Cranial epigastric perforator flap: a rat model of a true perforator flap

The major advantage of a true perforator flap is the ability to capture the skin portion of what previously was a musculocutaneous flap, while totally excluding the muscle for function preservation. To understand better the physiology and dynamics of this flap subtype, a comparable and reliable animal model is essential. This has now been accomplished in the Sprague-Dawley rat using the same abdominal skin territory of the standard rat transverse rectus abdominis musculocutaneous flap, but differing in that all rectus abdominis fascial perforators are isolated via an intramuscular dissection back to the cranial epigastric artery source vessel. Hence, this has appropriately been termed the cranial epigastric perforator flap. From a series of eight rats to date, consistent survival of this flap was as predicted. The dissection itself can be somewhat tedious, but it became easier with experience, making this an excellent training model for learning proper technique in the elevation of any true perforator flap.     

胸廓内动脉穿支皮瓣修复气管造瘘口和颈前皮肤缺损

目的 探索带蒂胸廓内动脉穿支皮瓣修复气管造瘘口和颈前皮肤缺损的临床效果.方法 2009年4月至12月应用带蒂胸廓内动脉穿支皮瓣修复颈部皮肤缺损共4例,其中气管造瘘口周围缺损2例,颈部手术后皮肤缺损2例.4例均选择第2肋间穿支血管供血,皮瓣面积(4～7)cm×(10～13)cm.结果 3例皮瓣全部存活,1例发生部分坏死.供区缺损均直接拉拢关闭且无并发症.结论 带蒂胸廓内动脉穿支皮瓣是头颈部缺损修复的新技术,供区并发症低,主要适用于气管造瘘口和颈部手术后皮肤缺损.

Abstract：

Objective To investigate the application of pedicled internal mammary artery perforator(IMAP) flap for tracheostoma and anterior cervical defect. Methods From April to December 2009, 4 IMAP flaps, based on the second internal mammary artery perforator, were used for two cases of tracheostoma and two cases of anterior cervical skin defect. The flap size was (4-7) cm× ( 10-13 )cm.Results 3 of 4 flaps survived completely. Partial necrosis happened in one flap. The defects at donor sites were closed directly. Conclusions The IMAP flap is a new method for head and neck defect. It is very suitable for tracheostoma and cervical skin defect, with less morbidity at donor site.     

Anterolateral thigh perforator flap from previously burned skin for secondary reconstruction of neck with post burn sequelae, new limits explored.

We report the use of anterolateral thigh perforator flap (ALTF) from previously burned skin for reconstruction of burn cervical contracture. At the time of treatment, there are no reports of the use of perforator flaps from previously burned skin. We have used this technique and feel that it might be an option to consider in view of the fact that massively burned patients often have limited donor site availability, despite requiring flap tissue to resurface difficult anatomical regions.     

Waveform-arranged multiple skin paddles: A novel design to reconstruct complex soft tissue defects of the extremities with a modified multi-lobed perforator flap

BackgroundMulti-lobed perforator flap was one of popular approaches for one-stage reconstruction of complex soft tissue defects because of its minimal donor-site morbidity. However, the area of skin island that can be harvested on the donor site is limited on the angiosome distribution, Moreover, large defects require more than the conventional skin island provided by a traditional multi-lobed perforator flap. For further extended skin paddles, this study presented a novel design of waveform-arranged skin paddles to elevated a modified multi-lobed perforator flap for the reconstruction of complex soft tissue defects in the extremities.MethodsFrom March of 2015 to March of 2020, fifteen patients underwent complex soft tissue defects reconstruction with waveform-arranged multi-lobed perforator flaps. According the size, shape and localization of the defects, two strategies were performed to design this modified multi-lobed flap.ResultsA total of fifteen waveform-arranged multi-lobed perforator flaps were successfully harvested to reconstruct complex soft tissue defects of the extremities. Among of them, Waveform–arranged dual skin paddles perforator flap were performed in eleven cases, and the waveform–arranged tripaddle perforator flaps were used in four cases. All the flaps survived and no flap related complication was observed postoperatively. The donor sites were closed directly in all cases. The mean follow-up time was 15.6 months. Most of the cases showed satisfactory contour.ConclusionThe waveform design of multi-lobed perforator flap was an alternative approach for reconstruction of complex soft tissue defects; it can maximize the harvested skin area of the donor site to provide extended skin island.     

