FLAPS WITH AXIAL VASCULAR PATTERN IN CRANIAL-FACIAL SURGERY, TYPES, ADVANTAGES AND DISADVANTAGES, INDICATIONS, APPLICATIONS. MICROSURGERY DEFECTS OF THE MAXILLO-FACIAL AREA SOFT TISSUES AND BONES: NATURE, INDICATIONS, TECHNIQUES AND EQUIPMENT FOR OPERATIONS.
Introduction
Axial pattern flaps are pedicle grafts which incorporate a direct cutaneous artery and vein into the base of the flap. Major tributaries of these vessels run the length of the flap to a variable degree. Inclusion of direct cutaneous arteries allow the surgeon to create flaps of greater dimensions compared to skin flaps based on the subdermal plexus circulation.
It is not necessary, nor is it possible, to include a direct cutaneous artery (and vein) into every flap created. The axial pattern flaps designed for veterinary use have been mapped over known major direct cutaneous vessels, utilizing regional anatomic landmarks. Effective use of a given axial pattern flap will depend on the size and location of the defect in relation to a given pedicle graft’s arc of rotation. The vessels
must be preserved for complete flap survival: occlusion of the artery and vein will result in an average loss of 50% of a given axial pattern flap.
Axial pattern flaps generally are used to close larger wounds in the head, neck, trunk, and upper to mid- extremity regions. In cats, and smaller dogs with comparatively short legs in proportion to the trunk length, the thoracodorsal and caudal superficial epigastric flaps can extend to the distal areas of the limbs.
Prior to the use of an axial pattern flap, the surgeon should consider alternative techniques that may be technically easier to perform that can achieve the desired functional results. The most useful alternative techniques include the use of local flaps, skin stretchers, skin grafts, and myocutaneous flaps. Careful assessment of the wound will help determine if closure can be achieved by the natural healing processes of wound contraction and epithelialization.
Craniofacial surgery
Craniofacial surgery is a surgical subspecialty of plastic surgery and oral and maxillofacial surgery that deals with congenital and acquired deformities of the skull, face, and jaws. Although craniofacial treatment often involves manipulation of bone, craniofacial surgery is not tissue-specific, i.e., craniofacial surgeons deal with bone, skin, muscle, teeth, etc. Craniofacial surgery does not, however, include surgery of the brain or eye.
Defects typically treated by craniofacial surgeons include craniosynostosis (isolated and syndromic), rare craniofacial clefts, acute and chronic sequellae of facial fractures, cleft lip and palate, micrognathia, Treacher Collins Syndrome, Apert’s Syndrome, Crouzon’s Syndrome, hemifacial microsomia and many others.
Training in craniofacial surgery usually consists of a 1-year surgical fellowship completed after a residency in either plastic surgery, oral and maxillofacial surgery, or otolaryngology.
Craniosynostosis
Fig. 1 Cranial sutures viewed from top of head
Fig. 2 Skull deformities associated with single suture synostosis
The bones of the human skull are joined together by cranial sutures (see figure 1). The anterior fontanelle is where the metopic, saggital and coronal sutures meet. Normally the sutures gradually fuse within the first few years after birth. In infants where one or more of the sutures fuses too early the growth of the skull is restricted, resulting in compensation mechanisms which cause irregular growth patterns. Growth in the skull is perpendicular to the sutures. When a suture fuses too early, the growth perpendicular to that suture will be restricted, and the bone growth near the other sutures will be stimulated, causing an abnormal head shape. The expanding brain is the main stimulus for the rapid growth of the skull in the first years of life. Inhibited growth potential of the skull can restrict the volume, needed by the brain. In cases in which the compensation does not effectively provide enough space for the growing brain, craniosynostosis results in increased intracranial pressure.[1]
Craniosynostosis is called simple when one suture is involved, and complex when two or more sutures are involved. It can occur as part of a syndrome or as an isolated defect (nonsyndromic).[2]
There are several classifications of deformities of the human skull, we will discuss them in order of prevalence.
Scaphocephaly
In scaphocephaly the saggital suture is prematurely fused. The saggital suture runs from the front to the back of the head. The shape of this deformity is a long narrow head, formed like a boat (Greek skaphe, “light boat or skiff”). The incidence of scaphocephaly is 2.8 per 10 000 births in the
Trigonocephaly
In trigonocephaly the metopic suture is prematurely fused. The metopic suture is situated in the medial line of the forehead. Premature fusion of this suture causes the forehead to become pointed, giving the head a triangular shape when viewed from above (Greek trigono, “triangle”). The incidence of trigonocephaly is 1 – 1.9 per 10 000 births in the Netherlands.[3]
Plagiocephaly
In plagiocephaly one of the coronal sutures is prematurely fused. The coronal sutures run over the top of the head, just in front of the ears. The shape of this deformity is an asymmetrical distortion (flattening of one side of the head) as you can see in figure 2. The incidence is 1 in 10 000 births.[3][5]
Brachycephaly
In brachycephaly both of the coronal sutures are prematurely fused. The shape of this deformity is a wide and high head. The incidence at birth is 1/20 000.[6]
Surgical procedures
Fig. 3 Locations of the incisions used in fronto-supraorbital advancement.
In cases where the forehead is involved (trigonocephaly and plagiocephaly), a technique called fronto-supraorbital advancement is used to correct the shape of the head. The procedure is performed at a young age in order to provide the brain with enough space to grow and prevent further abnormal growth of the skull. Fronto-orbital advancement literally means moving the front of the skull including the eye sockets forward. A section of the skull, ranging from the coronal sutures to the eye sockets is cut loose in order to correct the shape of the skull. The incision is cut in a zigzag shape from ear to ear so that the hair will cover the scar and make it less visible. The incision is made to the bone only, leaving the underlying meninges intact. The top half of the eye sockets is cut loose. Once the eye socket section has been cut loose, a vertical incision is made in the midline, and the whole section of the eye socket is bent outwards in order to correct the pointed shape of the forehead. Because the section is now too wide, a wedge needs to be cut on either side to allow the section to fit into the skull. Figure 4 shows the sections that are loosened and adjusted, and figure 3 shows the location of the vertical incision (arrow A) and the two wedges (arrow B).
In scaphocephaly the sagittal suture is prematurely fused, preventing the skull from growing perpendicular to the suture. Thus the head becomes very narrow and long. If a scaphocephaly is diagnosed within 4 to 5 months after birth, it can be corrected with a relatively simple procedure whereby the saggital suture is surgically reopened. Once the suture has been opened the bone segments will be able to grow again and the head can regain its normal shape. This operation is only performed on patients younger than five months old with a scaphocephaly. This is due to the fact that the bone segments only have the ability to adapt so severely when the operation is performed at this young age. A scaphocephaly that is diagnosed and treated later in life requires a more extensive secondary operation than one which is treated before five months.
Fig. 4 Bone segments that are removed in fronto-supraorbital advancement
Ethical considerations
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Craniosynostosis
Before and After
It is estimated that 1 of 3,100 to 3,500 infants are diagnosed with craniosynostosis or premature fusion of the cranial sutures (spaces between the skull bone plates).
Although many infants have mis-shapened heads from:
Delivery at birth and positioning on the back (deformational plagiocephaly)
Tight neck muscles (torticollis)
Ocular movement problems
Cervical spine abnormalities
These groups of patients do not require surgery
Patients with craniosynostosis require surgical release of the fused sutures (excision) and cranial vault remodeling.
Before and After
At UCLA the craniofacial team of craniofacial surgeons, neurosurgeons, pediatricians, geneticists and others evaluate all patients and recommend treatment. Procedures are tailored to the individual needs of the patient. The team is very experienced in treating patients with:
scaphocephaly or sagittal suture fusion
plagiocephaly or unilateral coronal suture fusion
brachycephaly or bilateral coronal synostosis
trigonocephaly or metopic suture fusion
(the more rare) lamboidal synostosis or posterior plagiocepahly.
The team works closely with the UCLA pediatric anethesiologists and critical care team who provide a safe recovery.
CF Syndromes
Craniosynostosis or premature cranial suture fusion may be nonsyndromic and occur as an ‘isolated’ happening.
Cranioysnostosis may also occur along with other anomalies in well-defined patterns that make up clinically recognizable syndromes. Syndromic craniosynostosis is often caused by genetic abnormalities. (It may be passed on from one generation to the next or occur by a new mutation). Recently, some syndromic craniosynostosis have been found to map to FGFR (fibroblast growth factor receptor) genes.
There are almost 100 reported craniosynsotosis syndromes. The most common ones include: Apert, Crouzon, Pfeiffer and Saethre-Chotzen Syndromes. Most patients with craniosynsotosis syndromes have normal intellegence but may be treated by others as developmentally slow or retarded until correction of their facial anomalies are performed.
The UCLA Cranifacial Clinic Treatment Protocol for these disorders is designed to maximize the benefits of corrective surgery and minimize the numbers of procedures. Timing of the procedures (optimal age) may vary depending on the diagnosis and individual patient’s functional needs (ie. elevated intracranial pressure, airway obstruction, eye exposure problems, etc.)
6 months: (Craniosynostosis): Release of fused cranial sutures and Frontal-Orbital Advancement (forward movement of forehead and brow).
6-10 years: (Mid-face hypoplasia): Le Fort III or Monobloc (forehead and midface) advancement by distraction osteogenesis (gradual lengthening).
6-10 years: (Hypertelorism): Facial Bipartition or orbital box-osteotomy correction.
15-20 years(age of facial skeletal maturity): (Malocclusion) Othodontic preparation followed by orthognathic (jaw) surgery.
15-20 years (after orthognathic procedure) : Septorhinoplasty may be beneficial. Other procedures may be required during childhood. For instance, patients with cleft palate defects undergo initial palatal closure at 1 year of age.
Apert Syndrome may occur in 1 in 160,000 births. Craniosynostosis typically involves the bilateral coronal sutures resulting in a turribrachycephalic shape with a broad, flat forehead and occipital (back of head) flattening. The lambdoidal suture may also be involved. Mid-face hypoplasia results in proptosis (eyes bulging), possibly hypertelorism (eyes widened) and class III malocclusion (‘underbite’). Hand polysyndactyly or complex fusion of the fingers may result in a mid-digit hand mass with a free thumb. Surgical treatment for the akull and face follow the protocol above. Reconstructive hand surgery may begin at age 1 year and require multiple stages.
Crouzon Syndrome may occur in 1 in 25,000 births. Craniosynostosis usually involves the coronal sutures resulting in a brachycephalic shape but schaphocephaly (sagittal suture), trigonocephaly (metopic suture) or clover-leaf deformity may also occur. In addition, mid-face hypoplasia may develop with shallow orbits.
Pfeifer Syndrome has features of craniosynostosis, broad thumbs and toes and partially syndactyly (finger fusion) of the second and third digits.
Saethre-Chotzen Syndrome patients are known to have low-set hairline and eyelid ptosis (drooping).
Treacher-Collins
Before and After
Treacher-Collins Syndrome or mandibulofacial dysostosis is a genetically inherited condition which may vary in its facial deformity from mild to severe.
It manifests bilaterally (on both sides) to involve the eyes, cheek bones, external ears and lower jaw.
Dr. Paul Tessier (1917-2008), the father of modern craniofacial surgery, considered this condition a grouping of facial clefts or defects which resulted in:
A downward slant of the lateral (outer) eyes
Deficiencies of the malar (cheek) bones
Absent or malformed external ears
Deficiencies of the mandible (lower jaw) and other facial anomalies
A cleft lip and/or palate may also be present.
The UCLA Craniofacial Clinic Protocol for correction of Treacher-Collins may vary depending on the individual patient and the severity of the deformity. However, guidelines for timing of the procedures are as follows:
3 months: Repair of Cleft lip and/or 1 year: Repair of cleft palate; If airway obstruction is problematic as an infant, surgically procedures may be used for correction of this including: a tracheostomy, mandibular or hyoid advancement or another procedures.
6-8 years: Reconstruction of malar region-Zygomatic arch, lateral orbital wall and orbital floor with cranial bone graft and eyelid correction;
6-8 years: External ear reconstruction;
5-8 years: Mandibular lengthening with distraction osteogenesis using intraoral devices;
14-18 years (facial skeletal maturity) Orthognathic (Jaw) surgery
14-18 years(after jaw surgery): Septorhinoplasty, Laser removal of sideburn hair or other ancillary (‘finishing’) procedures.
Hemifacial Microsomia
Hemifacial Microsomia (Goldenhar syndrome)
Hemifacial Microsomia or Craniofacial Microsomia occurs in 1 in 5600 patients.
This facial deformity is typically asymmetric (one side more affected) and ranges from mild to severe. In its full form patients may have:
Absence of the mandibular (lower jaw) ramus and an occlusal cant (crooked bite)
Microtia or absence of the external ear
Weakness of facial muscles of expression and/or mastication
Vertical orbital dystopia or eye asymmetry.
Goldenhar syndrome is a variant of craniofacial microsomia and has cervical (neck) and rib anomalies and epibulbar dermoids (excess eye tissue).
The UCLA Craniofacial Clinic Protocol is aimed at maximizing results and minimizing the number of procedures. The timing and types of procedures may vary depending on the severity of the deformity and the individual patient. Typically, corrections include many of the following:
Preauricular skin tags: (age under 1 year): Excision;
Macrostomia or wide mouth: (age under 1 year): Commisuroplasty;
Mandibular hypoplasia: (5-8 years of age): Internal distraction osteogenesis is used to lengthen the lower jaw . (For severe cases with absence of mandibular condyle and ramus, a rib graft may be necessary).
External ear deformity or absence: (6-8 years of age): Staged ear reconstruction with a rib graft framework, elevation, lobule (ear lobe) and tragus (front of ear) reconstruction are performed.
Orbital dystopia (asymmetric eyes): (6-11 years of age): Although rarely required, repositioning of the orbit and/or advancement of the forehead and brow (fronto-orbital advancement) may be performed.
