Doppler-Sonografie und Farbdopplersonografie zur präoperativen Perforatordarstellung beim anterolateralen Oberschenkellappen

Reconstruction of Head and Neck Defects Using Medial Sural Artery Perforator Free Flap

AIM

To study the use of medial sural artery perforator (MSAP) free flap in head and neck reconstruction.

MATERIAL AND METHOD

This was a prospective study. The patients with cancers of head and neck underwent excision of tumor along with neck dissection, and MSAP free flap was used for reconstruction.

RESULTS

The free MSAP flaps were used in 30 patients to reconstruct head and neck soft tissue defects. There were sixteen male and six female patients with the median age of 40 years. The most common site of tumor resection was the tongue (14 cases), followed by buccal mucosa (12 cases), neck skin(2 cases), skin over parotid(1 case) and lip(1 case). Average flap size was 56 cm2. Thickness of the flap ranged from 4 to 8 mm. The length of the vascular pedicle ranged from 8 to 14 cm (12 cm mean) which provides sufficient length during vessel anastomosis. Arterial diameter ranged from 1.0 to 1.5 mm(Average - 1.25 mm) and venous diameter of both veins in pedicle ranged from 1.5 to 2.5 mm(Average - 2 mm) in size. Most flaps were based on two perforators. Primary closure was attained in 11 cases whereas 19 patients required split thickness skin graft(STSG). The average flap harvesting time was 45 min. Flap was failed in two cases.

CONCLUSION

MSAP is good alternative to FRAFF in the reconstruction of defect after resection of head and neck cancer.

Advances in perforator imaging through holographic CTA and augmented reality: a systematic review

Introduction: Free tissue transfer has become a mainstay in reconstructive plastic surgery, and techniques to plan such surgery continue to evolve. Novel technologies and increases in computational power have enabled computed tomographic angiography (CTA)data augmentation onto patients to assist in pedicle identification and dissection. Given the rapidly evolving field and research in this domain, a systematic re-view was undertaken to establish the evidence for its usefulness in pedicle identification and dissection. Methods: An extensive search using keywords in EMBASE and PubMed with bibliographic linkage following PRISMA guidelines was performed. 107 articles were identified. Duplicate articles were removed prior to review. Two reviewers independently screened the titles for appropriate topic relevance. Full articles were then screened for review. Results: Eleven articles were appropriate for review. Two articles analysed the time taken to identify perfo-rators using augmented reality (AR) compared to Doppler ultrasound. The remainder of the articles ana-lysed time to perforator identification, differences between projected location and dissected perforator location, qualitative feedback from surgeons on the use of AR systems for perforator identification and proof of concept and the usefulness of AR in perforator flap surgery. Conclusion: This review demonstrates that while established methods of data rendering and projection can achieve holographic projection and AR, there is a lack of objective outcome data to demonstrate its usefulness. This, combined with a cost analysis, are the main obstructions to this technology being more widely adopted.

A single-center retrospective comparison of Duplex ultrasonography versus audible Doppler regarding anterolateral thigh perforator flap harvest and operative times

INTRODUCTION

We reported on the superiority of preoperative Duplex mapping ("Duplex") over audible Dopplers ("Doppler") in anterolateral thigh perforator (ALT) free flaps for upper extremity reconstruction. To corroborate our findings on a larger cohort, we conducted this present study focusing on surgical efficiency and patient safety.

METHODS

150 consecutive ALT free flaps were divided into 65 cases of preoperative Duplex versus 85 Doppler controls. We first compared patient demographics, operative details, and defect and flap characteristics. We then assessed group differences in the number and course of perforators pursued intraoperatively, flap harvest and operative times, and donor-site complications. Additionally, the impact of the training level of the primary microsurgeon was evaluated.

RESULTS

Cases and controls were comparable regarding age (p = .48), sex (p = .81), ASA class (p = .48), and BMI (p = .90). Duplex was associated with an increased likelihood of raising flaps on one single dominant perforator of purely septal course and significant reductions of flap harvest (68 ± 10 min, p < .0001) and operative times (74 ± 16 min, p < .0001), regardless of the experience of the primary microsurgeon. There were strong negative linear correlations between preoperative Duplex and both the flap harvest and operative times (p < .0001). Additionally, while there was no effect on the emergency take-back rate (OR = 1.3, p = .60), revisions were significantly less likely among duplexed patients (OR = 0.15, p = .04).

