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Steven F. Morris - One of the best experts on this subject based on the ideXlab platform.
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Anatomy and physiology of Perforator Flaps of the upper limb.
Hand clinics, 2014Co-Authors: Sarah E. Appleton, Steven F. MorrisAbstract:Abstract Perforator Flaps are an excellent reconstructive option for a functional upper limb reconstruction. This article explores the physiology and general principles of Perforator Flaps and their indications for use in reconstruction of the upper extremity. Workhorse Perforator Flaps of the upper extremity, such as the radial artery Perforator, ulnar artery Perforator, lateral arm Perforator, posterior interosseous artery, first dorsal metacarpal artery Perforator and Perforator-based propeller Flaps, are discussed in greater detail.
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The anatomic basis of Perforator Flaps
Clinics in plastic surgery, 2010Co-Authors: Steven F. Morris, Maolin Tang, Khalid Almutari, Christopher Geddes, Daping YangAbstract:The recent enthusiasm for Perforator Flaps underlines the need for a detailed understanding of the cutaneous vasculature. The principle determinant of success in Perforator flap surgery is the inclusion of an adequately sized cutaneous Perforator in the flap. Therefore, the size, distribution, and variability of cutaneous Perforators of the human body are crucial to the design and execution of successful Perforator flap surgery. Based on numerous anatomic studies, the authors have found that the main source arteries supplying the skin are fairly constant but the individual cutaneous Perforators are quite variable. Knowledge of the overall architecture of the vasculature and an awareness of the variability, combined with a flexible operative plan, will enable the Perforator flap surgeon to take advantage of the most appropriate Perforators to execute a successful operative plan.
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a pilot study on three dimensional visualization of Perforator Flaps by using angiography in cadavers
Plastic and Reconstructive Surgery, 2008Co-Authors: Maolin Tang, Zhixun Yin, Steven F. MorrisAbstract:Background: Perforator Flaps have become popular worldwide, in part because of their ability to reliably support a large skin territory on a single Perforator. Although the lead oxide injection technique provides excellent images for anatomical study, it is not possible to show the location, course, and direction of the source artery. Materialise’s Interactive Medical Image Control System allows microvascular anatomy to be evaluated in three-dimensions to design Perforator Flaps. Methods: Two fresh cadavers were injected using the lead oxide–gelatin injection technique. The cadavers were imaged using a spiral computed tomography scanner. The computed tomographic data were transferred to Digital Imaging and Communications in Medicine format and imported to a personal computer. Three-dimensional reconstructions of various parts of the body were then performed using Materialise’s Interactive Medical Image Control System software. Results: Three-dimensional visualization of various parts of the body was obtained. This technique clearly shows the bone, soft tissue, skin, and vascular structures in a layer-by-layer transparent process. The detailed views of the microvasculature provide extensive information regarding the course of vessels in all layers of tissue. Conclusions: The intricate vascular details captured by this technique clearly demonstrate the three-dimensional anatomy of the integument, bone, and soft tissue in a layer-by-layer transparent process. It is a powerful, quick, easy method with which to demonstrate cadaver vascular anatomy that may be useful in the design of surgical Flaps.
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The superior and inferior gluteal artery Perforator Flaps
Plastic and reconstructive surgery, 2007Co-Authors: Reza Ahmadzadeh, Léonard Bergeron, Maolin Tang, Steven F. MorrisAbstract:Background Perforator Flaps have allowed reconstruction of soft-tissue defects throughout the body. The superior and inferior gluteal artery Perforator Flaps have been used clinically, yet the published anatomical studies describing the blood supply to the gluteal skin are inadequate. This study comprehensively evaluated the anatomical basis of these Flaps to present anatomical landmarks to facilitate flap dissection. Methods In six fresh cadavers, the integument of the gluteal region was dissected. Cutaneous Perforators of the superior and inferior gluteal arteries were identified. Their course, size, location, and type (septocutaneous versus musculocutaneous) were recorded based on dissection, angiography, and photography. The surface areas of cutaneous territories and Perforator zones were measured and calculated. Results The average number of superior and inferior cutaneous Perforators greater than or equal to 0.5 mm in the gluteal region was 5 +/- 2 and 8 +/- 4, respectively, with all of the superior and 99 percent of the inferior gluteal artery Perforators being musculocutaneous. Their average Perforator internal diameter was 0.6 +/- 0.1 mm. The average superior and inferior gluteal artery cutaneous vascular territory was 69 +/- 56 cm and 177 +/- 38 cm, respectively. The superior gluteal Perforators were found adjacent to the medial two-thirds of a line drawn from the posterior superior iliac spine to the greater trochanter. The inferior gluteal artery Perforators were concentrated along a line in the middle third of the gluteal region above the gluteal crease. Conclusion The reliable size and consistency of the superior and inferior gluteal artery Perforators allow the use of pedicled and free superior and inferior gluteal artery Perforator Flaps in a variety of clinical situations.
