Circumflex Iliac Artery Research Articles

Augmented Reality Microsurgical Planning with a Smartphone (ARM-PS): A dissection route map in your pocket

Perioperative microsurgical planning increases the likelihood of successful results. Augmented reality (AR) is the addition of artificial information to allow the user to perform tasks more efficiently. The aim of our study is to report the use of AR for microsurgical planning with a smartphone (ARM-PS) as a dissection route map. AR was used for superficial circumflex iliac artery perforator (SCIP) flap planning. Three-dimensional (3D) reconstruction images of the inguinal and lower abdomen vascular anatomy were obtained by computed tomography angiography. These 3D images were imported to a smartphone and an AR app was used to superimpose them with the camera. The drawings performed with ARM-PS were correlated with handheld Doppler and intraoperative findings. The correlation of ARM-PS drawings with handheld Doppler results was 100% for superficial inferior epigastric artery (SIEA) and superficial and deep branches of SCIP in 60 inguinal areas studied. Intraoperative findings matched perfectly in all 30 cases with ARM-PS drawings for the location of the mentioned vessels and lymph nodes. Flap harvest time decreased in 20% compared with our traditional timing. ARM-PS is an easy, noninvasive, and accurate method that provides a dissection route map, thereby standardizing flap harvesting, and shows a perfect correlation with intraoperative findings. It reduces operating time and may improve operative results, thus decreasing donor site morbidity.

Quantifying Lymph Nodes During Lymph Node Transplantation: The Role of Intraoperative Ultrasound.

Quantifying lymph nodes in vascularized lymph node transfer (VLNT) has been performed using preoperative percutaneous ultrasound. The higher resolution and accuracy of intraoperative ultrasound (IOUS) over transcutaneous ultrasound has been demonstrated in the radiology literature for the identification and characterization of finer structures including hepatic lesions, pancreatic lesions, and biliary or pancreatic ducts. We hypothesize that IOUS during VLNT would be a superior method to quantify and map lymph nodes in our flaps. A prospectively collected database of patients undergoing VLNT over 3 years (October 2014 to October 2017) was reviewed. Patients who underwent IOUS during flap harvest, before pedicle ligation to simultaneously map and quantify the number of lymph nodes were included in the study. Twenty-one patients with an average age of 58.7 years and a mean BMI of 32.3 underwent VLNT with IOUS for chronic lymphedema during the study period. Extremity lymphedema was classified as Campisi IB (n = 7), IIA (n = 7), IIB (n = 5), and IIIA (n = 2). There were 14 superficial circumflex iliac artery flaps, including 4 performed concomitantly with a deep inferior epigastric perforator flap, 1 transverse cervical artery flap, and 6 omental flaps. The average number of lymph nodes transferred per IOUS was 4.3 for superficial circumflex iliac artery flaps, 4 for the transverse cervical artery flap, and 5.2 for the omental flaps. Intraoperative ultrasound allows the lymphatic surgeon to precisely map the location of lymph nodes which can guide intraoperative decision making. As there is no data correlating the number of lymph nodes transferred and outcomes after VLNT, developing a precise intraoperative quantification method is important.

Abstract 17160: Quantitative Characterization of Porcine Peripheral Artery Disease Models

