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The fasciocutaneous (FC) flap or the axial flap consists of skin, subcutaneous tissue, and deep fascia. In the literature today, there is no evidence suggesting that either surgery is superior to the other in terms of outcome and complications. Reviews in the literature currently compare the outcomes of skin closure after Orthopedic surgeries. The meta-analysis aims to compare the clinical outcomes, complication rates, need for re-surgery, and donor site morbidity between the AF flaps and FC flaps. A null hypothesis that stated inferior outcomes of FC flaps along with more complication rates over AF flaps was kept at the start of the study.
Methods
Cochrane Library, PubMed, Embase were searched until December 2020. The review included all original studies which compared the outcomes or complications between FC and AF flaps. The quality of studies was assessed using the Minors score.
Results
A total of 7 original studies with AF and FC flap procedures of which 136 underwent FC flap and 212 underwent AF flap. The pooled data meta-analysis and the subgroup analysis of these studies found no standardized protocol for reporting the outcomes or the cosmetic outcome of the flap surgery. The adipofascial group showed overall shorter operative time, less bulky flap and ability to wear footwear. Also the complications did not differ in both groups with respect to flap loss, complication following surgery, wound dehiscence, wound closure, donor site complications.
Conclusion
The current meta-analysis reveals that there is no added benefit of using AF flaps over the FC flaps. The rates of partial or total flap necrosis along with donor site morbidities and successful wound closure and overall complication rates were similar between the two groups. However, there is evidence to support the superiority of AF flaps over the FC variety with respect to ease of wearing footwear and a less bulky flap.
The fasciocutaneous (FC) flap or the axial flap consists of skin, subcutaneous tissue, and deep fascia. The first FC flaps in lower limb deformities were described by Ponten et al.
Eventually, these flaps were extended to cover defects in the upper limbs, trunks, and head which are essential following orthopaedic intervention. These flaps provide coverage in specific cases where skin grafts or random skin flaps are not enough. Adipofascial flaps are made up of subcutaneous tissue and fascia with associated blood supply.
A comparison of fasciocutaneous and adipofascial methods in the reverse sural artery flap for treatment of diabetic infected lateral malleolar bursitis -.
They provide orthopaedic and plastic surgeons with an interesting variation on coverage.
The surgical planning of wound closure has evolved dramatically since the advent of microanastomosis and the availability of multiple options for the surgeon. AF or fasciosubcutaneous flaps and FC flaps offer themselves as an option for the treating surgeon. Flaps of the AF variety are more refined and offer a slimmer profile when compared to those of the FC variety. However, they often require an extended harvesting time.
A comparison of fasciocutaneous and adipofascial methods in the reverse sural artery flap for treatment of diabetic infected lateral malleolar bursitis -.
FC flaps are currently the workhorse of surgeons for treating wounds. The bulky nature of these flaps often requires secondary thinning procedures, are less cosmetically appealing, and have donor site morbidity.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
Distally based peroneal artery perforator-plus fasciocutaneous flap in the reconstruction of soft tissue defects over the distal forefoot: a retrospectively analyzed clinical trial -.
In the literature today, there is no evidence suggesting that either surgery is superior to the other in terms of outcome and complications. Reviews in the literature currently compare the outcomes of skin closure after surgeries.
No additional benefits of tissue adhesives for skin closure in total joint arthroplasty: a systematic review and meta-analysis of randomized controlled trials -.
The meta-analysis aims to compare the clinical outcomes, complication rates, need for re-surgery, and donor site morbidity between the AF flaps and FC flaps. A null hypothesis that stated inferior outcomes of FC flaps along with more complication rates over AF flaps was kept at the start of the study.
