Branch Of Femoral Artery Research Articles

High preservation rates of the ascending branch of the lateral femoral circumflex artery during total hip arthroplasty through the direct anterior approach.

(i) To investigate the rate of preservation of the ascending branch of the lateral femoral circumflex artery (a-LFCA) during total hip arthroplasty (THA) through a direct anterior approach (DAA), and (ii) to study factors that contribute to its successful preservation. All patients who underwent primary THA between 1 September 2023 and 29 February 2024 were reviewed. One-hundred seventy-two patients were included in the study, 91 females and 81 males, aged 63.2 ± 12.6, with a body mass index of 26.1 ± 4.6 kg/m2. THA was performed through a minimally invasive DAA in all patients, using either a standard vertical DAA or a Bikini incision. Patients were stratified by the preservation of the a-LFCA (preserved, ligated/electrocauterized due to obstruction of the surgical field during dissection, electrocauterized due to bleeding during femoral broaching or stem insertion). Descriptive statistics were used to summarise the data. Logistic regression analyses were performed to explore possible factors associated with the preservation of a-LFCA. The a-LFCA was preserved in 130 patients (75.6%), had to be ligated/electrocauterized due to obstruction of the surgical field during dissection in 31 patients (18.0%), and had to be electrocauterized due to bleeding during femoral broaching or stem insertion in 11 patients (6.4%). Multivariable logistic regression analyses revealed that preservation of a-LFCA was significantly more likely in female patients (odds ratio [OR] = 2.22; 95% confidence interval [CI] = 1.1-4.6; p = 0.029), as well as in patients with younger age (OR = 0.97; 95% CI = 0.9-1.0; p = 0.036) and lower weight (OR = 0.97; 95% CI = 0.9-1.0; p = 0.005). Preservation of the a-LFCA is possible in the majority of patients (75.6%) undergoing THA through minimally invasive DAA. Furthermore, preservation of the a-LFCA is more likely in female patients, younger patients and patients with lower weight. Level IV.

Application of Flow-through Anterolateral Thigh Perforator Flaps in Replantation of Complex Severed Limb

ObjectiveTo explore the clinical application value of flow-through anterolateral thigh perforator (ALTP) flaps in replantation of complex severed limbs. MethodsThirteen severe vascular, nerve injury, and skin or soft tissue defects in patients with complex severed limbs from August 2017 to January 2019 were enrolled in this retrospective study. The skin flap has covered the wound by using the flow-through ALTP flap technique. The main vascular defect was repaired by using the descending branch of the lateral circumflex femoral artery, and the blood supply of the transplanted limb was reconstructed. The blood supply of the flap and wound healing observed were observed after the operation. Regular follow-up was performed to observe the survival and functional recovery of the replanted limb. ResultsEleven cases of replanted limb and perforator flap survived completely. Limb shortening occurred in 3 patients owing to bone defects caused by distal amputation. After the second stage of bone transplantation, the limb length and function of those 3 patients recovered well. One case showed necrosis of the little finger after replantation of the severed palm. One case showed that the crushed forearm was severed completely. The anastomotic vascular inflammatory embolism was caused by infection and necrosis of soft tissue after replantation for 2 weeks, and then the stump wound was covered with a survived skin flap in the second stage. ConclusionThe flow-through ALTP flap technique has a good therapeutic effect on the functional reconstruction of complex severed limbs with severe skin and vascular injuries.

Application of antibiotic bone cement combined with lobulated perforator flap based on descending branch of the lateral circumflex femoral artery in treatment of infected traumatic tissue defects of foot

