Free Flap Donor Site Research Articles

Anteromedial thigh perforator-assisted closure of the anterolateral thigh free flap donor site

Primary closure of the anterolateral thigh free flap donor site is advisable as skin grafting can be associated with higher morbidity. However, this is not possible when anterolateral thigh free flap width is over 8-9 cm with a corresponding flap width-to-thigh circumference ratio over 16%. The authors report their experience and technique with the anteromedial thigh perforator dissection during anterolateral thigh free flap donor-site closure that, on demand, can be used to design a local perforator flap to achieve primary closure of the donor site. Between July and December 2012, 20 consecutive patients underwent elective anterolateral thigh free flap reconstruction for head and neck oncologic surgery. Attempts to close directly the anterolateral thigh free flap donor site failed in two patients with large flaps and V-Y anteromedial thigh perforator flaps were advanced to close the defect. Flaps healed uneventfully. Except two patients, at least one>1-mm perforator was found in all the remaining thighs. Further investigation is needed to establish the maximum anterolateral thigh free flap donor-site width that can be served by this reconstruction. This represents an ideal model for residents to start training on perforator dissection.

Objective preoperative estimation of the ability of primary closure on anterolateral thigh free flap donor site: Circumference and area ratios of deep tissue to thigh

The purpose of this study was to consider the relationship between the ratio of deep tissue including muscle to thigh at donor sites and the possibility of performing primary closure of donor site. The subjects were 74 patients who had harvesting of anterolateral thigh (ALT) free flap from June 2005 to June 2011. Primary closure was possible for 65 but not possible for 9. All received CT angiography of lower extremity before their operations. We measured circumference and cross-sectional area of thigh and deep tissue including muscle at the reference point. Using the measured data, we examined the ratio of circumference as well as cross-sectional area of deep tissue including muscles to thighs. For whom primary closure was possible, the ratio of deep tissue including muscle's circumference to thigh's at the reference point was 0.83 ± 0.07 on average, and the ratio of cross-sectional area was 0.68 ± 0.11. For whom primary closure was not possible, the ratio of circumference was 0.89 ± 0.06 on average, and the cross-section areas was 0.8 ± 0.07. The average width of flap for those with primary closure was 64.9 mm and without primary closure was 84.4 mm. There was statistical significance in ratios of circumference and cross-sectional area between primary closure and without primary closure. Primary closure of donor site when performing ALT free flap gets increasingly difficult as the ratio of deep tissue including muscle in the thighs increased. Such information prior to the procedure will be helpful in determining flap design and finalizing the operation plan.

Colorimetric Examination of Typical Free Flap Donor Sites and Comparison to Recipient Sites in the Extremities

Results after free flap reconstruction in the extremities are often impaired by missing color match of the transferred flap and the recipient site. But pre-existing color match is the precondition for satisfying aesthetic results. To obtain suitable free flap donor sites in terms of color for extremity reconstruction and to understand frequent color mismatch, we performed a colorimetric study including 60 healthy volunteers. Ten free flap donor sites were compared with ten recipient sites in the extremities. The results of our study showed that lower extremity sites are markedly lighter than upper extremity sites with the exception of the palmar forearm. We encountered an excellent color match of the radial forearm flap to the back of the hand (4.10 ± 1.91) and the palm of the hand (5.62 ± 2.21), and significantly relevant color match to the palmar aspect of the forearm (2.52 ± 1.23). Additionally, the lateral arm flap showed a remarkable color match to the dorsal aspect of the forearm (3.13 ± 2.06). Furthermore we encountered significantly relevant color match of the fibula flap to the anterior aspect of the lower leg (2.01 ± 1.08) and excellent color match of the anterolateral thigh flap (ALT) to the palmar aspect of the forearm (3.66 ± 2.10). No further significantly relevant color differences between the other donor sites and recipient regions were found. Colorimetric measurements are a helpful tool in reconstructive surgery to compare skin color of different anatomic sites.

