A technique for primary closure of the free radial artery forearm flap donor site – Early results

Dhanushya Gohil; Dushyant Mandlik; Yusuf Abbas Mistry; Purvi Patel; Aditya Joshipura; Gurpreet Kaur; Kaustubh Patel

doi:10.4103/jhnps.jhnps_6_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 10 | Issue : 1 | Page : 75-79

A technique for primary closure of the free radial artery forearm flap donor site – Early results

Dhanushya Gohil¹, Dushyant Mandlik², Yusuf Abbas Mistry², Purvi Patel², Aditya Joshipura², Gurpreet Kaur², Kaustubh Patel²
¹ Department of Plastic and Reconstructive (Onco-Plastic) Surgery, HCG Cancer Center, Ahmedabad, Gujarat, India
² Department of Head and Neck Oncology and Reconstructive Surgery, HCG Cancer Center, Ahmedabad, Gujarat, India

Date of Submission	29-Jan-2022
Date of Decision	04-Mar-2022
Date of Acceptance	06-Mar-2022
Date of Web Publication	23-Jun-2022

Correspondence Address:
Dhanushya Gohil
Department of Plastic and Reconstructive (Onco-Plastic) Surgery, HCG Cancer Center, Sola, Science City Road, Ahmedabad - 380 060, Gujarat
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jhnps.jhnps_6_22

Abstract

Introduction: Free radial artery forearm flap is a feasible reconstructive option for small defects in the head and neck. However, one of the major drawbacks is covering of the donor site with split-thickness graft, which leads to donor site morbidity, in terms of compromised cosmesis. An alternative strategy to close this defect primarily, utilizing native skin, can be helpful to mitigate this issue. Materials and Methods: We have described a technique of primary closure of donor site defect of the radial forearm flap using a transposition flap in 24 patients. The principle used is to transpose the ulnar skin flap which derives its blood supply from the perforators of the ulnar artery. The efficacy and complications were recorded and described. Results: We were able to close defects of up to 8 cm × 5 cm using this technique. No major complications were reported in any patients. Seven (29.1%) patients had small areas of necrosis at the tri-pointer area and skin edge. All of them healed using conservative measures by secondary intention except one case which required a secondary skin grafting procedure. Hypertrophic scarring was seen in three patients. Conclusions: This technique has many advantages over traditional skin grafting such as improved cosmesis, avoidance of a secondary donor site, and skin graft-associated complications. Further studies to prove the efficacy of this technique with objective function evaluation over a larger cohort are desirable.

Keywords: Donor site closure, microvascular, radial forearm flap

How to cite this article:
Gohil D, Mandlik D, Mistry YA, Patel P, Joshipura A, Kaur G, Patel K. A technique for primary closure of the free radial artery forearm flap donor site – Early results. J Head Neck Physicians Surg 2022;10:75-9

How to cite this URL:
Gohil D, Mandlik D, Mistry YA, Patel P, Joshipura A, Kaur G, Patel K. A technique for primary closure of the free radial artery forearm flap donor site – Early results. J Head Neck Physicians Surg [serial online] 2022 [cited 2022 Jun 27];10:75-9. Available from: https://www.jhnps.org/text.asp?2022/10/1/75/347991

Introduction

Reconstruction of small defects in head and neck is a challenging task for reconstructive surgeons. Surgeons lean toward utilizing local tissues for smaller defects which may result in compromised function and cosmesis. With the introduction and popularization of free microvascular flaps, there has been a shift in practice toward reconstruction of these defects with microvascular flaps, resulting in better function and cosmesis.^[1],[2]

Free radial artery forearm flap (FRAFF) is a feasible reconstructive option for smaller defects. However, one of the major drawbacks is covering of the donor site with split-thickness graft (STG), which leads to donor site morbidity, in terms of compromised cosmesis.^[3]

An alternative strategy to close this defect primarily, utilizing native skin, can be helpful to mitigate this issue. The principle used is to transpose the ulnar skin flap which derives its blood supply from the perforators of the ulnar artery.

