Free Fascial Flap Research Articles

Anatomical bases of the free posterior brachial fascial flap

Fascias can be used for reconstruction of gliding surfaces of upper and lower extremities or when thin, pliable coverage is required. Free large and well-vascularised fascial flaps are not very many and harvesting is seldom onto upper limb. The aim of this work was to study blood supply of the posterior brachial fascia in order to define the anatomical bases of a new free fascial flap. Our study included dissection on 18 anatomic specimens from 10 cadavers. Measures of the flap and blood supply were studied. Histological study was performed to analyse vessels location and measures into flap thickness. The posterior brachial fascia was thin, with a broad surface area and easily separable from the subcutaneous and muscular plane. Its average surface size is 115-mm length and 54-mm width. It was richly vascularised by two major pedicles: the cutaneous posterior brachial pedicule and the fascial branch of the superior ulnar collateral artery. Satellite venous elements were always present. A rich vascular network exists within the thickness of the fascia. Surgical procedure of flap harvesting is described. Harvesting of the flap can be carried out by a posteromedial approach into upper limb, without significant donor-site morbidity. This flap is adapted to cover and reconstruct gliding tendinous surfaces onto hand or fingers.

Temporoparietal fascial free flap for correction of first web space atrophy

Fourteen temporoparietal fascial free flaps were used for correction of first web space atrophy from ulnar nerve palsy in 13 patients. Ten sustained ulnar nerve injuries and three suffered from leprosy. The procedures were performed under general anesthesia except one leprosy patient with bilateral ulnar nerve palsy in which local anesthesia and brachial block were employed to harvest bilateral free flaps and recipient site preparations, respectively. The follow-up time varied from 4 to 64 months. The postoperative results were satisfactory and there was no resorption of the free flaps. The consistency of the augmented first web space was soft and compressible like natural feel. The size of the flap was more than enough for augmentation of first web space and donor site morbidity was minimal and accepted by all patients. We conclude that temporoparietal fascial free flap is an ideal autogenous tissue for correction of first web space atrophy.

Bilateral temporoparietal fascial free flaps for reconstruction of bilateral hand defects: A report of two cases

Bilateral temporoparietal fascial free flaps were used for reconstruction of bilateral hand defects in two male patients. A 42-year-old man sustained crushed injury to both hands with avulsion defects and exposed bones and tendons. The two separate procedures were performed under general anesthesia. The temporoparietal fascial free flap was skin grafted on the ward on the following day after the operation. The other patient was a 61-year-old leprosy patient who had bilateral high ulnar nerve palsy for 28 years. One simultaneous procedure was performed under local anesthesia for harvesting the temporoparietal fascial free flaps and under brachial block for preparation of the recipient sites. The free flaps were used for augmentation of the atrophic first web spaces. The postoperative results of the two cases were satisfactory. The functions of both hands were restored with normal gliding mechanism of the tendons in the first case, and permanent correction of the atrophic web spaces was demonstrated in the second case. The temporoparietal fascial free flap is an ideal flap for coverage of hand defects as well as augmentation of first web space atrophy.

Free radial forearm adiposo-fascial flap for inferior maxillectomy defect reconstruction

A free radial forearm fascial flap has been described for intraoral reconstruction. Adiposo-fascial flap harvesting involves few technical modifications from the conventional radial forearm fascio-cutaneous free flap harvesting. We report a case of inferior maxillectomy defect reconstruction in a 42-year-old male with a free radial forearm adiposo-fascial flap with good aesthetic and functional outcome with minimal primary and donor site morbidity. The technique of raising the flap and closing the donor site needs to be meticulous in order to achieve good cosmetic and functional outcome.

