• Archives of Plastic Surgery
• /
• v.41 no.5
• /
• pp.542-547
• /
• 2014

Background Abdominal wall free flaps are used most frequently in autologous breast reconstruction, and these flaps require intact and robust deep inferior epigastric perforator (DIEP) vessels. Pfannenstiel incisions are often present during preoperative visits for breast reconstruction and could potentially signal compromised blood supply to the lower abdominal wall. In this study, we compared the number of DIEP vessels between patients with and without Pfannenstiel incisions undergoing autologous breast reconstruction. Methods A retrospective review of medical records was performed for patients with (study) and without (control) Pfannelstiel incisions (n=34 for each group) between June 2010 and July 2013. In addition to patient demographics, number of caesarian sections, and outcomes of free flap reconstruction, abdominal wall vasculature was compared using the preoperative computed tomography angiographic data between the groups. For each patient, vessels measuring greater than 1 mm were counted and divided into four sections of the lower abdominal wall. Results The mean number of perforator vessels was 10.6 in the study group and 11.4 in the control group, which was not statistically different (P=0.575). Pfannenstiel incisions with history of repeat caesarian sections were not associated with decreased number of perforator vessels. Conclusions Pfannenstiel scars are associated with neither a change in the number of DIEP vessels nor decreased viability of a free transverse rectus abdominis myocutaneous and DIEP flap. Lower abdominal free flaps based on DIEP vessels appear safe even in patients who have had multiple caesarian sections through Pfannenstiel incisions.

• Archives of Reconstructive Microsurgery
• /
• v.16 no.2
• /
• pp.63-67
• /
• 2007

This study was designed to introduce free toe tissue transfer using infiltration method of local anesthetic agent. Four toe pulp tissues were transferred to reconstruct finger tip defect in four patients who were not suitable for general anesthesia. Two flaps taken from the lateral side of the great toe was used for reconstruction of thumb defect and two flaps from the medial side of the second toe for resurfacing of the index and fifth finger. Flap sizes were various from $2.0{\times}2.0\;cm^2$ to $1.6{\times}4.0\;cm^2$. Anesthesia was induced by infiltration of 2% lidocaine hydrochloride (with 1:100,000 epinephrine) with dilution of normal saline in same volume unit, as like as in ordinary digital block. All vessels were anastomosed within 2 cm of distance from the proximal margin of the defect. Whole operative procedures were carried out by one team. All flaps were successfully taken without complication. The average operation time was 4 hours 10 minutes. The amount of anesthetic agent used in whole operative procedures was roughly 4 mL in the toe, 8 mL in the finger, and 12 mL totally. In conclusion, free toe tissue transfer using infiltration method of local anesthetic agent would be good strategy for finger tip reconstruction in the patient not suitable for general anesthesia.

• Archives of Plastic Surgery
• /
• v.44 no.2
• /
• pp.136-143
• /
• 2017

Background The goal of this study was to investigate the anatomy of the peroneal artery and its perforators, and to report the clinical results of reconstruction with peroneal artery perforator flaps. Methods The authors dissected 4 cadaver legs and investigated the distribution, course, origin, number, type, and length of the perforators. Peroneal artery perforator flap surgery was performed on 29 patients. Results We identified 19 perforators in 4 legs. The mean number of perforators was 4.8 per leg, and the mean length was 4.8 cm. Five perforators were found proximally, 9 medially, and 5 distally. We found 12 true septocutaneous perforators and 7 musculocutaneous perforators. Four emerged from the posterior tibia artery, and 15 were from the peroneal artery. The peroneal artery perforator flap was used in 29 patients. Retrograde island peroneal flaps were used in 8 cases, anterograde island peroneal flaps in 5 cases, and free peroneal flaps in 16 cases. The mean age was 59.9 years, and the defect size ranged from $2.0cm{\times}4.5cm$ to $8.0cm{\times}8.0cm$. All the flaps survived. Five flaps developed partial skin necrosis. In 2 cases, a split-thickness skin graft was performed, and the other 3 cases were treated without any additional procedures. Conclusions The peroneal artery perforator flap is a good alternative for the reconstruction of soft tissue defects, with a constant and reliable vascular pedicle, thin and pliable skin, and the possibility of creating a composite tissue flap.

