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[The perforator propeller flap].
Abstract
The perforator flaps are increasingly used in reconstructive surgery. Among their many applications, propeller perforator flap technique is one of the most recent. It allows any part of the body to become a potential donor site for a perforator flap based on the Doppler tracing. The shape of the flap is adapted bespoke then it is turned like a propeller up to 180 degrees to fill the wound. The donor site is most often self-closing or grafted. We describe the principles, the operative technique and advantages of this method.
2009 Elsevier Masson SAS. All rights reserved.
... As well as the risk of complications present for each flap such as necrosis, venous congestion, and dehiscence of the wound. Muscular or musculocutaneous flaps offer a better coverage by their volume, a pedicle allowing a wider rotation, but with a morbidity of the donor site linked to the muscular sacrifice and the vascular axis [14]. Perforator flaps may also be needed to cover the posterior cubital region. ...
... Perforator arteries are vascularizing the skin paddle covering the medial head of the triceps brachii. It is recommended to perform a preoperative angiographic examination to identify bi-directional flow, and a Doppler ultrasound or MRI or CT angiography, to detect the projections of the perforating arteries [14,22,26,27]. Imaging can visualize the variations of the perforator arteries and help in the dissection procedure [26,28]. ...
Introduction
The medial head of the triceps brachii flap is already described as a local muscular or as a free flap. It allows coverage of defects of the posterior cubital region. The aim of this study was to describe the vascular anatomy of the musculocutaneous medial triceps brachii pedicled flap.
Methods
Eleven fresh–frozen upper limbs (6 come from women and 5 from men) were proximally injected with Indian ink agar solution. The medial head of the triceps brachii muscle was dissected and the superior ulnar collateral artery (SUCA) was isolated with its collaterals. The collateral arteries were dissected to determine whether there were septocutaneous or musculocutaneous arteries for vascularization of the skin in front of the medial head. Lengths of those collaterals arteries were measured.
Results
The average number of collaterals arteries from the SUCA supplying the medial head of the triceps brachii is 4.5 (from 3 to 6 arteries). Among these collaterals’ arteries, there are one average 1.5 (0.6–4.5) septocutaneous arteries and 3 (1–4.8) musculocutaneous arteries.
Discussion and conclusion
A musculocutaneous flap with the medial head of the triceps brachii muscle can be described with the muscle. The SUCA gives perforator arteries musculocutaneous and septocutaneous for the vascularization of the triceps brachii medial head. The use of local pedicled flap with similar tissue maximizes healing with a minimal morbidity of the donor site. This study demonstrated the feasibility of the medial head triceps brachii musculocutaneous flap to cover defect of the posterior aspect of the elbow.
... Por último, debido a la gran variedad de los numerosos sitios donantes en el brazo y el antebrazo, estos colgajos se realizan con facilidad en un único sitio quirúrgico, lo que permite un interesante ahorro de tiempo. Por tanto, la facilidad de utilización y las numerosas posibilidades de colgajos perforantes en el miembro superior los convierten en un colgajo de elección que merece figurar en el arsenal terapéutico de los cirujanos reconstructores del miembro superior [16] . En la Figura 2 se ilustran los distintos colgajos perforantes que pueden movilizarse en el miembro superior. ...
... Estos colgajos se definen como colgajos elípticos en isla que cubren las pérdidas de sustancia mediante un movimiento de rotación alrededor de una perforante como una hélice. Las dos paletas de estos colgajos suelen ser de distinto tamaño y se sitúan a ambos lados de la perforante [16] (Fig. 3). ...
Resumen
El tratamiento de las pérdidas de sustancia cutánea del miembro superior es complejo y ha evolucionado mucho en los últimos 20 años. En la actualidad, está bien codificado y debe respetar unos requisitos que combinan criterios funcionales y estéticos. Desde el punto de vista funcional, la cobertura debe planificarse en función del sector de movilidad de las articulaciones contiguas, por lo que es propia de cada región anatómica. La región del pliegue del codo se caracteriza por un tejido cutaneoadiposo muy fino y muy móvil, sometido constantemente a fuerzas de cizallamiento. Por tanto, el cirujano reconstructor debe utilizar colgajos finos y perfectamente adaptables a la pérdida de sustancia que permitan recuperar con rapidez amplitudes articulares aceptables. En el caso del hombro, la región del hueco axilar es crítica, porque cualquier resección a este nivel limitará las amplitudes de abducción. Desde el punto de vista estético, el cirujano reconstructor se enfrenta a un dilema: reconstruir de la forma más estética posible la región traumatizada sin provocar por ello una secuela cicatricial excesiva en la zona donante. El arsenal terapéutico del que dispone el cirujano es amplio y utiliza muchas técnicas de cirugía reparadora, que oscilan desde el colgajo local o regional hasta el colgajo libre. La utilización cada vez más frecuente de los colgajos perforantes ha sido un gran avance en el tratamiento de las pérdidas de sustancia del miembro superior. Estos colgajos cutaneoadiposos reúnen todos los criterios que se buscan para la cobertura del miembro superior. Asocian delgadez y una escasa morbilidad del sitio donante, a la vez que conservan las arterias nutricias y los músculos. Los colgajos perforantes en hélice son fáciles de utilizar si se dominan las técnicas quirúrgicas y constituyen una solución terapéutica interesante en el amplio arsenal terapéutico del cirujano reconstructor del miembro superior.
