A New Option to Preserve Esthetics in Perioral Defect Reconstruction With Normal Anatomical Structures: Bipedicled Preexpanded Forehead Flap With Random Skin Flap Extension.

Plastic surgeons charged with reconstructing extensive perioral defects face dual challenges of functional restoration and esthetic considerations. While forehead flaps are commonly used to reconstruct perioral defects, in cases involving partial upper lip defects where normal anatomical structures are preserved, traditional forehead flaps may compromise esthetics. This study aimed to address this issue by employing bipedicled preexpanded forehead flaps based on the frontal branches of the superficial temporal artery (hereafter, "STA-bfb-based preexpanded forehead flap") with random flap extensions to repair perioral defects. Between April 2004 and July 2020, 7 patients (5 males and 2 females; 6 had post-burn facial scars involving the entire lower lip and part of the upper lip, and 1 presented with noma sequelae) underwent perioral defect reconstruction using this approach. Tissue expanders were placed in the forehead donor area, and an STA-bfb-based preexpanded forehead flap with random flap extensions was used to repair the perioral defect. The flap pedicle was divided into 3 weeks. All flaps remained viable with no perfusion-related complications. At follow-up 12 to 96 months later, the color and texture of the flaps demonstrated excellent compatibility with the surrounding skin, suggesting that the use of an STA-bfb-based preexpanded forehead flap with random skin flap extensions is a reliable method for repairing perioral defects. The authors' results have implications for plastic surgeons seeking a solution for challenging perioral defect reconstructions, balancing the need for esthetic outcomes with functional restoration.

Successful Reconstruction of Complex Sacrococcygeal Defects Using Chimeric Perforator Propeller Flap.

BACKGROUND: Complex soft tissue defects, which result from the surgical resection of sacral tumors, manifest as a combination of skin defects, dead space, infection, and prosthesis exposure. Because the traditional musculocutaneous flap lacks flexibility because of the close connection between the skin flap and the muscle component, the musculocutaneous flap is not suitable for reconstructing complex soft tissue defects where the dead space and skin defects are located at different sites. Furthermore, the perforator flap is also not appropriate for reconstructing complex defects because it lacks the muscular component. We considered the possibility of using the chimeric perforator propeller flap for reconstructing complex sacrococcygeal defects. METHODS: This study included 7 patients who underwent, between July 2007 and July 2021, the reconstruction of complex soft tissue defects of the sacrococcygeal region using a chimeric perforator propeller flap. RESULTS: Among the included cases, the etiologies were chordoma (n = 3), sacral tumor (n = 3), and squamous cell carcinoma (n = 1). In all the cases, vacuum-assisted closure therapy was used to treat wound infections before surgery. The average sizes of the skin and muscle flaps were 195.8 cm 2 (range, 100-350 cm 2 ) and 83.6 cm 2 (range, 60-140 cm 2 ), respectively. The superior gluteal artery was the source artery for the chimeric perforator propeller flap. The donor sites were primarily closed in all cases. One patient had delayed wound healing, and the secondary wound healed using conservative dressing changes. The other 6 flaps had no complications. The average follow-up time was 5.3 months (range, 1-9 months). Muscle weakness and compromised ambulation in the affected lower extremities were not observed in any of the patients. Furthermore, all 7 patients had no tumor recurrence, prosthesis exposure, and infection events in the sacrococcygeal region. CONCLUSIONS: The chimeric perforator propeller flap may be an option for reconstructing complex soft tissue defects in the sacrococcygeal region.

Utility of Indocyanine Green Angiography for Preventing Pre-expanded Extended Lower Trapezius Myocutaneous Flap Necrosis: How to Make the Correct Decision for Hypoperfused Areas.

