Wrist immobilisation of radial artery forearm flap (RAFF) donor site following split-thickness skin graft: A scoping review

Abstract

Introduction

The radial artery forearm flap (RAFF) is a versatile free tissue transfer used for many clinical presentations. RAFF donor sites typically require a split-thickness skin graft (STSG) for closure. Whilst early rehabilitation of RAFF donor site(s) following STSG commonly involves wrist immobilisation, best practice for this immobilisation procedure remains unknown.

Purpose of the Study

The purpose of this study was to systematically ‘map’ wrist immobilisation methods post-STSG of the RAFF wound and explore the impact of immobilisation methods on donor site morbidity.

Methods

A scoping review was completed. Literature searching was conducted from database inception to February 1, 2024 in PubMed, Medline, Cochrane, CINAHL, Embase, Web of Science. Title/abstract screening was conducted by one researcher, full text screening was conducted by two researchers independently. Data extraction included number of participants, participant age and gender, wrist immobilisation details and reported donor site complications. Critical appraisal of articles was not completed.

Results

Thirty-seven studies were included in the review. Thermoplastic orthoses (TPO) or ‘splinting’ (n = 22) and plaster casts (n = 8) were the most frequent immobilisation methods reported with 7 days (n = 15) the most frequent immobilisation period. Detail regarding type of TPO material and location/design of the splint/cast was limited. Frequent donor site morbidities included graft complications (n = 18), changes in sensation (n = 9) and infection (n = 7).

Conclusion

Best practice wrist immobilisation procedure for RAFF donor site following STSG cannot be concluded at this time. Additional prospective research is recommended to evaluate the association between wrist immobilisation and donor site morbidity for this complex procedure.

Keywords

hand therapy radial artery forearm flap split thickness skin graft immobilisation rehabilitation

Background

The radial artery forearm flap (RAFF), is considered to be a versatile microvascular reconstructive option for patients with large defects in the head and neck due to its pliability, accessibility, and reliable anatomy.¹ Whilst it is commonly classified as a fasciocutaneous flap, a segment of the radial bone can also be incorporated in the flap and used for reconstruction of bony defects, particularly for oral and oropharyngeal regions.² A limitation of this procedure is the secondary trauma created at the donor site, which is located over the radial forearm region. The forearm donor site can rarely be closed primarily and typically requires a split-thickness or full thickness skin graft (STSG/FTSG) to achieve closure.^3,4 Post-operative complications to the donor site such as delayed wound healing, altered sensation, changes in appearance, changes in hand function, oedema and pain have been reported historically⁵ and more recently.⁶

Rehabilitation following RAFF, which includes immobilisation of the donor site, is common practice to decrease the risk of post-operative complications.^7,8 Immobilisation of the wrist during the early phase of wound healing has been shown to promote graft healing, as it decreases the amount of sher force placed across the healing donor site, until it is able to withstand these forces.^9,10 Despite the current clinical practice of protecting the donor site following RAFF, there is no gold standard protocol to guide therapists or surgeons regarding best practice immobilisation timeframe or immobilisation method.

Aim

The purpose of this study was to systematically ‘map’ wrist immobilisation factors, such as timeframe and method, for STSG (donor site) following RAFF to explore the impact of immobilisation on donor site complications (morbidity) to identify the optimal wrist immobilisation practice.

Method

A scoping review design was selected in favour of a systematic review, as it is the preferred methodology when addressing an exploratory research question, or a highly specialised topic.¹¹ The PRISMA Extension for Scoping Reviews (PRISMA-ScR)¹² was adhered to. A protocol was developed and registered via the Open Science Framework.¹³

Eligibility criteria

Studies were deemed eligible if they reported:

• an adult population (≥18yrs of age, of any gender),

• conducted RAFF surgery with a standard STSG for donor site closure,

• wrist immobilisation intervention of any description,

• published in English.

Studies were excluded if they:

• included paediatric participants,

• did not use STSG for wound donor site closure,

• did not report donor site interventions or outcomes,

• were study protocols, not available in full text, literature reviews, book chapters, conference abstracts, letters to the editor, newspaper articles, or webpages.

