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J Reconstr Microsurg 2024; 40(05): 392-397
DOI: 10.1055/s-0043-1776734
Original Article

Surface to Perforator Index: Assessing the Importance of the Number of Perforators in Successful Harvesting of the Anterolateral Thigh Flap

Noah Saad
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
,
Michelle McGill
2   Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
,
Georgios Karamitros
3   Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Ioaninna, Ioaninna, Greece
,
Douglas Cromack
2   Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
,
Howard Wang
2   Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
,
Samuel Fisher
4   University of Southern Illinois School of Medicine, Carbondale, Illinois
,
Efstathios Karamanos
2   Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
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Abstract

Background The use of perforator flaps has become more popular with improvement of surgical technique, technology, as well as understanding of microvascular anatomy. The selection of well-perfused angiosomes is critical to the successful outcome of patients undergoing free tissue transfer. The number of perforators that are needed is dependent upon the surface area of the flap being harvested; however, there have been no studies to assess the optimal surface area supplied by each perforator. We hypothesized that the smaller the surface area supplied by each perforator correlated with fewer flap-related complications in the harvesting of the anterolateral thigh (ALT) flap.

Methods All ALT flaps harvested from 2015 to 2021 at our institution were retrospectively reviewed. The surface area of the flap harvested was calculated as A = πab, where a is the long radius and b is the short radius of the ellipse. The surface-perforator index (SPI) was calculated for each flap by dividing the surface area of the ALT flap by the number of perforators supplying the flap. Our primary outcomes were flap-related complications that included: partial flap loss, dehiscence, and venous congestion.

Results A total of 106 patients were identified. Twenty-four patients (22.6%) developed perforator-related complications. An increasing SPI and SPI to body surface area were strongly associated with development of complications (adjusted odds ratio [95% confidence interval], adjusted p: 1.02 [1.01, 1.03], < 0.001and 1.23 [1.12, 1.42], p < 0.001). An SPI of greater than 150 cm2/perforator was associated with a higher probability of complications (p < 0.001).

Conclusion Flap-related complications are significantly related to the number of perforators supplying the flap. The smaller the surface area supplied by a single perforator correlates with significantly fewer flap-related complications. SPI is a new index that may be used as a predictive tool to aid in identifying flaps that may be more prone to complications in free tissue transfer.

Keywords

ALT - Perforator - perfusion - extremity - reconstruction


Publication History

Received: 11 March 2023

Accepted: 28 September 2023

Article published online:
07 December 2023

© 2023. Thieme. All rights reserved.

