Subdermal Dissection for Elevation of Pure Skin Perforator Flaps and Superthin Flaps: The Dermis as a Landmark for the Most Superficial Dissection Plane

Abstract

Background: Pure skin perforator and superthin flaps have been reported and are becoming popular, as they allow one-stage thin skin reconstruction even from a thick donor site. However, currently reported elevation procedures use proximal-to-distal dissection requiring free-style perforator selection and primary thinning procedures. With distal-to-proximal dissection using the dermis as a landmark for dissection plane, it is expected that elevation of pure skin perforator or superthin flaps can be simplified. Methods: Patients who underwent pure skin perforator or superthin flap transfers with the subdermal dissection technique were included. Flaps were designed based on location of pure skin perforators visualized on color Doppler ultrasound, and elevated just below the dermis under an operating microscope. Medical charts were reviewed to obtain clinical and intraoperative findings. Characteristics of the patients, flaps, and postoperative courses were evaluated. Results: Thirty-six flaps were transferred in 34 patients, all of which were elevated as true perforator flaps (superficial circumflex iliac artery perforator flap in 29 cases, other perforator flaps in seven cases). Mean ± SD flap thickness was 2.24 ± 0.77 mm (range, 1.0 to 4.0 mm). Skin flap size ranged from 3.5 × 2 cm to 27 × 8 cm. Time for flap elevation was 27.4 ± 11.6 minutes. All flaps survived without flap atrophy/contracture 6 months after surgery, except for two cases of partial necrosis. Conclusion: The subdermal elevation technique allows straightforward and direct elevation of a pure skin perforator or superthin flap within 30 minutes on average without the necessity of primary thinning. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Imaging for thinned perforator flap harvest: current status and future perspectives

“…The high accuracy and sensitivity in perforator localizations of CDU [ 30 ] have contributed to its reliability as a preoperative flap evaluation device in thin anterolateral thigh (ALT) flaps [ 31 ]. What is more interesting is the recent successful direct pure skin and superthin perforator flap elevations under CDU guidance [ 32 ]. Precise perforator recognition by CDU-permeated distal-to-proximal dissected ‘perforator branch flap’ [29] avoids additional thinning as with routine proximal-to-distal dissection [ 32 ].…”

Evaluating effects of primary defatting for flap thinning on the development of perfusion‐related complications in free perforator flap reconstruction

“…recently, (Agostini et al, 2014;Hong et al, 2014;Kim et al, 2018;Yamamoto et al, 2021) because bulky flaps usually result in less satisfactory contour and limited functional outcomes, especially in cases of joint or extremity reconstruction. In addition, transfer of an excessively thick flap may require secondary debulking procedures to improve outcomes additionally.…”

“…Among several kinds of surgical techniques for obtaining thin perforator flaps, (Hong et al, 2014;Lee et al, 2017;Park et al, 2018;Yamamoto et al, 2021) a method of primary defatting after flap elevation has been suggested to have several advantages. It can address not only deep fat layers but also superficial fat tissue above the superficial fascia, which might allow for efficient debulking of the flap as it is not constrained by the inherent anatomy of fat layers; eventually, sufficiently thinned flaps can be achieved.…”

Color Doppler Ultrasonography for Precise Patency Evaluation of Injured Artery

“…Moreover, in cases of severe lower extremity trauma, evaluation of injured artery perfusion is critical to consider optimal strategy for the challenging reconstruction. [2][3][4][5] Especially, when free flap reconstruction is required, evaluation of arterial patency is critical to select an appropriate recipient artery. Distal capillary refilling, palpation of the artery pulsation, and sound Doppler are the mainstays of arterial patency evaluation.…”

“…1), whereas the proximal anterior tibial artery was revealed with positive signal. 2 In cases where a recipient vessel is available close to a defect, a less-invasive flap, such as superficial circumflex iliac artery perforator flap, should be selected but a long-pedicled flap is needed when a recipient vessel is distant. 3,4 In the following reconstructive surgery, the DPA showed no flow when transected as expected based on the preoperative color Doppler examination, and an anterolateral thigh flap was selected as a free flap reconstructive method with a long pedicle, using the anterior tibial artery as a recipient artery.…”