Double-layered free temporal fascia flap as a two-layered tendon-gliding surface

We report the use of a two-layered free fascial flap consisting of temporoparietal and deep temporal fascia based on a single vascular pedicle, the superficial temporal artery and vein. The flap was used to reconstruct an extensive degloving injury of the dorsum of the hand, in which multiple intact extensor tendons lay fully exposed on all sides, with exposed bone beneath them. By sandwiching the tendons between the layers of vascularized fascia, gliding surfaces were provided, both superficial and deep to the exposed tendons. The single-stage reconstruction was completed with a split-thickness skin graft. The patient returned to heavy manual work within 12 weeks of injury. He obtained an excellent range of movement without the need for tenolysis.     

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.     

Free anterolateral thigh adipofascial perforator flap

The anterolateral thigh adipofascial flap is a vascularized flap prepared from the adipofascial layer of the anterolateral thigh region. It is a perforator flap based on septocutaneous or musculocutaneous perforators of the lateral circumflex femoral system. With methods similar to those used for the free anterolateral thigh flap, only the deep fascia of the anterolateral thigh and a 2-mm-thick to 3-mm-thick layer of subcutaneous fatty tissue above the fascia were harvested. In 11 cases, this flap (length, 5 to 11 cm; width, 4 to 8 cm) was used for successful reconstruction of extremity defects. Split-thickness skin grafts were used to immediately resurface the adipofascial flaps for eight patients, and delayed skin grafting was performed for the other three patients. The advantage of the anterolateral thigh adipofascial flap is its ability to provide vascularized, thin, pliable, gliding coverage. In addition, the donor-site defect can be closed directly. Other advantages of this flap, such as safe elevation, a long wide vascular pedicle, a large flap territory, and flow-through properties that allow simultaneous reconstruction of major-vessel and soft-tissue defects, are the same as for the conventional anterolateral thigh flap. The main disadvantage of this procedure is the need for a skin graft, with the possible complications of subsequent skin graft loss or hyperpigmentation.     

Surgical anatomy and blood supply of the fascial layers of the temporal region

In 15 fresh cadavers (30 sides), we studied the two layers of fascia in the temporal region, with particular regard to their blood supply and to their usefulness--together or separately--as microvascular free-tissue autografts. The superficial temporal fascia (temporoparietal fascia, epicranial aponeurosis) lies immediately deep to the hair follicles. It is part of the subcutaneous musculoaponeurotic system and is continuous in all directions with other structures belonging to that layer--including the galea above and the SMAS layer of the face below. The deep temporal fascia (temporalis fascia, investing fascia of temporalis) is separated from the superficial fascia by an avascular plane of loose areolar tissue. It completely invests the superficial aspect of the temporalis muscle down to (but not beyond) the zygomatic arch. It is firmly attached to periosteum all around the margin of the muscles. Below it is attached to the upper border of the zygomatic arch. We found the deep temporal fascia to be supplied solely by the middle temporal artery, a constant branch of the superficial temporal. The middle temporal artery arises 1 to 3 cm below the upper border of the zygomatic arch, runs always superficial to the arch, and enters the deep temporal fascia immediately above that layer's attachment to the zygomatic arch. If the middle temporal vessels are protected, the two layers of temporal fascia can be raised together as a fully vascularized tissue island. This island can be fashioned as a bilobed or a double-layered flap, depending on the manner of dissection. The potential surgical usefulness of these findings is discussed.     

Prefabricated superficial temporal fascia flap combined with a submental flap in noma surgery

The authors report their experience with a new procedure: the combination of a prefabricated superficial temporal fascia flap and a submental flap performed in an African hospital on five patients with cheek deformities caused by noma. The prefabricated superficial temporal fascia flap makes the inner lining of the cheek, which is anchored on the peripheral scar tissue. The submental flap is released during the second operation and makes the outer lining. The main advantages are the excellent aesthetic color of this last flap and the short distance between the donor site and the recipient site. Moreover, the submental flap is positioned in a single operation (when the outer-lining reconstruction is performed with a deltopectoralis flap, a third operation is necessary to cut the pedicle). None of the flaps failed, and the functional results were good. The prefabricated superficial temporal fascia flap and submental flap are versatile and reliable flaps, with reasonably long vascular pedicles, that can be used successfully, even under suboptimal conditions in weak patients with huge defects of the face.     

