+
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) xx, 1e5
Preoperative color Doppler ultrasound assessment in planning of SCIP flaps Kensuke Tashiro*, Mitsunobu Harima, Motoi Kato, Takumi Yamamoto, Shuji Yamashita, Mitsunaga Narushima, Takuya Iida, Isao Koshima Department of Plastic and Reconstructive Surgery, The University of Tokyo Hospital, Japan Received 7 September 2014; accepted 5 March 2015
KEYWORDS Microsurgery; Supermicrosurgery; SCIP flap; Color Doppler ultrasound; Preoperative imaging; Perforator flap
Summary Introduction: Superficial circumflex iliac artery perforator (SCIP) flap is based on the perforator of superficial circumflex iliac artery (SCIA) system, and is a highly useful surgical tool with a wide variety of clinical applications. The SCIA system is associated with considerable anatomical variation, however, rendering transfer of a SCIP flap technically difficult. Patients and methods: Using preoperative color Doppler ultrasound (US), we examined a total of 11 flaps of 11 patients who had undergone reconstruction with SCIP flap from April to August of 2014. The origin of SCIA from femoral artery and the bifurcation of its superficial branch and deep branch were easily identifiable in all patients. Perforator courses and their penetration points were marked to guide dissection. Results: Although one patient required secondary revision and skin grafting because of partial necrosis, there were no serious postoperative complications such as total necrosis or resulting absorption of the transferred adiposal flap. In all cases, findings from the preoperative color Doppler US were useful in delineating the dominant vessel within the groin lesion. Conclusion: Using the technique described above, difficulties arising from the anatomical variation within the SCIA system are easily overcome, simplifying SCIP flap harvest. In addition to being relatively easy, the technique is also quick to administer and safe. ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Department of Plastic and Reconstructive Surgery, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 1138655, Japan. Tel.: þ81 3 3815 5411; fax: þ81 3 5800 6929. E-mail address: [email protected] (K. Tashiro). http://dx.doi.org/10.1016/j.bjps.2015.03.004 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Tashiro K, et al., Preoperative color Doppler ultrasound assessment in planning of SCIP flaps, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.03.004
+
MODEL
2
K. Tashiro et al.
Introduction
difficulties associated with anatomical variation during SCIP flap elevation.
Perforator flaps have been widely used across the world for the past two decades, and have revolutionized the field of reconstructive surgery. Many different types of flap are used throughout the body. The superficial circumflex iliac artery perforator (SCIP) flap is based on the perforator of superficial circumflex iliac artery (SCIA) system, and its use in the reconstruction of limb defects was first reported by Koshima et al., in 2004.1 Although SCIP flap is less frequently used than anterolateral thigh (ALT) flaps or deep inferior epigastric artery perforator (DIEP) flap, it is a highly useful surgical tool with a wide variety of clinical applications. In recent years, SCIP flap has been widely used for reconstructive surgery, including head and neck reconstruction,2 external auditory canal reconstruction with a very thin flap,3 penile reconstruction,4 lower extremity reconstruction with perforatorto-perforator anastomosis.14 Designing and marking the course of perforators are essential components of a successful perforator flap transfer. There have been many reports on preoperative examination for perforator flap surgery. The handheld Doppler system represents the traditional method of identifying the course of vessels, though multi-detector row computed tomography (MDCT) has been shown to be useful in harvesting DIEP flaps5 and may be applicable to other types of perforator flap. Nonetheless, no gold standard method has been established for preoperative examination prior to SCIP flap harvest. The usefulness of MDCT has been widely reported, but may not be suitable for SCIP flap elevation due to the relatively short course of the SCIA in the subcutaneous layer. This feature renders delineation of the precise perforator course of the SCIA by MDCT difficult. There are many reports on the usefulness of color Doppler ultrasound (US) during preoperative examination for a variety of perforator flap surgeries,6 including ALT flaps,7 DIEP flaps,8 gluteal perforator flaps9 and sural artery perforator flaps.10 However, there have been no reports describing the application of color Doppler US for preoperative examination prior to SCIP flap elevation. The significant anatomical variation within the SCIA system renders SCIP flap surgery particularly difficult. Here we provide the first report on the usefulness of preoperative color Doppler US for overcoming the technical
