Musculocutaneous Perforators Research Articles

A pragmatic evaluation of the role of the medial sural artery perforator flap

The medial sural artery perforator (MSAP) flap is based on musculocutaneous perforators of the medial gastrocnemius muscle. A perforator within this region is routinely present. The flap has a potentially long vascular pedicle of large caliber which serves well to allow a local flap about the knee, or as a relatively thin free flap where vein grafts are rarely needed to reach a recipient site. Harvest of the flap is straightforward. Unfortunately, a skin graft if necessary to close the donor site or even a scar if primary closure were possible usually causes an unacceptable aesthetic residue. Choice of this donor site on this basis alone usually will make this only to be a secondary consideration.

Clinical application of submental artery perforator flap in oral and maxillofacial defect restoration after tumor resection

Objective: To summarize the clinical anatomical features and surgical technique of the submental artery perforator flap (SMAPF), and to evaluate the outcome and value of the flap for oral cavity reconstruction after cancer ablation. Methods: A total of 56 patients with oral cancer were included in this study. The modified SMAPF excluded the anterior belly of the digastric muscle and submental fatty tissue. The primary sites of malignancy were buccal mucosa (n=24), tongue (n=21), mandibular gingiva (n=6), mouth floor (n=3), soft palate (n=2). Results: The flap size varied from 3 cm×5 cm to 5 cm×12 cm. Four flaps presented mild venous congestion, which was salvaged with conservative measures such as acupuncture and blood letting. Overall flap survival rate was 100%. The SMAPF with septocutaneous perforator was used in 49 cases and with musculocutaneous perforator in seven cases. External jugular vein and internal jugular vein provides venous drainage were applied in half cases respectively. All the patients showed a good recovery of tongue mobility and mouth opening with a follow-up of 3-41 months. Local recurrence was detected in one patient 4 months after operation. Conclusions: The SMAPF is a reliable flap for oral cavity reconstruction with outstanding functional and aesthetic outcomes.

Le lambeau médial sural perforant : bases anatomiques, technique chirurgicale et indications en reconstruction cervicofaciale

The medial sural artery perforator (MSAP) flap is defined as a thin cutaneo-adipose perforator flap harvested on the medial aspect of the leg. The aims of this study were to describe the anatomical basis as well as the surgical technique and discuss the indications in head and neck reconstructive surgery. We harvested 10 MSAP flap on 5 fresh cadavers. For each case, the number and the location of the perforators were recorded. For each flap, the length of pedicle, the diameter of source vessels and the thickness of the flap were studied. Finally, we performed a clinical application of a MSAP flap. A total of 23 perforators with a diameter superior than 1mm were dissected on 10 legs. The medial sural artery provided between 1 and 4 musculocutaneous perforators. Perforators were located in average at 10.3cm±2cm from the popliteal fossa and at 3.6cm±1cm from the median line of the calf. The mean pedicle length was 12.1cm±2.5cm. At its origin, the source artery diameter was 1.8mm±0.25mm and source veins diameters were 2.45mm±0.9mm in average. There was no complication in our clinical application. This study confirms the reliability of previous anatomical descriptions of the medial sural artery perforator flap. This flap was reported as thin and particularly adapted for oral cavity reconstruction and for facial or limb resurfacing. Sequelae might be reduced as compared to those of the radial forearm flap with comparable results.

Ischemic flap survival improvement by composition-selective fat grafting with novel adipose tissue derived product - stromal vascular fraction gel

