A prospective study of super-thin anterolateral thigh flap harvesting assisted by high-frequency color Doppler ultrasound in detecting perforators in deep adipose layers_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LIU Qianyuan ^1,2 , ZHOU Jiandong ³ ^△ , WANG Wencheng ³ , CHEN Xueming ³ , XU Yajun ³ , HUANG Hai ⁴ ,  MI Jingyi ²

1. Suzhou Medical College of Soochow University, Suzhou Jiangsu, 215123, P. R. China;
2. Department of Sport Medicine, Wuxi 9th People’s Hospital Affiliated to Soochow University, Wuxi Jiangsu, 214062, P. R. China;
3. Department of Foot and Ankle Surgery, Wuxi 9th People’s Hospital Affiliated to Soochow University, Wuxi Jiangsu, 214062, P. R. China;
4. Department of Ultrasonic Diagnosis, Wuxi 9th People’s Hospital Affiliated to Soochow University, Wuxi Jiangsu, 214062, P. R. China;

Corresponding?author：

MI Jingyi, Email: jy8586yz@163.com

Keywords：

High-frequency color Doppler ultrasound; perforator; super-thin flap; anterolateral thigh flap

DOI：

10.7507/1002-1892.202310091

Video：

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Objective To investigate the clinical application of high-frequency color Doppler ultrasound (HFCDU) in detecting perforators in the deep adipose layers for harvesting super-thin anterolateral thigh flap (ALTF). Methods Between August 2019 and January 2023, 45 patients (46 sides) with skin and soft tissue defects in the foot and ankle were treated, including 29 males and 16 females, aged from 22 to 62 years, with an average of 46.7 years. The body mass index ranged from 19.6 to 36.2 kg/m², with an average of 23.62 kg/m². The causes of injury included traffic accident injury in 15 cases, heavy object crush injury in 20 cases, mechanical injury in 8 cases, heat crush injury in 1 case, and chronic infection in 1 case. There were 20 cases on the left side, 24 cases on the right side, and 1 case on both sides. After thorough debridement, the wound size ranged from 5 cm×4 cm to 17 cm×11 cm. All patients underwent free super-thin ALTF transplantation repair. HFCDU was used to detect the location of the perforators piercing the deep and superficial fascia, as well as the direction and branches of the perforators within the deep adipose layers before operation. According to the preoperative HFCDU findings, the dimensions of the super-thin ALTF ranged from 6 cm×4 cm to 18 cm×12 cm. The donor sites of the flaps were directly sutured. Results A total of 55 perforators were detected by HFCDU before operation, but 1 was not found during operation. During operation, a total of 56 perforators were found, and 2 perforators were not detected by HFCDU. The positive predictive value of HFCDU for identifying perforator vessels was 98.2%, and the sensitivity was 96.4%. Among the 54 perforators accurately located by HFCDU, the orientation of the perforators in the deep adipose layers was confirmed during operation. There were 21 perforators (38.9%) traveled laterally and inferiorly, 12 (22.2%) traveled medially and inferiorly, 14 (25.9%) traveled laterally and superiorly, 5 (9.3%) traveled medially and superiorly, and 2 (3.7%) ran almost vertically to the body surface. Among the 54 perforators accurately located by HFCDU, 35 were identified as type 1 perforators and 12 as type 2 perforators (HFCDU misidentified 7 type 2 perforators as type 1 perforators). The sensitivity of HFCDU in identifying type 1 perforators was 100%, with a positive predictive value of 83.3%. For type 2 perforators, the sensitivity was 63.2%, and the positive predictive value was 100%. The surgeries were successfully completed. The super-thin ALTF had a thickness ranging from 2 to 6 mm, with an average of 3.56 mm. All super-thin ALTF survived, however, 1 flap experienced a venous crisis at 1 day after operation, but it survived after emergency exploration and re-anastomosis of the veins; 1 flap developed venous crisis at 3 days after operation but survived after bleeding with several small incisions; 3 flaps had necrosis at the distal edge of the epidermis, which healed after undergoing dressing changes. All 45 patients were followed up 6-18 months (mean, 13.6 months). Three flaps required secondary defatting procedures, while the rest had the appropriate thickness, and the overall appearance was satisfactory. Conclusion Preoperative application of HFCDU to detect the perforator in the deep adipose layers can improve the success and safety of the procedure by facilitating the harvest of super-thin ALTF.

