ARTÍCULO CLÍNICO

 

Lateral arm flap in oral cavity reconstruction

Colgajo lateral de brazo en reconstrucción de la cavidad oral

 

 

A. Dean Ferrer¹, F.J. Alamillos Granados², J.J. Ruiz Masera³, A. Redondo Camacho³, J. Torres Corpas³, G. Barrios Sánchez⁴, J.A. García de Marcos⁵

¹ Jefe de Sección. Hospital Universitario "Reina Sofía". Córdoba. Fellow of the European Board of Oral and Maxillofacial Surgery. Profesor asociado de la Facultad de Medicina. Universidad de Córdoba. España.
² Facultativo Especialista de Área. Hospital Universitario "Reina Sofía". Córdoba. Fellow of the European Board of Oral and Maxillofacial Surgery. Profesor asociado de la Facultad de Medicina. Universidad de Córdoba. España.
³ Facultativo Especialista de Área. Hospital Universitario "Reina Sofía". Córdoba.
⁴ Especialista en Cirugía Oral y Maxilofacial. Práctica privada.
⁵ Médico Residente. Servicio de Cirugía Oral y Maxilofacial. Hospital Universitario "Reina Sofía". Córdoba. España

Correspondence

 

 

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ABSTRACT

Introduction. The availability of easily pliable skin has allowed the functional reconstruction of oral cavity defects. Although the radial forearm free flap is the most frequently used flap for the reconstruction of surface defects of the oral cavity, the lateral arm free flap may be preferable in some situations.
Objectives. The aim of the present paper is to show the advantages and disadvantages and our indications and results for the lateral arm flap in intraoral reconstruction.
Material and methods. This is a prospective work on the use of the lateral arm free flap for the reconstruction of oral cavity defects after ablative surgery. The parameters that have been evaluated are: flap viability, morbidity in the donor site, length of the pedicle, selection of recipient vessels, complications and functional results in the reconstructed area.
Results. The lateral arm flap has been used in primary reconstruction after ablative surgery for squamous cell carcinoma of the oral cavity in ten patients. One flap was lost because of venous thrombosis. The donor site was repaired by direct closure in 8 cases and a split thickness skin graft had to be used in 2 cases. Mean pedicle length was 8.75 cm. In 9 cases a favorable functional result was achieved.
Conclusions. Fasciocutaneous lateral arm flap allows the reconstruction of oral cavity defects achieving good functional results. Morbidity in the donor site is minimal and, in most cases, direct closure permits the repair of the donor site.

Key words: Free flaps; Oral cavity defects; Oral cavity reconstruction; Lateral arm free flap; Radial free flap.

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RESUMEN

Introducción. La posibilidad de emplear una piel fácilmente plegable ha permitido reconstruir defectos de la cavidad oral consiguiendo una gran funcionalidad. Aunque el colgajo radial es el colgajo que se utiliza con más frecuencia para reconstruir defectos de superficie de la cavidad oral, el colgajo lateral de brazo puede ser de elección en algunas situaciones.
Objetivos. El objetivo del presente trabajo es mostrar las ventajas e inconvenientes y nuestras indicaciones y resultados del colgajo lateral de brazo en reconstrucción de defectos de la cavidad oral.
Material y método. Se trata de un estudio prospectivo sobre la utilización del colgajo lateral de brazo en la reconstrucción de defectos de la cavidad oral tras cirugía ablativa. Se ha valorado: la viabilidad del colgajo, la morbilidad del lecho donante, la longitud del pedículo, la selección de vasos receptores, las complicaciones y los resultados funcionales de la zona reconstruida.
Resultados. Hemos utilizado el colgajo lateral de brazo en 10 pacientes en reconstrucciones primarias tras cirugía ablativa por carcinoma epidermoide de la cavidad oral. Hubo un caso de necrosis por trombosis venosa. El defecto donante se cerró en 8 casos de modo directo y en 2 con un injerto libre de espesor parcial. La longitud media del pedículo ha sido de 8,75 cm. En 9 casos el resultado funcional de los pacientes ha sido satisfactorio.
Conclusiones. El colgajo fasciocutáneo lateral de brazo permite la reconstrucción de la cavidad oral consiguiendo buenos resultados funcionales. Además la morbilidad de la zona donante es mínima y puede realizarse cierre directo del defecto cutáneo del brazo en la mayoría de los casos.

