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Escandón JM, Ciudad P, Mayer HF, Pencek M, Mantilla-Rivas E, Mohammad A, Langstein HN, Manrique OJ. Free flap transfer with supermicrosurgical technique for soft tissue reconstruction: A systematic review and meta-analysis. Microsurgery 2023; 43:171-184. [PMID: 35551691 DOI: 10.1002/micr.30894] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/16/2022] [Accepted: 04/29/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Supermicrosurgery is a technique that allows microsurgeons to accomplish dissections and anastomoses of vessels and nerve fascicles with diameters of ≤0.8 mm. Considering the potential benefits of this technique and limited literature synthesizing the outcomes of supermicrosurgery, the aim of this study was to summarize the available evidence of reconstructive supermicrosurgery and to estimate the success rate. METHODS We conducted a comprehensive search across PubMed, Scopus, Embase, and Web of Science. We included patient-based studies reporting on procedures for soft-tissue reconstruction with free flaps specifying the use of supermicrosurgery. We excluded studies reporting on lymphatic surgery, solely peripheral nerve surgery, and tissue replantation. Our primary endpoint was to calculate the flap success rate. Pooled estimates were calculated using a random-effects meta-analytic model. RESULTS Forty-seven studies reporting outcomes of 698 flaps were included for qualitative synthesis. Overall, 15.75% of flaps were used for head and neck, 4.4% for breast and trunk, 9.3% for upper limb, and 69.2% for lower limb reconstruction. The most used flap was the superficial circumflex iliac artery perforator flap (41.5%). The overall flap success rate was 96.6% (95%CI 95.2%-98.1%). The cumulative rate of partial flap loss was 3.84% (95%CI 1.8%-5.9%). The overall vascular complication rate resulting in complete or partial flap loss was 5.93% (95%CI 3.5%-8.3%). CONCLUSIONS Supermicrosurgery displays a high success rate. Further studies are necessary to explore the true potential of supermicrosurgery. This technique reformulates the boundaries of reconstructive surgery due to its extensive application.
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Affiliation(s)
- Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Pedro Ciudad
- Department of Plastic and Reconstructive Surgery, Archbishop Loayza National Hospital, Lima, Peru
| | - Horacio F Mayer
- Department of Plastic Surgery, Hospital Italiano de Buenos Aires, University of Buenos Aires, Buenos Aires, Argentina
| | - Megan Pencek
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Esperanza Mantilla-Rivas
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, District of Columbia, USA
| | - Arbab Mohammad
- School of Medicine, Aarupadai Veedu Medical College and Hospital, Puducherry, India
| | - Howard N Langstein
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
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Abstract
Supermicrosurgery is defined as microsurgery working on vessels less than 0.8 mm, allowing applications in smaller-dimension microsurgery, such as lymphedema, minimal invasive reconstruction, small parts replantation, and application of perforator as recipient. To accommodate this technique, developments and use of finer instruments, smaller sutures, new diagnostic tools, and higher-magnification microscopes have been made. Although supermicrosurgery has evolved naturally from microsurgery, it has developed into a unique field based on different thinking and tools to solve problems that once were difficult to solve.
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Affiliation(s)
- Joon Pio Hong
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, 88 Olympicro 43 gil, Songpagu, Seoul 05505, Korea.
| | - Changsik John Pak
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, 88 Olympicro 43 gil, Songpagu, Seoul 05505, Korea
| | - Hyunsuk Peter Suh
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, 88 Olympicro 43 gil, Songpagu, Seoul 05505, Korea
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Abstract
LEARNING OBJECTIVES After reviewing this article, the participant should be able to: 1. Understand the trends in reconstruction using flaps. 2. Understand the surgical anatomy and elevation of the three best flaps: superficial circumflex iliac artery perforator, profunda artery perforator, and thin anterolateral thigh perforator. 3. Understand the core principle and the modern evolution of microsurgery. 4. Be acquainted with new microsurgical tips to maximize outcomes. SUMMARY Plastic surgery has a long history of innovation expanding the conditions we can treat, and microsurgical reconstruction has played a pivotal role. Freestyle free flaps now create another paradigm shift in reconstructive surgery, relying on a better understanding of anatomy and physiology, opening the door to patient-specific customized reconstruction. This article aims to provide information regarding useful and practical new advances in the field of microsurgery.
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Scaglioni MF, Meroni M, Fritsche E. Free tissue transfer with supermicrosurgical perforator-to-perforator (P-to-P) technique for tissue defect reconstruction around the body: Technical pearls and clinical experience. J Plast Reconstr Aesthet Surg 2020; 74:1791-1800. [PMID: 33388271 DOI: 10.1016/j.bjps.2020.12.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 11/06/2020] [Accepted: 12/02/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Resorting to perforators as recipient vessels is a valid alternative that might offer a series of advantages in many situations. They allow the use of a shorter pedicle, reduce the time of dissection, and are a good solution when deep vessels are difficult to reach. The aim of this study is to investigate the efficacy of P-to-P tissue transfer for reconstructing defects in different areas of the body. PATIENTS AND METHODS Between April 2018 and February 2020, 40 patients presenting soft tissue defects were reconstructed by using P-to-P-anastomosed free flap transfer. The cause of the defect was trauma in 16 cases and surgically excised tumor in 24. Five defects were located in the upper extremities, 1 in the neck, 1 in the thorax, and 21 in the lower limb, and 13 cases were breast reconstructions, 2 of which bilateral (43 total flaps). RESULTS Of all 43 flaps, 22 were abdominal flaps, 17 flaps were harvested from the upper thigh, and 4 were harvested from the lower leg. At the 9 month follow-up, 42 flaps were successfully healed, 36 without complications, 3 after wound dehiscence, and 3 after wound infection, and only 1 flap was lost requiring further surgery. Flap failure rate was 2.3%. CONCLUSIONS Free flaps anastomosed in perforator-to-perforator fashion can be safely used in different settings throughout the body. Even if they are technically more demanding, they may allow a quicker operation time and lower morbidity. With the developments in microsurgical instruments, we believe that this technique may become the gold standard for tissue-defect reconstruction.
