Skin Perforator Flap Research Articles

Use of a skin perforator flap pedicled by the intercostal muscle for reconstruction of a posterior cervical defect

A posterior cervical defect featuring exposed spinal and occipital bone can be covered in various ways. The "ideal" flap should be a low-morbidity, pedicled locoregional flap that can reach the occiput. Cervical adjuvant radiation therapy may limit the coverage options, because many pedicles are located in areas that are often irradiated. Here, we describe a new surgical technique; we used a skin perforator flap pedicled by the intercostal muscle to cover a posterior cervical defect in a patient with metastatic squamous cell lung carcinoma. This technique is a valuable option; the flap originated from outside the irradiated area and reached the occiput. It adds to the options for cervical coverage in patients who require head-and-neck reconstruction. EVIDENCE-BASED MEDICINE: Level V: opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Lacrimal Gland Adenocarcinoma with Apocrine Metaplasia: A Case Report

We present the case of lacrimal gland adenocarcinoma with apocrine metaplasia and a literature review for similar cases. A 65-year-old male with painless eyelid swelling was admitted to our hospital. A physical examination revealed tumor on the caudal side of the left orbital cavity, and a biopsy indicated apocrine adenocarcinoma. The patient underwent a total left orbital exenteration with eyelid resection and reconstruction using a deep inferior epigastric perforator skin flap. The pathological evaluation led to a definitive diagnosis of lacrimal gland adenocarcinoma with apocrine metaplasia. Lacrimal carcinomas are rare in the head and neck region, so there are few studies of lacrimal gland carcinoma with apocrine metaplasia. The rarity hinders extensive elucidation of the pathological characteristics and evidence-based treatment strategies.

Hürthle Cell Carcinoma of the Thyroid - Well-Differentiated Thyroid Cancer or Something Else?

We present the case of lacrimal gland adenocarcinoma with apocrine metaplasia and a literature review for similar cases. A 65-year-old male with painless eyelid swelling was admitted to our hospital. A physical examination revealed tumor on the caudal side of the left orbital cavity, and a biopsy indicated apocrine adenocarcinoma. The patient underwent a total left orbital exenteration with eyelid resection and reconstruction using a deep inferior epigastric perforator skin flap. The pathological evaluation led to a definitive diagnosis of lacrimal gland adenocarcinoma with apocrine metaplasia. Lacrimal carcinomas are rare in the head and neck region, so there are few studies of lacrimal gland carcinoma with apocrine metaplasia. The rarity hinders extensive elucidation of the pathological characteristics and evidence-based treatment strategies.

Deep circumflex iliac artery perforator flap: a new option for reconstruction of lumbosacral defects

Reconstruction of lower back defects is challenging. Since primary repair is often not possible to achieve, there is a need for local or regional flap transfer. This report presents a new technique of reconstruction of lumbosacral defects by deep circumflex iliac artery perforator skin flap based on a propeller flap design. A lower back scar contracture and contour deformity in a 10-year-old female patient required excision and flap reconstruction. Deep circumflex iliac artery perforator flap was marked in the groin region as an elliptical skin paddle and dissected as an island flap based on a dominant musculocutaneous perforator. Following creation of the lumbosacral defect, reconstruction was accomplished by flap rotation based on a propeller flap design around the perforator. Donor site was closed primarily in layers. Complete flap survival was noted with uneventful recovery. Revision was later performed for flap debulking and contour restoration with pleasing result at 1 year. Deep circumflex iliac artery perforator flap can be utilized for lower back defect reconstruction by means of a propeller flap design. It is offered as a new flap option for lumbosacral reconstruction. The technique allows well-vascularized tissue transfer while accomplishing primary closure of the donor site with easily hidden scar. The disadvantages include tedious dissection as well as absence of a dominant perforator in some cases. Level of Evidence: Level V, therapeutic study.

Discussion: Pure Skin Perforator Flaps: The Anatomical Vascularity of the Superthin Flap.

Discussion: Pure Skin Perforator Flaps: The Anatomical Vascularity of the Superthin Flap.

Pure Skin Perforator Flaps: The Anatomical Vascularity of the Superthin Flap.

