New nomenclature concept of perforator flap

On a Hunt for the "True" Septocutaneous Perforator: A Histology Cross-Section Study

BACKGROUND

 Modern trends in reconstructive surgery involve the use of free perforator flaps to reduce the donor site morbidity. The course of perforator vessels has a great anatomic variability and demands detailed knowledge of the anatomical relationships and the variability of the course of the perforators. The numerous modifications to perforator nomenclature proposed by various authors resulted in confusion rather than simplification. In our study, we focused on the hypothesis that a septocutaneous perforator traverses from the given source vessel to the deep fascia adherent to but not to within the septum itself.

METHODS

 Sixty-nine septocutaneous perforators from three different limb donor sites (lateral arm flap, anterolateral thigh flap, and radial forearm free flap) were collected from the gross pathology specimens of 14 fresh cadavers. The gross picture and the cross-sections with the histological cross-sections on different levels were examined to determine the position of the vessel to the septal tissue.

RESULTS

 Of the observed 69 septal perforators, 61 (88.5%) perforators were adherent to but not within the septum. The remaining eight (12.5%) perforators passed through the septum. All these eight perforators were found in multiple different cross-section levels (2 of 19 in lateral arm flap, 3 of 27 in anterolateral thigh flap, and 3 of 23 in radial forearm free flap).

CONCLUSION

 Although septocutaneous vessels appear identical macroscopically, microscopically two types of vessels with paraseptal and intraseptal pathways are observed. The majority of these vessels are merely adherent to the septum having a paraseptal pathway, while a minority are within the septum and are "true" septocutaneous perforators. It is advisable to dissect with a piece of the septum in order to avoid damage or injury to the perforator.

A Comprehensive Flap Classification: Beyond the Reconstructive Ladder

ABSTRACT

Perforator flaps have progressed massively in the last years. The improved vascular imaging techniques and the use of supermicrosurgery have shifted the practice from the traditional predefined angiosomal flaps to the endless variations of custom-made flaps. In this article, we propose a broadened classification of free-style flaps in 3 categories, the angiosomal, including all traditional perforator flaps and their variations, the extra-angiosomal, including flaps that are manufactured to include tissue from a different angiosome, such as turbocharging or supercharging a flap, and neoangiosomal flaps, which are based on the process of neoangiogenesis on autologous or allogenous tissue, such as the venous flow-through flap and integra flap. With this classification, we hope to help unify the classifications and, by doing so, facilitate the exchange of ideas, techniques and knowledge.MeSH terms: surgical flap / classification, terminology as topic.

Research Advances in Vascular Remodeling in Choke Vessels of Perforator Flap: A Systematic Review

BACKGROUND

As a significant bridge between perforasomes, choke vessels are the key structure of blood supply expansion, also a prerequisite for preventing distal ischemic necrosis of the multiterritory perforator flap, where the remodeling of choke vessels after flap elevation plays an essential role. This systematic review highlights the underlying mechanisms and clinical ways to promote remodeling of choke vessels, as well as experimental observation approaches to further guide researchers.

METHODS

A systematic review was conducted from 1975 to 2023 through PubMed, EMBASE, Web of Science, and Cochrane database with the key words "choke vessels" and "perforator flap" to investigate the mechanisms and ways to promote remodeling of choke vessels as well as observation approaches. The inclusion criteria and exclusion criteria were set to screen the literature.

RESULTS

A total of 94 literatures were obtained through database retrieval. After removing the duplicate literature, reading the title and abstract, and reviewing the full text finally, 33 articles were included in the final study.

CONCLUSIONS

The underlying remodeling of choke vessels may be related to fluid shear stress, hypoxia, and inflammation. The clinical ways to promote remodeling of choke vessels include surgical delay, arterial supercharge, venous superdrainage, drugs, and stem cells. Various experimental methods of observing microvascular morphology allow for a comprehensive research of choke vessels.

A Cadaveric Study on Perforator Anatomy of the Medial Sural Artery Perforator Flap

Background  The medial sural artery perforator (MSAP) flap was described by Cavadas et al in 2001. The aim of this study was to analyze the flap characteristics in the regional population and was planned as a cadaveric dissection study. Methods  Thirty-three legs of fresh cadavers were studied for perforator characteristics, length, and origin of pedicle and skin paddle thickness. Observations were documented and analyzed. Results  Seventeen right legs (51.5%) and sixteen left legs (48.5%) were studied. Twenty-five pedicles originated from popliteal artery (86.2%) and four (13.8%) from the common sural trunk. No perforators were seen in four legs. The mean number of perforators is 2 (0-6). The mean distance of perforator from midpoint of popliteal fossa was 10.7 cm (8-13 cm) and from posterior midline it was 3.2 cm. The mean size of the perforator was 1.1 ± 0.8 mm (0.8-1.5 mm). The mean pedicle length was 9.3 ± 1.3 cm. The mean flap thickness was 4.3 ± 0.7 mm (3.0-5.5 mm). There was no correlation for flap or perforator characteristics with side of leg. Conclusion  This study concludes that MSAP is a good flap in terms of perforator characteristics, pedicle length, and flap thickness, when a medium sized thin flap with long pedicle is needed. The location of perforator on calf varies in different population. Being a perforator flap, anatomical variability is common and should be thought of while choosing this flap.

