Neovascularization in prefabricated flaps using a tissue expander and an implanted arteriovenous pedicle

Creating prefabricated flaps using tissue expanders in combination with the implantation of maximal blood flow vascular pedicles into suitable tissue areas represents a new tendency in the reconstruction of large skin defects. In 42 Chinchilla Bastard female rabbits weighing 3,700-4,600 g, skeletonized arteriovenous pedicles with maximal blood flow, dissected from the femoral and saphena magna bundles, were implanted underneath abdominal fasciocutaneous flaps. Oval tissue expanders of 250 ml were placed and fixed on the abdominal wall to expand these prefabricated flaps. The evaluation parameters were macroscopic observation, blood analysis, selective microangiography, histology, and scintigraphy. The study results showed that neovascularization in expanded prefabricated flaps was established from newly formed vessels generated from the implanted pedicles and their vascular connections with the originally available vasculature in the flap. After 20 days of prefabrication, the entirety of the expanded prefabricated flaps was perfused by blood flow supplied from newly implanted arteriovenous pedicles. The study indicated that an expanded prefabricated flap can be successfully created by the simultaneous implantation of a maximal blood flow pedicle in combination with flap expansion.     

Accelerated flap prefabrication with vascular endothelial growth factor

Vascular endothelial growth factor (VEGF) is a potent promoter of angiogenesis that has been shown to enhance revascularization of ischemic tissues, including skin flaps. This study was designed to investigate the value of a single topical application of recombinant human VEGF to accelerate flap viability in a rat model of a non-ischemic prefabricated flap. Prefabricated flaps were created in 48 Sprague-Dawley rats. An autologous tail artery loop was anastomosed to the femoral artery and vein, and implanted subcutaneously in the lower abdomen. Flaps were divided into two groups of 24 each. At the time of loop implantation the control group received 0.9 percent NaCl or a 16 percent vol/wet polyvinyl alcohol (PVA) solution: the treatment group received VEGF in 0.9 percent NaCl or VEGF in PVA. The PVA gel was used to facilitate topical application In each group, 3- x 4-cm flaps nurtured by the tail artery pedicle were elevated and resutured into place after 3, 4, and 5 weeks. The percentage of surviving skin of each flap was determined by planimetry 7 days after flap elevation. Mean skin survival areas at 3, 4, and 5 weeks were control group 0 percent. 8 percent and 17.5 percent; and VEGIF-treated group, 6 percent, 40 percent, and 66.7 percent respectively VEGF significantly improved flap survival by 5 weeks (p = 0.02). These results suggest that VEGF can accelerate maturation of prefabricated flaps. This approach could expand the application of flap prefabrication as a resource for reconstructive surgery.     

血管内皮生长因子促进预构皮瓣成活的实验研究

目的　研究使用重组人类血管内皮生长因子 (Vascularendothelialgrowthfactor,VEGF)对预构皮瓣存活的作用 ,探讨VEGF能否促进正常血供组织的血管化。方法　取大鼠自体尾动脉 8cm移植 ,两端分别与股动、静脉吻合 ,成环状植入下腹部皮下组织 ,对照组局部应用 0 9%NaCl和16 %聚乙烯乙醇 ,实验组将VEGF分别溶于 0 9%NaCl和 16 %聚乙烯乙醇局部应用。分别于术后 3,4 ,5周以植入的尾动脉为血管蒂于下腹部形成 3cm× 4cm大小皮瓣 ,游离掀起皮瓣后缝回原处 ,7d后运用面积仪测出存活皮瓣面积的百分比。结果　第 5周后的皮瓣存活率VEGF组 (75 0 0 % ,5 8 4 1% )明显优于实验组 (10 % ,2 5 % )。结论　VEGF有利于预构皮瓣的存活。     

Neovascularization and free microsurgical transfer of in vitro cartilage-engineered constructs

