Pedicled Perforator Research Articles

Free extended posterior tibial artery perforator flap with the neurovascular plexus of a saphenous nerve branch for large soft tissue and sensory reconstruction: Anatomic study and clinical application.

The posterior tibial artery perforator (PTAP) flap is a useful tool for reconstruction of soft tissue defects in the leg. However, the size and reliability of the flap largely depends on the quality of the perforator by which the flap is supplied, and the sensory recovery of the flap is limited. In this study, the anatomy of the saphenous nerve branches and their accompanying vessels was investigated, and a free extended PTAP flap with the neurovascular plexus of a saphenous nerve branch was designed for large soft tissue and sensory reconstruction in a series of clinical cases. Sixteen adult cadaveric legs perfused with red latex in the femoral artery were dissected. The number and location of the saphenous nerve branches and the features of their accompanying vessels were dissected and studied. From January 2016 to December 2017, six patients with soft tissue defects ranged from 8 × 2.5 cm to 21 × 4 cm were repaired by the free extended PTAP flap. The patients' average age was 48 years. The causes of the defects included machine injuries in three patients and traffic injuries in the other three. The defects located at the hand in three cases, foot in two cases, and ankle in one case. The flap was designed based on the perforators of the posterior tibial artery and included a branch of saphenous nerve. The perforator pedicle and the nerve branch were connected to the vessels and nerve in the recipient site, respectively. The saphenous nerve gave off 5.8 ± 1.1 branches, with a relatively constant one issuing 8.1 ± 0.7 cm distal to the medial femoral condyle. Every nerve branch had an accompanying vessel, which connected with the PTAPs and supplied the skin. The size of the flap ranged from 10 × 3.5 cm to 23 × 5 cm. All of the flaps survived completely without complications. Follow-up varied from 6 to 12 months. All the patients obtained cold/hot sensation and pain sensation. The results of Semmes-Weinstein monofilament test ranged from 4.31(2 g) to 5.46 (26 g), and the 2-point discrimination test varied from 20 to 35 mm. The free extended PTAP flap, containing the saphenous nerve branch and its accompanying vessels, may be an alternative for large soft tissue reconstruction with improved sensation recovery.

Thoracodorsal Artery Perforator Flap in Partial Breast Reconstruction: A Systematic Review.

Introduction:Breast conserving surgery followed by radiation therapy represents the standard of care for early stage breast cancer. Oncoplastic breast surgery includes several reconstructive techniques essentially summarized in 2 categories: volume displacement and volume replacement procedures. These latest procedures have evolved over time from the use of the entire latissimus dorsi muscle to the use of pedicled perforator flaps, namely the thoracodorsal artery perforator (TDAP) flap. The aim of this article is to provide a comprehensive review of the literature regarding the use of the TDAP flap in partial breast defects.Methods:A literature search was performed via PubMed, Medline, and Cochrane. Studies reporting the use of the TDAP flap after breast conserving surgery were included. Patient characteristics, topography and size of breast defect, flap size and design, number of perforators, and operative time were analyzed. Moreover, aesthetic and functional (shoulder morbidity) results, patient satisfaction, postoperative complications, and donor site morbidity were registered.Results:Twelve articles fulfilled inclusion criteria, and 337 patients were included. All articles except 1 described the use of the TDAP flap for defects in every breast quadrant. The mean weight of resected breast tissue was 97.28 g, and patients with over 20% of volume deficiency were considered eligible for TDAP flap volume replacement. The ellipse-shaped skin paddle (oriented oblique downward, transversal or oblique upward in most cases) was extended over the anterior border of the latissimus dorsi muscle to include possible septocutaneous perforator vessels. Most authors began the dissection from the anterior and caudal border of the flap to reserve the possibility to convert the TDAP to a musculocutaneous flap and check for septocutaneous perforators. Flap size ranged from 4 × 12 to 21 × 9 cm. The mean procedure time was 192.21 minutes. Mean follow-up was 17.42 months. Evaluation by way of a 5-point Likert scale reported overall mean values of over 4 points. Satisfactory outcomes were reported in 92.85%–100% of cases. Patient satisfaction ranged from 80% to 94% of cases. The incidence of seroma (1 case) and “shoulder-related” donor site morbidity was very low.Conclusions:Despite the heterogeneity of the evaluation methods, our review suggested that the use of the TDAP flap in oncoplastic surgery allows for satisfactory aesthetic outcomes and quite high levels of patient satisfaction. The TDAP flap represents an effective and versatile tool that amplifies the oncoplastic surgeon’s arsenal, which allows for satisfactory outcomes.

