Free Perforator Flap Research Articles

Reconstruction of a medium-sized congenital melanocytic nevus defect using a thin thoracodorsal artery perforator free flap: a case report

Congenital melanocytic nevus (CMN) is a benign condition that either is present at birth or develops in the first weeks of life. Surgical removal is typically performed to improve cosmetic appearance and reduce the risk of malignant transformation. In this report, we present the case of a 26-year-old woman with a medium-sized CMN on her left breast. The nevus measured 14×8 cm, and the patient desired a single-stage excision. However, this approach would result in a large skin defect that would be challenging to reconstruct using a local flap or skin graft. Moreover, it could potentially compromise the maintenance of natural sagging and the contour of the breast. Consequently, we opted to place a thin thoracodorsal artery perforator free flap following the removal of the CMN. The patient was satisfied with the overall surgical results. By utilizing this free flap for reconstruction, we successfully preserved the natural shape and contour of the breast without complications such as postoperative hypertrophic scarring or contracture at the recipient site.

Surgical and patient-reported outcomes in an Asian female population with or without adjuvant radiotherapy after immediate free perforator flap breast reconstruction: A retrospective review

BackgroundThe majority of English literature has reported on the somewhat conflicted outcomes of the effect of radiotherapy on immediate breast reconstruction. However, data specifically related to patients of Asian descent has been scarce. This retrospective study aims to shed light on this topic to aid in the management of this group of patients. MethodsAll patients who received immediate free perforator flap-based breast reconstruction under a single surgeon over a 10-year period were included in the study. Patient characteristics, oncological and surgical data were collected. Patients were divided into post-mastectomy radiotherapy (PMRT) and non-PMRT groups. The final aesthetic outcome was assessed by a surgeon-reported outcome questionnaire. Patient satisfaction and psychological outcomes were assessed using validated patient-reported outcome (PRO) questionnaire (BREAST-Q), breast reconstruction, and postoperative module. ResultsA total of 101 women, with an average age of 44.7 ± 8.4 underwent perforator flap-based reconstruction. Fifteen patients received PMRT, with remaining 86 patients in the non-PMRT group. The mean duration of follow-up was over 5 years (p = 0.514). The recurrence rate was acceptable in the PMRT group (3/15, p = 0.129). There were no significant differences in complication rates between the two groups (p = 1.000). The aesthetic outcomes were comparable (p = 0.342). PRO appears to be lower in the PMRT group. ConclusionsImmediate breast reconstruction with PMRT in the local patient cohort is oncologically safe, acceptable complication profile, revision rate, and aesthetic outcome. PRO showed lower scores in several categories, which differ from normative data generated in the Western population. Further studies will need to examine the confounding effects of radiation in this specific population.

Improved Operative Efficiency and Surgical Times in Autologous Breast Reconstruction: A 15-year Single-center Retrospective Review.

Autologous breast reconstruction using a free deep inferior epigastric perforator (DIEP) flap is a complex procedure that requires a dedicated approach to achieve operative efficiency. We analyzed data for DIEP flaps at a single center over 15 years to identify factors contributing to operative efficiency. A single-center, retrospective cohort analysis was performed of consecutive patients undergoing autologous breast reconstruction using DIEP free flaps between January 1, 2005, and December 31, 2019. Data were abstracted a priori from electronic medical records. Analysis was conducted by a medical statistician. Analysis of 416 unilateral and 320 bilateral cases (1056 flaps) demonstrated reduction in operative times from 2005 to 2019 (11.7-8.2 hours for bilateral and 8.4-6.2 hours for unilateral, P < 0.000). On regression analysis, factors significantly correlating with reduced operative times include the use of venous couplers (P < 0.000), and the internal mammary versus the thoracodorsal recipient vessels (P < 0.000). Individual surgeon experience correlated with reduced OR times. Post-operative length of stay decreased significantly, without an increase in 30-day readmission or emergency presentations. Flap failure occurred in two cases. Flap take-back rate was 2% (n = 23) with no change between 2005 and 2019. Operative times for breast reconstruction have decreased significantly at this center over 15 years. The introduction of venous couplers, use of the internal mammary system, and year of surgery significantly correlated with decreased operative times. Surgeon experience and a shift in surgical workflow for DIEP flap reconstruction likely contributed to the latter finding.