Introduction: Peripheral artery disease (PAD) is a significant age-related medical condition affecting over 200 million patients worldwide. PAD cell therapy clinical trials have shown minimal benefits, and questions remain regarding the optimal cell type, dose, and delivery method. A large animal preclinical PAD model has not been standardized nor quantitatively characterized, potentially contributing to the lack of success in these trials. Hypothesis: We hypothesize that a durable model of PAD can be created in swine to test cell therapy efficacy as determined through quantitative measurements of microvascular muscle perfusion and limb functionality while walking. Methods: Swine were divided into three cohorts and underwent unilateral ligation of 1) the external iliac and circumflex iliac arteries, 2) the external, internal, and circumflex iliac arteries, or 3) distal hind limb arteries to create models of PAD. Automated gait analysis with a pressure-sensitive walkway was performed at various time points pre- and post-model creation to quantify functional deficits of trotting animals. Objective calculation of various gait parameters was performed by walkway software. A pulsed arterial spin labeling (ASL) MRI sequence was used to measure perfusion in pig hind limbs during cuff-induced reactive hyperemia. Fluoroscopy-based angiography was performed during model creation and sixth week terminal procedures, and fluorescent microsphere perfusion measurements were obtained for limb muscles at study conclusions. Results: The most severe, durable functional deficits were exhibited in Cohort 2. Cohort 1 exhibited transient functional abnormalities in ischemic vs. non-ischemic hind limbs that returned to baseline in one week. Animals in Cohort 3 also displayed slight deficits early that quickly resolved. ASL MRI successfully quantified microvascular perfusion in hind limb skeletal muscle. Extensive collateral formation in ischemic hind limbs was detected at the end of each study. Conclusions: External and internal iliac artery ligation is a promising strategy to establish a durable model of hind limb ischemia in which to test the efficacy of cell and other therapeutics, better facilitating the transition of PAD therapies from bench to bedside.

The Deep Circumflex Iliac Artery Perforator Flap for Breast Reconstruction: Un lambeau perforateur de l'artère iliaque circonflexe profonde pour la reconstruction mammaire.

Autologous breast reconstruction using abdominal-based perforator flaps produces excellent aesthetic results with minimal donor site morbidity. The superficial inferior epigastric artery and deep inferior epigastric perforator (DIEP) flaps reliably perfuse a hemi-abdomen, up to the anterior axillary line. Beyond this line laterally, the flank or "love handle" tissue is primarily perfused by the deep circumflex iliac artery (DCIA) or secondarily by the superficial circumflex iliac artery. The flank tissue is a valuable addition to increase flap size when harvested with a DIEP flap or to provide vascularized tissue when the abdomen has been previously harvested. Harvesting the flank tissue in combination with the anterior abdominal tissue improves the contour of the trunk, accentuates the waist, and minimizes secondary revisions to excise prominent "dogears." The DCIA flap is a novel technique for breast reconstruction. In this article, we describe our technique, pearls and pitfalls, and early results.

Abstract: Tripedicled Extended Abdominal Perforator Flap: An Alternative for Low Body Weight Patients Requiring Large Autologous Bilateral Breast Reconstruction

PURPOSE: Autologous breast reconstruction is challenging in thin patients who present for bilateral breast reconstruction. The Stacked Hemi-abdominal Extended Perforator (SHAEP) flap has been shown to increase the volume of useable abdominal tissue by adding a secondary, more lateral pedicle to the DIEP. We present a novel approach to obtaining even more volume by adding another pedicle to the SHAEP. This is the first description of the Tripedicled Extended Abdominal Perforator (TEAP) flap that allows for use of the entire circumference of the lower trunk by adding two additional pedicles to the DIEP. METHODS: To perform the TEAP flap, circumferential body lift principles are followed in order to recruit more lower truncal tissue. The flap consists in an extended DIEP flap with three pedicles. Preoperative MRA is performed in order to localize vessels. The main pedicle is the deep inferior epigastric artery perforator. Two additional perforators are used, the most common being the deep circumflex iliac artery (DCIA) and the superficial inferior epigastric artery (SIEA). The lumbar artery perforator (LAP), the superficial circumflex iliac artery (SCIA) and the intercostal perforators (IP) can also be used. The DIEP pedicle is harvested with additional branches, and length on the superior continuation. The two additional pedicles are anastomosed on a back table to these branches using couplers for arteries and veins. The DIE artery and vein are then anastomosed to the internal mammary artery and vein. We analyzed our case series evaluating patient demographics, surgical techniques, operative time and complications. RESULTS: Six TEAP flaps were performed by two surgeons, on three patients undergoing bilateral breast reconstruction. A total of 6 anastomosis with 3 pedicles were performed for each breast reconstruction. Three flaps included one DIEP pedicle, one SCIA and one SIEA. One flap included one DIEP, one SIEA and one DCIA pedicle. Another flap included one DIEP pedicle, one SIEA and one Intercostal perforator and the last one included one DIEP pedicle, one DCIA and one LAP. The additional pedicles allowed for an average of 45% more volume than the DIEP alone. All flaps were successful with a mean follow up of 154 days (60–225 days). CONCLUSION: The TEAP flap is a novel procedure that avails the microsurgeon of the use of the entire abdominal circumference of the thin patient for use in breast reconstruction, providing total autologous breast reconstruction with increased volume, enhanced flap perfusion, and muscle preservation.

