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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 27  |  Issue : 4  |  Page : 187-192

The versatile use of fasciocutaneous flaps in coverage of extensive soft tissue defects


Aesthetic, Plastic and Reconstructive Surgery Clinic, Bursa, Turkey

Date of Submission28-Dec-2018
Date of Acceptance24-May-2019
Date of Web Publication26-Sep-2019

Correspondence Address:
Dr. Ayhan Okumus
Ilknur Sokak Bulvar 224 Sitesi 1/B – 10, Ihsaniye, Nilüfer, Bursa
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_100_18

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  Abstract 


Background: Coverage of large soft tissue defects has always been difficult. Despite an increase in free flap options and many of combinations, it is still a big problem to repair large defects in some patients. In this study, repair of large defects with random fasciocutaneous flaps prepared from adjacent regions to the defect has been evaluated in functional and esthetic terms, especially in cases where microsurgery methods cannot be implemented or do not suffice. Patients and Methods: Ten patients' large soft tissue defects in different regions were repaired with random fasciocutaneous flaps. Average defect size was 15.2 cm × 18.3 cm, and defects were covered with random flaps with an average size of 14.8 cm × 28.1 cm. Average operation duration and average hospital stay were measured at 2.7 h and 2.2 days, respectively. Results: Patients were followed for 6 months on average. Complications such as flap loss, bleeding, or infection were not encountered in any patient at an early or late stages. Recovery of donor sites was evaluated unproblematic, and esthetic appearance was regarded acceptable. Conclusion: Fasciocutaneous flaps neighboring the defect can be prepared in larger dimensions compared to their alternatives, and they can cover the defect with less problems. Producing quite successful results is highly possible, especially in cases where the use of free and axial flaps is inappropriate. With the rapid development in microsurgery, many flap alternatives have emerged for the coverage of basic or complicated defects. However, random fasciocutaneous flaps have to be kept in mind as they are more basic and often have the potential to produce better and more effective results than these methods.

Keywords: Fasciocutaneous flap, large soft tissue defect, random flap


How to cite this article:
Okumus A. The versatile use of fasciocutaneous flaps in coverage of extensive soft tissue defects. Turk J Plast Surg 2019;27:187-92

How to cite this URL:
Okumus A. The versatile use of fasciocutaneous flaps in coverage of extensive soft tissue defects. Turk J Plast Surg [serial online] 2019 [cited 2019 Nov 21];27:187-92. Available from: http://www.turkjplastsurg.org/text.asp?2019/27/4/187/267925




  Introduction Top


Repair of large soft tissue defects has been an issue for years despite graft or multisession regional flap options. Along with advancing flap surgery, repair options increased after 1980s, and esthetic expectations were added to functional ones. Swift changes and modifications, especially in free flaps and then perforated flaps reduced donor site morbidity and enabled us to produce more functional and esthetic results.[1],[2],[3] However, in spite of all these developments, difficulties persist in coverage of very large defects, especially in patients unsuitable for microsurgery procedures.[4],[5] Conventional methods can produce more successful results compared to their alternatives without requiring a specific anatomic flap donor site. However, reconstructive surgery is quite concentrated on vascular flap alternatives and free, perforated flaps are more often preferred for defects which can be covered with a reliable, easily prepared random flaps instead. Such interventions cause formation of multiple surgical regions that cause muscles, vessels and nerves to be compromised. Reliable flap alternatives in close proximity with the defect area are frequently neglected.

In this study, results of ten patients with soft-tissue defects, on whom random fasciocutaneous flaps were used for repairing although microsurgery methods could possibly be the first option in many clinics, have been evaluated. Random flaps were preferred on all patients because they were more reliable, cheaper and easier to apply compared to other flap alternatives. They also caused less donor site morbidity and lower complication risk.

