A clinical and histologic comparison between free temporoparietal and scapular fascial flaps

Temporoparietal Fascial Flap for Soft Tissue Reconstruction of Pediatric and Young Adult Foot Defects: A Case Series

Soft tissue defects of the foot due to trauma, infection, or malignancy are common and present a reconstructive challenge, as the foot requires specialized tissue that is thin, supple, yet durable enough to support the high demand of its function. The temporoparietal fascial flap, based on the superficial temporal artery and vein, is a reliable and versatile flap that possesses all these advantages. We present a case series detailing our experience with this flap for reconstruction of post-traumatic soft tissue defects of the foot in 4 patients (3 children and 1 young adult) with 5-year follow-up data. All patients were able to use the foot normally again to full capacity and wear normal footwear. They were also satisfied with the aesthetic outcome of the reconstruction and well-concealed donor site. This series highlights the success of this flap in providing excellent functional and aesthetic coverage for soft tissue foot defects in children and young adults, with minimal donor site morbidity.

Implications of Free Temporoparietal Fascial Flap Reconstruction in the Pediatric Population

ABSTRACT

The temporoparietal fascial flap (TPFF) is a versatile tool that can be used in the reconstruction of head and neck and distal upper and lower extremity defects. The TPFF may be harvested as a pedicle or free flap as well as with the temporalis muscle and/or adjacent calvarial bone as a composite flap. As a free flap, the TPFF has been used as a joint gliding surface with coverage of nerves and tendons, for extremity soft tissue repair, for tracheal and pharyngeal coverage and for defects of the nose, scalp, and auricle. This article focuses on the use of the free TPFF in the pediatric population through systemic review of the medical literature. Current perspectives on the use of this flap and microsurgery in general in pediatric patients are addressed.

Free Serratus Fascia Flap for Reconstruction of Soft Tissue Defects Involving the Distal Upper and Lower Extremity

BACKGROUND

Free fascial flaps are widely used for the reconstruction of defects located on the distal extremities as they provide thin yet durable soft tissue coverage. The serratus anterior fascia flap stands out from other fascial flap alternatives as it has optimal anatomical properties that can provide ideal coverage in a wide range of reconstructive challenges. The purpose of this study was to present our experience with the serratus anterior fascia flap in a variety of complex soft tissue defects.

METHODS

A retrospective review was conducted on patients who underwent reconstruction with the free serratus anterior fascia flap for complex soft tissue defects involving the distal extremities.

RESULTS

Complex soft tissue defects of 13 patients were reconstructed using the free serratus fascia flap. No major postoperative complications such as flap loss, dehiscence, infection, or hematoma were encountered in any of the patients. All of the patients demonstrated durable and harmonious long-term flap coverage that facilitated movement without any signs of scar contractures and tendon adhesions at the site of reconstruction.

CONCLUSIONS

The serratus anterior fascia flap demonstrates versatility and stability for the closure of complex distal extremity defects. It creates thin yet durable coverage that facilitates underlying tendon gliding while providing harmony with the natural contours of these anatomic areas and has low donor site morbidity, making it a primary choice in the reconstruction complex soft tissue defects involving the hands and feet.

Characterization and morphological comparison of human dura mater, temporalis fascia, and pericranium for the correct selection of an autograft in duraplasty procedures

PURPOSE

The objective of this study was to characterize and compare the morphological characteristics of the dura mater, the pericranium, and the temporal fascia to ascertain the most adequate tissue to use as a dura graft.

METHODS

20 dura mater, 20 pericranium and 20 temporalis fascia samples were analyzed. Each of the samples was stained with hematoxylin and eosin, orcein, Van Gieson, Masson's trichrome and Verhoeff-Van Gieson (600 slides in total) for a general morphological evaluation, as well as a quantitative, morphometric and densitometric analysis of elastic fibers present in each of the tissues.

RESULTS

The micro-densitometric analysis of the tissues indicated that the area occupied by the elastic fibers showed values of 1.766 ± 1.376, 4.580 ± 3.041, and 8.253 ± 4.467 % for the dura mater, the temporalis fascia and the pericranium, respectively (p < 0.05, all pairs). The values observed in the analysis of the density intensity were 3.42E+06 ± 2.57E+06, 1.41E+07 ± 1.28E+07, and 1.63E+07 ± 9.19E+06 for the dura mater, the temporalis fascia and the pericranium, respectively (p < 0.05), dura mater vs. temporalis fascia and dura mater vs. pericranium).

CONCLUSIONS

This is the first study to compare the dura mater with tissues for dural autograft and to quantify the elastic component present in these tissues. The results indicate that the temporalis fascia is a better dural graft because of its intrinsic tissue properties.

