Revisiting the Lateral Arm Free Flap for Oral Defects: A Case Series on Flap Viability and Primary Donor Site Closure.

Revisiting the Lateral Arm Free Flap for Oral Defects: A Case Series on Flap Viability and Primary Donor Site Closure. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Revisiting the Lateral Arm Free Flap for Oral Defects: A Case Series on Flap Viability and Primary Donor Site Closure. 1. Salah El-Dein Gaber Shaltout, 2. Ayman Abdelwehab Amin, 3. Mohamed Hamdallah Hafez Zedan, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9125548/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background: The reconstruction of complex oral cavity defects following oncologic resection requires versatile soft tissue flaps. While the Radial Forearm Free Flap (RFFF) is a standard option, it is associated with conspicuous donor site morbidity. This study evaluates the efficacy, functional outcomes, and donor site morbidity of the Lateral Arm Free Flap (LAF) in head and neck reconstruction. Methods: A prospective case series was conducted from June 2022 to June 2024 at the National Cancer Institute (Cairo University) and Assiut University Hospitals. Twelve patients with medium-sized soft-tissue defects (tongue, cheek, floor of the mouth) underwent reconstruction with LAF. Parameters assessed included flap viability, operative time, donor site closure (primary vs. secondary), and postoperative complications. Results: The study included 12 patients (7 females, 5 males) with a mean age of 57.5 years. The majority of defects were in the tongue (75%). The flap success rate was 91.7%, with one total flap loss, and the average flap harvesting time was 47.08 minutes. Primary closure of the donor site was achieved in 83.3% of cases. Complications included hypertrophic scarring (58.3%). Furthermore, 41.7% of patients developed sensory deficits (numbness/hypesthesia) due to division of the posterior cutaneous nerve of the forearm (PCNF), with no patients developing radial nerve injury or wrist weakness. Conclusions: The Lateral Arm Free Flap is a reliable alternative to the RFFF for small-to-medium oral defects. It offers the distinct advantage of primary donor site closure and adequate tissue bulk for glossectomy defects, though variable vessel caliber remains a technical consideration. Lateral arm flap Oral cancer Microvascular reconstruction Donor site morbidity Figures Figure 1 Figure 2 Figure 3 Figure 4 Background The excision of oral squamous cell carcinoma (OSCC) often results in composite defects requiring sophisticated reconstruction to restore speech, swallowing, and airway protection. While the Radial Forearm Free Flap (RFFF) has long been the "workhorse" for such defects due to its pliability and long pedicle, it necessitates sacrificing a major artery and often requires skin grafting at the donor site, leading to aesthetic and functional morbidity [ 1 ]. The Lateral Arm Free Flap (LAF), first described by Song in 1982, is a septocutaneous flap supplied by the posterior radial collateral artery (PRCA) [ 2 ]. It offers several theoretical advantages: it does not sacrifice a major dominant artery, provides variable tissue thickness suitable for "dead space" obliteration, and allows for primary closure of the donor site in defects less than 6–7 cm wide [ 3 ]. Despite these benefits, it remains underutilized compared to the RFFF and Anterolateral Thigh (ALT) flap. This study aims to evaluate the clinical reliability and donor site outcomes of the LAF in a cohort of Egyptian patients with oral malignancy. Methods Study Design and Setting This prospective case series was conducted between June 2022 and June 2024. Patients were recruited from the Surgical Oncology Department at the National Cancer Institute (NCI), Cairo University, and the Maxillofacial Unit at Assiut University Hospitals, Egypt [ 4 ]. Patient Selection Inclusion criteria comprised patients with histologically proven oral malignancy who required soft tissue reconstruction for medium-sized defects (tongue, floor of mouth, or buccal mucosa). Exclusion criteria included patients with defects small enough for direct closure, those medically unfit for prolonged general anesthesia, or those with distant metastasis. Surgical Technique Tumor excision was performed with safety margins and frozen section control. Neck dissection was performed (Levels I-V) as indicated by N-staging. The flap was designed on the distal lateral aspect of the arm. The axis extended from the deltoid insertion to the lateral