Thin and superthin perforator flap elevation based on preoperative planning with ultrahigh-frequency ultrasound

Abstract

The ability to directly harvest thin and superthin perforator flaps without jeopardizing their vascularity depends on knowledge of the microsurgical vascular anatomy of each perforator within the subcutaneous tissue up to the dermis. In this paper, we report our experience with ultrahigh-frequency ultrasound (UHF-US) in the preoperative planning of thin and superthin flaps. Between May 2017 and September 2018, perforators of seven patients were preoperatively evaluated by both ultrasound (using an 18-MHz linear probe) and UHF-US (using 48- and 70-MHz linear probes). Thin flaps (two cases) and superthin flaps (five cases) were elevated for the reconstruction of head and neck oncologic defects and lower limb traumatic defects. The mean flap size was 6.5×15 cm (range, 5×8 to 7.5×23 cm). No complications occurred, and all flaps survived completely. In all cases, we found 100% agreement between the preoperative UHF-US results and the intraoperative findings. The final reconstructive outcomes were considered satisfactory by both the surgeon and the patients. In conclusion, UHF-US was found to be very useful in the preoperative planning of thin and superthin free flaps, as it allows precise anticipation of very superficial microvascular anatomy. UHF-US may represent the next frontier in thin, superthin, and pure skin perforator flap design.

Suprafascial Free Flaps: Classification and Comprehensive Review of the Literature

“…This improves flap survival and shortens operating time. 7,37,38 It also allows us to have thinner flaps, which are more suitable for extremity or head and neck reconstruction, and have lower donor site morbidity. These flaps combined with super-microsurgical techniques, 39 which allow us to anastomose ever smaller vessels (in general under 0.8 mm in diameter), improve our reconstructive options and lead to better outcomes.…”

“…As we can see, the evolution shows that soft tissue free flaps have become thinner as they are raised in a more superficial plane of dissection. This has been possible due to new technologies such a Computed Tomographic Angiography (CTA) and high-frequency ultrasound 7 as well as a deeper knowledge in vascular anatomy such as the perforasome theory described by Saint-Cyr et al 8 Narushima et al 9 proposed a classification of thin flaps based on the anatomical plane on which they are raised: thin flaps dissected in the plane of the superficial adipose fascia, super thin flaps going above the superficial fascia, full thickness skin flap or pure skin perforator (PSP) flaps that are only as thick as the dermis and its superficial plexus of vessels, and split thickness skin flaps.…”

Recent Advances in Ultrasound Technology: Ultra-High Frequency Ultrasound for Reconstructive Supermicrosurgery

“…By using these preoperative findings, PSP are directly harvested above the subdermal plane using the “hot and cold zone” technique reported by Hong et al 25 Visconti et al also reported preoperative planning with UHFUS for thin and superthin perforator flap based on this knowledge. 16…”

Superficial Circumflex Iliac Artery Perforator Flap Elevation Using Preoperative High-Resolution Ultrasonography for Vessel Mapping and Flap Design

“…The highresolution ultrasound system is able to deploy a probe with 70 MHz which is usually used in lymphatic surgeries and in elevation of extremely thin flaps. [18][19][20][21][22][23][24] A high-resolution ultrasound system (Vevo MD ultrasound device, Fujifilm Visual Sonics, Amsterdam, the Netherlands) is used for identification and mapping of the SCIA and the superficial circumflex iliac vein (SCIV). Using a 48-MHz probe, the vessels are sought at their distal portion, placing the probe in the proximity of the anterior superior iliac spine (ASIS; ►Fig.…”