraoral defects. The thinner part of the flap could be adapted to the remaining attached gingiva or the floor of mouth and the thicker part could be adapted to the site which needed most volume, such as the tongue. A similar appli,cation has also been reported by CIVANTOS et al.2. Control of flap thickness
109
is the unique asset of L U F F for intraoral reconstruction. Functional evaluation of recipient site of LUFF
Functional evaluation after intraoral reconstruction has focused on swallowing and speech 9,15. MATLOr3~ et al. 15 first evaluated swallowing, articulation, range of tongue motion and sensation in patients reconstructed with L U F F and nerve repair. Some surgeons reported, however, that nerve repair is not effective8, or only effective in 50% of patients e, or effective enough to reduce morbidity after surgery TM. In the present group of patients, no attempts were made to repair continuity of interrupted sensory innervation to the graft. Although our results cannot prove that lack of sensory innervation of the fasciocutaneous flaps has little to do with the degree of dysfunction, we suggest that functional results are more related to location and dimension of the defect. Especially in group I and II patients, soft tissue reconstruction of the oral cavity, including all mobile parts, was successful with LUFF, i.e. the remaining tissue was allowed to function. Some patients reported thermal and touch sensation even though there was no nerve repair performed. This could probably be attributed to the thin nature of the flap. Prospective studies including objective evaluation of intraoral function in comparison to a control group are recommended. Recipient site morbidity: LUFF
vs
RFFF
According to GRAHAM et al. s flap survival rate of L U F F is greater than 90%. They experienced 4.5% flap necrosis in 123 cases. STOB~R27 reported a 96% success rate in his series of 73 cases. HARPF et al. 9 reported 5 cases of flap failure in 72 cases and CWANTOS et al. 2 used L U F F in 28 cases of head and neck reconstruction and had no flap failure. The present series included one total and one partial flap failure using LUFF, whereas no flap failure occurred with R F F E Compared to RFFF, however, flap harvesting in L U F F is more time consuming. Although the anatomy of L U F F is simple and consistent, the surgeon has to be careful while dissecting because of the small vessel size. There are some reports of accidental injury to the pedicle9,17 even by experienced surgeons.
11 0
Gellrich et aL
T h e incidence o f m a r g i n dehiscence, infection a n d c u t a n e o u s fistula o f the recipient site was slightly higher w i t h R F F E b u t this does n o t imply t h a t R F F F is less suitable for i n t r a o r a l rec o n s t r u c t i o n . R F F F h a d less h a i r - b e a r ing area, b u t it h a s to be t a k e n into acc o u n t t h a t there were m o r e w o m e n a m o n g the R F F F cases. Bulkiness a n d the need o f flap d e b u l k i n g has been rep o r t e d as a p o t e n t i a l d i s a d v a n t a g e o f L U F F 5's'12, yet we f o u n d t h a t c o n t r o l o f flap thickness was a n advantage, particularly w h e n a distal extension was used. It eliminated the need for debulki n s in all o u r cases. Donor site morbidity: LUFF
vs
RFFF
While there is a certain risk o f radial nerve d a m a g e 11,17,28, there h a s b e e n n o r e p o r t o f p e r m a n e n t radial nerve palsy after L U F F harvesting. We also h a d n o p r o b l e m s defining the radial nerve at surgery, n o r was there either a t e m p o r a r y or p e r m a n e n t radial nerve palsy. However, it was difficult to preserve the p o s t e r i o r c u t a n e o u s nerve o f the forea r m ( P C N F ) in all cases d u r i n g dissection. A t times, cutting o f the P C N F d u r i n g dissection m a y be inevitable. This m a y p r o d u c e sensory d i s t u r b a n c e o f the p r o x i m a l f o r e a r m . GRAHAM et al. 8 a n d GErmKING et al. 5 f o u n d t h a t in 58.7% a n d 50% o f cases, respectively, sensory loss in the u p p e r f o r e a r m area h a d occurred. Even in cases o f preserv a t i o n or a x o t o m y a n d ligation o f P C N E sensory loss h a s b e e n r e p o r t e d in 20% 4 o f patients. This n u m b n e s s m a y aS,z7 or m a y n o t improve over time s. C o m p a r e d to L U F E the sensory nerve d i s t u r b a n c e area o f R F F F at the volar aspect o f the f o r e a r m was smaller b u t m u c h m o r e conspicuous. While failure o f skin g r a f t take a n d t e n d o n exposure are serious c o n d i t i o n s after R F F F , there is n o similar risk in L U F F . I n general, dealing w i t h L U F F m e a n s exposure o f large muscles, whereas h a r v e s t i n g o f R F F F m e a n s exposure o f n u m e r o u s t e n d o n s a n d structures t h a t are responsible for the fine m o v e m e n t o f the h a n d . T h e n a t u r a l b a r r i e r to protect these structures is weakened in R F F F , whereas in L U F F this b a r r i e r hardly changes f r o m the preoperative situation. A l t h o u g h p r i m a r y w o u n d closure was achieved in all cases o f L U F F , we did n o t see any significant r e d u c t i o n in u p p e r a r m circumference at the d o n o r site. A l t h o u g h L U F F h a d a similar incidence of complications, it was superior
to R F F F with regard to d o n o r site m o r bidity. Based u p o n this study, we reco m m e n d L U F F to be the first choice for i n t r a o r a l soft tissue r e c o n s t r u c t i o n after t u m o r ablation. T h e flexibility o f this flap allows surgeons to r e c o n s t r u c t the a n a t o m y o f the lost soft tissues as adequately as possible. R F F F s h o u l d be used in cases o f L U F F failure or w h e n a n extended pedicle length is required.