epicondyle, corresponding to the lateral intermuscular septum. Flap width was limited to 6 cm to facilitate primary closure. A posterior incision was made first to identify the triceps muscle and the intermuscular septum. The PRCA and its perforators were identified. The radial nerve was visualized and preserved. The pedicle was traced proximally to the profunda brachii vessels to maximize length and caliber. Microvascular anastomosis was performed using the facial artery as the donor vessel in all cases. Venous drainage was established via the common facial vein or external jugular vein. Outcome Measures Data were collected on operative time, flap survival (total/partial necrosis), donor site closure method, and complications (infection, fistula, nerve injury). Results Demographics and Tumor Characteristics The study included 12 patients (5 males, 7 females) with a mean age of 57.5 years (range 45–70). Smoking was a risk factor in 58% of patients. The most common tumor site was the tongue (75%), followed by the cheek/retromolar trigone (17%) and floor of the mouth (8%). Histopathology revealed SCC Grade 2 in 58% of cases. Operative Data and Flap Survival The facial artery was used in 100% of cases. The common facial vein was the recipient vein in 58% of cases, while the external jugular vein was used in 42%. The overall success rate was 91.7%. Total flap loss occurred in one patient (8.3%) due to venous congestion leading to necrosis. Partial flap loss occurred in two patients (16.7%), which healed with conservative management. The average flap harvesting time was 47.08 minutes. Complications and Donor Site Morbidity Postoperative chest infection occurred in 50% of patients. An orocutaneous fistula developed in one patient (8.3%), necessitating pectoralis major flap salvage. Regarding the donor site, primary closure was achieved in 83.3% of patients. Secondary intention healing was required in 16.7%. Hypertrophic scarring was noted in 58.3% of patients. About 41.7% of patients developed sensory deficits as numbness due to division of the posterior cutaneous nerve of the forearm (PCNF) which resolved spontaneously with great success, and no patients developed radial nerve injury or wrist weakness. Discussion Reconstruction of the oral cavity aims to restore form and function with minimal morbidity. Our study confirms that the LAF is a versatile option for medium-sized defects, particularly glossectomy defects, where the flap's moderate bulk provides better mobility than the thicker ALT flap and more volume than the thin RFFF [ 4 ]. Flap Reliability Our flap survival rate of 91.7% is comparable to international standards for fasciocutaneous flaps [ 5 ]. The single total failure was attributed to venous thrombosis, highlighting the importance of meticulous dissection of the venae comitantes, which can be small in this region. Donor Site Advantage A major finding of this study is the high rate of primary donor site closure (83.3%). This contrasts sharply with the RFFF, which almost invariably requires a skin graft, leading to poor aesthetics and potential tendon exposure [ 6 ]. Although 58% of our patients developed hypertrophic scars, the linear scar on the lateral arm is generally more concealable than a radial forearm graft. Vascular Anatomy and Neurological Safety We used the facial artery and common facial vein for anastomosis in most cases. The LAF pedicle (PRCA) was found to be consistent, though shorter than the radial artery pedicle. Extending the dissection proximally to the profunda brachii provided sufficient length [ 7 ]. There was concern about sensory deficits, including numbness over the lateral elbow and forearm, following division of the posterior cutaneous nerve of the forearm (PCNF) without radial nerve injury. This supports the consensus that with careful identification of the nerve in the spiral groove, the flap is safe to harvest [ 8 ]. Conclusions The Lateral Arm Free Flap is a safe, effective, and reliable option for oral cavity reconstruction. It provides pliable, moderately thick tissue suitable for reconstruction of the tongue and floor of the mouth. Its primary advantage lies in its ability to close the donor site, avoiding the morbidity associated with the radial forearm flap. Declarations Ethics approval and consent to participate This study was performed in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board (IRB) / Research Ethics Committee of the Faculty of Medicine, Assiut University, prior to initiating this study, with the number ( 17200706). Written