Suprafascial compared with subfascial harvest of the radial forearm flap: an anatomic study

PURPOSE: Inclusion of the deep fascia within the radial forearm flap is conventionally thought to be essential for flap viability. Angiography and dissection studies were used in this study to elucidate the role of the deep fascia in perfusion of the radial forearm flap. METHODS: Twenty-four radial forearm flaps were harvested from 12 fresh cadavers. Ten paired suprafascial and subfascial flaps were harvested, the radial arteries were cannulated, and methylene blue dye was injected into the radial artery followed by a barium sulfate/gelatin mixture. The flaps were digitally radiographed, and the vascular territory was measured using software. The cutaneous dye staining patterns for paired flaps were recorded photographically. Computed tomography scans were performed for 3 paired flaps to evaluate the vascular pattern within the flap. Two pairs of forearms were subjected to intravascular injection with colored latex through the brachial artery prior to flap harvest, and microdissection of the flap and fascia was performed. RESULTS: No significant difference was found in the vascular territory measured for the flap when harvested using the subfascial or the suprafascial technique. Flap dissection studies confirmed that this is because of the poorly developed subfascial plexus in the forearm, with preservation of the deep fascia not contributing to the mechanism of flap perfusion. CONCLUSIONS: Inclusion of the deep fascia during flap harvest does not contribute to the perfusion of the radial forearm flap and therefore the deep fascia does not need to be included to maintain flap vascularity.     

颞肌筋膜瓣与全厚皮片移植修复下睑凹陷性畸形

目的 探讨颞筋膜瓣或颞肌筋膜瓣与自体全厚皮片移植，在下睑凹陷性瘢痕畸形修复中的应用效果。方法 设计以颞浅动脉为蒂的颞筋膜瓣，对伴眶下壁骨缺损者同时行以颞浅、深动脉为蒂的颞肌筋膜瓣，并取耳后全厚皮片移植联合矫正下睑凹陷性畸形。结果 8例患者，术后组织瓣及皮片成活良好，凹陷处填充效果满意。随访6个月至1年，睑外翻矫正，瘢痕不显，颞部供区毛发生长良好。结论 应用颞筋膜瓣或颞肌筋膜瓣与全厚皮片移植，联合矫正下睑凹陷性畸形的方法，具有操作简便。且无明显的供区损害的特点，是修复下睑凹陷性瘢痕畸形较理想的方法。     

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.     

游离削薄股前外侧皮瓣修复手腕部软组织缺损

目的探讨游离削薄型股前外侧皮瓣修复手腕部较大面积软组织缺损的临床效果方法首先对手腕部创面控制感染，减少分泌物，术中彻底清创，对受区血管状况做出判断，保证吻合血管质量，其次切取股前外侧皮瓣后，断蒂前修薄皮瓣至浅筋膜层，一般保留穿支血管周围1．5～2．0cm血管袖组织，可仅保留1支穿支血管。皮瓣移植修复创面后密切观察血供，及时处理血管危象：结果临床应用19例，移植皮瓣均成活，其中2例手术后24h出现血液循环危象，经及时处理后恢复皮瓣血液循环。结论削薄型股前外侧皮瓣厚度适宜，供区隐蔽、简便实用，可用于手腕部创面缺损修复，尤其适用于较大面积及肌腱、血管、神经外露创面的修复     

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.     

Detail microscopic analysis of deep fascia of lower limb and its surgical implication

Background:

The knowledge regarding the structural details of deep fascia remains inadequate. It was described to be relatively avascular having predominantly protective function. Anatomical and surgical studies revealed that it had associated vascular arcade and hence incorporated it to ascertain additional vascularity to the flaps. However, not much importance has been directed towards the detailed study of the various constituents of deep fascia in order to explain its physiological and clinical implications. Therefore, this study was undertaken to unveil these details.

