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VY advancement flap: The flap is raised based on a perforator and advanced forward. Additional advancement can be obtained by isolation and dissection of the perforator. The donor site can easily be closed linearly.
Source publication
Lower extremity soft tissue defects frequently result from high-energy trauma or oncological resection. The lack of suitable muscle flap options for the distal leg and foot makes defects in these locations especially challenging to reconstruct and free tissue transfer is commonly used. Another option that has become more popular in the past two dec...
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Citations
... [25][26][27] During elevation, preservation of the subdermal plexus is essential for the viability of these flaps. 17,28 A handheld Doppler should be used to confirm perforators and minimize the risk of necrosis. The ratio of the flap base can extend upwards toward 1.5:1 and 3:1 for larger defects, as long as blood supply is confirmed to the extended area. ...
... A key advantage of local RpFs in cases of plantar defects allows for locoregional replacement of similar histological tissue, which was supported by our significantly greater use of RpFs for plantar wounds. 23,28 Our study saw RpFs also had higher rates of dehiscence. Considering that they were most often used for plantar defects, the dehiscence was likely secondary due to excessive tension on closure, insufficient distal perforators, or poor adherence to offloading protocols postoperatively. ...
Background
The aim of this study was to compare the use of pedicled local (PFs) versus random pattern flaps (RpFs) in foot and ankle reconstruction in patients with chronic, nonhealing wounds.
Methods
A single-center, retrospective review of 204 patients with 118 PFs and 86 RpFs was performed. The primary outcome included rates of limb salvage.
Results
PFs were used more often in the hindfoot (44.1% versus 30.2%, P = 0.045), lateral and medial surface (39.8% versus 18.6%, P = 0.001), and wounds containing exposed bone and hardware (78.8% versus 62.8%, P = 0.018). RpFs were used more for forefoot (19.8% versus 10.2%, P = 0.053) and plantar defects (58.1% versus 30.3%, P = 0.000). RpFs had a higher rate of immediate success (100% versus 95.8%, P = 0.053), with no significant differences in rate of long-term limb salvage (77.1% versus 69.8%, P = 0.237). PFs had higher rates of ischemia requiring intervention (11.0% versus 3.5%, P = 0.048). RpFs had a higher rate of minor amputations (15.12% versus 6.8%, P = 0.053) but similar rates of major amputation (15.1% versus 16.1%, P = 0.848). There were no significant differences in rates of mortality or ambulatory status.
Conclusions
Both RpFs and PFs remain reliable options to reconstruct defects of the foot and ankle. Optimizing the use of each flap type should consider wound characteristics. RpFs are preferred for dorsal and plantar defects, whereas PFs are protective for minor infections and preferred for deeper wounds despite a higher rate of partial necrosis.
... These flaps spare the underlying muscles, resulting in reduced donor morbidities, durable coverage, and more aesthetically pleasing outcomes. [2][3][4][5][6] Proper flap planning is crucial in reconstructive surgery to minimize the risk of flap failure, such as a partial or complete necrosis of the flap, as well as to increase reliability, predictability, and efficiency. 3,7-10 Therefore, preoperative perforator mapping is necessary to ensure the safety and applicability of these flaps. ...
Background Chronic defects in the lower leg present significant challenges in plastic surgery due to their diverse etiologies and association with impaired peripheral circulation. This study describes the localization of stable perforators and assesses their changing velocities after digital subtraction angiography (DSA) and alterations of flow characteristics.
Methods Ten patients with lower extremity defects requiring DSA had undergone examinations by using standard methods. The localization of 40 stable perforators originating from the anterior tibial artery, posterior tibial artery, fibular artery, and medial sural artery was performed before and after angiography. Where stenoses or occlusions were observed, percutaneous transluminal angioplasty (PTA) was conducted, and velocity changes following reperfusion were measured.
