The radial artery forearm flap (RAFF) is a versatile free tissue transfer used for many clinical presentations. RAFF donor sites typically require a split-thickness skin graft (STSG) for closure. Whilst early rehabilitation of RAFF donor site(s) following STSG commonly involves wrist immobilisation, best practice for this immobilisation procedure remains unknown.
Purpose of the Study
The purpose of this study was to systematically ‘map’ wrist immobilisation methods post-STSG of the RAFF wound and explore the impact of immobilisation methods on donor site morbidity.
Methods
A scoping review was completed. Literature searching was conducted from database inception to February 1, 2024 in PubMed, Medline, Cochrane, CINAHL, Embase, Web of Science. Title/abstract screening was conducted by one researcher, full text screening was conducted by two researchers independently. Data extraction included number of participants, participant age and gender, wrist immobilisation details and reported donor site complications. Critical appraisal of articles was not completed.
Results
Thirty-seven studies were included in the review. Thermoplastic orthoses (TPO) or ‘splinting’ (n = 22) and plaster casts (n = 8) were the most frequent immobilisation methods reported with 7 days (n = 15) the most frequent immobilisation period. Detail regarding type of TPO material and location/design of the splint/cast was limited. Frequent donor site morbidities included graft complications (n = 18), changes in sensation (n = 9) and infection (n = 7).
Conclusion
Best practice wrist immobilisation procedure for RAFF donor site following STSG cannot be concluded at this time. Additional prospective research is recommended to evaluate the association between wrist immobilisation and donor site morbidity for this complex procedure.
AveryCMPereiraJBrownAE. Suprafascial dissection of the radial forearm flap and donor site morbidity. Int J Oral Maxillofac Surg2001; 30(1): 37–41.
2.
MeekMFVermeyARobinsonPH, et al.Radial forearm flap: eight years experience with oral and oropharyngeal reconstructions - donor and acceptor site morbidity. Eur J Plast Surg1998; 21: 293–298.
3.
BoaheneKRichmonJByrneP, et al.Hinged forearm split-thickness skin graft for radial artery fasciocutaneous flap donor site repair. Arch Facial Plast Surg2011; 13(6): 392–394.
4.
ClarkJMRychlikSHarrisJ, et al.Donor site morbidity following radial forearm free flap reconstruction with split thickness skin grafts using negative pressure wound therapy. Le Journal d'oto-rhino-laryngologie et de chirurgie cervico-faciale [Journal of otolaryngology - head & neck surgery]2019; 48(1): 21.
5.
TimmonsMJ. The vascular basis of the radial forearm flap. Plast Reconst Surg1986; 77(1): 80–92.
6.
FataniB. Radial forearm free flap for head and neck defect reconstruction: an up-to-date review of the literature. Cureus2023; 15(3): e35653.
JonesNFJarrahyRKaufmanMR. Pedicled and free radial forearm flaps for reconstruction of the elbow, wrist, and hand. Plast Reconst Surg2008; 121(3): 887–898.
9.
ClarkJMRychlikSHarrisJ, et al.Donor site morbidity following radial forearm free flap reconstruction with split thickness skin grafts using negative pressure wound therapy. J Otolaryngol Head Neck Surg2019; 48(1): 21.
10.
SwansonEBoydJBManktelowRT. The radial forearm flap: reconstructive applications and donor-site defects in 35 consecutive patients. Plast Reconstr Surg1990; 85(2): 258–266.
11.
MunnZPetersMDJSternC, et al.Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol2018; 18(1): 143.
12.
TriccoACLillieEZarinW, et al.PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med2018; 169(7): 467–473.
13.
DaveYBWisemanJMcCarronL, et al.Wrist immobilisation of radial artery forearm flap (RAFF) donor site following split-thickness skin graft: a scoping review. OSF Registries. 2021. DOI:10.17605/OSF.IO/Q5C68.
