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

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.

Neuropathic Donor-Site Pain following Radial Forearm Free Flap Harvest: A Multicenter Study on Incidence, Prognostic Factors, and Quality of Life

“…An algorithm provided by Calotta et al suggests that a divided RSN during RFFF harvest should have its proximal end implanted into a muscle to prevent painful neuroma. 4 Even though identification of the RSN showed a slight significant negative correlation with neuropathic pain, this result is most likely due to missing data where RSN identification in incomplete surgery reports was automatically reported as “no.” To the best of our knowledge, studies investigating the effect of primary denervation of the RSN on neuropathic pain at the donor site following RFFF harvest are lacking. The trend observed in the present study makes primary RSN denervation for neuropathic pain prevention interesting to investigate in future research.…”

“…3 A review by Calotta et al reported four nerves to be prone to iatrogenic trauma during RFFF harvesting, of which specifically the RSN is at high risk due to its superficial location. 4 Moreover, multiple wrist-and distal forearm surgeries may cause neuropathic pain due to iatrogenic RSN damage, 5 including wrist arthroscopies, [6][7] first dorsal compartment release in De Quervain's disease 8 and Kirschner wire fixation in distal radius fractures. [9][10] Neuropathic pain complaints due to LABCN damage have also been reported, 4 however, to a lesser extent.…”

“…4 Moreover, multiple wrist-and distal forearm surgeries may cause neuropathic pain due to iatrogenic RSN damage, 5 including wrist arthroscopies, [6][7] first dorsal compartment release in De Quervain's disease 8 and Kirschner wire fixation in distal radius fractures. [9][10] Neuropathic pain complaints due to LABCN damage have also been reported, 4 however, to a lesser extent.…”

Higher incidences of neuropathic pain and altered sensation following radial forearm free flap: A systematic review

“…Determining the exact source of neuropathic pain between these nerves, however, remains difficult. The RSN is at high risk to iatrogenic nerve damage due to its superficial location, especially during closure of the donor-site with a skin graft [25][26] . However, even though the LABCN is almost always dissected during RFFF surgery, little to no studies report specific on damage of the LABCN and subsequent pain complaints.…”