Abstract
Purpose
Radial forearm free flaps (RFFFs) and fibular osteocutaneous flaps (FOFs) are mainstays of head and neck reconstruction. Removal of the donor tissue often leaves a soft tissue defect requiring a split thickness skin graft (STSG) for coverage. The purpose of this study is to evaluate the potential to reduce the morbidity of removal of the STSG from a second site.
Materials and methods
We report a series of 9 patients who had the STSG taken from the free flap donor skin paddle as an alternative to removal from the standard distant sight.
Results
9/9 (100%) flaps were successfully transferred with no primary or secondary loss of the flap. 8/9 (89%) of STSGs were successfully harvested from the donor skin paddle. Postoperative complications included infection and partial STSG loss (2/9, 22%).
Conclusions
This study demonstrates the feasibility and reduced morbidity associated with removal of the STSG from the donor flap skin paddle in addition to the placement of a de-epithelialized free flap in head and neck reconstruction patients. Given this research, which supports the previously published research on this topic, this technique could be considered in an effort to reduce morbidity in patients undergoing head and neck reconstruction using the RFFF and FOF.
1
Introduction
The use of radial forearm free flaps (RFFFs) and fibular osteocutaneous flaps (FOFs) has been a mainstay of microvascular reconstruction in the field of head and neck surgery. These techniques have become the workhorses of head and neck reconstruction, and can be used to reconstruct a wide variety of head and neck defects. Both flaps have adequate and readily accessible vasculature, soft tissue volume ideal for reconstruction, and in the case of FOFs, boney structure which readily accepts dental hardware . In addition to the aforementioned surgical benefits of microvascular free flaps, is the relatively low surgical morbidity related to the removal of the donor tissue from the extremity.
Coverage of the defect left by the transfer of the RFFF and FOF is with a split thickness skin graft (STSG) harvested from a secondary site, most often the anterior or lateral thigh. The morbidity that is present with the placement of a STSG to the donor site from a location that is remote to the donor site itself is not benign and includes an additional site of pain, scarring, and a possible source of infection .
There have been a few studies that have investigated the utility of using the donor site skin paddle for the STSG . These studies have concluded that this technique offers the benefit of decreased morbidity usually associated with the STSG from an alternative site. In these two reports, minimal complications were noted and it was determined that using the donor skin paddle for the STSG was advantageous on many fronts. Our study is an extension of this previously performed research. Therefore, the purpose of this case series study is to add to the literature in order to better understand whether this technique truly offers greater benefit than the STSG harvesting technique. We report our experience using this technique in a series of patients in order to add to the literature on this method.
2
Materials and methods
After institutional IRB approval, data were retrospectively collected on patients treated in the Department of Otolaryngology at Mayo Clinic, Rochester, Minnesota, from July 2010 through January 2011 who had a split thickness skin graft taken from either an RFFF or FOF donor site. All surgeries were to provide reconstruction of head and neck defects. Information collected from the preoperative period included demographics, specific comorbidities (tobacco use, diabetes mellitus, alcohol use, and etc.), tumor location, history of prior head and neck surgery, prior radiation therapy to the region, and prior lymphadenectomy. For the operative period, data were gathered on total tourniquet time, vein coupler size, split thickness skin graft thickness, and location of the free flap surgical site. Final tumor pathology, total length of follow up, the presence or absence of postoperative radiotherapy and/or chemotherapy, and complications were recorded.
2.1
Surgical technique
Prior to harvesting the free flap, the extremity was exsanguinated, a tourniquet inflated to the appropriate pressure, and an STSG was harvested from the area of the planned skin paddle using a Zimmer dermatome (Zimmer, Warsaw, IN) at 0.020 inch thickness. The skin graft was typically left pedicled distally at the wrist or ankle ( Fig. 1 ). After the harvesting of the donor free flap, the STSG was placed over the defect and sewn in place with 5-0 Chromic Gut suture (Ethicon, Somerville, NJ), and finally, the graft was then pie crusted to allow for drainage ( Fig. 2 ). A petroleum based dressing was then applied over the STSG, and a wound VAC placed for 5 days with the extremity appropriately splinted.
2
Materials and methods
After institutional IRB approval, data were retrospectively collected on patients treated in the Department of Otolaryngology at Mayo Clinic, Rochester, Minnesota, from July 2010 through January 2011 who had a split thickness skin graft taken from either an RFFF or FOF donor site. All surgeries were to provide reconstruction of head and neck defects. Information collected from the preoperative period included demographics, specific comorbidities (tobacco use, diabetes mellitus, alcohol use, and etc.), tumor location, history of prior head and neck surgery, prior radiation therapy to the region, and prior lymphadenectomy. For the operative period, data were gathered on total tourniquet time, vein coupler size, split thickness skin graft thickness, and location of the free flap surgical site. Final tumor pathology, total length of follow up, the presence or absence of postoperative radiotherapy and/or chemotherapy, and complications were recorded.
2.1
Surgical technique
Prior to harvesting the free flap, the extremity was exsanguinated, a tourniquet inflated to the appropriate pressure, and an STSG was harvested from the area of the planned skin paddle using a Zimmer dermatome (Zimmer, Warsaw, IN) at 0.020 inch thickness. The skin graft was typically left pedicled distally at the wrist or ankle ( Fig. 1 ). After the harvesting of the donor free flap, the STSG was placed over the defect and sewn in place with 5-0 Chromic Gut suture (Ethicon, Somerville, NJ), and finally, the graft was then pie crusted to allow for drainage ( Fig. 2 ). A petroleum based dressing was then applied over the STSG, and a wound VAC placed for 5 days with the extremity appropriately splinted.
