• Archives of Plastic Surgery
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• 제32권3호
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• pp.271-280
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• 2005

There are various types of flap in head and neck reconstruction. We chose the appropriate flap considering the indication and patient's condition. In case of conventional flaps, its type is decided according to the reconstruction site. In other words, the types of considerable flaps are limited in a way. But, perforator flaps can reduce donor limitation and harvest flaps depending on the condition of the recipient. Therefore, the flap is very useful for the head and neck reconstruction needed for 2-dimensional or 3-dimensional reconstruction. We report the 29 cases of perforator-based flap including 8 cases of latissimus dorsi perforator free flap, 5 thoracodorsal perforator free flap, 4 anterolateral thigh perforator free flap, 3 peroneal osteocutaneous perforator free flap and 9 submental perforator island flap for the head and neck reconstruction. Free flaps include 2 cases of chimeric pattern, 7 controlled resurfacing pattern, 4 3-D pattern, 3 dermoadiposal pattern, 1 folded pattern and 3 osteocutaneous pattern. The flaps were successfully used for the head and neck reconstruction. But one patient died during a follow up period because of the recurrence of tumor. Various perforator flaps(island/free pattern) can be highly competitive to the conventional flaps in the head and neck reconstruction, considering a thin character for resurfacing, more flexible and versatile option, variable composition, long pedicle with donor structures saved, and less prominent donor morbidity.

• Archives of Plastic Surgery
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• 제33권2호
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• pp.187-192
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• 2006

The perforator flaps are based on cutaneous vessels which are originated from a main pedicle and penetrate fascia or muscle to reach the skin. The lateral lower leg is one of the most suitable areas for harvesting perforator flaps because a number of perforator vessels exist. The authors applied peroneal perforator flaps in nine patients. Five flaps were reverse island flaps based on peroneal artery and septocutaneous perforator, and four flaps were free flap based on musculocutaneous perforator only. The recipient site was the posterior ankle in three patients, posterior heel in three patients, lateral malleolus, anterolateral ankle, and foot dorsum in one patient each. The flap size ranged from 5 to 12cm long, from 3 to 5cm wide, and the primary closure of the donor site was possible in most cases. All flaps, except for the flap in two patients in the reverse island flap series, survived completely. The peroneal perforator flap is a very thin, pliable flap with minimal donor site morbidity and is suitable for the reconstruction of small and medium sized superficial skin defects. Also, this flap may be considered as an alternative to radial forearm flap or other perforator flaps.

• Archives of Plastic Surgery
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• 제39권2호
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• pp.94-105
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• 2012

Simple or complex defects in the lower leg, and especially in its distal third, continue to be a challenging task for reconstructive surgeons. A variety of flaps were used in the attempt to achieve excellence in form and function. After a long evolution of the reconstructive methods, including random pattern flaps, axial pattern flaps, musculocutaneous flaps and fasciocutaneous flaps, the reappraisal of the works of Manchot and Salmon by Taylor and Palmer opened the era of perforator flaps. This era began in 1989, when Koshima and Soeda, and separately Kroll and Rosenfield described the first applications of such flaps. Perforator flaps, whether free or pedicled, gained a high popularity due to their main advantages: decreasing donor-site morbidity and improving aesthetic outcome. The use as local perforator flaps in lower leg was possible due to a better understanding of the cutaneous circulation, leg vascular anatomy, angiosome and perforasome concepts, as well as innovations in flaps design. This review will describe the evolution, anatomy, flap design, and technique of the main distally pedicled propeller perforator flaps used in the reconstruction of defects in the distal third of the lower leg and foot.

• 대한두경부종양학회지
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• 제35권1호
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• pp.1-11
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• 2019

In head and neck reconstruction, microsurgeons are faced with various demands, such as thin resurfacing, or three-dimensional reconstruction, and therefore, conventional flap as well as perforator flaps are all useful for the functional and aesthetic reconstruction successfully. Among perforator flaps, the pros and cons of anterolateral thigh perforator flap(ALTp) and thoracodorsal perforator flap(TAp) is compared and selected depending on the surgeon's preference, recipient site condition or patient status. Both flaps can be elevated in a chimeric pattern by combining different aspects of tissue components. Customized or tailored reconstruction as well as 3 dimensional reconstructions are all available with perforator flaps and it is useful in head and neck reconstruction. The most outstanding update in head and neck reconstruction is the perforator based island flap (PBIF) compared to conventional flaps. The conventional local flap has evolved on behalf of the perforator concept and its design becomes more flexible and freestyle with less limitations. Actually, random pattern flap is now a misnomer and most conventional local flaps turn into PBIFs. Finally we can say all conventional donor site becomes universal, depending on the surgeons' preference or idea. Moreover, there is no more "flap of choice" and postoperative results are quite variable by surgeons' ability. Operative procedures and plans are very flexible to freestyle flap. With all these advantages, surgeons should be armed with both conventional and perforator concepts for solving any defects or problems.