BackgroundFlap necrosis due to insufficient blood supply is a common postoperative complication in random pattern flaps. Stem cell therapies have emerged as promising biologics for tissue ischemia. A novel fat derived product, stromal vascular fraction gel (SVF-gel), can be prepared with lipoaspirate through simple mechanical processing, removing only the lipid content. SVF-gel enriches adipose-derived stem cells and potentially beneficial for flap necrosis. MethodsNude mice ischemic flaps were treated with human SVF-gel, stromal vascular fraction (SVF) cell suspension or saline (n = 10). They were injected to the flap recipient beds, and necrosis and vascularization was assessed on postoperative day 14. We harvested the necrosis-free distal to evaluated skin healthiness and neovasculogenesis by Masson's trichrome stain and immunofluorescence, etc. Pro-angiogenic factors were assessed with tissue qRT-PCR. Finally, we traced the grafted human tissue with immunofluorescence. ResultsSVF-gel-treated flaps have the smallest necrotic zones (22.05% ± 0.0438) compared with the saline controls (53.78% ± 0.1412) or SVF-treated ones (35.54% ± 0.0850, p = 0.039). Numerous functional musculocutaneous perforators were developed around SVF-gel grafts. The SVF-gel-treated skin had the best fat restoration (231.3 ± 48.1 μm) among three groups (F = 10.83, p = 0.0102) while saline-treated flap distal appeared fibrotic. SVF-gel-treated flaps also had ∼43% more CD31 + capillaries (p = 0.0152) with ∼3 folds more gene expression of angiogenic cytokines of VEGF and bFGF (p = 0.0310 and 0.0303, respectively) than saline-treated controls. Furthermore, we found hSVF-gel cells (hGolgi+) had directly engrafted as vessel component (α-smooth muscle actin, α-SMA+) to the flap. ConclusionAdipose cellular matrix enhanced flap neovascularization partly by direct incorporation, improved flap survival and fat restoration. The composition-selective fat grafting with SVF-gel demonstrated efficacy comparable with stem cell therapy and is especially valuable for clinical translation.

Reconstruction of intraoral defects after resection of cancer with two types of submental artery perforator flaps

The submental island flap is a common choice for reconstruction of intraoral defects. To obtain a thinner, more pliable flap and get a better oncological result, the submental artery perforator flap has been proposed, and to assess its feasibility for closure of defects after resection of cancers of the oral cavity we studied 20 patients, each of whom was treated in this way. All the flaps were classified into those with septocutaneous perforators (n=16) and those with musculocutaneous perforators (n=4), and the main veins that drained the flaps were two submental veins (n=17). There were two patterns of venous drainage: in pattern 1 (n=9) the external jugular vein provided the primary venous drainage, and in pattern 2, the submental veins drained mainly into the facial vein, the common facial vein, and the internal jugular (n=10). In one patient the submental veins bypassed the facial vein to drain into the internal jugular. Eighteen of the 20 patients had no postoperative complications. The remaining two developed mild venous congestion of the flaps, which was resolved with conservative management and no skin loss. No local or regional recurrence was detected after a mean (range) follow-up of 21 (4-35) months. This is a simple, reliable flap that can be used for the reconstruction of intraoral defects after resections for cancer, but its oncological outcome still requires proof in long-term, large-scale, clinical trials.

Donor site morbidity of the anterolateral thigh flap

IntroductionThe purpose of this study was to investigate donor site morbidity after reconstruction of defects in the head and neck region with an anterolateral thigh (ALT) flap. MethodsFrom 07/2006 to 12/2015 the anterolateral thigh flap was used for reconstruction of large intra- or extraoral defects in 138 patients. The donor sites were available to examine for morbidity in 51 patients (36.7%). All patients completed a standardized questionnaire, received a physical examination, and underwent isokinetic muscle exercises of the lower extremity with a Dynamometer. ResultsThe average postoperative follow-up was 29 months and showed significant donor site morbidity in the form of sensory disturbance as well as revealing significant differences in extension and flexion between donor and normal thighs in the isokinetic power test. Range of motion at the hip and knee was moderately compromised. ConclusionThe results of this study suggest that dissection of the musculocutaneous perforators can compromise the function of vastus lateralis, which is the largest compartment of the quadriceps group. This could also affect the antagonistic muscles such as the semitendinosus, semimembranosus and biceps femoris. Because of its versatility, adequate tissue stock, possibility of simultaneous two-team approach large and long pedicle and minimal donor site morbidity, the ALT flap has become one of the most preferred transplants for soft tissue reconstruction in the head and neck region. Most authors described the donor site morbidity as minimal (Song et al. 1984; Wolff et al., 2006; Xu et al., 1988; Kimata et al., 1997; Kuo et al., 2001; Collins et al., 2012). In summary, the study shows that functional impairment of the donor thigh can occur but does not affect the patients in their daily life.