Jaw asymmetry: (15-18 years or age of skeletal maturity): Preoperative orthodontics followed by jaw (orthognathic) surgery with Le Fort I (upper jaw) and mandibular sagittal-split (lower jaw) osteotomies are ofteecessary.
Soft tissue asymmetry: (after jaw surgery): Final facial contouring with autogenous fat grafting, dermal fat grafts or even a fascial-fat free flap from the upper back are ofteecessary after other corrections.
Flap Surgery
Classification and Principles of Flap Surgery
This article defines flaps, describes their purpose, and details what to remember when performing flap surgery.
Flap surgery is a subspecialty of plastic and reconstructive surgery. Various types of flaps are performed, and the indications for them are even more diverse.
Flap Definition, History, and Classification
A flap is a unit of tissue that is transferred from one site (donor site) to another (recipient site) while maintaining its own blood supply.
Flaps come in many different shapes and forms. They range from simple advancements of skin to composites of many different types of tissue. These composites need not consist only of soft tissue. They may include skin, muscle, bone, fat, or fascia.
How does a flap differ from a graft? A flap is transferred with its blood supply intact, and a graft is a transfer of tissue without its own blood supply. Therefore, survival of the graft depends entirely on the blood supply from the recipient site.
History of flap surgery
The term flap originated in the 16th century from the Dutch word flappe, meaning something that hung broad and loose, fastened only by one side. The history of flap surgery dates as far back as 600 BC, when Sushruta Samita described nasal reconstruction using a cheek flap. The origins of forehead rhinoplasty may be traced back to approximately 1440 AD in
The surgical procedures described during the early years involved the use of pivotal flaps, which transport skin to an adjacent area while rotating the skin about its pedicle (blood supply). The French were the first to describe advancement flaps, which transfer skin from an adjacent area without rotation. Distant pedicle flaps, which transfer tissue to a remote site, also were reported in Italian literature during the Renaissance period.
Subsequent surgical flap evolution occurred in phases. During the First and Second World Wars, pedicled flaps were used extensively. The next period occurred in the 1950s and 1960s, when surgeons reported using axial pattern flaps (flaps with named blood supplies). In the 1970s, a distinction was made between axial and random flaps (unnamed blood supply) and muscle and musculocutaneous (muscle and skin) flaps. This was a breakthrough in the understanding of flap surgery that eventually led to the birth of free tissue transfer.
In the 1980s, the number of different tissue types used increased significantly with the development of fasciocutaneous (fascia and skin) flaps (which are less bulky than muscle flaps), osseous (bone) flaps, and osseocutaneous (bone and skin) flaps.
The most recent advancement in flap surgery came in the 1990s with the introduction of perforator flaps. These flaps are supplied by small vessels (previously thought too small to sustain a flap) that typically arise from a named blood supply and penetrate muscle, muscle septae, or both to supply the overlying tissue. An example of this is the deep inferior epigastric perforator (DIEP) flap, which has now become the criterion standard in breast reconstruction. Noncontrast MRI is now used for preoperative mapping of perforator flaps.[1]
Classification of flaps
Most classification systems have been designed for the sole purpose of aiding communication with peers by being familiar with the correct vocabulary to use. However, the crucial point for any physician to remember is that communication with the patient is of foremost importance. The patient must be able to picture, with the surgeon’s guidance, what the surgeon is planning.
Many different methods have been used to classify flaps. Furthermore, these classification systems are often complex and varied in principle.
To improve the reader’s understanding of flap classification, the author has summarized the most commonly used classifications into 3 simplified categories: type of blood supply, type of tissue to be transferred, and location of donor site.
Blood supply
Like any living tissue, flaps must receive adequate blood flow to survive. A flap can maintain its blood supply in 2 main ways.
If the blood supply is not derived from a recognized artery but, rather, comes from many little unnamed vessels, the flap is referred to as a random flap. Many local cutaneous (skin) flaps fall into this category. If the blood supply comes from a recognized artery or group of arteries, it is referred to as an axial flap. Most muscle flaps have axial blood supplies.
Because of the complexity and variation observed in axial blood supply, a further subclassification (axial types I-V) was made by Mathes and Nahai and is readily used in plastic and reconstructive surgery literature to describe different types of muscle flaps (see the image below).[2]
Patterns of muscle flap vascular anatomy. Type I – One vascular pedicle. Type II – Dominant pedicle(s) and minor pedicle(s). Type III – Two dominant pedicles. Type IV – Segmental vascular pedicles. Type V – One dominant pedicle and secondary segmental pedicles.
The classification of flaps based on blood supply, including the Mathes and Nahai subclassification, can be summarized as follows:
Random (no named blood vessel)
Axial (named blood vessel) Mathes and Nahai classification
One vascular pedicle (eg, tensor fascia lata)
Dominant pedicle(s) and minor pedicle(s) (eg, gracilis)
Two dominant pedicles (eg, gluteus maximus)
Segmental vascular pedicles (eg, sartorius)
One dominant pedicle and secondary segmental pedicles (eg, latissimus dorsi)
Tissue to be transferred
In general, flaps may comprise in part or in whole almost any component of the human body, as long as an adequate blood supply to the flap can be ensured once the tissue has been transferred.
Flaps may be composed of just one type of tissue or several different types of tissue. Flaps composed of one type of tissue include skin (cutaneous), fascia, muscle, bone, and visceral (eg, colon, small intestine, omentum) flaps. Composite flaps include fasciocutaneous (eg, radial forearm flap), myocutaneous (eg, transverse rectus abdominis muscle [TRAM] flap),[3] osseocutaneous (eg, fibula flap), tendocutaneous (eg, dorsalis pedis flap), and sensory/innervated flaps (eg, dorsalis pedis flap with deep peroneal nerve).
Therefore, another way of classifying flaps is by describing the different types of tissue that are being used in the flap.
Location of donor site
Tissue may be transferred from an area adjacent to the defect. This is known as a local flap. It may be described based on its geometric design, be advanced, or both. Pivotal (geometric) flaps include rotation, transposition, and interpolation. Advancement flaps include single pedicle, bipedicle, and V-Y flaps.
Tissue transferred from an noncontiguous anatomic site (ie, from a different part of the body) is referred to as a distant flap.
Distant flaps may be either pedicled (transferred while still attached to their original blood supply) or free. Free flaps are physically detached from their native blood supply and then reattached to vessels at the recipient site. This anastomosis typically is performed using a microscope, thus is known as a microsurgical anastomosis. Visible light spectroscopy can be used to measure tissue oxygenation in free flap reconstruction.[4, 5]
Principles of flap surgery
Now that the main ways of classifying flaps have been introduced, the remaining sections of this article are devoted to the most important principles to remember before performing flap surgery. Like any surgical procedure, flap surgery is not devoid of risk. Complications such as complete flap loss can be catastrophic. Considering the following basic principles before any flap surgery serves patients well by optimizing outcome and decreasing operative morbidity.
Principle I: Replace Like With Like
This is a particularly important principle. When filling in a defect, replace like with like. Ralph Millard once said, “when a part of one’s person is lost, it should be replaced in kind, bone for bone, muscle for muscle, hairless skin for hairless skin, an eye for an eye, a tooth for a tooth.”
If this cannot be accomplished, use the next most similar tissue substitute. For example, the surgeon can use scalp to replace a beard or skin from the forehead to cover a nose wound. The goal is to camouflage the reconstruction as much as possible. Everyone can learn from Mother Nature’s blending tricks. The surgeon’s goal is to create an effect as subtle as a chameleon changing colors as it moves through its surroundings.
An example of this can be found in the treatment of any eyelid injury. The best course of action when faced with a full-thickness defect is to use eyelid skin from the contralateral eye. If this is not possible, the next best substitute is a full-thickness posterior auricular skin graft. This provides the most similar substitute tissue, with a satisfactory color match and minimal tendency toward contracture.
If the surgeon’s work can pass unnoticed, he is to be congratulated as having accomplished his task as a reconstructive surgeon.
Principle II: Think of Reconstruction in Terms of Units
According to Millard, human beings may be divided into 7 main parts: the head, neck, body, and extremities. Each of these body parts can be further subdivided into units. The head, for example, is composed of several regional units: scalp, face, and ears. Consider that each of these units has its own unique features, and each feature has, in turn, multiple subunits with their own special shapes. All of these different units and subunits must be considered and reproduced during reconstruction.
As emphasized by Millard, “The most important aspects of a regional unit are its borders, which are demarcated by creases, margins, angles and hair liners.” Taking this a step further, perhaps the most important principle is the way in which the borders between units come together and interact rather than just the borders themselves.
Adherence to these natural borders during reconstruction is important. Most often, it is better to convert a defect that covers only a partial unit to a whole-unit defect prior to reconstruction. According to Millard, “If possible make the defect fit the flap or graft to that unit!”
Principle III: Always Have a Pattern and a Back-up Plan
As with all surgery, comparing the pros and cons of each surgical option is of the utmost importance. The reconstructive ladder is a mental exercise that provides the surgeon with options ranging from the simplest to most complex. Usually, things should be kept as simple as possible. This benefits both the surgeon and the patient; the simplest plan is often the safest.
However, physicians should not sell themselves or patients short. Avoid settling for the simplest procedure just for the sake of simplicity. More complex problems may require more complex solutions, and the simplest approach may be, frankly, inadequate. A sound plan must provide restoration of function and aesthetic form; these are the fundamental goals of plastic and reconstructive surgery.
A nose, breast, or finger reconstruction should be designed to fit its use and location, rather like the philosophy used by architects when designing buildings. In 1949, a pioneer of 20th-century architecture, Frank Lloyd Wright, said, “Form and function thus become one in design and execution if the nature of materials and methods and purposes are all in unison.” Several years earlier, Wright had been asked to build a hotel in
Once a plan has been determined, rehearse it. Trace the defect or cut a pattern to fit the defect. Transpose the pattern and experiment with it to decide on the best donor area and orientation. Omitting this step is akin to Wright building his hotel without a blueprint, and his materials were much cheaper than the surgeon’s.
Finally, the surgeon should ask him or herself “what do I do next if this fails?” Proceed to the operating room only after answering this question definitively. Once in the operating room, keep an open mind and be ready to adjust the surgical plan as the situation dictates.
Principle IV: Steal From Peter to Pay Paul
Apply the “Robin Hood” principle: steal from Peter to pay Paul, but only when Peter can afford it. Using what the body has to reconstruct a deficit is essentially “robbing the bank.” The goal to achieve is ultimate efficiency, or, according to Millard, “getting something for almost nothing.” Examples of local flaps illustrating Millard’s point are shown in the images below.
An interpolated flap. The donor site is separated from the recipient site, and the pedicle of the flap must pass above or beneath the tissue to reach the recipient area. (A) Flap is outlined and elevated. (B) Donor site is closed. (C) Pedicle is divided once the flap is revascularized. (D) Insetting of the flap is completed.
A rotation flap. Movement is in the direction of an arc around a fixed point and primarily in one plane. This is a semicircular flap.
A transposition flap. The rectangular flap is rotated on a pivot point. The more the flap is rotated, the shorter the flap becomes.
An advancement flap. Advancement flaps are moved primarily in a straight line from the donor site to the recipient site. No rotational or lateral movement is applied. Triangles y (Burrow triangles) have been removed lateral to the base equal to the distance of the advancement (x = y). Incisions are made into the base of the flap to assist in the advancement.
A bipedicle flap with incisions parallel to the advancement.
A V-Y advancement flap.
Do not make the naive mistake of merely advancing tissue to the deficient area unless this can be accomplished completely without tension. Tension compromises the blood supply of the advanced tissue and, ultimately, results in flap failure. Tension is to be feared the most. It must be recognized and prevented or else used to the surgeon’s advantage.
Principle V: Never Forget the Donor Area
Surgeons once believed in treating the primary defect without worrying about the secondary defect. Plastic surgery has since progressed. Plastic and reconstructive surgeons now realize the importance of considering both defects equally.
The reality is that it is not possible to get something for nothing; a price usually must be paid following reconstruction of a primary defect. The significance of providing coverage of a defect with minimal deformity and disability is one of the foremost principles on which the reconstructive surgery specialty is based.
If reconstruction of the primary defect is too costly in terms of resultant deformity or disability, reevaluate and use another reconstructive option.
Remember that donor areas are not limitless. One cannot continuously use tissue without paying back in some way. Carelessness or overuse of a donor area eventually causes damage that may be far greater than the original defect.
Final Thoughts
Be thoughtful. Consider all options, simple to complex, prior to any flap surgery.
Be knowledgeable. Know and understand the anatomy, blood supply, and quality of tissue available.
Be prepared for failure. Have a back-up plan available in case the first plan fails.
Microvascular Surgical Technique and Methods of Flap Monitoring
Introduction
The hand is capable of coordinated activity finer than the eye can direct. With the aid of magnification, the true capability of the hand can be exploited. As a tool for the plastic surgeon, microsurgery has allowed reconstructions that were simply not possible before. However, microvascular free tissue transfer is not a technique for the occasional microsurgeon. The catastrophic complication of flap failure looms over every microsurgical case; therefore, expertise in the execution of a free flap as well as its postoperative surveillance is key to a successful outcome.
Experience has shown that flap loss is a preventable complication and that elective microsurgery should have a failure rate of less than 2%. Most cases of flap loss are technical iature. The fault may lie in the choice of flap, the harvest of the flap, preparation of donor vessels, insetting of pedicle or microsurgical technique. In general, it is best to think of all possible errors as additive in the process of thrombosis. Failure will occur if the procoagulatory factors outweigh the intrinsic ability of the vessels, in particular intact and uninjured intima, to prevent clot formation.
Flap Choice
The first step for success in microsurgery is flap choice. The specifics of different flaps are discussed in subsequent chapters. The most important determining factors for flap choice should be the surgeon’s experience and the goals of reconstruction.
