Timing of Split Thickness Skin Grafting for Radial Forearm Free Flaps on Donor Site Morbidity

The radial forearm free flap (RFFF) is a versatile free flap in the reconstruction of head and neck defects. There is little consensus on the optimal technique for reconstructing RFFF donor site defects. Our group previously reported early results using staged reconstruction with initial placement of Integra, a dermal regeneration matrix, followed by a split thickness skin graft (STSG), resulting in excellent aesthetic and functional outcomes. Here we provide our long-term experience using staged STSG compared to primary STSG for the reconstruction of RFFF donor site defects.

Patients undergoing RFFF reconstruction of head and neck defects at a single institution between May 2012 and April 2023 were retrospectively reviewed. Primary versus staged STSG placement was compared in terms of donor site morbidity.

A total of 179 patients were included: 46 (25.7%) primary STSG and 133 (73.3%) staged STSG. Following primary STSG, 34 (73.9%) patients had a vacuum-assisted closure (VAC) and 12 (26.1%) had an iodine-coated petroleum gauze bolster placed. In the staged STSG group, all patients had a VAC after Integra placement. After the second stage, 30 (22.6%) patients had a VAC, and 103 (77.4%) patients had a bolster placed. Compared to the staged group, the primary group had a significantly higher rate of skin graft breakdown (21.7% vs. 6.0%; p = 0.008) and tendon exposure (19.6% vs. 3.8%; p = 0.002). In the staged group, bolster placement was associated with a lower rate of skin graft breakdown compared to VAC (2.9% vs. 16.7%; p = 0.015).

When reconstructing donor site defects following RFFFs, staged reconstruction with initial placement of Integra followed by STSG and bolster placement may result in lower rates of skin graft breakdown and tendon exposure.