Clinical Study to Analyze the Intramuscular Anatomy of Musculocutaneous Perforators of Anterolateral Thigh Flaps.

Background Anterolateral thigh (ALT) flap is a common flap used for many microsurgical reconstructive procedures. Majority of these flaps are based on the musculocutaneous perforators, which, after arising from source artery, course through the bulk of the vastus lateralis muscle. The vascular anatomy of the ALT flap has been often decried as its limiting factor. Methods In this prospective study conducted over 3 years, 207 cases of ALT flap were evaluated. During the harvest of ALT flap, musculocutaneous perforators were laid open through the vastus lateralis, and its variations and pattern were studied for clinical anatomy as well as impact of anatomy on the viability of the flap postoperatively. Results The perforators were recognized to be grouped into three broadly distinguishable anatomical patterns: linear (I), branching (Y), or tortuous (S). While the majority of perforators (51%) were linear “I” perforators, serpentine “S” and branching “Y” perforators were 28 and 21%, respectively. The clinical outcomes were also related to the simplicity of these perforators course as linear “I” perforators had 100% flap viability. Conclusion During the harvest of 207 ALT flaps through 3 years, it could be deciphered that the musculocutaneous perforators traverse through the bulk of vastus lateralis muscle in only three types of patterns (IYS pattern). This identification of pattern could help in prevention of injury while delineating the perforators. Identification and typing of anatomical variation of the musculocutaneous perforator within the vastus muscle could lead to a predictable and safer harvest of the ALT flap.

Peroneal Flap: Clinical Application and Cadaveric Study.

BackgroundThe goal of this study was to investigate the anatomy of the peroneal artery and its perforators, and to report the clinical results of reconstruction with peroneal artery perforator flaps.MethodsThe authors dissected 4 cadaver legs and investigated the distribution, course, origin, number, type, and length of the perforators. Peroneal artery perforator flap surgery was performed on 29 patients.ResultsWe identified 19 perforators in 4 legs. The mean number of perforators was 4.8 per leg, and the mean length was 4.8 cm. Five perforators were found proximally, 9 medially, and 5 distally. We found 12 true septocutaneous perforators and 7 musculocutaneous perforators. Four emerged from the posterior tibia artery, and 15 were from the peroneal artery. The peroneal artery perforator flap was used in 29 patients. Retrograde island peroneal flaps were used in 8 cases, anterograde island peroneal flaps in 5 cases, and free peroneal flaps in 16 cases. The mean age was 59.9 years, and the defect size ranged from 2.0 cm×4.5 cm to 8.0 cm×8.0 cm. All the flaps survived. Five flaps developed partial skin necrosis. In 2 cases, a split-thickness skin graft was performed, and the other 3 cases were treated without any additional procedures.ConclusionsThe peroneal artery perforator flap is a good alternative for the reconstruction of soft tissue defects, with a constant and reliable vascular pedicle, thin and pliable skin, and the possibility of creating a composite tissue flap.

Lateral thigh perforator flap for breast reconstruction: Computed tomographic angiography analysis and clinical series

Although abdominal-based flaps remain the first choice for autologous breast reconstruction, alternative donor sites are necessary when the abdomen is unavailable. Abdominal donor site suitability is determined, at times, according to deep inferior epigastric perforator (DIEP)-protocol computed tomographic angiography (CTA) results. CTA provides information about the pelvis/upper thigh that can be used to evaluate the suitability of other donor sites. This study aimed to examine the utility of DIEP-protocol CTA in the assessment of a lateral thigh perforator (LTP) flap. Furthermore, a small clinical LTP flap breast reconstruction series was presented. The LTP flap anatomy was studied in 100 DIEP-protocol CT angiographies (200 thighs). Collected data included lateral circumflex femoral artery (LCFA) origin; number, type, and course of LTPs; pedicle characteristics; and reference point measurements. Relative relationships between reference point anatomy and perforator anatomy were analyzed. Perforators originated from the LCFA ascending branch (4.6mm average diameter), averaging 2.6 perforators/thigh. The mean estimated pedicle length was 7.7cm (±0.7cm). Septocutaneous perforators were present in 97% (1.8 perforators/thigh). Musculocutaneous perforators were present in 64% (0.9 perforators/thigh). The mean distance between anterior superior iliac spine and perforator was 9.9cm (±1.5cm). Perforators were located 0.13cm (±1.1cm) below the pubic symphysis. Our LTP flap clinical series featured dissection in the supine position and primary donor site closure and highlighted the difficulty in flap design (six patients, nine LTP flaps). LTPs are consistent, reliably present, and radiographically appear to be suitable for microsurgical transfer. DIEP-protocol CTA is an acceptable method for imaging the pertinent LTP anatomy.

