Peninsular Flap Research Articles

The keystone island perforator flap: An “ideal” local soft tissue flap for the lower extremity

BackgroundLower extremity reconstruction best requires co-operation between orthopedic and plastic surgeons to preserve the musculoskeletal integrity while establishing essential skin coverage. Traditional dogma suggests microvascular tissue transfers alone would be preferable, but today inherent risks can be avoided by instead using mainly local perforator flaps. MethodsOver a 5 year timeframe, 68 local flaps were used in 66 patients for non-specific lower extremity problems in all regions of the lower extremity in lieu of a free flap. These included both muscle and perforator flaps, the latter including peninsular, propeller, “true” island, and advancement variations. Particular emphasis on the choice of the keystone advancement flap alternative was here undertaken. ResultsAll chosen lower extremity local flaps were successful without resorting to a second flap or skin graft to treat complications. Muscle flaps were used only on 4 occasions, whereas the remaining flaps were perforator flaps. Of these, the keystone island perforator flap was by far the most common choice, [27 (42.2 %)], even exceeding the combined use of propeller and peninsular flaps [26 (40.6 %)]. Keystone flap complications were virtually nil. Keystone flaps were most often used within the flexible tissues of the thigh, but could be used throughout the lower extremity. ConclusionPerforator flaps may be the optimal local flap choice for the lower extremity. Since no discrete perforator need be dissected, the simplest variation is the keystone flap. Harvest and insetting is facile, reliable, aesthetically acceptable, and often sensate. The keystone island perforator flap indeed is an “ideal” lower extremity local soft tissue flap.

Smartphone Thermography for Lower Extremity Local Flap Perforator Mapping.

The versatile application of local perforator flaps for coverage throughout the lower extremity has already been well proven. Often a "free-style" approach has been used to design these flaps, as conventional imaging devices for perforator identification may be too expensive or unavailable. The recent adaptation of Smartphone thermal digital imaging may now prove to be a cheaper and more readily available means for identifying the requisite perforators that will sustain these local flaps. Over the past year, a prospective study was undertaken of all patients having a local perforator flap for coverage of a lower extremity defect. Twenty-eight local perforator flaps involving all subtypes were utilized in 25 patients. Smartphone thermography was used in all patients preoperatively to identify preferable perforator or vascular network "hot spots" that allowed appropriate flap design. Intraoperative and postoperative monitoring was similarly done for all flaps to determine outcomes. All local perforator flaps were based on perforators identified using smartphone thermography. All flaps (23 or 82.1%) that the thermal digital image predicted 100% viability totally survived. Five flaps were predicted to have marginal viability, but two nevertheless survived completely while the others required only minor readjustments. Peninsular and keystone variety perforator flaps were those most commonly used.Thermography always facilitated making the correct decision as to whether a proximal- or distal-based peninsular flap would be superior. Subfascial elevation of cool spots in keystone flaps were found to be least likely to interfere with flap perfusion. Smartphone thermography is an inexpensive and expeditious means for identification of "hot spots" that is always used by us to ensure perfusion to lower extremity perforator local flaps. This is a complementary technique for their safer design, harvest, and subsequent monitoring in conjunction with more complex screening tools as indicated.

Saphenous artery-based flap models in rats: new flap designs for experimental studies

BackgroundExperimental research using laboratory animals provides substantial data about reconstructive surgery. However, the literature does not include any experimental studies that have used flap models on the hind limbs of rats. To gain an understanding of the physiology of lower-extremity flaps and of flap failures, this study assessed the cutaneous perforators of the saphenous artery, and new flap models were designed for the hind limbs of rats. Materials and methodsThe experiment was designed to include three stages and used 35 rats. The first stage involved mapping the perforators of the saphenous artery. In the second stage, the contents and structures of McFarlane, epigastric, and anterior hind limb flap tissues were compared histologically. The third stage of the study involved designing and comparing different flaps for the hind limbs of the rats and included random flaps, perforator-based peninsular flaps, perforator-based island flaps, and perforator-based flaps with rotated pedicles. Postoperative necrosis ratios were evaluated using computer-based software. ResultsMapping of the saphenous artery perforators revealed an average of 2.2 septocutaneous arteries in each hind limb. Histologic studies showed thick dermis and panniculus carnosus in the McFarlane flaps, thick dermis, and thin panniculus carnosus layers in the epigastric flaps, and thin subcutaneous tissue with no panniculus carnosus tissue in the skin of the hind limbs. The results of the flap studies that used random flaps showed a 52.4% necrosis, while there was no necrosis when perforator-based peninsular flaps, island flaps, and flaps with rotated pedicles were used. ConclusionsNew flap models used on the saphenous artery perforators of the hind limbs of rats can provide valuable information about the physiology of lower-extremity flaps. New studies can also be designed based on these flap models to acquire more knowledge about pathologic conditions such as ischemia and venous insufficiency.