Addendum This p a p e r is dedicated to Prof. Dr. Dr. E. M a c h t e n s o n the occasion o f his 65th birthday.
References 1. BRANDT KE, KHotmI RK. The lateral/ proximal forearm flap. Plast Reconstr Surg 1993: 92: 1137-43. 2. CIVANTOS FJ JR, Bugm~Y B, LU FL, ARMSTRONG W. Lateral arm microvascular flap in head and neck reconstruction. Arch Otolaryngol Head Neck Snrg 1997: 123: 830-6. 3. CORMACK GC, LAMBERTY BGH. Fasciocutaneous vessels in the upper arm: application to the design of new fasciocutaneous flaps. Plast Reconstr Surg 1984: 74: 244-50. 4. FOGDESTAMI, TARNOWP, KALAAJIA. Extended free lateral arm flap with preservation of the posterior cutaneous nerve of the forearm. Scand J Plast Reconstr Surg Hand Surg 1996: 30: 49-55. 5. GEHRKING E, REMMERT S, KRAPPEN S, SOMMERK. Klinischer Vergleich zwischen Radialis- und lateralem Oberarmtransplantat. Laryngorhinootologie 1997: 76: 16~8. 6. GEItRKING E, REMMERT S, MAJOCCO A. Der laterale Oberarmlappen: Topographisch-anatomische Studie fuer den klinischen Einsatz als gefaessgestieltes Transplantat. Laryngorhinootologie 1995: 74: 317-21. 7. GELLRICHN-C, BREMERICHA, KUGLERJ, WELZEL-RUHRMANN C, Rtrm~ANN S. Rehabilitation in der Mund-, Kiefer- und Gesichtschirurgie - eine patientengestfitzte Studie beim Mundh6hlenkarzinom. Dtsch Z Mund Kiefer GesichtsChir 1993: 17: 215-7. 8. GRAHAM B, ADKINS P, SCttENKER LR. Complications and morbidity of the donor and recipient sites in 123 lateral arm flaps. J Hand Surg 1992: 17: 189-92. 9. HARPF C, PAPP C, NINKOVIC M, ANDERL H, HussL H. The lateral arm flap: review of 72 cases and technical refinements. J Reconstr Microsurg 1998: 14: 39-48. 10. JACOBSON MC, FRANSSEN E, FLISS DM, BIRT BD, GILBERTRW. Free forearm flap
in oral reconstruction: functional outcome. Arch Otolaryngol Head Neck Surg 1995: 121: 959~4. 11. KATSAROSJ, SCHUSTERMANM, BEPPU M, BASIS JC JR, ACLAND RD. The lateral upper arm flap: anatomy and clinical applications. Ann Plast Surg 1984: 12: 489500. 12. KATSAROS J, TAN E, ZOLTIE N, et al. Further experience with the lateral arm free flap. Plast Reconstr Surg 1991: 87: 902 10. 13. KUEK LB, CHUAN TL. The extended lateral arm flap: a new modification. J Reconstr Microsurg 1991: 7: 167-73. 14. LANZETTA M, BERNmR M, CHOLLET A, ST-LAURENTJY. The lateral forearm flap: an anatomic study. Plast Reconstr Surg 1997: 99: 460-4. 15. MATLOUB HS, LARSON DL, KUHN JC, YOUSIF N J, SANGERJR. Lateral arm free flap in oral cavity reconstruction: a functional evaluation. Head Neck 1989: 11: 205 11. 16. MIKIWAKI Y, OrlNO K, IMAI S, et al. Functional effects of intraoral reconstruction with free radial forearm flap. J Craniomaxillofac Surg 1990: 18: 164-8. 17. MOFFETTR, MADISONSA, DERR JW, ACLAND RD. An extended approach for the vascular pedicle of the lateral arm free flap. Plast Reconstr Surg 1992: 89: 259-67. 18. REINERT S, GELLRICH N-C, EUFINGERH. The free revascularized lateral upper arm flap in intraoral reconstruction following ablative tumor surgery. J Craniomaxillofac Surg 1996:24 (Suppl. 1): 93. 19. RICHARDSON D, FISI-mR SE, VAUGI-~N ED, BROWN JS. Radial forearm flap donor-site complications and morbidity: a prospective study. Plast Reconstr Surg 1997: 99: 109-15. 20. RIVET D, BUrTET M, M~TIN D, et al. The lateral arm flap: an anatomical study. J Reconstr Microsurg 1987: 3: 12132. 21. Ross DA, THOMSONJG, R~STn~OR, %a~RO JM, SASAKICT. The extended lateral arm free flap for head and neck reconstruction: the Yale experience. Laryngoscope 1996: 106: 14-8. 22. SCHLIEPHAKE H, SCHMELZEISEN R, SCHONWEILER R, SCHNELLER T, ALTENBERND C. Speech, deglufition and life quality after intraoral tumour resection. A prospective study. Int J Oral Maxillofac Surg 1998: 27: 99-105. 23. SCHMELZEISEN R, NEUKAM FW, HAUSAMEN J-E, eds.:. Atlas der Mikrochirurgie im Kopf-Halbereich. Munich: Carl Hanser Verlag, 1996. 24. SCHMELZEISENR, SCHLIEPHAKE H. Interdisciplinary microvascular reconstruction of maxillary, midfacial and skull base defects. J Craniomaxillofac Surg 1998: 26: 1-10. 25. SONG R, SONG Y, YU Y, SONG Y. The upper arm free flap. Clin Plast Surg 1982: 9: 27-35. 26. SOUTAR DS, McGREGOR IA. The radial
Lateral upper arm free flap forearm flap in intraoral reconstruction: the experience of 60 consecutive cases. Plast Reconstr Surg 1986: 78: 1-8. 27. STOBERR. Erfahrungen mit dem lateralen Oberarmlappen. Handchir Mikrochir Plast Chir 1996: 28: 22-7. 28. SULLIVANM J, CARROLL WR, KURILOFF DB. Lateral arm free flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg 1992: 118: 1095-101. 29. VAUOr~ANED. The radial forearm flap in orofaciai reconstruction. Int J Oral Maxillofac Surg 1994: 23: 194~204. 30. TIMMONS M J, MISSOTTEN FEM, POOLE
MD, DAvis DM. Complications of radial forearm flap donor site. Br J Plast Surg 1986: 39: 176-8. 31. WAx MK, BRIANT TD, MAHONEY JL. Lateral-arm free flap for reconstruction in head and neck. J Otolaryngol 1996: 25: 1404. 32. WENIa BL. The lateral arm free flap for head and neck reconstruction. Otolaryngol Head Neck Surg 1993: 109:1169. 33. Yusn~ NJ, WARREN R, MANTLOUB HS, SANGER JR. The lateral arm fascial free flap: its anatomy and use in reconstruc-
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tion. Plast Reconstr Surg 1990: 86:113845.