BACKGROUND: Designing a skin flap that perfectly covers the anatomical and dynamic territories is challenging. Tissues capturing territories beyond may be insufficiently perfused, and these hypoperfused areas can lead to partial flap necrosis. Indocyanine green angiography (ICGA) is an effective tool for identifying hypoperfused areas. This retrospective study proposes a standardized strategy for managing the hypoperfused areas identified by ICGA in pre-expanded extended lower trapezius myocutaneous (e-LTMC) flaps. METHODS: Patients who underwent pre-expanded e-LTMC flap surgery with perfusion assessment using ICGA between June 2016 and January 2022 were identified. A standardized protocol was applied, and patients were divided into four groups according to different management options for hypoperfused areas detected by ICGA. Preoperative and operative variables of interest and postoperative outcomes, including flap necrosis and flap survival length, were collected and analyzed. RESULTS: Sixty-nine flaps were included in the study. No total flap necrosis was observed. Partial necrosis occurred in 10 flaps. Significant differences were observed in the incidence of full-thickness necrosis between the management groups. The incidence of flap necrosis in cases where management relied on ICGA findings was significantly lower than that of cases where management did not rely on ICGA findings. There were no differences in the relative survival length of the flap between cases with and without intervention for the hypoperfused areas. CONCLUSION: The proposed standard strategy effectively reduced the necrosis rate of the pre-expanded e-LTMC flap, thus it is sensible to act on the ICGA findings. Prophylactic resection of the hypoperfused area should be recommended. Where resection may lead to poor reconstructive outcomes, flap trimming or a second flap should be the preferred option.

A Comparison of Handheld Doppler and Indocyanine Green Angiography for Perforator Localization.

BACKGROUND: The preoperative identification of perforators is critical to the success of perforator flaps. Several technologies, including handheld Doppler (HHD) and indocyanine green angiography (ICGA), facilitate this process; however, each technology comes with unique downsides. This study directly compares the performance of HHD and ICGA in preoperative perforator identification and measures the effects of flap thickness and body mass index (BMI) on perforator localization. METHOD: Data from preoperative HHD and ICGA assessments were compared with the criterion standard of intraoperative perforator localization. Sensitivity, specificity, accuracy, and positive predictive values were calculated for both and correlated with flap thickness and BMI. RESULTS: Thirty flaps were transferred in 30 patients across 15 different donor sites. Indocyanine green angiography had higher sensitivity, accuracy, and positive predictive value (79.2%, 74.2%, and 87.5%, respectively) than HHD (55.6%, 46.6%, and 69.4%, respectively). Perforators detected by ICGA were used as flap pedicles in 21 cases compared with 13 with HHD. There were no correlations between HHD or ICGA performance and patient BMI (both P > 0.05). Increasing flap thickness was negatively correlated with the accuracy of ICGA ( P = 0.001) but not HHD ( P > 0.05). CONCLUSIONS: Indocyanine green angiography was more sensitive, specific, and accurate than HHD in identifying perforators across various donor sites; however, its performance suffered in thicker flaps, whereas HHD did not. Patient BMI was not correlated with the performance of either technology. Additional research can further delineate the interrelationships of flap thickness and technologies for perforator localization.

Lower Trapezius Myocutaneous Propeller Flap Based on Dorsal Scapular Artery.

BACKGROUND: The pedicled lower trapezius myocutaneous flap is generally transferred to the recipient site through a subcutaneous tunnel, and a portion of the flap buried in the tunnel needs to be de-epithelialized. Thus, considerable amount of normal skin is sacrificed, and the redundant tissue buried in the tunnel can cause bulging deformity. We believe that transferring the lower trapezius myocutaneous flap in a propeller fashion can avoid the aforementioned issues. METHODS: A retrospective review was performed on all lower trapezius myocutaneous propeller flap reconstructions by a single surgeon from July 2013 to March 2021. Data on patient demographics, diagnosis, features of the defect, characteristics of the flap, and the outcome were collected and analyzed. RESULTS: Thirty-three lower trapezius myocutaneous propeller flaps were used to reconstruct soft tissue defects in the head, neck, and back. The etiologies were malignancy, trauma, postburn scar contracture, and congenital melanocytic nevus. The mean skin paddle dimensions were 29.0 cm in length (range, 13-45 cm) and 10.9 cm in width (range, 6-15 cm). The donor sites were closed primarily in 30 patients, closed using a skin graft in 1 patient, and covered with the second flap in 2 patients. Venous congestion occurred in the distal portion of 4 flaps and partial necrosis in the distal 6 cm of 1 flap. The average follow-up time was 17.5 months (range, 1-56 months). The normal contour of the back was preserved without bulging deformity. No patient developed a winged scapula or a decrease in shoulder elevation. CONCLUSIONS: The lower trapezius myocutaneous propeller flap may be an option for reconstruction of soft tissue defects of the head, neck, and back with less waste of normal tissue and bulging deformity.

Use of Serial Flap Transfer Technique in En Bloc Reconstruction of Extensive Soft Tissue Defects in the Head and Neck.

