INVITED COMMENTARY

INVITED COMMENTARY I would like “fasciocutaneous” to be more emphasized in The author has arrived at results which could be all the flap terminology, as it is the basis of my success- termed as inconclusive. In time the principles touched on ful flaps. If they are trilaminate (skin, fat and fascia), it is here are not unlike many of my ideas. Reconstructive better for difficult lower limb reconstruction with fewer techniques using these principles should be adopted in complications. We do not have to hark back to the old time. I make an earnest plea to strive for universal days of cross leg flaps (with skin and fat), when some of acceptance of the same terminology. Dr. Dave them fell off and others went black. If they had a fascial McCombe’s comments are appropriate, eg. peri neural substrate in those cross leg flaps, or in any other flap in tissue may be inadequate for flap survival except in the the lower limb, maintaining vascular support by perfora- distal tip of digit. Yet any neuro vascular island flap tors from any muscular access, then such flaps worked. I without any major visualised vascular supports must repeat, if the flaps are designed as islands, the umbrella have peri venular and peri arteriolar/adventitial vascular of tissue forces a perfusion up and down in a vertical di- supply. This has been the basis of many of my successful rection. The moat effect created by dividing around the flaps in which the nerve is definitely visualised without cutaneous limit not only has a satisfying result from the strikingly obvious vascular support. For example the point of view of sensation (as it tends to be pain-free), it following are all part of a series: also prevents any venous stasis from the subdermal plex- 1. Sural nerve, neuro vascular island flap, calcaneal us, which, as we know, is the most common cause of flap repair. necrosis. 2. Saphenous nerve, neuro vascular island flap for ankle The next point is that I do design these flaps along joint cover. dermatomic precincts. With embryonic buds, the nerves 3. The anterior tibial nerve for neuro vascular flap and the vessels (spiraling or otherwise) should be going closure for compound metatarsal defects of the foot. in a longitudinal plane. “Adiponeurovenous” sounds bur- Each flap illustrates these principles. densome; “neurocutaneous” is certainly the same as F. Behan ( ) “neurovascular” island. Yet “fasciocutaneous” (FCIF), if Royal Parade, 3052 Parkville, it is a trilaminate, is better and embraces all concepts. Victoria, Australia AUTHOR’S REPLY According to Dr Behan, the concept of the fasciocutane- er than that of flaps in the study of Noreldin et al. (1.5× ous flap, if it is trilaminate, embraces all flaps. In clinical 2.5 cm). As stated by Xiu and Chen [2], the survival rate use, a flap based on the loose areolar tissue around the su- of these flaps is decreased with the increase of flap size, perficial nerve and vein has at least two longitudinal vas- but is better when the flaps are small. Thirdly, both partial cular plexuses, the perineural vascular plexus and the and complete survival was recorded as complete survival perivenous vascular plexus. Such flaps are usually elevat- in the study of Noreldin et al. In our study, we measured ed as island flaps. The deep fascia may be taken with the viable flap surface area and determined the percentage these flaps, to raise them more safely. A layer of the deep viability of the flap. Our study is therefore not comparable fascia on both sides of the thin vascular pedicle may be with that of Noreldin et al. cut and included in the pedicle. In our opinion, a strip of Despite the controversy over the pedicle of these flaps the deep fascia does not play a dominant role in the via- and the terminology, they appear to provide a simple bility of such flaps, if several longitudinal plexuses exist. means of supplying good quality coverage for small or It prevents undue tension being put on the flap, thus mini- medium sized skin defects. mizing traction injury to very small vessels in the pedicle. An island flap, including the deep fascia, should not be automatically classified as a fasciocutaneous flap. References In the study of Noreldin et al. [1], the survival rate of 1. Noreldin AA, Fukuta K, Jackson IT (1992) Role of perivenous venous flaps which included perivenous areolar tissue was areolar tissue in the viability of venous flaps: An experimental 90%. In our study, the maximum mean survival rate was study on the inferior epigastric venous flap of the rat. Br J Plast 6%. As stated by Dr McCoombe, these two studies show Surg 45: 18–22 wide variations in flap survival. Some factors appear to 2. Xiu ZF, Chen ZJ (1996) The effect of glutathione, superoxide dismutase and adenosine triphosphate on venous flap survival. contribute to the lower survival rate of our experimental Eur J Plast Surg 19: 170 model. Firstly, flaps in our animal model were designed somewhat differently from those elevated by Noreldin et A. Karacalar ( ) Department of Plastic and Reconstructive Surgery, al. In that study, the flaps were elevated between the groin Division of Hand Surgery, and abdomen. In our animal model, flaps were centered Medical Faculty of Uludag University, on the inguinal region, lateral to the ipsilateral nipple line. Bursa, Turkey Secondly, the flap size in our study (3.5×3.5 cm) was larg- Tel.: +224-442-8400, Fax: +224-442-8079 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Plastic Surgery Springer Journals

