Perforator flaps

Last updated

Perforator flap surgery is a technique used in reconstructive surgery where skin and/or subcutaneous fat are removed from a distant or adjacent part of the body to reconstruct the excised part. [1] The vessels that supply blood to the flap are isolated perforator(s) derived from a deep vascular system through the underlying muscle or intermuscular septa. Some perforators can have a mixed septal and intramuscular course before reaching the skin. The name of the particular flap is retrieved from its perforator and not from the underlying muscle. [1] If there is a potential to harvest multiple perforator flaps from one vessel, the name of each flap is based on its anatomical region or muscle. For example, a perforator that only traverses through the septum to supply the underlying skin is called a septal perforator. Whereas a flap that is vascularised by a perforator traversing only through muscle to supply the underlying skin is called a muscle perforator. [1] According to the distinct origin of their vascular supply, perforators can be classified into direct and indirect perforators. Direct perforators only pierce the deep fascia, they don't traverse any other structural tissue. Indirect perforators first run through other structures before piercing the deep fascia. [1]

Contents

Overview

Soft tissue defects due to trauma or after tumor extirpation are important medical and cosmetic topics. Therefore, reconstructive surgeons have developed a variety of surgical techniques to conceal the soft tissue defects by using tissue transfers, better known as flaps. In the course of time these flaps have rapidly evolved from "random-pattern flaps with an unknown blood supply, through axial-pattern flaps with a known blood supply to muscle and musculocutaneous perforator flaps" for the sole purpose of optimal reconstruction with minimum donor-site morbidity. [2] Koshima and Soeda were the first to use the name “perforator flaps” in 1989 [3] and since then perforator flaps have become more popular in reconstructive microsurgery. [1] Thus perforator flaps, using autologous tissue with preservation of fascia, muscle and nerve represent the future of flaps. [4] The most frequently used perforator flaps nowadays are the deep inferior epigastric perforator flap (DIEP flap), [5] [6] and both the superior and inferior gluteal (SGAP/ IGAP) flap, [7] all three mainly used for breast reconstruction; the lateral circumflex femoral artery perforator (LCFAP) flap (previously named anterolateral thigh or ALT flap) [8] and the thoracodorsal artery perforator (TAP) flap, [9] mainly for the extremities and the head and neck region as a free flap and for breast and thoracic wall reconstruction as a pedicled perforator flap.

Classification

Perforator flaps can be classified in many different ways. Regarding the distinct origin of their blood supply and the structures they cross before they pierce the deep fascia, perforators can either be direct perforators or indirect perforators. [10] We will discuss this classification based on the perforators' anatomy below.

Direct and indirect perforators Direct and indirect perforators.png
Direct and indirect perforators

[ citation needed ]

Direct cutaneous

Direct cutaneous perforators only perforate the deep fascia, they do not traverse any other structural tissue. [10]

It is questionable whether these perforators are true perforators, because it might be more logical to not include these perforators. The surgical approach needed for direct perforators is slightly different from the one needed for indirect perforators. When direct perforators are not included, surgeons can focus on the anatomy of the perforator and the source vessel. [1]

Indirect cutaneous

Indirect cutaneous perforators traverse other structures before going through the deep fascia. These other structures are deeper tissues, and consist of mainly muscle, septum or epimysium. [10] According to the clinical relevance, two types of indirect cutaneous perforators need to be distinguished. [1] We will clarify these two types below.[ citation needed ]

Muscle and musculocutaneous

Musculocutaneous perforators supply the overlying skin by traversing through muscle before they pierce the deep fascia. [1]

A perforator which traverses muscle before piercing the deep fascia can do that either transmuscular or transepimysial. This latter subdivision is however not taken into account during the dissection of the perforator. Only the size, position, and course of the perforator vessel are considered then. [1]

When a flaps’ blood supply depends on a muscle perforator, this flap is called a muscle perforator flap. [1]

Septal and septocutaneous

Septocutaneous perforators supply the overlying skin by traversing through an intermuscular septum before they pierce the deep fascia. These perforators are cutaneous side branches of muscular vessels and perforators. [1]

When a flap's blood supply depends on a septal perforator, this flap is called a septal perforator flap. [1]

Nomenclature

Due to confusion about the definition and nomenclature of perforator flaps, a consensus meeting was held in Gent, Belgium, on September 29, 2001. Regarding the nomenclature of these flaps, the authors stated the following:

