The effects of optimizing blood inflow in the pedicle on perforator flap survival: A pilot study in a rat model

Background Perforator flaps have led to a revolution in reconstructive surgery by reducing donor site morbidity. However, many surgeons have witnessed partial flap necrosis. Experimental methods to increase inflow have relied on adding a separate pedicle to the flap. The aim of our study was to experimentally determine whether increasing blood flow in the perforator pedicle itself could benefit flap survival.

Methods In 30 male Lewis rats, an extended posterior thigh perforator flap was elevated and the pedicle was dissected to its origin from the femoral vessels. The rats were assigned to three groups: control (group I), acute inflow (group II) and arterial preconditioning (group III) depending on the timing of ligation of the femoral artery distal to the site of pedicle emergence. Digital planimetry was performed on postoperative day (POD) 7 and all flaps were monitored using laser Doppler flowmetry perioperatively and postoperatively in three regions (P1-proximal flap, P2-middle of the flap, P3-distal flap).

Results Digital planimetry showed the highest area of survival in group II (78.12%±8.38%), followed by groups III and I. The laser Doppler results showed statistically significant higher values in group II on POD 7 for P2 and P3. At P3, only group II recorded an increase in the flow on POD 7 in comparison to POD 1.

Conclusions Optimization of arterial inflow, regardless if performed acutely or as preconditioning, led to increased flap survival in a rat perforator flap model.

Keywords

Surgery, plastic - Perforator flap - Animal experimentation

This work was funded by the Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, Bern, Switzerland.

This work will form part of the PhD thesis of Radu Olariu at the Lucian Blaga University of Sibiu, Sibiu, Romania.

Publication History

Received: 09 July 2019

Accepted: 05 March 2020

Article published online:
22 March 2022

• REFERENCES

• 1 Blondeel PN, Van Landuyt KH, Monstrey SJ. et al. The “Gent” consensus on perforator flap terminology: preliminary definitions. Plast Reconstr Surg 2003; 112: 1378-83
• 2 Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989; 42: 645-8
• 3 Quaba O, Quaba A. Pedicled perforator flaps for the lower limb. Semin Plast Surg 2006; 20: 103-11
• 4 Bekara F, Herlin C, Somda S. et al. Free versus perforator-pedicled propeller flaps in lower extremity reconstruction: what is the safest coverage? A meta-analysis. Microsurgery 2018; 38: 109-19
• 5 Bekara F, Herlin C, Mojallal A. et al. A systematic review and meta-analysis of perforator-pedicled propeller flaps in lower extremity defects: identification of risk factors for complications. Plast Reconstr Surg 2016; 137: 314-31
• 6 Tanaka Y, Tajima S. The influence of arterial inflow and venous outflow on the survival of reversed-flow island flaps: an experimental study. Plast Reconstr Surg 1997; 99: 2021-9
• 7 Hallock GG, Rice DC. Efficacy of venous supercharging of the deep inferior epigastric perforator flap in a rat model. Plast Reconstr Surg 2005; 116: 551-5
• 8 Groth AK, Campos AC, Goncalves CG. et al. Effects of venous supercharging in deep inferior epigastric artery perforator flap. Acta Cir Bras 2007; 22: 474-8
• 9 Yamamoto Y, Sakurai H, Nakazawa H. et al. Effect of vascular augmentation on the haemodynamics and survival area in a rat abdominal perforator flap model. J Plast Reconstr Aesthet Surg 2009; 62: 244-9
• 10 Gumus N, Erkan M, Ercocen AR. Vascular pressure monitorization for necessity of vascular augmentation in a rat extended abdominal perforator flap model. Microsurgery 2012; 32: 303-8
• 11 Georgescu AV, Matei I, Ardelean F. et al. Microsurgical nonmicrovascular flaps in forearm and hand reconstruction. Microsurgery 2007; 27: 384-94
• 12 Coskunfirat OK, Islamoglu K, Ozgentas HE. Posterior thigh perforator-based flap: a new experimental model in rats. Ann Plast Surg 2002; 48: 286-91
• 13 Tim CR, Martignago CCS, da Silva VR. et al. A comparison of three methods for the analysis of skin flap viability: reliability and validity. Adv Wound Care (New Rochelle) 2018; 7: 157-63
• 14 Saint-Cyr M, Wong C, Schaverien M. et al. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg 2009; 124: 1529-44
• 15 Artiaco S, Battiston B, Colzani G. et al. Perforator based propeller flaps in limb reconstructive surgery: clinical application and literature review. Biomed Res Int 2014; 2014: 690649
• 16 Chang H, Nobuaki I, Minabe T. et al. Comparison of three different supercharging procedures in a rat skin flap model. Plast Reconstr Surg 2004; 113: 277-83
• 17 Chen W, Li YQ, Tang Y. et al. Which vessel, the artery or the vein is more important in vascular supercharge: an investigation of vascular changes on rat abdominal supercharging flap models. Zhonghua Zheng Xing Wai Ke Za Zhi 2013; 29: 40-4
• 18 Sano K, Hallock GG, Rice DC. Venous “supercharging” augments survival of the delayed rat TRAM flap. Ann Plast Surg 2003; 51: 398-402
• 19 Zheng J, Xi S, Ding M. et al. Effects of venous superdrainage and arterial supercharging on dorsal perforator flap in a rat model. PLoS One 2016; 11: e0160942
• 20 Dunn RM, Mancoll J. Flap models in the rat: a review and reappraisal. Plast Reconstr Surg 1992; 90: 319-28
• 21 Ghali S, Butler PE, Tepper OM. et al. Vascular delay revisited. Plast Reconstr Surg 2007; 119: 1735-44
• 22 Taylor GI, Corlett RJ, Ashton MW. The functional angiosome: clinical implications of the anatomical concept. Plast Reconstr Surg 2017; 140: 721-33
• 23 Seyhan T, Deniz M, Borman H. et al. Comparison of two different vascular delay methods in a rat cranial epigastric perforator flap model. Ann Plast Surg 2010; 64: 89-92
• 24 Gianesini S, Sisini F, Di Domenico G. et al. Lower limbs venous kinetics and consequent impact on drainage direction. Phlebology 2018; 33: 107-14
• 25 Uhl JF, Gillot C. Anatomy of the veno-muscular pumps of the lower limb. Phlebology 2015; 30: 180-93