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Abstract

Objective

To determine the effect of radial forearm free (RFF) flap harvest on patient-reported postoperative upper extremity disability.

Methods

Patients undergoing RFF flap reconstruction following resection of head and neck cancer were recruited and matched with similar patients undergoing non-RFF reconstruction. All subjects completed the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire preoperatively and at least 1 year postoperatively.

Results

Postoperative DASH scores were significantly higher (more severe disability) in patients undergoing RFF flap reconstruction (6.93 ± 5.54; n = 52) compared with those undergoing non-RFF flap surgeries (2.95 ± 4.42; n = 52). Preoperative DASH score, flap size, patient age and tumour stage were significantly correlated with postoperative DASH score.

Conclusion

Excluding the effect of neck dissection, RFF flap reconstruction has a significant deleterious effect on upper extremity function.

Keywords

Radial forearm free flap upper extremity function questionnaire neck dissection

Introduction

The radial forearm free (RFF) flap was introduced in 1981¹ and has become widely used in reconstructive head and neck surgery. The procedure is useful for repairing head and neck defects, as it provides reliable anatomy, long pedicle length, good size vessels, sufficient skin thickness and lack of hair.^2,3 Donor site complications can arise, however, including poor cosmetic appearance and functional morbidity following the sacrifice of a major artery.^4–8 RFF flaps have been found to have widely varying effects on hand function,^4–11 but studies of their effect on upper extremity function are few and have failed to take into consideration the possible effect of neck dissection.^4,5,8,9 The aim of the present prospective matched-pair study was to determine the effect of the RFF flap on upper extremity function.

Patients and methods

Study population

The study recruited consecutive patients undergoing RFF flap reconstruction following resection of head and neck cancer at the Department of Oral and Maxillofacial Surgery Tumour Centre, China Medical University, Liaoning, China, between January 2008 and December 2011. The control group comprised individuals undergoing non-RFF flap reconstruction surgeries following resection of head and neck cancer. They were also recruited between January 2008 and December 2011. Control subjects were matched to patients by age (±5 years), sex, primary cancer site and neck treatment (selective neck dissection; modified radical neck dissection). All tumours were graded according to the Union for International Cancer Control (UICC) classification system.¹²

All study subjects were asked to complete the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire¹³ preoperatively and ≥1 year postoperatively. The DASH questionnaire measures upper extremity disabilities from the patient’s perspective, and evaluates disability regardless of which arm, shoulder or hand the patient uses to perform the activity. The questionnaire comprises 30 items, with a higher score indicating more severe disability.

The institutional research committee of China Medical University approved the study and all participants provided written informed consent.

RFF flap reconstruction

In RFF flap reconstruction, flap elevation in the left arm and recipient site surgery were performed simultaneously to shorten the total duration of surgery. The radial artery and cephalic vein were used as donor vessels and closure of the donor site was performed via full-thickness skin graft from the abdomen. The lower arm was immobilized in a splint, and the first bandage change was performed on the fifth day postoperatively. Postoperative flap control was performed hourly during the first 24 h and then every 4 h for the next 2 days.

Statistical analyses

Data were presented as mean ± SD or median (range). Between-group comparisons were made with paired t-test. Pearsons’s and Spearman’s correlation analyses were used to determine the predictive factors for postoperative DASH score. Statistical analyses were conducted using SPSS® version 13.0 (SPSS Inc., Chicago, IL, USA) for Windows®. P-values < 0.05 were considered statistically significant.

Results

The study recruited 69 patients with RFF flap reconstruction, 17 of whom died during follow-up and so were excluded from the final analysis. The study therefore included a total of 52 cases (34 male/18 female; mean age 55.6 ± 9.1 years; age range: 33–72 years). All patients received unilateral or bilateral neck dissections: 47 cases were selective neck dissection (SND) and five cases were modified radical neck dissection (MRND). According to the UICC classification system,¹² one tumour was stage T1, 11 were T2, 20 were T3 and 20 were T4. The primary cancer sites were: tongue, 24 cases; floor of mouth, 12 cases; gingiva, 7 cases; cheek, 8 cases; and lip, one case. The mean flap size was 58.9 cm² (range: 24–150 cm²). Partial necrosis occurred in four skin grafts and there were no total failures. All flaps survived, but three required immediate re-exploration because of complications (haematoma).

The control group comprised 52 patients (34 male/18 female; mean age 55.8 ± 9.3 years; age range: 34–75 years). Reconstruction methods were primary closure (n = 6), platysma myocutaneous flap (n = 8), submental island flap (n = 8) and anterolateral thigh flap (n = 30).