Reconstruction of totally degloved fingers: a novel application of the bilobed spiraled innervated radial artery superficial palmar branch perforator flap design provides for primary donor-site closure.

To investigate the results of resurfacing completely degloved digits using bilobed innervated radial artery superficial palmar branch (RASPB) perforator flap in a spiral fashion. A detailed anatomic study on 30 adult fresh frozen cadavers preinjected with silicone rubber compound to demarcate arterial anatomy documented locations, numbers, and diameters of arteries and skin perforators with surrounding nerves. The flap-raising procedure was performed using four fresh cadaver specimen. We reviewed the reconstruction of 12 digits by using a bilobed spiraled innervated RASPB free perforator flap after non-replantable degloving injury. Two skin paddles were marked out using standard points of reference. At least two separate cutaneous perforator vessels were identified using a hand-held Doppler and were dissected back to the RASPB in retrograde fashion. The skin paddles were then divided between the two cutaneous perforators to provide two separate paddles with a common vascular supply. The skin paddles were stacked in a spiral fashion on the flap inset, effectively increasing the width of the flap to cover the totally degloved finger while still allowing closure of the primary donor-site. The RASPB was present within the flap in all cadavers. The direct perforator and the musculocutaneous perforator were available in 93.33 and 76.67%, respectively, with neither of them in 6.67% of the cases. The constantly present two perforators allowed the design of a new bilobed spiraled innervated radial artery superficial palmar branch perforator flap. We used the proposed flap to reconstruct completely degloved digits in 12 patients (mean age 28.6years; range 17-35years). With our proposed flap, no flap failure or re-exploration occurred and the donor site was closed primarily in all cases. All the flaps survived uneventfully. Total active motion ranged from 92° to 140° and 111° to 155° in the cases with and without metacarpophalangeal joint involvement, respectively. The static 2 point discrimination test varied from 6 to 11mm. All the patients were satisfied with the overall results. The bilobed flap is large enough to cover totally degloved finger defects and contain direct skin perforators, provides a bespoke cover for complex soft tissue defects of completely degloved digits while also improving morbidity and cosmesis of the donor site. Level IV, retrospective series.

Abstract: The Usage Of Adipofascial Anterolateral Thigh Flap For The Reconstruction Of Soft Tissue Defects At Extremities

