Subdermal Plexus Research Articles

Thinning of the Medial Sural Artery Perforator Flap: The Anatomical Examination of the Medial Sural Artery Perforator Branch.

The medial sural artery perforator (MSAP) flap is thin, pliable, and versatile. This study aims to understand the anatomical basis of the MSAP flap and the subcutaneous course of the perforator for safe flap thinning. A total of 24 MSAP flaps were dissected under red silicone dye injection guidance. Full-thickness horizontal slides of flaps were performed, and the perforator courses were identified in the subcutaneous plane. Slides were placed on a millimeter board, and the perforator patterns were photographed and observed with loupes. A total of 68 perforator courses were identified: type 1: 30.9%, type 2: 57.3%, and type 3: 11.8%. They traveled 1-25 mm to the subdermal plexus, with percentile 2.5 at 1 mm, percentile 90 at 18.2 mm, percentile 95 at 21.65 mm, and percentile 100 at 25 mm. The mean flap thickness was 7.75 ± 1.7 mm, with an average of 5.7 ± 1.3 perforators per flap. Perforators clustered between 2 and 18.4 cm from the popliteal crease and 0-8 cm from the posterior midline of the leg. The dominant perforators accounted for 45.2% (62 of 137), averaging 2.58 per flap. The medial sural artery branching pattern types were type 1: 37.5%, type 2: 50%, and type 3: 12.5%. The average pedicle length was 16.2 ± 1.3 cm, and the mean external diameter of the medial sural artery was 1.98 ± 0.13 mm. MSAPs branch within a maximal radius of 2.5 cm after emerging from the deep fascia. To maintain vascularity, the safe suprafascial dissection should be 2.5 cm apart from the point of emerging.

Simple modified silicone rubber injection technique in fresh cadaveric pelvis and extremities.

The silicone rubber injection technique was first described in 1999 and has been used in the vascular study of neurology and head and neck dissection. Silicone rubber is durable, flexible, and inexpensive. However, the original silicone rubber injection formula perfuses poorly into the pelvis and extremities. We present a simple modification to the silicone rubber injection technique, showcasing its effectiveness in studying the vascular structures in the pelvis and extremities. We used an ordinary mold-making silicone rubber. The new formula involves mixing the silicone rubber with silicone thinner, acetone, catalyst, and resin color. The mixture is then injected into the artery until the color becomes visible under the skin. The specimen is left at room temperature for 0.5-1 h for the silicone rubber to harden. With our technique, the silicone rubber substance perfuses adequately into small arterial perforators and can penetrate into the subdermal plexus. The smallest subdermal arteries identified under a light microscope measured 6 μm. The modified silicone rubber injection technique has proven to be a valuable tool in anatomical education and surgical training.

“Pure Fat Flap”—Perforator-based Adiposal Layer Only Flap for Lateral Ankle Reconstruction

AbstractLateral ankle soft tissue defects pose challenges, especially in cases due to chronic pressure from cross-legged sitting, which usually present with a large dead space, small skin opening that often accompanies an open joint. Traditional reconstruction methods using fasciocutaneous flaps may result in donor site morbidity such as delayed wound healing or nerve injury. In this article, we present a case of diabetes-related lateral ankle defect successfully treated using adiposal layer only flap, also known as pure fat flap. The anatomy and the surgical technique of adiposal layer only flap were reviewed. These flaps preserve the subdermal plexus and deep fascia while obliterating dead space and providing a gliding surface for proper ankle movement. A perforator-based adiposal layer only flap was elevated from the peroneal artery and used to cover the defect. Flap perfusion was confirmed using indocyanine green video angiography and color duplex ultrasound. Patient had a successful recovery with minimal donor site morbidity. The technique expands the reconstructive microsurgeon's options for complex ankle coverage, ensuring optimal wound healing and functional outcomes.

Complications and influence of cutaneous closure technique on subdermal plexus flaps in 97 dogs (2006-2022).

