Preoperative imaging is sought prior to DIEA (Deep Inferior Epigastric Artery) perforator flaps due to the potential for maximizing operative success and minimizing operative complications. Recent advances include the use of computed tomography (CT) angiography (CTA) and magnetic resonance angiography. Image-guided stereotactic surgery is a recent technique that has been used with success in several fields of surgery. The variability of perforator anatomy makes DIEA perforator flap surgery a suitable candidate for such technology, but as yet this has not been described. A study was undertaken to determine the feasibility of CT-guided stereotaxy technique in DIEA perforator flap surgery and to compare findings with both conventional CTA and operative findings. Five consecutive patients planned for an elective DIEA perforator flap were recruited. Each patient underwent preoperative imaging of the anterior abdominal wall vasculature with both conventional CTA and CT-guided stereotactic imaging. Imaging findings were compared to operative findings. In all cases, all the major perforators were accurately localized with stereotactic imaging and with conventional CTA. Stereotactic navigation demonstrated a slightly better (nonsignificant) correlation with perforator location than conventional CTA. As such, CT-guided stereotactic imaging is an accurate method for the preoperative planning of DIEA perforator flaps, providing additional and potentially more accurate data to conventional CTA. With no additional scanning required, the method described in this paper allows the combined use of both methods for preoperative planning.(c) 2008 Wiley-Liss, Inc. Microsurgery, 2008.

BACKGROUND: The deep inferior epigastric artery (DIEA) perforator flap is frequently used for autologous breast reconstruction following mastectomy. Thinning of the flap is often performed to debulk the flap of excess fatty tissue, such as in partial mastectomy defects. Thinning may disrupt the blood supply to the flap and compromise viability, however adequate guidelines for thinning are lacking from the literature. METHODS: Clinical and anatomical studies were concurrently undertaken to explore the cutaneous course of perforators as a guide to flap thinning. Twenty consecutive patients undergoing DIEA perforator flap breast reconstruction underwent preoperative computerised tomography angiography (CTA), and a cadaveric study was also undertaken, in which six fresh, whole abdominal walls underwent CTA. All perforators greater than 2mm were analysed for their cutaneous course. RESULTS: In all cases, perforators emerged from the anterior rectus sheath and traversed an oblique, but direct course through the deep layer of adipose tissue, before reaching Scarpa's fascia. Branching of perforators occurred in two planes of the superficial adipose layer: just superficial to Scarpa's fascia (the fascial plexus) and in the subdermal plexus. CONCLUSION: Thinning of DIEA perforator flaps can only be performed safely deep to Scarpa's fascia. Thinning performed superficial to Scarpa's fascia threatens the intrinsic blood supply to the flap.

Preoperative imaging of the donor site vasculature for deep inferior epigastric artery (DIEA) perforator flaps and other abdominal wall reconstructive flaps has become more commonplace. Abdominal wall computed tomography angiography (CTA) has been described as the most accurate and reproducible modality available for demonstrating the location, size, and course of individual perforators. We drew on our experience of 75 consecutive patients planned for DIEA-based flap surgery undertaking CTA at a single institution. Seven of these cases have been reported to highlight the utility of CTA for preoperative planning, emphasizing the unique information supplied by CTA that may influence operative outcome. Among all cases that underwent preoperative imaging with CTA, there was 100% flap survival, with no partial or complete flap necrosis. We found that in three of the cases described, the choice of operation was necessarily selected based on CTA findings (DIEA perforator flap, transverse rectus abdominis myocutaneous flap, and superficial superior epigastric artery flap). In addition, three cases demonstrate that CTA findings may dictate the decision to operate at all, and one case demonstrates the utility of CTA for evaluating the entire abdominal contents for comorbid conditions. Our experience with CTA for abdominal wall perforator mapping has been highly beneficial. CTA may guide operative technique and improve perforator selection in uncomplicated cases, and in difficult cases it can guide the most appropriate operation or indeed if an operation is appropriate at all. This is particularly the case in the setting of comorbidities or previous abdominal surgery.(c) 2008 Wiley-Liss, Inc. Microsurgery, 2008.

