Technical Aspects of High-Resolution Color-Coded Duplex Sonography for the Design of Perforator Flaps

Abstract

Background Technical aspects are of utmost significance for an efficient execution in designing perforator flaps with high-resolution color-coded Duplex sonography (CCDS). The following study evaluates decisive factors for a successful microvessel examination conducted by the microsurgeon.

Methods Technical knowledge presented in this study was based on a series of more than 200 perforator flaps planned with CCDS. Flap reconstructions were performed at the University Hospital Regensburg, Germany, from July 2013 to January 2021. Standard high-resolution ultrasound (US) devices with linear multifrequency transducers of 4 to 18 MHz were used. Modes and device settings were evaluated regarding applicability by microsurgeons. Key steps for safe perforator identification and further optional steps for additional assessment should be discriminated.

Results Different US modes including brightness mode (B-mode), color flow (CF), power Doppler (PD), pulse wave (PW), and blood flow (B-Flow) were used. Transducers from 15 MHz and up were favorable to detect microvessels. Knobology of a standard US device regarding buttons, switches, and specific onscreen options with relevance for perforator mapping was subcategorized in four different groups. For qualitative and quantitative evaluation of microvessels, different US modes were tested with respect to their usefulness.

Vital elements of the CCDS exam are disaggregated into three key steps for safe perforator identification and three optional steps for further perforator characterization. A standardized protocol for the CCDS exams was applied. Downregulation of pulse-repetition frequency/scale to adapt device sensitivity to slow-flow velocities represented the most important criterion to visualize microvessels.

Qualitative microvessel evaluation was performed in B-mode, CCDS, PD mode, and B-Flow mode. Quantitative assessment was executed using PW-mode and CCDS measuring the microvessels' diameter (mm) and flow characteristics. Quantitative information may be obtained using PW-mode and the distance-measuring tool in CF-mode.

Conclusion Technical aspects with respect to proper device trimming and application decisively impact CCDS-guided perforator vessel identification and evaluation.