Materials and Methods:

Fifty fresh specimens of human deep fascia overlying the gastrocnemius muscle were analyzed regarding the (i) vasculature, (ii) matrix, and (iii) other structural elements. The deep fascia was procured in three forms; (a) both the layers, (b) superficial layer, and (c) deep layer. Detail study was conducted by light, confocal, and electron microscopy.

Results:

Under light microscopy, blood vessels including capillaries were seen associated with both the layers. Perforators traversing the intra-fascial plane could be visualized. Confocal microscope optical sections showed well-organized bright fluorescent collagen fibers and nuclei of various cells. Electron microscopic evaluation revealed many interesting constituents which are relatively unknown to the anatomist and clinicians. There were arterioles, capillaries, venules, lymphatics, nerves, mast cells, and myofibroblasts apart from collagen and elastic fibers.

Conclusion:

The detail structural analysis of deep fascia provided the clue to its rich vascularity and other structural constituents. They all contribute to enhance the vascularity and maintenance of the physiological functions of fasciocutaneous, adipofascial, and fascial flaps, frequently used for reconstructions. Thus, incorporation of deep fascia in the flaps during reconstruction is highly beneficial for ensuring optimal vascularity.     

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.     

The prefabricated superficial temporal fascia flap in noma surgery

In a series of 15 patients with facial deformity due to noma, the authors report their experience with a prefabricated superficial temporal fascia (PTF) flap performed in an African hospital. The operative method has been simplified as compared with methods described by others. In the first stage, the temporal fascia is skin grafted and the wound is closed over the graft. After only 1 week, this prefabricated flap is harvested. One of 15 flaps was discarded because of damage to the vascular pedicle. Later this situation was prevented by including a rim of deep temporal fascia in the flap. All other 14 flaps, including four osteocutaneous flaps and one flap with double sided skin grafts, survived and healed without major complications at both the recipient and the donor site. The prefabricated temporal fascia flap is a pliable and well vascularized flap with a reasonably long vascular pedicle, which can be used successfully, even under suboptimal conditions. Received: 11 November 1999 / Accepted: 20 January 2000     

The reverse sural flap: modifications to improve efficacy in foot and ankle reconstruction

The aim of this work is to evaluate the efficacy of the reverse sural flap in covering defects in the foot and ankle region when certain technical modifications are employed. We provide a retrospective review of 32 consecutive reverse sural flaps for foot and ankle defects, and compare the technique and results with other reports. There were 23 fasciocutaneous flaps, 7 fascial flaps, and 2 tissue-expanded flaps. Four flaps (12.5%) suffered significant flap loss, and 4 patients had delayed healing.Several modifications are suggested to increase the versatility of the sural flap in covering foot and ankle defects, including preserving the mesentery connecting the sural nerve to the deep fascia, inclusion of skin of the upper third of the leg, limiting pedicle width to 2 cm with preservation of a tongue-like skin process all along its length, and generous release of the fascia over the peroneal compartment. In addition, we describe the use of tissue expanded sural flaps.     

The bottom-up approach to the suprafascial harvest of the radial forearm flap

Suprafascial radial forearm flaps cause far less donor morbidity compared with the conventional method of including the deep fascia. Here we describe our technique of harvesting the flap with a bottom-up approach, which simplifies flap elevation and is safe and expedient. The radial artery pedicle is ligated distally and secured to the flap. Gentle traction on the pedicle presents the inferior surface of the pedicle, facilitating dissection. The superficial layer of the deep fascia is taken with the flap, together with a generous cuff of subcutaneous tissue above the pedicle in which vessels nourishing the flap are located. It is crucial to preserve the conjoin of the deep layer of the deep fascia to the fascia covering the brachioradialis laterally and flexor carpi radialis medially. This fascial layer prevents bow-stringing of the tendons during wrist and finger flexion and allows the use of a full-thickness skin graft to close the donor site. The latter delivers superior cosmetic results than can be achieved with a split-thickness skin graft.     

