Portable Color-Flow Ultrasound Facilitates Precision Flap Planning and Perforator Selection in Reconstructive Plastic Surgery

Preoperative assessment of depressor anguli oris to prevent myectomy failure: An anatomical study using high-resolution ultrasound

BACKGROUND

Myectomies of the lower lip depressor muscles have unexplained high failure rates. This study aimed to examine the depressor anguli oris (DAO) muscle using high-resolution ultrasound to identify potential anatomical explanations for surgical failures and to determine the accuracy of utilizing preoperative ultrasound assessment to improve myectomies.

METHODS

Anatomical features of DAO and the surrounding anatomy were examined in 38 hemifaces of human body donors using high-resolution ultrasound and dissection.

RESULTS

The ultrasound and dissection measurements showed the DAO muscle width to be 16.2 ± 2.9 versus 14.5 ± 2.5 mm, respectively, and the location of the lateral muscle border 54.4 ± 5.7 versus 52.3 ± 5.4 mm lateral to the midline. In 60% of the cases, the facial artery was either completely covered by lateral DAO muscle fibers or was found to be in direct contact with the lateral border. Significant muscle fiber continuity was present between the DAO and surrounding muscles in 5% of cases, whereas continuity between the depressor labii inferioris and surrounding muscles was considerably more common and pronounced.

CONCLUSIONS

High-resolution ultrasound can accurately reveal important preoperative anatomical information in myectomies. Two potential explanations for the surgical failures were discovered: an overlap of lateral DAO muscle fibers over the facial artery could lead to inadequate resections and continuity with the surrounding muscles might lead to muscle function takeover despite adequate resections. Both can be uncovered preoperatively by the surgeon through a brief, directed ultrasound examination, which may allow for modification of the surgical plan to reduce surgical failure.

Comparison of Various Modalities Utilized for Preoperative Planning in Microsurgical Reconstructive Surgery

BACKGROUND

 The benefits of preoperative perforator imaging for microsurgical reconstruction have been well established in the literature.

METHODS

 An extensive literature review was performed to determine the most commonly used modalities, and their applicability, advantages and disadvantages.

RESULTS

 The review demonstrated varioius findings including decreases in operative time and cost with the use of CT angiography to identification of perforators for inclusion in flap design with hand-held Doppler ultrasound. Modalities like MR angiography offer alternatives for patients with contrast allergies or renal dysfunction while maintaining a high level of clarity and fidelity. Although the use of conventional angiography has decreased due to the availability of less invasive alternatives, it continues to serve a role in the preoperative evaluation of patients for lower extremity reconstruction. Duplex ultrasonography has been of great interest recently as an inexpensive, risk free, and extraordinarily accurate diagnostic tool. Emerging technologies such as indocyanine green fluorescence angiography and dynamic infrared thermography provide real-time information about tissue vascularity and perfusion without requiring radiation exposure.

CONCLUSION

 This article presents an in-depth review of the various imaging modalities available to reconstructive surgeons and includes hand held Doppler ultrasound, CT angiography, MR angiography, conventional angiography, duplex ultrasonography, Indocyanine Green Fluorescence Angiography and Dynamic Infrared Thermography.

Mapping 216 Perforator Flaps Using Highly Portable Tablet-Based Color Doppler Ultrasound (PT-CDU)

BACKGROUND

 The first reports of using color Doppler ultrasound for evaluation of the microvasculature were in the 1990s. Despite the early reports of its efficacy, color Doppler ultrasound did not achieve popularity nor general usage in part due to the cumbersome size, cost and poor resolution. This is the first study to demonstrate the potential utility of a new, highly portable, tablet-based color Doppler ultrasound (PT-CDU) system for imaging perforator flaps.

METHODS

 The deep inferior epigastric artery (DIEP), lateral arm (LA), anterolateral thigh (ALT), thoracodorsal artery (TDAP), and the medial sural artery (MSAP) perforator flaps were imaged within classic topographic landmarks to visualize and measure variables related to perforator flap anatomy. The Philips Lumify L12-4 linear array probe attached to the Samsung Galaxy Tab A tablet was the system used for all examinations.

