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BACKGROUND: Understanding of the temporal region remains confused, largely because of the ambiguous nomenclature. Aspects of the anatomy also remain unclear and are variably reported in the literature. The aim of this study was twofold: (1) to clarify details of the anatomy, using fresh cadaver dissections; and (2) to propose a standardized nomenclature that is based on recognized principles of nomenclature, contemporary use, and correct anatomical detail. METHODS: A cadaver dissection study on 24 fresh hemifaces (13 male, 11 female; mean age, 72 years) was undertaken at the University of Melbourne to clarify the anatomy of the tissue layers and dissection planes of the region. A comprehensive literature review was undertaken to clarify the nomenclature of the region and to investigate the current understanding of the anatomy itself. RESULTS: The tissue layers, ligamentous structures, and anatomy of two separate soft-tissue compartments within the temporal region were consistently identified across all dissection specimens. A standardized nomenclature system for the temporal region has been proposed. CONCLUSIONS: The use of consistent nomenclature to describe the structures in the temporal region facilitates understanding and discussion of the anatomy. Two separate soft-tissue compartments exist in the temporal region, bounded by ligamentous structures. The tissue layers differ considerably between the two compartments, and anatomical landmarks within these layers provide useful information to the surgeon operating in the temporal region.

Background Despite a plethora of monitoring techniques reported in the literature, only a small number of studies directly address clinical relevant end points, such as the flap salvage rate and false-positive rate. Method We conducted a systematic review of current evidence regarding the postoperative monitoring of microvascular free-tissue transfer via extensive electronic and manual search and perusing databases, such as PubMed, Cochrane, American College of Physicians (ACP) Journal Club, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (EMBASE), and Ovid MEDLINE. The included literature (n = 184 publications) was critically appraised using March 2009 Oxford Centre for Evidence-Based Medicine definitions, focusing on the evidence for the efficacy of each technique in improving the flap salvage rate of compromised flaps. Result There is a paucity of outcome-based studies, with only implanted Doppler probes, near-infrared spectroscopy, laser Doppler flowmetry, quantitative fluorimetry, and digital photography assessment using smartphones having been demonstrated in comparative studies to improve flap salvage rate. Currently, the implantable Doppler probe is the technique with the largest number of comparative studies and case series to demonstrate its effectiveness compared with clinical monitoring. Conclusions Future studies need to evaluate the most promising monitoring techniques further with a focus on assessing clinically relevant outcomes, such as the flap salvage rate and the false-positive rate, and not simple clinical series reporting patient and physician satisfaction.

Important prognostic factors in patients with cutaneous melanoma include primary tumour thickness/depth of invasion, ulceration and mitotic rate, and the presence of tumour cells in regional lymph nodes. More recently, features of stromal components, such as blood and lymphatic vessel density, have been suggested as additional indicators of metastatic potential. Our aim was to investigate the relationship between tumour lymphatic vessels and lymph node metastasis.Metastasizing (n = 11) and non-metastasizing (n = 11) primary melanoma samples matched for depth/thickness, mitotic rate and ulceration were examined for lymphatic vessel density (LVD) in the primary tumour, using an antibody to podoplanin. Significant differences were found between LVD (vessels/unit area) in the peripheral (5.73 ± 0.67) versus central (1.72 ± 0.42) regions of the metastasizing tumour group (P 0.001), and between LVD in the peripheral areas of metastasizing (5.73 ± 0.67) versus non-metastasizing (4.21 ± 0.37) tumours (P 0.01). No overall difference was found between total average LVD in the two tumour groups or between their vessel morphology.Our results show that LVD is associated with risk of lymph node metastasis. Furthermore, the ratio of peripheral LVD:central LVD is a useful marker of primary melanomas that are likely to metastasize to lymph nodes.

Background: Although preoperative imaging of perforator vasculature in planning microvascular reconstruction is commonplace, there has not been any clear demonstration of the evidence for this practice, or data comparing the many available modalities in an evidence-based approach. This article aims to provide an objective, evidence-based review of the literature on this subject. Methods: The evidence supporting the use of various modalities of imaging was investigated by performing focused searches of the PubMed and Medline databases. The articles were ranked according to the criteria set out in March 2009 Oxford Centre for Evidence-Based Medicine definitions. Endpoints comprised objective outcome data supporting the use of imaging, including flap loss, unplanned returns to theater, operative time reduction, and surgeon-reported stress. Results: The objective high level of evidence for any form of preoperative perforator imaging is low with only small number of comparative studies or case series investigating computed tomographic angiography (CTA), magnetic resonance angiography, handheld Doppler, color duplex, and classic angiography. Of all modalities, there is a growing body of level 2b evidence supporting the use of CTA. Conclusion: While further multicenter trials testing hard outcomes are needed to conclusively validate preoperative imaging in reconstructive surgery, sufficient evidence exists to demonstrate that preoperative imaging can statistically improve outcomes, and that CTA is the current gold standard for perforator mapping.

Background Although a surgical insult may substantially alter local vascular anatomy within tissues, studies that have clearly demonstrated these changes as being dynamic phenomena have not been widely reported. The current study aimed to explore the changes in abdominal wall vasculature after a surgical insult. Methods The arterial and venous anatomy of both the deep and superficial epigastric systems of the abdominal wall were explored with computed tomographic angiography (CTA) performed before and after bilateral removal of both bilateral deep and superficial inferior epigastric systems. Results Several unique anatomic findings were evident, with dilatation of both deep superior epigastric arteries and recanalization of the superficial inferior epigastric veins across the surgical scar, despite previous surgical division. Conclusion The current study demonstrated that there are changes in both major and minor axial vessels and in both the arterial and venous systems after surgical insult. CTA may be of value in identifying these changes prior to surgery utilizing local vasculature.

