Face resurfacing using a cervicothoracic skin flap prefabricated by lateral thigh fascial flap and tissue expander

FACE RESURFACING USING A CERVICOTHORACICSKIN FLAP PREFABRICATED BY LATERAL THIGHFASCIAL FLAP AND TISSUE EXPANDER

QINGFENG LI, M.D., Ph.D.,* TAO ZAN, M.D., Ph.D., BIN GU, M.D., KAI LIU, Ph.D.,

GUOXIONG SHEN, M.D., YUN XIE, M.D., and RUI WENG, Ph.D.

Background: Resurfacing of facial massive soft tissue defect is a formidable challenge because of the unique character of the region andthe limitation of well-matched donor site. In this report, we introduce a technique for using the prefabricated cervicothoracic skin flap for fa-cial resurfacing, in an attempt to meet the principle of flap selection in face reconstructive surgery for matching the color and texture, largedimension, and thinner thickness (MLT) of the recipient. Materials: Eleven patients with massive facial scars underwent resurfacing proce-dures with prefabricated cervicothoracic flaps. The vasculature of the lateral thigh fascial flap, including the descending branch of the lat-eral femoral circumflex vessels and the surrounding muscle fascia, was used as the vascular carrier, and the pedicles of the fascial flapwere anastomosed to either the superior thyroid or facial vessels in flap prefabrication. A tissue expander was placed beneath the fascialflap to enlarge the size and reduce the thickness of the flap. Results: The average size of the harvested fascia flap was 6.5 3 11.7 cm.After a mean interval of 21.5 weeks, the expanders were filled to a mean volume of 1,685 ml. The sizes of the prefabricated skin flapsranged from 12 3 15 cm to 15 3 32 cm. The prefabricated skin flaps were then transferred to the recipient site as pedicled flaps for facialresurfacing. All facial soft tissue defects were successfully covered by the flaps. The donor sites were primarily closed and healed withoutcomplications. Although varied degrees of venous congestion were developed after flap transfers, the marginal necrosis only occurred intwo cases. The results in follow-up showed most resurfaced faces restored natural contour and regained emotional expression. Conclu-sion: MLT is the principle for flap selection in resurfacing of the massive facial soft tissue defect. Our experience in this series of patientsdemonstrated that the prefabricated cervicothoracic skin flap could be a reliable alternative tool for resurfacing of massive facial soft tissuedefects. VVC 2009 Wiley-Liss, Inc. Microsurgery 29:515–523, 2009.

Facial deformity and disfigurement, especially resulted

from massive soft tissue defects after burn injury or tu-

mor excision, represent a profound disruption of body

image and may constitute a major social and psychologi-

cal crisis. Skin grafts and flap techniques have been com-

monly used following the removal of scar tissue for

resurfacing the lost skin in patients. However, contracture

of skin graft may cause not only deformity and disability

of facial function and expression but also color and tex-

ture mismatched to the recipient, especially in nonwhite

patients. Local flap transfer techniques often encounter

some problems, such as insufficient donor sites, limited

vascular territory, and difficulty for flap inset.1–8 The free

flap transfer has revolutionized reconstruction, especially

in the head and neck, where local flap is seldom avail-

able. However, free flaps are usually used for coverage

of the tissue defect, rather than for aesthetically and func-

tionally resurfacing the face because free flaps also have

problems for color, texture, and thickness mismatched

and notable bulk.1 Thus, there has not been an ideal tech-

nique for achieving satisfactory functional and aesthetic

results in facial resurfacing.

On the basis of the special anatomic characteristic of

head and neck area, we proposed the principle of

‘‘matching, large size, and thinner thickness’’ (MLT) in

flap selection for reconstruction and resurfacing of mas-

sive facial soft tissue defects. The principle requires that

the selected flap should have 1) the color and texture

matched to the recipient region; 2) the size large enough

to cover massive defects; and 3) the thinner thickness to

mediate facial expression and coincide the facial contour.

According to anatomic characteristics, the closer the do-

nor site is located to the recipient, the better skin texture

matches the recipient site. The skin of cervicothoracic

area is considered a good donor site for reconstruction of

massive facial skin defects because its color and texture

well matched to face and the potential large size for har-

vest. However, the traditional flaps raised from this area

are lack of reliable axial blood supplies and thus are not

consistent in size of flap and length of pedicles to reach

the recipient.3–7 A more sophisticated approach is needed

for optimal resurfacing of massive facial soft tissue

defects.

