Perifascial Areolar Tissue Graft as a Nonvascularized Alternative to Flaps

Sir: The treatment of skin ulcers and fistulas with poor blood circulation associated with tendon and bone exposure1,2 is frequently difficult. Various distant flaps and free flaps are used for treatment; however, Kouraba et al. have recently advocated the use of perifascial areolar tissue as a free graft material, which survives on such areas.3–5 Perifascial areolar tissue is the loose connective tissue on the deep fascias and has an abundant vascular plexus. This study reports the utility of the perifascial areolar tissue used as a minimally invasive surgical material for skin ulcers and fistulas accompanied by tendon or bone exposure. The clinical indications were (1) small range of defects, (2) restricted use of local flaps because of a post-irradiation or postoperative scar around the graft bed, and (3) absence of perifascial areolar tissue grafted onto an infected wound. The donor site was usually in the inguinal region or outside of the thigh for elevation of the grafts. The graft can be raised easily with a scalpel because of the loose attachment to the deep fascia (Fig. 1). The graft was laid over the defect, and spread thinly for close attachment.Fig. 1.: The loose connective tissue on the deep (muscle) fascias was exposed.A 28-year-old man sustained an orocervical fistula after ablation of submandibular gland cancer. The perifascial areolar tissue graft filled in the fistula and the outer surface in the mouth was covered with a lip mucosal flap, whereas the outer surface of the neck remained a raw surface (Fig. 2, left). Six months after surgery, the wound was well healed without complications (Fig. 2, right).Fig. 2.: (Left) Orocervical fistula after the abrasion of submandibular gland cancer. The perifascial areolar tissue graft filled in the fistula. (Right) The wound was well healed without complications 6 months after surgery.Perifascial areolar tissue is a new material that has a rich vascular plexus and that can survive on an area with scarce circulation while providing new blood circulation to the defect. The tissue is sufficiently flexible to fix many types of defects, such as a plane or spaces with complex shapes, and does not require microsurgical anastomosis. This is advantageous in patients such as those with many complications or in poor general condition. A skin graft should be performed with delayed surgery, but a simultaneous skin graft was successful in some cases. Therefore, a simultaneous skin graft is possible at the initial operation, depending on the condition of the graft bed or the thickness of the graft. Schwabegger et al.2 stated that fascial flaps can be molded to fit a three-dimensional defect; thus, perifascial areolar tissue can obviously be used as an amorphous material to fill a fistula. With its special advantages of minimal donor-site morbidity and a short and easy surgical procedure, perifascial areolar tissue may become a valuable tool available to the reconstructive surgeon. Takuya Koizumi, M.D. Masahiro Nakagawa, M.D. Shogo Nagamatsu, M.D. Shuji Kayano, M.D. Satoshi Akazawa, M.D. Division of Plastic and Reconstructive Surgery Shizuoka Cancer Center Hospital Shizuoka, Japan