CASE REPORT – OPEN ACCESS
International Journal of Surgery Case Reports 28 (2016) 270–273
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Osseocutaneous radial forearm flap with beavertail modification; a
case report of a novel, single, reconstructive free flap for the tongue,
floor of mouth and mandible
Alastair Henry, James A. McCaul ∗
The Royal Marsden Hospital, Fulham Rd, London SW3 6JJ, United Kingdom
a r t i c l e
Article history:
Received 8 August 2016
Received in revised form 6 October 2016
Accepted 6 October 2016
Available online 12 October 2016
Keywords:
Case report
Radial forearm flap
Osseocutaneous
Novel technique
a b s t r a c t
i n f o
INTRODUCTION: Complex hard and soft tissue defects produced as a result of ablative resection of head
and neck malignancy can represent a reconstructive challenge, especially when patients are medically
compromised. PRESENTATION OF CASE: We present the case of 72-year-old women presenting with an
oral squamous cell carcinoma of the right floor of mouth invading the right mandible. Surgical management of the disease required ablative surgery with complex free tissue transfer reconstruction to
provide restoration of form and function. Potential reconstructive options were limited by her medical
comorbidities and poor vessel patency in the lower limbs, requiring novel thinking and adaptation of
established techniques.
DISCUSSION: We describe the first reported use of an osseofasciocutaneous radial forearm flap with a
‘beavertail modification’ to provide a single and combined reconstructive option to reconstruct a complex
hard and soft tissue defect.
CONCLUSION: This novel free-flap technique adds to the reconstructive armamentarium of the head and
neck surgeon.
© 2016 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
Complex hard and soft tissue defects produced as a result of
resection of head and neck malignancy can represent a reconstructive challenge. It is vital that both the form and function of the
reconstruction are carefully considered to provide the best possible chance of making a good recovery, providing restoration of
quality of life after curative treatment. As highlighted by this case,
accomplishing these reconstructive goals can be challenging in
the presence of comorbidity such as ischaemic heart disease and
peripheral vascular disease. This case was managed by an experienced consultant head and neck surgeon within a specialist tertiary
hospital, and has been reported in compliance with the Surgical
CAse REport (SCARE) Guidelines [1].
2. Case report
A 72-year-old woman was referred to the department of oral and
maxillofacial surgery by her dental practitioner with a two-month
history of a painful ulcerated lesion on the right floor of mouth,
neck pain and dysphagia. At examination this lesion was three cen-
timetres in diameter, indurated and exophytic. An urgent incisional
biopsy confirmed poorly differentiated squamous cell carcinoma.
Staging magnetic resonance imaging revealed a soft tissue lesion
measuring 2.8 × 1.5 × 2.7 centimetres in the right anterior floor of
mouth and extending into the ventral tongue and mandible, as well
as multiple suspicious ipsilateral Level Ib cervical lymph nodes.
Marrow signal change was evident adjacent to the tumour mass.
Computed tomography (CT) of the mandible confirmed erosion of
the alveolar crest of the mandible consistent with bone invasion. CT
of the thorax displayed evidence of chronic inflammatory lung disease but no evidence of metastasis. On the basis of involvement of
the extrinsic muscles of the tongue, bony invasion of the mandible
and multiple ipsilateral level Ib cervical lymph nodes, the disease
was staged clinically as T4a N2b M0.
Risk factors for oral squamous cell carcinoma included an
85-pack year history of smoking and a long history of excess
alcohol consumption. Medically, she had multiple cardiovascular
comorbidities including poorly controlled essential hypertension,
ischaemic heart disease and atrial fibrillation for which she was
taking warfarin. Echocardiogram revealed moderate mitral stenosis and regurgitation as well bilateral atrial dilatation and tricuspid
regurgitation. Anaesthetic and cardiology opinions placed her at
increased risk of complications from prolonged general anaesthesia.
∗ Corresponding author.
E-mail address: jim.mccaul@mac.com (J.A. McCaul).
http://dx.doi.org/10.1016/j.ijscr.2016.10.019
2210-2612/© 2016 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
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271
Fig. 2. The beavertail is rolled under the skin paddle demonstrating increased flap
volume achieved.
Fig. 1. Elevation of the radial forearm fasciocutaneous element with proximal subcutaneous fat and fascia (the beavertail).
Following discussion within the multidisciplinary head and
neck cancer team, this lady was offered treatment for cure. This was
planned to involve primary surgical resection and reconstruction,
followed by adjuvant radiotherapy (+/− concurrent chemotherapy)
because of evidence of local bony invasion and neck metastatic
spread. Surgical management included bilateral neck dissection,
resection of the primary tumour with segmental resection of the
right mandible, floor of mouth and right tongue and reconstruction
using free tissue transfer.
The choice of which specific reconstructive option was critical
when considering this patient’s multiple complex comorbidities
and consequent increased risks of prolonged general anaesthesia
and major surgery.
