Planning Of Flaps Research Articles

Bilateral Lower Limb Injuries and the Need for Two Free Flaps: Simultaneous or Sequential

Abstract Objective To determine the choice of flap cover for patients presenting with bilateral lower limb trauma requiring free flap cover and to derive a step-wise guide to the planning of bilateral lower limb free flaps. Materials and Methods This was a retrospective study of patients over a 20 year period from 2000 to 2020 who presented with bilateral lower limb defects following trauma and were managed with two free flaps for wound cover, done either simultaneously or sequentially in the same admission. Results Of the 11 cases with 22 defects, there were 3 re-explorations with 1 flap loss managed with delayed fasciocutaneous flap cover. Donor morbidity was minimal requiring aspiration of seroma for 1 patient and secondary SSG for recipient area graft loss over muscle flap in 2 patients. Conclusion Use of single donor site ensures economy of time and tissue with the use of skin and muscle chimeric flaps. Harvesting of twin ALT flaps or the use of lattisimus dorsi as one of the flaps requires a 2 stage surgery to avoid prolonged operative time.

Noninvasive visualization of the midline-crossing arterial variation in the deep inferior epigastric artery perforator flap using photoacoustic tomography for application in patients with abdominal scars

BackgroundThe importance of the subcutaneous arterial network crossing the midline in transverse abdominal flaps has been reported. Photoacoustic tomography can be used to noninvasively visualize subcutaneous vascular networks. We applied this novel technology preoperatively in patients undergoing breast reconstruction to detect individual variations in the midline-crossing arteries. MethodsSix patients scheduled to undergo breast reconstruction using free deep inferior epigastric artery perforator flaps were examined. Each scan of the 12×8-cm region took approximately 8min. The accuracy of the tentative arteries evaluation defined by photoacoustic tomography was compared with the arterial phase detected by intraoperative indocyanine green angiography. The number of perforator vessels used for the flap, surgical time for flap elevation, and perfusion area ratio were compared with those of the control group. ResultsThe average match rate between tentative arteries prediction by photoacoustic tomography and arterial-phase assessment by intraoperative angiography in 5 patients was 79.8%. Each midline crossing artery showed individual variations. The photoacoustic tomography group (PAT-1 to 5) showed 1.8 perforators per flap, 163minutes for flap elevation, and 93% perfusion area, with no significant differences from the control group (N=5). A 63-year-old woman (PAT-6) with abdominal scars, including a midline abdominal incision, showed a preserved midline crossing artery. The planned single perforator deep inferior epigastric perforator flap was successfully applied to the contralateral perfusion area. ConclusionsPhotoacoustic tomography noninvasively visualizes the subcutaneous midline-crossing arterial networks. Understanding individual vascular variations can support preoperative planning and surgical indication of abdominal flaps, especially in patients with postsurgical scars.

The glove hand: an innovative method for effective bedside preoperative flap planning in hand injuries.

The glove hand: an innovative method for effective bedside preoperative flap planning in hand injuries.

Patient-specific Implants Improve Volumetric Surgical Accuracy Compared to Stock Reconstruction Plates in Modern Paradigm Virtual Surgical Planning of Fibular Free Flaps for Head and Neck Reconstruction

