Perforator Flap Reconstruction Research Articles

The Path to ‘Dieps by Dinner’ Involves The Entire Operative Team

More and more breast cancer patients are turning to autologous options for reconstruction. Deep Inferior Epigastric Perforator (DIEP) flap reconstruction is considered the gold standard flap breast reconstruction procedure; however, it requires a significant number of resources, including two surgeons and microsurgical equipment. A multidisciplinary group was tasked with reducing operative time of DIEP flap procedures by 25% so that complex surgeries can become more routine and accessible to patients. Using participatory ergonomics, members of the operative team were engaged to identify interventions. Following implementation, 22 DIEP flap cases were evaluated using workload surveys and patient outcomes to determine the success of the interventions. DIEP flap surgical durations were reduced by 25% on average (M=12.9 hours, SD=5.7 to M=9.7 hours, SD=1.4). When cases lasted longer than 9 hours, surgeons reported 31% more physical demand and 78% more fatigue than cases that were 9 hours or less. Survey results linked positive team characteristics to reduced frustrations and distractions.

Superficial peroneal nerve accessory artery (SPNAA) flap for head and neck reconstruction: A cadaveric anatomical study and retrospective case series review

Several different flaps can reconstruct intraoral defects or lower limb deficits after free fibula osteo-cutaneous flap harvesting for jaw reconstructions. However, commonly used options may not be available for various reasons and can be associated with significant morbidity. We hypothesized that flaps supplied by the superficial peroneal nerve accessory artery (SPNAA) could be a viable alternative reconstructive option. We describe the SPNAA's anatomy using 20 human cadaveric leg dissections and report eight cases involving SPNAA-based perforator flap reconstructions (six propeller flaps and two free flaps) in a retrospective case series. Patient-specific baseline variables and intraoperative and postoperative outcomes are described. Cadaveric dissection suggests that the location of the SPNAA is reliable but its origin varies, with 40% (N = 8) of SPNAAs being of type I origin, 20% type II (N = 4), and 40% (N = 8) type III in our series. All reconstructions were successful. No intraoperative complications occurred during propeller or free-flap reconstructions. No flap failures occurred. One propeller reconstruction showed distal superficial skin necrosis and one donor site wound dehisced; both were successfully managed conservatively. No other short-term or long-term complications occurred. Flaps based on SPNAA perforators appear effective, reliable, and safe reconstructive methods for covering fibula osteocutaneous donor site defects and for intraoral reconstructions. Controlled trials are required to compare its effectiveness and safety with other reconstructive methods.

Perforator Mapping of the Profunda Artery Perforator Flap: Anatomy and Clinical Experience.

Discovering alternatives to workhorse flaps that have more consistent anatomy and lower donor-site morbidity has become a focus of reconstructive surgery research. This study provides a simplified approach to profunda artery perforator flap design and harvest based on reliable anatomical landmarks. A retrospective review was conducted of 70 patients who underwent 83 profunda artery perforator flap reconstructions for postoncologic defects from 2016 to 2018. The authors recorded and analyzed the profunda artery perforator flap sizes and clinical applications, the numbers and locations of the perforators, and the patient outcomes. Most of the profunda artery perforator flaps were for head and neck [46 patients (65.7 percent)] and breast [21 patients (30 percent)] reconstructions. Flaps were most commonly based on perforator A (33.7 percent) and perforator B (33.7 percent), followed by perforators B and C combined (18.1 percent). Perforators were located a mean of 7.5 cm (perforator A), 12.7 cm (B), and 17.6 cm (C) distal to the pubic tubercle parallel to the axis between the pubic tubercle and the medial femoral condyle and 7.9 cm (A), 7.3 cm (B), and 6.1 cm (C) posterior from the axis. There was no flap loss. One patient underwent successful salvage surgery after arterial flap thrombosis. Eight patients (9.6 percent) developed superficial wound dehiscence that was managed conservatively. Perforator mapping demonstrated consistent anatomical locations of sizeable profunda artery perforators in the inner thigh. Along with its consistent and robust vascular anatomy and minimal donor-site morbidity, the profunda artery perforator flap's volume and pliability make it a reliable option for soft-tissue reconstruction. Therapeutic, IV.

Preoperative computed tomography assessment for a deep inferior epigastric perforator (DIEP) flap: a new easy technique from the Bologna experience.