Recently, a superthin "pure skin perforator" flap without any subcutaneous tissue was proposed, but the vascularity is still unclear. The authors therefore investigated the vascularity of the proposed superficial circumflex iliac artery-pure skin perforator along with its clinical applications and findings on indocyanine green imaging. The locations and dimension of 70 pure skin perforators on 40 flaps were investigated and classified into central-peripheral and mediolateral parts. Indocyanine green angiography was used to analyze the patterns of the vascular anatomy. Twenty-seven of 29 cases (93.1 percent) presented with pure skin perforator vessels within the area 5 cm above and 1 cm below the inguinal ligament and 4 cm medial and 2 cm lateral from the anterior superior iliac spine. The total flap size averaged 39 ± 22 cm(2) (range, 3 to 90 cm(2)). A subanalysis of the relationship between the flap size and location of pure skin perforators within the single, double, and triple pure skin perforator flap subgroups did not reveal any significance. Indocyanine green angiography revealed three interesting perfusion patterns of pure skin perforator flap: a radial diffusion pattern, direct linking vessels in the intradermal layer, and intradermal arteriovenous shunts. The location number of the pure skin perforators within the flap was not considered to be a crucial factor in the flap design and size in this study. This new knowledge regarding the pure skin perforator concept will allow surgeons to elevate a full-thickness skin flap safely.

The chimeric lateral femoral condyle flap for reconstruction of a long bone defect in the hand

The medial femoral condyle when based on the descending genicular artery (DGA) or superomedial genicular artery (SMGA) has a reputation as an excellent source of a vascularised bone flap, that also allows combinations as a chimeric flap with other soft tissue components including skin perforator flaps for reconstruction of complex defects in the hand. In a similar fashion the superolateral genicular artery (SLGA) supplies the lateral femoral condyle (LFC), that can also support different types of bone flaps including chimeric designs. The pertinent surgical anatomy and flap harvesting techniques are described in detail. A representative case example using a chimeric LFC flap to provide vascularized corticocancellous bone to replace a metacarpal shaft with a perforator flap for sentinel flap monitoring demonstrates the potential versatility of this donor site.

Effect of exogenous L-arginie on survival of extended dorsal perforator flaps in rats

Objective: To investigate the effect of exogenous L-Arg on the survival of extended perforator flap in rats. Methods: Sixteen male Sprague Dawley rats were randomly divided into L-Arg group (n=8) and control group(n=8). The extended dorsal three-vascular territory perforator flaps were made in rats. L-Arg (400 mg·kg-1·d-1) was injected intraperitoneally in L-Arg group 1d before operation, immediately and 1-7 d after operation, while the same volume of saline was injected intraperitoneally in control group at the same time points. The appearance and distribution of blood vessels were observed, and the flap survival areas were measured 7d after operation. The tissue samples were harvested from choke zone Ⅱ for histological study and the expression of vascular endothelial growth factor (VEGF) was detected by immunohistochemistry and Western blot, respectively. Results: After 7d, the clearer vascular structure and more new vessels in choke zone Ⅱ were observed in L-Arg group. The survival rate of flap in L-Arg group was (88.42±4.19)%, which was significantly higher than that in control group[(76.52±5.37)%, t=3.707, P<0.01]. The microvessel density and caliber of choke zone Ⅱ in L-Arg group was (29.47±5.28)/mm2 and(47.27±5.32)μm, which were significantly higher than those in control group (t=2.694 and 2.389, P<0.05 or P<0.01). The immunohistochemistry and Western blot showed that the expression of VEGF in choke zone Ⅱ of L-Arg group was significantly higher than that in control group (t=9.428 and -3.054,P<0.05 or P<0.01). Conclusion: Exogenous L-Arg can increase the survival rate of extended dorsal perforator skin flap through promoting vascularization and dilatation of vessels in choke zone Ⅱ in rats.

Skin Perforator Flap Pedicled by Intercostal Muscle for Repair of a Tracheobronchoesophageal Fistula

A tracheobronchial fistula (TBF) is a rare complication when an operation is performed to treat esophageal carcinoma; no consensus treatment strategy has emerged. We describe a surgical interposition strategy, using a new flap, to repair a TBF that arose when esophageal squamous cell carcinoma was treated with neoadjuvant chemoradiation and minimally invasive esophagectomy (the 3-stage McKeown procedure). We performed a skin perforator flap pedicled by the intercostal muscle. It is a valuable option that may be the optimal first-line treatment, especially in the context of neoadjuvant radiation therapy. Furthermore, this strategy affords new options for intrathoracic reconstruction.

Alternative Regional Flaps When Anterolateral Thigh Flap Perforator is not Feasible.

