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Ngoc-Huyen N, The-Hoang N, Lam K, Quang-Vinh N, Staudenmaier R. The Arterial System of the Fasciocutaneous Deltoid Flap Pedicle on 320-Detector Row Computed Tomography and Clinical Application in the Foot and Hand. J Reconstr Microsurg 2024. [PMID: 38914111 DOI: 10.1055/s-0044-1787774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
BACKGROUND Fasciocutaneous free deltoid flaps are used to reconstruct hand, foot, and maxillofacial defects. Although anatomical studies of this flap pedicle have been performed on cadavers, there are no reports on the use of 320-detector row computed tomography angiography (CTA-320) to investigate the deltoid flap pedicle in living humans. This study aimed to investigate the arterial characteristics of the deltoid flap pedicle using the CTA-320 system in living humans. METHODS Twenty-seven adult Vietnamese patients with 54 healthy deltoid regions underwent CTA-320 to investigate arterial blood supply before clinical free-flap transfer. Two- and three-dimensional reconstruction images of the arterial pedicle were visualized, and clinical reconstruction results were evaluated. RESULTS The cutaneous vessel branches of the deltoid flap were separated from the posterior circumflex humeral artery (PCHA) and originated from the axillary (77.78%), subscapular (12.96%), and brachial (9.26%) arteries. The PCHA penetrated the quadrangular space in 90.74% of patients. The cutaneous arterial branch was present in the deltoid-triceps groove in 100% of patients. The average diameter and length of the PCHA were 3.38 ± 0.58 and 43.08 ± 6.60 mm, respectively. The average diameter and length of the flap cutaneous branch were 1.49 ± 0.28 and 44.57 ± 4.83 mm, respectively. The findings of CTA-320 were aligned with the intraoperative clinical findings well. All deltoid flaps were successfully free-transferred with good outcomes. CONCLUSION The CTA-320 is a practical and effective method for investigating deltoid flap pedicles. It enables accurate flap design and harvesting of flaps, thereby enhancing the clinical success of free-flap transfer.
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Affiliation(s)
- Nguyen Ngoc-Huyen
- Department of Upper Extremity Surgery and Microsurgery, Institute of Traumatology, Orthopedics and Plastic Surgery, Central Hospital 108, Hanoi, Vietnam
| | - Nguyen The-Hoang
- Department of Upper Extremity Surgery and Microsurgery, Institute of Traumatology, Orthopedics and Plastic Surgery, Central Hospital 108, Hanoi, Vietnam
| | - Khanh Lam
- Department of Diagnosis Imaging, Central Hospital 108, Hanoi, Vietnam
| | - Nguyen Quang-Vinh
- Department of Upper Extremity Surgery and Microsurgery, Institute of Traumatology, Orthopedics and Plastic Surgery, Central Hospital 108, Hanoi, Vietnam
| | - Rainer Staudenmaier
- Department of Plastic and Reconstructive Surgery, Technical University of Munich, Munich, Germany
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Shaffrey EC, Moura SP, Seitz AJ, Jupitz S, Seets T, Kawahara T, Uselmann A, Lin C, Poore SO. Use of Ambient Light Compatible Fluorescence-Guided Surgical Technology for Objective Assessment of Flap Perfusion in Autologous Breast Reconstruction. J Reconstr Microsurg 2024. [PMID: 38838710 DOI: 10.1055/s-0044-1787267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
BACKGROUND Decreased autologous flap vascular perfusion can lead to secondary procedures. Fluorescence angiography during surgery reduces the probability of repeat surgery but suffers from interpretation variability. Recently, the OnLume Avata System was developed, which evaluates real-time vascular perfusion in ambient light. This study aims to predict complications in autologous breast reconstruction using measures of relative intensity (RI) and relative area (RA). METHODS Patients undergoing autologous breast reconstruction underwent intraoperative tissue perfusion assessment using the OnLume Avata System. Post-hoc image annotation was completed by labeling areas of the flap interpreted to be "Well Perfused," "Questionably Perfused," and "Under Perfused." RIs and RAs were calculated for the marked areas. Primary complications of interest were overall complication rate, fat and mastectomy skin flap necrosis, and surgical revision. Logistic regression was applied to determine the odds of developing a complication based on RI and RA for each image. RESULTS A total of 25 patients (45 flaps) were included. In total, 17 patients (68%) developed at least one complication. Patients who developed any complication (p = 0.02) or underwent a surgical revision for complications (p = 0.02) had statistically lower RI of under-perfused portions of the flap. Patients with greater areas of under-perfused flap had a significantly higher risk of developing fat necrosis (odds ratio [OR]: 5.71, p = 0.03) and required a revision operation (OR: 1.10, p = 0.01). CONCLUSION Image-based interpretation using the OnLume Avata System correlated with the risk of developing postoperative complications that standard fluorescence imaging systems may not appreciate. This information can benefit surgeons to improve perfusion assessment and intraoperative decision-making.
