Bidirectional perforators in the lower limb are not physiologically normal: A brief commentary

The suggestion that bidirectional flow is a normal feature seen in venous perforators of the lower leg has been a longstanding debate. Newer published evidence has changed the perspective on normal perforator flow and is presented here to resolve the misunderstandings and different viewpoints previously held.

[A prospective study of super-thin anterolateral thigh flap harvesting assisted by high-frequency color Doppler ultrasound in detecting perforators in deep adipose layers]

Objective

To investigate the clinical application of high-frequency color Doppler ultrasound (HFCDU) in detecting perforators in the deep adipose layers for harvesting super-thin anterolateral thigh flap (ALTF).

Methods

Between August 2019 and January 2023, 45 patients (46 sides) with skin and soft tissue defects in the foot and ankle were treated, including 29 males and 16 females, aged from 22 to 62 years, with an average of 46.7 years. The body mass index ranged from 19.6 to 36.2 kg/m 2, with an average of 23.62 kg/m 2. The causes of injury included traffic accident injury in 15 cases, heavy object crush injury in 20 cases, mechanical injury in 8 cases, heat crush injury in 1 case, and chronic infection in 1 case. There were 20 cases on the left side, 24 cases on the right side, and 1 case on both sides. After thorough debridement, the wound size ranged from 5 cm×4 cm to 17 cm×11 cm. All patients underwent free super-thin ALTF transplantation repair. HFCDU was used to detect the location of the perforators piercing the deep and superficial fascia, as well as the direction and branches of the perforators within the deep adipose layers before operation. According to the preoperative HFCDU findings, the dimensions of the super-thin ALTF ranged from 6 cm×4 cm to 18 cm×12 cm. The donor sites of the flaps were directly sutured.

Results

A total of 55 perforators were detected by HFCDU before operation, but 1 was not found during operation. During operation, a total of 56 perforators were found, and 2 perforators were not detected by HFCDU. The positive predictive value of HFCDU for identifying perforator vessels was 98.2%, and the sensitivity was 96.4%. Among the 54 perforators accurately located by HFCDU, the orientation of the perforators in the deep adipose layers was confirmed during operation. There were 21 perforators (38.9%) traveled laterally and inferiorly, 12 (22.2%) traveled medially and inferiorly, 14 (25.9%) traveled laterally and superiorly, 5 (9.3%) traveled medially and superiorly, and 2 (3.7%) ran almost vertically to the body surface. Among the 54 perforators accurately located by HFCDU, 35 were identified as type 1 perforators and 12 as type 2 perforators (HFCDU misidentified 7 type 2 perforators as type 1 perforators). The sensitivity of HFCDU in identifying type 1 perforators was 100%, with a positive predictive value of 83.3%. For type 2 perforators, the sensitivity was 63.2%, and the positive predictive value was 100%. The surgeries were successfully completed. The super-thin ALTF had a thickness ranging from 2 to 6 mm, with an average of 3.56 mm. All super-thin ALTF survived, however, 1 flap experienced a venous crisis at 1 day after operation, but it survived after emergency exploration and re-anastomosis of the veins; 1 flap developed venous crisis at 3 days after operation but survived after bleeding with several small incisions; 3 flaps had necrosis at the distal edge of the epidermis, which healed after undergoing dressing changes. All 45 patients were followed up 6-18 months (mean, 13.6 months). Three flaps required secondary defatting procedures, while the rest had the appropriate thickness, and the overall appearance was satisfactory.

Conclusion

Preoperative application of HFCDU to detect the perforator in the deep adipose layers can improve the success and safety of the procedure by facilitating the harvest of super-thin ALTF.

Variability of anterolateral thigh flap perforator locations - clinical implications

<b><br>Introduction:</b> The anterolateral thigh flap is an example of a free flap widely applied for reconstruction of tissues within various areas of the body.</br> <b><br>Aim:</b> The aim of the study was to determine the most common locations of the ALT flap perforators in men and women as well as to clarify any potential differences in the location of the vessel in male vs. female subjects.</br> <b><br>Material and method:</b> In years 2021-2022, a study was conducted at the Plastic, Reconstructive, and Aesthetic Surgery Clinic in a group of 90 volunteers (45 women and 45 men, a total of 180 lower extremities) to determine the location of the anterolateral thigh flap perforator against the flap surface using a portable Doppler probe.</br> <b><br>Results:</b> Variable locations were revealed for the anterolateral thigh flap perforator within the study. In women, the perforator is located more distally from the anterior superior iliac spine, most frequently within the inferolateral quadrant, while being located closer to the anterior superior iliac spine, and most frequently within the superolateral quadrant, in men. No perforator was found in 3.3% of the examined limbs. No statistically significant differences were observed between the course of the perforators within the left and right lower limbs in individual patients.</br> <b><br>Conclusions:</b> The location of the ALT flap perforator is subject to sexual dimorphism, which facilitates the investigation area being narrowed down to the well-defined locations of its most frequent occurrence when planning anterolateral thigh flap reconstructive procedures.</br>.

Usefulness of perforating branches of the deep femoral artery and vein as recipient vessels during free-flap reconstruction for extensive defects of the thigh

The perforating branches of the deep femoral artery and vein are considered useful recipient vessels during free-flap reconstruction for extensive defects extending from the knee to the mid-thigh or from the lateral to the posterior region of the thigh. Despite being located deep between the adductor longus and magnus muscles, they can be easily identified, allowing for a sufficient surgical field for the vascular anastomosis. Approximately four perforators from the deep femoral artery can be found on the posterior aspect of the thigh, easily identified by dissecting the semitendinosus and biceps femoris muscles. The calibre and length of the perforators were suitable for vascular anastomosis. In this study, we present three cases of free-flap reconstruction for extensive thigh defects using perforating branches of the deep femoral artery and vein as recipient vessels.

High-Fidelity Perforator Visualization for Cadaver Dissection in Surgical Training

In the first half of the third century B.C., Herophilus and Erasistratus performed the first systematic dissection of the human body. For subsequent centuries, these cadaveric dissections were key to the advancement of anatomical knowledge and surgical techniques. To this day, despite various instructional methods, cadaver dissection remained the best way for surgical training. To improve the quality of education and research through cadaveric dissection, our institution has developed a unique method of perforator-preserving cadaver injection, allowing us to achieve high-fidelity perforator visualization for dissection studies, at low cost and high efficacy. Ten full body cadavers were sectioned through the base of neck, bilateral shoulder, and hip joints. The key was to dissect multiple perfusing arteries and draining veins for each section, to increase "capture" of vascular territories. The vessels were carefully flushed, insufflated, and then filled with latex dye. Our injection dye comprised of liquid latex, formalin, and acrylic paint in the ratio of 1:2:1. Different endpoints were used to assess adequacy of injection, such as reconstitution of eyeball volume, skin turgor, visible dye in subcutaneous veins, and seepage of dye through stab incisions in digital pulps. Dissections demonstrated the effectiveness of the dye, outlining even the small osseous perforators of the medial femoral condyle flap and subconjunctival plexuses. Our technique emphasized atraumatic preparation, recreation of luminal space through insufflation, and finally careful injection of latex dye with adequate curing. This has allowed high-fidelity perforator visualization for dissection studies.

