• Archives of Plastic Surgery
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• 제40권6호
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• pp.754-760
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• 2013

Background Classical flaps for perinasal defect reconstruction, such as forehead or nasolabial flaps, have some disadvantages involving limitations of the arc of rotation and two stages of surgery. However, a perforator-based flap is more versatile and allows freedom in flap design. We introduced our experience with reconstruction using a facial artery perforator-based propeller flap on the perinasal area. We describe the surgical differences between different defect subtypes. Methods Between December 2005 and August 2013, 10 patients underwent perinasal reconstruction in which a facial artery perforator-based flap was used. We divided the perinasal defects into types A and B, according to location. The operative results, including flap size, arc of rotation, complications, and characteristics of the perforator were evaluated by retrospective chart review and photographic evaluation. Results Eight patients were male and 2 patients were female. Their mean age was 61 years (range, 35-75 years). The size of the flap ranged from $1cm{\times}1.5cm$ to $3cm{\times}6cm$. Eight patients healed uneventfully, but 2 patients presented with mild flap congestion. However, these 2 patients healed by conservative management without any additional surgery. All of the flaps survived completely with aesthetically pleasing results. Conclusions The facial artery perforator-based flap allowed for versatile customized flaps, and the donor site scar was concealed using the natural nasolabial fold.

• Archives of Reconstructive Microsurgery
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• 제25권2호
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• pp.69-71
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• 2016

Reconstruction of the lower extremities is difficult due to a lack of skin laxity and muscular tissues. Here, we present a case of lower extremity reconstruction via the anterior tibial artery perforator based segmental muscle island flap. Our patient was a 75-year-old male with a chronic ulcerative wound on the right lower leg from an old car accident. A $5.0{\times}0.5cm$ size ulcerative wound with tibial bone exposure was noted. We planned to reconstruct the lower extremity defect with a free flap, but the vessel status was severely compromised intraoperatively. Thus, we found the anterior tibial artery perforator using Doppler ultrasound, elevated the tibialis anterior muscle segment flap, and transposed it to cover the defect successfully. The flap presented with a nice contour and the skin graft covering the flap survived completely. There were no complications of the surgical site at three months follow-up and no gait morbidity. This is a meaningful case applying the concept of segmental muscle flap based on a perforator that had advantages including proper bulkiness, vascularization, and preservation of function, which were well applied, leading to great success.

• 대한두개안면성형외과학회지
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• 제23권2호
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• pp.64-70
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• 2022

Background: Anterolateral thigh (ALT) flaps are versatile soft tissue flaps that have become the standard soft-tissue flaps used for head and neck reconstruction. They provide a long vascular pedicle, constant vessel diameter, abundant soft tissue coverage, and minimal donor site morbidity. The ALT flap was initially designed on the basis of a septocutaneous (SC) perforator. However, more recent research has shown that a substantial number of ALT flaps are now based on musculocutaneous (MC) perforators, and the ratio between MC and SC perforators varies among studies. In this study, we analyzed the perforating pattern of ALT flaps along with their clinical outcomes during head and neck reconstruction in the Korean population. Methods: From October 2016 to July 2020, 68 patients who had undergone an ALT flap procedure for head and neck reconstruction were enrolled retrospectively. The perforating pattern of the cutaneous perforator vessel (MC perforator/SC perforator/oblique branch), pedicle length, and flap size were analyzed intraoperatively. Patient demographics and flap necrosis rates were also calculated. Results: The highest number of cutaneous perforator vessels supplying the ALT flap were the MC perforators (87%). The proportion of MC perforators was significantly higher than that of the SC perforators and oblique branches. Flap necrosis occurred in seven cases (11.86%); sex, hypertension, diabetes mellitus, coronary artery disease, perforator course, and history of radiotherapy did not significantly affect flap necrosis. Conclusion: The ALT free flap procedure remains popular for reconstruction of the head and neck. In this study, we observed that the majority of cutaneous vessels supplying the flaps were MC perforators (87%). When using the MC perforator during flap elevation, careful dissection of the perforator is required to achieve successful ALT flaps because intramuscular dissection is difficult. Perforator pattern and history of radiotherapy did not affect flap necrosis.