主干蒂与穿支蒂穿支皮瓣血流动力学的比较研究

目的研究主干蒂与穿支蒂穿支皮瓣血流动力学的差异。方法选成年小型猪4只,雌雄各2只,体重23.0±2.0kg。设计自身对照的以两侧腹壁上动脉主干血管或其穿支为蒂的腹部横行皮瓣,一组为逆行解剖血管蒂至腹壁上动脉主干的穿支皮瓣;一组为腹壁上血管腹直肌穿支为蒂的穿支皮瓣。于术后2h,1、2和3周分别以激光多普勒血流仪测量皮瓣皮肤的血流灌注量,以彩色多普勒超声测定腹壁上动脉的血流速度。术后1周计算皮瓣成活面积。3周时处死动物行氧化铅凝胶动脉灌注皮瓣造影。结果术后2h、1周时主干蒂穿支皮瓣较穿支蒂穿支皮瓣水肿严重;两组皮瓣的皮肤血流灌注量有统计学差异（P〈0.05）,术后2、3周两组皮瓣皮肤的血液灌注量、皮瓣的坏死面积（主干蒂穿支皮瓣组19.73%±3.21%;穿支蒂穿支皮瓣组19.81%±3.33%）无统计学差异（P〉0.05）。术后2h、1周时主干蒂穿支皮瓣组的腹壁上动脉平均流速减慢,与另一组比较有统计学差异（P〈0.05）;术后2、3周时两组接近。3周时皮瓣造影显示主干蒂穿支皮瓣组的腹壁上血管有新生血管。结论1主干为血管蒂的穿支皮瓣血流动力学表现在术后1周皮瓣皮肤血流灌注量下降,但不影响皮瓣的成活面积;2血管主干至其他组织的或受区血管的分支结扎不能对皮瓣起到超灌注的作用。     

Combined method of free lateral leg perforator flap with cervicoplasty for reconstruction of anterior cervical scar contractures: a new flap

Anterior cervical scar contracture remains a challenging problem for the plastic surgeon. Recent advances in flap techniques have made it possible to transfer various kinds of autogenous tissue. A free lateral leg perforator flap (LLPF) was first introduced and developed to reconstruct this burn deformity, according to the special nature of perforator anatomy. The authors used this flap to resurface post-burn anterior cervical contracture in a 31-year-old female patient with second-to-third-degree flame burns. The size of the excised scar was 25 x 5.5 cm; the size of the flap was 22 x 8 cm, with total flap survival. The hospital stay was 9 days, and the donor site was covered with a split-thickness skin graft. After a 5-month follow-up, functional improvement was evaluated by an increase in extension of 33 degrees (preoperative 92 to postoperative 125 degrees); an increase in rotation of 15 degrees (preoperative 70 to postoperative 85 degrees); and an increase in lateral flexion of 10 degrees (preoperative 35 to postoperative 45 degrees). The cervicomandibular angle was improved by 20 degrees (preoperative 110 degrees to postoperative 90 degrees). Both functional and aesthetic results, including contour restoration, can be achieved, using this kind of perforator flap combined with cervicoplasty.     

Alternative Regional Flaps When Anterolateral Thigh Flap Perforator is not Feasible

This paper presents the scheme to select alternative flaps limited to the region of the ipsilateral thigh when the perforator of the anterolateral thigh flap is not feasible. Total of 564 consecutive microsurgery cases using anterolateral thigh perforator flap was reviewed from March of 2001 to January of 2009. Total of 12 cases used a contingent flap due to anatomical and technical complications of the anterolateral thigh perforator. The alternatives were skin perforator flaps adjacent to the initial flap (3 cases of upper anterolateral thigh flap, 4 cases of anteromedial thigh flap), vastus lateralis muscle flap with skin graft (2 cases), and anterolateral thigh flap as septocutaneous flap without a prominent perforator on the septum (3 cases). All flaps survived and provided coverage as planned but one case using septocutaneous flap without a prominent perforator was noted with partial necrosis. Adjacent flaps around the anterolateral thigh perforator flap may provide useful alternative flaps in cases of failed elevation. Limiting the contingent secondary flap to this region may reduce further donor site morbidity and still provide an adequate flap for reconstruction.     

