Anatomical Understanding of Target Subcutaneous Tissue Layer for Thinning Procedures in Thoracodorsal Artery Perforator, Superficial Circumflex Iliac Artery Perforator, and Anterolateral Thigh Perforator Flaps

Resurfacing of multiple adjacent defects with free multipaddle SCIAP flaps

BACKGROUND

The efficient resurfacing of multiple adjacent defects (MADs) requires precise reconstructive strategy. Various approaches (e.g., several flap transferring or prelamination of the recipient site) have been reported, but recipient-site impairments, pain, long hospitalization, and low cost-benefit results fatefully considered them as compromise approaches. This study aims to evaluate the feasibility of MADs reconstruction with free multipaddle superficial circumflex iliac artery perforator (SCIAP) flaps.

METHODS

From Dec 2015 to Dec 2020, we enrolled patients with upper and lower extremity defects treated with various multipaddle SCIAP flaps (2-paddle, 3-paddle, and 4-paddle). Patient demographics and outcomes of each group were collected.

RESULTS

Thirty-two, 21, and 6 patients underwent 2-paddle, 3-paddle, and 4-paddle SCIAP flaps transfers, respectively. All multipaddle SCIAP flaps survived without vascular problems, and the donor sites were closed directly. Except for 3 cases of 2-paddle SCIAP flaps drained by superficial circumflex iliac vein venous return, most cases (n = 56) were drained by venae comitans. Minor complications, including partial flap necrosis (4 cases) and lateral femoral cutaneous nerve palsies (11 cases), were treated conservatively. All patients were satisfied with the reconstructive outcome.

CONCLUSION

Multiple adjacent defects reconstruction is still a Gordian knot and lacks a golden standard. The free multipaddle SCIAP flap was demonstrated as a promising alternative, not only enriching its versatility but also initially highlighting the "replace need with need" reconstructive demand.

High-frequency ultrasound-assisted perforator mapping enhances efficiency in microsurgical reconstruction using thin ALT and SCIP flaps

BACKGROUND

With the growing demand for the use of thin perforator flaps, obtaining knowledge on the superficial anatomy of perforators is imperative for stable flap elevation. Conventional modalities for perforator mapping fall short in providing such information. High-frequency ultrasound (HFUS), known for visualizing the superficially located anatomic structures, may potentially fill this void. This study aimed to evaluate the effectiveness of HFUS in the outcome of anterolateral thigh (ALT) and superficial circumflex iliac artery perforator (SCIP) flap-based reconstructions.

METHODS

Consecutive patients who underwent free ALT or SCIP flap-based reconstruction from January 2021 to November 2022 were retrospectively reviewed. Perforator mapping was conducted using a handheld Doppler during the first year, while HFUS was used in the latter part. The two techniques were compared in terms of flap harvesting time and perfusion-related complication rates while considering the flap elevation plane.

RESULTS

In total, 123 cases were analyzed, including 82 ALT flaps (41 in each group) and 41 SCIP flaps (16 in the Doppler and 25 in the HFUS group). The time required for flap elevation exhibited a tendency to decrease in the HFUS group, with a significant difference observed in cases involving thin flap elevation (super-thin ALT flaps and pure-skin-perforator SCIP flaps). Compared with the Doppler group, the HFUS group demonstrated significantly lower rates of PRCs, particularly partial flap necrosis. This difference remained significant in multivariable analyses.

CONCLUSION

Our results suggest that HFUS might be an appealing modality for perforator mapping in cases requiring thin ALT and SCIP flap.

Comparison of The Thickness of Free Anterolateral Thigh Flap in Different Fascial Planes: Clinical Results of Subfascial and Superficial Fat Flap

