Perforator Flap versus Conventional Flap.
Kim Jeong Tae,Kim Sang Wha
Journal of Korean medical science
The introduction of perforator flaps represented a significant advance in microsurgical reconstruction. However, confusion has developed due to the erroneous belief that perforator flaps are different from conventional flaps. The concept of the perforator is not new, but is an idea that evolved from the conventional flap. In fact, some of the flaps used by microsurgeons were perforator flaps. The only difference is the anatomical level of the blood vessels involved; the perforator concept is focused on the distal circulation, so-called 'perforator'. Therefore, thinner sections of tissue can be taken from the conventional donor sites of myocutaneous flaps. With the use of perforators, there are no longer "flap of choice" for specific reconstructions, because conventional donor sites have become universal donor sites, enabling the harvesting of a variety of flaps. Moreover, depending on the surgeon's ability, any flap can be utilized as a perforator-based island flap whose source vessel has been completely preserved. Therefore, tissues can be efficiently customized and tailored into any configuration required for reconstruction. The application of perforator flap technique enables more precise dissection, and allows more selective harvesting of thinner flaps, which will expand options in reconstructive surgery. No doubt the technique will continue to evolve.
10.3346/jkms.2015.30.5.514
Axial Pattern Flaps.
Mankin Kelley Thieman
The Veterinary clinics of North America. Small animal practice
Axial pattern flaps are based on a direct cutaneous artery and vein supplying a segment of skin. They provide a large, robust option for large wound closure. Many different axial pattern flaps have been described to provide options for closure of wounds located from the nose to the tail. All axial pattern flaps require good surgical technique and careful attention to detail while developing of the flap.
10.1016/j.cvsm.2017.06.008
A Prospective Head-to-Head Comparison of Color Doppler Ultrasound and Computed Tomographic Angiography in the Preoperative Planning of Lower Extremity Perforator Flaps.
Feng Shaoqing,Min Peiru,Grassetti Luca,Lazzeri Davide,Sadigh Parviz,Nicoli Fabio,Torresetti Matteo,Gao Weiqing,di Benedetto Giovanni,Zhang Wenjie,Zhang Yi Xin
Plastic and reconstructive surgery
BACKGROUND:This investigation compared the application of color Doppler ultrasound and computed tomographic angiography in preoperative planning of lower extremity perforator flaps. METHOD:This study was a prospective comparative analysis of 40 patients with lower extremity defects who underwent reconstruction with perforator flaps. The position, caliber, route, and quality of the perforator vessels were detected by computed tomographic angiography and color Doppler ultrasound preoperatively. The results of the preoperative navigation with both imaging techniques were verified during the operation. RESULTS:Color Doppler ultrasound had a higher accuracy in terms of identifying (95 percent versus 90 percent) and locating (95 percent versus 82.5 percent) the perforators in the lower extremity. Color Doppler ultrasound required approximately 25 minutes for examination, whereas computed tomographic angiography required 46 seconds for the scan and approximately 22 minutes for the image analysis. There was no significant difference between the two methods. CONCLUSIONS:Preoperative radiologic vessel navigation is capable of offering valuable information such as the perforator's location, diameter, and path; and information regarding the quality of the perforators, which can shorten the operative time and improve the surgical results. The authors recommend color Doppler ultrasound for preoperative planning when harvesting perforator flaps from the lower extremity. In cases where the patient has a metal implant, allergy to the contrast agent, or renal insufficiency, color Doppler ultrasound is the only option. In time, the use of color Doppler ultrasound and computed tomographic angiography in combination will be recommended to improve the accuracy of preoperative perforator navigation. CLINICAL QUESTION/LEVEL OF EVIDENCE:Diagnostic, IV.
10.1097/PRS.0000000000001895
Quantitative assessment of bone microvascularization after osteocutaneous flap transplantation using contrast-enhanced ultrasound (CEUS).
