Direct Cutaneous Branch Research Articles

Designing Lateral Thoracic Wall Perforator Flaps for Breast Reconstruction Using Ultrasound.

Lateral thoracic flaps represent a precious source for partial and total breast reconstruction, in some cases as first option and in other cases as alternative of free flaps. This article describes the ultrasound (US)-based planning of the lateral thoracic wall perforator adipocutaneous flaps and it reports our experience on 52 consecutive flaps. From November 2018 to May 2021, 52 consecutive lateral thoracic wall perforator flaps were performed using the US-based method for reconstruction of partial breast defects and total breast reconstruction. High-frequency US was performed in all cases prior to surgery to select the best perforator and design the flap. Of the 52 cases, 41 were lateral intercostal artery perforator flaps (78.8%), and 11 were thoracodorsal artery perforator (TDAP) flaps. Of the 11 TDAP flaps, 2 cases were based on the direct cutaneous branch. Moreover, in two other cases clinically scheduled for lateral thoracic perforator flaps due to the presence of an appropriate axillary roll, no suitable local/regional perforators were detected with the preoperative US examination and the latissimus dorsi myocutaneous flap was performed. Preoperative planning of these flaps using US speeds the surgery and makes it easier and more efficient. Therefore, it is reasonable that the color duplex ultrasound is the operative surgeon's tool for mapping the lateral thoracic wall perforators and to appropriately plan each flap.

Le lambeau perforant de l’artère fémorale profonde : une étude anatomique morphométrique

Within the framework of mammary reconstruction, since 2012 when Allen first described it, the profunda femoral artery perforator flap (PAP) takes an important place in the current therapeutic options. This anatomical study aims to analyze the anatomy and morphologic consideration of the PAP: position of the perforating artery; length of the pedicle, area and volume of vascularization. Sixteen flaps were harvested on fresh subjects at the University Department of Anatomy of Rockfeller, Lyon. The first direct cutaneous branch from the deep femoral vessels was located between or through the adductor magnus and gracilis muscles. Pedicle location, diameter, length and position regard to the great saphenous vein were recorded. A flap based on this vessel was designed. Height, width, and surface of the skin paddle were recorded. Three-dimensional computed tomographic angiography was used to analyze the area and volume of cutaneous territory supplied by the studied perforator. On the 16 analyzed flaps, localization of the perforating artery is on average to 8.2cm of the pubic tuber and 3.7cm behind a line connecting the pubic tuber to the internal femoral condyle. The length of the pedicle is on average of 11.7cm and the average area of skin perfused was 94,68cm2. The way of this perforating arterty is primarily through the adductor magnus. On the radiological images of the 8 flaps, the analysis shows an average surface of 111,25cm2 and a mean volume of 325.3cm3. PAP is an interesting therapeutic choice within the framework of a mammary reconstruction. Its surface and its volume associated with a discrete scar make a valid indication within the framework of this surgery.

Application of microdissected thin anterior lateral thigh perforator flap in precise microsurgical reconstruction of oral and maxillofacial soft tissue defects

Objective To investigate the application of microdissected thin anterior lateral thigh perforator flap (ALTP flap) in precise reconstruction of oral and maxillofacial soft tissue defects and to assess the clinical reconstruction outcome. Methods From January, 2014 to September, 2015, utilizing the technique of microdissected thin anterior lateral thigh flaps to repair the defects resulted from radical resections of primary sites in 42 patients with oral cancer. Before the operation, the dominant perforator was detected and marked on the skin where the planned flap would be harvested later by Doppler probing. Initial incision was made medial to the perforator marker. Careful dissection was conducted suprafascially to isolate the dominant perforator as well as identifying its source and type. The size of flap was determined according to the area of defect after tumor ablation. Meanwhile the flap was thinned in accordance with the contour of the defect or the organ to be reconstructed. The procedure should be performed under operating microscope. Results Forty-five microdissected thin ALTP flaps were harvested and used to reconstruct the defects of tongue, buccal, oral floor, and gingiva in 42 patients. Among them, 28 flaps were nourished by single perforator, 14 flaps were nourished by 2 perforators, and 3 flaps were nourished by 3 perforators. In total, 65 perforators were identified, in which 28 were direct cutaneous branches, 13 were fascia-cutaneous branches, and 24 were fascia branches. One take-back occurred within 6 hours due to cervical haematoma. During re-exploration, pedicle compression was found. And the flap was salvaged successfully after haemotoma removement and proper bleeding point ligation. Four flaps underwent marginal necrosis which healed smoothly after debridement and dressing changes. Post-operative 6 to 24 months’ follow-up showed satisfactory appearance of the recipient sites with favorable speech and swallowing function. All donor sites were closed primarily, leaving no donor-site complications including incision disruption, scar hyperplasia or muscle strength degeneration of the lower limb. Conclusion Microdissected thin anterior lateral thigh perforator flap is an optimal choice for personalized reconstruction of soft tissue defects of the tongue, buccal, oral floor, and gingiva, for it can decrease donor-site morbidity and achieve better appearance and function reconstruction effect of the recipient site. Key words: Oral and maxillofacial defects; Anteriolateral thigh flap, perforator flap; Microdissected thin flap; Microsurgical technigue