2. Material and methods
The current review and meta-analysis were performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
The online databases Pubmed, Embase, Cochrane library were searched by two authors (B.S.R and V.M). The last date of the search was 31/12/2020 and all the databases were searched from the date of inception to the above specified time. The search terms used where “AF perforator flap(s)", “turn over flap(s)", “fascia subcutaneous flap(s)", “FC flap(s)", “outcome”, “complication”, “resurgery’, ‘functional score” with Boolean operators “AND” and “OR”. The flow diagram representing the search is shown in Fig. 1. The abstracts were identified first by the above-mentioned search methods and were assessed for eligibility based on the criteria mentioned below. The shortlisted abstracts were then followed up for full texts and were again assessed for eligibility. An additional search of the reference list of the finalized articles was searched for further relevant studies. The process was repeated two times and any disagreements between the authors were sorted out by the senior author (Dr M.V).
The review included all original studies which compared the outcomes or complications between FC and AF flaps. Only papers in the English language were included. The exclusion criteria included
A comparison of fasciocutaneous and adipofascial methods in the reverse sural artery flap for treatment of diabetic infected lateral malleolar bursitis -.
Two separate reviewers (Dr V.M and Dr A.G) extracted the data using a standardized form. The extracted data included article details including author name, year of publication, journal, study location, study design, level of evidence, sample size, follow-up periods, outcomes (scores if present), and complications as events. The continuous variables were extracted and expressed as mean ± standard deviation. In case of missing data, the authors were contacted for the specific information and the articles were excluded if responses were not obtained. Disagreements between the reviewers were discussed and the senior author (Dr M.V) took the final decision.
The review and meta-analysis were done using the RevMan version 5.3 statistical software. The random-effects model was taken for pooled estimates in the meta-analysis assuming the heterogeneity in the methods, techniques and that the included studies represent a random sample from the larger population of such studies wherein each study has its own underlying effect size. The heterogeneity of the sample was assessed with the I2 statistic with values of 25, 50, and 75% considered as low, moderate, and high heterogeneity, respectively.
Funnel plots were used to assess the publication bias. The odds ratio was used for estimates for dichotomous variables. If the standard deviation was not mentioned in the study, it was calculated using the range of values as per Hozo et al.
Two separate reviewers (Dr V.M and Dr A.G) assessed the quality of the studies included in the review. Minors score was used for the analysis and it consisted of 12 parameters for which each item is scored 0 (not reported), 1 (reported but inadequate) or 2 (reported and adequate). The global ideal score is 16 for non-comparative studies and 24 for comparative studies.
The score was not used as an exclusion criterion for the selected articles. The senior doctor sorted out any disagreements if any by discussion. The senior author (Dr M.V) sorted out any disagreements and a consensus was reached.
2.5 Surgical technique & Rehabilitation
Operations were performed under general or spinal anesthesia and positioning of patient was done and tourniquet was applied. First, complete debridement was performed. Following debridement, features including the size and shape of defects were identified. For lower limb wounds path of the lesser saphenous vein was drawn on the donor site. The location of the perforator was preoperatively identified with a Doppler.
Fasciocutaneous flap - A flap was designed at the donor site, and a reverse sural artery fasciocutaneous flap procedure was performed. Once the flap was elevated, a skin incision was made at the point where the pedicle would be located and where the flap was placed. The tourniquet was then released, and circulation in the flap was assessed.
Adipofascial flap – An incision was given to expose the subcutaneous fat layer. Size of the required flap at the subcutaneous fat layer were designed, and the flap was then elevated with the pedicle. Skin incision was made at the place where the pedicle would be located and where the flap needs to be placed. The tourniquet was released, and after confirming circulation in the flap, STSG is performed on the flap.
Postoperatively, drains were inserted, followed by bulky dressing. Regular dressing to assess the blood supply in the flaps with adequate antibiotics coverage post-operatively.
3. Results
3.1 Study characteristics
The review included a total of 7 original studies with AF and FC flap procedures of which 136 underwent FC flap and 212 underwent AF flap. The study demographics have been listed in Table 1. Six studies compared the use of both flaps in traumatic wounds,
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects - Ulus Travma Ve Acil Cerrahi Derg Turk.
A comparison of fasciocutaneous and adipofascial methods in the reverse sural artery flap for treatment of diabetic infected lateral malleolar bursitis -.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects - Ulus Travma Ve Acil Cerrahi Derg Turk.
