Pedicled Perforator Flaps Research Articles

Abdominal wall reconstruction after resection of an enterocutaneous fistula with an island pedicled anterolateral thigh perforator flap. Case report.

Entero-cutaneous fistula resulting from a locally invasive large bowel carcinoma is a difficult surgical challenge. En-bloc resection of the involved organs and the entero-cutaneous fistula tract with a healthy tissue margin will result in a composite abdominal wall defect that requires closure. Reconstructive surgical options include primary closure, components separation and the use of local, regional or free flaps with or without prosthetic mesh. We report a case of an abdominal enterocutaneous fistula secondary to a locally invasive sigmoid carcinoma, which was reconstructed with a pedicled antero-lateral thigh perforator (ALT) flap. To our knowledge, this is the first case of a malignant entero-cutaneous fistula, which was reconstructed with an ALT flap.

ROL DEL COLGAJO PERFORANTE PEDICULADO EN HÉLICE (PROPELLER FLAP) EN RECONSTRUCCIÓN POST TRAUMÁTICA DE EXTREMIDADES

abstract Propeller flap in post-traumatic lower limb defects aim: To describe indications and results obtained in distal lower leg post traumatic reconstruction using pediculated perforator propeller flap. Patients and methods: Prospective series of consecutive patients treated with propeller flaps between March 2011 and March 2014. Patient’s characteristics, defects and flaps characteristics and post operative complications were recorded. Descriptive statistical methods were used in this study. results: Eight patients were included with a median age of 40 years. The injuries were caused by degloving (one case) and fractures (seven cases), including four calcaneal fractures, two open tibial fractures and one ankle fracture. Three cases were reconstructed with posterior tibial artery pedicled perforator flaps, and five cases with peroneal artery perforator flaps. The median average area of the flaps was 55.8 cm 2 (range 40-117.8 cm 2 ). Coverage was achieved in all cases. no total flap necrosis was reported.

Strategies for customized neck reconstruction based on the pre-expanded superficial cervical artery flap

It is still highly challenging to restore the esthetic neck contour for postburn deformities. In many patients with burns, the back skin remains intact, which is a useful donor site for extensive contracture release. As the main technique, the refinement of the pre-expanded superficial cervical artery (SCA) flaps may improve its application in diverse neck contractures. This study reviewed the cases of three types of neck contractures that were reconstructed with pre-expanded SCA flaps: (1) for unilateral neck contractures, the flaps were harvested as pedicled perforator flaps including a small amount of muscle; (2) for lateral and anterior neck contractures, vascular augmentation with circumflex scapular vessels was used to increase the flap size; (3) for contractures of the entire neck, maximal flap release with pedicle dissection toward the origin of the superficial cervical vessels allowed for reaching contralateral defects. From March 2010 to September 2012, pre-expanded SCA flaps were recommended in 15 patients with severe neck contracture. Tip necrosis occurred in one patient. The donor sites were closed primarily in all cases. One patient had donor-site wound dehiscence that healed within 2 weeks by conservative management. All patients had restored neck extension to a near-normal position without the sense of restricted neck flexion or rotation. Pre-expanded SCA flaps are practical and flexible for the reconstruction of diverse scar contractures ranging from unilateral to total neck lesions. Considering the reconstructive efficiency and the reduced donor-site morbidity, this flap may be an ideal option for the reconstruction of severe neck scar contractures.

The effect of mesenchymal stem cells and sildenafil on flap viability in perforator-based flaps for ischemia/reperfusion injury: An experimental study.