Massive Flap Donor Sites and the Role of Negative Pressure Wound Therapy

Report our experience with negative pressure wound therapy (NPWT) applied to massive scapular and latissimus free flap donor sites, in the setting of microvascular reconstruction for extensive head and neck defects. Retrospective case series with chart review. Tertiary academic referral center. Retrospective review was conducted of all patients who underwent scapular or latissimus free tissue transfer by the senior author for head and neck reconstruction, over a 5-year period (2006-2011). In addition to NPWT details, comprehensive patient data were abstracted and compiled, including demographics, operative details, hospital stay, postoperative follow-up, and donor site complications. Ninety-four patients underwent reconstruction of extensive postablative head and neck defects using either a scapular or latissimus free flap. Mean harvested flap skin paddle size was 140 cm(2). All donor sites were closed primarily. Fifty-two patients (55%) had NPWT applied over closed donor site incisions postoperatively. The other 42 patients (45%) received only conventional incision care. Major donor site complications occurred in 12% (n = 5) of the patients who did not undergo NPWT, as compared with a 6% (n = 3) complication rate among patients in the NPWT-treated group. This is the first study to examine NPWT in the postoperative treatment of closed high-tension wounds following scapular or latissimus dorsi harvest for reconstruction of extensive head and neck defects. Our results suggest that NPWT is a safe technique in the management of massive scapular and latissimus free flap harvest sites that may decrease associated major donor wound complications.

Radial Forearm Free Flap Donor Site Morbidity<subtitle>Ulnar-Based Transposition Flap vs Split-Thickness Skin Graft</subtitle>

To evaluate morbidity associated with the radial forearm free flap donor site and to compare functional and aesthetic outcomes of ulnar-based transposition flap (UBTF) vs split-thickness skin graft (STSG) closure of the donor site. Case-control study. Tertiary care institution. The inclusion criteria were flap size not exceeding 30 cm(2), patient availability for a single follow-up visit, and performance of surgery at least 6 months previously. Forty-four patients were included in the study and were reviewed. Twenty-two patients had UBTF closure, and 22 had STSG closure. Variables analyzed included wrist mobility, Michigan Hand Outcomes Questionnaire scores, pinch and grip strength (using a dynamometer), and hand sensitivity (using monofilament testing over the radial nerve distribution). In analyses of operated arms vs nonoperated arms, variables obtained only for the operated arms included Vancouver Scar Scale scores and visual analog scale scores for Aesthetics and Overall Arm Function. The mean (SD) wrist extension was significantly better in the UBTF group (56.0° [10.4°] for nonoperated arms and 62.0° [9.7°] for operated arms) than in the STSG group (59.0° [7.1°] for nonoperated arms and 58.4° [12.1°] for operated arms) (P = .02). The improvement in wrist range of motion for the UBTF group approached statistical significance (P = .07). All other variables (Michigan Hand Outcomes Questionnaire scores, pinch and grip strength, hand sensitivity, and visual analog scale scores) were significantly better for nonoperated arms vs operated arms, but no significant differences were observed between the UBTF and STSG groups. The radial forearm free flap donor site carries significant morbidity. Donor site UBTF closure was associated with improved wrist extension and represents an alternative method of closure for small donor site defects.

Hinged Forearm Split-Thickness Skin Graft for Radial Artery Fasciocutaneous Flap Donor Site Repair

To present a modified technique in the harvest and application of split-thickness skin graft (STSG) from the primary flap donor site in forearm fasciocutaneous free flaps. A prospective review was performed on 16 consecutive patients who had undergone a radial forearm free flap procedure for reconstruction of head and neck defects with a hinged forearm STSG used to reconstruct the flap donor site defect. Sixteen patients with a mean (SD) defect size of 53.7 (29.9) cm(2) underwent the hinged STSG procedure. A hinged STSG was successfully harvested from all patients without disruption. Graft take was greater than 90% in all patients by postoperative day 7. A secondary skin graft donor site was avoided in all but 2 patients. Good color match of the deepithelialized flap with surrounding oral and pharyngeal mucosa was observed. Visible scarring along the graft hinge margin was absent. No bridging scars resulted from the deepithelialized flaps. The hinged STSG from the forearm is a reliable method of repairing radial forearm free flap donor site defects and offers the advantages of reduced suture line scarring, minimal STSG disruption, low or no secondary donor site morbidity, and good color match at the donor and recipient flap sites.