ABSTRACT: En bloc reconstruction of extensive head and neck defects is feasible with matched tissue from the medial arm or chest. Nevertheless, the donor site faces significant morbidity following massive cutaneous flap harvesting. The serial flap transfer technique can increase the reconstructive ability of these flaps and minimize the donor site morbidity. A retrospective review was conducted from 2016 to 2020 on all patients who had undergone extensive head and neck reconstruction with the serial flap transfer technique. En bloc reconstruction of defects in the head and neck was performed using expanded perforator-plus flaps from the medial arm or chest; various flaps from the back were used to close the donor-site defects. Flap type, flap survival, complications, and revision procedures were assessed. This case series included 16 patients. The donor site of the chest or medial arm was successfully closed with the assistance of the thoracodorsal artery perforator flap, the latissimus dorsi myocutaneous flap, ortheparascapular flap. A medial arm flap with a width of 15 cm and a chest flap with a 16 cm width could be transferred with the primary closure of the donor sites. All flaps survived, except 1 had marginal necrosis. Complications occurred in 2 patients and were successfully managed nonsurgically. Both the recipient and donor sites were restored with good aesthetic results. Application of the serial flap transfer technique in extensive head and neck reconstruction decreases the donor site morbidity to a minimum and improves the overall outcomes.

Use of Indocyanine Green Angiography to Identify the Superficial Temporal Artery and Vein in Forehead Flaps for Facial Reconstruction.

ABSTRACT: The superficial temporal artery (STA) frontal branch flap is susceptible to venous congestion because of its unpredictable and variable outflow. The authors applied indocyanine green angiogra-phy in identifying the superficial temporal vessels to help surgeons with proper flap designs to avoid severe complications. A retrospective review from 2015 to 2020 was conducted. All the patients who underwent indocyanine green angiography before forehead flap transfer for facial defect reconstruction were reviewed. The STA and vein were observed using indocyanine green angiography preoperatively. The relationship between the artery and vein was investigated. The venous anatomy was analyzed to guide the pedicle design. The survival of the flap and complications were assessed. A total of 12 patients were identified and included in this study. Indocyanine green angiography allows clear visualization of the detailed anatomy of the STA and vein. The frontal branch of the vein had great variations and generally diverged from the arterial branch. The tiny venae comitantes provided sufficient drainage for 2 small forehead flaps. The frontal branch of the vein entered the forehead and was used as the outflow channel in 4 patients. The parietal branch of the vein, which consistently gave off secondary tributaries to the superior forehead, was included in the pedicle in 6 patients. All flaps survived without complications. indocyanine green angiography provided accurate localization of the superficial temporal vessels. This technique may be helpful in the precise planning forehead flap surgeries and in avoiding the risk of venous congestion.

Defect Reconstruction Using the Propeller Flaps Based on the Perforators Derived From the Lateral Circumflex Femoral Artery System.

BACKGROUND: Although propeller flaps are a useful option for soft tissue defect reconstruction, reports based on the perforators of the lateral circumflex femoral artery (LCFA) are rare. We aimed to present our experience in defect reconstruction using the propeller flaps based on perforators from different branches of LCFA and apply these flaps in soft tissue defect reconstruction of the lower extremities. METHODS: Twenty nine patients (32 flaps) underwent defect reconstruction using propeller flaps based on the perforator of the LCFA. Defects were located from the groin to the proximal leg. According to the source vessels from which the perforator originated, flaps were categorized into types I, II, III and IV, which represented perforators from the transverse, descending, oblique, and rectus femoris branches, respectively. Type II flaps were subdivided into types IIa and IIb flaps based on antegrade and reverse flows of the descending branch. RESULTS: Flap sizes ranged from 12 × 6 cm to 30 × 15 cm (average, 22.69 × 9.19 cm) with the length of the vascular pedicle ranging from 3 to 7 cm (average, 4.86 cm). Flaps were rotated from 60° to 180° (average, 144.06°). There were 3 type I, 10 type IIa, 4 type IIb, 13 type III and, and 2 type IV flaps. Twenty-nine flaps survived after surgery. Total flap necrosis and venous congestion of the distal flap portion occurred in 1 and 2 patients, respectively. CONCLUSIONS: Reconstruction using propeller flaps based on perforators of the LCFA is a safe, reliable, and versatile option for defect reconstruction of the lower extremities; however, it requires meticulous surgical dissection and patience.

