Optimizing Wound Healing in Radial Forearm Donor Sites: A Comparative Study of Ulnar-Based Flap and Split-Thickness Skin Grafting

Abstract

Background: The radial forearm free flap (RFFF) is a common technique in head and neck reconstructive surgery. This study aimed to compare the clinical and biochemical outcomes of wound healing following ulnar-based transposition flap (UBTF) versus split-thickness skin grafting (STSG) for donor site closure, with a particular emphasis on tissue regeneration. Materials and Methods: A total of 24 patients (6 women, 18 men), underwent RFFF reconstruction. The donor site was closed using the UBTF technique in 10 cases, while STSG was performed in 14 cases. Postoperative complications-including necrosis, edema, hematoma, infection, and wound dehiscence-along with healing times were assessed daily during the first seven postoperative days and at monthly follow-ups over six months. Pre- and postoperative biochemical analyses included hemoglobin (HB), white blood cell count (WBC), platelets (PLT), albumin, and C-reactive protein (CRP) levels. An aesthetic evaluation of the flap was also performed. Results: The two groups were homogeneous. Postoperative complications occurred more frequently in the STSG group, which also demonstrated significantly longer healing times (p = 0.0004). In contrast, the UBTF group showed significantly better aesthetic outcomes in terms of skin color (p = 0.000021), skin texture (p = 0.000018), and flap stability (p = 0.0398). Additionally, pre- and postoperative PLT counts were significantly higher in the UBTF group (p = 0.001 and p = 0.043, respectively). Conclusions: While STSG remains a well-established method for forearm donor site closure following RFFF harvest, this study demonstrates that UBTF is a viable alternative associated with better clinical and aesthetic outcomes.

Keywords: radial forearm free flap (RFFF); split-thickness skin graft (STSG); tissue regeneration; ulnar-based transposition flap (UBTF); wound healing.

Figure 1

Schematic representation illustrating the step-by-step procedure for harvesting an STSG and subsequent closure of the RFFF donor site. Abbreviations: RFFF—radial forearm free flap; STSG—split-thickness skin graft.

Figure 2

Schematic illustration showing the incision design for the ulnar-based transposition flap (A) and the typical appearance of donor site closure following flap transfer (B).

Figure 3

Schematic intra-operative illustration of the ulnar-based transposition flap technique. (A) Elevated view of the ulnar-based flap; (B) flap transposition to cover the radial forearm free flap (RFFF) donor site; (C) final closure with skin sutures and insertion of a drainage tube.

Figure 4

Schematic representation of tumor histopathology in both evaluated groups: (A) STSG group and (B) ulnar-based flap group. Abbreviations: BCC—basal cell carcinoma; SCC—squamous cell carcinoma.

Figure 5

Schematic representation of tumor location distribution in both evaluated groups: (A) STSG group and (B) ulnar-based flap group. Abbreviation: STSG—split-thickness skin graft.

Figure 6

Schematic representation of aesthetic outcomes three months post-surgery using (A) the STSG technique and (B) the UBTF technique. Abbreviations: STSG—split-thickness skin graft; UBTF—ulnar-based transposition flap.

Figure 7

Schematic illustration showing the approximate timeline of the STSG healing process (A), followed by a step-by-step depiction of the biological phases involved (B). The process begins with plasmatic imbibition, during which basic nutrients and oxygen diffuse passively from the wound bed into the graft. This is followed by the phase of inosculation, where initial vascular connections begin to form between the graft and the recipient site. Subsequently, revascularization occurs, marked by active angiogenesis that restores a functional blood supply. Finally, the healing process concludes with integration and remodeling, during which the grafted tissue matures and reorganizes structurally to achieve long-term stability and functionality. Abbreviations: STSG—split-thickness skin graft; PDGF—platelet-derived growth factor; VEGF—vascular endothelial growth factor; FGF—fibroblast growth factor.