The arterial anatomy of skin flaps

Summary Breast reconstruction with DIEP flap is a well-accepted and well-established technique for autologous breast reconstruction. In the past, this reconstructive option was typically offered to a limited group of patients as previous surgeries or low BMI were considered to be an obstacle to the success of the procedure or for the achievement of a satisfactory cosmetic outcome due to the lack of available tissue. Nowadays, this does not correspond to truth anymore and DIEP flaps are performed routinely on slender patients and on women who have undergone previous liposuction or abdominal surgeries. This paper analyzes current surgical options for volume recruitment in patients with scanty abdominal tissue or with abdominal scars and presents our standardized approach for DIEP volume augmentation with the “Calzone style” bipedicled DIEP flap.

Diep Flap Volume Augmentation: Literature Review and “Calzone” Flap Shaping Technique

Background A second dorsal metacarpal artery cutaneous branches flap is often used to repair skin defects in the hand. The location of the cutaneous branch of that artery is very critical for the removal of the flap. In this study, we quantitatively analyzed the origin of the cutaneous branches of the second dorsal metacarpalartery and the distribution characteristics of the radial and ulnar side to provide an anatomical basis for designing a flap. Methods Sixteen upper limb specimens were perfused with latex. Four specimens were infused with ethyl acetate plus plastic, and four specimens were perfused with red latex to create pellucid specimens. The origin, travel paths, and distribution of the cutaneous branches of the second dorsal metacarpal artery were anatomically observed, and we measured the length of the cutaneous branch from the midpoint of the second web space edge. We also measured the diameters and pedicle lengths of the radial and ulnar distributions of cutaneous branches of the second dorsal metacarpal artery. Results The cutaneous branches of the second dorsal metacarpal artery were mainly clustered at three positions, the second cluster point was at 43.9%, the fourth cluster point was at 61.2%, and the fifth cluster point was at 72.1%. The first cluster point was at 30.8% and the sixth cluster point was at 85.6%. The diameter and pedicle length of the sixth cluster point were the largest. There was no significant difference in the distribution of the diameters and pedicle lengths of the cutaneous branch between the radial and ulnar side. The second dorsal metacarpal artery sent out 1-2 cutaneous branches before the tendon joint, and formed a blood vessel anastomosis with other cutaneous branches located further from the tendon joint. The dorsal branch of the radial nerve in the hand extended a nerve branch at the wrist joint and traveled between the cutaneous branches of the second dorsal metacarpal artery to dominate the corresponding skin. Conclusion Three clusters in the distal second dorsal metacarpal artery were selected to be the flap pedicle containing a cutaneous nerve for use in repairing a skin defect in the hand and fingers.

/pdf/anatomical-characteristics-of-cutaneous-branches-extending-1i58peft6f.pdf

Anatomical Characteristics of Cutaneous Branches Extending From the Second Dorsal Metacarpal Artery.

Background and Objective The deep inferior epigastric artery perforator (DIEP) flap was first described by Koshima and Soeda in 1989 and is now well-established as the gold standard in breast reconstruction. Lately, this issue has been explored in the context of head and neck reconstruction, highlighting growing interest in the use of the DIEP flap beyond breast reconstruction, but its usage in other anatomical regions appears elusive. Nevertheless, DIEP flap reconstruction may be a viable choice for complex, three-dimensional head and neck deformities while upholding the criteria of minimal donor site morbidity, according to a recent review. To determine whether the DIEP flap may be used successfully in other types of reconstruction, we conducted a review on the use, applications, and outcomes of the DIEP flap in non-breast reconstruction. This is, as far as we are aware, the first comprehensive analysis of all applications of the DIEP flap other than for breast reconstruction. Methods A literature review was performed using PubMed to include all relevant articles in English or French published up to February 2022. Keywords included “DIEP flap” and “deep inferior epigastric perforator flap”. Key Contents and Findings A total of 1,299 articles were identified with 105 on the use of the DIEP flap in non-breast reconstruction. This suggests increasing recognition of the DIEP flap as a feasible option for reconstruction of most anatomical regions, especially in lower limb and head and neck reconstruction, followed by gynecological reconstruction. The DIEP flap was also utilized in the reconstruction of upper limb, thigh and hip defects. Less commonly, it has been used for penoscrotal, groin, sternal, buttock and abdomen reconstruction. Conclusions The scientific body of evidence showed the robustness and versatility of the DIEP flap in non-breast reconstruction, with its relative pros and cons at different anatomical regions.