We hereby present a study of primary closure of donor site defect using a transposition flap.

Materials and Methods

The study was conducted from March 2019 to July 2020 in our institute. Preoperatively, all patients were evaluated for adequate perfusion using Allen's test of nondominant hand. A pinch test was performed on the patient to evaluate the pliability of the skin. Any defect which required a skin paddle of <5 cm width was evaluated for the feasibility of primary closure. As a rule of thumb, the mid-forearm girth was measured and any requirement greater than 1/3^rd of the forearm girth was rejected for primary closure technique. For example, if the mid-forearm girth was 12 cm then primary closure was attempted only if defect size was 4 cm or less. Exception to this rule was excessive skin pliability (as in the case of old patients or lean female patients) where primary closure could be attempted for a defect greater than 1/3^rd of the forearm girth. Patients with previous scars and highly obese patients were excluded from the study. This method of closure was used in 24 patients. All patients were followed up regularly at intervals of 3 weeks, 6 weeks, and 3 and 6 months for evaluation of donor sites.

Method of harvesting the flap:

The flap skin paddle was designed as rhomboid with rounded edges in the distal aspect of the forearm such that the maximum length of the vascular pedicle gets incorporated [Figure 2]a
The ulnar edge of the skin paddle was marked approximately 0.5 cm ulnar to Palmaris Longus tendon (which can be included if necessary), and the radial edge was marked in the dorsum of the wrist distally according to the skin paddle required, taking care that cephalic vein gets incorporated in the flap
The skin paddle was planned as a rhomboid such that the distal point of the ulnar edge formed the obtuse angle of the rhomboid and the distal point of the radial edge formed the acute angle [Figure 1]
A proximal curvilinear incision from the proximal corner of the radial skin paddle edge was marked up to the cubital fossa for dissection of the vascular pedicle and back cut was given if required at the proximal end of forearm incision
The flap was then raised in standard manner, preserving the superficial cutaneous branch of the radial nerve. Radially, the skin was raised just enough to allow dissection of the cephalic vein. We try to preserve as many musculocutaneous perforators on that aspect as possible [Figure 2]b
After harvesting the flap, the triangular skin flap on the proximal aspect was transposed into the defect as distally as possible and sutured to the ulnar edge [point x in [Figure 2]c and [Figure 2]d]. The remaining triangular defect on the distal aspect was then closed primarily [point y in [Figure 2]c and [Figure 2]d]. A K-90 drain was kept at the proximal end
Tension while suturing was minimized by keeping the wrist in slight palmar-flexion. A splint was given postoperatively for 1 week to maintain this position.

Figure 1: Schematic diagram

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Figure 2: Steps of harvesting the flap (a) Markings (b) Raising of the flap (c) Donor site defect (d) Final closure after drain placement

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On the 3^rd postoperative day, the suture line was inspected for healing and related issues. If indicated, the drain was also removed on the 3^rd day.

After 2 weeks, the dressing and sutures were removed.

Hand function was assessed at 3 and 6 months. Motor function assessment was done by examining wrist movement (flexion, extension, radial, and ulnar deviation) and fingers' grip, comparing the operated hand with the nonoperated hand. Sensation was assessed by cotton swab test at the dorsal aspect of the first web space of the operated hand.

Results

Twenty-four patients were selected for the study. The mean age of the participants was 50.1 years (Min = 26, Max = 72). Half (50%) of the defects were arising from small buccal mucosa resections. Other sites reconstructed were tongue (46.1%) and lower alveolus (8.3%) [Table 1].

Table 1: General Charactristics an Complications

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The maximum length of the flap (proximal-distal) used was 8 cm and the maximum width that enabled primary closure was 5 cm. Overall, the average area of skin paddle was 23.5 ± 2.5 cm². The pedicle length varied between 9 cm and 14 cm depending on the forearm size [Table 1] and [Figure 3].

