Aesthetic improvements of radial forearm flap donor site by autologous fat transplantation

Radial and Ulnar Forearm Free Flaps: A Critical Comparison of Donor-Site Morbidity and Its Impact on Quality of Life

BACKGROUND

A poor evidence basis exists regarding directly comparing objective and subjective donor-site morbidity associated with the forearm flap. The authors evaluated the postoperative donor-site complications and quality-of-life outcomes between the radial forearm free flap (RFFF) and the ulnar forearm free flap (UFFF).

METHODS

All patients undergoing RFFF or UFFF harvest were included. Grip strength, pinch strength, wrist range of movement, and testing of skin sensitivity were assessed with the appropriate scales at different time intervals. In addition, appearance and quality of life were assessed using the Patient and Observer Scar Assessment Scale and the Disabilities of Arm, Shoulder, and Hand instruments.

RESULTS

Eighty patients were enrolled (RFFF, n = 40; and UFFF, n = 40). A short-term reduction in grip strength, fine motor skills (tip pinch, key pinch, palmar pinch), and range of motion was observed for the RFFF group and improved over time. None of the patients in either group experienced functional disturbance in grip strength, wrist motion, fine motor skills, or sensation to light touch at 1 year. Nine patients experienced partial skin graft loss (RFFF, n = 6; UFFF, n = 3). There was a significantly higher incidence of temporary numbness in the RFFF group ( P = 0.040). Persistent numbness occurred in 3 cases in the RFFF group. Cold intolerance was significantly lower in the UFFF group (2.5%) than in RFFF group (22.5%). Moreover, the mean Patient and Observer Scar Assessment Scale and Disabilities of Arm, Shoulder, and Hand scores were reduced at 12 months compared with 6 months, significantly superior for UFFF.

CONCLUSIONS

Objective function limitations are reversible short-term effects after forearm flap and do not affect daily routines in the long term. In addition, UFFF appears to be preferred over RFFF for subjective outcomes, which emphasizes that UFFF should be considered as an alternative to RFFF for reconstructing soft-tissue defects.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Analysis of the Radial Forearm Phalloplasty Donor Site: Do Dermal Matrices Improve Donor Site Morbidity?

Background

The radial forearm free flap is frequently chosen for phalloplasty; however, flap size required for phalloplasty is associated with a large scar burden and functional concerns. We sought to investigate donor site functionality, aesthetics, and volume deficits in a cohort of individuals who underwent radial forearm phalloplasty (RFP) with donor site skin grafting alone or dermal substitute and subsequent skin grafting.

Methods

Donor site functionality was assessed using the quick Disabilities of Arm, Shoulder, and Hand (qDASH). Patient- and clinician-reported aesthetics were assessed using the Patient and Observer Scar Assessment Scale (POSAS). An Artec Leo three-dimensional scanner was used to measure volumetric differences from the donor site forearm and contralateral forearm.

Results

Fifteen patients who underwent RFP agreed to participate. No statistically significant differences were identified between different donor site closure methods regarding qDASH, patient-reported POSAS, or total volumetric deficits. A blinded clinician reported that POSAS approached significance at 4.7 for biodegradable temporizing matrix (BTM), 4.2 for Integra, and 3.0 for split-thickness skin graft (P = 0.05). No statistically significant differences were identified regarding distal, middle, or proximal volume deficits; however, a trend was observed regarding total volumetric deficits with BTM experiencing the lowest deficit (10.3 cm3) and skin graft experiencing the highest deficit (21.5 cm3, P = 0.82).

Conclusions

The addition of dermal matrix (BTM or Integra) to the treatment algorithm for RFP did not show statistically significant improvement in donor site volume deficits, patient-reported scar appearance (POSAS), or functionality (qDASH).

Application of decellularization-recellularization technique in plastic and reconstructive surgery

ABSTRACT

In the field of plastic and reconstructive surgery, the loss of organs or tissues caused by diseases or injuries has resulted in challenges, such as donor shortage and immunosuppression. In recent years, with the development of regenerative medicine, the decellularization-recellularization strategy seems to be a promising and attractive method to resolve these difficulties. The decellularized extracellular matrix contains no cells and genetic materials, while retaining the complex ultrastructure, and it can be used as a scaffold for cell seeding and subsequent transplantation, thereby promoting the regeneration of diseased or damaged tissues and organs. This review provided an overview of decellularization-recellularization technique, and mainly concentrated on the application of decellularization-recellularization technique in the field of plastic and reconstructive surgery, including the remodeling of skin, nose, ears, face, and limbs. Finally, we proposed the challenges in and the direction of future development of decellularization-recellularization technique in plastic surgery.

