Anatomic basis for vascularized outer-table calvarial bone flaps

The vascularization of the scalp and calvarium was studied in cadavers to better define the design of vascularized split- or full-thickness calvarial bone flaps. Selective dye injections of the superficial temporal and internal maxillary arteries established a horizontal and vertical network of vessels within and between each layer of the scalp. The periosteum of the frontoparietal region continues over the temporal aponeurosis as a separate, distinct layer, the innominate fascia, which is irrigated by numerous proximal branches of the superficial and deep temporal arteries. The periosteum can sustain the outer table of the calvarium by means of multiple small, vertical perforators. Between the periosteum and the outer table is a thin areolar layer of subperiosteum which continues beneath the temporal muscle. We feel that vascularized outer-table calvarial flaps can safely be pedicled using only the temporal aponeurosis, innominate fascia, and periosteum without including the galea or temporal muscle.     

The anatomic basis for the platysma skin flap

Meticulous anatomic dissection of the vasculature of the superficial anterolateral neck indicates that the platysma and overlying skin are supplied by direct cutaneous arteries measuring 0.5 mm in diameter. The small arteries are branches of the postauricular and occipital arteries in the upper lateral neck, the facial and submental arteries in the upper medial neck, the superior thyroid artery in the middle of the neck, the subclavian artery in the lower medial neck, and the transverse or superficial cervical arteries in the lateral aspect of the neck. These vessels traverse the undersurface of the platysma muscle to provide blood flow to the overlying skin. As opposed to this direct cutaneous system, the myocutaneous blood supply perforating through the sternocleidomastoid is scant. The platysma skin flap will survive if the blood supply from at least one region is preserved. In addition, it may be beneficial to include the external jugular and/or the communicating veins in the flap. By following these guidelines, the platysma flap has been successfully used for facial reconstruction in 7 of 8 consecutive patients.     

An anatomic study of the septocutaneous vessels of the leg

The vascular anatomy of the skin and fascia of the leg were studied in 20 cadaver legs that were injected and dissected under magnification to identify the origin, course, and distribution of vessels from the subfascial level to the skin. In addition to the longitudinally oriented fasciocutaneous arteries and the musculocutaneous perforators, the study demonstrated a third and important system of blood supply: the septocutaneous vessels. These vessels arise directly from the posterior tibial, anterior tibial, and peroneal arteries, run along the intermuscular septum, pierce the crural fascia, and ramify radially in the subcutaneous tissue superficial to the fascia. Longitudinally oriented anastomotic arcades are formed along the leg between branches of adjacent septocutaneous vessels. Each septocutaneous vessel has one or two venae comitantes. Selected methylene blue injections of the septocutaneous vessels revealed rich staining of the superficial surface of the fascia, the subcutaneous tissue, and distinct longitudinally oriented skin territories. There was no injection of dye in the deep surface of the fascia. It is felt that the septocutaneous vessels constitute an important source of skin circulation in the leg and form the basis for various fasciocutaneous flaps that have useful clinical applications.     

Blood supply of the upper craniofacial skeleton: the search for composite calvarial bone flaps

This study investigated the blood supply of the upper craniofacial skeleton by injection studies. The major supply to the calvaria is provided by the middle meningeal artery and its branches. This vessel is difficult for the plastic surgeon to exploit in composite bone-flap design. The majority of the outer surface of the craniofacial skeleton is supplied by tiny perforators from the overlying periosteum. The vascular interconnections within the periosteum are poorly developed. For this reason, the galea and the overlying vascular network (derived from the superficial temporal, occipital, supraorbital, and supratrochlear vessels) should be left broadly attached to the bone when transferring a vascularized calvarial bone flap. Dissection of the scalp away from this vascular network should be carried out just below the hair follicles. By observing these principles, vascularized calvarial bone can be transferred on the superficial temporal, deep temporal, supraorbital, supratrochlear, or occipital vessels. Details of the use of each are discussed.     

