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Thomas B, Haug V, Falkner F, Arras C, Nagel SS, Boecker A, Schmidt VJ, Kneser U, Bigdeli AK. A single-center retrospective comparison of Duplex ultrasonography versus audible Doppler regarding anterolateral thigh perforator flap harvest and operative times. Microsurgery 2022; 42:40-49. [PMID: 34165203 DOI: 10.1002/micr.30775] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 03/15/2021] [Accepted: 05/18/2021] [Indexed: 12/21/2022]
Abstract
INTRODUCTION We reported on the superiority of preoperative Duplex mapping ("Duplex") over audible Dopplers ("Doppler") in anterolateral thigh perforator (ALT) free flaps for upper extremity reconstruction. To corroborate our findings on a larger cohort, we conducted this present study focusing on surgical efficiency and patient safety. METHODS 150 consecutive ALT free flaps were divided into 65 cases of preoperative Duplex versus 85 Doppler controls. We first compared patient demographics, operative details, and defect and flap characteristics. We then assessed group differences in the number and course of perforators pursued intraoperatively, flap harvest and operative times, and donor-site complications. Additionally, the impact of the training level of the primary microsurgeon was evaluated. RESULTS Cases and controls were comparable regarding age (p = .48), sex (p = .81), ASA class (p = .48), and BMI (p = .90). Duplex was associated with an increased likelihood of raising flaps on one single dominant perforator of purely septal course and significant reductions of flap harvest (68 ± 10 min, p < .0001) and operative times (74 ± 16 min, p < .0001), regardless of the experience of the primary microsurgeon. There were strong negative linear correlations between preoperative Duplex and both the flap harvest and operative times (p < .0001). Additionally, while there was no effect on the emergency take-back rate (OR = 1.3, p = .60), revisions were significantly less likely among duplexed patients (OR = 0.15, p = .04). CONCLUSIONS Preoperative Duplex is associated with a significant reduction in ALT free flap harvest and overall operative times, as well as donor-site revisions as opposed to Doppler planning, regardless of the training level of the primary microsurgeon.
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Affiliation(s)
- Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Florian Falkner
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Christian Arras
- Department of Regenerative Musculoskeletal Medicine, Institute of Musculoskeletal Medicine, Westfaelische Wilhelms University Muenster, Muenster, Germany
| | - Sarah S Nagel
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Arne Boecker
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Volker J Schmidt
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
- Department of Plastic and Breast Surgery, Zealand University Hospital, Roskilde, Denmark
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Amir K Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
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2
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Moore R, Mullner D, Nichols G, Scomacao I, Herrera F. Color Doppler Ultrasound versus Computed Tomography Angiography for Preoperative Anterolateral Thigh Flap Perforator Imaging: A Systematic Review and Meta-Analysis. J Reconstr Microsurg 2021; 38:563-570. [PMID: 34959247 DOI: 10.1055/s-0041-1740958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The anterolateral thigh (ALT) perforator flap is a commonly used flap with a predictable, though often variable, perforator anatomy. Preoperative imaging with color Doppler ultrasound (CDU) and computed tomography angiography (CTA) of ALT flap perforators can be a useful tool for flap planning. This study provides a complete review and analysis of the relevant preoperative ALT imaging literature. METHODS Studies related to preoperative CDU and CTA imaging were reviewed, and information related to imaging method, sensitivity, false-positive rates, and perforator course identification (musculocutaneous vs. septocutaneous) were analyzed. RESULTS A total of 23 studies related to preoperative ALT flap CDU and CTA imaging were included for review and analysis. Intraoperative perforator identification was compared with those found preoperatively using CDU (n = 672) and CTA (n = 531). Perforator identification sensitivity for CDU was 95.3% (95% CI: 90.9-97.6%) compared with the CTA sensitivity of 90.4% (95% confidence interval [CI]: 74.4-96.9%). The false-positive rate for CDU was 2.8% (95% CI: 1.1-4.5%) compared with 2.4% (95% CI: 0.7-4.1%) for CTA. Accuracy of perforator course identification was 95.5% (95% CI: 93.6-99.2%) for CDU and 96.9% (95% CI: 92.7-100.1%) for CTA. CONCLUSION CDU provides the reconstructive surgeon with greater preoperative perforator imaging sensitivity compared with CTA; however, false-positive rates are marginally higher with preoperative CDU. Preoperative imaging for ALT flap design is an effective tool, and the reconstructive surgeon should consider the data presented here when selecting a flap imaging modality.
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Affiliation(s)
- Reece Moore
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Donna Mullner
- Division of Plastic and Reconstructive Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Georgina Nichols
- Division of Plastic and Reconstructive Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Isis Scomacao
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina.,Division of Plastic and Reconstructive Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Fernando Herrera
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina.,Division of Plastic and Reconstructive Surgery, Medical University of South Carolina, Charleston, South Carolina
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Nassar AH, Maselli AM, Manstein S, Shiah E, Slatnick BL, Dowlatshahi AS, Cauley R, Lee BT. Comparison of Various Modalities Utilized for Preoperative Planning in Microsurgical Reconstructive Surgery. J Reconstr Microsurg 2021; 38:170-180. [PMID: 34688218 DOI: 10.1055/s-0041-1736316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Amer H Nassar
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amy M Maselli
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Samuel Manstein
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Eric Shiah
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Brianna L Slatnick
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Arriyan S Dowlatshahi
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ryan Cauley
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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4
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Islam S, Ansari U, Walton GM. Role of real-time colour-flow Doppler in perforator free flap head and neck reconstruction. Br J Oral Maxillofac Surg 2020; 59:111-113. [PMID: 32861470 DOI: 10.1016/j.bjoms.2020.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/06/2020] [Indexed: 11/19/2022]
Abstract
We discuss the use of real-time colour-flow Doppler ultrasound to optimally evaluate the vascular anatomy of patients receiving free perforator flap head and neck reconstruction. We explore the advantages of the technique and its role as a valuable adjunct for the planning and harvesting of perforator flaps.