Reconstruction of a Severe Open Tibiofibular Fracture using an Ipsilateral Vascularized Fractured Fibula with a Thoracodorsal Artery Perforator Free Flap.

The Gustilo IIIB tibiofibular fractures often result in long bone loss and extensive soft tissue defects. Reconstruction of these complex wounds is very challenging, especially when it includes long bone grafts, because the donor site is limited. We describe our experience using a set of chimeric ipsilateral vascularized fibula grafts with a thoracodorsal artery perforator free flap to reconstruct the traumatic tibia defects. A 66-year-old male suffered a severe comminuted tibia fracture and segmented fibula fracture with large soft tissue defects as a result of a traffic accident. He also had an open calcaneal fracture with soft tissue defects on the ipsilateral side. All the main vessels of the lower extremity were intact, and the cortical bone defect of the tibia was almost as large as the fractured fibula segment. We used an ipsilateral vascularized fibula graft to reconstruct the tibia and a thoracodorsal artery perforator flap to resurface the soft tissue, using the distal ends of peroneal vessels as named into sequential chimeric flaps. After 3 weeks, the calcaneal defect was reconstructed with second thoracodorsal artery perforator free flap. Reconstruction was successful and allowed rapid rehabilitation because of reduced donor site morbidity.

Free lateral tarsal artery perforator flap for repair of volar skin defect of thumb.

To investigate the effect of free lateral tarsal artery perforator flap in the repair of the volar skin defect of the thumb. From January 2020 to December 2022, the free lateral tarsal artery perforator flap was used to repair the skin defect of the palmar side of the thumb in 11 cases. There were 9 males and 2 females with an average age of 45 years (range, 35-62 years). The causes of injury were mechanical injury in 8 cases, traffic accident in 3 cases, combined with different degrees of tendon and bone exposure and injury. The time from injury to operation was 1 to 4 hours, with an average of 2.5 hours. The size of the flap ranged from 3.0 cm × 3.0 cm to 5.5 cm × 5.0 cm, and the donor site was repaired with the skin graft. All the flaps and skin grafts survived successfully, and the wounds healed in the first stage. All patients were followed up for 6 to 24 months, with an average of 15 months. The appearance of the flap was good, with normal color, no pigmentation, and a soft texture. The 2-point discrimination of the flap was 6 to 11 mm, with an average of 8.5 mm at 6 months after operation. At the last follow-up, 8 cases were excellent and 3 cases were good according to the trial standard of upper limb function evaluation of the Chinese Society of Hand Surgery of the Chinese Medical Association, and the excellent and good rate was 100%. There was no significant effect on the sensation and function of the feet in the donor site, and the patient satisfaction was high. Free lateral tarsal artery perforator flap is a good choice to repair the skin defect of the palmar side of the thumb because of its simple operation, high survival rate and good sensory recovery of the recipient area.

Free posterior interosseous artery perforator flap in the treatment of finger with skin and soft tissue defect

To explore clinical effects of repairing skin and soft tissue defect of finger with free posterior interosseous artery perforator flap. Totally 8 patients with finger skin and soft tissue defect repaired with free posterior interosseous artery perforator flap were treated from May 2021 to November 2022, including 7 males and 1 female aged from 24 to 54 years old, and soft tissue defect area ranged from 3.0 cm×1.5 cm to 5.0 cm×3.0 cm. The time from injury to flap repair ranged from 3 to 83 h. The free posterior interosseous artery perforator flap was applied to repair finger defect, the area of the flap ranged from 3.5 cm×2.0 cm to 5.2 cm×3.5 cm, the donor area of flap was sutured directly. The survival, appearance, texture and donor complications of the flap were observed after operation, and Dargan functional standard was used to evaluate clinical effect of finger function. All flap of 8 patients were survived, and followed up from 3 to 12 months. There was no obvious swelling, soft texture, obvious pigmentation, linear intaglio in donor area only, and without obvious complications were found. Among them, 3 patients'skin flaps were repaired for the defect of palm of the fingers, and sensory recovery was good, two-point discrimination ranged from 5 to 9 mm. According to Dargan functional evaluation, 3 patients excellent, and 5 good. Free posterior interosseous artery perforation branch flap could be used to repair the defect of finger. The thickness of flap is moderate, operation is convenient, appearance and texture of the operative flap are good, and the donor site is small without obvious complications, and obtain satisfactory clinical effect.