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Affiliation(s)
- Ellen C Shaffrey
- Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Steven P Moura
- Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Boston University Chobanian and Avedisian School of Medicine, Division of Plastic and Reconstructive Surgery, Boston, Massachusetts
| | - Allison J Seitz
- Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Sydney Jupitz
- Onlume Surgical, Research Division, Madison, Wisconsin
| | - Trevor Seets
- Onlume Surgical, Research Division, Madison, Wisconsin
| | | | - Adam Uselmann
- Onlume Surgical, Research Division, Madison, Wisconsin
| | - Christie Lin
- Onlume Surgical, Research Division, Madison, Wisconsin
| | - Samuel O Poore
- Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Gravina P, Singh A, Conlon C, Spiegel A. Preoperative Imaging Mapping of DIEP Perforators and Intraoperative Selection: Does It Correlate? J Reconstr Microsurg 2024; 40:205-210. [PMID: 37315932 DOI: 10.1055/a-2110-0350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Preoperative imaging prior to deep inferior epigastric perforator (DIEP) flap harvest is a common practice to locate perforators and identify aberrant anatomy. METHODS We report a retrospective review of 320 consecutive patients who underwent preoperative computed tomographic angiography (CTA) or magnetic resonance angiography prior to DIEP flap breast reconstruction. The locations relative to the umbilicus of preoperatively identified perforators were compared with the selected intraoperative perforators. The diameter of all intraoperative perforators was also measured. RESULTS Across the 320 patient, 1,833 potentially suitable perforators were identified on preoperative imaging. A total of 564 of the 795 perforators selected intraoperatively for DIEP flap harvest were within 2 cm of a predicted perforator, for a rate of 70.1%. The size of the perforator was unrelated to the detection rate. CONCLUSION We were able to demonstrate a sensitivity of 70% of clinically selected DIEP perforators identified on preoperative imaging in this large series. This contrasts with the nearly 100% predictive value reported by others. Continued reporting of findings and methods of measuring are needed to improve the practical efficacy of CTA and raise awareness about the limitations of CTA, despite its well-documented usefulness.
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Affiliation(s)
- Paula Gravina
- Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
| | - Aspinder Singh
- Michael E. DeBakey Department of General Surgery, Baylor College of Medicine, Houston, Texas
| | | | - Aldona Spiegel
- Center for Breast Restoration, Houston Methodist Institute for Reconstructive Surgery, Houston, Texas
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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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Customizing Anterolateral Thigh Flap With Magnetic Resonance Angiography Differential Subsampling With Cartesian Ordering Imaging for Individualized Reconstruction of Extremity Defects. J Surg Res 2023; 283:733-742. [PMID: 36463812 DOI: 10.1016/j.jss.2022.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 11/06/2022] [Accepted: 11/16/2022] [Indexed: 12/05/2022]
Abstract
INTRODUCTION Magnetic resonance angiography (MRA) with the differential subsampling with cartesian ordering (DISCO) imaging technique is rarely used in anterolateral thigh (ALT) flap. In our series, MRA DISCO imaging technique is used as a tool to customize ALT flaps. The aim of this study was to report the accuracy of cutaneous perforators identified by the MRA DISCO imaging. METHODS Nineteen patients underwent the MRA DISCO imaging for perforator mapping before the ALT flap transfer. A total of 38 ALT regions were studied on the MRA DISCO images. Flap thinning was performed under the guidance of MRA DISCO imaging. RESULTS The lateral circumflex femoral artery (LCFA) most commonly stems from the deep femoral artery (84.2%), followed by the common femoral artery (15.8%). The average number of perforator vessels per LCFA was 10.2 ± 1.7. The distinct oblique branch was observed in 16 out of the 38 ALT regions (42.1%). Among the 19 ALT flaps harvested, 5 were septocutaneous perforator flaps and 14 musculocutaneous perforator flaps. Ten were harvested based on the descending branch, and 3 used the oblique branch as the flap vascular pedicle. In addition, the displayed course and types of perforator vessels on the DISCO images of the 18 skin flaps were consistent with the intraoperative findings, with an accuracy of 94.7%. CONCLUSIONS The state of the cutaneous perforators of LCFA can be identified on the MRA DISCO images. The 3D-CE-MRA DISCO imaging is a practical method, which can ameliorate the design and customization of ALT flap for an individualized reconstruction.
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Knoedler L, Oezdemir B, Moog P, Prantl L, Broer PN, Knoedler C, Rieger UM, Perl M, von Isenburg S, Gassner UM, Obed D, Haug V, Panayi AC, Knoedler S. Thinking like a Lawyer-Human Rights and Their Association with the Plastic Surgeon of Today. Aesthetic Plast Surg 2023; 47:490-497. [PMID: 35922668 PMCID: PMC9944724 DOI: 10.1007/s00266-022-02990-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 06/11/2022] [Indexed: 11/24/2022]
Abstract
Plastic surgeons are trained to perform a wide repertoire of surgeries-ranging from standard local procedures to highly specialized operations. Therefore, plastic surgeons treat a plethora of clinical presentations and address multiple patient needs. Their daily workflow is increasingly entwined with legal topics. The concrete legal interpretation falls within the remit of legal experts. However, by understanding the legal basics of selected surgical procedures, plastic surgeons may generate synergies in patient care and clinical practice. The legal situation is to be elucidated based on the German Basic Law (GBL) and the European Convention on Human Rights (ECHR). LEVEL OF EVIDENCE V: "This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ."
