Flap size/flow rate relationship in perforator flaps and its importance in DIEAP flap drainage (original) (raw)
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The anatomic basis of perforator flaps
Clinics in plastic surgery, 2010
The recent enthusiasm for perforator flaps underlines the need for a detailed understanding of the cutaneous vasculature. The principle determinant of success in perforator flap surgery is the inclusion of an adequately sized cutaneous perforator in the flap. Therefore, the size, distribution, and variability of cutaneous perforators of the human body are crucial to the design and execution of successful perforator flap surgery. Based on numerous anatomic studies, the authors have found that the main source arteries supplying the skin are fairly constant but the individual cutaneous perforators are quite variable. Knowledge of the overall architecture of the vasculature and an awareness of the variability, combined with a flexible operative plan, will enable the perforator flap surgeon to take advantage of the most appropriate perforators to execute a successful operative plan.
Archives of Hand and Microsurgery, 2020
Purpose: Extensive studies regarding vascular anatomy and clinical applications of anterolateral thigh (ALT) flap has been conducted for many years. However, the ALT flap perforator vessels anatomy in the Malaysian population is not well-analyzed. The purpose of this study was to determine the distribution of ALT flap perforator vessels and its clinical applications in reconstructive surgery.Methods: This is a retrospective cross-sectional study conducted in two main centers of reconstructive surgery. A total of 142 cases of ALT flaps that used as an option for soft tissue reconstruction was selected. Vascular anatomy of ALT flaps was studied precisely including the origin of vessels, location of perforators, and types of perforator vessels intraoperatively during the flap harvest.Results: The distribution of ALT flap perforator vessels can be found at three specific locations on the thigh namely perforators A, B, and C. The highest number of cutaneous perforator vessels that suppli...
A Comparative Clinical Study of Flap Thickness
Annals of Plastic Surgery, 2018
Introduction: The purpose of this study is to measure flap thicknesses of anterolateral thigh (ALT) and medial sural artery perforator (MSAP) flaps in healthy subjects by Doppler ultrasonography and compare the results in relation to sex and body mass index (BMI). Method: The perforators of ALT and MSAP flaps were marked on 30 healthy subjects. The thickness of skin and subcutaneous tissue was measured in millimeters at the site of the perforator using Doppler ultrasonography. Results: The mean ± SD age of the participants was 36.4 ± 10.5, the mean ± SD BMI was 25.2 ± 3.9 (19.4-32.5). The mean ± SD flap thickness was 11.55 ± 4.38 mm for ALT and 8.31 ± 3.6 mm mm for MSAP (P < 0.01). Anterolateral thigh flap was significantly thicker than MSAP in both males (9.02 vs 6.11 mm) and females (14.07 vs 10.52 mm) (P < 0.05). The thickness of both MSAP and ALT flap had a positive correlation with BMI. The relationship was stronger for ALT in males (r = 0.66 for ALT, r = 0.59 for MSAP) and for MSAP in females (r = 0.70 for ALT, r = 0.83 for MSAP). Discussion: This study confirms that MSAP flap is thinner than ALT and the results correlate with BMI. Therefore, MSAP flap can be considered a good alternative to ALT, to avoid bulk, in reconstruction of shallower soft tissue defects.
Posterior Thigh Perforator-Based Flap: A New Experimental Model in Rats
Annals of Plastic Surgery, 2002
Animal research has added a great deal of understanding to flap hemodynamics. The rat is the most commonly used animal in flap research, and various flap models have been devised. In the current study the authors developed a single-perforator-based flap model in rats. In 30 rats, anatomic dissection and flap elevation based on a single musculocutaneous perforator artery arising from the biceps femoris muscle were performed. The vascular basis of this new flap was cleared by anatomic dissection of the posterior thigh in 6 rats. The survival pattern of the proposed flap was investigated in three groups of rats. Each group consisted of 8 rats and had different flap dimensions. In the first group the flap was located in the posterior thigh and was 3 ؋ 2 cm. All flaps survived in this group at the end of the first week. In the second group the same flap was extended to the gluteal region and was 3 ؋ 4 cm. Again, all flaps survived. In the last group an oversized flap (3 ؋ 12 cm) was planned from the posterior thigh to the scapular region based on the same perforator artery. In this group only 61 ؎ 7.2% (mean ؎ standard deviation) of the flap survived at the end of the first week. Microangiography was performed in each group and the vascular architecture of the pedicle (perforator artery) was seen. This new posterior thigh perforator-based flap model is simple and reliable with a constant survival pattern. Thus, it could be used in studies investigating the physiological and pathophysiological changes of perforator-based flaps.
