Short-term functional donor site morbidity after radial forearm fasciocutaneous free flap harvest

OBJECTIVES/HYPOTHESIS: The existing literature on postoperative donor extremity function describes a spectrum of morbidity in the long term (>3 mo after surgery). However, the consensus is that there is minimal to no impact of flap harvest on patients' activities of daily living. No previous reports have examined functional donor site morbidity in the early postoperative period; such may affect patients' overall perioperative progress, especially with respect to donor extremity dominance. The authors' objective was to quantify functional morbidity of the donor site in radial forearm fasciocutaneous free flaps during the early postoperative period. STUDY DESIGN: Retrospective case series review. METHODS: Patient data were obtained from hospital records of 12 consecutive patients who underwent head and neck reconstruction with radial forearm fasciocutaneous free tissue transfer over a 6-month period at a tertiary academic medical center. Functional results of each patient's donor extremity obtained preoperatively and at 5 to 8 days after surgery were determined by quantifying forearm supination and pronation, wrist flexion and extension, and sharp and dull hand sensations in radial, median, and ulnar nerve distributions. RESULTS: Mean patient age was 57 years (age range, 42-71 y). The nondominant extremity was the donor site in 9 of 12 patients. Using the paired two-tailed t test, statistically significant differences were demonstrated in preoperative versus postoperative forearm supination (P <.032), pronation (P <.006), wrist flexion (P <.000), and wrist extension (P <.000). Three of 12 patients demonstrated diminished sharp sensation in the "anatomical snuffbox" distribution. CONCLUSION: The authors describe statistically significant functional forearm and wrist range-of-motion morbidity associated with the harvest of a radial forearm fasciocutaneous free flap in the early postoperative period.     

Ipsilateral full-thickness forearm skin graft for covering the radial forearm flap donor site

OBJECTIVES/HYPOTHESIS: The technique of the ipsilateral full-thickness forearm skin graft for covering the defect of radial forearm free flap (RFFF) improves aesthetic impairment at the recipient and donor sites by split-thickness skin graft repair and omits the need to make an extraoperative site for harvesting the skin graft. However, in this technique, the RFFF is limited in size. In the present study, we considered a model of the forearm and calculated the possible size of the RFFF for using this technique. METHODS: The calculation was conducted under assumptions that the isosceles-triangle skin graft is elevated as its height is twice the RFFF length in the direction of the forearm axis and that the forearm skin defect can be primarily closed with a width shorter than one-fourth of the wrist circumference. The calculation revealed that this technique is feasible when the RFFF width, that is, the length vertical to the forearm axis, is shorter than half of the wrist circumference. We repaired the RFFF defect using this technique in 15 patients with head and neck cancer in whom the RFFF size conformed to the above-mentioned condition. RESULTS: When the RFFF width was shorter than half of the wrist circumference and the isosceles-triangle skin graft was elevated as its height was twice the RFFF length, the RFFF defect could be repaired using this technique in all 15 patients. CONCLUSION: The above-mentioned condition (that the RFFF width is shorter than half of the wrist circumference) is useful for determining whether or not the technique of ipsilateral full-thickness forearm skin graft can be used for covering the RFFF defect.     

Management of the radial forearm free flap donor site with the vacuum-assisted closure (VAC) system

INTRODUCTION: The radial forearm free flap is a popular reconstructive flap in modern head and neck surgery. Poor wound healing at the forearm donor site is common and frequently results in tendon exposure. The Vacuum-Assisted Closure (VAC) system (Kinetic Concepts Inc., San Antonio, TX) is a topical negative pressure dressing that has been shown to improve skin graft viability when used as a bolster dressing. In this study, we investigated the use of the VAC system in the management of the radial forearm free flap donor site. METHODS: A retrospective chart review was performed on all subjects who underwent a radial forearm free flap reconstruction in which the VAC system was used as a bolster dressing at the donor site from January 1, 2003, through March 31, 2005. RESULTS: Thirty-four consecutive subjects were included in the study. Exposed tendon did not occur in 14 (0%) subjects in which the VAC bolster was used for a minimum of 6 days. Eleven of the 20 subjects (55%) who used the VAC bolster for 5 days demonstrated small amounts of tendon exposure (<2 cm) on follow-up clinic examination. The minimum follow up for all subjects was 4 months. CONCLUSION: This study demonstrates that the VAC system is a feasible alternative to conventional bolster dressing in the management of the radial forearm free flap skin-grafted donor site. Based on this study, when used for a minimum of 6 days, the VAC bolster dressing eliminated tendon exposure at the forearm donor site.     

