Double Pedicles Research Articles

The Effect of Medial Circumflex Artery Variation on the Success Rate of Gracilis Flap Procedures: A Systematic Review.

This systematic review examines the impact of anatomical variations in the medial circumflex artery (MCA) on the outcomes of gracilis flap procedures in reconstructive surgery. Incorporating 16 studies, this review analyzes how different MCA variants influence the success rates of these procedures. Findings highlight critical MCA variations, including cases of split and double pedicles and differences in pedicle length and branching patterns, which can complicate flap harvesting and vascular anastomosis. The studies consistently underscore the need for precise preoperative imaging and intraoperative adaptability to manage these anatomical differences effectively. Notably, variants with shorter or branched pedicles present higher risks of partial flap loss and complications, particularly in autologous breast reconstruction and lower extremity repairs. The findings support the adoption of advanced imaging protocols, such as high-resolution Doppler and CT angiography, to enable detailed vascular mapping. Interdisciplinary collaboration among anatomists, radiologists, and surgeons is essential for developing comprehensive strategies tailored to individual anatomical landscapes, optimizing both the success and viability of gracilis flaps. The review emphasizes that understanding MCA variability is crucial for enhancing surgical precision and improving patient outcomes. Standardizing preoperative assessment protocols and exploring alternative flap techniques may mitigate risks associated with MCA variations, advancing the field of reconstructive surgery.

Thoracoscopy resection of a giant solitary fibrous tumor with double pedicles and double blood supply: a case report

BackgroundSolitary fibrous tumors are rare tumors derived from the pleura. A tumor generally has only one pedicle. Video-assisted thoracoscopic surgery is generally used when a tumor is small (< 10 cm), and traditional open surgery is often used when a tumor is large.Case presentationWe report a 49-year-old male patient with a space-occupying lesion in the right chest. Three-dimensional reconstruction showed that the blood supply to the tumor originated from the right lower pulmonary artery and vein. The patient was treated with minimally invasive surgery. Intraoperative exploration revealed that the tumor had two tumor pedicles, and each pedicle has an independent blood supply. The special bagging and extraction of the specimen were applied. The size of the specimen was 18 × 12 × 6 cm. Postoperative pathological examination revealed a solitary fibrous tumor.ConclusionsThe solitary fibrous tumor with double pedicles and double blood supply is very rare, and it has not been reported before. Preoperative three-dimensional reconstruction plays an important role in understanding the blood supply to the tumor and the location of the tumor pedicles. After careful and comprehensive evaluation, endoscopic surgery can also be applied to the treatment of the larger fibroma (> 10 cm). The larger specimen can be extracted from the smaller incision by the “pulling carrot” method.

Repair of soft tissue defect of foot and ankle with the supercharged peroneal artery perforator propeller flap

Objective To explore the clinical technical points of the treatment of soft tissue defect of the foot and ankle with the supercharged peroneal artery perforator propeller flap, and to provide theoretical support by anatomical observation. Methods From January, 2010 to February, 2018, a total of 10 patients with soft tissue defect of foot and ankle were treated with supercharged peroneal artery perforator propeller flap. Cause of injury: trauma in 7 cases, wound ulcer in 1 case, and poor healing of the calcaneus incision in 2 cases. Defect site: 5 cases of heel, 2 cases of medial and lateral malleolus, and 3 cases of dorsum and sole. The size of flap ranged from 6.0 cm×3.0 cm to 16.0 cm×5.0 cm. All patients were followed-up at 1, 3, 6 months after operation, and the function recovery was judged by AOFAS Ankle Hindfood Scale at 3 months post-opertively. From November, 2016 to May, 2017, the anatomical basis and operative points of the supercharged peroneal artery perforator flap were summarized. Results All the 10 cases of supercharged peroneal artery perforator propeller flap survived. Two of them had local epidermal necrosis at the proximal end of the flap. After 1 to 2 weeks of dressing, they finally healed. The other 8 cases healed well. Anatomical studies showed that different planes of the supercharged peroneal artery perforator propeller flap can only reduce the compression of the double pedicles and reduce the distal necrosis rate of the flap by rotating in different rotation directions. Conclusion The supercharged peroneal artery perforator propeller flap can enhance the blood supply and venous return in the big paddle artery of the flap, preventing distal necrosis. Key words: Peroneal artery perforator flap; Propeller flap; Supercharged; Foot and ankle

Vertically Set Sombrero-shaped Abdominal Flap for Asian Breast Reconstruction after Skin-sparing Mastectomy.