Table 1 1 2 3 4 5 6 7 8 9 10 11
Patients and methods We examined a total of 11 flaps of 11 patients who had undergone reconstruction with SCIP flap from April to August of 2014, at the Department of Plastic and Reconstructive Surgery, University of Tokyo Hospital, under the University of Tokyo Hospital Institutional Review Boardapproved protocol. Patient characteristics are listed in Table 1; the study cohort comprised 9 men and 2 women, with a mean age of 45 years (range, 10e79 years). All patients underwent color Doppler US prior to SCIP flap surgery with either an island flap (n Z 3) or a free flap (n Z 8). The flap dimensions ranged from 3 10 cm to 12 36 cm, with a mean size of 7 20 cm. Color Doppler US examinations were performed the day before surgery using a Noblus US diagnostic scanner (Hitachi Aloka Medical, Ltd., Tokyo, Japan) with a 12 or 15 MHz transducer. The examination was completed within 10 min, and did not require specialist skills. The femoral artery and anterior superior iliac spine (ASIS) were marked, and the SCIA system was subsequently identified by color Doppler US. The muscular, lymphatic, nervous and vascular anatomy of the inguinal region was also investigated to facilitate precise dissection. The origin of SCIA from femoral artery and the bifurcation of its superficial branch and deep branch (Figure 1) were easily identifiable in all patients. Perforator courses and their penetration points were marked to guide dissection (Figure 2).
Results Although one patient required secondary revision and skin grafting due to partial necrosis (case 5), there were no serious postoperative complications, such as total necrosis or absorption of the transferred adipose flap. The mean time to completion of the US examination was 10 min. In many cases, findings from the preoperative color Doppler US examination provided helpful information for surgery. The deep branch of SCIA was easily identifiable in
Detailed information of patients. 37M 40M 43M 60F 30M 25M 79M 44M 59M 67M 10F
SCIP SCIPOC SCIP SCIP SCIPOC SCIP(SIEA) SCIP adiposal SCIP SCIP SCIP SCIP
Left eye socket reconstruction Penile reconstruction Facial deformity 1st toe defect Penile reconstruction Right hand VM FP Facial deformity Penile reconstruction Dorsal pedis burn injury Right floating thumb
Free Island Free Free Island Free Free Free Island Free Free
8 17 cm 12 36 cm 8 25 cm 6 20 cm 10 28 cm 3 10 cm 5 15 cm 7 12 cm 10 31 cm 4 15 cm 4 15 cm
No complication No complication No complication No complication Partial necrosis No complication No complication Partial necrosis No complication No complication No complication
Please cite this article in press as: Tashiro K, et al., Preoperative color Doppler ultrasound assessment in planning of SCIP flaps, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.03.004
+
MODEL
Preoperative color Doppler ultrasound assessment in planning of SCIP flaps
Figure 1 The anatomy of SCIA system and the position where US probe should be set.
the deep fascia of the sartorius muscle, which it penetrated on the lateral side (Figure 3). In some cases, it was difficult to trace the route of the deep branch of SCIA after penetration of the deep fascia. As to superficial branch of SCIA, its bifurcation from femoral artery was also easily identifiable, and its supply to inguinal lymph nodes was evident on color Doppler US. In some cases it was missing, while in others it flowed together with superficial inferior epigastric artery (SIEA). Where possible, all identified perforators were dissected at the time of flap elevation (Figure 4). Each perforator was found at the exact site at which it had been marked preoperatively, and their diameters were found to be largely equivalent to predicted dimensions. In case 2, the preoperative color Doppler US examination revealed hypoplasia of the deep branch of SCIA, and hyperplasia of the superficial branch of SCIA. Consequently, we decided to harvest the SCIP flap based on the superficial rather than the deep branch.
Figure 2 Marking the course of SCIA system using color Doppler US. FA: femoral artery, ASIS: anterior superior iliac supine, sup: superficial branch of SCIA, deep: deep branch of SCIA, Sar: Sartorius muscle.
Figure 3
3
The color Doppler US findings of SCIA system.
In case 6, hypoplasia of the SCIA system and hyperplasia of the SIEA system were evident on preoperative examination. These findings were confirmed during dissection, and the flap was harvested based on the SIEA system. Given that the pedicle was changed preoperatively, alteration of the surgical strategy was not problematic.