In this study, we evaluated the individual and combined effects of mesenchymal stem cells (MSCs) and sildenafil citrate (SC) on the viability of pedicled perforator flaps in which ischemia/reperfusion injury developed after induction of primary ischemia. Seven Sprague-Dawley rats were used as donors of cells. Rectangular flaps (7 × 7 cm2 ) were created featuring the right second epigastric musculocutaneous perforator in 63 male Sprague-Dawley rats. The animals were randomly divided into two experimental groups (based on the ischemia time of 4 or 8 hours) and a control group. Each of the experimental group was further divided into four subgroups with no treatment, subcutaneous administration of MSCs after termination of ischemia, intraperitoneal administration of SC after termination of ischemia, and combined MSCs and SC treatments at the end of the period of ischemia (n = 7 for each subgroup). A sham group with no-ischemia to flap was used as the control (n = 7). On day 7, viable areas on the flaps were calculated from photographs. The levels of the antioxidative enzymes, such as superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPX), were analyzed in tissue samples obtained from the most distal regions of the flap prior to ischemia and on day 7 after induction of ischemia. No difference was detected between the no-ischemia group and 4-hours SC-treated subgroup, 4-hours combined MSC and SC treated subgroup, 8-hours MSC-treated subgroup, or 8-hours SC-treated subgroup (P > 0.05). In 4-hours ischemia group, the viable flap area of combined MSC and SC treated subgroup was significantly greater than that of the ischemia subgroup (17.17 ± 12.56 cm2 vs. 7.24 ± 7.17 cm2 ; P = 0.015). However, in 8-hours ischemia group, the viable flap area of MSC- treated subgroup was significantly greater than that of the ischemia subgroup (2.69 ± 3.71 cm2 vs. 14.52 ± 8.57 cm2 ; P = 0.004). There were no significant differences in SOD, CAT, and GPX levels detected between no-ischemia group and any of the treated subgroups in 4- and 8-hours ischemia groups (P > 0.05). However, SOD, CAT, and GPX levels in the no-ischemia group were lower than that in 4-hours ischemia control subgroup or 8-hours ischemia control subgroup (P < 0.05). In this rat pedicled perforator based abdominal flap, we found that after primary ischemia, application of MSCs and SC, either individually or in combined form, significantly enhanced antioxidant enzyme levels compared with those in the control group, and provided protection against ischemia/reperfusion injury. The two treatments acted synergistically to protect against damage after 4 hours of ischemia, but either treatment alone more effectively enhanced viable flap area after 8 hours of ischemia, although some flap damage was apparent. © 2015 Wiley Periodicals, Inc. Microsurgery 36:402-409, 2016.

Experimental study of survival of pedicled perforator flap with flow-through and flow-end blood supply.

Flap viability after transfer depends on blood flow from the arterial blood supply below the fascia. This study evaluated survival of a pedicle flap with a perforator lateral branch and flow-through blood supply, compared with that of a flap with a flow-end blood supply and perforator terminal branch. Forty Sprague-Dawley rats, 20 in each group, were assigned to transfer of a superficial epigastric artery pedicle island flap with a flow-through or flow-end configuration of blood supply. Laser Doppler imaging was used to evaluate flap perfusion 2 h, 3 days and 5 days after surgery. The rats were killed on day 5, and lead oxide-gelatine-enhanced flap angiography and histology with haematoxylin and eosin staining was performed. Dorsal midline tissue was excised for quantification of vascular endothelial growth factor by western blot assay. On day 5 after surgery, the flow-through group exhibited a significantly greater mean(s.d.) flap survival area (97·8(3·5) versus 80·8(10·2) per cent; P = 0·003), microvascular density (303(19) versus 207(41) per mm(2) ; P < 0·001) and perfusion (8·64(0·14) versus 5·95(0·14) perfusion units; P < 0·001) than the flow-end group. The flow-through group exhibited more angiosomes connected by dilated vascular anastomoses between the skin and subcutaneous fasciae. The flow-through blood supply improved pedicle perforator flap survival. Surgical relevance Perforator flap failure is mainly the result of impaired blood supply, as a flow-end blood configuration is nourished only by the perforator terminal branch of the artery. This work showed that the flow-through blood supply nourished by the perforator lateral branch improved flap survival, with dilatation of collateral vascular anastomoses and increased neoangiogenesis. The use of a flow-through configuration improves perforator flap survival and could therefore minimize morbidity resulting from flap necrosis.