Closure of the Radial Forearm Free Flap Donor Site Defect With a Full-Thickness Skin Graft From the Inner Arm: A Preferred Technique

Over the past 20 years, microvascular free tissue transfer has become the primary choice for reconstruction of acquired or developmental defects of the head and neck. Multiple free flaps have been described and used for reconstruction of the inherently challenging defects of this region, effectively meeting the demands of reestablishing form and function. The radial forearm free flap is particularly popular because of ease of harvest, versatility, minimal morbidity, and predictable successful outcomes. Although the radial forearm free flap is highly reliable, there remains the problem of closing the distal forearm donor site defect. Primary closure is not feasible in most of these defects because of the paucity of soft tissues in the area, as well as the potential of placing the distal upper extremity in danger of ischemia. 1 Sidebottom A.J. Stevens L. Moore M. et al. Repair of the radial free flap donor site with full- or partial-thickness skin grafts: A prospective randomised controlled trial. Int J Oral Maxillofac Surg. 2000; 29: 194 Abstract Full Text PDF PubMed Google Scholar Although the literature is replete with a variety of techniques for closure of these defects, currently there remains no adopted standard procedure.

Massive Flap Donor Sites and Vacuum‐Assisted Closure Devices

ObjectiveDetermine the effect of vacuum assisted closure (VAC) on massive scapular and latissimus dorsi free flap donor site morbidity, when used over a closed incision line under great tension.MethodPatients who underwent complex head and neck reconstruction with scapular fasciocutaneous/osteocutaneous and latissimus dorsi myocutaneous free flaps between the years of 2006 and 2010 at a tertiary academic referral center were identified and a retrospective chart review was performed.ResultsSeventy patients who underwent scapular or latissimus dorsi free flap reconstruction were identified. Those with and those without VAC over the closed incision line were identified. The method of application of the VAC dressing was performed by the same team at one institution. None of these patients required skin grafting, and only 1 patient had donor site breakdown secondarily requiring wound care and VAC replacement and 1 patient had an asymptomatic seroma; all others with VAC treatment over the closed incision line were without donor site complications.ConclusionVacuum‐assisted closure is a safe technique in the postoperative management of massive back free flap donor sites closed under great tension, and may eliminate the need for skin grafting. In our study, data suggests this approach decreases seroma formation and secondary wound breakdown.

Fibula Flap Donor Site Wound Healing with Compression Stockings

Objective: Investigate the efficacy of graduated compression stockings (GCSs) at improving donor site skin graft take after fibula free flap (FFF). Method: Retrospective review of 12 patients (13 donor sites) that underwent FFF for mandibular reconstruction over a 1-year period. One-third of the patients were instructed to use graduated compression stockings after removal of the initial wound-vac dressing. Wound healing was followed closely for all patients. Operative and comorbid factors were reviewed. Results: Two patients reported regular GCS use and 2 were non-compliant. Both patients with regular use had excellent wound healing and 90% to 100% skin graft take. Of the remaining 11 donor sites, 3 had no wound complications, 4 had minor wound complications, 3 had major wound complications, and 1 was lost to follow-up. Skin graft area varied with an average of 25 cm2 for GCS patients and 60 cm2 for non-GCS. Cardiovascular disease, alcohol use, and smoking were more common among the non-GCS group with strong tendency toward patients with major wound complications. Other operative and comorbid factors were similar between groups. Conclusion: Graduated compression stocking use demonstrates some promise for use in fibula free flap donor site healing. Patients wearing GCSs had excellent wound healing and no morbidities related to their use. Further studies are warranted to determine if improvement in fibular donor site wound healing occurs with GCS use.

