Long-Term Patient-Reported Outcomes of Radial Forearm Free Flap Donor Site in the Context of Head and Neck Cancer Reconstruction

Abstract

Radial forearm free flap (RAFF) is the workhorse flap for oral cavity reconstruction. In the context of oncological reconstruction with radial forearm flap, the patient-reported outcomes of donor site morbidity amongst Indian patients have not been reported previously. Cultural and racial differences prevent extrapolation of morbidity data from Western literature. We aimed to evaluate subjectively the subjective long-term functional and aesthetic outcomes of the RAFF donor site. Patients who underwent RAFF reconstruction for intra-oral defects between 2014 and 2016 were included. Two questionnaires (Cosmesis and Sensibility and Forearm Disability) were administered. Fifty-two patients who completed a 2-year follow-up were identified. Thirty-five patients (67%) had complaints regarding the donor site. With regard to cosmesis and sensibility, hand numbness was seen in 21 (40.4%) patients. With regard to forearm disability, a problem in lifting heavy weights was seen in 22 (42.3%) patients. Only three patients in the entire cohort had complaints regarding the cosmesis of the forearm scar. Overall disability score was low (7.83). With regard to donor site morbidity, numbness and difficulty in lifting weights was the most common complaint. There is good acceptance of the donor site and scar with minimum morbidity. These findings are useful for the preoperative counselling of the patients. This is the first Indian study evaluating the long-term subjective outcomes of the radial forearm donor site. We believe the RAFF is still the most preferred flap for oral reconstruction.

Introduction

Head and neck cancers are common in Indian subcontinent [1]. Large defects of the oral cavity following ablative surgery require immediate reconstruction to reduce morbidity. Ideal reconstruction should be tailored in such a way that maximizes function of the remaining native tissue in the oral cavity with minimal donor site morbidity [2, 3]. There are several potential donor sites for free tissue transfer. With regard to cheek and tongue defects, a thin and pliable flap is ideal [4, 5].

The radial forearm free flap (RAFF) is a versatile flap for head and neck reconstruction. It is suitable for replacing the tissue in the oral cavity and other areas of head and neck [6]. The good vascularity of the flap and long vascular pedicle makes it a workhorse flap. Being a distant site, two surgical teams can work simultaneously which reduces surgery time [7–10].

The morbidity of radial forearm flap harvest is well known, and this relates to the technique of donor site closure. Few techniques exist to minimize the donor site morbidity [8]. Recent advances and frequent use of other flaps like the anterolateral thigh flap and lateral arm flap have raised questions in reconstructive community regarding acceptance of radial forearm donor site [8, 11, 12]. Hand sensation, grip strength and range of motion at the wrist are important functions in active, daily life, and a compromise can have profound effects on the patient’s quality of life [13, 14]. Current data about RFFF donor site morbidity is from the West and cultural and racial differences prevent extrapolation of data from Western literature. We attempted to study the patient-reported outcomes on the long-term morbidity of the RAFF donor site.

Material and Methods

This is a retrospective study of patients treated at a tertiary care centre between January 2015 and December 2016. All patients underwent adequate treatment for the primary lesion and defect reconstruction was done using the free radial forearm flap. Only patients who had completed 2 years of follow-up and were disease-free were included in the study. A total of 60 patients were identified out of which 52 patients were available for assessing response.

The radial forearm flap was harvested from the non-dominant hand simultaneously with a two-team approach. The flap harvest was with a standard technique and in all cases the branches of the superficial radial nerve and lateral ante-brachial cutaneous nerve of forearm was preserved. Suprafascial dissection was done until the vascular pedicle was reached in the forearm after which the dissection proceeded subfascially. The donor site was closed with a split thickness skin graft from the thigh. The graft was immobilized for 4 days using a rigid slab over the forearm and hand. Graft inspection was done on the 4th post-operative day after which the wound was covered with paraffin impregnated dressing. The donor site sutures were removed on 7th post-operative day. Patients were instructed to mobilize the hand and fingers from day 7.

