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Besmens IS, Zoller FE, Guidi M, Giovanoli P, Calcagni M. How to measure success in lower extremity reconstruction, which outcome measurements do we use a systematic review and metanalysis. J Plast Surg Hand Surg 2023; 57:505-532. [PMID: 36779747 DOI: 10.1080/2000656x.2023.2168274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
Different factors have to be considered and weighted in the treatment algorithm of lower extremity reconstruction. A combination of both clinicians' and patients' perspectives is necessary to provide a conclusive picture. Currently, there aren't any standardized and validated measurement data sets for lower extremity reconstructions. This makes it necessary to identify the relevant domains. We, therefore, performed a systematic review and metanalysis of outcome measurements and evaluated their ability to measure outcomes after lower extremity reconstruction. A systematic review and metanalysis according to the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' protocol were performed for studies reporting at least one structured outcome measurement of lower extremity reconstruction. Both Patient (PROMs)- and Clinician reported outcome measurements (CROMs)were analyzed. Of the 2827 identified articles, 102 were included in the final analysis. In total 86 outcome measurements were identified, 34 CROMs, 44 PROMs and 8 (9.3%) outcome measurements that have elements of both. Twenty-four measure functional outcome, 3 pain, 10 sensations and proprioception, 9 quality of life, 8 satisfaction with the result, 5 measure the aesthetic outcome, 6 contours and flap stability and 21 contain multidomain elements. A multitude of different outcome measurements is currently used in lower extremity reconstruction So far, no consensus has been reached on what to measure and how. Validation and standardization of both PROMs and CROMs in plastic surgery is needed to improve the outcome of our patients, better meet their needs and expectations and eventually optimize extremity reconstruction by enabling a direct comparison of studies' results.
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Affiliation(s)
- Inga S Besmens
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Florence E Zoller
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Marco Guidi
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Pietro Giovanoli
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Maurizio Calcagni
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Morrison E, Lu J, Graziano F, Mah E, Shahzad F. Propeller Flaps for Lower Back Defects. EPLASTY 2023; 23:QA2. [PMID: 36793659 PMCID: PMC9891771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
What are the reconstructive challenges of the lumbosacral area?What are the goals and principles of reconstructing the lumbosacral defect?What are propeller flaps?How are propeller flaps used in the lumbosacral region?
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Affiliation(s)
- Edwin Morrison
- Department of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY,Correspondence: Edwin Morrison, MBBS;
| | - Jocelyn Lu
- Division of Plastic and Reconstructive Surgery, The Mount Sinai Hospital, New York, NY
| | - Francis Graziano
- Division of Plastic and Reconstructive Surgery, The Mount Sinai Hospital, New York, NY
| | - Eldon Mah
- Department of Plastic and Reconstructive Surgery, St. Vincent's Hospital, Melbourne, Australia
| | - Farooq Shahzad
- Department of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Abstract
The propeller flap challenges conventional wisdom for the safe raising of flaps. Its unique design is based on a belief that a sizeable fasciocutaneous flap can be perfused by only a single perforator. What is more remarkable is the concept that this cleanly dissected pedicle can continue to safely perfuse the flap even when it is twisted 180 degrees. Clearly, meticulous technique is essential and the key points in raising this flap and its versatility for reconstruction of defects around the foot and ankle are discussed in this article.
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Affiliation(s)
- Tiew Chong Teo
- Department of Plastic Surgery, Queen Victoria Hospital, East Grinstead, West Sussex, United Kingdom
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Soteropulos CE, Shulzhenko NO, Nayar HS, Poore SO. The Effect of Perforator Skeletonization on Pedicled Fasciocutaneous Flaps of the Lower Extremity: A Systematic Review. J Reconstr Microsurg 2020; 36:634-644. [DOI: 10.1055/s-0040-1713598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Abstract
Background Lower extremity defects often require free tissue transfer due to a paucity of local donor sites. Locoregional perforator-based flaps offer durable, single-stage reconstruction while avoiding the pitfalls of microsurgery. Multiple harvest techniques are described, yet few studies provide outcome comparisons. Specifically, no study has examined the impact of perforator flap pedicle skeletonization on reconstructive outcomes. This systematic review characterizes technique and impact of pedicle skeletonization on perforator-based fasciocutaneous flaps of the lower extremity.