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Affiliation(s)
- Mario F Scaglioni
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland.
| | - Matteo Meroni
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Elmar Fritsche
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
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Wang X, Pan J, Xiao D, Li M, Huang T, Lu C, Lineaweaver WC, Chen H, Yang H. Comparison of arterial supercharging and venous superdrainage on improvement of survival of the extended perforator flap in rats. Microsurgery 2020; 40:874-880. [PMID: 33068317 DOI: 10.1002/micr.30660] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 08/28/2020] [Accepted: 09/03/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Arterial supercharging and venous superdrainage have been the commonly used vascular augmentation techniques for resolving partial loss of flaps in reconstructive surgery. It remains controversial which one of them is more effective in improving flap survival. The purpose of this study was to compare the effect of distal venous superdrainage and arterial supercharging on the survival of an extended dorsal perforator flap in rats. MATERIALS AND METHODS Sixty Sprague-Dawley rats were randomly divided into three groups (n = 20 in each group). An extended dorsal perforator flap with the size of 3 × 12 cm based on the deep circumflex iliac artery and vein was elevated in each rat. In arterial supercharging group, the thoracodorsal artery was retained as the distal supercharging vessel; In venous superdrainage group, the thoracodorsal vein was retained as the distal superdrainage vessel. In control group, no other arteries and veins were retained except the main vascular pedicle. On the seventh day after operation, the survival area of flap was calculated as a percentage of viable area to the total flap. Vascular changes in the choke zones were assessed by angiography. Microvascular density and diameter were assessed via immunohistochemistry staining of CD31 on the fifth day after operation. RESULTS The flap survival area in arterial supercharging group was significantly higher than that in venous superdrainage group (98.9 ± 0.8% vs. 81.5 ± 3.5%, p < .001). By gross observation, the extent of dilation of choke zone vessels in venous superdrainage group was smaller compared with that in arterial supercharging group. The density of CD31-positive vessels and the diameter of choke zone vessels in arterial supercharging group were significantly larger than that in venous superdrainage group (23.4 ± 4.6 mm-2 vs. 13.1 ± 4.2 mm-2 , p < .05; and 37.5 ± 5.8 μm vs. 27.8 ± 4.9 μm, p < .05). CONCLUSION Compared with venous superdrainage, distal arterial supercharging in the potential territory resulted in better survival of an extended dorsal perforator flap in a rat model.
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Affiliation(s)
- Xin Wang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China.,Department of Hand Surgery, Ningbo No. 6 Hospital, Ningbo, China
| | - Jiadong Pan
- Department of Hand Surgery, Ningbo No. 6 Hospital, Ningbo, China
| | - Dongchao Xiao
- Department of Hand Surgery, Ningbo No. 6 Hospital, Ningbo, China
| | - Miaozhong Li
- Department of Hand Surgery, Ningbo No. 6 Hospital, Ningbo, China
| | | | - Chenlin Lu
- Ningbo University Medical School, Ningbo, China
| | | | - Hong Chen
- Department of Hand Surgery, Ningbo No. 6 Hospital, Ningbo, China
| | - Huilin Yang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
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Scaglioni MF, Rodi T, Wishart K, Fritsche E. Unilateral breast reconstruction with the free contralateral split breast flap using supermicrosurgical anastomosis: A case report. Microsurgery 2020; 41:258-262. [PMID: 32949420 DOI: 10.1002/micr.30654] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 06/23/2020] [Accepted: 09/03/2020] [Indexed: 11/11/2022]
Abstract
Consecutive or simultaneous contralateral breast reduction is a frequent request from patients undergoing unilateral breast reconstruction. Both procedures can be combined using otherwise discarded tissue as a split breast graft for reconstruction of the contralateral side. There have been few reports on the use of pedicled split breast grafts. We present a 75-year-old female with multicentric mammary carcinoma following chemotherapy, mastectomy, axillary lymph node dissection and radiotherapy. She requested a reconstruction of the left breast as well as reduction of the right breast. Risk factors, including heavy alcohol and tobacco dependence and COPD, limited the surgical options. While a free flap breast reconstruction was the standard feasible option, we opted for a procedure with minimal surgery-related morbidity. The right breast was evidently tumor-free, and the patient had no family history of breast cancer. Reconstruction was performed 22 months postmastectomy. The split-breast free flap was based on the right internal mammary artery (IMA) perforator and harvested during the right-sided breast reduction. Microsurgical anastomosis was performed on the IMA perforator on the left side. Mastopexy was performed on the right side and the nipple-areola complex (NAC) was transferred to its new position as a free graft to complete the breast reduction. A tattoo of the left NAC was performed 4 months postreconstruction. There was complete flap survival with a pleasant cosmetic result. Split breast reconstruction could be an alternative to more common procedures. However, this approach is only feasible in patients with hypertrophic contralateral breast and absence of risk factors for developing a second primary breast cancer.
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Affiliation(s)
- Mario F Scaglioni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Timo Rodi
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland.,Heidelberg Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Katarina Wishart
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Elmar Fritsche
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
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Peng W, Lü C, Zhou B, Song D, Li Z. [Application and prospect of preoperative computed tomographic angiography in deep inferior epigastric artery perforator flap for breast reconstruction]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:927-931. [PMID: 32666740 DOI: 10.7507/1002-1892.201907017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To generalize the application and prospect of computed tomographic angiography (CTA) in deep inferior epigastric artery perforator (DIEP) flap transfer for breast reconstruction. Methods The related literature using CTA for DIEP flap reconstruction of breast in recent years was reviewed and analyzed. Results Preoperative CTA can accurately assess the vascular anatomy of the chest and abdomen wall, precisely locating the perforator in the abdominal donor site, and identifying the dominant perforator; guide the selection of intercostal space to explore internal mammary artery and internal mammary artery perforator in the chest recipient vessels. It can also reconstruct the volume of the abdominal flap with reference to the size of the contralateral breast and pre-shape the abdominal flap, which are crucial to formulate the surgical plan and improve the reliability of flap. Conclusion Preoperative CTA has enormous application potential and prospects in locating donor area perforator, in selecting recipient vessels, and in evaluating breast volume for autologous breast reconstruction with DIEP flap.
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Affiliation(s)
- Wen Peng
- Department of Head and Neck/Oncology Plastic Surgery, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Chunliu Lü
- Department of Head and Neck/Oncology Plastic Surgery, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Bo Zhou
- Department of Head and Neck/Oncology Plastic Surgery, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Dajiang Song
- Department of Head and Neck/Oncology Plastic Surgery, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Zan Li
- Department of Head and Neck/Oncology Plastic Surgery, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
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Abstract
Despite advances in supermicrosurgical techniques, the ability to anastomose vessels with a diameter of less than 0.2 mm remains limited. One of the reasons for this limitation is that the dilation methods currently available, such as inserting the tip of a microforceps into the lumen or topical application of a vasodilator such as papaverine hydrochloride or xylocaine spray, are not effective in very small vessels. To overcome this problem, we have developed a method whereby nylon monofilaments are placed inside the vessel lumen to act as a dilator. Using this method, a smaller nylon monofilament is inserted into the vessel as a guide before inserting a larger nylon monofilament as a dilator. After the smaller guide monofilament has been inserted, it is then much easier to insert another monofilament for dilation, even if it is a larger one. Using this method, even a vessel with a diameter of less than 0.1 mm could be dilated to greater than 0.2 mm. The dilator monofilament can also be used as an intravascular stent in the anastomosis. We have found that anastomosis of vessels with a diameter of less than 0.1 mm is possible using this method. In our experience, the immediate patency rate has been 100%. We believe mechanical dilation with a nylon monofilament is helpful for supermicrosurgery and even ultramicrosurgery.