Free-Style Local Perforator Flaps

Free-style local perforator flaps can be harvested from any region of the body where an appropriate and detectable perforator vessel is present. Their use allows the surgeon to perform a "like with like" reconstruction by mobilizing surrounding tissues on a consistent vascular source. The authors report their experience with V-Y free-style perforator flaps in reconstruction of soft-tissue defects subsequent to skin cancer excision. Forty elective defects in different regions of the body were reconstructed with V-Y advancement local perforator flaps raised in a free-style fashion. There were 23 male patients and 17 female patients. Mean age at surgery was 63 years. All defects resulted from skin cancer ablation. Mean defect size was 5×3.7 cm. Mean flap dimensions were 8.8×4.2 cm. The flaps were based on one (n=10), two (n=18), or three (n=12) perforators. Mean operative time was 93 minutes. Thirty-seven flaps (92.5 percent) healed uneventfully. In three flaps (7.5 percent), moderate venous insufficiency occurred, leading to partial flap necrosis that required surgical revision. In three cases (7.5 percent), the flap was converted to a rotation/hatchet perforator-based peninsular flap. Slight venous stasis was the most common postoperative finding registered (eight flaps; 20 percent). All flaps achieved adequate and durable reconstruction with excellent contour, with a follow-up ranging between 6 months and 2 years. Free-style local perforator flaps advanced in V-Y fashion proved to be a valid and reliable solution to restore function and aesthetics of the operated site after skin cancer excision. Therapeutic, IV.

Le lambeau de conque à pédicule supérieur pour les reconstructions hélicéennes supérieures ou moyennes

The middle or upper third of the auricle can be reconstructed with a composite chondro-cutaneous peninsular flap of the conchal part of the auricle. This peninsular flap is based on the anastomotic network between the posterior auricular and the superficial temporal artery. The authors report their experience about 24 clinical cases. Most of the cases were partial auricular amputations for squamous cell carcinoma. The surgical procedure allows a hidden cartilaginous donor site, the concha, allowing in a single operation a color- and texture-matched reconstruction. This flap represents an alternative to more complex surgical procedures, and can easily be realised under local anaesthesia.

Versatility of the pedicled peroneal artery perforator flaps for soft-tissue coverage of the lower leg and foot defects

Even a small defect in the lower leg and foot with exposure of bones or tendons can result in an intractable wound, which may require a microsurgical tissue transfer. With the concept of the perforator flap, a pedicled peroneal artery perforator flap can be used for coverage of this difficult region. Between August 2001 and August 2008, 18 pedicled peroneal artery perforator flaps were performed in 18 patients. The fasciocutaneous flaps were employed to cover defects in the pretibial area (n=6), Achilles' tendon and/or hindfoot (n=7) and lateral malleolar area (n=5). The pedicled peroneal artery perforator flaps are classified into five types: propeller flap (n=11), peninsular flap (n=4), advancement flap (n=2), proximally based island flap (n=1) and distally based island flap (n=0). The size of the flaps ranged from 7.5×3 cm(2) to 20×8 cm(2). The selected perforator depended on the defect location, ranging from 4.5 to 18 cm above the tip of the lateral malleolus. Postoperative venous congestion was encountered in four propeller flaps and one proximally based island flap. Venous congestion subsided within days without complications, except one which needed further reconstruction with skin grafts. In conclusion, the peroneal artery perforators are predictable and reliable for the design of a perforated-based flap. Elevation of the flap can be performed easily in the supine or prone position, depending on the defect location. Different designs of this perforator-based flap can repair a variety of leg and foot defects.

An algorythmic approach to restoration of the fronto-naso-periorbital skin defects using the forehead flaps

The classic forehead flaps, which are designed vertically, two-staged and exteriorised pedicled peninsular flaps, are still a reconstructive option for nasal and periorbital defects. However, some drawbacks such as conspicuous donor-site scar, multi-staged procedure, rather short pedicle, hairy appearance (in narrow foreheads), and inability to use the forehead flap when the donor site is involved are often encountered during surgery. To avoid these issues, three unusual designs of the forehead flap are presented, and also a new algorithm is proposed to guide surgeons in their solutions. Nineteen patients (10 women and nine men) were managed with 21 forehead flaps to restore the nasal, medial canthal and frontal defects caused by skin tumours. The flaps were applied as interpolation island, V-Y island, and transverse peninsular designs in 12, four and three patients, respectively. All donor sites were closed primarily except one, where a split thickness skin graft was used. The average follow-up was 14 months. All flaps survived (totally) but in one partial necrosis developed. Aesthetic and functional recoveries were acceptable in all patients. Based on the algorithm presented, the forehead flaps with their superb anatomic characteristics including rich vascular supply and pliable skin can be safely used in either classic or extraordinary fashion for small to medium sized defects of the nasoorbital and frontal regions.

