Medial lower leg perforators: An anatomical study of their distribution and characteristics.

PURPOSE: The integument of the medial lower leg is underestimated as a donor site for local and distant reconstructions. Comprehensive knowledge of its perforator anatomy is lacking. This study aims to determine perforator location and characteristics and to compare these regarding the proximal, middle and distal third of the medial lower leg. MATERIALS AND METHODS: The medial lower leg region (MLLR) of 16 cadavers was delineated and investigated after injecting the popliteal artery with acrylic paint. Following dissection, all perforators larger than 0.3 mm were localized and mapped. Their course, source vessel, length and diameter were subsequently documented. RESULTS: Overall, 122 perforators were found, 102 (83.6%) originating from the posterior tibial artery, 16 (13.1%) from the medial sural artery and 4 (3.3%) from the anterior tibial artery. A mean of 7.6 ± 2.4 perforators (range 4-13) per MLLR was found. Most perforators (42.6%) were localized in the distal third of the MLLR, followed by the middle (36.9%) and proximal third (20.5%). The largest and longest perforators were found in the proximal third of the MLLR (diameter 1.4 mm, length 9.1 cm), followed by the middle and distal third respectively. Of all musculocutaneous perforators, the majority (78.6%) was located in the middle third of the MLLR. Of all septocutaneous perforators, most (55.3%) were found in the distal third of the MLLR. A small number of unexpected anatomical variants were found. CONCLUSION: In each third of the MLLR different perforator characteristics were found. Knowledge of these characteristics can be used to direct the reconstructive plan. © 2016 Wiley Periodicals, Inc. Microsurgery 37:319-326, 2017.

Breast Reconstruction Using the Geometrically Modified Profunda Artery Perforator Flap From the Posteromedial Thigh Region: Combining the Benefits of Its Predecessors.

BACKGROUND: Occasionally, the deep inferior epigastric perforator flap is unavailable for autologous breast reconstruction. Alternative options, such as gluteal artery perforator flaps, the transverse upper gracilis flap, and the profunda artery perforator (PAP) flap, have been well documented. In our initial experience, the PAP flap was associated with limitations at the donor site. Therefore, a geometrically modified PAP flap was evaluated. METHODS: Forty geometrically modified PAP flap reconstructions were performed on 30 patients. Our modification comprised flap harvest from a more cranial area, hereby adding abundant inferior gluteal tissue to the flap while sparing superior thigh tissue. Patient characteristics, anatomical variables, and clinical outcome were prospectively evaluated. RESULTS: Mean patient age was 44 years, and mean body mass index (BMI) was 23.3 kg/m. Mean flap size was 32 × 12 cm, and mean weight was 385 g. Mean number of suitable perforators (diameter ≥ 0.5 mm) in the adductor magnus area was 1.7 per thigh. All flaps survived completely. Wound dehiscence at the donor site occurred after 4 unilateral reconstructions. Transient lymphedema of the leg occurred after 4 other unilateral reconstructions. Other wound morbidity or systemic complications did not occur. Secondary breast surgery for symmetry and volume was indicated after 16 reconstructions. Preoperative bra size was unchanged or larger in 36 reconstructions. Scar position in the crease was achieved after 39 reconstructions. Sensibility changes of the posteromedial thigh region were not observed. CONCLUSIONS: The geometrically modified PAP flap ensures in-the-crease scar positioning and provides sufficient tissue to restore preoperative bra size.

A retrospective investigation of abdominal visceral fat, body mass index (BMI), and active smoking as risk factors for donor site wound healing complications after free DIEP flap breast reconstructions.

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) flap is one of the most common techniques for breast reconstruction. Body mass index (BMI) is considered as an important predictor of donor site healing complications such as wound dehiscence. The use of computed tomography (CT) proved to be a precise and objective method to assess visceral adipose tissue. It remains unclear whether quantification of visceral fat provides more accurate predictions of abdominal wound healing complications than BMI. PATIENTS AND METHODS: A total of 97 patients with DIEP flap were retrospectively evaluated. Patients' abdominal visceral fat (AVF) was quantified on CT angiography (CTA). The patients were postoperatively assessed for abdominal wound healing complications. We analyzed for the correlations between AVF, BMI, and dehiscence and established a logistic regression model to assess the potential high-profile predictors in anatomic and patient characteristics such as weight, smoking, and diabetes. RESULTS: We included 97 patients, and of them, 24 patients (24.7%) had some degree of abdominal dehiscence. No significant differences were observed between the dehiscence group and the non-dehiscence group, except for smoking (p = 0.002). We found a significant correlation between AVF and BMI (R = 0.282, p = 0.005), but neither was significant in predicting donor site dehiscence. Smoking greatly increased the likelihood of developing wound dehiscence (OR = 11.4, p = < 0.001). CONCLUSIONS: AVF and BMI were not significant predictors of abdominal wound healing complications after DIEP flap reconstruction. This study established active smoking (OR = 11.4, p = < 0.001) as the significant risk factor that contributed to the development of abdominal wound dehiscence in patients with DIEP.