Painting the Pedicle: A Twist-Proof Marking Method

Pedicle twist in microsurgery can lead to flap compromise and inevitable failure if not identified and addressed in time. With increasing use of perforator flaps,[1] inadvertent twist of pedicle can take place at the time of raising, transferring, or insetting the flap, which can be difficult to detect. We would like to propose a simple, quick, and effective method of marking the pedicle prior to transfer.

Using “methylene blue dye,” we paint one side of the pedicle but leave the ends bare. The venae comitantes in the bare zone are also marked on one side.

This marking system on the same side of the pedicle provides a rapid and accurate reference point of correct spatial orientation of the pedicle, thus minimizing the risk of pedicle twist. The marking of the venae comitantes in the bare area also assists in rapid identification of the veins from the artery (Fig. [1]).

Figure 1 Left image: Free ends of the venae comitantes marked with blue dye for ease of identification. Central image: One side of the pedicle is painted, leaving the other side bare. Right image: Note the blue skip patches in the presence of a twist.

This marking method allows the surgeon to reduce inadvertent pedicle twist when it comes to insetting the flap. We routinely employ this technique in our free flap reconstructions and have avoided any flap compromise secondary to pedicle twist. Time is also saved by easily distinguishing the veins from the artery.

We recommend this fast, simple, and effective twist-proof pedicle marking method in microsurgery and especially in perforator flaps.

REFERENCES

• 1 Geddes C R, Morris S F, Neligan P C. Perforator flaps: evolution, classification, and applications.  Ann Plast Surg. 2003;  50 90-99