Sven Weum

The Value of Dynamic Infrared Thermography (DIRT) in Perforator Selection and Planning of Free DIEP Flaps

The aim of this paper is to evaluate dynamic infrared thermography (DIRT) as a technique to assist in preoperative perforator selection and planning of free deep inferior epigastric perforator (DIEP) flaps. Twenty-seven patients, scheduled for secondary autologous breast reconstruction with either a free DIEP flap or superficial inferior epigastric artery flap, were included in this prospective clinical study. Preoperative mapping of perforators was performed with a hand-held Doppler and DIRT. A multidetector computer tomography scan was additionally carried out in the last 8 patients. In 23 patients a DIEP flap was used. The perforator as selected from DIRT was a suitable perforator in all DIEP flaps. The location and quality of the selected perforator from DIRT corresponded well with the multidetector computer tomography scan results. Preoperative perforator selection and planning of DIEP flaps is facilitated with the use of DIRT. The technique is noninvasive and easy to use.

Dynamic Infrared Thermography

This article describes how dynamic infrared thermography (DIRT) can be used in autologous breast reconstruction with a deep inferior epigastric perforator flap. This noninvasive and noncontact technique for indirect monitoring of skin blood perfusion can be used in the preoperative planning and intraoperative evaluation of flap perfusion, as well as the postoperative monitoring of perfusion dynamics of DIEP flaps. DIRT provides valuable information on the perfusion physiology of perforators.

Autologous breast reconstruction with a free lumbar artery perforator flap

Autologous breast reconstruction with a perforator flap has become increasingly popular. This paper presents the free lumbar artery perforator (LAP) flap as an option for breast reconstruction. Flap harvest is easy, no muscle is sacrificed and donor-site morbidity is minimal. Anastomosis of the sensory nerve to the fourth intercostal nerve is possible. The successful use of a LAP flap for breast reconstruction is illustrated with a case report, and the surgical technique is described. This method may be a good alternative for patients with relative contraindications to breast reconstruction with a DIEP flap.

A large abdominal intercostal hernia in a patient with vascular type Ehlers-Danlos syndrome: a surgical challenge.

A patient with vascular type Ehlers-Danlos syndrome developed a large abdominal intercostal hernia secondary to coughing. The tissue friability and associated risks for arterial ruptures and visceral perforations in these patients make hernia repair challenging. The hernia was successfully treated using a novel approach.

The sensate medial dorsal intercostal artery perforator flap for closure of cervicothoracic midline defects after spinal surgery: an anatomic study and case reports.

Complex cervicothoracic midline defects after spinal surgery are traditionally treated with the use of muscle and myocutaneous flaps. The authors introduce the sensate medial dorsal intercostal artery perforator flap as an alternative treatment for these defects. Following an anatomic study, the use of the flap is illustrated with 3 case reports. This well-vascularized flap is easy to harvest and causes minimal donor site morbidity. It can provide enough volume to obliterate dead space. Inclusion of the cutaneous nerve gives protective sensibility to the reconstructed area.

A new approach in the repair of a myelomeningocele using amnion and a sensate perforator flap

Soft-tissue coverage over the neural repair of a large myelomeningocele was obtained using an autologous amnion graft and a sensate perforator flap. This new technique provides a watertight closure and tension-free, stable, soft-tissue coverage. Protective sensibility in the reconstructed area and minimal donor-site morbidity are additional advantages.

Visualising skin perfusion in isolated human abdominal skin flaps using dynamic infrared thermography and indocyanine green fluorescence video angiography

This experimental study compared the direct technique indocyanine green fluorescence angiography (ICG-FA) and the indirect technique dynamic infrared thermography (DIRT) for visualising skin perfusion. Eight isolated human transverse abdominal skin flaps, obtained from female patients undergoing abdominoplasty, were used. A total of 19 selected vessels were individually perfused. Warm and cold perfusate was used for visualising skin perfusion with DIRT. Both techniques were tested for repeatability, making up a total of 34 perfusions. Qualitative analysis of the rate and pattern of perfusion visualised by both techniques was carried out. The extent of the perfused area indicated by the indirect DIRT technique corresponded well with the perfused area indicated by the direct ICG-FA technique. The appearance of distinct hot spots in the IR images provided additional information on the distribution of perforating vessels. It is concluded that in experimental situations the non-invasive DIRT technique is a good alternative to the invasive ICG-FA technique for visualising skin perfusion.