This paper presents the scheme to select alternative flaps limited to the region of the ipsilateral thigh when the perforator of the anterolateral thigh flap is not feasible. Total of 564 consecutive microsurgery cases using anterolateral thigh perforator flap was reviewed from March of 2001 to January of 2009. Total of 12 cases used a contingent flap due to anatomical and technical complications of the anterolateral thigh perforator. The alternatives were skin perforator flaps adjacent to the initial flap (3 cases of upper anterolateral thigh flap, 4 cases of anteromedial thigh flap), vastus lateralis muscle flap with skin graft (2 cases), and anterolateral thigh flap as septocutaneous flap without a prominent perforator on the septum (3 cases). All flaps survived and provided coverage as planned but one case using septocutaneous flap without a prominent perforator was noted with partial necrosis. Adjacent flaps around the anterolateral thigh perforator flap may provide useful alternative flaps in cases of failed elevation. Limiting the contingent secondary flap to this region may reduce further donor site morbidity and still provide an adequate flap for reconstruction.

Do Skin Perforator Flaps Accommodate Foot Growth in Children after Reconstruction?

Backgrounds Whether or not the flap accommodates growth is unpredictable and remains to be determined. We hypothesized that perforator flaps may accommodate growth after reconstruction in children and evaluated change of the flap after foot and ankle reconstruction. Methods A retrospective review of 28 children from 2003 to 2015 was performed with children under 14 years of age who had foot and ankle soft tissue defects. The following evaluations were made: (1) comparing flap to foot growth, (2) comparing flap/foot dimension using the photo-anthropometric technique defined as proportionality index (PI), and (3) comparing PI ratio of flap to foot area at intervals (ΔPI). All values were measured and statistically evaluated by Pearson's correlation analysis and paired t-test. Subsequent complications and functional results were also evaluated. Result Foot and flap after growth had positive correlation in Pearson's correlation analysis, showing the flap expands as the foot grows. The mean intraoperative and postoperative PI was 0.3 and 0.2475, respectively, with statistical significance (ΔPI; p < 0.01). However, no patient had growth disturbance or functional impairment. There was no correlation between ΔPI and motor power grade or between ΔPI and range of motion (p > 0.01). Conclusion The skin perforator flap significantly expands during growth after reconstruction. Although the expansion of the flap to foot may not be a one-to-one ratio, it expands enough not to impair the growth or functional outcome of the foot. Skin perforator flap showed growth as children grow and can be considered as a reliable and feasible option in pediatric reconstructive surgery.

The experiment study of DMOG on the survival of cross-boundary flap via tail vein injection in rats

Objective To investigate the effects of DMOG on the microcirculation of the choke-area and the survival of the cross-boundary flap in rats via tail vein injection. Methods Rats with ischemic three-territory perforator flaps on the dorsum were treated with DMOG at a dosage of 40 mg/kg body weight via tail vein injection at 1 day before surgery (day-1) , the time of surgery (day 0) , 1 day after surgery (day 1) , 2 days after surgery (day 2) and 3 days after surgery (day 3). Control group received sterile saline at the same time points and same dosage via tail vein injection. ① Draw materials from the choke-area at day 1, day 3 and day 7, HE stain was used to compare the diameter size of the artery and vein at the same site. ② Western blotting to check the expression of PCNA and HIF-1α, ELISA to detect the content of PCNA, HIF-1α, SDF-1α and VEGF at day 7. ③At day 7, measure the survival area of the flap and observe the vessel of the flap by lead oxide-gelatine technique. Results ① There was a greater survival rate of (96.3 ± 5.1) % in the treatment group than in the control group with (73.9 ± 5.8) % at day 7 (P < 0.05). ② The diameter size of the arterioles and venules were dilated in both groups until postoperative days 7. But the treatment group was more expanded than the control group at day 3 (2.20 ± 0.26 vs.1.50 ± 0.20, P < 0.05) and day 7 (3.67 ± 0.35 vs. 2.03 ± 0.15, P < 0.05). ③ The skin expression of PCNA and HIF-1α in the treatment group were greater than the control group (P < 0.05) at day 7. ④ The content of skin PCNA in the treatment group and control group were (8.95 ± 0.71) ng/mg and (4.15 ± 0.72) ng/mg, HIF-1α were (5.04 ± 0.50) ng/mg and (2.98 ± 0.29) ng/mg, SDF-1α were (2.91 ± 0.61) ng/mg and (1.39 ± 0.62) ng/mg, and VEGF were (2.17 ± 0.41) ng/mg and (0.95 ± 0.44) ng/mg, respectively. The treatment group was greater than the control group (P < 0.05). Conclusion DMOG can improve the microcirculation of the choke area, and then increase the survival of the perforator skin flaps in rats via tail vein injection. Key words: Dimethyloxalylglycine; Choke vessels; Cross-boundary flap; Perforator flap; Hemodynamics