Keywords

ultrasound - perforator flap - perforator mapping

• References

• 1 Cheng HT, Lin FY, Chang SC. Diagnostic efficacy of preoperative 64-section multidetector computed tomographic angiography in identifying the cutaneous perforators in the anterolateral thigh flap: an evidence-based review. Plast Reconstr Surg 2012; 130 (05) 771e-772e
• 2 Cheng HT, Lin FY, Chang SC. Evaluation of diagnostic accuracy using preoperative handheld Doppler in identifying the cutaneous perforators in the anterolateral thigh flap: a systematic review. Plast Reconstr Surg 2012; 129 (04) 769e-770e
• 3 Cheng HT, Lin FY, Chang SC. Diagnostic efficacy of color Doppler ultrasonography in preoperative assessment of anterolateral thigh flap cutaneous perforators: an evidence-based review. Plast Reconstr Surg 2013; 131 (03) 471e-473e
• 4 Tashiro K, Yamashita S, Araki J, Narushima M, Iida T, Koshima I. Preoperative color Doppler ultrasonographic examination in the planning of thoracodorsal artery perforator flap with capillary perforators. J Plast Reconstr Aesthet Surg 2016; 69 (03) 346-350
• 5 Su W, Lu L, Lazzeri D. et al. Contrast-enhanced ultrasound combined with three-dimensional reconstruction in preoperative perforator flap planning. Plast Reconstr Surg 2013; 131 (01) 80-93
• 6 Vaienti L, Cottone G, De Francesco F, Borelli F, Zaccaria G, Amendola F. The suprafascial course of lower leg perforators: an anatomical study. Arch Plast Surg 2020; 47 (02) 165-170
• 7 Visconti G, Bianchi A, Hayashi A. et al. Thin and superthin perforator flap elevation based on preoperative planning with ultrahigh-frequency ultrasound. Arch Plast Surg 2020; 47 (04) 365-370
• 8 Schwabegger AH, Bodner G, Rieger M, Jaschke WR, Ninković MM. Internal mammary vessels as a model for power Doppler imaging of recipient vessels in microsurgery. Plast Reconstr Surg 1999; 104 (06) 1656-1665
• 9 Yamamoto T, Yamamoto N, Fuse Y, Kageyama T, Sakai H, Tsukuura R. Subdermal dissection for elevation of pure skin perforator flaps and superthin flaps: the dermis as a landmark for the most superficial dissection plane. Plast Reconstr Surg 2021; 147 (03) 470-478
• 10 Gravvanis A, Petrocheilou G, Tsoutsos D, Delikonstantinou I, Karakitsos D. Integrating imaging techniques in lower limb microsurgical reconstruction: focusing on ultrasonography versus computed tomography angiography. In Vivo 2013; 27 (03) 371-375
• 11 Alzaraa A, Gravante G, Chung WY. et al. Contrast-enhanced ultrasound in the preoperative, intraoperative and postoperative assessment of liver lesions. Hepatol Res 2013; 43 (08) 809-819
• 12 Hallock GG. Doppler sonography and color duplex imaging for planning a perforator flap. Clin Plast Surg 2003; 30 (03) 347-357 , v–vi
• 13 Kehrer A, Sachanadani NS, da Silva NPB. et al. Step-by-step guide to ultrasound-based design of alt flaps by the microsurgeon - basic and advanced applications and device settings. J Plast Reconstr Aesthet Surg 2020; 73 (06) 1081-1090
• 14 Kehrer A, Lonic D, Heidekrueger P. et al. Feasibility study of preoperative microvessel evaluation and characterization in perforator flaps using various modes of color-coded duplex sonography (CCDS). Microsurgery 2020; 40 (07) 750-759
• 15 Cho MJ, Kwon JG, Pak CJ, Suh HP, Hong JP. The role of duplex ultrasound in microsurgical reconstruction: review and technical considerations. J Reconstr Microsurg 2020; 36 (07) 514-521
• 16 Hwang JY. Doppler ultrasonography of the lower extremity arteries: anatomy and scanning guidelines. Ultrasonography 2017; 36 (02) 111-119
• 17 Kruskal JB, Newman PA, Sammons LG, Kane RA. Optimizing Doppler and color flow US: application to hepatic sonography. Radiographics 2004; 24 (03) 657-675
• 18 Saba L, Atzeni M, Rozen WM. et al. Non-invasive vascular imaging in perforator flap surgery. Acta Radiol 2013; 54 (01) 89-98
• 19 Naqvi TZ, Perese S. Noninvasive vascular appropriateness criteria–review and comments on the American College of Cardiology (ACC) Guidelines. J Am Soc Echocardiogr 2013; 26 (05) A34
• 20 Borgbjerg J, Bøgsted M, Lindholt JS, Behr-Rasmussen C, Hørlyck A, Frøkjær JB. Superior reproducibility of the leading to leading edge and inner to inner edge methods in the ultrasound assessment of maximum abdominal aortic diameter. Eur J Vasc Endovasc Surg 2018; 55 (02) 206-213
• 21 Kehrer A, Hsu MY, Chen YT, Sachanandani NS, Tsao CK. Simplified profunda artery perforator (PAP) flap design using power Doppler ultrasonography (PDU): a prospective study. Microsurgery 2018; 38 (05) 512-523
• 22 Dorfman D, Pu LL. The value of color duplex imaging for planning and performing a free anterolateral thigh perforator flap. Ann Plast Surg 2014; 72 (Suppl. 01) S6-S8
• 23 Rand RP, Cramer MM, Strandness Jr DE. Color-flow duplex scanning in the preoperative assessment of TRAM flap perforators: a report of 32 consecutive patients. Plast Reconstr Surg 1994; 93 (03) 453-459
• 24 Visconti G, Bianchi A, Hayashi A, Salgarello M. Pure skin perforator flap direct elevation above the subdermal plane using preoperative ultra-high frequency ultrasound planning: a proof of concept. J Plast Reconstr Aesthet Surg 2019; 72 (10) 1700-1738
• 25 Visconti G, Hayashi A, Bianchi A, Salgarello M. Technological advances in lymphatic surgery: the emerging role of ultrasound. Plast Reconstr Surg 2019
• 26 Hayashi A, Visconti G, Yamamoto T. et al. Intraoperative imaging of lymphatic vessel using ultra high-frequency ultrasound. J Plast Reconstr Aesthet Surg 2018; 71 (05) 778-780
• 27 Visconti G, Hayashi A, Yoshimatsu H, Bianchi A, Salgarello M. Ultra-high frequency ultrasound in planning capillary perforator flaps: preliminary experience. J Plast Reconstr Aesthet Surg 2018; 71 (08) 1146-1152
• 28 Kehrer A, Heidekrueger PI, Lonic D. et al. High-resolution ultrasound-guided perforator mapping and characterization by the microsurgeon in lower limb reconstruction. J Reconstr Microsurg 2021; 37 (01) 75-82
• 29 Rafailidis V, Sidhu PS. Vascular ultrasound, the potential of integration of multiparametric ultrasound into routine clinical practice. Ultrasound 2018; 26 (03) 136-144
• 30 Rübenthaler J, Reiser M, Clevert DA. Diagnostic vascular ultrasonography with the help of color Doppler and contrast-enhanced ultrasonography. Ultrasonography 2016; 35 (04) 289-301
• 31 Kehrer A, Mandlik V, Taeger C, Geis S, Prantl L, Jung EM. Postoperative control of functional muscle flaps for facial palsy reconstruction: ultrasound guided tissue monitoring using contrast enhanced ultrasound (CEUS) and ultrasound elastography. Clin Hemorheol Microcirc 2017; 67 (3-4): 435-444
• 32 Lin CT, Huang JS, Hsu KC, Yang KC, Chen JS, Chen LW. Different types of suprafascial courses in thoracodorsal artery skin perforators. Plast Reconstr Surg 2008; 121 (03) 840-848
• 33 Hayashi A, Giacalone G, Yamamoto T. et al. Ultra high-frequency ultrasonographic imaging with 70 MHz scanner for visualization of the lymphatic vessels. Plast Reconstr Surg Glob Open 2019; 7 (01) e2086
• 34 Pratt GF, Rozen WM, Chubb D, Ashton MW, Alonso-Burgos A, Whitaker IS. Preoperative imaging for perforator flaps in reconstructive surgery: a systematic review of the evidence for current techniques. Ann Plast Surg 2012; 69 (01) 3-9