Cervicofacial Defect Reconstruction Using the Pre-Expanded Medial Arm Flap Without Immobilization of the Upper Extremity.

SUMMARY: The medial arm flap has multiple advantages when used for cervicofacial defect reconstruction but remains underused. The main drawback of the medial arm flap is that the patient must maintain the passive immobilized posture before the pedicle division. This clinical study aims to introduce a reconstructive method for cervicofacial defects using the medial arm flap without the immobilization of the upper extremity. This retrospective study was performed with data from 14 patients requiring pre-expanded medial arm flaps to reconstruct cervicofacial defects. Indocyanine green (ICG) angiography was used to detect perforators and evaluate the flap perfusion; all the flaps underwent pre-transfer tissue expansion. A total of 15 full-length medial arm flaps were used. All the perforators identified by ICG angiography were directly visualized during flap elevation. In four cases, poor perfusion areas in the flaps were noted by intraoperative ICG angiography. Combined with the clinical observation, parts with poor perfusion were resected. The average flap size was 203.9 ±â€Š75.2 cm2 and ranged 20 to 28 cm in length after tissue expansion. The medial arm donor sites were closed directly or using another flap. All flaps survived completely. The patients were followed-up for 1 to 22 months. All patients and their family members were satisfied with the outcomes. Cervicofacial defect reconstruction using a medial arm flap with the aid of tissue expansion and ICG angiography can provide sufficient tissue for defect resurfacing and also eliminate the necessity of the immobilization of the upper extremity during surgery.

Periorbital and Perioral Defect Reconstruction Using the Split Pre-Expanded Medial Arm Flap Aided by Using Indocyanine Green Angiography.

ABSTRACT: The pre-expanded medial arm flap provides suitable skin for the resurfacing of a periorbital or perioral defect. However, the flap must be intraoperatively split to imitate the appearance of the oral or ophthalmic fissure, which can compromise flap perfusion. This study aimed to evaluate the safety and effectiveness of splitting pre-expanded medial arm flaps with the aid of indocyanine green angiography. All 8 patients underwent periorbital or perioral soft tissue reconstruction using a split pre-expanded medial arm flap. Flap splitting was aided by indocyanine green angiography. It was used during 2 stages of the procedure, tissue expander placement and flap transfer. The pedicle was divided 3 weeks later, and the flaps were used to resurface the defect. The distal portion of the flap was split into a fishmouth pattern in 5 patients and a window pattern in 3 patients. The donor sites were closed directly or by using a latissimus dorsi myocutaneous flap. There were no perioperative complications or flap necrosis. A pre-expanded split medial arm flap could be an option for the reconstruction of periorbital and perioral defects. With the assistance of indocyanine green angiography, vessel distribution and distal flap perfusion can be reliably evaluated, facilitating the safe splitting of the flap for the reconstruction of defects.

Improving the Versatility of the Latissimus Dorsi Myocutaneous Flap Using the Perforator Propeller Flap Concept.

BACKGROUND: The latissimus dorsi myocutaneous flap is widely used in reconstructive surgery; however, primary donor-site closure remains challenging when a wide flap is harvested. METHODS: A large latissimus dorsi myocutaneous flap was elevated and transferred to repair defects. Perforators adjacent to the donor site of the myocutaneous flap were explored using an ultrasound Doppler probe or a technique of extensive exploration along the margins of the donor site wound. A single or multiple perforator propeller flaps based on these perforators were used to close the donor site defect. RESULTS: From June 2012 to April 2018, this method was used to restore posttraumatic and oncologic defects of the chest wall in 14 cases, upper extremity in 6 cases, and lower extremity in 1 case. The size and width of the latissimus dorsi myocutaneous flaps ranged from 16 × 11 cm to 33 × 17 cm (mean area, 335.6 cm) and 9 cm to 20 cm (mean width, 14 cm), respectively. The donor site defect was closed primarily by using a single flap in 11 cases, dual flap in 9, and triple flap in one. Donor site breakdown was not observed in any of the cases. CONCLUSIONS: The perforator propeller flap could be used to reconstruct a latissimus dorsi myocutaneous flap donor site defect, ensuring not only the harvesting of a wide flap but also achieving primary donor site closure, thus greatly improving the versatility and capability of the latissimus dorsi myocutaneous flap in the reconstruction of large-sized defects.