The Ultrasound Evolution of Lateral Thoracic Perforator Flaps Design and Harvest for Partial and Total Breast Reconstruction

BACKGROUND

The lateral thoracic area is a known source for perforator flaps for partial breast reconstruction. In this paper, we report our experience in designing and harvesting lateral thoracic perforator flaps for partial and total breast reconstruction with the introduction of the "propuller" concept.

PATIENTS AND METHODS

Between September 2013 and August 2021, 95 flaps were performed for immediate, partial and total breast reconstruction. On a total of 95 flaps, 30 (19 thoracodorsal artery perforator(TDAP) flaps, 10 lateral intercostal artery perforator(LICAP) flaps and 1 lateral thoracic artery perforator(LTAP) flap) were harvested in the traditional fashion (control group) and 65 (57 LICAP, 2 LTAP and 6 TDAP flaps) according to the propeller concept (study group). All cases were preoperatively planned with Color-Coded Duplex Ultrasound.

RESULTS

No flap losses were experienced in both groups. The mean operative time was 156 minutes (range 118-234) for the control group and 75 minutes (range 53-125) for the study group (p < 0.0001). A significantly higher number of LICAP flaps were chosen in the study group compared to control group. None of the patients had donor site complications. Patients' and Surgeons' satisfaction was high to very high.

CONCLUSION

The ultrasound preoperative planning led to the development of an easier and safer method of local perforator flap harvesting, that we named as propuller design. Its novelty lies in that perforator intraoperative selection and fully skeletonization are not needed and a more efficient flap movement (propeller plus advancement) which transfers more tissue into the new breast can be achieved safely, faster and easier.

Proximal peroneal perforator flap, cadaveric study, and clinical applications for shallow defect reconstructions

PURPOSE

Peroneal artery perforator offers a versatile range of microvascular tissue transfer methods from local flaps to vascularized osteocutaneous fibula flaps. It is one of the few flaps that can cover shallow defects that require thin and pliable skin paddles, such as in hands and feet (Han et al., 2018). The proximal region of the lower leg offers such flexible and thin flap compared to the middle and distal lower leg (Winters & de Jongh, 1999). However, the anatomy of the proximal peroneal artery perforator is relatively unknown in literature and its proximity to the common peroneal nerve (CPN) has not yet been studied. This study conducted a cadaveric study and put it in application into clinical settings.

METHODS

Twenty lower leg specimens were dissected according to the methods of clinical proximal peroneal artery perforator flap harvest. Perforators arising in the proximal lower leg area of between 20 and 40 percentile of fibular length were inspected. Perforator length, location from fibular head, course, and location of CPN were recorded. Clinical reconstruction cases using the proximal lateral lower leg were analyzed. Six patients between the ages of thirty and seventy were included. Five cases were due to trauma, and one from mass excision, but all required thin and pliable flaps for reconstructions in hands or feet. Flaps were designed concentrical oval shapes, and harvest was done similarly to cadaveric perforator dissection, but perforator dissection was done only up to the required pedicle length. Perforator length, flap size, thickness, and long-term complications were recorded.

RESULTS

Among 20 specimens, a total of 20 perforators were found in 18 cadavers (90%). Two specimens showed no perforators while two specimens showed multiple perforators. The perforators were located at an average of 101 mm from fibular head, with an average length of 55 mm ranging from 20 to 153 mm. The average size of perforator at origin was 2.0 mm, ranging from 1.0 to 3.6 mm. 45% showed septocutaneous course and 55% intramuscular course. Two out of 20 perforators were shown to arise from source vessels other than the peroneal artery. All clinical cases were successful without complications or debulking for contour shaping. Flap sizes ranged from 15 to 40 cm² . Largest flap width was 5 cm, and all donor sites were primarily closed without complications. One year of follow-up showed no complications.

CONCLUSION

Proximal peroneal artery perforator flap provides a reliable pedicle for a versatile tissue transfer. This study shows that the perforators of the proximal lateral lower leg often arise from vessels other than the peroneal artery, such as the anterior tibial artery or popliteal artery, as had been previously reported (Winters & de Jongh, 1999). Although the source vessel varies, perforator anatomy is at a safe distance from CPN. This variation of source vessels suggests a change in nomenclature to "proximal peroneal perforator flap." The clinical applications of this flap showed that it can be effectively used for reconstructions of shallow defects, such as in the hands and feet without secondary procedures for debulking.

Genital Reconstruction following Fournier's Gangrene

INTRODUCTION

Fournier's gangrene is a urological emergency, comprising of type I necrotizing fasciitis resulting in anatomic defects affecting the perineum, perianal region, and external genitalia in both men and women, often requiring reconstruction.

OBJECTIVES

The aim of this article is to provide a comprehensive review of the different reconstructive techniques for Fournier's gangrene.

METHODS

A literature search was performed on PubMed with the search terms "Fournier"s gangrene" "genital reconstruction" and "Fournier's gangrene phalloplasty." The European Association of Urology's guidelines on Urological infections were also consulted for recommendations.