Use of allogenic dermis for radial forearm free flap donor site coverage

OBJECTIVE: The radial forearm free flap has become the method of choice for reconstruction of head and neck defects following oncologic ablation. Harvesting of a radial forearm free flap leaves a donor site defect. This is most commonly closed with a split-thickness skin graft. Morbidity, most commonly owing to a lack of graft take over the tendons, can be quite high. Recently, an acellular matrix (Alloderm) has been advocated to decrease complications at the radial forearm donor site, as well as obviate taking a split-thickness skin graft from the thigh. MATERIAL AND METHODS: Tertiary referral academic centre. Retrospective chart review of 15 patients. Five patients received allogenic dermis, 10 patients received split-thickness skin grafting to the radial forearm donor site. RESULTS: Patients with allogenic dermis took between 12 and 16 weeks to heal completely. Patients undergoing split-thickness skin graft were completely healed within 4 to 6 weeks. Cosmesis was judged to be marginally better in the allogenic dermis group. Allogenic dermis placement had a greater impact on hand function owing to prolonged healing, whereas patients with split-thickness skin graft required wound care at the thigh for a 2- to 3-week period owing to the harvesting of the skin graft. CONCLUSIONS: Allogenic dermis may be a viable alternative to split-thickness skin grafting and radial forearm free flap donor sites. Prolonged healing with subsequent increased health care services use needs to be addressed.     

Fistula analysis after radial forearm free flap reconstruction of hypopharyngeal defects

Objective/Hypothesis: To evaluate risk factors and management options for fistula formation after hypopharyngeal reconstruction using the radial forearm free flap reconstruction. Study Design: Retrospective cohort study. Methods: Patients undergoing radial forearm free flap for hypopharyngeal reconstruction were retrospectively reviewed. A total of 104 patients underwent this procedure between 2001 and 2007. Fistulas were classified as mild or severe depending on the response to conservative management. Demographics, operative details, pathology, and postoperative course were recorded as the prognostic variables. Univariate analysis and a logistic regression model were used to identify associated factors. Results: Pharyngocutaneous fistula developed in 30 (28.8%) patients. Recurrence, cancer stage, cancer location, type of ablative surgery, and the addition of other oncologic procedures were identified as significant predictors of fistula formation. Fistula significantly increases hospital stay and recipient site complications such as flap survival, infection, and bleeding. Functional results such as diet, deformity, and socialization were also negatively affected by fistula development. One third of the cases responded to conservative management, and 20 cases required a surgical procedure to definitively close the fistulous track. Conclusions: Fistula formation remains a significant cause of morbidity associated with hypopharyngealreconstruction. Postoperative course and successful preventive strategies are discussed.     

Radial forearm free flap pharyngoesophageal reconstruction

OBJECTIVES: This study evaluates the outcome of pharyngoesophageal reconstruction using radial forearm free flaps with regard to primary wound healing, speech, and swallowing in patients requiring laryngopharyngectomy. STUDY DESIGN: Retrospective review in the setting of a tertiary, referral, and academic center. PATIENTS AND METHODS: Twenty patients underwent reconstruction of the pharyngoesophageal segment using fasciocutaneous radial forearm free flaps. RESULTS: All free flap transfers were successful. An oral diet was resumed in 85% of the patients after surgery. Postoperative pharyngocutaneous fistulas occurred in 4 patients (20%) with 3 resolving spontaneously. Distal strictures also occurred in 20% of the patients. Five patients who underwent tracheoesophageal puncture achieved useful speech. CONCLUSIONS: Advantages of radial forearm free flaps for microvascular pharyngoesophageal function include high flap reliability, limited donor site morbidity, larger vascular pedicle caliber, and the ability to achieve good quality tracheoesophageal speech. The swallowing outcome is similar to that achieved after jejunal flap pharyngoesophageal reconstruction. The main disadvantage of this technique relates to a moderately high incidence of pharyngocutaneous fistulas, which contributes to delayed oral intake in affected patients.     