Free perivascular tissue flap transfer

Local flaps and composite grafting are the procedures of choice for reconstructing relatively small soft tissue defects. However, despite their limited conveyable volume, local flaps sometimes require a wide dissection area and long new incisions. Composite grafts also have serious limitations and require a well-vascularized recipient bed. To overcome these limitations, we used a free vascularized perivascular tissue flap based on the descending branch of the lateral femoral circumflex artery. Using this method, we performed reconstructions for seven patients (four cases in head and neck region and three cases in lower limb) with various soft tissue defects (ranged from 4.0 cm(3) to 40.0 cm(3)). This flap was easily elevated, without the need for precise preoperative flap design, and the flap volume was adjustable regardless of whether deep fascia and muscle were included. The flap has a rich vascular supply, which allows bone and cartilage tissue to be combined with the transfer of soft tissue, and satisfactorily treats chronic wounds with poor blood supply.

The reconstruction of the mutilated hand

The challenging reconstructive treatment of defects in the upper extremity requires a sound working knowledge of a variety of flaps. As the hand surgeon weighs the pros and cons of each possible flap to obtain definitive closure, he or she must also integrate the priorities of function, contour, and stability as well as the anticipation of further reconstructive surgery in choosing the flap of choice. This review describes the various flaps available for closure of soft tissue defects of the upper extremity. The principles of management of wounds of the upper extremity is described to guide hand surgeons in the early treatment of massive wounds that will eventually need free tissue coverage. Currently used flaps include fasciocutaneous, fascial, musculocutaneous, muscle, and osteocutaneous flaps. Flap selection is based on the characteristics of the defect including size, shape, and location, the availability of donor sites, and the goals of reconstruction. Improved techniques of microsurgery and an ever increasing repertoire of flaps provide the framework for hand surgeons to offer the most appropriate flap based on donor site, thickness, amount of tissue needed, and composition. A discussion of the selection of ideal flaps for any given defect should enable the reconstructive hand surgeon to provide the most appropriate coverage of wounds to the hand and upper extremity.

Free serratus anterior fascia flap for reconstruction of hand and finger defects

INTRODUCTION

Reconstruction of the dorsal surface of hand defects requires thin, pliable, well vascularized tissue with a gliding surface for the extensor tendon course. Also defects of the palmar hand and degloved fingers need non-bulky soft tissue for reconstruction. We present a retrospective analysis of nine patients with free serratus anterior fascia flaps used to cover defects of the palmar and dorsal hand and of degloved fingers.

METHODS

Three of the patients presented limited range of hand motion due to full-thickness burns; one patient had defects of the dorsum of one hand after acute burn injury. Two patients had an acute trauma of the dorsum of the hand with extensor tendon injury, another patient a soft-tissue defect of his thumb and dorsal hand due to an avulsion injury. One patient presented dorsal defect of three fingers after degloving injury. One patient had a palmar defect after industrial crush injury with exposed tendons, vessels, and nerves. The flaps were applied as pure fascial flaps with an immediate partial-thickness skin graft.

RESULTS

One patient presented a partial necrosis of <10% flap size. All other flaps survived completely. Two of the patients presented wound healing problems of the skin graft that healed secondarily. All patients recovered useful hand function without a bulky contour of their hand or fingers. Except for the scar, no donor-site morbidity was reported.

CONCLUSION

The free serratus anterior fascia flap has good functional and cosmetic properties and there is low donor-site morbidity. It is an excellent flap for soft-tissue reconstruction combined with extensor tendon reconstruction on the dorsum of the hand. The flap is also very useful for palmar and finger defects.

Anatomical study of subcutaneous adipofascial tissue: a concept of the protective adipofascial system (PAFS) and lubricant adipofascial system (LAFS)

The subcutaneous adipofascial tissue over the entire body was radiographically and macroscopically investigated in 20 fresh and embalmed cadavers. The subcutaneous adipofascial tissue was made up of two adipofascial layers. Because the superficial layer forms a solid structure and is thought to protect against external forces, the adipofascial system formed by the solid structure was named the "protective adipofascial system (PAFS)". Because the deep layer forms a mobile layer and is thought to lubricate musculoskeletal movement, the adipofascial system formed by the mobile structure was named "lubricant adipofascial system (LAFS)". By classifying subcutaneous adipofascial tissue by its functional characteristics, we found we could understand the subcutaneous adipofascial structure over the entire body well.

Coverage of soft-tissue defects of the hand with free fascial flaps

Coverage of exposed functional structures such as tendons, bones, vessels, or nerves at the dorsal and palmar surface of the hand requires thin, supple tissue to provide adequate range of motion and a satisfying aesthetic result. The purpose of this retrospective study was to evaluate the functional and aesthetic results after coverage of the hand with free fascial flaps. From 1994-2002, 14 patients underwent free fascial flap coverage of the hand with 4 tempo-parietal fascia flaps and 11 serratus fascia flaps. Eight patients could be reexamined and answered a questionnaire about their satisfaction with the functional and aesthetic results. The mean follow-up was 41.7 months. Average active range of motion of the hand, functional improvement, and the aesthetic result were satisfying in all follow-up patients. No secondary debulking or other contouring procedures were required. We recommend the use of free fascial flaps as a valuable alternative to fasciocutaneous or muscle flaps, since the functional results are excellent, no additional procedures were necessary, and the aesthetic results are appealing.