Use of an Expanded Temporoparietal Fascial Flap Technique for Total Auricular Reconstruction

The authors propose an expanded technique of the temporoparietal facial flap of sufficient size to provide complete coverage in a single-stage procedure for the projected three-dimensional autogenous cartilage framework, including the tragus or lobule.A temporoparietal fascial flap measuring 9 x 9 cm was prepared and wrapped around an expander. The expander was gradually infused with saline solution. Approximately 6 months after the first operation, a projected three-dimensional auricular framework was covered by the expanded temporoparietal fascial flap. Nine patients underwent total ear reconstruction using the expanded temporoparietal fascial flap technique. Of these, two cases were anotia, five were failed reconstructed microtia, and two were posttraumatic absence of ear.A final aesthetic assessment of the results was analyzed subjectively. Three cases showed excellent results, four cases showed good results, one case showed a fair result, and one case showed a poor result.This expansion technique is indicated in reconstruction of anotia patients who require longer and wider fascial flaps and in auricular reconstruction patients undergoing microvascular free fascial flap transfer for lessening postoperative vascular obstruction, when microvascular anastomosis is performed on the retroauricular region. The technique is also indicated in salvage auricular reconstruction for patients with an unusual vascular pattern on the temporoparietal fascial flap, or for patients showing a vascular insufficiency of the flap's distal portion after flap elevation.

Degloving Combined with Structural Trauma at the Digital Level: Functional Coverage with Fascial Free Flaps

Major trauma to the digit that includes skin degloving and tendon loss, as well as fractures, nerve segmental loss, and devascularization can render that digit chronically painful, stiff, insensate, and a detriment to the overall function of the hand to the point that such digits may be candidates for ray resection. Large wounds may exceed the ability to achieve coverage by regional pedicle flaps. When the wound is restricted to the level of the digit, the narrow cylindrical shape and the ability to flex and fold make an absolute requirement for a very thin, as well as supple, flap a requirement that cutaneous free flaps cannot meet. This series reports on 12 male patients with major degloving and structural trauma at the digit level in which bone, tendon, and nerve reconstructions were covered with free fascial flaps and immediate split-thickness skin grafts, followed by early rehabilitation. All patients achieved sufficient functional recovery so that subsequent surgeries were not indicated.

Funktionelle und ästhetische Gesichtspunkte bei der Defektdeckung der Streckseite an Hand und distalem Unterarm mit freien Lappenplastiken

Free coverage of exposed functional structures of the hand and distal forearm can be achieved using a variety of free flaps. However, there is a lack of data in the literature which tissue components are best used for defect coverage of this specific area regarding aspects such as tendon gliding and tissue elasticity. The purpose of this retrospective study was to compare and to evaluate the functional and aesthetical results using free cutaneous, fascial and muscle flaps. Between 1994 and 2002, a total of 56 patients underwent free flap coverage at the dorsal side of the hand and forearm at our institution. Of these patients, 20 with 21 free flaps met the study criteria and were available for follow-up examination. Depending on the tissue component used patients were allocated into three different groups. In group 1 eight patients received a fascial flap, in group 2 eight a cutaneous flap and in group 3 five a muscle flap. The mean follow-up was 50 months (range: 4-103 months). At follow-up examination the patients answered the Client Satisfaction Questionnaire (CSQ 8) and the DASH questionnaire. Regarding range of motion of the wrist and fingers, fascial flaps clearly showed the best results. Concerning grip strength and pinch grip, fascial and cutaneous flaps demonstrated the same results. Patients with cutaneous flaps showed the best DASH score. Regarding the overall aesthetical outcome, fascial and cutaneous flaps were far better than muscle flaps. Donor site morbidity was lowest for fascial flaps followed by muscle flaps and was highest for cutaneous flaps. Cutaneous and fascial flaps had the best functional and aesthetical results. Fascial flaps achieved the best aesthetical outcome of the donor site. We recommend free fascial flaps and cutaneous flaps as the first choice due to their advantages in the specific area of the dorsal site of the hand and distal forearm which requires pliable and thin tissue coverage.