INTRODUCTION: Although reconstruction with adipofascial anterolateral thigh flap (ALTA) is commonly recommended treatment alternative for the extremity defects there are a few studies published in the literature. In this study it was aimed to show the advantageous and disadvantageous of ALTA flap due to experiences that we got from 9 patients at whom superficial extremity defects were reconstructed with ALTA flap. MATERIALS AND METHODS: From 2008 to 2016, 9 patients with extremity defects were treated. All soft tissue defects are superficial and are localized on the hand dorsum in 2 patients, on the palmar aspect of left hand in one patient, on the right wrist in 2 patients, on the left wrist in 2 patients, on the knee in one patient and on the foot dorsum in remaining patient. Wounds were prepared by serial debridement and closed with ALTA flap as soon as possible. During the separation of the flap a minimum of 3 mm fat (a little bit more around the perforator vessel entry) should be preserved over the fascia to ensure the vascularity of the flap. The flaps were inset to the defect adipose side upward in three patient and downward in 4 patients. RESULTS: Eight of nine flaps were supplied with musculocutaneous perforators, while the remaining flap was supplied with septocutaneous perforator. The overall flap survival rate was 100 %. In three cases, which all are adipose tissue up-ward inset flaps, partial skin graft loss occurred. Secondary skin grafting was performed and the wounds closed successfully. Other flaps have also minor graft loss due to minor hematoma, but these areas do not need any surgical intervention and epithelized spontaneously. No secondary debulking procedures were required in any of the flap. All of the donor sites were closed directly with acceptable appearance, minimal donor site morbidity and no contour deformation except in one patient. In that patient wound dehiscence was occurred in the donor site incision. The wound was closed with split thickness skin graft. CONCLUSION: In this study we observed that ALTA flap is an appropriate choice for the reconstruction of soft tissue defects at the extremity. The main advantages of the flap are; sufficient size and pedicle length with pliable structure, minimal donor side morbidity, good aesthetic result and prevention of adhesions. DISCLOSURE:None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript

Effect of Atherosclerosis on the Lateral Circumflex Femoral Artery and Its Descending Branch: Comparative Study to Nonatherosclerotic Risk.

Background:The anterolateral thigh (ALT) flap has been widely used for reconstructions. Nevertheless, the atherosclerotic risk factors that affect the lateral circumflex femoral artery (LCFA) are still inconclusive. The aim was to study the effect of atherosclerosis on the LCFA and descending branch (dLCFA) visualized by computer tomographic angiography (CTA) between nonatherosclerosis and atherosclerosis.Methods:Retrospective studies of CTA of lower extremity were reviewed. The patients were divided into 2 groups: nonatherosclerotic and atherosclerotic risk factors. The angiographic study of LCFA and dLCFA was analyzed, and atherosclerotic and nonatherosclerotic risk factors were compared.Results:Ninety-seven patients with 194 lower extremities were enrolled. Atherosclerotic risks comprised 76 patients. A total of 14, 16, and 46 patients had 1, 2, and 3 risk factors, respectively. Musculocutaneous perforator was 79.38%. The LCFA originated from deep femoral, common femoral, and superficial femoral artery was 97.42%, 2.06%, and 0.52%, respectively. The dLCFA was classified into 5 types depending on its origin. Diameters of LCFA in nonatherosclerotic and atherosclerotic patients were 4.03 ± 0.71 and 4.07 ± 0.97 mm, respectively. No statistical significance was found between both groups in diameters of LCFA. Diameters of dLCFA in nonatherosclerotic patients were 2.28 ± 0.28 mm and in atherosclerotic patients were 2.11 ± 0.28 mm. Statistical significance of diameters of dLCFA was found in patients having 3 risk factors and smoker groups (p < 0.05).Conclusions:LCFA is not atherosclerosis resistant. Stenosis of the LCFA and dLCFA occurred in varying degrees in atherosclerosis-risk patients. Preoperative CTA should be considered to evaluate the patency in multiple risk factors patients.

Clinical follow-up of 16 cases delayed reverse anterolateral thigh pedicled flap for reconstruction of soft tissue defect of the knee

Objective To report clinical follow-up of 16 cases delayed reverse anterolateral thigh pedicled flap for reconstruction soft-tissue defect of the knee. Methods From January, 2006 to January, 2013, 16 patients (10 male, 6 female) with soft-tissue defect in the knee underwent reconstruction with a delayed reverse anterolateral thigh pedicled flap. They ranged in age from 30 to 58 years (mean, 46 years). Soft-tissue defect size in the knee were from 10.0 cm × 12.0 cm-10.5 cm × 20.0 cm. The septocutaneous and musculocutaneous perforator flaps were 5 and 11 cases respectively. The delay period ranged from 9 to 15 days (mean, 12 days). Temporary wound coverage was achieved by vacuum sealing drainage during the delay period. Results One patient developed small wound dehiscence, which spontaneous healed at one month after surgery. All the flaps survived completely. Follow-up period ranged from 2.5-4.0 years (mean, 3 years) postoperatively. A good contour was confirmed at the recipient area. The function of the lower extremity were evaluated with LEM. Very good results were obtained in 9 cases, good in 6 cases and fair in 1 case. Satisfactory clinical results were obtained in this series. Conclusion This technique is safe, reliable, and particularly suitable for patients with diabetes or larger flap. Key words: Anterolateral thigh flap; Perforator flap; Soft-tissue defect; Knee; Repair