... Les lambeaux perforants pédiculés « freestyle » (en hélices ou en V-Y) utilisent pleinement ces connaissances anatomiques [16,[25][26][27]. N'ayant pas la contrainte de l'anastomose microchirurgicale, ils offrent une méthode de choix pour les pertes de substances du membre inférieur [27][28][29][30]. ...
... Les lambeaux perforants pédiculés « freestyle » (en hélices ou en V-Y) utilisent pleinement ces connaissances anatomiques [16,[25][26][27]. N'ayant pas la contrainte de l'anastomose microchirurgicale, ils offrent une méthode de choix pour les pertes de substances du membre inférieur [27][28][29][30]. Ils ont malheureusement peu d'indications pour la reconstruction du talon et ne règlent pas toujours le problème de la rançon au site donneur [31]. ...
Introduction:
Heel coverage requires the surgeon to considerate of multiple parameters: the type of defect, the exposed tissues, the weight-bearing requirements, the donor site morbidity, and the shape of the reconstructed heel allowing at best normal footwear. Although many methods of coverage exist, they are often chosen at the cost of a compromise between all the parameters described. In recent years, perforator freestyle free flaps offer plastic surgeons an unparalleled freedom that can adapt the constraints of the reconstruction while minimizing the functional and scar donor site morbidity.
Patients and methods:
We present four cases of heel defect of different origins treated by three types of tailored perforator freestyle free flaps (ALT, TAP and SCIP Flaps). End-to-side anastomosis to the posterior tibial vessels was used in three flaps while one flap was anastomosed to the internal plantar artery in an end-to-end fashion.
Results:
No postoperative complication occurred. This approach allowed, in all patients, a reconstruction of excellent quality with minimal cicatricial morbidity. All patients were walking effectively at 21 days postoperatively.
Conclusion:
Perforator freestyle free flaps offer a solution of first choice for heel reconstruction. At the price of a linear hidden scar, they offer a functional, aesthetic and durable coverage.
... Ils sont plus longs à réaliser et nécessitent un plateau technique adapté. Il est souvent reproché aux lambeaux libres musculaires d'être trop épais [21,23] , c'est pourquoi beaucoup d'auteurs optent pour les lambeaux libres fasciocutanés en raison de leur finesse et de leur souplesse. Ces derniers engendrent cependant des séquelles esthétiques et fonctionnelles importantes au niveau de leur site donneur [21,26]. ...
The distal third of the leg, ankle and foot is an anatomical region where reconstructive surgery is difficult and many flaps are described. The authors describe their own experience in the reconstruction of this anatomical region using the gracilis muscle free flap.
From January 2009 to April 2012, the authors operated 32 patients for reconstructive surgery of the distal third of the leg, ankle or foot using a free gracilis muscle flap. A retrospective analysis of the etiology and the size of the loss of tissue substance were performed. The operative data, complications, as well as aesthetic and functional results were analyzed.
Thirty-two free gracilis muscle flap were performed. The authors reported five necrosis requiring surgical use of a locoregional flap. The mean duration of follow-up was 15.2months (6-34months). The average size of the defect was 53.4cm(2) (35.7 to 78.1cm(2)) and the etiology was traumatic in 81.3% of cases. The Vancouver score of the area reconstructed was excellent. Functional assessment of the ankle was satisfactory and usual footwear was possible in 96% of patients. Concerning the isokinetic study of the ankle, maximum and average forces were similar to the healthy ankle in a tumor etiology, but less when traumatic.
In our experience, the free gracilis muscle flap is an excellent technique for the reconstruction of tissue defects of the distal third of the leg, ankle or foot. Its donor site morbidity is very low. The free gracilis flap is suitable for small or long lost of substance and its adaptation at the receptor site is excellent. For these reasons, the gracilis muscle free flap should have its place in reconstructive surgery of the foot and ankle.
... Ils sont plus longs à réaliser et nécessitent un plateau technique adapté. Il est souvent reproché aux lambeaux libres musculaires d'être trop épais [21,23] , c'est pourquoi beaucoup d'auteurs optent pour les lambeaux libres fasciocutanés en raison de leur finesse et de leur souplesse. Ces derniers engendrent cependant des séquelles esthétiques et fonctionnelles importantes au niveau de leur site donneur [21,26]. ...
Objet
Le tiers distal de la jambe, la cheville et le pied constituent une région anatomique où la chirurgie reconstructrice est difficile et où de nombreuses possibilités de reconstruction plus ou moins fiables sont décrites. Les auteurs décrivent leur expérience dans la reconstruction de cette région anatomique par le lambeau libre de muscle gracilis.
Méthode
De janvier 2009 à avril 2012, les auteurs ont opéré 32 patients pour une chirurgie reconstructrice du tiers distal de la jambe, de la cheville ou du pied, par un lambeau libre de muscle gracilis. Une analyse rétrospective de l’étiologie et de la taille de la perte de substance était réalisée, ainsi que le recueil des données opératoires, des complications et des éventuelles ré-interventions. Une évaluation esthétique et fonctionnelle exhaustive était également conduite.
