Step-by-step guide to ultrasound-based design of alt flaps by the microsurgeon – Basic and advanced applications and device settings. Issue 6 (June 2020)

• Record Type: Journal Article
• Authors: Kehrer, Andreas; Sachanadani, Neil S.; da Silva, Natascha Platz Batista; Lonic, Daniel; Heidekrueger, Paul; Taeger, Christian D.; Klein, Silvan; Jung, Ernst Michael; Prantl, Lukas; Hong, Joon-Pio
• Is Part Of: Journal of plastic, reconstructive & aesthetic surgery. Volume 73:Issue 6(2020)
• Page Start: 1081
• Page End: 1090
• Publication Date: 2020-06
• Subjects: Plastic surgery -- Reconstructive surgery -- ALT flap -- Perforator -- Perforator mapping -- Ultrasound -- Sonography -- Angiography -- Color Duplex ultrasound -- Color coded -- Duplex sonography -- Power Doppler -- Flap design -- Suprafascial harvest -- Thin ALT flap; ALT Anterolateral Thigh Flap -- AMT Anteromedial Thigh Flap -- ASIS anterior superior iliac spine -- DB descending branch (of lateral circumflex fermoral artery) -- DFA deep femoral artery (DFA) -- DSA digital subtraction angiography -- HHD handheld Doppler -- CF Color flow imaging -- CTA Computed Tomographic Angiography -- LCFA lateral circumflex femoral artery -- MRA/MRI Magnetic Resonance Angiography/Imaging -- B mode brightness modulation (two-dimensional greyscale US image display) -- EP emergence point -- EDV end diastolic velocity -- IS intermuscular septum -- US Ultrasound -- VL Vastus lateralis muscle -- RF rectus femoris muscle -- VI Vastus intermedius muscle -- IMS intermuscular septum -- OR operating room -- PSV Peak systolic velocity (cm/second) -- PDU Power Doppler ultrasound -- PAP Profunda Artery Perforator flap -- PRF Pulse Repetition Frequency/Scale -- TFL Tensor-fascia-lata -- WF Wall filter (WF) -- nil nihil (nothing, zero) -- rt right -- lt left -- m male -- inf inferior; Surgery, Plastic -- Great Britain -- Periodicals; Reconstructive Surgical Procedures -- Periodicals; Surgery, Plastic -- Great Britain -- Periodicals; 617.9505
• DOI: 10.1016/j.bjps.2019.11.035
• Languages: English
• ISSNs: 1748-6815

Abstract

Summary: Background: The anterolateral thigh (ALT) perforator flap is a popular reconstructive tissue transfer. Consistent with the "hot/cold zone" concept for rapid dissection and thin flap harvest, reliable preoperative perforator mapping is mandatory. Color-coded duplex sonography (CCDS) has been shown to have the highest pooled sensitivity and positive predictive value to identify ALT perforating vessels. By reviewing this guide, the reader should learn: 1. Probe selection and basic/advanced device settings 2. Interpreting tissue morphology 3. Structured mapping approach 4. Pedicle position planning 5. Safe flap design 6. Assess subcutaneous course and flap's thickness for subfascial/epifascial/suprafascial harvest 7. Implement perforators identified into a tailor-made flap design including chimeric flaps. Methods: Experiences with ultrasound-guided flap design gained from 125 ALT perforator flap free tissue transfers performed in two reconstructive centers was the basis of our guide. Our structured method comprises standardized markings, patient positioning, and simple ergonomics. Basic and advanced CCDS settings, selection, and conventional probe guidance are outlined for the microsurgeon. Results: Linear multifrequency probes (6–15 MHz) were used. Best preset programs were breast, thyroid, and vascular. Favorable device properties were depth focused to 2–5 cm, pulse repetition frequency (PRF/Scale) set low to 0.5–1.5 kHz/3–10 cm/s, color gain high, and wall filter (WF) low/off (< 50 Hz). Additional parameters were discussed. A 100% concordance rate was seen comparing preoperative perforator visualization with CCDS and intraoperative findings. Detailed picture and video material were demonstrated. Conclusion: CCDS is a powerful tool for preoperative perforator mapping in perforator flaps such as the ALT.