In general, each surgeon should identify at least four flaps they feel comfortable with. These flaps should include a bulky muscle flap, a bulky fasciocutaneous flap, a thin fasciocutaneous flap, and a bone flap. With this armamentarium, the reconstructive surgeon will have tools that can be applied to most situations. By limiting himself to a small number of flaps, more experience can be obtained with each one. This increased experience translates to increased success. It is not advantageous to explore every novel flap that is reported, as this dilutes the experience and increases the chance of failure. With increasing experience with each flap comes increasing success and a lower failure rate.
This does not imply that specific flaps may not be beneficial over others in certain situations. There is no doubt that the donor properties of a latissimus dorsi flap differ from those of the gracilis flap and that each may be a better choice for a specific patient. However, the patient is best served with successful reconstruction. If there is significant benefit in a flap where the surgeon has no experience, the surgeon should consider referral or should seek additional training in order to add that flap to his or her armamentarium. This may include time in a cadaver lab or observing a surgeon with a particular skill.
Having mastered the tools of reconstruction, the surgeon should judiciously consider the requirements for reconstruction. Bulky muscle flaps are best for contaminated defects and bony injuries with high risk for infection. Thick fasciocutaneous flaps are useful for contour and shape reconstruction. Thin fasciocutaneous flaps provide stable, noncontracting coverage. Bone flaps provide structural integrity.
Specific aspects of each flap harvest are discussed elsewhere in this book. Certain principles, however, hold true despite the flap chosen. While harvesting a flap, the pedicle should be carefully dissected with as much length as possible. It is important not to limit the pedicle length to the anticipated need, but to harvest the maximum that can safely be obtained. It is much more advantageous to discard unneeded length than to find oneself requiring more pedicle length. Vein grafts should be avoided unless absolutely necessary.
While harvesting the flap and dissecting the pedicle, the most common mistake is damaging the vessels. Forceps should only touch the adventia and never purchase the vessel as the intimal layer is extremely fragile and easily fractured or crushed by manipulation. Any grasping of the vessels will cause damage to the intima which increases the likelihood of clot formation. This intimal injury leads to platelet deposition and thrombosis as the injured endothelial cell layer loses its natural thrombolytic properties.
Division of the pedicle should be reserved until the last possible moment. Prior to division, the donor vessels should be dissected, isolated, prepared and positioned for the anastomosis. It is helpful to mark the vessels in their natural state to assure that they are not twisted when transferred to the recipient site. Prior to division, the artery should be occluded first, followed by the vein. This will avoid excess blood pooling in the flap. Immediately after the flap is removed, one can consider cooling the flap with chilled saline as this decreases the metabolic activity of the tissue and allows the luxury of a longer ischemic time.
There is seldom a need to separate the artery and vein within the pedicle for anything more than a minimal distance. The only exception is the case where the recipient vessels are not paired. The vessels should not be skeletonized until they are brought to the recipient site and carefully prepared under the microscope. Any branches within 2 mm of the anastomosis are best sutured closed with microtechnique to avoid blood pooling near the anastomosis.
Preparation of Recipient Site
Preparing the recipient site mirrors the harvest of the flap. Vessels should be chosen that are simple to use and of the largest caliber available. They should be expendable when possible and have sufficient length. Again, care should be taken in the preparation of the vessels. They should not be extensively manipulated or injured. They should only be skeletonized for 2-3 mm around the anastomotic site, and this should be done under the microscope.
Microsurgical Technique
The anastomosis can be done in several fashions. These include end-to-end or end-to-side. They can be performed by multiple suture techniques or with coupling devices. The general philosophy is to gain experience with two or three techniques and apply those techniques to different situations. With careful planning, preparation, and mobilization of both the pedicle and recipient vessels, this is generally possible.
General principles of proper microsurgical technique are:
Pass sutures perpendicularly through the adventitia into the intima.
Avoid grasping or manipulating the intima.
Avoid multiple suture passes.
Avoid torquing the needle in the vessel; grasp and regrasp the needle in order to pass
it through the vessel following the curve of the needle perfectly.
Dilate and visualize the inside of the vessels with heparinized saline irrigation on an ocular anterior chamber needle.
Use polished vessel dilating forceps to gently open spasmodic vessels or for vessel expansion.
Leave long tails on the sutures for manipulation and visualization.
Perform both anastomoses prior to reperfusion.
Release clamps on the vein first.
Inspect the anastomosis using the long suture tails as handles.
Place additional sutures in gaps with pulsatile or pressurized bleeding.
Avoid the temptation to place excess sutures in cases of mild oozing of blood from the anastomosis.
Apply warm saline to the flap and papaverine to the anastomosis after reperfusion to dilate the vessels and relax spasm.
Anastomotic Techniques
End-to-End
The end-to-end anastomosis is the simplest and the most reliable method. There are several techniques of suture placement including the 180˚-180˚ and triangulation methods. The easiest is probably the 180˚-180˚ technique. This can be applied to any situation and is probably the best technique for size-mismatched vessels.
Important points to remember are:
The vessels must not be twisted prior to placement in the double clamp holder. This can be ensured by inking one surface of the pedicle and recipient vessels prior to their division or dissection.
The first two sutures are placed at opposite poles of the vessels.
The third suture is placed midway between the poles.
In most cases, the next sutures bisect the gap though on occasion, two sutures will be needed in the gap.
Once the anterior wall is complete, twist the entire double clamp to show the backwall.
Visually inspect every suture of the anterior wall from the posterior view to assure that they are evenly spaced and have not purchased the back wall of the vessel.
Place another bisecting suture midway between the poles on the back wall.
All remaining sutures can be placed and left long (not tied).
Dilate the vessel with saline when tying the back wall to assure that there is no purchase of the anterior wall.
End-to-Side
The end-to-side technique is occasionally necessary. For example, it is used in the leg when there is only one vessel available or for an anastomosis in the head and neck (for example, to the internal jugular vein). Principles are:
The pedicle vessels should enter the recipient vessel at a gentle angle.
Perform a limited arterioectomy, removing a small window of vessel.
Place heel and toe sutures first.
Initially close the heel.
Follow with closure of the toe.
Coupling Devices
Coupling devices are useful for veins or thin-walled arteries. They save some time in the anastomosis. They, however, are not a panacea. The major time consumption in a microsurgical case is not the anastomosis, but the set up and preparation. If coupling devices are used, the set up and preparation time remain the same. Principles of gentle handling of vessels are still required as is avoidance of damage to the intima. Overall, the devices appear to have a place in the venous anastomosis, where they can also act as a stent, or in cases with significant size mismatch. Points to consider are:
Use the largest size coupler that will comfortably fit (range 2-3.5 mm).
Draping of the vessel over the spikes is performed by one surgeon while the other
maintains the engagement of the spike as the vessel is seated.
Seat the vessel 180˚ apart to assure even spacing on the coupler.
Avoid grasping the intima of the vessel as it is draped over the spikes.
Assure that the coupling device is closed and guide it off of the coupling applier.
Draping of the Pedicle
After the anastomosis is complete and the flap is successfully revascularized, it is not uncommon for significant problems to arise. Kinking or unnatural curvature of the pedicle will certainly cause thrombosis. In fact, any turbulent, nonlaminar flow increases the likelihood of thrombosis and flap loss. The pedicle should be carefully draped. Gelfoam sponge or Alloderm can be used to help maintain the proper position of the pedicle.
Closure
A sound closure technique is again crucial for success. Both the flap and pedicle can be compressed by a tight closure. Anticipation of this is critical, as well planned incisions will allow closure after the edema of these long cases has set in. If there is any question, the liberal use of skin grafts to allow tensionless closure is recommended. The anastomosis should never be situated immediately under a suture line.
Monitoring
There is no “perfect” monitoring technique. Despite numerous ingenious techniques and improvements in technology, the ideal monitoring technique should be the one that surgeons and ancillary staff at a particular hospital are most familiar with and meet the restraints (budgetary or manpower) of the institution. What is ideal at one institution may not be practical at another. What is clear over many years of clinical experience, although this remains to be formally proven, is that the presence of dedicated staff in a dedicated unit stands the best chance of picking up problems earlier. The impetus to closely monitor a flap comes from the enormous investment undertaken on the part of the patient as well as the surgeon regarding microvascular free tissue transfer. The utility of postoperative flap surveillance has been proven, with an increase in the salvage rate of the failing flap from 33% to about 70% in some series.
The clinical exam is useful when performed by the experienced clinician. The transition of a healthy, plump flap or vibrant replanted digit to cold, flat, lifeless tissue can proceed via either arterial occlusion or venous congestion. These characteristics are useful in deciding whether to explore a flap or perhaps treat with leech therapy. Although it is the least technologically-based, much information can be gleaned from a thorough physical exam. Turgor can indicate the state of arterial inflow or venous outflow. Like a balloon, the flap or digit will inevitably declare itself if it has arterial insufficiency or venous congestion. Bleeding can be useful, as the qualitative and quantitative flow in response to pinpricks or rubbing of wound edges can declare the state of circulatory flow to the flap. In particular, a congested flap may bleed briskly, but the blood will appear dark and unoxygenated. The blood flow of a flap with compromised arterial inflow will be weak or absent. A caution regarding the pinprick test is that it is useful for evaluating a flap, but will occasionally cause trauma leading to vasospasm or hematoma in the confined space of a finger.
It is possible to monitor free flaps with a temperature probe. This method consists of placing surface temperature probes on the skin of the free flap and comparing them to probes placed oeighboring native skin. The probes are attached to a temperature monitor that will give off an alarm if there is a difference in temperature between the two sites greater than the specified amount (typically, 2-3˚C). Although appealing, there are limitations to the use of temperature probes, as the readings may be affected by regional changes in blood flow that are not secondary to flap flow disturbances.
Doppler ultrasonography is perhaps the most widely used monitoring tool. Two permutations exist. The first is the external Doppler. A recent innovation is the implantable internal Doppler. This tool permits monitoring of the segment of artery and vein a short distance downstream of the anastomosis. Its use has obviated the need for an external sentinel skin segment, and is ideally suited for buried anastomosis (e.g., jejunal free flaps in the head and neck, or vascularized bone transfers). These techniques are extremely useful; however, complications such as probe dislodgement and the occasional monitoring of an adjacent vessel that is not the pedicle can result.
In replants, the pulse oximeter is extremely useful. Some centers have reported success with fluorescein infusion and fluorescent lamp observation. This technique is not as useful in pigmented skin. Other techniques that at this time must be considered experimental include pH monitoring, duplex ultrasound, photoplethysmography, reflection photometry and radioisotope studies. None of these are currently widely used.
Pearls and Pitfalls
Although the microsurgical trainee may be eager to execute a large variety of occasionally exotic flaps, it is much more important to master a limited number of flaps and apply these flaps to different defects throughout the body. The principles outlined in this chapter serve as the basis to successfully execute any type of microsurgical transfer the plastic surgeon will encounter, even unusual flaps. In summary, it is essential to:
Sharpen microsurgical skills in the lab.
Handle the vessels gently.
Place significant attention on closure and pedicle position.
Familiarize oneself with one or two monitoring techniques. This will maximize salvage of the inevitable free flap failure.
The most important indicator of a problem with the free-flap is a change in the
clinical exam. This necessitates that the flap be seen as soon as possible by a surgeon who has been actively managing the patient.
Axial Pattern Flap Selection
Adjacent axial pattern flaps can overlap potential wound closure areas, with one another, in their potential coverage of a given defect. For example, upper forelimb/axillary defects may be covered by the thoracodorsal or omocervical axial pattern flap. Selection of a given flap will depend on personal preference of the surgeon, ease of transfer, and the relative flap size required. In this example, the thoracodorsal flap has a superior blood supply, thus enabling the surgeon to elevate a longer flap with less potential for partial flap necrosis for larger regional defects in these regions.
Surgical Considerations
Preservation of the artery and vein are critical to successful flap execution. This would include avoiding twisting or kinking of the vascular pedicle during flap transfer. Guidelines for flap elevatiooted in the literature are no guarantee of complete flap survival; necrosis of small portions of the terminal flap occasionally is noted. These areas can be resected and the defect closed by advancement of the flap. Otherwise, small areas may be left open to heal by second intention.
Axial Pattern Flaps: Potential Uses
Omocervical: Head, neck, shoulder, axilla
Thoracodorsal: Neck, thorax, axilla, forelimb
Caudal Superficial Epigastric: Hindlimb, flank, abdomen, perineum
Cranial Superficial Epigastric: Sternum, lower thoracic region.
Deep Circumflex Iliac (dorsal branch): lateral abdominal, dorsal/lat pelvis, gr. Trochanter
Deep Circumflex Iliac (ventral branch): inguinal, dorsal pelvic regions
Superficial Brachial: Proximal forelimb, elbow area
Genicular: Lateral/medial Prox-/mid- tibial region
Reverse Saphenous Conduit Flap: metatarsal area
Caudal Auricular: Facial area, head, ear
Lateral Caudal (Tail): Perineum, dorsal pelvic area
Surgeons must carefully follow the guidelines, described in the veterinary literature, for elevation and transfer of a given axial pattern flap. Improper outlining of the flap can result in failure to incorporate the direct cutaneous artery and vein into the flap. Previous trauma can result in compromise to these vessels and the associated capillary circulation, rendering axial pattern flap elevation useless.
Greyhounds, whippets and similar breeds possessing thin, “tight” skin are more prone to partial flap necrosis compared to other breeds. It is useful to keep a given axil pattern flap about 25% shorter than the guidelines noted in the literature, based on my
clinical experience. In general, it is a good idea to keep all flaps as short as needed to
close a given wound and restore function to the area: this reduces the likelihood of flap necrosis.