Is Pedicle Perforator Flap Safe and Reliable for Lower Limb Reconstruction?

Is Pedicle Perforator Flap Safe and Reliable for Lower Limb Reconstruction?

Safety and Efficacy With Augmented Second-Generation Perforated Pedicle Screws in Treating Degenerative Spine Disease in Elderly Population.

Degenerative spine disease is a common cause of low back pain in people age 65 years or older. Nonsurgical treatment is tried first, but if it is unsuccessful, surgery is advocated. This has special connotations for both underlying disease and the biomechanical characteristics of osteoporotic bone. We conducted an observational study to investigate the clinical and radiological outcome in patients in this age group with poor bone quality and degenerative lumbar instability treated with fusion using perforated pedicle screws augmented with polymethylmethacrylate (PMMA). We collected prospective data on treatment, outcome, and patient characteristics from our institution's database. The primary outcome was a change in pain and physical function measured by the visual analog scale, the Core Outcome Measures Index, and the Oswestry Disability Index. Control participants were also analyzed for secondary complications such as hardware mobilization, fusion (as apparent on radiographs), and adjacent fractures or adjacent degenerative disc disease. We included 89 patients who underwent surgery between October 2015 and February 2018 at a mean age of 78 years (range, 67-88 years) and were then monitored for at least 12 months (range, 12-40 months). Findings on pain and function questionnaires showed improvement at 6 months after surgery, maintained at the final evaluation; 90% of patients had final score increases of ≥15 points. No patient developed clinical complications secondary to PMMA leakages. One patient had nonunion and screw breakage. No other patient had clinical or radiological nonunion. Of the control participants, 6 had adjacent disc disease, with 2 of them requiring instrumentation extension. Six deep infections required surgical revision without removal of material. PMMA-augmented cannulated pedicle screw instrumentation in spine fusion effectively and safely treats degenerative lumbar disease in patients who are age 65 years or older with poor bone quality.

Wide Local Excisions and Pedicled Perforator Flaps in Hidradenitis Suppurativa: A Study of Quality of Life.

Hidradenitis suppurativa (HS) is a chronic skin pathology characterized by the occurrence of inflamed and swollen lesions, with a devastating impact of the disease on patient's quality of life. Wide local excision (WLE) of the affected tissue is the criterion-standard treatment, but there is no general consensus on the best reconstructive technique. The aim of this article is to evaluate the quality of life before and after WLE combined with pedicled perforator flap reconstruction, in patients suffering from HS. We analyzed 26 consecutive patients suffering from Hurley stage III HS. Every patient underwent WLE, followed by reconstruction with pedicled perforator flap. Dermatology Quality of Life Index (DLQI) tests were administered to every patient preoperatively and 6 months after surgery, when the clinical condition was considered stable. Dermatology Quality of Life Index scores were compared in terms of means with Student t test. Linear regression studies were used to compare the changes in DLQI score with the surgical and clinical variables. Axillary area involvement was found in 21 of 27 patients; 6 patients had more than 1 body region involved. Thirty-two pedicled perforator flaps were performed, and 22 were thoracodorsal artery perforator flaps. Mean DLQI test score before the first operation was 21.31 ± 4.79; the average DLQI score after the last follow-up was 5 ± 2.95 (P < 0.0001). Dermatology Quality of Life Index scores were not influenced by complications including reoperation. There were also no correlations found between DLQI score delta and number of reoperation (-0.18) or days of hospital stay (-0.13). Wide local excision followed by pedicled perforator flap reconstruction allows a radical excision of HS areas with short postoperative healing periods. Dermatology Quality of Life Index scores confirmed high levels of patients' satisfaction. Disadvantages of this technique include difficult learning curve, long operating time, and a nonnegligible complications rate.