Medial lower leg perforators: An anatomical study of their distribution and characteristics

The integument of the medial lower leg is underestimated as a donor site for local and distant reconstructions. Comprehensive knowledge of its perforator anatomy is lacking. This study aims to determine perforator location and characteristics and to compare these regarding the proximal, middle and distal third of the medial lower leg. The medial lower leg region (MLLR) of 16 cadavers was delineated and investigated after injecting the popliteal artery with acrylic paint. Following dissection, all perforators larger than 0.3 mm were localized and mapped. Their course, source vessel, length and diameter were subsequently documented. Overall, 122 perforators were found, 102 (83.6%) originating from the posterior tibial artery, 16 (13.1%) from the medial sural artery and 4 (3.3%) from the anterior tibial artery. A mean of 7.6 ± 2.4 perforators (range 4-13) per MLLR was found. Most perforators (42.6%) were localized in the distal third of the MLLR, followed by the middle (36.9%) and proximal third (20.5%). The largest and longest perforators were found in the proximal third of the MLLR (diameter 1.4 mm, length 9.1 cm), followed by the middle and distal third respectively. Of all musculocutaneous perforators, the majority (78.6%) was located in the middle third of the MLLR. Of all septocutaneous perforators, most (55.3%) were found in the distal third of the MLLR. A small number of unexpected anatomical variants were found. In each third of the MLLR different perforator characteristics were found. Knowledge of these characteristics can be used to direct the reconstructive plan. © 2016 Wiley Periodicals, Inc. Microsurgery 37:319-326, 2017.

Reliability of eccentric position of the pedicle instead of central position in a thoracodorsal artery perforator flap.

To obtain longer vascular pedicle in perforator flaps, surgeons often use eccentrically rather than centrally located perforators. The aim of this study was to compare the safety and reliability of thoracodorsal artery perforator (TDAP) flaps harvested with centrally or eccentrically located perforators. Between January 2008 and March 2012, 100 TDAP flaps were used to reconstruct the lower extremity defects. Flaps longer than 10 cm, with a single musculocutaneous perforator, and one artery-one vein anastomoses were included. The cases were divided into two groups according to perforator location; Central perforators in 60 cases (group 1), and peripheral perforators in 40 cases (group 2). Total pedicle length was between the points where the perforator enters the flap to the end of the pedicle. Real pedicle length was from flap margin to the end of the pedicle. The flap dimension, total pedicle length, real pedicle length, and flap related complications were measured. The flaps were smaller in group 1 than in group 2 (159.6 ± 94.08 vs.189.95 ± 134.30 cm2 , P = 0.455). Total pedicle length was almost the same (12.12 ± 1.57 vs.12.88 ± 2.10 cm, P = 0.420), but the mean real pedicle length was longer in group 2 (6.13 ± 1.33 vs.11.65 ± 2.08 cm, P < 0.05). There were 4 cases of partial loss of flap in group 1 and 3 partial loss and one total flap loss in group 2 without significant difference (P = 0.547). Using eccentrically located perforators is simple method of extending real pedicle length, but there have been concerns regarding flap perfusion and distal vascularity. Our findings suggest that, in TDAP flaps, both eccentric and central perforator are safe options. © 2014 Wiley Periodicals, Inc. Microsurgery 37:44-48, 2017.

