Free versus Pedicled Perforator Flaps for Lower Extremity Reconstruction: A Multicenter Comparison of Institutional Practices and Outcomes

2018 ◽  
Vol 34 (08) ◽  
pp. 572-580 ◽  
Author(s):  
Keith Koh ◽  
Terence Goh ◽  
Christopher Song ◽  
Hyun Suh ◽  
Peter Rovito ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Lower Extremity ◽  
Soft Tissues ◽  
Perforator Flap ◽  
Free Flaps ◽  
Careful Consideration ◽  
Pedicled Flap ◽  
Perforator Flaps ◽  
Body Regions ◽  
Significant Difference

Background Of all body regions, lower extremity wounds have been and remain the greatest challenge. Perforator free flaps have been accepted as a reasonable option to solve this dilemma but require the complexity of microsurgery. As a consequence, the possibility that pedicled perforator flaps could supplant even perforator free flaps has recently gained intense enthusiasm. Methods A retrospective investigation was undertaken to compare the validity for the use of perforator flaps of all types at three dissimilar institutions, that is, a university, a regional center, and a community hospital. All flaps performed in the 5-year period, 2011 to 2015, were included to allow at least 1-year follow-up before data analysis. A total of 433 free perforator flaps and 52 pedicled perforator flaps had been performed specifically for the lower extremity. Results Patient demographics, wound etiology, and comorbidities were similar for all institutions. Free flaps were more commonly needed after trauma and for chronic ulcers. Pedicled flaps were more likely an option after tumor excision. Large defects or those involving the foot were better served by free flaps. Overall success for free perforator flaps was 90.1% and for pedicled perforator flaps was 92.3%, with no significant difference noted (p = 0.606) between institutions. Peripheral vascular disease was the only significant comorbidity risk factor for both free and pedicled flap failure. Conclusion Perforator flaps in general have become a reasonable solution for soft tissue defects of the lower extremity. Following careful consideration of the etiology, dimensions, location, patient comorbidities, and presence of adequate perforators, a pedicled or free perforator flap could potentially be successful. Pedicled perforator flaps, if adequate healthy soft tissues remain adjacent to the defect, forecast a continuance of the evolution in seeking simplicity yet reliability by the best flap possible for soft tissue closure of the lower limb wound.

scholarly journals A Review of Pedicled Perforator Flaps for Reconstruction of the Soft Tissue Defects of the Leg and Foot

2019 ◽  
Vol 52 (01) ◽  
pp. 026-036 ◽  
Author(s):  
O-Wern Low ◽  
Sandeep J. Sebastin ◽  
Andre E. J. Cheah
Keyword(s):  
Soft Tissue ◽  
Lower Extremity ◽  
Surgical Techniques ◽  
Perforator Flap ◽  
Free Tissue Transfer ◽  
High Energy ◽  
Soft Tissue Defects ◽  
Perforator Flaps ◽  
Tissue Transfer ◽  
Tissue Defects

AbstractLower extremity soft tissue defects frequently result from high-energy trauma or oncological resection. The lack of suitable muscle flap options for the distal leg and foot makes defects in these locations especially challenging to reconstruct and free tissue transfer is commonly used. Another option that has become more popular in the past two decades are pedicled perforator flaps. Based on a thorough literature review and the authors’ experience on leg perforator flaps for over a decade, this article presents a historical review, the anatomical basis of common perforator flaps of the leg and foot, patient selection, wound selection, perforator selection, flap design, surgical techniques, refinements, and postoperative care. A review of the clinical outcomes and complications of these flaps was also performed and was noted to be comparable to the outcomes of free tissue transfer with significantly lower total flap failure rate. It is hoped that this review will assist surgeons in the formulation of a comprehensive step-by-step guide in performing pedicled perforator flap reconstruction of the lower extremity.