Use of Free Serratus Anterior Muscle Slips for the Reconstruction of Dorsal-Side Defects of the Hand Resulting From Hot Press Injury

Mutilation of the hand as a result of hot press injury, the common characteristics of which are extensive soft tissue and extensor tendon loss, metacarpal and phalangeal necrosis, exposition of multiple joints, and infection, presents a serious challenge to the hand surgeon. Free transfer of the inferior three slips of the serratus anterior muscle is a useful surgical option for the reconstruction of dorsal-side defects in the hand. The versatility of the three separate slips, which are easily divisible for contouring, enables individual reconstruction of the different digits. Long vascular pedicle, low donor-site morbidity, and durability are other advantages. Four male patients with hot press injury of the dorsal side of the hand were treated with free transfer of serratus anterior muscle slips and split-thickness skin grafts. Follow-up period ranged between 5 and 12 years. Late functional and cosmetic results are presented.

Prefabricated galeal flap based on superficial temporal and posterior auricular vessels

Scalp layers are widely used in reconstructive procedures. The authors used prefabricated galeal flaps based on the superficial temporal or postauricular vessels for ear, cheek, mandible, and cranium reconstructions in three cases. In case 1, synchronous beard and ear reconstructions were accomplished by using the temporoparietal and retroauricular flaps. In case 2, a buccomandibular defect was reconstructed by transposing the supra-auricular and retroauricular galea with prefabricated bone and skin. In case 3, an epidural hematoma in the left frontoparietal area was evacuated after a circular craniectomy. The harvested bone was not put back on the defect area but buried between the periosteal and galeal layers because of brain edema. These layers were raised as an osteogaleoperiosteal flap and transposed onto the defect area after 7 weeks. When used with a prefabrication method, scalp layers offer versatile options for repairing composite defects of the head region. A galeal flap based on the posterior auricular vessels is practical and reliable in reconstructive procedures. The authors suggest that this flap is an option in cases in which the temporoparietal fascia artery or the superficial temporal artery is not available. Prefabrication of the harvested cranial bone inside the adjacent tissues offers several advantages in that a viable bone is provided at the end of the procedure, intervention at a distant area is avoided, the graft is placed on osteogenic tissue (periosteum) that is also transposed onto the defect, and sophisticated procedures such as microsurgical techniques are not needed.

Soft tissue coverage in devastating hand injuries

Plastic surgical therapy of mutilating hand injuries represents a multifaceted task to the hand surgeon, where considerations about indication, timing, and structure of the soft tissue coverage play a major role in reconstruction. The concept of early primary reconstruction (including emergency procedures) and fast rehabilitation not only demands thoughtful tissue preparation but also mastering of a bandwidth of plastic surgical techniques. Systematic algorithms based on the reconstructive ladder help in decision making in the complexity of soft tissue coverage but have to be adjusted to the individual case profile. General considerations and strategic planning are explained and illustrated by three clinical cases.

Soft tissue coverage options for dorsal foot wounds

The soft tissue of dorsum of the foot consists of a thin pliable surface that allows for significant excursion and tendon gliding. Reconstructive options must preserve these important functions and allow for reasonable contour so the patient may wear a shoe postoperatively. Special attention must be given to the mechanism of injury and overlying pathophysiology involved with each wound. Local flaps can provide adequate wound coverage in settings in which the vasculature and subcutaneous structures have been preserved. In wounds in which the regional vascularity is compromised or in which tendon and bone have been lost, a free-tissue transfer can provide for more substantial coverage. The multiple options available with free-tissue transfer allows for the possibility of composite tissue transfer, including vascularized bone or tendon, and the ability to create a sensate flap with excellent contour.

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.

The combined use of a pedicled Scarpa's fascia flap and a groin flap for simultaneous coverage of dorsal and palmar finger defects

A case is reported in which the dorsal and palmar aspects of the fingers in a severely crushed hand were covered by combining a pedicled Scarpa's fascia flap and a groin flap. Secondary heterotopic finger transposition was additionally performed to restore satisfactory hand function. An acceptable result was obtained.

Three-dimensional reconstruction of cutaneous arteries of the back by computer graphic imaging

Computer graphics using a personal computer were introduced to demonstrate the three-dimensional architecture of cutaneous arteries of the back in humans: the direct cutaneous artery of the circumflex scapular artery and the perforating cutaneous branches and musculocutaneous perforators of the superficial cervical, posterior intercostal, and thoracodorsal arteries. The entire thickness of the skin and underlying subcutaneous tissue over the deep fascia was obtained from five fresh cadavers injected systemically with lead oxide-gelatin mixture, and the integument was divided into the three layers; the skin, superficial adipofascial layer with the superficial fascia, and the deep adipofascial layer. Computer graphic reconstruction of the cutaneous arteries was performed using data based on angiograms of the three layers. The computer graphic depictions demonstrated in which layer cutaneous arteries branched and how the vessels were running in each layer by displaying each layer in different colors: red, yellow, and blue. Knowledge of the three-dimensional structure and architecture of the cutaneous arteries will aid in the development of flaps that use a portion of the skin and subcutaneous adipofascial tissue.