RESULTS

 A total of 216 flaps were scanned in 50 healthy adult volunteers: 44 DIEP, 44 LA, 40 ALT, 48 TDAP, and 40 MSAP. Precise anatomic information regarding perforator size, number, and location was obtained. Overall, the percent of flaps having at least 1 perforator within the specified topographical landmarks was 89% for the DIEP, 84.1% for the LA, 72.5% for the ALT, 50% for the TDAP, and 30% for the MSAP (p = 2.272e-09). The percent of patients having an asymmetry (right versus left) in the number of perforators was 72.7% (ALT), 65% (DIEP), 59.1% (LA), 41.7% (TDAP), and 30% (MSAP) (p = 0.0351).

CONCLUSIONS

 Portable, tablet-based color Doppler ultrasound offers high-resolution images of perforators and represents a facile technology that may be of interest to microsurgeons in the planning of perforator flaps. Variations in vascular anatomy were well-demonstrated. This surgeon-driven imaging technology may represent an excellent alternative to other imaging modalities.

Abdominal-based free flaps in head and neck reconstruction

PURPOSE OF REVIEW

The head and neck reconstructive surgeon is intimately familiar with the anterolateral thigh, radial forearm, and parascapular flaps. This review serves to describe the major abdominal-based free tissue transfers in head and neck reconstruction that can be used as alternatives to these traditional workhorse flaps.

RECENT FINDINGS

Abdominal-based free flaps, while not traditionally used in head and neck reconstruction, are great alternatives or second-line flaps. For example, the deep circumflex iliac artery flap is an excellent alternative to the fibular free flap due to its bone height and greater overall quality of life.

SUMMARY

This review article serves to review the major abdominal-based free tissue transfers in head and neck reconstruction in order to expand the toolbox of the head and neck surgeon.

Performing Distance Measurements in Curved Facial Regions: A Comparison between Three-Dimensional Surface Scanning and Ultrasound Imaging

Facial flap surgery depends strongly on thorough preoperative planning and precise surgical performance. To increase the dimensional accuracy of transferred facial flaps, the methods of ultrasound and three-dimensional (3D) surface scanning offer great possibilities. This study aimed to compare different methods of measuring distances in the facial region and where they can be used reliably. The study population consisted of 20 volunteers (10 males and 10 females) with a mean age of 26.7 ± 7.2 years and a mean body mass index of 22.6 ± 2.2 kg/m². Adhesives with a standardized length of 20 mm were measured in various facial regions through ultrasound and 3D surface scans, and the results were compared. Regardless of the facial region, the mean length measured through ultrasound was 18.83 mm, whereas it was 19.89 mm for 3D surface scans, with both p < 0.0001. Thus, the mean difference was 1.17 mm for ultrasound measurements and 0.11 mm for 3D surface scans. Curved facial regions show a great complexity when it comes to measuring distances due to the concavity and convexity of the face. Distance measurements through 3D surface scanning showed more accurate distances than the ultrasound measurement. Especially in "complex" facial regions (e.g., glabella region and labiomental sulcus), the 3D surface scanning showed clear advantages.

How to Design and Harvest a Propeller Flap

Propeller flaps are local flaps based either on a subcutaneous pedicle, a single perforator, or vessels entering the flap in such a way so as to allow the flap to rotate on their axis. Depending on the kind of pedicle and the anatomical area, the preoperative investigation and the harvesting techniques may vary. An adequate knowledge of skin and subcutaneous tissue perfusion in the different areas of the body is very important to plan a propeller flap to be successful. The surgeon should begin by finding the most suitable perforators in the area surrounding the defect using available technology. The position, size, and shape of the flap are planned about this point. For perforator-pedicled propeller flaps, the procedure starts with an exploration from the margins of the defect or through a dedicated incision to visualize any perforators in the surroundings. The most suitable perforator is selected and isolated, the skin island is replanned, and the flap is harvested and rotated into the defect. The variations in surgical technique for other types of propellers and in specific anatomical areas are also described. Compared with free flaps, propeller flaps have the advantage of a simpler, shorter operation, without the need for a recipient vessel for microanastomosis. Yet, from a technical point of view, an adequate experience in dissecting perforators and the use of magnifying glasses are almost always required.