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Application of Posterior Thigh Three-Dimensional Profunda Artery Perforator Perforasomes in Refining Next-Generation Flap Designs: Transverse, Vertical, and S-Shaped Profunda Artery Perforator Flaps

Mohan, Anita T. M.R.C.S., B.Sc.; Zhu, Lin M.D.; Sur, Yoo Joon M.D., Ph.D.; Morsy, Mohamed M.B.Ch.B.; Michalak, Gregory J. Ph.D.; Lachman, Nirusha Ph.D.; Rammos, Charalambos K. M.D.; Saint-Cyr, Michel M.D.

Plastic and Reconstructive Surgery: April 2017 - Volume 139 - Issue 4 - p 834e–845e
doi: 10.1097/PRS.0000000000003224
Breast: Original Articles
Cover Article

Background: This study aimed to delineate and compare the hot spots and three-dimensional vascular territories of dominant profunda artery perforators in the posterior thigh region, and modifications in flap design are discussed.

Methods: Twenty-nine posterior thigh flaps were raised in fresh cadaveric specimens, and profunda artery perforators were documented. Dominant perforators were injected with iodinated contrast to assess perforasomes using computed tomographic angiography. Analysis with three-dimensional rendering and volume calculations of perfusion patterns was performed.

Results: In total, 316 perforators were mapped and 33 perforators were injected for analysis. The hot spot for dominant perforators was the proximal medial quadrant, 5 to 10 cm from the inferior gluteal crease, with two smaller hot spots in the upper lateral and distal posterior midline. Although 69 percent were musculocutaneous, distal perforators were predominantly septocutaneous in the posterior midline, 5 to 8 cm from the popliteal crease. Proximal perforators were classified into first (most proximal) and second perforators, and their median perforasome was 233 and 286.4 cm2, respectively (p = 0.86). There were no significant differences between proximal and distal perforators in perforasome surface areas, percentage areas perfused, and perforasome volumes. Large linking vessel networks were attributed to a broader perforasome and greater overlap between adjacent or distal perforators.

Conclusions: Dominant linking vessels and recurrent flow through the subdermal plexus contribute to the robust vascular supply of profunda artery perforator flaps. Posterior thigh region perforator hot spots and their perfusion characteristics can inform the potential limits, orientation, and modifications of flap or skin paddle designs.

Rochester Minn.; Middlesex and Cambridge, United Kingdom; Seoul, Republic of Korea; and Assiut, Egypt

From the Division of Plastic Surgery, the Division of Radiology, Biomedical Resource Imaging, and the Department of Anatomy, Mayo Clinic; the Restoration of Appearance and Function Charitable Trust; the Department of Surgery, University of Cambridge; the Department of Orthopedic Surgery, Uijeongbu St Mary’s Hospital, College of Medicine, The Catholic University of Korea; and the Department of Orthopedics, Assiut University.

Received for publication February 19, 2016; accepted September 30, 2016.

Disclosure:Dr. Saint-Cyr is a consultant for Pacira and has no conflicts of interest to declare. The other authors have no financial disclosures or conflicts of interest to declare.

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Michel Saint-Cyr, M.D., Division of Plastic Surgery, Baylor, Scott and White, 2401 South 31st Street, Temple, Texas 76508, msaint-cyr@sw.org

©2017American Society of Plastic Surgeons