Information sources and literature search

Databases were searched from inception to February 1, 2024. Databases included PubMed, Medline, Cochrane, CINAHL, Embase, Web of Science. Search terms included radial artery forearm flap OR RAFF OR RAFFF OR free radial forearm flap OR FRFF. No authors were contacted for additional information. Reference lists of included systematic reviews were hand searched. The complete search strategy can be found in Supplemental Table 1 and was developed with guidance from the university health faculty librarian.

Selection of sources of evidence

Citations were imported into Covidence,¹⁴ with duplicates removed. A single researcher (YD) completed title and abstract screening. Two independent researchers (YD and OP) completed full text screening. A third reviewer settled disagreements if required. A critical appraisal of the reported outcome measures was not conducted.

Data charting and synthesis

Data extraction tables were developed and piloted. Extracted data included demographic details and wrist immobilisation details. Demographic data included author, publication year, number of participants, participant age (mean and/or range years), and gender. Wrist immobilisation details included immobilisation type, location and duration, and reported donor site morbidity. For consistency, data regarding duration of wrist immobilisation was converted from weeks into days to allow comparison between studies. Data was extracted by one researcher (YD) and independently checked for accuracy by a second researcher.

Results

Study characteristics

A total of 37 studies met the inclusion criteria and were included for analysis. Figure 1 illustrates the outcome of the search strategy, with detailed reasons for exclusion. Publication year ranged from 1987 to 2023 and participants ages ranged from 20 to 93 years. Table 1 outlines the demographic and immobilisation characteristics of included studies.

Figure 1.

Search results - Prisma Flow-Chart.

Table 1.

Demographic and immobilisation characteristics of included studies.

