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Supermicrosurgical Perforator-to-Perforator Flaps in Lower Extremity Reconstruction: Feasibility of Perforators as Recipient Vessels
Elena Galvano
*1, Laura K. Tom
2, Grant Kleiber
2, Rajiv Parikh
21Georgetown University School of Medicine, Washington , ; 2Department of Plastic Surgery, MedStar Health Washington Hospital Center, Washington,
Background:Supermicrosurgery (anastomoses <0.8 mm) has gained popularity as a reconstructive option for challenging problems where conventional approaches are limited. Benefits include defect-centered reconstruction that replaces "like with like" and expanded indications with perforator-to-perforator techniques. In lower extremity reconstruction, however, limited reports in the US population exist to support their safety and feasibility. The purpose of this study is to characterize the safety and outcomes of perforator-to-perforator anastomoses in a diverse patient population.
Methods:This is a prospective matched cohort study of patients undergoing lower extremity reconstruction at a tertiary care center between January 2021 and January 2025. Anastomoses of 0.3-0.8 mm were considered perforator-to-perforator cases and compared to conventional cases using major artery recipient vessels. Patients were matched on defect location and size (cm
2). Demographics, comorbidities, and outcomes were analyzed. Functional limb salvage was defined as flap success with ambulation at 6 months postoperatively.
Results:70 patients were included: 35 in the conventional cohort and 35 in the supermicrosurgery cohort. Mean BMI was 31.1 kg/m
2 and mean CCI was 4.4, reflecting high comorbidity. SCIP (N=13, 37.1%) and MSAP flaps (N=13, 37.1%) were most common in the supermicrosurgery cohort, while ALT flaps (N=20, 57.1%) to anterior or posterior tibial vessels were most common in conventional cases. Functional limb salvage was similar: 97.1% vs 94.2% (p>0.15). Overall complications did not differ (p>0.15); partial flap failure was lower in perforator-to-perforator cases (p=0.041). Operative time was also shorter (p=0.011).
Conclusions:Supermicrosurgical perforator-to-perforator anastomoses are reliable in lower extremity reconstruction, including obese and comorbid patients, with similar limb salvage rates to conventional techniques. We advocate for use of this technique when long pedicles are unnecessary, shorter operative time is advantageous, or main-line vessels are depleted or injured.
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