"A perforator flap should be named after the nutrient artery or vessels and not after the underlying muscle. If there is a potential to harvest multiple perforator flaps from one vessel, the name of each flap should be based on its anatomical region or muscle." [1]

This so-called 'gent consensus' was needed because the lack of definitions and standard rules on terminology created confusion in communication between surgeons. [1]

Method of application

Flaps can be transferred either free or pedicled. Regarding the nomenclature, one is free to add the type of transfer to the name of a flap. [1]

Free perforator flaps

A free flap is defined as a tissue mass that has been taken away from the original site to be used in tissue transplantation. [11] When a surgeon uses a free flap, the blood supply is cut and the pedicle reattached to recipient vessels, performing a microsurgical anastomosis. [12]

For more information on free flaps, see also free flap.

Pedicled perforator flaps

Pedicled perforator flaps can be transferred either by translation or rotation. These two types will be discussed separately below.[ citation needed ]

Translation

This type of transfer is also called "advancement".The surgeon disconnects the flap from the body, except for the perforators. After this procedure, the flap is advanced into the defect. [13]

Rotation

The subgroup of pedicled perforator flaps, transferred in the defect by rotation is the so-called "propeller flap". Confusion concerning definition, nomenclature and classification of propeller flaps led to a consensus meeting similar to the "gent consensus meeting”. The consensus that was reached is named "the tokyo consensus". This article stipulates the definitions of propeller flaps and especially perforator propeller flaps. [14] The definition that was set up is cited below:

"A propeller flap can be defined as an “island flap that reaches the recipient site through an axial rotation.” Every skin island flap can become a propeller flap. However, island flaps that reach the recipient site through an advancement movement and flaps that move through a rotation but are not completely islanded are excluded from this definition. " [14]

Propeller flap Propeller flap.png
Propeller flap

Regarding the classification of propeller flaps, the surgeon should specify several aspects of these flaps. It is important that the type of nourishing pedicle, the degree of skin island rotation and, when possible, the artery of origin of the perforator vessel are mentioned. [14]

The perforator propeller flap is the propeller flap which is used most commonly. It is a perforator flap with a skin island, which is separated in a larger and smaller paddle by the nourishing perforator. These paddles can rotate around the perforator (pedicle), for as many degrees as the anatomical situation requires (90-180 degrees). This flap looks like a propeller when the two paddles are not too different in size. [14]

Fields of application

Trauma, oncological treatments or pressure ulcers can result in severe tissue defects. Those defects can be covered and closed by using autologe tissue transposition. The fact that each tissue defect is different makes it necessary for each tissue defect to be assessed individually. The choice of the type of tissue transposition depends on the location, nature, extent and status of the deformity. [15]

However, the health of the patient and possible contra-indications play an important role as well. Due to the development and improvement of cutaneous, myocutanous and fasciocutaneous tissue transpositions plastic surgeons are able to successfully restore the defect to its original shape. [15] Nevertheless, functional recovery is not guaranteed in all patients. For the optimal renewal of shape and function, a suitable flap can be chosen to reconstruct the defect. In the case of using a so-called perforator flap, a reliable vascularization and the possibility of sensory (re) innervation can be combined with less donor-site morbidity and limited loss of function in the donor area. [15]

Oncological background

The surgical removal of both benign and malignant tumors often result in serious tissue defects involving not only soft tissue but also parts of the bone. [16] Depending on the location aneligible flap can be selected. In breast reconstruction for example, perforator flaps have raised the standard by replacing like with like. [17] When taking breast reconstruction into consideration, several surgical options are available to achieve lasting natural results with decreased donor-site deformities. The broad option of donor-sites makes practically all patients candidates for autogenous perforator flap reconstruction. [17] Some examples include, Deep inferior epigastric perforator flap (DIEP flap), superior gluteal (SGAP) flaps and inferior gluteal (IGAP) flaps.[ citation needed ]

Traumatic background

Treatment of tissue defects caused after a trauma present major surgical challenges especially those of the upper and lower limb, due to the fact that they often not only cause damage to the skin but also to bones, muscles/tendons, vessels and/or nerves. [18]