The technique of flap prefabrication has been proved

for creating new skin flaps that are not restricted to

natural vascular territories by means of neovasculariza-

tion.9–13 In this report, we present our experience on pre-

fabrication of a cervicothoracic skin flap with the lateral

thigh fascial flap as vascular carrier and tissue expander

for creating large and thinner flap to match the MLT

Department of Plastic and Reconstructive Surgery, The Ninth Hospital, Medi-cal School of Shanghai Jiao Tong University, Shanghai, China

Grant sponsor: National Natural Science Foundation of China; Grant number:30730092; Grant sponsor: Research Special Fund Public Welfare Industry ofHealth; Grant number: 200802014.

*Correspondence to: Qingfeng Li, M.D., Ph.D., Department of Plastic andReconstructive Surgery, The Ninth Hospital, Medical School of ShanghaiJiao Tong University, Shanghai 200011, China. E-mail: [email protected]

Received 14 November 2008; Accepted 16 January 2009

Published online 23 March 2009 in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/micr.20640

VVC 2009 Wiley-Liss, Inc.

principle. We used the prefabricated skin flaps for facial

resurfacing in a series of 11 patients.

PATIENTS AND METHODS

From March 2006 to April 2008, 11 patients received

prefabricated cervicothoracic pedicled skin flaps for head

and neck reconstruction and facial resurfacing of massive

soft tissue defects after scar resections in our institution.

There were six male and five female patients with age

ranging from 11 to 56 years old (average 31.7 years old).

The initial causes of the defects included burn injuries

with molten steel (four cases), acid or lye (three cases),

high voltage electricity (two cases), and flame (two

cases). The prefabricated skin flaps were used for recon-

struction of the lower jaw and cheek in five cases, peri-

oral reconstruction in three cases, releasing neck contrac-

ture in two cases, and perioral and nasal reconstruction in

one case.

Surgical Technique for Flap

Prefabrication and Transfer

Fascial flap harvest. The lateral thigh fascial flap

nourished by the descending branch of the lateral circum-

flex femoral artery was designated as the vascular carrier

for flap prefabrication based on its characters of the vas-

cular pedicle around 8–16 cm in length, with a vessel di-

ameter larger than 2 mm (see Fig. 1).14–16 In the opera-

tion design, a reference line was drawn from the anterior

superior iliac spine to the superolateral border of the pa-

tella. An ‘‘S’’-shaped incision was made along the lower

2/3 of the line. The tensor fascia lata muscle was sepa-

rated for exposure of the lateral intermuscular septum

between the rectus femoris and the vastus lateralis mus-

cle. The rectus femoris muscle was retracted medially.

The descending branch of the lateral circumflex femoral

artery and its venae comitantes were carefully dissected

from the rectus femoris and vastus lateralis muscles. The

distal end of the vessels before penetrating the muscles

were divided and ligated. The motor nerve to the vastus

lateralis was preserved by separating it from the main

vascular pedicle during harvest of the fascial flap.

Fascial flap transfer and tissue expander place-

ment. The recipient vessels and the donor site for pre-

fabricated flap were designed under consideration of eas-

ier rotation of the pedicled flap and skin texture close to

the recipient in face and neck. An approximate 6–7 cm

in length incision was made along the upper half of the

anterior margin of the sternocleidomastoid muscle,

extending into the anterior margin of the trapezius mus-

cle. Either the superior thyroid artery or the facial artery

and its venae comitantes were dissected as the recipient

vessels. The lateral thigh fascial flap with its vascular

pedicles was inset into a subcutaneous pocket of the cer-

vicothoracic area after the blood perfusion to the flap was

reestablished by microvascular anastomoses. A rectangu-

lar remote filling tissue expander was then placed under-

neath the fascial flap. A negative pressure drain was

placed in the tissue pocket until the volume of drainage

was less than 10 ml.

