Temporal fascial flap: a versatile free flap for coverage of complex skin defects

The use of temporal fascial flap (TFF) as a microsurgical option permits the covering of skin defects which expose bones, nerves and vessels; it also provides a gliding surface which facilitates tendon excursion. Other advantages of the TFF are a reasonably constant surgical anatomy, minimal donor-site morbidity, and a thin and pliable surface which results in good cosmetic contour. In this paper we present our experience using TFF to cover wounds with significant exposed surfaces in different body areas (hands, feet, popliteal fossa); an average of 7 years follow-up is presented. Eleven patients with various wounds are presented: 91% had a successful surgery, and the TFF was able to solve the primary problem. On follow-up it was seen that the surgical aim had been reached, with excellent skin quality in terms of pliability, range of motion and protection from secondary ulceration. All patients were satisfied with the final result, and were able to return to their normal lifestyle. Scars secondary to flap harvesting were of good quality and were able to be hidden by the hair. No significant areas of alopecia were noticed.     

Endoscopic harvest of temporoparietal fascial free flaps for coverage of hand wounds

The temporoparietal fascial (TPF) flap is a thin, pliable, and well-vascularized flap that is ideal for reconstructing hand defects. Conventionally harvested flaps, however, result in a large scar over the temporal fossa, which may be problematic in patients with male-pattern baldness. We describe an endoscopic technique for harvesting the TPF flap through a 4-cm preauricular incision to reduce donor site morbidity. Five TPF flaps were used to cover hand wounds. Three of the flaps were successful and there were no injuries to the frontal branch of the facial nerve in this series. Endoscopic harvest of the TPF flap is an ideal solution for covering medium-sized hand defects without potentially prominent scars in the temporal area.     

Serratus anterior free flap: A personal series and meta-analysis review

Background

Serratus anterior muscle free flap is a versatile flap used for various microsurgical reconstructive procedures, especially when the amount of needed muscle is limited.

Methods

Reviewing retrospectively our own series of 12 patients (13 flaps), we made an extensive review of the medical literature in order to proceed to a meta-analysis concerning that flap.

Results

The serratus anterior flap was used for reconstruction of eight lower limbs, three head and neck, and one abdominal soft tissue defects. The etiology of the tissue defect was trauma in four cases, cancer in five cases and complications of other surgical procedures in three cases.The meta-analysis did not show any specific occurrence or association relative to this flap and just reveals geographical differences concerning the indications, the type of flap, and sex ratio from a continent to another.

Conclusions

We consider this flap a very effective and useful tool in the daily armamentarium of the microsurgeon. The main advantage of this flap is the possibility to design a reliable small muscular free flap, with only one muscular digitation. Uses are many and various: trauma or post-trauma, cancers, vascular deformities or diseases, facial paralysis, and osteomyelitis. Level of Evidence: Level IV, therapeutic study     

Dorsal hand coverage with free serratus fascia flap

In reconstructing a defect on the dorsum of the hand, with the extensor tendons exposed or even missing, functional, as well as cosmetic, goals are of major importance. The authors present three cases of extensor tendon reconstruction, combined with soft-tissue reconstruction, with the free serratus fascia flap, the connective tissue over the serratus muscle, for dorsal hand coverage. The flap consists of thin and well-vascularized pliable tissue, with gliding properties excellent for covering exposed tendons. It is based on the branches of the thoracodorsal artery, which are raised in the flap, leaving the long thoracic nerve intact on the serratus muscle. Coverage of the flap with split-thickness skin graft is done immediately. The free serratus fascia flap is an ideal flap for dorsal hand coverage when the extensor tendons are exposed, especially because of low donor-site morbidity.     

Reverse radial forearm fascial flap for soft tissue coverage of hand and forearm wounds

Six patients with severe hand and forearm injuries involving open wounds and exposed structures were treated with reverse radial forearm fascial flaps and split-thickness skin grafts for soft tissue cover. There were five men and one woman aged between 16 and 36 years. Injuries included soft tissue avulsion on the dorsum of the hand and fingers, extensive flexor and extensor tendon damage, multiple phalangeal fractures, a grade IIIB open dislocation of the index to little carpometacarpal joints, a grade III open metacarpal fracture and a finger amputation. The average wound size was 9 cm in length and 7 cm in width. The mean duration of follow-up was 12 months (range, 5-20 months). All flaps healed well, and all patients were satisfied.     

