Perforator Flap Research Articles

Ultrasound Point-of-care in Soleous Muscle Flap Reconstruction

Introduction: Point-of-care ultrasound has been successfully used in intensive care medicine, trauma surgery and anesthesia. The soleus muscle is indicated for the reconstruction of wounds with bone exposure in the middle and lower thirds of the leg. The objective is to present study is to verify the evidence of the application of point-of-care ultrasound in the soleus muscle flap planning reconstruction. Method: A study was conducted by searching the Pubmed/Medline, SciELO and LILACS databases, applying the descriptors ultrasound, surgical flaps, perforator flap, myocutaneous flap and plastic, surgery. Results: In the reconstruction with the soleus muscle flap, the application of point-of-care ultrasound consisted of the use of the acoustic window concepts with the visualization of the limits of the soleus muscle and adjacent anatomical structures, such as the Achilles tendon and the flexor hallucis longus muscle. Conclusion: The evidences of the application of point-of-care ultrasound in the reconstructions of the lower limbs, using the soleus muscle flap, allowed the visualization of the soleus muscle and the adjacent anatomical structures, such as the Achilles tendon and the tendon of the flexor hallucis longus muscle, important anatomical reference points during the preparation of the soleus muscle flap. Ultrasound is a great non-invasive resource to assist in creating the soleus muscle flap.

Efficacy of combining a medial superior malleolar perforator flap from the posterior tibial artery with a vacuum-assisted closure dressing for skin and soft tissue defects of the Achilles tendon area.

This randomized clinical trial aimed to investigate the clinical efficacy of combining a medial superior malleolar perforator flap from the posterior tibial artery (PTAPF) with a vacuum-assisted closure (VAC) dressing for skin and soft tissue defects in the Achilles tendon area. Twenty-eight patients were randomly divided into two equally sized groups: the control group received treatment with a medial superior malleolar perforator flap, while the experimental group was treated with a perforator flap from the posterior tibial artery in combination with a VAC dressing. Perioperative data, including average operative time, intraoperative blood loss, intraoperative complications, time to ambulation, and hospital stay after surgery, were recorded. Clinical outcomes were assessed based on the time to first weight-bearing walking, time to full weight-bearing activity, Visual Analog Scale (VAS) score, American Orthopaedic Foot and Ankle Society hindfoot and ankle score, and the range of motion for ankle plantar flexion. The patients were monitored for 3-12 months (average, 8.5), and it was observed that the flaps remained stable without enlargement, and their texture and color were similar to the surrounding tissue. Significantly enhanced postoperative indices were noted in the experimental group compared to the control group (P<0.05). The medial superior malleolar perforator flap from the posterior tibial artery, especially when combined with a VAC dressing, proves to be an effective method for repairing medium-sized skin defects in the Achilles tendon area. This approach offers several benefits, including a reliable blood supply, simplicity of the procedure, decreased damage to the donor site, improved aesthetic outcomes, and fewer postoperative complications.

Indocyanine green is an integral part of breast reconstructive surgery using perforator flaps

The use of allotransplants for breast reconstruction in surgical stage of the the breast cancer treatment requires tissue perfusion control. The aim of the study was to analyze the effectiveness of using indocyanine green as a drug for determining the perfusion of perforant flaps in breast reconstructive surgery. A retrospective series of observations of 27 breast reconstructions using autologous transplants is presented: 19 reconstructions with DIEP-flap, 2 with SIEA-flap, 5 with TD-flap; 1 with thoracoepigastric flap. Intraoperative fluorescence angiography was performed using a Stryker device (5900 Optical Court, USA). The intensity of the flap fluorescence was recorded after intravenous bolus injection of 7.5 mg indocyanine green. The optimal time interval from the moment of drug administration to indicative visualization of flap perfusion was 55-60 seconds. In all patients, the area of insufficient blood flow was excised within intensively blood-supplied tissues, according to mapping data with the indocyanine green. With free transplant of flaps postoperative complications during follow-up were recorded in 1 (4.8%) case (marginal necrosis), which is associated with insufficient compression of auxiliary vessels (violation of the dominant vessel contrast technique). With non-free transplant of flaps no complications were detected in the postoperative period. Indocyanine green allows to prevent necrotic changes and reduce the rehabilitation period. The optimal time for the indicative visualization of flap perfusion was 55-60 seconds. The use of indocyanine green in free transplant of flaps ensured a postoperative period without complications in 20 (95.2%) cases, in non-free flap transplantation - in 6 (100%) cases.

