Perforasome
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Transcript of Perforasome
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Journal meetingTrauma Department of PRS in CGMH
11.17.2009R4 Pang-Yun Chou, MDR4 Pang-Yun Chou, MD
Prof. Chih-Hung Lin, MDProf. Chih-Hung Lin, MD
November, 2009, PRSNovember, 2009, PRS
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Introduction
• Evolution– Random-pattern flaps– Fasciocutaneous flaps– Myocutaneous flaps– Perforator flaps
• Manchot, Salmon, Cormack, Lamberty, Taylor, Palmer, Morris, Tang…
• Ultimate goal of reconstruction– Match optimal tissue replacement– Minimal donor-site expenditure– Maintain function
Perforator flaps
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Perforator flaps
• Koshima– Began in 1989
• inferior epigastric artery skin flap with the rectus abdominis muscle for reconstruction of floor-ofmouth and groin defects
• Br J Plast Surg. 1989;42:645–648Br J Plast Surg. 1989;42:645–648
– Large skin flap• Survive without muscle• Based on a single perforator
• Kroll and Rosenfield– Perforator flaps
• Blood supply from MC flap, without deteriorating donor site
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Perforator flap
• Clinically, harvested as– Pedicle perforator flap– Free flap
• Over 350 perforatorsOver 350 perforators in body– Diameter and length of source artery– Location of pivot point
• Perforators– Direction– Axiality of flow
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Perforators
• Taylor and palmer– Angiosome concept
• Source artery perforators itself• Dynamic vascularity of perforator flapsDynamic vascularity of perforator flaps• Limiation of static image
– Vascular distribution and flow characteristics
• Perforators– Axiality of blood flow– Connections with adjacent perforators– Subdermal plexus and fascia contribution
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Perforasome
• 3 years research
• 217 flaps, totally
• 40 fresh cadavers40 fresh cadavers
• Dissect by loupe
• Methylene blue
Texas Southwestern Medical CenterTexas Southwestern Medical Center
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Materials and Methods
• Anterior trunks– Internal mammary artery, superior epigastric artery, deep inferior
epigastric artery, and supraclavicular artery perforator flaps
• Posterior trunks– Thoracodorsal artery, posterior intercostal artery, lumbar artery,
and superior and inferior gluteal artery perforator flaps
• Upper extremity– Ulnar artery, radial artery, and posterior interosseous and the Qu
aba flaps
• Lower extremity– ALT, AMT, ATA, peroneal artery, and PTA perforator flap
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Flap harvesting technique• Trunk
– Harvested from midline to midaxillary line– Anterior trunk
• 26 IMA flaps – supraclavicular to costal chondral margin• 60 DIEP flaps• 13 SEAP flaps – superior epigastrium to lower
– Posterior trunk• TDA flaps• LA flaps – T12 to iliac crest
• Extremity– Skin incisions
• ForearmForearm -- made opposite the source artery• ALT, AMTALT, AMT – groin crease to supra-patellar region• Lower legLower leg – circumferential skin dissection
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Dynamic 4D-CT
• 4D-CT angiography– 3D-CT angiography + TIMETIME
• Scanned with contrast media just injected• Characteristics and distribution of vascular perfusionvascular perfusion
• Flaps– Placed skin downward
• Prevent pressure on the pedicle• Minimize the risk of ↑resistance during perfusion
• Contrast media– Heated to 373700 ↓Viscosity, ↑ Vascular filling– 2 to 5 ml/flap
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Static 3D-CT
• Barium-gelatinBarium-gelatin mixture– 100ml N/S to 404000 + 3g gelatin– Slowly adding 40g barium sulfate– Vascular tree was saturated– Flaps frozen at least 24 hrs before CT scan
• Static 3D– Branching patterns of perforators– Characteristics of linking vessels
• Dynamic 4D– Axiality or preferential direction of flow
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Results
• PerforasomePerforasome– Each perforator has its
own unique vascular arterial territory
• CT image– Multiple direct linking v
essels– Direction of flow
PerforasomePerforasome
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First principle
• Two mechanism– DirectDirect linking vessels
• Communicating directly from one perforator to the next• Within the suprafascial and adipose layer
– Indirect Indirect linking vessels• Recurrent flow through the subdermal plexus
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Linking vessels
• Linking vessels– Multiple perforasomes– To one another
• Flow through– Communicating branCommunicating bran
chesches– BidirectionalInjury to direct or indir
ectPerfusion maintainedPerfusion maintained
Dynamic 4D-CTDynamic 4D-CT
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ALT to AMT, By Large direct linking vesselsALT to AMT, By Large direct linking vessels
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AMT to ALT, Reverse perfusion, bi-directionalAMT to ALT, Reverse perfusion, bi-directional
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ALT to AMT, By LVs, communicating branchesALT to AMT, By LVs, communicating branches
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AMT to ALT, bi-directionalAMT to ALT, bi-directional
