Management of the radial forearm free flap donor site using a topically applied tissue expansion device

Management of the radial forearm free flap donor site using a topically applied tissue expansion device

Vol. 116 No. 1 July 2013 Management of the radial forearm free flap donor site using a topically applied tissue expansion device James P. Bonaparte, M...

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Vol. 116 No. 1 July 2013

Management of the radial forearm free flap donor site using a topically applied tissue expansion device James P. Bonaparte, MD, MSc, FRCSC,a Martin J. Corsten, MD, FRCSC,a Michael Odell, MD, FRCSC,a Michael Gupta, MD, FRCSC,b Murray Allen, MD, FRCSC,c and Darren Tse, MDa The University of Ottawa, Ottawa, Ontario, Canada; and McMaster University, Hamilton, Ontario, Canada

Background. The purpose of this study was to prospectively assess clinical outcomes in patients undergoing a new method of donor site management for radial forearm free flaps. Methods. 177 patients underwent reconstruction of ablative defects of the head and neck using a radial forearm free-flap. All patients had topical tissue expansion tapes applied to their forearms preoperatively. Closure rates, healing time and complications associated with the technique were assessed. Results. Ninety-five percent of patients had their donor sites closed primarily with a locally harvested full thickness skin graft. Complications related to the tissue expansion device included a loss of device adhesion (19.3%) requiring reapplication and minor pruritic reactions (4.1%). Conclusions. This system of donor site management has resulted in a significant reduction in the requirement of a split thickness skin graft for coverage of the donor site in a radial forearm free flap without any significant economic cost or patient morbidity. (Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:28-34)

Surgical closure of a radial forearm free-flap (RFFF) donor site traditionally requires a split-thickness skin graft (STSG).1 Postoperatively, both the STSG and the free flap donor sites require considerable wound care2-6 that can be painful7 and time consuming.5,8 Even with judicious care, complications such as tendon adhesion at the recipient site,5,8 loss of sensation,1,9 cold intolerance10 and poor cosmetic results3,11,12 continue to occur. Due to these potential limitations, reconstructive surgeons have attempted to develop other options for repairing the free flap donor site defect. Options include harvesting a full-thickness skin graft (local13,14 or distant4,5,15-18), primary closure,8,19 local flaps8,20 or a combination of these techniques.21 Although ideal, primary closure of the defect is rarely possible due to considerable tension placed on skin edges. Methods such as purse string suturing19,22 and cross suturing23 have been applied with the goal of reducing the size of the defect thus allowing increased rates of primary closure. However these techniques continue to require either a full or split thickness skin grafts from a distant site and rarely allow for full primary closure. This paper was presented at the North American Head and Neck Society annual Meeting in Toronto, Ontario in August 2012. a Department of Otolaryngology e Head and Neck Surgery, The University of Ottawa, Ottawa, Ontario, Canada. b Department of Surgery, Division of Otolaryngology, McMaster University, Hamilton, Ontario, Canada. c Department of Surgery, Division of Plastic Surgery, The University of Ottawa, Ottawa, Ontario, Canada. Received for publication Oct 3, 2012; returned for revision Nov 27, 2012; accepted for publication Jan 10, 2013. Ó 2013 Elsevier Inc. All rights reserved. 2212-4403/$ - see front matter http://dx.doi.org/10.1016/j.oooo.2013.01.007

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Tissue expansion has shown considerable efficacy in increasing the rate of primary closure of forearm defects. Although highly effective, tissue expansion typically utilizes invasive implantable expansion devices8,24,25 or cumbersome topical devices.26 In 2007 our team developed a program of radial forearm free flap donor site management27 with the primary goal of reducing the use of split thickness skin grafts. This technique relies on preoperative expansion of the forearm skin using an inexpensive, non-invasive device placed on the forearm skin a minimum of 7 days prior to harvesting the free flap. Specifically, the device consists of a series of adhesive tapes with a central elastic component which pulls the skin medially thus expanding the skin around the future wound edges (Figure 1). Recently published trials have demonstrated a 75% reduction in the mean healing time of the free flap donor site, a 40% reduction in overall postoperative pain28 and a reduction in the economic cost of wound care29 in those patients undergoing this method of donor site management compared to the standard use of a split thickness skin graft. Long-term results were