Pedicled vertical posteromedial thigh (vPMT) flap for the reconstruction of extensive perianal-genital defects

Perianal and genital defects occur because of a vast etiology making the reconstruction of function and esthetics remain challenging. Depending on the extent of the defect, different techniques have been employed for coverage including skin grafts, local skin flaps, musculocutaneous flaps, and pedicled perforator flaps. The pedicled vertical posteromedial thigh (vPMT) flap is a new perforator flap that has rarely been employed for this kind of reconstruction. The purpose of this article is to focus on the vPMT perforator flap, which is mainly used as a propeller flap, for reconstructing the perianal and genital region as a feasible option in this area. From July 2013 to December 2018, we treated twelve patients with extensive perianal and/or genital defects with 21 pedicled vPMT flaps. Three patients needed unilateral reconstruction, while 9 patients bilateral needed bilateral reconstruction. The location of the defects included the scrotal region (3 cases), the perianal region (8 cases), and the vulvar region (5 cases), whereby some cases had combined defects. The flap sizes varied from 5-9 cm in width to 18-35 cm in length and all flaps were harvested as perforator-based island flaps. The flap movements used for defect coverage included V-Y advancement in three cases and rotation in propeller fashion in eighteen cases. All flaps survived without any major complications and all donor sites were closed primarily. Our case series showed an exemplary model for the coverage of the perianal and genital region by using the pedicle vPMT flap and the achievement of a sustainable treatment with a minor morbidity of the donor site. We believe that the vPMT flap could be an alternative option for the reconstruction of the perianal and genital region and could be inserted in the armamentarium of the reconstructive microsurgeon.

Lower limb perforator flaps: Current concept

Following a long period dominated by random fasciocutaneous flaps or muscle flaps, solutions to cover the lower limb have been largely diversified by the advent of so-called "perforator" flaps. Extended knowledge of vascular anatomy has propagated the development of this innovative procedure, in the objective of reducing morbidity. The existence of close to 400 perforator vessels in the body makes it possible to offer new flap perspectives for many defects, which were sometimes previously impossible to manage before except by free flap. For us, perforator flaps have become the current first-line solutions for small to medium size loss of substances. Understanding of vascular physiology and surgical experience are essential in choosing indications, detecting perforators, and modeling flaps to be optimally positioned in the reconstructive decisional algorithm. New skills are needed to master this type of reconstruction and limit failures, which implies a learning curve not only for flap design, perforator detection and surgical procedure, but also for monitoring and management of complications. In this manuscript, we outline the concepts and principles of the majority of the pedicled perforator flaps available for coverage of the lower limb, based on experience of more than 400 perforator flaps suitable for this localization.

Perforator-Pedicled Propeller Flaps for Lower Extremity Reconstruction.

Reconstruction of the lower extremity is considered a major challenge due to frequent bone exposure and the absence of local tissue redundancy, as well as often due to the presence of vascular insufficiency. Many surgeons have preferred free flaps especially for reconstructing the more distal lower limb defects until the evolution of pedicled perforator flaps and propeller flaps in particular provided a like-with-like reconstruction of the lower extremity without affecting the main vessels of the limb or the underlying muscles, and without the risk of any microanastomosis especially in patients with multiple comorbidities. Perforator-pedicled propeller flaps as local flaps in the lower extremity are best suited for small- and medium-sized defects with minimal donor-site morbidity, regardless of the cause of the defect. Any of the three source vessels of the leg can provide reliable perforators for propeller flap coverage of the distal leg and foot. The three main risk factors that are relative contraindications may be advanced age, diabetes mellitus, and atherosclerotic peripheral vascular disease.

Diametric Comparison between the Thoracodorsal Vessel and Deep Inferior Epigastric Vessel in Breast Reconstruction

Background In microvascular anastomosis, size discrepancy is common and can increase thrombotic complications. If size differences can be predicted, then vessels of the appropriate size can be selected. This study documented the difference in diameter between the thoracodorsal (TD) vessel and deep inferior epigastric perforator (DIEP) pedicle in each patient who underwent breast reconstruction using free tissue transfer. Patients and Methods. This retrospective study included 32 anastomoses (27 breasts including five cases of supercharged anastomosis) of breast reconstruction with the free DIEP flap and TD recipient between August 2018 and June 2019. In the microscopic view, the caliber of the TD vessel, the largest branch to the serratus anterior muscle, the descending branch, the largest and the second largest branches to the latissimus dorsi muscle, and the DIEP pedicle were measured. Results The diameter of the deep inferior epigastric artery was similar to that of the descending branch, and their anastomosing rate was 56.3%. The diameter of the deep inferior epigastric vein was similar to the branch to the serratus anterior muscle and the descending branch, and their anastomosing rates were 29.3% and 29.3%, respectively. All flaps were survived; however, in one case, a reoperation was needed to remove the hematoma, in which case fat necrosis occurred as the only complication. Conclusion TD branches of similar size to the DIEP pedicle were prioritized in anastomosis. The descending branch and the branch to the serratus anterior muscle are expected to be good candidates as recipients in breast reconstruction with DIEP free flap. Moreover, supercharged anastomosis of DIEP pedicles can be achieved within TD branches.

