Pursestring closure of radial forearm fasciocutaneous donor sites

The Natural Evolution of Facial Surgical Scars: A Retrospective Study of Physician-Assessed Scars Using the Patient and Observer Scar Assessment Scale Over Two Time Points

Background: The natural evolution of facial scars has not been well described. Identifying factors that correlate with optimal scar healing may help patients and physicians during the perioperative period. Methods: A retrospective study of 108 facial skin cancer patient scars was performed. The Patient and Observer Scar Assessment Scale (POSAS) was used to grade scars at two time points (1 week and 3 months postoperatively). Paired two-tailed t-tests identified differences in scar ratings between the time points. Analysis of variance (ANOVA) explored whether POSAS scores differed by anatomic site or reconstruction type. Receiver operating characteristic analysis was performed to identify if 1-week scar appearance correlated with scar appearance at 3 months. Results: Between 1 week and 3 months the total POSAS score improved by 36.3% and overall opinion of the scar improved by 38.6% (p < 0.001). Facial cosmetic units differed in their 1-week and 3-month scores and all anatomic sites demonstrated significant improvement between time points. Differential scoring occurred among reconstruction types. Scar appearance at 1 week was able to predict overall scar appearance at the 3-month visit (area under the curve = 0.7732). Conclusions: Early scar appearance predicts later scar appearance, and scars will improve by nearly 40% 3 months after surgery. These data can be used to assist with perioperative counseling and expectation management.

Reconstructing Forearm Free Flap Donor Sites Using Full-Thickness Skin Grafts Harvested from the Ipsilateral Arm

Objective

To compare morbidity and aesthetic outcomes of full-thickness skin grafts (FTSGs) and split-thickness skin grafts (STSGs) in the reconstruction of the forearm free flap donor site.

Study Design

Case series, retrospective chart review.

Setting

Institutional microvascular database.

Subjects and Methods

Subjects who underwent forearm free flaps and FTSGs for donor site reconstruction from April 2016 to November 2017 were included. FTSGs were obtained from the donor forearm with a proximal S-shaped incision, thereby avoiding additional wound creation. Morbidity outcomes were compared to 68 consecutive patients with STSG reconstruction from January 2009 to May 2010. Complications, including tendon exposure, subjective functional impairment, complete graft loss, partial graft loss, infection, paresthesias, and hematoma/seroma, were evaluated, as were aesthetic outcomes.

Results

Sixty-eight patients underwent FTSG reconstruction. No significant differences between FTSGs and STSGs were demonstrated in terms of graft loss ≥40% (4% vs 4%, P = 1.000), partial graft loss (<40%) (29% vs 40%, P = .207), tendon exposure (9% vs 12%, P = .573), infection (15% vs 13%, P = .805), paresthesias (12% vs 7%, P = .382), subjective functional impairment (0% vs 2%, P = .316), or hematoma/seroma (2% vs 0%, P = .316). Aesthetic outcomes were better in the FTSG group compared to the STSG group, as determined by both patients ( P = .004) and surgeon ( P < .001).

Conclusions

Our results advocate for the consideration of FTSGs in the reconstruction of the forearm free flap donor site given superior aesthetic results without additional donor site morbidity or additional wound creation when compared to STSGs.

Closure of radial forearm free flap donor site: A comparative study between keystone flap and skin graft

BACKGROUND

The aim was to investigate the feasibility of radial forearm free flap (RFFF) donor site closure by keystone flap (KF) and compare its outcomes to those of skin graft (SG) closure.

METHODS

One hundred and one patients who underwent RFFF for head and neck reconstruction were included (35 KF closure and 65 SG closure). Duration of wound healing and donor site complications was collected. After a minimal follow-up of 1 year, patients were questioned about functional and esthetic impairment.

RESULTS

Coverage of donor site by KF was successful in all cases. The duration of wound healing was longer after SG than after KF (32 days vs 18 days, P < .001). Healing complications, esthetic and functional results were not statistically different.

CONCLUSION

Forearm donor site closure by KF is a feasible alternative to the traditional SG. Its main advantages are the reduced wound healing time and the avoidance of a second donor site.

[Rotation and advancement of the radial-based fasciocutaneous flap for primary closure of the radial forearm flap donor defect]

OBJECTIVE

This study aims to investigate the feasibility and clinical application value of a new method for primary donor-site closure of radial forearm flaps with the use of rotation and advancement of radial-based fasciocutaneous flaps.