Palabras clave: Colgajos libres; Defectos de cavidad oral; Reconstrucción oral; Colgajo libre lateral de brazo; Colgajo libre antebraquial.

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Introduction

The lateral arm flap is a flap that is very versatile and used widely in post-traumatic defects of the upper extremities, but it is not very often used in reconstructions of the head and neck. This flap was first described by Song in 1982.¹ However, it was not significantly applied in the head and neck until 1992, when Sullivan y Cols.² used it. Since then, as a result of numerous works, the possibilities of using this flap at an oro-cervical-facial level have increased.

This flap has similar tissue to that of the radial flap, but it differs in that it has the great advantage of a pedicle that is not essential for the vascularization of the distal extremity of the upper limb.^3,4 It is a fasciocutaneous flap that receives its vascular supply from a terminal branch of the deep brachial artery, the posterior radial collateral artery, which is located in the lateral intermuscular septum of the arm.^2,5

The objectives of this paper are:

1. To show the indications, advantages and disadvantages and our indications and results in the reconstruction of defects of the oral cavity with a lateral arm flap.

2. To revise the surgical technique for harvesting the flap, giving an anatomical description and presenting the refinements.

 

Material and methods

The reconstruction of defects of the oral cavity was carried out in ten patients using a lateral arm free flap. In all cases primary reconstruction was carried out following ablative surgery for squamous cell carcinoma of the oral cavity. The location and characteristics of these cases are reflected in table 1. The age and sex of the patients was taken into consideration together with the location of the primary tumor, the type of neck dissection, the size of the cutaneous island, length of the pedicle, selection of the receptor vessels, closure of the arm defect, viability of the flap, possible complications, functional results and the need for secondary surgery.

Anatomy and technical surgery

The arm is divided by the intermuscular septum into extensor and flexor compartments. The vascular pedicle of the lateral arm flap is the posterior radial collateral branch of the deep brachial artery that runs from the brachial artery. By the distal third of the humerus, the deep brachial artery divides into an anterior collateral branch and another posterior branch. The posterior radial collateral artery (PRCA) is located in the lateral intermuscular septum between the triceps muscle posteriorly, and the brachioradial muscle anteriorly, and it provides vascularization to the lateral part of the arm. The radial nerve runs together with this branch to the spiral groove of the humerus (Fig. 1). The average caliber of the artery is 1.5 to 2 mm^2,5,6 and the average caliber of the vein is 2 to 3 mm.^5,6 The average length of the pedicle is 6-8 cm, but this can be increased by another 2-3 cm, by dissecting the deep brachial artery by the spiral groove after separating the deltoid and the triceps, or by separating the tendon from the lateral head of the triceps. ^2,3,7-9

The PRCA gives off four to seven perforating branches that ascend to the lateral intermuscular septum and they are to be found between 1 cm and 15 cm above the epicondyle.⁷ The larger of these, or the dominant one, is found some 10 cm proximal to the epicondyle of the arm.⁷ Anatomical variations are rare. Cases of two parallel PRCA have been described that provided the flap with vascularization, and the anastomosis of just one of them was enough to achieve the correct skin perfusion.^2,7,10 The pedicle provides branches for the vascularization of the humerus, the intermuscular fascia, the subcutaneous tissue and skin. The nerve that provides sensitivity to the skin of the flap is the posterior cutaneous nerve of the arm, and it can be harvested as a neurotized flap. It can be anastomosed to a sensory nerve of the receptor bed. Should it be necessary, the forearm posterior cutaneous nerve can be transferred as a vascularized nerve.

The lateral arm flap can have two venous systems for drainage: the superficial and deep systems. The deep system is formed by concomitant veins that accompany the PRCA that can join to form just one vessel by the spiral groove of the humerus.² The superficial venous system is made up of veins in the subcutaneous plexus that drain into the cephalic vein. Both systems are enough for draining this flap, although we have always used the concomitant system of the PRCA.

The lateral arm free flap can be raised with the patient in a supine position while the ablation is carried out. In older people, due to the flaccidity of dermoepidermic tissues, care has to be taken on designing the cutaneous island, as this could be displaced with regard to the intermuscular septum. The flap can be raised with or without a tourniquet. We use a pediatric tourniquet because the adult one, as it is wider, makes raising the uppermost part of the flap difficult. If extending the length of the pedicle were necessary, the tourniquet can be removed at this point and the dissection can be continued without a tourniquet.