The SNaP Wound Care System for Head and Neck Wound Closure

Objective: Vacuum-assisted closure of head and neck wounds has been previously described. Negative pressure wound therapy, although efficacious, has practical limitations in the outpatient setting. The purpose of this study is to describe a novel method of treating complex head and neck wounds using an ultraportable mechanical vacuum wound care system. Method: A cohort study at 2 tertiary care centers. All head and neck patients with complex, low to moderately exudative wounds were treated by the senior author using the SNaP Wound Care System. Patient comorbidities, wound etiology, site, length of treatment, outcomes, and ancillary procedures were recorded. Results: A variety of wounds was treated with this system and included mucocutaneous fistulas, a tracheocutaneous fistula, soft tissue defects of the head and neck, and tendon exposure of a radial forearm free flap donor site. Outpatient SNaP therapy was utilized in five patients with 6 small- to medium-sized wounds. This system was successful in obtaining wound closure in all patients. These patients were able to complete routine activities of daily living, participate in public social settings, and tolerate therapy without adverse events. One patient required an adjunctive procedure of split thickness skin grafting. Conclusion: This study demonstrates a novel use of the first FDA-approved ultraportable, mechanical negative pressure device in the treatment of several complex head and neck wounds. The device has utility in the outpatient setting for adjunctive closure of wounds with minimal disturbance to patients’ activities of daily living and lifestyle.

Cost-effectiveness of a topically applied pre-operative tissue expansion device for radial forearm free flaps: a cohort study1

The objective of this study is to test the hypothesis that using a non-invasive and inexpensive pre-operative tissue expansion device (DynaClose) for radial forearm free-flap donor sites will result in a significant reduction in the cost of both in-hospital and out-of-hospital wound care compared with that of unexpanded radial forearm free-flap donor sites. A cohort study consisting of patients previously randomised in a randomised controlled trial. An intention to treat design was utilised. A large tertiary care centre in eastern Ontario, Canada. Thirty-four patients presenting to Otolaryngology Head and Neck clinic were enroled. Of these patients, 29 were previously enroled in a randomised controlled trial, while an additional five patients were enroled and randomised for the purpose of this study. Patients were randomised to either the treatment (pre-operative tissue expansion, DynaClose Expansion System) or control group. Wound care costs (in US dollars) were calculated for all patients for both in-hospital care and for patients requiring home care. Non-parametric data analysis was utilised for statistical assessment. There was a 93% reduction in the use of split-thickness skin grafts in the treatment group. There was a significant reduction in total wound care cost for patients in the treatment group versus the control group (P < 0.0001). Patients in the treatment group required a mean (SD) total of $36.00 (23.50) per patient, while the control group required $277.00 (325.00) of wound care. After excluding the cost of home care, the treatment group continued to have a significant reduction in total and in-hospital wound care costs compared with the control group (P < 0.001). Using a simple, inexpensive and non-invasive method of pre-operative tissue expansion results in a significant reduction in the costs of wound care for both in-hospital and out-of-hospital treatment. The DynaClose dynamic skin expansion system results in a cost-effective method to reduce the need of a split-thickness skin graft for coverage of a radial forearm free-flap donor site.