Statement of Clinical Relevance This paper represents an additional method, which can be used to improve patient outcomes when undergoing a radial forearm free flap. We feel this represents an inexpensive yet effective approach. This study represents a long-termelarge population prospective follow-up of a method we developed 4 years ago confirming our initial findings.

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Fig. 1. Image of DynaClose preoperative tissue expansion tapes applied to the forearm of patient. The adhesive components of the tapes (white translucent portion) were attached to the dorsal forearm. Application of the tapes in this manner results in the elastic component (transparent portion) pulling the surrounding tissue toward the harvest site. Two to three tapes were placed over the distal aspect of the volar forearm depending on the size of the patients forearm (A). The tapes were crossed and centered over the predicted site of flap harvest. An additional tape was placed over the proximal volar foramen skin (B). The purpose of this tape was to expand the skin over the vascular pedicle allowing our team to harvest an FTSG from redundant tissue if primary closure was not possible.

equally encouraging as expert observers noted a significant improvement in cosmesis of the donor site without any difference in functional status of the patients forearm.30 Although only 26% of patients’ defects were closed primarily, the added benefit of this technique is the availability of highly flexible redundant skin on the proximal forearm. The availability of this skin allows for the majority of defects to be closed using a locally harvested full-thickness skin graft (FTSG)29 resulting in less than 10% of patients requiring a distant skin graft. Although these previous studies are promising, they were limited by their small sample size as well as the lack of blinding. Both these limitations, when taken together, create a semblance doubt as to whether this method of donor site management may actually result in a real clinical effect or if the effect is due to bias. A larger, more robust sample size would provide additional evidence as to the efficacy of this method, particularly when taken in the context of the current standard of care. Furthermore, a larger study performed prospectively would provide a comprehensive evaluation of the incidence of closure methods as well as an assessment of the complications associated with this method of donor site management. Therefore, the purpose of this study was to prospectively assess the closure method required for a radial forearm free flap after utilizing this new method of donor site management in a large cohort of patients. As a secondary objective an assessment of the short and long-term complications and healing time of the forearm defect associated with each method of closure in our population was conducted.

ORIGINAL ARTICLE Bonaparte et al. 29

Fig. 2. Typical radial forearm free flap donor site preparation used by our team. Donor site is designed as a wide ellipse. Measurements on forearm are in centimeters. Dotted lines corresponded to location of vasculature.

MATERIALS AND METHODS Study design and population All patients 18 years of age or older undergoing a radial forearm free flap for reconstruction of surgical defects of the Head and Neck at the Ottawa Hospital were identified prospectively between January 2008 and September 2011. The Ottawa Hospital is a large Tertiary Care Center in Eastern Ontario, Canada with a referral base of 1.5 million. The institutional ethics review board of The Ottawa Hospital reviewed and approved this study. One reconstructive Plastic Surgeon and 2 Head and Neck Surgeons were responsible for screening and identifying patients. Medical records, billing records, physician clinic records and resident operative case records were retrospectively reviewed to ensure adequate case ascertainment. We utilized an intention to treat approach such that any patient in whom we attempted to apply the DynaClose (Canica Design Inc., Montreal, Canada) device remained in the data analysis, regardless of whether or not the tissue expansion tapes were removed prematurely. All patients were followed up for a minimum of 1-year for the purpose of this study. Surgical technique and application of DynaClose All patients presented to either Plastic Surgery or Otolaryngology clinic 1-2 weeks prior to their surgical procedure for an assessment. At this visit, the DynaClose tapes were applied to the patients’ forearms as described in Figure 1. The DynaClose tapes were removed on the morning of the operative procedure. The radial forearm free-flap was harvested using a standard surgical technique. All cutaneous skin flaps were designed as a wide ellipse on the volar aspect of the distal forearm (Figure 2). The size of the donor site was estimated by calculating the area of the ellipse.28 Our team utilized a step-wise approach for closure of the free flap defect. If possible the wound was closed primarily by advancement of the available skin (Figure 3). If a primary closure was not possible or the tissue was under high tension (Figure 4), we attempted

