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Abstract

Study Design:

Suprafascial free flaps have become common place in reconstructive surgery units. Nomenclature related to these flaps has not been uniform throughout the scientific literature, especially in regard to planes of dissection. This study is designed as a comprehensive review of the literature.

Objectives:

Our study highlights which flaps are used most frequently, their main indications, their survival rate, and how they have evolved in the last few decades as innovations have been introduced.

Methods:

A review of the literature was performed using keywords and Medical Subject Headings search terms. PubMed, Embase, and Cochrane Library were searched using the appropriate search terms. Data collected from each study included flap type, dissection plane, preoperative planning, area of reconstruction, as well as complications, donor-site morbidity and survival rate.

Results:

Seven hundred and fifty-five studies were found based on the search criteria. After full-text screening for inclusion and exclusion criteria 34 studies were included. A total of 1332 patients were comprised in these studies. The most common types of flaps used were superficial circumflex iliac perforator flap (SCIP), anterolateral thigh flap (ALT), and radial forearm flap. The most common areas of reconstruction were head & neck and limbs. There was no significant difference in survival rates between flaps that were raised in different planes of dissection.

Conclusions:

Based on the author’s review of the literature, suprafascial flaps are reliable, they have low donor site morbidity, and there is a wide selection available for harvest. The use of new technologies for preoperative planning, such as CT-Angiography and UHF ultrasound, have contributed to have more predictable results. We propose a standardized classification for these flaps, in order to create a uniform nomenclature for future reference.

Keywords

free flaps suprafascial thin

Introduction

The plane of dissection for soft tissue free flaps has changed significantly in the last few decades. The first type of free flaps was musculocutaneous flaps,¹ which included the underlying muscle and the skin paddle above it. These were very popular but presented significant donor site morbidity and bulk. In 1981, Pontén² described the fasciocutaneous flap which consisted of cutaneous and subcutaneous tissue and the deep muscle fascia, leaving behind the muscle. These flaps were raised in the subfascial plane, such as the radial forearm flap originally described by Yang et al³ in 1981.

Perforator flaps, first described by Koshima and Soeda⁴ in 1989, are an evolution of the fasciocutaneous flaps, because they rely on the perforating vessels going through the muscle or muscle septum and into the skin and subcutaneous tissue superficially, leaving behind the muscle and sometimes deep muscle fascia. Using supermicrosurgical techniques that allow anastomosis of vessels less than 0.8 mm in diameter, these flaps could be raised without the need to dissect a long pedicle, and thus avoid trauma to the muscle.

Recently, studies carried out by Hong et al^5,6 show that a flap can be raised safely in the plane of the superficial adipose fascia that separates the superficial and deep fat lobules of the subcutaneous adipose tissue. We refer to free flaps raised in this plane as thin flaps.

As we can see, the evolution shows that soft tissue free flaps have become thinner as they are raised in a more superficial plane of dissection. This has been possible due to new technologies such a Computed Tomographic Angiography (CTA) and high-frequency ultrasound⁷ as well as a deeper knowledge in vascular anatomy such as the perforasome theory described by Saint-Cyr et al.⁸

Narushima et al⁹ proposed a classification of thin flaps based on the anatomical plane on which they are raised: thin flaps dissected in the plane of the superficial adipose fascia, super thin flaps going above the superficial fascia, full thickness skin flap or pure skin perforator (PSP) flaps that are only as thick as the dermis and its superficial plexus of vessels, and split thickness skin flaps.

The objective of this study is to do a review of the flaps raised above the deep muscle fascia and their different variations. Our goal is to identify which flaps are used most frequently, their main indications, their survival rate, and how they have evolved in the last few decades as innovations have been introduced. We also propose a standardized classification for these flaps, to create a uniform nomenclature for future reference.

Materials and Methods

Between January 2019 and September 2020, a comprehensive search and review of the PubMed, Embase and Cochrane databases was carried out. This study has been conducted in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.¹⁰ Two independent reviewers (S.R. and S.H.) screened each study for relevance, conflicting studies were reviewed by a third reviewer (M.F). The following search terms were used: “suprafascial free flap,” “thin perforator flap,” “super thin perforator flap,” “ultra thin perforator flap,” and “pure skin perforator flap.” A complete list of keywords and medical subject headings is reported (Table 1).

