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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Versatility of Radial Forearm Free Flap in Reconstruction of Different Defects: A Cross-sectional Study
Correspondence Address :
Rojalin Mishra,
Flat No. 308/B, Royal Residency, Cantonment Road, Buxi Bazar, Cuttack-753001, Odisha, India.
E-mail: rosalinmishra8@gmail.com
Introduction: The Radial Forearm Free Flap (RFFF) is a commonly used flap for soft tissue reconstruction, offering several advantages despite sacrificing the radial artery in the forearm. Understanding the anatomy of radial artery perforators, including their distribution, territory, and flow is crucial for reliable and safe flap harvest and design.
Aim: To describe the versatility and applications of RFFF in reconstructing defects in various body parts.
Materials and Methods: This cross-sectional study was conducted in the Department of Plastic and Reconstructive Surgery at SCB Medical College and Hospital, Cuttack, between January 2019 and January 2021, on 39 cases (age group: 20-70 years) who underwent RFFF. RFFF was utilised for reconstruction of the lip, palate, buccal mucosa, tongue, foot, nose, and phallus. Preoperative evaluation included assessing the vascular status of the non dominant hand using the Allen’s test.
Results: RFFF was used for postcancer resection reconstruction in 11 cases of buccal mucosa (28.2%), 7 cases of the lip (17.9%), 6 cases of the tongue (15.3%), 2 cases of the palate (5.1%), 2 cases of phallus reconstruction (5.1%), 1 case of post-traumatic nose defect, and 1 case of 1st web space of the hand (2.5%). In 26 cases of postcarcinoma resection reconstruction, RFFF was used for buccal mucosa, lip, tongue, and palate. The patients were followed-up for 2-8 months.
Conclusion: RFFF fulfills most of the anatomical prerequisites for an ideal flap, providing a microvascular reconstructive option for patients with large defects in the head and neck, foot and ankle, and phallus. It exhibits a high success rate, good aesthetic and functional outcomes, allowing for the reconstruction of various defects. This study confirms the reliability of the radial free flap as a method for reconstructive surgery.
Buccal mucosa, Phallus, Resection, Vascular
The Radial Forearm Free Flap (RFFF), often referred to as the Chinese flap, was initially introduced as a free flap by Yang and Gao in 1981 (1). Lu and Biemer later reintroduced it as a pedicle flap based on retrograde flow (2). Refinements in the vascular anatomy have increased the reliability and applicability of this flap for reconstructing defects in various parts of the body. The forearm flap, known for its thin, pliable, and hairless skin, consistent vascular anatomy, and acceptable donor site morbidity, is frequently used for free tissue transfers (1),(2). It is commonly employed as a fasciocutaneous flap for reconstructing defects in the head, neck, and limbs. RFFF is considered a primary reconstructive strategy in challenging defects involving the lip, buccal mucosa, cheek, extremities, and phallus. Microvascular free flaps have evolved significantly since the reconstruction of a dorsal ankle defect using a groin flap in 1973 (3).
RFFF is applied for oral cavity reconstruction (tongue, lip, palate) as well as foot, ankle, and phallus reconstruction. An osteocutaneous flap can be raised by including the bony segment of the radius. Before harvesting the RFFF, confirmation of the patency of the palmar arch through Allen tests or angiography is crucial (4), as the radial side fingers rely on blood supply from the ulnar artery through the palmar arch after the flap is harvested. In head and neck reconstruction, the RFFF offers various options due to its low flap loss and complication rates, making it an excellent choice for oral lining restoration when bulk is not required (5).
Phallic reconstruction is a complex procedure requiring a multidisciplinary approach, and the RFFF is considered the gold standard for phallus reconstruction. The flap is versatile, reliable, and offers large vessels suitable for anastomosis, while also being relatively hairless (6). For foot reconstruction, the RFFF meets most of the anatomical prerequisites for an ideal foot flap, providing a normal foot contour, durable weight-bearing surface, and excellent aesthetic results. The radial artery, with a typical pedicle length of about 18 cm and lumen width of approximately 3 mm, is suitable for microanastomosis in the head and neck region with facial, superior thyroidal, and superficial temporal arteries (7). The cephalic vein is commonly used for venous drainage of the RFFF.
