The Advantages of Delayed Nasal Full-Thickness Skin Grafting After Mohs Micrographic Surgery

BACKGROUND: Full-thickness skin grafting following Mohs micrographic surgery (MMS) of the nasal tip and ala provides easy postoperative wound care and avoids functional impairment caused by wound contraction of the nasal ala free margins. Direct comparison of immediate and delayed skin grafting determined which offers greater success and defined factors contributing to success. OBJECTIVE: To determine if delayed or immediate full-thickness skin grafting results in better graft survival with improved function and appearance, and to identify the recipient bed characteristics, including the size of the wound, the proportion of the wound base having perichondrium, denuded cartilage, and granulation tissue, and graft survival for each technique. METHODS: We used a prospective study comparing 200 patients with wounds having a 3-5 cm2 surface area repaired immediately with a full-thickness skin graft (FTSG) to 200 patients with a delayed FTSG. The depth and diameter of the wound of the nasal ala and tip, and characteristics of recipient bed including size (cm2), location, proportion of wound base with perichondrium present, denuded cartilage, granulation tissue, and proportion of graft loss were the main outcomes measured. RESULTS: Partial graft loss occurred in 11% of those having delayed skin grafts and 30% of those with immediate repair. Delayed grafting was associated with a larger wound surface area (P <.0001), more denuded cartilage (P =.017), greater exposed perichondrium (P <.0001), and less partial graft loss (P <.001). When partial graft loss occurred, the area of loss was smaller with delayed FTSG (P =.036). Contraction of the wound and subsequent nasal valve impairment occurred less often with delayed FTSG (P <.0001). Graft depression was significantly less with delayed FTSG of the ala (P <.0001) and also improved on the nasal tip (P =.47). CONCLUSION: This prospective clinical trial of immediate and delayed FTSGs of the nasal tip and ala with denuded cartilage showed improved graft survival in cases where grafting was delayed for 12-14 days. During this period, substantial granulation tissue formed in the wound base. Assessment of the wound base and the presence of granulation tissue are key factors in the success of full-thickness skin grafting.     

Cultured human keratinocytes as a single cell suspension in fibrin glue combined with preserved dermal grafts enhance skin reconstitution in athymic mice full-thickness wounds

Cultured human keratinocytes as a single cell suspension in fibrin glue combined with preserved dermal grafts enhance skin reconstitution in athymic mice full-thickness wounds. The technique of transplanting cultured human keratinocytes suspended as single cells in a fibrin-glue matrix (KFGS) has been recently developed to overcome common disadvantages of standard cultured epidermal sheet grafts. The combination of this method with glycerolized (nonvital) xenograft overlays in standardized nude mice full-thickness wounds, as compared to KFGS alone or controls with no grafts, showed enhancement of epithelial regeneration in terms of epithelial thickness and diminished wound contraction during the 6-week follow-up. Total scar thickness was increased after the combined KFGS/xenograft technique. The time taken to complete wound reepithelialization was similar in the two groups. Reconstitution of the dermo-epidermal junction zone as shown by electron microscopy and immunohistochemistry was enhanced by the KFGS+xenograft technique, showing structures resembling rete ridges 6 weeks postoperatively. The combined KFGS/xenograft technique is able to transfer proliferative single keratinocytes. The method simplifies the application when compared to conventional epithelial sheet grafting and reduces wound contraction when compared to pure keratinocyte grafting. Received: 15 October 1998 / / Accepted: 10 March 1999     

Effect of Full-Thickness Skin Graft Initial Dimension on Secondary Wound Contraction: Experimental Study in Rats