Address:
Nils-Claudius Gellrich, MD, DMD, PhD Department of Oral and Maxillofacial Surgery Hugstetter Str. 55 D-79106 Freiburg Germany Tel." +49 761 270 4919 Fax: +49 761 270 4800 e-mail: gellrich@zmk2, ukl. uni-freiburg, de
Copyright©Munksgaard2000 InternationalJournalof
Oral& MaxillofaciaISurgay ISSN 0901-5027
Oncology
The lateral upper arm free flap for intraoral reconstruction
N.-C. Gellrich ~, T. G. Kwon 2, G. Lauer ~, O. Fakler ~, R. Gutwald ~, J,-E. Otten ~, R. Schmelzeisen ~ 1Department of Oral and Maxillofacial Surgery, Albert-Ludwigs University Freiburg, Germany; 2Department of Oral and Maxillofacial Surgery, College of Dentistry, Kyungpook National University, Taegu, Korea
N.-C. Gellrich, T. G. Kwon, G. Lauer, O. Fakler, R. Gutwald, J.-E. Otten, R. Schmelzeisen: The lateral upper arm free flap for intraoral reconstruction. Int. J. Oral Maxillofac. Surg. 2000; 29: 104-111. © Munksgaard, 2000 Abstract. Twenty-three consecutive patients who were reconstructed with a lateral upper arm free flap ( L U F F ) 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 L U F F 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 L U F F were comparable to the results of 14 cases in which radial forearm free flaps ( R F F F ) were used. Although the length of the pedicle and the diameter of the vessels in L U F F 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 R F F E L U F F is, therefore, the flap of choice for intraoral soft tissue reconstruction and it is advised to reserve R F F F for cases in which L U F F fails.
Reconstruction of lost parts of the oral and maxillofacial area is difficult because this area is composed of various kinds of hard and soft tissues. The latter are supposed to maintain a maximum of mobility. Reconstruction without ensuring mobility of the tongue or the remaining muscles often results in severe swallowing or speech problems 7,22. Thin and pliable free flaps like the fasciocutaneous radial forearm free flap ( R F F F ) have, therefore, been regarded as superior to reconstruct lost parts of the oral cavity9"19'22'24'26, however, postoperative donor site morbidity is considered to be one of the problems of R F F F a9,25.
The lateral upper arm free flap (LUFF), first described by SONG et a l Y , is thought to give rise to less donor site morbidity 32. L U F F is a thin and pliable flap with consistent anatomy and a high success rate. It is also claimed that there is no risk of vascular compromise to the arm 2,2s. MATLOUB et al. a5 first reported successful intraoral reconstruction with L U F F with additional sensory nerve repair in six cases2,s,2°. KATSAROS et al. a2 reported 150 cases and STOBER27, HARPF et al. 9 reported an extended indication of this flap. It can be used as a pure fascia1 flap2s or as a tendo-fasciocutaneous flap I1. Some surgeons reported the in-
Key words: lateral upper arm free flap (LUFF); intraoral reconstruction; radial forearm free flap (RFFF); oral cancer; microsurgery. Accepted for publication 3 December 1999
clusion of the cortex of the humerus so that an osteocutaneous flap can be harvested2,12,2°. Application of L U F F for the head and neck area has recently become popular 2'18'21'28'31. L U F F is thought to be a reliable alternative to R F F F for intraoral soft tissue reconstruction 18,2547. Limited pedicle length and sensory deficit of the proximal forearm have, however, been reported as disadvantages 5,8,26. The purpose of this study was to evaluate the esthetic and functional results of patients treated with L U F F and to assess postoperative morbidity, as compared to the use of R F F F over the same period.
Lateral upper arm free flap
105
Fig. 1. LUFF was designed to slightly extend onto the forearm area passing over the lateral epicondyle 2 cm distally. The width should not exceed 6 cm in order to allow for primary wound closure.
Fig. 2. Dissected right LUFF before removal. The ruler lies parallel to the transplant vessels; "T" marks the long head of the triceps muscle (Fig. 2a). The radial nerve (RN) could be easily dissected from the pedicle; a pointer directs to the RN in Fig. 2b.
Fig. 4. One year follow-up result after reconstruction of left retromolar zone, pharyngeal wall, posterior floor of mouth and buccal mucosa with LUFF. LUFF allows for good reconstruction of concave and convex surfaces.
