Local Fasciocutaneous Flaps Research Articles

Versatility of Local Fasciocutaneous Flaps for Coverage of Soft Tissue Defects in Upper Extremity

Appropriate soft tissue coverage is of paramount importance for coverage of bone, joint, tendons, neurovascular structures, and hardware in upper extremity. In this article we have tried to renew the importance and simplicity of using the local fasciocutaneus flaps for coverage of shoulder, elbow and hand joints with showing the techniques in three examples. During a 5year period,from 2004 to 2009, we have been treating soft tissue defects of the upper extremity over joints and hardware with local fasciocutaneous flaps. During this time we had 50 cases of exposed hardware, 20 over shoulder joint and 30 over olecranon. Also, we had 100 cases of exposed joints,30 over shoulder, 45 over olecranon 10 over wrist and 15 over finger joints. The etiology of exposed joints were 60 cases from burn, 10 from bursitis, 20 from traumatic injuries and the rest from other injuries such as animal bites.In this article we present 3 cases with the technique of operations and their associated figures: one exposed hardware at the shoulder treated by a distally based local fasciocutaneous flap,one exposed elbow joint due to flame burn treated by antecubital flap and the third case exposed bone and joint in the fifth and an example of fourth fingers treated by local fasciocutaneous flap from the same fingers. In these 150 cases we had 6 cases of superficial necrosis of the flaps which healed with supportive therapy. There was no cases of complete necrosis. 27 patients underwent revision of the dog-ear and were completely satisfied with the result. we present our experience of 150 case to prove that local fasciocutaneous flaps are versatile and can be used with good results if properly planned.

A prospective randomized cost billing comparison of local fasciocutaneous perforator versus free Gracilis flap reconstruction for lower limb in a developing economy

Distal half leg complex wounds are usually a formidable problem that necessitates either local or free flap coverage. The aim of this study was to compare cost billing charges in free Gracilis flap (fGF) and local fasciocutaneous perforator flap (lFPF) in reconstructing complex soft tissue leg and foot defects. Thirty consecutive adult (>15-year-old) patients with soft tissue defects in the leg and/or foot requiring tissue coverage with a flap in the period between 2012 and 2015 were randomly assigned (block randomization) to either an fGF or lFPF procedure. The outcome measures addressed were total billed charges costs, perioperative billed charges cost, partial or complete flap loss, length of hospital stay, inpatient postsurgical care duration, complications, operating time and number of operative scrub staff. One patient suffered from complete flap loss in each group. Reconstruction with lFPF showed total lower billed charges costs by 62% (2509 USD) (p<0.001) and perioperative billed charges cost by 54% (779 USD) (p<0.001), and shorter total hospital stay (36.5 days; p<0.001), inpatient postsurgical care duration (6.4 days; p<0.001), operating time (4.3h; p<0.001) and fewer scrub staff (2.2 persons; p<0.001). These results suggest that neither flap is totally superior to the other; the choice should instead be based on the outcome sought and logistics. lFPF requires lower billed charges cost and resource use and saves operative time and personnel and reduces length of hospital stay. Our approach changed towards using perforator flaps in medium-sized defects, keeping the free flap option for larger defects.

Profunda artery perforator flap for isolated vulvar defect reconstruction after oncological resection.

Isolated vulvar reconstruction using profunda artery-based perforator flaps have good functional as well as quality of life restoration. Surgical techniques, complications, and final evaluation using questionnaires are presented. Vulvar reconstruction remains a great challenge to reconstructive surgeons. A local fasciocutaneous flap from the medial thigh is a good option with multiple choices of the donor arteries. Here, we extended the clinical application of a profunda perforator artery (PAP) flap with the design of an island pedicle flap. From 2012 to 2015, 12 female patients with vulvar cancer received tumor ablation and immediate reconstruction using a PAP flap. The flaps (n = 19) were divided into V-Y advancement perforator flap (group I, n = 4) and island pedicle perforator flap (group II, n = 15). All of the demographic data were collected and analyzed. All of the flaps were transferred successfully, and all of the donor sites were closed without morbidities. Group II was superior to group I because of the smaller required flap size (P = 0.004), the smaller defect size/flap size ratio (P = 0.001), and a lower rate of post-op debridement (P = 0.037). The other parameters were not statistically significant. PAP flap is a good choice for vulvar reconstruction. We preferred an island pedicle setting for its thin and pliable fasciocutaneous component and robust flap circulation. The favorable functional and aesthetic results can be achieved with limited donor site morbidities. J. Surg. Oncol. 2016;113:828-834. © 2016 Wiley Periodicals, Inc.