BACKGROUND: The size of a full-thickness skin graft (FTSG) is typically determined using a pattern of the defect usually obtained following excision of a skin lesion. OBJECTIVE: The aim of this experimental study is to investigate the effects of various graft sizes on secondary wound contraction. METHODS: Four 2.5 x 2.5 cm defects were created on the backs of 20 rats. Defect A was left to heal by secondary intention. The graft obtained from defect B (exact size graft) was sutured to its original bed. The wound of defect C (large graft) was patterned, and this was used to obtain a generous graft from the abdomen. A presized 1.5 x 1.5 graft obtained from defect D (small graft) was sutured to its original wound. Graft areas on days 0, 3, 7, 10, 14, 18, and 21 were calculated and converted into a percentage of the original wound size. Analysis of variance was used for statistical comparison. Open wounds reached a final wound size of 5% at day 21. Exact-size grafts showed the least secondary contraction rate (74.19 +/- 4.30 %) (p < .05). CONCLUSION: A graft in the size of a planned excision preserves its original area better than grafts larger or smaller in size in the rodent model. The size of a FTSG is an important factor in preventing secondary wound contraction. However, it should be stressed that the results of this study cannot necessarily be extrapolated to real clinical scenarios without further detailed studies.     

The efficacy of collagen dermis membrane and fibrin on cultured epidermal graft using an athymic mouse model

A human skin substitute consisting of human cultured keratinocytes, collagen dermis, and fibrin was evaluated in athymic mice. Eighty athymic mice were divided randomly into four groups. A 1.5x1.5-cm full-thickness wound defect was created on the back of each athymic mouse under anesthesia. These wounds were covered by sheets of cultured epidermal graft (group A), cultured epidermal graft with collagen dermis and fibrin (group B), cultured epidermal graft with collagen dermis (group C), or cultured epidermal graft with fibrin (group D). The grafts were secured and kept moist by specially designed saline gauze chambers. The take rates of the cultured graft with more than 50% of the wound covered were 65%, 15%, 50%, and 45% respectively. Group B had a significantly lower graft take rate, however the difference was not significant among groups A, C, and D. Light microscopy of biopsies of the grafted sites at 12 days showed complete epithelialization. The incidence of discharge from wound beds in groups A, B, C, and D was 0%, 15%, 15%, and 10% respectively. The results suggest that cultured cells are best grafted directly onto the wound bed or in combination with either a thin layer of collagen or fibrin but not both because the collagen dermal membrane and the fibrin together may impose too great a diffusion barrier for the cultured cell graft to become vascularized.     

Inhibition of wound contraction: comparison of full-thickness skin grafts, Biobrane, and aspartate membranes

The mechanism by which open wounds contract is unknown. Although myofibroblasts are implicated in this natural process of wound healing, the evidence, however convincing, is only circumstantial. Control of wound contraction has been sought for many years, but only the application of full-thickness skin grafts is able to produce safe and effective clinical results. By comparing the synthetic skin substitute Biobrane and its component parts with full-thickness skin grafts in a rat wound model, we have demonstrated that dermis is not required for inhibition of wound contraction. We postulate that physical properties of skin and its synthetic analogues, including adherence to the wound surface, may be the signals to the open wound that effectively inhibit contraction. Whether myofibroblasts participate in this interaction remains unanswered.     

Skin grafting with fibrin glue in burns

Summary In an attempt to obtain better function and appearance minimize blood loss and increase graft survival with minimal postoperative care, deep burns are treated by applying the fibrin glue to difficult recipient sites. A two-component fibrin sealant is used, fibrinogen made from pooled human plasma and bovine thrombin (Tissucol, Immuno AG, Vienna, Austria). The fibrin sealant is described as well as the technique used to seal the skin grafts in 15 patients (18 procedures). Indications for graft sealing are limited to grafts over areas subject to movement (joints, face, neck, hands) and to non-meshed grafts for cosmetic reasons. This clinical experience demonstrates several advantages of sealing skin grafts on burn wounds: hemostasis, early adherence and wound healing are improved; better cosmetic results are obtained with sheet grafts on the face and neck; operating time is reduced; no special dressings are required; physiotherapy starts after 24 h; the period of rehabilitation is reduced as well as the incidence of secondary procedures.     