Use of the Superthin Superficial Circumflex Iliac Artery Perforator Flap for Reconstruction of Lower Lip Defects.

Wide local excision remains the main treatment modality for primary lip cancer, which often results in considerable deficits of lip tissue and requires reconstruction using free tissue transfer. Although diverse free flaps, such as radial forearm flap or anterolateral thigh flap, have been used, their application is often limited by their inherent limitations, including donor-site morbidity and flap bulkiness. This report details the authors' experience of lower lip reconstruction using a superthin superficial circumflex iliac artery perforator (SCIP) free flap. Two patients with primary squamous cell carcinoma spanning their lower lip underwent wide local excision with an 8-mm lateral excision margin and superficial layer of orbicularis oris muscle. To cover the shallow but extensive lower lip defects, a superthin SCIP flap elevating along the intraadipose tissue layer and a pure-skin perforator SCIP flap elevating along the subdermal layer were harvested. The thickness of the harvested SCIP flap was 3 mm in both cases. The microvascular anastomoses of pedicles were conducted using the inferior labial artery and adjacent subcutaneous vein as recipient vessels, and the flaps were inset. The flaps survived completely without any perfusion-related complications. The patients were discharged uneventfully. Postoperatively, both patients displayed complete functional recovery with good lip competence and aesthetically pleasing results, without requiring secondary debulking operations. The authors' results suggest that the superthin or pure-skin perforator SCIP flap might be considered as an effective method for covering shallow and wide lower lip defect.

The harvestion and application experience of free multi-lobed anterior thigh flap

Objective: To introduce the technique and clinical application of free lobed anteromedial thigh perforator pedicle flap. Methods: From September 2015 to September 2021, 72 patients with perforating buccal and oral cancer defects were treated at the Oncology Plastic Surgery Department of Hunan Cancer Hospital. There were 61 males and 11 females, with an average age of 36.7 years (31-56 years). According to Union for International Cancer Control (UICC) TNM staging, there were 20 cases of T3N1M0, 13 cases of T3N2M0, 24 cases of T4N0M0, and 15 cases of T4N1M0. All defects were planned to be repaired with free lobed anteromedial perforator flaps. When there was only one set of vascular pedicle, the perforating vascular pedicle artery was anastomosed with the superior thyroid artery, and the accompanying vein was anastomosed with the superior thyroid vein by end-to-end. Results: The areas of soft tissue defects after radical resection of oral and buccal cancers in 72 patients were between 5.0 cm × 4.0 cm and 11.0 cm×7.0 cm; the areas of the first anterior femoral skin islands were between 5.0 cm × 4.0 cm and 13.0 cm×7.0 cm; the areas of the second anterior femoral skin islands were between 5.0 cm × 3.0 cm and 10.0 cm × 7.0 cm; and all flap donor sites were directly closed. In 35 cases, the vascular pedicle was accompanied by a lateral femoral muscle flap for filling the gap defect at the base of the mouth. The average length of the vascular pedicles of the flaps was 7.2 cm (range: 6.8-8.2 cm). The average diameter of the vascular pedicle arteries was 1.6 mm (range: 1.4-2.2 mm). The blood flow reconstruction of flap was completed by anastomosing one accompanying vein. The average diameter of the accompanying veins was 2.1 mm (range: 1.6-2.8 mm). Postoperative hematoma occurred in 3 patients, with one having vascular crisis. After emergency exploration, 2 of them were successfully saved, and the other one had complete necrosis of skin flap, which was repaired by pedicled pectoralis major skin flap transplantation. With following up of 12-38 months, the appearances of the flaps were satisfactory without significant swelling. The mouth opening and language function were satisfactory in all cases, and only linear scars were left in the donor sites, with no significant impact on thigh functions. Five patients with local recurrence of tumor were treated with second radical resection and repair with pedicled pectoralis major myocutaneous flap. Six patients developed cervical lymph node metastasis (4 on the same side and 2 on the opposite side) and underwent neck dissection again. Conclusion: The anatomical basis of the branches of the anteromedial femoral perforating branches in the anterolateral region of the thigh can be helpful to prepare the anterolateral femoral lobed flap, which is suitable for repairing the perforating defects after the radical operation of oral and buccal cancers.