穿支皮瓣修复的新进展

目的了解皮瓣修复的新进展之一,即穿支皮瓣修复技术。方法广泛查阅近年来国内外有关各种穿支皮瓣的文献,并对其研究成果进行回顾与综合分析。结果穿支皮瓣是对传统肌皮瓣的技术改良,其优点是保留了供区的肌肉、筋膜和神经,从而将供区并发症发生率降到最低,已在临床广泛应用。结论穿支皮瓣是新的修复组织缺损的可靠技术,有可能成为缺损修复的首选皮瓣。     

Utilisation des lambeaux fasciocutanés dans les fractures ouvertes de type III à la jambe

The use of pedicular fascio-cutaneous flaps to cover Gustilo III fractures of the leg is based on the vascular anastomotic system of the fascia. This system is provided by aterial branches from the deep muscles in the proximal third of the leg and by direct fascio-cutaneous branches in the distal third. The different fascio-cutaneous flaps are described with particular attention to specific indication in tibial fractures.     

The random fasciocutaneous flap for upper extremity coverage.

Rapid and appropriate healing of any upper extremity wound is essential for preservation of normal hand function. If vascularized tissue must be used, local cutaneous flaps nourished by the multiple perforators to the fasciocutaneous plexus avoid the complexity of microsurgical tissue transfers or prolonged immobilization required for distant pedicled flaps. For small or moderate-sized defects, assuming that adequate adjacent deep fascia has remained intact, these simple, rapidly elevated, so-called random fasciocutaneous flaps deserve initial consideration, as demonstrated in all 11 cases in this reported series.     

旋股外侧动脉升支薄型皮瓣的临床应用

目的 报道临床应用旋股外侧动脉升支薄型皮瓣的成功经验．方法 自2002年10月起，以旋股外侧动脉升支为蒂切取皮瓣、并将皮瓣的深筋膜和大部脂肪去除后移植5例患者。结果所有患者皮瓣全部成活。结论 该皮瓣具有供区隐蔽，切取范围大，并可修成薄型皮瓣的优点，尤其适用于手足软组织缺损的修复。     

Demonstration of live lymphatic circulation in the deep fascia and its implication

It is well known that vascular arcades and lymphatic networks co-exist all over the body with distinct physiological functions complimentary to each other. We visualized lymphatics in the deep fascia under electron microscope using 4000 magnification. Encouraged by our previous research with demonstration of live microcirculation in the deep fascia, we successfully explored the possibility of demonstrating live lymphatic circulation. The fascial extension of inferiorly based fasciocutaneous flaps were dissected in five patients with distal leg defects. The fascial extension was mounted on a glass slide and examined under microscope using 600 magnification (×40 lens). We witnessed live microcirculation as well as live lymphatic circulation in the same field of observation with specific characteristics. A video recording was made to document these important features which to the best of our knowledge is not mentioned in the literature. The theme of this study is to explain, how by incorporating the deep fascia in the flap, besides vascularity, other physiological functions are augmented.     

吻合血管的阔筋膜瓣移植修复足部软组织缺损

目的总结吻合血管的阔筋膜瓣移植修复足部软组织缺损的临床应用结果。方法修复8例足部软组织缺损，阔筋膜瓣的血管蒂与受区的血管行端端吻合。结果阔筋膜瓣术后全部成活，取得了满意的临床效果。1例阔筋膜瓣术后发生远端尖部小片植皮坏死，经交换敷料逐渐自行愈合。供区没有发生明显的功能障碍。结论阔筋膜瓣以旋股外侧动脉降支为血供，血运丰富、血管解剖恒定、血管蒂长以及切取容易，而且较薄，适宜修复足部软组织缺损。     

