Long-term biomechanical analysis of donor site morbidity after radial forearm free flap

Long-term biomechanical analysis of donor site morbidity after radial forearm free flap

Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e5 Contents lists available at ScienceDirect Journal of Cranio-Maxillo-Facial Surgery journal h...

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Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e5

Contents lists available at ScienceDirect

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Long-term biomechanical analysis of donor site morbidity after radial forearm free flap € rn Riecke a, 1, Carsten Kohlmeier a, 1, Henri Kreiker a, Anna Suling b, Bjo Alexandre Thomas Assaf a, Johannes Wikner a, Henning Hanken a, Max Heiland a, € be a, Carsten Rendenbach a, * Alexander Gro a

Department of Oral & Maxillofacial Surgery (Head: Max Heiland, MD, DMD, PhD), University Medical Center Hamburg Eppendorf, Martinistraße 52, 20246 Hamburg, Germany Department of Medical Biometry and Epidemiology (Head: Karl Wegscheider, PhD), University Medical Center Hamburg Eppendorf, Martinistraße 52, 20246 Hamburg, Germany

b

a r t i c l e i n f o

a b s t r a c t

Article history: Paper received 11 June 2015 Accepted 31 July 2015 Available online xxx

Background: Although the radial forearm free flap (RFF) is a commonly used microvascular graft for head and neck reconstruction, long-term biomechanical results regarding donor site morbidity are rare. Patients and methods: In a prospective panel study, 32 patients were included. Biomechanical assessment was performed preoperatively, three months postoperatively and two years postoperatively. The primary endpoint of the study was grip strength. In addition, the Mayo wrist score, DASH score (disabilities of the arm, shoulder and hand score), fine motor skill strengths (tip pinch, key pinch, palmar pinch) and the range of motion were analysed. Primary defects were closed with local full-thickness skin grafts (FTSG) from the donor site forearm avoiding a secondary defect site. Results: In the long-term analysis, grip strength was reduced in both arms. A significant improvement over time was found only for the donor arm. A persistent deficit of tip pinch strength and dorsal extension was recorded. Persistent sensory limitations occurred in four cases. Patient contentment after two years of follow-up was high and daily life routine was not restricted. Conclusion: Gross and fine motor skill limitations are reversible short-term effects after RFF harvesting and do not restrict daily routine in the long term. These findings substantiate the value of the RFF as a workhorse in reconstructive surgery. © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Keywords: Biomechanical evaluation Donor site morbidity Harvesting defect Radial forearm free flap Skin graft

1. Introduction When deciding which free flap to use for reconstructing soft tissue defects, donor site morbidity is an important factor (Rosenberg et al., 2009). Since its introduction in 1981, the radial forearm free flap (RFF) has become the most commonly used free flap for head and neck reconstruction (Yang et al., 1997; Jones et al., 1996; Gurtner and Evans, 2000). It is a thin and pliable fasciocutaneous flap with high calibre vessels and a long vascular pedicle substantiating its high success rates. Harvesting of a radial

* Corresponding author. Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20246 Hamburg, Germany. Tel.: þ49 152 2282 7397; fax: þ49 40 7410 55467. E-mail address: [email protected] (C. Rendenbach). 1 These authors contributed equally to the work.

forearm free flap can be carried out quickly and simultaneously to ablative surgery in the head and neck region (Kesting et al., 2011). Radial forearm free flaps have been associated with donor site morbidity including: attenuated strength of the hand; a reduced range of motion of the wrist; oedema formation; dysaesthesia in the distribution area of the superficial branches of the radial nerve; cold intolerance; the formation of a poor transplant bed for splitthickness skin grafts; and the risk of wound healing problems due to moving tendons (Bardsley et al., 1990; Boorman et al., 1987; Soutar and McGregor, 1986; Swanson et al., 1990; Timmons et al., 1986). For indirect defect closure, autogenous full-thickness skin grafts (FTSG) have been reported to achieve the same or better aesthetic results than a split-thickness skin graft (STSG) (van der Lei et al., 1999; Sidebottom et al., 2000). In head and neck microvascular reconstruction a long pedicle as well as a thin flap is often needed which commonly leads to raising the RFF at the distal

http://dx.doi.org/10.1016/j.jcms.2015.07.039 1010-5182/© 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Riecke B, et al., Long-term biomechanical analysis of donor site morbidity after radial forearm free flap, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.07.039