Autologous skin transplantation: comparison of minced skin to other techniques

BACKGROUND: Skin grafting may be necessary to close nonhealing skin wounds. This report describes a fast and minimally invasive method to produce minced skin suitable for transplantation to skin wounds. The technique was evaluated in an established porcine skin wound healing model and was compared to split-thickness skin grafts and suspensions of cultured and noncultured keratinocytes. MATERIALS AND METHODS: The study included 90 wounds on 3 pigs. Fluid-treated full-thickness skin wounds were grafted with minced skin, split-thickness skin grafts, noncultured keratinocytes, or cultured keratinocytes. Controls received either fluid or dry treatment. The wound healing process was analyzed in histologies collected at Days 8 to 43 postwounding. Wound contraction was quantified by photoplanimetry. RESULTS: Wounds transplanted with minced skin and keratinocyte suspension contained several colonies of keratinocytes in the newly formed granulation tissue. During the healing phase, the colonies progressed upward and reepithelialization was accelerated. Minced skin and split-thickness skin grafts reduced contraction as compared to keratinocyte suspensions and saline controls. Granulation tissue formation was also reduced in split-thickness skin-grafted wounds. CONCLUSIONS: Minced skin grafting accelerates reepithelialization of fluid-treated skin wounds. The technique is faster and less expensive than split-thickness skin grafting and keratinocyte suspension transplantation. Minced skin grafting may have implications for the treatment of chronic wounds.     

Single-donor fibrin glue for hand burns

Early tangential excision sometimes results in considerable blood loss, prolonged operative time, and partial loss of the graft secondary to hematoma formation. Previous reports document positive hemostatic effects and improved skin fixation with fibrin "glue." The commercial preparation used in Europe, however, has not been approved by the United States Food and Drug Administration because of the high risk of hepatitis and human immunodeficiency virus transmission. Using a method developed at the University of Virginia, we applied single-donor fibrin glue as an adjunct in early excision and grafting in 16 patients (26 hands). The overall graft take was 99%. In all patients, better adherence of the split-thickness graft to the recipient bed, during and immediately after application, was noted. We have observed no negative effects with regard to infection or healing. We recommend the use of single-donor fibrin glue to reduce operative blood loss, improve survival and ease of graft application, and possibly to accelerate healing.     

血管内皮细胞和成纤维细胞混合移植对人工真皮血管化的影响

目的观察同种血管内皮细胞和成纤维细胞移植对人工真皮血管化的促进作用。方法在27只Wistar大鼠背部造成2．5 cm×2．5 cm全层皮肤缺损创面(2处／只),将其分为血管内皮细胞组:将血管内皮细胞混入0．5 ml纤维蛋白胶中,按1．0×105／cm2的密度均匀喷洒于移植床;混合组:将血管内皮细胞和成纤维细胞混入等量纤维蛋白胶后,同前密度喷洒于移植床;对照组:按同样方法喷洒等量纤维蛋白胶。随后各组移植人工真皮,每组9只大鼠18处创面。于移植后5、10 d切取移植的真皮及周围组织行HE、血管内皮生长因子(VEGF)、Masson和墨汁灌注染色,观察新生血管生长情况。于移植后5 d行伊文思蓝灌注,以分光光度计定量检测法测定微血管形成情况。结果移植后5 d,HE、VEGF、Masson和墨汁灌注染色均可见各组移植床有新生血管长入。HE染色见血管内皮细胞组、混合组新生血管数量分别为(14．2±3．6)、(12．1±2．5)条,较对照组[(3．9±1．6)条]明显增多(P<0．05)。移植后10 d,人工真皮内及移植床均有微血管形成,且胶原组织的合成增加。移植后5 d,经伊文思蓝灌注,收集并检测血管内皮细胞组、混合组真皮组织溶出的上清液,吸光度值分别为0．167±0．058、0．155±0．046,均高于对照组的0．066±0．024(P<0．05)。结论同种血管内皮细胞和成纤维细胞移植可促进创面愈合过程中的血管新生,加速人工真皮移植后血管化过程,促进类真皮组织的成熟。     

Fibrin sealant improves graft adherence in a porcine full-thickness burn wound model