BackgroundVirtual surgical planning (VSP) for composite microvascular free flaps has become standard of care for oncologic head and neck reconstruction. Controversy remains as to the use of three-dimensional (3D)-printed titanium patient specific implants (PSI) versus hand-bent stock reconstruction plates. Proponents of PSIs cite improved surgical accuracy, reduced operative times, and improved clinical outcomes. Detractors purport increased cost associated with PSIs and presumed equivalent accuracy with less expensive stock plates. PurposeThe study purpose was to measure and compare the 3D-volumetric accuracy of PSI versus stock reconstruction plates among subjects undergoing VSP-guided mandibular fibular free flap reconstruction. Study Design/Setting/SampleA retrospective cohort study of subjects undergoing VSP-guided fibular free flap reconstructions at Mayo Clinic between 2016-2023 was performed. Subjects were excluded for non-VSP guidance, midfacial reconstruction, non-fibular free flaps, and lack of requisite study variables. Predictor VariableThe primary predictor was the type of reconstruction plate utilized (PSI versus stock plate). Main Outcome VariableThe main outcome was volumetric surgical accuracy of the final reconstruction compared to the preoperative surgical plan by root mean square error (RMSE) calculation. Lower RMSE values indicated a higher surgical accuracy. CovariatesCovariates included age, sex, race, smoking status, ASA classification, Charlson Comorbidity Index, preoperative diagnosis, and number of fibular segments. AnalysisDifferences in surgical accuracy were assessed between pre- and post-operative segmented scans using volumetric overlays from which RMSE values were calculated. Univariate and multivariate modeling of plate type to RMSE calculation was performed. Statistical significance set to p<0.05. ResultsTotal of 130 subjects were identified, 105 PSI and 25 stock plates. Calculated mean RMSE in millimeters (mm) for stock plates was 1.46 (SD: 0.33) and 1.15 (SD: 0.36) for PSIs. Univariate modeling demonstrated a statistically significant difference in RMSE of 0.31 (95% CI: 0.16-0.47) (p<0.001) equating to a 21.2% (p<0.001) improved volumetric surgical accuracy for PSIs. The association of improved volumetric accuracy with PSIs maintained in all multivariate models controlling for confounding. Conclusion and RelevanceIn modern era VSP-guided head and neck fibular free flap reconstruction, patient-specific 3D-printed titanium implants confer a statistically significant improvement in volumetric surgical accuracy over stock reconstruction plates.

Ultrasound in Microsurgery: Current Applications and New Frontiers.

Ultrasound has revolutionized reconstructive microsurgery, offering real-time imaging and enhanced precision allowing for preoperative flap planning, recipient vessel identification and selection, postoperative flap monitoring, and lymphatic surgery. This narrative review of the literature provides an updated evidence-based overlook on the current applications and emerging frontiers of ultrasound in microsurgery, focusing on free tissue transfer and lymphatic surgery. Color duplex ultrasound (CDU) plays a pivotal role in preoperative flap planning and design, providing real-time imaging that enables detailed perforator mapping, perforator suitability assessment, blood flow velocity measurement, and, ultimately, flap design optimization. Ultrasound also aids in recipient vessel selection by providing assessment of caliber, patency, location, and flow velocity of recipient vessels. Postoperatively, ultrasound enables real-time monitoring of flap perfusion, providing early detection of potential flap compromise and improved flap survival rates. In lymphatic surgery, ultra-high frequency ultrasound (UHFUS) offers precise mapping and evaluation of lymphatic vessels, improving efficacy and efficiency by targeting larger dilated vessels. Integrating ultrasound into reconstructive microsurgery represents a significant advancement in the utilization of imaging in the field. With growing accessibility of devices, improved training, and technological advancements, using ultrasound as a key imaging tool offers substantial potential for the evolution of reconstructive microsurgery.

Oncologic Staging Computed Tomography with IV Contrast Has Similar Efficacy to Dedicated Computed Tomography Angiography for Preoperative DIEP Flap Planning

Background: Due to variations in perforator vasculature, deep inferior epigastric artery perforator (DIEP) flap preoperative imaging can minimize operative time required to locate the most suitable perforators. Dedicated computed tomography angiography (CTA) has been the gold standard; however, many patients have already undergone a staging computed tomography (CT) per oncologic workup. The benefits from CTA may also be realized with a staging CT or CT with IV contrast. Methods: Ten patients who underwent DIEP flap reconstruction with staging CT and CTA within 3 years of one another were included in this study. Reviewers evaluated axial views of both imaging modalities separately to identify each visible perforator in reference to the pubic symphysis from the xiphoid to the pubic symphysis. An intraclass correlation coefficient (ICC) was used to determine agreement in location of perforators between the two imaging studies. Statistical analysis was performed using an ICC and Wilcoxon signed rank-tests. Results: The identified perforators within the patient cohort had an excellent correlation between their location on CT and CTA based upon ICC. The mean number of perforators identified in the CT group was 15.3 (SD 4.9) and in the CTA group was 18.8 (SD 6.4), which was not statistically different (P = 0.247). Conclusions: CT has similar efficacy in identifying number of perforators and perforator location to dedicated CTA for preoperative planning in DIEP flaps. This has the potential for decreased patient contrast and ionizing radiation exposure as well as improved patient and healthcare resource utilization.

