Comparative Analysis of Single-Layer Integra with Split-Thickness Skin Grafting in Radial Forearm Free Flap

Introduction: Radial forearm free flaps (RFFF) have been a workhorse in head and neck reconstruction due to their versatile and reliable nature. The purpose of this study is to compare the gold-standard split-thickness skin grafting (STSG) to a novel technique of single-layer integra application followed by split-thickness skin grafting in a single-stage.

Methods: Patient charts were reviewed for individuals who underwent RFFF procedures at a single institution between February 2023 and December 2024. The cohort included patients treated by three fellowship-trained microvascular H&N surgeons. One surgeon utilized integra in their practice, while the other two adhered to traditional STSG techniques. Postoperative photographs were obtained at various time points and evaluated using a blinding protocol. Wound characteristics were assessed using the validated Vancouver Scar Scale (VSS) and a modified scar scale measuring aesthetic outcomes and tendon exposure.

Results: Fifty-seven patients met the inclusion criteria, with 26 in the integra group and 31 in the STSG group. Demographic variables, including age, gender, and ASA scores, were comparable between the groups. A total of 118 photographs were analyzed across the following postoperative intervals: 1–3 weeks (n=55), 3–6 weeks (n=33), and beyond 6 weeks (n=30). No statistically significant differences in healing outcomes were observed between the groups across all time intervals. Although a small, statistically insignificant trend toward improved VSS scores was noted in the integra group, this was not corroborated by the modified scar scale results.

Conclusions: This study suggests that single-layer integra application with subsequent split-thickness skin grafting does not yield superior healing or aesthetic outcomes compared to traditional split-thickness skin grafting for radial forearm free flap donor sites. The lack of significant differences in scar quality or tendon exposure indicates that the integra technique may not offer a clear advantage over the established standard.