Author (Year of Publication)	Number of participants	Age (years) Mean ± SD	Gender*	Wrist Immobilisation		Donor Site Morbidity
Author (Year of Publication)	Number of participants	Age (years) Mean ± SD	Gender*	Type	Duration	Donor Site Morbidity
Andrews et al. (2006)	34	Mean: 60.0	Male: 18	Plaster splint	5-7 days	Mild dermatitis (2/34)
Andrews et al. (2006)	34	Range: 37-85	Female: 16	Plaster splint	5-7 days	Tendon exposure (<2 cm) (11/34)
Arganbright et al. (2013)	167	Mean: 61	Male: 68%	Rigid ulnar gutter splint	5 days	Radial fracture 1/167 (0.5%)
		Mean: 61	Male: 68%			Tendon exposure 47/167 (28%)
		Range: 20-93	Female: 32%			Hand weakness/numbness 13/167 (9%)
						Radial hardware infection 2/167 (1%)
						Wound infection 9/167 (5%)
Avery et al. (2001)	Total: 25	Mean: 51	Male to female ratio: 3:2	Dorsal support splint	12 days	Partial (5%) graft loss (1/8)
	Group 1 (FTSG) = 17	Range: 26-82				Partial (5%) graft loss (1/8)
	Group 1 (FTSG) = 17					No cases of tendon exposure
	Group 2 (STSG) = 8					No cases of tendon exposure
Bhathena et al. (1988)	5	Mean: 51	Male: 5	‘Splintage’	7 days	Loss of skin graft (20%)
Bhathena et al. (1988)	5	Range: 38-60	Female: 0	‘Splintage’	7 days	Loss of skin graft (20%)
Bonaparte et al. (2013)	Total: 177	Mean: 63.2 (13.3)	Male: 91	Forearm splint	5 days	Tendon exposure (2/8, 25%)
Bonaparte et al. (2013)	Total: 177	Mean: 63.2 (13.3)	Female: 86	Forearm splint	5 days	Minor skin reaction (3/8, 37.5%)
	Group 1 (Primary): 49	Group 1	Group 1
		Group 1	Male: 21
		Mean: 65.2 (10.4)	Male: 21
		Mean: 65.2 (10.4)	Female: 28
	Group 2 (FTSG): 120	Group 2 Mean 65.6 (12.1)	Group 2
			Male: 63
			Female: 57
	Group 3 (STSG): 8	Group 3	Group 3
		Group 3	Male: 7
		Mean 56.0 (21.1)	Male: 7
		Mean 56.0 (21.1)	Female: 1
Chandrappa et al. (2020)	7	Range: 14-76	Male: 6	‘Splinting’	7-10 days	Nil
Chandrappa et al. (2020)	7	Range: 14-76	Female: 1	‘Splinting’	7-10 days	Nil
Chavre et al. (2020)	Total: 30			POP splint	4 days	Sensory deficit (14/30, 47%)
	Group 1 (CRFF): 15	Group 1 Mean: 50.4 ± 9.5	Group 1
			Male: 11
			Female: 4
			Female: 4			Donor site itching and hypertrophic scar formation (5/30, 17%)
	Group 2 (SMRF): 15	Group 2 Mean: 51.6 ± 12.5	Group 2
			Male: 13
			Female: 2
Chen et al. (2005)	37	Mean: 48.6	Male: 37	‘Postoperative immobilization’	-	Partial skin graft failure (11%)
		Range: 31-70	Female: 0			Partial skin graft failure (11%)
		Range: 31-70	Female: 0			Further skin grafting (1/37, 3%)
Chio et al. (2010)	Total: 54			Volar wrist immobilizing splint	-	Skin graft failure/tendon exposure (19/50, 38%)
	Group 1 (Bolster dressing): 27	Group 1 Mean: 58.1	Group 1
			Male: 16
			Female: 11
	Group 2 (NP dressing): 27	Group 2 Mean: 62.1	Group 2
			Male: 14
			Female: 9
Clark et al. (2019)	Total: 24			Volar splint	7 days	‘Minor graft complication’ (45%)
	Group 1 (SP dressing): 12	Group 1 Mean: 59.3 ± 11.8	Group 1
			Male: 80%
			Female: 20%
	Group 2 (NP dressing): 12	Group 2 Mean: 59.7 ± 12.6	Group 2
			Male: 33%
			Female: 67%
D’Arpa et al. (2018)	61	Range: 53-77	Male: 32	Wrist splinting	7 days	Partial necrosis with tendon exposure (4/61, 7%)
			Male: 32			Partial necrosis without tendon exposure (2/61, 3%)
			Female: 29			Infection (2/61, 3%)
			Female: 29			Additional surgery (3/61, 5%)
De Bree et al. (2004)	37	Mean: 63.6 ± 10.8	Not specified	‘Dorsal hand-to-upper-arm splint’	7 days
De Bree et al. (2004)	37	Range: 40-85	Not specified	‘Dorsal hand-to-upper-arm splint’	7 days
Deva et al. (2023)	Total: 44	Mean: 43.4		Dorsal forearm splinting	7 days	Scar formation (22/22, 100%)
Deva et al. (2023)	Total: 44	Range: 25-60				Scar formation (22/22, 100%)
	Group 1 (RAFF): 22	Group 1	Group 1 (RAFF)
		Group 1	Group 1 (RAFF)			Reduced sensation (9/22, 41%)
		Mean: 42.8 ± 1.97	Male: 21
		Mean: 42.8 ± 1.97	Female: 1
	Group 2 (STSG): 22	Group 2 Mean: 43.1 ± 2.41	Group 2 (STSG)
			Male: 21
			Female:1
de Vicente et al. (2008)	Total: 20			Dorsal splinting – “extended beyond the metacarpophalangeal joints of the fingers and the thumb was left free”	7 days	Partial skin graft failure of less than 20% (4/10, 40%)
	Group 1 (RAFF): 10	Group 1 (RAFF)	Group 1 (RAFF)
		Mean: 56.5	Male: 6
		Range: 44-73	Female: 4
	Group 2 (ATF): 10	Group 2 (ATF)	Group 2 (ATF)
		Mean: 62.3	Male: 8
		Range: 48-87	Female: 2
de Witt et al. (2007)	50	Mean: 59.2 ± 11.1	Male: 28	Dorsal hand-to-upper-arm splint	7 days	Donor site: appearance (13, 27%), contact sensitivity (12, 24%), numbness (11, 22%), itchiness (11, 22%), cold sensitivity (4, 8%)
de Witt et al. (2007)	50	Range: 26-77	Female: 22	Dorsal hand-to-upper-arm splint	7 days
Dewyer et al. (2020)	1	53	Male: 0	“Bolster and splint”	-	“Minimal donor site morbidity”
Dewyer et al. (2020)	1	53	Female: 1	“Bolster and splint”	-	“Minimal donor site morbidity”
Jackson et al. (2015)	1	61	Male: 1	Post-operative “forearm immobilisation cast” replaced with a “removable splint”	“Temporarily immobilized per normal postoperative protocol”
Jackson et al. (2015)	1	61	Female: 0		“Temporarily immobilized per normal postoperative protocol”
Jani et al. (2020)	52	Mean: 47	Male: 41	“Rigid slab over the forearm and hand”	4 days	Numbness (21, 40%), upper limb weakness (21, 40%), itching (7, 13%), appearance (3, 6%), holding steering wheel (2, 4%), cold sensitivity (1, 2%), lying or leaning on the donor site (1, 2%)
Jani et al. (2020)	52	Range: 32-78	Female: 11	“Rigid slab over the forearm and hand”	4 days
Jaquet et al. (2012)	Total: 44			“Postoperative splinting”	7 days
	Group 1 (UBTF): 22	Group 1	Group 1
		Mean: 66	Male: 15
		Range: 32-88	Female: 7
	Group 2 (STSG): 22	Group 2	Group 1
		Mean: 65	Male: 11
		Range: 20-86	Female: 11
Jeng et al. (2002)	Total: 52	Mean: 52	Total	Resting splint	14 days	Flap failures due to arterial occlusion: 2 (7%), partial skin loss: 2 (7%).
		Range: 26-86	Male: 50
		Range: 26-86	Female: 2
	Group 1 (RAFF): 29
	Group 2 (RAFF + ATE): 23
Jones et al. (2008)	Total: 66 (67 flaps)	Mean: 45	Male: 42	Palmer POP splint	7 days	Further surgery at the donor site: 3 (5%)
Jones et al. (2008)	Total: 66 (67 flaps)	Range: 2-87	Female: 24	Palmer POP splint	7 days	Further surgery at the donor site: 3 (5%)
	Group 1 (pedicled RAFF): 57
	Group 2 (RAFF): 10
Lee et al. (2005)	13	Mean: 42	Male: 12	Volar splint, with wrist in a neutral position.		Partial loss of the artificial dermis was noticed but negligible: 2 patients (15%). No functional problems
Lee et al. (2005)	13	Range: 27-67	Female: 1	Volar splint, with wrist in a neutral position.
McGregor (1987)	16	Not specified	Not specified		20 days	Delayed graft healing in 2 patients (12.5%)
				Day 0-10: “Circumferential plaster from elbow to fingertips with the wrist, thumb and fingers completely immobilised in the position of function with the wrist fully extended”
				Day 10-20: “Volar part of the plaster is replaced as a splint”
Moazzam et al. (2003)	Total: 20	Mean: 58	Male: 17	Palmar POP splint	10-14 days	There were 3 (30%) graft losses in the control group, one complete and two partial. ‘Most’ cases had delayed healing of the skin graft donor site.
Moazzam et al. (2003)	Total: 20	Range: 28-84	Female: 3	Palmar POP splint	10-14 days
	Group 1 (Cross suturing) n = 10	Group 1 Range: 41-84	Group 1
			Male: 9
			Female: 1
	Group 2 (control) n = 10	Group 2 Range: 28-72	Group 2
			Male: 8
			Female: 2
Motomura et al. (2006)	12	Mean: 61.4	Male: 9	“Cast and tie-over fixation”	10 days	Hypertrophic scar: 1 patient (8%) at a single point
Motomura et al. (2006)	12	Range: 19-79	Female: 3	“Cast and tie-over fixation”	10 days	Colour changes: 1 patient (8%)
Muldowney et al. (1987)	14 (15 RAFFs)	Mean: 64	Male: 8	Forearm splint	14 days	Postoperative fracture in the donor forearm: 1 patient (7%). Partial slough (10% to 20%) of the skin graft at the donor site “was not uncommon” without the need for further surgery.
Muldowney et al. (1987)	14 (15 RAFFs)	Range: 41-80	Female: 6	Forearm splint	14 days
Orlik et al. (2014)	10	Mean: 59	Male: 5	Volar slab	7 days	Donor forearm fracture: 1
						Stitch abscess: 1
						Bothered by scar appearance: 3
						Sensitivity to clothing/wrist watch: 3 Cold intolerance: 4
		Range: 37-72	Female: 5			Sensitivity to clothing/wrist watch: 3 Cold intolerance: 4
						Decreased pronation compared to the non-donor side (p = 0.031)
						Manual dexterity was significantly slower (p = 0.008)
						Decreased mean sensation (p = 0.017)
