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Prefabricated and Prelaminated Flaps for Head and Neck Reconstruction
Abstract
Flap prefabrication and prelamination are evolving, new techniques that are useful in reconstructing complex defects of the head and neck. Flap prefabrication involves the introduction of a new blood supply by means of a vascular pedicle transfer into a volume of tissue. After a period of neovascularization, this volume of tissue may be transferred, based only on its implanted vascular pedicle. The transfer may be local transposition or by microsurgical transfer. Flap prelamination refers to a technique in which additional tissue is added to an existing flap (without manipulation of its axial blood supply) to make a multilayered flap that may be used for complex, three-dimensional multilayered reconstructions. This technique may be used locally or at a distance, requiring microvascular transfer. Examples of each are described in this article.
... The technique involves vascular induction of a transplantable tissue by implanting a definite vascular pedicle to the donor tissue and allowing sufficient time for the donor tissue to assume supply from the transplanted vessels [44,45]. The donor tissue can then be harvested and transferred pedicled on the implanted vessel as a vascular carrier or transferred as a free flap which can be anastomosed to a recipient vessel in the facial region [44,[46][47][48]. ...
... Closely related to the technique of flap prefabrication is the concept of prelamination flap. Prelamination is a viable option for the reconstruction of composite aesthetic units of the face such as the ear, nose and eye lids [47,49]. Using this technique, tissues such as bone, cartilage, muscles and skin can be preassembled to form a precise composite structure [45]. ...
... Using this technique, tissues such as bone, cartilage, muscles and skin can be preassembled to form a precise composite structure [45]. The composite is vascularized by burying in a vascular territory and later harvested as a free flap and anastomosed to the recipient bed to replace the missing part [44,47]. These developments have enhanced facial reconstruction and can be used in combination with intraoperative navigation to accomplish pre-planned surgical objectives. ...
Surgical correction of congenital and acquired facial deformities has transcended the primitive era of using non biologic materials to current attempts at own face growing through biotechnology. A summative account of this trend is still lacking in the literature. The objective of this article is to present an update on current knowledge in the strides to achieve functionally and aesthetically perfect facial reconstruction. It highlights the impact of advancements in 3D imaging, stereolithographic biomodelling, microvascular surgical tissue transplantation and tissue biotechnology in the surgical efforts to solve the problems of facial disfigurement whether congenital or acquired.
... Преламинация превращает нативный аксиальный лоскут в многослойный путем добавления соответствующих структур для композитной реконструк-ции [8]. Это процесс, включающий имплантацию тканей или конструктов в кровоснабжающее микроокружение до их переноса непосредственно в область дефекта [8][9][10]. ...
After removal of metastatic malignant tumors of the hypopharynx and larynx, hypopharyngeal defects are formed. To restore the hypopharynx, a mucosa and a muscular component are needed.
The objective of this study is to develop a hypopharyngeal reconstruction technique using prelaminated pectoralis major flap with mucosal epithelium analogue from autologous epithelial layers.
Materials and methods. Nine patients underwent reconstruction of the hypopharynx using bioengineered prelaminated pectoralis major flaps. The mucosa was restored by tissue-engineered autologous epithelial cell layers that were obtained by culturing in vitro cells isolated from skin biopsies that were previously obtained from patients.
Results. Oral nutrition was restored in all cases. Pharyngeal stenosis was detected in one (11%) patient. A stratified squamous epithelium on the pectoral fascia was revealed in 67% of cases at week 2 after prelamination, in 89% of cases at week 4 after reconstruction and in 100% of cases at month 3, 6, 12 and 24 after reconstruction.
Conclusion. Reconstruction using prelaminated bioengineered flaps allows recreating the anatomical integrity and function of the hypopharynx.
... In the same year, Daniel and Taylor [3] repeated this reconstructive microvascular surgery. They, with many other pioneers [4][5][6][7][8][9][10] developed core principles of reconstructive microsurgery which are still pertinent today. This therapeutic procedure has quickly spread across US, European and Far South-East medical and oncology centers. ...
... 1,3,4 Exceptional cases may require different approaches because the reconstructive goals could be more structural than aesthetic. [5][6][7][8][9][10][11] An important factor in this regard is the mechanical properties of the skin that will provide coverage. 12 It is mandatory to individualize patients' requirements, which could be either structural or aesthetic. ...
Summary: The anatomic position of the auricle leaves it vulnerable to traumatic lesions. In most cases, the best reconstructive outcome is accomplished using a temporoparietal flap with a costal cartilage frame and a partial thickness skin graft. Exceptional cases may require different approaches because the reconstructive goals could be more structural than aesthetic. An important factor in this regard is the mechanical properties of the skin that will provide coverage. This study aimed to share a particular case of total auricular reconstruction assisted by 3D surface imag- ing and 3D printing in a radial forearm free flap. We present a 58-year-old man with a history of having tympanic barotrauma causing hearing loss, burdening him with the use of auricular devices for hearing assistance. Seven days before presenting for the initial treatment, he sustained ear trauma while performing mechanical repara- tions in a car. The wheel was activated, causing a total amputation of the right ear. He first went to another hospital‚ where they performed primary closure and then referred him to our unit. The team performed a prelaminated radial forearm free flap assisted by 3D scanning and planning. A detailed comparison between the left ear and the result of the reconstruction was measured and described. The radial fore- arm prelaminated free flap is a viable structural alternative with the disadvantage of poor auricular definition in some cases.
... Here we describe the pioneering clinical implementation of an ectopically prefabricated (i.e., including a vascular pedicle for transfer) and prelaminated (i.e., multilayer composite including a soft tissue interface) (11) flap as osteogenic and vasculogenic graft for hemimaxillary reconstruction in a patient with Cordeiro type IIIa maxillectomy. The implant was first constructed in a latissimus dorsi muscle flap by combining a custom-shaped scaffold with autologous SVF cells, BMP-2, and an AV bundle. ...
The reconstruction of complex midface defects is a challenging clinical scenario considering the high anatomical, functional, and aesthetic requirements. In this study, we proposed a surgical treatment to achieve improved oral rehabilitation and anatomical and functional reconstruction of a complex defect of the maxilla with a vascularized, engineered composite graft. The patient was a 39-year-old female, postoperative after left hemimaxillectomy for ameloblastic carcinoma in 2010 and tumor-free at the 5-year oncological follow-up. The left hemimaxillary defect was restored in a two-step approach. First, a composite graft was ectopically engineered using autologous stromal vascular fraction (SVF) cells seeded on an allogenic devitalized bone matrix. The resulting construct was further loaded with bone morphogenic protein-2 (BMP-2), wrapped within the latissimus dorsi muscle, and pedicled with an arteriovenous (AV) bundle. Subsequently, the prefabricated graft was orthotopically transferred into the defect site and revascularized through microvascular surgical techniques. The prefabricated graft contained vascularized bone tissue embedded within muscular tissue. Despite unexpected resorption, its orthotopic transfer enabled restoration of the orbital floor, separation of the oral and nasal cavities, and midface symmetry and allowed the patient to return to normal diet as well as to restore normal speech and swallowing function. These results remained stable for the entire follow-up period of 2 years. This clinical case demonstrates the safety and the feasibility of composite graft engineering for the treatment of complex maxillary defects. As compared to the current gold standard of autologous tissue transfer, this patient’s benefits included decreased donor site morbidity and improved oral rehabilitation. Bone resorption of the construct at the ectopic prefabrication site still needs to be further addressed to preserve the designed graft size and shape.
... Depending on the cause of the facial disfigurement, various clinical and investigative modalities are required for thorough evaluation and several surgical options have been made available [4][5][6][7] . The ultimate goal is to achieve a near perfect repair such that the individual could be completely rehabilitated 4 . ...
Background: Facial reconstruction in a paediatric patient requires peculiar considerations. For optimal outcome, comprehensive pre-surgical evaluation, surgical expertise, appropriate tools and facilities, and serial outcome monitoring are essential. The aim of this study was to highlight some challenges militating against optimal outcome in facial reconstruction in a developing country based on the experience in managing a paediatric patient. Methods: Using a case of post-traumatic facial deformity in a paediatric patient, the factors affecting optimal outcome in a resource-poor setting were identified and discussed. Results: Identified issues related to: nature of injury, age and gender considerations, depth of expertise and extent of surgery required for bony, soft tissue and nerve repairs, facility for comprehensive evaluation, surgical planning and execution and finance. Conclusion: The restoration of a deformed face is challenging, but the scenario could be further complicated when essential resources are not available. Additional considerations must be entertained in a paediatric patient.
... After a period of neovascularization (usually 8 weeks), this prefabricated flap may be transferred, based on its newly acquired vascular pedicle. The transfer may be local transposition or by microsurgical transfer (Guo and Pribaz 2009;Pribaz and Fine 2001). ...
... The goal in prelamination is to transform a native axial flap into a multilayered flap by adding the appropriate support and lining structures needed for complex reconstructions, and the composite flap is allowed to heal for at least 1 month before transfer to the face (2-stage procedure). This process can be useful for patients with central facial defects, especially of the nose and surrounding cheek, lips, and palate (Mathy & Pribaz, 2009;Pribaz & Fine, 2001;Sinha, Scott, & Watson, 2008). Prelamination is also compatible with tissue engineering, as biomaterials and cultured cells may be introduced into the constructs, thus greatly expanding the usefulness, versatility, and the promise of further innovative applications. ...
... The original forearm picture with prefabricated nose and the settled graft is shown in l and m quality tissues from distant locations, without compromising or further scarring local or loco-regional tissues. Advances in understanding of the skin circulation have led to the development of chimeric flaps and prelamination and prefabrication techniques [13][14][15][16][17][18]. These advances further reduce the number of stages necessary for reconstruction of complex defects, as tissues of various qualities can be transferred together. ...
Post-traumatic facial defects need to be treated sensitively, as the emotional repercussions and possible deformity can have lasting effects on the patient’s psychological well-being. Thus, the management of posttraumatic facial injuries requires meticulous planning and adherence to both aesthetic and reconstructive principles. We describe the case of a 29-year-old male who underwent multistage reconstruction following extensive facial injuries. The clinical challenges presented by this rare case and steps of the reconstruction procedure are presented. Sequential flaps that were placed during the restoration survived, and the patient had no lasting donor site morbidity. Post-surgery, the patient’s self-confidence was dramatically improved, as were his interactions with his family and friends. Careful planning and staged microvascular procedures were important in the management of this patient with severe injuries. The patient was rehabilitated and able to live a near-normal life, without the need for synthetic implants or lifelong immune suppression.
Level of Evidence: Level V, therapeutic study.
... Flep çevresinde kollateral damar oluşumu ameliyat sonrası birinci haftadan sonra başlar, sekiz hafta içinde güvenilir hale gelir; anastomozun bu dönem zarfında flebin yeterli kanlanmasını sağlaması gerekir. [14] Anastomoz sorunları özellikle ilk 72 saat içinde olmaktadır; damar intimasının epitelizasyonu bu dönemden sonra tamamlanır. [15] Mikrovasküler serbest doku flepleri ile ilgili büyük serilerde reeksplorasyon oranı %8-9, flep kayıp oranı %1-11 arasında değişmektedir. ...
Objectives:
This study aims to assess the success rate of surgery and postoperative morbidity in patients who underwent major head and neck surgery with reconstruction by microvascular free flaps performed by otolaryngologists.
Patients and methods:
We retrospectively analyzed the medical records of 63 patients (31 males, 32 females; mean age 47.9±12.5 years; range 20-71 years) operated in our clinic between September 2012 - August 2016. The indications of reconstruction by free flap, success rates, need for revision and re-exploration, reasons of flap failure, morbidity and mortality were evaluated.
Results:
Thirty-seven (56.9%) of the 65 microvascular free flaps were radial forearm; 23 flaps (35.4%) were fibula and five flaps (7.7%) were rectus abdominis. Three of the total 65 flaps ended up in failure; accordingly the success rate was 95.4%. Except for these three failure cases, an urgent re-exploration was performed on 13 patients in the first postoperative 48 hours (n=16, %24.6). No permanent major sequel was observed in any of the patients.
Conclusion:
From the otolaryngologists' point of view, we observed that performing microvascular surgery and the successful surgical results not only gives the flexibility in reconstruction but also provides safer resection during ablative surgery.
... However, when the entire nasal scaffold has to be recreated, the RFFF may not be adequate due to the lack of substantial bony tissue. To overcome this problem, a bony or cartilaginous graft might be introduced into the flap but the risk of graft resorption or displacement and the need of several surgical stages represent two critical issues (Pribaz and Fine, 2001). In our experience, the corticoperiosteal MFCFF can represent an effective alternative for the reconstruction of both the inner and bony layer of the nose. ...
The nose is a functionally complex organ implicated in breathing, olfaction, and phonation, with a critical role also in the aesthetic appearance of a person. This latter aspect should be carefully considered whenever a total or subtotal rhinectomy is performed for resection of locally advanced nasal cancer. To reconstruct large nasal defects, several techniques were described, including the use of cartilaginous grafts, bony grafts, local flaps, and free flaps. In cases of extensive full-thickness resections, free flaps probably represent the most adequate option. The aim of this report is to present the functional and aesthetical outcomes of a reconstruction of the nose after rhinectomy, using the medial femoral condyle free flap associated with the forehead flap.
... 9 Recently, nonintestinal flap prelamination/prefabrication models were demonstrated for the reconstruction of complex pharyngeal/tracheal defects. 10,11 In our study, a deep inferior epigastric perforator (DIEP) flap was revascularized from the jejunal segment by means of prefabrication to obtain an intestinal/cutaneous composite flap based on mesenteric vessels. ...
Background Reconstruction of complex pharyngoesophageal defects presents a major challenge, particularly in soft tissue deficient and previously scarred surgical sites. In recent years, the free jejunum flap method has emerged as a reliable means of esophageal reconstruction. However, it may require cutaneous coverage with an additional flap in extensively scarred, secondary reconstructions. Prefabrication of an intestinal/cutaneous composite flap can potentially solve this problem. Materials and Methods Total 28 Sprague Dawley rats were used in the study protocol. A vascularized jejunal segment was transposed beneath the deep inferior epigastric perforator (DIEP) flap. Contact with underlying abdominal fascia was prevented using a silicone sheet. Animals were distributed into five groups based on the timing of deep inferior epigastric vessel ligation to determine the time required for successful revascularization. The viability and the vascular anatomy of the prefabricated structures were analyzed using histology and microangiography. Results A jejunum/DIEP composite flap was successfully prefabricated based on mesenteric vessels. The skin component survived intact after 5 days of contact with serosal surface of the jejunal segment. Conclusion The clinical application of this technique can provide an alternative means of single-stage esophageal reconstruction, especially in patients with soft tissue deficiency and donor vessel unavailability.
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... So far, this design has been used for bone, fat and skin tissue engineering with success [5][6][7] . As well, plastic surgeons performing prelamination and prefabrication applications before the advent of biomaterials are familiar with the process [13]. ...
Objectives: Treatments of long peripheral nerve defects are limited and a means to construct a vascularized nerve graft substitute has been sought. Material and Methods: An in vivo chamber bioreactor was designed with the White New Zealand rabbit's superficial inferior epigastric pedicle (SIEP) and using autologous Schwann cell (ASC) suspension, a tissue volume containing rich vascularization and a dense presence of Schwann cells was constructed. This construct was comparatively tried on 3 cm of a sciatic nerve defect. Results: A vascularized build with rich blood supply and an abundance of Schwann cells was engineered and utilized for nerve regeneration and transmission, axonal passage being displayed. Conclusion: According to the literature review, this is the first achievement of engineering a nerve graft substitute containing vascularized Schwann cells. Therefore, it is believed this study has yielded significant preliminary results, providing a basis for future studies.
... 9-11 Furthermore, evidence of neovascularization of surrounding tissues after transfer of a vascular pedicle has been well established. 12 These data lend credence to a potential radioprotective effect on surrounding structures (e.g., mandible, adjacent muscles/nerves) when free tissue transfer is employed. ...
Treatment of advanced parotid or cutaneous malignancies often requires sacrifice of the facial nerve as well as resection of the parotid gland and surrounding structures. In addition to considerations regarding reinnervation and dynamic reanimation, reconstruction in this setting must take into account unique factors such as soft tissue volume deficits and the high likelihood of adjunctive radiation therapy. Furthermore, considerations of patient comorbidities including advanced age and poor long-term prognosis often influence reconstructive modality. The optimal reconstructive technique would provide potential for restoration of facial tone and voluntary movement as well as immediate restoration of facial support and function. Beyond considerations of facial movement and rest position, restoration of lost soft tissue volume is critical to obtain facial symmetry. To control long-term volume in the setting of adjunctive radiation therapy, vascularized tissue is required. In this chapter, we describe a comprehensive approach to the management of radical parotidectomy and similar facial defects that addresses these concerns and also describes management strategies over time. Specific techniques employed include anterolateral thigh free flaps, nerve grafting utilizing motor nerves to the vastus lateralis muscle, and orthodromic temporalis tendon transfer. Further considerations relative to the eye, forehead, and long-term facial refinement are also discussed.
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... Flap prefabrication is used to create an axial pattern f lap suitable for either pedicled or free f lap transfer after subdermal implantation of the vascular carrier. 1,2,8 Tissue expansion technique is often combined with f lap prefabrication procedure. The combination of soft skin tissue expansion and f lap prefabrication techniques can exploit the 2 techniques and achieve ultrathin and large f laps. ...
Background:
Prefabricated flap is an important technique to reconstruct massive face and neck skin defects. But its vascularization remains unpredictable and often leads to abnormal blood supply of the harvested flap, even necrosis. Flap supercharging and turbo supercharging techniques are effectively used to improve flap blood supply. However, few studies have been reported on the application of these techniques in prefabricated induced expanded flaps.
Methods:
From March 2008 to September 2012, 13 patients who have face and neck soft tissue defects were treated with prefabricated cervicothoracic flap. To overcome insufficient blood supply, 5 of them received additional microvascular augmentation in which the second or third perforator of the internal mammary artery (IMAP) and its venae comitantes were anastomosed to facial or superficial temporal vessels, contrary to the remaining 8 patients. The following results were compared: flap viability, hospital stay, complications, frequency of dressing change, reoperation rate, and remaining scars.
Results:
No flap necrosis was observed in patients who received the supercharging procedure. By contrast, of the 8 patients who were not treated with supercharging technique, various degrees of flap necrosis occurred in 3 patients, 2 of whom received secondary operations. The frequency of dressing changes, the hospital stay, and hospital cost were reduced. Postoperative view showed better aesthetic restoration.
Conclusions:
The IMAP-supercharged cervicothoracic flap technique offers a reliable method for massive face and neck reconstruction. We recommended that the IMAP should always be preserved in the flap as a saving option for potential flap congestion or arterial insufficiency.
... The epidermis of the radial forearm flap is thin, and the color of flaps from the upper extremity often adapts over time. Prefabricated flaps using, for example, supraclavicular skin at the neck area have the advantage of replacing tissue with (almost) like tissue 59 and are therefore a good option for forehead reconstruction. However, this approach is not an alternative when immediate reconstruction is needed after trauma or in cases of malignancy. ...
The treatment of scalp and forehead defects is challenging. There are few cases in which an untreated scalp defect can heal by secondary intention. However, lack of adequate treatment can also lead to fatal consequences. Adequate judgment and treatment of a defect on the scalp are therefore mandatory. There are many options to reconstruct a scalp defect. Each option has its role in the reconstruction repertoire. Various factors need to be considered when choosing the method to be used. These factors include etiology and the size of the defect, age and general health of the patient, as well as the situation at the hospital/unit where the treatment is performed. In this article, different reconstruction methods are presented, and guidelines for the selection of the various options are provided.
The study investigated the osteogenic capacity of a prefabricated periosteal flap created using only skeletonized pedicle transfer without fascia or muscle for vascular induction in rabbit calvarium. A critical-sized bone defect was made in the parietal bone centered on the sagittal suture, and the demineralized bone matrix was implanted. The periosteofascia over the defect was used as a form of prefabricated periosteofascial flap (PPF group, N=10), conventional periosteofascial flap (CPF group, N=10), and nonvascularized free periosteofascial graft (FPG group, N=6). The prefabricated flap was designed via vascular induction by transferring the central artery and vein of the right auricle onto the periosteofascia for 4 weeks prior to flap elevation. A quantitative comparison of volume restoration and radiodensity in the bone defect and a histological study were performed after 6 weeks of covering the bone defect with periosteofascia. The volume restoration of the bone defect covered with the PPF (43.4%) was not different from that of the CPF (46.2%), but significantly increased compared to that of the FPG (24.6%). The radiodensity of the bone defect covered with the PPF (-186.3 HU) was not different from that of the CPF (-153.6 HU), but significantly increased compared with that of the FPG (-329.8 HU). The results were based on adequate vascular development of the periosteum and were closely related to the osteogenic changes in the implanted DBM. In conclusion, even in the
Composite full-thickness nasal defects that include adjacent facial units still remain a challenge for reconstructive surgeons. The commonly used auricular free flap (AFF) might not be sufficient for full coverage of a defect, and radial forearm free flap (RFFF) lacks the rigid component for nasal framework. Therefore, the authors present a chimeric flap combined of both AFF and RFFF for the reconstruction of extended nasal defects. Auricular free flap enables the restoration of the exact contour of nose, and it preserves similar texture and color of the skin. Moreover, its harvesting results in minimal deformity of donor site. Radial forearm free flap gives the possibility of covering extensive defects of the facial units thanks to its elasticity and long vascular pedicle. The combination of both flaps seems to be an optimal solution for the reconstruction of extended nasal defects, giving satisfactory aesthetic results. Also, it might not require any further corrections, remaining a one-stage procedure.
Nasal reconstruction following a total or subtotal resection presents a challenging clinical scenario. Ample external skin coverage is readily available using the paramedian forehead flap (PMFF), but restoring adequate internal lining of sufficient size and pliability is a major limitation. Intranasal mucosal flaps or free tissue transfer is often employed for this purpose, each with their own sets of limitations. Prelamination of the PMFF with a skin graft prior to transfer is a method to create a composite flap with both internal and external lining. Another challenge in subtotal nasal reconstruction centres around restoring adequate dimensions to the nose without an existing template to work from. Three-dimensional (3D) printing has become an increasingly popular tool in reconstructive surgery as it captures precise patient-specific dimensions to guide reconstruction. Herein, we describe a case of subtotal nasal reconstruction using a prelaminated PMFF using a patient-specific 3D printed model as a template for reconstruction.
Engineering large and functional tissue constructs with complex structures (e.g., external ear or nose) for reparation and reconstruction of tissue defects remains one of the major challenges in regenerative medicine, which demands abundant cell sources, advanced biofabrication schemes, and satisfactory integration with the host for long‐term efficacy post implantation. Here the ‘Microtissue Assembly in 3D‐Printed‐template‐Scaffold’ (3D‐MAPS), as a platform technology to rapidly fabricate centimeter‐sized functional tissue constructs with complex structures, is developed. 3D‐MAPS facilitates bottom‐up assembly of large‐scale manufactured microtissues within the 3D‐printed hollow polymeric templates with pre‐defined architectures. The assembly and fusion of 2×106 mesenchymal stem cell–based microtissues within the defined 3D‐printed template is further enhanced by addition of a natural protein crosslinker (i.e., transglutaminase (TGase)), and thereby achieves construction of centimeter‐sized tissue with high cell viability and mechanical stability in vitro within 30 min. Further in vivo implantation of the 3D‐MAPS‐fabricated ear‐like tissue construct in rabbit models assisted by flap prefabrication technique results in increased structural vascular support and strengthened functional survival. Thus, the TGase‐enhanced 3D‐MAPS demonstrates its potential and feasibility as a powerful biofabrication platform for tissue engineering application. A ‘Microtissue Assembly in 3D‐Printed‐template‐Scaffold' (3D‐MAPS) platform is developed for rapid and precise fabrication of large tissue constructs by assembling large‐scale manufactured microtissues within the 3D‐printed hollow templates with pre‐defined architectures. High cell viability and mechanical stability are achieved by adoption of transglutaminase as enzymatic crosslinker and the flap prefabrication approach is applied for enhanced vascularization.
Die rekonstruktive Chirurgie ist eine der Säulen der Plastischen Chirurgie, in welcher unterschiedliche Lappenplastiken zum Einsatz kommen. Die Temporalisfaszienlappenplastik (TPFF) ist eine vielseitig anwendbare Lappenplastik, die in der gestielten oder der freien Variante bei jeweils unterschiedlichen Indikationen schon mehrfach in der Literatur beschrieben wurde. Die Studie macht sich zum Ziel, diese Methode der rekonstruktiven Chirurgie anhand der in der Plastisch- und Handchirurgischen Klinik in Erlangen durchgeführten Temporalisfaszienlappenplastiken zu untersuchen. Es sollen die beiden Varianten der gestielten und der freien Lappenplastik verglichen und der Outcome des Gesamtkollektivs und dessen Einflussfaktoren ermittelt werden. Für diese Studie werden 23 Temporalisfaszienlappenplastiken, darunter 14 freie und 9 gestielte Varianten, welche in der Plastisch- und Handchirurgischen Klinik des Universitätsklinikums Erlangen im Zeitraum von 2007 bis 2016 durchgeführt wurden, retrospektiv analysiert. In der Auswertung wird das Kollektiv zunächst anhand deskriptiver Statistik untersucht. Hierbei werden die Parameter Art der Lappenplastik, die Verteilung der operativen Eingriffe über den Zeitraum, das Patientenalter, die Geschlechterverteilung, die Zusammensetzung des Operationsteams, der Nachuntersuchungszeitraum, die Defektgröße, die Defektätiologie, die Defektlokalisation, die Komorbiditäten, die Anzahl der Voroperationen und die Gesamtzahl der operativen Eingriffe miteinbezogen. Im Vergleich der freien mit der gestielten Lappenplastik wird der Zusammenhang der Parameter Indikation, Beschaffenheit der verwendeten Gewebetransplantate, Komorbiditäten, Operationsdauer, Dauer des stationären Aufenthaltes, Minor- und Majorkomplikationen jeweils mit der Art der Lappenplastik evaluiert. Zu den Parametern, anhand welcher der Einfluss auf den Outcome des Gesamtkollektivs berechnet wird, zählen die Operationsdauer, das Patientenalter, die Defektätiologie und die Anzahl der Komorbiditäten. In dieser Studie kann die Vielfältigkeit der Temporalisfaszienlappenplastik an den unterschiedlichen Defektlokalisationen und den diversen Indikationen der beiden Varianten dargestellt werden. Beim Vergleich der freien und der gestielten TPFF kann ein signifikanter Unterschied in der Operationsdauer, der gesamten und der postoperativen stationären Aufenthaltsdauer ermittelt werden. Bei Betrachtung der Komplikationsrate wird im Vergleich der beiden Varianten kein signifikanter Unterschied gefunden, weder bei den Majorkomplikationen, noch bei den Minorkomplikationen. Die in der Literatur häufig aufgezeigte Komplikation der Alopezie wird bei keinem der 23 Patienten beschrieben und somit werden ästhetisch ansprechende Ergebnisse an den Entnahmestellen verzeichnet. Der Outcome des Gesamtkollektivs wird anhand der Länge des postoperativen Aufenthaltes und anhand des postoperativen Auftretens von Komplikationen gemessen. Hinsichtlich der Einflussfaktoren auf den Outcome des Gesamtkollektivs zeigen Patienten mit einer längeren Operationszeit tendenziell längere stationäre Aufenthalte, jedoch statistisch nicht signifikant. Das Alter der Patienten hat keinerlei statistisch signifikanten Einfluss auf den Outcome. Die Länge des postoperativen, stationären Aufenthalts ist signifikant von der Indikation abhängig; das Auftreten von Komplikationen jedoch nicht. Der Einfluss der Komorbiditäten zeigt sich ebenso anhand eines signifikant längeren postoperativen stationären Aufenthalts bei Patienten, welche 3 oder mehr Komorbiditäten aufweisen. Zusammenfassend geht aus den Ergebnissen dieser Studie hervor, dass die Temporalisfaszienlappenplastik aufgrund ihrer vielfältigen Anwendung und ihrer geringen Komplikationsrate insbesondere in Kombination mit einer sorgfältigen, chirurgischen Präparation bei entsprechender Indikationsstellung empfohlen werden kann. Die Temporalisfaszienlappenplastik zeigt ein ansprechendes, ästhetisches Ergebnis an der Entnahmestelle bei erfolgreicher Vermeidung des Auftretens der Alopezie.
Gene therapy (GT), or the altering of genetic material within cells to modify protein structure and quantity, is an emerging field in skeletal muscle regeneration (SMR) and maintenance [1–6]. GT techniques are acquiring increasingly significant functions in approaching various surgical problems [7, 8]. A key insight necessary for maximizing the value from the great deal already known on the regulation of SMR is that every regulatory product is potentially amenable to targeting through multiple GT techniques. This chapter will focus on current GT techniques used in muscle discussing, in particular, potential benefits for Plastic and Reconstructive Surgery (PRS).
This article describes the use of prefabricated flaps in burn reconstruction. Several case examples are provided that demonstrate the versatility and power of this approach to restoration of form and function after burn injury.
Autotransplantation of the trachea to extended hemilaryngectomy defects is based on vascular induction of a segment of trachea and is an example of flap prefabrication. Composite tissue reconstruction of tracheal defects is another application of flap prefabrication: composite tissue consisting of fascia, buccal mucosa and ear cartilage can be used for reconstruction of an anterior tracheal defect after a stage of prefabrication to allow for survival of the cartilage component.
We report a case of a 61-year-old patient who presented to us for nose and cheek reconstruction post multiple excisions of an extensive recurrent basal cell carcinoma (BCC) of the right cheek and most of the nose. Nasal reconstruction was achieved with a free helical rim flap for the right ala and a staged prefabricated radial artery forearm free fascial flap. We were successful in producing a very favorable esthetic result and restoring nasal function.
Level of Evidence: Level V, therapeutic study
Very often scientific publications begin with the pompous words: A new technique for., or An innovative method for.. But are these procedures really new? The French physician and philosopher Émile Littré (1801-1881) wrote the following in the foreword of his Oeuvres complètes d'Hippocrate (Complete Works of Hippocrates): There is no development, even the most advanced of contemporary medicine, which is not found in embryo in the medicine of the past [12]. This opinion is easy to demonstrate by doing some research in a historical library. One will discover that old books not only provide palpable contact with the medical past, but also serve to establish the precedence of an idea, a theory or a technique. Regrettably, we often realise that most of the so-called new techniques derive from ideas which were already published but then forgotten. Numerous examples exist, but we restrict our list to just a few for obvious reasons.
Scar and defect in the lower face always lead to serious facial deformity and asymmetry. Conventional method such as skin graft or free flap is hard to obtain a satisfactory outcome. In this article, we present a skin expanding technique. An expanded flap was designed to repair the lower face scar or defect on submental and submandibular regions. A tissue expander was implanted into the region and inflated for 2 to 3 months. After removing the expander, we harvested the flap as a rotation flap to repair the lower facial defect. The longest follow-up period was 3 years. All of the flaps were well matched to the surrounding skin with respect to color, texture, and thickness. An expanded flap on submental and submandibular regions is suitable to repair a lower face defect.
Tissue engineering of cartilage tissue offers a promising method for reconstructing ear, nose, larynx and trachea defects. However, a lack of sufficient nutrient supply to cartilage constructs limits this procedure. Only a few animal models exist to vascularize the seeded scaffolds. In this study, polycaprolactone (PCL)-based polyurethane scaffolds are seeded with 1 × 10(6) human cartilage cells and implanted in the right hind leg of a nude mouse using an arteriovenous flow-through vessel loop for angiogenesis for the first 3 weeks. Equally seeded scaffolds but without access to a vessel loop served as controls. After 3 weeks, a transposition of the vascularized scaffolds into the groin of the nude mouse was performed. Constructs (verum and controls) were explanted 1 and 6 weeks after transposition. Constructs with implanted vessels were well vascularized. The amount of cells increased in vascularized constructs compared to the controls but at the same time noticeably less extracellular matrix was produced. This mouse model provides critical answers to important questions concerning the vascularization of engineered tissue, which offers a viable option for repairing defects, especially when the desired amount of autologous cartilage or other tissues is not available and the nutritive situation at the implantation site is poor.
Background:
In the reconstruction of facial burn scars, large, thin, color-matching flaps are desirable due to aesthetic and functional demands. There have been many reports using prefabricated flaps to resurface facial skin lesions. However, an algorithm to select the most suitable treatment option for the individual patient is lacking.
Methods:
An algorithm for facial resurfacing based on three types of prefabricated flaps from the cervical, periclavicular, and lateral thoracic area was setup, and 15 were patients treated accordingly.
Results:
All 15 prefabricated flaps survived. Minor necrosis at the distal flap edge developed in three cases. After a follow-up of at least 6 months, all patients showed satisfactory aesthetic and functional outcomes.
Conclusion:
By individual selection of the most suitable option among these three types of prefabricated flaps, satisfactory resurfacing can be achieved for most facial burn scars.
Collagen substitutes represent a good option for burn scars release. Authors describe a new technique using prefabricated flap associated with collagen substitute. This technique is illustrated by a scar contracture removal on a young child located on the dorsum of the hand and wrist using a pedicle axial flap and a collagen substitute. Neo-collagen prefabricated flap is a new sophisticated surgical technique regarding the flap technique due to the possibility to create by patient cells themselves neo-fashioned flaps much more adapted to the recipient site and decreasing sequels on the donor site.
Flap prefabrication offers a bridging role between traditional reconstructive surgery and tissue engineering; however, because flap prefabrication is based on the concept of implanting a nourishing vascular pedicle in the target tissues before transfer, survival remains unreliable. Furthermore, the extended period required for neovascularization hampers its clinical application.
Based on two different venous angiosomes involving two sides of thoracoepigastric veins (taken as the vascular carrier) in rabbits, a large abdominal flap measuring 12 × 13 cm was designed by anastomosing the transferred femoral artery with the thoracoepigastric vein distally and prefabricated by incision of the proximal and distal ends of the flap for 1 week. Traditional arterial flaps, arterialized venous flaps, and composite skin grafts of the same size were used as control groups. Flap viability, status of vascular perfusion and microvasculature, and level of epidermal metabolite in each group were assessed.
The large prefabricated flaps achieved results similar to the traditional flaps in terms of flap viability, status of vascular perfusion and microvasculature, and level of epidermal metabolite.
Large skin flaps with good quality can be prefabricated within a shorter period for aesthetic and plastic surgery reconstruction using the inherent venous system. This technique may prove to be a viable alternative for successful flap prefabrication.
Die Verbrennung der Gesichtsregionen stellt eine große Herausforderung für alle in der Verbrennungsbehandlung tätig werdenden
Berufsgruppen dar. Neben psychologischen Beeinträchtigungen aufgrund der vorliegenden Gesichtsdeformitäten bei Betroffenen
kann es gerade bei Kindern zu Alterationen mit schweren Gesichtsentstellungen und Vernarbungen während der einzelnen Phasen
der Gesichtsentwicklung kommen (Fricke et al. 1999, Achauer 1992). Der Rekonstruktion der Kopf- und Halsregion als elementarer Bestandteil der persönlichen Identität, Kommunikationsorgan
und Träger von Sinnesorganen kommt daher eine große Bedeutung zu. Die Behandlung der Gesichtsverbrennung erfordert ein solides
Wissen in rekonstruktiv-chirurgischen Prinzipien. Des weiteren sind fundierte Grundlagen in der Narbentherapie wie die Kompressionsbehandlung,
die Steroidinjektion oder die ablativen Verfahren, wie z. B. die Lasertherapie essentiell.
The face allotransplantation is a unique procedure, requiring a lifetime immunosuppressive therapy, and as such brings an ethical debate among medical societies and general public. The indications for this procedure have to be considered when the classic reconstructive procedures failed, and the patients are left with debilitating defects precluding them from normal social life. The transplantation protocol must be approved and registered by the institutional review board and health agencies. It is crucial that a thorough assessment of the patient for each indication will be performed by a multidisciplinary team and panel of experts in the field of plastic and reconstructive surgery, maxillo facial surgery, immunology of transplantations and psychiatry. The thorough psychiatric and psychological evaluation of potential candidates is mandatory, as well as evaluation by ethic experts. Numerous experimental models and extensive anatomical studies in cadaver model lead to the clinical success of face transplantation, raising a complex ethical question despite the fact that it is an important progress in plastic and reconstructive surgery. Three face transplantations have been performed since 2005. The transplants differed and were tailored, to match the extend of each patient facial defect. In this article we present the clinical cases of face transplantation based on our experience and dissections studies and a literature review.
Bei allen Entscheidungen über plastisch-rekonstruktive Maßnahmen im Gesicht müssen Funktion und Ästhetik gleichermaßen berücksichtigt werden, denn die soziale Reintegration des Betroffenen kann nur möglich sein, wenn das operative Ergebnis eines Defektverschlusses ästhetisch unauffällig ist. Einige der vorgestellten Verfahren können bei richtiger Indikation relativ einfach durchgeführt werden. Teilweise sind die Therapieoptionen jedoch komplex und erfordern nicht nur eine gründliche systematische Planung, sondern auch Routine in diesen Eingriffen und deren Nachbehandlung. Die verschiedenen Methoden müssen gegeneinander abgewogen werden. Ziel dieser Arbeit ist es, die in der Anatomie des Gesichtes vorgegebenen Gesetzmäßigkeiten aufzuzeigen. Neben bewährten Techniken sollen auch die aktuellen Entwicklungen und Perspektiven aus den Bereichen des Tissue-Engineering und der Gentherapie mit Relevanz für die plastische Gesichtschirurgie dargestellt werden.
Learning objectives:
After reading this article, the participant should be able to: 1. Discuss the principles behind the choice of reconstructive techniques for all major head and neck regions. 2. Differentiate between the optimal choices for reconstruction of the different mandibulectomy defects. 3. List the requirements for successful reconstruction of the skull base. 4. Further study new and evolving head and neck reconstruction techniques and options.
Summary:
Management of head and neck cancer has undergone many significant changes during the past two decades. This article gives an overview of the major areas in the head and neck, highlighting current practice and more recent trends in reconstruction choices. Further detail is given in the related videos. The five attached videos depict individual techniques of mandibular reconstruction, showing the technique of fibular dissection and osteotomy: endoscopic skull base reconstruction through a transpterygoid/lateral canthotomy approach, scalp reconstruction using a latissimus dorsi free flap and skin graft, maxillary reconstruction using the deep circumflex iliac artery iliac crest and internal oblique flap, and pharyngoesophageal reconstruction using an anterolateral thigh flap.
Conventional reconstruction in the head and neck has undergone a revolution as microsurgery has evolved and expanded our ability to reconstruct the most difficult defects. Vascularized composite allotransplantation (VCA) has provided a new paradigm of options to restore in 1 stage what in the past has been performed in multiple stages with multiple combinations of free flaps and local flap options. This review demonstrates an evolving perspective of head and neck reconstructive surgery incorporating the indications and advantages gained over a career that has developed in parallel with microsurgery, prefabrication, prelamination, and face transplant. All current conventional reconstructions for the most severe defects often involve multistage procedures, using every rung of the reconstructive ladder, and the end results can still be lacking despite our best efforts. Despite all the tailoring and planning of these multiple flap and multiple-stage reconstructions, in our experience, these interventions never quite exactly recapitulate the face and fall short of full restoration. The early experience with VCA has been very promising and yields results that are superior to those achieved using conventional methods of reconstruction. However, it will be synergistic efforts in both VCA and conventional reconstruction to take us to the next level of full face restoration.
This article is a discussion and presentation for plastic surgeons, in which each section is dedicated to a principle necessary for complex wound reconstruction. Each principle is discussed and includes detailed images of the associated operations.
Composite-tissue allotransplantation (CTA) is a new therapeutic modality to reconstruct major tissue defects of the face, larynx, and extremities. Unlike most life-saving organ-transplantation procedures, CTA is considered to improve qualiy of life. Therefore, the question arises, do the risks posed by the immunosuppression drugs that patients must take to prevent rejection justify the benefits of these procedures? The purpose of this study was to assess the relative risk that individuals are willing to accept in order to receive the benefits of CTA procedures. We used a psychometrically reliable and valid instrument to question two primary populations of individuals: those who live with the risks of immunosuppression, and healthy individuals. The level of risk acceptance for the seven transplant procedures tested (foot, single hand, double hand, larynx, kidney, hemiface, and full face) showed significant differences in research participants' risk acceptance for the different transplant procedures, but no significant differences between groups. Based on these findings, we conclude that certain CTA procedures convey benefits to recipients that are perceived by subjects, including individuals who live with the risks of immunosuppression, to warrant the risks of these procedures. © 2006 Wiley-Liss, Inc. Microsurgery, 2006
Various different procedures for partial or total reconstruction of the nose have been described, the methods of residual nasal tissue, and of buccal, frontal and temporal flaps being most widely used. Reconstruction of the nose with free vascular transplants is rarely used. Reconstruction of a nasal defect due to war injury of the nose with the use of prelaminated fasciocutaneous forearm flap with preserved allogeneic cartilage is described.
Mikrochirurgische Rekonstruktionen sind heute integraler Bestandteil komplexer plastisch-chirurgischer Rekonstruktionen, vor allem im Bereich Trauma, Tumorrekonstruktion und Korrektur kongenitaler Missbildungen. Den gestiegenen Anforderungen der Patienten an Funktion und sthetik der Lappenplastiken wird mit immer neuen Entwicklungen und Verbesserungen des Lappendesigns Rechnung getragen, die gleichzeitig auch fr eine deutliche Verminderung der Hebedefektmorbiditt sorgen. Die mittlerweile verfgbaren Konzepte und die immer weiter reduzierten Komplikationsraten machen mikrochirurgische Rekonstruktionsmglichkeiten heute zu einem Therapieverfahren der 1. Wahl und nicht wie frher oft postuliert zu einem Instrument der "letzten Verteidigungslinie".Microsurgical reconstructions are considered an integral art of modern reconstructive concepts, especially in the fields of trauma, tumor reconstruction, and correction of congenital deformities. Patient expectations regarding function and aesthetics of plastic surgical reconstructions are satisfied with permanently improved flap designs that also lead to a significant reduction in donor site morbidity. Together with steadily decreasing complication rates, these options have made microsurgical reconstructions a prime choice in plastic surgery, in contrast to the past, where they were considered the "last line of defense."
Introduction:
In reconstructive surgery, the integration of tissue-engineered cartilage in a prefabricated free flap may make it possible to generate flaps combining a variety of tissue components to meet the special requirements of a particular defect. The aim of the present study was to establish the technique of prefabricating a microvascular free flap by implanting a vessel loop under a skin flap in a rabbit model. The second aim was to gather experience with prelaminating the flap with autologous tissue-engineered cartilage in terms of matrix development, inflammatory reaction and host-tissue interaction.
Methods:
The microvascular flap was created by implanting a vessel loop under a random pattern abdominal skin flap. The tissue-engineered cartilage constructs were made by isolating chondrocytes from auricular biopsies. Following a period of amplification, the cells were seeded onto a non-woven scaffold made of a hyaluronic acid derivative and cultivated for 2-3 weeks. One cell-biomaterial construct was placed beneath the prefabricated flap, and the others were placed subcutaneously under the abdominal skin and intermuscularly at the lower extremity. In addition, a biomaterial sample without cells was placed subcutaneously as a control. All implanted specimens were left in position for 6 or 12 weeks. After explantation, the specimens were examined by histological and immunohistological methods. The prefabricated flap was analyzed by angiography.
Results:
The prefabricated flaps showed a well-developed network of blood vessels formed by neovascularization between the implanted vessel loop and the original random-pattern blood supply. The tissue-engineered constructs remained stable in size and showed signs of tissue similar to hyaline cartilage, as evidenced by the expression of cartilage-specific collagen type II and proteoglycans. No hints of inflammatory reactions were observed.
Conclusion:
These results show the potential of prefabricated flaps as custom-made flaps for reconstructive surgery in difficult circumstances, more or less independent of anatomical prerequisites. Cartilage tissue engineering provides a 3-dimensional structure with minimal donor-site morbidity.
Flap prefabrication and prelamination are complex procedures reserved for cases in which conventional, simpler flaps will
not achieve the desired goal or are unavailable [3, 6, 8, 9, 11]. The term prefabrication was first introduced by Shen [14]
in 1982 and describes the implantation of a vascular pedicle into a new territory, followed by a period of maturation and
neovascularization, and then the subsequent transfer of tissue based on its implanted pedicle [11]. Prefabrication allows
any defined tissue volume to be transferred to any specified recipient site, greatly expanding the armamentarium of reconstructive
options. Flap prelamination, first coined by Pribaz and Fine in 1994 [8], describes a process in which tissues or other devices
are implanted into a vascular territory before it is transferred; the blood supply is not manipulated [9, 12]. Prelamination
transforms a native axial flap into a multilayered flap by adding the appropriate support and lining structures for composite
reconstruction.
Although most nasal reconstructions are performed using local tissues, there are 2 groups of patients who may benefit from nasal reconstruction using microsurgical techniques. The first group is patients with a subtotal loss of the distal part of the nose that may be reconstructed with a free flap from the ascending helix of the ear, which has a remarkably similar appearance to the distal part of the nose. The second group is patients who have sustained a total loss of the nose, including all layers and often adjacent tissues, who may be reconstructed in a staged fashion with a prelaminated flap from the forearm. This flap has previously been lined and laminated with structural support and subsequently transferred to the face. These flaps need revisions and generally a forehead flap for final esthetic coverage once they have stabilized.
In a rat model, a skin flap was fabricated by implantation of a distally ligated arteriovenous pedicle. The femoral artery and vein were implanted as a unit beneath the abdominal skin, a portion of which was later raised as an island flap, based on these vessels. Percentage area of survival, tissue blood flow, and pattern of vascularity were compared in two groups of flaps. In group I, the pedicle to be implanted was dissected with a cuff of surrounding muscle still attached; in group II, the pedicle was skeletonized to the level of adventitia. Flap survival in the two groups was similar (73% vs. 77%), as was skin blood flow (5.4 vs. 5.7 ml/100 g/min). Angiography demonstrated two principal patterns of vascularization: connection between donor and recipient vessels (inoculation), and sprouting and arborization of new vessels. Strengths and limitations of this and other models of flap "prefabrication" are discussed.
We have developed a new model of thin flap prefabrication in the rabbit with an exteriorised vascular pedicle in a skin tube. Study of these prefabricated flaps after transfer demonstrated that distal flap survival improved as the interval between implantation and flap transfer increased. Exteriorising the pedicle minimises both donor deformity and pedicle trauma and allows easier experimental study of the neovascularisation process in flap prefabrication.
As flap prefabrication becomes a more commonly used clinical tool, it is necessary to investigate the limitations of this technique. Reconstructive procedures of the face often require "custom fitted" flaps to satisfy esthetic demands. This study examines and compares the safety of manipulating thin prefabricated skin flaps versus established axial pattern skin flaps. Twenty-seven New Zealand white rabbits were used to determine if prefabricated flaps can be folded 180 degrees around the edge of the rabbits' ears. The survival of these folded prefabricated flaps was compared with the survival of axial pattern flaps sutured into an identically recipient site. In addition, flaps prefabricated in the same manner were sutured onto a straight recipient bed to evaluate the viability of the newly vascularized tissue. The folded prefabricated flaps had reduced survival (56%) compared to equivalent folded axial pattern flaps (85%), P < 0.005. The nonmanipulated prefabricated flaps and axial pattern flaps survived completely.
Modification of flaps prior to local or distant transfer has gained wide acceptance. The term prefabricated has been used to describe all possible modifications. In this article we introduce the term prelamination to refer to the implantation of tissue or other devices into a flap prior to transfer and suggest that prefabrication be restricted to the implantation of vascular pedicles. A case is presented illustrating these concepts.
Twelve temporoparietal fascial flaps were prefabricated to line the oral and/or nasal cavities in 10 patients. Bilateral flaps were used both in a patient suffering from lye ingestion and in a patient undergoing bilateral lip reconstruction. All reconstructions were performed in two stages separated by 3 to 4 weeks. The first stage involved creation of an epithelial lining by placing a non-hair-bearing skin graft over the temporoparietal fascia. The second stage raised the fascial flaps as vascular islands and transferred them as either pedicled or free flaps. All 12 flaps survived and improved function for the patients involved. Although all possible applications for this flap have not been explored fully, there appears to be great potential for the use of this procedure in refined reconstructions of moderately sized intraoral and nasal defects.
Neovascularisation of thin skin flaps after arteriovenous pedicle implantation (flap prefabrication) and the impact of the delay mechanism on the viability of these flaps were investigated. Twenty-four full thickness skin flaps were raised in twelve New Zealand white rabbits. Delay incisions were made at the lateral borders of the planned flaps at the same time as pedicle implantation, 1 week before pedicle implantation, or 1 week after pedicle implantation and the flaps based on the implanted vessels raised at 2 weeks after implantation. Flap survival assessed at 1 week was found to be improved when flap delay was performed 1 week before or after pedicle implantation. Angiographic studies demonstrated an increased density and linearity of the vascular pattern in these delay group flaps. The combination of the time-tested concept of delaying a flap with the newer technique of flap prefabrication appears to improve flap viability.
A free flap derived from the ascending helix of the ear has been used to reconstruct an anatomically diverse set of defects of the distal nose in 6 patients. Our cadaver injection studies have demonstrated that the blood supply to the auricular flap is via small, consistent branches from the superficial temporal artery. The patients were carefully selected, and most had failed prior attempts at reconstruction. The auricular flaps were used to reconstruct the nasal tip, ala, columella, and sill. The donor vessels were anastomosed either to the facial artery and vein or to vessels in the neck, via vein grafts. The flaps survived in all cases, but all patients required minor subsequent revision. The auricular donor site was closed by rotation and advancement of local tissue. This flap is presented as a surgical option for selected patients with complex defects of the distal nose, where excellent match of color and contour, predictable outcome, and avoidance of central facial donor site are desired.
The authors present some clinical applications of the concept of flap prefabrication. Three cases are described where reconstructions around the head and neck were accomplished. The radial vascular territory of the forearm was selected for prefabrication of structures which were then transferred by microsurgical techniques. In two cases, a sensate flap was used, with nerve repair in the neck.
This study was designed to determine whether tissue expansion after vascular pedicle implantation would increase the survival area of prefabricated skin flaps. In 20 New Zealand white rabbits, the vascular pedicle consisting of the central artery and vein of the left ear was implanted into the neck. At the time of pedicle implantation a subcutaneous pocket was created measuring 5 x 14 cm beneath the implantation site. Tissue expanders of three different sizes and volumes were implanted in the rabbits of three treatment groups. No tissue expander was implanted in the animals of the control group. All flaps were transposed after 3 weeks to the contralateral ear, and flap survival was assessed 1 week later. The increased area of the flap survival was statistically significant in all three treatment groups compared to the nonexpanded flaps (P = 0.003, P = 0.004, P < 0.0001, respectively). In addition there was a statistically significant larger area of survival using a 100-cc expander measuring 5 x 14 cm (the same size as the elevated flap) compared to 40-cc (3 x 5 cm) or to 60-cc (4 x 8 cm) expanders (P < 0.001, P = 0.004, respectively). The one-way analysis of variance and the t-test were used to show statistical differences. We conclude that the time necessary for neovascularisation of the skin flap could be used to expand the tissue, not only increasing the amount of available tissue, but also enhancing the vascularity.
Flap prefabrication is dependent on the neovascular response that occurs between the implanted arteriovenous pedicle and the recipient tissue. Augmentation of this neovascular response with angiogenic growth factors would maximize flap survival and minimize the interval between pedicle implantation and flap rotation. Maximizing the biologic activity of endogenous growth factors would likewise positively impact upon flap survival. This study examined the role of basic fibroblast growth factor, a known potent angiogenic growth factor, on flap survival in a rabbit ear prefabrication model. Sucrose octasulfate, a substance that binds basic fibroblast growth factor, stabilizes it, and protects it from degradation, was also studied to determine its impact on flap survival. Flap survival was increased using basic fibroblast growth factor, sucrose octasulfate, and the two substances combined together. The use of substrates designed to maximize the biologic activity of endogenous growth factors, rather than relying on the artificial addition of exogenous growth factors, represents a new approach in the search for methods that will improve flap survival.
For reconstruction of intraoral soft-tissue defects after radical resection of squamous-cell carcinomas, the microvascular jejunal patch has been a reconstructive graft option of first choice. in addition to other advantages, these jejunal grafts are able to produce mucus. In cases in which the use of jejunal grafts is contraindicated, the fasciocutaneous radial forearm flap has enlarged the spectrum of reconstructive options. A disadvantage is that mucus production will be absent, because mucosal and lining reconstruction is performed with tissue lacking mucus-providing qualities. The authors successfully prelaminated a distal radial forearm flap with buccal mucosa in five patients. Mucosal prelamination of the distal radial forearm flap enables a physiologic reconstruction with resultant mucus production, in combination with the provision of thin, pliable, and resistant flaps. The technique lowers donor-site morbidity because of the preservation of skin and subcutaneous tissue. Reconstruction with fasciomucosal, osteomyomucosal, and myomucosal flaps by this method seems feasible.
Tissue neovascularized by implanting a vascular pedicle can be transferred as a "prefabricated flap" based on the blood flow through the implanted pedicle. This technique potentially allows any defined tissue volume to be transferred to any specified recipient site, greatly expanding the armamentarium of reconstructive options. During the past 10 years, 17 flaps were prefabricated and 15 flaps were transferred successfully in 12 patients. Tissue expanders were used as an aid in 11 flaps. Seven flaps were prefabricated at a distant site and later transferred using microsurgical techniques. Ten flaps were prefabricated near the recipient site by either transposition of a local vascular pedicle or the microvascular transfer of a distant vascular pedicle. The prefabricated flaps were subsequently transferred as island pedicle flaps. These local vascular pedicles can be re-used to transfer additional neovascularized tissues. Common pedicles used for neovascularization included the descending branch of the lateral femoral circumflex, superficial temporal, radial, and thoracodorsal pedicles. Most flaps developed transient venous congestion that resolved in 36 to 48 hours. Venous congestion could be reduced by incorporating a native superficial vein into the design of the flap or by extending the prefabrication time from 6 weeks to several months. Placing a Gore-Tex sleeve around the proximal pedicle allowed for much easier pedicle dissection at the time of transfer. Prefabricated flaps allow the transfer of moderate-sized units of thin tissue to recipient sites throughout the body. They have been particularly useful in patients recovering from extensive burn injury on whom thin donor sites are limited.
This article is a review of five patients who underwent reconstruction of nasal and paranasal facial defects with prelaminated forearm free flaps. The defects resulted from thermal injury, gunshot wound, excision of tumor, and arteriovenous malformation (n = 2). The forearm flaps were based on the radial artery (n = 4) and ulnar artery (n = 1) and were prelaminated with grafts of skin and cartilage. All flaps were successfully transferred to the face, but revisions were needed to separate the subunits and improve appearance. A prelaminated free flap should be considered for a patient requiring reconstruction of a complex central facial defect.