Evaluation of Functional and Esthetic Outcomes in Oral Cancer Patients Reconstructed with Medial Sural Artery Perforator Free Flap

Evaluation of Functional and Esthetic Outcomes in Oral Cancer Patients Reconstructed with Medial Sural Artery Perforator Free Flap

The Fate of Sensation in Noninnervated Perforator Free Flaps in the Lower Extremity.

The recovery of sensation for noninnervated perforator flaps is not well understood. This prospective study aims to evaluate the quality, tendency, and related factors for recovery of sensation. A total of 187 patients over a 6-year period were evaluated at intervals of 3, 6, 12, and +24 months for demographic data and sensory tests [Semmes-Weinstein (SW) monofilament test, static two-point discrimination, temperature, and pain] on peripheral and central regions of the flap. Further detailed assessment using the SW monofilament test was made according to flap thickness, size, type, and recipient sites. Factors correlated to poor recovery were evaluated. Among the flaps tested, the 5.07 SW monofilament test revealed that the peripheral flap sensory recovery was achieved in 72% at +24 months with a significantly increasing linear trend ( P < 0.001). However, the central recovery was noted in only 26% to 28%. The two-point discrimination was achieved in 21% without a significant trend, whereas temperature and pain showed significant improvement, achieving 49% and 64% on the peripheral region and 22% and 31% for the central region, respectively. The flap thickness, size, type, and recipient sites did not exert significance. Only smoking was a significant factor, with 13 times higher odds of hindering sensory recovery. The SW monofilament test, temperature, and pain sensation on the periphery of the flap showed increasing trend of recovery over the +24 months. Among the various factors, only smoking attenuated recovery. Understanding the fate of sensory recovery in noninnervated perforator flaps will allow the surgeons to further customize the reconstruction based on the defect and maximize efficiency. Risk, III.

Discussion: The Fate of Sensation in Noninnervated Perforator Free Flaps in the Lower Extremity.

Discussion: The Fate of Sensation in Noninnervated Perforator Free Flaps in the Lower Extremity.

A modified induced membrane 2-stage technique using a thoracodorsal artery perforator free flap followed by vascularized or non-vascularized free fibular transfer for the treatment of complex bone infection with concomitant severe soft tissue lesion–A case series of 9 cases

Treatment of post-traumatic complex bone infection is very challenging. The two principal bone reconstruction approaches are the single-stage vascularized bone graft technique and the two-stage induced membrane technique (IMT). Here we introduce a modified 2-stage induced membrane technique (MIMT) for complex long bone infection with a major bone defect and a concomitant severe soft tissue lesion. The 2-stage procedure consists of bone debridement, placement of a PMMA spacer and soft tissue reconstruction with a thoracodorsal artery perforator free flap (“Tdap”) at stage 1. At stage 2, the thoracodorsal artery perforator flap is elevated and a fibular strut graft (either vascularized of non-vascularized) is placed for bone reconstruction.We retrospectively analyzed the extents of lower extremity, long bone, post-traumatic bone infection treated via MIMT from 2008 to 2020. There were nine such cases (eight males) of mean age 59.8 (range 31 to 79) years. The osteomyelitis durations ranged from 3 to 360 months (mean 53 months). The cortical bone defect sizes was ranged from 9 to 14 cm (mean10.7 cm). All skin resurfacing employed Tdap. Vascularized fibular grafts were placed in six patients and non-vascularized grafts were placed in three. The fibular graft size ranged from 12.5 to 19 cm (mean 16.2 cm). Non-vascularized iliac bone grafts served as the fibula docking sites.Unfortunately, all patients suffered complications before bone union was achieved. One case of plate stress fracture and one case of screw fracture required plate and screw change. In three cases of cellulitis, one resolved by use of intravenous antibiotics, others required plate and screw removal. Wound disruption required re-suture and distal skin flap partial necrosis was covered by perforator-based island flap. One case of fibular stress fracture needed cast for 4 weeks. A peroneal nerve palsy patient recovered spontaneously. Bone union was achieved after 6 months in five patients and after 8 months in three (mean 6.9 months). All patients were able to walk unaided. The follow-up period ranged from 2 to 14 years (mean 6.2 years).MIMT saves the limbs in cases with difficult post-traumatic bone infection. It is valid treatment option for complex bone infections with severe soft tissue lesions. However, even with this technique potential complication must be considered.