Fig. 5. Reconstruction of 2]3 of the right tongue and anterior floor of mouth with LUFF. Good flap margin at the tongue. Fig. 6. Reconstruction of right floor of mouth, glossoalveolar sulcus with LUFF. The pliable flap allows for good reconstruction of form. Fig. 7. Minimal donor site morbidity on the left arm with no functional impairment (Fig. 7a). Close view of the donor site (Fig. 7b) three months postoperatively with a linear scar.
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Gellrich et al.
Table 1. Location and type of tumor in patients reconstructed with LUFF (lateral upper arm free flap) Radiation
Case 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Age/Sex 58/M 61/M 47/F 59/M 68/M 43/M 54/M 70/M 48lM 54/M 58/M 69/M 58/M 63/F 47/M 56/M 65/M 55lM 53/M 51/F 47/M 57/F 70/M
Location of tumor
Type of tumor
Neck dissection
therapy
Left floor of mouth Left cheek Right floor of mouth Left floor of mouth Anterior floor of mouth Anterior floor of mouth Right floor of mouth Right floor of mouth & gingiva Right soft palate Anterior floor of mouth & tongue Tongue base, soft palate & epiglottis Left floor of mouth Right cheek Right floor of mouth Left floor of mouth Larynx Left tonsil Right floor of mouth Right tonsil Left floor of mouth (Osteoradionecrosis) Anterior floor of mouth Right retromolar region Right anterior floor of mouth
SCC (T4 N2) SCC (T2 NO) SCC (T2 NO) SCC (T1 NO) SCC (T4 NO) SCC (T4 N2) SCC (T1 NO) SCC (T2 NO) SCC (T1 NO) SCC (T1 NO) SCC (T3 N2) SCC (T2 NO) SCC (T2 NO) SCC (T2 NO) SCC (T2 NO) SCC, Secondary SCC (T4 Nx) SCC (T4 N2) SCC (T3 Nx) SCC, Secondary SCC (T3 NO) SCC (T2 NO) SCC (T2 NO)
Rt. SOND, Lt. FND Lt. FND Rt. FND, Lt. SOND Rt. SOND, Lt. FND Rt. RND, Lt. SOND Rt. + Lt. SOND Rt. FND, Lt. SOND Rt. FND, Lt. SOND Lt. SOND Rt. + Lt. SOND Rt. SOND, Lt. FND Rt. SOND, Lt. FND Rt. SOND Rt. FND, Lt. SOND Rt. SOND, Lt. FND
IORT 25 Gy IORT 20 Gy Post op 60 Gy Post op 6 Gy Post op 66 Gy
Post op 60 Gy Pre op 60 Gy Post op 66 Gy
Post op 60 Gy
Rt.+Lt. FND Rt. FND, Lt. SOND Rt. FND, Lt.SOND Rt. FND, Lt. SOND Rt. SOND Rt. FND, Lt. SOND
SCC: squamous cell carcinoma, SOND: supraomohyoid neck dissection, FND: functional neck dissection, IORT: intraoperative radiation therapy.
Material and methods In an 18-month period, intraoral reconstruction with LUFF was used in 23 patients (19 men, 4 women) out of a total of 52 cases of microvascular reconstruction involving soft tissue defects of the head and neck region. All intraoral tumors were diagnosed as squamous cell carcinoma. The average age of the patients was 54.7 years (range: 43 to 71). The location and type of tumor are listed in Table 1. In all but two cases, the operations were for primary reconstruction after ablative tumor surgery. In one case secondary reconstruction was carried out after osteoradionecrosis and in one case oesophageal reconstruction was carried out after extensive laryngeal carcinoma resection. The preoperative assessment consisted of clinical examination of the donor site, but neither a special clinical testing nor a preoperative angiography was performed to study LUFF's vascular supply. Tumor excision and flap harvesting were performed by separate teams in order to reduce operating time. LUFF was designed to extend onto the proximal forearm area passing over the lateral epicondyle, 2 cm distally (Fig. 1). The average flap size was 6×8.5 cm2. The average pedicle length was 8.8 cm. The distal portion of the flap was usually thinner than the proximal one. Flap adaption to the intraoral defect was usually done by taking into account the different thicknesses. The anastomosing vessel of LUFF was the posterior radial collateral artery (PRCA) and vein (Fig. 2a,b). PRCA (diameter: ranging between 1.5-2.2 mm) is smaller than the radial artery
but shows a consistent anatomy. The superior thyroid artery and vein were the preferred recipient vessels. In some cases the facial artery and vein were used, depending on the diameter of the artery and pedicle length. Arterial anastomosis was in all cases end-toend, whereas venous anastomosis was in 15 cases end-to-end, and in eight cases end-toside with the internal jugular vein. In three cases, the pedicle of LUFF was connected to contralateral cervical vessels. LUFF was used only as a fasciocutaneous flap. Marginal resections of the mandible were done in 11 cases; continuity resections (n= 10) of the mandible were bridged by a Unilock-plate (Stratec Medical, Oberdorf, Switzerland). Bony reconstruction is usually performed in our institution after one year when no recurrence has presented. An elastic dressing on the lateral upper arm was applied in all patients and was usually removed after two days. For five days 2 g cefotiam® i.v. were administered twice daily, while a low dose heparin (0.4 mg clexane ® s.c.) was given prophylactically. If postoperative radiotherapy had to be given, it was started after completion of wound healing after approximately two weeks. Eight patients (35%) received postoperative radiotherapy. Intraoperative radiotherapy (IORT) with a linear accelerator as a single shot procedure to the tumor area was performed in two patients. The patients with LUFF reconstruction were divided into three groups (Fig. 3) according to the area of reconstruction, using the classification of JACOBSON et al.l°. Group I patients (Cases 1, 2, 3, 4, 7, 8, 12, 13, 14, 15,