Résultats
Un total de 32 lambeaux libres de muscle gracilis était réalisé. Les auteurs rapportent cinq nécroses du lambeau microchirurgical ayant nécessité le recours à un lambeau loco-régional. La durée moyenne de suivi était de 15,2 mois (six à 34 mois). La superficie moyenne de la perte de substance était de 53,4 cm2 (35,7–78,1 cm2) et l’étiologie de cette dernière était traumatologique dans 81,3 % des cas. Du point de vue esthétique, le score de Vancouver au niveau de la région reconstruite était excellent. L’évaluation fonctionnelle de la cheville était jugée comme satisfaisante et le port de chaussures du commerce était possible pour 96 % des patients. Concernant l’étude isocinétique de la cheville, les forces maximale et moyenne étaient équivalentes à la cheville saine dans un contexte tumoral, mais inférieures dans un contexte traumatologique.
Conclusion
Dans notre expérience, le lambeau libre de muscle gracilis constitue une excellente technique de reconstruction des pertes de substance tissulaires du tiers distal de la jambe, de la cheville et du pied. La morbidité de son site donneur est très faible. Il est approprié pour les petites ou les longues pertes de substance et son adaptation au niveau de son site receveur est excellente. Pour ces raisons, le lambeau libre de muscle gracilis doit avoir une place prépondérante en chirurgie reconstructrice du pied et de la cheville.
Riassunto
La gestione delle perdite di sostanza cutanea dell’arto superiore è complessa e si è notevolmente evoluta negli ultimi 20 anni. Ora è ben codificata e deve rispettare una lista di gestioni che combina criteri funzionali ed estetici. Da un punto di vista funzionale, la copertura deve essere riflettuta in base al settore di mobilità delle articolazioni vicine ed è, quindi, specifica per ciascuna regione anatomica. La regione della piega del gomito è caratterizzata da un tessuto cutaneoadiposo molto sottile e molto mobile, costantemente sottoposto a forze di taglio. Perciò, il chirurgo ricostruttivo deve usare lembi sottili perfettamente adattabili alla perdita di sostanza, che consentano un rapido ritorno ad ampiezze articolari accettabili. Per quanto riguarda la spalla, è la regione del cavo ascellare a essere critica, poiché qualsiasi retrazione a questo livello limiterà le ampiezze di abduzione. Da un punto di vista estetico, il chirurgo ricostruttivo si trova di fronte a un dilemma: ricostruire la regione traumatizzata nella maniera più estetica possibile senza causare troppi esiti cicatriziali nella zona donatrice. L’arsenale terapeutico messo a disposizione del chirurgo è vasto e utilizza numerose tecniche di chirurgia ricostruttiva, che vanno dal lembo locale o regionale al lembo libero. L’uso sempre più frequente di lembi perforanti è stato un’evoluzione importante nella gestione delle perdite di sostanza dell’arto superiore. Infatti, questi lembi cutaneoadiposi riuniscono tutti i criteri ricercati per la copertura dell’arto superiore. Combinano finezza e bassa morbilità del sito donatore, preservando le arterie d’origine e i muscoli. I lembi perforanti a elica sono facili da usare, se le tecniche chirurgiche sono ben padroneggiate, e rappresentano un’interessante soluzione terapeutica nel vasto arsenale terapeutico del chirurgo ricostruttivo dell’arto superiore.
Soft tissue sarcomas are rare malignant tumors with pejorative prognosis. They require a multidisciplinary approach in a specialized hospital belonging to the NetSarc network in France. In all cases treated with curative intent, the objective of excision surgery is to achieve wide, microscopically negative margins (R0 according to the UICC classification). When growing on a limb, sarcomas may threaten functionally relevant structures and even lead to amputation. Nowadays, when combined with radiation therapy, wide exeresis limb-sparing surgery is achievable in 90 to 95% of the cases, of which 25% will nevertheless require reconstructive surgery to preserve the limb, to limit postoperative complications and to manage possible sequelae. Progress in reparative surgery, particularly in microsurgery, has helped not only to improve limb salvage rates but also to create wider margins without altering oncologic goals of curative resection. After determining the range of resection, reconstructive surgery should be tailored to address the tissue defect. The converse is to be strongly discouraged. The extent of resection must not be compromised or reduced in order to facilitate reconstructive surgery. A plastic surgeon must master all the flap techniques, including microsurgery, while taking into account the impact of preoperative and postoperative radiation therapy on previously irradiated tissues or on wounds requiring adjuvant therapy. Recent developments, especially as regards perforator flaps, have helped to enhanced the quality of reconstruction procedure while reducing donor site morbidity. In our experience, perforator flaps are a workhorse in reconstructive surgeries subsequent to soft tissue sarcoma of the extremities. On a parallel track, lipofilling (otherwise known as fat grafting or fat transfer) has become the first-line treatment for patients with post-surgical functional or cosmetic sequalae. It is performed after long-term follow-up during disease-free survival. Strict clinical examination and MRI are mandatory prior to programming any local procedure. Usually, three to four sessions of fat grafting are needed to enhance local trophicity or the cosmetic aspect. Sequalae treatments are of great interest in terms of psychological as well as functional outcome.
