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Ebopras > Perforator Flaps > Flashcards

Perforator Flaps Flashcards

1
Q

What is the arterial source of a perforator flap?

A

Either septocutaneous or musculocutaneous vessels.

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2
Q

What is an angiosome?

A

The angiosomes of the body are distinct vascular territories that are composed of muscle and the overlying skin and the adipose tissues. The angiosomes define the anatomical borders from which tissues are available for composite transfer.

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3
Q

How are the cutaneous vessels defined according to their course?

A

They are defined as septocutaneous and myocutaneous vessels. Septocutaneous vessels course either between the tendons or muscles following the intermuscular septa. Myocutaneous perforators penetrate through the muscle to nourish the subcutaneous tissue.

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4
Q

What is the anatomical basis for perforator-based skin flap design and harvest?

A

The size, length, direction, and connections of the cutaneous perforators provide basis of flap design. At least one
adjacent anatomical cutaneous vascular territory can be captured with safety when based on a particular perforator.

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5
Q

What is the contribution of Taylor and Daniel to the evolution of the perforator flap surgery?

A

These authors were the first who attempted to harvest skin flaps on the septocutaneous and myocutaneous perforators that they had identified during their vascular anatomy studies on cadavers. They mapped the vascular anatomy of the skin and identified an average of 374 dominant cutaneous vessels of 0.5 mm or greater in diameter, and introduced the angiosome concept for further perforator flap surgery.

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6
Q

What is a true perforator flap?

A

A “true” perforator flap relies on perforator vessels from a given source vessel that must first penetrate a muscle before piercing the deep fascia to reach the skin.

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7
Q

What are the advantages of the perforator flaps?

A
  1. Less donor site morbidity.
  2. Muscle sparing.
  3. Versatility in design to include as little or as much tissue as required. 4. Improved postoperative recovery of the patient.
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8
Q

What is the definition of a reliable perforator vessel?

A

The reliable perforator is defined as a perforator that sprouts from the carrier muscle with a “visible” pulsation, usually greater than 1 mm in diameter. A reliable perforator is believed to have the ability to expand its perfusion over its territory after the perforator flap elevation.

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9
Q

How are the perforator vessels identified?

A

Currently, the most practical, simple, safe, speedy, and inexpensive method is the use of handheld Doppler ultrasound probe. Other techniques include computed tomographic angiography, magnetic resonance imaging, and color-flow duplex scanning.

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10
Q

How are the axial artery and perforators discriminated with the Doppler probe?

A

The axial artery has a unidirectional pulsating course whereas there is no evident pulsating sound around the
perforator.

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11
Q

What are the available preoperative tools to identify the exact location of the perforators?

A

The available and reliable image studies include multidetector-row helicon computed tomography angiography and
magnetic resonance imaging.

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12
Q

What is the most common consequence when a tiny perforator is selected?

A

Marginal flap necrosis beyond the territory of the perforators.

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13
Q

What are the requirements for an acceptable perforator flap donor site?

A
  1. Predictable and consistent blood supply;
  2. At least one large perforator with the diameter greater than 1 mm;
  3. Sufficient pedicle length; and
  4. Primary closure of the donor site with the absence of excessive wound tension.
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14
Q

What are the most commonly used perforator flaps?

A

Anterolateral thigh perforator flap, deep inferior epigastric perforator (DIEP) flap, super gluteal artery perforator flap, inferior gluteal artery perforator flap, thoracodorsal perforator flap, tensor fascia lata perforator flap, medial plantar perforator flap, deep circumflex iliac perforator flap, medial sural artery perforator flap, transverse gracilis perforator flap, and internal mammary artery perforator flap.

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15
Q

What is a free-style free flap?

A

An anatomic region that is not the traditional flap territory with the appropriate size, color, and pliability is selected, and the skin perforators in that region are mapped using a Doppler probe. Mapped perforators are dissected toward source vessels to provide adequate vessel length and size. By applying the concept of free-style free flap, small- or moderate-sized flap can be designed and harvested to almost any part of the body as long as the donor site appearance is acceptable to the patient.

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16
Q

What is the main advantage of free-style free flap?

A

The advantage of this concept is that it provides the surgeon an extra sense of freedom and variability when
approaching a flap harvest and choosing the recipient site.

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17
Q

What are the most common causes of the perforator thrombosis?