Deep inferior epigastric perforator (DIEP) flap reconstruction is the gold standard reconstructive technique for women undergoing breast cancer surgery. A preoperative computed tomography angiography (CTA)-dedicated protocol and 3D reconstructions are mandatory for correct surgical planning. To evaluate the diagnostic performance of a new preoperative CTA protocol and a new reconstruction method in the assessment of DIEP technique. A total of 263 women (median age 49 years, age range 26-73 years) underwent preoperative CTA examination before DIEP flap breast reconstruction. A CTA-dedicated protocol followed by 3D-reconstructions were performed. Identification, branching pattern, and caliber at origin were assessed for each perforator. Intraoperative findings were the standard of reference. The sensitivity, positive predictive value, and diagnostic accuracy of the preoperative CTA protocol were calculated. In 255/263 (97%) patients, the dominant perforators assessed by CTA resulted adequate for surgical reconstruction. In 260/263 (99%) cases, the imaging localization of the dominant perforators corresponded with those seen intraoperatively (mean errors ≤1 cm). The preoperative CTA imaging sensitivity, positive predictive value, and diagnostic accuracy in determining the localization of perforators were 99% (95% CI 98-100), 100% and 99% (95% CI 98-100), respectively. No statistically significant differences were found between the CTA findings and the surgical findings for the assessment of branching pattern and caliber of the dominant perforators (P < 0.001). The present protocol has demonstrated high accuracy in the CTA imaging assessment of the perforators before DIEP flap reconstruction with high reproducibility between CT and surgical findings.

Assessment of surgical outcomes and oncological safety for submental artery perforator flap reconstruction after ablation of oral cancer

The submental artery perforator flap (SAPF) has been a new option for the intraoral reconstruction of oral squamous cell carcinoma (OSCC) patients in recent years, but its surgical outcomes have not been well assessed. We compared the surgical outcomes and oncological safety of SAPF reconstruction for medium-sized soft-tissue defects after the ablation of primary oral cancer with traditional submental island flaps (SIF) and anterolateral thigh perforator flaps (ALTPF). Fifty-one SAPFs, 30 SIF, and 74 ALTPF were reviewed for the intraoral medium-sized reconstructions after the ablation of oral cancer from our institutional clinical oncological databases. We performed comparative assessments on the variables of surgical outcome and oncological safety among the 3 cohorts. A Kaplan-Meier estimate of survival for each flap was calculated. Operating time was significantly reduced in the SIF and SAPF groups than ALTPF (p = 0.021 and 0.014, respectively). Flap thickness of SAPF was the significantly thinnest (mean 0.5 cm) among three groups. The common complications of donor site for both SAPF and SIF group were incision dehiscence and orocutaneous fistula. There was no significant difference in disease-free survival (DFS) among the 3 groups. However, several OSCC patients with the SIF reconstruction were found to have recurrences with a metastatic lymph node under the flap after the first operation. SAPF could be a versatile choice of the intraoral reconstruction for the medium-sized soft-tissue defects after the ablation of oral cancer.

375 Poster - Breast cancer patients undergoing delayed deep inferior epigastric perforator (DIEP) flap reconstruction differ from their matched controls by a higher socioeconomic status and better overall survival

375 Poster - Breast cancer patients undergoing delayed deep inferior epigastric perforator (DIEP) flap reconstruction differ from their matched controls by a higher socioeconomic status and better overall survival

Impact of opioid-free anesthesia on complications after deep inferior epigastric perforator flap surgery: A retrospective cohort study

This study measured the number of complications after deep inferior epigastric perforator (DIEP) flap reconstruction performed under opioid-free anesthesia (OFA) combined with goal-directed fluid therapy or opioid anesthesia with liberal fluid therapy (OA). This retrospective cohort study consisted of 204 patients who underwent DIEP flap reconstruction at AZSint Jan Brugge between April 2014 and March 2019. Primary outcomes were complications, according to the Clavien-Dindo classification and the length of hospital stay (LOS). The secondary outcomes were flap failure, postoperative nausea and vomiting (PONV), postoperative pain, postoperative opioid consumption, and postoperative skin flap temperature. OFA included a combination of dexmedetomidine, lidocaine, and ketamine without any opioid administered pre- or intraoperatively. OA included a combination of sufentanil and remifentanil. OFA patients received strict goal-directed fluid therapy, whereas OA patients received liberal fluids to maintain perfusion pressure. All patients except 7 (TIVA with remifentanil) received inhalation anesthesia combined with an infusion of propofol. Of the 204 patients, 55 received OFA and 149 received OA. There were no differences in major complications, but fewer minor complications in the OFA group (17.9% vs. 51.4% and P<0.001). Flap failure occurred in three patients of the OA group. Six patients developed flap thrombosis (five OA patients and one OFA patient). OFA was associated with fewer postoperative opioids, shorter LOS, less PONV, and less pain. In patients without previous nausea, the PONV incidence was higher in the OA group than in the OFA group (12.7% vs. 43.6% and P<0.001). Patients with previous nausea more frequently required postoperative opioids and had a nausea rate of 60.87%.

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.

Delayed free deep inferior epigastric perforator flap reconstruction following a bilateral nipple-sparing mastectomy: a case report

Delayed free deep inferior epigastric perforator flap reconstruction following a bilateral nipple-sparing mastectomy: a case report

Use of deep inferior epigastric perforator flap reconstruction as single-stage definitive treatment of symptomatic diabetic mastopathy: a case report

Use of deep inferior epigastric perforator flap reconstruction as single-stage definitive treatment of symptomatic diabetic mastopathy: a case report

The Medial Sural Artery Perforator Flap: Lessons Learned from 200 Consecutive Cases

The medial sural artery perforator flap is a versatile option in reconstructive microsurgery. However, most reports of this flap have been limited by sample size. This study reviews the experience of a single large-volume center using the medial sural artery perforator flap and its variants for a variety of reconstructive purposes. A retrospective review of all patients who received the medial sural artery perforator flap reconstruction between March of 2006 and July of 2014 was performed. Two-hundred medial sural artery perforator flaps were used at three anatomical regions: head and neck (n = 129), upper extremity (n = 47), and lower extremity (n = 24). Flaps were transferred as free (n = 189) and pedicled (n = 11). Overall flap survival was 96 percent. Flap variants used included chimeric flap (n = 11) and dual skin paddle (n = 2). Plantaris tendon and saphenous/sural nerve graft were harvested in conjunction in 20 and seven patients, respectively. In 5 percent of the cases harvested in the conventional manner, a reliable perforator could not be found. The medial sural artery perforator flap is a reliable, alternative workhorse flap for nearly any small- to medium-size defect. It can be harvested as free or pedicled and the option to include multiple tissue components further expands its versatility. Therapeutic, IV.

Unilateral or bilateral freestyle infra-orbital perforator flap in reconstruction of external soft tissue nasal defects

Nasal reconstruction is one of the most challenging procedures for plastic surgeons, and whether it should be performed using the subunit principle versus the defect-only principle remains a matter of debate. Skin grafting and local flaps such as dorsal nasal, bi-lobed, V-Y advancement, glabellar, nasolabial, forehead, and para-median forehead flaps have been used in nasal reconstruction. Another style of flap that has also been used for nasal reconstruction is the perforator flap. In this work, we will evaluate the utility of unilateral or bilateral freestyle infra-orbital perforator flaps in the reconstruction of nasal skin defects. This prospective clinical study was conducted in the plastic surgery department of Tanta University Hospital, Egypt, between February 2015 and April 2019. A total of 34 patients who presented with nasal skin tumours that did not invade the nasal bones or cartilage were ultimately enrolled in the study. The age of the patients ranged from 43 to 78 years, with a mean of 53 years. Clinical assessment was performed by three plastic surgeons who did not share in this study using a four-point scale. The assessment indicated excellent results in 22 (64.7%) patients, good results in 7 (20.6%) patients, fair results in 5 (14.7%) patients, and no poor results. No significant complications were observed in our experience. We believe that unilateral and bilateral infra-orbital perforator flaps may provide an alternative reconstruction method for different nasal defects. Level of Evidence: Level IV; therapeutic study.

Perforator Mapping Practice for Deep Inferior Epigastric Artery Perforator Flap Reconstructions: A Survey of the Benelux Region.