Breast reconstruction plays a highly important role in the management of patients with breast cancer, from a psycho-social and sexual stand-point. Given that immediate breast reconstruction does not impair the oncologic safety of breast cancer management, with no increase in local recurrence rates, and no delays in the initiation of adjuvant chemotherapy or radiotherapy, the need to balance cosmesis in reconstruction with the oncologic needs of breast cancer patients is no more evident than in the discussion of radiotherapy. Radiotherapy is essential adjuvant therapy in the treatment of breast cancer, with the use of adjuvant radiotherapy widely shown to reduce local recurrence after both partial and total mastectomy and shown to prolong both disease-free and overall survival in patients with nodal disease. In the setting of breast reconstruction, the effects of radiotherapy are potentially two-fold, with consideration required of the impact of breast reconstruction on the administration of and the initiation of radiotherapy, as well as the effects of radiotherapy on operative complications and cosmetic outcome following immediate breast reconstruction. The current editorial piece aims to analyze this balance, contrasting both autologous and implant-based reconstruction. The literature is still evolving as to the relative role of autologous vs. alloplastic reconstruction in the setting of radiotherapy, and the more recent introduction of acellular dermal matrix and other compounds further complicate the evidence. Fat grafting and evolving techniques in breast reconstruction will herald new discussions on this front.

Background: Since the birth of reconstructive microvascular surgery, attempts have been made to shorten the operative time while maintaining patency and efficacy. Several devices have been developed to aid microsurgical anastomoses. This article investigates each of the currently available technologies and attempts to provide objective evidence supporting their use. Methods: Techniques of microvascular anastomosis were investigated by performing searches of the online databases Medline and Pubmed. Returned results were assessed according to the criteria for ranking medical evidence advocated by the Oxford Centre for Evidence Based Medicine. Emphasis was placed on publications with quantifiable endpoints such as unplanned return to theatre, flap salvage, and complication rates. Results: There is a relative paucity of high-level evidence supporting any form of assisted microvascular anastomosis. Specifically, there are no randomized prospective trials comparing outcomes using one method versus any other. However, comparative retrospective cohort studies do exist and have demonstrated convincing advantages of certain techniques. In particular, the Unilink™/3M™ coupler and the Autosuture™ Vessel Closure System® (VCS®) clip applicator have been shown to have level 2b evidence supporting their use, meaning that the body of evidence achieves a level of comparative cohort studies. Conclusion: Of the available forms of assisted microvascular anastomoses, there is level 2b evidence suggesting a positive outcome with the use of the Unilink™/3M™ coupler and the Autosuture™ VCS® clip applicator. Other techniques such as cyanoacrylates, fibrin glues, the Medtronic™ U-Clip®, and laser bonding have low levels of evidence supporting their use. Further research is required to establish any role for these techniques. © 2011 Wiley Periodicals, Inc. Microsurgery, 2012.

Summary Background: Lore’s fascia and the platysma-auricular ligament are discreet fascial structures anterior and inferior to the auricle respectively. The nomenclature and descriptions of these structures have been presented inconsistently in the literature. There is also concern that placement of platysma suspension sutures into these structures may risk damage to the underlying facial nerve trunk. The aim of this study was to clarify the anatomy of Lore’s fascia and the platysma-auricular ligament, and their relationship to the facial nerve trunk. Materials & methods: A cadaveric study utilising twelve fresh cadaveric hemi-faces was undertaken, investigating the anatomy of Lore’s fascia and the platysma-auricular ligament. This comprised dissection of the periauricular fascial layers and identification of the relationship of thesetwostructurestothefacialnervetrunk.AhistologicalstudyofLore’sfasciawasperformed. Results: Lore’s fascia and the platysma-auricular ligament were identified in all 12 hemi-faces. The structures were anatomically distinct in all cases. The relationship of the facial nerve was documented in each case, with the facial nerve trunk found to lie at least 2 cm deep to the most superficial parts of both structures. Lore’s fascia was demonstrable with histology. Conclusions: Lore’s fascia and the platysma-auricular ligament are separate and consistently demonstrable structures. Both are suitable for platysma suspension sutures in terms of facial nerve trunk safety, and Lore’s ligament can be used as a guide to facial nerve preservation in parotidectomy.

The internal thoracic (IT) vessels (otherwise known as the thoracica interna or internal mammary vessels) are widely used as recipient vessels in autologous breast reconstruction. Despite this, normal and pathological variations in IT artery architecture have been described, and these have the potential to complicate dissection and the selection of suitable vessels. A clinical anatomical study of 240 IT arteries (120 patients) and review of the literature was undertaken. Participants comprised 120 female patients undergoing preoperative imaging of the IT artery prior to autologous breast reconstruction, 42 with computed tomographic angiography (CTA) and 78 with ultrasound. There was complete concordance between surgical and radiological findings. An IT artery was present in 100% of cases, with a duplicate IT artery in two cases (1% overall). The position of the IT artery was between two IT veins most frequently (71.5% of cases), and was lateral to the vein(s) least frequently (6%). There were large IT perforators from the first and second intercostal spaces in 87 and 91% of cases, respectively, with the incidence of such perforators reducing in the lower spaces. The literature highlighted a range of cadaveric and clinical cases in which there was absence of a patent IT artery, variant course or size, and variant relationship to the IT vein. A range of congenital, pathological and iatrogenic variants in IT artery anatomy have the potential to limit the use of the IT artery in autologous breast reconstruction. Preoperative imaging with ultrasound or CTA may provide a clear and accurate method of identifying these anatomical variations pre-operatively.