Emergency rectus abdominis free flap coverage of the hand

Summary A 42-year-old patient suffered a complete loss of soft tissue coverage over the carpus and metacarpus of her dominant hand. With exposure of vessels and nerves, and an open joint dislocation and finger amputations, immediate cover of the circumferential defect was achieved using a free rectus abdominis muscle flap covered with a skin graft. Healing was uneventful, and the flap bulkiness decreased within one-half year; debulking was not required. The final hand function was excellent. Emergency free flap coverage can salvage a hand; the rectus abdominis muscle flap transfer is safe, technically easy and expendable.     

Free temporoparietal fascial flap for coverage of a large palmar forearm wound after hand replantation

A free temporoparietal fascial flap with a split-thickness skin graft was used to cover a large palmar forearm wound in a patient whose hand had been replanted 21 days earlier after traumatic amputation at the distal forearm level. At a 39-month follow-up, the patient had achieved an excellent cosmetic and functional result, with no alopecia or facial nerve injury. The flap is advantageous for coverage of wounds that require a large amount of thin, pliable tissue, and it leaves a concealed donor-site scar.     

Experimental fascial flap model in the dog: free flap of the dorsal thoracic fascia

For years, various types of fascial flaps have been used in clinical practice; however, there are many unanswered questions regarding their basic physiology, anatomy and histopathologic changes occurring after transfer. Simple and reliable flap models are needed to investigate these questions, but very few of these flap models have been described in experimental animals to date. The purpose of this study was to describe a new reliable fascia flap model in the dog-the dorsal thoracic fascia flap. This fascia is defined as the anatomic layer that contains the blood supply to the scapular and parascapular fasciocutaneous flaps. Fourteen adult dogs were used in this experiment. The vascular anatomy of the dorsal thoracic fascia was studied by anatomic dissection and microangiography. Anatomic dissection revealed that the main axial vessel supplying the dorsal thoracic fascia was the superficial branch of the thoracodorsal vessel. Based on the vascular pedicle, fascia flaps generally measuring 15 x 24 cm were created. At gross observation, all of these large flaps based solely on the vascular pedicle were observed to be well-perfused. Microangiographic examination revealed the intense vascularity of the superficial branches of the thoracodorsal vessels in the whole area of all flaps. It was concluded that this is a simple and reliable fascial flap model which can be prepared as a free or pedicled flap. It has a consistent, long vascular pedicle with large vessel diameters supporting a large fascial flap.     

The free fascial forearm flap

The unpleasant appearance of the donor site after harvesting a forearm flap limits its use in many centers. In this paper, the author records his experience with a modification of the standard fasciocutaneous forearm flap. Such modification involves the utilization of the fascial component of the flap sparing the skin of the forearm, which is closed as a longitudinal line. This fascial forearm flap (FFF) was used as a free flap in eight cases. All the flaps survived well, and the donor site appearance was excellent. The fascial forearm flap advantages and limitations are discussed with recommendations for further utilization of other fascial flaps.     

Serratus anterior-rib free flap in limb bone reconstruction

The authors present their experience in surgical reconstruction of bone lesions in posttraumatic bone defects, pseudarthrosis, and osteitis by using the free serratus anterior-rib flap. The flap was used in 12 cases: 7 cases in the upper limb, and 5 cases in the lower limb. The overall immediate success rate in our series was of 91.7%. We had only one failure, due to a venous thrombosis. In all successful cases, the rib showed good integration. This procedure seems to be very useful in the reconstruction of small and medium bone defects, especially in the upper limb.     

The use of combined latissimus-serratus free flap for soft tissue coverage in the hand

Summary A case report is presented on the successful use of a combined latissimus-serratus free muscle transfer in a farmer whose hand was degloved in corn husking bin. There have been no previous reports of the use of such a flap for soft tissue coverage on the hand. The patient was transferred eight days post-injury with an infected wound, a gangrenous thumb and viable fingers. Flap coverage was undertaken four days later. The latissimus dorsi and the lower four slips of the serratus anterior muscle were anastomosed via a common vascular pedicle to the radial artery. The post-operative course was uneventful and donor site morbidity minimal.     

