British Journal of Oral and Maxillofacial Surgery (1999) 37, 119–122 © 1999 The British Association of Oral and Maxillofacial Surgeons
BRITISH JOURNAL OF ORAL
& M A X I L L O FA C I A L S U R G E RY
TECHNICAL NOTE Closure of radial forearm free flap donor site with local full-thickness skin graft B. van der Lei, C. A. Spronk, J. G. A. M. de Visscher Department of Plastic, Reconstructive, Aesthetic and Hand Surgery and Department of Oral and Maxillofacial Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands SUMMARY. A triangular shaped full-thickness skin graft harvested adjacent to the donor site of the radial forearm flap, as originally described by Liang et al,1 has successfully been used in seven consecutive patients for coverage of the donor site of the radial forearm free flap. In all patients this resulted in a robust coverage with no late wound breakdown and an aesthetic appearance far superior to split-thickness skin-graft coverage. We recommend this technique which is feasible in the majority of cases and reduces both donor site and graft site morbidity of the radial forearm flap.
length (Fig. 2). This full-thickness skin graft is first harvested without subcutaneous fat and stored in a saline soaked gauze. In the exposed subcutanous area, branches of the lateral cutaneous antebrachial nerve and the cephalic vein can be easily dissected. Then, the radial forearm flap is harvested routinely and used for reconstruction. Closure of the donor site is performed from proximal to distal as to the point pointed out before harvesting the flap (Figs 1, 2). Now the remaining triangular defect is closed with the triangular shaped full-thickness graft in a V–Y fashion. A suction drain is positioned between the forearm muscles. A nonadherent dressing (Adaptic) is applied followed by wetted gauzes and fluffed coarse gauze. A plaster is used to immobilize the hand and forearm. After 7 days, donor site inspection is performed (Fig. 3B). Then, a new light dressing is applied with a lightweight splint for an additional week.
INTRODUCTION The radial forearm free flap is a versatile fasciocutaneous flap that is ideal for reconstruction of intraoral defects.2,3 The most commonly cited disadvantage of the use of this free flap, however, is the aesthetic deformity of its donor site when using a split-thickness skin graft. Moreover, delayed healing and breakdown of the split-thickness skin graft overlying the wrist tendons account for a high complication and morbidity rate of the donor site.4–7 To improve the aesthetic deformity and to reduce the complication and morbidity rate of the donor site, Liang et al1 proposed to triangulate the volar donor defect of the radial forearm free flap and close it with a triangular shaped full-thickness skin graft harvested adjacent to the donor site. They advised and have used this flap only in the distal volar forearm not extending more dorsal than the level of the radial styloid. We have found this technique also successful for closure of the more dorsally located donor site of the sensate fasciocutaneous radial forearm free flap innervated by the lateral antebrachial cutaneous nerve.
RESULTS This technique has been applied in a series of 7 consecutive patients. The flap sizes ranged from 4 × 6 to 5 × 9 cm. In 5 patients a radiodorsal located sensate radial forearm free flap was harvested (Fig. 3A, B, C), in 1 patient a radiovolar located radial forearm free flap, and in 1 patient a radiovolar/dorsal located osteofasciocutaneous radial forearm free flap. All grafts took well, even over the flexor carpi radialis tendon. In 3 patients early bullae appeared on a small part of the full-thickness skin graft, which subsequently reepithelialized with some hyperpigmentation. There was no late wound breakdown nor scarring of a grafted donor site. In all patients a good cosmetic result was obtained (Fig. 3C) and all patients were satisfied with the appearance of the donor site. There has been no request for donor site revision.
TECHNIQUE The dimensions of the triangular shaped full-thickness skin graft can easily be estimated and designed adjacent to the planned radial forearm free flap (Figs 1–3; the schematic drawings are outlined for clarity on the distal volar forearm). For a mediumsized flap, a triangular shaped full-thickness skin graft is designed with the length of that of the radial forearm flap (Figs 1, 3A), for the larger-sized flap and/or when closure of the proximal end of the flap donor site may not be possible, a triangular shaped full-thickness skin graft is designed with a longer 119
British Journal of Oral and Maxillofacial Surgery
Fig. 1 – Schematic drawing of the triangular shaped full-thickness skin graft is shaded. Pre/peroperatively, it can easily be estimated that the proximal width A–A´ can be approximated.
Fig. 2 – Schematic drawing of the triangular shaped full-thickness skin graft, in which the proximal width A–A´ cannot be approximated. A longer full-thickness skin graft is designed, the defect is closed as in a V–Y fashion. B–B´ can be approximated, as estimated peroperatively.
DISCUSSION When a split-thickness skin graft is used to close the donor site of the radial forearm free flap, the aesthetic deformity and the donor site morbidity are recognized as major disadvantages. Most series on evaluating the donor site morbidity of the radial forearm flap report problems in the range of 30–50%.4–7 Various techniques have been reported to improve the aspect of the donor defect and/or to reduce the donor site morbidity. Fenton and Roberts8 imbricated
muscle over the exposed flexor carpi radialis tendon to decrease the risk of late breakdown of the splitthickness skin graft. Elliot et al9 used an ulnar transposition flap for direct closure of small to medium sized defects on the volar forearm. However, this technique is of limited value for covering the donor defect of the sensate radial forearm free flap, which is located on the radiodorsal site of the forearm.10 Hallock11 used tissue expansion as a secondary procedure to improve the donor site, but this implicates two additional operative procedures, a significant
Closure of radial forearm flap with full-thickness skin graft
Fig. 3 – (A) Preoperative design of a moderate-sized sensate radial forearm free flap, with the proximal triangular shaped fullthickness skin graft, located on the distal radiodorsal forearm. (B) Donor site inspection of the triangular shaped full-thickness skin graft in the same patient after 1 week. (C) Final result of the donor site in the same patient after 6 months.