Evaluating the Impact of Prior Abdominal Surgeries and Mesh Use on Abdominal Wall Morbidity after Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstruction

Evaluating the Impact of Prior Abdominal Surgeries and Mesh Use on Abdominal Wall Morbidity after Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstruction

Inset techniques for the DIEP flap - what improves aesthetic outcomes?

The deep inferior epigastric perforator (DIEP) flap is widely considered as the gold standard in breast reconstruction. The inset technique of the DIEP flap is crucial in determining the overall aesthetic outcome; however, to date no systematic review is available that comprehensively assesses the various techniques. Evaluation of topic: A systematic review was performed according to the PRISMA guidelines. The methodology is outlined within our published protocol (Prospero CRD42023449477). Included articles met a minimal criterion compromising of the intervention (DIEP free flap for breast reconstruction) and outcomes (aesthetic and clinical outcomes). Six articles were included in this review, with a total of 346 patients and a follow-up ranging from 6 months to 4 years. Four articles were of a prospective case series study design, one article was a randomized controlled trial, and one article was a case-control study. The risk of bias was assessed to be high in the case series, but low and moderate in the randomized controlled trial and case-control study respectively. Although limited by the quality of the evidence, the single aesthetic unit principle, dual-plane inset, elimination of the need for a skin paddle, appropriate flap positioning and rotation, and algorithmic in-setting may all improve the aesthetic outcome of DIEP free flaps.

Microneedling in Abdominal Scarring after DIEP-flap Breast Reconstruction to Improve Scar Quality: A Randomized Controlled Split Scar Trial.

Deep inferior epigastric perforator (DIEP) flap breast reconstruction leads to large scars in the breast and abdominal region. Common symptoms related to abdominal scarring include changes in color, stiffness, thickness, and irregularity of the skin. The aim of this study was to examine whether microneedling improves the abdominal scar quality after DIEP-flap breast reconstruction. A prospective randomized controlled within subject comparison design (N = 30) was used to study the effect of microneedling treatments on the abdominal scar, versus no treatment. Three electrically powered microneedling sessions were performed every 4 weeks on one side of the abdominal scar. Abdominal scar assessment was performed at baseline and 3-, 6-, and 9-month follow-up using the Patient and Observer Scar Assessment Scale (POSAS). Treated and untreated sides were compared using a t test or Wilcoxon signed-rank test in case the data were not normally distributed. Twenty-seven women completed the study. Microneedling treatment led to lower POSAS scores compared with the untreated scar side after the 3- and 9-month follow-up. At the 9-month follow-up, the POSAS total score (Mdn = 17, interquartile range = 18.3 versus Mdn = 21.4, interquartile range = 17.5) was statistically lower for the treated side compared with the untreated side, implying a better-appraised scar quality. The observer POSAS total score was statistically lower for the treated side compared with the untreated side. Based on patient and observer ratings, overall abdominal scars after DIEP-flap surgery improve significantly after microneedling treatment. Scar symptoms reduce faster under the influence of microneedling treatment compared with no treatment.

Clinical application of digital technology in the use of anterolateral thigh lobulated perforator flaps to repair complex soft tissue defects of the limbs.

It is challenging to repair wide or irregular defects with traditional skin flaps, and anterolateral thigh (ALT) lobulated perforator flaps are an ideal choice for such defects. However, there are many variations in perforators, so good preoperative planning is very important. This study attempted to explore the feasibility and clinical effect of digital technology in the use of ALT lobulated perforator flaps for repairing complex soft tissue defects in limbs. Computed tomography angiography (CTA) was performed on 28 patients with complex soft tissue defects of the limbs, and the CTA data were imported into Mimics 20.0 software in DICOM format. According to the perforation condition of the lateral circumflex femoral artery and the size of the limb defect, one thigh that had two or more perforators from the same source vessel was selected for 3D reconstruction of the ALT lobulated perforator flap model. Mimics 20.0 software was used to visualize the vascular anatomy, virtual design and harvest of the flap before surgery. The intraoperative design and excision of the ALT lobulated perforator flap were guided by the preoperative digital design, and the actual anatomical observations and measurements were recorded. Digital reconstruction was successfully performed in all patients before surgery; this reconstruction dynamically displayed the anatomical structure of the flap vasculature and accurately guided the design and harvest of the flap during surgery. The parameters of the harvested flaps were consistent with the preoperative parameters. Postoperative complications occurred in 7 patients, but all flaps survived uneventfully. All of the donor sites were closed directly. All patients were followed up for 13-27months (mean, 19.75months). The color and texture of each flap were satisfactory and each donor site exhibited a linear scar. Digital technology can effectively and precisely assist in the design and harvest of ALT lobulated perforator flaps, provide an effective approach for individualized evaluation and flap design and reduce the risk and difficulty of surgery.