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Affiliation(s)
- Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Berkin Oezdemir
- Faculty of Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Philipp Moog
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Lukas Prantl
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - P Niclas Broer
- Department of Plastic, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital, Munich, Germany
| | - Christoph Knoedler
- Faculty of Applied Social and Health Sciences, Regensburg University of Applied Sciences, Regensburg, Germany
| | - Ulrich M Rieger
- Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, Academic Teaching Hospital of the J.W. Goethe University, Frankfurt am Main, Germany
| | - Markus Perl
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
| | | | | | - Doha Obed
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
- Department of Surgery, Division of Plastic Surgery, Brigham and Womens Hospital, Harvard Medical School, Boston, USA
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
- Department of Surgery, Division of Plastic Surgery, Brigham and Womens Hospital, Harvard Medical School, Boston, USA
| | - Adriana C Panayi
- Department of Surgery, Division of Plastic Surgery, Brigham and Womens Hospital, Harvard Medical School, Boston, USA
| | - Samuel Knoedler
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.
- Department of Surgery, Division of Plastic Surgery, Brigham and Womens Hospital, Harvard Medical School, Boston, USA.
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Illg C, Krauss S, Lauer H, Daigeler A, Schäfer RC. Precision of Dynamic Infrared Thermography in Anterolateral Thigh Flap Planning: Identification of the Perforator Fascia Passage. J Reconstr Microsurg 2022. [DOI: 10.1055/s-0042-1758183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Abstract
Background The anterolateral thigh (ALT) flap is commonly utilized in reconstructive surgery. Preoperative perforator mapping facilitates dissection. Dynamic infrared thermography can be applied to identify ALT perforators. However, its accuracy has not been evaluated in detail before. Therefore, this study aimed to assess the precision of dynamic infrared thermography in ALT perforator localization.
Methods The survey site was defined as a 25 × 8 cm rectangle on the anterolateral thigh and a coordinate system was established. The area was examined consecutively by dynamic infrared thermography with a FLIR ONE camera after 2-minute fan precooling. Two surgeons then independently performed color duplex ultrasound on the basis of the identified hotpots.
Results Twenty-four healthy subjects were examined. About 74.8% of perforators were musculocutaneous or musculoseptocutaneous. The mean distance between study area center and perforator or hotspot center was 51.8 ± 27.3 and 46.5 ± 26.2 mm, respectively. The mean distance from hotspot center to sonographic perforator fascia passage was 15.9 ± 9.9 mm with a maximum of 48.4 mm. The positive predictive value of thermographic ALT perforator identification was 93%.
Conclusion Thermographic hotspot and perforator location diverge widely in ALT flaps. Dynamic infrared thermography can therefore not be used as standalone technique for preoperative ALT perforator identification. However, the application before color duplex ultrasound examination is a reasonable upgrade and can visualize angiosomes and facilitate the examination.
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Affiliation(s)
- Claudius Illg
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Sabrina Krauss
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Henrik Lauer
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Adrien Daigeler
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Ruth Christine Schäfer
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
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Illg C, Krauss S, Rachunek K, Thiel JT, Daigeler A, Schäfer RC. Thermography Supported Color Duplex Ultrasound Accelerates ALT Perforator Imaging. J Reconstr Microsurg 2022; 39:295-300. [PMID: 36150693 DOI: 10.1055/s-0042-1755614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND The anterolateral thigh flap is a versatile and dependable perforator flap and is a popular choice in the reconstruction of various body sites. The variable perforator anatomy suggests preoperative perforator imaging to improve safety and speed of dissection. An innovative perforator imaging technique is thermography, which lately gained attention in plastic surgery. METHODS Thirty-two healthy participants were included in this randomized study. One thigh was examined with dynamic infrared thermography and consecutively with ultrasound, while the contralateral thigh was examined with ultrasound as standalone technology. RESULTS The application of dynamic infrared thermography prior to ultrasound perforator identification significantly accelerated the ultrasound examination duration by 90 to 130 seconds. The mean duplex ultrasound examination duration correlated positively with the hotspot and perforator quantity per thigh. CONCLUSION The addition of thermographic perforator mapping can accelerate color duplex ultrasound anterolateral thigh perforator imaging. Furthermore, thermography supplements color duplex ultrasound with crucial information on angiosome location.
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Affiliation(s)
- Claudius Illg
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Sabrina Krauss
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Katarzyna Rachunek
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Johannes Tobias Thiel
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Adrien Daigeler
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Ruth Christine Schäfer
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
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