A

Stretching, twisting, drying, and compression of the perforator.

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18
Q

What are the strategies to reexplore a thrombosed perforator flap?

A
  1. Explore early.
  2. Resect the thrombosed vessel segment and reanastomose with or without vein graft.
  3. Open the vessels and squeeze the proximal vessel to evacuate the thrombus.
  4. Do not inject any solution from the cut end since this maneuver may cause migration and plugging of thrombus into the smaller perforators.
  5. Relieve the tension from the flap.
  6. Inject few thrombolytic agents, such as urokinase, streptokinase from the donor artery and drain it out from the
    donor vein in an attempt of thrombolysis.
  7. Systemic infusion of low-dose heparin 2,500 to –5,000 units/day.
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19
Q

What are the principles in “thinning” of a perforator flap?

A
  1. Preserve the fat and the fascia within a circle of 1 cm diameter around the perforator;
  2. Use loupes or microscope to perform the procedure;
  3. Perform thinning when there is circulation in the flap, either before division of pedicle or after restoration of blood circulation.
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20
Q

What is “supermicrosurgery” technique?

A

Supermicrosurgery technique involves division of the perforator flap pedicle above the deep fascia and anastomosing small vessels that are less than 1 mm (0.5–0.7 mm) using 12-0 Nylon with a greater magnification microscope. It allows free transfer of flaps on vessels harvested without breaching deep fascia, so-called “perforator-to-perforator” free flap transfer.

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21
Q

What are the advantages in applying supermicrosurgery technique in perforator flap surgery?

A

The donor site morbidity is reduced since the fascia remains intact and the muscle is not dissected. Flap harvest can be performed quickly without intramuscular dissection. Besides, only a short vascular pedicle is taken without sacrificing perfusion to the surrounding tissues.

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22
Q

What are disadvantages to apply supermicrosurgery technique in perforator flap surgery?

A

The primary disadvantage is the short and small pedicle rendering the inset and the difficulty of performing anastomosis on tiny diameter vessels on a short pedicle.

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23
Q

What does the “supermicrosurgery” impact on management of extremity lymphedema?

A

Multiple lymphaticovenular anastomoses on a single limb were reported to improve the lymphedema significantly.

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24
Q

List the perforator flaps and their accompanying nerves that can be harvested as a sensate flap.

A

Thoracodorsal perforator flap—lateral branch of the intercostal nerve;
Medial plantar artery perforator flap—medial plantar nerve;
Anterolateral thigh flap—lateral femoral musculocutaneous nerve;
Deep inferior epigastric perforator flap—sensory branch of the intercostal nerve; Superior gluteal artery perforator flap (SGAP)—super and middle gluteal nerve.

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25
Q

What is a pedicled perforator flap?

A

By applying the concept of perforator flap into regional reconstruction, a perforator flap close to the defect is dissected and transferred by meticulous intramuscular dissection of the perforator without division and reanastomosis of the vascular pedicle.

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26
Q

What are the advantages of pedicled perforator flap?

A

The microsurgical anastomosis is eliminated and the potential risk of flap loss diminished. A perforator flap is designed near the defect and can be based on traditional flap design, like rotation, transposition, advancement and interposition/island flaps and transposed to the recipient site based on the perforator. Traditional flaps can be designed with improvement of providing an axial and reliable blood supply. Owing to the preservation of the perforator, the traditional pedicle flap length-to-width rule is no longer needed.

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27
Q
A
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28
Q

List examples of pedicled perforator flap in head and neck reconstruction.

A
  1. Submental artery perforator flap;
  2. Facial artery musculomucosal flap;
  3. Temporoparietal artery perforator flap;
  4. Internal mammary artery perforator flap.
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29
Q

Who described anterolateral thigh flap?

A

Song et al. described it as a septocutaneous perforator flap in 1984.

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30
Q

What is the source artery of the ALT perforator flap?

A

Septocutaneous or musculocutaneous perforators derived from the descending or transverse branch of lateral
circumflex femoral system.

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31
Q

What is the landmark for the perforators in the anterolateral thigh region?

A

A line is drawn from anterior superior iliac spine to the lateral border of the patella and the perforators are usually located in a circle 3 cm around the midpoint of this line.

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32
Q

What is the ratio of septocutaneous versus myocutaneous perforators in the anterolateral thigh perforator
flap?