Resurfacing complex knee and upper third leg defect with reverse vastus lateralis muscle flap in a flap exhausted leg - A case report

Coverage of upper third leg and knee defects are complex and the main supply of pedicled flaps come from the uninjured leg. Hence planning of flaps from leg must be meticulous, because if these fail then reveres flow flaps from thigh or micro vascular surgery will become the only option. Both have their own set of complications and patients who cannot tolerate micro vascular surgery due to their prolonged duration, co morbidities, and severe atherosclerosis of vessels, end up as thigh flaps being the only resort. Thigh flaps come with a set of complications of their own and even these fail, with above knee amputation being the ultimate option, which patient hardly expects as end result with many stages of reconstruction already being done. It’s a nightmare for both surgeon and patient.

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.

Role of Infrared Thermography in Planning and Monitoring of Head and Neck Microvascular Flap Reconstruction.

Reconstruction using microvascular free flaps has become the standard of care in head and neck cancer surgery, and their success lies in appropriate planning, adequate revascularization, and early detection of flap compromise so that prompt salvage is possible. This study evaluates the role of infrared thermography in the planning, execution, and postoperative monitoring of microvascular flaps in head and neck reconstructions. This is a single institutional, prospective observational study conducted at a tertiary care hospital in South India for 13 months. Twenty patients were included, and their thermographic images were captured in the preoperative, intraoperative, and postoperative settings using the infrared camera FLIR T400. These images were analyzed along with the Doppler, and clinical monitoring findings in all the settings and the temperature difference were calculated postoperatively. Hotspot perforator marking was made using infrared camera, and perforator marking was made using hand-held Doppler preoperatively, which correlated in 93% of cases. Intraoperatively, flap rewarming was successfully demonstrated in 19 of 20 cases. Postoperatively, flap compromise was observed on infrared thermography during the first 24 hours but not on clinical monitoring in three cases. The temperature difference values recorded were 5.4°C, 2.4°C, and 4.9°C. The mean of temperature difference of the healthy flaps was 1.0°C (range 0.1°C-1.8°C). Infrared thermography provides simple and reliable imaging, which can be used in perforator marking and flap designing preoperatively and checking the flap perfusion and vascular anastomosis patency intra- and postoperatively.

Preoperative Preparatory Talk (PPT): Developing Operative Expertise of Plastic Surgery Trainees by Three Rounds of Preceptor-Trainee Discussions.

Background Plastic surgery training requires the trainee to assist in surgeries to improve their on-table decision making and hone their surgical skills, but this results in an increased risk of intraoperative complications and increased operative time. It is important to have a training method that orients the trainee toward the surgery to ensure patient safety. Materials and Methods A training method called preoperative preparatory talk (PPT) was devised in which the preceptor orients the trainee toward the planned surgery in three phases. Comparison and statistical analysis of mean operative times of four stages of free flap surgeries after PPT and without PPT were done. Objective Structured Assessment of Technical Skill (OSATS) scores of surgical trainees were also documented for surgeries done with and without PPT and statistical analysis was done for comparing these scores. Results Statistical analysis via unpaired t -test confirmed that after applying PPT, there was a significant decrease in time taken in three out of four stages of free flap surgeries: flap planning and harvesting, recipient site preparation and vessel dissection, and flap division and partial inset. Trainees were found to be better oriented toward the surgery which resulted in a better performance on table that was confirmed by statistical analysis of OSATS score via unpaired t -test. Conclusion PPT ensures better learning for the resident and improves patient safety because of better orientation of the operating team toward the procedure and operating steps. This reduces the operative time of free flap surgeries. We recommend this training method to be incorporated in plastic surgery training programs.

