Pedicled perforator flaps

DEFF Research Database (Denmark)

Demirtas, Yener; Ozturk, Nuray; Kelahmetoglu, Osman

2009-01-01

Described in this study is a surgical concept that supports the "consider and use a pedicled perforator flap whenever possible and indicated" approach to reconstruct a particular skin defect. The operation is entirely free-style; the only principle is to obtain a pedicled perforator flap...... to reconstruct the defect. The perforators are marked with a hand-held Doppler probe and multiple flaps are designed. The appropriate flap is elevated after identifying the perforator(s). Dissection of the perforator(s) or complete incision of the flap margins are not mandatory if the flap is mobilized...... adequately to cover the defect. Defects measuring 3 x 3 cm up to 20 x 20 cm at diverse locations were successfully reconstructed in 20 of 21 patients with 26 flaps. Pedicled perforator flaps offer us reliable and satisfactory results of reconstruction at different anatomic territories of the body. It sounds...

Large-Scale Skin Resurfacing of the Upper Extremity in Pediatric Patients Using a Pre-Expanded Intercostal Artery Perforator Flap.

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Wei, Jiao; Herrler, Tanja; Gu, Bin; Yang, Mei; Li, Qingfeng; Dai, Chuanchang; Xie, Feng

2018-05-01

The repair of extensive upper limb skin lesions in pediatric patients is extremely challenging due to substantial limitations of flap size and donor-site morbidity. We aimed to create an oversize preexpanded flap based on intercostal artery perforators for large-scale resurfacing of the upper extremity in children. Between March 2013 and August 2016, 11 patients underwent reconstructive treatment for extensive skin lesions in the upper extremity using a preexpanded intercostal artery perforator flap. Preoperatively, 2 to 4 candidate perforators were selected as potential pedicle vessels based on duplex ultrasound examination. After tissue expander implantation in the thoracodorsal area, regular saline injections were performed until the expanded flap was sufficient in size. Then, a pedicled flap was formed to resurface the skin lesion of the upper limb. The pedicles were transected 3 weeks after flap transfer. Flap survival, complications, and long-term outcome were evaluated. The average time of tissue expansion was 133 days with a mean final volume of 1713 mL. The thoracoabdominal flaps were based on 2 to 6 pedicles and used to resurface a mean skin defect area of 238 cm ranging from 180 to 357 cm. In all cases, primary donor-site closure was achieved. Marginal necrosis was seen in 5 cases. The reconstructed limbs showed satisfactory outcome in both aesthetic and functional aspects. The preexpanded intercostal artery perforator flap enables 1-block repair of extensive upper limb skin lesions. Due to limited donor-site morbidity and a pedicled technique, this resurfacing approach represents a useful tool especially in pediatric patients.

[APPLICATION OF V-Y ADVANCED SENSE-REMAINED POSTERIOR TIBIAL ARTERY PERFORATOR FLAP IN REPAIRING WOUND AROUND ANKLE].

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Tang, Xiujun; Wang, Bo; Wei, Zairong; Wang, Dali; Han, Wenjie; Zhang, Wenduo; Li, Shujun

2015-12-01

OBJECTIVE To explore the feasibility and effectiveness of V-Y advanced sense-remained posterior tibial artery perforator flap in repairing wound around the ankle. METHODS Between March 2012 and January 2015, 11 patients with wounds around the ankle were treated by V-Y advanced sense-remained posterior tibial artery perforator flap. There were 6 males and 5 females with a median age of 37 years (range, 21-56 years). The causes were traffic accident injury in 3 cases, thermal injury in 2 cases, burn in 2 cases, iatrogenic wounds in 2 cases, and local contusion in 2 cases. The disease duration ranged from 1 to 3 weeks (mean, 2 weeks). Injury was located at the medial malleolus in 4 cases, at the lateral malleolus in 3 cases, and at the heel in 4 cases. All had exposure of bone, tendon, or plate. The defect area ranged from 4 cmx2 cm to 5 cmx3 cm; the area of the flap ranged from 11 cmx4 cm to 15 cmx6 cm. Necrosis of distal flap occurred in 1 case after operation; re-operation to amputate the posterior tibial artery was given and the wound was repaired by proximal skin graft. Light necrosis of distal end was observed in 2 cases, and wound healed at 3 weeks after dressing. And other flaps successfully survived, and primary healing of wounds were obtained. The patients were followed up 6-24 months (mean, 11 months). The flaps were good in color, texture, and appearance. The ankle joint had normal activity. At last follow-up, 10 cases restored fine sense, and 1 case restored protective feeling with posterior tibial artery advanced flap after amputation. V-Y advanced sense-remained posterior tibial artery perforator flap has the advantages of reliable blood supply, simple operation, good appearance, and sensory recovery. Therefore, it is an ideal method to repair wound around the ankle.

Perforator anatomy of the radial forearm free flap versus the ulnar forearm free flap for head and neck reconstruction.

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Hekner, D D; Roeling, T A P; Van Cann, E M

2016-08-01

The aim of this study was to investigate the vascular anatomy of the distal forearm in order to optimize the choice between the radial forearm free flap and the ulnar forearm free flap and to select the best site to harvest the flap. The radial and ulnar arteries of seven fresh cadavers were injected with epoxy resin (Araldite) and the perforating arteries were dissected. The number of clinically relevant perforators from the radial and ulnar arteries was not significantly different in the distal forearm. Most perforators were located in the proximal half of the distal one third, making this part probably the safest location for flap harvest. Close to the wrist, i.e. most distally, there were more perforators on the ulnar side than on the radial side. The ulnar artery stained 77% of the skin surface area of the forearm, showing the ulnar forearm free flap to be more suitable than the radial forearm free flap for the restoration of large defects. Copyright © 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Ten-year experience of superior gluteal artery perforator flap for reconstruction of sacral defects in Tri-Service General Hospital

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Chin-Ta Lin

2014-01-01

Full Text Available Background: Despite advances in reconstruction techniques, sacral sores continue to present a challenge to the plastic surgeon. The superior gluteal artery perforator (SGAP flap is a reliable flap that preserves the entire contralateral side as a future donor site. On the ipsilateral side, the gluteal muscle itself is preserved and all flaps based on the inferior gluteal artery are still possible. However, the dissection of the perforator is tedious and carries a risk of compromising the perforator vessels. Patients and Methods: During the period between April 2003 and March 2013, 30 patients presented to our section with sacral wounds causing by pressure sores or infected pilonidal cysts. Of a total of 30 patients, 13 were female and 17 were male. Their ages ranged from 22 to 92 years old (mean 79.8 years old. Surgical intervention was performed electively with immediate or delayed reconstruction using a SGAP flap. The characteristics of patients′ age, and sex, and cause of sacral defect, co-morbidities, wound culture, flap size, perforator number, hospital stay, and outcome were reviewed. Results: For all operations, the length of the pedicle dissection will not exceed 1 cm because of the vascular anatomy of the SGAP, which lies adjacent to the sacral region. Due to short pedicle dissection, all SGAP flap were elevated around an hour. All flaps survived except two, which had partial flap necrosis and were finally treated by contralateral V-Y advancement flaps coverage. The mean follow-up period was 14.8 months (range 3-24. No flap surgery-related mortality was found. Conclusion: Perforator-based flaps have become popular in modern reconstructive surgery because of low donor site morbidity and good preservation of muscle. Our study shows that deep pedicle dissection is unnecessary when the surgery involves an accurate indicating perforator, adequate flap size design, and correct selection of flap utilization between tunnel and rotation. The

Parasacral Perforator Flaps for Reconstruction of Sacral Pressure Sores.

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Lin, Chin-Ta; Chen, Shih-Yi; Chen, Shyi-Gen; Tzeng, Yuan-Sheng; Chang, Shun-Cheng

2015-07-01

Despite advances in reconstruction techniques, pressure sores continue to present a challenge to the plastic surgeon. The parasacral perforator flap is a reliable flap that preserves the entire contralateral side as a future donor site. On the ipsilateral side, the gluteal muscle itself is preserved and all flaps based on the inferior gluteal artery are still possible. We present our experience of using parasacral perforator flaps in reconstructing sacral defects. Between August 2004 and January 2013, 19 patients with sacral defects were included in this study. All the patients had undergone surgical reconstruction of sacral defects with a parasacral perforator flap. The patients' sex, age, cause of sacral defect, flap size, flap type, numbers of perforators used, rotation angle, postoperative complications, and hospital stay were recorded. There were 19 parasacral perforator flaps in this series. All flaps survived uneventfully except for 1 parasacral perforator flap, which failed because of methicillin-resistant Staphylococcus aureus infection. The overall flap survival rate was 95% (18/19). The mean follow-up period was 17.3 months (range, 2-24 months). The average length of hospital stay was 20.7 days (range, 9-48 days). No flap surgery-related mortality was found. Also, there was no recurrence of sacral pressure sores or infected pilonidal cysts during the follow-up period. Perforator-based flaps have become popular in modern reconstructive surgery because of low donor-site morbidity and good preservation of muscle. Parasacral perforator flaps are durable and reliable in reconstructing sacral defects. We recommend the parasacral perforator flap as a good choice for reconstructing sacral defects.

The posterolateral mid-forearm perforator flap: anatomical study and clinical application.

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Zhuang, Yue-Hong; Lin, Jian; Fu, Fei-Huan; Cai, Zhen-De; Huang, Hui-Mei; Zheng, He-Ping

2013-11-01

Defects sustained at the distal forearm are common and pedicled perforator flaps have unique advantages in resurfacing it. The purpose of this study is to reappraise the anatomy of the perforator in the posterolateral aspect of the mid-forearm and present our clinical experience on using perforator flaps based on it for reconstruction of defects in the distal forearm. This study was divided into anatomical study and clinical application. In the anatomical study, 30 preserved upper limbs were used. Clinically, 11 patients with defects at the forearm underwent reconstruction with the posterolateral mid-forearm perforator flaps. The defects, ranging from 4.5 × 2.5 cm to 10.5 × 4.5 cm, were located at the dorsal aspect of the distal forearm in 6 cases and at the volar aspect of the distal forearm in 5 cases. Three patterns of the perforator were observed in the posterolateral aspect of the mid-forearm, which originated from the posterior interosseous artery, the proximal segment of the radial artery or the radial recurrent artery, and the middle segment of the radial artery, respectively. The perforator was located 11.8 ± 0.2 cm to 15.8 ± 0.4 cm inferior to the lateral humeral epicondyle. Clinically, flaps in 8 cases survived uneventfully, while the other 3 cases suffered mild marginal epidermal necrosis, which was cured with continuous dress changing. The location of the perforator at the posterolateral aspect of the mid-forearm is consistent; the posterolateral mid-forearm perforator flap is particularly suitable to cover defects in the distal one-third of the forearm. Copyright © 2013 Wiley Periodicals, Inc.

The Versatile Modiolus Perforator Flap

DEFF Research Database (Denmark)

Gunnarsson, Gudjon Leifur; Thomsen, Jorn Bo

2016-01-01

BACKGROUND: Perforator flaps are well established, and their usefulness as freestyle island flaps is recognized. The whereabouts of vascular perforators and classification of perforator flaps in the face are a debated subject, despite several anatomical studies showing similar consistency. In our...... experience using freestyle facial perforator flaps, we have located areas where perforators are consistently found. This study is focused on a particular perforator lateral to the angle of the mouth; the modiolus and the versatile modiolus perforator flap. METHODS: A cohort case series of 14 modiolus...... perforator flap reconstructions in 14 patients and a color Doppler ultrasonography localization of the modiolus perforator in 10 volunteers. RESULTS: All 14 flaps were successfully used to reconstruct the defects involved, and the location of the perforator was at the level of the modiolus as predicted...

Anatomical basis of the lateral superior gluteal artery perforator (LSGAP) flap and role in bilateral breast reconstruction.

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Fade, Geraldine; Gobel, Fabienne; Pele, Eric; Chaput, Benoit; Garrido, Ignacio; Pinsolle, Vincent; Pelissier, Philippe; Sinna, Raphael

2013-06-01

Deep inferior epigastric perforator (DIEP) flap is one of the gold standards in autologous breast reconstruction. When the abdominal tissue is not available, the superior gluteal artery perforator (SGAP) is often a second option with its drawback, especially the donor-site deformity. Reports have highlighted that a higher and more lateral SGAP flap can be harvested to overcome several drawbacks of the classical SGAP, allowing in the same procedure a body-contouring procedure. In order to set the anatomical basis of this flap, we proposed to study the characteristics of a reliable and easily identifiable superior and lateral perforator of the superior gluteal artery (lateral SGAP (LSGAP)) situated in the region of the lower body-lift resection allowing to perform bilateral breast reconstruction at the same time. The anatomical study of 50 scans (or 100 buttocks) allows us to set forth a diagnostic assumption on the localisation of the perforator with respect to osseous landmarks (coccyx, iliac crest and great trochanter) which will be verified during the dissection of 10 cadavers (or 20 buttocks) and during the 20 colour Doppler examination (or 40 buttocks). In our computed tomography (CT) scan study, in 96% of cases, the perforator was situated in a circle with a radius≤3 cm with a 95% confidence interval and located at the junction of the proximal third-middle third of the distance summit of the posterior iliac crest (point B), most lateral point of the greater trochanter (point C). This assumption was verified by the cadaveric dissection and in vivo studies. Our study sets the anatomical landmarks of the LSGAP flap. This option allows the raising of an SGAP flap avoiding the main drawbacks of this flap and allows harvesting a flap with the tissue that is often discarded during the body-lift procedure. Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Use of inferior gluteal artery and posterior thigh perforators in management of ischial pressure sores with limited donor sites for flap coverage.

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Unal, Cigdem; Ozdemir, Jale; Yirmibesoglu, Oktay; Yucel, Ergin; Agir, Hakan

2012-07-01

Reconstructive surgery for ischial pressure sore defects presents a challenge because of high rates of recurrence. The aim of this study was to describe the use of inferior gluteal artery (IGA) and posterior thigh perforators in management of ischial pressure sores with limited donor sites. Between September 2005 and 2009, 11 patients (9 male, 2 female) with ischial sores were operated by using IGA and posterior thigh perforator flaps. The data of patients included age, sex, cause of paraplegia, flap size, perforator of flap, previous surgeries, recurrences, complications, and postoperative follow-up. Nine IGA and 5 posterior thigh perforator flaps were used. Six patients presented with recurrent lesions, 5 patients were operated for sacral and contralateral ischial pressure sores previously. In 2 patients, IGA and posterior thigh perforator flaps were used in combination. Patients were followed for an average of 34.3 months. In 2 recurrent cases, readvancement of IGA perforator flap and gluteus maximus myocutaneous flap were treatment of choice. Treatment of patients with recurrent lesions or multiple pressure sores is challenging because of limited available flap donor sites. In this study, posterior thigh perforator flaps were preferred in patients in whom the previous donor site was the gluteal region. IGA perforator flaps were the treatment of choice in patients for whom posterior thigh region was previously used. Alternately, preserved perforators of previous conventional myocutaneous flaps enabled us to use these perforators in recurrences.

Perforator anatomy of the ulnar forearm fasciocutaneous flap.

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Mathy, Jon A; Moaveni, Zachary; Tan, Swee T

2012-08-01

The ulnar forearm fasciocutaneous flap (UFFF) is a favourable alternative to the radial forearm flap when thin and pliable tissue is required. The precise anatomy of the cutaneous perforators of UFFF has not been previously reported. The position of cutaneous perforators>0.5 mm was recorded while raising 52 consecutive free UFFFs in 51 patients at our Centre. Three (6%) UFFFs in two patients demonstrated direct cutaneous supply through a superficial ulnar artery, a known anatomic variance. There was no cutaneous perforator>0.5 mm in one flap. Among the remaining 48 dissections, an average of 3 (range, 1-6) cutaneous perforators were identified. Ninety-four percent of these forearms demonstrated at least one perforator>0.5 mm within 3 cm, and all had at least one perforator within 6 cm of the midpoint of the forearm. Proximal perforators were more likely to be musculo-cutaneous through the edge of flexor carpi ulnaris or flexor digitorum superficialis, while mid- to distal perforators were septo-cutaneous. UFFF skin paddle designed to overlie an area within 3 cm of the midpoint between the medial epicondyle and the pisiform is most likely to include at least one cutaneous perforator from the ulnar artery, without a need for intra-operative skin island adjustment. This novel anatomic finding and other practical generalisations are discussed to facilitate successful elevation of UFFF. Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Novel use of a supraclavicular transverse cervical artery customised perforator flap: a paediatric emergency.

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Dolan, R T

2013-08-01

Perforation of the piriform fossa is a rare, potentially life-threatening paediatric emergency. Prompt diagnosis and early operative intervention is key to patient survival, yet restoring aerodigestive continuity can pose a significant reconstructive challenge. A seven-month old baby girl presented to an emergency department acutely unwell with a twenty-four-hour history of haemoptysis, cough and worsening respiratory distress. A contrast swallow demonstrated extension of contrast into the retropharyngeal region necessitating immediate surgical intervention. A 3.0 cm×1.0 cm perforation within the left posterolateral piriform fossa was identified. The defect was repaired with a supraclavicular transverse cervical artery customised perforator flap. This was inset into the piriform fossa luminal defect as a life-saving procedure. Following a stormy post-operative course, the child was discharged home on day 28 of admission and admitted electively 6 weeks later for division of flap pedicle. This case highlights the novel use of this fasciocutaneous island flap to reconstruct an extensive, potentially fatal, piriform fossa defect in an acute paediatric setting. This simple flap design offers timely mobilisation, reliable blood supply, adequate tenuity and surface area, to reconstruct this extensive defect as a life-saving intervention in a profoundly septic child.

Intraoperative indocyanine green fluorescent angiography-assisted modified superior gluteal artery perforator flap for reconstruction of sacral pressure sores.

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Chang, Chun-Kai; Wu, Chien-Ju; Chen, Chun-Yu; Wang, Chi-Yu; Chu, Tzi-Shiang; Hsu, Kuo-Feng; Chiu, Han-Ting; Liu, Hung-Hui; Chou, Chang-Yi; Wang, Chih-Hsin; Lin, Chin-Ta; Dai, Niann-Tzyy; Tzeng, Yuan-Sheng

2017-12-01

Pressure sores are often observed in patients who are bedridden. They can be a severe problem not only for patients and their caregivers but also for plastic surgeons. Here, we describe a new method of superior gluteal artery perforator flap harvesting and anchoring with the assistance of intraoperative indocyanine green fluorescent angiography. In this report, we describe the procedure and outcomes for 19 patients with grades III and IV sacral pressure sores who underwent the operation between September 2015 and November 2016. All flaps survived, and two experienced wound-edge partial dehiscence. With the assistance of this imaging device, we were able to acquire a reliable superior gluteal artery perforator flap and perform modified operations with it that are safe, easy to learn and associated with fewer complications than are traditional. © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd.

The freestyle pedicle perforator flap

DEFF Research Database (Denmark)

Gunnarsson, Gudjon Leifur; Jackson, Ian T; Westvik, Tormod S

2015-01-01

BACKGROUND: Perforating vessels are a consistent anatomical finding and well described in the current literature. Any skin flap can be raised on a subcutaneous pedicle as long as it contains at least one supplying perforator. Perforator flaps have been interlinked with microsurgery and generally...... not widely performed by the general plastic surgeons. The aim of this paper is to present the simplicity of pedicled perforator flap reconstruction of moderate-sized defects of the extremities and torso. METHODS: We retrospectively reviewed the charts of 34 patients reconstructed using 34 freestyle pedicled...... perforator flaps for moderate-sized defects of the truncus and extremities. We registered indications, flap size and localization, success rate, and complications. Most importantly, we describe a simple approach to the design of freestyle pedicled perforator flaps and elaborate on technical aspects...

Using perforators as recipient vessels (supermicrosurgery) for free flap reconstruction of the knee region.

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Hong, Joon Pio; Koshima, Isao

2010-03-01

The purpose of this article is to evaluate the feasibility of a perforator as a recipient vessel to reconstruct soft tissue defects of the knee region.From December of 2006 to August of 2008, total of 25 patients underwent reconstructive procedure using either an anterolateral thigh or an upper medial thigh perforator flap. The flaps were anastomosed in a perforator to perforator manner using supermicrosurgery technique.Minimum of 3 perforators were traced around the knee defect. All flaps survived attached to a recipient perforator with artery diameter ranging from 0.4 to 0.9 mm and accompanying veins ranging from 0.4 to 1.2 mm. This approach allowed reduction in time for pedicle and recipient vessel dissection and minimized the trauma involved during isolation of the vessels.Using the perforator as recipient vessel allows an increase in selection for choice of recipient. By using a perforator as recipient, less time is consumed to secure the vessel, does not need long pedicles for flap, is not bound by the condition of major arteries, and minimizes any risk for major vessel injury while having acceptable flap survival.

[The sural medial perforator flap: Anatomical bases, surgical technique and indications in head and neck reconstruction].

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Struk, S; Schaff, J-B; Qassemyar, Q

2018-04-01

The medial sural artery perforator (MSAP) flap is defined as a thin cutaneo-adipose perforator flap harvested on the medial aspect of the leg. The aims of this study were to describe the anatomical basis as well as the surgical technique and discuss the indications in head and neck reconstructive surgery. We harvested 10 MSAP flap on 5 fresh cadavers. For each case, the number and the location of the perforators were recorded. For each flap, the length of pedicle, the diameter of source vessels and the thickness of the flap were studied. Finally, we performed a clinical application of a MSAP flap. A total of 23 perforators with a diameter superior than 1mm were dissected on 10 legs. The medial sural artery provided between 1 and 4 musculocutaneous perforators. Perforators were located in average at 10.3cm±2cm from the popliteal fossa and at 3.6cm±1cm from the median line of the calf. The mean pedicle length was 12.1cm±2.5cm. At its origin, the source artery diameter was 1.8mm±0.25mm and source veins diameters were 2.45mm±0.9mm in average. There was no complication in our clinical application. This study confirms the reliability of previous anatomical descriptions of the medial sural artery perforator flap. This flap was reported as thin and particularly adapted for oral cavity reconstruction and for facial or limb resurfacing. Sequelae might be reduced as compared to those of the radial forearm flap with comparable results. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Facial reconstruction with a unique osteomyocutaneous DCIA perforator flap variant: a case report.

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Wechselberger, G; Schwaiger, K; Hachleitner, J; Oberascher, G; Ensat, F; Larcher, L

Anatomical variance of the deep circumflex iliac artery is of high clinical value in facial reconstruction using a deep circumflex iliac artery perforator (DCIAP) flap. We present the case of a 76-year-old woman treated with an osteomyocutaneous DCIAP flap variant for facial reconstruction. We also review here the literature on DCIA perforator flaps and the different anatomical variances, which might bring clinical benefits. The observed anatomy in our patient offered the possibility to raise a free flap variant with high mobility of a large skin paddle and a long vascular pedicle combined with a variable osteomuscular portion. The characteristics of the flap thus raised help overcome the disadvantages of the conventional DCIAP flap and offer excellent options for facial reconstruction.

Immediate Bilateral Breast Reconstruction with Unilateral Deep Superior Epigastric Artery and Superficial Circumflex Iliac Artery Flaps

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Keith S. Hansen

2016-09-01

Full Text Available Autologous breast reconstruction utilizing a perforator flap is an increasingly popular method for reducing donor site morbidity and implant-related complications. However, aberrant anatomy not readily visible on computed tomography angiography is a rare albeit real risk when undergoing perforator flap reconstruction. We present an operative case of a patient who successfully underwent a bilateral breast reconstruction sourced from a unilateral abdominal flap divided into deep superior epigastric artery and superficial circumflex iliac artery flap segments.

Anatomical study of terminal peroneal artery perforators and their clinical applications

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Rajendran Purushothaman

2013-01-01

Full Text Available Introduction: Peroneal artery gives off plenty of perforators that pass through fascial septum to supply skin and tenosynovium of peroneal muscles. Aim: The aim of this study was to study the anatomical basis of perforators from terminal part of peroneal artery axiality and to make use of this knowledge in reconstructing defects of posterior heel with the advantage of reducing the morbidity of conventional flaps. Materials and Methods: Our study was conducted at Department of Plastic surgery, Madras Medical College and Rajiv Gandhi Government General Hospital, India. We have carried out eleven cadaver dissections (from six cadavers-four fresh cadavers and two preserved cadavers and delineated all septocutaneous and septosynovial perforators of distal peroneal axis and studied their relation with short saphenous vein (SSV and sural nerve. Using this anatomical knowledge we have fashioned perforator based flaps in 13 patients (three propeller, four V-Y advancement, six tenosynovial flaps for reconstruction of defects over tendo achilles and pericalcaneal region . Results: In all cases, SSV and sural nerve were preserved and donor site was closed primarily. No total flap loss was noted. Conclusion: Perforator based flaps from distal most part of peroneal artery provide a good and reliable method for reconstruction of pericalcaneal and tendo achilles region defects with preservation of SSV and sural nerve. It also avoids contour deformity of the grafted donor site of the classical lateral calcaneal artery axial flap.

Pre-operative CT angiography and three-dimensional image post processing for deep inferior epigastric perforator flap breast reconstructive surgery.

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Lam, D L; Mitsumori, L M; Neligan, P C; Warren, B H; Shuman, W P; Dubinsky, T J

2012-12-01

Autologous breast reconstructive surgery with deep inferior epigastric artery (DIEA) perforator flaps has become the mainstay for breast reconstructive surgery. CT angiography and three-dimensional image post processing can depict the number, size, course and location of the DIEA perforating arteries for the pre-operative selection of the best artery to use for the tissue flap. Knowledge of the location and selection of the optimal perforating artery shortens operative times and decreases patient morbidity.

Enhanced Preoperative Deep Inferior Epigastric Artery Perforator Flap Planning with a 3D-Printed Perforasome Template: Technique and Case Report.

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Chae, Michael P; Hunter-Smith, David J; Rostek, Marie; Smith, Julian A; Rozen, Warren Matthew

2018-01-01

Optimizing preoperative planning is widely sought in deep inferior epigastric artery perforator (DIEP) flap surgery. One reason for this is that rates of fat necrosis remain relatively high (up to 35%), and that adjusting flap design by an improved understanding of individual perforasomes and perfusion characteristics may be useful in reducing the risk of fat necrosis. Imaging techniques have substantially improved over the past decade, and with recent advances in 3D printing, an improved demonstration of imaged anatomy has become available. We describe a 3D-printed template that can be used preoperatively to mark out a patient's individualized perforasome for flap planning in DIEP flap surgery. We describe this "perforasome template" technique in a case of a 46-year-old woman undergoing immediate unilateral breast reconstruction with a DIEP flap. Routine preoperative computed tomographic angiography was performed, with open-source software (3D Slicer, Autodesk MeshMixer and Cura) and a desktop 3D printer (Ultimaker 3E) used to create a template used to mark intra-flap, subcutaneous branches of deep inferior epigastric artery (DIEA) perforators on the abdomen. An individualized 3D printed template was used to estimate the size and boundaries of a perforasome and perfusion map. The information was used to aid flap design. We describe a new technique of 3D printing a patient-specific perforasome template that can be used preoperatively to infer perforasomes and aid flap design.

Reconstruction of hand contracture by reverse ulnar perforator flap

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Cengiz Eser

2016-04-01

Full Text Available Hand burn scar contractures affect patients in aesthetic and functional aspects. After releasing these scars, the defects should be repaired. The reconstruction methods include primary suturation, Z plasty, skin grafting, local or free flaps, etc. All methods have their own advantages and disadvantages. One of the most useful flaps is the reverse ulnar perforator flap. We performed a two-staged procedure for repairing a post-burn contracture release defect in a 40-year-old male. In the first stage we applied reverse ulnar perforator flap for the hand defect, and ulnar artery and vein repair in the second stage. In conclusion, this two-staged procedure is a non-primary but useful option for hand and finger defects and prevents major vascular structure damage of the forearm. [Hand Microsurg 2016; 5(1.000: 40-43

The Use of Magnetic Resonance Imaging in Planning a Pedicled Perforator Flap for Pressure Sores in the Gluteal Region.

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Park, Sun-June; Lee, Kyeong-Tae; Jeon, Byung-Joon; Woo, Kyong-Je

2018-04-01

Pedicled perforator flaps (PPFs) have been widely used to treat pressure sores in the gluteal region. Selection of a reliable perforator is crucial for successful surgical treatment of pressure sores using PPFs. In this study, we evaluate the role of magnetic resonance imaging (MRI) in planning PPF reconstruction of pressure sores in the gluteal region. A retrospective chart review was performed in patients who had undergone these PPF reconstructions and who had received preoperative MRI. Preoperatively, the extent of infection and necrotic tissue was evaluated using MRI, and a reliable perforator was identified, considering the perforator location in relation to the defect, perforator size, and perforator courses. Intraoperatively, the targeted perforator was marked on the skin at the locations measured on the MRI images, and the marked location was confirmed using intraoperative handheld Doppler. Superior gluteal artery, inferior gluteal artery, or parasacral perforators were used for the PPFs. Surgical outcomes were evaluated. A total of 12 PPFs were performed in 12 patients. Superior gluteal artery perforator flaps were performed in 7 patients, inferior gluteal artery perforator flaps were performed in 3 patients, and parasacral perforator flaps were performed in 2 patients. We could identify a reliable perforator on MRI, and it was found at the predicted locations in all cases. There was only one case of partial flap necrosis. There was no recurrence of the pressure sores during the mean follow-up period of 6.7 months (range = 3-15 months). In selected patients with gluteal pressure sores, MRI is a suitable means for not only providing information about disease extent and comorbidities but also for evaluating perforators for PPF reconstructions.

Inferior gluteal artery perforator flap: a viable alternative for ischial pressure sores.

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Kim, Young Seok; Lew, Dae Hyun; Roh, Tai Suk; Yoo, Won Min; Lee, Won Jai; Tark, Kwan Chul

2009-10-01

The ischial area is by far the most common site for pressure sores in wheelchair-bound paraplegic patients, because most of the pressure of the body is exerted on this area in the seated position. Even after a series of successful pressure sore treatments, the site is very prone to relapse from the simplest everyday tasks. Therefore, it is crucial to preserve the main pedicle during primary surgery. Several surgical procedures, such as myocutaneous flap and perforator flap, have been introduced for the treatment of pressure sores. During a 4-year time period at our institute, we found favourable clinical results using the inferior gluteal artery perforator (IGAP) procedure for ischial sore treatment. A total of 23 patients (20 males and three females) received IGAP flap surgery in our hospital from January 2003 to January 2007. Surgery was performed on the same site again in 10 (43%) patients who had originally relapsed after undergoing the conventional method of pressure sore surgery. The average age of patients was 47.4 years (range 26-71 years). Most of the patients were paraplegic (16 cases, 70%) and others were either quadriplegic (four cases, 17%) or ambulatory (three cases, 13%). Based on hospital records and clinical photographs, we attempted to assess the feasibility and practicability of the IGAP flap procedure through comparative analysis of several parameters including the size of the defective area, treatment modalities, relapses, complications, and postoperative treatments. The average follow-up duration for 23 subjects was 25.4 months (range 5-42 months). All flaps survived without major complications. Partial flap necrosis developed in one case but secondary healing was achieved and the final outcome was not impaired. Most of the cases healed well during the follow-up period. Postoperative complications such as wound dehiscence and fistula developed in some subjects, but all healed well with a secondary treatment. A total of five cases relapsed

[Reconstruction of ankle and foot with combination of free perforator flaps and skin graft].

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Yin, Lu; Gong, Ketong; Yin, Zhonggang; Zhang, Bo; Xu, Jianhua

2017-03-01

To evaluate the clinical outcomes of free perforator flaps combined with skin graft for reconstruction of ankle and foot soft tissue defects. Between June 2014 and October 2015, 20 cases of ankle and foot soft tissue defects were treated. There were 16 males and 4 females, aged from 19 to 61 years (mean, 43.3 years). Injury was caused by traffic accident in 7 cases, by crashing in 9 cases, and machine twist in 4 cases. The locations were the ankle in 6 cases, the heel in 3 cases, the dorsum pedis in 4 cases, and the plantar forefoot in 7 cases of avulsion injury after toes amputation. The size of wound ranged from 15 cm×10 cm to 27 cm×18 cm. The time from injury to treatment was from 11 to 52 days (mean, 27 days). The anterolateral thigh perforator flap was used in 11 cases, thoracodorsal antery perforator flap in 3 cases, medial sural artery perforator flap in 4 cases, deep inferior epigastric perforator flap in 1 case, and anteromedial thigh perforator flap in 1 case, including 5 chimeric perforator flaps, 5 polyfoliate perforator flaps, 3 flow-through perforator flaps, and 3 conjoined perforator flaps. The size of the perforator flap ranged from 10.0 cm×6.5 cm to 36.0 cm×8.0 cm, the size of skin graft from 5 cm×3 cm to 18 cm×12 cm. Venous crisis occurred in 2 flaps which survived after symptomatic treatment; 18 flaps survived successfully and skin grafting healed well. The follow-up time ranged 4-18 months (mean, 8.3 months). The flaps had good appearance, texture and color, without infection. The patients could walk normally and do daily activities. Only linear scars were observed at the donor sites. Free perforator flap can be used to reconstruct defects in the ankle and foot, especially in the weight-bearing area of the plantar forefoot. A combination of free perforator flap and skin graft is ideal in reconstruction of great soft tissue defects in the ankle and foot.

[CLINICAL APPLICATION AND EXPERIENCE IN RECONSTRUCTION OF SOFT TISSUE DEFECTS FOLLOWING MALIGNANT TUMOR REMOVAL OF LIMBS USING PERFORATOR PROPELLER FLAPS].

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Zhu, Shan; Liu, Yuanbo; Yu, Shengji; Zang, Mengqing; Zhao, Zhenguo; Xu, Libin; Zhang, Xinxin; Chen, Bo; Ding, Qiang

2016-01-01

To explore the feasibility and technical essentials of soft tissue defect reconstruction following malignant tumor removal of limbs using perforator propeller flaps. Between July 2008 and July 2015, 19 patients with malignant limb tumor underwent defect reconstruction following tumor removal using the perforator propeller flaps. There were 13 males and 6 females with an average age of 53.4 years (range, 20-82 years). The disease duration ranged from 1 to 420 months (mean, 82 months). The tumors located at the thigh in 10 cases, at the leg in 2 cases, at the arm in 1 case, at the forearm in 1 case, around the knee in 2 cases, and around the elbow joint in 3 cases. Totally 23 flaps (from 8 cm x 3 cm to 30 cm x 13 cm in size) were used to reconstruct defects (from 4 cm x 4 cm to 24 cm x 16 cm in size). The potential source arteries included the femoral artery (n = 2), profunda femoral artery (n = 3), superficial circumflex iliac artery (n = 1), lateral circumflex femoral artery (n = 6), superior lateral genicular artery (n = 2), peroneal artery (n = 2), anterior tibial artery (n = 1), brachial artery (n = 4), and radial artery (n = 1). The remaining one was a free style perforator flap. Partial distal flap necrosis occurred in 3 cases after surgery with rotation angles of 180, 150, and 100 degrees respectively, which were reconstructed after debridement using a free-style perforator flap in 1 case and using free skin grafting in the other 2 cases. The other 20 flaps survived completely after surgery. Primary healing of incisions was obtained at the donor and recipient sites. There was no severe complication such as infection, hematoma, and total flap failure. All patients were followed up 3 months to 5 years (mean, 19 months). One patient with malignant melanoma around the elbow joint had tumor recurrence, and underwent secondary tumor resection. The appearance, texture, and color of the flaps were similar to those at the recipient site. For patients with malignant

A theoretical model describing arterial flow in the DIEP flap related to number and size of perforator vessels.

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Patel, Sameer A; Keller, Alex

2008-11-01

The deep inferior epigastric perforator flap is rapidly becoming a more widely employed method of autologous breast reconstruction. The technical considerations involved in the execution of the flap are many and include the selection of perforators to be incorporated in the flap. We attempt to give a mathematical explanation, based on the physics of flow through vessels and the properties of circuits with multiple resistances in parallel, for the clinical observations which have been arrived at through clinical experience. We compare the system of perforators to a circuit with multiple resistances in parallel. Each of these resistances represents a perforator vessel. In the event that there is only one perforator vessel, this simplifies to a single resistance in series with the capillary bed perfusing the flap. The flow through the flap is optimized by incorporation of the largest diameter perforator. Inclusion of other smaller perforators in addition to the largest diameter perforator will reduce the overall resistance, but this reduction in resistance is dependent on the diameter of the additional perforator and may not be worth the additional trauma of dissection and increased operative time. Incorporating several smaller perforators at the expense of excluding the largest diameter perforator appears to increase the overall resistance, unless the smaller perforators are only slightly smaller. We conclude that the best perfused flap involves use of the largest diameter vessel, that although adding additional perforators will decrease the resistance and increase flow, the magnitude of the benefit depends largely on the calibre of the additional perforator, and that this benefit needs to be weighed against the downside of increased muscle and facial trauma.

The Dorsoulnar Artery Perforator Adipofascial Flap in the Treatment of Distal Radioulnar Synostosis

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Alessia Pagnotta

2017-01-01

Full Text Available Posttraumatic radioulnar synostosis (RUS is a rare event following forearm fractures. Consequences are disabling for patients who suffer from functional limitation in forearm pronosupination. Distal RUS are even more rare and more difficult to treat because of high recurrence rates. The patient we describe in this paper came to our attention with a double distal RUS recurrence and a Darrach procedure already performed. We performed a radical excision of RUS and interposition with a vascularized dorsoulnar artery (DUA adipofascial perforator flap. Four years after surgery, the patient shows the same complete range of motion in pronosupination, and MRI confirms that the flap is still in place with signs of vascularization. Simple synostosis excision has been proven ineffective in many cases. Interposition is recommended after excision, and biological material interposition seems to be more effective than foreign material. Surgeons are increasingly performing vascularized interposition, and the results are very encouraging.

In-vivo quantitative evaluation of perfusion zones and perfusion gradient in the deep inferior epigastric artery perforator flap

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Saint-Cyr, Michel; Lakhiani, Chrisovalantis; Cheng, Angela; Mangum, Michael; Liang, Jinyang; Teotia, Sumeet; Livingston, Edward H.; Zuzak, Karel J.

2013-03-01

The selection of well-vascularized tissue during DIEP flap harvest remains controversial. While several studies have elucidated cross-midline perfusion, further characterization of perfusion to the ipsilateral hemiabdomen is necessary for minimizing rates of fat necrosis or partial fat necrosis in bilateral DIEP flaps. Eighteen patients (29 flaps) underwent DIEP flap harvest using a prospectively designed protocol. Perforators were marked and imaged with a novel system for quantitatively measuring tissue oxygenation, the Digital Light Hyperspectral Imager. Images were then analyzed to determine if perforator selection influenced ipsilateral flap perfusion. Flaps based on a single lateral row perforator (SLRP) were found to have a higher level of hemoglobin oxygenation in Zone I (mean %HbO2 = 76.1) compared to single medial row perforator (SMRP) flaps (%HbO2 = 71.6). Perfusion of Zone III relative to Zone I was similar between SLRP and SMRP flaps (97.4% vs. 97.9%, respectively). These differences were not statistically significant (p>0.05). Perfusion to the lateral edge of the flap was slightly greater for SLRP flaps compared SMRP flaps (92.1% vs. 89.5%, respectively). SMRP flaps had superior perfusion travelling inferiorly compared to SLRP flaps (88.8% vs. 83.9%, respectively). Overall, it was observed that flaps were better perfused in the lateral direction than inferiorly. Significant differences in perfusion gradients directed inferiorly or laterally were observed, and perforator selection influenced perfusion in the most distal or inferior aspects of the flap. This suggests broader clinical implications for flap design that merit further investigation.

Colgajo perforante tóracodorsal Toracodorsal perforator flap

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C. Angrigiani

2006-12-01

Full Text Available La espalda es una excelente zona dadora de colgajos. El colgajo perforante tóracodorsal basado en ramas cutáneas de la arteria y vena tóracodorsales que perforan el músculo dorsal ancho, es una modifica ción del tradicional colgajo musculocutáneo de dorsal ancho que permite lograr una mayor flexibilidad en su traslado y una disminución de su volumen. Puede emplearse como colgajo libre o en isla. Presentamos su anatomía, disección e indicaciones.Back is an excellent donor site for flaps. The tora codorsal perforator flap, based on cutaneous vessels from toracodorsal artery and vein that pass through Latissimus Dorsi muscle, is a modified conventional musculocutaneous Latissimus Dorsi flap that allows easier movility and a volume reduction. This flap can be used both, free flap or island flap. We present the anatomy, dissection and applica tions of this flap.

Free-style puzzle flap: the concept of recycling a perforator flap.

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Feng, Kuan-Ming; Hsieh, Ching-Hua; Jeng, Seng-Feng

2013-02-01

Theoretically, a flap can be supplied by any perforator based on the angiosome theory. In this study, the technique of free-style perforator flap dissection was used to harvest a pedicled or free skin flap from a previous free flap for a second difficult reconstruction. The authors call this a free-style puzzle flap. For the past 3 years, the authors treated 13 patients in whom 12 pedicled free-style puzzle flaps were harvested from previous redundant free flaps and recycled to reconstruct soft-tissue defects at various anatomical locations. One free-style free puzzle flap was harvested from a previous anterolateral thigh flap for buccal cancer to reconstruct a foot defect. Total flap survival was attained in 12 of 13 flaps. One transferred flap failed completely. This patient had received postoperative radiotherapy after the initial cancer ablation and free anterolateral thigh flap reconstruction. Another free flap was used to close and reconstruct the wound. All the donor sites could be closed primarily. The free-style puzzle flap, harvested from a previous redundant free flap and used as a perforator flap to reconstruct a new defect, has proven to be versatile and reliable. When indicated, it is an alternative donor site for further reconstruction of soft-tissue defects.

Extended Islanded Reverse Sural Artery Flap for Staged Reconstruction of Foot Defects Proximal to Toes

International Nuclear Information System (INIS)

Yousaf, M.A.; Abidin, Z.U.; Khalid, K.; Haq, A.U.; Tarar, F.A.; Asif, M.U.; Tarar, M.N.

2018-01-01

To assess the outcome of extended delayed reverse sural artery flap for reconstruction of foot defects proximal to toes in terms of flap survival, complication and extended area. Study Design:Case series. Place and Duration of Study:Jinnah Burn and Reconstructive Surgery Centre, Lahore, from February 2015 to April 2017. Methodology:Cases who underwent delayed sural artery flap were inducted. Preoperative hand-held doppler was done to confirm the location of perforator. Two suitable perforators were chosen to raise the extended flap by crossing the proximal limit in all cases. The pedicle was kept minimum 3 cm wide and perfusion was assessed. Flap was delayed for one week and vaccum-assisted closure (VAC) dressing was applied over wound. The second surgery was performed after one week. Proximal perforator was clamped and ligated after checking adequate perfusion of flap. Flap was insetted into defect. Results:Thirty-two patients were reconstructed with delayed reverse sural artery flap. The mean age of the patients was 26.5 +12.2 years. Twenty-four (75%) patients were males and 8 (25%) were females. Twenty-two (68.7%) cases were degloving wounds after road traffic accidents (RTA), 6 (18.7%) were diabetic foot wounds, 4 (12.5%) sustained injury after falling from height and 7 (21.8%) patients had fracture of metatarsals. Twenty-eight flaps were transferred after one week delay, and only in 4 cases, flap were transferred after two weeks. All flaps survived completely. Complications of infection noted in 3 (9.3%) flaps, 3 (9.3%) flaps showed tip necrosis, 2 (6.2%) flaps undergone epidermolysis and only 2 (6.2%) showed venous congestion. Conclusion:Delayed islanded reverse sural artery perforator flap is a reliable and versatile option for resurfacing soft tissue defects of lower limb proximal to the toes with lesser complications and extended coverage area. (author)

Extended Islanded Reverse Sural Artery flap for Staged Reconstruction of Foot Defects Proximal to Toes.

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Yousaf, Muhammad Amin; Abidin, Zain Ul; Khalid, Kamran; Haq, Ata Ul; Khalid, Farrukh Aslam; Tarar, Faraz Ahmad; Asif, Muhammad Umar; Tarar, Moazzam Nazeer

2018-02-01

Obective:To assess the outcome of extended delayed reverse sural artery flap for reconstruction of foot defects proximal to toes in terms of flap survival, complication and extended area. Case series. Jinnah Burn and Reconstructive Surgery Centre, Lahore, from February 2015 to April 2017. Cases who underwent delayed sural artery flap were inducted. Preoperative hand-held doppler was done to confirm the location of perforator. Two suitable perforators were chosen to raise the extended flap by crossing the proximal limit in all cases. The pedicle was kept minimum 3 cm wide and perfusion was assessed. Flap was delayed for one week and vaccum-assisted closure (VAC) dressing was applied over wound. The second surgery was performed after one week. Proximal perforator was clamped and ligated after checking adequate perfusion of flap. Flap was insetted into defect. Thirty-two patients were reconstructed with delayed reverse sural artery flap. The mean age of the patients was 26.5 12.2 years. Twenty-four (75%) patients were males and 8 (25%) were females. Twenty-two (68.7%) cases were degloving wounds after road traffic accidents (RTA), 6 (18.7%) were diabetic foot wounds, 4 (12.5%) sustained injury after falling from height and 7 (21.8%) patients had fracture of metatarsals. Twenty-eight flaps were transferred after one week delay, and only in 4 cases, flap were transferred after two weeks. All flaps survived completely. Complications of infection noted in 3 (9.3%) flaps, 3 (9.3%) flaps showed tip necrosis, 2 (6.2%) flaps undergone epidermolysis and only 2 (6.2%) showed venous congestion. Delayed islanded reverse sural artery perforator flap is a reliable and versatile option for resurfacing soft tissue defects of lower limb proximal to the toes with lesser complications and extended coverage area.

Reconstruction of pressure sores with perforator-based propeller flaps.

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Jakubietz, Rafael G; Jakubietz, Danni F; Zahn, Robert; Schmidt, Karsten; Meffert, Rainer H; Jakubietz, Michael G

2011-03-01

Perforator flaps have been successfully used for reconstruction of pressure sores. Although V-Y advancement flaps approximate debrided wound edges, perforator-based propeller flaps allow rotation of healthy tissue into the defect. Perforator-based propeller flaps were planned in 13 patients. Seven pressure sores were over the sacrum, five over the ischial tuberosity, and one on the tip of the scapula. Three patients were paraplegic, six were bedridden, and five were ambulatory. In three patients, no perforators were found. In 10 patients, propeller flaps were transferred. In two patients, total flap necrosis occurred, which was reconstructed with local advancement flaps. In two cases, a wound dehiscence occurred and had to be revised. One hematoma required evacuation. No further complications were noted. No recurrence at the flap site occurred. Local perforator flaps allow closure of pressure sores without harvesting muscle. The propeller version has the added benefit of transferring tissue from a distant site, avoiding reapproximation of original wound edges. Twisting of the pedicle may cause torsion and venous obstruction. This can be avoided by dissecting a pedicle of at least 3 cm. Propeller flaps are a safe option for soft tissue reconstruction of pressure sores. © Thieme Medical Publishers.

The Versatility of Perforator-Based Propeller Flap for Reconstruction of Distal Leg and Ankle Defects

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Durga Karki

2012-01-01

Full Text Available Introduction. Soft tissue coverage of distal leg and ankle region represents a challenge and such defect usually requires a free flap. However, this may lead to considerable donor site morbidity, is time consuming, and needs facility of microsurgery. With the introduction of perforator flap, management of small- and medium-size defects of distal leg and ankle region is convenient, less time consuming, and with minimal donor site morbidity. When local perforator flap is designed as propeller and rotated to 180 degree, donor site is closed primarily and increases reach of flap, thus increasing versatility. Material and Methods. From June 2008 to May 2011, 20 patients were treated with perforator-based propeller flap for distal leg and ankle defects. Flap was based on single perforator of posterior tibial and peroneal artery rotated to 180 degrees. Defect size was from 4 cm × 3.5 cm to 7 cm × 5 cm. Results. One patient developed partial flap necrosis, which was managed with skin grafting. Two patients developed venous congestion, which subsided spontaneously without complications. Small wound dehiscence was present in one patient. Donor site was closed primarily in all patients. Rest of the flaps survived well with good aesthetic results. Conclusion. The perforator-based propeller flap for distal leg and ankle defects is a good option. This flap design is safe and reliable in achieving goals of reconstruction. The technique is convenient, less time consuming, and with minimal donor site morbidity. It provides aesthetically good result.

Comparison of the Multidetector-row Computed Tomographic Angiography Axial and Coronal Planes' Usefulness for Detecting Thoracodorsal Artery Perforators

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Kim, Jong Gyu

2012-01-01

Background During the planning of a thoracodorsal artery perforator (TDAP) free flap, preoperative multidetector-row computed tomographic (MDCT) angiography is valuable for predicting the locations of perforators. However, CT-based perforator mapping of the thoracodorsal artery is not easy because of its small diameter. Thus, we evaluated 1-mm-thick MDCT images in multiple planes to search for reliable perforators accurately. Methods Between July 2010 and October 2011, 19 consecutive patients (13 males, 6 females) who underwent MDCT prior to TDAP free flap operations were enrolled in this study. Patients ranged in age from 10 to 75 years (mean, 39.3 years). MDCT images were acquired at a thickness of 1 mm in the axial, coronal, and sagittal planes. Results The thoracodorsal artery perforators were detected in all 19 cases. The reliable perforators originating from the descending branch were found in 14 cases, of which 6 had transverse branches. The former were well identified in the coronal view, and the latter in the axial view. The location of the most reliable perforators on MDCT images corresponded well with the surgical findings. Conclusions Though MDCT has been widely used in performing the abdominal perforator free flap for detecting reliable perforating vessels, it is not popular in the TDAP free flap. The results of this study suggest that multiple planes of MDCT may increase the probability of detecting the most reliable perforators, along with decreasing the probability of missing available vessels. PMID:22872839

Three-dimensional computed tomographic angiography to predict weight and volume of deep inferior epigastric artery perforator flap for breast reconstruction.

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Rosson, Gedge D; Shridharani, Sachin M; Magarakis, Michael; Manahan, Michele A; Stapleton, Sahael M; Gilson, Marta M; Flores, Jaime I; Basdag, Basak; Fishman, Elliot K

2011-10-01

Three-dimensional computed tomographic angiography (3D CTA) can be used preoperatively to evaluate the course and caliber of perforating blood vessels for abdominal free-flap breast reconstruction. For postmastectomy breast reconstruction, many women inquire whether the abdominal tissue volume will match that of the breast to be removed. Therefore, our goal was to estimate preoperative volume and weight of the proposed flap and compare them with the actual volume and weight to determine if diagnostic imaging can accurately identify the amount of tissue that could potentially to be harvested. Preoperative 3D CTA was performed in 15 patients, who underwent breast reconstruction using the deep inferior epigastric artery perforator flap. Before each angiogram, stereotactic fiducials were placed on the planned flap outline. The radiologist reviewed each preoperative angiogram to estimate the volume, and thus, weight of the flap. These estimated weights were compared with the actual intraoperative weights. The average estimated weight was 99.7% of the actual weight. The interquartile range (25th to 75th percentile), which represents the "middle half" of the patients, was 91-109%, indicating that half of the patients had an estimated weight within 9% of the actual weight; however, there was a large range (70-133%). 3D CTA with stereotactic fiducials allows surgeons to adequately estimate abdominal flap volume before surgery, potentially giving guidance in the amount of tissue that can be harvested from a patient's lower abdomen. Copyright © 2011 Wiley-Liss, Inc.

Lower Extremity Salvage with Thoracodorsal Artery Perforator Free Flap in Condition of Symmetrical Peripheral Gangrene

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Soo Yeon Lim

2018-01-01

Full Text Available Symmetrical peripheral gangrene (SPG is rare but devastating complication which is characterized by symmetrical ischemic change of the distal extremities. In this report, we describe our management protocol for SPG, focusing on surgical approaches. Between January 2007 and February 2016, 10 thoracodorsal artery perforator (TDAP free flaps were performed in 6 patients with SPG. Three patients were male and mean age was 56 (range, 44–69 years. All the patients were in shock. The causes of shock were sepsis in 4 cases, respiratory arrest in 1 case, and hypovolemia in 1 case. Eight transmetatarsal amputations and 2 Lisfranc amputations were performed. Flap sizes ranged from 7 × 11 cm to 25 × 15 cm. There were 3 cases of partial necrosis of the flap: two healed conservatively with dressings and one required skin graft. Three of the patients were later able to walk independently at Functional Ambulation Classification (FAC level 6, one patient could walk independently on level surfaces at FAC level 5, and 2 could walk independently using walking aids, classified at FAC level 4. The average follow-up period was 18 (range, 6–54 months. In patients with SPG, minimal bone amputation and foot salvage with TDAP flaps were successful. Separate reconstruction of bone and soft tissue had good outcomes.

A Novel Perforator Flap Training Model Using a Chicken Leg.

