Total auricular reconstruction without skin grafting

Successful ear reconstruction depends on two factors: an ear framework and the skin covering the framework. However, the relative deficiency of skin for coverage of the cartilage framework remains an issue. This new method for total auricular reconstruction is a three-stage operation and involves the use of two tissue expanders. First, two skin expanders are implanted, one underneath the scalp and the other sited behind the microtic ear. At the second stage, after lobule transposition, the two expanded skin flaps (upper and lower) and mastoid fascial flap are raised. At the same time, the autogenous rib cartilage is harvested and the framework constructed. The cartilage framework is then anchored between the upper expanded skin flap and the fascial flap with its inferior pole inserted into the rotated earlobe. The upper expanded skin flap covers the whole anterior surface of the framework and drapes over the margins of the fascial flap, which wrap the framework from beneath. The raw surface of fascial flap is covered with the lower expanded skin flap. The formation of a pseudomeatus and tragus is performed at the third stage. Deficiency of skin is the major problem encountered with the other conventional methods. Our innovations using two tissue expanders in combination with an autogenous rib cartilage framework eliminate this problem completely.     

The scapular/parascapular flap in reconstruction of distal lower extremity soft tissue defects over the Achilles tendon

Combined defects of soft tissue and Achilles tendon are rare and are usually seen following repair of the tendon. Large size defects frequently cannot be reconstructed with local tissue. Various free flaps such as the radial forearm flap and the temporoparietal fascia flap have been described for reconstruction. In selected cases with concomitant Achilles tendon defect or loss of gliding tissue, the fasciocutaneous scapular/parascapular flap with an axial fascial extension offers considerable advantages. Three cases with soft tissue and Achilles tendon defects have been treated with a scapular/parascapular flap during an 18 months period. The defect size ranged from 8×9 or 6×15 cm. All flaps survived, donor site morbidity was not significant and primary donor site closure was possible in all cases. Achilles tendon function was good in two cases and fair in one case. One flap had to be revised to produce better contour, but the other flaps were aesthetically pleasing. The scapular/parascapular flap with fascial extension is a useful addition in reconstruction of combined soft tissue and Achilles tendon defects. The axial fascial part is versatile and can be wrapped around the tendon to provide tendon reinforcement, gliding tissue or both. The thickness of the flap is uniform and a custom tailored flap is possible. Received: 7 July 1997 / Accepted: 25 May 1998     

Use of the free prefabricated temporoparietal fascia-chondro-cutaneous flap nourished by only arterial inflow: an arterial flap

Summary Pedicled temporoparietal fascial flaps have been used extensively in head and neck reconstruction for many years. Also, the fascia has been grafted, and the skin graft transformed into a vascularized pedicled flap (prefabricated temporoparietal fasciocutaneous flap). On the other hand, some authors have used free temporoparietal fascial flaps for defects that require to be filled in lower and upper extremity wounds. In this case, a free prefabricated temporoparietal fascio-chondro-cutaneous flap having only an arterial inflow was used in eyelid reconstruction.Presented at the 14th Congress of Turkish Plastic and Reconstructive Surgery, Ankara, Turkey, October 1992     

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.     

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.     

Donor site morbidity of the prelaminated fasciomucosal and fasciocutaneous radial forearm flap: a comparative study

In order to reconstruct intraoral lining defects after radical tumor resection, mucosal prelamination of the fascia of the distal radial forearm flap was performed in ten patients. By this method a physiologic reconstruction with mucus-producing tissue could be achieved. Preservation of skin and subcutaneous tissue enabled primary closure of the donor site. The exposed median nerve and flexor tendons could be covered by well-vascularized tissue with, hopefully, less donor site morbidity. To investigate this, eight prelamination patients were compared to five patients in whom conventional fasciocutaneous distal radial forearm flaps were harvested. Follow-up was 6–25 months (mean 12.8 months). All patients with prelaminated forearm flaps revealed excellent functional and cosmetic results. Restricted hand function and a poor cosmetic result were found in 40% of the fasciocutaneous flap patients. Subjective cold intolerance could be objectified using thermography, but could not be confirmed, using rheography and photoplethysmography. Received: 9 March 1998 / Accepted: 16 November 1998     

Two modifications of the radial forearm flap for reconstruction of complex facial defects