Axial pattern flaps can be designed in the conventional “peninsula” shape or elevated as a right angle or “hockey-stick” variation. Peninsula APFs are longer than the latter: right angle APFs can be useful to close shorter, wider defects or irregular shaped wounds. Island arterial flaps generally are not need in most cases. It is my experience
that island APFs are most useful when closing defects that encroach on the base of a
proposed flap, with the adjacent direct cutaneous artery and vein enabling the flap to
pivot 180into the defect.
Axial Pattern Flaps; Clinical Applications
An axial pattern flap is a skin flap containing a single, consistent myocutaneous artery, vein and nerve that supply a specific region of dermal tissue.1,2 As a result,
axial pattern flaps have a more (reliable) and robust blood supply as compared to randomly chosen local flaps, which rely on the subdermal plexus alone for their
circulation. Axial pattern flaps are used most commonly to facilitate wound closure following a traumatic event or after extensive tumor resection.
Full Thickness Skin Cover
Axial pattern flaps provide a durable full thickness skin cover for skin defects that can be closed primarily without the need for a vascular (well granulated) wound bed or strict postoperative immobilization (which are critical to the success of skin grafts). Since the blood supply is well preserved and the flaps are created from full-thickness skin, the cosmetic appearance of the flaps are considered excellent (they can be expected to closely resemble the donor site skin). The main advantage of axial pattern flaps over randomly chosen subdermal flaps is that they can be made with a narrow base or with no skin connection, thereby allowing considerable flexibility in flap rotation and transfer of skin to more distant areas. In axial pattern flaps, the length of the flap that can be safely created is related to the known length of the axial vessel supplying the flap. Since the blood supply is so reliable, the survival rate of axial pattern flaps is estimated to be about twice that for local random flaps of comparable size. In randomly chosen flaps, the safe length of a flap can only be estimated by the width of skin connected to the flap base. Smaller length to width ratios for random subdermal flaps are safer since there is better chance that the blood supply to the distal portions of the flap is secure. Thus, the use of these local flaps is usually limited to open wounds min the immediate vicinity of the flap base.
Disadvantage
One disadvantage of axial pattern flaps is that they have specific anatomical borders that must be followed to ensure survival of the flap (incorporating the axial vessel in the flap is imperative). When these borders have been damaged or the axial pattern flap landmarks have been altered by patient positioning, a previous surgery, or trauma, the axial vessel may not be located in the described boundaries and the risk of partial flap necrosis is high. Axial vessels are distributed in many locations throughout the body surface so the application of these flaps is quite broad. There are, however, some body regions that are not readily covered by axial flaps. These include the more distal extremity areas, and the dorsal and ventral midline (in the central areas of the body). The most commonly used axial pattern flaps in small surgery are the thoracodorsal and the caudal superficial epigastric. The following list of axial pattern flaps includes the more common regions they are employed for wound closure.
Axial Flap (Clinical Application-region of defects)
Omocervical Axial Flap
(head and neck, brisket and axillary region)
Thoracodorsal Axial Flap (thoracic defects, proximal forelimb defects, axillary region)
Superficial Brachial Axial Flap
(elbow and proximal forelimb defects)
Caudal Superficial Epigastric Axial Flap (flank defects, perineal defects, stifle defects, preputial defects)
Technical Considerations
Axial pattern flaps are made rectangular in shape (with a tapered or rounded end usually), but can be modified with a right angle extension (hockey stick) or by making the axial flap into an island flap (connected only by the neurovascular supply, but no skin). These modifications increase both the mobility and length of an axial pattern flap. Island flaps can be rotated up to 180 degrees to cover a specific defect provided there is minimal tension on the twisted vessels. The axial pattern flaps listed previously can be created using principles and boundary guidelines that are well described in most current veterinary surgical textbooks. Please refer to these texts for technical details. The following brief description is intended to outline the general perioperative principles of axial pattern flap application.
Preoperative Considerations
• Carefully plan the design of the flap (use a permanent marker if necessary to mark the planned procedure).
• Consider how the resultant defect at the donor area will be closed.
• Be sure the skin and the direct cutaneous artery that will be used for the flap are viable.
Surgical Procedure
Objectives
• Preserve viability of the direct cutaneous artery by avoiding excessive surgical trauma to the tissue. Know precisely where the direct cutaneous vessel originates
so accidental disruption during flap dissection isavoided. Equipment
• General surgery pack, abdominal laparotomy sponges, skin hooks or stay sutures should be available. A (Jackson-Pratt) drain may be needed if the wound is susceptible to seroma formation.
Technique
1. Aseptically prepare a large skin region around the donor and recipient areas.
2. Be particularly careful when positioning the patient such that the vascular pedicle will not become distorted before planning the boundary incisions.
3. Create incisions along predetermined donor site boundaries of the skin to be transferred to the defect.
4. Control hemorrhage and make sure the boundary incisions extend deep to the panniculus muscle layer or layer containing the subdermal plexus.
5. Deeply undermine the flap beginning at the distal most aspect (use stay sutures or skin hooks to
Deep Circumflex Iliac Axial Flap (pelvic and sacral defects, flank defects, lateral abdominal wall, defects over the greater trochanter)
Genicular Axial Flap (medial or lateral aspects of the proximal pelvic limb)
Caudal Auricular Axial Flap (lateral aspects of the head, cervical area)
Superficial Temporal Axial Flap (dorsal maxillofacial area)
6. Dissect very carefully around the origin of the direct cutaneous vessel to avoid inadvertent damage to this vessel that is vital to the survival of the flap.
7. Avoid creating a kink and avoid too much tension at the base of the flap, which could obstruct blood flow.
8. Drain the dead space if deemed necessary.
9. Suture or staple the flap to the defect edges. Interrupted subcutaneous and skin sutures are preferred. Begin suturing the flap at the most distant area first.
Postoperative Care and Complications
• Restrict exercise until suture removal.
• Apply an Elizabethan collar before the patient is recovered from anesthesia and leave it on the until the flaps are completely healed.
• Change wound dressings as necessary.
• Major complications resulting from skin flaps include local problems, such as partial or total ischemia of the flap, infection, seroma, and dehiscence of the flap or donor suture line. Once the flap necrosis has fully demarcated, debride the flap, and treat the area as you would for any open skin wound.
• Dehiscence of donor site incisions is usually due to excessive skin tension. If dehiscence occurs, allow these areas to heal by second intention.
Clinical Studies of Complications and Outcome
Partial flap necrosis was a frequent complication of thoracodorsal axial pattern flap reconstruction of forelimb skin defects and required additional wound care or surgical intervention to achieve healing in an earlier study published by the author. Thoracodorsal axial pattern flaps can provide full-thickness skin coverage of extensive skin defects of the forelimb. There were few complications in this study, and partial flap necrosis or dehiscence was rare (this was most likely due to the robust blood supply of this axial vessel).
As a result of recent advancements in bone science, reconstruction of the mandible caow be straightforward, permanent, predictable, and have a low morbidity . After the setup surgery just described, the authors recommend using condensed autogenous cancellous marrow grafts with platelet-rich plasma (PRP) growth factor additions in place of free vascular bone transfers. Although the free vascular transfer of soft tissue is a valuable technique for soft-tissue reconstruction, free vascular bone transfers of fibula are too small and straight and transfers of ilium are too bulky and have an unacceptably high rate of morbidity. Neither bone aligns the arch form of the jaws or is readily amenable to dental implants in their proper trajectory for denture support or for other types of dental rehabilitation. The rigid reconstruction plates used in the setup surgery serve as the containment crib for the graft, as noted above. Earlier concerns about the negative effects of stress shielding on bone grafts have been proven to be clinically insignificant and today the plates are left permanently in place
once the graft has been placed. The plate is uncovered and the tissue bed developed using the same incision used for the setup surgery. Autogenous cancellous marrow is harvested from the posterior ilium, which represents the greatest reservoir of cancellous bone marrow and allows for the lowest degree of discomfort and earliest ambulation. The marrow is first condensed into 5-mL syringes to compact the bone and thereby increase its cellular density. The tips of the syringes are then cut off and the graft material expressed and further compacted into the recipient site using bone packers. PRP is added to the cancellous marrow during the compaction process and
then as a final layer over the compacted graft. The PRP is developed from approximately 50mL of autogenous blood drawn in 7mL of ACD-A anticoagulant immediately before surgery and then sterile-processed in the Smart PReP PRP device (Harvest Technologies, Boston, MA), where it undergoes a double-centrifugation process of approximately 11,000 g minutes to separate the platelets from the other components of blood. The platelets are then activated by adding two drops of a mixture of 10% calcium chloride and 5000 units of bovine thrombin to initiate a clotting process causing the concentrated platelets to actively secrete at least seven growth factors shown to support bone regeneration and soft-tissue healing: three platelet-derived growth factors (PDGFaa, PDGFbb, and PDGFab); two transforming growth factor betas (TGF-b and TGF-b2); a vascular endothelial growth factor (VEGF); and an epithelial growth factor (EGF) (13). Since the PRP contains four to seven times the number of platelets found in the normal blood clot around a graft, the bone regenerates more quickly, producing a much greater degree of bone density. Studies have shown that grafts treated with PRP mature in one half the usual time and contain 19% enhanced bone content . Such grafts are placed into the developed tissue bed and closed primarily. The use of such cancellous marrow grafts does not prolong recovery and does not require intensive care, transfusions, adjuvant systemic anticoagulation, or volume expansion. With the combined use of rigid plate fixation and the PRP, such grafts can be released from maxillomandibular fixation after just 3 weeks rather than the 6-week average. After just 3 months, the graft is sufficiently mature to undergo placement of dental implants and oral scar releases (vestibuloplasty procedures) in preparation for dental rehabilitation. Because the bone density is enhanced, the dental implants can be activated after just 3 months rather than waiting the usual 6 months, thus allowing the patient to proceed to dental rehabilitation much sooner. A. Assessment of Hard and Soft Tissue Most reconstructive maxillofacial surgeons receive many referrals of patients who were initially managed elsewhere, and usually several weeks or months will have elapsed since their original injury. Even if the initial management was accomplished by the definitive reconstructive surgeon, he=she should not assume that the tissues of the patient are ready for reconstructive surgery and should resist the temptation to immediately begin extensive bone grafting. Three keys factors in achieving a successful definitive bony reconstruction of the mandible are: (1) an adequate vascular soft-tissue cover, (2) a stabilized and immobile graft, and (3) an infection-free, contamination-free tissue bed into which a bone graft can be placed (12). Therefore, the soft tissue should be assessed in terms of its adequacy of vascularity and size for covering a planned bone graft; the presence of contracted scar tissue and
foregin bodies; and the presence of fistulae or periodic episodes of swelling, which sould alert one to the possible presence of a focus of infection such as necrotic bone or tooth fragments. The assessment of the andible should also focus on the alignment of residual bone segments and the presence of exposed bone. An avulsion of the body of the mandible will usually cause the proximal segment, consisting of the ramus, condyle, and coronoid process, to be contracted superiorly and medially owing to the force vector of the temporalis, masseter, and pterygoid muscle groups on this segment. This may in turn produce a perforation of bone through the mucosa in the molar region or cause the patient to ulcerate the mucosa by biting it. The distal segment will collapse into the defect and rotate medially from the pull of the mylohyoid muscle. This displacement will produce malocclusion, compromise speech and swallowing, and if severe, compromise the airway. Skin grafting is a type of medical grafting involving the transplantation of skin. The transplanted tissue is called a skin graft.
Skin grafting is often used to treat:
Extensive wounding or trauma
Burns
Areas of extensive skin loss due to infection such as necrotizing fasciitis or purpura fulminans
Specific surgeries that may require skin grafts for healing to occur – most commonly removal of skin cancers.
Skin grafts are often employed after serious injuries when some of the body’s skin is damaged. Surgical removal (excision or debridement) of the damaged skin is followed by skin grafting. The grafting serves two purposes: it can reduce the course of treatment needed (and time in the hospital), and it can improve the function and appearance of the area of the body which receives the skin graft.
There are two types of skin grafts, the more common type is where a thin layer is removed from a healthy part of the body (the donor section), like peeling a potato, or a full thickness skin graft, which involves pitching and cutting skin away from the donor section. A full thickness skin graft is more risky, in terms of the body accepting the skin, yet it leaves only a scar line on the donor section, similar to a Cesarean section scar. For full thickness skin grafts, the donor section will often heal much more quickly than the injury and is less painful than a partial thickness skin graft.
Flap Surgery
Flap surgery is a piece of tissue that is still attached to the body by a major artery and vein or at its base. This piece of tissue with its attached blood supply is used in reconstructive surgery by being set into a recipient site (injured area onto which a flap or graft is placed). Sometimes, the flap is comprised of skin and fatty tissue only, but a flap may also include muscle from the donor site (the area from which the flap is raised).
Who Might Need Flap Surgery?
If you have suffered tissue loss over any area of your body, you may be a candidate for flap surgery. This type of reconstructive plastic surgery is typically used to repair defects left behind after traumatic injury or mastectomy. Flap techniques can also produce excellent results in facial reconstruction after skin cancer excision.(Mohs surgery).
There are as many types of flaps as there are types of injuries which might require the use of a flap. Flaps come from many different locations, and are used in many different ways to accomplish the desired result. However, flaps used for reconstructive plastic surgery can be broken down into two main categories.
Local (Pedicled) Flap:
Tissue is freed and rotated or moved in some manner from an adjacent area to cover the defect, yet remains attached to the body at its base and has blood vessels that enter into the flap from the donor site. The type of flap movement required determines which of the four main types of local flaps is used.
The four major types of local flaps include the advancement flap (moves directly forward with no lateral movement), the rotation flap (rotates around a pivot point to be positioned into an adjacent defect), the transposition flap (moves laterally in relation to a pivot point to be positioned into an adjacent defect) and the interpolation flap.