Previous descriptions of the thoracolumbar spinal nerves innervating the anterior abdominal wall have been inconsistent. With modern surgical and anesthetic techniques that involve or may damage these nerves, an improved understanding of the precise course and variability of this anatomy has become increasingly important. The course of the nerves of the anterior abdominal is described based on a thorough cadaveric study and review of the literature. Twenty human cadaveric hemi-abdominal walls were dissected to map the course of the nerves of the anterior abdominal wall. Dissection included a comprehensive tracing of nerves and their branches from their origins in five specimens. The branching pattern and course of all nerves identified were described. All thoracolumbar nerves that innervate the anterior abdominal wall were found to travel as multiple mixed segmental nerves, which branch and communicate widely within the transversus abdominis plane (TAP). This communication may occur at multiple locations, including large branch communications anterolaterally (intercostal plexus), and in plexuses that run with the deep circumflex iliac artery (DCIA)(TAP plexus) and the deep inferior epigastric artery (DIEA)(rectus sheath plexus). Rectus abdominis muscle is innervated by segments T6-L1, with a constant branch from L1. The umbilicus is always innervated by a branch of T10. As such, identification or damage to individual nerves in the TAP or within rectus sheath is unlikely to involve single segmental nerves. An understanding of this anatomy may contribute to explaining clinical outcomes and preventing complications, following TAP blocks for anesthesia and DIEA perforator flaps for breast reconstruction. Clin. Anat. 21:325-333, 2008.(c) 2008 Wiley-Liss, Inc.

Introduction: The anterolateral thigh flap is an increasingly popular reconstructive option despite uncertainty in its perforator anatomy. Perforators are not always present, vary in size and intramuscular course, and have variable cutaneous courses and supply. As such, preoperative imaging has become favored. Methods: The current study describes the preliminary use of two new modalities for preoperative imaging: computed tomography (CT) Angiography and CT-guided stereotaxy. These have been utilized in the preoperative imaging of two patients undergoing ALT flap reconstruction. Each patient underwent each of these techniques combined with Doppler ultrasound, the previous standard modality. The size, location, and course of perforators were explored and compared with operative findings. Results: Both techniques are technically feasible, highly accurate, and provide more information to the surgeon than ultrasound. Conclusion: CT Angiography and CT-guided stereotaxy are useful adjuncts to Doppler ultrasound for imaging perforators prior to ALT flaps. A larger study is suggested to quantify the accuracy of these techniques.(c) 2008 Wiley-Liss, Inc. Microsurgery, 2008.

The abdominal wall integument is becoming the standard donor tissue for postmastectomy breast reconstruction, with its vascular supply of key importance to the reconstructive surgeon. Refinements in tissue transfer, from pedicled to free flaps and musculocutaneous to perforator flaps, have required increasing understanding of finer levels of this vascular anatomy. The widespread utilization of the deep inferior epigastric artery (DIEA) perforator flap, particularly for breast reconstruction, has rekindled clinical interest in further levels of anatomical detail, in particular the location and course of the musculocutaneous perforators of the DIEA. Advances in operative techniques, and anatomical and imaging technologies, have facilitated an increase in this understanding. The current review comprises an appraisal of both the anatomical and clinical literature, with a view to highlighting the key anatomical features of the abdominal wall vasculature as related to reconstructive flaps. Clin. Anat., 2008.(c) 2008 Wiley-Liss, Inc.

Purpose Abdominal donor site flaps are the standard in autologous breast reconstruction. With significant variation in the vascular anatomy of the abdominal wall, preoperative imaging is essential. Computerised Tomography Angiography (CTA) has been recently described for this purpose. Uniquely, the branching pattern of the Deep Inferior Epigastric Artery (DIEA) is demonstrated clearly on CTA. We sought to correlate the branching pattern of the DIEA to the location and course of perforators, as a tool for preoperative planning. Methodology 45 hemi-abdominal walls from both fresh and embalmed cadavers were used for isolated injection of the DIEA with contrast and radiographic imaging, allowing analysis of the location and intramuscular course of the perforators. The branching pattern on radiography was thus correlated to individual perforators. Results DIEA branching pattern correlated closely with the intramuscular course of perforators. A bifurcating branching pattern demonstrated a reduced intramuscular transverse distance traversed by each perforator. A trifurcating (Type 3) branching pattern demonstrated perforators that traversed significantly greater transverse distances. The vessel type, however, displayed no correlation with the number of perforators. Conclusions Intramuscular courses of perforators are significantly greater with a trifurcating branching pattern of the DIEA, and reduced with a bifurcating pattern. This correlates with less rectus abdominis muscle sacrificed during a DIEA perforator flap. As CTA is the optimal modality for demonstrating this pattern preoperatively, we suggest the use of CTA for preoperative assessment in TRAM and DIEA perforator flaps.

