Use of Radial Vessel Stump in Free Radial Forearm Flap as Flap Monitor in Head and Neck Reconstruction

The use of the free radial forearm flap for reconstruction of pharyngoesophageal defects has been proven to be ideal in previous studies. However, how to monitor flap viability, when the flap is buried underneath the skin in head and neck surgery, still poses technical difficulties. A new method for monitoring the buried free radial forearm flap by using the distal radial vessel stump elevated over the skin was presented.

Eighteen patients received free radial forearm flap reconstruction for pharyngoesophageal defects after tumor ablation from June 2003 to March 2005. All the patients were males, with ages ranging from 36 to 71 years (average: 53.2 years). Fourteen skin tubings and four patches were designed for the defects, which ranged from 6 to 12 cm in length, averaging 8.5 cm. The free radial forearm flap was designed to allow a distal radial vessel stump about 3 cm long, which was then elevated above the skin in the neck region after insetting, to act as a monitor for the viability of the buried flap. Flap viability can be easily demonstrated simply by observing with the naked eye the continuous pulsation coming from the distal radial vessel stump. The monitoring stump was then ligated at bedside after the viability of the buried flap was insured after 2 postoperative weeks.

All free flap transfers were successful. The radial vessel stump monitoring method was used for the immediate detection of the compromised pedicle by direct observation of the pulsatile radial vessel stump. One case of intraoperative kinking of the artery was detected by cessation of pulsation, and it was corrected immediately. One case of flap venous thrombosis was detected on postoperative day 2, and the flap was successfully salvaged by thrombectomy and venous re-anastomosis. Three patients developed temporary fistula and, after conservative treatment, they healed spontaneously. Two patients had deep neck infections and recovered after aggressive antibiotic treatment. Two patients had esophagocutaneous fistula requiring secondary surgical intervention. This method of using the distal stump of the radial vessel as a monitor for a buried flap after head and neck surgery is reliable, allows easy observation, needs no special equipment, and produces no further morbidity at the donor site.