Cutaneous and fascial vasculature of the leg: anatomic study of fasciocutaneous vessels

In order to understand the fasciocutaneous circulation of the leg more clearly, the vasculature of the skin and deep fascia was investigated. We mapped the vascular plexus of the deep fascia and found that the vessels and fascial plexus have their own axes. The vasculature of the deep fascia was categorized into six types. This classification should help in the planning of various fasciocutaneous flaps of the leg.     

Angiographic evaluation of fasciocutaneous flaps

Extensive studies have been carried out to understand the vascular anatomy of fasciocutaneous flaps both in human cadavers and in experimental models. Seldom has angiographic study been undertaken in clinical cases. Before peroperative clinical angiography, microangiographic study was performed on rabbits to understand the vascular supply of the skin and deep fascia. Major vascular dominance could be seen in the deep fascia compared with the skin. Thereafter, peroperative angiography was carried out to visualize the vascular network of fasciocutaneous flaps. The study was conducted in 10 patients who required antegrade fasciocutaneous flap for exposed upper two thirds of the tibia. It showed longitudinally oriented rich vascular network in the flap. This study provided peroperative objective assessment of the nature of vascularity and an explanation for the viability of fasciocutaneous flaps of nonconventional dimensions. The procedure did not have any detrimental effect on the physiology of the flap.     

皮神经营养血管组织瓣的临床应用原则与命名

目的 探讨皮神经营养血管组织瓣的临床应用原则，并提出新的命名方法。方法 总结皮神经营养血管组织瓣的解剖研究和临床经验。结果 皮神经多与皮静脉伴行，在其周围均存在丰富的链式吻合血管丛，显著增加了这类组织瓣的血供。临床以远端(31例)或近端(3例)为蒂，在前臂(26例)和小腿(8例)切取带皮神经和皮静脉营养血管的岛状筋膜皮瓣(20例)和筋膜皮下组织瓣(14例)共34例，长宽比例2．7～5．1：1，平均3．5：1，完全成活。结论 带皮神经营养血管的组织瓣是传统筋膜皮瓣和筋膜皮下组织瓣的特殊范例，临床应用应遵循一定的原则。     

The lower posterolateral thigh flap

The vascular basis of a new distally based flap in the distal third of the posterolateral thigh has been studied in 30 cadaver limbs. This flap is supplied mainly by direct cutaneous branches of the popliteal artery and of the lateral superior genicular artery. Its use as a distally based fasciocutaneous flap for defects of the knee is illustrated and its potential as a free flap is discussed. A classification of various flaps from the posterolateral region of the thigh is also proposed. In the light of the anatomical studies, the cutaneous blood supply of the distal posterolateral region and other regions of the thigh is reviewed.     

四肢筋膜蒂皮瓣改良手术的临床应用

目的对四肢筋膜蒂皮瓣手术方法进行改良及总结,进一步提高疗效。方法1999年2月～2005年12月,应用筋膜蒂皮瓣修复四肢皮肤、软组织缺损58例。男39例,女19例;年龄10～68岁,平均30岁。21例小腿中下段胫前皮肤缺损,12例足跟部皮肤缺损,16例踝关节皮肤缺损,3例膝关节周围皮肤缺损,1例骶尾部巨大褥疮,5例手腕背部皮肤缺损。创面范围5cm×3cm～18cm×12cm。根据创面不同采取四肢不同部位筋膜蒂皮瓣修复创面,其中4例前臂内侧皮神经、贵要静脉筋膜蒂皮瓣,1例前臂外侧皮神经、头静脉筋膜蒂皮瓣,3例顺行带隐神经、大隐静脉的筋膜蒂皮瓣,1例左大腿股后皮神经筋膜蒂皮瓣,32例带腓肠神经、小隐静脉逆行筋膜蒂皮瓣,17例带隐神经、大隐静脉筋膜蒂皮瓣。皮瓣范围6cm×4cm～18cm×13cm。供区创面39例直接缝合,19例取大腿或下腹部全厚皮片6cm×3cm～13cm×6cm植皮修复。结果术后16例皮瓣肿胀、淤血,经远端小切口切开放血3～5d,其中12例皮瓣成活,创面期愈合;4例远端皮缘部分坏死,经再次手术清创植皮后成活。余患者皮瓣均成活,创面期愈合。供区创面期愈合,植皮成活。58例患者均获随访1～20个月,平均8个月。皮瓣色泽正常,质地柔软,外形和功能满意。结论四肢筋膜蒂皮瓣是修复四肢皮肤、软组织缺损的理想治疗方法,通过手术方法的改良,可使皮瓣成活率进一步提高。     

The viability of skin flaps.