The vascular axis of the flap is found 1 cm dorsal to the line joining the epicondyle and the elbow with the deltoid insertion. The amount of skin that the PRCA can irrigate according to injection studies is of some 8x10 cm to 14x15 cm.^5,11,12

Most authors recommend limiting the width of the flap to 6-7 cm to allow direct closure of the defect.^10,11,13 Like Sullivan, we favor the possibility of direct closure by means of "pinching" the skin fold in the area of the flap.

The dissection of the skin island can be started in the anterior or posterior part. The skin, subcutaneous cellular tissue and underlying muscle fascia that are to be included in the flap are incised. The dissection continues in a subfascial sense until the intermuscular septum is reached via the anterior and posterior faces, and until the insertion of the humerus is reached. The brachioradial muscle has muscular insertions in the anterior face of the septum, and the dissection has to be carried out very carefully in order not to damage the vessels of the pedicle. In the posterior part, the triceps does not have muscular insertions into the septum and the dissection is easier. The vessels of the pedicle are found in the deeper part of the septum, very near the humerus. The septum is sectioned distally and the extensions are ligated distal to the pedicle. The radial nerve should be preserved and separated from the intermuscular septum once the posterior radial collateral vessels have been identified. If a superior extension of the cutaneous incision is carried out along the posterior border of the deltoid, the pedicle can be dissected upwards to the spiral groove of the humerus. The dissection of the pedicle by the spiral groove increases its length by 2 to 3 cm.

Closure of the defect can be carried out directly or by means of a skin graft. Leaving drainage in the surgical bed is advisable. The arm does not require a splint.

Case 9: Female, 37 years old, with squamous cell carcinoma of the lateral border of the tongue. T2 N0 M0. Right supraomohyoid neck dissection was carried out together with a partial glossectomy and reconstruction of the tongue defect by means of a lateral left arm flap. She later underwent radiotherapy treatment (Figs. 2, 3, 4 and 5 y 6).

 

Results

The results of all the parameters analyzed are reflected in table 1.

In nine cases the functional result for the patients was satisfactory. Only one patient with a defect in the ventral face of the flap required secondary surgery to reduce the flap as the bulge made moving the remaining tongue difficult. The remaining patients did not require secondary surgery.

 

Discussion

The possibility of using skin that is easily pliable and that adapts to the shape of the oral cavity has permitted repairing defects of the oral cavity mucosa and achieving very good functional results. If the tissue obtained for reconstructing an oral defect is not pliable, and if it does not adapt to the contours, and if the remaining tongue cannot be moved, it will meet the requirements as to covering and closing the oral cavity, but swallowing and speech will be limited. The fasciocutaneous radial flap has been widely used for covering surface defects of the oral cavity as it is very reliable and the technique is simple. However, the thinness of this flap means that on occasions the volume of tissue obtained is less than what is required.⁶ The lateral arm flap should be considered as an option in reconstructions as it is valid in certain cases. There are patients with negative Allen’s tests, and others that do not accept the aesthetic sequelae in the donor site, and there is the morbidity of the donor bed of the radial flap inherent to its use, and the suppression of an important artery in the vascularization of the hand^6,14 One of the advantages of the lateral arm flap with regard to the radial flap is that it uses a vascular system that is not essential for the vascularization of the arm.^3,6

With regard to the venous system of the lateral arm flap, some authors use the venous system of the cephalic vein in stead of the concomitant system.¹⁰ In the cases presented, we have always used the concomitant venous system. The flap can be harvested with both venous systems, and the cephalic system can be used should the deep system not be adequate. If there is an absence of receptor venous vessels in the head and neck, the cephalic vein can be moved to the subclavian vein and continuity is not lost at any moment, and arterial anastomosis is carried out in the neck.¹⁵

The flap can be harvested without skin, as a fascial flap, if less volume is needed or if skin is not required in the reconstruction (when increasing volume in facial contour reconstruction). ^2,4,5,11 There are in addition injection studies that show how there is an area of humerus measuring 10x1 cm that is vascularized by periosteal branches of the PRCA, and that an osteofasciocutaneous flap can be harvested.¹¹ The septum can be divided and the continuity of the perforating branches can be maintained. A flap with tissue islands, fascia with its own vascular branch, and with a single pedicle can be obtained.⁷ The flap can be extended towards the skin of the forearm (Lateral arm/proximal forearm flap)¹⁶ in order to obtain a pedicle that is as long as possible and with the greatest skin surface possible.