Retrospective Analysis in Lower Limb Reconstruction: Propeller Perforator Flaps versus Free Flaps

2017 ◽  
Vol 33 (S 01) ◽  
pp. S34-S39 ◽  
Author(s):  
Marta Cajozzo ◽  
Alessandro Innocenti ◽  
Massimiliano Tripoli ◽  
Giovanni Zabbia ◽  
Salvatore D'Arpa ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Retrospective Analysis ◽  
Revision Surgery ◽  
Lower Limb ◽  
Lower Extremities ◽  
Free Flaps ◽  
Soft Tissue Defects ◽  
Perforator Flaps ◽  
Hospitalization Period ◽  
Tissue Defects

Background Technical advancements and increasing experience in the management of soft tissue defects in lower extremities have led to the evolution of decisional reconstructive algorithms. Both propeller perforator flaps (PPFs) and free flaps (FFs) proved to be useful methods of reconstruction for lower extremities defects, offering alternative reconstructive tools. We present a case series of PPFs and FFs for reconstruction of lower limbs defects, analyzing and comparing treatment and outcomes. Methods Through a retrospective analysis, we report our experience in performing PPFs or FFs for reconstruction of soft tissue defects of the lower extremities, in patients admitted between 2010 and 2015 at the Department of Plastic and Reconstructive Surgery, University of Palermo. In these patients, we evaluated location and causes of defects, types of flaps used, recipient vessels, complications, time to healing, and aesthetic outcome. Results A primary healing rate was obtained in 13 patients for PPF and 16 cases for FF. Revision surgery for partial skin necrosis was required in eight cases (PPF: four and FF: four). Recovery time and hospitalization period were eventually shorter in patients with FFs, due to lower rate of complications and revision surgery. Conclusion In the past years, our indications for reconstruction with PPFs in the lower limb have become more restricted, while we favor reconstruction with FFs. Recommendations are provided to orient surgical treatment in small, medium, and large lower limb defects.

scholarly journals Being Prepared for the Next Conflict Part II: Case Analysis of a Military Level 1 Trauma Center

2020 ◽  
Vol 185 (7-8) ◽  
pp. e1235-e1239
Author(s):  
Thomas T Wood ◽  
Haydn J Roberts ◽  
Daniel J Stinner
Keyword(s):  
Soft Tissue ◽  
Lower Extremity ◽  
Trauma Center ◽  
Free Flaps ◽  
Soft Tissue Coverage ◽  
Combat Casualty ◽  
Civilian Trauma ◽  
Low Volume ◽  
Level 1 ◽  
Level 1 Trauma Center

Abstract Introduction Combat-related injuries have declined substantially in recent years as we have transitioned to a low-volume combat casualty flow era. Surgeons must remain actively committed to training for the next engagement to maintain life and limb-saving skills. Soft tissue coverage procedures were imperative to the management of complex lower extremity trauma that occurred during recent conflicts. The purpose of this study was to evaluate advanced soft tissue coverage procedures performed on the lower extremity over the previous decade on military and civilian trauma patients at a Department of Defense Level 1 trauma center to provide data that can be used to guide future training efforts. Materials and Methods The electronic surgical record system was searched for cases that utilized advanced soft tissue coverage (rotational and free flaps) to the lower extremity. The date of treatment, indication, procedure performed, and military/civilian patient designation were recorded. The data was categorized between military and civilian cases, rotational versus free flap, and indication and then charted over time. It was assessed as moving averages over a 12-month period. Statistically distinct periods were then identified. Results From January 2006 to March 2015, 132 advanced soft tissue coverage procedures were performed on the lower extremity (100 military, 32 civilian). Military soft tissue coverage data demonstrated peaks in 2007 and late 2011 to late 2012, averaging 6.5 (3.5–9.6) and 4.5 (3.2–5.8) per quarter, respectively. There were two low periods, from 2008 to mid-2010 and from mid-2012 to the end of the study, averaging 1.1 (0.6–1.6) and 1.8 (1.1–2.6) cases per quarter, respectively. Civilian procedures averaged 0.9 per quarter (0.5–1.2) throughout the study, but notably were equal to the number of military procedures by the last quarter of 2013 at 2.0 (1.2–2.8 civilian, 0.8–3.1 military). Conclusions This data supports prior identified trends in military cases correlating increased number of procedures with increased combat activity related to the conflicts in Iraq and Afghanistan in 2007 and 2011, respectively. The data showed relative stability in the numbers of civilian procedures with a slight uptrend beginning in mid-2012. A comparison after mid-2012 shows military procedures declining and civilian procedures increasing to eventually become equivalent at the end of the data collection. These trends follow previously reported data on tibia fracture fixation procedures and lower extremity amputations for the same time periods. These data demonstrate the importance of the civilian trauma mission for maintaining surgical skills relevant to limb salvage, such as rotational and free flaps, during a low-volume combat casualty flow era.