Mycobacterium marinum is an atypical and non-tuberculosis mycobacterium that mainly leads to cutaneous infections. Infections occur through inoculation of the organism through injury to the skin in the presence of contaminated water or fish. The patient often presents with unspecific symptoms and the evolution, in the absence of adequate treatment, is characterized by an expansion of the cutaneous lesion and a spread to deep structures. Infections of tendon sheaths and joints are described, rarely osteomyelitis. Sure diagnosis is hard to obtain and is established from the medical history and microbiological examination. There are no specific therapeutic guidelines. Double or triple antibiotherapy is often effective and should be continued several months after complete resolution of clinical signs. Surgical debridement is required in cases of invasive or resistant infections. We report the case of a young immunocompetent fishmonger with a rare osteocutaneous M. marinum infection of the elbow. Treatment included large surgical excision of infected skin and bone areas and a triple antibiotics administration. Reconstruction have been ensured by a radial collateral artery perforator-based propeller flap, satisfying appropriates functional and cosmetical concerns of this anatomical region. Surgery and appropriate antibiotics treatment were effective and allowed healing of an invasive cutaneous and bone M. marinum infection.
Copyright © 2015 Elsevier Masson SAS. All rights reserved.
Perforators flaps take a special place in reconstructive surgery. These flaps can be dissected and turned as a propeller blade on its pedicule axis. We report the case of a 54-year-old man presenting a recurrence of a dermatofibrosarcoma in the right hypochondrium. Tumor resection caused a large abdominal wall defect taking the anterior aponeurosis of the rectus abdominis. An angioscanner was realized in preoperative to locate the perforators of the deep superior epigastric artery. We realized a propeller flap based on a perforator of the left superior epigastric artery who allowed to cover the wall defect. We set up a patch of Vicryl(®) to reconstruct the aponeurosis plan at the same operative time. We didn't note any necrosis and complete healing occurred in 2 weeks. The margins were healthy. The cosmetic result and the low morbidity make this flap a good therapeutic option. This flap seems reliable, arteries perforators are constant with good diameter.
Introduction:
Skin graft is still a method of choice for the coverage of temporal defects. But there are some disadvantages like a "patch" appearance, the need of dressing or longer healing time. Numbers of local flaps have been described for closing skin defects on temporal region. Yet, they may cause distortion of the surrounding tissues, especially in the temporal hairline and eyebrow. We present a series of seven local flaps based on small branches (SB) of the superficial temporal artery (STA) for the coverage of temporal defects, and discuss their advantages.
Patients and methods:
Supermicrodissection of SB of the STA was performed to obtain local flaps for reconstruction of temporal defects after skin cancer excisions in seven patients. Patient's age ranged from 70 to 88 years old and the diameter of defects ranged from 4 to 6 cm. All procedures were performed under local anesthesia except one. In all cases, defects were obtained after skin cancer excisions.
Results:
The operative time ranged from 55 to 75 min. All flaps survived with an average follow-up of 8 months, reconstructions have maintained a cosmetically pleasing result.
Conclusion:
We believe that SB flaps may be a new option for reconstruction of temporal defects with the advantages of local flaps, without the inconvenience of a skin pedicle. Moreover, these flaps raise the question of the use of SB based flaps for the coverage of moderate-sized skin defects anywhere in the body, and open new fields in reconstructive surgery.
After Koshima and Soeda first described perforator flaps in 1988, Wei has improved the technique by describing the "free style perforator flap". These flaps have the advantage of being performed on all skin perforators and in reducing donor site morbidity. The disadvantage, however is that the size of their angiosome is not defined and the evaluation of their relay on the experience of the surgeon. An evaluation of the size of an angiosome by conducting intraoperative angiography is proposed. Intraoperative angiography is performed after injection of indocyanine green. Stimulation of the indocyanine green by infrared causes the emission of fluorescent radiation. This fluorescence is then detected by a specific camera that displays real-time visualization of the skin's perfusion. We present the case of a 39-year-old patient who had an open tibial pilon fracture, for which we performed a pedicled propeller flap based on a posterior tibial perforator. Angiography was used to determine accurately the optimal skin perfusion of the propeller flap, which was based on a perforator from the posterior tibial artery. Angiography identified several levels of skin perfusion with a high fluorescence, intermediate and absent. The non-vascularized part of the skin paddle was resected. Given the unreliability of this technique, hypoperfused area was retained. Debridment of this area, however was necessary at day 5 postoperative with repositionning of the flap. Indocyanine green angiography may be a useful decision-making tool for intraoperative surgeon. It allows to adjust the size of the propeller flap's skin paddle to it angiosome. However, this evaluation method needs to be improved with the introduction of a quantitative threshold.
In recent years, perforator flaps have become an indispensable tool for the reconstruction process. Most recently, "propeller" perforator flaps allow each perforator vessels to become a flap donor site. Once the perforator of interest is identified by acoustic Doppler, the cutaneous or fascio-cutaneous island is designed and then customized according to the principle of "perforasome". So, the flap can be rotated such a propeller, up to 180°. Ideally the donor site is self-closing, otherwise it can be grafted at the same time. Through a skin necrosis secondary to a contrast medium extravasation of the cubital fossa in a 47-year-old man, we describe the use of propeller perforator flap based on a perforator of the radial collateral artery (RCAP). The perforator was identified preoperatively by acoustic Doppler then the flap was adapted bespoke to cover the loss of substance. Ultimately, the result was very satisfying. Well experienced for lower-extremity reconstruction, perforator-based propeller flap are still few reported for upper limb. It is likely that in the future, propeller flap supersede in many indication not only free flaps and locoregional flaps but also, leaving no room for uncertainties of the vascular network, the classic random flaps.