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B. Riecke et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e5

forearm. The resulting donor site defect close to the hand and wrist places special demands on wound closure due to superficial flexor tendons and the restricted amount and movability of the local tissue. Although the RFF is a commonly used microvascular flap for orofacial reconstruction, prospective and biomechanical studies regarding its donor site morbidity are rare (Loeffelbein et al., 2012). In particular, reports on whether the known limitation of wrist movement or hand strength after RFF harvest ameliorate in the long term do not exist. With the current study we aimed to evaluate the long-term outcomes in comparison with preoperative and short-term postoperative results. 2. Materials and methods The hypothesis of the current study is that long-term donor-site morbidity rates are lower than short-term postoperative results after RFF harvesting. In order to pursue this hypothesis we designed and implemented a single-institutional, uncontrolled, clinical panel study. The study sample was composed of adult patients (>18 years of age) undergoing soft tissue resection of the head and neck region and plastic reconstruction via transplantation of a radial forearm free flap. Subjects were excluded from study enrolment if they had any pre-existing vascular, neurological or orthopaedic pathology, or discomfort or illness on testing days. Written informed consent was obtained from all participants. Time points of examination were one day before surgical intervention, between three and six months postoperatively, and more than 18 months postoperatively for long-term analysis. The maximum grip strength in kilograms (with comparison of both sides) was the primary outcome parameter of the study. Secondary endpoints of the trial were biomechanical assessment tests of fine motor skills (tip pinch, key pinch, palmar pinch), and the range of motion of the wrist joint, as well as the disabilities of the arm, shoulder and hand score (DASH) and Mayo wrist score. Additionally, sensory limitations and patient satisfaction with the appearance of the donor site were evaluated with a subjective questionnaire. In this study preoperative and postoperative evaluation of both arms was performed to exclude errors from preexisting differences in the donor and contralateral arms. 2.1. Surgical technique and postoperative treatment regimen All flaps were harvested as fasciocutaneous flaps at least 3 cm proximal to the wrist and without the use of a tourniquet. Flap harvesting was performed simultaneously to the ablative surgical procedure. No flap was extended to the dorsal aspect of the arm due to aesthetic reasons. To achieve an optimal wound bed the paratenon was meticulously left untouched. Extensive mobilization and oversewing of the surrounding muscle bellies were not performed. The superficial branch of the radial nerve was carefully preserved during further dissection in all cases to prevent dysaesthesia of the hand. Reconstruction of the radial artery was not performed in any patient. Donor site defects were uniformly closed with two spindleshaped local FTSGs gained out of a sinusoidal access incision as recently described (Riecke et al., 2015). Thus, the disadvantages of a split-thickness skin graft and a secondary donor site defect could be avoided. No fenestrating incisions or cross-sutures for sizereduction of the wound were performed. A tie-over dressing was used for ten days to maintain attachment of the skin graft to the underlying tissue and to prevent seroma formation. A passive silicone capillary drain was placed subfascially before wound closure. Routinely no subatmospheric pressure dressing or immobilizing cast was used. The radial forearm flaps had been raised from the non-dominant sides in all cases. Preoperatively, the Allen-test had

