"Racing-stripe" Modification of Radial Forearm Free Flap: Technique and Experience (704 Consecutive Cases)

Abstract

The radial forearm fasciocutaneous free flap (RFFF) has proven to be a versatile and reliable tool for the reconstructive microsurgeon when addressing soft-tissue defects. A significant drawback of the traditional RFFF is related to donor site morbidity and wound healing complications, especially when coverage of sizable defects is planned. The authors describe the "racing-stripe" modification of the RFFF (RS-RFFF) that involves harvesting a large segment of the deep forearm fascia with a narrow strip of skin overlying the radial vessels, thus allowing primary closure of the donor site.

Methods: Retrospective chart review was conducted of a single surgeon's (E.G.M.) experience of patients who underwent RS-RFFF.

Results: Seven hundred four RS-RFFFs were performed in 698 patients over a 19-year period (2000-2019) for lower extremity reconstruction (657 flaps, 93.3%), upper extremity reconstruction (32 flaps, 4.5%), and head and neck reconstruction (15 flaps, 2.1%). Wounds secondary to trauma were the most common reason for flap reconstruction (655 wounds, 93.8%). Five hundred four RS-RFFFs were used for soft-tissue defects of the foot (129 flaps, 18.3%), ankle (309 flaps, 43.9%), and heel (66 flaps, 9.4%; 27 of which provided coverage for Achilles tendon repair or exposure). There were three flap losses (0.4%). Limb salvage rate was 100% for extremity wounds. Forearm donor site wound complications were minimal.

Conclusions: The RS-RFFF can be consistently and safely harvested and permits low-profile, reliable coverage of small-to-medium size soft-tissue defects. Primary closure of the donor site is possible in all cases, thus minimizing wound healing complications.

Fig. 1.

RS-RFFF surgical technique and representative case (left dorsal foot). A, RS-RFFF designed with a narrow skin paddle centered over the axis of the radial vessels. Collateral circulation through the ulnar artery assessed with handheld Doppler. B, Suprafascial dissection of RS-RFFF. C, Subfascial dissection of RS-RFFF incorporating radial artery and vena comitans. D, RS-RFFF islanded on the radial vessels with the tourniquet deflated. E, This 22-year-old man presented after a high-speed motor vehicle collision with a left dorsal foot wound and multiple comminuted metatarsal fractures (second through fifth) and fracture of the talar body. Wound following debridement and bone stabilization with pins, screws, and application of an external fixator. F, RS-RFFF inset just before placement of STSG. End-to-end arterial anastomosis to the anterior tibial artery was performed. The cephalic vein and a single vena comitans were used for venous anastomoses to anterior tibial veins. G, The patient is shown here at 2 months postoperatively with the flap well-healed and with good contour. H, Forearm donor site well-healed and with good contour.

Fig. 2.

RS-RFFF representative case (right medial ankle). This 51-year-old man presented with an open grade IIIB right bimalleolar fracture with syndesmotic disruption after a car that he was unloading from a truck rolled over his right lower leg. There was a medial ankle wound with exposed tendon, bone/hardware, and posterior tibial neurovascular bundle. The posterior tibial vessels were noted to be severely contused, but there was excellent pulsatile flow to the foot through the anterior tibial system with retrograde flow through the posterior tibial system by Doppler examination. A, Wound following bone stabilization and serial irrigation and debridement. B, RS-RFFF inset just before placement of STSG. End-to-end arterial anastomosis to the posterior tibial artery was performed. Two venous anastomoses were completed for flap drainage (cephalic vein and a single vena comitans). C, The patient is shown at 3 months postoperatively with the flap well-healed and with good contour. D, Forearm donor site well-healed and with good contour.

Fig. 3.

RS-RFFF representative case (left lower extremity). This 60-year-old woman was involved in a motorcycle collision and transferred from an outside hospital with an open grade IIIB distal tibial-fibular pilon fracture of the left lower extremity. A, Wound following serial irrigation and debridement and bone stabilization with pins, screws, and application of an external fixator. B, RS-RFFF inset just before placement of STSG. Microvascular anastomoses consisted of end-to-side arterial anastomosis to the anterior tibial artery and two venous anastomoses for flap drainage (using both flap vena comitans). C, The patient is shown here at 18 months postoperatively with the flap well-healed and with good contour. Flap reelevation was required for bone grafting and fixation of a distal tibia nonunion. There were no wound healing sequelae following the secondary flap reelevation procedure. D, Forearm donor site well-healed and with good contour.

Fig. 4.

Schematic drawing illustrating RS-RFFF cross-sectional anatomy and dissection planes. A, Radial vessels. B, Antebrachial fascia. C, Cephalic vein. D, Superficial branches of the radial nerve.