In vivo comparison of microcirculation and histomorphology of two different flap donor sites

In soft tissue reconstruction surgery using free flaps, different donor sites from various anatomical regions should be considered. Local microperfusion and histomorphology at these donor sites are often neglected during planning and operation of free tissue transfers. The aim of this in vivo study was to evaluate the microperfusion and, simultaneously, the tissue morphology of two potential free fasciocutaneous flap donor sites on the upper and lower extremity. In 23 healthy nonsmoking individuals (aged 30 ± 8.4 years), potential free-flap donor sites for the radial forearm flap (RFF) and the anterolateral thigh flap (ALTF) were investigated using high-resolution in vivo Reflectance-Mode-Confocal-Microscopy (Vivascope 1500, Lucid, Rochester, NY). The following parameters were evaluated: quantitative blood-cell flow; density of functional dermal capillaries; minimal epidermal thickness, and viable thickness of the epidermis. The quantitative blood-cell flow was higher in the RFF donor site (62 ± 3.1 cells/min) compared with the ALTF donor site (51 ± 2.4 cells/min, P < 0.05). The density of functional dermal capillaries at the RFF donor site was higher than at the ALTF donor site (38 ± 3 vs. 22 ± 2.2 capillaries/mm(2) , P < 0.05). The minimal epidermal thickness was thinner at the RFF donor site compared with the ALTF donor site (44 ± 2.9 vs. 55 ± 3.8 μm, P < 0.05). The viable thickness of the epidermis of the RFF region was thinner compared with the region of the ALTF (31 ± 2.1 vs. 42 ± 2.7 μm, P < 0.05). For the first time, significant differences in the in vivo microperfusion and histomorphology could be shown when comparing two different free-flap donor sites. The correlation to flap failure needs to be substantiated in further systematic trials.

Comparative Study of the Postoperative Complications of Microvascular Surgery in Elderly and Young Patients

Free flap reconstruction of complex defects has revolutionized cancer and trauma treatment and offers a reliable and efficient method for reconstructing tissue defects. We analyzed the donor, flap, and systemic complications in an aging group and in a group of younger patients to identify whether age is an important factor in complication rates. This study was a retrospective review of the medical records of 43 consecutive patients who underwent free flap reconstructions. Patients were divided into two groups according to age (group A: younger than 60 years, group B: 60 years or older). We analyzed the free flap types and donor site, flap, and postoperative systemic complications. Statistical analyses were performed to determine the influence of age on complication rate. Donor site complications developed in three cases in group A and in three cases in group B. Flap complications occurred in 17 cases in group A and in 5 cases in group B. Systemic complications occurred in two cases in group A and in five cases in group B. Age did not have a statistically significant impact on free flap complications, and old age was not a risk factor for free flap surgery.

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.

Development of the International Classification of Functioning, Disability and Health as a brief head and neck cancer patient questionnaire

WHO has adopted the International Classification of Functioning, Disability and Health (ICF) to assess functioning and disability. A Brief ICF Core Set for head and neck cancer comprises 19 items. This study developed a patient self-completed questionnaire from the items of the brief core set (BCSQ-H&N), compared the BCSQ-H&N questionnaire with the University of Washington v.4 (UW-QOLv4) and compared the BCSQ-H&N results with a clinician-rated evaluation. UW-QOL v4 and BCSQ-H&N were sent to 751 disease-free head and neck cancer patients in April 2008. 376 patients responded to the questionnaire and 25 were interviewed. The percentage reporting significant problems in BCSQ-H&N items ranged between 11% and 43%. The type of problem varied with tumour site. Patients with smaller tumours and patients without radiotherapy reported better outcomes. The BCSQ-H&N correlated well with appropriate items in the UW-QOLv4 especially for functional outcome. There were systematic differences between observer-rated scores and patient self-completed questionnaire responses. Patients suggested additional items for inclusion, namely taste, jaw opening, articulation function, structure of shoulder region, loss of function at the free flap donor site, and intimate relationships. Further validation is required but BCSQ-H&N shows promise as an outcome measure for global use.

