A Comparison of Full and Split Thickness Skin Grafts in Radial Forearm Donor Sites

To formally evaluate the functional and aesthetic outcomes between full versus split thickness skin graft coverage of radial forearm free flap donor sites. A retrospective chart review of 47 patients who underwent pedicled or free radial forearm free flap reconstruction from May 1997 to August 2004 was performed. Comparisons were made between patients who had donor site coverage with split thickness skin grafts (STSG) or full thickness skin grafts (FTSG). There was no statistically significant difference between the STSG and FTSG in the number of post-operative dressings, incidence of tendon exposure, time to healing at the skin graft donor site, and time to healing at the skin graft recipient site. The questionnaire data showed there was a trend toward higher scores with the radial forearm scar aesthetics and satisfaction in the FTSG group. Full thickness skin graft coverage of radial forearm free flap donor site is superior to split thickness skin graft coverage in terms of aesthetic outcome, and has no statistically significant difference in terms of tendon exposure, time to healing at the skin graft donor site, time to healing at the skin graft recipient site, or post operative pain.     

Analysis of radial forearm free flaps in 37 consecutive cases

Thirty-seven radial forearm free flap transfers have been performed in a three year period. The results obtained have proven that the radial forearm free flap, a pioneer in free flaps, is going to keep its useful position in reconstructive procedures. Out of 37 cases there was only one total flap loss (2.7%). Other complications experienced arose from the donor site; two partial skin graft losses and one transient radial nerve injury. Preparation of a better recipient bed for split skin grafting and application of silicone sheeting also reduced the morbidity of donor defect. Received: 21 October 1996 / Accepted: 29 January 1997     

Radial forearm flap surgery—evaluation of donor site morbidity

The free radial forearm flap is an excellent method for reconstruction of defects in the head and neck region. In the literature, there is still disagreement about the best surgical treatment of the forearm defect to avoid functional and cosmetic drawbacks. There is a debate about using full-thickness skin graft or better split thickness skin graft. To evaluate our own results after radial forearm flap surgery, a follow-up examination and standardized interview of 25 patients was performed. For closure of the donor site, a full skin graft from the groin was used in 17 cases and split skin graft from the thigh in eight cases. All patients were satisfied with postoperative results and hand function for everyday use. Subjective complaints were more common in the split skin graft group, especially related to loss of sensibility. Because of severe wound healing failure with tendon exposure in one case after split skin grafting, there was the necessity for surgical revision. During the medical examination, we documented more functional impairments in the split skin graft group than in patients after full skin grafting. Only the development of hypertrophic scars dominated in the full skin graft group. According to the trend to fewer complications, we prefer full-thickness skin grafts for the closure of the donor site after radial forearm flap surgery. This study was presented at the International Forum: Plastic and Reconstructive Surgery of the Head and Neck, Annual Meeting of the German Academy of Otorhinolaryngology—Head and Neck Surgery Foundation, May 16–20 2007, Munich, Germany.     

Reconstruction of the radial forearm free flap donor site using integra artificial dermis

Autologous skin grafting to the donor site in patients who undergo radial forearm free flap reconstruction (RFFF) is associated with cosmetic and functional morbidity. Integra artificial dermis (Integra Lifesciences, Plainsboro, NJ) is a bovine collagen based dermal substitute that can be used as an alternative to primary autologous skin transplantation of the donor site. We describe a staged reconstruction using Integra followed by ultrathin skin grafting that results in highly aesthetic and functional outcomes for these defects. A retrospective review of 29 patients undergoing extirpative head and neck oncologic resection were examined. Integra graft placement was performed at the time of RFFF harvest followed by autologous split thickness skin grafting at 1 to 5 weeks postoperatively. Healing fully occurred within 4-6 weeks with negligible donor site complications, excellent cosmesis, and minimal scar contracture. Composite reconstruction with Integra artificial dermis offers advantages over traditional methods of coverage for select cases of radial forearm free flap donor site closures.     