Repair of soft tissue defect in hand or foot with lobulated medial sural artery perforator flap

To explore the clinical effect of the lobulated medial sural artery perforator flap in repairing soft tissue defect in hand or foot. Since March 2012 to September 2014, 6 cases with soft tissue defects in hands or feet were treated by lobulated medial sural artery flaps pedicled with 1st musculo-cutaneous perforator and 2st musculo-cutaneous perforator of the medial sural artery. The size of the flaps ranged from 4.5 cm x 10.0 cm to 6.0 cm x 17.0 cm. 5 cases of lobulated flap survived smoothly, only 1 lobulated flap had venous articulo, but this flap also survived after the articulo was removed by vascular exploration. All flaps had desirable appearance and sensation and the two-point discrimination was 6 mm in mean with 4 to 12 months follow-up (average, 7 months). Linear scar was left in donor sites in 3 cases and skin scar in 3 cases. There was no malfunction in donor sites. Lobulated medial sural artery perforator flap is feasible and ideal method for the treatment of soft tissue defect in hand or foot with satisfactory effect.

Upper Medial Tigh Perforator Flap in the Lower Extremity Reconstruction

INTRODUCTION: The medial circumflex femoral perforator flap was named according to the convention of the Gent consensus for perforator flap nomenclature1, on the basis of its customary source vessel. It is a true perforator flap, because intramuscular dissection of the gracilis musculocutaneous perforators is necessary to ensure inflow to the cutaneous flap2.In this report, we present upper medial tigh perforator flap (gracilis perforator flap) in a hori- zontal (transverse to the gracilis muscle) manner based on any reliable perforators from the upper medial thigh. MATERIALS AND METHODS: All of four patient have lower extremity soft tissue defects due to traumatic injuries. There were 1 female patients and 3 male patients. The average age of the patients was 23 years (range, 6 to 35 years). All flaps were raised subfascially in a free-style flap fashion. RESULTS: All perforators were originated from the medial circumflex femoral artery and the perforators were musculocutaneous. Mean flap diameter were 13x6,5cm. In one patient, gracilis muscle also included in flap design and upper medial tigh perforator based skin island also harvested. All flaps were survived and donor sites were closed primarily (Figure 1).Figure 1: Preoperative view of patient (A), the view of harvested upper medial tigh perforator flap (B;C), Postoperative view of patient (D).CONCLUSION: The major advantages of this flap were noted as its donor site that allowed surgeon concealing scar to gluteal creases. However, its major disadvantages was inconsistent perforator position and we believe that free style free flap approach can solve this advantages in experienced hands. The flap can obtain reasonable size, well-hidden scar, function, good pliability.

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.

Comparison of Limited and Full Dissection Abdominoplasty Using Laser Fluorescence Imaging to Evaluate Perfusion of the Abdominal Skin

In an effort to reduce risk, some surgeons promote a limited dissection abdominoplasty technique. They believe that preserving musculocutaneous perforators improves blood supply to the overlying abdominal tissue and that improved vascularity avoids seromas and reduces wound healing problems. Laser fluorescence imaging is a new method that allows quantitative measurements of perfusion. Twenty-two consecutive women undergoing abdominoplasty agreed to participate in this prospective study. The inclusion rate was 100 percent. The SPY Elite Intraoperative Perfusion Assessment System was used to quantitate flap perfusion. Patients served as their own controls to avoid confounders. All patients received superwet infusions followed by liposuction of the abdomen and flanks. First, a limited dissection was performed, preserving medial musculocutaneous perforating blood vessels and the Scarpa fascia on the lower abdomen. The rectus fascia was repaired in all cases. A temporary superficial fascial wound closure was performed. The patient was imaged after injection of the contrast agent. The dissection was then extended to a full abdominoplasty and the Scarpa fascia was removed from the lower abdomen. The patient was reimaged. Wound tension was also measured. Complications included one distal deep venous thrombosis, one infection, and one seroma. There were no cases of marginal necrosis or dehiscence. There was no significant difference (p < 0.05) in perfusion measurements comparing the limited and full dissections. Wound tensions were significantly less (p < 0.001) in the full-dissection group. The limited dissection abdominoplasty does not provide a significant improvement in perfusion compared with a full dissection. Therapeutic, II.

A technical pearl to ensure reliable harvest of the anterolateral thigh myocutaneous flap.

