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DOI: 10.1055/s-0042-1751099
The New Imaging Techniques in Reconstructive Microsurgery: A New Revolution in Perforator Flaps and Lymphatic Surgery






Microsurgery has continuously evolved over the past 40 years. The early period was dedicated to the delineation of soft tissue microvascular anatomy and understanding the hemodynamic of flaps and their perfusion led to the establishment of fasciocutaneous, musculocutaneous muscle and bony flaps.[1] In late 1980s, the anatomical work from Taylor and Palmer led to the introduction of the angiosome concept and to the description of an average of 374 major perforators through the human body.[2] Later, the clinical work by Koshima and Soeda opened the perforator era in microsurgery.[3]
After the introduction of perforator flap concept, the following 20 years were focused on the discovery of new perforator flaps and large case series reports on the outcomes of the most common perforator flaps for specific indications and reconstructions. It progressively became clear and evident that perforator flaps represent the natural evolution of conventional flaps, which lead to a paradigm shift in the reconstructive algorithm: from the older “flap-of-choice” to the newer “flap choosen.”[4]
After the establishment of perforator flap concepts, it became also obvious that traditional perforator flaps cannot always accommodate reconstruction needs especially when the purpose is resurfacing rather than creating volume or filling space. In this perspective, the thinning procedures already described for traditional flaps were then successfully applied to perforator flaps,[5] [6] although this generated different grade of confusions, especially in terminology.
Later, the advent of supermicrosurgery again pioneered by Koshima et al[7] further stimulated the next level of evolution: the ability to safely manipulate vascular structures below 0.8mm means a further expansion in reconstructive freedom and a reduction in surgery invasiveness. It is in fact possible, when indicated, to harvest perforator flaps without dissecting the main pedicle and revascularize them using recipient perforating vessels. Moreover, supermicrosurgery revolutionized also the lymphatic surgery, with the introduction of supermicrosurgical lymphaticovenular anastomosis that nowadays is an established method for treating lymphedema patients.
This fascinating evolution of microsurgery, however, still has a common denominator limiting factor for all the procedure described: the exact knowledge of soft tissue anatomy and microvascular anatomy of each patient varies from patient to patient. This drawback has been already addressed in the past, initially by using the audible Doppler examination and then introducing multidetector computed tomography scan[8] and magnetic resonance imaging[9] with the intent of locating reliable perforator and define the peculiar microanatomy of each patient. However, those technologies still have shortcuts and were not enough to enhance the confidence of microsurgeons, who still needed explorative dissection to confirm the imaging findings as well as rely on skin coordinates system to locate the hot perforator areas.
In the last decade, there was a fast evolution of portable imaging technologies that can be directly used by the operating microsurgeon. First, plastic surgeons progressively recognized the usefulness of ultrasound technology in perforator flap surgery that allows a highly specific and highly sensible preoperative planning compared with any other technology, especially when in the hands of the operating surgeon.[10] Moreover, the improved skills in high-frequency ultrasound and the introduction of ultra-high frequency ultrasound allowed an enhanced visualization of very tiny structures (such as terminal perforator branches within the subcutaneous tissue up to and within the dermis as well as lymphatic channels) comparable to histologic images, which further expand the preoperative preoperative vision, allowing high detailed preoperative studies that lead to improve safety, efficacy, reliability, and microsurgical creativity.[11] [12] [13] [14] [15] [16] [17] [18] [19] [20] Ultrasound in experienced hands allows to skip the explorative time in perforator flap dissection and move the process of study the “chosen flap” to that of ultrasound-choice of the flap based on the most suitable microanatomy for the given indication. The magic of mastering ultrasound is to perform a high-precision, more predictable, and effective lymphatic supermicrosurgery procedure as well as increasing the confidence related to perforator flap dissection leading to further creative solutions such as thin, superthin and even pure-skin perforator flaps.[11] [12] [13] [14] [15] [16] [17] [18] [19] [20]
We can say that ultrasound, either high-frequency and ultra-high-frequency, represents nowadays the quintessence in microsurgery.
New imaging technologies are emerging with promising applications that may further improve microsurgical outcomes and safety. The intraoperative microscope-integrated laser tomography[21] allows to have more intraoperative details of lymphatic channel morphology and anastomosis quality and photoacoustic technologies are emerging as a further low-invasive three-dimensional technology for preoperative evaluation of microvascular and lymphatic anatomy.[22]
The advances in technologies must be strictly followed by plastic surgeons and microsurgeons as the power of new imaging technology may further improve safety, efficacy, and cost-effectiveness of microsurgery and may lead to new frontiers also eventually integrating such technologies with the augmented reality[23] and the artificial intelligence of software.
We look forward to seeing microsurgical technology enthusiastic colleagues at the next Imaging in Reconstructive Microsurgery Symposium on June 5, 2022 as Official World Society of Reconstructive Microsurgery (WSRM) Postcongress meeting.
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Conflict of Interest
J.P.H. is an editorial board member of the journal but was not involved in the peer reviewer selection, evaluation, or decision process of this article. No other potential conflicts of interest relevant to this article were reported.
Author Contributions
Writing-original draft: G.V. and A.H. Writing-review & editing: J.P.H.