Perforator Flap Reconstruction for the Distal Third of Lower Extremity Defects: Clinical Application and Guideline Recommendation

2019 ◽  
Vol 18 (4) ◽  
pp. 376-388 ◽  
Author(s):  
Chairat Burusapat
Keyword(s):  
Lower Extremity ◽  
Perforator Flap ◽  
Lower Extremities ◽  
Advancement Flap ◽  
Guideline Recommendation ◽  
Perforator Flaps ◽  
Posterior Tibial ◽  
First Choice ◽  
Wide Range ◽  
Surgical Guidelines

A distal third of lower extremity defect is challenging for plastic surgeons. The standard for treatment is microsurgery. Recently, perforator flap has been reported for small to medium defects. The objective was to analyze the outcomes of perforator flaps for distal third of lower extremity defects and to establish surgical guidelines. A retrospective review of patients with defects in distal third of lower extremities was conducted. Patients with multiple levels of lower extremity defects were excluded. A total of 8 patients with distal third of lower extremity defects were included. Seven patients were male. Overall mean age was 35.3 (18-60) years. Patients had 3 anterior, 3 lateral, and 2 medial defects. Lateral and anterior defects in 6 patients were closed using a peroneal-based propeller perforator flap with an angle of rotation of 90° to 160°. Medial defects in 2 patients were closed using a posterior tibial-based perforator advancement flap. Three patients (37.5%) developed venous congestion. No complications occurred for patients with medial defect closure using an advancement posterior tibial-based perforator flap. No total flap loss was observed. The perforator flap provides a similar texture to the skin at recipient area and a wide range of rotation. Perforator flaps should be the first choice for defects reconstruction in distal third lower extremities. Perforator flaps can be used for small to large defects, and can be moved by propeller or advancement depending on the perforator location. A guideline for perforator flaps reconstruction of the distal third of lower extremity defects was established.

Smartphone Thermography for Lower Extremity Local Flap Perforator Mapping

2020 ◽  
Author(s):  
Nicolás Pereira ◽  
Geoffrey G. Hallock
Keyword(s):  
Lower Extremity ◽  
Hot Spots ◽  
Perforator Flap ◽  
Screening Tools ◽  
Local Flaps ◽  
Perforator Flaps ◽  
Postoperative Monitoring ◽  
Flap Design ◽  
A Prospective Study ◽  
Flap Perfusion

Abstract Background The versatile application of local perforator flaps for coverage throughout the lower extremity has already been well proven. Often a “free-style” approach has been used to design these flaps, as conventional imaging devices for perforator identification may be too expensive or unavailable. The recent adaptation of Smartphone thermal digital imaging may now prove to be a cheaper and more readily available means for identifying the requisite perforators that will sustain these local flaps. Methods Over the past year, a prospective study was undertaken of all patients having a local perforator flap for coverage of a lower extremity defect. Twenty-eight local perforator flaps involving all subtypes were utilized in 25 patients. Smartphone thermography was used in all patients preoperatively to identify preferable perforator or vascular network “hot spots” that allowed appropriate flap design. Intraoperative and postoperative monitoring was similarly done for all flaps to determine outcomes. Results All local perforator flaps were based on perforators identified using smartphone thermography. All flaps (23 or 82.1%) that the thermal digital image predicted 100% viability totally survived. Five flaps were predicted to have marginal viability, but two nevertheless survived completely while the others required only minor readjustments. Peninsular and keystone variety perforator flaps were those most commonly used.Thermography always facilitated making the correct decision as to whether a proximal- or distal-based peninsular flap would be superior. Subfascial elevation of cool spots in keystone flaps were found to be least likely to interfere with flap perfusion. Conclusion Smartphone thermography is an inexpensive and expeditious means for identification of “hot spots” that is always used by us to ensure perfusion to lower extremity perforator local flaps. This is a complementary technique for their safer design, harvest, and subsequent monitoring in conjunction with more complex screening tools as indicated.