The free radial forearm flap has been one of the most common free flaps of recent decades. This flap is employed predominantly in head and neck reconstruction. The possibility of combining bone, muscle, and nerves with the fasciocutaneous flap greatly enhanced reconstructive options. However, the frequently unsightly donor site and the development of other readily available free flaps have led to a decline in the use of the radial forearm flap. Nevertheless, for reconstruction in head and neck surgery, with the need for thin, pliable tissues and a long vascular pedicle, the radial forearm flap still remains a prime choice. Two modifications of the standard forearm flap are presented. The first patient had two large defects at the nose and mental area after radical resection of a basal-cell carcinoma. Soft-tissue reconstruction was achieved with a conventional forearm flap and a second additional skin island based on a perforator vessel originating proximally from the pedicle. Both skin islands were independently mobile and could be sutured tension-free into the defects after tunneling through the cheek, with vascular anastomosis to the facial vessels. The second patient required additional volume to fill the orbital cavity after enucleation of the eye due to an ulcerating basal-cell carcinoma. In this case, the body of the flexor carpi radialis muscle was included in the skin flap to fill the defect. The skin island was used to reconstruct the major soft-tissue defect.     

Reconstruction of acquired sub-total ear defects with autologous costal cartilage.

Acquired sub-total ear defects are common and challenging to reconstruct. We report the use of an autologous costal cartilage framework to reconstruct sub-total defects involving all anatomical regions of the ear. Twenty-eight partially damaged ears in 27 patients were reconstructed with this technique. The defects resulted from bites (14), road traffic accidents (five), burns (four), iatrogenic causes (four) and chondritis following minor trauma (one). Computerised image analysis revealed a median of 31% (range 13-72%) ear loss. An autologous costal cartilage framework was fashioned in all cases. If adequate local skin was available, this was draped over the framework, but in nine cases preliminary tissue expansion was used and in a further three cases with significant scarring, the framework was covered with a temporoparietal fascial flap. Clinical assessment after ear reconstruction was undertaken, scoring for symmetry, the helical rim, the antihelical fold, the lobe position and a 'natural look' to produce a four-point scale; 11 were excellent, 12 were good, two were fair and three were poor. Our experience suggests that formal delayed reconstruction with autologous costal cartilage is to be recommended when managing acquired, sub-total ear deformity.     

The thoracodorsal vascular tree-based combined fascial flaps

In this study, combined fascial flaps pedicled on the thoracodorsal artery and vein were raised and used for thin coverage of dorsal surfaces of the fingers and the dorsum of hand and foot with favorable results. The combined fascial flaps consist of the serratus anterior fascia and the axillary fascia at the entrance of the latissimus dorsi. These flaps were used for reconstruction of the hand, fingers, or foot in nine patients. Reconstruction was performed for burn or burn scar contracture, after resection of malignant tumors, posttraumatic skin defects, and chronic regional pain syndrome. The sites of reconstruction were dorsal surfaces of fingers, dorsum of hand, wrist and palm, forearm, lower leg, and foot. The flaps were used in various configurations including two independent fascial flaps, two-lobed fascial flap with separate feeding vessels, and composite fascial and thoracodorsal artery perforator flap. The fascial and skin flaps survived in all nine patients, with favorable results both functionally and esthetically. Good coverage of soft tissue defects and good recovery of range of motion in resurfaced joints were achieved. There were no complications. The scars at the sites of harvest were not noticeable. The advantage of this method is that not only a single flap but flaps of a variety of configurations can be harvested for different purposes. The thoracodorsal vascular tree-based combined fascial flaps are useful for the reconstruction of soft tissue defects in the extremities.     

Temporoparietal Fascia Flaps for Surgical Treatment of Cartilage Exposure After the First-Stage Microtia Reconstruction

Significant improvements have been achieved in microtia reconstruction using an autogenous costal cartilage framework. However, complications such as skin necrosis and cartilage exposure often destroy the final contour of the reconstructed auricle. Local fascia flaps are commonly used in salvage surgery because of their reliability and satisfactory results. Here, we report the case of a 26-year-old woman with multiple skin necroses and cartilage exposure on day 21 after the first-stage microtia reconstruction. The exposure area was covered by a temporoparietal fascia flap as a single-stage procedure. The most essential subunits survived, and the esthetic concours were harmonious and natural at 12 months postoperatively. Temporoparietal fascia flaps are recommended as the surgical treatment for multiple skin necroses and cartilage exposure in microtia reconstruction. The axial-pattern temporoparietal fascia flap is reliable for salvage auricular reconstruction and ensures satisfactory results at long-term follow-up.     

