PURPOSE:
To describe an exceedingly rare case of acute intraoperative hand ischemia associated with harvest of a radial forearm free flap in a patient with a normal preoperative arteriogram.
Background: Since its first description in 1981, and then introduction in the western medical literature soon thereafter, the radial forearm free flap has become a valuable tool for reconstructive microsurgery. Despite its reliability and versatility, there are potential complications associated with the flap, the most feared being hand ischemia from sacrifice of the radial artery. Fortunately, acute ischemic complications are exceedingly rare, with only two cases reported in the literature. Options for preoperative evaluation of the donor extremity include the Allen’s test, ultrasonography, and angiography. A preoperative arteriogram is considered the definitive study to evaluate arterial anatomy, patency, and collateralization between the radial and ulnar arteries. Here, we present our experience with a patient who had a mildly delayed Allen’s test and a normal arteriogram of his left upper extremity, who subsequently developed acute intraoperative hand ischemia, requiring reconstruction of his radial artery after elevation of a radial forearm free flap.
METHOD: LR is a 73 year-old right hand dominant male with a history of papillary adenocarcinoma to his hard palate that was resected without reconstruction. He functioned well with an obturator for his hard palatal defect for twelve years and remained disease-free. However, over time, he began to develop recurrent ulcerations and loosening of his anterior dentition related to his prosthesis. With impending inability to retain his obturator and the subsequent risk of severe functional disability from his large oronasal fistula, he was evaluated regarding reconstructive options. A radial forearm free flap was planned to reconstruct his palatal defect. Because of a past medical history significant for myocardial infarction and signs of peripheral vascular disease on exam, including a mildly delayed Allen’s test, an arteriogram was obtained preoperatively. The angiographic results documented patency of his palmar arches. Intraoperatively, a fasciocutaneous radial forearm flap was elevated from the left forearm to reconstruct the intraoral defect. After inset of the free flap, the hand was examined and noted to be pale and cold with mottled skin. Clips were removed from the stump of the distal radial artery, which documented absence of arterial backflow. A reverse saphenous vein interposition graft was used to reconstruct the segmental arterial defect, with resultant reperfusion of the hand. A skin graft was then applied to the volar forearm soft tissue defect after appropriate muscle coverage of the vein graft.
RESULTS: The patient subsequently had an uneventful postoperative recovery with no functional deficits of the hand.
CONCLUSION: Though exceedingly rare, the occurrence of acute vascular insufficiency is always a possibility and must be kept in mind when harvesting a radial forearm free flap. In principle, the plastic surgeon should always have a “lifeboat”, and should be prepared to perform a vein graft reconstruction to avoid any potential untoward intraoperative complications. In this case, clinical examination and judgment were more important and relevant than radiological studies. Furthermore, when it comes to patient selection, peripheral vascular disease and smoking should be considered as relative risk factors for the radial forearm flap.