The interpolation flap is different from the others in that it rotates around a pivot point to be positioned into a nearby (but not adjacent) defect. The result is that a portion of the flap passes above or below a section of intact tissue, forming a sort of “skin bridge.” This type of flap is intended to be sectioned (separated) from the donor site in a subsequent procedure.
Free Flap:
Tissue from another area of the body is detached and transplanted to the recipient site and the blood supply is surgically reconnected to blood vessels adjacent to the wound.
Gingival flap surgery is a type of gum procedure. The gums are separated from the teeth and folded back temporarily. This allows a dentist to reach the root of the tooth and the bone.
What It’s Used For
Gingival flap surgery is used to treat gum disease (periodontitis). It may be recommended for people with moderate or advanced periodontitis. Usually, a treatment that doesn’t involve surgery is done first. This is called scaling and root planing. If this treatment does not eliminate the gum infection, gingival flap surgery may be used. It also may be done along with another procedure known as osseous (bone) surgery.
Preparation
Your periodontist or your dental hygienist will first remove all plaque and tartar (calculus) from around your teeth. He or she will make sure that your oral hygiene is good. Your periodontist also will evaluate your health and the medicines you take. This is important to make sure that surgery is safe for you.
How It’s Done
First you will get a shot to numb the area. Then the periodontist will use a scalpel to separate the gums from the teeth. They will be lifted or folded back in the form of a flap. This gives the periodontist direct access to the roots and bone supporting the teeth.
Inflamed tissue will be removed from between the teeth and from any holes (defects) in the bone. The periodontist then will do a procedure called scaling and root planing to clean plaque and tartar. If you have bone defects, your periodontist may eliminate them. This procedure is called osseous recontouring. It smoothes the edges of the bone using files or rotating burs.
Finally, the gums will be placed back against the teeth and stitched in place. Some periodontists use stitches that dissolve on their own. Others use stitches that have to be removed a week to 10 days later. Your periodontist also may cover the surgical site with a bandage. This is called a periodontal pack or dressing.
Follow-Up
You will have mild to moderate discomfort after the procedure. Your periodontist can prescribe pain medicine to control it. Many people feel fine with just an over-the-counter pain reliever.
It is very important for you to keep your mouth as clean as possible while the surgical site is healing. This means you should brush and floss the rest of your mouth normally. If the surgical site is not covered by a periodontal pack, you can use a toothbrush to gently remove plaque from the teeth. Antimicrobial mouth rinses containing chlorhexidine are often prescribed after gum surgery. These rinses kill bacteria, delay plaque growth and help your mouth to heal.
You may have some swelling. This can be reduced if you apply an ice pack to the outside of your face in the treated area. In some situations, antibiotics may be prescribed to prevent an infection. Be sure to take them as instructed. Your periodontist will want to reexamine the area in 7 to 10 days.
Risks
After the surgery, you may have some bleeding and swelling. There is a risk that you could develop an infection.
Your gums in the area that was treated are more likely to recede over time. The teeth that were treated may become more sensitive to hot and cold. The teeth also are more likely to develop cavities in the roots.
When To Call a Professional
It is normal to have some discomfort or pain and some minor bleeding during the first 48 hours after the procedure. These symptoms usually go away after a couple of days. Call your periodontist if bleeding continues or if the symptoms get worse after the first three days. This could be caused by an infection. If so, it should be treated promptly.
Ear Reconstruction
In total construction of the auricle (external ear) the plastic surgeon must sculpt a delicate convoluted framework from rib cartilage and cover it with a fine skin envelope.
Alloplastic (or artificial) frameworks are not well-tolerated. At UCLA, it is believed that a patient’s rib (or costal) cartilage is the most reliable framework.
The goal of the surgeon is to create an acceptable representation of an external ear with proper size, position and orientation to other facial structure. The procedure is usually undertaken at 6 to 9 years of age.
Generally, the reconstruction may be done is 4 stages (Brent technique) or 2 stages (Nagata technique) depending on the patient’s ear deformity (microtia type) and surgeon preference for each case.
The 4 staged technique consists of:
Framework fabrication from rib cartilage;
Elevation of framework with skin graft and banked cartilage;
Lobule (ear lobe) rotation;
Creation of tragus (front of ear, covering the ear canal).
The 2 stage technique consists of:
Framework fabrication from rib cartilage, including the tragus;
Elevation of framework with temporal parietal flap and skin graft.
The first stage of the reconstruction requires an overnight stay in the hospital. Other stages are outpatient procedures. The entire process may take 6 months to one year to complete.
Orbital Reconstruction
Deformities of the orbit include:
Before and After
Orbital dystopia-The bony orbital cavities do not lie in the same horizontal plane
(Horizontal Dystopia) or the same vertical plane (Vertical Dystopia`).
Exorbitism- Normal orbital soft tissue exists (fat, muscles and the globe or eye) but a sfmall bony orbit results in proptosis (eyes bulging). This may occur in patients with Crouzon, Apert and other syndromes.
Posttraumatic enophthalmos-Recessed globe (eye) results from discrepancy between the orbital volume and bony orbital cavity.
Correction of these deformities requires proper diagnosis and preoperative planning with the help of CT scans. Orbital bony and soft tissue reconstruction are often required. Surgical techniques used (many devised by Dr. Paul Tessier) include:
Box osteotomy
Facial bipartition
Midface Advancement
Repositioning of the sygomatic maxillary complex.
At the UCLA Craniofacial Clinic the decision as to which procedure(s) will be most effective in correcting a patient’s orbital deformity depends on the patient’s diagnosis, the severity of deformity and the team’s evaluation.
Thoracodorsal Artery Perforator Flap
The thoracodorsal artery perforator or TAP flap is a fasciocutaneous flap based on a musculocutaneous perforator or perforators from the thoracodorsal vessel axis and/or its vertical branch derivative. In contrast to the other well-known DIEP (deep inferior epigastric perforator) and SGAP (superior gluteal artery perforator) flaps that provide bulk, the TAP flap provides a relatively thin and pliable skin paddle. In a reasonably thin person, the flap ranges from 1 – 2 cm in thickness. In heavier patients the flap may be thinned by delaminating the deep adipose layer from the superficial adipose layer at the level of the superficial fascia. The resulting thickness of the skin and superficial fat layer will be approximately 1 cm. The TAP flap is well suited for extremity, head and neck, and peri-articular resurfacing as well as for the contouring of shallow defects. As is the case with other perforator flaps, the surgical dissection can be difficult.
A flap of dimensions 15 X 8 cm can be harvested on a single perforator. These dimensions allow for both primary closure of the donor site and avoidance of post-operative venous congestion in the flap.
Anatomy
After originating from the subscapular axis, the thoracodorsal vessels course toward the latissimus dorsi. On reaching the deep surface of the muscle, the thoracodorsal vessels most commonly divide into two primary muscular branches: the transverse branch, and the lateral or vertical branch. These branches usually diverge at near 45 degree angles to one another. Both travel from the deep surface of the muscle to become intramuscular. The lateral branch courses vertically and at least 2 – 3 cm inside the lateral border of the latissimus, often greater. A perforator or combination of perforators off the distal main thoracodorsal and/or it’s lateral branch constitute the vascular supply of the TAP flap.
The TAP flap is nourished by perforators of the descending branch of the thoracodorsal artery.
TA TB: Thoracodorsal artery transverse branch.
TA DB: Thoracodorsal artery descending branch.
The first perforator is located approximately 6 – 8 cm below the posterior axillary fold and may be either a branch of the distal main thoracodorsal or arise from it’s lateral branch. Subsequent perforators, up to a total of three, arise at 1.5 – 4 cm intervals inferiorly off the lateral branch. Each perforator displays a 3 – 5 cm oblique course through the substance of the muscle giving off numerous muscular branches before penetrating through the dorsal thoracic fascia to supply the overlying skin and subcutaneous fat layers. Each perforating artery is 0.3 – 0.6 mm in diameter and accompanied by two venae commitans.
Operative Technique
The patient is placed in the lateral decubitus position on a beanbag just as in the latissimus harvest. The ipsilateral arm is left free and included in the operative scrub. A stockinette around the arm and Mayo stand with a well-padded pillow helps to rest and optimally position the arm during surgery.
The lateral border of the latissimus is palpably identified and outlined with a marking pen. A pencil Doppler is used to identify and map out the perforators starting about 6 – 8 cm below the posterior axillary fold and 2 – 4 cm inside the lateral border of the latissimus. The loudest one to two perforators are marked.
The main perforator(s) are identified with a pencil Doppler probe, posterior to the anterior border of the latissimus muscle.
The flap dimensions needed are outline, with the perforator on the longitudinal axis of the flap. The perforator can be at the center, distal or proximal aspect of the flap, depending on the needed orientation in the recipient area. This results in an ellipse with its anterior longitudinal arc skirting the lateral border of the latissimus. The maximal width is determined by the pinch test to determine what can be closed primarily. The maximum reliable length of a TAP flap that can be elevated on a single perforator has not been clearly established. Flaps up to 25 cm in length have been reported.
The flap is centralized around the perforator.
The anterior or posterior incision can be made first. If you are unsure of your marking, the anterior exposure may be simpler to start with. The perforator(s) are identified. The dominant perforator is traced through the muscle to the descending branch of the thoracodorsal artery. A cutaneous nerve may be seen accompanying the largest perforator. A second perforator that appears to be in the same longitudinal plane as the first can also be dissected free and used to further nourish the flap (not pictured).
The flap is elevated medial to lateral or lateral to medial, and the perforator through the latissimus muscle to the overlying skin and fat is identified.
The perforator or perforators and the lateral branch of the thoracodorsal vessels are traced proximally until the deep surface of the muscle is found and the plane between the latissimus and serratus is entered. The latissimus muscle can then be retracted posteriorly with further dissection done in this plane. Bipolar cautery is used to ligate the multiple small muscular branches that are present during all stages of the dissection.
The perforator is traced through the muscle and the artery is followed toward the axilla and the thoracodorsal system.
The vessels distal to the perforator are clipped after care is taken to separate the accompanying thoracodorsal nerve. The proximal vessels are also separated from the nerve and the desired length of thoracodorsal pedicle liberated. The vessels are ligated, and with gentle traction on the flap are simply pulled through the split in the muscle.
For maximal length and vessel caliber, the artery can be followed to subscapular origin on the axillary vessels.
If adequate pedicle length and vessel diameter are present, the pedicle may be divided here. If a longer pedicle with larger diameter vessels is necessary, the transverse branch of the thoracodorsal is ligated and dissection proceeds up the main thoracodorsal axis as required. Distally, the perforator becomes so small that separating the nerve at this level could prove disastrous. Therefore, at some point, the distal intramuscular branches of the thoracodorsal nerve accompanying the perforator must be sacrificed and left adherent to the pedicle. This trivial amount of denervation is surely inconsequential. If there is a desire to neurotize the flap the previously mentioned cutaneous nerve can be separated off the maierve branches proximally by intrafascicular dissection.
The edges of the vertical muscle split are approximated with absorbable suture. Closure of the back wound proceeds in the usual fashion. Suction drains are placed and the patient is allowed to move the ipsilateral arm post-operatively.
What are the benefits of TDAP flap?
When the breast is reconstructed entirely with your own tissue, the results are generally more natural. As a “stand-alone” flap, however, the TDAP is typically not adequate to provide the volume and contour required for the final result. Therefore, combination with a small implant, or with fat grafting techniques, may be needed in order to optimize the volume and shape of the breast. It is an ideal flap when there is radiation damage to the breast, or if small volumes of tissue are required to contour the breast.
The TDAP flap technique is suited for specialized patients; your surgeon will determine if you are a good candidate.
What will I look like post surgery?
Your plastic surgeon will do everything possible to make your breasts look and feel natural. There will be scars at in the back region as well as on the reconstructed breast, but these tend to be well hidden by standard clothing. Oftentimes patients require a final outpatient surgery after the TDAP flap to make the breasts appear as symmetric and natural as possible. You should discuss with your surgeon all of your concerns and expectations for post-surgery appearance and recovery.
How long will it take to recover?
TDAP flap surgery requires a hospital stay of approximately two days. You will be able to begin eating and you will get out of bed with assistance on the first day after surgery. Typically patients are able to return home on the on the second day. While at home you will be able to perform all necessary activities of daily living.
Perforator flaps
Perforator flap surgery is a technique used in reconstructive surgery where skin and/or subcutaneous fat are removed from a distant or adjacent part of the body to reconstruct the excised part.[1] The vessels that supply blood to the flap are isolated perforator(s) derived from a deep vascular system through the underlying muscle or intermuscular septa. Some perforators can have a mixed septal and intramuscular course before reaching the skin. The name of the particular flap is retrieved from its perforator and not from the underlying muscle.[1] If there is a potential to harvest multiple perforator flaps from one vessel, the name of each flap is based on its anatomical region or muscle. For example a perforator that only traverses through the septum to supply the underlying skin is called a septal perforator. Whereas a flap that is vascularised by a perforator traversing only through muscle to supply the underlying skin is called a muscle perforator.[1] According to the distinct origin of their vascular supply, perforators can be classified into direct and indirect perforators. Direct perforators only pierce the deep fascia, they don’t traverse any other structural tissue. Indirect perforators first run through other structures before piercing the deep fascia.
Overview
Soft tissue defects due to trauma or after tumor extirpation are important medical and cosmetic topics. Therefore reconstructive surgeons have developed a variety of surgical techniques to conceal the soft tissue defects by using tissue transfers, better known as flaps. In the course of time these flaps have rapidly evolved from “random-pattern flaps with an unknown blood supply, through axial-pattern flaps with a known blood supply to muscle and musculocutaneous perforator flaps” for the sole purpose of optimal reconstruction with minimum donor-site morbidity.[2] Koshima and Soeda were the first to use the name “perforator flaps” in 1989 [3] and since then perforator flaps have become more popular in reconstructive microsurgery.[1] Thus perforator flaps, using autologous tissue with preservation of fascia, muscle and nerve represent the future of flaps.[4] The most frequently used perforator flaps nowadays are the deep inferior epigastric perforator flap (DIEP flap), [5][6] and both the superior and inferior gluteal (SGAP/ IGAP) flap,[7] all three mainly used for breast reconstruction; the lateral circumflex femoral artery perforator (LCFAP) flap (previously named Anterolateral thigh or ALT flap)[8] and the thoracodorsal artery perforator (TAP) flap,[9] mainly for the extremities and the head and neck region as a free flap and for breast and thoracic wall reconstruction as a pedicled perforator flap.
