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Zhu Y, Pan S, Xu Y, Shi J, Shi Z. The Efficacy of Modified Ilizarov Distraction-Tension Device on Limb Wound Difficult to Cover with Skin Flaps. Orthop Surg 2024. [PMID: 39223103 DOI: 10.1111/os.14217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 08/07/2024] [Accepted: 08/07/2024] [Indexed: 09/04/2024] Open
Abstract
INTRODUCTION Closure of complex limb wounds poses challenges and requires innovative approaches. This research aimed to evaluate the effectiveness of a modified distraction-tension device using Ilizarov external fixation for wound closure in challenging cases. METHODS A retrospective analysis was conducted on 43 patients with extremity wounds that were difficult to cover with skin flaps between January 2019 and December 2022. Tension-relieving traction was applied using the Ilizarovexternal fixator apparatus, tailored to individual wound characteristics. Three types of wire-pin connections were used in this study. The distraction begins on the third postoperative day, with a speed of 0.5mm/d. Clinical wound healing scores were evaluated at 5 and 30 days postoperatively. Complications were documented following the Paley classification system. RESULTS Traction using modified Ilizarovexternal fixation promoted a significant reduction in wound size. The mean traction period was 11.2 ± 7.3 days, and the mean healing duration was 17.0 ± 3.7 days. The clinical wound healing score improved from 3.7 ± 2.9 at 5 days to 1.7 ± 0.7 at 30 days postoperatively (p < 0.05). Complications were minimal, with no significant obstacles or sequelae observed. Direct closure healing was achieved in 21 cases, skin graft healing in 13 cases, and suture healing in 9 cases. No recurrences were reported. Using Paley's classified complications, there were 17 problems, 9 obstacles, and 0 sequelae. CONCLUSION The Ilizarov tension-relieving traction shows promise in facilitating wound closure that is challenging to manage with skin flaps. The modified three types of pin-skin connection configuration could satisfy various types of wound closure.
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Affiliation(s)
- Yueliang Zhu
- The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Sunwen Pan
- The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yongqing Xu
- 920th Hospital of Joint Logistics Support Force of PLA, Kunming, China
| | - Jian Shi
- 920th Hospital of Joint Logistics Support Force of PLA, Kunming, China
| | - Zhen Shi
- The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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2
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Bianchi A, Hayashi A, Salgarello M, Gentileschi S, Visconti G. Designing Perforator Flaps Using Ultrasound. Oral Maxillofac Surg Clin North Am 2024:S1042-3699(24)00045-1. [PMID: 39217089 DOI: 10.1016/j.coms.2024.07.004] [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: 09/04/2024]
Abstract
Microsurgeons have today the freedom of the "chosen flap," as opposed to the "flap of choice," but the preoperative knowledge of the microanatomy of each patient is mandatory. The need for preoperative evaluation of the perforators, not only in terms of position, but also for dimensions, flow, and relationship with the surrounding structures became essential and allows more personalized reconstruction, less invasiveness, more safety and finally increase microsurgeon creativity.
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Affiliation(s)
- Alessandro Bianchi
- UOSD Chirurgia Plastica, Dipartimento Salute Donna, Bimbo e Sanità Pubblica, Università Cattolica del "Sacro Cuore" - Fondazione Policlinico Universitario "Agostino Gemelli" IRCSS, Largo A. Gemelli 8, Rome 00168, Italy
| | - Akitatsu Hayashi
- Department of Breast Center, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Marzia Salgarello
- UOSD Chirurgia Plastica, Dipartimento Salute Donna, Bimbo e Sanità Pubblica, Università Cattolica del "Sacro Cuore" - Fondazione Policlinico Universitario "Agostino Gemelli" IRCSS, Largo A. Gemelli 8, Rome 00168, Italy
| | - Stefano Gentileschi
- UOSD Chirurgia Plastica, Dipartimento Salute Donna, Bimbo e Sanità Pubblica, Università Cattolica del "Sacro Cuore" - Fondazione Policlinico Universitario "Agostino Gemelli" IRCSS, Largo A. Gemelli 8, Rome 00168, Italy
| | - Giuseppe Visconti
- UOSD Chirurgia Plastica, Dipartimento Salute Donna, Bimbo e Sanità Pubblica, Università Cattolica del "Sacro Cuore" - Fondazione Policlinico Universitario "Agostino Gemelli" IRCSS, Largo A. Gemelli 8, Rome 00168, Italy.
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3
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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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4
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Heredero S, Falguera MI, Gómez V, Sanjuan-Sanjuan A. Customized Soft Tissue Free Flaps in Head and Neck Reconstruction. Oral Maxillofac Surg Clin North Am 2024:S1042-3699(24)00050-5. [PMID: 39155167 DOI: 10.1016/j.coms.2024.07.009] [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: 08/20/2024]
Abstract
The integration of imaging technologies such as computed tomography angiography and color Doppler ultrasonography are transforming soft tissue free flap reconstruction. The search for thinner and more refined flaps has expanded indications for flaps harvested from donor sites that were not commonly used in head and neck reconstruction. This article explores how these tools and techniques facilitate precise flap selection, thickness, and design customization based on detailed patient preoperative perforator anatomy and vascular configuration mapping. Optimizing outcomes with tailored flap designs improves surgical accuracy and patient-specific results in soft tissue reconstruction.
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Affiliation(s)
- Susana Heredero
- Department of Maxillofacial Surgery, Hospital Universitario Reina Sofía, Avd. Menéndez Pidal s/n, Córdoba 14004, Spain; Unidad de Cirugía Reconstructiva Avanzada, Hospital Cruz Roja, Paseo de la Victoria s/n, Córdoba 14004, Spain.
| | - Maria Isabel Falguera
- Unidad de Cirugía Reconstructiva Avanzada, Hospital Cruz Roja, Paseo de la Victoria s/n, Córdoba 14004, Spain
| | - Vicenç Gómez
- Department of Maxillofacial Surgery, Hospital Universitario Vall d'Hebron, Pg. Vall d'Hebron 119, Barcelona 08035, Spain
| | - Alba Sanjuan-Sanjuan
- Oral and Maxillofacial Surgery, Charleston Area Medical Center, Charleston, WV 24314, USA
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5
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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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Tartaglione G. Advantages of the intradermal lymphoscintigraphy. World J Radiol 2024; 16:241-246. [PMID: 39086608 PMCID: PMC11287431 DOI: 10.4329/wjr.v16.i7.241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 05/30/2024] [Accepted: 07/01/2024] [Indexed: 07/24/2024] Open
Abstract
Lymphoscintigraphy is a nuclear medicine procedure that uses a small quantity of radioactive particles for visualizing the lymphatic system. Traditionally, the radiotracer was injected subcutaneously, but the quality of lymphatic path imaging was scarce due to high background. Intradermal radiotracer injection is considered the modern-day intralymphatic injection. We propose rest/stress intradermal lymphoscintigraphy for the diagnosis, staging and surgical planning of lymphedema. Major and minor findings were described in primary and secondary lymphedema. Based on the in-depth information of the lymphatic pathways, physiotherapists and microsurgeons can obtain important functional information in patients' selection to treat with physical treatments and/or undergo microsurgery.
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7
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Lee MK, Choi Y, Mun GH, Lee KT. Safety of performing multiple free flap surgeries by a single surgeon in a single day. J Plast Reconstr Aesthet Surg 2024; 97:163-173. [PMID: 39154529 DOI: 10.1016/j.bjps.2024.07.054] [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: 04/02/2024] [Revised: 07/02/2024] [Accepted: 07/22/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND With the growing popularity of the use of free flaps, surgeons may frequently encounter situations necessitating the performance of multiple free flap surgeries in a single day. Given its prolonged duration and technical complexity, concerns remain regarding their safety. This study investigated whether a single surgeon conducting multiple free flap surgeries in a day heightens the risk of complications. METHODS Patients who underwent free flap-based reconstruction from March 2002 to May 2023 were reviewed and categorized into 3 groups: one flap per day (Group 1), multiple flaps per day on the same patient (Group 2), and multiple flaps per day on different patients (Group 3). Outcomes, particularly perfusion-related complications (PRCs), were compared. RESULTS In total, 1910 cases were analyzed: 1570 in Group 1, 126 in Group 2, and 214 in Group 3. Over time, the proportion of cases in Group 3 increased. Group 3 had fewer breast reconstruction cases but more lower extremity reconstructions, with a higher prevalence of chronic wounds. Although the rates of PRCs varied among groups, multivariable analysis exhibited no association of performing multiple flaps in a day with their occurrence, regardless of breast or nonbreast reconstruction. The rate of arterial insufficiency was significantly higher in group 3 compared with group 1 after adjusting for other variables. CONCLUSIONS Performing multiple free flaps in a single day may not significantly increase the risks of overall PRCs. However, there appears to be a higher incidence of arterial insufficiency, emphasizing the need for careful planning and precise execution of procedures.