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Affiliation(s)
- Shofiq Islam
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Rd, Coventry CV2 2DX.
| | - Umair Ansari
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Rd, Coventry CV2 2DX
| | - Gary M Walton
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Rd, Coventry CV2 2DX
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5
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Thomas B, Warszawski J, Falkner F, Nagel SS, Schmidt VJ, Kneser U, Bigdeli AK. A comparative study of preoperative
color‐coded
Duplex ultrasonography versus handheld audible Dopplers in
ALT
flap planning. Microsurgery 2020; 40:561-567. [DOI: 10.1002/micr.30599] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 03/03/2020] [Accepted: 04/24/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Benjamin Thomas
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
| | - Jan Warszawski
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
| | - Florian Falkner
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
| | - Sarah S. Nagel
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
| | - Volker J. Schmidt
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
| | - Amir K. Bigdeli
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
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6
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Huang JW, Huang CS, Shih YC, Perng CK, Lin YY, Wu SH. Comparison of perioperative outcomes between endoscope-assisted technique and handheld acoustic Doppler for perforator identification in fasciocutaneous flaps. Medicine (Baltimore) 2018; 97:e10849. [PMID: 29851798 PMCID: PMC6392539 DOI: 10.1097/md.0000000000010849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The endoscopic technique has been utilized to harvest muscle flaps and detect perforators of fasciocutaneous flaps. This study aimed to compare the perioperative outcomes between the endoscope-assisted technique and handheld acoustic Doppler for perforator identification in fasciocutaneous flaps.This retrospective case-control study included patients who underwent fasciocutaneous flap reconstruction for traumatic soft tissue defects. In the case group, perforator identification was assisted by the endoscope-assisted technique. In the control group, age- and sex-matched patients received handheld acoustic Doppler to detect perforators. Perioperative outcomes, flap characteristics, and postoperative complications were compared.There were 12 patients in the case group and 12 in the control group. Compared with the control group, the case group had a significantly shorter length of donor-site wounds (9 cm vs 12 cm, P = .023) and a significantly smaller proportion of patients receiving skin grafting at the donor sites (0% vs 41.7%, P = .037). The case group had a longer operative time, but the difference was not statistically significant (180 minutes vs 150 minutes, P = .367). The amount of blood loss, the time length of postoperative drainage, and complications did not significantly differ between the 2 groups.The endoscope-assisted technique for perforator identification of fasciocutaneous flaps provided less donor-site morbidity and a significantly shorter length of donor-site wounds than the conventional handheld acoustic Doppler, which suggests that this technique could be a valuable alternative when a precise design is indicated.
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Affiliation(s)
- Jen-Wu Huang
- Department of Surgery, National Yang-Ming University Hospital, Yi-Lan
- Institute of Emergency and Critical Care Medicine
| | - Chih-Sheng Huang
- Department of Surgery, National Yang-Ming University Hospital, Yi-Lan
- Department of surgery
| | - Yu-Chung Shih
- Division of Plastic and reconstructive surgery, Department of Surgery, Taipei Veterans General Hospital
- Institute of Clinical Medicine, School of Medicine, National Yang-Ming University
| | - Cherng-Kang Perng
- Department of surgery
- Division of Plastic and reconstructive surgery, Department of Surgery, Taipei Veterans General Hospital
| | - Yi-Ying Lin
- Institute of Emergency and Critical Care Medicine
- Department of Pediatrics, Heping Fuyou Branch, Taipei City Hospital, Taipei, Taiwan
| | - Szu-Hsien Wu
- Department of surgery
- Division of Plastic and reconstructive surgery, Department of Surgery, Taipei Veterans General Hospital
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7
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Retrospective Review of Free Anterolateral Thigh Flaps for Limb Salvage in Severely Injured High-Voltage Electrical Burn Patients. Ann Plast Surg 2018; 80:232-237. [PMID: 29309334 DOI: 10.1097/sap.0000000000001283] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND High-voltage electrical injuries usually cause extensive and devastating damages to the extremities. Timely and effective coverage of the wounds to maximally preserve the viable tissue is important for salvage and the ultimate functional outcome of the involved extremities. In this study, free anterolateral thigh flaps with a single-perforator pedicle were conducted to maximize tissue salvage and decrease late skeletal and neuromuscular complications of the involved extremities injured by high-voltage electricity. METHODS From June 2012 to December 2015, 12 patients with high-voltage electrical injuries on the extremities were recruited. After primary or secondary debridement, free anterolateral thigh flaps with a single-perforator pedicle were used for limb salvage. Patients' clinical records, including etiology, sex, age, perforator type, defect location, duration before admission, defect and flap size, timing of reconstruction, and complications, were extracted and analyzed. RESULTS All patients were followed up ranging from 10 to 25 months, with an average follow-up of 15.9 months. Free anterolateral thigh flap with a single-perforator pedicle was performed for 12 consecutive patients with high-voltage electrical injuries. The mean time taken before the transplantation of the flap was 5.25 days, with a range from 2 to 8 days. The average size of the resultant defects after debridement was 187.0 cm (84-350 cm), the average size of the flaps was 265.3 cm (119-448 cm), and the average time of the surgical operation was 314.6 minutes (260-355 minutes). All flaps healed uneventfully without associated complications. No weakness of the donor thigh was observed in all cases. CONCLUSIONS Free anterolateral thigh flaps with a single-perforator pedicle were an effective and reliable therapeutic intervention for the management of severe high-voltage electrical injuries on the extremities.
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