Cutaneous Perforators Research Articles

Anatomical basis of a proximal fasciocutaneous extension of the distal-based posterior interosseous flap that allows exclusion of the proximal posterior interosseous artery

The objective of this study was to provide anatomical information for the repair of small tissue defects in the hand with posterior interosseous artery chain-link perforator flaps, a proximal fasciocutaneous extension of the distal-based posterior interosseous flap, which allows the exclusion of the proximal posterior interosseous artery. Fourteen posterior interosseous artery chain-link perforator flaps taken from human cadavers were studied by the following three methods: latex perfusion for microanatomy analysis, denture material and vinyl chloride mixed packing for cast analysis, and latex perfusion for the production of clearance specimens. Statistical analysis was performed on cutaneous perforators coming from the intermuscular septum of the extensor carpi ulnaris and the extensor digitorum communis. A cluster analysis was conducted to determine the overall distribution of perforators. There are two main clusters of perforators at a relative distance of 21% and 48% along the ulnar head-to-lateral epicondyle interval. On average, the posterior interosseous artery extends six cutaneous perforators through the intermuscular septum of the extensor carpi ulnaris and the extensor digitorum communis. Of these six arteries, two are clinically significant perforators (0.5mm or more in diameter) and are located 6±2cm proximal to the head of the ulna and 10±1cm distal to the lateral epicondyle of the humerus. Their mean diameters are 0.5±0.1 and 0.6±0.1mm, with pedicle lengths of 16.8±5.1 and 21.2±12.3mm, respectively. At the two main clusters of perforator-intensive sites, the vessel chains formed by adjacent perforators are parallel to the intermuscular septum of the extensor carpi ulnaris and the extensor digitorum communis. This study demonstrates that the posterior interosseous artery has two main clusters of perforators in the middle and distal one-fifth of the forearm, which can be used for repairing hand defects with posterior interosseous artery chain-link perforator flaps.

Cheek mucosa territories perfused by perforators from the facial artery

The cutaneous areas perfused by the cutaneous perforators of the facial artery have been well defined. However, the oral mucosal areas perfused by perforators of the facial artery have not been described. We studied 20 hemifaces from 10 cadavers. Perforators between the branching off sites of the labial arteries larger than 0.5mm were selected and their diameters were measured; the distance between their exit point over the facial artery and the branching-off point from the superior labial artery was also measured. The selected perforators were injected with 1ml of diluted ink. Both labial arteries were ligated to limit the study to the mucosal perforators from the facial artery. Seventy-four perforators from 20 hemifaces were studied; the mean diameter was 0.58mm and the mean number per artery was 3.7. The total stained area, a triangle-shaped zone on the cheek, was determined. The more constant perforators larger than 0.5mm were localized next to the branching-off site of the superior labial artery. With this information, flaps based on the mucosal perforators from the facial artery could be designed.

Preoperative Peroneal Perforator Mapping with Dynamic Time‐Resolved Magnetic Resonance Angiography

Objectives: Dynamic time-resolved magnetic resonance angiography (DTR MRA) is a novel imaging algorithm that allows for better visualization of small-caliber vessels when compared with standard MRA. We sought to estimate the technique sensitivity when compared with intraoperative findings. Methods: Retrospective review of 25 patients undergoing reconstruction with free fibula flap at an academic tertiary setting from 2009 to 2013. Preoperative DTR MRA was performed in all cases. Two radiologists performed blind reviews of the images and their findings were compared with surgical descriptions of the perforator anatomy. Results: Surgical exploration identified 32 perforators while DTR MRA identified 45 vessels. The technique confirmed the presence of perforators in 22 out of 23 patients with at least one perforator, and their absence in 1 out of 2 patients who had a negative exploration. There was a significant correlation in the number of perforators identified clinically and radiologically in each case ( P = .005). Twenty-seven perforators were localized to their correct anatomic location by the technique, yielding a sensitivity of 84.4% and a specificity of 16.7%. Ten out of the 18 vessels incorrectly identified by this technique were located within 30 mm of a confirmed perforator. Conclusions: DTR MRA is a highly sensitive technique for determining the presence and location of cutaneous perforators in patients undergoing reconstruction with free fibula flap. The majority of the false-positive findings corresponded to vessels located within 30 mm of a confirmed perforator; we hypothesize that they could represent distal branching patterns presenting radiologically as separate entities. These results compare favorably to perforator mapping with standard MRA techniques.