This paper describes a technique of fasciocutaneous island flaps used in reconstruction of the lower limb. It is very versatile and some 26 individual flaps in 22 patients have been used to reconstruct skeletal and soft tissue problems from the popliteal fossa to the ankle joint. These longitudinally designed flaps made up of a trilaminate of skin, subcutaneous fat and fascia are aligned within the dermatomal precincts. The most important location for such flap design is along the peroneal compartment sitting within the L5 dermatome and incorporating the superficial peroneal nerve. It can be lengthened as far as the lateral malleolus and is an excellent reconstructive method to close defects over the lower third of the tibia. The medial compartment of the leg employing the saphenous nerve (L4 dermatome) is another area for fasciocutaneous island flap reconstruction, but use is restricted to the upper two-thirds of the tibial area. Posteriorly the island flap design sits along the S2 dermatome, this time incorporating the sural nerve to reconstruct defects of the calf and can be extended to include problems of the popliteal fossa. In the overall flap technique, the age of the patient is not a contraindication and cases with peripheral vascular disease have been treated successfully. The flaps may extend up to a 5:1 ratio in dimension. The operating time can be considerably shortened.

With the increasing use of preoperative imaging of the abdominal vasculature prior to free flaps based on the abdominal wall, the identification of a previously undescribed anatomic structure has, that of large-vessel (macroscopic) arteriovenous communications, has emerged. These macrovascular arteriovenous shunts are observed in most patients, and provide a communication between the arterial perforators of the deep inferior epigastric artery and the superficial inferior epigastric vein. These communications provide vascular shunting occurring prior to capillary filling and have potentially profound clinical implications and therapeutic possibilities in a range of medical and surgical conditions. Although these have been demonstrated previously on computed tomographic angiography imaging, their macroscopic and microscopic anatomy has not been described. We present images in vivo, ex vivo, and histologically to highlight their anatomic features.

Background The timing of soft tissue reconstruction for severe open lower limb trauma is critical to its successful outcome, particularly in the setting of exposed metalware and pre-existing wound infection. The use of negative pressure wound therapy (NPWT) may allow a delay in soft tissue coverage without adverse effects. This study evaluated the impact of delayed free-flap reconstruction, prolonged metalware exposure, pre-flap wound infection, and the efficacy of NPWT on the success of soft tissue coverage after open lower limb injury. Methods Retrospective review of all free-flap reconstructions for lower limb trauma undertaken at a tertiary trauma centre between June 2002 and July 2009. Results 103 patients underwent 105 free-flap reconstructions. Compared with patients who were reconstructed within 3 days of injury, the cohort with delayed reconstruction beyond 7 days had significantly increased rates of pre-flap wound infection, flap re-operation, deep metal infection and osteomyelitis. Pre-flap wound infection independently predicted adverse surgical outcomes. In the setting of exposed metalware, free-flap transfer beyond one day significantly increased the flap failure rate. These patients required more surgical procedures and a longer hospital stay. The use of NPWT significantly lowered the rate of flap re-operations and venous thrombosis, but did not allow a delay in reconstruction beyond 7 days from injury without a concomitant rise in skeletal and flap complications. Conclusions Following open lower limb trauma, soft tissue coverage within 3 days of injury and immediately following fracture fixation with exposed metalware minimises pre-flap wound infection and optimises surgical outcomes. NPWT provides effective temporary wound coverage, but does not allow a delay in definitive free-flap reconstruction.

BACKGROUND: Venous congestion leading to partial or total nipple necrosis is a relatively uncommon complication of breast reduction and mastopexy procedures but still occurs, particularly in larger reduction procedures. This is largely preventable if the surgeon has an understanding of the venous drainage to the nipple and carefully preserves it. METHODS: An anatomical study was undertaken on 16 fresh female cadaveric breast specimens. The venous drainage of the breast was explored through vascular injection, radiographic, and cross-sectional studies. RESULTS: The venous drainage of the breast consists of an extensive network of vessels. The nipple-areola complex is drained by a superficial subareolar ring of veins that drains by means of medial and lateral veins. Laterally, superolateral and inferolateral veins drain into the subclavian veins, whereas medially, two veins drain into the internal mammary veins. An inferior vein drains the inferior quadrant of the breast in the midmammary line. Medially, the veins have a superficial course, whereas laterally, the veins follow a deeper course. CONCLUSIONS: The breast contains an extensive venous network. To avoid necrosis of the nipple-areola complex, this venous network should be preserved. The superomedial/medial and inferior pedicles contain the most extensive and more reliable venous drainage patterns.

The deep circumflex iliac artery (DCIA) is rarely used as a perforator flap, despite a clear clinical need for thin osteocutaneous flaps, particularly in head and neck reconstruction. The poor adoption of such a flap is largely due to a poor understanding of the perforators of the DCIA, despite recent publications demonstrating suitable vascular anatomy of the DCIA perforators, particularly evident with the use of preoperative computed tomographic angiography (CTA). We have applied this method of peroperative imaging to successfully select those patients suitable for the DCIA perforator flap and use it clinically.We present a case series of patients who underwent DCIA perforator flap reconstruction following preoperative planning with CTA. Imaging findings, clinical course, and outcomes are presented.Six out of seven patients planned for DCIA perforator flap reconstruction underwent a successful DCIA perforator flap, with imaging findings confirmed at operation, and without any flap loss, hernia, or other significant flap-related morbidities. Because of abberent anatomy and change in defect following excision of pathology, one patient was converted to a free fibular flap.With preoperative CTA planning, the DCIA perforator flap is a versatile and feasible flap for reconstruction of the mandible and extremities.

