Development of a Cutting Guide for Osteocutaneous Radial Forearm Free Flap Harvest

ABSTRACT

Objectives

The osteocutaneous radial forearm free flap (OCRFFF) is used for the reconstruction of bony head and neck defects. Being a weight‐bearing bone, precise harvesting of the radius is required to maintain structural integrity, postoperative forearm function, and to prevent postoperative fracture. A radius cutting guide may allow head and neck surgeons to be more precise and confident in performing bony harvest, and may improve allocation of orthopedic specialist resources.

Methods

A custom radius cutting guide was developed in an iterative process with six head and neck surgeons and one hand surgeon. Following design approval, a prospective feasibility study was conducted. Patient‐specific cutting guides were created using pre‐operative upper‐extremity computed tomography (CT) scans. The length and cross‐sectional width of harvested radius bone were measured. The length of time using the guide was recorded. Providers were surveyed to assess their perception of cutting guide utility.

Results

A total of eight patients were enrolled, and the cutting guide was used successfully in seven patients. The mean length of the radius harvested was 77.1 ± 13.8 mm. The mean cross‐sectional width of the radius planned for harvest was 11.7 ± 1.7 mm. The mean width of the bone harvested was 12.1 ± 1.2 mm, with a mean difference of + 0.81 mm. The mean total time using the guide was 12.94 min (range 10.0–20.1 min). Survey respondents (n = 7) agreed that the guide did not interfere with their ability to harvest radius bone (mean response 9.0 ± 1.3) and that they would utilize the guide in practice (9.4 ± 1.1).

Conclusions

Patient‐specific cutting guides for OCRFFF harvest are feasible and may improve head and neck reconstructive surgeons' comfort with harvest.

Level of Evidence

3.

A custom radius cutting guide for osteocutaneous radial forearm free flap harvest was developed in an iterative process with six head and neck surgeons and one hand surgeon. This article details its development and use in eight patient cases.

1. Introduction

The osteocutaneous radial forearm free flap (OCRFFF) is a reliable reconstructive option for head and neck defects requiring both bone and soft tissue [1]. Its pliable skin paddle, volume of soft tissue, and adequate vascularized bone stock provide a unique reconstructive option, especially for the reconstruction of a lateral mandibular defect [2]. Additionally, the radial forearm offers a 10–13 cm pedicle that is sufficient for the length typically required to span the distance from the midface to the cervical vessels without vein grafting [2]. Notably, the OCRFFF provides an alternative bony flap option in patients with lower extremity peripheral vascular disease or poor functional status that precludes fibula harvest [3].

A general concern about the OCRFFF is that the radius is a weight‐bearing bone and therefore has less available bone stock that can be safely harvested when compared to non‐weight‐bearing grafts such as the fibula free flap (FFF). Thus, precise measurement and cutting of the radius to provide adequate bone while maintaining its structural integrity and preventing postoperative fracture is essential [1, 4, 5, 6]. Given these limitations, the OCRFFF has historically been used less commonly than the FFF for head and neck reconstruction [7]. However, the advent of prophylactic plating of the radius following radial harvest has significantly reduced the risk of postoperative fracture [8, 9], and current studies report similar functional outcomes and long‐term complications when comparing OCRFFF to FFF and scapular tip free flaps [10, 11]. Our current institutional workflow is to have an orthopedic hand surgeon perform the radial osteotomy portion of the harvest followed by prophylactic plating of the radius. This is one of the catalysts for this project; the precision and comfort an orthopedic hand surgeon has with harvesting a significant portion of the radius bone to provide adequate bone for head and neck reconstruction is felt by our group to be invaluable. We desired to create a way to translate this expertise to expand the use of OCRFFF to institutions that may not have reliable access to an orthopedic hand surgeon and/or to improve head and neck surgeon comfort with OCRFFF harvest.

While patient‐specific cutting guides are common for FFF [12, 13] and have been used in scapular tip harvest [14], they have not yet become the standard of care for OCRFFF harvest. Prior research has demonstrated that three‐dimensional (3D) printed cutting guides for bony free flap harvest have the potential to decrease operative times [13], reduce the rates of radiographic nonunion [15], reduce post‐operative complications [15], and improve surgeon confidence and comfort with flap harvest [16]. Given the precision required for OCRFFF harvest, a cutting guide has the potential to improve orthopedic and/or head and neck surgeon comfort in harvesting the radius and increase operative efficiency. The present study details the development of a patient‐specific radius cutting guide by six head and neck surgeons, an orthopedic fellowship‐trained hand surgeon, and a team of biomedical engineers. We report results from a prospective study trialing the cutting guide in eight patient cases to investigate its feasibility for OCRFFF harvest. The ultimate goal is to improve head and neck surgeon comfort with safely performing radius bone harvest and increase the widespread applicability of this reconstructive option.

