Download PDF
J Reconstr Microsurg 2021; 37(01): 075-082
DOI: 10.1055/s-0040-1702162
Original Article

High-Resolution Ultrasound-Guided Perforator Mapping and Characterization by the Microsurgeon in Lower Limb Reconstruction

Andreas Kehrer
1   Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
,
Paul I. Heidekrueger
1   Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
,
Daniel Lonic
1   Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
,
Christian D. Taeger
1   Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
,
Silvan Klein
1   Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
,
Philipp Lamby
1   Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
,
Neil S. Sachanadani
2   Department of Plastic and Reconstructive Surgery, Beaumont Hospital, Royal Oak, Detroit, Michigan
,
Ernst Michael Jung
3   Department of Radiology, Ultrasound Center, University Medical Center Regensburg, Regensburg, Germany
,
Lukas Prantl
1   Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
,
Natascha Platz Batista da Silva
3   Department of Radiology, Ultrasound Center, University Medical Center Regensburg, Regensburg, Germany
› Author Affiliations Funding None.
› Further Information
Also available at
    Permissions and Reprints

Abstract

Background Preoperative ultrasound (US)-guided perforator mapping has immensely simplified perforator flap planning. It may be executed by the microsurgeon. Device settings and selection of ultrasound modes are of utmost significance for detection of low-flow microvessels. The following study evaluates different US modes.

Methods A prospective complete data acquisition was performed from July 2018 to June 2019 in a subset of patients who underwent US-guided flap planning. Multifrequency linear transducers were used applying five US modes. Brightness (B)-mode, color flow (CF), power Doppler (PD), pulse wave (PW), and B-flow modes were evaluated regarding applicability by microsurgeons. Peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) were chosen to evaluate flow characteristics. US results were correlated to intraoperative findings.

Results A total number of eight patients (six males and two females) undergoing anterolateral thigh (ALT) or superficial circumflex iliac artery perforator (SCIP) flap surgery received an extensive standardized US-guided perforator characterization. Qualitative evaluation was performed in B-mode, color-coded duplex sonography (CCDS), PD, and B-flow mode. Quantitative assessment was executed using PW-mode and CCDS measuring the microvessels' diameter (mm) and flow characteristics (PSV, EDV, and RI). CCDS provided a mean diameter of 1.93 mm (range: 1.2–2.8 ± 0.51), a mean systolic peak of 16.9 cm/s (range: 9.9–33.4 ± 7.79), and mean RI of 0.71 (range: 0.55–0.87 ± 0.09) for lower limb perforators. All perforators located with US were verified by intraoperative findings. An optimized, time-effective US mapping algorithm was derived. Qualitative parameters may be evaluated with B-mode, CF, or B-flow. Smallest microvessels may be assessed in PD-mode. Lowering pulse-repetition frequency (PRF)/scale is mandatory to image low-flow microvessels as perforators. Quantitative information may be obtained using PW-mode and the distance-measuring tool in CF-mode. Image and video materials are provided.

Conclusion CCDS proved to be a powerful tool for preoperative perforator characterization when using a structured approach and mapping algorithm. Different techniques may be applied for specific visualizations and performed by the microsurgeon.