Skin viability and wound strength in single and multiple based perforator flaps in an experimental rat model.

Our aim was to evaluate the effect of single and multiple based perforator flaps on the skin viability and wound strength in rats. We used 17 Wistar rats in which two symmetrical abdominal flaps were raised around the midline. On one side all major perforators to the flap were left intact, and on the other side only one perforator was retained. After dissection, the flaps were sutured back in their original position. After seven days each rat was killed and the skin viability and wound strength were measured. The multiple based perforator flap had a mean skin viability of 98% compared with 95% in the single based perforator flap (p =0.08). The mean (SD) wound strength was 3.8 (0.9) N in the multiple based perforator flap compared with 3.0 (1.1) N in the single based perforator flap (p =0.02). We conclude that there is significantly greater wound strength at day 7 with the multiple based perforator flap than with the single one.     

Can a true perforator flap survive on venous blood? A case report of anterolateral thigh true perforator flap supplied by antegrade venous inflow

In some cases of degloving injury, as a result of multiple venous anastomoses formed on the peripheral and proximal sides, the detached flap skin did survive, though with patchy necrosis. On the basis of this experience, the skin and soft-tissue defects after removing skin cancer were closed with an anterolateral thigh true perforator flap, measuring 4 × 5 cm in size, which is nourished by venous blood. The subcutaneous vein on the peripheral side of the defect was anastomosed to the perforator artery, and the veins on the proximal side of the defects were anastomosed to the concomitant veins of the perforator. After surgery, to ensure a sufficient blood flow to the flap, the affected limb was positioned lower than the heart for 1 week. To prevent microthrombus in the perforator branch and the flap, preventive anticoagulant therapy was performed. The transplanted flap had marked cyanosis for a few days, but turned pinkish on the sixth day after surgery. The flap survived completely. As opposed to venous flaps reported in the past, the physiologic direction of blood flow of the flap is from arteries to veins, and it is nourished exclusively by venous blood. If a flap is small, and there are no appropriate recipient vessels nearby, this method could serve as a favorable alternative.     

The gracilis (medial circumflex femoral) perforator flap: a medial groin free flap?

The superior medial thigh skin territory has previously been successfully transferred as a free flap as part of a gracilis musculocutaneous flap. However, muscle bulk can be avoided and its function preserved by instead retaining only the musculocutaneous perforators arising from the gracilis pedicle like in a true perforator flap. A clinical example of this new perforator flap is described as the gracilis (medial circumflex femoral) perforator flap. This could become an ideal skin flap because no muscle is included, a well-defined segment of skin can be reliably harvested, closure of the donor site leaves a scar in the groin that can be readily concealed, and its dominant vascular pedicle is consistent in location and already familiar to most reconstructive surgeons.     

Skin perforator flaps: an algorithm for leg reconstruction

The local fasciocutaneous flap has the advantage of low donor site morbidity when used for the coverage of lower limb defects. However, flap reliability remains a major problem with its use. Perforator flaps are indicated for several clinical problems. The versatility of the perforator flap makes it ideal for the reconstruction of extremities. Between September 2007 and November 2010, 34 skin perforator flaps were raised in 33 cases. Flaps which were executed as peroneal artery flaps were 13, 0.16 flaps were raised as posterior tibial artery perforator flaps, and 5 flaps as medial sural medial gastrocnemius muscle perforator skin flap. A segmental perforator was dissected and retained. Thirty-two flaps survived completely and none exhibited venous compromise. In one patient, flap was lost completely and the other showed partial tip necrosis. Complicated flaps were responded to conservative treatment. Skin perforator flap represents a technical advancement over conventional lower limb skin flaps because of its improved vascularity. It provides the surgeon with additional reconstructive options in reconstruction of difficult areas and injuries of leg. Clinical judgment is essential to assess the potential vascular territory of the flap.     

