Two options for perforator flaps in the flank donor site: latissimus dorsi and thoracodorsal perforator flaps

Two types of perforators, septocutaneous and musculocutaneous, are found in the same donor site of the flank area, and two perforator flaps based on each perforator are clinically available. Therefore, it is necessary to distinguish them from one another using different nomenclatures. Accordingly, the perforator flap based on a musculocutaneous perforator is named according to the name of the muscle perforated, the latissimus dorsi perforator flap, and the perforator flap based on a septocutaneous perforator, located between the serratus anterior and latissimus dorsi muscles, is named according to the name of the proximal vessel, the thoracodorsal perforator flap. In this series of 42 latissimus dorsi perforator flaps, flap size ranged from 5 x 3 cm to 20 x 15 cm, and two complications were observed: a marginal necrosis in an extremely large flap (26 x 12 cm) and a failure caused by infection. The thoracodorsal perforator flap was used in 14 cases, including two cases of chimeric composition. Flap size ranged from 4.5 x 3.5 to 18 x 15 cm, with no complications. In the two patterns of perforator flap that the author used, initial temporary flap congestion was observed in five latissimus dorsi perforator flap cases and two thoracodorsal perforator flap cases, when the flap was designed as a large flap or a less reliable perforator was selected. However, the congestion was not serious enough to cause flap necrosis. Several techniques, such as T anastomosis or inclusion of an additional perforator or a small portion of muscle, are recommended to prevent the initial flap congestion, especially when an unreliable perforator is inevitably used or when a flap larger than 20 cm long is required. A small portion of the muscle was included in six cases, when an unduly large or improperly long flap was planned. All of the flaps were successful and ranged from 22 x 7 to 15 x 28 cm, except for one case of distal flap necrosis in an extraordinarily large flap measuring 34 x 10 cm. Diverse selection of the perforator flap is one of the great advantages of the flank donor site, providing it with wider availability and more versatile composition for reconstruction or resurfacing.     

Cost-based comparison between perforator flaps and TRAM flaps for breast reconstruction

More women than ever before are undergoing mastectomies secondary to increased awareness and screening. This increase has also caused a corresponding increase in the number of breast reconstructions requested each year. The increased demand for reconstruction has fueled recent advances in new techniques. Aside from foreign-body reconstruction such as implants, the methods now being used are related to autogenous donations and reconstruction. Transverse rectus abdominis myocutaneous (TRAM) flaps and perforator flaps are currently being used for autogenous breast reconstruction. This study will compare these two techniques on the basis of cost and length of stay. A retrospective study of 49 patients undergoing a total of 64 perforator flap breast reconstructions at Memorial Medical Center in New Orleans, Louisiana, during the 1997 calendar year was used. There were 59 deep inferior epigastric perforator and five gluteal artery perforator breast reconstructions. All patients underwent some form of breast reconstruction and differed only in respect to whether a mastectomy was performed and whether the reconstruction was unilateral or bilateral. Those patients who underwent a mastectomy with immediate perforator flap reconstruction (n = 26) were then compared with patients undergoing mastectomy with immediate TRAM flap reconstruction (n = 154) at the University of Texas M. D. Anderson Cancer Center. The data from the Anderson Study were obtained from material published in Plastic and Reconstructive Surgery in 1996. Comparison of patients was limited to those who underwent mastectomy with immediate breast reconstruction because this was the design of the M. D. Anderson study. This approach allowed a cost and length of stay comparison while keeping other variables relatively similar. Patients in the perforator flap series enjoyed a marginally shorter operating time and a much shorter length of stay. On average, the operative time for all perforator flap reconstructions was approximately 2 hours shorter than for all TRAM flaps. As for length of stay, perforator flap patients were discharged, on average, 3 days after the initial reconstruction. In contrast, TRAM flap patients remained in the hospital for an average of approximately 7 days after the initial reconstruction. The overall total, average cost for the perforator flap reconstruction in this study is $9625, whereas the average cost of all TRAM flaps performed in the Anderson study is $18,070.     

Direct and indirect perforator flaps: the history and the controversy

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Recognize the major role of the vascular supply to a cutaneous flap. 2. Predict its reliability. 3. Understand basic schemes for classification. 4. Realize that the evolution of these concepts is an ongoing dynamic process. Currently, the vascular supply to the fascial plexus is considered the factor of greatest importance in ensuring the reliability of any skin-bearing flap. The multiplicity of origins of the deep fascial perforators to this plexus has led to a bewildering array of terminology intended to encompass all possible flap options. A brief review of the history of the evolution of cutaneous flaps provides insight essential in understanding a simple proposal for their classification. Because all fascial perforators course either directly from a source vessel or indirectly first through some other tissue to ultimately reach the suprafascial layer, the corresponding flaps based on any such perforators could most simply be termed either direct perforator flaps or indirect perforator flaps, respectively.     

Clinical applications of free soleus and peroneal perforator flaps

Clinical applications of two free lateral leg perforator flaps are described: a free soleus perforator flap that is based on the musculocutaneous perforator vessels from one of the three main arteries in the proximal lateral lower leg, and a free peroneal perforator flap that is based on the septocutaneous or direct skin perforator vessels from the peroneal artery in the distal and middle thirds of the lateral lower leg. The authors applied free soleus perforator flaps to 18 patients and free peroneal perforator flaps to five patients with soft-tissue defects. The recipient site was the great toe in 14 patients, the hand and fingers in five patients, the leg in two patients, and the upper arm and the jaw in one patient each. The largest soleus perforator flap was 15 x 9 cm, and the largest peroneal perforator flap was 9 x 4 cm. Vascular pedicle lengths ranged from 6.5 to 10 cm in soleus perforator flaps and from 4 to 6 cm in peroneal perforator flaps. All flaps, except for the flap in one patient in the peroneal perforator flap series, survived completely. Advantages of these flaps are that there is no need to sacrifice any main artery in the lower leg, and there is minimal morbidity at the donor site. For patients with a small to medium soft-tissue defect, these free perforator flaps are useful.     

Contribution of bone marrow-derived endothelial cells to human tumor vasculature

It has been shown that bone marrow-derived stem cells can form a major fraction of the tumor endothelium in mouse tumors. To determine the role of such cells in human tumor angiogenesis, we studied six individuals who developed cancers after bone marrow transplantation with donor cells derived from individuals of the opposite sex. By performing fluorescence in situ hybridization (FISH) with sex chromosome-specific probes in conjunction with fluorescent antibody staining, we found that such stem cells indeed contributed to tumor endothelium, but at low levels, averaging only 4.9% of the total. These results illustrate substantial differences between human tumors and many mouse models with respect to angiogenesis and have important implications for the translation of experimental antiangiogenic therapies to the clinic.     

Free medial plantar perforator flaps for the resurfacing of finger and foot defects

In this article, three cases in which free medial plantar perforator flaps were successfully transferred for coverage of soft-tissue defects in the fingers and foot are described. This perforator flap has no fascial component and is nourished only by perforators of the medial plantar vessel and a cutaneous vein or with a small segment of the medial plantar vessel. The advantages of this flap are minimal donor-site morbidity, minimal damage to both the posterior tibial and medial plantar systems, no need for deep dissection, the ability to thin the flap by primary removal of excess fatty tissue, the use of a large cutaneous vein as a venous drainage system, a good color and texture match for finger pulp repair, short time for flap elevation, possible application as a flow-through flap, and a concealed donor scar.