Cartilage tissue engineering shows to have tremendous potential for the reconstruction of three-dimensional cartilage defects. To ensure survival, shape, and function, in vitro cartilage-engineered constructs must be revascularized. This article presents an effective method for neovascularization and free microsurgical transfer of these in vitro constructs. Twelve female Chinchilla Bastard rabbits were used. Cartilage-engineered constructs were created by isolating chondrocytes from auricular biopsies, amplifying in monolayer culture, and then seeding them onto polycaprolactone scaffolds. In each prefabricated skin flap, three in vitro cartilage-engineered constructs (2 x 2 x 0.5 cm) and one construct without cells (served as the control) were implanted beneath an 8 x 15 cm random-pattern skin flap, neovascularized by implantation of an arteriovenous vascular pedicle with maximal blood flow. Six weeks later, the neovascularized flaps with embedded cartilage-engineered constructs were completely removed based on the newly implanted vascular pedicle, and then freely retransferred into position using microsurgery. Macroscopic observation, selective microangiography, histology, and immunohistochemistry were performed to determine the construct vitality, neovascularization, and new cartilage formation. The results showed that all neovascularized skin flaps with embedded constructs were successfully free-transferred as free flaps. The implanted constructs were well integrated and protected within the flap. All constructs were well neovascularized and showed histologically stability in both size and form. Immunohistology showed the existence of cartilage-like tissue with extracellular matrix neosynthesis.     

Use of free interpositional vein grafts as pedicles for prefabrication of skin flaps

Pedicles created from a long vein graft increase the scope and applications of prefabricated skin flaps. This study reports the survival and pattern of neovascularization of lower abdominal skin flaps in rabbits based on a pedicle formed by interposition of a long vein graft between the divided ipsilateral femoral artery and vein. Flaps were elevated 2–5 weeks after pedicle implantation and the surviving area quantitated and vascular patterns examined 1 week later. Only 8 out of 35 flaps were greater than 50% alive, the most frequent cause of flap failure being pedicle non-patency. If the pedicle remained patent, complete flap survival was possible as early as 2 weeks after implantation. In non-patent pedicles, recanalization or formation of a new vascular network may, given at least 4 weeks, be sufficient to ensure partial flap survival. The findings indicate that implantation of a long, skeletonized vein graft is an unreliable method of prefabrication of abdominal skin flaps in this model. © 1994 Wiley-Liss, Inc.     

TISSUE ENGINEERING OF HIGH DENSITY POROUS POLYETHYLENE IMPLANT FOR THREE-DIMENSIONAL RECONSTRUCTION: AN EXPERIMENTAL STUDY

Three-dimensional defects have been reconstructed with carved and remodelled frameworks wrapped within vascular carriers. If sufficient vascular penetration can be established without any change in the size and shape of an implant, it will be possible to cover it with a skin graft and aesthetically important fine details can be obtained. To achieve this, we first prefabricated high-density porous polyethylene implant in rabbits. Secondly, we applied full-thickness skin grafts over the anterior surface of the prefabricated implant. The implants were placed and anchored underneath the superficial inferior epigastric artery and vein pedicle bilaterally. A total of 10 implants were prefabricated and then grafted in five rabbits. The implants were evaluated by perfusion scintigraphy and histological examination. Results showed that the implants were invaded by fibroneovascular tissue, and that this tissue, which can be transferred as a pedicled or a free flap, was sufficient to sustain a skin graft.     

Reconstruction of tracheal defects with dehydrated human costal cartilage: an experimental study in rats.

Reconstruction of tracheal defects continues to be a difficult problem in head and neck surgery. In this study, to evaluate the outcomes of tracheal reconstruction with a nonautogenous material, we used solvent-dehydrated human costal cartilage in 3 different forms: graft, neovascularized graft, and prefabricated free flap. Thirty-five Sprague-Dawley rats were distributed into 3 groups with 10 animals in groups 1, 10 in group 2, and 15 in group 3. Surgically created tracheal defects were repaired with a free cartilage graft in group 1, and a piece of cartilage was neovascularized for 3 weeks in the inguinal region and then used as a fibrovascular tissue-coated cartilage graft in group 2. In group 3, the neovascularized cartilage was transferred to the defect as a prefabricated free flap based on a vascular pedicle containing femoral vessels. Four weeks later, the tracheal reconstruction specimens were evaluated with light microscopy to determine cartilage survival, infection, and epithelial regrowth. The most favorable outcomes were obtained in group 3, where the material was used as a prefabricated neovascularized free flap.     

