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Sun JM, Yamamoto T. Thinned Perforator Flaps in Head and Neck Reconstruction. Oral Maxillofac Surg Clin North Am 2024:S1042-3699(24)00054-2. [PMID: 39198073 DOI: 10.1016/j.coms.2024.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2024]
Abstract
The authors aim to provide a comprehensive overview of the advancements in head and neck reconstructive surgery using thinned perforator flaps. The article categorizes these flaps based on thickness and discusses the importance of standardized terminology. Critical aspects like flap vascularity, pre-operative planning, and imaging technologies for perforator mapping are examined with practical considerations. The article then delves into various thinning techniques and their applications in head and neck reconstructions, highlighting challenges and concerns. In conclusion, significant progress in reconstructive surgery using thinned perforator flaps has brought advancements in improving surgical precision and patient outcomes in head and neck reconstructions.
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Affiliation(s)
- Jeremy Mingfa Sun
- Plastic, Reconstructive and Aesthetic Surgery Service, Department of Surgery, Changi General Hospital, 2 Simei Street 3, Singapore 529889, Singapore
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, Center Hospital of National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan.
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Riva FMG, Kerawala C. Perforator Flaps and Robotic Surgery for Head and Neck Reconstruction. Oral Maxillofac Surg Clin North Am 2024:S1042-3699(24)00047-5. [PMID: 39142950 DOI: 10.1016/j.coms.2024.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
Head and neck cancer (HNC) is the sixth most common cancer across the world. Despite a general reduction in tobacco consumption and therefore reduction in risk exposure there has been an increasing incidence of oropharyngeal squamous cell carcinoma. Progress made in the past decades in free tissue transfer reconstruction and robotic surgery have merged into transoral robotic reconstruction with free perforator flaps for head and neck. We reviewed and discussed indications and contraindications for this type of procedure, as well as potential limits refinements.
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Affiliation(s)
- Francesco M G Riva
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK.
| | - Cyrus Kerawala
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
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Coquillard CL, Bai J, Ko JH. Thin and Thinned Anterolateral Thigh Flaps for Upper Extremity Reconstruction. Hand Clin 2024; 40:199-208. [PMID: 38553091 DOI: 10.1016/j.hcl.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Upper extremity reconstruction remains challenging due to the high functional and esthetic demands of this location. The anterolateral thigh (ALT) flap is a workhorse flap for microsurgical reconstruction of the upper extremity and can be elevated in various planes depending on desired thickness of the flap. Microsurgical reconstruction of the upper extremity often benefits from a thin flap that can resurface the extremity, which can provide improved functional and esthetic outcomes. This article reviews the anatomy, preoperative planning, and operative technique, as well as presents 4 cases to illustrate the outcomes and benefits of thin and thinned ALT flaps.
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Affiliation(s)
- Cristin L Coquillard
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, 259 East Erie Street Suite 2060, Chicago, IL 60611, USA
| | - Jennifer Bai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, 259 East Erie Street Suite 2060, Chicago, IL 60611, USA
| | - Jason H Ko
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, 259 East Erie Street Suite 2060, Chicago, IL 60611, USA; Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 259 East Erie Street Suite 2060, Chicago, IL 60611, USA.