Table 1.

Keywords, MeSH Terms and Search Syntax Used for Screening.

Database	Search Terms
PubMed	(“suprafascial”[All Fields] OR “suprafascially”[All Fields]) AND (“free tissue flaps”[MeSH Terms] OR (“free”[All Fields] AND “tissue”[All Fields] AND “flaps”[All Fields]) OR “free tissue flaps”[All Fields] OR (“free”[All Fields] AND “flap”[All Fields]) OR “free flap”[All Fields]). “thin”[All Fields] AND (“perforator flap”[MeSH Terms] OR (“perforator”[All Fields] AND “flap”[All Fields]) OR “perforator flap”[All Fields]). (“super”[All Fields] OR “supers”[All Fields]) AND “thin”[All Fields] AND (“perforator flap”[MeSH Terms] OR (“perforator”[All Fields] AND “flap”[All Fields]) OR “perforator flap”[All Fields]). “ultra”[All Fields] AND “thin”[All Fields] AND (“perforator flap”[MeSH Terms] OR (“perforator”[All Fields] AND “flap”[All Fields]) OR “perforator flap”[All Fields]). “pure”[All Fields] AND (“skin”[MeSH Terms] OR “skin”[All Fields]) AND (“perforator flap”[MeSH Terms] OR (“perforator”[All Fields] AND “flap”[All Fields]) OR “perforator flap”[All Fields])
Embase	“suprafascial free flap” OR (suprafascial AND free AND (“flap”/exp OR flap)). “thin perforator flap” OR (thin AND perforator AND (“flap”/exp OR flap)). “super thin perforator flap” OR (super AND thin AND perforator AND (“flap”/exp OR flap)). “ultra thin perforator flap” OR ((“ultra”/exp OR ultra) AND thin AND perforator AND (“flap”/exp OR flap)). “pure skin perforator flap” OR (pure AND (“skin”/exp OR skin) AND perforator AND (“flap”/exp OR flap)).
Cochrane Library	MeSH descriptor: (suprafascial free flap): ti, ab, kw. explode all trees213. MeSH descriptor: (thin perforator flap): ti, ab, kw. explode all trees14. MeSH descriptor: (super thin perforator flap): ti, ab, kw. explode all trees622. MeSH descriptor: (ultra thin perforator flap): ti, ab, kw. explode all trees40. MeSH descriptor: (pure skin perforator flap): ti, ab, kw. explode all trees112.

The inclusion criteria were: 5 or more clinical cases, only free flaps, dissection plane above the deep muscle fascia, and accessibility through the aforementioned databases. The exclusion criteria were: secondary thinning of the flaps, cadaveric or radiological studies. Only English language articles were reviewed. Studies from the same institution with verified, identical, duplicated data were excluded.

After a thorough review of the selected articles, we identified the following variables: flap type, plane of dissection, preoperative imaging and planning, area of reconstruction, number of patients, complications, donor-site morbidity, flap survival, final outcome and conclusions. Information from the included studies was recorded using Microsoft Excel 2019.

In the variable “plane of dissection” we will use the following classification: suprafascial flap refers to the plane above the deep muscle fascia, thin flaps refers to the plane of the superficial adipose fascia, super thin for flaps dissected above the superficial adipose fascia, and pure skin perforator flaps (PSP) that are only as thick as the dermis and the subdermal vessel plexus. Institutional ethics board approval was not required for this study, as it was a retrospective review of published literature.

Results

The initial literature search provided a total of 755 articles. We removed 203 duplicates from the selection, leaving 552 articles. After a first round of title and abstract screening, we removed 313 articles which were irrelevant to our study, leaving 239 articles. In the third round of screening, we completed full-text review and removed 205 articles based on our inclusion and exclusion criteria, leaving 34 articles for our final review (Figure 1).

Figure 1.

Systematic search scheme divided by screening.

