Therapy,Vol. Vol.••, 28,2015, 2015,••–•• 226–229 Dermatologic Therapy, Printed in in the the United United States States · All Allrights rightsreserved reserved
C 2015 Wiley Periodicals, Inc. V © 2015 Periodicals, Inc.
DERMATOLOGIC THERAPY ISSN ISSN 1396-0296 1396-0296
THERAPEUTIC HOTLINE Freestyle perforator flaps: an innovative approach to soft tissue reconstruction Beniamino Brunetti, Stefano Campa, Stefania Tenna, Tiziano Pallara & Paolo Persichetti Plastic and Reconstructive Surgery Unit, Campus Bio-Medico of Rome University, Rome, Italy
ABSTRACT: Resurfacing of soft tissue defects consequent to skin cancer, melanoma, or sarcoma excision in different anatomical districts represents a difficult challenge for the plastic surgeon. Classic reconstructive procedures are frequently charged by unsatisfactory results. The introduction of perforator flaps in the clinical practice represented a revolution in the field of reconstructive plastic surgery. The technique further evolved with the introduction of the freestyle concept, allowing one to harvest a skin flap from any region of the body where an appropriate and detectable Doppler signal is present and to resurface soft tissue defects mobilizing the surrounding tissues, which present similar features compared with the recipient site in terms of color and texture, on a consistent vascular source and in a tension-free manner. The authors present their personal approach to the reconstruction of soft tissue defects after excision for a basal cell carcinoma involving the medial tibial region. KEYWORDS: posterior tibial artery perforator flap, soft tissue reconstruction
Introduction Resurfacing of soft tissue defects consequent to skin cancer, melanoma, or sarcoma excision in different anatomical districts represents a difficult challenge for the plastic surgeon. Classic reconstructive procedures are frequently charged by unsatisfactory results. Skin grafts usually produce a suboptimal aesthetic and functional outcome because of retraction, hypo-hyper-pigmentation, and difference in color, thickness, and texture, Address correspondence and reprint requests to: Beniamino Brunetti, MD, Consultant Plastic and Reconstructive Surgeon, Department of Plastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Campus Biomedico University of Rome, Via Alvaro del Portillo, Rome 200-00128, Italy, or email: [email protected].
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usually leaving a depressed and patched appearance at the recipient site. On the contrary, random pattern flaps present several other disadvantages, such as restricted movement with tension and distortion on the suture lines, eventually leading to distal flap necrosis and hypertrophic scars. The introduction of perforator flaps in the clinical practice represented a revolution in the field of reconstructive plastic surgery, allowing to raise adipocutaneous flaps, based on well-known sets of perforator vessels, with preservation of muscle, fascia, motor nerves, and major vessels (1). The technique further evolved with the introduction of the freestyle concept (2). With this approach, the surgeon is able to harvest a skin flap from any region of the body where an appropriate and detectable Doppler signal is present and to resurface soft tissue defects mobilizing the surrounding tissues, which present similar features compared
1
Freestyle flaps philosophy
Brunetti et al.
with the recipient site in terms of color and texture, on a consistent vascular source and in a tensionfree manner. The authors present their personal approach to the reconstruction of soft tissue defects with freestyle perforator flaps.
Oncological evaluation In case of oncological resection, according to our institution surgical guidelines, all the patients undergo a two-stage procedure, waiting for clear margins on pathology after cancer excision before being re-admitted for surgical reconstruction. When a skin tumor with metastatic potential (squamous cell carcinoma, melanoma) has been completely resected, priority is given to cancer staging (preoperative positron emission tomography–computed tomography and/or sentinel node biopsy) before scheduling the patient for flap reconstruction. In case of loco-regional tumor dissemination (in transit metastasis, satellitosis), the use of local flaps is avoided and the patient is scheduled for skin graft reconstruction.