To determine the incidence and severity of complications for subdermal plexus flaps in dogs and compare the complications when using sutures or staples for cutaneous closure of subdermal plexus flaps. Retrospective monocentric study. Ninety-seven client-owned dogs. Dogs that underwent wound reconstruction using subdermal plexus flaps were retrospectively identified. Type of flap, cutaneous closure technique, complications and level of complication associated with their use were recorded. Follow-up was considered adequate if it was more than 10 days postoperatively or until a complication occurred. Complications were seen in 52 dogs (53.6%), of which 13/18 (72.2%) of dogs had cutaneous closure with skin staples versus 39/79 (49.3%) with skin sutures. The location of the mass/wound on the head and use of an advancement flap was associated with lower incidence of complications (p < .001; p = .018 respectively). Location of the mass/wound on the proximal pelvic limb was associated with a low level of complications (p = .01) on univariable analysis only. On multivariable analysis, only an increased bodyweight was associated with an increased incidence of complications (p = .029). Increased weight may be associated with an increased risk of complications with subdermal plexus flaps. No risk factor was found to be associated with the severity of complications. Overall incidence of complications for subdermal plexus flaps in dogs in this study was 53.6%. The number of dogs included in the study was not sufficient to assess if the skin closure technique affects the incidence of complications.

Optimizing the Approach to STA-MCA Bypass Surgery and Reducing Wound Complications

The treatment of complex intracranial aneurysms with bypass surgery using 2 branches of the superficial temporal artery (STA) proves to be an effective surgical option. However, the harvest of these 2 STA branches, combined with a pterional craniotomy, carries the potential risk of delayed wound healing of the skin flap. This study undertook a retrospective analysis to examine and identify the factors associated with this delayed wound healing. A total of 56 consecutive cases, including both ruptured and unruptured complex intracranial aneurysms, that underwent bypass surgery with 2 branches of the STA, were analyzed retrospectively. Major delayed wound healing was observed in 6 (10.7%) cases. Univariate analysis demonstrated significant associations with the following factors: rupture (P= 0.023), presence of diabetes mellitus (P= 0.028), large craniotomy size (P= 0.012), and the type of skin incision (P ≤ 0.001). Age (P= 0.283), sex (P= 0.558), body mass index (P= 0.221), and other blood test parameters did not demonstrate any statistical significance. Similarly, the presence of a dominant frontal branch (P= 0.515) or a low-positioned frontal branch (P= 0.622) did not reveal statistically significant results. In the treatment of complex intracranial aneurysms, where harvesting of the 2 STA branches is involved with a pterional craniotomy, producing a smaller skin flap (L- or T-shaped incision) is effective in minimizing the risk of delayed wound healing. The process of harvesting the STA and closing the wound demands meticulous care, taking into consideration the normal anatomical structures and the subdermal vascular plexus of the scalp.

Bloodless de-epithelialization in reduction mammoplasty with hydrodissection using a digital automatic anesthesia injector: case series

De-epithelialization is a technique that thins out the epidermis layer of the skin to resurface defects in a cavity or to implant a flap pedicle subcutaneously, preserving the subdermal plexus to support the vascularity of the flap. However, in reduction mammoplasty, de-epithelialization of the pedicle is a time-consuming and tedious step. Although various methods have been proposed to facilitate the completion of this step, a standard has not been established. We used a digital automatic injector that could inject a mixture of lidocaine and epinephrine at a constant, adjustable rate without any special effort. With this method, we could inject local anesthetic into the junction of the epidermis and dermis accurately, which saved time by making dissection easier (hydrodis-section) and decreased bleeding during de-epithelialization. Furthermore, we could use less of the lidocaine and epinephrine mixture, thereby reducing its potential side effects.