RESULTS

Reconstructive procedures include primary closure, scrotal advancement flaps, fasciocutaneous flaps, myocutaneous flaps, skin grafts, and phalloplasty. There is insufficient evidence to support that flaps lead to better outcomes than skin grafts, or vice versa, particularly for scrotal defects. Both techniques have been shown to have satisfactory aesthetic results, with good skin color match and natural scrotal contour. With regards to phalloplasty, there is a lack of data specifically relating to Fournier's gangrene, as most articles were addressed toward gender affirmation surgery. Furthermore, there is a lack of guidelines in both the immediate and reconstructive management of Fournier's gangrene. Lastly, the outcomes reported following reconstructive surgery have been objective rather than subjective, meaning that patient satisfaction was rarely recorded.

CONCLUSION

Further research is required in the field of reconstructive surgery specific to Fournier's gangrene, which should also take into consideration patient demographics and subjective reports regarding cosmesis and sexual function. Michael P, Peiris B, Ralph D, et al. Genital Reconstruction following Fournier's Gangrene. Sex Med Rev 2022;XX:XXX-XXX.

The Sc-GAP makeover flap: eliminating the need for position changes in gluteal flap breast reconstruction

Background

The gluteal region is one of the many alternative donor sites for autologous breast reconstruction. However, the harvest of the gluteal flap is rather difficult, and the major drawback of gluteal flaps has been the need for position changes for flap harvest and inset. A new approach of a gluteal flap is introduced, based on the septocutaneous perforators of the superior gluteal artery: the septocutaneous gluteal artery perforator (Sc-GAP) makeover flap.

Methods

A prospective study was performed in Maastricht University Medical Center between January 2018 and December 2019. Patients who underwent a Sc-GAP makeover flap breast reconstruction in the Maastricht University Medical Center and have had preoperative magnetic resonance angiography (MRA) of the abdomen between January 2018 and June 2019 were included.

Results

Nine patients underwent breast reconstruction with thirteen Sc-GAP makeover flaps, of which nine flaps were innervated. Indications were the abdomen not being available as a donor site (n = 4) or the flank region was preferred as a donor site by the patient (n = 5). The total operative time was 430 min on average (range 311–683). Mean flap weight was 638 g (range 370–1004) and the mean ischemia time was 53 ± 9.96 min. Coupler size used was 2.0–2.5 mm. All flaps survived.

Conclusion

The Sc-GAP makeover flap overcomes the disadvantages of the conventional gluteal flaps, especially by eliminating the need for position changes during the reconstruction procedure. It is a reliable flap that provides sufficient volume and good esthetic outcomes.

Level of evidence: Level IV, therapeutic study.

Definition of perforator flap: what does a "perforator" perforate?

Perforator flap concept plays an important role in reconstructive surgery, because it allows less invasive and more complex reconstruction by preserving major vessels and muscles with intramuscular vessel dissection. Originally "perforator" represents vessel perforating the muscle, then vessel perforating the deep fascia regardless of muscle perforation. With technical progress in reconstructive microsurgery, the previous definition becomes inappropriate for least invasive flaps, only requiring intra-adiposal vessel dissection, such as superficial circumflex iliac artery perforator flap. Based on our experience of various least invasive flap reconstructive surgeries, a new concept for perforator flap has been developed. The new definition of perforator is a vessel perforating an envelope of a targeted tissue to be transferred; the superficial fascia for skin, the periosteum for bone, the perineurium for nerve, and the deep fascia for muscle. According to the new definition, all flaps can be precisely classified based on the corresponding "perforator".

Biofabrication of thick vascularized neo-pedicle flaps for reconstructive surgery

Wound chronicity due to intrinsic and extrinsic factors perturbs adequate lesion closure and reestablishment of the protective skin barrier. Immediate and proper care of chronic wounds is necessary for a swift recovery and a reduction of patient vulnerability to infection. Advanced therapies supplemented with standard wound care procedures have been clinically implemented to restore aberrant tissue; however, these treatments are ineffective if local vasculature is too compromised to support minimally-invasive strategies. Autologous "flaps", which are tissues equipped with their own hierarchical vascular supply, can be harvested from one region of the patient and transplanted to the wound where it is reperfused upon microsurgical anastomosis to appropriate recipient vessels. Despite the success of autologous flap transfer, these procedures are extremely invasive, incur obligatory donor-site morbidity, and require sufficient donor-tissue availability, microsurgical expertise, and specialized equipment. 3D-bioprinting modalities, such as extrusion-based bioprinting, can be used to address the clinical constraints of autologous flap transfer, primarily addressing donor-site morbidity and tissue availability. This advancement in regenerative medicine allows the biofabrication of heterogeneous tissue structures with high shape fidelity and spatial resolution to generate biomimetic constructs with the anatomically-precise geometries of native tissue to ensure tissue-specific function. Yet, meaningful progress toward this clinical application has been limited by the lack of vascularization required to meet the nutrient and oxygen demands of clinically relevant tissue volumes. Thus, various criteria for the fabrication of functional tissues with hierarchical, patent vasculature must be considered when implementing 3D-bioprinting technologies for deep, chronic wounds.

The Perineal Turnover Perforator Flap: A New and Simple Technique for Perineal Reconstruction After Extralevator Abdominoperineal Excision

BACKGROUND

Extralevator abdominoperineal excision (ELAPE) is increasingly used to treat locally advanced low rectal cancer as it has been related to superior oncological outcomes than traditional abdominoperineal excision.However, ELAPE also has been associated with high perineal wound morbidity rates as it creates a larger perineal cavity than standard abdominoperineal excision. This greater defect, along with the effects of preoperative chemoradiation on wound healing, makes uneventful perineal reconstruction post-ELAPE a real challenge for the plastic surgeon.In this paper, the authors present a new technique for perineal reconstruction post-ELAPE, using a perforator, islanded, turnover, de-epithelialized local flap (perineal turnover perforator [PTO] flap).