Use of Indocyanine Green Imaging for Perforator Identification in Preexpanded Brachial Artery Perforator Flaps.

The tissues of the medial arm as a donor site for perforator flap design have several advantages. However, they are relatively underused with limited reports, partly due to unreliable perforator anatomy. Therefore, we aimed to review our preliminary experience using indocyanine green (ICG) angiography to design and elevate preexpanded pedicled brachial artery perforator (BAP) flaps for regional reconstruction. All patients underwent soft tissue reconstructions using a preexpanded BAP flap in two or three stages. ICG angiography was used to localize perforators during both expander insertion and flap elevation. The pedicle was divided at the third stage 3 weeks following flap elevation for head and neck cases. Sixteen patients underwent reconstructions of the head and neck (n = 13) or shoulder/trunk (n = 3) using 14 perforator-plus and 2 propeller BAP flaps. In total, 50 perforators were identified using ICG imaging, all of which were appreciable during both expander placement and flap elevation. Thirty-five perforators were directly visualized during flap elevation, and an additional 15 perforators were not explored but incorporated into the flap. All flaps survived without necrosis, and the donor sites healed uneventfully without complications. The medial arm provides thin and pliable skin for the resurfacing of regional defects with relatively minimal donor-site morbidity. With the assistance of ICG angiography, perforators of the brachial artery can be reliably identified, facilitating the preexpansion and elevation of pedicled BAP flaps for use in head-neck and trunk reconstruction.

Perforator Propeller Flap "Relay" for Distal Lower Extremity Soft Tissue Reconstruction.

The peroneal artery perforator propeller flap is commonly used for distal lower extremity reconstruction; however, closure of the donor site defect can limit the utility of this flap. To overcome this limitation, we introduced a perforator propeller flap relay technique to reconstruct the donor-site defect. Between July 2015 and February 2019, the propeller flap relay technique was applied in 9 patients. In each case, a peroneal artery perforator propeller flap was transferred to repair a defect in the distal lower leg or the foot. In addition, a neighboring perforator propeller flap was transferred to close the donor-site defect. The peroneal artery perforator propeller flaps ranged from 14 × 4 to 29 × 8 cm2 in size. Donor-site closure was accomplished using the relaying propeller flaps based on perforators from the peroneal, medial sural, and lateral sural arteries. Normal contour of the lower leg was preserved with acceptable scars. Additional time for the second flap procedure was less than 1 hour in each case. One peroneal artery perforator flap presented with partial flap necrosis. Other flaps survived completely without complication. Coverage of the donor-site defects of the peroneal artery perforator flaps can be achieved using various perforator propeller flaps. The perforator propeller flap relay technique allows surgeons to harvest a large peroneal artery perforator flap without being limited by significant donor-site morbidity. This technique can reconstruct defects at distal lower extremity with low morbidity and improved overall reconstructive results.

Intraoperative Perfusion Assessment in Mastectomy Skin Flaps: How Close are We to Preventing Complications?

BACKGROUND: Mastectomy flap necrosis is the source of considerable morbidity and cost following breast reconstruction. A great deal of effort has been put forth to predicting and even preventing its incidence intraoperatively. METHODS: A review of the literature was performed evaluating the evidence of mastectomy skin flap perfusion technologies. RESULTS: Multiple technologies have leveraged spectroscopy and/or angiography to provide real-time assessment of flap perfusion, including indocyanine green, fluorescein, and light-based devices. CONCLUSION: This manuscript endeavors to review the evidence on mastectomy skin flap perfusion analysis, highlighting the benefits, and downsides of the current technologies and identifying exciting areas of future research and development.

Facial Defect Reconstruction Using the True Scarless Pre-Expanded Forehead Flap.

