Circumflex Scapular Artery Perforator Research Articles

Revisiting the pedicled circumflex scapular artery (pCSA) perforator flap: From simple to complex locoregional reconstructions

Soft tissue defects involving the axilla and the upper back region are often complex to treat. The complexity of these defects may be extremely different, ranging from superficial skin damage to large loss of substance with lymphatic drainage impairment. The pedicled circumflex scapular artery (pCSA) perforator flap represents a valid procedure in this setting. It can be tailored according to the patient's needs, and its intraseptal pedicle allows a quick dissection with a wide range of motion. Twenty-four consecutive patients treated by means of pCSA perforator flap were included. All the flaps were pedicled and were used for locoregional reconstructions. The etiology of the defects was an oncologic resection in 15 cases, acne/hidradenitis suppurativa resection in 6 cases, lymphatic complication in 2 cases, and burn in 1 case. Patients' mean age was 61 years old; seventeen were males and seven were females. All the patients were successfully treated with good aesthetic and functional results. One patient presented with a wound dehiscence, which required secondary surgical treatment. No partial or complete flap losses were encountered. Primary closure of the donor site was achieved in all cases. The mean follow-up period was 10.5 months (range 6-12). This case series shows the reliability and versatility of the pCSA perforator flap for locoregional reconstructions. Because of its rich vascularisation, extensive or unconventionally-shaped flaps are possible. Moreover, its lymphatic rich tissues make it suitable for the treatment of complications related to axillary lymphadenectomy.

Anatomic Study and Clinic Application of Transverse Circumflex Scapular Artery Perforator Flap Repair of Lower Limb Soft Tissue Defects in Children.

The aim of this study was to demonstrate the viability of the transverse circumflex scapular artery perforator flap (TCSAPF) in children with soft tissue defects of the lower limb. In an anatomic study, 25 fresh cadavers were injected with lead oxide-gelatin for spiral computed tomography and 3-dimensional image reconstruction. In a 3-year clinical application study, children with soft tissue defects and exposed tendons and/or bones in the lower limb underwent free-TCSAPF repair of the defect. Perforators from the transverse branch of the circumflex scapular artery were identified in both anatomical and clinical studies. The average external diameter was 0.9 ± 0.3 mm. Each perforator supplied an average area of 63.5 ± 16.8 cm in anatomical. Twenty-one children were included in this group (9 boys, 12 girls, mean age, 6.6 ± 2.7 years). The size of the flaps ranged from 6 to 17 cm × 4.5 to 7 cm (average, 65.3 ± 22.6 cm). The average flap harvesting time was 30.1 ± 8.5 minutes, average operation time was 138.6 ± 31.5 minutes, and average blood loss was 89.5 ± 21.9 mL. The average length of the vessel pedicle was 8.2 ± 2.4 cm. Arterial congestion occurred in one child, 18 hours postoperatively; subsequent re-exploration and great saphenous vein transplantation were successful. Of the 3 children who had bulky flaps, 1 patient underwent defatting. Satisfactory outcomes included good appearance and function of the recipient and donor areas. The TCSAPF provides high-quality skin and vessel flexibility, providing a reliable blood supply in children. The flap has potential benefits over existing perforator flaps.

Effects of free transplantation of expanded perforator flaps in the treatment of severe scar contracture deformities in children

