Cross-suturing as an aid to wound closure: a prospective randomised trial using the forearm flap donor site as a model.

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.