• Archives of Plastic Surgery
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• 제34권5호
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• pp.562-568
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• 2007

Purpose: Many studies reported anatomy of posterior tibial artery perforator. But, it is not easy to use this flap in clinical case. Methods: Authors performed cadaver dissection on 26 legs from 13 cadavers and identified the number, location, type, length and diameter of perforator. Based on anatomic study, posterior tibial artery perforator flap was performed on 3 clinical cases. Results: The perforator was found on a line drawn from the medial boarder of central patella to posterior boarder of medial malleolus. The main perforator which was longer and greater caliber than others was found was found 13 to 17cm distant from medial boarder of central patella in 23 of 26 leg(88.5%). Average length was 6.2cm and average diameter was 1.4mm. The main perforator was musculocutaneous perforator at 20 of 26 leg(77%). The posterior tibial artery perforator flap was clinically use in 3 cases. All flap were survived without any complication. Conclusion: The author found the main perforator of posterior tibial artery perforator flap was located 15cm distant from medial boarder of central patella within the circle drawn with a radius of 4cm. The posterior tibial artery perforator flap is expected to be used as one of the option for the reconstruction of hand and foot.

• Archives of Reconstructive Microsurgery
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• 제16권1호
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• pp.23-29
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• 2007

The reconstruction of deep soft tissue defect such as pressure sore has difficult problems. Myocutaneous flaps have been used commonly as the best coverage method for pressure sore. But, they have several drawbacks such as sacrifice of functional muscle, high morbidity of the donor sites and bulkiness at the recipient site. The concepts of perforator flap has recently developed and widely used to overcome these disadvantages. Between March 2005 to July 2006, we have treated 9 patients who had pressure sore using perforator based fasciocutaneous island rotation flap. Preoperative unidirectional Doppler was used in all cases. Mean number of perforator vessels was 3.8 and flap sizes were from $7{\times}5\;cm$ to $14{\times}13\;cm$. Rotation angles of flap were from 90 degree to 180 degree. In all cases, donor sites were closed primarily. All flap survived completely and postoperative complications were wound dehiscence in 1 case, wound infection in 3 cases. The mean postoperative follow up period was 15.7 months and recurrence was not reported. We could decrease donor site morbidity and cover wound sites easily by using flap rotation and get robust blood supply without sacrifice of functional muscle. Fasciocutaneous perforator island rotation flap would be very useful for various pressure sore treatment.

• Archives of Reconstructive Microsurgery
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• 제25권2호
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• pp.72-74
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• 2016

The keystone flap is a fascia-based island flap with two conjoined V-Y flaps. Here, we report a case of successful treatment of a trochanter pressure sore patient with the traditional keystone flap. A 50-year-old male patient visited our department with a $3{\times}5cm$ pressure sore (grade III) to the left of the greater trochanter that was covered with eschar. Debridement was done and the defect size increased to $5{\times}8cm$ in an elliptical shape. Doppler ultrasound was then used to locate the inferior gluteal artery perforator near the wound. The keystone flap was designed to the medial side. The perforator based keystone island flap covered the defect without resistance. The site remained clean, and no dehiscence, infection, hematoma, or seroma developed. In general, greater trochanter pressure sores are covered with a perforator based propeller flap or fascia lata flap. However, these flaps have the risk of pedicle kinking and require a large operation site. For the first time, we successfully applied the keystone flap to treat a greater trochanter pressure sore patient. Our design was also favorable with the relaxation skin tension lines. We conclude that the keystone flap including a perforator is a reliable option to reconstruct trochanteric pressure sores.

• Archives of Plastic Surgery
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• 제50권2호
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• pp.194-199
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• 2023

Moderate soft-tissue defects need stable coverage, ideally with tissue of similar characteristics and low donor site morbidity. We propose a simple technique for the coverage of moderate skin defects in the limbs. It allows intraoperative transformation of a propeller perforator flap (PPF) into a keystone design perforator flap (KDPF) in cases of unsatisfying perforator vessel or in cases of unpredictable intraoperative events. Between March 2013 and July 2019, nine patients with moderate soft-tissue defects (mean defect size 4.5 × 7.6 cm) in the limbs (two on the upper limbs and seven on the lower limbs) were covered using this technique. We performed four PPFs and five KDPFs. The mean follow-up was 5 months. There was one complication, partial distal tip necrosis in a PPF located in the leg, which healed by secondary intention within 3 weeks. The donor site was closed directly in all cases. No functional impairments were noted regardless of the perforator flap utilized. This technique enables us to employ flexible surgical strategies and allows us to make adjustments based on the patient's vascular anatomy.