Color Doppler ultrasound versus CT angiography for DIEP flap planning: A randomized controlled trial

Identifying relevant perforators is crucial in planning a deep inferior epigastric perforator (DIEP) flap. Color Doppler ultrasonography (CDU) has gained popularity for localizing perforators; however, current evidence on its efficiency is still inconclusive. This study aimed to compare the efficiency of CDU with that of computed tomography angiography (CTA) in localizing and selecting the relevant perforators. In this randomized controlled trial, 60 patients undergoing DIEP flap breast reconstruction (uni- or bilateral) were randomly assigned to the CDU group (i.e., CDU was performed to map and select the relevant perforators preoperatively) or the CTA+CDU group (i.e., mapping was based on CTA and supplemented by CDU). CDU was performed by the same surgeon with a well-defined sonography experience from our previous study. The reference XY coordinates of the dissected perforators were measured intraoperatively, and deviations from preoperatively deducted coordinates were calculated (ΔCDU or ΔCTA+CDU). The flaps were categorized according to the number of dissected perforators, and adherence to the preoperative strategy was evaluated. Overall, 22 patients (30 flaps) in the CTA+CDU group and 27 (39 flaps) patients in the CDU group were evaluated. The average ΔCDU (0.6cm) was significantly lower than the average ΔCTA+CDU (1.0cm) (p<0.001). Adherence to the mapping-based dissection strategy was higher in the CDU group; however, the difference was insignificant (p=0.092). CDU is not inferior to CTA + CDU in localizing and selecting relevant DIEA perforators. Therefore, CDU mapping is a possible complementary or substitute modality for CTA mapping.

The Use of Conventional Lower-Frequency Color Doppler Ultrasound for Flap Planning in the Lower Extremity.

Handheld Doppler is often inaccurate in localization of perforators for pedicled and free flaps. Color Doppler ultrasound (CDU), in contrast, allows more accurate mapping and characterization of perforators to facilitate rapid flap harvest. Forty-seven flaps harvested from the lower extremity were evaluated preoperatively with CDU by a single surgeon with a conventional low-frequency ultrasound device (Philips Sparq, Cambridge, Mass). Flaps evaluated included profunda artery perforator flaps (n = 36), anterolateral thigh flaps (n = 2), pedicled propeller perforator flaps (n = 7), and toe transfers (n = 2). In all cases where a free profunda artery perforator or anterolateral thigh flap was used, the location of the dominant perforator visualized preoperatively correlated exactly with intraoperative findings. In cases where CDU was used preoperatively to locate a large perforator close to a lower extremity defect for reconstruction with a propeller perforator flap, all perforators could be used, and all flaps were successful. Preoperative CDU is particularly useful for flap planning where knowledge of the location of the dominant perforator is critical. This includes planning of thin and superthin free flaps, as well as freestyle perforator flaps. Our clinical experience suggests that this technology should be routinely adopted in certain aspects of reconstructive microsurgery.

Preoperative planning of unilateral breast reconstruction with pedicled transverse rectus abdominis myocutaneous (TRAM) flaps: a pilot study of perforator mapping.

Pedicled transverse rectus abdominis myocutaneous (TRAM) flaps are well-established autologous reconstructive options for breast reconstruction. Preoperative computed tomographic angiography (CTA) has since become part of the routine workup in breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps. CTA provides an improved understanding of perforator anatomy which can facilitate optimal choice of hemiabdominal wall, and guide sheath harvest. Despite this knowledge, the role of preoperative CTA for breast reconstruction with the pedicled TRAM flap has not yet been established. A consecutive cohort of patients undergoing breast reconstruction with pedicled TRAM flaps without preoperative imaging were compared to a similar cohort of consecutive patients undergoing the same procedure with the use of preoperative CTA. Both flap and donor outcomes were assessed. Thirty-four consecutive patients undergoing ipsilateral breast reconstruction with pedicled TRAM flaps were included. There was no statistical difference in the operative times or outcomes between the two groups. There were no complete flap losses in either group. The use of preoperative CTA may help to guide surgical technique and provide the surgeon with greater confidence intraoperatively, however, this study did not show significant change in operative outcomes. Further study and risk/benefit analysis may better highlight the role of CTA in pedicled TRAM flap planning.