A brief discussion on the harvest of thinned perforator flap, detection of perforator vessels, and evaluation of flap blood supply

Repair and reconstruction surgery is not just a simple repair and reconstruction of tissue and organ defects in different parts, but also requires perfect repair that matches the defect and confuses the real. The thinning strategy of perforator flap is one of its main contents. In recent years, the concept of pure skin perforator flap and its clinical application have overturned the traditional concept that flaps must carry subdermal vascular plexus and improved our understanding of flap surgery, and it is expected to enhance the level of repair and reconstruction. This article explores the harvest of thinned perforator flaps, especially the harvest of innovative pure skin perforator flap with the thickness similar to full thickness skin, as well as the preoperative detection of perforator vessels, blood supply evaluation of perforator flaps, and their clinical applications. It proposes a "Jinshan" repair that perfectly matches the recipient area defect, and also prospects research on the perforasome and three-dimensional visualized digital anatomy of pure skin perforator flaps.

Skin Perfusion After Hemostatic Net: An Anatomic and Radiologic Study in a Cadaver Model.

The hemostatic net is a recent technique initially developed to reduce the occurrence of postoperative hematomas following facelift procedures. Its applications have expanded to include skin redraping, deep plane fixation, and other areas beyond the face. However, no experimental study has investigated its effect on skin blood supply. The aim of this study was to analyze facial skin vascularization after applying a hemostatic net to fresh cadavers. Fourteen hemifaces from fresh adult cadavers were examined. The study model involved a deep plane facelift procedure with the use of a hemostatic net. The first step, involving 4 hemifaces, included dissections and two-/three-dimensional angiographies by digital microangiography and computed tomography scan, respectively. The purpose was to evaluate the influence of the hemostatic net on vascular perfusion. The second step involved a sequential dye perfusion study performed on 10 other hemifaces that underwent facelift procedures with the hemostatic net to determine its impact on skin perfusion. The anatomic and radiologic techniques enabled visualization of skin, and showed the arterial system reaching the subdermal vascular plexus and branching between the vascular territories, without interference from the net. The sequential dye perfusion study showed staining after injection in each facelift flap, with comparable coloration distributions before and after the application of the net. The hemostatic net did not affect the skin blood supply, correlating with no clinical increases in ischemia and necrosis rates in the facelift flap. This study provides additional evidence supporting the safety of the hemostatic net in clinical practice.

Systematic review and meta-analysis of the effect of retraction techniques on the complication rate following mastectomy

Of 55,000 UK annual new breast cancers, approximately 15,000 undergo mastectomy; 1% complication will affect 150 women. Complications include mastectomy skin flap necrosis, wound infections, complicated seromas, haematomas, and loss of reconstruction. In immediate breast reconstruction (IBR), most native skin with/without nipple-areola with subcutaneous fat (with subdermal vascular plexus) needs preservation. 1 Agrawal A. et al. Skin sparing mastectomy and immediate breast reconstruction: a review. Eur J Surg Oncol. 2013; 39 (Apr): 320-328 Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar

D146. What Nipple Reconstruction Can Tell Us About the Latissimus Dorsi Flap Subdermal Plexus

PURPOSE: We previously presented our experience of local flap nipple reconstruction over various breast mound reconstructive modalities. Despite a conception that nipple reconstruction may be more reliable over flap beds than mastectomy skin, we preliminarily found that C-V flap designs on latissimus dorsi flap reconstructed breast mounds experience a 10-fold higher necrosis rate compared to implants or abdominally based flaps, leading the senior author to change his practice to exclusively base C-V flaps laterally over latissimus flaps. METHODS: A retrospective review was conducted from 2012 to 2022 of patients who underwent primary C-V subdermal pedicle flap nipple reconstruction by a single surgeon over implant-based, latissimus dorsi, and abdominally-based flap breast reconstruction. Demographics, C-V flap orientation, and nipple necrosis complications were recorded. RESULTS: Four hundred ninety-three nipple reconstructions in 312 patients were included, consisting of 41 latissimus dorsi, 45 deep inferior epigastric perforator, and 51 pedicled transverse rectus abdominis muscle flaps, 203 staged expander-to-implant, and 125 direct to implant reconstructions. In the latissimus cohort, 24.3% of patients experienced postoperative necrosis versus 1.6% to 5.9% among other reconstructive modalities. More interestingly, since the implementation of a laterally-based C-V flap on latissimus breast mounds, the complication rate fell to 10%. CONCLUSION: Our initial data, confirmed with the latest update, seem to highlight the unique subdermal plexus directionality in the latissimus dorsi flap compared to all other common reconstructed breast mounds. Extrapolated, these findings may imply a potential directional relationship between the subdermal vascular plexus and the axial pedicle of the underlying flap.