Repair of hand soft tissue defects with vascularized fascia lata flap plus free skin flap

目的 总结吻合血管的阔筋膜瓣加游离皮片移植修复手部软组织缺损的临床应用效果.方法 1998年5月～2005年2月修复18例手部软组织缺损,行一期中厚网状游离植皮,供区直接缝合,阔筋膜瓣的血管蒂与受区的血管行端端吻合.结果 术后1例因静脉危象失败,2例发生远端尖部小片植皮坏死,经换药后逐渐愈合.15例患者术后顺利成活,术后获1～6年(平均3.5年)随访,供区愈合良好,受区质地及厚薄均较好,手部功能恢复满意.结论 阔筋膜瓣以旋股外侧动脉降支为血供,血运丰富、血管解剖恒定、血管蒂长及切取容易,其质地及厚薄均适宜修复手部软组织缺损。

Digital Reconstruction Using Free Fascial Flaps for Major Trauma

Digital Reconstruction Using Free Fascial Flaps for Major Trauma

Use of an Expanded Temporoparietal Fascial Flap Technique for Total Auricular Reconstruction

The authors propose an expanded technique of the temporoparietal facial flap of sufficient size to provide complete coverage in a single-stage procedure for the projected three-dimensional autogenous cartilage framework, including the tragus or lobule. A temporoparietal fascial flap measuring 9 x 9 cm was prepared and wrapped around an expander. The expander was gradually infused with saline solution. Approximately 6 months after the first operation, a projected three-dimensional auricular framework was covered by the expanded temporoparietal fascial flap. Nine patients underwent total ear reconstruction using the expanded temporoparietal fascial flap technique. Of these, two cases were anotia, five were failed reconstructed microtia, and two were posttraumatic absence of ear. A final aesthetic assessment of the results was analyzed subjectively. Three cases showed excellent results, four cases showed good results, one case showed a fair result, and one case showed a poor result. This expansion technique is indicated in reconstruction of anotia patients who require longer and wider fascial flaps and in auricular reconstruction patients undergoing microvascular free fascial flap transfer for lessening postoperative vascular obstruction, when microvascular anastomosis is performed on the retroauricular region. The technique is also indicated in salvage auricular reconstruction for patients with an unusual vascular pattern on the temporoparietal fascial flap, or for patients showing a vascular insufficiency of the flap's distal portion after flap elevation.

Radial Artery Fascial Free Flap with Vascular Donor Reconstruction: A Low-Cost, Versatile Reconstructive Choice

Radial Artery Fascial Free Flap with Vascular Donor Reconstruction: A Low-Cost, Versatile Reconstructive Choice

Combined use of a radial fore arm free flap for extra-intracranial bypass and for antero-lateral skull base reconstruction – a new technique and review of literature

This article describes a new surgical technique consisting of the combined use of a fascial radial fore arm free flap (RFFF) as vascular graft for extra-intracranial bypass and as dura mater plasty for reconstruction of the antero-lateral skull base. This new technique is illustrated by a case of a complex intracranial meningioma with extracranial extension necessitating resection of internal carotid artery. The technical issues of antero-lateral skull base reconstruction and extra-intracranial bypass are discussed and the literature is reviewed.

Defektdeckung an der Hand mit dem freien Serratus-Faszien-Lappen

Coverage of exposed functional structures such as tendons, bones, vessels or nerves at the dorsal and palmar surface of the hand requires thin, supple tissue to provide adequate range of motion and a satisfying aesthetic result. Free fascial flaps are possible alternatives to cutaneous, fasciocutaneous and muscle flaps. The purpose of this retrospective study was to evaluate the functional and aesthetic results after coverage of the hand with free serratus fascial flaps in our department. From 1994 to 2002, ten patients underwent free fascial flap coverage of the hand with eleven serratus fascial flaps. Six patients could be re-examined and answered a questionnaire about their satisfaction with the functional and aesthetic results. The mean follow-up was after 34 months. Average active range of motion of the hand, functional improvement and the aesthetic result were satisfying in all follow-up patients. No secondary debulking or other contouring procedures were required. We recommend the use of free serratus fascial flaps as a valuable alternative to fasciocutaneous or muscle flaps since the functional results are excellent; no additional procedures were necessary and the aesthetical results are appealing.