2. Materials and Methods

2.1. Cutting Guide Development

The cutting guide was developed in an iterative process by six fellowship‐trained head and neck surgeons (A.L., E.R., K.M., M.T., R.S., S.R.) and one orthopedic fellowship‐trained hand surgeon (D.W.) in partnership with a medical device company (KLS Martin, Jacksonville, FL, USA). The cutting guide development process is detailed in the following section and is shown in Figure 1.

FIGURE 1.

Schematic detailing the iterative design process for cutting guide development.

2.2. Initial Planning Meeting (July 2022)

Initial design conception was based on the pre‐existing cutting guide design for FFF. Suggestions for the adaptation of an OCRFFF design included: (1) the ability for the guide to be adjustable on the day of surgery, allowing for intraoperative length selection based on defect size, and (2) a patient‐specific design approach based on preoperative computed tomography (CT) scan of the upper extremity, given the variability in radius size and shape between patients, precluding a generic design for use in all patients. Two designs were created, a partial wrap and a full wrap. The shape of the osteotomy slots was changed from boat‐like to straight, maximizing the amount of bone harvested. Finally, it was felt that the cross‐sectional width to be harvested could be increased from the standard 40% to 60% [17], in line with the amount typically harvested at our institution when performing the harvest free‐hand.

2.3. Design #1

This feedback was incorporated, and the partial and full wrap options were presented to the group. The partial wrap option was preferred due to concerns for the full wrap design interfering with the perforator vessels to the bone. Additionally, it was felt that the cutting guide should follow radial curvature based on the patient's CT scan to maintain an even cross‐sectional width as the radius bone naturally curves.

2.4. Design #2

A drawback to this design was the concern for saw blade beveling, which could affect the total width harvested. The proposed solution was to increase the saw‐insertion slot sidewall height from 2 to 5 mm.

2.5. Design #3

Further feedback included concern that the number and placement of the cutting guide screw fixation holes on the radius to be harvested could compromise the blood supply to the harvested bone. The screw fixation holes on the portion of the radius to be harvested were removed, leaving only screw fixation holes to secure the cutting guide to the remnant radius.

2.6. Design #4

The orthopedic surgeon felt that the cutting guide may be confusing to orient, and if it was placed incorrectly, this would require too much soft tissue elevation for the cutting guide to be flush with the radius. Based on this feedback, registration tabs were added. Finally, the osteotomy slot was changed to a single ulnar‐toto‐radial cut to avoid interfering with perforator vessels.

2.7. Design #5

Additional registration tabs were added to allow for more seamless placement of the guide. Screw fixation hole orientation was changed from parallel to the radius to perpendicular.

2.8. Final Design

The final radial forearm cutting guide included vertical and horizontal cutting slots, screw fixation holes situated on the remnant radius only, and registration tabs on the interosseous border. The cutting slots were 0.6 mm in width. The horizontal slot marked 50%–60% of cross‐sectional width needed for the radial flap, with one slot centered along the osteotomy line and vertical slots demarcating the segment length. The cutting slots were set at a height of 5 mm. The guides were designed to be placed 4 cm from the palpable styloid process with a length that was customizable and able to be planned relative to the projected defect size during the preoperative planning meeting.

2.9. Cadaver Studies

A patient‐specific cutting guide of Design #5 was tested in two cadaver specimens with upper‐extremity CT scan data by S.R. and M.T. (Figure 2). This design was approved by all authors for the feasibility study.

FIGURE 2.

Images from cadaver feasibility studies (A) patient‐specific cutting guide alongside 3D printed reconstruction of radius bone (B) in vivo placement of cutting guide on radius bone and (C) cutting guide placed next to harvested OCRFFF bony segment with flap and pedicle.

2.10. Feasibility Study

This prospective study was approved by the Vanderbilt University Medical Center Institutional Review Board (IRB #221409). All patients provided written informed consent prior to participation. Patients over the age of 18 scheduled to undergo surgery with OCRFFF reconstruction were considered for inclusion. All patients underwent preoperative non‐contrast CT scans of the upper extremity to be harvested. Patient demographics for each case were collected from the electronic medical record. All data was stored in a HIPAA‐compliant data management system (REDCap, Nashville, TN, USA).