Background  The anterolateral thigh (ALT) flap is a preferred option in the reconstruction of a wide variety of defects, enabling multiple tissue components and thicknesses. Methods  This study was conducted to investigate the correlation of the thickness of the traditional subfascial ALT flap and superficial fat flap with age, gender, and body mass index (BMI). A total of 42 patients (28 males and 14 females) were included in the study. Results  Mean age was 50.2 (range, 16-75) years and mean BMI was 24.68 ± 4.02 (range, 16.5-34.7) kg/m 2 . The subfascial flap thickness was significantly thinner in male patients (16.07 ± 2.77 mm) than in female patients (24.07 ± 3.93 mm; p  < 0.05), whereas no significant difference was found between male (4.28 ± 1.15 mm) and female patients (4.85 ± 1.09 mm) regarding superficial fat flap thickness ( p  = 0.13). The thickness of both flaps had a positive correlation with BMI, and the strongest correlation was found for subfascial ALT thickness in female patients ( r  = 0.81). Age had no effect on both flap thickness measurements. The anterior thigh is thicker in women than in men, although it varies according to BMI. This shows that flap elevation is important in the superthin plane, especially if a thin flap is desired in female patients in defect reconstruction with the ALT flap. Thus, a single-stage reconstruction is achieved without the need for a defatting procedure after subfascial dissection or a second defatting procedure 3 to 6 months later. Conclusion  The appropriate ALT flap plane should be selected considering the gender and BMI of the patient.

Multiple digit resurfacing with a lateral thoracic free flap: Two-stage mitten hand and division procedures

PURPOSE

The conventional abdominal and groin flaps for resurfacing the defect have several disadvantages, including the risk of flap failure due to accidental traction or detachment, immobilization of the arm before division, and aesthetic dissatisfaction because of the flap bulkiness. The aim of this study was to share our experiences with the free lateral thoracic flap and elucidate the optimal timing of division in complex hand reconstruction, which yielded favorable outcomes in terms of both functionality and aesthetics.

METHODS

This article is a retrospective review of multiple digit resurfacing using free tissue transfer from 2012 to 2022. Patients who underwent two-stage operation including mitten hand creation using superthin thoracodorsal artery perforator (TDAp) free flap and secondary division were included. A flap was elevated over the superficial fascia layer the midportion between the anterior border of the latissimus dorsi and pectoralis major muscles and once the pedicle was found, an outline that matched the defect was created. A process named "pushing with pressure and cutting" was carried out before pedicle ligation until all the superficial fat tissue had been removed except for around the perforator. Two cases (18%) involved defects of the entire fingers reconstructed by TDAp flap with anterolateral thigh flap. Six cases (55%) had a super-thin TDAp flap only. In two cases (18%), non-vascularized iliac bone grafting was required for finger lengthening. One case (9%) was resurfaced with a TDAp chimeric flap including a skin paddle with the serratus anterior muscle. The primary outcome was defined as the survival or failure of the flap, while the secondary outcomes associated complications such as infection and partial flap necrosis. A statistical analysis was not performed due to the size of the case series.

RESULTS

All 13 flaps survived completely without any complications. Flap dimension ranged from 12 cm × 7 cm to 30 cm × 15 cm. Mitten hand duration prior to division was 41.9 days on average which was essential for the optimal result. During the division procedures, there were nine cases of debulking (82%), six cases of split-thickness skin graft (STSG) (55%), and three cases of Z-plasty performed on the first web space (27%). The mean follow-up period was 20.2 months. Mean Disability of the Arm, Shoulder, and Hand (DASH) Questionnaire score was 10.76.

CONCLUSIONS

We resurfaced severe soft tissue defects of multiple fingers with thin to super-thin free flaps, mainly TDAp flaps. Surgeons can restore original hand shape using a two-stage reconstructive strategy of mitten hand creation and proper division timing to create a 3-dimensional hand structure, even in severely injured hands with multiple soft tissue defects of the digits.

[Clinical application of microdissected thin thoracodorsal artery perforator flaps for repair of diabetic foot ulcers]

Objective

To explore the effectiveness of microdissected thin thoracodorsal arterial perforator flap (TDAP) in repairing diabetic foot ulcers (DFUs).