Tissue expansion. After the fascial flap transfer, an

Ultrasound Doppler was used to identify the patency of

the microvascular anastomosis. With confirming persist-

ence of pulsation in the pedicle, tissue expansion begun 2

weeks postoperatively and was performed twice a week

with 5–10% expansion of the total volume of the ex-

pander. When the expanded area of skin was estimated

over the size of the tissue defect, expansion was stopped

and the flap transfer was planned.

Inset of the prefabricated flap. Angiogram or Ultra-

sonic Doppler was used to assess the persistence of blood

flow in the vascular pedicles and neovascularization

induced by flap prefabrication before the flap transfer

procedure. The prefabricated cervicothoracic skin flap

was then raised from the underlying tissue expander, and

the vascular pedicles were identified. Dissection was per-

formed carefully because of fibrous tissue around the

pedicle. After the scar tissue in the face and neck was

removed and the fibrous synechiae was completely

released, the prefabricated skin flap was rotated to cover

the skin defect based on the pedicle of lateral circumflex

femoral vessels. The donor site was primarily closed.

Figure 1. Graphical diagram of vascular carrier. The fascial flap

nourished by the descending branch of the lateral femoral circum-

flex vessels. The descending branch gives off up to 10 branches

that penetrate the deep surface of the proximal and middle thirds of

the vastus lateralis muscle in the company of supplying nerves.

[Color figure can be viewed in the online issue, which is available

at www.interscience.wiley.com.]

516 Li et al.

Microsurgery DOI 10.1002/micr

RESULTS

The average size of harvested lateral thigh fascial

flaps was 6.5 3 11.7 cm (ranging from 3 3 8 cm to 7 315 cm). The average length of the vascular pedicles was

5.1 cm (ranging from 3 to 6 cm). After a mean interval

of flap prefabrication for 21.5 weeks (ranging from 10 to

32 weeks), the tissue expanders were filled to a mean

volume of 1,685 ml (ranging from 830 to 2,670 ml).

The sizes of raised prefabricated skin flaps ranged

from 12 3 15 cm to 15 3 32 cm, and all flaps could

covered and resurfaced the entire defects of the face and

neck. All flaps survived after transfer. Varied degrees of

venous congestion were observed after flap insets in all

cases. Three flaps with venous congestion were treated

by the technique of venous bloodletting from the flap

edges, whereas other flaps did not receive any treatment.

Marginal skin necrosis (<3 cm) was eventually found in

two cases. The wounds healed with dressing changes.

Three flaps underwent secondary debulking procedures

for the skin pedicles of flap rotation. In follow-ups rang-

ing from 3 to 21 months, the texture and color of trans-

ferred flaps were found matched to the adjacent skin

around the repair sites. No complications were observed

in either thigh or cervicothoracic donor sites. All patients

were satisfied with the functional and esthetic outcomes.

Case Report

Case 1. A 40-year-old man sustained a severe burn

injury over 40% of his total body surface in a forest fire.

The patient received burn treatment for body in a burn

unit, but requested further facial reconstruction in our

institution. The patient presented a facial disfigurement

caused by hypertrophic scarring in the perioral, nasal,

and mandibular regions, and functional disability with

difficulty in nasal breathing and mouth eating (Fig. 2,

above). The patient underwent a four-step procedure for

facial resurfacing. A 7 3 12 cm lateral thigh fascial flap

based on the descending branches of the lateral femoral

circumflex vessels was transferred to the cervicothoracic

area, and the vascular pedicles of flap were anastomosed

to the right superior thyroid vessels. The flap was inset

over a 600-ml rectangular tissue expander under the cer-

vicothoracic skin (Fig. 3, above). The expanders were

Figure 2. Preoperative and postoperative views in case 1. Above: Preoperative views of hypertrophic scarring in the perioral, nasal, and

mandibular areas. Below: Postoperative views for appearance of nose and mouth after debulking procedure. [Color figure can be viewed in

the online issue, which is available at www.interscience.wiley.com.]