Flap prefabrication and prelamination with tissue-engineered cartilage

In reconstructive surgery, the integration of tissue-engineered cartilage in a prefabricated free flap may make it possible to generate flaps combining a variety of tissue components, to meet the special requirements of particular defects. One aim of the present study was to investigate prefabrication of a microvascular free flap by implanting a vessel loop under a skin flap in a rabbit model. A second aim was to report on the authors' preliminary experiences in prelaminating prefabricated flaps with autologous tissue-engineered cartilage, in terms of matrix development, inflammatory reaction, and host-tissue interaction. The flap was prefabricated by implanting a vessel loop under a random-pattern abdominal skin flap. The tissue-engineered cartilage constructs were made by isolating chondrocytes from auricular biopsies. Following a period of amplification, the cells were seeded onto a non-woven scaffold made of a hyaluronic-acid derivative and cultivated for 2 weeks. One cell-biomaterial construct was placed beneath the prefabicated flap, and two additional constructs were placed subcutaneously and intramuscularly. In addition, a biomaterial sample without cells was placed subcutaneously to provide a control. All implanted specimens were left in position for 6 or 12 weeks. Neovascularization in the prefabricated flap and biomaterial construct was analyzed by angiography. After explantation, the specimens were examined by histologic and immunohistochemical methods. The prefabricated flaps showed a well-developed network of blood vessels between the implanted vessel loop and the original random-pattern blood supply. The tissue-engineered constructs remained stable in size and showed signs of tissue similar to hyaline cartilage, as evidenced by the expression of cartilage-specific collagen type II and proteoglycans. No inflammatory reactions were observed. The physiologic environment of the autologous rabbit model provided favorable conditions for matrix deposition and maturation of the cell-biomaterial constructs. These initial results demonstrated the potential of prefabricating an axial perfused flap, combined with tissue-engineered cartilage, thus creating functionally competent tissue components for reconstructive surgery with minimal donor-site morbidity.     

兔股动脉和静脉预构轴型扩张皮瓣的实验观察

目的 通过兔股动脉、静脉预构轴型扩张皮瓣的微循环血流晕动态变化、光镜下结构的改变及其成活面积,为预构轴型扩张皮瓣的临床应用提供依据.方法 选择新西兰白兔40只,随机分为4组:预构轴型扩张皮瓣组、预构轴型不扩张皮瓣组、单纯预构轴型皮瓣组及无蒂游离皮瓣组,每组4只,前2组股动脉、静脉移位后,预构轴型扩张皮瓣组、预构轴型不扩张皮瓣组分别在肉膜深面置入容量为50 ml长方形皮肤软组织扩张器,预构轴型扩张皮瓣组7 d后开始注水;无蒂游离皮瓣组为对照组,未采取预构及扩张处理.定期对4组皮肤进行微循环血流量检测,并取样进行光镜观察.预构术后52 d,前3组形成以预构股动静脉血管束为蒂的岛状皮瓣,游离皮瓣组则形成无蒂游离皮瓣后均原位缝合,观察其成活面积.结果 预构轴型扩张皮瓣组较其他组微循环血流量增加,成活面积大[(97.54±2.73)%],光镜下改变显著(P<0.05).结论 扩张术能促进预构轴型皮瓣的血管化进程,明显增大预构轴型皮瓣成活面积,增加其移植的安全性.     

Prefabricated free flaps with vascularized porous polytetrafluoroethylene (Proplast II)

Summary The use of porous polytetrafluoroethylene (Proplast II), as a framework for prefabricated, composite transplants was investigated in 28 New Zealand rabbits. A portion of Proplast II was implanted into an inguinal fat flap, explanted after six weeks, followed by a prefabricated free flap covered with a skin graft transplant in three variations. In eight specimens, the microvascular transplantation was from the inguinal to the neck region. This transplantation procedure was possible due to vascularisation and proliferation of connective tissue interwoven into and throughout the Proplast II which was used as an interface matrix. Histological findings in the microangiographic and Tc 99m examination technique showed vascularisation of Proplast II and the presence of a capillary network between Proplast II and the dermal transplant. The employment of porous PTFE as a framework for prefabricated free flaps is a promising one.     