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Lancien U, Brault N, Ouar N, Atlan M, Qassemyar Q. Bilateral pure adipose free flap for aesthetic purposes replacing infected malar implants: About a case and review of the literature. ANN CHIR PLAST ESTH 2019; 65:171-175. [PMID: 31421923 DOI: 10.1016/j.anplas.2019.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 07/18/2019] [Indexed: 10/26/2022]
Affiliation(s)
- U Lancien
- Department of Plastic, Reconstructive and Aesthetic Surgery, Microsurgery, Tissue Regeneration, centre hospitalier Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France.
| | - N Brault
- Department of Plastic, Reconstructive and Aesthetic Surgery, Microsurgery, Tissue Regeneration, centre hospitalier Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France
| | - N Ouar
- Department of Plastic, Reconstructive and Aesthetic Surgery, Microsurgery, Tissue Regeneration, centre hospitalier Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France
| | - M Atlan
- Department of Plastic, Reconstructive and Aesthetic Surgery, Microsurgery, Tissue Regeneration, centre hospitalier Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France; Sorbonne university, medical school, 91-105, boulevard de l'hôpital, 75013 Paris, France
| | - Q Qassemyar
- Department of Plastic, Reconstructive and Aesthetic Surgery, Microsurgery, Tissue Regeneration, centre hospitalier Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France; Sorbonne university, medical school, 91-105, boulevard de l'hôpital, 75013 Paris, France
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10
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Hong JP(J, Song S, Suh HSP. Supermicrosurgery: Principles and applications. J Surg Oncol 2018; 118:832-839. [DOI: 10.1002/jso.25243] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 08/23/2018] [Indexed: 12/30/2022]
Affiliation(s)
- Joon Pio (Jp) Hong
- Department of Plastic SurgeryAsan Medical Center, University of Ulsan College of MedicineSeoul Korea
| | - Sinyoung Song
- Department of Plastic SurgeryAsan Medical Center, University of Ulsan College of MedicineSeoul Korea
| | - Hyun Suk Peter Suh
- Department of Plastic SurgeryAsan Medical Center, University of Ulsan College of MedicineSeoul Korea
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Lee YJ, Baek SE, Lee J, Oh DY, Rhie JW, Moon SH. Perforating vessel as an alternative option of a recipient selection for posterior trunk-free flap reconstruction. Microsurgery 2018; 38:763-771. [DOI: 10.1002/micr.30369] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 06/15/2018] [Accepted: 07/18/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Yoon Jae Lee
- Department of Plastic and Reconstructive Surgery; Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea; Seoul South Korea
| | - Seung Eun Baek
- Department of Plastic and Reconstructive Surgery; Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea; Seoul South Korea
| | - Junho Lee
- Department of Plastic and Reconstructive Surgery; Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea; Seoul South Korea
| | - Deuk Young Oh
- Department of Plastic and Reconstructive Surgery; Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea; Seoul South Korea
| | - Jong Won Rhie
- Department of Plastic and Reconstructive Surgery; Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea; Seoul South Korea
| | - Suk-Ho Moon
- Department of Plastic and Reconstructive Surgery; Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea; Seoul South Korea
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Badash I, Gould DJ, Patel KM. Supermicrosurgery: History, Applications, Training and the Future. Front Surg 2018; 5:23. [PMID: 29740586 PMCID: PMC5931174 DOI: 10.3389/fsurg.2018.00023] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 03/01/2018] [Indexed: 11/13/2022] Open
Abstract
Supermicrosurgery, a technique of dissection and anastomosis of small vessels ranging from 0.3 to 0.8 mm, has revolutionized the fields of lymphedema treatment and soft tissue reconstruction. The technique offers several distinct benefits to microsurgeons, including the ability to manipulate small vessels that were previously inaccessible, and to minimize donor-site morbidity by dissecting short pedicles in a suprafascial plane. Thus, supermicrosurgery has become increasingly popular in recent years, and its applications have greatly expanded since it was first introduced 20 years ago. While supermicrosurgery was originally developed for procedures involving salvage of the digit tip, the technique is now routinely used in a wide variety of microsurgical cases, including lymphovenous anastomoses, vascularized lymph node transfers and perforator-to-perforator anastomoses. With continued experimentation, standardization of supermicrosurgical training, and high quality studies focusing on the outcomes of these novel procedures, supermicrosurgery can become a routine and valuable component of every microsurgeon's practice.
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Affiliation(s)
- Ido Badash
- Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Daniel J Gould
- Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, CA, United States
| | - Ketan M Patel
- Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, CA, United States
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Seo SW, Kim KN, Ha W, Yoon CS. Validity of the use of a subfascial vessel as the recipient vessel in a second free flap transfer: A retrospective clinical review. Medicine (Baltimore) 2018; 97:e9819. [PMID: 29384886 PMCID: PMC5805458 DOI: 10.1097/md.0000000000009819] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Performing a greater number of free flap procedures inevitably results in an increase in the number of cases that experience free flap failure. In cases that require a second free flap after the failure of the first, recipient vessel selection becomes difficult. Furthermore, recipient vessel selection can be complicated if the vessel is deep in the recipient site, or if there is an increased risk of vessel damage during the dissection. Thus, we present our experience where a subfascial vessel beneath the deep fascia was used as a recipient vessel for a second free flap in lower extremity reconstruction due to total or partial first flap failure.Between January 2010 and April 2015, 5 patients underwent second free flap reconstruction using a subfascial vessel as the recipient vessel. The flaps were anastomosed in a perforator-to-perforator manner, using the supermicrosurgery technique. We measured the sizes of the flaps, which varied from 5 × 3 to 15 × 8 cm, and the recipient subfascial vessel diameters.The mean time for the dissection of the recipient perforator was 45 minutes. All the flaps exhibited full survival, although a partial loss of the skin graft at the flap donor site was observed in 1 patient; this defect healed with conservative management.We recommend using a subfascial vessel as the recipient vessel for both first and second free flaps, especially if access to the major vessel is risky or challenging.
