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.
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.
Experimentally, choke anastomoses are functional and control flow between perforator angiosomes. They (1) permit capture of an adjacent angiosome when the flap is raised on a cutaneous perforator in 100 percent of cases, with the necrosis line occurring usually in the next interperforator connection; (2) confine flow to the territory of the involved artery when a toxin is introduced by spasm around its perimeter; and (3) lose this property of spasm when choke vessels are converted to true anastomoses following surgical delay, or where true anastomoses occur naturally, thereby allowing unimpeded blood flow and capture of additional angiosome territories. Clinical experience supports these observations.
The functional angiosome is the volume of tissue that clinically can be isolated on a source vessel. The area extends beyond its anatomical territory to capture an adjacent territory if connections are by choke anastomoses, or more if they are by true anastomoses.
Island "perforator flaps" have become state of the art for free-skin flap transfer. Recent articles by Saint-Cyr et al. and Rozen et al. have focused on the anatomical and the clinical territories of ...individual cutaneous perforating arteries in flap planning, and it is timely to compare this work with our angiosome concept.
The angiosome concept, published in 1987, was reviewed and correlated with key experimental and clinical work by the authors, published subsequently at different times in different journals. In addition, new data are introduced to define these anatomical and clinical territories of the cutaneous perforators and to aid in the planning of safe skin flaps for local and free-flap transfer.
The anatomical territory of a cutaneous perforator was defined in the pig, dog, guinea pig, and rabbit by a line drawn through its perimeter of anastomotic vessels that link it with adjacent perforators in all directions. The safe clinical territory of that perforator, seen not only in the same range of animals but also in the human using either the Doppler probe or computed tomography angiography to locate the vessels, was found reliably to extend to include the anatomical territory of the next adjacent cutaneous perforator, situated radially in any direction.
The data provided by Saint-Cyr et al. and Rozen et al., coupled with the authors' own original work on the vascular territories of the body and their subsequent studies, reinforce the angiosome concept and provide the basis for the design of safe flaps for patient benefit.
Fiona Wood AM has changed international plastic surgery and the way we treat burns patients. This book is a 'must read' for Australasian plastic surgeons.
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.
RESULTS:A total of eight studies satisfied the inclusion criteria. Pooled data from four similar experiments in normal dogs showed an average long-term (≥5 months) patency of 52 percent. The only experiment in dogs with chronic lymphedema failed to show any long-term patency.
CONCLUSIONS:The creation of peripheral lymphovenous anastomoses with a moderate long-term patency rate has become technically possible. However, the long-term results in chronic lymphedema are limited.
BACKGROUND:In a comprehensive review of 17,096 deep inferior epigastric perforator (DIEP) flaps in 693 articles published between the first description of the DIEP flap in 1989 and August of 2011, ...the authors found that the methods used to categorize partial necrosis and fat necrosis were inconsistent. As a result, these surgical outcomes cannot be meaningfully compared among series and centers. In contrast, complete flap failure is an unambiguous and universally reported outcome that represents only a portion of the entire spectrum of flap necrosis.
METHODS:The authors created a database of every article with data on DIEP flaps by searching PubMed and Embase for the terms “DIEP,” “DIEAP,” “epigastric AND perforator,” “perforator,” and “flap AND reconstruction” and manually reviewing the 14,480 citations the search generated. The authors then reviewed 693 articles with data on DIEP flaps for incidence and other clinical details of flap loss, partial necrosis, and fat necrosis.
RESULTS:The authors found a broad range of definitions of partial and fat necrosis based on different parameters (e.g., percentage of flap lost, area of flap lost, necessity of reoperation) that were not directly comparable. Of 152 documented DIEP flap losses, 67 had reported causes40 percent (27 of 67) involved venous problems, 28 percent (19 of 67) arterial, and 21 percent (14 of 67) mechanical (pedicle kinking, hematoma).
CONCLUSIONS:At present, there is no consensus on the reporting of partial necrosis and flap necrosis. The authors propose a new flap necrosis classification system that prevents ambiguity and allows direct objective comparison of surgical outcomes among centers.
The calculator of writing Lee, Mark; Ashton, Mark W
Australasian journal of plastic surgery,
03/2023, Letnik:
6, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Throughout history there have been many revolutionary advances in technology that have shaken up the status quo. What role will artificial intelligence have in medical writing?
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). Indications were tumor ablation (n = 286), trauma (n = 84), osteomyelitis (n = 2), and the congenital deformities hemifacial microsomia (n = 2) and pseudarthrosis of the tibia (n = 9) and ulna (n = 1).
RESULTS:Successful transfer was achieved in 95 percent of patients. Union varied with the recipient bone, from 6 to 8 weeks in the jaw, 2 to 3 months in the upper limb, and 3 to 4 months in the femur and tibia. Union was fastest with iliac crest. The fibula provided easier dissection; it could be raised on either peroneal or anterior tibial vessels; the skin flap could be designed distally; it could be placed centrally in the medullary cavity of long bones; and hairline stress fracture in the lower limb frequently preceded rapid subperiosteal hypertrophy. The fibula lacks sufficient height for osseointegration, whereas iliac crest is ideal. Osteotomies of either bone are possible to straighten or increase curvature.
CONCLUSIONS:The fibula is best for long bone or angle-to-angle jaw reconstruction, especially in edentulous patients. Iliac crest is best for hemimandible, curved bones (pelvis, carpus, and metacarpus), and as an alternative for short, straight, 6- to 8-cm-long bone defects.
Thieves and kidnappers Lee, Mark; Ashton, Mark
Australasian journal of plastic surgery,
04/2024, Letnik:
7, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Plagiarism undermines the integrity of research. Editor-in-Chief Mark Lee outlines some tools that can help researchers avoid unintentional plagiarism and promote a culture of integrity in plastic ...surgery research.
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.
BACKGROUND:Reports of more than two cutaneous perforator angiosome territories being raised successfully in distally based sural flaps are appearing in the literature. Previous anatomical studies ...have noted that cutaneous arteries, connected by true anastomosis without change in caliber, frequently parallel cutaneous nerves.
METHODS:Twenty-four (48 sides) total body lead oxide cadaver injection studies, including seven arterial and two venous neurovascular, were examined, and the results were compared with clinical thermography in Part II.
RESULTS:Long branches of cutaneous perforators, connected in a series by true anastomoses, paralleled at variable distances the main trunks of cutaneous nerves in the head, neck, torso, and upper and lower extremities. Specifically, in the leg, an average of 3.2 true anastomoses (range, 1 to 5) connected perforators that paralleled the sural nerve on the back of the calf; and 2.5 (range, 1 to 4) connected perforators on the medial side of the leg. These vascular freeways were paralleled by the short and long saphenous veins, respectively.
CONCLUSIONS:True anastomoses frequently connect skin perforators that course in parallel with cutaneous nerves and veins. They provide an explanation for the long viable flaps noted in the leg, and it will be shown in Part II that they can be detected preoperatively with thermography.