Chimeric Anterolateral Thigh Flap for Primary Functional Reconstruction of Complex, Composite Near Total Hemi Facial Post Excision Defects.

Microvascular free tissue transfer has revolutionized the management of complex composite head and neck defects. To evaluate the functional and aesthetic outcomes in the primary reconstruction of post-excisional near total hemifacial defects with the chimeric anterolateral thigh flaps (cALT). The author as a prelude to this clinical study has done a cadaveric study on the quadriceps artery angiosome. In this retrospective cohort study, data are collected from the records of 6 patients who had undergone primary cALT flap reconstruction for their post excisional near total hemifacial defects from January 2013 to December 2017. All 6 patients with various advanced malignancies involving the hemiface underwent wide local excision. Wide local excision resulted in the loss of skin and critical facial muscles that led to near total hemiface composite defects. Reconstructions were done with the cALT flaps that included segment of the vastus lateralis muscle harvested on its independent neurovascular perforator pedicle and the skin paddle on a separate perforator. In all cases, the facial nerve stumps were anastomosed to the nerve to vastus lateralis for reanimation of the face. In addition, 4 patients underwent primary radical neck dissection, but all had postoperative radiotherapy and chemotherapy. All patients attained well-pronounced nasolabial fold, symmetrical smile, and good oral competence in an average period of 10.75 months post operatively. In an average of 22 months follow up, none of them had locoregional recurrences. None required any secondary procedures. In the post excisional near total hemifacial composite defects, primary functional reconstruction with tailored cALT flaps can bring good aesthetic and functional results.

Bipedicled dorsal intercostal artery propeller flaps for reconstruction of extensive cervicothoracic midline defects.

Propeller flaps have been reported to cover cervicothoracic midline defects with lower donor site morbidity compared to muscle flaps. When these defects are extensive, we propose a propeller flap technique that we have named dorsal intercostal artery perforator plus (DICAP+) flap based on two perforator pedicles, to secure the large skin paddle. In this article, we present our experience. Six propeller DICAP+ flap procedures were performed on five patients, to reconstruct cervicothoracic midline defects. Three of them were caused by tumors and two were secondary to hardware exposure after spinal surgery. Defect sizes ranged from 16 × 5 to 24 × 9 cm. Every propeller flap was harvested on two perforators including one DICAP, and rotated from 80° to 180°. Skin ellipse size ranged from 15 × 7 cm or 82.4 cm2 to 25 × 12 cm or 235.5 cm2 , equal to a mean surface area of 160 cm2 . The donor site was closed by primary suturing in four of the six procedures, by a contralateral propeller DICAP flap in one patient, and was left to heal by secondary intention in another one. All six flaps successfully covered the underlying defects with no evidence of partial or complete necrosis. No other complications were observed at recipient and donor sites. The follow-up period ranged from 9 months to 2 years. Propeller flaps based on two dorsal perforators including one dorsal intercostal artery perforator, DICAP+, are a reliable means of reconstructing extensive cervicothoracic midline defects.

The effects of optimizing blood inflow in the pedicle on perforator flap survival: A pilot study in a rat model.

BackgroundPerforator flaps have led to a revolution in reconstructive surgery by reducing donor site morbidity. However, many surgeons have witnessed partial flap necrosis. Experimental methods to increase inflow have relied on adding a separate pedicle to the flap. The aim of our study was to experimentally determine whether increasing blood flow in the perforator pedicle itself could benefit flap survival.MethodsIn 30 male Lewis rats, an extended posterior thigh perforator flap was elevated and the pedicle was dissected to its origin from the femoral vessels. The rats were assigned to three groups: control (group I), acute inflow (group II) and arterial preconditioning (group III) depending on the timing of ligation of the femoral artery distal to the site of pedicle emergence. Digital planimetry was performed on postoperative day (POD) 7 and all flaps were monitored using laser Doppler flowmetry perioperatively and postoperatively in three regions (P1-proximal flap, P2-middle of the flap, P3-distal flap).ResultsDigital planimetry showed the highest area of survival in group II (78.12%±8.38%), followed by groups III and I. The laser Doppler results showed statistically significant higher values in group II on POD 7 for P2 and P3. At P3, only group II recorded an increase in the flow on POD 7 in comparison to POD 1.ConclusionsOptimization of arterial inflow, regardless if performed acutely or as preconditioning, led to increased flap survival in a rat perforator flap model.

