What is the expected appearance of a radial forearm free flap used for mandibular reconstruction after oral cancer surgery during healing?

Expected Appearance of a Radial Forearm Free Flap in Mandibular Reconstruction During Healing

A radial forearm free flap used for mandibular reconstruction after oral cancer surgery should initially appear pink to slightly pale with good capillary refill, progressively developing a color match closer to surrounding oral mucosa over weeks to months, while the donor site on the forearm heals with skin graft coverage showing gradual re-epithelialization and color stabilization.

Initial Post-Operative Appearance (Days 0-7)

Recipient Site (Mandible/Oral Cavity)

• The flap should appear pink with brisk capillary refill immediately after surgery, indicating adequate arterial inflow and venous drainage 1
• Slight pallor or mild venous congestion may occur transiently but should resolve within 24-48 hours as the microvascular anastomoses stabilize 1
• The flap will be edematous initially, which is a normal inflammatory response to surgical manipulation and will gradually decrease over the first week 1
• Monitor for signs of flap compromise: dusky blue-purple color (venous congestion), white/pale appearance (arterial insufficiency), or lack of capillary refill warrant immediate surgical re-exploration 1

Donor Site (Forearm)

• The forearm donor site will be covered with either a full-thickness or split-thickness skin graft, appearing as a flat, adherent patch over the defect 2, 3
• Initial graft appearance shows a pale yellow-white color as the graft relies on plasma imbibition for the first 48-72 hours 2
• By days 3-5, the graft should develop a pink hue indicating successful neovascularization (inosculation) from the recipient bed 2

Early Healing Phase (Weeks 1-4)

Recipient Site

• The flap tissue should maintain consistent pink coloration and begin to integrate with surrounding oral mucosa 1
• Suture lines will show granulation tissue formation and early epithelialization along the margins 1
• The flap may appear slightly thicker than surrounding tissue initially due to persistent edema, which gradually resolves over 2-4 weeks 1
• Saliva exposure is normal and expected; the flap adapts to the oral environment without requiring special moisture management 1

Donor Site

• Skin graft take should be evident by 7 days, with adherent graft tissue and no fluid collections underneath 2
• The graft will appear pink to red as neovascularization completes 2
• Partial graft loss may occur in small areas (typically <10% of graft surface) but is usually negligible and heals by secondary intention 2
• Bolster dressings are typically removed at 5-7 days, revealing the grafted surface 3

Intermediate Healing Phase (Weeks 4-12)

Recipient Site

• The flap should now closely match the color of adjacent oral mucosa, though it may remain slightly paler or pinker depending on individual healing 1
• Flap contour should be smooth without significant bulging or depression once edema fully resolves 1
• The flap surface should be moist and pliable, similar to normal oral lining 1
• Sensation will be absent or significantly diminished in the flap itself, as it is a free tissue transfer without sensory nerve coaptation in most cases 1

Donor Site

• The skin graft should be fully healed and stable by 4-6 weeks 2
• Color will gradually lighten from bright pink to a more normal skin tone, though it typically remains slightly different from surrounding forearm skin 3, 4
• The graft surface may appear slightly shiny or have a different texture compared to native forearm skin 3
• No significant contour deformity, depression, or contracture should be present if proper grafting technique was used 5

Long-Term Appearance (Months 3-12+)

Recipient Site

• The flap should be indistinguishable from surrounding oral mucosa in color and texture in most patients 1
• Flap thickness should match adjacent tissue, providing good contour for mandibular reconstruction 1
• The flap remains hairless and pliable, which is a key advantage of the radial forearm donor site 1
• No ulceration, chronic inflammation, or tissue breakdown should occur in a successfully healed flap 1

Donor Site

• Final scar appearance shows a flat, well-healed graft site with color similar to surrounding forearm skin 3, 4
• Full range of motion at the wrist and elbow should be preserved without contracture 5
• The aesthetic outcome is generally acceptable, particularly when full-thickness grafts or modified closure techniques are used 3, 4

Red Flags Requiring Immediate Evaluation

• Sudden color change to dusky blue, purple, or white in the first 72 hours indicates vascular compromise requiring urgent surgical exploration 1
• Progressive darkening or black eschar formation suggests flap necrosis 1
• Purulent drainage, foul odor, or systemic fever may indicate infection requiring cultures and antimicrobial therapy 6
• Exposed bone or hardware through the flap indicates flap failure or inadequate soft tissue coverage 6
• Persistent pain beyond expected post-operative discomfort may signal ischemia or infection 7

Common Pitfalls to Avoid

• Do not mistake normal post-operative edema for flap failure; edema is expected and resolves gradually over weeks 1
• Avoid aggressive debridement of the flap surface unless there is clear necrotic tissue, as overly aggressive removal of viable tissue worsens outcomes 8, 6
• Do not delay evaluation of color changes; vascular compromise requires intervention within hours, not days 1
• Ensure adequate monitoring in the first 48-72 hours, as this is the highest-risk period for microvascular thrombosis 1