Feasibility of perforator flaps in Day surgery. A retrospective study through a two-years' experience.

BACKGROUND: Day surgery is developing and its popularity is increasing for a variety of reasons: economic constraints, changes in professional practices, a greater adhesion of the patient. In an era of progress in surgical procedures, pedicled-perforator flaps reducing donor site morbidity and avoiding micro-anastomosis could take their place in Day surgery if planned and managed by an experienced team. METHODS: In the period January 2019 to January 2021, we performed perforator flaps for soft tissue coverage in ambulatory setting. The patients were included retrospectively and data were collected by reviewing the medical records. Major and minor complications were recorded. RESULTS: The retrospective cohort included 32 surgical procedures in 32 patients. In all cases, perforator flaps were realized for resurfacing soft tissue defects consequent to oncodermatology surgery (84.3%), soft tissue sarcoma surgery (12.5%), invasive ductal breast carcinoma (3.1%). Major complications needing a surgical revision overcame 3/32 times (9.4%). In these cases, a failure requiring the drop off the flap overcame once. The average wound healing time was of 33 days (15-90) and the mean duration of follow-up was 9.6 months (1-22). CONCLUSION: The low complication rate in our series suggests that this first experience on perforator flaps in outpatient surgery is promising in terms of safety and feasibility. Day surgery could be a practical option for this type of surgical procedures avoiding the conventional department's saturation and allowing the delivery of proper surgical cares.

Internal mammary artery perforator flap for repair of an upper thoracic tracheo-oesophageal fistula.

Tracheoesophageal fistulas (TOF) following esophagectomy for esophageal cancer are rare but potentially fatal. There is no consensus on treatment between stenting and surgical repair, although the latter is associated with better distant survival. In surgical repair, the interposition of a flap improves healing by providing well-vascularized tissue and reinforcing the repair zone. The flaps described are usually muscular and decaying. We present the case of a malnourished fifty-year-old man who underwent intrathoracic surgical repair of symptomatic recurrent TOF using a skin flap based on the perforators of the internal thoracic artery (IMAP). The perforator flap was completely de-epidermized and tunneled under the sternum by a proximal and limited resection of the 3rd costal cartilage and placed at the posterior aspect of the trachea, with the excess tissue rolled up on either side. At 9 months, the patient showed no recurrence and improved general condition. The de-epidermized IMAP tunneled under the sternum intrathoracically is a reliable alternative to the conventional muscle flaps described in TOF management and an attractive additional tool in the plastic surgeon's surgical arsenal.

Lower limb perforator flaps: Current concept.

Following a long period dominated by random fasciocutaneous flaps or muscle flaps, solutions to cover the lower limb have been largely diversified by the advent of so-called "perforator" flaps. Extended knowledge of vascular anatomy has propagated the development of this innovative procedure, in the objective of reducing morbidity. The existence of close to 400 perforator vessels in the body makes it possible to offer new flap perspectives for many defects, which were sometimes previously impossible to manage before except by free flap. For us, perforator flaps have become the current first-line solutions for small to medium size loss of substances. Understanding of vascular physiology and surgical experience are essential in choosing indications, detecting perforators, and modeling flaps to be optimally positioned in the reconstructive decisional algorithm. New skills are needed to master this type of reconstruction and limit failures, which implies a learning curve not only for flap design, perforator detection and surgical procedure, but also for monitoring and management of complications. In this manuscript, we outline the concepts and principles of the majority of the pedicled perforator flaps available for coverage of the lower limb, based on experience of more than 400 perforator flaps suitable for this localization.

Propeller perforator flaps for coverage of soft tissue defects in the middle and distal lower extremities.

INTRODUCTION: The middle and distal leg coverage is demanding procedure for reconstructive surgeon until evolution of local perforator flaps which becomes as valuable options in lower limb reconstruction. The goal of our study was to assess the results, reliability, safety, and possible complications of the local propeller perforator flaps in lower extremity reconstruction. PATIENTS AND METHODS: We demonstrate a case series of 11 patients in whom we cover small-to-medium soft-tissue defects of the middle and distal leg by application of local propeller perforator flaps. RESULTS: The site of soft tissue defects were in the distal third in 9 cases (81.8%) and 2 cases (18.1%) in the middle third. Flap dimensions ranged from 48 to 192cm2, with an average size of 88.9 cm2. The flap rotation was 180 degrees in (63.6%) of cases. The flaps were based on a single perforator of the posterior tibial artery in 8 (72.7%) cases and peroneal artery perforator in 3 (27.2%) cases. Complications were present in 18% of the perforator flaps which were based on peroneal artery perforator, one partial necrosis and one flap with a superfacial epidermolysis. The donor area is covered by split thickness skin graft in 63.6% of our cases and primary closure of in 36.3% of cases. CONCLUSION: The perforator propeller flaps are safe, relatively simple procedure and consider as an ideal option in reconstructing small-medium defects of the middle and distal third of the leg which provide similar skin texture with low donor site morbidity.

Coverage losses of substance in the shoulder.