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Cifuentes, Ignacio J; Yañez, Ricardo A; Salisbury, Maria C; Rodriguez, José R; Varas, Julian E; Dagnino, Bruno L

2016-04-01

Living animal models are frequently used for perforator flap dissection training, but no ex vivo models have been described. The aim of this study is to present a novel nonliving model for perforator flap training based on a constant perforator in the chicken leg. A total of 15 chicken legs were used in this study. Anatomical dissection of the perforator was performed after its identification using ink injection, and in four of these specimens a perforator-based flap was raised. The anatomical dissection revealed a constant intramuscular perforator with a median length of 5.7 cm. Median proximal and distal vessel diameters were 0.93 and 0.4 mm, respectively. The median dissection time was 77.5 minutes. This study introduces a novel, affordable, and reproducible model for the intramuscular dissection of a perforator-based flap using an ex vivo animal model. Its consistent perforator and appropriate-sized vessels make it useful for training.

Color Doppler Ultrasonography-Targeted Perforator Mapping and Angiosome-Based Flap Reconstruction

DEFF Research Database (Denmark)

Gunnarsson, Gudjon Leifur; Tei, Troels; Thomsen, Jørn Bo

2016-01-01

Knowledge about perforators and angiosomes has inspired new and innovative flap designs for reconstruction of defects throughout the body. The purpose of this article is to share our experience using color Doppler ultrasonography (CDU)-targeted perforator mapping and angiosome-based flap reconstr......Knowledge about perforators and angiosomes has inspired new and innovative flap designs for reconstruction of defects throughout the body. The purpose of this article is to share our experience using color Doppler ultrasonography (CDU)-targeted perforator mapping and angiosome-based flap...

Tensor fascia lata flap versus tensor fascia lata perforator-based island flap for the coverage of extensive trochanteric pressure sores.

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Kim, Youn Hwan; Kim, Sang Wha; Kim, Jeong Tae; Kim, Chang Yeon

2013-06-01

Tensor fascia lata (TFL) musculocutaneous flaps often require a donor site graft when harvesting a large flap. However, a major drawback is that it also sacrifices the muscle. To overcome this disadvantage, we designed a TFL perforator-based island flap that was harvested from a site near the defect and involved transposition within 90 degrees without full isolation of the pedicles. We performed procedures on 17 musculocutaneous flaps and 23 perforator-based island flaps, and compared the outcomes of these surgeries. The overall complication rate was 27.5% (11 regions). There were 7 complications related to the musculocutaneous flaps and 4 complications related to the perforator flaps. Although there were no statistical differences between those groups, lower complication rates were associated with procedures involving perforator flaps. The TFL perforator procedure is a simple and fast operation that avoids sacrificing muscle. This decreases complication rates compared to true perforator flap techniques that require dissection around the perforator or pedicle.

Perforator plus flaps: Optimizing results while preserving function and esthesis

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Mehrotra Sandeep

2010-01-01

Full Text Available Background: The tenuous blood supply of traditional flaps for wound cover combined with collateral damage by sacrifice of functional muscle, truncal vessels, or nerves has been the bane of reconstructive procedures. The concept of perforator plus flaps employs dual vascular supply to flaps. By safeguarding perforators along with supply from its base, robust flaps can be raised in diverse situations. This is achieved while limiting collateral damage and preserving nerves, vessels, and functioning muscle with better function and aesthesis. Materials and Methods: The perforator plus concept was applied in seven different clinical situations. Functional muscle and fasciocutaneous flaps were employed in five and adipofascial flaps in two cases, primarily involving lower extremity defects and back. Adipofascial perforator plus flaps were employed to provide cover for tibial fracture in one patients and chronic venous ulcer in another. Results: All flaps survived without any loss and provided long-term stable cover, both over soft tissue and bone. Functional preservation was achieved in all cases where muscle flaps were employed with no clinical evidence of loss of power. There was no sensory loss or significant oedema in or distal to the flap in both cases where neurovascular continuity was preserved during flap elevation. Fracture union and consolidation were satisfactory. One patient had minimal graft loss over fascia which required application of stored grafts with subsequent take. No patient required re-operation. Conclusions: Perforator plus concept is holistic and applicable to most flap types in varied situations. It permits the exercise of many locoregional flap options while limiting collateral functional damage. Aesthetic considerations are also addressed while raising adipofascial flaps because of no appreciable donor defects. With quick operating times and low failure risk, these flaps can be a better substitute to traditional flaps and at

An alternative method for facial resurfacing: supraclavicular skin prefabrication by perforator fascia flap.

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Hocaoğlu, Emre

2014-01-01

Prefabrication of supraclavicular skin provides a useful source for flaps congruent with the face skin. Among various vascular sources that have been used for this purpose, anterolateral thigh fascia seems to represent a greater value because of having a long and strong vascular pedicle and negligible donor-site morbidity. In this regard, we present a technical report on using the lateral circumflex femoral artery perforator flap harvest technique in preparing an anterolateral thigh fascia flap for the prefabrication of the supraclavicular skin. The technique proved successful in resurfacing the facial skin of a young female patient with a giant congenital melanocytic hairy nevus on the left side of her face.

Preoperative CT angiography reduces surgery time in perforator flap reconstruction

NARCIS (Netherlands)

Smit, Jeroen M.; Dimopoulou, Angeliki; Liss, Anders G.; Zeebregts, Clark J.; Kildal, Morten; Whitaker, Iain S.; Magnusson, Anders; Acosta, Rafael

The use of perforator flaps in breast reconstructions has increased considerably in the past decade. A disadvantage of the perforator flap is difficult dissection, which results in a longer procedure. During spring 2006, we introduced CT angiography (CTA) as part of the diagnostic work-up in

Increased Flap Weight and Decreased Perforator Number Predict Fat Necrosis in DIEP Breast Reconstruction

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Carolyn L. Mulvey, BS

2013-05-01

Conclusions: Flaps with increasing weight have increased risk of fat necrosis. These data suggest that inclusion of more than 1 perforator may decrease odds of fat necrosis in large flaps. Perforator flap breast reconstruction can be performed safely; however, considerations concerning race, body mass index, staging with tissue expanders, perforator number, and flap weight may optimize outcomes.

Perforator chimerism for the reconstruction of complex defects: A new chimeric free flap classification system.

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Kim, Jeong Tae; Kim, Youn Hwan; Ghanem, Ali M

2015-11-01

Complex defects present structural and functional challenges to reconstructive surgeons. When compared to multiple free flaps or staged reconstruction, the use of chimeric flaps to reconstruct such defects have many advantages such as reduced number of operative procedures and donor site morbidity as well as preservation of recipient vessels. With increased popularity of perforator flaps, chimeric flaps' harvest and design has benefited from 'perforator concept' towards more versatile and better reconstruction solutions. This article discusses perforator based chimeric flaps and presents a practice based classification system that incorporates the perforator flap concept into "Perforator Chimerism". The authors analyzed a variety of chimeric patterns used in 31 consecutive cases to present illustrative case series and their new classification system. Accordingly, chimeric flaps are classified into four types. Type I: Classical Chimerism, Type II: Anastomotic Chimerism, Type III: Perforator Chimerism and Type IV Mixed Chimerism. Types I on specific source vessel anatomy whilst Type II requires microvascular anastomosis to create the chimeric reconstructive solution. Type III chimeric flaps utilizes the perforator concept to raise two components of tissues without microvascular anastomosis between them. Type IV chimeric flaps are mixed type flaps comprising any combination of Types I to III. Incorporation of the perforator concept in planning and designing chimeric flaps has allowed safe, effective and aesthetically superior reconstruction of complex defects. The new classification system aids reconstructive surgeons and trainees to understand chimeric flaps design, facilitating effective incorporation of this important reconstructive technique into the armamentarium of the reconstruction toolbox. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Total nasal reconstruction with 3D custom made porous titanium prosthesis and free thoracodorsal artery perforator flap: A case report.

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Qassemyar, Quentin; Assouly, Nathaniel; Madar, Yoni; Temam, Stéphane; Kolb, Frédéric

2018-02-21

Total nasal reconstruction is a challenging surgical procedure which usually involves a free flap, forehead flap, and cartilage grafts. In certain failure situations where patients do not accept the idea of anaplastology, possibilities become very limited. We report the case of a patient who underwent several reconstruction steps with multiple failures including free and local flaps and cartilage harvests which showed recurrent episodes of necrosis and infection leading to melting and collapse of reconstructed structures. Furthermore, the patient did not want any anaplastological rehabilitation. We proposed to the patient an innovative method that consists to print a three-dimensional custom-made porous titanium prosthesis, based on the original shape of his nose, to replace the cartilage support. This implant was first inserted in a thoracodorsal artery perforator flap for primary integration before the free transfer of the complete structure, two months later. The free transfer was successful without any complication. A stable reconstruction and satisfying result was obtained. The patient did not want additional surgical improvement 24 months post-operatively, and resumed his professional activities. The possibility of using three-dimensional custom titanium prostheses to replace the bone and cartilage support seems to be an interesting alternative for patients in the failure situation of nasal reconstruction. © 2018 Wiley Periodicals, Inc.

A simple concept for covering pressure sores: wound edge-based propeller perforator flap.

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Kelahmetoglu, Osman; Van Landuyt, Koenraad; Yagmur, Caglayan; Sommeling, Casper E; Keles, Musa K; Tayfur, Volkan; Simsek, Tekin; Demirtas, Yener; Guneren, Ethem

2017-12-01

We present a new surgical modification to allow propeller perforator flaps to cover pressure sores at various locations. We used a propeller perforator flap concept based on the detection of newly formed perforator vessels located 1 cm from the wound margin and stimulated by the chronic inflammation process. Between January 2009 and January 2017, 33 wound edge-based propeller perforator flaps were used to cover pressure sores at various locations in 28 patients. In four cases more than one flap was used on the same patient. The patients comprised 18 males and 10 females with a mean age of 41·25 (range, 16-70) years. All patients underwent follow-up for 0-12 months. The mean follow-up duration was 5·03 months. Venous congestion was observed in three flaps that were rotated by 180° (9·1%). However, there was a significant difference between flaps rotated by 90° and 180° according to the complication rate (P = 0·034). Out of 33 flaps, 29 flaps healed uneventfully. Patients were able to sit and lie on their flaps three weeks after surgery. In our study, we were able to obtain satisfying final results using these novel flaps. © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd.

Bilateral simultaneous breast reconstruction with SGAP flaps.

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Flores, Jaime I; Magarakis, Michael; Venkat, Raghunandan; Shridharani, Sachin M; Rosson, Gedge D

2012-07-01

Two work-horse approaches to postmastectomy breast reconstruction are the deep inferior epigastric perforator flap and the superior gluteal artery perforator (SGAP) flap [and its variation, the lateral septocutaneous superior gluteal artery perforator flap]. Our purpose was fourfold: 1) to analyze our experience with the SGAP flaps for simultaneous bilateral breast reconstruction; 2) to analyze our experience with lateral septocutaneous superior gluteal artery perforator flaps for that procedure; 3) to compare our results with those in the literature; and 4) to highlight the importance of preoperative three-dimensional computed tomographic angiography. A retrospective chart review was completed for 23 patients who underwent breast reconstruction between December 2005 and January 2010 via an SGAP flap (46 flaps). We reviewed flap weight, ischemia time, length of stay, overall flap survival, fat necrosis development, and emergency re-exploration. Mean weights were 571.2 ± 222.0 g (range 186-1,117 g) and 568.0 ± 237.5 g (range 209-1,115 g) for the left and right buttock flap, respectively. Mean ischemia time was 129.1 ± 15.7 and 177.7 ± 24.7 minutes for the first and second flap, respectively. Mean hospital stay was 5.3 ± 2.5 days. All flaps survived. Fat necrosis developed in five flaps (10.8%), and emergency re-exploration was required in three patients (three flaps). When harvesting abdominal tissue is a poor option, the SGAP flap is an efficacious procedure for patients desiring autologous breast reconstruction, and bilateral procedures can be performed simultaneously. Copyright © 2012 Wiley Periodicals, Inc.

Non-invasive vascular imaging in perforator flap surgery

International Nuclear Information System (INIS)

Saba, Luca; Piga, Mario; Atzeni, Matteo; Ribuffo, Diego; Rozen, Warren Matthew; Alonso-Burgos, Alberto; Bura, Raffaella

2013-01-01

Preoperative imaging using a range of imaging modalities has become increasingly popular for preoperative planning in plastic surgery, in particular in perforator flap surgery. Modalities in this role include ultrasound (US), magnetic resonance angiography (MRA), and computed tomographic angiography (CTA). The evidence for the use of these techniques has been reported in only a handful of studies. In this paper we conducted a non-systematic review of the literature to establish the role for each of these modalities. The role of state-of-the-art vascular imaging as an application in perforator flap surgery is thus offered

Giant trochanteric pressure sore: Use of a pedicled chimeric perforator flap for cover

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Mehrotra Sandeep

2009-01-01

Full Text Available Pressure sores are increasing in frequency commensurate with an ageing population with multi-system disorders and trauma. Numerous classic options are described for providing stable wound cover. With the burgeoning knowledge on perforator anatomy, recent approaches focus on the use of perforator-based flaps in bedsore surgery. A giant neglected trochanteric pressure sore in a paraplegic is presented. Since conventional options of reconstruction appeared remote, the massive ulcer was successfully managed by a chimeric perforator-based flap. The combined muscle and fasciocutaneous flaps were raised as separate paddles based on the anterolateral thigh perforator branches and provided stable cover without complications. Perforators allow versatility in managing complex wounds without compromising on established principles.

Colgajos de perforantes de las arterias epigástricas inferiores profunda y superficial Deep and superficial inferior epigastric artery perforator flaps

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A. R. Gagnon

2006-12-01

Full Text Available Con el desarrollo de los colgajos miocutáneos de recto abdominal (TRAM, el abdomen inferior ha sido reconocido como la principal área dadora de tejidos autólogos de alta calidad, especialmente útiles en reconstrucción mamaria. Más recientemente la habilidad para obtener componentes adiposocutáneos similares sin sacrificar el músculo recto ha revolucionado el campo de la Cirugía Reconstructiva. El advenimiento de los colgajos de perforantes ha permitido a los cirujanos plásticos lograr los mismos buenos resultados estéticos que con los colgajos miocutáneos tradicionales, pero con un considerable descenso en la morbilidad del área donante. Con los colgajos de perforantes de la arteria epigástrica inferior profunda (DIEP y de la arteria epigástrica inferior superficial (SIEA, los pacientes han incrementado sus opciones de reconstrucción. Este artículo revisa la anatomía quirúrgica de la pared abdominal relativa a los colgajos SIEA y DIEP. Se explican detalladamente los pasos principales para la preparación preoperatoria, la técnica quirúrgica y los cuidados postoperatorios. Se discuten las ventajas y desventajas y se presen- tan los trucos técnicos que pueden ayudar a mejorar el resultado final. Además se ilustran con ayuda de casos clínicos las indicaciones típicas y atípicas.Following the development of the transverse rectus abdominis myocutaneous (TRAM flap, the lower abdomen has been recognized as a prime source of high quality autogenous tissue, especially useful in breast reconstruction. More recently, the ability to harvest a similar adipocutaneous component without sacrifice of the rectus muscle has revolutionized the field of reconstructive surgery. The advent of perforator flaps has allowed plastic surgeons to achieve the same highly esthetic results as with the former myocutaneous flaps while significantly decreasing the donor site morbidity. With the deep inferior epigastric artery perforator (DIEP flap and

[Effects of anteriolateral thigh perforator flap and fascia lata transplantation in combination with computed tomography angiography on repair of electrical burn wounds of head with skull exposure and necrosis].

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Li, X Q; Wang, X; Han, Y L; Ji, G; Chen, Z H; Zhang, J; Zhu, J P; Duan, J X; He, Y J; Yang, X M; Liu, W J

2018-05-20

Objective: To explore the effects of anteriolateral thigh perforator flap and fascia lata transplantation in combination with computed tomography angiography (CTA) on repair of electrical burn wounds of head with skull exposure and necrosis. Methods: Seven patients with head electrical burns accompanied by skull exposure and necrosis were admitted to our burn center from March 2016 to December 2017. Head CTA was performed before the operation. The diameters of the facial artery and vein or the superficial temporal artery and vein were measured, and their locations were marked on the body surface. Preoperative CTA for flap donor sites in lower extremities were also performed to track the descending branch of the lateral circumflex femoral artery with the similar diameter as the recipient vessels on the head, and their locations were marked on the body surface. Routine wound debridement and skull drilling were performed successively. The size of the wounds after debridement ranged from 12 cm×8 cm to 20 cm×12 cm, and the areas of skull exposure ranged from 8 cm×6 cm to 15 cm×10 cm. Anteriolateral thigh perforator flaps with areas from 13 cm×9 cm to 21 cm×13 cm containing 5-10 cm long vascular pedicles were designed and dissected accordingly. The fascia lata under the flap with area from 5 cm×2 cm to 10 cm×3 cm was dissected according to the length of vascular pedicle. The fascia lata was transplanted to cover the exposed skull, and the anteriolateral thigh perforator flap was transplanted afterwards. The descending branch of the lateral circumflex femoral artery and its accompanying vein of the flap were anastomosed with superficial temporal artery and vein or facial artery and vein before the suture of flap. The flap donor sites were covered by intermediate split-thickness skin graft collected from contralateral thigh or abdomen. Results: The descending branch of the lateral circumflex femoral artery and its accompanying vein were anastomosed with superficial

Perforator Flaps after Excision of Large Epidermal Cysts in the Buttocks

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Sang Wha Kim

2014-03-01

Full Text Available Background Epidermal cysts are commonly occurring masses usually less than 5 cm in diameter, but in predisposed patients, epidermal cysts can grow relatively large due to chronic infection. Methods From June 2002 to July 2010, 17 patients received 19 regional perforator-based island flaps to cover defects due to the excision of large epidermal cysts (diameter >5 cm in the buttocks. Eight patients had diabetes, and seven had rheumatoid arthritis. The pedicles were not fully isolated to prevent spasms or twisting. Results All the flaps survived completely, except for one case with partial necrosis of the flap, which necessitated another perforator-based island flap for coverage. There were two cases of wound dehiscence, which were re-closed after meticulous debridement. There were no recurrences of the masses during follow-up periods of 8.1 months (range, 6-12 months. Conclusions In patients with large epidermal cysts and underlying medical disorders, regional perforator-based island flaps can be the solution to coverage of the defects after excision.

Reconstruction of cica-contracture on the face and neck with skin flap and expanded skin flap pedicled by anterior branch of transverse cervical artery.

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Chen, Baoguo; Song, Huifeng; Xu, Minghuo; Gao, Quanwen

2016-09-01

A high-quality flap is necessary for repairing faciocervical scar contractures. The supraclavicular region and chest wall are the preferred choices for reconstruction. The supraclavicular island flap (SIF) pedicled by the transverse cervical artery (TCA) has been reported. Compared to the traditional SIF flap, another type of flap pedicled by the anterior perforator of transverse cervical artery (ap-TCA) is more convenient for transfer to the faciocervical area. In this article, we use this type of perforator flap and expanded perforator flap to repair the faciocervical contracture. In this study, 10 cases (deformity caused by burn or trauma to the face and neck sites) with an average age of 32 years-old, were treated by ap-TCA flap and this type of expanded flap. In between, the flap was pre-expanded for approximately 3 months prior to transfer in 6 patients. Another 4 cases did not want the expander because of the long duration required for saline filling and potential complications of the expander. Bilateral prefabricated flaps were designed in two female cases. All 12 flaps in 10 patients were transferred tension-free to the defects and no flap was lost. The size of the flap ranged from 12 cm × 8 cm to 15 cm × 20 cm. All 12 flaps survived completely. The donor sites were closed directly in the above 6 patients where an expander had been used and reconstructed by split skin graft in 4 patients where no expander had been employed. Through a mean time of 6 months' follow-up, only one female patient was disappointed with the cicatrix that presented on the upper polar skin of both breasts, the other 9 patients were satisfied with both recipient function and appearance. The color and the texture matched well with the recipient area. The ap-TCA flap and expanded ap-TCA flap can be considered reliable options for faciocervical deformities as it can be easily elevated and it matches well with faciocervical area in color. With regards to the expanded flap, we

Reducing radiation dose without compromising image quality in preoperative perforator flap imaging with CTA using ASIR technology.

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Niumsawatt, Vachara; Debrotwir, Andrew N; Rozen, Warren Matthew

2014-01-01

Computed tomographic angiography (CTA) has become a mainstay in preoperative perforator flap planning in the modern era of reconstructive surgery. However, the increased use of CTA does raise the concern of radiation exposure to patients. Several techniques have been developed to decrease radiation dosage without compromising image quality, with varying results. The most recent advance is in the improvement of image reconstruction using an adaptive statistical iterative reconstruction (ASIR) algorithm. We sought to evaluate the image quality of ASIR in preoperative deep inferior epigastric perforator (DIEP) flap surgery, through a direct comparison with conventional filtered back projection (FBP) images. A prospective review of 60 consecutive ASIR and 60 consecutive FBP CTA images using similar protocol (except for radiation dosage) was undertaken, analyzed by 2 independent reviewers. In both groups, we were able to accurately identify axial arteries and their perforators. Subjective analysis of image quality demonstrated no statistically significant difference between techniques. ASIR can thus be used for preoperative imaging with similar image quality to FBP, but with a 60% reduction in radiation delivery to patients.

Distally based sural neuro-fasciocutaneous perforator flap for foot and ankle reconstruction: Surgical modifications for flap pedicle and donor site closure without skin graft.

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Chi, Zhenglin; Chen, Yiheng; Chu, Tinggang; Gao, Weiyang; Li, Zhijie; Yan, Hede; Song, Yonghuan

2018-02-01

The conventional procedure of the sural neuro-fasciocutaneous flap enables the supply of blood and venous drainage by increasing the width of the adipofascial tissue and preserving tiny venous return routes. Moreover, skin graft is a common method for donor site closure, which may lead to some complications and influence the aesthetic appearance. We report modifications for a distally based sural neuro-fasciocutaneous perforator flap and a relaying flap for donor site closure without skin graft. Twelve patients undergoing the modified flap for foot and ankle reconstruction were included in this study between 2014 and 2016. A peroneal-based perforator, a superficial vein, and the vascular axis of the sural nerve were included in the pedicle. A Z-shape skin incision was performed to explore the perforator vessels and a relaying island perforator flap was used to close the donor site. All flaps survived completely without necrosis. The area of the flaps ranged from 16 × 8 cm to 30 × 15 cm. The diameter width of the pedicle ranged from 1.0 to 2.0 cm. A relaying perforator island flap was used in 10 cases for donor site closure and no skin graft was performed. There were no serious donor site complications. All patients were satisfied with the aesthetic outcome postoperatively at the final follow-up. The distally based sural neuro-fasciocutaneous perforator flap is considered a reliable method for foot and ankle reconstruction. The modification for flap pedicle and donor site closure method without skin graft should be recommended. Copyright © 2017. Published by Elsevier Ltd.

Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps for reconstruction of sacral pressure sores.

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Chen, Yen-Chou; Huang, Eng-Yen; Lin, Pao-Yuan

2014-03-01

The gluteus maximus myocutaneous flap was considered the workhorse that reconstructed sacral pressure sores, but was gradually replaced by fasciocutaneous flap because of several disadvantages. With the advent of the perforator flap technique, gluteal perforator (GP) flap has gained popularity nowadays. The aim of this study was to compare the complications and outcomes between GP flaps and gluteal fasciocutaneous rotation (FR) flaps in the treatment of sacral pressure sores. Between April 2007 and June 2012, 63 patients underwent sacral pressure sore reconstructions, with a GP flap used in 31 cases and an FR flap used in 32 cases. Data collected on the patients included patient age, gender, co-morbidity for being bedridden and follow-up time. Surgical details collected included the defect size, operative time and estimated blood loss. Complications recorded included re-operation, dehiscence, flap necrosis, wound infection, sinus formation, donor-site morbidity and recurrence. The complications and clinical outcomes were compared between these two groups. We found that there was no significant difference in patient demographics, surgical complications and recurrence between these two groups. In gluteal FR flap group, all recurrent cases (five) were treated by reuse of previous flaps. Both methods are comparable, good and safe in treating sacral pressure sores. Gluteal FR flap can be performed without microsurgical dissection, and re-rotation is feasible in recurrent cases. The authors suggest using gluteal FR flaps in patients with a high risk of sore recurrence. Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Free anterolateral thigh perforator flap for sacroiliac defect: First case report in pediatric population

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Alejandro E. Ramirez

2016-08-01

Full Text Available Soft tissue defects of the sacroiliac area, usually can be covered by local flaps. However, for more complex defects, free flap transfers became necessary. We report a case of reconstruction with a free anterolateral thigh (ALT perforator flap for coverage of a sacroiliac bone exposure in a child. A six-years-old boy, suffered a car accident, resulting in pelvic and sacral fractures, as well as degloving injuries of the left thigh, buttocks, and trunk. The patient evolved with an unstable scar over the sacroiliac region with bone exposure. ALT free flap was performed. Left superior gluteal vessels were used as the recipient vessels. A stable coverage was achieved without complications. This is the first case reported of a free ALT perforator flap for sacroiliac coverage in the pediatric population. In cases of complex reconstruction in children, free perforator flap is a safe choice and should be considered in the algorithm of treatment.

Laparoscopic creation of neovagina and neocervix, followed by their reconstruction with polytetrafluoroethylene graft/buccal mucosa and pudendal artery perforator flap

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Yi-Chieh Li

2015-11-01

Full Text Available Congenital cervical agenesis of is a rare Müllerian anomaly that may be associated with partial or complete vaginal aplasia and renal anomalies. Symptoms such as amenorrhea and abdominal pain usually develop shortly after menarche, when the absence or obstruction of the cervical canal results in blood accumulation in the uterus and fallopian tubes, and finally in the peritoneal cavity. Physical examination sometimes reveals normally developed external sex organs. Delayed diagnosis and treatment may potentially result in extensive endometriosis, which may potentially cause severe adhesion and damage to reproductivity. Such consequences could complicate further the management of the disease. Traditionally, hysterectomy has been the treatment of choice in these cases because of the high failure rate of canalization procedures and risk of serious ascending infection. With advanced laparoscopic techniques, conservative management seems feasible and has been recommended. We herein present a patient with complete cervical and vaginal agenesis. Creation of a neovagina and uterovaginal anastomosis were performed first under the guidance of laparoscopy (Figure 1. A neocervix was composed of a polytetrafluoroethylene graft and a piece of oral mucosa retrieved from the buccal area. The neovagina was reconstructed with an external pudendal artery perforator flap. A cervical Fr 16 size Foley was left in place as a stent. The patient had uneventful postoperative recovery and fair wound healing at the outpatient follow-up. Congenital agenesis of the uterine cervix and vagina can be differentiated accurately and reconstructed laparoscopically. Using mesh-buccal mucosa composite and pudendal perforator flap is a practical way to reconstruct neocervix and neovagina after their creation.

An innovative method of planning and displaying flap volume in DIEP flap breast reconstructions

NARCIS (Netherlands)

Hummelink, S.L.; Verhulst, A.C.; Maal, T.J.J.; Hoogeveen, Y.L.; Schultze Kool, L.J.; Ulrich, D.J.O.

2017-01-01

BACKGROUND: Determining the ideal volume of the harvested flap to achieve symmetry in deep inferior epigastric artery perforator (DIEP) flap breast reconstructions is complex. With preoperative imaging techniques such as 3D stereophotogrammetry and computed tomography angiography (CTA) available

Bilirubin provides perforator flap protection from ischaemia-reperfusion injury in a rat model: a preliminary result.

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Kim, Sung Young; Rah, Dong Kyun; Chong, Yosep; Lee, Song Hyun; Park, Tae Hwan

2016-10-01

The use of bilirubin, a well-known and powerful antioxidant, has gained popularity in recent years because of its role in the prevention of ischaemic heart disease in patients with Gilbert's syndrome. We investigate the effects of bilirubin on ischaemia-reperfusion (I/R) injury using a rat perforator flap model. Forty-eight rats were randomly divided into two groups: experimental (bilirubin) group (n = 24) and control group (n = 24). In each group, elevated bilateral deep inferior epigastric perforator (DIEP) flaps were created. The right (no ischaemia side) and left (ischaemia side) DIEP flaps were separated according to the presence of ischaemia induction. Ischaemia was induced in anaesthetised rats by perforator clamping for 15 or 30 minutes. After surgery, the flap survival was assessed daily on postoperative days 0 to 5, and overall histological changes of DIEP flaps above the perforator were analysed at postoperative day 5. The flap survival rate in the bilirubin group was significantly higher than that in the control group at the ischaemia side following perforator clamping for 15 or 30 minutes (93·42 ± 4·48% versus 89·63 ± 3·98%, P = 0·002; and 83·96 ± 4·23% versus 36·46 ± 6·38%, P bilirubin was found to alleviate perforator flap necrosis caused by I/R injury in this experimental rat model. © 2015 Medicalhelplines.com Inc and John Wiley & Sons Ltd.

Angiotomografía computerizada, colgajos de perforante, cirujano y OsiriX Computed tomography angiography, perforator flaps, surgeon and OsiriX

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M. Rodríguez-Vegas

2013-03-01

consecuencia, parece aconsejable que el cirujano plástico relacionado con los colgajos de perforante se involucre decididamente en el postprocesamiento de las imágenes de angiotomografía computerizada. El visor de imágenes DICOM gratuito OsiriX es una alternativa eficiente, comparable a aplicaciones más profesionales sólo disponibles en servicios de Radiología.With the advent of perforator-based skin transfer, computed tomography angiography has emerged as an invaluable tool in the preoperative planning of perforator flaps. But most likely, the exploitation of the technique is less than desirable. Through our experience with 144 patients, we evaluate the use of the free DICOM viewer OsiriX for Mac in the preoperative planning of perforator flaps with three objectives: 1 increase the present knowledge related with the preoperative planning of perforator flaps with computed tomography angiography, 2 evaluate the OsiriX application in the image post-processing of perforator flaps and 3 evaluate the performance of the procedure when performed by a surgeon (not specialized in Radiology. The experience has shown that the image post-processing performed by the surgeon with the OsiriX application usually allows an adequate evaluation of different structures and parameters of great preoperative interest in perforator flap surgery: 1 source artery, 2 diameter of artery and vein/s at the hypothetical site of microsurgical anastomoses, 3 course and branching pattern of the flap pedicle, 4 perforator course in the subcutaneous fat (theoretical flap axis, 5 measurement of the skin and fat where the perforator pierces the deep fascia (theoretical flap thickness , 6 measurement of the distance between the point of entrance of the perforator in the subcutaneous fat to the source artery (theoretical maximal pedicle length and 7 measurement of the perforator diameter where it pierces the deep fascia. Ultimately, in the authors' opinion, those plastic surgeons involved in perforator flap

Anatomical basis of the extended TDAP flap: study of its territories of vascularization and its volume.

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Dast, Sandy; Havet, Eric; Dessena, Lidia; Abdulshakoor, Abeer; Alharbi, Mohammed; Vaucher, Richard; Herlin, Christian; Sinna, Raphael

2017-08-01

The concept of extended thoracodorsal artery perforator (TDAP) flap was described in 2015 for breast reconstruction. Our anatomical study aims to identify the territories vascularised by the thoracodorsal artery perforator via the deep muscular fascial network. The second goal was to define the volume of the extended TDAP flap. Ten extended TDAP flaps were dissected on 5 fresh human cadavers. Around the classical skin paddle of a TDAP flap, the dissections were performed in a subfascial level, including the muscular fascia and the adipose tissue compartments to increase the volume of the flap. After injection of methylene blue in the thoracodorsal artery, we measured the length and width, the surface and the volume of the coloured flap. The mean sizes of the extended TDAP flap were 24.9 cm × 20.1 cm. The mean surface of the total vascularization zone was 441 cm 2 . The mean volume of the vascularized flap was 193 ml. The thoracodorsal artery perforator via the deep muscular fascial network allows us to harvest a flap of 25 cm × 20 cm with a mean surface of 441 cm² and a mean volume of 193 ml. The extended TDAP flap is a credible option in breast reconstruction.

The Pacman Perforator-Based V-Y Advancement Flap for Reconstruction of Pressure Sores at Different Locations.

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Bonomi, Stefano; Salval, André; Brenta, Federica; Rapisarda, Vincenzo; Settembrini, Fernanda

2016-09-01

Many procedures have been proposed for the treatment of pressure sores, and V-Y advancement flaps are widely used to repair a defect. Unfortunately, the degree of mobility of a V-Y advancement flap is dependent on the laxity of the underlying subcutaneous tissue. This is an important disadvantage of traditional V-Y advancement flap and limits its use.We used V-Y advancement flaps as perforator-based to overcome mobility restriction problem, with a further modification (Pacman-like shape) to improve the covering surface area of the flap. Between January 2012 and December 2014, the authors used 37 V-Y Pacman perforator-based flaps in 33 consecutive patients for coverage of defects located at sacral (n = 21), ischial (n = 13), trochanter (n = 1) regions. There were 27 male and 6 female patients with a mean age of 49.9 years (range, 15-74 years). All flaps survived completely (92.3%) except 3 in which one of them had undergone total necrosis due to hematoma and the other 2 had partial necrosis. No venous congestion was observed. The mean follow-up period was 14.9 months (range, 2-38 months). No flap surgery-related mortality or recurrence of pressure sores was noted. The V-Y Pacman perforator-based advancement flaps are safe and very effective for reconstruction of pressure sores at various regions. The advantage of our modification procedure include shorter operative time, lesser pedicle dissection, low donor site morbidity, good preservation of muscle, and offers remarkable excursion to the V-Y flap, which make the V-Y Pacman perforator-based flaps an excellent choice for large pressure sore coverage.

[Identification of perforating vessels by augmented reality: Application for the deep inferior epigastric perforator flap].

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Bosc, R; Fitoussi, A; Pigneur, F; Tacher, V; Hersant, B; Meningaud, J-P

2017-08-01

The augmented reality on smart glasses allows the surgeon to visualize three-dimensional virtual objects during surgery, superimposed in real time to the anatomy of the patient. This makes it possible to preserve the vision of the surgical field and to dispose of added computerized information without the need to use a physical surgical guide or a deported screen. The three-dimensional objects that we used and visualized in augmented reality came from the reconstructions made from the CT-scans of the patients. These objects have been transferred through a dedicated application on stereoscopic smart glasses. The positioning and the stabilization of the virtual layers on the anatomy of the patients were obtained thanks to the recognition, by the glasses, of a tracker placed on the skin. We used this technology, in addition to the usual locating methods for preoperative planning and the selection of perforating vessels for 12 patients operated on a breast reconstruction, by perforating flap of deep lower epigastric artery. The "hands-free" smart glasses with two stereoscopic screens make it possible to provide the reconstructive surgeon with binocular visualization in the operative field of the vessels identified with the CT-scan. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

What Is Safe Limit of the Perforator Flap in Lower Extremity Reconstruction? Do We Have Answers Yet?

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Nikhil S. Panse

2011-01-01

Full Text Available We make an attempt to define the safe extent of local perforator flap for lower limb reconstruction by comparing it with the limb length of the patient. The maximum flap length from the perforator was compared to the limb length in 35 patients using EPI info 6.04 D software. On comparison of flaps that were less than one-third of limb length to those which were more than one-third of limb length, the statistical values were significant. The odds ratio calculated was 6, which means that there is a six times more chance that a local perforator flap will necrose if it is more than one-third of the limb length as compared to a flap which is less than one-third of the limb length.

An innovative method of planning and displaying flap volume in DIEP flap breast reconstructions.

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Hummelink, S; Verhulst, Arico C; Maal, Thomas J J; Hoogeveen, Yvonne L; Schultze Kool, Leo J; Ulrich, Dietmar J O

2017-07-01

Determining the ideal volume of the harvested flap to achieve symmetry in deep inferior epigastric artery perforator (DIEP) flap breast reconstructions is complex. With preoperative imaging techniques such as 3D stereophotogrammetry and computed tomography angiography (CTA) available nowadays, we can combine information to preoperatively plan the optimal flap volume to be harvested. In this proof-of-concept, we investigated whether projection of a virtual flap planning onto the patient's abdomen using a projection method could result in harvesting the correct flap volume. In six patients (n = 9 breasts), 3D stereophotogrammetry and CTA data were combined from which a virtual flap planning was created comprising perforator locations, blood vessel trajectory and flap size. All projected perforators were verified with Doppler ultrasound. Intraoperative flap measurements were collected to validate the determined flap delineation volume. The measured breast volume using 3D stereophotogrammetry was 578 ± 127 cc; on CTA images, 527 ± 106 cc flap volumes were planned. The nine harvested flaps weighed 533 ± 109 g resulting in a planned versus harvested flap mean difference of 5 ± 27 g (flap density 1.0 g/ml). In 41 out of 42 projected perforator locations, a Doppler signal was audible. This proof-of-concept shows in small numbers that flap volumes can be included into a virtual DIEP flap planning, and transferring the virtual planning to the patient through a projection method results in harvesting approximately the same volume during surgery. In our opinion, this innovative approach is the first step in consequently achieving symmetric breast volumes in DIEP flap breast reconstructions. Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Successful Deep Inferior Epigastric Perforator Flap Harvest despite Preoperative Therapeutic Subcutaneous Heparin Administration into the Abdominal Pannus.

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Duncumb, Joseph W; Miyagi, Kana; Forouhi, Parto; Malata, Charles M

2016-01-01

Abdominal free flaps for microsurgical breast reconstruction are most commonly harvested based on the deep inferior epigastric vessels that supply skin and fat via perforators through the rectus muscle and sheath. Intact perforator anatomy and connections are vital for subsequent optimal flap perfusion and avoidance of necrosis, be it partial or total. The intraflap vessels are delicate and easily damaged and it is generally advised that patients should avoid heparin injection into the abdominal pannus preoperatively as this may compromise the vascular perforators through direct needle laceration, pressure from bruising, haematoma formation, or perforator thrombosis secondary to external compression. We report three cases of successful deep inferior epigastric perforator (DIEP) flap harvest despite patients injecting therapeutic doses of low molecular weight heparin into their abdomens for thrombosed central venous lines (portacaths™) used for administering primary chemotherapy in breast cancer.

Successful Deep Inferior Epigastric Perforator Flap Harvest despite Preoperative Therapeutic Subcutaneous Heparin Administration into the Abdominal Pannus

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Joseph W. Duncumb

2016-01-01

Full Text Available Abdominal free flaps for microsurgical breast reconstruction are most commonly harvested based on the deep inferior epigastric vessels that supply skin and fat via perforators through the rectus muscle and sheath. Intact perforator anatomy and connections are vital for subsequent optimal flap perfusion and avoidance of necrosis, be it partial or total. The intraflap vessels are delicate and easily damaged and it is generally advised that patients should avoid heparin injection into the abdominal pannus preoperatively as this may compromise the vascular perforators through direct needle laceration, pressure from bruising, haematoma formation, or perforator thrombosis secondary to external compression. We report three cases of successful deep inferior epigastric perforator (DIEP flap harvest despite patients injecting therapeutic doses of low molecular weight heparin into their abdomens for thrombosed central venous lines (portacaths™ used for administering primary chemotherapy in breast cancer.

The value of dynamic infrared thermography (DIRT) in perforatorselection and planning of free DIEP flaps.

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de Weerd, Louis; Weum, Sven; Mercer, James B

2009-09-01

The aim of this paper is to evaluate dynamic infrared thermography (DIRT) as a technique to assist in preoperative perforator selection and planning of free deep inferior epigastric perforator (DIEP) flaps. Twenty-seven patients, scheduled for secondary autologous breast reconstruction with either a free DIEP flap or superficial inferior epigastric artery flap, were included in this prospective clinical study. Preoperative mapping of perforators was performed with a hand-held Doppler and DIRT. A multidetector computer tomography scan was additionally carried out in the last 8 patients. In 23 patients a DIEP flap was used. The perforator as selected from DIRT was a suitable perforator in all DIEP flaps. The location and quality of the selected perforator from DIRT corresponded well with the multidetector computer tomography scan results. Preoperative perforator selection and planning of DIEP flaps is facilitated with the use of DIRT. The technique is noninvasive and easy to use.

Perforating arteries originating from the posterior communicating artery: a 7.0-Tesla MRI study

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Conijn, Mandy M.A.; Hendrikse, Jeroen; Takahara, Taro; Mali, Willem P.T.M. [University Medical Center Utrecht, Department of Radiology (Hp E 01.132), P.O. Box 85500, Utrecht (Netherlands); Zwanenburg, Jaco J.M. [University Medical Center Utrecht, Image Sciences Institute, Utrecht (Netherlands); Geerlings, Mirjam I. [University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Utrecht (Netherlands); Luijten, Peter R. [University Medical Center Utrecht, Department of Radiology (Hp E 01.132), P.O. Box 85500, Utrecht (Netherlands); University Medical Center Utrecht, Image Sciences Institute, Utrecht (Netherlands)

2009-12-15

The aim of this study was to investigate the ability of time-of-flight (TOF) magnetic resonance (MR) angiography at 7.0 Tesla to show the perforating branches of the posterior communicating artery (PCoA), and to investigate the presence of such visible perforating branches in relation to the size of the feeding PCoA. The secondary aim was to visualise and describe the anterior choroidal artery and the perforating branches of the P1-segment of posterior cerebral artery (P1). Forty-six healthy volunteers underwent TOF MR angiography at 7.0 Tesla. With 7.0-Tesla imaging, we visualised for the first time perforating arteries originating from the PCoA in vivo without the use of contrast agents. A perforating artery from the PCoA was found in a large proportion of the PCoAs (64%). The presence was associated with a larger diameter of the underlying PCoA (1.23 versus 1.06 mm, P = 0.03). The anterior choroidal artery was visible bilaterally in all participants. In 83% of all P1s, one or two perforating branches were visible. Non-invasive assessment of the perforating arteries of the PCoA together with the anterior choroidal artery and the perforating arteries of the P1 may increase our understanding of infarcts in the deep brain structures supplied by these arteries. (orig.)

Perforating arteries originating from the posterior communicating artery: a 7.0-Tesla MRI study

International Nuclear Information System (INIS)

Conijn, Mandy M.A.; Hendrikse, Jeroen; Takahara, Taro; Mali, Willem P.T.M.; Zwanenburg, Jaco J.M.; Geerlings, Mirjam I.; Luijten, Peter R.

2009-01-01

The aim of this study was to investigate the ability of time-of-flight (TOF) magnetic resonance (MR) angiography at 7.0 Tesla to show the perforating branches of the posterior communicating artery (PCoA), and to investigate the presence of such visible perforating branches in relation to the size of the feeding PCoA. The secondary aim was to visualise and describe the anterior choroidal artery and the perforating branches of the P1-segment of posterior cerebral artery (P1). Forty-six healthy volunteers underwent TOF MR angiography at 7.0 Tesla. With 7.0-Tesla imaging, we visualised for the first time perforating arteries originating from the PCoA in vivo without the use of contrast agents. A perforating artery from the PCoA was found in a large proportion of the PCoAs (64%). The presence was associated with a larger diameter of the underlying PCoA (1.23 versus 1.06 mm, P = 0.03). The anterior choroidal artery was visible bilaterally in all participants. In 83% of all P1s, one or two perforating branches were visible. Non-invasive assessment of the perforating arteries of the PCoA together with the anterior choroidal artery and the perforating arteries of the P1 may increase our understanding of infarcts in the deep brain structures supplied by these arteries. (orig.)

Perforating arteries originating from the posterior communicating artery: a 7.0-Tesla MRI study.

Science.gov (United States)

Conijn, Mandy M A; Hendrikse, Jeroen; Zwanenburg, Jaco J M; Takahara, Taro; Geerlings, Mirjam I; Mali, Willem P Th M; Luijten, Peter R

2009-12-01

The aim of this study was to investigate the ability of time-of-flight (TOF) magnetic resonance (MR) angiography at 7.0 Tesla to show the perforating branches of the posterior communicating artery (PCoA), and to investigate the presence of such visible perforating branches in relation to the size of the feeding PCoA. The secondary aim was to visualise and describe the anterior choroidal artery and the perforating branches of the P1-segment of posterior cerebral artery (P1). Forty-six healthy volunteers underwent TOF MR angiography at 7.0 Tesla. With 7.0-Tesla imaging, we visualised for the first time perforating arteries originating from the PCoA in vivo without the use of contrast agents. A perforating artery from the PCoA was found in a large proportion of the PCoAs (64%). The presence was associated with a larger diameter of the underlying PCoA (1.23 versus 1.06 mm, P = 0.03). The anterior choroidal artery was visible bilaterally in all participants. In 83% of all P1s, one or two perforating branches were visible. Non-invasive assessment of the perforating arteries of the PCoA together with the anterior choroidal artery and the perforating arteries of the P1 may increase our understanding of infarcts in the deep brain structures supplied by these arteries.

Peroneal perforator-based peroneus longus tendon and sural neurofasciocutaneous composite flap transfer for a large soft-tissue defect of the forearm: A case report.

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Hayashida, Kenji; Saijo, Hiroto; Fujioka, Masaki

2018-01-01

We describe the use of a composite flap composed of a sural neurofasciocutaneous flap and a vascularized peroneus longus tendon for the reconstruction of severe composite forearm tissue defects in a patient. A 43-year-old man had his left arm caught in a conveyor belt resulting in a large soft-tissue defect of 18 × 11 cm over the dorsum forearm. The extensor carpi radialis, superficial radial nerve, and radial artery were severely damaged. A free neurofasciocutaneous composite flap measuring 16 × 11 cm was outlined on the patient's left lower leg to allow simultaneous skin, tendon, nerve, and artery reconstruction. The flap, which included the peroneus longus tendon, was elevated on the subfascial plane. After the flap was transferred to the recipient site, the peroneal artery was anastomosed to the radial artery in a flow-through manner. The vascularized tendon graft with 15 cm in length was used to reconstruct the extensor carpi radialis longus tendon defect using an interlacing suture technique. As the skin paddle of the sural neurofasciocutaneous flap and the vascularized peroneus longus tendon graft were linked by the perforator and minimal fascial tissue, the skin paddle was able to rotate and slide with comparative ease. The flap survived completely without any complications. The length of follow-up was 12 months and was uneventful. Range of motion of his left wrist joint was slightly limited to 75 degrees. This novel composite flap may be useful for reconstructing long tendon defects associated with extensive forearm soft tissue defects. © 2016 Wiley Periodicals, Inc.

The Versatile Extended Thoracodorsal Artery Perforator Flap for Breast Reconstruction

DEFF Research Database (Denmark)

Jacobs, Jordan; Børsen-Koch, Mikkel; Gunnarsson, Gudjon L.

2016-01-01

complications occurred in 10 of 106 (10%) cases and included hematoma (1/108), venous congestion (2/108), and partial flap necrosis (7/108). The reconstructive goal was achieved in 103 of 106 (97%) flaps. CONCLUSIONS: The TAP flap is a pedicled, fasciocutaneous flap that can be used for total breast...

Sural artery perforator flap with posterior tibial neurovascular decompression for recurrent foot ulcer in leprosy patients

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Ismail, Hossam El-din Ali

2017-01-01

Full Text Available Introduction: The sensory loss and alteration of the shape of the foot make the foot liable to trauma and pressure, and subsequently cause more callus formation, blisters, and ulcers. Foot ulcers usually are liable to secondary infection as cellulitis or osteomyelitis, and may result in amputations. Foot ulcers are a major problem and a major cause of handicaps in leprosy patients. The current study is to present our clinical experience and evaluate the use of sural flap with posterior tibial neurovascular decompression (PTND in recurrent foot ulcers in leprosy patients.Patient and methods: A total number of 9 patients were suffering from chronic sequelae of leprosy as recurrent foot ulcers. All the patients were reconstructed with the reverse sural artery fasciocutaneous flap with posterior tibial neurovascular decompression from September 2012 to August 2015. Six patients were male and three were female with a mean age of 39.8 years (range, 30–50 years. All the soft tissue defects were in the weight-bearing area of the inside of the foot. The flap sizes ranged from 15/4 to 18/6 cm. Mean follow-up period was 21.2 months (range, 35–2 months.Results: All the flaps healed uneventfully. There was no major complication as total flap necrosis. Only minor complications occurred which were treated without surgical intervention except in two patients who developed superficial necrosis of the skin paddle. Surgical debridement was done one week later. The flap was completely viable after surgery, and the contour of the foot was restored. We found that an improvement of sensation occurred in those patients in whom the anesthesia started one year ago or less and no sensory recovery in patient in whom the anesthesia had lasted for more than two years.Conclusion: The reverse sural artery flap with posterior tibial neurovascular decompression provides a reliable method for recurrent foot soft tissue reconstruction in leprosy patients with encouraging

Long-term follow-up for keystone design perforator island flap for closure of myelomeningocele.

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Donaldson, Christopher; Murday, Hamsaveni K M; Gutman, Matthew J; Maher, Rory; Goldschlager, Tony; Xenos, Chris; Danks, R Andrew

2018-04-01

We have previously reported a small series on the closure of large myelomeningocele (MMC) defects with a keystone design perforator island flap (KDPIF) in a paediatric neurosurgical centre in Australia. We are now presenting an updated longer term follow-up of an expanded series demonstrating longer term durability of this vascularized flap for large myelomeningocele defects. The prospective data from the Monash Neurosurgical Database were used to select all cases of MMC between December 2008 and September 2016. Retrospective analysis of the neurosurgical database revealed an additional three patients who underwent KDPIF closure at the Monash Medical Centre for MMC repair at birth. Wound healing was satisfactory in all six cases. With delayed follow-up, there was no associated skin flap separation, skin flap dehiscence, skin flap necrosis, cerebro-spinal fluid leak, however two infections were encountered, both resolved with conservative management including antibiotics and simple washout. In this expanded case series with increased longevity of follow-up, the keystone design perforator island flap remains a robust alternative for closure of large myelomeningocele defects.

A systematic review of complication and recurrence rates of musculocutaneous, fasciocutaneous, and perforator-based flaps for treatment of pressure sores.

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Sameem, Mojib; Au, Michael; Wood, Thomas; Farrokhyar, Forough; Mahoney, James

2012-07-01

Management of pressure sores poses a significant reconstructive challenge for plastic surgeons. Currently, there is no consensus on whether musculocutaneous, fasciocutaneous, or perforator-based flaps provide superior results for treating pressure sores. The following databases were searched: Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, LILACS (January of 1950 to November of 2010), MEDLINE (January of 1950 to November of 2010), and EMBASE (January of 1980 to November of 2010). Only articles reporting on the use of musculocutaneous, fasciocutaneous, and perforator-based flaps were included. The primary study outcomes were complication and recurrence rates. Fifty-five articles were included in the final analysis (kappa = 0.78). From this total, 28 were categorized as pertaining to musculocutaneous flaps, 13 studied fasciocutaneous flaps, and 14 evaluated perforator-based flaps. The authors' review revealed recurrence and complication rates of 8.9 and 18.6 percent, respectively, following reconstruction with musculocutaneous flaps, 11.2 and 11.7 percent following reconstruction with fasciocutaneous flaps, and 5.6 and 19.6 percent following reconstruction with perforator-based flaps. Overall, statistical analysis revealed no significant difference in complication or recurrence rates among these three techniques. The authors' review revealed that there was no statistically significant difference with regard to recurrence or complication rates among musculocutaneous, fasciocutaneous, or perforator-based flaps. This suggests that surgeons performing such reconstructive procedures may choose to consider the advantages of a specific approach rather than the complication and recurrence rates. Therapeutic, IV.

A Novel Augmented Reality-Based Navigation System in Perforator Flap Transplantation - A Feasibility Study.

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Jiang, Taoran; Zhu, Ming; Zan, Tao; Gu, Bin; Li, Qingfeng

2017-08-01

In perforator flap transplantation, dissection of the perforator is an important but difficult procedure because of the high variability in vascular anatomy. Preoperative imaging techniques could provide substantial information about vascular anatomy; however, it cannot provide direct guidance for surgeons during the operation. In this study, a navigation system (NS) was established to overlie a vascular map on surgical sites to further provide a direct guide for perforator flap transplantation. The NS was established based on computed tomographic angiography and augmented reality techniques. A virtual vascular map was reconstructed according to computed tomographic angiography data and projected onto real patient images using ARToolKit software. Additionally, a screw-fixation marker holder was created to facilitate registration. With the use of a tracking and display system, we conducted the NS on an animal model and measured the system error on a rapid prototyping model. The NS assistance allowed for correct identification, as well as a safe and precise dissection of the perforator. The mean value of the system error was determined to be 3.474 ± 1.546 mm. Augmented reality-based NS can provide precise navigation information by directly displaying a 3-dimensional individual anatomical virtual model onto the operative field in real time. It will allow rapid identification and safe dissection of a perforator in free flap transplantation surgery.

A Rare Case of Giant Basal Cell Carcinoma of the Abdominal Wall: Excision and Immediate Reconstruction with a Pedicled Deep Inferior Epigastric Artery Perforator (DIEP) Flap.