Cross‐finger flap as ultima ratio for the reconstruction of defects of the finger flexor sides

Cross‐finger flap as ultima ratio for the reconstruction of defects of the finger flexor sides

Evaluation of Survival of Subdermal Plexus Skin Flaps in 8 Cats After Injection of Platelet Rich Plasma

The aim of the present study was to evaluate the effect of platelet-rich plasma injection on the survival of experimentally developed subdermal plexus skin flaps in cats. Two flaps, 2 cm wide and 6 cm long were created bilaterally in the dorsal midline in 8 cats. Each flap was randomized to 1 of 2 groups: platelet-rich plasma injection and control. After flap development, the flaps were immediately placed back on the recipient bed. Then 1.8 mL of platelet-rich plasma was equally injected into 6 different parts of the treatment flap. All flaps were evaluated macroscopically daily and on days 0, 7, 14, and 25 by planimetry, Laser Doppler flowmetry, and histology. Mean flap survival on day 14 was 80.437 % (±22.745) for the treatment group and 66.516 % (±24,12) for the control group with no statistically significant difference between the 2 groups (P = .158). Histologically, a significant difference was found between the base of the PRP and the control flap in edema score on day 25 (P = .034). In conclusion, there is no evidence to support the use of platelet-rich plasma in subdermal plexus flaps in cats. However, the use of platelet-rich plasma may aid in reducing edema of subdermal plexus flaps.

Skin-Fat Composite Grafts for Reconstructing Large Full-Thickness Skin Defects.

The uppermost layer of subcutaneous tissue has a rich vascular network, the subdermal plexus and multiple perforating vessels in the interlobular septa. When skin-fat composite grafts (SFCGs) include this uppermost layer, they can be readily vascularized to enhance survival. The authors describe their clinical experience with large SFCG transplantations. This retrospective study included patients who underwent SFCG transplantation for large, full-thickness skin defects, formed after burn scar contracture or contraction deformity excision. The recipient tissue bed was prepared by retaining the deepest layer of scar tissue or reticular dermis to preserve the interlobular septa, subdermal plexus, and ascending arterioles above the subcutaneous tissue. The SFCG was prepared by trimming fat lobules and preserving the interlobular septa and vessels to form a 1- to 4-mm-thick base of subdermal fat tissue. The trimmed SFCG was placed onto the defective tissue and secured with a tie-over dressing. Among 86 grafts, 76 (88.4%) survived completely (sizes, 6 to 161 cm 2 ; mean surface area, 68.7cm 2 ). Focal skin sloughing or graft loss occurred in 10 cases. These events were followed by spontaneous healing in eight cases. Focal hypertrophic scars formed in six cases. In 15 cases, hyperpigmentation occurred, but improved gradually. Most transplantations achieved satisfactory pliability (93.0%), contour (90.7%), and color (88.4%). SFCGs survived better than expected with minimal complications, probably because of the preservation of rich vascular networks in both the recipient and SFCG tissues. Therefore, SFCG transplantation may be a good option for reconstructing full-thickness skin defects with a large surface area. Therapeutic, IV.

Single Pedicle Advancement Flap Models for Teaching Veterinary Reconstructive Surgical Techniques.