• Archives of Plastic Surgery
• /
• v.42 no.5
• /
• pp.619-625
• /
• 2015

Background The reconstruction of ankle and heel defects remains a significant problem for plastic surgeons. The following options exist for reconstructing such defects: local random flaps, reverse flow island flaps, and free flaps. However, each of these methods has certain drawbacks. Peroneal artery perforators have many advantages; in particular, they are predictable and reliable for ankle and heel reconstructions. In this study, we report our clinical experience with peroneal artery perforator-based pedicled flaps in ankle and heel reconstructions. Methods From July 2005 to October 2012, 12 patients underwent the reconstruction of soft tissue defects in the ankle and heel using a peroneal artery perforator-based pedicled flap. These 12 cases were classified according to the anatomical area involved. The cause of the wound, comorbidities, flap size, operative results, and complications were analyzed through retrospective chart review. Results The mean age of the patients was 52.4 years. The size of the flaps ranged from $5{\times}4$ to $20{\times}8cm^2$. The defects were classified into two groups based on whether they occurred in the Achilles tendon (n=9) or heel pad (n=3). In all 12 patients, complete flap survival was achieved without significant complications; however, two patients experienced minor wound dehiscence. Nevertheless, these wounds healed in response to subsequent debridement and conservative management. No patient had any functional deficits of the lower extremities. Conclusions Peroneal artery perforator-based pedicled flaps were found to be a useful option for the reconstruction of soft tissue defects of the ankle and heel.

• Archives of Plastic Surgery
• /
• v.40 no.1
• /
• pp.44-50
• /
• 2013

Background The aim of this investigation was to systematically review the current literature to provide the best data for indications, outcomes, survival, and complication rates of pedicled propeller perforator flaps for upper body defects. Methods A comprehensive literature review for articles published from January 1991 to December 2011 was performed using the PubMed, Medline, and Cochrane Databases. Articles without available full-text, single case reports or papers with excessive missing data were excluded. Papers reporting pedicle-perforator (propeller) flaps used for lower extremity reconstruction were excluded from meta-analysis. Results From the initial 1,736 studies our search yielded, 343 studies qualified for the second stage of selection. Of 117 full-text reports screened, 41 studies, met the definitive inclusion and exclusion criteria. Of the selected 41 articles, 26 were case series, original papers or retrospective reviews and were included, whereas 15 were case report papers and therefore were excluded. Two hundred ninety-five propeller flaps were reported to have been used in a total of 283 patients. Indications include repair of trauma-induced injuries, post-trauma revision surgery, cancer resection, chronic infection, pressure sores, and chronic ulcers with a major complication rate (3.3%) comparable to that of free flaps. No specific exclusion criteria for the procedure were presented in the studies reviewed. Conclusions Pedicled propeller flaps are a versatile and safe reconstructive option that are easy and quick to raise and that provide unlimited clinical solutions because of the theoretical possibility of harvesting them based on any perforator chosen among those classified in the body.

• Archives of Plastic Surgery
• /
• v.47 no.4
• /
• pp.365-370
• /
• 2020

The ability to directly harvest thin and superthin perforator flaps without jeopardizing their vascularity depends on knowledge of the microsurgical vascular anatomy of each perforator within the subcutaneous tissue up to the dermis. In this paper, we report our experience with ultrahigh-frequency ultrasound (UHF-US) in the preoperative planning of thin and superthin flaps. Between May 2017 and September 2018, perforators of seven patients were preoperatively evaluated by both ultrasound (using an 18-MHz linear probe) and UHF-US (using 48- and 70-MHz linear probes). Thin flaps (two cases) and superthin flaps (five cases) were elevated for the reconstruction of head and neck oncologic defects and lower limb traumatic defects. The mean flap size was 6.5×15 cm (range, 5×8 to 7.5×23 cm). No complications occurred, and all flaps survived completely. In all cases, we found 100% agreement between the preoperative UHF-US results and the intraoperative findings. The final reconstructive outcomes were considered satisfactory by both the surgeon and the patients. In conclusion, UHF-US was found to be very useful in the preoperative planning of thin and superthin free flaps, as it allows precise anticipation of very superficial microvascular anatomy. UHF-US may represent the next frontier in thin, superthin, and pure skin perforator flap design.

• Archives of Plastic Surgery
• /
• v.40 no.3
• /
• pp.173-180
• /
• 2013

As microvascular techniques continue to improve, perforator flap free tissue transfer is now the gold standard for autologous breast reconstruction. Various options are available for breast reconstruction with autologous tissue. These include the free transverse rectus abdominis myocutaneous (TRAM) flap, deep inferior epigastric perforator flap, superficial inferior epigastric artery flap, superior gluteal artery perforator flap, and transverse/vertical upper gracilis flap. In addition, pedicled flaps can be very successful in the right hands and the right patient, such as the pedicled TRAM flap, latissimus dorsi flap, and thoracodorsal artery perforator. Each flap comes with its own advantages and disadvantages related to tissue properties and donor-site morbidity. Currently, the problem is how to determine the most appropriate flap for a particular patient among those potential candidates. Based on a thorough review of the literature and accumulated experiences in the author's institution, this article provides a logical approach to autologous breast reconstruction. The algorithms presented here can be helpful to customize breast reconstruction to individual patient needs.

