• Archives of Plastic Surgery
• /
• v.34 no.5
• /
• pp.562-568
• /
• 2007

Purpose: Many studies reported anatomy of posterior tibial artery perforator. But, it is not easy to use this flap in clinical case. Methods: Authors performed cadaver dissection on 26 legs from 13 cadavers and identified the number, location, type, length and diameter of perforator. Based on anatomic study, posterior tibial artery perforator flap was performed on 3 clinical cases. Results: The perforator was found on a line drawn from the medial boarder of central patella to posterior boarder of medial malleolus. The main perforator which was longer and greater caliber than others was found was found 13 to 17cm distant from medial boarder of central patella in 23 of 26 leg(88.5%). Average length was 6.2cm and average diameter was 1.4mm. The main perforator was musculocutaneous perforator at 20 of 26 leg(77%). The posterior tibial artery perforator flap was clinically use in 3 cases. All flap were survived without any complication. Conclusion: The author found the main perforator of posterior tibial artery perforator flap was located 15cm distant from medial boarder of central patella within the circle drawn with a radius of 4cm. The posterior tibial artery perforator flap is expected to be used as one of the option for the reconstruction of hand and foot.

• Archives of Craniofacial Surgery
• /
• v.23 no.2
• /
• pp.64-70
• /
• 2022

Background: Anterolateral thigh (ALT) flaps are versatile soft tissue flaps that have become the standard soft-tissue flaps used for head and neck reconstruction. They provide a long vascular pedicle, constant vessel diameter, abundant soft tissue coverage, and minimal donor site morbidity. The ALT flap was initially designed on the basis of a septocutaneous (SC) perforator. However, more recent research has shown that a substantial number of ALT flaps are now based on musculocutaneous (MC) perforators, and the ratio between MC and SC perforators varies among studies. In this study, we analyzed the perforating pattern of ALT flaps along with their clinical outcomes during head and neck reconstruction in the Korean population. Methods: From October 2016 to July 2020, 68 patients who had undergone an ALT flap procedure for head and neck reconstruction were enrolled retrospectively. The perforating pattern of the cutaneous perforator vessel (MC perforator/SC perforator/oblique branch), pedicle length, and flap size were analyzed intraoperatively. Patient demographics and flap necrosis rates were also calculated. Results: The highest number of cutaneous perforator vessels supplying the ALT flap were the MC perforators (87%). The proportion of MC perforators was significantly higher than that of the SC perforators and oblique branches. Flap necrosis occurred in seven cases (11.86%); sex, hypertension, diabetes mellitus, coronary artery disease, perforator course, and history of radiotherapy did not significantly affect flap necrosis. Conclusion: The ALT free flap procedure remains popular for reconstruction of the head and neck. In this study, we observed that the majority of cutaneous vessels supplying the flaps were MC perforators (87%). When using the MC perforator during flap elevation, careful dissection of the perforator is required to achieve successful ALT flaps because intramuscular dissection is difficult. Perforator pattern and history of radiotherapy did not affect flap necrosis.

• Archives of Plastic Surgery
• /
• v.49 no.4
• /
• pp.482-487
• /
• 2022

In lower abdominal flap representing transverse rectus abdominis musculocutaneous (TRAM) flap or deep inferior epigastric perforator (DIEP) flap, superficial inferior epigastric vein (SIEV) exists as superficial and independent venous system from deep system. The superficial venous drainage is dominant despite a dominant deep arterial supply in anterior abdominal wall. As TRAM or DIEP flaps began to be widely used for breast reconstruction, venous congestion issue has been arisen. Many clinical series in regard to venous congestion despite patent microvascular anastomosis site were reported. Venous congestion could be divided in two conditions by the area of venous congestion and each condition is from different anatomical causes. First, if venous congestion was shown in whole flap, it is due to the connection between SIEV and vena comitantes of DIEP. Second, if venous congestion is limited in above midline (Hartrampf zone II), it is due to problem in venous midline crossover. In this article, the authors reviewed the role of SIEV in lower abdominal flap based on the various anatomic and clinical studies. The contents are mainly categorized into four main issues; basic anatomy of SIEV, the two cause of venous congestion, connection between SIEV and vena comitantes of DIEP, and midline crossover of SIEV.

