Radial forearm free flaps and skin grafts

What is a radial forearm free flap?

A radial (section) forearm (below the elbow) free (released from its source) flap (piece of tissue with its own blood supply) is used to reconstruct the hole caused when a cancer has been surgically removed. It is one of the most common ways of replacing tissue in the head and neck.

Benefits of this surgery

The benefit of this procedure is to remove the cancer and to cosmetically improve the appearance of the area where the surgery has been performed.

What can I expect from the operation?

The operation is performed under a general anaesthetic, which means that you will be asleep throughout the procedure. A piece of tissue will be removed from the inside of your forearm near the wrist, including the skin and fat layer (the flap), along with the vein (drains blood from the flap) and the artery (which supplies blood to the flap). Once the flap and blood vessels are freed from the arm, they are moved to the mouth or neck and sewn into the hole made when your cancer was removed.

The blood vessels are joined to blood vessels in your neck and will keep the flap alive while it heals into its new place. The hole created in your forearm is then covered with a thin skin graft, usually from your tummy.

How will I be cared for after my operation?

Usually, you will be looked after in the intensive care unit for the first night following your surgery, to make sure the flap is getting a good supply of blood and oxygen. Occasionally, a tube is put in your throat (called a tracheostomy) to help with your breathing. It is usually only needed during the time when swelling may be a problem after surgery. The tube is looked after by the ward nurses and is usually removed after 5 to 7 days, see page ‘Having a temporary tracheostomy’ GHPI0547. Please ask a member of staff if you would like a copy in leaflet form.

You will not be allowed to eat or drink for the first few days after your surgery. This is to allow your flap to heal. You will therefore be fed either via a thin plastic tube, inserted through your nostril and into your stomach (a nasogastric tube) or by a special feeding tube which is inserted directly into your stomach (a gastrostomy). If you require a gastrostomy, this is usually put into your stomach several days before your operation. You will be given special feeds which will be carefully monitored by the dietitian.

As part of the recovery process, you will be seen on the ward by a physiotherapist and given a range of neck and shoulder movement exercises to prevent stiffness and loss of strength.

What will my arm be like afterwards?

At the end of the operation, your arm will be bandaged and held with a splint to keep it still. This will be removed after about 10 days and replaced with a lighter dressing.

Will I have any discomfort?

There may be some soreness around the graft area which can be controlled with pain relief. At first, your arm movement will be restricted but after 48 hours, movement will gradually be reintroduced.

Some of your stitches will be taken out 7 to 10 days after your operation and the remaining ones a few days later. You will be able to use your arm normally after 2 weeks. However, returning to full use could take longer if you generally use heavy machinery or equipment.

There will be drains (thin plastic tubing) coming out through the skin on your neck and your arm.

During the operation, small nerves may be cut which can make your neck skin numb. This means that many patients do not have much neck pain after the operation but if you do suffer any pain or discomfort, please tell the ward nurses.

What problems can happen?

If cancer has spread into the lymph nodes in the neck, some or all of the lymph nodes may be removed. This is called a neck dissection. For further information, see page ‘About neck dissection’ GHPI0429. Please ask a member of staff if you would like a copy in leaflet form. Occasionally, it may be necessary to put a tube in your throat to help with your breathing.

Flap failure

Sometimes a blood clot can block the vein or artery attached to the flap. This can cause damage to the flap. If this happens you may have to have another operation to remove the clot or to replace the flap with one from another area on your body.

Infection

The dressings on your arm will help to protect the donor site. Your wounds will be cleaned and dressed as necessary but sometimes infection can happen but this is easily treated with antibiotics. You will be given advice about how to keep your mouth and teeth clean to avoid any infection developing inside your mouth. Any signs of infection such as a raised temperature, redness, new pain or discharge should be reported to the Dressing Clinic staff or to the nursing staff on Ward 2B out of normal working hours.

Nerve damage

It is likely that there will be an area of decreased sensation around the scar, and you may experience some numbness at the base of your thumb.

How quickly will I recover?

Recovery depends on the type of treatment you have had as well as healing. When you are ready, resuming daily activities can help the healing process. You should avoid vigorous exercise for 6 weeks after the operation. Your doctor will advise you about returning to work.

Your feelings

The scar and skin graft will look different from the rest of your arm and it can take 6 to 12 months for the scar to fade. This can sometimes affect your feelings about how you look and may be difficult to cope with. Your specialist nurse or consultant can offer advice and support if you are concerned about this, for example putting you in touch with another person who has had the same experience or organisations that can help.

Contact information

If you have any questions or concerns, please contact:

Dressing Clinic staff

Tel: 0300 422 3194 and ask for the dressing clinic

Monday to Thursday, 9:00am to 4:00pm

Friday, 9:00am to 1:00pm

Macmillan Head and Neck Clinical Nurse Specialists

Tel: 0300 422 6785

Monday to Thursday, 8:00am to 4:00pm

Friday, 8:00am to 1:00pm

Out of Hours

Ward 2b

Gloucestershire Royal Hospital:

Tel: 0300 422 6184

Please note that the Ward 2b contact number is only to be used out of hours.

Further information

If you need further support before or after the surgery please contact your GP, consultant, Clinical Nurse Specialist or the Macmillan helpline. NHS 111 and the Macmillan helpline are available outside of normal working hours.

Macmillan Cancer Support Helpline

Website: www.macmillan.org.uk

Tel: 0808 808 0000

Macmillan Information Hub

To access the service either drop in (no appointment needed) or telephone to speak to the advisor.

The Atrium

Gloucestershire Royal Hospital

Tel: 0300 422 8880

Email: ghn-tr.macmillanhub@nhs.net

Monday to Friday, 9:00am to 4:00pm

NHS 111

Tel: 111