The use of thermography to design tissue flaps - experimental studies on animals.

IntroductionMethods allowing one to locate the position of a cutaneous perforator do not allow one to determine the boundaries of the vascularized skin. In clinical practice this causes complications in the form of marginal necrosis of the flap.AimTo examine the usefulness of thermography to assess the extent of vascularization of the skin and subcutaneous tissue by a single perforator.Material and methodsThirty-one male rats were used. Using dynamic thermography the perforators on the abdominal skin were located. Afterwards the flap was prepared on a randomly chosen perforator. After 24 h the extent of vascularization of the skin by a single perforator was examined.ResultsIn 22.5% of cases the number of perforators marked in the thermography was equal to the number of perforators marked intraoperatively, in 64.5% it was lower and in 13% higher. The use of thermography has shown that basing the flap vascularization on the perforator with low efficiency resulted in statistically more frequent occurrence of ischemia and partial necrosis of the flap (p = 0.024). Partial necrosis of the flap occurred in 12 of 31 cases, always in the area in which during the preoperative thermography no perforators were found. The areas of necrosis occurred irrespectively of the distance from the supplying vessel.ConclusionsWhen designing the shape of the flap, the distribution of all perforators must be considered. The perforators need to be included in the area of prepared tissues because their location indicates the area with a more efficient network of vessels.

Another option of perforator flap in the lateral thoracic area: lateral thoracic perforator flap.

The lateral thoracic donor site provides two types of perforator flap; the latissimus dorsi perforator flap based on the musculocutaneous perforator, and the thoracodorsal perforator flap based on the septocutaneous perforators from the thoracodorsal artery. In this article, we introduce a direct cutaneous perforator derived from the lateral thoracic artery, which provides another option for harvesting a perforator flap from the lateral thoracic region. Overall 17 patients underwent reconstructions using the lateral thoracic perforator flap for defects resulting from tumor-ablative surgery in the head and neck region, chronic osteomyelitis, and trauma or chronic wounds of the lower extremities. All flaps survived without major complications and six of the flaps were harvested in a chimeric pattern. When the latissimus dorsi and thoracodorsal perforator flaps are not suitable, the lateral thoracic perforator flap provides another option from the lateral thoracic region that is useful for a variety of reconstructions. However, anatomic variation and the shorter and smaller pedicle compared with the thoracodorsal vessels are drawbacks of the lateral thoracic perforator flap that make it difficult to approach. The combination of the versatility of the previous two perforator flaps based on the thoracodorsal system and this additional type of lateral thoracic perforator flap makes the lateral thoracic region a universal donor site.

Mucosal perforators from the facial artery

The cutaneous perforators of the facial artery have been well described, but to our knowledge the oral mucosal perforators have not. We studied 10 facial arteries from 10 hemifaces in 5 cadavers. The arteries were injected with latex, and we studied all perforators that extended from the facial artery and headed directly to the oral mucosa. The diameter and length of the facial artery and its mucosal perforators were measured and compared. We found 52 oral mucosal perforators in the 10 facial arteries injected with latex. Their mean (SD) diameter was 0.5 (0.2) mm and the mean (SD) number/facial artery was 5.2 (1.1). Their mean (SD) length was 16.4 (5.3) mm. Most of those to the cheek were localised between the branching-off points of the inferior and superior labial arteries. The facial artery has perforators to the oral mucosa of the cheek, most of them between the points at which the labial arteries emerge.

The Use of Doppler/Power Doppler Ultrasound and Angiography for the Evaluation of Cutaneous Perforators in the Thigh and Lumbar-Sacral Region in Pigs

The Use of Doppler/Power Doppler Ultrasound and Angiography for the Evaluation of Cutaneous Perforators in the Thigh and Lumbar-Sacral Region in Pigs

The Use of Doppler/Power Doppler Ultrasound and Angiography for the Evaluation of Cutaneous Perforators in the Thigh and Lumbar-Sacral Region in Pigs

Introduction: Highlighting perforating cutaneous arteries in pig, by imaging methods, is of special importance, for detecting local and regional vascular flaps with perforating pressure source, in reconstructive surgery. However there is a high degree of variability in terms of their anatomical availability.