Surgical procedures

Defects of patients were all adjacent enough to be closed by flaps prepared from abdominal and lumbar regions. Flaps were prepared as random fasciocutaneous. No specific vessel was chosen or work was not done to include any specific vessel in the flap during preparation of the flap. Flaps were adjacent to defect on one side, and they were adapted as transposition flaps on the defect. Flap planning was made in accordance with the classical aspect ratio rule of ⅓. Lateral thoracic region was chosen as donor site for breast defects, while both lumbar sides were used for meningomyelocele cases. On the other hand, lower left abdomen for left inguinal region defects and upper and lower abdomen for local tumor recurrences in the lumbar region were used as donor sites. Donor sites were primary closed with ease.


  Patients and Methods Top


Ten patients who applied to our clinic with local tumor recurrence or lumbar meningomyelocele were included in this study. Five patients were directed from neurosurgery clinic due to meningomyelocele, three were directed from general surgery clinic due to local breast tumor recurrence on skin, while one patient was directed from oncological surgery clinic due to local renal cell carcinoma recurrence in the lumbar region. Another patient applied directly with hypersensitivity and local recurrence in the left inguinal region following a previous operation. All defects were adjacent enough to be closed by flaps prepared from abdominal and lumbar regions, smallest one having a size of 15 cm × 17 cm in adults, and 7 cm × 10 cm in infants (average 15.2 cm × 18.3 cm), and relatively too big to cover with several microsurgical flaps. Operations of all patients were performed under general anesthesia and in 2.7 h on average (range 2–4 h) following the start of flap surgery. Flaps were planned and raised to precisely cover the defect without tension (average 14.8 cm × 28.1 cm). Flaps sufficed to cover the defect in all patients. Need for an additional flap or a graft to cover the main defect or donor site did not occur. All donor sites were primary closed. Patients concerned with flap surgery were discharged from the clinic in 2.2 days on average (range 1–3 days), and their ambulatory follow-up continued [Table 1]. Patients were followed for 6 months on average (range: 2 months–2 years). In the 2nd-week postoperation, infection developed under flap of the patient whose left breast defect was repaired with thoracoabdominal fasciocutaneous flap. Infection regressed after dual antibiotherapy, but medial sutures broke open meanwhile. After infection was fought off, flap sides were resutured. No additional problems were encountered during their follow-up. There were no partial or total losses on the flap in other patients' follow-up either. Wound healing problems related to donor site or esthetically unacceptable results were not encountered.
Table 1: Statistical data of patients

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Case reports

Case 1

A 26-year-old woman applied to our clinic in 2011. She had been operated in another clinic due to lymphangioma in the left inguinal region in 2008. Repair was made with split thickness skin graft taken from the same thigh formed as mesh on inguinal area and upper thigh muscles. Hypersensitivity developed in the graft region following the operation. After the year 2009, even contact with clothes started to indicate hypersensitivity signs. Toward the sides of the graft, five vesicles were present in the size of 1–2 mm, bearing similarity to lesions before her first operation. Pulsation of femoral vessels was macroscopic under the graft. There was more sensitivity in the lateral femoral cutaneous nerve trace than the entire grafted area, and there was also hypoesthesia where it received Nerval sense. Any mass to suggest subcutaneous or intra-abdominal recurrence or tumor was not encountered in Magnetic Resonance Imaging (MRI) or Ultrasonography (US) examinations. The patient was taken into operation under general anesthesia. Excision was planned on the existing skin lesions, 2 cm to the side of the first operation's boundaries. After a careful dissection, old skin graft and adjacent tissues were removed by cutting down to muscle tissue and protecting inguinal neuromuscular blocks. Risky regions and surgical boundaries were inspected with frozen section examination. Hemostasis was achieved after observing that resection was adequate. The formed defect was measured at 20 cm × 23 cm [Figure 1]. The flap was planned on from the left lumbar region in dimensions of 20 cm × 40 cm considering the distance during rotation so that it would precisely cover the defect, and elevated as the scar from previous operation being the bottom boundary, stretching to the midline between lower abdomen and mons pubis on the medial [Figure 2]. Transfer was made onto the defect and covered in precise dimensions without any tension. Flap donor site was dissected over the rectus towards the superior and inferior and then primary closure was performed. Abdominal location did not change, and it was not deformed. However, the depressed scar, which was related to previous appendectomy operation, on the opposite side of the flap began to appear deeper as a result of skin coverage stretching over it. A drain was placed in the donor site and another one under the flap to complete the operation.
Figure 1: Case 1; left upper anterior thigh and groin possible defect size