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  • References

  • 1 Kroll SS, Rosenfield L. Perforator-based flaps for low posterior midline defects. Plast Reconstr Surg 1988; 81 (04) 561-566
    CrossrefPubMedGoogle Scholar
  • 2 Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984; 37 (02) 149-159
    CrossrefPubMedGoogle Scholar
  • 3 Koshima I, Fukuda H, Utunomiya R, Soeda S. The anterolateral thigh flap; variations in its vascular pedicle. Br J Plast Surg 1989; 42 (03) 260-262
    CrossrefPubMedGoogle Scholar
  • 4 Wei FC, Jain V, Celik N, Chen HC, Chuang DCC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002; 109 (07) 2219-2226 , discussion 2227–2230
    CrossrefPubMedGoogle Scholar
  • 5 Lee JC, St-Hilaire H, Christy MR, Wise MW, Rodriguez ED. Anterolateral thigh flap for trauma reconstruction. Ann Plast Surg 2010; 64 (02) 164-168
    CrossrefPubMedGoogle Scholar
  • 6 Rodriguez ED, Rosson GD, Bluebond-Langner R. et al. The utility of the anterolateral thigh donor site in reconstructing the United States trauma patient. J Trauma 2007; 62 (04) 892-897
    PubMedGoogle Scholar
  • 7 Fujino T. Contribution of the axial and perforator vasculature to circulation in flaps. Plast Reconstr Surg 1967; 39 (02) 125-137
    CrossrefPubMedGoogle Scholar
  • 8 Patel SA, Keller A. A theoretical model describing arterial flow in the DIEP flap related to number and size of perforator vessels. J Plast Reconstr Aesthet Surg 2008; 61 (11) 1316-1320 , discussion 1320
    CrossrefPubMedGoogle Scholar
  • 9 Zapata-Ospina A, Chen J, Tee R, Jeng SF, Karki B, Shih HS. Harvesting the anterolateral thigh flap with non-sizable perforators. J Plast Reconstr Aesthet Surg 2021; 74 (05) 1022-1030
    CrossrefPubMedGoogle Scholar
  • 10 Gholami M, Shaban B, Hejazi A, Sazegar G, Soufizadeh R. Anatomical variations of anterolateral thigh flap: a fresh cadaver dissection study. World J Plast Surg 2021; 10 (03) 18-24
    CrossrefPubMedGoogle Scholar
  • 11 Baumann DP, Lin HY, Chevray PM. Perforator number predicts fat necrosis in a prospective analysis of breast reconstruction with free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg 2010; 125 (05) 1335-1341
    CrossrefPubMedGoogle Scholar
  • 12 Bhullar H, Hunter-Smith DJ, Rozen WM. Fat necrosis after DIEP flap breast reconstruction: a review of perfusion-related causes. Aesthetic Plast Surg 2020; 44 (05) 1454-1461
    CrossrefPubMedGoogle Scholar
  • 13 Mulvey CL, Cooney CM, Daily FF. et al. Increased flap weight and decreased perforator number predict fat necrosis in DIEP breast reconstruction. Plast Reconstr Surg Glob Open 2013; 1 (02) 1-7
    CrossrefPubMedGoogle Scholar
  • 14 Lee KT, Mun GH. Effects of obesity on postoperative complications after breast reconstruction using free muscle-sparing transverse rectus abdominis myocutaneous, deep inferior epigastric perforator, and superficial inferior epigastric artery flap: a systematic review and meta-analysis. Ann Plast Surg 2016; 76 (05) 576-584
    CrossrefPubMedGoogle Scholar
  • 15 Hembd A, Teotia SS, Zhu H, Haddock NT. Optimizing perforator selection: a multivariable analysis of predictors for fat necrosis and abdominal morbidity in DIEP flap breast reconstruction. Plast Reconstr Surg 2018; 142 (03) 583-592
    CrossrefPubMedGoogle Scholar
  • 16 Kamali P, Lee M, Becherer BE. et al. Medial row perforators are associated with higher rates of fat necrosis in bilateral DIEP flap breast reconstruction. Plast Reconstr Surg 2017; 140 (01) 19-24
    CrossrefPubMedGoogle Scholar
  • 17 Yu P. Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction. Head Neck 2004; 26 (09) 759-769
    CrossrefPubMedGoogle Scholar
  • 18 Kim EK, Kang BS, Hong JP. The distribution of the perforators in the anterolateral thigh and the utility of multidetector row computed tomography angiography in preoperative planning. Ann Plast Surg 2010; 65 (02) 155-160
    CrossrefPubMedGoogle Scholar
  • 19 Thiele JR, Weiß J, Braig D, Zeller J, Stark GB, Eisenhardt SU. Evaluation of the suprafascial thin ALT flap in foot and ankle reconstruction. J Reconstr Microsurg 2022; 38 (02) 151-159
    Article in Thieme ConnectPubMedGoogle Scholar
  • 20 Diamond S, Seth AK, Chattha AS, Iorio ML. Outcomes of subfascial, suprafascial, and super-thin anterolateral thigh flaps: tailoring thickness without added morbidity. J Reconstr Microsurg 2018; 34 (03) 176-184
    Article in Thieme ConnectPubMedGoogle Scholar