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Affiliation(s)
- Sang Won Seo
- Department of Emergency Medicine, Eulji University Hospital, University of Eulji College of Medicine, Seo-Gu, Daejeon
| | - Kyu Nam Kim
- Department of Plastic and Reconstructive Surgery, Konyang University Hospital, University of Konyang College of Medicine, Myunggok Medical Research Center, Daejeon
| | - Won Ha
- Department of Plastic and Reconstructive Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Dong-Gu, Ulsan, Korea
| | - Chi Sun Yoon
- Department of Plastic and Reconstructive Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Dong-Gu, Ulsan, Korea
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An Appraisal of Internal Mammary Artery Perforators as Recipient Vessels in Microvascular Breast Reconstruction-An Analysis of 515 Consecutive Cases. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 4:e1144. [PMID: 28293504 PMCID: PMC5222649 DOI: 10.1097/gox.0000000000001144] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 10/05/2016] [Indexed: 11/25/2022]
Abstract
Background: The usage of internal mammary artery perforators (IMAPs) has been described in autologous breast reconstruction although IMAPS are not yet considered standard recipient vessels. It remains unclear if these vessels can be safely used in large flaps after radiation therapy or in delayed breast reconstruction. Methods: Over a 2-year period, 515 free flaps for autologous breast reconstruction were performed on 419 patients by 2 surgeons (S1 and S2). In a retrospective analysis, time of reconstruction, ischemia time, flap weight, diameter of couplers, and complications were analyzed. All 515 flaps were compared in a subset with regard to the 2 surgeons: S1 who always used the IMA as a recipient vessel and S2 who attempted IMAP use if possible. Results: Of all 515 flaps, 424 were abdominal flaps and 91 flaps were from the upper thigh. Three hundred six cases were immediate reconstructions, and 112 were delayed reconstructions. In 97 cases, implants were converted to autologous tissue. In 112 cases, the IMAPs were used; of these, 82 were immediate and 17 were delayed reconstructions, and in 13 cases, implants were removed. Thirty-five percent of all anastomoses to IMAPs had previous radiation therapy. The flap failure rate was 1.9%. In none of these cases, the IMAPs were used. S1 never used the IMAP, and S2 used the IMAP in 37% of all of his flaps. Conclusions: IMAPs were safely used in all kinds of reconstructions and after radiation therapy, with no flap failure or negative effects on mastectomy skin flap perfusion. Using the IMAPs as recipient vessels is a further step toward simplifying microsurgical breast reconstruction.
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"Mini-Flow-Through" Deep Inferior Epigastric Perforator Flap for Breast Reconstruction with Preservation of Both Internal Mammary and Deep Inferior Epigastric Vessels. Arch Plast Surg 2015; 42:783-7. [PMID: 26618128 PMCID: PMC4659994 DOI: 10.5999/aps.2015.42.6.783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 08/21/2015] [Accepted: 09/14/2015] [Indexed: 11/08/2022] Open
Abstract
This procedure was developed for preservation of the rectus muscle components and deep inferior epigastric vessel after deep inferior epigastric perforator (DIEP) flap harvesting. A 53-year-old woman with granuloma caused by silicone injection underwent bilateral nipple-sparing mastectomies and immediate reconstruction with "mini-flow-through" DIEP flaps. The flaps were dissected based on the single largest perforator with a short segment of the lateral branch of the deep inferior epigastric vessel that was transected as a free flap for breast reconstruction. The short segments of the donor deep inferior epigastric vessel branch are primarily end-to-end anastomosed to each other. A short T-shaped pedicle mini-flow-through DIEP flap is interposed in the incised recipient's internal mammary vessels with two arterial and four concomitant venous anastomoses. Although it requires multiple vascular anastomoses and a short pedicle for the flap setting, the mini-flow-through DIEP flap provides a large pedicle caliber, enabling safer microsurgical anastomosis and well-vascularized tissue for creating a natural breast without consuming time or compromising the rectus muscle components and vascular flow of both the deep inferior epigastric and internal mammary vessels.
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The Pacman Perforator-Based V-Y Advancement Flap for Reconstruction of Pressure Sores at Different Locations. Ann Plast Surg 2015; 77:324-31. [PMID: 26418776 DOI: 10.1097/sap.0000000000000613] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Many procedures have been proposed for the treatment of pressure sores, and V-Y advancement flaps are widely used to repair a defect. Unfortunately, the degree of mobility of a V-Y advancement flap is dependent on the laxity of the underlying subcutaneous tissue. This is an important disadvantage of traditional V-Y advancement flap and limits its use.We used V-Y advancement flaps as perforator-based to overcome mobility restriction problem, with a further modification (Pacman-like shape) to improve the covering surface area of the flap. METHODS Between January 2012 and December 2014, the authors used 37 V-Y Pacman perforator-based flaps in 33 consecutive patients for coverage of defects located at sacral (n = 21), ischial (n = 13), trochanter (n = 1) regions. There were 27 male and 6 female patients with a mean age of 49.9 years (range, 15-74 years). RESULTS All flaps survived completely (92.3%) except 3 in which one of them had undergone total necrosis due to hematoma and the other 2 had partial necrosis. No venous congestion was observed. The mean follow-up period was 14.9 months (range, 2-38 months). No flap surgery-related mortality or recurrence of pressure sores was noted. CONCLUSIONS The V-Y Pacman perforator-based advancement flaps are safe and very effective for reconstruction of pressure sores at various regions. The advantage of our modification procedure include shorter operative time, lesser pedicle dissection, low donor site morbidity, good preservation of muscle, and offers remarkable excursion to the V-Y flap, which make the V-Y Pacman perforator-based flaps an excellent choice for large pressure sore coverage.
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Qassemyar Q, Gianfermi M. Supermicrosurgery and hyaluronic acid: experimental feasability study of a new method. ANN CHIR PLAST ESTH 2014; 60:e59-65. [PMID: 25447214 DOI: 10.1016/j.anplas.2014.08.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 08/28/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION As a technique of anastomosis for vessels of less than 0.8mm in diameter, supermicrosurgery has aroused renewed interest on account of its potential clinical applications. The technical difficulty of surgery at such a small scale necessitates exploration of new methods likely to render the anastomoses accessible and reliable. The aim of this article is to present the results of an experimental study on the feasibility of anastomoses (arterial diameter ≤0.5mm), assisted by the injection of hyaluronic acid (HA). MATERIALS AND METHODS Ten end-to-end arterial anastomoses of the inferior epigastric artery (diameter ≤0.5mm) were performed in 5 rats. An injection of HA had previously been carried out in the vessel lumen and the sutures were made with 12-0 nylon. Immediate and 3-day permeability were controlled and anastomosis times were measured. RESULTS Average diameter of the arteries was 0.42 mm (range 0.29-0.48 mm). Mean anastomosis duration was 19.5 min (range 15-23 min). The average number of stitches was 6. Immediate patency was 100% with a success rate of 80% at 3 days. CONCLUSIONS The properties of HA seem to effectively facilitate anastomoses of arteries with a diameter ≤0.5mm. HA provides comfort and promotes safety in performance of exceedingly small-scale surgery. While the results appear promising, but further studies are needed in order to determine the potential toxicity of this method on tissues.