The distally-based dorsal hand flap

The planning and clinical applications of a series of reverse dorsal hand flaps are described. This new flap is based on a direct cutaneous branch of the dorsal metacarpal artery. It is particularly useful in resurfacing web spaces as well as dorsal metacarpal and phalangeal skin defects. The behaviour of 21 such flaps, all raised in the form of an island, was that of a conventional axial pattern flap.     

Soft tissue coverage of the hand with a free digital fillet flap

A free digital fillet flap was used to achieve soft tissue coverage of the ulnar border of the hand in a 38 year old man with an industrial fan blade injury to the dominant hand. The use of a digital fillet flap from an unsalvageable ring finger allowed for a one-stage procedure avoiding donor site morbidity or need for additional reconstructive surgery.     

Reversed island forearm fascial flap in hand surgery

We present a technique using a reversed island forearm fascial flap based on the distal portion of the radial artery and veins, with a skin graft on top, to repair a soft tissue defect of the hand. Good results were obtained in a total of 18 operations in 17 postburn cases. The operation can be completed in one stage even when it involves the excision of scar tissue, correction of the secondary deformities of deep structures, and repair of the soft tissue defect of the hand. The advantages and disadvantages of the method and key points of the technique are discussed.     

Island radial artery fasciotendinous flap for dorsal hand reconstruction.

The authors report a one-stage repair for a dorsal hand injury that involves the loss of skin and tendons. The injury was repaired using an island radial artery flap complete with fascia and tendons, leaving the forearm skin behind. The functional and aesthetic results are excellent, and there was minimal donor site morbidity.     

Soft-tissue coverage of complex dorsal hand and finger defects using the turnover adipofascial flap

Complex hand wounds with exposed tendon or bone often require free tissue transfer. We report results in 13 patients with complex dorsal hand or digital wounds who underwent soft-tissue reconstruction using a turnover adipofascial flap and skin grafting over a 35-month period. The mean patient age was 44 years. Mechanism of injury included the following: three gunshot, four degloving, one table saw, three chain saw, one thumb avulsion, and one crush. Flap sizes varied from 2 × 4 to 10 × 18 cm, involving the dorsum of the hand in four patients, thumb in two patients, index finger in one patient, long finger in three patients, long and ring fingers in one patient, and web space in two patients. Skin graft survival was 100% in 12 patients. One patient died of sepsis from unrelated medical conditions. All fractures were healed at follow-up, and there were no donor site complications. The adipofascial flap is a good alternative to free tissue transfer for the coverage of complex dorsal hand and finger soft-tissue defects and is associated with technical ease, good cosmetic results, and minimal donor site morbidity.     

Peroneal tendofascial flap: a new fascial flap for Achilles tendon coverage, a preliminary report.

The tendons of the both peroneus longus and brevis muscles lie in the lateral compartment of the leg, enclosed in a fascial sheath. This sheath has been dissected off the tendons in three cases and opened longitudinally forming a sheet of vascularised fascia proximally based and continuous with the peroneal muscles. These sheets of 6 x 12 cm dimensions have been successfully transposed with split skin graft to cover an exposed Achilles tendon. In another case, the peroneus brevis muscle and the opened fascial sheath of the peroneus longus tendon forming one sheet was used to cover a defect over the Achilles tendon 10 cm above the heel. This 'tenofascial flap' offers regional tissue to solve the difficult lower third leg defects especially those of Achilles tendon exposure, as it is thin, pliable, allows gliding of the tendon underneath it and vascular enough to sustain a durable skin graft.     

Free flap coverage of the hand

The microvascular cutaneous transplant, or "free flap", suitable for hand resurfacing is described in detail. Anatomic and clinical indications are stressed, and the operative steps involved in the preparation and transfer of each flap are outlined.     

Serratus fascia "sandwich" free-tissue transfer for complex dorsal hand and wrist avulsion injuries.

The serratus anterior fascia was used as a free-tissue transfer in four patients for the reconstruction of dorsal hand defects. All patients had multiple open metacarpal fractures with extensor tendon injuries. The fascia was used to "sandwich" the extensor tendons in a bed of areolar gliding tissue to avoid adhesions. The mean follow-up was 2 years. There were no complications and all flaps survived completely. All flaps were grafted with meshed split-thickness skin at the time of transfer with a 100 percent take in all cases. A good functional result was noted in all patients. This free-tissue transfer is recommended for complex injuries to the dorsum of the hand associated with soft-tissue defects.