Extended locoregional use of intercostal artery perforator propeller flaps

Besides conventional flaps, intercostal artery perforator flaps have been reported to cover trunk defects. In this report the use of anterior intercostal artery perforator (AICAP) flap, lateral intercostal artery perforator (LICAP) flap and dorsal intercostal artery perforator (DICAP) flap for thoracic, abdominal, cervical, lumbar and sacral defects with larger dimensions and extended indications beyond the reported literature were reevaluated. Thirty‐nine patients underwent surgery between August 2012 and August 2014. The age of the patients ranged between 16 and 79 with a mean of 49 years. The distribution of defects were as follows; 12 thoracic, 8 parascapular, 3 cervical, 8 abdominal, 4 sacral and 4 lumbar. AICAP, LICAP and DICAP flaps were used for reconstruction. Fifty‐two ICAP flaps were performed on 39 patients. Flap dimensions ranged between 6 × 9 cm and 14 × 35 cm. Twenty‐six patients had single flap coverage and 13 patients had double flap coverage. Forty‐six flaps have been transferred as propeller flaps and 6 flaps have been transferred as perforator plus flap. Forty flaps (75%) went through transient venous congestion. In one DICAP flap, 30% of flap was lost. No infection, hematoma or seroma were observed in any patient. Follow‐up period ranged between 3 and 32 months with a mean of 9 months. The ICAP flaps provide reliable and versatile options in reconstructive surgery and can be used for challenging defects in trunk.     

The versatility of the inter-costal artery perforator (ICAP) flaps.

INTRODUCTION: Anatomy and classification of intercostal perforator flaps in addition to our experience with will be demonstrated for different indications. MATERIAL AND METHODS: The intercostal vessels form an arcade between the aorta and the internal mammary vessels. Different pedicled perforator flaps can be raised on this neurovascular bundle to cover defects on the trunk. They are classified as following: dorsal intercostal artery perforator flap (DICAP); lateral intercostal artery perforator (LICAP); and anterior intercostal artery perforator (AICAP) flap. RESULTS: Between 2001 and 2004, 20 pedicled (ICAP) flaps were harvested in 16 patients. The indications were: immediate partial breast reconstruction in eight patients who had a quadrantectomy for breast cancer; midline back and sternal defects in three patients who had radical excisions for a dermatofibrosarcoma or malignant melanoma; and autologous breast augmentation (four bilateral and one unilateral flap) in five post-bariatric-surgery patients. The average flap dimension was 18 x 8 cm(2) (range 8 x 5-24 x 12 cm(2)). There were two DICAP flaps, two (AICAP) flaps and 16 (LICAP) flaps. All but two flaps were based on one perforator. Mean harvesting time was 45min for a single flap. Bilateral breast augmentation with LICAP flap necessitated longer operative time (range 2-3h) depending whether it was combined or not with mastopoexy. Complete flaps survival was obtained. All donor sites were closed primarily. CONCLUSION: The (ICAP) flaps provide valuable options in breast surgery; and for challenging defects on the trunk without sacrifice of the underlying muscle.     

Lateral Intercostal Artery Perforator (LICAP) flap for lateral breast defect reconstruction

Lateral breast defect after partial mastectomy is a difficult challenge. Pedicled perforator flap is a new indication for breast surgery. Perforator flaps and fat tissue transplant are new concepts in this kind of reconstruction. Lateral intercostal artery perforator (LICAP) flap has been used for a lot of indications. It can be used for lateral breast defect reconstruction. This flap provides several advantages: minimal donor site morbidity, advantages in flap shaping, better aesthetic results and higher patient satisfaction. The aim of this paper is to present indications of LICAP flap. We discuss its advantages and its limits in lateral breast reconstruction after partial mastectomy. LICAP flap provides a new solution instead of conventional flaps.     