Keywords

ultrasound - perforator flap - color coded duplex ultrasound


Publication History

Received: 05 November 2019

Accepted: 19 December 2019

Article published online:
28 February 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Yu P, Youssef A. Efficacy of the handheld Doppler in preoperative identification of the cutaneous perforators in the anterolateral thigh flap. Plast Reconstr Surg 2006; 118 (04) 928-933 , discussion 934–935
    CrossrefPubMedSearch in Google Scholar
  • 2 Ensat F, Babl M, Conz C. et al. The efficacy of color duplex sonography in preoperative assessment of anterolateral thigh flap. Microsurgery 2012; 32 (08) 605-610
    CrossrefPubMedSearch in Google Scholar
  • 3 Rozen WM, Anavekar NS, Ashton MW. Magnetic resonance angiography in preoperative planning of deep inferior epigastric artery perforator flaps. J Plast Reconstr Aesthet Surg 2010; 63 (01) e120-e121
    CrossrefPubMedSearch in Google Scholar
  • 4 Wong C, Nagarkar P, Teotia S, Haddock N. The profunda artery perforator flap: investigating the perforasome using 3D CT angiography. Plast Reconstr Surg 2015; 136 (05) 915-919
    CrossrefPubMedSearch in Google Scholar
  • 5 Newman TM, Vasile J, Levine JL. et al. Perforator flap magnetic resonance angiography for reconstructive breast surgery: a review of 25 deep inferior epigastric and gluteal perforator artery flap patients. J Magn Reson Imaging 2010; 31 (05) 1176-1184
    CrossrefPubMedSearch in Google Scholar
  • 6 Onoda S, Azumi S, Hasegawa K, Kimata Y. Preoperative identification of perforator vessels by combining MDCT, doppler flowmetry, and ICG fluorescent angiography. Microsurgery 2013; 33 (04) 265-269
    CrossrefPubMedSearch in Google Scholar
  • 7 Sheena Y, Jennison T, Hardwicke JT, Titley OG. Detection of perforators using thermal imaging. Plast Reconstr Surg 2013; 132 (06) 1603-1610
    CrossrefPubMedSearch in Google Scholar
  • 8 Phillips BT, Munabi NC, Roeder RA, Ascherman JA, Guo L, Zenn MR. The role of intraoperative perfusion assessment: what is the current state and how can i use it in my practice?. Plast Reconstr Surg 2016; 137 (02) 731-741
    CrossrefPubMedSearch in Google Scholar
  • 9 de Weerd L, Mercer JB, Setså LB. Intraoperative dynamic infrared thermography and free-flap surgery. Ann Plast Surg 2006; 57 (03) 279-284
    CrossrefPubMedSearch in Google Scholar
  • 10 Su W, Lu L, Lazzeri D. et al. Contrast-enhanced ultrasound combined with three-dimensional reconstruction in preoperative perforator flap planning. Plast Reconstr Surg 2013; 131 (01) 80-93
    CrossrefPubMedSearch in Google Scholar
  • 11 Sheriff HO, Mahmood KA, Hamawandi N. et al. The supraclavicular artery perforator flap: a comparative study of imaging techniques used in preoperative mapping. J Reconstr Microsurg 2018; 34 (07) 499-508
    Thieme ConnectPubMedSearch in Google Scholar
  • 12 Gentileschi S, Servillo M, De Bonis F. et al. Radioanatomical study of the pedicle of the superficial circumflex iliac perforator flap. J Reconstr Microsurg 2019; 35 (09) 669-676
    Thieme ConnectPubMedSearch in Google Scholar
  • 13 Hallock GG. Attributes and shortcomings of acoustic Doppler sonography in identifying perforators for flaps from the lower extremity. J Reconstr Microsurg 2009; 25 (06) 377-381
    Thieme ConnectPubMedSearch in Google Scholar
  • 14 Saito A, Furukawa H, Hayashi T, Oyama A, Funayama E, Yamamoto Y. Intraoperative color Doppler sonography in the elevation of anterolateral thigh flap. Microsurgery 2011; 31 (07) 582-583
    CrossrefPubMedSearch in Google Scholar
  • 15 Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med 2007; 357 (22) 2277-2284
    CrossrefPubMedSearch in Google Scholar
  • 16 Kooiman J, Le Haen PA, Gezgin G. et al. Contrast-induced acute kidney injury and clinical outcomes after intra-arterial and intravenous contrast administration: risk comparison adjusted for patient characteristics by design. Am Heart J 2013; 165 (05) 793-799 , 799.e1
    CrossrefPubMedSearch in Google Scholar
  • 17 Cheng HT, Lin FY, Chang SC. Diagnostic efficacy of color Doppler ultrasonography in preoperative assessment of anterolateral thigh flap cutaneous perforators: an evidence-based review. Plast Reconstr Surg 2013; 131 (03) 471e-473e
    CrossrefPubMedSearch in Google Scholar
  • 18 Schwabegger AH, Bodner G, Rieger M, Jaschke WR, Ninković MM. Internal mammary vessels as a model for power Doppler imaging of recipient vessels in microsurgery. Plast Reconstr Surg 1999; 104 (06) 1656-1665
    CrossrefPubMedSearch in Google Scholar
  • 19 Kehrer A, Hsu MY, Chen YT, Sachanandani NS, Tsao CK. Simplified profunda artery perforator (PAP) flap design using power Doppler ultrasonography (PDU): A prospective study. Microsurgery 2018; 38 (05) 512-523
    CrossrefPubMedSearch in Google Scholar
  • 20 Kehrer A, Sachanadani NS, Platz Batista da Silva N. et al. Step by step guide to ultrasound based design of alt flaps by the microsurgeon – basic and advanced applications and device settings. JPRAS 2019;
    CrossrefPubMedSearch in Google Scholar
