• Archives of Plastic Surgery
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• 제49권2호
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• pp.240-252
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• 2022

Rather than just another "review," this is intended to be an "overview" of the entire subject of the medial sural artery perforator (MSAP) flap as has been presented in the reconstructive literature from its inception in 2001 until the present, with any exceptions not purposefully overlooked. Unfortunately, the pertinent anatomy of the MSAP flap is always anomalous like most other perforator flaps, and perhaps even more variable. No schematic exists to facilitate the identification of a dominant musculocutaneous perforator about which to design the flap, so some adjunctive technology may be highly valuable for this task. However, if a relatively thin free flap is desirable for a small or moderate sized defect that requires a long pedicle with larger caliber vessels, the MSAP flap deserves consideration. Indeed, for many, this has replaced the radial forearm flap such as for partial tongue reconstruction. Most consider the donor site deformity, even if only a conspicuous scar on the calf, to be a contraindication. Yet certainly if used as a local flap for the knee, popliteal fossa, or proximal leg, or as a free flap for the ipsilateral lower extremity where a significant recipient site deformity already exists, can anyone really object that this is not a legitimate indication? As with any perforator flap, advantages and disadvantages exist, which must be carefully perused before a decision to use the MSAP flap is made. Perhaps not a "workhorse" flap for general use throughout the body, the MSAP flap in general may often be a valuable alternative.

• Archives of Plastic Surgery
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• 제35권1호
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• pp.28-35
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• 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.

• 대한족부족관절학회지
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• 제11권2호
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• pp.232-237
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• 2007

Introduction: To report the result of the thigh perforator free flap for the reconstruction of the soft tissue defect of the lower extremities and usefulness of this flap. Materials and Methods: We have performed 23 cases of thigh perforator free flap to reconstruct the soft tissue defect of the lower extremities between February 2004 and July 2005. The anterior aspect of the legs were 9 cases, the ankle joints were 4 cases, the dorsal aspect of the feet were 6 cases, the sole of the feet were 4 cases as recipient sites. The anterolateral thighs were 13 cases, the anteromedial thighs were 10 cases as donor sites. The size of the flap ranged from $4{\times}5\;cm$ to $12{\times}18\;cm$. The mean flap area was $73.2\;cm^2$. The length of the pedicle ranged from 5 cm to 15 cm. Every patient except children was operated under the spinal anesthesia. Results: 21 flaps (91.3%) survived, 2 flaps (8.7%) failed. In the 21 flaps that had survived, there were partial necrosis in 4 cases, which healed without any additional operation. In the 13 anterolateral thigh perforator flaps, 9 cases survived totally, 3 cases had the partial necrosis, 1 case failed. In the 10 anteromedial thigh perforator flaps, 8 cases survived totally, 1 case had the partial necrosis, 1 case failed. Conclusion: The authors had a good result with the thigh perforator free flap and believe that this flap is a good option for the reconstruction of the soft tissue defect of the lower extremities, because this flap has a thin thickness and it is easy to dissect the vessels. Moreover the patients can be operated with supine position.

• Archives of Reconstructive Microsurgery
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• 제23권2호
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• pp.70-75
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• 2014

Purpose: Soft-tissue reconstruction in the knee area requires thin, pliable, and tough skin. The range of motion of the knee also acts as a limitation in using only local flaps for coverage. The author has successfully used various perforator flaps for soft tissue reconstruction around the knee while preserving its functional and cosmetic characteristics. Materials and Methods: Out of the twenty patients assessed from April 2009 to March 2011, seven received anterolateral thigh perforator flaps, four received medial sural perforator island flaps, four received lateral supragenicular perforaor perforator flaps, and five received medial genicular artery flaps. The age of the patients ranged from 44 to 79 and the size of the defects ranged from $4{\times}5cm$ to $17{\times}11cm$. Fifteen of the twenty patients had histories of total knee replacement (TKR) surgery. Results: There were no flap losses in any of the twenty patients assessed. Two patients showed partial losses in the distal area of the flap, but were treated through careful wound care. One patient presented with pedicle adhesion at the drainage site from a past TKR, but it did not hinder the flap survival. Primary closure at the donor site was possible in nine patients, while split skin graft was necessary for the other 13. Conclusion: In soft tissue reconstruction of the knee, various perforator flaps can be used depending on the condition of the preoperation scar, wound site, and size. It also proved to provide better functional and cosmetic results than in primary wound closure or skin grafts.

• Archives of Plastic Surgery
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• 제33권2호
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• pp.181-186
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• 2006

Myocutaneous flaps have improved the management of soft tissue defects on buttocks and lower extremity. However, there are several inherent disadvantages of muscle flaps such as functional deficits of the donor sites and the bulkiness at the recipient site. To overcome these disadvantages, we have used perforator-based fasciocutaneous rotation flaps for reconstruction of the buttock and lower extremity defects. From March 2003 to February 2005, we have treated 14 patients using perforator-based fasciocutaneous rotation flaps. 10 flaps were based on perforators of the gluteus maximus muscle, and 4 flaps were nourished by perforators from the tibialis anterior and posterior system. The mean postoperative follow-up period was about 1 year. The technique involves localization of the flap perforators preoperatively with a Doppler. The flaps were elevated superficial to the fascia with preservation of one to three perforators. The donor site is then closed primarily. All flaps completely survived and there was no perioperative complications. There was no functional disability of the donor area with esthetically pleasing results. Perforator-based fasciocutaneous rotation flaps for the reconstruction of buttock and lower extremity defects are excellent alternatives to musculocutaeous flaps. The vascularity of the flaps is robust and dissection is technically easy. Perforator flaps do not require sacrificing muscles, but provide sufficient volume and are durable Furthermore, these flaps result in less scar formation and allow more liberal dissection with safety. We conclude that perforator-based fasciocutaneous rotation flaps are very useful for reconstruction of the buttock and lower extremity.

