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Does Prior Axillary Lymph Node Dissection Affect Radial Forearm Free Flap Reliability: A Single Surgeon's Seventeen Year Experience
Clifford Thomas Pereira, MD; Travis Shiba, MD; Joel Sercarz, MD; Elliot Abemayor, MD; Vishad Nabili, MD; Keith Blackwell, MD;

Introduction: Axillary Lymph Node Dissection (ALND) is a commonly performed procedure in breast cancer patients. There is no reported data on the use of ipsilateral Radial Forearm Free Flaps (RFFFs) in patient with prior ALND. The purpose of this study was to evaluate donor limb morbidity and clinical reliability of RFFFs in post-oncologic resection reconstruction in patients with prior ALND.

Methods: An Institutional Review Board approval was obtained prior to commencement of study. A retrospective chart review was conducted of all patients with ipsilateral ALND admitted to our institute for RFFF reconstruction, from 1995 to 2012. Of a total of 516 RFFFs performed 8 patients met the above criteria. All reconstructions were performed for head and neck cancer resections. All patients had negative Allen’s tests and the non-dominant side was used in all cases. Data collected included patient demographics, tumor staging, pathology, intra and post-operative complications. Additionally a telephonic Disability of Arm, Shoulder and Hand (DASH) questionnaire was conducted 7.8±4.8 years post-operatively for the donor arm. Data was analyzed using Microsoft Office Excel 2007.

Results: Mean age of the patients was 68 years with a female predominance (87.5%). The primary pathology was squamous cell carcinoma in all patients. Fifty percent patients had had previous radiation to the neck. All RFFFs were performed at least 15 years after ALND. Tourniquet time was 78±13 minutes and flap ischemia time was 154±16 minutes. All flaps had one arterial and one venous anastomosis except one flap which required a second venous anastomosis (at the time of surgery) to improve out-flow. None of the flaps had any microvascular complications. We had a 50% response to DASH questionnaires and DASH scores were consistently below 5 indicating a low disability. None of the patients reported lymphedema in the involved limb in the immediate or late post-operative period.

Conclusions: We report the first the series of RFFFs in patients with ipsilateral prior ALND. Patients with prior ALND with a subsequent RFFF carry a theoretical risk of increased donor limb lymphedema secondary to sacrifice of the cephalic vein during harvest. Our series however seems to indicate no increased risk of donor limb lymphedema or worsening of function in donor hand. Since all our RFFFs were performed at least 15 years after ALND, this time lag probably allowed for a for a compensatory augmentation venous return in these limbs. Thus RFFFs are clinically reliable free flaps in this patient cohort.

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