The quality assessment revealed that all studies had scores of more than 15 with 2 studies showing scores of 17. Detailed assessment of studies studied in Table 2.
The review observed no standardized protocol for reporting the outcomes or the cosmetic outcome of the flap surgery. The cosmetic outcome in the review was studied in 5 articles namely Goil P, Schmidt, Parodi, Kim, Akdag. They noted that no standardized outcome measure for flap usage was used in the articles included.
A comparison of fasciocutaneous and adipofascial methods in the reverse sural artery flap for treatment of diabetic infected lateral malleolar bursitis -.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects - Ulus Travma Ve Acil Cerrahi Derg Turk.
The methods were heterogeneous. According to Goil P et al. cosmetic satisfaction score with reverse sural flap was 7.51/10 and in Two-staged FC Reverse Sural Flap was 5.07/10.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
A comparison of fasciocutaneous and adipofascial methods in the reverse sural artery flap for treatment of diabetic infected lateral malleolar bursitis -.
According to Parodi et al. the cosmetic outcome of the coverage was rated by an external professional grader and patient as good to excellent in 25 of the 27 patients.
Akdag et al. noted the patients treated with RARFF expressed their satisfaction about the operation at recipient area as Excellent: 8; Good: 4 and Excellent: 12 at donor area while among the 11 patients treated with PIAF, at recipient area - Excellent: 7; Good: 4 and Fair: 8; Poor: 3 at donor area.
Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects - Ulus Travma Ve Acil Cerrahi Derg Turk.
Cosmetic outcomes are an important part of orthopaedic surgery as most of the open wounds are primarily treated with fixator application. So bulkiness of implant along with added cosmetic appearance of flap are a major considerate.
3.4 Complications requiring surgery
7 studies reported on the complications that required surgery post initial procedure between the two groups.
A comparison of fasciocutaneous and adipofascial methods in the reverse sural artery flap for treatment of diabetic infected lateral malleolar bursitis -.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects - Ulus Travma Ve Acil Cerrahi Derg Turk.
The pooled analysis revealed no significant difference in the rate of complications requiring resurgery (95% CI: 0.51 to 4.46; p 0.46, I2 = 46%, Fig. 2). Only one study looked at the incidence in upper limb wounds and found that - RARFF showed better results than PIAF in dorsal hand defects, but in RARFF, the major arteries of the hand are sacrificed.
Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects - Ulus Travma Ve Acil Cerrahi Derg Turk.
A comparison of fasciocutaneous and adipofascial methods in the reverse sural artery flap for treatment of diabetic infected lateral malleolar bursitis -.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects - Ulus Travma Ve Acil Cerrahi Derg Turk.
The pooled analysis revealed no significant difference in the rate of partial flap loss (95% CI: 0.46 to 3.89; p 0.59, I2 = 18%, Fig. 3A) between the two groups. Overall, partial flap loss was found to be 9.9% in the AF and 9.6% in the FC groups respectively.
A comparison of fasciocutaneous and adipofascial methods in the reverse sural artery flap for treatment of diabetic infected lateral malleolar bursitis -.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects - Ulus Travma Ve Acil Cerrahi Derg Turk.
The pooled analysis revealed no significant difference in the rate of total flap loss (95% CI: 0.41 to 3.93; p 0.68, I2 = 5%, Fig. 3B) between the two groups. Overall total flap loss was found to be 4.7% in the AF and 3.7% in the GC groups respectively.
3.7 Dehiscence/epidermolysis
6 studies reported on total flap loss following the procedure.
A comparison of fasciocutaneous and adipofascial methods in the reverse sural artery flap for treatment of diabetic infected lateral malleolar bursitis -.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects - Ulus Travma Ve Acil Cerrahi Derg Turk.
The pooled analysis revealed no significant difference in the rate of total flap loss (95% CI: 0.34 to 2.59; p 0.90, I2 = 33%, Fig. 4) between the two groups.