Background Abdominal donor site flaps, including the Transverse Rectus Abdominis Musculocutaneous (TRAM) and Deep Inferior Epigastric Artery (DIEA) perforator flaps, are the standard in autologous breast reconstruction. With variation in the vascular anatomy of the abdominal wall, preoperative imaging is essential for preoperative planning and reducing intraoperative error. Ultrasound has been used previously with varying results, and the quest continues for optimal preoperative assessment. Computerised Tomography Angiography (CTA) has been recently proposed as a non-invasive modality for this purpose. This is the first study to formally compare preoperative Doppler ultrasound with CTA for imaging the DIEA. Methodology Eight consecutive patients undergoing DIEA perforator flaps for breast reconstruction undertook both CTA and Doppler ultrasound preoperatively. All investigations and procedures were undertaken at the same institution with the same surgeon and radiology team. Results CTA was superior at identifying the course of the DIEA, its branching pattern and in visualizing its perforators than Doppler ultrasound. Preoperative CTA was highly specific (100%) and more sensitive in mapping and visualising perforators (p < 0.001). CTA was also proficient at identifying the superficial epigastric arterial system and for effectively displaying the results intraoperatively. CTA was substantially quicker and removed the inter-observer error associated with Doppler ultrasonography. The study was ceased after eight patients due to the overwhelming benefit of CTA over Doppler. Conclusions CTA is a valuable imaging modality for the preoperative assessment of the donor site vascular supply for TRAM and DIEA perforator flaps.

Background Free tissue transfer using microvascular surgery has become a safe a reliable means to repair soft tissue and/or bony defects of the head and neck. Operative success reaches 98%, however the incidence of significant post-operative complication is also relatively high (32%). One common and often severe complication is haematoma formation at either donor or recipient sites. The incidence of recipient site haematoma is reported at 6%, however the causes and outcomes of haematomas have not been well investigated. A retrospective historical analysis of both donor and recipient site wound haematoma was performed to identify causative factors and the effect on patient outcome. Methodology A five year review was conducted for microvascular free tissue transfer to defects in the head and neck at The Royal Melbourne Hospital, for the period from February 2001 until February 2006. The medical records of these 150 patients were reviewed for donor and recipient site wound haematoma and outcomes. Results Significant factors for the development of post-operative haematomas included lood pressure control during the first post-operative, correlating with the likelihood of developing either a donor or recipient site haematoma (p value < 0.001), drain-tube outputs (both high and low), smoking and the use of pre-operative NSAIDs. Conclusion There are significant reversible factors that contribute to the development of post-operative haematomas in head and neck surgery. Close monitoring of patient blood pressure by theatre and recovery nursing staff, close monitoring of drain outputs, and pre-operative counselling on the use of NSAIDs and smoking may all be useful in the prevention of haematoma formation.

Purpose The use of anticoagulant therapy as a causative agent in the development of chronic subdural haematomas (CSDH) was investigated. We suspected a high incidence of anticoagulant therapy or anti-thrombotic therapy in patients who presented with CSDH. Methodology Retrospective analysis of charts of eighty-one cases of CSDH admitted to the neurosurgical unit of the Royal Hobart Hospital (RHH), Tasmania, Australia, over a 5-year period were reviewed. A database of neurosurgical procedures performed at RHH was examined to retrieve these patients undergoing surgery for CSDH. We found that anticoagulant therapy was used by a significant percentage of CSDH patients. Results/Conclusions In the patient group presenting to our unit the risk of developing a CSDH was at least 42.5 times higher in warfarinised patients and also increased for patients on aspirin, although the risk could not be quantified.