The reevaluation and surgical strategy of the superficial circumflex iliac artery perforator (SCIP) flap

Objective To introduce the classification of the perforators of the superficial circumflex iliac artery (SCIA) , and the superficial circumflex iliac artery perforator (SCIP) flaps based on different perforators have different characters and harvesting methods. To explore a set of coping strategy for the drawbacks of the SCIP flap. Methods Review 90 cases of SCIP flaps in August, 2011 to June, 2017. The pre-operative radiology navigation was conducted in all cases. Different surgical approaches were applied in flaps based on different perforators. The pedicle elongation method was adopted when necessary. The thickness of the flap, the length of the pedicle, the survival rate of the flap and the closure of the donor site were analyzed. Regular follow-up was performed after the operation. Results All flaps were followed-up for 6-15 months (average 8 months) . Fifty-seven flaps were raised on the basis of the proximal perforators of the superficial branch of the SCIA, whereas 29 cases were based on the distal perforators from the deep branch, and in 4 cases, the pedicle was switched to the superficial inferior epigastric artery. In 8 cases, the arterial pedicle lengthen technique was applied with a maximum length of 10 cm. All donor sites were closed directly. Conclusion These surgical strategies simplified the intraoperative decision-making and conquered the shortcomings of the SCIP flap. It is believed that the SCIP flap can possibly become the new workhorse flap in the field of reconstructive surgery. Key words: Superficial circumflex iliac artery perforator flap; Computed tomographic angiography(CTA); Color Doppler sonography ultrasound(CDU); Preoperative radiology navigation

Effects of ultrathin abdomen flap on repairing deep electric burn wounds in finger of pediatric patients

Objective: To investigate the effects of ultrathin abdomen flap in repairing deep electric burn wounds in finger of pediatric patients. Methods: A total of 14 pediatric patients with simple electric burns in finger were admitted to our unit from March 2013 to October 2017. Six patients had electric burns in one finger, 5 patients had electric burns in two fingers, and 3 patients had electric burns in three fingers. The size of wounds in single finger ranged from 2.0 cm×1.0 cm to 3.5 cm×2.0 cm. After complete preoperative examination, wounds debridement and ultrathin abdomen flap repair operation were performed on 3 to 6 days post injury. Six pediatric patients were treated with abdominal random flap, 4 patients were treated with inferior epigastric artery paraumbilical perforator bilobed flap, and the other 4 patients were treated with superficial circumflex iliac artery bilobed flap. The size of flaps ranged from 4.0 cm×2.0 cm to 8.0 cm×4.0 cm. The donor sites were sutured directly. Results: The flaps of 14 pediatric patients survived well after operation, and no flap showed blood supplying disorder. During follow-up of 3 to 24 months, the appearance and function of fingers were good, and the donor sites recovered well, with no cicatrix contracture deformity. Conclusions: The ultrathin abdomen flap is one of the good choices for repairing deep electric burn wounds in finger of pediatric patients.

Elevation Technique for Medial Branch based Superficial Circumflex Iliac Artery Perforator flap.