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Affiliation(s)
- Q Qassemyar
- Service de chirurgie plastique et reconstructrice, Gustave-Roussy, cancer campus Grand-Paris, 114, rue Édouard-Vaillant, 94805 Villejuif, France; Laboratoire d'anatomie et d'organogenèse, université de Picardie Jules-Verne, rue des Louvels, 80000 Amiens, France.
| | - M Gianfermi
- Laboratoire d'anatomie et d'organogenèse, université de Picardie Jules-Verne, rue des Louvels, 80000 Amiens, France
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Araki J, Mihara M, Narushima M, Iida T, Sato T, Koshima I. Vascularized anal autotransplantation model in rats: preliminary report. Transplant Proc 2014; 43:3552-6. [PMID: 22099840 DOI: 10.1016/j.transproceed.2011.08.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Ostomy has served as an effective surgery for various anorectal disfunctions. However, it must also be noted that those patients suffered greatly from stresses caused by their stoma. Many alternative therapies have been developed, but none have solved this critical issue. Meanwhile, due to the improvements in operative methods and immunosuppressive therapy, allotranplantation has gained great popularity in recent years. Therefore, we began development of an anal transplantation model. The operation was performed in six adult Wistar rats that were divided into two groups. Group 1 underwent vascular anastomoses, while group 2 did not Group 1 grafts survived, fully recovering anal function. However, many of the group 2 grafts did not survive; those that did survive showed major defects in their anus, never recovering anal function. We succeeded in establishing the rat anal transplantation model utilizing super-microsurgery. While research in anal transplantation was behind compared to that in other fields, we hope that this model will bring significant possibilities for the future.
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Affiliation(s)
- J Araki
- Department of Plastic Surgery, University of Tokyo, Tokyo, Japan.
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Eburdery H, Chaput B, Andre A, Grolleau JL, Chavoin JP, Lauwers F. Can we consider standard microsurgical anastomosis on the posterior tibial perforator network? An anatomical study. Surg Radiol Anat 2014; 36:747-53. [PMID: 24482060 DOI: 10.1007/s00276-014-1261-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 01/17/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE The main vessels in an injured leg can be spared with perforator-to-perforator anastomosis. However, supermicrosurgery is not a routine procedure for all plastic surgeons. Our objective was to establish if the diameter of the perforators of the leg could allow anastomosis with standard microsurgical procedures. METHODS Twenty lower legs harvested from ten fresh cadavers were dissected. Arterial and venous vessels were injected with colored latex. The limbs were then dissected in a suprafascial plane. All the perforating arteries of a diameter >0.8 mm were located and their external diameter, the number and external diameter of the venae comitantes were reported. RESULTS We found at least three tibial posterior artery perforators with diameters >0.8 mm per leg with a mean external diameter of 1.1 mm and one vena comitans in almost all cases (96 %). The vena comitans was usually bigger than the perforating artery with a mean diameter of 1.6 mm. After statistical analysis, we were able to locate two main perforator clusters: at the junctions of the upper two-thirds of the leg and of the lower two-thirds of the leg. CONCLUSION The low-morbidity concept of perforator-to-perforator anastomosis can apply to posterior tibial artery perforators without using supermicrosurgical techniques. This is of high interest for open leg fractures where main vessels could be injured. We hope that the results of our study will incite surgeons to consider sparing of main vessels for coverage of open leg fractures whether surgical teams master supermicrosurgery or not.
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Affiliation(s)
- Harold Eburdery
- Plastic and Reconstructive Surgery Unit, CHU Toulouse Rangueil, 1 avenue Jean Poulhès, 31400, Toulouse, France,
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Comparing five alternative methods of breast reconstruction surgery: a cost-effectiveness analysis. Plast Reconstr Surg 2014; 132:709e-723e. [PMID: 24165623 DOI: 10.1097/prs.0b013e3182a48b10] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to assess the cost-effectiveness of five standardized procedures for breast reconstruction to delineate the best reconstructive approach in postmastectomy patients in the settings of nonirradiated and irradiated chest walls. METHODS A decision tree was used to model five breast reconstruction procedures from the provider perspective to evaluate cost-effectiveness. Procedures included autologous flaps with pedicled tissue, autologous flaps with free tissue, latissimus dorsi flaps with breast implants, expanders with implant exchange, and immediate implant placement. All methods were compared with a "do-nothing" alternative. Data for model parameters were collected through a systematic review, and patient health utilities were calculated from an ad hoc survey of reconstructive surgeons. Results were measured in cost (2011 U.S. dollars) per quality-adjusted life-year. Univariate sensitivity analyses and Bayesian multivariate probabilistic sensitivity analysis were conducted. RESULTS Pedicled autologous tissue and free autologous tissue reconstruction were cost-effective compared with the do-nothing alternative. Pedicled autologous tissue was the slightly more cost-effective of the two. The other procedures were not found to be cost-effective. The results were robust to a number of sensitivity analyses, although the margin between pedicled and free autologous tissue reconstruction is small and affected by some parameter values. CONCLUSIONS Autologous pedicled tissue was slightly more cost-effective than free tissue reconstruction in irradiated and nonirradiated patients. Implant-based techniques were not cost-effective. This is in agreement with the growing trend at academic institutions to encourage autologous tissue reconstruction because of its natural recreation of the breast contour, suppleness, and resiliency in the setting of irradiated recipient beds.
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Boucher F, Mojallal A. Atlas des artères perforantes de la peau du tronc et des membres – Guide dans la réalisation des lambeaux perforants. ANN CHIR PLAST ESTH 2013; 58:644-9. [DOI: 10.1016/j.anplas.2013.04.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 04/21/2013] [Indexed: 12/11/2022]
Affiliation(s)
- F Boucher
- Service de chirurgie plastique, reconstructrice et esthétique, hôpital de la Croix Rousse, centre hospitalier universitaire, hospices civils de Lyon, 103, Grande rue de la Croix Rousse, 69004 Lyon, France.
