Preoperative Perforator Mapping Research Articles

Smartphone Thermal Imaging for Preoperative Perforator Mapping in Perforator Based Flaps.

To determine the diagnostic accuracy of smartphone thermal imaging for preoperative perforator mapping in perforator-based flaps, taking visual inspection as gold standard. It was a cross-validation study conducted at the Department of Plastic Surgery, Dr. Ruth K. Pfau Civil Hospital, Karachi, Pakistan, from August 2022 to January 2023. All adult patients aged 18 to 40 years of either gender undergoing perforator flap surgery were included. Each patient followed the same treatment regimen, which involved the preoperative identification of the perforator location using the FLIR One camera. Subsequently, confirmation was achieved during the surgical procedure through visual inspection. A two-by two table was used to calculate sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy. The mean age of the patients was 30.10±6.87 years, ranging from 18 to 40 years. Most of the patients were males (58.7%), and 41.3% were females. Almost 80.4% were pedicle flaps, and 19.6% were free flaps. The accuracy of thermal imaging was found to be 83.2%, with a sensitivity of 84.3%, a specificity of 80%, a PPV of 92.9%, and a NPV of 62.2%, respectively. Smartphone-based thermal imaging is useful for the diagnosis of perforators and has high sensitivity and specificity.

Preoperative Imaging Mapping of DIEP Perforators and Intraoperative Selection: Does It Correlate?

Preoperative imaging prior to deep inferior epigastric perforator (DIEP) flap harvest is a common practice to locate perforators and identify aberrant anatomy. We report a retrospective review of 320 consecutive patients who underwent preoperative computed tomographic angiography (CTA) or magnetic resonance angiography prior to DIEP flap breast reconstruction. The locations relative to the umbilicus of preoperatively identified perforators were compared with the selected intraoperative perforators. The diameter of all intraoperative perforators was also measured. Across the 320 patient, 1,833 potentially suitable perforators were identified on preoperative imaging. A total of 564 of the 795 perforators selected intraoperatively for DIEP flap harvest were within 2 cm of a predicted perforator, for a rate of 70.1%. The size of the perforator was unrelated to the detection rate. We were able to demonstrate a sensitivity of 70% of clinically selected DIEP perforators identified on preoperative imaging in this large series. This contrasts with the nearly 100% predictive value reported by others. Continued reporting of findings and methods of measuring are needed to improve the practical efficacy of CTA and raise awareness about the limitations of CTA, despite its well-documented usefulness.

Preoperative Perforator Mapping in DIEP Flaps for Breast Reconstruction. The Impact of New Contrast-Enhanced Ultrasound Techniques.

Deep inferior epigastric artery flaps (DIEP) represent the gold standard of autologous breast reconstruction. Due to significant variations in vascular anatomy, preoperative perforator mapping (PM) is mandatory in order to ensure the presence of a sufficient perforator within the flap. In this regard, CT angiography (CTA) is currently the method of choice. Therefore, we investigated the value of contrast-enhanced ultrasound (CEUS) techniques for preoperative PM in comparison to CTA. Patients underwent PM, utilizing both CTA and CEUS techniques. Documentation included the course of the vascular pedicle through the rectus muscle (M), fascial penetration (F), the subcutaneous plexus (P) and the skin point (SP) on either side of the abdomen. Thus, contrast-enhanced B-Flow (BCEUS), B-Flow ultrasound (BUS), CEUS, color Doppler ultrasound (CDUS) and CTA were evaluated in terms of the diagnostic consistency and effectiveness of PM. Precision (∆L) was then calculated in relation to the actual intraoperative location. Statistical analysis included Kruskall-Wallis, Levene and Bonferroni tests, as well as Spearman correlations. A total of 39 DIEP flaps were analyzed. Only CTA (∆L = 2.85 mm) and BCEUS (∆L = 4.57 mm) enabled complete PM, also including P and SP, whereas CDUS, CEUS and BUS enabled clear PM throughout M and F only. Regarding the number of detected perforators, PM techniques are ranked from high to low as follows: CTA, BCEUS, BUS, CEUS and CDUS. CTA and BCEUS showed sufficient diagnostic consistency for SP, P and F, while CDUS and CTA had a superior performance for M. BCEUS offers precise image-controlled surface tags and dynamic information for PM without imposing radiation and may, therefore, be considered a feasible add-on or alternative to CTA. However, BCEUS requires an experienced examiner and is more time-consuming.