ORAL AND MAXILLOFACIAL SURGERY 30 Bonaparte et al.

Fig. 3. Demonstration of an RFFF wound closed primarily (A). After 10 months of healing time, an excellent cosmetic result was achieved (B). The original defect size was 8.5 cm  6 cm.

to close a small portion of the distal defect primarily, thus reducing the total defect area. After this, we then attempted to harvest a full-thickness skin graft from redundant tissue on the ipsilateral proximal forearm incision line (Figure 5). If there was insufficient skin to allow closure with a local FTSG, a distant STSG was harvested from the anterolateral thigh (Figure 6). To do this, a pneumatic dermatome was set to a depth of 0.010-0.012 inches to harvest the distant STSG. In all cases the proximal incision was closed primarily. Dressings and wound care Wounds closed primarily were covered with a layer of Jelonet (Smith and Nephew, Mississauga, Ontario, Canada) covered with sterile dry gauze. The initial dressing change for this closure method occurred on postoperative day 2 and then daily until healing was achieved. All split thickness and full-thickness skin grafts were covered with Jelonet and a dry sterile dressing. For split thickness skin grafts, a forearm splint was placed over the recipient limb to provide immobilization for a total of 5 days post-op. The initial wound assessment and dressing change for both full- and split-thickness skin grafts occurred on postoperative day 5 followed by daily dressing changes consisting of Jelonet covered with sterile gauze. If a split-thickness skin graft was required, the donor site on the lateral thigh was covered with an Allevyn (Smith and Nephew) dressing. This was secured using an OpSite (Smith and Nephew) dressing. The lateral thigh donor site dressing was changed every 5 days. Any split or full-thickness skin graft failures were treated with an application of Allevyn dressings to encourage healing by secondary intention. Any patient in which a wound was not healed at the time of

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Fig. 4. Surgical technique for closure of radial forearm free flap using a full thickness skin graft. The original defect in this male patient was 8 cm  7 cm. Initially a series of towel clamps are applied to estimate the approximation of the wound edges.

discharge, a home care nurse assessed and dressed the wound on a daily basis. If a home care nurse believed the wound was healed, dressing changes were discontinued and the patient was reassessed by the treating surgeon the following week.

OUTCOMES Wound closure method The specific method of closure for each patient was recorded (primary, local FTSG or distant STSG). If a patients defect was partially closed primarily however a residual defect requiring a skin graft remained, the defect was considered closed using the skin graft. Wound healing The definition of time to wound healing utilized for this assessment was based on the total number of days in which dressing changes were required for each patient. Wounds were assessed daily and healing time was determined by the Plastic Surgery and Otolaryngology team. Complications Any patient who requested early removal, reported a loss of adhesion or reported a complication of the DynaClose tapes were reassessed in clinic. In the case of loss of adhesion, the tapes were reapplied at this clinic visit. All patients remained in the final assessment as per an intention to treat analysis. A patient was defined as having failure of the DynaClose if the tapes were removed or lost adhesion and not-reapplied within 48 h or more before their operative procedure. Partial split or full-thickness graft loss was defined as any necrosis, retraction or underlying tissue exposure occurring in less than 50% of the total graft area. Complete loss was defined as a greater than 50% loss of the skin graft.

