Efficiency Assessment of Multidetector-Row Computed Tomographic Angiography Using Reconstruction with Locoregional Perforator Flaps.

Background: Reconstruction with the use of perforator flaps makes it possible to make the skin surface resistant to the influence of mechanical factors and as similar to the lost skin cover as possible. However, while planning any flap, along with the design of the required shape and size, its blood supply should be taken into account to ensure optimal viability. Therefore, the task to precisely determine the topographic-anatomical relationships suitable for the formation of a pedicle of perforators is still relevant. The aim of this study was to increase the efficiency of surgical reconstruction of wound defects by transposition of locoregional perforator flaps. Methods: The authors conducted a retrospective analysis of 72 cases of reconstruction by means of locoregional perforator flaps with vascular pedicle detachment to determine the efficiency of preoperative diagnostic preparation with the help of multidetector-row computed tomographic angiography (MDCT) in the process of reconstruction. Thirty-seven individual cases of surgical interventions were chosen using a case-controlled study from the study group when MDCT with angiography was used for preoperative planning of perforator flaps, as well as 35 control cases similar in terms of important predictive peculiarities with the reconstruction at the same level of difficulty. The patient groups were precisely matched by gender (P = .950), age (P = .804), flap area (P = .192), and type of reconstruction that was performed. Results: In all cases, the location of the perforator with a diameter greater than 1.0 mm was marked. All perforators determined during MDCT scanning were faultlessly localized intraoperatively. The distance between the intraoperative position of the perforator and the position obtained in the result of the examination did not exceed 1 cm. There was no need to change the planned design of the flap intraoperatively. In all cases where MDCT was performed, the duration of the surgical procedure varied from 60 to 150 minutes (average: 120.77 [18.90] minutes) and was reduced by 49.40 minutes (95% CI: 39.17-59.63) compared with the patients who did not undergo preoperative visualization of perforators where the average duration of the operation was 170.17 (19.19) minutes (from 140 to 220 minutes). Among the patients examined by MDCT, surgical complications were noted in 5 cases (13.51%) compared to 14 cases (40.00%) in the control group. Conclusions: The preoperative MDCT for the locoregional perforator flap reconstruction makes it possible to increase the efficiency of patient treatment given the reduction in surgery duration by 49.40 minutes (95% CI: 39.17-59.63) on average and the reduction in the level of postsurgery complications from 40% to 13.5% compared with the group of patients in whom presurgical visualization was not performed (P = .031).

Contexte : La reconstruction faisant appel à des lambeaux perforants permet de rendre la surface de la peau résistante à l'influence de facteurs mécaniques et de la rendre aussi semblable que possible à la couverture cutanée perdue. Cependant, tout en planifiant un lambeau, son approvisionnement en sang doit être pris en compte au même titre que sa forme et sa taille pour assurer une viabilité optimale. Par conséquent, la tâche visant à déterminer avec précision les rapports topographiques-anatomiques convenables pour la formation d'un pédicule perforateur reste pertinente. L'objectif de cette étude était d'augmenter l'efficacité de la reconstruction chirurgicale des lacunes post-blessures par transposition de volets perforateurs locorégionaux. Méthodes : Les auteurs ont réalisé une analyse rétrospective de 72 cas de reconstruction utilisant le détachement d'un pédicule vasculaire de volets perforateurs locorégionaux pour déterminer l'efficacité de la préparation diagnostique préopératoire aidée par la tomoangiographie numérisée à multidétecteurs (MDCT) dans le processus de reconstruction. 37 cas individuels d'interventions chirurgicales ont été choisis dans une étude cas-contrôles à partir du groupe d'étude quand la tomoangiographie numérisée à multidétecteurs a été utilisée pour la planification préopératoire des lambeaux perforants. 35 cas-contrôles similaires en termes de particularismes prédictifs importants pour la reconstruction avec le même niveau de difficulté. Les groupes de patients ont été appariés avec précision pour le genre (P = 0,950), l'âge (P = 0,804), la surface du lambeau (P = 0,192) et le type de reconstruction qui était exécuté. Résultats : Dans tous les cas, l'emplacement du perforateur avec un diamètre supérieur à 1 mm a été marqué. Tous les perforateurs déterminés au cours de la MDCT ont été localisés sans erreur en peropératoire. La distance entre la position peropératoire du perforateur et la position obtenue dans le résultat de l'examen n'a pas dépassé 1 cm. Il n'a pas été nécessaire de modifier le plan prévu du lambeau en peropératoire. Dans tous les cas où la MDCT a été réalisée, la durée de la procédure chirurgicale a été de 60 à 150 minutes (moyenne, 120,77 [18,90] minutes) et a été réduite de 49,40 minutes (IC à 95%: 39,17 à 59,63) comparativement aux patients qui n'ont pas eu de visualisation préopératoire des perforateurs; pour ces derniers, la durée de l'intervention a été de 170,17 (19,19) minutes (de 140 à 220 minutes). Parmi les patients examinés par MDCT, des complications chirurgicales ont été observées dans 5 cas (13,51%) comparativement à 14 cas (40,00%) dans le groupe témoin. Conclusions : La MDCT préopératoire pour la reconstruction avec lambeau perforateur locorégional permet d'améliorer l'efficacité du traitement des patients compte tenu de la réduction des temps opératoires de 49,40 minutes (IC à 95%, 39,17 à 59,63) en moyenne et de la réduction de 40% à 13,5% des complications postopératoires comparativement au groupe de patients n'ayant pas bénéficié de visualisation avant l'intervention (P = 0,031).

