Case 1
Clinical Presentation
A 19-year-old White male with right alveolar squamous cell carcinoma (SCC) of the mandible underwent local surgical excision of the alveolar edge and the floor of the mouth and a marginal mandibulectomy via a lower lip split approach as well as a right modified neck lymph node dissection by the surgical oncology service ( Fig. 4.1 ). Intraoperative frozen sections of the peripheral and deep margins were confirmed negative for SCC. Following resections, there was a 6.5 × 4.5 cm full-thickness intraoral mucosal defect with exposed alveolar bony bridge ( Fig. 4.2 ).
Operative Plan and Special Considerations
After assessing the intraoral soft tissue defect including the alveolar defect of the mandible, a free radial forearm skin flap was selected for coverage of the floor of the mouth wound and the alveolar defect. The flap is reliable, versatile, and thin and could provide an excellent soft tissue coverage for such an intraoral defect with an easy inset and water-tight closure. In addition, the length of the flap’s pedicle can reach any part of the neck recipient vessels.
Operative Procedures
A free radial forearm skin flap was designed on the nondominant side of the forearm after a negative Allen test. A 7.5 × 5.5 cm skin paddle of the flap, oriented longitudinally, was marked ( Fig. 4.3 ). The skin incision was made through the fascia and subfascial dissection was performed for elevation of the skin paddle including the pedicle vessels that also contained the cephalic vein ( Fig. 4.4 ). With a zig-zag incision, the dissection of the pedicle in the forearm was made between the flexor carpi radialis and brachioradialis muscles to the antecubital fossa. The radial artery and its venae comitantes as well as the cephalic vein were then divided with hemoclips.
The flap inset was done first to cover all intraoral soft tissue defect. A water-tight closure of the flap to the adjacent mucosa was performed with a 3-0 interrupted Vicryl suture in an interrupted half-buried horizontal mattress fashion. The pedicle of the flap was tunneled to the right neck where microvascular anastomoses were performed.
The right facial vessels were explored in the neck via the preexisting incisions for cancer resection and neck lymph node dissection. After further dissection, both the facial artery and vein were found to be a good size and dissected proximally for an adequate length. Under a microscope, an end-to-end venous microvascular anastomosis between the cephalic vein and the facial vein was performed with an 8-0 nylon sutures in an interrupted fashion using a double-armed microclamp. The arterial microvascular anastomosis was also performed in an end-to-end fashion with interrupted 8-0 nylon sutures. Additional intraoral closure was completed and the intraoral free radial forearm free flap reconstruction was completed ( Fig. 4.5 ).
The lower lip and chin incisions were closed in two layers. The neck incision was also closed in two layers after a JP drain placement.
The forearm donor site skin incision was closed in two layers. A split-thickness skin graft was placed to the flap donor site, sutured to the adjacent normal skin edge, and secured with a tie-over dressing.
Management of Complications
The patient unfortunately developed a hematoma in the neck at postoperative day 2 and was brought back to the operating room for evacuation ( Fig. 4.6 ). He had no recurrent hematoma after reoperation.
Follow-Up Results
The patient did well postoperatively without complications related to the free radial forearm flap reconstruction. He was discharged from the hospital on postoperative day 5. The drain was removed during the first week follow-up. His intraoral flap site as well as his lip and chin incisions healed well ( Fig. 4.7 ). His left forearm flap donor site also healed well ( Fig. 4.8 ).