We found a total of 34 articles that describe suprafascial free flaps and met all of our criteria. These studies are summarized in Table 2. There were 1332 patients included in these studies. The articles included were published between 1996 and 2020. Of these, 79% were published in the last 10 years. There were 14 articles that described flaps raised above the deep muscle fascia (suprafascial flaps), with 9 of them comparing suprafascial vs subfascial dissection planes. In 16 articles, the authors reported series of flaps raised on the superficial adipose fascia (thin flaps), with 1 of them comparing thin vs suprafascial dissection planes. There was 1 article that described ALT flaps raised above the superficial fascia (super thin), and compared them to the suprafascial dissection plane. In 3 articles Narushima presented clinical series of flaps dissected in a subdermal plane while preserving the subdermal vessel plexus (pure skin perforator flaps).

Table 2.

Main Characteristics of the Articles Included for Review.

	Year	Authors	PMID	Flap type	Plane of dissection	Planning	Area reconstruction	# of patients	Complications	Morbidity	Survival	Outcome/Conclusions
1	2020	Wang	32591211	SIEA	THIN	CTA, Duplex	Head & Neck	7	Vein thrombosis	Low donor site morbidity, 1ª closure. Visible scar	100%	SIEA thin flap is a good option for soft tissue reconstruction of H&N
2	2020	Visconti	32718115	SCIP/ALT	THIN	HHD, Duplex	Limbs and H&N	7	N/A	No available data	100%	UHF-US is very useful for planning of thin and superthin flaps
3	2019	Ulas Bali	31663935	ALT	SUPRAFASCIAL	CTA	Limbs and H&N	19	N/A	No available data	100%	CTA predicts the suprafascial course of perforators, increases safety
4	2019	D’Arpa	31307106	DIEP	THIN	CTA	Axilla	12	Wound dehiscence	Lower because 1 flap for bilateral reconstruction	100%	Suprafascial dissection avoids 2° and 3° thinning
5	2019	Heredero	31233631	PAP	THIN	CTA, HHD	Head & Neck	10	Vasospasm	Low donor site morbidity, 1ª closure	90%	PAP flap: Suprafascial dissection and pliable skin
6	2018	Narushima	30148784	SCIP	PSP	IGA, HHD	Ear and limbs	29	Vein thrombosis	No available data	N/A	SCIP flaps has a reliable subdermal plexus and we can obtain PSP flaps from it
7	2018	Diamond	29113000	ALT	SUPER-THIN	None	Limbs and H&N	23 SPF, 12 ST	No difference	No difference between subfascial and suprafascial	98%	Subfascial dissection took longer than Suprafascial
8	2017	Fisher	29152783	ALT	SUPRAFASCIAL	None	Limbs and H&N	20 SBF, 20 SPF	Similar for both	Similar for both	N/A	Sub- and suprafascial techniques are equivalent
9	2017	Lamaris	28114212	ALT	SUPRAFASCIAL	None	Head & Neck	14	N/A	Low donor site morbidity, 1ª closure	93%	SCALP: Suprafascial increases flap pliability and reduces thickness
10	2017	Shonka	28061548	Radial	SUPRAFASCIAL	None	Head & Neck	25 SBF, 22 SPF	Similar for both	Suprafascial doesn´t increase harvest time	100%	Suprafascial dissection decreases risk of tendon exposure
11	2017	Maruccia	28990694	ALT	SUPRAFASCIAL	CTA, HHD	Limbs	34 SBF, 26 SPF	Similar for both	Lower morbidity in suprafascial	96%	Less morbidity and less 2° debulking
12	2017	Seth	28363228	ALT	THIN	HHD	Limbs	14 SPF, 11 Thin	24%	Similar for both	100%	Extremities: Suprafascial improves flap contour and pliability
13	2016	Narushima	27085610	SCIP	PSP	HHD, Duplex	Hands	6	Vein thrombosis (15%)	No available data	100%	Hands: PSP flaps avoids the need for 2ª debulking, flap thickness of 2 mm