ObjectiveTo evaluate the clinical effectiveness of antibiotic bone cement combined with the lobulated perforator flap based on the descending branch of the lateral circumflex femoral artery (d-LCFA) in the treatment of infected traumatic tissue defects in the foot, in accordance with the Enhanced Recovery after Surgery (ERAS) concept.MethodsFrom December 2019 to November 2022, 10 patients with infected traumatic tissue defects of the foot were treated with antibiotic bone cement combined with the d-LCFA lobulated perforator flap. The cohort comprised 6 males and 4 females, aged 21 to 67 years. Initial infection control was achieved through debridement and coverage with antibiotic bone cement, requiring one debridement in nine cases and two debridements in one case. Following infection control, the tissue defects were reconstructed utilizing the d-LCFA lobulated perforator flap, with the donor site closed primarily. The flap area ranged from 12 cm×6 cm to 31 cm×7 cm. Postoperative follow-up included evaluation of flap survival, donor site healing, and ambulatory function of the foot.ResultsThe follow-up period ranged from 7 to 24 months, averaging 14 months. Infection control was achieved successfully in all cases. The flaps exhibited excellent survival rates and the donor site healed by first intention. Based on the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, pain and function were evaluated as excellent in 3 cases, good in 5 cases, and moderate in 2 cases.ConclusionThe application of antibiotic bone cement combined with the d-LCFA lobulated perforator flap is an effective treatment for infected traumatic tissue defects of the foot with the advantages of simplicity, high repeatability, and precise curative effects. The application of the d-LCFA lobulated perforator flap in wound repair causes minimal damage to the donor site, shortens hospital stays, lowers medical expenses, and accelerates patient rehabilitation, aligning with the ERAS concept. Therefore, it is a practice worth promoting in clinical use.

The Piggyback Superficial Circumflex Iliac Perforator Flap for Complex Free Flap Reconstructions.

This article introduces a reproducible strategy for complex reconstruction scenarios that require the use of two flaps. It specifically focuses on the utilization of the superficial circumflex iliac artery perforator (SCIP) flap as a secondary flap, particularly in complex cases where available arterial options are limited. In the first scenario, the SCIP flap is elevated simultaneously during elevation of a fibula bone flap. The pedicle of the fibula flap will be anastomosed to the recipient vessels, and the pedicle artery of the SCIP flap, the superficial circumflex iliac artery, will be anastomosed to the distal end of the peroneal artery. The SCIP flap pedicle offers greater length compared with a cutaneous flap sourced from the peroneal artery, thus providing increased flexibility for the flap inset. In the second scenario, the SCIP flap is combined with the anterolateral thigh (ALT) flap to manage a significant defect. The pedicle of the ALT flap is anastomosed to the recipient vessels, and the superficial circumflex iliac artery is anastomosed to the distal end of the pedicle artery of the ALT flap, the descending branch of the lateral circumflex femoral artery. The SCIP flap can be harvested simultaneously with a fibula flap or an ALT flap from the same side, and its arterial anastomosis can always be established with the distal ends of the arterial pedicle of these two flaps. This efficient and reproducible method can also contribute to minimal donor site morbidity and will be particularly valuable in settings where recipient artery choices are limited.

Precise maxillofacial soft tissue reconstruction: A combination of cone beam computed tomography and 3dMD photogrammetry system

IntroductionThe reconstruction of both extra- and intra-oral soft tissue defects, particularly in restoring the morphology of the lip and the corners of the mouth, has posed a significant challenge for surgeons. Inappropriate methods often lead to maxillofacial deformity which then causes psychological and functional problems. This study aimed to address the challenge of reconstructing extensive and complex maxillofacial soft tissue defects, mainly focusing on the lip, the corners of the mouth, and the surrounding areas. Materials and methodsWe developed a reconstruction approach by combining the 3dMDface System (3dMD) with the cone beam computed tomography (CBCT). Firstly, with the extra-oral incision line, we evaluated the shape and the size of the extra-oral defect with 3dMD digitally. Then we used the corresponding maxillary and mandible tooth positions to record the intra-oral defect, which was then converted to digital images by combining 3dMD and CBCT. The islands of the anterolateral thigh perforator flap were then designed after the locations of the perforators were detected with Doppler ultrasonography. ResultsA clinical case diagnosed as dermatofibrosarcoma protuberans was presented to illustrate the approach. The patient's tumor resection and the size of multiple defects were measured and simulated via the virtual surgery system. A three-island perforator flap from the descending branch of the lateral femoral circumflex artery was designed accurately. Two weeks postoperatively, the flap was healed as anticipated and the patient was satisfied with the profile. ConclusionThe combination of the 3dMD and CBCT technologies improves the accuracy and fitness of extra- and intra-oral soft tissue reconstruction.

