(0536) Unique Case of Pedicled Radial Forearm Flap in Glossectomy Reconstruction

Introduction: The radial forearm microvascular free flap (RFFF) is a workhorse in head and neck reconstruction for soft tissue defects in the oral cavity due to flexible skin paddle design and reliability of vascular anatomy. However, if aberrant forearm anatomy is encountered intraoperatively, a pedicled flap may be performed instead to avoid addition donor site morbidity.

Methods: We present a unique case of a pedicled radial forearm flap for reconstruction of a partial glossectomy defect due to anomalous upper extremity vascular anatomy discovered intraoperatively precluding microvascular anastomosis.

Results: A 63-year-old male with Stage IVA T3N2bM0 oral tongue squamous cell carcinoma presented for right partial glossectomy and RFFF reconstruction. During distal to proximal dissection following the radial artery and venae comitantes, the caliber of veins from the deep system was insufficient for microvascular anastomosis, and there was no bridging vein between the superficial and deep system. The radial and ulnar arteries remained separated in the antecubital fossa. Due to the absence of both a suitable donor vein for microvascular anastomosis and a brachial artery, the dissection continued proximally until pedicle length was sufficient to tunnel the flap to the oral cavity. The radial and ulnar arteries were dissected proximally into the upper arm and appeared to confluence abutting teres major. Two step ladder incisions were made proximally to facilitate subcutaneous tunneling of the flap superficial to the clavicle into the neck prior to tunneling through the floor of mouth into the glossectomy defect. The flap was monitored via physical examination, doppler signal on the skin paddle, and intermittent needle pricking. He progressed appropriately and was discharged without complication.

Conclusions: This patient's aberrant venous anatomy precluded use of microvascular anastomosis, but his arterial anatomy, a high brachial bifurcation seen in about 8% of people, allowed for extra pedicle dissection and use of the forearm flap in a pedicled fashion. This is the first reported case in head and neck reconstruction.