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