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ORIGINAL ARTICLE Bonaparte et al. 31

Table I. Demographics

Fig. 5. Primary closure was not possible in this patient therefore a portion of the proximal forearm skin underlying the area of prior tissue expansion was grasped to harvest redundant forearm skin. This redundant full thickness tissue is excised and debulked of fat. Typically, we are able to reduce the defect size by over 50% through primary closure of a portion of the defect (black arrow), thus a small FTSG (white arrow) is typically required for the completion of closure of the donor site. This residual defect was 2 cm  3 cm (original 8 cm  7 cm).

Fig. 6. Once completed, the FTSG is placed on the remaining defect over the distal cutaneous harvest site. The FTSG was secured to the surrounding skin using a combination of absorbable braided sutures and surgical staples.

STATISTICAL ANALYSIS To assess time to wound healing, a cumulative failure plot using the KaplaneMeier estimator was plotted for each closure method. A failure was defined as a patient achieving a completion of wound healing. A log-rank test was used to compare time to wound healing between each closure method. A general linear model analysis of variance (ANOVA) was utilized to assess for differences in both defect surface area and age between each of the closure method. Tukey’s multiple comparison test was used to assess for differences between groups within the ANOVA. Chi-square testing was used to assess for association between closure method and gender as well as closure method and complications. For all testing, a significant P-value was defined as a P < .05.

Closure

No. (%)

Age (years)

Primary FTSG STSG All patients

49 (28) 120 (68) 8 (5) 177

65.2 65.6 56.0 63.2

(10.4) (12.1) (21.1) (13.3)

Gender count (female)

Stage (TNM) (median)

28 57 1 86 (48%)

3 3 2 2

RESULTS A total of 184 patients undergoing a radial forearm free flap for a head and neck reconstructive procedure were identified. Of these patients, 177 underwent the new method of donor site management and all are included in this assessment. The sole reason for the 7 patients not using the new method of donor site management occurred in circumstances where the tissue expansion device was not available to the treating physician at the clinic visit. All those patients who did not have the DynaClose applied required a distant-splitethickness skin graft; however given that the DynaClose was not applied they are not included in the overall assessment of closures methods and thus excluded from the data analysis. Patients included in previous studies performed by our research team28-30 assessing this method of donor site management were not included in this study. Demographic data is presented in Table I. The mean (SD) size of the forearm defect was 38.9 (14.1) cm2. There was no significant difference between forearm defect area and closure method (P ¼ .5). A total of 49 (27.6%) patients were closed primarily, 120 (67.7%) were closed using a locally harvested FTSG and 8 (4.5%) required a distant STSG. The overall mean (95% confidence interval [C.I.]) time to completion of wound healing for all patients was 7.7 (6.9-8.6) days (Table II). The mean (95% C.I.) for time to wound healing in days was 3.6 (2.8-4.3), 8.7 (8.0-9.5) and 13.6 (11.2-15.9) for primary closure, FTSG and STSG closure respectively (P < .0001, logrank ¼ 85.4) (Figure 7). A total of 15 patients had the DynaClose tape fail. Of the 8 patients closed using an STSG, 7 patients (75%) had the DynaClose tapes removed prematurely. Of these, 4 patients had the DynaClose tapes fall-off and not return for re-application, 1 patient asked for removal of the DynaClose tapes and 2 patients developed a minor pruritic reaction requiring tape removal. All of the patients achieving primary closure had the DynaClose applied for the full 2 weeks. The largest defect closed primarily was 80 cm2 and the largest defect closed with a local FTSG was 96 cm.2 Female gender was associated with a higher proportion of primary closure compared to males (P ¼ .03). Two patients who had an STSG developed tendon exposure. Two patients with an FTSG developed partial

ORAL AND MAXILLOFACIAL SURGERY 32 Bonaparte et al.