Figure 3: Results of primary closure. (a) Result in an old-age patient (b) Healing by secondary intention near tip (c) Complete healing of case in [Figure 2] (d) Result in a young female with normal flexion movement

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None of the patients developed wound infection. Tip necrosis at the tri-pointer area was the most common complication (n = 7). Proximal skin edge necrosis and wound gaping was noted in one case each. Six cases had necrosis area less than 1 cm × 1 cm near the distal tip of the flap. One case had raw area of 3 cm × 3 cm. A STG was done after 14 days in this case. Except this, all other cases healed well with secondary intention within 3 months of surgery.

There were three cases of hypertrophic scarring (12.5%) [Figure 4] and [Table 1].

Figure 4: Complications (a) Tip necrosis (b) Tip edge necrosis. Both healed by secondary intention (b and c) Large area of necrosis which required secondary grafting (d) Hypertrophic scar

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Patients who developed hypertrophic scars reported no change in hand function.

Sensation was normal in all except 1 case, having paraesthesia in the superficial radial nerve sensory area.

Discussion

We come across many small size defects in the head and neck, where a local flap closure is possible, but compromises local cosmesis and function. FRAFF is one of the highly utilized flaps for reconstruction, especially in small size defects.^[4] Routinely, FRAFF donor site is covered with STG which can result in sequelae such as graft loss, tendon exposure, and delayed healing.^[5] That can considerably hamper the patients' recovery and resumption of normal life. Moreover, the poor esthetics is often a cause of concern.

We observed that the donor site used for these small defects can be reconstructed utilizing local skin by modifying the design of skin paddle and using a transposition flap.

According to the reconstructive ladder for any small wound, primary closure offers the best healing. In this regard, various attempts have been made to primarily close the radial forearm surgical defect. There is scanty literature regarding primary closure of the forearm after harvesting the radial flap.

One of the earliest attempts to achieve primary closure was by Hui et al.^[6] in 1999 who described a primary closure technique using a Z-plasty and another case report was published by Akyürek and Safak^[7] in 2001 describing a double-opposing rhomboid transposition flap using an oblique skin incision. They noticed that the drawbacks of these methods were that only very small defects could be closed by this method and it also involved a very long scar line.

Other methods such as ulnar-artery-based local flaps either as V-Y sliding flaps^[8] or perforator island flaps as described by Juretic et al.^[9] have been used. However, according to the study, drawback of these flaps is that they require an extensive amount of mobilization of skin and hence predispose to denervation of extensive areas of forearm and lymphedema of the hand. A series of such an ulnar artery perforator-based flaps was published by Hsieh et al.^[10] with encouraging results.

Jaquet et al.^[11] conducted a case–control study between ulnar-based transposition flap (UBTF) and STG. Although they admitted that they were only able to use it for small defects, they found no significant differences in function, pinch and grip strength, hand sensitivity, and visual analog scale scores between the UBTF and STG groups.

Perhaps, the largest series of direct closure was reported by Lane et al.^[12] in 2012. They reported a series of 45 closures using a “Hatchet Flap.” They were able to harvest areas up to 7.6 cm in length and 4.5 cm in width. Apart from minor wound complications in 42% of patients, they reported excellent long-term result of these patients in terms of function and cosmesis.

Few other scattered reports and series have been presented in literature, each with its pros and cons.

One of the main reasons to attempt a primary closure in all these reports is reduction in donor site morbidity. A traditional STG over the donor site has many inherent drawbacks as described earlier.

The technique described by us, firstly, avoids the need for a second donor site (usually the thigh) which is helpful in avoiding much discomfort and complications of STG harvest itself.

In our experience, more often than not, the patient complains about pain and itching on the STG donor site than the forearm or primary surgical site. The complications of donor site healing of STG such as itching, infection, dyschromia, hypo-pigmentation, hyper-pigmentation, and hypertrophic scars,^[13] though rare, are also avoided.