INVITED COMMENTARY

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Publisher
Springer Journals
Copyright
Copyright © 2000 by Springer-Verlag Berlin Heidelberg
Subject
Medicine & Public Health; Plastic Surgery
ISSN
0930-343X
eISSN
1435-0130
D.O.I.
10.1007/PL00020991
Publisher site
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Abstract

I would like “fasciocutaneous” to be more emphasized in The author has arrived at results which could be all the flap terminology, as it is the basis of my success- termed as inconclusive. In time the principles touched on ful flaps. If they are trilaminate (skin, fat and fascia), it is here are not unlike many of my ideas. Reconstructive better for difficult lower limb reconstruction with fewer techniques using these principles should be adopted in complications. We do not have to hark back to the old time. I make an earnest plea to strive for universal days of cross leg flaps (with skin and fat), when some of acceptance of the same terminology. Dr. Dave them fell off and others went black. If they had a fascial McCombe’s comments are appropriate, eg. peri neural substrate in those cross leg flaps, or in any other flap in tissue may be inadequate for flap survival except in the the lower limb, maintaining vascular support by perfora- distal tip of digit. Yet any neuro vascular island flap tors from any muscular access, then such flaps worked. I without any major visualised vascular supports must repeat, if the flaps are designed as islands, the umbrella have peri venular and peri arteriolar/adventitial vascular of tissue forces a perfusion up and down in a vertical di- supply. This has been the basis of many of my successful rection. The moat effect created by dividing around the flaps in which the nerve is definitely visualised without cutaneous limit not only has a satisfying result from the strikingly obvious vascular support. For example the point of view of sensation (as it tends to be pain-free), it following are all part of a series: also prevents any venous stasis from the subdermal plex- 1. Sural nerve, neuro vascular island flap, calcaneal us, which, as we know, is the most common cause of flap repair. necrosis. 2. Saphenous nerve, neuro vascular island flap for ankle The next point is that I do design these flaps along joint cover. dermatomic precincts. With embryonic buds, the nerves 3. The anterior tibial nerve for neuro vascular flap and the vessels (spiraling or otherwise) should be going closure for compound metatarsal defects of the foot. in a longitudinal plane. “Adiponeurovenous” sounds bur- Each flap illustrates these principles. densome; “neurocutaneous” is certainly the same as F. Behan ( ) “neurovascular” island. Yet “fasciocutaneous” (FCIF), if Royal Parade, 3052 Parkville, it is a trilaminate, is better and embraces all concepts. Victoria, Australia AUTHOR’S REPLY According to Dr Behan, the concept of the fasciocutane- er than that of flaps in the study of Noreldin et al. (1.5× ous flap, if it is trilaminate, embraces all flaps. In clinical 2.5 cm). As stated by Xiu and Chen [2], the survival rate use, a flap based on the loose areolar tissue around the su- of these flaps is decreased with the increase of flap size, perficial nerve and vein has at least two longitudinal vas- but is better when the flaps are small. Thirdly, both partial cular plexuses, the perineural vascular plexus and the and complete survival was recorded as complete survival perivenous vascular plexus. Such flaps are usually elevat- in the study of Noreldin et al. In our study, we measured ed as island flaps. The deep fascia may be taken with the viable flap surface area and determined the percentage these flaps, to raise them more safely. A layer of the deep viability of the flap. Our study is therefore not comparable fascia on both sides of the thin vascular pedicle may be with that of Noreldin et al. cut and included in the pedicle. In our opinion, a strip of Despite the controversy over the pedicle of these flaps the deep fascia does not play a dominant role in the via- and the terminology, they appear to provide a simple bility of such flaps, if several longitudinal plexuses exist. means of supplying good quality coverage for small or It prevents undue tension being put on the flap, thus mini- medium sized skin defects. mizing traction injury to very small vessels in the pedicle. An island flap, including the deep fascia, should not be automatically classified as a fasciocutaneous flap. References In the study of Noreldin et al. [1], the survival rate of 1. Noreldin AA, Fukuta K, Jackson IT (1992) Role of perivenous venous flaps which included perivenous areolar tissue was areolar tissue in the viability of venous flaps: An experimental 90%. In our study, the maximum mean survival rate was study on the inferior epigastric venous flap of the rat. Br J Plast 6%. As stated by Dr McCoombe, these two studies show Surg 45: 18–22 wide variations in flap survival. Some factors appear to 2. Xiu ZF, Chen ZJ (1996) The effect of glutathione, superoxide dismutase and adenosine triphosphate on venous flap survival. contribute to the lower survival rate of our experimental Eur J Plast Surg 19: 170 model. Firstly, flaps in our animal model were designed somewhat differently from those elevated by Noreldin et A. Karacalar ( ) Department of Plastic and Reconstructive Surgery, al. In that study, the flaps were elevated between the groin Division of Hand Surgery, and abdomen. In our animal model, flaps were centered Medical Faculty of Uludag University, on the inguinal region, lateral to the ipsilateral nipple line. Bursa, Turkey Secondly, the flap size in our study (3.5×3.5 cm) was larg- Tel.: +224-442-8400, Fax: +224-442-8079

Journal

European Journal of Plastic SurgerySpringer Journals

Published: Jul 17, 2000

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