腺病毒-VEGF基因重组体促进预构皮瓣成活的实验研究

目的：应用大鼠预构皮瓣模型,探讨基因治疗技术产生的血管内皮生长因子促进预构皮瓣血管新生和皮瓣存活的可能性,为临床上寻找加速预构皮瓣成熟的新方法提供实验依据。方法：20只SD大鼠每只腹部两侧各构建一个预构皮瓣,共构建40个皮瓣,每只大鼠两侧皮瓣按随机原则进行不同的处理,分别归于实验组或对照组,每组各20个皮瓣。于大鼠腹部两侧各标记3cm×2cm矩形预构区,短边平行于腹股沟韧带,自尾侧短边中点向后纵向切开后肢皮肤,剥离出长约2cm的股动静血管束,远端结扎切断。在两侧预构区域的中轴线上,于真皮与肉膜层间各制作一皮下隧道,实验组的隧道壁皮下组织内注射携带有VEGF基因的腺病毒,同法向所有对照组的隧道壁软组织内注射等量生理盐水。将已剥离好的血管束向颅侧翻转置入相应皮下隧道内。所有已植入股血管的预购区域2周后均被制成以植入血管束为蒂的岛状皮瓣,从两组中各取一个皮瓣进行免疫组化染色,观察有无VEGF生成,其余岛状皮瓣均缝回原处。形成岛状皮瓣后第七天观察皮瓣存活及血管新生情况。结果：实验组与对照组的皮瓣平均存活率分别为（90．48±1．89）％、（69．75±2．36）％,其差异有统计学意义（P〈0．01）;血管放射显影图上,实验组植入血管周围见广泛白色显影,尤以血管两端明显,而对照组新生血管显影仅局限于植入血管周围;组织学切片显示实验组植入血管周围新生血管丰富,以毛细血管为主,并见肉芽成份,对照组新生血管相对较少,两组间新生小血管管腔大小则无明显差异;免疫组化检测显示仅实验组皮瓣中有VEGF表达。结论：腺病毒-VEGF基因重组体能通过促进预构皮瓣的血管新生,增加预构皮瓣的存活率。     

Nasal spreader grafts: a comparison of medpor to autologous tissue reconstruction

Reconstruction of the damaged nasal vault is challenging. Limited available autologous tissue has lead surgeons to pursue alloplastic alternatives. A retrospective review comparing 18 patients who underwent secondary rhinoplasty with internal nasal valve reconstruction with spreader graft (SG) implants using either autologous tissue or high-density porous polyethylene (Medpor) was performed. All underwent bilateral SG reconstruction of the internal nasal valve with Medpor (10 cases) or autologous cartilage (8 cases). Mean follow-up was 26 months for the autologous group and 29 months for the Medpor group. Functional performance and aesthetic results were identical. Complications were few: 1 case of unilateral infection in the Medpor group treated with partial excision, and 1 case of erythema at the auricular donor site for the autologous tissue group. For patients who have exhausted autologous tissue options or are unwilling to tolerate potential donor-site morbidity, the Medpor SG is an appropriate option that allows for excellent aesthetic and functional results that remains stable over time.     

Prefabricated Nasolabial Flap for Reconstruction of Full-Thickness Distal Nasal Defects

BACKGROUND: The reconstruction of full-thickness nasal tip and alar defects is challenging owing to the distal nose's triple-layer structure: skin, cartilage, and mucosa. OBJECTIVE: In the reconstruction of wounds of the distal half of the nose involving the rim, the most important issue to be considered is to provide a good functional and an acceptable esthetic result. Various local and distant flaps have been described for this purpose. The nasolabial flap is one of the most frequently used flaps in reconstruction of small- to moderate-size distal nasal defects. Its reliable blood supply, minimal donor site morbidity, and excellent texture and color match are some of the advantages of this local flap. METHODS: In this study, superiorly based subcutaneous pedicled nasolabial flaps have been prefabricated with cartilage and skin grafts. This method has been used in 10 cases. RESULTS: One patient had partial flap necrosis, and two patients experienced hyperpigmentation on the suture line. Scar revision was performed in one patient for hypertrophic scar tissue at the flap margins. No other complications were seen in the remaining patients. None of the patients experienced a skin graft loss or cartilage exposure. CONCLUSION: The prefabricated nasolabial flap offers a superior esthetic and functional result and may be an appropriate reconstructive option in reconstruction of small- to moderate-size distal nasal defects.     

Fabricating Flaps in the Forearm Prior to Tracheal Reconstruction

Background  The process of reconstruction of tracheal defects is complex and still not optimum. Options range from using staged reconstructions, combining flaps with autologous or alloplastic implants, as well as use of tissue-engineered constructs combined with vascularized tissues which are lined with cell cultures. Staged reconstructions using prelaminated epithelium, and prefabricated flaps, help in reconstruction of this complex structure. Prefabricating the flap at a different site allows for integration of the tissues prior to its transfer. Method  This article reports two patients planned for tracheal reconstruction for the purpose of advanced papillary carcinoma of the thyroid invading the trachea. Staged reconstruction using a prefabricated radial artery forearm flap (RAFF) and split rib cartilage was performed. In the second patient, a young girl, a similar construct of the RAFF, prelaminated with buccal mucosa, was performed. However, in the latter case, an intraoperative decision by the head and neck team to limit excision of the trachea sparing the mucosa was taken; the reconstruct in the forearm was redundant and needed to be discarded, replacing the defect with a free superficial circumflex iliac artery perforator (SCIP) flap. Result  At 3 years follow-up, both the patients are free of disease, with the construct serving its purpose in the older female.     

