The perforator-centralizing technique for super-thin anterolateral thigh perforator flaps: Minimizing the partial necrosis rate

Suh, Young Chul,Kim, Na Rim,Jun, Dai Won,Lee, Jung Ho,Kim, Young Jin Korean Society of Plastic and Reconstructive Surge 2021 Archives of Plastic Surgery Vol.48 No.1

Background Despite the wide demand for thin flaps for various types of extremity reconstruction, the thin elevation technique for anterolateral thigh (ALT) flaps is not very popular because of its technical difficulty and safety concerns. This study proposes a novel perforator-centralizing technique for super-thin ALT flaps and analyzes its effects in comparison with a skewed-perforator group. Methods From June 2018 to January 2020, 41 patients who required coverage of various types of defects with a single perforator-based super-thin ALT free flap were enrolled. The incidence of partial necrosis and proportion of the necrotic area were analyzed on postoperative day 20 according to the location of superficial penetrating perforators along the flap. The centralized-perforator group was defined as having a perforator anchored to the middle third of the x- and y-axes of the flap, while the skewed-perforator group was defined as having a perforator anchored outside of the middle third of the x- and y-axes of the flap. Results No statistically significant difference in flap thickness and dimension was found between the two groups. The arterial and venous anastomosis patterns of patients in both groups were not significantly different. Only the mean partial necrotic area showed a statistically significant difference between the two groups (centralized-perforator group, 3.4%±2.2%; skewed-perforator group, 15.8%±8.6%; P=0.022). Conclusions The present study demonstrated that super-thin ALT perforator flaps can be elevated safely, with minimal partial necrosis, using the perforator-centralizing technique.

구강악안면재건을 위한 천공지 피판의 적용

김성민,오진실,강지영,명훈,이종호,Kim, Soung Min,Oh, Jin Sil,Kang, Ji Young,Myoung, Hoon,Lee, Jong Ho 대한악안면성형재건외과학회 2013 Maxillofacial Plastic Reconstructive Surgery Vol.35 No.3

Over the past few years, a large number of perforator flaps have been revised by several microsurgeons in the USA, France, Canada and Japan. A perforator flap is a flap of skin or subcutaneous tissue that is based on the dissection of a perforating vessel, which is a perforator. In short, a perforator is a vessel that has its origin in one of the axial vessels of the human body. By reducing any muscle harvesting and trauma to a minimum, perforator flaps aim to minimize donor site morbidity, and by avoiding the transfer of dennervated muscle, the long-term bulk of the free tissue transfer becomes more predictable. There are a finite number of potential perforator flaps in the body, which are based on the named source arteries. The most commonly used perforator flaps are deep inferior epigastric perforator, superior gluteal artery perforator, thoraco dorsal artery perforator, medial sural artery perforator, and anterolateral thigh perforator flap. For a better understanding of perforators as a routine reconstructive procedure in oral and maxillofacial surgery, the definition with nomenclature, classifications with special characteristics, and review points for their individual applications must be learned and memorized by the young doctors in the course regarding the special curriculum periods for the Korean national board of oral and maxillofacial surgery. Perforator flaps have been known to have many advantages, so this review article summarized their applications to the maxillofacial reconstruction in the Korean language.

Dual Perforator Flap for Reconstruction of Large Sacral Defects: Superior Gluteal Artery Perforator Super-Flap with Parasacral Perforator

Tae, Sang Pil,Lim, Seong Yoon,Song, Jin Kyung,Joo, Hong Sil The Korean Society for Microsurgery 2017 Archives of reconstructive microsurgery Vol.26 No.1

The superior gluteal artery perforator flap technique has increasingly been used for soft tissue defects in the sacral area following its introduction nearly 25 years ago. Advantages in covering sacral defects include muscle sparing, versatility in design, and low donor side morbidity. The bilateral superior gluteal artery perforator flap procedure is planned in cases of large sacral defects that cannot be covered with the unilateral superior gluteal artery perforator flap. Here, we report two cases of large sacral defects in which patient factors of poor general health, such as old age, pneumonia, and previous operation scar, led to use of a large unilateral superior gluteal artery perforator super-flap with parasacral perforator. The approach was utilized to reduce the operation time and prevent unpredictable flap failure due to the large flap size. Even though the parasacral perforator was included, the versatility of the large superior gluteal artery perforator flap was preserved because sufficient perforator length was acquired after adequate dissection.