V-Y advancement flaps in the reconstruction of skin defects of the posterior heel and ankle

A V-Y advancement pedicle flap including fascia has been used for reconstruction of soft-tissue defects of the posterior heel and ankle region. This flap has been used to cover 17 defects in 16 patients ranging in age from 4 to 58 years, and results have been good. We limited this application to patients without systemic disease and under 60 years of age and did not apply it to the elderly, debilitated, or systemic vascular damaged patients. There were no complications or loss of overlying skin, with the exception of one superficial tip necrosis of the flap. The results indicate the reliability and usefulness of this procedure in coverage of the posterior heel and ankle regions. It is a relatively quick and simple procedure that is without a free skin graft, and it involves only one stage that adequately corrects the skin defect at the posterior heel and ankle without prolonged splintings and results in negligible deformity of the donor site.     

A fasciocutaneous flap for vaginal and perineal reconstruction

A skin and fascia flap from the medial thigh is proposed for vaginal and perineal reconstruction. Dissection, vascular injection, and radiographs of 20 fresh cadaver limbs uniformly demonstrated the presence of a communicating suprafascial vascular plexus in the medial thigh. Three to four nonaxial vessels were consistently found to enter the proximal plexus from within 5 cm of the perineum. Preservation of these vessels permitted reliable elevation of a 9 X 20 cm fasciocutaneous flap without using the gracilis muscle as a vascular carrier. Fifteen flaps in 13 patients were used for vaginal replacement and coverage of vulvectomy, groin, and ischial defects. Depending on the magnitude of the defect, simultaneous and independent elevation of the gracilis muscle provided additional vascularized coverage as needed. Our experience indicates that the medial thigh fasciocutaneous flap is a durable, less bulky, and potentially sensate alternative to the gracilis musculocutaneous flap for vaginal and perineal reconstruction.     

Prefabricated thin flap using the transversalis fascia as a carrier.

To harvest a thin flap from the groin and hypogastric area, the authors developed a new prefabricated flap using the transversalis fascia as a carrier. The transversalis fascia is a very thin and abundantly vascularized tissue nourished by the deep inferior epigastric vessels. Flap prefabrication was performed by inserting the transversalis fascia between the thinly undermined skin flap and the tissue expander placed beneath the skin flap, followed by a pretransfer delay procedure around the flap. After a 3-week interval, the flap was transplanted with no complications, such as congestion and thrombus of anastomosis. By using this technique, it was possible to elevate an equally thin flap from the groin and hypogastric area while avoiding morbidity of the donor site.     

The sandwich temporoparietal free fascial flap for tendon gliding.

Microsurgical transfer of the superficial and deep temporal fascia based on the superficial temporal vessels has been documented. This article analyzes the functional recovery when each layer of this facial flap is placed on either side of reconstructed or repaired tendons, to recreate a gliding environment. This fascial flap also provided a thin, pliable vascular cover in selected defects of the extremities.Six patients (four male and two female) with tendon loss and skin scarring of the hand (three dorsum, one palmar, and one distal forearm) and posttraumatic scarring of the ankle with tendoachilles shortening (one patient) underwent this procedure. No flap loss was witnessed. Good overall functional recovery and tendon excursion were observed. Complication of partial graft loss was observed in two patients.     

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.     

Temporoparietal fascia: an anatomic and histologic reinvestigation with new potential clinical applications