Rehabilitative treatment of lower leg injury was studied by using anterolateral free thigh flap with CT scan

ObjectiveIn cases of severe soft tissue loss and deep tissue exposure in the lower part of the leg, microsurgical skin flap transplantation is the primary treatment method. MethodsBased on the anatomy of the descending branch of the lateral circumflex femoral artery and its musculocutaneous perforators, a free, ultra-thin anterolateral thigh perforator flap is designed for the repair of soft tissue defects in hands and feet. This method has been successfully used at our hospital to treat three patients. Postoperative recovery was favorable, with no vascular crises, and all skin flaps survived. ResultsThe aesthetic appearance of the repaired area was approved by patients, and there were no severe complications post-surgery. Patients were followed up for a period ranging from 6 to 24 months, averaging 14 months. The skin flaps were soft and elastic, without swelling, and the color matched that of normal skin, with good sensory function recovery. ConclusionIn surgical treatment of lower leg wounds, prioritizing using a free anterolateral thigh flap can enhance the repair of the wound and expedite functional recovery postoperatively.

Subdermal dissection technique for pure skin SCIA and ALT perforator flaps in burns and trauma defects: Clinical experience.

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. 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. 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). 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.

Improved flap perfusion and hemostasis after postoperative embolization in free flap surgery: a case report

This study aims to present a novel use of coil embolization in managing postoperative bleeding after free flap surgery, a technique typically reserved for other medical complications. We report the case of a 77-year-old female patient who underwent muscle-sparing latissimus dorsi free flap surgery for recurrent myxofibrosarcoma on her left thigh. Although hemostasis was achieved hemostasis during surgery, the patient experienced postoperative bleeding, which was initially managed with compression and blood transfusions. Upon a critical drop in the hemoglobin level, coil embolization was performed at the proximal segment of the descending branch of the lateral circumflex femoral artery. Coil embolization successfully controlled bleeding, while preserving blood flow to the flap. The patient’s hemoglobin levels stabilized, and the flap’s perfusion improved post-procedure. This approach proved effective in managing bleeding in areas other than the anastomosis site, with the patient showing a satisfactory recovery and no significant complications in the 30-day postoperative period. Coil embolization, a method commonly used for gastrointestinal bleeding and other vascular issues, can be a viable and effective option for controlling postoperative bleeding after free flap surgery. This case demonstrates its potential as a lifesaving intervention while preserving flap viability. However, further research with more cases is needed to evaluate the generalizability and long-term outcomes of this technique in similar surgical contexts.

Clinical diagnosis and treatment of 14 cases of scar cancer ulcer wound on head and face

To analyze the clinical characteristics of scar cancer ulcer wound of head and face, and to investigate its diagnosis and treatment. The clinical data of 14 patients with head and facial scar cancer ulcer wounds who met the selection criteria and admitted between January 2021 and March 2022 were retrospectively analyzed. There were 8 males and 6 females. The age of onset ranged from 21 to 81 years with an average age of 61.6 years. The incubation period ranged from 1 month to 70 years, with a median of 4 years. Site of the disease included 7 cases of head, 6 cases of maxillofacial region, and 1 case of neck region. Injury factors included trauma in 5 cases, scratch in 5 cases, scalding in 2 cases, burn in 1 case, and needle puncture in 1 case. Pathological results showed squamous cell carcinoma in 9 cases, basal cell carcinoma in 3 cases, sebaceous adenocarcinoma in 1 case, papillary sweat duct cystadenoma combined with tubular apocrine sweat gland adenoma in 1 case. There was 1 case of simple extensive tumor resection, 1 case of extensive tumor resection and skin grafting repair, 7 cases of extensive tumor resection and local flap repair, and 5 cases of extensive tumor resection and free flap repair. All the 14 patients were followed up 16-33 months (mean, 27.8 months). Two patients (14.29%) had scar cancer ulcer wound recurrence, of which 1 patient recurred at 2 years after 2 courses of postoperative chemotherapy, and was still alive after oral traditional Chinese medicine treatment. One patient relapsed at 1 year after operation and died after 2 courses of chemotherapy. One patient underwent extensive resection of the left eye and periocular tumor and the transfer and repair of the chimaeric muscle axial flap with the perforating branch of the descending branch of the left lateral circumflex femoral artery, but the incision healing was poor after operation, and healed well after anti-infection and debridement suture. The wounds of other patients with scar cancer ulcer did not recur, and the wounds healed well. Scar cancer ulcer wound of the head and face is common in the middle-aged and elderly male, and the main pathological type is squamous cell carcinoma. Local extensive resection, skin grafting, or flap transfer repair are the main treatment methods. Early active treatment of wounds after various injuries to avoid scar repeated rupture and infection is the foundamental prevention of scar cancer.

