When is a fasciocutaneous (fasciocutaneous, referring to a type of surgical flap) advancement flap recommended for wound closure or reconstruction?

Fasciocutaneous Advancement Flap Indications

Fasciocutaneous advancement flaps are recommended for moderate-sized, relatively uncontaminated soft tissue defects where local tissue coverage with preserved blood supply is needed, particularly in periarticular areas and lower extremity wounds where they can avoid the morbidity of free tissue transfer. 1, 2

Primary Indications

Skin Cancer Excision

• Periarticular defects following skin cancer excision are ideal candidates, as these flaps provide adequate tissue coverage while withstanding regional changes in tensile pressures around mobile joints 2
• Defects up to 75 mm × 40 mm × 15 mm can be successfully closed with keystone-type fasciocutaneous advancement flaps 2
• These flaps demonstrate color and cosmetic appearance comparable to adjacent tissue without impairing joint range of motion 2

Lower Extremity Trauma

• Moderate-sized, relatively uncontaminated lower extremity defects are well-suited for local fasciocutaneous flaps, avoiding the complexity of microsurgical tissue transfer 3
• The inclusion of deep fascia during flap elevation enhances viability of large local flaps in the lower leg 3
• Success rates reach 95% (39/41 cases) in appropriately selected patients without peripheral vascular insufficiency 3

Pressure Sore Reconstruction

• Sacral and ischial pressure sores benefit from gluteal fasciocutaneous rotation-advancement flaps, particularly when combined with V-Y closure patterns 4, 5
• Defects up to 12 cm diameter (unilateral) or 18 cm diameter (bilateral flaps) can be successfully closed 4
• These flaps are reusable for recurrent pressure sores when perforator vessels are preserved during initial surgery 5

Critical Patient Selection Factors

Vascular Status Assessment

• Peripheral vascular disease is a relative contraindication to fasciocutaneous flaps in lower extremity reconstruction 6
• In PVD patients, fasciocutaneous flaps demonstrate higher complication rates (41.2%) compared to muscle flaps (24.4%), though this difference approaches but does not reach statistical significance (p = 0.067) 6
• Fasciocutaneous flaps in PVD patients have 3.4 times higher odds of ulceration requiring repeat angiography within one year compared to muscle flaps (OR 3.4,95% CI: 1.07-10.95, p = 0.047) 6
• Consider muscle flaps instead when PVD is present, as low vascular resistance in muscle may be more advantageous for wound healing 6

Wound Contamination Level

• Flap closure should be avoided in wounds infected with multidrug-resistant organisms, which require extra-anatomic approaches 1
• Relatively uncontaminated wounds are essential for success—contaminated wounds show higher failure rates 3
• Primary closure and grafts demonstrate higher recurrence rates than flap reconstruction in contaminated or previously infected wounds 1

Advantages Over Alternative Techniques

Compared to Free Tissue Transfer

• Fasciocutaneous flaps are conceptually simple, rapidly elevated and inset, and minimize the region of surgical insult 3
• They avoid donor site morbidity associated with free flaps while maintaining defined vascular pedicles 1

Compared to Skin Grafts

• Flap reconstruction for hidradenitis suppurativa shows 0% recurrence compared to 69.9% with primary closure 1
• Locoregional fasciocutaneous coverage alleviates risks of graft failure and contour defects 2

Compared to Muscle Flaps

• Rotation fasciocutaneous flaps demonstrate 12% complication rates in pressure ulcer surgery, among the lowest of all flap types 1
• However, in PVD patients specifically, muscle flaps are superior due to better vascular characteristics 6

Common Pitfalls to Avoid

• Peripheral vascular insufficiency is the primary cause of flap necrosis—only 2 of 41 flaps failed in one series, both due to vascular insufficiency requiring limb amputation in one case 3
• Distal third lower leg wounds have higher complication rates (19% overall complication rate in one series, concentrated in distal wounds) 3
• Wide skin pedicles should be preserved to augment blood supply and reduce risk of wound-healing problems 4
• Tension-free closure is essential—the V-Y advancement component relieves tension at the distal end of rotation flaps 4