14	2016	Schwarzer	27450896	Radial	SUPRAFASCIAL	None	Head & Neck	25 SBF, 25 SPF	Tendon exposure in sub	Similar for both	N/A	No difference in success rate or morbidity
15	2016	Chen	27152581	ALT	SUPRAFASCIAL	HHD	Head & Neck	31 SBF, 30 SPF	Similar for both	No available data	96%	Suprafascial: Fewer abnormal sensations and higher satisfaction
16	2015	Kim	26322492	TDAP	THIN	CTA, HHD	Limbs	13	Partial flap loss	Less donor site morbidity	85%	Provides good flap contour, large surface and volume when needed.
17	2015	Kim	26220431	SCIP	THIN	HHD	Limbs	52	N/A	Low donor site morbidity, 1ª closure	92%	Better flap contour and volume, no need for 2ª debulking
18	2015	Goh	25357163	SCIP	THIN	HHD	Limbs and H&N	210	Mostly in recipient site	Low donor site morbidity, 1ª closure	95%	SCIP: Reliable vascularity, thin skin flap. New “workhorse flap”
19	2014	Choi	25329846	SCIP	THIN	CTA, HHD	Head & Neck	6	N/A	No available data	100%	SCIP flap provides good contour and aesthetics for facial reconstruction
20	2014	Hong	24445881	GAP	THIN	CTA, HHD	Limbs	27	Partial flap loss	Low donor site morbidity, 1ª closure	100%	Good contour and thin flap, but short pedicle. Requires supermicro skills
21	2014	Kim	24211117	LD	THIN	CTA	Hands	7	Partial flap loss	Scar contracture	100%	LD flap is good for large, multi-digit and circumferential hand defects
22	2013	Narushima	23714796	SCIP	PSP	HHD, Duplex	Ear	9	Partial flap loss	Lower incidence of ear infection than skin grafts	88%	PSP flap allows reconstruction of EAC with minimal bulk
23	2013	Hong	23187712	SCIP	THIN	CTA, HHD	Lower limb	71	N/A	Lower incidence of lymphorrea	95%	SCIP: Avoids debulking, perforator-to-perforator anastomosis
24	2013	Hong	23038140	ALT	THIN	CTA, HHD	Limbs and H&N	54	N/A	Some donor sites required skin grafts for closure	98%	ALT can be raised safely in the superficial fascia plane
25	2012	Riva	23827444	AMT	SUPRAFASCIAL	HHD	Head & Neck	41	N/A	Good subjective perception and functional tests	95%	AMT flap is a good back up flap if the ALT fails and has low morbidity
26	2011	Avery	22079565	Radial	SUPRAFASCIAL	None	Head & Neck	30 SBF, 30 SPF	N/A	No available data	N/A	Similar sensory recovery, except for palmar light touch
27	2011	Sagalongos	21701330	Fibula	SUPRAFASCIAL	HHD	Head & Neck	18 SPF, 9 SBF	N/A	Low donor site morbidity, no alteration to ankle	N/A	Less morbidity and better contour outcome
28	2007	Dabernig	17825774	Scapular	THIN	HHD	Limbs	5	N/A	Low donor site morbidity, 1ª closure	100%	Scapular flap: High quality, hairless skin paddle, with chimeric options.
29	2007	Avery	17537558	Radial	SUPRAFASCIAL	None	Head & Neck	121	Skin graft, Tendon exposure	Less morbidity with suprafascial dissection	97%	Radial flap is reliable, and suprafascial dissection has less morbidity
30	2006	Avery	16061309	Radial	SUPRAFASCIAL	None	Head & Neck	20 SBF, 20 SPF	N/A	No available data	N/A	No difference in sensory recovery
31	2006	Kimura	16525296	Groin/SCIP	THIN	HHD	Limbs	11	28%	Minimum donor site morbidity	100%	Thin groin flap (future SCIP) provides thin, pliable skin with a long pedicle.
32	2001	Kim	11214052	LD	THIN	HHD	Limbs	12	N/A	Low donor site morbidity, 1ª closure	100%	Thin LD flap has constant thickness, vascular supply, and low morbidity
33	1999	Lutz	9915173	Radial	SUPRAFASCIAL	None	Head & Neck	95	N/A	Complete skin graft is better	96%	Less morbidity and higher take of skin grafts, avoids 2ª complications
34	1996	Chang	9016457	Radial	SUPRAFASCIAL	None	Head & Neck	49	N/A	Less tendon exposure, better sensory recovery	N/A	Less donor site morbidity in suprafascial dissection

