FIGURE  3.1 Floor of the mouth repair using the radial forearm free flap. The cancer is demonstrated (A) prior to resection. The defect included the floor of the mouth with invasion of the gingival surface with exposed bone and a connection into the neck (B). The 6-month postoperative appearance of the flap with blunting of the alveolus and appropriate healing (C).

Although the distal aspect of the flap should be set proximal enough to be covered by the shirt sleeve, thinner tissue is often present in the distal aspect of the arm and may be required in obese patients. The arm is then exsanguinated, and a tourniquet is inflated to approximately 250 mm Hg. The first skin incision is made at the distal end of the skin paddle along the ulnar border down to fascia, and a subfascial dissection is performed toward the flexor carpi radialis tendon. Care should be taken to preserve paratenon over the tendon to prevent loss of the skin graft. The use of suprafacial dissection has been described that results in improved take of the split-thickness skin graft without vascular compromise to the skin paddle. The distal ends of the radial artery and venae comitantes are isolated and ligated with suture, and the radial margin of the flap is incised down to brachioradialis preserving the distal branches of the radial nerve. The lateral intermuscular septum is identified, and the flap is raised from distal to proximal following the course of the vascular pedicle to the antecubital fossa. Small branches from the pedicle are isolated and taken along the way with bipolar cautery and/or small vascular clips. The ulnar artery is identified and preserved and a common radial vein isolated where possible and the tourniquet lowered and hemostasis obtained using bipolar cautery and clips on the pedicle. The vascularity of the thumb and forefingers should be assessed prior to dividing the pedicle. The flap is transferred to the recipient site for inset. Total ischemia time should be less than 6 hours for optimum flap survival.

The distal forearm defect can be closed in a number of ways. A split-thickness skin graft harvested from the forearm prior to raising the graft or from the lateral thigh is pie crusted and inset into the donor site defect. This is typically held in position with absorbable suture. The skin graft site is bolstered into place with a nonadherent dressing and the forearm splinted with the wrist slightly extended for 5 days. This improves survival of the split-thickness skin graft by limiting movement between the skin graft and the underlying muscles and tendons. Other options for repair of the distal forearm defect have been described. These include cadaveric skin grafting or placement of a skin graft with a negative pressure dressing to improve take rate. The advantage of a negative pressure dressing is elimination of a splint, which allows better postoperative monitoring of the distal extremity; however, it is associated with significantly higher costs. The negative pressure dressing is typically left in place for 3 to 5 days. Take rates are relatively equivalent, although significant contracture of the wound can occur with the negative pressure dressing resulting in overall improved appearance.

The recipient site is prepared, and the flap is transferred to the floor of the mouth. The harvested forearm tissue is arranged in a manner so as to fully fill the defect and inset is begun. The flap is sutured to the mucosa of the oral cavity with interrupted Vicryl suture using great effort to provide a watertight seal. If no mucosa remains on the surface of the mandible, suture can be placed around the base of the remaining teeth or small holes can be drilled directly into the mandible to hold the flap securely in place.

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