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Long-Term Vascular, Sensory, and Motor Outcomes after Ulnar Forearm Flap Harvest
Emile N. Brown, M.D., Jeffrey Feiner, M.D., Eduardo Rodriguez, M.D., D.D.S..
R Adams Cowley Shock Trauma Center, Baltimore, MD, USA.
PURPOSE: Many surgeons are reluctant to utilize the ulnar forearm flap (UFF) because of concerns about compromise of donor extremity perfusion and the close proximity of the ulnar artery and nerve. However, the UFF offers certain advantages over the RFF, both in donor and recipient site aesthetics. The ulnar forearm skin is generally less hairy than the radial skin, while the donor site is less noticeable during daily life and tends to have better skin graft take because of more underlying muscle bellies as opposed to tendons.
METHODS: Thirty three UFF’s were performed over a 6 year period. All patients had routine postoperative follow-up. A subset of postoperative patients (n=20) underwent bilateral upper extremity arterial duplex studies with velocity and digital plethysmography measurements. Some postoperative patients (n=10) also had sensory and motor evaluations of bilateral upper extremities, as well as functional evaluation via the Quick-DASH questionnaire. Motor function was tested by digital grip impulse and key grip sustained dynamometry. Sensation in the ulnar nerve distribution (little finger pulp and ulnar hand dorsum) was tested by evaluation of one- and two-point perceived pressure thresholds and two-point discrimination measurements using the Pressure-Specified Sensory Device (PSSD). For each patient, the contralateral unaffected arm served as an internal control.
RESULTS: All flaps were viable postoperatively and all donor sites healed with good aesthetic outcomes (see figure). The average flap size was 41±28cm. The majority of donor sites (31/33, 94%) were reconstructed with a full thickness skin graft, while the remaining were closed primarily (2/33, 6%). Mean follow-up was 28.8 months for patients undergoing vascular studies and 45.3 months for patients undergoing motor, sensory, and Quick-DASH evaluations. Although mid and distal radial artery flow velocities were significantly higher in donor versus control arms evaluated at less than one year postoperatively (74.9±14.4 vs. 57.8±22.2, p=0.03; 71.5±16.7 vs. 46.7±16.7cm/s, p<0.001), there was no significant difference in arms evaluated more long term (59.6±29.5 vs. 57.8±17.2, p=0.91; 59.2±28.9 vs. 49.4±19.0cm/s, p=0.22). Digital pressures were equivalent between donor and control hands (135.3±22.7 vs. 132.8±22.3mmHg, p=0.24). There was no significant difference in grip or key pinch strength between the donor and control upper extremities (17.6±7.0 vs. 17.1±5.2kg, p=0.73; 4.3±0.9 vs. 5.2±1.5kg, p=0.38). Sensation in the ulnar nerve distribution was equivalent between the donor and control hands (little finger pulp 1-point 5.2±8.9 vs. 5.8±5.3g/mm2, p=0.78; little finger pulp 2-point 6.9±4.4 vs. 6.8±4.5mm, p=0.56, 15.1±14.8 vs. 8.0±5.1g/mm2, p=0.12; ulnar hand dorsum 1-point 2±7.3 vs. 5.6±12.9g/mm2, p=0.09; ulnar hand dorsum 2-point 12±8.7 vs. 12±9.5mm, p=0.24, 22.4±12.6 vs. 34.6±17.9g/mm2, p=0.31). The average Quick-DASH score was 22.4±25.0.
CONCLUSION: The ulnar forearm flap can be harvested reliably and is an ideal choice for head and neck reconstruction due to its soft and pliable nature and long vascular pedicle. Long term follow-up shows no evidence of vascular compromise and no evidence of detrimental effects on motor or sensory function in the donor extremity.
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