Intraoperative color Doppler sonography in the elevation of anterolateral thigh flap

Abstract

There are currently multiple imaging techniques available for planning perforator flap harvest. Some studies demonstrated the superiority of computed tomographic angiography (CTA) over the other options for the preoperative mapping in the perforator flaps because it could evaluate the perforators more precisely.1 Nevertheless, CTA has a disadvantage that it cannot be used in real time and provide real-time feedback during harvesting flap. Color Doppler sonography is another effective tool for surgical planning. Color Doppler sonography has advantage that it can be used in real time.2 However, with regard to harvest of perforator flap, it is usually used for preoperative assessment, not for intraoperative detection of perforators in real time.Between April and November 2010, we have performed intraoperative color Doppler sonography in real-time use during anterolateral thigh (ALT) flap harvest in eight patients. Preoperatively, the locations of cutaneous perforators were evaluated, using color Doppler sonography with a 12-MHz linear probe. Perioperatively, according to the preoperative assessment, the longitudinal incision line was designed in the middle of the anterior thigh. An incision was made and extended down through the fascia of the rectus femoris. The cut end of the deep fascia of the vastus lateralis was grasped with several clamps and retracted laterally. We carefully dissected between the fascia and the underlying muscle, and cutaneous perforator could be found. We then looked for the intermuscular septum between vastus lateralis and rectus femoris. Having defined the septum, we explored the septum with finger dissection to expose the full extent of the descending branch of the lateral circumflex femoral artery and the origin of perforating vessels. We prepared color Doppler sonography when the perforators were identified with a myocutaneous type. The probe was placed directly on to the surface of the vastus lateralis, and intramuscular perforator could be visualized by color mode (Fig. 1). The course and depth of the intramuscular perforator could be identified, and we marked the dissecting line on the surface of vastus lateralis (Fig. 2). We then begun to dissect out the perforators according to the intraoperative color Doppler sonography assessment and elevated the flap. In all cases, intramuscular perforators were detected by intraoperative color Doppler sonography and the flaps could be harvested safely.There are two key steps involved in elevating ALT flap. The first step is to locate the cutaneous perforators at the subfascial level, and the second is to follow these perforators to their main pedicle.3 Therefore, knowledge about anatomic variation of the vessel and information regarding the distribution of the perforators might be required in elevating the ALT flap. Many studies have discussed anatomical variations of the descending branch of lateral circumflex pedicle and the relationships between the lateral circumflex femoral pedicle and perforators. 3,4 But the perforator anatomy of

Feasibility study of preoperative microvessel evaluation and characterization in perforator flaps using various modes of color‐coded duplex sonography (CCDS)

“…High‐resolution CCDS guided vascular flow imaging has proven as a potent instrument for microsurgeons in evaluating perforator vessels to simplify the design of perforator flaps in reconstructive surgery. Within the last few years, it has developed impetus and may spread faster than other modalities for detection and assessment of microvessels required for preoperative microvascular flap planning (Debelmas, Camuzard, Aguilar, & Qassemyar, 2018; Dorfman & Pu, 2014; Ensat et al, 2012; Feng et al, 2016; Gravvanis et al, 2010; Saito et al, 2011; Su et al, 2013). Anatomic and hemodynamic information may be provided in real‐time imaging by CCDS of both vascular structures of the donor and recipient sites of flap reconstructions (Gravvanis, Petrocheilou, Tsoutsos, Delikonstantinou, & Karakitsos, 2013).…”

Simplified profunda artery perforator (PAP) flap design using power Doppler ultrasonography (PDU): A prospective study

“…Each method features different advantages and limitations. Comparing diagnostic imaging with intraoperative findings in free flap surgery commonly shows differing results concerning perforator size, location, anticipated course, and relation to surrounding structures (Hallock, ; Saito et al, ).…”

High-Resolution Ultrasound-Guided Perforator Mapping and Characterization by the Microsurgeon in Lower Limb Reconstruction

“…17 CCDS has quickly gained momentum and seems to spread faster than other diagnostic modalities for perforator evaluation. 2,10,14,25,[27][28][29] Kehrer et al demonstrated that sensitivity of CCDS was 96.7% with an average distance from the true projection of EP to the CCDS skin marking of 2.45 AE 1.90 mm (range: 0-6 mm). 19 All perforators detected by CCDS and confirmed intraoperatively were sizable (!…”

“…[1][2][3][4][5][6][7][8][9][10][11][12] However, comparing diagnostic imaging with intraoperative findings may show differing results concerning perforator size, location, anticipated course, and relation to surrounding structures. 13,14 Furthermore, most of the named diagnostic imaging tools present disadvantages in terms of invasiveness of techniques, costs or availability. 5,15 It was reported that 1.5 to 2.0% of all cancers in the United States may be attributable to the radiation from CT studies.…”