IntroductionAutograft take and rapid wound closure is essential for the survival of severely burned patients. Loss of skin grafts typically occurs during the first few days after coverage, mainly due to shear forces and inadequate contact with the wound bed. Slow-clotting fibrin sealant, applied with a spray-on device, has been shown to improve healing of skin grafts in large wounds. However, its use in burn wounds has not been studied so far.Study aimTo evaluate the effectiveness of sprayed fibrin sealant in excised and grafted full-thickness burns.Material and methodsTen female Yorkshire pigs (30–45 kg) received a full-thickness contact burn of approximately 15% total body surface area. The burns were excised to the level of the muscular fascia after 24 h and covered with meshed skin autograft (mesh ratio 1:3). Wounds were randomized to either fibrin sealant (n = 20) or standard skin staples (n = 16) for graft fixation. Fibrin sealant was used as a slow-clotting spray (4 IU thrombin/ml). Outcome measurements included clinical scoring at days 2, 5, 9 and 14 postoperatively, planimetric analysis of wound closure, and histological examination of epidermal and dermal thickness 14 days after autografting.ResultsIn the fibrin sealant group, graft adherence scores were significantly increased (p < 0.02) and graft dislocation scores significantly decreased (p < 0.01) at days 2 and 5 postoperatively, when compared to controls. Planimetric analysis of remaining open mesh interstices showed acceleration of wound closure in the fibrin sealant group but did not reach statistical significance (day 14 p = 0.04 at significance level p < 0.025). Wound contraction, occurrence of hematoma, and dermal as well as epidermal thickness were not different between the groups at 14 days postoperatively.ConclusionThe results indicate that the use of slow-clotting fibrin sealant spray for autograft fixation is advantageous over skin staples. Easy handling and reduced graft dislocation at early time points are key qualities of this method.     

Value of fibrin glue in surgery of patients with severe burns]

From January 1985 to May 1986, fibrin glue was used for graft sealing in 158 cases of our 200 skin grafts performed for the treatment of burns. When the graft area was less than 200 cm2, primary and complete healing was routinely observed. In the remainder, we noticed a higher quality of healing when fibrin glue was used compared to the other grafts. In 2 patients, infection of the wound was responsible for a total graft lysis which occurred immediately in the non-sealed grafts and was delayed in the sealed ones. Fibrin glue shortens skin graft healing time while it procures a better quality of life in patients with burns during in hospital stay. However the use of this healing-facilitating compound has to be limited to well-defined indications.     

Autologous fibrin glue in full-thickness skin grafting

Full-thickness skin grafts can be anchored to the recipient site using fibrin glue made from the patient's own blood and commercially available thrombin and epsilon aminocaproic acid. The technique works well for small grafts on irregularly contoured sites where suture fixation of a graft would be technically difficult. Full-thickness skin grafts anchored with autologous fibrin glue have been uniformly successful in 50 patients followed for a minimum period of four months.     

Use of fibrin glue for covering microsurgical autotransplants with free split skin

An experimental study on 90 Wistar rats has been carried out. A split skin transplant about 2.25 cm(2) in size was taken from the back of the animal with scalpel and fixed on the neck's muscles with: 1) 8 sutures; 2) pressure dressing of "Pelot" type; 3) 0.2 ml of "Tissukol" fibrin glue. There were no complications. Complete skin retention was achieved in all the cases. Histological study demonstrated acceleration of reparative processes and decreased inflammation in autotransplant and muscular bed due to improvement of revascularization, a decrease of fibrous transformation of the skin graft and muscular tissue when fibrin glue (to a greater extent) and pressure dressing (to a lesser extent) were used for fixation of skin graft. But it is preferable to use fibrin glue due to acceleration of complete skin retention compared with pressure dressing of "Pelot" type.     

成纤维细胞移植促进人工真皮内血管新生的研究

目的观察成纤维细胞与人工真皮共同移植对移植床及真皮海绵内微血管形成、胶原沉积的影响,促进人工真皮海绵内类真皮组织形成,缩短"二期植皮"的间隔时间.方法 Wistar大鼠18只,背部两侧各制作2.5 cm×2.5 cm全层皮肤缺损创面,在移植人工真皮之前分为两组,即成纤维细胞移植组(A组):向创面喷洒混入密度为1.0×105/cm2的同种真皮成纤维细胞的纤维蛋白胶0.5 ml;对照组(B组):只喷洒纤维蛋白胶0.5 ml.于移植后5和10天分别切取移植的真皮及周围组织,进行HE染色、Masson染色、VEGF免疫抗体染色和墨汁灌注染色,观察移植床及真皮海绵内微血管新生及胶原沉积状态;于移植后5天行伊文蓝组织灌注,分光光度计测定真皮海绵内染料含量,定量检测真皮海绵内循环渗透情况.结果移植后5天,新生血管主要集中在真皮下移植床,A组新生血管较B组明显增多,A组(9.64±2.36)个/高倍视野,B组(3.88±1.62)个/高倍视野,差异有统计学意义(P＜0.05);VEGF阳性细胞亦明显增多.移植后10天,移植床及真皮内均有微血管形成,A组血管数量和管径均较B组增加,胶原沉积量也明显增加.A组(46.04±8.90)个/高倍视野,B组(30.08±7.76)个/高倍视野,有统计学意义(P＜0.05).结论同种成纤维细胞移植可明显加快人工真皮内及移植床的血管新生和胶原沉积,加快真皮海绵内类真皮组织的形成.     