Abbreviations: SIEA, superficial inferior epigastric artery perforator flap; ALT, anterolateral thigh flap; AMT, anteromedial thigh flap; PAP, profunda artery perforator flap; DIEP, deep inferior epigastric perforators flap; SCIP, superficial circumflex iliac perforator flap; TDAP, thoracodorsal artery perforator flap; GAP, gluteal artery perforator flap; LD, latissimus dorsi flap; UHF-US, ultra-high frequency ultrasound; HHD, hand-held acoustic Doppler; Duplex, color Doppler ultrasound; CTA, CT angiography; MRA, magnetic resonance angiography; IGA, indocyanine green angiography; SPF, suprafascial; SBF, subfascial; ST, super thin; N/A, no available data. Radial refers to the radial forearm flap. Scapular refers to the thin circumflex scapular artery perforator flap. Fibula refers to the free fibula flap.

^aprimary closure.

With regard to nomenclature, we found that the authors used different terms to describe the plane of dissection and the types of flap. If we consider Narushima’s classification of thin flaps, 94% of authors used this terminology. Those that did not use this nomenclature referred to thin flaps as super thin flaps.^11,12

There were 12 different types of flaps used in the articles reviewed. The frequency of the flaps that were used was as follows: superficial circumflex iliac perforator flap (SCIP) 8 articles (398 total patients), anterolateral thigh flap (ALT) 7 articles (309 total patients), radial forearm flap 7 articles (462 total patients), latissimus dorsi (LD) 2 articles (19 patients in total). The following had 1 article per flap type: scapular, fibula, superficial inferior epigastric artery perforator flap (SIEA), thoracodorsal artery perforator flap (TDAP), deep inferior epigastric perforator flap (DIEP), profunda artery femoris flap (PAP), gluteal artery perforator flap (GAP), anteromedial thigh flap (AMT).

A summary of indications and outcomes grouped by the different flap types is provided in Table 3. These indications and outcomes are solely based on the articles included in this review, and do not include the full range of indications for the flaps listed.

Table 3.

Indications and Outcomes Grouped by the Different Flap Types (Based on the Articles Included in This Review).

Flap type	Indications	Outcomes
ALT	Head and Neck Limbs (especially lower limb)	97.27% survival. Good option for soft tissue reconstruction, long pedicle (10-12 cm), customizable thickness.
AMT	Head and Neck, Limbs	95% survival. AMT flap is a good back up flap if the ALT fails.
DIEP	Axilla, Breasts	100% survival. Provides a large-surface flap which can be split to reconstruct multiple sites.
Fibula	Head and Neck Mandible reconstruction	Suprafascial dissection provides lower donor site morbidity and better wound contour.
GAP	Limbs (especially lower limb)	100% survival. Good contour and thin flap, but short pedicle. Requires supermicrosurgical skills.
LD	Limbs (especially upper limb and hands)	100% survival. LD is good for large circumferential defects; it has a constant thickness and vascular supply.
PAP	Head and Neck (especially tongue)	90% survival. Thin and pliable flap, with customizable thickness.
Radial	Head and Neck	Lower donor site morbidity with suprafascial dissection. 97.67% survival. Thin and pliable flap with long pedicle.
Scapular	Limbs	100% survival. Hairless skin paddle, with chimeric options (muscle and bone).
SCIP	Head and Neck Limbs	96.25% survival. Reliable vascularity, thin, pliable skin with a long pedicle. Provides lymph nodes to improve lymphatic drainage.
SIEA	Head and Neck	100% survival. Good option for soft tissue reconstruction of H&N.
TDAP	Limbs	85% survival. Provide good flap contour and large surface.

Abbreviations: ALT, anterolateral thigh flap; AMT, anteromedial thigh flap; DIEP, deep inferior epigastric perforators flap; GAP, gluteal artery perforator flap; LD, latissimus dorsi flap; PAP, profunda artery perforator flap; SCIP, superficial circumflex iliac perforator flap; SIEA, superficial inferior epigastric artery perforator flap; TDAP, thoracodorsal artery perforator flap. Fibula refers to the free fibula flap. Radial refers to the radial forearm flap. Scapular refers to the thin circumflex scapular artery perforator flap.

