British Journal of Plastic Surgery (1982) 35, 430435 (i$ 1982 The Trustees of British Association of Plastic Surgeons

0007-1226/82/0401-0430 $02.00

Fasciocutaneous flaps in the axillary region DAVID E. TOLHURST and BAREND HAESEKER

Plastic Surgery Department, University Hospital Dgkzigt, Rotterdam, The Netherlands

Summary-Fifteen fasciocutaneous flaps with a base to length ratio of I:3 or more have remained totally viable and were successfully used to correct axillary contractures. The blood supply of the deep fascia is described and the advantages of fasciocutaneous flaps are discussed.

When Ponten (1981) first communicated his remarkably useful discovery to the members of the British Association of Plastic Surgeons that it is possible to transpose flaps, without delay, in the lower leg, providing the deep fascia is in- cluded in the flap, we hastened to try the idea on a variety of recalcitrant lower leg defects. To many these flaps are already known as “super flaps” which was the name that Ponten’s assistants bestowed upon them because of their excellent qualities. Our small series of nine fasciocutaneous flaps in the lower leg confirmed Ponttn’s work and in all cases of skin loss in the leg where bone, joints or tendons are exposed, we now first consider the possibility of using a FCF to close the wound.

Although myocutaneous flaps and muscle flaps have proved very satisfactory for the closure of a variety of difficult defects, especially in the lower limbs, the new fasciocutaneous flaps possess the attraction of being less bulky, easier to dissect and there is no question of their compromising function when used in the lower limb. Further success with fasciocutaneous flaps raised on the trunk encouraged us to design large flaps over- lying the latissimus dorsi muscle to correct con- tractures of the axilla.

Axillary contractures

Burns around the axillary region frequently lead to contractures which may require release and correction (Fig. 1A). The time-honoured tech- nique is to insert a split-skin graft in the defect once maximum abduction of the shoulder joint has been achieved. A “tie-over” bolus, a bulky dressing and a plaster of Paris splint are applied. There is usually a good take of the graft, as part at least is laid directly on muscle. But unless the arm is kept in abduction for three months with a cumbersome splint some degree of recurrence of

the contracture is inevitable and a repeat pro- cedure is often required.

If the graft does not take a prolonged and frustrating period ensues. Not only is the shoul- der joint difficult and uncomfortable to im- mobilise, but the granulating area in the axilla can prove, like areas in the back, exasperatingly resistant to further skin-grafts.

A reliable flap transposed from the adjacent area of the back or anterior thorax to the axillary defect should overcome these draw- backs. The size and position of the defect is such that most local transposition flaps will exceed the traditional safety ratio of 1:l for a random- pattern flap: indeed to release a contracture beyond the anterior axillary fold will require a flap ratio of 1:3 or more. A latissimus dorsi flap would satisfy the requirements but besides being too bulky is a somewhat drastic solution. A fasciocutaneous flap appeared to be eminently suitable and has proved an unqualified success in all 15 patients.

Technique

After release of the axillary contracture the defect is measured and a suitable flap is designed with its base situated superiorly (Fig. 1B) and transposed to lie in the axillary defect (Fig. 1C). There need be no fear of raising a flap with a ratio of 1: 3 or more. The deep fascia overlying the latissimus is included in the flap and upon dissecting it free from the muscle one can see a rich vascular network on the under side of the fascia. Extensive undermining is needed to close the donor defect primarily if it is more than 8 cm in width. As there are often other skin grafts and scars in the vicinity, a split-skin graft to close the donor defect is an acceptable and safe procedure especially as the graft is placed on muscle.

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FASCIOCUTANEOUS FLAPS IN THE AXILLA .RY REGION

D

Fig. 1A. Pre-operative view of a post-bum axillary contracture. B. View of the defect following release of the axillary contracture and dissection of a fasciocutaneous flap. C. Flap transposed. D. Post-operative view of the final result.

432 BRITISH JOURNAL OF PLASTIC SURGERY

A bulky dressing and a plaster splint is applied for concern and healed perfectly. In another and five days later the graft and flap are in- patient half of the width of the flap throughout spected. The plaster is discarded, a light dressing its entire length was composed of grafted skin applied and the patient is encouraged to move (Fig. 3A). This flap also healed without com- the shoulder joint (Fig. ID). plications and gave an excellent result (Fig. 3B).

Discussion

Occasionally we have found it desirable to design a flap on the antero-lateral aspect of the chest including part of the deep fascia covering the serratus anterior muscle.

On the back the presence of grafted skin bordering on or overlapping the site from which the transposition flap is to be taken is no contra- indication to the use of a fasciocutaneous flap. In our first encounter with this problem we included a skin grafted area which comprised about 10% of the total area of the flap (Fig. 2) and about 50% of its base. The entire flap gave no cause

Fig 2 A small area of grafted skin has been included in the base of this fasciocutaneous flap.

Long ago surgeons including Gillies and Esser (1918) suggested that it might be advantageous to include the deep fascia in what we now recognise as random-pattern flaps and John Cobbett for many years taught the wisdom of including the deep fascia as a routine in cross-leg flaps. But PontCn clearly deserves the credit for discovering the value of the fasciocutaneous flap: as Darwin said, “in science the credit belong to the man who convinces the world, not to the man to whom the idea occurs”.