While free flaps are reliant on their vascular pedicle for survival intraoperatively and for a variable period of time postoperatively, there have been reports of late pedicle compromise after which complete flap survival has ensued. Successful neovascularization and revascularization at the edges of a flap in such cases result in the flap becoming independent of its pedicle. We report a case in which free flap survival occurred following pedicle compromise before postoperative day seven. The use of preoperative computed tomographic angiography (CTA) assessment to map flap vasculature was able to demonstrate the intrinsic vascular anatomy of the flap, and both clinical assessment and photoplethysmography (PPG) assessment of cutaneous blood flow obtained during and after flap compromise were able to highlight the changes in flap perfusion. With complete flap survival despite the lack of pedicle revision, the roles for close monitoring with clinical assessment and PPG, and delaying debridement are discussed.

Nipple malformations are common congenital or acquired conditions that can have tremendous cosmetic, psychological, breast-feeding, sexual, and hygienic ramifications. Ideal reconstruction of the nipple-areola complex (NAC) requires symmetry in position, size, shape, texture, pigmentation, and permanent projection, and although many technical descriptions of NAC reconstruction exist in the medical literature, there are insufficient data presented to accurately compare outcomes. The current article comprises a thorough review of the literature, exploring the techniques described for NAC reconstruction, comparing reported outcomes and complications, and providing an evidence-based approach to NAC reconstruction. The findings of the review suggest that evidence regarding surgical correction of nipple deformity and complete NAC reconstruction is lacking, and loss of nipple projection over time is a pervasive problem common to all flap techniques. A combination of a single pedicle local flap with tattooing for complete NAC reconstruction is currently the most supported method; however, data concerning which type of reconstruction is best suited to immediate versus delayed and type of breast mound remain to be examined.

An understanding of the angiosome of a source vessel in supply to a perforator flap is essential to flap design. With substantial interindividual variability in the size and reliability of such territories, preoperative awareness of factors that affect the number or size of perforators in a given territory can aid operative planning. Body weight and scarring are known to modify a given territory, and anecdotally so too can the "dominance" of adjacent vascular territories. A clinical study of 300 patients (600 body sides) was undertaken, using computed tomographic angiography, to map the vessels of six vascular territories. The effect of interplay between vascular territories was assessed by establishing whether a dominant territory was associated with a diminutive adjacent territory. For every vascular territory investigated, the effect of "dominance" was evident, with a statistically significant effect shown between the deep inferior epigastric artery and superficial inferior epigastric artery territories (p < 0.01), and the anteromedial thigh and anterolateral thigh perforator territories (p = 0.01). The size or dominance of perforators in a given vascular territory is influenced by the dominance of adjacent vascular territories. This concept of perforator or angiosome dominance is an important factor in the design of perforator flaps.

[Extract] The anterolateral thigh flap is well established as a versatile reconstructive option for a range of soft tissue defects, with excellent results reported. However, controversy exists regarding the reliability of the vascular anatomy of the flap. Some authors describe a consistent relationship of perforators to anatomical landmarks and between sides of the body, whereas others have described uncertainty in predicting individual perforator anatomy and advocated the use of preoperative imaging. A major advantage of preoperative imaging is the selection of the side of the body with better vascular anatomy. Computed tomographic angiography has been shown to be accurate in detecting the optimal perforator and limb for flap harvest. To confirm this benefit, the current study aimed to compare the course of anterolateral thigh perforators between body sides.

Summary Background Gluteal artery perforator (GAP) flaps have gained popularity in autologous breast reconstruction, however substantial variability in vascular anatomy has limited their more widespread utilisation. While previous anatomical studies have been limited by specimen numbers and study design, computed tomographic angiography (CTA) can demonstrate in-vivo vascular anatomy in large numbers. We thus undertook an anatomical study with the use of CTA, the largest such study in the literature, and present a clinical series utilising CTA to plan GAP flaps. Methods Eighty consecutive patients (160 gluteal regions) underwent pre-operative CTA, with superior and inferior gluteal artery perforators (SGAPs and IGAPs) assessed for location, size and course. The utility of pre-operative CTA is explored in a series of seven consecutive patients undergoing autologous breast reconstruction. Results There were an average of 11 SGAPs per region (range 6–17), with mean diameter 0.6mm (range 0.3–2.4) and SGAPs >0.8mm diameter identified in every region. In contrast, there were nine IGAPs per region (range 5–14), with mean diameter 0.4mm (range 0.3–1.6) and IGAPs >0.8mm diameter identified in 95% of regions. Individual SGAP and IGAP territories were different between sides and between individuals, with the central tissue variably supplied by either system. In a clinical series, CTA was found to aid operative planning and correlate with operative findings. Conclusion There are regularly abundant SGAPs and IGAPs identifiable per gluteal region, and while many are diminutive in size, the identification of suitable perforators with CTA may aid operative planning for gluteal flap harvest.

The superficial inferior epigastric artery (SIEA) is a useful pedicle in supply to the lower abdominal integument, with its use sparing damage to rectus abdominis muscle or sheath. However, it is limited in usefulness due to its anatomical variability. While previous anatomical studies have been limited in number and study design, the use of preoperative imaging has enabled the analysis of this vasculature in large numbers and greater anatomical detail.A clinical anatomical study of 500 hemi-abdominal walls in 250 consecutive patients undergoing preoperative computed tomographic angiography (CTA) prior to autologous breast reconstruction was undertaken. The presence, size, location, and branching pattern of the SIEA were assessed in each case.The SIEA was identified in 468 cases, an incidence of 94%. Its mean diameter was 0.6 mm, and in 24% of cases was of a diameter1.5 mm. SIEA location was highly variable, with mean position 2-cm lateral to the linea semilunaris (range 0-8 cm lateral), and relationship to the superficial inferior epigastric vein (SIEV) was also highly variable, with the distance between them ranging from 0.3 to 8.5 cm apart. SIEA branches directly crossed the abdominal midline in 5% of cases. Larger SIEA diameters correlated with a decrease in diameter of ipsilateral DIEA perforators.The SIEA is present more frequently than previously demonstrated, but is typically too small for use in free tissue transfer. The variable degree of SIEA branching suggests that its territory of supply is also variable, and that preoperative imaging may be useful in planning SIEA flaps.