Prefabricated Flap for Face Resurfacing 517


expanded twice a week until a total volume of 1,800 ml

was achieved. At 6 months after flap prefabrication, the

facial scars were removed and the prefabricated cervico-

thoracic skin flap with 21 3 20 cm in size was raised

and transferred for coverage of lower face including

entire mouth and nose (Fig. 3, Below). The flap survived

after surgery. However, a slight venous congestion was

developed postoperatively, which subsided in 2 weeks

without special treatment. Three weeks after flap transfer,

the flap was partially divided to form the mouth and

nose. At the fourth postoperative month, the patient

underwent debulking procedure for the skin pedicle. At

7 months of follow-up, the patient could breathe and eat

without difficulty and was satisfied with the outcomes

(Fig. 2, below).

Case 2. A 35-year-old woman had extensive scarring

and disfigurement of chin and cheek caused by burn and

requested a improved aesthetic appearance (Fig. 4,

above). A flap was prefabricated over the right cervico-

thoracic area by inset of a later thigh fascial flap with the

descending branches of the lateral femoral circumflex

vessels as the vascular pedicles. The vessels were anasto-

mosed to the facial artery and vein. A tissue expander

was placed under the lateral thigh fascial flap. Six months

after flap prefabrication, the total volume of tissue expan-

sion was 1,240 ml. The angiogram showed the extensive

neoangiogenesis in the prefabrication area. The facial

scar was excised and the prefabricated cervicothoracic

skin flap with 28 3 12 cm in size was dissected based

on its vascular pedicles and then rotated to cover the skin

defect. Both sides of the lower third of cheek, chin, and

lower lip were resurfaced with the flap (see Fig. 5). The

flap survived after surgery. A mild venous congestion of

flap presented in the first postoperative week. The venous

congestion was released by multiple puncturing on the

marginal part of flap with a needle and topical applica-

tion of heparin. Partial necrosis occurred at the distal

margin of flap and the wound healed after dressing

Figure 3. Prefabricated skin flap for face resurfacing in case 1, Above, left: Harvest of the lateral thigh fascial flap with the descending

branches of the lateral femoral circumflex vessels as the pedicles. Above, center: Design for the position of the tissue expander, the free

fascia flap, and the recipient vessels (superior thyroid vessels). Above, right: Pedicles of the fascial flap anastomosed to the right superior

thyroid vessels. Below, left: Expansion of the prefabricated skin flap at 6 months before harvest. Below, center: Elevation of the prefabri-

cated skin flap. Below, right: Inset of the pedicled prefabricated skin flap. [Color figure can be viewed in the online issue, which is available

at www.interscience.wiley.com.]

518 Li et al.


Figure 4. Preoperative and postoperative views in case 2. Above: Preoperative appearance of the extensive scar on the chin and cheek.

Below: Postoperative views after facial resurfacing with mild scar remaining in the margin of right cheek. [Color figure can be viewed in the

online issue, which is available at www.interscience.wiley.com.]

Figure 5. Prefabricated skin flap for face resurfacing in case 2. (a) Arteriogram showed the patency of the vascular pedicles (arrow) and

the neoangiogenesis area over the transferred fascia flap 6 months after prefabrication. (b) Design of the pedicled flap based on the

implanted vessels. (c) Rotation of the prefabricated cervicothoracic skin flap (1, supraclavicular vessels; 2, facial vessels). (d) Inset of the

prefabricated skin flap and primary close of the donor site. (e) Venous congestion at first day after operation. (f) Venous congestion

released by puncturing with a needle and topical application of heparin. (g) Partial necrosis at the distal margin of the flap and wound

healing with mild scar formation 2 weeks postoperatively. [Color figure can be viewed in the online issue, which is available at www.

interscience.wiley.com.]

changes (see Fig. 5). The patients were satisfied with the

functional and aesthetic outcomes at 4 months of follow-

up (Fig. 4, below).

Case 3. A 28-year-old woman suffered from the burn

injury on the face, neck, extremities, and chest. The

wound was initially treated by skin grafting. The patient

developed mentosternal contracture with an unstable ulcer

1 year after injury (Fig. 6, above). A skin flap was pre-

fabricated at the right shoulder region where a relatively

healthy patch of skin remained. The prefabricated skin

flap was nourished by a 3 3 8 cm lateral thigh fascial

flap based on the descending branches of the lateral fem-

oral circumflex vessels that were anastomosed to the

superior thyroid vessels. The fascial flap was fixed to a

subcutaneous pocket and a 300-ml tissue expander was

placed underneath the fascial flap. Three months after

flap prefabrication, the vasculature of flap was identified

by an Ultrasonic Doppler examination. A 16 3 12 cm

prefabricated skin flap was then raised and transferred to

the skin defects at chin and neck after scar resections

(see Fig. 7). The donor site was primarily closed. The

postoperative course was uneventful. Complete release of

mentosternal contracture was achieved at 3 months of

follow-up (Fig. 6, below).