To evaluate the long-term patient-reported outcomes, we used two questionnaires which have been previously used in the context of RAFF donor site morbidity evaluation in the study by de Witt et al. [13]. Two questionnaires, namely, the Cosmesis and Sensibility and the Disability for hand and forearm. The Cosmesis and Sensibility questionnaire included whether the patient feels any hand numbness, scar itch and cold intolerance over the scar. Also, it inquires whether the patient is bothered about its cosmetic appearance and their ability to wear a bracelet or wristwatch. The forearm disability questionnaire included complaints in daily life activities, lying on the forearm, wrist movements, waking up at night due to scar, leaning of hands/elbows, writing/ typing, holding wheel of a car or a bike, lifting heavy objects and opening or closing a door [13]. Patients were asked to answer the questions with reference to the previous 24 h.

Response possibilities for each question was yes, no or not applicable. Total score was calculated by dividing all yes scores with the total number of questions. The total score ranged from 0 to 100 with 0 indicating no problems (no disability) and 100 indicating severe problems (severe forearm and/or wrist disabilities).

Results

Patient Characteristics

All the patients included in the study were treated between January 2015 and December 2016, with longest follow-up of 4 years and shortest follow-up of 2 years. A total of sixty patients were identified in the study period, out of which 52 were available for participation in the study. The mean age of cohort was 47 years (age range 32–78 years). Majority of patients were male 41 (78.8%) and female 11 (21.2%). The male:female ratio was 3.75:1. There were 4, 23, 9 and 8 cases respectively in T1, T2, T3 and T4 stages. 7 cases were recurrent tumours and 1 case was of palatal fistula repair secondary to tumour surgery.

Sensibility and Cosmesis Analysis

Regarding sensibility and cosmesis evaluation out of fifty-two patients, 24 (46.2%) patients had no complaints. Hand numbness was the most common complaint seen in 21 (40.4%) patients. Scar itching was present in 13.5% [7]. Cosmetic outcome showed that only 3 patients out of 52 (5.8%) were bothered about their donor site appearance and cold intolerance was complained by only 1 patient (1.9%) (Table 1).

Table 1.

Pattern of response with regard to Cosmesis and Sensibility

Questions	No. of positive responses—n (%)
Can you wear bracelet or wrist watch?	0 (0)
Does the hand feel numb?	21(39.6)
Does the scar itch?	7 (13.2)
Do you experience problems in cold?	1(1.9)
Does the appearance bother you?	3(5.7)

Disability Analysis

In the Disability Questionnaire, out of fifty-two patients, 30 (57.7%) patients had no complaints. Lifting heavy weight was the most common complaint seen in 22 (42.3%) cases, 2 patients (3.8%) complained regarding difficulty in holding wheel of car or bike and 1 patient each (1.9%), complained regarding lying on forearm and leaning on the hand or elbow ear. No patients complained regarding wrist movements, writing/typing, opening/closing door and interference in daily life activity (Table 2).

Table 2.

Pattern of response with regard to Disability

Questions	No. of positive responses (%)
I wake up at night because of my forearm	0 (0)
I have complaints lying on my forearm.	1 (1.9)
I have complaints during my daily life activities.	0 (0)
I have complaints during movements of my wrist.	0 (0)
I have complaints during leaning on my elbows or hands.	1 (1.9)
I have complaints during writing or typing.	0 (0)
I have complaints while holding wheel of car or bike.	2 (3.8)
I have complaints during lifting a heavy object.	21 (39.6)
I have complaints during opening or closing a door.	0 (0)

Radial Forearm Morbidity Score Analysis

Subjective evaluation score with regard to radial forearm donor site morbidity shows that minimum score of 0 was reported by 17 (32.7%) amongst 52 patients. The highest score was 21.4 which was reported in 4 (7.7%) patients. The overall mean score of the cohort was 7.83.

Discussion

Oral cavity carcinomas form the vast majority of head and neck cancers in the subcontinent. Wide excision with adequate margins and neck dissection is the primary treatment modality of choice. With large defects, primary reconstruction is recommended to reduce the long-term morbidity and improve functional outcomes. The radial forearm flap is a reliable, easy-to-learn and versatile flap for head and neck reconstruction [9, 10]. The thin pliable skin, long pedicle length and good vascularity make it an ideal flap for resurfacing tongue and cheek defects. However, the donor site morbidity has raised some questions regarding its use and other alternate methods of reconstruction have been proposed [3]. The placement of skin graft on the radial artery donor site is one of the major factors contributing to this morbidity. The technique that ensures graft take is the suprafascial dissection of the radial forearm [7, 16]. The suprafascial dissection ensures that there is an adequate bed for graft uptake. This combined with a negative pressure dressing is recommended for early graft uptake [16].