The blood supply of the deep fascia

Text books of anatomy pay little or no attention to the vascular characteristics of the deep fascia and we have examined the relationship of the fascia and its vessels to the tissues both deep and superficial to it.

Our initial investigations were carried out on cadaver legs. These were perfused with saline for one to two hours through the popliteal vessels followed by injection of a solution of micropaque to demonstrate the vascular tree of the deep fascia. The results were most unsatisfactory as there was very little filling of the small vessels. Our anatomical colleagues pointed out that perfusion should be continued for several days to remove clots effectively and this was not possible for obvious reasons. Haertsch (1981) suggested diluting the micropaque solution with turpentine to make the perfusion of small vessels more effective. We were able to obtain a good picture of the vascular tree in the deep fascia when the iliac vessels were cannulated in anaesthetised pigs and injected with pure micropaque (Fig. 4).

In fact it is often possible to examine the superficial surface of the deep fascia. in humans during surgical operations, just as it is possible to inspect the under surface of a fasciocutaneous flap when it is raised at operation. If one looks carefully, vascular networks are visible on both sides of the fascia both in humans and pigs and, in the latter, these networks fill well when the limb is perfused with micropaque. This ob- servation is at variance with the views of Haertsch (1981) who stated that the deep plexus was only occasionally present.

FASCIOCUTANEOUS FLAPS IN THE AXILLARY REGION 433

A B

Fig. 3A. Half of this fasciocutaneous flap consists of tissue from a previously grafted area. B. The flap well healed with no complications.

All this is of little help in explaining why the deep fascial plexus can support an overlying skin flap. One can only postulate that such is the richness of the circulation in the fascia, that it can readily support tissues lying superficial to it, as long as the base of the fascial flap remains intact. To test this hypothesis two identical fasciocutaneous flaps (with a length : width ratio of 4:l) were raised in the hind limbs of pigs. The base of the fascia was divided on one side before giving an intravenous injection of fluorescein. Ultraviolet illumination of the flaps showed fluorescence in the intact flap for 90% of its length but in the “divided” flap for no more than 25% of its length. This observation con- firms the very important role of the fascia in the viability of a fasciocutaneous flap.

Schafer (1975) examined the blood supply of the human leg and his findings, though more detailed, correspond with our observations. He

showed that the deep fascia is supplied by three major arterial systems (Fig. 5):

(0

(ii)

(iii)

Perforating arteries These vessels leave the muscle, perforate the fascia (Fig. 6) and provide radiating branches which anastomose with the super- ficial plexus. Schafer called these “cutaneous arteries” but nowadays the term perforating arteries has become popular. Subcutaneous arteries Where there are few perforating arteries, the subcutaneous arteries turn deeply from the superficial fascia (fat) and run in various directions, anastomosing freely with each other and the superficial network. Subfascial arteries These vessels are derived from the inter- muscular septa and run in the loose areolar tissue beneath the deep fascia where they join

434 BRITISH JOURNAL OF PLASTIC SURGERY

Fig. 4 Vascular tree in a fasciocutaneous flap following perfusion of a pig’s leg with micropaque.

Fig. 6 Dissection to show perforating arteries leaving the muscle and perforating the deep fascia.

the network on the deep surface of the fascia. This plexus also anastomoses with the superficial plexus via the fascia. According to Schafer there is uniform perfusion of these networks and a rich collateral circulation which explains why interruption of one branch or system has little effect on the overall circulation in the fascia and the tissues it largely supports.

_. :...

Fig. 5 Arterial blood supply of the deep fascia 0 Q 0.

Although these systems were described in the leg there is no reason why they should not be present elsewhere. The plexuses are clearly visible on the fascia of the trunk as are the perforating vessels. The mapping of the blood vessels

FASCIOCUTANEOUS FLAPS IN THE AXILLARY REGION 435

supplying the deep fascia all over the body would The Authors take a lifetime but as long as fasciocutaneous flaps remain reliable and safe there seems little David E. Tohrst, MB, FRCS, Plastic Surgeon, University

. . Hospital Dijkzigt, Rotterdam. one’s CurlosltY~ to Bard Haeseker. MD. Assistant Plastic Surneon. Universitv need, apart from satisfying

embark upon such a labour. Hospital Dijkzigt. Rotterdam. Y

References

E&r, J. S. F. (1918). Schwerer Verschluss einer Brust- wandperforation. Berliner Klinische Wochenschrzfi, 55, 1197.

Haertsch, P. (1981). The surgical plane in the leg. British Journal of Plastic Surgery, 34, 464.

Haertsch, P. (1981). The blood supply to the skin of the leg: a post-mortem investigation. British Journal of Plastic Surgery, 34, 470.

Pot&n, B. (1981). The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Brifish Journal of Plastic Surgery, 34, 215.

Schifer, K. (1975). Das subcutane Gefissystem (untere Extremitlt) Mikropraparatorische Untersuchungen. Requests for reprints to: D. E. Tolhurst, MB, FRCS, Plastic Gegenbaurs Morphologisches Juhrbuch (Leipzig), 121, 4, Surgery Department, University Hospital Dijkzigt, Rotterdam. 492. Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.