Previous studies of cutaneous perforators of the peroneal artery have shown great variability, and attest to the significant anatomical variability in this region. Furthermore, the vascular anatomy of the region has been considered unreliable in the prediction of ideal perforator topography. Preoperative imaging has been suggested as a means for improving preoperative awareness, with Doppler ultrasound and eco-colour (duplex) ultrasound as useful tools. Multi-detector row computed tomographic angiography (CTA or angio CT), has emerged as a significant improvement, providing non-invasive operator-independent details of the vascular anatomy. We utilised this tool to perform an in vivo, anatomical study of the peroneal artery perforators, and demonstrating the usefulness of CTA in planning the osteocutaneous free fibula flap.Forty-one consecutive patients (82 limbs) underwent CTA of the lower limb vasculature, with the anatomical details of the peroneal artery cutaneous perforators assessed.CTA was able to demonstrate the size, course and penetration pattern of all perforators over 0.3 mm in diameter, with measurements for perforators over 0.8 mm diameter recorded for analysis. Of 171 such perforators, accurate identification of the size (mean diameter 1.91 mm), course (59.6% septocutaneous, 29.2% musculocutaneous and 11.1% septomusculocutaneous) and location was achieved.The vascular anatomy of peroneal artery perforators is highly variable, and thus there is a role for preoperative imaging. CTA can demonstrate cases where there is aberrant or non-preferred anatomy, or select the limb of choice for harvest.

Background: While modern reconstructive surgery was revolutionized with the introduction of microsurgical techniques, microsurgery itself has seen the introduction of a range of technological aids and modern techniques aiming to improve dissection times, anastomotic times, and overall outcomes. These include improved preoperative planning, anastomotic aides, and earlier detection of complications with higher salvage rates. Despite the potential for substantial impact, many of these techniques have been evaluated in a limited fashion, and the evidence for each has not been universally explored. The purpose of this review was to establish and quantify the evidence for each technique. Methods: A search of relevant medical databases was performed to identify literature providing evidence for each technology. Levels of evidence were thus accumulated and applied to each technique. Results: There is a relative paucity of evidence for many of the more recent technologies described in the field of microsurgery, with no randomized controlled trials, and most studies in the field comprising case series only. Current evidence-based suggestions include the use of computed tomographic angiography (CTA) for the preoperative planning of perforator flaps, the intraoperative use of a mechanical anastomotic coupling aide (particularly the Unilink® coupler), and postoperative flap monitoring with strict protocols using clinical bedside monitoring and/or the implantable Doppler probe. Conclusion: Despite the breadth of technologies introduced into the field of microsurgery, there is substantial variation in the degree of evidence presented for each, suggesting the role for much future research, particularly from emerging technologies such as robotics and modern simulators. © 2010 Wiley-Liss, Inc. Microsurgery, 2010.

Methods to improve operative outcomes in deep inferior epigastric artery perforator flap surgery have previously focussed on operative technique and postoperative-course modification. Recently, preoperative imaging has become capable of mapping the entire course of perforating vessels, including those vessels as small as 0.3 mm, enabling 'virtual surgery' to be performed preoperatively. This has been shown to facilitate faster and safer surgery. The recent 'Navarra' meeting classified current imaging modalities and discussed the current status of imaging modalities for this role. This article discusses the current expectations and optimal techniques for achieving these outcomes through the available imaging modalities: Doppler ultrasound, colour Doppler ( duplex) ultrasound, computed tomography angiography (CTA) and magnetic resonance angiography (MRA). Features of imaging that are of importance to the surgeon are explored, and a consensus statement has been developed that describes exactly what the current imaging modalities should aim to deliver to the surgeon prior to operating, as well as the benefits and pitfalls of each of these modalities. The techniques described herein permit the radiologist and the surgeon to perform virtual surgery together, preoperatively.

Cadaveric research has widely influenced our understanding of clinical anatomy. However, while many soft-tissue structures remain quiescent after death, other tissues, such as viscera, undergo structural and functional changes that may influence their use in predicting living anatomy. In particular, our understanding of vascular anatomy has been based upon cadaveric studies, in which vascular tone and flow do not match the living situation.An angiographic analysis of the abdominal wall vasculature was performed using plain film and computed tomography angiography in 60 cadaveric hemi-abdominal walls (from 31 cadavers) and 140 living hemi-abdominal walls (in 70 patients). The deep inferior epigastric artery (DIEA) and all of its perforating branches larger than 0.5 mm were analysed for number, calibre and location.Both large, named vessels and small calibre vessels show marked differences between living anatomy and cadaveric specimens. The DIEA was of larger diameter (4.2 mm versus 3.1 mm, P0.01) and had more detectable branches in the cadaveric specimens. Perforators were of greater calibre (diameter 1.5 mm versus 0.8 mm, P0.01) and were more plentiful (16 versus 6, P0.01) in cadaveric specimens. However, the location of individual vessels was similar.Cadaveric anatomy displays marked differences to in vivo anatomy, with the absence of living vascular dynamics affecting vessel diameters in cadaveric specimens. Blood vessels are of greater measurable calibre in cadaveric specimens than in the living. Consequently, cadaveric anatomy should be interpreted with consideration of post-mortem changes, while living anatomical studies, particularly with the use of imaging technologies, should be embraced in anatomical research.

