Subscribe to RSS
DOI: 10.1055/s-0031-1275283
© Georg Thieme Verlag KG Stuttgart · New York
Propeller-Lappenplastiken: die Reliabilität der präoperativen, unidirektionalen Dopplersonografie
Propeller Flaps: The Reliability of Preoperative, Unidirectional Doppler SonographyPublication History
eingereicht 10.12.2010
akzeptiert 04.03.2011
Publication Date:
20 April 2011 (online)
![](https://www.thieme-connect.de/media/hamipla/201102/lookinside/thumbnails/10.1055-s-0031-1275283-1.jpg)
Zusammenfassung
Hintergrund: Propellerlappen stellen eine gute Alternative zum freien Gewebetransfer in vielen Körperregionen dar. Der präoperativen Diagnostik kommt große Bedeutung zu um die entsprechenden Perforatoren zu lokalisieren, den Drehpunkt der Lappenplastik zu bestimmen und die Lappenlänge zu planen. Am häufigsten kommt die unidirektionale Dopplersonografie zum Einsatz. Die Verlässlichkeit dieser Methode wurde im Hinblick auf lokale Perforatorlappen bisher wenig untersucht. Die retrospektive Studie evaluiert die Reliabilität der Dopplersonografie bei der Planung von Propellerlappen.
Patienten und Methoden: Bei insgesamt 68 Patienten mit lappenpflichtigen Defekten wurde basierend auf der präoperativen unidirektionalen Dopplersonografie eine Rekonstruktion mit Propellerlappen geplant. Die Defekte waren an der unteren Extremität (48), Gesäß (15) und Rumpf (5) lokalisiert.
Ergebnisse: Intraoperativ konnte bei 12 Patienten trotz positiver präoperativer Markierung kein adäquater Perforator gefunden werden. Im Unterschenkelbereich zeigte sich in 21% der Fälle ein falsch-positives Dopplerergebnis, in der Gesäßregion in 13%. Der positive Prädiktivwert der unidirektionalen Dopplersonografie lag insgesamt bei 82%. Als Alternativen zur Propellerlappenplastik kamen der Suralislappen, freie Lappenplastiken sowie lokale Lappen zum Einsatz.
Schlussfolgerung: Die alleinige unidirektionale Dopplersonografie ist zur präoperativen Lokalisation und Selektion eines dominanten Perforators mit einer hohen Rate an falsch-positiven Befunden behaftet. Gerade bei Propellerlappen ist die exakte Lokalisation des Perforators als Drehpunkt des Lappens zur Lappenplanung wichtig. Bei 18% der Fälle war eine alternative Lappenplastik zur Defektdeckung notwendig mit dem entsprechenden organisatorischen und zeitlichen Mehraufwand. Demnach ist die Reliabilität der unidirektionalen Dopplersonografie als alleinige Diagnostik inadäquat. Die Farbdopplersonografie sollte zur 3-dimensionalen Gefäßdarstellung eingesetzt werden.
Abstract
Background: Propeller flaps represent an elegant and reliable method for soft-tissue reconstruction of the extremities and trunk, obviating the need for free tissue transfer. Preoperative localisation of perforators adjacent to the defect is important regarding the pivot point and length of the flap. Most commonly unidirectional Doppler sonography is used. The reliability of this method regarding propellerflaps has not thoroughly been evaluated. The aim of this study is to assess the positive predictive value of this method for planning propeller flaps.
Patients and Method: In a total of 68 patients, soft-tissue reconstruction using propeller flaps was planned with unidirectional Doppler sonography. Defects were located on the lower extremity in 48 cases, the buttock area in 15 cases and the trunk in 5 cases.
Results: In 12 cases no adequate perforators were located intraoperatively despite a positive Doppler signal. In the lower extremity Doppler produced a false-positive result in 21% of the cases, whereas in the buttock region only 13% false positives result were found. The positive predictive value overall was 82%. When no perforator was located, flap coverage was achieved using the reverse sural artery flap in 6 cases, the free peroneal artery perforator flap in 3 cases, local advancement flaps in 2 cases and skin grafting in 1 case.
Discussion: The reliability of unidirectional Doppler sonography is inadequate for localisation and selection of the dominant perforator when planning propeller flaps. A high rate of false-positive results needs to be anticipated especially distally in the extremities. In 18% of cases an alternative surgical plan was required to achieve soft tissue coverage. We recommend using colour duplex sonography for a more reliable preoperative localisation of perforators.