Sir: The anterolateral thigh flap is qualified to be close to an ideal soft-tissue flap.1 The flap has the versatility of transferring different tissue components to fulfill the requirements of reconstruction. In particular, the muscle is invaluable for providing bulk, obliterating dead space, or neutralizing a hostile wound. Muscle viability is therefore of utmost importance.2 The myocutaneous anterolateral thigh flap is traditionally harvested en bloc without skin vessel dissection.3 This approach does not provide the opportunity to visualize the vascular connection between the muscle and skin to confirm the presence of reliable circulation in between, it does not address vascular variations of the anterolateral thigh flap, and it may result in skin vessel/muscular vessel injury during muscle cut, leading to skin paddle or even total flap loss, especially if the muscle segment is small.2–4 The authors propose using a perforator dissection technique for safe dissection of the anterolateral thigh myocutaneous flap. A video for demonstration is also presented. Marking is performed in standard fashion and then ultrasound Doppler imaging is used to identify skin vessels. The anteromedial border is incised down to the deep fascia. Dissection proceeds laterally either suprafascially or subfascially. Skin vessels are identified, and then a suitable vein (or veins) is selected. After that, chosen skin vessels are unroofed by cutting the minimal amount of muscle fibers covering them. Vessel unroofing is complete when the entire course of the musculocutaneous perforator and its source artery are exposed. The vascularly robust muscle needed is then marked. The designed muscle is dissected with meticulous hemostasis. The posterior border of the skin paddle is cut once the defect is clear. The flap is then divided and transferred to the defect and the donor site is closed primarily. (SeeVideo, Supplemental Digital Content 1, which shows part 1 of stepwise harvest of the anterolateral thigh myocutaneous flap with retrograde vessel unroofing, https://links.lww.com/PRS/B240; Video, Supplemental Digital Content 2, which shows part 2, https://links.lww.com/PRS/B241; and Video, Supplemental Digital Content 3, which shows part 3, https://links.lww.com/PRS/B242.)Video 1: Supplemental Digital Content 1 shows part 1 of stepwise harvest of the anterolateral thigh myocutaneous flap with retrograde vessel unroofing, https://links.lww.com/PRS/B240.Video 2: Supplemental Digital Content 2 shows part 2 of stepwise harvest of the anterolateral thigh myocutaneous flap with retrograde vessel unroofing, https://links.lww.com/PRS/B241.Video 3: Supplemental Digital Content 3 shows part 3 of stepwise harvest of the anterolateral thigh myocutaneous flap with retrograde vessel unroofing, https://links.lww.com/PRS/B242.The indisputable advantages of the anterolateral thigh flap are as follows: two-team approach, composite reconstruction, long pedicle, and minimal donor-site morbidity.1 The flap’s vascular anatomy variations are its curse. Kimata et al. reported a 15.7 percent variability in the perforator’s vascular origin.4 Wong et al. reported a 14 percent rate of using the oblique branch as a reliable alternative pedicle.5 These findings imply that in the anterolateral thigh myocutaneous flap, the skin and muscle could be nourished by different vessels, and failure to address this during flap dissection may jeopardize the flap’s skin or muscle viability.4 The anterolateral thigh myocutaneous flap is different from the vastus lateralis myocutaneous flap in that only a segment of the vastus lateralis muscle, not all of it, is harvested with the skin paddle.2 Therefore, (1) fewer skin vessels are captured in the flap’s territory, necessitating utmost protection to chosen perforator; and (2) there is an increased risk of perforator injury during muscle cut unless its path is clear. Thus, vessel unroofing increases the safety and reliability of the technique. The authors’ proposed technique could slightly increase flap harvest time compared with the classic method. However, the benefits as seen warrant the utmost emphasis. In conclusion, the proposed technique is easy to perform. It prevents accidental injury to skin/muscle nourishing vessel(s) and addresses possible anatomical variations. This technique is invaluable for young surgeons. DISCLOSURE The authors have no financial interest to declare. Nidal Farhan ALDeek, M.D., M.Sc. Chung-Kan Tsao, M.D. Huang-Kai Kao, M.D. Fu-Chan Wei, M.D. Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital Chang Gung Medical College and Chang Gung University Taipei, Taiwan