• Archives of Plastic Surgery
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• 제48권1호
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• pp.121-126
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• 2021

Background Despite the wide demand for thin flaps for various types of extremity reconstruction, the thin elevation technique for anterolateral thigh (ALT) flaps is not very popular because of its technical difficulty and safety concerns. This study proposes a novel perforator-centralizing technique for super-thin ALT flaps and analyzes its effects in comparison with a skewed-perforator group. Methods From June 2018 to January 2020, 41 patients who required coverage of various types of defects with a single perforator-based super-thin ALT free flap were enrolled. The incidence of partial necrosis and proportion of the necrotic area were analyzed on postoperative day 20 according to the location of superficial penetrating perforators along the flap. The centralized-perforator group was defined as having a perforator anchored to the middle third of the x- and y-axes of the flap, while the skewed-perforator group was defined as having a perforator anchored outside of the middle third of the x- and y-axes of the flap. Results No statistically significant difference in flap thickness and dimension was found between the two groups. The arterial and venous anastomosis patterns of patients in both groups were not significantly different. Only the mean partial necrotic area showed a statistically significant difference between the two groups (centralized-perforator group, 3.4%±2.2%; skewed-perforator group, 15.8%±8.6%; P=0.022). Conclusions The present study demonstrated that super-thin ALT perforator flaps can be elevated safely, with minimal partial necrosis, using the perforator-centralizing technique.

• Archives of Plastic Surgery
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• 제38권6호
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• pp.815-820
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• 2011

Purpose: Perforator flaps have been widely used for reconstruction of pressure sores because they have many benefits, especially reducing tension. Otherwise in order to prevent recurrence of a pressure sore, sufficient thickness of a flap is desirable, so a musculocutaneous flap is also useful for reconstruction of a pressure sore. Therefore, the authors considered about the postoperative results of reconstruction of pressure sores between using perforator flaps and musculocutaneous flaps. Methods: In this study, 33 patients (46 flaps) who underwent reconstructive operation of pressure sores from January 2007 to February 2011 were reviewed. Patients operated by using perforator flaps were 18 (18 flaps), and musculocutaneous flaps were 17 (28 flaps). We studied postoperative complications and recurrence. Results: We experienced five patients (10 flaps) with complications or recurrences who were operated using musculocutaneous flaps and one patient using a perforator flap. One case using a perforator flap stemmed from dehiscence caused by a urinary fistula occurring in two months after the surgery. Among ten cases using musculocutaneous flaps, one case was caused by total necrosis of flap, five cases by partial necrosis of flap and dehiscence, and four cases by recurrences during follow-up period. Conclusion: Even if more cases were required, it can be more considerable to operate using the perforator flap rather than the musculocutaneous flap to reduce the complication or recurrence of pressure sore.

• 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.

• Archives of Plastic Surgery
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• 제33권2호
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• pp.181-186
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• 2006

Myocutaneous flaps have improved the management of soft tissue defects on buttocks and lower extremity. However, there are several inherent disadvantages of muscle flaps such as functional deficits of the donor sites and the bulkiness at the recipient site. To overcome these disadvantages, we have used perforator-based fasciocutaneous rotation flaps for reconstruction of the buttock and lower extremity defects. From March 2003 to February 2005, we have treated 14 patients using perforator-based fasciocutaneous rotation flaps. 10 flaps were based on perforators of the gluteus maximus muscle, and 4 flaps were nourished by perforators from the tibialis anterior and posterior system. The mean postoperative follow-up period was about 1 year. The technique involves localization of the flap perforators preoperatively with a Doppler. The flaps were elevated superficial to the fascia with preservation of one to three perforators. The donor site is then closed primarily. All flaps completely survived and there was no perioperative complications. There was no functional disability of the donor area with esthetically pleasing results. Perforator-based fasciocutaneous rotation flaps for the reconstruction of buttock and lower extremity defects are excellent alternatives to musculocutaeous flaps. The vascularity of the flaps is robust and dissection is technically easy. Perforator flaps do not require sacrificing muscles, but provide sufficient volume and are durable Furthermore, these flaps result in less scar formation and allow more liberal dissection with safety. We conclude that perforator-based fasciocutaneous rotation flaps are very useful for reconstruction of the buttock and lower extremity.

• Archives of Plastic Surgery
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• 제37권1호
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• pp.52-58
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• 2010

Purpose: The digital artery perforator flap was recently introduced and has been proven to be useful for reconstruction of various finger defects. Short operative time, less invasive surgery, and reliable flap circulation are the major advantages of this flap. The authors presented the clinical cases of the digital artery perforator flap and compared them with the distant flaps within a hand (thenar and hypothenar flaps) to reveal their differences. Methods: From May of 2006 to February of 2009, the authors performed reconstructions of finger defects with the digital artery perforator flaps in 10 patients as with the distant flaps within hand in 9 patients (7 thenar and 2 hypothenar flaps). In these two groups of the patients, flap size, use of skin graft, length of stay in hospital, healing time, complications were reviewed retrospectively and compared with statistical analysis (Student's t-test). Results: All flaps survived completely. The mean size of the perforator flap was $0.9{\times}1.9\;cm$ and the mean distant flap within a hand was $1.9{\times}2.0\;cm$. The use of skin graft was reduced in the perforator group because the donor site of the flap was closed primarily. The hospitalization period and healing time also reduced significantly in the perforator group. Minor complications (partial flap loss) were noted in small percentages in both groups but resolved with conservative management. Mean follow-up period was about 6 weeks. Conclusion: The digital artery perforator flap was smaller than the distant flap but its reconstruction of finger defects was reliable and comparable to the conventional distant flaps within a hand. This flap would be not only an alternative method but very useful in the management of various finger defects, because of ease of operative technique, less invasive surgery, decreased need of skin graft, and shorter period of hospitalization and healing time.

• 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.