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Affiliation(s)
- Mi Kyung Lee
- Department of Plastic Surgery, Ewha Womans University Mokdong Hospital, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Yun Choi
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Goo-Hyun Mun
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Kyeong-Tae Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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8
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Russo A, Patanè V, Gagliardi F, Urraro F, Ronchi A, Vitiello P, Sica A, Argenziano G, Nardone V, Reginelli A. Preliminary Experience in Ultra-High Frequency Ultrasound Assessment of Cutaneous Primary Lymphomas: An Innovative Classification. Cancers (Basel) 2024; 16:2456. [PMID: 39001518 PMCID: PMC11240684 DOI: 10.3390/cancers16132456] [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: 05/02/2024] [Revised: 06/25/2024] [Accepted: 07/03/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND Primary cutaneous lymphoma (PCL) is a rare form of extranodal non-Hodgkin's lymphoma characterized by malignant lymphocytes confined to the skin. Accurate diagnosis and staging are crucial for optimal management, yet radiological literature on imaging PCL remains limited. This study aims to delineate the imaging characteristics of PCLs using high and ultra-high frequency ultrasound (UHFUS) and proposes a classification system based on ultrasound findings. METHODS A cohort of 88 individuals with suspected PCL underwent high-resolution ultrasound (HRUS) and color Doppler examination of lesions. Lesions were categorized based on sonographic appearance, and subsequent histopathological assessment confirmed the diagnosis. RESULTS Ultrasound imaging revealed distinct patterns for primary cutaneous T-cell lymphomas (PCTCL) and primary cutaneous B-cell lymphomas (PCBCL), with characteristic features such as hypoechoic nodules, pseudonodular lesions, and dermal infiltration. Histopathological analysis confirmed the ultrasound findings, supporting the proposed classification system. CONCLUSIONS Ultrasonography, particularly UHFUS, offers valuable insights into the imaging characteristics of primary cutaneous lymphomas, aiding the accurate diagnosis and assessment of treatment response. The proposed classification system based on ultrasound findings enhances the diagnostic approach to PCLs, and paves the way for improved patient care and management strategies.
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Affiliation(s)
- Anna Russo
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Vittorio Patanè
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Federico Gagliardi
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Fabrizio Urraro
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Andrea Ronchi
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, Università degli Studi della Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Paola Vitiello
- Dermatology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Antonello Sica
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Giuseppe Argenziano
- Dermatology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Valerio Nardone
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Alfonso Reginelli
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
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9
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Lin Wu ZQ, Bulla A, Aguilera Sáez J, Serracanta Domènech J, Barret JP, Rivas Nicolls DA. Subdermal dissection technique for pure skin SCIA and ALT perforator flaps in burns and trauma defects: Clinical experience. Microsurgery 2024; 44:e31189. [PMID: 38798132 DOI: 10.1002/micr.31189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 03/21/2024] [Accepted: 05/01/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND The pure skin perforator (PSP) flap is gaining popularity for its remarkable thinness. The subdermal dissection technique was recently introduced, allowing for a quicker elevation of a PSP flap. In this report, we present our two-year experience utilizing subdermal dissection for harvesting PSP flaps. METHODS All patients who had undergone PSP flap reconstruction at our hospital from February 2021 to February 2023 were included. Demographic data, intraoperative variables, flap characteristics, and postoperative outcomes were collected. Surgical planning involved locating the perforator using ultrasound and harvesting the flap using the subdermal dissection technique. RESULTS A total of 26 PSP flap reconstructions were conducted on 24 patients aged between 15 and 86 years. The flaps were based on perforators issuing from the superficial circumflex iliac artery in 24 cases, and from the descending branch of the lateral circumflex femoral artery in 2 cases. Flap sizes ranged from 3 × 1.5 cm to 19 × 6 cm, with a mean thickness of 3.48 mm. The average time for flap harvest was 131.92 min. Postoperatively, we observed four cases of partial necrosis, 1 total flap loss, and 2 instances of vascular thrombosis at the anastomosis site. The flaps exhibited good pliability without contracture, and no debulking procedures were required during the follow-up period (minimum 6 months, range 6-24; mean 9.4615). CONCLUSION The subdermal dissection technique is a safe and efficient approach for elevating PSP flaps. Our initial experience with this technique has been encouraging, and it currently serves as our preferred reconstructive option for defects requiring thin reconstruction.
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Affiliation(s)
- Zhan Q Lin Wu
- Departament of Plastic and Reconstructive Surgery, Vall d'Hebrón University Hospital, Barcelona, Spain
| | - Antonio Bulla
- Departament of Plastic and Reconstructive Surgery, Vall d'Hebrón University Hospital, Barcelona, Spain
| | - Jorge Aguilera Sáez
- Departament of Plastic and Reconstructive Surgery, Vall d'Hebrón University Hospital, Barcelona, Spain
| | - Jordi Serracanta Domènech
- Departament of Plastic and Reconstructive Surgery, Vall d'Hebrón University Hospital, Barcelona, Spain
| | - Juan P Barret
- Departament of Plastic and Reconstructive Surgery, Vall d'Hebrón University Hospital, Barcelona, Spain
- Department of Surgery, School of Medicine, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Danilo A Rivas Nicolls
- Departament of Plastic and Reconstructive Surgery, Vall d'Hebrón University Hospital, Barcelona, Spain
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10
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Cowan R, Mann G, Salibian AA. Ultrasound in Microsurgery: Current Applications and New Frontiers. J Clin Med 2024; 13:3412. [PMID: 38929941 PMCID: PMC11204189 DOI: 10.3390/jcm13123412] [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: 05/08/2024] [Revised: 06/01/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
Ultrasound has revolutionized reconstructive microsurgery, offering real-time imaging and enhanced precision allowing for preoperative flap planning, recipient vessel identification and selection, postoperative flap monitoring, and lymphatic surgery. This narrative review of the literature provides an updated evidence-based overlook on the current applications and emerging frontiers of ultrasound in microsurgery, focusing on free tissue transfer and lymphatic surgery. Color duplex ultrasound (CDU) plays a pivotal role in preoperative flap planning and design, providing real-time imaging that enables detailed perforator mapping, perforator suitability assessment, blood flow velocity measurement, and, ultimately, flap design optimization. Ultrasound also aids in recipient vessel selection by providing assessment of caliber, patency, location, and flow velocity of recipient vessels. Postoperatively, ultrasound enables real-time monitoring of flap perfusion, providing early detection of potential flap compromise and improved flap survival rates. In lymphatic surgery, ultra-high frequency ultrasound (UHFUS) offers precise mapping and evaluation of lymphatic vessels, improving efficacy and efficiency by targeting larger dilated vessels. Integrating ultrasound into reconstructive microsurgery represents a significant advancement in the utilization of imaging in the field. With growing accessibility of devices, improved training, and technological advancements, using ultrasound as a key imaging tool offers substantial potential for the evolution of reconstructive microsurgery.
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Affiliation(s)
| | | | - Ara A. Salibian
- Division of Plastic and Reconstructive Surgery, University of California, Davis School of Medicine, Sacramento, CA 95817, USA
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Malagón P, Miyazaki T, Sakai H, Tsukuura R, Yamamoto T. How to perform the preoperative planning of PSP flaps? A practical guide of 5 steps using high-frequency ultrasound. J Plast Reconstr Aesthet Surg 2024; 92:72-74. [PMID: 38507861 DOI: 10.1016/j.bjps.2024.02.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 03/22/2024]
Affiliation(s)
- Paloma Malagón
- Department of Plastic and Reconstructive Surgery, Hospital Germans Trias I Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Toko Miyazaki
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hayahito Sakai
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Reiko Tsukuura
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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12
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Lee SH, Lee KT. High-frequency ultrasound-assisted perforator mapping enhances efficiency in microsurgical reconstruction using thin ALT and SCIP flaps. Microsurgery 2024; 44:e31171. [PMID: 38549389 DOI: 10.1002/micr.31171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 12/18/2023] [Accepted: 01/24/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND With the growing demand for the use of thin perforator flaps, obtaining knowledge on the superficial anatomy of perforators is imperative for stable flap elevation. Conventional modalities for perforator mapping fall short in providing such information. High-frequency ultrasound (HFUS), known for visualizing the superficially located anatomic structures, may potentially fill this void. This study aimed to evaluate the effectiveness of HFUS in the outcome of anterolateral thigh (ALT) and superficial circumflex iliac artery perforator (SCIP) flap-based reconstructions. METHODS Consecutive patients who underwent free ALT or SCIP flap-based reconstruction from January 2021 to November 2022 were retrospectively reviewed. Perforator mapping was conducted using a handheld Doppler during the first year, while HFUS was used in the latter part. The two techniques were compared in terms of flap harvesting time and perfusion-related complication rates while considering the flap elevation plane. RESULTS In total, 123 cases were analyzed, including 82 ALT flaps (41 in each group) and 41 SCIP flaps (16 in the Doppler and 25 in the HFUS group). The time required for flap elevation exhibited a tendency to decrease in the HFUS group, with a significant difference observed in cases involving thin flap elevation (super-thin ALT flaps and pure-skin-perforator SCIP flaps). Compared with the Doppler group, the HFUS group demonstrated significantly lower rates of PRCs, particularly partial flap necrosis. This difference remained significant in multivariable analyses. CONCLUSION Our results suggest that HFUS might be an appealing modality for perforator mapping in cases requiring thin ALT and SCIP flap.