Geis S,Prantl L,Mueller S,Gosau M,Lamby P,Jung E M
Ultraschall in der Medizin (Stuttgart, Germany : 1980)
BACKGROUND:Extensive wound defects frequently have to be covered by free flap transplantation. A monitoring device for measuring capillary level perfusion of bone is currently not available. OBJECTIVE:The aim of the study was to detect complications after osteocutaneous flap transplantation using contrast-enhanced ultrasound (CEUS). Additionally quantitative analysis was performed by special perfusion software (QONTRAST®; Bracco, Italy). METHODS:22 patients were examined after osteocutaneous flap transplantation during the first 72 h after operation. CEUS was performed with a linear transducer (6-9 MHz, LOGIQ E9/GE) after bolus injections of 2.4 ml ultrasound contrast agent (SonoVue®; Bracco, Italy). The osseous perfusion and soft tissue perfusion were analyzed separately and quantitative perfusion analysis was performed. Five patients had to undergo reoperation due to compromised flap microvascularization. RESULTS:In all 5 complications reduced osseous and soft tissue perfusion was seen using CEUS. Additionally using the perfusion parameters TTP (time to PEAK), RBV (regional blood volume), RBF (regional blood flow) und MTT (mean transit time), significantly lower soft tissue and osseous perfusion was detected. CONCLUSION:CEUS seems to be capable of detecting vascular disturbances and of assessing microvascularization of the osseous component after osteocutaneous flap transplantation.
10.1055/s-0033-1335133
Postoperative monitoring of local and free flaps with contrast-enhanced ultrasound (CEUS)--analysis of 112 patients.
Geis S,Prantl L,Dolderer J,Lamby P,Mueller S,Jung E M
Ultraschall in der Medizin (Stuttgart, Germany : 1980)
PURPOSE:Tissue defects are a common problem in trauma surgery and oncology. Flap transplantation is often the only therapy to cover such defects. Several monitoring systems are currently available but none has made it to the clinical routine. The aim of this study was to assess perfusion disturbances of local and free flaps using contrast-enhanced ultrasound (CEUS). MATERIALS AND METHODS:112 patients were examined during the first 72 hours after operation. CEUS was performed by one experienced examiner with a linear transducer (6 - 9 MHz, LOGIQE9/GE) after a bolus injection of 2.4 ml sulfohexa-fluoride microbubbles (SonoVue®, Bracco, Italy). Retrospective vascular perfusion was quantified by evaluating the stored DICOM cine loops using the perfusion software QONTRAST® (Bracco, Italy). Over a total penetration depth of 3 cm, every centimeter was analyzed separately. 27 complications were observed. Complete flap loss was only seen in 4 cases, while 23 flaps had to undergo minor revision and survived. RESULTS:Regarding the complete flap size, quantitative analysis showed significantly higher perfusion values in patients without complications compared to patients with complications: PEAK 16.5 vs. 10.0 (p = 0.001), TTP 32.6 vs. 22.2 (p = 0.001), RBV: 738.8 vs. 246.2 (p < 0.001), RBF 17.5 vs. 10.1 (p < 0.001) and MTT 43.1 vs. 29.5 (p = 0.001). Analysis of the correlation of the different flap types, age, sex and etiology of the tissue defect to the complication rate showed no statistical correlation. CONCLUSION:CEUS was capable of detecting vascular disturbances after flap transplantation. TTP, RBV and MTT seem to be the most accurately parameters and are not susceptible to malfunction during measurement.
10.1055/s-0033-1355758
Superficial Circumflex Iliac Artery Perforator Flap Elevation Using Preoperative High-Resolution Ultrasonography for Vessel Mapping and Flap Design.
Journal of reconstructive microsurgery
BACKGROUND: The superficial circumflex iliac artery (SCIA) perforator (SCIP) flap has gained acceptance among reconstructive microsurgeons, the minimal donor site morbidity being its greatest advantage. The purpose of this article is to introduce the use of preoperative ultrasonography to facilitate elevation and to avoid postoperative complications of the SCIP flap. METHODS: Preoperative mapping of the SCIA and the superficial circumflex iliac vein (SCIV) using a high-resolution ultrasound system were performed in patients undergoing reconstruction using a free SCIP flap. The skin paddle was designed placing the SCIA and the SCIV in the middle of the flap. RESULTS: Preoperatively marked SCIA and SCIV were found intraoperatively in all cases. The skin paddle design for sufficient arterial inflow and venous drainage resulted in no postoperative flap complications. CONCLUSION: The use of a preoperative high-resolution ultrasound system significantly facilitates elevation of the SCIP flap, notably via the following 2 points: 1) pedicle can always be found under the markings made with preoperative ultrasonography, 2) satisfactory perfusion of the flap can be guaranteed via a safe flap design that includes preoperatively marked vessels within the skin paddle.