According to early studies on the superficial circumflex iliac artery perforator flap, there are two major types of perforators that are presumed to originate from the superficial circumflex iliac artery: the medial perforator with a direct cutaneous vessel (superficial branch) - located relatively medially on the flap, and the lateral perforator, traveling laterally beneath the deep fascia and often with an intramuscular pathway penetrating the deep fascia on the lateral aspect (deep branch) of the flap. Although there are well described studies on the anatomy of the arterial vasculature, design and elevation of the flap are different issues, as there are always some potential for anatomical variations, such as pedicle anatomy, location of lymph nodes, and thickness of superficial fascia. The presence of internal pudendal artery and superficial inferior epigastric artery in the groin may add to the confusion. One should also beware of the presence of major lymphatics which are drained into the superficial venous system. Therefore this paper will try to simplify the elevation technique based on the medial perforator. However, one must always be ready to identify a good perforator and to elevate it as a freestyle approach to overcome the variations wherever the perforator may originate from. The best way to feel comfortable using any flap is from practice and repetitive elevation. The same is for the medial branch based SCIP flap. The direct cutaneous nature of the pedicle will make the dissection even easier as the dissection course bypasses muscle and lymph nodes. This technical note describes practical surgical tips for elevating the medial perforator based SCIP flap.

Anatomical Understanding of Target Subcutaneous Tissue Layer for Thinning Procedures in Thoracodorsal Artery Perforator, Superficial Circumflex Iliac Artery Perforator, and Anterolateral Thigh Perforator Flaps.

Thinned perforator flaps, reported techniques, and degree of thinning differ by study. This study investigated the anatomy of subcutaneous tissue according to the varying fattiness and identified which component and how much of the subcutaneous tissue layer needed to be excluded to meet target flap thickness using computed tomography. Three stratified fattiness groups consisting of 30 donors were formed for thoracodorsal artery perforator, superficial circumflex iliac artery perforator, and anterolateral thigh flaps. Thickness of the superficial fat and the deep fat layers was measured at specific points in donor sites of the three flaps and the proportion of superficial and deep fat layers to exclude to reach the target flap thickness (4, 6, and 8 mm) was calculated. The median proportion for the superficial fat layer varies depending on donor fattiness. The estimated percentage reduction of thickness after thin flap elevation along superficial fascia was approximately one-third of the whole layer. A variable proportion of each fat layer needs to be excluded to obtain required thinness and in very thick groups, part of the superficial fat layer must be removed to reach any of the target thicknesses for the three flaps. The present study demonstrated the frequent need for superficial fat layer manipulation when obtaining a thin perforator flap. To cope with various combinations of donor-site fattiness and different required thicknesses effectively, an appropriate thinning method should have increased adaptability, including the ability to control superficial fat layer thickness.

Thin elevation: A technique for achieving thin perforator flaps.

Elevating thin flaps has long been a goal of reconstructive surgeons. Thin flaps have numerous advantages in reconstruction. In this study, we present a surgical method for elevating a thin flap and demonstrate the safety of the procedure. A retrospective review was performed of the electronic medical records of patients who underwent thin flap elevation for lower extremity reconstruction from April 2016 to September 2016 at the Department of Plastic Surgery of Asan Medical Center. All flaps included in this study were elevated above the superficial fascia. A total of 15 superficial circumflex iliac artery free flaps and 13 anterolateral thigh free flaps were enrolled in the study. The total complication rate was 17.56% (n=5), with total loss of the flap in one patient (3.57%) and partial necrosis of the flap in four patients (14.28%). No wound dehiscence or graft loss at the donor wound took place. Elevation above the superficial fascia is not inferior in terms of flap necrosis risk and is superior for reducing donor site morbidity. In addition to its safety, it yields good aesthetic results.