18, 20) had resection and reconstruction including the floor of the mouth and the lateral tongue; intraoral cheek mucosa excision was also included in this group. Group II (Cases 5, 6, 10, 21, 23) included resection and reconstruction of the anterior tongue or anterior floor of the mouth. Group III patients (Cases 9, 11, 17, 19, 22) had resection and reconstruction of the oropharynx, including the tonsilar region and soft palate. Case 16, a laryngeal cancer patient, could not be included in this classification. To evaluate swallowing function, we used a swallowing index from 0 to 3 based on the patient's subjective judgement. Speech ability was scored from 1 to 3 according to the patient's ability to communicate. Average scores were compared between groups. Four patients were lost to follow-up, so that their postsurgical function could not be included. Nearly half of the patients (n= 10) had systemic disease such as diabetes mellitus (n=4), coronary heart disease (n=3), COPD (n=3) or liver cirrhosis (n=l), which might have influenced the vascular condition of the recipient site. The choice of R F F F or LUFF for reconstruction of defects was based on selection criteria. All patients who should be reconstructed with a fasciocutaneous flap were scheduled to receive LUFE except that patients with positive Allen test and no former injuries to the forearm or hand and few hairs at the forearm were chosen for reconstruction with RFFF (n=7); defects which required grafts with long pedicles were also chosen for reconstruction with R F F F (n=7). The 14 R F F F patients (six men, eight women) had an average age of 62.0 years
Lateral upper arm free flap Group L"Reconstructionincludingfloor of mouth & ventral tongue or cheek [
Case
1, 14
Case 7, 8, 18, 20
107
Group II: Reconstructionincludinganteriortongue or anteriorfloor of mouth ]
Case 4, I5 Case 5, 10
Case 6, 21, 23
Group III: Reconstructionincludinglateralpharyngealwall & soft palate ]
Case 3, 12
Case 2
Case 13
Case 9
Case
11, 17
Case 19, 22
Fig. 3. Classification of the area of reconstruction in patients with LUFF, according to JACOBSONet al. (1995) l°.
(ranging from 45 to 85). Except for two patients with basal cell carcinoma and one with sclerosing duct carcinoma, all other patients had squamous cell carcinoma (Table 2). Most received radiotherapy (n=9) and 3 patients suffered from systemic disease. All RFFFs were fasciocutaneous flaps. The average size w a s 7x5 cm 2. The average pedicle length was 10.5 cm. All patients passed the Allen test preoperatively. In two patients, a reconstruction plate (Unilock system) was used after mandibular continuity resection. The donor site defect was covered by a split thickness skin graft from the anterior thigh. Seven days of tie-over dressings on the forearm and additional dressings on the lateral thigh were needed for RFFE Donor site complications of LUFF and
R F F F were evaluated with respect to wound healing, take of skin graft (only in RFFF), tendon exposures motor dysfunction (radial nerve) and quality [hypo-, par-, hyperesthesia] and extent of sensory deficits directly at and distally to the flap harvesting area. The recipient sites were assessed with particular reference to wound healing, graft take, presence of fistula and intraoral hair growth.
Results Functional evaluation of recipient site of I.UFF
Examples of intraoral reconstruction with L U F F are s h o w n in Figs. ~ 6 . T h e
results o f the evaluation o f p o s t o p e r a tive f u n c t i o n at the recipient site are presented in Table 3. F l o o r o f m o u t h excisions - included in p a t i e n t s o f g r o u p I r e c o n s t r u c t i o n s - were usually a c c o m p a n i e d by removal o f lingual att a c h e d gingiva; buccal m u c o s a excisions often included labial a t t a c h e d gingiva. T h e r e was a s m o o t h t r a n s i t i o n f r o m the flap to the n e i g h b o u r i n g oral m u c o s a a n d t o n g u e (Figs. 4-6). This g r o u p h a d good postoperative swallowing capability a n d speech (Table 3). M o s t o f t h e m could m a i n t a i n a n o r m a l diet, b u t some needed water to wash o u t the f o o d debris after they h a d swallowed.
Table 2. Location and type of tumor in patients reconstructed with R F F F (radial forearm free flap) Case
Age/Sex
Location of tumor
Type of tumor
Neck dissection
1 2 3 4
73/M 45/F 56/M 67/M
Hard palate & nasal cavity Right maxillary sinus Left anterior floor of mouth Left anterior floor of mouth & tongue
SCC SCC SCC SCC
Rt. Rt. Rt. Rt.
5 6 7 8 9 10 11 12 13 14
75/M 48lM 71/F 70/F 49/M 85/F 57/F 57/F 48/M 67/F
Left medial orbit & frontal bone Maxillary sinus & skull base Right maxillary & frontal sinus Left upper lip Right retromolar & cheek Left orbit & frontal bone Right posterior floor of mouth Left floor of mouth & tonsil Right tongue & floor of mouth Anterior floor of mouth
(T4 (T4 (T2 (T2
N2) N1) N2) N0)
FND, Lt. SOND FND SOND, Lt. FND SOND, Lt. FND
Basal cell carcinoma Adenocarcinoma (T2 N0) Rt. SOND SCC (T4 N0) Lt. SOND Sclerosing duct carcinoma (T2 N0) Lt. SOND SCC (T2 NO) Rt. FND, Lt. SOND Basal cell carcinoma SCC (T2 N0) Rt. FND, Lt. SOND SCC (T2 N1) Rt. SOND, Lt. RND SCC (T1 N2) Rt. FND, Lt. SOND SCC (T2 Nx) Rt. + Lt. SOND
Radiation therapy Post op 62 Gy Post op 64 Gy Post op 64 Gy IORT 12 Gy & Post op 50 Gy Post op 50 Gy Pre op 60 Gy Post op 60 Gy Post op 60 Gy
Post op 60 Gy
SCC: squamous cell carcinoma, SOND: supraomohyoid neck dissection, FND: functional neck dissection, IORT: intraoperative radiation therapy.