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Affiliation(s)
- Sang-Hun Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeong-Tae Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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13
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Visconti G, Bianchi A, Di Leone A, Franceschini G, Masetti R, Salgarello M. The Ultrasound Evolution of Lateral Thoracic Perforator Flaps Design and Harvest for Partial and Total Breast Reconstruction. Aesthetic Plast Surg 2024; 48:894-904. [PMID: 36517641 DOI: 10.1007/s00266-022-03208-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 11/19/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The lateral thoracic area is a known source for perforator flaps for partial breast reconstruction. In this paper, we report our experience in designing and harvesting lateral thoracic perforator flaps for partial and total breast reconstruction with the introduction of the "propuller" concept. PATIENTS AND METHODS Between September 2013 and August 2021, 95 flaps were performed for immediate, partial and total breast reconstruction. On a total of 95 flaps, 30 (19 thoracodorsal artery perforator(TDAP) flaps, 10 lateral intercostal artery perforator(LICAP) flaps and 1 lateral thoracic artery perforator(LTAP) flap) were harvested in the traditional fashion (control group) and 65 (57 LICAP, 2 LTAP and 6 TDAP flaps) according to the propeller concept (study group). All cases were preoperatively planned with Color-Coded Duplex Ultrasound. RESULTS No flap losses were experienced in both groups. The mean operative time was 156 minutes (range 118-234) for the control group and 75 minutes (range 53-125) for the study group (p < 0.0001). A significantly higher number of LICAP flaps were chosen in the study group compared to control group. None of the patients had donor site complications. Patients' and Surgeons' satisfaction was high to very high. CONCLUSION The ultrasound preoperative planning led to the development of an easier and safer method of local perforator flap harvesting, that we named as propuller design. Its novelty lies in that perforator intraoperative selection and fully skeletonization are not needed and a more efficient flap movement (propeller plus advancement) which transfers more tissue into the new breast can be achieved safely, faster and easier.
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Affiliation(s)
- Giuseppe Visconti
- Dipartimento Salute della Donna, Bambino e Sanità Pubblica, UO Chirurgia Plastica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore University Hospital A. Gemelli, Largo Agostino Gemelli, 8, 00168, Roma, Italy.
| | - Alessandro Bianchi
- Dipartimento Salute della Donna, Bambino e Sanità Pubblica, UO Chirurgia Plastica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore University Hospital A. Gemelli, Largo Agostino Gemelli, 8, 00168, Roma, Italy
| | - Alba Di Leone
- Dipartimento Salute della Donna, Bambino e Sanità Pubblica, UO Chirurgia Plastica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore University Hospital A. Gemelli, Largo Agostino Gemelli, 8, 00168, Roma, Italy
- Dipartimento Salute Della Donna, Bambino e Sanità Pubblica, UOC Chirurgia Senologica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Gianluca Franceschini
- Dipartimento Salute Della Donna, Bambino e Sanità Pubblica, UOC Chirurgia Senologica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Riccardo Masetti
- Dipartimento Salute Della Donna, Bambino e Sanità Pubblica, UOC Chirurgia Senologica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Marzia Salgarello
- Dipartimento Salute della Donna, Bambino e Sanità Pubblica, UO Chirurgia Plastica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore University Hospital A. Gemelli, Largo Agostino Gemelli, 8, 00168, Roma, Italy
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Vejbrink Kildal V, Meng S, Pruidze P, Reissig L, Weninger WJ, Tzou CHJ, Rodriguez-Lorenzo A. Preoperative assessment of depressor anguli oris to prevent myectomy failure: An anatomical study using high-resolution ultrasound. J Plast Reconstr Aesthet Surg 2024; 88:296-302. [PMID: 38029476 DOI: 10.1016/j.bjps.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/25/2023] [Accepted: 11/08/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Myectomies of the lower lip depressor muscles have unexplained high failure rates. This study aimed to examine the depressor anguli oris (DAO) muscle using high-resolution ultrasound to identify potential anatomical explanations for surgical failures and to determine the accuracy of utilizing preoperative ultrasound assessment to improve myectomies. METHODS Anatomical features of DAO and the surrounding anatomy were examined in 38 hemifaces of human body donors using high-resolution ultrasound and dissection. RESULTS The ultrasound and dissection measurements showed the DAO muscle width to be 16.2 ± 2.9 versus 14.5 ± 2.5 mm, respectively, and the location of the lateral muscle border 54.4 ± 5.7 versus 52.3 ± 5.4 mm lateral to the midline. In 60% of the cases, the facial artery was either completely covered by lateral DAO muscle fibers or was found to be in direct contact with the lateral border. Significant muscle fiber continuity was present between the DAO and surrounding muscles in 5% of cases, whereas continuity between the depressor labii inferioris and surrounding muscles was considerably more common and pronounced. CONCLUSIONS High-resolution ultrasound can accurately reveal important preoperative anatomical information in myectomies. Two potential explanations for the surgical failures were discovered: an overlap of lateral DAO muscle fibers over the facial artery could lead to inadequate resections and continuity with the surrounding muscles might lead to muscle function takeover despite adequate resections. Both can be uncovered preoperatively by the surgeon through a brief, directed ultrasound examination, which may allow for modification of the surgical plan to reduce surgical failure.
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Affiliation(s)
- Villiam Vejbrink Kildal
- Department of Surgical Sciences, Plastic and Maxillofacial Surgery, Uppsala University, Uppsala, Sweden.
| | - Stefan Meng
- Division of Anatomy, Medical University of Vienna, Vienna, Austria; Department of Radiology, Hanusch Hospital, Vienna, Austria
| | - Paata Pruidze
- Division of Anatomy, Medical University of Vienna, Vienna, Austria
| | - Lukas Reissig
- Division of Anatomy, Medical University of Vienna, Vienna, Austria
| | - Wolfgang J Weninger
- Division of Anatomy, Medical University of Vienna, Vienna, Austria; BioImaging Austria (CMI), Vienna, Austria
| | - Chieh-Han John Tzou
- Plastic and Reconstructive Surgery, Department of Surgery, Hospital of Divine Savior (Krankenhaus Goettlicher Heiland), Vienna, Austria; Facial Palsy Center, Tzou Medical, Vienna, Austria
| | - Andrés Rodriguez-Lorenzo
- Department of Surgical Sciences, Plastic and Maxillofacial Surgery, Uppsala University, Uppsala, Sweden
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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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Banerjee A, Jou E, Wong KY. Supermicrosurgery: past, present and future. Br J Hosp Med (Lond) 2023; 84:1-10. [PMID: 37906072 DOI: 10.12968/hmed.2022.0482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Supermicrosurgery was popularised in 1997 and is defined as a technique of microvascular anastomosis for single nerve fascicles and vessels 0.3-0.8 mm in diameter. It requires the use of powerful microscopes, ultradelicate microsurgical instruments and specialist dyes. The development of supermicrosurgery has vastly improved the ability of microsurgeons to create true perforator flaps with minimal donor site morbidity for reconstructive surgery and improved the precision of additional microsurgical techniques. This review outlines the origins and history of supermicrosurgery, its current applications in reconstructive surgery (including fingertip reconstructions, true perforator flap surgery, nerve flaps and lymphoedema surgery), supermicrosurgery training and future directions for the field.