Assessment of the Length of the Pedicle of the Anterolateral Thigh Flap.

Purpose To estimate the length of the pedicle of the anterolateral thigh flap (ALT) and to assess how this length corresponds with the distances between the anatomical landmarks. Methods The study group consisted of patients who underwent computed tomography angiograms ranging minimally from the anterior superior iliac spine (ASIS) superiorly and tibia inferiorly. In the study we included 44 patients. In the axial window we identified single scans with (1) ASIS, (2) the apex of the greater trochanter, (3) the origin of the descending branch of the lateral femoral circumflex artery (LFCA), (4) the superolateral corner of the patella, (5) knee joint gap.Knowing the slice thickness in every patient and the difference in scan number we measured(A)-the distance between the scan (1) and the scan (4). This distance (A) represented the length of the line connecting ASIS and the superolateral corner of the patella (AP line). Next, we identified (6) the midpoint of the distance (A). Next we measured (B)-the distance between the scan (2) and the scan (5) and (C)-the distance between the scan (3) andthe midpoint of the AP line (6). Results Mean distances between the scans were: (A) 45.34 cm (SD=4.14), (B) 43.12 cm (SD=4.08), (C) 11.69 cm (SD=1.62). There was low positive correlation between the distance (A) and the distance (C) (rs=0.43) and moderate positive correlation between the distance (B) and the distance (C) (rs=0.53). Conclusion Our study suggests that the mean estimated length of the ALT flap pedicle is11.69 cm and that it positively correlates with the length of the femur and the length of the AP line.

Anatomical Relations of the Perforators from the Descending Lateral Femoral Circumflex Artery and Vastus Lateralis Motor Nerve Branches.

The anterolateral thigh (ALT) flap, which is nourished by perforators from the descending branch of the lateral femoral circumflex artery (P), is one of the most commonly used flaps in soft tissue reconstruction. With the growing use of ALT flaps, attention toward donor-site morbidity has increased in recent years. Damage to the motor nerve branches of the vastus lateralis muscle (N) is one of the causes of donor-site morbidity, particularly muscle weakness. This study investigated the anatomical locations of the P and N in fresh-frozen cadaveric specimens. This study included 43 cadaver limbs. A silicone rubber compound (30 mL) was injected into the femoral artery to visualize the vessel. The locations of the P and motor points of N were measured to assess the risk of N injury during ALT flap harvesting. There were one to six (mean, 2.7) P and two to seven (mean, 4) N. When the two most proximal perforators were used for flap harvesting, an average of 1.5 motor nerve branches (42%) was damaged because transection of the motor nerve branches was required for flap harvesting. In 33% of the limbs, only one motor nerve branch remained after the flap harvest. However, there were no cases where all motor nerve branches were severed. When an ALT flap with two perforators is harvested, weakness of the vastus lateralis muscle may occur in cases with a small number of motor nerve branches.

Comparative Study of the Morphological Characteristics of Perforators of the Transverse and Descending Branches of the Lateral Circumflex Femoral Artery in Anterolateral Thigh Flap Surgery.

