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Direct closure of a full thickness skin defect by suturing is the simplest and best solution in most cases. When suturing is not possible, then a skin graft may be the next choice for reconstruction. It is usual for the graft to be applied to the unaltered defect, accepting the size of the wound as the area to be grafted. This approach ignores the potential contribution of the elastic properties of the wound edges, which are so readily used to advantage in direct closure. A simple technique, which makes skin defects substantially smaller prior to skin grafting, is described. This technique benefits the primary defect by minimising the area of scar produced, as well as minimising the size of skin graft required and thus the graft donor site.
The secondary defect of the radial forearm flap was used as a model wound in a prospective randomised trial to assess the use of this technique. Twenty successive patients undergoing free radial forearm flap surgery were entered into the trial. The technique consisted of preliminary cross-suturing of the wound prior to skin grafting. Half of the cases received cross-wound suturing and half of the cases had grafts applied to the unaltered area of the defect. Measurements of the forearm flap donor defects were taken using templates made at the time of surgery and at later intervals. A statistically significant reduction in the flap donor defects was achieved using the cross-suturing technique. Fewer complications such as skin graft failure and tendon adherence to graft were seen with the new technique. This technique is recommended not only for minimising morbidity in the radial forearm flap donor site, but also for reducing the size of any full thickness skin defect prior to skin grafting.
Emphasis has always been placed on reducing donor site morbidity in free flap surgery. The radial forearm flap is a commonly used flap with few shortcomings and many advantages over other flaps. However, for functional and cosmetic reasons, donor site morbidity remains a concern.
Many authors have addressed this problem, and a number of different techniques have been suggested with the aim of reducing complications at the donor site. There have been very few prospective trials in this field.
We describe a simple method whereby the full thickness skin defect at the donor site on the wrist can be made significantly smaller prior to skin graft if required. This method, which involves preliminary cross-suturing of the defect, reduces the cosmetic deformity at the donor site quite significantly. A prospective randomised controlled trial was undertaken involving twenty patients undergoing free radial forearm flap surgery.
1. Patients and methods
Ethical approval for the project was obtained from the local ethical committee. Informed written consent was obtained from all of the patients prior to surgery. A patient information sheet was also distributed. Twenty successive patients were recruited into the study. The indications for use of the radial forearm flap were either for reconstruction of defects after excision of a head and neck tumour (19 patients) or for coverage of a traumatic defect of the hand (one patient). The average age of the patients was 58 years (range 28–84 years). Seventeen of the patients were male and three were female.
The patients were randomised using sealed envelopes to determine which patients would receive cross-suturing of the forearm wound, and which patients would be controls. In the study group, the donor defect in the forearm was reduced in size by cross-suturing prior to application of the skin graft. In the control group, the unaltered wound was covered with skin graft in the normal fashion.
Technique: A template of the proposed area of the flap to be elevated from the forearm was made from a thin flat piece of sponge and labelled as ‘A’. After the forearm flap was raised, another template of the resulting defect was made, and labelled as ‘B’ (Fig. 1, Fig. 2) . At this stage, the patient was randomised by opening one of the prepared envelopes. If the patient was randomised to receive cross-wound suturing, the optimum lines of tension for the partial closure of the wound were judged. The skin edges were not undermined. Cross-suturing was then commenced using a 4/0 gauge suture of Polyglyconate (Maxon, Davis and Geck). A secure bite of the dermis was taken at one end of the wound and knot was tied to itself. Subsequent bites of the dermis were then taken, traversing the wound in a zigzag fashion. Fascia over exposed muscle bellies and in between the tendons was also picked up to avoid tenting of the suture across the wound. After every few bites, the suture was pulled tight which helped in advancing the skin edges (Fig. 3, Fig. 3) . After the last bite, the suture was again tied to itself, and the knot was buried.
Fig. 1Sponge template A made of flap outline prior to elevation.
Another template of the reduced wound defect was then made and labelled as ‘C’ (Fig. 4) . A Watson knife was used to harvest a split skin graft from either the same forearm (for a smaller defect) or the thigh (for a larger defect). The graft was perforated sparingly with a scalpel blade and then secured to the defect with 4/0 catgut peripheral and quilting sutures. Vaseline gauze dressings and a palmar Plaster of Paris splint were applied. The graft was inspected after five days. A splint on the wrist was maintained for 10–14 days, and then replaced with a light bandage to permit mobilisation.
If the patient was in the control group, then the graft was applied without cross-suturing of the wound. No template ‘C’ was made in these cases.
The forearm flaps were elevated from distal third of forearm and none of the flaps were sensate. The cephalic vein was elevated with the flap and used for drainage in all cases. All of the flaps were fasciocutaneous. The templates were sent to a pathology research laboratory where the areas of the templates were calculated using computerised analysis (Kontron Image Analyser using Kontron Videoplan Interactive Software).
After an interval of between three and seven months, the area of the grafted forearm defect was reassessed, and a template of the healed forearm defect was made and labelled ‘D’. Comparisons were then made between the controls and the subjects who received cross-suturing, both subjectively and by the measurements of the templates. Delays in wound healing, graft loss and patient satisfaction with the appearance of the forearm scar were noted. The percentage reductions in the sizes of the defects were calculated for both the trial and control groups. (Table 2) . The two groups were compared statistically using the Mann–Whitney U-Test.
