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

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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.	黄泽林, 段梦娴, 杨俊涛, 等. 逆行供血的游离股前外侧皮瓣修复儿童足踝部创面. 中华显微外科杂志, 2023, 46(2): 147-151.
3.	杨薛康, 张栋梁, 何亭, 等. 游离颞浅筋膜瓣/股前外侧筋膜瓣联合皮片移植修复四肢特殊部位深度组织缺损的临床经验. 中华烧伤与创面修复杂志, 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, 陈国荣, 等. 显微削薄腓动脉穿支皮瓣修复手指背侧软组织缺损. 中华显微外科杂志, 2022, 45(6): 617-621.
6.	周建东, 张兴飞, 许同龙, 等. 浅筋膜浅深交界层平面逆行分离穿支血管切取超薄股前外侧皮瓣修复足部创面. 中华显微外科杂志, 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.	周飞亚, 张弦, 褚庭纲, 等. 以彩色多普勒术前定位的短蒂股前外侧穿支皮瓣游离移植修复四肢中小面积皮肤缺损. 中华手外科杂志, 2023, 39(1): 77-80.
10.	方军, 赵光宗, 李华壮, 等. 三维CT血管造影辅助游离腓肠内侧动脉穿支皮瓣修复足部创面的疗效. 中华烧伤与创面修复杂志, 2023, 39(4): 343-349.
11.	李雪栋, 赵刚, 潘筱云, 等. 非增强和增强核磁共振定位股前外侧皮瓣穿支的临床对照研究. 中华手外科杂志, 2021, 37(1): 27-30.
12.	钟怡鸣, 汤欣, 王锦姝, 等. 应用游离双侧股前外侧穿支皮瓣串联修复手部大面积皮肤缺损15例. 中华手外科杂志, 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.	张韬, 程俊楠, 杨林, 等. 多穿支腓浅动脉穿支皮瓣修复手足创面的疗效. 中华烧伤与创面修复杂志, 2023, 39(3): 234-240.
16.	杜伟力, 沈余明, 胡骁骅, 等. 巨大腹壁下动脉脐旁穿支皮瓣修复腕部环状高压电烧伤创面的临床效果. 中华烧伤与创面修复杂志, 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.	林伟栋, 糜菁熠, 潘筱云, 等. 动态红外热成像联合彩超在游离股前外侧皮瓣术前穿支定位的应用研究. 中华手外科杂志, 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. 黄泽林, 段梦娴, 杨俊涛, 等. 逆行供血的游离股前外侧皮瓣修复儿童足踝部创面. 中华显微外科杂志, 2023, 46(2): 147-151.
3. 杨薛康, 张栋梁, 何亭, 等. 游离颞浅筋膜瓣/股前外侧筋膜瓣联合皮片移植修复四肢特殊部位深度组织缺损的临床经验. 中华烧伤与创面修复杂志, 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, 陈国荣, 等. 显微削薄腓动脉穿支皮瓣修复手指背侧软组织缺损. 中华显微外科杂志, 2022, 45(6): 617-621.
6. 周建东, 张兴飞, 许同龙, 等. 浅筋膜浅深交界层平面逆行分离穿支血管切取超薄股前外侧皮瓣修复足部创面. 中华显微外科杂志, 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. 周飞亚, 张弦, 褚庭纲, 等. 以彩色多普勒术前定位的短蒂股前外侧穿支皮瓣游离移植修复四肢中小面积皮肤缺损. 中华手外科杂志, 2023, 39(1): 77-80.
10. 方军, 赵光宗, 李华壮, 等. 三维CT血管造影辅助游离腓肠内侧动脉穿支皮瓣修复足部创面的疗效. 中华烧伤与创面修复杂志, 2023, 39(4): 343-349.
11. 李雪栋, 赵刚, 潘筱云, 等. 非增强和增强核磁共振定位股前外侧皮瓣穿支的临床对照研究. 中华手外科杂志, 2021, 37(1): 27-30.
12. 钟怡鸣, 汤欣, 王锦姝, 等. 应用游离双侧股前外侧穿支皮瓣串联修复手部大面积皮肤缺损15例. 中华手外科杂志, 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. 张韬, 程俊楠, 杨林, 等. 多穿支腓浅动脉穿支皮瓣修复手足创面的疗效. 中华烧伤与创面修复杂志, 2023, 39(3): 234-240.
16. 杜伟力, 沈余明, 胡骁骅, 等. 巨大腹壁下动脉脐旁穿支皮瓣修复腕部环状高压电烧伤创面的临床效果. 中华烧伤与创面修复杂志, 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. 林伟栋, 糜菁熠, 潘筱云, 等. 动态红外热成像联合彩超在游离股前外侧皮瓣术前穿支定位的应用研究. 中华手外科杂志, 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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