The most common area of reconstruction was head and neck (21 articles, 748 patients), followed by limbs (14 articles, 610 patients). Other areas of reconstruction included hands (2 articles, 13 patients) and axilla (1 article, 12 patients). The number of patients included ranged from 5 to 210 patients, with an average of 43 of patients per study.

Preoperative imaging planning to find dominant perforators was done in 67% of articles. The most common method of imaging was the hand-held acoustic Doppler (9 articles, 444 patients), followed by CT-Angiography (3 articles, 38 patients) or a combination of both (7 articles, 248 patients). Other forms of preoperative planning included ultra-high frequency ultrasound (UHF-US) (4 articles, 29 patients) and indocyanine green angiography (1 article, 29 patients). No preoperative planning was done with radial forearm flaps.

The complication rate was generally underreported, with many articles not making any mention of them (only 50% of studies made direct reports of complications). In general, they included partial flap loss (6%), wound dehiscence (8%), vein thrombosis (9%), seroma (2%) and tendon exposure in radial flaps (up to 20% in subfascial dissection). However, most authors did mention that the rate of complications was similar for both suprafascial and subfascial flaps (mentioned in 5 out of the 9 articles that made the comparison).

The donor site morbidity of the flaps was low in all cases, and allowed for primary closure in 85% of cases (except in radial flap). Most articles that reported donor site morbidity showed that it was similar in subfascial and suprafascial dissections (12 out of 34 articles). Suprafascial dissection showed less morbidity over the subfascial dissection in ALT flaps.¹³ In radial flaps, suprafascial dissection has shown to decrease tendon exposure and improved healing of skin grafts.^14

–17 Fibula flaps dissected in the suprafascial plane have also shown lower donor site morbidity and better wound contour.¹⁸ Thin flaps (dissected in the superficial adipose fascia) have also shown to improve donor site aesthetics due to a more uniform wound contour and higher primary closure rate.⁶

All free flaps had survival rates of more than 85%. The flaps that presented the best survival rates based on more than 50 patients in the study were radial forearm (97.67%, 263 patients), ALT (97.29%, 258 patients), and superficial circumflex iliac perforator (SCIP) flap (96.25%, 369 patients). The following list shows the rest of the survival rate average based on the flap type: gluteal artery perforator (GAP) flap (100%, 27 patients), latissimus dorsi flap (100%, 19 patients), deep inferior epigastric artery perforator (DIEP) flap (100%, 12 patients), superficial inferior epigastric artery (SIEA) perforator flap (100%, 7 patients), scapular flap (100%, 5 patients), profunda artery perforator (PAP) flap (90%, 10 patients), anteromedial thigh (AMT) flap (95%, 41 patients), and thoracodorsal artery perforator (TDAP) flap (85%, 13 patients).

There was no significant difference in survival between flaps that were raised in different planes of dissection. Suprafascial flaps had a 96.14% survival rate, based on 498 flaps that were included. Thin flaps had a 96.78% survival rate, based on 529 flaps that were included. Super thin flaps had a 98% survival rate, based on 12 flaps that were included. PSP flaps had a 99% survival rate, based on 15 flaps. Using a one-way ANOVA test no significant statistical differences were found between these survival rates (P = 0.16).

Discussion

In this study we conducted a thorough review of the literature in regard to suprafascial free flaps. We presented the most useful techniques available for reconstruction that require thin, pliable and customizable flaps, and only included articles with clinical cases and significant caseloads, in order to show the reader feasible and reliable practices.

When looking at the chronological order and evolution, we see that initially soft tissue free flaps were dissected in a subfascial plane, therefore, when surgeons required a thin flap the one that was used the most was the radial forearm flap. Next there was a progressive surge in the use of perforator flaps, following studies carried out by Wei et al^19,20 describing a perforator-based ALT flap. Following this there have been different types of perforator flaps described, and the trend has been to leave behind the fasciocutaneous flaps for cutaneous perforator flaps in an ever-thinner plane of dissection. In our study we see that in the first 10 years radial flaps were primarily being used, then SCIP flaps, and in the last 10 years mostly ALT. Almost 80% of the articles included were published in the last decade,^{21

–36} indicating that this a very contemporary subject in reconstructive surgery (Figure 2).