Methods

The clinical data of 11 patients with DFUs admitted between March 2020 and February 2021 were retrospectively analyzed, including 5 males and 6 females, aged from 22 to 67 years, with an average of 49.3 years. There were 10 cases of type 2 diabetes and 1 case of type 1 diabetes; the duration of diabetes ranged from 3 months to 25 years (median, 8 months). The duration of DFUs ranged from 6 days to 120 months (median, 1 month). There were 6 cases of grade 3 and 5 cases of grade 4 according to Wagner classification. The tissue necrosis and purulent secretions were found in all ulcer wounds, as well as different degrees of tendon and bone exposure; skin defects ranged from 5 cm×3 cm to 17 cm×6 cm. The DFUs were repaired by microdissected thin TDAP, including 6 cases of flaps (including 1 case of lobulated flap), ranging from 10.0 cm×4.5 cm to 26.0 cm×7.0 cm; 5 cases of chimeric perforator flaps, the range of the flap was 10.0 cm×4.5 cm to 16.0 cm×5.5 cm, and the range of the muscle flap was 6 cm×2 cm to 10 cm×3 cm. The donor site was sutured directly.

Results

The operation time ranged from 3.42 to 11.17 hours, with an average of 5.92 hours. All 11 flaps survived and no vascular crisis occurred; 1 patient had a sinus at the edge of the flap, and the surgical area healed well after dressing change. All 11 patients were followed up 6-12 months, with an average of 9 months. The flap texture was good, the recipient site was in good shape, and there was no swelling; the foot contour was good, the shoes were comfortable to wear, and the movement was good. The incision at the donor site healed by first intention, leaving only linear and concealed scar, without obvious depression deformity, and the shoulder joint function was good.

Conclusion

On the premise of ensuring sufficient blood supply to the lower extremities and strengthening perioperative management, the microdissected thin TDAP to repair DFUs wounds can achieve better effectiveness and appearance; however, the prolonged operation time increases the probability of anesthesia and surgical risks in patients with DFUs.

Designing Anterolateral Thigh Flap Using Ultrasound

BACKGROUND

 Preoperative knowledge of themicrovascular anatomy of a patientmay improve safetyand efficacy and reduce morbidity. Today, with the advancement in technology, ultrasound can provide minute details of the structures within the body, which makes this technology very helpful in preoperative evaluation of the traditional perforator flaps as well as thin, superthin, and pure skin perforator flaps.

METHODS

 In this article, we will describe the design of one of the most popular perforator flaps, the anterolateral thigh (ALT) flap, using high-frequency and ultrahigh-frequency ultrasound technology.

RESULTS

 Ultrasound technology allows to study preoperatively the ALT donor-site and its microvascular anatomy by using different US modalities in order to provide a virtual surgical plan to the operating surgeon.

CONCLUSION

 Ultrasound technology allow to expand preoperative knowledge of flap microvascular anatomy and its course within the subcutaneous tissue up to and within the dermis, allowing to select the best perforator for the given reconstruction and the plane of elevation for thin, superthin and pure skin perforator flap.

Super-thin ALT flap elevation using preoperative color doppler ultrasound planning: Identification of horizontally running pathway at the deep adipofascial layers

INTRODUCTION

Presently, super-thin ALT flap, which is elevated above the superficial fascial plane, is gaining popularity. Although there is a huge demand for thin flaps for various types of extremity reconstruction, the technique for ALT flap thinning remains controversial. In this study, we investigated the distance and vector between penetrating points of perforators in deep and superficial fascia using color duplex and clinical measurement to suggest a reliable super-thin flap elevation technique.

MATERIALS AND METHODS

From June 2018 to February 2020, 44 patients with various types of defects who were treated using super-thin ALT flaps were enrolled; 69 surgically detected perforators were analyzed. All patients' flap outcomes and characteristics of the perforators were analyzed. In addition, the effects of patients' body mass index (BMI) and thickness of super-thin flap were evaluated.

RESULTS

The average traveling length of perforator at the deep adipofascial layer (DAL) was 2.43 cm, and the vector of traveling was randomly arranged. The mean thickness of super-thin ALT flap was 6.8 mm. The thickness of super-thin flap was not significantly correlated with patients' BMI (ranged from 17.4 to 34.2 kg/m²; p = 0.183).

CONCLUSION

The novel elevation technique for super-thin ALT might be useful, as evidenced by perforator traveling distance and vector in DAL. Preoperative color duplex ultrasonography is helpful to detect the running course of the perforators during elevating the flap. This anatomic concept must be considered to obtain the reliability of the super-thin ALT flap.