METHODS

The PTO flap is raised based on perforators from internal pudendal artery. The flap is based on the concept that thick gluteal dermis can act as an "autologous dermal vascularized" substitute for the excised pelvic floor muscles, whereas the bulk of its subcutaneous tissue is used to obliterate dead space.Fourteen patients underwent perineal reconstruction using this approach. Patients' demographics, neoadjuvant chemoradiotherapy, histopathology, duration of surgery, follow-up, and complications were analysed retrospectively.

RESULTS

Median operating time was 49 minutes. There were no flap, donor site, or major wound complications. One patient had superficial skin dehiscence, and one patient developed perineal hernia. None of the patients developed chronic perineal pain.

CONCLUSIONS

The PTO flap is a quick, simple yet safe and reliable option for perineal reconstruction after ELAPE that offers many advantages over the heretofore used reconstructive techniques including primary closure, myocutaneous flaps, and biological meshes.

Free-style Capillary Perforator-Based Island Flaps for Reconstruction of Skin Cancer Defects of the Face, Body, and Extremities

BACKGROUND

The perforator flap concept has revolutionized reconstructive surgery. Recently, the attention has moved toward flaps based on capillary perforators, which have been usually neglected in the past as reliable perforators. The aim of this article is to report a series of freestyle capillary perforator-based island flap (c-PBIF) for reconstruction of skin cancer defects of the face, body, and extremities.

PATIENTS AND METHODS

Between September 2015 and July 2017, 20 consecutive patients underwent c-PBIF reconstruction of facial, body, and limb defects after melanoma and nonmelanoma skin cancer excision. Perforators were detected by means of unidirectional Doppler, and the flaps were designed taking into account the laxity of the surrounding skin in order to allow primary closure of the donor site. The mean defect dimension was 3.75 × 4.43 cm (ranging from 1 × 2 to 4.5 × 8 cm). All but 1 procedure was performed under local anesthesia.

RESULTS

Mean flap size was 5.37 × 9.97 cm (ranging from 1 × 3 to 6 × 8 cm). In all cases, flaps were based on visible capillary perforators with a caliber of approximately 0.5 mm. All flaps survived. One minor tip flap necrosis was experienced in the largest flap of the series, which was successfully managed with dressing changes. The final reconstructive outcomes were satisfactory both for the patients and surgeons.

CONCLUSIONS

Freestyle c-PBIF might represent a further method for local reconstruction of skin cancer defects of the face, body, and extremities, allowing a high tissue efficiency, reduced scarring, and expeditious reconstruction with pleasant outcomes. Further research is needed in order to explore the maximal perforasome potential of capillary perforators.

Evaluation of facial artery perforator-based flaps in reconstruction of facial defects

Introduction

Several flaps have been described for reconstructing facial or oral defects. Flaps such as forehead and pectoralis major are often too bulky for small-to-moderate-sized defects, for which nasolabial flaps are often ideal. However, nasolabial flaps have limited mobility and reach and may need two stages, particularly for intraoral defects. According to recent literatures, facial artery provides numerous small cutaneous perforators, based on which skin flaps can be islanded, with greater mobility and reach for reconstruction of small-to-moderate-sized intraoral and facial defects in one stage. Our study aims to evaluate the reliability and versatility of facial artery perforator-based flaps in the reconstruction of such defects.

Materials and Methods

A ethical committee-approved retrospective study was conducted on data of the patients attending our outpatient department between February 2014 and October 2015 with small-to-moderate-sized facial/oral lesions. The total sample size was 23. We studied the relation of flap survival with size of flap, route of inset and neck dissection, functional and aesthetic outcomes and feasibility of adjuvant therapy in cases of malignancies.

Results and Analysis

A wide range of facial defects, especially intraoral defects, could be reconstructed in one stage using facial artery perforator-based flaps. The flaps were reliable. Complications included only partial skin loss of the flaps in a few cases. Complications were directly related to the length of the flaps and the route of inset. Functional and aesthetic outcomes were satisfactory and none of the flaps showed any significant post-radiotherapy changes.

Conclusions

We concluded that facial artery perforator flap can be a simple, safe, versatile and one-stage alternative to the traditional flaps in the reconstruction of small-to-moderate-sized facial defects. Neck dissection can be safely done in the same sitting.

Improvement of ischemic or congested wound conditions by reconstruction with microsurgical flaps

BACKGROUND

Intractable chronic wounds share the basic problem of the environment being unfavorable for wound healing and prone to infection, inflammation, and recurrences. Microsurgical flap provides a healthy, well-vascularized normal tissue to compromised intractable environment, and promotes wound healing. In this report, we present the results of microsurgical flaps used for the reconstruction of chronic intractable conditions including chronic ulcer with an ischemic environment and pathologic lesions with a congestive environment.