The lateral arm flap is finer in its distal portion and it widens progressively. This has to be taken into account on adapting it to the surgical defect, and it can be an advantage for certain types of oropharyngeal defects.^14,17 The finer part can be used for the pharyngeal wall and the thicker part for the base of the tongue. The lateral arm flap is thicker than the radial forearm free flap, but it continues being a fine flap and one that is suitable for adapting to the shape of the mouth. When more volume is needed, the lateral arm flap can be raised with a portion of triceps muscle.^18,19

The sectioning of the posterior cutaneous nerve of the forearm, that is produced in most cases when raising the flap, leads to a loss in sensitivity in the extension area of the forearm that is not normally appreciated by the patient and that reduces over time.²

There are many ways of obtaining a longer pedicle: by proximal dissection as described in the surgical technique, separating the triceps muscle or by placing the skin island more distally.¹⁴

Direct closure of the lateral arm flap can nearly always be carried out (if the width of the defect is less or equal to 6 cm). In our case 2 patients required grafts. There is less of an aesthetic defect with the lateral arm flap than with the radial flap.³ The morbidity associated with the lateral flap donor site is very little, although the following have been described: pain in the epicondyle area, hypoesthesia of the skin proximal to the forearm, and a reduction in elbow movement. ²⁰

The flap can be harvested by a second surgical team working simultaneously with the ablative team.⁵ The preoperative examination consists only in an examination of the donor area. The vessels of the neck that adapt better to the caliber of the flap’s vessels are the superior thyroid artery and the facial artery and veins of the thyro-linguo-facial trunk.⁵

This flap is as reliable as any other used for the reconstruction of the head and neck, and in general there is a success rate of 95%.^4,6,14,17

The lateral arm flap should be considered as a reconstructive option for oral mucosa surface defects. The advantages of this flap are: it offers a fine covering that is pliable and that adapts to the shape of the oral cavity, and good functional results for surface defects can be obtained. It possesses a consistent vascular pedicle that, in addition, is not essential for the vascularization of the distal extremity of the upper limb. It can be harvested as a neurotized flap, it is fast and easy to raise, and it can be harvested at the same time as the ablation is carried out. The patient can keep the same posture, it is of an intermediate thickness and, as a result, it is useful for defects of the oral cavity that require more volume than that provided by the radial forearm flap. There is little morbidity at the donor site and direct closure of the cutaneous defect can be carried out. On many occasions a very acceptable aesthetic result can be obtained in the donor site and, although the pedicle is short, there are surgical techniques for elongating it.

The disadvantages of this flap are: the small caliber of the vessels, and the dissection and preparation of the receptor vessels which should be done very carefully: "any vessel of the receptor bed can be necessary". In obese patients the flap may be too bulky. Its size is limited, and it can be small for large defects. The length of the pedicle can, on occasions, be limited and an area of hypoesthesia-anesthesia in the forearm will be produced.

 

Conclusions

The lateral arm flap is useful for reconstructing intraoral and oropharyngeal soft tissues, as tissue that is sufficiently fine and adaptable to the posterior and lateral pharyngeal walls is required. It also provides adequate volume when reconstructing the base of the tongue, and the mobility of the segment that has not been excised can be maintained.

 

 

Correspondence:
Dra. Alicia Dean
C/ José Mª Martorell 4, 2º-2
14005 Córdoba. España
Email: ADF10101@teleline.es

Recibido: 27.12.05
Aceptado: 28.04.08

 

 

References

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14. Gellrich NC, Schramm A, Hara I, Gutwald R, Duker J, Schmelzeisen R. Versatility and donor site morbidity of the lateral upper arm flap in intraoral reconstruction. Otolaryngol Head Neck Surg 2001;124:549-55.        [ Links ]

15. Inoue T, Fujino T. An upper arm flan pedicled on the cephalic vein with arterial anastomosis for head and neck reconstruction. Br J Plast Surg 1986;39:451-3.        [ Links ]

16. Brandt KE, Khouri RK. The lateral arm/proximal forearm flap. Plast Reconstr Surg 1993;92:1137-43.        [ Links ]

17. Nahabedian MY, Deune EG, Manson P. Utility of the lateral arm flap in head and neck reconstruction. Ann Plast Surg 2001;46:501-505.        [ Links ]

18. Gordon DJ, Small JO. The addition of muscle to the lateral arm and radial forearm flaps for wound coverage. Plast Reconstr Surg 1992;89:563-5.        [ Links ]

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