Bilobed fasciocutaneous flap for reconstruction of the posterior neck after necrotizing fasciitis

Necrotizing fasciitis is an aggressive, deep-seated infection of the fascia and subcutaneous fat with necrosis of overlying skin. Eleven cases of necrotizing fasciitis of the posterior neck are reviewed to demonstrate the advantage of using a bilobed fasciocutaneous flap for repair following surgical debridement. Nine men and two women aged 40 to 65 years (mean age, 54.8 years) presented for reconstruction from April of 1999 to March of 2003. The blood supply of the bilobed fasciocutaneous flap originates from a constant row of musculocutaneous perforators of posterior intercostal arteries. The technique enabled regional reconstruction, conserved tissues, and provided satisfactory aesthetic results.     

Anatomical consideration of reverse-flow island flap transfers from the midpalm for finger reconstruction.

Primary soft-tissue coverage for large palmar defects of the fingers is a difficult problem for cases in which homodigital or heterodigital flaps cannot be used. The aim of this study was to explore the vascular and neural anatomy of the midpalmar area to assess the possibility of reverse island flaps from this area. In 24 cadaver hands perfused with a silicone compound, the arterial pattern of the superficial palmar arch and common palmar digital artery was examined. The cutaneous perforating arteries and nerve branches supplying the midpalmar area were dissected, and the number, location, and arterial diameter of these branches were measured. In six other specimens, the common palmar digital artery was injected to determine the skin territory supplied by the artery. The superficial palmar arch contained the three common palmar digital arteries and its terminal branch coursed along the radial margin of the index metacarpus. This terminal branch had three to six cutaneous perforators (diameter range, 0.1 to 0.5 mm) and supplied the radial aspect of the midpalmar area located over the ulnar half of the adductor pollicis muscles. The midpalmar area was divided into two regions-the proximal and distal-according to the vascular distributions. The proximal region contained dense aponeurosis and thin subcutaneous tissue, and the cutaneous perforators were rather sparse (between three and nine) and had a small diameter (0.1 to 0.3 mm). The distal region, which had loose aponeurosis and abundant subcutaneous tissue, had a rich vascular supply from the common and proper digital artery. Perforating arteries of this region coursed frequently in an oblique fashion and the number of perforators (between eight and 15) and their arterial diameters (diameter range, 0.1 to 0.5 mm) were higher than those of the proximal region. The area of skin perfused by the common palmar digital artery was 5 x 3 cm at the distal midpalmar region. There were three to five cutaneous nerve branches from the palmar digital nerve supplying the midpalmar area. From this study, two different reverse flaps were proposed. First, a 5 x 2 cm flap from the distal midpalmar region was elevated on the basis of the common and proper palmar digital artery. Measurement of the rotation arc revealed that the pivot point of this flap was located at the proximal interphalangeal joint level and could cover the finger pulp of the digits. The second flap candidate was that from the radial aspect of the midpalm, which was supplied by the terminal branch of the superficial palmar arch. In studies with cadaver hands, connection of this artery with the deep arterial system enabled this flap to reach the thumb pulp. These flaps may be a useful reconstruction option for significant palmar soft-tissue loss of the fingers.     

Clinical applications of the subgaleal fascia

The anatomic boundaries and vascular supply of the subgaleal fascia have been described previously. The thin and malleable subgaleal fascia was selected for difficult reconstructive problems in seven patients. This flap has been based on either the supraorbital or the superficial temporal vascular leash. The subgaleal fascia is readily dissected from superficial galea and deep periosteum, leaving behind a well-vascularized scalp and a skin-graftable calvarium. The flap conforms to a cartilage framework for ear reconstruction. It takes a skin graft well. The subgaleal fascia can patch dural defects and fill sinus dead space. It has been used to augment facial contour. Free vascularized transfer of the subgaleal fascia has included the temporoparietal fascia, which was partially split from the subgaleal fascia for bilobed flap resurfacing of the hand. The subgaleal fascial flap should be considered when ultrathin, vascularized coverage is needed.     

Arterial supply of the anterior ear.

