Chapter 1 IMAGING Apart from anatomical dissection, radiological studies have enhanced the knowledge of the vascular anatomy of perforator flaps. The imaging of blood vessels started in 1895 with the first post-mortem angiography by Diener22. In 1923 the first peripheral angiogram in the living subject was performed by Berberich and Hirsch23 using strontium bromide as a contrast medium. The first axial flaps in the early 1960s were based on well-known and constant vessels, meaning that the characteristics of the pedicle were well-predictable without imaging. In the past 20 years the evolution of perforator flaps with a less constant anatomy was aimed at improving flap design using radiological techniques. Preoperative vascular mapping has been introduced to help identify the dominant perforator, its course and, as such, speed up the flap dissection. CTA and MRA are nowadays the gold standard for preoperative imaging in perforator flap surgery46: even if CTA has great sensitivity for perforator with a calibre of 1 mm of more, is fast, widely available and reproducible, sensitivity to the contrast medium and radiation (5.6mSv) remain a problem. MRA is growing up as gold standard in perforator flap surgery having anyway an high accuracy in identifying perforators without use of radiation. OUTLINE OF THIS THESIS This thesis addresses several major topics with regard to the anatomy of new developed perforator flaps and their clinical applications. The initial studies were solely supported by anatomical dissection findings whereas in the latter studies radiological imaging was included. In chapter 2 we investigate variability of vascular anatomy of the anterolateral thigh flap identifying the areas with the highest concentration of perforators. In chapter 3 the anatomy of the pedicle of the medial sural artery perforator flap was studied trying to find guidelines for the clinical application of the flap. In chapter 4 we performed a preliminary anatomical study on septocutaneous perforators of the superior gluteal artery. A dissection study was correlated to a color Doppler study. The results give the basic knowledge for the clinical application of the septocutaneous gluteal artery perforator (sc-GAP). In chapter 5 we present a series of patients undergoing an sc-GAP flap for breast reconstruction. The presence of septocutaneous perforators is preoperatively investigated with MRA or CTA. 13
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