Preoperative Identification of a Perforator Using Computed Tomography Angiography and Metal Clip Marking in Perforator Flap Reconstruction

Lee, Jung Woo,Kim, Han Kyeol,Kim, Sin Rak,Han, Yea Sik,Park, Jin Hyung Korean Society of Plastic and Reconstructive Surge 2015 Archives of Plastic Surgery Vol.42 No.1

In perforator flap reconstruction, vascular mapping using preoperative computed tomography (CT) angiography is widely used to confirm the existence and location of an appropriate perforator. This study proposes a rapid, accurate, and convenient method for marking the perforator location on the skin surface. For 12 patients who underwent perforator flap reconstruction between November 2011 and November 2013, metal clips were fixed on the skin surface at the anticipated perforator locations, which were decided using a handheld Doppler. CT angiography was used to compare the location between the metal clip and the actual perforator. The metal clip was moved and repositioned, if needed, on the basis of the CT images. The locations of the appropriate perforator and the metal clip, which were observed during the surgery, were then compared. In CT angiography, the mean distance between the metal clip and the perforator was $3{\pm}3.9mm$, and the mean distance that was measured during surgery was $0.8{\pm}0.8mm$. In conclusion, we report a simple, rapid, and precise technique to indicate the accurate location of the appropriate perforator on the skin surface.

천공지를 이용한 근막회전피판

안희창,김연환,성건용 대한성형외과학회 2006 Archives of Plastic Surgery Vol.33 No.2

Myocutaneous flaps have improved the management of soft tissue defects on buttocks and lower extremity. However, there are several inherent disadvantages of muscle flaps such as functional deficits of the donor sites and the bulkiness at the recipient site. To overcome these disadvantages, we have used perforator- based fasciocutaneous rotation flaps for reconstruction of the buttock and lower extremity defects.From March 2003 to February 2005, we have treated 14 patients using perforator-based fasciocutaneous rotation flaps. 10 flaps were based on perforators of the gluteus maximus muscle, and 4 flaps were nourished by perforators from the tibialis anterior and posterior system. The mean postoperative follow-up period was about 1 year.The technique involves localization of the flap perforators preoperatively with a Doppler. The flaps were elevated superficial to the fascia with preservation of one to three perforators. The donor site is then closed primarily.All flaps completely survived and there was no perioperative complications. There was no functional disability of the donor area with esthetically pleasing results. Perforator-based fasciocutaneous rotation flaps for the reconstruction of buttock and lower extremity defects are excellent alternatives to musculocutaeous flaps. The vascularity of the flaps is robust and dissection is technically easy. Perforator flaps do not require sacrificing muscles, but provide sufficient volume and are durable. Furthermore, these flaps result in less scar formation and allow more liberal dissection with safety. We conclude that perforator-based fasciocutaneous rotation flaps are very useful for reconstruction of the buttock and lower extremity.

두경부 재건에 있어서 천공지 피판의 다양한 유용성

김정태 대한성형외과학회 2005 Archives of Plastic Surgery Vol.32 No.3

There are various types of flap in head and neck reconstruction. We chose the appropriate flap considering the indication and patient's condition. In case of conventional flaps, its type is decided according to the reconstruction site. In other words, the types of considerable flaps are limited in a way. But, perforator flaps can reduce donor limitation and harvest flaps depending on the condition of the recipient. Therefore, the flap is very useful for the head and neck reconstruction needed for 2-dimensional or 3-dimensional reconstruction. We report the 29 cases of perforator- based flap including 8 cases of latissimus dorsi perforator free flap, 5 thoracodorsal perforator free flap, 4 anterolateral thigh perforator free flap, 3 peroneal osteocutaneous perforator free flap and 9 submental perforator island flap for the head and neck reconstruction. Free flaps include 2 cases of chimeric pattern, 7 controlled resurfacing pattern, 4 3-D pattern, 3 dermoadiposal pattern, 1 folded pattern and 3 osteocutaneous pattern. The flaps were successfully used for the head and neck reconstruction. But one patient died during a follow up period because of the recurrence of tumor. Various perforator flaps(island/free pattern) can be highly competitive to the conventional flaps in the head and neck reconstruction, considering a thin character for resurfacing, more flexible and versatile option, variable composition, long pedicle with donor structures saved, and less prominent donor morbidity.