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Sub-dermal plexus
• TaylorTaylor– Choke vessels– Indirect linking vessels– Recurrent flow from
sub-dermal plexus
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Indirect linking vessels
• Perforators– Oblique branch, Vertical branch to subdermal plexus
• Indirect linking vessels– Recurrent flowRecurrent flow from the subdermal plexus
Lateral viewLateral view
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Communicating branches
• Communicating branches– Coronal, sagittal, and transverse planes– Confer a protective mechanismprotective mechanism to ensure vascular flow to skin
Transverse viewTransverse view
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Second principle• Flap design, Skin paddle orientation
– Based on the direction of linking vesselsdirection of linking vessels• Axial in extremity
– Parallel to the axis of the limbs– Flaps designed in parallel to axis of linking vessels
• Perpendicular to the midline in trunk– TDA flap (latissimus dorsi muscle fibers), IMA flap– Perforators follow a vertical row distribution
» Have contra-lateral ones– Flow away from the midline for lateral vascularity– Ant. and posterior midlines of trunk
» Heavily populated in perforators
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Axiality
Thoracodorsal flapThoracodorsal flap
Forearm flapForearm flap
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Lower legAnterior legAnterior leg Posterior legPosterior leg
Cross midlineCross midline Follow axiality of limbFollow axiality of limb
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Trunk
Linking vesselsLinking vessels
Perpendicular to midline of trunkPerpendicular to midline of trunk
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Abdomen
Transverse abdominal skin flapTransverse abdominal skin flap
Linking vessels, perpendicular, Linking vessels, perpendicular, bi-directional fashionbi-directional fashion
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Back
Perpendicular, cross midlinePerpendicular, cross midline
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Third principle
• Preferential filling of perforasomes– Within perforators of the same source artery
– Followed by perforators of adjacent source arteries adjacent source arteries• DB-LFCA AMT superficial FA perforasomes• Vascular filling, density maximized, then spread-out
– Single large perforatorsSingle large perforators from a source artery• Medial circumflex femoral artery• Less axial vascular distribution
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Preferential filling
Adjacent source arteriesAdjacent source arteries
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Fourth principle
• Mass vascularity– A perforator adjacent to an articulation
• Directed away from same articulation
• Radial A. perforator flap
– A perforator at midpoint between two articulations, or in trunk• Multi-directional flow distribution
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Direction of flow• Vascular density
– ↓distally away from• Midline of trunk• An articulation
• Orientation of LV– Orientation of vascular flow
• Perpendicular to midline• Parallel to limb axis
• Perforator locationPerforator location– Flap design– LVs between two perforators
• Bi-directional flow• Protection against injury
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Discussion
• Each perforator– Its own vascular territory, PerforasomePerforasome– Multidirectional flow pattern– Highly variable and complex
• Single perforator–based flap reconstructions– Knowledge of individualindividual perforator vascular anatomy
• supersedes that of source artery vascular anatomy
• Perforasomes are linked– Direct and indirect linking vessels– Communicating branches– ProtectionProtection from ischemia and vascular injury in case of trauma
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Discussion
• Perforator flap harvested– All branches from the source artery are ligated– Results in hyperperfusionhyperperfusion ↑ ↑ vascular filling pressures
• Dilate the perforator itself• Allow extensive interperforator flow
– LVs, higher than normal filling pressures• Capture additional adjacent perforator vascular territories
• Perforator flaps designed at a midpoint – Designed in multiple fashions
• Multidirectional perforator flow distribution
– Dense fibrous septae/ligamentous attachments over articulation• Maintain skin stability and draping during flexion and extension• Perforators directed away from the articulationaway from the articulation
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Conclusion
• Every perforator has the potential – Become either a pedicle or a free perforator flap
• HyperperfusionHyperperfusion of a single perforator – Capture multiple adjacent perforasomes– Large perforator flaps based on a single perforator
• Additional adjacent perforasome territories– Captured through direct and indirect LVs by hyperperf
usion
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Conclusion
• Perforasome theoryPerforasome theory
– Provides additional insight into the mechanisms of perforator flap vascularity
– Serves to facilitate the understanding, design, and clinical use of both free and pedicle perforator flaps
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Thanks for your attention!