Significant Reduction in Length of Stay in Deep Inferior Epigastric Perforator Flap Breast Reconstruction With Implementation of Multimodal ERAS Protocol.

Enhanced Recovery After Surgery (ERAS) implementation achieves earlier recovery, reduced hospital length of stay (LOS) and improved outcomes in patients undergoing deep inferior epigastric perforator (DIEP) free flaps. We sought to review our ERAS protocols and their impact on our patients' LOS compared with the literature. This was a retrospective review of a single surgeon's experience from 2017 to 2021 of patients undergoing DIEP free-flap breast reconstruction with LOS as the primary outcome. Complication rates and patient demographics are described as secondary outcomes. One hundred twenty-one patients underwent DIEP free-flap breast reconstruction. After adapting ERAS protocols, there has been a 0.98 [SD, 0.17; confidence interval [CI], -1.3 to -0.64; P < 0.001) day decrease in length of stay comparing pre-ERAS to post-ERAS implementation. Length of stay has routinely decreased from an average discharge on day 4.17 (SD, 1.1; range, 3-8 days) in 2017 to discharge on day 2.91 (SD, 1.1; range, 1-5 days) in 2021. Seventy-five percent of patients in 2021 were hospitalized for 3 or fewer days compared with 75% of patients in 2017 hospitalized for 4 or more days. One patient experienced a flap failure. Our study supports successful discharge on postoperative days 2-3 compared with postoperative days 3-4 in the current literature. The implementation of our ERAS protocol for DIEP free-flap breast reconstruction has resulted in a shorter LOS compared with contemporary literature. The ERAS protocols can be efficiently adopted in microsurgical DIEP breast reconstruction to achieve a shorter LOS without jeopardizing patient outcomes.

Superficial Circumflex Iliac Artery Perforator-Free Flaps in Head and Neck Reconstruction: A Report on 10 Cases

Abstract The superficial circumflex iliac artery flap or as it was traditionally called the groin flap has gained a growing interest recently with the concept of perforators that revolutionized our understanding of many other classic flaps like the deep inferior epigastric artery, the thoracodorsal artery-based flaps, and many others. This revisiting process was brought about by further deeper knowledge of the anatomy of these flaps at finer levels. These advances made it possible to raise flaps with minimal donor site morbidities as well as to expand the applications for certain flaps to include different tissue components that serve the reconstructive needs better. Recent studies investigated its vascular supply, and a refined approach was adopted for using it in reconstruction. Another factor for revisiting this flap, is the lymph nodes that lie in its territory that may be used for lymph node transplant in lymphedema cases. Our objective from this report on 10 cases, is to display the flexibility and uses of the superficial circumflex iliac artery perforator (SCIP) free flap. We utilized the SCIP flap for ten sequential patients between November 2019 to August 2020 that were reconstructed with primary or secondary reconstruction in the head and neck region. All were performed by the same primary surgeon and his team. The serial cases incorporated 6 females and 4 males with a mean age of 51.5 years (range 16–80 years). In two cases, this flap was designed in a chimeric fashion including a bony segment from the iliac crest. In conclusion, we have found that the superficial circumflex iliac artery perforator flap has a reliable anatomy which facilitates a fast and easy dissection. Among others, this flap has shown that it has a strong advantage since it displayed minimal donor site morbidity.