The Versatility of Lateral Chest Wall Perforator Flaps in Immediate and Delayed Breast Reconstruction: Retrospective Study of Clinical Experience with 26 Patients

Rationale: Lateral chest flaps represent versatile reconstructive options, especially valuable in times of global healthcare resource restriction. In this series, we present our experience with the use of lateral chest wall flaps in both immediate and delayed reconstruction from both breast conserving and mastectomy surgery. Methods: A retrospective cohort study of patients who had undergone a lateral chest wall flap for immediate or delayed breast reconstruction of a lumpectomy or mastectomy defect was performed. Data collected consisted of patient demographics, procedure type, tumor/oncological characteristics, as well as postoperative complications. Findings: Between September 2015 and April 2021, 26 patients underwent breast reconstruction using a lateral chest wall flap. Fifteen patients (58%) underwent immediate reconstruction (9 lumpectomy; 6 mastectomy) and 11 (42%) underwent delayed breast reconstruction. All flaps survived, though 1 patient required partial flap debridement following venous compromise hours after surgery. There were no incidences of hematoma, seroma, infection, or wound healing delay at either the donor site or breast. There was one positive margin which occurred in a mastectomy patient. Significance: This study describes the use of lateral chest wall flaps in a wide variety of reconstructive breast surgery scenarios. This technique can be safely performed in an outpatient setting and does not require microvascular techniques. Review of our outcomes and complications demonstrate that this is a safe and effective option. Our experience is that this is an easy to learn, versatile flap that could be a valuable addition to the surgeon's arsenal in breast reconstruction.

Use of the superficial inferior epigastric vein in breast reconstruction with a deep inferior epigastric artery perforator flap

Background

Autologous breast reconstruction is highly regarded in reconstructive surgery after mastectomy. DIEP flap reconstruction represents the gold standard for autologous breast reconstruction. The major advantages of DIEP flap reconstruction are its adequate volume, large vascular caliber and pedicle length. Despite reliable anatomy, there are procedures where the plastic surgeon's creativity is required, not only to shape the new breast, but also to overcome microsurgical challenges. An important tool in these cases is the superficial epigastric vein (SIEV).

Methods

150 DIEP flap procedures performed between 2018 and 2021 were retrospectively evaluated for SIEV use. Intraoperative and postoperative data were analyzed. Rate of anastomosis revision, total and partial flap loss, fat necrosis and donor site complications were evaluated.

Results

In a total of 150 breast reconstructions with a DIEP flap performed in our clinic, the SIEV was used in 5 cases. The indication for using the SIEV was to improve the venous drainage of the flap or as a graft to reconstruct the main artery perforator. Among the 5 cases, no flap loss occurred.

Conclusions

Use of the SIEV is an excellent method to expand the microsurgical options in breast reconstruction with DIEP flap surgery. It provides a safe and reliable procedure to improve venous outflow in cases of inadequate outflow from the deep venous system. The SIEV could also provide a very good option for fast and reliable application as an interposition device in case of arterial complications.

Improving visualization of free fibula flap perforators and reducing radiation dose in dual-energy CT angiography

Background

The precise assessment of the perforators of the fibula free flap (FFF) is crucial for minimizing procedure-related complications when harvesting the FFF in patients with maxillofacial lesions. This study aims to investigate the utility of virtual noncontrast (VNC) images for radiation dose saving and to determine the optimal energy level of virtual monoenergetic imaging (VMI) reconstructions in dual-energy computed tomography (DECT) for visualization of the perforators of the fibula free flap (FFF).

Methods

Data from 40 patients with maxillofacial lesions who received lower extremity DECT examinations in the noncontrast and arterial phase were collected in this retrospective, cross-sectional study. To compare VNC images from the arterial phase with true non-contrast images in a DECT protocol (M_0.5-TNC) and to compare VMI images with 0.5 linear images blending from the arterial phase (M_0.5-C), the attenuation, noise, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and subjective image quality were assessed in different arteries, muscles, and fat tissues. Two readers evaluated the image quality and visualization of the perforators. The dose-length product (DLP) and CT volume dose index (CTDIvol) were used to determine the radiation dose.

Results

Objective and subjective analyses showed no significant difference between the M_0.5-TNC and VNC images in the arteries and muscles (P>0.09 to P>0.99), and VNC imaging could reduce 50% of the radiation dose (P<0.001). Compared with those of the M_0.5-C images, the attenuation and CNR of VMI reconstructions at 40 kiloelectron volt (keV) and 60 keV were higher (P<0.001 to P=0.04). Noise was similar at 60 keV (all P>0.99) and increased at 40 keV (all P<0.001), and the SNR in arteries was increased at 60 keV (P<0.001 to P=0.02) in VMI reconstructions compared with those in the M_0.5-C images. The subjective scores in VMI reconstructions at 40 and 60 keV was higher than those in M_0.5-C images (all P<0.001). The image quality at 60 keV was superior to that at 40 keV (P<0.001), and there was no difference in the visualization of the perforators between 40 and 60 keV (P=0.31).

Conclusions

VNC imaging is a reliable technique for replacing M_0.5-TNC and provides radiation dose saving. The image quality of the 40-keV and 60-keV VMI reconstructions was higher than that of the M_0.5-C images, and 60 keV provided the best assessment of perforators in the tibia.

The effect of intraoperative nerve identification technique on distally-based dorsal fasciocutaneous flap for thumb and fingertip reconstruction

INTRODUCTION

Thumb and fingertip resurfacing continues to be a challenge for hand surgeons, as the treatment varies widely. Being donor nerves in the flap for sensory restoration, the dorsal cutaneous nerves in hand have been widely described in the literature. However, their applications in providing anatomical information to sufficiently harvest the longitudinal axis of a robust flap are usually underestimated. This study reports reconstruction of thumb and fingertip defects with the distally-based dorsal fasciocutaneous (DDF) flap and explores the effect of intraoperative nerve identification technique on clinical outcomes.

HYPOTHESIS

The nerve identification technique can contribute considerably to the improvement of flap circulation, with less risk of poor venous return.

MATERIALS AND METHODS

A retrospective study was conducted in 89 patients who had thumb or fingertip defects treated with the DDF flap from February 2014 to June 2020. Patients were divided into two groups based on whether intraoperative nerve identification technique was used. Flap survival was evaluated. The follow-up was conducted by using smartphone or by face-to-face visit. Time for complete wound healing, time to return to work, hand performance, the total active motion of the joints and static two-point discrimination of flaps were analyzed.

RESULTS

The 46 flaps (group A) that underwent intraoperative nerve identification technique had an 8.7 percent venous congestion rate versus a 27.9 percent venous congestion rate in the 43 flaps (group B) without using nerve identification technique (p = 0.018). The mean follow-up was 11.08 (range, 6 - 26) months. Time for complete wound healing and time to return to work were significantly shorter in group A (p = 0.026 and p=0.012). Michigan Hand Outcomes Questionnaire (MHQ) scores were similar between groups. In the face-to-face follow-up, there was no significant difference in the total active motion of the injured fingers and static two-point discrimination between the two groups (p = 0.657 and p=0.182).

DISCUSSION

The use of nerve identification technique could decrease the odds of postoperative venous congestion in DDF flap for thumb and fingertip reconstruction, and result in improved outcomes in terms of time for complete wound healing and time to return to work.

LEVEL OF EVIDENCE

III; retrospective comparative study.

Profunda Artery Perforator Flaps From the Posteromedial Region of the Thigh for Head and Neck Reconstruction

OBJECTIVE

Profunda femoris artery perforator flaps (PAPFs) have not been widely used in head and neck reconstructions. The feasibility and outcomes of PAPFs for various head and neck reconstructions need to be investigated.