CONCLUSIONS

Preoperative Duplex is associated with a significant reduction in ALT free flap harvest and overall operative times, as well as donor-site revisions as opposed to Doppler planning, regardless of the training level of the primary microsurgeon.

Aesthetic and functional outcomes of thinned anterolateral thigh flap in reconstruction of complex wounds of the upper limb

We studied outcomes of reconstruction of complex upper limb wounds using thinned anterolateral thigh flaps. There were 18 patients with a mean age of 27.5 years. The mean thickness of the flap before and after thinning was 23 mm and 5 mm, respectively. Two patients had partial tip necrosis that was treated conservatively. Aesthetic and functional evaluations were performed using a 5-point Likert scale, QuickDASH score, passive range of motion and power grip at 12 months after surgery. The study showed good results in the aesthetic evaluation by a panel of plastic surgeons (mean score: 19.7) and patient self-assessment (mean score: 18.1). There was a significant correlation between the total scores of the panel and the patients. The mean QuickDASH score was 21, with a high percentage in the middle category 'had a problem but working'. The thinned anterolateral thigh flap is versatile and safe in upper limb reconstruction with good aesthetic and functional results.Level of evidence: IV.

Medial Sural Artery Perforator Flap for Head and Neck Reconstruction

Aim:

The aim is to study the assessment of feasibility of medial sural artery perforator (MSAP) free flap for head and neck reconstruction at our center.

Materials and Methods:

Oral cancer patients with squamous cell carcinoma of the tongue, buccal mucosa, and floor of mouth cancer attending our center were reconstructed using MSAP flap after oncologic resection. Handheld 8 MHz Doppler was used to identify the perforator preoperatively.

Results:

We reconstructed 10 patients using MSAP flap. The flap was designed according to defect and donor site was primarily closed in all cases. Excellent results were seen in nine patients reconstructed with MSAP flap without any postoperative complication. Flap failure occurred in one patient due to venous thrombosis. The thickness of flap ranged from 4 to 8 mm. The vascular pedicle length ranged from 9 to 13 cm.

Conclusion:

The MSAP flap is appropriate for medium-sized oral defect reconstruction, with a long pedicle of matching caliber, adequate tissue volume, and minimal donor-site morbidity which makes it comparable to other microvascular free flaps such as radial artery free flap (RAFF) and anterolateral thigh flap.

Color Doppler Ultrasonography-Targeted Perforator Mapping and Angiosome-Based Flap Reconstruction

Knowledge about perforators and angiosomes has inspired new and innovative flap designs for reconstruction of defects throughout the body. The purpose of this article is to share our experience using color Doppler ultrasonography (CDU)-targeted perforator mapping and angiosome-based flap reconstruction throughout the body. The CDU was used to identify the largest and best-located perforator adjacent to the defect to target the reconstruction. The cutaneous or fasciocutaneous flaps were raised, mobilized, and designed according to the reconstructive needs as rotation, advancement, or turnover flaps. We performed 148 reconstructions in 130 patients. Eleven facial reconstructions, 118 reconstructions in the body, 7 in the upper limbs, and 12 in the lower limbs. The propeller flap was used in 135 of 148 (91%) cases followed by the turnover design in 10 (7%) and the V to Y flap in 3 (2%) cases. The flaps were raised on 1 perforator in 98 (67%), 2 perforators in 48 (33%), and 3 perforators in 2 (1%) flaps. The reconstructive goal was achieved in 143 of 148 reconstructions (97%). In 5 cases, surgical revision was needed. No flaps were totally lost indicating a patent pedicle in all cases. We had 10 (7%) cases of major complications and 22 (15%) minor complications. The CDU-targeted perforator mapping and angiosome-based flap reconstruction are simple to perform, and we recommended its use for freestyle perforator flap reconstruction. All perforators selected by CDU was identified during surgery and used for reconstruction. The safe boundaries of angiosomes remain to be established.

Endoscope-assisted medial sural artery perforator flap for head and neck reconstruction

BACKGROUND

Head and neck defect reconstructions with various free perforator flaps have been widely reported. We recommend a technique of using endoscopy to confirm the location of the medial sural artery perforator (MSAP). Further, we use a free MSAP flap for the reconstruction of head and neck defects.

