Is longer bolster duration associated with improved split-thickness skin graft (STSG) uptake in fibula free flap donor sites?
In this cohort study including 42 adults receiving fibula free flaps, based on photographs taken 1 month postoperatively, 14-day bolster duration was associated with a better STSG uptake rate than 5-day bolster duration (77.5% vs 59.9%) with a moderate effect size. Patients with the highest Adult Comorbidity Evalution-27 scores were also found to have poorer rates of STSG uptake with a moderate effect size.
Larger studies are needed, but the findings of this cohort study suggest that longer bolster duration may be associated with improved outcomes for patients undergoing STSGs.
The fibula free flap donor site is associated with both short-term and long-term morbidity. Split-thickness skin graft (STSG) loss can lead to long delays in donor site healing and is associated with significant adverse sequelae. Patients may experience initial good STSG uptake after bolster removal but may have subsequent partial or total loss related to contact pressure or shearing.
To determine if increased duration of bolster use is associated with increased STSG uptake rates following fibula free flap reconstruction.
Design, Setting, and Participants
This retrospective cohort study included patients 18 years and older undergoing fibula free flap reconstruction following head and neck extirpative surgery at a tertiary care academic medical center from May 2013 to March 2019. The donor sites were photographed 4 weeks postoperatively, and areas of graft uptake were measured using image processing software. The baseline demographic, comorbidity, and operative characteristics were also collected.
A fine mesh gauze with 3% bismuth tribromophenate and petrolatum blend bolster was sutured over leg STSGs placed on fibula free flap donor sites intraoperatively, and the ankle and lower leg were immobilized for 5 days in a plaster splint. Bolsters were either removed on postoperative day 5 or 14. Thereafter, the STSGs were covered with a petroleum and bismuth gauze and a cotton dressing.
Main Outcomes and Measures
Rates of donor site infection and STSG percentage uptake at 4 weeks.
Of the 42 included patients, 31 (74%) were male, and the mean (SD) age was 62.1 (13.1) years. A total of 20 patients were included in the 5-day group, and 22 were included in the 14-day group. The 14-day bolster group had a higher mean percentage skin graft uptake rate compared with the 5-day bolster duration group (77.5% vs 59.9%), with an effect size of −0.632 (95% CI, −1.260 to −0.004). Patients with Adult Comorbidity Evalution-27 scores of 3 had poorer rates of STSG uptake compared with patients with Adult Comorbidity Evalution-27 scores of 0 to 2 (65.9% vs 82.9%), with an effect size of 0.599 (95% CI, −0.191 to 1.389). No donor site infections were noted in either group.
Conclusions and Relevance
Fourteen-day bolster application to the fibula free flap donor site was associated with better STSG uptake rates than 5-day bolster application.
Identify all potential conflicts of interest that might be relevant to your comment.
Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.
Err on the side of full disclosure.
If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.
Not all submitted comments are published. Please see our commenting policy for details.
David AP, Heaton C, Park A, Seth R, Knott PD, Markey JD. Association of Bolster Duration With Uptake Rates of Fibula Donor Site Skin Grafts. JAMA Otolaryngol Head Neck Surg. Published online April 16, 2020. doi:10.1001/jamaoto.2020.0160
Coronavirus Resource Center
Customize your JAMA Network experience by selecting one or more topics from the list below.
Create a personal account or sign in to: