Principles of Prefabricated Flaps

EDITORIAL COMMENT

This chapter, by one of our most innovative microsurgery and plastic surgeons, is recommended for solutions to some of the most difficult reconstructive problems. Preforming a body part before transfer is an elegant concept, although the vagaries of healing tissue do not always allow perfect results.

Flap prefabrication may be considered a generic description referring to the remodeling, reshaping, or rebuilding of pedicled or free flaps, in effect, a tailored or customized flap. Using the concept of prefabrication, the area of the potential flap can be enlarged, a more reliable vascularity can be achieved, and the availability of donor materials can be maximized before transfer of the flap.

INDICATIONS

Because the use of prefabrication involves a wide variety of complementary or associated surgical techniques, perhaps the only common denominator is the ability to extend the indications and potentials of pedicled or free flaps in several donor and recipient body areas. Techniques can include the use of delay as a preliminary stage for a free flap, thus increasing the survival area by enlargement of the choke vessels that link vascular territories (1, 2). Flap preexpansion can enhance the available area of a flap, contribute to better vascularity and safety, and allow easier primary closure at the donor site (3, 4, 5, 6). Induced neovascularization or preliminary vascular induction can expand the possibilities of tissue use by delaying or staging transfer until dependable vascularization is achieved (7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24). Combinations using several elements of prefabrication make it possible to reconstruct several anatomic and aesthetic units in sequential procedures done at a single donor site with the addition of free or pedicled flaps (25, 26, 27).

OPERATIVE TECHNIQUE

Induced Neovascularized Flap

Orticochea (13) was the first to use this principle for reconstruction of the nose. He transferred the superficial temporal vessels to the retroauricular conchal area, which then was used in a second stage as a pedicled composite flap. Subsequently, Erol (14) developed the conversion of a thick split-thickness skin graft as a secondary vascularized flap. The temporoparietal branch or the frontal branch of the superficial temporal vessels was used in nine patients to prepare vascular pedicled flaps, which then were transferred at least 3 weeks later for reconstruction of the infraorbital, zygomatic, or buccal regions as well as for nose and ear reconstruction.

Shen (16) reconstructed the helix of the ear after implanting the superficial temporal artery and vein into a long, thin tube on the neck. The average time between the two operations was 4.5 weeks. He also was the first to transfer a prefabricated flap with preliminary vascular induction successfully (17). In a first stage, the descending branch of the lateral femoral circumflex artery was implanted beneath the skin territory of the lateral aspect of the thigh. Six weeks later, a 2.6 × 16-cm flap was transferred and revascularized in the neck for treatment of a severe burn contracture. According to the same principle, a skin territory can be neovascularized by the free transfer of an arteriovenous pedicle and its surrounding fascia or a muscle cuff done as a first stage (18, 19).

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