Classification
Perforator flaps can be classified in many different ways. Regarding the distinct origin of their blood supply and the structures they cross before they pierce the deep fascia, perforators can either be direct perforators or indirect perforators.[10] We will discuss this classification based on the perforators’ anatomy below.
Direct and indirect perforators
Direct cutaneous
Direct cutaneous perforators only perforate the deep fascia, they do not traverse any other structural tissue.[10]
It’ s questionable whether these perforators are true perforators, because it might be more logical to not include these perforators. The surgical approach needed for direct perforators is slightly different from the one needed for indirect perforators. When direct perforators are not included, surgeons can focus on the anatomy of the perforator and the source vessel.[1]
Indirect cutaneous
Indirect cutaneous perforators traverse other structures before going through the deep fascia. These other structures are deeper tissues, and consist of mainly muscle, septum or epimysium.[10] According to the clinical relevance, two types of indirect cutaneous perforators need to be distinguished.[1] We will clarify these two types below.
Muscle and musculocutaneous
Musculocutaneous perforators supply the overlying skin by traversing through muscle before they pierce the deep fascia.[1]
A perforator which traverses muscle before piercing the deep fascia can do that either transmuscular or transepimysial. This latter subdivision is however not taken into account during the dissection of the perforator. Only the size, position, and course of the perforator vessel are considered then.[1]
When a flaps’ blood supply depends on a muscle perforator, this flap is called a muscle perforator flap.[1]
Septal and septocutaneous
Septocutaneous perforators supply the overlying skin by traversing through an intermuscular septum before they pierce the deep fascia. These perforators are cutaneous side branches of muscular vessels and perforators.[1]
When a flap’s blood supply depends on a septal perforator, this flap is called a septal perforator flap.[1]
Nomenclature
Due to confusion about the definition and nomenclature of perforator flaps, a consensus meeting was held in
“A perforator flap should be named after the nutrient artery or vessels and not after the underlying muscle. If there is a potential to harvest multiple perforator flaps from one vessel, the name of each flap should be based on its anatomical region or muscle.” [1]
This so-called ‘gent consensus’ was needed because the lack of definitions and standard rules on terminology created confusion in communication between surgeons.[1]
Method of application
Flaps can be transferred either free or pedicled. Regarding the nomenclature, one is free to add the type of transfer to the name of a flap.[1]
Free perforator flaps
A free flap is defined as a tissue mass that has been taken away from the original site to be used in tissue transplantation.[11] When a surgeon uses a free flap, the blood supply is cut and the pedicle reattached to recipient vessels, performing a microsurgical anastomosis.[12]
For more information on free flaps, see also free flap.
Pedicled perforator flaps
Pedicled perforator flaps can be tranferred either by translation or rotation. These two types will be discussed separately below.
Translation
This type of transfer is also called “advancement”.The surgeon disconnects the flap from the body, except for the perforators. After this procedure, the flap is advanced into the defect.[13]
Rotation
The subgroup of pedicled perforator flaps, transferred in the defect by rotation is the so-called “propeller flap”. Confusion concerning definition, nomenclature and classification of propellor flaps led to a consensus meeting similar to the “gent consensus meeting”. The consensus that was reached is named “the
“A propeller flap can be defined as an “island flap that reaches the recipient site through an axial rotation.” Every skin island flap can become a propeller flap. However, island flaps that reach the recipient site through an advancement movement and flaps that move through a rotation but are not completely islanded are excluded from this definition. ” [14]
Propeller flap
Regarding the classification of propeller flaps, the surgeon should specify several aspects of these flaps. It is important that the type of nourishing pedicle, the degree of skin island rotation and, when possible, the artery of origin of the perforator vessel are mentioned.[14]
The perforator propeller flap is the propeller flap which is used most commonly. It is a perforator flap with a skin island, which is separated in a larger and smaller paddle by the nourishing perforator. These paddles can rotate around the perforator (pedicle), for as many degrees as the anatomical situation requires (90-180 degrees). This flap looks like a propeller when the two paddles are not too different in size.[14]
Fields of application
Trauma, oncological treatments or pressure ulcers can result in severe tissue defects. Those defects can be covered and closed by using autologe tissue transposition. The fact that each tissue defect is different makes it necessary for each tissue defect to be assessed individually. The choice of the type of tissue transposition depends on the location, nature, extent and status of the deformity.[15]
However, the health of the patient and possible contra-indications play an important role as well. Due to the development and improvement of cutaneous, myocutanous and fasciocutaneous tissue transpositions plastic surgeons are able to successfully restore the defect to its original shape.[15] Nevertheless, functional recovery is not guaranteed in all patients. For the optimal renewal of shape and function, a suitable flap can be chosen to reconstruct the defect. In the case of using a so-called perforator flap, a reliable vascularization and the possibility of sensory (re) innervation can be combined with less donor-site morbidity and limited loss of function in the donor area.[15]
Oncological background
The surgical removal of both benign and malignant tumors often result in serious tissue defects involving not only soft tissue but also parts of the bone.[16] Depending on the location aneligible flap can be selected. In breast reconstruction for example, perforator flaps have raised the standard by replacing like with like.[17] When taking breast reconstruction into consideration, several surgical options are available to achieve lasting natural results with decreased donor-site deformities. The broad option of donor-sites makes practically all patients candidates for autogenous perforator flap reconstruction.[17] Some examples include, Deep inferior epigastric perforator flap (DIEP flap), superior gluteal (SGAP) flaps and inferior gluteal (IGAP) flaps.
Traumatic background
Treatment of tissue defects caused after a trauma present major surgical challenges especially those of the upper and lower limb, due to the fact that they often not only cause damage to the skin but also to bones, muscles/tendons, vessels and/or nerves.[18]
If there is extensive destruction a fasciotomy is needed, therefore it is generally accepted that the best way to cover these types of tissue defects is a free flap transplantation.[3][18][19] Nevertheless, over the years surgeons have tried to increase the application of perforator flaps, due to their proven advantages. In the case of upper limb surgery, perforator flaps are successfully used in minor and major soft tissue defects provided that in major defects the flap is precisely planed.[18][20]
In lower limb surgery there have also been reports of successful use of perforator flaps.[21][22]
Advantages and disadvantages
Twenty three years after the first perforator flap was described by Koshima and Soeda,[3] there has been a significant step towards covering tissue defects by using only cutaneous tissue.[23] Results obtained from studies done on musculocutaneous and septocutaneous perforator flaps have shown a reduction of donor-site morbidity to a minimum [23][24] due to refined perforator flap techniques that allow collection of tissue without scarifying the underlying muscles.[25][23] As a matter of fact, preventing damage to the underlying muscle including its innervation, has led to less cases of abdominal hernia,[25] the absence of postoperative muscle atrophy [26] and a better vascularised and functioning donor muscle.[17] Furthermore patients have shown decreased postoperative pain and accelerated rehabilitation [17][24] Nevertheless there will always be a chance that the displaced tissue partially or completely dies considering the fact that the perfusion of the flap is difficult to assess intraoperatively.[27] Furthermore when using this technique additional scars are made. Thus considering the complexity and length of this procedure microsurgical expertise is required and patients need to undergo a longer period of anesthetics that of course could result in increased risk factors.
Indications and contra-indications
Indications:
the need to cover exposed vital components such as tendons, vessels, joint surfaces and bone free from periosteum
the need to reestablish function
the need to restore structure and shape, like after a mastectomy
Contraindications:[28][29]
Associated with the patient:
condition that could be harmful to the patients’ life (critically ill, sepsis, peripheral vascular disease and renal disease)
condition that enlarge the possibility of reconstructive failure (peripheral vascular disease and renal disease)
patient’ s ability to withstand sustained anesthesia (severe respiratory disease is an absolute contraindication)
Relative contra-indications[30]
Any condition that probably increases the risk of intraoperative or postoperative complications:
cardiovascular disease
diabetes mellitus
Raynaud syndrome
scleroderma
other collagen vascular diseases
smoking
radiation
ongoing infections
By inducing thrombogenic state through vasoconstriction of the microvasculature, tobacco influences blood flow, wound healing and the survival of pedicled flaps. On the contrary there is no published data on damaging effects of cigarette smoke on free tissue transfer.[31][32]
Examples of perforator flaps
Deep inferior epigastric perforator flap (DIEP flap)
Thoracodorsal artery perforator (TAP) flap
Superior gluteal (SGAP) flaps
Inferior gluteal (IGAP) flaps
Thoracodorsal artery perforator fasciocutaneous flap: A versatile alternative for coverage of various soft tissue defects
Abstract
Objective: The thoracodorsal artery perforator (TDAP) flap has contributed to the efficient reconstruction of tissue defects that require a large amount of cutaneous tissue. The optimal reconstruction method should provide thin, and well-vascularized tissue with minimal donor-site morbidity. The indications for the use of this particular flap with other flaps are discussed in this article. Materials and Methods: Thirteen patients underwent soft tissue reconstruction using TDAP flaps between 2009 and 2011. Of those, there were four cases of antecubital burn contracture, three cases of axillary burn contracture, two cases of giant hair cell nevus of upper extremity, two cases of axillary reconstruction following severe recurrent hidradenitis, and two cases of crush injury. All patients were male and their ages ranged from 20 to 23 (average, 21 years). The mean follow-up period was 8 months (range, 4-22 months). Results: All reconstructive procedures were completed without any major complications. Minor complications related to transfered flaps were wound dehiscence in one case, transient venous congestion in two cases. Minor complication related to the donor site was seroma in one case. The success rate was 100%, with satisfactory cosmetic results. Conclusions: The TDAP flap is a safe and extremely versatile flap that offers significant advantages in acute and delayed reconstruction. Although the vascular anatomy may be variable, free and pedicled TDAP flap is a versatile alternative for soft tissue defects. It adapts very well to the soft tissue defects with acceptable donor site scar.
Introduction
The thoracodorsal artery perforator (TDAP) flap is a relatively new member of the perforator flap family in reconstructive surgery. Over the past years, free or pedicled transfers of TDAP flap were used for reconstruction of defects that require a large amount of cutaneous tissue. It has been used as a pedicled flap for reconstruction of regional soft tissue defects, including trunk, axilla and breast, or as a free flap in reconstruction of various distant tissue defects such as face, elbow, forearm and lower extremity. [1],[2],[3],[4],[5] Advantages of the TDAP flap include simultaneous flap elevation, easy dissection, minimal donor-site morbidity, and constant vascular anatomy with a long pedicle. Therefore, the TDAP flap has become more popular among reconstructive surgeons recently. [4],[5],[6],[7],[8]
Up to the present time, there are not sufficient articles published concerning the versatile use of the TDAP flap in soft tissue reconstruction. We have used a number of designs of the TDAP flap, depending on the needs of the recipient areas, including free and local pedicle fasciocutaneous flaps. Our experience is presented in this article.
» Materials and Methods
Thirteen patients were reconstructed with TDAP flap between july 2009 and july 2011 in our department. All patients were male and their ages ranged from 20 to 23 years old (average, 21 years). There were four cases of antecubital burn contracture, three cases of axillary burn contracture, two cases of giant hair cell nevus of upper extremity, two cases of axillary reconstruction following severe recurrent hidradenitis, and two cases of crush injury. The size and orientation of the skin islands were planned according to the defect sizes and orientations. The details of the patients are given in [Table 1].
Table 1: The dermographic features of the patients
» Surgical Technique
A marking line was drawn from the posterior axillary fold to the posterior superior iliac spine, which demarcates the lateral border of the latissimus dorsi muscle. The location of cutaneous perforators of the thoracodorsal artery on the back were marked using a handheld Doppler preoperatively. Subsequently, we designed fasciocutaneous TDAP flap preoperatively, including the point where the cutaneous perforator was marked, as its long axis was perpendicular to the running of the latissimus dorsi muscle [Figure 1]. The proximal perforator was usually located 8-10 cm below the axilla and 2-3 cm behind the lateral border of the latissimus dorsi muscle.
Figure 1: Locating the perforators and flap designs in lateral decubitus position. The dotted line is the lateral border of the latissimus dorsi muscle. Point P is the point presenting the main perforator artery of flap. Point P is usually located in 2-3 cm from the lateral margin of the LD
All the cases were positioned in a lateral decubitus position with the arm abducted 90 degree over the head to achieve flap elevation under general anaesthesia. The flap size and shape was designed according to the defect size, with incorporation of the point of perforator artery to obtain a long pedicle for free flap transfer and provide appropriate mobilization for pedicled flap transfers. Usually pedicled flaps were designed in such a way that the perforator enters the skin paddle right in the centre of flap skin island. However, the free flaps were designed on the basis of the proximal perforator, which was placed on the proximal third of the flap to increase effective pedicle length, and the size of the flap. The first incision was made at the lateral margin of the flap, and dissection was carried carefully out medially through the loose areolar tissue above the muscle under loupe magnification for identification of the pulsating perforator. The fascia was incised in order to carry out a subfascial dissection plane. After identifying the pulsating perforator, dissection was continued through the muscle until the thoracodorsal vessels were found. In all of these cases the pedicle was dissected as high as the bifurcation of subscapular artery. However, a very tiny amount of muscle was added to the pedicled flap in order to prevent any harm to the perforators for pedicled flap transfers. During this dissection, the thoracodorsal nerve and its branches were preserved. The flap was harvested on the thoracodorsal perforator and separated from the underlying muscles. Subsequently, the flap was transferred to the defect. The pedicled flap was tunneled in every case towards the defect. At this step, it was important to be careful not to damage the perforator and to avoid all external pressure. In all cases, the donor site was closed primarily and negative pressure aspiration drains was inserted. A follow-up of the flaps was done by clinical observation of capillary refilling, congestion, and handheld Doppler.
