Plastic Surgery and Flap Graft Management of Radial Forearm, VRAM, and TRAM Flaps in Critically Ill Cancer Patients

  • Jason Silva
  • Amy Jackson
  • Justin Broyles
Reference work entry


Cancer is prevalent in society. Many oncological surgeries result in a tissue defect. Reconstructive surgery to restore the function and shape of the resected tissue is often required. The radial forearm free flap, vertical rectus abdominis myocutaneous flap, and transverse rectus abdominis myocutaneous flap are commonly used for oncological reconstruction surgery. Free flaps are particularly vulnerable to prolonged ischemia. Most flap complications to flaps occur in the first 3 day postoperatively. Monitoring of the flap is critically important. Physical assessment of the flap site should include: capillary refill, skin color, temperature, and turgor, and presence of arterial blood flow by Doppler will identify changes in tissue perfusion. Measures should be taken to ensure adequate perfusion pressure to the surgical flap. Reconstructive surgeries with free flaps have success rates of 91–99%.


Free tissue transfer Flap checks Free flap Radial forearm VRAM TRAM Complications Postoperative Microvascular Cancer 


  1. 1.
    American Society of Plastic Surgeons (ASPS). 2017 plastic surgery statistics report. 2018. Retrieved from
  2. 2.
    Brodbeck R, Horch RE, Arkudas A, Beier JP. Plastic and reconstructive surgery in the treatment of oncological perineal and genital defects. Front Oncol. 2015;5(212):1–8.Google Scholar
  3. 3.
    Chang DW, Reece GP, Wang B, Robb GL, Miller MJ, Evans GRD, Langstein HN, Kroll SS. Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction. Plast Reconstr Surg. 2000a;105(7):2374–80.CrossRefGoogle Scholar
  4. 4.
    Chang DW, Wang B, Robb GL, Reece GP, Miller MJ, Evans GRD, Langstein HN, Kroll SS. Effect of obesity on flap and donor-site complications in free transverse rectus abdominis myocutaneous flap breast reconstruction. Plast Reconstr Surg. 2000b;105(5):1640–8.CrossRefGoogle Scholar
  5. 5.
    Chao AH, Lamp S. Current approaches to free flap monitoring. Plast Surg Nurs. 2014;34(2):52–6.CrossRefGoogle Scholar
  6. 6.
    Chao AH, Meyerson J, Povoski SP, Kocak E. A review of devices used in the monitoring of microvascular free tissue transfers. Expert Rev Med Devices. 2013;10(5):649–60.CrossRefGoogle Scholar
  7. 7.
    Gardiner MD, Nanchahal J. Strategies to ensure success of microvascular free tissue transfer. J Plast Reconstr Aesthet Surg. 2010;63(9):665–73.CrossRefGoogle Scholar
  8. 8.
    Hanasono M, Butler C. Prevention and treatment of thrombosis in microvascular surgery. J Reconstr Microsurg. 2008;24(5):305–14.CrossRefGoogle Scholar
  9. 9.
    Lee B, Agarwal J, Ascherman J, Caterson S, Gray D, Hollenbeck S, Khan S, Loeding L, Mahabir R, Miller A, Perdikis G, Schwartz J, Sieling B, Thoma A, Wolfman J, Wright J. Evidence-based clinical practice guideline: autologous breast reconstruction with DIEP or pedicled TRAM abdominal flaps. Plast Reconstr Surg. 2017;140(5):651–64.CrossRefGoogle Scholar
  10. 10.
    Motakef S, Mountziaris PM, Ismail IK, Agag RL, Patel A. Emerging paradigms in perioperative management for microsurgical free tissue transfer: review of the literature and evidence-based guidelines. Plast Reconstr Surg. 2015;135(1):290–9.CrossRefGoogle Scholar
  11. 11.
    Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects. Plast Reconstr Surg. 2009;123(1):175–83.CrossRefGoogle Scholar
  12. 12.
    Nimalan N, Branford O, Stocks G. Anaesthesia for free flap breast reconstruction. BJA Educ. 2016;16(5):162–6.CrossRefGoogle Scholar
  13. 13.
    Quinlan J. Anaesthesia for reconstructive surgery. Anaesth Intensive Care Med. 2006;7(1):31–5.CrossRefGoogle Scholar
  14. 14.
    Roehl KR, Mahabir RC. A practical guide to free tissue transfer. Plast Reconstr Surg. 2013;132(1):147–58.CrossRefGoogle Scholar
  15. 15.
    Saint-Cyr M, Wong C, Buchel EW, Colohan S, Pederson WC. Free tissue transfers and replantation. Plast Reconstr Surg. 2012;130(6):858–78.CrossRefGoogle Scholar
  16. 16.
    Touny A, Othman H, Maamoon S, Ramzy S, Elmarakby H. Perineal reconstruction using pedicled vertical rectus abdominis myocutaneous flap (VRAM): perineal reconstruction using VRAM flap. J Surg Oncol. 2014;110(6):752–7.CrossRefGoogle Scholar
  17. 17.
    Villaret DB, Futran NA. The indications and outcomes in the use of osteocutaneous radial forearm free flap. Head Neck. 2003;25(6):475–81.CrossRefGoogle Scholar
  18. 18.
    Wong AK, Joanna Nguyen T, Peric M, Shahabi A, Vidar EN, Hwang BH, Niknam Leilabadi S, Chan LS, Urata MM. Analysis of risk factors associated with microvascular free flap failure using a multi-institutional database. Microsurgery. 2015;35(1):6–12.CrossRefGoogle Scholar
  19. 19.
    Zoccali G, Molina A, Farhadi J. Is long-term postoperative monitoring of microsurgical flaps still necessary? J Plast Reconstr Aesthet Surg. 2017;70:996–1000.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Jason Silva
    • 1
  • Amy Jackson
    • 1
  • Justin Broyles
    • 1
  1. 1.The University of Texas MD Anderson Cancer CenterHoustonUSA

Section editors and affiliations

  • Garry Brydges
    • 1
  1. 1.Department of Anesthesiology Division of Anesthesia, Critical Care and Pain MedicineThe University of Texas MD Anderson Cancer CenterHoustonUSA

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