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Computed Tomographic Angiography Imaging and Clinical Implications of Internal Mammary Artery Perforator Vessels as Recipient Vessels in Autologous Breast Reconstruction. Ann Plast Surg 2013; 71:533-7. [PMID: 22868328 DOI: 10.1097/sap.0b013e31824e29c2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Saba L, Atzeni M, Rozen WM, Alonso-Burgos A, Bura R, Piga M, Ribuffo D. Non-invasive vascular imaging in perforator flap surgery. Acta Radiol 2013; 54:89-98. [PMID: 23125392 DOI: 10.1258/ar.2012.120245] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Preoperative imaging using a range of imaging modalities has become increasingly popular for preoperative planning in plastic surgery, in particular in perforator flap surgery. Modalities in this role include ultrasound (US), magnetic resonance angiography (MRA), and computed tomographic angiography (CTA). The evidence for the use of these techniques has been reported in only a handful of studies. In this paper we conducted a non-systematic review of the literature to establish the role for each of these modalities. The role of state-of-the-art vascular imaging as an application in perforator flap surgery is thus offered.
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Affiliation(s)
- Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (AOU), di Cagliari - Polo di Monserrato, Cagliari, Italy.
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Taeger CD, Horch RE, Dragu A, Beier JP, Kneser U. [Perforator flaps. A new era in reconstructive surgery]. Chirurg 2012; 83:163-71. [PMID: 21748383 DOI: 10.1007/s00104-011-2137-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Multimodal therapeutic concepts in cancer therapy more and more often allow a curative approach even in advanced stages of the disease. Frequently, however, the radical resection of tumor tissue results in a significant defect of the soft tissue and the reconstruction is a challenge for reconstructive surgery. As tissue engineering for artificial tissue replacement predominantly still remains experimental, reconstruction of defects with autologous tissue constitutes state of the art treatment. Different types of flaps are used, which are, however, are accompanied by sometimes substantial defects at the donor site. To reduce donor site morbidity so-called perforator flaps represent an interesting option in modern reconstructive surgery. The flaps are raised without the underlying muscle which means a reduction of donor site morbidity to a minimum. As there still remains a residual risk for failure precise preoperative planning should be given a high priority. The use of modern imaging procedures, such as computed tomography (CT) angiography, can minimize the risk of total loss of the flap, making the use of perforator flaps a safe procedure in modern reconstructive surgery.
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Affiliation(s)
- C D Taeger
- Plastisch- und Handchirurgische Klinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstrasse 12, Erlangen, Germany
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Microvascular Anastomosis of Vessels Less Than 0.5 mm in Diameter: A Supermicrosurgery Training Model in Lagos, Nigeria. J Hand Microsurg 2012; 3:15-7. [PMID: 22654412 DOI: 10.1007/s12593-011-0035-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Accepted: 02/01/2011] [Indexed: 10/18/2022] Open
Abstract
The development of reconstructive microsurgery has now reached the supermicrosurgery stage. However the anastomosis of vessels under 0.5 mm is still out of the comfort zone of the many microsurgeons. To confirm the technical feasibility and the reliability of this technique We relate our own experience in this regard using the free superficial inferior epigastric flap of the rat as a model for supermicrosurgery training at the Microsurgery Laboratory of the Lagos University teaching hospital. 18 of the 20 free flaps transferred survived at 1 week. Two flaps necrosed and two flaps dehisced. We believe based on our work that the average microsurgeon can become comfortable working with these vessels.
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Abstract
Lower back defects remain a major challenge for reconstructive surgeons. Advances in perforator flap techniques now make it possible to repair lower back defects using a gluteal perforator flap based on the free-style flap design. We used a free-style gluteal perforator flap in 10 patients with lower back defects due to skin cancer treatment (6 patients) or infection following spine surgery (4 patients). V-Y advancement flaps were used for defects <6 cm in length, and rotation flaps for defects >6 cm. Perforators were detected at the upper parasacral area, and the flap design was drawn on the skin of the upper gluteal region. Coverage was successful and donor sites were closed primarily in all cases. There were 4 complicated cases: 1 of partial flap loss that led to delay of the wound closure, 2 of initial venous congestion, and 1 of hematoma. These complications resolved, and there was no case of flap loss during a 12 to 62 months follow-up (mean, 32.4 months). The present series indicated that the free-style gluteal perforator flap provides a safe, effective, and relatively easy option for lower back defect reconstruction.
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Qassemyar Q, Sinna R. De la microchirurgie à la « supermicrochirurgie » : étude expérimentale de faisabilité et perspectives. ANN CHIR PLAST ESTH 2011; 56:518-27. [DOI: 10.1016/j.anplas.2010.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2010] [Accepted: 11/15/2010] [Indexed: 10/18/2022]
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Simultaneous Contralateral Breast Reduction/Mastopexy With Unilateral Breast Reconstruction Using Free Abdominal Flaps. Ann Plast Surg 2011; 67:336-42. [DOI: 10.1097/sap.0b013e31820859c5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Quantitative regression analysis of the cutaneous vascular territories in a rat model. Surg Radiol Anat 2011; 33:789-99. [PMID: 21455836 DOI: 10.1007/s00276-011-0809-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Accepted: 03/16/2011] [Indexed: 12/31/2022]
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Abstract
The introduction of supermicrosurgery, which allows the anastomosis of smaller caliber vessels and microvascular dissection of vessels ranging from 0.3 to 0.8mm in diameter, has led to the development of new reconstructive techniques. New applications of this technique are for crushed fingertip replantations with venule grafts, toe tip transfers for fingertip loss, partial auricular transfers for total tracheal and eyelid defects, and lymphaticovenular anastomoses under local anesthesia for lymphedema. Regarding free flaps, free perforator-to-perforator flaps, including deep inferior epigastric perforator or paraumbilical perforator flaps, gluteal artery perforator flaps, thoracodorsal artery perforator flaps, anterolateral thigh perforator flaps, superficial circumflex iliac artery perforator flaps, tensor fasciae lata perforator flaps, and medial plantar perforator flaps, with a short pedicle, have been used for extremity and facial defects. The success rate is almost the same as that of usual free flap transfers with large and long pedicles. The advantages of these flaps are the simple operation and the short time needed for flap elevation, plus the fact that the flaps can be obtained from anywhere in concealed areas. The disadvantages are the need for supermicrosurgical technique and the anatomic variation of these perforators.
