Reply to letter to the editor

To the Editor: We are grateful for the opportunity to respond to Dr. Hakim’s recent Letter to the Editor commenting on our article on donor site morbidity of free ulnar forearm flap (UFF), which was first published online, in Head & Neck, over 2 years ago. We presented our entire series, up to 2009, of 242 consecutive free UFF reconstructions since the flap was first developed in our unit in 1982. We provided detailed descriptions of the flap and technical nuances of our original technique, including pointers to flap design and elevation, underscored by the understanding of its perforator anatomy. Importantly, the skin paddle is sited proximally in the forearm (Figure 1). We showed that 62 of the 242 donor sites (26%) were closed directly, whereas the rest were repaired with split thickness grafting (Figure 2A and 2B). The handedness of the patients and full range of motion of the elbow, wrist, and hand joints on both donor and opposite limbs were recorded. There was minimal donor site morbidity, specifically, detailed assessment of hand function showed minimal incidence of cold intolerance, paresthesia, and pain among the most recent 50 patients who had been followed up for at least 12 months. Furthermore, no difference in grip and pinch strength, and moving 2-point discrimination of the little finger, was noted between the donor and the opposite limbs (Figure 3). There was excellent donor site cosmesis, assessed independently by the patients and a doctor not originally involved in the patients’ care (Table 1 and Figure 4A–4C). Although providing excellent tissues for intraoral lining reconstruction, the significant donor site morbidity of radial forearm flap (RFF) has been well and extensively documented, especially poor skin graft healing over the flexor tendons, wrist stiffness, reduced grip, and pinch strength, and also acute and chronic hand ischemia, despite the presence of a normal Allen’s test. A major disadvantage of RFF is poor cosmesis of the donor site, which is obtrusive because it is situated in the exposed working surface in the distal forearm. UFF is an excellent alternative to the RFF with several advantages: (1) the donor site is generally less hirsute; (2) it is situated on the ulnar and volar aspect of the proximal forearm and is thus less obtrusive; (3) when only a small flap is required (eg, in intraoral reconstruction), the donor defect can often be closed directly; and (4) if a skin graft is needed, it is applied over the muscle bellies rather than the exposed tendons. In discussing the merit of UFF over RFF, we drew to the readers’ attention a body of published work with multiple anatomic and functional investigations consistently showing the ulnar artery being the dominant supply of the hand. This further underscores the advantage of UFF in that the dominant artery of the hand is not sacrificed. Dr. Hakim made a number of intriguing and incorrect statements, presumably because of a lack of the appreciation and misinterpretation of the data we have presented, and his own personal opinion. He stated repeatedly that the patients who underwent detailed assessment of their hand function all had their donor sites closed directly and implied that this must explain our findings of low donor site morbidity because they were either not found or absent in the first place! Contrary to Dr. Hakim’s understanding of our study, assessment of donor site morbidity including detailed assessment of hand function and donor site cosmesis was applied to the entire subset of 50 patients, including those whose donor sites were closed directly (n 5 10) and split skin grafted (n 5 40). We also disagree with Dr. Hakim’s view on the validity of comparing hand function between the donor and opposite limbs in our study, presumably because of his erroneous assumption that all or the majority of the UFF were raised from the dominant limbs. Consistent with our high regard for donor site morbidity, we routinely raise the UFF from the nondominant limb, unless there is a compelling reason to do otherwise. Of the 50 patients who underwent detailed assessment of hand function and donor site cosmesis, all were right-handed except 5 who were left-handed. Bilateral UFFs were raised from 2 right-handed patients, and an UFF was raised from the left side of 2 left-handed patients and from the right side of 2 right-handed patients. UFF was raised from the nondominant limbs of the remaining patients. Dr. Hakim’s statement, “Considering only common features assessed in both studies and only those of crucial impact on daily life of patients, grip strength reduction after UFF harvest may be of special interest,” is intriguing. There is no basis in this proposition. A global evaluation is needed to meaningfully assess donor site morbidity, which should include cosmesis and critical aspects of hand function. Our detailed assessment of hand function showed no difference in grip and pinch strength, and moving 2-point discrimination of the little finger, between the donor limb and the opposite, mostly dominant, limb after elevation of UFF (Figure 3). Dr. Hakim’s statement, “As the authors evaluated a comparable number of patients to that published by our group 1 month earlier in the same journal, it is interesting to see how differences in methods and study design obtained Head & Neck 36: 1231–1232, 2014 Published online 2 May 2014 in Wiley Online Library (Wileyonlinelibrary.com). DOI 10.1002/hed.23668 VC 2014 Wiley Periodicals, Inc. LETTERS TO THE EDITOR