Propeller, Perforator, and Other Local Flaps: Changing Reconstruction Michel Saint-Cyr, M.D., F.R.C.S 2015 ©2013 MFMER | 3295165-1 Introduction 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 ©2013 MFMER | 3295165-2 Goals • 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 ©2013 MFMER | 3295165-5 Have a Plan! Pedicle Perforator Flaps PAF 1. Pre-operative (Plan) 2. Intra-operative (Action) 3. Post-operative (Follow) ©2013 MFMER | 3295165-6 Pedicle Perforator Flaps Pre-operative (Plan) 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 ©2013 MFMER | 3295165-7 Incorporate dominant perforator blood supply in flap! Maximal arterial and venous perfusion Dominant perforator(s) ©2013 MFMER | 3295165-8 Key perforators distributed into hot & cold spots ©2013 MFMER | 3295165-9 Perforator cluster distribution is predictable Design axis of flap parallel and centered over major perforator clusters ex: LCFA ©2013 MFMER | 3295165-10 A wealth of reconstructive options are available ©2013 MFMER | 3295165-11 Perforator flap options/freestyle approach ©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 ©2013 MFMER | 3295165-13 Vascular Anatomy The Cold and Hot Spot Principle 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 ©2013 MFMER | 3295165-14 Hot & Cold Spots around the body Flap Harvest ©2013 MFMER | 3295165-15 Safe and Efficient Flap Harvest: Using the The Cold and Hot Spot Principle Axial vessels in the extremities Radial Forearm Flap RFF ©2013 MFMER | 3295165-16 Vascular anatomy of perforator flaps The importance of Linking Vessels ©2013 MFMER | 3295165-17 Linking vessels Direct, Indirect and Communicating Fascia Perforator Subdermal plexus ©2013 MFMER | 3295165-18 General Principles in Flap Design 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 ©2013 MFMER | 3295165-19 Angle of Perfusion The wider the angle the more eccentric the perforator can be within the flap Decreasing angle of perfusion decreases number of linking vessels included within the flap ©2013 MFMER | 3295165-20 Angle of Perfusion and DIEP Flap Peripheral perforator location but wide angle of perfusion ©2013 MFMER | 3295165-21 Make flap harvest easy and simple Identify Septum Early, Start with Easy Tissue Planes of Dissection, Allows for Earlier Exposure of Critical Anatomy ©2013 MFMER | 3295165-22 Safe and Efficient Flap Harvest: The Cold and Hot Spot Principle Early identification of pedicle or perforator Speeds up flap harvest by allowing earlier decision making ©2013 MFMER | 3295165-23 Case Examples ©2013 MFMER | 3295165-24 Pedicle perforator flaps versus free flaps (ALT) For same purpose…. ©2013 MFMER | 3295165-25 PTA Perforators Anatomy ©2013 MFMER | 3295165-26 PTA pedicle perforator flap 165 Degree Rotation ©2013 MFMER | 3295165-27 Flap design for lateral lower leg defect ©2013 MFMER | 3295165-28 Perforators identified ©2013 MFMER | 3295165-29 ©2013 MFMER | 3295165-30 PTA pedicle perforator flap: Planning ©2013 MFMER | 3295165-31 Identify perforators with handheld Doppler ©2013 MFMER | 3295165-32 Circumferential flap incision after pedicle dissection & confirming vascularity ©2013 MFMER | 3295165-33 Flap rotation and inset under minimal tension ©2013 MFMER | 3295165-34 Pedicle perforator flap & conventional muscle flaps: gastrocnemius flap • 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 ©2013 MFMER | 3295165-35 Intra-operative resection Use an exploratory incision for perforator identification SFAP Flap Fig 1. Intra-op pre-resection Fig 2. Intra-op post-resection ©2013 MFMER | 3295165-36 Can identify linking vessels & adjacent perforators Incorporate axial linked perforators in flap design Maximal flap perfusion via inter-perforator flow ©2013 MFMER | 3295165-37 SFAP Flap Circumferential flap incision, rotation & inset Tension free, no pedicle kink or compression ©2013 MFMER | 3295165-38 SFAP Flap Flap inset, closure & result at 4 weeks postop ©2013 MFMER | 3295165-39 Don’t base flap on retrograde vessel Perforator from SFA ©2013 MFMER | 3295165-40 Intraoperative considerations Free up pedicle and increase length the more you anticipate degrees of rotation required ©2013 MFMER | 3295165-41 SFA pedicle perforator flap ©2013 MFMER | 3295165-42 Right Proximal Thigh Sarcoma 14-Year-Old Patient ©2013 MFMER | 3295165-43 Safe and Efficient Flap Harvest: The Cold and Hot Spot Principle ALT flap ©2013 MFMER | 3295165-44 Safe and Efficient Flap Harvest: The Cold and Hot Spot Principle Smaller flap design potentially limits options ©2013 MFMER | 3295165-45 Safe and Efficient Flap Harvest: The Cold and Hot Spot Principle Larger flap design affords potentially more options ©2013 MFMER | 3295165-46 Pedicle ALT ©2013 MFMER | 3295165-47 ALT: Anterior Incision First ©2013 MFMER | 3295165-48 ALT Harvest ©2013 MFMER | 3295165-49 Back up ALT Flap: muscle sparing VL If no suitable perforators ©2013 MFMER | 3295165-50 Safe and Efficient Flap Harvest: The Cold and Hot Spot Principle Flap/pedicle ratio Make flap bigger when starting out High F/P ratio Low F/P ratio ©2013 MFMER | 3295165-51 Pedicle ALT Groin Coverage & Trochanteric coverage ©2013 MFMER | 3295165-52 Abdominal wall reconstruction: pedicle ALT flap ©2013 MFMER | 3295165-53 ©2013 MFMER | 3295165-54 ©2013 MFMER | 3295165-55 ©2013 MFMER | 3295165-56 Use Donor Site Outside Zone of Injury • Radiotherapy, Scarring, Undermining, Trauma, Tension etc. ©2013 MFMER | 3295165-57 Pedicle DIEP flap Proximal thigh coverage following sarcoma excision ©2013 MFMER | 3295165-58 Pedicle DIEP flap Proximal thigh coverage, intraoperative radiotherapy ©2013 MFMER | 3295165-59 Pedicle DIEP flap Proximal thigh coverage ©2013 MFMER | 3295165-60 Pedicle DIEP flap Proximal thigh coverage ©2013 MFMER | 3295165-61 Pedicled DIEP flap Trochanter coverage ©2013 MFMER | 3295165-62 Pedicled DIEP flap Trochanteric coverage Mobilization of flap and final inset ©2013 MFMER | 3295165-63 Split pedicle DIEP for vulva reconstruction Two perforator based DIEP flap 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. ©2013 MFMER | 3295165-64 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 2 reconstruction with mesh, Sartorius flap, keystone flap (700cm ) ©2013 MFMER | 3295165-66 Anterior thigh Keystone flap Design within aesthetic units of thigh Keep incisions mid-axial ©2013 MFMER | 3295165-67 Perforator flap modification Pre-expansion Pedicle DIEP flap for anterior abdominal coverage ©2013 MFMER | 3295165-68 Pedicle gluteal perforator flap ©2013 MFMER | 3295165-69 Pedicle Profunda Artery Perforator Flap ©2013 MFMER | 3295165-70 Pedicle PAP flap Groin, perineal, ischial coverage etc. ©2013 MFMER | 3295165-71 Internal mammary artery perforator IMAP Flap Flow perpendicular to midline ©2013 MFMER | 3295165-72 IMA Pedicle Perforator Flap Based on multiple IMA Perforators, partial flap incision ©2013 MFMER | 3295165-73 ©2013 MFMER | 3295165-74 Pedicle bilateral SEA perforator flaps Angiosarcoma ©2013 MFMER | 3295165-75 Lumbar pedicle perforator flap Flap axis perpendicular to midline Courtesy A. Cholet M.D. ©2013 MFMER | 3295165-76 DMA perforator flap ©2013 MFMER | 3295165-77 Conversion of TDAP flap into MS-LD Flap Have back up