Plastic surgery made a dramatic step forward with the introduction of the angiosome concept by Taylor and Palmer, which increased our knowledge of vascular territory of the skin flap and led to improved flap elevation techniques.1–3 Now, the concept of vascular territory has evolved from angiosomes as the basic unit, to applying the perforator as the basic unit termed “perforasome.”4 Increased understanding of the flap anatomy and physiology, with a focus on minimizing donor-site morbidity without compromising safety and achieving ideal form and function, can be achieved. This new “elevator” approach (evolved from the classical reconstructive “ladder” approach) to defect reconstruction strives for the most accurate or anatomical reconstruction in a single setting.5 Furthermore, donor-site deformity is limited because the flap can be precisely tailored for the defect. The more recent introduction of perforator flaps has expanded our options and brought us to the era of free-style flaps.6 With the explosive introduction of new flaps, new ideas, and new findings, it is difficult to keep up with all the innovations in this field. Thus, what makes a “best new flap”? We defined “best flap” as follows: able to restore “normal” (like with like), results in minimal donor-site deformity, has relatively constant anatomy, and can be technically easy to raise. We defined “new flap” as follows: newly emerging, able to be replicated, reliable, and adds further value to previous flaps by way of new innovative techniques. In this context, we consider the following flaps that meet the criteria as best new flaps: superficial circumflex iliac artery perforator flap, profunda artery perforator flap, and thinned anterolateral thigh perforator flap. Brief description and technique of these flaps are reviewed.
The evolution of flap surgery cannot be discussed without considering the development of microsurgery. The era of microsurgery in reconstruction began with the pioneering work of Harry J. Buncke, M.D., and created a new dimension of reconstruction.7 He, along with many pioneers from this era, developed the core principles of microsurgery that are still pertinent today: (1) proper working environment, including microscopes and loupes; (2) preoperative evaluation and planning; (3) microsurgical technique, including elevation, pedicle dissection, recipient preparation, microanastomosis, and flap insetting; and (4) postoperative care.7–9 The principles remain the same, but the world of microsurgery has been expanded to manipulate vessels of very small diameter. It was previously believed that there was a significant risk for failure once the vessel diameter was less than 1 mm.10 With improved instruments and microscopes, in addition to training and technique, microsurgeons are now able to perform anastomosis of vessels smaller than 1 mm. Supermicrosurgery technique is defined as microsurgical anastomosis of vessels with a diameter less than 0.8 mm.11–13 This technique allows reconstruction using free flaps by anastomosing perforator to perforator.11,13,14 In addition, preoperative imaging, which has brought significant change in selecting and elevating flaps, intraoperative tips such as using monopolar coagulation to minimize bleeding, and postoperative management such as bandaging will be discussed to offer practical tips for microsurgery. This CME article aims to provide the reader with useful and practical new advances in the field of microsurgery.
Superficial Circumflex Iliac Artery Perforator Flap
It seems entirely appropriate that one of the best new flaps is also the first free flap described in publication in 1973 by Taylor and Daniel.15 Despite being described more than 45 years ago, it has not been used as often as many other flaps because of its perceived shortcomings: short pedicle with small vessel diameter, variable anatomy, and limited size. However, a renaissance has been growing for the use of the superficial circumflex iliac artery perforator flap because of a more in-depth understanding of the anatomy and the ability to delineate the individual patient’s vascular anatomy preoperatively.16–19 The superficial circumflex iliac artery perforator flap provides an excellent option for reconstruction of moderate sized skin and soft-tissue defects of the extremities and the head and neck but can be used as a composite or chimeric flap including lymph nodes, bone, muscle, and multiple skin islands.18,20–23
Preoperative imaging using computed tomographic angiography or color duplex ultrasound greatly improves the ability to plan and execute the elevation of the superficial circumflex iliac artery perforator flap. [See Video 1 (online), which displays the elevation of the superficial circumflex iliac artery perforator flap. The medial branch of the superficial circumflex iliac artery is used to elevate a moderate size flap for reconstruction. Note that the accompanying veins of the medial branch drain into the superficial vein, allowing elevation of the flap based on the medial perforator artery and a single superficial vein.]