DISCUSSION

Reconstruction and resurfacing of massive soft tissue

deformity in the face and neck is a great challenge to

reconstructive surgeons.1,2,10–12 Besides coverage of the

defects, the major aim of reconstruction is to restore the

facial aesthetics and function. Flap prefabrication is a rel-

atively new and evolving technique that provides a

ready-for-use alternative when traditional options are not

available. With this technique, the tissue suitable for face

and neck reconstruction and resurfacing may be used for

flap prefabrication. When compared with free flaps, the

prefabricated flap could be achieved with improved prop-

erties to aesthetic and functional match of the recipient

site. Moreover, the donor site morbidity could be signifi-

cantly reduced. The prefabricated flap may be a valuable

tool for reconstruction of large defects in the head and

neck region where aesthetics and function are highly

demanded. The disadvantage of this technique is that the

Figure 6. Preoperative and postoperative views in case 3. Above: Postburn mentosternal contracture with skin ulcer after skin grafts.

Below: Improvement of the range of motion after complete release of synechiae and reconstruction with transfer of the prefabricated skin

flap 3 month postoperatively. [Color figure can be viewed in the online issue, which is available at www.interscience.wiley.com.]

520 Li et al.


patient suffers from multiple procedures in delayed

stages.13 However, this complex technique is worthwhile

for achieving improved results of reconstruction. Clini-

cally, tissue expansion technique is often combined with

flap prefabrication procedure. Tissue expansion increases

the size and vascularity of the prefabricated flap, while

allowing primary closure of the donor site.17 In addition,

tissue expansion could reduce the thickness of subcutane-

ous tissue and dermis,2,18 which would be more suitable

for the face and neck resurfacing.

The skin flap prefabrication means creating an axial

pattern flap suitable for either pedicled or free-flap trans-

fer with an angiogenic response after vascular carrier im-

plantation into the subdermal level of donor tissue.9–13

The prefabricated skin flap mainly consisted of two ele-

ments, the donor site selection and the vascular carrier

creation. For massive facial resurfacing, the ideal donor

site is cervicothoracic skin because its color and texture

match the recipient site. Ideally, a vascular carrier does

not contain any tissue other than a densely spread capil-

lary network, and it is maintained with a very long pedi-

cle with large-caliber blood vessels that facilitates micro-

vascular anastomosis. Several tissues, such as muscle,19

fascia,11,20–22 omentum,23 and vessel bundles13,24,25 have

been used as the carriers. Kimura et al.22 reported that

the vessel bundle and muscle are not adequate as carriers

for making a thin and large prefabricated skin flap. The

vascularized fascia may be the most suitable tissue as a

carrier for making a thin prefabricated skin flap. There

have been several reports that described use of the tem-

poroparietal fascia,11,20 radial forearm fascia,21 and trans-

versalis fascia22 for flap prefabrication.

In this report, we describe a new vascular carrier for

prefabrication of a cervicothoracic skin flap with a fascial

flap nourished by the descending branches of the lateral

femoral circumflex vessels. The descending branch of the

lateral femoral circumflex artery is commonly used as the

pedicle for supplying the anterolateral thigh flap, which is

one of the most versatile and reliable tools in soft-tissue

reconstruction.15,26–29 The descending branch of the lat-

eral femoral circumflex artery was also used as an arterial

graft for the coronary artery bypass grafting.14,30 Pribaz

et al.10–12 described use of the descending branches of

the lateral femoral circumflex vessels as a vascular carrier

in flap prefabrication. The vascular pedicle along with the

muscle cuff was used to provide blood supply to the

Figure 7. Prefabricated skin flap for neck reconstruction in case 3. Above, left: Identification of the vessels by Ultrasonic Doppler blood-

flow signals (arrow) 3 months after implantation of the vascular carrier. Above, right: Design of the pedicled skin flap based on the

implanted vessels. Below, left: Elevation of the prefabricated skin flap with vascular pedicles (arrow). Below, right: Inset of the prefabricated

skin flap and primary close of the donor site. [Color figure can be viewed in the online issue, which is available at www.interscience.wiley.