Reconstruction of hand soft-tissue defects: alternatives to the radial forearm fasciocutaneous flap

Soft-tissue defects of the hand and wrist are not an uncommon problem confronting the hand surgeon. Over the past 20 years the retrograde radial forearm fasciocutaneous flap has gained widespread acceptance in reconstruction of these defects. Appreciation of the inherent limitations of this workhorse flap and increased understanding of the blood supply of the upper extremity have prompted the development of several alternative pedicled forearm flaps. Aspects of surgical technique, specific limitations, and indications for the radial forearm fascial flap, the posterior interosseous artery flap, the retrograde radial artery perforator flap, and the dorsal ulnar artery flap are discussed and a reconstructive algorithm for flap selection is presented.     

Distant pedicle flaps for soft tissue coverage of severely burned hands: an old idea revisited

Burns to the hand that are complicated by exposure of bone, joint or tendon cannot be closed with conventional skin grafts and require flap procedures to prevent further damage. Local or regional flaps may be unavailable if electrical or blast trauma produces a large zone of injury, or when forearm burn injury extends beyond fascia. Free tissue transfer may not be tolerated by critically ill burn patients. In these circumstances, distant pedicle flaps are one option for safe and effective soft tissue coverage. Over a 5-year period, we have performed six distal pedicle flaps for coverage of exposed hand structures when local or free flaps were contraindicated or unavailable. The patients required an average of 4.5 surgical procedures to complete hand reconstruction and soft tissue coverage. Soft tissue coverage was completely successful in five patients and partially successful in one patient. Single stage local or free flaps remain the treatment of choice when burned hands cannot be covered with skin grafts. When these flap options are not available, distant pedicle flaps provide a safe alternative.     

The radial forearm flap without fascia and other refinements

The radial forearm flap is generally classified as a fasciocutaneous flap. The skin of the forearm is, however, supplied by branches from the radial artery which pierce the fascia of the forearm to course and branch subcutaneously. We have used the flap as a skin flap in 300 cases over 11 years. It is not necessary to take the fascia with the flap. Two other refinements of the forearm flap, also used over the past 11 years, are described. The venous drainage of the flap is simplified by utilising the usual anatomical confluence of deep and superficial veins at the elbow. Secondly, draping a large loop of pedicle in the neck during intraoral reconstruction enables a larger calibre vein to be used for the anastomosis, thus increasing its reliability.     

Free temporoparietal fascial flaps and full-thickness skin grafts in aesthetic restoration of the nose

Free tissue transfers have been rapidly replacing distant flaps for use in nasal reconstruction. The temporoparietal fascial flap is a thin, broad, pliable, and well-vascularized flap. It can be used to drape over the cartilaginous and bony framework of the nasal skeleton and nourish the underlying primary cartilage grafts as well as the overlying full-thickness skin graft. The thin contour of the flap is aesthetically superior to thicker skin flaps and eliminates the need for secondary defatting or touch-up procedures. A large, single sheet of full-thickness skin graft, harvested from the supraclavicular region, can be applied over the fascial flap in the same session and provide a quite acceptable color match. The authors present a case whose alar margins and atrophic nasal skin were restored in one session by primary conchal cartilage grafts, a free temporoparietal fascial flap, and a full-thickness supraclavicular skin graft.     

Reconstruction of extensive defects of the cranium using free-tissue transfer

Fourteen patients with large tissue deficits in the calvarium and orbits were reconstructed using microvascular free-tissue transfer (15 flaps). The etiology of these defects was skin neoplasms (seven), osteomyelitis (four), burn (two), and trauma (one). The free flaps used were the latissimus dorsi muscle flap with a split-thickness skin graft (seven), latissimus dorsi myocutaneous flap (two), rectus abdominis myocutaneous flap (three), radial forearm fasciocutaneous flap (two), and split-iliac crest flap (one). There was one postoperative death, one flap failure, two recurrences of neoplasm, and one loss of bone grafts and flap from infection. The free flaps can offer good results in patients undergoing wide resection in the cranium and orbits providing immediate repair with acceptable cosmetic result, minimized morbidity, and short hospitalization. However, immediate reconstruction following tumor resection carries a danger of positive margins discovered on permanent histologic sections or the difficulty in detecting recurrence underneath a bulky free flap.     

Penis reconstruction using three different operative methods.