STUDY DESIGN

Retrospective analysis.

SETTING

A single-institution review.

METHODS

PAPFs were utilized in head and neck reconstructions from 2019 to 2021. Local anatomy, surgical technique, and complications were discussed. Chimeric PAPF applications with muscle components were described for coverage of extensive multiunit defects. Additionally, aesthetic and functional outcomes were compared with anterolateral thigh perforator flaps.

RESULTS

A total of 33 cases were included. The average age was 54.2 years (range, 30-74). The most common underlying pathology was oral squamous cell carcinoma (n = 26, 78.8%), while the mean ± SD body mass index was 25.4 ± 2.8 kg/m² . Middle perforators (n = 14, 42.4%) were the most commonly utilized ones. The perforator-based chimeric/composite applications were used in 9 (27.3%), with the muscular components consisting of gracilis (n = 3, 9.1%), adductor magnus (n = 5, 15.2%), or semimembranosus muscles (n = 1, 3.0%). Venous thromboses of the PAPFs were found in 2 (6.1%), though salvaged. The occurrence of postoperative 90-day morbidity (complication) was related to mandibulectomy/maxillectomy (P = .020). Postoperative validated questionnaires showed a trend of intermediate to high scores, indicating noninferior outcomes in several categories, when compared with the anterolateral thigh perforator flap counterparts.

CONCLUSION

PAPFs are a good reconstructive alternative for intermediate to large head and neck reconstructions. Besides, PAPFs can provide sufficient tissue volume and versatility of potentially incorporating adjacent muscle components.

Diabetic foot resurfacing using microvascular tissue transfer from lateral thoracic region

AIMS

Diabetic foot ulcer is a major complication of diabetes mellitus and amputation is often needed. Since mortality rate after amputation is comparatively high, saving diabetic foot is required not only for preserving function and life quality, but also for decreasing mortality rate. This study was designed to analyse experience of limb salvage in patients with diabetic foot using free flaps from the lateral thoracic region over a 10-year period.

MATERIALS AND METHODS

Between 2009 and 2018, 297 cases of diabetic foot underwent surgical procedures. We analysed the 83 cases who underwent free flap from lateral thoracic region. Patient data were reviewed retrospectively.

RESULTS

A total of 83 patients, 56 of them males, were included in this study. Age of patients ranged from 27 to 80 years. Twenty patients underwent percutaneous transluminal angioplasty procedures. The latissimus dorsi muscle sparing technique was used in 7 cases. A thoracodorsal artery perforator flap was used in 68 cases. A thoracodorsal artery perforator chimaeric flap was performed in 8 cases. The flap survival rate was 98.8% and the limb salvage rate was 96.4%. The mean follow-up was 6.5 years. During follow-up 14 patients suffered recurrence of foot ulcers.

CONCLUSIONS

Ten-year experience of using flaps from the lateral thoracic region revealed superior outcomes in terms of flap survival and limb saving compared to those in a recent meta-analysis and other reports. Long vascular pedicle technique and the chimaeric technique might be the alternative methods for multiple or vascular insufficient diabetic foot defects.

Dual-Perforator Flap With Wide Pedicle Versus Sural Neurocutaneous Flap With Peroneal Artery Perforator in the Treatment of Soft Tissue Defects of Foot and Ankle

How to deal with large soft tissue defects around the foot and ankle is still controversial. The aim of this study was: (1) to display a new pedicled flap, also named the dual-perforator flap with wide pedicle (DPFWP), and (2) to compare it with the sural neurovascular flap with peroneal artery perforator (SNFPAP) in foot and ankle reconstruction. According to different surgical methods, 82 patients were divided into 2 groups: the DPFWP group (42 cases) and the SNFPAP group (40 cases). All cases underwent a flap surgery after radical debridement. The 2 groups were homogeneous in terms of age, sex, body mass index (BMI), etiology, location, and follow-up duration. Operation indexes were compared, including flap length, flap width, operation time and blood loss. Complications, cosmetic appearance, and functional outcome were analyzed, and statistical analysis was performed. The DPFWP group had larger flap length (24.5 ± 4.6 cm vs 16.3 ± 3.8 cm), and flap width (10.5 ± 2.7 cm vs 7.8 ± 1.7 cm) than the SNFPAP group. In postoperative follow-up, DPFWP group showed a lower complication rate and better cosmetic, functional outcomes than SNFPAP group. In conclusion, this study showed that a DPFWP flap brought better results than a SNFPAP flap in terms of complications, cosmetic appearance, and functional outcomes for patients undergoing reconstruction of foot and ankle defects.

A trial to visualize perforators images from CTA with a tablet device: experience of operating on minipigs

A reliable method for precise perforator mapping can be extremely valuable in perforator flap surgery. In this study, we attempted to map perforator location using 3-dimensional computed tomography angiography (CTA), a newly developed application, and a tablet device. Preliminary examinations to test the device were conducted in mini-pigs. We used 5 female mini-pigs. Preoperative imaging of the vasculature was undertaken with CTA in the prone position, following Iopamidol (200 ml) injection via the internal jugular vein. Prior to the examination, we placed round markers on the backs of the mini-pigs. To assess accuracy, we compared the perforator positions acquired with an optical position measurement device with the perforator positions acquired with the tablet device. Furthermore, we compared the perforator positions with the tablet navigation device, which we measured directly. We measured 12 perforators with the optical position measurement device. The mean difference was 10 mm (minimum, 2 mm; maximum, 20 mm). We measured these perforators with the tablet navigation device. The mean difference was 5.4 mm (minimum, 0 mm; maximum, 20 mm). The perforator flaps were elevated safely. The perforator flaps could be elevated safely using our device, as the mean difference was only 10 mm, which is acceptable for navigating perforator flap operations. Pig backs are triangular in shape; therefore, we were unable to place markers on the contralateral side. Thus, for clinical applications of the device, we should determine the ideal marker locations.

Preoperative perforator localization in anterolateral thigh free flap using acoustic doppler and computed tomography angiography

Objectives

Our aim in this study was to investigate if we could predict perforator localization during ALTF elevation, using information from acoustic Doppler (AD) and computed tomography angiography (CTA).

Methods

Prospective observational data were collected from H&N cancer patients who received reconstruction with ALTF in Ajou University Hospital Cancer Center from June to December, 2021. Total of 21 cases were included in the analysis. Lower extremity angio-CT scans were used to determine the course and depth of the perforator before surgery. During intraoperative design of the ALTF, the possible location of the perforator was identified by AD. After flap elevation, the distance between the actual and Doppler-identified location of the perforator was measured.

Results

The average distance from the actual location to the Doppler-identified location was 1.29 ± 1.26 cm. Among 21 cases, almost all perforators (20 cases) were identified in a circle with a radius equivalent to the depth of the perforator. Perforator depth measured by CTA showed a significant positive correlation with the distance from the actual to Doppler-identified location, regardless of skin thickness or body mass index (BMI).

Conclusions

A circle with a radius equivalent to the CTA-assessed depth of the perforator successfully predicted the location of the perforator in almost all cases. Depth of the perforator measured by CTA combined with Doppler-identified location can help safely locate the perforator during ALTF harvesting.Level of Evidence: 4.