scholarly journals An assessment of the anatomical basis of the thoracoacromial artery perforator flap

2003 ◽  
Vol 11 (1) ◽  
pp. 23-27 ◽  
Author(s):  
Christopher Robert Geddes ◽  
Maolin Tang ◽  
Daping Yang ◽  
Steven F Morris
Keyword(s):  
Head And Neck ◽  
Donor Site ◽  
Perforator Flap ◽  
Neck Region ◽  
Donor Site Morbidity ◽  
Pedicled Flap ◽  
Perforator Flaps ◽  
Thoracoacromial Artery ◽  
Lateral Thoracic Artery ◽  
Anatomical Basis

Background Musculocutaneous perforator flaps offer advantages over musculocutaneous flaps, including reduced donor site morbidity, more predictable reconstruction of soft tissue deformities, and a wider variety of flap options. Perforator flaps are becoming increasingly popular for many applications. In the present study, we set out to examine the various perforators of the thoracoacromial axis through the pectoralis major (PM) muscle with respect to their suitability for transfer to the head and neck region as a pedicled flap. Methods A series of 10 fresh cadavers were injected with lead oxide, gelatin and water (250 mL/kg) through the femoral vessels. The cadavers were cooled and the integument was removed. Perforating vessels from the underlying muscles were marked and the resulting angiograms of the integument and deep tissues were compared with the dissection notes describing the course, size and distribution of the perforating vessels. Results The perforators through the PM muscle to the overlying skin included three regional groups: perforators of the thoracoacromial axis; perforators of the medial intercostal vessels; and perforators of the lateral thoracic artery. The major group of perforators supplying the overlying skin was from the intercostal vessels. However, the thoracoacromial axis did consistently give rise to perforators in the upper portion of the PM muscle. In particular, there were reliable perforators from the clavicular and deltoid branches of the thoracoacromial artery. Discussion The present study illustrates the potential clinical applications of a series of perforator flaps based on the thoracoacromial axis, which may be useful in head and neck reconstructive surgery.

Minimally invasive soft tissue reconstruction with free peroneal artery perforator flap

2016 ◽  
Vol 2 (8) ◽  
Author(s):  
Kenji Kawamura ◽  
Hiroshi Yajima ◽  
Shohei Omokawa ◽  
Takamasa Shimizu ◽  
Naoki Maegawa ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Minimally Invasive ◽  
Donor Site ◽  
Perforator Flap ◽  
Peroneal Artery ◽  
Soft Tissue Reconstruction ◽  
Perforator Flaps ◽  
Major Vessel ◽  
Tissue Reconstruction ◽  
Artery Perforator

<p> </p><p><span style="font-family: Times New Roman;"> The development of a concept of perforator flap has dramatically changed the soft tissue reconstructive surgery. The surgery with perforator flaps enables to minimize donor-site morbidity by preserving important tissues including the muscle and the major vessel. The peroneal artery perforator flap is one of perforator flaps that can be harvested from the lower leg. The peroneal artery perforator flap has been widely used as a local flap for soft tissue reconstruction in the lower extremity; however, the free peroneal artery perforator flap transfer has been little reported. Utilities of the free peroneal artery perforator flap for soft tissue reconstruction of the extremities are reported, and minimally invasive flap surgery with perforator flaps is reviewed.</span></p><p> </p>

Reconstruction of soft tissue and bone defects in lower extremity with free flaps

Microsurgery ◽  
1998 ◽  
Vol 18 (3) ◽  
pp. 176-181 ◽  
Author(s):  
Ibrahim Kaplan ◽  
Sait Ada ◽  
Fuat Özerkan ◽  
Arslan Bora ◽  
Yalçin Ademoglu
Keyword(s):  
Soft Tissue ◽  
Lower Extremity ◽  
Free Flaps ◽  
Bone Defects

scholarly journals Propeller perforator flaps from the dorsal digital artery perforator chain for repairing soft tissue defects of the finger