The deep inferior epigastric artery perforator flap: a narrative review on its various uses in non-breast reconstruction

The dorsal metacarpal artery flap (DMAF) is irrefutable as an effective way of repairing long finger defects, and hand surgeons might consider using it for long finger reconstruction or degloved injury repair. Unfortunately, the DMAF containing a single dorsal metacarpal artery (DMA) hinders the treatment effect. The sensory restoration of long fingers and the reconstruction of phalangeal joints and tendon grafts are unsolved challenges as well. We reported our experience in reconstructing the index and middle finger by a reverse-island flap with two DMAs and dorsal metacarpal nerves (DMNs) with blood supply. We reviewed ten patients with finger-crush injuries affecting eight index fingers and two middle fingers. Degloving injuries occurred in two patients, and finger amputations occurred in eight others. Two patients received simple flap reconstruction, and eight received finger reconstruction, including seven from abandoned phalangeal joints and tendon grafts of the severed finger and one from the iliac crest bone graft. All patients underwent finger reconstruction by an expanded reverse-island flap consisting of two DMAs and DMNs up to a maximal size of 9 × 8 cm2. Postoperative follow-up evaluation showed a satisfactory appearance and functional recovery of the reconstructed fingers. We posit that the expanded reverse-island flap involving two DMAs and DMNs constitutes a feasible and safe option for restoring a severely damaged index or middle finger, particularly for patients who are unwilling to undergo toe-to-finger transplantation to reconstruct the injured long fingers. 

Clinical application of an expanded reverse-island flap with two dorsal metacarpal arteries and dorsal metacarpal nerves in index- and middle-finger-degloving injury repair and amputation reconstruction.

Flaps Based on the Dorsal Metacarpal Artery.

Plastic surgery is an attractive specialty to medical students. Residency training programs have the luxury of selecting their trainees from the "cream of the crop" from United States medical schools. Because of the steep competition for PGY-1 integrated program positions, the temptation exists for applicants to falsify parts of their applications, particularly those parts that are difficult to verify. Methods A retrospective analysis of the Integrated Plastic Surgery applications from the years (2010-2013) was done. Two reviewers manually and independently handsearched each of the articles in the databases (Medline, Scopus, Clinical trials, Google scholar) additionally, a specialized medical librarian corroborated. A ghost article was defined as the inability to find the listed applicant in the authorship list of the claimed article/abstract/chapter or the inability to find the submitted article. Misrepresentation was defined as a change in authorship order. Data were summarized and analyzed, generalized estimating equations model was used. SAS software, v9.4. Results All 392 applicants were included, 159 (2010-2011), 120 (2011-2012), and 119 (2012-2013). The number of manually reviewed records was 2,124. "Ghost" authorship was found in 234 articles out of 2,124 (11.02%). The overall rate of "Ghost" authorship in applicants to our program was found to be 34.4%, 135 applicants and misrepresentation in 5 cases (1.28%). Conclusions Ghost publications are present in Plastic Surgery applications, its trend is similar through the years, "protective" factors are: first authorship and published peer reviewed abstract/article.

Trends in Academic "Ghost Publications" in Plastic Surgery Residency Applications: A 3-Year Study.

Pre-expanded Deep Inferior Epigastric Perforator Flap

Pre-expanded Internal Mammary Artery Perforator Flap.

BACKGROUND
Microsurgery is conducted on tiny anatomical structures like blood vessels and nerves. Over the past few decades, little has changed in the way plastic surgeons visualize and interact with the microsurgical field. New advances in Augmented Reality (AR) technology present a novel method for microsurgical field visualization. Voice and gesture-based commands can be used in real-time to adjust the size and position of a digital screen. Surgical decision support and/or navigation may also be employed. The authors assess the use of AR in microsurgery.


METHODS
The video feed from a Leica Microsystems OHX surgical microscope was streamed to a Microsoft HoloLens2 AR headset. A fellowship-trained microsurgeon and 3 plastic surgery residents then performed a series of 4 arterial anastomoses on a chicken thigh model using the AR headset, a surgical microscope, a video microscope or "exoscope", and surgical loupes.


RESULTS
The AR headset provided an unhindered view of the microsurgical field and peripheral environment. The subjects remarked on the benefits of having the virtual screen track with head movements. The ability of participants to place the microsurgical field in a tailored comfortable, ergonomic position was also noted. Points of improvement were the low image quality compared to current monitors, image latency, and the lack of depth perception.


CONCLUSION
AR is useful tool that has the potential to improve microsurgical field visualization and the way surgeons interact with surgical monitors. Improvements in screen resolution, latency, and depth of field are needed.

Augmented Reality Microsurgery (ARM) - Proof of Concept for a Novel Approach to Microsurgical Field Visualization in Plastic Surgery.

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