Perforator Flap versus Conventional Flap

김정태,김상화 대한의학회 2015 Journal of Korean medical science Vol.30 No.5

The introduction of perforator flaps represented a significant advance in microsurgical reconstruction. However, confusion has developed due to the erroneous belief that perforator flaps are different from conventional flaps. The concept of the perforator is not new, but is an idea that evolved from the conventional flap. In fact, some of the flaps used by microsurgeons were perforator flaps. The only difference is the anatomical level of the blood vessels involved; the perforator concept is focused on the distal circulation, socalled ‘perforator’. Therefore, thinner sections of tissue can be taken from the conventional donor sites of myocutaneous flaps. With the use of perforators, there are no longer “flap of choice” for specific reconstructions, because conventional donor sites have become universal donor sites, enabling the harvesting of a variety of flaps. Moreover, depending on the surgeon’s ability, any flap can be utilized as a perforator-based island flap whose source vessel has been completely preserved. Therefore, tissues can be efficiently customized and tailored into any configuration required for reconstruction. The application of perforator flap technique enables more precise dissection, and allows more selective harvesting of thinner flaps, which will expand options in reconstructive surgery. No doubt the technique will continue to evolve.

Preoperative Identification of a Perforator Using Computed Tomography Angiography and Metal Clip Marking in Perforator Flap Reconstruction

이종우,김한열,김신락,한예식,박진형 대한성형외과학회 2015 Archives of Plastic Surgery Vol.42 No.1

In perforator flap reconstruction, vascular mapping using preoperative computed tomography(CT) angiography is widely used to confirm the existence and location of an appropriateperforator. This study proposes a rapid, accurate, and convenient method for marking theperforator location on the skin surface. For 12 patients who underwent perforator flapreconstruction between November 2011 and November 2013, metal clips were fixed on theskin surface at the anticipated perforator locations, which were decided using a handheldDoppler. CT angiography was used to compare the location between the metal clip and theactual perforator. The metal clip was moved and repositioned, if needed, on the basis of the CTimages. The locations of the appropriate perforator and the metal clip, which were observedduring the surgery, were then compared. In CT angiography, the mean distance between themetal clip and the perforator was 3±3.9 mm, and the mean distance that was measuredduring surgery was 0.8±0.8 mm. In conclusion, we report a simple, rapid, and precisetechnique to indicate the accurate location of the appropriate perforator on the skin surface.

쥐의 단일천공지 기저복부 피부판에서 Lipo-PGE1(Prostaglandin E1)의 지연처치 효과

손원일,조성필,변준희 大韓成形外科學會 2004 Archives of Plastic Surgery Vol.31 No.2

The suprafascial course of lower leg perforators: An anatomical study

Vaienti, Luca,Cottone, Giuseppe,De Francesco, Francesco,Borelli, Francesco,Zaccaria, Giovanna,Amendola, Francesco Korean Society of Plastic and Reconstructive Surge 2020 Archives of Plastic Surgery Vol.47 No.2

Background Perforator mapping has been well described in the literature. Once the suprafascial plane is reached, the course of perforators is considered constant. However, the surgeon must be aware of whether an anastomosis exists between perforators superficially to the fascia, in order to choose the best vessel upon which to base the reconstruction. Our retrospective in vivo anatomical study of lower leg perforator flaps presents the first description of variations in the suprafascial path of perforators, which may influence preoperative flap design. Methods An anatomical study of lower limb perforators was performed on 46 nonconsecutive patients who were referred to our department from June 2012 to October 2018. Reconstruction with perforator-based propeller flaps was planned for each of the patients. In total, 72 perforators were preoperatively identified and surgically isolated. The suprafascial course of each perforator was reported. Results During suprafascial surgical exploration, branching patterns were observed in four perforators. These perforators had been classified as single vessels in the preoperative ultrasonographic analysis. However, after surgical dissection, distal converging branches were noted in two of them. Conclusions Our study is the first description in the literature of suprafascial converging perforators, which might constitute an obstacle to planned reconstruction procedures. Despite the accuracy of preoperative evaluations, anatomical variations were present. Knowledge of suprafascial perforator variations may help surgeons to choose the correct perforator upon which to base a planned flap.