Salvage of free radial artery forearm flap following reconstruction of lower lateral lip: A case report

Abstract

The increasing success rate of free flaps along with their reconstructive advantages have got them into regular practice options in Maxillofacial reconstruction. Although associated complications are inevitable in a percentage of patients, it is good postoperative care and monitoring that determines the success or failure of the reconstruction. With early recognition and prompt intervention salvage of compromised flap is possible. The purpose of this article is to emphasise the importance of keeping low threshold for re-exploration in situation of any suspected failing free flap. Pt ReportA 60 year-old male patient presented with an ulcero-proliferative mass measuring around 4cmx3.5 cm which involved the right lip mucosa and had infiltrated the underlying tissue to appear over the skin with central zone of necrosis and surrounding erythematous induration. (Fig. 1) Incisional biopsy from mucosal surface of the lesion revealed well to moderately differentiated squamous cell carcinoma. The neck was clinically N0 which similarly correlated following contrast CT scan of the neck. The surgical planning for the tumour was wide excision, SOND (Supra Omohyoid neck dissection) and reconstruction of the defect with FRAFF. Wide excision of the primary lesion was carried out along with the SOND on the affected side.The neck dissection was done with extreme care to preserve the facial vessels when dissecting level IB. Dissection of the submandibular gland was done by safely ligating the submandibular branches of the facial artery to the gland and preserving the whole artery along its course on the posterior aspect of the gland. The right lip commissure involving lateral one third of the lower lip, part of skin in the cheek along with underlying part of cheek musculature, inner buccal and labial mucosa, gingivo-buccal sulcus and gingiva along with the alveolar bone sparing the lower border of the mandible were resected. The size of the primary defect following tumour resection was 5.2x4.8x3.7 cm. The reconstruction of the surgical defect was done with FRAFF. On completion of the reconstruction the flap looked well perfused and healthy. The flap was monitored clinically at an hourly basis. By 4 th -5 th hours mild ooze from the drain port had become noticeable along with marked oedema in the flap. (Fig. 2) On the 8 th hour post operatively there was dusky appearance of the flap, along with oedema. On needle prick there was dark blood ooze from the flap and therefore the decision for re exploration was taken suspecting venous compromise. On re exploration a huge hematoma was noticed under the flap, around the anastomosis and along the IJV. The clots were delicately removed. The adjoining areas were irrigated with warm saline, and venous and arterial anastomoses were evaluated. There were no clots in the vein and normal flow through the artery was seen. Acland's "milking" test was performed. In the test the artery was occluded with a forceps immediately caudal to anastomosis and then with a second forceps artery was occl...