Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Introduction: The radial forearm free flap (RFFF) is commonly used for head and neck reconstruction given its versatility and reliability. A split thickness skin graft (STSG) is usually needed to close the donor site and has the benefit of improved cosmesis and function. Failure of complete STSG take at the forearm donor site is reported at 15-20%, despite the use of a bolster and cast to apply positive pressure and prevent shearing of the graft. Longer bolster time has been associated with better STSG take; however, no randomized or prospective studies have been pursued on this topic. We therefore aimed to determine if longer bolster/cast time (5 vs. 10 days) is associated with improved STSG take, identify predictive factors associated with improved STSG, and determine if there are any complications associated with longer bolster duration.
Methods: We designed a randomized prospective cohort study comparing outcomes for 5 vs. 10 days bolster/cast time for patients undergoing STSG for RFFF donor site closure. Our optimal recruitment goal was 87 patients based on a power analysis using an effect size of 0.632, 80% power and alpha 0.05. Patients were randomized according to a block randomization scheme, with a block size of 4. For inclusion in the study, patients were required to complete the Rosenberg self-esteem survey and the 36-item short form quality of life survey at the pre-operative and 1-month post-operative time point, and have a picture taken of their forearm STSG recipient site at the 1-month post-operation time point. The primary outcome was percent STSG take. Each STSG photo was analyzed by two independent reviewers using adobe photoshop in a blinded fashion. Secondary outcomes included Rosenberg self-esteem and SF 36 quality of life survey scores, and rate of STSG donor site related complications. Standard demographic, surgical and post-operative variables were collected. Fisher’s exact and Mann Whitney statistical tests were utilized for categorical and continuous variables, respectively. Significance was set to p = 0.05.
Results: Between January 2021 and May 2024, 43 patients have been recruited into this study and completed all required follow up, with 20 patients in the 5-day study arm and 23 patients in the 10-day study arm. There were no statistically significant differences between the two study arms. The median % STSG take at 1 month post-operation was 84% and 90% for the 5-day and 10-day cohorts, respectively (p = 0.84). We identified no predictive factors for STSG take. No differences in post operative STSG donor site related complications or quality of life survey responses were observed between the two cohorts.
Conclusions: We found no difference in STSG take or rate of STSG donor site complication between STSG take at 5 versus 10 days cast/bolster time. Our study requires further recruitment to reach full power; however, preliminary results suggest that use of a 5-day bolster duration should be adequate at 84% take.