informed consent to participate in this study was obtained from all individual participants prior to their inclusion. Consent for publication Written informed consent for the publication of clinical details, outcomes, and accompanying clinical images was obtained from all patients. Conflict of interests The authors declare that they have no conflicts of interest. Funding The authors declare that no specific funding, grants, or financial support were received for the conceptualization, design, data collection, or publication of this research. Author Contribution Ayman A.Wahab and Mohamed Zedan conceptualized the study and performed the surgical procedures. Hasan M.Harby collected and analyzed the patient data. Hamdan S. Abbas drafted the initial manuscript. All authors reviewed the results, contributed to the final manuscript preparation, and read and approved the final submitted version. Acknowledgements The authors would like to thank the surgical oncology and maxillofacial nursing staff at the National Cancer Institute and Assiut University Hospitals for their assistance in perioperative patient care. Data Availability The datasets generated and/or analyzed during the current study are not publicly available due to patient privacy and confidentiality, but are available from the corresponding author on reasonable request. References Nabil S, Samman N (2012) The impact of case reports in oral and maxillofacial surgery. Int J Oral Maxillofac Surg 41:789–796 Song R, Song Y, Yu Y et al (1982) The upper arm free flap. Clin Plast Surg 9:27–35 Laskin DM (2011) Improving the dissemination of surgical knowledge. Ann Maxillofac Surg 1:1 Harby HM (2025) Lateral Arm Free Flap for Reconstruction of the oral cavity and head and neck soft tissue defects [Thesis]. Assiut University Katsaros J, Schusterman M, Beppu M et al (1984) The lateral upper arm flap: anatomy and clinical applications. Ann Plast Surg 12:489–500 Disa JJ, Cordeiro PG (1999) The lateral arm flap for head and neck reconstruction. Ann Plast Surg 42:490–498 Scheker LR, Kleinert HE, Hanel DP (1987) Lateral arm composite tissue transfer to ipsilateral hand defects. J Hand Surg Am 12:665–672 Graham B, Adkins P, Scheker LR (1993) Complications of the lateral arm flap. J Hand Surg Br 18:403–417 Tables Table 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files listofTables.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 16 May, 2026 Reviewers agreed at journal 16 May, 2026 Reviewers agreed at journal 09 Apr, 2026 Reviewers agreed at journal 04 Apr, 2026 Reviewers invited by journal 04 Apr, 2026 Editor assigned by journal 17 Mar, 2026 Submission checks completed at journal 17 Mar, 2026 First submitted to journal 14 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9125548","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":607147476,"identity":"6903f73a-a6aa-44fb-b538-d149aa0c3a11","order_by":0,"name":"1.\tSalah El-Dein Gaber Shaltout","email":"","orcid":"","institution":"Assiut University","correspondingAuthor":false,"prefix":"","firstName":"1.\tSalah","middleName":"El-Dein Gaber","lastName":"Shaltout","suffix":""},{"id":607147477,"identity":"ab9510e7-b64f-4360-90e9-504787be36d3","order_by":1,"name":"2.\tAyman Abdelwehab Amin","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"2.\tAyman","middleName":"Abdelwehab","lastName":"Amin","suffix":""},{"id":607147478,"identity":"90fab5ae-f5ab-4e5e-abac-a08bac261e55","order_by":2,"name":"3.\tMohamed Hamdallah Hafez Zedan","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"3.\tMohamed","middleName":"Hamdallah Hafez","lastName":"Zedan","suffix":""},{"id":607147479,"identity":"8768f59e-34a0-42de-97de-59b61add3d1f","order_by":3,"name":"4.\tHassan Mohamed Harby","email":"","orcid":"","institution":"Assiut University","correspondingAuthor":false,"prefix":"","firstName":"4.\tHassan","middleName":"Mohamed","lastName":"Harby","suffix":""},{"id":607147480,"identity":"99d60a09-a8b8-4a60-be67-00b695b40cdd","order_by":4,"name":"Hamdan Saadi Abbas","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYBACAyCWgDATGx9AGAnEa2k2IFVLAhuMgV+LOfvpxBs/d9TJ87cnt1X8bLvDwM+eY8Dw4RduLZY9uZste88cNpxx5mHbzd62ZwySPW8MGGf24XHYgdxtErxtBxgbbiS23eBtO8xgcCPHgJm3B4+W82+3Sf5tq7OfD9RS+BeoxR6k5S8+LTdyt0nztjEnbgBqYQbbIgHUwvADn5a3m61l2w4nbzzzsFla5txhHokzzwoO9jbgc1juxptv2+ps5x1Pf/jxTdlhOWDQbXzw4w9uLRiAB0QcYGwjQQsUkGLLKBgFo2AUDHcAAJ04XVb8fYANAAAAAElFTkSuQmCC","orcid":"","institution":"Assiut University","correspondingAuthor":true,"prefix":"","firstName":"Hamdan","middleName":"Saadi","lastName":"Abbas","suffix":""}],"badges":[],"createdAt":"2026-03-15 