Giant Pilomatrix Carcinoma of the Thorax: An Uncommon and Clinically Misdiagnosed Tumor

Summary: Pilomatrix carcinoma is an unusual and aggressive malignant tumor deriving from follicular matrix cells and exhibiting a metastatic potential to lungs and regional lymph nodes in 10% of cases. We report the case of a 54-year-old male patient who presented with a biopsy-proven malignant pilomatrixoma of the thoracic region, which recurred multiple times after previous excisions. Due to the size of the tumor (28 by 22 cm), wide excision and axillary lymphadenectomy of levels I and II were performed, followed by reconstruction with a free deep inferior epigastric artery perforator flap and adjuvant radiotherapy. Owing to its rarity, this tumor can initially be misdiagnosed, resulting in delayed treatment and recurrences if inadequately excised. Also, large tumor size is correlated with a higher incidence of metastasis. High index of clinical suspicion and wide excision are recommended, along with the need of establishing oncological guidelines for better prognosis.

Extremity reconstruction with superficial circumflex iliac artery perforator free flap: Refinements and innovations after 101 cases

The superficial circumflex iliac artery perforator flap is based on perforators originated on the superficial circumflex iliac artery. This flap is thin and pliable, of moderate size, and has a concealed donor site. The authors report their experience, innovations, and refinements in both planning and execution, and the outcomes obtained after 101 extremity reconstruction consecutive cases. A total of 101 superficial circumflex iliac artery perforator flaps were prospectively reviewed and followed up for at least one year at Hospital del Trabajador. The flaps were used for both upper (n=21) and lower limbs (n=80), planned with computed tomography angiography/augmented reality, and raised above the superficial fascia using a standardized approach. Demographic data, anatomy of the flap, surgical technique, and the results were assessed. Average flap size was 90.5cm2, ranging from 25 to 212cm2. Total flap loss occurred in 6 flaps (5.9%). Four patients developed complications at the donor site. Debulking surgery was performed in 7 patients (6.9%). The average follow-up period was 850 days (range, 370-1405 days). The superficial circumflex iliac artery perforator flap is versatile, thin, and pliable, suitable for covering even large defects in either the upper or lower extremities, obtaining a shallow contour and optimal esthetics results. The elevation can be standardized, but requires training and proper planning. This is the largest series in a Western country reporting the experience, refinements, and innovation that allows for better results in limb reconstruction.

Reconstruction of Head and Neck Defects Using Medial Sural Artery Perforator Free Flap.

To study the use of medial sural artery perforator(MSAP) free flap in head and neck reconstruction. This was a prospective study. The patients with cancers of head and neck underwent excision of tumor along with neck dissection, and MSAP free flap was used for reconstruction. The free MSAP flaps were used in 30 patients to reconstruct head and neck soft tissue defects. There were sixteen male and six female patients with the median age of 40 years. The most common site of tumor resection was the tongue (14 cases), followed by buccal mucosa (12 cases), neck skin(2 cases), skin over parotid(1 case) and lip(1 case). Average flap size was 56 cm2. Thickness of the flap ranged from 4 to 8mm. The length of the vascular pedicle ranged from 8 to 14cm (12cm mean) which provides sufficient length during vessel anastomosis. Arterial diameter ranged from 1.0 to 1.5mm(Average - 1.25mm) and venous diameter of both veins in pedicle ranged from 1.5 to 2.5mm(Average - 2mm) in size. Most flaps were based on two perforators. Primary closure was attained in 11 cases whereas 19 patients required split thickness skin graft(STSG). The average flap harvesting time was 45min. Flap was failed in two cases. MSAP is good alternative to FRAFF in the reconstruction of defect after resection of head and neck cancer.

The Use of the Deep Brachial Artery as the Recipient Artery for Free Perforator Flap Transfer: An Anatomic Study and Clinical Applications.