Perforators in Local Peninsular and Island Flaps: Are They Always Useful?

Perforators in Local Peninsular and Island Flaps: Are They Always Useful?

Perforators in Local Peninsular and Island Flaps: Are They Always Useful?

Perforators in Local Peninsular and Island Flaps: Are They Always Useful?

Perforators in Local Peninsular and Island Flaps: Are They Always Useful?

Perforators in Local Peninsular and Island Flaps: Are They Always Useful?

Skeletonised retrograde distal perforator island fasciocutaneous flaps for leg and foot defects

Defects involving the distal leg and foot are frequently encountered following various aetiological factors. Paucity of local tissue causes surgeons to resort to the retrograde peninsular flap, the cross leg flap or the free flap. With specific knowledge of perforators, the fasciocutaneous flap from the calf area can be transferred to the defect in a single stage based on skeletonised distal perforators. The surgical anatomy, flap planning and procedure have been detailed. Nineteen patients were treated during the period 1995 to 2005. The perforators were identified preoperatively by audio Doppler. The flaps were marked and dissected proximal to the defect skeletonising the distal perforators under loupe magnification and transferred to the defect in a single stage. The donor site was skin grafted. Out of 19 cases, 16 flaps healed uneventfully, one flap necrosed completely and in two cases there was marginal necrosis. The cases were followed up for 2-10 years with an average of 6 years. With detailed knowledge of perforators one can safely reconstruct distal moderate-size defects of the lower limb in a single stage, thus having the benefits of free tissue transfer without resorting to microsurgery. This technique has proved to be an advancement in the reconstructive repertoire allowing flaps of non conventional dimensions to be perfused by skeletonised perforators.

Perforator-Plus Flaps: A New Concept in Traditional Flap Design

Conventional fasciocutaneous flaps in reconstructive surgery, especially in the lower extremities, have limited utility. Traditional flaps are essentially random pattern, often require delays, and are limited in mobility and reach. Islanded fasciocutaneous flaps pedicled on perforators can be raised anywhere on the body and have a reliable blood supply and greater freedom of movement. However, venous compromise is a common problem. A new approach to raising conventional fasciocutaneous flaps while including and retaining perforators in their substance was used to offset these disadvantages. This concept offers a dual blood supply to the flap from the dissected perforator plus the flap base. The approach was attempted in 12 cases and used successfully in 10. In two cases, the flaps were converted to pure islanded perforator flaps because of limited movement. Fasciocutaneous perforator-plus flaps were used in six patients with lower limb trauma and one patient with postburn elbow contracture. Peninsular flaps were planned to include known or identified perforators, which were dissected to allow mobility. All flaps survived completely and none exhibited venous compromise. In three patients, perforator-plus flaps were used to the medial hemisoleus muscle while providing coverage to exposed tibial fractures. The muscle flap was based either proximally or distally, and a segmental perforator was dissected and retained. There were no complications relating to flap congestion or necrosis except wound infection in two patients, one each in the fasciocutaneous and muscle flap groups. Both responded to conservative treatment. No case required reoperation. The perforator-plus flap appears to be a versatile and reliable option in lower limb injuries and other diverse indications, in both the emergency and the elective settings.

Peninsular Conchal Axial Flap to Reconstruct the Upper or Middle Third of the Auricle

The reconstruction of partial amputations of the auricle is a continuous subject of publications, in particular, the techniques of ear reconstruction with postauricular flaps. To present in detail the surgical procedure of a new peninsular conchal transposition flap. This new conchal transposition flap has been used since 1998 to reconstruct seven partial amputations of the upper or middle third of the auricle. If we compare the flap to a tennis racket, the head corresponds to a skin-cartilage-skin flap harvested from the concha and the shaft to a post- and supra-auricular cutaneous and subcutaneous pedicle based around the posterior auricular artery and the superior auricular branch of the superficial temporal artery. The blood supply is reliable because the superior branch of the posterior auricular artery anastomoses with the superior auricular branch of the superficial temporal artery. There have been no significant complications, except one case of partial rim necrosis, which responded well to wound healing by secondary intention. Our peninsular flap could be an alternative to more complex procedures involving costal cartilage harvesting, provided that auricle amputations are confined to the upper or middle third of the peripheral structures and spare the concha.