Numerous new and novel imaging techniques for preoperative perforator selection in deep inferior epigastric artery perforator (DIEP) flap planning have been introduced. To what extent, these have been adopted into or replaced routine practice has hitherto remained unknown. The purpose of this study was to identify the currently preferred technique by reconstructive surgeons, the criteria that they regard as most relevant and what impact these have on the preoperative decision-making. An online survey consisting of 25 questions was sent to members of the Benelux Societies for Plastic Surgery. Information regarding experience and preferred imaging modality was requested. Specific questions addressed the utilization of computed tomography angiography (CTA) and factors that could inform preoperative perforator selection. Results were anonymously collected, managed using REDCap, and analyzed using Chi-square statistic. Seventy-nine principal surgeons could be included. A variation in surgeon experience was observed. On CTA, the preferred imaging modality, large-caliber vessels, the location of the perforator in the flap, and its intramuscular course were considered the most significant criteria. Surgeons doing more than 20 DIEP flaps per year are less concerned about the distance of the perforator from the umbilicus (p = 0.003) but more likely to choose a medial perforator (p = 0.011). No statistical difference was found in surgeons' experience between those who would choose and use one specific (medial or lateral) perforator when they are analogous on CTA, and those who would delay the decision until both perforators have been exposed. Advantages and disadvantages of the current practice of preoperative perforator selection by surgeons who are primarily responsible for harvesting a DIEP flap have been clearly identified. Indications are that these could be widely representative in which case, the quest for a protocol or modality that maximizes the benefit and minimizes harm in preoperative perforator mapping is urgently required.

Thin superficial inferior epigastric artery perforator flap for reconstruction of the tongue.

The superficial inferior epigastric artery (SIEA) flap is widely used in the repair of large soft tissue defects of the extremities and in breast reconstruction. Because of the high fat content of the abdomen, it has been less used for glossectomy reconstruction. Here we present a series of seven patients who each underwent reconstruction with a thin SIEA flap after resection of the tongue. There were six men and one woman (mean age 48, range 24-66 years). All patients underwent preoperative computed tomographic (CT) angiography, and colour Doppler ultrasound (US) was used to select and map the most suitable SIEA. The flap was raised above the Scarpa's layer while adjusted the plane of dissection according to the specific needs for bulk in each case. All the flaps survived; one flap required a secondary anastomosis because of a venous anastomotic embolus. The size of flap used was 5.0cm×6.0cm - 7.0cm×9.0cm, and the flap was 0.8cm-1.4cm thick. The functional outcome was evaluated at 6 - 18 months follow up, when speech and swallowing were both good in all cases. The dissection above the pubic symphysis is an important refinement of the SIEA flap, and we conclude that the thin SIEA flap is a good choice for reconstruction after excision of cancer of the tongue.

Perineal resection and anorectal amputation with perforator flap reconstruction by a dorsal approach in prone Jackknife position

Some gynecological malignancies, such as vulvar or vaginal cancer, can present a local extension to the anus or rectum due to their close anatomical relationship. The frontline treatment in the...

The Impact of Combined Risk-Reducing Gynecological Surgeries on Outcomes in DIEP Flap and Tissue-Expander Breast Reconstruction.

In addition to prophylactic mastectomies, BRCA1 and BRCA2 mutation carriers are increasingly choosing to undergo risk-reducing procedures such as hysterectomies and salpingo-oophorectomies. Sometimes these surgeries are performed in the same visit as a mastectomy or a revisionary reconstruction procedure. Literature lacks descriptions of complications and trends for these combined surgeries. Group 1 patients (n = 10, flaps = 20) had abdominal gynecologic procedures at the time of deep inferior epigastric artery perforator flap (DIEP flap) reconstruction. Group 2 patients (n = 29, breasts = 58) had gynecologic procedures at the time of mastectomy and tissue-expander placement. Group 3 patients (n = 141, breasts = 257) had mastectomy and tissue-expander reconstruction without gynecologic procedures and were used as a control group for group 2. Group 4 patients (n = 357, flaps = 673) had autologous breast reconstruction without gynecologic procedures and were used as a control for group 1. Categorical variables such as complications and flap loss were analyzed using χ2 tests. Continuous variables such as age, body mass index (BMI), operative time, length of stay were analyzed with 2-tailed t tests. Multivariate analyses were run to control for group differences. Groups 1 and 4 were equivalent in age and comorbidities, except group 1 (32.8 kg/m2) had significantly higher BMI than group 4 (31.4 kg/m2), P = .028. Average operating time was statistically equivalent for group 1 patients (610 minutes) and group 4 patients (503 minutes), P = .289. Average hospital stay was equivalent as well (group 1 = 4.4 days, group 4 = 4.1 days, P = .676). Operative times for group 2 patients (457 minutes) were significantly longer than for group 3 patients (288 minutes), P < .01. Group 2 patients (3 nights) had significantly longer hospital stays than group 3 patients (2 nights), P < .01. Group 1 patients (2/20 flaps, 10%) had a significantly higher rate of flap loss than group 4 patients (8/673 flaps, 1%), P < .01. There were no differences in other flap complications. Additionally, there were no significant differences in postoperative tissue-expander complications between group 2 and group 3. Both flap losses in Group 1 patients occurred in a single patient with BMI = 39.3 kg/m2 and a personal history of recurrent DVTs. Additionally, the rates of complications across other measures were equivalent between groups. Thus, despite the increased rate of flap loss in Group 1 (10%) vs Group 4 (1.3%), along with the increased operative times and hospital stays, certain patients can be advised that a prophylactic gynecological procedure is safe to combine with breast reconstruction.