Twenty cadaver auricles were injected with a latex solution to define the arterial supply of the anteroauricular surface. Two arterial networks exist, the network of the triangular fossa-scapha and the network of the concha. Both eventually communicate on the anthelix. The triangular fossa-scapha network originates from one subbranch of the upper auricular branch of the superficial temporal artery and from branches of the posterior auricular artery that come through the earlobe and triangular fossa and over the helical margin. The conchal network is provided by two to four perforators that come from the posterior auricular artery, piercing the conchal floor. Auricular branches of the superficial temporal artery in the preauricular region and their communications with the posterior auricular artery also were confirmed. We believe that a greater understanding of the detailed arterial anatomy in this area allows one to develop safely a variety of surgical techniques for reconstruction of the ear.     

The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging.

Controversy persists regarding the relationship of the superficial facial fascia (SMAS) to the mimetic muscles, deep facial fascia, and underlying facial nerve branches. Using fresh cadaver dissection, and supplemented by several hundred intraoperative dissections, we studied facial soft-tissue anatomy. The facial soft-tissue architecture can be described as being arranged in a series of concentric layers: skin, subcutaneous fat, superficial fascia, mimetic muscle, deep facial fascia (parotidomasseteric fascia), and the plane containing the facial nerve, parotid duct, and buccal fat pad. The anatomic relationships existing within the facial soft-tissue layers are (1) the superficial facial fascia invests the superficially situated mimetic muscles (platysma, orbicularis oculi, and zygomaticus major and minor); (2) the deep facial fascia represents a continuation of the deep cervical fascia cephalad into the face, the importance of which lies in the fact that the facial nerve branches within the cheek lie deep to this deep fascial layer; and (3) two types of relationships exist between the superficial and deep facial fascias: In some regions of the face, these fascial planes are separated by an areolar plane, and in other regions of the face, the superficial and deep fascia are intimately adherent to one another through a series of dense fibrous attachments. The layers of the facial soft tissue are supported in normal anatomic position by a series of retaining ligaments that run from deep, fixed facial structures to the overlying dermis. Two types of retaining ligaments are noted as defined by their origin, either from bone or from other fixed structures within the face.(ABSTRACT TRUNCATED AT 250 WORDS)     

Island scalp flap for superior forehead reconstruction

An island scalp fasciocutaneous flap, based on the posterior superficial temporal vessels, is described for single-stage reconstruction of full-thickness forehead and scalp defects. The hairline can be precisely determined and tailored to restore symmetry. By removing the hair-bearing dermis of the forehead portion of the flap and placing a full-thickness skin graft, aesthetic reconstitution of the forehead skin is achieved. This flap is especially useful when exposed calvarium limits other techniques.     

Blood supply of the abdomen revisited, with emphasis on the superficial inferior epigastric artery

The key to understanding the blood supply of the anterior hemiabdomen is knowledge of the central superficial inferior epigastric artery system and the peripheral contribution of the epigastric, deep and superficial circumflex, and iliac arteries and external oblique perforators. These systems all feed into the subdermal plexus of the anterior abdominal wall. Angiographic confirmation of multiple communications between the superficial inferior epigastric artery and other major sources of abdominal wall blood supply has been obtained. Experience using the superficial inferior epigastric artery flap as a pedicled and microsurgical transfer has been described.     