Secondly, a primary closure of the forearm inherently avoids most complications in the forearm such as partial or complete graft loss and tendon exposure.^[5]

Compared to other methods of primary closure described above in literature, the technique developed by us avoids extensive mobilization of forearm skin, hence preventing hematoma and avoiding excessive edema. The resultant scar on the forearm is esthetically acceptable and offers much better cosmesis than a traditional skin grafted site as shown in [Figure 3].

The only complication of this technique we observed in this study is that small areas of tip necrosis at site closure were seen in 29.1% of the patients. However, these patients were treated with conservative measures and healed with secondary intention (except one case which required a secondary skin grafting procedure). Another shortcoming of this study is that we have not objectively evaluated hand function and scar cosmesis although all patients agreed that they had no functional deficit and were content with their scar.

Conclusions

This technique has many advantages over traditional skin grafting such as improved cosmesis, avoidance of a secondary donor site, and skin graft-associated complications. Tip necrosis and hypertrophic scar were the complications faced by us.

We recommend our technique over skin grafting in carefully selected cases in which the skin defect in the forearm is small, for primary closure of donor site. A drawback of the study was a short follow-up time and small sample size. Further studies with longer follow-ups and larger numbers are desirable.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer reviewed publication.

Ethical approval

The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

References

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2.	Ji YB, Cho YH, Song CM, Kim YH, Kim JT, Ahn HC, et al. Long-term functional outcomes after resection of tongue cancer: Determining the optimal reconstruction method. Eur Arch Otorhinolaryngol 2017;274:3751-6.
3.	Bardsley AF, Soutar DS, Elliot D, Batchelor AG. Reducing morbidity in the radial forearm flap donor site. Plast Reconstr Surg 1990;86:287-92.
4.	Soutar DS, Scheker LR, Tanner NS, McGregor IA. The radial forearm flap: A versatile method for intra-oral reconstruction. Br J Plast Surg 1983;36:1-8.
5.	Richardson D, Fisher SE, Vaughan ED, Brown JS. Radial forearm flap donor-site complications and morbidity: A prospective study. Plast Reconstr Surg 1997;99:109-15.
6.	Hui KC, Zhang F, Lineaweaver WC. Z-plasty closure of the donor defect of the radial forearm free flap. J Reconstr Microsurg 1999;15:19-21.
7.	Akyürek M, Safak T. Direct closure of radial forearm free-flap donor sites by double-opposing rhomboid transposition flaps: Case report. J Reconstr Microsurg 2002;18:33-6.
8.	Elliot D, Bardsley AF, Batchelor AG, Soutar DS. Direct closure of the radial forearm flap donor defect. Br J Plast Surg 1988;41:358-60.
9.	Juretic M, Car M, Zambelli M. The radial forearm free flap: Our experience in solving donor site problems. J Craniomaxillofac Surg 1992;20:184-6.
10.	Hsieh CH, Kuo YR, Yao SF, Liang CC, Jeng SF. Primary closure of radial forearm flap donor defects with a bilobed flap based on the fasciocutaneous perforator of the ulnar artery. Plast Reconstr Surg 2004;113:1355-60.
11.	Jaquet Y, Enepekides DJ, Torgerson C, Higgins KM. Radial forearm free flap donor site morbidity: Ulnar-based transposition flap vs. split-thickness skin graft. Arch Otolaryngol Head Neck Surg 2012;138:38-43.
12.	Lane JC, Swan MC, Cassell OC. Closure of the radial forearm donor site using a local hatchet flap: Analysis of 45 consecutive cases. Ann Plast Surg 2013;70:308-12.
13.	Otene CI, Olaitan PB, Ogbonnaya IS, Nnabuko RE. Donor site morbidity following harvest of split-thickness skin grafts in south Eastern Nigeria. J West Afr Coll Surg 2011;1:86-96.