Flap surgery is a technique in plastic and reconstructive surgery where any type of tissue is lifted from a donor site and moved to a recipient site with an intact blood supply. Highlight pertinent anatomy and techniques for selected. Read more patient demand for perforator flap procedures is quickly growing due to positive results. The detailed surgical technique with its variations is explained in this report. The tie between perforator flaps and skin flaps as well as perforator flaps and musculocutaneous flaps is explained. Atlas of perforator flap and wound healing microsurgical. Musculocutaneous perforator flaps offer advantages over musculocutaneous flaps, including reduced donor site morbidity, more predictable reconstruction of soft tissue deformities, and a wider variety of flap options. The keystone perforator island flap kpif was introduced as an alternative in nasal reconstruction by senior authors. This atlas is organized in a way with a combination of basic theory and clinical practices, and of real photos and text description in perforator flap. Pdf perforator flaps in head and neck reconstruction. The deep inferior epigastric artery perforator diep flap. The keystone perforator island flap concept 9780729539715. Surgical atlas of perforator flaps free medical books. Accompanying the book are four supplemental dvds that demonstrate actual operating procedures.
Pu and chunmei wang, is devoted to preexpanded perforator flaps. Perforator flap options for breast reconstruction include. Unlike conventional tram flap reconstructions, use of our refined perforator flap techniques allow for collection of this tissue without sacrifice of underlying abdominal muscles. In the distal third of the forearm, an island flap based on a single dorsal perforator of the ulnar artery has been used. When the larger perforator s are identified as one proceeds medially, they are traced into the muscle with bipolar dissection and dissected to their exit from between the piriformis and gluteus medius muscles. Perforator flaps have evolved, and they have provided many new flaps with new pedicles all over the body presenting important advantages. Then you can start reading kindle books on your smartphone, tablet, or computer no kindle device required. Along with its companion dvd, it highlights the keystone flap method as a valuable supplement to the reconstructive repertoire in the field of reparative surgery and a simple solution to many reconstructive problems. Allen, md handchirurgie mikrochirurgie plastische chirurgie vol. It marks a new era in reconstructive surgery where surgeons are no longer bound by the traditional conventions of flap surgery. Perforator flap reconstruction plastic surgeon austin. The introduction of the perforatorbased flaps and expanding knowledge regarding vascular anatomy of body have unveiled a nearly endless array of possible perforator flaps, such as the lumbar artery perforator lap flap. Pius branzeu center perforator flap harvesting seminars. Better understanding of vascular anatomy and pattern of skin circulation has become possible by numerous cadaveric studies.
Many new developments have taken place in the field, including the use of local perforator flaps, including freestyle propeller. Despite advances in reconstruction techniques, pressure sores continue to present a challenge to the plastic surgeon. Profunda artery perforator pap flap for breast reconstruction. Perforator flaps for breast reconstruction and millions of other books are available for amazon kindle. The flap is elevated from lateral and superior toward the medial aspect, deep to the muscular fascia and above the gluteus maximus muscle. For the successful reconstruction of facial defects, various perforator flaps have been used in singlestage surgery, where tissues are moved to adjacent defect sites. Perforator flap entity the angiosomes of the body and their supply to perforator flaps perforator flap terminology. The versatility of the perforator flap makes it ideal for the reconstruction of threedimensional defects such as breast reconstruction or as a thin flap for resurfacing shallow wounds when bulk is considered a disadvantage. Hyakusoku 1991 coined the term propeller flap, although it wasnt until later that the hub providing flap circulation was found to be more versatile if relying on a perforator vessel. The abc assessment system combined with colour dopplercomputed tomography angiography will facilitate an ideal individual assessment of this perforator flap. We limit the proximal extent of the flap to the midforearm. The deep circumflex iliac artery bone flap provides a large concave segment of bone suitable for reconstruction of the upper extremity, lower extremity and mandible.
Atlas of perforator flap and wound healing bookshare. Diep flap surgery the center for microsurgical breast. Perforator flaps have provided freedom of flap design with over 350. Advances in understanding of vascular anatomy, the dynamic nature of perforator perfusion, inter perforator flow and the hotspot principle have led to reconstructive techniques that allow innovative autologous tissue transfer while limiting donor site morbidity. The perforators, llc opened for business in november of 2004, with two wireline trucks based in roosevelt, utah. Introduction the conventional latissimus dorsi muscle or myocutaneous flap has undoubtedly served an important role as one of the most common flaps in reconstructive microsurgery. Key topics two days of b2c breakfasttococktail sessions encompass all the cutting edge aspects of technologyrich perforator surgery including functional reconstruction, lymphedema, targeted muscle reinnervation tmr, biologic, imaging, flap monitoring and emerging technology. A perforator flap should be named after the nutrient artery or vessels and not after the underlying muscle.