Figure 2.

Chronological evolution of included studies.

In regard to the nomenclature, some authors used the term suprafascial indistinctively when mentioning the deep and superficial fascia. Also, some referred to thin flaps as super thin.^11,12 This was noted in the 34 articles that we reviewed in depth, but there was a lack of consensus in regard to the definition of these terms in the scientific literature. For this reason, we believe that adopting a common classification is necessary and we propose to use the following classification: Subfascial = below the deep muscle fascia, Suprafascial = above the deep muscle fascia but below the superficial adipose fascia, Thin flaps = dissected on the plane of the superficial adipose fascia, Super thin flaps = dissected above the superficial adipose fascia, Pure skin perforator (PSP) flaps = include only the skin and subdermal plexus vessels (Figure 3).

Figure 3.

Dissection planes and nomenclature of flaps.

According to the literature, the main areas of reconstruction were head and neck, and limbs. This is because these areas normally require thin and pliable flaps, with long pedicles for anastomosis. For example, even though the radial forearm flap is the most commonly used flap for tongue reconstruction after hemiglosectomy, flaps like the PAP or ALT flap are preferable alternatives that provide thin and pliable tissue when they are dissected as thin flaps. Heredero et al³⁷ demonstrated that these thin flaps can be obtained even in obese patients when dissected above the superficial adipose fascia.

Most of the reviewed series of flaps dissected above the deep or the superficial fascia include preoperative imaging planning. Studies carried out by Heredero et al³⁷ with CT-angiography and Visconti et al^7,38 using ultra-high frequency ultrasound (UHF-US) allow us to map out the patterns of the perforating vessels in the suprafascial plane preoperatively. When we combine this knowledge with hand-held acoustic Doppler and/or duplex ultrasound, we have high confidence in the anatomical disposition of the vessels in our flaps. This improves flap survival and shortens operating time.^7,37,38 It also allows us to have thinner flaps, which are more suitable for extremity or head and neck reconstruction, and have lower donor site morbidity. These flaps combined with super-microsurgical techniques,³⁹ which allow us to anastomose ever smaller vessels (in general under 0.8 mm in diameter), improve our reconstructive options and lead to better outcomes.

Donor site morbidity has been improved with the advent of suprafascial flaps. Our series of articles show that donor site morbidity in suprafascial dissection is either similar or better than subfascial dissection, with no authors reporting inferior results. Suprafascial flaps also provide better wound contour and aesthetics,^6,18,40,41 decrease the risk of tendon exposure and improve the healing of skin grafts in the radial forearm flap donor site,^15,42 as well as allowing for a higher rate of primary closure in the ALT flap donor site.⁶

One of the key aspects that has allowed for thin flaps to become mainstream today, is that the flap survival is independent to the plane of dissection. Studies carried out by Hong and Chung⁶ and Narushima et al⁴³ showed that if the vascular network of vessels is preserved, we can dissect extremely thin flaps. These authors also described 3 key areas which are critical to flap survival and must be carefully manipulated, which are the subdermal plexus, the perforating vessels that go through the deep muscle fascia, and the microsurgical anastomosis. Some flaps require customized design to see the perforating vessel patterns, and this is where new technologies have had an important role.^{7,37,38,43,44}

Conclusions

Suprafascial free flaps are becoming the new workhorse for surgeons as their variety and reliability have improved. We have seen that these flaps are just as reliable as subfascial flaps, they have less donor site morbidity, and there is a wide selection available for harvest. The use of new technologies for preoperative planning, such as CT-Angiography and UH-F ultrasound, have contributed to have more predictable results and they are becoming common techniques for surgeons harvesting these flaps. We propose a standardized classification for these flaps, in order to create a uniform nomenclature for future reference.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

María Isabel Falguera-Uceda, MD

Susana Heredero, MD, PhD

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Suprafascial Free Flaps: Classification and Comprehensive Review of the Literature

Abstract

Study Design:

Objectives:

Methods:

Results:

Conclusions:

Keywords

Introduction

Materials and Methods

Results

Discussion

Conclusions

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iDs

References