BhathenaHMKavaranaNM. Bipaddled, retrograde radial extended forearm flap with microarterial anastomosis for reconstruction in oral cancer. Br J Plast Surg1988; 41(4): 354–357.
16.
BonaparteJPCorstenMJOdellM, et al.Management of the radial forearm free flap donor site using a topically applied tissue expansion device. Oral Surg Oral Med Oral Pathol Oral Radiol2013; 116(1): 28–34.
17.
ChandrappaABBatthRSVasudevanS, et al.Assessment of functional recovery and subjective donor-site morbidity following radial forearm flap reconstruction in Small-to moderate-sized palatal defects. Craniomaxillofac Trauma Reconstr2020; 13(1): 71–77.
18.
D’arpaSCillinoMMazzuccoW, et al.An algorithm to improve outcomes of radial forearm flap donor site. Acta Chir Belg2018; 118(4): 219–226.
19.
DewyerNASethiRKYamasakiA, et al.Radial forearm free flap for cochlear implant coverage in a post-irradiated field. Otol Neurotol2020; 41(2): 192–195.
20.
JaquetYEnepekidesDJTorgersonC, et al.Radial forearm free flap donor site morbidity: ulnar-based transposition flap vs split-thickness skin graft. Arch Otolaryngol Head Neck Surg2012; 138(1): 38–43.
21.
MuldowneyJBCohenJIPortoDP, et al.Oral cavity reconstruction using the free radial forearm flap. Arch Otolaryngol Head Neck Surg1987; 113(11): 1219–1224.
22.
ShonkaDCKohliNVMilamBM, et al.Suprafascial harvest of the radial forearm free flap decreases the risk of postoperative tendon exposure. Ann Otol Rhinol Laryngol2017; 126(3): 224–228.
23.
ArganbrightJMTsueTTGirodDA, et al.Outcomes of the osteocutaneous radial forearm free flap for mandibular reconstruction. JAMA Otolaryngol Head Neck Surg2013; 139(2): 168–172.
24.
WerleAHTsueTTTobyEB, et al.Osteocutaneous radial forearm free flap: its use without significant donor site morbidity. Otolaryngol Head Neck Surg2000; 123(6): 711–717.
25.
De BreeRHartleyCSmeeleLE, et al.Evaluation of donor site function and morbidity of the fasciocutaneous radial forearm flap. Laryngoscope2004; 114(11): 1973–1976.
26.
DevaFALKalsotraGKalsotraP, et al.Tissue transfer after tongue resection: micro-vascular reconstruction using radial artery free flap versus reconstruction by split thickness skin graft in T2 lesions of tongue carcinoma. Indian J Otolaryngol Head Neck Surg2023; 75(2): 529–539.
27.
de VicenteJCde VillalaínLTorreA, et al.Microvascular free tissue transfer for tongue reconstruction after hemiglossectomy: a functional assessment of radial forearm versus anterolateral thigh flap. J Oral Maxillofac Surg2008; 66(11): 2270–2275.
28.
De WittCADe BreeRVerdonck-de LeeuwIM, et al.Donor site morbidity of the fasciocutaneous radial forearm flap: what does the patient really bother?Eur Arch Otorhinolaryngol2007; 264: 929–934.
29.
ThieleAWulkeCRoepkeE, et al.Radial forearm flap surgery—evaluation of donor site morbidity. Eur J Plast Surg2008; 31: 109–113.
30.
ChioEGAgrawalA. A randomized, prospective, controlled study of forearm donor site healing when using a vacuum dressing. Otolaryngol Head Neck Surg2010; 142(2): 174–178.
31.
ClarkJMRychlikSHarrisJ, et al.Donor site morbidity following radial forearm free flap reconstruction with split thickness skin grafts using negative pressure wound therapy. Journal of Otolaryngology-Head & Neck Surgery2019; 48(1): 21.
32.