Evaluation of the donor site in patients who underwent reconstruction with a free radial forearm flap

A major disadvantage of free radial forearm flaps is the conspicuous donor site. However, there have been few studies on donor scars. The authors evaluated the donor site in patients who underwent oral-floor reconstruction with a free radial forearm flap. The subjects were 23 patients (19 males and four females) who underwent reconstruction with a free radial forearm flap following resection of a malignant oral tumor, and were followed for 1 year or longer. The fasciocutaneous flap collection site was closed by full-thickness skin graft (FTSG) from the groin with tie-over dressing. All grafts took perfectly. At the scar at the donor site, five items (pigmentation, scar width, depression, wrist mobility, and sensory abnormalities) were evaluated. Depression and pigmentation were often observed, but patient dissatisfaction was slight. While their main postoperative concern was the oral reconstruction site, after about 1 year, the donor site became more important to patients. However, the results were good. A 100 percent take of the FTSG at the donor site should produce good results. Surgeons should pay adequate attention not only to the outcome at the reconstruction site, but also to the closure of the donor site.     

Use of the artificial dermis for free radial forearm flap donor site

The radial forearm free flap has been popular in many area of reconstructive surgery. Despite the many attributes of this flap in surgical reconstruction, one of the clear disadvantages has been the morbidity of the donor site. To solve problems associated with closure of the radial forearm flap donor site, the artificial dermis was used for better outcome in the donor site. From July of 2001 to October 2003, 13 patients (12 male, 1 female) ranging in age from 27 to 67 years underwent free radial forearm transfers. Flap size measured 49 to 144 cm2. Donor-site defects secondary to the flap elevation was closed first with the artificial dermis (Terudermis), marketed by Terumo Inc, Japan, and secondary split-thickness skin graft to the artificial dermis was performed in 15 days (range, 13 to 17 days) on average. There was no flap failure in all cases. Partial loss of the artificial dermis graft was noticed in 2 cases, but it was negligible. Secondary skin graft take was noticed in about 7 days, and there was no remarkable skin graft loss. The artificial dermis was used successfully in 13 patients with the donor defects of free radial forearm flap. Despite the disadvantage to need the secondary split-thickness skin graft, use of the artificial dermis gave us not only soft-tissue augmentation and graft-skin quality similar to full-thickness skin graft but also fast graft healing and diminished morbidity of the skin-graft donor site.     

全鼻再造手术方法的探讨

目的　介绍 4种全鼻再造的手术方法及适应证。方法　 1975～ 2 0 0 3年我们应用①上臂皮管全鼻再造术、②传统前额正中皮瓣全鼻再造术 额部植皮术、③额部正中皮瓣全鼻再造术 双侧额颞皮瓣滑行修复额部供区、④额部皮瓣扩张术后行额正中皮瓣全鼻再造术 ,对 2 2例行上述全鼻再造术者进行了回顾性分析 ,并讨论了上述手术方法的优缺点及其适应证。结果　本组病例均获成功 ,外形及通气功能效果良好。应用第 2种方法虽然再造鼻外形满意 ,但在额部留下明显而深暗的凹陷痕迹 ,影响美观 ;而应用第 1种方法额部不留任何痕迹 ,但鼻再造所需时间较长 (约 2个月 ) ,且需将上臂与头部间固定 3周 ,是其不足之处。结论　如采用前额正中皮瓣法行全鼻再造时 ,建议对鼻型较小者应用第 3种方法 ;而对鼻型较大者以用第 4种方法为好 ;而对于不接受在额部造成新的创伤或额部组织不足者 ,应选用第 1种方法为宜     

Negative‐pressure wound therapy for donor‐site closure in radial forearm free flap: A systematic review and meta‐analysis

Negative‐pressure wound therapy (NPWT) is often used for skin graft site dressing, and several studies have reported that its use improves skin graft failure in the forearm flap donor site. The present systematic review aimed to evaluate the efficacy of NPWT with skin graft for donor‐site closure in radial forearm free flap (RFFF) reconstruction. A systematic search in PubMed, Web of Science, and Cochrane Library databases was conducted. The search terms used for PubMed were ([radial forearm]) AND ([donor]) AND ([negative pressure or vacuum]). This review was registered in the International Prospective Register of Systematic Reviews and performed in accordance with the preferred reporting items for systematic reviews and meta‐analyses statement. Three prospective randomised controlled trials and three retrospective comparative studies were included. Compared with conventional bolster dressing, the use of NPWT dressing did not lead to significant improvements in partial skin graft loss, tendon exposure, and other complications. NPWT improved hand functionality earlier; nonetheless, the cost of the device and dressings was a disadvantage. The use of NPWT for skin graft fixation in the RFFF donor site is not generally recommended.     