Dermatofibrosarcoma protuberans: A 10-year experience

Summary Background Providing soft-tissue coverage after wide excision of dermatofibrosarcoma protuberans (DFSP) is always challenging; according to the literature, a skin graft is often chosen as the first option. However, possible suboptimal functional and cosmetic results have been noted. Aims and objectives We present our 10-year experience using pedicled or free flaps for reconstruction after a wide excision of DFSP to provide adequate soft-tissue augmentation and enhanced esthetic results. Materials and methods This was a retrospective study comprising 14 DFSP patients who were treated between February 2003 and December 2013. All patients underwent a wide excision with a 3-cm safe margin with immediate reconstruction, and a negative deep margin confirmed with a frozen section. The reconstruction method included nine pedicled perforator flaps and five free perforator flaps. All patients received adjuvant radiotherapy after surgery. Results The peak incidence that occurred in this series was the highest in patients younger than 30 years. None of the 14 patients exhibited recurrence, and the mean follow-up time was 30 months. Half of the patients exhibited DFSP distributed over the trunk; the patients in the series were predominantly male. A total of 13 flaps were successful except for one pedicled flap that failed from venous congestion; we used it in a salvage procedure by using full-thickness skin graft for coverage. Conclusion A wide excision with a 3-cm margin of safety with immediate reconstruction is a reliable method for DFSP resection. Initiating adjuvant radiotherapy might reduce the chance of local recurrence. To minimize the complications of skin graft, pedicled, or free flaps provide superior functional outcome, soft-tissue augmentation, and esthetic results.

Lateral thoracic artery perforator (LTAP) flap in partial breast reconstruction

Partial breast reconstruction using pedicled perforator flaps from the thoracodorsal (TDAP) and lateral intercostal arteries (LICAP) is well described. The article introduces the lateral thoracic artery perforator (LTAP) flap as an additional valuable option from the lateral chest wall and reports clinical experience and outcomes. The anatomy of the LTAP flap is reviewed and the results of a consecutive series are reported. In a series of 75 consecutive cases of lateral chest wall perforator flaps used for reconstruction of partial breast defects, 12 (17%) were raised as pure LTAP flaps, and a further 19 (27%) as combined LTAP/LICAP flaps. The LTAP was therefore used in 44% of flaps overall. One LTAP flap (delayed case) had early venous compromise that settled spontaneously. The LTAP flap is a reliable option for partial breast reconstruction from the lateral chest wall, particularly in the immediate setting. It allows comparable flap size to be harvested compared to LICAP flaps. The LTAP flap can be raised on its own pedicle allowing greater mobilization or it can be incorporated into the more commonly used LICAP flap to augment perfusion.

Pedicle perforator flaps for vulvar reconstruction — New generation of less invasive vulvar reconstruction with favorable results

ObjectivesVulvar reconstruction after cancer surgery remains challenging. Pedicle perforator flaps are believed to be a less invasive option with better cosmesis. MethodsA retrospective review identified 27 flaps in 16 patients who underwent vulvar reconstruction after cancer surgery using island pedicled perforator flaps. Their average age was 55.7±17.8years (Range: 22–85). The average BMI was 23.5±4.0 (range: 18.8–28.5). Five of the 16 patients underwent unilateral vulvar reconstruction, and 11 of them underwent bilateral vulvar–perineal reconstructions. The perforator flaps included deep femoral (profunda) artery perforator (DFAP or PAP) flaps (n=11), medial circumflex femoral perforator (MCFAP) flaps (n=8), external pudendal artery perforator (EPAP) flaps (n=2), medial thigh free style perforator flaps (n=2), and internal pudendal artery perforator flaps (n=4). ResultsAll flaps survived with a 100% success rate. Three patients developed small wounds that required debridement and closure after the reconstruction. All donor sites were closed primarily. One patient developed temporary peroneal nerve palsy.During follow-up, none of the patients presented with donor site morbidities. All of the patients were satisfied with the cosmetic and functional results, except that one patient underwent a flap debulking procedure three months after surgery. ConclusionsCompared to traditional myocutaneous flaps, perforator flaps provide thinner fasciocutaneous flaps for vulvar reconstruction with favorable reconstruction results and fewer donor site morbidities. The medial or inner thigh is a region that is rich in perforators, which allow for more versatile flap design according to the defect. Furthermore, most of the donor site can be closed primarily without complications.

