Prefabrication and Prelamination


Introduction

Flap prefabrication and prelamination are distinct techniques designed to address complex reconstructive needs. While these techniques are generally not primary reconstructive options, their usage has increased in response to demands for more sophisticated reconstructive efforts. In reconstructive surgery, a delicate balance exists between the availability of matching donor tissue and the complexity of the recipient defect. Prefabrication and prelamination techniques have been applied to areas where a special surface, contour, or structure is desired and reconstructive goals cannot be met by conventional means. Areas of the body where prefabrication ( Fig. 5.1 ) and prelamination have played a role in reconstruction include facial subunits, facial cartilage, facial skeleton, oropharynx/esophagus, and the penis ( Tables 5.1–5.5 ). This chapter focuses on problems of the head and neck region, where aesthetic, structural, and functional needs are complex and demanding, with scarce reconstructive options.

Figure 5.1, Flap prefabrication technique.

Table 5.1
Clinical applications of prefabrication and prelamination: Facial soft tissue subunits
Defect Technique Flap location Technique description References
Lips
  • (a)

    Superficial (hair-bearing) lip loss

  • (b)

    Full-thickness upper lip loss

  • (c)

    Upper and lower lip (mouth) loss

Direct axial flap
Prefabrication
Prelamination
Prelamination
Scalp/submental scalp
Submental forearm
Staged transfer of hair-bearing flap from scalp/submental
Vascular pedicle implant + secondary transfer
Tissue expander + skin graft on underside of submental platysma flap
Subfascial skin grafts in radial forearm flap
Hyakusoku et al.
Pribaz and Guo
Pribaz and Fine
Costa et al.
Baudet
Cheek
  • (a)

    Partial thickness (e.g., burn)

  • (b)

    Full thickness

Direct axial flap
Prefabrication
Prelamination
Submental neck/upper chest or distant forearm Submental island flap to cheek
Implant vascular pedicle beneath skin and over a tissue expander with secondary transfer
Subfascial skin graft over a tissue expander in radial forearm territory, or
subfascial mucosal graft and silicone sheeting in radial forearm territory (± nerve)
Martin et al.
Faltaous et al.
Kim
Khouri et al.
Pribaz et al.
Pribaz et al.
Rath et al.
Rath et al.
Neck
Burn contracture Prefabrication Thigh forearm upper chest Implantation of pedicle subcutaneously placed over a tissue expander and subsequently transferred to neck Khouri et al.
Pribaz et al.

Table 5.2
Clinical applications of prefabrication and prelamination: Facial soft tissue with cartilage
Defect Technique Flap location Technique description References
Nose
  • (a)

    Partial or full-thickness loss

  • (b)

    Total

Existing laminated flap
Prelamination
Prelamination
Ear
Forehead
Forearm
Ascending helical free flap based on superficial temporal artery
Skin graft for lining and cartilage for support in paramedian forehead flap
Skin graft for lining and cartilage for support in radial forearm flap
Pribaz and Falco
Gilles
Pribaz et al.
Costa et al.
Baudet
Ear
Absent ear Prelamination Forearm Carved costal cartilage graft or silicone framework covered with radial forearm fascia and skin graft with secondary transfer to ear Costa et al.
Baudet
Hirase et al.
Trachea/Larynx
  • (a)

    Tracheal defect/stenosis

  • (b)

    Hemilarynx defect

Prelamination
Prefabrication
Radial forearm
Radial forearm fascia
Mucosa or ear cartilage prelaminated onto antebrachial fascia for tracheal defects
Free radial forearm fascial flap wrapped around upper trachea, which is subsequently moved for hemilarynx reconstruction
Vranckx et al.
Delaere et al.