OBJECTIVE: This clinical study describes a reconstructive method for facial soft-tissue defects that uses the pre-expanded forehead flap and minimizes donor site morbidities. METHODS: The surgery was subdivided into 3 stages. First stage, an appropriately sized expander was buried underneath the forehead. Second stage, after adequate inflation of the expander, a forehead flap based on the frontal branches of the superficial temporal artery was raised, and the distal portion of the flap was used to reconstruct the facial defect. The cutaneous pedicle of the flap was designed near the frontal hairline. Third stage, 3 weeks later, the flap pedicle was divided, and the forehead incisional scar was melted into the neoreconstructed hairline. RESULTS: Between July 2010 and December 2016, 16 patients underwent facial defect reconstruction. Etiologies included postburn scar (31%), melanocytic nevus (56%), and hemangioma (13%). The mean size of the defects was 8.78 × 5.06 cm (range, 3 × 2.5 to 15 × 7 cm). The average dimension of the forehead flap was 21.63 × 7.38 cm (range, 12 × 4 to 28 × 10 cm). Fifteen flaps survived without any perfusion-related complications. Venous congestion occurred in 1 flap and gradually subsided without any flap loss. Patients were followed after surgery, ranging from 4 to 48 months. Patients and/or their family members were satisfied with the final aesthetic outcomes. CONCLUSION: Facial defect reconstruction using a pre-expanded forehead flap, with the donor-site incisional scar designed along the hairline, can not only provide sufficient tissue for defect reconstruction, but also maximally reduce donor-site morbidities.

Distally Based Anterolateral Thigh Flap Algorithm for Unexpected Situations during Soft-Tissue Defect Reconstruction around the Knee.

BACKGROUND: The distally based (d) anterolateral thigh (ALT) flap is an effective option for soft-tissue reconstruction around the knee; however, unexpected situations may occur intraoperatively, impeding flap harvest. The authors proposed an algorithm for surgical conversion for unexpected situations encountered intraoperatively. METHODS: Between 2010 and 2021, 61 dALT flap harvests were attempted for soft-tissue defect reconstruction around the knee; 25 patients underwent surgical conversion for anomalies, including lack of a suitable perforator, hypoplasia of the descending branch, and compromised reverse flow from the descending branch. After excluding improper cases, 35 flaps were harvested as planned (group A) and 21 surgical conversion cases (group B) were finally enrolled for analysis. An algorithm was developed based on the cases in group B. Outcomes, including complication and flap loss rates, were compared between groups to verify the algorithm's rationality. RESULTS: In group B, the dALT flap was converted to a distally based anteromedial thigh flap ( n = 8), bipedicled dALT flap ( n = 4), distally based rectus femoris muscle flap ( n = 3), free ALT flap ( n = 2), or other locoregional flap that required additional incision ( n = 4). No differences in outcomes were observed between the two groups. CONCLUSION: The proposed contingency planning algorithm for dALT flap surgery proved rational, as surgical conversion could be made by means of the same incision in most cases, and outcomes generated by the algorithm were acceptable. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Extensive Defect Reconstruction Using Multiple Perforator Propeller Flaps in a Jigsaw Puzzle Approach.

BACKGROUND: Reconstruction of extensive defects remains challenging for plastic surgeons. We report our experience with extensive defect reconstruction using multiple perforator propeller flaps and provide a systematic review of the literature on this approach. METHODS: This retrospective study included patients who underwent defect reconstruction with multiple perforator propeller flaps from 2014 to 2021. A systematic review was conducted by retrieving studies on reconstructive strategy from PubMed, Web of Science, EMBASE, and Scopus published before December 1, 2022. RESULTS: Thirty patients underwent defect reconstruction using 65 perforator propeller flaps. The posterior trunk (66.7%) was the most common site of defects. Complete flap survival was achieved in 61 flaps (93.8%). Partial necrosis of four flaps in three patients and venous congestion of one flap resulted in an overall complication rate of 13.3%. One flap experienced distal tip necrosis in 21 patients undergoing posterior trunk or perineal defect reconstruction, leading to an overall complication rate of 4.7%. Other complications were observed during the reconstruction of defects in the lower extremities (one of five patients) and anterior trunk (two of four patients). In the systematic review, 11 articles involving 74 patients were identified. The commonly reported locations of the defects were the perineum (55.4%) and posterior trunk (33.8%). Flap-related complications included venous congestion, and no flaps were lost. CONCLUSIONS: This study on the use of multiple perforator propeller flaps in a jigsaw puzzle approach demonstrated that the method can be effectively used for extensive posterior trunk and perineal defect reconstruction.

Pre-expanded Brachial Artery Perforator Propeller Flap: An Addition to the Armamentarium for Postburn Axillary Contracture Reconstruction.