Lower limb reconstruction using propeller flaps

Background: The islanded pedicled perforator-based propeller design flap is a versatile local flap for reconstruction of defects of lower limbs from knee to leg to ankle to foot. Patients and Methods: All patients with small-and moderate-sized defects in lower limbs which required a flap cover are included in the study. Between October 2014 and September 2015, prospective study of patients undergoing perforator-based propeller flap procedure was performed. Patients were evaluated for defect size, defect location, procedure done, and donor site cover. Results and complications of the propeller flap were also analyzed. Atotal of eight flaps were done to cover defects of lower limbs. Results: Out of the eight flaps, seven were islanded on posterior tibial artery, one on the lateral geniculate artery perforator. Four flaps were used to cover lower one-third leg, three for middle one-third leg, and one for knee. The flap dimensions ranged from 3 cm×7 cm to 7 cm×19 cm. The median angle of rotation was 160°(ranging from 60° to 180°). Sixty-three percent of patients had associated fractures. Seven flaps survived completely and one flap had partial necrosis, which was managed with secondary split skin grafting. Conclusion: The islanded propeller design pedicled perforator flaps provides reliable coverage for small-to medium-sized defects for lower limbs, particularly lower one-third leg defects. This flap can provide an esthetically acceptable result as well.

The freestyle pedicle perforator flap: a new favorite for the reconstruction of moderate-sized defects of the torso and extremities.

BackgroundPerforating vessels are a consistent anatomical finding and well described in the current literature. Any skin flap can be raised on a subcutaneous pedicle as long as it contains at least one supplying perforator. Perforator flaps have been interlinked with microsurgery and generally not widely performed by the general plastic surgeons. The aim of this paper is to present the simplicity of pedicled perforator flap reconstruction of moderate-sized defects of the extremities and torso.MethodsWe retrospectively reviewed the charts of 34 patients reconstructed using 34 freestyle pedicled perforator flaps for moderate-sized defects of the truncus and extremities. We registered indications, flap size and localization, success rate, and complications. Most importantly, we describe a simple approach to the design of freestyle pedicled perforator flaps and elaborate on technical aspects in the context of current literature.ResultsThe reconstructive goals were achieved in all cases without any total flap loss or major complications. Minor complications occurred in 7/34 (21 %) cases consisting of venous congestion leading to distal tip necrosis or epidermolysis; partial flap loss was significant in 4 cases, however never more than 10 % of the total flap size. Reconstruction was performed on the lower limb in 13 cases, upper limb in 12, and 9 cases were on the truncus. The angle of rotation was 90° in 21 cases and 180° in 13 cases. The most common indication was reconstruction of oncological skin defects; melanoma 19, BCC 6, SCC 2, other 7. The flap size varied from 1.5×3 cm to 12×22 cm. The perforator identification was done by intraoperative exploration in 17 cases and by color Doppler ultrasonography in 17 cases.ConclusionsModerate-sized defects of the torso and extremities can be successfully reconstructed by pedicled perforator flaps. The flap dissection is simple, and the complication rates comparable to other reconstructive options.Level of evidence IV, therapeutic study

Pedicled Perforator Flaps for Reconstruction of Bilateral Knee Defects: A Case Report

Pedicled Perforator Flaps for Reconstruction of Bilateral Knee Defects: A Case Report

Hemodynamic changes of peroneal perforator flaps and their clinical significance

Objective To determine the blood flow velocity of peroneal artery perforator flaps and the related clinical significance.Methods Peak systolic flow velocity (PSFV) of 38 peroneal artery perforator flaps were measured with color doppler flow imaging (CDFI) before and after flap surgery.Flap design and surgical points were summarized in combination with correlation factors affecting vascular supply and survival of perforator flaps and clinical data.Results All flaps survived.PSFV of the supplying skin perforators was (24.68± 15.15) cm/s preoperatively and (38.65± 16.96) cm/s postoperatively.There were 12 free perforator flaps with significant increase in PSFV after operation in comparison with that before operation [(32.69± 15.86) cm/s vs (14.19±6.28) cm/s,P＜0.01].Pedicled perforator flaps amounted to 26 and PSFV significantly increased from preoperative (29.52± 15.65)cm/s to postoperative (41.40± 17.04)cm/s (P＜0.01).Conclusion The vessel pedicles should be dissected thoroughly and all irrelevant branches arising from them should be ligated to gain maximal flow through the perforator.The phenomenon of crossing angiosomes of the flap' s blood supply especially through the long and low-resistant neurocutaneous vascular axis can be explained from a hemodynamic view. Key words: Soft tissue injuries; Hemodynamics; Perforator flaps

Pre-operative planning of pedicled perforator flaps with contrast-enhanced ultrasound

