Invited Discussion: “Shape-modified method using the radial forearm perforator flap for reconstruction of soft-tissue defects of the scalp” (J Reconstr Microsurg 2005;21:21-24)

The authors are to be commended on their valuable contribution to the literature on radial forearm flaps. The use of double- and even triple-paddled[2] radial forearm flaps is not new. In the past, two islands would be designed in a “random” fashion over the distal portion of the septum between the brachioradialis and the flexor carpi radialis. Sometimes the flaps would be connected by deepithelialized dermis (folded[3]) and sometimes they would be completely independent.[1] [4] In either case, the vascularity is very reliable.

Double-paddle radial forearm flaps are mainly utilized for reconstructing “full-thickness” defects - those that have a mucosal in addition to a skin deficiency.[1] [2] [3] Examples include composite defects consisting of skin, bone, and oral mucosa following trauma,[5] or oromandibular resection for squamous-cell carcinoma of the oral cavity.[6] [7] Flaps can be folded, suspended, and reinnervated for total lower[8] or even upper lip[9] reconstruction. Another example is the use of double-paddle folded radial forearm flaps in peno-urethral reconstruction.[10] [11] [12]

Manipulation of the skin paddle of the radial forearm flap to reconstruct such disparate complex three-dimensional defects, such as the lower lip and the penis, together with its ability to accomodate prefabrication,[13] testify to its unique reliability and flexibility.

The recent focus of attention on perforator flaps has led to identification and mapping of perforators throughout the body. As a result, the radial forearm is no longer subject to the “tyranny of the septum” and may be raised on a single perforator, if desired.[4] This gives the skin paddle much greater flexibility in positioning when the flap is used as an osteocutaneous transfer. Furthermore, as Mateev et al. have shown, this flexibility of positioning also pertains to the relational placement of two or three skin paddles. As a result, the radial forearm flap can be taken as a narrow ellipse (for primary closure) and yet formed into a large circular or oval flap to reconstruct scalp defects. Thus, the multiple paddle technique has been extended from multi-surface reconstruction to a “cut-and-paste” reshaping.

There is no generally established term for the repositioning of the different cutaneous elements of flaps in order to create a specific shape for reconstruction. Gilbert et al.[14] perhaps came closest to giving us one when they likened the “cricket bat” phalloplasty[12] to a “transformer” toy. By a number of articulations, such a toy may be converted from an action figure to a fighting vehicle. The flap described by the present authors likewise changes its form, and could be termed a “transformer flap” as well. Perhaps the term should be used with all such manipulations.

Direct closure of the radial forearm defect has also been described before.[15] The most popular technique relies on a small distal transverse harvest, and closure using an ulnar-based distal rotation of proximal skin. At best, this provides a skin island of 6 cm x 4 cm that would be useless in scalp reconstruction. Another technique that utilizes a bilobed flap based on a perforator of the ulnar artery[16] has the same limitations. The technique described here potentially allows direct closure (and therefore less donor-site morbidity) while providing enough skin for a large-scale reconstruction.

The importance of this paper lies not only in scalp reconstruction but in the concept of rearranging different perforator-based skin islands based on the same vascular axis, to create different shapes for individualized reconstruction (transformer flap) while, at the same time, simplifying and minimizing the donor deficit.

REFERENCES

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