Results Angiographic abnormalities were observed in all of patients, thus necessitating PTA interventions. Prior to PTA, handheld acoustic Dopplers detected 37 out of 40 perforators (90%), whereas color-coded sonography detected 35 out of 40 perforators (87.5%). After PTA, these numbers increased to 38 out of 40 (95%) and 37 out of 40 (92.5%), respectively. The diameter of the perforators ranged between 1.14 and 1.16 mm. The mean flow characteristics included the peak systolic velocities (PSV) of 21.9 and 27.2, end-diastolic velocities (EDV) of 9.4 and 11.4, and resistance indexes (RI) of 0.63 and 0.71, respectively. In the postintervention period, 16 microvessels exhibited enlarged lumen diameters ranging from 1 to 3 mm, resulting in increased perfusion values for PSV in 85.2% (21.9/27.2) and EDV in 88.2% (9.4/11.4) of the patients. The RI increased from 0.63 to 0.71. However, two perforators showed decreases in flow velocity after PTA.
Conclusion In most patients with chronic lower leg wounds and other comorbidities, adequate perforators for reconstruction can be identified by using conventional methods. PTA interventions positively impact blood flow in perforators, although they are not necessarily required prior to reconstruction.
... Vascularized and pedicled flaps are an effective surgical solution in reconstructive surgery to prevent and treat these outcomes with minimal morbidity in the donor areas. These flaps must be considered before the surgery and not only after the oncologic procedure [15][16][17][18][19][20][21]. Their preoperative design helps to preserve maximal function, allows soft tissue reconstruction and prevents unsuitable complications [22][23][24][25]. ...
... Hospital discharge does not correspond in all cases as these are patients who need chronic oncology treatment. Adjuvant chemotherapy was early reprised after an average of 21 (15)(16)(17)(18)(19)(20)(21) days. No orthopedic limitations or thoracic involvement were reported after 5.34 (2.58-11.78) ...
... Free tissue transfer is reserved for situations where pedicled flaps are unavailable, insufficient or have been previously radiated. Pedicled flaps are technically less demanding and quicker to perform than free tissue transfers [16,27,[29][30][31]. In our series, we did not need to resort to free flaps in any of our patients. ...
The aim of this study is to review the indications of pedicled flaps and analyze the results. A observational retrospective study of under 18-year-old oncology patients who required reconstructive surgery with pedicled flaps between 2011 and 2022 was performed. Demographic and clinical variables, indications, complications, and outcomes were collected. 236 patients were reviewed and 13 met inclusion criteria, eight girls and five boys (mean age: 10.6 years). Indications were Ewing’s sarcoma (5), osteosarcoma (5), neuroblastoma, desmoid tumor, and neurofibroma. Preoperative PET-CT, MRI and bone scintigraphy were performed. The flaps were used on costal and extremity reconstruction: latissimus dorsi (5), pectoralis (2), medial gastrocnemius (2), combined latissimus dorsi, trapezius and serratus muscle, biceps femoris, fascio-neuro-cutaneous saphenous and cutaneous advancement-rotation. Two were performed on allograft and eight on prosthesis. All allowed immediate and complete closure. Six patients received intraoperative radiotherapy. One flap infection and two vascular complications were reported, a total necrosis, which required a new flap, and a partial necrosis, treated with a local plasty. Chemotherapy was resumed after 21 days (15–31). Mean follow-up time was 5.34 years. Flaps are an effective therapeutic option allowing reconstruction of large defects after pediatric oncologic surgeries. The most frequent complication was vascular.
... When a wound occurs in the middle area of the lower leg, a propeller flap or soleus flap can generally be tried for small and medium defects and a free flap for large defects. On the other hand, when a wound occurs on the foot, a distally based sural flap or free flap can be tried for small and medium-sized defects, and a free flap for large defects [1,[7][8][9]. ...
Reconstruction of lower extremity wounds in patients with abnormalities in vascular anatomy is often challenging. A 71-year-old man was admitted to our hospital after sustaining two contact burns on his right leg while sleeping on an electric blanket. Fourth-degree burns amounting to approximately 3% of total body surface area were confirmed, with eschar formation on the right instep and pretibial area. Both wounds on the lower leg required flap reconstruction. In addition, the patient had anterior tibial artery hypoplasia. We considered a two-flap reconstruction method that should leave the source artery and muscle intact and generally has a good prognosis. A peroneal artery perforator-based keystone flap was used on the right lower leg, and a right dorsalis pedis island flap on the foot dorsum. Surgery was performed successfully, and at 8 months postoperatively, the patient walked naturally and had no complaints of discomfort. Additionally, cosmetic results were satisfactory. Accordingly, we introduce a surgical method that is useful in cases similar to that described.
