Royer E, Rausky J, Binder J-P, May P, Virzi D, Revol M
Université Paris Diderot, Sorbonne Paris Cité, Paris, France; Service de chirurgie plastique, hôpital Saint-Louis, AP-HP, 1, avenue Claude-Vellefaux, 75010 Paris, France.
Université Paris Diderot, Sorbonne Paris Cité, Paris, France; Service de chirurgie plastique, hôpital Saint-Louis, AP-HP, 1, avenue Claude-Vellefaux, 75010 Paris, France.
Ann Chir Plast Esthet. 2014 Feb;59(1):70-5. doi: 10.1016/j.anplas.2013.04.002. Epub 2013 Jul 26.
After Koshima and Soeda first described perforator flaps in 1988, Wei has improved the technique by describing the "free style perforator flap". These flaps have the advantage of being performed on all skin perforators and in reducing donor site morbidity. The disadvantage, however is that the size of their angiosome is not defined and the evaluation of their relay on the experience of the surgeon. An evaluation of the size of an angiosome by conducting intraoperative angiography is proposed. Intraoperative angiography is performed after injection of indocyanine green. Stimulation of the indocyanine green by infrared causes the emission of fluorescent radiation. This fluorescence is then detected by a specific camera that displays real-time visualization of the skin's perfusion. We present the case of a 39-year-old patient who had an open tibial pilon fracture, for which we performed a pedicled propeller flap based on a posterior tibial perforator. Angiography was used to determine accurately the optimal skin perfusion of the propeller flap, which was based on a perforator from the posterior tibial artery. Angiography identified several levels of skin perfusion with a high fluorescence, intermediate and absent. The non-vascularized part of the skin paddle was resected. Given the unreliability of this technique, hypoperfused area was retained. Debridment of this area, however was necessary at day 5 postoperative with repositionning of the flap. Indocyanine green angiography may be a useful decision-making tool for intraoperative surgeon. It allows to adjust the size of the propeller flap's skin paddle to it angiosome. However, this evaluation method needs to be improved with the introduction of a quantitative threshold.
1988年小岛和添田首次描述穿支皮瓣后，Wei通过描述“自由式穿支皮瓣”改进了该技术。这些皮瓣的优点是可用于所有皮肤穿支，并能降低供区发病率。然而，其缺点是血管体的大小未明确界定，对其评估依赖于外科医生的经验。本文提出通过术中血管造影评估血管体大小。术中血管造影在注射吲哚菁绿后进行。红外光对吲哚菁绿的激发会导致荧光辐射的发射。然后通过特定相机检测这种荧光，该相机可实时显示皮肤灌注情况。我们报告一例39岁开放性胫骨平台骨折患者的病例，对此我们采用了基于胫后穿支的带蒂螺旋桨皮瓣。血管造影用于准确确定基于胫后动脉穿支的螺旋桨皮瓣的最佳皮肤灌注情况。血管造影确定了几个皮肤灌注水平，包括高荧光、中等荧光和无荧光。皮瓣非血管化部分被切除。鉴于该技术的不可靠性，灌注不足区域被保留。然而，术后第5天有必要对该区域进行清创并重新调整皮瓣位置。吲哚菁绿血管造影可能是术中外科医生有用的决策工具。它可以根据血管体调整螺旋桨皮瓣皮瓣的大小。然而，这种评估方法需要引入定量阈值来改进。