Objective: To explore the effects of using free transplantation of expanded perforator flaps in the treatment of severe scar contracture deformities in children. Methods: From January 2010 to December 2018, 18 pediatric patients with severe scar contracture were admitted to Xijing Hospital of Air Force Medical University, and 3 pediatric patients with severe scar contracture were admitted to Shenzhen Hospital, Southern Medical University. There were 14 males and 7 females among the 21 pediatric patients, who were 3-12 years old, with 15 cases of cervicothoracic adhesion, 5 cases of chin-chest adhesion, and 1 case of ankle joint contracture. According to the location of scar contracture and the size of wound after release, the donor site of perforator flap and expander volume were selected, and the expander was inserted to expand the flap. After expanding to proper volume, the contracted scar was resected and released. The perforator flap was designed and transplanted freely according to the wound. The flap area ranged from 14 cm×6 cm to 18 cm×15 cm. The location of the expanded flaps, the number, location, rated volume, and the location of injection port of the inserted expanders, the survival condition of flaps, the complications, the repair of donor sites, and the follow-ups were analyzed. Results: Among this group of pediatric patients, 16 cases used expanded thoracodorsal artery perforator flap, 3 cases used expanded circumflex scapular artery perforator flap, and 2 cases used expanded anterolateral thigh perforator flap, with 14 cases of pure donor site expansion and 7 cases of donor site expansion together with expansion beside donor site. Thirty-four expanders were inserted in 21 pediatric patients, with 21 under flaps, 6 near scars, and 7 near donor sites. The rated volumes of 26 expanders were 200 mL, while those of the remaining 8 expanders were 400 mL. Eight injection ports were placed externally, while the rest were placed internally. All the 21 flaps survived completely. Vascular crisis occurred in 1 pediatric patient 5 days after operation, and exploratory operation and reanastomosis were performed. The donor sites of 19 pediatric patients were closed directly, while the small wounds in lateral thoracic donor sites of 2 pediatric patients were repaired with thin intermediate split-thickness skin graft collected beside the donor site. Follow-up for 6 to 36 months showed that the texture and color of area repaired by the flaps were close to the surrounding skin. The flaps in the neck region of 8 pediatric patients were slightly bulky, requiring debulking operation, while the other cases had good appearance. The movement function of the involved regions was basically restored to normal, and no recurrence of contracture occurred. Conclusions: Free transplantation of expanded perforator flaps can achieve favorable appearance, texture, and function restore in treating severe scar contracture deformities in children, and the curative effect is stable and lasts long.

Reconstruction of moderate-sized soft tissue defects in foot and ankle in children: Free deep inferior epigastric artery perforator flap versus circumflex scapular artery perforator flap

This retrospective study was conducted to compare the outcomes between the free deep inferior epigastric artery perforator (DIEP) flap and the circumflex scapular artery perforator (CSAP) flap in reconstruction of moderate-sized soft tissue defects in the foot and ankle of pediatric patients. From January 2004 to December 2016, 42 patients, ranging from 2 to 13 years old, underwent foot and ankle reconstruction, with a free DIEP flap in 21 cases and a free CSAP flap in the other 21cases. All the flaps survived. No marked differences were observed in the demographics, flap size, recipient vessels, and overall early or late complication rate (p>0.05). The CSAP group had a shorter operation time (134.3 ± 25 min vs. 202.4 ± 24.3 min, p<0.05) and flap harvest time (29.7 ± 8.1 min vs. 52.2 ± 9.8 min, p<0.05) than the DIEP group had. In long-term follow-up, the CSAP group showed a lower fat hyperplasia rate (14% vs. 52%, p<0.05) and better cosmetic outcomes than the DIEP group did (p<0.05). The functional outcomes had no marked differences (p>0.05). The DIEP flap and the CSAP flap are both good options for foot and ankle reconstruction of moderate-sized defects in pediatric patients. The CSAP flap has a shorter operation time and flap harvest time, a lower fat hyperplasia rate, and better long-term cosmetic outcomes than the DIEP flap does.

A Design for the Dual Skin Paddle Circumflex Scapular Artery Perforator Flap for the Reconstruction of Complex Soft-Tissue Defects in Children

The main drawbacks of the use of the circumflex scapular artery perforator (CSAP) flap for complex soft-tissue defect repair are the limitation of skin paddle size, which can be harvested to allow precise wound coverage and primary closure of the donor site. We developed a variant of the dual skin paddle CSAP flap to extend its applications and minimize donor-site morbidity when reconstructing complex soft-tissue defects in children. A detailed anatomical investigation of circumflex scapular artery (CSA) branches was conducted using a standardized injection of lead oxide in 25 fresh cadavers. Dual skin paddle CSAP flaps were harvested for the reconstruction of complex defects in the extremities in 16 children. Three types of dual skin paddle CSAP flap were used in this study: transverse chain-shaped, oblique chain-shaped, and trefoil-shaped flaps. Three CSA branching patterns with superior branch diameters were observed: 34% of CSAs were of the transverse branch dominant type, 54% were of the descending branch dominant type, and 12% were of the codominant type. Sixteen dual skin paddle CSAP flaps were elevated successfully; they were of the transverse chain-shaped type in 2 cases, the oblique chain-shaped type in 9 cases, and the trefoil-shaped type in 5 cases. All flaps survived postoperatively. Primary closure of the donor site was achieved in all cases. The CSA system is an appropriate source for harvesting dual skin paddle CASP flap. Use of this flap for the reconstruction of complex soft-tissue defects in the extremities in children is an alternative approach that reduces morbidity and improves the cosmetic outcome at the donor site.