How to do a fourth dorsal metatarsal artery perforator flap for reconstruction of distal dorsal foot defects

The authors present a how-to-do-it guide for a dorsal metatarsal artery perforator (DMtAP) flap reconstruction of the foot following a burns injury.

Safety of Combined Deep Inferior Epigastric Artery Perforator Flaps and Gynecologic Procedures

Safety of Combined Deep Inferior Epigastric Artery Perforator Flaps and Gynecologic Procedures

Surgical Delay of Thoracodorsal Artery Perforator Flaps for Bilateral Autologous Breast Reconstruction.

Surgical Delay of Thoracodorsal Artery Perforator Flaps for Bilateral Autologous Breast Reconstruction.

The use of augmented reality for preoperative preparation of perforated flaps: a pilot study

Augmented reality (AR - augmented reality) is the addition of digital information to one or more senses, which allows the user to perform tasks more efficiently. This can be achieved by overlaying images, videos, or computer models. The aim the study is to study the use of AR for preoperative planning of perforant flaps and compare the results of visualization accuracy of various research methods. 3 patients with oncological diseases were examined, who were planned to lift and transplant a SCIP flap (in two cases) and a propeller flap on the perforant branch of the peroneal artery (in one case). All patients underwent a high-frequency ultrasound of 75 GHz examination of the donor zone and marking along it in the area of the planned flap lift. A CT scan of the donor area was also performed, followed by the superimposition of a segmentation image using HoloLens 2 virtual reality glasses. 7 measurements were obtained. AR for microsurgical planning was performed in two inguinal regions and was 100% correlated with the results of high-frequency ultrasound, in the case of perforant vessels of the peroneal artery, a discrepancy of 5 mm was noted for the X and Y axes in three perforant vessels. Augmented reality allows the reconstructive surgeon to see the anatomy of the area of interest in a particular patient before the incision. This area of medicine is certainly in demand, promising and requires further research with larger patient samples and randomization.

The Free Medial Sural Artery Perforator Flap for Microsurgical Reconstruction of Limbs: A Systematic Review and Meta-Analysis of Flap Characteristics and Outcomes

The medial sural artery perforator (MSAP) continues to gain popularity. Providing a versatile, thin and pliable alternative for commonly used workhorse flaps, it can be used to reconstruct extremities, with reduced donor site morbidity. This meta-analysis was conducted to analyse the current literature to help identify flap characteristics and outcomes. A systematic review was performed following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines and a literature search was conducted using Medline, Google Scholar and the Cochrane Library. The aim was to identify the outcomes of free MSAP flap reconstructions of upper and lower limb defects over a 10-year period from January 2010 to July 2020. The data was then tabulated and a meta-analysis was carried out. A total of 11 studies for lower limbs and 7 studies for upper limbs were reviewed and analysed with a total number of 257 patients. Limb reconstructions were primarily due to trauma. The most common site of reconstruction of the upper limb was the hand or wrist and the lower limb was the ankle or feet. The mean length of the flap was 9.6 cm. The mean width was 5.4 cm. The mean pedicle length was 9.7 cm. The mean flap thickness was noted as 5.9 mm. The number of perforators was an average of 1.5. The pedicle’s mean arterial diameter was 1.9 mm (mean) and the vein’s mean arterial diameter was 2.9 mm. 80% of donor sites were closed directly. Overall, the flap success rate was 98%. Our results find the MSAP flap to be a versatile, reliable, functionally and aesthetically good reconstructive option for both lower and upper limb defects with low donor site morbidity.

Septal perforation

Aim: This study isolates septal perforations due to nasal surgery for clinical analysis and their effect on bilateral mucosal flap repair. Methods: This is a retrospective review of a single surgeon’s 20-year experience with endonasal perforation repair utilizing bilateral mucosal advancement flaps supported with an autologous tissue interposition graft. Patients with a minimum of 4-month postoperative follow-up were included in the study. Comparative analyses of repair failure rates and perforation size of failures between surgical and non-surgical etiologies were performed. Results: Three hundred ninety-two patients met the criteria for inclusion in the study. The incidence of perforation and prior septal surgery was 40.6%. Overall repair closure in patients with a minimum of 4 months follow-up was 94.8%. Failures were noted in 5.7% of surgical and 4.7% of non-surgical perforation etiologies (P = 0.816). Mean differences in perforation length and height in failed repairs between non-surgical and surgical etiologies (19.4 vs. 13.7 and 15.5 vs. 9.3 mm, respectively) were significant (P = 0.048 length, P = 0.006 height). Conclusion: Post-surgical nasal septal perforations can be repaired with a low rate of failure. However, this study found that the size of perforations in failed repairs was significantly smaller in patients with a history of septal surgery, suggesting that prior septal surgery increases the technical difficulty of a bilateral flap perforation repair.

