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J Reconstr Microsurg 2020; 36(09): 680-685
DOI: 10.1055/s-0040-1714149
Original Article

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

Nicholas A. Calotta
1   Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
,
Akash Chandawarkar
1   Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
,
Shaun C. Desai
2   Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
,
A. Lee Dellon
1   Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
3   Dellon Institutes for Peripheral Nerve Surgery, Baltimore, Maryland
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Abstract

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.

Keywords

neuroma - radial forearm free flap - pain


Publication History

Received: 06 January 2020

Accepted: 28 May 2020

Article published online:
29 July 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.

 

  • References

  • 1 Yang GF, Chen PJ, Gao YZ. , et al. Forearm free skin flap transplantation: a report of 56 cases. 1981. Br J Plast Surg 1997; 50 (03) 162-165
    CrossrefPubMedGoogle Scholar
  • 2 Matti BA, Matthews RN, Davies DM. Phalloplasty using the free radial forearm flap. Br J Plast Surg 1988; 41 (02) 160-164
    CrossrefPubMedGoogle Scholar
  • 3 Longo B, Sorotos M, Laporta R, Santanelli di Pompeo F. Aesthetic improvements of radial forearm flap donor site by autologous fat transplantation. J Plast Surg Hand Surg 2019; 53 (01) 51-55
    CrossrefPubMedGoogle Scholar
  • 4 Bardsley AF, Soutar DS, Elliot D, Batchelor AG. Reducing morbidity in the radial forearm flap donor site. Plast Reconstr Surg 1990; 86 (02) 287-292 , discussion 293–294
    CrossrefPubMedGoogle Scholar
  • 5 Lindau RH, Wax MK. Abnormal anatomy of the superficial branch of the radial nerve. Head Neck 2013; 35 (09) E262-E263
    CrossrefPubMedGoogle Scholar
  • 6 Abrams RA, Brown RA, Botte MJ. The superficial branch of the radial nerve: an anatomic study with surgical implications. J Hand Surg Am 1992; 17 (06) 1037-1041
    CrossrefPubMedGoogle Scholar
  • 7 Boutros S, Yuksel E, Weinfeld AB, Alford EL, Netscher DT. Neural anatomy of the radial forearm flap. Ann Plast Surg 2000; 44 (04) 375-380
    CrossrefPubMedGoogle Scholar
  • 8 Mackinnon SE, Dellon AL. The overlap pattern of the lateral antebrachial cutaneous nerve and the superficial branch of the radial nerve. J Hand Surg Am 1985; 10 (04) 522-526
    CrossrefPubMedGoogle Scholar
  • 9 Dellon AL, MacKinnon SE. Injury to the medial antebrachial cutaneous nerve during cubital tunnel surgery. J Hand Surg [Br] 1985; 10 (01) 33-36
    CrossrefPubMedGoogle Scholar
  • 10 Dellon AL, Mackinnon SE. Radial sensory nerve entrapment in the forearm. J Hand Surg Am 1986; 11 (02) 199-205
    CrossrefPubMedGoogle Scholar
  • 11 Ehrlich W, Dellon AL, Mackinnon SE. Classical article: Cheiralgia paresthetica (entrapment of the radial nerve). A translation in condensed form of Robert Wartenberg's original article published in 1932. J Hand Surg Am 1986; 11 (02) 196-199
    CrossrefPubMedGoogle Scholar
  • 12 Naff N, Dellon AL, Mackinnon SE. The anatomical course of the palmar cutaneous branch of the median nerve, including a description of its own unique tunnel. J Hand Surg Br 1993; 18 (03) 316-317
    CrossrefPubMedGoogle Scholar
  • 13 Evans GR, Dellon AL. Implantation of the palmar cutaneous branch of the median nerve into the pronator quadratus for treatment of painful neuroma. J Hand Surg Am 1994; 19 (02) 203-206
    CrossrefPubMedGoogle Scholar
  • 14 Harris BN, Bewley AF. Minimizing free flap donor-site morbidity. Curr Opin Otolaryngol Head Neck Surg 2016; 24 (05) 447-452
    CrossrefPubMedGoogle Scholar
  • 15 Wood JW, Broussard KC, Burkey B. Preoperative testing for radial forearm free flaps to reduce donor site morbidity. JAMA Otolaryngol Head Neck Surg 2013; 139 (02) 183-186
    CrossrefPubMedGoogle Scholar
  • 16 Yun TK, Yoon ES, Ahn DS. , et al. Stabilizing morbidity and predicting the aesthetic results of radial forearm free flap donor sites. Arch Plast Surg 2015; 42 (06) 769-775
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 Hekner DD, Abbink JH, van Es RJ, Rosenberg A, Koole R, Van Cann EM. Donor-site morbidity of the radial forearm free flap versus the ulnar forearm free flap. Plast Reconstr Surg 2013; 132 (02) 387-393
    CrossrefPubMedGoogle Scholar
  • 18 Orlik JR, Horwich P, Bartlett C, Trites J, Hart R, Taylor SM. Long-term functional donor site morbidity of the free radial forearm flap in head and neck cancer survivors. J Otolaryngol Head Neck Surg 2014; 43: 1
    CrossrefPubMedGoogle Scholar
  • 19 Fang QG, Shi S, Zhang X, Li ZN, Liu FY, Sun CF. Upper extremity morbidity after radial forearm flap harvest: a prospective study. J Int Med Res 2014; 42 (01) 231-235
    CrossrefPubMedGoogle Scholar
  • 20 Sinclair CF, Gleysteen JP, Zimmermann TM. , et al. Assessment of donor site morbidity for free radial forearm osteocutaneous flaps. Microsurgery 2012; 32 (04) 255-260
    CrossrefPubMedGoogle Scholar
  • 21 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
    CrossrefPubMedGoogle Scholar
  • 22 Nehrer-Tairych GV, Millesi W, Schuhfried O, Rath T. A comparison of the donor-site morbidity after using the prelaminated fasciomucosal flap and the fasciocutaneous radial forearm flap for intraoral reconstruction. Br J Plast Surg 2002; 55 (03) 198-202
    CrossrefPubMedGoogle Scholar
  • 23 Taghinia AH, Upton J. The radial forearm flap. In: Wei F-C, Mardini S. , eds. Flaps and Reconstructive Surgery, 2nd ed. Philadelphia, PA: Elsevier; 2017: 538
    Google Scholar
  • 24 Mackinnon SE. Evaluation and treatment of the painful neuroma. Tech Hand Up Extrem Surg 1997; 1 (03) 195-212
    CrossrefPubMedGoogle Scholar
  • 25 Dellon AL. Painful neuromas. In: Mathes SJ. , ed. Plastic Surgery, 2nd ed. Philadelphia, PA: Elsevier; 2006: 929-947
    Google Scholar
  • 26 Dellon AL, Mackinnon SE. Treatment of the painful neuroma by neuroma resection and muscle implantation. Plast Reconstr Surg 1986; 77 (03) 427-438
    CrossrefPubMedGoogle Scholar
  • 27 Mackinnon SE, Dellon AL. Results of treatment of recurrent dorsoradial wrist neuromas. Ann Plast Surg 1987; 19 (01) 54-61
    CrossrefPubMedGoogle Scholar
  • 28 Van Kouwenberg EA, Yan A, Patel A. , et al. Endoscopic-assisted radial forearm free flap harvest: a novel technique to reduce donor site morbidity. J Reconstr Microsurg 2019; 35 (01) 22-30
    Article in Thieme ConnectPubMedGoogle Scholar