Reestablished Circulation After Free Radial Forearm Flap Transfer

New circulation in the free flap reestablished at the recipient site is the key to successful microvascular reconstructive surgery. This study is the first evaluation of long-term circulatory changes in nine free radial forearm flap transfers. Postoperatively, color Doppler studies revealed that the flow volume through the arterial pedicle increased rapidly during the first 3 days, gradually increased until day 14 (exceeding flow volume through the facial artery of the unoperated contralateral side), then decreased slightly until the sixth month. The pulsatility index, representing vascular resistance downstream, decreased successively. Ohm's law explains that this flow increase is caused by reduced vascular resistance downstream, attributed to changes in the vascularity of the transferred flap and in the recipient bed. The authors believe the circulatory changes are determinants of the clinical properties of the flap. This study addresses the importance of clarifying the events that transpire at the macroscopic circulatory level in the transferred free flap.

Reestablished circulation - recipient site - radial forearm flap transfer

REFERENCES

• 1 Mathes S J, Nahai F. Classification of the vascular anatomy of muscles: experimental and clinical correlation.  Plast Reconstr Surg. 1981;  67 177-187
• 2 Timmons M J. The vascular basis of the radial forearm flap.  Plast Reconstr Surg. 1986;  77 80-92
• 3 Netscher D T, Sharma S, Alford E L, Thornby J, Leibman N S. Superficial versus deep: options in venous drainage of the radial forearm free flap.  Ann Plast Surg. 1996;  36 536-541
• 4 Khashaba A A, McGregor I A. Haemodynamics of the radial forearm flap.  Br J Plast Surg. 1986;  39 441-450
• 5 Taylor G I, Palmer J H. The vascular territories (angiosomes) of the body: experimental study and clinical applications.  Br J Plast Surg. 1987;  40 113-141
• 6 Salmi A M, Tierala E K, Tukiainen E J, Asko-Seljavaara S L. Blood flow in free muscle flaps measured by color Doppler ultrasonography.  Microsurgery. 1995;  16 666-672
• 7 Lorenzetti F, Salmi A, Ahovuo J, Tukiainen E, Asko-Seljavaara S. Postoperative changes in blood flow in free muscle flaps: a prospective study.  Microsurgery. 1999;  19 196-199
• 8 Evans G R, Schusterman M A, Kroll S S et al.. The radial forearm free flap for head and neck reconstruction: a review.  Am J Surg. 1994;  168 446-450
• 9 Moscoso J F, Urken M L. Radial forearm flaps.  Otolaryngol Clin North Am. 1994;  27 1119-1140
• 10 Swartz W M, Banis J C. Head and Neck Microsurgery. Baltimore; Williams and Wilkins 1992: 36-46
• 11 Soutar D S, McGregor I A. The radial forearm flap in intraoral reconstruction: the experience of 60 consecutive cases.  Plast Reconstr Surg. 1986;  78 1-8
• 12 Demirkan F, Wei F C, Lutz B S, Cher T S, Chen I H. Reliability of the venae comitantes in venous drainage of the free radial forearm flaps.  Plast Reconstr Surg. 1998;  102 1544-1548
• 13 Benacquista T, Strauch B. Microsurgery. In: Goldwin RM Plastic Surgery. Philadelphia; Lippincott Williams & Wilkins 1999: 205-256
• 14 Ichinose A, Tahara S, Terashi H, Nomura T, Omori M. Short-term postoperative flow changes after free radial forearm flap transfer: possible cause of vascular occlusion.  Ann Plast Surg. 2003;  50 160-164
• 15 Sasmor M T, Reus W F, Straker D J, Colen L B. Vascular resistance considerations in free-tissue transfer.  J Reconstr Microsurg. 1992;  8 195-200
• 16 Lorenzetti F, Suominen S, Tukiainen E et al.. Evaluation of blood flow in free microvascular flaps.  J Reconstr Microsurg. 2001;  17 163-167
• 17 Kroll S S, Schusterman M A, Reece G P et al.. Choice of flap and incidence of free flap success.  Plast Reconstr Surg. 1996;  98 459-463
• 18 Khouri R K, Cooley B C, Kunselman A R et al.. A prospective study of microvascular free-flap surgery and outcome.  Plast Reconstr Surg. 1998;  102 711-721