• Archives of Reconstructive Microsurgery
• /
• v.3 no.1
• /
• pp.54-63
• /
• 1994

Pulp and palm of the hand and heel of the sole are anatomically unique. Satisfactory reconstruction of these areas presents the plastic surgeon with many challenges and requires durable and sensible skin coverage, minimal donor morbidity and reliable operative procedure. We presents 7 clinical cases of sensate instep free flap transfer in this paper during the last 2 years. Three cases were soft tissue defects due to crushing and avulsion injury on the pulp of finger. 1 case was unstable scar and redundant flap after reconstruction of soft tissue dect of palm and 1 case was contracture of first web of hand. One case was a soft tissue defect due to avulsion injury on heel. Lastly, one case was chronic osteomyelitis with open wound on lateral malleolar area. Follow-up period ranged from 3 months to 2 years. Through the whole follow-up period, all flaps were viable and durable to persistant stress or weight bearing and were sensible enough to porotect the recocstructed area from injuries and maintain functions. In conclusions, the instep free flap should be considered as a valuable tool in reconstruction of hand and extremity requiring durability and sensation.

• Archives of Plastic Surgery
• /
• v.50 no.5
• /
• pp.523-528
• /
• 2023

The Gustilo IIIB tibiofibular fractures often result in long bone loss and extensive soft tissue defects. Reconstruction of these complex wounds is very challenging, especially when it includes long bone grafts, because the donor site is limited. We describe our experience using a set of chimeric ipsilateral vascularized fibula grafts with a thoracodorsal artery perforator free flap to reconstruct the traumatic tibia defects. A 66-year-old male suffered a severe comminuted tibia fracture and segmented fibula fracture with large soft tissue defects as a result of a traffic accident. He also had an open calcaneal fracture with soft tissue defects on the ipsilateral side. All the main vessels of the lower extremity were intact, and the cortical bone defect of the tibia was almost as large as the fractured fibula segment. We used an ipsilateral vascularized fibula graft to reconstruct the tibia and a thoracodorsal artery perforator flap to resurface the soft tissue, using the distal ends of peroneal vessels as named into sequential chimeric flaps. After 3 weeks, the calcaneal defect was reconstructed with second thoracodorsal artery perforator free flap. Reconstruction was successful and allowed rapid rehabilitation because of reduced donor site morbidity.

• Archives of Plastic Surgery
• /
• v.34 no.1
• /
• pp.52-59
• /
• 2007

Purpose: The venous flap is used as an alternative method to the standard free flap for the management of small and thin soft tissue defects. Especially, the venous flap has advantages of being thin, easy harvest and various donor sites, as well as it having lower morbidity. Yet their clinical applications have been limited by their unstable postoperative course and also by their complications such as partial necrosis. The aim of this study is to extend the clinical indications of venous flaps with using various methods. Methods: From May 2005 to March 2006, total of 19 patients(21 cases) underwent various venous flaps for soft tissue defects as a result of trauma(15 cases), facial skin cancer(3 cases), chronic ulcer(1 case) and surgical wound for congenital anomaly(2 cases). The arterialized venous free flap were applied in 18 cases, the pure venous free flap was applied in 1 case and the pure venous pedicled flap were applied in 2 cases. Among them, two flow-through arterialized venous free flaps were applied that used the great saphenous vein to reconstructed major arteries as well as the injured skin and soft tissues in the arm. All the flap were harvested from the volar wrist(11 cases), dorsum of foot(5 cases), thenar(2 cases), and medial thigh(3 cases). Results: The sizes of the flap ranged from $0.75cm^2$ to $264cm^2$(mean size: $40.06cm^2$). The follow-up period ranged from two to twelve months. In the majority of cases, we obtained satisfying results, which was the excellent reconstruction of skin and soft tissue defects and especially in the case of limb salvage, replantation and cancer reconstruction. However, there were 5 cases of partial necrosis and 2 cases of complete failure. The donor sites were closed primarily in 7 cases and wound closure with skin graft were in 14 cases. Conclusion: We conclude that the venous flap will not only be useful for reconstruction of small defect in the hand and foot, but also be useful for various other clinical indications.