Prefabrication and Prelamination
Prefabrication and Prelamination
Prefabrication and Prelamination
5 Prefabrication and
Prelamination
Indranil Sinha | Lifei Guo | Julian J. Pribaz
Muscle TE • Neovascularization
of skin and capsule
around tissue
Deep vascular pedicle expander
16
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CHAPTER 5 — Prefabrication and Prelamination 17
Table 5.1 Clinical applications of prefabrication and prelamination: Facial soft tissue subunits
Lips
(a) Superficial (hair- Direct axial Scalp/submental Staged transfer of hair-bearing flap from Hyakusoku et al.1
bearing) lip loss flap scalp scalp/submental Pribaz and Guo2
(b) Full-thickness upper Prefabrication Submental Vascular pedicle implant + secondary Pribaz and Fine3
lip loss Prelamination forearm transfer Costa et al.4
(c) Upper and lower lip Prelamination Tissue expander + skin graft on Baudet5
(mouth) loss underside of submental platysma flap
Subfascial skin grafts in radial forearm
flap
Cheek
(a) Partial thickness Direct axial Submental neck/ Submental island flap to cheek Martin et al.6
(e.g., burn) flap upper chest or Implant vascular pedicle beneath skin Faltaous et al.7
(b) Full thickness Prefabrication distant forearm and over a tissue expander with Kim8
Prelamination secondary transfer Khouri et al.9
Subfascial skin graft over a tissue Pribaz et al.10
expander in radial forearm territory, or Pribaz et al.3,11
subfascial mucosal graft and silicone Rath et al.12
sheeting in radial forearm territory Rath et al.13
(± nerve)
Neck
Burn contracture Prefabrication Thigh forearm Implantation of pedicle subcutaneously Khouri et al.9
upper chest placed over a tissue expander and Pribaz et al.10
subsequently transferred to neck
Table 5.2 Clinical applications of prefabrication and prelamination: Facial soft tissue with cartilage
Nose
(a) Partial or Existing Ear Ascending helical free flap based on Pribaz and Falco14
full-thickness laminated flap Forehead superficial temporal artery Gilles15
loss Prelamination Forearm Skin graft for lining and cartilage for support Pribaz et al.11
(b) Total Prelamination in paramedian forehead flap Costa et al.4
Skin graft for lining and cartilage for support Baudet5
in radial forearm flap
Ear
Absent ear Prelamination Forearm Carved costal cartilage graft or silicone Costa et al.4
framework covered with radial forearm Baudet5
fascia and skin graft with secondary Hirase et al.16
transfer to ear
Trachea/Larynx
(a) Tracheal defect/ Prelamination Radial forearm Mucosa or ear cartilage prelaminated onto Vranckx et al.17
stenosis Prefabrication Radial forearm antebrachial fascia for tracheal defects Delaere et al.18
(b) Hemilarynx fascia Free radial forearm fascial flap wrapped
defect around upper trachea, which is
subsequently moved for hemilarynx
reconstruction
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18 PART 1 — PRINCIPLES
Maxilla
(a) Partial Existing Second toe Osteointegrated implants placed into proximal Pribaz and Guo2
– premaxilla laminated proximal phalanx with composite flap based on dorsalis Holle et al.19
(b) Extensive flap phalanx pedis artery and transferred to premaxilla Rohner et al.20
defect Prelamination Scapular or fibula Prelaminate scapular bone or fibula dermal graft +
wrap with silicone sheeting ± osteointegrated
implants
Mandible
Segmental or Prelamination Scapular Cancellous bone in carrier tray placed in scapular Orringer et al.21
total loss flap territory + secondary transfer to mandible
Table 5.4 Clinical applications of prefabrication and prelamination: Oropharynx and esophagus
Intraoral
Mucosa-lined Prelamination Forearm Mucosal grafts placed over radial forearm and later Rath et al.12
soft tissue loss transferred for intraoral reconstruction Carls et al.22
Chiarini et al.23
Esophagus
(a) Cervical Prelamination Radial forearm Skin surface of the radial forearm flap is rolled into a Chen et al.24
esophagus Prelamination Tensor fascia lumen during first stage to allow healing of suture
(b) Entire lata (TFL) line; during second stage 2 weeks later,
esophagus microvascular transfer is completed
Longer defect requires TFL flap with skin lumen
prelaminated the same way
Penis
Absence secondary Prelamination Lateral arm radial Prelamination with skin tube for neo-urethra Young et al.25
to tumor or trauma forearm fibula reconstruction with subsequent transfer of Capelouto et al.26
osteocutaneous flap when using fibula
TECHNIQUE
FLAP PREFABRICATION
A vascular pedicle includes at least an artery and its venae
comitantes, surrounded by an adventitial cuff. It may be
CONCEPT
available locally or, if not, imported as a small free flap and
The first step in planning a reconstruction is to delineate implanted beneath the intended donor tissue. The distal
the specific needs. It is desirable to use flaps that provide end of the pedicle is ligated. To prevent scarring around the
a good color match and restore surface and contour. base of the pedicle and to facilitate secondary harvest of the
Regarding head and neck reconstruction, in particular, prefabricated flap, a short segment of Gore-Tex (polytetra-
the recipient site may require further specialized flaps, fluoroethylene) tubing or thin silicone sheeting can be
such as hair-bearing or mucus-producing flaps, for optimal placed around the pedicle up to the undersurface of the
reconstruction.29 Although there may be local flap options tissue that the new pedicle is expected to support (Fig. 5.1).