If there is extensive destruction a fasciotomy is needed, therefore it is generally accepted that the best way to cover these types of tissue defects is a free flap transplantation. [18] [19] [20] Nevertheless, over the years surgeons have tried to increase the application of perforator flaps, due to their proven advantages. In the case of upper limb surgery, perforator flaps are successfully used in minor and major soft tissue defects provided that in major defects the flap is precisely planed. [18] [21]

In lower limb surgery there have also been reports of successful use of perforator flaps. [22] [23]

Advantages and disadvantages

Twenty three years after the first perforator flap was described by Koshima and Soeda, [3] there has been a significant step towards covering tissue defects by using only cutaneous tissue. [24] Results obtained from studies done on musculocutaneous and septocutaneous perforator flaps have shown a reduction of donor-site morbidity to a minimum [24] [25] due to refined perforator flap techniques that allow collection of tissue without scarifying the underlying muscles. [24] [26] As a matter of fact, preventing damage to the underlying muscle including its innervation, has led to less cases of abdominal hernia, [26] the absence of postoperative muscle atrophy [27] and a better vascularised and functioning donor muscle. [17] Furthermore, patients have shown decreased postoperative pain and accelerated rehabilitation [17] [25] Nevertheless, there will always be a chance that the displaced tissue partially or completely dies considering the fact that the perfusion of the flap is difficult to assess intraoperatively. [28] Furthermore, when using this technique additional scars are made. Thus considering the complexity and length of this procedure microsurgical expertise is required and patients need to undergo a longer period of anesthetics that of course could result in increased risk factors.[ citation needed ] Microsurgical expertise in perforator flap dissection can be acquired using perforator flap training models in living tissue. [29]

Indications and contra-indications

Indications:

Contraindications: [30] [31]

Associated with the patient:

Relative contra-indications

Any condition that probably increases the risk of intraoperative or postoperative complications: [32]

By inducing thrombogenic state through vasoconstriction of the microvasculature, tobacco influences blood flow, wound healing and the survival of pedicled flaps. On the contrary there is no published data on damaging effects of cigarette smoke on free tissue transfer. [33] [34]

Examples of perforator flaps

See also

Related Research Articles

<span class="mw-page-title-main">Breast reconstruction</span> Surgical rebuilding of a breast

Breast reconstruction is the surgical process of rebuilding the shape and look of a breast, most commonly in women who have had surgery to treat breast cancer. It involves using autologous tissue, prosthetic implants, or a combination of both with the goal of reconstructing a natural-looking breast. This process often also includes the rebuilding of the nipple and areola, known as nipple-areola complex (NAC) reconstruction, as one of the final stages.

<span class="mw-page-title-main">Rhinoplasty</span> Surgical procedure to enhance or reconstruct a human nose

Rhinoplasty, commonly called nose job, medically called nasal reconstruction, is a plastic surgery procedure for altering and reconstructing the nose. There are two types of plastic surgery used – reconstructive surgery that restores the form and functions of the nose and cosmetic surgery that changes the appearance of the nose. Reconstructive surgery seeks to resolve nasal injuries caused by various traumas including blunt, and penetrating trauma and trauma caused by blast injury. Reconstructive surgery can also treat birth defects, breathing problems, and failed primary rhinoplasties. Rhinoplasty may remove a bump, narrow nostril width, change the angle between the nose and the mouth, or address injuries, birth defects, or other problems that affect breathing, such as a deviated nasal septum or a sinus condition. Surgery only on the septum is called a septoplasty.

Grafting refers to a surgical procedure to move tissue from one site to another on the body, or from another creature, without bringing its own blood supply with it. Instead, a new blood supply grows in after it is placed. A similar technique where tissue is transferred with the blood supply intact is called a flap. In some instances, a graft can be an artificially manufactured device. Examples of this are a tube to carry blood flow across a defect or from an artery to a vein for use in hemodialysis.

<span class="mw-page-title-main">Microsurgery</span> Surgery requiring an operating microscope

Microsurgery is a general term for surgery requiring an operating microscope. The most obvious developments have been procedures developed to allow anastomosis of successively smaller blood vessels and nerves which have allowed transfer of tissue from one part of the body to another and re-attachment of severed parts. Microsurgical techniques are utilized by several specialties today, such as general surgery, ophthalmology, orthopedic surgery, gynecological surgery, otolaryngology, neurosurgery, oral and maxillofacial surgery, endodontic microsurgery, plastic surgery, podiatric surgery and pediatric surgery.