Reconstruction of soft tissue defects in the extremities with a pedicled perforator flap: series of 25 patients

Since the introduction of perforator-based flaps, new flaps have been described for reconstruction of soft tissue defects in the extremities. Pedicled perforator flaps, often called propeller flaps, are based on a single perforator and are local axial flaps that can be rotated up to 180(0) with the single perforator as the pivotal point. Pedicle perforator flaps have gained popularity because they have a shorter operating time than free flaps. However, some concern has been raised about their reliability. Here we report our results of 11 soft tissue reconstructions in the lower leg and 14 in the upper extremity. The defects were mostly traumatic or caused by release of burn scars. The mean size of the flaps in the lower leg was 52 cm(2) (range 126-15 cm(2)). In the upper extremity it was 24 cm(2) (range 12-35 cm(2)). All patients were followed until the wound had healed. In the upper extremity there was only one partial necrosis of the flap, and one patient had an infected wound. One haematoma was evacuated postoperatively, and all the rest healed uneventfully. In the lower leg we had one total necrosis and one partial necrosis of the flap and one infected wound. A free scapular flap was used for salvage in one case, and revision and skin grafting in two. The pedicled perforator flap is reliable, particularly in the upper extremity. The operation is quick and can be done under regional anaesthesia. The flap is thin and has a local texture that gives a good functional and aesthetic result. The pedicled perforator flap is a little unpredictable in the lower leg, probably because the directions of the vessels that arise from the perforator are not consistent.     

Customized reconstruction with the free anterolateral thigh perforator flap

From April of 2003 through September of 2006, 70 free anterolateral thigh (ALT) flaps were transferred for reconstructing soft-tissue defects. The overall success rate was 96%. Among 70 free ALT flaps, 11 were elevated as cutaneous ALT septocutaneous vessel flaps. Fifty-seven were harvested as cutaneous ALT myocutaneous "true" perforator flaps. Two flaps were used as fasciocutaneous perforator flaps based on independent skin vessels. Fifty-four ALT flaps were used for lower extremity reconstruction, 11 flaps were used for upper extremity reconstruction, 3 flaps were used for trunk reconstruction, and 1 flap was used for head and neck reconstruction. Total flap failure occurred in 3 patients (4.28% of the flaps), and partial failure occurred in 5 patients (7.14% of the flaps). The three flaps that failed completely were reconstructed with a free radial forearm flap, a latissimus dorsi flap and skin grafting, respectively. Among the five flaps that failed partially, three were reconstructed with skin grafting, one with a sural flap, and one with primary closure. The free ALT flap has become the workhorse for covering defects in most clinical situations in our center. It is a reliable flap with consistent anatomy and a long, constant pedicle diameter. Its versatility, in which thickness and volume can be adjusted, leads to a perfect match for customized reconstruction of complex defects.     

Reconstruction of elbow region defects using radial collateral artery perforator (RCAP)-based propeller flaps

Perforator-based propeller flaps permit flap rotation up to 180°. This ability to transfer skin from one longitudinal axis to another has led to the increasing use of perforator-based propeller flaps in extremity reconstruction, especially lower-extremity reconstruction. However, the application of perforator-based propeller flaps to upper-extremity reconstruction is still limited. This article reports two cases of successful reconstruction of elbow region defects with radial collateral artery perforator (RCAP)-based propeller flaps. The elbow region has a variety of perforators available for perforator-based propeller flap reconstruction. Among them, the RCAP seems to be one of the most reliable options. This is because there are less anatomical variations of perforators' location on the lateral upper arm than on the medial upper arm. By using an RCAP perforator as a flap pedicle, the small-to-medium sized defects (<6?cm in diameter) around elbow regions can be closed primarily without skin grafts.     

The thin circumflex scapular artery perforator flap.