Immediate autologous breast reconstruction after skin-sparing mastectomy is an esthetically superior method, and a free abdominal flap is often used. However, in Asian patients, little redundant abdominal skin and thin subcutaneous tissue are common, necessitating the development of a more suitable flap design and setting. We devised a narrow flap, the sombrero-shaped flap (S-flap), set vertically, to reduce postoperative abdominal morbidity without sacrificing cosmetic results. To assess this new flap design and setting, the recipient- and donor-site complications of consecutive patients treated by S-flap (n = 40) and conventional flap (C-flap) (n = 22) were retrospectively investigated. Postoperative abdominal pain, stiffness, and patient activity were also assessed in each group with our original grading scale. Compared with the C-flap group, the S-flap group had a significantly lower skin paddle vertical height (mean, 14.0 and 10.2 cm, respectively; P < 0.001), lower abdominal stiffness (P = 0.023), and higher rate of double-pedicled flap use (27.3% and 52.5%, respectively; P < 0.048). The rates of donor and recipient site complications, postoperative abdominal pain, and activity did not significantly differ between the groups. For immediate breast reconstruction after skin-sparing mastectomy in Asian patients, our newly designed S-flap and vertical flap setting achieved cosmetically good, consistent results with low abdominal morbidity, even though the abdominal flap was thin and narrow. The viability of the S-flap, including medial fan-shaped adipose flap, was reliable, even though the flap often required elevation with double pedicles.

The Suitability of End-to-Side Microvascular Anastomosis in Free Flap Transfer for Limb Reconstruction

End-to-end (ETE) microvascular anastomosis used in free flap transfer for limb reconstruction often requires the sacrifice of a major artery, which may aggravate distal circulation of the limb. The purpose of this study is to investigate the relationship between the type of microvascular anastomosis and the survival of free flaps, and to highlight the end-to-side (ETS) anastomotic technique when facing vascular anatomic variations. Between 1999 and 2008, a retrospective review was conducted by a single microsurgeon on 203 patients who underwent free flap reconstruction for limb reconstruction. We examined the clinical course of 209 arterial and 308 venous anastomoses. ETS anastomoses were performed for 99 vessels, whereas ETE anastomoses for 418 vessels. The distribution and outcome of ETS and ETE anastomoses were compared. One arterial thrombosis (1.15%, 1/87) was recorded in ETS anastomosis group, whereas none (0%, 0/122) was recorded in ETE anastomosis group (P = 0.419). Four venous thromboses (1.35%, 4/296) were found in ETE group, whereas none was found in ETS group (0%, 0/12). There was no statistically significant difference between the 2 anastomotic techniques. Six cases with double pedicles needed ETS anastomosis for 2 arterial and 2 venous reconstructions. Flap survival rate in ETS arterial group was 98.8%, whereas in ETE arterial group, it was 100%. ETS microvascular anastomosis has an equivalent flap survival rate as compared with ETE microvascular anastomosis. ETS anastomosis should be considered first when facing vessel size discrepancy and for preserving the major arteries of limbs.

Anatomical and technical aspects of hepatic artery reconstruction in living donor liver transplantation

We describe our experience with arterial reconstruction in living donor liver transplantation (LDLT) focusing on anatomic and technical aspects. From June 1994 to February 2003, 132 grafts were implanted in 130 LDLT recipients including 1 re-transplant and 1 dual graft transplantation. Donor and recipient records were retrospectively reviewed. Anatomical variations in graft arteries were classified as: Type I, single pedicle with (Ia) or without (Ib) aberrant artery (left hepatic artery (HA) from left gastric artery or right HA from superior mesenteric artery); Type II, double pedicles with (IIa) or without (IIb) aberrant artery; Type III, equal to or greater than 3 pedicles. Statistical analyses were carried out using Mann-Whitney U-test. There were 72 male and 58 female recipients. The median age at transplantation was 3 years (range, 0.5 to 61). In left grafts, there were 34 Type Ia, 6 Type Ib, 33 Type IIa, 13 Type IIb, and 3 Type III; whereas in right grafts, there were 35 Type Ia, 6 Type Ib, 1 Type IIa, and 1 Type IIb. Two-in-one (2-in-1) segmental resection technique in graft HA harvest was carried out whenever there were tiny arteries supplying the donor graft. All HA reconstructions were done under microvascular techniques. There was no donor mortality and 1 recipient in-hospital mortality. There was no graft or patient loss due to HA occlusion. Donor complications included 3 biloma, 1 bile leak, 1 biliary stricture, and 1 late intestinal obstruction secondary to postoperative adhesions that were all successfully managed by non-operative interventions, except the biliary stricture that needed a revision to Roux-en-Y hepatico-jejunostomy. The 1-year and 5-year recipient survivals were 98% and 94%, respectively. Successful HA reconstruction can be safely carried out in LDLT recipients and live donors with multiple graft arteries using the 2-in-1 segmental resection of donor HA under microvascular techniques.