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Virós Porcuna D, Viña Soria C, Vila Poyatos J, Palau Viarnès M, Malagon López P, Gonzàlez Lluch C, Higueras Suñe C, Pollán Guisasola CM, Carrasco López C. Oropharyngeal free flap reconstruction: Transoral robotic surgery versus open approach. Laryngoscope Investig Otolaryngol 2023; 8:1564-1570. [PMID: 38130254 PMCID: PMC10731478 DOI: 10.1002/lio2.1176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/22/2023] [Accepted: 10/15/2023] [Indexed: 12/23/2023] Open
Abstract
Objective Transoral robotic surgery (TORS) has evolved since its 2009 US Food and Drug Administration approval for use in local stage T1-T2 oropharyngeal carcinoma. The ability to resect increasingly larger and more complex lesions has led to the need to introduce reconstructive techniques through this route, avoiding the classic transmandibular or pull-through approach. Few studies have compared the safety, efficacy, and advantages of TORS versus classic open approaches in oropharyngeal salvage surgery with reconstruction using microanastomosed flaps. Here we retrospectively compare our center's experience with the open approach and TORS and describe the technical variations used. Methods Between 2013 and 2021, 30 stage III-IV oropharyngeal cancer patients underwent salvage surgery with reconstruction in our center. From 2013 to 2017, 15 patients underwent surgery with the classic open approach, and from 2018 to 2021, an additional 15 patients underwent TORS. We have compared surgical outcomes, post-surgical results, and survival in the two groups. Results Patient characteristics were similar in the two groups. TORS was associated with shorter surgical time (p < .001), fewer complications (p = .01), shorter hospital stay (p < .001), and lower feeding tube requirements (p = .003). No significant differences were observed between the two groups in the free margin rate or survival. Conclusion Oropharyngeal salvage surgery with TORS with free flap reconstruction reduced associated morbidity compared to the open approach in a patient cohort with poor prognosis. Level of Evidence 4.
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Affiliation(s)
- David Virós Porcuna
- Otolaryngology Section, Head and Neck SurgeryHospital Germans Trias i PujolBadalonaSpain
| | - Constanza Viña Soria
- Otolaryngology Section, Head and Neck SurgeryHospital Germans Trias i PujolBadalonaSpain
| | - Jordi Vila Poyatos
- Plastic and Reconstructive Surgery DepartmentHospital Germans Trias i PujolBadalonaSpain
| | - Mar Palau Viarnès
- Otolaryngology Section, Head and Neck SurgeryHospital Germans Trias i PujolBadalonaSpain
| | - Paloma Malagon López
- Plastic and Reconstructive Surgery DepartmentHospital Germans Trias i PujolBadalonaSpain
| | - Carlota Gonzàlez Lluch
- Otolaryngology Section, Head and Neck SurgeryHospital Germans Trias i PujolBadalonaSpain
| | - Carmen Higueras Suñe
- Plastic and Reconstructive Surgery DepartmentHospital Germans Trias i PujolBadalonaSpain
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Tuluy Y, Bali ZU, Ünsal MÖ, Parspancı A, Yoleri L, Çiçek Ç, Filinte GT. Comparison of The Thickness of Free Anterolateral Thigh Flap in Different Fascial Planes: Clinical Results of Subfascial and Superficial Fat Flap. Arch Plast Surg 2023; 50:601-609. [PMID: 38143845 PMCID: PMC10736183 DOI: 10.1055/s-0043-1772586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 06/29/2023] [Indexed: 12/26/2023] Open
Abstract
Background The anterolateral thigh (ALT) flap is a preferred option in the reconstruction of a wide variety of defects, enabling multiple tissue components and thicknesses. Methods This study was conducted to investigate the correlation of the thickness of the traditional subfascial ALT flap and superficial fat flap with age, gender, and body mass index (BMI). A total of 42 patients (28 males and 14 females) were included in the study. Results Mean age was 50.2 (range, 16-75) years and mean BMI was 24.68 ± 4.02 (range, 16.5-34.7) kg/m 2 . The subfascial flap thickness was significantly thinner in male patients (16.07 ± 2.77 mm) than in female patients (24.07 ± 3.93 mm; p < 0.05), whereas no significant difference was found between male (4.28 ± 1.15 mm) and female patients (4.85 ± 1.09 mm) regarding superficial fat flap thickness ( p = 0.13). The thickness of both flaps had a positive correlation with BMI, and the strongest correlation was found for subfascial ALT thickness in female patients ( r = 0.81). Age had no effect on both flap thickness measurements. The anterior thigh is thicker in women than in men, although it varies according to BMI. This shows that flap elevation is important in the superthin plane, especially if a thin flap is desired in female patients in defect reconstruction with the ALT flap. Thus, a single-stage reconstruction is achieved without the need for a defatting procedure after subfascial dissection or a second defatting procedure 3 to 6 months later. Conclusion The appropriate ALT flap plane should be selected considering the gender and BMI of the patient.