Methods PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were reviewed for literature examining perforator-based fasciocutaneous flaps from knee to ankle, from January 2000 through November 2018. The Preferred Reporting Items for Systematic Reviews-Individual Participant Data (PRISMA-IPD) structure was used.
Results Thirty-six articles were included for quantitative analysis. Of 586 flaps, 365 were skeletonized (60.1%) with 58 major (9.9%) and 19 minor complications (3.2%). With skeletonization, overall reoperative rate was higher (odds ratio [OR]: 9.71, p = 0.004), specifically in propeller (OR: 12.50, p = 0.004) and rotational flaps (OR: 18.87, p = 0.004). The complication rate of rotational flaps also increased (OR: 2.60, p = 0.04). Notably, skeletonization reduced complications in flaps rotated 90 degrees or more (OR: 0.21, p = 0.02). Reoperative rate of distal third defects (OR: 14.08, p = 0.02), flaps over 48 cm2 (OR: 33.33, p = 0.01), and length to width ratios over 1.75 (OR: 7.52, p = 0.03) was increased with skeletonization. Skeletonization increased complications in traumatic defects (OR: 2.87, p = 0.04) and reduced complications in malignant defects (OR: 0.10, p = 0.01).
Conclusion Pedicled, perforator-based flaps can provide a reliable locoregional alternative to free tissue transfer for lower extremity defects. Though skeletonization increased the overall reoperative rate, the complication rate for flaps with 90 degrees or more of rotation was significantly reduced. This suggests skeletonization should be considered when large rotational movements are anticipated to reduce complications that can arise from pedicle compression and venous congestion.
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Affiliation(s)
- Carol E. Soteropulos
- Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Nikita O. Shulzhenko
- Division of Plastic Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Harry S. Nayar
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Samuel O. Poore
- Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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The Microvascular Peroneal Artery Perforator Flap as a "Lifeboat" for Pedicled Flaps. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 7:e2396. [PMID: 31942377 PMCID: PMC6908404 DOI: 10.1097/gox.0000000000002396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 06/25/2019] [Indexed: 11/26/2022]
Abstract
Pedicled perforator flaps have expanded reconstructive options in extremity reconstruction. Despite preoperative mapping, intraoperative findings may require microvascular tissue transfer when no adequate perforators can be found. The free peroneal artery perforator flap may serve as a reliable back-up plan in small defects.
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Interperforator Flow Pattern and Clinical Application of Distal Extended Peroneal Artery Perforator Flaps. Ann Plast Surg 2019; 80:546-552. [PMID: 29215367 PMCID: PMC5916457 DOI: 10.1097/sap.0000000000001290] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Introduction Peroneal artery perforator flaps are the most widely used pedicled flaps for soft tissue defects of the distal lower extremity. Most research regarding peroneal artery flaps focuses on the location, diameter, and number of peroneal artery perforators. However, there is little literature regarding interperforator flow patterns within the peroneal artery perforator flaps. The aims of the present study were to describe interperforator flow patterns of the distally based extended peroneal artery perforator flaps through digital subtraction angiography and review their clinical application. Methods Twelve consecutive patients underwent digital subtraction angiography of the lower-limb arteries. The number and classification of peroneal artery perforators and the interperforator flow patterns were observed. Based on these observations, distally based extended peroneal artery perforator flaps were designed to repair nonhealing wounds located on the ankles and feet of 14 patients. Results The peroneal artery gives out grades I to IV perforators in the lateral leg. There were 2 to 7 grade I perforators and true anastomoses between adjacent grade II perforators, which generate directly linked vessels in the middle leg. The grade III or IV perforators form a reticular vascular network through a large number of chock and potential anastomoses. All flaps survived and had excellent appearance and texture. Conclusions Distally based extended peroneal artery perforator flaps appear reliable for repairing wounds located on or around the ankle and front foot. However, whether the middle perforator or peroneal artery should be used depends on the condition of the anastomosis between direct linking vessels and the distal perforator.