Evaluation of hand circulation before radial forearm free flap surgery

The radial forearm free flap (RFFF) is a versatile flap offering many reconstructive options for head and neck defects. Its low bulk, ease of dissection, and excellent vascularity are among its advantages. Its low flap loss and complication rates offer the best choice for the reconstruction of oral, oropharyngeal, and hypopharyngeal lining. Evaluation of collateral circulation to the hand is important to avoid distal ischemia and donor site morbidity. Pulse oximetry can be used to augment Allen's test to assess collateral supply to the hand. This cost‐neutral technique can be used in routine preoperative screening prior to RFFF surgery. Laryngoscope, 2009     

Analysis of recurrence and survival after hypopharyngeal ablative surgery with radial forearm free flap reconstruction

OBJECTIVES/HYPOTHESIS: To address the controversial acceptable distal resection margin for the surgical management of patients with hypopharyngeal cancer. STUDY DESIGN: Retrospective review of the records of 28 consecutive patients who underwent pharyngoesophagectomy and reconstruction with radial forearm free flaps between 1996 to 2001. METHODS: The Kaplan-Meier method was used to estimate survival and recurrence-free time. RESULTS: The minimum follow-up time was 2 years, and there were 14 (50%) patients who had recurrences. Analysis revealed that only one (3%) patient experienced a recurrence at the inferior resection margin, the junction of the free flap reconstruction, and the cervical esophagus. Estimated 4 year survival was 48.5%. CONCLUSIONS: Total laryngopharyngectomy and partial esophagectomy with radial forearm free flap reconstructions in appropriately selected patients with hypopharyngeal cancer does not compromise local recurrence rates at the distal esophageal margin.     

Evaluation of donor site function and morbidity of the fasciocutaneous radial forearm flap

OBJECTIVE: To assess the results of the use of the free radial forearm flap in terms of objective morbidity and subjective patient response. STUDY DESIGN: The donor sites were examined from 37 patients who underwent reconstruction with a free fasciocutaneous radial forearm flap in the head and neck after ablative tumor surgery. METHODS: Patients were asked to fill in a written questionnaire. The following additional tests were performed: resting skin temperature of digits I and V, temperature after submersion in iced water, grip and pinch tests, and goniometry. RESULTS: Resting skin temperature was slightly decreased for donor hands 0.69 degrees C (P < .001) and 0.31 degrees C (P = .048) for digits I and V, respectively, but recovery after submersion in iced water showed no differences. The strength tests and goniometry revealed no statistically significant findings between donor and control sides. On the questionnaire, 9 patients (24%) reported slightly impaired function, 14 (38%) could not wear their watch or bracelet, 17 (46%) reported numbness, 5 (14%) reported soreness, 5 (14%) reported itching, 6 (16%) reported cold intolerance, 5 (14%) reported bad cosmetic appearance, and 9 (24%) expressed the opinion that they were insufficiently counseled. CONCLUSION: There is a negligible objective morbidity of a free radial forearm flap harvest procedure, but a number of patients have subjective complaints when asked. Elaborate presurgical counseling can probably reduce these complaints.     

Tracheoesophageal fistula and pharyngoesophageal stenosis repair by double skin paddle radial forearm flap

Tracheoesophageal fistula (TEF) constitutes a rare, but serious complication in laryngectomized patients, usually occurring after radiotherapy. TEF may occur spontaneously or may be due to enlargement of the TEF created for placement of a voice prosthesis. Surgical treatment of TEF can be complex, especially in the presence of a concomitant pharyngoesophageal stenosis (PES), and is associated with a high failure rate. In this article, we describe the surgical reconstruction technique for TEF associated with PES using a double skin paddle fasciocutaneous radial forearm free flap. The key points of this technique consist of correct positioning of the 2 skin paddles in order to reconstruct the anterior pharyngoesophageal wall and posterior tracheal wall, as well as de-epidermization of the intermediate part of the flap, which is then placed in the tracheoesophageal space.     