Discussion In this report, we have demonstrated the usefulness of preoperative color Doppler US during SCIP flap harvest. The use of SCIP flaps was first reported by Koshima et al.,1 and the range of its clinical applications is becoming increasingly extensive. The SCIA system has two main branches: the superficial and the deep. The latter is generally the dominant branch of this system, and its inclusion in the SCIP flap is essential to surgical success. The popularity of the SCIP flap has gradually superseded that of the groin flap, which is limited by the short pedicle length.
Figure 4 The deep branch of SCIA just penetrated the deep fascia of the Sartorius muscle (arrow).
Please cite this article in press as: Tashiro K, et al., Preoperative color Doppler ultrasound assessment in planning of SCIP flaps, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.03.004
+
MODEL
4 The advantages of the SCIP flap are as follows1: lower donor site morbidity; shorter elevation time; and longer pedicle length compared to the conventional groin flap. By contrast, the disadvantages of the SCIP flap include the relatively reduced diameter of pedicle vessels and the anatomical variation within the SCIA system. Sinna et al. conducted an anatomical study of the SCIP flap in 2010.11 In this report, the mean diameter of the dominant perforator of the deep branch of SCIA was 0.85 mm; this dominant perforator was shown to provide a constant and reliable blood supply and to ensure a relatively large perforator groin flap. The high degree of anatomical variation within the SCIA system is widely known, and contributes to the perception that SCIP flap surgery is particularly difficult. In some cases, the SCIA system is hypoplastic or missing, requiring the reconstructive strategy to be altered during surgery. Usually, the superficial branch of SCIA runs in close proximity to the inguinal lymph node and through subcutaneous fat tissue toward the ASIS; on the other hand, the deep branch of SCIA is found just below the deep fascia of the Sartorius muscle, which it subsequently penetrates. The main trunk of the SCIA is hypoplastic if other arterial systems near this lesion are hyperplastic. The relationship between the SCIA, SIEA and deep circumflex iliac artery (DCIA) is complimentary; it is therefore important to have a flexible surgical plan that can be adapted if the SCIA system is not dominant in a particular lesion. Prior knowledge of any hypoplasia or hyperplasia in the SCIA, SIEA, and DCIA systems within a groin lesion promotes the ease and safety of SCIP flap surgery. In one of the 11 cases included in this study, the preoperative color Doppler US examination revealed hypoplasia of the deep branch of SCIA, indicating dominance of the superficial branch. We consequently elevated the SCIP flap based on the superficial branch in this case, although the SCIP flap is usually harvested with the deep branch. In one case within this study, the preoperative color Doppler US examination revealed hypoplasia of the entire SCIA system, indicating dominance of the SIEA system in this lesion. Consequently, the SIEA flap, rather than the SCIP flap, was elevated in this case. MDCT angiography or MRI angiography are not suitable for delineating the course of the superficial and deep branches of SCIA system, owing to the short perforator length of the major vessels in this lesion.12 Color Doppler US is superior to MDCT angiography or MRI angiography in terms of finding small perforators less than 0.5 mm and seeing pulsation of perforators in real time, which assures the reliability of perforators as pedicle of the flap. The handheld Doppler system is similarly inferior to color Doppler US in preoperative identification of SCIP flap perforators because it cannot provide precise information on the subcutaneous tissue layer.13 The advantages of using color Doppler US for SCIP flap elevation are as follows: 1) It is easy to perform at the bedside 2) Examination times are shorter 3) It is possible to mark the course of the SCIA system preoperatively
K. Tashiro et al. 4) It is possible to alter the surgical plan if the SCIA system is hypoplastic 5) It is possible to adapt the surgical plan depending on which SCIA branch (the superficial or the deep) is dominant 6) There is no radiation exposure 7) The muscular, lymphatic, nervous and vascular anatomy of the inguinal region can also be investigated to aid dissection In this article, we have demonstrated the usefulness of preoperative color Doppler US examination for SCIP flap elevation. The SCIP flap is still considered technically difficult relative to other perforator flaps, though difficulties arising from the anatomical variation within the SCIA system can be easily overcome using the technique described here.
Conclusion Preoperative color Doppler US examination renders SCIP flap harvest and transfer safer and more reliable.
Funding None declared.
Conflicts of interest None declared.
