Propeller, Perforator, and Other Local Flaps: Changing Reconstruction

Michel Saint-Cyr, M.D., F.R.C.S 2015

Blood supply means everything…

• Plastic Surgery = vascular anatomy/blood supply • Defines what ‘we do and how we do it’ • Determines our outcomes • Impacts patient satisfaction and morbidity • Socioeconomic & global health impact

• Pedicle perforator flaps • Flap design and perforator selection • General principles of flap perfusion & harvest • Indications and case examples • Tips and tricks for safe harvest • Have a back-up plan: • Local regional flap • Keystone flap • MS-pedicle flap • Free flap

©2013 MFMER | 3295165-3 Introduction Pedicle Perforator Flaps Advantages • Large availability of perforators (>500 perf.) • Replace “like with like” • Plasticity in flap design and donor sites (‘Freestyle) • No sacrifice of major source vessel • Can be ‘pre-expanded’ for larger flap • Can replace FF in certain situations

©2013 MFMER | 3295165-4 Introduction Pedicle Perforator Flaps Disadvantages • Learning curve • Vascular territory of each perforator not completely defined • Still requires micro dissection • Key perforators often close to zone of injury (pivot point) • Donor site STSG sometimes required

PAF 1. Pre-operative (Plan) 2. Intra-operative (Action) 3. Post-operative (Follow)

1. Patient selection

1. Previous XRT 2. Previous trauma 3. Previous surgeries 4. Timing of surgery 5. Medical co-morbidities 6. Life style habits ex: nicotine dependence 7. Support system and patient expectations/ compliance

Maximal arterial and venous perfusion Dominant perforator(s)

©2013 MFMER | 3295165-12 How to get started… • Identify location of dominant perforators close to defect (Doppler, CTA, MRA etc.) • Draw a line over dominant axial vessel Ex: PTA, ATA, RA, UA, SFA, Dsc.Br. LCFA etc. • Doppler perforators along axial vessel, note dominance • Design flap long axis parallel to and over axial vessel • Start with medial exploratory incision first • Identify perforator, dissect pedicle to appropriate length • Rotate flap into defect, confirm Doppler and perfusion • Have a back-up: Keystone, FF, MS-pedicle flap

Each flap has its own unique vascular anatomy, pedicle and perforator distribution:

1. High density 2. Medium density 3. Low density

Flap hyper-density and hypo-density vascular distribution: Cold spots & Hot spots

Radial Forearm Flap RFF

Fascia Perforator

Subdermal plexus

Design flap long axis parallel to PTA course

1st exploratory incision to Identify perforator

Complete circumferential Doppler signal perforators close to wound flap incision after and along axis of PTA perforator dissection Maximal inter-perforator flow

Decreasing angle of perfusion decreases number of linking vessels included within the flap

Speeds up flap harvest by allowing earlier decision making

• The skin paddle can be raised off the medial gastrocnemius based on the medial sural artery perforator. • The skin paddle can be inset in a different orientation to the underlying muscle flap

SFAP Flap

Fig 1. Intra-op pre-resection Fig 2. Intra-op post-resection

SFAP Flap Circumferential flap incision, rotation & inset Tension free, no pedicle kink or compression

Smaller flap design potentially limits options

Larger flap design affords potentially more options

• Radiotherapy, Scarring, Undermining, Trauma, Tension etc.

Cheng A, Saint-Cyr M. Split and thinned pedicle deep inferior epigastric perforator (DIEP) flap for vulvar reconstruction. J Reconstr Microsurg. 2013 May;29(4):277-82.

Groin Coverage: Pedicled ALT or DIEP flap Keystone Flap also a great option

©2013 MFMER | 3295165-65 66 F, Recurrent SCC, Chemo-XRT, groin disease, extending into abdominal cavity, retroperitoneal space. Abdominal wall reconstruction with mesh, Sartorius flap, keystone flap (700cm2)

Courtesy A. Cholet M.D.

More Less Back-up

DMA

Perforator

Release all scar contractures and capsule Avoid constrictive forces on flap Account for post-operative swelling Use wide base for pedicle, don’t over skeletonize

Perforator

Reduced perfusion seen intra-operatively

• Incorporate dominant perforator(s) ‘hot spots’ • Dissect pedicle length as needed to avoid perforator kink/twist • Have back up loco-regional plan and plan exploratory incision accordingly • Harvest longer/larger flap then need to facilitate inset • Think outside ‘The Box’