Hypnosis Influence on the Perfusion in Perforator Flaps in Early Postoperative Period: A Series of 18 Cases.

In practice worldwide, there are experiences affecting different body functions via central control mechanisms with the help of psychotherapy methods. In plastic and reconstructive surgery, there is the experience of applying hypnosis, with the main goal of eliminating pain. The aim of this research is to study the impact of hypnosis on the perfusion level in perforator flaps in the early postoperative period, which could enhance flap survival. PATIENTS AND METHODS: For studying the impact of hypnosis on blood circulation in perforator flaps, the analysis of a 18 cases has been conducted. All patients had hypnosis sessions on the second day after the reconstruction, and some had additional sessions on the third and fifth days. In the state of trance, the patient was given specially organized instructions aimed at improvement of perforator flap perfusion. Monitoring of microcirculation in the flap during hypnosis sessions was carried out using a Moor VMS-LDF1 Laser Doppler Perfusion and Temperature Monitor. RESULTS: When applying hypnosis, the vast majority of patients had significant increases in perfusion as well as flap surface temperature rise. Most of the patients had significant increases in perfusion during the second part of the hypnosis session in synchrony with hypnosis instruction translation aimed at increasing perfusion. CONCLUSIONS: The results of our research cannot be distributed widely in medical practice, but, despite that, they illustrate the central nervous system influence on perforator flap perfusion. Including hypnosis in a medical protocol can contribute to increasing the effectiveness of flap surgery.

Extensive Mine-Shrapnel and Gunshot Wound Closure Using Keystone Island Perforator Flaps.

BACKGROUND: During military operations, one aspect of a plastic surgeon's work is to restore extensive and deep wound defects in a short period of time and provide a high degree of functional recovery to the damaged area. Because many injuries caused by military operations cannot be closed using a primary suture, the specialist has to select another surgical approach to close the wound defect. Surgeons must select methods that not only cover the extensive wound defect in 1 step but also allow skin coverage that is anatomically, functionally, and visually similar to the surrounding tissues to reduce the length of the hospital stay and ensure optimal functional recovery of the damaged organ. METHODS: From 2014 to 2015, 25 patients underwent 36 reconstructions at our center after receiving mine-shrapnel and gunshot wounds. All reconstructions occurred during the acute period and used keystone island perforator flaps. The authors' wound management technique was characterized by an aggressive surgical and antibiotic therapy protocol. RESULTS: In all cases, after surgical debridement, the mine-shrapnel and gunshot wound defects were completely closed in 1 stage during the acute period. The working time in the operating room to perform the transposition of the flap ranged from 45 to 90 minutes, with an average of 68 minutes. All displaced flaps were similar in structure and color to the surrounding tissues and did not change the contours of the body. The adequate restoration of skin allowed patients to begin early recovery of functional activity. CONCLUSIONS: Local keystone island perforator flaps can be considered one of the primary methods of plastic closure of extensive defects caused by mine-shrapnel and gunshot wounds at different anatomical locations, providing that the tissue surrounding the defect is intact and usable as a donor resource.

Multidetector-row Computed Tomographic Angiography in the Planning of the Local Perforator Flaps.

UNLABELLED: The perforator vessels are highly variable in number, localization types, hemodynamic specifications, and the anatomical interactions with other structures. For these reasons, the identification of the best perforator before the operation is very important for the choice of the main feed vessel and the design of the perforator flap. METHODS: The authors retrospectively analyzed all cases in which multiple detector computed tomography (MDCT) with 3-dimensional (3D) image reconstruction was used in the preoperative planning in preparation for the reconstruction with local perforator flaps, which took place between July 2012 and December 2014 in the hospital. RESULTS: A total of 24 people were examined and underwent operations with 26 reconstructions using local perforator flaps. All perforators, which were identified during the MDCT with 3D reconstruction examination, were located intraoperationally without any errors. CONCLUSIONS: The preoperative MDCT with 3D reconstruction investigations of the topographic anatomical specifics of the perforator vessel on which the formation of the flap feed pedicle is planned allow for the fast and precise identification of the perforation at the preoperative stage while minimizing the amount of injury caused to the perforator during the operation and decrease the operation time.