... Though all these techniques have made perforator flaps easier, they have also shown good outcomes in terms of complications and survival rate. However, limitations like highly advanced surgical skills, lack of accessibility due to non-portable equipment, administration of intravenous contrast, and financial constraints within low-resource healthcare settings, compounded by the need for highly specialized and trained personnel, have made these modalities difficult to use frequently [8,9]. ...
Objective: To determine the diagnostic accuracy of smartphone thermal imaging for preoperative perforator mapping in perforator-based flaps, taking visual inspection as gold standard.
Methodology: It was a cross-validation study conducted at the Department of Plastic Surgery, Dr. Ruth K. Pfau Civil Hospital, Karachi, Pakistan, from August 2022 to January 2023. All adult patients aged 18 to 40 years of either gender undergoing perforator flap surgery were included. Each patient followed the same treatment regimen, which involved the preoperative identification of the perforator location using the FLIR One camera. Subsequently, confirmation was achieved during the surgical procedure through visual inspection. A two-by two table was used to calculate sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy.
Results: The mean age of the patients was 30.10±6.87 years, ranging from 18 to 40 years. Most of the patients were males (58.7%), and 41.3% were females. Almost 80.4% were pedicle flaps, and 19.6% were free flaps. The accuracy of thermal imaging was found to be 83.2%, with a sensitivity of 84.3%, a specificity of 80%, a PPV of 92.9%, and a NPV of 62.2%, respectively.
Conclusion: Smartphone-based thermal imaging is useful for the diagnosis of perforators and has high sensitivity and specificity.
... A reconstructive algorithm including the defect location, size and depth (supra-versus sub fascial), the need for sensate coverage, and surgeon preference/comfort should guide reconstruction (15) flaps provide a better aesthetic result and are more resistant to shear, but they are difficult to contour. The heel region requires that the flap be contoured around the curve of the calcaneus in both the medio-lateral and proximal-distal axes. ...
Soft tissue reconstruction of the lower limb has seen a paradigm shift over the past two decades. Typically, these defects arise from trauma, infection or tumor. It is no longer enough to simply achieve coverage. Factors like patient-reported outcomes and aesthetic considerations are essential in the decision-making process. This is especially in light of increasing technological advancement, availability of dermal substitutes, microsurgical expertise and development of the field of microsurgical reconstruction as a whole with more novel flaps and techniques. Advancements in reconstructive modalities have also been equally matched by better emergency medical mobilization, transportation and access, early initiation of subspecialty care, accessibility and types of imaging, as well as oncological advances in radiotherapy and chemotherapy regimens. Yet, this has also meant that our patient profile has expanded to include older patients with more co-morbidities and other considerations such as frailty or the irradiated field which could influence what reconstructive modality is suitable and the goals of reconstruction specific to the patient. Previously deemed unsalvageable limbs are now being successfully reconstructed with good function and aesthesis. In the lower limb, this implicates the ability for early mobilization, range of motion and weight bearing which allow the patient to successfully partake in early rehabilitation. Expedient and reliable healing is also important in the oncological population where a proportion of these patients would need to go on to receive post-operative chemotherapy or radiotherapy. The reconstructive ladder has been what many reconstructive surgeons have been taught upon with regard to the basic principles of pre-operative planning and choosing the appropriate reconstructive modality. In this article, we examine the relevance of the reconstructive ladder in modern practice and the additional considerations in the approach to a soft tissue defect in the lower extremity.
... Recently, the introduction and application of perforator aps based on the anterior tibial (ATA), posterior tibial (PTA), and peroneal (PA) arteries have advanced the treatment for soft-tissue defects in the lower leg. A pedicled fascio-cutaneous ap, for example, has some advantages: 1) color and histological similarity to the recipient area (like-with-like) since the ap is taken in the vicinity of the soft-tissue defect and 2) versatility during surgery as the ap can easily be rotated, preserving the main arterial supply and limiting injury to the donor ap area [1,[5][6][7]. Conversely, this ap presents some disadvantages: 1) the size of the pedicle artery is very small and 2) the location and morphology of the artery are not constant, which may result in di culty when selecting the best perforator artery with which to make the ap pedicle. Currently, imaging methods such as Doppler ultrasound, digital subtraction angiography (DSA), and magnetic resonance imaging (MRI) are commonly and widely used in the vascular examination. ...