BACKGROUND: Postburn axillary contracture is a common complication that leads to functional impairment and unsatisfactory aesthetic outcomes. This article aims to present our experience with axillary contracture reconstruction using pre-expanded brachial artery perforator propeller (BAPP) flaps and provide a systematic review of other regional or free flaps. METHODS: This retrospective study included patients who underwent postburn axillary contracture reconstruction using pre-expanded BAPP flaps from 2015 to 2022. Data on the flap characteristics and function of the affected shoulders were recorded. A systematic review was conducted by retrieving studies that assessed the outcomes of regional or free cutaneous/fasciocutaneous flaps for treating axillary contracture from PubMed, Web of Science, EMBASE, and Scopus published before October 1, 2023. RESULTS: Twelve pre-expanded BAPP flaps measuring up to 26 cm × 11 cm (mean, 116.9 cm 2) survived completely with no major complications, and the donor sites were closed primarily. The average range of shoulder abduction increased from 77.9° to 141.7° (p=0.002). The systematic review included 34 articles, reporting 12 regional and three free flaps. The most reported flaps were the thoracodorsal artery perforator flap, scapular flap, and parascapular flap. The overall complication rate ranged from 0 to 25%, and the average change in shoulder abduction ranged from 72.5° to 99.4°. CONCLUSIONS: Pre-expanded BAPP flaps can be effectively used for reconstructing postburn anterior axillary fold contracture. The donor site availability and the specific axillary contracture type should be considered when selecting a regional or free flap.

Finding Perforator "Freeway" for Design Optimization of Expanded Flaps by Indocyanine Green Angiography.

SUMMARY: Indocyanine green angiography (ICGA) is a useful tool for the visual assessment of superficial blood flow. Herein, we used ICGA to visualize perforator branches and linking vessels to provide a road map for flap design of an expanded flap. Twenty-eight expansions were planned to use back-cut technique in 26 patients. ICGA was used to visualize perforator branching pattern with the linking vessels and the venous network in the expanded flap before expander explantation. The appropriate perforator was selected, and the flap was designed following the axiality of its branch linked by true anastomoses. The vein running closely was chosen as the axial vein. The back cut was designed to avoid transection of the axial artery and vein. Patient demographics, defect characteristics, and reconstructive outcomes were assessed. ICGA clearly visualized the perforator branches and the linking vessels in the expanded flap at the head and neck, trunk, and extremity. The back-cut flap containing the axial artery and vein was raised successfully in 27 expansions. The arterial perforator and superficial vein separated greatly and resulted in design modification from back-cut to advancement flap in one expansion. All expanded flaps met the reconstructive needs and exhibited complete survival. ICGA allowed the visualization of the preoperative topography of the vascular network in the expanded flap and helped surgeons locate the vascular axis and perform an appropriate back-cut design for efficient and safe flap transfer.

Extrinsic Vascular Pathway Preservation Improves Survival in a Rat Three-territory Flap Model Based on the Deep Circumflex Iliac Artery.

BACKGROUND: Extended flaps are commonly applied for large defects. However, a postoperative flap necrosis incidence of 11%-44% remains a major complication. Previous clinical studies have shown that maintaining the extrinsic vascular pathway can increase the survival area of extended flaps. The authors hypothesized that preserving the extrinsic vascular pathway would improve flap survival by reducing blood resistance within the vascular territory. METHODS: Twenty-four adult male Sprague-Dawley rats were used. Tissue samples were obtained from eight untreated rats as a baseline control. Three-territory flaps were elevated in the remaining sixteen rats. The extrinsic vascular pathway was preserved or ligated. Flap perfusion was assessed immediately using indocyanine green angiography. Rats were sacrificed on day 7. The flap survival area was measured using Adobe Photoshop. Hematoxylin and eosin staining, CD-31 immunostaining, and western blot analysis of VEGF protein expression were used to quantitatively assess vasodilation and angiogenesis in choke zones. RESULTS: Indocyanine green angiography revealed that blood could flow through the preserved extrinsic vascular pathway and perfuse the third vascular territory of the flap. Extrinsic vascular pathway preservation significantly increased flap survival area (86.3%, 19.3% difference, p < 0.001), promoted vasodilation (5.0 /choke zone, 3.0 /choke zone difference, p = 0.013) and angiogenesis (29.3 /mm 2, 14.3 /mm 2 difference, p = 0.002), and increased VEGF expression (0.6, 0.2 difference, p = 0.067) in the second choke zone. CONCLUSIONS: Extrinsic vascular pathway preservation improves flap survival in this rat three-territory flap model. Further investigation in large animal models is required for clinical translation.