Pre-operative planning of pedicled perforator flaps with contrast-enhanced ultrasound

Pedicled Perforator Flaps for Vulvar Reconstruction – A Versatile, Less Invasive and Simple Way with Favorable Results

BACKGROUND: Vulvar reconstruction after cancer surgery remains a great challenge for reconstructive surgeons. Vulvar area is an easy-contaminated region by secretions. Soft tissue reconstruction is a superior choice over skin graft for better wound healing, tolerable tissue for further radiotherapy and better cosmetic results.1 MATERIALS AND METHODS: A retrospective review identified 23 flaps in 13 patients with vulvar reconstruction using island pedicled perforator flaps. The average patients’ age was 58.5 ± 17.6 (Range: 22-85). The average of BMI was 24±3.7 (range: 18.8-28.5). All of them received vulectomy for cancer or pre-cancer lesions. Three patients had unilateral vulvar reconstruction while the others 10 patients had bilateral vulvar reconstruction. The perforator flaps included were profunda artery perforator flaps (n=12), gracilis perforator flaps (n=7), external pudendal artery perforator flap (n=2), medial thigh perforator flap (n=2), and internal pudendal artery perforator flap (n=4). 9 of the flaps were designed as V-Y fashion to facilitate donor site wound closure in larger defect reconstruction and the rest 14 flaps were designed as fusiform shape. RESULTS: All the flaps survived with a 100% successful rate. Three patients experienced small wound disruption that requires wound debridement and wound closure after the reconstruction. All the donor sites were closed primarily. One patient developed temporary peroneal nerve palsy. None of them presented with medical complications. With follow-up, none of the patients presented with donor site morbidities. All the patients were satisfied with the cosmetic and functional results except that one patient received flap debulky procedure three months after surgery. The thickness of the flap caused discomfort during her walking. DISCUSSION AND CONCLUSION: Comparing to traditional myocutaneous flaps, perforator flaps provides thinner fasciocutaneous flaps for vulvar reconstruction with favorable reconstruction results and few donor site morbidities.2-4 The medial or inner thigh is a region rich of perforators. These perforators allow a versatile flap design depending on the location and extension of the vulvar defect after vulectomy. Furthermore, most of the donor site can be closed primarily without complications.

Lumbar and thoracic perforators: vascular anatomy and clinical implications.

Pedicled perforator flaps in the thoracic and lumbar regions allow reconstruction of the posterior trunk. They enable reconstruction of various local defects without microvascular anastomoses and with minimal donor-site morbidity and excellent cosmesis. The authors examined the locations of perforators in the lumbar and thoracic regions. Ten cadaver hemithoraces and lumbar regions were freshly harvested and dissected. Intraarterial injections were performed with colored latex, followed by dissection in the suprafascial plane. Perforators with a diameter larger than 0.5 cm were located and measured from the midline and from C7 (thoracic) and coccygeal (lumbar) reference points. The most dominant perforators were injected with radiopaque dye and scanned with high-resolution computed tomography. The patterns were analyzed by the quadrat counting test (based on chi-square statistics) for the null hypothesis of complete spatial randomness. A total of 164 thoracic and 216 lumbar perforators were identified. These were clustered in highest density in two major areas within 10 to 20 cm of the C7 and coccygeal reference points and 10 cm from the midline; this pattern was not a random distribution (p < 0.001). Perforasomes of lumbar perforators in some instances crossed the midline, joining adjacent contralateral lumbar perforators by means of direct and indirect linking vessels. Lumbar and thoracic pedicled perforator flaps provide useful options for reconstructing complex defects. Use of these flaps is aided by anatomical knowledge of the location of major clusters of perforators.

The medial arm pedicled perforator flap: Application of phenomenon of one perforator perfusing multiple perforator angiosomes