Losses of substance of the shoulder are less common than elsewhere in the upper limb. They arise essentially from tumors (sarcomas), infectious diseases (hidradenitis) or traumatic events, (burns). The objectives of reconstruction depend on whether the losses of substance are located on the curve of the shoulder or in the axillary area. There exist numerous regional solutions, including perforator, propeller, pedicled and free flaps. The donor region may be the thorax (latissimus dorsi, serratus anterior), the back (trapezium, scapular or subscapular flaps, occipito-cervico-thoracic flap), the anterior surface of the thorax (pectoralis major or minor, supraclavicular, perforators of the acromiothoracic artery, delto-pectoral flap) or arm (brachial lateral or medial). Multitissular reconstructions are also possible in regional and pedicled form, as well as microanastomosed flaps in exceptional conditions.

[Harvesting method of thoracodorsal perforator flap: Adaptation]. / Technique de prélèvement d'un lambeau perforant thoracodorsal : mise au point.

The thoracodorsal artery perforator (TDAP) flap is a reliable method of reconstruction by which the indications were on a constant rise during the last few years. Several surgical variants exist and different harvesting techniques were described. However, with our experience using this flap for substance-loss coverage, we frequently faced a complex and relatively time-consuming pedicle dissection. This brought us to adapt our harvesting technique according to the anatomical situations of the neighboring structures. The purpose of this study is to revisit and adapt the method of the pedicle dissection for the TDAP flap. The conservation of both the nervous network and a section of a circumferential muscular collar with a diameter of two centimeters are the main keys of our study.

Thoracotomy and esophageal surgery: Key points to preserve the possibilities of flaps.

Anastomotic leakage frequently complicates esophagectomy and can trigger a rare life- threatening complication, a tracheoesophageal fistula. No guideline has yet addressed this complication. Plastic surgeons play a crucial role for salvage surgery. When a re-operation is chosen the possibilities of flap interposition depend on how the thoracotomy was initially performed. This study tried to identify key techniques in order help thoracic or general surgeons to preserve all the local flaps available for TEF if it occurs. These techniques improve flap conservation, helping plastic surgeons when a later transposition flap is required.

[Thin flaps in the management of hand and upper limb defects]. / Les lambeaux cutanés minces dans la prise en charge des pertes de substance cutanée de la main et du membre supérieur.

Cutaneous defect of the hand and the upper limb expose the underlying anatomical structures. The reconstruction therefore often resorts to flaps. The ideal flap must be thin and flexible, allowing a good resurfacing and a satisfactory functional result. The objective of this study is to analyze the various thinned flaps, to reveal their advantages and to underline their limits. We presented a literature review on the various techniques of thin skin flaps developed over the last 20 years, bringing together 18 articles, and including 225 patients. For 3 articles, the skin flaps were thinned down by preliminary expansion and for the 15 others they were surgically thinned during the harvesting of the flap. Thinning the flap seems to be an interesting surgical alternative in the management of cutaneous defect of the hand and the upper limb, but it would be interesting to be able to compare the results of these thin flaps to those of the conventional ones. This study also led us to propose a classification of thin flaps according to their thickness in order to clarify the terminology.

[Complex carcinological head and neck reconstruction in pediatric surgery]. / Reconstructions complexes par lambeaux libres en cancérologie cervicofaciale pédiatrique.

Head and neck reconstruction in pediatric oncology, even if it is based on adult experience, presents important characteristics including age-related growth, the type of tumor and donor sites features. Indications of free flaps are rare but required care that should be codified, taking into account the details specific to context, and not giving place for improvisation as it is important that surgical outcomes must be as simple as possible. The objective of this article is not to present the technical details of free flaps harvesting in children because it is what is certainly the least different with adults. The aim is to share our experience of the specificities and singularities of pediatric head and neck reconstruction in order to focus attention to everything that makes this surgery demanding. We present the most common indications, the types of free flaps used for reconstruction, facial location modalities of reconstruction and the perioperative management.

[Thin perforator flaps elevated in the plane of the superficial fascia: Principle and surgical procedure]. / Lambeaux perforants fins prélevés dans le plan du fascia superficialis : principe et technique opératoire.

Perforator flaps have an ever growing place in reconstructive surgery and classical surgical procedures describe sub or supra-fascial plane elevation. In some indications, defatting of perforator flaps may be necessary and different methods have been described, primary or secondary, but may expose to partial loss of the flap or to another operation. Recently, a new method of perforator flap elevation in the plane of the superficial fascia has been described. This method permits to obtain a thin and reliable flap in the same procedure without the need of debulking and while decreasing donor site morbidity. We present the principle and the surgical procedure of this new method. Advantages and drawbacks are discussed with the help of clinical cases.

[Intraoperative verification of a perforator flap vascularization by indocyanine green angiography]. / Vérification peropératoire de la vascularisation d'un lambeau perforant par angiographie au vert d'indocyanine.