METHODS

The forearm donor-site defects of 36 patients were primarily closed by rotation and advancement of radial-based fasciocutaneous flaps after radial flap harvest from November 2014 to May 2015. Patients included 28 males and 8 females aged 28 to 67 years (53.6 years old on average). Flap size ranged from 3.0 cm×5.0 cm to 4.0 cm×6.0 cm. Wound healing, scar hyperplasia, and forearm appearance were recorded and evaluated. Wrist flexion angle, dorsal extension angle, ulnar deviation angle, and radial deviation angle were measured three and six months after the operation. Wrist joint loss index was calculated and compared with the preoperative index to evaluate wrist function recovery. The results were subjected to comparative t-
test to perform statistical analysis with SPSS 19.0 statistical software package.

RESULTS

Forearm donor sites were successfully closed without skin grafting in all patients. Skin ischemia caused by excessive tension was observed at the incision edge in five cases, thereby leading to skin exfoliation and pigment loss without affecting wound healing. All patients were followed up at six and twelve months, and presented a satisfactory appearance. No scar hyperplasia was observed. No significant difference was observed in radial deviation, ulnar deviation, palmar flexion, dorsiflexion, radial deflection angle, or wrist joint loss index (P>0.05) after the operation.

CONCLUSIONS

Application of rotation and advancement of radial-based fasciocutaneous flaps can directly close small-to-medium radial forearm flap donor defects. Satisfactory postoperative appearance can be achieved with no loss in wrist joint function. The novel method prove worthy of promotion and application in clinical work.

Role of free tissue transfer in skull base reconstruction

Objective

Free tissue transfer to the skull base provides a watertight seal to prevent CSF leakage and donor tissue tailored to the individual defect.

Study Design and Setting

Retrospective chart review of 38 patients who underwent free tissue transfer to the skull base between November 1995 and October 2005 at an academic, tertiary referral center.

Results

There were 23 male and 15 female patients (average age, 58.1 years) with skull base defects resulting from oncologic resection or head trauma most frequently. Donor sites included the radial forearm (25), rectus abdominis (12), latissimus dorsi (4), anterolateral thigh, scapula, serratus anterior, and ulna (1 each). Seven patients required a second free tissue transfer indicated for flap death (3), partial flap necrosis (2), pneumocephalus (1), or tumor recurrence (1). Two patients died in the immediate postoperative period.

Conclusions

Free tissue transfer is a robust option in the repair of post-surgical and post-traumatic skull base defects. © 2007 American Academy of Otolaryngology-Head and Neck Surgery Foundation. All rights reserved.

AlloDerm with split-thickness skin graft for coverage of the forearm free flap donor site

OBJECTIVE

Major causes of donor site morbidity after free flap harvest are lack of split-thickness skin graft (STSG) take and tendon exposure. Long-term cosmesis remains poor. AlloDerm has shown cosmetically better donor site healing, albeit prolonged healing. We sought to evaluate the use of STSG with AlloDerm compared with STSG alone.

STUDY DESIGN

Case series with chart review.

SETTING

Academic tertiary care medical center.

METHODS AND SUBJECTS

Institutional review board-approved study. Microvascular database queried from 2002 to 2012. Subjects with forearm free flaps and either AlloDerm + STSG or STSG alone for donor site reconstruction were included. Morbidity outcomes were compared.

RESULTS

Eighty patients (50 male, 30 female) received AlloDerm + STSG at the donor site. Major and minor donor site complications were 15.0% and 18.8% in the AlloDerm + STSG group compared with 10.2% and 16.9% in the STSG-only group (P = .30 and P = .72), respectively. Complete STSG loss (5.0% vs 3.0%, P = .48), tendon exposure (5.0% vs 5.4%, P = 1.0), functional impairment (2.5% vs 1.8%, P = .66), infection (8.8% vs 9.6%, P = 1.0), hematoma/seroma (5.0% vs 3.6%, P = .73), and paresthesia (1.3% vs 3.6%, P = .43) were not significant. No patients required a second STSG after loss in the AlloDerm + STSG group compared with 60% (P = .17). Cosmetic results were superior in the AlloDerm + STSG group as rated by the surgeon (3.5 vs 2.6, P = .03) and patients (3.7 vs 2.9, P = .05) on a scale of 1 to 5.

CONCLUSION

Our results suggest that the use of AlloDerm with STSG can provide thicker coverage of the forearm defect, with minimal donor site morbidity and superior cosmetic results compared with STSG alone.