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Figure 2: Case 1; lower abdominal fasciocutaneous flap size

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No problems were experienced postoperation. Drains were withdrawn on the 2nd day postoperation because the amount coming from donor site and under the flap dropped under 30 ml and it was of serous quality; and the patient was discharged. In the pathological examination, signs for local recurrence emerged, yet bottom and side boundaries were clean. The patient was followed for 2-year postoperation. Problems such as recurrence, wound healing problems, or esthetic deformities were not encountered on the flap area [Figure 3] or donor site [Figure 4].{Figure 3}
Figure 4: Case 1; 2 years after the surgery, view of donor site

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Case 2

A 56-year-old woman applied to our clinic in 2015. Local skin tumor recurrence was present in lumbar region of the patient who had been operated ten times on her intra-abdominal, abdominal, and lumbar areas due to renal cell carcinoma [Figure 5]. Operation planning was made together with general surgery because council of oncology and general surgery decided for excision of the local recurrence. However, flap alternatives were scarce due to both patient's general condition and numerous operations she had undergone. Repair with random fasciocutaneous flaps was planned due to such reasons as problem of possibly finding a recipient vessel in the region, patient's general condition not tolerating a relatively large operation, recurrence expectation, and patient and relatives' demand for a low-risk treatment. The patient was taken into operation under general anesthesia. The patient was taken over after the general surgery team had resected the tumor. It was observed that the defect occurred in size of about 20 cm × 22 cm, as estimated preoperation [Figure 6]. As it was not possible to close the defect with a single flap because of previous operations which the patient underwent, lateral-based fasciocutaneous flaps of sizes 10 cm × 15 cm and 15 cm × 25 cm were prepared from upper left abdomen and bottom left abdomen, respectively. Dense scars and deformities from former operations located in the vicinity of the defect caused the flaps to be carried further during transfer; thus, they were prepared in larger sizes. Defect was covered by lateral-based flaps prepared from top and bottom of the defect. Donor sites were primary closed. A suction drain was placed under the defect flap only. There were not any problems postoperation, and the patient was discharged on the 2nd day after the operation. In the 6-month follow-up period, there were no problems related to flap area, donor site, or recurrence. [Figure 7].
Figure 5: Case 2; lateral lumbar deformities after multiple surgeries

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Figure 6: Case 2; tumor recurrence area of the left back side and flaps planning

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Figure 7: Case 2; 2 months after the surgery, view of flaps and donor sites

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Case 3

A 48-year-old woman was directed from general surgery due to bilateral local breast cancer recurrence in 2013. The patient applied to our hospital after coming from a Middle East country ravaged by an ongoing war. The patient, who had undergone mastectomy due to bilateral breast cancer but had not had breast reconstruction, was planned to have an operation because of bilateral skin infiltration breast cancer recurrence by the general surgery. However, the patient did not want breast reconstruction even though it was proposed. Soft tissue defect of 15 cm × 20 cm on the right breast and 20 cm × 25 cm on the left breast occurred on the patient who had been operated by general surgery. Random fasciocutaneous flaps of 10 cm × 25 cm on the right and 15 cm × 30 cm on the left, prepared from lateral thoracic region at the same session, were elevated and repair was made. Donor sites were primary closed. Drains were withdrawn on the 2nd day postoperation, and the patient was discharged. During the 2-month follow-up period, no problems related to flap area or donor site were encountered [Figure 8] and [Figure 9]. The patient then had to return back to her country for social reasons.
Figure 8: Case 3; right thorax defect repaired with right lateral thoracic fasciocutaneous flap, 2 months after the surgery