Supraclavicular artery island flap in head and neck reconstruction

Due to the complex anatomy of the head and neck, a wide range of pedicled or free flaps must be available to ensure optimal reconstruction of the various defects resulting from cancer surgery. The supraclavicular artery island flap is a fasciocutaneous flap harvested from the supraclavicular and deltoid regions. The blood supply of this flap is derived from the supraclavicular artery, a direct cutaneous branch of the transverse cervical artery in 93% of cases or the supraclavicular artery in 7% of cases. The supraclavicular artery is located in a triangle delineated by the posterior border of the sternocleidomastoid muscle medially, the external jugular vein posteriorly, and the median portion of the clavicle anteriorly. This pedicled flap is thin, malleable, and is easily and rapidly harvested with a reliable pedicle and minimal donor site morbidity. It can be used for one-step innervated reconstruction of many types of head and neck defects. It constitutes an alternative to local flaps, while providing equivalent functional results and must be an integral part of the cancer surgeon's therapeutic armamentarium.

A composite gluteofemoral flap for reconstruction of large pressure sores over the sacrococcygeal region

Gigantic pressure sores pose a daunting challenge for plastic surgeons. This paper presents a composite gluteofemoral flap for reconstruction of large pressure sores over the sacrococcygeal region. In this anatomical study, 30 embalmed cadaveric lower limbs were used for dissection to observe the musculocutaneous perforators of the inferior gluteal artery and the longitudinal nutritional vascular chain of the posterior femoral cutaneous nerve. In this clinical study, eight patients underwent surgical harvest of the composite gluteofemoral flap for coverage of grade IV sacrococcygeal pressure sores. The size of the pressure sores ranged between 16×9cm and 22×10cm. The inferior gluteal artery was present in 26 cases and absent in four cases. It gave off two to four musculocutaneous branches with a diameter larger than 0.5mm to the gluteus maximus. A direct cutaneous branch was given off at the inferior margin of the gluteus maximus, serving as a nutritional artery for the posterior femoral cutaneous nerve. The size of the flap harvested ranged between 22×9cm and 32×10cm. Flaps in seven patients survived uneventfully and developed epidermal necrosis at the distal margin in one case. An average 2-year follow-up revealed no recurrence of pressure sores. The composite gluteofemoral flap, being robust in blood supply, simple in surgical procedure, and large in donor territory, is an important addition to the armamentarium.

Superficial Femoral Artery Perforator Flap

The medial thigh has been infrequently studied as a donor site for pedicled or free flaps. In their previous studies, the authors observed a direct cutaneous branch from the superficial femoral artery. This study aimed to investigate the anatomy and potential possibility for flap elevation (the midmedial thigh flap) on this direct branch of the superficial femoral vessels. Circumferential adipocutaneous thigh flaps were harvested from 14 fresh adult cadaver legs. The direct cutaneous branch from the superficial femoral vessels was located between the sartorius and gracilis muscles. Pedicle location, diameter, and length and position of the great saphenous vein and saphenous nerve were recorded. A flap based on this vessel was designed. Height, width, and surface of the skin paddle were recorded. Three-dimensional computed tomographic angiography was used to analyze the area of cutaneous territory supplied by the studied perforator. The pedicle was located at an average distance of 22.79 ± 1.55 cm below the pubic tubercle on the medial axis of the thigh, and it was found in 100 percent of dissections. It was always located between the sartorius and gracilis muscles, with a mean diameter of 2.82 ± 0.69 mm and mean length of 4.79 ± 0.52 cm. The average area of skin perfused was 182.24 cm, located preferentially distal and posterior to the perforator pedicle. Two clinical cases illustrate the feasibility of the midmedial thigh perforator flap. The superficial femoral artery perforator flap appears to be reliable and has a constant vascular anatomy. Donor-site morbidity is low, resulting in only a vertical scar on the medial thigh. Therapeutic, V.