Perforator flap surgery was described as extravagant and exceptional in those days but it has now become the mainstream reconstructive technique for restoring. Perforator flaps have the advantages of reduced donorsite morbidity, versatility to accurately replace the components required at the recipient site, a longer pedicle than is achievable with the parent musculocutaneous flap, and freedom from orientation of the. Posterior tibial arterybased perforator flaps were used in five cases and peroneal arterybased perforator flaps in three cases. The principle that additional effort and time need to be spent to dissect the perforator out from between the muscle fibers to reduce the donor morbidity was the. This perforator uses a rotarystyle perforating wheel. Perforator variability in the anterolateral thigh free flap. In addition to the ulnar artery perforator, this flap is also nourished by the dorsal carpal arch through its communications with the descending branch. The deltoid fasciocutaneous flap was first described anatomically and applied clinically by franklin. Many new developments have taken place in the field, including the use of local perforator flaps, including freestyle propeller flaps as well as. An elliptical flap is marked according to the required dimensions centred around the perforator, with the anterior anterior flap border being anterior to mal. Perforator flaps for breast reconstruction gives plastic surgeons the detailed instructions they need to perform these sophisticated breast.
The editors, leading reconstructive surgeons and pioneers in the field of perforator flap surgery, have assembled a group of worldrenowned experts who discuss perforator anatomy and clinical indications for the use of these flaps. Allen at the th international course on perforator flaps in mexico city. The first patient was a 52yearold woman who had undergone previous attempts at breast reconstruction with a failed transverse rectus abdominis muscle tram flap and a failed implant. This new edition has been updated to include ten new chapters and extensive updates on all existing chapters. However, success begins with planning and continues with operative procedure. Perforator flaps for breast reconstruction download. The keystone perforator island flap concept is an authoritative keystone flap textbook. Keystone and pedicle perforator flaps in reconstructive. On the right side of the abdomen, a large diep perforator through the rectus muscle is illustrated.
Perforator flaps are increasingly used because of advantages such as the superselection of soft tissues with reduced bulk and less donorsite morbidity. On the contralateral side, the superficial inferior epigastric artery siea and the superficial inferior epigastric vein siev are demonstrated. Reverse thenar perforator, seyhan 2009 reverse palmar perforator flap, palmar perforator omokawa 2001, 2002. Keystone perforator island flap as an alternative reconstruc. The abdomen is the most common donor site, since excess fat and skin are usually found in this area. This flap is based on the ascending branch of the dorsal ulnar artery dua. Perforator pedicle flaps are largely replacing the concept of random flaps in our practice, and for the past 8 years, freestyle perforator flaps have been our first choice local flap for facial reconstruction.
Stacked deep inferior epigastric perforator flap breast reconstruction. Editor peter neligan, one of the worlds leading experts in perforator flaps, has assembled highly experienced authors. The vessels that supply blood to the flap are isolated perforator s derived from a deep vascular system through the underlying muscle or intermuscular septa. The true ulnar artery perforator uap flap includes skin from the ulnar forearm or hand based on an ulnar artery perforator, with preservation of the ulnar artery. Perforator flap perforator flap meeting 2017 columbus ohio. Comprehensive analysis of the anterolateral thigh flap. The flap dimensions needed are outline, with the perforator on the longitudinal axis of the flap. This new edition has been updated to include ten new. Perforator flap surgery was described as extravagant and exceptional in those days but it has now become the mainstream reconstructive technique for restoring defects throughout the body.
Perforator flaps for breast reconstruction gives plastic surgeons the detailed instructions they need to perform these sophisticated breast reconstruction procedures. Watch surgeons perform procedures in real time with an unparalleled twohour video collection that demonstrates harvest of the fibula flap for use in mandible reconstruction, the jejunum for esophagus reconstruction, and the siea, diep and igap flaps for breast reconstruction functioning muscle transfers for a variety of defects, including the gracilis muscle for facial reanimation and the gracilis musculocutaneous flap for finger flexion reconstruction with innervation using the. In this article, the authors describe a true ulnar artery perforator flap with perforator mapping. The paraumbilical perforator flap is a type of axial vascular flap in which perforator vessels beside the umbilicus are used as nutritional vessels. This helps in correct identification of the interface between ld and serratus anterior muscle through which the septocutaneous perforators are given off figure 1. Allen 1994 borrowed koshimas original work 16 and became the champion of the diep flap for breast reconstruction 19. Freestyle local perforator flaps for facial reconstruction. Purchase preexpanded perforator flaps, an issue of clinics in plastic surgery, volume 441 1st edition. A piece of tissue, usually consisting of skin and subcutaneous fat and blood vessels which perforate the underlying muscle, supplying the blood to the flap.
