Long Pedicled Superficial Circumflex Iliac Artery Flap Based on a Medial Superficial Branch.

BACKGROUND: A superficial circumflex iliac artery perforator flap has several advantages, such as reduced thickness, minimal donor-site morbidity, and inconspicuous scar. However, the application of a superficial circumflex iliac artery perforator flap is restricted because of its limited pedicle length. The aim of this article was to outline the technical modifications of superficial circumflex iliac artery perforator flap elevation to obtain long pedicles. METHODS: This is a prospective study of 31 consecutive patients who required a long pedicled superficial circumflex iliac artery perforator flap between September of 2016 and December of 2019 at the authors' center. According to a preoperatively marked pathway of the superficial branch of the superficial circumflex iliac artery, the superficial circumflex iliac artery perforator flap was designed. During the elevation, the design was modified according to the perforator location in the free-style technique. The characteristics of the patients and the flaps, including pedicle length, were recorded. The revision rate, complication rate, and need for a secondary procedure were analyzed. RESULTS: The mean follow-up period was 563 days (range, 92 to 1383 days). The mean length of the pedicle obtained was 6.9 cm (range, 6 to 8 cm) from the point where the pedicle merges into the flap. Long pedicles were anastomosed to the main source vessel or branch without tension. No major complications were reported. CONCLUSIONS: Overcoming the short pedicle length of a superficial circumflex iliac artery perforator flap by designing the flap laterally and performing an intraflap dissection is a reliable option when a longer pedicle is required, irrespective of the specific anatomy of the superficial circumflex iliac artery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Caso Clínico: Cirugía Reconstructiva de Tobillo / Case Report: Reconstructive Ankle Surgery

INTRODUCCIÓN: La diabetes mellitus es un importante problema de salud pública, según la Organización Mundial de la Salud, 422 millones de adultos en todo el mundo en 2014. En 2012 provocó 1.5 millones de muertes a nivel mundial; es la primera causa de amputación no traumática en miembros inferiores y las infecciones del pie ocurren con alta frecuencia en pacientes mal controlados. Este caso muestra la reconstrucción de defectos de partes blandas en el tercio inferior pierna, talón, maléolos y pie a través de la descripción del colgajo sural reverso. En este estudio se discuten las ventajas y desventajas de la utilización de esta técnica. CASO CLÍNICO: Paciente de sexo femenino 56 años de edad con antecedentes de Diabetes Mellitus tipo 2 mal controlada, que sufrió una fractura de tobillo izquierdo tratada con osteosíntesis; durante el postoperatorio acudió a emergencia, por presentar dolor de gran intensidad en tobillo izquierdo, fiebre, dehiscencia de herida quirúrgica, acompañada de secreción serosa. EVOLUCIÓN: La paciente luego de varias limpiezas quirúrgicas y cambios de terapia de cierre asistido por presión negativa, se consigue controlar la infección, con persistencia del defecto de cobertura ósea y del material de osteosíntesis. Se presentaron complicaciones adicionales como la rigidez articular, atrofia muscular; se decidió realizar reconstrucción del tercio distal del pie usando colgajo fasciocutáneo sural de flujo reverso, que evolucionó satisfactoriamente, consiguiendo cubrir el defecto con tejido biológico. CONCLUSIÓN: El colgajo sural de flujo reverso, es una técnica reproducible, que permite cubrir defectos de cobertura en tercio distal de pierna y tobillo; acortar los tiempos de hospitalización, especialmente cuando hay exposición ósea o de material de osteosíntesis.

BACKGROUND: Diabetes mellitus is a major public health problem, according to the World Health Organization, 422 million adults worldwide in 2014. In 2012, it caused 1.5 million deaths worldwide. Diabetes is the leading cause of non-traumatic amputation in lower limbs and foot infections occur with high frequency in poorly controlled patients. This case shows the reconstruction of soft tissue defects in the lower third leg, heel, malleoli and foot through the description of the reverse sural flap. In this study the advantages and disadvantages of the use of this technique are discussed. CASE REPORT: A 56-year-old female patient with a poorly controlled history of Diabetes Mellitus type 2, who suffered a fracture of the left ankle treated with osteosynthesis, and who during the postoperative period attended emergency orthopedics and traumatology, due to severe pain in the left ankle, fever, dehiscence of surgical wound, accompanied by serous secretion. EVOLUTION: The patient, after several surgical cleanings and changes in closure therapy assisted by negative pressure, manages to control the infection, with persistence of the bone coverage defect and the osteosynthesis material. There were additional complications such as joint stiffness, muscle atrophy; it was decided to reconstruct the distal third of the foot using a reverse flow sural fasciocutaneous flap, which evolved satisfactorily, managing to cover the defect with biological tissue. CONCLUSIONS: The sural flap of reverse flow is a reproducible technique that allows to cover coverage defects in the distal third of the leg and ankle; shorten hospitalization times, especially when there is bone exposure or osteosynthesis material.

Future Perspectives of Pre-expanded Perforator Flaps.