PATIENTS AND METHODS

From 1997 to 2015, 18 patients received microsurgical flaps for chronic intractable conditions. Among them, three patients had radiation ulcers with an ischemic environment and 15 had pathologic lesions with a congested environment, such as vascular malformations. Nine patients were male, and nine were female. The mean age was 31.9 years. All patients were treated using radical excision and reconstruction with microsurgical tissue transfer.

RESULTS

All flaps survived completely. Among three patients with radiation ulcers, two had minor wound disruptions, which were managed conservatively. No further episodes of infections or breakdowns occurred. Among 15 patients who had pathologic lesions, one suffered facial palsy of the forehead. No complications in terms of infection, or recurrences were noted, and resolution of the residual surrounding lesions was observed on follow-ups. No donor related problems occurred in any patients. The mean follow-up period was 10.7 years.

CONCLUSION

In this report, we present the results of reconstruction of chronic intractable conditions using microsurgical flaps. The reconstruction using microsurgical flaps was clinically successful, with long-term improvement of surrounding tissues and no recurrence.

Repair of Full-Thickness Nasal Alar Defects Using Nasolabial Perforator Flaps

BACKGROUND

The repair of full-thickness nasal alar defects presents difficulties because of their complex 3-dimensional structure. Reconstructions using inappropriate methods may lead to asymmetries and dissatisfying functional results. In this study, our aim was to present the repairs of full-thickness alar defects performed using cartilage-supported nasolabial perforator flaps.

MATERIALS AND METHODS

Eight patients who presented to our clinic between January 2011 and April 2014 with full-thickness defects in the alar wings were included in this study. The nasolabial perforator flap was prepared on the basis of the closest perforator to the defect area and in a way to include 2 to 3 mm of subcutaneous adipose tissue. The medial section of the flap was adapted to form the nasal lining. In the 7 patients in whom cartilage support was used, the cartilage graft was obtained from the septum nasi. After the cartilage was placed on the flap, the lateral section of the flap was folded over the medial section and the defect was repaired. In 1 patient in whom cartilage support was not required, the flap was folded over itself before the repair was performed. The flap donor area was primarily repaired.

RESULTS

No detachment around the suture lines, infection, venous insufficiency in the flap, or partial or total flap losses were observed in any of the patients. Retraction developed in 1 patient in whom no cartilage support was used. No retraction was observed in any of the patients in whom cartilage support was used. The results were functionally and esthetically satisfying in all the patients.

CONCLUSIONS

The greatest advantage of perforator-based nasolabial flaps is the greater mobilization achieved in comparison with the other nasolabial flaps. Thus, full-thickness defects can be repaired in 1 session in some patients, no revision is required around the flap pedicle, and much less donor area morbidity occurs. Nasal alar reconstructions performed using this type of flap lead to both esthetically and functionally satisfying results.

A novel method to correctly place the fasciotomy incision for decompression of the anterior and peroneal compartments of the leg

Incorrectly placed fasciotomy incisions can lead to catastrophic complications in compartment syndrome. Two distinctly different techniques are widely practiced to decompress the anterior and peroneal compartments. In one technique the anterior compartment is decompressed directly, and then the peroneal via the inter-muscular septum, avoiding the peroneal perforators. The second technique relies on surface anatomy landmarks to place the skin incision immediately over the inter-muscular septum, and then the respective fascial envelopes are incised separately. A study in healthy active volunteers was conducted to explore the feasibility of a new technique for the placing the incision very accurately over the inter-muscular septum and so avoiding perforator vessels. Hypothesis The inter-muscular septum can be reliably identified using hand-held ultrasound, and confirmed with MRI.

METHODS

Fourteen healthy active volunteers underwent hand-held ultrasound to identify the antero-lateral inter-muscular septum in the left lower limb, which was then marked using cod liver oil capsules. The positions of the anterior, septal and peroneal perforators were then identified using hand-held Doppler, and marked in the same way. MRI was then used to measure the relationship between the surface land marks, the septum (compared to its US position), and the relationship of the perforators themselves.

RESULTS

Hand held ultrasound was successful in identifying the position of the inter-muscular septum in healthy volunteers, as confirmed on MRI scanning. The position and number of peroneal and anterior perforators proved very variable. Direct decompression of the anterior compartment would result in the loss of all anterior perforators in all subjects. Decompression with the skin incision over the inter-muscular septum would not jeopardise any peroneal muscular perforators.

CONCLUSION

This new technique enables decompression both the anterior and peroneal compartments through an accurately placed incision, sparing the greatest number of perforators. Two brief case histories in which the technique was used are presented.

The Versatile Facial Artery Perforator-Based Nasolabial Flap in Midface Reconstruction

INTRODUCTION

Defects in the lower two thirds of the face occur due to trauma, tumoral masses, or infections. In this study, repairs of various defects located in the midface using facial artery perforator-based nasolabial flaps are presented.

PATIENTS AND METHODS

Between January 2009 and June 2013, 15 patients with defects in the lower two thirds of the face or the intraoral region underwent repairs with facial artery perforator-based nasolabial flaps. The etiology was malignant skin tumor excisions in 11 patients, infection in 2 patients, and trauma in 2 patients. Among the patients, 10 were male and 5 were female. Their mean age was 65.1 (range: 20-86) years. The mean duration of follow-up was 14 (7-24) months. The defects were located at the upper lip, cheek, lower lip, intraoral region, and the nasal area. The size of the defects varied between 10 × 10 mm and 40 × 50 mm. All the flaps were prepared as perforator flaps. The flap donor area was primarily closed.