<span class="mw-page-title-main">Rhytidectomy</span> Type of cosmetic surgery

A facelift, technically known as a rhytidectomy, is a type of cosmetic surgery procedure intended to give a more youthful facial appearance. There are multiple surgical techniques and exercise routines. Surgery usually involves the removal of excess facial skin, with or without the tightening of underlying tissues, and the redraping of the skin on the patient's face and neck. Exercise routines tone underlying facial muscles without surgery. Surgical facelifts are effectively combined with eyelid surgery (blepharoplasty) and other facial procedures and are typically performed under general anesthesia or deep twilight sleep.

<span class="mw-page-title-main">Buttock augmentation</span> Cosmetic and corrective surgery

Gluteoplasty denotes the plastic surgery and the liposuction procedures for the correction of congenital, traumatic, and acquired defects/deformities of the buttocks and the anatomy of the gluteal region; and for the aesthetic enhancement of the contour of the buttocks.

<span class="mw-page-title-main">Gracilis muscle</span> Most superficial muscle on the medial side of the thigh

The gracilis muscle is the most superficial muscle on the medial side of the thigh. It is thin and flattened, broad above, narrow and tapering below.

The terms free flap, free autologous tissue transfer and microvascular free tissue transfer are synonymous terms used to describe the "transplantation" of tissue from one site of the body to another, in order to reconstruct an existing defect. "Free" implies that the tissue is completely detached from its blood supply at the original location and then transferred to another location and the circulation in the tissue re-established by anastomosis of artery(s) and vein(s). This is in contrast to a "pedicled" flap in which the tissue is left partly attached to the donor site ("pedicle") and simply transposed to a new location; keeping the "pedicle" intact as a conduit to supply the tissue with blood.

<span class="mw-page-title-main">Breast implant</span> Prosthesis used to change the size, shape, and contour of a persons breast

A breast implant is a prosthesis used to change the size, shape, and contour of a person's breast. In reconstructive plastic surgery, breast implants can be placed to restore a natural looking breast following a mastectomy, to correct congenital defects and deformities of the chest wall or, cosmetically, to enlarge the appearance of the breast through breast augmentation surgery.

Harry J. Buncke was an American plastic surgeon who has been called "The Father of Microsurgery" for his contributions in the history and development of reconstructive microsurgical procedures. He is a past president of the American Society for Surgery of the Hand, the International Society of Reconstructive Microsurgery, and the American Association of Plastic Surgery. He served as a clinical professor of surgery at both Stanford University and the University of California - San Francisco. He was the author of 15 movies and television tapes, four surgical textbooks, and more than 400 peer-reviewed publications.

G. Patrick Maxwell is a plastic surgeon and an assistant clinical professor of surgery at Vanderbilt University, based in Nashville, Tennessee.

<span class="mw-page-title-main">Superficial circumflex iliac artery</span>

The superficial iliac circumflex artery, the smallest of the cutaneous branches of the femoral artery, arises close to the superficial epigastric artery, and, piercing the fascia lata, runs lateralward, parallel with the inguinal ligament, as far as the crest of the ilium.

A DIEP flap is type of breast reconstruction where blood vessels, fat, and skin from the lower belly are relocated to the chest to rebuild breasts after mastectomy. DIEP stands for the deep inferior epigastric perforator artery, which runs through the abdomen. This is a type of autologous reconstruction, meaning one's own tissue is used.

<span class="mw-page-title-main">Smile surgery</span> Surgical procedure to restore smile

Smile surgery or smile reconstruction is a surgical procedure that restores the smile for people with facial nerve paralysis. Facial nerve paralysis is a relatively common condition with a yearly incidence of 0.25% leading to function loss of the mimic muscles. The facial nerve gives off several branches in the face. If one or more facial nerve branches are paralysed, the corresponding mimetic muscles lose their ability to contract. This may lead to several symptoms such as incomplete eye closure with or without exposure keratitis, oral incompetence, poor articulation, dental caries, drooling, and a low self-esteem. This is because the different branches innervate the frontalis muscle, orbicularis oculi and oris muscles, lip elevators and depressors, and the platysma. The elevators of the upper lip and corner of the mouth are innervated by the zygomatic and buccal branches. When these branches are paralysed, there is an inability to create a symmetric smile.