Poeschl et al. (2003)	Total: 32			Not specified, “immobilization of the forearm”	7 days	Donor site wound infection requiring revisional surgery: 1 patient (6%).
	Group 1 (PFF): 16	Group 1 Range: 35-76	Group 1
			Male: 13
			Male: 13			Small superficial epidermiolysis of the radial–distal skin: 2 patients (12%).
			Female: 3
	Group 2 (NPFF): 16	Group 2 Range: 43-89	Group 2
			Group 2			Hypertrophic scar development at the forearm: 1 patient (6%).
			Male: 12
			Female: 4
Shonka et al. (2017)	Total: 47			Not specified, “wrist was immobilized with a splint”	6 days	Postoperative tendon exposure at the donor site occurred in 5 patients (20%), managed with twice daily dressing changes until closure which took up to 3 months.
	Group 1 (RAFF - Subfascial harvest): 25	Group 1 Mean: 55.8	Group 1
			Male: 16
			Female: 9
	Group 2 (RAFF - Suprafascial harvest): 22	Group 2 Mean: 53.8	Group 2
			Male: 17
			Female: 5
Sinclair et al. (2012)	Part 1 Total: 218	Part 1	Part 1	ntdA volar forearm splint (5 days), downgraded to “a lighter weight volar splint” (14 days)	19 days	Fracture (1 patient, 0.5%)
	Part 1 Total: 218					Sensory neuropathy (5 patients, 2.3%),
	Part 2 Total: 60
		Age >60 n: 133	Male: 137
		Age >60 n: 133	Female: 81			Skin graft failure greater than 50% (10, 4.6%)
		Part 2:	Part 2:
	Group 1 (FRFOCF): 30	Group 1	Group 1
		Age >60 n: 17	Male: 18
		Age >60 n: 17	Female: 12
	Group 2 (FRFF): 30	Group 2	Group 2
		Age >60 n: 15	Male: 17
		Age >60 n: 15	Female: 13
Sittitrai et al. (2019)	Total: 54			A volar splint that immobilises the patient’s forearm and wrist	-	Partial loss of the skin graft in 6 patients (24%)
	Group 1 (Submental island flap): 29	Group 1	Group 1			Partial loss of the skin graft in 6 patients (24%)
		Mean: 59.2	Male: 18			Restricted arm function, e.g. reduced grip strength, pinch strength and wrist movements, in 14 patients (56%).
		Range: 35-84	Female: 11
	Group 2 (RAFF): 25	Group 2	Group 2
		Mean: 548	Male: 15
		Range: 31-73	Female: 10
Skoner et al. (2003)	12	Mean: 57	Not specified	Plaster volar splint immobilising the forearm and wrist	5 days	Mildly diminished sensation to sharp versus dull stimuli in the anatomical snuffbox region of the radial nerve distribution in 3 patients (25%);
Skoner et al. (2003)	12	Range: 42-71	Not specified	Plaster volar splint immobilising the forearm and wrist	5 days	No infection, skin graft failure, tendon exposure, vascular compromise, or other donor site wound complications were reported.
Stark et al. (1998)	47	Mean: 61	Male: 15	No casts were used, “but the wrist was immobilized in a bandage”	14 days	Incomplete skin graft closure over the flexor carpi radialis and palmaris longus tendon due to haematoma (3 patients, 6%) and infection (9 patients, 19%). All donor sites healed spontaneously. No patient required secondary skin grafting.
Stark et al. (1998)	47	Range: 38-77	Female: 32		14 days
Thiele et al. (2008)	Total: 25	Not specified	Not specified	Dorsal arm splint	7 days, then reassessed re: clinical findings.	Paraesthesia, loss of sensation, or hot and cold intolerance: 3 patients (37.5%).
	Group 1 (FTSG): 17
	Group 2 (STSG): 8
Werle et al. (2000)	54	Mean: 62	Male: 30	Rigid ulnar gutter splint	7 days	Tendon exposure, flexor carpi radialis: 23 patients (43%).
		Range: 16-89	Female: 24			Tendon exposure, flexor carpi radialis: 23 patients (43%).
						Necrosis around the incision site requiring subsequent debridement and skin grafting: 1 patient (2%).
						Donor radius fracture: 6 patients (11%).
Wood et al. (2013)	143	Mean: 59.1 ± 14.1	Male: 95 (66.7%)	Hand and wrist extension splint, “followed by a cast from below the elbow to the hand.”	7 days	Ischemic hand complications (IHCs): 2 patients (1.9%)
Wood et al. (2013)	143	Mean: 59.1 ± 14.1	Female: 48 (33.3%)		7 days	Ischemic hand complications (IHCs): 2 patients (1.9%)
Zuidam et al. (2005)	Total: 34			Not specified: “The hand and forearm were immobilized for … 7 days with STSG”.	7 days	Partial necrosis: 1 patient (7%). Hypergranulation: 1 patient (7%).
	Group 1 (STSG): 15	Group 1: 56.8 ± 10.2	Group 1
			Male: 8
			Female: 7
	Group 2 (FTSG): 19	Group 2: 62.0 ± 9.0	Group 2
			Male: 13
			Female: 6