com.]



overlying skin. However, this technique would make a

prefabricated flap bulky because the muscle content was

included. We chosen the fascial flap nourished by the de-

scending branches of the lateral femoral circumflex ves-

sels as the vascular carrier based on: 1) the descending

branches have adequate length and diameter, which facili-

tates anastomosis in the skin flap prefabrication and flap

rotation in the reconstruction; 2) although anatomical var-

iants of the lateral femoral circumflex artery have been

reported,30,31 in our experience, the main trunk of the de-

scending branches had a constant location in the groove

between the rectus femoris and vastus lateralis muscles;

3) the fascia usually remains healthy and available even

in the severe burn injury because of its deep location; 4)

it is a relatively simple procedure for harvesting a fascial

flap with at least 6 3 8 cm in size without damaging the

accompanying nerve.32 In our experience, no notable

complications were found at the donor sites after harvest

of fascial flaps.

Selection of the recipient vessels in the flap prefabrica-

tion is important for achieving good results in facial resur-

facing. The recipient vessels near the region of deformity

or disfigurement in the face and neck areas allow transfer

of the pedicled prefabricated flap without performing a

complex manipulation. In our series, both the facial artery

and superior thyroid artery were selected as the recipient

arteries, and either facial vein or a branch of the internal

jugular vein was chosen as the recipient vein.

The supraclavicular island flap described by Lamberty

and Pallua et al.3–7 has been used for facial reconstruc-

tion, providing satisfactory results without need of micro-

vascular anastomoses. However, the supraclavicular island

flap is designed based on the supraclavicular vessels. The

pivot of the supraclavicular flap is about 7–12 cm lower

than the facial artery and the superior thyroid artery,

which cause difficulty for flap to cross the median line to

reach distal areas of defect in the face. The prefabricated

skin flap described in our report was supplied by either

the facial artery or the superior thyroid artery. Therefore,

the pivot of prefabricated flap was more close to the

facial defect so that the flap was transferred without ten-

sion. Furthermore, the technique of flap prefabrication

allowed us to have more choices for selection of the do-

nor sites in areas of neck, shoulder, and upper chest.

Thus, the flap prefabrication technique is able to provide

sufficient tissue for optimal face reconstruction and resur-

facing. The prefabricated supraclavicular flap with thora-

coacromial vessels was introduced by Margulis et al.25

for reconstruction of the anterior cervical contractures.

However, because of the low position of the pivot of

rotation and the short length of the vessel pedicle, this

flap based on the implanted thoracoacromial vessels could

be difficult for reconstruction of the upper and middle

face areas.

The skin flap prefabrication is based on neovasculari-

zation between the implanted vascular carries and the

overlying skin of donor site. Nevertheless, if the process

of neovascularization is insufficient, the risk of partial

flap necrosis will inevitably occur. In our series, the arte-

riogram studies showed that the vascularized area was la-

ger than the initial size of the transferred fascia flap.

However, it was difficult to define the exact size of the

flap that could be transferred without risk of necrosis. Ex-

perimental and clinical studies have demonstrated that

survival of the prefabricated skin flap with tissue

expansion was improved as the prefabrication period was

prolonged. Under safety consideration, a longer pre-

fabrication interval with overexpansion was recom-

mended.11,33–34 Clinically, moderate overexpansion could

modify the characters of the flap and increase the surface

area.35 In our series, overexpansion with long interval could

provide an abundant tissue to facilitate donor sites closure.