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Gellrich et al.
Only one patient (Case 8) in this group complained of severe speech difficulty, another patient had a mild dysarthria which did not preclude speech. G r o u p II patients revealed a mild degree of dysphagia and dysarthria. Speech intelligibility, however, had decreased significantly. In group III patients, swallowing ability and speech intelligibility were markedly decreased. U n d e r videofluoroscopy, some aspiration of contrast
medium during swallowing was observed in one patient. Recipient site morbidity: LUFF
vs
RFFF
The results of the evaluation of recipient site morbidity of L U F F and R F F F are summarized in Table 4. There was one case of complete and one case of incomplete flap necrosis using L U F E N o flap necrosis occurred with R F F E The one total and one partial flap ne-
Table 3. Evaluation of postoperative function of patients reconstructed with LUFF*
Classification
Case No.
Swallowing Index
Speech Index
Group I
Case 1 Case 2 Case 3 Case 4 Case 7 Case 8 Case 12 Case 13 Case 14 Case 15 Case 18 Case 20
3 2 3 3 3 2 3 3 2 3 flap failure -
3 2 3 3 2 1 3 3 3 3 flap failure -
Group II
Group III
Mean
2.7
2.6
Case 5 Case 6 Case 10 Case 21 Case 23
2 3 3 2
2 2 2 2
Mean
2.5
2.0
Case Case Case Case Case
9 11 17 19 22
1 1 2 1 (partial flap failure) 2
Mean
2 2 1
1 (partial flap failure) 3
1.4
1.8
Swallowing Index: 3 - No problem in swallowing, near normal 2 - Difficult to swallow hard or dry food 1 - Difficult to swallow liquid food 0 - Impossible to swallow Speech Index: 3 - Good speech intelligibility 2 - Moderate speech intelligibility 1 - Poor speech intelligibility (-): impossible to access long term follow-up data * Laryngeal cancer patient (Case 16) was impossible to evaluate.
Table 4. Recipient site complications
Total flap loss Partial flap loss Partial dehiscence of margin Infection Cutaneous fistula Iutraoral hair
LUFF (n=23)
RFFF (n = 14)
1 (4.3%) 1 (4.3%) 2 (8.6%) 0 1 (4.3%) 3 (13.0%)
0 0 3 (21.4%) 2 (14.2%) 1 (7.1%) 1 (7.1%)
crosis were attributed to general vascular insufficiency of the patient - even though there was no systemic disease present and the ischemic time was not longer as compared to other cases. In both cases, P R C A and vein were successfully harvested without difficulty, but there was arterial circulatory impairment of the recipient site artery (superior thyroid, facial and - later on external carotid artery). With the use of R F F F , three cases of wound dehiscence and two cases of infection occurred. L U F F had excellent flap margin integration to the recipient site. There was only a small a m o u n t of hair on the intraorally positioned flap in four patients but none of them complained about this. The proportion of hair-bearing skin was higher in L U F F than in R F F F , which was probably due to the higher male:female ratio in L U F F (19:4) compared to R F F F (7:7). Donor site morbidity: LUFF
vs
RFFF
Functional and esthetic problems of the donor site were evaluated and are listed in Table 5. The most c o m m o n problem of L U F F was a sensory deficit in the lateral proximal forearm area. D u r i n g the flap harvesting procedure, the posterior cutaneous nerve of the forearm (PCNF) was cut in most cases, but injury of P C N F did not fully coincide with the postoperative sensory deficit. The area of sensory disturbance ranged from 5 x 9 cm 2 to 5.5×16.5 cm 2. Most patients did n o t complain about their cutaneous sensory disturbance, but one patient had pain on pressure around the lateral epicondyle of the humerus. The hypoesthesia (n=6) did not improve before 3 to 6 m o n t h s after surgery, however, patients with paresthesia (n=2) or hyperesthesia (n=2) improved over time. There was one case of 5th digit adduction difficulty due to temporary ulnar nerve compression probably caused by incorrect positioning of the elbow during operation. The wound healing was uneventful after surgery except for one case of donor site infection in a poorly controlled diabetic woman. In five patients with R F F F , paresthesia on the proximal t h u m b area was noted but there was no functional disturbance. Paresthesia persisted during the period of follow-up 6 to 12 months after surgery. The flexor carpi radialis tendon was exposed in two cases, followed by partial loss of the
Lateral upper arm free flap Table 5. Donor site complications
Sensory disturbance Hypoesthesia Paresthesia Hyperesthesia Infection (delayed healing) Poor take of skin graft Tendon exposure
split thickness skin graft on the flap harvesting area. After several weeks of local wound care, the wounds healed by secondary intention. Compared to LUFF, the area of sensory disturbance in cases of R F F F was prone to injury. Average scar length at the lateral upper arm was 20 cm (ranging from 17 cm to 23 cm). In all cases, the donor site was primarily closed without the use of a skin graft, so that this part of the scar, where the tissue had been excised, was 8 cm long and 4 nun wide on average. No conspicuous scars were visible on the whole linear incision of the arm (Fig. 7a,b). Compared to RFFF, in which an average 5×4.5 cm 2 rectangular scar and a 15 cm long conspicuous linear scar were visible, the scar of L U F F was positioned posterolaterally and could be easily covered by a T-shirt. Discussion