Using the proximal perforator-based anterolateral thigh flap from the same donor site to salvage the reconstruction after failure of the distal perforator-based anterolateral thigh flap

We presented a patient who experienced the anterolateral thigh (ALT) flap failure but the reconstruction was successfully salvaged by harvesting a second ALT flap from the same donor site 2 days after the first reconstruction. A 47-year-old man received cancer ablation for right mouth floor squamous cell carcinoma. The resultant defect was planned to be reconstructed with the ALT flap. During the flap dissection, we identified three proximal cutaneous perforators originating from the transverse branch of the lateral circumflex femoral artery (t-LCFA) and two distal cutaneous perforators originating from the descending branch (d-LCFA). We harvested a skin flap based on the distal two perforators and divided the d-LCFA just distal to the bifurcation of the d-LCFA and the t-LCFA. Unfortunately, the ALT flap showed venous congestion on postoperative day 2 and eventually failed. We harvested a second ALT flap from the same donor site based on the previously preserved perforators. The recovery course was smooth thereafter. We believe that the harvest of a second ALT flap from the same donor site may be an option, to avoid other donor site violation, in some patients who experienced the first flap loss. © 2014 Wiley Periodicals, Inc. Microsurgery 34:409-412, 2014.

True and 'Choke' Anastomoses between Perforator Angiosomes

Cadaveric studies have revealed that cutaneous perforators are linked by either reduced-caliber "choke" arteries, or by vessels without change in caliber, the true anastomoses. These true anastomotic vessels are often found in parallel with the cutaneous nerves and accompanying veins, and are associated both experimentally and clinically with larger areas of flap survival. The Doppler probe and computed tomographic angiography are already used preoperatively to determine perforator locations but currently cannot reveal the type of anastomotic connections. Thermal images were taken in a previously described fashion and compared with both computed tomographic angiographic studies where available and with cadaveric angiographic studies previously performed by the authors' laboratory. Perforators larger than 1 mm were accurately localized by thermography when compared with computed tomographic angiography. Perforator angiosome rewarming closely approximated a log-based line of best fit. Interperforator zones were variable in their rewarming and correlated with known anatomical patterns of true and choke anastomoses between perforator angiosomes. Thermography now offers a new modality with which to bridge the gap not only by identifying the perforator "hot spots" but also by the robustness of their interconnections. The pattern of these interconnections seen on thermographic imaging has in turn been found to match those seen in the authors' cadaveric studies.

True and 'Choke' Anastomoses between Perforator Angiosomes

Reports of more than two cutaneous perforator angiosome territories being raised successfully in distally based sural flaps are appearing in the literature. Previous anatomical studies have noted that cutaneous arteries, connected by true anastomosis without change in caliber, frequently parallel cutaneous nerves. Twenty-four (48 sides) total body lead oxide cadaver injection studies, including seven arterial and two venous neurovascular, were examined, and the results were compared with clinical thermography in Part II. Long branches of cutaneous perforators, connected in a series by true anastomoses, paralleled at variable distances the main trunks of cutaneous nerves in the head, neck, torso, and upper and lower extremities. Specifically, in the leg, an average of 3.2 true anastomoses (range, 1 to 5) connected perforators that paralleled the sural nerve on the back of the calf; and 2.5 (range, 1 to 4) connected perforators on the medial side of the leg. These vascular freeways were paralleled by the short and long saphenous veins, respectively. True anastomoses frequently connect skin perforators that course in parallel with cutaneous nerves and veins. They provide an explanation for the long viable flaps noted in the leg, and it will be shown in Part II that they can be detected preoperatively with thermography.

