Evolution in Flap Design: From the Supraclavicular Artery Island Flap to the Anterior Supraclavicular Artery Perforator Flap

Abstract Introduction While the originally described transverse profunda artery perforator (tPAP) flap is designed to capture the first profunda perforator, our group hypothesized the dominant perforator may not always be captured in this configuration. This study maps the location of dominant profunda perforators using imaging and cadaveric dissections to determine the probability of capturing dominant perforators with the transverse flap design versus the vertical PAP (vPAP) variant. Methods Fifty preoperative magnetic resonance angiogram or computed tomographic angiogram scans (100 total extremities) were examined from autologous breast reconstruction patients between 2015 and 2019. Profunda perforator characteristics that were examined included the distance from the pubic tubercle to the infragluteal fold (IGF), the distance of the perforators from the IGF, distance posterior to the gracilis, the diameter of the perforator at fascial exit, and total number of perforators present. Profunda perforator dissection was performed in 18 cadaveric extremities. Analysis included mean distance from pubic tubercle, distance posterior to the gracilis, diameter at fascial exit, and total number of perforators. Results In imaging analysis, the mean distance from the IGF to the fascial exit of all dominant perforators was 7.04 cm. The mean diameter of the dominant perforator at the fascial exit was 2.61 mm. Twenty-six thighs (26%) demonstrated dominant perforators that exited the fascia greater than 8 cm below the IGF. In cadaver dissections, the mean distance from the pubic tubercle to the fascial exit of all the dominant perforators was 10.17 cm. Nine cadaver specimens (50%) demonstrated perforators that exited the fascia greater than 8 cm below the estimated IGF. Conclusion The dominant perforator can often be missed in the traditional tPAP design. The vPAP incorporates multiple perforators with a long pedicle, excellent vessel diameter, and favorable donor-site.

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A new lateral thoracic artery perforator flap design with multiple vascular territories in rats

Journal of Surgical Research ◽

10.1016/j.jss.2016.08.066 ◽

2017 ◽

Vol 209 ◽

pp. 70-78

Author(s):

Seçkin Aydın Savaş ◽

Tahsin Gorgulu ◽

Cumhur İbrahim Başsorgun ◽

Arzu Akcal

Keyword(s):

Perforator Flap ◽

Lateral Thoracic Artery ◽

Flap Design ◽

Artery Perforator

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Use of Indocyanine Green Imaging for Perforator Identification in Preexpanded Brachial Artery Perforator Flaps

Facial Plastic Surgery ◽

10.1055/s-0040-1713791 ◽

2020 ◽

Vol 36 (05) ◽

pp. 650-658

Author(s):

Tinglu Han ◽

Nima Khavanin ◽

Mengqing Zang ◽

Shan Zhu ◽

Bo Chen ◽

...

Keyword(s):

Indocyanine Green ◽

Head And Neck ◽

Brachial Artery ◽

Donor Site ◽

Perforator Flap ◽

Donor Site Morbidity ◽

Icg Angiography ◽

Flap Design ◽

Flap Elevation ◽

Artery Perforator

AbstractThe tissues of the medial arm as a donor site for perforator flap design have several advantages. However, they are relatively underused with limited reports, partly due to unreliable perforator anatomy. Therefore, we aimed to review our preliminary experience using indocyanine green (ICG) angiography to design and elevate preexpanded pedicled brachial artery perforator (BAP) flaps for regional reconstruction. All patients underwent soft tissue reconstructions using a preexpanded BAP flap in two or three stages. ICG angiography was used to localize perforators during both expander insertion and flap elevation. The pedicle was divided at the third stage 3 weeks following flap elevation for head and neck cases. Sixteen patients underwent reconstructions of the head and neck (n = 13) or shoulder/trunk (n = 3) using 14 perforator-plus and 2 propeller BAP flaps. In total, 50 perforators were identified using ICG imaging, all of which were appreciable during both expander placement and flap elevation. Thirty-five perforators were directly visualized during flap elevation, and an additional 15 perforators were not explored but incorporated into the flap. All flaps survived without necrosis, and the donor sites healed uneventfully without complications. The medial arm provides thin and pliable skin for the resurfacing of regional defects with relatively minimal donor-site morbidity. With the assistance of ICG angiography, perforators of the brachial artery can be reliably identified, facilitating the preexpansion and elevation of pedicled BAP flaps for use in head–neck and trunk reconstruction.