References 1. Koshima I, Nanba Y, Tsutsui T, et al. Superficial circumflex iliac artery perforator flap for reconstruction of limb defects. Plast Reconstr Surg 2004 Jan;113(1):233e40. 2. Iida T, Mihara M, Yoshimatsu H, Narushima M, Koshima I. Versatility of the superficial circumflex iliac artery perforator flap in head and neck reconstruction. Ann Plast Surg 2014 Mar; 72(3):332e6. http: //dx.doi.org/10.1097/SAP.0b013e318260a3ad. 3. Narushima M, Yamasoba T, Iida T, et al. Pure skin perforator flap for microtia and congenital aural atresia using supermicrosurgical techniques. J Plast Reconstr Aesthet Surg 2011 Dec;64(12):1580e4. http: //dx.doi.org/10.1016/j.bjps.2011.07.005 [Epub 2011 Sep 7]. 4. Koshima I, Nanba Y, Nagai A, Nakatsuka M, Sato T, Kuroda S. Penile reconstruction with bilateral superficial circumflex iliac artery perforator (SCIP) flaps. J Reconstr Microsurg 2006 Apr; 22(3):137e42. 5. Masia J, Larran ˜aga J, Clavero JA, Vives L, Pons G, Pons JM. The value of the multidetector row computed tomography for the preoperative planning of deep inferior epigastric artery perforator flap: our experience in 162 cases. Ann Plast Surg 2008 Jan;60(1):29e36. http: //dx.doi.org/10.1097/SAP.0b013e31805003c2. 6. Blondeel PN, Beyens G, Verhaeghe R, et al. Doppler flowmetry in the planning of perforator flaps. Br J Plast Surg 1998 Apr; 51(3):202e9. 7. Ensat F, Babl M, Conz C, et al. The efficacy of color duplex sonography in preoperative assessment of anterolateral thigh
Please cite this article in press as: Tashiro K, et al., Preoperative color Doppler ultrasound assessment in planning of SCIP flaps, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.03.004
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Preoperative color Doppler ultrasound assessment in planning of SCIP flaps flap. Microsurgery 2012 Nov;32(8):605e10. http: //dx.doi.org/10.1002/micr.20835 [Epub 2012 Mar 21]. 8. Cina A, Salgarello M, Barone-Adesi L, Rinaldi P, Bonomo L. Planning breast reconstruction with deep inferior epigastric artery perforating vessels: multidetector CT angiography versus color Doppler US. Radiology 2010 Jun;255(3):979e87. http://dx.doi.org/10.1148/radiol.10091166 [Epub 2010 Apr 14]. 9. Isken T, Alagoz MS, Onyedi M, Izmirli H, Isil E, Yurtseven N. Preoperative color Doppler assessment in planning of gluteal perforator flaps. Ann Plast Surg 2009 Feb;62(2):158e63. http: //dx.doi.org/10.1097/SAP.0b013e31817e9cbd. 10. Kosutic D, Pejkovic B, Anderhuber F, et al. Complete mapping of lateral and medial sural artery perforators: anatomical study with Duplex-Doppler ultrasound correlation. J Plast Reconstr Aesthet Surg 2012 Nov;65(11):1530e6. http: //dx.doi.org/10.1016/j.bjps.2012.04.045 [Epub 2012 May 29].
5
11. Sinna R, Hajji H, Qassemyar Q, Perignon D, Benhaim T, Havet E. Anatomical background of the perforator flap based on the deep branch of the superficial circumflex iliac artery (SCIP Flap): a cadaveric study. Eplasty 2010 Jan 18;10:e11. 12. Hong JP. The use of supermicrosurgery in lower extremity reconstruction: the next step in evolution. Plast Reconstr Surg 2009 Jan;123(1):230e5. http: //dx.doi.org/10.1097/PRS.0b013e3181904dc4. 13. 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 Sep 15;118(4): 928e33 [discussion 934-5]. 14. Hong JP, Sun SH, Ben-Nakhi M. Modified superficial circumflex iliac artery perforator flap and supermicrosurgery technique for lower extremity reconstruction: a new approach for moderate-sized defects. Ann Plast Surg 2013 Oct;71(4):380e3.