Although preoperative imaging is not mandatory for use of this flap, the integration of computed tomographic angiography and preoperative color duplex ultrasound allows for accurate planning and expeditious raising. Furthermore, the anatomical variability of the superficial branch can be delineated, which can help determine whether the necessary flap dimensions can be adequately perfused on the superficial branch, or may require use of the contralateral side or a flap based on the deep branch.20
The medial (superficial) branch arises most frequently from the superficial circumflex iliac artery after it branches from the femoral artery. The medial perforator penetrates the deep fascia (95 percent) in a well-circumscribed area 4.5 cm lateral and 1.5 cm cephalad to the pubic tubercle. The branch then travels toward the anterior superior iliac spine in the superficial fat layer. The specific course of the superficial branch is ideally marked preoperatively using color duplex ultrasound, allowing for the flap to be centered along this axis. Having a detailed three-dimensional understanding of the course of the superficial branch of the superficial circumflex iliac artery can allow for the lateral placement of the desired flap, which effectively creates a longer pedicle. With the flap marked for elevation, the inferior border is incised and dissection continued to the level of the Scarpa fascia (superficial fascia, smaller superficial fat lobules above and larger deep fat lobules below). The flap is elevated above the Scarpa fascia in a bloodless fashion (Fig. 1). Electrocautery provides an excellent tool for flap elevation, and its safety is supported by previous studies.24 A superficial vein that is separate from the superficial circumflex iliac artery pedicle (caudad) is regularly present and should be included in the flap to allow for eventual anastomosis for the venous egress from the flap. This vein usually communicates with the accompanying veins of the pedicle but is of larger diameter. After the pedicle has been clearly delineated, the superior portion of the flap can be elevated rapidly, allowing for the final dissection of the proximal pedicle. A short period (3 days) of bed rest with hip flexion can be used for wider flaps (8 to 10 cm). Strengths and weaknesses are listed in Table 1, and a case presentation is shown in Figure 2.
Table 1. -
Strengths and Weaknesses of the Superficial Circumflex Iliac Artery Perforator Flap
| Thin fasciocutaneous flap
| Suitable for small to moderate defects
| No sacrifice of major artery
| Well-tolerated donor site
| Rapid flap elevation
| Can be based on deep perforator
| Chimeric flaps
| Short pedicle*
| Variable anatomy†
| Small-diameter vessels
| Upper extremity defects
| Lower extremity defects
*The effective pedicle length can be increased by lateral positioning of the flap in relation to the femoral artery (axial pattern perforators).
†The variable anatomy can be readily addressed by use of preoperative imaging (computed tomographic angiography and duplex ultrasound).
Essential Tips and Tricks: Superficial Circumflex Iliac Artery Perforator Flap
- Prepare with preoperative computed tomographic angiography and color duplex ultrasound. Have a clear understanding of the three-dimensional anatomy (is it the superficial perforator axial pattern and where does it become “superficial”?).
- Position the flap to obtain the necessary pedicle length.
- Elevate the flap with monopolar cautery.
- Include the superficial vein.
Profunda Femoris Artery Perforator Flap
The profunda femoris artery perforator flap was initially described in 2012 by Saad et al. as a new thigh-based perforator flap to provide an additional option in autologous breast reconstruction.25 Subsequent series have demonstrated the utility of this flap in breast reconstruction, and in other regions.26,27 The proposed benefits of this thigh-based flap include the relatively long pedicle with larger diameter vessels and straightforward dissection, producing a moderately large fasciocutaneous flap with limited donor-site morbidity.
Preoperative imaging using computed tomographic angiography greatly improves the ability to plan and execute the elevation of the profunda femoris artery perforator flap.28 [See Video 2 (online), which displays the elevation of the profunda femoris artery perforator flap, based on the first perforator of the profunda femoris artery. Note the abundant volume of fat, making this flap adequate for breast reconstruction.] The course of the available perforators can be delineated (approximately 50 percent septocutaneous), allowing for the harvest of the flap in the supine, frog leg position. Alternatively, the flap can be harvested without imaging in the prone position in a lateral to medial fashion (using the transverse upper gracilis perforators as a bailout option).