Citation： LIU Qianyuan, ZHOU Jiandong, WANG Wencheng, CHEN Xueming, XU Yajun, HUANG Hai, MI Jingyi. A prospective study of super-thin anterolateral thigh flap harvesting assisted by high-frequency color Doppler ultrasound in detecting perforators in deep adipose layers. Chinese Journal of Reparative and Reconstructive Surgery, 2024, 38(1): 62-68. doi: 10.7507/1002-1892.202310091 Copy

1.	Gur E, Tiftikcioglu YO, Kuybulu TF, et al. The use of chimeric-superthin anterolateral thigh flap in reconstruction of laryngopharyngoesophagectomy defects of hypopharyngeal cancer. Microsurgery, 2023, 43(6): 563-569.
2.	黃澤林, 段夢嫻, 楊俊濤, 等. 逆行供血的游離股前外側皮瓣修復兒童足踝部創面. 中華顯微外科雜志, 2023, 46(2): 147-151.
3.	楊薛康, 張棟梁, 何亭, 等. 游離顳淺筋膜瓣/股前外側筋膜瓣聯合皮片移植修復四肢特殊部位深度組織缺損的臨床經驗. 中華燒傷與創面修復雜志, 2023, 39(6): 507-511.
4.	Mohammed A, Lee KT, Mun GH. Evaluating effects of primary defatting for flap thinning on the development of perfusion-related complications in free perforator flap reconstruction. Microsurgery, 2021, 41(8): 716-725.
5.	余少校, 周望高, 陳國榮, 等. 顯微削薄腓動脈穿支皮瓣修復手指背側軟組織缺損. 中華顯微外科雜志, 2022, 45(6): 617-621.
6.	周建東, 張興飛, 許同龍, 等. 淺筋膜淺深交界層平面逆行分離穿支血管切取超薄股前外側皮瓣修復足部創面. 中華顯微外科雜志, 2022, 45(5): 515-520.
7.	Schaverien M, Saint-Cyr M, Arbique G, et al. Three- and four-dimensional computed tomographic angiography and venography of the anterolateral thigh perforator flap. Plast Reconstr Surg, 2008, 121(5): 1685-1696.
8.	Kimura N, Satoh K, Hasumi T, et al. Clinical application of the free thin anterolateral thigh flapin 31 consecutive patients. Plast Reconstr Surg, 2001, 108(5): 1197-1208.
9.	周飛亞, 張弦, 褚庭綱, 等. 以彩色多普勒術前定位的短蒂股前外側穿支皮瓣游離移植修復四肢中小面積皮膚缺損. 中華手外科雜志, 2023, 39(1): 77-80.
10.	方軍, 趙光宗, 李華壯, 等. 三維CT血管造影輔助游離腓腸內側動脈穿支皮瓣修復足部創面的療效. 中華燒傷與創面修復雜志, 2023, 39(4): 343-349.
11.	李雪棟, 趙剛, 潘筱云, 等. 非增強和增強核磁共振定位股前外側皮瓣穿支的臨床對照研究. 中華手外科雜志, 2021, 37(1): 27-30.
12.	鐘怡鳴, 湯欣, 王錦姝, 等. 應用游離雙側股前外側穿支皮瓣串聯修復手部大面積皮膚缺損15例. 中華手外科雜志, 2022, 38(2): 129-131.
13.	Visconti G, Bianchi A, Hayashi A, et al. Designing an anterolateral thigh flap using ultrasound. J Reconstr Microsurg, 2022, 38(3): 206-216.
14.	Cheng HT, Lin FY, Chang SC. Diagnostic efficacy of color Doppler ultrasonography in preoperative assessment of anterolateral thigh flap cutaneous perforators: an evidence-based review. Plast Reconstr Surg, 2013, 131(3): 471e-473e.
15.	張韜, 程俊楠, 楊林, 等. 多穿支腓淺動脈穿支皮瓣修復手足創面的療效. 中華燒傷與創面修復雜志, 2023, 39(3): 234-240.
16.	杜偉力, 沈余明, 胡驍驊, 等. 巨大腹壁下動脈臍旁穿支皮瓣修復腕部環狀高壓電燒傷創面的臨床效果. 中華燒傷與創面修復雜志, 2023, 39(6): 527-533.
17.	Tashiro K, Harima M, Mito D, et al. Preoperative color Doppler ultrasound assessment of the lateral thoracic artery perforator flap and its branching pattern. J Plast Reconstr Aesthet Surg, 2015, 68(6): e120-e125.
18.	Lin CT, Huang JS, Hsu KC, et al. Different types of suprafascial courses in thoracodorsal artery skin perforators. Plast Reconstr Surg, 2008, 121(3): 840-848.
19.	林偉棟, 糜菁熠, 潘筱云, 等. 動態紅外熱成像聯合彩超在游離股前外側皮瓣術前穿支定位的應用研究. 中華手外科雜志, 2022, 38(3): 192-195.
20.	Suh YC, Kim SH, Baek WY, et al. Super-thin ALT flap elevation using preoperative color doppler ultrasound planning: Identification of horizontally running pathway at the deep adipofascial layers. J Plast Reconstr Aesthet Surg, 2022, 75(2): 665-673.