Evaluating effects of primary defatting for flap thinning on the development of perfusion-related complications in free perforator flap reconstruction

BACKGROUND

Primary defatting is suggested as an effective and appealing technique for achieving flap thinning. There has been a long-standing concern regarding its potential adverse effects on flap perfusion, for which limited clinical evidence exists. This study aimed to investigate whether primary defatting negatively influences the outcomes of free perforator flap reconstruction.

METHODS

Patients who underwent upper or lower extremity reconstruction using free perforator flaps between 2002 and 2020 were investigated. They were categorized into two groups according to whether they underwent primary defatting. The association of primary defatting with the development of perfusion-related complications was evaluated.

RESULTS

A total of 421 patients were included in the analysis. Perfusion-related complications developed in 61 (14.5%) cases, including 12 cases (2.9%) of total flap loss. In total, 302 patients underwent primary defatting and 119 did not. The patients who underwent primary defatting had a higher body mass index (BMI), lower rate of comorbidities, and smaller harvested flaps than the controls. Both groups had similar rates of perfusion-related complications (13.9% vs. 16.0%, p = .589), including total flap loss (3.0% vs. 2.5%, p = .799). In the multivariate analyses, primary defatting was not associated with the development of perfusion-related complications (p = .957). In the subgroup analyses, the rate of perfusion-related complications did not differ between the two groups regardless of the BMI (≥25 or <25 kg/m² ), comorbidities, and flap size (≥200, 100-200, or <100 cm² ).

CONCLUSIONS

Primary defatting does not appear to be associated with the development of perfusion-related complications in free perforator flap extremity reconstruction.

Donor site sequelae and patient satisfaction after head and neck reconstruction with a radial forearm free flap

PURPOSE

Radial forearm free flap (RFFF) being a workhorse flap in head and neck reconstruction, we investigated its donor site delayed consequences.

METHODS

Multicentric case series evaluating 189 patients who underwent RFFF for carcinologic reasons at least 6 months before. Patients and surgeon's appreciation regarding the aesthetic and functional consequences of the flap harvest on their daily life were evaluated by questionnaires using likert scales. Medical data were collected from patients' charts retrospectively.

RESULTS

Thirty percent of patients had at least one sequelae. Experiencing a graft necrosis did not worsen long-term results. Cosmetic satisfaction was significantly worst for women, according to patients' and surgeons' opinion. For 81% and 92% patients, respectively, the flap harvest had no impact on daily life nor sport practice. Ratio between the benefits of reconstruction and the sequelae at the donor site was judged "excellent" for 77% patients.

CONCLUSIONS

Although objectively important, RFFF morbidity has little impact in head and neck cancer patient's life.

Observational study of the long-term impact of donor-site sequelae after head and neck reconstruction by free anterolateral thigh flap

OBJECTIVE

Free anterolateral thigh flap has many applications in head and neck reconstruction surgery. The aims of the present study were: (1) to assess functional and esthetic sequelae of harvesting for oncologic purposes; and (2) to assess long-term impact of harvesting on quality of life according to patient and to physician.

MATERIALS AND METHODS

Forty-one patients undergoing reconstruction by free anterolateral thigh flap following oncologic head and neck surgery were assessed by questionnaire at>6 months postoperatively. Donor site sequelae were assessed in consultation. Harvesting impact was assessed on 5-point Likert scales by patient and by surgeon.

RESULTS

Thirty nine percent of patients showed≥1 sequelae. Donor site sequela impact on sport, daily living and work was assessed by patients as none or mild in 94%, 98% and 100% of cases, respectively. Sixty-one percent of patients and 58.5% of surgeons considered scar esthetics to be discreet or very discreet.

CONCLUSION

Morbidity related to anterolateral thigh flap harvesting was low, and functional sequelae at the donor site were well tolerated. The scar was only moderately satisfactory, but could easily be hidden.

Reconstruction of Soft Tissue Defects in the Hand with a Free Anterolateral Thigh Deep Fascia Flap

OBJECTIVE

To report our experience in the reconstruction of soft tissue defects in the hand with a free anterolateral thigh deep fascia flap and describe the clinical outcomes.