Abstract 11.05 THE MICROVASCULAR “TUBE- IN- TUBE” CONCEPT FOR PENILE CONSTRUCTION IN FEMALE TO MALE TRANSSEXUALS

INTRODUCTION: In most female-to-male transsexual patients the construction of an aesthetic and functional neo-phallus after penile amputation represents the terminal step in a series of invasive and non-invasive procedures. For this surgery, a lot of different techniques have been described. Among these microsurgical free-flap phalloplasties remain the most popular method in clinical routine. For many years, the radial forearm free flap has been considered to be the best procedure. With the aim to reduce donor site morbidity and to optimize functional outcome many other flaps have been developed. Therefore, pedicled flaps have shown to be reliable and to decrease the risk of total failure. RESULTS: We describe a new “tube- in tube” technique combining either a pedicled SCIP (Superficial circumflex iliac artery perforator) flap or a free RFF (radial forearm) flap with an ALT (Anterolateral thigh flap) free flap. By using the SCIP/ radialis flap as part mobile of the Urethra the inner tube is formed. The ALT flap builds the outer tube. By presenting cases of this technique, first experiences, outcome and the most occurring complications should be showed. CONCLUSION: By combining the reliability of pedicled flaps with the benefits in aesthetic outcome of free flaps, this new “tube- in- tube” technique represents a method to reduce complete flap failure by simultaneously decrease complication rate.

Superficial Circumflex Iliac Artery-Based Iliac Bone Flap Transfer for Reconstruction of Bony Defects.

The superficial circumflex iliac artery (SCIA)-based iliac bone flap has yet to be widely used. The purpose of this article is to validate the feasibility of SCIA-based iliac bone flap transfers for reconstruction of small to moderate-sized bony defects. Retrospective outcome comparisons between SCIA-based iliac bone flaps and fibula flaps were made. Twenty-six patients with bony tissue defects underwent reconstructions using either free SCIA-based iliac bone flaps (13) or fibula flaps (13). Outcomes were evaluated 9 months after the reconstruction on the following basis: bone length, pedicle length, skin paddle area, bone union, donor-site complications, skin paddle survival, and complications at the reconstructed site. There was no statistically significant difference in pedicle length (iliac bone vs. fibula; 5.5 ± 1.8 vs. 4.1 ± 1.5 cm; p = 0.181), in bone union rate (iliac bone vs. fibula; 100 vs 92.3%; p = 0.308), in donor-site complication rate (iliac bone vs. fibula; 0 vs. 7.7%; p = 0.308), or in skin paddle complete survival rate (iliac bone vs. fibula; 100 vs. 83.3%; p = 0.125). Statistically significant differences were observed in bone flap length (iliac bone vs. fibula; 4.8 ± 2.2 vs. 11.1 ± 4.8 cm; p = 0.0005), in skin paddle area (superficial circumflex iliac artery perforator flap vs. peroneal artery perforator flap; 58.8 ± 35.6 vs. 27.7 ± 17.5 cm2; p = 0.0343), and in reconstructed site complication rate (iliac bone vs. fibula; 0 vs. 30.8%; p = 0.030). In our series of SCIA-based iliac bone flap transfers, up to 8 × 3 cm could be procured along the iliac crest. When compared with fibula flap transfers, there were no significant statistical differences in pedicle length or in bone union rate; the SCIA-based iliac bone flap may be a feasible option for bony defects of small to moderate size.

Ultrasonographical identification of the superficial circumflex iliac artery as a landmark for location of the femoral nerve in dogs

ObjectiveTo investigate the utility of identifying the superficial circumflex iliac artery (SCIA) via ultrasound as an anatomical landmark for ultrasound-guided femoral nerve block. Study designObservational study. AnimalsA group of six canine cadavers weighing >20 kg. MethodsPelvic limbs from six canine cadavers were examined to study the relationship between the SCIA and the femoral nerve. Ultrasonographic imaging of the SCIA in each limb was obtained with the transducer placed transversely in the medial aspect of the pelvic limb at the inguinal area. Subsequently, a needle was inserted in close proximity to the femoral nerve using an in-plane technique based on the anatomical relationship between the SCIA and femoral nerve. A total of 0.1 mL of colored latex was then injected at the location where the femoral nerve was expected to be in relationship to the SCIA. Gross dissection of the inguinal region in each pelvic limb was performed after injection. Positive nerve location was defined when the colored latex was in contact with the femoral nerve. ResultsA total of eleven pelvic limbs were injected because the SCIA could not be successfully visualized in one limb. Upon dissection, colored latex was found to be in direct contact with the femoral nerve in all 11 injected limbs. Conclusions and clinical relevanceWe concluded that the ultrasonographic visualization of the SCIA assisted in the accurate deposition of dye in proximity to the femoral nerve of canine cadavers. Further investigation will determine the efficacy of this technique for performing femoral nerve blocks.