Reconstructive surgical techniques are used in both general and referral veterinary practice to facilitate closure of challenging wound defects. During veterinary studies, there are often limited opportunities for students to practice these techniques on live patients or cadavers. Surgical models, including suture pads and ovariohysterectomy models, have been successfully incorporated into veterinary teaching, providing students with additional practice. Models to simulate veterinary reconstructive surgical techniques are lacking. In the current study, a single pedicle advancement flap model was designed. The design consisted of a silicone model secured by a plate, providing tension. Fifth-year veterinary science students (n = 34) were surveyed to assess the model's impact on surgical technique and confidence. Students were also assessed to determine surgical technique using the models. It was hypothesized that students who had two additional practice sessions using the models (Trial group, n = 17) would show greater improvement in technique than students who had no practice sessions between assessments (Control group, n = 17). Students strongly agreed (median score 5/5) that using the model helped to reinforce the subdermal plexus flap technique and improved their confidence in performing a subdermal plexus flap. Students from both groups performed significantly better in the follow-up assessment compared to the initial assessment. No significantly greater improvement was observed in technique between the control and the trial groups. Results suggest that the students' reconstructive surgical technique improved after a single practice session and that the single pedicle advancement flap model can be used synergistically with other teaching methods.

A new skin flap from the zygomaticotemporal region: Anatomical study and clinical application to eyelid reconstruction.

Eyelid reconstruction is a demanding task faced by plastic surgeons. Island flaps from the zygomaticotemporal region, where the zygomatico-orbital artery predominates in vascularization, represent the recent local approaches to this problem. Questions exist as to where and on what element the flap should be based, and whether or not they should be adapted in relation to the behavior of the zygomatico-orbital artery. A total of 22 fresh-frozen adult cadaver heads were employed. The fasciocutaneous perforators of the zygomatico-orbital artery and their anastomoses with the surrounding arteries, especially those in the upper palpebra, were investigated. On this basis, a distally based perforator flap was created and executed for eyelid reconstruction in 7 patients. The zygomatico-orbital artery was interconnected through its perforators with the subdermal plexus over the zygomaticotemporal region and with the arteries in the surroundings. The transverse facial artery took the place of zygomatico-orbital artery where it was absent. Both the arteries anastomosed consistently with the superficial orbital arcade at a predictable site. All 7 flaps survived completely. A new distally based perforator flap from the zygomaticotemporal region is described regarding its anatomical basis and clinical applications to eyelid reconstruction. With a vascular axis consistently present and a pivot adjacent to the defects, the flap is more reliable in vascularization, and less harm to its donor site than orbicularis oculi myocutaneous flaps, and poses no concern about whether the zygomatico-orbital artery is present or not.

SUBDERMAL PLEXUS AS A GUIDE FOR SKIN FLAP THICKNESS IN MODIFIED RADICAL MASTECTOMY IN BREAST CANCER

Introduction: Breast cancer is the most common invasive cancer to affect women in the world and is the second highest cause of cancer death in women after lung cancer. Different surgical options are available for treating breast cancer but Modified Radical Mastectomy is still the most common surgery performed worldwide for breast cancer and has the lowest incidence of loco-regional recurrence. Aim: The aim of this study to find out the role of sub-dermal plexus as a guide to achieve optimum skin flap thickness during modified radical mastectomy for breast cancer. Materialsandmethods: This prospective study was conducted in the Department of Surgery and Pathology, Zoram Medical College Hospital, Falkawn, Mizoram. A total of 40 patients with Breast carcinoma for which Modified Radical Mastectomy were included in this study. Results: All the patients were observed for skin flap necrosis. The overall incidence of Flap necrosis was 0% as observed on POD1, POD2, POD4 and POD6. Although after POD14, there were a total of 5 patients who had surgical site infection with wound gaping for whom debridement, dressings and secondary suturing were done. Conclusion: we concluded that there is minimal chance of skin flap necrosis and minimal chance of leaving behind breast tissue using subdermal plexus of vein as a guide for optimum skin flap thickness in modified radical mastectomy in patients with breast cancer.

Superthin Flap Harvesting Procedure: Technical Note.

The anterolateral thigh (ALT) flap has been extensively discussed in the literature as it allows for a wide variety and depth of tissues for complex wound coverage. Thanks to many cadaveric and angiographic studies of the subdermal plexus, it is to date ascertained that tailoring ALT thickness can be safely performed without compromising flap outcomes or causing additional morbidity. Recently, the authors applied and described a simpler, safer, and less time-consuming superthin ALT perforator (ALTP) free flap harvesting technique. The aim of this article is to show the versatility of the adipofascial flap harvested around the chosen perforators, which allowed us to safely expand the usage of ALTP superthin flaps.