BackgroundThe medial arm is an optimal potential donor site for treating skin defects around the elbow. However, whether a reliable pedicled perforator flap could be harvested from the medial arm remains unanswered. The purpose of this study was to report the technique and our results using the medial arm pedicled perforator flaps. MethodsA total of eight flaps in seven patients underwent the medial arm pedicled perforator flaps to treat skin defects around the elbow. The flap was pedicled on one perforator 1.3±0.3mm in diameter within 3cm above the medial epicondyle. The flap size varied between 10 and 20cm in length and between 6 and 10cm in width. ResultsOf the eight flaps in seven patients, seven flaps survived uneventfully except that one suffered venous insufficiency. Six patients were followed up for 1 month to 2 years. One patient was lost to follow-up after 7 days. The wounds in all patients healed satisfactorily. No deep wound infection and wound dehiscence developed. No revision surgery was performed in the survived flaps. ConclusionsThe survival of the medial arm pedicled perforator flap confirms the phenomenon of one perforator perfusing multiple perforator angiosomes in the medial arm, although this study has the retrospective clinical nature and limited number of the patients. The medial arm pedicled perforator flap is a useful tool to treat skin defects around the elbow.

Reconstruction of a Posterior Trunk Defect using a Pedicled Dorsolateral Posterior Intercostal Artery Perforator Flap.

Reconstruction of a Posterior Trunk Defect using a Pedicled Dorsolateral Posterior Intercostal Artery Perforator Flap.

Venous-supercharged freestyle posterior thigh flap without a descending branch of the inferior gluteal artery for reconstruction in the infragluteal region

The posterior thigh flap is a workhorse flap for reconstruction in the gluteal region. The main vascular pedicle of the flap is commonly the descending branch of the inferior gluteal artery, although it is at risk for transection during sarcoma resection. We report successful reconstruction of an infragluteal defect resulting from sarcoma resection with a venous-supercharged freestyle posterior thigh flap in the absence of the descending branch of the inferior gluteal artery. A 77-year-old man underwent sarcoma resection in the infragluteal region. The descending branch of the inferior gluteal artery was sacrificed. We found a sizable perforator through the long head of the biceps femoris and harvested a posterior thigh flap on the basis of that perforator with a freestyle approach. The flap gradually developed a congestive appearance after transfer. We therefore anastomosed the vein of the second perforator to an accompanying vein of the sciatic nerve at the recipient site. The complete flap survived, and the postoperative course was uneventful. We believe that combined use of the freestyle approach and the perforator-supercharging technique can enhance the versatility and the safety of pedicled perforator flap transfer.

Microsurgical Pedicle Lengthening for Pedicled Thoracodorsal Artery Perforator Flap Transfer

The pedicled thoracodorsal artery perforator flap has been shown to be an effective option for reconstruction of various regions, including the breast, axilla, upper arm, lateral chest, and shoulder area. However, the original length of the pedicle limits the flap's reach to remote locations. We devised a technique that involves microsurgical lengthening of the pedicle to extend the arc of rotation of the pedicled perforator flap. After exposure of the subscapular vascular tree, we divided the thoracodorsal vessel at the point of bifurcation to the serratus branch and then the pedicle was reconnected to the distal end of the serratus branch. Here, we present 2 cases in which this technique was effectively applied to reconstruct a defect of the elbow using a thoracodorsal artery perforator flap with a pedicle lengthening procedure.

The ulnar palmar perforator flap: Anatomical study and clinical application

Defects sustained at the little finger and the ulnar aspect of the hand are common and pedicled perforator flaps have unique advantages in resurfacing it. The purpose of this study is to reappraise the anatomy of the septocutaneous perforator in the postero-medial aspect of the hand and present our clinical experience in using perforator flaps based on it. This study was divided into anatomical study and clinical application. In the anatomical study, 30 preserved upper limbs were used. Clinically, 16 patients with defects at the little finger or the ulnar aspect of the hand underwent reconstruction with flaps based on the perforator from the ulnar palmar artery of little finger. The defects ranged from 2.3 × 1.3 cm(2) to 5.7 × 3.0 cm(2). The septocutaneous perforator was constantly located 1.3 ± 0.3 cm superior to the fifth metacarpophalangeal joint with a diameter of 0.8 ± 0.2 mm. It travelled through the space between the superficial layer and the deep layer of hypothenar muscles, and ramified into three branches before entry into the skin. The ascending branch of the perforator has two patterns of anastomoses with the descending dorsal carpal branch of the ulnar artery: true anastomoses and choked anastomoses. Clinically, flaps in all 16 cases survived uneventfully, and donor sites healed without deformity. The location of the perforator at the postero-medial aspect of the hand is consistent; the ulnar palmar perforator flap is particularly suitable to cover defects in the little finger or the ulnar aspect of hand.