The anterolateral thigh flap (ALTF) is a kind of lateral thigh flap that uses branches of the lateral circumflex femoral artery (LCFA) as the vessel pedicle and is widely used in plastic surgery. During classic ALTF surgery, some perforators from the descending branch of the lateral circumflex femoral artery (LCFA-db) are hard to harvest due to their anatomical variants and individual differences; thus, it is necessary to design an appropriate alternative surgical plan. The transverse branch of the LCFA (LCFA-tb) has unique advantages and can be a potential complement to ALTF vascular pedicle selection. The aim of this study was to compare the difference in morphology between LCFA-db and LCFA-tb, and to verify the feasibility and clinical effect of ALTF with LCFA-tb as the source artery. The morphological and clinical data of patients who underwent wound repair of the extremities with the ALTF pedicled with the LCFA-tb and LCFA-db were retrospectively analyzed. This study consisted of the clinical data of 62 patients who accepted an ALTF pedicled with LCFA-tb, and 45 patients accepted an ALTF pedicled with LCFA-db. A total of 68 cutaneous perforators originating from the LCFA-tb were found in the surgical field, of which 35 perforators were direct cutaneous perforators (51.5%), 28 perforators were septocutaneous perforators (41.2%), and 5 perforators were musculocutaneous perforators (7.3%). Seventy-four cutaneous perforators were found in the LCFA-db group. The proportions of septocutaneous perforators and musculocutaneous perforators were 23% and 77%, respectively, and the number of direct cutaneous perforators was 0. The harvest time of flaps pedicled with LCFA-tb was remarkably shortened. Regarding prognosis, there were no significant differences between the curative effects of the 2 types of flaps. This study verified that most LCFA-tb perforators are direct cutaneous perforators and that the piercing-in positions of LCFA-tb perforators on superficial fascia were higher than those of LCFA-db perforators. Furthermore, the ALTF pedicled with LCFA-tb can provide satisfactory soft tissue reconstruction and can be used as a useful supplement to the traditional flap design.

3D printing for an anterolateral thigh phalloplasty

BackgroundPhalloplasty procedures are performed to create a phallus, typically as a gender-affirming surgery for treating gender dysphoria. Due to the controversial nature of this specific procedure, more innovation is needed to directly assist surgical teams in this field. As a result, surgeons are left to improvise and adapt tools created for other procedures to improve surgical outcomes. This study developed a patient-specific 3D printed model from segmented computed tomography (CT) scans to accurately represent the relevant vasculature necessary for anterolateral thigh (ALT) flap phalloplasty. The surgical procedure seeks to maintain intact vessels that derive from the descending branch of the lateral circumflex femoral artery, typically found traveling within the intermuscular septum between the rectus femoris and vastus lateralis.MethodsIn this study, we created and printed 3D models of the leg and vasculature using two techniques: (1) a standard segmentation technique with the addition of a reference grid and (2) a bitmap method in which the total CT volume is colorized and printed.ResultsThe results gathered included the physician’s view on the model’s accuracy and visualization of relevant anatomy. Bitmap-printed models resulted in a high amount of detail, eliciting surgeons’ undesirable reactions due to the excess of information. The hybrid method produced favorable results, indicating positive feasibility.ConclusionsThis study tested the ability to accurately print a patient-specific 3D model that could represent the vasculature necessary for ALT flap procedures and potentially be used in surgical reference and planning in the future. A surgeon performing phalloplasty procedures discussed their approval of both models and their preference for grid creation and application.

Doppler ultrasonography can be used to evaluate the arterial blood supply of hip joints in skeletally immature cats.

To investigate hemodynamics and morphology of hip joint vasculature in cats with the use of color and pulsed-wave Doppler ultrasonography. 30 client-owned healthy skeletally immature cats presented for routine examinations between September 7, 2022, and March 25, 2023. Cats between 3.5 to 18 months old with healthy hip joints and Hct within reference ranges (26% to 44.2%) were eligible for inclusion. Color and pulsed-wave Doppler ultrasonography was performed without sedation. Peak systolic velocity (PSV), mean diastolic velocity (MDV), resistance index (RI), and pulsatility index (PI) were measured for major arteries of the hip joints. Intermediate pulsatility, resistance to flow, and pandiastolic anterograde flow were evident for all arteries evaluated for each joint except for the ligamentum capitis ossis femoris artery (LCOFA). Spectral waveforms for the LCOFA showed a low-resistance pattern with continuous forward diastolic flow. No significant differences were found in the mean PI or MDV between the left and right sides for the ascending branch of the lateral circumflex femoral artery or in the mean PI of the ascending branch of the medial circumflex femoral artery. Mean PSV of the LCOFA was lower (but nonsignificantly) for left hip joints vs right hip joints, whereas other values were often higher on cats' left side vs their right. This study provided insight into the morphology and hemodynamics of the femoral head vasculature in skeletally immature cats and showed Doppler ultrasound values to study the clinically normal blood supply to hip joints in cats.

