Planes for Perforator/Skin Flap Elevation—Definition, Classification, and Techniques

Abstract

Background Elevation in different layers achieving thin flaps are becoming relatively common practice for perforator flaps. Although postreconstruction debulking achieves pleasing aesthetic results and is widely practiced, customized approach during elevation to achieve the ideal thickness will increase efficiency while achieving the best possible aesthetic outcome. Multiple planes for elevation have been reported along with different techniques but it is quite confusing and may lack correspondence to the innate anatomy of the skin and subcutaneous tissue.

Methods This article reviews the different planes of elevation and aims to clarify the definition and classification in accordance to anatomy and present the pros and cons of elevation based on the different layers and provide technical tips for elevation.

Results Five different planes of elevation for perforator flaps are identified: subfascial, suprafacial, superthin, ultrathin, and subdermal (pure skin) layers based on experience, literature, and anatomy.

Conclusion These planes all have their unique properties and challenges. Understanding the benefits and limits along with the technical aspect will allow the surgeon to better apply the perforator flaps.

Keywords

perforator flap - flap elevation planes - thin flaps - superthin flaps

Publication History

Received: 10 January 2022

Accepted: 23 April 2022

Article published online:
22 November 2022

• References

• 1 Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg 1994; 93 (07) 1503-1504
• 2 Ross GL, Dunn R, Kirkpatrick J. et al. To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects. Br J Plast Surg 2003; 56 (04) 409-413
• 3 Sharabi SE, Hatef DA, Koshy JC, Jain A, Cole PD, Hollier Jr LH. Is primary thinning of the anterolateral thigh flap recommended?. Ann Plast Surg 2010; 65 (06) 555-559
• 4 Kimura N. A microdissected thin tensor fasciae latae perforator flap. Plast Reconstr Surg 2002; 109 (01) 69-77 , discussion 78–80
• 5 Park BY. Flap thinning: Defatting after conventional elevation. Arch Plast Surg 2018; 45 (04) 314-318
• 6 Hong JP, Choi DH, Suh H. et al. A new plane of elevation: the superficial fascial plane for perforator flap elevation. J Reconstr Microsurg 2014; 30 (07) 491-496
• 7 Hong JP, Chung IW. The superficial fascia as a new plane of elevation for anterolateral thigh flaps. Ann Plast Surg 2013; 70 (02) 192-195
• 8 Hong JP, Yim JH, Malzone G, Lee KJ, Dashti T, Suh HS. The thin gluteal artery perforator free flap to resurface the posterior aspect of the leg and foot. Plast Reconstr Surg 2014; 133 (05) 1184-1191
• 9 Jeong HH, Hong JP, Suh HS. Thin elevation: a technique for achieving thin perforator flaps. Arch Plast Surg 2018; 45 (04) 304-313
• 10 Sakarya AH, Do N. Nomenclature of thin and super-thin flaps-comment on: outcomes of subfascial, suprafascial, and super-thin anterolateral thigh flaps: tailoring thickness without added morbidity. J Reconstr Microsurg 2018; 34 (03) e3-e4
• 11 Park SO, Chang H, Imanishi N. Anatomic basis for flap thinning. Arch Plast Surg 2018; 45 (04) 298-303
• 12 Kim KN, Hong JP, Park CR, Yoon CS. Modification of the elevation plane and defatting technique to create a thin thoracodorsal artery perforator flap. J Reconstr Microsurg 2016; 32 (02) 142-146
• 13 Narushima M, Yamasoba T, Iida T. et al. Pure skin perforator flaps: the anatomical vascularity of the superthin flap. Plast Reconstr Surg 2018; 142 (03) 351e-360e
• 14 Kimura N, Satoh K. Consideration of a thin flap as an entity and clinical applications of the thin anterolateral thigh flap. Plast Reconstr Surg 1996; 97 (05) 985-992