with the desired characteristics, these may not have a reli- A nonadhesive sheeting may be placed under the implanted
able axial blood supply on which they can be transferred. pedicle, away from the proposed flap, not only to facilitate
The technique of flap prefabrication provides this by secondary elevation of the flap but also to shunt the direc-
implanting an axial blood supply into the donor tissue, tion of neovascularization from the pedicle toward the flap
rendering that tissue transferable once neovascularization to be prefabricated. A tissue expander is frequently used
has occurred. in this capacity. In experimental animal models, a neural
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CHAPTER 5 — Prefabrication and Prelamination 19
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20 PART 1 — PRINCIPLES
A B C
D E
Figure 5.3 (A) Frontal view of a young patient with a history of a right facial arteriovenous malformation, presenting with facial contour defor-
mity following an embolization of her lesion and reconstruction subsequent facial tissue necrosis. Furthermore, there was thrombosis of multiple
external carotid branches. (A) The patient continued to have significant facial contour deformity and tethering of right oral commissure following
debridement and radial forearm free flap reconstruction. (B,C) Design of flap to be prefabricated in the submental region, with descending
branch of the lateral femoral circumflex vascular pedicle transferred into the area and anastomosed with the external carotid; Gore-Tex tubing
was applied to the proximal pedicle (visible in C). The transferred pedicle was placed over a tissue expander. (D) Early postoperative result
following prefabricated flap transfer. A left facial artery musculomucosal (FAMM) flap was utilized for upper lip reconstruction. (E) Result 6
months later, after two thinning and refinement procedures.
to the burn injury. For cheek and mustache reconstruction, different layers into an axial vascular territory, allowing time
a distant radial forearm fascial flap along with its pedicle is for the tissues to mature before being transferred. During
anastomosed into the external carotid and jugular systems stage 2 the laminated layers are transferred to the defect as
and inserted over a tissue expander beneath a hairy postau- a composite structure based on the original axial blood
ricular region of the scalp. This newly axialized hair-bearing supply. As with any composite graft, these added layers have
flap is transposed 8 weeks later to reconstruct the patient’s to be sufficiently thin or small for them to take. The ratio-
mustache and beard area. nale for prelaminating those layers at a different site prior
Possibilities with flap prefabrication are endless and many to transfer rests on the belief that this offers the best chance
combinations of transplanted vascular pedicles, donor for the prelaminating layers to heal, stabilize, and assume
tissues, and geographic locations have been described for their expected structures and positions if the construction
various clinical needs. This technique is especially powerful is done in a reliable vascular bed at a less conspicuous
in reconstructing specialized tissues, such as hair-bearing site versus in situ, where local complicating factors can
areas and nerves (in cases of vascularized nerve grafts),39 be numerous. This is particularly important for reconstruc-
where conventional approaches are often inadequate. tion of functional units that need to be transferred
to complex local environments, where loss of structural
integrity may precipitate grave complications, for example,
neo-urethra in the perineum and neo-esophagus in the
FLAP PRELAMINATION
mediastinum.
CONCEPT
TECHNIQUE
The word “lamination” means bonding together of thin
sheets. In reconstructive surgery, the term flap prelamination Aside from skin, the added graft materials may be as diverse
describes a two-stage process. The first stage involves adding as cartilage, bone, mucus-producing membrane,40 nerve
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CHAPTER 5 — Prefabrication and Prelamination 21
A B
C D
E F
Figure 5.4 (A) A young woman with extensive burn scars in the neck, neck resurfacing
and contracture release. (B,C) Given the lack of donor sites, as well as the need for relatively
large amounts of skin, a template was designed in the patient’s lower abdomen. Bilateral
deep inferior epigastric vessels were harvested and placed subcutaneously, overlying a
tissue expander. Gore-Tex tubing was again applied to the base of the pedicle. (D) Appear-
ance of prefabricated lower abdominal flaps following expansion. (E) A large, pliable cuta-
neous flap was harvested and maintained complete vascularity on a single pedicle. (F)
Following neck contracture release, there was a significant portion of the neck that required
G resurfacing. (G) The 6-month postoperative outcome following prefabricated flap inset.