Immediate TRAM Flap Reconstruction of the Breast after Mastectomy for Cancer: A Thai Experience

: From January 1990 to June 1995, immediate transverse rectus abdominis myocutaneous (TRAM) flap reconstruction of the breast after mastectomy for cancer was performed in 40 patients with the objective of improving the quality of life. The 40 cases included one malignant cystosarcoma phyllodes (MCP), two intraductal carcinomas, four mucinous carcinomas (T1–2 NO), one lobular carcinoma (T2N1), and 32 invasive ductal carcinomas (T1–2 NO = 19, T3NO = 1, T1–2N1 = 9, T3N1 = 3). Modified radical mastectomy (MRM) was performed in all but one patient (MCP) who had subcutaneous mastectomy. A single pedicle TRAM flap was used for breast reconstruction in 36 cases and double pedicles in the remaining four cases. Since mid-1991, the mastectomy incision has been modified from elliptical incision to new skin-sparing incisions of various patterns depending on the tumor sites (n= 30). This change permitted a better cosmetic result and lessened the paresthetic area of the breast. Major complications were found in only 6 cases (20% skin flap necrosis in 1, major fat necrosis with discharge in 3, wound infection with foreign body in 1, and abdominal wound dehiscence in 1 case). The average postoperative hospital stay was 9 days (5–23 days). Adjuvant chemotherapy was given in 22 cases. All but two cases received the treatment within 1 month postoperatively (PO). Subsequent nipple reconstruction was accomplished in 18 cases using local skin flap in 16 and nipple sharing in 2 patients. There were two deaths from distant metastasis (one also had local chest wall recurrence). In the other cases no evidence of disease was found. The follow-up periods ranged from 6 to 72 months. From our experience so far, we have found that, in early breast cancer patients, MRM with a skin-sparing incision and immediate TRAM flap reconstruction does not compromise the oncological sound, but improves the cosmetic result, provided that the patients receive a full course of treatment as planned.

Re: Extended Anterior Thigh Flaps for Repair of Massive Cervical Defects Involving Pharyngoesophagus and Skin

"Mosaic" flaps, i.e., connected anteromedial thigh-groin flaps, and connected anterolateral thigh-medial thigh flaps, the pedicles of which are the perforators of the lateral circumflex femoral system, the superficial circumflex iliac vessels, and the perforators from the femoral vessels are used to repair cervical skin defects involving the pharyngoesophagus. Although they appear to be similar to "siamese" flaps, these mosaic flaps are a new concept because they consist of two adjacent flaps that are simultaneously elevated with double pedicles including the lateral circumflex femoral system. The pedicles of the groin or the medial thigh flaps are anastomosed to the muscle branch or the descending branch of the lateral circumflex femoral system, which is the pedicle of the anterior thigh flaps, and the system is joined to a single recipient vessel as a "bridge" flap. The main advantages of these mosaic flaps are (1) they offer single recipient vessels, (2) they offer a larger extension of the vascular territory of a skin flap, and (3) they offer the possibility of creating custom-made composite flaps such as musculocutaneous and osteocutaneous flaps, and (4) the elevation of the flaps simultaneous with head and neck tumor resection is possible. Based on cited cases, it is suggested that mosaic flaps are suitable to use for reconstruction of massive cervical defects involving the cervical skin and the pharyngoesophagus due to recurrent laryngeal carcinomas.