Is the oblique branch of the lateral circumflex femoral artery a common variant?

The oblique branch of the lateral circumflex femoral artery, a short branch of the deep femoral artery, is highly prevalent (32-46%) and is usually considered a normal variant, although this is still controversial. This study aimed to evaluate whether the oblique branch of the lateral circumflex femoral artery is a variant. We reviewed medical record data of patients with skin and soft tissue defects of the extremities who underwent flap repair using free anterolateral thigh (ALT) flaps at our hospital in 2019. The anatomical characteristics of the flaps were examined intraoperatively by high-frequency color Doppler ultrasound. A total of 153 ALT flaps from 146 patients were included. Among the branches, 232 (73.7%) were oblique branches, and 83 (26.4%) were descending branches. Of the 232 oblique branches, 141 (60.8%) were from septocutaneous branches, and the other 83 (39.2%) were from musculocutaneous branches. In addition, 20 (24.1%) descending branches were from septocutaneous branches, and the other 63 (75.9%) were from musculocutaneous branches. Analyzing the prevalence of the oblique branch in septocutaneous branches, more than half of the patients had oblique branches rather than descending branches. The high proportion of oblique branches from septocutaneous branches (median: 100 (0-100) vs. 0 (0-50), p=0.002) supports the understanding that the oblique branch is a normal anatomical element rather than a variant. The main type was the intramuscular branches, which required significantly less time for flap harvesting. The oblique branch may be the preferred vascular pedicle for free ALT flaps.

Diversity of the free helical rim flap: A case series tailoring the microsurgical technique to esthetically optimize full-thickness nasal defect reconstructions

The free helical rim (FHR) flap offers like-with-like reconstruction for full-thickness nasal defects. A case series of nasal reconstruction using an FHR flap was presented, detailing surgical steps and refinements, as well as functional and esthetic outcomes. This is a retrospective cohort study of composite nasal defect reconstruction with FHR flap from August 2018 to March 2020. Descriptive data were analyzed by SPSS software. Six cases were recruited, four were unilateral alar defects, one was hemi-nose, and one was ala plus tip. The average size of the defect was 2.5×2.8cm2. Three FHR flaps were designed with retrograde pedicles and three with anterograde pedicles. The facial artery and veins were the recipient vessels in all cases. Vascular grafts were used in all six cases. Descending branch of the lateral circumflex femoral (DLCxF) artery and vein functioned as interposition vascular conduits in five cases. Superficial forearm vein grafts were used in one case. One patient needed flap re-exploration due to venous congestion. One patient had partial flap necrosis due to delayed infection, and one developed delayed wound dehiscence in the irradiated wound. The average follow-up was 18 months. The FHR flap has consistent vascular anatomy. It can be raised as an anterograde or retrograde flap for a contralateral or ipsilateral inset. FHR flap can be used in extensive composite nasal defects. This case series demonstrates that interposition vascular grafts are invariably needed and the possibility of using forearm vessels as grafts instead of DLCxF artery and vein.

Value of the combination of a smartphone-compatible infrared camera and a hand-held doppler ultrasound in preoperative localization of perforators in flaps