1. Gur E, Tiftikcioglu YO, Kuybulu TF, et al. The use of chimeric-superthin anterolateral thigh flap in reconstruction of laryngopharyngoesophagectomy defects of hypopharyngeal cancer. Microsurgery, 2023, 43(6): 563-569.
2. 黃澤林, 段夢嫻, 楊俊濤, 等. 逆行供血的游離股前外側皮瓣修復兒童足踝部創面. 中華顯微外科雜志, 2023, 46(2): 147-151.
3. 楊薛康, 張棟梁, 何亭, 等. 游離顳淺筋膜瓣/股前外側筋膜瓣聯合皮片移植修復四肢特殊部位深度組織缺損的臨床經驗. 中華燒傷與創面修復雜志, 2023, 39(6): 507-511.
4. Mohammed A, Lee KT, Mun GH. Evaluating effects of primary defatting for flap thinning on the development of perfusion-related complications in free perforator flap reconstruction. Microsurgery, 2021, 41(8): 716-725.
5. 余少校, 周望高, 陳國榮, 等. 顯微削薄腓動脈穿支皮瓣修復手指背側軟組織缺損. 中華顯微外科雜志, 2022, 45(6): 617-621.
6. 周建東, 張興飛, 許同龍, 等. 淺筋膜淺深交界層平面逆行分離穿支血管切取超薄股前外側皮瓣修復足部創面. 中華顯微外科雜志, 2022, 45(5): 515-520.
7. Schaverien M, Saint-Cyr M, Arbique G, et al. Three- and four-dimensional computed tomographic angiography and venography of the anterolateral thigh perforator flap. Plast Reconstr Surg, 2008, 121(5): 1685-1696.
8. Kimura N, Satoh K, Hasumi T, et al. Clinical application of the free thin anterolateral thigh flapin 31 consecutive patients. Plast Reconstr Surg, 2001, 108(5): 1197-1208.
9. 周飛亞, 張弦, 褚庭綱, 等. 以彩色多普勒術前定位的短蒂股前外側穿支皮瓣游離移植修復四肢中小面積皮膚缺損. 中華手外科雜志, 2023, 39(1): 77-80.
10. 方軍, 趙光宗, 李華壯, 等. 三維CT血管造影輔助游離腓腸內側動脈穿支皮瓣修復足部創面的療效. 中華燒傷與創面修復雜志, 2023, 39(4): 343-349.
11. 李雪棟, 趙剛, 潘筱云, 等. 非增強和增強核磁共振定位股前外側皮瓣穿支的臨床對照研究. 中華手外科雜志, 2021, 37(1): 27-30.
12. 鐘怡鳴, 湯欣, 王錦姝, 等. 應用游離雙側股前外側穿支皮瓣串聯修復手部大面積皮膚缺損15例. 中華手外科雜志, 2022, 38(2): 129-131.
13. Visconti G, Bianchi A, Hayashi A, et al. Designing an anterolateral thigh flap using ultrasound. J Reconstr Microsurg, 2022, 38(3): 206-216.
14. Cheng HT, Lin FY, Chang SC. Diagnostic efficacy of color Doppler ultrasonography in preoperative assessment of anterolateral thigh flap cutaneous perforators: an evidence-based review. Plast Reconstr Surg, 2013, 131(3): 471e-473e.
15. 張韜, 程俊楠, 楊林, 等. 多穿支腓淺動脈穿支皮瓣修復手足創面的療效. 中華燒傷與創面修復雜志, 2023, 39(3): 234-240.
16. 杜偉力, 沈余明, 胡驍驊, 等. 巨大腹壁下動脈臍旁穿支皮瓣修復腕部環狀高壓電燒傷創面的臨床效果. 中華燒傷與創面修復雜志, 2023, 39(6): 527-533.
17. Tashiro K, Harima M, Mito D, et al. Preoperative color Doppler ultrasound assessment of the lateral thoracic artery perforator flap and its branching pattern. J Plast Reconstr Aesthet Surg, 2015, 68(6): e120-e125.
18. Lin CT, Huang JS, Hsu KC, et al. Different types of suprafascial courses in thoracodorsal artery skin perforators. Plast Reconstr Surg, 2008, 121(3): 840-848.
19. 林偉棟, 糜菁熠, 潘筱云, 等. 動態紅外熱成像聯合彩超在游離股前外側皮瓣術前穿支定位的應用研究. 中華手外科雜志, 2022, 38(3): 192-195.
20. Suh YC, Kim SH, Baek WY, et al. Super-thin ALT flap elevation using preoperative color doppler ultrasound planning: Identification of horizontally running pathway at the deep adipofascial layers. J Plast Reconstr Aesthet Surg, 2022, 75(2): 665-673.

Chinese Journal of Reparative and Reconstructive Surgery

A prospective study of super-thin anterolateral thigh flap harvesting assisted by high-frequency color Doppler ultrasound in detecting perforators in deep adipose layers

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