Objective functional assessment of the forearm donor site has been reported previously in literature Richardson et al showed subjective rating of 63.2-83.7 % impairment in hand function compared to the pre-operative status [17]. Toschka et al studiesd the Raff donor site morbidity in patients where Raff was used for Maxillofacial reconstruction. There was no clinically relevant morbidity of the donor site noticed, however the size of the flap harvested was relatively small [18]. Lutz et al reported that 98% of the patient ratied the aesthetic outcomes to be satisfactory, however all the patients who developed post-operative wound healing complications complained of reduction in grip strength [19]. Nehrer et al described a two staged pre-laminated fasico-mucosal flap for reducing the donor site morbidity and showed significant reduction [20]. Early post-operative morbidity included diminished pronation, supination, wrist flexion, wrist extension and reduction of sensation in the anatomical snuff box [22]. Long-term morbidity studies revealed that pronation at the wrist, manual dexterity and sensation were found to be reduced in the donor side compared to the non-donor side [23]. De Bree and colleagues evaluated the morbidity of the radial forearm donor site. Their evaluation consisted of a questionnaire and objective tests to check for differences in the strength between the donor hand and the normal side. The questionnaire evaluation revealed that 24% of patients reported impaired function. The most common complaint was inability to wear a watch or bracelet and 14% complained of bad cosmetic scar [15].

Ito and colleagues evaluated the cosmesis of the donor site in patients who had reconstruction of the oral defects. In their series of 23 patients, five characteristics of the scar were evaluated (pigmentation, scar width, depression, wrist mobility and sensation). A majority of their patients had no concern with regard to the donor site (60.9%). Depression of the scar site was the most significant complaint (30.4%). They also reported that the scar becomes important to the patient after 1 year of the primary treatment [21]. However, it is to be noted that their study included patients who had medium size defects, and, in their patients, a full thickness skin graft was used to close the donor site defect.

We chose to conduct the study using a subjective assessment for two reasons. First, extrapolation of the patient-reported outcomes from Western data is not appropriate due to racial and cultural differences. Second, we wished to study the morbidity and perception of the donor site in patients who have completed a minimum 2-year follow-up. In the questionnaire regarding Cosmesis and Sensibility, the most common concern of the patients was found to be hand paresthesia (40.4%) and scar itch (13.5%), whereas de Witt et al. reported that the most common impairment was ability to wear bracelet or wrist watch (24%) followed by hand paresthesia and scar itch or both (22%) [13]. None of the patients in our study population showed concern regarding ability to wear bracelet or wrist watch. Other concerns regarding appearance and cold intolerance were showed by and 5.7% and 1.9% of the patients respectively.

It is interesting to note that only 3 out of 52 (5.8%) patients in our study had complaints regarding the cosmesis of the scar. This is in contrast with the findings of the study by de Witt wherein 27% of patients had problems with scar cosmesis. This is an important finding to note as it is common perception amongst surgeons that the donor site scar appearance is most relevant in the RAFF donor site. Regarding the Disability evaluation, the most common complaint in our study was found to be difficulty in lifting heavy weights (42.3%) which was quite similar with the result in study by de Witt et al. [13]. The disparity in lifting heavy weights could exist preoperatively as it is the non-dominant forearm from where the flap is elevated and may relate only in part to the flap harvest. Other complaints included difficulty in holding wheel of car or bike handle (3.8%), difficulty in leaning on hands or elbow (1.9%) and difficulty in lying on forearm (1.9%). However, it is to note that the mean score of the entire cohort was only 7.83, indicating minimal subjective morbidity. Overall, there was good acceptance of the donor site and none of the patients reported any major impairment in their day-to-day activities which is evident by the low overall score.

Conclusion

Long-term subjective evaluation of the RAFF donor site indicates good acceptance of scar with regard to morbidity and cosmesis. Problems that are most common include paresthesia and difficulty in lifting heavy weights. The data from our study could be used for pre-operative counselling of the patients. We believe that the RAFF is still the most preferred flap for oral cavity reconstruction due to its acceptable donor site characteristics.