METHODS

This study was a retrospective trial. From November 2016 to January 2020, six patients (four men and two women) with soft tissue defects in the hand were included in this study. The average age of the patients was 33.7 ± 12.7 years (range, 20 to 50 years). All patients underwent reconstructions with free anterolateral thigh deep fascia flaps. Relevant clinical characteristics were recorded prior to surgery. The size and thickness of the deep fascia flap and the thickness of the skin were measured intraoperatively. The survival of the flaps and skin grafts and the occurrence of infection were recorded after the operation. At follow-up, donor site complications and postoperative effects were evaluated according to the outcome satisfaction scale. The pain in the injured hand was assessed using the visual analog scale.

RESULTS

The average body mass index (BMI) was 26.6 ± 1.7 kg/m² (range, 23.9 to 28.7 kg/m² ). The defect sizes ranged from 5 cm × 5 cm to 13 cm × 8 cm (average, 53.1 ± 27.9 cm² ). The six anterolateral thigh deep fascia flaps ranged from 7 cm × 6 cm to 14 cm × 9 cm in size (average, 71.8 ± 29.1 cm² ). The thicknesses of skin ranged from 25 mm to 40 mm (average, 32.5 ± 4.8 mm), and the thicknesses of the deep fascia flaps ranged from 2 mm to 3 mm (average, 2.5 ± 0.5 mm). After the operation, the blood supply of the deep fascia flap was normal in all cases. The second-stage skin grafts of most patients survived completely. The skin graft in one case was partially necrotic and healed after a dressing change. No infection occurred. At follow-up (average, 16.3 ± 6.9 months), there was only a linear scar and no loss of sensation at the donor site of each patient. According to the outcome satisfaction scale, the outcome satisfaction score ranged from 6 to 8 (average, 7.2 ± 0.9), all of which were satisfactory. Apart from one patient who reported mild pain, all the other patients reported no pain. Three typical cases are presented in this article.

CONCLUSIONS

The free anterolateral thigh deep fascia flap, which is suitable for reconstruction of soft tissue defects in the hand, can provide very good outcomes both functionally and aesthetically.

The perforator-centralizing technique for super-thin anterolateral thigh perforator flaps: Minimizing the partial necrosis rate

Background

Despite the wide demand for thin flaps for various types of extremity reconstruction, the thin elevation technique for anterolateral thigh (ALT) flaps is not very popular because of its technical difficulty and safety concerns. This study proposes a novel perforatorcentralizing technique for super-thin ALT flaps and analyzes its effects in comparison with a skewed-perforator group.

Methods

From June 2018 to January 2020, 41 patients who required coverage of various types of defects with a single perforator-based super-thin ALT free flap were enrolled. The incidence of partial necrosis and proportion of the necrotic area were analyzed on postoperative day 20 according to the location of superficial penetrating perforators along the flap. The centralized-perforator group was defined as having a perforator anchored to the middle third of the x- and y-axes of the flap, while the skewed-perforator group was defined as having a perforator anchored outside of the middle third of the x- and y-axes of the flap.

Results

No statistically significant difference in flap thickness and dimension was found between the two groups. The arterial and venous anastomosis patterns of patients in both groups were not significantly different. Only the mean partial necrotic area showed a statistically significant difference between the two groups (centralized-perforator group, 3.4%±2.2%; skewed-perforator group, 15.8%±8.6%; P=0.022).

Conclusions

The present study demonstrated that super-thin ALT perforator flaps can be elevated safely, with minimal partial necrosis, using the perforator-centralizing technique.

Characteristics of the Superficial Circumflex Iliac Artery Perforator Flap in a Western Population and a Practice Approach for Free Flap Reconstruction

BACKGROUND

 There has been increasing interest in the superficial circumflex iliac artery perforator (SCIP) flap as a source of thin, pliable soft tissue combined with a favorable donor site. Despite several clinical series from Asia, barriers to adoption include reluctance to perform submillimeter "supermicrosurgery" and the effect of body habitus on flap feasibility. The purpose of this study is to distinguish vascular anatomic characteristics of the SCIP flap in a North American population.