• Archives of Plastic Surgery
• /
• v.38 no.3
• /
• pp.235-240
• /
• 2011

Purpose: Management of pressure sores has been improved, along with development of musculocutaneous flaps and perforator flaps. Nowadays, the treatment of pressure sore with perforator flaps has shown several advantages, including minimal donor site morbidity, relatively versatile flap design not only in primary cases but also in recurred cases and minimized anatomical rearrangement of regional muscle position. In this study, we report our clinical experience of gluteal perforator flap used in the treatment of a greater trochanteric pressure sore. Methods: A clinical study was performed on 7 patients who underwent total 10 operations. 1 superior gluteal artery perforator flap and 9 inferior gluteal artery perforator flaps were used to reconstruct the defect, followed by the mean observation duration of 22 months. Results: There were no total flap loss. We treated 2 cases of partial flap loss with debridement and primary repair. 2 recurred cases were successfully treated using the same method. Donor sites were all primarily repaired. Conclusion: The gluteal perforator flap could be considered as a safe and favorable alternative in the treatment of soft tissue defects in the greater trochanteric area. The advantages of the flap include low donor site morbidity and the possibility of versatile flap design not only in primary cases but also in recurred cases.

• 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.35 no.1
• /
• pp.28-35
• /
• 2008

Purpose: The pedicle of transverse rectus abdominis myocutaneous(TRAM) flap and deep inferior epigastric arterial perforator flap is deep inferior epigastic artery (DIEA) and accurate anatomic knowledge about perforator of DIEA is very important for the elevation of these flap. The authors investigated a detailed vascular network of perforator of DIEA in Koreans. Methods: 24 fresh cadavers were studied. Among them, 15 were examined based on the plain X-ray examination for the distribution and location of perforator of DIEA. And 9 fresh cadavers were examined based on the 3-dimensional computed tomography(CT) study for the distance between ending point of perforator of DIEA and mother artery, the distance between most medial mother artery and midline, the distance between most lateral mother artery and midline, and the running type of perforators of DIEA. Results: Based on the plain X-ray examination, suitable(external diameter$${\geq_-}0.5mm$$) perforators of DIEA are located between the level of umbilicus and 8 cm below it. Based on the 3D-CT study, average distance between the ending point of perforator of DIEA and the mother artery is 30.26 mm on the left, 28.62 mm on the right, respectively. The average distance between most medial mother artery and midline is 17.13 mm on the left, 15.76 mm on the right, respectively. The average distance between most lateral mother artery and midline is 56.31 mm on the left, 50.90 mm on the right, respectively. The main running course of suitable perforators of DIEA is type a, which is a direct musculocutaneous perforator vessel from main vascular axis passing outward to join the subdermal plexus, directly. Conclusion: 3-dimensional computed tomography study as well as plain X-ray examination provided more accurate and detail informations about perforators of DIEA in Koreans. These informations will help us understand the detailed vascular anatomy and operation with ease and safe in the lower abdomen of Koreans.

• Journal of the Korean Association of Oral and Maxillofacial Surgeons
• /
• v.42 no.5
• /
• pp.265-270
• /
• 2016

Objectives: To gain information on anatomical variation in anterolateral thigh (ALT) flaps in a series of clinical cases, with special focus on perforators and pedicles, for potential use in reconstruction of oral and maxillofacial soft tissue defects. Materials and Methods: Eight patients who underwent microvascular reconstructive surgery with ALT free flaps after ablative surgery for oral cancer were included. The number of perforators included in cutaneous flaps, location of perforators (septocutaneous or musculocutaneous), and the course of vascular pedicles were intraoperatively investigated. Results: Four cases with a single perforator and four cases with multiple perforators were included in the ALT flap designed along the line from anterior superior iliac spine to patella. Three cases had perforators running the septum between the vastus lateralis and rectus femoris muscle (septocutaneous type), and five cases had perforators running in the vastus lateralis muscle (musculocutaneous type). Regarding the course of vascular pedicles, five cases were derived from the descending branch of the lateral circumflex femoral artery (type I), and three cases were from the transverse branch (type II). Conclusion: Anatomical variation affecting the distribution of perforators and the course of pedicles might prevent use of an ALT free flap in various reconstruction cases. However, these issues can be overcome with an understanding of anatomical variation and meticulous surgical dissection. ALT free flaps are considered reliable options for reconstruction of soft tissue defects of the oral and maxillofacial area.

