In this video, Mount Sinai head and neck cancer surgeons perform a radial forearm free flap to reconstruct a soft tissue defect of the head and neck after removing a large, cancerous tumor. Free flaps are pieces of tissue from a patient’s own body taken with a specific artery and vein that are then connected, or anastomosed to vessels in the patients head and neck. The radial forearm free flap is rather versatile and can be used to reconstruct a variety of areas. Mount Sinai is one of the largest head and neck cancer centers in the United States and routinely performs hundreds of free flaps. For smaller tumors of the throat, Mount Sinai is able to offer patients transoral robotic surgery, a minimally invasive approach. For more information, go to: https://www.mountsinai.org/locations/head-neck-institute
Eric M. Genden, MD, MHCA, FACS Dr. Isidore Friesner Professor and Chair of Otolaryngology – Head and Neck Surgery Senior Associate Dean for Clinical Affairs Professor of Neurosurgery and Immunology Icahn School of Medicine at Mount Sinai Director, Head and Neck Institute-Center of Excellence for Head and Neck Cancer Mount Sinai Health System Michael Berger, MD Assistant Professor, Department of Otolaryngology-Head and Neck Surgery Division of Otology-Neurotology, Lateral Skull Base Surgery Mount Sinai Health System Raymond L. Chai, MD Associate Professor, Otolaryngology – Head and Neck Surgery Mount Sinai Health System Mohemmed Nazir Khan, MD Assistant Professor, Department of Otolaryngology Mount Sinai Union Square Diana N. Kirke, MD Assistant Professor, Otolaryngology, Head and Neck Surgery The Mount Sinai Hospital Scott Allan Roof, MD Assistant Professor, Head and Neck Surgery Mount Sinai Health System Marita S. Teng, MD Professor, Otolaryngology – Head and Neck Surgery Mount Sinai Health System Mark Urken, MD Chief, Division of Head and Neck Surgical Oncology, Co-Director, Institute for Head and Neck and Thyroid Cancer, Department of Otolaryngology, Mount Sinai Union Square Mount Sinai Health System Zachary G. Schwam, MD Assistant Professor, Department of Otolaryngology-Head and Neck Surgery Division of Otology-Neurotology, Lateral Skull Base Surgery Mount Sinai Health System The Mount Sinai Oto Laryngology. Surgical video series presents radio forearm free flab. This procedure is performed by our head and neck oncologic surgeons for reconstruction of extensive ablative defects. This video is edited by Zachary Swum. This is a patient with recurrent tongue cancer with a relatively large ablative defect in need of reconstruction. A preoperative all test confirmed adequate ulnar collateral circulation. Here we have a left or non dominant hand with a skin paddle and proximal incision marked out a red tourniquet with sufficient padding underneath sits on the proximal arm and is set to 250 millimeters of mercury or 100 millimeters of mercury above their systolic blood pressure. We set a timer for 60 minutes. The tourniquet will allow for largely bloodless surgery to exsanguinate the hand and form of blood. An S R wrap is applied from distal to proximal before the tourniquet is inflated. The hand is kept in a somewhat sued position by a blue towel and white gauze. The incision is made on the proximal forearm with a scalpel and extended into the radial aspect of the skin battle. The radial aspect of the proximal forearm skin flap is elevated with a knife. The plaintiff dissection is superficial to branches of the cephalic vein which comes into view. The skin and soft tissue elevation continues in the same plane, exposing more of the cephalic vein. The breaky radialis muscle comes into view and is also the deep limit of this part of the dissection. The skin incision is carried distally into the wrist. The cephalic vein is further skeletonized and branches of it are clipped and cut. The breaky radial's muscles further skeletonized from distal to proximal. The v of the two tennis insertions is seen. The cephalic vein is further skeletonized on its ulmer aspect, cutting down to the level of the bray radialis muscle belly. The cephalic vein is further isolated circumferentially with a knife. More branches off the cephalic are clipped and cut the muscle belly of the breaky radialis is then retracted in a radial direction and the facial attachments cut with a knife. This is where the main peta is expected to be the brachy radialis tendon is retracted distally and underneath the radial nerve comes in a view. It is labeled here. The FAA medial to the radial nerve is dissected out and cut. A similar plaintiff dissection is carried distally into the wrist. The radial nerve is traced out and isolated the skin incision is then taken across the distal aspect of the skin peddle. The two perpendicular lines mark the anticipated location of the pedicle. The ulmar aspect of the skin paddle is also in size down to the depth of the FASA covering the flexor carpi radialis or F C R. This label diagram shows the vascular pentacle consisting of the radial artery and its two va traveling between the bray radialis and the F C R. The cephalic vein runs superficially on the bray radialis and the radial nerve runs between its 2 10 and it heads skin and soft tissue were elevated off the ner aspect of the forearm. With the depth being the FC, the palmera tenant is seen medial to the F C R. This label diagram shows the important anatomical relationships. Thus far in the more proximal forearm, we again see the retracted skin and soft tissue flaps. The vascular pentacle running between the F C R and the brachioradialis and the cephalic vein superficial to the brachioradialis. This walkthrough shows the same anatomy. The skin flaps are retracted. The cephalic vein immediately seen the brachy radialis muscle belly pointed out, followed by the peta, the radial nerve which pierces the two breaky radialis 10 in his heads and goes into the wrist to provide sensation to the dorsal hand. The break here, radialis and F C R. Tenons are pointed out the fascist surrounding the pentacle is then incised first on its radial aspect and then on its owner aspect. While the F C R tendon is retracted. The distal aspect of the pentacle is then identified by cutting the soft tissue over the hatch lines, we then see the radial artery in its va the pentacle is sequentially clipped and cut. Distally. Two clips are placed on each side of the artery. The pentacle is then further isolated by lic its facial attachments. Small perforators are seen emanating from the radial artery through the bray radialis and eventually into the radius. If one were to take an osteocutaneous free flap, the deep side of the flap and pedicle are released from the underlying tissue. Working distal approximal vessels are clipped and cut. As one goes proximately. A Venus plexus is encountered a cephalic vein and pedicle which includes the radial artery and its two va can clearly be seen. This Venus plexus is dissected out unnecessary branches are sequentially clipped and cut. Next. The radial artery is traced proximately into the level of the radial recurrent artery. This marks the proximal aspect of the arterial dissection. The tourniquet is then let down the flap allowed to perfuse for a few minutes and hemostasis on the flap achieved with clips and bipolar cotter. The flap in its entirety can now be seen. The skin pedal will reconstruct the soft tissue defect in the tongue and the vessels will be anastomose or recipient vessels in the neck. The proximal vessels are then sequentially clipped and ligated and ischemia time begins after the flap is removed, a soft tissue defect remains in the arm. This is covered with a split thickness skin graft which is pie crusted to prevent accumulation of blood underneath. The proximal incision is closed with virola moore suture and a Jackson pratt drin is placed, a wound vac is placed on the skin graft site and a splint placed around the donor site for one week.