Letters to the Editor

Link pattern adipofascial flap

Sir. We have read the article ” Experience with the Adipofascial Turn-over Flap” by Sarhadi and Quaba’ with great interest. The authors state the various uses of random pattern turn- over adipofascial flaps in extremity coverage and propose that the length: width ratio of the flap should be restricted to no more than 2: I

It is true that adipofascial flaps, as well as fascial and fascia-subcutaneous flaps, are all derived from fascio- cutaneous flaps. They have the same blood supply from the

Fig. 1

Figure 1 -A 70.year-old man suffered a crush injury of his left foot over the dorsum. The wound becalne Infected. After debridement, the defect measured X x 5 cm wth exposure of denuded tendons.

Fig. 2

Figure 2 Elevation ofdisraily hased adlpolilxial flap. Ii x 5 cm in si/e. wth a pedicle wdth of4 cm Length:width ratio ~5 3.3: I.

Fig. 3

Figure 3 Turn-over transposltlon of the flap. The donor site M;I?I closed directly. and the flap wab covered with a full-thickness skin graft from the abdomen.

Fig. 4

Figure 4. Appearance three months pohtoperativrl>

attachment base. through which septal perforating vessels pass between adjacent muscle bellies. fan out at both surfaces of the deep fascia. form two vascular plexuses (i.r.. the minor subfascial plexus and the rich suprafascial plexus). and finally contribute to subcutaneous plexus and nourish the overlying skin. It is possible to design proximally or distally based fascia-pedicled flaps because blood could run ortho- gradely or retrogradely along the plexus freely.

We have successfully transferred distally based island fasciocutaneous flaps. turn-over fascial flaps and adipo- fascial Haps from forearm and lovver Icg to reconstruct the hand and foot.’ ’ The greatest length:width ratio ot‘ our cases was 5.1 : I. with an average of 3.5: I. Here we present

Letters to the EJditol l-13

Lmother apphcatmn of the distally based adipofascial flap, from the anterior lower leg to cover the dorsum of the foot. which me ha\c not found in the literature (Figs I-4). This Ilap receiT,es blood supply through retrograde flow by the distal septo-fl~~ciocutaneous perforating vessels of the an- terior tibia1 artery f hat enter the flap at its distal base and a knou n confluence of proximal severed perforators. Cormack .md Lambert!” proposed that if the long axis of a fascio- cutaneous Rap lies in the same direction as the predominant direction 01‘ the fascial vascular plexus, it could survive to a greater length for a giLten width because blood could run ;I long distance along the plexus. Therefore. in this sense. it is not truly random pattern blood supply. The term “link pattern ” may gi\,e a clear description about its \,ascular- isation since the flap’s territory is in fact made up of a series of interlinking anatomlcal territories of individual perfor- ators which arc aligned one after another to form a chain of vessels along the length of the flap. As our clinical appli- cations demonstrated in the extremities. the link pattern adipofascial flap can survive to a length:width ratio of 3-5 : I. much greater than random pattern flaps.

L’ourz faithfully.

Shi-Min (‘hang, MD, Lian-Sheng Zhang, MD, Department of Orthopaedics. Fifty-Fifth Hospital. Shanghai 2OO~W. China.

References

I Sarhaclr NS. Quaba ,44. Experience with the adipofascial turn-

o\er Rap Hr J Plast Surg 1993; 46: 307- 17.

7 Chang SM. The distally based radial forearm fwx Ilap. Plant

Reconstr Surg 1990: X5: 13% I. 3 Chang SM. (‘hen ZW. Distally hased radial forearm I’kcial flap

without radial .Irtsry. Chinese Journal of Microsurger) 1990:

1.3: I-l3 i

1. C‘hang SM. (~‘hen ZW Anatonxal studies on the blood supply

LJ!’ re:\crwd mdial forearm Island fawocutaneous flap.

Ctunccc Journal of Clinical Anatomq 1990: 8 : 136 X 5. (‘hng SM. Lhang LS. Han PL. Chen DS. Distally based

forr.lrm turn-over fasclo-subcutaneous-fat flap for coverage 01‘ wt’t tls\ue defects of the hand Chinese Journal of Hand

Surkrrr\ 1993: 9: X2-1. . . h (‘~wnack GC. Lambert! BGH. A classiticat~on 01 fascio-

cutancou\ Ilaps according to thclr patterns of v~~sculari\atioli.

