Tips on Raising Reliable Local Perforator Flaps.

From early on in the development of plastic surgery, it was quickly realized that utilizing locally adjacent tissue, or "matching like with like," yielded superior aesthetic reconstructions to those in which the tissue was derived from a distant location. In many cases, the use of a local perforator flap is a simpler procedure with less patient morbidity and a quicker recovery from surgery. The difficulty with local perforator flaps has been locating the supplying perforators, ensuring that the flap has a robust and reliable blood supply, and that sufficient tissue is able to be transferred.

Increasing Perfusion Pressure Does Not Distend Perforators or Anastomoses but Reveals Arteriovenous Shuntings.

Background: It has been proposed that hyperperfusion of perforators and distension of anastomotic vessels may be a mechanism by which large perforator flaps are perfused. This study investigates whether increasing perfusion pressure of radiographic contrast in cadaveric studies altered the radiographic appearance of vessels, particularly by distending their anastomotic connections.

Methods: From 10 fresh cadavers, bilateral upper limbs above the elbow were removed.

The Functional Anatomy of the Ophthalmic Angiosome and Its Implications in Blindness as a Complication of Cosmetic Facial Filler Procedures.

Background: Blindness following facial filler procedures, although rare, is devastating, usually acute, permanent, and attributed to an ophthalmic artery embolus. However, blindness may be delayed for up to 2 weeks, sometimes following injection at remote sites, suggesting alternative pathways and pathogenesis.

Methods: Seeking solutions, fresh cadaver radiographic lead oxide injection, dissection, and histologic studies of the orbital and facial pathways of the ophthalmic angiosome, performed by the ophthalmic artery and vein, both isolated and together, and facial artery perfusions, were combined with total body archival arterial and venous investigations.

The quadriceps Femoris allograft as an extension of the Angiosome concept: A cadaveric-based anatomical feasibility study.

Background: Vascularised composite allo-transplantation (VCA) is emerging as a tailored approach for complex tissue reconstruction. This study focuses on the quadriceps VCA as a potential solution for tissue repair, following trauma, necrotising fasciitis/myositis, or tumor ablation.

Methods: Dissections were undertaken in 10 adult cadaveric lower limbs to characterize the blood supply to the quadriceps femoris for en bloc muscle allo-transplantation.

The Role of Anastomotic Vessels in Controlling Tissue Viability and Defining Tissue Necrosis with Special Reference to Complications following Injection of Hyaluronic Acid Fillers.

Background: Most target areas for facial volumization procedures relate to the anatomical location of the facial or ophthalmic artery. Occasionally, inadvertent injection of hyaluronic acid filler into the arterial circulation occurs and, unrecognized, is irreparably associated with disastrous vascular complications. Of note, the site of complications, irrespective of the injection site, is similar, and falls into only five areas of the face, all within the functional angiosome of the facial or ophthalmic artery.

The Functional Angiosome: Clinical Implications of the Anatomical Concept.

Background: The angiosome is a three-dimensional block of tissue supplied by a source vessel with its boundary outlined either by an anastomotic perimeter of reduced-caliber choke vessels or by true anastomoses with no reduction of vessel caliber. This article focuses on the role of these anastomotic vessels in defining flap survival or the necrotic pattern seen in fulminating meningococcal septicemia.

Methods: Experiments in pigs, dogs, guinea pigs, and rabbits over the past 46 years were reviewed, focusing on the necrosis line of flaps, the effects of various toxins in vivo, and correlating these results in the clinical setting.

Angiosome-Based Allografts: Vascularized Composite Allotransplantation for Tailored Subunit Reconstruction with Volkmann Ischemic Contracture as a Case in Point.

Background: As we enter an age with new approaches to tissue reconstruction, the emphasis on the adage "like for like" has become even more relevant. This study illustrates the potential for several tailored vascularized composite allotransplantation reconstructive techniques and, in particular, for the management of Volkmann contracture.

Methods: Twenty fresh cadaver dissections and 30 archival lead oxide radiographic studies were examined to (1) identify potential upper limb vascularized composite allotransplantation donor sites (i.

The Relationship of Superficial Cutaneous Nerves and Interperforator Connections in the Leg: A Cadaveric Anatomical Study.

Background: The lower limb is a source of many flaps both for closure of local defects and for free transfer. Fasciocutaneous flap techniques have been progressively refined, although the vascular basis for their success needs clarification.

Methods: Archival studies of 48 lower limbs were reviewed and combined with 20 studies of lower limbs from fresh cadavers, making a total of 68 investigations.

The Lymphatic Anatomy of the Lower Eyelid and Conjunctiva and Correlation with Postoperative Chemosis and Edema.

Background: There are minimal data in the literature regarding the lymphatic drainage of the conjunctiva and lower eyelid and the relationship with postoperative chemosis and edema.

Methods: Injection, microdissection, and histologic and radiologic studies were conducted on 12 hemifacial fresh cadaver specimens. Indocyanine green lymphography was conducted in five volunteers.

Long-Term Patency of Lymphovenous Anastomoses: A Systematic Review.

