CLINICAL SCRUTINY OF THE DE-FACTO SUPERIORITY OF PROXIMALLY VERSUS DISTALLY BASED FASCIOCUTANEOUS FLAPS

Just as the dogma that skin flap survival depends on rigid length-to-w idth ratios has been refuted as a consequence of advances in understan ding the anatomical basis of the cutaneous circulation, the generaliza tion that distally based flaps are inherently inferior to proximally b ased flaps also deserves to be challenged, All else being equal, the t ruly critical factor for flap viability in either case is the nature o f their intrinsic blood supply ladler than any arbitrary configuration or orientation. Previous laboratory evidence has proved this fact and is now further validated by a clinical experience with 194 local fasc ia flaps in 174 patients. There was a 22.2 percent overall incidence o f complications, hut no statistically significant difference in this r ate was observed whether the flap was distally based (18.8 percent of 16 flaps) or proximally based (23.5 percent of 162 flaps) (p = 0.669). Major complications, usually a failure of the intended coverage, actu ally were more common for proximally based flaps (12.9 percent) than t hose distally based (6.3 percent), although not statistically differen t (p = 0.436). Bi-pedicled fasciocutaneous flaps, which should have ha d augmented perfusion from their dual sources of inflow, sustained com plications in 12.5 percent of 16 flaps, Although none was classified a s a major problem, again no difference was apparent when compared with proximally based (p(prox) = 0.316) or distally based (p = 0.626) flap s. Some caution is prudent in interpreting these retrospective data, n ot because of an admitted bias for more frequent selection of proximal ly based flaps, but because the choice for any of these local fasciocu taneous flap always followed a careful assessment of the starers of th e fascial plexus adjacent to any defect. Audible or color Doppler ultr asound localization of available cutaneous perforators can predetermin e the feasibility of any option, thereby ensuring a reasonable success rate regardless of pedicle orientation.