Deepithelialized reverse pedicled forearm flap: a technical modification useful in hand and wrist reconstruction

Reverse pedicled forearm flap is a reliable and easy option for hand and wrist reconstruction. Between 2000 and 2009, eight patients underwent elective reconstruction of an upper extremity using a pedicled reverse radial forearm flap with a modified technique; a retrospective chart review of the results is presented. The surgically modified procedure is described. The flap donor area is deepithelialized with a dermatome and the split-thickness skin graft obtained is left on the donor site pedicled proximally; the deepithelialized flap is then elevated and rotated with the standard technique and the forearm donor site is covered by repositioning and suturing the skin previously harvested with the dermatome. This useful and easy technical modification allows prevention of post-operative pain and long-term dyschromia in the split-thickness skin graft donor site, making the reverse pedicled forearm flap an even better option in hand and wrist reconstruction.     

Aesthetic improvements of radial forearm flap donor site by autologous fat transplantation

Despite its reliability, radial forearm (RF) flap is still affected by high donor site morbidity with poor cosmetic and functional outcomes after coverage with skin grafts. Having fat grafting demonstrated promising and effective filling and rejuvenating properties, we considered and tested it as a valuable alternative to dermal substitutes for the aesthetic improvement of RF flap donor site. Thirty-three patients with previous RF free flap reconstruction and poor donor site outcomes after full-thickness skin grafting to RF region were evaluated for secondary fat injection to improve outcomes. Objective and subjective assessments of results with standardized ultrasonographic soft tissue thickness measurements, cutaneous sensibility tests with the pressure-specified sensory device and scar assessment scale (POSAS) have been performed. Bivariate statistical analyses were performed comparing outcomes with contralateral healthy forearm. All cases showed significant improvement in soft tissue thickness (p< 0.031), cutaneous sensibility and scar appearance, with improved patient’s and observers’ scar assessment scores (<0.001). In conclusion, fat transplantation is an effective procedure that provided us with an adjunctive autologous layer in-between skin graft and underlying fascia, as well as a rejuvenating effect on skin and scars.     

吻合血管股前外侧筋膜瓣的临床应用

目的探讨吻合血管股前外侧筋膜瓣修复前臂及手部创面的临床应用。方法2000年9月-2003年12月收治前臂及手部软组织缺损13例,男8例,女5例;年龄19-43岁。机器碾压伤3例,皮带绞伤4例,重物压伤6例。软组织缺损部位前臂掌侧6例,手背部6例,食指桡、背侧1例。缺损范围17.5cm×7.7cm-4.6cm×3.4cm,其中4例合并前臂、手部骨折,9例合并前臂、手部伸肌腱损伤。患者均急诊行清创、骨折复位内固定,修复损伤的神经、肌腱及血管,术后抗感染治疗3-5d后,采用吻合血管的股前外侧筋膜瓣联合中厚皮片植皮修复软组织缺损。结果术后患者均无血管危象发生。1例第4、5指蹼处约2.0cm×1.0cm植皮坏死,经换药及再次取全厚皮植皮后成活,余患者筋膜瓣及植皮均成活。全部获3-12个月随访,修复后的创面外形均良好,无皮肤挛缩。按中华医学会手外科学会上肢部分功能评定标准优9例,良2例,可1例,差1例,优良率85%。结论吻合血管股前外侧筋膜瓣联合植皮修复前臂及手部创面外形好,不需再次手术整形,远期无皮肤瘢痕挛缩发生,供区处理简单,创伤小。     

Free radial forearm flap with adipofascial tissue extension for reconstruction of oral cancer defect

The radial forearm flap has been one of the most popular flaps used to reconstruct defects after oral cancer ablation. However, it sometimes may not provide sufficient soft tissue to obliterate the dead space after tumor excision and lymph node dissection, which can result in deep wound infection of the neck or even orocervical fistula. The authors modified the radial forearm flap with a sheet of adipofascial tissue extension to prevent such postoperative complications. From January 1997 to December 2000, 52 patients who underwent ablative oral cancer surgery were studied. A total of 29 patients (group I) underwent reconstruction with the traditional radial forearm flap retrospectively, and 23 patients (group II) underwent reconstruction with the radial forearm flap along with a sheet of adipofascial tissue extension. The radial forearm flap was designed on the axis of the radial artery, was 8 x 4 to 12 x 10 cm in size, and was sufficient to resurface the intraoral defect. In group II, the radial forearm skin flap along with a sheet of adipofascial tissue 8 x 8 to 12 x 10 cm was used to obliterate the dead space of the oral floor and neck. The donor site of both groups was resurfaced with a split-thickness skin graft. In group II, the skin flap of the adipofascial tissue was resutured to its original site. Two flaps in group I failed because of arterial occlusion and required other skin flaps for reconstruction. Postoperative hematoma, which required surgical treatment for drainage, developed in five patients in group I. None of the patients in group II had hematoma formation. Nine patients in group I had a neck wound infection compared with only 2 patients in group II (a significant difference). The average volume of drainage and days of hospitalization were similar in both groups. The morbidity of the donor site of both groups was not significant. The advantages of this modification include 1) suitable soft tissue available for dead space obliteration to decrease the chance of postoperative hematoma; 2) the important vessels in the neck can be protected; 3) there is a decrease in neck wound infections; and 4) donor site morbidity is similar to the traditional group.     