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22 PART 1 — PRINCIPLES
C
A B
E F G
H I J
Figure 5.5 (A) A 59-year-old man with extensive burn scars in the forehead, right orbit, upper and lower lips, reconstructed with a split-
thickness skin graft at the time of injury, wanted to have facial resurfacing and reconstruction of the mustache and beard to match the opposite
side. (B) A template illustrated the area to be reconstructed, hatched area designating mustache and beard skin with required hair. (C) Scapular
flap design and orientation for reconstruction of the forehead and right orbit. (D) Radial forearm fascial flap for flap prefabrication for the lips
and cheek. (E) Scapular free flap inset for the forehead and orbit defect, vascularized radial forearm fascia flap tunneled beneath the scalp and
laid over a tissue expander. (F) At 8 weeks later, the prefabricated flap was ready for transfer and additional scar revision on the right cheek
planned. (G) Intraoperative dissection of the prefabricated flap raised based on its implanted pedicles. (H) Early postoperative and (I,J) 9 months
later, the prefabricated flap has good hair growth.
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CHAPTER 5 — Prefabrication and Prelamination 23
graft,13 cultured keratinocyte sheet,41 or bioengineered the flap is healed, the patient may have dental implants
tissues.42 Tissue expansion again can play an important role placed in the transferred bone.
in many cases of flap prelamination, especially when a large If a flap is prelaminated within the head and neck
surface is desired, for example, during reconstruction of region, it takes only a pedicled transfer to inset the com-
mucosal intraoral linings. posite flap. Local prelamination may involve the forehead
skin flap based on the supratrochlear or supraorbital
vessels, the TPF based on the superficial temporal vessels,
FLAP MATURATION or the submental skin flap based on branches of the facial
Because the blood supply is not manipulated, the time artery. Advantages of prelaminating in the head and neck
required for a prelaminated flap to mature is shorter than include no need for microanastomosis during the second
for a prefabricated flap3 – usually 3–4 weeks. stage of the procedure and a good match of skin color
and contour. A significant disadvantage is that the prepara-
tion stage may be socially awkward with obvious deformi-
FLAP TRANSFER ties present. However, if a suitable donor site is available
Since the layering of structures takes place in an established locally, it is clearly the best option. An example of local
vascular territory, venous congestion is usually not the tissue prelamination without the need for microanastomo-
problem in a prelaminated flap that it can be in a prefabri- sis is illustrated in Figure 5.8, where a forehead flap is
cated flap. However, all flaps, including prelaminated flaps, raised for nasal reconstruction, bilateral submental flaps
become edematous after transfer and exhibit increased scar- are prelaminated with full-thickness skin grafts for intra-
ring at each healing interface. In attempting to reconstruct oral lining, and an Abbé flap is used to reconstruct the
complex 3-dimensional structures, the multiple layers with upper lip.
scarring and contractile forces at each interface can result Traditionally, prelaminated flaps are used to reconstruct
in distortion and loss of contour of the flap. Because of this, central facial defects11 and other anatomies that have a sig-
the initial result is often suboptimal and, in general, revision nificant degree of 3-dimensional structure, such as the penis
operations are necessary. and esophagus. Extensive defects that are not amenable to
local flaps often require multiple layers reconstructed to
provide framework, lining, and tissue bulk for future refine-
ments. The goal of flap prelamination is not to provide a
CLINICAL EXAMPLES
one-step solution; it simply delivers the tissue support and
The forearm remains a preferred site for non-bony flap bulk to the area to render further reconstructive revisions
prelamination because of easy accessibility, patient conve- possible.
