Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy.
Microsurgery. 2024 Jan;44(1):e31129. doi: 10.1002/micr.31129. Epub 2023 Oct 25.
The reported complications' rate of perforator propeller flaps is variably high, but the etiology of distal flap necrosis, potentially linked to vascular insufficiency, is yet to be clarified. Vascular augmentation procedures have been previously described involving an extra anastomosis of a superficial vein, while a perforator-to-perforator supercharging approach has been only sporadically documented in literature. We present a case of perforator-to-perforator vascular supercharging of an extended dorsal intercostal artery perforator (DICAP) propeller flap to provide a salvage option for pedicled flap complicated by venous congestion. A 71-year-old male patient underwent Dermatofibrosarcoma Protuberans resection in the upper back, leading to a 17 × 17 cm defect with bone exposure. A 30 × 9 cm DICAP propeller flap was planned, with the distal third of the flap designed over the adjacent Thoracodorsal artery perforasome, in a conjoined fashion. Considering the small DICAP pedicle caliber and the flap lateral extension, a thoracodorsal artery perforator vein was dissected and included in the distal flap. Once the flap was raised on its main pedicle, the skin paddle turned blue, showing signs of venous insufficiency. Indocyanine green angiography (ICG) showed a viable proximal half of the flap. Hence, after rotating the skin paddle to reach the upper margin of the defect, an additional anastomosis between the perforating thoracodorsal vein and the perforating vein of the dorsal scapular pedicle was performed according to the perforator-to-perforator approach. Doing so, both clinical and ICG examinations showed a well perfused flap, with normal capillary refill. The postoperative course was uneventful, and the patient obtained a good oncological and reconstructive result 4 months postoperatively. The second Vasconez law ("all of the flap will survive except the part that you need") is often encountered in propeller flaps surgery. Our case shows that it is possible to prevent or overcome this problem by planning appropriate vascular augmentation procedures according to the perforator-to-perforator approach, being guided by advanced vascular imaging tools like ICG.
报告的穿支螺旋桨皮瓣并发症发生率较高，但远端皮瓣坏死的病因，可能与血管不足有关，尚未阐明。先前已经描述了血管增强程序，包括浅静脉的额外吻合，而文献中仅零星记录了穿支到穿支的超负荷方法。我们报告了一例扩展的肋间后动脉穿支（DICAP）螺旋桨皮瓣的穿支到穿支血管超负荷，为伴有静脉淤血的带蒂皮瓣提供了一种挽救选择。一名 71 岁男性患者在上背部行皮肤纤维肉瘤切除术，导致 17×17cm 大小的缺损并伴有骨外露。计划使用 30×9cm 的 DICAP 螺旋桨皮瓣，皮瓣的远端三分之一设计在相邻的胸背动脉穿支体上，以联合方式设计。考虑到 DICAP 蒂的小口径和皮瓣的外侧延伸，解剖了一根胸背动脉穿支静脉并包含在远端皮瓣中。当皮瓣在其主要蒂上抬起时，皮瓣的皮肤瓣变成蓝色，显示出静脉不足的迹象。吲哚菁绿血管造影（ICG）显示皮瓣的近端有一半是有活力的。因此，在将皮瓣旋转到达缺损的上缘后，根据穿支到穿支的方法，在穿支胸背静脉和肩胛背动脉穿支静脉之间进行了额外的吻合。这样，临床和 ICG 检查均显示皮瓣血供良好，毛细血管再充盈正常。术后过程顺利，患者在术后 4 个月获得了良好的肿瘤学和重建结果。第二个 Vasconez 法则（“除了你需要的部分外，整个皮瓣都会存活”）在螺旋桨皮瓣手术中经常遇到。我们的病例表明，通过根据穿支到穿支的方法进行适当的血管增强程序规划，可以避免或克服这个问题，同时可以使用 ICG 等先进的血管成像工具进行指导。