A pre‐surgical planning meeting was held with the ablative and reconstructive surgeons and a planning engineer. Patient anatomy from preoperative CT scan data was manipulated during the planning session to simulate surgery, and the details of the harvest site, resection margins, and reconstructive anatomy were discussed. The custom radius guides were 3D printed with additively manufactured titanium alloy. Cutting guides were sterilized and brought to the operating room for use on the day of surgery.

A two‐team surgical approach for concurrent ablation and defect reconstruction was utilized. Raising of the OCRFFF proceeded as previously described [18]. As is typical at our institution, an orthopedic surgeon arrived to perform the osteotomy portion of the harvest, followed by prophylactic radius plating. The cutting guide was placed onto the radius at the measured distance from the styloid process based on preoperative plans. Screws were used to fixate the cutting guide to the remnant radius. A sagittal saw was used to perform the osteotomies, and the cutting guide was removed. The cutting guide allows for a complete horizontal osteotomy from the ulnar to radial surfaces; an osteotome is used to free up the bone segment after the cut is made through and through. The bone was released, and the remainder of the harvest and prophylactic plating proceeded per standard of care (Note: Osteotome use for final radius delivery is the standard fashion in which the bony segment is delivered at our institution, there may be slight variability, but at the point at which the osteotome is used we feel that it is negligible.).

2.11. Outcome Measures

The length and width of the radius bone harvested intraoperatively was recorded and compared to preoperative surgical plans. Preoperative measurements were obtained from preoperative CT scan data and were rounded to the nearest one‐tenth mm. Intraoperative measurements were taken using a sterile flexible ruler and were rounded to the nearest whole mm. Cross‐sectional width was taken from the widest portion of the radius in both the preoperative and intraoperative measurements. To calculate the percent of actual radius harvested, intraoperative measurements of the radius harvested were measured to the nearest mm and compared to the total width of the radius measured on the preoperative CT scan, rounded to the nearest mm. Time required to use the cutting guide (placement, osteotomies, and total time) was recorded.

2.12. Surgeon Survey

A survey designed to assess the utility of the guide and gather qualitative feedback was administered to the surgeon(s) who performed the OCRFFF harvest. The survey instrument can be found in Figure S1. Responses were set on a scale from 0 to 10, with 0 being “Strongly Disagree” and 10 being “Strongly Agree”.

3. Results

3.1. Feasibility Study

A total of 8 patients were included in the prospective feasibility study. Mean patient age was 69.6 (range 52–82) years All patients underwent ablative surgery with segmental mandibulectomy immediately followed by mandibular reconstruction with OCRFFF. The majority of patients (87.5%) underwent primary surgical resection for invasive squamous cell carcinoma of the oral cavity. One patient underwent surgical resection for hyalinizing clear cell carcinoma of the anterior floor of the mouth (FOM). Three patients were being treated for recurrent oral cavity cancer. Primary anatomic subsites included mandibular alveolar ridge (28%), gingiva (28%), FOM (28%), and buccal mucosa (14.2%). The majority of patients (75%) were edentulous at the time of reconstruction. Complete case characteristics are summarized in Table 1.

TABLE 1.

Case characteristics.