Surgical technique A handled acoustic Doppler ultrasound device connected to an 8-MHz vascular probe is used to preoperatively identify the perforator vessels in the native skin surrounding the defect. If an audible signal is recognized in close proximity to the defect, the flap is designed eccentric with respect to the perforator vessel and planned to reach the defect with a rotational movement (3) on the pedicle (propeller flap design). On the contrary, if the perforators are detected at an intermediate distance from the defect, a V-Y advancement flap is planned (4).
Flaps are harvested with the aid of a 2.5× loupe magnification. An exploratory incision is performed to expose the perforator vessel in a prefascial or subfascial plane. The perforators chosen to obtain the desired movement are carefully dissected for 2–3 cm by gently teasing muscle fibers. Extensive intramuscular dissection is recommended only when pedicle elongation is needed to improve flap reach, especially in case of propeller movement. After pedicle dissection, the skin paddle is confirmed or redrawn according to the intraoperative findings and circumcised. In case of restricted movement, minor peripheral perforators can be sacrificed to obtain further mobility. The flap is sutured without tension to the recipient site under suction drains and the donor site is always closed by primary intention.
Case report An exemplary case is shown to document the freestyle reconstructive approach. A 60-year-old male patient underwent excision for a basal cell carcinoma involving the medial tibial region, leaving a 3.5 × 3 cm soft tissue defect along the tibial shaft (Fig. 1, left). A skin graft was excluded because of contour deformity and poor aesthetic and functional result produced in case of direct placement over bony prominences. Local random pattern flaps were considered risky because of poor skin elasticity and restricted movement associated with possible distal flap necrosis, delayed healing, or hypertrophic scars. The angiosome of the posterior tibial artery (PTA) was investigated with handled acoustic Doppler ultrasound device for the presence of cutaneous perforators, identifying a reliable pedicle caudally and in close proximity to the defect. An 8 × 3 cm PTA perforator propeller flap was planned to resurface the defect in a tensionfree manner (Fig. 1, left). An exploratory incision allowed to expose the previously Dopplered
FIG. 1. Left: An 8 × 3 cm posterior tibial artery perforator propeller flap has been planned to resurface a 3.5 × 3 cm defect in the medial tibial region. Right: 6-month post-operative follow-up.
2
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Brunetti et al.
Freestyle flaps philosophy
FIG. 2. Left: The pedicle is exposed and isolated (arrow pointing to the perforator complex entering the flap). Right: The flap sutured at the end of the procedure.
pedicle, which was dissected from the surrounding fibrous attachments with a prefascial dissection, thus preserving the great saphenous vein (Fig. 2, left). The opposite margin was subsequently incised and the flap completely islanded on the perforator vessel (Fig. 2, right). The island flap design was preferred to the more classical transposition movement because it allowed one to obtain a tension-free insetting and avoid dog-ear development at the base of the flap. The flap was transposed to the recipient site with a 45 degree counterclockwise pedicle rotation. Flap donor site was closed primarily without tension. The postoperative course was uneventful, as documented by the 6-month follow-up picture (Fig. 1, right). The patient was highly satisfied with the aesthetic and functional outcome.
Discussion The use of freestyle pedicled perforator flaps in the field of soft tissue reconstruction presents several advantages. The extended range of motion, not restricted by the empiric width-to-length ratio used to design random flaps, produces a tensionfree insetting with better aesthetic and functional outcome. Furthermore, only the tissues necessary for reconstruction are mobilized, avoiding the classic bulky aspect of major reconstructions with myocutaneous flaps. Compared with random pattern flaps, pincushion deformity is more frequently observed, especially in the first postoperative months, but it usually tends to settle down over time. According to the perforasome theory (5), we consider as obsolete the random flap concept and try to approach each most of the reconstructive cases with this particular philosophy, limiting the use of random pattern flaps to the reconstruction of certain facial subunits, where abundant vascularization and elasticity of the soft tissues
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minimize the risk of distal flap necrosis and venous insufficiency. In agreement with this concept, we consider as mandatory the execution of preoperative Doppler examination and suggest harvesting each flap using the deep muscular fascia as a guide for the dissection in order to have more chance to encounter the perforator vessels. The “cut as you go” approach results very useful to maximize vascular safety: in fact, if the perforators are found to be small or absent, the opposite skin bridge can be partially maintained, converting the flap to a perforator plus model, which provides, despite of a more difficult insetting, additional blood supply and improved venous outflow. Freestyle surgical approach obviously presents a learning curve, which is usually shorter for centers provided with microsurgical expertise. Nevertheless, this kind of surgery can be performed by every reconstructive surgeon, given that a detailed knowledge of the vascular anatomy of the integument is possessed.