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Table II. Outcome for each closure method Closure Primary FTSG STSG All patients

Graft size (cm2) 38.35 38.6 44.3 40.55

(16.6) (12.9) (16.9) (15.4)

RFFF intra-oral failure (%)

Donor site complication (%)

2 (4.1) 2 (1.67) 0 4 (2.3)

0 4 (3.3) 2 (25) 8 (4.5)

Fig. 7. Cumulative failure plot for time to completion of wound healing. Patients were considered to have completed healing of the RFFF donor site once the surgical team determined dressing changes were not required.

necrosis of the graft while 2 patients developed complete necrosis of the graft. There were no episodes of wound dehiscence in patients closed primarily. One patient with primary closure developed a minor local cellulitis treated with enteral antibiotics (Figure 6). With respect to complications associated with the freeflap, 14 patients required a return to the operating room for salvage. Of those, 4 were not salvageable resulting in an overall flap success rate of 97.7% (Table II). Complications specific to the DynaClose were infrequent and mild. The most serious complication occurred in 1 patient who developed superficial blistering under the DynaClose. This resolved after removal of the tapes. The remainder of the reactions consisted of pruritic reactions to the adhesive of the tape with all resolving after removal of the tapes.

DISCUSSION The routine use of this method of donor site management has resulted in a significant reduction in patient morbidity at our center. The results of this case series demonstrate the considerable efficacy of this method. Importantly, these benefits occur without any significant cost or added patient morbidity. In patients who required a split-thickness skin graft, all were either young, otherwise healthy males or those who the DynaClose lost adhesion and the patient did not return for reapplication. For this trial, we did not shave the arms of patients’, however it seems plausible that doing this may improve adhesion. However, based on

Healing time (days) 2.7 7.3 14 6.3

(1.3) (2.4) (4.3) (3.4)

Loss of adhesion of DynaClose (%) 1 5 7 13

(2) (9.1) (87.5) (7.3)

Minor skin reaction to DynaClose 0 1 3 4 (2.3%)

our experience, young males appear to have tissue that has reduced pliability thus the tension provided by the DynaClose does not appear to be sufficient enough to expand the tissue. This is further supported by the data suggesting that females have an increased rate of primary closure compared to males. Perhaps male patients require higher levels of tension to achieve similar levels of tissue expansion. Typically our team utilizes 3 DynaClose tapes for each patient. Higher levels of tension could theoretically be achieved by applying more individual DynaClose tapes to a patient’s forearm thus potentially overcoming this problem. It remains unclear whether these patients would benefit from increasing the number of tapes. A study is currently underway assessing the physiologic changes in skin and whether additional tapes would increase tissue expansion. Another possible improvement in this method would be to reapply tapes after the original tapes loose their elasticity. Based on our experience, after 5-7 days the primarily applied tapes either loose their adhesion or appear to loose their elastic tension. Perhaps removing these tapes and reapplying them would allow for further expansion. Unfortunately this was not possible in our center due to clinic time limitations and patients not wanting to return for additional visits. As our experience increased using this method, it became apparent that the availability of the fullthickness skin from the proximal forearm was available in nearly all patients who had the DynaClose applied. Of the 8 patients requiring a split-thickness skin graft 7 were performed during the initial year we began using this method, after which only 1 patient required a split thickness skin graft. This finding is likely due to our increased reliance and comfort with harvesting a local full-thickness skin graft. Although we were unable to achieve primary closure in the majority of cases, the laxity of the surrounding tissue allowed a partial primary closure thus a reduction in the original size of the defect of the donor site. In many patients with a full-thickness graft, this resulted in a final defect that was considerably less than the original size quoted in the results. Unfortunately we did not formally assess the change in size nor the size of the full-thickness graft harvested. Subjectively, it appears as though a reduction in original defect size greater than 50% is easily achieved in all patients undergoing tissue expansion. This likely explains the overall reduced healing time in those patients who