Cross-suturing as an aid to wound closure: a prospective randomised trial using the forearm flap donor site as a model.

Direct closure of a full thickness skin defect by suturing is the simplest and best solution in most cases. When suturing is not possible, then a skin graft may be the next choice for reconstruction. It is usual for the graft to be applied to the unaltered defect, accepting the size of the wound as the area to be grafted. This approach ignores the potential contribution of the elastic properties of the wound edges, which are so readily used to advantage in direct closure. A simple technique, which makes skin defects substantially smaller prior to skin grafting, is described. This technique benefits the primary defect by minimising the area of scar produced, as well as minimising the size of skin graft required and thus the graft donor site. The secondary defect of the radial forearm flap was used as a model wound in a prospective randomised trial to assess the use of this technique. Twenty successive patients undergoing free radial forearm flap surgery were entered into the trial. The technique consisted of preliminary cross-suturing of the wound prior to skin grafting. Half of the cases received cross-wound suturing and half of the cases had grafts applied to the unaltered area of the defect. Measurements of the forearm flap donor defects were taken using templates made at the time of surgery and at later intervals. A statistically significant reduction in the flap donor defects was achieved using the cross-suturing technique. Fewer complications such as skin graft failure and tendon adherence to graft were seen with the new technique. This technique is recommended not only for minimising morbidity in the radial forearm flap donor site, but also for reducing the size of any full thickness skin defect prior to skin grafting.     

Free peroneal skin flap for oropharyngeal reconstruction.

The thicknesses of three dermal flaps, platysma, forearm, and fibula, which are often used for oropharyngeal reconstruction, were measured in 21 subjects using 15 MHz Doppler ultrasonography. The mean (SD) thicknesses were 2.2 (0.3), 3.1 (0.5), and 3.8 (0.6) mm, respectively. The free peroneal skin flap from the leg was used in 14 patients with head and neck cancer. These flaps were successfully transplanted in 13 of 14 patients (93%) with no problems at the donor site. This flap offers many advantages, including its distance from the head and neck, its cosmetic superiority to a forearm flap, it allows two flaps with two cutaneous branches, it is possible to close the donor site primarily without a skin graft, and it has thin subcutaneous tissue. We found that the free peroneal skin flap is particularly useful for oropharyngeal reconstruction.     

Free forearm flap for reconstruction of soft tissue defects concurrent with improved peripheral circulation

The free forearm flap is an accepted procedure for covering defects due to osteitis in the lower leg. End-to-end anastomoses have usually been preferred, if the diameters of the donor and recipient arteries are more or less equal. However, if one or more arteries of the lower leg are absent, end-to-end anastomosis is not indicated, because further disturbances of blood circulation will ensue. We present a procedure in which the flap vessels act as an arterial and venous bypass, thus improving the circulation in the lower leg, while concurrently perfusing the flap. Following full thickness skin graft, cosmetic results at the donor site are not especially pleasing. Results can be improved by a split skin graft (used as a mesh graft), and by situating the donor site on the upper third of the forearm. At the recipient site, the flap can be infolded and connected in anatomic right or reverse directions, depending on the required length of the flap vascular pedicle needed for reconstruction. This can lead to a reverse blood flow in he vessels of the transferred free forearm flap. The radial artery can be restored by vein graft from the same forearm. In 25 free forearm flaps to the lower leg, arterial bypass was performed in 14 cases, venous bypass as well in four cases, with reverse blood flow in three cases.     