  • 21 Borgbjerg J, Bøgsted M, Lindholt JS, Behr-Rasmussen C, Hørlyck A, Frøkjær JB. Superior reproducibility of the leading to leading edge and inner to inner edge methods in the ultrasound assessment of maximum abdominal aortic diameter. Eur J Vasc Endovasc Surg 2018; 55 (02) 206-213
    CrossrefPubMedSearch in Google Scholar
  • 22 Kruskal JB, Newman PA, Sammons LG, Kane RA. Optimizing Doppler and color flow US: application to hepatic sonography. Radiographics 2004; 24 (03) 657-675
    CrossrefPubMedSearch in Google Scholar
  • 23 Naqvi TZ, Perese S. Noninvasive vascular appropriateness criteria--review and comments on the American College of Cardiology (ACC) Guidelines. J Am Soc Echocardiogr 2013; 26 (05) A34
    CrossrefPubMedSearch in Google Scholar
  • 24 Zwiebel WJ, Pellerito JS. Introduction to Vascular Ultrasonography. 5th ed. Philadelphia, Pa.: Elsevier Saunders; 2005
    Search in Google Scholar
  • 25 Dorfman D, Pu LL. The value of color duplex imaging for planning and performing a free anterolateral thigh perforator flap. Ann Plast Surg 2014; 72 (Suppl. 01) S6-S8
    CrossrefPubMedSearch in Google Scholar
  • 26 Lin CT, Huang JS, Hsu KC, Yang KC, Chen JS, Chen LW. Different types of suprafascial courses in thoracodorsal artery skin perforators. Plast Reconstr Surg 2008; 121 (03) 840-848
    CrossrefPubMedSearch in Google Scholar
  • 27 Feng S, Min P, Grassetti L. et al. A prospective head-to-head comparison of color doppler ultrasound and computed tomographic angiography in the preoperative planning of lower extremity perforator flaps. Plast Reconstr Surg 2016; 137 (01) 335-347
    CrossrefPubMedSearch in Google Scholar
  • 28 Gravvanis A, Karakitsos D, Dimitriou V. et al. Portable duplex ultrasonography: A diagnostic and decision-making tool in reconstructive microsurgery. Microsurgery 2010; 30 (05) 348-353
    CrossrefPubMedSearch in Google Scholar
  • 29 Debelmas A, Camuzard O, Aguilar P, Qassemyar Q. Reliability of color doppler ultrasound imaging for the assessment of anterolateral thigh flap perforators: a prospective study of 30 perforators. Plast Reconstr Surg 2018; 141 (03) 762-766
    CrossrefPubMedSearch in Google Scholar
  • 30 Daigeler A, Schubert C, Hirsch T, Behr B, Lehnhardt M. Colour duplex sonography and “Power-Duplex” in perforator surgery - improvement of patients safety by efficient planning [article in German]. Handchir Mikrochir Plast Chir 2018; 50 (02) 101-110
    Thieme ConnectPubMedSearch in Google Scholar
  • 31 Gunnarsson GL, Thomsen JB. The versatile modiolus perforator flap. Plast Reconstr Surg Glob Open 2016; 4 (03) e661
    CrossrefPubMedSearch in Google Scholar
  • 32 Rand RP, Cramer MM, Strandness Jr DE. Color-flow duplex scanning in the preoperative assessment of TRAM flap perforators: a report of 32 consecutive patients. Plast Reconstr Surg 1994; 93 (03) 453-459
    CrossrefPubMedSearch in Google Scholar
  • 33 Rafailidis V, Sidhu PS. Vascular ultrasound, the potential of integration of multiparametric ultrasound into routine clinical practice. Ultrasound 2018; 26 (03) 136-144
    CrossrefPubMedSearch in Google Scholar
  • 34 Rübenthaler J, Reiser M, Clevert DA. Diagnostic vascular ultrasonography with the help of color Doppler and contrast-enhanced ultrasonography. Ultrasonography 2016; 35 (04) 289-301
    CrossrefPubMedSearch in Google Scholar
  • 35 Hong JP, Choi DH, Suh H. et al. A new plane of elevation: the superficial fascial plane for perforator flap elevation. J Reconstr Microsurg 2014; 30 (07) 491-496
    Thieme ConnectPubMedSearch in Google Scholar
  • 36 Hong JP, Chung IW. The superficial fascia as a new plane of elevation for anterolateral thigh flaps. Ann Plast Surg 2013; 70 (02) 192-195
    CrossrefPubMedSearch in Google Scholar
  • 37 Visconti G, Bianchi A, Hayashi A, Salgarello M. Pure skin perforator flap direct elevation above the subdermal plane using preoperative ultra-high frequency ultrasound planning: a proof of concept. J Plast Reconstr Aesthet Surg 2019; 72 (10) 1700-1738
    CrossrefPubMedSearch in Google Scholar
  • 38 Visconti G, Hayashi A, Bianchi A, Salgarello M. Technological advances in lymphatic Surgery: bringing to light the invisible. Plast Reconstr Surg 2019; 144 (05) 940e-942e
    CrossrefPubMedSearch in Google Scholar
  • 39 Hayashi A, Visconti G, Yamamoto T. et al. Intraoperative imaging of lymphatic vessel using ultra high-frequency ultrasound. J Plast Reconstr Aesthet Surg 2018; 71 (05) 778-780
    CrossrefPubMedSearch in Google Scholar
  • 40 Visconti G, Hayashi A, Yoshimatsu H, Bianchi A, Salgarello M. Ultra-high frequency ultrasound in planning capillary perforator flaps: preliminary experience. J Plast Reconstr Aesthet Surg 2018; 71 (08) 1146-1152
    CrossrefPubMedSearch in Google Scholar
  • 41 Hayashi A, Giacalone G, Yamamoto T. et al. Ultra high-frequency ultrasonographic imaging with 70 MHz scanner for visualization of the lymphatic vessels. Plast Reconstr Surg Glob Open 2019; 7 (01) e2086
    CrossrefPubMedSearch in Google Scholar