Anatomy and Neuroscience - Theses

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Start date: 2010 × End date: 2019 × Type: Masters Research thesis × Author: Ting, Wen Ching Jeannette ×

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    The anatomical and clinical study of the posterolateral trunk in reconstructive surgery: a study of the deep circumflex iliac artery and gluteal artery perforators
    Ting, Wen Ching Jeannette ( 2011)
    Background: Perforator flaps are becoming increasingly popular methods of reconstruction. Its appeal lies in the predictability of tissue bulk and low donor site morbidity when compared to the more traditionally accepted musculocutaneous flaps. The deep circumflex iliac artery osteomusculocutaneous flap, first described in 1979, has been used in a variety of reconstructions. In particular, it is well documented for use in the hemi-mandible. Similarly, the superior and inferior gluteal musculocutaneous flaps have been used for various breast and perianal reconstructions. As perforator flaps, they are poorly understood and therefore, surgeons often avoid them. Both the deep circumflex iliac artery (DCIA) and superior and inferior gluteal artery perforator (SGAP and IGAP) flaps are located in the posterolateral region of the abdomen and pelvis. The skin overlying these flaps is hairless and both flaps are associated with well hidden donor scars. The perforators have versatile pedicle length, diameter and arc. A study was therefore undertaken to better understand the anatomy of the perforator associated with the DCIA perforator and the SGAP/IGAP with a view to improve preoperative assessment of appropriate patients and improving surgical outcome. Method: A combined cadaveric and clinical study of the vascular anatomy of the posterolateral trunk was undertaken. This included an ink and lead-oxide injection of cadavers to investigate the DCIA perforators. The lead-oxide specimen also underwent x-ray radiographic assessment of the perforators. A Computer Tomographic Angiography (CTA) assessment of 44 DCIA and 160 SGAP/IGAP flap perforators were also performed in patients who were undergoing preoperative CTA prior to breast reconstruction. The clinical study was a series of patients who underwent pre-operative imaging with a view to proceed to a DCIA or GAP perforator flap. Their pre-operative findings and post-operative outcomes were assessed. Appropriate institutional ethical approvals were obtained. Result: Both the cadaveric and CTA studies demonstrated that just over half of hemi-abdomens were suitable for DCIA perforator flaps. All patients studied had sizable SGAP perforators whilst 95% of patients had sizable IGAP perforators. All patients who underwent a planned DCIA, SGAP or IGAP perforator flap at one institute had pre-operative imaging and assessment of their perforators. Whilst just over half of these patients had suitable DCIA, all the patients had well sized SGAP or IGAP. Those with poor DCIA perforators underwent the traditional free fibula flap instead. Their outcomes were comparable with low morbidity and high flap survival rate. Conclusion: Both the DCIA perforator and SGAP/IGAP flaps are useful reconstructive options. The DCIA flap is useful for reconstruction requiring bone, soft tissue as well as skin coverage. The SGAP and IGAP flaps are viable options for reconstruction of variable amount of soft tissue and skin defects. With an understanding of their perforators and a detailed planning of the surgery with CTA, both these flaps can be performed safely and effectively. These posterolateral wall perforator flaps are associated with low donor site morbidity, a well hidden scar and with improved understanding of their anatomy; the DCIA and SGAP/IGAP perforator flaps are safe and sure option available to the reconstructive surgeon.