Please cite this article in press as: Tashiro K, et al., Preoperative color Doppler ultrasound assessment in planning of SCIP flaps, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.03.004
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) xx, 1e5
Preoperative color Doppler ultrasound assessment in planning of SCIP flaps Kensuke Tashiro*, Mitsunobu Harima, Motoi Kato, Takumi Yamamoto, Shuji Yamashita, Mitsunaga Narushima, Takuya Iida, Isao Koshima Department of Plastic and Reconstructive Surgery, The University of Tokyo Hospital, Japan Received 7 September 2014; accepted 5 March 2015
KEYWORDS Microsurgery; Supermicrosurgery; SCIP flap; Color Doppler ultrasound; Preoperative imaging; Perforator flap
Summary Introduction: Superficial circumflex iliac artery perforator (SCIP) flap is based on the perforator of superficial circumflex iliac artery (SCIA) system, and is a highly useful surgical tool with a wide variety of clinical applications. The SCIA system is associated with considerable anatomical variation, however, rendering transfer of a SCIP flap technically difficult. Patients and methods: Using preoperative color Doppler ultrasound (US), we examined a total of 11 flaps of 11 patients who had undergone reconstruction with SCIP flap from April to August of 2014. The origin of SCIA from femoral artery and the bifurcation of its superficial branch and deep branch were easily identifiable in all patients. Perforator courses and their penetration points were marked to guide dissection. Results: Although one patient required secondary revision and skin grafting because of partial necrosis, there were no serious postoperative complications such as total necrosis or resulting absorption of the transferred adiposal flap. In all cases, findings from the preoperative color Doppler US were useful in delineating the dominant vessel within the groin lesion. Conclusion: Using the technique described above, difficulties arising from the anatomical variation within the SCIA system are easily overcome, simplifying SCIP flap harvest. In addition to being relatively easy, the technique is also quick to administer and safe. ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Department of Plastic and Reconstructive Surgery, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 1138655, Japan. Tel.: þ81 3 3815 5411; fax: þ81 3 5800 6929. E-mail address: [email protected] (K. Tashiro). http://dx.doi.org/10.1016/j.bjps.2015.03.004 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Tashiro K, et al., Preoperative color Doppler ultrasound assessment in planning of SCIP flaps, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.03.004
+
MODEL
2
K. Tashiro et al.
Introduction
difficulties associated with anatomical variation during SCIP flap elevation.
Perforator flaps have been widely used across the world for the past two decades, and have revolutionized the field of reconstructive surgery. Many different types of flap are used throughout the body. The superficial circumflex iliac artery perforator (SCIP) flap is based on the perforator of superficial circumflex iliac artery (SCIA) system, and its use in the reconstruction of limb defects was first reported by Koshima et al., in 2004.1 Although SCIP flap is less frequently used than anterolateral thigh (ALT) flaps or deep inferior epigastric artery perforator (DIEP) flap, it is a highly useful surgical tool with a wide variety of clinical applications. In recent years, SCIP flap has been widely used for reconstructive surgery, including head and neck reconstruction,2 external auditory canal reconstruction with a very thin flap,3 penile reconstruction,4 lower extremity reconstruction with perforatorto-perforator anastomosis.14 Designing and marking the course of perforators are essential components of a successful perforator flap transfer. There have been many reports on preoperative examination for perforator flap surgery. The handheld Doppler system represents the traditional method of identifying the course of vessels, though multi-detector row computed tomography (MDCT) has been shown to be useful in harvesting DIEP flaps5 and may be applicable to other types of perforator flap. Nonetheless, no gold standard method has been established for preoperative examination prior to SCIP flap harvest. The usefulness of MDCT has been widely reported, but may not be suitable for SCIP flap elevation due to the relatively short course of the SCIA in the subcutaneous layer. This feature renders delineation of the precise perforator course of the SCIA by MDCT difficult. There are many reports on the usefulness of color Doppler ultrasound (US) during preoperative examination for a variety of perforator flap surgeries,6 including ALT flaps,7 DIEP flaps,8 gluteal perforator flaps9 and sural artery perforator flaps.10 However, there have been no reports describing the application of color Doppler US for preoperative examination prior to SCIP flap elevation. The significant anatomical variation within the SCIA system renders SCIP flap surgery particularly difficult. Here we provide the first report on the usefulness of preoperative color Doppler US for overcoming the technical
Table 1 1 2 3 4 5 6 7 8 9 10 11
Patients and methods We examined a total of 11 flaps of 11 patients who had undergone reconstruction with SCIP flap from April to August of 2014, at the Department of Plastic and Reconstructive Surgery, University of Tokyo Hospital, under the University of Tokyo Hospital Institutional Review Boardapproved protocol. Patient characteristics are listed in Table 1; the study cohort comprised 9 men and 2 women, with a mean age of 45 years (range, 10e79 years). All patients underwent color Doppler US prior to SCIP flap surgery with either an island flap (n Z 3) or a free flap (n Z 8). The flap dimensions ranged from 3 10 cm to 12 36 cm, with a mean size of 7 20 cm. Color Doppler US examinations were performed the day before surgery using a Noblus US diagnostic scanner (Hitachi Aloka Medical, Ltd., Tokyo, Japan) with a 12 or 15 MHz transducer. The examination was completed within 10 min, and did not require specialist skills. The femoral artery and anterior superior iliac spine (ASIS) were marked, and the SCIA system was subsequently identified by color Doppler US. The muscular, lymphatic, nervous and vascular anatomy of the inguinal region was also investigated to facilitate precise dissection. The origin of SCIA from femoral artery and the bifurcation of its superficial branch and deep branch (Figure 1) were easily identifiable in all patients. Perforator courses and their penetration points were marked to guide dissection (Figure 2).