Science.gov (United States)

Di Lorenzo, Sara; Zabbia, Giovanni; Corradino, Bartolo; Tripoli, Massimiliano; Pirrello, Roberto; Cordova, Adriana

2017-12-04

BACKGROUND Basal cell carcinoma (BCC) greater than 5 cm in diameter is called giant basal cell carcinoma (GBCC), or super giant basal cell carcinoma if it has a diameter larger than 20 cm. Giant BCC only accounts for 0.5% of BCCs and super giant BCC is exceedingly rare. On account of their rarity, there are no established guidelines for GBCC treatment. CASE REPORT We describe a peculiar case of an 82-year-old woman with a GBCC carcinoma of the lower abdominal wall. The tumor was surgically removed with ipsilateral inguinal lymph nodes and the abdominal wall was reconstructed immediately with a pedicled deep inferior epigastric artery perforator (DIEP) flap. CONCLUSIONS Treatment of giant basal cell carcinoma is often difficult, especially in elderly patients with poor general health and multiple pathologies. The pedicled DIEP flap is rotated to cover the loss of substance without tension, and it is easy to harvest and transfer. This flap allowed a good result without local or systemic complication. We present this report as a reminder of the occasional occurrence of extremely aggressive BCCs. We believe that, especially for rare tumors like these, it is very useful for the entire scientific community to publish these cases and the therapeutic strategies used to treat them.

Evaluation of dynamic infrared thermography as an alternative to CT angiography for perforator mapping in breast reconstruction: a clinical study

International Nuclear Information System (INIS)

Weum, Sven; Mercer, James B.; Weerd, Louis de

2016-01-01

The current gold standard for preoperative perforator mapping in breast reconstruction with a DIEP flap is CT angiography (CTA). Dynamic infrared thermography (DIRT) is an imaging method that does not require ionizing radiation or contrast injection. We evaluated if DIRT could be an alternative to CTA in perforator mapping. Twenty-five patients scheduled for secondary breast reconstruction with a DIEP flap were included. Preoperatively, the lower abdomen was examined with hand-held Doppler, DIRT and CTA. Arterial Doppler sound locations were marked on the skin. DIRT examination involved rewarming of the abdominal skin after a mild cold challenge. The locations of hot spots on DIRT were compared with the arterial Doppler sound locations. The rate and pattern of rewarming of the hot spots were analyzed. Multiplanar CT reconstructions were used to see if hot spots were related to perforators on CTA. All flaps were based on the perforator selected with DIRT and the surgical outcome was analyzed. First appearing hot spots were always associated with arterial Doppler sounds and clearly visible perforators on CTA. The hot spots on DIRT images were always slightly laterally located in relation to the exit points of the associated perforators through the rectus abdominis fascia on CTA. Some periumbilical perforators were not associated with hot spots and showed communication with the superficial inferior epigastric vein on CTA. The selected perforators adequately perfused all flaps. This study confirms that perforators selected with DIRT have arterial Doppler sound, are clearly visible on CTA and provide adequate perfusion for DIEP breast reconstruction. Retrospectively registered at ClinicalTrials.gov with identifier NCT02806518

A Renal Perforating Artery Mistaken for Arterial Bleeding after Percutaneous Renal Biopsy: A Case Report

International Nuclear Information System (INIS)

Kim, Ye Lim; Lee, Chang Hee; Kim, Kyeong Ah; Park, Cheol Min

2009-01-01

Perirenal hematoma after a renal biopsy is a common complication that usually resolves spontaneously, but this rarely requires transfusions or surgical/radiological intervention. We report here on a case of a renal perforating artery that was mistaken for renal arterial bleeding in a 53-year-old woman who was complicated with perirenal hematoma after undergoing a percutaneous renal biopsy. On the color and pulsed wave Doppler ultrasonography, linear blood flow was seen in the perirenal hematoma, which extended perpendicularly from the renal parenchyma into the perirenal space, and this linear blood flow exhibited an arterial pulse wave. On CT angiography, the renal perforating artery was demonstrated as a curvilinear vessel coursing tangentially to the renal margin and we decided that it was a pseudolesion caused by the renal perforating artery. A renal perforating artery may be mistaken for renal arterial bleeding after a percutaneous renal biopsy. A renal perforating artery and arterial bleeding can be differentiated by the location and shape seen on a color Doppler examination and the pulse waves characteristics

A Renal Perforating Artery Mistaken for Arterial Bleeding after Percutaneous Renal Biopsy: A Case Report

Energy Technology Data Exchange (ETDEWEB)

Kim, Ye Lim; Lee, Chang Hee; Kim, Kyeong Ah; Park, Cheol Min [Korea University College of Medicine, Seoul (Korea, Republic of)

2009-12-15

Perirenal hematoma after a renal biopsy is a common complication that usually resolves spontaneously, but this rarely requires transfusions or surgical/radiological intervention. We report here on a case of a renal perforating artery that was mistaken for renal arterial bleeding in a 53-year-old woman who was complicated with perirenal hematoma after undergoing a percutaneous renal biopsy. On the color and pulsed wave Doppler ultrasonography, linear blood flow was seen in the perirenal hematoma, which extended perpendicularly from the renal parenchyma into the perirenal space, and this linear blood flow exhibited an arterial pulse wave. On CT angiography, the renal perforating artery was demonstrated as a curvilinear vessel coursing tangentially to the renal margin and we decided that it was a pseudolesion caused by the renal perforating artery. A renal perforating artery may be mistaken for renal arterial bleeding after a percutaneous renal biopsy. A renal perforating artery and arterial bleeding can be differentiated by the location and shape seen on a color Doppler examination and the pulse waves characteristics

Ad hoc posterior tibial vessels perforator propeller flaps for the reconstruction of lower third leg soft- tissue defects

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Thalaivirithan Margabandu Balakrishnan

2017-01-01

Full Text Available Introduction: Lower third leg soft tissue defects with anatomical and pathological constraints are posing formidable challenges to reconstructive surgeon. Aim: This retrospective study was conducted to assess the effectiveness of ad hoc posterior tibial vessels perforator-propeller flaps for the reconstruction of small and medium sized soft tissue defects in the lower third leg. Patients and Methods: 22 patients (16 were males and 6 were females were involved in this study between period of January 2012 and December 2016.We followed the protocol of initial non delineating exploratory incision made to find out single best perforator in all patients. All the defects in leg reconstructed with adhoc posterior tibial vessel propeller flaps. Results: All 22 flaps survived well. All in an average of 13 months follow up period, had pain free walking, with minimal scarring and acceptable aesthesis at the reconstruction sites with no need for any secondary procedure. Conclusion: With inability of preoperatively dopplering the perforators in the lower third leg region, the exploratory posterior nondelineating incision was used in all cases to secure the single best perforator for the propeller flaps. Thus adhoc posterior tibial vessel propeller flaps are dependable, easily adoptable for the reconstruction of soft tissue defects of the lower third leg region.

Reconstruction of trochanteric pressure sores with pedicled anterolateral thigh myocutaneous flaps.

Science.gov (United States)

Wang, Chih-Hsin; Chen, Shih-Yi; Fu, Ju-Peng; Dai, Niann-Tzyy; Chen, Shao-Liang; Chen, Tim-Mo; Chen, Shyi-Gen

2011-05-01

To provide an alternative choice for covering trochanteric pressure sores, we report on a modified pedicle anterolateral thigh (ALT) myocutaneous flap based on the descending branch of the lateral circumflex femoral artery. From August 2007 to January 2010, 20 consecutive patients (10 men and 10 women) underwent 21 pedicled ALT myocutaneous flaps for reconstruction of trochanteric pressure sores. The flap was designed and elevated, resembling the ALT perforator flap including part of the vastus lateralis muscle but without skeletonisation of the perforators. The mean age of patients was 79.4 years (range: 46-103). The mean follow-up period was 13.9 months (range: 3-32). The flaps were 8-21 cm long and 5-11 cm wide. All flaps healed without major complications. All donor sites were closed primarily without skin grafting and showed good aesthetic results. No recurrence was observed. This modified design of pedicled ALT myocutaneous flap without skeletonisation of perforators is a reliable and easily harvested flap for reconstruction of trochanteric pressure sores with limited morbidity. Crown Copyright © 2010. Published by Elsevier Ltd. All rights reserved.

Free-flap surgical correction of facial deformity after anteromedial maxillectomy.

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Sarukawa, Shunji; Kamochi, Hideaki; Noguchi, Tadahide; Sunaga, Ataru; Uda, Hirokazu; Mori, Yoshiyuki; Nishino, Hiroshi; Yoshimura, Kotaro

2017-09-01

Anteromedial maxillectomy is typically performed in conjunction with low-dose radiotherapy and intraarterial chemotherapy. In doing so, the extent of surgical defects is reduced. However, nasal deviation and oral incompetence may ensue, due to cicatricial contracture of wounds, and may be distressing to these patients. Herein, we report a series of eight free perforator flap procedures (anterolateral thigh [ALT] flap, 6; thoracodorsal artery perforator [TAP] flap, 2) used to correct such deformities. The TAP flap was combined with scapular tip [ST] osseous flap in patients with added zygomatic prominence defects. Three adipocutaneous parts developed from each perforator flap were applied as follows: two to reconstruct nasal lining and oral vestibule, and one to augment cheek volume. All aesthetic results proved satisfactory, although orbital dystopia and contracture of mimic muscles were not resolved completely. These secondary interventions are suitable for sequelae of simple anteromedial maxillectomy. Immediate reconstruction should be considered if orbital floor and mimic muscles are involved. Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Island Latissimus Dorsi Muscle Flap and a Perforator Flap in Repairing Post-Gunshot Thoracic Spine CSF Fistula: Case Presentation

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Nangole F. Wanjala

2015-01-01

Full Text Available Persistent posttraumatic CSF fluid leakage may present a challenge to manage. Failure to address the leakage may result in complications such as meningitis, septicemia, radiculopathy, muscle weakness, and back pains. While the majority of the leakages may be managed conservatively, large dura defects as a result of gunshot wounds or motor vehicle accidents are best managed by surgical interventions. This may range from primary closure of the defect to fascial grafts, adhesive glues, and flaps. We present our experience with the use of flaps in a patient who had sustained such wounds in the thoracic spine. An island latissimus dorsal flap and a perforator fasciocutaneous flap were used to close the defect. Postoperatively the patient recovered well and the wounds healed without any complications.

Perforating arteries originating from the posterior communicating artery: a 7.0-Tesla MRI study

OpenAIRE

Conijn, Mandy M. A.; Hendrikse, Jeroen; Zwanenburg, Jaco J. M.; Takahara, Taro; Geerlings, Mirjam I.; Mali, Willem P. Th. M.; Luijten, Peter R.

2009-01-01

The aim of this study was to investigate the ability of time-of-flight (TOF) magnetic resonance (MR) angiography at 7.0?Tesla to show the perforating branches of the posterior communicating artery (PCoA), and to investigate the presence of such visible perforating branches in relation to the size of the feeding PCoA. The secondary aim was to visualise and describe the anterior choroidal artery and the perforating branches of the P1-segment of posterior cerebral artery (P1). Forty-six healthy ...

Applying the Keystone Design Perforator Island Flap Concept in a Variety of Anatomic Locations: A Review of 60 Consecutive Cases by a Single Surgeon.

Science.gov (United States)

Lanni, Michael Alan; Van Kouwenberg, Emily; Yan, Alan; Rezak, Kristen M; Patel, Ashit

2017-07-01

The keystone design perforator island flap has been gaining popularity for reconstruction of cutaneous defects. Published experience of this technique in North America is limited predominantly to the trunk and extremities; our study aims to demonstrate expanding applications. Retrospective chart review was conducted on all patients who underwent keystone flap reconstruction by a single surgeon. Outcomes of interest were wound healing complications (WHC) and surgical site infections (SSI). Mean follow up time was 24.4 months. Sixty consecutive flaps were performed with an overall WHC rate of 26.7% and SSI rate of 11.7%. Reconstructed sites included 25 lower extremity, 20 trunk, 5 upper extremity, and 10 head and neck. Flap size averaged 405.6 cm (range 16-2303). Wound healing complications were associated with coronary artery disease (P = 0.04) and traumatic defects (P = 0.043). Surgical site infections were associated with coronary artery disease (P = 0.02) and flap size of 251 to 500 cm (P = 0.039), although this association was not seen among flaps greater than 500 cm. Although more common in lower extremity reconstructions, no statistically significant associations between flap location and WHC (P = 0.055) or SSI (P = 0.29) were identified. There were no reconstructive failures and no patients required reoperation. This series demonstrates the versatility of the keystone flap in a wide variety of anatomic locations, with similar complication rates to those previously reported and no reoperations. Flap design was frequently modified based on the anatomical topography and adjacent subunits. To our knowledge, this is the largest and most diverse North American series of keystone flap reconstructions to date.

Indications, Outcomes, and Complications of Pedicled Propeller Perforator Flaps for Upper Body Defects: A Systematic Review

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Davide Lazzeri

2013-01-01

Full Text Available Background The aim of this investigation was to systematically review the current literatureto provide the best data for indications, outcomes, survival, and complication rates ofpedicled propeller perforator flaps for upper body defects.Methods A comprehensive literature review for articles published from January 1991 toDecember 2011 was performed using the PubMed, Medline, and Cochrane Databases. Articleswithout available full-text, single case reports or papers with excessive missing data wereexcluded. Papers reporting pedicle-perforator (propeller flaps used for lower extremityreconstruction were excluded from meta-analysis.Results From the initial 1,736 studies our search yielded, 343 studies qualified for the secondstage of selection. Of 117 full-text reports screened, 41 studies, met the definitive inclusionand exclusion criteria. Of the selected 41 articles, 26 were case series, original papers orretrospective reviews and were included, whereas 15 were case report papers and thereforewere excluded. Two hundred ninety-five propeller flaps were reported to have been used ina total of 283 patients. Indications include repair of trauma-induced injuries, post-traumarevision surgery, cancer resection, chronic infection, pressure sores, and chronic ulcers with amajor complication rate (3.3% comparable to that of free flaps. No specific exclusion criteriafor the procedure were presented in the studies reviewed.Conclusions Pedicled propeller flaps are a versatile and safe reconstructive option that areeasy and quick to raise and that provide unlimited clinical solutions because of the theoreticalpossibility of harvesting them based on any perforator chosen among those classified in the body.

Indications, Outcomes, and Complications of Pedicled Propeller Perforator Flaps for Upper Body Defects: A Systematic Review

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Davide Lazzeri

2013-01-01

Full Text Available BackgroundThe 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.MethodsA 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.ResultsFrom 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.ConclusionsPedicled 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.

Perforator anatomy of the radial forearm free flap versus the ulnar forearm free flap for head and neck reconstruction

NARCIS (Netherlands)

Hekner, D.D.; Roeling, TAP; van Cann, EM

The aim of this study was to investigate the vascular anatomy of the distal forearm in order to optimize the choice between the radial forearm free flap and the ulnar forearm free flap and to select the best site to harvest the flap. The radial and ulnar arteries of seven fresh cadavers were

The truly distal lateral arm flap: rationale and risk factors of a microsurgical workhorse in 30 patients

NARCIS (Netherlands)

Hage, J. Joris; Woerdeman, Leonie A. E.; Smeulders, Mark J. C.

2005-01-01

The forearm part of the extended lateral arm flap may be separately raised on the most distal septocutaneous perforator of the posterior collateral radial artery. This truly distal lateral arm flap shares most of the advantages of the radial forearm flap and is associated with less donor site

Pilot study of breast sensation after breast reconstruction: evaluating the effects of radiation therapy and perforator flap neurotization on sensory recovery.

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Magarakis, Michael; Venkat, Raghunandan; Dellon, A Lee; Shridharani, Sachin M; Bellamy, Justin; Vaca, Elbert E; Jeter, Stacie C; Zoras, Odysseas; Manahan, Michele A; Rosson, Gedge D

2013-09-01

Some sensation to the breast returns after breast reconstruction, but recovery is variable and unpredictable. We primarily sought to assess the impact of different types of breast reconstruction [deep inferior epigastric artery perforator (DIEP) flaps versus implants] and radiation therapy on the return of sensation. Thirty-seven patients who had unilateral or bilateral breast reconstruction via a DIEP flap or implant-based reconstruction, with or without radiation therapy (minimum follow-up, 18 months; range, 18-61 months) were studied. Of the 74 breasts, 27 had DIEP flaps, 29 had implants, and 18 were nonreconstructed. Eleven breasts with implants and 10 with DIEP flaps had had prereconstruction radiation therapy. The primary outcome was mean patient-perceived static and moving cutaneous pressure threshold in nine areas. We used univariate and multivariate analyses to assess what independent factors affected the return of sensation (significance, P sensation (P = 0.041) than did DIEP flaps. However, among irradiated breasts, skin over DIEP flaps had significantly better sensation than did that over implants (static, P = 0.019; moving, P = 0.028). Implant reconstructions with irradiated skin had significantly worse static (P = 0.002) and moving sensation (P = 0.014) than did nonirradiated implant reconstructions. Without irradiation, skin overlying implants is associated with better sensation recovery than DIEP flap skin. However, with irradiation, DIEP flap skin had better sensation recovery than did skin over implants. Neurotization trended toward improvement in sensation in DIEP flaps. Copyright © 2013 Wiley Periodicals, Inc.

Routine closure of the donor site with a second dorsal metacarpal artery flap to avoid the use of a skin graft after harvest of a first dorsal metacarpal artery flap.

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Chi, Zhenglin; Lin, Damu; Chen, Yiheng; Xue, Jixin; Li, Shi; Chu, Tinggang; Li, Zhijie

2018-06-01

Closure of the donor site on the index finger after raising a first dorsal metacarpal artery (DMA) flap harvest is challenging. The conventional choice is to use a full-thickness skin graft. However, this procedure is associated with several complications and a second donor site to harvest the skin graft is inevitable. The aim of this study was to design a modified incision to allow harvest of a first DMA flap without skin graft. From 2015 to 2016, 18 patients with a soft tissue defect of the thumb had reconstruction of the defect using a first DMA flap. A modified incision was used and a relaying perforator flap pedicled on the second DMA was raised through the same incision to cover the donor site. Patient satisfaction, appearance of the injured hand, and the active range of motion (ROM) were assessed. The sensitivity was evaluated by the 2-point discrimination (2-PD) test. All flaps survived completely without complications. Good coverage was obtained with only one linear scar in the dorsum of the hand and no skin grafts. All patients recovered full range of movement in their fingers and regained sensitivity of the flaps. All patients were satisfied with their hand function according to the Michigan Hand Outcomes Questionnaire (MHQ). The mean cosmetic score for the appearance of the injured hand was 8.2 out of 10. Using our modified incision, it was possible to harvest a second DMA flap at the same time as a first DMA flap allowing simultaneous coverage of the donor defect on the index finger. This prevented the need for a skin graft with all of the associated disadvantages. Copyright © 2018. Published by Elsevier Ltd.

Medial circumflex femoral artery flap for ischial pressure sore

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Palanivelu S

2009-01-01

Full Text Available A new axial pattern flap based on the terminal branches of the medial circumflex femoral artery is described for coverage of ischial pressure sore. Based on the terminal branches of the transverse branch of medial circumflex femoral artery, which exit through the gap between the quadratus femoris muscle above and the upper border of adductor magnus muscle below, this fascio cutaneous flap is much smaller than the posterior thigh flap but extremely useful to cover ischeal pressure sores. The skin redundancy below the gluteal fold allows a primary closure of the donor defect. It can also be used in combination with biceps femoris muscle flap.

Intraoperative use of indocyanine green angiography for selecting the more reliable perforator of the anterolateral thigh flap: A comparison study.

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La Padula, Simone; Hersant, Barbara; Meningaud, Jean Paul

2018-03-30

Anatomical variability of anterolateral thigh flap (ALT) perforators has been reported. The aim of this study is to assess if the use of intraoperative indocyanine green angiography (iICGA) can help surgeons to choose the ALT flap best perforator to be preserved. A retrospective study was conducted in 28 patients with open tibial fracture, following a road traffic crash, who had undergone ALT flap. Patients were classified into two groups: ICGA group (iICGA was used to select the more reliable perforator) and control group. The mean tissue loss size of the ICGA group (n = 13, 11 men and 2 women, mean age: 52 ± 6 years) was of 16.6 cm × 12.2 cm. The mean defect size of the control group (n = 15, 14 men and 1 women, mean age: 50 ± 5.52 years) was of 15.3 cm × 11.1 cm. Statistical analysis was performed to analyze and compare the results. ICGA allowed preserving only the most functional perforator, that provided the best ALT flap perfusion in 10 out of the 13 cases (77%). ICGA allowed a significant operative time reduction (160 ± 23 vs. 202 ± 48 minutes; P < .001). One case of distal necrosis was observed in the ICGA group (mean follow-up 12.3 months), while partial skin necrosis occurred in three cases of the control group (mean follow-up 13.1 months); P = .35. No additional coverage was required and a successful bone healing was observed in both groups. These findings suggest that iICGA is an effective method that allows to select the most reliable ALT flap perforators and to reduce operative time. © 2018 Wiley Periodicals, Inc.

[Application of distal palm perforator mini-flap in repair of scar contracture of digital web-spaces].

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Zhou, Xiao; Xu, Yajun; Rui, Yongjun; Shou, Kuishui; Yao, Qun

2011-02-01

To discuss the effectiveness of distal palm perforator mini-flap in the treatment of scar contracture of digital web-spaces. Between August 2008 and March 2010, 6 cases of scar contracture of digital web-spaces were treated, including 4 males and 2 females and aging 16-68 years (mean, 45 years). The causes were burn injury, twisting injury, and crush injury in 2 cases, respectively. The disease duration was from 3 months to 3 years. The affected digital web-spaces were from index finger to middle finger in 2 cases, from middle finger to ring finger in 3 cases, and from ring finger to small finger in 1 case. The maximum abduction degree of digital web-spaces was 5-10 degrees. The sizes and the depths of reshape of digital web-spaces disappeared. The defect size ranged from 20 mm x 8 mm to 30 mm x 13 mm after opening digital web-spaces. The size of the distal palm perforator mini-flap ranged from 25 mm x 10 mm to 35 mm x 15 mm. The donor sites were sutured directly. All 6 flaps survived and got primary healing. Incisions at donor sites healed by first intention. All patients were followed up 6-12 months. The reconstructed digital web-spaces had good appearance and soft texture. The range of motion of metacarpophalangeal joint was normal. The sizes and the depths of reshape of digital web-spaces were similar to normal ones. The maximum abduction degree of digital web-spaces was 40-60 degrees. There was no scar contracture of incision of palm. The shape of flaps and function of the fingers were satisfactory after 6-12 months of follow-up. It is an ideal method to treat scar contracture of digital web-spaces with distal palm perforator mini-flap.

Comparison of dissection with harmonic scalpel and conventional bipolar electrocautery in deep inferior epigastric perforator flap surgery: A consecutive cohort study.

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Lee, Yoon Jae; Kim, Hak Young; Han, Hyun Ho; Moon, Suk-Ho; Byeon, Jun Hee; Rhie, Jong Won; Ahn, Sang Tae; Oh, Deuk Young

2017-02-01

Reduced tissue damage is a theoretical advantage of using an ultrasonic harmonic scalpel. We hypothesized that the harmonic scalpel would outperform electrocautery in deep inferior epigastric perforator flap surgery, possibly resulting in a shorter operative time and reduced postoperative drainage and pain. Between January and August 2015, 24 consecutive patients were assigned to immediate deep inferior epigastric perforator flap elevation (12 for bipolar electrocautery and 12 for harmonic scalpel). The main outcome variables were total operative time, flap elevation time (starting from the fascia incision), and drainage volume. We compared the number of perforators isolated and the Moon and Taylor classification of the pedicle. Data were tested for normality using the Kolmogorov-Smirnov test before analysis. Continuous variables were compared by Wilcoxon rank-sum test. Data were analyzed using the statistical software SAS, version 9.3 (SAS Institute, Cary, NC, USA). Both groups were comparable with respect to clinical characteristics (mean age, body mass index, and flap weights). There was a statistically significant difference in the operative time between dissection with the harmonic scalpel and electrocautery (305.2 vs. 380.3 min, respectively, p = 0.002). The flap elevation time was reduced, particularly when using the harmonic scalpel where its usage seems crucial for dissecting deep inferior epigastric perforators (59.8 vs. 145.9 min, respectively, p electrocautery. Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Versatility of the Angularis Oris Axial Pattern Flap for Facial Reconstruction.

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Losinski, Sara L; Stanley, Bryden J; Schallberger, Sandra P; Nelson, Laura L; Towle Millard, Heather A M

2015-11-01

To describe the versatility of the axial pattern flap based on the cutaneous perforating branch of the angularis oris artery for reconstruction of large facial defects in dogs, including complications and clinical outcomes. Retrospective clinical case series. Client-owned dogs (n = 8). Facial flaps (n = 9) based at the commissure of the lip with a caudodorsal orientation were utilized, with established anatomical borders. Flaps were elevated deep to the panniculus carnosus in a caudal to rostral direction, preserving the angularis oris artery, its cutaneous perforator, and surrounding cutaneous vasculature. Flaps were rotated dorsally or ventrally to cover the defect. Primary closure of the donor site was by direct apposition in all cases. Angularis oris axial pattern flaps were most commonly used to close large defects of the nasomaxillary area rostral to the eyes (6 dogs), followed by orbital (2) and intermandibular (1) defects. Defects occurred because of tumor resection (6 dogs), trauma (2), and a chronic, non-healing wounding (1). All flaps healed with acceptable functional and cosmetic outcomes without major complications. Followup ranged from 10 days to 16 months. Minor postoperative complications included flap edema (8 dogs), partial incisional dehiscence (3), distal tip necrosis (2), and oroantral fistula recurrence (1). Angularis oris axial pattern flaps provided hirsute, full-thickness skin coverage of a variety of large facial defects with minor complications, and should be considered when restructuring large defects of the rostral face or chin. © Copyright 2015 by The American College of Veterinary Surgeons.

Sudden shrinkage of free rectus abdominis musculocutaneous flap 15 years after maxilla reconstruction

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Yasushi Mochizuki

2018-03-01

Full Text Available A 60-year-old male displayed sudden shrinkage of a left free rectus abdominis musculocutaneous flap, which had been grafted to his left maxilla 15 years previously. No post-reconstructive irradiation had been performed, and no late occlusion of the vascular anastomosis, local infection, recurrence of the maxillary cancer, or body weight loss was observed. However, the shrinkage amounted to approximately 50%. This is considerably more than previously reported cases of shrinkage of various free flaps, which ranged between 10% and 25%. The resultant depression was successfully augmented with a right free deep inferior epigastric artery perforator flap. The residual fat volume of the previously grafted shrunken flap was revealed to be compatible with that of the newly harvested contralateral perforator flap. Thus, the volume of the previously grafted flap may reflect the status of the intact contralateral donor site, although the mechanism of sudden flap shrinkage is unclear.

Transmural coil embolization—alternative technique for management of arterial perforation during subintimal angioplasty

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Karthikeyan Damodharan

2016-01-01

Full Text Available Subintimal angioplasty of lower limb arterial occlusion carries a relatively higher risk of vessel perforation compared to transluminal angioplasty. Vessel perforation is a potentially life threatening complication which requires prompt recognition and management. They are usually managed by endovascular techniques such as low-pressure balloon tamponade, covered stents, and coil embolization of the ruptured artery. We describe a technique of treating vessel perforation following balloon angioplasty. Patient developed a large perforation of the proximal superficial femoral artery (SFA after balloon inflation during subintimal angioplasty of complete SFA occlusion. Following failure of balloon tamponade in sealing the perforation, we successfully treated it by deploying an embolization coil at the site of perforation through the vessel wall followed by balloon tamponade. Our technique could be a useful relatively inexpensive alternative treatment option in the management of vessel perforation compared to covered stents.

Colgajo bilateral de perforantes lumbares para la reconstrucción de un severo defecto tóracolumbar Bilateral lumbar perforator flap in reconstruction of a wide toracolumbar defect

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P. Benito Duque

2006-06-01

Full Text Available En la reconstrucción de los defectos toracolumbares se han empleado numerosas técnicas quirúrgicas. Ocasionalmente se puede utilizar el cierre directo, injertos de piel, colgajos de dorsal ancho volteado y lumbosacro transverso, colgajos de transposición o de rotación tipo random, pero están limitados cuando los tejidos circundantes están radiados o presentan cicatrices por cirugías previas. Igualmente, la extensión del defecto puede hacerlos inviables. Los colgajos de perforantes están especialmente indicados en pacientes con deambulación conservada, haciendo posible el aporte de una gran superficie de piel y tejido subcutáneo bien vascularizado, basado en los vasos perforantes y evitando así el sacrificio de vasos principales o músculos. Presentamos el caso de una paciente con un defecto en la espalda de 17 cm. De diámetro secundario a la resección de un tumor espinocelular con exposición de cuerpos vertebrales, tratado mediante la transposición de dos colgajos basados en las arterias perforantes lumbares asociados a un colgajo de rotación de dorsal ancho miocutáneo.Thoracolumbar defects have been treated by a variety of surgical methods. Primary closure, skin grafting, reverse latissimus dorsi musculocutaneous flap, transverse lumbosacral back flap, local randomly designed rotation, or transposition flaps may be indicated in occasional cases, but there is limited indication for their use in some cases with a wide lesion or when the surrounding tissues have been compromised by previous surgery or irradiation. Perforator flaps are specially indicated for ambulatory patients, in which large amounts of well-vascularized skin and subcutaneous tissue are transfered easily based on one perforator vessel without sacrificing main vessels or muscles. The authors present a patient with a 17 cm wide defect in the midback region and exposed bone after excision of a squamous cell carcinoma, treated by two perforator flaps based on

Anterograde Intra-Arterial Urokinase Injection for Salvaging Fibular Free Flap

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Dae-Sung Lee

2013-05-01

Full Text Available We present a case of a 57-year-old male patient who presented with squamous cell carcinoma on his mouth floor with cervical and mandibular metastases. Wide glossectomy with intergonial mandibular ostectomy, and sequential reconstruction using fibular osteomyocutaneous free flap were planned. When the anastomosis between the peroneal artery of the fibular free flap and the right lingual artery was performed, no venous flow was observed at the vena comitans. Then re-anastomosis followed by topical application of papaverine and lidocaine was attempted. However, the blood supply was not recovered. Warm saline irrigation over 30 minutes was also useless. Microvascular thromboses of donor vessels were clinically suspected, so a solution of 100,000 units of urokinase was infused once through a 26-gauge angiocatheter inserted into the recipient artery just at the arterial anastomotic site, until the solution gushed out through the flap vena comitans. Immediately after the application of urokinase, arterial flow and venous return were restored. There were no complications during the follow-up period of 11 months. We believe that vibrating injuries from the reciprocating saw during osteotomies and flap insetting might be the cause of microvascular thromboses. The use of urokinase may provide a viable option for the treatment of suspicious intraoperative arterial thrombosis.

Triple flap technique for vulvar reconstruction.

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Mercut, R; Sinna, R; Vaucher, R; Giroux, P A; Assaf, N; Lari, A; Dast, S

2018-04-09

Perineal defects are encountered ever more frequently, in the treatment of vulvar cancers or abdominoperineal resection. The surgical treatment of vulvar cancer leads to significant skin defect. The aim of the reconstruction is not to provide volume but rather to resurface perineum. We propose a new solution to cover the extensive skin defect remaining after excision. We report 3 patients who underwent large excision for vulvar cancer, with lymph node dissection. For reconstruction, we performed 3 advancement flaps. Two V-Y flaps cantered on the infra-gluteal folds and based on pudendal perforator arteries were used to cover the postero-lateral parts of the defect. The third advancement flap from the superior aspect of the defect was a Y-V Mons pubis flap. The defects were successfully covered by the 3 flap technique. The first patient suffered a non-union that slowly healed by secondary intention. For the other cases, we used the same technique, but applied negative pressure wound therapy on the sutures, with excellent results. The 3 flap technique is a simple and reliable method and the donor site morbidity is minimal. It can be realised without changing the position of the patient after tumour excision, and does not require delicate perforator dissection. This surgical option can be easily applied, allowing better management of these cases. Copyright © 2018 Elsevier Masson SAS. All rights reserved.

Possible cause underlying gastric necrosis and perforation: Celiac artery thrombosis

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Ahmet Peker

2017-12-01

Full Text Available In this article, we are sharing a case of a 76-year-old woman with known hypertension, atrial fibrillation,diabetes mellitus, coronary artery disease, who is presenting with stomach necrosis and perforation possibly due to celiac artery thrombosis after newly developed abdominal pain and bloody vomiting. In our case, emergency surgery was planned and the patient refused the operation and was lost at 48 hours of clinical follow-up. We aimed to discuss the etiology of celiac artery thrombosis, briefly. We believe that necrosis and perforation of the stomach due to celiac artery thrombosis deserves to be shared because it is a rare and difficult case to manage.

Improving outcomes in microsurgical breast reconstruction: lessons learnt from 406 consecutive DIEP/TRAM flaps performed by a single surgeon.

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Damen, Tim H C; Morritt, Andrew N; Zhong, Toni; Ahmad, Jamil; Hofer, Stefan O P

2013-08-01

Multiple preoperative, intraoperative and postoperative decisions can influence the outcome of microsurgical breast reconstruction. We have simplified the decision-making process by incorporating a number of algorithms into our microsurgical breast reconstruction practice and critically review our results in this study. Prospectively maintained databases for all microsurgical breast reconstructions performed by a single surgeon over a nine-year period were examined to determine: patient demographics; operative details including flap choice, donor and recipient vessel selection; and, details of intraoperative and early postoperative (406 Consecutive free flap microsurgical breast reconstructions (164 unilateral and 121 bilateral) were performed in 285 patients over the study period. Deep inferior epigastric artery perforator (DIEP) flaps (88%, n=359) were used most commonly followed by muscle-sparing transverse rectus abdominis musculocutaneous (MS-TRAM) flaps (11%, n=44), and fascial-sparing TRAM (FS-TRAM) flaps (0.7%, n=3). One-hundred-seventy-one (48%) DIEP flaps were based on a single perforator while 188 (52%) had multiple perforators. The internal mammary (IM) artery and vein were used as the recipient vessels for 99% (n=403) of flaps. A second venous anastomosis was required for 11.8 percent (n=48) of flaps. Partial flap failure occurred in nine (2.2%) flaps while total flap failure occurred in two flaps (0.5%). Minimum follow-up was three months. Incorporating a number of algorithms into our practice has enabled us to simplify the decision-making processes involved in microsurgical breast reconstruction and to consistently obtain successful surgical outcomes. Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Overcoming the Obstacles of the Ilizarov Device in Extremity Reconstruction: Usefulness of the Perforator as the Recipient Vessel.

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Kim, Kyu Nam; Hong, Joon Pio; Park, Sung Woo; Kim, Sang Woo; Yoon, Chi Sun

2015-07-01

When patients using the Ilizarov device need a free-flap procedure for their thigh and leg, it is difficult to isolate the major vessels as the recipient vessel due to the limited working space around the Ilizarov rings and pins. The usefulness of a perforator as the recipient vessel to allow minimally invasive surgery was investigated in this study. Between October 2011 and December 2013, 77 patients using the Ilizarov device needed free flap reconstruction using an anterolateral thigh perforator flap or superficial circumflex iliac artery perforator flap. The perforator was used as a recipient vessel in 50 cases, with which end-to-end anastomosis was performed using a perforator-to-perforator approach, and major vessels were used as a recipient vessel in 27 cases (n = 20, anterior tibial vessel; n = 7, posterior vessel). When the perforator was used as the recipient vessel, total loss developed in one case and marginal necrosis in four cases. When the major vessel was used as the recipient vessel, whole necrosis developed in one case and marginal necrosis in two cases. The procedure increased the freedom of hand movement, decreased the recipient vessel dissection time, and reduced the recipient dissection scar. The use of perforators as recipients overcomes the obstacles associated with the Ilizarov device and allows convenient and rapid reconstruction, with similar success as microsurgery using major vessels. Further studies are needed to address the limitations of this approach, which include perfusion physiology and the viable limit of the flap dimension. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Spacer Facial Artery Musculomucosal Flap: Simultaneous Closure of Oronasal Fistulas and Palatal Lengthening.

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Lee, Jonathan Y; Alizadeh, Kaveh

2016-01-01

In this series, the authors describe a modification of the facial artery musculomucosal flap for oronasal fistula repair. The spacer facial artery musculomucosal flap technique is characterized by a pedicle inset into the retromolar trigone and palate, obviating a second operative stage. This was performed in 14 patients with a 5.2-cm mean fistula size. Average follow-up was 4.3 years, with one partial flap necrosis but no recurrent oronasal fistula. There was a mean decrease of 18 percent in the distance between the velum and the posterior pharyngeal wall. The spacer facial artery musculomucosal flap provides a single-stage reconstruction of oronasal fistula while lengthening the palate through a pushback mechanism. Although further study of velopharyngeal function is needed, the spacer facial artery musculomucosal flap may be beneficial for patients with a short velum and an oronasal fistula. Therapeutic, IV.

Chimeric superficial temporal artery based skin and temporal fascia flap plus temporalis muscle flap - An alternative to free flap for suprastructure maxillectomy with external skin defect

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Dushyant Jaiswal

2011-01-01

Full Text Available Flaps from temporal region have been used for mid face, orbital and peri-orbital reconstruction. The knowledge of the vascular anatomy of the region helps to dissect and harvest the muscle/fascia/skin/combined tissue flaps from that region depending upon the requirement. Suprastructure maxillectomy defects are usually covered with free flaps to fill the cavity. Here we report an innovative idea in which a patient with a supra structure maxillectomy with external skin defect was covered with chimeric flap based on the parietal and frontal branches of superficial temporal artery and the temporalis muscle flap based on deep temporal artery.

Computed tomography angiographic study of internal mammary perforators and their use as recipient vessels for free tissue transfer in breast reconstruction

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Aditya V Kanoi

2017-01-01

Full Text Available Context: The internal mammary artery perforator vessels (IMPV as a recipient in free flap breast reconstruction offer advantages over the more commonly used thoracodorsal vessels and the internal mammary vessels (IMV. Aims: This study was designed to assess the anatomical consistency of the IMPV and the suitability of these vessels for use as recipients in free flap breast reconstruction. Patients and Methods: Data from ten randomly selected female patients who did not have any chest wall or breast pathology but had undergone a computed tomography angiography (CTA for unrelated diagnostic reasons from April 2013 to October 2013 were analysed. Retrospective data of seven patients who had undergone mastectomy for breast cancer and had been primarily reconstructed with a deep inferior epigastric artery perforator free flap transfer using the IMPV as recipient vessels were studied. Results: The CTA findings showed that the internal mammary perforator was consistently present in all cases bilaterally. In all cases, the dominant perforator arose from the upper four intercostal spaces (ICS with the majority (55% arising from the 2nd ICS. The mean distance of the perforators from the sternal border at the level of pectoralis muscle surface on the right side was 1.86 cm (range: 0.9–2.5 cm with a mode value of 1.9 cm. On the left side, a mean of 1.77 cm (range: 1.5–2.1 cm and a mode value of 1.7 cm were observed. Mean perforator artery diameters on the right and left sides were 2.2 mm and 2.4 mm, respectively. Conclusions: Though the internal mammary perforators are anatomically consistent, their use as recipients in free tissue transfer for breast reconstruction eventually rests on multiple variables.

Brachial artery protected by wrapped latissimus dorsi muscle flap in high voltage electrical injury

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Gencel, E.; Eser, C.; Kokacya, O.; Kesiktas, E.; Yavuz, M.

2016-01-01

Summary High voltage electrical injury can disrupt the vascular system and lead to extremity amputations. It is important to protect main vessels from progressive burn necrosis in order to salvage a limb. The brachial artery should be totally isolated from the burned area by a muscle flap to prevent vessel disruption. In this study, we report the use of a wrap-around latissimus dorsi muscle flap to protect a skeletonized brachial artery in a high voltage electrical injury in order to salvage the upper extremity and restore function. The flap wrapped around the exposed brachial artery segment and luminal status of the artery was assessed using magnetic resonance angiography. No vascular intervention was required. The flap survived completely with good elbow function. Extremity amputation was not encountered. This method using a latissimus dorsi flap allows the surgeon to protect the main upper extremity artery and reconstruct arm defects, which contributes to restoring arm function in high voltage electrical injury. PMID:28149236

臀下动脉穿支蒂复合组织瓣修复骶尾部巨大褥疮的解剖与临床应用%Anatomy study and clinical applications of complex tissue flap pedicled with inferior gluteal artery perforator for repairing giant sacrococcygeal pressure sore

Institute of Scientific and Technical Information of China (English)

谢昀; 林建华; 叶君健; 郑和平

2014-01-01

Objective To discuss the technical feasibility and clinical effectiveness of using complex tissue flap pedicled with inferior gluteal artery perforator for repair giant sacrococcygeal pressure sore.Methods Thirty embalmed lower limbs of adult cadavers perfused with red latex were used for anatomical study,and the followings were observed:①The course,branche and distribution of gluteal artery.②The course and distribution of the posterior femoral cutaneous nerve.③Anastomosis between the posterior cutaneous branch of gluteal artery and nutrient vessels of the posterior femoral cutaneous nerve.8 cases aging from 17 years to 56 years were completed during May 2007 to July 2013,6 cases were males and 2 cases were females.The sizes of pressure sore with the depth to Ⅳ degree were ranged from 16 cm × 9 cm to 22 cm × 10 cm.The sizes of flaps were harvested from 32 cm × 10 cm to 25 cm × 9 cm.Results The gluteal artery crossed the edge of the piriformis,the main stem was (3.1 ± 0.4) mm in diameter and gave out 2-5 muscular branches to supply the gluteus maximus.The posterior femoral cutaneous nerve crossed the edge of gluteus maximus and descended between biceps femoris and semitendinosus.Perforating deep fascia point located was (5.9 ± 0.8) cm above the line between medial and lateral femoral epicondyle.The constant anastomosis were formed by the posterior cutaneous branch of gluteal artery,the obturator artery perforator and the direct popliteal artery perforator around the posterior femoral cutaneous nerve.The complex flap survived successfully in all patients.Sutures were removed at 14 days postoperatively and the wounds healed well.All supplied areas were closed by directly suturing.Recurrent sacrococcygeal pressure sore was not observed in all cases with satisfied appearance and normal color during the outpatient follow-up period from 5 months to 5 years.Conclusion The united flap of gluteal myocutaneous flap and the posterior femoral cutaneous

Distally based saphenous neurocutaneous perforator flap combined with vac therapy for soft tissue reconstruction and hardware salvage in the lower extremities.

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Wen, Gen; Wang, Chun-Yang; Chai, Yi-Min; Cheng, Liang; Chen, Ming; Yi-Min, L V

2013-11-01

The complex wound with the exposed hardware and infection is one of the common complications after the internal fixation of the tibia fracture. The salvage of hardware and reconstruction of soft tissue defect remain challenging. In this report, we presented our experience on the use of the distally based saphenous neurocutaneous perforator flap combined with vacuum-assisted closure (VAC) therapy for the coverage of the soft tissue defect and the exposed hardware in the lower extremity with fracture. Between January 2008 and July 2010, seven patients underwent the VAC therapy followed by transferring a reversed saphenous neurocutaneous perforator flap for reconstruction of the wound with exposed hardware around the distal tibia. The sizes of the flaps ranged from 6 × 3 cm to 15 × 6 cm. Six flaps survived completely. Partial necrosis occurred in one patient. There were no other complications of repair and donor sites. Bone healing was achieved in all patients. In conclusion, the reversed saphenous neurocutaneous perfortor flaps combined with the VAC therapy might be one of the options to cover the complex wound with exposed hardware in the lower extremities. © 2013 Wiley Periodicals, Inc.

Cost-effectiveness analysis of implants versus autologous perforator flaps using the BREAST-Q.

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Matros, Evan; Albornoz, Claudia R; Razdan, Shantanu N; Mehrara, Babak J; Macadam, Sheina A; Ro, Teresa; McCarthy, Colleen M; Disa, Joseph J; Cordeiro, Peter G; Pusic, Andrea L

2015-04-01

Reimbursement has been recognized as a physician barrier to autologous reconstruction. Autologous reconstructions are more expensive than prosthetic reconstructions, but provide greater health-related quality of life. The authors' hypothesis is that autologous tissue reconstructions are cost-effective compared with prosthetic techniques when considering health-related quality of life and patient satisfaction. A cost-effectiveness analysis from the payer perspective, including patient input, was performed for unilateral and bilateral reconstructions with deep inferior epigastric perforator (DIEP) flaps and implants. The effectiveness measure was derived using the BREAST-Q and interpreted as the cost for obtaining 1 year of perfect breast health-related quality-adjusted life-year. Costs were obtained from the 2010 Nationwide Inpatient Sample. The incremental cost-effectiveness ratio was generated. A sensitivity analysis for age and stage at diagnosis was performed. BREAST-Q scores from 309 patients with implants and 217 DIEP flap reconstructions were included. The additional cost for obtaining 1 year of perfect breast-related health for a unilateral DIEP flap compared with implant reconstruction was $11,941. For bilateral DIEP flaps compared with implant reconstructions, the cost for an additional breast health-related quality-adjusted life-year was $28,017. The sensitivity analysis demonstrated that the cost for an additional breast health-related quality-adjusted life-year for DIEP flaps compared with implants was less for younger patients and earlier stage breast cancer. DIEP flaps are cost-effective compared with implants, especially for unilateral reconstructions. Cost-effectiveness of autologous techniques is maximized in women with longer life expectancy. Patient-reported outcomes findings can be incorporated into cost-effectiveness analyses to demonstrate the relative value of reconstructive procedures.

Extending the use of the gracilis muscle flap in perineal reconstruction surgery.

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Goldie, Stephen J; Almasharqah, Riyadh; Fogg, Quentin A; Anderson, William

2016-08-01

Reconstruction of the perineum is required following oncological resections. Plastic surgical techniques can be used to restore the aesthetics and function of the perineum. The gracilis myocutaneous flap provides a substantial skin paddle, with minimal donor site morbidity. The flap is pedicled on a perforator from the medial circumflex femoral artery, giving it limited reach across the perineum. Tunnelling the flap under the adductor longus muscle may free up more of the arterial pedicle, increasing its reach. On three female cadavers, bilateral gracilis flaps were raised in the standard surgical manner, giving six flaps in total. With the flaps pedicled across the perineum, the distance from the tip of each flap was measured to the anterior superior iliac spine (ASIS). The flaps were then tunnelled under the adductor longus muscle. The distances to the ASIS were measured again. The average pedicle length was greater than 7 cm. Tunnelling the flap under the adductor longus muscle increased the reach by more than 4 cm on average. Cadaveric dissection has shown that tunnelling of the flap in a novel way increase its reach across the perineum. This additional flexibility improves its use clinically and is of benefit to plastic surgeons operating in perineal reconstruction. Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Reconstruction of fingers after electrical injury using lateral tarsal artery flap

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Zhang MH

2017-07-01

Full Text Available Minghua Zhang, Mitao Huang, Pihong Zhang, Pengfei Liang, Licheng Ren, Jizhang Zeng, Jie Zhou, Xiong Liu, Tinghong Xie, Xiaoyuan Huang Department of Burns Reconstruction Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, People’s Republic of China Objective: Electrical injuries to the fingers account for the majority of total severe burns that occur each year. While several types of flaps have been used in covering finger defects, all have limitations or disadvantages. The purpose of this study was to introduce our clinical experiences of using the lateral tarsal artery (LTA flap to successfully restore fingers after electrical injury.Patients and methods: From 2005 to 2012, 10 patients with 14 severe electrical burns to their fingers, including six thumbs and four index and four middle fingers, were treated with LTA flap. The wound size ranged from 2.0×3.0 cm to 3.5×5.0 cm. The flap with free tendon graft was used to repair the tendon defect in four cases, free nerve graft was used to repair the feeling defect in two cases, and the flap with nerve was used to repair the feeling defect in two cases. All the patients were followed up for 3 months to 2 years.Results: All skin flaps adhered successfully and there were no complications. All patients were satisfied with the esthetic appearance and functional outcome of the finger reconstruction.Conclusion: LTA flap is a reliable method to restore fingers after severe electrical injuries. Keywords: electrical injuries to fingers, lateral tarsal artery flap

Coverage of Exposed Bone of the Lateral Malleolus With a Proximally Based Lateral Malleolar Perforator Flap.

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van der Zee, Caroline W; Moerman, Esther; Haverlag, Robert; Schepers, Tim

2015-01-01

The treatment of soft tissue defects of the ankle, combined with an implant-related infection, remains a challenge. The present case report illustrates the use of a pedicled perforator flap for soft tissue reconstruction to cover a postoperative defect at the lateral malleolus after an ankle fracture. Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.

Experience with peroneus brevis muscle flaps for reconstruction of distal leg and ankle defects

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Babu Bajantri

2013-01-01

Full Text Available Objective: Peroneus brevis is a muscle in the leg which is expendable without much functional deficit. The objective of this study was to find out its usefulness in coverage of the defects of the lower leg and ankle. Patients and Methods: A retrospective analysis of the use of 39 pedicled peroneus brevis muscle flaps used for coverage of defects of the lower leg and ankle between November 2010 and December 2012 was carried out. The flaps were proximally based for defects of the lower third of the leg in 12 patients and distally based for reconstruction of defects of the ankle in 26 patients, with one patient having flaps on both ankles. Results: Partial flap loss in critical areas was found in four patients requiring further flap cover and in non-critical areas in two patients, which were managed with a skin graft. Three of the four critical losses occurred when we used it for covering defects over the medial malleolus. There was no complete flap loss in any of the patients. Conclusion: This flap has a unique vascular pattern and fails to fit into the classification of the vasculature of muscles by Mathes and Nahai. The unusual feature is an axial vessel system running down the deep aspect of the muscle and linking the perforators from the peroneal artery and anterior tibial artery, which allows it to be raised proximally or distally on a single perforator. The flap is simple to raise and safe for the reconstruction of small-to moderate-sized skin defects of the distal third of the tibia and all parts of the ankle except the medial malleolus, which is too far from the pedicle of the distally based flap. The donor site can be closed primarily to provide a linear scar. The muscle flap thins with time to provide a good result aesthetically at the primary defect.

Banking a hemi-abdominal DIEP flap: a pilot report of indications, technique, and utility.

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Shridharani, Sachin M; Singh, Navin K; Taylor, Jesse A; Rosson, Gedge D

2009-01-01

We present a pilot report of "banking" the contralateral hemi-abdominal deep inferior epigastric perforator (DIEP) flap under the abdominal closure in patients undergoing unilateral autologous breast reconstruction when a hemi-abdominal flap suffices. Four patients undergoing unilateral autologous breast reconstruction with a hemi-abdominal DIEP or superficial inferior epigastric artery flap had their contralateral hemi-abdominal flap left in position, or "banked," under their abdominal closure to be used in case of failure. This novel method may be of assistance when a free microvascular hemi-abdominal flap is felt to be threatened or suspect. It provides a life-boat for the younger and experienced surgeon alike, and most importantly, for the breast cancer survivor. Economic analysis of the technique reveals that the contralateral hemi-abdominal flap should be banked more often than intuition alone would suggest. (c) 2009 Wiley-Liss, Inc.

Refining the intrinsic chimera flap: a review.

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Agarwal, Jayant P; Agarwal, Shailesh; Adler, Neta; Gottlieb, Lawrence J

2009-10-01

Reconstruction of complex tissue deficiencies in which each missing component is in a different spatial relationship to each other can be particularly challenging, especially in patients with limited recipient vessels. The chimera flap design is uniquely suited to reconstruct these deformities. Chimera flaps have been previously defined in many ways with 2 main categories: prefabricated or intrinsic. Herein we attempt to clarify the definition of a true intrinsic chimeric flap and provide examples of how these constructs provide a method for reconstruction of complex defects. The versatility of the intrinsic chimera flap and its procurement from 7 different vascular systems is described. A clarification of the definition of a true intrinsic chimera flap is described. In addition, construction of flaps from the lateral femoral circumflex, deep circumflex iliac, inferior gluteal, peroneal, subscapular, thoracodorsal, and radial arterial systems is described to showcase the versatility of these chimera flaps. A true intrinsic chimera flap must consist of more than a single tissue type. Each of the tissue components receives its blood flow from separate vascular branches or perforators that are connected to a single vascular source. These vascular branches must be of appropriate length to allow for insetting with 3-dimensional spatial freedom. There are a multitude of sites from which true intrinsic chimera flaps may be harvested.

Funding analysis of bilateral autologous free-flap breast reconstructions in Australia.

