Preliminary Exploration: When Angiosome Meets Prefabricated Flaps

Abstract

Background The best known limitation to the use of prefabricated flaps is their limited survival area. One explanation for this is insufficient neovascularization. However, blood flow of prefabricated flaps is through their innate vascular network. This could lead one to conclude that angiosomes may impede blood perfusion. This study aims to settle this contradiction between theory and clinical practice.

Methods We performed a two-stage operation of a prefabricated abdominal flap in a rat model. The rats were divided into five groups (n = 6/group). Group A: fixed pedicle at a horizontal angle; Group B: fixed pedicle at an oblique angle; Group C: fixed pedicle at a vertical angle; Group D: fixed pedicle in the same position as Group A; and Group E: axial flap. Groups A and B were prefabricated for 2 weeks and Groups C and D were prefabricated for 3 weeks. Macroscopic appearance was noted, and analysis of near-infrared fluorescence imaging and capillary density was performed.

Results There was no significant difference in the flaps' survival area between Groups A and B. Group D had a significantly larger survival area when compared with Group C. The boundary between two angiosomes (medioventral line) seemed to limit the indocyanine green perfusion in Groups B, C, and E, while in Groups A and D, no such limitation was seen. Capillary density was positively correlated with neovascularization time.

Conclusions Angiosomes impede blood perfusion in prefabricated flaps. Cross-bound neovascular vessels nourish the flap, thus overcoming the limitation of choke vessels.

Keywords

prefabricated flaps - angiosome - near-infrared fluorescence imaging

Note

Heng Xu and Zheng Zhang have contributed equally to the preparation of the work.

• References

• 1 Yao ST. Vascular implantation into skin flap: experimental study and clinical application: a preliminary report. Plast Reconstr Surg 1981; 68 (3) 404-410
• 2 Pribaz JJ, Fine N, Orgill DP. Flap prefabrication in the head and neck: a 10-year experience. Plast Reconstr Surg 1999; 103 (3) 808-820
• 3 Li JN, Hu Y. A review of the experimental study and clinical application of the prefabricated flap. Eur J Plast Surg 2001; 24: 271-274
• 4 Hoang NT, Kloeppel M, Werner J, Staudenmaier R, Biemer E. Proposed new method for angiographically quantifying neovascularization in prefabricated flaps. Microsurgery 2005; 25 (3) 220-226
• 5 Xie F, Zhu H, Gu B, Zan T, Liu K, Li Q. Resurfacing severe facial burn scars: an algorithm based on three different types of prefabricated expanded flaps. J Reconstr Microsurg 2014; 30 (9) 627-634
• 6 Lazzeri D, Su W, Qian Y , et al. Prefabricated neck expanded skin flap with the superficial temporal vessels for facial resurfacing. J Reconstr Microsurg 2013; 29 (4) 255-262
• 7 Abbase EA, Shenaq SM, Spira M, el-Falaky MH. Prefabricated flaps: experimental and clinical review. Plast Reconstr Surg 1995; 96 (5) 1218-1225
• 8 Tark KC, Khouri RK, Shin KS, Shaw WW. The fasciovascular pedicle for revascularization of other tissues. Ann Plast Surg 1991; 26 (2) 149-155
• 9 Ersoy B, Bayramiçli M, Ercan F, Şirinoğlu H, Turan P, Numanoğlu A. Comparison of bone prefabrication with vascularized periosteal flaps, hydroxyapatite, and bioactive glass in rats. J Reconstr Microsurg 2015; 31 (4) 291-299
• 10 Chang H, Minn KW, Imanishi N, Minabe T, Nakajima H. Effect of venous superdrainage on a four-territory skin flap survival in rats. Plast Reconstr Surg 2007; 119 (7) 2046-2051
• 11 Taylor GI, Corlett RJ, Dhar SC, Ashton MW. The anatomical (angiosome) and clinical territories of cutaneous perforating arteries: development of the concept and designing safe flaps. Plast Reconstr Surg 2011; 127 (4) 1447-1459
• 12 Dhar SC, Taylor GI. The delay phenomenon: the story unfolds. Plast Reconstr Surg 1999; 104 (7) 2079-2091
• 13 Ribatti D, Crivellato E. “Sprouting angiogenesis”, a reappraisal. Dev Biol 2012; 372 (2) 157-165
• 14 Tark KC, Shaw WW. The revascularization interface in flap prefabrication: a quantitative and morphologic study of the relationship between carrier size and surviving area. J Reconstr Microsurg 1996; 12 (5) 325-330
• 15 Guo L, Pribaz JJ. Clinical flap prefabrication. Plast Reconstr Surg 2009; 124 (6, Suppl): e340-e350