The venous congestion is another common problem

after transfer of the prefabricated skin flap. Pribaz and

Guo12 postulated that the venous congestion may be

caused by unequal neovascularization of the lower venous

pressure compared with the higher arterial pressure from

the vascular pedicles. This problem could be ameliorated

with different techniques, such as flap delay, prolonging

prefabrication interval, increasing the contact area

between the pedicle and overlyingskin, temporary leech-

ing (chemical or medicinal), avoiding flap folding, and

performing an additional venous anastomosis using a sub-

cutaneous vein in the prefabricated flap.12 In our series,

many of these maneuvers were attempted. However, var-

ied degrees of venous congestion were found in all trans-

ferred prefabricated skin flaps. The venous congestion

was found more serious in the distal area of flap. The

size of harvested prefabricated flap over the implanted

fascia vascular carrier could be the another cause of ve-

nous congestion. From our experience, we suggest that

size of prefabricate flap should be designed carefully

based on the size of implanted vascular fascia flap to

ensure the flap survival. The ratio of sizes between the

harvested prefabricated flap and implanted vascular fascia

flap needs to be further studied.

In summary, we report use of a lateral thigh fascial

flap nourished by the descending branches of the lateral

femoral circumflex vessels as the vascular carrier for the

skin flap prefabrication, based on its thinner thickness

and dense capillary network of the fascial flap. The cervi-

cothoracic skin flap prefabricated by the vascularized

fascial flap and tissue expender matches the principle of

‘‘matching, large size, and thinner thickness’’ in flap

selection, it and is reliable and versatile alternative in

reconstruction and resurfacing of massive soft tissue

defects of the face and neck. The venous congestion and

distal necrosis of the prefabricated flap are problems in

522 Li et al.


the flap transfer. Improvement of flap survival and the

ideal size of flap for transfer need to be further investi-

gated.

REFERENCES

1. Menick FJ. Facial reconstruction with local and distant tissue: Theinterface of aesthetic and reconstructive surgery. Plast Reconstr Surg1998;102:1424–1433.

2. MacLennan SE, Corcoran JF, Neale HW. Tissue expansion in headand neck burn reconstruction. Clin Plast Surg 2000;27:121–132.

3. Lamberty BG. The supra-clavicular axial patterned flap. Br J PlastSurg 1979;32:207–212.

4. Pallua N, Machens HG, Rennekampff O, Becker M, Berger A. Thefasciocutaneous supraclavicular artery island flap for releasing post-burn mentosternal contractures. Plast Reconstr Surg 1997;99:1878–1884.

5. Pallua N, Magnus Noah E. The tunneled supraclavicular island flap:An optimized technique for head and neck reconstruction. PlastReconstr Surg 2000;105:842–851.

6. Pallua N, von Heimburg D. Pre-expanded ultra-thin supraclavicularflaps for (full-) face reconstruction with reduced donor-site morbidityand without the need for microsurgery. Plast Reconstr Surg2005;115:1837–1844.

7. Vinh VQ, Ogawa R, Van Anh T, Hyakusoku H. Reconstruction ofneck scar contractures using supraclavicular flaps: Retrospectivestudy of 30 cases. Plast Reconstr Surg 2007;119:130–135.

8. Rose EH. Aesthetic restoration of the severely disfigured face inburn victims: A comprehensive strategy. Plast Reconstr Surg1995;96:1573–1585.

9. Khouri RK, Upton J, Shaw WW. Principles of flap prefabrication.Clin Plast Surg 1992;19:763–771.

10. Pribaz JJ, Fine NA. Prefabricated and prelaminated flaps for headand neck reconstruction. Clin Plast Surg 2001;28:261–272.

11. Pribaz JJ, Fine N, Orgill DP. Flap prefabrication in the head andneck: A 10-year experience. Plast Reconstr Surg 1999;103:808–820.

12. Pribaz JJ, Guo L. Flap prefabrication and prelamination in head andneck reconstruction. Semin Plast Surg 2003;17:351–362.

13. Morrison WA, Penington AJ, Kumta SK, Callan P. Clinical applica-tions and technical limitations of prefabricated flaps. Plast ReconstrSurg 1997;99:378–385.

14. Wang Wl, Cai KC, Zhong SZ, Wang WJ. Study on feasibility ofusing the descending branch of lateral circumflex femoral artery asan autograft for coronary artery bypass grafting. J Reg Anat OperSurg 2000;4:309–312.

15. Ribuffo D, Cigna E, Gargano F, Spalvieri C, Scuderi N. The inner-vated anterolateral thigh flap: Anatomical study and clinical implica-tions. Plast Reconstr Surg 2005;115:464–470.