下斜方肌肌皮瓣修复枕项部高压电烧伤

目的 探讨用下斜方肌肌皮瓣修复枕项部深度电烧伤创面的方法和效果.方法 2003年3月-2007年9月笔者单位共收治枕项部高压电烧伤患者12例,清创后采用改良的下斜方肌肌皮瓣修复.该皮瓣位于下斜方肌中下部位,有2种类型:一种为偏上的肌皮瓣,靠颈横动脉背段浅降支起始段的皮支和肌皮穿支为主要血供;另一种为部位偏下的肌皮瓣,以颈横动脉背段深降支和肩胛背动脉到斜方肌下部穿支为血供,只携带血管附近少量肌袖而保留大部分斜方肌.结果 8例患者皮瓣一次成活;2例因皮瓣邻近创面感染、液化,换药后愈合;1例皮瓣远端小部分坏死,经再次手术后愈合.11例患者存活,1例患者虽皮瓣成活良好,但术后21 d因全身脓毒血症、多器官功能衰竭而死亡.成活皮瓣外观不臃肿,肩背部供瓣区平整,无翼状或下垂肩胛畸形.结论 下斜方肌肌皮瓣能满足枕项部各种创面修复的需要,血管恒定,血运可靠,切取方便,是修复枕项部深度电烧伤创面的良好方法.     

Coverage of pelvis and thigh region by pedicled perforator flap like deep inferior epigastric perforator (DIEP)

The deep inferior epigastric perforator flap (DIEP) is a variation of the transverse rectus abdominis myocutaneous flap (TRAM). This flap was used as a pedicled flap to reconstruct the pelvis and thigh region after resection for cancer (four cases). Various flaps have been described for covering theses tissue defects but we prefer this perforator flap for its many advantages. This flap is very reliable and generates minimal functional sequelae on donor site. This flap is useful to cover soft tissue defects after vascular and oncologic surgery, a situation that was rarely reported to our knowledge.     

Free medial sural artery perforator flap for ankle and foot reconstruction

Resurfacing shallow defects over the ankle and foot with an appropriately thin flap is a common but difficult task. This can be accomplished by harvesting the medial sural artery perforator flap from the medial aspect of the upper calf. Based on the musculocutaneous perforator of the medial sural artery, this flap preserves the medial gastrocnemius muscle and avoids unnecessary flap bulkiness. Between January 2002 and February 2004, we used 2 variants of the free medial sural artery perforator flap for ankle and foot reconstruction in 13 patients (10 fasciocutaneous flaps and 3 adipofascial flaps). In these patients, skin defects were combined with bone, joint, or tendon exposure. The main advantage of this flap is that it provides a thin and pliable coverage to achieve better accuracy in the reconstructive site. Other advantages include maintaining the function of the medial gastrocnemius muscle, providing a long vascular pedicle, and avoiding the need to sacrifice major arteries of the leg. The main disadvantages are the tedious process of intramuscular retrograde dissection of the perforator and the unsightly skin graft over the medial calf.     

Rhomboid perforator flap for a large skin defect due to lumbosacral meningocele: a simple and reliable modification

To date, very few studies have reported the use of perforator flaps in newborn infants with an immature vascular system. Therefore, it is not clear whether perforator flaps can be used in newborns, as in adults. In this study, we applied the perforator flap procedure to a newborn infant, who had a large skin defect due to lumbosacral meningocele. We used the rhomboid perforator flap, which was a combination of using a rhomboid flap reported by Ohtsuka et al and preserving paraspinal perforator vessels according to Thomas. Although perforator vessels were so thin as to necessitate careful dissection and flap design, a good result was obtained by this procedure. We consider that the rhomboid perforator flap is a simple and reliable procedure for the treatment of lumbosacral meningocele.     

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.     

