C.M.E. Avery

Review of the radial free flap: is it still evolving, or is it facing extinction? Part one: soft-tissue radial flap

The versatile fasciocutaneous radial flap is robust and reliable, straightforward to harvest, and often produces a satisfactory reconstruction with relatively little long-term morbidity at the donor site. Many surgeons prefer to use a limited number of trusted flaps, and these qualities will ensure that in the intermediate future most surgical trainees will continue to be shown the fasciocutaneous radial flap as both the basic training flap and the established option for reconstruction. Evidence from observational clinical studies and one randomised clinical trial indicates that there is increasing support for the use of the evolutionary technique of suprafascial dissection to minimise morbidity at the donor site. The suprafascial donor site may be repaired with either a meshed or unmeshed partial-thickness skin graft, or a fenestrated full-thickness skin graft, with good rates of successful healing. The application of a negative pressure dressing to the wound seems to facilitate the healing of all types of skin graft. The subfascial donor site, however, remains more prone to complications. It may be helpful to position the donor site of the flap more proximally, but this has not been proven. These refinements probably produce the best outcomes that can currently be achieved, given the inherent flaws of the radial donor site.

Review of the radial free flap: still evolving or facing extinction? Part two: osteocutaneous radial free flap

The osteocutaneous radial flap is robust, reliable, and relatively simple to harvest, which will ensure that it remains one of the established reconstructive options in most maxillofacial units. Evidence based on clinical observational studies and biomechanical studies supports the routine or selective use of prophylactic internal fixation to strengthen the radial osteocutaneous donor site. This allows safe harvesting of the maximum volume of available bone, up to half of the circumference, with minimal risk of fracture or long term complications. The incidence of fracture with the plate placed either anteriorly or posteriorly is equally low, but the anterior position is technically easier and probably less likely to cause additional morbidity. This approach probably produces the least morbidity that may currently be achieved when managing the inherent flaws of the radial hard tissue donor site. The introduction of prophylactic internal fixation consolidates the role of the osteocutaneous radial flap for repair of defects that require a relatively small volume of bone and an appreciable area of thin soft tissue, particularly when a long vascular pedicle is desirable. This includes low level defects of the maxilla, some defects of the mandible, and niche reconstructions, such as the orbital rim. It remains useful as a first choice of flap when there is appreciable peripheral vascular disease, when there are other serious coexisting medical conditions; if it is the preferred choice of the patient for functional reasons such as mobility of the lower limb or hip, and as a salvage flap when other reconstructive options have been exhausted.

The use of a T-shaped contoured unilocking titanium radial plate for prophylactic internal fixation of the radial osteocutaneous donor site

The radial osteocutaneous flap retains a limited role in reconstructive maxillofacial surgery The application of prophylactic internal fixation, using straight 3.5 mm plates, has become established to substantially reduce the incidence of fracture at the radial donor site. New lower profile T-shaped 2.4 mm plates and anatomically contoured 3.5 mm plates are now available, both with unilocking screw fixation systems. These plates are easy to apply and allow the removal of up to 50% of the circumference of the radial bone, including the maximum amount of good quality bone from the distal radius. Although there have been no reports of complications as a result of a stress shielding effect with larger plates these refinements in plate design should lessen any remaining concerns.

Re: McAlister K, Ameerally P, Avery C. Protection of the patient's hair with a standard swimming cap during major maxillofacial operations. Br J Oral Maxillofac Surg 2005; 43:85-6.

he battery is charged before the session, and the contents re played on continuous mode, which is loaded on a memry card. We used this technique in a poster presentation uring the 18th International Conference on Oral and Maxllofacial Surgery in Bangalore and it was well-received. It ot only adds a dynamic dimension to the poster, but also rovides an opportunity for more information to be produced nd discussed.