Results Although one patient required secondary revision and skin grafting due to partial necrosis (case 5), there were no serious postoperative complications, such as total necrosis or absorption of the transferred adipose flap. The mean time to completion of the US examination was 10 min. In many cases, findings from the preoperative color Doppler US examination provided helpful information for surgery. The deep branch of SCIA was easily identifiable in
Detailed information of patients. 37M 40M 43M 60F 30M 25M 79M 44M 59M 67M 10F
SCIP SCIPOC SCIP SCIP SCIPOC SCIP(SIEA) SCIP adiposal SCIP SCIP SCIP SCIP
Left eye socket reconstruction Penile reconstruction Facial deformity 1st toe defect Penile reconstruction Right hand VM FP Facial deformity Penile reconstruction Dorsal pedis burn injury Right floating thumb
Free Island Free Free Island Free Free Free Island Free Free
8 17 cm 12 36 cm 8 25 cm 6 20 cm 10 28 cm 3 10 cm 5 15 cm 7 12 cm 10 31 cm 4 15 cm 4 15 cm
No complication No complication No complication No complication Partial necrosis No complication No complication Partial necrosis No complication No complication No complication
Please cite this article in press as: Tashiro K, et al., Preoperative color Doppler ultrasound assessment in planning of SCIP flaps, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.03.004
+
MODEL
Preoperative color Doppler ultrasound assessment in planning of SCIP flaps
Figure 1 The anatomy of SCIA system and the position where US probe should be set.
the deep fascia of the sartorius muscle, which it penetrated on the lateral side (Figure 3). In some cases, it was difficult to trace the route of the deep branch of SCIA after penetration of the deep fascia. As to superficial branch of SCIA, its bifurcation from femoral artery was also easily identifiable, and its supply to inguinal lymph nodes was evident on color Doppler US. In some cases it was missing, while in others it flowed together with superficial inferior epigastric artery (SIEA). Where possible, all identified perforators were dissected at the time of flap elevation (Figure 4). Each perforator was found at the exact site at which it had been marked preoperatively, and their diameters were found to be largely equivalent to predicted dimensions. In case 2, the preoperative color Doppler US examination revealed hypoplasia of the deep branch of SCIA, and hyperplasia of the superficial branch of SCIA. Consequently, we decided to harvest the SCIP flap based on the superficial rather than the deep branch.
Figure 2 Marking the course of SCIA system using color Doppler US. FA: femoral artery, ASIS: anterior superior iliac supine, sup: superficial branch of SCIA, deep: deep branch of SCIA, Sar: Sartorius muscle.
Figure 3
3
The color Doppler US findings of SCIA system.
In case 6, hypoplasia of the SCIA system and hyperplasia of the SIEA system were evident on preoperative examination. These findings were confirmed during dissection, and the flap was harvested based on the SIEA system. Given that the pedicle was changed preoperatively, alteration of the surgical strategy was not problematic.