The profunda femoris perforators arise from the source artery and supply the posterior skin and soft tissues of the posterior thigh. The course of the selected perforator can be either septocutaneous (between the gracilis and adductor magnus or the adductor magnus and semitendinosus) or intramuscular (through the adductor magnus). More lateral perforators can be present and used, but will increase the difficulty of dissection in the supine position. The location of the selected perforator is verified preoperatively with handheld Doppler or color duplex ultrasound. The flap is marked with the patient in the standing position with the flap extending from the gracilis muscle medially to the lateral extent of the gluteal fold. The flap is marked 1 cm below the gluteal fold extending 7 to 8 cm distally, depending on the required tissue and laxity of the posterior thigh skin. The procedure is then performed with the patient in the frog leg supine position. The flap is elevated using electrocautery including the gracilis muscle fascia from medial to lateral. The perforators from the medial femoral circumflex system can be preserved until the profunda perforator is verified. The fascia over the adductor magnus is incised and dissection is continued laterally until the planned perforator is identified. Frequently, two or more distal perforators can be identified that join to form the identified profunda perforator. The perforator is then dissected through the adductor muscle or between the muscles. This dissection generally benefits from the creation of an additional visualization window between the gracilis muscle and the adductor magnus, and occasionally between the adductor longus and the gracilis muscle. When the perforator is fully dissected, the lateral portion of the flap can be elevated rapidly in a suprafascial plane (Fig. 3). Strengths and weaknesses are listed in Table 2, and a case application is shown in Figure 4.
Table 2. -
Strengths and Weaknesses of the Profunda Femoris Artery Perforator Flap
| Adequate dimensions for most autologous breast reconstruction
| Adequate length pedicle (7–10 cm)
| Adequate vessel diameter (2–2.5 mm)
| No sacrifice of major artery
| Well-tolerated donor site
| Flap dimensions constrained
| Donor-site closure challenging
| Risk of donor-site dehiscence
| Dissection can be tedious
| Breast reconstruction
Essential Tips and Tricks: Profunda Femoris Artery Perforator Flap
- Prepare with preoperative computed tomographic angiography and color duplex ultrasound/handheld Doppler. Have a clear understanding of the preferred medial profunda artery perforator.
- Preserve the medial femoral circumflex perforator until the profunda perforator is identified.
- Elevate the flap with monopolar cautery.
- Ensure adequate visualization with dissection between the medial thigh muscles.
- Elevate the lateral portion of the flap in the suprafascial plane to minimize the risk of injury to the posterior cutaneous nerve of the thigh.
Thin Anterolateral Thigh Perforator Flap
The anterolateral thigh free flap was initially described by Song et al. and Baek as a new thigh-based perforator flap to provide a large fasciocutaneous flaps.29,30 Despite an excellent anatomical description of the flap and its potential uses, the anterolateral thigh flap was slow to be adopted, largely because of the variability of the anatomy and the thickness of the flap in patients with a larger body mass index. Thirty-five years later, the anterolateral thigh flap is one of the standard techniques available to the reconstructive microsurgeon, but is not commonly used to its maximal potential as a thin fasciocutaneous flap based specifically on the most desirable perforator. The shortcomings of the “standard” anterolateral thigh flap can be obviated or limited by more thorough preoperative planning and modified flap elevation.31–33 The superthin, freestyle anterolateral thigh flap demonstrates utility for reconstruction of soft-tissue defects in all regions of the body, but can also be designed as a chimeric flap to include muscle to address dead-space issues.34 The proposed benefits of this revised approach to the elevation of this thigh-based flap are the long potential pedicle with larger diameter vessels and straightforward dissection, producing a large, thin skin flap with limited donor-site morbidity.
Preoperative imaging using computed tomographic angiography and color duplex ultrasound greatly improves the ability to plan and execute the elevation of the thin, freestyle anterolateral thigh flap.31,32 [See Video 3 (online), which displays the anterolateral thigh flap being elevated on the superficial fascial plane (superthin). The cold and hot zones are marked before surgery, facilitating the elevation.]