16. Kawai K, Imanishi N, Nakajima H, Aiso S, Kakibuchi M, HosokawaK. Vascular anatomy of the anterolateral thigh flap. Plast ReconstrSurg 2004;114:1108–1117.

17. Maitz PK, Pribaz JJ, Hergrueter CA. Impact of tissue expansion onflap prefabrication: An experimental study in rabbits. Microsurgery1996;17:35–40.

18. Leighton WD, Russell RC, Feller AM, Eriksson E, Mathur A, ZookEG. Experimental pretransfer expansion of free-flap donor sites. II.Physiology, histology, and clinical correlation. Plast Reconstr Surg1988;82:76–87.

19. Shintomi Y, Ohura T. The use of muscle vascularized pedicle flaps.Plast Reconstr Surg 1982;70:725–735.

20. Khouri RK, Ozbek MR, Hruza GJ, Young VL. Facial reconstructionwith prefabricated induced expanded (PIE) supraclavicular skin flaps.Plast Reconstr Surg 1995;95:1007–1015.

21. Teot L, Cherenfant E, Otman S, Giovannini U. Prefabricated vascu-larized supraclavicular flaps for face resurfacing after postburns scar-ring. Lancet 2000;355:1695–1696.

22. Kimura N, Hasumi T, Satoh K. Prefabricated thin flap using thetransversalis fascia as a carrier. Plast Reconstr Surg 2001;108:1972–1980.

23. Erol OO, Spira M. Reconstructing the breast mound employing asecondary island omental skin flap. Plast Reconstr Surg 1990;86:510–518.

24. Yao ST. Vascular implantation into skin flap: Experimental studyand clinical application: A preliminary report. Plast Reconstr Surg1981;68:404–410.

25. Margulis A, Agam K, Icekson M, Dotan L, Yanko-Arzi R, NeumanR. The expanded supraclavicular flap, prefabricated with thoracoa-cromial vessels, for reconstruction of postburn anterior cervical con-tractures. Plast Reconstr Surg 2007;119:2072–2077.

26. Song YG, Chen GZ, Song YL. The free thigh flap: A new free flapconcept based on the septocutaneous artery. Br J Plast Surg 1984;37:149–159.

27. Shieh SJ, Chiu HY, Yu JC, Pan SC, Tsai ST, Shen CL. Free antero-lateral thigh flap for reconstruction of head and neck defects follow-ing cancer ablation. Plast Reconstr Surg 2000;105:2349–2357.

28. Koshima I. Free anterolateral thigh flap for reconstruction of headand neck defects following cancer ablation. Plast Reconstr Surg2000;105:2358–2360.

29. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have wefound an ideal soft-tissue flap? An experience with 672 anterolateralthigh flaps. Plast Reconstr Surg 2002;109:2219–2226.

30. Fabbrocini M, Fattouch K, Camporini G, DeMicheli G, Bertucci C,Cioffi P, Mercogliano D. The descending branch of lateral femoralcircumflex artery in arterial CABG: Early and midterm results. AnnThorac Surg 2003;75:1836–1841.

31. Fukuda H, Ashida M, Ishii R, Abe S, Ibukuro K. Anatomical var-iants of the lateral femoral circumflex artery: An angiographic study.Surg Radiol Anat 2005;27:260–264.

32. Kimata Y, Uchiyama K, Ebihara S, Nakatsuka T, Harii K. Anatomicvariations and technical problems of the anterolateral thigh flap: Areport of 74 cases. Plast Reconstr Surg 1998;102:1517–1523.

33. Kostakoglu N, Manek S, Green CJ. The development of neovascu-larisation in flap perfabrication with vascular implantation: Anexperimental study. Br J Plast Surg 1997;50:428–434.

34. The Hoang N, Kloeppel M, Staudenmaier R, Schweinbeck S, BiemerE. Neovascularization in prefabricated flaps using a tissue expanderand an implanted arteriovenous pedicle. Microsurgery 2005;25:213–219.

35. Di Mascio D, Castagnetti F, Mazzeo F, Caleffi E, Dominici C. Over-expansion technique in burn scar management. Burns 2006;32:490–498.



Documents

Face resurfacing using a cervicothoracic skin flap prefabricated by lateral thigh fascial flap and tissue expander