A

In different reported series, only 12% to 33% of the patients were reported to have septocutaneous vessels while 67% to 88% had myocutaneous perforators.

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33
Q

What can be the maximum dimension of an anterolateral thigh perforator flap?

A

8 × 20 cm.

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34
Q

What are the advantages of thinning anterolateral thigh perforator flaps?

A
  1. Uniformly thin and pliable flaps become available especially for reconstruction of oral cavity, neck, hand and
    fingers, axilla, forearm, and anterior tibial area;
  2. Avoids secondary defatting procedure;
  3. Improved sensory recovery;
  4. Early range-of-motion training when used in hands and fingers.
35
Q

What is the upper width limit of the anterolateral thigh flap that can be usually closed primarily?

A

Although the laxity is important for this issue, generally up to 8 cm defect can be closed primarily.

36
Q

What are the variations in the anatomy of the anterolateral thigh flap?

A

Variations occur in 2% of the cases.
1. Absence of any perforator to the skin.
2. Small perforator.
3. Perforator pedicle that contains an artery but no vein. 4. Artery not going with the vein side by side.

37
Q

What is the technical management when anatomical variations are encountered during elevation of anterolateral thigh flap?

A
  1. Try to dissect a perforator from the transverse branch in the upper thigh or use the tensor fascia lata perforator flap.
  2. Use an anteromedial thigh flap.
  3. Convert to ALT myocutaneous flap.
  4. Shift to the opposite thigh.
38
Q

What are the main application areas of the anterolateral thigh flap?

A

Head and neck reconstruction, esophagus reconstruction, chest empyema with bronchocutaneous fistula,
abdominal wall reconstruction, pelvic reconstruction, upper and lower extremity reconstruction.

39
Q

How is the decision made if an anterolateral thigh perforator flap should be used pedicled or as a free flap in abdominal wall reconstruction?

A

This depends on the location of the defect and length of the pedicle. The flap is raised first without division of the pedicle. If simple transposition is enough, microvascular anastomosis can be saved. If not, the recipient vessels should be explored.

40
Q

What are the advantages of using an ALT flap for head and neck reconstruction?

A
  1. Long pedicle (12.01 ± 1.05 cm) with sufficient diameter (2.0–2.5 mm)
  2. Pliable and wide flap
  3. Allows for two-team approach
  4. Feasibility to design as either a single skin paddle for one-layer defect reconstruction or double-skin paddle for through-and-through defects
  5. Moderate flap thickness
  6. Possibility for thinning
  7. Possibility to harvest as a chimeric flap or composite flap along with the neighboring tissues, including the vastus lateralis muscle, fascia of the tensor fascia lata, and iliac crest for bony reconstruction
  8. Potentially sensate by including the lateral femoral cutaneous nerve
  9. Inconspicuous scar over the donor site
41
Q

What are the contraindications of the anterolateral thigh flap?

A

The absolute contraindications are severe atherosclerosis, previous injury, and injury in the thigh region. Obesity is
the relative contraindication.

42
Q

Describe the thigh flaps according to their source artery.

A
  1. ALT flap—descending branch of the lateral femoral circumflex artery (LCFA)
  2. Medial thigh flap—a branch from the LCFA or descending branch of LCFA
  3. Proximal two-thirds of lateral thigh skin—transverse branch of the LCFA
  4. Skin at the medial thigh—medial femoral circumflex artery
  5. Skin at posterolateral thigh—third or fourth perforator from the deep femoral artery 6. Inferior gluteal thigh flap—inferior gluteal artery
  6. Posterior popliteal thigh flap—a branch of the popliteal artery
43
Q

Compare the tensor fascia lata perforator flap and anterolateral thigh flap.

A

The most remarkable difference is the anatomy of the vessels. The descending branch of the LCFA that supplies the anterolateral thigh flap runs longitudinally in the intermuscular septum between the rectus femoris and vastus lateralis muscle, whereas the transverse or ascending branch of the TFL flap runs laterally. Tensor fascia lata flap has a shorter pedicle, and the subcutaneous tissue is thicker.

44
Q

Which perforator flaps are available for breast reconstruction?

A

Deep inferior epigastric perforator (DIEP) flap, thoracodorsal artery perforator (TAP) flap, gluteal artery perforator
flap, anterolateral thigh flap.

45
Q

What is the blood supply of the DIEP flap?