Reverse-flow island sural flap

The reverse flow island sural flap is presented as an alternative to flaps currently used for reconstruction of small and medium substance losses in the distal third of the leg, ankle, and heel. This is a random type of flap, based on the reverse flow of the superficial sural artery, which mainly depends on the anatomy of the perforators of the peroneal artery system.The anatomic structures that constitute the pedicle are the superficial and deep fascias, the sural nerve, the short saphenous vein, and the superficial sural artery. The skin island and the subcutaneous cellular tissue complement the flap proper. This skin island was demarcated at any point of the median or distal thirds of the leg, having the short saphenous vein and the sural nerve on its central axis. The distal dissection limit of the pedicle is located 5 centimeters above the lateral malleolus. This limit is established so as to ensure the integrity of the perforators from the principal arteries of the leg, mainly the peroneal artery, responsible for the reverse flow nourishing the flap. These perforators will affect anastomoses with the superficial sural artery in charge of irrigating the structures compounding the flap.A total of 71 patients were operated on with this technique, some of them with basic pathologic abnormalities limiting the distal blood flow, such as diabetes mellitus, and some others having proven vascular insufficiency or displaying unstable areas attributable to problems such as pseudarthrosis and osteomyelitis, which needed to be covered. Fifteen flaps (21.1 percent) suffered partial necrosis, which did not compromise the final result, and another three (4.2 percent) showed total loss. The flap in question has great mobility and versatility, allowing the treatment of specific areas of the lower limb, without sacrificing important arteries or mobilizing structures that might bring about functional deficits.     

Fasciocutaneous vessels in the upper arm: application to the design of new fasciocutaneous flaps

The principles of the blood supply to the upper arm are described. Despite the large, fleshy nature of the biceps and the triceps, the blood supply to upper arm skin is not from the underlying muscles, but is by fasciocutaneous perforators emerging along the medial and lateral intermuscular septa. Fifty dissections of preserved cadavers have shown that on the lateral side the fasciocutaneous perforators consistently arise from the middle collateral artery. The available length of this vessel and its diameter have been measured and are reported. The design of a flap based on this vessel, in a manner analogous to the Chinese forearm flap on the radial artery, is described.     

Anatomy of the veins of the head in the domestic fowl

The anatomy of the cephalic venous system in the fowl was studied in 19 specimens by means of latex-injected preparations and by dissection. The brain sinuses converge dorsally upon the large cervical sinus and vertebral veins. Dorso-ventral communication is provided by the occipital veins posteriorly, while the ophthalmic system unites both dorsal and ventral sinuses and the temporal rete with the extracranial veins anteriorly. The jugular veins are formed from the superficial branches of the facial veins and serve mainly as outlets for extracranial blood. They are united at the base of the head by a prominent transverse anastomosis which slopes caudally towards the larger, right jugular. As in mammals, the carotid veins envelop the internal carotid arteries and anteriorly form a bulbous sinus cavernosus around the inter-carotid anastomosis.     

Personal experiences and algorithm of endoscopically assisted subperiosteal face lift in orientals for 5 years.

Orientals are anatomically distinct from Caucasians and are characterized by a thick dermis, a Mongoloid slant of the palpebral fissure, a relatively prominent zygoma and mandible angle, and a relatively flat nose. Given these characteristics, it was believed that the subperiosteal face lift was not suitable for Orientals. However, at our institution, endoscopically assisted subperiosteal face lifts were performed from May of 1994 to October of 1998 on 236 patients; variable pitfalls, as well as satisfying results, were reported. Patient ages ranged from 29 to 66 years (mean age, 55.2 years), and follow-up ranged from 6 to 44 months (mean follow-up, 23 months). All forehead and brow lifts were performed using an endoscopic guide, and routine corrugator resections and procerus myotomies were performed. Three slanted cortical tunnels were made at the corresponding locations on the outer table of the calvarium, and 1-0 nylon or screw suspension and fixation were performed after a 1-cm to 2-cm lift. Midface lifts were performed through lower blepharoplasty incisions and vertical temporal incisions instead of through conventional preauricular and postauricular incisions. Dissections were made subperiosteally and over the deep layers of deep temporal fascia. Malar fat pads were suspended with 1-0 nylon and affixed to deep temporal fascia.Most patients have been satisfied with their postoperative results, but unfavorable results and complications have been reported. Complications were classified as early or late complications or unfavorable results on the basis of the 3-week postoperative evaluation. There were 28 early complications (11.9 percent), consisting of ecchymosis with edema (persisting for up to 4 weeks), paresthesia, lagophthalmos, accentuated Mongoloid slant, small dimpling on the scalp, and scalp fold formation on the fixation site. There were 13 late complications/unfavorable results (5.5 percent), consisting of insufficient lift, exaggeration of sunken upper eyelids, intermittent headaches, itching sensations, and paresthesia on the scalp. The unfavorable results occurred in the patients who had previously undergone blepharoplasty and in those who had a history of foreign body injections into the face, fatty and thick faces, sunken upper eyelids, Mongoloid slants, and asymmetric facial expressions. Through understanding the anatomic characteristics of the Oriental face (i.e., thick dermis, Mongoloid slant of palpebral fissure, prominent zygoma and mandible angle, and flat nose), satisfying results were achieved by appropriate application of the modified procedures.     