Sequential transplantation of exosomes and BMSCs pretreated with hypoxia efficiently facilitates perforator skin flap survival area in rats

Bone marrow mesenchymal stem cells (BMSC) are promising candidates for the treatment of trans-territory perforator flap necrosis. However, the low retention and survival rate of engrafted BMSCs limit their therapeutic efficacy. Strategies either modifying BMSCs or alleviating the inflammatory environment may solve this problem. Thus, we aimed to explore the therapeutic efficacy of sequential transplantation of exosomes and hypoxia pretreated BMSCs on flap necrosis. After the perforator flap model was created, the exosomes derived from BMSCs were injected immediately into choke zone II followed by transplantation of hypoxia pretreated BMSCs on Day 2. Gross view was performed to assess the flap survival, enzyme-linked immunosorbent assay was performed to evaluate the inflammatory factor level, microvessel number was assessed and quantitative polymerase chain reaction (qPCR) was performed to assess angiogenesis. We found that exosome delivery significantly reduced inflammatory cytokines levels on Day 1 and Day 3 and promoted the engrafted BMSCs’ survival on Day 7. After combining with transplantation of hypoxia pretreated BMSCs, the flap survival rate and the angiogenesis-related gene expression were significantly higher than in the other three groups; the von Willebrand factor (vWF) vascular diameter and vWF vascular count were significantly higher than in the phosphate buffered saline (PBS) group. Thus, we concluded that sequential transplantation of exosomes and BMSCs combinatorially pretreated with hypoxia further facilitated flap survival. This sequential transplantation approach provides novel insights into the clinical treatment of flap necrosis.

Surgical and health related quality of life outcomes following treatment with zygomatic implant perforated (ZIP) flaps.

The zygomatic implant perforated (ZIP) flap is a novel approach to the challenge of reconstructing the maxilla. We report on our experience using the ZIP flap technique for patients undergoing infrastructure maxillectomy at Chris O'Brien Lifehouse, Sydney, Australia. Thirteen patients who underwent a ZIP flap reconstruction between August 2019 and August 2021 were identified. Demographic, surgical, and histopathological information was collected. Health Related Quality of Life (HRQOL) was assessed using the FACE-Q Head and Neck Cancer module, the M.D. Anderson Dysphagia Inventory, and the Speech Handicap Index. A total of 44 zygomatic implants were placed, of which 42 (95%) survived. The median time from surgery to dental rehabilitation was 35 days. HRQOL data was available for nine patients over 24 months, demonstrating improved speech and swallowing outcomes over the follow up period. The ZIP flap is a reproducible surgical technique that facilitates rapid dental rehabilitation post infrastructure maxillectomy.

Trends in free flap reconstruction of the head and neck: a single surgeon series of 1027 free tissue transfers.

Free tissue transfer has fundamentally changed head and neck surgery, enabling reliable reconstruction of large defects with better function and aesthetics. This study assesses two decades of trends in free flap reconstruction, and how disease incidence, survival, surgeon caseload, team approach, and technology have impacted practice. Retrospective analysis of 1027 head and neck free flaps from 2006 to 2022. Outcomes examined include chronological changes in flap selection, indication, length of stay, incorporation of virtual surgical planning (VSP), annual caseload, survival, and their associations with the single versus multi-team approach. There were 764 soft-tissue and 263 osseous reconstructions utilizing 21 different flaps. Anterolateral thigh and radial forearm accounted for 76.7% of soft tissue flaps, with recent increase in superficial circumflex iliac perforator flaps in young patients. Osseous flap proportion remained stable, but fibula flaps increased five-fold with more VSP, dental implants, oral cancer, and multi-team surgery. Outcomes such as complication rates, length of stay and disease specific/overall survival have improved over time despite increasing complexity (P = 0.001, P = 0.001, P < 0.001, and P < 0.001, respectively). However, there was no significant difference in operative time, complication rate, or disease specific/overall survival between single team or multi-team approaches (P = 0.45, P = 0.054, P = 0.57, and P = 0.60, respectively). Single and multi-team approaches may have similar fundamental outcomes, but as caseload, complexity, and life-expectancy increases, both patients and surgeons benefit from a collaborative multi-team approach that focuses on improving long-term functional outcomes.

