The Skin Bridge Is More Important as an Additional Venous Draining Route in a Perforator-Plus Flap

Anterolateral Chest Reconstruction Using a Posterior Intercostal Artery Perforator-Based Latissimus Dorsi Musculocutaneous Flap

Latissimus dorsi (LD) flaps are ideal for reconstructing deep and complex anterolateral chest defects because they provide both coverage and volume with relatively short surgery and acceptable donor-site morbidity. The LD flap is suitable for patients who have undergone lung surgery and should avoid prolonged or invasive reconstruction surgery. However, the LD main pedicle, the thoracodorsal artery (TDA), is often damaged in these patients. A hitherto poorly known alternative is an LD flap that is based on a posterior intercostal artery perforator (P-ICAP). Here, we present the case of a 65-year-old man with a postpleurectomy anterolateral chest defect involving exposed lung tissue who was planned to undergo reconstruction with an ipsilateral TDA-pedicled musculocutaneous LD flap. In preoperative imaging and intraoperative exploration, the TDA was found to be damaged, but the eighth dorsal branch P-ICAP was identified and shown to have a strong Doppler signal. Thus, it served as the pedicle, and the entire LD muscle was elevated. The cutaneous part of the flap was designed as a superoposteriorly based transposition flap that maintained a skin bridge to reduce the risk of venous congestion. The donor site was closed primarily. The postoperative course was uneventful. This case supports the use of a P-ICAP-based LD musculocutaneous flap for reconstructing anterolateral chest defects in cases where the TDA is damaged.

The Effects of Angiosome Morphology on Choke Vessels and Flap Necrosis in a Rat Multiterritory Perforator Flap

BACKGROUND

Although the angiosome concept has been proposed for a long time, very few studies have been done on its morphology. Our study investigated the effects of angiosome morphology on choke vessels and flap necrosis in a rat multiterritory perforator flap.

METHODS

Seventy-two male Sprague-Dawley rats were randomly divided into 3 groups (n = 24/group). The flap contained the right iliolumbar, posterior intercostal, and thoracodorsal angiosomes (TDAVs), termed angiosomes I, II, and III, respectively. Only the posterior intercostal artery and iliolumbar vein were preserved in group 1, whereas only the posterior intercostal artery and vein were preserved in group 2, and only the posterior intercostal artery and thoracodorsal vein were preserved in group 3. Distances from angiosome II to angiosome I (II-I), angiosome II to angiosome III (II-III), angiosome I to the caudal side of the flap (I-caudal), and angiosome III to the cranial side of the flap (III-cranial) were measured. Arteriography, flap necrosis, average microvascular density, and vascular endothelial growth factor expression were evaluated.

RESULTS

The II-I distance was significantly greater than that of II-III (3.853 ± 0.488 versus 3.274 ± 0.433 cm, P = 0.012), whereas the distance of I-caudal resembled that of III-cranial (1.062 ± 0.237 versus 0.979 ± 0.236 cm, P = 0.442). The iliolumbar and posterior intercostal angiosomes were multidirectional, whereas the TDAV was craniocaudal and unidirectional. Seven days after the operation, the choke arteries had transformed into true anastomotic arteries. Flap necrosis was lowest in group 3, followed by group 2, and highest in group 1 (10.5% ± 2.4% versus 18.3% ± 3.5% versus 25.5% ± 4.6%, P < 0.01), whereas group 3 showed the highest microvascular density and vascular endothelial growth factor expression, in contrast to groups 2 and 1, with the lowest.

CONCLUSIONS

The choke vessel adjacent to the craniocaudal and unidirectional TDAV significantly blocked venous return. Increasing venous return may reduce the necrosis.

Differences between novel hybrid mode flaps and traditional perforator flaps at the level of metabolites using LC-MS

The multi-territory perforator flaps are widely used in plastic surgery. However, partial necrosis flap in the potential territory remains a challenge to plastic surgeons. We raised a novel "hybrid nourished mode" (HNM) flap based on the multi-territory deep inferior epigastric perforator (DIEP) flap to improve flap survival. Thirty-two rabbits were randomly divided into DIEP and HNM groups. Untargeted metabolic mechanisms between the DIEP and HNM groups were performed using LC-MS under the filter criteria of fold change >20.0 times or <0.05, and variable importance in projection (VIP) value was set at ≥1, P < 0.05. Between the two groups, flap survival, perfusion, microvasculature, histopathology, and immunohistochemistry of CD31 were assessed on post-operative day 7. We screened 16 different metabolites that mainly participated in biosynthesis of secondary metabolites, aminoacyl transfer RNA biosynthesis, phenylalanine metabolism, arginine and proline metabolism, among others. The results of the HNM flaps were higher than those of the DIEP flaps (P < 0.05) in the aspects of flap survival, flap perfusion, and microvasculature. Compared with the DIEP flaps, HNM has a stronger advantage in tissue metabolism. This study provided us with a better understanding and strong evidence in terms of metabolites on how HNM achieves the survival of large multi-territory perforator flaps.

Which one is better for multi-territory perforator flap survival, central perforator artery or central perforator vein?

BACKGROUND

The survival of multi-territory perforator flap is associated with the position of the perforators. This study aimed to explore whether use of the central perforator artery or vein was better for flap survival.