Bulky flaps like the pectoralis major or latissimus dorsi myocutaneous flaps were previously used for intraoral reconstruction following ablative tumor surgery. At present, it is known that volume replacement does not necessarily result in good rehabilitation of oral function 23. There are still cases, however, where voluminous flaps are indicated. Thin and pliable fasciocutaneous free flaps are preferred when the aim is to restore delicate oral anatomy, including a concave sulcus 16. The remaining mobile structures are then allowed to move without being fixed by a bulky nonmoving tissue mass. The RFFF, which is easy to harvest, is still the most often used flap to fulfil these requirements 1°,23,26. Donor site morbidity, however, is still a problem, because of the necessity of skin grafting in most cases, while there are also esthetic concerns 3°. Removal of one of the two essential arteries of the hand also implies a certain risk to the vascular supply of
LUFF (n=23)
RFFF (n= 14)
10 (43.4%) .6 2 2 1 (4.3%) 0 ,9
5 (35.7%) 0 5 0 0 2 (14.3%) 2 (14.3%)
the hand. L U F F has many advantages, including relatively simple and reliable anatomy 2,3,32,33 with minimal vascular variation 11'14,2°. According to anatomical studies, complete duplication of the profunda brachii artery is reported in 40/511 to 12% 2o of cases, however this was not noticed in the present series of patients. This figure is comparable to R F F F in which the arterial anomaly rate has been reported to be 10% 29. The diameter of the artery in L U F F is smaller than in R F F E as mentioned by various authors 3,6,21, which does not appear to be a problem. P R C A in L U F F is not essential to the vascular supply of the arm and there is no risk of vascular compromise and no need for preoperative evaluation of the donor site vessel as with R F F E Another advantage of L U F F is that the donor site region can be closed directly if the graft does not exceed 6 cm in width 17,31. The flap length can be over 15 cm if the flap is extended distally to the lateral epicondylelA3,TM. In the patient group presented, all intraoral defects could be covered with an average flap of 6× 8 cm 2 without any tension. Recent modification includes extension of L U F F more distally to extend the pedicle length 1,13,14,21. A too distally positioned LUFF, however, may leave a conspicuous scar behind as with the R F F F in the proximal forearm area. We extended the flap 2 cm distal to the lateral epicondyle to achieve additional pedicle length and to extend the thinner part of the flap. This was found sufficient to guarantee primary closure, while sufficient extension of the flap was achieved to close large intraoral defects. The thinner part of the flap could be adapted to the remaining attached gingiva or the floor of mouth and the thicker part could be adapted to the site which needed most volume, such as the tongue. A similar appli,cation has also been reported by CIVANTOS et al.2. Control of flap thickness
109
is the unique asset of L U F F for intraoral reconstruction. Functional evaluation of recipient site of LUFF
Functional evaluation after intraoral reconstruction has focused on swallowing and speech 9,15. MATLOr3~ et al. 15 first evaluated swallowing, articulation, range of tongue motion and sensation in patients reconstructed with L U F F and nerve repair. Some surgeons reported, however, that nerve repair is not effective8, or only effective in 50% of patients e, or effective enough to reduce morbidity after surgery TM. In the present group of patients, no attempts were made to repair continuity of interrupted sensory innervation to the graft. Although our results cannot prove that lack of sensory innervation of the fasciocutaneous flaps has little to do with the degree of dysfunction, we suggest that functional results are more related to location and dimension of the defect. Especially in group I and II patients, soft tissue reconstruction of the oral cavity, including all mobile parts, was successful with LUFF, i.e. the remaining tissue was allowed to function. Some patients reported thermal and touch sensation even though there was no nerve repair performed. This could probably be attributed to the thin nature of the flap. Prospective studies including objective evaluation of intraoral function in comparison to a control group are recommended. Recipient site morbidity: LUFF
vs
RFFF
According to GRAHAM et al. s flap survival rate of L U F F is greater than 90%. They experienced 4.5% flap necrosis in 123 cases. STOB~R27 reported a 96% success rate in his series of 73 cases. HARPF et al. 9 reported 5 cases of flap failure in 72 cases and CWANTOS et al. 2 used L U F F in 28 cases of head and neck reconstruction and had no flap failure. The present series included one total and one partial flap failure using LUFF, whereas no flap failure occurred with R F F E Compared to RFFF, however, flap harvesting in L U F F is more time consuming. Although the anatomy of L U F F is simple and consistent, the surgeon has to be careful while dissecting because of the small vessel size. There are some reports of accidental injury to the pedicle9,17 even by experienced surgeons.