Application of free superficial circumflex iliac artery perforator flap with end to side anastomosis for repair of hand skin and soft tissue defects

Objective To explore the clinical effects of free superficial circumflex iliac artery perforator flap with end to side anastomosis in the treatment of hand skin and soft tissue defects. Methods From January 2012 to December 2016, 26 cases of hand skin and soft tissue defects were treated by the transplantation of free superficial circumflex iliac artery perforator flap. The area of flap ranged from 5.0 cm×8.0 cm to 9.0 cm×20.0 cm. The superficial iliac circumflex artery and its accompanying vein were anastomosed to the ulnar artery or radial artery and its accompanying vein respectively by end-to-side suture technique. The superficial iliac circumflex vein was anastomosed with the cephalic vein or subcutaneous superficial vein by end-to-end suture technique. Results Postoperatively all the flaps survived uneventfully. The follow-up time was 3 to 18 months, with an average of 11 months. The texture of flap was soft with good blood supply. The fingers of injured limb were warm. Conclusion Free superficial circumflex iliac artery perforator flap with end to side anastomosis is an ideal method for repair of hand skin and soft tissue defects, which not only retains the main vessel of recipient area, but also solves the mismatching of the caliber of the flap pedicle vessel and recipient vessel. The flap transplantation is no longer limited by the caliber of donor and recipient vessels, and has high patency rate and low operation risk. Key words: Surgical flaps; Hand injuries; Superficial circumflex iliac artery; End-to-side anastomosis

Ilioinguinal conjoined perforator flap transplantation for repairing large skin defects of the upper extremity

Objective To evaluate the clinical efficacy of ilioinguinal conjoined perforator flap transplantation pedicled with the superficial circumflex iliac artery, the anterior fourth lumbar artery or the posterior intercostal artery. Methods Between April, 2005 to August, 2015, 6 patients diagnosed as large skin defects in the upper extremity were treated with ilioinguinal conjoined perforator flap transplantation pedicled with the superficial circumflex iliac artery, the anterior fourth lumbar artery or the posterior intercostal artery. The proximal flap blood supply was offered by the superficial circumflex iliac artery, and the distal flap blood supply was provided by the anterior fourth lumbar artery or the posterior intercostal artery. The maximal size of the flap was measured as 35.0 cm×15.0 cm, and the minimal size was 25.0 cm×9.0 cm. The donor sites of the flap were directly sutured. All cases were implemented by postoperative follow-up visit in hospital for observation of appearance, texture, functions and donor site of flaps. Results Postoperatively, all flaps survived. The follow-up time endured for 6 to 24 months. The flap thickness was appropriate with normal shape and soft texture. Protective sensation and perspiration function of the flap were restored. Linear scars alone were observed in the donor sites of the flap. Conclusion Ilioinguinal conjoined perforator flap transplantation pedicled with the superficial circumflex iliac artery, the anterior fourth lumbar artery or the posterior intercostal artery can extend the excision scope of the flap and provides sufficient blood supply for the flap. The flap texture is soft and can be directly sutured. This technique is an ideal option for repairing of large soft tissue defects of the upper extremity. Key words: Perforator flap, conjoined; Superficial circumflex iliac artery; Posterior intercostal artery; Fourth lumbar artery

Suprafascial dissection of the pedicled groin flap: A safe and practical approach to flap harvest.