Precision of Dynamic Infrared Thermography in Anterolateral Thigh Flap Planning: Identification of the Perforator Fascia Passage.

The anterolateral thigh (ALT) flap is commonly utilized in reconstructive surgery. Preoperative perforator mapping facilitates dissection. Dynamic infrared thermography can be applied to identify ALT perforators. However, its accuracy has not been evaluated in detail before. Therefore, this study aimed to assess the precision of dynamic infrared thermography in ALT perforator localization. The survey site was defined as a 25 × 8 cm rectangle on the anterolateral thigh and a coordinate system was established. The area was examined consecutively by dynamic infrared thermography with a FLIR ONE camera after 2-minute fan precooling. Two surgeons then independently performed color duplex ultrasound on the basis of the identified hotpots. Twenty-four healthy subjects were examined. About 74.8% of perforators were musculocutaneous or musculoseptocutaneous. The mean distance between study area center and perforator or hotspot center was 51.8 ± 27.3 and 46.5 ± 26.2 mm, respectively. The mean distance from hotspot center to sonographic perforator fascia passage was 15.9 ± 9.9 mm with a maximum of 48.4 mm. The positive predictive value of thermographic ALT perforator identification was 93%. Thermographic hotspot and perforator location diverge widely in ALT flaps. Dynamic infrared thermography can therefore not be used as standalone technique for preoperative ALT perforator identification. However, the application before color duplex ultrasound examination is a reasonable upgrade and can visualize angiosomes and facilitate the examination.

Multidetector-Row Computed Tomographic Analysis of the Superficial Palmar Branch of Radial Artery Perforator Flaps.

Soft-tissue defects in the hand and digits can be effectively covered by using the free superficial palmar branch of the radial artery (SPBRA) flap, which is harvested from the radial volar wrist. Because previous anatomical studies on this flap are limited, multidetector-row computed tomographic angiography of the upper limbs was conducted to characterize the three-dimensional anatomical structure of the SPBRA and its perforators in living patients. This retrospective anatomical study was conducted from 2014 to 2019. All data from Digital Imaging and Communications in Medicine were analyzed by using their viewer. SPBRA diameter and the location where it bifurcated from the radial artery were recorded, as were the number, location, branching patterns, and diameters of its perforators and their lengths. In total, 30 patients met all eligibility criteria. All had the SPBRA. The vessel bifurcated from the radial artery on average 13.2 mm proximally from the radial styloid process. The 30 patients had 40 SPBRA perforators in total. Their average SPBRA-to-dermis length was 6.43 mm. All patients had at least one direct cutaneous perforator. Nine and one also had one musculocutaneous perforator and another direct perforator, respectively. All direct cutaneous perforators were located inside a 16.4-mm-diameter circle with an origin on the scaphoid tubercle. The mean diameters of the SPBRA and its perforators were 1.12 and 0.62 mm, respectively. All patients had at least one reliable SPBRA perforator in the radial volar wrist. The authors' results suggest that plastic surgeons can easily and safely plan the SPBRA flap design, potentially without preoperative perforator mapping.

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.
 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).
 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.
 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>0.05).
 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.