Detection of Perforators Using Thermal Imaging

Perforator flaps are commonly used in reconstructive surgery and require accurate vascular anatomy navigation. Several imaging methods help surgeons, including hand-held Doppler, color Doppler ultrasound, computed tomography, and magnetic resonance angiography. A growing literature supports the efficacy of thermal imaging in identifying perforators. This study assessed the efficacy of thermal imaging and perforator anatomy in four body regions. Twenty volunteers had their abdomen, sacrum, and both anterolateral thighs assessed for cutaneous perforators using thermal imaging. Key surface landmarks were marked with black crosshairs centered on the umbilicus, superior natal cleft, and traditional anterolateral thigh flap markings. All thermal imaging-identified perforators were marked by red crosses, immediately checked with a hand-held Doppler device, and marked with blue circles if not confirmed. A color digital photograph taken of each region was analyzed. Thermal imaging identified a total of 757 "hotspots," of which 732 (97.0 percent) were confirmed by hand-held Doppler. In 40 anterolateral thighs, the mean number of perforators identified was 1.3 within 2.5 cm and 4.6 within 5 cm of traditional landmarks. In the abdomen, the mean number of perforators was 0.7 and 3.7 within 2.5 cm and 5 cm of the umbilicus, respectively. In the sacral region, there was a mean number of 0.3 and 2.3 perforators within 2.5 cm and 5 cm, respectively, of the superior natal cleft. Thermal imaging is a quick, easy method of assessing cutaneous perforators. It should be considered a useful adjunct, and further investigated, to determine its best role among the established perforator imaging methods. Diagnostic, II.

Application of Anteromedial Thigh Flap for the Reconstruction of Oral and Maxillofacial Defects

To discuss the vascular anatomy of the anteromedial thigh (AMT) flap and to evaluate the feasibility of the AMT flap for the reconstruction of oral and maxillofacial defects. A retrospective review was performed of 18 patients who underwent reconstruction of oral and maxillofacial defects with AMT flaps from January 2009 through December 2011 in the Second Xiangya Hospital. Eleven unifoliate AMT flaps were elevated to reconstruct defects of the tongue, soft palate, and floor of the mouth and 7 chimeric anterolateral thigh (ALT) and AMT flaps were harvested to reconstruct through-and-through cheek defects. The flaps were 4 × 6 to 9 × 11 cm(2). All the AMT flaps were nourished by the descending branch (DB) of the lateral circumflex femoral artery. The cutaneous perforators were derived from the rectus femoris branch of the DB in 15 cases and directly from the DB in the other 3 cases. Postoperatively, all flaps survived completely, without major complications. Of the 18 donor sites, 14 were closed directly, leaving only linear scars, and 4 were closed using full-thickness skin grafts owing to larger defects. All patients were followed for approximately 6 to 30 months, and they were satisfied with the esthetic and functional results of the donor and recipient sites after the reconstruction. Because of easy perforator dissection, the AMT flap can be used as an alternative to the ALT flap or harvested with the ALT flap as chimeric ALT and AMT flaps for the reconstruction of oral and maxillofacial defects.

A New Facial Artery Free-Style Perforator Flap and Conchal Cartilage Graft for One-Step Reconstruction of the Alar Defects

The nose is the most commonly affected area by basal and squamous skin carcinomas of the head and neck area (D'Arpa et al. J Plast Reconstr Aesthet Surg. 2009, 62:36-42). The nasolabial flap is a very well known local flap that provides excellent color and texture matches. However, its major drawback is that it requires a 2-stage procedure to restore an adequate nasal cheek groove (Karsidag et al. J Craniofac Surg. 2010;21:1887-1889). In the perforator flaps, there are numerous studies that describe flaps whose vascular supply depend on perforators from the fascial artery.We planned to harvest a perforator flap around the medial cheek area, which included one cutaneous perforator from the facial artery. Free-style facial artery perforator flaps and auricular conchal cartilage framework were performed in 9 patients who have alar defect due to malignancies.From September 2010 to December 2011, the free-style facial perforator artery flap was performed in 9 patients at the Plastic and Reconstructive Surgery Department of the Ankara Numune Training and Research Hospital, Turkey. The whole flap was used to reconstruct the whole alar unit, which includes cartilaginous tissues.Our aim is to define a one-stage reconstruction technique with a perforator-based flap. Our flap is supplied by a perforating branch of the facial artery. We develop this method because of its reliable vascularization, that is, the possibility of performing one-stage technique with sensation preservation.In conclusion, we strongly recommend one-stage reconstruction in any kind of alar region defect with this versatile facial perforator flap.