After Koshima and Soeda first described perforator flaps in 1988, Wei has improved the technique by describing the "free style perforator flap". These flaps have the advantage of being performed on all skin perforators and in reducing donor site morbidity. The disadvantage, however is that the size of their angiosome is not defined and the evaluation of their relay on the experience of the surgeon. An evaluation of the size of an angiosome by conducting intraoperative angiography is proposed. Intraoperative angiography is performed after injection of indocyanine green. Stimulation of the indocyanine green by infrared causes the emission of fluorescent radiation. This fluorescence is then detected by a specific camera that displays real-time visualization of the skin's perfusion. We present the case of a 39-year-old patient who had an open tibial pilon fracture, for which we performed a pedicled propeller flap based on a posterior tibial perforator. Angiography was used to determine accurately the optimal skin perfusion of the propeller flap, which was based on a perforator from the posterior tibial artery. Angiography identified several levels of skin perfusion with a high fluorescence, intermediate and absent. The non-vascularized part of the skin paddle was resected. Given the unreliability of this technique, hypoperfused area was retained. Debridment of this area, however was necessary at day 5 postoperative with repositionning of the flap. Indocyanine green angiography may be a useful decision-making tool for intraoperative surgeon. It allows to adjust the size of the propeller flap's skin paddle to it angiosome. However, this evaluation method needs to be improved with the introduction of a quantitative threshold.

The Vertebrobasilar Trunk and Its Anatomical Variants: A Microsurgical Anatomical Study.

BACKGROUND: The trunk of the basilar artery has not been included in microanatomy studies. Anatomical variants of the perforant branches of the vertebrobasilar trunk and their relationship with neural structures are very important in surgical approaches. Surgical dissection for the treatment of vascular lesions requires a perfect knowledge of the microsurgical anatomy. METHODS: We conducted a descriptive analysis of 50 brains, which were fixed with formalin at 10% for 2 weeks, and the arterial system was injected with colored latex. After microsurgical dissection, it was divided into three segments: the lower portion went from the anterior spinal artery to the anteroinferior cerebellar artery, the middle segment was raised from the upper limit of the lower portion to the origin of the superior cerebellar artery, and the upper segment ranged from the previous portion until the origin of the posterior cerebral artery. RESULTS: The basilar artery had an average length of 30 mm. The average diameter at its junction with the vertebral arteries was 4.05 mm. The average middle segment was 3.4 mm in diameter and 15.2 mm in length. The diameter of the upper segment was 4.2 mm, and its average length was 3.6 mm. The average number of bulbar arteries was three, and their average diameter was 0. 66 mm. The number of caudal perforator arteries were five on average, with a diameter of 0.32 mm. We found three rare cases of anatomical variants in the vertebra-basilar junction. CONCLUSIONS: The basilar artery emits penetrating branches in its lower, middle, and upper portions. The origin of penetrating branches was single or divided after forming a trunk. However, we observed long branches from perforant arteries.

[Reconstruction of elbow defect by perforator propeller flap of the brachial region--clinical observation]. / Reconstruction des pertes de substance du coude par lambeau perforant en hélice de la région brachial--observation clinique.

INTRODUCTION: The elbow defects can raise problem to plastic surgeon. Indeed, this region is characterized by thin and mobile tissues; its reconstruction must be long-lasting, resistant to movements, to shear forces and to external support. Perforator propeller flaps beings appear an interesting option in the reconstruction of elbow defects. In this report, we describe a patient having benefited from the excision of a melanoma of the region of the elbow. After multidisciplinary meeting and resection of new margins, a reconstruction by perforator propeller flap was realized. A perforator pedicle of the lateral brachial region was located and used. The postoperative result in term of cover and function was considered very satisfactory. The perforator propeller flaps appear a reliable and interesting solution in the coverage of elbow defect.

[Atlas of skin perforator arteries of trunk and limbs - guide in the realization of perforator flaps]. / Atlas des artères perforantes de la peau du tronc et des membres - Guide dans la réalisation des lambeaux perforants.

INTRODUCTION: Since Harvey, anatomists and surgeons have developed better knowledge of skin vascularization. Descriptive anatomy evolved from the direct and indirect cutaneous arteries concept to that of skin perforator arteries. These skin perforator arteries have preferential locations or clusters. An atlas of skin perforator arteries allows identifying these clusters in relation to anatomical landmarks. MATERIAL AND METHODS: A literature review was undertaken in order to find the characteristics of perforator arteries originating in the source arteries described by Taylor. This research allowed us to uncover 895 citations. We have selected from this abundant literature source only the articles that specifically treated the perforator arteries localization. All the data concerning the perforator arteries localization, their source artery, the caliber and territory, were analyzed and recorded. We described the perforators that were covered most frequently. RESULTS: The definition of these clusters is based on a work of collecting and synthesizing of anatomical, radiological and clinical data. The preferential territories or clusters of skin perforators were defined using simple anatomical landmarks. A synthesized iconography was imagined to allow easy and fast usage of the atlas. CONCLUSIONS: This atlas is a learning tool that helps realizing locoregional or free perforator flaps. It can form a "winning duo" with the acoustic Doppler in preoperatory design of a perforator flap. This duo is easily available, portable, easy to use, non-invasive and inexpensive. In conclusion, the precise localization of perforator arteries associated to adherence to the big principles and definitions of the perforator flaps will allow users to better understand the surface and orientation of the skin paddle that can be taken on one perforator artery.