The pedicled inferior paraumbilical perforator (I-PUP) flap for a volar wrist defect: a reconstructive solution across the ages.

Full-thickness soft-tissue defects overlying vital forearm or wrist structures frequently result from acute trauma or tumor ablation. These defects present reconstructive challenges, due to the thin pliable skin to be replaced and the non-graftable bed beneath. The authors discuss a case of a renal-transplant patient with a volar wrist SCC, in whom local vascular anatomy deemed microvascular free tissue transfer inappropriate. The authors present a successful novel reconstructive solution; the pedicled inferior paraumbilical perforator flap (I-PUP), a two-staged procedure that incorporates principles of distant flaps--which pre-date microsurgery--combined with techniques and lessons learned in the era of perforator flap surgery.

Rotation mastopexy: an anatomical approach.

The goal of a mastopexy is to restore the shape and volume of the breast after ptosis of the breast. Ptosis occurs commonly in response to aging and breastfeeding. A low nipple position on the breast mound can be corrected by addressing the skin envelope, but maintenance of upper pole fullness and a youthful shape of the breast is the challenge to surgeons. To address this, techniques using local glandular flaps and implants have been suggested. A new technique has been created with regard to a detailed knowledge of the breast gland's vascular anatomy. The lower breast gland is raised as a large vascularized flap and rotated into a pocket beneath the upper pole. The operative procedure is presented together with the experience of the first author with a consecutive series of 25 patients.

Image-guided, stereotactic perforator flap surgery: a prospective comparison of current techniques and review of the literature.

BACKGROUND: Image-guided stereotaxy is a recent advancement in imaging technology, allowing computer guidance to aid surgical planning and accuracy. Despite the use of multiple techniques for patient registration in several surgical specialities, only fiducial marker registration has been described for use in soft tissue reconstructive surgery. The current study comprises an evaluation of the current techniques available for this purpose. METHODS: A cohort of nine consecutive patients planned for elective free flaps were recruited, with the first five patients (four for the abdominal wall and one anterolateral thigh donor site) undergoing fiducial marker registration with a variable number of fiducial markers in order to determine the optimal number of fiducial markers to be used. Four subsequent patients undergoing perforator flap surgery underwent registration using three available registration modalities: fiducial marker registration, surface matching pointer/landmark and surface matching laser registration. RESULTS: For the abdominal wall, registration was not able to be achieved with five fiducial markers, and was successfully achieved in all cases with either six or seven fiducial markers. For the anterolateral thigh, registration was achieved with either nine or ten markers. The four patients who also underwent surface-landmark registration and 'Z-touch' laser surface matching registration all failed the registration process. CONCLUSION: Stereotactic navigation is a useful adjunct to the preoperative imaging of perforator flaps. Fiducial marker registration was able to be achieved in all cases, can be successfully achieved with a low and predictable number of fiducial markers, is highly accurate, and was the only reliable registration process in our experience.

The cutaneous course of deep inferior epigastric perforators: implications for flap thinning.

BACKGROUND: The deep inferior epigastric artery (DIEA) perforator flap is frequently used for autologous breast reconstruction following mastectomy. Thinning of the flap is often performed to debulk the flap of excess fatty tissue, such as in partial mastectomy defects. Thinning may disrupt the blood supply to the flap and compromise viability, however adequate guidelines for thinning are lacking from the literature. METHODS: Clinical and anatomical studies were concurrently undertaken to explore the cutaneous course of perforators as a guide to flap thinning. Twenty consecutive patients undergoing DIEA perforator flap breast reconstruction underwent preoperative computerised tomography angiography (CTA), and a cadaveric study was also undertaken, in which six fresh, whole abdominal walls underwent CTA. All perforators greater than 2 mm were analysed for their cutaneous course. RESULTS: In all cases, perforators emerged from the anterior rectus sheath and traversed an oblique, but direct course through the deep layer of adipose tissue, before reaching Scarpa's fascia. Branching of perforators occurred in two planes of the superficial adipose layer: just superficial to Scarpa's fascia (the fascial plexus) and in the subdermal plexus. CONCLUSION: Thinning of DIEA perforator flaps can only be performed safely deep to Scarpa's fascia. Thinning performed superficial to Scarpa's fascia threatens the intrinsic blood supply to the flap.

Stereotactic image-guided navigation in the preoperative imaging of perforators for DIEP flap breast reconstruction.