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Affiliation(s)
- Yavuz Tuluy
- Address for correspondence Yavuz Tuluy, MD Plastic, Reconstructive and Aesthetic Surgery, Manisa Turgutlu State HospitalTurgutlu, Manisa, 45000Turkey
| | | | - Merve Özkaya Ünsal
- Department of Plastic, Reconstructive and Aesthetic Surgery, İzmir, Turkey
| | - Aziz Parspancı
- Department of Plastic Reconstructive and Aesthetic Surgery, Bayburt State Hospital, Bayburt, Turkey
| | - Levent Yoleri
- Department of Plastic Reconstructive and Aesthetic Surgery, Manisa Celal Bayar University Faculty of Medicine, Manisa, Turkey
| | - Çağla Çiçek
- Department of Plastic Reconstructive and Aesthetic Surgery, İstanbul Kartal Dr. Lütfi Kırdar City Hospital, İstanbul, Turkey
| | - Gaye Taylan Filinte
- Department of Plastic Reconstructive and Aesthetic Surgery, İstanbul Kartal Dr. Lütfi Kırdar City Hospital, İstanbul, Turkey
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Zhu W, Yang Y, Jiang J, Zhu Q, Qi J, Qin B, Fan J, Fu M, Li P. Value of the combination of a smartphone-compatible infrared camera and a hand-held doppler ultrasound in preoperative localization of perforators in flaps. Heliyon 2023; 9:e17372. [PMID: 37389045 PMCID: PMC10300357 DOI: 10.1016/j.heliyon.2023.e17372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 07/01/2023] Open
Abstract
This study was conducted to evaluate the effectiveness of the FLIR ONE PRO, a thermal imaging camera for smartphones, combined with handheld Doppler (HHD) in the localization of perforator arteries and to assess the efficacy of the FLIR ONE PRO in distinguishing perforators of the descending branch of the lateral circumflex femoral artery (LCFA) from other perforators of the anterolateral thigh perforator (ALTP) flap. We enrolled 29 free perforator flaps from 22 patients in our study. Before surgery, dynamic infrared thermography was performed using a FLIR ONE PRO to visualize hotspots on the flaps. Subsequently, HHD was used to further determine the perforators under the hotspots, which were ultimately identified and confirmed through intraoperative findings. Additionally, infrared images of the ALTP flap were analyzed using FLIR Tools. The performances of the FLIR ONE PRO and FLIR ONE PRO + HHD groups were evaluated by comparing the intraoperative findings. Using FLIR ONE PRO + HHD, 119 hotspots and 106 perforators were identified during surgery. Using FLIR ONE PRO + HHD, sensitivity and positive predictive value were 97.87% and 88.46%, respectively, in the young (age≤45 years). In the elderly group (age>45 years), these percentages were 93.22% and 82.09%, respectively. In addition, we found that the FLIR ONE PRO could be useful for differentiating perforators in the descending branch of the LCFA from other perforators within 5 min. The results showed a sensitivity of 96.15%, a specificity of 98.9%, a positive predictive value of 96.15%, and a negative predictive value of 98.9%. Compared to using FLIR ONE PRO alone, the combined application of HHD and FLIR ONE PRO had a higher value in perforator localization by increasing the positive predictive value. The FLIR ONE PRO may have significance in the rapid prediction of perforators deriving from the descending branch of the LCFA.