Fig. 4Epidermolysis/ Dehiscence following surgery.
A comparison of fasciocutaneous and adipofascial methods in the reverse sural artery flap for treatment of diabetic infected lateral malleolar bursitis -.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects - Ulus Travma Ve Acil Cerrahi Derg Turk.
The pooled analysis revealed no significant difference in the rate of successful wound closure (95% CI: 0.45 to 5.92; p 0.45, I2 = 13%, Fig. 5A) between the two groups.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects - Ulus Travma Ve Acil Cerrahi Derg Turk.
The pooled analysis revealed no significant difference in the rate of donor site complications (95% CI: 0.33 to 26.40 p 0.34, I2 = 71%, Fig. 5B) between the two groups. Schmidt et al. noted complications in 11 patients associated with the AF group and 6 patients associated with FC group with infection being the commonest complication.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects - Ulus Travma Ve Acil Cerrahi Derg Turk.
The pooled analysis revealed no significant difference in the rate of flap advancement (95% CI: 0.55 to 34.34; p 0.16, I2 = 1%, Fig. 5C) between the two groups.
3.11 Ability to wear footwear
3 studies reported on the ability to wear footwear following the procedure.
A comparison of fasciocutaneous and adipofascial methods in the reverse sural artery flap for treatment of diabetic infected lateral malleolar bursitis -.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
The pooled analysis revealed a significant difference in the ability to wear footwear (95% CI: 0.02 to 0.18; p < 0.00001, I2 = 0%, Fig. 6A) between the two groups. The AF group had a better ability to wear normal size footwear in comparison to the FC group.
Fig. 6Bulkiness of flap and ability to wear normal footwear.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
The pooled analysis revealed a significant difference in the incidence of bulky flaps (95% CI: 32.32 to 2084.05; p < 0.00001, I2 = 0%, Fig. 6B) between the two groups. The AF group was associated with a less bulky flap in comparison to the FC group.
3.13 Operative time
5 studies reported on the Operative time following the procedure.
A comparison of fasciocutaneous and adipofascial methods in the reverse sural artery flap for treatment of diabetic infected lateral malleolar bursitis -.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects - Ulus Travma Ve Acil Cerrahi Derg Turk.
Over the decades the free flaps have become the workhorse of the orthopaedic and plastic surgeons for wound coverage in the extremities owing to their technique and an intact blood supply.
However, wounds of extremities often may be operated on with the pedicle flaps due to the inability of the microsurgeons and the resources in small hospitals. Among the flaps available there include the FC flaps and the fasciosubcutaneous or AF flaps. In the literature there exists little evidence to suggest the superiority of one technique to the other. The current systematic review found that the AF flaps offer no superiority over the FC flaps except for the ease of wearing normal size footwear and providing a less bulky flap.
Wounds of the extremities especially of lower extremities often provide a diagnostic dilemma for the surgeon. The thin skin in the region along with less elastin amount and relative ease of exposure of tendons and bones makes the above-mentioned site difficult to manage with respect to wound coverage.
The aesthetics, which often is not considered while doing a free tissue transfer, poses a concern for the patient. Moreover, many times the lack of availability of resources forces the surgeon to consider pedicled flaps provided the vascular supply is intact. The pedicled flaps especially the sural flaps are extremely helpful.
The AF flaps are a variety of FC flaps wherein the skin is not included. Few works of literature exist which compare the AF flaps with the FC variety and no systematic review exists in the above topic to validate the superiority of one technique to another. To the best of our knowledge, the current review is the first to comprehensively assess the complications especially of the donor and the graft site along with outcomes. The details of the complications are detailed in Table 3.
Table 3Complications.