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Kapoor T, Banuelos J, Adabi K, Moran SL, Manrique OJ. Analysis of clinical outcomes of upper and lower extremity reconstructions in patients with soft-tissue sarcoma. J Surg Oncol 2018; 118:614-620. [DOI: 10.1002/jso.25201] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 07/19/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Trishul Kapoor
- Department of Surgery, Division of Plastic Surgery; Mayo Clinic; Rochester Minnesota
| | - Joseph Banuelos
- Department of Surgery, Division of Plastic Surgery; Mayo Clinic; Rochester Minnesota
| | - Kian Adabi
- Department of Surgery, Division of Plastic Surgery; Mayo Clinic; Rochester Minnesota
| | - Steven L. Moran
- Department of Surgery, Division of Plastic Surgery; Mayo Clinic; Rochester Minnesota
| | - Oscar J. Manrique
- Department of Surgery, Division of Plastic Surgery; Mayo Clinic; Rochester Minnesota
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Color Doppler ultrasonography targeted reconstruction using pedicled perforator flaps-a systematic review and meta-analysis. EUROPEAN JOURNAL OF PLASTIC SURGERY 2018; 41:495-504. [PMID: 30294069 PMCID: PMC6153870 DOI: 10.1007/s00238-018-1435-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 06/11/2018] [Indexed: 11/16/2022]
Abstract
Background Flaps are increasingly popularized in reconstructive surgery and there is need to test and increase their reliability. Color Doppler ultrasound has been stated to be valuable in flap planning. The aim of this study was to conduct a systematic review and meta-analysis of the literature of Color Doppler ultrasound targeted pedicled perforator flaps and provide information on outcomes and complication rates. Method A systematic review and meta-analysis were conducted for articles published until April 2017 in PubMed and Embase. We aimed to include randomized clinical trials, meta-analysis, prospective studies, case-control studies, and cohort studies written in English. We included studies where CDU was used to identify the perforator(s) prior to surgery. We evaluated the quality of the included studies using checklists recommended by the Cochrane group. Results From the initial 219 studies, only 12 studies using Color Doppler targeted pedicled perforator flaps in 252 cases met the inclusion and exclusion criteria. Eleven of these were case series and one a prospective study. The incidence of major complications was 8% (21/252) and minor complications was 14%, comprising of mostly necrosis 8% (24/252) and venous congestion 8% (21/252). Conclusions The reconstructive success rate following pedicled perforator flap reconstruction targeted by CDU appears to be high and the procedure provides a wide scope of applications and margin of safety. It is evident that the risk of venous congestion is 11 times greater in the lower extremities than the truncus, a finding that needs further attention in future studies. Level of Evidence: Level IV, risk/prognostic study
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Balakrishnan TM, Ramkumar J, Jaganmohan J. Ad hoc posterior tibial vessels perforator propeller flaps for the reconstruction of lower third leg soft- tissue defects. Indian J Plast Surg 2018; 50:281-287. [PMID: 29618863 PMCID: PMC5868107 DOI: 10.4103/ijps.ijps_67_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Lower third leg soft tissue defects with anatomical and pathological constraints are posing formidable challenges to reconstructive surgeon. Aim This retrospective study was conducted to assess the effectiveness of ad hoc posterior tibial vessels perforator-propeller flaps for the reconstruction of small and medium sized soft tissue defects in the lower third leg. Patients and Methods 22 patients (16 were males and 6 were females) were involved in this study between period of January 2012 and December 2016.We followed the protocol of initial non delineating exploratory incision made to find out single best perforator in all patients. All the defects in leg reconstructed with adhoc posterior tibial vessel propeller flaps. Results All 22 flaps survived well. All in an average of 13 months follow up period, had pain free walking, with minimal scarring and acceptable aesthesis at the reconstruction sites with no need for any secondary procedure. Conclusion With inability of preoperatively dopplering the perforators in the lower third leg region, the exploratory posterior nondelineating incision was used in all cases to secure the single best perforator for the propeller flaps. Thus adhoc posterior tibial vessel propeller flaps are dependable, easily adoptable for the reconstruction of soft tissue defects of the lower third leg region.