10.1055/s-0041-1736317
Perforator navigation using color Doppler ultrasound and three-dimensional reconstruction for preoperative planning of optimal lateral circumflex femoral artery system perforator flaps in head and neck reconstruction.
Shen Yi,Lu Lin-Guo,Low David W,Zhou Hui-Hong,Li Jun,Sun Jian
Journal of plastic, reconstructive & aesthetic surgery : JPRAS
BACKGROUND:The authors introduce an algorithm for preoperative planning of optimal lateral circumflex femoral artery system perforator flap (LCFAPF) supplied by the best quality and the easiest dissection of the perforators and the source vessels for simplified and customized strategies in head and neck reconstruction with perforator navigation using color Doppler ultrasound and three-dimensional reconstruction (3D-CDUS PN). METHODS:Between June 2011 and September 2015, a prospective cohort study was performed with an algorithm based on defect site, perforator type, and pedicle length using 3D-CDUS PN to select optimal perforators arising from the different branches of LCFA in 108 patients. The optimal perforator and flap were determined by perforator caliber and quality, difficulty in flap dissection, and length of the source vessels. Cause and classification of the defect, flap choice, recipient vessels, postoperative course, and complications were analyzed. RESULTS:The source vessels of the perforators were lateral descending branch in 73 cases and oblique branch in 17 cases with ALTPFs, medial descending branch in 12 cases with AMTPFs, and ascending branch in 6 cases with TFLPFs. Straightforward dissection of flaps with septocutaneous (n = 40) and semi-septocutaneous (n = 17) perforators was performed in 52.8% cases. Successful exploration rate and overall flap survival rate were both 100%. Satisfactory functional and esthetic results in both recipient and donor sites with no serious complications were observed in all patients. CONCLUSIONS:Our algorithm using 3D-CDUS PN facilitates selection of optimal flap with better caliber and quality of the perforators and sufficient pedicle length for easy dissection.
10.1016/j.bjps.2018.12.025
Role of Ultrahigh Frequency Ultrasound in Evaluating Experimental Flaps.
Morarasu Stefan,Ghetu Nicolae,Coman Corneliu George,Morarasu Bianca Codrina,Boicu Daniel,Spiridon Irene Alexandra,Gardikiotis Ioannis,Danciu Mihai,Pieptu Dragos
Journal of reconstructive microsurgery
BACKGROUND: Experimental flap follow-up needs faster, safer, and less invasive techniques that can be easily correlated to clinical procedures. For this reason, we aimed to test the role of ultrahigh frequency ultrasound in follow-up of flap viability. Further on, we aimed to analyze if the chimeric groin flap can be mobilized in a sandwiched position without affecting its vascular supply by twisting its pedicle. METHODS: A total of 12 male Wistar rats, split into three groups, were used. Group A ( = 4) had the chimeric groin flap repositioned in a sandwich position on the anterior abdominal wall and underwent ultrahigh frequency ultrasound follow-up at days 10 and 14. Group B ( = 4) also had the flaps sandwiched, however, at day 14 the vascularity of flaps was proven by infusion of nontargeted ultrasound contrast agents, after which flaps were sent for histological analysis. Group C (C1 = 2, C2 = 2) was the control group. In C1 the chimeric groin flap was harvested and sent for histology on day 0, acting as a histological benchmark of flap viability, and in C2 the chimeric groin flap was re-sutured in its anatomical position and after 14 days, flaps were harvested and sent for histological analysis, acting as a direct control for Group B. RESULTS: Ultrasound showed constant vascular flow in both adipose and skin flaps in the sandwiched position. Microbubble study showed diffuse perfusion within flaps. Ultrasound measurements of flow velocity, flap volume, and percentage of vascularity showed a decrease in flap volume and increase in vascularity over 14 days. Histology showed similar viability in both groups. CONCLUSION: Ultrahigh frequency ultrasound may be a valuable tool for postoperative flap assessment, while the chimeric flap can be moved freely in a sandwich position making it suitable for adding tissue substitutes within its components.
10.1055/s-0040-1718392