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received a full-thickness skin graft as the vast majority of grafts were small (5-15 cm2) thus requiring minimal care. Both a clinically relevant and an interesting observation in this study was the low rate of full-thickness skin graft failure in our population. In all patients undergoing skin-expansion, we have only 4 documented cases of a partial or complete loss of the FTSG. A study conducted by Alex et al.31 noted a number histological changes in tissue undergoing expansion. Similar to the devices used by our research team, 2 dimensional skin expansion resulted in low levels of epidermal thickening, increased angiogenesis and less compression of dermal layers of skin compared to implantable balloon 3D tissue expansion. The authors hypothesized that the increase in angiogenesis at 1week may result in improvements in flap viability and healing in 2D pre-expanded skin. However basic science research is required to determine if these changes are occurring in our patients and whether this is influencing graft survival. Even with the possibility of these histological changes, it is unclear if this method of tissue expansion actually increases skin surface area or if other biomechanical changes are occurring. Given the tension levels provided by the DynaClose tapes, it is likely patients’ forearm skin is undergoing both stress relaxation and creep, resulting in more pliable forearm skin. Subjectively, it appears as though there is a significant increase in the pliability of patients’ skin. This is purely speculative at this time as formal objective basic science research assessing the biomechanical changes occurring in forearm skin during this method of tissue expansion is ongoing. Recently our team has conducted a pilot study utilizing the Cutometer (CourageþKhazaka Electronic, Cologne, Germany), a device which has the ability to assess the pliability and elasticity of skin. Measurements using this device indicated an increase in pliability of the forearm skin after 1-week of tissue expansion compared to both unexpanded skin and agematched untreated patients. A clinical trial is currently underway using this device to determine the degree at which the DynaClose are increasing skin pliability. Even though this method of reconstruction results in significant reductions in patient morbidity, limitations remain. Importantly, our reconstructive team utilized a subfascial radial forearm free flap technique in the majority of cases (87% of cases). Recent evidence has demonstrated a reduction in skin graft failure when using a suprafascial technique.32,33 Although the use of a suprafascial technique may have resulted in a reduction in graft failure in those patients undergoing a splitthickness skin graft, the effects on closure method would likely not have changed. In addition to this, the use of a suprafascial approach often leads to easier

ORIGINAL ARTICLE Bonaparte et al. 33

undermining of tissue and may assist with mobilization of tissues. However, given the low rates of STSG requirements, this does not appear to be the only explanation for the increased closure rates. An important limitation of this study is the definition used to define “healing time.” Similar to the majority of other studies, we utilize days required for wound care as a proxy for healing time. Obviously this is not ideal as true healing is likely not occurring at the same time as a cessation of wound care. In the primary closure group, patients required an average of 2.7 days of wound care. However, these patients required sutures and surgical staples to remain in place for a minimum of 7 days therefore one could argue that it is in fact 7 days of healing time. This demonstrates the difficulty in defining healing time, however we believe that as long as a standard definition is utilized, the data can be compared within a study. The difficulty appears to arise when one compares 2 studies as such a subjective definition is open to many interpretations and opinions. Furthermore, it is difficult to compare healing in a primarily closed wound versus 1 closed with a skin graft. There is no standard way to assess this at this time thus the estimation of healing time likely would show wide variability between raters. This is certainly a limitation of this study however the closure rates as well as complication rates suggest that primary closure likely results in a reduction in the care required and the healing time of the wound. An additional point relates to the size of the defect. Our practice is primarily a head and neck oncologic practice thus we typically require smaller flap sizes than larger reconstructions at other body sites. However, the defect sizes used by our team are similar to those reported in the literature yet our closure rates are considerably higher. What remains unclear is if this method of donor site management would be of benefit in significantly larger defects.

CONCLUSION The use of our donor site closure strategy with preoperative tissue expansion represents a significant advancement in our management of patients undergoing reconstructive surgery with a radial forearm free flap. The use of this technique has allowed us to avoid a STSG in nearly 96% of patients. The cost of the tissue expansion device is minimal and the side effects are minor. Reconstructive surgeons should consider this method of tissue expansion for patients requiring a radial forearm free flap.