Closure or reduction of the donor defect of a sural flap with a purse-string suture: long-term results

We aimed to reduce the defect with a purse-string suture to minimise the deformity of the flap donor area and to assess the later efficiency at long-term follow-up. We studied 20 patients who required a sural flap for the reconstruction of defects of the lower extremity. The mean (SD) area of the donor defect was roughly 28.7 (20.3) cm(2). The mean (SD) defect area after closure with a purse-string was 8.2 (5.8) cm(2) (p < 0.001). The measurements made in the third year were 8.4 (5.3) cm(2). The purse-string can be used successfully in the distal lower extremity, the long-term cosmetic outcome is good, and the scar has not expanded since the postoperative period.

Review of the radial free flap: is it still evolving, or is it facing extinction? Part one: soft-tissue radial flap

The versatile fasciocutaneous radial flap is robust and reliable, straightforward to harvest, and often produces a satisfactory reconstruction with relatively little long-term morbidity at the donor site. Many surgeons prefer to use a limited number of trusted flaps, and these qualities will ensure that in the intermediate future most surgical trainees will continue to be shown the fasciocutaneous radial flap as both the basic training flap and the established option for reconstruction. Evidence from observational clinical studies and one randomised clinical trial indicates that there is increasing support for the use of the evolutionary technique of suprafascial dissection to minimise morbidity at the donor site. The suprafascial donor site may be repaired with either a meshed or unmeshed partial-thickness skin graft, or a fenestrated full-thickness skin graft, with good rates of successful healing. The application of a negative pressure dressing to the wound seems to facilitate the healing of all types of skin graft. The subfascial donor site, however, remains more prone to complications. It may be helpful to position the donor site of the flap more proximally, but this has not been proven. These refinements probably produce the best outcomes that can currently be achieved, given the inherent flaws of the radial donor site.

A novel Split-Thickness Skin Graft Donor Site

OBJECTIVE: To eliminate morbidity of the thigh split-thickness skin graft (STSG) donor site in forearm flaps, the feasibility of harvesting from an alternate site was assessed.

STUDY DESIGN: Case series with planned data collection.

SETTING: A tertiary care academic setting.

SUBJECTS AND METHODS: Data were collected from patients undergoing forearm flap reconstruction over 13 months. The forearm flap harvesting procedure was modified to incorporate STSG harvest directly from the flap skin paddle.

RESULTS: There were 66 patients in this cohort, with mean age of 62.6 years. There were 58 fasciocutaneous radial forearm free flaps (RFFFs), three osteocutaneous RFFF, three ulnar flaps, and two reverse-flow RFFFs. The majority of flaps were used for mucosal coverage (n = 54), but 12 flaps were used for external skin coverage. The mean forearm defect was 36.5 cm2 (12–77 cm2). Harvesting from the forearm skin paddle was successful in 64 patients (97%). Two patients required a thigh STSG; both patients were octogenarians with frail skin.

CONCLUSION: A thigh STSG donor site, with its associated morbidities, can be eliminated in 97 percent of patients undergoing forearm flaps. Older patients with frail skin may require a thigh donor site.

Closure of radial forearm free flap donor site defect with a local meshed full-thickness skin graft: a retrospective study of an original technique

INTRODUCTION

Closure of the radial free flap donor site remains a problem. Donor site morbidity is related to poor skin graft taking, inaesthetic appearance and hand sensory dysfunction.

PATIENTS AND METHODS

From January 1998 to December 2002, 41 radial free flaps were harvested. The donor site closure technique consisted of a combination of: flexor tendons coverage, purse string and local meshed full-thickness skin graft.

RESULTS

The mean time of wound healing of the donor site was 4.68 weeks. Four patients (16%) developed a partial necrosis of the skin graft. Nine patients (36%) showed a definitive hypoaesthesia in the dorsal region of the thumb. Neither total necrosis of the skin graft nor exposure of flexor carpi radialis tendon was noted. The average visual analogue scale of the aesthetics was 6 (patients), 4.18 (students) and 7.2 (first author) out of 10.

CONCLUSION

This technique for closing a small-to-medium sized radial donor site defect is recommended.

Full-thickness skin graft from the groin for coverage of the radial forearm free flap donor site

PURPOSE

The purpose of this study is to describe the use of a full-thickness skin graft from the groin for coverage of the radial forearm free flap donor site. Our hypothesis is that the use of the full-thickness skin graft decreases morbidity and improves functional and cosmetic outcome at the skin graft donor site while also providing excellent coverage of the forearm donor site.

