Rationale
Worldwide, head and neck cancer accounts for over 900.000 cases annually [
1]. Following ablative surgery, head and neck defects can be reconstructed using microvascular flaps. The radial forearm free flap (RFFF) was first described by Yang et al. in 1981 and is used for various reconstruction purposes [
2]. Thanks to its relative thinness, pliability, long and high-calibre pedicle and reliable anatomy, it is one of the workhorses in microvascular reconstruction [
3]. However, donor site morbidity such as tendon exposure due to skin graft loss, altered sensitivity and reduced arm function has been reported [
4]. These are all factors that could potentially lead to decreased quality of life.
As reconstructive outcomes at the recipient site have improved, a further reduction of morbidity at the donor site has become an essential goal for surgeons [
5,
6]. It is believed that the wound closure technique may have an impact on donor site morbidity [
4].
When RFFF was first described, Yang et al. suggested donor site closure with a split-thickness skin graft (STSG) [
2]. Over the years, various surgical closure techniques have been proposed. Logically, with a small donor site, primary wound closure can be attempted, but this is less common. About 40% of RFFF donor site closure studies report using STSG, and 50% report using full-thickness skin grafts (FTSG), making these the most common closure techniques [
4,
7]. Apart from that, other approaches using allogeneic and xenogeneic materials have been described [
8‐
10].
Very recently Mosquera et al. (22/11/2023), Saleki et al (23/11/2023) and Zhang et al. (13/12/2023) published systematic reviews regarding RFFF closure with FTSG vs. STSG [
11‐
13]. However, the conclusions were contradictory. While Mosquera et al. (8 included studies, no meta-analysis) and Saleki et al. (8 included studies, 3-4 in the meta-analysis) concluded improved aesthetics for FTSG with comparable wound-related outcomes, Zhang et al. (13 included studies, 4-6 in the meta-analysis) claimed no benefit in aesthetics with a higher risk of graft failure in FTSG. The reasons for this may be that although all three research groups claim to adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, there are some important methodological shortcomings and missed opportunities [
14].
Mosquera et al. did not register a study protocol, which diminishes transparency, and did not provide a comprehensive search strategy, which potentially led to not identifying all studies meeting the eligibility criteria. Saleki et al. did not provide full search queries for databases, which raises concerns about the replicability, and the number of retrieved records was relatively low (
n = 78). Zhang et al. conducted statistical syntheses with results from individual studies from different levels of the evidence pyramid and did not provide an explanation or justification for this approach. The authors also used a relatively simple risk of bias assessment, which led to the inclusion of several studies in meta-analyses that either did not provide information on donor site defect size or did not control for differences in donor site defect size between the groups [
8,
15‐
18]. Despite the fact, that RFFF originated in China, where flap surgeons have historically made significant contributions [
19], none of the authors included studies in Chinese or searched Chinese databases. Furthermore, none of the authors assessed the quality of evidence using a systematic and transparent framework.
Our systematic review will ensure rigor and comprehensiveness by implementing an exhaustive search strategy, expanding our database coverage, and by including Chinese literature, utilizing advanced risk of bias assessments, and applying the GRADE approach for a robust evaluation of evidence quality. This new systematic review and meta-analysis regarding donor site management after RFFF, with strict adherence to the PRISMA statement would give us reliable evidence for answering the favorable surgical closure technique question, particularly whether STSG or FTSG is preferred. The answer to this question would impact clinical practice and would be very important for developing future clinical guidelines.