OPERATIVE TECHNIQUES IN RECONSTRUCTION WITH THE LATERAL ARM FREE FLAP

DAVID J. ARNOLD, MD, EJ. CIVANTOS, JR., MD

The lateral arm provides a unique tool for reconstructive composite oropharyngeal defects. Herein are provided guidelines for use and techniques of harvest for this flap.

Major advances in surgical options for reconstruction of defects created by ablation of cancers of the head and neck over the past 20 years allow today's ablative and reconstruc- tive surgeons a wide range of choices in the treatment of patients with large defects. The lateral arm free flap (LAFF), first described by Song in 1982,1 is a very versatile tool that provides a unique piece of soft tissue, also allowing possibilities for an osteocutaneous and osteofascio- cutaneous flap. Techniques for raising and using this flap are reviewed herein.

The lateral arm free flap fills a unique void in the head and neck reconstructive surgeon's armamentarium. Oro- pharyngeal (especially tongue base/lateral pharyngeal wall) defects often require reconstructive tissue of variable thickness. The tongue base is best reconstructed with a flap capable of providing bulk. Pharyngeal defects are best replaced with thinner tissue. Many oropharyngeal defects involve both of these anatomic zones and, therefore, present a significant challenge. The lateral arm flap pro- vides an excellent composite with the tissue above the lateral epicondyle providing bulk and that below the epicondyle providing thin sculptable material. It is also possible to harvest one component independent of the other.

The LAFF is particularly well suited for oropharyngeal reconstruction because of its ability to be used as a sensate flap, thereby providing an advantage for rehabilitating swallowing function over nonsensate flaps. The posterior cutaneous nerve of the arm (Fig 1) can be anastamosed to a suitable sensory nerve in the defect. Similarly, Katsaros 2 has described the use of the posterior cutaneous nerve of the forearm as a vascularized nerve graft for facial nerve reconstruction.

The vascular anatomy of the LAFF (Fig 2) provides it with another unique advantage because no vessel that is potentially crucial to distal arm circulation is affected by harvesting the flap. Blood supply to the flap is provided by the profunda brachii artery, which is the largest branch of the brachial artery. This artery spirals around the humerus from medial to lateral as it proceeds distally and has an average diameter of 2.45 ram. It branches into the radial

From the Division of Head and Neck Surgery, Department of Otolaryn- gology, University of Miami School of Medicine, Miami, FL.

Please address reprint requests to D.J. Arnold, MD, PO Box 16960, Miami, FL 33101-6960.

Copyright © 2000 by W.B. Saunders Company 1043-1810/00/1103-0008510.00 doi: 10.1053/otot.2000.18566

collateral artery (which runs with the radial nerve) and the middle collateral artery, which anastamoses with the recur- rent interosseous artery. This complex but relatively large bore system of arteries allows for the design of the LAFF as a flow-through flap.

The venous system is redundant in that it has both superficial and deep components. The superficial consists of the cephalic vein. The deep component has 2 vena comitantes that, when followed proximally, often converge as a single vessel.

The donor site characteristics of the LAFF are particu- larly attractive because there is relatively little morbidity caused by raising the flap. The donor site can be designed to allow harvest of up to one third of the circumference of the arm while still allowing primary closure. Further tissue can be harvested by using a split thickness skin graft for coverage.

The LAFF can also be designed to include up to 10 cm × 1 cm x 1 cm of bone from the humerus. Although useful for mandibular and midface reconstruction, there is not

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FIGURE 1. Muscular and neurovascular anatomy of the lateral arm free flap.

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 11, NO 3 (SEPT), 2000: PP 193-194 193

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FIGURE 2. Cross- sectional anatomy of the upper arm with corresponding view of the partially raised lateral arm free flap.

sufficient bone stock to reliably allow placing implants for dental rehabilitation. Addit ional bulk can be provided by harvest ing muscle wi th the flap. If vascularized connective tissue is useful, part of the triceps tendon can be harvested with the flap.

Harves t of the flap can be accomplished by a reconstruc- tive team (usually in approximately 2½ hours) while a second team resects the tumor. The nondominan t arm is favored for harvest. A tourniquet is not used. Doppler u l t rasonography is used to confirm that vessels of the pedicle are included in the flap. Addit ional pedicle length can be gained by shifting the p lanned skin paddle more distally on the forearm as well as by incising the distal insertion of the deltoid muscle to allow maximal dissection of the pedicle to its take-off f rom the brachial vessels. The flap can include soft tissue 6 to 10 cm distal to the lateral epicondyle. 3 Once skin incisions are made, the flap is raised off the antebrachial fascia distal to the lateral epicondyle. Dissection identifies the radial nerve as it runs be tween the brachialis and brachioradialis muscles. The vessels that form the pedicle are then dissected free of the nerve as it courses th roughout the radial groove. As the dissection proceeds, port ions of the triceps muscle, triceps

tendon, and humerus (fed by perforators that branch from the pedicle) can be included in the flap.

C O N C L U S I O N

The LAFF is an extremely versatile flap that can be adapted to include composite tissues. It can be harvested simulta- neously with tumor ablation and causes very little donor site morbidity. These attributes, as well as its unique soft-tissue profile, make the LAFF a workhorse for head and neck and especially oropharyngeal reconstruction.

R E F E R E N C E S

1. Song R, Song Y, Yu Y: The upper arm free flap. Clin Plast Surg 9:27-35, 1982

2. Civantos FJ, Burkey B, Lu FL, et al: Lateral arm microvascular flap reconstruction in head and neck reconstruction. Arch Otolaryngol Head Neck Surg 123:830-836,1997

3. Katsaros J, Schusterman M, Beppu M, et al: The lateral arm flap: Anatomy and clinical applications. Ann Plast Surg 12:489-500, 1984

4. Urken ML, Cheney ML, Sullivan MJ, et al: Atlas of Regional and Free Flaps For Head and Neck Reconstruction, New York, NY, Raven Press, 1985.

194 THE LATERAL ARM FREE FLAP IN OROPHARYNGEAL RECONSTRUCTION