Coverage of soft-tissue defects of the hand with free fascial flaps

Coverage of exposed functional structures such as tendons, bones, vessels, or nerves at the dorsal and palmar surface of the hand requires thin, supple tissue to provide adequate range of motion and a satisfying aesthetic result. The purpose of this retrospective study was to evaluate the functional and aesthetic results after coverage of the hand with free fascial flaps. From 1994-2002, 14 patients underwent free fascial flap coverage of the hand with 4 tempo-parietal fascia flaps and 11 serratus fascia flaps. Eight patients could be reexamined and answered a questionnaire about their satisfaction with the functional and aesthetic results. The mean follow-up was 41.7 months. Average active range of motion of the hand, functional improvement, and the aesthetic result were satisfying in all follow-up patients. No secondary debulking or other contouring procedures were required. We recommend the use of free fascial flaps as a valuable alternative to fasciocutaneous or muscle flaps, since the functional results are excellent, no additional procedures were necessary, and the aesthetic results are appealing.

Epithelialization process of free fascial flaps used in reconstruction of oral cavity mucosa defects in dogs.

Bare free fascial flaps are increasingly used for restoration of soft-tissue defects of the oral cavity because they provide thin, foldable tissues with high epithelialization capacity to preserve local anatomy as well as chewing, phonation, and deglutition. However, there are unanswered questions regarding the epithelialization process and other histopathologic changes occurring after transfer of these flaps into the oral cavity. To investigate these changes thoroughly, an experimental study was conducted in the dog model. Bare dorsal thoracic fascia was used as the free flap model. Ten adult dogs were used in this experiment. Oral mucosa defects measuring 6 x 5 cm were created. Free dorsal thoracic fascia flaps were harvested. The vascular pedicle of the fascia flap was anastomosed with the superior thyroidal artery and external jugular vein. Then, the flaps were transferred into the mucosa defects. The dogs were divided into groups, each composed of two animals. At 7, 14, 21, 30, and 60 days postoperatively, general anesthesia was administered to the groups 1, 2, 3, 4, and 5, respectively. First, clinical assessment was performed; then specimens were obtained. Initially, the flaps were gradually infiltrated by acute inflammatory cells coming from the circulation and then replaced by granulation tissue. Epithelial cells deriving from wound margins migrated onto the granulating flaps with eventual coverage of highly organized epithelium after 4 weeks, and the fascia flap could not be differentiated from the native mucosa. The flaps were replaced by normally maturated fibrous tissue containing regular collagen fibers, instead of atypical scar tissue. Wound contraction was calculated as 18 percent at postoperative day 60. It was detected that bare free fascia flaps used in the repair of mucosa defects act as a scaffold and complete epithelialization from surrounding margins. They can be accepted as the main surgical option for the reconstruction of oral cavity mucosa defects.

Epithelialization Process of Free Fascial Flaps Used in Reconstruction of Oral Cavity Mucosa Defects in Dogs

Boston, Mass. Received for publication October 3, 2003. Julian Pribaz, M.D. Division of Plastic Surgery Brigham and Women’s Hospital 75 Francis Street Boston, Mass. 02115 [email protected]

Management of an acquired tracheoesophageal fistula with a fascial free flap

Failure in the primary repair of a benign acquired tracheoesophageal fistula limits the operative options available at revision. Use of a fascial free flap to treat this condition has not been previously reported. We review the case of a patient who had a tracheoesophageal fistula develop after percutaneous tracheostomy, who had failed previous primary repair with strap muscle interposition. A radial forearm fascial free flap was used at revision and resulted in resolution of the fistula. Use of a fascial free flap to address a persistent acquired tracheoesophageal fistula, when an accompanying stenotic segment is not present, is a viable treatment option.