Genitocrural Island Perforator Flap (GIP-Flap): An ideal surgical technique for covering uni- or bilateral vulvar loss tissue

Vulvar loss of soft tissue leads to urinary, sexual and morphological dysfunctions. Most patients affected are comorbid making it difficult to perform a flap, which is the most appropriate way to reconstruct. Our multidisciplinary plastic and gynecologic surgery team has developed a new technique using a pedicled internal pudendal island flap. Reconstruction is reliable, quick and applicable to all patients, with a highly satisfactory final appearance.

Hotspots of facial artery perforators and perforasomes for easier flap guidance: An anatomical study

BackgroundThe facial artery perforator flap is a valuable alternative for reconstruction of small to medium defects in the central midface and provide pleasing cosmetic results, allowing reconstruction in a one-stage procedure. Since Doppler ultrasound is not applicable to distinguish perforator from source artery, anatomical studies are needed to identify perforator areas along the course of the facial artery. MethodsTwenty facial arteries of 10 fresh anatomical head specimens were dissected. All perforators with an outer diameter of at least 0.50 mm were identified and injected with dye to color their respective vascular territories. Size and location of colored skin territories as well as the location of its perforators were documented and statistically analyzed. ResultsIn total, 89 perforators were identified. The average number of perforators per facial artery was 4.45±1.15. The mean outer diameter of the perforator at the origin of the facial artery was 0,65±0.14 mm. The mean size of the colored skin territories was 577.57±488.81 mm2. Perforator diameters were significantly associated with the size of its resulting perforasomes. Furthermore, perforators mostly originated in two specific areas: 3.5 cm lateral and caudal and 4.5 cm lateral and 5.5 cm caudal of the anterior nasal spine. ConclusionThis study provides evidence of two predominant locations of emergence of facial artery perforators. Additionally, the significant correlation between perforator size and its appendant perforasomes as well as their location with reference to the anterior nasal spine as relevant osseous landmarks helps surgeons in decision making for flap design and surgery.

A Guide to Perforator Flap Selection for Buttock Pressure Sore Reconstruction.

Perforator flaps have been increasingly used to repair stage IV buttock pressure ulcers. However, no one has proposed an approach for stage IV buttock pressure ulcers repairing based on the subregion of buttock pressure ulcers. This study aims to evaluate the effect of perforator flaps in the repair of stage IV buttock pressure ulcers, and flap selection was based on the location of the pressure ulcers. Over the past 5 years, we evaluated 65 cases of stage IV buttock pressure ulcers repaired using perforator flaps. Flap selection was based on the subregion of each buttock pressure ulcer, following our approach. A total of 87 perforator flaps were used for 65 cases, including 42 superior gluteal artery perforator flaps, 19 fourth lumbar artery perforator flaps, and 26 descending inferior gluteal artery perforator flaps. All patients showed satisfactory reconstruction. The authors' approach can support surgeons in selecting the appropriate flaps to repair stage IV buttock pressure ulcers and achieve excellent reconstructive outcomes. This method makes the selection of flaps for pressure ulcer repair systematic, simple, and highly feasible and thus is worthy of promotion.

Aesthetic Evaluation and Validation: Umbilicus Reconstruction after DIEP Flap.

The most common method for autologous breast reconstruction is the deep inferior epigastric perforator (DIEP) flap. The umbilicus can be managed in various ways, including re-inset, neoumbilicus, and umbilectomy without reconstruction. This study evaluated the aesthetic differences in umbilicus reconstruction choice and variation in patients' postoperative satisfaction with their abdomen. A retrospective review of 1,019 patients treated with DIEP flap breast reconstruction between August 2009 and January 2022 was conducted. Patients were stratified by management of the umbilicus: preservation and re-inset of the native umbilicus, umbilectomy with delayed reconstruction, and umbilectomy with no reconstruction. A crowdsourced survey was created to assess the aesthetic preference of each photograph using a Likert scale. There were 1,063 responses to the umbilicus preference crowd source survey. Patients who had delayed umbilicus reconstruction after umbilectomy were rated to be significantly more attractive (4.397 ± 1.697) than both preservation of the native umbilicus (4.176 ± 1.669) and lack of the umbilicus (3.994 ± 1.733; p < 0.001 and <0.001, respectively). In an analysis of the BREAST-Q scores, delayed reconstruction patients had a similar change across measures when compared to the re-inset group. The delayed group had a significantly higher change in overall satisfaction and well-being with abdomen when compared with the no reconstruction group (p = 0.006 and 0.027, respectively). This study demonstrates that umbilectomy with delayed reconstruction yields a significantly higher aesthetic rating and comparable patient satisfaction when compared to re-inset of the umbilicus.