Purpose
To investigate the leg perforator arterial system, identify the perforator flap’s pedicle artery and its projected cutaneous point using a 320-slice computed tomography (CT 320) scanner.
Methods
A total of 24 patients with leg soft-tissue defects unilaterally underwent 320-slice CT angiography scanning (CTA 320) with 47 legs. The used method enabled investigation of the perforator arteries originating from the tibial, peroneal arteries, perforator flap’s pedicle artery and its projected cutaneous point. These data were used to preoperatively design an improved flap. Then, the CT-confirmed location and length of the flap’s pedicle artery were compared with intraoperative findings.
Results
Findings of the CTA 320 on 47 legs showed that 217 perforator arteries with diameters of ≥ 0.5 mm were detected; the average number of arteries per leg, their average length and diameter were 4.6 ± 2.1, 30.7 ± 10.4 mm and 1.16 ± 0.27 mm, respectively. The perforator arteries originating from the anterior tibial artery were mainly distributed in the proximal and middle thirds of the leg. Perforators from the posterior tibial and peroneal arteries were distributed abundantly in the middle and distal thirds of the leg. As identified in the CT, the location and length of the flap’s pedicle artery and its projected cutaneous point were consistent with those observed during the surgery.
Conclusions
The CTA 320 is a minimally invasive imaging method that provides high-quality images of the leg perforator arterial system and can identify the exact location and projected cutaneous point of the perforator flap’s pedicle artery.
... In perforator flaps, the skin and subcutaneous fat are removed from a distant or adjacent part of the body so as to reconstruct the excised part. Vessels that give blood supply to the flap are isolated perforators derived from a deep source artery and travel through the intermuscular septa or the underlying muscle [5]. ...
... Early and quantitative assessment of the flap status and prompt surgical intervention are key contributors to successful flap salvage when complications do arise. In addition, when faced with large and complex defect reconstruction, a single perforasome may not be suitable for this situation, and therefore, it is necessary for surgeons to explore to use the multiterritory perforator flaps involving several perforasomes (6)(7)(8). ...
Background:
A comprehensive understanding of cutaneous microvessels is key to the design and use of the perforator skin flap. Compared with the various imaging technologies that have been applied in the clinical practice of the perforator skin flap, photoacoustic microscopy (PAM) is a very promising noninvasive imaging modality with high resolution and deep penetration in biological tissues.
Methods:
PAM was employed to explore its multiple applications in a perforator skin flap. The following experiments were then conducted in 3 parts. In part 1, 7 mice were used to obtain the preoperative perforator mapping on the mouse back. In parts 2 and 3, 7 mice were used to design and harvest the multiterritory perforator flap. The status of the flap and the morphological changes of choke vessels were subsequently observed by PAM at several time points.
Results:
The results showed that PAM could visualize and assess the vascular physiological and pathological conditions of the skin tissue in real time in vivo with high spatial and temporal resolution. It could also provide preoperative perforator mapping, including the total number of perforators, localization, vascular territories, and diameter. Furthermore, it could offer a quantitative, objective method to monitor the status of the perforator skin flap, and was capable of noninvasive characterization of the changes of choke vessels that play an important role in multiterritory perforator skin flap expansion and survival.
Conclusions:
PAM has great potential to be an effective and precise quantitative imaging tool for perforator skin flap research, such in as flap design, monitoring, and choke vessel observation.
... Reconstruction of the lower leg and ankle soft tissue defects is not that the convenient task, mostly, due to the inherent anatomy: The decreased bulk of the soft tissues and the subcutaneous bony aspect [1]. Vascularity is also an important aspect on the level of the main vessels, and indeed on the level 219 of the perforators, which have variant numbers, sites, lengths, and diameters, even in the same person on the opposite sides [2,3]. ...