Decision algorithm and surgical strategies for managing tracheocutaneous fistula.

BackgroundPersistent tracheocutaneous fistula (TCF) is a complication of prolonged use of tracheostomy tube. Although many procedures exist to correct this issue, there is no consensus regarding its optimal management. We constructed a decision algorithm to determine appropriate surgical strategies for TCF repair.MethodsRetrospectively reviewing our hospital’s records, we found fourteen consecutive patients who had received surgical repair of tracheocutaneous fistula (primary closure or advanced local flap) between February 2013 and December 2018 and collected data relevant to their cases.ResultsWe identified 11 male and 3 female patients. Duration of tracheostomy dependence was 8.1±4.7 months, and timespan from decannulation to surgical closure 7.4±6.5 months. Seven patients received primary closures, six received hinged turnover flaps, and one received random and perforator flap reconstruction. There was no perioperative mortality or morbidity except for one patient requiring a repeat tracheostomy 11 months after TCF repair due to pneumonia and subsequent respiratory failure. We used our findings and those reported in the literature to construct a modified risk factor scoring system based on patient’s physical status, major comorbidities, perifistular soft tissue condition, and nutritional status and an algorithm for managing TCF based on the patients’ fistula size and modified risk factor scores.ConclusionsIn conclusion, we were able to review our cases and those of other studies to create a risk scoring system and a decision algorithm that we believe will help optimize patient-directed surgical management of TCF repair.

Abstract P3-08-44: The relevance of internal mammary lymph nodes found during autologous breast reconstruction