The Emerging Role of the Direct Cutaneous Muscle Perforator Found Arising from the Muscle Vessel Hilum

Perforator flaps based on either musculocutaneous or septocutaneous perforators are no longer a curiosity, but rather in the past decade have become "workhorse" soft tissue alternatives. Yet a keener understanding of their anatomy abetted by sophisticated imaging techniques has revealed other deep fascia perforators whose potential impact should not be overlooked. An important triad of these perforators can be found to arise ultimately from the source vessel to a muscle. This triumvirate includes the well-known, almost insignificant, capillary-like musculocutaneous perforator and the larger-caliber and often dominant musculocutaneous perforator that has become the basis of the conventional muscle perforator flap. An overlooked member of this tripartite system, though, is the direct cutaneous branch from the muscle hilum, which may be far more common than previously realized. The latter typically takes a paramuscular or extramuscular course to the skin, so that its corresponding perforator flap can be raised most simply while totally avoiding entering any muscle substance per se, and thus by definition will best ensure function preservation. Any surgeon considering a muscle perforator flap must be aware of the possibility of this tripartite system and the advantages as well as limitations of each component.

Hourglass Dorsal Metacarpal Island Flap: A New Design for Syndactylized Web Reconstruction

Web space reconstruction is the key point and an important component of syndactyly treatment. A design of the dorsal metacarpal artery flap was used as an island flap based on the direct cutaneous branch arising from the dorsal metacarpal artery at the distal end of the flap to reconstruct congenital web syndactyly. The flap rotated from 0 degrees to 180 degrees and passed under a skin bridge at the distal end of the flap to reach the web defect. Such design enables a better use of the skin territory from the intermetacarpal space proximal to the pedicle, with a short donor site scar and a more supple reconstruction of the web space.

Investigation and clinical application of a novel axial pattern flap for nasal and facial reconstruction in the dog

To describe the vascular supply to a facial skin flap based at the commissure of the lip in the dog and report on its use in four dogs. Experimental and prospective clinical study. Animals Five canine cadavers and four client-owned dogs. In the cadavers, the ventral aspect of the zygomatic arch, the ventral margin of the caudal mandible and the wing of the atlas were marked as anatomical boundaries of a skin flap that was elevated from the subcutaneous tissues to the level of the medial canthus of the eye. Methylene blue dye and barium sulphate solution were independently infused through a common carotid (three dogs) or facial artery (two dogs) catheter. Distribution of dye throughout the harvested skin was assessed subjectively. After contrast infusion the flap was excised and radiographed. The technique was used to reconstruct large facial or nasal defects in four dogs after tumour or skin lesion excision. Cadaver dissections and contrast studies clearly demonstrated three direct cutaneous arteries, the superior and inferior labial arteries and the angularis oris artery, arborising within the base of the flap. A separate direct cutaneous branch of the angularis oris artery was identified. An arterial plexus was identified within the distal flap, within which this artery communicates with the transverse facial artery and a cutaneous branch of the masseteric artery. Dye infusion caused discolouration of the elevated skin and vasculature within the flap. The flap survived in all clinical cases with marginal distal necrosis in one dog. The complex facial flap described is perfused by three direct cutaneous arteries and functions reliably in clinical cases.

Use of the Medial Side of the Knee Skin as a Free Flap: Saphenous Flap

The knee region is a good free skin flap donor site, as it has minimal subcutaneous tissue and provides a hidden donor site. Acland et al. first used the skin over the medial side of the knee as a "saphenous flap" based on the saphenous branch of the descending genicular artery. The authors studied the descending genicular artery and its saphenous branch in six cadaver limbs and elevated the skin over the medial side of the knee as a free flap in six patients to reconstruct lower extremity defects. In all clinical cases, the authors were able to elevate a skin flap from the skin on the medial side of the knee. The saphenous branch was absent in one cadaveric limb and one patient limb; instead, a direct cutaneous branch from the femoral artery reached the skin and had nearly the same caliber as the saphenous branch of the other cases. All the flaps survived and the defects healed well. The medial side of the knee is a good donor site, as it provides thin skin with innervation potential by means of the medial femoral cutaneous nerve and leaves an inconspicuous donor-site scar.