The development of microsurgery has most recently been focused upon the evolution of perforator flaps, with the aim of minimising donor site morbidity, and avoiding the transfer of functionally unnecessary tissues. The vascular basis of perforator flaps also facilitates radical primary thinning prior to flap transfer, when appropriate. Based upon initial clinical observations, cadaveric, and radiological studies, we describe a new, thin, perforator flap based upon the circumflex scapular artery (CSA). A perforator vessel was found to arise within 1.5cm of the CSA bifurcation (arising from the main trunk, or the descending branch). The perforator arborises into the sub-dermal vascular plexus of the dorsal scapular skin, permitting the elevation and primary thinning of a skin flap. This thin flap has been employed in a series of five clinical cases to reconstruct defects of the axilla (two cases of hidradenitis suppurativa; pedicled transfers), and upper limb (one sarcoma, one brachial to radial artery flowthrough revascularisation plus antecubital fossa reconstruction, and one hand reconstruction with a chimeric flap incorporating vascularised bone, fascia, and thin skin flaps; free tissue transfers). No intramuscular perforator dissection is required; pedicle length is 8-10cm and vessel diameter 2-4mm. There was no significant peri-operative complication or flap failure, all donor sites were closed primarily, patient satisfaction was high, and initial reconstructive aims were achieved in all cases. Surgical technique, and the vascular basis of the flap are described. The thin circumflex scapular artery perforator flap requires no intramuscular dissection yet provides high quality skin (whose characteristics can be varied by orientation of the skin paddle), and multiple chimeric options. The donor site is relatively hair-free, has favourable cosmesis and no known functional morbidity. This flap represents a promising addition to the existing range of perforator flaps.     

以肩胛下血管为蒂的侧胸皮瓣修复上肢组织缺损

目的 探讨以肩胛下血管为蒂的侧胸皮瓣带蒂转移修复上肢较大面积组织缺损的可行性及临床效果. 方法 2003年6月至2009年9月,我们对5例上肢较大面积组织缺损的患者,应用以肩胛下血管为蒂的侧胸皮瓣带蒂转移修复,皮瓣切取面积为23 cm×8 cm～40 cm ×20 cm.术中将肩胛下血管、胸背血管和胸背血管外侧支及其皮穿支等营养血管均包含于皮瓣内.为了减少肌皮穿支的损伤,应在其周围携带2～3 cm宽的背阔肌袖.供瓣区创面直接缝合或移植皮片修复. 结果 单纯侧胸皮瓣带蒂转移4例、侧胸-脐旁联合皮瓣带蒂转移1例.转移的皮瓣除1例远端小部分坏死外,其余全部成活.4例患者获得2～14个月的随访,皮瓣色泽、质地及厚薄较满意,供、受区外形与功能恢复也较满意. 结论 带蒂转移的以肩胛下血管为蒂的侧胸皮瓣血供可靠,转移方便,供瓣区损伤小,是修复上肢较大面积组织缺损的理想方法.     

Use of the lateral intercostal artery perforator-based pedicled reverse thoraco-abdominal flap for treatment of antecubital burn contractures

We describe a lateral intercostal artery perforator-based pedicled reverse thoraco-abdominal flap for coverage of the antecubital fossa after burn scar release. In this study we describe raising and insetting the flap and reported our clinical results and observations.Antecubital contracture release was carried out in six patients, and the lateral intercostal artery perforator-based pedicled reverse thoraco-abdominal flap was raised based on the anterolateral cutaneous perforator of the appropriate intercostal artery. The defects were repaired with this flap.All the flaps survived and antecubital contractures were repaired successfully. No recurrent contracture occurred in any of the patients at a mean of 15.3 months.The lateral intercostal artery perforator-based pedicled reverse thoraco-abdominal flap can be used effectively for repair of antecubital tissue defects as an alternative to other reconstructive methods.     

Reconstruction of lower extremity with perforator free flaps by free style approach in pediatric patients

Pediatric reconstruction using microsurgery is accepted normal practice, and the use of perforator flaps is slowly increasing. This study presents clinical work using various perforator free flaps by free style approach to reconstruct lower extremity soft tissue defects in pediatric patients and evaluates its efficacy. Between June 2002 and February 2011, 32 cases (mean age: 10.1 years) were reconstructed with free style perforator free flaps. Retrospective evaluations for flap survival, growth character, and other associated morbidities were performed. Flaps used in this series are anterolateral thigh (ALT) perforator, superficial circumflex iliac artery perforator (SCIP), upper medial thigh perforator, and posterior interosseous perforator free flaps. The free style approach for pedicle dissection was successful in all cases. Early postoperative complications were 15.6% from hematoma collection to partial loss of flap. Although there was no total loss in this series, one case needed additional flap coverage to cover the partial loss of the flap. The long-term follow-up showed contracture along the margin, with 16% needing a releasing procedure. Bone growth was not affected by flap contracture. The overall results show perforator flaps using the free style approach to be a reliable and feasible approach for lower extremity reconstruction in the pediatric population.     

