| Background:Since the beginning of its application,the superficial circumflex iliac artery flap(SCIP)has gradually replaced the anterolateral thigh flap(ALTP)for repairing extremity trauma because of its advantages such as large excisable area,good flap extensibility,thin subcutaneous fat,ability to carry a variety of tissues,and concealed donor area.However,the superficial circumflex iliac artery flap also suffers from high vascular variability,small perforators and short vascular pedicle length.In order to overcome these shortcomings,various techniques have been widely used in recent years,but each has its own shortcomings.Preoperative hand-held Doppler ultrasound has the advantages of being easy to perform and noninvasive,and is able to explore the vascular information of the donor area more comprehensively,but the accuracy of detection of arterial penetrations has a high rate of false positives and false negatives.Color Doppler ultrasound can detect and evaluate the location of the perforators,the source of the perforator,the vascular path,and even measure the hemodynamic information of the penetrating vessel;however,it cannot form three-dimensional images and cannot be combined with digital software to design and simulate flap cutting.Both handheld Doppler ultrasound and color Doppler ultrasound are highly dependent on the operator’s proficiency.Computed Tomography Angiography(CTA)has gradually been considered as one of the best preoperative design techniques for flap surgery,which can display the anatomical information of blood vessels in the donor site including the perforators from all viewing surfaces,as well as fully display the hierarchical relationship between blood vessels and surrounding muscles and bones,and display the perforators more clearly,and can perform 3D reconstruction on its own software to locate the perforators;however,it still has shortcomings such as unsatisfactory visualization of small perforators,exposation of radiation,complicated self-contained software and hardware,insufficient imaging clarity,and cannot be used to design and simulate the excision of flaps,which are all shortcomings of common CTA.Recently,the digital technique of CTA combined with Digital subtraction angiography(DSA)and Mimics software has been gradually used to study the vascular anatomy of the flap,but there is a lack of studies on preoperative design and intraoperative guidance models,and the technique is not yet mature.And the technique has not yet been applied to the donor site of the superficial circumflex iliac artery flap.Objective:1.The anatomy of the donor site of the superficial circumflex iliac artery flap was clearly and completely reconstructed using digital technology combined with catheter-based CTA.2.Accurately locate the perforators on the virtual 3D model,and simulate and design the flap that can precisely and individually repair the defect according to the location of the perforator,simulate the incision,anticipate the surgical procedure in advance,and guide the surgery.Method:1.From October 2020 to July 2021,a total of 24 patients were enrolled,all of whom decided to apply a SCIP to reconstruct extremity defects.There were 20 male patients and 4 female patients,aged 22-63 years,with a mean of 42 years.The trauma sites were: hand in 2 cases,forearm in 5 cases,foot in 3 cases,ankle in 2 cases,calf in 10 cases,and knee in 2 cases.All traumas were combined with tendon and bone defects,and skin-graft could not cover the defects.2.Preoperatively,a highly selective catheter-based CTA scan of the superficial circumflex iliac artery was performed,and the original CTA data was opened using Mimics 20.0 software to detect the location of the superior perforator,to measure the relevant data,to locate the perforator in the form of coordinates,and to design and cut an individualized SCIP according to the location of the perforator.3.According to the perforators located on the three-dimensional model and the design of the flap,guide the intraoperative incision,observe the vascular anatomy of the flap,measure the corresponding preoperative data,and repair the defect.4.SPSS 27.0 and Graph Pad Prism 8.0 were used for statistical processing,analysis and graphing.Results:1.The digital technique combined with catheter-based CTA clearly and unambiguously reconstructed the anatomical information of the soft tissue,bone and blood vessels in the donor site of the superficial circumflex iliac artery on the computer.The location of the perforator can be accurately located on the skin surface using the form of coordinates.The flap was successfully designed and cut by simulation.2.Preoperatively,the model was reconstructed in Mimics 20.0 software based on CTA data,and 63 perforators(all with an outer diameter greater than 0.5 mm)were found to be available for flap design in the 24 donor sites.And all of them were found intraoperatively with 100% accuracy rate.The source of the perforations found in the preoperative reconstruction was in complete agreement with the intraoperative findings.10 of the 24 donor areas(42%)were found to have 2 perforators,13 of 3(54%),and 1 of 4(4%),with an average of 2.62±0.57 perforators per side.Intraoperatively,the outer diameter of the 63 perforations found ranged from 0.51 mm to 0.83 mm,with a mean of0.66 ± 0.09 mm.Preoperatively,according to the designed flap model,the length of resectable vessel pedicles was measured in the range of 3.1-9.1 cm,with a mean of 5.81±2.05 cm,and intraoperatively,the length of resectable pedicles was measured in the range of 3.0-9.1 cm,with a mean of 5.78±2.06 cm,with no statistically significant difference.3.In the preoperative reconstructed three-dimensional model,it was found that the superficial circumflex iliac artery originated directly from the femoral artery in 22 cases(92%,22/24),co-trunked with the superficial inferior Results:epigastric artery in 1 case(4%,1/24),and originated from the deep iliac circumflex artery in 1 case(4%,1/24).In complete agreement with the intraoperative observations.4.The preoperative localized puncture coordinates and the intraoperative found puncture coordinates were statistically analyzed in terms of horizontal and vertical coordinates.The longitudinal coordinates of the preoperatively positioned perforators ranged from 1.1 to 5.8 cm,with a mean of 4.77±1.50 cm;the longitudinal coordinates of the intraoperatively positioned perforators ranged from 1.0 to 5.9 cm,with a mean of 3.81±1.51 cm,with no statistically significant difference.5.In all 24 cases,the preoperative digital flap design,flap excision,and defect reconstruction were successfully completed.All donor sites were closed in one stage and all healed well in one stage.All patients were followed up for an average of 2 to 12 months(mean 8.6 months),and the flaps were not bulky,had a satisfactory shape,were not significantly different in color from the surrounding skin,had a little pigmentation around the flap,and had a good texture.Only linear scarring was left in the donor area,and there was no restriction of hip movement.Conclusions:1.The donor site model of the superficial circumflex iliac artery flap reconstructed from CTA data using digital technology can clearly show the anatomical information of the donor tissue and blood vessels,and clarify the perforator and safe blood supply area before surgery.2.The superficial circumflex iliac artery flap harvested based on digital technology can meet the functional and aesthetic requirements of repairing defects,directly or indirectly improve the surgical precision,meet the requirements of precision medicine,personalized medicine and minimally invasive medicine,avoid potential risks,and guide the precise and safe flap elevation during surgery. |
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