The course of the available perforators can be delineated, allowing for the selection of the most appropriate perforator with the least amount of intramuscular dissection. Moreover, understanding of the pattern of the extrafascial course of the perforator permits designing “cold and hot zones” of the flap and facilitates rapid, safe, superthin (superficial fascial plane) flap harvest.
The descending branch of the lateral circumflex femoral artery is the source vessel of the anterolateral thigh flap, traveling between the rectus femoris and the vastus lateralis muscles. One can select the perforator with an easier dissection course using computed tomographic angiography. Using color duplex ultrasound will further provide detailed information of the perforator course after it pierces the deep fascia, thus minimizing the chance for perforator injury during elevation in the hot zone (classically, 2 to 3 cm around the perforator). The dimensions of the required flap can then be marked surrounding the perforator. Primary closure is frequently possible with flaps up to 8 to 10 cm in width, but skin graft reconstruction of the donor site for larger flaps raised in the superficial fascial plane is less deforming because of the shallower fat recipient site. The flap is elevated using electrocautery at the level of the superficial fascia very rapidly through the cold zone. The direction of dissection is toward the hot zone and, once that is reached, one should be meticulous in identifying the perforator and the branches. After perforator identification, it is traced through the longitudinally opened deep fascia, allowing for further dissection of the pedicle toward the source vessel (Fig. 5). The length of the pedicle can be tailored to the anatomical requirements of the recipient site, in terms of both length and vessel diameter. Specifically, perforator-to-perforator anastomosis drastically shortens the required dissection because of the need for a shorter pedicle with smaller diameter vessels. However, a very long pedicle with large-diameter vessels remains available as required. Perforator dissection proceeds through the vastus lateralis or in the intramuscular septum. The femoral nerve branches must be preserved if dissection proceeds to this depth. The fascia lata is closed following flap harvest. Strengths and weaknesses are listed in Table 3, and a case is demonstrated in Figure 6.
Table 3. -
Strengths and Weaknesses of the Thin, Freestyle Anterolateral Thigh Flap
| Large fasciocutaneous flap
| Adequate length pedicle (7–10 cm)
| Adequate vessel diameter (2–3 mm)
| Flap thickness can be adjusted
| No sacrifice of major artery
| Well-tolerated donor site
| Dissection can be tedious
| Possible marginal necrosis
| Risk of femoral nerve injury (rare)
| Head and neck reconstruction
| Extremity reconstruction
Essential Tips and Tricks: Thin Anterolateral Thigh Flap
- Prepare with preoperative computed tomographic angiography and color duplex ultrasound. Design flap around most “favorable” perforator.
- Match flap elevation with recipient-site goal. Suprafascial elevation is suitable and appropriate for most defects.
- Elevate the flap with monopolar cautery.
- Match flap pedicle dissection to the recipient site vessels; consider perforator-to-perforator anastomosis.