Free radial forearm adiposo-fascial flap for inferior maxillectomy defect reconstruction

A free radial forearm fascial flap has been described for intraoral reconstruction. Adiposo-fascial flap harvesting involves few technical modifications from the conventional radial forearm fascio-cutaneous free flap harvesting. We report a case of inferior maxillectomy defect reconstruction in a 42-year-old male with a free radial forearm adiposo-fascial flap with good aesthetic and functional outcome with minimal primary and donor site morbidity. The technique of raising the flap and closing the donor site needs to be meticulous in order to achieve good cosmetic and functional outcome.     

Direct closure of radial forearm free-flap donor sites by double-opposing rhomboid transposition flaps: case report

A basic disadvantage of the radial forearm flap is the removal of skin from a functionally important and cosmetically exposed region. The donor site is conventionally repaired by skin grafting. However, this method is associated with complications of graft take and a poor aesthetic appearance. In this report, the authors describe a simple technique for direct closure of a distal forearm flap donor defect, using double-opposing rhomboid transposition flaps. This method is based on the existence of an oblique skin laxity in the distal forearm from the ulnar to the radial side, allowing a double-opposing local flap design. In a 32-year-old female patient, a 6- X 4-cm longitudinally-oriented elliptical skin defect of a radial forearm free flap was succesfully closed directly with the described technique without any complications. This method is a useful alternative for primary closure of small- to medium-sized distal forearm defects.     

The use of integra artificial dermis to minimize donor-site morbidity after suprafascial dissection of the radial forearm flap

In an effort to minimize the radial forearm flap donor-site morbidity, the flap was elevated using the suprafascial dissection technique, in six patients with various facial defects. The donor site was covered primarily with Integra artificial skin and secondarily with an ultrathin split-thickness skin graft. The mean time to wound healing of the forearm donor site was 24 days. There were no flap failures, and all flaps healed uneventfully. At the end of the follow-up, all patients showed normal range of motion of the wrist and the fingers, normal power grip, and power pinch. All patients evaluated the esthetic appearance of the forearm donor site as very good. In conclusion, suprafascial dissection of the forearm flap creates a superior graft recipient site, and the use of Integra artificial dermis is a valuable advancement to further minimize the donor-site morbidity, resulting in excellent functional and aesthetic outcomes.     

An algorithm to improve outcomes of radial forearm flap donor site

Background: Due to the high rate of donor site complications the Radial Forearm Flap (RFF) has lost ground in favor of the Antero-lateral tight flap (ALT) and other flaps. We have designed a reconstruction algorithm for reconstruction of its donor site. The goal of this study was to retrospectively evaluate the impact of this algorithm on RFF donor site complication rates.

Methods: The authors analyzed retrospectively 31 patients who underwent free radial forearm flap reconstruction between November 2009 and May 2013. Donor site complications were compared with data from patients treated before introdutction of the algorithm. Within the group were compared patients in which the flap was harvested suprafascial with those in which the flap was harvested as subfascial.

Results: Before application of the algorithm, there was a 23.3% complication rate at the RFF donor site, in our experience. After introduction of the algorithm, complication rate has dropped to 3.2%, consisting in a partial skin graft necrosis treated by local wound-care and healed without further intervention.

Conclusions: Application of the algorithm described has led to a significant reduction in RFF donor site complication rates. This demonstrates that if flap donor sites are analyzed and tailor treated in the same way as primary defects are, instead of being given secondary importance and just grafted, outcomes improve.     

The effect of radial artery reconstruction on the radial forearm donor site: a prospective study

The purpose of this study was to evaluate the effect of radial artery reconstruction after radial forearm flap elevation and to study whether a vein graft can stay patent in this position. Ten consecutive oral cancer patients were included in the study. Pre-operative Allen's test was performed, and the flow velocity of both radial and ulnar arteries was recorded using colour Doppler ultrasonography. After flap elevation, the radial artery was reconstructed using the cephalic vein of the donor forearm as a free vein graft. The reconstructed artery was completely covered with surrounding skin, while the actual donor defect was covered with a split thickness skin graft. Colour Doppler ultrasonography was performed at 1–2 weeks and at 6–12 months post-operatively to record long-term patency. Radial artery reconstruction did not prolong the operations. All donor sites healed uneventfully. All of the reconstructed arteries were patent at the post-operative controls. In one patient, graft flow was missing on the first post-operative day but normal in the follow-up. A vein graft can remain patent with a very high success rate after radial artery reconstruction. A negative Allen’s test is not an absolute contraindication of a radial forearm flap as radial artery reconstruction can be performed.