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Affiliation(s)
- Arka Banerjee
- Department of Plastic Surgery, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Eric Jou
- Medical Sciences Division, Oxford University Hospitals, University of Oxford, Oxford, UK
- Kellogg College, University of Oxford, Oxford, UK
| | - Kai Yuen Wong
- Department of Plastic Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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17
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Kwon JG, Brown E, Suh HP, Pak CJ, Hong JP. Planes for Perforator/Skin Flap Elevation-Definition, Classification, and Techniques. J Reconstr Microsurg 2023; 39:179-186. [PMID: 36413994 DOI: 10.1055/s-0042-1750127] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Elevation in different layers achieving thin flaps are becoming relatively common practice for perforator flaps. Although postreconstruction debulking achieves pleasing aesthetic results and is widely practiced, customized approach during elevation to achieve the ideal thickness will increase efficiency while achieving the best possible aesthetic outcome. Multiple planes for elevation have been reported along with different techniques but it is quite confusing and may lack correspondence to the innate anatomy of the skin and subcutaneous tissue. METHODS This article reviews the different planes of elevation and aims to clarify the definition and classification in accordance to anatomy and present the pros and cons of elevation based on the different layers and provide technical tips for elevation. RESULTS Five different planes of elevation for perforator flaps are identified: subfascial, suprafacial, superthin, ultrathin, and subdermal (pure skin) layers based on experience, literature, and anatomy. CONCLUSION These planes all have their unique properties and challenges. Understanding the benefits and limits along with the technical aspect will allow the surgeon to better apply the perforator flaps.
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Affiliation(s)
- Jin Geun Kwon
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan Collage of Medicine, Songpa-gu, Seoul, Republic of Korea
| | - Erin Brown
- Department of Plastic and Reconstructive Surgery, University of British Columbia, Vancouver, British Columbia
| | - Hyunsuk Peter Suh
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan Collage of Medicine, Songpa-gu, Seoul, Republic of Korea
| | - Changsik John Pak
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan Collage of Medicine, Songpa-gu, Seoul, Republic of Korea
| | - Joon Pio Hong
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan Collage of Medicine, Songpa-gu, Seoul, Republic of Korea
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18
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Escandón JM, Ciudad P, Mayer HF, Pencek M, Mantilla-Rivas E, Mohammad A, Langstein HN, Manrique OJ. Free flap transfer with supermicrosurgical technique for soft tissue reconstruction: A systematic review and meta-analysis. Microsurgery 2023; 43:171-184. [PMID: 35551691 DOI: 10.1002/micr.30894] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/16/2022] [Accepted: 04/29/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Supermicrosurgery is a technique that allows microsurgeons to accomplish dissections and anastomoses of vessels and nerve fascicles with diameters of ≤0.8 mm. Considering the potential benefits of this technique and limited literature synthesizing the outcomes of supermicrosurgery, the aim of this study was to summarize the available evidence of reconstructive supermicrosurgery and to estimate the success rate. METHODS We conducted a comprehensive search across PubMed, Scopus, Embase, and Web of Science. We included patient-based studies reporting on procedures for soft-tissue reconstruction with free flaps specifying the use of supermicrosurgery. We excluded studies reporting on lymphatic surgery, solely peripheral nerve surgery, and tissue replantation. Our primary endpoint was to calculate the flap success rate. Pooled estimates were calculated using a random-effects meta-analytic model. RESULTS Forty-seven studies reporting outcomes of 698 flaps were included for qualitative synthesis. Overall, 15.75% of flaps were used for head and neck, 4.4% for breast and trunk, 9.3% for upper limb, and 69.2% for lower limb reconstruction. The most used flap was the superficial circumflex iliac artery perforator flap (41.5%). The overall flap success rate was 96.6% (95%CI 95.2%-98.1%). The cumulative rate of partial flap loss was 3.84% (95%CI 1.8%-5.9%). The overall vascular complication rate resulting in complete or partial flap loss was 5.93% (95%CI 3.5%-8.3%). CONCLUSIONS Supermicrosurgery displays a high success rate. Further studies are necessary to explore the true potential of supermicrosurgery. This technique reformulates the boundaries of reconstructive surgery due to its extensive application.
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Affiliation(s)
- Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Pedro Ciudad
- Department of Plastic and Reconstructive Surgery, Archbishop Loayza National Hospital, Lima, Peru
| | - Horacio F Mayer
- Department of Plastic Surgery, Hospital Italiano de Buenos Aires, University of Buenos Aires, Buenos Aires, Argentina
| | - Megan Pencek
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Esperanza Mantilla-Rivas
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, District of Columbia, USA
| | - Arbab Mohammad
- School of Medicine, Aarupadai Veedu Medical College and Hospital, Puducherry, India
| | - Howard N Langstein
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
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19
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Shpitser IM, Vedyaeva AP, Bolshakov MN. [Comparative analysis of the groin and SCIP flap in reconstructive microsurgery of soft tissues of the maxillofacial area and oral cavity]. STOMATOLOGIIA 2023; 102:68-75. [PMID: 37997316 DOI: 10.17116/stomat202310206168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
Most of the articles on the groin flap were published in the period from 1975 to 2010, from 2015 to 2022, the SCIP flap surpassed the groin flap in the number of publications. According to the results of a literature search in PubMed and RINC, 30 articles were found and selected, including 288 flaps from the iliac region. The length of the vascular pedicle, the diameter of the vessels, the complications, the prevalence of the flap in the reconstruction of the head and neck, the thickness and the size of the flap were evaluated. Both of these flaps have the same nutrition, but different levels of dissection. In comparison with the groin flap, the SCIP flap has a longer vascular pedicle, which can be enlarged due to new techniques, which also allows it to be used as an ultra-thin flap, and it reduces the need for secondary procedures for defatting and reduces the risks of the complications in the donor area. The thickness of the SCIP flap is less than the groin one, which, according to the author, increases the aesthetic level of operations in the facial area in the case of the texture and color of the flap. Vascular anatomy of the SCIP flap is variable, therefore, the use of preoperative planning is necessary. Despite this, complications in the donor or recipient area during reconstruction with a SCIP flap are minimal. It has been proved that the SCIP flap is versatile and safe in all aspects of reconstruction. It can be concluded that the SCIP flap should be considered as a «workhorse» in reconstructive microsurgery of soft tissues of the throat and oral cavity.
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Affiliation(s)
- I M Shpitser
- Central Research Institute of Stomatology and Maxillofacial Surgery, Moscow, Russia
| | - A P Vedyaeva
- Central Research Institute of Stomatology and Maxillofacial Surgery, Moscow, Russia
| | - M N Bolshakov
- Central Research Institute of Stomatology and Maxillofacial Surgery, Moscow, Russia
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20
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Escandón JM, Mohammad A, Mathews S, Bustos VP, Santamaría E, Ciudad P, Chen HC, Langstein HN, Manrique OJ. Definitive Closure of the Tracheoesophageal Puncture Site after Oncologic Laryngectomy: A Systematic Review and Meta-Analysis. Arch Plast Surg 2022; 49:617-632. [PMID: 36159387 PMCID: PMC9507600 DOI: 10.1055/s-0042-1756347] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 06/08/2022] [Indexed: 11/10/2022] Open
Abstract
Tracheoesophageal puncture (TEP) and voice prosthesis insertion following laryngectomy may fail to form an adequate seal. When spontaneous closure of the fistula tract does not occur after conservative measures, surgical closure is required. The purpose of this study was to summarize the available evidence on surgical methods for TEP site closure. A comprehensive search across PubMed, Web of Science, SCOPUS, and Cochrane was performed to identify studies describing surgical techniques, outcomes, and complications for TEP closure. We evaluated the rate of unsuccessful TEP closure after surgical management. A meta-analysis with a random-effect method was performed. Thirty-four studies reporting on 144 patients satisfied inclusion criteria. The overall incidence of an unsuccessful TEP surgical closure was 6% (95% confidence interval [CI] 1–13%). Subgroup analysis showed an unsuccessful TEP closure rate for silicone button of 8% (95% CI < 1–43%), 7% (95% CI < 1–34%) for dermal graft interposition, < 1% (95% CI < 1–37%) for radial forearm free flap, < 1% (95% CI < 1–52%) for ligation of the fistula, 17% (95% CI < 1–64%) for interposition of a deltopectoral flap, 9% (95% CI < 1–28%) for primary closure, and 2% (95% CI < 1–20%) for interposition of a sternocleidomastoid muscle flap. Critical assessment of the reconstructive modality should take into consideration previous history of surgery or radiotherapy. Nonirradiated fields and small defects may benefit from fistula excision and tracheal and esophageal multilayer closure. In cases of previous radiotherapy, local flaps or free tissue transfer yield high successful TEP closure rates. Depending on the defect size, sternocleidomastoid muscle flap or fasciocutaneous free flaps are optimal alternatives.