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The role of cinematic rendering in pre-operative planning of a thoracodorsal artery perforator flap (TDAP) phalloplasty: a case study

BJR|case reports ◽

10.1259/bjrcr.20180084 ◽

2019 ◽

Vol 5 (2) ◽

pp. 20180084

Author(s):

Carolina Lugo-Fagundo ◽

Hannah Ahn ◽

Devin O’Brien-Coon ◽

Elliot K. Fishman

Keyword(s):

Volume Rendering ◽

Three Dimensional ◽

Perforator Flap ◽

Muscle Involvement ◽

Thoracodorsal Artery ◽

Operative Planning ◽

Flap Design ◽

Tdap Flap ◽

Artery Perforator ◽

Volume Rendering Technique

The thoracodorsal artery perforator (TDAP) flap is a muscle-sparing skin and fat flap that requires precise intramuscular dissection of the thoracodorsal artery perforators in the axillary region. Pre-operative image-based treatment planning is a crucial part of flap design. In this article, we discuss the first-ever reported use of the cinematic volume rendering technique (CVRT) to evaluate the thoracodorsal artery for a TDAP flap phalloplasty in a 49-year-old transgender patient. Cinematic volume rendering technique uses light maps to generate photo-realistic three-dimensional images of the thoracodorsal artery and its perforators. These images aid the surgeon in evaluating optimal perforators and latissimus dorsi muscle involvement for more efficient flap design.

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Clinical application of pedicled thoracoacromial artery perforator flaps for tracheal reconstruction

10.21203/rs.3.rs-41623/v2 ◽

2020 ◽

Author(s):

Di Deng ◽

Feng Xu ◽

Jifeng Liu ◽

Bo Li ◽

Linke Li ◽

...

Keyword(s):

Clinical Application ◽

Perforator Flap ◽

Good Choice ◽

Island Flap ◽

Esophageal Reconstruction ◽

Perforator Flaps ◽

Tracheal Reconstruction ◽

Thoracoacromial Artery ◽

The Mean ◽

Artery Perforator

Abstract Background: Large or complex trachea defects often require some tissue to reconstruct,various flaps have been reported for reconstructing this defect.However, pedicled thoracoacromial artery perforator flap have not been reported in tracheal reconstruction.Therefore,this study is to assess the efficacy and clinical application of pedicled thoracoacromial artery perforator flaps for tracheal reconstruction.Methods: Eight patients who underwent tracheal reconstructions with pedicled TAAP flaps between December 2017 and October 2019 were retrospectively reviewed.Results: All of the pedicled TAAP flaps in our study survived. The flap size ranged from 2 cm x 5 cm to 4 cm x 10 cm, and the size of each island of one double-island flap was 2 cm x 2.5 cm. The mean thickness was 0.6 cm, and the pedicle length varied between 6 cm and 9 cm (mean 7.9 cm). The mean time of flap harvest was 17 min. The mean age of the patients was 62.4 years and five elderly patients had comorbidities,such as diabetes,hypertension and asthma. One patient received a double-island flap for tracheal and esophageal reconstruction, and the other patient received simple tracheal reconstruction. One patient died due to cancer metastasis.Six patients obtained functional recovery of breathing, except one patients who did not experience closure of the tracheostomy opening due to uncompleted I131 treatment.Conclusion: Pedicled TAAP flaps provide a short harvesting time, thin thickness and stable blood supply, and they do not require microsurgical skills. This flap is a good choice for the reconstruction of tracheal defects,especially in the aged or patients with comorbidities who are not able to tolerate prolonged surgery.