Background:
Coverage of tissue defects of the lower limbs is a complex problem. Free gracilis muscle flap is a reliable surgical technique and the morbidity of its donor site is considered as minimal. Our retrospective study involved all patients who underwent a free gracilis muscle flap in a reconstructive surgery of the lower limb. To the best of our knowledge, this is the first study to assess comprehensively the aesthetic and functional morbidity of the free gracilis flap donor site.
Patients and methods:
Thirty-two patients underwent a gracilis muscle free flap in our plastic surgery department, between January 2009 and April 2012, as part of a reconstructive surgery of the lower limb. All medical datas were carried out using computerized records. Aesthetic and functional assessments of the donor site were done by the patient using questionnaires and by a plastic surgeon and a physiotherapist using a clinical evaluation, 6 months after surgery. A comparative study between both limbs including the thigh perimeter analysis, an isokinetic study of the knee, a study of the range of motion of hip and knee, and an assessment of the strength of adduction of the hip were conducted.
Results:
Concerning the aesthetic outcomes, the clinical and subjective scores were satisfactory with a Vancouver score under 1. Five patients had a decrease in the volume of the thigh after surgery. Concerning the functional outcomes, no motor or sensory defects were reported. No statistically significant difference was demonstrated for the range of motion of the hip and knee between both limbs. The strength of hip adduction was not altered by the removal of the gracilis muscle.
Conclusion:
This study confirms the low aesthetic and functional donor site morbidity of the free gracilis muscle flap. The aftermath of the donor area of the flap are very well accepted by patients, which is a sign of good acceptance of the whole reconstruction. Because of these findings and the suitability of the flap at the recipient site, the gracilis muscle free flap should be part of the armamentarium of any reconstructive surgeon.
The propeller flap is defined as (1) being island-shaped, (2) having an axis that includes the perforators, and (3) having the ability to be rotated around an axis. The advantage of the propeller flap is that it is a pedicle flap that can be applied to cover defects located at the distal ends of the extremities. The specific aims of the authors' study were (1) to evaluate the usefulness of multidetector-row computed tomography in the planning of propeller flaps and (2) to present a clinical case series of propeller flap reconstructions that were planned preoperatively using multidetector-row computed tomography.
The authors retrospectively analyzed all cases between April of 2007 and April of 2010 at Nippon Medical School Hospital in Tokyo, where multidetector-row computed tomography was used preoperatively to plan surgical reconstructions using propeller flaps.
Thirteen patients underwent 16 flaps using the propeller flap technique. The perforators were identified accurately by multidetector-row computed tomography preoperatively in all cases.
This is the first report describing the application of multidetector-row computed tomography in the planning of propeller flaps. Multidetector-row computed tomography is superior to other imaging methods because it demonstrates more precisely the perforator's position and subcutaneous course using high-resolution three-dimensional images. By using multidetector-row computed tomography to preoperatively identify a flap's perforators, the surgeon can better plan the flap design to efficiently conduct the flap surgery.
Over the past few decades, methodological progress and better anatomical knowledge have reduced the morbidity of reconstructive surgery. Muscle-sparing flaps and perforator flaps provide the surgeon with additional options for reconstruction. Based on a review of the local flaps used for perineal reconstruction, this article describes these new solutions and presents a decision tree (based on whether abdominal incision is required or not). If laparotomy is required, abdominal flaps should be preferred. If surgical excision is performed with the patient in the prone position, then gluteal and pudendal donor sites are recommended.
Due to its increasing popularity, more and more articles on the use of perforator flaps have been reported in the literature during the past few years. Because the area of perforator flaps is new and rapidly evolving, there are no definitions and standard rules on terminology and nomenclature, which creates confusion when surgeons try to communicate and compare surgical techniques. This article attempts to represent the opinion of a group of pioneers in the field of perforator flap surgery. This consensus was reached after a terminology consensus meeting held during the Fifth International Course on Perforator Flaps in Gent, Belgium, on September 29, 2001. It stipulates not only the definitions of perforator vessels and perforator flaps but also the correct nomenclature for different perforator flaps. The authors believe that this consensus is a foundation that will stimulate further discussion and encourage further refinements in the future.
Numerous studies compare techniques for free flap breast reconstruction techniques, with no consensus regarding differences in complication rates. This study compared the risk of fat necrosis, partial flap loss, total flap loss, abdominal bulge, laxity, or weakness, and abdominal hernia after deep inferior epigastric perforator (DIEP) and free transverse rectus abdominis myocutaneous (TRAM) flap surgery for breast reconstruction.
A MEDLINE and manual search of English-language articles on DIEP and free TRAM flap surgery published up to April of 2007 yielded 338 citations. Two levels of screening identified 37 relevant studies. The Mantel-Haenszel fixed-effects and DerSimonian and Laird random-effects models were used to perform the meta-analysis.