The groin flap has been relied upon for more than 4 decades and is well suited for reconstruction of the mutilated hand. Classic groin flap harvest is subfascial and includes the superficial circumflex iliac artery (SCIA). SCIA perforator flaps have shown that one perforator is sufficient to supply a large flap without breaching fascia. Accordingly, we routinely preserve the fascia and rely wholly on the superficial branch of the SCIA, sparing the deep branch. We aim to investigate the safety of suprafascial flap elevation and encourage a paradigm shift in reconstruction with groin flap transfer. Between 2008 and 2013, 77 hand injuries were treated with pedicled groin flap transfers. According to surgeons' preference, 49 flaps were elevated with conventional technique ("subfascial") and 28 were harvested with suprafascial approach ("fascia sparing"). Demographic data including flap size, operative time, and outcome were reviewed in both approaches and compared. Suprafascial flaps were taken as large as 32 × 12 cm2 and subfascial flaps large as 30 × 10 cm2 (p = 0.08). Operative time was 268.2 ± 104.7 minutes in the suprafascial group and 227.4 ± 89.0 in the subfascial group (p = 0.14). One suprafascial flap (3.6%) had partial necrosis compared to four subfascial flaps (8.2%) (p = 0.65). All patients were followed for a minimum of six months. All the wounds finally healed without further flap reconstruction, and all the patients were back to the normal life with activities. Suprafascial dissection is safe and does not adversely influence outcomes. Thinner flaps are expected to facilitate flap insetting and reduce revisionary debulking surgery. III (Therapeutic).

Anatomy of superficial inferior epigastric vessels: revival of superficial inferior epigastric (SIEA) flap

Development of perforator flaps evolves the perspective of reconstructive surgery to another level due to many of their advantages over the pedicled flaps, particularly lower donor-site morbidity and versatility in flap design. Superficial inferior epigastric artery (SIEA) flap offers this significant advantage over other lower abdominal flaps, as dissection of the rectus abdominis muscle is not required. However, both vascular agenesis and inappropriate vessel size for anastomosis are the major limitations. This study was therefore aimed to investigate these aspects of this flap. Twenty cadavers were dissected bilaterally to demonstrate vascular anatomy of these vessels. The SIEA of each cadaver was dissected and traced from the origin (femoral arteries) to their presence in the subcutaneous layer. Originating patterns of these vessels, whether sharing a common trunk with other vessels such as superficial circumflex iliac (SCI) or superficial external pudendal (SEP) arteries, was determined and their diameters measured. SIEA agenesis rate was found to be 7.5% (3/40). The diameters greater than 1 and 1.5 mm were found in 86% (32/37) and 30% (11/37), respectively. The distance between its origin and point of entering Scarpa’s fascia varies from 10.29 to 62.62 mm (mean 37.48 mm). As opposed to the artery, the superficial inferior epigastric vein was found to be present in all dissections with a diameter ranging from 2.12 to 5 mm (mean 3.09 mm) and the distance, as measured in SIEA, ranging from 20.1 to 74.28 mm (mean 41.24 mm). SIEA usually crosses the inguinal ligament within area between mid-inguinal point and 3 cm medially. Correlations were found (1) between SIEA diameter and pedicle length and (2) between bilateral pedicle lengths of both artery and vein. The high prevalence of both SIEA presence and appropriate diameter for anastomosis, and thus flap success, makes the SIEA perforator flap an appropriate option for reconstructive treatment. Level of Evidence: not ratable.

Radiological anatomy of the perforators of the gluteal region: The "radiosome" based anatomy.