Reconstruction of Large Acquired Scalp Defects: Ten-Year Experience.

The method of choice for reconstruction of large acquired scalp defects depends on numerous factors. The aim of our study was to analyze reconstructions of large acquired scalp defects performed on 135 patients in the period of 10 years. We have monitored the factors with an impact on the reconstruction method, complications, and the achieved results. Skin grafts, local, regional and free flaps, have been applied for reconstruction of defects. The depth, size, defect localization, condition of surrounding tissue, co-morbidities and causes of occurrence of defect have an impact on the method of choice for defect reconstruction. Acquired scalp defects are the most frequent in the older population and, in most cases, occur upon the surgical removal of malignant tumors. Local fasciocutaneous flaps are the method of choice for small and acquired scalp defects of medium size while free flaps are the best solution for reconstruction of the large full-thickness scalp defects. Frequency of severe complications is significantly higher in the patients who undergo craniotomy, or those with liquorrhea.

Overview of Local Flaps of the Face for Reconstruction of Cutaneous Malignancies: Single Institutional Experience of Seventy Cases.

Context:The most common malignant tumours of the face are basal cell carcinoma, squamous cell carcinoma and melanoma. While the results of skin graft are less than satisfactory for large areas to cover, distant flaps are bulky with a poor colour match. Local fasciocutaneous flaps provide reasonable option for reconstruction of facial defects with good colour and texture match and good success rate.Aims:This study aimed to analyse the various modalities of reconstruction after resection of facial malignancies and their advantages and disadvantages.Settings and Design:This was a retrospective study.Materials and Methods:Of 70 patients, 34 were managed with V-Y advancement flap, 24 with nasolabial flap, 8 with median forehead flap and 4 with standard forehead flap cover. The duration of follow-up ranged from 6 months to 2 years.Statistical Analysis Used:Nil.Results:Of 34 V-Y advancement flaps, 2 showed suture dehiscence at the apex of triangle which was allowed to heal secondarily with regular dressings. All the 24 nasolabial flaps were healthy without any complication. All patients had satisfactory functional and cosmetic outcomes.Conclusions:In our experience, local flaps give the best results and are the first choice for reconstruction of the face. Most defects can be best closed by nasolabial, V-Y advancement and forehead flap. Outstanding functional and cosmetic results can be achieved. Proper execution requires considerable technical skill and experience.

The Role of Muscle Flaps for Salvage of Failed Perforator Free Flaps.

Background:Despite the most heroic efforts, sometimes free flaps fail. Perforator free flaps are not invincible and can suffer the same fate. The real challenge is how to decide what is the next best choice for achieving the desired outcome.Methods:Over the past decade, 298 free perforator flaps were used in our institution. Total failure occurred in 16 patients, and partial failure requiring a second free flap occurred in an additional 6 patients for a true success rate of 93%. All failures had some form of secondary vascularized tissue transfer, which included the use of muscle flaps in 9 (41%) different patients.Results:Initial flap salvage after a failed perforator free flap was attempted with 12 perforator and 5 muscle free flaps as well as 1 perforator and 2 muscle local flaps. These were not all successful, with loss of 3 muscle free flaps and 3 perforator flaps. Tertiary free flap coverage was successful in 3 cases using 2 muscle flaps and 1 perforator free flap. Local fasciocutaneous flaps or primary wound closure was used in the remaining individuals.Conclusions:Microsurgical tissue transfers can be the most rewarding and at the same time the most challenging reconstructive endeavor. Persistence in achieving the desired outcome can require multiple steps. Perforator flaps are an important asset to obtain this goal. However, muscle flaps can still be a useful alternative, and the message is that they should not be overlooked as sometimes a viable option.