Conclusions The freestyle approach allows resurfacing almost each defect in different regions of the body, mobilizing the surrounding tissues on a consistent vascular source. In our hands, application of this philosophy proved to be a reliable solution to obtain optimal aesthetic results with minimization of donor site morbidity and complication rates.
Disclosure The authors who have taken part in this study declare that they do not have any commercial associations that might pose or create a conflict of interest with information presented in this paper. No intramural or extramural funding supported any aspect of this work.
3
Brunetti et al.
References 1. Blondeel PN, Van Landuyt KH, Monstrey SJ, et al. The “Gent” consensus on perforator flap terminology: preliminary definitions. Plast Reconstr Surg 2003: 112 (5): 1378–1383. 2. Wallace CG, Kao HK, Jeng SF, Wei FC. Free-style flaps: a further step forward for perforator flap surgery. Plast Reconstr Surg 2009: 124 (Suppl. 6): e419–e426. 3. Teo TC. The propeller flap concept. Clin Plast Surg 2010: 37 (4): 615–626, vi.
4
Freestyle flaps philosophy 4. Brunetti B, Tenna S, Aveta A, et al. Free-style local perforator flaps: versatility of the V-Y design to reconstruct soft tissue defects in the skin cancer population. Plast Reconstr Surg 2013: 132 (2): 451–460. 5. Saint-Cyr M, Wong C, Schaverien M, et al. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg 2009: 124 (5): 1529–1544.
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C 2015 Wiley Periodicals, Inc. V © 2015 Periodicals, Inc.
DERMATOLOGIC THERAPY ISSN ISSN 1396-0296 1396-0296
THERAPEUTIC HOTLINE Freestyle perforator flaps: an innovative approach to soft tissue reconstruction Beniamino Brunetti, Stefano Campa, Stefania Tenna, Tiziano Pallara & Paolo Persichetti Plastic and Reconstructive Surgery Unit, Campus Bio-Medico of Rome University, Rome, Italy
ABSTRACT: Resurfacing of soft tissue defects consequent to skin cancer, melanoma, or sarcoma excision in different anatomical districts represents a difficult challenge for the plastic surgeon. Classic reconstructive procedures are frequently charged by unsatisfactory results. The introduction of perforator flaps in the clinical practice represented a revolution in the field of reconstructive plastic surgery. The technique further evolved with the introduction of the freestyle concept, allowing one to harvest a skin flap from any region of the body where an appropriate and detectable Doppler signal is present and to resurface soft tissue defects mobilizing the surrounding tissues, which present similar features compared with the recipient site in terms of color and texture, on a consistent vascular source and in a tension-free manner. The authors present their personal approach to the reconstruction of soft tissue defects after excision for a basal cell carcinoma involving the medial tibial region. KEYWORDS: posterior tibial artery perforator flap, soft tissue reconstruction
Introduction Resurfacing of soft tissue defects consequent to skin cancer, melanoma, or sarcoma excision in different anatomical districts represents a difficult challenge for the plastic surgeon. Classic reconstructive procedures are frequently charged by unsatisfactory results. Skin grafts usually produce a suboptimal aesthetic and functional outcome because of retraction, hypo-hyper-pigmentation, and difference in color, thickness, and texture, Address correspondence and reprint requests to: Beniamino Brunetti, MD, Consultant Plastic and Reconstructive Surgeon, Department of Plastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Campus Biomedico University of Rome, Via Alvaro del Portillo, Rome 200-00128, Italy, or email: [email protected].