Effect of Botulinum Toxin-A Injected to Muscle Tissue on Perfusion and Survival of Fasciocutaneous Single Perforator-pedicled Propeller Flap in Rats

Background:In plastic surgery practice, fasciocutaneous single-perforator-pedicled propeller flap is a preferred procedure; however, its survival rate is below than expected, especially in flaps with a big rotation arc. When botulinum toxin-A is injected into the muscle tissue that the perforator pedicle is arisen, the tonus of pertinent muscle can reduce and the blood flow of its perforator pedicle can increase. Therefore this procedure can improve the survival rate of single-perforator-pedicled propeller flap.Aims:To evaluate the effect of botulinum toxin-A injected with ultrasonographic guidance into the muscle tissue that the perforator pedicle is arisen from one month ago on the perfusion of flap scintigraphically and the survival rate of single-perforator-pedicled propeller flap in a rat model.Study Design:Animal experiment.Methods:Three study groups were receiving botulinum toxin-A (16 IU-0.4 mL), normal saline (0.4 mL), and no study drug one month ago before flap surgery. Injections were performed under ultrasonography guidance. Flaps were elevated fasciocutaneously over the right 2nd perforator pedicle, under the corneous, with a surgical loupe and microsurgery tool and were rotated clockwise 180°. Then the scintigraphic measurements were obtained after flap elevations in the study groups, including the whole-body and flap perfusions in the study rats. The involvement rate presents the ratio of flap perfusion to whole-body perfusion. Flaps were sutured back to the abdominal wall at the latest twisting angles. With standard photographs taken in all the groups on day 8 after the operation, whole and necrotic flap areas were calculated.Results:Scintigraphically the involvement rate (the ratio of flap perfusion to whole-body perfusion) of the flaps in the botulinum toxin-A group were found significantly higher than those in the other groups (p<0.05). The area of a flap in the botulinum toxin-A group on day 8 post flap suturing was found to be significantly higher than those in the other groups (p<0.05). The area of a necrosis and the percentage of necrosis on day 8 post flap suturing in the botulinum toxin-A group was found significantly lower than those of the sham and null groups (p<0.05).Conclusion:In a rat model, if with the ultrasonographic guidance, botulinum toxin-A is injected to the muscle which perforator of the prospective single-perforator-pedicled propeller flap originated and flap surgery is performed one month later after this injection, the perfusion of single-perforator-pedicled propeller flap increases scintigraphically and this improves flap survival and reduces its necrosis.

Pedicled perforator flaps for mid-tibial soft tissue reconstruction in medically compromised patients

BackgroundThe soft tissue of the central pretibial area is difficult to reconstruct often requiring free tissue transfer. Especially medically compromised patients are not ideal candidates for free tissue transfer and may benefit from expeditiously harvested local flaps with limited donor site morbidity. As muscle flaps are rare, pedicled flaps based on lateral perforators represent an alternative as the arc of rotation can often be limited to 90°. Material and MethodsA retrospective analysis of patient data was conducted to identify patients over the age of 60 years with comorbidities that underwent pretibial soft tissue reconstruction with a single-pedicle perforator flap. Patient demographics, size and cause of the defect, flap dimension, arc of rotation and complications were recorded. ResultsFive patients with an average age of 71.4 years were included. The arc of rotation was 69°, all flaps healed. There were two recurrences of osteomyelitis. ConclusionLateral perforators originating from the anterior tibial artery or peroneal artery are adequate source vessels for single pedicled perforator flaps even in medically compromised patients. A perforator located proximal to the defect allows limiting the arc of rotation to less than 90°, which increases the safety of the flap. Patients benefit from a simple procedure without a microvascular anastomosis and a donor site confined to one extremity.

