Combined Local Triangular Full-Thickness Skin Graft for the Closure of the Radial Forearm Free Flap Donor Site: A New Technique

Abstract

Sir: The radial forearm free flap has proved to be a reliable method for reconstruction of soft-tissue defects involving the oral cavity. However, many donor-site complications have been described, such as delayed healing or partial loss of skin grafts, swelling of the hand, sensory disturbance, tendon exposure, and aesthetic defects.1 Several methods for recovering the exposed donor-site have been reported, such as the split-thickness skin graft, full-thickness skin graft, acellular dermal matrix, skin expansion, local V-Y full-thickness skin transposition, Z-plasty closure, and others.2 The authors describe a new technique for covering the radial forearm free flap donor site based on the use of combined local full-thickness skin graft triangles within a geometrical model concept. A quadrangular or rectangular radial forearm flap must be outlined on the distal forearm. A doubled curvilinear line must be outlined from the proximal portion of the radial forearm flap to the proximal forearm to provide access to the proximal portion of the neurovascular pedicle. The doubled curvilinear line allows the design of two opposed arcs. Once the radial forearm flap is completely harvested, two bowstrings are outlined within the concavities of the arcs. At the midpoint of each bowstring, a perpendicular dotted line is outlined to the midpoint of each arc. This perpendicular dotted line should not exceed 3 cm in length, to allow a direct closure of the forearm skin flaps. At this point, four isosceles triangles have been designed (Fig. 1, above). Subsequent triangular full-thickness skin grafts are harvested and freed from the forearm. In a geometrical conception of the design, the length of the base of each triangle must be half of the length of the minor side of the rectangular defect. Direct closure of the forearm is achieved. Skin triangles are easily placed covering the donor defect (Fig. 1, below).Fig. 1.: (Above) Design of the combined local triangular full-thickness skin graft based on four skin triangles. (Below) Clinical view of the combined local triangular full-thickness skin graft over the donor site and direct closure of the forearm.Because of the ease with which it can be harvested and used, the split-thickness skin graft has been the most popular method of reconstruction, although several complications such as delayed skin graft healing, hand swelling, and partial loss of the graft with exposure of the forearm flexor tendon have been reported.3 In cases in which the skin graft was harvested from the thigh, pain, infection, and hypertrophic scar formation have been reported.4 The use of a full-thickness skin graft combined with a direct closure of the full-thickness skin graft donor site provides better pliability and promotion of the healing process, with less postoperative pain and discomfort from the donor site, although it is more time consuming. Local fasciocutaneous transposition flaps have been reported to give good quality skin and to heal rapidly without functional deficit.5 However, they usually require extensive dissection of the forearm, with subsequent sensory loss and edema. The combined local triangular full-thickness skin graft provides easy closure of the donor defect, avoiding the need for a second surgical site and subsequent distant donor-site complications. Optimal aesthetics are obtained with the use of this pliable full-thickness skin graft (which has a good color match), substantially decreasing the risk for scar tissue formation. Functional and aesthetic outcomes of this promising technique must be further evaluated, although preliminary results are encouraging. Raúl González-García, M.D. Luis Ruiz-Laza, M.D. Damián Manzano, M.D. Florencio Monje, M.D., Ph.D. Department of Oral and Maxillofacial-Head and Neck Surgery University Hospital Infanta Cristina Badajoz, Spain