Six studies reporting both DIEP and free TRAM flap outcomes were used to estimate pooled relative risks of complications and confidence intervals. There was a twofold increase in the risk of fat necrosis (relative risk, 1.94; 95 percent CI, 1.28 to 2.93) and flap loss (relative risk, 2.05; 95 percent CI, 1.16 to 3.61) in DIEP patients compared with free TRAM patients. There was no difference in the risk for fat necrosis when the analysis was limited to studies using muscle-sparing free TRAM flaps (relative risk, 0.91; 95 percent CI, 0.47 to 1.78). DIEP patients had one-half the risk of abdominal bulge or hernia (relative risk, 0.49; 95 percent CI, 0.28 to 0.86). Sixteen studies reporting DIEP outcomes and 23 studies reporting free TRAM outcomes were used to estimate pooled complication rates. Pooled flap-related complication rates were higher in DIEP patients, whereas donor-site morbidity was higher in free TRAM patients.
This analysis suggests that the DIEP flap reduces abdominal morbidity but increases flap-related complications compared with the free TRAM flap in breast reconstruction.
Ultrasound guidance has become popular for performance of regional anesthesia and analgesia. This systematic review summarizes existing evidence for superior risk to benefit profiles for ultrasound versus other techniques. Medline was systematically searched for randomized controlled trials (RCTs) comparing ultrasound to another technique, and for large (n > 100) prospective case series describing experience with ultrasound-guided blocks. Fourteen RCTs and 2 case series were identified for peripheral nerve blocks. No RCTs or case series were identified for perineural catheters. Six RCTs and 1 case series were identified for epidural anesthesia. Overall, the RCTs and case series reported that use of ultrasound significantly reduced time or number of attempts to perform blocks and in some cases significantly improved the quality of sensory block. The included studies reported high incidence of efficacy of blocks with ultrasound (95%-100%) that was not significantly different than most other techniques. No serious complications were reported in included studies. Current evidence does not suggest that use of ultrasound improves success of regional anesthesia versus most other techniques. However, ultrasound was not inferior for efficacy, did not increase risk, and offers other potential patient-oriented benefits. All RCTs are rather small, thus completion of large RCTs and case series are encouraged to confirm findings.
Defect reconstruction according to the free-style concept applied to perforator flaps allows flap harvesting in any anatomical region where an audible Doppler signal of a perforator is detected. We report the results of a study in which local perforator flaps were selected for reconstruction in different anatomical areas and were harvested using the free-style concept.
During a 2-year period, defect coverage was carried out in 21 patients (n=21) in the following anatomical areas: cervical (n=3), sternal/parasternal (n=4), axillary (n=2), tibial (n=5), trochanteric (n=2) and sacral/gluteal (n=5). The mean age of patients (15 male and six female) was 57.8 years. Flap selection was based solely on preoperative Doppler mapping in areas adjacent to soft-tissue defects. The mean follow-up period was 1 year.
All flaps survived, demonstrating postoperatively acceptable aesthetic results with good patient satisfaction. The donor sites were closed primarily in 17 patients; four patients required skin grafting. Two patients required surgical revision due to flap-margin dehiscence. There was no loss of function at donor sites. Increased flap mobility could be achieved through extended perforator dissection. One perforator-based flaps offered the widest arc of rotation serving as propeller flaps. If more than one perforator vessel was preserved, flap mobility was limited, but still allowed sufficient flap movement either as a rotation or advancement flap or as a combination of both. A classification is proposed according to the number of perforator vessels preserved and to the type of flap movement.
The concept of free-style local perforator flaps represents a safe, versatile and reliable surgical procedure. It not only offers a greater freedom in flap selection but also provides good aesthetic results. The classification proposed might aid in the decision-making process involved in order to achieve adequate results with this procedure.
Gluteal artery perforator flaps have gained popularity due to reliability, preservation of the muscle, versatility in flap design without restricting other flap options, and low donor-site morbidity in ambulatory patients and possibility of enabling future reconstruction in paraplegic patients. But the inconstant anatomy of the vascular plexus around the gluteal muscle makes it hard to predict how many perforators are present, what their volume of blood flow and size are, where they exit the overlying fascia, and what their course through the muscle will be. Without any prior investigations, the reconstructive surgeon could be surprised intraoperatively by previous surgical damage, scar formation, or anatomic variants.For these reasons, to confirm the presence and the location of gluteal perforators preoperatively we have used color Doppler ultrasonography. With the help of the color Doppler ultrasonography 26 patients, 21 men and 5 women, were operated between the years 2002 and 2007. The mean age of patients was 47.7 (age range: 7-77 years). All perforator vessels were marked preoperatively around the defect locations. The perforator based flap that will allow primary closure of the donor site and the defect without tension was planned choosing the perforator that showed the largest flow in color Doppler ultrasonography proximally. Perforators were found in the sites identified with color Doppler ultrasonography in all other flaps. In our study, 94.4% flap viability was ensured in 36 perforator-based gluteal area flaps. Mean flap elevation time was 31.9 minutes. We found that locating the perforators preoperatively helps to shorten the operation time without compromising a reliable viability of the perforator flaps, thus enabling the surgeon easier treatment of pressure sores.