The most suitable reconstructive option was considered to be
an osseocutaneous radial forearm free flap. This option allowed
restoration of bony continuity of the mandible, as well as a soft pliable skin paddle to reconstruct the floor of mouth and tongue as a
single reconstructive flap. However, one of the often-quoted advantages of the radial flap flap (thinness) was less ideal in this case
which required some bulk to reconstruct a relatively large defect.
Central flap volume is required to restore swallow by providing bulk
centrally to allow the suprahyoid musculature to propel the food
bolus superiorly and posteriorly against the hard palate. Additional
bulk for this flap was provided by adapting a concept previously
described by Seikaly [2] by utilising a beavertail modification. This
technique includes proximal fat and fascia (the beavertail; shown in
Fig. 3. Resulting complex defect anterior floor of mouth, ventral tongue and
mandible.
Fig. 1) in addition to the fasciocutaneous component which can be
dissected free from the vascular pedicle and folded under the skin
paddle to provide additional bulk to this normally thin flap (Fig. 2).
This combination of an osseocutaneous radial forearm flap and use
of a beavertail modification to provide additional bulk to reconstruct a complex hard and soft tissue defect has not been described
in the literature.
CASE REPORT – OPEN ACCESS
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defects [11]. However, this option was considered not possible for
this patient due to lower limb peripheral vascular disease evident
by symptoms and on imaging. The fibula flap provides a relatively
thick skin paddle which is less suitable for certain situations [12]
such as reconstruction of the tongue and floor of mouth. The fibula
flap is also not easily customised to provide differential soft tissue
bulk.
No established single free flap was considered to have the ideal
characteristics to reconstruct this patient. The use of two simultaneous free flaps is an option for reconstruction of large complex
defects [13] and also to allow the independent selection of ideal
osseous or soft tissue elements [14]. This was considered to be not
appropriate for this patient as the use of two free flaps would have
significantly increased operation time, risk of complications and
donor site morbidity.
The osteocutaneous radial forearm free flap is generally reserved
for elderly patients to support early mobilisation in the post operative period [15], due to reduced donor site morbidity when
compared to harvesting a fibula flap. The osseocutaneous radial flap
is also considered useful in a number of other circumstances; when
there is appreciable peripheral vascular disease (as the radial artery
is usually relatively unaffected [16,17]), when there is other serious comorbidity, and as a salvage flap when other reconstructive
options have been exhausted [8].
Fig. 4. Osteotomised radial bone forming the neomandible, held by titanium reconstruction plate.
Tumour ablation resulted in a bony defect extending from the
left parasymphysis to the right ramus of mandible (Fig. 3) which
was reconstructed with the segment of osteotomised radial bone
held with a carefully contoured preformed titanium reconstruction
plate (Fig. 4). The fasciocutaneous portion was used to reconstruct
the large soft tissue defect of the right anterior floor of mouth and
ventral tongue.
This lady made a steady post-operative recovery and was discharged from hospital after 31 days. Her swallowing function was
assessed as excellent with no dysphagia, owing to the added bulk of
the free flap, and her weight remained stable prior to commencement of radiotherapy. Our speech and language team assessed
her post-operative speech intelligibility as excellent. Histopathological examination of the primary tumour and cervical nodes
confirmed the clinical staging of T4a N2b M0. She went on to have
the prescribed course of radiotherapy lasting 6.5 weeks (66 Gy in
33 fractions) which she tolerated remarkably well.
3. Discussion
Microvascular free tissue transfer has become the primary
choice for reconstruction after oncological resection in the head
and neck. The radial forearm free flap (RFFF), first described over
three decades ago [3], is particularly popular because of ease of harvest, versatility, minimal morbidity and a long pedicle with a large
external diameter [4,5]. The inclusion of a segment of radial bone as
part of the flap was first described by Biemer in 1983 to reconstruct
the thumb [6]. Soutar et al. later described using the an osteocutaneous radial flap to reconstruct a mandibular bony defect [7] and
this is now a useful reconstructive option in selected cases [8].
Alternative options for reconstruction of mandibular bony
defects most commonly include the fibula free flap or a segment of
iliac crest bone based on the deep circumflex iliac artery (DCIA free
flap). Owing to the voluminous skin paddle, osteomyocutaneous
DCIA flaps are often considered too bulky for intraoral reconstruction [9,10]. Many surgeons now consider the fibula free flap as the
optimal reconstructive option for composite segmental mandibular
4. Conclusion
The osseocutaneous radial forearm flap with beavertail modification is a novel reconstructive option, which provides sufficient
bulk of bone and a soft tissue component which can be of variable thickness. Additional advantages of reduced surgical time and
early post-operative mobilisation are likely to be most beneficial in
elderly or medically compromised patients.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Consent
Written informed consent was obtained from the patient for
publication of this case report and accompanying images. A copy
of the written consent is available for review by the Editor-in-Chief
of this journal on request.
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