Brown MT, Couch ME, Huchton DM. Assessment of Donor-Site Functional Morbidity From Radial Forearm Fasciocutaneous Free Flap Harvest. Arch Otolaryngol Head Neck Surg. 1999;125(12):1371-1374. doi:10.1001/archotol.125.12.1371
To quantitate the functional morbidity to the hand and wrist following harvest of a radial forearm fasciocutaneous free flap.
Prospective case-control study, with each patient providing his or her internal control, comparing preoperative and postoperative operated to nonoperated forearms.
Tertiary care hospital in large metropolitan area.
A consecutive sample of 11 patients who underwent a radial forearm free flap reconstruction of the head and neck from April 1997 to May 1998.
Main Outcome Measures
Range of motion of the wrist (flexion and extension, ulnar and radial deviation), grip and pinch strength, and sharp and dull sensation in the distribution of the radial, ulnar, and median nerves.
Statistically significant differences (P<.05) were measured in wrist flexion, pinch strength, and sharp sensation in the anatomical snuffbox of the operated forearm. No subjective complaints of loss of function were reported by any patient.
Donor-site functional morbidity associated with harvest of the radial forearm fasciocutaneous free flap is measurable. The statistical differences found do not translate into subjective patient complaints of everyday functional morbidity.
THE RADIAL forearm free fasciocutaneous flap1 is a remarkably versatile and reliable tool in head and neck reconstruction. A spectrum of functional donor-site deficits following harvest of this flap is reported. These include no deficit, to wrist stiffness with loss of range of motion, diminished strength of the hand and wrist, dysesthesias, hand or wrist swelling, pain, and healing problems due to exposed wrist tendons. The harvest of an osseous component from the radial bone introduces even more severe potential morbidity and dysfunction2- 5 and we therefore do not perform or advocate this flap.
The incidence of the functional deficits previously reported varies widely. Timmons et al4 described a high incidence of reduced hand or wrist strength (40%); Richardson et al6 noted persistent wrist stiffness (27%). Bootz and Biesinger5 found mobility parameters to be reduced in 12% to 38% of patients. Swanson et al7 found normal range of motion in all but 1 patient in their series of 20. Bardsley et al2 and Boorman et al3 found no restriction in range of motion or power in patients who underwent fasciocutaneous flap harvest. All of these studies are retrospective and uncontrolled.
Brown et al8 published the first evaluation of the donor-site morbidity of the radial forearm using control groups. No limitation of motion, weakness, or sensation loss in the operated hand and wrist was found. Comparison groups included the following: (1) patients with radial forearm free flap, (2) age-matched patients in whom another free flap was used to reconstruct a cancer-related defect, and (3) age-matched normal volunteers.
Two studies that assess the radial forearm donor site prospectively are available for review. Forty patients in one study6 underwent preoperative and postoperative evaluations of range of motion and strength parameters in both hands and wrists. It is unclear how many had a fasciocutaneous flap vs an osseofasciocutaneous flap. However, these data suggest no loss of function at the donor sites from which no bone was harvested. The other series by Lutz et al9 is the largest yet reported. Fifty consecutive patients underwent the harvest of a "suprafascial" radial forearm flap, a technique that is thought to limit morbidity at the donor site. All were tested for strength of grip and pinch as well as range of motion of the wrist. Only those patients with partial skin graft failure experienced a reduction of flexion and grip strength. All others had normal function.
This investigation prospectively and objectively quantifies the morbidity to the donor site of the radial forearm using standardized measurements of the range of motion of the wrist, hand strength, pinch strength, and sensation. Each patient provides his or her internal control to decrease the influence of global confounding variables.
Between April 1997 and May 1998, our service performed 17 radial forearm fasciocutaneous free flaps. There were no exclusion criteria to enrollment in the study. All 11 patients were asked to participate and gave informed consent, as approved by the Johns Hopkins University School of Medicine Joint Committee on Clinical Investigation, prior to their enrollment in the study. One patient suffered a high median nerve injury (likely related to the tourniquet cuff or arm positioning intraoperatively and therefore independent of the free flap harvest) and was excluded from the postoperative testing group. Ten subjects (7 men, 3 women) whose ages ranged from 26 to 70 years old (median age, 49 years) completed both parts of the examination. All flaps were obtained from the left (nondominant) hand.
Two patients who remained in the study had wound healing problems at the donor site. One patient had a partial skin graft loss (an approximately 4 × 2-cm area) over the flexor muscle belly that required dressing changes and a secondary skin graft. The other patient had exposure of the palmaris longus tendon that healed quickly after excision of the tendon.
The same occupational therapists examined all patients. The protocol was identical for both testing sessions. The initial preoperative evaluation occurred within 3 weeks of the operation. Postoperative testing uniformly occurred from 3.5 to 6.5 months after surgery (average duration, 4.85 months). The preoperative assessment was unavailable to the occupational therapist during the postoperative examination to avoid influencing performance or measurements.
Patients performed grip strength and pinch strength tests using dynamometers at the beginning and the end of the testing sessions. The average of 6 attempts was the value used for analysis. Using standard goniometers, we assessed wrist and forearm active range of motion (including extension, flexion, radial deviation, ulnar deviation, pronation, and supination). Sharp and dull sensations in the radial, median, and ulnar nerve distributions were also appraised. Patients performed all preoperative and postoperative evaluations on hands and wrists bilaterally. At each postoperative visit, the patients were questioned about any functional limitations of the operated wrist and hand.