In the 20 patients in the trial, 10 received cross wound suturing and 10 were controls (Table 1) . Two patients (Case no. 6 and 20), both of whom were controls, died after surgery due to complications, and long-term follow-up was not possible.
In the rest of the patients, the final measurements of the forearm scar were made between 3 and 7 months after their surgery. In the cross-sutured trial group, the immediate reduction in size after cross-suturing, (area B–C) was in the range of 30–68% with a mean reduction of 53% (Table 2). Measurements of the areas of the cross-sutured forearm scars made after 3–7 months revealed reductions in area (B–D) from 40 to 77%, with a mean reduction of 65%.
Similar measurements 3–7 months after surgery in the control cases revealed reduction in scar area (B–D) ranging from 17 to 68% with a mean of 38%.
The final percentage reductions in the two groups were compared using the Mann–Whitney U-Test. Significance testing was two-tailed and the p value was reported to be 0.0044, which is considered to be very significant.
There were three graft losses in the control group, one complete and two partial. In the case with total loss of skin graft (Case no. 4) the area was grafted again after two weeks with further partial loss of graft. No further grafting was undertaken and the area healed by secondary intention over a period of ten weeks. Case no. 3 had partial loss of the skin graft overlying the flexor carpi radialis tendon, which took three months to heal completely with resultant adherence of the skin graft to the tendon. There were no complete or partial losses of graft in the cross-sutured cases. In one case, tiny raw areas formed in the grafted site with mild inflammation of the suture line. In another of the cross-sutured cases, a buried knot of the Maxon suture was visible under the graft that caused irritation and some hyperaemia of the surrounding area. The knot extruded itself in time with no long-term problem.
Partial closure of many of the forearm defects resulted in the elevation of dog-ears at either end of the axis of closure. At the final examination in all such cases, the dog-ears had completely disappeared.
It was noticed that none of the patients who had skin grafts taken from the thigh experienced any problem in healing of the donor site for the skin graft. However, most of the cases where the donor skin graft was taken from forearm had delayed healing of the skin graft donor site.
An assessment of wrist and hand function and graft appearance at the final examination did not reveal a significant difference between the two groups.
3. Discussion
When a forearm donor site is small and the surrounding tissue is lax, it may be possible to achieve direct closure of the wound after undermining of the edges. A variety of other techniques have been described to achieve wound healing when it is not possible to close the defect directly. These include split skin grafting, application of a full thickness graft,
In this randomised series of 20 patients, statistically significant reductions in the size of the forearm flap donor site defects were achieved by using cross-suturing of the defect prior to skin grafting, a technique which we have not seen previously described in the literature.
The technique is applicable to wounds of any shape, unlike a purse string suturing technique,
which requires a wound to be circular or elliptical. It is applicable to wounds of large size, and the authors have applied it to surgical wounds other than forearm flap donor sites of up to 220×120 mm2.
Not only does this method of wound closure overcome the natural expansion of the wound after flap elevation, it also overcomes the elasticity of the skin to reduce significantly the area of the wound to less than that of the designed flap. This reduction is greater than would otherwise be achieved by normal wound and graft contracture, a fact demonstrated by a comparison of the study and control groups. Furthermore, a significant reduction in scar area was maintained in all of the study group cases at the time of the final measurement several months after surgery. One of the common complications of the radial forearm defect is graft loss with tendon exposure.
Different methods have been described to reduce the rate of skin graft failure. These include suturing the local muscle bellies to cover the exposed tendon of flexor carpi radialis,
We did not experience any major graft failure in the study group. Although the numbers in the study are not sufficient for this to be statistically significant, we attribute the high rate of graft take in the study group to the provision of a flat bed, for grafting, by picking up the ‘troughs’ of the muscle bellies with the sutures between the ‘peaks’ of the flexor carpi radialis and brachioradialis tendons. Graft take did not appear to be negatively influenced by the presence of the absorbable suture between the graft and the bed. There were no other long-term sequelae of the presence of the absorbable cross suture. The smaller area of the cross sutured wound meant that in the study group a small split skin graft donor site was required. This had obvious advantages. All of the patients with cross-suturing were satisfied with the appearance of the forearm scar. (Fig. 5)
Fig. 5A cross sutured forearm defect after six months.
We noted significant problems with the healing of split skin donor sites on the forearm adjacent to the flap site, and it is now our practice to avoid this donor site in every case. This observation was previously made by Richardson et al.
Additionally, the addition of the scarring from a split skin donor site on an already scarred forearm is undesirable.
A cross-suturing technique is presented to reduce the deformity of the radial forearm flap donor defect. It is a simple technique, which can be performed quickly and without complication. It decreased the area of the flap donor defect significantly, mean 65% versus 38% in the control group. It also reduced the area of the split skin graft donor site. This technique can be used in any wound with a graftable bed, and we would suggest its use to reduce the size of any suitable wound prior to skin grafting.
Acknowledgements
The authors would like to thank Mr Sid Trewin of Cellular Imaging and Quantitative Pathology Department of Queen's University of Belfast for his invaluable help in image analysis of the templates. This project was based on an idea from the late Mr Geoff Ashall to whose memory this paper is dedicated.
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