Background: Superior gluteal artery perforator flaps are surgical options in breast and pressure sore reconstructions. Based on the recipient site, primary thinning of these flaps may be necessary for final optimal contour. As the thinning of a superior gluteal artery perforator flap should be based on the knowledge of perforator vascular territories to prevent vascular compromise, the authors performed an anatomical study to determine the number, location, and diameter of the perforators present in the superior gluteal artery perforator flap. Accompanying veins and acceptable locations for surgical incisions were also determined. Methods: Fourteen superior gluteal artery perforator flaps were harvested from seven cadavers. Perforator flaps were thinned to 8 to 15 mm, except for a 2.5-cm radius around the dissected perforator. Vascular territory areas were quantified before and after thinning by photographic and radiographic methods, and respective vascular territory maps were constructed. Surgical incision "danger zones" of vertical and horizontal axes were determined at specific depths (relative to the skin surface) for each flap. Danger zone measurements were determined with an automatic three-dimensional vascular tree construction using computed tomographic images and several modeling algorithms. Results: Mean perforator artery diameter and number at the fascia level were 0.91 Ϯ 0.07 mm and 2.86 Ϯ 0.77 (mean Ϯ SD), respectively. Perforator pedicles were located midway between the posterior superior iliac spine and the greater trochanter. After thinning, skin surface and whole flap vascular territories were reduced 80.9 percent (photographic) and 76.9 percent (radiographic), respectively, compared with unthinned vascular territory areas. From the skin at 4-, 6-, and 8-mm thicknesses, elliptical danger zones (two vertical segments and two horizontal segments) had overall vertical segment axis length ranges from the pedicles of 59 to 66 mm, 51 to 57 mm, and 49 to 51 mm, respectively. Horizontal axis segment length ranges were 61 to 76 mm, 61 to 66 mm, and 60 to 57 mm for 4-, 6-, and 8-mm skin thicknesses, respectively. Conclusions: The superior gluteal artery perforator flap provides an excellent blood supply to adipose tissue but may be compromised when aggressively thinned. Surgeons may design and harvest partially thinned superior gluteal artery perforator flaps based on the anatomical vascular territory maps provided by this study. (Plast. Reconstr. Surg.
Vascular analysis of radial artery perforator flaps
Annals of Maxillofacial Surgery, 2018
Background: Radial forearm free flap with all its present day modifications is the workhorse of soft tissue reconstruction in head & neck. Although there are several advantages, it requires the sacrifice of a major artery of forearm. There are several modifications of harvesting a forearm flap based on perforator principles. A clear understanding of vascular anatomy of individual perforators relative to its vascular territory & flow characteristics is essential for both flap harvest & design. The purpose of this cadaveric observational anatomical study was to determine the location, size & vascular territory of the radial artery cutaneous perforators. Materials and Methods: 12 fresh human cadavers & 24 cadaveric forearms were dissected to determine the total number, location, size & vascular territory of radial artery adipo-fascio cutaneous perforator. The cutaneous territory of distally dominant perforators was analyzed using methylene blue injections & three-dimensional computed tomographic angiogram. Results: In the 12 fresh human cadavers & 24 forearm specimens, a total of 222 perforators were dissected for an average of 18.5 radial artery perforators per forearm. Of the total 222 perforators dissected 118 were smaller than 0.5mm in diameter (53.15%) these were not clinically significant. 104 perforators were greater than 0.5mm in diameter (46.84%) these were clinically significant. Of the 222 radial artery perforators dissected, 127 perforators (57.20%) were radially distributed & 95 perforators (42.79%) had ulnar distribution. A total of 90 perforators (40.54%) were identified on distal side (Radial styloid) & 132 perforators (59.45%) were identified on proximal side (Lateral epicondyle). Mean number of perforators on radial side was 10.6 & 7.9 on ulnar side, a comparison of both using student t paired test gives a P value of 0.006, which was statistically significant. Comparison of mean number of perforators on the distal side was 7.5 & proximal side was 11.0, Student Paired t test gives a P value of 0.003, which was statistically significant. Comparison of mean Diameter of perforators between the Distal side (1.11) & Proximal side (0.86) using Student Paired t test gives a P value of 0.01 which was statistically significant. A chi square test was done to compare mean diameter of perforators on distal side, which were more than 1mm (80%) & less than 1mm (20%) & on proximal side more than 1mm (35.6%) & less than 1mm (64.4%). Chi square value of 42.406 was obtained, degree of freedom value was 1& P value of <0.001 was achieved which was found to be highly significant. Methylene blue injections into the proximal part of radial artery demonstrated clusters both in proximal & distal forearm & also cutaneous territory of flap. Three-dimensional computed tomographic angiography reveals a network of linking vessels found to communicate between adjacent perforators & running parallel to radial artery. Large network of linking vessels could be found between fascia & dermis, which also explains the ability to harvest forearm flap at the supra-fascial level. Conclusion: Increase in knowledge of vascular territory of radial artery perforators with regards to numbers, size, location, and cutaneous territory can lead to expanded use of radial forearm flap based on either distal or proximal perforator alone, without sacrificing the radial artery.
Postoperative changes in blood flow in free muscle flaps: A prospective study
Microsurgery, 1999
We used color Doppler ultrasound (US) to study postoperative changes in blood flow in 10 non-innervated free latissimus dorsi (LD) muscle flaps transplanted onto lower extremities. The peak, mean, and minimum velocities, resistance index, and diameter of the pedicle, and the recipient and control arteries were recorded preoperatively and on the 2nd, 5th, and 10th days after surgery. In the pedicle of the transplant, the peak and mean velocities increased but not significantly during the follow-up. The minimum velocity value in the thoraco-dorsal artery was (mean ± SD) 4 ± 5 cm/sec preoperatively, and was in the leg 19 ± 9 cm/sec (P < 0.05) on the 5th and 17 ± 10 cm/sec (P < 0.05) on the 10th postoperative day. The preoperative value of the resistance index decreased from 0.92 ± 0.12 to 0.79 ± 0.08 on the 10th postoperative day (P < 0.05). In the recipient artery, the peak (117 ± 37) and mean (35 ± 16 cm/sec) velocities increased significantly on the 5th postoperative day compared to the preoperative value (79 ± 22 and 14 ± 6 cm/sec, respectively). The minimum velocity increased but not significantly. The resistance index was preoperatively 1.23 ± 0.09 and 0.88 ± 0.16 (P < 0.05) on the 10th postoperative day. This prospective clinical study demonstrates that blood flow in the pedicle and in the recipient artery of a free muscle flap increases after surgery. This phenomenon may be due to loss of vascular tone and decreased resistance after denervation. Increased blood flow helps to keep the microanastomosis open and also promotes wound healing.