226
usually leaving a depressed and patched appearance at the recipient site. On the contrary, random pattern flaps present several other disadvantages, such as restricted movement with tension and distortion on the suture lines, eventually leading to distal flap necrosis and hypertrophic scars. The introduction of perforator flaps in the clinical practice represented a revolution in the field of reconstructive plastic surgery, allowing to raise adipocutaneous flaps, based on well-known sets of perforator vessels, with preservation of muscle, fascia, motor nerves, and major vessels (1). The technique further evolved with the introduction of the freestyle concept (2). With this approach, the surgeon is able to harvest a skin flap from any region of the body where an appropriate and detectable Doppler signal is present and to resurface soft tissue defects mobilizing the surrounding tissues, which present similar features compared
1
Freestyle flaps philosophy
Brunetti et al.
with the recipient site in terms of color and texture, on a consistent vascular source and in a tensionfree manner. The authors present their personal approach to the reconstruction of soft tissue defects with freestyle perforator flaps.
Oncological evaluation In case of oncological resection, according to our institution surgical guidelines, all the patients undergo a two-stage procedure, waiting for clear margins on pathology after cancer excision before being re-admitted for surgical reconstruction. When a skin tumor with metastatic potential (squamous cell carcinoma, melanoma) has been completely resected, priority is given to cancer staging (preoperative positron emission tomography–computed tomography and/or sentinel node biopsy) before scheduling the patient for flap reconstruction. In case of loco-regional tumor dissemination (in transit metastasis, satellitosis), the use of local flaps is avoided and the patient is scheduled for skin graft reconstruction.
Surgical technique A handled acoustic Doppler ultrasound device connected to an 8-MHz vascular probe is used to preoperatively identify the perforator vessels in the native skin surrounding the defect. If an audible signal is recognized in close proximity to the defect, the flap is designed eccentric with respect to the perforator vessel and planned to reach the defect with a rotational movement (3) on the pedicle (propeller flap design). On the contrary, if the perforators are detected at an intermediate distance from the defect, a V-Y advancement flap is planned (4).
Flaps are harvested with the aid of a 2.5× loupe magnification. An exploratory incision is performed to expose the perforator vessel in a prefascial or subfascial plane. The perforators chosen to obtain the desired movement are carefully dissected for 2–3 cm by gently teasing muscle fibers. Extensive intramuscular dissection is recommended only when pedicle elongation is needed to improve flap reach, especially in case of propeller movement. After pedicle dissection, the skin paddle is confirmed or redrawn according to the intraoperative findings and circumcised. In case of restricted movement, minor peripheral perforators can be sacrificed to obtain further mobility. The flap is sutured without tension to the recipient site under suction drains and the donor site is always closed by primary intention.
Case report An exemplary case is shown to document the freestyle reconstructive approach. A 60-year-old male patient underwent excision for a basal cell carcinoma involving the medial tibial region, leaving a 3.5 × 3 cm soft tissue defect along the tibial shaft (Fig. 1, left). A skin graft was excluded because of contour deformity and poor aesthetic and functional result produced in case of direct placement over bony prominences. Local random pattern flaps were considered risky because of poor skin elasticity and restricted movement associated with possible distal flap necrosis, delayed healing, or hypertrophic scars. The angiosome of the posterior tibial artery (PTA) was investigated with handled acoustic Doppler ultrasound device for the presence of cutaneous perforators, identifying a reliable pedicle caudally and in close proximity to the defect. An 8 × 3 cm PTA perforator propeller flap was planned to resurface the defect in a tensionfree manner (Fig. 1, left). An exploratory incision allowed to expose the previously Dopplered
FIG. 1. Left: An 8 × 3 cm posterior tibial artery perforator propeller flap has been planned to resurface a 3.5 × 3 cm defect in the medial tibial region. Right: 6-month post-operative follow-up.