Total breast reconstruction using thoracodorsal artery perforator (TDAP) flap with or without implants

Introduction: The thoracodorsal artery perforator (TDAP) flap has been increasingly used for breast reconstruction mainly due to reduced donor site morbidity compared to latissimus dorse (LD) flap. TDAP flap was mainly described for partial reconstruction of breast defects following breast conserving surgery. This study describes the use of the TDAP flap in total breast reconstruction with or without synthetic implants in two breast units. Methods: Between June 2017 and June of 2022, seven patients were included. Six patients from the Oncology Center, Egypt and one patient from Cambridge Breast Unit. Preoperative perforator mapping method was recorded. Patients’ demographic data, type of mastectomy and reconstruction and surgical outcome were recorded. Results: Five patients had total breast reconstruction without implants, whilst two patients had implant-enhanced TDAP reconstruction. The mean age of was 39 years (31-43), and the mean mean body mass index (BMI) was 28 kg/m2 (23-36). Median hospital stay was 3 days. All patients had immediate breast reconstruction following mastectomy without the need for contralateral symmetrization or corrective surgery. No seroma was reported. Only one patient had complete flap loss, while one patient who had minor wound infection.

Total breast reconstruction using thoracodorsal artery perforator (TDAP) flap with or without implants: Two centers experience

Introduction: The thoracodorsal artery perforator (TDAP) flap has been increasingly used for breast reconstruction mainly due to reduced donor site morbidity compared to latissimus dorse (LD) flap. TDAP flap was mainly described for partial reconstruction of breast defects following breast conserving surgery. This study describes the use of the TDAP flap in total breast reconstruction with or without synthetic implants in two breast units. Methods: Between June 2017 and June of 2022, seven patients were included. Six patients from the Oncology Center, Egypt and one patient from Cambridge Breast Unit. Preoperative perforator mapping method was recorded. Patients’ demographic data, type of mastectomy and reconstruction and surgical outcome were recorded. Results: Five patients had total breast reconstruction without implants, whilst two patients had implant-enhanced TDAP reconstruction. The mean age of was 39 years (31-43), and the mean mean body mass index (BMI) was 28 kg/m2 (23-36). Median hospital stay was 3 days. All patients had immediate breast reconstruction following mastectomy without the need for contralateral symmetrization or corrective surgery. No seroma was reported. Only one patient had complete flap loss, while one patient who had minor wound infection.

Preoperative perforator mapping of anterolateral thigh flaps using computed tomographic angiography and visual coordinate system for the reconstruction of head and neck defects.

The anterolateral thigh (ALT) flap is a versatile workhorse flap for the reconstruction of head and neck defects; however, variations in the location of perforators are a significant concern. This prospective study proposes a rapid, effective, and convenient method for mapping the location of sizeable perforators on the curved thigh skin surface using the visual coordinate system in computed tomographic angiography (CTA) images. Fourteen patients suffering from defects after head and neck carcinoma resection underwent CTA prior to ALT flap reconstruction at the Department of Otolaryngology-Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, from January 2018 to August 2021. Using sterile gauze swab developing lines pasted on the patients' thighs, we established a coordinate system visualized both in CTA images and the thighs. The perforator information was then compared between the CTA and intraoperative findings. Twenty-one perforators were detected on CTA in the designed flaps, which were also confirmed during the operation with a visual pulse. The course and source of the perforators were consistent with the intraoperative findings. The distances of perforator coordinate points between CTA and intraoperative findings were <5 mm. Another five perforators (mostly without visual pulse) found intraoperatively could not be identified on preoperative CTA. Most flaps survived in their entirety, and one flap suffered a small area of necrosis due to perforator compression. This study demonstrated the efficacy of a novel perforator mapping method for anterolateral thigh flaps.

Deep inferior epigastric perforator flap preoperative planning: A comparative analysis between dynamic infrared thermography, computerized tomography angiography, and hand-held Doppler.