Although less commonly used than the RFFF, the Ulnar Forearm Free Flap (UFFF) has seen an increase in usage in recent years. However, limitations such as operator-dependent factors, limited knowledge of deep forearm muscle anatomy, and the risk of ulnar nerve damage in close proximity to the ulnar vessels contribute to its lesser utilisation (8),(9). Previous literature has focused on the use of RFFF for specific regions of the body, such as the head and neck, tongue, or limbs individually. This study was conducted with the aim to demonstrate the versatility of RFFF in reconstructing defects in nearly all regions of the body, including buccal mucosa, lip, tongue, palate, phallus, and foot defects. The study highlights the potential of RFFF as a solution for defects arising from different regions of the body.
This cross-sectional study was conducted in the Department of Plastic and Reconstructive Surgery at SCB Medical College and Hospital, Cuttack, between January 2019 and January 2021, and included 39 cases of RFFF, following clearance from the Institutional Ethical Committee (IEC number 137/7.2.2020). The surgeries were performed from January 2019 to 2020, and the follow-up period was from February 2020 to January 2021. Informed consent was obtained from all patients. As this was a time-bound study, all patients who visited the hospital for reconstructive surgery during the study duration were included, resulting in a total of 39 cases of RFFF included in the study.
Inclusion criteria:
- Patients aged between 20 and 70 years.
- Patients with stage I-III buccal mucosa, lip, and tongue carcinoma.
- Patients with traumatic amputation of the phallus.
- Patients with post-traumatic nose defects.
Exclusion criteria:
- Patients aged below 20 years or above 70 years.
- Patients with co-morbidities such as uncontrolled diabetes mellitus, chronic end-stage renal disease, or sepsis.
Study Procedure
RFFF was utilised for the reconstruction of various areas including the lip, palate, buccal mucosa, tongue, foot, nose, and phallus. Preoperative evaluation involved assessing the vascular status of the non dominant hand using the Allen’s test. The patient was instructed to tightly clench their fist for one minute, and pressure was applied to occlude the radial and ulnar arteries. The patient was then asked to open their fingers, and the radial artery was released to observe the vascularity of the fingers. The same procedure was repeated for the ulnar artery. This test helped to determine the patency of the palmar arch and the dominant vessel of the hand (7).
The RFFF was harvested by elevating the flap towards the flexor carpi radialis in an ulnar to radial direction, superficial to the muscular fascia. The flap was elevated until the brachioradialis tendon was encountered, while preserving the cephalic vein and the superficial branch of the radial nerve. Distally, the radial artery was ligated and divided along with the venae commitantes. The proximal aspect of the skin paddle was focused on, and the skin overlying the cephalic vein was incised proximally to the antecubital fossa. The skin flap was then elevated off the flexor carpi radialis and brachioradialis, while preserving the cutaneous perforator to the flap. Finally, the flap was raised with its vascular pedicle from distal to proximal by elevating the radial artery and venae commitantes. The tourniquet was released, haemostasis was achieved, and the pedicle was divided. After the flap harvest, the donor site was closed with a split-thickness skin graft from the thigh (1).
Statistical Analysis
Descriptive statistics was used for the analysis of data.
A total of 39 patients underwent RFFF, with age group ranging from 20 to 70 years. Of these, 23 (58.9%) were males and 16 (41.1%) were females. The minimum duration of surgery was 170 minutes, while the maximum duration was 380 minutes (Table/Fig 1).
In cases of postcancer resection reconstruction, RFFF was used for buccal mucosa (11 cases, 28.2%), lip (7 cases, 17.9%), tongue (6 cases, 15.3%), and palate (2 cases, 5.1%) (Table/Fig 2)a-c,(Table/Fig 3)a-c.
In cases of post-traumatic reconstruction, RFFF was utilised for foot defects (9 cases, 23.1%), phallus reconstruction (2 cases, 5.1%), reconstruction of post-traumatic nose defects (1 case, 2.5%), and reconstruction of the 1st web space of the hand (1 case, 2.5%).
The patients were followed-up for a period of 6 months. Out of the 39 patients, 26 did not experience any complications, while five patients were lost to follow-up. Of which, three cases had complete flap loss, with two cases due to radial artery thrombosis and one case due to venous thrombosis. The two cases of radial artery thrombosis were managed by re-exploration and reanastomosis, while the case of venous congestion was managed by re-exploration and venous anastomosis. One case with buccal mucosa defect underwent reconstruction using the Pectoralis Major Myocutaneous Flap (PMMC) due to flap loss (Table/Fig 4)a-c,(Table/Fig 5)a-c,(Table/Fig 6)a-c.