• Archives of Reconstructive Microsurgery
• /
• v.18 no.1
• /
• pp.1-8
• /
• 2009

Purpose: The perforator flaps have established their role in the reconstruction of various soft tissue defects. For the last five years, we have extensively used anterolateral thigh (ALT) flap for the reconstruction of the complex tissue defects of the hand and upper extremity and report the clinical results and our experiences with the versatile applications of this flap. Materials and Methods: From March 2003 through May 2008, 119 free ALT perforator flaps were transferred for reconstruction of the complex tissue defects of the elbow, forearm, wrist and hand after crushing or degloving injuries as well as severe scar contractures. There were 95 females and 24 males. The mean age of the patients was 37 years and mean size of the flap was 170 $cm^2$. In 20 cases, the flap was vascularized by septocutaneous and in 99 cases by musculocutaneous perforators. Intra-muscular dissection length averaged 3.4 cm. The total length of pedicle averaged 8.4 cm and the average arterial diameter was 0.84 mm. End-to-end arterial anastomosis was performed in 103 cases and end-to-side in 16 cases. Results: Flap survival rate was 98.3%(117/119) and there were 6 cases of partial necrosis. Donor site was closed primarily in 41 cases and skin grafts were applied in 78 cases. Conclusion: The reliability and versatility of ALT flap makes it one of the foremost choices for the reconstruction of complex tissue defects of the upper extremity.

• Archives of Reconstructive Microsurgery
• /
• v.22 no.1
• /
• pp.7-12
• /
• 2013

Purpose: Breast reconstruction with lower abdominal tissue can produce the best outcome with acceptable rates of long-term complication. However, for cases in which sufficient abdominal tissue is not available, an superior gluteal artery perforator (SGAP) flap can be considered as the next option for autologous breast reconstruction. Materials and Methods: Among a total of 63 women who underwent breast reconstruction with free autologous tissue transfer from July 2010 to April 2011, SGAP flap was performed for four patients. In two cases, patients did not have enough abdominal tissue for sizable breast reconstruction. In another case, the patient had a long abdominal scar due to donor hepatectomy of liver transplantation. In the last case, which was a revisional case after radiation necrosis of a previous pedicled transverse rectus abdominis musculocutaneous (TRAM) flap, a large amount of healthy skin and soft tissue was needed. SGAP flap was elevated in lateral decubitus position. The internal mammary vessels were used for recipient vessels in all cases. Results: Breast reconstruction was performed successfully in all four cases without flap loss. Donor site complication was not observed, except for one case of seroma. The shape of the reconstructed breast was satisfactory in all patients. Conclusion: SGAP flap is an excellent alternative option for the TRAM or deep inferior epigastric artery perforator flap for breast reconstruction. In terms of narrower width, harder consistency of soft tissue, and shorter pedicle, it is clear that the SGAP flap is less competent than the TRAM flap. However, in cases where abdominal tissue is not available, SGAP flap is the only way of providing a large amount of healthy tissue.

• Archives of Plastic Surgery
• /
• v.34 no.2
• /
• pp.191-196
• /
• 2007

Purpose: Gluteal perforator is easily identified in the gluteal region and gluteal perforator flap is a very versatile flap in sacral sore reconstruction. We obtained satisfying results using the gluteal perforator flap, so we report this clinical experiences with a review of the literature. Methods: Between November of 2003 and April 2006, the authors used 16 gluteal perforator flaps in 16 consecutive patients for coverage of sacral pressure sores. The mean age of the patients was 47.4 years (range, 14 to 78 years), and there were 9 male and 7 female patients. All flaps in the series were supplied by musculocutaneous arteries and its venae comitantes penetrating the gluteus maximus muscle and reaching the intrafascial and suprafascial planes, and the overlying skin forming a rich vascular plexus arising from gluteal muscles. Patients were followed up for a mean period of 11.5 months. Results: All flaps survived except one that had undergone total necrosis by patient's negligence. Wound dehiscence was observed in three patients and treated by secondary closure. There was no recurrence during the follow-up period. Conclusion: Gluteal perforator flaps allow safe and reliable options for coverage of sacral pressure sores with minimal donor site morbidity, and do not sacrifice the gluteus maximus muscle and rarely lead to post-operative complications. Freedom in flap design and easy-to perform make gluteal perforator flap an excellent choice for selected patients.