NIR-II imaging with ICG for identifying perforators, assessing flap status and predicting division timing of pedicled flaps in a porcine model

The use of skin flaps to fill large defects is a key surgical technique in reconstructive surgery, effective real-time in vivo imaging for flap design and use is urgent. Currently, fluorescent imaging in the second NIR window (NIR-II; 1000-1700 nm) is characterized by non-radiation, less expensive and higher resolution in comparisons with the first NIR window (NIR-I; 700-900 nm) and other traditional imaging modalities. In this article, we identified the location and numbers of perforators and choke zone via NIR-II imaging. Then, eight abdominal perforator flaps were established and the perfusion zones were evaluatedat special time points. Finally, after eight pedicled flaps establishment, NIR-II imaging was used to guide the optimal timing for division of flap pedicle. The results showed that NIR-II fluorescence imaging with indocyanine green (ICG) can reliably visualize vascular supply, which makes it to be an accurate and in vivo imaging approach to flap clinical design and use.

Lateral arm perforator flap as an island advancement flap for posterior elbow soft-tissue reconstruction

Many flap designs for coverage of soft-tissue defects of the posterior elbow have been reported, and the lateral arm flap is considered reliable. With the advantages of less donor site morbidity and preservation of the continuity of the source artery, perforator flaps have taken the place of lateral arm flap recently. The lateral arm perforator flaps for elbow soft-tissue coverage have a propeller design. In this report, we describe a case of posterior elbow defect that was reconstructed with posterior radial collateral artery perforator island advancement flap. Lateral arm perforator island advancement flap is a good alternative for a propeller flap for coverage of soft-tissue defects of the posterior elbow.

Improving the Safety of DIEP Flap Transplantation: Detailed Perforator Anatomy Study Using Preoperative CTA

Background: Deep inferior epigastric perforator and muscle sparing transverse rectus abdominis muscle flaps are commonly used flaps for autologous breast reconstruction. CT-angiography allows to analyse the perforator course preoperatively. Our aim was to compare the different aspects of perforator anatomy in the most detailed study. Methods: CT-angiographies of 300 female patients with autologous breast reconstruction of 10 years were analysed regarding the anatomy of the deep inferior epigastric artery and every perforator. Results: Overall, 2260 perforators were included. We identified correlations regarding the DIEA branching point and number of perforators and their intramuscular course. The largest perforator emerged more often from the medial branch of the DIEA than the smaller perforators (70% (416/595) vs. 54% (878/1634), p < 0.001) and more often had a direct connection to the SIEV (large 67% (401/595) vs. small 39% (634/1634), p < 0.01). Medial row perforators were larger than the laterals (lateral 1.44 mm ± 0.43 (n = 941) vs. medial 1.58 mm ± 0.52 (n = 1304) (p < 0.001)). The larger and more medial the perforator, the more likely it was connected to the SIEV: perforators with direct connection to the SIEV had a diameter of 1.65 mm ± 0.53 (n = 1050), perforators with indirect connection had a diameter of 1.43 ± 0.43 (n = 1028), perforators without connection had a diameter of 1.31 mm ± 0.37 (n = 169) (p < 0.001). Medial perforators were more often directly connected to the SIEV than lateral perforators (medial 56% (723/1302) vs. lateral 35% (327/941), p < 0.001). A lateral perforator more often had a short intramuscular course than medial perforators (69% (554/800) vs. 45% (474/1055), p < 0.001), which was also more often observed in the case of a small perforator and a caudal exit of the rectus sheath. Conclusion: The largest perforator emerges more often from the medial branch of the DIEA and frequently has a direct connection to the SIEV, making medial row perforators ideal for DIEP flap transplantation.

Anatomy of septocutaneous blood vessels of the anterior forearm

Aim To measure a calibre of radial and ulnar septocutaneous perforators at the anterior forearm, and to count its number in proximal, middle and distal thirds. Methods The study was conducted on 50 fresh amputated forearms (trauma, tumours) in the period between January 2012 and December 2021. Forearms were collected from several hospitals in Belgrade, and analysed at the Institute of Anatomy, Medical School, University of Belgrade, Serbia. Injection of ink-gelatin and fine dissection of autopsy material was performed on 30 forearms, and corrosion method with injecting methyl methacrylate for 3D analysis on the other 20 forearms. Results A mean calibre of septocutaneous perforators on the radial artery was 0.53±0.46 mm (0.2-0.85). Averagely, there were 8.1 radial artery septocutaneous perforators - two perforators on the proximal third, 3.7 on the middle third, and 2.7 on the distal third. The mean calibre of ulnar artery perforators was 0.65±0.35 mm (0.18-1.8). The average number of septocutaneous perforators of the ulnar artery was 5.6; 1.2 on the proximal third, two on the middle third, and 2.2 on distal third. Conclusion Determination of the origin, calibre and spreading directions of the arterial septocutaneous perforators on the anterior forearm provide quantification of data about arborisation of radial and ulnar septocutaneous perforators at the anterior forearm. Clinical relevance of those anatomical data is in defining of safe locations and dimensions of forearm fasciocutaneous flaps in plastic surgery.

Do medial sural artery perforator flaps have better clinical outcomes compared to the rectus abdominis perforator (DIEAP) flap in reconstruction of glossectomy defects? A Prisma guided meta-analysis

BACKGROUND

There is an increasing evidence for the use of thin flaps based on vascular perforators for reconstructive surgeries. The medial sural and deep inferior epigastric artery flaps offer versatility for the reconstruction of major defects of the head and neck.

OBJECTIVES

"Whether medial sural artery perforator (MSAP) flap or rectus abdominis perforator flap is better for the reconstruction of glossectomy defects in terms of functional outcome?"

DATA SOURCES

PubMed, Cochrane Library, clinicaltrials.gov and hand searches.

PARTICIPANTS AND INTERVENTIONS

Patients who underwent tongue reconstruction with either MSAP flap or deep inferior epigastric artery perforator (DIEAP) flap.

STUDY APPRAISAL AND SYNTHESIS METHODS

Based on defined study criteria 6 studies were selected according to Prisma Guidelines. The overall estimated effect was categorized as significant where P < 0.05.

RESULTS

There was no significant difference between both flaps in terms of receptor site complications (P = 0.223). Overall odds ratio (OR) for complications was 1.35 (95% confidence interval [CI]: 0.412-0.736) and the test for overall effect t value was 2.836, P < 0.05. Overall OR was 6.01 (95% CI 0.5-7.45) and the test for overall effect t value was 1.41, P < 0.05 indicating there was a statistical difference in the intelligibility of speech.

LIMITATIONS

Anatomical variations, under-reporting of studies and lack of universal tool for speech intelligibility.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Both the flaps are comparable in terms of functional outcome. Medium-sized defects can be reconstructed with MSAP and composite larger defects would benefit from DIEAP. In females, anterolateral thigh flap still remains the choice for composite reconstructions.

Keystone-designed perforator island flaps for reconstruction after chest keloid excision: A retrospective case series

OBJECTIVE

We retrospectively evaluated the efficacy and safety of keystone-designed perforator island flaps for chest keloid reconstruction.

METHODS

We reviewed consecutive patients who received keystone flap reconstruction after chest keloid resection between January 2017 and February 2018. The patient demographic data, defect size, flap size, complications, and recurrence were recorded.

RESULTS

Thirty-eight patients were evaluated in this retrospective case series. After keloid resection, dimension of wound defects was 5.5-9.5 cm × 9.5-12.5 cm, with an average dimension of 7.3 cm × 10.7 cm. The dimension of keystone flaps was between 6-10 cm × 20-34.5 cm, with an average dimension of 7.5 cm × 25.5 cm. The flaps healed smoothly without any complication. There was no keloid recurrence with 15 months of follow-up. 89.4% of the patients had good outcome with no apparent scarring, and 10.6% patients had satisfactory outcome with localized scarring.