医用生物蛋白胶在皮肤移植术中的应用

目的:研究医用生物蛋白胶在皮肤移植术中的应用前景。方法:对7例双手瘢痕的患者行左右手对照实验,比较两者止血时间及皮片成活率,并观察18例其他部位瘢痕切除合并使用医用生物蛋白胶后皮片的成活情况。结果:7例手部皮片成活良好,使用医用生物蛋白胶组手术时间明显缩短;其他部位中17例皮片基本完全成活,1例有2cm×3cm的皮片坏死,经补充植皮后出院。结论:医用生物蛋白胶有良好的止血作用,只要使用合适,在皮肤移植术中也有较大的使用价值。     

The application of new biosynthetic artificial skin for long-term temporary wound coverage

Temporary dressings protect wounds from desiccation and infection. In our previous study, we used meshed acellular porcine dermis (APD) to enhance wound healing and decrease wound contraction; however, the wounds showed meshed scar [Wang HJ, Chen TM, Cheng TY. Use of a porcine dermis template to enhance widely expanded mesh autologous split-thickness skin graft growth: preliminary report. J Trauma 1997;42(2):177–82]. In this study, we produced an artificial skin composed of a cross-linked silicon sheet on the surface of APD which we have called silicone acellular porcine dermis (SAPD). This new artificial skin can protect the wound long enough to promote wound healing either by second intention or covered long enough until cultured epithelium autograft (CEA) or autologous skin graft can be harvested for permanent coverage.

We delivered 4 cm × 5 cm full-thickness wound on the back of 350 g Sprague–Dawley rats. Thirty-six rats were divided into two groups. Eighteen rats had SAPD and the other 18 were covered with Biobrane. The wounds were first examined 2 weeks after grafting and followed weekly for an additional 4 weeks to evaluate the wound and study pathological changes by using H.E. and Masson's stains. Wound size was calculated by ruler and analyzed by Student's t-test.

At the 2-week inspection, both SAPD and Biobrane showed tight adherence to the wound with no change of wound size. Both the SAPD and Biobrane dermal templates were pink. In the Biobrane-covered group, the wounds contracted soon after the tie-over dressing was removed. Its dermal layer is a layer of thin porcine dermal substance, which was promptly digested by tissue hyaluronidase and provides no real dermal template. In the SAPD-covered group however, the wound size was maintained significantly from third to sixth week after grafting (p < 0.001). SAPD was designed with thick epidermal silicone and a well-organized porcine dermis so that it incorporates into the recipient wound. Clinically the silicone layer of SAPD dislodged from APD about 6–7 weeks after grafting and was followed by dermal matrix exposure and infection. In pathological examination, much like a human skin graft, new vessels were found in APD about 1 week after grafting with minimal inflammatory cells infiltrated in the graft and wound. Six weeks after grafting, the collagen of APD incorporated into the wound, showing palisade arrangement and no sign of rejection. In the Biobrane group however, the wounds showed severe inflammation, the porcine dermal matrix was digested and disappeared 3 weeks after coverage.

In conclusion, SAPD is a thick biosynthetic artificial skin, which protects the rat wound significantly longer than Biobrane and prevents contraction. We expect that using of SAPD for temporary wound coverage will provide enough time to grow autologous-cultured epithelium or to reharvest skin grafts.     