We would like to acknowledge Dr. Jeffson Chung, Jacki Leclerc and Dawn Lamothe for assistance with this manuscript.

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OOOO July 2013 18. Zuidam JM, Coert JH, Hofer SO. Closure of the donor site of the free radial forearm flap: a comparison of full-thickness graft and split-thickness skin graft. Ann Plast Surg. 2005;55:612-616. 19. Smith GI, O’Brien CJ, Choy ET, Andruchow JL, Gao K. Clinical outcome and technical aspects of 263 radial forearm free flaps used in reconstruction of the oral cavity. Br J Oral Maxillofac Surg. 2005;43:199-204. 20. Hsieh CH, Kuo YR, Yao SF, Liang CC, Jeng SF. Primary closure of radial forearm flap donor defects with a bilobed flap based on the fasciocutaneous perforator of the ulnar artery. Plast Reconstr Surg. 2004;113:1355-1360. 21. Loeffelbein DJ, Al-Benna S, Steinstrasser L, et al. Reduction of donor site morbidity of free radial forearm flaps: what level of evidence is available? Eplasty. 2012;12:e9. 22. Winslow CP, Hansen J, Mackenzie D, Cohen JI, Wax MK. Pursestring closure of radial forearm fasciocutaneous donor sites. Laryngoscope. 2000;110:1815-1818. 23. Moazzam A, Gordon DJ. Cross-suturing as an aid to wound closure: a prospective randomised trial using the forearm flap donor site as a model. Br J Plast Surg. 2003;56:695-700. 24. Berge SJ, Wiese KG, von Lindern JJ, Niederhagen B, Appel T, Reich RH. Tissue expansion using osmotically active hydrogel systems for direct closure of the donor defect of the radial forearm flap. Plast Reconstr Surg. 2001;108:1-5. 25. Masser MR. The preexpanded radial free flap. Plast Reconstr Surg. 1990;86:295-301. 26. Samis AJ, Davidson JS. Skin-stretching device for intraoperative primary closure of radial forearm flap donor site. Plast Reconstr Surg. 2000;105:698-702. 27. Gupta M, Allen M, Corsten M. Reduction of donor site morbidity in the radial forearm free flap by use of topical tissue expanders. J Otolaryngol Head Neck Surg. 2009;38:628-631. 28. Bonaparte J, Corsten M, Allen M. Healing time of radial forearm free flap donor sites after pre-operative tissue expansion: a randomized controlled trial. J Otolaryngol Head Neck Surg. 2011;40(suppl 1):S20-S27. 29. Bonaparte JP, Corsten M, Allen M. Cost-effectiveness of a topically applied pre-operative tissue expansion device for radial forearm free flaps: a cohort study. Clin Otolaryngol. 2011;36:345-351. 30. Bonaparte JP, Corsten MJ, Allen M. Cosmetic and functional outcomes after preoperative tissue expansion of radial forearm free flap donor sites: a cohort study. J Otolaryngol Head Neck Surg. 2011;40:427-435. 31. Alex JC, Bhattacharyya TK, Smyrniotis G, O’Grady K, Konior RJ, Toriumi DM. A histologic analysis of threedimensional versus two-dimensional tissue expansion in the porcine model. Laryngoscope. 2001;111:36-43. 32. Avery C. Prospective study of the septocutaneous radial free flap and suprafascial donor site. Br J Oral Maxillofac Surg. 2007;45: 611-616. 33. Chau J, Harris J, Nesbitt P, Allen H, Guillemaud J, Seikaly H. Radial forearm donor site: comparison of the functional and cosmetic outcomes of different reconstructive methods. J Otolaryngol Head Neck Surg. 2009;38:294-301. Reprint Requests: James P. Bonaparte, MD, MSc, FRCSC Department of Otolaryngology e Head and Neck Surgery 167 Sheppard Avenue West, Toronto, Ontario M2N 1M9, Canada [email protected]