The deep inferior epigastric artery (DIEA) is a reliable pedicle in the design of DIEA perforator flaps, with variations in its anatomy infrequent. Previous studies describing its branching pattern have all been based on cadaveric anatomy and described the following three branching patterns: Type 1 (single trunk), Type 2 (bifurcating trunk), and Type 3 (trifurcating trunk). The increased use of preoperative imaging, particularly with computed tomographic angiography (CTA), has enabled visualization of the DIEA and its branches in vivo, providing a functional view of this anatomy. We undertook a study of 250 patients (500 hemiabdominal walls) undergoing preoperative CTA before DIEA perforator flaps for breast reconstruction. The branching pattern of the DIEA and correlation to the contralateral hemiabdominal wall were assessed. The branching patterns of the DIEA were found to be different in vivo compared with cadaveric studies, with a higher than previously reported incidence of Type 1 patterns and lower than reported incidence of Type 3 patterns, and that some patterns exist which were not included within the previous nomenclature (namely, Type 0 or absent DIEA and Type 4 or four-trunk DIEA). There was also shown to be no overall concordance in the branching patterns of the DIEA between contralateral sides of the same abdominal wall; however, there was shown to be a statistically significant concordance in cases of a Type 1 DIEA (51% concordance, P = 0.04). As such, a new modification to the classification system for the branching pattern of the DIEA is presented based on imaging findings.

New techniques in the harvest of deep inferior epigastric artery perforator (DIEP) flaps have become introduced as a result of modern imaging technologies that can allow virtual surgery to be achieved preoperatively. With computed tomographic angiography, individual anatomy can be appreciated in detail to a level not previously appreciated. These imaging techniques can be successfully used to guide DIEP flap surgery. 'Optimal' perforators can be selected based on size, location, intramuscular and subcutaneous course, and their association with motor nerves. Flap design can be safely achieved based on the cutaneous distribution of perforators. Abdominal wall closure can be improved based on the abdominal contour seen with imaging. Preoperative planning can aid patient selection, plan all aspects of the operative technique, reduce operating time and improve operative outcomes.

Background Despite improving outcomes, venous problems in the harvest of deep inferior epigastric artery perforator (DIEP) flaps remain the more common vascular complications. However, it is apparent that the venous anatomy of the anterior abdominal wall has not been described to the same extent as the arterial anatomy. Previous anatomical studies have focused on cadaveric anatomy or excisional specimens. The current study uses in vivo computed tomographic angiography to evaluate this anatomy, in combination with a cadaveric radiographic study. Methods Both cadaveric and in vivo studies were undertaken using eight whole fresh cadaveric specimens (16 sides) and 100 patients undergoing DIEP flap breast reconstruction (200 sides). The cadaveric component used direct catheter venography and the in vivo studies were undertaken using preoperative computed tomographic angiography, mapping in vivo venous flow. Results : The location, caliber, course, and distribution of the superficial and deep inferior epigastric veins were recorded. The dominance of each system and their direction of drainage were described. Mechanisms for poor venous drainage were postulated, including perforator size, midline crossover of the superficial inferior epigastric vein, and the superficial and deep inferior epigastric vein communications. The incidence of each of these anatomical factors was evaluated. Conclusion The cause of venous compromise is multifactorial, with the current study showing that preoperative computed tomographic angiography may predict venous problems during flap harvest, by demonstrating perforator diameter, midline crossover, and deep-superficial venous communications.

Although the need for mastectomy has been evident for many years, postmastectomy reconstruction has been recognized as an achievable outcome for only a little over a century. A review of the evolution of both autologous and prosthetic options for reconstruction was undertaken. The earliest attempts at reconstruction used autologous techniques that were either unsuccessful, not reproducible, or were associated with significant morbidity. Prosthetic techniques became sought after, with silicone prostheses widely used until concerns about potential adverse effects led to the investigation of alternate options. With these concerns shown to be unfounded, silicone and saline prostheses evolved with successive generations of implants. Concurrent advances in reconstructive surgery led to a revival in autologous techniques for breast reconstruction, with microsurgical free-tissue transfer potentiating a new range of potential donor sites. The abdominal wall became the donor site of choice, and with the advent of perforator flaps, morbidity associated with flap harvest was minimized. In cases where the abdominal wall is unsuitable, flaps such as the superior and inferior gluteal artery perforator flaps, the musculocutaneous gracilis flap, and the "stacked" deep inferior epigastric artery perforator flap are frequently used options. The development of minimally invasive techniques for implant placement and flap harvest, such as endoscopy, continue to evolve, and research in tissue engineering offers a vision for a future without the need for a donor site.

The previously described "perfusion zones" of the abdominal wall vasculature are based on filling of the deep inferior epigastric artery (DIEA) and all its branches simultaneously. With the advent of the DIEA perforator flap, only a single or several perforators are included in supply to the flap. As such, a new model for abdominal wall perfusion has become necessary. The concept of a "perforator angiosome" is thus explored.A clinical and cadaveric study of 155 abdominal walls was undertaken. This comprised the use of 10 whole, unembalmed cadaveric abdominal walls for angiographic studies, and 145 abdominal wall computed tomographic angiograms (CTAs) in patients undergoing preoperative imaging of the abdominal wall vasculature. The evaluation of the subcutaneous branching pattern and zone of perfusion of individual DIEA perforators was explored, particularly exploring differences between medial and lateral row perforators.Fundamental differences exist between medial row and lateral row perforators, with medial row perforators larger (1.3 mm vs. 1 mm) and more likely to ramify in the subcutaneous fat toward the contralateral hemiabdomen (98% of cases vs. 2% of cases). A model for the perfusion of the abdominal wall based on a single perforator is presented.The "perforator angiosome" is dependent on perforator location, and can mapped individually with the use of preoperative imaging.