2
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Brunetti et al.
Freestyle flaps philosophy
FIG. 2. Left: The pedicle is exposed and isolated (arrow pointing to the perforator complex entering the flap). Right: The flap sutured at the end of the procedure.
pedicle, which was dissected from the surrounding fibrous attachments with a prefascial dissection, thus preserving the great saphenous vein (Fig. 2, left). The opposite margin was subsequently incised and the flap completely islanded on the perforator vessel (Fig. 2, right). The island flap design was preferred to the more classical transposition movement because it allowed one to obtain a tension-free insetting and avoid dog-ear development at the base of the flap. The flap was transposed to the recipient site with a 45 degree counterclockwise pedicle rotation. Flap donor site was closed primarily without tension. The postoperative course was uneventful, as documented by the 6-month follow-up picture (Fig. 1, right). The patient was highly satisfied with the aesthetic and functional outcome.
Discussion The use of freestyle pedicled perforator flaps in the field of soft tissue reconstruction presents several advantages. The extended range of motion, not restricted by the empiric width-to-length ratio used to design random flaps, produces a tensionfree insetting with better aesthetic and functional outcome. Furthermore, only the tissues necessary for reconstruction are mobilized, avoiding the classic bulky aspect of major reconstructions with myocutaneous flaps. Compared with random pattern flaps, pincushion deformity is more frequently observed, especially in the first postoperative months, but it usually tends to settle down over time. According to the perforasome theory (5), we consider as obsolete the random flap concept and try to approach each most of the reconstructive cases with this particular philosophy, limiting the use of random pattern flaps to the reconstruction of certain facial subunits, where abundant vascularization and elasticity of the soft tissues
228
minimize the risk of distal flap necrosis and venous insufficiency. In agreement with this concept, we consider as mandatory the execution of preoperative Doppler examination and suggest harvesting each flap using the deep muscular fascia as a guide for the dissection in order to have more chance to encounter the perforator vessels. The “cut as you go” approach results very useful to maximize vascular safety: in fact, if the perforators are found to be small or absent, the opposite skin bridge can be partially maintained, converting the flap to a perforator plus model, which provides, despite of a more difficult insetting, additional blood supply and improved venous outflow. Freestyle surgical approach obviously presents a learning curve, which is usually shorter for centers provided with microsurgical expertise. Nevertheless, this kind of surgery can be performed by every reconstructive surgeon, given that a detailed knowledge of the vascular anatomy of the integument is possessed.
Conclusions The freestyle approach allows resurfacing almost each defect in different regions of the body, mobilizing the surrounding tissues on a consistent vascular source. In our hands, application of this philosophy proved to be a reliable solution to obtain optimal aesthetic results with minimization of donor site morbidity and complication rates.
Disclosure The authors who have taken part in this study declare that they do not have any commercial associations that might pose or create a conflict of interest with information presented in this paper. No intramural or extramural funding supported any aspect of this work.
3
Brunetti et al.
References 1. Blondeel PN, Van Landuyt KH, Monstrey SJ, et al. The “Gent” consensus on perforator flap terminology: preliminary definitions. Plast Reconstr Surg 2003: 112 (5): 1378–1383. 2. Wallace CG, Kao HK, Jeng SF, Wei FC. Free-style flaps: a further step forward for perforator flap surgery. Plast Reconstr Surg 2009: 124 (Suppl. 6): e419–e426. 3. Teo TC. The propeller flap concept. Clin Plast Surg 2010: 37 (4): 615–626, vi.
4
Freestyle flaps philosophy 4. Brunetti B, Tenna S, Aveta A, et al. Free-style local perforator flaps: versatility of the V-Y design to reconstruct soft tissue defects in the skin cancer population. Plast Reconstr Surg 2013: 132 (2): 451–460. 5. Saint-Cyr M, Wong C, Schaverien M, et al. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg 2009: 124 (5): 1529–1544.
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