Background and Objectives: Soft tissue reconstruction after sarcoma ablation in the posterior aspect of the upper arm has been commonly addressed using the pedicled latissimus dorsi musculo-cutaneous flap. The use of a free flap for coverage of this region has not been reported in detail. The goal of this study was to characterize the anatomical configuration of the deep brachial artery in the posterior upper arm and assess its clinical utility as a recipient artery for free-flap transfers. Materials and Methods: In total, 18 upper arms from 9 cadavers were used for anatomical study to identify the deep brachial artery's origin and point of crossing the x-axis, which was set from the acromion to the medial epicondyle of the humerus. Measurements of the diameter were taken at each point. The anatomic findings of the deep brachial artery were employed clinically in the reconstruction of the posterior upper arm after sarcoma resection using free flaps in 6 patients. Results: The deep brachial artery was found in all specimens between the long head and the lateral head of the triceps brachii muscle, and it crossed the x-axis at an average distance of 13.2 ± 2.9 cm from the acromion, with an average diameter of 1.9 ± 0.49 mm. In all 6 clinical cases, the superficial circumflex iliac perforator flap was transferred to cover the defect. The average size of the recipient artery, the deep brachial artery, was 1.8 mm (range, from 1.2 to 2.0 mm). The average diameter of the pedicle artery, the superficial circumflex iliac artery, was 1.5 mm (range, from 1.2 to 1.8 mm). All flaps survived completely with no postoperative complications. Conclusions: The deep brachial artery can be a reliable recipient artery in free-flap transfers for posterior upper arm reconstruction, given its anatomical consistency and sufficient diameter.

Value of the combination of a smartphone-compatible infrared camera and a hand-held doppler ultrasound in preoperative localization of perforators in flaps

This study was conducted to evaluate the effectiveness of the FLIR ONE PRO, a thermal imaging camera for smartphones, combined with handheld Doppler (HHD) in the localization of perforator arteries and to assess the efficacy of the FLIR ONE PRO in distinguishing perforators of the descending branch of the lateral circumflex femoral artery (LCFA) from other perforators of the anterolateral thigh perforator (ALTP) flap. We enrolled 29 free perforator flaps from 22 patients in our study. Before surgery, dynamic infrared thermography was performed using a FLIR ONE PRO to visualize hotspots on the flaps. Subsequently, HHD was used to further determine the perforators under the hotspots, which were ultimately identified and confirmed through intraoperative findings. Additionally, infrared images of the ALTP flap were analyzed using FLIR Tools. The performances of the FLIR ONE PRO and FLIR ONE PRO + HHD groups were evaluated by comparing the intraoperative findings. Using FLIR ONE PRO + HHD, 119 hotspots and 106 perforators were identified during surgery. Using FLIR ONE PRO + HHD, sensitivity and positive predictive value were 97.87% and 88.46%, respectively, in the young (age≤45 years). In the elderly group (age>45 years), these percentages were 93.22% and 82.09%, respectively. In addition, we found that the FLIR ONE PRO could be useful for differentiating perforators in the descending branch of the LCFA from other perforators within 5 min. The results showed a sensitivity of 96.15%, a specificity of 98.9%, a positive predictive value of 96.15%, and a negative predictive value of 98.9%. Compared to using FLIR ONE PRO alone, the combined application of HHD and FLIR ONE PRO had a higher value in perforator localization by increasing the positive predictive value. The FLIR ONE PRO may have significance in the rapid prediction of perforators deriving from the descending branch of the LCFA.

The Use of Conventional Lower-Frequency Color Doppler Ultrasound for Flap Planning in the Lower Extremity.

Handheld Doppler is often inaccurate in localization of perforators for pedicled and free flaps. Color Doppler ultrasound (CDU), in contrast, allows more accurate mapping and characterization of perforators to facilitate rapid flap harvest. Forty-seven flaps harvested from the lower extremity were evaluated preoperatively with CDU by a single surgeon with a conventional low-frequency ultrasound device (Philips Sparq, Cambridge, Mass). Flaps evaluated included profunda artery perforator flaps (n = 36), anterolateral thigh flaps (n = 2), pedicled propeller perforator flaps (n = 7), and toe transfers (n = 2). In all cases where a free profunda artery perforator or anterolateral thigh flap was used, the location of the dominant perforator visualized preoperatively correlated exactly with intraoperative findings. In cases where CDU was used preoperatively to locate a large perforator close to a lower extremity defect for reconstruction with a propeller perforator flap, all perforators could be used, and all flaps were successful. Preoperative CDU is particularly useful for flap planning where knowledge of the location of the dominant perforator is critical. This includes planning of thin and superthin free flaps, as well as freestyle perforator flaps. Our clinical experience suggests that this technology should be routinely adopted in certain aspects of reconstructive microsurgery.