Viability and versatility of arterialized venous perfusion flaps and prefabricated flaps: an experimental study in rabbits.

The purpose of this study was to investigate the viability of two types of unconventional flaps: 1) the arterialized venous perfusion (AVP) flap; and 2) the prefabricated flap. Four experimental groups were studied: an AVP flap group with assessment of the viability of single and paired flaps nourished by the same vascular pedicle; a prefabricated flap group with the abdominal flap pedicled on the epigastric artery and vein; a prefabricated flap group in which the flap was supplied by an arterialized vein graft (A-V shunt), and paired flaps of different designs, but based on the same vascular pedicle, were investigated; and a free composite graft group. Survival of the skin flaps exceeded 92 percent in each group, except in the free composite group which showed complete necrosis. Results of the study validated that flap viability was independent of flap size (large or small), type (AVP flap or prefabricated flap), and the number of flaps on each vascular pedicle (single or paired).     

Experimental tracheal reconstruction with free prefabricated arterialized venous flap

Summary A technique of tracheal reconstruction in the rat model has been developed using the microvascular transfer of a prefabricated compound flap. This flap consists of a tubed cartilage graft incorporated within an arterialized venous flap created in the abdominal skin. Twenty-five Wistar male rats were operated on in three stages. First, the subcutaneous venous network was arterialized by doing an arteriovenous anastomosis. Seven days later, a tube of autologous cartilage was made from the xiphoid cartilage. This neotrachea was buried in a subcutaneous pocket within the arterialized abdominal area. Eight weeks later, the free flap containing the neotrachea, a skin island and a vascular pedicle was transferred to the neck, doing the afferent and efferent anastomosis to the carotid artery and the jugular vein. The neotrachea was interposed into a 1 cm tracheal defect. Microangiography and pathological studies were done in all cases. The pathologic study revealed a stable, viable cartilage tube with an internal lining of fibrous periprosthetic capsule. Angiography demonstrated enhanced vascularization in the abdominal flap. Flap viability was 85%. Postoperative survival ranged from 12 h to 5 days. In all cases, the animal died with a patent airway.     

Prefabrication of skin flaps using vein grafts: an experimental study in rabbits.

Prefabrication provides a new method for creating donor sites which are not limited by natural vascular territories. There are several methods for prefabrication, and these include implantation of greater omentum, blood vessels or muscle flaps. Based on the concept that an arterio-venous (A-V) shunt results in sufficient neovascularisation to support a free flap, we used a rabbit model to investigate the characteristics of these flaps. Prefabrication of an abdominal wall donor site was performed using the left epigastric vein in 20 male New Zealand white rabbits. An 8 x 10 cm skin flap was elevated 10 days after prefabrication, either as an island or a free flap. Survival of the skin flaps exceeded 93% and was independent of position of the vascular pedicle, direction of blood flow, or nature of the flap (island or free flap). Angiograms showed a very rich neovascularisation within the prefabricated flap.     

Neurocutaneous island flap:: an experimental model using the rabbit ear

The rabbit ear has often been used as an experimental model; however, a neurocutaneous flap has never been described before. The authors examined the reliability of a skin cartilage flap with a pedicle composed only of a sensory nerve with its vascular network in a rabbit model: A 2 x 2-cm cutaneous cartilage flap was harvested on the dorsal side of the ear bilaterally. Vessels were tied and cut on the 4 sides of the flap, including the central auricular artery and vein. The nerve was cut at the distal side of the flap and was "skeletonized" to the extent of 1 cm on the proximal side, meticulously preserving its vascular network. Subsequently, the flap was elevated with the cartilage as a composite flap and was sutured back to its natural site. The authors elevated 28 skin cartilage flaps on the dorsal side of both the ears of 14 New Zealand White rabbits, centered on the central neurovascular axis. All 28 flaps survived. In the control group of 7 rabbits, the artery, vein, and nerve (pedicle) were severed, and the skin cartilage island was sutured back as a composite graft. None of these 14 grafts survived. In 4 additional rabbits, the authors performed a histologic examination 1 day, 3 days, 7 days, and 3 weeks postoperatively of the neurovascular axis after the same skin cartilage flap was harvested. They compared these results with the histologic examination of the nerve of the contralateral nonoperated ear, and noted a marked dilatation and multiplication of blood vessels in the operated ear beginning on day 1 postoperatively. The presence of this neurocutaneous vascularization should be considered when other kinds of flaps (venous flaps or others) are used as experimental models using the rabbit ear.     