Temporoparietal fascia constitutes a very important structural unit from both an aesthetic and a reconstructive surgical point of view. A histologically supported anatomic study was conducted for the reappraisal of the anatomic relationships and clinical application potentials of the data obtained. Anatomy of the temporoparietal fascia was investigated on 20 sides from 10 cadavers. After dissections, necropsies were obtained to demonstrate histologic features of the temporoparietal fascia. The outer part of the temporoparietal fascia is continuous with the superficial musculoaponeurotic system (SMAS) in the inferior border and with orbicularis oculi and frontalis muscles in the anterior border. Therefore, plication of the temporoparietal fascia can increase tightness of the SMAS, orbicularis oculi, and frontalis muscle in rhytidectomy. The frontal branches of facial nerve were noted to course parallel to the frontal branch of the superficial temporal artery, lying deeper to the temporoparietal fascia within the innominate fascia. In the view of these findings, conventional subfascial dissection, which is performed to protect frontal branches of the facial nerve, is not reasonable during the temporal part of rhytidectomy. Careful subcutaneous dissection just under the hair follicles is more appropriate to avoid nerve injury and also provides excellent exposure of the temporoparietal fascia for plication in rhytidectomy with protection of the auriculotemporal nerve and the superficial temporal vessels. Furthermore, two layered structures of the temporoparietal fascia are very suitable to insert a framework into the temporoparietal fascia for ear reconstruction to eliminate some of the shortcomings of Brent's technique. A thin muscle layer was also noted within the outer part of the temporoparietal fascia below the temporal line; the term "temporoparietal myofascial flap" would, therefore, be more accurate than "temporoparietal fascial flap." Finally, the innominate fascia and the deep temporal fascia can be elevated with the two layers of the temporoparietal myofascial flap to obtain a well-vascularized, four-layered myofascial flap based on the superficial temporal vessels. This multilayered flap can be used to reconstruct all defects when fine, pliable, thin, multilayered flaps are required.     

Prefabricated temporalis fascia pedicled flap for previously skin-grafted contracted eye socket

The use of free skin, mucous membrane, or dermis-fat grafts in eye socket reconstruction proved to be unsatisfactory in long-term follow-up because of the progressive contraction of the socket. For achieving eye socket expansion of proper size and shape and a good vascularized lining that can last despite eventual fibrosis, a prefabricated temporalis fascia flap pedicled on the superficial temporal bundle is described in this report. In this technique, a split-thickness skin graft is applied over the termporalis fascia to create a sort of prefabricated flap, on which the proper dimensions of the socket can be fabricated on the grafted temporalis fascia. This study was conducted on 17 patients who had previously undergone eye socket reconstruction with skin graft after posttraumatic enucleation. All patients presented with a contracted eye socket, which manifested clinically by extrusion and migration of the ocular prosthesis. The procedure was performed in two stages. The purpose of prefabrication was to provide the proper shape and size of the newly created socket after release of skin-graft contracture to get a proper fit of the prosthesis, because the flap is thin and can be shaped well. The follow-up period ranged between 1 and 5 years, and the results were good.     

The reversed fasciosubcutaneous flap in the leg

A reversed fasciosubcutaneous tissue flap in the leg is described. This distally based flap is vascularized by the perforating cutaneous branches of the peroneal and tibialis posterior arteries. It must carry all its subcutaneous tissue. A study on the vascularization of the subcutaneous tissue reveals the predominance of the vascular network in this layer with regard to the dermal or fascial plane. The dermal vascular network at the donor site is sufficient to let the skin survive without its underlying subcutaneous vascular support. The flap can reach the malleolar and heel region. The advantages of this technique are (1) easy dissection, (2) preservation of the major vascular pedicles of the lower limb, (3) skin preservation at the donor site, thus preserving the shape of the limb, and (4) versatility (it is supple and can adapt to every surface, and it can be grafted on the deep or the superficial side). The addition of this technique to the armamentarium of the reconstructive surgeon has proved to be very useful in repairing soft-tissue defects in the lower limb. Often it can replace the classical fasciocutaneous flap or even a free flap.     

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.     

Prefabrication of composite free flaps through staged microvascular transfer: an experimental and clinical study

The feasibility of prefabricating free flaps by inducing, through the process of staged reconstruction, an arteriovenous bundle and its surrounding fascia to perfuse a selected block of tissue was investigated experimentally and clinically. Sixteen rat knee joints were wrapped with their ipsilateral superficial inferior epigastric (SIE) fascia. In 8 joints, the composite flaps were resected en bloc and were immediately replaced orthotopically pedicled upon the superficial inferior epigastric vessels. In the remaining joints, the resection and orthotopic transfer were performed 2 weeks later. Only the joints in the latter group, which benefited from the staging period, were found to be perfused. The long finger proximal interphalangeal joint of a child was reconstructed by the staged microvascular transfer of his second toe proximal interphalangeal joint. At the first stage, a temporalis fascia flap was wrapped around the toe proximal interphalangeal joint and revascularized to the dorsalis pedis vessels. Six weeks later, the joint and its temporalis fascia envelope were dissected, and the "prefabricated" joint flap was transferred to the hand and revascularized to the wrist vessels. Bony union progressed uneventfully with excellent recovery of the range of motion. We conclude that regardless of the indigenous vascular anatomy, an unlimited array of composite free flaps can be constructed and transferred based on induced large vascular pedicles.     