• 19 Witzleb E. Functions of the vascular system. In: Schmidt RF, Thews G Human Physiology. Berlin, Heidelberg, New York; Springer-Verlag 1983: 397-455
• 20 Guyton A C, Hall J E. Textbook of Medical Physiology. 10th ed. Philadelphia; WB Saunders 2000: 144-194
• 21 Ciria L G, Gomez C T, Talegon M A. Analysis of flow changes in forearm arteries after raising the radial forearm flap: a prospective study using colour duplex imaging.  Br J Plast Surg. 1999;  52 440-444
• 22 Numata T, Iida Y, Shiba K et al.. Usefulness of color Doppler sonography for assessing hemodynamics of free flaps for head and neck reconstruction.  Ann Plast Surg. 2002;  48 607-612
• 23 Ichinose A, Tahara S, Terashi H et al.. Importance of the deep vein in the drainage of a radial forearm flap: a haemodynamic study.  Scand J Plast Reconstr Surg Hand Surg. 2003;  37 145-149
• 24 Muijsers G J, van Huisseling H, Hasaart T H. The effect of maternal hypoxemia on the umbilical and femoral artery blood flow velocity waveforms and the relationship with mean arterial pressure in fetal sheep.  Gynecol Obstet Invest. 1993;  35 1-6
• 25 O'Brien B M, Morrison W A, Gumley G J. Principles and techniques of microvascular surgery. In: McCarthy JG Plastic Surgery. Philadelphia; WB Saunders 1990: 412-483
• 26 Daniel R K, Kerrigan C L. Principals and physiology of skin flap surgery. In: McCarthy JG Plastic Surgery. Philadelphia; WB Saunders 1990: 275-328
• 27 Taylor G I, Corlett R J, Caddy C M, Zelt R G. An anatomic review of the delay phenomenon: II. Clinical applications.  Plast Reconstr Surg. 1992;  89 408-416 , discussion 417-408
• 28 Walkinshaw M, Engrav L, Gottlieb J, Holloway G A. Flow recovery and vasoconstriction following microvascular anastomosis.  Ann Plast Surg. 1988;  20 533-539
• 29 Weinzweig N, Lukash F, Weinzweig J. Topical and systemic calcium channel blockers in the prevention and treatment of microvascular spasm in a rat epigastric island skin flap model.  Ann Plast Surg. 1999;  42 320-326
• 30 Sigurdsson G H. Perioperative fluid management in microvascular surgery.  J Reconstr Microsurg. 1995;  11 57-65
• 31 Mason D T, Bartter F C. Autonomic regulation of blood volume.  Anesthesiology. 1968;  29 681-692
• 32 Palmer B, Jurell G, Norberg K A. The blood flow in experimental skin flaps in rats studied by means of the 133 xenon clearance method.  Scand J Plast Reconstr Surg. 1972;  6 6-12
• 33 Weinzweig N, Davies B W. Foot and ankle reconstruction using the radial forearm flap: a review of 25 cases.  Plast Reconstr Surg. 1998;  102 1999-2005
• 34 Musharafieh R, Osmani O, Musharafieh U, Saghieh S, Atiyeh B. Efficacy of microsurgical free-tissue transfer in chronic osteomyelitis of the leg and foot: review of 22 cases.  J Reconstr Microsurg. 1999;  15 239-244
• 35 Yamamoto Y, Furukawa H, Sugihara T, Fukuda S, Furuta Y, Ryu T. Radial forearm free-flap reconstruction following radiotherapy and total laryngectomy.  J Reconstr Microsurg. 1999;  15 15-18
• 36 Miller S H, Rudolph R. Healing in the irradiated wound.  Clin Plast Surg. 1990;  17 503-508
• 37 Lutz B S, Wei F C, Chen H C, Lin C H, Wei C Y. Reconstruction of scalp defects with free flaps in 30 cases.  Br J Plast Surg. 1998;  51 186-190
• 38 Swartz W M, Izquierdo R, Miller M J. Implantable venous Doppler microvascular monitoring: laboratory investigation and clinical results.  Plast Reconstr Surg. 1994;  93 152-163
• 39 Kroll S S, Schusterman M A, Reece G P et al.. Timing of pedicle thrombosis and flap loss after free-tissue transfer.  Plast Reconstr Surg. 1996;  98 1230-1233
• 40 McKee N H. Operative complications and the management of intraoperative flow failure.  Microsurgery. 1993;  14 158-161
• 41 Taylor G I, Caddy C M, Watterson P A, Crock J G. The venous territories (venosomes) of the human body: experimental study and clinical implications.  Plast Reconstr Surg. 1990;  86 185-213
• 42 Johnson P C, Barker J H. Thrombosis and antithrombotic therapy in microvascular surgery.  Clin Plast Surg. 1992;  19 799-807