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초록
Purpose:
In a random fasciocutaneous flap, deep fascia was thought to play an essential role. However, studies have reported that the superficial fascial plane could be elevated safely in fasciocutaneous flaps. We studied a porcine model to evaluate whether a random fasciocutaneous flap could be elevated by the superficial fascial plane in a hemodynamically safe manner.
Methods:
A total of sixteen 3×9 cm proximal-based dorsal flank fasciocutaneous flaps were elevated by different planes: above the superficial fascial plane, below the superficial fascial plane and below the deep fascial plane. Distal flap necrosis and microangiography of each flap and histologic examination were evaluated.
Results:
Distal flap necrosis was not significantly different among the various elevated planes. Microangiography showed that the suprafascial plexus of the superficial fascia was the most frequent dominant blood supply in a random fasciocutaneous flap. Biopsy also showed that the dominant vessels were located in the suprafascial layer of the superficial fascia.
Conclusion:
The suprafascial plexus of the superficial fascia was the most frequently dominant blood supply in a random fasciocutaneous flap regardless of flap elevation plane. Therefore, the superficial fascia plane could be elevated safely in random fasciocutaneous flaps. In addition, even if without superficial fascia, fasciocutaneous flap can be elevated safely with inclusion of suprafascial plexus of the superficial fascia and this plane could be used as a flap debulking plane.
REFERENCES
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Fig.1.
(A) A total of eight 3×9 cm proximally based dorsal flank random fasciocutaneous flaps were made on the back of each Micropig® (Medikinetics, Korea). 1-cm full-thickness skin and soft tissue defects around the flap margins to prevent the vascular inosculation from adjacent normal skin. (B) Flap locations on the back of Micropigs® (Medikinetics, Korea). The flap elevation planes were selected by random pattern. BS: below superficial fascial plane, AS: above superficial fascial plane, D: deep fascial plane.
Fig.2.
(A) Skin and subcutaneous layers of Micropig® (Medikinetics, Korea). Superficial fascia (black arrow) was dominant and it divided the superficial and deep fat layers. Deep fascia (red arrow) lay just above the muscle. (B) The flap was elevated just above the superficial fascia. (C) The flap was elevated below the superficial fascia. (D) The flap was elevated below the deep fascia. AS: above superficial fascial plane, BS: below superficial fascial plane, D: deep fascial plane.
Fig.3.
Placement of silicone sheet under the flap to prevent plasma imbibition and vascular inosculation from flap beds.
Fig.5.
Full-thickness biopsy was performed at the distal demarcated zone, middle transition zone, and proximal normal skin zone to determine the correlation between arterial organization and skin and soft tissue layers.
Fig.6.
(A) Distal flap ischemia on postoperative day 1. Left side back of Micropig® (Medikinetics, Korea). Group D showed the largest ischemic area. The ischemic areas were not correlated with flap elevation planes (arrow). (B) Distal flap necrosis on postoperative day 4. Parts of ischemic areas changed to normal skin color, and the necrotic area demarcation became more defined. BS: below superficial fascial plane, D: deep fascial plane, AS: above superficial fascial plane.
Fig.7.
Results of microangiography. The suprafascial plexus of the superficial fascia (white arrow) was the most frequently dominant arterial plexus in random fasciocutaneousflaps. (A, B) The suprafascial plexus of the superficial fascia was the most dominant arterial plexus and it communicated with subdermal plexus (black arrow). (C, D) The suprafascial plexus of the superficial fascia was the most dominant arterial plexus and it communicated with other arterial plexuses. (E, F) The suprafascial plexus of the superficial fascia was the most dominant arterial plexus. Black arrowhead indicates the superficial fat and white arrowhead indicates the deep fat. AS: above superficial fascial plane, BS: below superficial fascial plane, D: deep fascial plane.
Fig.8.
Histologic findings. Large artery (asterisk) was noted above the superficial fascia layer (hematoxylin and eosin stain, ×25).
Table1.
Measurement of distal flap ischemic areas at postoperative day 1, according to flap elevation planes
| Variable | L1∗ | L2 | L3 | L4† | R1∗ | R2 | R3 | R4† |
|---|---|---|---|---|---|---|---|---|
| Pig A | ||||||||
| Group | BS | AS | BS | AS | BS | D | AS | D |
| Distal ischemia (cm2) | 0.9 | 1.1 | 0.9 | 2.0 | 1.5 | 0.8 | 1.9 | 0.9 |
| Pig B | ||||||||
| Group | BS | D | AS | AS | D | D | BS | AS |
| Distal ischemia (cm2) | 0.8 | 4.1 | 2.9 | 1.2 | 3.0 | 1.9 | 0.9 | 1.4 |
Table2.
Measurement of distal flap necrosis areas at postoperative day 4, according to flap elevation planes
| Variable | L1* | L2 | L3 | L4† | R1* | R2 | R3 | R4† |
|---|---|---|---|---|---|---|---|---|
| Pig A | ||||||||
| Group | BS | AS | BS | AS | BS | D | AS | D |
| Distal necrosis (cm2) | 0.5 | 0.9 | 0.7 | 1.4 | 1.2 | 0.4 | 1.6 | 0.5 |
| Pig B | ||||||||
| Group | BS | D | AS | AS | D | D | BS | AS |
| Distal necrosis (cm2) | 0.5 | 3.2 | 2.7 | 0.7 | 2.8 | 1.6 | 0.5 | 1.0 |
Table3.
Distribution of dominant arterial plexus according to flap elevation plane
| Group | AS | BS | D |
|---|---|---|---|
| Subdermal plexus | 1 | 1 | |
| Subcutaneous plexus (superficial fat) | 2 | ||
| Suprafascial plexus (superficial fascia) | 5 | 2 | 4 |
| Superficial fascia plexus | |||
| Subfascial plexus (superficial fascia) | |||
| Subcutaneous plexus (deep fat) | N/A∗ | N/A∗ | 1 |
| Suprafascial plexus (deep fascia) | N/A∗ | N/A∗ | |
| Deep fascia plexus | N/A∗ | N/A∗ | |
| Subfacial plexus (deep fascia) | N/A∗ | N/A∗ | |
| Total | 6 | 5 | 5 |
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