CONCLUSIONS

Keystone-designed perforator island flap is an effective and reliable method for reconstruction following chest keloid resection.

Endothermal ablation for the treatment of clinically significant incompetent lower limb perforating veins: factors influencing the early outcomes

BACKGROUND

To review the clinical experience and early outcomes of endothermal perforator ablation.

METHOD

Retrospective review of an endovenous practice from 2007-2019. Clinically significant incompetent perforators were treated by Endovenous Laser Ablation (EVLA), or segmental radiofrequency ablation (RFA).

RESULT

Complete data were available for 110 of the 116 symptomatic incompetent perforating veins treated. Radiofrequency ablation of 20 perforators produced a 55% perforator closure rate, while 90 EVLA perforator ablations resulted in a closure rate of 80%. Closure rates with EVLA varied by location and perforator length. Closure rates for truncal ablation were 95.5% for RFA and 97.2% for EVLA.

CONCLUSION

Early closure rates following endothermal ablation of incompetent lower limb perforating veins are lower than those obtained for truncal ablation. EVLA perforator closure appears to be more effective than segmental RFA in most situations but short treatment lengths and location at the ankle are associated with the poorest outcomes.

Nerve vascularity in free vascularized nerve flaps

The blood supply of peripheral nerves consists of a complex internal vessels' network, feeding external vessels and the interlinking vasa nervorum. Patients with nerve damage may require nerve substitution. While the commonly performed avascular nerve grafts obtain vascularization only from random and slow inosculation into the vasa nervorum, their insufficient revascularization causes loss of the graft's potential due to central necrosis. This gets more relevant with the larger diameter of nerves injured. Examples for neurovascular flaps are the lateral femoral cutaneous nerve vascularized via the superficial circumflex iliac artery perforator (LFCN-SCIP) flap or the iliohypogastric nerve graft vascularized via the superficial inferior epigastric artery (SIEA). LFCN-SCIP shows a well concealed donor scar site with a maintained vascularization and a minor donor site morbidity. Therefore, the guaranteed axial nerve vascularity in LFCN-SCIP makes it a preferred autologous vascularized nerve therapy for peripheral nerve defects. A further option example is the anterior lateral thigh (ALT) flap with the LFCN.

Solitaire AB stent-angioplasty for stenoses in perforator rich segments: A single-center experience

BACKGROUND

Vascular angioplasty and stenting of middle cerebral artery (MCA) and basilar artery (BA) stenoses are associated with poor clinical outcomes and high mortality rates thought to be related to the abundance of perforating arteries in those segments. This study explores the use of Solitaire AB as an off-label vascular stent to treat stenoses in the MCA and BA.

METHODS

Solitaire AB stents were placed during angioplasty and stenting of MCA and BA stenoses in patients at our department between January 2015 and May 2017 with 6-36 months follow-up. Operative results were assessed by follow-up angiography and transcranial doppler after the procedure. Neurologic status was evaluated before and after treatment according to the modified Ranking Scale (mRS).

RESULTS

A total of 32 patients were included in the study. Seventeen (53.12%) patients presented with MCA stenosis and 15 (46.87%) with BA stenosis. The 30-day rate of procedure-related complications was 3.1% (1/32). Post-stenting residual stenosis degrees ranged from 0% to 40% (mean 13.44% ± 10.66%). Mean degree of residual stenosis in 26 patients followed up by DSA was 8.64% ± 9.67%. The mRS 0-2 was achieved in all (100%) patients at 6-12 months post-procedure.

CONCLUSIONS

Our study indicates the off-label use of Solitaire AB for stenting is effective and safe for MCA and BA stenoses with high technical success and low complications. We recommend that lesion-specific therapy with an anatomically fitted stent design enables optimal treatment for intracranial stenosis.

The Effect of Muscle Exercise on Perforators Flow: A Prospective Cohort Study

Background and objectives: The metabolic response after exercise causes a significant increase in the muscle blood flow. While these effects are demonstrated for intra-muscular vessels, there is no evidence about the inter-muscular vessels, such as the septocutaneous perforators supplying the skin after they branch out from the deep source artery. The aim of our prospective study was to quantify the changes in the anterior tibial artery perforators arterial blood flow after mild isotonic exercise in a young and healthy population. Material and Methods: We performed a prospective analysis of 34 patients who were admitted to the Plastic Surgery Department from December 2019 to April 2020. Flow velocities of two previously identified anterior tibial artery perforators were recorded both before and after 10 complete flexion-extensions of the foot. The time to revert to basal flow was measured. We further classified the overmentioned patients based on their level of physical activity. Results: We registered a significant increase in systolic, diastolic and mean blood flow velocities both in proximal and distal anterior tibial artery perforators after exercise. Fitter patients exhibited a higher increase in proximal leg perforators than those who did less than three aerobic workouts a week. The time to return to basal flow ranged from 60 to 90 s. Conclusions: This was the first study to describe the effect of muscular activity on perforators blood flow. Even mild exercise significantly increases the perforator flow. Waiting at least two minutes at rest before performing the Doppler study, thus avoiding involved muscle activation, can notably improve the reliability of the pre-operative planning.

Pure perforator free sensory proximal ulnar artery perforator flap for resurfacing hand defects

Objective

This prospective study was performed to investigate the distribution of proximal ulnar artery perforating vessels through three-dimensional blood vessel reconstruction and examine the presence and consistency of the perforating vessels intraoperatively.

Methods

For anatomical guidance, three-dimensional blood vessel reconstruction was performed to determine the consistent presence of perforating vessels in the proximal ulnar artery. A free proximal ulnar artery perforator flap was then transferred in 17 patients to resurface skin defects on the hands. Color Doppler ultrasound was used to identify and mark the perforating vessels. Intraoperative evaluation was conducted to check for anastomosis of the perforating vessels at the marked sites and assess the vessel anastomosis conditions.

Results

No vascular crisis, flap necrosis, or wound infection occurred after surgery in 15 patients. Postoperative follow-up was conducted for 6 to 36 months. The appearance of the flap was satisfactory, the texture of the flap was soft, sensation was well restored, and hand function was not limited. The mean two-point discrimination of the flap was 7.6 ± 2.2 mm.

Conclusions

Free sensory proximal ulnar artery perforator flap transfer is a safe and reliable surgical technique with respect to restoration of both the appearance and sensory function of the hand.

Successful application of modified keystone flaps following skin tumor ablation

Skin cancer and precancerous skin lesions cause significant soft-tissue defects following tumor ablation. Recently, keystone flaps have gained popularity due to their simplicity, versatility, and reliability.We evaluated the efficacy of modified keystone flaps for soft-tissue reconstruction following skin tumor ablation in 2 medical centers.We reviewed the medical records of patients who received modified keystone flaps following the removal of skin tumors from January 2017 to December 2017. The diagnosis, site, flap size, and complications were recorded.Forty-one modified keystone flaps were evaluated, and the wound dimensions ranged from 1 cm × 1 cm to 18 cm × 9.5 cm, with an average size of 9.8 cm × 6.4 cm. With our selection strategy, specific modified keystone flaps were designed for the soft-tissue defects. The flap dimensions ranged from 2.2 cm × 1 cm to 26 cm × 10 cm, with an average size of 14.3 cm × 7.5 cm. Two patients developed minor wound dehiscence (4.9%), and 1 patient developed partial flap loss (2.4%), but all of these patients healed after local wound care without the need for surgical intervention.Our selection strategy for modified keystone flaps is a feasible and reliable option for reconstruction following skin tumor excision.