A

Perforating vessels originating from the deep inferior epigastric artery.

46
Q

What are the advantages of DIEP flap over TRAM flap?

A

The rectus abdominis muscle with fascia is preserved in DIEP flap, which results in less donor site morbidity and shorter recovery period.

47
Q

contraindications for DIEP?

A

Midline abdominal scar, previous liposuction, inadequate subcutaneous tissue, and obesity

48
Q

What are the most significant risk factors of fat necrosis in the DIEP flap?

A

Radiotherapy and smoking.

49
Q

What are risk factors for flap failure in DIEP flap?

A

Tobacco use, small-sized perforators, venous congestion in contralateral lateral zone (Zone IV).

50
Q

What are the indications for bilateral breast reconstruction with bilateral DIEP flaps?

A
  1. Bilateral prophylactic mastectomies
  2. Therapeutic and contralateral prophylactic mastectomies
  3. Postexplantation of bilateral implants due to rupture or capsular contractures
  4. Bilateral subcutaneous mastectomies post foreign body injection
51
Q

Which vein is considered as a “lifeboat” and spared during the harvest of DIEP flap?

A

The ipsilateral and contralateral superficial inferior epigastric veins.

52
Q

What are alternative perforator flap for breast reconstruction if abdominal tissue is not available?

A

Anterolateral thigh perforator flap, thoracodorsal perforator flap, superior gluteal artery perforator flap, inferior
gluteal artery perforator flap.

53
Q

What is the main indication of the traditional gluteus maximus myocutaneous flap?

A

Since the gluteus maximus myocutaneous flap has a thick subcutaneous layer and can be raised as a pedicled flap, it
is an excellent tool to cover large sacral midline defects and obliterate the dead space.

54
Q

What are the disadvantages of the traditional gluteal maximus myocutaneous flap?

A

The exposure of the donor vessels is difficult, the vascular pedicle is short, and the flap dissection is challenging.

55
Q

What are the advantages of SGAP flap over superior gluteus maximus myocutaneous flap?

A

The SGAP flap provides a better intraoperative exposure and a longer vascular pedicle, the scar is well hidden and contour deformities are minimized. In SGAP flap, the anatomical and functional integrity of the muscle is preserved; therefore, exposure of any nerves or bony eminences is avoided, postoperative pain is decreased and hospitalization period is shortened.

56
Q

What are the preferred recipient vessels in breast reconstruction with SGAP flap?

A

The axillary vessels should not be used for SGAP flap in breast reconstruction since the pedicle length is often insufficient to allow the flap insetting medially. The preferred recipient vessels are either the perforators of the internal mammary vessels at the second or third intercostals space or the internal mammary vessels themselves at the third or fourth intercostal junction.

57
Q

Who first described the use of SGAP flap in breast reconstruction?

A

In 1995, Allen and Tucker first reported the use of the SGAP flap in breast reconstruction.

58
Q

What are the indications of SGAP flap in breast reconstruction?

A

SGAP flap can be used for total and partial breast reconstruction and is indicated in patients who have an athletic
body habitus or midline abdominal scar.

59
Q

Who first described the thoracodorsal artery perforator flap?

A

Angrigiani et al in 1995.

60
Q

What are the various compositions of the thoracodorsal artery perforator flap?

A

Dermoadiposal flap, a composite or chimeric fashion flap including bone or regional muscle flap or a flow-through
pattern flap.

61
Q

What are the advantages of the thoracodorsal artery perforator flap over scapular and parascapular flaps?

A

Thoracodorsal artery perforator flap has a longer pedicle and a relatively thinner subcutaneous tissue.

62
Q

What are the application areas of the thoracodorsal perforator flap?

A

Because the thoracodorsal perforator flap is a large and thin flap without hair, it can be used effectively for resurfacing the skin and soft tissue defect over the hand or thumb, pretibia, and foot, as well as after release of burn scar contracture, resection of malignant skin lesions or radiation ulcers. It is also suitable of facial resurfacing in the head and neck cancer surgery and is a good option in breast reconstruction in selected patients. A pedicled perforator flap can be designed for reconstruction of partial breast deformity after radiation, and chest wall reconstruction.

63
Q

What are the advantages of the thoracodorsal perforator flap?

A

Large flap size, well-hidden donor scar, a long and reliable pedicle and variable tissue compositions.