STUDY DESIGN

This study used a retrospective chart review design.

MATERIALS AND METHODS

Patients undergoing radial forearm free flap reconstructions from 1995 to 2005 were included. Forty patients underwent radial forearm free flap reconstruction with closure of the forearm donor site with a full-thickness skin graft harvested from the groin. The inguinal donor site was closed primarily. Medical records including clinic notes, operative reports, and photographs were reviewed.

RESULTS

There was 1 minor wound dehiscence at the groin site, and there were 5 minor forearm wound dehiscences with 2 cases of tendon exposure; all dehiscences were treated conservatively with local wound care. Both the groin wound and forearm donor sites healed satisfactorily in all cases, with no impairment of function related to the skin graft. All patients expressed satisfaction with the postoperative pain, functional outcome, and cosmetic appearance related to both the skin graft and forearm donor sites.

CONCLUSIONS

Full-thickness skin graft from the groin for coverage of the radial forearm free flap donor site is an effective, safe alternative to the traditional split thickness skin graft.

Incidence of donor site skin graft loss requiring surgical intervention with the radial forearm free flap

BACKGROUND

Many methods of managing the fasciocutaneous radial forearm free flap (RFFF) donor site have been described. Ideal management would be technically easy to perform, reliable, cost-effective, and prevent further complications.

METHODS

The clinical records of 54 consecutive patients undergoing RFFF surgery by the senior author were reviewed. Records were reviewed to identify donor sites with significant breakdown that required intervention.

RESULTS

Fifty-four patients were identified. Only 1 patient had significant tendon exposure. A V to Y closure was performed. The site healed well following this procedure and no further intervention was required. No other donor site complications were noted in this group.

CONCLUSION

The incidence of wound breakdown requiring surgical intervention at the RFFF donor site is less than 2% utilizing a simple technique of split thickness skin grafting, bolster, and short-term splinting. This study demonstrates the low donor site morbidity of the RFFF.

Proximal Forearm Flap Based on a Septocutaneous Vessel from the Radial Artery

BACKGROUND

The radial forearm flap has been a workhorse flap for soft-tissue or coverage reconstruction in the head and neck area. Although it has several major advantages, it requires sacrifice of the radial artery. In this article, the authors present their modification of harvesting a forearm flap based on a large septocutaneous branch of the radial artery in the proximal forearm with or without sacrificing the main radial artery. They name it the proximal radial forearm flap.

METHODS

From September of 2003 to March of 2004, a total of 14 free proximal radial forearm flaps were used for head and neck reconstruction in 12 patients. There was one female patient and 11 male patients. Their ages ranged from 32 to 85 years. The skin flap size ranged from 2.0 x 6.0 cm to 4.5 x 18 cm.

RESULTS

All free proximal radial forearm flap reconstructions had immediate success. There were one delayed flap loss caused by wound infection and one death attributable to advanced medical disease. Six flaps were harvested with preservation of the radial artery trunk. Six of the eight radial arteries that were killed during flap harvest were repaired with a short segment (3 to 4 cm) of vein graft. The average diameter and length of the septocutaneous vessel of the proximal radial forearm flap was 0.73 mm and 3.3 cm, respectively. Two flaps were harvested in conjunction with the conventional free radial forearm flaps. Nine donor sites were closed primarily and five donor sites required skin grafts.

CONCLUSIONS

The proximal radial forearm flap can be used successfully in head and neck reconstruction with the advantages of moving the donor site to the proximal forearm for better scar concealment and possible preservation of the radial artery trunk. The disadvantages of this flap are short pedicle length and small pedicle diameter when the radial artery is to be preserved.

Radial Forearm Free Tissue Transfer in the Management of Persistent Cerebrospinal Fluid Leaks

OBJECTIVE

Cerebrospinal fluid (CSF) leaks can occur after head trauma or skull base surgery. Persistent or spontaneous leaks should be repaired, since they put patients at risk for serious intracranial complications. Although numerous repair methods have been successful, the occasional patient develops a persistent leak. We describe our experience with free tissue transfer for repair of recalcitrant CSF leaks.

STUDY DESIGN

Retrospective chart review of patients undergoing free tissue transfer for repair of a CSF leak between November 1995 and October 2004. Setting was an academic, tertiary care referral center.

METHODS

Twelve patients with persistent CSF leak were studied. Eleven of 12 patients had undergone a previous repair attempt ranging from endoscopic repair with fat graft to craniotomy and primary repair of the dural defect. All patients underwent radial forearm free tissue transfer.