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Affiliation(s)
- Weiwen Zhu
- Department of Orthopedics, Trauma & Microsurgery, Joint Surgery, First Affiliated Hospital of Sun Yat-sen University, Zhongshan No. 2 Road, Guangzhou, 510080, China
| | - Yi Yang
- Department of Orthopedics, Trauma & Microsurgery, Joint Surgery, First Affiliated Hospital of Sun Yat-sen University, Zhongshan No. 2 Road, Guangzhou, 510080, China
| | - Jiyong Jiang
- Fourth District of Microsurgery and Hand Department, Heping Orthopedics Hospital, Jude Nan Road 112-120, Guangzhou, 510305, China
| | - Qingtang Zhu
- Department of Orthopedics, Trauma & Microsurgery, Joint Surgery, First Affiliated Hospital of Sun Yat-sen University, Zhongshan No. 2 Road, Guangzhou, 510080, China
| | - Jian Qi
- Department of Orthopedics, Trauma & Microsurgery, Joint Surgery, First Affiliated Hospital of Sun Yat-sen University, Zhongshan No. 2 Road, Guangzhou, 510080, China
| | - Bengang Qin
- Department of Orthopedics, Trauma & Microsurgery, Joint Surgery, First Affiliated Hospital of Sun Yat-sen University, Zhongshan No. 2 Road, Guangzhou, 510080, China
| | - Jingyuan Fan
- Department of Orthopedics, Trauma & Microsurgery, Joint Surgery, First Affiliated Hospital of Sun Yat-sen University, Zhongshan No. 2 Road, Guangzhou, 510080, China
| | - Ming Fu
- Department of Orthopedics, Trauma & Microsurgery, Joint Surgery, First Affiliated Hospital of Sun Yat-sen University, Zhongshan No. 2 Road, Guangzhou, 510080, China
| | - Ping Li
- Department of Orthopedics, Trauma & Microsurgery, Joint Surgery, First Affiliated Hospital of Sun Yat-sen University, Zhongshan No. 2 Road, Guangzhou, 510080, China
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Lee CR, Kim SH, Kwon HJ, Ahn MY, Nam YS, Moon SH. Proximal peroneal perforator flap, cadaveric study, and clinical applications for shallow defect reconstructions. Microsurgery 2023. [PMID: 36756700 DOI: 10.1002/micr.31018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/02/2022] [Accepted: 01/19/2023] [Indexed: 02/10/2023]
Abstract
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.
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Affiliation(s)
- Chae Rim Lee
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Hyun Kim
- Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyo Jeong Kwon
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Young Ahn
- Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong Seok Nam
- Department of Anatomy, College of Korean Medicine, Dongshin University, Chonnam, Republic of Korea
| | - Suk-Ho Moon
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
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Jeong SH, Koo DY, Moon KC, Dhong ES, Han SK. The turbocharged wide anterolateral thigh perforator flap to reconstruct massive soft tissue defects in traumatized lower extremities: A case series. Front Surg 2022; 9:991094. [PMID: 36386520 PMCID: PMC9645236 DOI: 10.3389/fsurg.2022.991094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/04/2022] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND Extensive traumatic soft tissue defects in the lower extremities typically require complete coverage of exposed bone because inadequate coverage, such as partial flap loss, may result in bony infection and ultimately lead to limb salvage failure. To achieve complete coverage of these defects, we used the wide anterolateral thigh perforator flap in which the turbocharging procedure augments the blood flow. Herein, we describe our turbocharging technique and discuss its effectiveness. METHODS From January 2014 to December 2020, the turbocharged wide ALTP free flaps were used to treat 13 patients with massive traumatic soft tissue defects in the lower extremities, ranging in size from 22 × 10 cm2 (220 cm2) to 21 × 17 cm2 (357 cm2) (mean, 270 cm2). All ALTP flaps were supplied by perforators from both the transverse branch of the lateral circumflex artery (TB-LCFA) and descending branch of the lateral circumflex artery (DB-LCFA) simultaneously. The turbocharging procedure by connecting the TB-LCFA to a side branch of the DB-LCFA was carried out in all these flaps. A retrospective review of medical records for each patient was performed. RESULTS The size of the transferred ALTP flap ranged from 23 × 12 cm2 (276 cm2) to 23 × 19 (437 cm2) (mean, 331 cm2). The total number of perforators included in the flaps was three on average. All ALTP flaps survived completely without partial necrosis. The postoperative course was uneventful except for two cases with minor complications, including hematoma and partial necrosis of the recipient's skin. CONCLUSION Free transfer of the turbocharged wide ALTP flap can be a reliable and effective reconstructive method to obtain complete coverage of extensive traumatic soft tissue defects in the lower extremities and achieve successful limb salvage.
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Affiliation(s)
- Seong-Ho Jeong
- Department of Plastic Surgery, Korea University Guro Hospital, Seoul, South Korea
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