Prelaminating the fascial radial forearm flap by using tissue-engineered mucosa: improvement of donor and recipient sites.

In reconstructive surgery, prelamination of free flaps using split-thickness skin is an established technique to avoid the creation of a considerable defect at the donor site, for example, in the case of a radial forearm flap. For oral and maxillofacial surgery, this technique is less than optimal for the recipient site because the transferred skin is inadequate to form a lining in the oral cavity. To create mucosa-lined free flaps, prelamination using pieces of split-thickness mucosa has been performed. However, the availability of donor sites for harvesting mucosa is limited. The present study combines a tissue-engineering technique with free flap surgery to create mucosa-lined flaps with the intention of improving the tissue quality at the recipient site and decreasing donor-site morbidity. On five patients undergoing resection of squamous cell carcinoma of the oral cavity, the radial forearm flap was prelaminated with a tissue-engineered mucosa graft to reconstruct intraoral defects. Using 10 x 5 mm biopsies of healthy mucosa, keratinocytes were cultured for 12 days and seeded onto collagen membranes (4.5 x 9 cm). After 3 days, the mucosal keratinocyte collagen membrane was implanted subcutaneously at the left or right lower forearm to prelaminate the fascial radial forearm flap. One week later, resection of the squamous cell carcinoma was performed, and the free fascial radial forearm flap pre- laminated with tissue-engineered mucosa was transplanted into the defect and was microvascularly anastomosed. Resection defects up to a size of 5 x 8 cm were covered. In four patients, the graft healed without complications. In one patient, an abscess developed in the resection cavity without jeopardizing the flap. During the postoperative healing period, the membrane detached and a vulnerable pale-pink, glassy hyperproliferative wound surface was observed. This surface developed into normal-appearing healthy mucosa after 3 to 4 weeks. In the postoperative follow-up period, such functions as mouth opening and closing and speech attested to the success of the tissue-engineering technique for flap prelamination.

Lateral arm fascial flap: microarterial anatomy and potential clinical applications.

Previously, muscle flaps and the omentum have been used to indirectly vascularize tissues. Induction of synangiogenesis, or indirect vascularization through the formation of collateral vessels, occurs through the development of vascular connections at the interface between the donor and recipient tissues. Unfortunately, muscle and omental flaps are bulky and, when used to salvage ischemic hands and digits, may limit digital range of motion. Additionally, disadvantages to using omentum include a requirement for an intraabdominal procedure and a lack of subsequent donor tissue if the contralateral limb becomes involved at a later time. The purpose of this anatomic study was to develop a customized lateral arm fascial flap (LAFF) which may be used for flap prefabrication or synangiogenesis of non-bypassable ischemia. Detailed anatomic dissections were performed to more thoroughly define the microvascular anatomy of the LAFF. Computer analysis of the data was performed to demonstrate the potential clinical application of using the LAFF. Dissections revealed a consistent pattern of vessels branching within the lateral arm fascia and to the neighboring musculature. In order to optimize the surgical use of available tissue, computer-aided design techniques were used to model a reliable fascial free flap for inducing synangiogenesis while imparting minimal donor-site morbidity. Anatomic studies of the LAFF revealed pitfalls in flap dissection, while computer-generated models illustrated the detailed microarterial anatomy of the LAFF and potential limitations in flap design. Potential clinical applications for use of this low-profile fasciovascular conduit are noted.

PRIMARY RECONSTRUCTION OF A DEGLOVED MIDDLE FINGER WITH A TEMPOROPARIETAL FREE FLAP

The treatment of complete ring avulsion injuries is very demanding, and frequently the results are less than optimal. We present a case of a degloved middle finger reconstructed with a temporoparietal fascial free flap and skin grafting. This produced an aesthetic and functional finger.