A review of visualized preoperative imaging with a focus on surgical procedures of the breast

Preoperative imaging has become a valuable tool in the planning of perforator flaps, and to date, computed tomographic angiography (CTA) has been shown to be the gold standard in this role. The evidence for this is a source of constant investigation, with advances in newer modalities coming to the fore. A literature review was undertaken to evaluate the current role of relevant imaging modalities in 'visualized surgery'-the ability to map anatomy prior to surgical incision. A focus is made on their accuracy in perforator mapping and correlation with improved clinical outcomes in the context of deep inferior epigastric artery perforator (DIEP) flap surgery. Other applications for preoperative imaging in breast surgery such as imaging of alternate donor sites or of the recipient site and imaging for volumetric assessment are also discussed. Preoperative imaging is integral to the planning of reconstructive breast surgery. This review has discussed the range of imaging techniques used to map and visualize perforator vasculature, and whilst there are varied clinical applications for the imaging modalities, CTA has been demonstrated to be the most precise and to confer the best clinical outcomes. Applications of the other imaging techniques are varied and these should remain as valid alternatives, particularly for patients where radiation or contrast exposure should be limited. Further studies could focus on the development of a more definitive protocol regarding the approach to preoperative imaging in breast surgery.

The Use of Magnetic Resonance Imaging in Planning a Pedicled Perforator Flap for Pressure Sores in the Gluteal Region

Pedicled perforator flaps (PPFs) have been widely used to treat pressure sores in the gluteal region. Selection of a reliable perforator is crucial for successful surgical treatment of pressure sores using PPFs. In this study, we evaluate the role of magnetic resonance imaging (MRI) in planning PPF reconstruction of pressure sores in the gluteal region. A retrospective chart review was performed in patients who had undergone these PPF reconstructions and who had received preoperative MRI. Preoperatively, the extent of infection and necrotic tissue was evaluated using MRI, and a reliable perforator was identified, considering the perforator location in relation to the defect, perforator size, and perforator courses. Intraoperatively, the targeted perforator was marked on the skin at the locations measured on the MRI images, and the marked location was confirmed using intraoperative handheld Doppler. Superior gluteal artery, inferior gluteal artery, or parasacral perforators were used for the PPFs. Surgical outcomes were evaluated. A total of 12 PPFs were performed in 12 patients. Superior gluteal artery perforator flaps were performed in 7 patients, inferior gluteal artery perforator flaps were performed in 3 patients, and parasacral perforator flaps were performed in 2 patients. We could identify a reliable perforator on MRI, and it was found at the predicted locations in all cases. There was only one case of partial flap necrosis. There was no recurrence of the pressure sores during the mean follow-up period of 6.7 months (range = 3-15 months). In selected patients with gluteal pressure sores, MRI is a suitable means for not only providing information about disease extent and comorbidities but also for evaluating perforators for PPF reconstructions.

Outcomes of using a modified anteromedial thigh perforator flap for repairing the anterolateral thigh free flap donor site: A retrospective clinical review

The anterolateral thigh (ALT) flap plays an essential part in plastic and reconstructive surgery. However, repair of the anterolateral donor site has not been the focus of the clinicians.To assess the clinical value and feasibility of using a modified anteromedial thigh (AMT) perforator flap for repairing the ALT free flap donor site.In this retrospective study, 16 ALT flaps were transferred to resurface large soft-tissue defects (ranged from 7 × 5 to 13 × 8 cm) in the foot or hand from June 2012 to March 2013. The donor sites were repaired with an advancement flap pedicled with an AMT perforator. Sensation within the advancement flap, return-to-work (RTW) time, the aesthetic appearance of the donor sites, and functional recovery were measured.All 15 flaps survived completely without necrosis. One flap developed partial necrosis in the tip but healed with dressing changes after 1 week. The medain follow-up period was 3.5 months (range, 3-6 months). The average median time was 9.5 weeks (range 8-13 weeks). There was no numbness of the advancement flap. Additionally, there was no specific complication at both the recipient and donor sites. Thigh quadriceps muscle strength and activities of the knee were normal. All patients were satisfied with the aesthetic outcome postoperatively at the 3-month to 6-month follow-up.The modified advancement flap pedicled with an AMT perforator is an ideal option for repairing the anterolateral donor site.

Supermicrosurgery: History, Applications, Training and the Future

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.

Validity of the use of a subfascial vessel as the recipient vessel in a second free flap transfer: A retrospective clinical review

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.

The Keystone Flap-A Case Series Demonstrating Practical Design, Use, and Applications

INTRODUCTION

The keystone design perforator island flap is a trapezoidal-shaped random perforator island flap with many advantages over primary closure, skin grafting, and other local flaps for soft tissue reconstruction commonly encountered with cancer excisions.

METHODS

This case series of 39 keystone flaps in 37 patients reviews the practical design, use, and applications of the flap while highlighting certain important considerations. Keystone flaps were designed as in the original description, with a minor modification in the lower extremity where a higher flap to defect width ratio was used.

RESULTS

Defects varying in size from 6 to 63 cm² were reconstructed in 23 males and 14 females ranging in age from 49 to 89. In all 39 cases, there were 2 minor complications of partial flap dehiscence and no major complications such as partial or complete flap loss.

CONCLUSION

The keystone flap is a versatile and reliable flap with applications almost anywhere on the body. A higher ratio of flap width to defect width up to 1:3 is more appropriate for the lower extremity where tension is higher.

Efficacy of high-resolution cone-beam CT in the evaluation of perforators in vertebral artery dissection

Introduction A major complication of internal coil trapping for vertebral artery dissection (VAD) is medullary infarction associated with perforator occlusion. Currently, higher spatial resolution imaging can be obtained with high-resolution cone-beam computed tomography (VASO CT), and the efficacy of perforator visualization adjacent to VAD was examined. Methods Eight patients who underwent internal coil trapping or stent-supported coil embolization underwent VASO CT to evaluate perforators around VAD. Visualization of perforators was compared with conventional digital subtraction angiography (DSA) and three-dimensional rotational angiography (3D-RA). Postoperative MRI was performed in all patients to investigate ischemic complications. The relationship between the perforators and the infarction was analyzed. Results Perforator visualization was much clearer on VASO CT than on 2D DSA or 3D-RA. It was sharp enough to identify each perforating artery. Medullary infarctions were detected in two cases. In these two cases, each ischemic lesion corresponded to the territory of a perforator that was well visualized on VASO CT. The axial view with adjoining tissue structures on VASO CT was useful to detect the territories of perforators. Conclusions VASO CT is an efficient modality for the detection and identification of perforators in the vicinity of VAD. It provides accurate anatomical information about the vertebrobasilar system that is useful for the treatment of unruptured VAD.