Nasal reconstruction using a paramedian forehead flap within oral and maxillofacial surgery, is a surgical technique to reconstruct different kinds of nasal defects. In this operation a reconstructive surgeon uses skin from the forehead above the eyebrow and pivots it vertically to replace missing nasal tissue. Throughout history the technique has been modified and adjusted by many different surgeons and it has evolved to become a popular way of repairing nasal defects.

The tint of forehead skin so exactly matches that of the face and nose that it must be first choice. Is not the forehead the crowning feature of the face and important in expression? Why then should we jeopardize its beauty to make a nose? First, because in many instances, the forehead makes far and away the best nose. Second, with some plastic juggling, the forehead defect can be camouflaged effectively.

<span class="mw-page-title-main">Flap (surgery)</span> Surgical procedure in which tissue is transferred with intact blood supply

Flap surgery is a technique in plastic and reconstructive surgery where tissue with an intact blood supply is lifted from a donor site and moved to a recipient site. Flaps are distinct from grafts, which do not have an intact blood supply and relies on the growth of new blood vessels. Flaps are done to fill a defect such as a wound resulting from injury or surgery when the remaining tissue is unable to support a graft, or to rebuild more complex anatomic structures like breasts or jaws.

Scalp reconstruction is a surgical procedure for people with scalp defects. Scalp defects may be partial or full thickness and can be congenital or acquired. Because not all layers of the scalp are elastic and the scalp has a convex shape, the use of primary closure is limited. Sometimes the easiest way of closing the wound may not be the ideal or best way. The choice for a reconstruction depends on multiple factors, such as the defect itself, the patient characteristics and surgeon preference.

The cheek constitutes the facial periphery and plays a key role in the maintenance of oral competence and mastication. It is also involved in the facial manifestation of human emotion and supports neighboring primary structures.

Free-flap breast reconstruction is a type of autologous-tissue breast reconstruction applied after mastectomy for breast cancer, without the emplacement of a breast implant prosthesis. As a type of plastic surgery, the free-flap procedure for breast reconstruction employs tissues, harvested from another part of the woman's body, to create a vascularised flap, which is equipped with its own blood vessels. Breast-reconstruction mammoplasty can sometimes be realised with the application of a pedicled flap of tissue that has been harvested from the latissimus dorsi muscle, which is the broadest muscle of the back, to which the pedicle (“foot”) of the tissue flap remains attached until it successfully grafts to the recipient site, the mastectomy wound. Moreover, if the volume of breast-tissue excised was of relatively small mass, breast augmentation procedures, such as autologous-fat grafting, also can be applied to reconstruct the breast lost to mastectomy.

