Practical Considerations for Perforator Flap Thinning Procedures Revisited

Background A thin perforator flap is one of the best methods for covering defects. This study aimed to revisit and further test the rapidly advancing field of flap thinning techniques.

Methods We performed two cadaveric studies to test the known flap thinning methods, and then applied these methods to a clinical series. In the first study, five cadavers were used to observe the anatomical relation of the perforator with the subdermal plexuses and the subcutaneous fat layer by injecting a colored latex solution. The second study was done on four cadavers independently from the first study. Last, a clinical series was performed on 15 patients.

Results The areolar fat lobules of 10 anterolateral thigh perforator (ALT), seven deep inferior epigastric artery perforator (DIEAP), and six thoracodorsal artery perforator (TAP) flaps were dissected to reduce the flap thickness guided by the colored vascular pattern. On average, the ALT, DIEAP, and TAP flaps were reduced to 32.76%±9.76%, 37.01%±9.21%, and 35.42%±9.41%, respectively. In the second study, the areolar fat lobules were directly dissected in six ALT, six TAP, and four MSAP flaps, and an average reduction in flap thickness of 53.41%±5.64%, 52.30%±2.88%, and 47.87%±6.41%, respectively, was found. In the clinical series, 13 out of the 15 cases yielded satisfactory outcomes with an average thickness reduction of 37.91%±7.15%.

Conclusions These multiple studies showed that the deep fat layer could be safely removed to obtain a thin yet viable perforator flap. This evidence suggests that the macroscopic flap thinning technique can achieve thin flaps. Surgeons should consider this technique before embracing the latest technique of supermicrosurgery.

Keywords

Microsurgery - Microvessels - Perforator flap - Subcutaneous fat - Surgical flaps

Part of this study was presented in the 14th Association of Southeast Asian Nations (ASEAN) Congress of Plastic Surgery (ACPS) in conjunction with 12th Annual Scientific Meeting of the Indonesian Association of Plastic Surgeons, Jakarta, Indonesia (May 9-11, 2008); the 15th World Congress of International Confederation for Plastic, Reconstructive and Aesthetic Surgery (IPRAS), New Delhi, India (November 29-December 3, 2009); and at the 11th Triennial Congress of International Federation of Society for Surgery of the Hand (IFSSH), Seoul, Republic of Korea (November 31-December 4, 2010).

Publication History

Received: 27 June 2014

Accepted: 04 August 2014

Article published online:
05 May 2022

• References

• 1 Chen HC, Tang YB, Mardini S. et al. Reconstruction of the hand and upper limb with free flaps based on musculocutaneous perforators. Microsurgery 2004; 24: 270-280
• 2 Koshima I, Nanba Y, Tsutsui T. et al. Perforator flaps in lower extremity reconstruction. Handchir Mikrochir Plast Chir 2002; 34: 251-256
• 3 Hamdi M, Van Landuyt K, Monstrey S. et al. A clinical experience with perforator flaps in the coverage of extensive defects of the upper extremity. Plast Reconstr Surg 2004; 113: 1175-1183
• 4 Gedebou TM, Wei FC, Lin CH. Clinical experience of 1,284 free anterolateral thigh flaps. Handchir Mikrochir Plast Chir 2002; 34: 239-244
• 5 Wolff KD, Kesting M, Thurmuller P. et al. The anterolateral thigh as a universal donor site for soft tissue reconstruction in maxillofacial surgery. J Craniomaxillofac Surg 2006; 34: 323-331
• 6 Kimura N. A microdissected thin tensor fasciae latae perforator flap. Plast Reconstr Surg 2002; 109: 69-77
• 7 Koshima I, Yamamoto T, Narushima M. et al. Perforator flaps and supermicrosurgery. Clin Plast Surg 2010; 37: 683-689
• 8 Hong JP. The use of supermicrosurgery in lower extremity reconstruction: the next step in evolution. Plast Reconstr Surg 2009; 123: 230-235
• 9 Hong JP, Chung IW. The superficial fascia as a new plane of elevation for anterolateral thigh flaps. Ann Plast Surg 2013; 70: 192-195
• 10 Kimura N, Saito M, Itoh Y. et al. Giant combined microdissected thin thigh perforator flap. J Plast Reconstr Aesthet Surg 2006; 59: 1325-1329
• 11 Alkureishi LW, Shaw-Dunn J, Ross GL. Effects of thinning the anterolateral thigh flap on the blood supply to the skin. Br J Plast Surg 2003; 56: 401-408
• 12 Gasperoni C, Gasperoni P. Subdermal liposuction: long-term experience. Clin Plast Surg 2006; 33: 63-73
• 13 Kimura N, Satoh K. Consideration of a thin flap as an entity and clinical applications of the thin anterolateral thigh flap. Plast Reconstr Surg 1996; 97: 985-992
• 14 Ross GL, Dunn R, Kirkpatrick J. et al. To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects. Br J Plast Surg 2003; 56: 409-413
• 15 Nakayama B, Hyodo I, Hasegawa Y. et al. Role of the anterolateral thigh flap in head and neck reconstruction: advantages of moderate skin and subcutaneous thickness. J Reconstr Microsurg 2002; 18: 141-146
• 16 Kimura N, Satoh K, Hasumi T. et al. Clinical application of the free thin anterolateral thigh flap in 31 consecutive patients. Plast Reconstr Surg 2001; 108: 1197-1208
• 17 Itoh Y, Arai K. The deep inferior epigastric artery free skin flap: anatomic study and clinical application. Plast Reconstr Surg 1993; 91: 853-863
• 18 Zaretski A, Wei F-C, Lin C-H. et al. Anterolateral thigh perforator flaps in head and neck reconstruction. Semin Plast Surg 2006; 20: 64-72
• 19 Kim HH, Jeong JH, Seul JH. et al. New design and identification of the medial sural perforator flap: an anatomical study and its clinical applications. Plast Reconstr Surg 2006; 117: 1609-1618
• 20 Nojima K, Brown SA, Acikel C. et al. Defining vascular supply and territory of thinned perforator flaps: part I. Anterolateral thigh perforator flap. Plast Reconstr Surg 2005; 116: 182-193
• 21 Rees MJ, Taylor GI. A simplified lead oxide cadaver injection technique. Plast Reconstr Surg 1986; 77: 141-145
• 22 Bergeron L, Tang M, Morris SF. A review of vascular injection techniques for the study of perforator flaps. Plast Reconstr Surg 2006; 117: 2050-2057
• 23 Hong JP, Choi DH, Suh H. et al. A new plane of elevation: the superficial fascial plane for perforator flap elevation. J Reconstr Microsurg 2014; 30: 491-496