The Lateral Proximal Phalanx Flap for Contractures and Soft Tissue Defects in the Proximal Interphalangeal Joint: An Anatomical and Clinical Study

Background: The management of contractures and soft tissue defects in the proximal interphalangeal (PIP) finger joint remains a challenge. We report a transposition flap from the lateral skin of the proximal phalanx that is based on perforating branches of the digital arteries and can be used safely for both palmar and dorsal cover defects. Methods: We first completed an anatomic study, dissecting 20 fingers in fresh cadavers with arterial injections and made the new flap in patients with dorsal or palmar defects in PIP joints. Results: In cadavers, we can reveal 4 constant branches from each digital artery in the proximal phalanx, with the more distal just in the PIP joint constituting the flap pedicle. Between February 2010 and February 2015, we designed 33 flaps in 29 patients, 7 for dorsal and 26 for palmar defects, with no instances of flap necrosis and 4 distal epidermolysis. The patients were between 4 and 69 years with no major complications, and all of the skin defects in the PIP joint were resolved satisfactorily without any relevant sequelae at the donor site. Conclusions: This flap procedure is an easy, reliable, versatile, and safe technique, and could be an important tool for the management of difficult skin defects and contractures at the PIP joint level.

Anomalous intraosseous venous drainage: Bone perforators?

Objectives Anomalous intraosseous venous drainage is a rare and almost unknown entity; only 14 cases have been reported in the literature and 4 mentioned in textbooks. We report the characteristics of 35 further cases observed in 32 patients. Method After the presentation of two cases at the congress of the French Society of Phlebology in Paris (2013), 12 colleagues joined to present a large series of so-called bone perforators observed in their practice, all identified with at least a duplex investigation. Results Thirty-two patients suffering from varicose veins and/or skin changes (C₂-C₆) associated with a bone perforator of the tibia (with bilateral anomalies in three) are reported: 19 females and 13 males, average age 56.9. The majority of the affected legs were symptomatic (30/35). Bone perforator was an isolated finding in 27/35 legs. In three cases, the investigations revealed that the venous reflux in the bone originated from an incompetent posterior tibial vein. Conclusions We suggest the name of "bone perforators" for an anomalous tibial intraosseous venous drainage, feeding varicose veins, and in more advanced stages lipodermatosclerosis and leg ulcers. Most of them were successfully treated with surgery or sclerotherapy.

Pedicle streaking: A novel and simple aid in pedicle positioning in free tissue transfer

Introduction:

The pedicle positioning in free tissue transfer is critical to its success. Long thin pedicles are especially prone to this complication where even a slight twist in the perforator can result in flap loss. Pedicles passing through the long tunnels are similarly at risk. Streaking the pedicle with methylene blue is a simple and safe method which increases the safety of free tissue transfer.

Materials and Methods:

Once the flap is islanded on the pedicle and the vascularity of the flap is confirmed, the pedicle is streaked with methylene blue dye at a distance of 6-7 mm. The streaking starts from the origin of the vessels and continued distally on to the under surface of flap to mark the complete course of the pedicle in alignment. The presence of streaking in some parts and not in rest indicates twist in the pedicle.

Observation and Results:

Four hundred and sixty five free flaps have been done at our centre in the last 5 years. The overall success rate of free flaps is 95.3% (22 free flap failures). There has not been a single case of pedicle twist leading to flap congestion and failure.

Conclusion:

This simple and novel method is very reliable for pedicle positioning avoiding any twist necessary for successful free tissue transfer.

Perforating arteries of the thigh: An anatomical and radiological study

INTRODUCTION

We aimed to advance the understanding of the anatomy of the perforating branches of the profunda femoris artery to facilitate the avoidance of iatrogenic injury in surgery around the thigh and ensure safe percutaneous embolisation.

METHODS

Dissection was carried out on seven cadavers, examining the relationship of the point of origin of the perforating branches of profunda femoris, relative to lines connecting palpable bony landmarks (lines A and B). These were compared with 16 computed tomography angiograms (CTA). Left to right variation within subjects and variation between the dissection and imaged group was examined. The anatomy of the two groups was then compared with that described in anatomical textbooks.

RESULTS

The side to side variation in number of perforators was not significant in the dissection (P = 0.20) nor the CT group (P = 0.70). Similarly, the point of origin of the perforating vessels along lines A and B did not demonstrate any significant difference except for the fourth perforator along line B (P = 0.03). There was no significant difference in points of origin along line B between the dissection and CT groups for the first four perforators on the left (P = 0.51, P = 0.80, P = 0.66, P = 0.09 respectively) and right (P = 0.79, P = 0.45, P = 0.56, P = 0.11 respectively). The number and distribution of perforators were then compared with commonly used anatomical texts.

CONCLUSION

As in other parts of the body, textbook descriptions of anatomical structures may not be reflected consistently in vivo. However, the perforating branches of the profunda femoris demonstrate a predictable topographical relationship to palpable bony landmarks.

Anatomy of the anteromedial thigh flap based on the oblique branch of the descending branch of the lateral circumflex femoral artery

Anteromedial thigh (AMT) flaps based on lateral circumflex femoral artery (LCFA) have characteristics which make them favourable for use in reconstruction of extensive thigh, head, neck and leg defects. AMT flap which is elevated on the artery has the advantages of low donor site morbidity and preservation of main arteries. Due to inconstant anatomy of the pedicle, the flap is mostly not preferable. Hence, we aimed to describe the anatomical features of the unnamed branch of the descending branch of the LCFA harvesting AMT flap. For this purpose, the external iliac artery was displayed bilaterally on 15 adult (13 males and 2 females; age range 55-82 years) preserved cadavers using latex injection. The perforator branch of the descending branch from the LCFA was microdissected under 4× loupe magnification. The perforator branch was located 28.53 (20.20-34.20) cm distal to the anterior superior iliac spine, 22.12 (13.40-28.00) cm distal to the pubic tubercle, and 13.20 (10.80-16.20) cm proximal to the interepicondylar line. At the level of origin point the mean diameter of the perforating branch was 0.17 cm and the mean diameter of its cutaneous branch was 0.14 cm. The mean length of the pedicle was 5.71 (3.70-9.00) cm. We conclude that our findings contribute to the literature in terms of anatomical knowledge for surgical safety.

Use of a distal ulnar artery perforator-based bilobed free flap for repairing complex digital defects

PURPOSE

To retrospectively evaluate the effectiveness and safety of using a distal ulnar artery perforator (DUAP)-based bilobed free flap (BFF) for the repair of complex digital defects in the hand.

METHODS

We retrospectively studied 15 patients who sustained traumatic digital defects with complicating tendon and phalanx exposure and were hospitalized for repair using a DUAP-based BFF. Main outcome measures included patients' self-assessed physical appearance, total active motion, and 2-point discrimination.

RESULTS

The flaps survived and the wounds healed with primary intention in all patients except one who experienced partial flap necrosis of the distal margin and required treatment with a second skin graft. Patients were observed for a mean of 13 months. The physical appearance and texture of the repaired fingers were assessed as good with minimal scarring. Total active motion and 2-point discrimination were 113° to 255° (contralateral, 255° to 275°) and 6 to 11 mm (contralateral, 5 to 8 mm), respectively.

CONCLUSIONS

Use of the DUAP-based BFF is a feasible, effective, and safe treatment alternative for repairing complex digital defects with favorable aesthetic and sensorimotor outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The use of thermography to design tissue flaps - experimental studies on animals

Introduction

Methods allowing one to locate the position of a cutaneous perforator do not allow one to determine the boundaries of the vascularized skin. In clinical practice this causes complications in the form of marginal necrosis of the flap.

Aim

To examine the usefulness of thermography to assess the extent of vascularization of the skin and subcutaneous tissue by a single perforator.