Hand-held Doppler (HHD) sonography and computerized tomography angiography (CTA) are the common assessment tools for deep inferior epigastric perforator (DIEP) flap preoperative planning. CTA is considered the gold standard method for preoperative perforator mapping but necessitates contrast medium and X-ray exposure. Dynamic infrared thermography (DIRT) does not have these drawbacks and allows the detection of hot and cold spots on a given body area. Our study aimed to compare DIRT, HHD, and CTA in perforator mapping for breast reconstruction using DIEP flap. From March to September 2020, 12 consecutive patients scheduled for DIEP flap breast reconstruction were preoperatively investigated with HHD, CTA, and DIRT. The patients' mean age was 53 and the mean BMI was 29.23 kg/m2 . All the reconstructions were due to breast cancer. The results of preoperative perforator mapping on the lower abdomen were compared among the three techniques. All the evidence was compared to the intraoperative findings, during flap harvesting, to establish if the techniques were able to correctly locate the perforator. We detected 178 perforators intraoperatively, 178 with CTA, 178 with DIRT, and 125 with HHD. The latter revealed a lower number of perforator vessels for each patient (10.42 ± 3.58), compared with CTA (14.83 ± 3.04) and DIRT (14.83 ± 4.76). DIRT resulted superior to HHD (p < .05), while no statistically significant difference (p > .05) was found between DIRT and CTA. We calculated a mean sensitivity of 93.87% for CTA, 69.02% for HHD, and 92.06% for DIRT. DIRT is a useful tool in the preoperative planning of DIEP flaps, as it provides information about the location of perforators and the hemodynamic properties of angiosomes. It is easy to use, and it does not involve ionizing radiation. DIRT could represent an innovative and promising implementation of CTA and HHD techniques for preoperative perforator mapping in DIEP breast reconstruction.

A Dynamic Anatomic Study of Parasacral Perforators: Mapping, Perforasome, and Applications for Buttock Enhancement.

Due to the lack of knowledge about parasacral artery perforators, flaps from this region cannot be used with complete confidence in their security and effectiveness. Knowledge of the clusters and perforasome of these perforators could help in the design of more reliable flaps and extend the range of applications. This study aimed to identify the location, number, and density of perforators, and to subsequently analyze the perfusion flow and linking vessel distribution. Five fresh cadavers were harvested and dissected. For the mapping, after injecting lateral sacral arteries with colored latex, perforators with a diameter of >0.5 cm were examined in 5 sacral regions. All data were collected on the suprafascial plane, with an orthonormal coordinate system placed on iliac crests and median lines. For perforasome analysis, 5 perforators and 3 three sacral flaps were injected with radiopaque dye. A dynamic (4-dimensional) computed tomographic angiography completed the analysis. A mean [standard deviation] of 8.4 [1.36] perforators per corpse, with a mean diameter of 0.72 [0.14] mm, were identified. There was a higher density of parasacral perforators close to the median line and 7.6 cm above the iliac crests. This pattern was not a random distribution (P < 0.05). The perfusion area was preferentially in the superior gluteal region. Perfusion flow was permitted by the dominant direct-linking vessels towards adjacent lumbar perforators, oriented diagonally upward and outward to the midline. Parasacral perforator flaps appear to be a useful procedure in reconstruction and in aesthetic surgery, especially in gluteal augmentation. Their reliability depends on sound anatomic knowledge, with accurate preoperative perforator mapping.

Current Applications of Ultrasound Imaging in the Preoperative Planning of DIEP Flaps.

The deep inferior epigastric artery perforator (DIEP) flap has become the gold standard for autologous breast reconstruction at many institutions. Although the deep inferior epigastric artery displays significant anatomic variability in its intramuscular course, branching pattern and location of perforating vessels, the ability to preoperatively visualize and map relevant vascular anatomy has increased the efficiency, safety and reliability of the DIEP flap. While computed tomography angiography (CTA) is often cited as the preoperative imaging modality of choice for perforator flaps, more recent advances in ultrasound technology have made it an increasingly attractive alternative. An extensive literature review was performed to identify the most common applications of ultrasound technology in the preoperative planning of DIEP flaps. This review demonstrated that multiple potential uses for ultrasound technology in DIEP flap reconstruction including preoperative perforator mapping, evaluation of the superficial inferior epigastric system and as a potential adjunct in flap delay procedures. Available studies suggest that ultrasound compares favorably to other widely-used imaging modalities for these indications. This article presents an in-depth review of the current applications of ultrasound in the preoperative planning of DIEP flaps and explores some potential areas for future investigation.