FTSG = Full Thickness Skin Graft; STSG = Split Thickness Skin Graft; CRFF = Conventional radial forearm flap; SMRF = Shape-modified radial forearm; POP = Plaster of Paris; NP = Negative pressure; SP = Static pressure; ATF = Anterolateral thigh flap; UBTF = Ulnar based transpositional flap; Adipofascial tissue extension = ATE; PFF = Prelaminated fasciomucosal flap; NPFF = Non-prelaminated fasciocutaneaous flap; FRFOCF = free radial forearm osteocutaneous flap; FRFF = free radial forearm fasciocutaneous flap.

* Number (n) unless otherwise stated.

Immobilisation methods

Donor site immobilisation methods that were reported included splinting (n = 22 studies^1,15–35), plaster cast (n = 8 studies^36–43), plaster cast followed by splinting (n = 3 studies^44–46), and bandage (n = 1 study⁴⁷). The immobilisation method was unspecified in three studies.^48–50

Length of immobilisation ranged from four to 20 days. Seven days immobilisation was the most common immobilisation duration and was reported in 15 studies.^{15,18,20,24–29,31,39,42,44,49,50} Five days immobilisation (n = 3 studies^16,23,43) and 14 days immobilisation (n = 3 studies^21,35,47) were the next most frequent immobilisation periods reported. The length of immobilisation was not reported in six studies.^{19,30,32,34,46,48}

Minimal detail was provided regarding the location or design of the immobilisation methods. Six studies identified specific positioning requirements or joint inclusions.^{27,32,34,39,44,45} However, the majority of studies described general positions of the plaster cast or splint to be volar (n = 7 studies^{30–34,42,43}), dorsal (n = 6 studies^1,25–29), ulnar (n = 2 studies^23,24), forearm (n = 7 studies^{16,21,38,43,46,49,50}), and wrist (n = 4 studies^18,22,43,47). Justification for immobilisation methods was not reported using cited literature for any of the studies (n = 37).