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a review of vascular injection techniques for the study of Perforator Flaps
Plastic and Reconstructive Surgery, 2006Co-Authors: Léonard Bergeron, Maolin Tang, Steven F. MorrisAbstract:Background:With a new era of flap surgery, additional anatomical information is required. The relatively recent interest in musculocutaneous Perforator Flaps has once again sparked interest in the vascular anatomy of surgical Flaps. There are a variety of anatomical techniques available to define th
Minghuei Cheng - One of the best experts on this subject based on the ideXlab platform.
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pedicle Perforator Flaps for vulvar reconstruction new generation of less invasive vulvar reconstruction with favorable results
Gynecologic Oncology, 2015Co-Authors: Jungju Huang, Naijen Chang, Hunghsueh Chou, Mohamed Abdelrahman, Hsinyu Chen, Minghuei ChengAbstract:Abstract Objectives Vulvar reconstruction after cancer surgery remains challenging. Pedicle Perforator Flaps are believed to be a less invasive option with better cosmesis. Methods A retrospective review identified 27 Flaps in 16 patients who underwent vulvar reconstruction after cancer surgery using island pedicled Perforator Flaps. Their average age was 55.7±17.8years (Range: 22–85). The average BMI was 23.5±4.0 (range: 18.8–28.5). Five of the 16 patients underwent unilateral vulvar reconstruction, and 11 of them underwent bilateral vulvar–perineal reconstructions. The Perforator Flaps included deep femoral (profunda) artery Perforator (DFAP or PAP) Flaps (n=11), medial circumflex femoral Perforator (MCFAP) Flaps (n=8), external pudendal artery Perforator (EPAP) Flaps (n=2), medial thigh free style Perforator Flaps (n=2), and internal pudendal artery Perforator Flaps (n=4). Results All Flaps survived with a 100% success rate. Three patients developed small wounds that required debridement and closure after the reconstruction. All donor sites were closed primarily. One patient developed temporary peroneal nerve palsy. During follow-up, none of the patients presented with donor site morbidities. All of the patients were satisfied with the cosmetic and functional results, except that one patient underwent a flap debulking procedure three months after surgery. Conclusions Compared to traditional myocutaneous Flaps, Perforator Flaps provide thinner fasciocutaneous Flaps for vulvar reconstruction with favorable reconstruction results and fewer donor site morbidities. The medial or inner thigh is a region that is rich in Perforators, which allow for more versatile flap design according to the defect. Furthermore, most of the donor site can be closed primarily without complications.
Paolo Persichetti - One of the best experts on this subject based on the ideXlab platform.
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free style local Perforator Flaps versatility of the v y design to reconstruct soft tissue defects in the skin cancer population
Plastic and Reconstructive Surgery, 2013Co-Authors: Beniamino Brunetti, Stefania Tenna, Achille Aveta, Francesco Segreto, Paolo PersichettiAbstract:BACKGROUND: Free-style local Perforator Flaps can be harvested from any region of the body where an appropriate and detectable Perforator vessel is present. Their use allows the surgeon to perform a "like with like" reconstruction by mobilizing surrounding tissues on a consistent vascular source. The authors report their experience with V-Y free-style Perforator Flaps in reconstruction of soft-tissue defects subsequent to skin cancer excision. METHODS: Forty elective defects in different regions of the body were reconstructed with V-Y advancement local Perforator Flaps raised in a free-style fashion. There were 23 male patients and 17 female patients. Mean age at surgery was 63 years. All defects resulted from skin cancer ablation. Mean defect size was 5×3.7 cm. Mean flap dimensions were 8.8×4.2 cm. The Flaps were based on one (n=10), two (n=18), or three (n=12) Perforators. RESULTS: Mean operative time was 93 minutes. Thirty-seven Flaps (92.5 percent) healed uneventfully. In three Flaps (7.5 percent), moderate venous insufficiency occurred, leading to partial flap necrosis that required surgical revision. In three cases (7.5 percent), the flap was converted to a rotation/hatchet Perforator-based peninsular flap. Slight venous stasis was the most common postoperative finding registered (eight Flaps; 20 percent). All Flaps achieved adequate and durable reconstruction with excellent contour, with a follow-up ranging between 6 months and 2 years. CONCLUSION: Free-style local Perforator Flaps advanced in V-Y fashion proved to be a valid and reliable solution to restore function and aesthetics of the operated site after skin cancer excision. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
Phillip Blondeel - One of the best experts on this subject based on the ideXlab platform.
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Free Perforator Flaps in children.