Algorithm for Autologous Breast Reconstruction for Partial Mastectomy Defects

The use of lateral thoracic skin and fat for breast reconstruction is advantageous because it does not require the use of muscle transfer, and the donor-site incision is well-hidden under the arm. In patients with redundant skin at the thoracic flank, use of this tissue has the added benefit of removal of an unsightly roll. The lateral thoracic skin and fat flap can be harvested using microsurgical technique based on three different pedicles: the thoracodorsal artery perforators; a direct cutaneous branch of either the thoracodorsal, axillary, or lateral thoracic arteries; and the lateral thoracic intercostal perforating vessels. In this report, the authors reviewed options, presented a case illustrating each option, and suggested an algorithm for deciding which pedicle to use.

Algorithm for Autologous Breast Reconstruction for Partial Mastectomy Defects

The use of lateral thoracic skin and fat for breast reconstruction is advantageous because it does not require the use of muscle transfer, and the donor-site incision is well hidden under the arm. In patients with redundant skin at the thoracic flank, use of this tissue has the added benefit of removal of an unsightly roll. The lateral thoracic skin and fat flap can be harvested using microsurgical technique based on three different pedicles: the thoracodorsal artery perforators; a direct cutaneous branch of the thoracodorsal, axillary, or lateral thoracic arteries; and the lateral thoracic intercostal perforating vessel. The authors describe the techniques for harvest of lateral thoracic tissue based on each of the pedicle options. A case is then presented to illustrate each option, and an algorithm is suggested for deciding which pedicle to use. The authors have used lateral thoracic tissue for partial breast reconstruction for a variety of defects. In this report, the authors review the results of three illustrative cases. Partial breast reconstruction may be required for patients after breast-conserving therapy or after breast reconstruction by other methods. Lateral thoracic tissue can be safely transferred to correct defects in treated or reconstructed breast, or to obtain symmetry. Knowledge of the vascular anatomy to this region is helpful in understanding the pedicle options when harvesting this tissue. The authors present an algorithm for determining which pedicle is most appropriate for the transfer of lateral thoracic tissue for partial breast reconstruction.

Distally based dorsal metacarpal flaps: a review of a series of patients treated in a 6-month period

The management of dorsal digital and hand injuries can pose a difficult problem to the trainee surgeon. Often repair involves using tissue from neighbouring digits. Our experience using local perforator flaps based on the direct cutaneous branch of the dorsal metacarpal arteries shows that these can be dissected and used successfully in the management of complex injuries of the dorsum of the hand and proximal phalanges. The flap has been used in a series of seven patients treated over a 6-month period by plastic surgery trainees with 100% success. This one-stage procedure resulted in good functional and aesthetic outcome and left an acceptable donor scar.

Dorsal metacarpal island flap in syndactyly treatment.

Web space reconstruction is an important component of syndactyly treatment. There are several methods for a skin graft-free reconstruction. Previously, the dorsal metacarpal island flap based on a direct cutaneous branch of the dorsal metacarpal artery has been used as an island V-Y advancement for web defects in syndactyly. In this study, dorsal metacarpal artery flap was raised similarly as an island but was used instead as a transposition flap in a series of 19 web defects. Early results of a median (range) follow-up of 3 (1-5) years reveal neither recurrence of the deformity nor web creeping. Such utilization of the flap enables a better use of the skin territory proximal to the pedicle and a more comfortable reconstruction of the web space.

Anatomic basis of the gastrocnemius perforator-based flap.

The gastrocnemius muscle is rarely considered today as a musculocutaneous flap. Yet, the posterior calf skin by itself can still be used to advantage as a source of local or perhaps free flaps. Fascial perforators in this region were reexamined in an anatomic study in 10 fresh cadaveric specimens to investigate the possibility of a gastrocnemius muscle perforator-based flap. At least two substantive perforators were found in all limbs, and there was always one overlying the medial gastrocnemius muscle (overall mean, 4.0 +/- 1.8 perforators; range, 2-7 perforators). The origin of these perforators in any given specimen was most commonly as a secondary branch from the medial or lateral sural arteries alone (60%), from the median sural artery as a direct cutaneous branch alone (10%), or from either of the muscle pedicles and/or the median sural artery (30%). Thus, in 90% of limbs, the potential for elevating a gastrocnemius perforator-based flap exists without the need for any muscle sacrifice. Otherwise, a more traditional posterior calf fasciocutaneous flap was possible. Other deeper intramuscular collaterals were also identified so that sequential use of the muscle as a separate flap does not seem to be compromised.