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Sinha, Shiba; Ruskin, Olivia; McCombe, David; Morrison, Wayne; Webb, Angela

2015-08-01

Bilateral breast reconstructions are being increasingly performed. Autologous free-flap reconstructions represent the gold standard for post-mastectomy breast reconstruction but are resource intensive. This study aims to investigate the difference between hospital reimbursement and true cost of bilateral autologous free-flap reconstructions. Retrospective analysis of patients who underwent bilateral autologous free-flap reconstructions at a single Australian tertiary referral centre was performed. Hospital reimbursement was determined from coding analysis. A true cost analysis was also performed. Comparisons were made considering the effect of timing, indication and complications of the procedure. Forty-six bilateral autologous free-flap procedures were performed (87 deep inferior epigastric perforators (DIEPs), four superficial inferior epigastric artery perforator flaps (SIEAs) and one muscle-sparing free transverse rectus abdominis myocutaneous flap (MS-TRAM)). The mean funding discrepancy between hospital reimbursement and actual cost was $12,137 ± $8539 (mean ± standard deviation (SD)) (n = 46). Twenty-four per cent (n = 11) of the cases had been coded inaccurately. If these cases were excluded from analysis, the mean funding discrepancy per case was $9168 ± $7453 (n = 35). Minor and major complications significantly increased the true cost and funding discrepancy (p = 0.02). Bilateral free-flap breast reconstructions performed in Australian public hospitals result in a funding discrepancy. Failure to be economically viable threatens the provision of this procedure in the public system. Plastic surgeons and hospital managers need to adopt measures in order to make these gold-standard procedures cost neutral. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Reconstruction in extensive axillary Hidradenitis suppurativa with local fasciocutaneous V-Y advancement flaps

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Sharma Ramesh

2006-01-01

Full Text Available We present our experience with the use of local fasciocutaneous V-Y advancement flaps in the reconstruction of 10 axillae in 6 patients for large defects following wide excision of long-standing Hidradenitis suppurativa of the axilla. The defects were closed with local V-Y subcutaneous island flaps. A single flap from the chest wall was sufficient for moderate defects. However, for larger defects, an additional flap was taken from the medial side of the ipsilateral arm. The donor defects could be closed primarily in all the patients. The local areas of the lateral chest wall and the medial side of the arm have a plentiful supply of cutaneous perforators and the flaps can be designed in a V-Y fashion without resorting to preoperative marking of the perforator. The flaps were freed sufficiently to allow adequate movement for closure of the defects. Although no attempt was made to identify the perforators specifically, many perforators were seen entering the flap. Some perforators can be safely divided to increase reach of the flap. All the flaps survived completely. A follow up of 2.5 years is presented.

Decision making in double-pedicled DIEP and SIEA abdominal free flap breast reconstructions: An algorithmic approach and comprehensive classification.

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Charles M Malata

2015-10-01

Full Text Available Introduction: The deep inferior epigastric artery perforator (DIEP free flap is the gold standard for autologous breast reconstruction. However, using a single vascular pedicle may not yield sufficient tissue in patients with midline scars or insufficient lower abdominal pannus. Double-pedicled free flaps overcome this problem using different vascular arrangements to harvest the entire lower abdominal flap. The literature is, however, sparse regarding technique selection. We therefore reviewed our experience in order to formulate an algorithm and comprehensive classification for this purpose. Methods: All patients undergoing unilateral double-pedicled abdominal perforator free flap breast reconstruction (AFFBR by a single surgeon (CMM over 40 months were reviewed from a prospectively collected database. Results: Of the 112 consecutive breast free flaps performed, 25 (22% utilised two vascular pedicles. The mean patient age was 45 years (range=27-54. All flaps but one (which used the thoracodorsal system were anastomosed to the internal mammary vessels using the rib-preservation technique. The surgical duration was 656 minutes (range=468-690 mins. The median flap weight was 618g (range=432-1275g and the mastectomy weight was 445g (range=220-896g. All flaps were successful and only three patients requested minor liposuction to reduce and reshape their reconstructed breasts.Conclusion: Bipedicled free abdominal perforator flaps, employed in a fifth of all our AFFBRs, are a reliable and safe option for unilateral breast reconstruction. They, however, necessitate clear indications to justify the additional technical complexity and surgical duration. Our algorithm and comprehensive classification facilitate technique selection for the anastomotic permutations and successful execution of these operations.

Adipofascial sural artery flap for foot and ankle reconstruction in children: for better aesthetic outcome

International Nuclear Information System (INIS)

Mahmood, F.

2015-01-01

Wheel spoke injury of the ankle and foot is very common in children and its reconstruction is challenging. Reverse flow sural artery fasciocutaneous flap is versatile for this area but lead to significant donor site morbidity. Free tissue transfer is an option in children which needs a micro-vascular expertise, expensive equipment and long operating time. Method: Fifteen adipofascial flaps were done for foot and ankle coverage from June 2011 to June 2014 at CH and ICH Lahore. The efficacy of adipofascial sural artery flap for the coverage of these defects was evaluated. Results: Fifteen children presented with defects of foot and ankle, 11 (73%) were male and 4 (27%) were female. Their age ranged from 1 - 13 years. All patients had trauma to the foot due to wheel spoke injury. Flaps were used to cover tendoachilles and malleoli. In one patient there was flap tip necrosis with partial graft loss which healed with dressings. Donor site aesthetic outcome was satisfactory in all cases. Mean follow-up was I year. Conclusion: Adipofascial Sural artery flap is quick and safe with wide arc of rotation, minimal donor site morbidity and better aesthetic outcome and it does not sacrifice major extremity vessel. (author)

An international comparison of reimbursement for DIEAP flap breast reconstruction.

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Reid, A W N; Szpalski, C; Sheppard, N N; Morrison, C M; Blondeel, P N

2015-11-01

The deep inferior epigastric artery perforator (DIEAP) flap is currently considered the gold standard for autologous breast reconstruction. With the current economic climate and health cutbacks, we decided to survey reimbursement for DIEAP flaps performed at the main international centres in order to assess whether they are funded consistently. Data were collected confidentially from the main international centres by an anonymous questionnaire. Our results illustrate the wide disparity in international DIEAP flap breast reconstruction reimbursement: a unilateral DIEAP flap performed in New York, USA, attracts €20,759, whereas the same operation in Madrid, Spain, will only be reimbursed for €300. Only 35.7% of the surgeons can set up their own fee. Moreover, 85.7% of the participants estimated that the current fees are insufficient, and most of them feel that we are evolving towards an even lower reimbursement rate. In 55.8% of the countries represented, there is no DIEAP-specific coding; in comparison, 74.4% of the represented countries have a specific coding for transverse rectus abdominis (TRAM) flaps. Finally, despite the fact that DIEAP flaps have become the gold standard for breast reconstruction, they comprise only a small percentage of all the total number of breast reconstruction procedures performed (7-15%), with the only exception being Belgium (40%). Our results demonstrate that DIEAP flap breast reconstruction is inconsistently funded. Unfortunately though, it appears that the current reimbursement offered by many countries may dissuade institutions and surgeons from offering this procedure. However, substantial evidence exists supporting the cost-effectiveness of perforator flaps for breast reconstruction, and, in our opinion, the long-term clinical benefits for our patients are so important that this investment of time and money is absolutely essential. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons

Reverse peroneal artery flap for large defects of ankle and foot: A reliable reconstructive technique

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Jose Tharayil

2012-01-01

Full Text Available Background: Large soft tissue defects around the lower third of the leg, ankle and foot always have been challenging to reconstruct. Reverse sural flaps have been used for this problem with variable success. Free tissue transfer has revolutionised management of these problem wounds in selected cases. Materials and Methods: Twenty-two patients with large defects around the lower third of the leg, ankle and foot underwent reconstruction with reverse peroneal artery flap (RPAF over a period of 7 years. The mean age of these patients was 41.2 years. Results: Of the 22 flaps, 21 showed complete survival without even marginal necrosis. One flap failed, where atherosclerotic occlusion of peroneal artery was evident on the table. Few patients had minor donor site problems that settled with conservative management. Conclusions: RPAF is a very reliable flap for the coverage of large soft tissue defects of the heel, sole and dorsum of foot. This flap adds versatility in planning and execution of this extended reverse sural flap.

Dual-dermal-barrier fashion flaps for the treatment of sacral pressure sores.

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Hsiao, Yen-Chang; Chuang, Shiow-Shuh

2015-02-01

The sacral region is one of the most vulnerable sites for the development of pressure sores. Even when surgical reconstruction is performed, there is a high chance of recurrence. Therefore, the concept of dual-dermal-barrier fashion flaps for sacral pressure sore reconstruction was proposed. From September 2007 to June 2010, nine patients with grade IV sacral pressures were enrolled. Four patients received bilateral myocutaneous V-Y flaps, four patients received bilateral fasciocutaneous V-Y flaps, and one patient received bilateral rotation-advanced flaps for sacral pressure reconstruction. The flaps were designed based on the perforators of the superior gluteal artery in one patient's reconstructive procedure. All flaps' designs were based on dual-dermal-barrier fashion. The mean follow-up time was 16 months (range = 12-25). No recurrence was noted. Only one patient had a complication of mild dehiscence at the middle suture line, occurring 2 weeks after the reconstructive surgery. The dual-dermal fashion flaps are easily duplicated and versatile. The study has shown minimal morbidity and a reasonable outcome.

An Algorithmic Approach to Total Breast Reconstruction with Free Tissue Transfer

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Seong Cheol Yu

2013-05-01

Full Text Available As microvascular techniques continue to improve, perforator flap free tissue transfer is now the gold standard for autologous breast reconstruction. Various options are available for breast reconstruction with autologous tissue. These include the free transverse rectus abdominis myocutaneous (TRAM flap, deep inferior epigastric perforator flap, superficial inferior epigastric artery flap, superior gluteal artery perforator flap, and transverse/vertical upper gracilis flap. In addition, pedicled flaps can be very successful in the right hands and the right patient, such as the pedicled TRAM flap, latissimus dorsi flap, and thoracodorsal artery perforator. Each flap comes with its own advantages and disadvantages related to tissue properties and donor-site morbidity. Currently, the problem is how to determine the most appropriate flap for a particular patient among those potential candidates. Based on a thorough review of the literature and accumulated experiences in the author’s institution, this article provides a logical approach to autologous breast reconstruction. The algorithms presented here can be helpful to customize breast reconstruction to individual patient needs.

A Case of Heel Reconstruction with a Reverse Sural Artery Flap in a Hemophilia B Patient

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Byung Kwon Lee

2012-03-01

Full Text Available Hemophilia B is a rare blood coagulation disorder. Complications such as bleeding and hematoma can cause necrosis of flaps, wound disruption, and the disturbance of wound healing. In particular, guidelines for flap operations in hemophilia B patients have still not been defined, and case reports are rare. We reconstructed the heel of a 41-year-old male hemophilia B patient using a reverse sural artery flap operation. The patient presented with mild hemophilia, having 27% of the normal value of coagulation factor IX. Coagulation and the changing value of the coagulation factor were regularly measured, and 70% of the normal value of coagulation factor IX was maintained through the injection of recombinant coagulation factors and antihemorrhagics. Hematoma developed twice (postoperative day [POD] 5 and POD 7 and in each case the hematoma was removed. Injections of recombinant coagulation factors and antihemorrhagics were continuously administered until postoperative week 2. When the coagulation factors were within normal ranges. In this article, a hemophilia B patient underwent reverse sural artery flap surgery and the healing progress was analyzed. We conclude that higher than baseline levels of coagulation factors are needed for successful healing in reverse sural artery flap surgery.

Superficial temporal artery flap for reconstruction of complex facial defects: A new algorithm

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Tarek M. Elbanoby

2018-03-01

Full Text Available Background A variety of island flaps can be based on the superficial temporal artery with variable tissue composition. They can be used for defect reconstruction, cavity resurfacing, facial hair restoration, or contracture release. Methods Seventy-two patients underwent facial reconstruction using a superficial temporal artery island flap from October 2010 to October 2014. The defects had various etiologies, including trauma, burns, tumors, exposed hardware, and congenital causes. We classified the patients by indication into 5 groups: cavity resurfacing, contracture release, facial hair restoration, skin coverage, and combined. The demographic data of the patients, defect characteristics, operative procedures, postoperative results, and complications were retrospectively documented. The follow-up period ranged from 24 to 54 months. Results A total of 24 females and 48 males were included in this study. The mean age of the patients was 33.7±15.6 years. The flaps were used for contracture release in 13 cases, cavity resurfacing in 10 cases, skin coverage in 17 cases, facial hair restoration in 19 cases, and combined defects in 13 cases. No major complications were reported. Conclusion: Based on our experiences with the use of superficial temporal artery island flaps, we have developed a detailed approach for the optimal management of patients with composite facial defects. The aim of this article is to provide the reader with a systematic algorithm to use for such patients.

Freestyle-Like V-Y Flaps of the Eyebrow: A New Outlook and Indication of an Historical Technique

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Angelo Alberto Leto Barone

2013-01-01

Full Text Available The eyebrow region is of utmost importance for facial movement, symmetry, and the overall cosmetic appearance of the face. Trauma or tumor resection often leave scars that may dislocate the eyebrow producing an alteration both in static symmetry of the face and in the dynamic expressivity. The authors present a technique for eyebrow’s defects repair using the remaining eyebrow advancement by means of a “freestyle-like” V-Y flap. In the past two years a total of eight consecutive patients underwent excision of skin lesions in the superciliary region and immediate reconstruction with this technique. On histology, six patients were affected from basal cell carcinomas, one from squamous cell carcinoma, and one from congenital intradermal melanocytic nevus. The pedicle of the flap included perforators from the supratrochlear, supraorbital, or superficial temporalis artery. Advancement of the entire aesthetic subunit that includes the eyebrow using a V-Y perforator flap was performed successfully in all cases achieving full, tension-free closure of defects up to 3.0 cm. “Freestyle-like” V-Y flaps should be considered as a first-line choice for partial defects of the eyebrow. The greater mobility compared to random subcutaneous flaps allows to reconstruct large defects providing an excellent cosmetic result.

A flap based on the plantar digital artery arch branch to improve appearance of reconstructed fingers: Anatomical and clinical application.

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Tang, Lin-Feng; Ju, Ji-Hui; Liu, Yue-Fei; Lan, Bo; Hou, Rui-Xing

2018-02-01

To investigate blood supply features of the flap based on the plantar digital artery arch and arch branch artery, and the treatment of outcomes of reconstructed fingers by the plantar digital artery arch branch island flap. Eight fresh foot specimens were employed with red emulsion infusion and microdissection. The vascular organization was observed in the second toe, such as initiation site, the course, and the number of the plantar digital artery arch branch. There were 15 fingers of 13 patients (8 males and 5 females) with finger defects accompanied by toe transfer, using the plantar digital artery arch branch flap inserted in the neck of the second toe to correct the appearance defect caused by a narrow "neck" and a bulbous tip. The intact plantar digital arches were identified in all specimens. The plantar digital artery arch had 5 branches. The range of external diameter of the arch branch was 0.4-0.6 mm. All the plantar digital artery arch branch island flaps and the reconstructed fingers survived. These cases were conducted with a follow-up period for 3-18 months (average, 9 months). All the plantar digital artery arch branch island flaps and reconstructed fingers demonstrated a satisfactory appearance and favorable sense function. The reconstructed finger-tip characteristic was good, with no obvious scar hyperplasia. The range of flexion and extension of reconstructed fingers was favorable as well. The plantar digital artery arch and arch branch artery possess regular vasa vasorum and abundant vascularity. A flap based on the plantar digital artery arch branch is an ideal selection for plastic surgery of reconstructed fingers. Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

[Reconstruction of combined skin and bilateral artey defects at palmar side of fingers by free posterior interrosseous artery flap in a bridge fashion].

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Xu, Bao-cheng; Liang, Gang; Chen, Fu-sheng

2012-05-01

To investigate the feasibility and therapeutic effect of free posterior interrosseous artery flap in a bridge fashion for combined skin and bilateral artery defects at palmar side of fingers. 6 cases with combined skin and bilateral artery defects at palmar side of fingers were treated with long-pedicled free posterior interrosseous artery flap in a bridge fashion. The flap size ranged from 3.5 cm x 2.0 cm to 6.5 em x 3.0 cm. The wounds at donor sites were closed directly. All the 6 flaps survived completely without any complication, and the wounds healed primarily. The blood supply and vein drainage in all the 6 fingers were normal. 4 cases were followed up for 1-12 months (average, 7 months). Satisfactory cosmetic and functional results were achieved. The flaps looked a little bit thicker than the surrounding tissue. The long-pedicled free posterior interrosseous artery flap in a bridge fashion is a good option for reconstruction of the combined skin and bilateral artery defects at palmar side of fingers in one stage.

Evolution in Monitoring of Free Flap Autologous Breast Reconstruction after Nipple-Sparing Mastectomy: Is There a Best Way?

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Frey, Jordan D; Stranix, John T; Chiodo, Michael V; Alperovich, Michael; Ahn, Christina Y; Allen, Robert J; Choi, Mihye; Karp, Nolan S; Levine, Jamie P

2018-05-01

Free flap monitoring in autologous reconstruction after nipple-sparing mastectomy remains controversial. The authors therefore examined outcomes in nipple-sparing mastectomy with buried free flap reconstruction versus free flap reconstruction incorporating a monitoring skin paddle. Autologous free flap reconstructions with nipple-sparing mastectomy performed from 2006 to 2015 were identified. Demographics and operative results were analyzed and compared between buried flaps and those with a skin paddle for monitoring. Two hundred twenty-one free flaps for nipple-sparing mastectomy reconstruction were identified: 50 buried flaps and 171 flaps incorporating a skin paddle. The most common flaps used were deep inferior epigastric perforator (64 percent), profunda artery perforator (12.1 percent), and muscle-sparing transverse rectus abdominis myocutaneous flaps (10.4 percent). Patients undergoing autologous reconstructions with a skin paddle had a significantly greater body mass index (p = 0.006). Mastectomy weight (p = 0.017) and flap weight (p < 0.0001) were significantly greater in flaps incorporating a skin paddle. Comparing outcomes, there were no significant differences in flap failure (2.0 percent versus 2.3 percent; p = 1.000) or percentage of flaps requiring return to the operating room (6.0 percent versus 4.7 percent; p = 0.715) between groups. Buried flaps had an absolute greater mean number of revision procedures per nipple-sparing mastectomy (0.82) compared with the skin paddle group (0.44); however, rates of revision procedures per nipple-sparing mastectomy were statistically equivalent between the groups (p = 0.296). Although buried free flap reconstruction in nipple-sparing mastectomy has been shown to be safe and effective, the authors' technique has evolved to favor incorporating a skin paddle, which allows for clinical monitoring and can be removed at the time of secondary revision. Therapeutic, III.

Freestyle multiple propeller flap reconstruction (jigsaw puzzle approach) for complicated back defects.

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Park, Sung Woo; Oh, Tae Suk; Eom, Jin Sup; Sun, Yoon Chi; Suh, Hyun Suk; Hong, Joon Pio

2015-05-01

The reconstruction of the posterior trunk remains to be a challenge as defects can be extensive, with deep dead space, and fixation devices exposed. Our goal was to achieve a tension-free closure for complex defects on the posterior trunk. From August 2006 to May 2013, 18 cases were reconstructed with multiple flaps combining perforator(s) and local skin flaps. The reconstructions were performed using freestyle approach. Starting with propeller flap(s) in single or multilobed design and sequentially in conjunction with adjacent random pattern flaps such as fitting puzzle. All defects achieved tensionless primary closure. The final appearance resembled a jigsaw puzzle-like appearance. The average size of defect was 139.6 cm(2) (range, 36-345 cm(2)). A total of 26 perforator flaps were used in addition to 19 random pattern flaps for 18 cases. In all cases, a single perforator was used for each propeller flap. The defect and the donor site all achieved tension-free closure. The reconstruction was 100% successful without flap loss. One case of late infection was noted at 12 months after surgery. Using multiple lobe designed propeller flaps in conjunction with random pattern flaps in a freestyle approach, resembling putting a jigsaw puzzle together, we can achieve a tension-free closure by distributing the tension to multiple flaps, supplying sufficient volume to obliterate dead space, and have reliable vascularity as the flaps do not need to be oversized. This can be a viable approach to reconstruct extensive defects on the posterior trunk. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Use if a soecuak sokubt ub reverse syrak artery flap to reduce venous congestion and flap necrosis

International Nuclear Information System (INIS)

Masood, T.; Ahmed, R.; Obaidullah, M.

2016-01-01

Background: Distally based sural fascio-cutaneous flap is a commonly performed plastic surgery procedure for the coverage of distal third of leg, ankle and foot defects. However congestion is the main complication of this flap which results into partial or complete loss of the flap. We devised a special splint to reduce this complication and retrospectively reviewed its effect on this complication between two groups. Methods: This retrospective study was carried out at Northwest General hospital between 1995 and 2012. Group-A included 30 patients who were managed without the splint between 1995 and 2005 and group B comprised of 35 patients were treated with the splint between 2006 and 2012. Complications like venous congestion, epidermolysis, and partial and complete flap failure were documented. Data were analyzed by SPSS.16.5 software. Chi- square test was used for data analysis. P value less than 0.05 was considered as the level of significance. Results: Total 65 patients were operated. Age of the patients ranged from 7 to 60 years. Road traffic accident and spoke wheel injury was the main cause of soft tissue loss in our patients. In group A 12 patients suffered from venous congestion. Out of 12, three patients had epidermolysis while partial flap necrosis occurred in 9 patients. Only 3 patients had venous congestion in group B. Two patients suffered from epidermolysis and one had partial flap necrosis. None of patient suffered from complete flap loss in both groups. Conclusion: Reverse sural artery flap continues to be a versatile flap for distal lower extremity reconstruction. By using a special splint to reduce pressure on the pedicle site as a modification, flap complication rate can be decreased significantly. (author)

The sural artery and vein as recipient vessels in free flap reconstruction about the knee.

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Johnson, P E; Harris, G D; Nagle, D J; Lewis, V L

1987-04-01

The sural artery and vein were used successfully as recipient vessels in nine patients who required free flap reconstruction about the knee. The anatomy of the sural vessels and the potential advantages of their use as free flap recipients are reviewed and discussed. Indications include popliteal vessels that are absent or severely damaged, as determined by preoperative angiography. No anastomotic complications were encountered in this series, indicating that the sural artery and vein can be used successfully as recipient vessels.

Contralateral lumbo-umbilical flap: A versatile technique for volar finger coverage

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Akram Hussain Bijli

2017-01-01

Full Text Available Background: While contemplating any difficult soft tissue reconstruction, patient comfort and compliance is of paramount importance. Reconstruction of the volar aspect of fingers and hand by the ipsilateral pedicled flaps (groin flap, abdominal flaps is demanding as the flap inset is difficult for the surgeon and very uncomfortable for the patient. This often leads to flap complications. For the comfort of the patient, better compliance and ease of complete inset, we planned to manage soft tissue defects of the volar aspect of fingers and hand by a new contralateral pedicled lumbo-umbilical flap. This flap is based on the paraumbilical perforators of deep inferior epigastric artery. Materials and Methods: The contralateral pedicled lumbo-umbilical flap was used in eight patients with high-tension electrical burn injuries involving the volar aspect of fingers and hand. The patients were closely observed for first 6 weeks for any flap or donor site complications and then followed monthly to assess donor and recipient site characteristics for 6 months to 2 years. Results and Conclusion: Large flaps up to 8 cm × 16 cm were raised. All but one flaps survived completely. All patients were mobilised within 48 h and five were discharged in less than a week after initial inset. The flap is reliable, easy to harvest and easy to inset on the volar aspect of fingers. The arm is positioned in a very comfortable position. The main disadvantage, however, is a conspicuous abdominal scar.

Peroneal island flap for wound coverage in complex injuries of the lower extremity

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Fazal A

2012-01-01

Full Text Available Akil Fazal1, Haroon-ur-Rashid1, Tahseen Cheema21Section of Orthopedics, Department of Surgery, Aga Khan University, Karachi, Pakistan; 2Department of Orthopedics and Rehabilitation, University of New Mexico, Albuquerque, NM, USABackground: Complex injuries of the lower extremity pose a therapeutic challenge owing to limited availability of local soft tissue for coverage. One option in this region is the pedicled fasciocutaneous flap based on perforators of the peroneal artery. In this case series, we present our experience of the peroneal island pedicled flap for reconstruction of lower extremity wounds.Methods: Records of 18 cases of peroneal island flap admitted consecutively to the Section of Orthopedics at Aga Khan University Hospital from January 1996 to December of 2009 were studied and their outcomes determined.Results: The most common indication for coverage was open wounds due to a road traffic accident (n = 10, followed by burns (n = 3. The most common area exposed was the lower third of the leg followed by the middle third. The tibia was exposed in 11 patients. The flaps ranged in size from 35 cm2 to over 200 cm2. In 13 patients, the flaps healed uneventfully, while in the remaining five there was partial flap necrosis. In four of the latter patients, the residual wound healed with conservative measures only, but the fifth patient required further surgery to achieve acceptable coverage.Conclusion: The peroneal artery flap appears to be a simple, useful, and reliable flap in the armamentarium of the surgeon when planning soft tissue coverage of the lower extremity.Keywords: leg injuries, surgical flaps, lower extremity

A composite gluteofemoral flap for reconstruction of large pressure sores over the sacrococcygeal region.

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Xie, Yun; Zhuang, Yue-Hong; Xue, Lan; Zheng, He-Ping; Lin, Jian-Hua

2015-12-01

Gigantic pressure sores pose a daunting challenge for plastic surgeons. This paper presents a composite gluteofemoral flap for reconstruction of large pressure sores over the sacrococcygeal region. In this anatomical study, 30 embalmed cadaveric lower limbs were used for dissection to observe the musculocutaneous perforators of the inferior gluteal artery and the longitudinal nutritional vascular chain of the posterior femoral cutaneous nerve. In this clinical study, eight patients underwent surgical harvest of the composite gluteofemoral flap for coverage of grade IV sacrococcygeal pressure sores. The size of the pressure sores ranged between 16 × 9 cm and 22 × 10 cm. The inferior gluteal artery was present in 26 cases and absent in four cases. It gave off two to four musculocutaneous branches with a diameter larger than 0.5 mm to the gluteus maximus. A direct cutaneous branch was given off at the inferior margin of the gluteus maximus, serving as a nutritional artery for the posterior femoral cutaneous nerve. The size of the flap harvested ranged between 22 × 9 cm and 32 × 10 cm. Flaps in seven patients survived uneventfully and developed epidermal necrosis at the distal margin in one case. An average 2-year follow-up revealed no recurrence of pressure sores. The composite gluteofemoral flap, being robust in blood supply, simple in surgical procedure, and large in donor territory, is an important addition to the armamentarium. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

DIEP flap customization using Fluobeam® indocyanine green tissue perfusion assessment with large previous abdominal scar

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Michael A. Fallucco

2017-06-01

Full Text Available The Fluobeam® is a portable, near-infrared camera that is held and controlled by the surgeon to visualize tissue perfusion using indocyanine green (ICG fluorescence imaging. This case report describes how data obtained from ICG imaging allows intraoperative customization in a previously surgically scarred abdomen during autologous Deep Inferior Epigastric Artery Perforator (DIEP flap bilateral breast reconstruction. The outcome was successful breast mound recreation without fat necrosis.

A anatomic evaluation of the lateral femoral circumflex artery system by using Multi detector-row CT

International Nuclear Information System (INIS)

Haraguchi, Kazunari; Kadota, Satoshi; Hosaka, Yoshiaki

2010-01-01

Flaps that are pedicled by perforators of the lateral femoral circumflex artery (LFCA) system have many advantages, including the transplantation of large and reliable skin with long pedicles and a large diameter, and little invasion of the donor sites. However, preoperative planning has been difficult because the perforators have many anatomic variations. We used multi detector-row CT for anatomical evaluation of the lateral femoral circumflex artery system. The patterns of LFCA from the main vessels were classified into three types and vessels coursing toward the lateral thigh region were classified into three groups. The distance from the anterior superior iliac spine to the lateral femoral circumflex artery showed no significant difference between men and women. We were able to evaluate vessels with a 2-mm diameter in the lateral femoral circumflex artery system, indicating that accurate evaluation and low invasive examination of the lateral femoral circumflex artery system, including the perforator area, can be achieved by adjusting the image conditions and the injection rate of the contrast dye. (author)

Embedded Pork Bone Causing Esophageal Perforation and an Esophagus-Innominate Artery Fistula

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Andrew C. Berry

2014-01-01

Full Text Available Chronically embedded foreign bodies can lead to perforations, mediastinitis, and abscess, amongst a host of other complications. A 20-year-old mentally challenged female presented with “something stuck in her throat,” severe dysphagia, and recurrent vomiting. Initial imaging was unremarkable; however, subsequent imaging and esophagogastroduodenoscopy two weeks later revealed an embedded pork bone. Surgery was performed to remove the bone and fix the subsequent esophageal perforation and esophagus-innominate artery fistula. This case helps reinforce the urgency in removing an ingested foreign body and the ramifications that may arise with chronically embedded foreign bodies.

Greenfield filter caval perforation causing an aortic mural thrombus and femoral artery occlusion.

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Chintalapudi, U B; Gutierrez, O H; Azodo, M V

1997-05-01

A 32-year-old woman suffered a right femoral artery embolic occlusion from an abdominal aortic mural thrombus associated with caval perforation by a stainless steel Greenfield Filter. The complication required thrombolytic therapy, surgical revascularization, and long-term anticoagulation.

Using a Thermal Imaging Camera to Locate Perforators on the Lower Limb

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Sharad P. Paul

2017-05-01

Full Text Available Reconstruction of the lower limb presents a complex problem after skin cancer surgery, as proximity of skin and bone present vascular and technical challenges. Studies on vascular anatomy have confirmed that the vascular plane on the lower limb lies deep to the deep fascia. Yet, many flaps are routinely raised superficial to this plane and therefore flap failure rates in the lower limb are high. Fascio-cutaneous flaps based on perforators offer a better cosmetic alternative to skin grafts. In this paper, we detail use of a thermal imaging camera to identify perforator ‘compartments’ that can help in designing such flaps.

Flow-Through Free Fibula Osteocutaneous Flap in Reconstruction of Tibial Bone, Soft Tissue, and Main Artery Segmental Defects.

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Li, Zonghuan; Yu, Aixi; Qi, Baiwen; Pan, Zhenyu; Ding, Junhui

2017-08-01

The aim of this report was to present the use of flow-through free fibula osteocutaneous flap for the repair of complex tibial bone, soft tissue, and main artery segmental defects. Five patients with bone, soft tissue, and segmental anterior tibial artery defects were included. The lengths of injured tibial bones ranged from 4 to 7 cm. The sizes of impaired soft tissues were between 9 × 4 and 15 × 6 cm. The lengths of defect of anterior tibial artery segments ranged from 6 to 10 cm. Two patients had distal limb perfusion problems. Flow-through free fibula osteocutaneous flap was performed for all 5 patients. Patients were followed for 12 to 18 months. All wounds healed after 1-stage operation, and all flow-through flaps survived. The distal perfusion after vascular repair was normal in all patients. Superficial necrosis of flap edge was noted in 1 case. After the local debridement and partial thickness skin graft, the flap healed uneventfully, and the surgical operation did not increase injury to the donor site. Satisfactory bone union was achieved in all patients in 2 to 4 months postoperation. Enlargement of fibula graft was observed during follow-up from 12 to 18 months. The functions of adjacent joints were recovered, and all patients were able to walk normally. Flow-through free fibula osteocutaneous flap was shown to be an effective and efficient technique for repairing composite tibial bone, soft tissue, and main artery segmental defects. This 1-stage operation should be useful in clinical practice for the treatment of complex bone, soft tissue, and vessel defects.

Combining rhinoplasty with septal perforation repair.

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Foda, Hossam M T; Magdy, Emad A

2006-11-01

A combined septal perforation repair and rhinoplasty was performed in 80 patients presenting with septal perforations (size 1 to 5 cm) and external nasal deformities. The external rhinoplasty approach was used for all cases and the perforation was repaired using bilateral intranasal mucosal advancement flaps with a connective tissue interposition graft in between. Complete closure of the perforation was achieved in 90% of perforations of size up to 3.5 cm and in only 70% of perforations that were larger than 3.5 cm. Cosmetically, 95% were very satisfied with their aesthetic result. The external rhinoplasty approach proved to be very helpful in the process of septal perforation repair especially in large and posteriorly located perforations and in cases where the caudal septal cartilage was previously resected. Our results show that septal perforation repair can be safely combined with rhinoplasty and that some of the routine rhinoplasty maneuvers, such as medial osteotomies and dorsal lowering, could even facilitate the process of septal perforation repair.

Different Recipient Vessels for Free Microsurgical Fibula Flaps in the Treatment of Avascular Necrosis of the Femoral Head: A Systematic Review and Meta-analysis.

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Tu, Yiji; Chen, Zenggan; Lineaweaver, William Charles; Zhang, Feng

2017-12-01

Several recipient vessels can be used in free microsurgical fibula flaps (MFFs) for the treatment of avascular necrosis of the femoral head (ANFH). Few articles investigate the influence of different recipient vessels on outcomes of MFF for ANFH. A comprehensive literature search of databases including PubMed-Medline, Ovid-Embase, and Cochrane Library was performed to collect the related studies. The Medical Subject Headings used were "femur head necrosis" and "bone transplantation." The relevant words in title or abstract included but not limited to "fibula flap," "fibular flap," "vascularized fibula," "vascularized fibular," "free fibula," "free fibular," "femoral head necrosis," "avascular necrosis of femoral head," and "ischemic necrosis of femoral head." The methodological index for nonrandomized studies was adopted for assessing the studies included in this review. Finally, 15 studies encompassing a total of 1267 patients (1603 hips) with ANFH were pooled in the overall analysis. Recipient vessels for MFF included the ascending branch of the lateral circumflex femoral artery and vein in 8 studies, descending branch of the lateral circumflex femoral artery and vein in 2 studies, second perforating branch of the deep femoral artery and vein in 4 studies, and inferior gluteal artery and vein in 1 study. Preoperative and postoperative average Harris hip score and pooled analyses of the rate of conversion, radiographic progression, and hip surgery-related complications showed no significant difference on the outcomes of MFF on ANFH between using different recipient vessels. Different recipient vessels did not affect outcomes in MFF procedures for ANFH. High-quality randomized controlled trials and prospective studies would be necessary to clarify reliable advantages and disadvantages between different recipient vessels. Until then, surgeons are justified in using ascending branch of the lateral circumflex femoral artery and vein, descending branch of the lateral

Cost analysis of postmastectomy reconstruction: A comparison of two staged implant reconstruction using tissue expander and acellular dermal matrix with abdominal-based perforator free flaps.

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Tran, Bao Ngoc N; Fadayomi, Ayotunde; Lin, Samuel J; Singhal, Dhruv; Lee, Bernard T

2017-09-01

Two staged tissue expander-implant with acellular dermal matrix (TE/I + ADM) and deep inferior epigastric perforator (DIEP) flap are the most common implant and autologous methods of reconstruction in the U.S. Implant-based techniques are disproportionally more popular, partially due to its presumed cost effectiveness. We performed a comprehensive cost analysis to compare TE/I + ADM and DIEP flap. A comparative cost analysis of TE/I + ADM and DIEP flap was performed. Medicare reimbursement costs for each procedure and their associated complications were calculated. Pooled probabilities of complications including cellulitis, seroma, skin necrosis, implant removal, flap loss, partial flap loss, and fat necrosis, were calculated using published studies from 2010 to 2016. Average actual cost for successful TE/I + ADM and DIEP flap were $13 304.55 and $10 237.13, respectively. Incorporating pooled complication data from published literature resulted in an increase in cost to $13 963.46 for TE/I + ADM and $12 624.29 for DIEP flap. The expected costs for successful TE/I + ADM and DIEP flap were $9700.35 and $8644.23, which are lower than the actual costs. DIEP flap breast reconstruction incurs lower costs compared to TE/I + ADM. These costs are lower at baseline and when additional costs from pooled complications are incorporated. © 2017 Wiley Periodicals, Inc.

Massive Bleeding from Guidewire Perforation of an External Iliac Artery: Treatment with Hand-made Stent-Graft Placement

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Mehta, Vimal, E-mail: drvimalmehta@yahoo.co.in; Pandit, Bhagya Narayan; Mehra, Pratishtha; Nigam, Arima; Vyas, Aniruddha; Yusuf, Jamal; Mukhopadhyay, Saibal; Trehan, Vijay [G.B. Pant Institute of Postgraduate Medical Education and Research (India)

2016-01-15

We report life-threatening bleeding from an external iliac artery perforation following guidewire manipulation in a patient with atherosclerotic iliac artery disease. This complication was successfully managed by indigenous hand-made stent-graft made from two peripheral stents in the catheterization laboratory.

Massive Bleeding from Guidewire Perforation of an External Iliac Artery: Treatment with Hand-made Stent-Graft Placement

International Nuclear Information System (INIS)

Mehta, Vimal; Pandit, Bhagya Narayan; Mehra, Pratishtha; Nigam, Arima; Vyas, Aniruddha; Yusuf, Jamal; Mukhopadhyay, Saibal; Trehan, Vijay

2016-01-01

We report life-threatening bleeding from an external iliac artery perforation following guidewire manipulation in a patient with atherosclerotic iliac artery disease. This complication was successfully managed by indigenous hand-made stent-graft made from two peripheral stents in the catheterization laboratory

Implementation and Analysis of a Lean Six Sigma Program in Microsurgery to Improve Operative Throughput in Perforator Flap Breast Reconstruction.

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Hultman, Charles Scott; Kim, Sendia; Lee, Clara N; Wu, Cindy; Dodge, Becky; Hultman, Chloe Elizabeth; Roach, S Tanner; Halvorson, Eric G

2016-06-01

Perforator flaps have become a preferred method of breast reconstruction but can consume considerable resources. We examined the impact of a Six Sigma program on microsurgical breast reconstruction at an academic medical center. Using methods developed by Motorola and General Electric, we applied critical pathway planning, workflow analysis, lean manufacturing, continuous quality improvement, and defect reduction to microsurgical breast reconstruction. Primary goals were to decrease preoperative-to-cut time and total operative time, through reduced variability and improved efficiency. Secondary goals were to reduce length of stay, complications, and reoperation. The project was divided into 3 phases: (1) Pre-Six Sigma (24 months), (2) Six Sigma (10 months), (3) and Post-Six Sigma (24 months). These periods (baseline, intervention, control) were compared by Student t test and χ analysis. Over a 5-year period, 112 patients underwent 168 perforator flaps for breast reconstructions, by experienced microsurgeons. Total operative time decreased from 714 to 607 minutes (P Six Sigma program in microsurgical breast reconstruction was associated with better operational and financial outcomes. These incremental gains were maintained over the course of the study, suggesting that these benefits were due, in part, to process improvements. However, continued reductions in total operative time and length of stay, well after the intervention period, support the possibility that "learning curve" phenomenon may have contributed to the improvement in these outcomes.

Valve-Like and Protruding Calcified Intimal Flap Complicating Common Iliac Arteries Kissing Stenting

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George S. Georgiadis

2015-01-01

Full Text Available Endovascular therapy for iliac artery chronic total occlusions is nowadays associated with low rates of procedure-related complications and improved clinical outcomes, and it is predominantly used as first-line therapy prior to aortobifemoral bypass grafting. Herein, we describe the case of a patient presenting with an ischemic left foot digit ulcer and suffering complex aortoiliac lesions, who received common iliac arteries kissing stents, illustrating at final antegrade and retrograde angiograms the early recognition of a blood flow obstructing valve-like calcified intimal flap protruding through the stent struts, which was obstructing antegrade but not retrograde unilateral iliac arterial axis blood flow. The problem was resolved by reconstructing the aortic bifurcation at a more proximal level. Completion angiogram verified normal patency of aorta and iliac vessels. Additionally, a severe left femoral bifurcation stenosis was also corrected by endarterectomy-arterioplasty with a bovine patch. Postintervention ankle brachial pressure indices were significantly improved. At the 6-month and 2-year follow-up, normal peripheral pulses were still reported without intermittent claudication suggesting the durability of the procedure. Through stent-protruding calcified intimal flap, is a very rare, but existing source of antegrade blood flow obstruction after common iliac arteries kissing stents.

The anatomy of forearm free flap phalloplasty for transgender surgery.

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Kim, S; Dennis, M; Holland, J; Terrell, M; Loukas, M; Schober, J

2018-03-01

Transgender surgeries are becoming more frequent and visual interpretation of anatomy is essential for both surgeons and patients. Since the forearm free flap phalloplasty was introduced in 1984, it has been known to provide reliable cosmetic and functional results for transitioning men compared with phalloplasty by different flaps. Surgical text descriptions were enhanced by the creation of new anatomic illustrations. The forearm free flap consists of the anterior forearm skin, subcutaneous tissue, fascia containing the radial artery as the perforator and its venae comitantes, cephalic and basilic veins, and lateral and medial antebrachial cutaneous nerves are demonstrated in relation to the surgically derived flap. Song's forearm free flap phalloplasty requires two surgical stages with a three-month interval between the stages: prelamination of a neourethra and construction of a neophallus. The neophallus created by forearm flap phalloplasty is reported to achieve acceptable aesthetical and psychological satisfaction, appropriate size and shape, and satisfying sexual intercourse. Despite increasing experiences in gender confirming surgery with modifications made by many authors, urethral complications including fistula and/or stricture formation are the leading causes of reoperation. The poor esthetic outcome of the forearm donor site and a decrease in rigidity of the neophallus are the main limitations. Illustrations of anatomy help inform surgical choice and understanding of risks and benefits by patients. The anatomy of the free forearm flap phalloplasty supports creation of a neophallus for transsexual anatomy revision. Clin. Anat. 31:145-151, 2018. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.

A clinical study on perforator stroke resulting from Wingspan stent angioplasty for symptomatic intracranial artery stenosis

International Nuclear Information System (INIS)

Wang Ziliang; Xu Haowen; Li Tianxiao; Zhu Liangfu; Li Zhaoshuo; Xue Jiangyu; Bai Weixing; Li Li; Guan Sheng

2011-01-01

Objective: To evaluate the incidence, potential hazards and effective countermeasure for perforator stroke (PS) resulting from stent angioplasty of symptomatic intracranial artery stenosis. Methods: Peri-operation PS complications of 258 patients receiving Gateway balloon-Wingspan stenting for severe symptomatic intracranial stenosis were analyzed. The incidence, clinical course, and prognosis of PS resulting from stenting were recorded. Special attention was given to the anatomical features, clinical manifestation and video materials of patients with PS. χ 2 test was used for statistics. Results: Two hundred and fifty-five patients received stent angioplasty successfully and 7 patients had PS (incidence rate 2.7%). The patients with basilar artery stenosis had a higher incidence of PS resulting from intracranial stenting (6.1%, 4/66) than patients with middle cerebral artery stenosis (2.5%, 3/118) (χ 2 =2.320, P= 0.025). The potential hazards for PS included preoperative perforator stroke adjacent to the stenotic segment and prominent dissection during operation. Six patients presented symptoms after awake from general anaesthesia and one had symptoms 3 hours after stenting. One deteriorated gradually and the others reached the maximum deficit almost at once. At the follow-up of 3 months, 3 patients were disabled and scored one, two, two by mRS respectively. Conclusion: The incidence of PS resulting from intracranial stenting was low and the prognosis was not disastrous. Stenosis at basilar artery and preoperative perforator stroke adjacent to the stenotic segment were potential risk factors for PS complication. Proper maneuver of angioplasty may decrease the incidence of PS and improve the prognosis. (authors)

The zygomatic implant perforated (ZIP) flap: a new technique for combined surgical reconstruction and rapid fixed dental rehabilitation following low-level maxillectomy.

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Butterworth, C J; Rogers, S N

2017-12-01

This aim of this report is to describe the development and evolution of a new surgical technique for the immediate surgical reconstruction and rapid post-operative prosthodontic rehabilitation with a fixed dental prosthesis following low-level maxillectomy for malignant disease.The technique involves the use of a zygomatic oncology implant perforated micro-vascular soft tissue flap (ZIP flap) for the primary management of maxillary malignancy with surgical closure of the resultant maxillary defect and the installation of osseointegrated support for a zygomatic implant-supported maxillary fixed dental prosthesis.The use of this technique facilitates extremely rapid oral and dental rehabilitation within a few weeks of resective surgery, providing rapid return to function and restoring appearance following low-level maxillary resection, even in cases where radiotherapy is required as an adjuvant treatment post-operatively. The ZIP flap technique has been adopted as a standard procedure in the unit for the management of low-level maxillary malignancy, and this report provides a detailed step-by-step approach to treatment and discusses modifications developed over the treatment of an initial cohort of patients.

Reconstruction of cervical scar contracture using axial thoracic flap based on the thoracic branch of the supraclavicular artery.

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Ma, Xianjie; Li, Yang; Wang, Lu; Li, Weiyang; Dong, Liwei; Xia, Wei; Su, Yingjun

2014-09-01

Cervical scar contracture causes both physical and psychological distress for burn patients. Many pedicle flaps or skin grafting have been suggested for reconstruction of cervical scar contracture with variable results in the literature. The authors present the axial thoracic flap based on the thoracic branch of the supraclavicular artery (TBSA) for reconstruction of cervical scar contracture. Postburn scar contractures in anterior neck region of 66 patients had been reconstructed with the axial pattern thoracic flaps based on the TBSA, including 1 expanded and 10 nonexpanded pedicle flaps, and 9 expanded and 46 nonexpanded island pedicle flaps, during 1988 through 2012. After removing and releasing the cervical scar contracture, the flap was designed in the thoracic region. The axial artery of the flap is the TBSA bifurcating from the intersection point of sternocleidomastoid muscle and omohyoid muscle with several concomitant veins as the axial veins. The flap can be designed in a large area within the borders of the anterior border of the trapezius muscle superiorly, the middle part of the deltoid muscle laterally, the midsternal line medially, and the level 3 to 4 cm below nipples inferiorly. After incisions were made along the medial, inferior, and lateral border, dissection was performed toward the pedicle. Donor site was closed directly in expanded cases and with skin grafting in nonexpanded cases. Cervical scar contractures were repaired with good functional and cosmetic results in 64 cases among this cohort. Flap tip necrosis in other 2 cases, caused by postoperative hematoma, was repaired by skin grafting. The color and texture of all flaps were fitted with those of the surrounding skin. The donor sites all healed primarily. The flap sensation in the thoracic region regained in the early stage postoperatively and that in cervical area recovered completely after 6 months according to the report of the patients. With reliable blood supply based on the

Experience with Perforator Based Flaps for Wound Cover of the Leg ...

African Journals Online (AJOL)

Background: Open fractures of the distal third of the tibia and fibular offer a challenge to the orthopedic surgeon because of skin coverage. The reconstructive surgeon's help is often required in trying to achieve this. There are several options: - local flap, free flap or a cross leg flap. Local flaps have always had limitations ...

Propeller flaps for lower-limb trauma | Rogers | South African ...

African Journals Online (AJOL)

The propeller flap has become a versatile and important component in our reconstructive algorithm following complex lower limb trauma. First described by Hyakusoku in 1991, it has since been adapted and modified by Hallock and Teo. This article outlines our experience specifically with perforator pedicled propeller flaps ...

Versatility of the Distally-Based Sural Artery Fasciocutaneous Flap on the Lower Leg and Foot in Patients with Chronic Disease

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Jin-Su Park

2013-05-01

Full Text Available Background  A recent advancement in microsurgery, the free flap is widely used in the re­construction ofthe lowerleg and foot. The simple and effective methods oflocal flaps, inclu­ding transposition and advancement flaps, have been considered for patients with chronicdebilitationwho are unable to endure long surgical procedures or general anesthesia.However,the location and size of the wound may restrict the clinical application of a local flap. Underthese circumstances, a sural flap can be an excellent alternative, rendering satisfying clinicaloutcomesin chronically debilitated patients.Methods  Between 2008 and 2012, 39 patients underwent soft tissue defect treatment bysural artery flap as a final method. All ofthe patients had atleast one chronic disease or more(diabetes, hypertension, vascular disease, etc.. Also, all ofthe patients had a history of chroniclower extremity ulceration, which revealed no response to several months of conservativetreatment.Results  The results of the 39 cases had a successrate of 100% with 39 complete recoveries.Nine casessuffered complications: partial necrosis(n= 4,wound dehiscencewithout necrosis(n= 3, hematoma (n= 1, and infection (n= 1.Conclusions  The sural artery flap is not only usefulforthe lowerleg but also forthe heel, andother various parts. Furthermore, itis a relatively simple surgicaltechnique forreconstructingthe defect area for patients with various chronic conditions with a high surgical risk or con­traindicationsto surgery

Immediate Reconstruction of a Soft-Tissue Defect in a Burn Patient whit a Peroforator-Based Propeller Flap: A Case Report

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Burhan Özalp

2017-06-01

Full Text Available Soft tissue reconstruction of the distal lower leg is a challenging issue for plastic surgeons. Immediate coverage of exposed anatomical structures with soft tissue after trauma prevents these structures from being infected, and this is very important for burn patients. Free flaps have recently been accepted as the gold-standard technique for ankle and foot reconstruction; however, this is changing with the increasing popularity of the perforator flaps. Today, perforator flaps are commonly performed for the reconstruction of the soft-tissue defects across the body. In this report, we want to present the reconstruction of a soft-tissue defect case using perforator-based propeller flap in a burn patient for immediate reconstruction. A 45-year-old male patient had a soft-tissue defect over the medial side of the ankle and foot due to a high-voltage electrical burn. The exposed bone tissue was covered with a propeller flap of 15×6 cm size, without any circulation problems during the postoperative period. In conclusion, we want to state that perforator-based propeller flaps are reliable, successful, and effective techniques for the immediate reconstruction of distal leg and foot. These flaps can be easily performed without requiring any microsurgical technique thus, they can be commonly performed by most of the plastic surgeons.

Microvascular anatomy of the cerebellar parafloccular perforating space.

Science.gov (United States)

Sosa, Pablo; Dujovny, Manuel; Onyekachi, Ibe; Sockwell, Noressia; Cremaschi, Fabián; Savastano, Luis E

2016-02-01

The cerebellopontine angle is a common site for tumor growth and vascular pathologies requiring surgical manipulations that jeopardize cranial nerve integrity and cerebellar and brainstem perfusion. To date, a detailed study of vessels perforating the cisternal surface of the middle cerebellar peduncle-namely, the paraflocculus or parafloccular perforating space-has yet to be published. In this report, the perforating vessels of the anterior inferior cerebellar artery (AICA) in the parafloccular space, or on the cisternal surface of the middle cerebellar peduncle, are described to elucidate their relevance pertaining to microsurgery and the different pathologies that occur at the cerebellopontine angle. Fourteen cadaveric cerebellopontine cisterns (CPCs) were studied. Anatomical dissections and analysis of the perforating arteries of the AICA and posterior inferior cerebellar artery at the parafloccular space were recorded using direct visualization by surgical microscope, optical histology, and scanning electron microscope. A comprehensive review of the English-language and Spanish-language literature was also performed, and findings related to anatomy, histology, physiology, neurology, neuroradiology, microsurgery, and endovascular surgery pertaining to the cerebellar flocculus or parafloccular spaces are summarized. A total of 298 perforating arteries were found in the dissected specimens, with a minimum of 15 to a maximum of 26 vessels per parafloccular perforating space. The average outer diameter of the cisternal portion of the perforating arteries was 0.11 ± 0.042 mm (mean ± SD) and the average length was 2.84 ± 1.2 mm. Detailed schematics and the surgical anatomy of the perforating vessels at the CPC and their clinical relevance are reported. The parafloccular space is a key entry point for many perforating vessels toward the middle cerebellar peduncle and lateral brainstem, and it must be respected and protected during surgical approaches to the

Free-flap cover of complex defects around the knee using the descending genicular artery as the recipient pedicle.

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Venkatramani, H; Sabapathy, S R; Nayak, S

2014-01-01

Selection of ideal recipient vessels is one of the most important factors determining success in free-flap reconstruction of the lower limb. At the knee, the choice of vessels has traditionally been either the common femoral or the popliteal vessels and their branches but these are often difficult to use or cannot be used. A series of 32 free flaps for cover of complex injuries of the knee involving the distal femur, the knee joint and the upper tibia were reconstructed using the descending genicular branch of the femoral artery in the adductor canal and its muscular branches to the vastus medialis as the recipient vessels. All but one flap survived with no major complications. The use of the descending genicular artery as the recipient vessel for reconstruction with free flaps around the knee has various advantages including: (i) it is mostly remote from the zone of trauma, (ii) it is constant in location, (iii) the recipient vessels are an excellent size match for end-to-end anastomosis, (iv) there is no need for changes of position of the patient when using most free flaps commonly used for knee reconstruction, (v) it is easy to harvest these simultaneously, (vi) secondary exposure of the underlying skeleton from all quadrants is unlikely to divide the flap pedicle as it is superior and (vii), perhaps most important of all, it obviates the need for exploration of the popliteal fossa. Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Distally based superficial sural artery flap for soft tissue coverage in the distal 2/3 of leg and foot

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Kamath B

2005-01-01

Full Text Available Background: Skin coverage for defects in the lower 2/3 of leg, ankle region and posterior heel has always been a difficult challenge for reconstructive surgeon. Methods: We describe our experience with the distally based superficial sural artery flap coverage in 48 patients with moderate sized defects in these difficult areas. Results: One out of 48 flaps (in 48 patients was lost totally and 3 suffered marginal necrosis which did not require any secondary procedure. These complications could have been avoided by proper selection of cases and refining technical skills. Conclusion: This simple procedure could be an important and versatile tool for any reconstructive surgeon in providing skin coverage in the distal leg and proximal foot. Preservation of major arteries of the lower limb, minimal donor defect, relatively uninjured donor area in compound fracture or poly trauma involving distal leg are some of the advantages of the flap.