The superior (SGA) and the inferior gluteal artery (IGA) perforator flaps are widely used in pressure-sore repair and in breast reconstruction. The aim was to exhaustively depict the topographical anatomy of the whole system of perforators in the buttock. Eighty lower-extremity computed tomographic angiography (CTA) of patients (20 males/20 females, mean age 61-years old, range 38-81) were considered. The source artery, location, type, and caliber of gluteal perforators were analyzed. The location of perforators was reproduced using a standardized two-dimensional grid on the coronal plane, centered onto defined bone landmarks. We defined "radiosome" the cutaneous vascular territory of a source artery inferred through the representation of its whole perforator system at the exit point through the deep fascia. A mean number of 25.6 ± 5.7 perforators in the gluteal region was observed, distributed as follows: 11.6 ± 4.8(45.2%) from SGA; 7.9 ± 4.5(30.8%) from IGA; 1.5 ± 0.8(5.8%) from fifth lumbar artery; 1.2 ± 0.8(4.7%) from internal pudendal artery; 1.2 ± 1(4.8%) from lateral circumflex femoral artery; 0.3 ± 0.7(1.2%) from circumflex iliac superficial artery. At least one large (internal diameter > 1 mm) SGA septocutaneous perforator was present in 77.5% of patients. The gluteal region is vascularized by perforators of multiple source arteries. Septocutaneous perforators of SGA and IGA were planned along a curve drawn from the posterior-superior border of the iliac crest to the greater trochanter. The lumbar artery perforators are clustered over the apex of the iliac crest; the internal pudendal artery perforators are clustered medially to the ischiatic tuberosity. Contributions can also come from the sacral and superficial circumflex iliac arteries.

Versatility of Free Cutaneous Flaps for Upper Extremity Soft Tissue Reconstruction

The goals of upper extremity soft tissue reconstruction should go well beyond providing coverage and restoring function. As the field of reconstructive microsurgery has evolved, free cutaneous flaps (FCFs) are gaining wider application. The advantages of FCF include minimizing donor-site morbidity by preserving the muscle and fascia, improving versatility of flap design, and superior aesthetic results. This review highlights the application of anterolateral thigh, superficial circumflex iliac artery, deep inferior epigastric perforator, superficial inferior epigastric artery, and flow-through flaps for reconstruction of upper extremity defects. These flaps share several qualities in common: well-concealed donor sites, preservation of major arteries responsible of providing inflow to distal extremity, and potential for a two-team approach (donor and recipient sites). While the choice of flaps should be decided based on individual patient and defect characteristics, FCF should be considered as excellent options to achieve the goals of upper extremity reconstruction.

Repairing donor site of foot after improved toe-to-thumb reconstruction utilizing superficial circumflex iliac ar-tery perforator chimeric flap

Objective To evaluate the clinical outcome of the method of repairing donor site of foot after im-proved toe-to-thumb reconstruction utilizing superficial circumflex iliac artery perforator (SCIAP) chimeric flap. Meth-ods Fourteen cases of thumb defect were recruited from April, 2012 to January, 2016. According to Gu Yudong’s clas-sification, 5 cases met the criterion of type I, 4 cases met the criterion of type II, and 5 cases met the criterion of type III. For type I, the thumb was reconstructed with the great toe wrap-around flap. For type II and III, the thumb was recon-structed by the combined tissue with mutual artery (great toe wrap-around flap, and the bone-tendon tissue of the sec-ond toe). All the donor sites of foot were repaired utilizing SCIAP chimeric flap. Results All the reconstructed thumbs survived. Among 14 free flaps of donor site, 1 case suffered venous crisis and survived after exploration and rescue sur-gery. Dorsal skin necrosis of the second toe was found in 1 case, which was healed by local skin flap transposition. All pa-tients were followed-up ranged from 3 to 30 months (averaged at 16 months). In spite of slightly bloated, the color and texture of all the flaps’was satisfied, and the average healing time of the bone in the donor sites was 2.5 months. All pa-tients did not feel painful and had no adverse effect when walking and running. Three months after the operation, 5 slight-ly bloated flaps in the donor sites under went flap plastic and achieved better appearance. On the part of iliaca, there was only one inconspicuous linear scar without any discomfort. Conclusion Repairing donor site of foot after improved toe-to-thumb reconstruction utilizing SCIAP chimeric flap was an ideal method. Using this method, the reconstructed thumb can achieve good appearance and function, all the toes of donor site were reserved, and the disability of the donor site is minimized. Key words: Superficial circumflex iliac artery; Chimeric flap, perforator flap; Tissue transplantation; Thumb reconstruction; Donor site; Microsurgical technique