LeeJ-WJangY-COhS-J. Use of the artificial dermis for free radial forearm flap donor site. Ann Plast Surg2005; 55(5): 500–502.
33.
SinclairCFGleysteenJPZimmermannTM, et al.Assessment of donor site morbidity for free radial forearm osteocutaneous flaps. Microsurgery2012; 32(4): 255–260.
34.
SittitraiPReunmakkaewDSrivanitchapoomC. Submental island flap versus radial forearm free flap for oral tongue reconstruction: a comparison of complications and functional outcomes. J Laryngol Otol2019; 133(5): 413–418.
35.
JengS-FKuoY-RWeiF-C, et al.Free radial forearm flap with adipofascial tissue extension for reconstruction of oral cancer defect. Ann Plast Surg2002; 49(2): 151–155.
36.
AndrewsBTSmithRBChangKE, et al.Management of the radial forearm free flap donor site with the vacuum‐assisted closure (VAC) system. Laryngoscope2006; 116(10): 1918–1922.
37.
ChavreSThankappanKMathewJ, et al.Shape‐modified radial forearm free tissue transfer in oral cavity reconstruction: technique and a prospective comparison with the conventional technique. Head Neck2020; 42(11): 3345–3351.
38.
JaniKMaharajaNAkaliNR, et al.Long-term patient-reported outcomes of radial forearm free flap donor site in the context of head and neck cancer reconstruction. Indian J Surg Oncol2020; 11: 192–195.
39.
JonesNFJarrahyRKaufmanMR. Pedicled and free radial forearm flaps for reconstruction of the elbow, wrist, and hand. Plast Reconstr Surg2008; 121(3): 887–898.
40.
MoazzamAGordonD. Cross-suturing as an aid to wound closure: a prospective randomised trial using the forearm flap donor site as a model. Br J Plast Surg2003; 56(7): 695–700.
41.
MotomuraHOhbaNOhashiN, et al.Improvement of the radial forearm donor site by compression with hydrocolloid dressing and adhesive sponge. Acta Otolaryngol2006; 126(2): 204–208.
42.
OrlikJRHorwichPBartlettC, et al.Long-term functional donor site morbidity of the free radial forearm flap in head and neck cancer survivors. Journal of Otolaryngology-Head & Neck Surgery2014; 43(1): 1.
43.
SkonerJMBascomDACohenJI, et al.Short‐term functional donor site morbidity after radial forearm fasciocutaneous free flap harvest. Laryngoscope2003; 113(12): 2091–2094.
44.
WoodJWBroussardKCBurkeyB. Preoperative testing for radial forearm free flaps to reduce donor site morbidity. JAMA Otolaryngol Head Neck Surg2013; 139(2): 183–186.
45.
McGregorA. The free radial forearm flap—the management of the secondary defect. Br J Plast Surg1987; 40(1): 83–85.
StarkBNathansonAHedénP, et al.Results after resection of intraoral cancer and reconstruction with the free radial forearm flap. Orl1998; 60(4): 212–217.
48.
ChenC-MLinG-TFuY-C, et al.Complications of free radial forearm flap transfers for head and neck reconstruction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod2005; 99(6): 671–676.
49.
PoeschlPKermerCWagnerA, et al.The radial free forearm flap—prelaminated versus non-prelaminated: a comparison of two methods. Int J Oral Maxillofac Surg2003; 32(2): 159–166.
50.
ZuidamJMCoertJHHoferSO. Closure of the donor site of the free radial forearm flap: a comparison of full-thickness graft and split-thickness skin graft. Ann Plast Surg2005; 55(6): 612–616.
51.
AkesonWAmielDAbelM, et al.Effects of immobilization on joints. Clin Orthop Relat Res1987; 219(1): 28–37.
52.
Splint classification system. American Society of Hand Therapists; 1992.
53.
PageMJMcKenzieJEBossuytPM, et al.The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ2021; 372: n71.
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