Fasciocutaneous Flap Surgery
Fasciocutaneous flaps are tissue flaps, which consist of skin and underlying tissues including fascia (a collagen-rich lining tissue). Fasciocutaneous flaps are used to provide coverage to bones and tendons in surgery when skin graft coverage is insufficient.
Advantages of using fasciocutaneous flaps over other flaps:
- Fasciocutaneous flaps are less bulky so they are used for most of the surgery.
- There is no functional loss with fasciocutaneous flaps, unlike muscle flaps.
- They are quick and reliable in healthy patients.
- It is easy to design and construct large fasciocutaneous flaps that are safe due to good circulation.
- The operating time is relatively short with an experienced surgeon, and no extra equipment is needed.
Fasciocutaneous flaps enable revision for orthopedic procedures and limit the need for secondary skin grafting. Fasciocutaneous flaps are preferred in reconstructing areas in which the skin or mucosa at the wound is thin; for example, the lower leg, dorsum of the hand, nasal lining, and oropharynx.
Similar to muscle flaps, fasciocutaneous flaps provide large blocks of tissue for defect reconstruction without the need for the prior delay but are limited by the arc of rotation of the vascular pedicle, unless transferred as a free flap. They are not recommended in case of a deep cavity where muscle flap has an indication.
Complications of fasciocutaneous flaps include:
- Numbness on the site where the flaps are placed
- Infections
- Complete or partial paralysis
The design of the flap depends on the location of the tissue defect and the donor site. It is necessary to anticipate the location of the pivot point and the required length of the flap pedicle. The flap surface should generally be larger than the tissue defect to avoid tension and necrosis of the distal end of the flap.
The incision is carried right through the skin, subcutaneous tissue, and fascia. The dissection of the subfascial plane to the muscle is more accessible than a dissection of the suprafascial planes, which should be protected to avoid damage of the perforating vessels running to the skin. It is not necessary to identify the perforating vessels to raise the flap. The retrograde dissection is done according to the length needed from the pedicle.
The skin surrounding the defect is excised, and tile edges of the wound undermined. The fasciocutaneous flap is then rotated or placed into position, and the fascia is sutured beneath the undermined skin. Only a few tacking sutures are needed to keep the flap in place: fine sutures are used to coapt the skin edges. When rotating huge flaps, a “dog’s ear” is unavoidable and should be left for correction later. The secondary defect can be covered immediately with a split skin graft. However, the surface is usually irregular, and it’s preferable to wait for granulation tissue. The area is bandaged with moderate pressure, and if possible, the distal part of the flap is left open for inspection. If bleeding is troublesome continuous suction drainage can be used for 24 hours or more.
An interprofessional team of an operative provider and an assistant nurse should perform the surgery. Follow up with a provider and a nurse experienced in wound management should be done to identify and minimize possible complications.
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