Further experience with the free soleus perforator flaps using CT-angiography as a planning tool – A preliminary study

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Abstract

Introduction

The soleus perforator flap is a soft tissue flap with minimal donor site morbidity however is not frequently utilised due to the unpredictability of the perforating vessel to serve as the vascular pedicle. We have trialed the use of CT-angiography as a planning tool to predict location, length, course, and calibre of the pedicle to make this a more reliable choice.

Methods

Twenty consecutive patients with intraoral squamous cell carcinomas were assessed with CT-angiography to examine the peroneal perforators before considering soleus flap raising. If a sizeable perforator could be visualised at the upper half of the lower leg, flap raising was carried out, and the result of the CT-angiography was compared with the intra-operative findings.

Results

CT-angiography allowed for visualisation of perforators measuring 1 mm in diameter and could predict location, length and course of the vessel. Accordingly, eight of the 20 patients had to be excluded from flap raising due to missing, too fine or too far distally located perforators. Intra-operative findings corresponded well with the results of the CT-scans.

Conclusion

CT-angiography is a useful tool for planning the soleus perforator flap and allows selection of the most suitable perforator making the use of this flap more reliable.

Introduction

With the introduction of perforator flaps by Koshima and Soeda (1989) and the description of supramicrosurgery by Koshima (Koshima et al., 1998), almost any region of the body can be used as a donor site to harvest skin flaps with minimal invasiveness. Among these, the soleus perforator flap was proposed for reconstructions of the head and neck, especially the oral cavity, and for defect cover on the extremities (Tsai et al., 2002, Wolff et al., 2004, Kawamura et al., 2005, Wolff et al., 2006, Kim et al., 2010). Despite its thinness, pliability and the minimal morbidity associated with flap raising, it has until now failed to become a routine procedure in reconstructive surgery. The main reason for its limited use is the variation in size, course and location of the perforator. The selection of the most suitable perforator is usually made intra-operatively, sometimes leading to a wide exposure and prolonged operation time. As a consequence, the surgeon might face an anastamosis on vessels with a diameter of less than 1 mm. When starting the operation without proper planning, the only suitable perforator that is exposed might have its origin too far distally in the leg, so that primary closure becomes impossible even in small flaps. In these cases, the need for a skin graft would significantly increase the donor site morbidity. It has been suggested that Doppler imaging could be used to predict the exact location of the perforator (Rand et al., 1994, Iida et al., 2003), however this gives no reliable information about size and course of the vessels (Satoh et al., 2011).

The aim of this preliminary study was to determine the suitability of CT-angiography (CTA) to visualise the side branches of the peroneal artery to allow identification of the most suitable perforator for raising the soleus perforator flap. We especially wanted to investigate if this technique can provide reliable information about the diameter, course, location, and length of the perforators. We also compared the vascular anatomy of both sides to make selection of the most appropriate donor leg possible.

Section snippets

Materials and methods

We identified 20 consecutive patients with Primary Squamous Cell Carcinoma (buccal, floor-of-mouth or tongue) for whom we felt the soleus perforator flap would potentially provide the best reconstruction (Fig. 1). Each patient underwent a high resolution CT-angiography study. The CTA acquisition parameters were 120 kV and 150 mAs, with a tube rotation speed of 0.3 s (table pitch, 1.2) at a 256-slice MSCT (multislice computed tomography) Brilliance iCT (Philips Healthcare, Netherlands). The

Results

Eight of the twenty patients were not suitable for the soleus perforator flap due to arteriosclerosis (2), missing (1) or very fine (2) perforators or perforators which were exclusively located at the distal third of the calf (3). Thus, only 12 patients were selected for perforator flap surgery. We found that perforators could only be visualised on the scan if the diameter was at least 1 mm intra-operatively, however we determined that 1.5 mm was the minimum diameter to allow successful

Discussion

In contrast to traditional soft tissue flaps, which with their straightforward raising procedures lead to high success rates in reconstructive surgery, perforator flaps have the disadvantage of a variable vascular anatomy and a pedicle which is short and of small calibre. On the other hand, the raising of these flaps leads to a negligible donor site morbidity, and the flaps are thin and pliable, making the ideally suited for head and neck reconstruction. It is known from numerous clinical and

Conclusion

From the results of our preliminary study, both preconditions for successful flap raising can be examined with CT-angiography, namely the quality and the location of the flap pedicle. There were deviations of up to 2 cm between CTA and clinical findings, however preoperative imaging always provided sufficient information which finally led to successful flap raising in all cases deemed suitable. Although further technical improvements in CTA imaging may lead to even more detailed measurements, we

Conflict of interest

All authors disclose any financial and personal relationships with other people or organisations that could inappropriately influence (bias) this work. The authors declare that there are no conflicts of interest including employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding.

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    Copyright © 2011 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.