Despite the increasing development of thin perforator flaps and continuous sophistication of flap-raising techniques at nearly any donor site of the body, the RFF remains the most commonly used free flap, mostly raised as a standard fasciocutaneous flap with dissection deep to the forearm fascia [24, 495, 583]. Using this conventional approach, a number of modifications concerning the soft and hard tissue components of the flap and its design, volume, and shape are possible and open a wide range of indications [24, 455]. Nevertheless, the numerous advantages of this flap are limited by a significant incidence of donor-site morbidity, which is the major stimulus to search for alternatives to the RFF. As described above, partial loss of the skin graft, delayed healing, and tendon exposure are the most-reported complications after subfascial flap raising, and many proposals have been made to overcome these problems like oversewing the tendons with musculature , primary closure , bilobed flaps , Z-plasty , V-Y advancement flaps [75, 310, 558], and various suturing techniques to reduce the size of the donor defect [366, 495, 580]. According to wide clinical experience and retrospective studies, full-thickness skin grafts seem to have a better functional and esthetic outcome over split-thickness skin grafts [26, 75, 159, 245, 493] and negative pressure wound dressings can further improve the outcome of wound healing at the RFF donor site [12, 21–23].
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