Workflow assessment of an augmented reality application for planning of perforator flaps in plastic reconstructive surgery: Game or game changer?

In contrast to the rising amount of financial investments for research and development in medical technology worldwide is the lack of usability and clinical readiness of the produced systems. We evaluated an augmented reality (AR) setup under development for preoperative perforator vessel mapping for elective autologous breast reconstruction. In this grant-supported research pilot, we used magnetic resonance angiography data (MR-A) of the trunk to superimpose the scans on the corresponding patients with hands-free AR goggles to identify regions-of-interest for surgical planning. Perforator location was assessed using MR-A imaging (MR-A projection) and Doppler ultrasound data (3D distance) and confirmed intraoperatively in all cases. We evaluated usability (System Usability Scale, SUS), data transfer load and documented personnel hours for software development, correlation of image data, as well as processing duration to clinical readiness (time from MR-A to AR projections per scan). All perforator locations were confirmed intraoperatively, and we found a strong correlation between MR-A projection and 3D distance measurements (Spearman r = 0.894). The overall usability (SUS) was 67 ± 10 (=moderate to good). The presented setup for AR projections took 173 min to clinical readiness (=availability on AR device per patient). In this pilot, we calculated development investments based on project-approved grant-funded personnel hours with a moderate to good usability outcome resulting from some limitations: assessment was based on one-time testing with no previous training, a time lag of AR visualizations on the body and difficulties in spatial AR orientation. The use of AR systems can provide new opportunities for future surgical planning, but has more potential for educational (e.g., patient information) or training purposes of medical under- and postgraduates (spatial recognition of imaging data associated with anatomical structures and operative planning). We expect future usability improvements with refined user interfaces, faster AR hardware and artificial intelligence-enhanced visualization techniques.

The Use of Thermal Imaging in Free Perforator Flap Planning

Background. Preoperative planning and design of microsurgical perforator flaps are the main steps for successful operation. The aim of this study was to determine the concordance between thermographic images obtained with smartphone thermal imaging camera and hand-held Doppler in the anterolateral thigh flap (ALT) model. Methods. A concordance study of diagnostic tests was carried out in Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Plastic and Reconstructive Surgery Department during 2020–2022. Patients’ who were scheduled to undergo reconstruction with ALT flap and healthy volunteers were included in the study. Dynamic thermal images were performed with smartphone thermal camera FLIR One PRO in the typical ALT flap territory. The number and distance of hotspots in the thermogram with respect to anterior superior iliac spine were recorded in the study protocol. Later, the examination was repeated with hand-held Doppler and the control of hotspot was performed. Sensitivity, specificity and concordance index calculations were performed. Statistical analysis was performed using IMB SPSS 23.0. Results. A total of 100 ALT flap territories were examined. 266 hotspots were detected with thermal imaging and 275 perforators with hand-held Doppler. In 96.6% of cases, hotspots detected by a thermal camera were confirmed by hand-held Doppler as perforators. The sensitivity and specificity of thermography for the detection of perforators with respect to the hand-held Doppler were 93.5% and 96.9% respectively. The measure of concordance kappa index was 0.095 (p = 0.001). Conclusion. Smartphone thermal imaging have a high concordance with hand-held Doppler in perforator mapping, thus could be considered a useful adjunct to conventional methods.