• Archives of Plastic Surgery
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• 제41권1호
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• pp.63-70
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• 2014

Background Perforator flaps minimize abdominal site morbidity during autologous breast reconstruction. The purpose of this study was to assess whether the number of perforators harvested influences the overall deep inferior epigastric perforator (DIEP) flap survival and flap-related complications. Methods A retrospective review was performed of all DIEP flaps performed at the Hospital of the University of Pennsylvania from 2006 to 2011. The outcomes assessed included flap loss and major complications. We compared flaps by the number of total perforators (1-4) and then carried out a subgroup analysis comparing flaps with one perforator to flaps with multiple perforators. Lastly, we conducted a post-hoc analysis based on body mass index (BMI) categorization. Results Three hundred thirty-three patients underwent 395 DIEP flaps. No significant differences were noted in the flap loss rate or the overall complications across perforator groups. However, the subgroup analysis revealed significantly higher rates of fat necrosis in the case of one-perforator flaps than in the case of multiple-perforator flaps (10.2% vs. 3.1%, P=0.009). The post-hoc analysis revealed a significant increase in the flap loss rate with increasing BMI (<30=2.0%, 30-34.9=3.1%, 35-39.9=3.1%, >40=42.9%, P<0.001) in the DIEP flaps, but no increase in fat necrosis. Conclusions This study demonstrates that the number of perforators does not impact the rate of flap survival. However, the rate of fat necrosis may be significantly higher in DIEP flaps based on a single perforator. Multiple perforators should be utilized if possible to decrease the risk of fat necrosis.

• Maxillofacial Plastic and Reconstructive Surgery
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• 제35권3호
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• pp.200-209
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• 2013

Over the past few years, a large number of perforator flaps have been revised by several microsurgeons in the USA, France, Canada and Japan. A perforator flap is a flap of skin or subcutaneous tissue that is based on the dissection of a perforating vessel, which is a perforator. In short, a perforator is a vessel that has its origin in one of the axial vessels of the human body. By reducing any muscle harvesting and trauma to a minimum, perforator flaps aim to minimize donor site morbidity, and by avoiding the transfer of dennervated muscle, the long-term bulk of the free tissue transfer becomes more predictable. There are a finite number of potential perforator flaps in the body, which are based on the named source arteries. The most commonly used perforator flaps are deep inferior epigastric perforator, superior gluteal artery perforator, thoraco dorsal artery perforator, medial sural artery perforator, and anterolateral thigh perforator flap. For a better understanding of perforators as a routine reconstructive procedure in oral and maxillofacial surgery, the definition with nomenclature, classifications with special characteristics, and review points for their individual applications must be learned and memorized by the young doctors in the course regarding the special curriculum periods for the Korean national board of oral and maxillofacial surgery. Perforator flaps have been known to have many advantages, so this review article summarized their applications to the maxillofacial reconstruction in the Korean language.

• Archives of Plastic Surgery
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• 제37권5호
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• pp.595-599
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• 2010

Purpose: Trochanteric pressure sores management has been improved through the development of musculocutaneous flaps. But it has many drawbacks such as donor site morbidity and functional muscle sacrifice. With the introduction of perforator flap, it is possible to use in every location where musculocutaneous perforators are present. We have reconstructed trochanteric pressure sores using perforator-based flaps from the ascending branch of lateral circumflex femoral artery. Methods: Between May of 2006 and April of 2008, we performed six cases of perforator-based flap from the ascending branch of lateral circumflex femoral artery for the coverage of trochanteric pressure sores. For identifying perforators, a line was drawn from the anterior superior iliac spine to the superolateral border of the patella as the vertical axis, from the pubis to the trochanteric prominence as the horizontal axis. In the lateral aspect of the intersection of these two axes, various flap were designed according to its defects. The flap was raised in the subcutaneous plane above the fascia and the pedicle was traced by doppler and identified. The pedicle was meticulously dissected not to injure the periadventitial tissues and transposed to the defect. The donor site was closed primarily. Results: The mean age of patients was 56.2 years. Four male and two female patients were studied. Five patients were paraplegic. The mean defect size was $6{\times}4\;cm$. The largest flap dimension was $14{\times}7\;cm$. Donor sites were closed primarily without any complications. All flaps survived completely without necrosis, hematoma or infection. There were no recurrence during the follow-up period. Conclusion: Trochanteric pressure sores using perforator-based flap from the ascending branch of lateral circumflex femoral artery can be performed safely and it would be a reliable option for coverage of trochanteric pressure sores with minimal donor site morbidity.