METHODS

75 male Sprague-Dawley rats were randomly divided into three groups (n=25 per group). The flap contained the right and left iliolumbar, left posterior intercostal, and left thoracodorsal angiosomes, termed angiosomes Ⅰ to Ⅳ, respectively. The anastomosis between angiosomes Ⅱ and Ⅲ was termed choke 2. In experimental group 2, only the right iliolumbar vein and the left iliolumbar artery were preserved; in experimental group 1, only the right iliolumbar artery and the left iliolumbar vein were preserved; and in the control group, only the right iliolumbar artery and vein were preserved. On day-7 after the operation, the flap arteriography, intraluminal diameter, average microvascular density, vascular endothelial growth factor (VEGF) expression and flap survival were compared among groups. Moreover, the percentages of the angiosomes were measured.

RESULTS

The dilation of the choke 2 artery was most pronounced in experimental group 2, followed by experimental group 1, and, finally, the control group (p<0.05). Similar results regarding average microvascular density, VEGF expression, and survival rate were found among the three groups. The percentages of angiosomes Ⅰ to Ⅳ were 23.1%, 23.0±3.1%, 23.0±1.9%, and 31.0±3.1%, respectively.

CONCLUSIONS

Compared with the central perforator vein, the central perforator artery was more beneficial in enhancing flap survival. A multi-territory perforator flap with the central perforator artery could capture 3 angiosomes safely.

Effectiveness and Prognosis: Drainage Skin-Bridge Sparing Surgery Combined with Fistulotomy versus Fistulotomy Only in the Treatment of Anal Fistula

Objective

This study intends to analyze the difference in the efficacy of drainage skin-bridge sparing surgery combined fistulotomy (DSCF) and fistulotomy alone.

Methods

125 patients with anal fistula were enrolled as study subjects and randomly divided into control group (CG) and observation group (OG) by double-blind lottery. The CG received drainage skin-bridge sparing surgery with fistulotomy and the OG received fistulotomy only.

Results

The VAS scores of the trauma in the OG were lower than those in the CG on 1st day of surgery and 7 days after surgery (P < 0.05). The length of hospital stay and time to wound healing were shorter in the OG than in the CG (P < 0.05). The incidence of postoperative bleeding in the OG was 9.52%, which was lower than 22.58% in the CG (P < 0.05). The rectal examination scores were lower in the OG than in the CG at 3 and 5 days postoperatively (P < 0.05). The Wexner scores of solid incontinence (0 to 4), liquid incontinence (0 to 4), gas incontinence (0 to 4), pad wearing (0 to 4), and lifestyle alteration (0 to 4) in the OG were lower than those of the CG at 5 days postoperatively (P < 0.05). Voiding function scores were lower in the OG than in the CG at 2 and 3 days postoperatively (P < 0.05).

Conclusions

The efficacy of drainage skin-bridge sparing surgery combined fistulotomy is better than that of fistulotomy alone, which can accelerate postoperative healing, enhance urinary function, reduce postoperative bleeding, and improve anal function.

A Modification to Enhance the Survival of the Island FDMA Flap by Adding a Skin Bridge

Distal thumb injuries are common in high construction load regions, and it is a challenging task for the plastic surgeon to find the optimum choice that preserves thumb length and provides a sensory substitute to the lost tissue. Introducing first dorsal metacarpal artery flap has solved the dilemma. One drawback is that the flap is susceptible to distal necrosis, which can happen because of tight tunneling or insufficient venous drainage. We combined Foucher and Holevich characteristics to design a flap that promises to solve the problem.

Improvement of multiterritory perforator flap survival supported by a hybrid perfusion mode: A novel strategy and literature review

Perforator flaps have been widely used in clinical Settings, however, unexpected necrosis was still commonly encountered in the distal portions of multiterritory flaps known as Choke zone III. In this study, we introduced a novel hybrid perfusion technique which is different from the established one of arterial supercharging or venous superdrainage to improve multiterritory flap survival with success. In order to ensure the entire flap survival of multiterritory flaps extending to choke zone III, a "hybrid perfusion" mode by anastomosing a distal vein of the flap with a recipient artery was carried out in two cases based on our previous basic study. In addition, a systematic literature review regarding the established microsurgical assistant techniques of arterial supercharging and venous superdrainage techniques were performed. Both flaps survived uneventfully. At a minimal follow-up of six months, both patients were satisfied with the results. This novel hybrid perfusion technique provides a simple new concept in solving partial necrosis of multiterritory flaps. Further practice is guaranteed for better understanding this unconventional attempt.

Effects of arterial blood supply and venous return on multi-territory perforator flap survival

This study aimed to design arterial ischemic and venous congested areas on the same multi-territory perforator flap, assessing the effects of arterial blood supply and venous return on flap survival. Totally 68 rats were randomly divided into the experimental (Exp) and control (Con) groups. In the Exp group, flaps were based on left superficial epigastric artery and right superficial epigastric vein. In the Con group, flaps were based on the left superficial epigastric artery and vein. Immediate postoperative ink-gelatin angiography, epidermal metabolite levels detection, tissue edema measurement, survival rate evaluation in half of the flaps and average microvessel density assessment were performed. Blood in the Exp group flowed through most angiosomes, but only flowed around pedicled vessels in the Con group; metabolite levels of left halves in the Con and Exp groups were comparable with those of right halves. Angiosomes with high water contents occurred in the Exp group. Survival rates of left halves in the Con and Exp groups were higher than those of right halves, and more microvessels were found in the left ventral areas of both groups compared with the right ventral area in the Exp group. These findings revealed that on the same multi-territory perforator flap, arterial blood supply, affected by venous return, is a prerequisite for flap survival.