RESULTS

No partial or total flap loss was observed in any of the flaps. The flap donor areas healed without problem. Full patient satisfaction was achieved both aesthetically and functionally.

CONCLUSION

The nasolabial perforator flap has certain advantages such as the 1-stage application, repair using a similar tissue, a wider rotation arc around the pedicle compared to the other regional flaps, and the primary closure of the donor area. Based on these characteristics, it is an ideal alternative for the repairs of the defects located in the lower two thirds of the face or the intraoral region.

Lateral Nasal Artery Perforator Flaps: Anatomic Study and Clinical Applications

Background

Previous studies have investigated facial artery perforators, but have reported inconsistent results regarding lateral nasal artery (LNA) perforators. Although several authors have described the use of LNA perforators for ala nasi and nasal sidewall reconstruction, the literature contains little information regarding the cadaveric dissection of LNA perforators, and most previously published studies have focused on facial artery perforators.

Methods

Sixteen hemifaces from eight fresh cadavers were dissected to study the LNA perforators. After the dissection was performed, the total length and diameter of the LNA and its perforators were measured. The quantity and the distribution of the LNA perforators supplying the overlying skin were then assessed. LNA perforator flaps were used for reconstruction in 10 nasal and perinasal defects.

Results

The mean total lengths of the LNA and its perforators were 49.37 mm and 16.06 mm, respectively. The mean diameters of the LNA and its perforators were 2.08 mm and 0.91 mm, respectively. Based on our findings, we mapped the face to indicate zones with a higher probability of finding perforators. No infection, hematoma, or complete flap necrosis were observed after the procedures.

Conclusions

Nasal reconstruction is a challenging procedure, and LNA propeller/V-Y perforator flaps are an excellent reconstructive option in certain cases. Based on our cadaveric study, we were able to identify an area in the upper third of the nasolabial groove with a high density of perforators.

Perforator chimerism for the reconstruction of complex defects: A new chimeric free flap classification system

Complex defects present structural and functional challenges to reconstructive surgeons. When compared to multiple free flaps or staged reconstruction, the use of chimeric flaps to reconstruct such defects have many advantages such as reduced number of operative procedures and donor site morbidity as well as preservation of recipient vessels. With increased popularity of perforator flaps, chimeric flaps' harvest and design has benefited from 'perforator concept' towards more versatile and better reconstruction solutions. This article discusses perforator based chimeric flaps and presents a practice based classification system that incorporates the perforator flap concept into "Perforator Chimerism". The authors analyzed a variety of chimeric patterns used in 31 consecutive cases to present illustrative case series and their new classification system. Accordingly, chimeric flaps are classified into four types. Type I: Classical Chimerism, Type II: Anastomotic Chimerism, Type III: Perforator Chimerism and Type IV Mixed Chimerism. Types I on specific source vessel anatomy whilst Type II requires microvascular anastomosis to create the chimeric reconstructive solution. Type III chimeric flaps utilizes the perforator concept to raise two components of tissues without microvascular anastomosis between them. Type IV chimeric flaps are mixed type flaps comprising any combination of Types I to III. Incorporation of the perforator concept in planning and designing chimeric flaps has allowed safe, effective and aesthetically superior reconstruction of complex defects. The new classification system aids reconstructive surgeons and trainees to understand chimeric flaps design, facilitating effective incorporation of this important reconstructive technique into the armamentarium of the reconstruction toolbox.

Perforator flaps: the next step in the reconstructive ladder?

Perforator flaps are claimed to be a sign of major progress in head and neck reconstruction, but are they a further step up the reconstructive ladder? In this paper I provide a short summary of the development and current clinical use of perforator flaps in the head and neck, which is based on a presentation to the annual meeting of the British Association of Oral and Maxillofacial Surgeons in 2014. I will describe 4 flaps from the lower leg, which are useful specifically for covering intraoral defects, as examples. When we consider the spectrum of new donor sites, and the precision of flap design that is offered by perforator flaps, it becomes evident that the potential of this new technique has not yet been reached.

Perforator Flap versus Conventional Flap

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.

Anterolateral thigh flap thinning: techniques and complications

BACKGROUND

A thinned anterolateral thigh flap is often necessary to achieve optimal skin resurfacing. In this article, we describe the techniques available for immediate flap thinning and the vascular complications that can follow trimming.

MATERIALS AND METHODS

A systematic literature review was performed to identify the different thinning techniques and any possible complications. Data were identified by performing a systematic search on Medline, Ovid, Embase, the Cochrane Database of Systematic Reviews, Current Contents, PubMed, Google, and Google Scholar. We cross-referenced the identified articles and conference abstracts in the English and French languages.

RESULTS

The study selection process was adapted from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, and 34 were articles compiled by using the study inclusion criteria. These articles were then reviewed for the author name(s), the publication year, the flap dimensions, the flap thickness (both before and after thinning), the perforator type, the type of flap transfer, the complications that followed the thinning, the thinning technique used, the amount of deep fascia preserved around the perforator, the number of cases in the study, the area of application, and the technique used for donor-site closure. We analyzed the possible vascular complications that stemmed from the flap area site selected, the flap thickness, the thinning technique used, and whether the deep fascia was spared.