Classification of massive postburn scars on neck and the reconstruction strategy using pre-expanded perforator flaps from the back

To explore the classification of massive postburn scars on neck and the reconstruction strategy using pre-expanded perforator flaps from the back. Thirty-seven patients with massive postburn scars on neck were admitted from January 2010 to December 2014 and treated by our treatment group. The massive postburn scars on neck were categorized into three types according to their size and location. Based on the principles of reconstructive ladder, matching in color and texture between donor site skin and neck skin, large size and thinner thickness of tissue of donor site skin, donor-recipient sites balance, and dominant supplying vessel, we proposed the following treatment strategy for choosing perforator flaps from the back. (1) In view of central cervical scar involving the central area (mainly in this area) and one side of peripheral zone, the free circumflex scapular artery perforator flap was chosen. (2) In view of peripheral cervical scar involving the central area and one side of peripheral zone (mainly in this area), the pedicled superficial cervical artery perforator flap was the first choice. In case the pedicled superficial cervical artery perforator flap was unavailable because of the absence of superficial cervical artery perforator or scarring within its vascular territory, the pedicled occipital artery perforator flap, pedicled dorsal scapular artery perforator flap, and free circumflex scapular artery perforator flap were chosen as alternative options considering specific condition. (3) In view of total cervical scar involving the central area and both sides of peripheral zone, the circumflex scapular artery perforator supercharged pedicled superficial cervical artery perforator flap was chosen. Tissue expansion was performed in the first stage for all the patients. In the second stage, after excision of the cervical scars, the flaps were transferred to cover the wounds. Among the 37 patients, 7 were with central cervical scar, 12 with total cervical scar, and 18 with peripheral cervical scar. Among patients with peripheral cervical scar, the pedicled superficial cervical artery perforator flaps were used in 11 cases, pedicled occipital artery perforator flaps in 2 cases, pedicled dorsal scapular artery perforator flap in 1 case, and free circumflex scapular artery perforator flaps in 4 cases. Tip necrosis occurred in 3 flaps of patients after surgery, which were healed by dressing change. The other flaps of patients grew well after surgery. Patients were followed up for 1 to 6 years, and all patients were able to extend neck beyond 110° with no sense of restricted neck flexion or rotation. No contracture of flap was observed. Thirty-five patients were satisfied with their appearance after surgery. Pre-expanded perforator flaps from the back are useful flaps for reconstruction of massive postburn scar on neck. Free circumflex scapular artery perforator flap is recommended for reconstruction of central cervical scar. Pedicled superficial cervical artery perforator flap is the first option for reconstruction of peripheral cervical scar, while the pedicled occipital artery perforator flap, pedicled dorsal scapular artery perforator flap and free circumflex scapular artery perforator flap are alternative options. For total cervical scar, the circumflex scapular artery perforator supercharged pedicled superficial cervical artery perforator flap is recommended.