应用肋间后动脉穿支皮瓣修复微囊型淋巴管畸形切除后的大面积缺损

目的 探讨微囊型淋巴管畸形（LMs）手术切除的可行性,并对肋间后动脉穿支（LICAP）皮瓣修复微囊型LMs切除后的大面积缺损的有效性进行评价。方法 2009年1月至2012年12月,对8例13-22岁腋胸侧壁微囊型LMs患者,应用MRI和B超确定病变切除的范围和层次,对彻底切除后均遗留的腋窝、胸侧壁皮肤组织缺损,应用LICAP皮瓣进行修复,7位患者皮瓣供区直接缝合,1位患者供区植皮覆盖。结果 应用LICAP皮瓣可成功修复所有微囊型LMs切除术造成的组织缺损。术后随访1-3年,皮瓣形态良好,B超和MRI证实无复发微囊腔出现,皮瓣供区无功能受损。结论 超声和MRI可为手术彻底切除病灶作精确定位并进行手术后评估。微囊型LMs手术切除术后遗留组织缺损可应用LICAP皮瓣获得良好的组织覆盖和修复,术后受区外形良好,供区无功能损伤。     

Free style perforator based propeller flaps: Simple solutions for upper extremity reconstruction!

Background:

The introduction of perforator flaps by Koshima et al. was met with much animosity in the plastic surgery fraternity. The safety concerns of these flaps following the intentional twist of the perforators have prevented widespread adoption of this technique. Use of perforator based propeller flaps in the lower extremity is gradually on the rise, but their use in upper extremity reconstruction is infrequently reported, especially in the Indian subcontinent.

Materials and Methods:

We present a retrospective series of 63 free style perforator flaps used for soft tissue reconstruction of the upper extremity from November 2008 to June 2013. Flaps were performed by a single surgeon for various locations and indications over the upper extremity. Patient demographics, surgical indication, defect features, complications and clinical outcome are evaluated and presented as an uncontrolled case series.

Results:

63 free style perforator based propeller flaps were used for soft tissue reconstruction of 62 patients for the upper extremity from November 2008 to June 2013. Of the 63 flaps, 31 flaps were performed for trauma, 30 for post burn sequel, and two for post snake bite defects. We encountered flap necrosis in 8 flaps, of which there was complete necrosis in 4 flaps, and partial necrosis in four flaps. Of these 8 flaps, 7 needed a secondary procedure, and one healed secondarily. Although we had a failure rate of 12-13%, most of our failures were in the early part of the series indicative of a learning curve associated with the flap.

Conclusion:

Free style perforator based propeller flaps are a reliable option for coverage of small to moderate sized defects.

Level of Evidence:

Therapeutic IV.KEY WORDS: Hand defects, perforator flaps, propeller flaps, perforator based propeller flaps, upper extremity, wrist defects     

膝上外侧动脉穿支髂胫束皮瓣的解剖特点与临床应用

目的 探讨膝上外侧动脉穿支髂胫束皮瓣的解剖学基础与临床应用效果.方法 自1999年9月至2009年7月,在40侧经动脉灌注红色乳胶的成人下肢标本上,解剖、观测膝上外侧动脉的起源、走行、分支、分布、吻合以及髂胫束的血供来源,临床应用吻合膝上外侧动脉穿支髂胫束瓣移植5例、髂胫束皮瓣4例.结果 80%(35侧)膝上外侧动脉单独起自腘动脉,起始外径(1.8±0.4)mm.该动脉向外蜿蜒上行分为升、降支,从股外侧肌与股二头肌短头肌之间的股外侧肌间隔穿出形成肌间隙(隔)筋膜皮肤穿支,或与膝上最外侧动脉在股外侧肌内吻合后发出肌皮穿支,供养大腿中下段髂胫束和前外侧皮肤,其中较粗大穿支起始外径(1.0±0.2)mm,并在深筋膜浅层或深层于近端与旋股外侧动脉降支吻合,远端与膝关节网吻合.临床应用9例,其中修复单纯跟腱缺损5例,跟腱伴皮肤缺损2例;修复小腿、足软组织缺损各1例.随访6个月～7年8个月,带血供髂胫束修复跟腱缺损功能恢复良好,4例髂胫束皮瓣全部成活.结论 吻合膝上外侧动脉穿支髂胫束皮瓣是一种新型、简便、实用的复合(软组织)缺损修复方法,适于临床推广应用.     