Prefabrication of combined composite (chimeric) flaps in rats

The purpose of this study was to prefabricate a new combined composite (chimeric) flap that consists of four different tissues. The tissues were prefabricated around two independent pedicles that ultimately join as a single main pedicle. In the inguinal area of 36 rats, the saphenous and the superficial inferior epigastric (SIE) pedicles were dissected and prepared as vascular carriers. A fascial graft and a local muscle flap were wrapped around the saphenous pedicle. The SIE pedicle was then implanted under the abdominal skin to supply a future skin flap. An ear cartilage graft was also inserted under the abdominal skin and adjacent to the implanted SIE pedicle. After allowing 2-, 4-, 6-, and 12-week prefabrication periods in different groups of nine animals, the prefabricated tissues were raised around two pedicles nourished by the femoral pedicle and then transferred. Flap survival was assessed by observation, microangiography and histology. The skin flaps showed survival rates of 52 +/- 17% (mean +/- standard error of the mean), 64 +/- 16%, 86 +/- 11%, and 100 +/- 0% of the total areas in the 2-, 4-, 6-, and 12-week prefabricated flaps respectively. None of the control grafts that were prepared on the contralateral side survived totally. A significant difference was found between the 12- and 2-week (p < 0.008), 12- and 4-week (p < 0.02), and 6- and 2-week (p < 0.05) prefabrication groups. Histologically, fascial and cartilage grafts, and portions of muscle were viable in the 2- and 4-week groups. Also, noticeable necrosis was found in the skin flaps in these groups. The muscle showed mild (at 2, 4, and 6 weeks) and moderate (at 12 weeks) atrophy. After prefabrication for 6 weeks, all tissues demonstrated good survival. This study shows that a combined composite flap can be prefabricated successfully in rats after a 6-week period of prefabrication.     

Use of fascial grafts as an interface in flap prefabrication: an experimental study.

An experimental study was conducted to investigate whether a fascial graft can be used as an interface between a vascular pedicle and target tissue to augment tissue survival in a prefabricated flap. Thirty-six male Sprague-Dawley rats were divided into three experimental groups according to the type of the recipient bed prepared for the vascular implantation. The left saphenous vascular pedicle was used as the vascular source. A 9 x 9-cm inferiorly based peninsular abdominal flap was elevated in each animal. In group I, the pedicle was tacked beneath the abdominal flap, in which the epigastric fascial layer was untouched. In group II, a 3 x 5-cm graft of epigastric fascia was harvested from the abdominal flaps under loupe magnification. The graft was sutured back into its original position after a 180-deg rotation. The vascular pedicle was then implanted just beneath the center of the fascial graft. In group III, the same size of epigastric fascia was removed in the same manner as group II, exposing the subcutaneous layer for pedicle implantation. Four weeks later, abdominal flaps were raised as island flaps connected only to the saphenous pedicle and were sutured in place. Flap viability was assessed visually on day 7. Overall, the ultimate flap survival in group I was the largest, with some necrotic areas at the periphery of the flaps. In group II, flap survival was typically centralized over the fascial graft, and crescent-shaped necrosis was noted superiorly. In group III, an almost linear pattern of survival overlying the vascular pedicle was observed. The mean surviving flap area of group I (12.13 +/- 1.615 cm2) was statistically greater than that of group II (8.83 +/- 0.663 cm2, p < 0.001) and group III (6.3 +/- 0.815 cm2; p < 0.001). There was a statistically significant difference between the mean flap survival in groups II and III (p < 0.001). Vascular arborization was examined by microangiography, and specimens were processed for histological staining. In group II, vascularization was distributed in a larger area along the fascial graft in comparison with limited vascularization around the pedicle in group III. In this study it was revealed that the interposition of a fascial graft as an interface between the vascular source and the target tissue seems to increase the size of the prefabricated flap.