3D-CTA assisted anterolateral thigh lobulated perforator flap in repairing soft tissue defect of limb: 11 cases report

Objective To investigate the effectiveness of preoperative 3D-CTA in assisting the preparation of free thinned anterolateral thigh lobulated perforator flap with nerve in repairing soft tissue defect of limb. Methods Between February, 2010 and May, 2018, free super-thin anterolateral thigh lobulated perforator flap with nerve was transferred to repair soft tissue defect of limbs in 11 cases. There were 8 males and 3 females with an average age of 35 (range, 22-56) years. The defect area was 8.0 cm×11.0 cm-9.0 cm×23.0 cm. Preoperation CT scan of the free flap donor site was performed to obtain 3D images of the region with arterial blood supply by digital 3D reconstruction CT, and to determine the origin, direction, classification, length, diameter and the position of pedicle perforator. Postoperative regular followed-up was carried according to the Upper Limb Function Evaluation Trial Standards of Chinese Medical Association of Hand Surgery and Enneking Evaluation System. Results All 11 flaps survived. No vascular crisis happened. All 11 cases were followed-up for 3 to 12 (average, 5) months. The flaps were supple and elastic with near normal color. There was no bulkiness. Sensory function was recovered well and two point discrimination was 3.0-6.0 mm. According to the Upper Limb Function Evaluation of Upper Limb of Chinese Medical Association of Hand Surgery, the results were excellent in 1 case, good in 3 cases and fair in 1 case. The Enneking system was used to assesse the lower limbs recovery. The average score was 21, an average of 70% of limb function restored. Conclusion The free super-thin anterolateral thigh lobulated perforator flap with nerve offers advantages to the traditional anterolateral thigh flap. The survived flaps are ideal in terms of covering limb defects and restoring functions. Preoperative 3D-CTA in the anterolateral thigh perforator flap transplantation is an accurate and useful method. It helps a safer and successful operation with optimal outcome. Key words: 3D-CTA; Anterolateral thigh perforator flap; Lobulated flap; Repair; Limb

Finger defect coverage with digital artery perforator flaps

AimThe aim of this paper is to demonstrate the advantages of using local resources in the coverage of such defects. Our approach in fingers’ defects is the use of local perforator flaps, both as propeller flaps or bi-lobed pedicled flaps. Patients and methodsAfter performing an anatomical study on cadaver segments injected with latex followed by transparentation, 81 local perforator flaps in 80 patients during a period of 10 years (2007–2016), i.e. 47 digital artery propeller perforator flaps (DAPP), 10 island transposition perforator flaps (DATP), and 24 bi-lobed pedicled perforator flaps (BLP) were performed in our department. The patients were evaluated regarding finger mobility (ROM), two-points discrimination (TPD), and degree of satisfaction (DS) from cosmetic point of view. ResultsThe mean interval for social and professional reintegration was 12 days. As complications, we registered only venous congestion in 7 cases followed by epidermolysis in 4 cases and superficial necrosis in 3 cases, which healed by reepithelialization. The range of motion (ROM) of the reconstructed fingers was normal in all the patients. All the flaps regain a satisfactory degree of sensibility (TPD between 4 mm and 14 mm). The DS was relatively high, with 67 patients very satisfied, 11 satisfied, and 2 unsatisfied. ConclusionsThis fast and less invasive method, which replaces like-with-like, allows an early and good reinervation and a rapid social and professional reintegration, proves to be a very reliable alternative in digital defects coverage.

Muscle electrical activity after perforator flap surgery: a pilot cohort study

Perforator flaps surgery barely damages underlying muscle function, but only clinical qualitative evidences exist about muscle preservation after surgical dissection. We have employed for the first time electromyography and nerve conduction studies in evaluating the latissimus dorsi electrical muscle function after thoraco-dorsal artery perforator flap dissection in a retrospective cohort study. We included ten consecutive patients requiring axillary reconstruction with thoraco-dorsal artery perforator flap, from June 2017 to June 2018. All patients were suffering from hidradenitis suppurativa. Electromyography (EMG) and nerve conduction study (NCS) were conducted on each patient, both before and after the operation. Differences between pre- and postoperative amplitude and latency values were calculated. Postoperative signal amplitude and latency means did not differ significantly from the preoperative one. Operative time and area of excision did not correlate with changes of electrical function. This is the first quantitative analysis performed for the evaluation of muscle electrical activity after perforator flap surgery. Perforator pedicle intra-muscular dissection does not cause any injury to the muscle fibers. TDAP flap confirms to be a safe procedure for latissimus dorsi muscle function. Level of evidence: Level III, therapeutic study.