Preexpanded Perforator Flaps of the Dorsolateral Trunk in Pediatric Patients

Contractures and broad scars of the axilla, anterior chest wall, and neck have detrimental effects on functional, physical, and psychological development of children. Perforator flaps have already been shown to be reliable options for the reconstruction of contractures, but there have been no reports demonstrating the value of preexpanded perforator flaps of the dorsolateral trunk region in the treatment of extensive contractures and scars of pediatric patients. The purpose of this study was to demonstrate these techniques by a case series formed of pediatric patients with broad scars and contractures of the anterior chest wall, axilla, neck, and breasts. Seven pediatric patients (mean age, 11.6 years) who were treated by preexpanded perforator flaps are presented. By this means, clinical experience regarding the intercostal artery perforator, thoracodorsal artery perforator, circumflex scapular artery perforator, and lumbar artery perforator flaps was shared. Flaps as large as 21 × 11 cm could be successfully transferred in pediatric patients. Broad scar tissues were resurfaced with broad flaps carrying similar characteristics with the uninjured anterior chest wall and neck skin in six of the authors' patients. In one patient with partial necrosis, a full-thickness skin graft was used for the residual defect. The mean duration of postoperative (after flap transfer) follow-up was 17.2 months. The preexpanded thoracodorsal artery perforator, intercostal artery perforator, and circumflex scapular artery perforator flaps are useful and effective reconstructive options for the treatment of scars and contractures of the anterior chest wall, axilla, neck, and breast in pediatric patients. : Therapeutic, IV.

The Anatomic and Radiologic Basis of the Circumflex Scapular Artery Perforator Flap

Microsurgical development has recently focused upon the perforator paradigm and primary thinning. Existing perforator flaps may require intramuscular dissection or lack reliable surface markings, whereas traditional scapular/parascapular flaps have low donor morbidity and reliable anatomy, but can be excessively bulky. Clinical application of a new flap based on a perforator from the circumflex scapular axis (CSA) has recently been published, but the vessel's anatomy has not been adequately characterized. The CSA was dissected in 115 sites in 69 cadavers. The number, external vessel diameter, and site of origin of perforators were measured relative to the CSA bifurcation. Color Doppler ultrasound was used to delineate the CSA and its perforators bilaterally in 40 volunteers. The number, origin relative to CSA bifurcation, diameter, length, and flow velocity of cutaneous perforators were determined. A CSA perforator was always present, running into the subdermal plexus, arising within 2.4 cm of the bifurcation. Cadaver studies: mean perforator diameter, 1.3 mm (SD, 0.66); 13% arose at bifurcation, 36% arose proximal (mean, 1.1 mm; SD, 0.63), and 52% distal to bifurcation (mean, 1.5 mm; SD, 0.88). Ultrasound: mean perforator diameter, 1.18 mm (SD, 0.41); mean flow velocity, 16.3 cm/s (SD, 3.65); perforator arose in 36% proximal, in 40% distal to bifurcation, and in 24% from the bifurcation. We definitively describe the anatomy of the perforator from the circumflex scapular artery upon which a new flap has been based. Its origin and dimensions are anatomically and radiologically reliable. The flap has certain potential benefits over existing perforator flaps.

The thin circumflex scapular artery perforator flap

The development of microsurgery has most recently been focused upon the evolution of perforator flaps, with the aim of minimising donor site morbidity, and avoiding the transfer of functionally unnecessary tissues. The vascular basis of perforator flaps also facilitates radical primary thinning prior to flap transfer, when appropriate. Based upon initial clinical observations, cadaveric, and radiological studies, we describe a new, thin, perforator flap based upon the circumflex scapular artery (CSA). A perforator vessel was found to arise within 1.5cm of the CSA bifurcation (arising from the main trunk, or the descending branch). The perforator arborises into the sub-dermal vascular plexus of the dorsal scapular skin, permitting the elevation and primary thinning of a skin flap. This thin flap has been employed in a series of five clinical cases to reconstruct defects of the axilla (two cases of hidradenitis suppurativa; pedicled transfers), and upper limb (one sarcoma, one brachial to radial artery flowthrough revascularisation plus antecubital fossa reconstruction, and one hand reconstruction with a chimeric flap incorporating vascularised bone, fascia, and thin skin flaps; free tissue transfers). No intramuscular perforator dissection is required; pedicle length is 8-10cm and vessel diameter 2-4mm. There was no significant peri-operative complication or flap failure, all donor sites were closed primarily, patient satisfaction was high, and initial reconstructive aims were achieved in all cases. Surgical technique, and the vascular basis of the flap are described. The thin circumflex scapular artery perforator flap requires no intramuscular dissection yet provides high quality skin (whose characteristics can be varied by orientation of the skin paddle), and multiple chimeric options. The donor site is relatively hair-free, has favourable cosmesis and no known functional morbidity. This flap represents a promising addition to the existing range of perforator flaps.