Björn Dirk Krapohl is a German surgeon, specializing in plastic surgery and hand surgery at the University of Lübeck and the Charité in Berlin. He is known for his work in the fields of reconstructive microsurgery, hand surgery, and breast surgery.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Blondeel PN, Van Landuyt KH, Monstrey SJ, et al. (October 2003). "The "Gent" consensus on perforator flap terminology: preliminary definitions". Plast. Reconstr. Surg. 112 (5): 1378–83, quiz 1383, 1516, discussion 1384–7. doi:10.1097/01.PRS.0000081071.83805.B6. PMID   14504524. S2CID   38395679.
  2. ↑ Morris S (2008). "Perforator flaps: a microsurgical innovation". Medscape J Med. 10 (11): 266. PMC   2605127 . PMID   19099016.
  3. 1 2 Koshima I, Soeda S (November 1989). "Inferior epigastric artery skin flaps without rectus abdominis muscle". Br J Plast Surg. 42 (6): 645–8. doi:10.1016/0007-1226(89)90075-1. PMID   2605399.
  4. ↑ Wei FC, Celik N (July 2003). "Perforator flap entity". Clin Plast Surg. 30 (3): 325–9. doi:10.1016/s0094-1298(03)00033-6. PMID   12916589.
  5. ↑ Granzow JW, Levine JL, Chiu ES, Allen RJ (2006). "Breast reconstruction with the deep inferior epigastric perforator flap: history and an update on current technique". J Plast Reconstr Aesthet Surg. 59 (6): 571–9. doi:10.1016/j.bjps.2006.01.004. PMID   16716950.
  6. ↑ Man LX, Selber JC, Serletti JM (September 2009). "Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review". Plast. Reconstr. Surg. 124 (3): 752–64. doi:10.1097/PRS.0b013e31818b7533. PMID   19342994. S2CID   26114453.
  7. ↑ Allen RJ, Tucker C (June 1995). "Superior gluteal artery perforator free flap for breast reconstruction". Plast. Reconstr. Surg. 95 (7): 1207–12. doi:10.1097/00006534-199506000-00010. PMID   7761507. S2CID   13358838.
  8. ↑ Kuo YR, Yeh MC, Shih HS, et al. (July 2009). "Versatility of the anterolateral thigh flap with vascularized fascia lata for reconstruction of complex soft-tissue defects: clinical experience and functional assessment of the donor site". Plast. Reconstr. Surg. 124 (1): 171–80. doi:10.1097/PRS.0b013e3181a80594. PMID   19568063. S2CID   5279225.
  9. ↑ Angrigiani C, Grilli D, Siebert J (December 1995). "Latissimus dorsi musculocutaneous flap without muscle". Plast. Reconstr. Surg. 96 (7): 1608–14. doi:10.1097/00006534-199512000-00014. PMID   7480280. S2CID   36267006.
  10. 1 2 3 Hallock GG (February 2003). "Direct and indirect perforator flaps: the history and the controversy". Plast. Reconstr. Surg. 111 (2): 855–65, quiz 866. doi:10.1097/01.PRS.0000040462.38363.C7. PMID   12560714.
  11. ↑ "Free flaps". Pubmed MESH terms database.
  12. ↑ Guyuron, Bahman; Eriksson, Elok; Persing, John A. (2009). "Ch. 9: Microsurgery and Free Flaps". Plastic Surgery: Indications and practice. Vol. 1. Saunders Elsevier. ISBN   978-1-4160-4081-1.
  13. ↑ Guyuron, Bahman; Elof Eriksson, John A. Persing (2009). Chapter 8: Flaps. Plastic Surgery: Indications and Practice. Saunders Elsevier. ISBN   978-1-4160-4081-1
  14. 1 2 3 4 Pignatti M, Ogawa R, Hallock GG, et al. (February 2011). "The "Tokyo" consensus on propeller flaps". Plast. Reconstr. Surg. 127 (2): 716–22. doi:10.1097/PRS.0b013e3181fed6b2. PMID   21285776. S2CID   34314915.
  15. 1 2 3 Klein S, Hage JJ, de Weerd L (October 2005). "[Perforator flaps--the evolution of a reconstructive surgical technique]". Ned Tijdschr Geneeskd (in Dutch). 149 (43): 2392–8. PMID   16277128.
  16. ↑ Schulten EA, Winters HA, Koch AE (April 2008). "[Reconstruction after surgical treatment of head and neck cancer: surgical and prosthetic possibilities]". Ned Tijdschr Tandheelkd (in Dutch). 115 (4): 215–23. PMID   18512520.
  17. 1 2 3 4 Granzow JW, Levine JL, Chiu ES, LoTempio MM, Allen RJ (July 2007). "Breast reconstruction with perforator flaps". Plast. Reconstr. Surg. 120 (1): 1–12. doi:10.1097/01.prs.0000256044.66107.a6. PMID   17572536. S2CID   34675486. (Retracted, see doi:10.1097/01.prs.0000318081.24460.65, PMID   18454036 . If this is an intentional citation to a retracted paper, please replace {{ retracted |...}} with {{ retracted |...|intentional=yes}}.)