Enter your mobile number or email address below and well send you a link to download the free kindle app. Elisabeth potter, a boardcertified plastic surgeon in austin, specializing in breast reconstruction, offers perforator flap reconstruction options including diep flap. They consist of 3 worms with varying appearances and sizes, and a crimson, fleshy hive. Key topics two days of b2c breakfasttococktail sessions encompass all the cutting edge aspects of technologyrich perforator surgery including functional reconstruction, lymphedema, targeted muscle reinnervation tmr, biologic, imaging, flap monitoring and emerging. Newer applications for perforator flaps are being developed as this issue of seminars in plastic surgery is being published.
Plastic surgery perforator flaps for breast reconstruction. Thirtyeight consecutive patients who underwent ulnar artery perforator flap surgery were included in the study. Thieme ebooks, the first edition of perforator flaps. Peter neligan the first edition of perforator flaps. Preexpanded perforator flaps, an issue of clinics in. Anatomic imaging of abdominal perforator flaps without. The deltoid free flap is a neurovascular fasciocutaneous tissue, providing relatively thin sensate tissue for use in softtissue reconstruction. The procedure aims to replace the lost breast tissue removed at the time of cancer surgery with skin and fat from under your arms and restore the size and shape of your breast.
A broad search was undertaken through the pubmed database using the. Depending on the shape of your body and your personal preference, several areas of the body can act as donor sites for the tissue needed to restore the shape and form of the breast. Angrigiani et al 1 first described harvesting a cutaneous island of the latissimus dorsi flap without the muscle based on one cutaneous perforator. Perforator flaps have gained popularity in recent years in many aspects of reconstruction and the initial chapter of the book provides a brief history of flap surgery. The perforators are a group of prehardmode bosses fought in the crimson. After a brief introduction of the concept and surgical rationale of perforator flaps, the book presents 24 different flaps from donor sites including upper limb, lower limb and the trunk. Perforator flap definition of perforator flap by medical. In the present case series, kpifs application is introduced into the alar subunit as an alternative, versatile, and reproducible reconstructive option, even for the novice plastic surgeon. Kim and hwang 2005, superficial palmar branch of radial artery flap supbra iwuagwu et al 20, ulnar palmar digital artery perforator uchida et al 2009, digital artery perforator flaps koshima et al 2006, basat et al 20 and palmar. As a result, widespread use of perforator flaps, either pedicled or free, has become possible. A total of 45 patients underwent partial or total autologous breast reconstruction after skinsparing mastectomy, skinreducing mastectomy, and quadrantectomy using a thoracodorsal artery perforator tdap flap.
Lateral intercostal artery perforator licap flap breast reconstruction is suitable for some patients whose breast cancer is in the outer part of the breast. Understand new principles in single and multiple perforator flap harvest and adjunct techniques that can be used in perforator flaps. This issue of clinics in plastic surgery, guest edited by drs. This tissue is then surgically transformed into a new breast mound. Parasacral perforator flaps for reconstruction of sacral. This is distinct from a graft, which does not have an intact blood supply and therefore relies on growth of new blood vessels. Perforator flaps, an issue of clinics in plastic surgery. In our department, the thoracodorsal artery perforator tdap flap is widely used as free flap for large defects on extremities. An assessment of the anatomical basis of the thoracoacromial. The perforator can be at the center, distal or proximal aspect of the flap, depending on the needed orientation in the recipient area. The carl rt200 perforator kit is one of the most affordable and versatile manual perforators on the market. Anatomy of the abdominal skin harvested with the diep flap. This issue of clinics in plastic surgery provides guidance to help plastic surgeons incorporate perforator flap techniques in their practices.
Introduction since it was first introduced in 1984 by song et al. The deep circumflex iliac artery perforator flap dciapa. The anterolateral thigh alt free flap is frequently used in the head and neck. Synovis mca, the microsurgeons most trusted resource, provides innovative, advanced technologies specifically for microsurgeons, including a family of products that proudly hold the gem global excellence in microsurgery brand. Patient demand for perforator flap procedures is quickly growing due to positive results. Perforator flap surgery is a technique used in reconstructive surgery where skin andor subcutaneous fat are removed from a distant or adjacent part of the body to reconstruct the excised part. The pap flap for breast reconstruction was originated in 2010 by dr. Plastic surgery patient demand for perforator flap procedures is quickly growing due to positive results.