Background: There is an increasing clinical need for evaluation of the lymphatic anatomy of the breast. Because of tissue putrefaction, previous studies have not been able to achieve radiographic analyses of bilateral breasts in cadaver specimens. The use of improved preservation techniques with computed tomographic lymphangiography (CT; CTL) has now allowed this analysis to be undertaken. Materials and Methods: The bilateral breasts and anterior upper torso from a female unembalmed human cadaver was studied over an 8-week period. Using microsurgical techniques, lymphatic vessels were identified with hydrogen peroxide, injected with lead oxide mixture, and radiographed to demonstrate lymphatic vessels in both breasts. Multiple frozen domestic ice bricks were used to cover the contralateral side of tissues to keep them partially frozen during this lengthy process. The specimen was radiographed, CT scanned, cross-sectioned, and radiographed again, with images digitalized for analysis. Results: A three-dimensional analysis of lymph collecting vessels in the breasts, anterior upper torso and the internal mammary vascular bundles was achieved using both plain radiography and CTL. The lymphatics of the breast and anterior upper torso drain radially into the axillary lymph nodes. A predominance of superficial lymphatics are noted. Importantly, lymphatic vessel patterns of the breast are asymmetric between breasts of each side. Conclusion: Three-dimensional images of the lymphatic drainage of the breasts using advanced imaging technologies are described, with lymphangiography achieved in bilateral cadaveric breasts and anterior upper torso for the first time. This has significant future application for clinical practice.

BACKGROUND: The anterolateral thigh flap is a popular reconstructive option, with a major advantage being its low donor-site morbidity. However, donor-site morbidity following anterolateral thigh flap harvest does occur, with postulated causes including damage to muscle, deep fascia, and the motor nerves to the vastus lateralis. No anatomical studies have yet described the relationship of these motor nerves to the vascular pedicle of the anterolateral thigh flap. METHODS: Thirty-six human cadaveric thighs underwent dissection studies, and the innervation of the vastus lateralis and the relationship of the nerves to the descending branch of the lateral circumflex femoral artery were documented. Variations were recorded. RESULTS: The nerve to the vastus lateralis branches extensively before entering the muscle, with four to seven nerves identified per thigh. Two particular variations of the nerve anatomy are uniquely susceptible to damage: where the motor nerve passes through the vascular pedicle itself or passes between perforators supplying the flap. At least one unfavorable variation was present in 28 percent of cases. CONCLUSIONS: The nerves innervating the vastus lateralis are intimately related to the vascular pedicle of the anterolateral thigh flap. These nerves may be damaged during flap harvest and may contribute to donor-site morbidity after anterolateral thigh flap surgery.

There remains much confusion regarding the pathophysiology of pressure ulcers. Data indicate that the prevalence of pressure ulcers is increasing. The heel is unique in structure and well adapted to the task of shock absorption. However, it is often subject to prolonged pressure, which predisposes it to tissue breakdown, with attempts at reconstruction prone to failure. Four dissections were carried out of the heel region, which included removing each heel pad en bloc for histology. Seventeen arterial injection studies, 12 venous studies, and a combined arterial and venous study of the foot were performed. The results were correlated with clinical cases and previous research. The heel was found to be richly vascularized by a subdermal plexus and periosteal plexus with vessels traveling between the 2 within fibrous septa that connect the reticular dermis and periosteum of the calcaneus. These septa effectively create isolated compartments containing relatively avascular fat. A layer of panniculus carnosus muscle was observed in the subcutaneous tissue. It is likely that the metabolically active panniculus carnosus muscle is involved early in the course of pressure ulcers. Extensive pressure damage can be concealed by intact skin. Friction and shear are additional factors important in skin breakdown.

The abdominal wall donor site has become popularized for autologous breast reconstruction, with low donor site morbidity one of its key attributes. Further improvements in donor site outcomes have been facilitated through muscle sparing techniques, such as the use of the deep inferior epigastric artery (DIEA) perforator (DIEP) flap, and the use of modifications to closing the rectus sheath following muscular dissection, such as the use of endoscopic techniques and the use of mesh. We describe a new and unique method for potentially minimizing donor site damage during DIEP flap harvest: the "limited rectus sheath incisions" technique. This approach is only possible in select cases, the choice of which can be aided with the use of preoperative computed tomography angiography (CTA). In select patients, there may be an extended segment of DIEA that does not give any musculocutaneous perforators, and thus does not require open exposure. In such cases, limited incision to the rectus sheath may be made: one to access the periumbilical perforators and a separate incision to access the pedicle near its origin on the external iliac artery. This incision may then be made in a muscle-splitting fashion, in the line of external oblique fibers. This approach may reduce damage to the anterior rectus sheath, and may contribute to improving donor site morbidity. (c) 2009 Wiley-Liss, Inc. Microsurgery, 2009.

