• Archives of Plastic Surgery
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• v.40 no.1
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• pp.44-50
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• 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
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• v.35 no.1
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• pp.67-72
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• 2008

Purpose: The hand is frequently affected area in high voltage electrical burn injury as an input or output sites. Electrical burn affecting the hand may produce full thickness necrosis of the skin and damage deep structures beneath the eschar, affecting the tendon, nerve, vessel, even bone which result in serious dysfunction of the hand. As promising methods for the reconstruction of the hand defects in electrical burn patients, we have used the peroneal perforator free flaps. Methods: From March 2005 to June 2006, we applied peroneal perforator free flap to five patients with high tension electrical burn in the hand. Vascular pedicle ranged from 4cm to 5cm and flap size was from $4{\times}2.5cm$ to $7{\times}4cm$. Donor site was closed primarily.Results: All flaps survived completely. There was no need to sacrifice any main artery in the lower leg, and there was minimal morbidity at donor site. During the follow-ups, we got satisfactory results both in hand function and in aesthetic aspects.Conclusion: The peroneal perforator flap is a very thin, pliable flap with minimal donor site morbidity and is suitable for the reconstruction of small and medium sized wound defect, especially hand with electrical burn injury.

• Archives of Plastic Surgery
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• v.36 no.2
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• pp.140-146
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• 2009

Purpose: Autologous breast reconstruction with abdominal tissue is one of the best options after mastectomy. In a free transverse rectus abdominis myocutaneous(TRAM) or deep inferior epigastric artery perforator(DIEP) flap, a preoperative evaluation of the precise location of perforating vessels and vascular run - off systems is required. The objective of this report is to demonstrate the usefulness of multidetector computed tomography(MDCT) in the preoperative planning of patients undergoing breast reconstruction with abdominal flap. Methods: From June 2006 to January 2008, 28 patients underwent MDCT evaluation before breast reconstruction. All subjects were females with an age range of 30 to 55 years. The CT scan was performed using a 64 - slice MDCT scanner(Brilliance 64; Philips Medical Systems, Best, Netherlands). Results: One perforator or two major perforators were marked on image in good relation with a hand - held Doppler examination and intraoperative findings. All vascular run - off systems were cleared before operation. Conclusion: Preoperative evaluation of perforator arteries with MDCT angiography is beneficial in patients undergoing breast reconstruction. This technique provides a noninvasive approach of the vascular anatomy of the entire anterior abdominal wall.

• Archives of Reconstructive Microsurgery
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• v.18 no.1
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• pp.31-34
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• 2009

Purpose: Merkel cell carcinoma, also called neuroendocrine carcinoma, is a very rare type of skin cancer that develops as Merkel cells grow out of control. Merkel cell carcinoma is reported below 1% of whole skin neoplasms in the United States and is known that the 2-year survival rate is about 50~70%. The principles of treatment are wide excision of primary lesion with radiotherapy and/or chemotherapy that decrease the local recurrent rate. There has been no report of reconstruction with free flap after resection of Merkel cell carcinoma in Korea. Methods: We reconstructed the skin and soft tissue defect after wide excision of Merkel cell carcinoma with anterolateral thigh perforator free flap in two cases. No distant metastasis was found at the preoperative imaging work-up. In one case, preoperative chemotherapy was performed and the size of lesion was decreased. Results: There were no recurrence and significant complications. Functionally and aesthetically satisfactory results were obtained with reconstruction. Conclusion: Wide excision and reconstruction with anterolateral thigh perforator free flap for Merkel cell carcinoma patient is the first report in Korea. We regard this method as the treatment of choice in Merkel cell carcinoma.

• Archives of Reconstructive Microsurgery
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• v.18 no.1
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• pp.1-8
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• 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
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• v.25 no.2
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• pp.43-48
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• 2016

Purpose: Perforator flap-using ischial sore reconstruction is performed in a prone position. But after the surgery, recurrence frequently occurs in a sitting position. In this sense, we introduce modified flap insetting method which closely resembles patient's sitting position to lessen the flap tension surgically. Materials and Methods: Authors tried to check a skin tension difference between prone position and sitting position in normal people group and to find out the importance of performing flap insetting in hip flexion position. Healthy volunteers were collected (n=20) and designed the same length of 4 divided sections around the ischium. Lengths of each section were measured when hip joint was flexed to 90 degree and when both hip and knee joints were flexed to 90 degree and the statistical evaluation was performed. Twenty cases with ischial sore underwent reconstructive surgery using perforator flap under hip flexion position and followed-up for any recurrences. Results: There was a meaningful difference between the joint flexed skin length and that of the neutral position. Flap showed sufficient thickness over 12 months. Conclusion: It seems that recurrence could be reduced when the reconstructed flap could sufficiently cover in a sitting position regarding its significant length difference in normal people group.