Pedicled Temporalis Muscle Flap for Craniofacial Reconstruction: A 35-Year Clinical Experience with 366 Flaps.

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Spanio di Spilimbergo, Stefano; Nordera, Paolo; Mardini, Samir; Castiglione, Giusy; Chim, Harvey; Pinna, Vittore; Brunello, Massimo; Cusino, Claudio; Roberto, Squaquara; Baciliero, Ugo

2017-02-01

In the past 130 years, the temporalis muscle flap has been used for a variety of different indications. In this age of microsurgery and perforator flaps, the temporalis muscle flap still has many useful applications for craniofacial reconstruction. Three hundred sixty-six temporalis muscle flaps were performed in a single center between 1978 and 2012. The authors divided the cases into two series-before and after 1994-because, after 1994, they started to perform free flap reconstructions, and indications for reconstruction with a temporalis muscle flap were changed RESULTS:: In the series after 1994, flaps were most commonly used for reconstruction of defects in the maxilla, mandible, and oropharynx, in addition to facial reanimation and filling of orbital defects. Complications included total flap necrosis (1.6 percent) and partial flap necrosis (10.7 percent). The rate of material extrusion at the donor site decreased after porous polyethylene was uniformly used for reconstruction from 17.1 to 7.9 percent. The pedicled temporalis muscle flap continues to have many applications in craniofacial reconstruction. With increasing use of free flaps, the authors' indications for the pedicled temporalis muscle flap are now restricted to (1) orbital filling for congenital or acquired anophthalmia; (2) filling of unilateral maxillectomy defects; and (3) facial reanimation in selected cases of facial nerve palsy. Therapeutic, IV.

[Management of vascular crisis of free flaps after reconstruction of head and neck defects caused by tumor resection].

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Ni, Song; Zhu, Yiming; Li, Dezhi; Liu, Jie; An, Changming; Zhang, Bin; Liu, Shaoyan

2015-11-01

To discuss the management of vascular crisis of free flaps after reconstruction of head and neck defects caused by tumor resection. A total of 259 cases of free flap reconstruction performed in the Cancer Hospital of Chinese Academy of Medical Sciences from 2010 to 2013 were retrospectively analyzed, including 89 cases of anterolateral thigh flaps, 48 cases of radial forearm flaps, 46 free fibula flaps, 5 cases of inferior epigastric artery perforator flaps, 5 cases of free latissimus dorsi flaps, one case of lateral arm flap, and one case of medial femoral flap. The surveillance frequency of free flaps was q1h on post-operative day (POD) 1, q2h on POD 2 and 3, and q4h after POD 3. Vascular crises were reviewed for analysis. The incidence rate of vascular crisis was 8.1% (21/259), with 15 males and 6 females. The average age was 54.8 years old (17-68), and the average time of vascular crisis was 100.8 h post-operation (3-432). There were 7 cases of free jejunum flaps and 14 dermal free flaps. Seven of these 21 cases with vascular crisis were rescued by surgery. The success rate of salvage surgery within 72 hours from the primary operation was 54.5% (6/11), significantly higher than that of salvage surgery performed later than 72 hours from primary operation (10.0%, 1/10, P=0.043). There were 14 cases of flap necrosis, two of which died of local infection. Early detection of vascular crisis can effectively improve the success rate of salvage, so as to avoid the serious consequences caused by free flap necrosis.

Saphenous vein grafts for perforator flap salvage in autologous breast reconstruction.

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Flores, Jaime I; Rad, Ariel N; Shridharani, Sachin M; Stapleton, Sahael M; Rosson, Gedge D

2009-01-01

Although the use of saphenous vein grafts in free-flap salvage and extremity replantation is relatively common, their use in breast reconstruction is rare. These two case reports represent extreme alternatives for breast reconstruction flap salvage. In our normal daily practice, the overwhelming majority of elective breast reconstructions proceed smoothly. However, the occasional patient may require saphenous vein graft flap rescue for completion of the reconstruction. (c) 2008 Wiley-Liss, Inc.

Pulmonary Artery Perforation as a Complication of Pleural Drainage - Case Report.

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Gołota, Janusz Jacek; Kiliańczyk, Michał; Szmyt, Piotr

2016-10-01

The case presented is a drainage of empyema of the left pleural cavity complicated with the penetration of the lung parenchyma and perforation of the left pulmonary artery with drain displacement to the right pulmonary artery. The cause of complications has been shown along with the possible ways of conduct. Drainage of the pleural cavity is a primary surgery in the chest. The presence of pleural air or fluid is an indication for its implementation. This procedure usually has no complications. Time pressure, anatomical anomalies, changes of the topography in the course of co-morbidities are the factors allowing for the creation of many complications. The aim of the work is to remind about the technical performance of this simple surgical procedure and to note that its complications may directly threaten the life of the patient. This is the first case reported in Polish literature.

A Case of Urethral Reconstruction Using a Superficial Circumflex Iliac Artery

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Kun-Woon Yoo

2012-05-01

Full Text Available A radial forearm free flap has been conventionally used for urethral reconstruction. However,aesthetic and functional complications occur frequently at the donor site. The use of asuperficial circumflex iliac artery perforator (SCIP flap can resolve these disadvantages.Here, we report our case with a review of literature. A 69-year-old man visited our hospitalwith multiple contusions of the abdomen and genital amputation. After necrotic tissuedebridement, the length of the residual corpus carvernosum was 1.5 cm and that of thecorpus spongiosum and urethra was 1 cm. For the reconstruction of the penis, a SCIP flap andanterolateral thigh free flap was performed. The primary closure was performed at the donorsite. Three weeks postoperatively, the patient had a urethral foley catheter removed. Theneourethra was functioning well without stricture. Four months postoperatively, the patienthad no complications such as urethral stricture. A good recovery was also achieved withno aesthetic deficits at the donor site. SCIP flap is appropriate for urethral reconstruction.Because of its proximity to the recipient sites, it makes surgical preparation easier and theprimary closure at the donor site available. It is also advantageous in that its location isalmost unnoticeable.

Anatomical variations in dorsal metatarsal arteries with surgical significance: A cadaveric study

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Preeti Shivshankar Awari

2017-01-01

Full Text Available Introduction: Based on angiosome concept to revascularize a particular artery, the microvascular and reconstructive surgeons must know the anatomy and variations in the arteries in that specific region of the body to achieve better results. Nowadays, dorsal metatarsal artery (DMTA perforator flaps and toe grafts are becoming popular which also demand adequate information about normal anatomy and variants in these arteries for fruitful results. Materials and Methods: The authors studied normal anatomy and variations in the origin of DMTAs in 50 lower extremities of 25 embalmed cadavers. Results: The authors found many variations as the absence of DMTAs, origin of the DMTA from the deep plantar arch. The places wherever the arcuate artery was absent the lateral tarsal artery gave rise to dorsal metatarsal arteries. Conclusion: Being familiar with the incidence of anatomical variations in the origin of the DMTAs can increase vigilance in vascular and reconstructive surgeries leading to better prognosis. surgeries leading to better prognosis.

Release of hand burn contracture: comparing the ALT perforator flap with the gracilis free flap with split skin graft.

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Misani, M; Zirak, C; Hau, Lê Thua Trung; De Mey, A; Boeckx, W

2013-08-01

The use of microsurgery in the management of burn sequelae is not a new idea. According to the properties of various types of free flaps different goals can be achieved or various additional procedures have to be combined. We report the comparison of two different free flaps on a single patient for reconstruction of both upper extremities for burn sequelae. A 1-year-old child sustained severe burns on both hands, arms and thorax and was initially only treated conservatively. This resulted in severe contractures. At the age of 4-years a free gracilis flap was selected for reconstruction of his left hand and a free anterolateral thigh flap for the right hand. We noticed a better functional and esthetic result for the gracilis flap associated with a shorter operative time and a minor donor site morbidity. The intraoperative technique and time, postoperative complications, functional and esthetic results and donor site morbidities were studied in the two types of flaps chosen. A review of literature was also performed. Our experience reported a better success of the gracilis muscle flap covered with a split skin graft compared to the anterolateral thigh flap in the reconstruction of hand function after severe burn sequelae. Copyright © 2013 Elsevier Ltd and ISBI. All rights reserved.

Perforation of Transverse Colon: A Catastrophic Complication of Uterine Artery Embolization for Fibroids

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Acharya, Jyotsna, E-mail: jyoacharya@yahoo.com; Bancroft, Karen; Lay, James [Royal Bolton Hospital (United Kingdom)

2012-12-15

We report a case of a 43-year-old woman who underwent uterine artery embolization (UAE) for a symptomatic large fibroid uterus and had spontaneous perforation of the transverse colon 3 months after embolisation with near-fatal consequences. We believe this is the first reported case in the literature of this serious complication of UAE. We briefly review the literature on bowel complications after UAE and discuss lessons to be learned regarding patient selection and postprocedure follow-up.

Perforation of Transverse Colon: A Catastrophic Complication of Uterine Artery Embolization for Fibroids

International Nuclear Information System (INIS)

Acharya, Jyotsna; Bancroft, Karen; Lay, James

2012-01-01

We report a case of a 43-year-old woman who underwent uterine artery embolization (UAE) for a symptomatic large fibroid uterus and had spontaneous perforation of the transverse colon 3 months after embolisation with near-fatal consequences. We believe this is the first reported case in the literature of this serious complication of UAE. We briefly review the literature on bowel complications after UAE and discuss lessons to be learned regarding patient selection and postprocedure follow-up.

The transverse musculocutaneous gracilis flap for breast reconstruction: guidelines for flap and patient selection.

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Schoeller, Thomas; Huemer, Georg M; Wechselberger, Gottfried

2008-07-01

The transverse musculocutaneous gracilis (TMG) flap has received little attention in the literature as a valuable alternative source of donor tissue in the setting of breast reconstruction. The authors give an in-depth review of their experience with breast reconstruction using the TMG flap. A retrospective review of 111 patients treated with a TMG flap for breast reconstruction in an immediate or a delayed setting between August of 2002 and July of 2007 was undertaken. Of these, 26 patients underwent bilateral reconstruction and 68 underwent unilateral reconstruction, and 17 patients underwent reconstruction unilaterally with a double TMG flap. Patient age ranged between 24 and 65 years (mean, 37 years). Twelve patients had to be taken back to the operating room because of flap-related problems and nine patients underwent successful revision microsurgically, resulting in three complete flap losses in a series of 111 patients with 154 transplanted TMG flaps. Partial flap loss was encountered in two patients, whereas fat tissue necrosis was managed conservatively in six patients. Donor-site morbidity was an advantage of this flap, with a concealed scar and minimal contour irregularities of the thigh, even in unilateral harvest. Complications included delayed wound healing (n = 10), hematoma (n = 5), and transient sensory deficit over the posterior thigh (n = 49). The TMG flap is more than an alternative to the deep inferior epigastric perforator (DIEP) flap in microsurgical breast reconstruction in selected patients. In certain indications, such as bilateral reconstructions, it possibly surpasses the DIEP flap because of a better concealed donor scar and easier harvest.

The transverse musculo-cutaneous gracilis flap for breast reconstruction: How to avoid complications.

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Bodin, Frédéric; Dissaux, Caroline; Dupret-Bories, Agnes; Schohn, Thomas; Fiquet, Caroline; Bruant-Rodier, Catherine

2016-01-01

The transverse musculocutaneous gracilis (TMG) flap has become a common solution for breast reconstruction. However, the safe skin paddle limits are not yet understood. In this study, we attempted to address this issue based on our experiences with inferior and posterior skin paddle extension. Forty-four breast reconstructions with TMG flaps performed between November 2010 and January 2014 were analyzed retrospectively. For the first 20 cases, the flap skin paddle was extended 3 cm posteriorly to the middle thigh (group 1). For the next 20 flaps (group 2), the posterior tip was limited to this line, whereas more fat was recruited inferiorly. In the four cases of group 3, the skin flap was extended posteriorly with a second vascular pedicle from the profunda artery perforator (PAP) flap. The weights and the dimensions of the flaps, operating durations, and postoperative complications of the entire series were analyzed. Groups 1 and 2 were statistically compared. Flap complications were statistically more frequent in group 1 compared with group 2 (45 vs. 0%, P = 0.0012); 40% posterior flap tip necrosis was observed in group 1. Conversely, donor site complications were statistically more frequent in group 2 than in group 1 (40 vs. 5%, P = 0.019) with 35% inner thigh dehiscence. In the TMG with extended PAP flap group, the operating duration was 77 min longer compared with the rest of the series with no donor site complications. In one case, limited necrosis occurred at the anterior skin tip. Harvesting the posterior portion of the TMG up to the middle of the posterior thigh may lead to partial flap necrosis. Extending subcutaneous fat removal under the inferior skin incision may increase the risk of donor site complications. Adding a second vascular pedicle from the PAP flap may improve posterior TMG tip perfusion at the expense of a longer operation. © 2015 Wiley Periodicals, Inc.

Venous coupler use for free-flap breast reconstructions: specific analyses of TMG and DIEP flaps.

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Bodin, Frédéric; Brunetti, Stefania; Dissaux, Caroline; Erik, A Sauleau; Facca, Sybille; Bruant-Rodier, Catherine; Liverneaux, Philippe

2015-05-01

The purpose of this report was to present the results of comparisons of anastomotic data and flap complications in the use of venous coupler in breast reconstruction with the transverse musculocutaneous gracilis (TMG) flap and the deep inferior epigastric perforator (DIEP) flap. Over a three-year period, 95 patients suffering from breast cancer were treated with mastectomy and breast reconstruction using free flaps. We performed 121 mechanical venous anastomoses for 105 flap procedures (80 DIEP and 25 TMG). The coupler size, anastomotic duration, number of anastomoses and postoperative complications were assessed for the entire series. The coupling device was perfectly suitable for all end-to-end anastomoses between the vein(s) of the flap and the internal mammary vein(s). No venous thrombosis occurred. The mean anastomotic time did not significantly differ between the DIEP (330 seconds) and TMG flap procedures (352 seconds) (P = 0.069). Additionally, there were no differences in coupling time observed following a comparison of seven coupler sizes (P = 0.066). The mean coupler size used during the TMG flap procedure was smaller than that used with the DIEP (2.4 mm versus 2.8 mm) (P TMG flap (28%) than with the DIEP flap (11%). The coupler size used was smaller for the TMG procedure and when double venous anastomosis was performed. Additionally, anastomotic time was not affected by the flap type or coupler size used or by anastomosis number. © 2014 Wiley Periodicals, Inc.

A retrospective study: Multivariate logistic regression analysis of the outcomes after pressure sores reconstruction with fasciocutaneous, myocutaneous, and perforator flaps.

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Chiu, Yu-Jen; Liao, Wen-Chieh; Wang, Tien-Hsiang; Shih, Yu-Chung; Ma, Hsu; Lin, Chih-Hsun; Wu, Szu-Hsien; Perng, Cherng-Kang

2017-08-01

Despite significant advances in medical care and surgical techniques, pressure sore reconstruction is still prone to elevated rates of complication and recurrence. We conducted a retrospective study to investigate not only complication and recurrence rates following pressure sore reconstruction but also preoperative risk stratification. This study included 181 ulcers underwent flap operations between January 2002 and December 2013 were included in the study. We performed a multivariable logistic regression model, which offers a regression-based method accounting for the within-patient correlation of the success or failure of each flap. The overall complication and recurrence rates for all flaps were 46.4% and 16.0%, respectively, with a mean follow-up period of 55.4 ± 38.0 months. No statistically significant differences of complication and recurrence rates were observed among three different reconstruction methods. In subsequent analysis, albumin ≤3.0 g/dl and paraplegia were significantly associated with higher postoperative complication. The anatomic factor, ischial wound location, significantly trended toward the development of ulcer recurrence. In the fasciocutaneous group, paraplegia had significant correlation to higher complication and recurrence rates. In the musculocutaneous flap group, variables had no significant correlation to complication and recurrence rates. In the free-style perforator group, ischial wound location and malnourished status correlated with significantly higher complication rates; ischial wound location also correlated with significantly higher recurrence rate. Ultimately, our review of a noteworthy cohort with lengthy follow-up helped identify and confirm certain risk factors that can facilitate a more informed and thoughtful pre- and postoperative decision-making process for patients with pressure ulcers. Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All

Long-term follow-up of changing practice patterns in breast reconstruction due to increased use of tissue expanders and perforator flaps.

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Manahan, Michele A; Prucz, Roni B; Shridharani, Sachin M; Baltodano, Pablo A; Rosson, Gedge D

2014-11-01

As the science of breast reconstruction evolves, significant changes in reconstruction strategies and outcomes are expected. The purpose of this study is to determine the changes in breast reconstruction trends and outcomes that occurred at a multidisciplinary academic institution during the last decade. We compared 265 patients over two distinct 6-month intervals separated by 5 years (2002 vs. 2007) and performed long-term follow-up (4.75 ± 3.38 years 2002, 2.99 ± 2.25 years 2007). We studied patients seeking prophylactic mastectomy, patients with early breast cancer, and patients with locally advanced disease. We analyzed demographic data, breast cancer history and treatment, type and timing of reconstruction, and complications. Implant to flap reconstruction ratio was 48:49 in 2002 and 76:102 in 2007. Use of transverse rectus abdominis myocutaneous flap declined from 57 to 4%; conversely, deep inferior epigastric perforator flap increased from 27 to 91% (P < 0.001). Correspondingly, donor site chronic pain (4 vs. 0, P = 0.012) and postoperative abdominal wall bulge (9 vs. 3, P = 0.004) rates decreased. Timing of reconstruction showed increased staged cases in 2007 compared to 2002 (P = 0.045). Post-final reconstruction radiation therapy was reduced in 2007 (P = 0.016), with subsequent lower rates of implant rupture (P < 0.001). At our institution and over the last decade, increasing staged reconstructions have successfully reduced the rates of post-final reconstruction radiotherapy with optimized outcomes. Contrary to national trends, the rates of autologous flap reconstructions have increased with reduced donor site morbidity. This suggests that academic breast reconstruction trends are independent from national trends. © 2014 Wiley Periodicals, Inc.

Use of anteromedial thigh perforator flap and immunological implications of Gorlin-Goltz syndrome: a case study.

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Scalise, A; Calamita, R; Tartaglione, C; Bolletta, E; Di Benedetto, G; Pierangeli, M

2016-12-02

Gorlin-Goltz syndrome is mainly characterised by the development of numerous multicentric and relapsing cutaneous basal cell carcinomas (BCCs). A major problem for patients with Gorlin-Goltz syndrome is the large amount of BCCs that can invade the deep underlying structures, especially the face. Here, we describe the case of a 23-year-old male affected by Gorlin-Goltz syndrome. He had recurrent BCCs on a hairless scalp and dorsum since he was 17 years old and underwent four surgical procedures to excise BCCs, including a reconstruction with anteromedial thigh perforator flap. For each of the surgical procedures, a phenotypic study on peripheral blood mononuclear cells using flow cytometry was performed on the same day of surgery, and on days 7, 14 and 21 after surgery. The role of the tumour-specific cytolytic immune response as a potential future treatment of syndromic BCCs and its trend in relation to surgical ablation of large portions of tumour tissue was examined, and the cosmetic and therapeutic results are shown.

Innervated boomerang flap for finger pulp reconstruction.

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Chen, Shao-Liang; Chiou, Tai-Fung

2007-11-01

The boomerang flap originates from the dorsolateral aspect of the proximal phalanx of an adjacent digit and is supplied by the retrograde blood flow through the vascular arcades between the dorsal and palmar digital arteries. To provide sensation of the boomerang flap for finger pulp reconstruction, the dorsal sensory branch of the proper digital nerve and the superficial sensory branch of the corresponding radial or ulnar nerve are included within the skin flap. After transfer of the flap to the injured site, epineural neurorrhaphies are done between the digital nerves of the pulp and the sensory branches of the flap. We used this sensory flap in five patients, with more than 1 year follow-up, and all patients achieved measurable two-points discrimination. The boomerang flap not only preserves the proper palmar digital artery but also provides an extended and innervated skin paddle. It seems to be an alternative choice for one-stage reconstruction of major pulp defect.

The Role of the Very Long Posterior Tibial Artery Flap following Severe Lower Limb Trauma: Case Series and Literature Review

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Leela Sayed, MBChB

2013-09-01

Full Text Available Summary: With advancing techniques, knowledge, and training, the decision to salvage a lower limb following severe trauma is becoming ever more popular and successful. However, in cases where amputation is inevitable due to extensive injury or infection, we encourage the use of the very long posterior tibial artery (VLPTA flap when the sole of the foot and posterior tibial neurovasculature are intact. We report 3 patients who underwent below-knee amputation and reconstruction using the VLPTA flap. A literature review was also performed to identify the outcomes and any complications associated with VLPTA flap.

Usefulness of Oncoplastic Volume Replacement Techniques after Breast Conserving Surgery in Small to Moderate-sized Breasts

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Jung Dug Yang

2012-09-01

Full Text Available BackgroundIn Korean women, many of whom have small to moderate-sized breasts, it is difficult to cover a partial breast defect using oncoplastic volume displacement techniques after removal of an adequate volume of tissue during oncologic surgery. In such cases, oncoplastic volume replacement techniques are more useful.MethodsFrom January 2007 to December 2011, 104 women underwent a total of 107 breast-conserving surgeries with various kinds of oncoplastic volume replacement techniques. We used latissimus dorsi (LD myocutaneous flap for cases in which the resection mass was greater than 150 g. In case with a resection mass less than 150 g, we used regional flaps such as a lateral thoracodorsal flap, a thoracoepigastric flap, or perforator flaps such as an intercostal artery perforator (ICAP flap or a thoracodorsal artery perforator (TDAP flap.ResultsThe mean age was 46.1 years, and the average follow-up interval was 10.3 months. The patients underwent oncoplastic volume replacement techniques with a lateral thoracodorsal flap (n=9, thoracoepigastric flap (n=7, ICAP flap (n=25, TDAP flap (n=12, and LD flap (n=54. There was one case of congestion in an LD flap, and two cases of fat necrosis in an ICAP flap. Most of the patients were satisfied with the cosmetic results.ConclusionsOncoplastic volume replacement techniques can be reliable and useful for the correction of breast deformity after breast-conserving surgery, especially in patients with small to moderate-sized breasts.

Radiographically occult perforation and dissection of the common carotid artery following stab injury to the neck

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Sebastian Gamba

2017-06-01

Full Text Available In recent years, many diagnostic algorithms have been devised to reduce the rate of negative explorations associated with indiscriminate surgical management of penetrating neck injuries. In hemodynamically stable patients, the need for surgical intervention is usually determined by integrating both clinical signs and radiological findings; if such investigations remain unremarkable, recommended treatment consists in close observation and sequential physical examinations. We report on a 29-year-old male who was admitted to a Swiss tertiary care hospital after sustaining a penetrating injury to his left neck following a knife attack. Disregarding a pre-hospital account of hemorrhage from the wound and slight dysphagia, no manifest symptoms or signs of internal organ damage were present on primary survey. Moreover, there was no evidence of vascular or aerodigestive tract injury on initial CT angiography. We nonetheless proceeded with immediate surgical exploration, exposing a significant perforation of the left common carotid artery with concomitant dissection of the said vessel. Surgical repair was successfully performed and the patient suffered no long-term sequelae. We thus recommend that a high level of suspicion be upheld in both asymptomatic and oligosymptomatic patients with PNI and that clinical practitioners remain cautious in the face of deceptively reassuring radiologic findings. Keywords: Penetrating neck injury, Carotid artery perforation, Carotid artery dissection, CT angiography

A Case of Urethral Reconstruction Using a Superficial Circumflex Iliac Artery

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Kun-Woon Yoo

2012-05-01

Full Text Available A radial forearm free flap has been conventionally used for urethral reconstruction. However, aesthetic and functional complications occur frequently at the donor site. The use of a superficial circumflex iliac artery perforator (SCIP flap can resolve these disadvantages. Here, we report our case with a review of literature. A 69-year-old man visited our hospital with multiple contusions of the abdomen and genital amputation. After necrotic tissue debridement, the length of the residual corpus carvernosum was 1.5 cm and that of the corpus spongiosum and urethra was 1 cm. For the reconstruction of the penis, a SCIP flap and anterolateral thigh free flap was performed. The primary closure was performed at the donor site. Three weeks postoperatively, the patient had a urethral foley catheter removed. The neourethra was functioning well without stricture. Four months postoperatively, the patient had no complications such as urethral stricture. A good recovery was also achieved with no aesthetic deficits at the donor site. SCIP flap is appropriate for urethral reconstruction. Because of its proximity to the recipient sites, it makes surgical preparation easier and the primary closure at the donor site available. It is also advantageous in that its location is almost unnoticeable.

Short and long term follow up results of (the versatile) reverse sural artery flap

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Ali, G.; Hameed, S.; Hassan, R.

2015-01-01

This study was designed to see the long and short term outcome of the reverse sural artery flap. Study Design: Case series. Patients and Methods: From January 2009 to December 2011, data was collected and analyzed for this study.Eighty nine patients with wounds on the ankle, heel, sole, distal leg, and foot were included in the study. They were followed up at 01 week, 02 weeks, and then 4 weekly for 06 months and at one year time from operation. They were examined for necrosis, congestion, surgical site infection, dehiscence of suture line, epidermolysis, donor site infection and functional outcome. Results: Most of the flaps healed nicely but two (2.25%) failed completely. Six flaps were delayed. However early follow up (within 04 weeks) revealed that there was partial loss of the distal 1-1.5 cm of flap in 04 patients (4.50%). Two patients (2.25%) developed superficial surgical site infection. Six patients (6.74%) developed venous congestion of the flaps which recovered within two weeks. Other minor complications included dehiscence of suture line in 3 patients (3.37%), and superficial Epidermolysis in four (4.50%) (Table-2). Twenty two patients (24.72%) returned to their work in 12-16 weeks, 31 (34.83%) in 16-20 weeks and 36 (40.45%) in 20-24 weeks. Long term follow-up to 06 months revealed hypertrophic scars at the donor site in three patients (4.91%) and recurrence of ulcer in 2 patients (3.27%). Conclusion: The sural fasciocutaneous flap provides reliable supple and durable most single-stage coverage of wounds of the distal third of the leg, heel, and foot with the results comparable to free-tissue transfer. (author)

Duplicated middle cerebral artery

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Perez, Jesus; Machado, Calixto; Scherle, Claudio; Hierro, Daniel

2009-01-01

Duplicated middle cerebral artery (DMCA) is an anomalous vessel arising from the internal carotid artery. The incidence DMCA is relatively law, and an association between this anomaly and cerebral aneurysms has been documented. There is a controversy whether DMCA may have perforating arteries. This is an important fact to consider in aneurysm surgery. We report the case of a 34-year-old black woman who suffered a subarachnoid hemorrhage and the angiography a left DMCA, and an aneurysm in an inferior branch of the main MCA. The DMCA and the MCA had perforating arteries. The aneurysm was clipped without complications. The observation of perforating arteries in our patient confirms that the DMCA may have perforating arteries. This is very important to be considered in cerebral aneurysms surgery. Moreover, the DMCA may potentially serve as a collateral blood supply to the MCA territory in cases of MCA occlusion. PMID:22140405

Clinical Application of Foci Contralateral Facial Artery Myomucosal Flap for Tongue Defect Repair

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Mengxiong Pan, MS

2018-02-01

Full Text Available Summary:. This study aims to investigate the clinical efficacy of foci contralateral facial artery myomucosal flap (FAMF in repairing the defect of tongue after tumor resection. There were 10 cases who received the operation to repair tongue tissue defects caused by tumor resection from January 2010 to January 2016. FAMF flap size ranged from 2.5 × 3 cm to 5 × 5 cm. All flaps survived after surgery, and no local necrosis occurred. For the donor and receptor sites of 10 cases, 8 cases got wounds healed at stage I, wound dehiscence of donor site occurred in 2 cases, and the dehisced wounds were healed after local cleaning. All 10 patients were followed up for 13 months to 5 years, with an average of 2 years and 4 months. No obvious deformity appeared on face after surgery, and there was no mouth floor leakage. After surgery, 3 cases had clinical manifestations of facial nerve marginal mandibular branch injury and returned to normal in 3 months. All patients had a limitation for mouth opening after surgery, 9 cases returned to normal after 1 year, and 1 case still had a mild limitation for mouth opening. There was no impact on patients’ eating, swallowing, language, or other functions. The foci contralateral FAMF surgery is simple and brings ideal plastic effect, high survival rate of flap, less donor site lesion, simple postoperative care, no breaking after surgery, and no impact on radical cure of tumor, which is suitable for repairing defect of tongue.

Analysis of deep inferior epigastric perforator (DIEP) arteries by using MDCTA: Comparison between 2 post-processing techniques.

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Saba, Luca; Atzeni, Matteo; Ribuffo, Diego; Mallarini, Giorgio; Suri, Jasjit S

2012-08-01

Our purpose was to compare two post-processing techniques, Maximum-Intensity-Projection (MIP) and Volume Rendering (VR) for the study of perforator arteries. Thirty patients who underwent Multi-Detector-Row CT Angiography (MDCTA) between February 2010 and May 2010 were retrospectively analyzed. For each patient and for each reconstruction method, the image quality was evaluated and the inter- and intra-observer agreement was calculated according to the Cohen statistics. The Hounsfield Unit (HU) value in the common femoral artery was quantified and the correlation (Pearson Statistic) between image quality and HU value was explored. The Pearson r between the right and left common femoral artery was excellent (r=0.955). The highest image quality score was obtained using MIP for both observers (total value 75, with a mean value 2.67 for observer 1 and total value of 79 and a mean value of 2.82 for observer 2). The highest agreement between the two observers was detected using the MIP protocol with a Cohen kappa value of 0.856. The ROC area under the curve (Az) for the VR is 0.786 (0.086 SD; p value=0.0009) whereas the ROC area under the curve (Az) for the MIP is 0.0928 (0.051 SD; p value=0.0001). MIP showed the optimal inter- and intra-observer agreement and the highest quality scores and therefore should be used as post-processing techniques in the analysis of perforating arteries. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Sonographic templates of newborn perforator stroke.

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Abels, Lyanne; Lequin, Maarten; Govaert, Paul

2006-07-01

Many paediatric strokes occur in the perinatal period. Improvement in neuroimaging has increased detection in newborns with neurological symptoms. To define sonographic templates of neonatal stroke in the territory of perforators of the anterior choroidal artery (AChA) and the anterior (ACA), middle (MCA) and posterior (PCA) cerebral arteries. In 24 neonates with perforator stroke, we retrospectively studied antenatal and perinatal events. Brain sonography was performed with an 8.5-MHz probe. Only hyperechoic lesions in the thalamus and/or striatum and/or centrum semiovale were included. MRI was obtained using a 1.5-T machine. We detected 28 perforator strokes in 24 infants (6 preterm): 5 MCA medial striate, 8 MCA lateral striate, 3 MCA centrum semiovale, 4 ACA Heubner's, 5 PCA thalamic arteries, 1 AChA, and 2 hypothalamic perforators. We attributed clinical seizures to stroke in two infants only. Catheter-related embolism (certain in three, possible in six others) and birth trauma (two) were probable causes. Specific conditions were found in six others. Only one infant (in nine evaluated) had an increased prothrombotic risk (fII mutation). In describing the lesions, we focused on the templates of infarction as seen in a parasagittal US sweep. Infarcts were confirmed by MRI in 21 patients. Our study showed that infarct topography can be evaluated reliably with brain sonography. This is important given the asymptomatic character of most lesions.

Rapid deterioration of Mooren?s ulcers after conjunctival flap: a review of 2 cases

OpenAIRE

Li, Saiqun; Deng, Yuqing; Du, Caiyuan; Huang, Haixiang; Zhong, Jing; Chen, Ling; Wang, Bowen; Yuan, Jin

2017-01-01

Background Conjunctival flaps are a widely used treatment for numerous corneal ulcers that are caused by microorganismal infections. However, whether it can be performed on immune-mediated corneal ulcers is controversial. Case presentation We present two cases of Mooren?s ulcer that were treated using conjunctival flap in an attempt to prevent further corneal perforation at their local hospital. A rapid acceleration in ulcer progression was observed after a conjunctival flap was applied. Ulti...

Aesthetic refinements and reoperative procedures following 370 consecutive DIEP and SIEA flap breast reconstructions: important considerations for patient consent.

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Enajat, Morteza; Smit, Jeroen M; Rozen, Warren M; Hartman, Ed H M; Liss, Anders; Kildal, Morten; Audolfsson, Thorir; Acosta, Rafael

2010-06-01

Breast reconstruction often requires multiple operations. In addition to potential complications requiring reoperation, additional procedures are frequently essential in order to complete the reconstructive process, with aesthetic outcome and breast symmetry shown to be the most important factors in patient satisfaction. Despite the importance of these reoperations in decision-making and the consent process, a thorough review of the need for such operations has not been definitively explored. A review of 370 consecutive autologous breast reconstructions (326 patients) was undertaken, comprising 365 deep inferior epigastric artery perforator (DIEP) flaps and 5 superficial inferior epigastric artery (SIEA) flaps. The need for additional procedures for either complications or aesthetic refinement following initial breast reconstruction was assessed. Overall, there was an average of 1.06 additional interventions for every patient carried out after primary reconstructive surgery. Of 326 patients, 46 underwent early postoperative operations for surgical complications (0.17 additional operations per patient as a consequence of complications). Procedures for aesthetic refinement included those performed on the reconstructed breast, contralateral breast, or abdominal donor site. Procedures for aesthetic refinement included nipple reconstruction, nipple-areola complex tattooing, dog-ear correction, liposuction, lipofilling, scar revision, mastopexy, and reduction mammaplasty. While DIEP flap surgery for breast reconstruction provides favorable results, patients frequently require additional procedures to improve aesthetic outcomes. The need for reoperation is an important part of the consent process prior to reconstructive surgery, and patients should recognize the likelihood of at least one additional procedure following initial reconstruction.

The dorsal thoracic fascia: anatomic significance with clinical applications in reconstructive microsurgery.

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Kim, P S; Gottlieb, J R; Harris, G D; Nagle, D J; Lewis, V L

1987-01-01

The anatomic distribution and potential arterial flow patterns of the circumflex scapular artery were investigated by Microfil injection. These studies demonstrated that the circumflex scapular artery lies within the dorsal thoracic fascia, which plays a significant role in the circulation of the overlying skin and subcutaneous tissue. We conclude that scapular/parascapular flaps are fasciocutaneous flaps, the dorsal thoracic fascia can be transferred as a free flap without its overlying skin and subcutaneous tissue, and intercommunication exists between the myocutaneous perforators of the latissimus dorsi myocutaneous flap and the vascular plexus of the dorsal thoracic fascia. We present microvascular cases in which the vascular properties of the dorsal thoracic fascia facilitated wound closure with free fascia flaps or expanded cutaneous or myocutaneous flaps.

[Assessment of the quality of life of oral cancer patients after reconstruction with free anterolateral thigh perforator flaps].

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Na, Deng; Wei, He; Rui, Li; Wenlu, Li; Ning, Gao; Wen, Zhang

2015-04-01

This study aims to evaluate the quality of life (QOL) of patients who underwent resection of oral cancer and reconstruction by free anierolateral thigh perforator flaps (ALTF). A total of 32 patients with oral and maxillofacial malignancies who had undergone the resection of oral cancer and reconstruction by ALTF were retrospectively analyzed. At 12 months postoperatively, the QOL of these patients was assessed by using the 14-item oral health impact profile (OHIP-14) and the medical outcome study short form-36 (SF-36) questionnaires. A total of 32 questionnaires were collected. In SF-36, the highest scoring domains were bodily pain (78.58 ± 14.82), physical functioning (72.08 ± 27.86), and the role of physical (60.00 ± 42.63), whereas the lowest scoring domains were role-emotional (41.67 ± 39.62), followed by mental health (50.75 ± 13.07) and health transition (54.17 ± 21.75). In OHIP-14, the lowest scoring domains were social disability (34.50 ± 11.32) and handicap (36.04 ± 12.05), indicating the functional recovery was better; and the highest scoring domains were physical pain (73.50 ± 18.96) and psychological discomfort (60.17 ± 20.66), indicating the functional recovery was worse. The ALTF is an ideal selection for the reconstruction of oral defects after cancer resection. In using this flap, the basic social need of patients after surgery can be satisfied. Moreover, the appearance and the functions of chewing, deglutition, and speech can be restored in varying degrees. Thus, ALTF can improve the patients' QOL.

Oromandibular reconstruction with chimeric double-skin paddle flap based on peroneal vessel axis for synchronous opposite double oral cancer.

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Huang, Shih-Tsai; Liu, Wen-Chung; Chen, Lee-Wei; Yang, Kuo-Chung

2015-05-01

Synchronous double oral cancer represents the minority of cases of head and neck cancer. After tumor ablation, 2 separate oromandibular defects, even combined with a through-and-through oral defect, pose a serious reconstructive challenge. The ideal method for reconstruction remains controversial. Based on the peroneal vessel axis, a chimeric double-skin paddle peroneal fasciocutaneous or fibular osteomyocutaneous flap could be designed to accomplish the difficult reconstruction. Six male patients, each with 2 separate oromandibular defects after tumor ablation of synchronous double oral cancer, received double-skin paddle flap reconstruction with 3 peroneal fasciocutaneous and 3 fibular osteomyocutaneous flaps. All 6 flaps survived; however, complications included 1 skin paddle lost due to insufficient perfusion of a visible perforator, and 1 superficial necrosis occurring over the tip of a longer skin paddle. One postoperative intraoral infection and 1 donor site infection were also reported. During follow-up, 3 months later, 1 patient succumbed to local recurrence and bony metastasis. One patient developed a new cancer in the maxillary gingiva, and another had osteoradionecrosis 8 months later. Four patients gained acceptable cosmesis with good oral competence. A chimeric flap based on the peroneal artery could provide a segment of fibular bone, 1 or 2 skin paddles, and a cuff of the flexor hallucis longus muscle simultaneously. For 1-stage reconstruction of separate oromandibular defects after tumor ablation of synchronous double oral cancer, this design could provide all components at 1 transfer.

The boomerang flap in managing injuries of the dorsum of the distal phalanx.

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Chen, S L; Chou, T D; Chen, S G; Cheng, T Y; Chen, T M; Wang, H J

2000-09-01

Finding an appropriate soft-tissue grafting material to close a wound located over the dorsum of a finger, especially the distal phalanx, can be a difficult task. The boomerang flap mobilized from the dorsum of the proximal phalanx of an adjacent digit can be useful when applied as an island pedicle skin flap. The vascular supply to the skin flap is derived from the retrograde perfusion of the dorsal digital artery. Mobilization and lengthening of the vascular pedicle are achieved by dividing the distal end of the dorsal metacarpal artery at the bifurcation and incorporating two adjacent dorsal digital arteries into one. The boomerang flap was used in seven individuals with injuries involving the dorsal aspect of the distal phalanx over the past year. Skin defects in all patients were combined with bone,joint, or tendon exposure. The authors found that the flap was reliable and technically simple to design and execute. This one-step procedure preserves the proper palmar digital artery to the fingertip and has proven valuable for the coverage of wide and distal defects because it has the advantages of an extended skin paddle and a lengthened vascular pedicle. When conventional local flaps are inadequate, the boomerang flap should be considered for its reliability and low associated morbidity.

Tracheocutaneous Fistula Closure with Turnover Flap and Polydioxanone Plate

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Justin R. Bryant, DO, MBA

2017-10-01

Full Text Available Summary:. An alternative surgical treatment is proposed for closure of tracheocutaneous fistulas. The authors present a new technique for reconstruction of persistent tracheocutaneous fistula resultant from temporary tracheostomy. The single-stage closure under local anesthesia involves a fistulous tract turnover flap with a perforated 0.15 mm polydioxanone plate between the flap and the subcutaneous closure. This article presents 3 cases of persistent tracheocutaneous fistula treated by this method. At follow-up examination after follow-up, no recurrent fistula formation had occurred, and no respiratory deformity was present.

Anatomy of vastus lateralis muscle flap.

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Tayfur, Volkan; Magden, Orhan; Edizer, Mete; Atabey, Atay

2010-11-01

A vastus lateralis muscle flap is used as a pedicled and free flap. In this study, the vastus lateralis muscles of 15 adult formalin-fixed cadavers (30 cases) were dissected. The dominant pedicle was found to be descending branch of the lateral circumflex femoral artery. The mean diameter of the artery was found to be 2.1 mm. This pedicle was located 119.4 mm distal to the pubic symphysis. The mean length of the major pedicle was found to be 56.8 mm when the dominant pedicle was chosen to nourish the flap. The dominant pedicle entered the muscle 155.8 and 213.7 mm from the greater trochanter and the anterior superior iliac spine, respectively. The muscle had proximal minor pedicles from the ascending and transverse branches of lateral circumflex femoral artery. These arteries had mean diameters of 1.8 and 2.0 mm, respectively. The distal minor branches were present in all of the dissections. The distal branch had a mean diameter of 1.8 mm. The origin of this distal branch was located 83.7 mm proximal to the intercondylar line. The motor nerve of the vastus lateralis was found to be originating from femoral nerve. The nerve entered the muscle 194.6 mm from the anterior superior iliac spine.

Robot-Assisted Free Flap in Head and Neck Reconstruction

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Han Gyeol Song

2013-07-01

Full Text Available Background  Robots have allowed head and neck surgeons to extirpate oropharyngealtumors safely without the need for lip-split incision or mandibulotomy. Using robots inoropharyngealreconstruction is newbut essentialfor oropharyngeal defectsthatresultfromrobotic tumor excision. We report our experience with robotic free-flap reconstruction ofhead and neck defectsto exemplify the necessity forrobotic reconstruction.Methods  We investigated head and neck cancer patients who underwent ablation surgeryand free-flap reconstruction by robot. Between July 1, 2011 andMarch 31, 2012, 5 caseswereperformed and patient demographics, location of tumor, pathologic stage, reconstructionmethods, flap size, recipient vessel, necessary pedicle length, and operation time wereinvestigated.Results  Among five free-flap reconstructions, four were radial forearm free flaps and onewas an anterolateral thigh free-flap. Four flaps used the superior thyroid artery and oneflap used a facial artery as the recipient vessel. The average pedicle length was 8.8 cm. Flapinsetting and microanastomosis were achieved using a specially manufactured roboticinstrument. The total operation timewas 1,041.0 minutes(range, 814 to 1,132 minutes, andcomplicationsincluding flap necrosis, hematoma, andwound dehiscence did not occur.Conclusions  Thisstudy demonstratesthe clinically applicable use ofrobotsin oropharyngealreconstruction, especially using a free flap. A robot can assist the operator in insettingthe flap at a deep portion of the oropharynx without the need to perform a traditionalmandibulotomy. Robot-assisted reconstruction may substitute for existing surgical methodsand is accepted asthemost up-to-datemethod.

Restoration of the orbital aesthetic subunit with the thoracodorsal artery system of flaps in patients undergoing radiation therapy.

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Chanowski, Eric J P; Casper, Keith A; Eisbruch, Avraham; Heth, Jason A; Marentette, Lawrence J; Prince, Mark E; Moyer, Jeffrey S; Chepeha, Douglas B

2013-10-01

Objectives To demonstrate the advantages of the thoracodorsal artery scapular tip autogenous transplant (Tdast) for patients requiring restoration of the orbital aesthetic subunit. Design Prospective case series. Setting Tertiary center. Participants Ten patients (M:F,6:4) with a mean age of 56 years (range, 21 to 78 years) underwent restoration of the orbital aesthetic subunit and radiation therapy between 2001 and 2008. Main Outcome Measures The two reconstructive advantages of the thoracodorsal artery system of flaps for orbital reconstruction are a long pedicle and the suitability of the scapula tip to meet the three-dimensional requirements of the orbit. Patients were assessed 1 year or more after treatment for cosmetic outcome, work status, and socialization. Results Eight of 10 patients benefited from the three-dimensional nature of the scapula tip bone and 7 of 10 avoided vein grafting. Four of five evaluable patients reported "frequently" socializing outside their home. Four of five evaluable patients working before undergoing their treatment were able to return to work posttreatment. Seven of nine patients with postoperative photographs had minimal or no facial contour deformity. Conclusions The Tdast can restore orbital contour without osteotomy, and the thoracodorsal artery system of flaps has a long vascular pedicle that reduces vein grafting. Patients have an acceptable cosmetic result and return to preoperative work status and socialization.

The retrograde transverse cervical artery as a recipient vessel for free tissue transfer in complex head and neck reconstruction with a vessel-depleted neck.

Science.gov (United States)

Ciudad, Pedro; Agko, Mouchammed; Manrique, Oscar J; Date, Shivprasad; Kiranantawat, Kidakorn; Chang, Wei Ling; Nicoli, Fabio; Lo Torto, Federico; Maruccia, Michele; Orfaniotis, Georgios; Chen, Hung-Chi

2017-11-01

Reconstruction in a vessel-depleted neck is challenging. The success rates can be markedly decreased because of unavailability of suitable recipient vessels. In order to obtain a reliable flow, recipient vessels away from the zone of fibrosis, radiation, or infection need to be explored. The aim of this report is to present our experience and clinical outcomes using the retrograde flow coming from the distal transverse cervical artery (TCA) as a source for arterial inflow for complex head and neck reconstruction in patients with a vessel-depleted neck. Between July 2010 and June 2016, nine patients with a vessel-depleted neck underwent secondary head and neck reconstruction using the retrograde TCA as recipient vessel for microanastomosis. The mean age was 49.6 years (range, 36 to 68 years). All patients had previous bilateral neck dissections and all, except one, had also received radiotherapy. Indications included neck contracture release (n = 3), oral (n = 1), mandibular (n = 3) and pharyngoesophageal (n = 2) reconstruction necessitating free anterolateral thigh (n = 3) and medial sural artery (n = 1) perforator flaps, fibula (n = 3) and ileocolon (n = 2) flaps respectively. There was 100% flap survival rate with no re-exploration or any partial flap loss. One case of intra-operative arterial vasospasm at the anastomotic suture line was managed intra-operatively with vein graft interposition. There were no other complications or donor site morbidity during the follow-up period. In a vessel-depleted neck, the reverse flow of the TCA may be a reliable option for complex secondary head and neck reconstruction in selected patients. © 2017 Wiley Periodicals, Inc.

Robot-Assisted Free Flap in Head and Neck Reconstruction

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Han Gyeol Song

2013-07-01

Full Text Available BackgroundRobots have allowed head and neck surgeons to extirpate oropharyngeal tumors safely without the need for lip-split incision or mandibulotomy. Using robots in oropharyngeal reconstruction is new but essential for oropharyngeal defects that result from robotic tumor excision. We report our experience with robotic free-flap reconstruction of head and neck defects to exemplify the necessity for robotic reconstruction.MethodsWe investigated head and neck cancer patients who underwent ablation surgery and free-flap reconstruction by robot. Between July 1, 2011 and March 31, 2012, 5 cases were performed and patient demographics, location of tumor, pathologic stage, reconstruction methods, flap size, recipient vessel, necessary pedicle length, and operation time were investigated.ResultsAmong five free-flap reconstructions, four were radial forearm free flaps and one was an anterolateral thigh free-flap. Four flaps used the superior thyroid artery and one flap used a facial artery as the recipient vessel. The average pedicle length was 8.8 cm. Flap insetting and microanastomosis were achieved using a specially manufactured robotic instrument. The total operation time was 1,041.0 minutes (range, 814 to 1,132 minutes, and complications including flap necrosis, hematoma, and wound dehiscence did not occur.ConclusionsThis study demonstrates the clinically applicable use of robots in oropharyngeal reconstruction, especially using a free flap. A robot can assist the operator in insetting the flap at a deep portion of the oropharynx without the need to perform a traditional mandibulotomy. Robot-assisted reconstruction may substitute for existing surgical methods and is accepted as the most up-to-date method.

Propeller Flap for Complex Distal Leg Reconstruction: A Versatile ...

African Journals Online (AJOL)

equipment, cost, steep learning curve, and prolonged operating ... A Versatile Alternative when Reverse Sural Artery Flap is .... He had wound debridement, fracture reduction, and .... flaps that were raised in the patient and the logistics of limb.

Regional Analysis of Soft Tissue Thickness on Korean Buttocks and Application to Fasciocutaneous Flap Design

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Do Yup Kim

2014-03-01

Full Text Available Background Various shapes and designs of the gluteal artery perforator flap have been used for treating sacral pressure sores and reconstructing breasts. To establish the ideal fasciocutaneous flap design for use in the gluteal area, the soft tissue thickness distribution was measured. Methods Twenty-one buttocks of adult Korean cadavers were analyzed through rectangular subfascial dissection. Each buttock was divided horizontally into 10 sections and vertically into 10 sections, and then, the thickness at the corners of the sections was measured. For the sake of comparison and statistical verification with living bodies, computed tomography (CT images of 120 buttocks of patients were randomly selected. Five horizontal sections and 4 vertical sections were made, and the thickness at each corner was recorded. Results According to the dissection and the CT images, the area with the thinnest soft tissues in the buttock was around the posterior superior iliac spine, close to the sacral area. The thickest area was the superolateral area of the buttock, which was 3.24 times and 2.15 times thicker than the thinnest area in the studies on cadaver anatomy and the CT images, respectively. Conclusions The thickness of the soft tissues in the buttocks differed by area. The superolateral area had the thickest soft tissues, and the superomedial area had the thinnest. This study includes information on the distribution of the thickness of the gluteal soft tissues of Koreans. The outcome of this study may contribute to the design of effective local flaps for pressure sore reconstruction and free flaps for breast reconstruction.

COVERED STENTS IN IATROGENIC CORONARY ARTERY FISTULA; A CASE REPORT

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Masoud Poormoghaddas

2010-11-01

Full Text Available Abstract    BACKGROUND: Coronary artery fistula is an abnormal communication between a coronary artery and a cardiac chamber or major cardiac vessels, mostly congenital but some of them are acquired as a consequence of coronary artery perforation.    CASE PRESENTATION: We report a case of cavity spilling coronary artery perforation during percutaneous coronary intervention 7 years ago. Because of continuing symptoms and risk of developing heart failure and pulmonary hypertension we were ought to treat this iatrogenically formed coronary artery fistula. We used stent graft implantation to treat it with acceptable results.    CONCLUSION: Beside their application as a rescue for acute coronary artery perforations, stent grafts can be used with acceptable results in iatrogenically acquired coronary artery coronary artery fistula      Keywords: Coronary artery perforation, Coronary artery fistula, Stent graft.

Versatality of supraclavicular flap in neck, face, and upper chest region coverage

International Nuclear Information System (INIS)

Almas, D.; Masood, T.; Dar, M.F.; Noman, B.

2015-01-01

The objective is to analyze the utility of the island supraclavicular flap in a region where skin graft cannot be used and free flap is not feasible. We assessed complications and functional outcomes. Study Design: Prospective descriptive study. Place and Duration of Study: The study was done at plastic and reconstructive surgery department CMH Rawalpindi during the period of 03 year from October 2011 to October 2014. Material and Patients: An island supraclavicular artery flap was used to reconstruct oncologic, and post burn neck contractures release defects. 30 patients were included in the study. Doppler probe was used to help with localization of vascular pedicle. All the patients with scarring in both shoulder regions, history of radiation to neck and undergoing radical neck dissection were excluded. Results: A total of 30 patients were included 20 (66.6%) male and 10 (33.3%) were female. Oncologicre section was followed by immediate reconstruction with island supraclavicular artery flap. Post burn contractures were released and covered by a pedicled supraclavicular artery flap. The recipient sites were neck, face, oral and upper chest region. The average harvest time was 1 and half hour. Donor site was closed primarily in 22 (73.3%) while 8 (26.6%) require skin grafting. Post burn contractures needed scar management with intralesional steroid, pressure garments and scar revision with Z-plasty in 4(13.3%) cases. 1 (3.3%) flap failed completely and the defect was covered with a skin graft. We had 01 (3.3%) mortality due to respiratory obstruction, despite adequate flap perfusion for 24 hours. Minor complications included, partial flap loss, seroma, and haematoma formation. In addition hypertrophied scar, spreading scar and keloid formation occurred at the donor site 18 (60%). Conclusion: Island supraclavicular artery flap with an easy learning curve is a reliable flap. It has a good colour and texture match with minimal donor site morbidity. It is an excellent

Impact of Right-Sided Aneurysm, Rupture Status, and Size of Aneurysm on Perforator Infarction Following Microsurgical Clipping of Posterior Communicating Artery Aneurysms with a Distal Transsylvian Approach.