CONCLUSIONS

The subfascial dissection of anterolateral thigh flaps revealed that the safest method for minimizing vascular complications accounted for a 3.1% probability for marginal necrosis, which can be managed conservatively. The overall breakdown of the vascular-related complications that followed flap thinning totals 13.4% and can be broken down as follows: partial flap loss of 4.1%, partial distal necrosis of 3.5%, marginal necrosis of 3.1%, and total flap loss of 2.5%.

Anatomy of anteromedial thigh perforators: CT-angiography study

The anatomy of perforator for anteromedial thigh (AMT) flap is a very much-debated issue. In this article, we report AMT perforator vascular anatomy by CT-Angiography (CTA) evaluation of 68 consecutive healthy thighs. Perforators emergence, caliber, length, course, and source vessel in the central three fifth of the thigh were studied by a virtual coordinate system. A mean 4.94 ± 1.75 perforators per thigh (average length, 2.6 ± 0.99 cm) from superficial femoral artery (SFA) were found, emerging medial and lateral to sartorius muscle. A mean 0.4 ± 0.74 perforators per thigh (average length, 2.45 ± 0.97 cm) branched from rectus femoris artery, of which 80% were emerging lateral to sartorius muscle. A mean 0.62 ± 0.91 perforators per thigh (average length, 3.1 ± 1.23 cm) branched from an unnamed branch of SFA, of which 88% were emerging lateral to the sartorius muscle. Perforators' calibre was inferior to 1-5 mm in 177 perforators (51.6%), between 1.5 and 2 mm in 159 (46.7%), and over 2 mm in 7 (2%). The findings from this study show that AMT region is plenty of reliable perforators with overlapping fascial emergence but branching from three different source arteries.

Reconstruction of various perinasal defects using facial artery perforator-based nasolabial island flaps

Background

Classical flaps for perinasal defect reconstruction, such as forehead or nasolabial flaps, have some disadvantages involving limitations of the arc of rotation and two stages of surgery. However, a perforator-based flap is more versatile and allows freedom in flap design. We introduced our experience with reconstruction using a facial artery perforator-based propeller flap on the perinasal area. We describe the surgical differences between different defect subtypes.

Methods

Between December 2005 and August 2013, 10 patients underwent perinasal reconstruction in which a facial artery perforator-based flap was used. We divided the perinasal defects into types A and B, according to location. The operative results, including flap size, arc of rotation, complications, and characteristics of the perforator were evaluated by retrospective chart review and photographic evaluation.

Results

Eight patients were male and 2 patients were female. Their mean age was 61 years (range, 35-75 years). The size of the flap ranged from 1 cm×1.5 cm to 3 cm×6 cm. Eight patients healed uneventfully, but 2 patients presented with mild flap congestion. However, these 2 patients healed by conservative management without any additional surgery. All of the flaps survived completely with aesthetically pleasing results.

Conclusions

The facial artery perforator-based flap allowed for versatile customized flaps, and the donor site scar was concealed using the natural nasolabial fold.

Perforator flap: A novel method for providing skin cover to lower limb defects

BACKGROUND

Soft tissue defects in the lower limb pose a formidable challenge due to lack of reliable local flap options. Due to thin non-expendable soft tissues and predisposition to massive edema formation, even small defects become problematic. Perforator flaps represent the latest trends in soft tissue coverage. The aim of this study was to evaluate the effectiveness of perforator flaps as coverage of soft tissue defects in lower limbs.

MATERIAL AND METHODS

A series of patients with soft tissue defects of various etiologies in the lower limb were treated using perforator flap at a tertiary care service hospital. Six were free flaps and fourteen pedicled flaps. Doppler ultrasound was used to identify recipient and donor vessels pre-operatively.

RESULTS

Only one flap was lost due to venous congestion. In another case of carcinoma penis there was delayed healing due to persistent lymphorrhoea as a result of post-operative status following lymph node dissection and radiotherapy. Fifteen donor sites required split skin grafting, as they could not be closed directly.

CONCLUSION

Perforator flaps are a reliable option for closure of soft tissue defects of lower limb irrespective of size, location and depth. There is minimal donor site morbidity. It has the advantage of rapid dissection, flap elevation and reliable skin territory. As no special equipment is required it can be replicated in smaller centers also.

Propeller flaps: classification and clinical applications

Propeller flaps feature a highly reliable reconstructive method, based on a perforator vessel. Since their introduction in 1991, a great variety of propeller flaps have been described, according to their shape and their potential of coverage. Indeed, these flaps have progressively been refined and modified, concerning their vascularity and space design. The authors present a classification of propeller flaps. This anatomical classification is necessary to understand the dissection procedure and the differences between the numerous types of propeller flaps nowadays described. It is the international classification, which should be used for the description and conception of these flaps.

Initial temporary vascular insufficiency in latissimus dorsi and thoracodorsal perforator flaps

BACKGROUND

Initial temporary vascular insufficiency of the perforator flap is confused with real flap ischemia or congestion during the initial period of reconstruction. Latissimus dorsi and thoracodorsal perforator flaps are no exception. Since a reliable perforator is not always consistent in its location or diameter, and recipient vessels may not always be healthy, the vascular pedicle is frequently spastic or the flap is readily congested. Risk factors were reviewed and several preparations were necessary.