A Comparison of Accuracy between Dynamic Infrared Thermography (DIRT) and Handheld Doppler Ultrasonography in Free Flap Reconstruction Perforator Mapping: A Prospective Study

Background: Preoperative perforator mapping is one of fundamental steps for successful surgery in microsurgical perforator free flap. Currently, there is still no gold standard for preoperative perforator mapping. Objective: The present study aims to compare accuracy in perforator mapping between dynamic infrared thermography (DIRT) and handheld doppler which is the main method we used in our hospital. Materials and Methods: Twenty patients scheduled for microsurgical free flap reconstruction between October 2018 to December 2020 was enrolled. Preoperative perforator mapping was performed by both handheld doppler and smartphone dynamic infrared thermography (DIRT). During rewarming period, &ldquo;Hot spots&rdquo; were marked. Then flaps were raised intraoperatively, numbers, diameter and location of each perforators were recorded. Location of perforators at its piercing fascia were reflected to skin. Distance from actual perforators to the nearest preoperative perforator marking point by each method were measured. Results: There were 9 male and 11 female patients enrolled in the present study with mean age of 54.30 years. The average body mass index was 23.85 kg/m2. Hand-held doppler and DIRT images were obtained for 20 flaps, including 15 anterolateral thigh flaps (75%), 1 anteromedial thigh flap (5%) and 4 fibular free flaps (20%). The mean caliber of selected perforators was 2.62 mm at point of their emergence through fascia. All the flap survived without postoperative major complication. The mean distance from actual perforator to the nearest perforator from handheld doppler was 11.88+7.51 mm, and to the nearest perforator from thermal images was 12.68+8.96 mm. The mean distance difference of both methods was 0.80 mm. Perforators were usually within a 20 mm radius of preoperative marking both handheld doppler and DIRT. Conclusion: Dynamic infrared thermography is low cost, non-invasive and reliable methods for preoperative perforator mapping. Keywords: Dynamic infrared thermography; Handheld doppler ultrasonography; Perforator mapping; DIRT; Perforator free flap

Photoacoustic microscopy: a novel approach for studying perforator skin flap in a mouse model.

A comprehensive understanding of cutaneous microvessels is key to the design and use of the perforator skin flap. Compared with the various imaging technologies that have been applied in the clinical practice of the perforator skin flap, photoacoustic microscopy (PAM) is a very promising noninvasive imaging modality with high resolution and deep penetration in biological tissues. PAM was employed to explore its multiple applications in a perforator skin flap. The following experiments were then conducted in 3 parts. In part 1, 7 mice were used to obtain the preoperative perforator mapping on the mouse back. In parts 2 and 3, 7 mice were used to design and harvest the multiterritory perforator flap. The status of the flap and the morphological changes of choke vessels were subsequently observed by PAM at several time points. The results showed that PAM could visualize and assess the vascular physiological and pathological conditions of the skin tissue in real time in vivo with high spatial and temporal resolution. It could also provide preoperative perforator mapping, including the total number of perforators, localization, vascular territories, and diameter. Furthermore, it could offer a quantitative, objective method to monitor the status of the perforator skin flap, and was capable of noninvasive characterization of the changes of choke vessels that play an important role in multiterritory perforator skin flap expansion and survival. PAM has great potential to be an effective and precise quantitative imaging tool for perforator skin flap research, such in as flap design, monitoring, and choke vessel observation.

Air Flow Cooling Improves Anterolateral Thigh Perforator Mapping Using the FLIR ONE Thermal Camera.

Due to the variable vascular anatomy preoperative perforator mapping facilitates anterolateral thigh (ALT) free flap harvesting. Dynamic infrared perforator imaging can assist preoperative planning by displaying hot spots that represent angiosomes. This study aims to compare previously described precooling methods to develop a standardized simplified protocol for ALT perforator planning. Fifty thighs were examined with a FLIR ONE thermal camera. Four different cold challenges, including alcoholic disinfection, wet laparotomy sponge cooling, fan cooling, and cold pack application, were compared. Hot spot locations within a 250 mm × 80 mm area were compared double-blinded to perforator locations determined by Doppler ultrasonography considered as gold standard. The matching rate of thermographic hot spots and sonographically identified perforators was 34.9 ± 22.2%. An increased matching rate of 62.2 ± 42.2% was noted taking only favored perforators (septocutaneous course, diameter >1 mm, distance <3 cm to the center, and visible concomitant veins) into account. Precooling with a fan followed by alcoholic disinfection provided clearest thermograms and fastest results. Thermographic imaging is a reliable method for perforator imaging. Its supplemental use to ultrasound may reduce examination time and yield additional information. Precooling by air flow or alcoholic disinfection can be easily implemented and provide the best thermograms. The matching rate of thermographic hot spots and perforators increases when taking only clinically relevant perforators into account. Thermal perforator mapping therefore reduces distraction by negligible perforators.