Anatomy of the arteries of the head in the domestic fowl

The anatomy of the cephalic arterial system in the fowl was studied in 24 specimens by means of latex-injected preparations and by dissection. Branches of the external carotid artery supply the extracranial regions. The vertebral arteries unite with the occipitals and have no major communications with the encephalic system. Blood can reach the brain directly from the internal carotid artery and indirectly by way of the extensive cerebral-extracranial anastomoses; especially prominent are those to the palatine and sphenomaxillary arteries from the maxillary and facial branches of the external carotid artery. A large external ophthalmic artery supplies the temporal rete and eye musculature, and an internal ophthalmic artery links the rete and the cerebral vessels. The circle of Willis is incomplete both anteriorly and posteriorly; the anterior cerebral arteries do not unite and the basilar artery is generally asymmetrical in origin. The basilar artery tapers caudally and is continued as the ventral spinal artery.     

The dorsal thoracic fascia: anatomic significance with clinical applications in reconstructive microsurgery

The anatomic distribution and potential arterial flow patterns of the circumflex scapular artery were investigated by Microfil injection. These studies demonstrated that the circumflex scapular artery lies within the dorsal thoracic fascia, which plays a significant role in the circulation of the overlying skin and subcutaneous tissue. We conclude that scapular/parascapular flaps are fasciocutaneous flaps, the dorsal thoracic fascia can be transferred as a free flap without its overlying skin and subcutaneous tissue, and intercommunication exists between the myocutaneous perforators of the latissimus dorsi myocutaneous flap and the vascular plexus of the dorsal thoracic fascia. We present microvascular cases in which the vascular properties of the dorsal thoracic fascia facilitated wound closure with free fascia flaps or expanded cutaneous or myocutaneous flaps.     

Retroauricular island flap for eye socket reconstruction

This paper describes the use of a flap which is the random portion of an island flap based on superficial temporal vessels. The flap has three distinct anatomic portions: the cutaneous portion, which includes the postauricular skin, the triangular deepithelialized scalp and fascia above the ear, which augments random-pattern blood circulation to the cutaneous portion, and the superficial temporal fascia encompassing the vascular pedicle, which is dissected down to the upper pole of the parotid gland and unfolded using a cutback incision between the vascular pedicle and the second portion of the flap in order to increase the reach of the cutaneous portion. The flap has been successfully used in eight patients for reconstruction of missing or contracted eye sockets. In two patients, inconsequential superficial loss of the distal portion of the distal flap was observed. This flap can also be used for reconstruction of the external face, eyelid, and palate as well as soft-tissue augmentation.     

Vascularized outer-table calvarial bone flaps

Based on an anatomic study of the vascularization of the calvarium in cadavers, a technique for the transfer of vascularized outer-table calvarial bone has been developed. The outer table of the calvarium receives numerous small perforators from its overlying periosteum. The periosteum is continuous with a distinct fascial layer overlying the temporal aponeurosis which we have termed the innominate fascia. Because of a network of anastomosing vessels from proximal branches of the superficial temporal artery and perforating branches of the deep temporal artery, the outer table of the calvarium can be carried on a pedicle which contains the temporal aponeurosis, innominate fascia, and periosteum. Thirty-seven vascularized outer-table calvarial bone flaps have been performed for a variety of craniofacial reconstructive deformities. Remarkable stability and lack of resorption have led the authors to favor this method of reconstruction particularly in poorly vascularized or previously infected recipient beds.