Donor site aesthetic and functional outcomes: comparison between radial forearm free flap and anterolateral thigh free flap

Background: The most commonly used free flaps are the anterolateral thigh (ALT) free flap and the radial forearm (RF) free flap, which often have overlapping indications. The aim of the present study is to compare the aesthetic and functional consequences for the donor site in patients undergoing ALT or RF flap harvesting. Methods: A questionnaire was administered to each patient to assess the functionality and aesthetics of the donor site. We used three different scales validated in the literature: the Patient and Observer Scar Assessment Scale (POSAS), the Manchester Scar Scale (MSS), and the donor site functionality questionnaire developed by Liu and colleagues. A total of 54 patients underwent ALT or RF free flap harvesting at the University Hospital of Verona in the period between February 2016 and September 2019. Of these, 14 had died at the time of the study. In addition, a complete follow-up was not available in 9 patients and they were therefore excluded from the study. Therefore, a total of 31 patients, 15 of whom underwent ALT flap harvesting (48%) and 16 RF flap harvesting (52%), were analyzed in the present study. Out of the 31 patients, 11 (36%) were female and 20 (64%) were male. The mean age at the time of surgery was 61 years (± 16 (SD), and ranging from 23 to 87 years). The flap size was on average 142.6 cm2 (90–198) in the ALT group and 36.5 cm2 (20–63) in the RFFF group. Results: Overall observer total score of the POSAS was 12 (8–15) for the ALT flap and 9.5 for the RF flap. For the patients’ opinion of the POSAS scale, the overall patient total score was 16 for the ALT flap and 9 for the RF flap. There was no difference in overall observer total score nor in patients opinion score between ALT and RF (12 (8–15) compared to 9.5 (8–12.25) and 16 (9.5–20) compared to 9 (7.75–15) (p = 0.28 and p = 0.13, respectively). For the MSS, the RF flap had a significantly better result with the VAS (visual analog scale) score (p = 0.04) compared with the ALT flap. In total, 94% of patients undergoing RF flap harvesting were satisfied with the appearance of the forearm against 73% of patients with the ALT flap. Conclusions: In this case series, the RF donor site achieved slightly better aesthetic and functional outcomes than the ALT donor site. Our results are discordant with the majority of published international studies, and are probably related to surgical management of the RF donor site using a locally harvested full-thickness skin graft (FTSG). Level of evidence: Level III, therapeutic/prognostic study.