An Innovative Approach for Preoperative Perforator Flap Planning Using Contrast-enhanced B-flow Imaging.

SUMMARYPrecise perforator mapping of the epifascial and subcutaneous course of the perforator flaps, including the precise detection of the skin point, is mandatory for successful preoperative flap design and planning of supramicrosurgery. We investigated the effectiveness of contrast-enhanced B-flow (BCEUS) imaging for perforator mapping and preoperative perforator flap planning and compared it with B-flow ultrasound, contrast-enhanced ultrasound, and color Doppler ultrasound. Sixteen patients who received an individualized perforator flap reconstruction were included in the study. Preoperative perforator mapping includes the following structures: subfascial course of the pedicle, fascial penetration point, subcutaneous course (epifascial and subcutaneous), and perforator skin point. The precision of the preoperative perforator mapping was analyzed for color Doppler ultrasound, contrast-enhanced ultrasound, B-flow ultrasound, and BCEUS. Each technique was able to precisely display the subfascial course of the vascular pedicle, including the fascial penetration point. However, only BCEUS enabled precise mapping of the epifascial and subcutaneous (suprafascial) course, including the skin point of the perforators with a clear delineation. Precise knowledge of the suprafascial course of the perforators is mandatory for successful supermicrosurgery and perforator flap planning. BCEUS imaging facilitates full perforator mapping, which improves the safety of flap harvesting. However, BCEUS is technically demanding and requires an experienced sonographer.

In Vivo Perforasome Perfusion in Hemi-DIEP Flaps Evaluated with Indocyanine-green Fluorescence Angiography and Infrared Thermography.

Background:There are no in vivo studies that evaluate the effect of perforator dissection on the perfusion territory of a perforator (perforasome). In this study, indocyanine green fluorescence angiography (ICG-FA) and infrared thermography (IRT) were used intraoperatively to evaluate perforasome perfusion in hemi-DIEP flaps.Methods:Patients selected for DIEP breast reconstruction were prospectively included in the study. Preoperative perforator mapping was performed with CTA and handheld Doppler ultrasound. In general anesthesia, perforasome perfusion was evaluated with ICG-FA and IRT both before surgery and after flap dissection with preserved dominant perforators.Results:Thirty hemi-DIEP flaps were dissected in 15 patients (average BMI 26.6 kg/m2), of which 40% had been operated on in the lower abdomen. Fluorescence spots from ICG were associated with infrared radiation hotspots on IRT and these corresponded with the locations of the selected perforators. IRT and ICG-FA demonstrated similar patterns in perforasome perfusion before and after perforator dissection. Perforator dissection changed the perforasome perfusion. IRT made it possible to continuously monitor the perforator activity during surgery. ICG-FA easily identified areas with impaired flap perfusion due to previous surgery.Conclusions:Perforasome perfusion is a dynamic process that changes with perforator dissection. ICG-FA and IRT are reproducible techniques for in vivo evaluation of perforasome perfusion and produce comparable results.

The Kiss Flap Technique: An Alternative Concept for Reconstruction of Extensive Scalp Defects.