Sequential vascularized iliac bone graft and a superficial circumflex iliac artery perforator flap with a single source vessel for established mandibular defects

The major problems in dealing with established mandibular loss are severe soft-tissue contracture and a limited number of recipient vessels. The skin portion of the iliac osteocutaneous flap often necrotizes in cases without perforators of the deep circumflex iliac vessel. To overcome these problems, eight patients with established mandibular loss and no skin perforators of the deep circumflex iliac vessel were treated with a sequential vascularized iliac bone graft and a superficial circumflex iliac perforator flap with a single recipient vessel. Regarding the recipient vessels, the ipsilateral cervical vessels were used for four patients, and the contralateral facial and ipsilateral superficial temporal vessels were used for two cases each. The superficial circumflex iliac perforator flaps were 7 to 28 cm in length and 3 to 15 cm in width. The iliac bone grafts ranged from 7 to 13 cm in length, and three cases were repaired with the inner cortex of the iliac bone. There were no serious complications, such as flap necrosis or bone infection and resulting absorption. The advantages of this method are that both pedicles are very close to each other and of suitable diameter for anastomosis. Simultaneous flap elevation and preparation for the recipient site is possible. The skin flap and vascularized bone graft can be obtained from the same donor site. A single source vessel can nourish both the large skin area and bone sequentially. Longer dissection of the superficial circumflex iliac system to the proximal femoral division is unnecessary. A large flap can survive with a short segment of the superficial circumflex iliac system. Only the vascularized inner cortex of the iliac bone needs to be used, and the outer iliac cortex can be preserved, which results in less morbidity at the donor site.     

Live demonstration of microcirculation in the deep fascia and its implication

The rich vascular network in the deep fascia has been emphasized by various scientists, but the actual demonstration of live circulation in the deep fascia has not previously been witnessed. Encouraged by the sight of live circulation in the web membrane of toad hind limb, a successful attempt was made to demonstrate the live circulation in the vascular network of the deep fascia. Fascial extensions of inferiorly based fasciocutaneous flaps were dissected in five patients with distal leg and heel defects. The fascial extension in continuity with a proximal retrograde fasciocutaneous flap was mounted on a glass slide and examined under a microscope. The authors witnessed the live microcirculation and the movement of individual red blood corpuscles in vascular channels of the deep fascia. The authors also noticed that the deep fascia has two layers with circulations that are independent of one other. A video recording was made to document these important features.     

Mandibular reconstruction with vascularized iliac crest: a 10-year experience

Since 1978, 35 patients have undergone mandibular reconstruction with vascularized iliac crest. During this time, the technique of raising and shaping the iliac crest has undergone a series of modifications. Initially, osteocutaneous segments based first on the superficial circumflex iliac system and later on the deep circumflex iliac system were used. More recently, only the inner table of the ilium has been employed, and where intraoral lining is required, an ulnar forearm free flap has been added. Thirty-two patients were reconstructed successfully. Of the three anastomotic failures, one bony segment was able to survive as a free graft. There were no donor-site complications. With continued experience, operative morbidity has been minimized, while the technique has been modified to tailor the reconstruction to the specific requirements of the patient. It is concluded that vascularized iliac crest provides the most appropriate mandibular reconstruction for a range of congenital and acquired defects.     

The reverse auricular flap: a new flap for nose reconstruction.

In the present article, the authors describe a new chondrocutaneous island flap from the ear helix for nose reconstruction. Anatomic studies showed that helix vascularization depends mainly on the superficial temporal vessels. The presence of vascular communications between the anterior frontal branch of the superficial temporal system and the supraorbital and supratrochlear arterial systems allows this flap to be used in a reverse vascular flow fashion. This new flap has been used successfully in seven cases for reconstructing composite defects of the nasal tip and ala. The donor-site defect is repaired with an advancement and rotation flap from the helical rim, leaving an inconspicuous scar and giving an acceptable cosmetic result of the donor area.