Step-by-step guide to ultrasound-based design of alt flaps by the microsurgeon – Basic and advanced applications and device settings

Kehrer, Andreas; Sachanadani, Neil S.; Silva, Natascha Platz Batista da; Lonic, Daniel; Heidekrueger, Paul I.; Taeger, Christian D.; Klein, S.; Jung, Ernst Michael; Prantl, Lukas; Hong, Joon-Pio

doi:10.1016/j.bjps.2019.11.035

Cited by 56 publications

(41 citation statements)

References 51 publications

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“…Specific US device programming and trimming is required and may tremendously enhance device sensitivity for detection of microvessels. A structured step‐by‐step approach for machine settings and perforator mapping sequences has been suggested previously by Kehrer et al (2020).…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2020

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Background: Color-coded duplex sonography (CCDS) is useful for perforator flap design showing the highest sensitivity in identifying microvessels. This prospective study evaluates the feasibility of different ultrasound (US) modes applied by the microsurgeon in daily practice suggesting quantifiable reference values. Methods: Twenty-four patients aged between 17 and 68 years (mean 43.3 ± 14.2 years) with 18 anterolateral thigh (ALT) and 6 superficial circumflex iliac artery (SCIP) flaps were included. Indications were traumatic (n = 12), infectious (n = 6), ischemic (n = 4), or tumor-associated defects (n = 2). Different US modes were evaluated regarding applicability using multifrequency linear probes (5-15 MHz). Vessels diameter, peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) were measured. Preoperative results were correlated to intraoperative findings. Results: In the examined patient group with 24 perforator flaps a 100% correlation

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Section: Introductionmentioning

confidence: 99%

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

et al. 2020

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“…This study included 40 forearms in 20 healthy volunteers (10 men and 10 women) with an average age of 25.5 years (range, 24-29 years). The dominant side was right in 18 and left in two volunteers. The average length between the pisiform and medial epicondyle was 276 mm (range, 223-290 mm).…”

Section: Methodsmentioning

confidence: 91%

“…7,17 Moreover, color Doppler US is noninvasive, low cost, uses portable equipment, and facilitates real-time preand intraoperative examinations. An in-depth description on correct program selection and device settings regarding perforator mapping and characterization for microsurgeons has been described by Kehrer et al 18,19 In our study, the analysis for UAPs using US was performed between the pisiform and 100 mm proximal to the pisiform, which was the distal half in the volar forearm. To compare with previous reports, the location of UAP was mapped as described by the previous reports [20][21][22][23][24][25] (►Fig.…”

Section: Discussionmentioning

confidence: 99%

Identification of Ulnar Artery Perforators Using Color Doppler Ultrasonography

Ishiko

Yano

Onode

et al. 2020

J Reconstr Microsurg

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Background The ulnar artery perforator (UAP) flap, which is hairless, thin, and pliable, has been used for the reconstruction of soft tissues from the finger to the elbow. Preoperative planning is essential for a perforator flap surgery, and there are some tests to identify perforators. Color Doppler ultrasonography (US) with a high-frequency transducer helps in detecting decreased flow in smaller vessels, such as perforators. The purpose of this study was to determine the anatomical locations and origins of perforators arising from the ulnar artery using color Doppler US in healthy volunteers. Methods Forty forearms of 20 healthy volunteers were included in the study. Perforators arising from the ulnar artery, within 100 mm proximal to the pisiform, were investigated using color Doppler US with a high-frequency transducer. Results A total of 205 perforators were identified. On comparing the locations in each 20 mm section from the pisiform, the largest number of perforators was 58 (28%), within 20 mm proximal to the pisiform. The axial view demonstrated 44 (21%), 64 (31%), 32 (16%), and 65 (32%) perforators in the radial, ulnar, superficial, and deep aspects of the ulnar artery, respectively. Fifty-two and 28 essential perforators were supplied by the UAPs arising from the superficial and ulnar aspect within 20 mm proximal to the pisiform and between 21 and 40 mm proximal to the pisiform, respectively, while elevating the UAP flap. Conclusion This is the first study to assess the UAP using color Doppler US. Identification of UAP using color Doppler US can be used as a preoperative assessment for reliable elevation of a UAP flap.

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“…In some departments, it seems therefore that it has become routine practice that all perforator flaps are planned with CCDS by the microsurgeon. 20,28,30,31 Reliable preoperative knowledge of perforator location shortens flap harvest time and may improve overall operative time, as well as outcome of complex reconstructions. 27 CCDS improves the microsurgeon's capability to design and elevate flaps by capturing dominant vessels and maximizing flap survival.…”

Section: Discussionmentioning

confidence: 99%

“…17 However, device settings for microvessel imaging are of utmost importance for a successful examination and have been described by our group previously. 20 Besides hard-and software trimming, appropriate selection and usage of various available ultrasound modes are compulsory.…”

mentioning

confidence: 99%

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

Kehrer

Heidekrueger

Lonic

et al. 2020

J Reconstr Microsurg

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Background Preoperative ultrasound (US)-guided perforator mapping has immensely simplified perforator flap planning. It may be executed by the microsurgeon. Device settings and selection of ultrasound modes are of utmost significance for detection of low-flow microvessels. The following study evaluates different US modes. Methods A prospective complete data acquisition was performed from July 2018 to June 2019 in a subset of patients who underwent US-guided flap planning. Multifrequency linear transducers were used applying five US modes. Brightness (B)-mode, color flow (CF), power Doppler (PD), pulse wave (PW), and B-flow modes were evaluated regarding applicability by microsurgeons. Peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) were chosen to evaluate flow characteristics. US results were correlated to intraoperative findings. Results A total number of eight patients (six males and two females) undergoing anterolateral thigh (ALT) or superficial circumflex iliac artery perforator (SCIP) flap surgery received an extensive standardized US-guided perforator characterization. Qualitative evaluation was performed in B-mode, color-coded duplex sonography (CCDS), PD, and B-flow mode. Quantitative assessment was executed using PW-mode and CCDS measuring the microvessels' diameter (mm) and flow characteristics (PSV, EDV, and RI). CCDS provided a mean diameter of 1.93 mm (range: 1.2–2.8 ± 0.51), a mean systolic peak of 16.9 cm/s (range: 9.9–33.4 ± 7.79), and mean RI of 0.71 (range: 0.55–0.87 ± 0.09) for lower limb perforators. All perforators located with US were verified by intraoperative findings. An optimized, time-effective US mapping algorithm was derived. Qualitative parameters may be evaluated with B-mode, CF, or B-flow. Smallest microvessels may be assessed in PD-mode. Lowering pulse-repetition frequency (PRF)/scale is mandatory to image low-flow microvessels as perforators. Quantitative information may be obtained using PW-mode and the distance-measuring tool in CF-mode. Image and video materials are provided. Conclusion CCDS proved to be a powerful tool for preoperative perforator characterization when using a structured approach and mapping algorithm. Different techniques may be applied for specific visualizations and performed by the microsurgeon.

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Step-by-step guide to ultrasound-based design of alt flaps by the microsurgeon – Basic and advanced applications and device settings

Cited by 56 publications

References 51 publications

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

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

Identification of Ulnar Artery Perforators Using Color Doppler Ultrasonography

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

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