This study was conducted to evaluate the effectiveness of the FLIR ONE PRO, a thermal imaging camera for smartphones, combined with handheld Doppler (HHD) in the localization of perforator arteries and to assess the efficacy of the FLIR ONE PRO in distinguishing perforators of the descending branch of the lateral circumflex femoral artery (LCFA) from other perforators of the anterolateral thigh perforator (ALTP) flap. We enrolled 29 free perforator flaps from 22 patients in our study. Before surgery, dynamic infrared thermography was performed using a FLIR ONE PRO to visualize hotspots on the flaps. Subsequently, HHD was used to further determine the perforators under the hotspots, which were ultimately identified and confirmed through intraoperative findings. Additionally, infrared images of the ALTP flap were analyzed using FLIR Tools. The performances of the FLIR ONE PRO and FLIR ONE PRO + HHD groups were evaluated by comparing the intraoperative findings. Using FLIR ONE PRO + HHD, 119 hotspots and 106 perforators were identified during surgery. Using FLIR ONE PRO + HHD, sensitivity and positive predictive value were 97.87% and 88.46%, respectively, in the young (age≤45 years). In the elderly group (age>45 years), these percentages were 93.22% and 82.09%, respectively. In addition, we found that the FLIR ONE PRO could be useful for differentiating perforators in the descending branch of the LCFA from other perforators within 5 min. The results showed a sensitivity of 96.15%, a specificity of 98.9%, a positive predictive value of 96.15%, and a negative predictive value of 98.9%. Compared to using FLIR ONE PRO alone, the combined application of HHD and FLIR ONE PRO had a higher value in perforator localization by increasing the positive predictive value. The FLIR ONE PRO may have significance in the rapid prediction of perforators deriving from the descending branch of the LCFA.

(439) Penile Revascularization Utilizing The Lateral Femoral Circumflex Artery After Pelvic Fracture Urethral Injury

Abstract Introduction Pelvic fracture urethral injury (PFUI) is associated with erectile dysfunction (ED) in up to 62% of patients, often due to decreased arterial inflow. For select healthy patients with isolated arterial insufficiency, penile revascularization utilizing the inferior epigastric artery to either the cavernosal or dorsal penile artery has been shown to be an effective treatment ED. The patient originally presented with a PFUI after a motor vehicle collision. He underwent suprapubic tube placement and selective embolization of a right internal pudendal artery pseudoaneurysm. Four months later, he underwent a posterior urethroplasty with corporal splitting and inferior pubectomy. During follow-up, he reported no erectile function following his initial trauma with no prior history of erectile dysfunction. He was trialed on PDE5is which were ineffective and ICI which was discontinued due to pain and minimal efficacy. Penile Doppler ultrasound with ICI showed bilateral arterial insufficiency with peak systolic velocities of 11.3 and 18.8 cm/second and no evidence of veno-occlusive dysfunction with end-diastolic flows of 2.85 and 4.66 cm/second of the cavernosal arteries (Figure 1). Bilateral inferior epigastric arteriography demonstrated 20-30% ostial stenosis with left traumatic occlusion of the internal pudendal and complete occlusion of the right internal pudendal artery post-embolization. The dorsal penile arteries filled in a delayed fashion via small-caliber collaterals. Objective We present this case to demonstrate use of an alternative arterial donor vessel for penile revascularization. Methods An infrapubic incision was made to expose the right dorsal penile artery. Another incision was made from the right anterior superior iliac spine to just above the patella tendon. The rectus femoris and vastus lateralis were atraumatically split and the descending branch of the lateral femoral circumflex artery was exposed. Small branches were clipped (Figure 2). The most distal branch to the rectus femoris was divided to become the donor vessel, leaving the proximal branch to maintain muscular perfusion. The donor branch was mobilized and passed via a subcutaneous tunnel into the infrapubic incision (Figure 3). Using an operating microscope the dorsal penile artery was ligated and the distal end was anastomosed to the donor artery and an end-to-end fashion using 8-0 nylon interrupted sutures. A drain was placed in the thigh wound, and both wounds were closed in two layers. Results The patient was started on 325mg of daily aspirin and remained on bed rest for two days. He was discharged on postoperative day two and his thigh drain remained in place for two weeks. He was restricted to less than 30-degree abduction of the right thigh for four weeks. Four months postoperatively the patient was achieving erections with 7/10 rigidity using only 5mg of tadalafil as needed. His SHIM was 17. At six months postoperatively he had increased his tadalafil dose to 20mg and was achieving erections with 8/10 rigidity from his pre-injury baseline. Conclusions This case demonstrates an excellent result from penile revascularization utilizing the lateral femoral circumflex artery. This artery can be considered an alternate donor for penile revascularization procedures following pelvic fracture urethral injury when there is a contraindication to the use of the inferior epigastric artery. Disclosure No

Microvascular Free Flap Reconstruction of Thigh Defects After Tumor Resection in the Setting of Radiation.