We report a method of elevating and rotating a flap, like a propeller, for the release of scar contractures. We have obtained satisfactory results in the repair of scar contractures in the cubital and axillary regions. This flap may be applied to the flexor side in other regions, for example the groin, popliteal fossa and fingers where burn contractures are common.
The Doppler probe was used to identify the dominant cutaneous perforating arteries in a series of 10 patients. The results were compared with our previous total body fresh cadaver anatomical studies and a close correlation was found. The instrument was used in a series of patients to plan the base, the axis and the dimensions of skin flaps for local, distant and free transfer. A dominant perforator was located at the base of the flap, the surrounding skin was scanned to identify the next dominant perforator in each direction and the appropriate axis was chosen by drawing a line between two nominated perforators. Often the flap was based distally or its axis departed from the main course of the supplying vessel. The technique proved to be simple and reliable and in many cases flaps of unusual dimensions and directions were transferred successfully. The instrument provides a useful link between the anatomical dissecting room and the operating theatre.
The rectus abdominis musculocutaneous flap has many advantages, but its disadvantages are also well-known. These are the possibility of abdominal herniation and, in certain situations, its bulk. To overcome these problems, an inferior epigastric artery skin flap without rectus abdominis muscle, pedicled on the muscle perforators and the proximal inferior deep epigastric artery, have been used in two patients. A large flap without muscle can survive on a single muscle perforator. © 1989 The Trustees of British Association of Plastic Surgeons. All rights reserved.
The blood supply to the skin and underlying tissues was investigated by ink injection studies, dissection, perforator mapping and radiographic analysis of fresh cadavers and isolated limbs. The results were correlated with previous regional studies done in this department. The blood supply is shown to be a continuous three-dimensional network of vessels not only in the skin but in all tissue layers. The anatomical territory of a source artery in the skin and deep tissues was found to correspond in most cases, giving rise to the angiosome concept. Arteries follow closely the connective tissue framework of the body. The primary supply to the skin is by direct cutaneous arteries which vary in calibre, length and density in different regions. This primary supply is reinforced by numerous small indirect vessels, which are "spent" terminal branches of arteries supplying the deep tissues. An average of 374 major perforators was plotted in each subject, revealing that there are still many more potential skin flaps. Our arterial roadmap of the body provides the basis for the logical planning of incisions and flaps. The angiosomes defined the tissues available for composite transfer.
Based on the septocutaneous artery flap concept, the thigh, which is the commonest conventional donor site for split-skin grafts, can also become a donor area for skin flaps. The thigh flap, with its large and long neuro-vascular pedicle, can be used either as a free flap or as an island flap as an alternative to the lower abdominal flap, groin flap, tensor fasciae latae myocutaneous flap, sartorius myocutaneous flap or the gracilis myocutaneous flap. The anatomical basis, operative technique and characteristics of the thigh flap are discussed.
The free anterolateral thigh flap is becoming one of the most preferred options for soft-tissue reconstruction. Between June of 1996 and August of 2000, 672 anterolateral thigh flaps were used in 660 patients at Chang Gung Memorial Hospital. Four hundred eighty-four anterolateral thigh flaps were used for head and neck region recontruction in 475 patients, 58 flaps were used for upper extremity reconstruction in 58 patients, 121 flaps were used for lower extremity reconstruction in 119 patients, and nine flaps were used for trunk reconstruction in nine patients. Of the 672 flaps used in total, a majority (439) were musculocutaneous perforator flaps. Sixty-five were septocutaneous vessel flaps. Of these 504 flaps, 350 were fasciocutaneous and 154 were cutaneous flaps. Of the remaining 168 flaps, 95 were musculocutaneous flaps, 63 were chimeric flaps, and the remaining ten were composite musculocutaneous perforator flaps with the tensor fasciae latae. Total flap failure occurred in 12 patients (1.79 percent of the flaps) and partial failure occurred in 17 patients (2.53 percent of the flaps). Of the 12 flaps that failed completely, five were reconstructed with second anterolateral thigh flaps, four with pedicled flaps, one with a free radial forearm flap, one with skin grafting, and one with primary closure. Of the 17 flaps that failed partially, three were reconstructed with anterolateral thigh flaps, one with a free radial forearm flap, five with pedicled flaps, and eight with primary suture, skin grafting, and conservative methods. In this large series, a consistent anatomy of the main pedicle of the anterolateral thigh flap was observed. In cutaneous and fasciocutaneous flaps, the skin vessels (musculocutaneous perforators or septocutaneous vessels) were found and followed until they reached the main pedicle, regardless of the anatomic position. There were only six cases in this series in which no skin vessels were identified during the harvesting of cutaneous or fasciocutaneous anterolateral thigh flaps. In 87.1 percent of the cutaneous or fasciocutaneous flaps, the skin vessels were found to be musculocutaneous perforators; in 12.9 percent, they were found as septocutaneous vessels. The anterolateral thigh flap is a reliable flap that supplies a large area of skin. This flap can be harvested irrespective of whether the skin vessels are septocutaneous or musculocutaneous. It is a versatile soft-tissue flap in which thickness and volume can be adjusted for the extent of the defect, and it can replace most soft-tissue free flaps in most clinical situations.