Superficial circumflex iliac artery pure skin perforator-based superthin flap for hand and finger reconstruction

For hand and finger reconstruction, thin and flexible skin coverage is ideally required. A free flap is one of the surgical options used for large defects. However, a flap containing the fat layer is bulky. Several debulking surgeries are often needed for aesthetic and functional purposes. To overcome this disadvantage, we herein report our experience of six cases of hand and finger reconstruction using a pure skin perforator (PSP) flap concept. A PSP flap is a thin skin flap that is vascularized by a perforator branch penetrating the dermis. The thickness of the PSP flap could be approximately ≤2mm as needed. The superficial circumflex iliac artery and superficial inferior epigastric artery were used as a flap pedicle. Secondary defatting operations were not required. For the success of PSP flap elevation, we applied three techniques: the microdissection technique for vessel separation, thin flap elevation at the superficial fascial layer, and the temporary clamping method. Temporary clamping was applied for the main trunk of pedicle vessels during debulking to prevent unwanted bleeding, which allowed us to freely perform three-dimensional defatting. Using these three techniques, the PSP flap can be elevated and adjusted for complex contouring of the hand and finger. Although the use of the PSP flap requires further study, the PSP flap is an effective, superthin flap with the advantages of both skin graft and perforator flaps.

Freestyle multiple propeller flap reconstruction (jigsaw puzzle approach) for complicated back defects.

The reconstruction of the posterior trunk remains to be a challenge as defects can be extensive, with deep dead space, and fixation devices exposed. Our goal was to achieve a tension-free closure for complex defects on the posterior trunk. From August 2006 to May 2013, 18 cases were reconstructed with multiple flaps combining perforator(s) and local skin flaps. The reconstructions were performed using freestyle approach. Starting with propeller flap(s) in single or multilobed design and sequentially in conjunction with adjacent random pattern flaps such as fitting puzzle. All defects achieved tensionless primary closure. The final appearance resembled a jigsaw puzzle-like appearance. The average size of defect was 139.6 cm(2) (range, 36-345 cm(2)). A total of 26 perforator flaps were used in addition to 19 random pattern flaps for 18 cases. In all cases, a single perforator was used for each propeller flap. The defect and the donor site all achieved tension-free closure. The reconstruction was 100% successful without flap loss. One case of late infection was noted at 12 months after surgery. Using multiple lobe designed propeller flaps in conjunction with random pattern flaps in a freestyle approach, resembling putting a jigsaw puzzle together, we can achieve a tension-free closure by distributing the tension to multiple flaps, supplying sufficient volume to obliterate dead space, and have reliable vascularity as the flaps do not need to be oversized. This can be a viable approach to reconstruct extensive defects on the posterior trunk.

Perineal and posterior vaginal wall reconstruction with a superior gluteal artery dual perforator-pedicled propeller flap.

Gluteal artery perforator flaps are a good option to reconstruct perineal and posterior vaginal wall defects after abdominoperineal resection. The bulkiness of the folded flap may compromise the results by obliterating the introitus and vaginal cavity. In this report, we present a case of the use of a superior gluteal artery dual perforator-pedicled propeller flap to reconstruct the posterior vaginal wall and perineum in a 60-year-old female who had an abdominoperineal resection of a locally progressive anal squamous cell carcinoma. Two perforators were completely skeletonized through gluteus maximus muscle fibers. The vascularization of the skin flap was based on the first perforator, whereas the aponeurotic flap was vascularized by the second perforator. The vaginal defect was reconstructed with a gluteus maximus aponeurotic flap, and the perineal reconstruction was based on a superior gluteal artery perforator skin flap. No postoperative infection or necrosis occurred. Skin healing was completed in 3 weeks. Vaginal opening was controlled using lubricant and graduated vaginal dilators during 6 weeks. The patient began sexual intercourse 2 months postoperatively. No revision was needed. Perineal and posterior vaginal wall defects may be reconstructed with a gluteal artery perforator flap. The thickness of the flap allows a complete filling of the full perineal cavity. The gluteus maximus aponeurosis may be suitable for the reconstruction of the posterior vaginal wall.

Muscle-chimaeric medial sural artery perforator flap: A new design for complex three-dimensional knee defect

Reconstructions of composite and three-dimensional knee defects remain challenging. Gastrocnemius musculocutaneous flaps have been widely used for complex knee-defect reconstruction, but problems of donor-site morbidity and bulkiness of flaps remain. In the present study, we designed a new muscle-chimaeric medial sural artery perforator flap and applied the technique in a clinical case. A gastrocnemius muscle segment with sufficient pedicle length was obtained by intramuscular dissection of the vascular pedicle. The muscle segment was then utilised to fill the underlying dead space and the remaining soft tissue and skin defects were reconstructed with the perforator skin flap. The flap survived completely and wound healing progressed smoothly without infection, haematoma or seroma. Our patients were satisfied with their aesthetic outcomes and did not experience any donor-site morbidity. The muscle-chimaeric medial sural artery perforator flap is a valuable option for the reconstruction of composite and three-dimensional knee defects.