Gene therapy with adenovirus-mediated VEGF enhances skin flap prefabrication

We investigated the feasibility in rats of enhancing skin-flap prefabrication with subdermal injections of adenovirus-encoding vascular endothelial growth factor (Ad-VEGF). The left saphenous vascular pedicle was used as a source for vascular induction. A peninsular abdominal flap (8 x 8 cm) was elevated as distally based, keeping the epigastric vessels intact on both sides. After the vascular pedicle was tacked underneath the abdominal flap, 34 rats were randomly divided into three groups according to treatment protocol. The implantation site around the pedicle was injected with Ad-VEGF in group I (n = 10), with adenovirus-encoding green fluorescent protein (Ad-GFP) in control group I (n = 14), and with saline in control group II (n = 10). All injections were given subdermally at four points around the implanted vessel by an individual blinded to the treatment protocol. The peninsular flap was sutured in its place, and 4 weeks later, an abdominal island flap based solely on the implanted vessels was elevated. The prefabricated island flap was sutured back, and flap viability was evaluated on day 7. Skin specimens were stained with hematoxylin and eosin for histological evaluation. In two rats from each group, microangiography was performed to visualize the vascularity of the prefabricated flaps. There was a significant increase in survival of prefabricated flaps in the Ad-VEGF group compared to the control groups: Ad-VEGF, 88.9 +/- 6.1% vs. Ad-GFP, 65.6 +/- 9.4% (P < 0.05) and saline, 56.0 +/- 3.4% (P < 0.05). Sections from four prefabricated flaps treated with Ad-GFP revealed multiple sites of shiny deposits of green fluorescent protein around the area of local administration 1 day and 3 weeks after gene therapy. Histological examination done under high-power magnification (x400) with a light microscope revealed increased vascularity and mild inflammation surrounding the implanted vessel in all groups. However, we were unable to demonstrate any significant quantitative difference with respect to vascularity and inflammatory infiltrates in prefabricated flaps treated with Ad-VEGF compared with controls. Microangiographic studies showed increased vascularity around the implanted pedicle, which was similar in all groups. However, vascularization was distributed in a larger area in the prefabricated flaps treated with Ad-VEGF. In this study, the authors demonstrated that adenovirus-mediated VEGF gene therapy increased the survival of prefabricated flaps, suggesting that it may allow prefabrication of larger flaps and have the potential to reduce the time required for flap maturation.

Comparative viability of peninsular and island axial pattern flaps incorporating the cranial superficial epigastric artery in dogs

Summary Experimental island and peninsular axial pattern flaps that incorporated the cranial superficial epigastric artery and vein were developed in 6 Beagles. Mean percentage of flap area that survived, for both flaps, was 87%, and percentage of surviving flap area was not significantly different for island versus peninsular flaps. In 1 dog, ligation of an aberrant, perforating branch of the cranial epigastric artery resulted in necrosis of 53% of the flap area. The cranial superficial epigastric axial pattern flaps have potential application for closure of skin defects within their arc of rotation and may be particularly useful for closure of large defects on the ventral aspect of the thorax. A peninsular flap was used to close a defect of the ventral portion of the thoracic wall in a clinical case.

Pedicle Flaps of the Upper Limb: Vascular Anatomy, Surgical Technique and Current Indications

This is English-language edition of Les Lambeaux Arteriels Pedicules du Membre Superieur , published in 1990. The list of 40 contributors from around world attests to international collaboration achieved by editors. As Hentz states in foreword, motivation for this English edition lies in unsubstantiated impression that surgeons in the United States are less experienced than their international colleagues in use of contemporary arterialized pedicle for reconstruction of cutaneous defects in upper limb. The book includes 24 chapters with individual references and a comprehensive index. The first three chapters describe historic evolution of study of cutaneous vascularity of upper limb with references to Esser, Littler, and others. Basic definitions of arterial island and peninsular flaps are provided along with standard classification of skin and fasciocutaneous and musculotaneous flaps based on pertinent vascular anatomy nourishing each flap.

Christopher R. Forrest

The rabbit island and peninsular axial pattern latissimus dorsi musculocutaneous (LDM) flaps were assessed for their appropriate use as experimental musculocutaneous flap models. Contralateral island and peninsular LDM flaps (10 X 20 cm) were constructed on rabbits, and their vascular anatomy, hemodynamics, and viability were compared. Anatomical dissections and fluorescein dye studies revealed that the skin overlying the latissimus dorsi muscle received its blood supply mainly from a direct cutaneous branch of the thoracodorsal artery before its entry to the latissimus dorsi muscle. A few small musculocutaneous arteries (perforators) were seen in the proximal portion of the latissimus dorsi muscle, but these perforators provided very little blood supply to the overlying skin. Results from hemodynamic and viability studies with rabbit peninsular and island LDM flaps also indicated that the blood supply from the musculocutaneous arteries to the overlying skin paddle was small and could not reliably support the survival of the cutaneous portion of these musculocutaneous flaps. We conclude that rabbit LDM flaps are different in vascular structure and blood supply compared with the human LDM flaps. Thus, discretion should be advised in applying the rabbit peninsular or island LDM flaps as experimental flap models for the study of the pathophysiology and pharmacology of the musculocutaneous flaps relevant to the clinical situation.