been performed to avoid impairment of blood supply to the hand after division of the radial artery. Postoperatively, passive drainage was applied for 3 days. Physical therapy started within the first postoperative week. The tie-over dressing and sutures were removed 10 days after surgery. Postoperative pain was treated according to the WHO level schema. 2.2. Biomechanical evaluation Biomechanical evaluation was performed identically at each assessment. All patients were examined bilaterally, donor arm and control arm. Standardized Mayo wrist scores and DASH scores were evaluated and the range of motion (ROM) was analysed with a goniometer. Full active motion of the wrist joint was assessed using a protractor. This examination included extension and flexion and radial and ulnar abduction. Grip-strength, tip pinch, key pinch and palmar pinch were evaluated using the B&L Engineering hand dynamometer B&L pinch gauge (B&L Engineering, Santa Ana, CA, USA). A standardized arm and hand position was used for all hand strength measurements. The patients were seated with their shoulder adducted, elbow flexed at 90 and forearm in neutral position. For each test, scores of three consecutive runs of both hands were noted. Only the best attempts were used for further analysis. The mean differences between preoperative and postoperative measurements for each arm are presented. 2.3. Mayo score, DASH score and patient satisfaction The DASH score, as described by the American Academy of Orthopaedic Surgeons, the Institute of Work and Health, and the Council of Musculoskeletal Speciality Societies in 1996 is an instrument to subjectively evaluate functionality and impairments of the upper extremities (Changulani et al., 2008). The questionnaire enables the patient to rate 30 elements concerning daily activities from one (no limitations) to five points (impossible). Twenty-one sub-items evaluate daily activities, such as opening a door with a key or picking up an object. Furthermore information on pain, sensory limitations, mobility, weakness and the impact of potential deficits in extremity function on social life, working ability, sleep and the patient's confidence are evaluated. The score ranges from 30 to 100, whereby 30 points indicate perfect functionality of the upper extremity. In addition, the Mayo wrist score, as described by Green and O'Brien (1978), was used to assess a potential impact of the harvesting procedure on daily activities. It consists of subjective and objective parameters regarding pain, patient satisfaction, range of motion and grip strength and could range from zero to 100, whereby 100 points indicate perfect functionality of the upper extremity. Finally a subjective questionnaire on aesthetic appearance of the donor site was performed postoperatively. 2.4. Statistical analysis Descriptive baseline characteristics are reported as mean (standard deviation (SD)) or as frequencies and percentages, where appropriate. We used linear mixed models to analyse the effect of time (short-term vs. long-term postoperative analysis) and hand (contralateral vs. donor) on changes from baseline to follow-up on the primary outcome, grip strength, and the secondary outcomes: tip pinch, key pinch and palmar pinch. We adjusted all models for the respective baseline measurement, age, sex, defect size, tumour and adjuvant therapy as well as the two-way interaction of time and hand (if significant). To take the cluster structure of the data into account, patient was included as a random effect. As further

Please cite this article in press as: Riecke B, et al., Long-term biomechanical analysis of donor site morbidity after radial forearm free flap, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.07.039

B. Riecke et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e5

secondary outcomes, the Mayo wrist score and DASH score are summarized scores for both hands. Changes in these scores were analysed with an analogous model that excluded the parameter hand as an independent variable. The secondary outcomes of dorsal extension, palmar flexion, radial and ulnar abduction were analysed accordingly, only for the donor hand. A two-tailed p-value was considered to be statistically significant if p < 0.05. All analyses were performed using STATA 13.1 (STATA Corporation, College Station, TX, USA). 3. Results Thirty-two patients meeting our inclusion criteria were enrolled in this study. Of these, 30 underwent pre- and short-term postoperative biomechanical assessment following the harvest of an RFF, and 20 took part in the long-term analysis. Six patients were excluded due to a loss of follow-up after the short-term analysis and six patients died, four of them between short- and long-term assessments. The baseline characteristics of the study sample are illustrated in Table 1. On average, the long-term assessment was performed 814.5 days (2.2 years) postoperatively (range: 535e1066 days), whereas the time lag between surgical intervention and short-term postoperative analysis was 95.6 days. No relevant circulatory problems were observed. All flaps were raised as fasciocutaneous flaps. The average size was 25 cm2 (range: 9e48 cm2). We found a significant correlation between time effect and hand (p ¼ 0.019). There was a significant loss of grip strength in both arms following the harvest of an RFF in the short-term analysis (p < 0.001 both) (Table 2 and Fig. 1A). In this context, the loss of strength was significantly higher in the donor arm than in the contralateral arm (2.7 kg; 95% CI, 0.39e4.97; p ¼ 0.022). The comparison of preoperative strength and long-term outcome also revealed a significant difference in both the donor and the contralateral arm (p ¼ 0.009 and p < 0.001 respectively). However, no significant difference was recorded when comparing grip strength loss of both arms (p ¼ 0.277). Regarding the difference between short- and long-term outcomes, a significant improvement of grip strength was detected only in the donor arm (þ3.8 kg, 95% CI (1.22; 6.32); p ¼ 0.004); (contralateral arm p ¼ 0.734). The secondary outcome values of the study are shown in Table 3 and Fig. 1BeD. Regarding all fine motor skills (tip pinch, key pinch and palmar pinch) a significant decrease between the preoperative and short-term postoperative assessment was found in both the donor and the contralateral hand and fingers. In analysing tip pinch strength, a significant difference between hands, independent of time (p ¼ 0.631) was detected. Regardless of the time of postoperative examination, an average difference of 1.42 kg (95% CI, 0.53e2.32) was recorded between both hands (p ¼ 0.002). In contrast to these findings are the results of key pinch and palmar pinch. For both assessments, a significant time-effect independent of side was recorded (interaction p ¼ 0.272 for palmar pinch; p ¼ 0.496 for key pinch). On average, an increase of 1.92 kg was found in both the donor and the contralateral arm regarding palmar and key pinch (95% CI, 0.85e2.98; p < 0.001 for palmar pinch and 95% CI, 0.85e2.89; p < 0.001 for key pinch). Additionally, Table 1 Baseline characteristics of the study sample. Number of patients (n) Male/female (total number, %) Age (years) mean (SD) Transplant size (mm2) mean (SD) Adjuvant therapy (total number, %)