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Discussion: Lymphaticovenular bypass for lymphedema management in breast cancer patients: a prospective study. Plast Reconstr Surg 2010; 126:759-761. [PMID: 20811211 DOI: 10.1097/prs.0b013e3181e71034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The Single Dominant Medial Row Perforator DIEP Flap in Breast Reconstruction: Three-Dimensional Perforasome and Clinical Results. Plast Reconstr Surg 2010; 126:739-751. [DOI: 10.1097/prs.0b013e3181e5f844] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Using perforators as recipient vessels (supermicrosurgery) for free flap reconstruction of the knee region. Ann Plast Surg 2010; 64:291-3. [PMID: 20179475 DOI: 10.1097/sap.0b013e3181ac4263] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The purpose of this article is to evaluate the feasibility of a perforator as a recipient vessel to reconstruct soft tissue defects of the knee region.From December of 2006 to August of 2008, total of 25 patients underwent reconstructive procedure using either an anterolateral thigh or an upper medial thigh perforator flap. The flaps were anastomosed in a perforator to perforator manner using supermicrosurgery technique.Minimum of 3 perforators were traced around the knee defect. All flaps survived attached to a recipient perforator with artery diameter ranging from 0.4 to 0.9 mm and accompanying veins ranging from 0.4 to 1.2 mm. This approach allowed reduction in time for pedicle and recipient vessel dissection and minimized the trauma involved during isolation of the vessels.Using the perforator as recipient vessel allows an increase in selection for choice of recipient. By using a perforator as recipient, less time is consumed to secure the vessel, does not need long pedicles for flap, is not bound by the condition of major arteries, and minimizes any risk for major vessel injury while having acceptable flap survival.
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Takeishi M, Fujimoto M, Ishida K, Makino Y. Muscle sparing-2 transverse rectus abdominis musculocutaneous flap for breast reconstruction: a comparison with deep inferior epigastric perforator flap. Microsurgery 2009; 28:650-5. [PMID: 18844226 DOI: 10.1002/micr.20563] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Breast reconstruction using free transverse rectus abdominis musculocutaneous (TRAM) flap can be divided into 4 muscle-sparing (MS) types: conventional TRAM flap containing full width muscle as MS-0, while deep inferior epigastric perforator (DIEP) flap containing absolutely no muscle as MS-3. We include only the muscle portion between the medial row and lateral row perforator vessels in TRAM flap, which is designated as MS-2. Between October 1999 and April 2006, the same surgeon performed 82 breast constructions using MS-2 free TRAM flaps in 79 patients. All the flaps survived. Postoperative complications included partial fat necrosis in 8 cases, all corresponding to zone IV or zone II. Bulging of donor site occurred in 5 patients, 4 of whom were obese and 1 had bilateral flap harvest. Compared with our own reconstructions using DIEP flap (30 cases), there were no significant differences in operative time and blood loss between the two techniques. In conclusion, MS-2 free TRAM flap is a useful technique for breast construction considering the easy surgical techniques, length of the vascular pedicle that can be harvested, and the degree of freedom of the flap.
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Affiliation(s)
- Meisei Takeishi
- Department of Plastic and Reconstructive Surgery, Jikei University School of Medicine, Minatoku, Tokyo, Japan.
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The Use of Supermicrosurgery in Lower Extremity Reconstruction: The Next Step in Evolution. Plast Reconstr Surg 2009; 123:230-235. [PMID: 19116557 DOI: 10.1097/prs.0b013e3181904dc4] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Successful microvascular ear replantation is well described, and often involves the use of arterial inflow anastomoses with leeches and systemic anticoagulation to augment outflow. Failed replantation attempts have also been published, with most of the failures attributed to venous drainage problems. A case of successful replantation of an ear is presented using a single 0.5-mm arteriovenous anastomosis, as no suitable artery could be identified in the amputated part. Postoperatively, dextran and leech therapies were employed to promote adequate venous drainage. We report a 100% successful ear replantation using a single arterialized vein as the inflow. In situations where no adequate artery is identifiable in the amputated part, an arteriovenous anastomosis may be a suitable alternative.
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Lasso JM, Sancho M, Campo V, Jiménez E, Pérez Cano R. Epiperitoneal vessels: more resources to perform DIEP flaps. J Plast Reconstr Aesthet Surg 2008; 61:826-9. [PMID: 17446150 DOI: 10.1016/j.bjps.2007.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2006] [Revised: 10/20/2006] [Accepted: 03/06/2007] [Indexed: 11/30/2022]
Abstract
The development of the DIEP flap established an accepted concept of reconstructive surgery, but in patients who demonstrate inadequate in vivo flap perfusion, alternative surgical options to improve vascularisation are limited. We present a 42-year-old patient, with a left mastectomy whose breast was reconstructed with a DIEP flap. After anastomosis to the internal mammary vessels there was insufficient arterial perfusion of the flap. The situation was resolved by using an independent medial perforator artery emerging from the peritoneal layer (epiperitoneal vessels). This new pedicle was anastomosed end-to-end to the distal portion of the inferior epigastric artery. We consider that epiperitoneal vessels can be an emergency pedicle when needed and a possible alternative to the main pedicle of the DIEP flap.
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Affiliation(s)
- J M Lasso
- Hospital General Universitario Gregorio Marañón, Servicio de Cirugía Plástica y Reparadora, Madrid, Spain.
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Thoma A, Sprague S, Temple C, Archibald S. The Role of the Randomized Controlled Trial in Plastic Surgery. Clin Plast Surg 2008; 35:275-84. [DOI: 10.1016/j.cps.2007.10.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Thoma A, Strumas N, Rockwell G, McKnight L. The Use of Cost-effectiveness Analysis in Plastic Surgery Clinical Research. Clin Plast Surg 2008; 35:285-96. [DOI: 10.1016/j.cps.2007.10.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Schoeller T, Wechselberger G, Roger J, Hussl H, Huemer GM. Management of infraumbilical vertical scars in DIEP-flaps by crossover anastomosis. J Plast Reconstr Aesthet Surg 2007; 60:524-8. [PMID: 17399662 DOI: 10.1016/j.bjps.2006.11.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2006] [Revised: 06/26/2006] [Accepted: 11/04/2006] [Indexed: 11/19/2022]
Abstract
The deep inferior epigastric perforator (DIEP)-flap continues to be the standard treatment in microsurgical breast reconstruction. Reasons for the popularity of the DIEP-flap include the availability of a large amount of tissue for the reconstruction of large breasts, a reliable vascular anatomy and an aesthetically pleasing donor site scar. However, the DIEP-flap is not considered the optimal choice as the donor tissue in all patients. Previous abdominal surgeries with resulting scars may threaten the success of a free DIEP-flap due to compromised vascularity within the flap. We elaborated a technique to increase the safety of breast reconstruction with the DIEP-flap in the presence of an infraumbilical vertical scar. After raising the DIEP-flap in a traditional manner on one side with harvesting of a considerate length of the inferior epigastric vessels, a segment of the superior epigastric vessels is left attached to the main pedicle. This stump of the superior epigastric vessels is now anastomosed under the microscope to a paraumbilical perforator on the contralateral side of the flap for in-flap microvascular augmentation. The above-mentioned technique was applied in five patients who presented with an infraumbilical vertical scar and were reconstructed with a DIEP-flap because of breast cancer. In three of the five patients there was an additional risk factor present such as smoking or diabetes mellitus. In all five patients no major complication due to marginal perfusion of the contralateral side of the flap was encountered. In two patients there was minor breakdown of fatty tissue that was managed conservatively in both cases. In-flap microvascular augmentation of DIEP-flaps is a valuable tool for the plastic surgeon in microvascular breast reconstruction. It permits usage of the lower abdominal tissue even if perfusion is compromised due to midline scarring. We recommend this technique as a safe alternative in patients seeking autologous breast reconstruction in the presence of a midline abdominal scar.