Medial sural artery perforator free flap msap british. The size, number, and location of perforators were recorded intraoperatively. Nov 17, 2017 pedicle perforator flaps and keystone perforator island flaps are additional tools for reconstructive surgeons. Perforator flaps were first introduced in 1992 and were developed out of a desire to further mimimize donor site morbidity and possibly recovery time without compromising safety or aesthetic outcomes. We are a company that takes pride in the services we provide.
Teaching facility the teaching faculty will consist of several consultant plastic surgeons from the canniesburn plastic surgery unit, who will aid the trainees during the cadaveric dissection. Because the donor vessels have traversed muscle before reaching the fascia, a longer vascular pedicle can be dissected. Perforator flap versus conventional flap article pdf available in journal of korean medical science 305. The superior gluteal artery perforator sgap flap uses tissue from the top of the buttocks to create breast tissue.
Perforator flaps the history of evolution jun 2002 robert j. A flap vascularized by a septal perforator is called a septal perforator flap. Plastic surgery perforator flaps thieme medical publishers. The book outlines techniques for flap harvest, from the most basic to the highly advanced. In total, ten patients were reconstructed with a msap flap for floor of mouth eight and lower extremity two defect reconstruction. Jan 30, 2017 the use of free flaps greatly improves reconstruction options and quality of life for patients undergoing oncological resections. The recent introduction of chimeric sentinel muscle perforator flaps for freeflap monitoring, local perforator flaps for lower extremity reconstruction, and perforatortoperforator free flaps is simply the beginning. Anatomy, technique, and clinical applications phillip blondeel. This results in an ellipse with its anterior longitudinal arc skirting the lateral border of the latissimus. Although the fibula has often replaced the dcia when bone reconstruction is necessary, especially in the mandible, the dcia provides a large segment of cancellous bone up to 15. Perforator flaps in the lateral thoracic region plastic. The parasacral perforator flap is a reliable flap that preserves the entire contralateral side as a future donor site.
Direct and indirect linking vessels play a critical part in perforator flap perfusion, and every clinically significant perforator has the potential to become either a pedicle or free perforator flap. Understand the future directions of the perforator flap concept. Perforator flaps have provided freedom of flap design with over 350 perforators all over the body, reliability, and reduced donor site morbidity. Many of the contributors to perforator flaps for breast reconstruction have pioneered the procedures presented in their respective chapters. Perforator flaps in the hand bmc proceedings full text. This is usually done if patients do not have adequate skin and tissue in their abdomens, or have had previous abdominal surgeries that may have interfered with blood vessels that the diep flap requires. Medial sural artery perforator free flap msap a medial sural artery perforator free flap is also known as an msap flap.
Chimeric stacked deep inferior epigastric perforator flap breast reconstruction. Evolution of flaps has continued after the introduction of fasciocutaneous and musculocutaneous flaps. The pivot point of the flap is 2 to 4 cm proximal to the radial styloid process red circle. The aims of this atlas are to introduce the clinical applications of perforator flaps in plastic surgery and skin replacement. If there is a potential to harvest multiple perforator flaps from one vessel, the name of each flap should be based on its anatomical region or muscle. Simply insert your paper, align the cutter and slide the perforating wheel across the paper. Although we provide a reading list, the course teaching should cover the essential aspects of flap anatomy, dissection and utilization. However, the 2 main disadvantages of this free flap are inconsistent vascular perforator anatomy and variable flap thickness.
The dciap flap is a good single flap option in these circumstances. The purists among us stated that a muscle perforator flap is the only real perforator flap. Perforator patterns of the ulnar artery perforator flap. What started as a small meeting among friends, has grown into a major international forum where colleagues share their new ideas in the field of perforator. However, its bulkiness and the sacrifice of donor structures often preclude its use. The first ever international course on perforator flaps icpf was organized in gent, belgium, 20 years ago in 1997, when perforator flap surgery was still in its pioneering phase. Our group successfully performed perforator flap surgery on 17 patients with small to moderate facial defects that affected the functional and aesthetic features of their faces. The alt flap provides a large skin paddle, potentially sensate skin, long pedicle length, and minimal donor site morbidity. The radial artery perforator flap provides volar coverage of the forearm and hand proximal to the distal palmar crease pink and dorsal coverage of the radial twothirds of the forearm and hand proximal to the metacarpophalangeal joints green. The propeller, flipover, conventional perforator, and musclesparing flaps have.
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