Perforator Propeller Flap “Relay” for Distal Lower Extremity Soft Tissue Reconstruction

The peroneal artery perforator propeller flap is commonly used for distal lower extremity reconstruction; however, closure of the donor site defect can limit the utility of this flap. To overcome this limitation, we introduced a perforator propeller flap relay technique to reconstruct the donor-site defect. Between July 2015 and February 2019, the propeller flap relay technique was applied in 9 patients. In each case, a peroneal artery perforator propeller flap was transferred to repair a defect in the distal lower leg or the foot. In addition, a neighboring perforator propeller flap was transferred to close the donor-site defect. The peroneal artery perforator propeller flaps ranged from 14 × 4 to 29 × 8 cm² in size. Donor-site closure was accomplished using the relaying propeller flaps based on perforators from the peroneal, medial sural, and lateral sural arteries. Normal contour of the lower leg was preserved with acceptable scars. Additional time for the second flap procedure was less than 1 hour in each case. One peroneal artery perforator flap presented with partial flap necrosis. Other flaps survived completely without complication. Coverage of the donor-site defects of the peroneal artery perforator flaps can be achieved using various perforator propeller flaps. The perforator propeller flap relay technique allows surgeons to harvest a large peroneal artery perforator flap without being limited by significant donor-site morbidity. This technique can reconstruct defects at distal lower extremity with low morbidity and improved overall reconstructive results.     

Dual perforator propeller internal mammary artery perforator (IMAP) flap for soft-tissue defect of the contralateral clavicular area

The internal mammary artery perforator (IMAP) flap represents the evolution from axially pedicled flaps (deltopectoral flap) to perforator flaps. Both flaps are typically used for neck and tracheostoma reconstruction in male patients. We present the case of a 68-year-old obese female patient with a right upper thoracic radionecrosis secondary to breast irradiation. Soft-tissue defect measured 12×18cm. She also complained of left breast hypertrophy. Following radical debridement, a left IMAP flap extending from midline to the anterior axillary fold was raised, based on the second and fourth IMAP vessels. The flap was rotated 180° on its second and fourth perforators to cover the defect and the left breast was reshaped. The flap survived entirely and wound healing was uneventful. Ptosis and breast hypertrophy were corrected at the same time. The IMAP flap can be harvested all the way to the anterior axillary fold and used as a large propeller flap, which makes this flap suitable for contralateral thoracic reconstructions, even in female patients.     

Lateral intercostal artery perforator flap used in salvage of exposed tissue expander of breast: case report

Management of an exposed tissue expander in breast reconstruction patients remains a challenging problem. For large defects that cannot be repaired primarily, local flap options are limited. In this case report, we describe the use of lateral intercostal artery perforator (LICAP) flap in salvage of an exposed tissue expander of a patient who had delayed immediate breast reconstruction after mastectomy. The postoperative recovery was uneventful and tissue expansion followed by radiotherapy was well tolerated by the flap. We believe this is the first article to describe the use of LICAP flap in salvage of an exposed tissue expander of the breast due to mastectomy flap necrosis in the early postoperative period.     