Discussion In this report, we have demonstrated the usefulness of preoperative color Doppler US during SCIP flap harvest. The use of SCIP flaps was first reported by Koshima et al.,1 and the range of its clinical applications is becoming increasingly extensive. The SCIA system has two main branches: the superficial and the deep. The latter is generally the dominant branch of this system, and its inclusion in the SCIP flap is essential to surgical success. The popularity of the SCIP flap has gradually superseded that of the groin flap, which is limited by the short pedicle length.
Figure 4 The deep branch of SCIA just penetrated the deep fascia of the Sartorius muscle (arrow).
Please cite this article in press as: Tashiro K, et al., Preoperative color Doppler ultrasound assessment in planning of SCIP flaps, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.03.004
+
MODEL
4 The advantages of the SCIP flap are as follows1: lower donor site morbidity; shorter elevation time; and longer pedicle length compared to the conventional groin flap. By contrast, the disadvantages of the SCIP flap include the relatively reduced diameter of pedicle vessels and the anatomical variation within the SCIA system. Sinna et al. conducted an anatomical study of the SCIP flap in 2010.11 In this report, the mean diameter of the dominant perforator of the deep branch of SCIA was 0.85 mm; this dominant perforator was shown to provide a constant and reliable blood supply and to ensure a relatively large perforator groin flap. The high degree of anatomical variation within the SCIA system is widely known, and contributes to the perception that SCIP flap surgery is particularly difficult. In some cases, the SCIA system is hypoplastic or missing, requiring the reconstructive strategy to be altered during surgery. Usually, the superficial branch of SCIA runs in close proximity to the inguinal lymph node and through subcutaneous fat tissue toward the ASIS; on the other hand, the deep branch of SCIA is found just below the deep fascia of the Sartorius muscle, which it subsequently penetrates. The main trunk of the SCIA is hypoplastic if other arterial systems near this lesion are hyperplastic. The relationship between the SCIA, SIEA and deep circumflex iliac artery (DCIA) is complimentary; it is therefore important to have a flexible surgical plan that can be adapted if the SCIA system is not dominant in a particular lesion. Prior knowledge of any hypoplasia or hyperplasia in the SCIA, SIEA, and DCIA systems within a groin lesion promotes the ease and safety of SCIP flap surgery. In one of the 11 cases included in this study, the preoperative color Doppler US examination revealed hypoplasia of the deep branch of SCIA, indicating dominance of the superficial branch. We consequently elevated the SCIP flap based on the superficial branch in this case, although the SCIP flap is usually harvested with the deep branch. In one case within this study, the preoperative color Doppler US examination revealed hypoplasia of the entire SCIA system, indicating dominance of the SIEA system in this lesion. Consequently, the SIEA flap, rather than the SCIP flap, was elevated in this case. MDCT angiography or MRI angiography are not suitable for delineating the course of the superficial and deep branches of SCIA system, owing to the short perforator length of the major vessels in this lesion.12 Color Doppler US is superior to MDCT angiography or MRI angiography in terms of finding small perforators less than 0.5 mm and seeing pulsation of perforators in real time, which assures the reliability of perforators as pedicle of the flap. The handheld Doppler system is similarly inferior to color Doppler US in preoperative identification of SCIP flap perforators because it cannot provide precise information on the subcutaneous tissue layer.13 The advantages of using color Doppler US for SCIP flap elevation are as follows: 1) It is easy to perform at the bedside 2) Examination times are shorter 3) It is possible to mark the course of the SCIA system preoperatively
K. Tashiro et al. 4) It is possible to alter the surgical plan if the SCIA system is hypoplastic 5) It is possible to adapt the surgical plan depending on which SCIA branch (the superficial or the deep) is dominant 6) There is no radiation exposure 7) The muscular, lymphatic, nervous and vascular anatomy of the inguinal region can also be investigated to aid dissection In this article, we have demonstrated the usefulness of preoperative color Doppler US examination for SCIP flap elevation. The SCIP flap is still considered technically difficult relative to other perforator flaps, though difficulties arising from the anatomical variation within the SCIA system can be easily overcome using the technique described here.
Conclusion Preoperative color Doppler US examination renders SCIP flap harvest and transfer safer and more reliable.
Funding None declared.
Conflicts of interest None declared.
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Please cite this article in press as: Tashiro K, et al., Preoperative color Doppler ultrasound assessment in planning of SCIP flaps, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.03.004
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