00:53:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9125548/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9125548/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106092991,"identity":"8d554ed4-6f46-42a2-b2c1-ef866af63144","added_by":"auto","created_at":"2026-04-03 11:32:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":465464,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(A, B):\u003c/strong\u003e Preoperative marking of the Lateral Arm Free Flap. The axis is drawn from the deltoid insertion to the lateral epicondyle. The posterior incision is marked to identify the intermuscular septum.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9125548/v1/3c0036ee544933b6785e0230.png"},{"id":104877062,"identity":"e34972f7-2f28-4e11-8dcb-850fa802f078","added_by":"auto","created_at":"2026-03-18 08:45:02","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1576367,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(A, B):\u003c/strong\u003e Intraoperative view of flap elevation. The vascular pedicle (Posterior Radial Collateral Artery) is visualized within the lateral intermuscular septum. The radial nerve is identified and preserved deep to the pedicle.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9125548/v1/e7fddf08ff59664e3ced6bfd.png"},{"id":104877064,"identity":"4efa230b-83f9-4aeb-97a9-a4bbece3d1a0","added_by":"auto","created_at":"2026-03-18 08:45:02","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":867975,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(A, B):\u003c/strong\u003e Postoperative view showing a viable Lateral Arm Flap reconstructing a hemiglossectomy defect (A) at 2 weeks postoperative. (B) View of the single case of total flap necrosis due to venous congestion.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9125548/v1/c78abf5f5c0334396a73a1ab.png"},{"id":104877063,"identity":"f3ad6db1-22d3-4581-80db-17560cda2df9","added_by":"auto","created_at":"2026-03-18 08:45:02","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1768124,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(A, B):\u003c/strong\u003e Donor site outcomes. (A) Immediate primary closure of the lateral arm defect. (B) Linear scar appearance at 6 months postoperative.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-9125548/v1/f33659161176a5c8f860656d.png"},{"id":106095509,"identity":"93297ff3-4407-46cb-b4fd-714d374d8cef","added_by":"auto","created_at":"2026-04-03 11:48:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5740284,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9125548/v1/9242191f-5383-4ec2-ae06-5df48cd969b6.pdf"},{"id":104877060,"identity":"ed474ddb-3c79-4494-a8ab-8e0ed9c652cb","added_by":"auto","created_at":"2026-03-18 08:45:02","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":16046,"visible":true,"origin":"","legend":"","description":"","filename":"listofTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-9125548/v1/1c11dbfaa08930b089ec583d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Revisiting the Lateral Arm Free Flap for Oral Defects: A Case Series on Flap Viability and Primary Donor Site Closure.","fulltext":[{"header":"Background","content":"\u003cp\u003eThe excision of oral squamous cell carcinoma (OSCC) often results in composite defects requiring sophisticated reconstruction to restore speech, swallowing, and airway protection. While the Radial Forearm Free Flap (RFFF) has long been the \"workhorse\" for such defects due to its pliability and long pedicle, it necessitates sacrificing a major artery and often requires skin grafting at the donor site, leading to aesthetic and functional morbidity [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Lateral Arm Free Flap (LAF), first described by Song in 1982, is a septocutaneous flap supplied by the posterior radial collateral artery (PRCA) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It offers several theoretical advantages: it does not sacrifice a major dominant artery, provides variable tissue thickness suitable for \"dead space\" obliteration, and allows for primary closure of the donor site in defects less than 6\u0026ndash;7 cm wide [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Despite these benefits, it remains underutilized compared to the RFFF and Anterolateral Thigh (ALT) flap. This study aims to evaluate the clinical reliability and donor site outcomes of the LAF in a cohort of Egyptian patients with oral malignancy.