穿支皮瓣移植修复四肢软组织缺损108例

目的 探讨应用穿支皮瓣修复四肢皮肤软组织缺损的临床效果. 方法2007年7月至2009年5月,分别采用腹壁下动脉穿支皮瓣、股前外侧穿支皮瓣、胸背动脉穿支皮瓣、股外侧穿支皮瓣、骨间背侧动脉穿支皮瓣、桡侧副动脉穿支皮瓣、腓肠内侧动脉穿支皮瓣、胫后动脉穿支皮瓣、旋髂深动脉穿支皮瓣、腓动脉穿支皮瓣移植修复四肢皮肤软组织缺损108例(游离移植98例,带蒂转移10例),皮瓣切取面积最小4 cm×2 cm,最大44 cm×9 cm,皮瓣供区均直接缝合.结果 术后5例发生静脉危象,其中1例松解包扎后危象解除,4例再次手术探查,2例成活,2例坏死,其余103例顺利成活,皮瓣受区与供区创121愈合良好.术后随访6-24个月(平均10个月),皮瓣颜色、质地好,外形不臃肿;皮瓣供区遗留线性瘢痕,功能无影响. 结论穿支皮瓣不携带肌肉、深筋膜及运动神经,对皮瓣供区影响小,还具有血供可靠、质地薄、不需二期去脂整形的优点,是修复四肢浅表创面的首选方法.     

应用穿支皮瓣治疗下肢远端慢性骨髓炎并皮肤缺损

目的 探讨游离或带蒂穿支皮瓣在治疗下肢远端慢性骨髓炎并皮肤缺损创面修复中的应用价值.方法 应用穿支皮瓣游离或带蒂移位修复胫前及足踝部慢性骨髓炎并皮肤缺损28例.游离移植13例:采用股前外侧穿支皮瓣修复胫前2例,踝前3例,足背2例,足跟2例;小腿外侧腓动脉穿支皮瓣修复足背4例.带蒂移位15例:胫后动脉穿支皮瓣修复胫前4例,修复内踝2例;腓动脉外踝后上穿支皮瓣修复足跟6例,外踝及足背各1例;第1跖背动脉穿支皮瓣修复近节(足母)趾背侧1例.抗生素液灌流伤口7例,万古霉素明胶海绵残腔填塞8例.结果 1例胫后动脉穿支皮瓣出现静脉回流不足,表浅坏死,自行愈合,其余皮瓣无坏死.随访6个月～2年,2例复发,分别经1次和2次手术后愈合,其余均一期愈合,皮瓣外形满意.3例行二期骨移植.最后一次随访时,患者可行走,患肢完全负重,按足部疾患治疗效果标准评定平均为84.5分.结论 游离或带蒂穿支皮瓣血供良好,可用于治疗残腔不大的慢性骨髓炎并皮肤缺损.     

Pedicled deep inferior epigastric perforator flap for lower abdominal defects and genital reconstructive surgery

The pedicled deep inferior epigastric perforator (DIEP) flap can be used successfully to reconstruct the lower abdominal, inguinal, and genital regions. This muscle-sparing technique offers many advantages, such as minimal donor-site morbidity, a wide arch of rotation, and more versatile flap design, and provides for easier reconstruction than free flaps. Four pedicled DIEP flap cases are described in this article. The flaps were used to reconstruct lower abdominal defects and groin defects and to perform a penile reconstruction. To the best of our knowledge, ours is the first report in the English literature to describe the use of a pedicled DIEP flap for penile reconstruction. The donor sites were closed directly, and morbidity in all cases was minimal.     

Reconstruction of extensive upper extremity defects using pre-expanded oblique perforator-based paraumbilical flaps

The pedicled paraumbilical flap is a reliable tissue transfer for hand and forearm reconstruction. However, its size, pedicle length and/or thickness limit its application in resurfacing of extensive defects of the upper limb. To conquer those limitations, this flap was pre-expanded for 10-24 weeks prior to transfer in 25 patients and used as a pedicle flap to cover upper extremity defects. Extensive defects of upper limb were reconstructed by the pre-expanded paraumbilical flaps. The flaps ranged in size from 10 cm × 8 cm to 30 cm × 14 cm. The donor sites were closed directly in all cases. All flaps survived, but two had partial flap necrosis due to venous congestion or infection. With pre-transfer expansion, a large, well-perfused abdominal pedicle flap can be raised and transferred based on the paraumbilical perforators. This pre-expanded flap might be useful in the patients who have the extensive upper limb defects and sufficient time to allow tissue expansion.