Tips in microsurgery
The most noteworthy innovation in preoperative planning is the ability to image perforators in relationship to the overlying skin. Using computed tomographic angiography allows patient-specific imaging of the perforator location, pathway, distribution, and caliber when designing a perforator flap.35 This is especially true for flaps that have a substantial amount of subcutaneous fat, permitting clear visualization of the perforator entering the flap and showing the intramuscular pathway of the perforator before penetrating the deep fascia. Preoperative computed tomographic angiography demonstrated significant reduction in flap harvest time, hospital stay, and complications.36–38 It also reveals the vascular status of the entire extremity, which can be useful when selecting recipient vessels in patients with peripheral artery disease or previous trauma.39 When peripheral artery disease is noted on the computed tomographic angiography scan, maximization of flow through vascular intervention with angioplasties and bypass may help increase the flow to the flap.40,41
Recent reports demonstrate that using color duplex ultrasound to map perforators is also effective preoperatively.42–44 Although highly user dependent, color duplex imaging permits the identification of additional information, including caliber, course, and flow velocity of essential perforators and any source vessel. It also avoids radiation exposure, is rapid and convenient, and is a simpler examination for perforator localization. Detecting flow velocities and perforator diameter may play a role in not only identifying ideal perforators but also monitoring the flap.40,41
Other methods to map dominant perforators, such as indocyanine green angiography and infrared thermal imaging, have been reported to be helpful. However, these methods are limited and will not delineate the specific pathway of the perforator.45,46
The core principles of intraoperative microsurgical technique remain the same: elevation, pedicle dissection, recipient preparation, microanastomosis, and flap inset. New tips and technique continue to improve efficiency and safety. We first identify/isolate the recipient vessel followed by wound/defect preparation (with the exception to cancer resection). Identifying the recipient vessel related to the defect allows an accurate estimate of the required pedicle length. Also, confirming the recipient condition avoids unforeseen situations, especially in patients with comorbidities such as hypertension, diabetes, and peripheral artery disease. The use of perforators as the recipient vessels has been a revolutionary change in approach to microvascular reconstruction. This saves time both in recipient dissection (which required the search for major vessels, frequently deep and spatially separated from the defect) and the dissection of the pedicle (which, to reach the perforator recipient, can now be much shorter).9,13,14,47 The perforator-to-perforator approach is feasible only when the flap requires a moderate flow volume. In cases where a large-volume flap is required, such as a composite or chimeric flap, one should use large vessels. The perforator-to-perforator approach is also very useful in patients that require preservation of distal flow, such as in the ischemic diabetic foot.40,41 In patients with ischemic conditions, collateral vessels increase in number and in caliber as the ischemia progresses, making the perforator a viable option as a recipient.39
Meticulous dissection of the pedicle during flap elevation requires the coagulation of numerous small branches. Ideal vessel dissection maximizes bleeding control through coagulation while minimizing vessel damage. Contrary to common belief, monopolar diathermy on cutting mode and bipolar diathermy are both safe for dissecting the pedicle vessels when used appropriately. Suh et al. demonstrated no significant difference in relation to flap survival, vessel spasm, and perfusion/velocity to the flap using monopolar and bipolar cautery. Furthermore, the extent of histologic damage may be less in monopolar diathermy on cutting mode at 40 W and blend mode.24 [See Video 4 (online), which shows using monopolar diathermy on cutting mode to provide efficient management of small vessels during pedicle dissection; however, this technique requires practice.]
Microanastomosis has become more efficient using coupling devices (primarily venous anastomosis) and shows significantly shorter time required for anastomosis while having similar or better patency rates.48,49 However, there may be a higher incidence of thrombosis when using smaller (1.5 mm) coupling devices compared to other, larger couplers.50 Further development in the field of microanastomotic devices may impact vessel coaptation, but the importance of basic microsurgical skills will remain essential and cannot be overemphasized.
Often, because of anesthesia, perfusion to the flap may be reduced. The safety of vasopressors in free tissue transfer remains controversial despite multiple experimental and clinical studies demonstrating increased flap blood flow with the use of various vasoactive agents without detrimental effects on flap survival.51–56 Evidence shows that norepinephrine and dobutamine may be ideal choices to increase the flow to the flap without excessive peripheral vasoconstriction. We request elevation of the blood pressure using dobutamine by the anesthesiologist when strong pulsatile flow is not observed in the recipient artery during microanastomosis. The use of prostaglandin E1 may also help increase flow to the flap. A report by Jin et al. shows that the maximal blood flow velocity was significantly increased at 30 minutes after lipo–prostaglandin E1 administration compared to the level before lipo–prostaglandin E1 administration without any related complications.57
Following anastomosis, intraoperative perfusion assessment can be useful in predicting flap survival, especially at the distal margins.58 This principle is frequently used to assess the viability of mastectomy skin flaps. Clinical examination may be inadequate to determine the extent of well-perfused tissue, with a 10 to 30 percent necrosis rate of mastectomy flaps being reported.58–60 A review by Khavanin et al. shows that fluorescein, indocyanine green, and measuring infrared light to assess intraoperative perfusion of the flap may be promising, but further study is warranted.61
Clinical observation remains one of the most efficient and reliable ways of monitoring the flap postoperatively. However, new modalities such as near-infrared spectroscopy provide highly localized measurements of tissue oxygenation, demonstrating specific and sensitive detection of postoperative vascular compromise in free tissue transfer, thus identifying impending complications earlier than alternative modalities.61–63 The duplex scan, by measuring the flow velocity, also allows early detection of undesirable changes in the flap.