Case	Age	Clinical staging	Ablative operation	Reconstruction	Histopathology	Anatomic subsite	Recurrence?	Edentulous?
1	61	T4aN0	Segmental mandibulectomy, composite resection L FOM, mandible, radical resection L chin soft tissue—7 × 5 cm.	L OCRFFF for reconstruction of mandibular, intraoral, and cutaneous defect.	SCCa	Mandibular alveolar ridge	Y	Y
2	77	T4aN0	Segmental mandibulectomy L lateral incisor to first R premolar, composite resection mandible, L FOM, ventral tongue	R OCRFFF for reconstruction of mandibular and intraoral defect	SCCa	FOM	N	Y
3	70	T4aN0	Segmental mandibulectomy paraysmphisis to parasymphisis, composite resection of lip, mandible, FOM, and tongue	R OCRFFF for reconstruction of mandibular and intraoral defect	SCCa	Anterior gingiva	Y	Y
4	71	T4aN0	Segmental mandibulectomy, composite resection of buccal mandible, floor of mouth, and tongue	L OCRFFF for reconstruction of mandibular and intraoral defect.	SCCa	FOM	Y	Y
5	52	T3N0	L segmental mandibulectomy, composite resection mandible, buccal mucosa, small portion of FOM	L OCRFFF for reconstruction of mandibular and intraoral defect.	Verrucous carcinoma	Buccal mucosa	N	N
6	81	T3N0	R segmental mandibulectomy, composite resection mandible, R FOM, sublingual region	L OCRFFF for reconstruction of mandibular and intraoral defect.	SCCa	Mandibular alveolar ridge	N	N
7	63	T3N0	R segmental mandibulectomy, composite resection mandible, buccal mucosa, FOM, and tongue.	L OCRFFF for reconstruction of mandibular and intraoral defect.	SCCa	R mandibular gingiva	N	Y
8	82	T4aN0	Anterior segmental mandibulectomy, composite resection anterior mandible, FOM, partial glossectomy without primary closure.	L OCRFFF for reconstruction of oromandibular defect	Hyalinizing clear cell carcinoma	Anterior FOM	N	Y

The cutting guide was successfully used in seven of eight planned cases. The mean length of bone planned for was 82.8 ± 7.6 mm. The mean length of bone harvested was 77.1 ± 13.8 mm. The cross‐sectional width of bone planned for harvest was 50% in three patients and 60% in five patients, with an average planned cross‐sectional width of 11.7 ± 1.7 mm. The average cross‐sectional width of bone harvested was 12.1 ± 1.2 mm. The mean difference in cross‐sectional width planned for versus actual width harvested was 0.81 mm. Complete preoperative and intraoperative bone measurement data for each case is summarized in Table 2.

TABLE 2.

Bone measurements.

Case	Length planned (mm)	Length harvested (mm)	Cross‐sectional width planned (mm) (%)	Cross‐sectional width harvested (mm) (%)	Difference in width planned vs. harvested (mm)
1	80	80	11.7 (60)	11 (56.4)	−0.7
2	80	60	12.9 (60)	13 (60.4)	+0.1
3	80	80	11.3 (60)	12 (63.7)	+0.7
4	80	80	13.5 (60)	13 (57.7)	−0.5
5	80	80	12.9 (60)	13 (60.5)	+0.1
6	80	60	10.8 (50)	13 (60.2)	+2.2
8 a	100	100	8.6 (50)	10 (58.1)	+1.4
Mean	82.8	77.1	11.7	12.1 (59.6)	+0.81

^a Cutting guide unable to be used in case #7 due to the discrepancy in the planned harvest and the actual amount of bone needed intraoperatively.

One cutting guide (case #7) was not able to be used due to a discrepancy in the planned length of the radius to be harvested and the actual length needed for the reconstruction. The cutting guide was planned with 10 and 12 cm options for bony harvest, when intraoperatively only 7 cm of bone was required. The reconstructive team decided to forego the use of the cutting guide and proceed with a free‐hand harvest. The length of bone harvested was 70 mm. The radius cross‐sectional width planned for was 50% (10.3 mm). The actual width harvested was 63.1% (13 mm). This was the largest margin of error in the positive direction, harvesting an additional 2.7 mm more than what was initially planned for.

Mean time from cutting guide placement to screw fixation was 2.85 min (range 1.63–3.92 min). Mean time to complete osteotomies using the cutting guide was 6.39 min (4.18–12.32 min). Mean total time using the cutting guide was 12.94 min (10.0–20.1 min). Complete intraoperative time data is illustrated in Table 3. Figure 3 provides an example of preoperative surgical plans. Figure 4 demonstrates intraoperative use of the cutting guide.

TABLE 3.

Intraoperative time data.

Case	Guide placement (s)	Screw fixation (s)	Sawing (s)	Guide removal (s)	Total time using guide (s)
1	218	148	739	101	1206
2	170	204	387	48	809
3	237	169	317	50	773
4	71	141	341	47	600
5	229	235	251	69	784
6	75	203	317	60	655
7 a	—	—	—	—	—
8	122	98	332	58	610
Mean (minutes)	2.67	2.86	6.39	1.03	12.94

^a Cutting guide unable to be used in Case #7 due to a discrepancy in the planned harvest and the actual amount of bone needed intraoperatively; therefore, time measurements were not recorded with the use of the guide.

FIGURE 3.