Preoperative imaging is sought prior to DIEA (Deep Inferior Epigastric Artery) perforator flaps due to the potential for maximizing operative success and minimizing operative complications. Recent advances include the use of computed tomography (CT) angiography (CTA) and magnetic resonance angiography. Image-guided stereotactic surgery is a recent technique that has been used with success in several fields of surgery. The variability of perforator anatomy makes DIEA perforator flap surgery a suitable candidate for such technology, but as yet this has not been described. A study was undertaken to determine the feasibility of CT-guided stereotaxy technique in DIEA perforator flap surgery and to compare findings with both conventional CTA and operative findings. Five consecutive patients planned for an elective DIEA perforator flap were recruited. Each patient underwent preoperative imaging of the anterior abdominal wall vasculature with both conventional CTA and CT-guided stereotactic imaging. Imaging findings were compared to operative findings. In all cases, all the major perforators were accurately localized with stereotactic imaging and with conventional CTA. Stereotactic navigation demonstrated a slightly better (nonsignificant) correlation with perforator location than conventional CTA. As such, CT-guided stereotactic imaging is an accurate method for the preoperative planning of DIEA perforator flaps, providing additional and potentially more accurate data to conventional CTA. With no additional scanning required, the method described in this paper allows the combined use of both methods for preoperative planning.

Establishing the case for CT angiography in the preoperative imaging of abdominal wall perforators.

Preoperative imaging of the donor site vasculature for deep inferior epigastric artery (DIEA) perforator flaps and other abdominal wall reconstructive flaps has become more commonplace. Abdominal wall computed tomography angiography (CTA) has been described as the most accurate and reproducible modality available for demonstrating the location, size, and course of individual perforators. We drew on our experience of 75 consecutive patients planned for DIEA-based flap surgery undertaking CTA at a single institution. Seven of these cases have been reported to highlight the utility of CTA for preoperative planning, emphasizing the unique information supplied by CTA that may influence operative outcome. Among all cases that underwent preoperative imaging with CTA, there was 100% flap survival, with no partial or complete flap necrosis. We found that in three of the cases described, the choice of operation was necessarily selected based on CTA findings (DIEA perforator flap, transverse rectus abdominis myocutaneous flap, and superficial superior epigastric artery flap). In addition, three cases demonstrate that CTA findings may dictate the decision to operate at all, and one case demonstrates the utility of CTA for evaluating the entire abdominal contents for comorbid conditions. Our experience with CTA for abdominal wall perforator mapping has been highly beneficial. CTA may guide operative technique and improve perforator selection in uncomplicated cases, and in difficult cases it can guide the most appropriate operation or indeed if an operation is appropriate at all. This is particularly the case in the setting of comorbidities or previous abdominal surgery.

Refining the course of the thoracolumbar nerves: a new understanding of the innervation of the anterior abdominal wall.

Previous descriptions of the thoracolumbar spinal nerves innervating the anterior abdominal wall have been inconsistent. With modern surgical and anesthetic techniques that involve or may damage these nerves, an improved understanding of the precise course and variability of this anatomy has become increasingly important. The course of the nerves of the anterior abdominal is described based on a thorough cadaveric study and review of the literature. Twenty human cadaveric hemi-abdominal walls were dissected to map the course of the nerves of the anterior abdominal wall. Dissection included a comprehensive tracing of nerves and their branches from their origins in five specimens. The branching pattern and course of all nerves identified were described. All thoracolumbar nerves that innervate the anterior abdominal wall were found to travel as multiple mixed segmental nerves, which branch and communicate widely within the transversus abdominis plane (TAP). This communication may occur at multiple locations, including large branch communications anterolaterally (intercostal plexus), and in plexuses that run with the deep circumflex iliac artery (DCIA) (TAP plexus) and the deep inferior epigastric artery (DIEA) (rectus sheath plexus). Rectus abdominis muscle is innervated by segments T6-L1, with a constant branch from L1. The umbilicus is always innervated by a branch of T10. As such, identification or damage to individual nerves in the TAP or within rectus sheath is unlikely to involve single segmental nerves. An understanding of this anatomy may contribute to explaining clinical outcomes and preventing complications, following TAP blocks for anesthesia and DIEA perforator flaps for breast reconstruction.

Developments in perforator imaging for the anterolateral thigh flap: CT angiography and CT-guided stereotaxy.

