Cautionary case for radial forearm free flap use in trisomy 21

The radial forearm free flap (RFFF) is considered a workhorse for head and neck cancer reconstructive surgery due to its generally consistent anatomy, pliability, long pedicle, and accessible harvest location.

A 63-year-old male with trisomy 21 and recurrent midface basal cell carcinoma presented for surgical management. The patient underwent tumor resection including left infrastructure maxillectomy with ipsilateral rhinectomy. Preoperative Allen's test was normal; however, the planned osteocutaneous radial forearm free flap reconstruction was aborted intraoperatively due to aberrant vascular anatomy in the form of a diminutive radial artery branch. Reconstruction was instead performed with an anterolateral thigh free flap.

The patient recovered well in the hospital and was subsequently discharged to his care facility.

Radial artery anomalies may be present among trisomy 21 patients making reconstruction with a RFFF not feasible, and thus preoperative Doppler ultrasound to assess arterial anatomy is essential in this population.