Author
Complications Requiring Surgery (n)
Partial Tip Necrosis (n)
Total Flap Necrosis (n)
Flap Advancement (n)
Epidermolysis/Dehiscence (n)
Successful wound closure (n)
Donor Site Complication (n)
Ability To Wear Regular Footwear, N (%)
Bulky Flap, N (%)
Operative Time (min)
Schmidt
FC: 11 AF: 24
FC: 5 AF: 19
FC: 3 AF: 6
FC: NS AF: NS
FC: 4 AF: 4
FC: 41 AF: 98
FC: 11 AF: 6
FC: 8 AF: 29
FC: 24 AF: 0
FC: 132.5 ± NS AF: 92.5 ± NS
Bocchi
FC: 0 AF: 5
FC: 1 AF: 1
FC: 0 AF: 4
FC: NS AF: NS
FC: NS AF: NS
FC: 11 AF: 10
FC: 1 AF: 4
FC: NS AF: NS
FC: NS AF: NS
FC: 30 ± NS AF: 80 ± NS
KJ Kim
FC: 0 AF: 0
FC: 0 AF: 0
FC: 0 AF: 0
FC: NS AF: NS
FC: 0 AF: 2
FC: 15 AF: 14
FC: NS AF: NS
FC: 15 AF: 14
FC: NS AF: NS
FC: 90 ± NS AF: 40 ± NS
P Goil
FC: 11 AF: 5
FC: 5 AF: 1
FC: 2 AF: 0
FC: 4 AF: 0
FC: 10 AF: 12
FC: 30 AF: 34
FC: 6 AF: 0
FC: 17 AF: 37
FC: 20 AF: 0
FC: 60 ± NS AF: 45 ± NS
TO Acarturk
FC: 2 AF: 0
FC: 1 AF: 0
FC: 1 AF: 0
FC: NS AF: NS
FC: 0 AF: 0
FC: 7 AF: 4
FC: 0 AF: 0
FC: NS AF: NS
FC: NS AF: NS
FC: NS AF: NS
Pier Camillo Parodi
FC: 1 AF: 1
FC: 0 AF: 0
FC: 0 AF: 0
FC: 1 AF: 1
FC: 1 AF: 7
FC: 17 AF: 27
FC: NS AF: NS
FC: NS AF: NS
FC: NS AF: NS
FC: NS AF: NS
Osman Akdag
FC: 0 AF: 0
FC: 1 AF: 0
FC: 1 AF: 0
FC: 0 AF: 0
FC: 1 AF: 0
FC: 11 AF: 12
FC: 0 AF: 0
FC: NS AF: NS
FC: NS AF: NS
FC: 161.8 ± 15.3 AF: 118.3 ± 5.7
FC; fasciocutaneous, AF; Adipofascial, NS; Not Specified.
The flaps that are harvested are often prone to necrosis which can often be partial flap necrosis or total necrosis. The review found that there exists no significant difference between the rates of partial or total flap necrosis between the two modalities of flaps. Schmidt et al. noted partial necrosis of the tip of the flap in 19 AF and 5 FC flaps whereas total flap necrosis was encountered in 6 AF and 3 FC flaps.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
A comparison of fasciocutaneous and adipofascial methods in the reverse sural artery flap for treatment of diabetic infected lateral malleolar bursitis -.
Bocchi et al. noted distal flap necrosis in 1 FC flap while 1 sural flap showed marginal ischemia which healed spontaneously with total flap necrosis was encountered in 4 AF flaps.
Goil P et al. noted partial necrosis in 5 FC flaps and in 1 AF flap. There were two cases of total flap necrosis in the FC group where the patient had multiple comorbidities.
Similarly, the rates of flap advancement were also found to be similar between the groups. Goil P et al. used flap advancement for all cases with partial flap necrosis.
Wound dehiscence or epidermolysis is a complication often seen with the graft edges implying the vascular status and the tension of sutures that are holding it. The review found no significant difference between the two groups with regards to the rate of wound dehiscence. Parodi et al. found an increased incidence of dehiscence in the AF group.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
The outcome in terms of successful closure of the wound was noted in many studies. The review found that overall, there exists no significant difference between the two groups signifying that both the two flap techniques offer themselves as an able option for flap coverage. Schmidt et al. noted successful closure of the wound in 41 of 44 FC flaps and 98 of 108 AF flaps.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
Bocchi et al. noted both FC flap and sural flap are technically simple, safe, and effective, and cause minimal injury to the donor site with successful wound closure in all FC flaps and 10 of 14 AF flaps.