Surgical outcomes of suprafascial and subfascial radial forearm free flaps in head and neck reconstruction

BACKGROUND

Conventional radial forearm free flaps (RFFFs) are known to be safe, but can result in donor site complications. Based on our experiences with suprafascial and subfascial RFFFs, we evaluated the safety of flap survival and surgical outcomes.

METHODS

This was a retrospective study of head and neck reconstructions using RFFFs from 2006 to 2021. Thirty-two patients underwent procedures using either subfascial (group A) or suprafascial (group B) dissection for flap elevation. Data were collected on patient characteristics, flap size, and donor and recipient complications, and the two groups were compared.

RESULTS

Thirteen of the 32 patients were in group A and 19 were in group B. Group A included 10 men and three women, with a mean age of 56.15 years, and group B included 16 men and three women, with a mean age of 59.11 years. The mean defect areas were 42.83 cm² and 33.32 cm², and the mean flap sizes were 50.96 cm² and 44.54 cm² in groups A and B, respectively. There were 13 donor site complications: eight (61.5%) in group A and five (26.3%) in group B. Flexor tendon exposure occurred in three patients in group A and in none in group B. All flaps survived completely. A recipient site complication occurred in two patients (15.4%) in group A and three patients (15.8%) in group B.

CONCLUSIONS

Complications and flap survival were similar between the two groups. However, tendon exposure at the donor site was less prevalent in the suprafascial group, and the treatment period was shorter. Based on our data, suprafascial RFFF is a reliable and safe procedure for reconstruction of the head and neck.

Robot-assisted radial forearm free flap harvesting: a propensity score-matched case-control study

Although some surgeons prefer anterolateral thigh and latissimus dorsi flap for soft tissue reconstruction in the head and neck area because it minimizes donor site complications, the radial forearm flap remains the workhorse for soft tissue reconstruction due to its reliability. To reduce donor site morbidity, the authors developed a novel technique for radial forearm flap harvesting using a robotic device. 42 radial forearm free flap reconstruction cases were studied, consisting of 31 conventional and 11 robot-assisted cases. 1:1 propensity score matching was done according to age, sex, previous and postoperative radiation therapy history and method used for vein anastomosis. There was no significant difference in flap outcome, which was 100% vitality in the robot-assisted group and 90.9% vitality in the conventional group. The robot-assisted group showed significantly longer mean harvesting time than did the conventional group, being 107.2 min and 67.0 min, respectively. Robot-assisted radial forearm flap harvesting can reduce donor site complications by minimizing incision. When more surgical experience is gained under appropriate case selection, we expect our robot-assisted method will yield a harvesting time similar to that of the conventional method and thus become more reliable and feasible.

Donor site sequelae and patient satisfaction after head and neck reconstruction with a radial forearm free flap

PURPOSE

Radial forearm free flap (RFFF) being a workhorse flap in head and neck reconstruction, we investigated its donor site delayed consequences.

METHODS

Multicentric case series evaluating 189 patients who underwent RFFF for carcinologic reasons at least 6 months before. Patients and surgeon's appreciation regarding the aesthetic and functional consequences of the flap harvest on their daily life were evaluated by questionnaires using likert scales. Medical data were collected from patients' charts retrospectively.

RESULTS

Thirty percent of patients had at least one sequelae. Experiencing a graft necrosis did not worsen long-term results. Cosmetic satisfaction was significantly worst for women, according to patients' and surgeons' opinion. For 81% and 92% patients, respectively, the flap harvest had no impact on daily life nor sport practice. Ratio between the benefits of reconstruction and the sequelae at the donor site was judged "excellent" for 77% patients.

CONCLUSIONS

Although objectively important, RFFF morbidity has little impact in head and neck cancer patient's life.