The “Chimeric” Trapezius Muscle and Fasciocutaneous Flap (Dorsal Scapular Artery Perforator Flap)

Multiple variations of the musculocutaneous trapezius flap have been described, each of which use a single composite musculocutaneous unit in their designs. The limitation of such designs is the ability to use the components in a 3-dimensional manner, with only 1 vector existing in the geometry of the musculocutaneous unit. A review of the literature was undertaken with regard to designs of the musculocutaneous trapezius flap, and we present a new technique for flap design. With identification of individual perforators to each of the muscle and fasciocutaneous portions of the trapezius flap, the 2 components can act in a chimeric fashion, able to fill both a deep and complex 3-dimensional space while covering the wound with robust skin. A range of flap designs have been described, including transverse, oblique, and vertical skin paddles accompanying the trapezius muscle. We describe a technique with which a propeller-style skin paddle based on a cutaneous perforator can be raised in any orientation with respect to the underlying muscle. In a presented case, separation of the muscular and fasciocutaneous components of the trapezius flap was able to obliterate dead space around exposed cervicothoracic spinal metalwork and obtain robust wound closure in a patient with previous radiotherapy. This concomitant use of a muscle and fasciocutaneous perforator flap based on a single perforator, a so-called chimeric perforator flap, is a useful modification to trapezius musculocutaneous flap design.

Vastus Lateralis Muscle Flaps for Monitoring Buried Anterolateral Thigh Flaps

Postoperative monitoring of buried anterolateral thigh flaps is difficult with standard methods. Although a monitoring skin flap based on a second cutaneous perforator is often used, it requires tedious dissection of 2 sets of perforators and cannot be used when a second perforator is absent. We present 2 patients who underwent head and neck reconstruction with buried anterolateral thigh flaps, which were monitored with a small, externalized segment of the vastus lateralis muscle accompanying the main skin island. Both flaps survived, and the monitoring muscle flaps remained pink throughout the postoperative period until removal. For monitoring, a vastus lateralis muscle flap has several advantages over a skin flap. This method obviates the need for dissecting a second cutaneous perforator and allows reliable monitoring regardless of the number of available cutaneous perforators. We believe this method is a versatile option for monitoring buried anterolateral thigh flaps.

Evaluation of the lower limb vasculature before free fibula flap transfer. A prospective blinded comparison between magnetic resonance angiography and digital subtraction angiography

Introduction The aim of this study was to compare magnetic resonance angiography (MRA) with digital subtraction angiography (DSA) in the preoperative assessment of crural arteries and their skin perforators prior to free fibular transfer. Patients and methods Fifteen consecutive patients, scheduled for free vascularized fibular flap transfer, were subjected to DSA as well as MRA of the crural arteries of both legs (n = 30). All DSA and MRA images were assessed randomly, blindly, and independently by two radiologists. Each of the assessors scored the degree of stenosis of various segments on a 5 point scale from 0 (occlusive) to 4 (no stenosis). The Cohen's Kappa coefficient was used to assess the agreement between DSA and MRA scores. In addition, the number of cutaneous perforators were scored and the assessors were asked if they would advise against fibula harvest and transplantation based on the images. Results A Cohen's Kappa of 0.64, indicating "substantial agreement of stenosis severity scores" was found between the two imaging techniques. The sensitivity of MRA to detect a stenosis compared with DSA was 79% (CI 95%:60-91), and a specificity of 98% (CI 95%: 97-99). In 53 out of 60 assessments, advice on suitability for transfer were equal between DSA and MRA. The median number of cutaneous perforators that perfuse the skin overlying the fibula per leg was one for DSA as well as MRA (P = 0.142).Conclusions A substantial agreement in the assessment of stenosis severity was found between DSA and MRA. The results suggest that MRA is a good alternative to DSA in the preoperative planning of free fibula flap transplantation.