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Figure 9: Case 3; left thorax defect repaired with left lateral thoracic fasciocutaneous flap, 2 months after the surgery

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Case 4

A 3-day-old female neonate with meningomyelocele was taken into operation by neurosurgery to repair the neural tube defect. When the patient was taken over after the dura repair was over, a soft tissue defect in the size of 10 cm × 12 cm was encountered. Two fasciocutaneous flaps of sizes 7 × 15 left and 5 cm × 10 cm right prepared from the gluteal region, neighboring the defect on the left lateral side and stretching toward abdominal region, were raised and adapted to the defect. After a follow-up period with neurosurgery, the patient was discharged without any problems on the 3rd day postoperation. In the 2nd month examination, no problems related to flap area or donor site were encountered [Figure 10].
Figure 10: Case 4; meningomyelocele defect repaired with bilateral lumbar fasciocutaneous flaps, 2 months after the surgery

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  Discussion Top


Cutaneous and subcutaneous defects of varying sizes occur on our bodies due to traumas, cancer, radiation, or iatrogenesis. For repair, skin grafts are sufficient for cases where vessels or nerves are not exposed,[6],[7],[8] while flaps are primarily preferred in terms of functionality and aesthetics.[9],[10],[11]

The second world war particularly marked a period when use and development of random fasciocutaneous flaps were most rapid.[12],[13],[14] Rapid development in microsurgery made use of free flaps standard after 1980s and use of perforated flaps after 2000s. There are several free or perforated flaps which have become standard in coverage of defects in particular body regions at the present time. As a matter of fact, modifications in these flaps enable less donor site morbidity, larger flaps, and more aesthetic results day by day.[15],[16],[17],[18]

However, it is obligatory to depend on a vascular area, tissue combination, and specific anatomic region for each free or perforated flap. For example, you have to depend on thoracodorsal artery and vein, latissimus dorsi muscle, and the skin above this muscle for latissimus dorsi muscle skin flap. In a similar manner, you have to use the specific thigh area for anterolateral thigh flap even if the defect to be covered is located on the face. Even though developing flap technology has reduced donor site morbidity, muscles, tendons, or main veins have to be compromised, without any such necessity, to simply be able to carry the flap. In repair of a defect to be covered with cutaneous–subcutaneous tissue, a large muscle tissue often has to be compromised as a carrier even though it is not necessary.[19]

At the present time, when a new flap or new modifications are introduced almost every day at a dazzling pace, we are observing that random flaps are being unrightfully forgotten, their uses are discontinued, and they are even being removed almost completely from the coalface of newly qualifying doctors. While planning the repair of a defect, it is usually started with free or perforated flaps. Surgical principles requiring to start with the cheapest and most basic method in the treatment pyramid seem to have been unrightfully revised against random flaps.

On the other hand, coverage of large soft tissue defects, especially on the body maintains its difficulty even at the present time. It is proving obligatory to use expanded free flaps, combined free flaps, or multisession repair alternatives on such large defects.[20],[21],[22] However, in cases where the patient has had too many operations and ideal options are unavailable, the patient does not have a good general condition, a quick repair is required, microsurgery team or equipment are not present, or opening of a second surgical area is to be avoided, it is obligatory to use random flaps for which adjacent tissues can be used. Even then, random flaps can be sometimes more advantageous for the patient in functional and esthetic terms without meeting the above conditions.[23],[24] For these reasons, if the flaps are not properly planned, are closed too tightly, or are prepared without paying attention to anatomical layers, some complications, especially circulatory problems may occur. However, these problems are not troubling than in alternative methods of making the same sloppy practice.