32 18/14 (56.3) 61.7 (15.9) 25.1 (8.1) 12/32 (37.5)

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a significant improvement of the DASH and Mayo wrist scores was recorded comparing short- and long-term analysis (p < 0.001 for both scores). In this respect the long-term outcome was equivalent to the preoperative results. Changes in the range of motion of the wrist joint are displayed in Table 4. There was a remaining deficit of dorsal extension in the comparison of preoperative and long-term postoperative functionality (p < 0.001). Finally, we recorded four cases of persistent peripheral sensory hypoesthesia in the thenar region. Eighteen patients (90%) claimed to be satisfied with the functional and aesthetic outcome in the long-term analysis. 4. Discussion There are various indications for the use of a radial forearm free flap in reconstructive surgery (Yang et al., 1997; Jones et al., 1996; Gurtner and Evans, 2000). Although frequently performed, there are only a few studies presenting valid data on the associated donor-site morbidity of this flap (Sidebottom et al., 2000; Loeffelbein et al., 2012; Riecke et al., 2015). In particular, there are no reports on whether known limitations of wrist movement or hand strength after RFF harvesting ameliorate in the long term (Loeffelbein et al., 2012). Furthermore, the conclusiveness of the majority of existing investigations is limited since most studies retrospectively used the contralateral arm as a reference instead of comparing pre- and postoperative results of the donor arm (Loeffelbein et al., 2012). The purpose of the current study was to evaluate the long-term clinical outcome after RFF harvesting with special regard to motor function. Since the reduction of grip strength was significantly higher in the donor arm, a harvest-effect was also evident in the short-term analysis. Regarding the results of the long-term assessment, this harvest effect reversed, whereas the non-harvest effect persisted. The results of fine motor testing are in contrast to this. The short-term postoperative reduction of palmar and key pinch was equal in both the donor and the contralateral arm and reversed in the long-term analysis (non-harvest effect in the short-term analysis). Contrary to this, there was a time-independent significant difference for tip pinch in both arms, indicating an isolated and persistent harvest effect. Similar effects were seen for range of motion. Whereas all motions were reduced in the short-term analysis, limitations were persistent only for dorsal extension in the long-term. The patients consistently perceived the objectively assessed impairments at different times of investigation. Accordingly, DASH scores significantly increased in the short-term analysis and ameliorated in the long-term. Reduced tip pinch of the donor-arm (non-dominant arm) was not considered impairing. Donor side morbidity is an important factor in the decision of which free flap to use for reconstruction of soft tissue defects. This prospective study demonstrates that the fasciocutaneous RFF is associated with low long-term morbidity. Regarding closure of the donor site defect, a non-negligible functional morbidity is widely accepted to occur in the early postoperative period (Skoner et al., 2003). For indirect defect closure autogenous FTSGs have been reported to achieve the same or better aesthetic results than split thickness skin grafts (STSG) (Riecke et al., 2015; Liang et al., 1994). Disadvantageously, this inevitably requires a secondary donor site defect (Liang et al., 1994; Avery et al., 2005; Sleeman et al., 1994; Kim et al., 2007). In our study, the primary donor site defect was closed by two local spindle-shaped FTSGs gained at the access incision for the vascular pedicle of the donor forearm. This technique avoids extension of the incision for a local flap technique, does not prolong wound healing and thus reduces both donor site

Please cite this article in press as: Riecke B, et al., Long-term biomechanical analysis of donor site morbidity after radial forearm free flap, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.07.039

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B. Riecke et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e5

Table 2 Primary endpoint (grip strength) at different times of examination.

Grip strength mean (SD) p-value hand

Difference pre-op/short-term

Difference pre-op/long-term

Difference short-term/ long-term

D

C

D

C

D

C

6.6 (5.5) p < 0.001

3.9 (3.6) p < 0.001

2.7 (5.5) p ¼ 0.009

4.3 (4.8) p < 0.001

p ¼ 0.004

p ¼ 0.734

p ¼ 0.022

P-value time*hand

Time effect

Hand effect

p ¼ 0.019

e

e

p ¼ 0.277

C: contralateral side; D: donor side.