METHODS

In a preliminary study, 73 patients undergoing reconstruction with a latissimus dorsi or thoracodorsal perforator flap were retrospectively reviewed. Temporary flap congestion was observed in 10 patients (13.7 percent), and six risk factors were identified. To alleviate flap congestion, four supplementary measures were prepared for patients with risk factors: T-anastomosis for the flow dispersion, inclusion of an additional vein, inclusion of a supercharged perforator, and a muscle-sparing technique.

RESULTS

Flap congestion was observed in two of 32 patients (6.3 percent); there was no marginal necrosis. T-anastomosis was the most commonly prepared measure. An additional draining vein or a supercharged perforator was frequently used in large, thin, or relatively long flaps, and a muscle-sparing technique was used for flaps based on a less reliable perforator.

CONCLUSIONS

Perforator selection and careful dissection of the pedicle are required for successful reconstruction in latissimus dorsi or thoracodorsal perforator flaps. A perforator pedicle is more sensitive than a conventional flap, and flap congestion is a concern in patients with risk factors, even though most cases are relieved in time. To prevent congestion, the appropriate flap design with preparation of supplementary measures is recommended for better results when the flap is elevated.

Free-style local perforator flaps: concept and classification system

BACKGROUND

Defect reconstruction according to the free-style concept applied to perforator flaps allows flap harvesting in any anatomical region where an audible Doppler signal of a perforator is detected. We report the results of a study in which local perforator flaps were selected for reconstruction in different anatomical areas and were harvested using the free-style concept.

METHODS

During a 2-year period, defect coverage was carried out in 21 patients (n=21) in the following anatomical areas: cervical (n=3), sternal/parasternal (n=4), axillary (n=2), tibial (n=5), trochanteric (n=2) and sacral/gluteal (n=5). The mean age of patients (15 male and six female) was 57.8 years. Flap selection was based solely on preoperative Doppler mapping in areas adjacent to soft-tissue defects. The mean follow-up period was 1 year.

RESULTS

All flaps survived, demonstrating postoperatively acceptable aesthetic results with good patient satisfaction. The donor sites were closed primarily in 17 patients; four patients required skin grafting. Two patients required surgical revision due to flap-margin dehiscence. There was no loss of function at donor sites. Increased flap mobility could be achieved through extended perforator dissection. One perforator-based flaps offered the widest arc of rotation serving as propeller flaps. If more than one perforator vessel was preserved, flap mobility was limited, but still allowed sufficient flap movement either as a rotation or advancement flap or as a combination of both. A classification is proposed according to the number of perforator vessels preserved and to the type of flap movement.

CONCLUSIONS

The concept of free-style local perforator flaps represents a safe, versatile and reliable surgical procedure. It not only offers a greater freedom in flap selection but also provides good aesthetic results. The classification proposed might aid in the decision-making process involved in order to achieve adequate results with this procedure.

The thin circumflex scapular artery perforator flap

The development of microsurgery has most recently been focused upon the evolution of perforator flaps, with the aim of minimising donor site morbidity, and avoiding the transfer of functionally unnecessary tissues. The vascular basis of perforator flaps also facilitates radical primary thinning prior to flap transfer, when appropriate. Based upon initial clinical observations, cadaveric, and radiological studies, we describe a new, thin, perforator flap based upon the circumflex scapular artery (CSA). A perforator vessel was found to arise within 1.5cm of the CSA bifurcation (arising from the main trunk, or the descending branch). The perforator arborises into the sub-dermal vascular plexus of the dorsal scapular skin, permitting the elevation and primary thinning of a skin flap. This thin flap has been employed in a series of five clinical cases to reconstruct defects of the axilla (two cases of hidradenitis suppurativa; pedicled transfers), and upper limb (one sarcoma, one brachial to radial artery flowthrough revascularisation plus antecubital fossa reconstruction, and one hand reconstruction with a chimeric flap incorporating vascularised bone, fascia, and thin skin flaps; free tissue transfers). No intramuscular perforator dissection is required; pedicle length is 8-10cm and vessel diameter 2-4mm. There was no significant peri-operative complication or flap failure, all donor sites were closed primarily, patient satisfaction was high, and initial reconstructive aims were achieved in all cases. Surgical technique, and the vascular basis of the flap are described. The thin circumflex scapular artery perforator flap requires no intramuscular dissection yet provides high quality skin (whose characteristics can be varied by orientation of the skin paddle), and multiple chimeric options. The donor site is relatively hair-free, has favourable cosmesis and no known functional morbidity. This flap represents a promising addition to the existing range of perforator flaps.

Tertiary resurfacing after one of the first free flaps in Europe, a reflection on 30 years of microsurgical progress

Free flaps have been used for over 30 years. During this period, improved anatomical understanding has increased donor options and available pedicle lengths, permitting safer, single-stage reconstructions with simpler anastomoses. Refinements, such as perforator flaps in particular, have greatly improved donor morbidity, recipient site cosmesis, and the ability to replace 'like with like' while retaining options for innervation. This case highlights the evolution from one of Europe's first free tissue transfers, effectively a perforator flap, through the advent of free muscle flaps to the current generation of contourable perforator flaps. Free flap transfer has become increasingly sophisticated, safer, and more predictable, yet the potential quality of reconstructive outcome has changed little.