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Affiliation(s)
| | - Jayagosh Ramkumar
- Department of Plastic and Faciomaxillary Surgery, Madras Medical College, Chennai, Tamil Nadu, India
| | - Janardhanan Jaganmohan
- Department of Plastic and Faciomaxillary Surgery, Madras Medical College, Chennai, Tamil Nadu, India
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Özalp B, Aydınol M. Perforator-based propeller flaps for leg reconstruction in pediatric patients. J Plast Reconstr Aesthet Surg 2016; 69:e205-11. [DOI: 10.1016/j.bjps.2016.07.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 06/24/2016] [Accepted: 07/16/2016] [Indexed: 10/21/2022]
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Ring A, Kirchhoff P, Goertz O, Behr B, Daigeler A, Lehnhardt M, Harati K. Reconstruction of Soft-Tissue Defects at the Foot and Ankle after Oncological Resection. Front Surg 2016; 3:15. [PMID: 27014697 PMCID: PMC4781863 DOI: 10.3389/fsurg.2016.00015] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 02/24/2016] [Indexed: 01/12/2023] Open
Abstract
Introduction Solid malignancies at the foot and ankle region are rare and include mainly soft-tissue sarcomas, bone sarcomas, and skin malignancies. Complete surgical resection with clear margins still remains the mainstay of therapy in these malignancies. However, attainment of negative surgical margins in patients with locally advanced tumors of the foot and ankle region may require extensive surgery and could result in loss of extremity function. In these circumstances, plastic surgical techniques can frequently reduce functional impairment and cover soft-tissue defects, particularly in cases of large tumor size or localization adjacent to critical anatomic structures, thereby improving the quality of life for these patients. The aim of this article is to illustrate the various treatment options of plastic surgery in the multimodal therapy of patients with malignant tumors of the foot and ankle region. Materials and methods This article is based on the review of the current literature and the evaluation of the author’s own patient database. Results The local treatment of malignant extremity tumors has undergone major changes over the last few decades. Primary amputations have been increasingly replaced by limb-sparing techniques, preserving extremity function as much as possible. Although defect coverage at the foot and ankle region is demanding due to complex anatomical features and functional requirements, several plastic surgical treatment options can be implemented in the curative treatment of patients with malignant solid tumors in this area. Soft-tissue defects after tumor resection can be covered by a variety of local flaps. If local flaps are not applicable, free flap transfers, such as the anterolateral thigh flap, parascapular flap, or latissimus dorsi flap, can be utilized to cover nearly all kinds of defects in the foot and ankle region. Conclusion Soft-tissue reconstruction in the foot and ankle region is a vital component of limb-sparing surgery. It enables complete resection of locally advanced tumors and subsequent adjuvant radiotherapy. Modern plastic surgical techniques should, therefore, be integrated in the multimodal treatment concept of malignancies in the foot and ankle region.
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Affiliation(s)
- Andrej Ring
- Department for Plastic and Hand Surgery, Burn Center/Sarcoma Reference Center, Ruhr-University Bochum , Bochum , Germany
| | - Pascal Kirchhoff
- Department for Plastic and Hand Surgery, Burn Center/Sarcoma Reference Center, Ruhr-University Bochum , Bochum , Germany
| | - Ole Goertz
- Department for Plastic and Hand Surgery, Burn Center/Sarcoma Reference Center, Ruhr-University Bochum , Bochum , Germany
| | - Bjorn Behr
- Department for Plastic and Hand Surgery, Burn Center/Sarcoma Reference Center, Ruhr-University Bochum , Bochum , Germany
| | - Adrien Daigeler
- Department for Plastic and Hand Surgery, Burn Center/Sarcoma Reference Center, Ruhr-University Bochum , Bochum , Germany
| | - Marcus Lehnhardt
- Department for Plastic and Hand Surgery, Burn Center/Sarcoma Reference Center, Ruhr-University Bochum , Bochum , Germany
| | - Kamran Harati
- Department for Plastic and Hand Surgery, Burn Center/Sarcoma Reference Center, Ruhr-University Bochum , Bochum , Germany
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