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cb\u003eStudy Design and Setting\u003c/b\u003e This prospective case series was conducted between June 2022 and June 2024. Patients were recruited from the Surgical Oncology Department at the National Cancer Institute (NCI), Cairo University, and the Maxillofacial Unit at Assiut University Hospitals, Egypt [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePatient Selection\u003c/strong\u003e \u003cp\u003eInclusion criteria comprised patients with histologically proven oral malignancy who required soft tissue reconstruction for medium-sized defects (tongue, floor of mouth, or buccal mucosa). Exclusion criteria included patients with defects small enough for direct closure, those medically unfit for prolonged general anesthesia, or those with distant metastasis.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSurgical Technique\u003c/strong\u003e \u003cp\u003eTumor excision was performed with safety margins and frozen section control. Neck dissection was performed (Levels I-V) as indicated by N-staging. The flap was designed on the distal lateral aspect of the arm. The axis extended from the deltoid insertion to the lateral epicondyle, corresponding to the lateral intermuscular septum. Flap width was limited to 6 cm to facilitate primary closure.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eA posterior incision was made first to identify the triceps muscle and the intermuscular septum. The PRCA and its perforators were identified. The radial nerve was visualized and preserved. The pedicle was traced proximally to the profunda brachii vessels to maximize length and caliber. Microvascular anastomosis was performed using the facial artery as the donor vessel in all cases. Venous drainage was established via the common facial vein or external jugular vein.\u003c/p\u003e \u003cp\u003e \u003cb\u003eOutcome Measures\u003c/b\u003e Data were collected on operative time, flap survival (total/partial necrosis), donor site closure method, and complications (infection, fistula, nerve injury).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cb\u003eDemographics and Tumor Characteristics\u003c/b\u003e The study included 12 patients (5 males, 7 females) with a mean age of 57.5 years (range 45\u0026ndash;70). Smoking was a risk factor in 58% of patients. The most common tumor site was the tongue (75%), followed by the cheek/retromolar trigone (17%) and floor of the mouth (8%). Histopathology revealed SCC Grade 2 in 58% of cases.\u003c/p\u003e \u003cp\u003e \u003cb\u003eOperative Data and Flap Survival\u003c/b\u003e The facial artery was used in 100% of cases. The common facial vein was the recipient vein in 58% of cases, while the external jugular vein was used in 42%. The overall success rate was 91.7%. Total flap loss occurred in one patient (8.3%) due to venous congestion leading to necrosis. Partial flap loss occurred in two patients (16.7%), which healed with conservative management. The average flap harvesting time was 47.08 minutes.\u003c/p\u003e \u003cp\u003e \u003cb\u003eComplications and Donor Site Morbidity\u003c/b\u003e Postoperative chest infection occurred in 50% of patients. An orocutaneous fistula developed in one patient (8.3%), necessitating pectoralis major flap salvage. Regarding the donor site, primary closure was achieved in 83.3% of patients. Secondary intention healing was required in 16.7%. Hypertrophic scarring was noted in 58.3% of patients. About 41.7% of patients developed sensory deficits as numbness due to division of the posterior cutaneous nerve of the forearm (PCNF) which resolved spontaneously with great success, and no patients developed radial nerve injury or wrist weakness.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eReconstruction of the oral cavity aims to restore form and function with minimal morbidity. Our study confirms that the LAF is a versatile option for medium-sized defects, particularly glossectomy defects, where the flap's moderate bulk provides better mobility than the thicker ALT flap and more volume than the thin RFFF [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eFlap Reliability\u003c/b\u003e Our flap survival rate of 91.7% is comparable to international standards for fasciocutaneous flaps [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The single total failure was attributed to venous thrombosis, highlighting the importance of meticulous dissection of the venae comitantes, which can be small in this region.