Improved flap viability with site-specific delivery of sildenafil citrate using fibrin glue

Sildenafil is a cyclic guanosine-specific phosphodiesterase type 5 (PD-5) inhibitor that is widely used for erectile dysfunction. Potent and competitive inhibition of PD-5 enhances levels of cyclic guanosine monophosphate (cGMP). Fibrin glue-apart from tissue fixation-has been used for slow release of drugs. In this study, local delivery of Sildenafil citrate with fibrin glue was accomplished to improve random flap survival. Fifty Wistar rats were randomized into 5 groups, and a standardized dorsal random-pattern skin flap was elevated in each rat. In Group I (n = 10), the base of the flap was divided, making it a "graft" control to study the graft effect. In Group II (n = 10), a thin Silastic sheet was used to separate the flap from the underlying vascular bed, and no pharmacologic treatment was given. In Group III (n = 10), only 0.5 mL of fibrin glue was applied to the flap donor site. In Group IV (n = 10), 2.5 mg of sildenafil citrate mixed in 0.5 mL of fibrin glue was applied to donor site of the flap, whereas 10 mg of sildenafil citrate mixed in 0.5 mL of fibrin glue was applied in Group V (n = 10). Area of flap survival was evaluated on postoperative seventh day. Total necrosis of all of the flaps was observed in "graft" control group (Group I). Sildenafil and fibrin glue groups (Group IV and V) resulted in a statistically significant decrease in flap necrosis compared with Groups II and III (P < 0.0001). A statistically significant difference could not be documented between Group II and Group III (P > 0.0001). The decrease in skin necrosis was statistically significant in Group V compared with Group IV (P < 0.0001). Histologic examination revealed significantly increased vascular density in Groups IV and V compared with Groups II and III (P < 0.0001), whereas a significant difference could not be documented between Groups IV and V (P > 0.0001) and between Groups II and III (P > 0.0001).In view of these results, topical sildenafil application seems to improve flap survival in random-pattern skin flaps in dose-dependent manner.     

外用罂粟碱抑制植皮片术后挛缩的实验研究

目的探讨外用罂粟碱霜对自体游离植皮片术后晚期挛缩的影响。方法在每头小型猪背部两侧皮肤制备10个2cm×2cm创面,从动物腹部正中取2cm×2cm的断层皮片并植于背部创面上,术后2周拆线,取同一动物身上100%成活且位置恰好左右侧相对的植皮片共12对,按左右侧分成A(罂粟碱治疗组)、B(空白霜剂对照组)2组,自拆线之日起,A组每日在植皮片表面外涂2%罂粟碱霜2次,B组仅涂抹空白对照霜剂,最后观察两组植皮片成活后1、2、3、4、5、6个月收缩率及植皮片成活后6个月时的组织学差异。结果A组植皮片收缩率较B组明显降低,两组之间差异有显著性意义(P<005)。组织切片显示A组植皮片成纤维细胞较B组明显减少,微血管数量较B组数量多,两组之间差异有显著性意义(P<005)。结论外用罂粟碱霜剂能够抑制自体游离植皮片术后挛缩,提高植皮效率。     

Adjacent-Tissue Skin Grafts for Reconstruction

BACKGROUND: Large defects not easily repaired with local flaps and defects near anatomic free margins or crossing anatomic units present unique challenges for reconstruction. Cosmetic results of full-thickness skin grafts may appear unsatisfactory owing to differences in color, texture, and thickness between donor and recipient sites. OBJECTIVE: The objective was to describe a skin-graft reconstructive method that better approximates skin characteristics between donor and recipient sites while following other criteria to improve the final aesthetic and functional result. METHODS: Careful evaluation of the tissue surrounding a surgical defect determines tissue laxity available for skin grafting and whether the defect crosses anatomic units or may distort anatomic free margins or landmarks. Through partial closure of the large surgical defect, preferably within cosmetic units, a tricone is created large enough to graft the remaining wound. RESULTS: Creating smaller wounds within cosmetic units or subunits, there is less chance of distortion of nearby anatomic free margins or landmarks. Skin grafting is accomplished with tissue of similar color, texture, and thickness CONCLUSION: Adjacent-tissue skin grafts provide a suitable reconstruction option for surgical defects too large for simpler repair or defects crossing cosmetic units or near free margins. This procedure permits repair with a full-thickness skin graft of more similar skin characteristics to the recipient site.     

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.