Science.gov (United States)

Tanabe, Jun; Ishikawa, Tatsuya; Moroi, Junta; Sakata, Yoshinori; Hadeishi, Hiromu

2018-03-01

Posterior communicating artery (PCoA) aneurysms are among the most common aneurysms. Because blockage of the PCoA and perforators can cause adverse outcomes, occlusion of these arteries by surgical clipping should be avoided. The impact of factors on PCoA perforator infarction when using a distal transsylvian approach for PCoA aneurysms was examined. A total of 183 patients underwent PCoA aneurysm clipping, excluding application of fenestrated clips. Patients were divided into 2 groups: patients with PCoA perforator infarction (infarction group) and patients without infarction (noninfarction group). Multiple factors were analyzed in the 2 groups. Twenty-two of the 183 patients (12.0%) showed perforator infarction, mainly on magnetic resonance imaging evaluation, resulting in permanent deficits in 2 patients (1.1%). The proportion of right-sided operations (86.4% vs. 53.4%; P = 0.005) and surgery for rupture (90.9% vs. 55.9%; P = 0.002) were significantly higher in the infarction group than in the noninfarction group. Aneurysms were significantly larger in the infarction group (8.4 ± 3.8 mm) than in the noninfarction group (6.3 ± 3.0 mm; P = 0.02). Ruptured status (odds ratio [OR], 7.35; P = 0.01), right side (OR, 5.19; P = 0.01), and aneurysm size (OR, 1.18; P = 0.02) remained independent predictors of perforator infarction on multivariate logistic regression analysis. Ruptured status, right side, and large PCoA aneurysm were independent predictors of PCoA perforator infarction. Symptoms due to PCoA perforating infarction were mostly transient and rarely affected outcomes. Copyright © 2018 Elsevier Inc. All rights reserved.

The reverse sural artery fasciomusculocutaneous flap for small lower-limb defects: the use of the gastrocnemius muscle cuff as a plug for small bony defects following debridement of infected/necrotic bone.

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Al-Qattan, M M

2007-09-01

The reverse sural artery fasciomusculocutaneous flap is a modification of the original fasciocutaneous flap in which a midline gastrocnemius muscle cuff around the buried sural pedicle is included in the flap. This modification was done to improve the blood supply of the distal part of the flap, which is harvested from the upper leg. The aim of this paper is to demonstrate that there is another important advantage of the modified flap: the use of the muscle cuff as a "plug" for small lower limb defects following debridement of infected/necrotic bone. A total of 10 male adult patients with small complex lower-limb defects with underlying bone pathology were treated with the modified flap using the muscle component to fill up the small bony defects. The bony pathology included necrotic exposed bone without evidence of osteomyelitis or wound infection (n = 1), an underlying neglected tibial fracture with wound infection (n = 4), and a sinus at the heel with underlying calcaneal osteomyelitis (n = 5). Primary wound healing of the flap into the defect was noted in all patients. No recurrence of calcaneal osteomyelitis was seen and all tibial fractures united following appropriate orthopedic fixation. It was concluded that the reverse sural artery fasciomusculocutaneous flap is well suited for small complex lower-limb defects with underlying bone pathology.

Clinical anatomy of the donor zone of venous flaps of forearm

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O. S. Kurochkina

2012-01-01

Full Text Available The variant anatomy of saphenous veins of forearm in the zones of venous flap rising remains unstudied yet, as well as the influence of the valve apparatus of saphenous veins on the arterial perfusion of venous flaps. The paper studies the variant anatomy of saphenous veins of the upper third of the volar surface of forearm. Two versions of saphenous veins are revealed: major (axial and retiform. It is found experimentally that the valve apparatus of saphenous veins does not influence considerably the arterial perfusion of venous flaps of forearm.

[Treatment of radiation-induced iliofemoral arterial complications with groin radionecrosis].

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Fichelle, J-M

2017-12-01

Long-term iliofemoral complications induced by radiation include vascular (arterial and venous) lesions, nervous lesions and soft tissue loss that can be cutaneous and subcutaneous and potentially lead to radionecrosis with vessel exposure. We present five cases of groin radionecrosis. There were three men and two women (age 30-73 years). Radiotherapy had been delivered 15 years earlier in three cases, and 2 years earlier in two cases. Symptoms were intermittent claudication (n=1), critical ischemia (n=1), and septic hemorrhage (n=1). Two patients had no vascular symptoms. Four patients underwent scheduled surgery after complete cardiac and cardiovascular evaluation with duplex-Doppler, CT scan and/or intra-arterial angiography. One woman underwent emergency surgery after septic hemorrhage of a previous in situ femoral revascularization fashioned 2 months earlier. Revascularization was achieved with trans-iliac (n=3), trans-muscular (n=1, and in situ (n=1) iliofemoral bypass. A retroperitoneal approach with section of large muscles was used. In three cases, a trans-iliac route was used by perforating the iliac wing with a 8-mm PTFE graft. Proximal anastomosis was done on the abdominal aorta (n=1) and the homolateral common iliac artery (n=2). Distal anastomosis was done on the distal profunda artery and popliteal artery (n=1) and on the distal femoral superficial artery (n=2). In two cases, an iliofemoral bypass was done with a 7-mm PTFE vascular graft. The proximal anastomosis was done on the proximal external iliac artery and the distal anastomosis on the proximal superficial femoral artery. A plastic procedure was performed in four cases. Three patients had a homolateral (n=1) or controlateral (n=2) rectus abdominis flap. In one case, plastic coverage was done with an antebrachial flap (Chinese flap), which has been released at 6 weeks. One patient had post-radiotherapy iliofemoral vascular disease, but there was no vascular exposure, and no plastic

Ipsilateral fasciocutaneous flaps for leg and foot defects

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Bhattacharya V

2003-01-01

Full Text Available It was a revolutionary enhancement for lower limb reconstruction when fasciocutaneous flaps were first described and used in clinical practice in 1981. Subsequently persistent studies were made to emphasize and confirm the rich vascular network associated with deep fascia. Thereafter studies were directed to identify the various types of perforators supplying the deep fascia and the overlying subcutaneous tissue and skin. Accordingly the scientists classified these flaps keeping in mind their clinical applications. The authors of this article have also performed extensive research on various aspects. This has led to better understanding about the finer details of vascularity. Based on this various modifications have been made for safe application of reconstruction for defects extending from knee to sole. To avoid complications the clinician should be able to select the proper procedure as regards the donor site and the possible preoperative and postoperative technical faults. A well-designed and meticulously executed flap usually has smooth recovery. Both Colour Doppler and Audio Doppler are useful tools in planning a safe flap. Now these flaps have proved to be standard technique without requiring a special set up extensive training.

[The influence of estradiol on histomorphology of skin flaps with ischemia reperfusion injury].

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Jianlong, Wu; Ruixing, Hou; Guangliang, Zhou; Jihui, Ju

2015-09-01

To study the influence of estradiol on histomorphology of skin flaps with ischemia reperfusion injury. 48 adult male Wistar rats aged 12-14 weeks old, were randomly divided into control group (group I), ischemia-reperfusion group (group II), saline group (group III), estradiol group (group IV). Superficial epigastric artery axial flap, 3 cm x 6 cm in size, was made in the left lower quadrant abdominal of each rat. Flap model with ischemia-reperfusion injury was established by using the nondestructive micro vascular clamp to clamp the superficial epigastric artery. The general condition of the flap was observed after operation. At 7 days after operation, the survival rate of the flap was detected, the flaps were harvested to receive histology and ultrastructural observation. The neutrophils level of the superficial epigastric vein were tested. 7 days after operation, the survival rate of the flap in group IV was significantly higher than that in group II, III (P organization structure in flap.

Adipofascial Anterolateral Thigh Flap Safety: Applications and Complications

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Tommaso Agostini

2013-03-01

Full Text Available BackgroundA thinned anterolateral thigh (ALT flap is often harvested to achieve optimal skin resurfacing. Several techniques have been described to thin an ALT flap including an adipocutaneous flap, an adipofascial flap and delayed debulking.MethodsBy systematically reviewing all of the available literature in English and French, the present manuscript attempts to identify the common surgical indications, complications and donor site morbidity of the adipofascial variant of the ALT flap. The studies were identified by performing a systematic search on Medline, Ovid, EMBASE, the Cochrane Database of Systematic Reviews, Current Contents, PubMed, Google, and Google Scholar.ResultsThe study selection process was adapted from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, and 15 articles were identified using the study inclusion criteria. These articles were then reviewed for author name(s, year of publication, flap dimensions and thickness following defatting, perforator type, type of transfer, complications, thinning technique, number of cases with a particular area of application and donor site morbidity.ConclusionsThe adipofascial variant of the ALT flap provides tissue to fill large defects and improve pliability. Its strong and safe blood supply permits adequate immediate or delayed debulking without vascular complications. The presence of the deep fascia makes it possible to prevent sagging by suspending and fixing the flap for functional reconstructive purposes (e.g., the intraoral cavity. Donor site morbidity is minimal, and thigh deformities can be reduced through immediate direct closure or liposuction and direct closure. A safe blood supply was confirmed by the rate of secondary flap debulking.

The effects of epinephrine and dobutamine on skin flap viability in rats

DEFF Research Database (Denmark)

Krammer, Caspar W; Ibrahim, Rami Mossad; Hansen, Tom G

2015-01-01

BACKGROUND: Intraoperative reduction in arterial pressure may cause hypoperfusion of skin flaps, which may increase the risk of flap failure. There is no international consensus regarding the use of vasoactive or inotropic agents to restore or maintain flap perfusion. The purpose of this study...

Balloon Occlusion Types in the Treatment of Coronary Perforation during Percutaneous Coronary Intervention

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Xiangfei Wang

2014-01-01

Full Text Available Coronary artery perforation is an uncommon complication in patients with coronary heart disease undergoing percutaneous coronary intervention. However, pericardial tamponade following coronary artery perforation may be lethal, and prompt treatment is crucial in managing such patients. Balloon occlusion and the reversal of anticoagulant activity are the common methods used to prevent cardiac tamponade by reducing the amount of bleeding. Herein, we discuss the pros and cons of currently used occlusion types for coronary perforation. Optimal balloon occlusion methods should reduce the amount of bleeding and ameliorate subsequent myocardial ischemia injury, even during cardiac surgery.

Colgajo de avance en V-Y de gastrocnemio medial basado en perforante para cierre de defectos del tercio medio de la pierna V-Y advancement gastrocnemius perforant based flap for closure of defects of the medial third of the leg

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V. Spröhnle

2010-06-01

Full Text Available Los colgajos de avance en V-Y han sido una alternativa popular para el cierre de heridas profundas, pero su movilidad es limitada. Los colgajos basados en perforantes son especialmente útiles cuando se necesita un mayor avance y cobertura. Diseñamos un colgajo de gastrocnemio que utiliza ambas técnicas para cubrir los defectos del tercio medio y superior de la pierna en sus caras lateral y posterolateral. Evaluamos en forma retrospectiva 5 pacientes con heridas en el tercio medio y superior de la pierna, tratados entre enero de 2005 y septiembre de 2007 en un solo centro y por un mismo cirujano. Todos fueron varones, con un promedio de edad de 48 años y la etiología fue traumática en todos los casos. El vaso perforante se evaluó preoperatoriamente por medio de doppler color en todos los casos. Valoramos telefónicamente la satisfacción del paciente en el postoperatorio tardío. En todos los casos, encontramos los vasos perforantes identificados en el preoperatorio; el tiempo operatorio promedio fue de 1.8 horas. No hubo complicaciones; la cobertura fue exitosa en todos los casos y los pacientes se mostraron satisfechos en la encuesta realizada. El tiempo medio de seguimiento postoperatorio fue de 19 meses. En conclusión, creemos que el colgajo de avance en V-Y de gastrocnemio basado en perforante se presenta como una alternativa segura para el cierre de defectos del tercio medial y superior de la pierna, en un sólo tiempo quirúrgico y con buenos resultados estéticos y funcionales a largo plazo.Advancement V-Y flaps have been a popular choice for closure of deep wounds but their mobility is limited. Perforant based flaps are specially useful when greater advancement and bigger coverage are needed. We designed a gastrocnemius based flap that uses both techniques for covering the defects of the medial third of the leg. We follow a retrospective evaluation of 5 patients that had their wounds in the medial and superior third of the leg

Suprascarpal fat pad thickness may predict venous drainage patterns in abdominal wall flaps.

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Bast, John; Pitcher, Austin A; Small, Kevin; Otterburn, David M

2016-02-01

Abdominal wall flaps are routinely used in reconstructive procedures. In some patients inadequate venous drainage from the deep vein may cause fat necrosis or flap failure. Occasionally the superficial inferior epigastric vessels (SIEV) are of sufficient size to allow for microvascular revascularization. This study looked at the ratio of the sub- and suprascarpal fat layers, the number of deep system perforators, and SIEV diameter to determine any correlation of the fat topography and SIEV. 50 abdominal/pelvic CT angiograms (100 hemiabdomens) were examined in women aged 34-70 years for number of perforators, SIEV diameter, and fat pad thickness above and below Scarpa's fascia. Data was analyzed using multivariate model. The average suprascarpal and subscarpal layers were 18.6 ± 11.5 mm and 6.2 ± 7.2 mm thick, respectively. The average SIEV diameter was 2.06 ± 0.81 mm and the average number of perforators was 2.09 ± 1.03 per hemiabdomen. Hemiabdomens with suprascarpal thickness>23 mm had greater SIEV diameter [2.69 mm vs. 1.8 mm (P fat layer thickness did not correlate with the number of perforators. Neither subscarpal fat thickness nor suprascarpal-to-subscarpal fat layer thickness correlated significantly with SIEV caliber or number of perforators in multivariate model. Suprascarpal fat pad thicker than 23 mm had larger SIEVs irrespective of the number of deep system perforators. This may indicate a cohort of patients at risk of venous congestion from poor venous drainage if only the deep system is revascularized. We recommend harvesting the SIEV in patients with suprascarpal fat pad >23 mm to aid in superficial drainage. © 2015 Wiley Periodicals, Inc.

Upper lip reconstruction using a pedicel superficial temporal artery flap

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Mohammad M. Al-Qattan

2018-01-01

Conclusion: We demonstrate that the pedicle flap is much simpler than the free flap and is adequate for reconstruction of partial upper lip defects. We also demonstrate a good cosmetic and functional outcome; and highlight several technical points to ensure a satisfactory outcome.

Reconstruction of soft-tissue lesions of the foot with the use of the medial plantar flap

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Jefferson Lessa Soares de Macedo

Full Text Available ABSTRACT OBJECTIVE: To study use of the medial plantar flap for reconstruction of the heel and foot. METHOD: The authors share their clinical experience with the use of the medial plantar artery flap for coverage of tissue defects around the foot and heel after trauma. Twelve cases of medial plantar artery flap performed from January 2001 to December 2013 were included. RESULTS: Of the 12 patients, ten were male and two were female. The indications were traumatic loss of the heel pad in ten cases and the dorsal foot in two cases. All the flaps healed uneventfully without major complications, except one case with partial flap loss. The donor site was covered with a split-thickness skin graft. The flaps had slightly inferior protective sensation compared with the normal side. CONCLUSION: From these results, the authors suggest that the medial plantar artery flap is a good addition to the existing armamentarium for coverage of the foot and heel. It is versatile flap that can cover defects on the heel, over the Achilles tendon and plantar surface, as well as the dorsal foot. It provides tissue to the plantar skin with a similar texture and intact protective sensation.

[Applied anatomy study and clinical application of great saphenous veno-saphenous neurocutaneous vascular flap].

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Li, Zelong; Ding, Zihai; Wang, Peixin; Xie, Yibo; Zeng, Bo

2006-03-01

To provide the anatomic basis for defect repair of the knee, leg, foot and ankle with great saphenous veno-saphenous neurocutaneous vascular island flaps. The origin, diameter, branches, distribution and anastomoses of the saphenous artery and saphenous neurocutaneous vascular were observed on 20 sides of adult leg specimens and 4 fresh cadaver voluntary legs. Another 4 fresh cadaver voluntary legs were radiographed with a soft X-ray system after the intravenous injection of Vermilion and cross-sections under profound fascial, other hand, micro-anatomic examination was also performed in these 4 fresh cadaver legs. The soft tissue defects in lower extremity, upper extremity, heel or Hucou in hand were repaired with the proximal or distal pedicle flaps or free flaps in 18 patients (12 males and 6 females,aging from 7 to 53 years). The defect was caused by trauma, tumour, ulcer and scar. The locations were Hucou (1 case), upper leg (3 cases), lower extremity and heal (14 cases). Of then, 7 cases were complicated by bone exposure, 3 cases by tendon exposure and 1 case by steel espouse, the defect size were 4 cm x 4 cm to 7 cm x 13 cm. The flap sizes were 4 cm x 6 cm to 8 cm x 15 cm, which pedicle length was 8-11 cm with 2.5-4.0 cm fascia and 1-2 cm skin at width. Genus descending genicular artery began from 9.33 +/- 0.81 cm away from upper the condyles medialis, it branched saphenous artery accompanying saphenous nerve descendent. And saphenous artery reached the surface of the skin 7.21 +/- 0.82 cm away from lower the condyles medialis, and anastomosed with the branches of tibialis posterior artery, like "Y" or "T" pattern. The chain linking system of arteries were found accompanying along the great saphenous vein as saphenous nerve, and then a axis blood vessel was formed. The small artery of only 0.05-0.10 mm in diameter, distributed around the great saphenous vein within 5-8 mm and arranged parallelly along the vein like water wave in soft X-ray film. All proximal

Reconstruction of the full thickness chest wall defect. A case report

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Moriguchi, T; Sano, S; Ogawa, Y; Fujimori, Y [Kyoto Univ. (Japan). Faculty of Medicine; Abe, R

1977-03-01

To treat the chest wall defect following the postoperative radiotherapy for breast cancer, we used an island flap prepared from the opposite mammary region preserving the perforating vessels from the internal thoracic artery.

The groin flap revisited--what the textbooks do not tell

NARCIS (Netherlands)

van Wingerden, J. J.

1999-01-01

The groin flap remains an excellent choice as a distant pedicled, or free microvascular flap for soft-tissue coverage of the hand because of its reliable arterial-venous pedicle and minimal donor site morbidity. Although interest has waxed and waned over the years, a number of valuable aids have

Changing the Paradigm in Medial Canthal Reconstruction: The Bridge Principle and the Croissant-Like Keystone Island Perforator Flap as An Alternative for Medium Size Soft Tissue Defects in Internal Canthus Reconstruction.

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Kostopoulos, Epameinondas; Agiannidis, Christos; Konofaos, Petros; Kotsakis, Ioannis; Hatzigianni, Panagiota; Georgopoulos, Gerasimos; Papadatou, Zoe; Konstantinidou, Chara; Champsas, Gregorios; Papadopoulos, Othon; Casoli, Vincent

2018-03-08

Medial canthus is a common area of skin cancer prevalence. Defects in this region represent a challenging reconstructive task. The nasal version of keystone perforator island flap (KPIF) has proven its versatility. The aim of the present study was to expand its utilization in the neighbor medial canthus area. A modified croissant-like KPIF (CKPIF) was used resolving inner convexity-related problems. The presence of procerus in the glabella area, bridging a surface from nasalis up to the frontalis, changed the traditional dissecting flap technique. Thus, the authors introduce the bridge principle, which consists of the indirect transfer of the flap to the defect site through a muscular "bridge" (the procerus). The authors report their experience in medial canthal reconstruction combining a modified KPIF with a new dissecting "principle." From November 2016 to July 2017, a series of patients presenting soft tissue defects of various dimensions in the medial canthus, secondary to tumor extirpation, sustained reconstruction with a CKPIF dissected with the bridge principle. A total of 15 patients were treated with this new technique. Their mean age was 75.3 years. The mean size of the defect was 2.08 cm (length) × 1.5 cm (width). All flaps survived without any sign of venous congestion. A transient epiphora presented in 4 patients (4/15 or 26.6%), which was subsided 2 months later. A new approach following a novel paradigm was introduced to resolve an old problem. Initial outcomes are encouraging. However, longer series are needed to extract definitive and safer conclusion.

Postirradiation flap infection about the oral cavity

International Nuclear Information System (INIS)

Cabbabe, E.B.; Herbold, D.R.; Sunwoo, Y.C.; Baroudi, I.F.

1983-01-01

Postirradiation alteration of oral flora is well documented in the literature. Infection as a complication leading to partial or complete loss of a flap used to reconstruct a defect in the oral cavity is a worrisome outcome. We describe how a flap that was judged clinically to be viable became overwhelmingly infected with the Klebsiella oxytoca, an oral cavity pathogen encountered in this patient following irradiation. Local and systemic changes led to detachment of the flap. This complication may be explained, in view of the absence of venous congestion or arterial ischemia both clinically and pathologically, by the proven contamination of the flap by the Klebsiella pathogen. Local factors resulted in lower resistance and subsequent overwhelming infection. Discussion of the case, review of pertinent literature, and proposed solutions are presented

Rapid deterioration of Mooren's ulcers after conjunctival flap: a review of 2 cases.

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Li, Saiqun; Deng, Yuqing; Du, Caiyuan; Huang, Haixiang; Zhong, Jing; Chen, Ling; Wang, Bowen; Yuan, Jin

2017-06-15

Conjunctival flaps are a widely used treatment for numerous corneal ulcers that are caused by microorganismal infections. However, whether it can be performed on immune-mediated corneal ulcers is controversial. We present two cases of Mooren's ulcer that were treated using conjunctival flap in an attempt to prevent further corneal perforation at their local hospital. A rapid acceleration in ulcer progression was observed after a conjunctival flap was applied. Ultimately, the two patients underwent corneal transplantation, which required the postoperative use of topical immunosuppressants and resulted in a final cure. In the current report, we also discussed this incorrect surgical choice via a review of conventional interventions that are used to treat Mooren's ulcer. These two cases demonstrate that keratoplasty combined with topical immunosuppressants is effective in treating Mooren's ulcer. Application of conjunctival flaps or autografting could promote progression of ulceration in Mooren's ulcers.

[A reverse vascular autograft finger island flap. A review of 15 cases and of the literature].

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Adani, R; Marcuzzi, A; Busa, R; Pancaldi, G; Bathia, A; Caroli, A

1995-01-01

The authors discuss the indications for homodigital island flap with a reverse vascular pedicle. This flap is based on the anastomoses between the radial and ulnar digital arteries. These anastomotic branches lie between the posterior wall of the tendon sheath and the periosteum to form an arch and are named the "digitopalmar arches". The vascularization of the reverse homodigital island flap is derived by using the middle transverse palmar arch. This flap was performed successfully in 14 patients involving 15 fingers to resurface amputation of the distal phalanx. In 6 cases the flap was used as an "artery" flap, and in 9 cases as a "sensitive" homodigital island flap. The pedicle in these cases was neurovascular also containing the digital nerve. The sensitivity of the flap was obtained by neurorraphy between the transposed digital nerve of the flap and the receiving digital nerve of the recipient finger. This technique achieves cover of the tactile pad in one operative stage and provides well vascularized skin allowing early mobilization. Sensation of the flap can be restored rapidly when neurorraphy of the transposed digital nerve is performed.

EXTENDED REVERSE SURAL FLAP FOR LOWER LIMB COVERAGE

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Biswajit Mishra

2018-12-01

Full Text Available BACKGROUND The reverse sural artery flap has been a workhorse for the reconstruction of distal third of leg, ankle, sole and foot. Major limitation of reverse sural flap has been venous congestion particularly when harvested from proximal third of the leg. Objective- To evaluate the efficacy, safety of the extended reverse sural flap from proximal third of the leg. MATERIALS AND METHODS A prospective study was conducted at the department of plastic surgery on twenty patients who needed soft tissue reconstruction in the distal third of the leg, ankle, heel, forefoot and midfoot due to various cause. In all cases flap was extended proximally to the upper third of the calf and neurovenoadipo fascial pedicled sural fasciocutaneous flap was harvested. RESULTS There were only two cases of marginal necrosis. None of the patients had complete necrosis. Two patients developed hypertrophy of the flap margin. CONCLUSION Distally based neuroveno adipofascial pedicled sural fasciocutaneous flap can be safely extended to proximal third of the leg and is a reliable option for reconstruction of the defects in the foot, ankle and sole.

鼻烟窝皮瓣在手部皮肤缺损中的应用%Application of snuff-box flap in repairing skin defects of the hand

Institute of Scientific and Technical Information of China (English)

陶水良; 曾林如; 汤样华

2010-01-01

目的 探讨应用带蒂鼻烟窝皮瓣修复手部中小面积软组织缺损的方法和临床效果.方法 2005年7月至2009年5月,对22例手部软组织缺损的患者,应用鼻烟窝皮瓣进行修复.结果 术后1例皮瓣远端部分坏死,经换药后愈合;余皮瓣全部存活.术后随访6～24个月,皮瓣质地、色泽及外观良好,皮瓣无臃肿及萎缩,感觉良好.结论 以桡动脉皮支为蒂的鼻烟窝皮瓣血管解剖恒定,是修复手部中小面积软组织缺损的有效方法.%Objective To explore the surgical technique and clinical outcomes of pedicled snuff-box flap to repair skin defects in the hand of small to medium sizes. Methods From July 2005 to May 2009 , the snuff-box flap was used to repair soft tissue defects of the hand in 22 cases. The survival rate, texture, colour and sensation of the flaps were evaluated. Results All 22 flaps survived except the partial distal necrosis in 1 case. Postoperative follow-up period ranged from 6 to 24 months. The texture, colour and appearance of the flaps were good. There was no bulkiness and atrophy of the flap. Flap sensation was good. Conclusion The snuffbox flap based on perforator of the radial artery has constant vascular anatomy. It is an effective procedure to repair small to medium size defects of the hand.

The Boomerang-shaped Pectoralis Major Musculocutaneous Flap for Reconstruction of Circular Defect of Cervical Skin.

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Azuma, Shuchi; Arikawa, Masaki; Miyamoto, Shimpei

2017-11-01

We report on a patient with a recurrence of oral cancer involving a cervical lymph node. The patient's postexcision cervical skin defect was nearly circular in shape, and the size was about 12 cm in diameter. The defect was successfully reconstructed with a boomerang-shaped pectoralis major musculocutaneous flap whose skin paddle included multiple intercostal perforators of the internal mammary vessels. This flap design is effective for reconstructing an extensive neck skin defect and enables primary closure of the donor site with minimal deformity.

Better and faster velocity pulsatility assessment in cerebral white matter perforating arteries with 7T quantitative flow MRI through improved slice profile, acquisition scheme, and postprocessing

NARCIS (Netherlands)

Geurts, LJ; Biessels, Geert Jan; Luijten, Peter; Zwanenburg, Jaco

2018-01-01

PURPOSE: A previously published cardiac-gated 2D Qflow protocol at 7 T in cerebral perforating arteries was optimized to reduce velocity underestimation and improve temporal resolution. METHODS: First, the signal-to-noise ratio (SNR) gain of the velocity measurement (SNRv ) was tested for two signal

Augmented reality and dynamic infrared thermography for perforator mapping in the anterolateral thigh.

Science.gov (United States)

Cifuentes, Ignacio Javier; Dagnino, Bruno Leonardo; Salisbury, María Carolina; Perez, María Eliana; Ortega, Claudia; Maldonado, Daniela

2018-05-01

Dynamic infrared thermography (DIRT) has been used for the preoperative mapping of cutaneous perforators. This technique has shown a positive correlation with intraoperative findings. Our aim was to evaluate the accuracy of perforator mapping with DIRT and augmented reality using a portable projector. For this purpose, three volunteers had both of their anterolateral thighs assessed for the presence and location of cutaneous perforators using DIRT. The obtained image of these "hotspots" was projected back onto the thigh and the presence of Doppler signals within a 10-cm diameter from the midpoint between the lateral patella and the anterior superior iliac spine was assessed using a handheld Doppler device. Hotspots were identified in all six anterolateral thighs and were successfully projected onto the skin. The median number of perforators identified within the area of interest was 5 (range, 3-8) and the median time needed to identify them was 3.5 minutes (range, 3.3-4.0 minutes). Every hotspot was correlated to a Doppler sound signal. In conclusion, augmented reality can be a reliable method for transferring the location of perforators identified by DIRT onto the thigh, facilitating its assessment and yielding a reliable map of potential perforators for flap raising.

Complete Lower Lip Reconstruction with a Large Lip Switch Flap and a Composite Modiolus Advancement Flap

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Gudjon L. Gunnarsson, MD

2017-12-01

Full Text Available Summary:. Total loss of the lower lip is debilitating and poses a reconstructive challenge. Aiming to restore oral continence and function and also cosmetic appearance, a successful reconstruction has a huge impact on the quality of life for the individual patient. Early sources of local tissue rearrangement for lip reconstruction date back 3000 years, with earliest reports of lip switch procedures more than 2 centuries ago in Europe, when noma was still endemic in Europe, indicating that the anatomy was better understood by the barber surgeons of the past than we like to acknowledge. We are still faced with such challenging cases all over the world where resources are limited. Our current understanding of perforator anatomy and blood supply makes more frequent revisits to flaps of the past with modern advances. Innovative solutions are imperative for salvage, and old ideas tend to reappear when they prove to be useful. Herein, we describe in open access a new reconstructive method where we combined a large lip switch flap together with a composite advancement modiolus flap to reconstruct a whole lower lip and the donor defect of the upper lip all at once, a procedure that is simple to perform and works in settings where it is greatly needed.

The Omental Pedicle Flap in Dogs Revised and Refined: A Cadaver Study.

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Doom, Marjan; Cornillie, Pieter; Simoens, Paul; Huyghe, Stephanie; de Rooster, Hilde

2016-08-01

To expand current knowledge on the canine omental vasculature and refine the existing lengthening technique of the canine omentum. Ex vivo study. Canine cadavers (n=20). In 10 canine cadavers the omental arteries were mapped using intravascular latex injection and these results were used to create an omental pedicle flap based on the splenic artery in 10 additional cadavers. The operating range of the flap was recorded with particular attention to the main regions of interest for omental transposition in dogs (axillary and inguinal regions). The superficial and deep omental leaves were each predominantly supplied by a left and a right marginal omental artery that anastomosed near the caudal omental border into a superficial and a deep omental arch, respectively. Anastomoses between arteries of the superficial and the deep omental leaves were weak and inconsistent, except for 1 anastomosis that was found in 8 of 10 dogs. By transposing the intact omentum, the right axilla could be reached in 3 dogs, both axillae in 1 dog, and both groins in all cadavers. In all cases, the omental pedicle reached to and beyond the axillary and inguinal regions. By unfolding the pedicle leaves, the width of the pedicle tip could be doubled. When lengthening the omentum is necessary to reach extra-abdominal structures, the omental pedicle flap based on the splenic artery appears to preserve the omental vascular supply. These observations warrant further clinical trials to evaluate this new omtental flap technique in vivo. © Copyright 2016 by The American College of Veterinary Surgeons.

Outcomes of patients with coronary artery perforation complicating percutaneous coronary intervention and correlations with the type of adjunctive antithrombotic therapy: pooled analysis from REPLACE-2, ACUITY, and HORIZONS-AMI trials.

Science.gov (United States)

Doll, Jacob A; Nikolsky, Eugenia; Stone, Gregg W; Mehran, Roxana; Lincoff, A Michael; Caixeta, Adriano; McLaurin, Brent; Cristea, Ecaterina; Fahy, Martin; Kesanakurthy, Vijaya; Lansky, Alexandra J

2009-10-01

The lack of a specific counteragent to bivalirudin may complicate the management of patients with coronary artery (CA) perforation during percutaneous coronary intervention (PCI). Assess outcomes of patients with CA perforation from three PCI trials comparing intravenous bivalirudin with provisional glycoprotein (GP) IIb/IIIa inhibition versus unfractionated heparin (UFH) plus GP IIb/IIIa. A pooled analysis of patients treated with PCI in three randomized trials including REPLACE-2, ACUITY, and HORIZONS-AMI. Among a total of 12,921 patients, CA perforation occurred in 35 patients (0.27%). By multivariable analysis, baseline creatinine clearance was the only independent predictor of CA perforation (per 10 mL/min decrease, odds ratio [95% confidence interval]= 1.28 [1.11, 1.47], P = 0.0007). At 30 days, patients with versus without CA perforation had significantly (all P values therapy of bivalirudin monotherapy was not associated with worse outcomes compared to treatment with UFH plus GP IIb/IIIa inhibitors.

Thermal injury in TAPIA breast reconstruction

DEFF Research Database (Denmark)

Børsen-Koch, Mikkel; Gunnarsson, Gudjon L.; Sørensen, Jens Ahm

2017-01-01

be due to the relative high frequency of this type of reconstructions. Reports of thermal injury to reconstructions using the Latissimus Dorsi flap are rare. The injuries previously described are most often caused by severe heat exposure. The thoracodorsal artery perforator (TAP)-flap can be used...... as an alternative to the Latissimus Dorsi flap but it may be more susceptible to thermal insult due to the total denervation, the restricted blood supply and the limited thickness of the flap. Precautions are recommended to avoid this type of injury....

Flap monitoring after head and neck reconstruction: evaluating an observation protocol.

Science.gov (United States)

Devine, J C; Potter, L A; Magennis, P; Brown, J S; Vaughan, E D

2001-01-01

This study evaluated the postoperative free-flap monitoring frequency protocol used in a maxillofacial unit for patients receiving free-tissue transfer for reconstruction following orofacial cancer. All free-tissue transfers undertaken in the unit between January 1992 and October 1998 were reviewed retrospectively. Of the 370 patients evaluated, 46 returned to theatre with compromised free flaps. The compromise was purely venous in origin in 37 of these cases, arterial in three and due to a combination of arterial and venous problems in six. Thirty-five of the flaps were successfully salvaged. On average, the clinical manifestation of the problem occurred 25.5 hours postoperatively. However, there was a significant time difference between flaps that were salvaged successfully and those that were not: in the salvaged group the compromise was identified 17.5 hours postsurgery compared with 51 hours for the unsuccessful group. The timing of the return to theatre following the identification of the compromise was a significant factor in the success rate: 71 minutes for those salvaged and 103 minutes for those not salvaged. It is recommended that flaps are monitored hourly for the first 72 postoperative hours and observations recorded on a chart.

CT and MRI findings of cerebral ischemic lesions in the cortical and perforating arterial system

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Kameyama, Masakuni; Udaka, Fukashi; Nishinaka, Kazuto; Kodama, Mitsuo; Urushidani, Makoto; Kawamura, Kazuyuki; Inoue, Haruhisa; Kageyama, Taku [Sumitomo Hospital, Osaka (Japan)

1995-07-01

It is clinically useful to divide the location of infarction into the cortical and perforating arterial system. Computerized tomography (CT) and magnetic resonance imaging (MRI) now make the point of infarction a simple and useful task in daily practice. The diagnostic modality has also demonstrated that risk factors and clinical manifestations are different for infarction in the cortical as opposed to the perforating system. In this paper, we present various aspects of images of cerebral ischemia according to CT and/or MRI findings. With the advance of imaging mechanics, diagnostic capability of CT or/and MRI for cerebral infarction has markedly been improved. We must consider these points on evaluating the previously reported results. In addition, we always consider the pathological background of these image-findings for the precise interpretation of their clinical significance. In some instances, dynamic study such as PET or SPECT is needed for real interpretations of CT and/or MRI images. We paid special reference to lacunar stroke and striatocapsular infarct. In addition, `branch atheromatous disease (Caplan)` was considered, in particular, for their specific clinical significances. Large striatocapsular infarcts frequently show cortical signs and symptoms such as aphasia or agnosia in spite of their subcortical localization. These facts, although have previously been known, should be re-considered for their pathoanatomical mechanism. (author).

CT and MRI findings of cerebral ischemic lesions in the cortical and perforating arterial system

International Nuclear Information System (INIS)

Kameyama, Masakuni; Udaka, Fukashi; Nishinaka, Kazuto; Kodama, Mitsuo; Urushidani, Makoto; Kawamura, Kazuyuki; Inoue, Haruhisa; Kageyama, Taku

1995-01-01

It is clinically useful to divide the location of infarction into the cortical and perforating arterial system. Computerized tomography (CT) and magnetic resonance imaging (MRI) now make the point of infarction a simple and useful task in daily practice. The diagnostic modality has also demonstrated that risk factors and clinical manifestations are different for infarction in the cortical as opposed to the perforating system. In this paper, we present various aspects of images of cerebral ischemia according to CT and/or MRI findings. With the advance of imaging mechanics, diagnostic capability of CT or/and MRI for cerebral infarction has markedly been improved. We must consider these points on evaluating the previously reported results. In addition, we always consider the pathological background of these image-findings for the precise interpretation of their clinical significance. In some instances, dynamic study such as PET or SPECT is needed for real interpretations of CT and/or MRI images. We paid special reference to lacunar stroke and striatocapsular infarct. In addition, 'branch atheromatous disease (Caplan)' was considered, in particular, for their specific clinical significances. Large striatocapsular infarcts frequently show cortical signs and symptoms such as aphasia or agnosia in spite of their subcortical localization. These facts, although have previously been known, should be re-considered for their pathoanatomical mechanism. (author)

DIEP breast reconstruction following multiple abdominal liposuction procedures.

Science.gov (United States)

Farid, Mohammed; Nicholson, Simon; Kotwal, Ashutosh; Akali, Augustine

2014-01-01

Previous abdominal wall surgery is viewed as a contraindication to abdominal free tissue transfer. We present two patients who underwent multiple abdominal liposuction procedures, followed by successful free deep inferior epigastric artery perforator flap. We review the literature pertaining to reliability of abdominal free flaps in those with previous abdominal surgery. Review of case notes and radiological investigations of two patients, and a PubMed search using the terms "DIEP", "deep inferior epigastric", "TRAM", "transverse rectus abdominis", "perforator" and "laparotomy", "abdominal wall", "liposuction", "liposculpture", "fat graft", "pfannenstiel", with subsequent appraisal of relevant papers by the first and second authors. Patient 1 had 3 episodes of liposuction from the abdomen for fat grafting to a reconstructed breast. Subsequent revision reconstruction of the same breast with DIEP flap was preceded by CT angiography, which demonstrated normal perforator anatomy. The reconstruction healed well with no ischaemic complications. Patient 2 had 5 liposuction procedures from the abdomen to graft fat to a wide local excision defect. Recurrence of cancer led to mastectomy and immediate reconstruction with free DIEP flap. Preoperative MR angiography demonstrated a large perforator right of the umbilicus, with which the intraoperative findings were consistent. The patient had an uneventful recovery and good healing with no fat necrosis or wound dehiscence. We demonstrate that DIEP flaps can safely be raised without perfusion-related complications following multiple liposuction procedures to the abdomen. The safe interval between procedures is difficult to quantify, but we demonstrate successful free flap after 16 months.

Versatility of the facial artery myomucosal island flap in neopharyngeal reconstruction

DEFF Research Database (Denmark)

Frisch, Thomas

2017-01-01

: Vitality of the flap was ascertained by fiber endoscopy. No donor-site morbidity was seen. Postoperatively, the patient had a minor stomal fistula with spontaneous healing. CONCLUSION: The pedicled FAMM island flap may be considered for smaller reconstructions of the upper hypopharynx. Accessibility, low...

Random Pattern Vertically Oriented, Partial Thickness Buccinator Myomucosal Flap for Intraoral Reconstruction: A Report of Two Cases

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Amin Rahpeyma

2016-05-01

Full Text Available Introduction: Reconstruction of the oral cavity witha flap design containing the buccal mucosa and buccinator muscle but excluding the facial artery and vein is the topic of these case reports. Case Reports: This article uses random pattern vertically oriented partial thickness buccinator myomucosal flap for intraoral reconstruction in two cases. The first was for lining the mandibular anterior vestibule in a trauma patient. The second was for oral side coverage of bone graft in special cleft patient. In both patients, this flap survived and good bone coverage with non-keratinized mucosa was obtained. Conclusion:  Thin long buccal myomucosal flap not including facial artery and vein can survive.

The Boomerang-shaped Pectoralis Major Musculocutaneous Flap for Reconstruction of Circular Defect of Cervical Skin

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Shuchi Azuma, MD

2017-11-01

Full Text Available Summary:. We report on a patient with a recurrence of oral cancer involving a cervical lymph node. The patient’s postexcision cervical skin defect was nearly circular in shape, and the size was about 12 cm in diameter. The defect was successfully reconstructed with a boomerang-shaped pectoralis major musculocutaneous flap whose skin paddle included multiple intercostal perforators of the internal mammary vessels. This flap design is effective for reconstructing an extensive neck skin defect and enables primary closure of the donor site with minimal deformity.

Nasolabial facial artery and vein as recipient vessels for midface microsurgical reconstruction.

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Oh, Suk Joon; Jeon, Man Kyung; Koh, Sung Hoon

2011-05-01

Although free flap transfer is commonly performed to reconstruct facial defects, the submandibular facial artery and vein have historically been considered as adequate recipient vessels for microsurgical reconstruction. If the vascular pedicles of the free flap are short, vein grafts are necessary. The purpose of this study was to determine the indications for and effectiveness of using the nasolabial facial vessels for midfacial reconstruction. A retrospective chart review of 6 patients undergoing microsurgical reconstruction for defects of the face revealed 6 free tissue transfers in which the nasolabial facial artery and vein were considered for use as recipient vessels. Flap success rates were evaluated. Six patients (5 men and 1 woman) underwent 6 free flap transfers. Five anterior helix free flaps were used for the reconstruction of defects in the lower third of the nose. Nasal defects were due to trauma in 4 patients and squamous cell carcinoma in 1 patient. In 1 neurofibromatosis type 1 case, a radial forearm flap was used for reconstruction of the left orbital defect. The facial artery and vein in the nasolabial fold were used as the recipient artery and vein in every case. The mean length of follow-up was 5.8 years. All flaps survived. All patients were satisfied with the degree of aesthetic improvement after surgery.Use of the facial artery and vein in the nasolabial fold for facial reconstruction is reliable and safe. The nasolabial facial artery and vein should be considered as primary recipient vessels in microsurgical reconstruction of the midface.

Arterial blood supply to the thalamus and midbrain on CT sections, 2

International Nuclear Information System (INIS)

Takeshita, Gen; Ottomo, Michinori; Satoh, Nobuko; Yokoyama, Yoshiaki.

1984-01-01

The selective injection of a dyestuff into thalamoperforating arteries from the posterior part of the circle of Willis, using five postmortem brains, was performed. After fixation, sections parallel to the orbito-meatal line were obtained. In cases which showed a standard development of the posterior communicating arteries, the usual patterns were as follows: the area supplied by perforators of the posterior communicating artery (anterior thalamoperforating artery) was visualized in the hypothalamus and the antero-lateral part of the thalamus; the area supplied by perforators of the proximal segment of the posterior cerebral artery (interpeduncular thalamoperforating artery) was visualized in the midbrain and the medial part of thalamus; the area supplied by perforators of the ambient segment of the posterior cerebral artery (thalamogeniculate artery) was visualized in the medial part of the geniculate body and the posterior part of the thalamus. According to the development of the posterior communicating artery, the area supplied by each perforator was quite variable. Three CT sections were obtained containing three different patterns of the posterior communicating artery: 1) well-developed; 2) moderately developed; and 3) poorly developed. The identification of the area supplied by thalamoperforating arteries on CT sections was quite useful in the CT diagnosis of cerebrovascular disorders which involved the thalamus and the midbrain. (author)

Prospective evaluation of outcome measures in free-flap surgery.

LENUS (Irish Health Repository)

Kelly, John L

2004-08-01

Free-flap failure is usually caused by venous or arterial thrombosis. In many cases, lack of experience and surgical delay also contribute to flap loss. The authors prospectively analyzed the outcome of 57 free flaps over a 28-month period (January, 1999 to April, 2001). The setting was a university hospital tertiary referral center. Anastomotic technique, ischemia time, choice of anticoagulant, and the grade of surgeon were recorded. The type of flap, medications, and co-morbidities, including preoperative radiotherapy, were also documented. Ten flaps were re-explored (17 percent). There were four cases of complete flap failure (6.7 percent) and five cases of partial failure (8.5 percent). In patients who received perioperative systemic heparin or dextran, there was no evidence of flap failure (p = .08). The mean ischemia time was similar in flaps that failed (95 +\\/- 29 min) and in those that survived (92 +\\/- 34 min). Also, the number of anastomoses performed by trainees in flaps that failed (22 percent), was similar to the number in flaps that survived (28 percent). Nine patients received preoperative radiotherapy, and there was complete flap survival in each case. This study reveals that closely supervised anastomoses performed by trainees may have a similar outcome to those performed by more senior surgeons. There was no adverse effect from radiotherapy or increased ischemia time on flap survival.

Temporalis myo-osseous flap: an experimental study

International Nuclear Information System (INIS)

Antonyshyn, O.; Colcleugh, R.G.; Hurst, L.N.; Anderson, C.

1986-01-01

The present paper investigates the anatomy and vascularization of the temporalis myo-osseous flap. This is a calvarial bone flap that employs temporalis muscle and its distal pericranial extension as a pedicle. In six human cadavers the flap was raised as an island on the anterior deep temporal artery after transecting the zygomatic arch and coronoid process. Maximal mobilization was thus obtained, allowing rotation of the flap into the mouth for intraoral reconstruction. The arc of rotation and potential surgical applications were noted. A comparative study of the temporalis myo-osseous flap and free calvarial bone graft was then conducted in a rabbit model. Vascularization of the calvarial bone flap was confirmed by technetium scintigraphy performed on the first postoperative day. The uptake of fluorochrome labels immediately after transfer verified the adequacy of the periosteal circulation in maintaining viability and new osteoid formation throughout the full thickness of calvarial bone. The transplantation of free calvarial bone grafts was followed by necrosis of most cellular elements. This was demonstrated by an absence of fluorochrome uptake up to 19 days postoperatively and a predominance of empty lacunae and nonviable marrow

Application of Indocyanine Green in Flap Surgery: A Systematic Review.

Science.gov (United States)

Li, Ke; Zhang, Zheng; Nicoli, Fabio; D'Ambrosia, Christopher; Xi, Wenjing; Lazzeri, Davide; Feng, Shaoqing; Su, Weijie; Li, Hua; Ciudad, Pedro; Tremp, Mathias; Zhang, Yi Xin

2018-02-01

 The vascularization of the distal portions of transferred tissue represents the most critical factor in the success of reconstructive surgery. In recent years, indocyanine green (ICG) fluorescence imaging techniques have been applied during surgery to evaluate flap perfusion. However, this investigation has found that there is little consensus regarding the standard dose of ICG as well as the pre-operative requirements of ICG allergy testing. The aim of this study is to summarize the applications of ICG to tissue transfers and safe dosing practices and to provide insight to the possible adverse effects of ICG on flap surgery with the goal of helping clinicians apply ICG safely and efficiently to tissue transfer procedures.  A literature search was performed using, Wiley InterScience, and Springer with the key words, 'Flap,' 'indocyanine green,' 'surgery,' and related mesh words for all publications between 2005 and 2015. Title and abstract screening was performed using predefined in- and exclusion criteria.  Seventy-three articles were included. These were classified as "application of ICG in flap surgery" and "the security of applying ICG in flap surgery".  ICG fluorescence imaging preoperatively facilitates the detection of perforators in tissue flaps with thickness <20 mm, aids in the evaluation of flap microcirculation and perfusion, and allows surgeons to select dominant cutaneous nerves while evaluating the quality of vascular anastomoses and locating thromboses. The literature also concluded that potential allergic reactions to ICG should be taken into consideration. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Ophthalmic Artery Embolization as Pretreatment of Orbital Exenteration for Conjunctival Squamous Cell Carcinoma

International Nuclear Information System (INIS)

Matsuo, Toshihiko; Ohara, Nobuya; Namba, Yuzaburo; Koshima, Isao; Ida, Kentaro; Kanazawa, Susumu

2009-01-01

The aim of this study is to describe the effect of transarterial embolization from the ophthalmic artery as a pretreatment for orbital exenteration. A 75-year-old Chinese man with a 7-year history of gradual increase of the left eye swelling showed a massive conjunctival tumor growing outwardly from the interpalpebral fissure and had no light perception in the left eye. Magnetic resonance imaging showed orbital invasion of the tumor around the left eyeglobe. The initial surgery for the planned orbital exenteration was discontinued after skin incision around the orbital margin due to massive hemorrhage. The patient underwent transarterial embolization with gelatin sponge (Spongel) of the feeding arteries from the left ophthalmic artery and, the next day, had orbital exenteration with well-controllable bleeding and reconstruction with free vascularized anterolateral thigh cutaneous flap transfer. Pathologically, well-differentiated squamous cell carcinoma proliferated in exophytic, papillary, and nested fashions, arising from the bulbar conjunctiva. Tumor cells were also found in the conjunctival stroma around the vessels. The sclera at the equator had a perforated site with tumor cell invasion, but no intraocular invasion was found. Hematoxylin-positive gelatin sponges were found inside the orbital vessels and large choroidal vessels. In conclusion, transarterial embolization of feeding arteries arising from the ophthalmic artery is a useful pretreatment to control bleeding at orbital exenteration for malignancy.

Conservative Management of an Epicardial Collateral Perforation During Retrograde Chronic Total Occlusion Percutaneous Coronary Intervention.

Science.gov (United States)

Ngo, Christian; Christopoulos, George; Brilakis, Emmanouil S

2016-01-01

Coronary artery perforation is a highly feared complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) and can lead to pericardial effusion, tamponade, and, rarely, emergent cardiac surgery. Perforation of epicardial collaterals during retrograde CTO-PCI may be particularly challenging to treat, as embolization from both sides of the perforation may be required to control the bleeding. However, conservative measures can occasionally be effective. We present a case of epicardial collateral vessel perforation that was managed conservatively with anticoagulation reversal.

Delayed Diagnosis of Iatrogenic Bladder Perforation in a Neonate

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Antoinette S. Birs

2016-01-01

Full Text Available Iatrogenic bladder injuries have been reported in the neonate during umbilical artery/vein catheterization, voiding cystourethrogram, urinary catheterizations, and overwhelming hypoxic conditions. Patients with iatrogenic bladder perforations can present with acute abdomen indicating urinary peritonitis, septic-uremic shock, or subtle symptoms like abdominal distension, pain, hematuria, uremia, electrolyte imbalances, and/or difficulty urinating. The following neonatal case report of perforated bladder includes a review of the signs, symptoms, diagnostic tools, and management of bladder injury in neonates.

Use of various free flaps in progressive hemifacial atrophy.

Science.gov (United States)

Baek, Rongmin; Heo, Chanyeong; Kim, Baek-kyu

2011-11-01

Romberg disease is an uncommon condition manifested by progressive hemifacial atrophy of the skin, soft tissue, and bone. Facial asymmetry with soft tissue deficiency in Romberg disease causes a significant disability affecting the social life and can bring about many psychological problems. The aim of surgical treatment is cosmetic amelioration of the defect. Several conventional reconstructive procedures have been used for correcting facial asymmetry. They include fat injections, dermal fat grafts, filler injections, cartilage and bone grafts, and pedicled and free flaps. We report our experiences with 11 patients involving 11 free flaps with a minimum 1-year follow-up. All patients were classified as having moderate to severe atrophy. The average age at disease onset was 4.5 years; the average duration of atrophy was 5.2 years. No patients were operated on with a quiescent interval of less than 1 year. The average age at operation was 20.1 years, ranging from 10 to 55 years. Reconstruction was performed using 4 groin dermofat free flaps, 4 latissimus dorsi muscle free flaps, and 3 other perforator flaps. To achieve the finest symmetrical and aesthetic results, several ancillary procedures were performed in 4 patients. These procedures included Le Fort I leveling osteotomy, sagittal split ramus osteotomy, reduction malarplasty and angle plasty, rib and calvarial bone graft, correction of alopecia, and additional fat graft. All patients were satisfied with the results. We believe that a free flap transfer is the requisite treatment modality for severe degree of facial asymmetry in Romberg disease.

DIEP breast reconstruction following multiple abdominal liposuction procedures

OpenAIRE

Farid, Mohammed; Nicholson, Simon; Kotwal, Ashutosh; Akali, Augustine

2014-01-01

Objective: Previous abdominal wall surgery is viewed as a contraindication to abdominal free tissue transfer. We present two patients who underwent multiple abdominal liposuction procedures, followed by successful free deep inferior epigastric artery perforator flap. We review the literature pertaining to reliability of abdominal free flaps in those with previous abdominal surgery. Methods: Review of case notes and radiological investigations of two patients, and a PubMed search using the ter...