Among the nine cases of foot defects managed with RFFF, two cases had complications and were managed with negative pressure wound therapy followed by reverse sural flap and Split Thickness Skin Grafting (SSG). Two cases experienced superficial marginal flap necrosis, which was debrided followed by SSG. Donor site complications included partial skin graft loss in two cases with tendon exposure, which was managed with SSG. Urethral complications occurred in two cases after three months, with one case developing a urethrocutaneous fistula repaired with excision and secondary suturing, and another case developing a urethral stricture managed by visual internal urethrotomy with the help of a urologist.
Each anatomic region of the body has distinguishing characteristics. The dorsum of the foot and ankle require thin, pliable soft tissue to cover exposed tendons without paratenon, bone, or joints. The Radial Forearm Free Flap (RFFF) is effective in restoring function and appearance for patients with soft tissue intraoral defects after tumour ablation surgery (10),(11),(12),(13),(14). The RFFF offers advantages such as ease of flap elevation, large vessel diameter, longer pedicle, pliability, mobility, and thinness, making it ideal for buccal reconstruction. Additionally, the RFFF can be folded, further enhancing its versatility.
In this study, two-folded free radial forearm flaps were used to repair full-thickness defects, resulting in satisfactory open-mouth width (15). The success rate for buccal mucosa reconstruction with RFFF was 82%, with only 2 out of 11 cases experiencing complications. Previous studies have reported even higher success rates, emphasising the reliability of RFFF for treating buccal defects (16),(17),(18). RFFF is also suitable for intraoral reconstruction, such as defects following hemi-glossectomy. In this study, a 100% success rate was achieved with RFFF reconstruction in the tongue region, without any complications. Other studies have reported more than 90% flap survival rate for intraoral reconstruction with RFFF (19). Its ability to offer less resistance to intraoral movements and avoid hindering muscular hypertrophy of the remnant tongue musculature makes it a preferred option (5).
The weight-bearing surface of the foot presents a challenging reconstructive scenario due to the high pressure it endures. In this study, RFFF was used in nine cases of foot reconstruction, seven of which were in the weight-bearing region. The success rate for these cases was 77%, with two flaps being completely lost. Similar success rates have been reported in previous studies (20),(21). RFFF has also shown positive outcomes in resurfacing the forefoot, weight-bearing surfaces, moderate-sized defects, and osteomyelitic wounds.
Phallic reconstruction is a complex procedure, and RFFF is considered the gold standard for modern phallic reconstruction. It offers versatility, dependability, and large vessels that are easy to anastomose. In this study, RFFF was used for two cases of phallus reconstruction, with one case presenting a urethral complication after three months, which was managed surgically (22). Donor site morbidity can occur due to partial loss of the skin graft over the tendons, leading to tendon exposure, adhesions, and delayed healing.
The advantages of RFFF include adequate venous drainage, a long vascular pedicle, large luminal diameter at the elbow facilitating high volume blood flow, and relative ease of anastomosis. The thin, pliable, and malleable flap offers multiple options for covering three-dimensional defects easily, including the ability to rotate the flap on itself for insetting. These characteristics make RFFF a versatile flap (1).
(Table/Fig 7) provides a comparative analysis of the present study findings with past data from other studies (17),(19),(21),(23).
Limitation(s)
The present was a single centre study and five patients lost to follow-up. Also, the sample size was not statistically calculated due to the study time-bound nature, and all patients who visited during the study duration for reconstructive surgery were included.
Radial forearm tissue transfer provides a rapid and versatile microvascular reconstructive option for patients with defects in the head and neck (lip, buccal mucosa, tongue, and palate), phallus, and foot. It is accessible, has reliable anatomy, and is easy to harvest, resulting in excellent aesthetic outcomes with minimal complications and donor site morbidity. These flap characteristics make radial forearm tissue transfer a pivotal flap in microvascular reconstruction.
This study revealed that the radial free flap is a reliable method for reconstructing defects in any anatomical region of the body. It is not restricted to any specific region and provides excellent outcomes with less technical demands compared to microsurgical tissue transfer. Therefore, radial forearm free flap surgery is an incredibly versatile option, especially when performed by an experienced microvascular surgeon.
DOI: 10.7860/JCDR/2023/58451.18565
Date of Submission: Jun 14, 2023
Date of Peer Review: Jun 28, 2023
Date of Acceptance: Aug 17, 2023
Date of Publishing: Oct 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jun 18, 2023
• Manual Googling: Jul 14, 2023
• iThenticate Software: Aug 15, 2023 (14%)
ETYMOLOGY: Author Origin
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