The Achilles tendon is the most frequently ruptured tendon in the lower limb and accounts for almost 20% of all large tendon injuries. Despite numerous published studies describing its blood supply, there has been no uniformity in describing its topography. The current study comprises a detailed anatomical study of both the intrinsic and extrinsic arterial supply of the Achilles tendon, providing the detail sought from studies calling for improved planning of surgical procedures where damage to the vascularity of the Achilles tendon is likely. A dissection, microdissection, histological, and angiographic study was undertaken on 20 cadaveric lower limbs from 16 fresh and four embalmed cadavers. The Achilles tendon is supplied by two arteries, the posterior tibial and peroneal arteries. Three vascular territories were identified, with the midsection supplied by the peroneal artery, and the proximal and distal sections supplied by the posterior tibial artery. The midsection of the Achilles tendon was markedly more hypovascular that the rest of the tendon. The Achilles tendon is at highest risk of rupture and surgical complications at its midsection. Individuals with particularly poor supply of the midsection may be at increased risk of tendon rupture, and approaches to the tendon operatively should consider the route of supply by the peroneal artery to this susceptible part of the tendon.

The radiation exposure of Computed Tomographic Angiography (CTA) in DIEP flap planning : low dose but high impact

Background: Perforator flaps frequently rely on small vessels for their supply, which may lead to problems with flap viability. To ensure a more dependable blood supply, larger perforators are sought either on preoperative imaging or intraoperatively. Body weight gain is usually associated with increasing cutaneous perforator size. The question remains whether body weight loss causes a diminution in the size of these perforators. Methods: Sixty-seven consecutive patients were recruited, each undergoing either deep inferior epigastric perforator flap breast reconstruction (n = 57) or abdominoplasty (n = 10), with measurement of all abdominal wall deep inferior epigastric artery perforators. This was calculated with either preoperative computed tomographic angiography scans or intraoperative measurements. Results: Higher body mass index (>29) was associated with a 2.7-fold increase in number of 1.5-mm perforators (p < 0.01), a 1.3-fold increase in the average diameter of the five largest perforators (p < 0.01), and a 1.2-fold increase in the diameter of the largest perforator (p < 0.01). Subsequent loss of body weight did not reduce the size of perforators. Patients who had been previously heavier had an average of a 2.6- to 3.3-fold increase in the number of perforators larger than 1.5 mm (p < 0.01) and a 1.2-fold increase in the average diameter of the five largest perforators. Conclusions: Body weight gain results in irreversible dilatation of the cutaneous perforators of the abdominal wall, with subsequent body weight loss not decreasing the size of perforators, facilitating optimal flap harvest in perforator flap surgery. Patients can therefore be advised to lose weight preoperatively, with benefit to both flap harvest and operative outcomes.

Imaging of the abdominal wall vasculature prior to deep inferior epigastric artery (DIEA) perforator (DIEP) flaps has been shown to significantly improve surgical outcomes. Although computed tomography angiography (CTA) has been shown to be highly accurate, it is associated with radiation exposure, and as such modalities without radiation exposure have been sought. Magnetic resonance angiography (MRA) has been proposed as such an option. We conducted a pilot study comparing MRA with CTA and with operative findings in six consecutive patients undergoing DIEP flaps for breast reconstruction. The DIEA, superficial inferior epigastric artery (SIEA) and perforators were all assessed with each modality. We found that the DIEA and SIEA were accurately imaged with both CTA and MRA, but that while MRA could identify some major perforators, CTA was more accurate than MRA for perforator mapping. As such, while MRA does have a role in the imaging of DIEA perforators, CTA is still the preferred modality. On the basis of these findings, a larger study into the role for MRA in this setting is warranted.

Cutaneous perforators that do not originate from the deep inferior epigastric artery (DIEA) are rare, but may significantly affect operative outcome. Peritoneal-cutaneous perforators have been described as a source for augmenting the blood flow to a deep inferior epigastric perforator (DIEP) flap, however if unrecognized, may compromise flap survival.We reviewed 375 DIEA perforator (DIEP) flaps (325 with preoperative CTA and 50 cadaveric dissections) to investigate the incidence of this anomaly.We detected this variation in 3/325 (1%) of DIEP flaps following preoperative computed tomography. In 1/50 (2%) of the cadaveric specimens, a peritoneal-cutaneous perforator was found and injected with lead oxide contrast. It was shown to fill the cutaneous veins of the majority of the lower abdominal integument.Peritoneal-cutaneous perforators are rare anatomical variations (4/375: 1.1%) that may have significant ramifications for surgery utilizing the vasculature of the abdominal wall. CTA was significantly able to detect this anomaly and aid operative planning. Preoperative CTA helps to safely identify individual vascular anatomy including rare variations.

Background The deep inferior epigastric artery perforator flap is increasingly used for autologous breast reconstruction, with low donor-site morbidity cited as a major advantage of this operation. Preoperative imaging of the donor-site vasculature is frequently used as a further means of improving operative outcome. Computed tomographic angiography has been increasingly described as a preferred imaging modality; however, its formal evaluation has not been described in a clinical setting. Methods A prospective, single-blind, cohort study was undertaken on 60 consecutive patients for whom deep inferior epigastric artery perforator flap surgery had been planned. Patients who did not undergo the procedure during the study period were excluded, with 42 patients ultimately included in the study. All computed tomographic angiography scans were obtained at a single institution. Perforators were mapped both on angiography and intraoperatively using a grid of 4-mm squares centered on the umbilicus. Only perforators larger than 1 mm were included in the study. All imaging findings were recorded by a single operator, and all intraoperative findings were recorded by the operating surgeon. Results Computed tomographic angiography identified 280 major perforators in 42 patients. It was highly accurate, demonstrating 279 perforators recorded accurately, with one false-positive and one false-negative. Its sensitivity for mapping perforators was thus 99.6 percent, with a positive predictive value of 99.6 percent. Conclusions Computed tomographic angiography is highly accurate in identifying and mapping the perforators of the deep inferior epigastric artery. Its accuracy is superior to that of the previous modalities used in this role and suggests the usefulness of this technique before deep inferior epigastric artery perforator flap surgery for breast reconstruction.