Propeller-Lappenplastiken: die Reliabilität der präoperativen, unidirektionalen Dopplersonografie

A Comparison of Handheld Doppler and Indocyanine Green Angiography for Perforator Localization

BACKGROUND

The preoperative identification of perforators is critical to the success of perforator flaps. Several technologies, including handheld Doppler (HHD) and indocyanine green angiography (ICGA), facilitate this process; however, each technology comes with unique downsides. This study directly compares the performance of HHD and ICGA in preoperative perforator identification and measures the effects of flap thickness and body mass index (BMI) on perforator localization.

METHOD

Data from preoperative HHD and ICGA assessments were compared with the criterion standard of intraoperative perforator localization. Sensitivity, specificity, accuracy, and positive predictive values were calculated for both and correlated with flap thickness and BMI.

RESULTS

Thirty flaps were transferred in 30 patients across 15 different donor sites. Indocyanine green angiography had higher sensitivity, accuracy, and positive predictive value (79.2%, 74.2%, and 87.5%, respectively) than HHD (55.6%, 46.6%, and 69.4%, respectively). Perforators detected by ICGA were used as flap pedicles in 21 cases compared with 13 with HHD. There were no correlations between HHD or ICGA performance and patient BMI (both P > 0.05). Increasing flap thickness was negatively correlated with the accuracy of ICGA ( P = 0.001) but not HHD ( P > 0.05).

CONCLUSIONS

Indocyanine green angiography was more sensitive, specific, and accurate than HHD in identifying perforators across various donor sites; however, its performance suffered in thicker flaps, whereas HHD did not. Patient BMI was not correlated with the performance of either technology. Additional research can further delineate the interrelationships of flap thickness and technologies for perforator localization.

The Microvascular Peroneal Artery Perforator Flap as a "Lifeboat" for Pedicled Flaps

Pedicled perforator flaps have expanded reconstructive options in extremity reconstruction. Despite preoperative mapping, intraoperative findings may require microvascular tissue transfer when no adequate perforators can be found. The free peroneal artery perforator flap may serve as a reliable back-up plan in small defects.

[Local flaps as a last attempt to avoid lower extremity amputation: an overview]

BACKGROUND

Soft tissue reconstruction in aged patients is challenging. Free tissue transfer can be carried out in healthy patients with a high success rate despite old age. When free tissue transfer is contraindicated in multimorbid patients, local flaps are often chosen, which are associated with a high complication rate. Such salvage interventions must be selected so that an amputation is not disadvantageously influenced by the selection of the donor site or is even impossible.

METHODS

The three distally based local flaps the sural artery flap, peroneus brevis muscle flap and perforator-based propeller flaps are discussed with respect to placement of the donor site as well as wound healing disorders.

RESULTS

The sural artery flap is disadvantageous as the donor site because the proximal dorsal calf region is affected, which in the case of a below the knee amputation enables soft tissue covering of the stump.

CONCLUSION

If a local flap is to be used as a salvage surgery in an attempt to prevent a below the knee amputation in a patient who is not suitable for free tissue transfer, special emphasis must be placed on the donor site of this flap. The proximal dorsal aspects of the distal calf are required for covering a potential stump and should not be violated by harvesting a local 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.

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.