Reconstruction of Extensive Lower Limb Defects with Thoracodorsal Axis Chimeric Flaps

Extensive defects of the lower extremities are usually reconstructed with microvascular free flaps because of inadequate local tissues and wound complexity. Many attempts have been made to reconstruct such defects using the chimeric flap concept, enabling flaps with larger surface areas to be used while maintaining economical tissue use. The latissimus dorsi chimeric flap is one of the most useful tools for resurfacing extensive limb defects. Twelve patients with extensive lower leg defects underwent reconstruction with latissimus dorsi chimeric flaps between January of 2008 and March of 2012. A skin flap based on the cutaneous perforators, a latissimus dorsi muscle flap based on the muscular branches, and a serratus anterior muscle flap based on the branch from the thoracodorsal artery were harvested accordingly; the flap design depended on the dimensions and characteristics of the defect. A total of 12 chimeric flaps were harvested and used, with the average surface area, including skin and muscle components, being 614 cm. The mean surface area of the skin flaps used was 355.6 cm. The mean area of the latissimus dorsi muscle flap was approximately 228 cm, and the surface areas of the three serratus anterior flaps used were 56 cm, 70 cm, and 180 cm. Flaps survived in all cases. Primary closure was used for all of the donor sites except one, and there was minimal donor-site morbidity. The authors' results show that the latissimus dorsi chimeric free flap is a useful and versatile reconstructive option for extensive defects of the lower extremities. Therapeutic, IV.

Descending Branch of the Perforating Branch of the Peroneal Artery Perforator–Based Island Flap for Reconstruction of the Lateral Malleolus with Minimal Invasion

Reconstruction of intractable ulcers on the lateral malleolus is challenging because affected patients suffer various complications. A lateral supramalleolar flap, nourished by the superficial cutaneous branch of the perforating branch of the peroneal artery, has been described as one of the most reliable methods for reconstructing this difficult region. Although the deep descending branch of the perforating branch of the peroneal artery has a tiny cutaneous perforator, a flap based on this perforator has not been described. The vascular anatomy of an island flap based on the descending branch perforator of the perforating branch of the peroneal artery was investigated using 20 cadaver legs. Distances from the lateral malleolus and the external diameters were investigated. Based on the anatomical study results, a perforator-based island flap was developed for clinical use and implemented in five cases. The anatomical study revealed the descending branch perforator diameter to be smaller than the superficial cutaneous branch diameter, and the location to be considerably closer to the lateral malleolus. All five island flaps used clinically survived without complications. A new perforator-based island flap of the descending branch of the perforating branch of the peroneal artery for reconstruction of the lateral malleolus was designed. The territory covered by the flap could be enlarged by including the adjacent angiosome area of the superficial cutaneous branch. This flap elevation technique was uncomplicated and sufficiently straightforward to be used for patients at high risk for complications with extended surgical procedures. Therapeutic, V.

Thoracoacromial Artery Perforator Flap

Concerns and criticism have been reported on the feasibility and vascular reliability of the thoracoacromial artery perforator flap because of the inconsistent size of the pectoral branch of the thoracoacromial artery and its cutaneous perforators. The authors have investigated its vascular basis through a cadaver dissection and described their clinical experience in the surgical strategy, range of application, and indications for the thoracoacromial artery perforator flap. Twelve fresh human cadavers were dissected to define the anatomy of the branches of the thoracoacromial artery and their perforators and the anatomical landmarks for clinical application. Single pectoral branch perforators were injected to measure the extension of the thoracoacromial artery perforator vascular territory. A constant thoracoacromial artery perforator was present in the septum between the clavicular and sternocostal heads of the pectoralis major muscle in 21 of 24 hemichests. The mean caliber of the perforator was 0.7 mm and the mean length of the vascular pedicle was 7.1 cm. The territory of the thoracoacromial artery perforator flap extended up to the fourth intercostal space inferiorly. Between 2006 and 2011, the thoracoacromial artery perforator flap was used to reconstruct head and neck defects in seven patients. All patients healed uneventfully. The authors' studies provide evidence of the vascular supply and the clinical application of the thoracoacromial artery perforator flap. The recruitment of the chest skin through a thoracoacromial artery perforator flap resulted in an adequate color match, texture, and pliability for local adjacent defect restoration and for head and neck reconstruction. Therapeutic, IV.