Table 5.3
Clinical applications of prefabrication and prelamination: Facial skeleton
Defect Technique Flap location Technique description References
Maxilla
  • (a)

    Partial – premaxilla

  • (b)

    Extensive defect

Existing laminated flap
Prelamination
Second toe proximal phalanx
Scapular or fibula
Osteointegrated implants placed into proximal phalanx with composite flap based on dorsalis pedis artery and transferred to premaxilla
Prelaminate scapular bone or fibula dermal graft + wrap with silicone sheeting ± osteointegrated implants
Pribaz and Guo
Holle et al.
Rohner et al.
Mandible
Segmental or total loss Prelamination Scapular Cancellous bone in carrier tray placed in scapular flap territory + secondary transfer to mandible Orringer et al.

Table 5.4
Clinical applications of prefabrication and prelamination: Oropharynx and esophagus
Defect Technique Flap location Technique description References
Intraoral
Mucosa-lined soft tissue loss Prelamination Forearm Mucosal grafts placed over radial forearm and later transferred for intraoral reconstruction Rath et al.
Carls et al.
Chiarini et al.
Esophagus
  • (a)

    Cervical esophagus

  • (b)

    Entire esophagus

Prelamination
Prelamination
Radial forearm
Tensor fascia lata (TFL)
Skin surface of the radial forearm flap is rolled into a lumen during first stage to allow healing of suture line; during second stage 2 weeks later, microvascular transfer is completed
Longer defect requires TFL flap with skin lumen prelaminated the same way
Chen et al.

Table 5.5
Clinical applications of prefabrication and prelamination: Penis
Defect Technique Flap location Technique description References
Penis
Absence secondary to tumor or trauma Prelamination Lateral arm radial forearm fibula Prelamination with skin tube for neo-urethra reconstruction with subsequent transfer of osteocutaneous flap when using fibula Young et al.
Capelouto et al.

They terms flap “prefabrication” and “prelamination” are two distinctive entities in reconstructive surgery. Flap prefabrication , first introduced by Shen in 1982, describes a two-stage process: the introduction of a vascular pedicle into a body of tissue that bears desired characteristics of the area to be reconstructed, followed by a transfer of this neovascularized tissue into the defect based on its implanted vascular pedicle. Flap prelamination , a term coined by Pribaz and Fine in 1994, also refers to a two-stage process, whereby one or more tissues are engrafted into a reliable vascular bed to create a composite flap. This flap is subsequently transferred on its original vascular supply, en bloc , for reconstruction. A clear understanding of these two techniques is helpful in choosing the appropriate method to deal with a specific clinical problem and also for scientific communication.

Flap Prefabrication

Concept

The first step in planning a reconstruction is to delineate the specific needs. It is desirable to use flaps that provide a good color match and restore surface and contour. Regarding head and neck reconstruction, in particular, the recipient site may require further specialized flaps, such as hair-bearing or mucus-producing flaps, for optimal reconstruction. Although there may be local flap options with the desired characteristics, these may not have a reliable axial blood supply on which they can be transferred. The technique of flap prefabrication provides this by implanting an axial blood supply into the donor tissue, rendering that tissue transferable once neovascularization has occurred.

Technique

A vascular pedicle includes at least an artery and its venae comitantes, surrounded by an adventitial cuff. It may be available locally or, if not, imported as a small free flap and implanted beneath the intended donor tissue. The distal end of the pedicle is ligated. To prevent scarring around the base of the pedicle and to facilitate secondary harvest of the prefabricated flap, a short segment of Gore-Tex (polytetrafluoroethylene) tubing or thin silicone sheeting can be placed around the pedicle up to the undersurface of the tissue that the new pedicle is expected to support ( Fig. 5.1 ). A nonadhesive sheeting may be placed under the implanted pedicle, away from the proposed flap, not only to facilitate secondary elevation of the flap but also to shunt the direction of neovascularization from the pedicle toward the flap to be prefabricated. A tissue expander is frequently used in this capacity. In experimental animal models, a neural island flap can also be prefabricated. In this model, a peripheral nerve can be placed under subcutaneous tissue and the intrinsic vasculature of the nerve can supply the flap following a delay period.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here