Donor site complications

Reported donor site morbidities (in order of frequency) included graft complication (including loss of graft and tendon exposure) (n = 18 studies^{1,15,16,18,21–24,27,30,31,33–36,40,47,48}), changes in sensation (including itch, pain, temperature sensitivity) (n = 9 studies^{23,26,28,29,33,37,38,42,43}), infection (n = 7 studies^{18,23,24,42,47,49,50}), radial fracture (n = 5 studies^{21,23,24,33,42}), additional surgery (n = 5 studies^{18,24,39,48,49}), changes in upper limb function (including upper limb weakness, reduced dexterity) (n = 4 studies^23,34,38,42), hypertrophic scar formation (n = 4 studies^26,37,41,49), changes in appearance or cosmesis (n = 4 studies^28,38,41,42), delayed wound healing (n = 3 studies^22,40,45), mild skin reactions (n = 3 studies^16,36,49), and ischemic hand complication (n = 1 study⁴⁴). The risk of radial fracture was increased in studies that implemented an osteocutaneous transfer technique.

Discussion

The current analysis encapsulates a broad spectrum of research spanning over three decades (1987-2023), which demonstrates the ongoing favourability for the RAFF as a reconstruction option for patients with large primary head and neck defects. The wide age range of participants (20-93 years) underscores the relevance of this procedure across diverse age groups, reflecting the necessity for an effective postoperative care strategy. The need for a documented post-operative care strategy of the RAFF donor site is further supported by the result that none of the included studies (n = 37) cited published literature to support their approach to donor site immobilisation.

A significant portion of the studies (22 out of 37) employed splinting as the primary method of immobilisation following RAFF, indicating its prevalent acceptance in clinical practice. Additionally, the use of plaster casts, either alone (n = 8 studies^36–43) or followed by splinting (n = 3 studies^44–46), was notable. The variations in immobilisation methods underscore the lack of consensus on a standardised approach, potentially due to differences in surgeon preference, patient needs, or institutional protocols. The duration of immobilisation varied substantially from four to 20 days, with 7 days being the most commonly reported period (n = 15 studies^{15,18,20,24–29,31,39,42,44,49,50}), suggesting a potential optimal immobilisation window that balances the need for early protection with the risks of long-term immobilisation such as joint stiffness and adhesions.⁵¹ However, the diversity in immobilisation duration also highlights the need for more precise guidelines to optimise patient outcomes.

The positioning of immobilisation, whether a splint or cast, was another critical variable explored in this study. Volar and dorsal immobilisation positions were both described, with specific mention of the forearm (n = 7 studies^{16,21,38,43,46,49,50}) and wrist (n = 4 studies^18,22,43,47). However, the degree of wrist extension/flexion or forearm supination/pronation was rarely specified, identifying a gap in detailed reporting crucial for replicating study outcomes and refining immobilisation techniques. Reporting inconsistencies has led to the American Society of Hand Therapists’ (ASHT) recommendation for the implementation of a standardised naming system to reduce communication errors and improve clinical effectiveness.⁵² Therefore, future prospective studies should consider implementing the ASHT naming scheme, provide a more specific immobilisation position that explicitly describes the included joints and approximate joint position (e.g. neutral to 30° wrist extension) and include pictures of the applied wrist immobilisation method.

Complications at the donor site were varied and significant, with graft complications being the most frequently reported (n = 18 studies^{1,15,16,18,21–24,27,30,31,33–36,40,47,48}). Post-operative rehabilitation can decrease the risk of sensory complications and infection, using desensitisation techniques, wound and scar management, and sensory re-education. Furthermore, given the increased risk of radial fractures following osteocutaneous RAFF, consideration should be given to developing a separate immobilisation protocol for this clinical presentation, which may be reduced with a consistent approach to immobilisation. In addition to clinical complications, the patient experience remains an underexplored dimension. While some studies briefly noted outcomes such as donor site pain, itch, temperature sensitivity, or cosmetic concerns, these issues are likely to have a substantial impact on daily functioning, psychological well-being, and overall satisfaction with surgery. Long-term changes in dexterity and sensation may also influence patients’ ability to return to work or leisure activities. Furthermore, the limited use of patient-reported outcome measures (PROMs) in this literature represents a critical gap. Future research should systematically incorporate validated PROMs alongside clinical outcomes to ensure that postoperative protocols are optimised not only for graft survival but also for quality of life and functional recovery. It should also be noted that the RAFF donor site is increasingly used in gender-affirming phalloplasty, where donor site morbidity and cosmesis are particularly relevant to patient satisfaction and informed consent.