The donor site morbidities were also found to be similar in both groups. Schmidt et al. and Goil P et al. noted that the AF groups were associated with lesser donor site complications
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
Theoretically, the FC group requires skin grafting in the donor site and is associated with more skin graft related complications. However, our review found out that the rate of donor site complications was similar in both groups and was not statistically significant. The overall rate of complications that needed surgery in both the FC and the AF groups were also similar. Goil P et al. noted that the FC flaps were associated with more complications that required operative interventions.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
Normal ankle and foot anatomy consists of concavity below malleolus for containment of the convex collar top line of a shoe. So bulky flaps over this concavity may lead to inability to wear footwear. The AF group were associated with a better ability to wear footwear and have a less bulky flap. Goil P et al. noted 13 cases FC flap were too bulky for shoe-wearing whereas in the AF group had nil.
Schmidt et al. noted 24 cases of FC flap were too bulky whereas in AF flap had nil complaints. 8 cases FC flap were able to wear regular footwear, whereas in AF flap 29 cases.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
A comparison of fasciocutaneous and adipofascial methods in the reverse sural artery flap for treatment of diabetic infected lateral malleolar bursitis -.
Studies noted the time for the procedure. Schmidt et al. noted a statistically increased time to harvest the FC flaps over AF flaps with operative time averaged 92.5 min for AF flaps and 132.5 min for FC flaps.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
. Akdag et al. noted an increased operative time associated with the FC flaps with the operative time for PIAF was on an average 161.8 min whereas for RARFF it was around 118.3 min
Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects - Ulus Travma Ve Acil Cerrahi Derg Turk.
Our review has its limitations. First, the review has mixed study types, many of which were retrospective. Ideally, one would strive for prospective studies. Second, most of the studies have sample sizes of less than 50 in each arm. Third, comparative outcomes have not been included. However, since there is a paucity of literature we needed to utilize all the available ones. The current study is the first review to compare AF and FC flaps. Third, we included only English language articles. Some of the studies in other languages may be missed.
5. Conclusion
The current meta-analysis reveals that there is no added benefit of using AF flaps over the FC flaps. The rates of partial or total flap necrosis along with donor site morbidities and successful wound closure and overall complication rates were similar between the two groups. However, there is evidence to support the superiority of AF flaps over the FC variety with respect to ease of wearing footwear and a less bulky flap.
Ethics approval
Approval from the institutional ethics committee was not required for this review article.
Consent to participants
Not Applicable.
Consent to publish
All authors have read the final prepared draft of the manuscript and approve this version, in its current format if considered further for publication.
Financial support and sponsorship
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Authors contribution
B.S.R - Planning of study, literature search, writing the manuscript, quality assessment of the included studies.
M.V - Data management, outcome assessment, manuscript preparation.
V.M − Data management, outcome assessment, manuscript preparation, Corrspondence
A.K.S.G - Literature search, writing the manuscript, quality assessment of the included studies.
A.J - Quality assessment of the included studies, writing and revising the manuscript.
P.K - Data management, outcome assessment, revising the manuscript.
Availability of data and materials
All included studies used in this retrospective study are available online. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Data regarding this study is not available in any electronic databases.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
References
Pontén B.
The fasciocutaneous flap: its use in soft tissue defects of the lower leg -.
A comparison of fasciocutaneous and adipofascial methods in the reverse sural artery flap for treatment of diabetic infected lateral malleolar bursitis -.
The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population -.
Distally based peroneal artery perforator-plus fasciocutaneous flap in the reconstruction of soft tissue defects over the distal forefoot: a retrospectively analyzed clinical trial -.
No additional benefits of tissue adhesives for skin closure in total joint arthroplasty: a systematic review and meta-analysis of randomized controlled trials -.
Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects - Ulus Travma Ve Acil Cerrahi Derg Turk.
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