To identify the relative success rates, including aesthetic success, of three penis reconstruction techniques, we reviewed 44 cases of penis reconstruction carried out over the past 12 years. The three operative methods we surveyed involved: lower abdominal pedicled fascia flaps; paraumbilical island flaps; and free forearm flaps. Reconstructions survived in only half of the patients receiving lower abdominal pedicled fascia flaps, but 100% success rates were obtained with paraumbilical island flaps and free forearm flaps. The paraumbilical island flap is safe in terms of its blood supply, and the operative procedure is relatively simple in that it does not require microsurgery. Although, the flap is thicker than the forearm skin flap, its shape is satisfactory in slim patients; furthermore, it can be defatted secondarily. The free forearm skin flap provides the best shape, but skilled microsurgery is necessary to carry out the procedure, and damage is likely to the forearm. In conclusion, the best methods to repair defects in the penis in our experience are the paraumbilical island flap and free forearm flap. Lower abdominal pedicled fascia flaps are unsuitable for penile reconstruction and should be used less often.     

Bipedicled fasciocutaneous flaps in the lower extremity.

It is well known that a bipedicled skin flap permits survival of longer flaps due to the secondary recruitment of vascularity. Inclusion of the deep fascia with such a flap, obeying the principles of the single-pedicled fasciocutaneous flap, provides even greater security for the immediate transposition of yet larger or riskier flaps without the need for delay maneuvers. This variation is especially valuable for the management of difficult wounds encountered in the lower extremity when no other local options may be available. Thirteen local bipedicled fasciocutaneous flaps including both vertical and horizontal orientations, without isolation of any discrete fascial perforators, have been successfully used for soft tissue coverage in the distal leg and ankle with only three (23%) minor complications as untoward sequelae. Another major advantage of this bipedicled version of the fasciocutaneous flap was that the inclusion of a distal pedicle simultaneously may be designed to prevent bone or tendon exposure at the donor site that otherwise frequently is a concern with a unipedicled flap.     

Fascial flaps based on perforators for reconstruction of defects in the distal forearm.

Twenty fascial flaps were used in the reconstruction of defects in the distal forearm, wrist and hand in 18 patients over a 2-year period. In 16 patients the fascial flaps were based on a single fascial feeding vessel or 'perforator' arising from the anterior interosseous artery and/or ulnar artery when the radial artery had been used as the donor vessel in free flap reconstruction elsewhere in the body. There was no loss of any fascial flap in the study. The use of fascial flaps based on fascial feeders of the anterior interosseous and ulnar arteries extends the range of fascial flaps that can be raised in the forearm for reconstruction of defects in the distal forearm, wrist and hand.     

Elevation of a constructed auricle using the anteriorly based mastoid fascial flap.

Two-stage methods for reconstruction of congenital microtia have been widely utilised. To obtain a desirable auriculocephalic angle and provide a nutrient support to the constructed auricle, elevation of reconstructed ears using a costal cartilage graft, the anteriorly based mastoid fascial flap transfer and a skin graft was performed as the second operation for nine microtia patients. In this procedure, the mastoid fascial flap was used instead of the temporoparietal fascial flap. Following the elevation of the reconstructed ear the anteriorly based mastoid fascial flap was harvested. A carved costal cartilage was grafted at the posterior wall of the concha and covered with the mastoid fascial flap, followed by a full-thickness skin graft from the inguinal region. The skin grafts took well and the appropriate auriculocephalic angle was preserved in all cases. This method was easy to perform and did not leave any scar in the temporal hair-bearing area.     

Extended vertical trapezius fasciocutaneous flap (back flap) in face and neck burn scar reconstruction

Elevation of the skin along with its deep fascia vascular network is a recent facility for flap design. The longitudinal trapezius fasciocutaneous flap was first introduced in 1996; at that time it did not receive much attention, although it has many significant benefits compared with other available procedures. Sixteen trapezius fasciocutaneous flaps were elevated in 15 patients for reconstruction of severe scarring of the neck and midface. All flaps were based on the deep branch of the transverse cervical artery and included the overlying fascia of the trapezius muscle. Delaying was applied for very long flaps. Two flaps developed minimal distal necrosis (<5 cm) due to longer pedicles (>10 cm below the muscle border). The results indicate that an extra-long back fascia flap based on the descending branch of the transverse cervical artery could be formed, which would be long enough to reconstruct the entire neck and safely transfer it to the midface. The vertical trapezius fasciocutaneous flap, with its abundant tissue, excellent blood supply, anatomic proximity, wide arc of rotation, and hidden donor site scar, provides a simple and reliable method for primary reconstruction of various midface and neck defects.