METHODS

 Computed tomography angiography was examined in 84 flaps in healthy prospective renal donor patients from a radiographic database. Descriptive statistics as well as linear regression comparing variables to body mass index (BMI) were performed.

RESULTS

 Mean BMI was 27.1 ± 3.5 kg/m², while the mean patient age was 47.8 ± 11.4 years. The superficial circumflex iliac artery (SCIA) originated from the common femoral artery in 92% cases, with remainder originating from the profunda femoris. The mean vessel diameter was 1.85 mm at source vessel origin. Distance from skin to source vessel averaged 30.7 mm. Suprascarpal subcutaneous thickness averaged 16.5 mm. The mean distance from Scarpa's fascia to vessel origin was 14.1 mm. Direct three-dimensional distance from vessel origin to pubic tubercle was 50.2 mm. A medial and lateral perforator split off of the SCIA was observed in 38 cases (45%). Significant differences were shown when comparing BMI to skin to source vessel distance (p < 0.001), suprascarpal subcutaneous fat thickness (p < 0.001), and fascial distance to vessel origin (p < 0.001). BMI did not significantly affect vessel diameter.

CONCLUSION

 Despite a significantly higher BMI than many previously published cohorts, the SCIP remains an excellent source of thin and pliable tissue. When dissected closer to the source vessel, a vessel caliber of nearly 2 mm can be achieved, which may obviate the need for "supermicrosurgery" in this population.

Thin and superthin perforator flap elevation based on preoperative planning with ultrahigh-frequency ultrasound

The ability to directly harvest thin and superthin perforator flaps without jeopardizing their vascularity depends on knowledge of the microsurgical vascular anatomy of each perforator within the subcutaneous tissue up to the dermis. In this paper, we report our experience with ultrahigh-frequency ultrasound (UHF-US) in the preoperative planning of thin and superthin flaps. Between May 2017 and September 2018, perforators of seven patients were preoperatively evaluated by both ultrasound (using an 18-MHz linear probe) and UHF-US (using 48- and 70-MHz linear probes). Thin flaps (two cases) and superthin flaps (five cases) were elevated for the reconstruction of head and neck oncologic defects and lower limb traumatic defects. The mean flap size was 6.5×15 cm (range, 5×8 to 7.5×23 cm). No complications occurred, and all flaps survived completely. In all cases, we found 100% agreement between the preoperative UHF-US results and the intraoperative findings. The final reconstructive outcomes were considered satisfactory by both the surgeon and the patients. In conclusion, UHF-US was found to be very useful in the preoperative planning of thin and superthin free flaps, as it allows precise anticipation of very superficial microvascular anatomy. UHF-US may represent the next frontier in thin, superthin, and pure skin perforator flap design.

Superthin Thoracodorsal Artery Perforator Flap for the Reconstruction of Palmar Burn Contracture

Supplemental Digital Content is available in the text.

Treating burn scar contractures is challenging. Although free flap transfer is an effective tool for hand reconstruction, free flaps are often bulky, causing functional disturbance and poor cosmetic appearance. Secondary debulking operations are required, resulting in a prolonged total treatment period and delayed return to daily life and work for the patient. Therefore, 1-stage reconstruction using a thin and pliable flap is ideal. In this report, we present the superthin TDAP flap as an option for the reconstruction of postburn palmar contracture. During TDAP flap elevation, the thoracodorsal artery perforator was identified and traced distally until its penetration into the dermis. Subsequently, the subdermal tissue was removed and a uniformly superthin TDAP flap was elevated. Postoperatively, early functional recovery was achieved with excellent palmar contour and texture. No revision surgery was required and no recurrence of contractures occurred during the 6-month follow-up. This procedure is useful in elevating a superthin TDAP flap and is a feasible option for the reconstruction of working surfaces, such as the palm.

Flap thinning: Defatting after conventional elevation

Perforator flaps become a reliable option for coverage of various defects and the interest is change from survival of perforator flaps to make thin flaps for better aesthetic and functional outcomes. Multiple flap thinning methods have been demonstrated but it has not been widely attempted because of concerns about compromising circulation of flap thinning. This article will demonstrate the feasibility and benefits of flap thinning technique: defatting after conventional flap elevation.