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Medium- and Large-Sized Autologous Breast Reconstruction using a Fleur-de-lys Profunda Femoris Artery Perforator Flap Design: A Report Comparing Results with the Horizontal Profunda Femoris Artery Perforator Flap

Journal of Reconstructive Microsurgery ◽

10.1055/s-0038-1649508 ◽

2018 ◽

Vol 35 (01) ◽

pp. 008-014 ◽

Cited By ~ 5

Author(s):

Martin Lhuaire ◽

Kevin Haddad ◽

Francesco-Saverio Wirz ◽

Samah Abedalthaqafi ◽

Déborah Obadia ◽

...

Keyword(s):

Breast Reconstruction ◽

Donor Site ◽

Perforator Flap ◽

Skin Surface ◽

Complication Rates ◽

Skin Paddle ◽

Profunda Femoris Artery ◽

Flap Design ◽

Artery Perforator ◽

Profunda Femoris

Background The volume of the profunda femoris artery perforator (PAP) flap limits its indications to small- and medium-sized breast reconstructions after modified radical mastectomy for cancer. We report a modified PAP flap design, including not only a vertical extension that increases its volume but also the skin surface, which suits larger breasts requiring immediate or delayed breast reconstructions and compare the results with our horizontal skin paddle PAP flap experience. Patients and Methods In our center between November 2014 and November 2016, 51 consecutive patients underwent a PAP flap breast reconstruction following breast cancer. A retrospective analysis on the collected data was performed to compare 34 patients with a bra cup smaller than C who underwent 41 horizontal PAP flap procedures, with those (n = 17) of a bra cup greater than or equal to C who underwent 21 fleur-de-lys PAP flap procedures. Demographic, anthropometric, flap and surgical characteristics, postoperative complication rates, and hospital stay were compared between the two groups. Results The average flap weight was 480 g (range: 340–735 g) for the fleur-de-lys PAP flap group compared with 222 g (range: 187–325 g) for the horizontal PAP flap procedure (p < 0.001). The mean flap dimensions were 25 × 18 cm for the fleur-de-lys PAP flap group compared with 25 × 7 cm in the horizontal PAP flap group. No flap failure was observed in the fleur-de-lys PAP flap group compared with two flap failures secondary to venous thrombosis in the horizontal PAP flap group (NS). Three patients (14%) experienced delayed healing at the donor site compared with four patients (10%) in the horizontal PAP flap group (NS). Conclusion The fleur-de-lys skin paddle design not only allows an increase of the horizontal PAP flap volume, but also increases the skin surface, with an acceptable donor site morbidity. For medium- or large-sized breasts, the fleur-de-lys PAP flap seems to be ideal when a DIEP flap-based reconstruction is contraindicated.

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Anatomical basis of the reverse lateral plantar artery perforator flap design

Surgical and Radiologic Anatomy ◽

10.1007/s00276-015-1426-7 ◽

2015 ◽

Vol 37 (8) ◽

pp. 983-988 ◽

Cited By ~ 5

Author(s):

Lei Li ◽

Dajiang Song ◽

Heping Zheng ◽

Chunlin Hou ◽

Jian Lin ◽

...

Keyword(s):

Perforator Flap ◽

Plantar Artery ◽

Anatomical Basis ◽

Flap Design ◽

Artery Perforator

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Authors’ Reply: Pre-operative imaging of the supraclavicular artery island flap plays a vital role in the flap design

Chinese Medical Journal ◽

10.1097/cm9.0000000000001761 ◽

2021 ◽

Vol 134 (16) ◽

pp. 2015-2016

Author(s):

Jing Zhou ◽

Yi-Ming Ding ◽

Meng-Jiao Zhou ◽

Yun-Xun Kuang ◽

Ting-Yao Ma ◽

...