Soft tissue reconstruction of the thigh defects can usually be achieved with local options. Free tissue transfer may be indicated in very large defects with exposed vital structures and/or a history of radiation therapy where the healing potential of local option is poor. In this study, we evaluated our experience on microsurgical reconstruction of oncological and irradiated thigh defects to assess the risk factors for complications. Institutional review board-approved retrospective case series study using electronic medical records from 1997 to 2020 was conducted. All patients with irradiated thigh defects derived from oncological resections who underwent microsurgical reconstruction were included. Patient demographics and clinical and surgical characteristics were recorded. Twenty free flaps were transferred in 20 patients. Mean age was 60 ± 11.8 years, and median follow-up time was 24.3 months (interquartile range [IQR], 71.4-9.2 months). The most common type of cancer was liposarcoma (n = 5). Neoadjuvant radiation therapy was performed in 60%. Most commonly used free flaps were latissimus dorsi muscle/musculocutaneous flap (n = 7) and anterolateral thigh flap (n = 7) Nine flaps were transferred immediately after resection. Overall, 70% of arterial anastomoses were end-to-end, whereas 30% were end-to-side. Deep femoral artery branches were chosen as the recipient artery in the 45%. Median length of hospital stay was 11 days (IQR, 16.0-8.3 days), and median time to start weight-bearing was 20 days (IQR, 49.0-9.5 days). All were successful except for 1 patient who required additional pedicled flap coverage. The overall major-complication rate was 25% (n = 5, hematoma = 2, venous congestion requiring emergent exploration surgery = 1, wound dehiscence = 1, surgical site infection = 1). Cancer recurred in 3 patients. One required amputation due to cancer recurrence. Age (hazard ratio [HR], 1.14; P = 0.0163), tumor volume (HR, 18.8; P = 0.0006), and resection volume (HR, 2.24; P = 0.0019) were statistically significantly associated with having a major complication. Based on the data, microvascular reconstruction of irradiated post-oncological resection defects shows high flap survival rate and success. Given the large size of flap required, the complex nature and size of these wounds, and history of radiation, wound healing complications are common. Despite this, free flap reconstruction should be considered in irradiated thighs with large defects. Studies with larger cohort and longer follow-up are still required.

Lower Extremity Reconstruction with Anterolateral Thigh Free-Flap Anastomoses: A Computational Fluid Dynamic Analysis.

The anterolateral thigh free flap is an option for repairing soft tissue defects of the distal lower extremity. This flap uses the descending branch of the lateral circumflex femoral (LCF) artery as the flap vessel. The recipient vessel in these flaps is often the anterior tibial (AT), posterior tibial (PT), or peroneal (P) arteries. Computational fluid dynamic (CFD) evaluation of anastomoses between these vessels can optimize outcomes. Thirty-eight CFD models were created to model end-to-side (ETS) and end-to-end (ETE) anastomoses for lower extremity reconstruction. Seven out of thirty-eight models represented ETS anastomoses between the LCF and AT arteries with varying anastomotic angles. Nine out of thirty-eight models represented 45-degree ETS anastomoses between varying diameters of the LCF and AT, PT, and P arteries. Nine out of thirty-eight models represented stenosis on the flap vessel and recipient vessel, pre- and post-bifurcation. Nine out of thirty-eight models represented ETE anastomoses, rather than ETS, with varying vessel diameters. Four out of thirty-eight models represented ETE anastomoses with varying regions and levels of stenosis. Stasis of blood flow in ETS models increased as anastomotic angle increased in a logarithmic relationship (R 2 = 0.918). Flow was optimized overall as flap and recipient vessel diameters approached one another. In ETS models, flap vessel and postbifurcation recipient vessel stenosis were found to substantially increase stasis. Selection of flap and recipient vessels with similar diameters can optimize outcomes in microvascular anastomoses. In the context of lower extremity reconstruction with the ALT flap, the PT artery can be recommended as a first-line recipient vessel due to its similar vessel caliber to the LCF and relative ease of surgical access compared with the P artery. Avoidance of areas of stenosis is recommended to ensure laminar flow and reduce the operative difficulty associated with performing anastomoses on nonpliable arteries. Striving for increased acuity of anastomotic angles is recommended to optimize the flow in ETS microvascular anastomoses.