• 15 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
• 16 Bhadkamkar MA, Wolfswinkel EM, Hatef DA. et al. The ultra-thin, fascia-only anterolateral thigh flap. J Reconstr Microsurg 2014; 30 (09) 599-606
• 17 Patel KM, Shauly O, Gould DJ. Introducing the subdermal free flap: preserving the ultrathin-free skin flap option in morbidly obese patients. J Surg Oncol 2018; 118 (03) 403-406
• 18 Yamamoto T, Yoshimatsu H, Kikuchi K. Free prepuce perforator flap: ultra-thin superficial penile artery perforator flap for a dorsal finger defect. Microsurgery 2017; 37 (03) 252-255
• 19 Kumar P, Pandey AK, Kumar B, Aithal SK. Anatomical study of superficial fascia and localized fat deposits of abdomen. Indian J Plast Surg 2011; 44 (03) 478-483
• 20 Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg 2009; 124 (05) 1529-1544
• 21 Saint-Cyr M, Schaverien MV, Rohrich RJ. Perforator flaps: history, controversies, physiology, anatomy, and use in reconstruction. Plast Reconstr Surg 2009; 123 (04) 132e-145e
• 22 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
• 23 Goh TLH, Park SW, Cho JY, Choi JW, Hong JP. The search for the ideal thin skin flap: superficial circumflex iliac artery perforator flap–a review of 210 cases. Plast Reconstr Surg 2015; 135 (02) 592-601
• 24 Suh HSP, Jeong HH, Choi DH, Hong JPJP. Study of the medial superficial perforator of the superficial circumflex iliac artery perforator flap using computed tomographic angiography and surgical anatomy in 142 patients. Plast Reconstr Surg 2017; 139 (03) 738-748
• 25 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
• 26 Chae MP, Hunter-Smith DJ, Rozen WM. Comparative analysis of fluorescent angiography, computed tomographic angiography and magnetic resonance angiography for planning autologous breast reconstruction. Gland Surg 2015; 4 (02) 164-178
• 27 Katayama H, Yamaguchi K, Kozuka T, Takashima T, Seez P, Matsuura K. Adverse reactions to ionic and nonionic contrast media. A report from the Japanese Committee on the Safety of Contrast Media. Radiology 1990; 175 (03) 621-628
• 28 Dillman JR, Ellis JH, Cohan RH, Strouse PJ, Jan SC. Frequency and severity of acute allergic-like reactions to gadolinium-containing i.v. contrast media in children and adults. AJR Am J Roentgenol 2007; 189 (06) 1533-1538
• 29 Rozen WM, Phillips TJ, Ashton MW, Stella DL, Gibson RN, Taylor GI. Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and Doppler ultrasound. Plast Reconstr Surg 2008; 121 (01) 9-16
• 30 Aubry S, Pauchot J, Kastler A, Laurent O, Tropet Y, Runge M. Preoperative imaging in the planning of deep inferior epigastric artery perforator flap surgery. Skeletal Radiol 2013; 42 (03) 319-327
• 31 Solomon GA, Yaremchuk MJ, Manson PN. Doppler ultrasound surface monitoring of both arterial and venous flow in clinical free tissue transfers. J Reconstr Microsurg 1986; 3 (01) 39-41
• 32 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
• 33 Visconti G, Bianchi A, Hayashi A, Salgarello M. Designing an anterolateral thigh flap using ultrasound. J Reconstr Microsurg 2022; 38 (03) 206-216
• 34 Thiele JR, Weiß J, Braig D, Zeller J, Stark GB, Eisenhardt SU. Evaluation of the suprafascial thin ALT flap in foot and ankle reconstruction. J Reconstr Microsurg 2022; 38 (02) 151-159
• 35 Blondeel PN, Beyens G, Verhaeghe R. et al. Doppler flowmetry in the planning of perforator flaps. Br J Plast Surg 1998; 51 (03) 202-209
• 36 Hallock GG. Evaluation of fasciocutaneous perforators using color duplex imaging. Plast Reconstr Surg 1994; 94 (05) 644-651
• 37 Wang LV, Hu S. Photoacoustic tomography: in vivo imaging from organelles to organs. Science 2012; 335 (6075): 1458-1462