Schlüsselwörter
gestielte Lappenplastiken - bildgebende Verfahren - sonstige Aspekte - Nekrose
Key words
pedicled flaps - perforator flaps - imaging diagnostics - necrosis
Literatur
- 1 Teo TC. The propeller flap concept. Clin Plast Surg. 2010; 37 615-626
- 2 Schaverien MV, Hamilton SA, Fairburn N. et al . Lower limb reconstruction using the islanded posterior tibial artery perforator flap. Plast Reconstr Surg. 2010; 125 (6) 1735-1743
- 3 Quaba O, Quaba A. Pedicled perforator flaps for the lower limb. Seminars Plast Surg. 2006; 20 (2) 103-111
- 4 Pignatti M, Pasqualini M, Governa M. et al . Propeller flaps for leg reconstruction. J Plast Reconstr Aesth Surg. 2008; 61 777-783
- 5 Jakubietz RG, Kloss DF, Gruenert JG. et al . The 180 degree perforator based propeller flap for soft tissue coverage of the distal lower extremity: a new method to achieve reliable coverage of the distal lower extremity with local perforator flap. Ann Plast Surg. 2007; 59 667-671
- 6 Masia J, Pons G, Fernandez M. et al . Experience with local perforator flaps in lower limb reconstruction using the propeller principle. J Reconstr Microsurg. 2006; 22 507-512
- 7 Hallock GG. The propeller flap version of the adductor muscle perforator flap for coverage of ischial or trochanteric pressure sores. Ann Plast Surg. 2006; 56 (5) 540-542
- 8 Wong CH, Ciu F, Tan BK. Nonlinear finite element stimulations to elucidate the determinants of perforator patency in propeller flaps. Ann Plast Surg. 2007; 59 672-678
- 9 Demirseren ME, Oguz M, Sibel Y. Island rat groin flaps with twisted pedicles. Plast Reconstr Surg. 2004; 114 1190
- 10 Bravo FG, Schwarze HP. Free-style local perforator flaps: concept and classification system. J Plast Reconstr Aesth Surg. 2009; 62 602-609
- 11 Blondeel PN, Beyens G, Verghaege R. et al . Doppler flowmetry in the planning of perforator flaps. Br J Plast Surg. 1998; 51 202-209
- 12 Giunta RE, Geisweid A, Feller AM. The value of preoperative Doppler sonography for planning free perforator flaps. Plast Reconstr Surg. 2000; 105 2381-2386
- 13 Smit JM, Klein S, Werker PM. An overview of methods for vascular mapping in the planning of free flaps. J Plast Reconstr Aesth Surg. 2010; 63 674-682
- 14 Khan DK, Miller JG. Reliability of handheld Doppler in planning local, perforator-based flaps for extremities. Aesth Plast Surg. 2007; 31 521-525
- 15 Yu P, Youssef A. Efficacy of the handheld Doppler in preoperative identification of the cutaneous perforators in the anterolateral thigh flap. Plast Reconstr Surg. 2006; 118 928-935
- 16 Rad AN, Singh NK, Rosson GD. Peroneal artery perforator based propeller flap reconstruction of the lateral distal lower extremity after tumor resection. Microsurg. 2008; 28 663-670
- 17 Jakubietz RG, Jakubietz MG, Jakubietz DF. et al . Ischial pressure sores: reconstruction using the perforator-based reverse flow musculocutaneous 180 degree propeller flap. Microsurg. 2009; 29 672-675
- 18 Woo KJ, Pyon JK, Lim SY. et al . Deep superior epigastric artery perforator propeller flap for abdominal wall reconstruction. A case report. J Plast Reconstr Aesthet Surg. 2010; 63 (7) 1223-1226
- 19 Battiston B, Artiaco S, Antonini A. et al . Dorsal metacarpal artery perforator based propeller flap for complex defect of the dorsal aspect in the index finger. J Hand Surg Eur Vol. 2009; 34 (6) 807-809
- 20 Hallock GG. Evaluation of fasciocutaneous perforators using color duplex imaging. Plast Reconstr Surg. 1994; 94 644-651
- 21 Masia J, Kosutic D, Clavero DA. et al . Preoperative computed tomographic angiogram for deep inferior epigastric artery perforator breast reconstruction. J Reconstr Microsurg. 2010; 26 21-28
- 22 Uppal RS, Casaer B, Van Landuyt K. et al . The efficacy of preoperative mapping of perforators in reducing operative time and complication in perforator flap breast reconstruction. J Plast Reconstr Aesthet Surg. 2009; 62 859-864
- 23 Ono S, Chung KC, Hayashi H. et al . Application of multidetector-row computed tomography in propeller flap planning. Plast Reconstr Surg. 2011; 127 703-711
Korrespondenzadresse
Dr. med. Rafael G. Jakubietz
Universitätsklinikum Würzburg
Klinik für Unfall-, Hand-
Plastische- und
Wiederherstellungschirurgie
Oberdürrbacherstraße 6
97080 Würzburg
Email: Jakubietz_R@klinik.uni-wuerzburg.de