PATIENTS AND METHODS

Since 2010, we have carried out 18 transfers of the free MSAP flap in various anatomical locations of the head and neck. The free flap was designed based on endoscopy confirmation and contained perforator vessels. The donor site was directly sutured or skin grafted.

RESULTS

Twenty perforators (35.7%) detected by Doppler were confirmed by endoscopy. The number of sizable perforators ranged from one to three (mean, 1.4). The size of the flaps ranged from 22 to 88 cm(2) (mean, 41 cm(2)). The length of vascular pedicle ranged from 5 to 14 cm (mean, 8.3 cm). All 18 flaps survived with good quality and aesthetic contours.

CONCLUSIONS

The MSAP flap is an ideal flap for head and neck reconstruction. It has generally thin and pliable skin, a long and reliable vascular pedicle, straightforward intramuscular dissection, the possibility of chimeric flap design, and minimal donor-site morbidity. The reliability and safety of harvesting an MSAP flap may be increased by endoscopic confirmation of the perforators.

Free anterolateral thigh flaps for upper extremity soft tissue reconstruction

INTRODUCTION

Limb-threatening wounds of the upper extremity pose a challenge to the micro vascular surgeon. The aim of this study is to analyze the outcome of free anterolateral thigh flaps for upper extremity soft tissue reconstruction.

METHODS

A retrospective review of patients undergoing this procedure from 2005 to 2012 was performed. Case note analysis was performed to determine demographic and perioperative factors, and complications and outcomes.

RESULTS

Thirty-two patients with a mean age of 53 years (9-84 yrs) underwent upper extremity reconstruction with an anterolateral thigh (ALT) flap. There were 24 (75%) males and 8 (25%) females. The etiology of the soft tissue defects was: infection (44.6%); post-tumor ablation (40%); and trauma (15.6%). The defect site was most commonly in the forearm (53.1%), followed by the elbow (12.5 %), arm (12.5%) and hand (21.9%). The mean timing of free flap transfer was 6.8 days after admission to our institution (minimum 1 days, maximum 9 days). Mean operative time of surgery was 4 h 39 min (minimum 3 h 2 min, maximum 6 h 20 min). The mean hospitalization was 24.8 days (minimum 5, maximum 85). The ALT success rate was at 92.3%. Partial flap necrosis was documented in five cases (15.6%). Complete flap loss occurred in two post-traumatic cases who both lost their limbs.

DISCUSSION

This flap, in the hands of experienced surgeons, provides reliable coverage of upper extremity defects.

The hand held Doppler device for the detection of perforators in reconstructive surgery: what you hear is not always what you get

BACKGROUND

Perforator-based flaps have become indispensable in the treatment of burn scars. Pre-operative perforator mapping is often performed by use of the hand held Doppler device, partly due to its convenience and the low costs. We expected to find sufficient evidence in literature to support the use of the device, however available literature showed a distinct lack of clinimetric studies that adequately tested the reliability.

METHODS

To assess reliability, perforator locations were mapped independently by two clinicians using an 8MHz Doppler device. In healthy volunteers the elbow region or the peri-umbilical region were randomly chosen to be the measurement areas of predefined squares (7cm×7cm). Subsequently, the perforators within the area were mapped with Duplex to establish the validity by means of the positive predictive value.

RESULTS

20 volunteers were included. The hand held Doppler technique showed moderate reliability with a mean Dice coefficient of 0.56. Also, poor validity was found expressed by a mean positive predictive value of 55%.

CONCLUSIONS

Surprisingly, this study has shown that performance of the hand held Doppler device was moderate. The Doppler should not be used alone for the detection of perforators.

[The anterolateral thigh flap: its versatility in oncological soft tissue reconstruction of the head and neck region]

The anterolateral thigh flap (ATL) has become a standard procedure in reconstructive microsurgery. In this study the results with the ALT for reconstruction in the head and neck area after tumor resection in 33 patients were retrospectively analyzed. Patients included 28 men and 5 women aged 47-70 years who suffered from intraoral and extraoral tumors. Satisfactory soft tissue coverage could be achieved in all patients and no flaps were lost. The ALT is a versatile free flap enabling reliable soft tissue reconstruction of complex defects in the head and neck region. Flap dissection and preparation of the recipient area can usually be performed simultaneously. Additional advantages include the long and strong caliber vascular pedicle, the low donor site morbidity and the different possibilities of tissue composition, making the ALT a workhorse flap in modern reconstructive microsurgery.