INTRODUCTION: The anterolateral thigh flap is an increasingly popular reconstructive option despite uncertainty in its perforator anatomy. Perforators are not always present, vary in size and intramuscular course, and have variable cutaneous courses and supply. As such, preoperative imaging has become favored. METHODS: The current study describes the preliminary use of two new modalities for preoperative imaging: computed tomography (CT) Angiography and CT-guided stereotaxy. These have been utilized in the preoperative imaging of two patients undergoing ALT flap reconstruction. Each patient underwent each of these techniques combined with Doppler ultrasound, the previous standard modality. The size, location, and course of perforators were explored and compared with operative findings. RESULTS: Both techniques are technically feasible, highly accurate, and provide more information to the surgeon than ultrasound. CONCLUSION: CT Angiography and CT-guided stereotaxy are useful adjuncts to Doppler ultrasound for imaging perforators prior to ALT flaps. A larger study is suggested to quantify the accuracy of these techniques.

Reviewing the vascular supply of the anterior abdominal wall: redefining anatomy for increasingly refined surgery.

The abdominal wall integument is becoming the standard donor tissue for postmastectomy breast reconstruction, with its vascular supply of key importance to the reconstructive surgeon. Refinements in tissue transfer, from pedicled to free flaps and musculocutaneous to perforator flaps, have required increasing understanding of finer levels of this vascular anatomy. The widespread utilization of the deep inferior epigastric artery (DIEA) perforator flap, particularly for breast reconstruction, has rekindled clinical interest in further levels of anatomical detail, in particular the location and course of the musculocutaneous perforators of the DIEA. Advances in operative techniques, and anatomical and imaging technologies, have facilitated an increase in this understanding. The current review comprises an appraisal of both the anatomical and clinical literature, with a view to highlighting the key anatomical features of the abdominal wall vasculature as related to reconstructive flaps.

The lymphatics of the skin filled by a dermal backflow: an observation in a scarred cadaver leg.

There have been few photographic studies done on lymphatics of human skin with previous images obtained by indirect dye injection into the dermis. We have developed a direct injection technique for investigating the lymphatic system in human adult cadavers and used this to investigate superficial lymphatics of the legs in a fresh human cadaver. We found an unusual observation in a skin graft scarred leg when the radio-opaque mixture injected into a lymph collecting vessel in the dorsal foot filled the skin lymphatics in the mid-lateral pretibial region. Further radiological investigation revealed that the dermal back flow was associated with a blockage of the lymph collecting vessel within the skin graft scar. We also found tracer transport through a circuitous pathway from the blocked collecting vessel to an adjacent intact collecting vessel. The transilluminated image of the skin demonstrated a three dimensional polygon of lymph capillaries and precollecting lymphatics in the dermis.

Aplasia cutis congenita of the scalp, the skull, and the dura.

A newborn baby boy presented with a full thickness defect of the scalp, skull, and dura measuring 6 x 7 cm caused by aplasia cutis congenita. Full thickness loss is extremely rare and to our knowledge this case is the twenty-first reported. It has an established mortality of up to 55%. An encephalocele forced us to do an emergency operation with a single large scalp flap based on the supratrochlear and superficial temporal arteries. After revision the child is now 9 months old and progressing well. There are several ways to treat these rare and delicate cases.

The developing neurovascular anatomy of the embryo: a technique of simultaneous evaluation using fluorescent labeling, confocal microscopy, and three-dimensional reconstruction.

The close spatial relationship between peripheral nerves and blood vessels in the adult is well known. However, evidence supporting the congruent development of these structures in embryos remains anecdotal. Neurovascular relationships also have been shown to be conserved in other vertebrates. This homology suggests that either peripheral nerves or blood vessels, or both, might have fundamental morphogenetic roles during embryologic development. Both peripheral nerves and blood vessels have been independently implicated as etiologic agents in the pathogenesis of congenital disabilities, and several congenital anomalies fit their distribution patterns. This article presents a technique for the simultaneous visualization of peripheral nerves and blood vessels at different stages in the developing embryo. The forelimbs of 310 quail embryos were dissected over a 1-year period. Peripheral nerves were labeled with the neural crest and axon antibody, HNK-1, followed by fluorescein-conjugated secondary antibodies. Blood vessels were labeled by a perfusion technique using the fluorescent dye, dioctadecyl-tetramethylindocarbocyanine. Specimens were processed and imaged in whole-mount with confocal microscopy, and images were reconstructed using three-dimensional modeling software. Both nerves and blood vessels seem to undergo a highly stereotypic sequence of development in the embryonic quail forelimb. Furthermore, the existence of a close spatial relationship between nerves and blood vessels suggests either a high degree of developmental interdependence or shared patterning mechanisms. This technique permits further evaluation of the possible role peripheral nerves and blood vessels might play in the pathogenesis of congenital disabilities and provides a starting point for further studies aimed at elucidating the means by which peripheral nerves and blood vessels are patterned in the forelimb of the avian embryo.