Extended Anterior Thigh Flaps for Repair of Massive Cervical Defects Involving Pharyngoesophagus and Skin: An Introduction to the "Mosaic" Flap Principle

"Mosaic" flaps, i.e., connected anteromedial thigh-groin flaps, and connected anterolateral thigh-medial thigh flaps, the pedicles of which are the perforators of the lateral circumflex femoral system, the superficial circumflex iliac vessels, and the perforators from the femoral vessels are used to repair cervical skin defects involving the pharyngoesophagus. Although they appear to be similar to "siamese" flaps, these mosaic flaps are a new concept because they consist of two adjacent flaps that are simultaneously elevated with double pedicles including the lateral circumflex femoral system. The pedicles of the groin or the medial thigh flaps are anastomosed to the muscle branch or the descending branch of the lateral circumflex femoral system, which is the pedicle of the anterior thigh flaps, and the system is joined to a single recipient vessel as a "bridge" flap. The main advantages of these mosaic flaps are (1) they offer single recipient vessels, (2) they offer a larger extension of the vascular territory of a skin flap, and (3) they offer the possibility of creating custom-made composite flaps such as musculocutaneous and osteocutaneous flaps, and (4) the elevation of the flaps simultaneous with head and neck tumor resection is possible. Based on cited cases, it is suggested that mosaic flaps are suitable to use for reconstruction of massive cervical defects involving the cervical skin and the pharyngoesophagus due to recurrent laryngeal carcinomas.

A Combined Rectus Abdominis Musculocutaneous Flap and Vascularized Iliac Bone Graft with Double Vascular Pedicles

Although a free vascularized iliac bone graft has been successfully used for the reconstruction of large bone defects, there is a serious problem of how to repair in one stage patients having a large bone defect with a very wide skin defect. A free combined rectus abdominis musculocutaneous flap and vascularized iliac bone graft with double vascular pedicles seems to be one of the most suitable methods for patients having large defects of both bone and skin. Based on our patient, the main advantage of this flap is the extreme width of the skin territory. The pedicle vessels are large and long, and the donor scar can be made in an unexposed area. This flap should be considered for use in one-stage reconstructions of large defects of both bone and skin in the leg region.

Double-Pedicle Transverse Rectus Abdominis Myocutaneous Flap for Unilateral Breast and Chest-Wall Reconstruction

Fifteen patients underwent unilateral breast and chest-wall reconstruction by a double-pedicle transverse rectus abdominis myocutaneous flap technique. Criteria for using both pedicles include (1) exceptionally large soft-tissue requirements, (2) prior abdominal operations compromising the vasculature to portions of the anterior abdominal wall, and (3) certain higher-risk patients with suspected microvascular pathology. Double pedicles allowed the transfer of the skin island as one unit or as two independent hemiellipses of tissue. Follow-up time ranges from 4 to 17 months. Complications included partial tissue loss in two patients, one abdominal flap seroma, and one patient with a hernia.

Reduction Mammaplasty with a Single Superiorly-Based Pedicle

We have reduced 68 breasts in 34 women, transposing the nipple-areolar complex on a single superiorly-based pedicle. The complication rate was 4.4 percent. The method appears to be safe, and it produces better shaped breasts than we obtained by operations using double pedicles.

The connectivity of cones and cone horizontal cells in a mosaic-type teleost retina.

A total of 20 Golgi-impregnated cone horizontal cells of Nannacara anomala (Cichlidae) were studied in alternating semi- and ultrathin sections in order to examine their connections with the overlying square mosaic of equal double and central single cones. Cone horizontal cells exhibiting three types of processes: (a) the long horizontal "axon", (b) short horizontal dendrites with a terminal swelling, and (c) cone contacting processes ascending towards the outer plexiform layer. As seen in tangential sections, the latter processes are arranged in the form of two concentric circles including a central "spot". The processes of the inner circle contact the eight double cone pedicles of one square unit: processes of the outer circle contact eight more double cone pedicles which are directly adjacent to the square unit. The central "spot" represents a process which contacts the central single cone. Processes of the inner circle most often terminate in a dichotomous branching which represents the lateral elements to one ribbon synapse, whereas in the outer circle only a single terminal swelling is observed. Because of the mosaic of the cones and the constancy of this pattern of connectivity a model can be constructed where the dendritic fields of the cone horizontal cells overlap to a considerable extent. From this model, it follows that each double cone pedicle is contacted by four different horizontal cells. The functional significance of these findings for color vision is discussed in the light of recent work with the microspectrophotometer characterizing the cone system of this species as bichromatic. The mosaic-like arrangement of the horizontal cell dendrites supports the conclusion that the parallels between the patterns of receptor and horizontal cells are no coincidence but play an important role in lateral inhibition and neural adaptation of the retina.