Abstract Background - Involvement of internal mammary lymph nodes (IMLN) in early breast cancer (EBC) leads to an upstaging of the disease anatomically. Unrecognized involvement of IMLNs leading to under-staging and under-treatment has been a hypothesis of studies demonstrating worse outcomes for medial tumours. Since surgery for removal of IMLNs is associated with high morbidity and radical surgical excision does not improve survival, surgical excision of IMLNs is not part of routine EBC treatment. Recent NCCN guidelines recommend IMLN irradiation for high risk EBC patients to reduce mortality. Metastasis to IMLNs may have a different impact on prognosis and management according to whether detected at the time of primary diagnosis, or later. Aims - The primary aim was to document the incidence of IMLN involvement in an EBC cohort - who underwent autologous deep inferior epigastric perforator (DIEP) flap reconstruction with unplanned sampling of 1 or more IMLNs - to ascertain the incidence of IMLN involvement. Our secondary aim was to ascertain whether IMLN involvement had an impact on management and/or prognosis. Materials and methods -We analyzed retrospectively collected data from a prospectively maintained database of patients who underwent DIEP flap reconstruction at the Royal Marsden Hospital, from April 2006 to March 2018. We used Freeman - Halton extension for Fisher’s test to assess association of IMN involvement with overall survival. Results - Of the 1471 women who underwent free flap reconstruction (1729 flaps) during this time period, 300 with EBC had their IMLNs sampled at the time of DIEP surgery. Of these, 36 had metastasis to their IMLN (incidence of 12%). The median age was 47 years and mean follow up was 34.5 months. Based on timing from initial diagnosis, 17 women had immediate DIEP flap reconstruction, 9 had delayed reconstruction (mean time from primary surgery 25 months) and 10 had reconstruction after mastectomy for loco-regional recurrence (7 at time of mastectomy for recurrence, 3 delayed). We compared outcomes for these 3 groups. Of these 36 patients, 19 had no preoperative staging and were staged only after they were found to have involved IMLNs. Four (2 in the delayed and 2 in the reconstruction after local recurrence group) of these 19 were found to have more widespread metastatic disease. Apart from these 4, based on IMLN involvement, treatment was altered in 17 others (total 21/36, 58.3%) - 8/17 in the immediate group, 7/9 in the delayed group and 2/8 for DIEP after local recurrence. The commonest alteration in treatment was addition of IMLN chain RT in 7 followed by change in endocrine therapy in 5; three had both. One patient who underwent immediate reconstruction had a negative SLN and had systemic adjuvant chemotherapy based solely on the involved IMLN. At a median follow up of 14 months, 12 patients (all either delayed or after local recurrence) of 19 relapsed with metastatic disease and 8 of them died due to disease progression. The local recurrence group had the highest rate of cancer-related mortality (p value &amp;lt; 0.0001) Conclusion - IMLN involvement leads to upstaging of the disease resulting in more significant change in treatment in those undergoing delayed autologous reconstruction. Local recurrence carries the worst prognosis. Staging prior to delayed DIEP surgery purely for reconstruction should be based on risk (from primary diagnosis) and all patients planned for DIEP reconstruction after local recurrence should undergo appropriate pre-operative staging investigations. Multivariate survival analysis using Cox’ proportional hazards model for those with involved versus uninvolved IMLNs to ascertain their prognostic significance will also be reported. Citation Format: Pooja Padmanabhan, Tania Policastro, Natalie To, Jennifer E Rusby, Stuart E James, Paul A Harris, Peter A Barry. The relevance of internal mammary lymph nodes found during autologous breast reconstruction [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-08-44.

Portable Color-Flow Ultrasound Facilitates Precision Flap Planning and Perforator Selection in Reconstructive Plastic Surgery.

Precise flap planning and perforator selection are paramount for successful perforator flap surgery. Portable color-flow ultrasound (PCFU) is a convenient, low-cost, easily accessible imaging modality that is pivotal in the planning of perforator flaps where anatomic variability is the rule. Perforator mapping was performed using an L12-4 linear-array ultrasound probe connected to an Android tablet. Images were obtained with the Lumify app (Philips Lumify, usa.philips.com). Perforator characteristics were recorded (arterial diameter, emergence points from fascia, subcutaneous course, and projection onto the skin surface) using still images and real-time videos. Thirty consecutive patients had 40 perforator or musculocutaneous flap reconstructions over a 2-year period. For the 15 flaps that had preoperative computed tomographic angiography (CTA) imaging, the preoperative sonographic measurements correlated with CTA and intraoperative findings. Portable color-flow ultrasound allowed perforator flap design and selection based on the largest available perforator, the most appropriate flap thickness, and comparison of multiple donor sites including left versus right. Two deep inferior epigastric perforator patients required take-back to the operating room for debridement of devitalized nonflap tissue. The superior gluteal artery perforator flap was abandoned intraoperatively due to proximal vascular anomalies. Overall flap success rate was 98% (39/40 flaps). Our experience with PCFU has rapidly improved, allowing individualized perforator flap selection and design based on each patient's unique perforator anatomy, reconstructive requirements, and donor site characteristics. In our practice, PCFU has supplemented CTA and in many cases has supplanted CTA as the primary imaging modality of choice in the planning of perforator flap reconstruction.

Medial sural artery perforator flap in reconstruction of soft tissue defect in upper and lower extremities: a clinical study

ABSTRACT Background: The quality of soft tissue reconstruction in upper and lower extremities caused by trauma, infection, burns, and tumor resection affects the patient function and esthetic outcome. Many flaps have been described in the literature to reconstruct such defects. Medial sural artery perforator flap is one of the options for reconstruction of upper and lower extremities. Patients and methods: Starting from July 2019 through August 2020, 20 pedicled and free MSAP flaps were used for reconstruction of upper and lower limbs soft tissue defects. Results: total flap loss occurred in two cases, partial flap loss occurred in two cases and the flap was abandoned in two cases. Otherwise, all flaps survived well. Conclusion: MSAP flap is an excellent option in the reconstruction of soft tissue defects in upper and lower extremities.