BMC Surgery ◽  
2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Haoliang Hu ◽  
Hong Chen ◽  
Jinjiong Hong ◽  
Weisheng Mao ◽  
Mintao Tian ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Perforator Flap ◽  
Width Ratio ◽  
Digital Artery ◽  
Soft Tissue Defects ◽  
Clinical Trial Registry ◽  
Perforator Flaps ◽  
And Function ◽  
Artery Perforator ◽  
Tissue Defects

Abstract Background When restoring the appearance and function of the fingers, hand surgeons face a challenge in choosing a suitable surgical method to repair finger skin defects. Methods In this study, we designed a long elliptical flap based on a propeller perforator flap and located slightly toward the dorsal lateral aspect of the finger. The flap with a pedicle consisting of the dorsal perforator of the distal digital artery and dorsal digital artery perforator chain is rotated to cover a large wound on the distal end. From December 2014 to December 2017, 10 patients with finger soft tissue defects were treated with the propeller perforator flap described in this study. Results All flaps survived after surgery, and 2 had a transient venous congestion. After a follow-up period of 3 to 12 months, the static two-point discrimination of the flap was 8.06 ± 1.75 mm, and the range of motion was 149.4 ± 12.9°. This designed flap can span several angiosomes supplied by the perforators. Due to the inclusion of a vessel chain between the dorsal digital artery perforators, the length-to-width ratio of the flap can be up to 3:1. Conclusions This technique increases the size of flap that can be harvested safely while retaining a reliable blood supply. The present study describes a new method for repairing soft tissue defects of the finger by using the technique of propeller perforator flaps based on dorsal digital artery perforator chains. Trial registration The registration number of this study is ChiCTR1800014588; it has been retrospectively registered with Chinese Clinical Trial Registry (chictr.org.cn), 18/11/2019.

scholarly journals Development of a model of soft tissue simulation using ballistic gelatin for CBCT acquisitions related to dentomaxillofacial radiology research

2020 ◽  
pp. 20200191
Author(s):  
Eduarda Helena Leandro Nascimento ◽  
Rocharles Cavalcante Fontenele ◽  
Priscila de Azeredo Lopes ◽  
Gustavo Machado Santaella ◽  
Karla Faria Vasconcelos ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Gold Standard ◽  
Soft Tissues ◽  
Cone Beam Ct ◽  
Acrylic Resin ◽  
Standard Group ◽  
Significant Difference ◽  
New Material ◽  
Ballistic Gelatin ◽  
The Mean

Objectives: To present the ballistic gelatin as a new material capable of simulating the soft tissues in cone-beam CT (CBCT) images. Methods: CBCT images of three piglet heads were acquired with their soft tissues intact (standard group). Subsequently, the piglet heads were fixed in a container using metallic pins and moulded with acrylic resin; the soft tissues were then removed and replaced by ballistic gelatin, with the same thickness of the original soft tissues. The images were evaluated by two oral radiologists, to check the adaptation on bone surfaces, thickness and density, penetration into large bone cavities and cancellous bone, and the presence of air bubbles using a 5-score scale. Additionally, an objective analysis was carried out by one oral radiologist. For each CBCT scan, three axial reconstructions were selected to represent the mandibular, occlusal, and maxillary levels. The mean and standard deviation (SD) of the grey values were calculated in four regions of interest determined on soft tissue areas and compared by two-way ANOVA. Results: The ballistic gelatin showed subjective scores ranging from good to excellent for all parameters evaluated. There was no significant difference in the mean and SD values of the grey values between ballistic gelatin and the gold standard groups for all levels (p > 0.05). Higher SD values were observed in the occlusal level for both groups (p < 0.05). Conclusions: Ballistic gelatin has visual and objective similarity with the gold standard. Thus, the ballistic gelatin is a promising material capable of simulating soft tissues in CBCT images.

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