改良掌背逆行岛状皮瓣的临床应用

目的：探讨切取掌背皮瓣的改进方法及其临床应用效果方法：复习相关掌背动脉解剖学研究成果,改进掌背动脉逆行岛状皮瓣的切取方法,以背侧指蹼中点和两掌骨基底部汇合点连线设计为轴线,距指蹼缘近侧约1．5cm为旋转点,在深筋膜下、伸肌腱腱膜浅层解剖皮瓣,保留掌背动脉远端皮支,临床分别应用修复12例食、中、环、小指中、近节皮肤软组织缺损。结果：12例皮瓣全部成活,1例皮瓣术后远端出现张力性水疱,皮瓣远端部分表皮坏死,后创面经换药后愈合。术后随访3～6个月,皮瓣质地、外观满意,手背部外形功能良好。结论：自深筋膜下、指伸腱膜浅面解剖皮瓣,保留掌背动脉远端皮支的掌背动脉逆行岛状皮瓣手术方法操作简便,对供区损伤小,应用于修复手指近、中节皮肤软组织软缺损创面临床效果好。     

吻合血管的阔筋膜瓣移植修复手指软组织缺损

目的 总结吻合血管的阔筋膜瓣移植修复手指软组织缺损的临床应用结果.方法 修复8例手指软组织缺损,行一期阔筋膜瓣移植加中厚网状游离植皮,供区直接缝合,阔筋膜瓣的血管蒂与受区的血管行端端吻合.结果 1例术后发生远端小片植皮坏死,经更换敷料逐渐自行愈合.7例术后经过顺利,全部成活,取得了满意的治疗效果.结论 该筋膜瓣以旋股外侧动脉降支为血供,血运丰富、血管解剖恒定、血管蒂长易于切取,而且较薄,适宜修复手指软组织缺损.     

穿支游离皮瓣修复头颈肿瘤术后缺损

目的 探索更为理想的穿支游离皮瓣修复技术，运用于头颈肿瘤术后缺损。方法 2003年12月-2005年5月用于头颈部手术缺损修复的穿支游离皮瓣共14例（股前外侧皮瓣8例，腹壁下深动脉穿支皮瓣6例）。其中10例为复发后挽救手术，12例曾行放疗（平均63．5Gy）。头颈部肿瘤手术缺损部位分别为舌体3例，颊黏膜3例，口咽壁3例，舌根2例，颅底、头皮以及中面部各1例。受区供吻合动脉主要是甲状腺上动脉和面动脉；静脉为颈内静脉。结果 13例穿支游离皮瓣成功（93％），有1例穿支皮瓣因吻合侧的颈内静脉血栓形成导致皮瓣坏死。受区未发现其它明显并发症。供区均直接缝合关闭并一期愈合，未发现腹壁疝和运动受限等手术并发症。结论 穿支游离皮瓣保留了供区的肌肉、筋膜和神经，将供区的并发症降到最低限度，是头颈部缺损修复新的可靠技术。     

颈部瘢痕挛缩手术治疗中的颏部重建

目的观察在颈部烧伤后瘢痕挛缩的手术治疗中，合理利用颈部组织瓣进行颏部重建的效果。方法对13例烧伤后颈部严重瘢痕挛缩伴颏部畸形的患者，设计以面动脉、甲状腺上动脉等分支血管供血的蒂部在上的颈阔肌肌瓣(4例)、颈部瘢痕组织瓣(6例)或颈深筋膜组织瓣(3例)，向上翻转补充颏部软组织，形成新的颏颈角及唇颏沟。应用局部扩张皮瓣(11例)、游离皮瓣(1例)或斜方肌肌皮瓣(1例)转移修复各患者的颈部瘢痕。结果本组患者术后颈部外形良好，用于颏部重建的组织瓣愈合较佳。随访10例，时间为6个月～2年，除4例患者颈部线状切口处形成瘢痕外，其余患者颏颈角及唇颏沟形态满意。结论在颈部瘢痕挛缩的手术治疗中，应用颈阔肌肌瓣、颈部瘢痕组织瓣或颈深筋膜组织瓣重建颏部方法简便、效果良好。其中应用颈部瘢痕组织瓣既可松解挛缩的瘢痕，又利于矫正颏部形态。