Pedicled local flaps: a reliable reconstructive tool for partial breast defects.

Breast conserving surgery (BCS) followed by radiotherapy has gained great popularity in the treatment of breast cancer over the past years. However, radiation therapy can lead to many unfavourable aesthetic outcomes including significant volume/skin deficiency, nipple areola complex distortion and skin contraction. We present our experience in using pedicled perforator flaps to tackle the resultant partial breast defects or deformities. A retrospective data analysis study on Thirty patients with post breast conserving surgery (BCS) partial breast defects who were managed with pedicled per-forator flaps including muscle sparing latissimus dorsi muscle flap (MSLD), thoraco-dorsal artery perforator flap (TDAP) and intercostal artery perforator flap (ICAP) in the period between December 2008 and December 2018. Defects were in all quadrants apart from the upper inner quadrant. The reconstructive techniques included TDAP flap 6/30 (20%), MSLD flap 20/30 (66.7%), AICAP flap 4/30 (13.3%). Age ranges 22-35 (mean 29). All flaps showed complete survival, one nipple areola complex superficial epidermolysis was experienced, and one patient presented with fat necrosis. No resultant donor site morbidity apart from scar revision for excess skin at the axillary fold in one patient. The overall satisfaction reached 94% with only 8 patients who required lipofilling to maximize the cosmetic outcome. The availability of a range of reliable techniques including thoracodorsal/intercostal artery perforator flap (TAP/ICAP) and muscle sparing lattissimus dorsi flap (MSLD) allow optimum results to be achieved in the treatment of partial breast defects following breast conserving surgery.

Anatomical study of the perforator flap based on the acromial branch of the thoraco-acromial artery (abTAA flap): a cadaveric study.

The aim of this anatomical study was to describe a local perforator flap, for covering shoulder defects, by determining the features of the acromial branch of the thoraco-acromial artery (abTAA), and the supplied cutaneous area. Thirteen fresh cadaveric thoraxes were dissected bilaterally. A precise and reproducible protocol was performed. For each abTAA flap cadaveric dissection, the following parameters were measured after arterial injection: distances between the origin of the perforator artery on the abTAA and the sternum, the acromion, the clavicle, diameter of the perforator artery of the abTAA, length of the perforator pedicle course through major pectoralis muscle, and rotation arc. We also calculated the surface of the injected skin paddle. These measurements were related to morphometric parameters evaluated through the distance between sternum and acromion. The mean distances measured from the origin of the perforator artery on the abTAA were 14.25cm to the sternum, 3.45cm to the acromion, 5.65cm to the clavicle. The mean diameter of the abTAA was 1.20mm ± 0.2. The arc of rotation was 180°, and the length of the perforator pedicle could be extended to 7.46cm ± 1.15. We observed an colored elliptical cutaneous paddle with a longer radius 18cm and a small radius 15cm. Our results suggest that this type of flap could be useful in clinical practice for reconstruction and covering of the acromial area with a thin cutaneous flap with low sequelae on the donor site.

Evaluation of the Intraoperative Blood Flow of Pedicled Perforator Flaps Using Indocyanine Green-fluorescence Angiography.

Background:Although indocyanine-green fluorescence angiography (ICG-FA) has been established as a useful tool to assess perfusion in free tissue transfer, only few studies have applied this modality to pedicled perforator flaps. As both volume and reach of pedicled perforator flaps are limited and tip necrosis often equals complete flap failure, ICG-FA may help to detect hypoperfusion in pedicled flaps.Methods:In 5 patients, soft tissue reconstruction was achieved with pedicled perforator flaps. ICG-FA was utilized intraoperatively to visualize flap perfusion.Results:Three pedicled anterolateral thigh flap flaps and 2 propeller flaps were transferred. ICG-FA detected hypoperfusion in 2 flaps. No flap loss occurred; in 2 cases, prolonged wound healing was encountered.Conclusions:ICG-FA confirmed clinical findings and reliably detected tissue areas with hypoperfusion. A clear cut-off point between nonvital tissue and such that stabilized in the following clinical course could not be found. ICG-FA is a promising technology which could also be used in pedicled perforator flaps.