• Archives of Plastic Surgery
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• 제38권3호
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• pp.235-240
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• 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
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• 제40권6호
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• pp.754-760
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• 2013

Background Classical flaps for perinasal defect reconstruction, such as forehead or nasolabial flaps, have some disadvantages involving limitations of the arc of rotation and two stages of surgery. However, a perforator-based flap is more versatile and allows freedom in flap design. We introduced our experience with reconstruction using a facial artery perforator-based propeller flap on the perinasal area. We describe the surgical differences between different defect subtypes. Methods Between December 2005 and August 2013, 10 patients underwent perinasal reconstruction in which a facial artery perforator-based flap was used. We divided the perinasal defects into types A and B, according to location. The operative results, including flap size, arc of rotation, complications, and characteristics of the perforator were evaluated by retrospective chart review and photographic evaluation. Results Eight patients were male and 2 patients were female. Their mean age was 61 years (range, 35-75 years). The size of the flap ranged from $1cm{\times}1.5cm$ to $3cm{\times}6cm$. Eight patients healed uneventfully, but 2 patients presented with mild flap congestion. However, these 2 patients healed by conservative management without any additional surgery. All of the flaps survived completely with aesthetically pleasing results. Conclusions The facial artery perforator-based flap allowed for versatile customized flaps, and the donor site scar was concealed using the natural nasolabial fold.

• Archives of Reconstructive Microsurgery
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• 제11권2호
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• pp.141-145
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• 2002

Rectus abdominis muscle free flap is widely used for breast reconstruction and soft tissue defect in lower leg but donor-site morbidities such as abdominal wall weakness, hernia, bulging are troublesome. Recently, to minimize donor-site morbidity, there has been a surge in interest in deep inferior epigastric perforator(DIEP) free flap preserving the anatomy of rectus abdominis muscle, fascia, and motor nerve. Between August of 1995 and September of 2002, topographic investigation of DIEP was performed during the elevation of 97 cases of TRAM free flap and 5 cases of DIEP free flap. There were 84 cases of breast reconstructions, 12 cases of lower leg reconstructions, and 6 cases of head and neck reconstruction. We could observe total 10 to 12 perforators on each rectus abdominis muscle below umbilicus. Among these, the numbers of large perforators(>1.5mm of diameter) were mean 2.1 in lateral half of rectus abdominis muscle, mean 1.2 in medial half, and mean 0.5 in linea alba and paramedian. DIEP free flap provides ample amount of well vascularized soft tissue without inclusion of any rectus abdominis muscle and fascia and minimizes donor-site morbidity. One perforator with significant flow can perfuse the whole flap. For large flap, a perforator of the medial row provides better perfusion to zone-4 than one of lateral row and, if diameter of perforator is small, $2{\sim}3$ perforators can be used. According to the condition of recipient-site, thin flap can be harvested. As DIEP free flap has many advantage, perforator topography will be useful in increasing clinical usage of DIEP free flap.

• Archives of Plastic Surgery
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• 제35권4호
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• pp.379-384
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• 2008

Purpose: Currently, using perforator artery flaps especially anterolateral thigh flaps are widely used for reconstruction of extremities, head and neck. Obtaining a precise anatomical picture prior to operation will translate to a more accurate, efficient and safe procedure. Authors used 3D-image work up via 64-slice MDCT to make a more precise preoperative plan. Methods: A total of 10 patients underwent soft tissue reconstruction with anterolateral thigh flap from December 2006 to December 2007. The 64-Channel MDCT (LightSpeed VCT, GE, USA) was used and 3D images were reconstructed. Findings from MDCT were applied to the preoperative planning and confirmed with intraoperative findings. Results: The average number of perforator arteries from lateral circumflex femoral artery was 2. The average lengths of vascular pedicle from the origin of lateral circumflex femoral artery to the first and second perforator artery were 11.0 cm and 20.0 cm, respectively. The average diameter of the pedicle artery was 2.2 mm. The locations of the perforator arteries were mapped and localized on the body surface based on the MDCT result. These were confirmed through direct visualization intraoperatively. Conclusion: MDCT has an advantage of obtaining accurate images of the general anatomy and even fine structures like perforator arteries. By using this state-of-the-art diagnostic imaging technique, it is now possible to make an operative plan safely and easily.

• Archives of Plastic Surgery
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• 제36권6호
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• pp.720-726
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• 2009

Purpose: Fasciocutaneous flap with random pattern flap has limitation in mobility and length - width ratio. This characteristic is more pronounced in lower extremity which has relatively poor vascularity. Perforator based flap in lower extremity reconstruction has various advantages as a axial flap, allowing abundant blood supply and widening of mobility range. So if it is not a case of wide defect, free flap can be replaced by perforator based flap. Methods: From April 2007 to March 2009, 18 cases of perforator flap were performed. 8 had defect in upper 1/3 of calf, 6 in middle 1/3, and 4 in lower 1/3. In 10 cases island flap were used, 3 case had transposition flap, 2 cases used advancement flap, 2 case had propeller flap and 1 case had rotation flap. Results: 17 cases survived without flap necrosis. Partial flap necrosis occurred in 1 case, so secondary split thickness skin graft was done. Chronic wound with pseudomonas infection occurred in 1 case, but it was completely cured with conservative treatment. Conclusion: Perforator based flap is useful in lower extremity reconstruction because of relative freedom in changing the size and thickness of the flap depending on the recipient site, good mobility, and abundant vascularity. And donor site morbidity can be minimized. Lower extremity reconstruction using perforator based flap is a good method because it can minimize the complication and obtain effective result.