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Affiliation(s)
- Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York, New York
| | - Arbab Mohammad
- Department of Surgery, Aarupadai Veedu Medical College and Hospital, Puducherry, Tamil Nadu, India
| | - Saumya Mathews
- Department of Plastic and Microvascular Services, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Valeria P Bustos
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Eric Santamaría
- Department of Plastic and Reconstructive Surgery, National Cancer Institute, Hospital General Dr. Manuel Gea Gonzalez, Mexico City, Mexico
| | - Pedro Ciudad
- Reconstructive and Burn Surgery Department, Arzobispo Loayza National Hospital, Lima, Peru.,Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Howard N Langstein
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York, New York
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York, New York
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Lymphatic Tissue Transfer: Ultrasound-Guided Description and Preoperative Planning of Vascularised Lymph Nodes, Lymphatic Units, and Lymphatic Vessels Transfers. J Pers Med 2022; 12:jpm12081346. [PMID: 36013294 PMCID: PMC9410514 DOI: 10.3390/jpm12081346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/13/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
Background: The modern concept of lymphatic transfer includes vascularised lymph node transfer (VLNT), lymphatic vessels transfer (lymph interpositional flap transfer, LIFT) and lymphatic system transfer (vascularised lymph nodes and afferent lymphatics, LYST). The aim of this paper was to report our experience with different types of lymphatic transfer. Patients and Method: From June 2016 to June 2020, 30 consecutive patients affected by extremity lymphedema and 15 patients affected by post-traumatic lower extremity soft tissue defects, underwent lymphatic transfer (VLNT, LYST or LIFT). All cases were preoperatively evaluated by both high frequency and ultra-high frequency ultrasound. Flap features were recorded, as well as qualitative and quantitative outcomes at 1 year postoperative. Results: The mean postoperative lymphedema index reduction was 7.2 ± 5.7 for upper extremity and 20.7 ± 7.1 for lower extremity. No dismission of compression garments occurred, 12 patients (26%) referred more stable results of physical treatment and 1 case showed a 1-class compression reduction. All the LIFTs aimed as preventive did not develop post-traumatic lymphedema. In all cases of distal placement of VLNT and/or LYST, patients were dissatisfied with the aesthetic appearance of reconstruction, while no donor site scar disappointment was referred. Conclusion: When LVA is not feasible, LTT may represent a valid treatment option. This report was aimed at comprehensively describing and assessing how different lymphatic tissue transfer modalities may fulfil the different reconstructive needs of lymphedema patients.
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22
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Visconti G, Hayashi A, Hong JP. The New Imaging Techniques in Reconstructive Microsurgery: A New Revolution in Perforator Flaps and Lymphatic Surgery. Arch Plast Surg 2022; 49:471-472. [PMID: 35919554 PMCID: PMC9340197 DOI: 10.1055/s-0042-1751099] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
- Giuseppe Visconti
- UOC Chirurgia Plastica, Dipartimento per la Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del "Sacro Cuore" Rome, Italy
| | - Akitatsu Hayashi
- Lymphedema Clinic, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Joon Pio Hong
- Department of Plastic Surgery, Asan Medical Center, Seoul, Korea
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23
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A Safer Way to Harvest a Superthin Perforator Flap. Plast Reconstr Surg 2022; 149:1259e-1260e. [PMID: 35468108 DOI: 10.1097/prs.0000000000009104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Aitzetmueller MM, Kueckelhaus M, Hirsch T, Wellenbrock S. Plastische Deckung thorakaler Defekte. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2022. [DOI: 10.1007/s00398-022-00506-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Glass GE, Staruch RMT, Sivakumar B, Stotland M. Thin and superthin free flaps: An innovative approach to pediatric extremity reconstruction. J Plast Reconstr Aesthet Surg 2022; 75:3970-3978. [PMID: 36163147 DOI: 10.1016/j.bjps.2022.06.090] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/23/2022] [Accepted: 06/21/2022] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Published standards for the management of open extremity fractures have improved limb salvage, fracture union, and deep infection rates, but the aesthetic and functional importance of our flap choices has been overlooked. Thin and superthin free flaps exhibit advantages over traditional free flaps in some situations but have seldom been reported in children. The aim of this paper is to present our experience of thin and superthin free flaps in pediatric extremity reconstruction. METHODS Children (≤13 years) who underwent soft tissue reconstruction using a thin and superthin free flap following major extremity trauma are presented. RESULTS Five patients (5 flaps) met the inclusion criteria. The median age was 9 (range 6-13). There were 3 Gustilo IIIB open fractures and 2 multiplanar degloving injuries. The median mangled extremity severity score (MESS) was 4 (range 2-6). The median time from injury to definitive soft tissue closure was 72 h (range 28-120 h). Four anterolateral thigh (ALT) flaps were raised as thin flaps, and 1 superficial circumflex iliac artery perforator (SCIP) was raised as a superthin flap. There was one re-exploration owing to venous congestion, and a second venous anastomosis was performed to enhance flap drainage. The same ALT flap exhibited necrosis at one margin, which was debrided and grafted before discharge. There were no other flap complications. No flap-related secondary surgeries were required. CONCLUSION Thin and superthin free flaps are viable options in pediatric extremity reconstruction. They exhibit excellent aesthetic and functional contouring when a slender fasciocutaneous flap is needed, especially when body habitus renders traditional options unfavorable.
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Fuse Y, Yoshimatsu H, Karakawa R, Yano T. Deep Fat Saving Elevation of the Superficial Circumflex Iliac Artery Perforator Flap. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:670. [PMID: 35630087 PMCID: PMC9145857 DOI: 10.3390/medicina58050670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 05/09/2022] [Accepted: 05/12/2022] [Indexed: 11/27/2022]
Abstract
Background and Objectives: Prolonged drain stay and lymphorrhea are often problems at the donor site of the superficial circumflex iliac artery perforator (SCIP) flap. This study aimed to introduce a novel technique of the SCIP flap elevation: Deep Fat Saving (DFS) technique. Materials and Methods: Thirty-two patients who underwent the SCIP flap transfer were divided based on the flap-elevated layer: above the deep fascia or the Camper fascia saving the deep fat. The duration of drain stay and the rates of flap survival and donor-site complications were compared between the groups. The inverse probability weighting (IPW) method was conducted to balance confounders. Results: By IPW, two balanced pseudo-populations were created: DFS = 33.9 and Conventional = 31.3. There were no significant differences in the rate of flap survival (DFS: 100% verses Conventional: 95.8%, p = 0.32) and donor site complications (DFS: 2.4% versus Conventional: 1.3%, p = 0.68, respectively). The duration of drain stay was shorter in the DFS group (weighted median: 6 versus 8 days; weighted difference: -1.6 days (95% confidence interval: -2.8 to -0.4), p = 0.01). Conclusions: An SCIP flap can be reliably harvested using the Deep Fat Saving technique.
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Affiliation(s)
- Yuma Fuse
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (H.Y.); (R.K.); (T.Y.)
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Hong JP, Kim HB, Park CJ, Suh HP. Using Duplex Ultrasound for Recipient Vessel Selection. J Reconstr Microsurg 2022; 38:200-205. [PMID: 35108731 DOI: 10.1055/s-0041-1740218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Among the many factors involved in reconstructive microsurgery, identifying a good recipient vessel is one of the key elements leading to a successful result. MATERIAL AND METHOD Multiple modalities have been used to identify recipient vessels from simple palpation of axial arteries to hand-held Doppler, duplex ultrasound, computed tomography angiograms, and other advanced techniques. Although these various modalities bring their own unique advantages, using the duplex ultrasound can provide far superior and real-time information based on the anatomy and physiology of the recipient vessel. RESULT Duplex ultrasound is a valuable and powerful tool for reconstructive surgeons who are interested in performing microsurgery or supermicrosurgery. CONCLUSION As we enter the era of individualized/customized reconstruction using superthin flaps, perforator-to-perforator anastomosis, and supermicrosurgery, understanding and becoming versatile with duplex ultrasound will be critical especially in choosing recipient vessels.