Material and methods

Thirty-one male rats were used. Using dynamic thermography the perforators on the abdominal skin were located. Afterwards the flap was prepared on a randomly chosen perforator. After 24 h the extent of vascularization of the skin by a single perforator was examined.

Results

In 22.5% of cases the number of perforators marked in the thermography was equal to the number of perforators marked intraoperatively, in 64.5% it was lower and in 13% higher. The use of thermography has shown that basing the flap vascularization on the perforator with low efficiency resulted in statistically more frequent occurrence of ischemia and partial necrosis of the flap (p = 0.024). Partial necrosis of the flap occurred in 12 of 31 cases, always in the area in which during the preoperative thermography no perforators were found. The areas of necrosis occurred irrespectively of the distance from the supplying vessel.

Conclusions

When designing the shape of the flap, the distribution of all perforators must be considered. The perforators need to be included in the area of prepared tissues because their location indicates the area with a more efficient network of vessels.

The evolving breast reconstruction: from latissimus dorsi musculocutaneous flap to a propeller thoracodorsal fasciocutaneous flap

The aim of this editorial is to give an update on the use of the propeller thoracodorsal artery perforator flap (TAP/TDAP-flap) within the field of breast reconstruction. The TAP-flap can be dissected by a combined use of a monopolar cautery and a scalpel. Microsurgical instruments are generally not needed. The propeller TAP-flap can be designed in different ways, three of these have been published: (I) an oblique upwards design; (II) a horizontal design; (III) an oblique downward design. The latissimus dorsi-flap is a good and reliable option for breast reconstruction, but has been criticized for morbidity and complications. The TAP-flap does not seem to impair the function of the shoulder or arm and the morbidity appears to be scarce. However, an implant is often needed in combination with the TAP-flap, which results in implant related morbidity over time. The TAP-flap seems to be a promising tool for oncoplastic and reconstructive breast surgery and will certainly become an invaluable addition to breast reconstructive methods.

Review and update on new horizon in the management of venous ulcers

Chronic venous ulcers (CVUs) contribute to functional deficits and are a source of significant morbidity among the affected population. In addition, they directly impact the quality of life of patients and are a significant economic burden on the health care system. In this review, we critically evaluate the current strategies for treating CVUs that have emerged within the last decade and outlined a suggested algorithm for treating patients with this difficult condition.

Telangiectasias resistant to sclerotherapy are commonly connected to a perforating vessel

Leg telangiectasias resistant to repeated courses of sclerotherapy in patients without deep and superficial venous incompetence are not uncommon. Little is known about factors which may underlie the resistance. Among 26 patients with such telangiectasias we found a direct communication of the vessels with deep and saphenous veins in 65% of patients. Ultrasound-guided injection of 0.5% polidocanol foam into the feeding veins or their perforating segments led to clearance of all the telanagiectasias. In 23% of cases no feeding veins could have been identified by ultrasound. Direct injections of a sclerosant into perforating feeding veins may clear refractory telangiectasias in a majority of patients though it is obvious that other factors may contribute to the failure of sclerotherapy in others.

An infundibulum of thalamoperforator arteries: Importance of angiographic images for appropriate diagnosis

Background:

The identification of infundibula on noninvasive imaging modalities may be challenging. Because these lesions have generally been viewed as nonpathological, distinguishing them from small or micro-aneurysms is important.

Case Description:

A 39-year-old male was diagnosed with recurrence of typical orgasmic headache. An outpoutching arising from the distal part of the right P1 at the take-off of thalamoperforator arteries was visualized on noninvasive investigations. The patient was referred to neurosurgery for surgical management of a right P1 aneurysm. Its unusual location and morphology led to be suspicious of an infundibular dilatation. Catheter angiography with 2D projections and 3D rotational reconstruction revealed an infundibulum at the common origin of two thalamoperforators, giving rise to a double-peaked shape, mimicking a true aneurysm, rather than the more characteristic conical shape of an infundibulum.

Conclusion:

Although noninvasive modalities may identify typical infundibula, the catheter angiogram with 2D projections was critical to establishing the diagnosis. The 3D rotational reconstruction enabled a straightforward understanding of the 3D vascular anatomy. This pyramidal variant of infundibular dilatation should be included in the differential diagnosis of a wide-based nonsaccular arterial contour deformities located in an area of multiple perforators.

CT angiographic evaluation of perforators in the lower limb and their reconstructive implication

BACKGROUND

The perforator flaps evolved on the knowledge of the vascular tree from the main vascular trunk up to the subdermal plexus. Therefore, we thought that it's necessary to map the whole vascular arcade by CT angiography. The aim of this study is to evaluate the perforators and the whole vascular tree of the lower limb by peripheral CT angiography with 3D reconstruction and intraoperative evaluation. This study helps in designing flaps of different constituents based on the selected perforators.

MATERIALS AND METHODS

Twenty patients having lower limb defects were selected. CT angiography was done using a non-ionic iodinated contrast media injected through the antecubital vein. The lower limbs were imaged using volume rendering CT scan machine. Three dimensional reconstructions were made. The whole arterial tree, along with the perforators, were mapped. Findings of the audio-Doppler were correlated with the CT angiographic observations. Further these evaluations were confirmed by intraoperative findings.

RESULTS

The three dimensional CT angiographic reconstruction with bone and soft tissue provided advanced knowledge of this vascular network. It delineated the main vessel, the perforators, their caliber, distance from fixed bony landmarks and course up to the subdermal plexus. These findings were confirmed during dissection of the proposed flap. The perforators were mainly musculocutaneous in the proximal leg and septocutaneous distally.

CONCLUSIONS

The vascular details visualized by this technique made advancement over the existing methods namely color Doppler, audio Doppler, two dimensional angiography etc. It improved the understanding of perforator flaps and their successful clinical application.

Reconstruction of infected abdominal wall defects using latissimus dorsi free flap

INTRODUCTION

Infected abdominal defects are a challenge to surgeons. In this study, we describe 10 cases in which the latissimus dorsi myocutaneous flap was used for successful reconstruction of abdominal wall defects severely infected with methicillin-resistant Staphylococcus aureus (MRSA).

METHODS

Retrospective review of 10 patients with abdominal wall defects that were reconstructed using the latissimus dorsi myocutaneous flap between 2002 and 2010. All patients had abdominal defects with hernias, combined with MRSA infections. The sizes of the flaps ranged from 120 to 364 cm(2) . The deep inferior epigastric artery was the recipient vessel in nine patients and the internal mammary vessels were used for one patient.

RESULTS

There were no complications relating to the flaps, although there were other minor complications including wound dehiscence, haematoma and fluid correction. After reconstruction, there were no signs of infection during follow-up periods, and the patients were satisfied with the final results.

CONCLUSION

Reconstruction using the latissimus dorsi myocutaneous flap, including muscle fascia structures, is a potential treatment option for severely infected large abdominal wall defects.

The evolution of the pedicled radial forearm flap

Because of the thin skin envelope of the hand, especially at the dorsum, flaps are frequently required for defect reconstruction in the hand. The pedicled radial forearm flap is a time proven procedure that offers reliable coverage in this area without the need of advanced microsurgical expertise. Despite several alternatives and an increasing acceptance of free tissue transfers, the pedicled radial forearm flap can still be the procedure of choice under special circumstances. Variations of the original technique address the two main disadvantages, the conspicuous donor site and the sacrifice of the radial artery. Indications, anatomy, surgical technique, and limitations of this classic workhorse flap are presented.