Plastic and reconstructive surgery, 2005Co-Authors: Koenraad Van Landuyt, Phillip Blondeel, Patrick Tonnard, Moustapha Hamdi, Alex Verpaele, Stan MonstreyAbstract:Background: Raising Perforator Flaps is said to be a tedious procedure. The benefits, however, are great. In adults, Perforator Flaps have proved their usefulness and reliability in various clinical situations. In children, donor sites for free Flaps are particularly scarce because of the need for a long and reliable vascular pedicle of sufficient size. There is also the need to minimize donor-site morbidity from aesthetic, functional, and psychological perspectives. Methods: The authors present a series of 23 consecutive free Perforator Flaps performed by the first author in 20 children; ages at the time of operation ranged from premature (born at 28 weeks) to 16 years (mean age, 7 years 5 months). Three children presented with upper limb defects; the remaining 17 children sustained major soft-tissue defects of the lower limb. All the lesions necessitated extensive coverage with a free flap. Flaps used in this series included nine deep inferior epigastric artery Perforator Flaps, seven thoracodorsal artery Perforator Flaps, and seven compound (chimera) thoracodorsal artery Perforator Flaps. Results: All Flaps but one were successful. With a follow-up of up to 7 years, the results in this series compare favorably with those of Perforator Flaps in adults or pediatric free Flaps in the literature. Conclusions: In children, as in adults, Perforator Flaps are a valuable alternative to the traditional muscle or myocutaneous free flap. Because of the added advantage of reducing donor-site morbidity, Perforator Flaps have become the authors' preferred option in reconstructive cases in children.
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autologous breast augmentation by pedicled Perforator Flaps
Annals of Plastic Surgery, 2004Co-Authors: Koenraad Van Landuyt, Phillip Blondeel, Moustapha Hamdi, Stan MonstreyAbstract:A technique is described for autologous breast augmentation based on Perforator Flaps of the lateral chest wall. Raising these Flaps as Perforator Flaps implies minimal donor site morbidity; however, the price to pay is a scar underneath the armpit extending from the lateral end of the inframammary fold onto the back. This scar can be relatively well hidden underneath the arm and in the brassiere. Indications depend on the aversion of the patient against prostheses and the extent of available tissue versus the desired augmentation. As typical indications, we would consider the occasional developmental asymmetry, autologous augmentation after contralateral breast reconstruction, or contour surgery in the bariatric patient.
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pedicled Perforator Flaps in breast reconstruction a new concept
British Journal of Plastic Surgery, 2004Co-Authors: Moustapha Hamdi, Stan Monstrey, Koenraad Van Landuyt, Phillip BlondeelAbstract:Abstract Introduction . Pedicled Perforator Flaps have not been widely described for the breast. The aim of this study is to report our clinical experience with pedicled Perforator Flaps in breast reconstruction. Material and methods . Between May 2000 and May 2003, pedicled Perforator Flaps were used in 31 patients. The indications were immediate partial breast reconstruction and thoracic reconstruction for carcinomatous mastitis or tumour recurrence. Perforators were identified by Doppler preoperatively. The Doppler-located thoracodorsal artery Perforator (TDAP) or another Perforator such as the intercostal artery Perforator (ICAP) was looked for. If the Perforators had good calibers, the Flaps were then based solely on these Perforators. If the Perforators were tiny but pulsating, the TDAP flap was harvested as a muscle-sparing latissimus dorsi type I (MS-LD I) with a small piece of muscle (4×2 cm) included to protect the Perforators. If the Perforators were not-pulsating, a larger segment of the LD muscle was incorporated to include the maximum of Perforators (MS-LD II flap). The nerve that innervates the rest of the LD muscle was always spared. If most of the LD was included in the flap, the flap was then classified as MS-LD III. Results . The mean flap dimensions were 20×8 cm. Using this algorithm, the TDAP flap was harvested in 18 cases and the ICAP flap in three cases. In addition, there were 10 MS-LD Flaps with a variable amount of muscle. In addition, one parascapular flap was dissected. A successful flap transfer was achieved in all but three patients, in whom limited partial necrosis occurred. Seroma was not encountered at the donor sites of the Perforator Flaps (0%) compared to four (40%) after a MS-LD flap. Conclusion . Our results show that pedicled Perforator Flaps are additional options for breast surgery and that they may be used whenever an adequate Perforator can be found. This technique is safe and reliable if the algorithm described is used when choosing a flap.