Multidisciplinary management of a mandibular buccal plate perforation

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Yuli Nugraeni

2010-12-01

Full Text Available Background: Endodontists often have difficulty in the management of endo-perio cases, because they cannot visually detect the condition of outer root surfaces, especially in bucco-lateral roots. The bone defect is rare and its treatment needs collaboration of endodontists and periodontists. An endodontist treats cases based on dental history, radiograph of root canals to measure root canals, to uncover abnormalities and to diagnose, but as the endodontists cannot directly see the affected parts, the unseen portion of the tooth could only be seen after flap surgery. Purpose: This case presents the importance of multidisciplinary approach by the endodontist and periodontitis to treat bucal plate perforations in endo-perio cases. Case: The first patient, a 47-year-old female had endodontic treatment and a porcelain crown restoration; however, after several months she felt pain. The second patient, a 45 year-old female had endodontic treatment and after six months she feel painful. Case management: The first patient, was referred to a periodontist. The opening flap surgery has been done, a bone defect was found in tooth 45. Subsequently, the exposed crater was filled with a bone graft and the pain disappeared. The second patient, with improper endodontic treatment. The flap surgery was conducted, there was found a bone defect in tooth 36. The last treatment, a bone graft has been covered and then the pain was not present. Conclusion: Proper diagnosis and treatment of perforations on the buccal aspect of a root was able to eliminate pain and avoid tooth extraction.Latar belakang: Endodontis sering mengalami kesulitan dalam menangani kasus endo-perio karena secara visual kondisi ini tidak tampak diluar permukaan akar, khususnya pada akar bukolateral. Defek tulang sangatlah jarang dan perawatannya membutuhkan kolaborasi endodotis dan periodontis. Seorang endodontis merawat kasus-kasus berdasarkan riwayat gigi, radiografis saluran akar untuk melihat

Harmonic Scalpel versus electrocautery and surgical clips in head and neck free-flap harvesting.

Science.gov (United States)

Dean, Nichole R; Rosenthal, Eben L; Morgan, Bruce A; Magnuson, J Scott; Carroll, William R

2014-06-01

We sought to determine the safety and utility of Harmonic Scalpel-assisted free-flap harvesting as an alternative to a combined electrocautery and surgical clip technique. The medical records of 103 patients undergoing radial forearm free-flap reconstruction (105 free flaps) for head and neck surgical defects between 2006 and 2008 were reviewed. The use of bipolar electrocautery and surgical clips for division of small perforating vessels (n = 53) was compared to ultrasonic energy (Harmonic Scalpel; Ethicon Endo-Surgery, Inc., Cincinnati, Ohio) (n = 52) free-tissue harvesting techniques. Flap-harvesting time was reduced with the use of the Harmonic Scalpel when compared with electrocautery and surgical clip harvest (31.4 vs. 36.9 minutes, respectively; p = 0.06). Two patients who underwent flap harvest with electrocautery and surgical clips developed postoperative donor site hematomas, whereas no donor site complications were noted in the Harmonic Scalpel group. Recipient site complication rates for infection, fistula, and hematoma were similar for both harvesting techniques (p = 0.77). Two flap failures occurred in the clip-assisted radial forearm free-flap harvest group, and none in the Harmonic Scalpel group. Median length of hospitalization was significantly reduced for patients who underwent free-flap harvest with the Harmonic Scalpel when compared with the other technique (7 vs. 8 days; p = 0.01). The Harmonic Scalpel is safe, and its use is feasible for radial forearm free-flap harvest.

Functional restoration of penis with partial defect by scrotal skin flap.

Science.gov (United States)

Zhao, Yue-Qiang; Zhang, Jie; Yu, Mo-Sheng; Long, Dao-Chou

2009-11-01

We investigated a reconstructive method with better sensory and erectile function for partial penile defects and report our long-term results of surgical correction using scrotal skin flaps. We retrospectively analyzed the records of 18 patients with penile defects referred to us between 1992 and 2007. All cases were treated with a scrotal skin flap initially to repair the secondary defect after penile elongation. Of the 18 cases treated during the 15-year period the mechanism of primary injury was circumcision in 3, animal bite in 9 and penile tumor dissection in 6. Penile elongation, division of the suspensory ligament and scrotal skin flaps achieved penile augmentation and enhancement. Six cases were treated with a bilateral scrotal skin flap supplied by the anterior scrotal artery and 12 were repaired with a total anterior scrotal skin flap supplied by the anterior and posterior scrotal arteries. Penile length in the flaccid and erectile states was obviously increased postoperatively (p <0.05). All patients were followed 1 to 9 years (mean 2.3) postoperatively. Deep and superficial sensation recovered and erectile function was retained. Of the 18 patients 15 reported satisfied sexual intercourse during the 0.5 to 5-year followup. The method of correcting partial penile defect using scrotal skin flaps is effective and simple according to our long-term experience. This method achieves reasonable cosmesis and penile length in most cases with better sensory and erectile function.

[Pedicled versus free TRAM flap for breast reconstruction].

Science.gov (United States)

Galla, T J; Lukas, B; Feller, A M

1999-03-01

In breast reconstruction, the free TRAM-flap offers many advantages over the pedicled TRAM-flap. Due to its superior perfusion, the free flap rarely develops necrosis. Shaping of the flap is easier due to the lack of the thick muscle pedicle. Because the rectus muscle is spared, there is minimal donor site morbidity. However, the necessary microvascular anastomoses reduced the acceptance of the free TRAM-flap. During a 13-months period, 51 breast reconstructions were performed in 41 patients, 31 unilateral and ten bilateral. 45 flaps served for delayed reconstruction and six flaps for immediate reconstruction. The operations were performed by two teams working simultaneously. The average operating time was 3.9 hours for unilateral and 6.9 hours for bilateral delayed reconstruction. For immediate reconstruction, 6.2 and 6.3 hours were required for uni- and bilateral procedures, respectively. In 38 flaps, the thoracodorsal vessels served as recipient vessels; 13 flaps were anastomosed to the internal mammary artery and vein. Postoperative complications were observed in 13 patients. Three vessel anastomoses had to be revised. In one flap, a partial necrosis occurred; in two flaps hematoma evacuation was necessary. Two patients suffered from fat necroses at the abdomen and one umbilicus was lost. Skin irritations and seromas at the abdomen occurred in five patients. Pulmonary embolism was diagnosed in one patient three weeks postoperatively. Abdominal hernias or bulging in the epigastric area were not observed up to 15 months after reconstruction. These results reveal a low complication rate for breast reconstruction with the free TRAM-flap. The advantages of this technique as compared to the pedicled technique are discussed.

Blood flow autoregulation in pedicled flaps

DEFF Research Database (Denmark)

Bonde, Christian T; Holstein-Rathlou, Niels-Henrik; Elberg, Jens J

2009-01-01

was to evaluate if, and to what extent, a tissue flap could compensate a reduction in blood flow due to an acute constriction of the feed artery. Further, we wanted to examine the possible role of smooth muscle L-type calcium channels in the autoregulatory mechanism by pharmacological intervention with the L......, the flow in the pedicle was reduced and the flow was recorded. RESULTS: The flaps showed a strong autoregulatory response with complete compensation for flow reductions of up to 70-80%. Infusion of nimodipine caused a 28+/-10% increase in blood flow and removed the autoregulation. Papaverine caused...... a further increase in blood flow by 61+/-19%. The time control experiments proved that the experimental procedure was reproducible and stable over time. CONCLUSIONS: A tissue flap can nearly completely compensate for repeated flow reductions of up to 70-80%. This is due to a decrease in the peripheral...

The Clinical Importance of Perforator Preservation in Intracranial Aneurysm Surgery: An Overview with a Review of the Literature.

Science.gov (United States)

Joo, Sung-Pil; Kim, Tae-Sun

2017-01-01

Clipping for intracranial aneurysms is done to achieve complete occlusion of the aneurysm without a remnant sac. Despite modern advancements of neurosurgical techniques, morbidity related to the clipping of intracranial aneurysms still exists. Clip occlusion of a parent artery or small hidden perforators commonly leads to permanent neurological deficits, and is a serious and unwanted complication. Thus, preserving blood flow in the branches and perforators of a parent artery is very important for successful surgery without postoperative morbidity and mortality. The aim of this review article is to discuss the consequences of perforator injury and how to avoid this phenomenon in aneurysm surgeries using intraoperative monitoring devices.

Edaravone enhances the viability of ischemia/reperfusion flaps.

Science.gov (United States)

Zhang, Dong-Yi; Kang, Shen-Song; Zhang, Zheng-Wen; Wu, Rui

2017-02-01

The purpose of the experiment was to study the efficacy of edaravone in enhancing flap viability after ischemia/reperfusion (IR) and its mechanism. Forty-eight adult male SD rats were randomly divided into 3 groups: control group (n=16), IR group (n=16), and edaravone-treated IR group (n=16). An island flap at left lower abdomen (6.0 cm×3.0 cm in size), fed by the superficial epigastric artery and vein, was created in each rat of all the three groups. The arterial blood flow of flaps in IR group and edaravone-treated IR group was blocked for 10 h, and then the blood perfusion was restored. From 15 min before reperfusion, rats in the edaravone-treated IR group were intraperitoneally injected with edaravone (10 mg/kg), once every 12 h, for 3 days. Rats in the IR group and control group were intraperitoneally injected with saline, with the same method and frequency as the rats in the edaravone-treated IR group. In IR group and edaravone-treated IR group, samples of flaps were harvested after reperfusion of the flaps for 24 h. In the control group, samples of flaps were harvested 34 h after creation of the flaps. The content of malondialdehyde (MDA) and activity of superoxide dismutase (SOD) were determined, and changes in organizational structure and infiltration of inflammatory cells were observed by hematoxylin-eosin (HE) staining, apoptotic cells of vascular wall were marked by terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) assay, and the apoptotic rate of cells in vascular wall was calculated. The ultrastructural changes of vascular endothelial cells were observed by transmission electron microscopy (TEM). Seven days after the operation, we calculated the flap viability of each group, and marked vessels of flaps by immunohistochemical staining for calculating the average number of subcutaneous vessels. The results showed that the content of MDA, the number of multicore inflammatory cells and apoptotic rate of cells in vascular wall

[Anatomical study and clinical application of a leg flap pedicle-included with cutaneous nerve and its concomitant vessels].

Science.gov (United States)

Liu, B; Hao, X; Goan, M

2000-05-01

To investigate the blood supply patterns and the clinical liability of a leg flap pedicle-included with cutaneous nerve and its concomitant vessels. Fresh cadaver legs with thirty-two in infants and two in adults were anatomically examined after the intravenous injection of the red Chlorinated Poly Vingl Choride (CPVC). Five patients with the soft tissue defects were selected for the treatment with the flap pedicle-included with the cutaneous nerve and its concomitant vessels. Four main cutaneous nerves were found in the leg after they perforated the deep fascia out. They were companioned with their concomitant vessels with different blood-supply pateeerns, which the upper part of the leg was in an axial pattern and the lower part was in a "chain-type anastomosing" pattern. Following the above-mentioned findings, five cases were successfully treated with this led flap. The leg flap should be designed along the cutaneous nerve and its concomitant vessels. When the flap is applied in the area of blood supply with "chain-type anastomosing" pattern, the deep fascia should also be included in the flap.

Medical image of the week: eosphageal perforation

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Bilal J

2015-04-01

Full Text Available No abstract available. Article truncated after 150 words. A 74 year old man with a past medical history of esophageal strictures status post dilatation, coronary artery disease status post CABG, and atrial fibrillation presented to hospital with complaints of severe chest pain that began after the consumption of tortilla chips one hour prior to presentation. Electrocardiogram and cardiac enzymes were not consistent with acute coronary syndrome. Chest X-ray was consistent with a widened mediastinal silhouette. Contrast esophogram was negative for extra luminal extravasation. CT scan of the chest with oral contrast demonstrated thickening of the mid-thoracic esophagus with an extra-luminal focus of gas in the mediastinum along with fluid along the inferior aspect of the esophagus (Figures 1 and 2. These findings were concerning for esophageal perforation. The patient was taken to the operating room for endoscopy which showed micro perforation in mid-esophagus. Esophageal perforation remains a highly morbid condition. Mortality rates are based predominantly on time of ...

Variabilidad en el diseño y composición del colgajo de perforante de tibial posterior para la reconstrucción de defectos en la pierna Versatility on design and composition of the tibial posterior perforator flap for reconstruction of leg defects

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C. Laredo Ortiz

2011-03-01

perforators allows the use of muscular and tendinous cuffs in the same flap to solve more complex defects, becoming something more than a free flap alternative. We present a serie of 43 patients to describe the reconstructive possibilities of the tibialis posterior perforator flap in its propeller form, as for design variability and composed flap use, with the aim of minimizing donor site morbility even more without the use of grafts.

Autologous Latissimus Dorsi Breast Reconstruction Flap Salvage: Microvascular Anastomosis with Serratus Branch

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Victoria Kuta, BScH

2017-07-01

Full Text Available Summary:. Autologous breast reconstruction has become a standard option during the recovery of breast cancer survivors. Although pedicle damage is a rare complication of this procedure, extensive torsion or tension can lead to partial or total flap failure. We report a case of partial flap salvage after accidental transection of the pedicled blood supply within the intramuscular course of a latissimus dorsi musculocutaneous flap. This salvage technique involved microvascular anastomosis between the remaining vasculature of the latissimus dorsi pedicle and the serratus branch of the thoracodorsal artery and vein.

Anatomic variability of the vascularized composite osteomyocutaneous flap from the medial femoral condyle: an anatomical study

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Trung-Hau Le Thua

2014-12-01

Full Text Available Aim: The anatomical study and clinical application for the vascularized corticoperiosteal flap from the medial femoral condyle have been performed and described previously. Although prior studies have described the composite osteomyocutaneous flap from the medial femoral condyle, a detailed analysis of the vascularity of this region has not yet been fully evaluated. Methods: This anatomical study described the variability of the arteries from the medial femoral condyle in 40 cadaveric specimens. Results: The descending genicular artery (DGA was found in 33 of 40 cases (82.5%. The  superomedial genicular artery (SGA was present in 10 cases (25%. All 33 cases (100% of the DGA had articular branches to the periosteum of the medial femoral condyle. Muscular branches and saphenous branches of the DGA were present in 25 cases (62.5% and 26 cases (70.3%, respectively. Conclusion: The current study demonstrates that the size and length of the vessels to the medial femoral condyle are sufficient for a vascularized bone flap. A careful preoperative vascular assessment is essential prior to use of the vascularized composite osteomyocutaneous flap from the medial femoral condyle, because of the considerable anatomical variations in different branches of the DGA.

The evolving breast reconstruction

DEFF Research Database (Denmark)

Thomsen, Jørn Bo; Gunnarsson, Gudjon Leifur

2014-01-01

The aim of this editorial is to give an update on the use of the propeller thoracodorsal artery perforator flap (TAP/TDAP-flap) within the field of breast reconstruction. The TAP-flap can be dissected by a combined use of a monopolar cautery and a scalpel. Microsurgical instruments are generally...... not needed. The propeller TAP-flap can be designed in different ways, three of these have been published: (I) an oblique upwards design; (II) a horizontal design; (III) an oblique downward design. The latissimus dorsi-flap is a good and reliable option for breast reconstruction, but has been criticized...... for oncoplastic and reconstructive breast surgery and will certainly become an invaluable addition to breast reconstructive methods....

The treatment of pharyngoesophageal perforation following anterior cervical spine intervention.

Science.gov (United States)

Aslıer, Mustafa; Doğan, Ersoy; Ecevit, Mustafa Cenk; Erdağ, Taner Kemal; Ikiz, Ahmet Omer

2016-06-01

We aimed to investigate the diagnostic and therapeutic approaches in pharyngoesophageal perforation (PEP) following anterior cervical spine intervention (ACSI). We reviewed the records of four patients with PEP after ACSI. Symptoms, physical examination findings, imaging results, treatment, and follow-up characteristics were evaluated. All four patients had undergone ACSI for either cervical trauma or cervical disc herniation with cervical cage reconstruction. Symptoms developed within the first 10 days of the postoperative period in three patients, and in the eighth month in one patient. Mucosal defects were detected during neck exploration in three patients. Reconstruction with primary suture and a local muscle flap was utilized in two patients. Three patients were discharged 3-8 weeks after surgical treatment. In cases of PEP after ACSI, a good prognosis can be achieved when symptoms are detected in the early period and reconstruction with local muscle flap is applied. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Critical Appraisal of Nasolabial Flap for Reconstruction of Oral Cavity Defects in Cancer Patients

International Nuclear Information System (INIS)

Mebed, A.; Hussein, H.A.; Saber, T.Kh.

2009-01-01

Purpose: Re-evaluation of nasolabial flap in lip and oral cavity reconstruction and role of each of its variants in reconstructing various intermediate size defects was addressed. Patients and Methods: Case-series study was con-ducted in National Cancer Institute, Cairo University over the period from July 2005 - January 2009 which included 23 patients with clinically T-l N0, T-2 N0 invasive squamous cell carcinoma of buccal mucosa and the vermilion border of the lower lip. Immediately after surgical excision, one stage reconstruction of the defect was done using a type of nasolabial flap. All patients were followed and the median follow-up period was 7.5 month. Results: Twelve patients with the lower lip carcinoma and 11 patients with the carcinoma of buccal mucosa underwent surgical excision under frozen section control. 19 fasciocutaneous nasolabial flap and 4 facial artery musculomucosal flaps were used for reconstruction. Minor wound complications occurred in 2 flaps and one patient required secondary suture. Flap viability was reliable and was not affected by performance of a synchronous neck dissection. Functional results were satisfactory, cosmetic results were good in most of the patients and excellent when facial artery musculomucosal flap was used. Conclusion: The nasolabial flap is a reliable and minimally traumatic local flap for one stage reconstruction of medium size defects in the oral cavity. The abundant blood supply allowed its modification in order to cover larger defects or to obtain better cosmetic results. This versatility makes it more widely used thus minimizing the use of local tongue flaps and split thickness grafts for covering these medium size defects in cases of buccal mucosa cancer or affecting the other lip or commissure in cases of lip cancer. It has a high viability rate, low complication rate; it is quick and easy to perform in addition to its satisfactory functional and cosmetic results.

Early Mobilization after Free-flap Transfer to the Lower Extremities: Preferential Use of Flow-through Anastomosis

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Shimpei Miyamoto, MD

2014-03-01

Conclusions: This study demonstrates that early mobilization after free-flap transfer to the lower extremity is made possible by flow-through anastomosis for both arteries and veins. Flow-through flaps have stable circulation from the acute phase and can tolerate early dangling and ambulation.

SURGICAL RECONSTRUCTION IN PRESSURE ULCERS- A RETROSPECTIVE STUDY OF THE WORKHORSE FLAP OPTIONS

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Sheeja Rajan T. M

2016-11-01

Full Text Available BACKGROUND Pressure ulcers can significantly contribute to morbidity and mortality by chronic infections. Radical debridement of all devitalised and infected tissues followed by a reconstructive algorithm for soft tissue padding over bony prominences to prevent recurrent breakdown are the mainstay of surgical management of pressure ulcers. Choice of the soft tissue flap for reconstruction is influenced by the dimensions of ulcers, local tissue availability and surgeon’s preferences. MATERIALS AND METHODS This retrospective study includes 140 patients with spinal injuries having pressure ulcers of NPUAP grade III and IV treated surgically over a period of four years. The demographics of pressure ulcers, the workhorse flap options as well as the outcome were analysed. RESULTS The pressure ulcers were seen predominantly in males (93.6% of 40-49 years’ age group (42.8%. Ischial pressure ulcers (n=104 constituted 74.2% followed by sacral pressure ulcers (n=24 that is 17.1% and trochanteric pressure ulcers (n=12 in 8.6%. Debridement and direct closure of wound were possible only in 10 cases. Majority (92.8% of patients needed additional tissues for wound coverage. Our workhorse fasciocutaneous flaps were rotation flaps from the gluteal region or posterior thigh with medial or lateral based designs (34.2%. Local muscle tissue was used in 64 cases (46% either as gluteal, tensor fascia lata and biceps femoris myocutaneous flaps or gluteus maximus, hamstring or gracilis muscle fillers in myoplasty. CONCLUSIONS Rotation flap along with myoplasty were our workhorse flap options in majority of the pressure ulcers. But, our future perspective is to spare muscle and use more fasciocutaneous perforator flaps for reconstruction according to evidence-based clinical practice.

Morphometric Study of the Anterior Thalamoperforating Arteries

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Kim, Sung-Ho; Yeo, Dong-Kyu; Shim, Jae-Joon; Yoon, Seok-Mann; Chang, Jae-Chil

2015-01-01

Objective To evaluate the morphometry of the anterior thalamoperforating arteries (ATPA). Methods A microanatomical study was performed in 79 specimens from 42 formalin-fixed adult cadaver brains. The origins of the ATPAs were divided into anterior, middle, and posterior segments according to the crowding pattern. The morphometry of the ATPAs, including the premammillary artery (PMA), were examined under a surgical microscope. Results The anterior and middle segments of the ATPAs arose at mean intervals of 1.75±1.62 mm and 5.86±2.05 mm from the internal carotid artery (ICA), and the interval between these segments was a mean of 3.17±1.64 mm. The posterior segment arose at a mean interval of 2.43±1.46 mm from the posterior cerebral artery (PCA), and the interval between the middle and posterior segments was a mean of 3.45±1.39 mm. The mean numbers of perforators were 2.66±1.19, 3.03±1.84, and 1.67±0.98 in the anterior, middle, and posterior segments, respectively. The PMA originated from the middle segment in 66% of cases. A perforator-free zone was located >2 mm from the ICA in 30.4% and >2 mm from the PCA in 67.1% of cases. Conclusion Most perforators arose from the anterior and middle segments, within the anterior two-thirds of the posterior communicating artery (PCoA). The safest perforator-free zone was located closest to the PCA. These anatomical findings may be helpful to verify safety when treating lesions around the PCoA and in the interpeduncular fossa. PMID:26113962

Free radial forearm flap versatility for the head and neck and lower extremity

International Nuclear Information System (INIS)

Chicarilli, Z.N.; Ariyan, S.; Cuono, C.B.

1986-01-01

Microsurgical techniques have developed numerous territories suitable for free tissue transfer. However, the demand for thin cutaneous resurfacing limits the choice of flaps available to the reconstructive microsurgeon. The radial forearm flap is a thin, axial, fasciocutaneous flap, offering pliable cutaneous resurfacing, with or without sensation. We have used 15 flaps to reconstruct defects in the head and neck and lower extremity resulting from burns, blunt and avulsive trauma, radiation necrosis, and tumor ablation. Two flaps (15 percent) developed venous congestion and were salvaged by reoperation. One retrograde flap (7.5 percent) developed partial necrosis from arterial insufficiency. Neural re-innervation was successful in two out of three patients in whom it was attempted. Two patients (15%) sustained minor donor site skin graft loss that healed secondarily. In our series of predominantly older patients the donor sites have been relatively inconspicuous at one year follow-up. A functional restoration was achieved in all patients

Typhoid Intestinal Perforation: 24 Perforations in One Patient

African Journals Online (AJOL)

Intestinal perforation is a common cause of peritonitis necessitating emergency surgical intervention. Perforation ... Mortality rates of typhoid intestinal perforation (TIP) cases are ... may be obscured clinical features with resultant delays in.

The Relationship between Oxygen Saturation and Color Alteration of a Compromised Skin Flap: Experimental Study on the Rabbit.

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Prasetyono, Theddeus O H; Adianto, Senja

2013-09-01

The aim of this study was to collect important data on the time of oxygen saturation change in relation to skin flap color alteration using non-invasive pulse oximetry to evaluate its ability to provide continuous monitoring of skin flap perfusion. An experimental study on the monitoring of blood perfusion of 20 tube-island groin flaps of 10 male New Zealand rabbits was performed using pulse oximetry. The animals were randomly assigned to one of two groups representing a blockage of either arterial or venous blood flow. The oxygen saturation change and clinical color alteration were monitored from the beginning of vessel clamping until the saturation became undetectable. The result was analyzed by the t-test using SSPS ver. 10.0. The mean times from the vessel clamping until the saturation became undetectable were 20.19±2.13 seconds and 74.91±10.57 seconds for the artery and vein clamping groups, respectively. The mean time of the clinical alteration from the beginning of vein clamping was 34.5±11.72 minutes, while the alteration in flaps with artery clamping could not be detected until 2.5 hours after clamping. The use of neonate-type reusable flex sensor-pulse oximetry is objective and effective in early detection of arterial and vein blockage. It provides real-time data on vessel occlusion, which in turn will allow for early salvaging. The detection periods of both arterial occlusion and venous congestion are much earlier than the color alteration one may encounter clinically.

The Relationship between Oxygen Saturation and Color Alteration of a Compromised Skin Flap: Experimental Study on the Rabbit

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Theddeus O. H. Prasetyono

2013-09-01

Full Text Available BackgroundThe aim of this study was to collect important data on the time of oxygen saturation change in relation to skin flap color alteration using non-invasive pulse oximetry to evaluate its ability to provide continuous monitoring of skin flap perfusion.MethodsAn experimental study on the monitoring of blood perfusion of 20 tube-island groin flaps of 10 male New Zealand rabbits was performed using pulse oximetry. The animals were randomly assigned to one of two groups representing a blockage of either arterial or venous blood flow. The oxygen saturation change and clinical color alteration were monitored from the beginning of vessel clamping until the saturation became undetectable. The result was analyzed by the t-test using SSPS ver. 10.0.ResultsThe mean times from the vessel clamping until the saturation became undetectable were 20.19±2.13 seconds and 74.91±10.57 seconds for the artery and vein clamping groups, respectively. The mean time of the clinical alteration from the beginning of vein clamping was 34.5±11.72 minutes, while the alteration in flaps with artery clamping could not be detected until 2.5 hours after clamping.ConclusionsThe use of neonate-type reusable flex sensor-pulse oximetry is objective and effective in early detection of arterial and vein blockage. It provides real-time data on vessel occlusion, which in turn will allow for early salvaging. The detection periods of both arterial occlusion and venous congestion are much earlier than the color alteration one may encounter clinically.

Clinical anatomy of the donor zone of venous flaps of forearm

OpenAIRE

O. S. Kurochkina

2012-01-01

The variant anatomy of saphenous veins of forearm in the zones of venous flap rising remains unstudied yet, as well as the influence of the valve apparatus of saphenous veins on the arterial perfusion of venous flaps. The paper studies the variant anatomy of saphenous veins of the upper third of the volar surface of forearm. Two versions of saphenous veins are revealed: major (axial) and retiform. It is found experimentally that the valve apparatus of saphenous veins does not influence consid...

Evaluation of tissue oxygen measurements for flap monitoring in an animal model

DEFF Research Database (Denmark)

Bonde, Christian; Elberg, Jens; Holstein-Rathlou, N.-H.

2008-01-01

Tissue oxygen tension (p(ti)O(2)) measurements are common in neurosurgery but uncommon in plastic surgery. We examined this technique as a monitoring method with probe placement in the subcutaneous tissue and addressed the importance of probe placement. Myocutaneous flaps were raised in an animal...... model and p(ti)O(2) measurements performed at different levels in the subcutaneous fat. Flap artery and vein were occluded until a 50% p(ti)O(2) reduction had occurred (T(1/2)). We found no significant effect of depth (P>0.10) on the level of p(ti)O(2). T(1/2)(arterial) was 7.2 minutes and T(1/2)(venous......) was 18 minutes. We found no significant relation between initial levels of p(ti)O(2) and T(1/2). Location of the probe and absolute p(ti)O(2) value is of little relevance for flap monitoring. It is the relative change in p(ti)O(2) that is important. The p(ti)O(2) technique is well suited for monitoring...

Double profunda brachii artery

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Gavishiddappa A Hadimani

2016-01-01

Full Text Available Brachial artery (BA is a continuation of the axillary artery at the lower border of teres major. In the cubital fossa, BA divides into radial artery and ulnar artery as terminal branches. Large branch given from the BA in the upper part is profunda brachii artery. In the present case, we noticed double profunda brachii that arises from the BA. They are profunda brachii artery 1 and profunda brachii artery 2. Profunda brachii artery 1 arises in the proximal part of the BA and profunda brachii artery 2 arises distal to the profunda brachii artery 1. Both the arteries run inferolaterally in the spiral groove along with radial nerve. Variations of profunda brachii artery are important during harvesting of the lateral arm flaps and may lead to inadvertent injury during percutaneous arterial catheterization or injection of drugs.

Pure Motor Stroke Secondary to Cerebral Infarction of Recurrent Artery of Heubner after Mild Head Trauma: A Case Report.

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Yilmaz, Ali; Kizilay, Zahir; Ozkul, Ayca; Çirak, Bayram

2016-03-15

The recurrent Heubner's artery is the distal part of the medial striate artery. Occlusion of the recurrent artery of Heubner, classically contralateral hemiparesis with fasciobrachiocrural predominance, is attributed to the occlusion of the recurrent artery of Heubner and is widely known as a stroke syndrome in adults. However, isolated occlusion of the deep perforating arteries following mild head trauma also occurs extremely rarely in childhood. Here we report the case of an 11-year-old boy with pure motor stroke. The brain MRI showed an acute ischemia in the recurrent artery of Heubner supply area following mild head trauma. His fasciobrachial hemiparesis and dysarthria were thought to be secondary to the stretching of deep perforating arteries leading to occlusion of the recurrent artery of Heubner. Post-traumatic pure motor ischemic stroke can be secondary to stretching of the deep perforating arteries especially in childhood.

Radial forearm free flap morbidity: A rare case of a normal preoperative arteriogram and acute intraoperative hand ischemia

OpenAIRE

Bruner, Terrence W; Hanasono, Matthew M; Skoracki, Roman J

2011-01-01

The radial forearm free flap is ideal for reconstructive microsurgery due to its thin, pliable fasciocutaneous tissue, reliable anatomy and ease and simplicity of flap elevation. However, one of the major complications is hand ischemia due to sacrifice of the radial artery, although it is a rare occurrence. A case involving a 73-year-old man who developed intraoperative hand ischemia after elevation of a radial forearm free flap is presented.

Dissecting aneurysms of the middle cerebral artery: neuroradiological and clinical features

International Nuclear Information System (INIS)

Ohkuma, H.; Suzuki, S.; Shimamura, N.; Nakano, T.

2003-01-01

There are few reported cases of nontraumatic dissecting aneurysms of the middle cerebral artery (MCA), and their neuroradiological and clinical features have not been analysed. We looked at these aspects in a collaborative study. We reviewed 13 patients diagnosed as having a dissecting aneurysm of the MCA based on clinical signs and neuroradiological findings in 46 stroke centres between 1995 and 1999. There were four patients who presented with cerebral ischaemia, and nine who presented with bleeding. Of the former group, three were aged less than 15 years. Cerebral angiography showed extensive stenosis and a double lumen of the M1 portion in all four patients. High signal on T1-weighted images around the arterial flow void, due to intramural haematoma, was often seen in the second week. MR angiography showed findings corresponding those of intra-arterial angiography in all four cases. We saw an infarct on CT or MRI in territory of the perforating branches of the M1 segment in all four patients. In the patients presenting with bleeding, pure subarachnoid haemorrhage or a sylvian fissure haematoma was seen on initial CT, and the predominant angiographic finding was dilatation with stenosis, but the site of the lesions was not uniform. A double lumen or intimal flap was seen in about half the cases. Rebleeding occurred within 14 days of the onset in five of the nine patients, with a poor prognosis. (orig.)

The Pedicled Buccal Fat Pad: Anatomical Study of the New Flap for Skull Base Defect Reconstruction After Endoscopic Endonasal Transpterygoid Surgery

Science.gov (United States)

Golbin, Denis A.; Lasunin, Nikolay V.; Cherekaev, Vasily A.; Polev, Georgiy A.

2016-01-01

Objectives To evaluate the efficacy and safety of using a buccal fat pad for endoscopic skull base defect reconstruction. Design Descriptive anatomical study with an illustrative case presentation. Setting Anatomical study was performed on 12 fresh human cadaver specimens with injected arteries (24 sides). Internal carotid artery was exposed in the coronal plane via the endoscopic transpterygoid approach. The pedicled buccal fat pad was used for reconstruction. Participants: 12 human cadaver head specimens; one patient operated using the proposed technique. Main outcome measures: Proximity of the buccal fat pad flap to the defect, compliance of the flap, comfort and safety of harvesting procedure, and compatibility with the Hadad–Bassagasteguy nasoseptal flap. Results: Harvesting procedure was performed using anterior transmaxillary corridor. The pedicled buccal fat pad flap can be used to pack the sphenoid sinus or cover the internal carotid artery from cavernous to upper parapharyngeal segment. Conclusion The buccal fat pad can be safely harvested through the same approach without external incisions and is compliant enough to conform to the skull base defect. The proposed pedicled flap can replace free abdominal fat in central skull base reconstruction. The volume of the buccal fat pad allows obliteration of the sphenoid sinus or upper parapharyngeal space. PMID:28180047

The Relationship between Oxygen Saturation and Color Alteration of a Compromised Skin Flap: Experimental Study on the Rabbit

Directory of Open Access Journals (Sweden)

Theddeus O. H. Prasetyono

2013-09-01

Full Text Available Background The aim of this study was to collect important data on the time of oxygensaturation change in relation to skin flap color alteration using non-invasive pulse oximetryto evaluate its ability to provide continuous monitoring of skin flap perfusion.Methods An experimental study on the monitoring of blood perfusion of 20 tube-islandgroin flaps of 10 male New Zealand rabbits was performed using pulse oximetry. The animalswere randomly assigned to one of two groups representing a blockage of either arterial orvenous blood flow. The oxygen saturation change and clinical color alteration were monitoredfrom the beginning of vessel clamping until the saturation became undetectable. The resultwas analyzed by the t-test using SSPS ver. 10.0.Results The mean times from the vessel clamping until the saturation became undetectablewere 20.19±2.13 seconds and 74.91±10.57 seconds for the artery and vein clamping groups,respectively. The mean time of the clinical alteration from the beginning of vein clampingwas 34.5±11.72 minutes, while the alteration in flaps with artery clamping could not bedetected until 2.5 hours after clamping.Conclusions The use of neonate-type reusable flex sensor-pulse oximetry is objective andeffective in early detection of arterial and vein blockage. It provides real-time data on vesselocclusion, which in turn will allow for early salvaging. The detection periods of both arterialocclusion and venous congestion are much earlier than the color alteration one may encounterclinically.

Success of free flap anastomoses performed within the zone of trauma in acute lower limb reconstruction.

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Bendon, Charlotte L; Giele, Henk P

2016-07-01

Traditionally, in free flap cover of lower limb injuries, every attempt is made to perform anastomoses proximal to the zone of injury. We report on the success of anastomoses within the zone of trauma, at the level of the fracture, avoiding further dissection and exposure. The records of free flap reconstructions for fractures of the lower extremity at a tertiary trauma centre between 2004 and 2010 were retrospectively reviewed. A total of 48 lower limb fractures required free flap reconstruction, performed at 28 days post injury (0-275 days). Anastomoses were proximal (21), distal (5) or within the zone of trauma (22). There was no significant difference (p > 0.05) in return to theatre, revision of anastomosis or flap survival between groups. Of the 22 performed within the zone of injury, five returned to theatre but only two for revision of anastomosis and 20 (91%) of these flaps survived. Of the 48 free flaps, arterial anastomoses were end to end in 34 (71%) and end to side in 14 (30%). There was no significant difference (p > 0.05) in return to theatre, revision of anastomosis or flap survival between the end-to-end and end-to-side groups. There was a tendency for arterial anastomoses to be performed end to end outside the zone of trauma (23/26) compared to within the zone of trauma (11/22). Our data suggest that free flap anastomoses can be performed safely in the zone of trauma in lower limb injuries. Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Reconstruction of the columella and the tip of the nose with an island-shaped forehead flap

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Vulović Dejan

2011-01-01

Full Text Available Background. Posttraumatic and postoperative defects of columella and the tip of the nose are difficult to reconstruct. There are several operative methods described in the literature, and many of them are step-by-step procedures with long duration. The aim of this study was to present one-step procedure for reconstruction of the columella and the tip of the nose with island-shaped arterial forehead flap. Case report. A 45-year old man was submitted to surgical excision of basocellular skin cancer. After the excision, a defect of the columella and tip of the nose the remained, 3 × 2.5 cm in dimensions, with exposed alar cartilages. During the same operation, the defect was covered with an island-shaped arterial forehead flap. Postoperative one-year course was uneventful, without signs of tumor recurrence after one year, and further surgical corrections were unnecessary. Conclusion. Considering the results of our operative technique, we believe that middle island-shaped forehead flap is suitable for reconstruction of the columella and the tip of the nose, due to the following reasons: safe vascularization of flap, similarity of the transferred tissue with the excised one, the procedure is completed in one step, simple surgical technique and uncomplicated healing of a flap-harvesting site.

Perforator based rectus free tissue transfer for head and neck reconstruction: New reconstructive advantages from an old friend.

Science.gov (United States)

Kang, Stephen Y; Spector, Matthew E; Chepeha, Douglas B

2017-11-01

To demonstrate three reconstructive advantages of the perforator based rectus free tissue transfer: long pedicle, customizable adipose tissue, and volume reconstruction without muscle atrophy within a contained space. Thirty patients with defects of the head and neck were reconstructed with the perforator based rectus free tissue transfer. Transplant success was 93%. Mean pedicle length was 13.4cm. Eleven patients (37%) had vessel-poor necks and the long pedicle provided by this transplant avoided the need for vein grafts in these patients. Adipose tissue was molded in 17 patients (57%). Twenty-five patients (83%) had defects within a contained space, such as the orbit, where it was critical to have a transplant that avoided muscle atrophy. The perforator based rectus free tissue transfer provides a long pedicle, moldable fat for flap customization, and is useful in reconstruction of defects within a contained space where volume loss due to muscle atrophy is prevented. Copyright © 2017 Elsevier Ltd. All rights reserved.

Management of Esophageal and Pharyngeal Perforation as Complications of Anterior Cervical Spine Surgery.

Science.gov (United States)

Kang, Moo Sung; Kim, Kyung Hyun; Park, Jeong Yoon; Kuh, Sung Uk; Chin, Dong Kyu; Jin, Byung Ho; Kim, Keun Su; Cho, Yong Eun

2017-06-01

To describe our experience in treating esophageal and pharyngeal perforation after anterior cervical spine surgery. Six patients with esophageal injury and one patient with pharyngeal injury after anterior cervical spinal surgery, managed at our department between 2000 and 2015, were analyzed retrospectively. During the study period, 7 patients (6 male and 1 female; mean age, 45 years) presented with esophageal perforation. The original anterior cervical spinal surgery was performed due to trauma in 2 patients and because of a degenerative cervical disorder in 5. Early esophageal perforation was diagnosed in 2 patients, and delayed esophageal injury due to chronic irritation with the cervical implants was noted in 5. Three of the five delayed perforation cases were related to cervical instrument displacement. Two patients showed no definite signs of infection, whereas 5 patients had various symptoms, including fever, neck pain, odynophagia, neck swelling, and upper extremity weakness. Two patients with a large defect underwent surgical repair and three with minimal perforation due to chronic irritation from the implants underwent instrument removal without direct repair of defect. Two asymptomatic patients received no intervention. Six patients with infection completely recovered from esophageal injury after treatment for a mean duration of 5.2 weeks (range, 4-8 weeks). One patient died because of postoperative pneumonia and sepsis after implant removal. Esophageal and pharyngeal injury after cervical spinal surgery may occur either directly due to spinal trauma and vigorous intraoperative retraction or due to chronic irritation with cervical implants. In cases of perforation associated with infection, various surgical modalities, including primary closure and reinforcement with a flap, could be considered depending on factors such as esophageal defect size, infection severity, and timing of recognition of injury. Copyright © 2017 Elsevier Inc. All rights reserved.

Therapy of deep radiation ulcer after the mammacarcinoma operation

International Nuclear Information System (INIS)

Nabeshima, Kengo; Imai, Susumu; Makino, Koreo; Koike, Makoto; Hayata, Yoshiharu.

1976-01-01

Eight cases of deep radiation ulcer after mammacarcinoma operations were treated in our clinic in the past 10 years. Four of them were treated by the large thoracic-abdominal flap after bony chest wall resection. Referring to these experiences we considered that the following four points were important. 1. Ulcers should be repaired in one stage if possible. 2. Necrotic mass and injured tissues should be resected completely. 3. The large tissue defect after the debridement can be covered directly with the opposite large thoracic-abdominal flap. 4. The I. II. III perforating branches of the internal mammary arteries should be kept intract in constructing the thoracic-abdominal flap. (auth.)

Direct delayed breast reconstruction with TAP flap, implant and acellular dermal matrix (TAPIA)

DEFF Research Database (Denmark)

Børsen-Koch, Mikkel; Gunnarsson, Gudjon L; Udesen, Ann

2015-01-01

BACKGROUND: The latissimus dorsi (LD) flap is considered one of the working horses within the field of breast reconstruction and it offers several advantages. However, donor-site morbidity may pose a problem. This article describes a new and modified technique for delayed breast reconstruction...... there is a learning curve, this simple modified technique does not demand any perforator or other vessel dissection. Any trained plastic surgeon should be able to adopt the technique into the growing armamentarium of breast reconstruction possibilities....

Rupture of major vessels after radiation

International Nuclear Information System (INIS)

Fajardo, L.F.; Lee, A.

1975-01-01

Rupture of irradiated large vessels is an uncommon complication which tends to occur in carotid, aorta, and femoral arteries, in decreasing order of incidence. It particularly affects men subjected to surgery and radiotherapy for epidermoid carcinomas in oropharynx, esophagus, or genitalia. Contrary to some opinion, radiation is not the most significant cause; this spontaneous arterial rupture can occur without radiation. The perforation is not associated with tumor invasion of arterial wall, as has been claimed. Surgical complications, especially necrosis of skin flaps, infection, and fistulas are most important etiologically. Only 2 of the 11 instances that we describe appear to have been caused mainly by radiation. The perforation is usually fatal, but several patients, including 3 of our series (2 carotid, 1 femoral), have been saved by hospital personnel aware of this complication. To prevent it, prolonged exposure or infection of arteries, whether irradiated or not, should be avoided. (auth)

Acute mesenteric ischemia and duodenal ulcer perforation: a unique double pathology

Directory of Open Access Journals (Sweden)

Haruna Lois

2012-10-01

Full Text Available Abstract Background Acute mesenteric ischaemia and duodenal perforation are surgical emergencies with serious consequences. Patients presenting with acute mesenteric ischaemia alone face a high mortality rate as high as 60% whereas those presenting with peptic ulcer perforation the mortality rates range from 6-14%. There are very few reported cases of patients presenting with this dual pathology. Case presentation We report a unique case of a 53 year old Italian lady who presented with acute mesenteric ischaemia and duodenal perforation. This is the first report of massive bowel ischaemia and duodenal perforation with no apparent underlying common pathophysiology leading to this presentation. Conclusion Early management in the intensive care unit and appropriate surgical intervention maximised the patient’s chances of survival despite the poor prognosis associated with her dual pathology. The rare pathology of the patient described can be explained by two possible hypotheses: peptic ulcer disease causing duodenal ulceration, which precipitated ischaemic infarction of the small bowel. The second hypothesis is the patient developed a stress related ulcer following ischaemic bowel infarction secondary to arterial thrombosis.

"Palmar pivot flap" for resurfacing palmar lateral defects of the fingers.

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Yam, Andrew; Peng, Yeong-Pin; Pho, Robert Wan-Heng

2008-12-01

Soft tissue defects on the lateral borders of the digits are difficult to reconstruct using local or local-regional flaps. We describe a "palmar pivot flap" to resurface an adjacent defect on the palmar-lateral aspect of the digit. The surgical technique is described. This flap is an axial pattern flap based on the subcutaneous transverse branches of the digital artery. The flap is pivoted up to 90 degrees on the neurovascular bundle in its base, into an adjacent defect. The flap can be raised from either the proximal or the middle phalangeal segments. It can cover defects sited from the level of the proximal interphalangeal joint up to the fingertip. The donor defect is limited to the same digit and is covered with a full-thickness skin graft. We have used this flap on 3 patients with defects at the middle phalangeal segment, the distal interphalangeal joint, and the fingertip. All healed primarily. One patient had a mild flexion contracture of the proximal interphalangeal joint, whereas the other 2 had no complications. The patients with distal interphalangeal joint and fingertip defects had excellent sensation in the flap (2-point discrimination of 5-6 mm). The palmar pivot flap is useful for resurfacing otherwise difficult defects on the lateral borders of the digits around and distal to the proximal interphalangeal joint, including those at the fingertip. It provides sensate, glabrous skin. The donor defect is on the same digit and is well hidden, producing an aesthetic and functional reconstruction.

Reconstruction of the pelvic floor and the vagina after total pelvic exenteration using the transverse musculocutaneous gracilis flap.

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Kaartinen, Ilkka S; Vuento, Maarit H; Hyöty, Marja K; Kallio, Jukka; Kuokkanen, Hannu O

2015-01-01

Total pelvic exenteration (TPE) is a rare operation in which the pelvic contents are removed entirely. Several options for pelvic floor and vaginal reconstruction have been described including transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flaps. The transverse musculocutaneous gracilis (TMG) flap has been introduced for breast reconstruction as a free flap. We adopted the pedicled TMG flap for reconstructions after TPE. To the best of our knowledge, this is the first report of this method in the literature. Between November 2011 and February 2014, 12 patients underwent TPE and reconstruction with unilateral (six patients) or bilateral (six patients) pedicled TMG flaps. Five patients underwent vaginal reconstruction with bilateral TMG flaps. We describe the operative procedure and the outcome of the operation in these patients. The total mean operative times for TPE with or without vaginal reconstruction were 467 ± 12 and 386 ± 59 min, respectively. The TMG flaps had enough vascular tissue and mobility for reconstructing the TPE defects. There was distal edge necrosis in one out of 18 flaps, while the rest survived completely. During the follow-up, complete wound healing with no signs of weakening of the pelvic floor was observed in all cases. Soft-tissue reconstructions are needed to reduce complications associated with TPE, to secure the pelvic floor and to reconstruct the vagina in select patients. The TMG flap is a logical flap choice that does not lead to functional deficits, complicate the abdominal ostomies or weaken the abdominal wall. It reduces the length of operation compared to that of abdominal flaps. IV, therapeutic. Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

The Anconeus Muscle Free Flap: Clinical Application to Lesions on the Hand

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Byung-Joon Jeon

2017-09-01

Full Text Available Background It can be difficult to select an appropriate flap for various defects on the hand. Although defects of the hand usually must be covered with a skin flap, some defects require a flap with rich blood supply and adequate additive soft tissue volume. The authors present their experience with the anconeus muscle free flap in the reconstruction of various defects and the release of scar contractures of the hand. Methods Ten patients underwent reconstruction of the finger or release of the first web space using the anconeus muscle free flap from May 1998 to October 2013. Adequate bed preparations with thorough debridement or contracture release were performed. The entire anconeus muscle, located at the elbow superficially, was harvested, with the posterior recurrent interosseous artery as a pedicle. The defects were covered with a uniformly trimmed anconeus muscle free flap. Additional debulking of the flap and skin coverage using a split-thickness skin graft were performed 3 weeks after the first operation. Results The average flap size was 18.7 cm2 (range, 13.5–30 cm2. All flaps survived without significant complications. Vein grafts for overcoming a short pedicle were necessary in 4 cases. Conclusions The anconeus muscle free flap can be considered a reliable reconstructive option for small defects on the hand or contracture release of the web space, because it has relatively consistent anatomy, provides robust blood supply within the same operative field, and leads to no functional loss at the donor site.

Retrograde Tibiopedal Access as a Bail-Out Procedure for Endovascular Intervention Complications

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Ahmed Amro

2016-01-01

Full Text Available Introduction. Retrograde pedal access has been well described in the literature as a secondary approach for limb salvage in critical limb ischemia (CLI patients. In this manuscript we are presenting a case where retrograde tibiopedal access has been used as a bail-out procedure for the management of superficial femoral artery (SFA intervention complications. Procedure/Technique. After development of a perforation while trying to cross the totally occluded mid SFA using the conventional CFA access, we were able to cross the mid SFA lesion after accessing the posterior tibial artery in a retrograde fashion and delivered a self-expanding stent which created a flap that sealed the perforation without the need for covered stent. Conclusion. Retrograde tibiopedal access is a safe and effective approach for delivery of stents from the distal approach and so can be used as a bail-out technique for SFA perforation.

Three-dimensional analysis and classification of arteries in the skin and subcutaneous adipofascial tissue by computer graphics imaging.

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Nakajima, H; Minabe, T; Imanishi, N

1998-09-01

To develop new types of surgical flaps that utilize portions of the skin and subcutaneous tissue (e.g., a thin flap or an adipofascial flap), three-dimensional investigation of the vasculature in the skin and subcutaneous tissue has been anticipated. In the present study, total-body arterial injection and three-dimensional imaging of the arteries by computer graphics were performed. The full-thickness skin and subcutaneous adipofascial tissue samples, which were obtained from fresh human cadavers injected with radio-opaque medium, were divided into three distinct layers. Angiograms of each layer were introduced into a personal computer to construct three-dimensional images. On a computer monitor, each artery was shown color-coded according to the three portions: the deep adipofascial layer, superficial adipofascial layer, and dermis. Three-dimensional computerized images of each artery in the skin and subcutaneous tissue revealed the components of each vascular plexus and permitted their classification into six types. The distribution of types in the body correlated with the tissue mobility of each area. Clinically, appreciation of the three-dimensional structure of the arteries allowed the development of several new kinds of flaps.

Rare Presentation of Left Lower Lobe Pulmonary Artery Dissection

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René Hako

2017-01-01

Full Text Available Background. Pulmonary arterial dissection with chronic pulmonary arterial hypertension as its major cause is a very rare but life-threatening condition. In most cases the main pulmonary trunk is the affected site usually without involvement of its branches. Segmental or lobar pulmonary artery dissection is extremely rare. Case Presentation. We report a unique case of left lower lobe pulmonary artery dissection in a 70-year-old male, with confirmed chronic pulmonary hypertension. To confirm dissection MDCT pulmonary angiography was used. Multiplanar reformation (MPR images in sagittal, coronal, oblique sagittal, and curved projections were generated. This case report presents morphologic CT features of rare chronic left lobar pulmonary artery dissection associated with chronic pulmonary hypertension at a place of localised pulmonary artery calcification. CT pulmonary angiography excluded signs of thromboembolism and potential motion or flow artefacts. Conclusion. To the best of our knowledge, no case of lower lobe pulmonary artery dissection with flap calcification has been reported yet. CT imaging of the chest is a key diagnostic tool that is able to detect an intimal flap and a false lumen within the pulmonary arterial tree and is preferred in differential diagnosis of rare complications of sustained pulmonary arterial hypertension.

Anatomical Basis and Clinical Application of Synovial Flaps in the Wrist and Distal Forearm.

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Colen, David L; Yeh, Jiun-Ting; Colen, Lawrence B

2017-05-01

Neuropathic symptoms after median nerve repair at the wrist or secondary to refractory carpal tunnel syndrome may become debilitating. These symptoms develop because of perineural adhesions, intraneural fibrosis, and fixation of the nerve to the transverse carpal ligament after surgery, and often require neurolysis. Interposition of vascularized soft tissue over the median nerve at the time of neurolysis prevents recurrence of such adhesions. The synovial flap, fashioned from the synovial lining of the flexor tendon sheath, is an ideal tissue for this purpose. Previous authors have described the surgical technique of the synovial flap, but the anatomical basis and design of the flap have not been previously discussed. Twenty fresh cadaver upper extremities were injected with Microfil to analyze the arterial anatomy, flap dimensions, and arc of rotation of the flexor tendon synovium mobilized as a flap suitable for coverage of the median nerve at the wrist. The authors determined that both radial and ulnar-based flaps are clinically useful for providing coverage in the wrist and distal forearm. This flap was used in 18 patients with complicated median nerve lesions in this region. All patients had an uncomplicated postoperative course. Of 13 patients treated for posttraumatic median nerve neuromas, all but two had significant resolution of symptoms. When used as a vascularized flap, the flexor tendon synovium provides adequate protection of the median nerve. Flap dimensions and vascularity of this tissue make it an ideal local flap option when performing reoperative surgery on the median nerve.