Superior nasolabial flap in reconstruction of the tongue: case report

&lt;p class="abstract"&gt;Hemiglossectomy with functional rehabilitation using a rotational superior nasolabial flap as a single stage procedure and its outcome has been described. Nasolabial sulcus and nasofacial was the donor site for the nasolabial flap. This hairless area except for the lower cheek in males, is an important consideration in oral cavity reconstruction. The flap constituted by skin, subcutaneous tissue and the underlying musculature has a subdermal plexus is supplied by feeder vessels from the branches of the facial artery and provides the blood supply to the nasolabial muscle and skin. Usually, the choice of pedicle is based on the site of the defect and any need for rotation or advancement of tissue to the site of the defect. In our patient the superior nasolabial flap based on alar and lateral nasal artery was utilized.&lt;/p&gt;&lt;p class="abstract"&gt; &lt;/p&gt;

Marginal excision of cutaneous mast cell tumors in dogs was not associated with a higher rate of complications or prolonged wound healing than marginal excision of soft tissue sarcomas.

To compare wound healing following planned marginal excision of cutaneous mast cell tumors (MCTs) with that of soft tissue sarcomas (STSs) and to identify risk factors for wound healing complications and delay in healing. 126 dogs that underwent intentional marginal excision of cutaneous MCTs (n = 77) or subcutaneous STSs (49). Medical records of included dogs were reviewed and signalment, tumor size, tumor location, skin closure type, time to healing, reported complications, histopathological grade, and surgical margins were recorded. These variables and outcomes (complication rate and time to complete healing) were compared between dogs in the MCT and STS groups. Potential risk factors for complications and delayed healing were analyzed. No significant difference between the groups was found in any of the variables. Wound healing complication rates were 29% (22/77) for the MCT group and 31% (15/49) for the STS group. The mean ± SD time to complete healing was 16.5 ± 7.5 days for the MCT group and 17.7 ± 9.3 days for the STS group. These outcomes did not differ significantly between groups. For both groups, the use of subdermal plexus flap reconstruction was associated with the development of complications and increased time to complete healing. Marginal excision of cutaneous MCTs was not associated with a higher rate of complication or prolonged wound healing, compared with marginal excision of STSs. The use of flap reconstruction in skin closure may delay healing and planned adjuvant therapy. Owners should be counseled regarding these risks and where appropriate and feasible, surgery without reconstruction should be considered.

Cross-sectional Vascularization Pattern of the Adipofascial Anterolateral Thigh Flap for Application in Tissue-engineered Bone Grafts.

Background:As part of the engineering of bone grafts, wrapping constructs in well-vascularized tissue, such as fascial flaps, improves bone formation. Our aim was to understand the cross-sectional vascularization pattern of human adipofascial flaps for this application.Methods:Seven adipofascial anterolateral thigh (ALT) flaps were harvested from five human cadaveric specimens. Axial vessel density was analyzed by immunohistochemistry and quantitative histology.Results:We found a high density of blood vessels directly superficial to and close to the fascia. A secondary plexus in between this first suprafascial plexus and the subdermal plexus was also identified. In all specimens, this second plexus showed less vascular density, and appeared to be at a constant level within the suprafascial fat throughout the flaps. The peak measurements for this secondary plexus varied between 1.2 and 2 mm above the deep fascia, depending on the donor’s body mass index.Conclusions:Quantitative immunohistochemistry is a reliable method to quantify and locate vessel density in an adipofascial flap. This is vital information before wrapping nonvascularized material into such a flap to estimate the inosculation potential of these vessels and likelihood of survival of the tissue. To profit from both suprafascial vascular plexuses, a correlation between subcutaneous tissue thickness and distance of the second plexus to the fascia should be further investigated. For the moment, we recommend maintaining at least 2–3 mm of subcutaneous fatty tissue on the fascia, to profit from both plexuses. Engineered constructs should be wrapped on the superficial medial side of the fascial flap to enhance vascularization.