» Case Reports
Four clinical cases are described in detail.
Case 1
A 20-year-old man had suffered postburn right antecubital burn contracture causing restriction of extremity abduction for 12 years due to flame burn. The patient had not previously undergone reconstructive surgery. The TDAP flap was planned for reconstruction. During the operation, the contracted scar was completely released. The thoracodorsal perforator-based cutaneous flap, 18 × 9 cm in size, was harvested by including the first two perforators of the lateral branch of thoracodorsal artery. After complete elevation of the flap, thinning was performed except at the area 1 cm around the vascular perforator. Subsequently, the flap then transferred to the defect on its pedicle and sutured in defect. The donor site was closed primarily. There was no restriction of the extremity abduction at 8-months postoperatively. The result was accepted as satisfactory by the patient and the physician [Figure 2].
Figure 2: (a) Severe antebrachial contracture. (b) Intraoperative view of contracture releasing. (c) 19 × 8 cm the thoracodorsal artery perforator flap was elevated and transferred the defect area. (d) Postoperative appearance 8 months after surgery
Case 2
A 23-year-old man referred for assessment and treatment of axillary hidradenitis suppurativa that had evolved over 10 years. He had undergone several conservative treatments with recurrence of the lesion. During the operation, all the hair-bearing area was completely resected. The pedicled TDAP flap was planned according to the defect size and subsequently, TDAP flap was performed to coverage of the defect. The donor area of TDAP was closed primarily. The TDAP flap survived completely, and all wounds healed without complication. The patient was able to complete arm abduction 3 weeks after surgery. A satisfactory result was obtained without long-term recurrence [Figure 3].
Figure 3: (a) Preoperative view of chronic left axillary hidradenitis. (b) Excision of hydraadenitis. (c) Design of a the thoracodorsal artery perforator flap according to the defect size. (d) View 10 months after surgery
Case 7
A 20-year-old man patient sustained a flame burn to his upper extremity and lateral thorasic area when he was 2-years-old. His burns were allowed to heal spontaneously with resulting axillary contracture. This contracture was limited his mobility during sport activities. The TDAP flap was chosen due to its surgical proximity and resemblance in skin texture. During the operation, the scar tissues and the contracture bands in the axillar area was removed and his shoulder joint was released completely. The TDAP flap was harvested on a single perforator and passed through the skin tunnel toward the defect. The donor site was closed primarily. The postoperative course and healing of the recipient area was uneventful. Ten months after surgery, TDAP flap adapted to the axillary region perfectly, and the patient was able to abduct his arm to 160 degree without any difficulty in the postoperative period [Figure 4].
Figure 4: (a) Severe axillary burn contracture. (b) The thoracodorsal artery perforator flap on a single perforator. (c) Intraoperative view. (d) Postoperative appearance 14 months after surgery
Case 11
A 20-year-old man had sustained an injury to the left foot dorsum while driving a car. He had referred to another center, where the dorsum defect was skin-grafted. Seven years after the initial trauma, he applied to our department. The free TDAP flap was planned for reconstruction. During the operation, the scar tissue was completely removed. The free TDAP flap flap 16 × 9 cm in size was designed and elevated to transfer the defect. The thoracodorsal artery and vein of flap were anastomosed to the posterior tibial artery and vein. The flap donor site was closed primarily without grafting. The patient was fully mobilized 3 weeks after the reconstruction. The follow-up period was 17 months. Flap contour was good, and no debulking procedures were required [Figure 5].
Figure 5: (a) Crush injury on the left foot. (b) A wide soft tissue defect after the scar tissue was excised. (c) A free The thoracodorsal artery perforator flap, in 16 × 10 cm in size. (d) Postoperative appearance 17 months after surgery
» Results
Dimensions of the flaps were determined according to the localization and orientations of soft tissue defects. The largest dimension of the TDAP flap used was 20 × 12 cm. No partial or complete flap loss was seen. Minimal venous congestion was observed in two flaps in the early postoperative period. This condition recovered spontaneously within 3 days. Minor complication related to the donor site was seroma in one case. The initial edema and bulky appearance was diminished by the 6 th month. All flaps remained stable and donor sites healed uneventfully. The mean operation time was 4 hours for free flap transfer and 2.5 hours for pedicled flap transfer. The average hospital stay was 16 days. Follow-up after surgery ranged from 4 months to 22 months. The linear scars in donor areas were acceptable during late follow-up period. Self-reported cosmesis was rated “acceptable” in all patients. Additional flap thinning procedures were not necessary after the operations. The results and clinical characteristics of the patients are given in [Table 1].
» Discussion
The perforator flap depending on muscle perforators without including the underlying muscle was first described by Koshima and Soeda in 1989. [9] Recently, the perforator-free flap is becoming increasingly popular because of its thinness, versatility, and low donor-site morbidity. The possibility of the thoracodorsal perforator flap was described by Angrigiani et al. [10] and many authors presented their experience with it since then. Spinelli et al. reported the presence of a predictable row of perforators from the lateral intramuscular branch of the thoracodorsal artery. [11] Kim et al. reported the use of thin latissimus dorsi perforator flaps including only the superficial adipose layer. [12] Binu et al. reported the cutaneous vascular supply of the thoracodorsal artery and and the number and type of perforators by means of human cadaver dissection. [13],[14]
The TDAP flap is popular perforator flap among reconstructive surgeons and it is the first flap choice in some clinics for the coverage of soft-tissue defects. The advent of microsurgical techniques has allowed this versatile flap to be transposed to reconstruct soft-tissue defects all around the body. In this study, the series of patients presents multiple versatile uses of TDAP flaps, according to experiences at our institution.
The reliability of the TDAP flap will depend on the presence and size of the perforating vessels. [4] The TDAP flap have two or three skin perforator arteries. A predictable row of perforators arise from the lateral branch of the thoracodorsal artery. [10] The first perforator artery reaches the subcutaneous tissue at a point located 2 or 3 cm behind the lateral edge of the latissimus dorsi muscle and 8-10 cm below the posterior axillary fold. The second perforator artery is located 1-2 cm below the previous one. All these perforator arteries give off numerous muscular branches before penetrating the fascia to supply the overlying skin and subcutaneous fat layers. [6],[7],[8],[15],[16] Even though the distribution of perforators varies widely, a good understanding of the entire perforator anatomy is essential for safe and efficient harvesting of the thoracodorsal artery perforator flap. [14]
TDAP flap has the common advantages of perforator flaps. While harvesting flap, preservation of the innervation and vascularization of the latissimus dorsi muscle provide less donor site complications. In addition, the TDAP flap offers distinct advantages, including a large flap dimension, a long pedicle length and excellent contour restoration. [6],[7],[8],[17]
Soft tissue defects on the lower and upper extremity require thin flaps, and patients who have relatively thin back tissue with the pinch test are ideal candidates for TDAP flap reconstruction. [17] The defects of shoulder and axilla have the same soft tissue properties like the donor site and TDAP flap provides good coverage when transferred pedicled to these areas. Hidradenitis suppurativa is a chronic and recurrent inflammatory disease of the apocrine glands characterized by recurrent abscesses frequently located in the axilla. [17] The surgical removal of all apocrine glands with wide excision of all hair-bearing skin in the axilla and covering the defect with a fasciocutaneous flap is the definitive treatment to eradicate the recurrence. To best of our knowledge, up to date, usage of the TDAP flap for the reconstruction of hidradenitis suppurativa have been reported by only a few authors. [3],[15],[17]
Patients with severe postburn contractures have many difficulties in their daily life. [6],[7],[8] These contractures often cause cosmetic problems and functional deficiency. Release of antecubital and axillary burn contractures results in relatively large soft-tissue defects in this region was seen. The aim of surgical correction is the restoration of movements at the shoulder joint that will permit the strategic positioning of the hand in its preoccupation with the activities of daily living. [18] Z-plasties, local flaps, island flaps, and free flaps, have been reported for treatment of the contractures. Although these techniques are effective for linear contractures, they are not suitable in patients with severe contractures. The TDAP flap may be safely raised to meet any size required even in the most severe contractures. [19] Recently, our team reported the use of TDAP flaps for the reconstruction of axillary, antecubital and thenar contractures. [6],[7],[8]
Defects of the foot and ankle with exposed tendons or bone require either local or free flap coverage. These areas are easily susceptible to trauma and are the site of numerous trophic problems (e.g., pressure sores, chronic ulcers, and penetrating injuries). Free flaps in the lower extremity may be necessary for high-energy injuries, open fractures of the middle and distal one-third tibia, radiation injuries, osteomyelitis, and large, soft tissue defect exposing bone tissue after radical resections of the tumors. [20],[21] Several publications in recent years have proven popularity of free fasciocutaneous flaps for the coverage of defects of the foot and ankle. An ideal reconstruction should be stable, thin, well contoured and durable to friction forces caused by footwear. In addition, the flap chosen should be easy to execute quickly with minimal discomfort to the patient and should provide durable coverage for the defect. [22] Among the fasciocutaneous free flap alternatives for soft tissue defects, the lateral arm flap, the scapular flap, the radial forearm flap, the anterolateral thigh flap, superficial circumflex inferior artery flap, superficial inferior epigastric artery flap may be used. The anterolateral thigh flap has gained great popularity among reconstructive and recently has become the first-choice flap at many centers for the reconstruction of soft-tissue defects. However, compared with TDAP flap, the ALT flap has numerous disadvantages. One disadvantage is that the anatomy of the perforator supplying the ALT flap is variable. The perforator may have different pathways such as septocutaneous, musculocutaneous, septomusculocutaneous, and the axial pattern leading ultimately to the source vessels. The variability of perforators and the difficult dissection of the musculocutaneous perforator may be the major challenge for a surgeon. Surgical dissection may easily damage the pedicle. Another disadvantage is the large number of musculocutaneous perforators, which are difficult to dissect without some sacrifice of the vastus lateralis muscle and its peripheral motor nerves. Sometimes patients complain of sensory deficits in the donor site. Infrequently, conspicuous flap donor site scar may be a disadvantage especially for females. Transferring hair-bearing tissue to the soft tissue defects like cervical area may be another disadvantage. [23] Compared with TDAP flap, scapular and parascapular flaps are also elevated from the same donor area and have similar skin texture. However, the pedicles of these flaps are shorter when compared with TDAP flap, and this limits the freedom in pedicled and free transfers. In addition, the donor-site morbidity; the need for a secondary defatting procedure; requirement for a change of position during the operation are the other disadvantages. [24],[25],[26],[27] The thickness of a free TDAP flap is between that of a radial forearm and scapular flap. The free TDAP flaps are able to resurface defects of any size and provide different types of tissue for reconstruction of composite defects. The free TDAP flap offers a long pedicle that may reach recipient vessel distant to soft tissue defects. On the other hand, a long pedicle provides an extensive arc of rotation in pedicled transfers. When the thoracodorsal artery perforator flap is based on a distal perforator, it has been reported that the pedicle length may reach up to 23 cm. [4] In our series, the pedicle length was 17-21 cm, with an average pedicle length of 20.0 cm. [6] To the best of our knowledge, there are a few reports demonstrating the free TDAP flap for reconstruction of dorsal surface of foot defects in literatures. [5],[28]
Despite lots of advantages and versality as mentioned above, there are also some disadvantages of TDAP flap. The meticulous planning and preoperative perforator mapping is required in order not to place the flap outside the angiosome of perforators, and this takes surgical experience. In clinical practice, identification of these skin perforators may be performed using some anatomic landmarks. The handheld Doppler study is useful in identifying the preoperative identification of perforators. There is a general correlation between the audible volume of the signal and the diameter of the perforator. Patient positioning and dissection of the perforator may increase operative time because of variations of the perforator anatomy. For this reason, the surgeon should be fully aware of perforator topographic variations. The meticulous dissection is worthwhile to obtain a longer pedicle because TDAP is not an axial flap and flap vascularization to the most distant parts is difficult to predict. This situation may predispose to partial fat and skiecrosis. The other disadvantage of the TDAP flap is scar widening or hypertrophic scar of the donor site in some of patients with relatively large flap dimensions. [8] The skin paddle is still too bulky in some circumstances, such as in resurfacing defects of the head and neck and in reconstructing defects resulting from traumatic injury of the hand or foot. The thinning procedure may be an ideal solution for these problems. [29],[30] Although our study demonstrated a low incidence of flap complications, care must be taken in high-risk patients such as smokers and patients with associated comorbi d diseases to decrease the risk of flap failure.
Our clinical experience with the TDAP flap in reconstruction of soft tissue defects at the same institution is described. [6],[7],[8] The location of defects has been variable and includes the neck, trunk, and upper and lower extremities. Our overall experience consists of 33 cases since 2004. Based on the data, according to our clinical experience, TDAP flap has many advantages in comparison with other perforator flaps, including the following:
The flap width may reach up to 7-12 cm, and the donor-site wound may be primarily closed without further skin graft coverage. The donor-site scar may be well hidden underneath the arm and in the underwear
The TDAP flap contains no muscle, allowing more reconstructive precision, and morbidity is minimised by preserving the function of the latissimus dorsi muscle. TDAP flap provide stable coverage with an acceptable aesthetic appearance for both the donor and reconstruction sites in long-term follow-up
The subcutaneous fat tissue at the back region is relatively thinner and thus may provide a thinner skin
The flap may provide an extra long pedicle. This feature provides a greater arc of rotation when the flap is used as an island flap. It also allows microvascular anastomosis outside the zone of injury when the flap is used as a free flap
The skin island may harvest along with intercostal nerves, this gave us the potential to develop a sensate flap
The versatility of the subscapular artery system facilitates combined or chimeric flap elevation.
