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Radial Free Forearm Flap-Intraoperative Dilemma Caused by the Unusual Branching of the Radial Artery

Shivakumar Thiagarajan* and Harsh Dhar
Department of Head & Neck Surgical Oncology, Tata Memorial Hospital, India


*Corresponding author: Shivakumar Thiagarajan, Department of Head & Neck Surgical Oncology, Tata Memorial Hospital, 1209, Homi Bhabha Block, Parel, Mumbai-400088, India


Published: 18 Dec, 2017
Cite this article as: Thiagarajan S, Dhar H. Radial Free Forearm Flap-Intraoperative Dilemma Caused by the Unusual Branching of the Radial Artery. Clin Surg. 2017; 2: 1823.

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We would like to share our experience of an unusual finding that we encountered while harvesting Radial Free Forearm Flap (RFFF) on two occasions. This was seen only twice in our series of over 150 RFFF, done between March 2010 to June 2017 for reconstructing various head and neck defects. Both the patients had oral squamous cell carcinoma; one on the buccal mucosa (Figure 1) and the other on the left lateral border tongue. On both occasions RFFF from the left side was used for reconstructing the defect. Allen’s test was done in both cases preoperatively (both clinical & radiological-with Ultrasound Doppler) to confirm adequate blood supply across the palmar arch, with the radial artery compressed & ulnar artery released. No other unusual findings were documented on the ultrasound Doppler. In case 1 two arteries, with accompanying venue committees were identified between the Flexor Carpi Radialis (FCR) and Brachio Radialis (BR) (Figure 1 and 2). One of the arteries was of a smaller caliber in comparison to the other. The palmaris long us tendon was present in its usual location. The dilemma now was whether it was an unusual branching of the radial artery or an anomalous ulnar artery and weather this artery could be sacrificed to complete the harvest without compromising the vascularity of the hand. To clear the dilemma, Ackland’s vascular clamp was applied on both the arteries and the tourniquet was deflated. The adequacy of blood supply to the hand after applying the clamp was confirmed. The vessel was then divided and the flap harvested. The course of radial artery in the forearm was normal, with no other anomalous findings. After the harvest, the flap was inspected and it was seen that the smaller caliber vessel was in fact a branch underneath the flap, from the main vessel beyond the flap (Figure 3), as seen in case 2 (Figure 3). In case 2: The radial artery was clearly seen branching as it was identified between the FCR and BR. There were no venue committees accompanying the branch, as was seen in case 1 (Figure 3). Hence the vessel was divided and flap harvested. Anomalies of the radial artery are uncommon [1]. Reports appear in literature about certain variations, such as high origin of radial artery, superficial course of dorsal ante brachial artery and duplication of radial artery. There is a case report of Accessory branch of the radial artery at level of mid forearm extending laterally subcutaneously into dorsal wrist [2]. But no reports of branching of radial artery have been reported as described our two cases. This is the first report of radial artery branching before its entry into the wrist.

Figure 1

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Figure 1
Case.1- Radial artery with the branch, note the accompanying vena committees of both the vessels.

Figure 2 and 3

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2 and 3
Case.2- Branch from the radial artery clearly seen

References

  1. Bhatt V, Green J, Grew N. Dealing with aberrant vessels in radial forearm flaps - Report of a case and review of literature. J Craniomaxillofac Surg. 2009;37(2):87-90.
  2. Acarturk TO, Newton ED. Aberrant branch of the radial artery encountered during elevation of the radial forearm free flap. J Reconstr Microsurg. 2004;20(8):611-4.