RESULTS

There were six female and six male patients. Average age was 52.7 years (range, 22-80 y). The most common presenting complaints were intracranial abscess, recurrent meningitis, or pneumocephalus (n=9) and CSF otorrhea or rhinorrhea (n=8). Cause was head trauma (n=6), prior surgery (n=4), cholesteatoma (n=1), or meningoencephalocele (n=1). Eleven of 12 patients failed prior procedures (range, 0-6 procedures; mean, 1.9). Ten flaps were placed in the anterior skull base and two were in the middle or posterior skull base. Radial forearm free tissue transfer resulted in sustained resolution of CSF leakage in all 12 patients.

CONCLUSIONS

Free tissue transfer is an efficacious option in the repair of recalcitrant CSF leaks.

Short-Term Functional Donor Site Morbidity After Radial Forearm Fasciocutaneous Free Flap Harvest

OBJECTIVES/HYPOTHESIS

The existing literature on postoperative donor extremity function describes a spectrum of morbidity in the long term (>3 mo after surgery). However, the consensus is that there is minimal to no impact of flap harvest on patients' activities of daily living. No previous reports have examined functional donor site morbidity in the early postoperative period; such may affect patients' overall perioperative progress, especially with respect to donor extremity dominance. The authors' objective was to quantify functional morbidity of the donor site in radial forearm fasciocutaneous free flaps during the early postoperative period.

STUDY DESIGN

Retrospective case series review.

METHODS

Patient data were obtained from hospital records of 12 consecutive patients who underwent head and neck reconstruction with radial forearm fasciocutaneous free tissue transfer over a 6-month period at a tertiary academic medical center. Functional results of each patient's donor extremity obtained preoperatively and at 5 to 8 days after surgery were determined by quantifying forearm supination and pronation, wrist flexion and extension, and sharp and dull hand sensations in radial, median, and ulnar nerve distributions.

RESULTS

Mean patient age was 57 years (age range, 42-71 y). The nondominant extremity was the donor site in 9 of 12 patients. Using the paired two-tailed t test, statistically significant differences were demonstrated in preoperative versus postoperative forearm supination (P <.032), pronation (P <.006), wrist flexion (P <.000), and wrist extension (P <.000). Three of 12 patients demonstrated diminished sharp sensation in the "anatomical snuffbox" distribution.

CONCLUSION

The authors describe statistically significant functional forearm and wrist range-of-motion morbidity associated with the harvest of a radial forearm fasciocutaneous free flap in the early postoperative period.

The ulnar fasciocutaneous free flap in head and neck reconstruction

OBJECTIVES/HYPOTHESIS

The radial forearm fasciocutaneous free flap has become the reconstructive tissue of choice for the majority of soft tissue defects in the head and neck. The forearm skin has many of the ideal soft tissue characteristics that optimize reconstruction and rehabilitation in these patients. The tissue is malleable, supple, and moldable in three dimensions; has a reliable pedicle; and can be harvested with a two-team approach. In some patients, the radial forearm cannot be used. An alternative is to use the adjacent tissue, which shares identical tissue characteristics. This tissue gets its vascular supply from the ulnar artery. The purpose of the report was to describe the authors' experience with the ulnar fasciocutaneous free flap in head and neck reconstruction.

STUDY DESIGN

Prospective consecutive case series.

METHODS

Retrospective review of all patients undergoing ulnar fasciocutaneous free tissue transfer by a group of microvascular surgeons was performed. Thirty patients underwent free tissue transfer using the ulnar fasciocutaneous free flap. The male-to-female ratio was 3:1.

RESULTS

Defects were located in the oral cavity (14), oropharynx (12), neck skin (1), and soft tissue of the lateral skull (3). The average size of the skin paddle that was transferred was 7 x 10 cm (range, 3 x 5 to 9 x 12 cm). The mean area of tissue that was transferred was 70 cm2 (range, 15-108 cm2). Vessel sizes were somewhat smaller than the comparable radial forearm. One patient had complete loss of the skin graft on the donor site. There were no median nerve or other wound-healing problems. Two flaps were lost in the postoperative period. Indications for use of the ulnar fasciocutaneous free flap were failed Allen's test (23), use of a less hairy part of the forearm (3), and surgical preference (4).

CONCLUSIONS

The ulnar fasciocutaneous free flap has all of the tissue characteristics of the radial forearm flap. When a radial forearm flap cannot be used and forearm skin is desired, consideration of an ulnar fasciocutaneous free flap should be undertaken.