Background: With advancements in technology and microsurgical techniques, lymphovenous anastomosis has become a popular reconstructive procedure in the treatment of chronic lymphedema. However, the long-term patency of these anastomoses is not clear in the literature.

Methods: A systematic review of the MEDLINE and EMBASE databases was performed to assess the reported long-term patency of lymphovenous anastomoses.

The Evolution of Free Vascularized Bone Transfer: A 40-Year Experience.

Background: The first successful free vascularized bone flap was performed on June 1, 1974 (and reported in 1975), using the fibula. This was followed by the iliac crest based on the superficial circumflex iliac artery in 1975 and then the deep circumflex iliac artery in 1978.

Methods: A total of 384 transfers using fibula (n = 198), iliac crest (n = 180), radius (n = 4), rib (n = 1), and metatarsal (n = 1) were used between June of 1974 and June of 2014 for reconstruction of the mandible (n = 267), maxilla (n = 20), clavicle (n = 1), humerus (n = 8), radius and ulna (n = 21), carpus (n = 3), pelvis (n = 2), femur (n = 11), tibia (n = 47), and foot bones (n = 4).

Vascularized Lymph Node Transfer: A Review of the Current Evidence.

Over the past decade, lymph node transfer has rapidly gained popularity among plastic surgeons for the treatment of chronic lymphedema because of the initial promising results and its unique technical advantages compared with the other reconstructive options. However, its functional mechanism is still a matter of great debate, and some concerning reports have emerged regarding the safety of this procedure in patients with chronic lymphedema. The authors review the literature on the experimental and clinical evidence for lymph node transfer, discuss its proposed functional mechanisms, review the potential risk of iatrogenic lymphedema following this procedure, and discuss the suggested strategies to avoid this complication.

The Microvascular Basis of the Superior Thyroid Artery Perforator Flap.

Background: The superior thyroid artery perforator flap has been presented previously in this Journal as a locoregional flap that provides an excellent tissue match with minimal donor morbidity for lateral face and temple defects. In the current study, the authors aimed to describe the microvascular anatomy of this flap.

Methods: The authors used in vivo computer tomographic angiography, cadaveric dissection, and ex vivo angiography in order to improve surgical safety and application of this technique.

Scarpa Fascia Preservation in Abdominoplasty: Does It Preserve the Lymphatics?

Background: The course of the cutaneous lymphatic collectors of the abdominal wall in relation to the Scarpa fascia is unclear in the literature. Preserving the Scarpa fascia in the lower abdomen to reduce the seroma rate following abdominoplasty has been suggested based on the assumption that the lower abdominal lymphatics run deep to this layer along their entire course.

Methods: Using the previously described technique, the superficial lymphatic drainage of eight hemiabdomen specimens from four fresh human cadavers was investigated.

Understanding the three-dimensional anatomy of the superficial lymphatics of the limbs.

Background: There are minimal data in the current literature regarding the depth of the superficial lymphatic collectors of the limbs in relation to the various subcutaneous tissue layers.

Methods: Injection, microdissection, radiographic, and histologic studies of the superficial lymphatics and the subcutaneous tissues of 32 limbs from 15 human cadavers were performed.

Results: Five layers were consistently identified in the integument of all the upper and lower limb specimens: (1) skin, (2) subcutaneous fat, (3) superficial fascia, (4) loose areolar tissue, and (5) deep fascia.

Hydrogen peroxide priming of the venous architecture: a new technique that reveals the underlying anatomical basis for venous complications of DIEP, TRAM, and other abdominal flaps.

Background: Previous studies of venous anatomy lack the detail of their arterial counterparts because of (1) the technical challenge of retrograde perfusion against competent valves and (2) anterograde venous perfusion failing to adequately delineate the area of interest. We introduced a novel technique: retrograde hydrogen peroxide priming that dilates veins and renders valves incompetent, thereby facilitating complete cadaveric venous perfusion.

Methods: The superficial and deep venous systems of 41 hemiabdomens and 20 hemichests of unembalmed human cadavers were primed by retrograde injection with 6% hydrogen peroxide.

Understanding the fascial supporting network of the breast: key ligamentous structures in breast augmentation and a proposed system of nomenclature.

Background: The fascial system of the breast has, to date, only been described in general terms. This anatomical study has developed two distinct methods for better defining existing breast structures such as the inframammary fold, as well as defining previously unnamed ligamentous structures.

Methods: The authors harvested and examined 40 frozen, entire chest wall cadavers.

True and 'choke' anastomoses between perforator angiosomes: part II. dynamic thermographic identification.

Background: Cadaveric studies have revealed that cutaneous perforators are linked by either reduced-caliber "choke" arteries, or by vessels without change in caliber, the true anastomoses. These true anastomotic vessels are often found in parallel with the cutaneous nerves and accompanying veins, and are associated both experimentally and clinically with larger areas of flap survival. The Doppler probe and computed tomographic angiography are already used preoperatively to determine perforator locations but currently cannot reveal the type of anastomotic connections.