Anterolateral thigh flap: A review of 168 cases.

The anterolateral thigh flap based on the descending branch of the lateral circumflex femoral vessel is one of the musculocutaneous or septocutaneous flaps in the thigh. The descending branch of the lateral circumflex femoral vessel has either perforating branches or direct cutaneous branches from the intermuscular space to the anterolateral femoral skin. Since 1983, we have transferred 168 anterolateral thigh flaps for reconstruction of old burn scars, infected wounds, carcinoma excisions, for coverage of open bone fracture of the lower leg, and for congenital diseases. One hundred fifty-two cases were free flaps. The other 16 cases were pedicled flaps. The skin branches were divided into four types in our clinical series: musculocutaneous perforators (135/168 [80.4%]); intermuscular cutaneous perforators (16/168 [9.5%]); direct cutaneous branches (14/168 [8.3%]); and tiny cutaneous perforators (3/168 [1.8%]). The results were satisfactory. Only one case resulted in a failure due to tiny cutaneous branches.

Island V-Y tensor fasciae latae fasciocutaneous flap for coverage of trochanteric pressure sores.

The distal fasciocutaneous portion of the lateral thigh is supplied by the direct cutaneous branch of the lateral descending branch of the lateral circumflex femoral artery and the third perforating artery of the deep femoral artery. This consistent vascular anatomy allows raising a distal skin island based on both arteries on the lateral thigh, and this flap can be advanced into a trochanteric defect according to the V-Y technique. Based on anatomic and clinical study, a new design has been developed of the tensor fasciae latae fasciocutaneous flap, which is supplied by two pedicles. Seven island V-Y tensor fasciae latae fasciocutaneous flaps have been used for the coverage of trochanteric pressure sores in six patients. It is believed that the island V-Y tensor fasciae latae fasciocutaneous flap could overcome the traditional drawbacks of the conventional tensor fasciae latae flap and its modifications, and this is an ideal flap for covering trochanteric pressure sores without any donor site deformity and morbidity, which greatly improves the aesthetic result.

The anatomic basis and clinical applications of flaps based on the posterior tibial vessels

The vascular anatomy of the posterior tibial vessels has been studied in 20 legs of 10 cadavers. The number, size and distribution of the direct cutaneous and direct muscle branches of the posterior tibial vessels were recorded. For analysis, the leg was divided into four equal segments, Zone I being the most distal and Zone IV the most proximal. The direct cutaneous branches were found to cluster mainly around Zone II. The direct muscle branches to the soleus and flexor digitorum longus muscles arose chiefly in Zones II and III. Based on this knowledge, we performed fasciocutaneous, island soleus muscle, musculo-fasciocutaneous and flexor digitorum longus muscle flaps based on the posterior tibial vessels in 12 patients. Four were free fasciocutaneous flaps and eight were pedicled flaps. All flaps survived and there were no major complications. Delayed wound healing was encountered in three patients.

The distally-based dorsal hand flap

The planning and clinical applications of a series of reverse dorsal hand flaps are described. This new flap is based on a direct cutaneous branch of the dorsal metacarpal artery. It is particularly useful in resurfacing web spaces as well as dorsal metacarpal and phalangeal skin defects. The behaviour of 21 such flaps, all raised in the form of an island, was that of a conventional axial pattern flap.

The lower posterolateral thigh flap

The vascular basis of a new distally based flap in the distal third of the posterolateral thigh has been studied in 30 cadaver limbs. This flap is supplied mainly by direct cutaneous branches of the popliteal artery and of the lateral superior genicular artery. Its use as a distally based fasciocutaneous flap for defects of the knee is illustrated and its potential as a free flap is discussed. A classification of various flaps from the posterolateral region of the thigh is also proposed. In the light of the anatomical studies, the cutaneous blood supply of the distal posterolateral region and other regions of the thigh is reviewed.