BACKGROUND: Free tissue transfer is an integral part of modern head and neck surgery in the adult population. Its use in the pediatric population has not been well described. Recently, there has been an increase in the application of these techniques in the pediatric population. The morbidity of free tissue transfer in small pediatric patients and its effect on growth has not been well described. OBJECTIVE: To evaluate the utility of microvascular reconstruction techniques in the pediatric population. STUDY DESIGN: A consensus study was performed by the microvascular committee of the American Academy of Otolaryngology-Head and Neck Surgery. Thirty active microvascular surgeons reviewed their databases to find patients less than 21 years of age who underwent free tissue transfer. RESULTS: 49 free tissue transfers performed between 1999 and 2005. The mean age was 12.1 years (age range, 3-21). The types of flaps transferred were radial forearm (10), fibula (21), rectus abdominus (7), scapula (1), latissimus dorsi (3), groin (1), gracillus (4), and jejunum (2). Morbidity at the donor site was relatively minimal. Five patients developed wound breakdown. One of these required return to the operating room. Morbidity at the reconstructed site was also rare. Patients were followed for an average of 49 months (range, 1-131 months), and no problems were noted with growth at the donor or recipient sites. CONCLUSIONS: Free flaps in the pediatric population have morbidity and survival similar to those in the adult population. SIGNIFICANCE: While indications differ from those in the adult population, these techniques are viable and valuable and should be considered in the pediatric reconstructive paradigm.

The availability of reliable recipient vessels for free flap transfer in head and neck reconstruction may be limited in cases of prior neck dissection or radiation therapy. One solution is to use the internal mammary vessels as recipients for a free omental flap.Five patients were treated with free omental flap transfer using the internal mammary vessels as recipient vessels during head and neck reconstruction. Two patients presented with a pharyngocutaneous fistula, 1 had mandibular osteomyelitis, 1 had primary esophageal cancer, and 1 had bilateral cervical radiation ulcers. All patients had received radiation therapy previously (average dose, 75.4 Gy), and 4 had undergone neck dissection (3 bilateral and 1 ipsilateral). All patients were reconstructed using a free omental flap. Four patients had a second free flap combined with the free omental flap (3 free jejunal flaps and 1 free fibular osteocutaneous flap).The mean follow-up was 26.4 months. All free flaps took entirely, the only complication ileus requiring reoperation in 1 patient.The internal mammary vessels are reliable recipient vessels for a free omental flap in head and neck reconstruction. This procedure is a good option for patients in whom previous surgery or radiation therapy has compromised local recipient vessels.

BACKGROUND:: Identification of a single donor site capable of providing all the components of the soft tissue envelope and the ability to selectively harvest a subset of these components is a central requirement for the microvascular reconstruction of the trauma patient. The anterolateral thigh (ALT) flap's long pedicle and adaptability in supporting a variety of tissues (muscle, fascia, soft tissue) make it a valuable tool for microsurgical reconstruction in these challenging patients. We investigated the utility of the ALT as a donor for microvascular tissue reconstruction in a Level I trauma center. METHODS:: We conducted a retrospective chart review on all trauma patients treated by the plastic surgery service at the R Adams Cowley Shock Trauma Center who required microsurgical free flap coverage from July 2002 to March 2005. Fifty-eight patients underwent reconstruction of traumatic deformities with 62 microvascular free flaps from the ALT region. RESULTS:: Of the 58 patients, 42 were male and 16 were female with an average age of 39 years. Recipient site locations for the 62 flaps were lower extremity, upper extremity, trunk, and head and neck. Analysis of flap anatomy revealed that 43 were fasciocutaneous, 14 were myocutaneous, 2 were adipofascial, and 3 were myofascial (vastus lateralis muscle). Six flaps were based on septocutaneous perforators, whereas the remainder contained myocutaneous perforators. Nine thigh donor sites required a split thickness skin graft, and 53 were closed primarily. The size of the flaps ranged from 36 cm to 600 cm. CONCLUSIONS:: The ALT is a predictable donor site that facilitates a 2-team approach. ALT displays minimal donor site morbidity and in most cases provided sufficient tissue to cover the entire traumatic defect. Our results suggest the ALT is a reliable tissue source and an ideal donor site for the management of complex traumatic wounds in the United States.