Grip strength

B

2

0

Mean change in key pinch (kg)

Mean change in grip strength (kg)

Key pinch

A

2

-2

-4

-6 donor contralateral

-8 1

2 Time

0

-2

-4

-6 donor contralateral

-8 3

1

2 Time

3

Palmar pinch

C

Tip pinch

D

2

0 Mean change in tip pinch (kg)

Mean change in palmar pinch (kg)

2

-2

-4

-6 donor contralateral

-8 1

2 Time

0

-2

-4

-6 donor contralateral

-8

3

1

2 Time

3

Fig. 1. Graphs showing mean changes over time, 1: preoperative; 2: postoperative 3e6 months; 3: postoperative 2 years. A) Grip strength; B) Key pinch; C) Palmar pinch; D) Tip pinch.

Table 3 Secondary outcome variables at different times of examination. Difference pre-op/short-term

Difference pre-op/long-term

Difference short-term/ long-term

D

D

D

C

C

Tip pinch 2.7 (3.5) p < 0.001 1.4 (2.5) p < 0.001 2.1 (3.6) p < 0.001 0.1 (2.9) p ¼ 0.630 e Palmar pinch 2.6 (3.2) p < 0.001 1.7 (2.4) p ¼ 0.001 0.2 (2.4) p ¼ 0.900 0.1 (2.5) p ¼ 0.862 e Key pinch 2.5 (3.5) p < 0.001 1.6 (2.7) p ¼ 0.003 0.3 (2.6) p ¼ 0.523 0 (2.9) p ¼ 0.939 e Mayo score 11.3 (13) p < 0.001 1 (21.7) p ¼ 0.605 e p ¼ 0.001 DASH score 16.1 (15.9) p < 0.001 6.6 (13.6) p ¼ 0.053 p < 0.001

P-value Time time*hand effect

Hand effect

C e e e

p ¼ 0.631 p ¼ 0.272 p ¼ 0.496

p ¼ 0.103 p ¼ 0.002 p < 0.001 p ¼ 0.099 p < 0.001 p ¼ 0.134

C: contralateral side; D: donor side. Table 4 Secondary outcome variables: full active range of motion. Motion

Difference pre-op/short-term

Difference pre-op/long-term

Difference short-term/long-term

Dorsal extension ( ) mean (SD) Palmar flexion ( ) mean (SD) Radial abduction ( ) mean (SD) Ulnar abduction ( ) mean (SD)

9.5 10.9 2.6 4.6

12.5 0.4 0.2 0.5

p p p p

(13), p < 0.001 (12), p < 0.001 (7.1), p ¼ 0.002 (9.8), p ¼ 0.007

(14), p < 0.001 (10.8), p ¼ 0.815 (11.7), p ¼ 0.424 (16.4), p ¼ 0.782

¼ 0.574 < 0.001 ¼ 0.004 ¼ 0.058

Please cite this article in press as: Riecke B, et al., Long-term biomechanical analysis of donor site morbidity after radial forearm free flap, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.07.039

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and secondary graft site morbidity of the RFF. The local FTSG does not reduce wrist function, if compared to prospective biomechanical studies on donor site morbidity (Kesting et al., 2011; Richardson et al., 1997). It contributes to a significant reduction of soft tissue healing problems and avoids a secondary donor site. 5. Conclusion The results of the current study indicate that gross and fine motor skill limitations are partially reversible short-term effects following the harvest of a radial forearm free flap, enabling the patients to carry out daily activities without restrictions. These observations substantiate the value of the RFF as a workhorse in microsurgical head and neck reconstruction. However, patients should be informed about the risk of persistent sensory deficits and a slight deficit in sagittal motion in the wrist. Since a second donor site defect can be avoided, we recommend a sigmoid incision and wound closure by using a spindle-shaped, local full-thickness skin graft out of the donor region. Conflict of interest All authors declare no conflict of interest. Sources of support None. Ethical approval Approval of the local ethics committee (Ethikkommission der € Arztekammer Hamburg): PV 3768. References Avery CM, Iqbal M, Orr R, Hayter JP: Repair of radial free flap donor site by fullthickness skin graft from inner arm. Br J Oral Maxillofac Surg 43: 161e165, 2005 Bardsley AF, Soutar DS, Elliot D, Batchelor AG: Reducing morbidity in the radial forearm flap donor site. Plast Reconstr Surg 86: 287e294, 1990 Boorman JG, Brown JA, Sykes PJ: Morbidity in the forearm flap donor arm. Br J Plast Surg 40: 207e212, 1987 Changulani M, Okonkwo U, Keswani T, Kalairajah Y: Outcome evaluation measures for wrist and hand: which one to choose? Int Orthop 32(1): 1e6, 2008 Green DP, O'Brien ET: Open reduction of carpal dislocations: indications and operative techniques. J Hand Surg Am 3(3): 250e265, 1978