PERFORATION OF INFERIOR ALVEOLAR NERVE BY MAXILLARY ARTERY. Perforation of inferior alveolar nerve by maxillary artery

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Prakash B Billakanti

2016-03-01

Full Text Available La fosa infratemporal es un área anatómica clínicamente importante para la administración de agentes anestésicos locales en odontología y cirugía maxilofacial. Fueron estudiadas variaciones en la anatomía del nervio alveolar inferior y la arteria maxilar en la disección infratemporal. Durante la disección rutinaria de la cabeza en el cadáver de un varón adulto, fue observada una variación excepcional en el origen del nervio alveolar inferior y su relación con las estructuras circundantes. El nervio alveolar inferior se originaba en el nervio mandibular por dos raíces y la primera parte de la arteria maxilar estaba incorporada entre ambas. El origen embriológico de esta variación y sus implicaciones clínicas es debatido. Dado que la arteria maxilar transcurría entre las dos raíces del nervio alveolar inferior, y el nervio estaba fijado entre el foramen oval y el foramen mandibular, el atrapamiento vásculo-nervioso pudo causar entume-cimiento o dolor de cabeza e interferir con la inyección de anestésicos locales en la fosa infratemporal.  Variaciones anatómicas en esta región deben ser tenidas en cuenta, especialmente en casos de tratamiento fallido de neuralgia del trigémino. Infratemporal fossa is clinically important anatomical area for the delivery of local anesthetic agents in dentistry and maxillofacial surgery. Variations in the anatomy of the inferior alveolar nerve and maxillary artery were studied in infratemporal dissection. During routine dissection of the head in an adult male cadaver an unusual variation in the origin of the inferior alveolar nerve and its relationship with the surrounding structures was observed. The inferior alveolar nerve originated from the mandibular nerve by two roots and the first part of the maxillary artery was incorporated between them. An embryologic origin of this variation and its clinical implications is discussed. Because the maxillary artery runs between the two roots of

Differentiating perforated from non-perforated appendicitis on contrast-enhanced magnetic resonance imaging

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Rosenbaum, Daniel G.; Kovanlikaya, Arzu; Askin, Gulce; Beneck, Debra M.

2017-01-01

The role of magnetic resonance imaging (MRI) in pediatric appendicitis is increasing; MRI findings predictive of appendiceal perforation have not been specifically evaluated. To assess the performance of MRI in differentiating perforated from non-perforated appendicitis. A retrospective review of pediatric patients undergoing contrast-enhanced MRI and subsequent appendectomy was performed, with surgicopathological confirmation of perforation. Appendiceal diameter and the following 10 MRI findings were assessed: appendiceal restricted diffusion, wall defect, appendicolith, periappendiceal free fluid, remote free fluid, restricted diffusion within free fluid, abscess, peritoneal enhancement, ileocecal wall thickening and ileus. Two-sample t-test and chi-square tests were used to analyze continuous and discrete data, respectively. Sensitivity and specificity for individual MRI findings were calculated and optimal thresholds for measures of accuracy were selected. Seventy-seven patients (mean age: 12.2 years) with appendicitis were included, of whom 22 had perforation. The perforated group had a larger mean appendiceal diameter and mean number of MRI findings than the non-perforated group (12.3 mm vs. 8.6 mm; 5.0 vs. 2.0, respectively). Abscess, wall defect and restricted diffusion within free fluid had the greatest specificity for perforation (1.00, 1.00 and 0.96, respectively) but low sensitivity (0.36, 0.25 and 0.32, respectively). The receiver operator characteristic curve for total number of MRI findings had an area under the curve of 0.92, with an optimal threshold of 3.5. A threshold of any 4 findings had the best ability to accurately discriminate between perforated and non-perforated cases, with a sensitivity of 82% and specificity of 85%. Contrast-enhanced MRI can differentiate perforated from non-perforated appendicitis. The presence of multiple findings increases diagnostic accuracy, with a threshold of any four findings optimally discriminating between

Differentiating perforated from non-perforated appendicitis on contrast-enhanced magnetic resonance imaging.

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Rosenbaum, Daniel G; Askin, Gulce; Beneck, Debra M; Kovanlikaya, Arzu

2017-10-01

The role of magnetic resonance imaging (MRI) in pediatric appendicitis is increasing; MRI findings predictive of appendiceal perforation have not been specifically evaluated. To assess the performance of MRI in differentiating perforated from non-perforated appendicitis. A retrospective review of pediatric patients undergoing contrast-enhanced MRI and subsequent appendectomy was performed, with surgicopathological confirmation of perforation. Appendiceal diameter and the following 10 MRI findings were assessed: appendiceal restricted diffusion, wall defect, appendicolith, periappendiceal free fluid, remote free fluid, restricted diffusion within free fluid, abscess, peritoneal enhancement, ileocecal wall thickening and ileus. Two-sample t-test and chi-square tests were used to analyze continuous and discrete data, respectively. Sensitivity and specificity for individual MRI findings were calculated and optimal thresholds for measures of accuracy were selected. Seventy-seven patients (mean age: 12.2 years) with appendicitis were included, of whom 22 had perforation. The perforated group had a larger mean appendiceal diameter and mean number of MRI findings than the non-perforated group (12.3 mm vs. 8.6 mm; 5.0 vs. 2.0, respectively). Abscess, wall defect and restricted diffusion within free fluid had the greatest specificity for perforation (1.00, 1.00 and 0.96, respectively) but low sensitivity (0.36, 0.25 and 0.32, respectively). The receiver operator characteristic curve for total number of MRI findings had an area under the curve of 0.92, with an optimal threshold of 3.5. A threshold of any 4 findings had the best ability to accurately discriminate between perforated and non-perforated cases, with a sensitivity of 82% and specificity of 85%. Contrast-enhanced MRI can differentiate perforated from non-perforated appendicitis. The presence of multiple findings increases diagnostic accuracy, with a threshold of any four findings optimally discriminating between

Differentiating perforated from non-perforated appendicitis on contrast-enhanced magnetic resonance imaging

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Rosenbaum, Daniel G.; Kovanlikaya, Arzu [New York-Presbyterian Hospital/Weill Cornell Medicine, Division of Pediatric Radiology, New York, NY (United States); Askin, Gulce [Weill Cornell Medical College, Division of Biostatistics and Epidemiology, New York, NY (United States); Beneck, Debra M. [New York-Presbyterian Hospital/Weill Cornell Medicine, Department of Pathology, New York, NY (United States)

2017-10-15

The role of magnetic resonance imaging (MRI) in pediatric appendicitis is increasing; MRI findings predictive of appendiceal perforation have not been specifically evaluated. To assess the performance of MRI in differentiating perforated from non-perforated appendicitis. A retrospective review of pediatric patients undergoing contrast-enhanced MRI and subsequent appendectomy was performed, with surgicopathological confirmation of perforation. Appendiceal diameter and the following 10 MRI findings were assessed: appendiceal restricted diffusion, wall defect, appendicolith, periappendiceal free fluid, remote free fluid, restricted diffusion within free fluid, abscess, peritoneal enhancement, ileocecal wall thickening and ileus. Two-sample t-test and chi-square tests were used to analyze continuous and discrete data, respectively. Sensitivity and specificity for individual MRI findings were calculated and optimal thresholds for measures of accuracy were selected. Seventy-seven patients (mean age: 12.2 years) with appendicitis were included, of whom 22 had perforation. The perforated group had a larger mean appendiceal diameter and mean number of MRI findings than the non-perforated group (12.3 mm vs. 8.6 mm; 5.0 vs. 2.0, respectively). Abscess, wall defect and restricted diffusion within free fluid had the greatest specificity for perforation (1.00, 1.00 and 0.96, respectively) but low sensitivity (0.36, 0.25 and 0.32, respectively). The receiver operator characteristic curve for total number of MRI findings had an area under the curve of 0.92, with an optimal threshold of 3.5. A threshold of any 4 findings had the best ability to accurately discriminate between perforated and non-perforated cases, with a sensitivity of 82% and specificity of 85%. Contrast-enhanced MRI can differentiate perforated from non-perforated appendicitis. The presence of multiple findings increases diagnostic accuracy, with a threshold of any four findings optimally discriminating between

Microsurgical free flap reconstructions of head and neck region in 406 cases: a 13-year experience.

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Gerressen, Marcus; Pastaschek, Claudia Inge; Riediger, Dieter; Hilgers, Ralf-Dieter; Hölzle, Frank; Noroozi, Nelson; Ghassemi, Alireza

2013-03-01

The reconstruction of extended soft tissue and bony defects in the maxillofacial region with microsurgical flaps is considered to be the therapy of first choice. The aim of this retrospective study was to detect different influencing factors concerning flap survival. We examined the data of 406 patient cases (121 female and 285 male cases; mean age, 57 years) undergoing reconstruction with a microsurgical flap in our facility between 1998 and 2010. In these cases 326 soft tissue flaps (radial forearm flap, scapula flap, latissimus dorsi flap, anterolateral thigh flap, lateral arm flap, and jejunum flap) and 80 bony flaps (fibula flap and deep circumflex iliac artery flap) were examined. Evaluated parameters were, among others, the timing of reconstruction, defect localization, and recipient vessels used (external vs internal jugular system), as well as anticoagulative management. We statistically analyzed data by means of a χ(2) test, taking account of the odds ratio with P < .05, which was deemed significant. The overall flap survival rate was approximately 92%, without any gender- or age-specific differences. Primary reconstructions proceeded distinctly more successfully than secondary reconstructions (P < .01). Likewise, the defect localization exerted a significant effect on the survival rate (P = .01), with a more caudal localization affecting flap survival positively. Finally, neither the anticoagulation regimen nor the choice of recipient vein system exercised an influence on the survival rate. Microsurgical tissue transfer is a convenient and reliable method in maxillofacial surgery, provided that one is aware of the determining factors for success. Copyright © 2013 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Iatrogenic injuries of the common femoral artery (CFA) and external iliac artery (EIA) during endograft placement: an underdiagnosed entity.

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Hingorani, Anil P; Ascher, Enrico; Marks, Natalie; Shiferson, Alexander; Patel, Nirav; Gopal, Kapil; Jacob, Theresa

2009-09-01

Early limb occlusions following endovascular treatment of aorto-iliac aneurysmal disease is not uncommon (4%-13%). To assess whether the femoral artery entry site could potentially cause this complication, we prospectively evaluated the ipsilateral common femoral artery (CFA) and distal external iliac artery (EIA) with intraoperative duplex scans (IDS). There were 134 patients with infrarenal nonruptured abdominal aorto-iliac aneurysms treated with endografts since 2002 at our institution. Age ranged from 65 to 89 years (mean: 77 +/- 7 years). Aneuryx (n = 41), Zenith (n = 50), and Excluder (n = 43) endografts were used for repair. All procedures were performed via open exposure of the CFA. Introducer diameter varied from 12 mm to 22 mm. All patients underwent IDS of the CFA and distal EIA after repair of the arteriotomies. In 34 patients (25%), we documented intimal dissections causing severe (>70%) stenoses. Of the 271 arteries that were examined, 38 (14%) had abnormal findings that demanded intervention. These were repaired with flap excision, tacking sutures revision, or patch angioplasty (n = 36). Repeat IDS confirmed the adequacy of the repair. No statistical difference was noted if the site of larger introducer sheath and the incidence of flap formation. In addition, 10 small flaps or plaques were visualized but did not create significant stenosis. No differences were noted in the incidence of positive duplex exams between each type graft (P = .4). No early or late iliac limb occlusions were noted. Follow-up of 94% was obtained. Completion arterial duplex scans are helpful in detecting a substantial number of clinically unsuspected technical defects caused by introducer sheaths. Timely diagnosis and repair of these defects may decrease the incidence of early limb occlusion following endograft placement.

Spontaneous external gallbladder perforation

International Nuclear Information System (INIS)

Noeldge, G.; Wimmer, B.; Kirchner, R.

1981-01-01

Spontaneous perforation of the gallbladder is one complication of cholelithiasis. There is a greater occurence of free perforation in the peritoneal cavity with bilary pertonitis, followed by the perforation into the stomach, small intestine and colon. A single case of the nowadays rare spontaneous perforation in and through the abdominal wall will be reported. Spontaneous gallbladder perforation appears nearly asymptomatic in its clinical course because of absent biliary peritonitis. (orig.) [de

Keystone flaps in coloured skin: Flap technology for the masses?

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Satish P Bhat

2013-01-01

Full Text Available Introduction: Viscoelastic properties of skin in coloured ethnic groups are less favourable compared to Caucasians for executing Keystone flaps. Keystone flaps have so far been evaluated and reported only in Caucasians. The potential of Keystone flaps in a coloured ethnic group is yet unknown. Aim: This article reviews the experience to reconstruct skin defects presenting in a coloured ethnic group, by using Keystone flaps, with a review of existing literature. Design: Uncontrolled case series. Materials and Methods: This retrospective review involves 55 consecutive Keystone flaps used from 2009 to 2012, for skin defects in various locations. Patient demographic data, medical history, co-morbidity, surgical indication, defect features, complications, and clinical outcomes are evaluated and presented. Results: In this population group with Fitzpatrick type 4 and 5 skin, the average patient age was 35.73. Though 60% of flaps (33/55 in the series involved specific risk factors, only two flaps failed. Though seven flaps had complications, sound healing was achieved by suitable intervention giving a success rate of 96.36%. Skin grafts were needed in only four cases. Conclusions: Keystone flaps achieve primary wound healing for a wide spectrum of defects with an acceptable success rate in a coloured skin population with unfavorable biophysical properties. By avoiding conventional local flaps and at times even microsurgical flaps, good aesthetic outcome is achieved without additional skin grafts or extensive operative time. All advantages seen in previous studies were verified. These benefits can be most appreciated in coloured populations, with limited resources and higher proportion of younger patients and unfavorable defects.

Guidewire-induced coronary perforation successfully treated with subcutaneous fat embolisation: A simple technique available to all.

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George, Sudhakar; Cotton, James; Wrigley, Ben

2015-12-01

A 62-year-old man presented with an anterior ST elevation myocardial infarction and underwent primary percutaneous coronary intervention to an occluded diagonal artery. Following stenting, a type III distal guidewire-induced coronary perforation of the diagonal branch was recognized with extravasation of contrast into the pericardial space. Prolonged balloon inflations proximal to the site of the perforation were unsuccessful. Subcutaneous fat was therefore harvested from the patients upper thigh under local anesthetic and embolized through an Export catheter into the distal diagonal vessel, resulting in the immediate cessation of leak through the site of perforation. We discuss the technical aspects of this technique as well as alternative methods of distal embolization and the potential complications that must be considered. © 2015 Wiley Periodicals, Inc.

A New Approach to Objective Evaluation of the Success of Nasal Septum Perforation

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Sinan Ozturk

2014-07-01

Full Text Available Background Perforations in the nasal septum (NSP give rise not only to disintegration of the septum anatomy but also impairment in normal nasal physiology. The successes of these surgical techniques are usually equated to anatomical closure of the perforation. The goal of this study is to evaluate the subjective and objective results of our surgical technique for septal perforation surgery. Methods All NSPs in the six patients were closed by inferior turbinate flap. The Nasal Obstruction Symptom Evaluation (NOSE instrument was used to evaluate the preoperative and postoperative subjective sensation of nasal obstruction. Measurement of preoperative and postoperative nasal airway resistance was performed using active anterior rhinomanometry which is an objective test. Wilcoxson signed rank test and Spearman correlation test were used to analyze correlation between NOSE scores and rhinomanometric measurements. Results The full closure of the septal perforations was noted in 100% of patients. The total NOSE score was 14 preoperatively and one postoperatively. The improvement in NOSE scores was statistically significant (P≤0.002. The mean preoperative total resistance (ResT150 value was 0.13 Pa/cm3s-1, which is below the normal range (0.16-0.31 Pa/cm3s-1, while the mean postoperative ResT150 value was 0.27 Pa/cm3s-1. The correlation between the improvement in NOSE scores and improvements in ResT150 values was statistically significant. Conclusions Surgical approaches should aim to solve both the anatomical and physiological problems of NSP. The application of subjective and objective tests in the postoperative period will help surgeons assess the applied techniques.

Emergency repair of upper extremity large soft tissue and vascular injuries with flow-through anterolateral thigh free flaps.

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Zhan, Yi; Fu, Guo; Zhou, Xiang; He, Bo; Yan, Li-Wei; Zhu, Qing-Tang; Gu, Li-Qiang; Liu, Xiao-Lin; Qi, Jian

2017-12-01

Complex extremity trauma commonly involves both soft tissue and vascular injuries. Traditional two-stage surgical repair may delay rehabilitation and functional recovery, as well as increase the risk of infections. We report a single-stage reconstructive surgical method that repairs soft tissue defects and vascular injuries with flow-through free flaps to improve functional outcomes. Between March 2010 and December 2016 in our hospital, 5 patients with severe upper extremity trauma received single-stage reconstructive surgery, in which a flow-through anterolateral thigh free flap was applied to repair soft tissue defects and vascular injuries simultaneously. Cases of injured artery were reconstructed with the distal trunk of the descending branch of the lateral circumflex femoral artery. A segment of adjacent vein was used if there was a second artery injury. Patients were followed to evaluate their functional recoveries, and received computed tomography angiography examinations to assess peripheral circulation. Two patients had post-operative thumb necrosis; one required amputation, and the other was healed after debridement and abdominal pedicle flap repair. The other 3 patients had no major complications (infection, necrosis) to the recipient or donor sites after surgery. All the patients had achieved satisfactory functional recovery by the end of the follow-up period. Computed tomography angiography showed adequate circulation in the peripheral vessels. The success of these cases shows that one-step reconstructive surgery with flow-through anterolateral thigh free flaps can be a safe and effective treatment option for patients with complex upper extremity trauma with soft tissue defects and vascular injuries. Copyright © 2017. Published by Elsevier Ltd.

Long-term outcome of forearm flee-flap phalloplasty in the treatment of transsexualism.

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Leriche, Albert; Timsit, Marc-Olivier; Morel-Journel, Nicolas; Bouillot, André; Dembele, Diala; Ruffion, Alain

2008-05-01

To assess the long-term outcome of forearm free-flap phalloplasty in transsexuals, as obtaining a satisfying neophallus in female-to-male transsexuals is a surgical challenge. We analysed retrospectively 56 transsexuals who had a phalloplasty using a radial forearm free-flap in our department from 1986 to 2002. The complication rate was assessed by regular examination. Patient satisfaction was evaluated by a questionnaire about cosmetic aspects, sexual life and overall satisfaction. The mean follow up was 110 months; 53 of the 56 patients (95%) currently have a neophallus, after a mean of six surgical procedures. Satisfaction was assessed in 53 patients using a specific questionnaire: 51 (93%) of the patients reported that the phalloplasty allowed them to accord their physical appearance with their feeling of masculinity. There were flap complications in 14 patients (25%); three (5%) flaps were lost, with one each due to early haematoma, cellulitis and late arterial thrombosis. The other 11 flap complications were all transitory, e.g. infection, haematomas and vascular thrombosis. There were prosthesis complications in 11 of 38 patients (29%). Moreover, seven of 19 patients (37%) who had a urethroplasty presented with complex strictures and fistulae that led to perineal urethrostomy. Our study shows that phalloplasty with a forearm free-flap leads to good results in term of flap survival and patient satisfaction. However, there was a high rate of complications. Patients must be clearly informed that the procedure can seldom be achieved in one stage.

THORACO - ABDOMINAL FLAP FOR RESURFACING LARGE POST MASTECTOMY DEFECTS IN LOCALLY ADVANCED CA. BREAST

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Srinivasa Rao

2015-02-01

Full Text Available Covering of large wounds after mastectomy in locally advanced Ca breast with skin that can withstand radiotherapy is a challenge to the surgeon. Here this study we used a local advancement flap from the adjacent area called Thoraco - A bdominal F la p (TA flap for such giant defects. This is based on superficial and lumbar arteries and is thick to with stand consequent RT . MATERIALS AND METHODS: Of the total 107 cases of LABC 32 had post mastectomy defects of larger than 12 cm and could not be closed by simple approximation. Among the 32 cases 17 cases are covered by split thickness skin grafting. 15 cases are covered by TA flap. These cases are assessed for mean operating time, mean blood loss, post - operative stay, flap necrosis and viability of the f lap after radiotherapy. RESULTS: There is minimal extra time or blood loss in these cases . All the flaps healed well except for small edge necrosis in 4 cases. In all the patients we could start radiotherapy in the fourth week of surgery and all the flaps withstood RT well. After further evaluation probably this can be recommended as procedure for giant post mastectomy defects particularly for those who require RT early

Salmonella intestinal perforation: (27 perforations in one patient, 14 perforations in another Are the goal posts changing?

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Adeniran J

2005-01-01

Full Text Available The pathology of salmonellosis after a faeco-oral transmission was first clearly described by Jenner in 1850. Over the years, the pathological manifestations in different tissues of the body have been described. The ileum is however mostly involved leading to enlarged Peyer′s patches, ulceration, and sometimes bleeding and perforation. Efforts at control have largely been improvement in public water supply, safe disposal of waste, and general public health measures. Despite these measures, intestinal perforation from salmonellosis remains the commonest cause of emergency operation in children above 3 years. The incidence continues to rise, so also the mortality, despite new antibiotics and improvement in facilities in the hospitals. Even more disturbing is that we now see more perforations per patient, and more involvement of the colon. Three recently managed patients with multiple ileal/colonic perforations were reviewed. Presenting problems, delay in referral, choice of antibiotics and postoperative complications were noted. One patient had 27 perforations and another 14 perforations. Both survived. Is salmonella changing? Are our patients changing? Is the environment changing? Are the goal posts changing? This article details our recent experience with this dreadful disease, reviews the new literature and makes suggestions for the way forwards.

Head and neck reconstruction with pedicled flaps in the free flap era.

Science.gov (United States)

Mahieu, R; Colletti, G; Bonomo, P; Parrinello, G; Iavarone, A; Dolivet, G; Livi, L; Deganello, A

2016-12-01

Nowadays, the transposition of microvascular free flaps is the most popular method for management of head and neck defects. However, not all patients are suitable candidates for free flap reconstruction. In addition, not every defect requires a free flap transfer to achieve good functional results. The aim of this study was to assess whether pedicled flap reconstruction of head and neck defects is inferior to microvascular free flap reconstruction in terms of complications, functionality and prognosis. The records of consecutive patients who underwent free flap or pedicled flap reconstruction after head and neck cancer ablation from 2006 to 2015, from a single surgeon, in the AOUC Hospital, Florence Italy were analysed. A total of 93 patients, the majority with oral cancer (n = 59), were included, of which 64 were pedicled flap reconstructions (69%). The results showed no significant differences in terms of functional outcome, flap necrosis and complications in each type of reconstruction. Multivariate regression analysis of flap necrosis and functional impairments showed no associated factors. Multivariate regression analysis of complicated flap healing showed that only comorbidities remained an explaining factor (p = 0.019). Survival analysis and proportional hazard regression analysis regarding cancer relapse or distant metastasis, showed no significant differences in prognosis of patients concerning both types of reconstruction. In this retrospective, non-randomised study cohort, pedicled flaps were not significantly inferior to free flaps for reconstruction of head and neck defects, considering functionality, complications and prognosis. © Copyright by Società Italiana di Otorinolaringologia e Chirurgia Cervico-Facciale, Rome, Italy.

RECONSTRUCTION OF POST ELECTRIC BURN DEFECTS OF UPPER LIMB WITH DIFFERENT FLAPS

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Satyajit

2015-08-01

Full Text Available INTRODUCTION: P ost electric burn defects are difficult to manage due to deep injury involving all the structures up to bony level. A good vascularized flap is required to resurface the defect for preventing the complication and for reconstruction of involved structures. AIM: Resurfacing the post electric burn defect with different flaps according to need of the defect. MATERIAL AND METHOD: All patients of electric burn hand and fore arm defect admitted to burn, p lastic and reconstructi ve department of SCB Medical College &hospital, Cuttack between January 2012 to December 2012 were included in the study. During this period the patients were followed up at weekly interval for first 2 month, then at 1 monthly interv al for next 6 - 8 month. OBSERVATION: Out of 40 cases of post electric burn forearm and hand reconstruction, 10 cases underwent groin flap cover, 6 cases underwent abdominal flap cover, 5 cases underwent cross finger flap cover 5 cases underwent free antero lateral thigh flap cover, 4 cases underwent free latissimus dorsi flap cover, 5 cases underwent first dorsal metacarpal artery flap cover, 5 cases reverse radial forearm flap cover. All the defects were resurfaced successfully with flaps. Four had marginal necrosis and six had wound infection. Eventually all flaps settled well without further intervention. Due to involvement of all important tendons & nerves, functional outcome is guarded. DISCUSSION: Hand and forearm are most commonly and most severely aff ected in electric burn injury because they are mostly first part of body to come in contact with electric circuit. Even though at initial part the injury appears to be superficial, deepe r structures like bone, tendon and neurovascular bundles are affected requiring flap cover for future reconstruction of these structures to get functional and sensate hand. CONCLUSION: Reconstruction of post electric burn defect of distal forearm and hand represents great challenge due to

Investigation on the Acoustic Absorption of Flexible Micro-Perforated Panel with Ultra-Micro Perforations

Science.gov (United States)

Li, Guoxin; Tang, Xiaoning; Zhang, Xiaoxiao; Qian, Y. J.; Kong, Deyi

2017-11-01

Flexible micro-perforated panel has unique advantages in noise reduction due to its good flexibility compared with traditional rigid micro-perforated panel. In this paper, flexible micro-perforated panel was prepared by computer numerical control (CNC) milling machine. Three kinds of plastics including polyvinylchloride (PVC), polyethylene terephthalate (PET), and polyimide (PI) were taken as the matrix materials to prepare flexible micro-perforated panel. It has been found that flexible micro-perforated panel made of PET possessing good porosity and proper density, elastic modulus and poisson ratio exhibited the best acoustic absorption properties. The effects of various structural parameters including perforation diameter, perforation ratio, thickness and air gap have also been investigated, which would be helpful to the optimization of acoustic absorption properties.

Drenaje suplementario del sistema venoso superficial en colgajos pediculados Supplementary drainage of superficial venous system in pedicled flaps

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A. Fernández García

2012-06-01

Full Text Available Los colgajos pediculados pueden sufrir edema y congestión debido a que su drenaje a trevés del sistema venoso superfical es imposible y el flujo hacia el sistema profundo a nivel del pedículo es precario. Esta situación suele evolucionar hacia la necrosis parcial o la pérdida total del colgajo en pocas horas. La apertura del sistema venoso superficial permite el drenaje adecuado de los tejidos transferidos y evita estas complicaciones. Este artículo analiza el papel de las anastomosis microquirúrgicas en el sistema venoso superficial de los colgajos pediculados. Esta técnica permite comunicar el sistema venoso superfical de los tejidos transferidos con el sistema venoso superficial del territorio que rodea al defecto. Presentamos los resultados obtenidos con esta técnica en colgajos de perforante en hélice, colgajos miocutáneos, colgajos neurocutáneos y colgajos fasciograsos volteados.The pedicled flaps can suffer edema and congestion due to the impossibility of drainage toward the superficial venous system and the precarious flow via the deep system at the level of the pedicle. The evolution of this situation is usually partial necrosis or total loss of the flap in a few hours. The opening of the venous superficial system achieves an appropriate drainage of the transfered tissues and avoids these complications. In this article we analyze the role of the microsurgical anastomosis at the level of the superficial venous system of pedicled flaps. This technique allows to communicate the superficial venous system of the transfered tissues with the superficial venous system of the territory around the defect. We report the results with this method in propeller perforator flaps, miocutaneous flaps, neurocutaneous flaps and adipofascial turn over flaps.

[Transposition of the cephalic vein in free flap breast reconstruction: Technical note].

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Silhol, T; Suffee, T; Hivelin, M; Lantieri, L

2018-02-01

Free flaps have become a reliable practice for breast reconstruction. However, the venous congestion is still the most frequent reason of flap failure. It is due to bad quality of the internal mammary veins, a preferential superficial venous outflow of the flap or due to venous thrombosis. The transposition of the cephalic vein could useful in some cases. We describe the surgical technique and suggest an intraoperative algorithm. Seventeen patients (15 DIEP and 2 PAP) were included. Twenty nine point four percent had an unusable internal mammary vein, 23.5% a preferential superficial venous outflow and 47.1% a venous thrombosis. The length of the cephalic vein dissected varied from 15 to 25cm. The mean time of dissection was 39min. There was no flap failure after cephalic vein transposition. The sequelae were one or two scars on the arm without any functional morbidity. The transposition of the cephalic vein is a reliable, less morbid alternative in case of bad quality internal mammary vein with a good quality internal mammary artery, in case of an additional venous outflow necessity or in case of venous thrombosis. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

A novel route for placing free flap pedicle from a palatal defect

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Rajeev B Ahuja

2014-01-01

Full Text Available One of the better options available to repair a large palatal defect is by employing a free flap. Almost all the times such free flaps are plumbed to facial vessels. The greatest challenge in such cases is the placement of the pedicle from palatal shelf to recipient vessels because there is no direct route available. As majority of large palatal fistulae are encountered in operated cleft palates there is a possibility of routing the pedicle through a cleft in the maxillary arch or via pyriform aperture. When such a possibility doesn′t exist the pedicle is routed behind the maxillary arch. We describe a novel technique of pedicle placement through a maxillary antrostomy, in this case report, where a large palatal fistula in a 16 year old boy was repaired employing a free radial artery forearm flap. The direct route provided by maxillary antrostomy is considered the most expeditious of all possibilities mentioned above.

Pedicle Anterolateral Thigh Flap Reconstruction after Pelvic Tumor Resection: A Case Report

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Robert M. Whitfield

2010-01-01

Full Text Available A 47-year-old female with a locally advanced urologic malignancy previously managed with resection, diversion, and postoperative radiation therapy presented for management of her recurrent cancer that had eroded through the soft tissues of the left inner thigh and vulva. On all staging studies the tumor involved the left common femoral artery, and vein, both above and below the inguinal ligament. The difficulty with such tumors is the availability of tissue to reconstruct the defect. The patient had a history of deep venous thrombosis in the femoral venous system. A local flap was the most logical type of reconstruction. The patient had a right lower quadrant ureterostomy with a large parastomal hernia which further limited the local flap options. An anterolateral thigh flap from the opposite thigh was used to reconstruct the soft tissue deficit in this patient. This resurfaced the defect and provided coverage for the vascular reconstruction.

Usage of a rotational flap for coverage of a large central forehead defect

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El-Sabbagh, Ahmed Hassan

2017-02-01

Full Text Available Background: The forehead is a donor site for facial reconstruction but has no generous donor site for its coverage. All options of the reconstructive ladder can be used. A large rotation flap was used to reconstruct a big central forehead defect following failed previous repair in an elderly diabetic patient after a motor car accident. Case presentation: A 64-year-old diabetic man presented with an extensive central forehead defect after failed previous repair following a motor car accident. Coverage of the defect was performed using a flap based around the ear on one side in a rotation movement. An accepted functional and esthetic result was achieved after 3 months of Conclusion: A rotation flap based on arteries around the ear can be used for coverage of a difficult lesion in the central forehead. Level of evidence: Level V, therapeutic study

Traumatic Hemipelvectomy with Free Gluteus Maximus Fillet Flap Covers: A Case Report

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WI Faisham

2012-07-01

Full Text Available threatening injury. We report a case of a 16-year-old boy involved in a traffic accident who presented with an almost circumferential pelvic wound with wide diastasis of the right sacroiliac joint and symphysis pubis. The injury was associated with complete avulsion of external and internal iliac vessels as well as the femoral and sciatic nerves. He also had ipsilateral open comminuted fractures of the femur and tibia. Emergency debridement and completion of amputation with preservation of the posterior gluteal flap and primary anastomosis of the inferior gluteal vessels to the internal iliac artery stump were performed. A free fillet flap was used to close the massive exposed area.

Differentiation of Acute Perforated from Non-Perforated Appendicitis: Usefulness of High-Resolution Ultrasonography

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Choi, Gyu Chang [Dept. of Radiology, Gumi Hospital, Soonchunhyang University College of Medicine, Gumi (Korea, Republic of)

2011-07-15

To evaluate the usefulness of high-resolution ultrasonography (US) for the differentiation of acute perforated appendicitis from non-perforated appendicitis. The high-resolution US features in 96 patients (49 males, 47 females; mean age, 33.8 years; age range, 4-80 years) with pathologically proven acute appendicitis were evaluated. The following US findings were evaluated for differentiation of acute perforated appendicitis from non-perforated appendicitis: circumferential loss of the echogenic submucosal layer, periappendiceal fluid collection, disruption of the serosal layer, asymmetrical wall thickening, maximum overall diameter > 10.5 mm, and the presence of appendicoliths. The sensitivity and specificity of the US features in the diagnosis of acute perforated appendicitis were calculated. All of the US findings, except for appendicoliths, were significantly more common in the acute perforated appendicitis group (p < 0.001). The sensitivity of circumferential loss of the echogenic submucosal layer, periappendiceal fluid collection, disruption of the serosal layer, asymmetrical wall thickening, maximum overall diameter > 10.5 mm, and the presence of appendicoliths was 85.4, 73.2, 68.3, 70.7, 80.5, and 36.6%, respectively, while the specificity was 65.5, 89.1, 96.4, 98.2, 81.8, and 80.0%, respectively. High-resolution US was found to be useful for differentiating acute perforated appendicitis from non-perforated appendicitis.

Nontraumatic terminal ileal perforation

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Wani Rauf A

2006-03-01

Full Text Available Abstract Background There is still confusion and controversy over the diagnosis and optimal surgical treatment of non traumatic terminal ileal perforation-a cause of obscure peritonitis. Methods This study was a prospective study aimed at evaluating the clinical profile, etiology and optimal surgical management of patients with nontraumatic terminal ileal perforation. Results There were 79 cases of nontraumatic terminal ileal perforation; the causes for perforation were enteric fever(62%, nonspecific inflammation(26%, obstruction(6%, tuberculosis(4% and radiation enteritis (1%. Simple closure of the perforation (49% and end to side ileotransverse anastomosis(42% were the mainstay of the surgical management. Conclusion Terminal ileal perforation should be suspected in all cases of peritonitis especially in developing countries and surgical treatment should be optimized taking various accounts like etiology, delay in surgery and operative findings into consideration to reduce the incidence of deadly complications like fecal fistula.

Applied anatomy of the submental island flap and its clinical application in the repair of defects following hypopharyngeal carcinoma resection

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Xi Chen

2015-09-01

Full Text Available Objective: To explore the feasibility of the submental island flap in the repair of hypopharyngeal defects. Methods: We collected wet specimens of fresh cadaveric heads from the Han Chinese adult population for applied anatomy of the submental island flap, and followed five patients with pyriform sinus carcinoma after reconstruction surgery using submental island flaps. Results: We found that the average length and width of the submental island flaps were (65.20 ± 11.69 mm and (46.70 ± 6.59 mm, respectively. The skin flap in all five patients survived after surgery, and tracheal tubes and gastric tubes were removed 7–36 days after surgery. Patients were followed up for 24–42 months, pharyngeal flaps grew well, and speech and swallowing functions were satisfactory. Conclusion: The submental island flap is a preferred material for the repair of hypopharyngeal defects after hypopharyngeal carcinoma resection, because of good blood supply, easy harvesting, and high survival rate. Keywords: Submental island flap, Submental artery, Submental vein, Hypopharyngeal neoplasms, Reconstructive surgical procedures

Comparing the donor-site morbidity using DIEP, SIEA or MS-TRAM flaps for breast reconstructive surgery

DEFF Research Database (Denmark)

Egeberg, Alexander; Rasmussen, Mads Kløvgaard; Sørensen, Jens Ahm

2012-01-01

Countless studies have compared the use of autologous tissue for breast reconstruction; however, rates of donor-site morbidity differ greatly. This study examined the donor-site morbidity of superficial inferior epigastric artery (SIEA), deep inferior epigastric perforator (DIEP) and muscle-spari...

Direct Open Venous Drainage: An Alternative Choice for Flap Congestion Salvage.

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Park, Su Han; Choi, Woo Young; Son, Kyung Min; Cheon, Ji Seon; Yang, Jeong Yeol

2015-12-01

In this report, we present a scalp defect reconstruction with lateral arm free flap. We highlight the difficulty in obtaining a recipient vein and the venous drainage managed through an open end of the donor vein. A 52-year-old woman presented with a pressure sore on the left scalp. A lateral arm free flap was transferred to cover this 8×6 cm defect. The arterial anastomosis was successful, but no recipient vein could be identified within the wound bed. Instead, we used a donor venous end for the direct open venous drainage. In order to keep this exposed venous end patent, we applied heparin-soaked gauze dressing to the wound. Also, the vein end was mechanically dilated and irrigated with heparin solution at two hour intervals. Along with fluid management and blood transfusion, this management was continued for the five days after the operation. The flap survived well without any complication. Through this case, we were able to demonstrate that venous congestion can be avoided by drainage of the venous blood through an open vessel without the use of leeches.

Ileal perforation caused by the ingestion of a micro battery in a dog

International Nuclear Information System (INIS)

Mikawa, K.; Mikawa, M.; Shii, H.

2006-01-01

A 9-month old 3.2 kg of body weight, male Chihuahua was presented with a history of the intermittent vomiting for two days. Abdominal radiograph showed a foreign body in abdominal cavity which was suggested to be a micro battery in small intestine. Although the dog was treated symptomatically for two days, physical condition of the patient worsened, therefore exploratory laparotomy was performed. A large adhesive lesion involved the perforated ileum and large intestines, was found. A micro battery was stuck in the ileum resulting in a intestinal perforation. A whole of the small intestine was resected because of the cranial mesenteric artery damage during separating the adhesion. The dog lost body weight gradually and died 158 days after first admission of short bowel syndrome

Successful surgical repair of impending rupture of a pseudoaneurysm of the brachiocephalic artery with prior reconstruction of the carotid artery

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Miyahara, Ken; Maeda, Masanobu; Sakai, Yoshimasa; Sakurai, Hajime; Murayama, Hiroomi; Hasegawa, Hiroki [Social Insurance Chukyo Hospital, Nagoya (Japan)

2003-01-01

We report the successful repair of impending rupture of a pseudoaneurysm of the brachiocephalic artery (BCA) in a 70-year-old man. He had undergone a mediastinal tumor resection through a median sternotomy in 1995. Pathological examination revealed non-Hodgkin's lymphoma. Two years later, he underwent radiation therapy of 65 Gray for metastasis to the supraclavicular lymph nodes. On January 18, 2000, plastic surgeons planned to perform a pectoralis major musculocutaneous flap to repair a radiation skin ulcer. During the operation, the BCA was lacerated, possibly in an area of radiation tissue damage. We performed a prosthetic graft (10-mm Gelseal) replacement of the BCA. The right subclavian artery had to be ligated. Postoperative digital subtraction angiography (DSA) showed excellent reconstruction of the artery. Magnetic resonance angiography of the brain showed a deficit in the anterior communicating artery and stenosis of the posterior communicating artery, which indicated that the reconstruction procedure was reasonable. Seven months later, on August 18, 2000, the patient was transferred to our hospital because of swelling of the right neck and oozing from the previous cutaneous wound. CT scan and DSA demonstrated the presence of a pseudoaneurysm of the proximal anastomosis site, which required emergency surgery. Before this third sternotomy, a saphenous vein graft was interposed between both external carotid arteries. Removal of the prosthetic graft and resection of the pseudoaneurysm were performed under mild hypothermia and cardiopulmonary bypass with left common carotid arterial perfusion. Then, the wound was closed completely using a left pectoralis major musculocutaneous flap. The postoperative course was uneventful and DSA showed good patency of the graft and intracranial arteries. The patient was discharged without neurological complications. We conclude that prior reconstruction of the carotid artery is a safe and effective procedure for patients

Successful surgical repair of impending rupture of a pseudoaneurysm of the brachiocephalic artery with prior reconstruction of the carotid artery

International Nuclear Information System (INIS)

Miyahara, Ken; Maeda, Masanobu; Sakai, Yoshimasa; Sakurai, Hajime; Murayama, Hiroomi; Hasegawa, Hiroki

2003-01-01

We report the successful repair of impending rupture of a pseudoaneurysm of the brachiocephalic artery (BCA) in a 70-year-old man. He had undergone a mediastinal tumor resection through a median sternotomy in 1995. Pathological examination revealed non-Hodgkin's lymphoma. Two years later, he underwent radiation therapy of 65 Gray for metastasis to the supraclavicular lymph nodes. On January 18, 2000, plastic surgeons planned to perform a pectoralis major musculocutaneous flap to repair a radiation skin ulcer. During the operation, the BCA was lacerated, possibly in an area of radiation tissue damage. We performed a prosthetic graft (10-mm Gelseal) replacement of the BCA. The right subclavian artery had to be ligated. Postoperative digital subtraction angiography (DSA) showed excellent reconstruction of the artery. Magnetic resonance angiography of the brain showed a deficit in the anterior communicating artery and stenosis of the posterior communicating artery, which indicated that the reconstruction procedure was reasonable. Seven months later, on August 18, 2000, the patient was transferred to our hospital because of swelling of the right neck and oozing from the previous cutaneous wound. CT scan and DSA demonstrated the presence of a pseudoaneurysm of the proximal anastomosis site, which required emergency surgery. Before this third sternotomy, a saphenous vein graft was interposed between both external carotid arteries. Removal of the prosthetic graft and resection of the pseudoaneurysm were performed under mild hypothermia and cardiopulmonary bypass with left common carotid arterial perfusion. Then, the wound was closed completely using a left pectoralis major musculocutaneous flap. The postoperative course was uneventful and DSA showed good patency of the graft and intracranial arteries. The patient was discharged without neurological complications. We conclude that prior reconstruction of the carotid artery is a safe and effective procedure for patients with

Blowing Flap Experiment: PIV Measurements

Science.gov (United States)

Hutcheson, Florence V.; Stead, Daniel J.; Bremmer, David M.

2004-01-01

PIV measurements of the flow in the region of a flap side edge are presented for several flap configurations. The test model is a NACA 63(sub 2)-215 Hicks Mod-B main element airfoil with a half-span Fowler flap. Air is blown from small slots located along the flap side edge on either the top, bottom or side surfaces. The test set up is described and flow measurements for a baseline and three blowing flap configurations are presented. The effects that the flap tip jets have on the structure of the flap side edge flow are discussed for each of the flap configurations tested. The results indicate that blowing air from a slot located along the top surface of the flap greatly weakened the top vortex system and pushed it further off the top surface. Blowing from the bottom flap surface kept the strong side vortex further outboard while blowing from the side surface only strengthened the flap vortex system. It is concluded that blowing from the top or bottom surfaces of the flap may lead to a reduction of flap side edge noise.

Experimental Study of Wake / Flap Interaction Noise and the Reduction of Flap Side Edge Noise

Science.gov (United States)

Hutcheson, Florence V.; Stead, Daniel J.; Plassman, Gerald E.

2016-01-01

The effects of the interaction of a wake with a half-span flap on radiated noise are examined. The incident wake is generated by bars of various widths and lengths or by a simplified landing gear model. Single microphone and phased array measurements are used to isolate the effects of the wake interaction on the noise radiating from the flap side edge and flap cove regions. The effects on noise of the wake generator's geometry and relative placement with respect to the flap are assessed. Placement of the wake generators upstream of the flap side edge is shown to lead to the reduction of flap side edge noise by introducing a velocity deficit and likely altering the instabilities in the flap side edge vortex system. Significant reduction in flap side edge noise is achieved with a bar positioned directly upstream of the flap side edge. The noise reduction benefit is seen to improve with increased bar width, length and proximity to the flap edge. Positioning of the landing gear model upstream of the flap side edge also leads to decreased flap side edge noise. In addition, flap cove noise levels are significantly lower than when the landing gear is positioned upstream of the flap mid-span. The impact of the local flow velocity on the noise radiating directly from the landing gear is discussed. The effects of the landing gear side-braces on flap side edge, flap cove and landing gear noise are shown.

Reactive perforating collagenosis

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Yadav Mukesh

2009-01-01

Full Text Available Reactive perforating collagenosis is a rare cutaneous disorder of unknown etiology. We hereby describe a case of acquired reactive perforating collagenosis in a patient of diabetes and chronic renal failure.

Patient-Reported Assessment of Functional Gait Outcomes following Superior Gluteal Artery Perforator Reconstruction

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Kevin Hur, BA

2013-08-01

Conclusions: SGAP flap surgery causes no statistically significant differences in overall LEFS. However, SGAP patients did report donor-site morbidity with decreased ability to perform certain activities and increased fatigue and pain in the longer follow-up period. We feel that patients should be educated regarding gait issues and undergo physical therapy during the early postoperative period.

Facial contour deformity correction with microvascular flaps based on the 3-dimentional template and facial moulage

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Dinesh Kadam

2013-01-01

Full Text Available Introduction: Facial contour deformities presents with varied aetiology and degrees severity. Accurate assessment, selecting a suitable tissue and sculpturing it to fill the defect is challenging and largely subjective. Objective assessment with imaging and software is not always feasible and preparing a template is complicated. A three-dimensional (3D wax template pre-fabricated over the facial moulage aids surgeons to fulfil these tasks. Severe deformities demand a stable vascular tissue for an acceptable outcome. Materials and Methods: We present review of eight consecutive patients who underwent augmentation of facial contour defects with free flaps between June 2005 and January 2011. De-epithelialised free anterolateral thigh (ALT flap in three, radial artery forearm flap and fibula osteocutaneous flap in two each and groin flap was used in one patient. A 3D wax template was fabricated by augmenting the deformity on facial moulage. It was utilised to select the flap, to determine the exact dimensions and to sculpture intraoperatively. Ancillary procedures such as genioplasty, rhinoplasty and coloboma correction were performed. Results: The average age at the presentation was 25 years and average disease free interval was 5.5 years and all flaps survived. Mean follow-up period was 21.75 months. The correction was aesthetically acceptable and was maintained without any recurrence or atrophy. Conclusion: The 3D wax template on facial moulage is simple, inexpensive and precise objective tool. It provides accurate guide for the planning and execution of the flap reconstruction. The selection of the flap is based on the type and extent of the defect. Superiority of vascularised free tissue is well-known and the ALT flap offers a versatile option for correcting varying degrees of the deformities. Ancillary procedures improve the overall aesthetic outcomes and minor flap touch-up procedures are generally required.

[Microsurgical anatomy importance of A1-anterior communicating artery complex].

Science.gov (United States)

Monroy-Sosa, Alejandro; Pérez-Cruz, Julio César; Reyes-Soto, Gervith; Delgado-Hernández, Carlos; Macías-Duvignau, Mario Alberto; Delgado-Reyes, Luis

2013-01-01

The anterior cerebral artery originates from the bifurcation of the internal carotid artery lateral to the optic chiasm, then joins with its contralateral counterpart via the anterior communicating artery. A1-anterior communicating artery complex is the most frequent anatomical variants and is the major site of aneurysms between 30 to 37%. Know the anatomy microsurgical, variants anatomical and importance of complex precommunicating segment-artery anterior communicating in surgery neurological of the pathology vascular, mainly aneurysms, in Mexican population. The study was performed in 30 brains injected. Microanatomy was studied (length and diameter) of A1-anterior communicating artery complex and its variants. 60 segments A1, the average length of left side was 11.35 mm and 11.84 mm was right. The average diameter of left was 1.67 mm and the right was 1.64 mm. The average number of perforators on the left side was 7.9 and the right side was 7.5. Anterior communicating artery was found in 29 brains of the optic chiasm, its course depended on the length of the A1 segment. The average length of the segment was 2.84 mm, the average diameter was 1.41 mm and the average number of perforators was 3.27. A1-anterior communicating artery complex variants were found in 18 (60%) and the presence of two blister-like aneurysms. It is necessary to understand the A1-anterior communicating artery complex microanatomy of its variants to have a three-dimensional vision during aneurysm surgery.

Spectrum of Perforation Peritonitis

Science.gov (United States)

Chakma, Sujit M.; Singh, Rahul L.; Parmekar, Mahadev V.; Singh, K.H. Gojen; Kapa, Buru; Sharatchandra, K.H.; Longkumer, Amenla T.; Rudrappa, Santhosh

2013-01-01

Introduction: Perforation peritonitis mostly results from the perforation of a diseased viscus. Other causes of perforation include abdominal trauma, ingestion of sharp foreign body and iatrogenic perforation. The diagnosis is mainly based on clinical grounds. Plain abdominal X-rays (erect) may reveal dilated and oedematous intestines with pneumoperitoneum. Ultrasound and CT scan may diagnose up to 72% and 82% of perforation respectively. The present study was carried out to study various etiological factors, modes of clinical presentation, morbidity and mortality patterns of perforation peritonitis presented in the RIMS hospital, Imphal, India. Material and Methods: The study was conducted from September 2010 to August 2012 on 490 cases of perforation peritonitis admitted and treated in the Department of Surgery. Initial diagnosis was made on the basis of detailed history, clinical examination and presence of pneumoperitoneum on erect abdominal X-ray. Results: A total of 490 patients of perforation peritonitis were included in the study, with mean age of 48.28 years. 54.29% patients were below 50 years and 45.71% patients were above 50 years. There were 54.29% male patients and 45.71% female patients. Only 30% patients presented within 24 hours of onset of symptoms, 31.43% patients presented between 24 to 72 hours and 38.57% patients presented 72 hours after the onset of symptoms. Mean duration of presentation was 54.7 hours. Overall 469 patients were treated surgically and 21 patients were managed conservatively. Overall morbidity and mortality recorded in this study were 52.24% and 10% respectively. PMID:24392388

Reversal of end-stage renal disease after aortic dissection using renal artery stent: a case report

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Parikh Chirag R

2004-05-01

Full Text Available Abstract Background Medical management is the conventional treatment for Stanford Type B aortic dissections as surgery is associated with significant morbidity and mortality. The advent of endovascular interventional techniques has revived interest in treating end-organ complications of Type B aortic dissection. We describe a patient who benefited from endovascular repair of renal artery stenosis caused by a dissection flap, which resulted in reversal of his end-stage renal disease (ESRD. Case presentation A 69 y/o male with a Type B aortic dissection diagnosed two months earlier was found to have a serum creatinine of 15.2 mg/dL (1343.7 μmol/L on routine visit to his primary care physician. An MRA demonstrated a rightward spiraling aortic dissection flap involving the origins of the celiac artery, superior mesenteric artery, and both renal arteries. The right renal artery arose from the false lumen with lack of blood flow to the right kidney. The left renal artery arose from the true lumen, but an intimal dissection flap appeared to be causing an intermittent stenosis of the left renal artery with compromised blood flow to the left kidney. Endovascular reconstruction with of the left renal artery with stent placement was performed. Hemodialysis was successfully discontinued six weeks after stent placement. Conclusion Percutaneous intervention provides a promising alternative for patients with Type B aortic dissections when medical treatment will not improve the likelihood of meaningful recovery and surgery entails too great a risk. Nephrologists should therefore be aggressive in the workup of ischemic renal failure associated with aortic dissection as percutaneous intervention may reverse the effects of renal failure in this population.

Perforations during contrast enema

International Nuclear Information System (INIS)

Vogel, H.; Steinkamp, U.; Grabbe, E.; Allgemeines Krankenhaus Ochsenzoll, Hamburg

1983-01-01

During contrast enema, perforation into the retroperitoneal space can be differentiated from perforation into the peritoneum and perforation into the intestinal wall associated with formation of barium granulomas or submucosal spreading of the contrast medium. Other special forms are perforation with contrast medium embolism of diverticula; of the processus vermiformis; penetration of contrast medium into fistulous systems and from the operated areas. Risk factors are: balloon catheter, intestinal tubes with a hard tip, preternatural anus, excessive enema pressure, contrast medium additions, preceding manipulations, intestinal diseases, advanced age and delegation of manipulations to assistants and unskilled staff. Children are particularly at risk. (orig.) [de

Dolichoectasia and dissection of the intracranial vertebrobasilar artery

International Nuclear Information System (INIS)

Stoyanov, D.; Boshnjakovich, P.; Zivkovic, M.

2001-01-01

The purpose is to determine the clinical neuro-radiological features of dolichoectatic intracranial vertebrobasilar artery dissection. The clinical features native and post-contrast CT scans of five patients (4 men and 1 woman; age ranged from 25 to 68 years) with dolichoectatic intracranial vertebrobasilar artery dissection were analysed retrospectively for a period of 3 years. Diagnosis was confirmed by vertebral angiography. Clinical symptoms due to ischemic cerebellar and/or brain stem lesion were present in 4 patient, 2 of them had Wallenberg syndrome. Occipital and/or posterior neck pains were found in 4 patients. Subarachnoid hemorrhage was shown in 1 patient. The incidence of previously documented hypertension was 60% (3 of 5 patients). The prognosis was relatively good. Dolichoectasia was detected by native, post-contrast CT scans and reconstructions in all patients. Intimal flap was visualized with post contrast CT scans in 1 patients. Extension of the basilar artery tip into the third ventricle was detected in 3 patients. Ischemic low-density lesions were detected in 3 patients and subarachnoid hemorrhage in 1 patient. Vertebral angiography disclosed elongation and dilatation of the vertebral and basilar arteries, double lumen sign - the presence of a true and false lumen and an intimal flap, double density and retention of contrast medium. Ischemic symptoms and head and/or neck pain were the most common clinical findings. The double lumen sign considered as the only pathognomonic angiographic finding of arterial dissection, was found in all patients. Angiography is still considered the 'gold standard' for diagnosis of intracranial vertebrobasilar artery dissection. (author)

Hemi-Intravascular Stenting for Supermicrosurgical Anastomosis