Fasciocutaneous Flap Reconstruction after Repair of Meningomyelocele: Technique and Outcome

Aims: The objectives of this study are to describe our technique in meningomyelocele (MMC) repair, analyzing the results and complications, as well as to study the effect of delay in operation on the complication rate. Patients and Methods: Between March 1997 and October 2012, 48 patients with MMC were treated at Jordan University Hospital by a combined neurosurgical and plastic surgical team. Patients underwent neurosurgical repair of the neural elements and soft tissue reconstruction using local fasciocutaneous flaps. The patients were further divided into two subgroups (local or referrals from other hospitals). Results: Of all patients, 8 (16.6%) had postoperative complications. When the complication rate was compared between the two groups, in the first group, who had early repair, only 2 out of 19 patients had complications (10.5%), while in the second group, with delayed operation, 6 out of 29 patients developed complications (20.7%). The follow-up of all patients showed that the soft tissue cover maintained good durability with no skin breakdown. Conclusion: We recommend early MMC repair using this rather simple method to provide a reliable soft tissue coverage. A combined approach by a neurosurgical and plastic surgical team in the management of this challenging neonatal emergency is appreciated.

Reverse vastus lateralis musculocutaneous flap for Marjolin's ulcer over the knee joint

Marjolin's ulcer is a rare and often aggressive cutaneous malignancy that arises in previously traumatized or chronically inflamed skin, particularly after burns. Treatment modalities of Marjolin's ulcers include wide local excision, block dissection of the regional nodes, amputation in advanced lesions of limbs, radiotherapy, and chemotherapy. Wide local excision, together with skin grafting, is usually considered appropriate in the treatment of Marjolin's ulcers. For lesions that are located at critical places skin grafting cannot be done because either the excised bed will not take the graft or skin grafting can be done but due to the unstable nature is often avoided preferring a flap cover. Defects over the knee is challenging especially when the defect is quiet large and the surrounding skin is scarred and unhealthy. In such situations neither any local fasciocutaneous flap nor muscle flap is possible, the only option left are in the form of free tissue transfer. But if this type of situation can be managed by transferring tissue from the upper part of the thigh in the form of pedicled flap then other complex reconstructions can be avoided. We describe a case of a 45-year-old male with Marjolin's ulcer over the post burn scar of right knee for 5 years duration with no regional or distant metastasis managed with wide local excision and cover with reverse vastus lateralis musculocutaneous flap. The post op outcome is uneventful with better patient satisfaction.

Reconstrucción de defectos amplios en tronco mediante colgajo de perforante en piedra clave

The Keystone Perforator Island Flap (KPIF) is a local fasciocutaneous islanded flap, first published in 2003 by Behan, that does not require identification o...

Distally based posterior tibial artery perforator flap for coverage of defects around the ankle, heel and lower third of leg

Introduction Reconstruction of distal leg region remained a difficult task. Free flaps had long been considered as a gold standard for these regions. However, due to various limitations of the free flap, a local fasciocutaneous flap could be considered as a good alternative. In this study, the use of a distally based posterior tibial artery perforator flap had been evaluated in the coverage of defects around the ankle, heel, and lower third of a leg. The study also outlined the donor-site morbidity and the technical details of the surgical procedure.

Complex Heel Reconstruction with a Sural Fasciomyocutaneous Perforator Flap

Reconstruction of weight-bearing surfaces at the foot and ankle is controversial. Free tissue transfer and local fasciocutaneous perforator flaps are preferred for plantar reconstruction, but high rates of flap breakdown and ulceration have caused unsatisfactory functional outcomes. We present a modified "sural fasciomyocutaneous perforator flap" and its functional outcome. Between January 2007 and September 2010, 19 patients were treated for soft-tissue defects in the weight-bearing area with sural fasciomyocutaneous perforator flaps. The gastrocnemius, preserved in the base of the flap, was applied as padding under the calcaneus. In follow-up from 9 to 25 months (mean 13.8 months), each patient's pain score, defect size, ulcer formation, protective sensation recovery, and normal footwear were analyzed. The majority of the flaps survived with satisfactory aesthetic and functional results. One case of partial flap loss and one case of delayed ulceration were noted. With partial weight bearing at 4 weeks, satisfactory gait recovery was obtained at 5 to 8 months (in conjunction with protective sensation recovery). Sural fasciomyocutaneous perforator flap is a reliable modality in heel construction, showing advantages of low ulceration rate, durability, and good protective sensation recovery compared with conventional free tissue transfer and local fasciocutaneous perforator flap.