  18. 1 2 3 Georgescu AV, Capota I, Matei I, et al. (June 2009). "The place of local/regional perforator flaps in complex traumas of the forearm". J Hand Microsurg. 1 (1): 25–31. doi:10.1007/s12593-009-0007-6. PMC   3453204 . PMID   23129928.
  19. ↑ Koshima, Isao; Moriguchi, Takahiko; Etoh, Hisashi; Tsuda, Kuniyoshi; Tanaka, Hitoshi (1995). "The Radial Artery Perforator-based Adipofascial Flap for Dorsal Hand Coverage". Annals of Plastic Surgery. 35 (5): 474–479. doi:10.1097/00000637-199511000-00005. ISSN   0148-7043. PMID   8579264. S2CID   44601964.
  20. ↑ Giunta R, Geisweid A, Lukas B, Feller AM (November 2000). "[Perforator flap-plasty and applications to hand surgery]". Handchir Mikrochir Plast Chir (in German). 32 (6): 399–403. doi:10.1055/s-2000-10908. PMID   11189893. S2CID   260155610.
  21. ↑ Auclair E, Guelmi K, Selinger R, Mitz V, Lemerle JP (June 1994). "[Free transfer in the emergency treatment of complex injuries of the arm. Apropos of 18 cases]". Ann Chir Plast Esthet (in French). 39 (3): 338–45. PMID   7717669.
  22. ↑ Rad AN, Christy MR, Rodriguez ED, Brazio P, Rosson GD (February 2010). "The anterior tibialis artery perforator (ATAP) flap for traumatic knee and patella defects: clinical cases and anatomic study". Ann Plast Surg. 64 (2): 210–6. doi:10.1097/SAP.0b013e3181a13dd6. PMID   20098108. S2CID   29990851.
  23. ↑ Quaba O, Quaba A (May 2006). "Pedicled Perforator Flaps for the Lower Limb". Semin Plast Surg. 20 (2): 103–111. doi:10.1055/s-2006-941717. PMC   2884776 .
  24. 1 2 3 LoTempio MM, Allen RJ (August 2010). "Breast reconstruction with SGAP and IGAP flaps". Plast. Reconstr. Surg. 126 (2): 393–401. doi:10.1097/PRS.0b013e3181de236a. PMID   20679825. S2CID   20950415.
  25. 1 2 Guerra AB, Lyons GD, Dupin CL, Metzinger SE (July 2005). "Advantages of perforator flaps in reconstruction of complex defects of the head and neck". Ear Nose Throat J. 84 (7): 441–7. doi: 10.1177/014556130508400717 . PMID   16813036.
  26. 1 2 Granzow JW, Levine JL, Chiu ES, Allen RJ (November 2006). "Breast reconstruction using perforator flaps". J Surg Oncol. 94 (6): 441–54. doi:10.1002/jso.20481. PMID   17061279. S2CID   24974920.
  27. ↑ Neligan PC, Lipa JE (May 2006). "Perforator Flaps in Head and Neck Reconstruction". Semin Plast Surg. 20 (2): 56–63. doi:10.1055/s-2006-941711. PMC   2884771 .
  28. ↑ Liu DZ, Mathes DW, Zenn MR, Neligan PC (July 2011). "The application of indocyanine green fluorescence angiography in plastic surgery". J Reconstr Microsurg. 27 (6): 355–64. doi:10.1055/s-0031-1281515. PMID   21717392. S2CID   260193952.
  29. ↑ Nistor, Alexandru; Jiga, Lucian P.; Miclaus, Gratian D.; Hoinoiu, Bogdan; Matusz, Petru; Ionac, Mihai E. (2022-04-11). Lumenta, David Benjamin (ed.). "Experimental swine models for perforator flap dissection in reconstructive microsurgery". PLOS ONE. 17 (4): e0266873. Bibcode:2022PLoSO..1766873N. doi: 10.1371/journal.pone.0266873 . ISSN   1932-6203. PMC   9000060 . PMID   35404988.
  30. ↑ Moran SL, Illig KA, Green RM, Serletti JM (March 2002). "Free-tissue transfer in patients with peripheral vascular disease: a 10-year experience". Plast. Reconstr. Surg. 109 (3): 999–1006. doi:10.1097/00006534-200203000-00031. PMID   11884824. S2CID   41801050.
  31. ↑ Moran SL, Salgado CJ, Serletti JM (June 2004). "Free tissue transfer in patients with renal disease". Plast. Reconstr. Surg. 113 (7): 2006–11. doi:10.1097/01.prs.0000122214.55090.16. PMID   15253190. S2CID   9975910.
  32. ↑ Principles of Microsurgery at eMedicine
  33. ↑ Chang LD, Buncke G, Slezak S, Buncke HJ (October 1996). "Cigarette smoking, plastic surgery, and microsurgery". J Reconstr Microsurg. 12 (7): 467–74. doi:10.1055/s-2007-1006620. PMID   8905547. S2CID   38357412.
  34. ↑ Yaffe B, Cushin BJ, Strauch B (1984). "Effect of cigarette smoking on experimental microvascular anastomoses". Microsurgery. 5 (2): 70–2. doi:10.1002/micr.1920050203. PMID   6748936. S2CID   10008050.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.