In the lower extremity, when the patient starts ambulation after reconstruction, limb swelling, transient congestion, and edema are commonly caused by gravity and mobilization, resulting in hydrostatic pressure putting a strain on the flap. Conditioning with a dangling protocol before ambulation has been shown to increase oxygenation and hemoglobin concentration in the flap.64 However, this approach may prolong hospitalization, and a new approach of early compression with a 30-mmHg pressure garment after flap surgery demonstrates reduced edema without impacting the perfusion of the perforator flap, thus stabilizing the flap and leading to faster ambulation.
The future of microsurgery is now shifting toward a new frontier using extensive preoperative examination, allowing us to understand and use anatomy in detail. The concept is moving toward smaller microsurgery (supermicrosurgery) based on better understanding the angiosome territory of perforators (perforasomes) and implementing approaches such as perforator-to-perforator anastomosis, leading to true freestyle reconstruction. Finally, we have the ability to customize the flap to the patient’s need using superthin flaps, chimeric flaps, and other combinations.
Plastic surgery has a long history of innovation to expand the conditions we can treat and the methods at our disposal to care for our patients. None of this occurs de novo, as we continue to add to the outstanding contributions of our colleagues. We truly stand on the shoulders of giants. Innovation continues with freestyle free flaps as we enter another paradigm shift in microvascular reconstructive surgery, relying on a better understanding of anatomy and physiology—the patient-specific customized approach. We have discussed three “new” flaps that demonstrate the patient-specific approach and we have covered new tips to improve microsurgical efficiency. The aim of this article was to address new knowledge by providing practical and practice-changing information. We hope this CME article will continue to ignite new ideas and help one to think out of the box, as the innovation will continue as part of our unique specialty.
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Coding perspective provided by Dr. Raymond Janevicius is intended to provide coding guidance.
- 15756 Free muscle or myocutaneous flap with microvascular anastomosis
- 15757 Free skin flap with microvascular anastomosis
- 15758 Free fascial flap with microvascular anastomosis
- 19364 Breast reconstruction with free flap
- The flaps described are free skin flaps and are reported with code 15757.
- If a skin flap incorporates fascia, code 15757 is reported. This is not considered a “free fascial flap” by Current Procedural Terminology definitions. Code 15758 (Free fascial flap with microvascular anastomosis) is used to report free fascial flaps such as the temporalis fascia flap, where skin is not incorporated into the flap.
- These codes are used to report the flap procedures only. Primary ablative procedures, for example, are reported separately.
- If a free flap is used for breast reconstruction, code 19364 is used.
- Code 19364 is used regardless of the specific free flap used in breast reconstruction.
- The method of microanastomosis (coupler versus suture) does not have an impact on the free flap code selected, nor is it reported separately.
- Use of the operating microscope is inherent in the free flap codes. It would be inappropriate to report code 69990 in addition to the free flap codes.
CODING PRINCIPLES: Free flap codes include the following components, which are not reported separately:
- Harvest of the free flap
- Donor vessel dissection
- Straightforward closure of donor site
- Dissection of recipient vessels
- Microvascular anastomosis of one artery and two veins
- Use of the operating microscope
- Inset of flap (including breast contouring with code 19364)
- Flap monitoring intraoperatively and postoperatively
- Ninety days of postoperative care
Additional procedures that are reported separately include the following:
- Primary ablative procedures
- Repair of injured structures in trauma
- Skin graft or skin flap closure of donor site
- Vein grafts
Disclosure: Dr. Janevicius ([email protected]) is the president of JCC, a firm specializing in coding consulting services for surgeons, government agencies, the insurance industry, attorneys, and other entities.