A Novel optimization technique of Computed Tomography Angiographic 3D-reconstructions for pre-operative planning of DIEP flaps

A Novel optimization technique of Computed Tomography Angiographic 3D-reconstructions for pre-operative planning of DIEP flaps

83. Role of Duplex scans in surgical planning of fibula free flaps – A retrospective study

Fibula free flaps remain the workhorse flap for composite reconstruction in Maxillofacial surgery. The peroneal vessels demonstrate anatomical variance and susceptibility to atherosclerosis. Assessing perfusion to ensure adequate blood supply to the remaining lower limb following flap harvest is paramount. We aim to assess and analyse the role and limitations of Duplex scans in surgical planning, as these are being increasingly replaced by alternative methods.

Surgeon-conducted color Doppler ultrasound deep inferior epigastric artery perforator mapping: A cohort study and learning curve assessment

Perforator mapping using diagnostic methods facilitates deep inferior epigastric perforator (DIEP) flap planning. Computed tomographic angiography (CTA) is a well-proven tool for perforator mapping. However, the benefits of color Doppler ultrasonography (CDU) are as follows: 1) CDU involves dynamic real-time examination and 2) does not use radiation. Comparing the accuracies of both methods in a cohort of patients, this study aimed to evaluate the learning curve of surgeon-conducted CDU perforator mapping. Twenty patients undergoing DIEP flap breast reconstruction were enrolled in a cohort study. All patients underwent CTA perforator mapping preoperatively. XY coordinates of significant perforators were subtracted by a radiologist. A single surgeon (sonographer) with minimal experience with CDU performed CDU perforator mapping, including XY coordinates subtraction. The sonographer was blinded to the CTA data. The reference coordinates of dissected perforators were measured during surgery. Deviations from reference coordinates for both methods were compared, and CDU mapping learning curve was assessed using Joinpoint Regression. We included 20 women (32 DIEP flaps and 59 dissected perforators). The mean deviation between mapped and reference coordinates was 1.00 (0.50-1.12) cm for CDU and 0.71 (0.50-1.12) cm for CTA. The learning curve of CDU mapping showed the breaking point after the seventh patient (≈ 21 localized perforators). After the breaking point, no significant differences between the deviations of both methods were found (p=0.980). A limited number of examinations were needed for the surgeon to learn CDU DIEA perforator mapping with accuracy similar to that of CTA mapping.

Methods of Perforator Vessels Visualization in Perforator Flap Preoperative Planning (Literature Review)ive planning (Review article)

Preoperative detection of perforator vessels in the perforator flap planning is an actual problem in clinical practice. There are various methods to visualize the localization of perforator vessels. This review presents the main of these methods with a description of their capabilities, advantages and limitations, as well as describes the priorities for using one or another approach depending on the localization of the donor site.

Algorithms for perforator-based flaps in different anatomical locations

Introduction: Perforator-based flaps can be planned in any anatomic location in the body when there is a detectable perforator. Although preoperative perforator mapping ensures safety and versatility of these flaps, there is no consensus yet about flap planning in different anatomical locations.&#x0D; Material and Method: 28 patients underwent perforator-based flap surgery for different anatomical locations as face (5), sternum (3), back (5), lomber (4), sacral (4) and scrotal (4) areas, leg (2) and foot (1). 19 of the patients were male while 9 were female. The mean age was 58.1±13.5 (22-80 years).&#x0D; Perforator-based flaps were planned as V-Y design in face, sacral and scrotal areas while as perforator plus transposition flaps for lomber area, leg and sternum. On the other hand, for foot the flap was planned as subcutaneous-pedicled turnover flap.&#x0D; Results: The mean follow-up time was 10 months (3-36 months). Partial flap necrosis is seen in all 3 patients who had underwent flap surgery on the lower extremity. There were no other complications seen in short- or long-term follow-ups. Comorbid diseases were not statistically significant on complications rates (P&gt;0.05).&#x0D; Conclusion: V-Y flap for the face and the sacral area; and perforator plus transposition flap for back ,lomber area and sternum are suggested as the ideal flap modifications for these anatomical locations. On the other hand, perforator-based flaps should not be used as a first choice in reconstruction of lower extremity defects.