11 0
Gellrich et aL
T h e incidence o f m a r g i n dehiscence, infection a n d c u t a n e o u s fistula o f the recipient site was slightly higher w i t h R F F E b u t this does n o t imply t h a t R F F F is less suitable for i n t r a o r a l rec o n s t r u c t i o n . R F F F h a d less h a i r - b e a r ing area, b u t it h a s to be t a k e n into acc o u n t t h a t there were m o r e w o m e n a m o n g the R F F F cases. Bulkiness a n d the need o f flap d e b u l k i n g has been rep o r t e d as a p o t e n t i a l d i s a d v a n t a g e o f L U F F 5's'12, yet we f o u n d t h a t c o n t r o l o f flap thickness was a n advantage, particularly w h e n a distal extension was used. It eliminated the need for debulki n s in all o u r cases. Donor site morbidity: LUFF
vs
RFFF
While there is a certain risk o f radial nerve d a m a g e 11,17,28, there h a s b e e n n o r e p o r t o f p e r m a n e n t radial nerve palsy after L U F F harvesting. We also h a d n o p r o b l e m s defining the radial nerve at surgery, n o r was there either a t e m p o r a r y or p e r m a n e n t radial nerve palsy. However, it was difficult to preserve the p o s t e r i o r c u t a n e o u s nerve o f the forea r m ( P C N F ) in all cases d u r i n g dissection. A t times, cutting o f the P C N F d u r i n g dissection m a y be inevitable. This m a y p r o d u c e sensory d i s t u r b a n c e o f the p r o x i m a l f o r e a r m . GRAHAM et al. 8 a n d GErmKING et al. 5 f o u n d t h a t in 58.7% a n d 50% o f cases, respectively, sensory loss in the u p p e r f o r e a r m area h a d occurred. Even in cases o f preserv a t i o n or a x o t o m y a n d ligation o f P C N E sensory loss h a s b e e n r e p o r t e d in 20% 4 o f patients. This n u m b n e s s m a y aS,z7 or m a y n o t improve over time s. C o m p a r e d to L U F E the sensory nerve d i s t u r b a n c e area o f R F F F at the volar aspect o f the f o r e a r m was smaller b u t m u c h m o r e conspicuous. While failure o f skin g r a f t take a n d t e n d o n exposure are serious c o n d i t i o n s after R F F F , there is n o similar risk in L U F F . I n general, dealing w i t h L U F F m e a n s exposure o f large muscles, whereas h a r v e s t i n g o f R F F F m e a n s exposure o f n u m e r o u s t e n d o n s a n d structures t h a t are responsible for the fine m o v e m e n t o f the h a n d . T h e n a t u r a l b a r r i e r to protect these structures is weakened in R F F F , whereas in L U F F this b a r r i e r hardly changes f r o m the preoperative situation. A l t h o u g h p r i m a r y w o u n d closure was achieved in all cases o f L U F F , we did n o t see any significant r e d u c t i o n in u p p e r a r m circumference at the d o n o r site. A l t h o u g h L U F F h a d a similar incidence of complications, it was superior
to R F F F with regard to d o n o r site m o r bidity. Based u p o n this study, we reco m m e n d L U F F to be the first choice for i n t r a o r a l soft tissue r e c o n s t r u c t i o n after t u m o r ablation. T h e flexibility o f this flap allows surgeons to r e c o n s t r u c t the a n a t o m y o f the lost soft tissues as adequately as possible. R F F F s h o u l d be used in cases o f L U F F failure or w h e n a n extended pedicle length is required.
Addendum This p a p e r is dedicated to Prof. Dr. Dr. E. M a c h t e n s o n the occasion o f his 65th birthday.
References 1. BRANDT KE, KHotmI RK. The lateral/ proximal forearm flap. Plast Reconstr Surg 1993: 92: 1137-43. 2. CIVANTOS FJ JR, Bugm~Y B, LU FL, ARMSTRONG W. Lateral arm microvascular flap in head and neck reconstruction. Arch Otolaryngol Head Neck Snrg 1997: 123: 830-6. 3. CORMACK GC, LAMBERTY BGH. Fasciocutaneous vessels in the upper arm: application to the design of new fasciocutaneous flaps. Plast Reconstr Surg 1984: 74: 244-50. 4. FOGDESTAMI, TARNOWP, KALAAJIA. Extended free lateral arm flap with preservation of the posterior cutaneous nerve of the forearm. Scand J Plast Reconstr Surg Hand Surg 1996: 30: 49-55. 5. GEHRKING E, REMMERT S, KRAPPEN S, SOMMERK. Klinischer Vergleich zwischen Radialis- und lateralem Oberarmtransplantat. Laryngorhinootologie 1997: 76: 16~8. 6. GEItRKING E, REMMERT S, MAJOCCO A. Der laterale Oberarmlappen: Topographisch-anatomische Studie fuer den klinischen Einsatz als gefaessgestieltes Transplantat. Laryngorhinootologie 1995: 74: 317-21. 7. GELLRICHN-C, BREMERICHA, KUGLERJ, WELZEL-RUHRMANN C, Rtrm~ANN S. Rehabilitation in der Mund-, Kiefer- und Gesichtschirurgie - eine patientengestfitzte Studie beim Mundh6hlenkarzinom. Dtsch Z Mund Kiefer GesichtsChir 1993: 17: 215-7. 8. GRAHAM B, ADKINS P, SCttENKER LR. Complications and morbidity of the donor and recipient sites in 123 lateral arm flaps. J Hand Surg 1992: 17: 189-92. 9. HARPF C, PAPP C, NINKOVIC M, ANDERL H, HussL H. The lateral arm flap: review of 72 cases and technical refinements. J Reconstr Microsurg 1998: 14: 39-48. 10. JACOBSON MC, FRANSSEN E, FLISS DM, BIRT BD, GILBERTRW. Free forearm flap
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tion. Plast Reconstr Surg 1990: 86:113845.
Address:
Nils-Claudius Gellrich, MD, DMD, PhD Department of Oral and Maxillofacial Surgery Hugstetter Str. 55 D-79106 Freiburg Germany Tel." +49 761 270 4919 Fax: +49 761 270 4800 e-mail: gellrich@zmk2, ukl. uni-freiburg, de