Perforator Plus Fasciocutaneous Flaps in the Reconstruction of Post-Burn Flexion Contractures of the Knee Joint

A post-burn flexion contracture of the knee joint is a disabling condition which interferes with an upright posture and a bipedal locomotion. Islanded perforator flaps have been used to resurface the tissue defect which is produced as a result of the contracture release. Despite their various advantages, they are limited by an increased tendency to undergo venous congestion. Perforator-plus flaps can be used to overcome this limitation, while retaining the merits of the islanded perforator flaps. Ninteen patients with post flame burn flexion contractures of the knee joints underwent surgical releases and coverages by various local fasciocutaneous perforator-plus flaps. The patients were followed up for 6 months and the various aspects of the functional and the aesthetic rehabilitations were assessed. All the local fasciocutaneous perforator-plus flaps resurfaced the tissue defect over popliteal fossa with good colour and texture match and maintenance of the contour. None of the flaps had any significant early or delayed complications (which included venous congestions) which necessitated reoperations. All the patients were satisfied with the functional and aesthetic outcomes. Local fasciocutaneous perforator-plus flaps can be considered as one of the primary treatment modalities for the surgical release and reconstruction of post burn flexion contractures of the knee.

Reconstruction of massive localised lymphoedema of the scrotum with a novel fasciocutaneous flap: A rare case presentation and a review of the literature

Massive localised lymphoedema (MLL) is a benign lymphoproliferative soft-tissue overgrowth in the morbidly obese patient. The diagnosis may be challenging, and is a form of secondary lymphoedema, often described as idiopathic scrotal elephantiasis. The lesion presents as a large mass in the morbidly obese, and patients seek treatment late in the disease course due to limitation of daily living or excoriation and wound breakdown. Resection, followed by reconstruction, is indicated in these cases. We present a unique case of a morbidly obese 52-year-old male with massive enlargement of the scrotum present for several years duration, despite massive weight loss (88.85kg) from gastric bypass surgery and no other identifiable cause of lymphoedema. Scrotal lymphoedematous tissue was resected and scrotal reconstruction with a novel posterior fasciocutaneous flap from the scrotum was performed in addition to penile reconstruction with a skin graft and local fasciocutaneous flaps as well as a panniculectomy. Histologically, the tissue was characterised by marked oedema with dermal fibrosis and patchy mild perivascular chronic inflammation. Postoperative follow-up revealed wound integrity and patient satisfaction with the outcome. MLL is an important disease process with distinct clinical and histopathologic characteristics that often requires complex reconstruction. Although there are several opposing classification schema, we propose the incorporation of idiopathic scrotal elephantiasis into the diagnostic category of MLL.

Successful salvage of exposed breast implants in previously irradiated patients using local fasciocutaneous flaps

Radiotherapy is used commonly in the treatment of breast cancer but can damage the surrounding tissues. For patients who have had implant-based breast reconstruction, this may result in tissue breakdown with exposure of the prosthesis. We present two cases in which an implant has become exposed following radiation therapy and been successfully salvaged with local fasciocutaneous flaps. The patients were aged 50 and 59 and had excellent results after at least 24-months follow-up. We aim to show that in selected patients local flaps remain a useful option in implant salvage in the irradiated breast. Level of Evidence: Level V, therapeutic study.

Postablative reconstruction of vulvar defects with local fasciocutaneous flaps and superficial fascial system repair

Postablative reconstruction of vulvar defects is a difficult challenge because of the functional, locational and cosmetic importance of this region. Local flaps carry a high incidence of delayed wound healing as local flaps may redistribute but not eliminate local wound tension. Repair of the superficial fascial system may avert local complications by minimising tension to the skin and increasing the initial biomechanical strength of wound. The aim of this study was to determine the clinical outcome of local fasciocutaneous flaps used for postablative reconstruction of vulvar defects in which the superficial fascial system was repaired. A retrospective analysis was conducted of patients with vulvar carcinoma in situ or vulvar carcinoma, who underwent ablation and immediate reconstruction with local fasciocutaneous flaps and superficial fascial system repair. Postoperative complications were recorded and clinical outcomes were evaluated. Twelve of the 13 flaps healed primarily. Complications included 2 superficial wound infections, both of which were treated successfully with antibiotic therapy. One flap was complicated by minor wound dehiscence, which healed with conservative treatment. Local fasciocutaneous flaps with superficial fascial system repair provide excellent design flexibility and can be designed and tailored to reconstruct postablative vulvar defects with good outcomes and minimal morbidity.