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References
- 1 Serafin D, Buncke HJ. MicroSurgical Composite Tissue Transplantation. St Louis: CV Mosby; 1979
- 2 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
- 3 Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989; 42 (06) 645-648
- 4 Kim JT, Kim SW. Perforator flap versus conventional flap. J Korean Med Sci 2015; 30 (05) 514-522
- 5 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
- 6 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
- 7 Koshima I, Inagawa K, Etoh K, Moriguchi T. [Supramicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the extremities]. Nippon Geka Gakkai Zasshi 1999; 100 (09) 551-556
- 8 Masia J, Clavero JA, Larrañaga JR, Alomar X, Pons G, Serret P. Multidetector-row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg 2006; 59 (06) 594-599
- 9 Ahn CY, Narayanan K, Shaw WW. In vivo anatomic study of cutaneous perforators in free flaps using magnetic resonance imaging. J Reconstr Microsurg 1994; 10 (03) 157-163
- 10 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
- 11 Hayashi A, Yamamoto T, Yoshimatsu H. et al. Ultrasound visualization of the lymphatic vessels in the lower leg. Microsurgery 2016; 36 (05) 397-401
- 12 Visconti G, Yamamoto T, Hayashi N, Hayashi A. Ultrasound-assisted lymphaticovenular anastomosis for the treatment of peripheral lymphedema. Plast Reconstr Surg 2017; 139 (06) 1380e-1381e
- 13 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
- 14 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
- 15 Bianchi A, Visconti G, Hayashi A, Santoro A, Longo V, Salgarello M. Ultra-High frequency ultrasound imaging of lymphatic channels correlates with their histological features: A step forward in lymphatic surgery. J Plast Reconstr Aesthet Surg 2020; 73 (09) 1622-1629
- 16 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
- 17 Yoshimatsu H, Hayashi A, Yamamoto T. et al. Visualization of the “Intradermal Plexus” using ultrasonography in the dermis flap: a step beyond perforator flaps. Plast Reconstr Surg Glob Open 2019; 7 (11) e2411
- 18 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
- 19 Jeong HH, Hong JP, Suh HS. Thin elevation: a technique for achieving thin perforator flaps. Arch Plast Surg 2018; 45 (04) 304-313
- 20 Park SO, Chang H, Imanishi N. Anatomic basis for flap thinning. Arch Plast Surg 2018; 45 (04) 298-303
- 21 Hayashi A, Yoshimatsu H, Visconti G. et al. Intraoperative real-time visualization of the lymphatic vessels using microscope-integrated laser tomography. J Reconstr Microsurg 2021; 37 (05) 427-435
- 22 Suzuki Y, Kajita H, Oh A. et al. Photoacoustic lymphangiography exhibits advantages over near-infrared fluorescence lymphangiography as a diagnostic tool in patients with lymphedema. J Vasc Surg Venous Lymphat Disord 2021
- 23 Pereira N, Kufeke M, Parada L. et al. Augmented reality microsurgical planning with a smartphone (ARM-PS): a dissection route map in your pocket. J Plast Reconstr Aesthet Surg 2019; 72 (05) 759-762
Address for correspondence
Publication History
Article published online:
30 July 2022
© 2022. The Korean Society of Plastic and Reconstructive Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
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References
- 1 Serafin D, Buncke HJ. MicroSurgical Composite Tissue Transplantation. St Louis: CV Mosby; 1979
- 2 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
- 3 Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989; 42 (06) 645-648
- 4 Kim JT, Kim SW. Perforator flap versus conventional flap. J Korean Med Sci 2015; 30 (05) 514-522
- 5 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
- 6 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
- 7 Koshima I, Inagawa K, Etoh K, Moriguchi T. [Supramicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the extremities]. Nippon Geka Gakkai Zasshi 1999; 100 (09) 551-556
- 8 Masia J, Clavero JA, Larrañaga JR, Alomar X, Pons G, Serret P. Multidetector-row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg 2006; 59 (06) 594-599
- 9 Ahn CY, Narayanan K, Shaw WW. In vivo anatomic study of cutaneous perforators in free flaps using magnetic resonance imaging. J Reconstr Microsurg 1994; 10 (03) 157-163
- 10 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
- 11 Hayashi A, Yamamoto T, Yoshimatsu H. et al. Ultrasound visualization of the lymphatic vessels in the lower leg. Microsurgery 2016; 36 (05) 397-401
- 12 Visconti G, Yamamoto T, Hayashi N, Hayashi A. Ultrasound-assisted lymphaticovenular anastomosis for the treatment of peripheral lymphedema. Plast Reconstr Surg 2017; 139 (06) 1380e-1381e
- 13 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
- 14 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
- 15 Bianchi A, Visconti G, Hayashi A, Santoro A, Longo V, Salgarello M. Ultra-High frequency ultrasound imaging of lymphatic channels correlates with their histological features: A step forward in lymphatic surgery. J Plast Reconstr Aesthet Surg 2020; 73 (09) 1622-1629
- 16 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
- 17 Yoshimatsu H, Hayashi A, Yamamoto T. et al. Visualization of the “Intradermal Plexus” using ultrasonography in the dermis flap: a step beyond perforator flaps. Plast Reconstr Surg Glob Open 2019; 7 (11) e2411
- 18 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
- 19 Jeong HH, Hong JP, Suh HS. Thin elevation: a technique for achieving thin perforator flaps. Arch Plast Surg 2018; 45 (04) 304-313
- 20 Park SO, Chang H, Imanishi N. Anatomic basis for flap thinning. Arch Plast Surg 2018; 45 (04) 298-303
- 21 Hayashi A, Yoshimatsu H, Visconti G. et al. Intraoperative real-time visualization of the lymphatic vessels using microscope-integrated laser tomography. J Reconstr Microsurg 2021; 37 (05) 427-435
- 22 Suzuki Y, Kajita H, Oh A. et al. Photoacoustic lymphangiography exhibits advantages over near-infrared fluorescence lymphangiography as a diagnostic tool in patients with lymphedema. J Vasc Surg Venous Lymphat Disord 2021
- 23 Pereira N, Kufeke M, Parada L. et al. Augmented reality microsurgical planning with a smartphone (ARM-PS): a dissection route map in your pocket. J Plast Reconstr Aesthet Surg 2019; 72 (05) 759-762