Perforator-Guided Drug Injection in the Treatment of Abdominal Wall Pain

BACKGROUND Pain from the abdominal wall can be caused by nerve entrapment, a condition called abdominal cutaneous nerve entrapment syndrome (ACNES). As an alternative to surgery, ACNES may be treated with injection of local anesthetics, corticosteroids, or botulinum toxin at the point of maximal pain. METHOD The point of maximal pain was marked on the abdominal skin. Using color Doppler ultrasound, the corresponding exit point of perforating blood vessels through the anterior fascia of the rectus abdominis muscle was identified. Ultrasound-guided injection of botulinum toxin in close proximity to the perforators exit point was performed below and above the muscle fascia. RESULTS The technique was used from 2008 to 2014 on 15 patients in 46 sessions with a total of 128 injections without complications. The injection technique provided safe and accurate administration of the drug in proximity to the affected cutaneous nerves. The effect of botulinum toxin on ACNES is beyond the scope of this article. CONCLUSION Perforator-guided injection enables precise drug administration at the location of nerve entrapment in ACNES in contrast to blind injections.

Evaluation of dynamic infrared thermography as an alternative to CT angiography for perforator mapping in breast reconstruction: a clinical study

BackgroundThe current gold standard for preoperative perforator mapping in breast reconstruction with a DIEP flap is CT angiography (CTA). Dynamic infrared thermography (DIRT) is an imaging method that does not require ionizing radiation or contrast injection. We evaluated if DIRT could be an alternative to CTA in perforator mapping.MethodsTwenty-five patients scheduled for secondary breast reconstruction with a DIEP flap were included. Preoperatively, the lower abdomen was examined with hand-held Doppler, DIRT and CTA. Arterial Doppler sound locations were marked on the skin. DIRT examination involved rewarming of the abdominal skin after a mild cold challenge. The locations of hot spots on DIRT were compared with the arterial Doppler sound locations. The rate and pattern of rewarming of the hot spots were analyzed. Multiplanar CT reconstructions were used to see if hot spots were related to perforators on CTA. All flaps were based on the perforator selected with DIRT and the surgical outcome was analyzed.ResultsFirst appearing hot spots were always associated with arterial Doppler sounds and clearly visible perforators on CTA. The hot spots on DIRT images were always slightly laterally located in relation to the exit points of the associated perforators through the rectus abdominis fascia on CTA. Some periumbilical perforators were not associated with hot spots and showed communication with the superficial inferior epigastric vein on CTA. The selected perforators adequately perfused all flaps.ConclusionThis study confirms that perforators selected with DIRT have arterial Doppler sound, are clearly visible on CTA and provide adequate perfusion for DIEP breast reconstruction.Trial registrationRetrospectively registered at ClinicalTrials.gov with identifier NCT02806518.

Closure of Complex Posterior Midline Defects After Spinal Surgery With Sensate Midline-based Perforator Flaps and the Long-term Results.

Study Design. Prospective study. Objective. Evaluating the use of a midline-based perforator flap for closure of complex midline defects after spine surgery complicated with implant exposure and deep subfascial infection. Summary of Background Data. Traditionally, muscle flaps are used to close complex defects after spine surgery complicated by exposed spinal implants and deep subfascial infections. There are no reports on the long-term results on the use of perforator flaps to close these defects. Methods. Information was prospectively registered of all patients in whom a medial dorsal intercostal artery perforator (MDICAP) flap was used for closure of a complex midline defect with exposed spinal implant and deep subfascial infection after spine surgery. Results. In 9 patients, 10 MDICAP flaps were used. All flaps survived with only 1 flap experiencing marginal flap necrosis. The flaps provided stable coverage of all defects and spinal instrumentation could be retained in all patients. The perforator flaps provided in all patients, except in the patient with a meningomyelocele, protective sensibility in the reconstructed areas. The mean postoperative hospital stay after closure of the defects was 10 days (range 4–21). During follow-up (mean 65 mo, range 7–106) only 1 patient developed an infection in the operated area which occurred 81 months postoperatively. None of the patients had any functional loss at the donor site of the flap. Conclusion. The medial dorsal intercostal artery perforator flap seems to be a reliable alternative for treatment of complex midline defects with exposed spinal implants and deep subfascial surgical site infections. Protective sensibility may be obtained in the reconstructed area with this flap. Donor site morbidity is minimal. In case of recurrence, complex reconstructive procedures using muscle flaps are still possible. The use of this perforator flap may contribute to shorter hospital stays and reduction of costs. Level of Evidence: 4