Human Acellular Dermal Matrix for Pelvic Floor Reconstruction after Cylindrical Abdominoperineal Resection

An alternative treatment for low rectal cancer is the extended posterior perineal approach with reconstruction of the pelvic floor (cylindrical technique). Pelvic floor defects often require flap reconstruction using gracilis flaps, vertical rectus abdominis myocutaneous flaps or local fasciocutaneous flap. In this article, the complicated pelvic floor defect was reconstructed with human acellular dermal matrix. Despite a large resection and previous irradiation therapy, the wound healed without complications.

Skin Perforator Flaps: An Algorithm for Leg Reconstruction

The local fasciocutaneous flap has the advantage of low donor site morbidity when used for the coverage of lower limb defects. However, flap reliability remains a major problem with its use. Perforator flaps are indicated for several clinical problems. The versatility of the perforator flap makes it ideal for the reconstruction of extremities. Between September 2007 and November 2010, 34 skin perforator flaps were raised in 33 cases. Flaps which were executed as peroneal artery flaps were 13, 0.16 flaps were raised as posterior tibial artery perforator flaps, and 5 flaps as medial sural medial gastrocnemius muscle perforator skin flap. A segmental perforator was dissected and retained. Thirty-two flaps survived completely and none exhibited venous compromise. In one patient, flap was lost completely and the other showed partial tip necrosis. Complicated flaps were responded to conservative treatment. Skin perforator flap represents a technical advancement over conventional lower limb skin flaps because of its improved vascularity. It provides the surgeon with additional reconstructive options in reconstruction of difficult areas and injuries of leg. Clinical judgment is essential to assess the potential vascular territory of the flap.

Le Lambeau perforant en hélice pour la couverture cutanée du genou

Previous pedicled techniques for coverage of the knee use muscular flaps and/or local fascio-cutaneous flaps limited to rotate until 90° on their cutaneous base. Freestyle perforator flaps match the patient's anatomy to fill a defect. Propeller perforator flaps have been used to treat three patients presenting with a skin loss over the knee. The surgery is based on the Echo-Doppler tracing the good perforator vessels around the wound. We performed two supero-medial flaps with a self-closing donor site and one supero-lateral flap where a graft was needed. All the patients healed in less than six weeks, with satisfying functional and esthetical results. We think freestyle perforator flaps are a reliable and predictable technique with a low morbidity rate and they are well adapted to cover skin defects over the knee.

Plastic intervention of fingers reconstructed by toe transfer

Objective To explore the methods of correcting malformation of reconstructed fingers in toe-to-hand transfer. Methods In a series of 77 reconstructed fingers in 65 cases of second toe-to-hand transfer since 2002,deformities of finger pulp,shaft or fingernail were present. Plastic interventions included inserting local fasciocutaneous flap and adjusting the bone and tendon of the reconstructed fingers with microsurgical techniques. Results The deformities were corrected and outward appearance was improved. Function of the fingers was improved while the sensation was not compromised. Conclusion Plastic intervention using microsurgical techniques to correct malformation of finger pulp,body and fingernail can improve the appearance and function of reconstructed fingers. Key words: Transplantation; Toes; Surgery,plastic

Perineoscrotal reconstruction using a medial circumflex femoral artery perforator flap

Major scrotal defects may result from infection due to Fournier's gangrene, excision of scrotal skin diseases, traumatic avulsion of scrotal and penile skin, and genital burns. The wide spectrum of bacterial flora of the perineum, difficulty in providing immobilisation, and obtaining a natural contour of the testes make testicular cover very difficult. Various methods have been reported to cover the penoscrotal area, including skin grafting, transposing them to medial thigh skin, and use of local fasciocutaneous or musculocutaneous flaps. In this report, reconstruction using six local medial circumflex femoral artery perforator (MCFAP) flaps was undertaken in five male patients (mean age, 47 years) with complex penoscrotal or perineal wounds. The cause of the wounds in four patients was Fournier's gangrene, and was a wide papillomateous lesion in the other patient. Flap width was 6-10 cm and flap length was 10-18 cm. The results showed that a MCFAP flap provided the testes with a pliable local flap without being bulky and also protected the testicle without increasing the temperature. The other advantage of the MCFAP flap was that the donor-site scar could be concealed in the gluteal crease. Our results demonstrated that the MCFAP flap is an ideal local flap for covering penoscrotal defects.