In conclusion, TDAP flap is a versatile alternative in soft tissue reconstruction both as a free and a pedicled flap, which may be used for a wide range of indications in appropriately selected patients. The success of the TDAP flap depends on patient selection, coordinated planning, and meticulous surgery.
Superiorly Based Facial Artery Musculomucosal Flap for Large Anterior Palatal Fistulae in Clefts
Abstract
Objective: An anterior hard palate fistula for which more than one attempt at repair using local tissue has failed is a difficult complication in cleft surgery. Prior to alveolar bone grafting, cleft patients have an open anterior maxillary arch that allows passage of a pedicled flap from cheek to hard palate. The superiorly based facial artery musculomucosal flap passed through the clefted alveolus is one of the newer techniques to solve this difficult problem. The aim of this study was to assess the validity of using a facial artery musculomucosal flap with an anterosuperiorly based pedicle with retrograde blood flow to repair a large anterior hard palate fistula when a lack of adequate local soft tissue precludes a local flap closure and the patient otherwise would need a tongue flap.
A palatal fistula is a common complication of cleft palate repair. The reported incidence varies between 8% and 40% (Cohen et al., 1991; Lazarus et al., 1999; Mohanna et al., 2001), although most would recognize that bilateral complete clefts have a higher incidence than do simple soft palate clefts. The usual location for a fistula is the junction of the hard and soft palates, but in bilateral complete cleft lip and palate it is often in the anterior hard palate. The repair of a fistula can be challenging, particularly in wide clefts or in the case of a recurrent fistula (Posnick and Getz, 1987; Marshall et al., 2003) (Fig. 1). In these cases, the palatal tissue surrounding the fistula can be quite scarred and in short supply. Provision of fresh, unscarred, and well-vascularized tissue in the form of a regional flap can be invaluable.
A variety of locoregional options commonly employed use local skin and mucosa. Historically, nasolabial flaps were used. Thiersch (1868) described closure of a palatal fistula with a superiorly based nasolabial flap. Later, inferiorly based flaps with or without a full-thickness skin graft to provide the nasal lining were described. Buccal mucosal flaps have been in use since the 1960s. Filiberti (1965) described using such a flap for repair of a septal perforation. They were initially used in the palate for lengthening either the nasal (Mukherji, 1969) or oral (
A tongue flap, based either anteriorly or posteriorly, is a good option for repairing a difficult palatal fistula (Coghlan et al., 1989; Contreas et al., 1989). However, it has the disadvantage of requiring two stages. It has a poor acceptance from patients and their parents, particularly in a pediatric population. Therefore, the need for a pedicled flap that can supply vascularized mucosal tissue and can be performed as a one-stage procedure remains high.
Pribaz et al. (1992) combined the principles of a nasolabial flap and a buccal mucosal flap to create an axial musculomucosal flap based on the facial artery. This has been called a facial artery musculomucosal (FAMM) flap. The FAMM flap is reliable and versatile. Pribaz et al. (2000) have used this flap in a variety of situations, including oronasal mucosal reconstruction and later on for lip, vermilion, and nasal reconstruction. Others have used it for palatal reconstruction in patients after ablative surgery, trauma, and cleft surgery (Dupoirieux et al., 1999; Joshi et al., 2005). Still, repair of an anterior cleft palate fistula remains one of the most valuable indications (Ashtiani et al., 2005) for this flap.
Surgical Anatomy
The facial artery, the vascular basis of the FAMM flap, is a branch of the external carotid artery. It crosses the body of the mandible at the anterior border of the masseter muscle, passes forward and upward across the cheek, close to the oral commissure and then lateral to the ala of the nose. The artery then divides into a number of branches, including the angular artery. Near the oral commissure, the facial artery lies deep (medial) to the risorius, zygomaticus major, and the superficial lamina of the orbicularis oris muscle. It is superficial (lateral) to the buccinator, levator anguli oris, and the deep lamina of the orbicularis oris.
In a cadaveric dissection study, Dupoirieux et al. (1999) described the spatial relationship between the facial artery and facial vein in the area between the superior border of the mandible and the ala nasi. This study found that the facial vein always lies posterior to the artery. The mean distance between the facial artery and vein gradually increases from 4 mm at the level of the upper border of the mandible to 15 mm at the level of the ala. These findings are clinically very significant, particularly while raising a superiorly based flap.
The facial artery rests on the outer (lateral) surface of the buccinator muscle in the cheek. The buccinator is covered on the lateral aspect by the buccal fat pad. On the medial (deep) aspect lie the submucosa and buccal mucosa. This region is supplied richly by a number of branches from the buccal artery (a branch of the maxillary artery) and a number of buccal branches arising from the facial artery. The veins correspondingly drain eventually either to the maxillary vein by means of the pterygoid venous plexus or to the facial vein.
The FAMM flap consists of buccal mucosa, underlying submucosa, a portion of the buccinator muscle, deeper fibers of the orbicularis oris, and the facial artery with its venous plexus. The flap is an axial pattern flap designed along and including the length of the facial artery, based either inferiorly with an orthograde flow or superiorly with a retrograde flow. The flap has been shown to be reliable with either of these two patterns. When based superiorly, it has a long arc of rotation and can be used to cover defects in the hard palate, alveolus, nasal lining, upper lip, and lower orbit. When based inferiorly, the flap can reach defects in the lower lip including the vermilion, alveolus, retromolar area, tonsillar fossa, and the floor of the mouth (Pribaz et al., 1992).
Materials and Methods
The senior author’s practice has been to manage most fistulae with local palatal flaps. For large anterior defects with inadequate local tissue, a tongue flap had been preferred. He was presented with a 15-year-old girl with learning difficulties and a symptomatic anterior fistula for whom a tongue flap would have presented difficulties with compliance. It was this patient who made us consider an anterosuperiorly based FAMM flap taken through the open alveolar cleft. This was a success (see Table 1). This flap then became the first choice of operation for correction of difficult and/or recurrent anterior hard palate fistulae.
We present a series of 16 FAMM flaps in 14 patients. All the flaps were anterosuperiorly based and were employed to close a large anterior palatal fistula following cleft palate repair. All procedures were performed by the same surgeon, the senior author. The relevant information was collected prospectively. The patient demographics and the outcome of the flaps are summarized in Table 1. Fully informed consents were obtained prior to surgery, and principles outlined in the Declaration of Helsinki were followed.
Operative Technique
The procedure was performed under general anesthesia with oral endotracheal intubation, and the patient was positioned as for other cleft surgery. The course of the facial artery was mapped from the lower border of the mandible to the level of the ala nasi with a handheld Doppler. A Dingman mouth gag was used to keep the mouth open. The fistula margins were infiltrated with lignocaine and adrenaline and then were dissected circumferentially in continuity with the alveolar cleft. A primary closure of the nasal mucosal layer was performed as much as possible. In unilateral clefts, the flap was raised from the side with the open alveolar cleft. In bilateral clefts, the flap was raised from the side with the bigger fistula in cases of bilateral oronasal fistulae. Otherwise, the right side was preferred for a right-handed operator.
Reverse planning was used to design the flap. A paper template was designed to cover the defect, as well as the length of the pedicle needed to transfer the flap through the alveolar cleft. This template was held over the buccal mucosa of the chosen side to draw the flap and the pedicle, with the pedicle situated anterosuperiorly. The flap can extend up to the oral commissure, if necessary. The flaps in our series have been up to 32 mm long and 16 mm wide. The flap was designed below the level of the parotid duct to avoid any inadvertent injury.
Lignocaine with adrenaline was injected under the planned flap. In addition to providing postoperative analgesia at the donor site, it also aided raising the flap by hydrodissection. The flap outline was incised through the buccal mucosa, submucosa, and underlying muscles (buccinator and orbicularis oris) into the layer of buccal fat. The facial artery and vein were identified and were divided at the inferior (caudal) border of the flap. The flap was dissected and was raised in a retrograde fashion, maintaining the artery and the vein with their ramifications within the pedicle. The flap was not islanded (i.e., a mucosal bridge was maintained over the pedicle). Once completely raised (Fig. 2), the flap was advanced through the alveolar cleft, maintaining vascular continuity via the angular artery (continuation of facial artery). Some degree of subperiosteal dissection over the maxilla was necessary to allow free rotation of the flap. Next, the flap was inset and the donor defect was closed primarily with absorbable sutures. The postoperative regime included a soft diet and usually discharge from hospital after 24 to 48 hours.
Results
The results, along with the patient demographics, are detailed in Table 1. Sixteen anterosuperiorly based FAMM flaps in 14 patients are presented. The mean age at the time of operation was 9.3 years (range, 5 to 16 years). Four patients had unilateral cleft lip and palate; the others had bilateral defects. All of the patients had undergone previous attempts at closure of anterior palatal fistulae by other surgeons. None of the patients had undergone alveolar bone grafting.
A steep learning curve was observed in the early part of the series. After complete success in the first patient, the second patient had a total flap failure from lack of adequate arterial input. The third operation was successful. In the next patient, a 50% flap loss was encountered, due to venous congestion in the flap.
At this stage, the senior author arranged for a peer review in the form of a thorough discussion of the cases in a morbidity meeting. Anatomical papers describing the vascular territory also were reviewed and some modifications were made in the operative technique. The main reason for the partial and complete loss of flap appeared to be the anatomical peculiarity of the facial artery and vein in this region. As described earlier in this paper, the vein follows the course of the artery at a variable distance, being up to 15 mm posterior to the artery on average in the upper part of the flap at the level of the ala nasi (range, 3 to 23 mm; Dupoirieux et al., 1999). This obviously has significant bearing on the operative technique, particularly in case of a superiorly based FAMM flap. The senior author completely islanded the flaps in the first few cases and kept a narrow pedicle around the artery. But following the early problems, the pedicles were widened to include the vein and a mucosal bridge was retained over the pedicle to maintain better vascular integrity, particularly the venous drainage of the flap.
With the modifications, the outcome significantly improved, with 1 partial and 1 complete flap loss in the next 12 flaps. Overall, 16 FAMM flaps were raised in 14 patients. Two flaps failed completely and two were partial losses. The other 12 flaps survived (Fig. 3). The flap failure rate, including both partial and complete failures, in the second part of the series is comparable to other published series: 16.7% (2 in 12 patients) compared with 16.7% (Pribaz et al., 1992; Dupoirieux et al., 1999) and 13.7% (Ashtiani et al., 2005).
The only other complication was encountered in a patient with bilateral wide anterior oronasal fistulae. The flap was successful in closing the right-sided fistula, but a wound dehiscence on the left side necessitated a second FAMM flap closure for the left side.
In the two patients with complete flap loss, the first patient was treated with a tongue flap. This was successful and the patient subsequently had an alveolar bone graft. The second patient has learning difficulties and was grossly noncompliant in terms of picking at the flap. It was decided to defer any further treatment for the time being.
Of the two partial losses (Fig. 4), the first patient and his family opted for a contralateral FAMM flap over a two-stage tongue flap. The second FAMM flap was successful. The other patient with a partial flap loss suffers from psychiatric problems and had tendencies to self-harm. This patient was treated with tongue flaps twice, but both times the tongue flaps became detached from the palate. No further surgical treatment is planned at the moment.
Discussion
Closure of an anterior hard palate fistula is a challenging problem. Attempts at repair with local palatal tissue can be difficult, due to both scarcity of tissue and residual scarring from previous surgical attempts. For reconstruction of these obdurate fistulae, a variety of locoregional and distant options have been described. However, the best reconstruction would always use tissues with properties similar to those being replaced. For palatal reconstruction, this means use of buccal mucosal or tongue flaps. The FAMM flap has the advantage over buccinator and other musculomucosal flaps by being a true axial pattern flap. The tongue flap, though a proven and established flap for repairing palatal defects, has the disadvantage of requiring two stages and a good deal of patient compliance.
The FAMM flap has quite a few advantages over other regional flaps. It has an excellent blood supply from the facial arterial axis, requires only a single stage, and involves less risk of flap dehiscence. The donor site morbidity is minimal. We have not encountered any donor site complications in our patients. The other published papers on FAMM flaps also do not report any problems with donor sites. Another concern with the FAMM flap is whether the mouth opening is affected by removing a strip of muscle and mucosa from the buccal surface. In our experience, this has not been a problem. The mouth opening, though reduced slightly postoperatively, has returned to normal by 3 months. None of our patients has complained of any restriction of his or her mouth opening.
The FAMM flap does have some limitations. For use in anterior hard palate fistulae, an open alveolar cleft is essential for the flap to gain access to the anterior palate.
Careful patient selection is also important. We had problems with compliance with two patients, both with severe behavior problems and self-harming tendencies. One had a partial, the other a complete flap failure. The patient suffering from a complete loss of flap had two subsequent attempts at closure of the fistula with a tongue flap, but the flap dehisced both times. It was at this stage that we discovered his tendency to self-harm and that he had interfered with his intraoral sutures. The other patient who had a delayed (detected at 6 weeks postoperatively) complete loss of flap had gross learning difficulties and again was observed interfering with the operative site. It should be mentioned here that a single-stage operation such as the FAMM flap is still probably a better option for this group of patients than a two-stage reconstruction such as a tongue flap. However, the compliance issue has to be taken into consideration before embarking on a complex reconstruction of a palatal defect.
Based on our experience, we believe that among the currently available options, the FAMM flap is the best surgical choice for difficult, recurrent, and wide anterior hard palate fistulae. It not only is associated with minimal donor site morbidity, it provides a large amount of highly vascular tissue of good quality that closely matches the characteristics of the tissue it replaces.