Although clinical application of a pre-expanded perforator flap is primarily focused on face and neck reconstructions, such a flap has also been used to reconstruct defects in the trunk, extremities, or hands. With better understanding of the improved blood supply to the flap and the mechanism on the prefabrication of blood supply within the flap, the pre-expanded perforator flap will definitely play a more important role in reconstructive surgery and can be used in selected patients by many plastic surgeons worldwide with good reconstructive and cosmetic outcomes.

Evolving Trends in Autologous Breast Reconstruction: Is the Deep Inferior Epigastric Artery Perforator Flap Taking Over?

BACKGROUND: Enthusiasm for the deep inferior epigastric artery perforator (DIEP) flap for autologous breast reconstruction has grown in recent years. However, this flap is not performed at all centers or by all plastic surgeons for breast reconstruction, and it is unclear whether practice patterns have measurably changed. This study aimed to (1) evaluate changing trends in breast flap use in the United States in recent years and (2) identify how these trends have affected charges and costs associated with autologous breast reconstruction. METHODS: Patients undergoing autologous breast reconstruction [latissimus dorsi (LD), pedicled transverse rectus abdominus myocutaneous (pTRAM), free TRAM (fTRAM), and DIEP] were identified using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database (2009-2011). A total of 19,182 hospital discharges were reviewed. Patient demographics, hospital teaching center status, payer status, length of stay, total charges, and total costs per discharge were reviewed. Statistical analysis was performed using linear regression, t test, and analysis of variance models. RESULTS: Between 2009 and 2011, the total number of discharges did not change significantly. Patient age distribution was similar for all flap groups. For individual flaps, there was a significant increase in DIEP flaps (P = 0.03), with a decreasing trend for other abdominal-based flaps. The patients receiving DIEP flap breast reconstruction were covered by private insurance at a higher rate than all other flap procedures (P = 0.03), whereas other potential cost determinants did not differ significantly between the groups. The mean charge per flap was $40,704 for LD, $51,933 for pTRAM, $69,909 for fTRAM, and $82,320 for DIEP. The mean cost per flap was $12,017 for LD, $15,538 for pTRAM, $20,756 for fTRAM, and $23,616 for DIEP. CONCLUSIONS: Between 2009 and 2011, the total amount of autologous breast reconstruction discharges was relatively stable, but the number of DIEP flaps increased significantly. Review of the Healthcare Cost and Utilization Project Nationwide Inpatient Sample data shows that, compared with LD, pTRAM, and fTRAM flaps, the DIEP flap is associated with higher charges and costs.

Perforator Flap versus Conventional Flap.

The introduction of perforator flaps represented a significant advance in microsurgical reconstruction. However, confusion has developed due to the erroneous belief that perforator flaps are different from conventional flaps. The concept of the perforator is not new, but is an idea that evolved from the conventional flap. In fact, some of the flaps used by microsurgeons were perforator flaps. The only difference is the anatomical level of the blood vessels involved; the perforator concept is focused on the distal circulation, so-called 'perforator'. Therefore, thinner sections of tissue can be taken from the conventional donor sites of myocutaneous flaps. With the use of perforators, there are no longer "flap of choice" for specific reconstructions, because conventional donor sites have become universal donor sites, enabling the harvesting of a variety of flaps. Moreover, depending on the surgeon's ability, any flap can be utilized as a perforator-based island flap whose source vessel has been completely preserved. Therefore, tissues can be efficiently customized and tailored into any configuration required for reconstruction. The application of perforator flap technique enables more precise dissection, and allows more selective harvesting of thinner flaps, which will expand options in reconstructive surgery. No doubt the technique will continue to evolve.

The evolution of perforator flap breast reconstruction: twenty years after the first DIEP flap.

It is over 20 years since the inaugural deep inferior epigastric perforator (DIEP) flap breast reconstruction. We review the type of flap utilized and indications in 2,850 microvascular breast reconstruction over the subsequent 20 years in the senior author's practice (Robert J. Allen). Data were extracted from a personal logbook of all microsurgical free flap breast reconstructions performed between August 1992 and August 2012. Indication for surgery; mastectomy pattern in primary reconstruction; flap type, whether unilateral or bilateral; recipient vessels; and adjunctive procedures were recorded. The DIEP was the most commonly performed flap (66%), followed by the superior gluteal artery perforator flap (12%), superficial inferior epigastric artery perforator flap (9%), inferior gluteal artery perforator flap (6%), profunda artery perforator flap (3%), and transverse upper gracilis flap (3%). Primary reconstruction accounted for 1,430 flaps (50%), secondary 992 (35%), and tertiary 425 (15%). As simultaneous bilateral reconstructions, 59% flaps were performed. With each flap, there typically ensues a period of enthusiasm which translated into surge in flap numbers. However, each flap has its own nuances and characteristics that influence patient and physician choice. Of note, each newly introduced flap, either buttock or thigh, results in a sharp decline in its predecessor. In this practice, the DIEP flap has remained the first choice in autologous breast reconstruction.