The Chimeric Gracilis and Profunda Artery Perforator Flap: Characterizing This Novel Flap Configuration with Angiography and a Cadaveric Model

Volumetric Analysis of a Novel Chimeric Gracilis and Profunda Artery Perforator Flap

BACKGROUND

 The presence of a chimeric gracilis and profunda artery perforator (PAP) flap with a common arterial pedicle has been demonstrated on computed tomography angiography in up to 59% of patients and confirmed in a cadaveric model. Already utilized for head and neck reconstruction by Heredero et al, this novel flap could provide more volume than either flap alone which is advantageous, particularly in patients with sizable defects. The purpose of this study was to determine the average tissue volume that can be utilized from this chimeric flap.

METHODS

 CT Angiogram imaging studies exhibiting chimeric flap anatomy were reviewed over a 7-year period at a single institution utilizing Visage Version 7.1, a radiology picture archiving and communication system. This software was used to trace the flap pedicles and to capture estimated soft tissue volumes of each respective flap.

RESULTS

 A total of 31 patients, consisting of 52 lower extremity gracilis and PAP chimeric flaps, underwent tissue volume analysis. The average total volume of soft tissue supplied by the gracilis flap was found to be 70.21 cm3 (standard deviation [SD] = 26.99). The average volume of the PAP flap was 31.73 cm3 (SD = 26.12). The average total volume captured by the chimeric gracilis and PAP flap was 101.94 cm3 (SD = 62.40).

CONCLUSION

 The potential soft tissue volume that can be harvested from a chimeric gracilis and PAP flap is significantly greater than solitary gracilis or PAP flaps. This chimeric flap may serve as a viable and advantageous reconstructive option for patients requiring large volume soft tissue coverage, particularly if other sizable options are not available.

Cadaveric Study for Safe Elevation of a Profunda Artery Perforator Flap: Anatomy of the Perforators and Obturator Nerves

BACKGROUND

 This cadaveric study aimed to describe the anatomy of the profunda artery perforators (PAPs).

METHODS

 In total, nine free cadavers with 18 upper thighs were dissected, 12 of which were from female cadavers, and 6 were from male cadavers. The average age of the cadavers was 84.7 ± 4.2 years. Dissection was performed to evaluate the anatomic position and characteristics of the femoral PAPs. The perforator distance from the gluteal sulcus, number of perforators, perforating muscles, diameter of the perforators, origin of the perforators, and number of nerves passing above and below the perforators were determined.

RESULTS

 The average number of perforators that penetrate the adductor magnus muscle was 2.5. The average distance from the origin of the perforators to the gluteal sulcus was 71.72 ± 28.23 mm. The average numbers of the obturator nerves passing above and below the perforator in the adductor magnus muscle were 1.3 (range, 0-4) and 0.7 (range, 0-2), respectively.

CONCLUSION

 The results provide a detailed anatomic basis for the PAP flap. The perforators of a PAP flap may be included in a flap with a transverse design. Sacrificing the small obturator nerves during dissection may not lead to significant donor site morbidity.

The profunda artery perforator flap for upper limb reconstruction: A case report and literature review on the flap applications in reconstruction

The profunda femoris artery perforator (PAP) flap has been recently popularized as an alternative option for microsurgical reconstruction. The use of PAP flap has never been reported and described for reconstruction of the upper extremities, in particular the forearm. The purpose of this case report is to describe a case suggesting the PAP flap as a further reconstructive option in the upper limb. A 16-year-old girl who sustained a traumatic injury to her right dominant forearm resulting in subtotal circumferential tissue loss following a road traffic accident was referred to the authors' department 2 years post-trauma. The disabling fibrotic sequelae on her volar forearm (15 × 10 cm) resulted in a nonfunctional hand. She was unable to perform any active movement of her wrist or digits. Passive movements in the finger joints were preserved. Following debridement and reconstruction of nerves and tendons, soft tissues were resurfaced with a PAP flap. The transverse skin paddle, 12 × 7 cm, was placed distally with the adipofascial portion positioned proximally above the muscle bellies and anastomoses site. A small raw area (4 × 3 cm) was covered with an acellular dermal matrix (ADM). The postoperative course was uneventful. At 9 months postoperatively, the patient demonstrated active flexion and extension of the fingers with independent function. The patient reported satisfaction with the flap donor site and forearm resurfacing. The PAP flap can be a further option for areas requiring soft tissue coverage in patients refusing visible scars. This flap had both the advantage of reducing the morbidity and visibility of the donor site, as well as the ability to resurface a large recipient site with soft and pliable tissue, covering exposed nerves and tendons.

Use of the Vertical Profunda Artery Perforator Flap to Capture the Dominant Perforator: A Cadaver Dissection and Imaging Study

INTRODUCTION

 While the originally described transverse profunda artery perforator (tPAP) flap is designed to capture the first profunda perforator, our group hypothesized the dominant perforator may not always be captured in this configuration. This study maps the location of dominant profunda perforators using imaging and cadaveric dissections to determine the probability of capturing dominant perforators with the transverse flap design versus the vertical PAP (vPAP) variant.

METHODS

 Fifty preoperative magnetic resonance angiogram or computed tomographic angiogram scans (100 total extremities) were examined from autologous breast reconstruction patients between 2015 and 2019. Profunda perforator characteristics that were examined included the distance from the pubic tubercle to the infragluteal fold (IGF), the distance of the perforators from the IGF, distance posterior to the gracilis, the diameter of the perforator at fascial exit, and total number of perforators present. Profunda perforator dissection was performed in 18 cadaveric extremities. Analysis included mean distance from pubic tubercle, distance posterior to the gracilis, diameter at fascial exit, and total number of perforators.

RESULTS

 In imaging analysis, the mean distance from the IGF to the fascial exit of all dominant perforators was 7.04 cm. The mean diameter of the dominant perforator at the fascial exit was 2.61 mm. Twenty-six thighs (26%) demonstrated dominant perforators that exited the fascia greater than 8 cm below the IGF. In cadaver dissections, the mean distance from the pubic tubercle to the fascial exit of all the dominant perforators was 10.17 cm. Nine cadaver specimens (50%) demonstrated perforators that exited the fascia greater than 8 cm below the estimated IGF.

CONCLUSION

 The dominant perforator can often be missed in the traditional tPAP design. The vPAP incorporates multiple perforators with a long pedicle, excellent vessel diameter, and favorable donor-site.