Acknowledgements The authors wish to thank I. Stokroos for the schematic drawings and K. Koster for the photography.
C drawback. Wolff et al12 used the technique of prefabricating a fascial-split thickness skin graft radial forearm flap to improve the radial forearm donor site, but this also requires an additional operative procedure 2 weeks prior to reconstruction. Gaukroger et al13 and Sleeman et al14 reported on the use of a full-thickness skin graft taken from the abdominal wall for closure of the donor defect of the radial forearm flap, leading to a robust coverage. The only disadvantage of this technique is the additional donor area/wound on the abdominal wall and the colour mismatch. The results of our series of patients as well of those of Liang et al,1 who have first described the technique of a local full-thickness skin graft for closure of the donor defect of the radial forearm flap, clearly demonstrate that this technique has several advantages as compared to other methods: (1) it is a one-stage procedure requiring no secondary donor site; (2) the colour match of a full-thickness skin graft of the forearm is excellent; and (3) there are no late wound breakdowns, not even over the flexor tendons. The method is suitable in the majority of the cases when using a radial forearm free flap for intraoral reconstruction. Only occasionally when harvesting a large radial forearm flap, closure of the planned donor site of the full-thickness skin graft may not be possible. In such a situation, a ‘conventional’ splitthickness skin graft or, probably far better, a fullthickness skin graft harvested from the abdominal wall should be used to close the donor site of the radial forearm flap.13,14
References 1. Liang MD, Swartz WM, Jones NF. Local full-thickness skingraft coverage for the radial forearm flap donor site. Plast Reconstr Surg 1994; 93: 621–625. 2. Soutar DS, Scherer LR, Tanner NSB, McGregor IA. The radial forearm flap: a versatile method for intraoral reconstruction. Br J Plast Surg 1983; 36: 1–8. 3. Soutar DS, McGregor IA. The radial forearm flap for intraoral reconstruction. The experience of 60 consecutive cases. Plast Reconstr Surg 1986; 78: 1–8. 4. Swanson E, Boyd JB, Manktelow RT. The radial forearm flap: Reconstructive applications and donor-site defects in 35 consecutive patients. Plast Reconstr Surg 1990: 85: 258–266. 5. Timmons MJ, Missotten FE, Poole MD, Davies DM. Complications of the radial forearm flap donor sites. Br J Plast Surg 1986; 39, 176–178. 6. Boorman JG, Brown JA, Sykes PJ. Morbidity in the forearm flap donor arm. Br J Plast Surg 1987; 1987, 207–212. 7. Richardson D, Fisher SE, Vaughan ED, Brown JS. Radial forearm donor-site complications and morbidity: a prospective study. Plast Reconstr Surg 1997; 99: 109–115. 8. Fenton OM, Roberts JO. Improving the donor site of the radial forearm flap. Br J Plast Surg 1985; 38: 504–505. 9. Elliot D, Bardsley AF, Batchelor AG, Soutar D. Direct closure of the radial forearm flap donor defect. Br J Plast Surg 1988; 41: 358–360. 10. Boyd B, Mulholland S, Gullane P, Irish J, Kelly L, Rotstein L, Brown D. Reinnervated lateral antebrachial cutaneous neurosome flaps in oral reconstruction: are we making sense. Plast Reconstr Surg 1994; 93: 1350–1359. 11. Hallock GG. Refinement of the radial forearm flap donor site using skin expansion. Plast Reconstr Surg 1988; 81: 21–25. 12. Wolff KD, Ervens J, Hoffmeister B. Improvement of the radial forearm donor site by prefabrication of fascial-split thickness skin grafts. Plast Reconstr Surg 1996; 98: 358–361. 13. Gaukroger MC, Langdon JD, Whear NM, Zaki GA. Repair of the radial forearm flap donor site with a full-thickness graft. Int J Oral Maxillofac Surg 1994; 23: 205–208. 14. Sleeman D, Carton ATM, Stassen LFA. Closure of radial forearm free flap defect using full-thickness skin from the anterior abdominal wall. Br J Oral Maxillofac Surg 1994; 32: 54–55.
British Journal of Oral and Maxillofacial Surgery
The Authors B. van der Lei MD, PhD Plastic Surgeon C. A. Spronk MD Plastic Surgeon Department of Plastic, Reconstructive, Aesthetic and Hand Surgery J. G. A. M. de Visscher MD, DDS Oral and Maxillofacial Surgeon Department of Oral and Maxillofacial Surgery Medical Center Leeuwarden The Netherlands
Correspondence and request for offprints to: Dr B. van der Lei, Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, Medical Centre Leeuwarden, Henri Dunantweg 2, 8934 AD Leeuwarden, The Netherlands. Paper received 17 April 1997 Accepted 16 June 1997