Functional outcomes after primary oropharyngeal cancer resection and reconstruction with the radial forearm free flap

OBJECTIVE: To report prospectively collected aeromechanical, acoustical, and perceptual speech outcomes, as well as preliminary swallowing data, in patients having reconstruction with radial forearm free flaps after primary resection for oropharyngeal cancer. STUDY DESIGN: Prospective cohort study. METHODS: Acoustical, aeromechanical, and perceptual speech data and swallowing data were gathered at three evaluation times (preoperatively and before and after radiation therapy) for patients treated for oropharyngeal cancer by means of primary resection and reconstruction with a radial forearm free flap. Degree of involvement of the soft palate and base of tongue, along with reconstructive techniques, were entered as between-group factors in the analysis. RESULTS: There were no significant differences in speech intelligibility between the patient groups based on the degree of palate and tongue resected. However, patients with resections of half or more than half of the soft palate had significantly higher nasalance values and larger velopharyngeal orifice areas than individuals who had less than half of the soft palate resected. Significant within-subject differences were revealed across evaluation times for the dependent variables nasalance, velopharyngeal orifice area, and word intelligibility. Ninety-four percent of the patients were able to resume a normal or soft diet. There was a 6% incidence of aspiration in 128 swallows that were analyzed. The amount of base of tongue resected did not significantly affect any of the speech or swallowing parameters. CONCLUSIONS: Radial forearm free flaps are a good reconstructive option after oropharyngeal cancer extirpation. Our acoustic and aeromechanical results indicated that issues related to quality of the speech signal require further study for resections of half or more than half of the soft palate.     

Vascularized radial forearm free tissue transfer for lining in nasal reconstruction

OBJECTIVES/HYPOTHESIS: Total and near-total nasal reconstruction requires the surgeon to replace external nasal cover, skeletal support, and internal nasal lining. The successful result must re-create the form and function of the original nose. In large defects, traditional sources of internal lining may be unavailable. The study describes the recreation of nasal lining in three patients with extensive nasal defects with vascularized radial forearm tissue. STUDY DESIGN: Retrospective review of three patients who underwent nasal reconstruction with radial forearm for internal lining, costal cartilage grafts for skeletal support, and paramedian forehead flap for cover. METHODS: The charts of three patients who underwent total nasal reconstruction with radial forearm tissue transfer for lining were retrospectively reviewed. The technique was evaluated. The authors present a method for internal lining reconstruction in extensive nasal defects. They discuss the advantages and disadvantages of this method. RESULTS: Three patients underwent successful total nasal reconstruction with radial forearm tissue transfer for lining, costal cartilage for skeletal support, and paramedian forehead flap. None of the patients had adequate septal mucosa or nasal subunit skin to support mucosal rotation grafts or epithelial turn-in flaps. All patients have completed reconstruction and have satisfactory nasal form and function. Loss of the lining flap or graft loss did not occur. CONCLUSION: Vascularized radial forearm tissue supplies ample quantities of skin to recreate nasal lining. The tissue provides excellent support of graft material, and it prevents contracture of the covering flap. Because of its bulk and donor site morbidity, free forearm tissue transfer should not be considered for reconstruction of smaller defects when another lining flap will suffice.     

Full-thickness skin graft from the groin for coverage of the radial forearm free flap donor site

PURPOSE: The purpose of this study is to describe the use of a full-thickness skin graft from the groin for coverage of the radial forearm free flap donor site. Our hypothesis is that the use of the full-thickness skin graft decreases morbidity and improves functional and cosmetic outcome at the skin graft donor site while also providing excellent coverage of the forearm donor site. STUDY DESIGN: This study used a retrospective chart review design. MATERIALS AND METHODS: Patients undergoing radial forearm free flap reconstructions from 1995 to 2005 were included. Forty patients underwent radial forearm free flap reconstruction with closure of the forearm donor site with a full-thickness skin graft harvested from the groin. The inguinal donor site was closed primarily. Medical records including clinic notes, operative reports, and photographs were reviewed. RESULTS: There was 1 minor wound dehiscence at the groin site, and there were 5 minor forearm wound dehiscences with 2 cases of tendon exposure; all dehiscences were treated conservatively with local wound care. Both the groin wound and forearm donor sites healed satisfactorily in all cases, with no impairment of function related to the skin graft. All patients expressed satisfaction with the postoperative pain, functional outcome, and cosmetic appearance related to both the skin graft and forearm donor sites. CONCLUSIONS: Full-thickness skin graft from the groin for coverage of the radial forearm free flap donor site is an effective, safe alternative to the traditional split thickness skin graft.