Br J Plant Surg 19X-I: 37’ X0 7.

Neurocutaneous axial island flaps

Sir.

I read with gruat Interest the article ” Neurocutaneous axial Island Ilap\ in the forearm: anatomical, experimental and preliminary climcal results”.’ I would like to comment on home points:

First. although the author attributed the clinical survival of the so called neurocutaneous island flap of the forearm to the arterial blood supply from the intra and perineural \exsels. Figures 3 and I3 in this article reveal that the flap wah actually transferred on a wide subcutaneous pedicle including the lateral cutaneous nerve and cephalic vein. Thatte and Thatte” in 1987 showed that an even bigger skin Hap from thiz region can survive completely as a venous flap based on the cephalic \ein. I would ask Dr Bertelli whether the flaps in hi> study would not have survived ifthe cutaneous nerve \b;:> not included in the vascular pediclr. In ml

opinion, this manoeuvre would result in an insensitive but

still viable flap. and Dr Bertelli’s neurocutaneous island flap is simply an innervated single pedicle venous flap.

Second. in the experimental part of this stud\. Dr Bertclli. using a new rat model. reported that island skin tlaps based on the lateral and medial cutaneous nerves can survive well. Not only are the flaps used in this study too small. i.‘,. IO x IO and I5 x 40 mm respectively, but also the lack of ;I control group makes it possible to raise the question whether these small flaps could survive as skin grafts.

Lastly. I would emphasise that the origInal idea and these mltlal efforts of Dr Bertelli’s. starting a new and interesting controversy. arc to be appreciated : however. the particular role of the neural vasculature in the survival of skin flaps is

still quite undefined. and further study is necessary.

Yours faithfully.

Mehmet Mutaf. .MD, Department of Plastic and Reconstructive Surgery. Nagasaki University, School of Medicine. 7-1 Sakamoto-machl. Nagasaki City. X51 Japan.

References

I Bertelh JA Neurocutaneous axial island Haps In the forearm: anatomical. experimental and prelitmnar! clinlc;ll rcsuI1s. HI

J Plast Surg 1993. 46: 4X9%96.

2 Thatte RI. Thatte MR. Cephalic \enou\ tl;~p HI. I Plast Surg

Reply to Dr Mutaf

Sir. I read with interest the criticisms ot‘Dr Mehmet Mutaf about my article entitled ‘* Neurocutaneous axial island tlaps In the forearm : anatomical. experimental and preliminary clinical results”.’

In our anatomical dissections an arterial \ asa nervorum which connected the cutaneous perforators \\as clearly identified. This vasa nervorum also vascularlsetl the \eins’ walls. Therefore. we strongly believe that the clinical and experimental flaps were supplied with arterial blood.

Recently we have performed experiments in rabbits to demonstrate that the arterial supply was necessary for the flap survival. Forty epigastric flaps were dissected based on the femoral vessels and were transposed to the contralateral inguinal region. Four groups of rabbits were constituted. In group 1. the flap femoral vein was anaatomoxed to the contralateral femoral vein and the flap femoral artery to the contralateral femoral artery (c,onc~c,rlfioncllfrrr /liir). In group ‘. only the femoral vein was anastomosed to the contralateral femoral vein (fi-c,r IWWXY,&J). In group 3. only the femoral vein was anastomosed to the contralateral femoral artery (trrtrricllisetf w~wI~.~ ,fl~p). Finally. in group 4. the flaps were transposed to the contralateral side without any anastomosis (.Y/G grclfi). ,411 anastomoses were performed end-to-end. using conventional microsurgical techniques. Flaps were then controlled for 10 days by inspection and histological studies. They were considered viable when the nscrotic. area was less than 2 “~0 of the total flap area.

All conventional free flaps survived. All free 1 cnoub flaps

underwent total necrosis, as did all skin grafts. Kghty percent of the arterialised venous flaps sur.r.l\ed. These results were statistically significant (P <’ 0.01 1.