Lokale Perforatorlappen

Local flaps are established procedures for reconstruction of skin and soft tissue defects. Although a cutaneous flap (the so-called Indian flap) had been applied more than 2000 years ago for reconstruction of nasal defects, axial pattern skin flaps for applications in reconstructive surgery were mainly developed in the second half of the twentieth century. Detailed knowledge of the vascular anatomy of the skin eventually led to development of a novel type of skin flap that entirely relies on perforating vessels. In the beginning these so-called perforator flaps were mainly used as microsurgical free flaps. However, the same concept also allows for safe and efficient transfer of large tissue volumes into given defects as a local pedicled flap. This article describes different technical aspects of local perforator flaps and provides examples for clinical applications in different regions. Specific Indications and contraindications of local perforator flaps are discussed in detail.     

Free tensor fascia lata perforator flap as a backup procedure for head and neck reconstruction

Free tissue transfer is an essential part of the head and neck reconstruction. Despite several flap options, free perforator flaps have become very popular for head and neck. Anterolateral thigh perforator flap has multiple advantages among other options and is preferred by most of the reconstructive microsurgeons. Besides its advantages, sometimes it is impossible to harvest an anterolateral thigh perforator flap, and the surgeon has to shift to another option. Between January 2002 and June 2005, 5 tensor fascia lata perforator flaps were used for head and neck reconstruction because anterolateral thigh perforator flap could not be elevated due to absence or insufficient musculocutaneous perforators. Only 1 flap was reexplored and salvaged by redoing the venous anastomosis. All flaps survived without any other problem. Donor sites were covered by split-thickness skin grafts in 4 patients and closed directly in 1 of them. Doppler examination is important in planning of anterolateral thigh perforator; if the signals of the perforators are absent or very weak, the surgeon can shift to another flap. This decision may also be made during the operation when insufficient perforators are seen. Based on our experience, tensor fascia lata perforator flap is a safe alternative when anterolateral thigh perforator harvest is not possible. Tensor fascia lata perforator flap can be harvested from the same anatomic region with almost same morbidity.     

Haemodynamic enhancement in perforator flaps: the inversion phenomenon and its clinical significance. A study of the relation of blood velocity and flow between pedicle and perforator vessels in perforator flaps.

Perforator flaps are perfused through a long vessel whose calibre decreases from its origin to the skin, because all branches have been sealed, resulting in a conduit with resistances in series, rather than a tree with resistances in parallel, as in the normal systemic circulation. This study was planned to assess whether the differences between perforator flap and normal systemic vasculature have an impact on haemodynamic parameters in perforator flaps and on their clinical significance. The study was performed on 10 patients. Echo-colour-Doppler measurement of diameters, velocity of flow and calculations of flow rate were made at the level of flap pedicle artery and skin perforator artery, pre- and post-operatively in each patient. Statistical analysis used the Wilcoxon matched pairs signed sum rank test. Our data show that in the donor area pre-operatively, blood velocity in skin artery perforator is lower that in the corresponding pedicle artery, whereas post-operatively, in perforator flaps, blood velocity in the perforator is higher than in the pedicle. The difference was statistically significant (P<0.01). There is an inversion of the gradient of blood velocity between pedicle artery and perforator artery compared to normal circulation. Furthermore, in normal circulation flow through the perforator was found smaller than that at the pedicle, whereas in perforator flaps, flow through the perforator is smaller but is a greater proportion of the flow through the pedicle and the difference is statistically significant (P<0.01). Therefore, the velocity of blood and the rate of flow reaching the skin are higher in perforator flaps than in normal circulation.     

Myocutaneous trapezius flap

A random pattern flap, such as the nape-of-the-neck flap, is a delayed cutaneous flap that relies on collateral circulation based on the skin pedicle. The myocutaneous trapezius flap, however, is a cervical flap that does not need to be delayed since it receives its blood supply from a musculocutaneous artery. The author has radiographic and clinical evidence that demonstrates that the upper one-half of the trapezius muscle is primarily, and abundantly, supplied by the transverse cervical artery. If this artery is kept intact during resection and reconstruction, a flap as large as 12 × 42 cm may be maintained. This flap has been used in various types of reconstruction on 23 patients, and it has been successful in terms of viability, versatility, safety, and cosmesis.