The angiosome concept applied to arteriovenous malformations of the head and neck.

Arteriovenous malformations remain a difficult clinical problem. There is very little understanding of the underlying pathogenesis of these lesions, and therapy frequently involves considerable risks with suboptimal outcomes. Recently, a comprehensive description of the angiosomes of the head and neck was completed in the authors' unit. It was noticed that the location of several clinically observed arteriovenous malformations in the head and neck seemed to correspond to the anatomic location of the choke anastomotic zones linking the angiosomes. Therefore, selective clinical angiograms were compared with those from the authors' previously performed fresh cadaver injection studies, in which they defined the angiosomes of the head and neck. In each patient, the location of the arteriovenous malformation corresponded directly to the choke vessel anastomotic zone linking two or more adjacent angiosomes. Clinical and pathologic ramifications of this observation are discussed.

A piecewise-homogeneous Markov chain process of lung transplantation.

BACKGROUND: Markov and semi-Markov models are increasingly used in clinical and public health epidemiology to represent disease processes. We present a Markov model of events following lung transplantation as a case study in clinical epidemiology. METHODS: A five-state discrete-time Markov model with two-way transitions between acute event states is applied to the analysis of 356 lung transplant patients. A two-state continuous time Markov model for chronic disease onset is fitted. Values of transition parameters are estimated by maximum likelihood using numerical methods. RESULTS: Accurate estimates of acute and chonic event rates, and survival probabilities are calculated from transition probabilities. Costs attributed to different acute and chronic states are calculated. CONCLUSIONS: Transition models provide a useful and flexible representation of acute and chronic events and can be used to explore the economic impact of changes in therapy.

The angiosomes of the head and neck: anatomic study and clinical applications.

The angiosome concept was introduced over a decade ago by Taylor and Palmer, whereby the body was considered to be composed anatomically of multiple three-dimensional composite blocks of tissue supplied by particular source arteries. Since then, detailed studies of the forearm and leg have been examined by Taylor and his coworkers. This study focuses on another region--the head and neck. Six fresh head and neck cadaver specimens were examined after infusion with a radio-opaque lead oxide mixture and correlated with over 24 previous body studies. The vascular anatomy of the skin, superficial musculoaponeurotic system (SMAS), muscles, brain, dura, and bone was examined. Each layer was painstakingly removed, photographed, labeled, and mapped to the respective arteries and veins. A radiologic subtraction technique was used to allow successive layers to be compared. This information was then scanned into a computer, analyzed, color coded, and labeled, thereby producing a three-dimensional study of the head and neck region to identify the respective angiosomes. As in previous detailed examinations of the leg and forearm, the angiosomes were found to be connected usually within tissues, such as muscle, skin, specialized organs or glands, rather than between the tissues. The muscles usually had vessels of two or more angiosomes supplying them and fell into three major groups based on the similarity of their arterial supply. In some areas, the midline anastomoses were rich, especially in the integument of the scalp, forehead, and lips. In other regions, the midline vascular connections were poor, especially in the tongue and palate. No fewer than 13 angiosomes of the head and neck, supplied by the branches of the external carotid, internal carotid, and subclavian arteries, have been defined, mapping their three-dimensional territories in the skin, the deep soft tissues, and the bones. Although most angiosomes spanned between skin and bone, three territories, those of the vertebral, lingual, and ascending pharyngeal vessels, were confined to the deep tissues without cutaneous representation. Finally, this study provides additional data for the surgeon to help plan safer incisions and better reconstructive flap procedures. It also gives information that may help explain the etiology and treatment of head and neck arteriovenous vascular malformations.

Surgical anatomy of the ligamentous attachments in the temple and periorbital regions.

This study documents the anatomy of the deep attachments of the superficial fasciae within the temporal and periorbital regions. A highly organized and consistent three-dimensional connective tissue framework supports the overlying skin and soft tissues in these areas. The regional nerves and vessels display constant and predictable relationships with both the fascial planes and their ligamentous attachments. Knowledge of these relationships allows the surgeon to use the tissue planes and soft-tissue ligaments as intraoperative landmarks for the vital neurovascular structures. This results in improved efficiency and safety for aesthetic procedures in these regions.