Pre‐operative virtual surgical planning (A) 3D reconstruction of an erosive SCCa of the mandibular alveolar ridge (red). (B) Proposed mandibular reconstruction (green) using radius segment (C) 3D reconstruction of left radius with proposed reconstructive segment (green) and (D) patient specific cutting guide with option to harvest 6 or 8 cm of radius bone (gray).

FIGURE 4.

Intraoperative use of cutting guide (A) Intraoperative use of patient‐specific cutting guide (B) intraoperative forearm x‐ray demonstrating correct placement of cutting guide flush with radius bone.

3.2. Surgeon Feedback

One faculty‐level orthopedic fellowship‐trained hand surgeon, three faculty‐level head and neck microvascular surgeons, two head and neck microvascular surgery fellows, and one orthopedic surgical resident completed the survey. Respondents agreed that the cutting guide did not interfere with the ability to harvest the radius (Mean response 9.0 ± 1.3) and that they would use the cutting guide again (9.4 ± 1.1). All respondents agreed that the cutting guide was safe and resulted in the correct amount of bone being harvested. Qualitative feedback from each individual case is summarized in Table 4. Complete surgeon survey responses are shown in Table S1.

TABLE 4.

Additional surgeon feedback.

Case	Lessons learned
1	Osteotomies scored using the cutting guide, remainder of harvest done free hand with osteotome and hammer. Need to release more periosteum on the dorsal radius in order to place cutting guide.
2	Requires additional set of hands to hold guide in place and ensure it is flush with the bone before securing screws.
3	Guide takes more dorsal than palmar bone, no real difference in bone properties. One screw on each end is plenty to secure the guide.
4	Once sawing began, felt that guide was forcing saw to take too much bone from radial side. Portable XR was brought in to confirm guide placement. Coming from ulnar to radial side, needed to dissect more radial side of the bone to assess total width of actual bone.
5	No additional feedback following this case.
6	Guide forces you to take more dorsal bone whereas hand surgeon would take more volar surface. Two screws (one at each end) is plenty to secure the guide.
7	No VSP for this case, cutting guide was printed based on predicted 10–12 cm bone harvest with 50% thickness, and only ended up needing 4.5–6 cm. Indicates need for formal pre‐operative planning session.
8	Guide takes more dorsal than volar bone than the hand surgeon would normally take free‐hand.

4. Discussion

The OCRFFF provides a versatile option for the reconstruction of complex head and neck defects with a combination of cutaneous, soft tissue, and bony components with a single vascular pedicle [1, 2]. The limited bone stock available in the radius and the need for careful harvest of 50%–60% [2, 17] of the radial circumference to prevent post‐operative complications have been described as potential limitations of this reconstructive option [4, 5]. The present study details the development of a patient‐specific cutting guide for use in OCRFFF harvest and reports findings from a prospective feasibility trial investigating its use in eight patient cases. The design process was comprehensive and involved multiple rounds of feedback from an experienced orthopedic hand surgeon as well as a group of head and neck microvascular surgeons with varying levels of experience. Prior to actual patient use, a cadaver study was performed to confirm that the final cutting guide design was suitable. In the prospective portion of the study, the cutting guide was used to efficiently harvest a safe amount of radius for use in OCRFFF reconstruction.

Our institutions' experience with an orthopedic fellowship‐trained hand surgeon harvesting the bony flap has demonstrated that 50%–60% of radius bone can be harvested safely when prophylactic plating is subsequently performed, which is consistent with recent studies establishing the safety and efficacy of this method [8, 9, 10, 11, 18]. However, not all institutions have access to this resource, and some head and neck surgeons may be less comfortable with this aggressive harvest of the radius bone given the sporadic use of this flap across the country. Accurate intraoperative assessment of the radius bone osteotomy depth is challenging due to overlying muscle and periosteum, which obscure direct visualization of the underlying bone, and the irregular 3D shape of the radius. This can lead to variable overharvesting or underharvesting of the radius, which can increase donor site morbidity or affect the integrity of the reconstructed mandible [19]. These considerations highlight the need for improved techniques to enhance surgeon confidence in harvesting an adequate and reliable bone stock for mandibular reconstruction while minimizing the risk of donor site morbidity.