nience, and the availability of a reliable but dispensable
vascular pedicle (usually radial or occasionally the ulnar
system, which has the benefit of being less hairy). Other sites
include the subscapular and fibular regions, where local CONCLUSION
bony structures can be readily incorporated into the pre
laminated flap for mandibular, maxillary, or even penile Flap prefabrication and prelamination offer sophisticated
reconstruction. approaches to difficult reconstructive needs that conven-
Distant prelamination, while it necessitates microvascular tional methods cannot meet. Tables 5.1–5.5 provide a com-
transfer and generally lacks good color match, does have prehensive overview of the clinical applications of these two
the appeal of being inconspicuous and being able to utilize techniques. The two techniques are distinctively different
local resource as needed (bone, cartilage, and other special- and yet can be perfectly complementary. Prelamination can
ized tissues). Furthermore, there is more freedom in flap add virtually anything to where there is a good axial blood
reach with a flexible pedicle. While the decision to choose supply and prefabrication can bring an axial blood supply
a site for flap prelamination takes into account all these to almost anywhere in the body. The two techniques can
factors, the foremost questions are always: What is needed? even be combined when certain complex reconstructive
What is available? Figure 5.6 shows a patient who needs a needs exist.
total nasal reconstruction after an arteriovenous malforma- Prefabrication and prelamination can also serve as a
tion resection. A flap is prelaminated in his forearm in the conduit through which products of tissue engineering and
ulnar artery distribution with a skin graft as for lining before embryonic stem cell technologies can be applied to the
being transferred en bloc to the nasal and cheek defect. By reconstruction of head and neck defects. Tissues synthe-
maintaining local options, further refinement of the nasal sized in vitro with better structural, color, texture, and
reconstruction can be performed by utilizing cartilage grafts functional match can be prelaminated to a site that
for reconstruction of the defect and a forehead flap for has already been prefabricated. Prefabrication of a bio
resurfacing. absorbable matrix system can create a well-perfused scaffold
In Figure 5.7, a patient presents with a large segment to which more and larger subunits can be prelaminated. As
of anterior maxilla missing. Reconstruction is planned with our understanding of the techniques evolves, the breadth
a scapular free flap. The flap is prelaminated by the addi- of their usage will also expand. Difficult problems that used
tion of a bone graft to mimic bony contour or the anterior to baffle the very best reconstructive surgeons may no
maxilla and a dermal graft. The construct is then covered longer seem so impossible and patients’ expectations may
in a silicone membrane and allowed to heal. Approximately also rise to a new level. This represents the beginning of a
4 weeks later, the flap is ready for transfer and inset. Once new era in reconstructive surgery.
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24 PART 1 — PRINCIPLES
A B
C D
E F
Figure 5.6 (A,B) A young woman with extensive defects of her nose, secondary following resection of an arteriovenous malformation. (C,D)
Reconstruction of the resultant defect was planned with a tailored radial forearm free flap that had been prelaminated with a skin graft of its
undersurface for mucosal lining. (E) Immediate postoperative outcome, as well as (F) postoperative outcome following cartilage grafting and
forehead flap for resurfacing.
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CHAPTER 5 — Prefabrication and Prelamination 25
A B C
D E F
G H I
Figure 5.7 (A) A patient presented with a hypoplastic anterior maxilla and absence of anterior maxillary teeth. A scapular free flap was designed
for reconstruction (B). (C,D) A template was created and a bone graft fashioned and fixated to reconstruct the anterior maxillary contour. (E)
Next, a dermal graft was attached to the surface to provided soft tissue covering. (F) The prelaminated flap was covered in a silicone wrap,
whereas the pedicle was isolated by covering with a Gore-Tex graft. (G,H). Approximately 4 weeks later, the prelaminated flap was harvested
and transferred to the donor site. (I) Postoperative appearance approximately 4 months following the procedure. The prelaminated flap provides
a stable bony base for subsequent dental implant reconstruction.
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26 PART 1 — PRINCIPLES
A B C
D E F
G H I
Figure 5.8 (A) An 18-year-old man with extensive defects of the upper lip, cheek, and nose, secondary to noma infection. (B,C) Tissue
expander with full-thickness skin graft to be placed in the submental area deep to the platysma and anterior belly of the digastric muscle. (D)
Lateral view at 4 weeks showing expansion of the submental and forehead areas. (E) Intraoperative view showing the design of right and left
prelaminated, submental composite flaps, each based on the submental branch of the facial artery and also containing innervated platysma
muscle. (F) The tissue expander was removed and the left submental flap raised, showing healed skin graft on the inner aspect of the prelami-
nated flap. (G) Nasal reconstruction with local turndown flap for lining and cartilage grafts for support; forehead flap raised and ready to provide
external coverage of the nose; also, the two prelaminated submental flaps are in place and the Abbé flap is planned for reconstruction of the
central part of the upper lip. (H,I) Frontal and lateral views 6 weeks later.
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CHAPTER 5 — Prefabrication and Prelamination 27
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