The historical development of skin flaps is outlined, and in particular their division into two types: random, which are supplied by small musculocutaneous vessels; and axial flaps, which are supplied by named cutaneous vessels running within the flap. Experiments are described into the viability of random skin flaps, using the pig as an experimental model. These experiments confirm that random flaps should not be designed longer than their base and probably should not exceed 12.5 cm (5 in) in length.     

Structure and construction: the system of skin flaps.

Studies done on the skin's blood circulation have also resulted in the development of new, more complex flaps. This complexity has made a standardized classification of flaps no longer possible. As a result of this, we have tried to analyze the inner system of flaps. This analysis has made a connection between the construction and the vascular structure of the flaps evident. Based on the fundamental construction and basic vascular structure, we are able to divide the flaps into three elementary types. All the complex flaps are composed of these three elementary types. This composition takes place in the form of a parallel connection or in the form of a sequential connection of the elementary types or both. To ensure the adequate blood supply of a flap, it is necessary to maintain the continuity of the elementary vascular patterns.     

Augmentation of experimental skin flap survival via postoperative phosphocreatine replacement

Despite improvements in our understanding of cutaneous vascular territories, clinical skin flap necrosis resulting from ischemic compromise is still a reality. Therapy with vasodilators has been generally unsuccessful, but replacement of high-energy phosphometabolites through the use of ATP-MgCl2 and fructose 1,6-diphosphate has been effective. Recently we reported that phosphocreatine is the major high-energy phosphometabolite in mammalian skin and that ATP levels and cellular well-being in skin flaps are dependent on adequate supply of this phosphometabolite. We report herein the successful augmentation of survival of ischemically compromised skin flaps through postoperative phosphocreatine infusion. This metabolite effectively circumvents the nonfunctioning mitochondrial creatine-phosphocreatine energy shuttle without disturbing the delicate [ATP]/[ADP] balance in the cytosol. In addition, phosphocreatine may favorably redistribute blood flow from muscle to the ischemically compromised skin.     

臂后侧筋膜皮瓣在腋臭术后并发腋部皮肤缺损修复中的应用

目的：探讨应用臂后侧筋膜皮瓣修复腋臭术后并发腋部皮肤缺损的临床疗效。方法：以臂后筋膜皮动脉为血管蒂,设计臂后侧筋膜皮瓣,皮瓣面积略大于缺损面积,皮瓣经隧道转移至受区,皮瓣供区直接缝合。结果：本组16例患者,腋部皮肤缺损面积为3.5 cm×4.0cm～6.0 cm×7.0cm,均获得了Ⅰ期修复,术后随访3～6个月,皮瓣全部成活,修复后缺损部位功能和外形良好。结论：臂后侧筋膜皮瓣具有良好的血运,且血管解剖结构恒定,是一种修复腋部皮肤缺损的可行方法。     

THE FASCIOCUTANEOUS ISLAND FLAP: AN EXTENSION OF THE ANGIOTOME CONCEPT

The concept of the fasciocutaneous island flap (FCIF) has been established as a result of clinical experience in which over 180 cases have been compiled. It is a reconstructive design principle based on vascular and neural anatomy. Even though the flap pattern varies from region to region, it is the trilaminate composition of skin, fat and fascia supplied by fasciocutaneous, musculocutaneous and septocutaneous vessels, which is the basis for its success. Sometimes regional variations in this arrangement occur, for example: there is no deep fascia evident in the trigeminal nerve (CN-V); and in the hand and the foot, the local vascular anatomy still supports this island flap idea without any defined fascial lining. Following their use in the head and neck region, and as more successful ones were designed, the flaps seemed to follow the circumferential layout on the trunk and the longitudinal distribution in the limbs, similar to the dermatomal markouts. Such dermatomal charts thus became the basis of unexplored flap potentials with or without axial vessels. In the past, the clinical word ‘angiotome’ (which means a vascularized segment) has been used in world literature to describe flap vasculature with axial input. Thus flaps with a fasciocutaneous basis may well be described as a fasciocutaneous angiotome.     

