|| C. When the flexor carpi radialis is encountered, the paratenon is preserved as the dissection passes superficial to the tendon. On the radial side of the flexor carpi radialis tendon, the dissection passes to a plane deep to the radial vessels. The distal incision is completed, and the radial vessels are exposed distally to where they go deep to the tendons in the first extensor compartment. To ensure hand viability, one may choose to deflate the tourniquet following flap elevation and temporarily clamp the radial artery where it is exposed distally while observing capillary filling in the hand. We generally plan to reconstruct the radial artery, so it is divided at this state of dissection to simplify flap elevation.
D. The radial aspect of the flap is then incised, and if it is overlying or dorsal to the brachioradialis, the dissection proceeds deep to the antebrachial fascia until the ulnar/flexor edge of the brachioradialis tendon is reached. Skin hooks are placed in this edge of the brachioradialis, and the tendon is elevated by sharp dissection from the underlying radial vessels.
E. Once on the radial side of the radial vessels, the dissection can be taken deep to the vessels to complete the flap elevation. Care is taken to identify and preserve the radial nerve. If bone is to be included in the flap, the incision does not go deep to the radial vessels but preserves the septal connection between these vessels and the periosteum of the radius. A cuff of flexor pollicis longus muscle origin is left attached to the radius to ensure preservation of the periosteal vessels. The periosteum is cut approximately 0.5 cm on either side of the radial vessels. A fine sagittal saw is used to make the bone cuts. At each end of the bone, the cuts are beveled rather than cut at 90 degrees; this decreases the stress rider at each end of the bone defect, which may in turn decrease the risk of postoperative fracture of the radius.
F. The flap is then completely elevated on its radial artery pedicle, venae comitantes, superficial vein, and lateral and/or medial antebrachial cutaneous nerve(s). The tourniquet is deflated to allow reperfusion of the flap before transfer. If bone has been elevated, bleeding from the medullary surface of the bone in the flap should be visible.
A 63-year-old man had had a squamous cell carcinoma of the floor of his mouth excised.
FIG. 14-01. After postoperative radiotherapy, an orocutaneous fistula developed. A previous attempt at closure with a deltopectoral flap had failed.
FIG. 14-02. Close-up view.
FIG. 14-03. A bipaddled radial forearm flap was marked out on volar and dorsal surfaces of the wrist.
FIG. 14-04. Isolated bilobed flap.
FIG. 14-05. The vascular anastomoses were carried out on the left side of the
neck out of the area of radiation injury, stressing the value of the long vascular pedicles.