Outcomes following temporal bone resection

To evaluate survival outcomes in patients undergoing temporal bone resection. Retrospective review. From 2002 to 2009 a total of 65 patients underwent temporal bone resection for epithelial (n = 47) and salivary (n = 18) skull base malignancies. Tumor characteristics, defect reconstruction, and postoperative course were assessed. Outcomes measured included disease-free survival and cancer recurrence. The majority of patients presented with recurrent (65%), advanced stage (94%), cutaneous (72%), and squamous cell carcinoma (57%). Thirty-nine patients had perineural invasion (60%) and required facial nerve resection; 16 (25%) had intracranial extension. Local (n = 6), regional (n = 2), or free flap (n = 46) reconstruction was required in 80% of patients. Free flap donor sites included the anterolateral thigh (31%), radial forearm free flap (19%), rectus (35%), and latissimus (4%). The average hospital stay was 4.9 days (range, 1-28 days). The overall complication rate was 15% and included stroke (n = 4), cerebrospinal fluid leak (n = 2), hematoma formation (n = 1), infection (n = 1), flap loss (n = 1), and postoperative myocardial infarction (n = 1). A total of 22 patients (34%) developed cancer recurrence during the follow-up period (median, 10 months), 17 (77%) of whom presented with recurrent disease at the time of temporal bone resection. Two-year disease-free survival was 68%, and 5-year disease-free survival was 50%. Aggressive surgical resection and reconstruction is recommended for primary and recurrent skull base malignancies with acceptable morbidity and improved disease-free survival.

Tissue Expansion of Radial Forearm Free Flap Donor Sites

Tissue Expansion of Radial Forearm Free Flap Donor Sites

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

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

A randomized, prospective, controlled study of forearm donor site healing when using a vacuum dressing

Objective 1) Compare skin graft healing of the radial forearm free flap (RFFF) donor site when using a negative pressure dressing (NPD) versus a static pressure dressing (SPD). 2) Examine the association of graft size and medical comorbidities with healing of RFFF donor site. Study Design Randomized, controlled trial. Setting Tertiary care hospital. Subjects and Methods After the study was approved, consenting adults undergoing RFFF for head and neck reconstructions were randomized into two arms: SPD and NPD groups. Fifty-four patients were enrolled from March 2007 to August 2009. Pre- and postoperative data were collected, including medical comorbidities, graft size, and area of graft failure/tendon exposure. Data were collected at two postoperative time points. Results The overall wound complication rate was 38 percent (19/50). Wound complications at the first postoperative visit (44.4% [12/27] SPD and 30.4% [7/23] NPD) were not significantly different between groups ( P = 0.816). Similarly, wound complications at the second visit (68.8% [11/16] SPD and 80% [12/15] NPD) were not significantly different ( P = 0.55). Percentage of area of graft failure between the groups also showed no difference (4.5% SPD vs 7.2% NPD, P = 0.361). The association of graft size with wound complications was analyzed by dividing the data set into three groups (<50 cm 2, 51-100 cm 2, and >100 cm 2). This difference was not found to be significant ( P = 0.428). Finally, when evaluating comorbidities, 50 percent (8/16) of subjects with comorbidities experienced complications compared with 32.4 percent (11/34) without comorbidities, also not reaching significance ( P = 0.203). Conclusions Although an attractive option for wound care, the NPD does not appear to offer a significant improvement over an SPD in healing of the RFFF donor site.

The ulnar forearm free flap for the reconstruction of soft tissue defects in the head and neck area: Free flap outcome and donor site outcome

The objective of this study was to evaluate the outcome of the Ulnar Forearm Free Flap (UFFF). The UFFF was applied for reconstruction of soft tissue defects in the head and neck area in 15 patients. The outcome was registered from the patients' notes, evaluated by clinical examination, and patients were interviewed. The statistics were descriptive. All 15 UFFFs appeared successful. Thirteen donor sites healed without wound-healing problems. Two donor sites showed minor wound-healing problems. No patient suffered abnormal sensation in the distribution area of the ulnar nerve. All patients were satisfied with the appearance of the scar and the shape of the donor site. The UFFF should be considered as a reconstruction method for soft tissue defects in the head and neck area instead of the radial forearm free flap, as the donor site of the UFFF is hardly noticeable, which makes acceptance easier for the patient.