Supermicrosurgical Reconstruction for Congenital Aural Atresia Using a Pure Skin Perforator Flap

Several surgical methods for creating an external auditory canal have been developed in step with clinical innovation. However, revision surgery is often required to address complications, which include external auditory canal stenosis, lateralization of the tympanic membrane, and chronic recurrent otorrhea. These complications occur frequently within 6 to 12 months after surgery. To decrease the incidence of complications, the authors reconstruct the external auditory canal and tympanic membrane in patients with congenital aural atresia using a free pure skin perforator flap that is as thin as a skin graft. They report their outcomes for hearing acuity and complications over 12 months after the operation. The authors performed reconstruction of the external auditory canal and tympanic membrane in nine patients with congenital aural atresia. The flap design was based on a pure skin perforator derived from the groin area in eight patients. The flap was folded into an approximately 1.5×3-cm sac and inserted into the external auditory canal. Anastomosis was performed between the perforator vessels and superficial temporal vessels. All pure skin perforator flaps survived, although one case had partial epidermal necrosis. The audiologic follow-up period ranged from 12 to 24 months (mean, 17 months). The mean pure-tone average was 65.1 dB (range, 53 to 80 dB) preoperatively and improved to 32.4 dB (range, 8 to 53 dB) postoperatively. None of these cases showed any potential complications. This flap may therefore reduce complications and help to maintain hearing acuity in the long term. Therapeutic, IV.

Free Tissue Transfer to the Lower Extremity

The free anterolateral thigh (ALT) skin perforator flap has gained enormous popularity as a free skin perforator flap. Currently being used for various reconstructions primarily in Asia, its routine application for soft-tissue reconstruction of the lower extremity remains unknown in the United States. The purpose of the present study was to review the current trend of flap selection for soft tissue reconstruction of the lower extremity. We performed a retrospective review of a single-surgeon case log between 2007 and 2011 in a tertiary academic medical center. Inclusion criteria were patients who underwent free tissue transfer for lower extremity reconstruction regardless of sex or age. Exclusion criteria were limited to patients with a body mass index greater than 35 kg/m. A total of 20 patients underwent reconstruction with a free tissue transfer for soft tissue coverage of the lower extremity wound were identified. Fourteen free ALT and 6 free muscle flap reconstructions were performed over a 4-year period. Good reconstructive outcomes resulting in reliable soft tissue coverage were achieved in all patients. It was noted that more ALT flaps were used in the last 2 years and less muscle flaps (0/8 vs 6/12, P = 0.042) when compared with the years prior. Although technically more challenging to perform, the free ALT flap has recently been used significantly more for lower extremity reconstruction because of its minimal donor-site morbidity, reliable coverage, and improved contour. This represents a paradigm shift in flap selection that is being highlighted as surgical proficiency in flap dissection technique improves.

Imaging evaluation of blood supply in deep inferior epigastric perforator skin flap

Imaging evaluation of blood supply in deep inferior epigastric perforator skin flap

The Possibility and Potential Feasibility of Putting an Extra Functioning Free Muscle Transplant onto a Normal Limb

Functioning free muscle transplantation is currently and popularly used clinically to restore motor deficit caused by traumatic muscle loss or chronic muscle denervation. However, no one uses functioning free muscle transplantation in a normal subject who has no motor deficit. This study was designed to investigate the possible and potential feasibility of transferring an extra free muscle transplant onto a normal limb. A chimeric flap including biceps muscle with its neurovascular pedicles and a skin perforator flap was designed, harvested, and transferred from a Lewis inbred rat to the other rat overlying the original biceps following neurovascular repair where the ulnar nerve was chosen as the neurotizer. Sixteen rats were operated on and evaluated 6 months after surgery. Outcome measurements included arm circumferences, electrophysiologic studies, elbow flexion force, and muscle mass. The contralateral normal biceps was used as the control. All outcome measurements revealed that the extra muscle transfer resulted in significant increases in size and function of the operative limb without interfering with the original biceps function. The authors' study demonstrates the possible and potential application of using extra free muscle transplantation for functional and aesthetic augmentation purposes in a normal subject.