Application of fasciocutaneous Z-plasty on old burn contractures

Summary It is almost impossible to achieve good results by the use of conventional Z-plasties on old burn contractures since necrosis of the transposed flap can occur. We have tried to raise the Z-plasty flaps as fasciocutaneous flaps to find out whether better results can be achieved. One hundred sixteen Z-plasties have been carried out on old burn contractures in 32 cases since 1985. Sixty-four of these Z-plasties were fasciocutaneous and results of the cutaneous and fasciocutaneous Z-plasty group were compared. These were successful in 53.8% and 81.2% respectively, indicating the superiority of the latter group. These results indicate that the ratio of flap necrosis was statistically diminished by the application of this technique. This technique could be used safely in such poorly nourished skin areas.Presented at the First Hellenic-Turkish Joint Meeting, for Plastic and Reconstructive Surgery, Athens, Greece, September 22-24, 1988     

A dye study in fresh cadavers to outline retrograde flaps of the lower limbs and to examine clinical implications

The reconstruction of distal lower limb defects to meet functional and cosmetic requirements is challenging. The aim of this study was to ascertain the safe hemodynamic territory of various retrograde flaps that are frequently used. We carried out a dye study on both lower limbs of ten fresh cadavers using methylene blue to assess the safe limit of retrograde flaps of different types (i.e., fasciocutaneous flap, adipofascial flap, and fasciocutaneous flap with adipofascial extension) based on the two lower perforators of the posterior tibial artery. The dye penetrated the vascular network up to 20 cm in the fasciocutaneous flaps from a point 8 cm proximal to the tip of the medial malleolus. The extent of the dye was 40 and 20% less in adipofascial flaps and fasciocutaneous flaps with adipofascial extension, respectively, compared to fasciocutaneous flaps. In live subjects, the safe territory is expected to be about 2 cm more in each flap, based on our clinical observations. These findings are of significance since such flaps can be safely selected for various defects depending on their location, their dimensions, and the availability of suitable local tissues.     

Coverage of widely separate defects of the lower extremity: application of cluster analysis.

A patient with lower extremity reconstruction is presented with a radial forearm free flap designed using the cluster analysis method of cutaneous perforators. The cutaneous vascular anatomy of fasciocutaneous flaps is discussed as well as the application of the mathematical model of analysis of the vascular territories within specific flaps to assist in "custom" flap design. The ultimate goal of this technique is the creation of flaps that provide a more precise and anatomical reconstruction of the proposed defect.     

ISLAND FLAPS INCLUDING THE BEZIER TYPE IN THE TREATMENT OF MALIGNANT MELANOMA

Despite the trend in current surgical practice in the treatment of melanoma to produce smaller excisional defects, any technique which can introduce a surgical closure that does not require split skin grafting must be of benefit. This paper introduces and illustrates a range of island flap techniques that employ no skin grafting for the treatment of malignant melanoma defects. The new cutaneous island flap described, termed the Bezier or the French Curve, employs a double V-Y appositional closure method, thus giving a more refined reconstructive result that fits into the line of the body curves aesthetically. The design of the Bezier flap is almost identical in size and shape to the excisional defect, with a fascial or muscular base for vascular support. Appropriate guidelines that determine the design and application of this island flap technique are listed. They are illustrated both diagrammatically and clinically. Other flaps illustrated include fasciocutaneous island flaps and myocutaneous island flaps that use a single V-Y flap appositional closure technique. All these flaps were designed with special reference to the derma-tomes, which act as an aid memoire upon which the flaps are marked.     