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Affiliation(s)
- Joon Pio Hong
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyung Bae Kim
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Changsik John Park
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyunsuk Peter Suh
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Kehrer A, Heidekrueger PI, Lonic D, Klein S, Anker A, Taeger C, Biermann N, Jung EM, Prantl L, da Silva NPB. Technical Aspects of High-Resolution Color-Coded Duplex Sonography for the Design of Perforator Flaps. J Reconstr Microsurg 2022; 38:181-192. [PMID: 35038751 DOI: 10.1055/s-0041-1740956] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Technical aspects are of utmost significance for an efficient execution in designing perforator flaps with high-resolution color-coded Duplex sonography (CCDS). The following study evaluates decisive factors for a successful microvessel examination conducted by the microsurgeon. METHODS Technical knowledge presented in this study was based on a series of more than 200 perforator flaps planned with CCDS. Flap reconstructions were performed at the University Hospital Regensburg, Germany, from July 2013 to January 2021. Standard high-resolution ultrasound (US) devices with linear multifrequency transducers of 4 to 18 MHz were used. Modes and device settings were evaluated regarding applicability by microsurgeons. Key steps for safe perforator identification and further optional steps for additional assessment should be discriminated. RESULTS Different US modes including brightness mode (B-mode), color flow (CF), power Doppler (PD), pulse wave (PW), and blood flow (B-Flow) were used. Transducers from 15 MHz and up were favorable to detect microvessels. Knobology of a standard US device regarding buttons, switches, and specific onscreen options with relevance for perforator mapping was subcategorized in four different groups. For qualitative and quantitative evaluation of microvessels, different US modes were tested with respect to their usefulness.Vital elements of the CCDS exam are disaggregated into three key steps for safe perforator identification and three optional steps for further perforator characterization. A standardized protocol for the CCDS exams was applied. Downregulation of pulse-repetition frequency/scale to adapt device sensitivity to slow-flow velocities represented the most important criterion to visualize microvessels.Qualitative microvessel evaluation was performed in B-mode, CCDS, PD mode, and B-Flow mode. Quantitative assessment was executed using PW-mode and CCDS measuring the microvessels' diameter (mm) and flow characteristics. Quantitative information may be obtained using PW-mode and the distance-measuring tool in CF-mode. CONCLUSION Technical aspects with respect to proper device trimming and application decisively impact CCDS-guided perforator vessel identification and evaluation.
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Affiliation(s)
- Andreas Kehrer
- Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Paul I Heidekrueger
- Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Daniel Lonic
- Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Silvan Klein
- Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Alexandra Anker
- Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Christian Taeger
- Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Niklas Biermann
- Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Ernst Michael Jung
- Department of Radiology, Ultrasound Center, University Medical Center Regensburg, Regensburg, Germany
| | - Lukas Prantl
- Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
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Khoong YM, Huang X, Gu S, Zan T. Imaging for thinned perforator flap harvest: current status and future perspectives. BURNS & TRAUMA 2021; 9:tkab042. [PMID: 34926708 PMCID: PMC8677592 DOI: 10.1093/burnst/tkab042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/24/2021] [Indexed: 11/12/2022]
Abstract
With advances in anatomical knowledge and technology, increased interest has been directed towards reconstruction with enhanced aesthetic and functional outcomes. A myriad of thinned perforator flap harvest approaches have been developed for this purpose; however, concerns about jeopardizing their vascularity remain. To ensure optimum reconstructive outcome without hampering the flap's microcirculation, it is important to make good use of the existing advanced imaging modalities that can provide clear visualization of perforator branches, particularly in the adipose layer, and an accurate assessment of flap perfusion. Therefore, this review will highlight the imaging modalities that have been utilized for harvesting a thinned perforator flap from these two perspectives, along with future insights into creating both functionally and aesthetically satisfying, yet simultaneously safe, thinned perforator flaps for the best reconstructive outcomes for patients.
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Affiliation(s)
- Yi Min Khoong
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
| | - Xin Huang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
| | - Shuchen Gu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
| | - Tao Zan
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
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Visconti G, Bianchi A, Hayashi A, Salgarello M. Designing Anterolateral Thigh Flap Using Ultrasound. J Reconstr Microsurg 2021; 38:206-216. [PMID: 34921373 DOI: 10.1055/s-0041-1740126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Preoperative knowledge of themicrovascular anatomy of a patientmay improve safetyand efficacy and reduce morbidity. Today, with the advancement in technology, ultrasound can provide minute details of the structures within the body, which makes this technology very helpful in preoperative evaluation of the traditional perforator flaps as well as thin, superthin, and pure skin perforator flaps. METHODS In this article, we will describe the design of one of the most popular perforator flaps, the anterolateral thigh (ALT) flap, using high-frequency and ultrahigh-frequency ultrasound technology. RESULTS Ultrasound technology allows to study preoperatively the ALT donor-site and its microvascular anatomy by using different US modalities in order to provide a virtual surgical plan to the operating surgeon. CONCLUSION Ultrasound technology allow to expand preoperative knowledge of flap microvascular anatomy and its course within the subcutaneous tissue up to and within the dermis, allowing to select the best perforator for the given reconstruction and the plane of elevation for thin, superthin and pure skin perforator flap.
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Affiliation(s)
- Giuseppe Visconti
- UOC Chirurgia Plastica, Dipartimento Scienze Salute della Donna, del Bambino e di Sanità Pubblica, Università Cattolica del "Sacro Cuore," Fondazione Policlinico Universitario "Agostino Gemelli" IRCSS, Rome, Italy
| | - Alessandro Bianchi
- UOC Chirurgia Plastica, Dipartimento Scienze Salute della Donna, del Bambino e di Sanità Pubblica, Università Cattolica del "Sacro Cuore," Fondazione Policlinico Universitario "Agostino Gemelli" IRCSS, Rome, Italy
| | - Akitatsu Hayashi
- Department of Breast Center, Kameda Medical Center Chiba, Chiba, Japan
| | - Marzia Salgarello
- UOC Chirurgia Plastica, Dipartimento Scienze Salute della Donna, del Bambino e di Sanità Pubblica, Università Cattolica del "Sacro Cuore," Fondazione Policlinico Universitario "Agostino Gemelli" IRCSS, Rome, Italy
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Hayashi A, Visconti G, Giacalone G, Hayashi N, Yoshimatsu H. Recent Advances in Ultrasound Technology: Ultra-High Frequency Ultrasound for Reconstructive Supermicrosurgery. J Reconstr Microsurg 2021; 38:193-199. [PMID: 34921372 DOI: 10.1055/s-0041-1740129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Currently, microsurgeons are in the era of supermicrosurgery and perforator flap reconstruction. As these reconstructions frequently utilize vessels that are smaller than a single millimeter, understanding of location of lymphatic vessels and perforator anatomy preoperatively is essential. To change with the times, the role of ultrasound has changed from just an adjunct to primary imaging of the choice in reconstructive supermicrosurgery. Recently, a novel ultrasonographic technique involving the use of ultra-high frequency ultrasound (UHFUS) frequencies has entered the scene, and appears a promising tool in surgical planning. METHODS The literatures on the applications of UHFUS in reconstructive supermicrosurgery were retrieved and reviewed from more than 60 literatures have been published on the surgical applications of UHFUS. RESULTS Nine studies were retrieved from the literature on the applications of UHFUS in reconstructive supermicrosurgery. The articles report both application for lymphatic surgery and perforator flaps. CONCLUSIONS UHFUS application involves an increasing number of reconstructive supermicrosurgery field. UHFUS is a valuable and powerful tool for any reconstructive surgeons who are interested in performing supermicrosurgery.
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Affiliation(s)
- Akitatsu Hayashi
- Lymphedema Center, Department of Breast Center, Kameda Medical Center, Chiba, Japan
| | - Giuseppe Visconti
- Department of Plastic and Reconstructive Surgery, Università Cattolica del "Sacro Cuore," University Hospital "A. Gemelli," Rome, Italy
| | - Guido Giacalone
- Department of Lymphatic Surgery, AZ Sint-Maarten Hospital, Duffel, Belgium
| | - Nobuko Hayashi
- Department of Plastic Surgery, Taiyo-kai Social Welfare Awachiiki Iryo Center, Chiba, Japan
| | - Hidehiko Yoshimatsu
- Department of Plastic Surgery, Cancer Institute Hospital of the JFCR, Tokyo, Japan
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Brunetti B, Salzillo R, Tenna S, Brunetti B, Bonetti MA, Rivieccio A, Persichetti P. Perforator-Based Flap Reconstruction after Melanoma Resection: Evaluation of Oncological, Aesthetic, and Functional Outcomes. J Reconstr Microsurg 2021; 38:555-562. [PMID: 34921368 DOI: 10.1055/s-0041-1740925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Evidence in literature about the best reconstructive approach after melanoma resection is controversial, with some authors advocating that tissue rearrangement flap techniques might hinder the early detection of local relapses. The aim of the present study is to evaluate oncological, aesthetic, and functional outcomes following melanoma reconstruction using pedicled perforator-based flaps. METHODS The authors reviewed all patients affected by melanoma treated during a 6-year period. Demographic data, tumor characteristics, and operative variables were evaluated. Locoregional recurrence was assessed with clinical and radiological follow-up. One-year postoperatively patients rated on a 5-point Likert scale the aesthetic and functional outcomes of the procedure. Three blind observers examined preoperative and 1-year postoperative photographs and rated the aesthetic outcome of the reconstructive procedure. RESULTS One-hundred sixty-five patients were treated with wide excision and delayed reconstruction, including pedicled perforator-based flaps in 70 patients (group A) and primary closure in 95 patients (group B). Mean Breslow thickness was 2.972 and 2.189 mm in group A and B, respectively. There was no statistically significant difference in locoregional recurrence (chi-squared test, p = 0.8333; Fisher's exact test, p > 0.9999) between the two groups. Group A reported a higher satisfaction with both the aesthetic (mean rating 4.390 in group A and 4.094 in group B) and functional (mean rating 4.732 in group A and 4.170 in group B) outcomes of the procedure, the latter being statistically significant (p = 0.0006). CONCLUSION This series suggests that pedicled perforator-based flaps provide optimal aesthetic and functional outcomes in melanoma reconstruction without impairing the locoregional control of the disease.