Perforator flaps increasingly find acceptance and use in the field of reconstructive surgery due to their decreased donor-site morbidity and increased like-tissue coverage. Nevertheless, they are more prone to vascular compromise, especially when the meticulous technique they require is not employed. Pedicle twisting is a condition occasionally encountered in flap procedures, sometimes inadvertently, sometimes inevitably. In this study, circulatory comprise induced by twisting of the pedicle on a true perforator flap in a rat model is investigated.Thirty-eight Wistar-Albino rats were randomized into 4 groups, and cranial epigastric artery true perforator flaps were elevated on a single perforator. The flaps were returned as they were in the control group (n = 9), and with 90 degrees , 180 degrees , and 270 degrees of torsion in groups 2 (n = 9), 3 (n = 10), and 4 (n = 10), respectively. The flaps were evaluated by their flap survival area, weight, and histopathological appearance by the end of the first week. The mean flap survival ratios for groups 1, 2, 3, and 4 were 97.78 +/- 4.41%, 72.22 +/- 44.10%, 73.50 +/- 30.46%, and 30 +/- 30.18% (mean +/- SD), respectively. The degree of degenerative changes in group 4 was found to be statistically significant (P < 0.016).Our histopathological examinations indicate that vascular compromise was moderate in group 3 and severe in group 4. Our findings suggest that under normal conditions, the pedicle of a true perforator flap must not be twisted more than 180 degrees .
Perforator flaps allow the transfer of the patient's own skin and fat in a reliable manner with minimal donor site morbidity. For breast reconstruction, the abdomen typically is our primary choice as a donor site. The deep inferior epigastric perforator (DIEP) flap remains our first choice as an abdominal perforator flap and has become a mainstay for the repair of mastectomy defects. It allows the transfer of the same tissue from the abdomen to the chest for breast reconstruction as the TRAM flap without sacrifice of the rectus muscle or fascia. We discuss our current techniques and specific issues related to the surgery. We present the results of 1095 cases of free tissue transfers from the abdomen for reconstruction of the breast.
The leg and peripatellar region have always been known as a poor source of available flaps. One flap donor site that has proven to be adequate is the distal anteromedial half of the thigh. Due to the potential and plentiful vascular sources of this anatomic region we decided to study the distal anteromedial thigh and its clinical applications. ANATOMIC STUDY: Sixteen cryopreserved inferior limbs were latex-injected in the femoral artery and the skin perforators of the distal anteromedial thigh and their source vessels were studied. CLINICAL STUDY: In a period between December 2000 and June 2005, skin islands from the distal anteromedial aspect of the thigh of six patients were transferred, as local perforator flaps, to reconstruct the peripatellar region and upper leg soft tissue defects. Every flap was based on a single adequate perforator vessel. The tissue was rotated, as a 'propeller', through 180 degrees and the flap was named 'the propeller distal anteromedial thigh perforator flap'.
In the distal anteromedial thigh the anatomic variability includes not only perforator vessels but also their source vessels. Skin perforators can come from each of the deep vessels. Our clinical results, with a follow up of 1-4 years, show no total flap losses. Partial necrosis > 20% happened in one diabetic patient.
The propeller distal anteromedial thigh perforator flap can be reliably transferred based on only one adequate perforator vessel. It reduces the morbidity and improves the availability of the distal anteromedial thigh as a flap donor site and represents an additional reconstructive option for knee and upper leg defects.
Traumatic and nontraumatic defects of the distal third of the tibia are challenging in regard to soft tissue coverage. While local, pedicled fasciocutaneous perforator flaps allow adequate coverage, the donor site often requires skin grafting. When a local perforator flap is designed as a 180-degree propeller flap, an excellent esthetic result and direct closure of the donor site can be achieved, with minimal morbidity.
Eight patients with defects in the malleolar region were treated with 180-degree propeller flaps based on perforators from the tibial and peroneal vessels.
One partial flap loss was encountered in an insulin-dependent diabetic. Partial superficial epidermolysis was encountered in 2 cases and healed without further interventions. No other complications were encountered. All patients returned to full ambulation within 8 weeks.
The 180-degree propeller flap is an elegant and versatile method to achieve soft tissue coverage with local tissue in defects of the distal tibia. Contrary to other local perforator flaps, this specific design facilitates direct closure of the donor site. As only local, thin tissue is used, no interference with normal shoe wear occurs. Even in older patients, this flap has proven to be a reliable option.
Encycl Med Chir. Techniques chirurgicales -Chirurgie plastique reconstructrice et esthétique, 45-080
- J M Servant
- M Revol
Servant JM, Revol M. Les lambeaux cutanés. Encycl Med Chir.
Techniques chirurgicales -Chirurgie plastique reconstructrice
et esthétique, 45-080. Éditions scientifiques et médicales,
Paris: Elsevier SAS; 1990.
Les lambeaux cutanés Encycl Med Chir. Techniques chirurgicales — Chirurgie plastique reconstructrice et esthétique, 45-080
- Jm Servant
- M Revol
Servant JM, Revol M. Les lambeaux cutanés. Encycl Med Chir.
Techniques chirurgicales — Chirurgie plastique reconstructrice
et esthétique, 45-080. Éditions scientifiques et médicales,
Paris: Elsevier SAS; 1990.