Subcutaneous tissue which is thick and has good circulation, particularly in the abdominal region, provides a rather reliable surgical area. In applicable patients, thick fasciocutaneous tissue size of 30 cm × 50 cm or larger amount can be raised and used to cover neighboring defects reliably, in a way that such dimensions can prove difficult to reach with microsurgical methods. It can be planned to reduce donor site morbidity at minimum to cover the defect in the best way as it is not dependent on any vein or circulation. Lumbar and abdominal regions, which are expandable, structurally flexible, and providing extra volume and flexibility, especially in women having given birth, are significantly superior to microsurgery alternatives when it comes to repairing extremely large soft tissue defects in neighboring regions such as thigh, waist, and thorax. The most important advantages are that they do not disrupt such structures as veins, nerves, and muscles which are often not actually necessary to repair defects but are used to carry and feed the skin mantle, that they are cheap and require little surgical equipment, that they allow for a short yet reliable operation, that they lead to short hospitalization and especially short treatment duration, less complication possibility in comparison to microsurgery, that they do not require a second surgical area, and that they provide a quick recovery.


  Conclusion Top


In conclusion, it should not be forgotten that fasciocutaneous flaps are in the first place in the soft tissue reconstruction pyramid compared to other flap alternatives and that they are more successful than alternative methods in appropriate patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Yamamoto Y, Nohira K, Minakawa H, Takeno N, Sugihara T, Shintomi Y, et al. The combined flap based on a single vascular source: A clinical experience with 32 cases. Plast Reconstr Surg 1996;97:1385-90.  Back to cited text no. 4
    
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Blackburn JH 2nd, Boemi L, Hall WW, Jeffords K, Hauck RM, Banducci DR, et al. Negative-pressure dressings as a bolster for skin grafts. Ann Plast Surg 1998;40:453-7.  Back to cited text no. 6
    
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Harvey I, Smith S, Patterson I. The use of quilted full thickness skin grafts in the lower limb – Reliable results with early mobilization. J Plast Reconstr Aesthet Surg 2009;62:969-72.  Back to cited text no. 7
    
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Satake T, Muto M, Ko S, Yasumura K, Ishikawa T, Maegawa J, et al. Breast reconstruction using free posterior medial thigh perforator flaps: Intraoperative anatomical study and clinical results. Plast Reconstr Surg 2014;134:880-91.  Back to cited text no. 11
    
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Kiehn CL. The progression of reconstructive plastic surgery to full maturity as a specialty in world war II. Plast Reconstr Surg 1995;95:1299-319.  Back to cited text no. 12
    
13.
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Pontén B. The fasciocutaneous flap: Its use in soft tissue defects of the lower leg. Br J Plast Surg 1981;34:215-20.  Back to cited text no. 14
    
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Gunnarsson GL, Jackson IT, Westvik TS, Thomsen JB. The freestyle pedicle perforator flap: A new favorite for the reconstruction of moderate-sized defects of the torso and extremities. Eur J Plast Surg 2015;38:31-6.  Back to cited text no. 15
    
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Xu Z, Zhao XP, Yan TL, Wang M, Wang L, Wu HJ, et al. A 10-year retrospective study of free anterolateral thigh flap application in 872 head and neck tumour cases. Int J Oral Maxillofac Surg 2015;44:1088-94.  Back to cited text no. 16
    
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Ozkan O, Coşkunfirat OK, Ozgentaş HE. An ideal and versatile material for soft-tissue coverage: Experiences with most modifications of the anterolateral thigh flap. J Reconstr Microsurg 2004;20:377-83.  Back to cited text no. 17
    
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21.
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22.
Aviv JE, Urken ML, Vickery C, Weinberg H, Buchbinder D, Biller HF. The combined latissimus dorsi-scapular free flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg 1991;117:1242-50.  Back to cited text no. 22
    
23.
Persichetti P, Tenna S, Cagli B, Scuderi N. Extended cutaneous 'thoracoabdominal' flap for large chest wall reconstruction. Ann Plast Surg 2006;57:177-83.  Back to cited text no. 23
    
24.
Iacobucci JJ, Marks MW, Argenta LC. Anatomic studies and clinical experience with fasciocutaneous flap closure of large myelomeningoceles. Plast Reconstr Surg 1996;97:1400-8.  Back to cited text no. 24
    


    Figures

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