• Archives of Reconstructive Microsurgery
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• v.22 no.1
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• pp.7-12
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• 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
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• v.34 no.2
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• pp.229-236
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• 2007

Purpose: Breast reconstruction with deep inferior epigastric perforator(DIEP) free flap is known to be the most advanced method of utilizing autologous tissue. The DIEP free flap method saves most of the rectus abdominis muscle as well as anterior rectus sheath. Therefore, the morbidity of the donor site is minimized and the risk of hernia is markedly decreased. Methods: We chose the internal mammary artery and its venae comitantes as recipient vessels, and deep inferior epigastric vessels as donor vessels. The number and location of the perforators derived from medial or lateral branch of deep inferior epigastric artery(DIEA) in 23 DIEP flaps were identified. Ten patients underwent evaluation of their abdominal wall function preoperatively and 6 months postoperatively by using Lacote's muscle grading system. Results: Of the 23 patients, a patient with one perforator from lateral branch of DIEA experienced partial necrosis of flap. Total flap loss occurred in one patient. Mild abdominal bulging was reported in one patient 4 months postoperatively probably because of early vigorous rehabilitational therapy for her frozen shoulder. Postoperative abdominal wall function tests in 10 patients showed almost complete recovery of muscle function upto their preoperative level of upper and lower rectus abdominis and external oblique muscle function at 6 months postoperatively. All patients have been able to resume their daily activities. Conclusion: The breast reconstruction with DIEP free flap is reliable and valuable method which provide ample soft tissue from abdomen without compromising the integrity of abdominal wall. Selection of reliable perforators is important and including more than two perforators may decrease fat necrosis and partial necrosis of flap.

• Archives of Plastic Surgery
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• v.34 no.2
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• pp.203-208
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• 2007

Purpose: Myocutaneous flap was widely used for trochanteric pressure sore but it had many drawbacks such as donor site morbidity, dog-ear deformity and functional muscle sacrifice. We have performed fasciocutaneous flap based on perforating vessels and succeeded in overcoming its drawbacks. Methods: We experienced 11 cases of perforator-based fasciocutaneous flap for the coverage of trochanteric pressure sore in 9 patients, 2 cases of which were bilateral. The ambulatory status of patient group is as follows: 6 of them used a wheelchair, 2 of them are free walking, 1 of them use a wheelchair or crutches. Flap was supplied by cutaneous perforating vessel of descending branch of the lateral circumflex femoral artery and the third perforating artery of the deep femoral artery. The size of wounds were from $4{\times}6.5cm$ to $10{\times}13cm$. Results: We did not find any flap loss or congestion except 2 partial wound dehiscences and 1 wound infection. Donor site morbidity was not found. We observed no recurrence of the pressure sore during the 2.5 year follow-up period. Conclusion: We considered that perforator-based fasciocutaneous flap could overcome the traditional drawbacks of the conventional myocutaneous flap and its modified flap for trochanteric pressure sore. And this flap has many advantages for covering trochanteric pressure sore without any donor site deformity and morbidity, which would greatly improve the aesthetic result.

• Archives of Plastic Surgery
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• v.46 no.5
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• pp.455-461
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• 2019

Background Various surgical management methods have been proposed for ischial sore reconstruction, yet it has the highest recurrence rate of all pressure ulcer types. A novel approach combining the advantages of a perforator-based fasciocutaneous flap and a muscle flap is expected to resolve the disadvantages of previously introduced surgical methods. Methods Fifteen patients with ischial pressure ulcers with chronic osteomyelitis or bursitis, who underwent reconstructive procedures with an inferior gluteal artery perforator (IGAP) fasciocutaneous flap and a split inferior gluteus maximus muscle flap from January 2011 to June 2016, were analyzed retrospectively. The split muscle flap was rotated to obliterate the deep ischial defect, managing the osteomyelitis or bursitis, and the IGAP fasciocutaneous flap was rotated or advanced to cover the superficial layer. The patients' age, sex, presence of bursitis or osteomyelitis, surgical details, complications, follow-up period, and ischial sore recurrence were reviewed. Results All ischial pressure ulcers were successfully reconstructed without any flap loss. The mean duration of follow-up was 12.9 months (range, 3-35 months). Of 15 patients, one had a recurrent ulcer 10 months postoperatively, which was repaired by re-advancing the previously elevated fasciocutaneous flap. Conclusions The dual-flap procedure with an IGAP fasciocutaneous flap and split inferior gluteus maximus muscle flap for ischial pressure ulcer reconstruction is a useful method that combines the useful characteristics of perforator and muscle flaps, providing thick dual padding with sufficient vascularization while minimizing donor morbidity and vascular pedicle injury.