Data were collected and the differences between preoperative and postoperative performance within each side were compared between the sides. By evaluating each side before and after harvest, patients had their own internal control. This method avoided ascribing to the harvest of the flap any decrement in function due to constitutional weakness.
Statistical analyses were performed using the paired, 2-tailed, t test. Statistical significance was achieved only at a greater than 95% confidence level.
No statistical significance was noted in the assessments of wrist extension, radial deviation, ulnar deviation, pronation, or supination. The differences in these measures varied from 0.1° to 3.3°. Wrist extension varied by −6° in the operated hand. This value did reach statistical significance at P = .02 (Table 1).
Grip strength did not have any meaningful distinction between operated and nonoperated sides. Pinch strength was weaker by 0.39 kg on the operated side, a value that reached statistical significance (P = .047) (Table 2).
Sensation data measured no statistically significant changes in the following nerve distributions of the hand: dull sensation of the radial nerve or sharp or dull sensation of the median or ulnar nerve. Sharp sensation at the anatomical snuffbox (falling within the area innervated by the radial nerve) was significantly decreased (P = .02) (Table 3).
After complete healing, patients reported no complaints regarding the operated wrist. All patients responded to direct questioning that the operated hand and wrist functioned as they did preoperatively.
Careful evaluations of data from the 2 patients who had wound healing complications did not reveal any decreased function relative to the others in the study.
First described in 1981 by Yang et al,1 the radial forearm fasciocutaneous free flap is the new workhorse in the reconstruction of many head and neck surgical and traumatic defects.10 Much like its reliable and unquestionably useful pedicled predecessors (ie, pectoralis major myocutaneous flap11), the radial forearm provides skin and soft tissue that provides a well-vascularized covering for external or internal soft tissue deficits. Unlike its pedicled counterparts, there is no limitation to where it may reach in the head or neck. The thin and pliable nature of the radial forearm flap enhances its versatility as a tool for reconstruction.
Our study confirms the remarkable lack of morbidity associated with the harvest of a radial forearm free flap. In this prospective case-control study, the only functional decrements that are statistically significant are wrist flexion, pinch strength, and sensation in the anatomical snuffbox. The wrist flexors are bared intraoperatively and then skin is grafted during the harvest of the flap. Therefore it is not surprising to find some decrement in function related to their manipulation.
The branch of the radial nerve to the anatomical snuffbox is also handled and exposed during the harvest of the flap. A previous study by Brown et al8 did not find any loss of sensation at this site. However, the patients in that study were examined an average of 9.5 months postoperatively, more than 4 months later than in our study. It may be that if we examine our patients again at a later time, the sensation to this area would be regained, thus, negating our finding.
Encouragingly, none of these findings correlate with subjective inhibition of everyday functions of the hand or forearm. Even the 2 patients who had wound healing problems at the donor site had no real objective findings or subjective complaints.
One of many important considerations during the planning of any operation is the potential morbidity incurred by the patient as a result of the procedure. A variety of reconstruction options in head and neck cancer surgery are available to the surgeon. Local, regional (ie, pedicled), and distant (ie, microvascular) flaps are all potentially useful tools for soft tissue reconstruction. The type of reconstruction a surgeon chooses depends on many variables, including the reliability of the various flaps, type of defect, morbidity at the proposed donor site, training of the surgeon, cost and potential length of hospitalization, and patient comorbidities.
The reliability of free tissue transfer in the head and neck is excellent, with flap survival rates approaching or exceeding 95% in large series.12- 16 Survival rates for the pectoralis major myocutaneous flap ranges from 86% to 99%.17- 19 There is an incidence of partial loss (3%-29%) not seen in free tissue transfer.18- 20
The results of our prospective, case-control study confirm that the radial forearm donor site is remarkably free of morbidity. While there are some measurable differences in the forearm after the harvest of the flap, they are minimal and do not seem to translate into any subjective difficulties for the patient. Unfortunately, little or no data are similarly dedicated to assessing the functional morbidity associated with the pectoralis major myocutaneous donor site.
Finally, the cost and duration of hospitalization are equivalent when comparing the expenditure of resources on patients reconstructed with free or pedicled flaps.17,21- 23 Functional rehabilitation of the recipient site achieved after use of a radial forearm free flap is also distinctly better than that seen with the use of a pectoralis major mycocutaneous flap.17,23
When deciding on the appropriate soft tissue reconstructive option in the head and neck, it is clear that there is little contraindication to the radial forearm fasciocutaneous flap. The flap survival data, cost, and duration of hospitalization are equivalent between the free and pedicled flaps. Additionally, patients exhibit improved postoperative function and a demonstrable lack of morbidity due to the flap harvest with the radial forearm flap. In our opinion, the use of pedicled flaps should be relegated to patients who are physically unable (ie, negative result of the Allen test bilaterally) or unwilling to undergo a radial forearm flap.
The results of our study confirm the extraordinary lack of morbidity found at the donor site of the radial forearm flap. A statistically verifiable specific sensory deficit and inhibition of flexion and pinch strength had no correlate in the daily lives of our patients.
Accepted for publication July 14, 1999.
We extend our thanks and gratitude to the occupational therapists in the Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Md. These specifically include Brooke O'Neill, Liz Krutz, Nikole Martineck, Amy Schimberg, Karen Manley, and Beth Erhardt.
Corresponding author: David M. Huchton, MD, Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Outpatient Center, Sixth Floor, 601 N Caroline St, Baltimore, MD 21287 (e-mail: firstname.lastname@example.org).