Radial Flap in Reconstructions of the Hand - Case Series Study

Radial forearm flap is an axial flap that has become an important technique in reconstructive surgery as a free flap or as a pedicled flap. Defects of the skin and other tissues on the hand are very common and most often they are work-related injuries. In deep defects, flap must be used, as well as in reconstruction of the amputated thumb. There are many flaps that provide adequate soft tissue coverage for the hand. Therefore, the aim of this paper is to present the results of the use of radial forearm flap in various reconstructions on the hand. The retrospective study included 35 patients who underwent reconstruction with radial forearm flaps due to defects of the skin and other tissues on the hand, in the period 1997-2019. Results and complications of the surgery were analyzed. The functional and aesthetic outcome was assessed using Michigan Hand Outcome Qusteionnarire. All patients were followed for a minimum of 1 year. Fasciocutaneous flap was the most commonly used (65.71%), followed by adiposofascial (20%) and osteocutaneous (14.29%). The size of the fasciocutaneous flap ranged from 2.2x3.1cm to 9x13.5cm. The majority of donor sites were closed with split-thickness skin grafts (56.52%), and less frequently with direct suture, local skin flap, and full-thickness skin graft. There were no complete flap losses in the study. Marginal necrosis was noted in 8.57%, and graft failure at the donor site in 14.29%. Secondary surgical procedures were performed in 13 patients. The functional-aesthetic result of the operation, based on the MHQ score, ranged from 31 (1/35) to 130 points (3/35). The ultimate aim of hand reconstruction is to restore sufficient function and form, also, closing the wound within three days following the injury is desirable. Meticulous intraoperative dissection of radial flap and early physical therapy after surgery are mandatory. The radial flap is a suitable method, especially for large and more distal skin defects on the hand, and a very good method for thumb reconstruction.

Long-term donor site morbidity after radial forearm flap elevation for tongue reconstruction: Prospective observational study

BACKGROUND

To assess long-term donor site morbidity after radial forearm free (RFF) flap harvesting.

METHODS

Enrolled patients were asked to complete the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and undergo wrist motion and hand strength examinations at different time points. The data were prospectively collected and retrospectively analyzed.

RESULTS

The postoperative DASH score did not return to normal until 24 months after the operation. The mean postoperative wrist motion degree of flexion was significantly decreased compared to the preoperative level and returned to normal at 12 months after the operation. Similar trends were noted regarding extension, radial abduction, and ulnar abduction. The mean postoperative grip strength was significantly decreased compared to the preoperative level and remained dysfunctional at 24 months after the operation. A similar trend was also noted with regard to tip pinch and key pinch.

CONCLUSION

The long-term negative effect on hand strength is sustained.

An Algorithm for the Prevention and Treatment of Pain Complications of the Radial Forearm Free Flap Donor Site

BACKGROUND

 The radial forearm free flap (RFFF) is a staple of microsurgical reconstruction. Significant attention has been paid to donor-site morbidity, particularly vascular and aesthetic consequences. Relatively few authors have discussed peripheral nerve morbidity such as persistent hypoesthesia, hyperesthesia, or allodynia in the hand and wrist or neuroma formation in the wrist and forearm. Here, we present a diagnostic and therapeutic algorithm for painful neurologic complications of the RFFF donor site.

MATERIALS AND METHODS

 The peripheral nerves that can be involved with the RFFF are reviewed with respect to the manner in which they may be involved in postoperative pain manifestations. A method for prevention and for treatment of each of these possibilities is also presented.

RESULTS

 Nerves from the forearm that can be harvested with the RFFF will have the most likelihood for injury and these include the lateral antebrachial cutaneous nerve, the radial sensory nerve, and the medial antebrachial cutaneous nerve. A nerve that may be injured at the distal juncture of the skin graft to the forearm is the palmar cutaneous branch of the median nerve. The "prevention" portion of the algorithm suggests that each nerve divided to become a recipient nerve should have its proximal end implanted into a muscle to prevent painful neuroma. The "treatment" portion of the algorithm suggests that if a neuroma does form, it should be resected, not neurolysed, and the proximal portion should be implanted into an adjacent muscle. The diagnostic role of nerve block is emphasized.

CONCLUSION

 Neurological complications following RFFF can be prevented by an appropriate algorithm as described by devoting attention to the proximal end of recipient nerves. Neurological complications, once present, can be difficult to diagnose accurately. Nerve blocks are critical in this regard and are employed in the treatment algorithm presented.