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDonor Site Advantage\u003c/strong\u003e \u003cp\u003eA major finding of this study is the high rate of primary donor site closure (83.3%). This contrasts sharply with the RFFF, which almost invariably requires a skin graft, leading to poor aesthetics and potential tendon exposure [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Although 58% of our patients developed hypertrophic scars, the linear scar on the lateral arm is generally more concealable than a radial forearm graft.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eVascular Anatomy and Neurological Safety\u003c/strong\u003e \u003cp\u003eWe used the facial artery and common facial vein for anastomosis in most cases. The LAF pedicle (PRCA) was found to be consistent, though shorter than the radial artery pedicle. Extending the dissection proximally to the profunda brachii provided sufficient length [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. There was concern about sensory deficits, including numbness over the lateral elbow and forearm, following division of the posterior cutaneous nerve of the forearm (PCNF) without radial nerve injury. This supports the consensus that with careful identification of the nerve in the spiral groove, the flap is safe to harvest [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe Lateral Arm Free Flap is a safe, effective, and reliable option for oral cavity reconstruction. It provides pliable, moderately thick tissue suitable for reconstruction of the tongue and floor of the mouth. Its primary advantage lies in its ability to close the donor site, avoiding the morbidity associated with the radial forearm flap.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study was performed in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board (IRB) / Research Ethics Committee of the Faculty of Medicine, Assiut University, prior to initiating this study, with the number ( 17200706). Written informed consent to participate in this study was obtained from all individual participants prior to their inclusion.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eWritten informed consent for the publication of clinical details, outcomes, and accompanying clinical images was obtained from all patients.\u003c/p\u003e\n\u003ch2\u003eConflict of interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThe authors declare that no specific funding, grants, or financial support were received for the conceptualization, design, data collection, or publication of this research.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eAyman A.Wahab and Mohamed Zedan conceptualized the study and performed the surgical procedures. Hasan M.Harby collected and analyzed the patient data. \u0026nbsp;Hamdan S. Abbas drafted the initial manuscript. All authors reviewed the results, contributed to the final manuscript preparation, and read and approved the final submitted version.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe authors would like to thank the surgical oncology and maxillofacial nursing staff at the National Cancer Institute and Assiut University Hospitals for their assistance in perioperative patient care.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to patient privacy and confidentiality, but are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNabil S, Samman N (2012) The impact of case reports in oral and maxillofacial surgery. Int J Oral Maxillofac Surg 41:789\u0026ndash;796\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSong R, Song Y, Yu Y et al (1982) The upper arm free flap. Clin Plast Surg 9:27\u0026ndash;35\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaskin DM (2011) Improving the dissemination of surgical knowledge. Ann Maxillofac Surg 1:1\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarby HM (2025) Lateral Arm Free Flap for Reconstruction of the oral cavity and head and neck soft tissue defects [Thesis]. Assiut University\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKatsaros J, Schusterman M, Beppu M et al (1984) The lateral upper arm flap: anatomy and clinical applications. Ann Plast Surg 12:489\u0026ndash;500\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDisa JJ, Cordeiro PG (1999) The lateral arm flap for head and neck reconstruction. Ann Plast Surg 42:490\u0026ndash;498\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScheker LR, Kleinert HE, Hanel DP (1987) Lateral arm composite tissue transfer to ipsilateral hand defects. J Hand Surg Am 12:665\u0026ndash;672\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGraham B, Adkins P, Scheker LR (1993) Complications of the lateral arm flap. J Hand Surg Br 18:403\u0026ndash;417\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-otolaryngology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [The Egyptian Journal of Otolaryngology](https://ejo.springeropen.com/)","snPcode":"43163","submissionUrl":"https://submission.springernature.com/new-submission/43163/3","title":"The Egyptian Journal of Otolaryngology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Lateral arm flap, Oral cancer, Microvascular reconstruction, Donor site morbidity","lastPublishedDoi":"10.21203/rs.3.rs-9125548/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9125548/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The reconstruction of complex oral cavity defects following oncologic resection requires versatile soft tissue flaps. While the Radial Forearm Free Flap (RFFF) is a standard option, it is associated with conspicuous donor site morbidity. This study evaluates the efficacy, functional outcomes, and donor site morbidity of the Lateral Arm Free Flap (LAF) in head and neck reconstruction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A prospective case series was conducted from June 2022 to June 2024 at the National Cancer Institute (Cairo University) and Assiut University Hospitals. Twelve patients with medium-sized soft-tissue defects (tongue, cheek, floor of the mouth) underwent reconstruction with LAF. Parameters assessed included flap viability, operative time, donor site closure (primary vs. secondary), and postoperative complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The study included 12 patients (7 females, 5 males) with a mean age of 57.5 years. The majority of defects were in the tongue (75%). The flap success rate was 91.7%, with one total flap loss, and the average flap harvesting time was 47.08 minutes. Primary closure of the donor site was achieved in 83.3% of cases. Complications included hypertrophic scarring (58.3%). Furthermore, 41.7% of patients developed sensory deficits (numbness/hypesthesia) due to division of the posterior cutaneous nerve of the forearm (PCNF), with no patients developing radial nerve injury or wrist weakness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The Lateral Arm Free Flap is a reliable alternative to the RFFF for small-to-medium oral defects. It offers the distinct advantage of primary donor site closure and adequate tissue bulk for glossectomy defects, though variable vessel caliber remains a technical consideration.\u003c/p\u003e","manuscriptTitle":"Revisiting the Lateral Arm Free Flap for Oral Defects: A Case Series on Flap Viability and Primary Donor Site Closure.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-18 08:44:57","doi":"10.21203/rs.3.rs-9125548/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-16T10:37:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73413421998510405238157523612365232121","date":"2026-05-16T10:05:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"256388289658575069293978171378760061638","date":"2026-04-09T14:03:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58046251580472889220792378224786719091","date":"2026-04-05T03:21:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-04T09:51:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-17T04:32:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-17T04:32:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"The Egyptian Journal of Otolaryngology","date":"2026-03-15T00:38:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-otolaryngology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [The Egyptian Journal of Otolaryngology](https://ejo.springeropen.com/)","snPcode":"43163","submissionUrl":"https://submission.springernature.com/new-submission/43163/3","title":"The Egyptian Journal of Otolaryngology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"49368496-ef6f-4736-b8ef-75fbcd94f791","owner":[],"postedDate":"March 18th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-16T10:37:17+00:00","index":27,"fulltext":""},{"type":"reviewerAgreed","content":"73413421998510405238157523612365232121","date":"2026-05-16T10:05:31+00:00","index":26,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-04T09:53:29+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-18 08:44:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9125548","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9125548","identity":"rs-9125548","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}