腓肠神经营养血管皮瓣修复膝至足踝部创面

目的探讨腓肠神经营养血管皮瓣移植修复膝至足踝部创面的临床特点和效果。方法2006年1月-2012年6月,对49例膝部、小腿、足踝部皮肤缺损患者采用腓肠神经血管皮瓣移植修复。结果本组49例50块皮瓣全部成活45块．2例出现边缘性部分坏死,3例皮瓣坏死,成功率90％。成活皮瓣色泽、质地及外形良好,术后经1-2年随访,供区功能无明显影响。结论应用腓肠神经营养血管皮瓣移植修复皮肤缺损是一种理想的方法。适应证的选择、手术具体操作方法以及对合并症或并发症的正确处理是成功的关键。     

Soft tissue coverage of the elbow: a reconstructive algorithm

Soft tissue defects can occur for various reasons, but they are primarily due to trauma, tumor, and infection. Coverage choices may include primary closure, skin grafting, local cutaneous flaps, fasciocutaneous transposition flaps, island fascial or fasciocutaneous flaps, muscle or myocutaneous pedicled flaps, and microvascular free-tissue transfer. Despite the multitude of options for coverage, the authors have found four flaps to provide reliable coverage for most elbow deficits within their practice; these flaps are the latissimus dorsi flap, the radial forearm flap, the anconeus flap, and the free anterior lateral thigh flap. This article provides an overview of treatment options for elbow coverage, with specific emphasis on the use of these four specific flaps.     

Utility of the sural fasciocutaneous flap for the treatment of chronic osteomyelitis of the distal tibia

Treatment of chronic osteomyelitis of distal tibia is complex. It often requires the association of antibiotic therapy and a surgical procedure. This consists of exhaustive debridement of infected bone and soft tissue which must have adequate cutaneous coverage and vascular supply which enables creating a barrier to microorganisms and greater resistance to infection. Free or pedicled muscular flaps have been the techniques most often used for this type of lesions. Free flaps require a precise microsurgical technique and prolonged surgery. Pedicled muscular flaps do not provide sufficient coverage and vascularisation of the distal tibia for large size defects. The fasciocutaneous flap has been used for the treatment of coverage defects in the perimalleolar area and the heel. We report the utility of this flap as management of chronic osteomyelitis of the distal third of the tibia with complete healing of the infection and correct cutaneous coverage without complications.     

Lower-Extremity Local Flaps

Some soft-tissue defects of the lower extremities can be covered reliably with local flaps. Five such flaps--the tensor fascia lata, gastrocnemius, soleus, posterior tibial artery fasciocutaneous, and dorsalis pedis flaps--are described. If the indications for each flap are understood and the vascular pedicle is carefully preserved, these flaps can be used to provide relatively simple and reliable coverage of selected soft-tissue defects on the lower extremities. However, the indications must not be overextended in an attempt to avoid a free-tissue transfer. The gastrocnemius flap is most often used. It reliably covers common defects about the knee and the proximal tibia. A skin graft is required for the gastrocnemius flap, as well as the soleus flap, which covers the midportion of the tibia. The soleus requires deeper dissection of the calf for elevation. The tensor fascia lata flap and the more recently described posterior tibial artery fasciocutaneous flap are relatively easy to raise, but there are fewer orthopaedic indications for their use. The dorsalis pedis cutaneous flap is technically more demanding, but it can be used to cover difficult defects around the ankle.     

Analysis of cutaneous perfusion: an aid to lower extremity reconstruction

The use of cutaneous and musculocutaneous flaps has been greatly enhanced by a better understanding of vascular anatomy. Cutaneous vessels reach the skin by three basic pathways: over the muscle layer, through the muscles, and between the muscles. The authors' anatomic investigation of each of these three types of vessels and the clinical application of this information is presented.     

Cutaneous perforators of the forearm: anatomic study for clinical application

We studied the distribution of constant cutaneous perforators of the forearm.A total of 25 amputated forearms of 13 Korean fresh cadavers were used for the study. The specimens were fixed in formaldehyde solution and phenol mixture in low concentration. Red latex was injected into the axillary arteries of 8 specimens, and lead oxide-gelatin mixture (radiopaque material) was given into another 8. And then the cutaneous perforators were isolated by dissection and radiographed. Free fasciocutaneous flaps with the pedicles of cutaneous perforators were exploited in 9 specimens.Two fasciocutaneous perforators were constant on the flexor surface and 3 on the extensor side. Most of the emerging points of 2 flexor perforators were within each circle, with 2.5 cm (87.5%) and 3.0 cm (75%) in diameter, respectively. Most of the emerging points of 3 extensor perforators were within each circle, with 2.0 cm (87.5%), 1.5 cm (75%), and 2.0 cm (87.5%) in diameter, respectively.A knowledge of constant perforators of the forearm is conducive to the free skin cutaneous flaps to be designed safely.