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Affiliation(s)
- Beniamino Brunetti
- Department of Plastic, Reconstructive and Aesthetic Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Rosa Salzillo
- Department of Plastic, Reconstructive and Aesthetic Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Stefania Tenna
- Department of Plastic, Reconstructive and Aesthetic Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | | | - Mario Alessandri Bonetti
- Department of Plastic, Reconstructive and Aesthetic Surgery, I.R.C.C.S. Istituto Galeazzi, University of Milan, Milan, Italy
| | - Antonia Rivieccio
- Department of Plastic, Reconstructive and Aesthetic Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Paolo Persichetti
- Department of Plastic, Reconstructive and Aesthetic Surgery, Campus Bio-Medico University of Rome, Rome, Italy
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Salgarello M, Visconti G. Designing Lateral Thoracic Wall Perforator Flaps for Breast Reconstruction Using the Ultrasound. J Reconstr Microsurg 2021; 38:228-232. [PMID: 34872122 DOI: 10.1055/s-0041-1740127] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Lateral thoracic flaps represent a precious source for partial and total breast reconstruction, in some cases as first option and in other cases as alternative of free flaps. This article describes the ultrasound (US)-based planning of the lateral thoracic wall perforator adipocutaneous flaps and it reports our experience on 52 consecutive flaps. PATIENTS AND METHODS From November 2018 to May 2021, 52 consecutive lateral thoracic wall perforator flaps were performed using the US-based method for reconstruction of partial breast defects and total breast reconstruction. High-frequency US was performed in all cases prior to surgery to select the best perforator and design the flap. RESULTS Of the 52 cases, 41 were lateral intercostal artery perforator flaps (78.8%), and 11 were thoracodorsal artery perforator (TDAP) flaps. Of the 11 TDAP flaps, 2 cases were based on the direct cutaneous branch. Moreover, in two other cases clinically scheduled for lateral thoracic perforator flaps due to the presence of an appropriate axillary roll, no suitable local/regional perforators were detected with the preoperative US examination and the latissimus dorsi myocutaneous flap was performed. CONCLUSION Preoperative planning of these flaps using US speeds the surgery and makes it easier and more efficient. Therefore, it is reasonable that the color duplex ultrasound is the operative surgeon's tool for mapping the lateral thoracic wall perforators and to appropriately plan each flap.
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Affiliation(s)
- Marzia Salgarello
- UOC Chirurgia Plastica, Dipartimento Scienze Salute della Donna, del Bambino e di Sanità Pubblica, Università Cattolica del "Sacro Cuore," Milan, Italy.,Fondazione Policlinico Universitario "Agostino Gemelli" IRCSS, Rome, Italy
| | - Giuseppe Visconti
- UOC Chirurgia Plastica, Dipartimento Scienze Salute della Donna, del Bambino e di Sanità Pubblica, Università Cattolica del "Sacro Cuore," Milan, Italy.,Fondazione Policlinico Universitario "Agostino Gemelli" IRCSS, Rome, Italy
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Hong JP, Hur J, Kim HB, Park CJ, Suh HP. The Use of Color Duplex Ultrasound for Local Perforator Flaps in the Extremity. J Reconstr Microsurg 2021; 38:233-237. [PMID: 34856627 DOI: 10.1055/s-0041-1740253] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The local flaps, especially perforator and keystone flaps, are used as first-line treatment option in reconstruction of small tomoderate-sized defect of the extremity. However, the high complication rate associated with these flaps may hinder this usage. METHODS This article reviews the technical and clinical aspect of using color duplex ultrasound )CDU) in the preoperative, intraoperative, and postoperative period for propeller and keystone flaps. RESULTS CDU allows the surgeon to understand the anatomical aspect of the perforator such as the location, point of penetration on the deep fascia, subcutaneous pathway )axiality) and physiological aspect such as velocity and flow volume. Understanding and utilizing this information will allow accurate preoperative design, intraoperative decision making, and postoperative monitoring, leading to better outcome. CONCLUSION Carefully designed local perforator flaps based on anatomy and physiology using CDU will be a powerful armamentarium for reconstruction of the lower extremity.
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Affiliation(s)
- Joon Pio Hong
- Department of Plastic Surgery, ASAN medical center, University of Ulsan College of Medicine, Seoul, Korea (the Republic of)
| | - Joon Hur
- Department of Plastic Surgery, ASAN medical center, University of Ulsan College of Medicine, Seoul, Korea (the Republic of)
| | - Hyung Bae Kim
- Department of Plastic Surgery, ASAN medical center, University of Ulsan College of Medicine, Seoul, Korea (the Republic of)
| | - Changsik John Park
- Department of Plastic Surgery, ASAN medical center, University of Ulsan College of Medicine, Seoul, Korea (the Republic of)
| | - Hyunsuk Peter Suh
- Department of Plastic Surgery, ASAN medical center, University of Ulsan College of Medicine, Seoul, Korea (the Republic of)
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Karakawa R, Yano T, Yoshimatsu H, Koto M, Nakao A, Ichi S. Use of Ultra-high-frequency Ultrasound for Aplasia Cutis Congenita of the Scalp. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3876. [PMID: 34815916 PMCID: PMC8604012 DOI: 10.1097/gox.0000000000003876] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/24/2021] [Indexed: 11/25/2022]
Abstract
Aplasia Cutis Congenita (ACC) in the scalp is a rare congenital malformation. The treatment for ACC with large defects involving the scalp, bone, and the dura is challenging. Local debridement of necrotic tissue is important to prevent lethal complications such as infection and meningitis. However, debridement has the risk of damaging the sagittal sinus or the dura. Recent developments in ultra-high-frequency ultrasound(US) systems provide frequencies of 70 MHz and capability resolution as fine as 30 μm, which could allow precise imaging of small and thin anatomical structures. The study aimed to describe the methods of precise evaluation of the defect in the scalp and safe debridement using ultra-high-frequency US. This is the first report on direct observation of a newborn’s brain using ultra-high-frequency US. The boy was delivered spontaneously with a large defect of the scalp and bone. After 14 days, due to signs of infection, local debridement was performed carefully under ultra-high-frequency US-based evaluation. The dura, the sagittal sinus, and the small anatomical structures such as arachnoid granulations could be observed. Because the brain herniation gradually aggravated, dural reconstruction using fascia lata and scalp reconstruction using transposition flap was performed. Finally, good skin coverage over the defects was obtained. This method minimizes the risk of damaging the sagittal sinus and the brain parenchyma, which may cause fatal complications. Although further clinical investigations will be required to confirm its efficacy, ultra-high-frequency US has the potential to be a useful device for ACC treatment.