• 38 Tsuge I, Saito S, Yamamoto G. et al. Preoperative vascular mapping for anterolateral thigh flap surgeries: a clinical trial of photoacoustic tomography imaging. Microsurgery 2020; 40 (03) 324-330
• 39 Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987; 40 (02) 113-141
• 40 Boyd JB. Discussion: qualitative and quantitative analyses of donor-site morbidity following suprafascial versus subfascial free fibula flap harvesting. Plast Reconstr Surg 2011; 128 (01) 146-147
• 41 Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg 2004; 114 (04) 910-916
• 42 Wallace CG, Kao HK, Jeng SF, Wei FC. Free-style flaps: a further step forward for perforator flap surgery. Plast Reconstr Surg 2009; 124 (6, Suppl): e419-e426
• 43 Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002; 109 (07) 2219-2226 , discussion 2227–2230
• 44 Schaverien M, Saint-Cyr M. Suprafascial compared with subfascial harvest of the radial forearm flap: an anatomic study. J Hand Surg Am 2008; 33 (01) 97-101
• 45 Sagalongos OS, Valerio IL, Hsieh CH. et al. Qualitative and quantitative analyses of donor-site morbidity following suprafascial versus subfascial free fibula flap harvesting. Plast Reconstr Surg 2011; 128 (01) 137-145
• 46 Su XZ, Yin SC, So HI. et al. Comparison of donor site complications of supra- versus subfascially harvested anterolateral thigh perforator free flaps: a meta-analysis. J Craniomaxillofac Surg 2020; 48 (01) 56-66
• 47 Fischer S, Diehm Y, Hirche C. et al. Comparison of sub- versus suprafascially raised anterolateral thigh free flaps with regard to donor-site morbidity, function and aesthetics. Microsurgery 2018; 38 (05) 444-449
• 48 Avery CM, Sundaram K, Jasani V, Peden A, Neal CP. Comparison of sensory recovery at the subfascial and suprafascial donor sites of the free radial flap. Br J Oral Maxillofac Surg 2012; 50 (06) 495-499
• 49 Hollenbeck ST, Woo S, Komatsu I, Erdmann D, Zenn MR, Levin LS. Longitudinal outcomes and application of the subunit principle to 165 foot and ankle free tissue transfers. Plast Reconstr Surg 2010; 125 (03) 924-934
• 50 Lee KT, Park SJ, Mun GH. Reconstruction outcomes of oncologic foot defect using well-contoured free perforator flaps. Ann Surg Oncol 2017; 24 (08) 2404-2412
• 51 Alkureishi LW, Shaw-Dunn J, Ross GL. Effects of thinning the anterolateral thigh flap on the blood supply to the skin. Br J Plast Surg 2003; 56 (04) 401-408
• 52 Chen YC, Scaglioni MF, Carrillo Jimenez LE, Yang JC, Huang EY, Lin TS. Suprafascial anterolateral thigh flap harvest: a better way to minimize donor-site morbidity in head and neck reconstruction. Plast Reconstr Surg 2016; 138 (03) 689-698
• 53 Suh YC, Kim NR, Jun DW, Lee JH, Kim YJ. The perforator-centralizing technique for super-thin anterolateral thigh perforator flaps: minimizing the partial necrosis rate. Arch Plast Surg 2021; 48 (01) 121-126
• 54 Kimura N, Satoh K, Hosaka Y. Microdissected thin perforator flaps: 46 cases. Plast Reconstr Surg 2003; 112 (07) 1875-1885
• 55 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; 64 (12) 1580-1584
• 56 Imanishi N, Nakajima H, Minabe T, Aiso S. Angiographic study of the subdermal plexus: a preliminary report. Scand J Plast Reconstr Surg Hand Surg 2000; 34 (02) 113-116
• 57 Narushima M, Yamasoba T, Iida T. et al. Supermicrosurgical reconstruction for congenital aural atresia using a pure skin perforator flap: concept and long-term results. Plast Reconstr Surg 2013; 131 (06) 1359-1366
• 58 Hong JP, Suh HP. Discussion: pure skin perforator flaps: the anatomical vascularity of the superthin flap. Plast Reconstr Surg 2018; 142 (03) 361e-362e