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Affiliation(s)
- Thomas Schoeller
- Clinical Department of Plastic and Reconstructive Surgery, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria
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Yildirim S, Taylan G, Aköz T. Freestyle Perforator-Based V-Y Advancement Flap for Reconstruction of Soft Tissue Defects at Various Anatomic Regions. Ann Plast Surg 2007; 58:501-6. [PMID: 17452833 DOI: 10.1097/01.sap.0000247953.36082.f4] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Perforator flap surgery has gained great popularity in the last decade because surgeons can prepare freestyle flaps in anywhere on the body if they find a perforator supplied to the flap. One of the basic principles of reconstructive surgery is that superior results can be obtained for color and texture match if immediately adjacent soft tissue is used to repair a defect. V-Y advancement flaps are used successfully based on this principle, but the degree of mobility of a V-Y advancement flap is dependent on the laxity of the underlying subcutaneous tissue. This is an important disadvantage of traditional V-Y advancement flap and limits its use. METHODS We used V-Y advancement flaps as perforator-based to overcome mobility restriction problem. The authors used 26 perforator-based V-Y advancement flaps in 24 consecutive patients for coverage of defects located at sacral (4), thigh (6), abdominal wall (3), inguinal (3), back (4), leg (2), and trochanter (2) regions. There were 14 female and 10 male patients with a mean age of 48.3 years (range, 22-70 years). RESULTS The patients were followed up for a mean period of 14.2 months (range, 9-21 months). The size of the defects ranged from 3 x 5 cm to 15 x 20 cm. All flaps survived completely (92.4%) except 2 in which one of them had undergone total necrosis and the other had marginal necrosis. Fifteen flaps (57.6%) were elevated based on 2 perforators, 7 flaps (26.9%) were used with only one perforator, and the remaining 4 (15.5%) had 3 perforators. CONCLUSIONS Perforator-based V-Y advancement flaps are safe and very effective for coverage of defects in which closure is impossible with a standard V-Y advancement flap. Dissection of the perforator or perforators offers remarkable excursion to the V-Y flap with minimal donor site morbidity. These axial pattern flaps can be used successfully with good esthetic and functional results at various regions of the body if there is any detectable perforator.
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Affiliation(s)
- Serkan Yildirim
- Department of Plastic and Reconstructive Surgery, Dr. Lütfi Kirdar Kartal Education and Research Hospital, Istanbul, Turkey.
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Ozkan O, Koshima I, Gonda K. A supermicrosurgical flap model in the rat: a free true abdominal perforator flap with a short pedicle. Plast Reconstr Surg 2006; 117:479-85. [PMID: 16462329 DOI: 10.1097/01.prs.0000197215.94170.b8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Perforator flaps have recently gained considerable popularity in reconstructive surgery, and their importance and advantages over conventional flaps have been widely accepted. Given the improvements in microsurgical techniques, researchers have encouraged the search for further perforator flap sources, such as a perforator flap with a short pedicle only. The purpose of this study was to describe a true perforator flap model with a short vascular pedicle in the abdominal region in the rat. METHODS Twenty-six adult Sprague-Dawley rats weighing 400 to 500 g were used. In 10 rats, the perforator vascular anatomy of the abdominal region was determined by anatomic dissection. In the remaining 16 rats, a true abdominal perforator-based flap was created based on a short segment of deep epigastric vessels. In eight rats, the flap was transferred to the groin region as a free flap, and anastomosis was performed between the artery and vein of the flap and the superficial inferior epigastric artery and vein of the recipient site. In addition, in two of these flaps, the long thoracic vein of the flap was anastomosed to the femoral vein. In the remaining eight rats, the flap was transferred to the groin region, but in this group anastomosis was not performed. The latter group was designated as the control group. RESULTS The skin islands of seven free perforator flaps survived completely, and the one remaining flap was determined to be necrotic. All the flaps in the control group underwent complete necrosis. CONCLUSIONS Not only is the free abdominal perforator flap a reliable and true perforator flap model for future physiological, biological, and pharmacological studies, it is also an excellent self-controlled supermicrosurgical training model for learning proper techniques, meticulous intramuscular dissection of true perforator flaps, and anastomosis of small-caliber vessels.
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Affiliation(s)
- Omer Ozkan
- Department of Plastic and Reconstructive Surgery, Akdeniz University Faculty of Medicine, Antalya, Turkey.
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Abstract
Perforator flaps increasingly find acceptance and use in the field of reconstructive surgery due to their decreased donor-site morbidity and increased like-tissue coverage. Nevertheless, they are more prone to vascular compromise, especially when the meticulous technique they require is not employed. Pedicle twisting is a condition occasionally encountered in flap procedures, sometimes inadvertently, sometimes inevitably. In this study, circulatory comprise induced by twisting of the pedicle on a true perforator flap in a rat model is investigated.Thirty-eight Wistar-Albino rats were randomized into 4 groups, and cranial epigastric artery true perforator flaps were elevated on a single perforator. The flaps were returned as they were in the control group (n = 9), and with 90 degrees , 180 degrees , and 270 degrees of torsion in groups 2 (n = 9), 3 (n = 10), and 4 (n = 10), respectively. The flaps were evaluated by their flap survival area, weight, and histopathological appearance by the end of the first week. The mean flap survival ratios for groups 1, 2, 3, and 4 were 97.78 +/- 4.41%, 72.22 +/- 44.10%, 73.50 +/- 30.46%, and 30 +/- 30.18% (mean +/- SD), respectively. The degree of degenerative changes in group 4 was found to be statistically significant (P < 0.016).Our histopathological examinations indicate that vascular compromise was moderate in group 3 and severe in group 4. Our findings suggest that under normal conditions, the pedicle of a true perforator flap must not be twisted more than 180 degrees .
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Affiliation(s)
- Ahmet Demir
- Department of Plastic and Reconstructive Surgery, Ondokuz Mayis University, Medical Faculty, Samsun, Turkey.
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