In the RFF flap group, postoperative DASH scores were significantly higher than preoperative scores (6.93 ± 5.54 vs. 2.58 ± 3.44; P < 0.001). There was no significant difference in preoperative and postoperative DASH scores in the control group, however (2.28 ± 3.32 and 2.95 ± 4.42, respectively). Postoperative DASH scores were significantly higher in the RFF flap group than the control group (6.93 ± 5.54 vs. 2.95 ± 4.42; P < 0.001).

Correlation analysis showed that preoperative DASH score (r = 0.851, P < 0.001), flap size (r = 0.293, P = 0.035), patient age (r = 0.417, P = 0.002) and tumour stage (r = 0.333, P = 0.016) were significantly associated with postoperative DASH score.

Discussion

The shoulder is an important component of the upper extremity, and any shoulder impairment is likely to lead to upper extremity dysfunction. The effects of SND and MRND on shoulder function are insufficiently investigated, with studies reporting varying levels of impairment.^14–16 It has been shown that non-SND reconstruction is a risk factor for a restricted range of shoulder motion, but the follow-up time of this study was extremely short and only 16.7% of patients underwent RFF flap reconstruction.¹⁷ Other studies have found that the use of a pectoralis major flap induced shoulder dysfunction.¹⁸ Control patients undergoing non-RFF flap reconstruction in the present study had slightly higher postoperative DASH scores than preoperative scores, but this was not statistically significant. In order to exclude the effect of neck dissection and directly evaluate the role of RFF flap surgery in upper extremity morbidity, patients in the present study were matched with a control patient undergoing non-RFF flap reconstruction.

The effects of SND and MRND on shoulder function are insufficiently investigated. Studies have variously reported 25% of patients with forearm disabilities,⁴ none or minimal disability in the majority of patients (58.3%),⁸ and moderate or extreme dysfunction in most cases (exact data not available).⁵ This between-study variation may be due to differences in sample size. A further study demonstrated disability of the upper extremity by analysing donor forearm supination and pronation and reported a significant reduction in the range of motion, but the follow-up time was only 5–8 days.⁹ All of these studies were retrospective, and the scales used to evaluate disability were simplistic or designed by the authors themselves, limiting the validity of the data. The present study used the DASH questionnaire,¹³ which is multifactorial and has sufficient detail to identify subtle changes. In addition, the questionnaire is brief and self-administered, and reflects the disability perceived by the patient. This scale has been validated in several studies.^5,8,11

There are few prospective studies regarding the effect of RFF flap reconstruction on function. When preoperative and postoperative forearms were compared with nonoperated forearms, there were statistically significant differences in wrist flexion, pinch strength and sensation, but no subjective complaints of loss of function by any patient.¹⁰ Others found small reductions in forearm circumference and wrist mobility, and restricted function of the donor arm in 16% of patients after fasciocutaneous RFF flap harvest.¹⁹ In a series of 50 patients undergoing RFF flap harvest, grip power and wrist flexion were significantly decreased after surgery compared with preoperative values.²⁰ In contrast to the present report, none of these studies took the possible effect of neck dissection into account. The current data show that RFF flap reconstruction significantly increased upper extremity disability compared with preoperative function. It should be noted, however, that the current patients were evaluated at least 1 year after surgery, and had been prescribed post-discharge physical therapy. Others have shown that disability improved with time, and rehabilitation played an important role in promoting function and reducing pain.^9,21–24

Some studies have focused on wrist mobility, but the effect of RFF flap harvest on this parameter is unclear.^7–10 In addition, it has been shown that objective measurements do not accurately reflect the patient’s experience.^4,6 This may be because the majority of RFF flaps are harvested from the non-dominant arm, and the reduction in wrist motion was not severe enough to impact significantly on daily life. The present study therefore did not analyse wrist mobility because of its limited clinical significance.

Older age was predictive of high postoperative DASH score in the present study, conversely to the findings of others.⁵ The current study is the first to report the correlations between postoperative function and preoperative DASH score, flap size and tumour stage. Further studies are required to clarify these findings, in particular the relationship between postoperative function and tumour stage.

In conclusion, excluding the effect of neck dissection, RFF flap reconstruction has a significant deleterious effect on upper extremity function.

Footnotes

Declaration of conflicting interest

The authors declare that there is no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

References

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Upper extremity morbidity after radial forearm flap harvest: a prospective study

Abstract

Objective

Methods

Results

Conclusion

Keywords

Introduction

Patients and methods

Study population

RFF flap reconstruction

Statistical analyses

Results

Discussion

Footnotes

Declaration of conflicting interest

Funding

References