The main scope of the kiss flap technique is to harvest double-skin paddle flaps, narrower than those harvested in a standard manner and rearrange them side-by-side ("kissing") in order to match the exact size and contour of the defect. Apart from the possibility of custom-designing the desired shape of soft tissue coverage, the kiss technique enables tension-free direct closure of the donor site, reducing its morbidity and improving aesthetic appearance. In this paper, two patients with severe scalp defects after cancer resections are presented. Due to poor elasticity of surrounding tissues, complexity of composite defect together with extensive range of resection: the kiss technique was applied to the anterolateral thigh flap in both cases. Possibility of implementing the described method in almost all perforator-based flaps is encouraging. Although, prolonged operating time, the necessity of meticulous preoperative perforator mapping as well as extended surgical dissection should be taken into consideration when planning kiss flaps.

Анатомия сосудистой системы переднелатерального бедренного лоскута

Aim: to analyze the anterolateral thigh flap use to eliminate oncological defects in the head and neck area with an emphasis on the flap raising characteristics. Patients and Methods: 146 patients aged 33 to 80 y.o. underwent the surgery in the period from 2011 to 2020. Single-stage reconstruction (143 surgeries) of the various parts of the upper aerodigestive tract (142 surgeries) was mainly performed. Most of the patients (130 cases) underwent the surgery at the first stage of antitumor treatment. In 13 cases, surgical treatment was performed concerning tumor recurrences; in 3 — delayed secondary reconstruction was performed. Flap raising was conducted according to the generally accepted method without the use of preoperative mapping of perforators. The surgery protocols and medical histories were analyzed for the patterns of vascular anatomy and the number and nature of flap-related complications. Results: typical vascular anatomy was noted in 115 cases (78.8%). When raising 31 flaps, anatomical deviations of the course and origin of cutaneous perforators were noted, which can be divided into 4 types: oblique branch anomaly (11 cases), upper type of anterolateral thigh flap (11), anteromedial thigh flap (6) and the rectus femoris muscle (3), while the latter type is rarely mentioned in the literature. The descending branch was the source of cutaneous perforator in 133 cases (91.1%). In 6 cases (3.9%), unfavourable vascular anatomy forced the use of a contralateral hip as a donor area. The reason for the failure in one of these cases was hypoplasia of the descending branch. The primary wound closure of the hip was performed in 143 patients (97.9%), even though the flap width exceeded 8 cm in 7 cases. Postoperative mortality was 1.4%. The main complications associated with the flap included: total flap loss (9 cases; 6.2%), partial necrosis (6; 4.1%) and donor wound complications (8; 5.5%). Conclusion: the anterolateral thigh flap is an excellent plastic material, however, it requires knowledge of the vascular anatomy characteristics of adjacent hip zones. KEYWORDS: head and neck surgery, reconstructive surgery, reconstructive microsurgery, free revascularized flaps, anterolateral thigh flap. FOR CITATION: Karpenko A.V., Sibgatullin R.R., Boyko A.A. et al. Vascular system anatomy of the anterolateral thigh flap. Russian Medical Inquiry. 2021;5(8):517–524 (in Russ.). DOI: 10.32364/2587-6821-2021-5-8-517-524.

The Use of Multispectral Imaging in DIEP Free Flap Perforator Selection: A Case Study.

SummaryPerforator selection is of paramount importance when performing a Deep Inferior Epigastric Perforator flap. Technological advancements within imaging modalities have proved invaluable in preoperative planning and intraoperative assessment. Computed tomographic angiography remains the gold standard for preoperative perforator mapping, while color ultrasound Doppler is considered more reliable for determining vessel caliber. Intraoperatively, an imaging modality that provides sequential, real-time assessment of various perforators’ supply to the flap would provide helpful insight to determine which perforator will optimize flap viability, especially of the most distal, lateral margins. Multispectral imaging, a variant of near infrared imaging, has emerged as an alternative method to assess tissue viability in the operating room as well as postoperatively. Unlike Spy technology, which is invasive and cost ineffective, the SnapshotNIR (KD203) is a handheld multispectral imaging device utilizing NIR to measure the oxygenation of the hemoglobin in the area to calculate the tissue oxygen content (StO2) displayed in a color image. The following case of a 46-year-old woman undergoing tertiary breast reconstruction for treatment of progressive grade 2 capsular contracture illustrates the utility and ease of KD203 application to intra-operative perforator determination in deep inferior epigastric perforator flap assessment.