Global Variations in Surgical Techniques and Postoperative Care for Radial Forearm Free Flap (RFFF) in Head & Neck Surgery: A Cross-Sectional International Survey

Objective: This cross-sectional survey aimed to comprehensively gather data on radial forearm free flap (RFFF) utilization and practices in head and neck reconstructive surgery. Methods: An online questionnaire was organized into seven sections: demographics, surgeon experience, harvesting techniques, microsurgical considerations, postoperative care, flap monitoring, and outcomes. It was distributed by email to 216 head and neck reconstructive surgeons who attended the International Federation of Head and Neck Oncologic Societies (IFHNOS) congress in Rome (21-25 June 2023) using the congress mailing list. Responses were collected from 54 surgeons (25% response rate), representing 15 countries across Europe, Asia, the Americas, and Oceania, underscoring the international scope of the survey between 5 February and 25 March 2024. The questionnaire was not formally piloted or validated. Missing data were managed on a per-question basis. Descriptive statistics were used, and 95% confidence intervals (CIs) were calculated for key surgical outcomes to indicate estimate precision. Associations between categorical variables were analyzed using Pearson's χ2 test with Cramér's V as an effect size, and relationships between continuous variables were examined using Spearman's rank correlation (ρ) with 95% confidence intervals (CIs). Given the exploratory design and limited sample size, no correction for multiple comparisons was applied, and the risk of both Type I and Type II errors was acknowledged. Results: Variations were observed in harvesting techniques, microsurgical preferences, and postoperative care protocols. Most surgeons initiated flap harvesting concurrently with tumor resection, primarily preserving superficial sensory nerves. Regarding venous outflow, 50% of respondents preferred the cephalic vein, 19% used comitant veins, and 29% utilized both systems when possible. Perioperative antibiotic use was standard practice, though anticoagulant preferences and flap monitoring methods varied. The study achieved a high success rate for RFFF procedures, exceeding 95%, with venous thrombosis identified as the main cause of flap failure. No significant correlations were found between flap failure rate and training method (p = 0.21), specialty (p = 0.37), annual number of RFFF procedures (p = 0.89), surgeon age (p = 0.42), or hospital type (p = 0.48). Effect sizes were small to moderate, indicating weak or negligible associations. Similarly, perioperative factors such as anticoagulant use (p = 0.84), preoperative antibiotics (p = 0.42), surgical instruments (p = 0.61), suture techniques (p = 0.51), and donor vein selection (p = 0.20) showed no statistically significant associations with flap loss. Patient satisfaction assessments were inconsistent, with only 39% of surgeons routinely performing them. Conclusions: The study provides valuable insights into current RFFF practices and outcomes across an international cohort of head and neck surgeons, highlighting patterns and variability in techniques, perioperative care, and monitoring strategies.

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International survey of 54 head and neck reconstructive surgeons on radial forearm free flap practice found wide variation in harvesting, venous outflow and anticoagulation, success rates exceeding 95%, and venous thrombosis the main cause of flap failure.

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