OBJECTIVE: The selection of recipient vessels suitable for microvascular anastomosis within the head and neck region is an essential element affecting patency and outcome. Our aim was to ascertain whether the use of external jugular vein as the sole recipient vein is related to an increase in free flap failure in head and neck reconstructive surgery. METHODS: A retrospective review of all head and neck free flaps performed at an academic centre during a 3-year period was performed. Cases in which the external jugular vein was the lone recipient vein were analyzed. The same two surgeons completed all microvascular anastomosis. The outcome measure was free flap survival. RESULTS: Forty-seven of 49 flaps (96%), which used the external jugular vein as the sole recipient vein, survived. The two failures resulted from venous thrombosis but were successfully salvaged. CONCLUSION: The free flap success rate is well within the range of figures previously reported in large studies. Use of the external jugular vein as the sole recipient vein in head and neck free flap reconstruction does not increase the risk of free flap failures. This suggests that the external jugular vein is a viable option when choosing a single recipient vein in head and neck free tissue transfers.

BACKGROUND/OBJECTIVES:: Microvascular "free flap" transplants have become the preferred method of reconstruction for a great variety of complicated head and neck defects. As recently as 10 years ago, having a microvascular surgeon within a department of otolaryngology was the exception rather than the rule, whereas it is our impression that today most academic programs have one or more microvascularly trained head and neck surgeons. Among microvascular surgeons, postoperative care and management regimens vary greatly. Through informal conversations, we discerned that some surgeons take a very aggressive approach to monitoring, perhaps including prolonged stays in an intensive care setting with implanted Doppler devices to monitor flap blood flow and intravenous administration of dextran or other pharmaceutical projects. Others report that patients are quickly discharged from the hospital after just aspirin and subcutaneous heparin for a few days. Some physicians perform "flap checks" hourly, whereas others have residents check only once daily. DESIGN/METHODS:: We surveyed academic otolaryngology-head and neck surgery departments that sponsor residency programs in the United States to 1) determine the prevalence of microvascular trained otolaryngologists within training programs and 2) assess variations in postoperative and monitoring regimens. RESULTS:: We found that on average, 12.2% of otolaryngologists per department perform free flap transplants, and 71.6% of microvascular trained surgeons continue to do free flaps. The surgeons self reported a 96.4% average success rate and a 6.88% return rate to the operating room for complications. Monitoring methods used included flap color (used by 79.4% of surgeons), Doppler signal (79.4%), pin prick and bleeding rate (67.6%), capillary refill (61.8%), skin surface temperature (11.8%), and implanted Doppler (8.8%). Anticoagulants used included aspirin (used by 76.5% of microvascular surgeons), low-molecular-weight dextran (35.3%), and subcutaneous heparin (26.5%). CONCLUSIONS:: Microvascular training has become commonplace in otolaryngology-head and neck surgery training programs, with more than one in eight of these academic physicians reporting microvascular training. There was no self-reported difference in flap failure rates on the basis of postoperative care and monitoring regimen. The results of this survey suggest that a simplified consensus postoperative regimen can be recommended.

OBJECTIVE: To analyze the feasibility and reliability of free anterolateral thigh flap transfers in head and neck reconstruction. METHODS: Twenty-two consecutive free anterolateral thigh flap transfers from January 2002 to January 2006 were reviewed. Data concerning the operation included date of surgery, defect description and site, stage and histology of tumor, design of anterolateral free flap, type of perforators, recipient vessel and type of anastomosis used and complications. RESULTS: There were 13 males and 9 females in this group, with age range of 35 to 70. Among 26 perforators, there were 6 septocutaneous perforators and 20 musculocutaneous perforators. One flap developed venous thrombosis 48 hours after operation, and the flap was removed after failed salvage. No vessel thrombosis occurred during and after operation with other flaps, which survived completely. All the donor sites were closed directly without skin graft. Apart from one case, all the donor sites healed uneventfully. CONCLUSIONS: Free anterolateral thigh flap is a safe and reliable donor site in the reconstruction of head and neck defects. It overcomes the shortcomings of traditional free radial forearm flap and free rectus abdominis myocutaneous flap.