64
Q

What are the disadvantages of the thoracodorsal perforator flap?

A

Longer operation time because of changing of position.

65
Q

Describe the anatomical location of the perforators of the medial sural artery perforator flap.

A

Most of the perforators located 9 to 18 cm from the popliteal crease in the medial calf area, and the numbers range
from one to four.

66
Q

What are the advantages of the medial sural artery perforator flap?

A
  1. Thin and pliable
  2. Less hair bearing
  3. Long and sizable vascular pedicle
  4. Volume can be adjusted by the inclusion of part of the gastrocnemius muscle
  5. The plantaris tendon can be harvested at the same time for tendon repair or as a ling 6. The location allows a two team approach in head and neck reconstruction
67
Q

What are the drawbacks of medial sural artery perforator flap?

A
  1. Donor site scar widening and contour deformity.
  2. Donor site cannot be closed primarily if the flap is greater than 5 cm in width.
68
Q

Describe the anatomic location of the deep circumflex iliac perforator (DCIP) artery.

A

The perforator is usually 1 cm to 2 m above the iliac crest and 5 cm posterior to the anterior superior iliac crest.

69
Q

How is the skin paddle of the DCIP flap designed?

A

The skin paddle is designed over the perforator and centered of the longitudinal axis of the upper border of the
anterior part of the iliac crest.

70
Q

What are the advantages of DCIP flap over standard iliac crest osseocutaneous flap?

A
  1. Easier contouring
  2. Eliminates the need for secondary debulking procedure
  3. Minimal sacrifice of the abdominal muscles and reduced the donor site morbidity
71
Q

Describe the anatomic location of the medial plantar perforator vessels.

A

The medial plantar system emerges through the septum between the abductor hallucis muscle and the flexor
digitorum brevis and sends several perforators through this intermuscular septum into the medial plantar skin.

72
Q

What are the main application areas of the medial plantar perforator flap?

A

The flap provides thick, glabrous skin and is especially suitable for the repair of a finger pulp, volar surfaces of the
digits, palm or foot plantar defects.

73
Q

Propose a perforator-based free flap for one-stage repair of an ischemic finger with pulp defect.

A

Free medial plantar perforator flap.

74
Q

What are the advantages of the medial plantar perforator flap?

A
  1. Minimal donor site morbidity
  2. Possibility of primary defatting
  3. Availability of two venous drainage systems (concomitant and cutaneous venous systems) 4. Good color and texture match with the finger skin
  4. Concealed location of the donor site 6. Ease in flap elevation
75
Q

Where is the most common location of perforators of the IMA perforator?

A

The largest and most commonly found internal mammary artery perforator has been reported to be in the second
and third intercostal spaces.

76
Q

What is the vascular pedicle of the IMA perforator flap?

A

Internal mammary artery and vein.

77
Q

What is the advantage of the IMA perforator flap?

A
  1. Freedom of arc of rotation to the chest wall and neck
  2. Reliable blood supply from the internal mammary vessels 3. Similar skin texture and color to the neck
  3. Primary closure of donor site
78
Q

What is a chimeric flap?

A

A chimeric flap has separate components with separate vascular supplies that are attached to a common source
vessel, either by artificial anastomosis or as a natural structure.

79
Q

What is a perforator-based chimeric flap?

A

Skin paddles or different tissue components can be elevated based on at least two perforators from different vascular
systems, which can be merged or anastomosed to a final source pedicle.

80
Q

What are the advantages of using a chimeric flap?

A

Easy three-dimensional insetting, acceptable aesthetic appearance, reduced donor site morbidity, precise flap design,
shorter operation time, and requirement of one pair of recipient vessels.

81
Q

What are the disadvantages of using a chimeric flap?

A

The possible variations of perforators, a learning curve, easy twisting of perforators and/or pedicle and sometimes
the need for a second venous drainage or shifting to double flaps.

82
Q

Which flaps are available to harvest chimeric flap?

A

Anterolateral thigh flap, thoracodorsal artery perforator flap, medial sural artery perforator flap.

83
Q

Propose a flap for one-stage reconstruction of wide and through-and-through cheek defect involving the oral commissure.

A

The anterolateral thigh chimeric flap with vastus lateralis for volume augmentation, and tensor fascia lata for mouth angle suspension.

Ebopras (32 decks)

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