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Gurtner GC, Evans GR: Advances in head and neck reconstruction. Plast Reconstr Surg 106: 672e682, 2000 Jones NF, Johnson JT, Shestak KC, Myers EN, Swartz WM: Microsurgical reconstruction of the head and neck: interdisciplinary collaboration between head and neck surgeons and plastic surgeons in 305 cases. Ann Plast Surg 36: 37e43, 1996 € lzle F, Wales C, Steinstraesser L, Wagenpfeil S, Mücke T, et al: Kesting MR, Ho Microsurgical reconstruction of the oral cavity with free flaps from the anterolateral thigh and the radial forearm: a comparison of perioperative data from 161 cases. Ann Surg Oncol 18: 1988e1994, 2011 Kim TB, Moe KS, Eisele DW, Orloff LA, Wang SJ: Full-thickness skin graft from the groin for coverage of the radial forearm free flap donor site. Am J Otolaryngol 28: 325e329, 2007 Liang MD, Swartz WM, Jones NF: Local full-thickness skin-graft coverage for the radial forearm flap donor site. Plast Reconstr Surg 93: 621e625, 1994 Loeffelbein DJ, Al-Benna S, Steinstrasser L, Satanovskij RM, Rohleder NH, Mücke T, et al: Reduction of donor site morbidity of free radial forearm flaps: what level of evidence is available? Eplasty 12: e9, 2012 Richardson D, Fisher SE, Vaughan ED, Brown JS: Radial forearm flap donor-site complications and morbidity: a prospective study. Plast Reconstr Surg 99: 109e115, 1997 €be A, Blessmann M, et al: Local fullRiecke B, Assaf AT, Heiland M, Al-Dam A, Gro thickness skin graft of the donor arm e a novel technique for the reduction of donor site morbidity in radial forearm free flap. Int J Oral Maxillofac Surg. http://dx.doi.org/10.1016/j.ijom.2015.02.021, Mar 21, 2015 Rosenberg AJ, Van Cann EM, van der Bilt A, Koole R, van Es RJ: A prospective study on prognostic factors for free-flap reconstructions of head and neck defects. Int J Oral Maxillofac Surg 38: 666e670, 2009 Sidebottom AJ, Stevens L, Moore M, Magennis P, Devine JC, Brown JS, et al: Repair of the radial free flap donor site with full or partial thickness skin grafts. A prospective randomized controlled trial. Int J Oral Maxillofac Surg 29: 194e197, 2000 Skoner JM, Bascom DA, Cohen JI, Andersen PE, Wax MK: Short-term functional donor site morbidity after radial forearm fasciocutaneous free flap harvest. Laryngoscope 113: 2091e2094, 2003 Sleeman D, Carton AT, Stassen LF: Closure of radial forearm free flap defect using full-thickness skin from the anterior abdominal wall. Br J Oral Maxillofac Surg 32: 54e55, 1994 Soutar DS, McGregor IA: The radial forearm flap in intraoral reconstruction: the experience of 60 consecutive cases. Plast Reconstr Surg 78: 1e8, 1986 Swanson E, Boyd JB, Manktelow RT: The radial forearm flap: reconstructive applications and donor-site defects in 35 consecutive patients. Plast Reconstr Surg 85: 258e266, 1990 Timmons MJ, Missotten FE, Poole MD, Davies DM: Complications of radial forearm flap donor sites. Br J Plast Surg 39: 176e178, 1986 van der Lei B, Spronk CA, de Visscher JG: Closure of radial forearm free flap donor site with local full-thickness skin graft. Br J Oral Maxillofac Surg 37: 119e122, 1999 Yang GF, Chen PJ, Gao YZ, Liu XY, Li J, Jiang SX, et al: Forearm free skin flap transplantation: a report of 56 cases. 1981. Br J Plast Surg 50: 162e165, 1997

Please cite this article in press as: Riecke B, et al., Long-term biomechanical analysis of donor site morbidity after radial forearm free flap, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.07.039