The absence of consensus in clinical practice highlights a therapeutic gap in post-operative rehabilitation following RAFF. While immobilisation is widely recognised as necessary to reduce donor site morbidity, considerable variation exists in the method, duration, and positioning prescribed. This lack of standardisation underscores the need for targeted prospective research to compare immobilisation strategies, define optimal protocols, and explore patient-reported outcomes. Clinicians reporting their approaches, including rehabilitation strategies and functional outcomes, would provide essential data to bridge this gap and inform evidence-based guidelines. Several key clinical questions remain unanswered and warrant investigation: (1) What is the optimal duration of wrist immobilisation following RAFF to balance graft protection and thus limitation of comorbidities impacting on daily functioning, psychological well-being, and overall satisfaction with surgery with minimising upper limb stiffness and functional decline? (2) Which immobilisation method (splint, plaster cast, or alternative) provides the best outcomes in terms of graft survival, complication rates, and patient comfort? (3) What role does the exact positioning of the wrist and forearm play in graft healing and long-term upper limb function? (4) How should immobilisation protocols differ when an osteocutaneous flap is harvested compared with a fasciocutaneous flap? Addressing these questions through prospective, comparative studies would provide the evidence needed to reduce variability in practice. In the interim, clinicians may consider adopting short-term immobilisation (approximately 7 days) with splinting, as this was the most commonly reported practice and may balance graft protection with early mobilisation. However, given the lack of high-quality comparative studies, such recommendations should be interpreted cautiously and refined as stronger evidence emerges.

Strengths

The study adhered to the PRISMA-ScR guidelines, ensuring a structured and transparent approach to the scoping review.⁵³ A comprehensive and robust search strategy was employed, utilising high-quality peer-reviewed databases to ensure the inclusion of relevant studies. The eligibility criteria were well-defined, providing clear inclusion and exclusion parameters. The review process was rigorous, with two independent researchers conducting the analysis and a third researcher available to resolve any disagreements. Additionally, the protocol was submitted a priori,¹³ further enhancing the study’s transparency and reproducibility.

Limitations

Despite the rigorous approach, the overall quality of the included studies was relatively poor. As this was a scoping review, a critical appraisal of the studies was not performed, which may impact the interpretation of the findings. Moreover, the authors were not contacted to clarify questions or study omissions regarding post-operative rehabilitation recommendations, which could have provided additional insights. The lack of supporting evidence for the reported wrist immobilisation recommendations suggests that surgeon opinion, rather than published evidence, may have influenced clinical decision-making. Future research may include a survey, focus group, or Delphi consensus to explore the professional opinions and perspectives of health professionals who regularly work with RAFF, or who are considered field experts, to document current practice and/or develop evidence based practice guidelines following RAFF.

Conclusion

Notable variations were identified regarding RAFF donor site post-operative rehabilitation. As such, the most ideal immobilisation practice cannot be accurately determined from the findings of this scoping review. The predominance of splinting and plaster casts for immobilisation reflect common clinical practices, yet the lack of standardised protocols suggests a need for further research to establish evidence-based guidelines. The reported donor site morbidities highlight the critical importance of effective immobilisation for optimal recovery. Future studies should focus on refining immobilisation method, durations, and upper limb positioning, including appropriate outcome measures to establish treatment efficacy, and follow the ASHT naming conventions for consistency. In addition, efforts should be directed towards filling the current therapeutic gap by developing and validating standardised immobilisation protocols that can be confidently implemented into clinical practice. Equally important, future research should integrate validated patient-reported outcome measures to capture the lived experience of RAFF patients, ensuring that rehabilitation strategies are optimised not only for clinical efficacy but also for quality of life.

Supplemental Material

Supplemental Material - Wrist immobilisation of radial artery forearm flap (RAFF) donor site following split-thickness skin graft: A scoping review

Supplemental Material Wrist immobilisation of radial artery forearm flap (RAFF) donor site following split-thickness skin graft: A scoping review by Yamini Dave, Luke McCarron, Olivia Palac, Hayley Mudge, Jodie Wiseman in Hand Therapy

Footnotes

Jodie Wiseman

Luke McCarron

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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