Virtual surgical planning to create patient‐specific cutting guides for OCRFFF harvest may provide guidance during this portion of the case, particularly when a head and neck surgeon has less comfort with the appropriate amount of radius bone that can be safely harvested. The complexity of the orthopedic component of this procedure is also significantly reduced by using the cutting guide. Reducing and fixing a distal radius is an entry‐level case that most orthopedic surgeons would feel comfortable with. While the cutting guide may not eliminate the need for orthopedic support entirely for this procedure, it may allow more head and neck surgeons to feel confident harvesting the radius bone independently. This would allow for more efficient allocation of specialists' resources at larger institutions and more widespread use of this flap outside of highly specialized centers. Further, a patient‐specific cutting guide may make patients with difficult or variable radius anatomy more amenable to undergoing this operation.

While patient‐specific cutting guides are common for FFF [12, 13, 20] and have been used in scapular tip harvest [14], they have not become the standard of care for OCRFFF harvest. Prior research has demonstrated the benefits of utilizing 3D printed cutting guides for bony free flap harvest. These patient‐specific guides have the potential to decrease operative times and even operative costs [13], reduce the rate of radiographic nonunion [15], reduce post‐operative complications [15], and improve surgeon confidence and comfort with flap harvest [16]. While a cutting guide for OCRFFF has previously been proposed by Thomas et al., this was designed to harvest a maximum of 40% circumference of bone [19]. As described above, our experience suggests that 50%–60% of radial bone circumference is safe to harvest. The cutting guide in the present study was therefore designed to take a sizable amount of bone, allowing for a sturdier reconstruction while maintaining the integrity of the remnant radius. Additionally, the cutting guide described in this study allows ablative and reconstructive surgeons to plan two options for the length of bone to be harvested (6 and 8, 8 and 10, 10 and 12 cm) which may be decided on intraoperatively.

In one of eight cases (case #7), the cutting guide was not able to be used due to a discrepancy in what was planned preoperatively and the amount of bone required for the reconstruction. The preoperative virtual surgical planning session was held, and the cutting guide was printed based on a 10–12 cm anticipated harvest. However, the reconstructive surgeon was not available due to a scheduling conflict. Intraoperatively, both surgeons felt that a more conservative length of 7 cm would be sufficient for reconstruction and ultimately better for the patient. The cutting guide was not used, and free‐hand harvest proceeded per standard of care. Interestingly, the free‐hand harvest resulted in the largest difference in cross‐sectional width (+2.7 mm, 63.1%) of bone being planned vs. harvested compared to the seven cases in which the cutting guide was successfully used.

While the length of bone harvested was consistent with preoperative plans and intraoperative surgeon preference, the cross‐sectional width of bone harvested was more variable. The actual width of radius bone harvested using the cutting guide was off by an average of 0.81 mm from the width planned pre‐operatively. This margin of error is felt by the authors to be multifactorial, including human error in measuring the actual width harvested intraoperatively. While the pre‐operative planned width was measured off the CT scan with computer software to the tenth of a millimeter, the actual width intraoperatively was only able to be measured to whole millimeters. Subjectively, based on survey data, all surgeons agreed that the cutting guide harvested a sufficient and safe amount of bone. Additionally, the cutting guide became easier to use over time as the team became more comfortable with it, and it is felt that after several trials, surgeons may become more accurate using the guide.

This study was limited by several additional factors. As previously mentioned, our institution has an orthopedic fellowship‐trained hand surgeon who has historically performed the radial osteotomy and prophylactic plating of the remnant radius for OCRFFF. We recognize that many institutions do not have access to a hand surgeon reliably, and therefore this is one of the inspirations for this endeavor. Additionally, this single‐arm, prospective study is limited by a small sample size within a single institution and lacks a comparison group to the current standard of care (no OCRFFF radius cutting guide). A future prospective trial with a standard of care comparison cohort is warranted to further demonstrate the utility of the radius cutting guide as well as the precision and consistency of the amount of radius harvested.

5. Conclusion

Virtual surgical planning can be used successfully to create patient‐specific cutting guides to aid in OCRFFF harvest and may ultimately improve otolaryngologist surgeon comfort in harvesting radial bone independently. The accuracy of radial harvest using a patient‐specific cutting guide for OCRFFF reconstruction requires further evaluation through prospective trials with more providers utilizing the cutting guide.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Table S1. Surgeon Survey Responses.

Figure S1. Surgeon Survey Instrument.

Fassler C., Topf M. C., Miller A., et al., “Development of a Cutting Guide for Osteocutaneous Radial Forearm Free Flap Harvest,” The Laryngoscope 135, no. 9 (2025): 3149–3157, 10.1002/lary.32117.