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a clinical experience with Perforator Flaps in the coverage of extensive defects of the upper extremity
Plastic and Reconstructive Surgery, 2004Co-Authors: Moustapha Hamdi, Stan Monstrey, Koenraad Van Landuyt, Phillip BlondeelAbstract:Traditional skin free Flaps, such as radial arm, lateral arm, and scapular Flaps, are rarely sufficient to cover large skin defects of the upper extremity because of the limitation of primary closure at the donor site. Muscle or musculocutaneous Flaps have been used more for these defects. However, they preclude a sacrifice of a large amount of muscle tissue with the subsequent donor-site morbidity. Perforator or combined Flaps are better alternatives to cover large defects. The use of a muscle as part of a combined flap is limited to very specific indications, and the amount of muscle required is restricted to the minimum to decrease the donor-site morbidity. The authors present a series of 12 patients with extensive defects of the upper extremity who were treated between December of 1999 and March of 2002. The mean defect was 21 x 11 cm in size. Perforator Flaps (five thoracodorsal artery Perforator Flaps and four deep inferior epigastric Perforator Flaps) were used in seven patients. Combined Flaps, which were a combination of two different types of tissue based on a single pedicle, were needed in five patients (scapular skin flap with a thoracodorsal artery Perforator flap in one patient and a thoracodorsal artery Perforator flap with a split latissimus dorsi muscle in four patients). In one case, immediate surgical defatting of a deep inferior epigastric Perforator flap on a wrist was performed to immediately achieve thin coverage. The average operative time was 5 hours 20 minutes (range, 3 to 7 hours). All but one flap, in which the cutaneous part of a combined flap necrosed because of a postoperative hematoma, survived completely. Adequate coverage and complete wound healing were obtained in all cases. Perforator Flaps can be used successfully to cover a large defect in an extremity with minimal donor-site morbidity. Combined Flaps provide a large amount of tissue, a wide range of mobility, and easy shaping, modeling, and defatting.
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The use of pedicled Perforator Flaps for reconstruction of lumbosacral defects.
Annals of plastic surgery, 2000Co-Authors: Nathalie Roche, Phillip Blondeel, Koenraad Van Landuyt, G. Matton, Stan MonstreyAbstract:Large lumbosacral defects remain a difficult challenge in reconstructive surgery, especially in the nonparaplegic patient. Traditional options for closure include local rotation or transposition Flaps and musculocutaneous Flaps. These Flaps, however, are not an optimal option in previously irradiated or operated areas, or in cases of large defects. Application of the Perforator principle to the traditional musculocutaneous flap creates Perforator Flaps, which are an additional tool in the treatment of these defects in the nonparaplegic patient. A large amount of healthy, well-vascularized tissue can be transferred on one Perforator without sacrificing important underlying muscles. The arc of rotation is also larger than in traditional Flaps. The authors present an anatomic overview of three types of pedicled Perforator Flaps: the superior gluteal artery Perforator flap, the lumbar artery Perforator flap, and the intercostal artery Perforator flap. They also report 4 patients in whom a pedicled Perforator flap was used to reconstruct a large lumbosacral defect.
Jungju Huang - One of the best experts on this subject based on the ideXlab platform.
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pedicle Perforator Flaps for vulvar reconstruction new generation of less invasive vulvar reconstruction with favorable results
Gynecologic Oncology, 2015Co-Authors: Jungju Huang, Naijen Chang, Hunghsueh Chou, Mohamed Abdelrahman, Hsinyu Chen, Minghuei ChengAbstract:Abstract Objectives Vulvar reconstruction after cancer surgery remains challenging. Pedicle Perforator Flaps are believed to be a less invasive option with better cosmesis. Methods A retrospective review identified 27 Flaps in 16 patients who underwent vulvar reconstruction after cancer surgery using island pedicled Perforator Flaps. Their average age was 55.7±17.8years (Range: 22–85). The average BMI was 23.5±4.0 (range: 18.8–28.5). Five of the 16 patients underwent unilateral vulvar reconstruction, and 11 of them underwent bilateral vulvar–perineal reconstructions. The Perforator Flaps included deep femoral (profunda) artery Perforator (DFAP or PAP) Flaps (n=11), medial circumflex femoral Perforator (MCFAP) Flaps (n=8), external pudendal artery Perforator (EPAP) Flaps (n=2), medial thigh free style Perforator Flaps (n=2), and internal pudendal artery Perforator Flaps (n=4). Results All Flaps survived with a 100% success rate. Three patients developed small wounds that required debridement and closure after the reconstruction. All donor sites were closed primarily. One patient developed temporary peroneal nerve palsy. During follow-up, none of the patients presented with donor site morbidities. All of the patients were satisfied with the cosmetic and functional results, except that one patient underwent a flap debulking procedure three months after surgery. Conclusions Compared to traditional myocutaneous Flaps, Perforator Flaps provide thinner fasciocutaneous Flaps for vulvar reconstruction with favorable reconstruction results and fewer donor site morbidities. The medial or inner thigh is a region that is rich in Perforators, which allow for more versatile flap design according to the defect. Furthermore, most of the donor site can be closed primarily without complications.