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Affiliation(s)
- Ryo Karakawa
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomoyuki Yano
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hidehiko Yoshimatsu
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Mayu Koto
- Department of Neonatology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Atsushi Nakao
- Department of Neonatology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Shunsuke Ichi
- Department of Neurosurgery, Japanese Red Cross Medical Center, Tokyo, Japan
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Yoshimatsu H, Karakawa R, Fuse Y, Hayashi A, Yano T. Superficial Circumflex Iliac Artery Perforator Flap Elevation Using Preoperative High-Resolution Ultrasonography for Vessel Mapping and Flap Design. J Reconstr Microsurg 2021; 38:217-220. [PMID: 34688219 DOI: 10.1055/s-0041-1736317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The superficial circumflex iliac artery (SCIA) perforator (SCIP) flap has gained acceptance among reconstructive microsurgeons, the minimal donor site morbidity being its greatest advantage. The purpose of this article is to introduce the use of preoperative ultrasonography to facilitate elevation and to avoid postoperative complications of the SCIP flap. METHODS Preoperative mapping of the SCIA and the superficial circumflex iliac vein (SCIV) using a high-resolution ultrasound system were performed in patients undergoing reconstruction using a free SCIP flap. The skin paddle was designed placing the SCIA and the SCIV in the middle of the flap. RESULTS Preoperatively marked SCIA and SCIV were found intraoperatively in all cases. The skin paddle design for sufficient arterial inflow and venous drainage resulted in no postoperative flap complications. CONCLUSION The use of a preoperative high-resolution ultrasound system significantly facilitates elevation of the SCIP flap, notably via the following 2 points: 1) pedicle can always be found under the markings made with preoperative ultrasonography, 2) satisfactory perfusion of the flap can be guaranteed via a safe flap design that includes preoperatively marked vessels within the skin paddle.
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Affiliation(s)
- Hidehiko Yoshimatsu
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ryo Karakawa
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yuma Fuse
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | | | - Tomoyuki Yano
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
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Visconti G, Bianchi A, Salgarello M. The use of the distal posterior radial collateral artery as recipient vessel in elbow resurfacing using SCIP flap. Microsurgery 2021; 41:699-700. [PMID: 34435376 DOI: 10.1002/micr.30799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 05/25/2021] [Accepted: 08/19/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Giuseppe Visconti
- UOC Chirurgia Plastica, Dipartimento Scienze Salute della Donna, Bambino e Sanità Publbica, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS - Università Cattolica del Sacro Cuore, largo Agostino Gemelli, 8, Rome, Italy
| | - Alessandro Bianchi
- UOC Chirurgia Plastica, Dipartimento Scienze Salute della Donna, Bambino e Sanità Publbica, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS - Università Cattolica del Sacro Cuore, largo Agostino Gemelli, 8, Rome, Italy
| | - Marzia Salgarello
- UOC Chirurgia Plastica, Dipartimento Scienze Salute della Donna, Bambino e Sanità Publbica, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS - Università Cattolica del Sacro Cuore, largo Agostino Gemelli, 8, Rome, Italy
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Kueckelhaus M, Gebur N, Kampshoff D, Hiort M, Varnava C, Harati K, Hirsch T, Wiebringhaus P. Initial experience with the superficial circumflex iliac artery perforator (SCIP) flap for extremity reconstruction in Caucasians. J Plast Reconstr Aesthet Surg 2021; 75:118-124. [PMID: 34509392 DOI: 10.1016/j.bjps.2021.05.069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/20/2021] [Accepted: 05/28/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The superficial circumflex iliac artery perforator (SCIP) flap has been established in Asia to provide an excellent option for soft tissue defect coverage. The main advantage of this delicate flap is its very thin design. However, the adoption of this technique in other parts of the world has been rarely reported. METHODS In this retrospective study, we analyzed outcomes of 32 SCIP flaps in a Caucasian patient population. The procedures were performed at our institution between March 2019 and August 2020. We present patient characteristics, surgical technique, perioperative care, and flap applications as compared to the Asian approaches. RESULTS Patients' average BMI was 28.7. Flap anatomy and flap thickness at the superficial fascial plane differed significantly within our population. With 1.7 mm on average, the arterial diameter was higher than reported in the literature. Flaps were based on an axial perforator in 52% of cases. The SCIP flap was performed safely in the majority of cases. The surgical flap elevation approach was modified toward speedy perforator identification. CONCLUSIONS The SCIP flap offers superior opportunities for thin soft tissue defect coverage with excellent functional outcomes in Caucasian patients. Based on higher BMI and anatomical differences as compared to Asian patient populations, modifications of flap elevation were necessary to increase reliability. More outcome reports from outside Asia need to become available to advance SCIP flap application internationally.
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Affiliation(s)
- Maximilian Kueckelhaus
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany; Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Muenster, Germany; Institute of Musculoskeletal Medicine, University Hospital Muenster, Germany.
| | - Nils Gebur
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany; Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Muenster, Germany; Institute of Musculoskeletal Medicine, University Hospital Muenster, Germany
| | - David Kampshoff
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany; Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Muenster, Germany; Institute of Musculoskeletal Medicine, University Hospital Muenster, Germany
| | - Mirkka Hiort
- Institute of Musculoskeletal Medicine, University Hospital Muenster, Germany
| | - Charalampos Varnava
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany; Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Muenster, Germany; Institute of Musculoskeletal Medicine, University Hospital Muenster, Germany
| | - Kamran Harati
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany; Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Muenster, Germany; Institute of Musculoskeletal Medicine, University Hospital Muenster, Germany
| | - Tobias Hirsch
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany; Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Muenster, Germany; Institute of Musculoskeletal Medicine, University Hospital Muenster, Germany
| | - Philipp Wiebringhaus
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany; Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Muenster, Germany; Institute of Musculoskeletal Medicine, University Hospital Muenster, Germany
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Lee YJ, Moon SH. Surgical treatment of pressure ulcer: various flaps and other surgical methods. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2021. [DOI: 10.5124/jkma.2021.64.1.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Pressure ulcers remain a common health problem, particularly among physically limited or bedridden older adults, and they can cause significant morbidity and mortality. Conservative management is ineffective for stage III or IV pressure ulcers, and surgery to create flap coverage becomes inevitable. Basic surgical principles for the treatment of pressure ulcers include complete excision of the ulcer, surrounding scar, underlying bursa, and soft tissue calcification; radical removal of underlying bone and any heterotropic ossification; padding of bone stumps and filling dead space; resurfacing with large regional pedicled flaps; and grafting the donor site of the flap, if necessary. For effective edge resection, all the flaps should be designed to be as large as possible, placing the suture line away from the area of direct pressure, and the flap design should also not violate adjacent flap territories to preserve all options for coverage if a breakdown or recurrence dictates further reconstruction. There are surgical methods for stage III or IV wide range pressure ulcers: reconstruction surgery using a skin flap, muscle flap, fascia-skin flap, or free flap. The skin graft is not generally recommended as a surgical procedure for stage III or IV pressure ulcers because it cannot provide enough strength to cover the wound. This review presents various surgical treatments of pressure ulcers including muscle, musculocutaneous, perforator-based, and free flap.
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Kim K, Kim J, Jeong W, Jo T, Park SW, Choi J. Outcome of distal lower leg reconstruction with the propeller perforator flap in diabetic patients. J Plast Surg Hand Surg 2020; 55:242-248. [PMID: 33337255 DOI: 10.1080/2000656x.2020.1858843] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
In diabetic foot patients, wound coverage options are quite limited due to vascular abnormalities. However, even though significant atherosclerotic changes are found in major vessels of the lower leg in diabetic foot patients, perforating vessels, which are used as the vascular pedicle of propeller perforator flaps, are often spared from atherosclerosis. Therefore, the propeller perforator flap could be an alternative option for diabetic foot patients. The purpose of this study was to compare the outcome of the propeller perforator flap between diabetic and nondiabetic patients in reconstruction of the distal lower leg. We retrospectively included all patients who underwent reconstruction of the distal lower leg with a propeller flap between 2014 and 2018. Thirty-five propeller perforator flaps in 20 diabetic patients and 15 nondiabetic patients were included. Of the 35 patients, 21 showed complete healing, and 14 showed flap complications. The rate of complications in diabetic patients was approximately 85.7%. Sex (p = .002), diabetes (p = .007), chronic renal failure (p < .001), and diabetic neuropathy (p = .011) were associated with flap complications. Crude regression analysis showed that the female sex (p = .002), diabetes (p = .01), and diabetic neuropathy (p = .012) were significant risk factors for the occurrence of any complications, but the significance of diabetes and diabetic neuropathy was not maintained in the adjusted models. Therefore, the propeller perforator flap might not be effective for reconstructing diabetic foot ulcers.
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Affiliation(s)
- Kyubeom Kim
- Department of Plastic and Reconstructive Surgery, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Junhyung Kim
- Department of Plastic and Reconstructive Surgery, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Woonhyeok Jeong
- Department of Plastic and Reconstructive Surgery, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Taehee Jo
- Department of Plastic and Reconstructive Surgery, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Sang Woo Park
- Department of Plastic and Reconstructive Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Jaehoon Choi
- Department of Plastic and Reconstructive Surgery, Keimyung University School of Medicine, Daegu, Republic of Korea
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