Keyword(s):

Vital Role ◽

Island Flap ◽

Flap Design ◽

Supraclavicular Artery Island Flap

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Do-It-Yourself Preoperative High-Resolution Ultrasound-Guided Flap Design of the Superficial Circumflex Iliac Artery Perforator Flap (SCIP)

Journal of Clinical Medicine ◽

10.3390/jcm10112427 ◽

2021 ◽

Vol 10 (11) ◽

pp. 2427

Author(s):

Daniel Schiltz ◽

Jasmin Lenhard ◽

Silvan Klein ◽

Alexandra Anker ◽

Daniel Lonic ◽

...

Keyword(s):

Iliac Artery ◽

Donor Site ◽

Perforator Flap ◽

Donor Site Morbidity ◽

Duplex Sonography ◽

Flap Design ◽

Do It Yourself ◽

Tissue Flap ◽

Simplified Procedure ◽

Artery Perforator

The superficial circumflex iliac artery perforator (SCIP) flap is a well-documented, thin, free tissue flap with a minimal donor site morbidity, and has the potential to become the new method for resurfacing moderate-size skin defects. The aim of this study is to describe an easy, reliable, systematic, and standardized approach for preoperative SCIP flap design and perforator characterization, using color-coded duplex sonography (CCDS). A list of customized settings and a straightforward algorithm are presented, which are easily applied by an operator with minimal experience. Specific settings for SCIP flap perforator evaluation were investigated and tested on 12 patients. Deep and superficial superficial circumflex iliac artery (SCIA) branches, along with their corresponding perforators and cutaneous veins, were marked individually with a permanent marker and the anatomy was verified intraoperatively. From this, a simplified procedure for preoperative flap design of the SCIP flap was developed. Branches could be localized and evaluated in all patients. A preoperative structured procedure for ultrasonically guided flap design of the SCIP flap is described. A 100% correlation between the number and emergence points of the branches detected by preoperative CCDS mapping and the intraoperative anatomy was found.

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Clinical application of pedicled thoracoacromial artery perforator flaps for tracheal reconstruction

BMC Surgery ◽

10.1186/s12893-020-00972-9 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Di Deng ◽

Feng Xu ◽

Jifeng Liu ◽

Bo Li ◽

Linke Li ◽

...

Keyword(s):

Clinical Application ◽

Cancer Metastasis ◽

Perforator Flap ◽

Island Flap ◽

Esophageal Reconstruction ◽

Perforator Flaps ◽

Tracheal Reconstruction ◽

Thoracoacromial Artery ◽

The Mean ◽

Artery Perforator

Abstract Background Large or complex trachea defects often require some tissue to reconstruct, various flaps have been reported for reconstructing this defect. However, pedicled thoracoacromial artery perforator flap have not been reported in tracheal reconstruction. Therefore, this study is to assess the efficacy and clinical application of pedicled thoracoacromial artery perforator flaps for tracheal reconstruction. Methods Eight patients who underwent tracheal reconstructions with pedicled TAAP flaps between December 2017 and October 2019 were retrospectively reviewed. Results All of the pedicled TAAP flaps in our study survived. The flap size ranged from 2 cm × 5 cm to 4 cm × 10 cm, and the size of each island of one double-island flap was 2 cm × 2.5 cm. The mean thickness was 0.6 cm, and the pedicle length varied between 6 and 9 cm (mean 7.9 cm). The mean time of flap harvest was 17 min. The mean age of the patients was 62.4 years and five elderly patients had comorbidities, such as diabetes, hypertension and asthma. One patient received a double-island flap for tracheal and esophageal reconstruction, and the other patient received simple tracheal reconstruction. One patient died due to cancer metastasis. Six patients obtained functional recovery of breathing, except one patients who did not experience closure of the tracheostomy opening due to uncompleted I131 treatment. Conclusion Pedicled TAAP flaps provide a short harvesting time, thin thickness and stable blood supply, and they do not require microsurgical skills. This flap is a good choice for the reconstruction of tracheal defects, especially in the aged or patients with comorbidities who are not able to tolerate prolonged surgery.

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