Good morning, everybody. Welcome to IC57 Ultrasounders in New Techniques for Reconstructive Surgery in the Hand and Upper Extremity. Well, thanks, everybody, for waking up early. It was hard for me to wake up myself, so I know how it feels. My name is Harvey Chim from the University of Florida. I'll be moderating this session. So first off, we have Rafael Diaz-Garcia, who's the System Division Chief of Plastic Surgery in the Allegheny Health Network, who'll be talking to us about point-of-care ultrasound for hand surgery, techniques, and clinical applications. Next we have Dr. Hide Yoshimatsu, who comes to us all the way from Japan, who'll be talking to us for ultrasound for planning of skip flaps for reconstruction in the hand and upper extremity. Next, I'll be talking about the super-thin PEP flap, profundus artery perforator flap for hand and upper extremity reconstruction flap planning with ultrasound. And finally, Dr. John Park from Asan Medical Center in Seoul, Korea, will be talking about ultrasound for planning of super-thin ALT flaps. Unfortunately, Dr. Park is unable to join us today because he had a family emergency, but we do have a video, and we look forward to watching the video that he sent over to us. And please, if you have any questions at the end of the session, please feel free to ask them or just enter them into the polling function in the app, and we'll try to address all your questions. Without further ado, I'd like to invite Dr. Diaz-Garcia. Thank you, Harvey. So my task is really to kind of talk to you about bringing ultrasound into your clinic if you're already not doing this. I have no conflicts regarding this presentation. So ultrasound has really grown across the medical spectrum. I think that there's been a lot of pressure to find ways to get diagnostics at a cheaper price point. Things like MRI are super expensive. Oftentimes, you have to go through a lot of prior authorization with insurance companies, and ultimately, sometimes diagnostic ultrasound can give you the same information at a much better price point. Ultrasound has really been used a lot in OB-GYN, as well as cardiology, but primary care, emergency medicine, orthopedics are really seeing a rapid growth in the use of diagnostic ultrasound at the point of care. As mentioned before, it is a lower cost alternative that oftentimes gives you sufficient information. People in orthopedics have been talking about this might be the new stethoscope of musculoskeletal care. It can be used for diagnostics, you can see fluid collections in real time, you can see infections, you can diagnose compression neuropathy, you can also see, for somebody who has a subluxating nerve or subluxating ECU tendon, you can see real time exactly what positions that nerve or tendon are flipping. Also can be used in therapeutics, and I'll quickly talk about how using therapeutics can be a way to actually pay for your point of care ultrasound. That market growth really were in that early majority, so a lot of people, early adopters in rural areas in breast were using this five or six years ago, and right now we're in that phase where specialist sports medicine are bringing into their office, and ultimately you'll probably see this expand even further into nursing care out in the, as we start looking at more of a hospital at home model in inpatient care. So these are a couple of options. I don't have any disclosures regarding these companies. I use the one on the right, which is the vScan Air, made by GE, the other one, a very popular choice is the Clarius, there's the Butterfly as well. They range in price point, the Butterfly's probably about, the cheaper model's about $3,800, the Clarius I think is about $7,000, the vScan's kind of in the middle, I think we paid just under five. So these are some of the things you can do using it in your office, both for management and potentially for diagnosis. So things that are very common in any hand surgeon's practice, carpal tunnel, decorvains, trigger fingers infections, and suspected tendon ruptures, particularly after somebody's had a repair, you're not sure that they're moving poorly because of tendon adhesions or because of potentially a gap or a rupture. So with static images, it's never as good as getting a good video, but when you look at the carpal tunnel at the inlet, you can, on any of these devices, take a still shot, and that still shot allows you to then measure the cross-sectional area. You can see on both of these images that the fascicles of the median nerve, and so you can measure this cross-sectional area, anything more than, somebody who has symptoms, anything more than one centimeter square of cross-sectional area is something to be concerned for carpal tunnel. Here you see that you can visualize that they actually have a bi-fit median nerve. And then you can also use this for diagnostic injections, so you can visualize, while having in the short axis your ultrasound, you can see the needle coming underneath the median nerve, making sure that the radial artery, which is over here, you can actually put it on flow, you can actually see the flow of the radial artery, as well as the pulsations, and you can slide this needle underneath the median nerve and do your carpal tunnel injection. With decrovanes, you can visualize that somebody has fluid around the APL and EPB tendons. You can also visualize that they have a vertical septum, as we know oftentimes you'll take someone to the OR and when you see that there's a septum, you can imagine that that injection was not getting both of those spaces, so you can actually see that in real time at a time of injection and can potentially inject both sides to make sure that both tendons are being treated at the time of care. Here you have a needle coming in from the radial direction and fluid filling up around the compartment. Trigger fingers, you can visualize the tendon in the longitudinal axis, you can see the longitudinal fibers, you can see thickening of the A1 pulley, here you can see thickening of the A1 pulley, and similarly, although there's evidence that you don't necessarily have to be in the tendon sheath to have therapeutic treatment, you can be sure that your medication gets where you'd like to have it. Also, I know some people are doing percutaneous needle resections of these, you can do it under ultrasound and visualize when you've had complete release and there's no longer any triggering. Finger infections, you can see on the left, this is a superficial abscess, visualizing the tendon sheath that you don't see any fluid around the tendon. On a deeper side, here you can see if somebody is concerned for possible flexor tenosynovitis, you can see that there's fluid in the tendon sheath, making you more concerned in the right clinical picture. Obviously, with these infections, they can have a lot of pain, so you don't really want to push too hard. You can actually put the hand in a basin with water, by just controlling your depth of field, you can actually, without actually touching, you can go through the water and actually see the same things that you normally would if you were compressing on the actual skin. Then tendon rupture, you can see, this is somebody who had a flexor tendon repair on the left, and you can actually see the suture material that's echogenic and visualize that the tendon fibers are lined up still and that there isn't any additional gapping, versus here you can see that the FDS tendon is still there, but the FTP tendon is absent, telling you that the tendon has ruptured, or somebody has a Jersey finger, knowing exactly where that tendon has retracted to. In terms of reimbursement, these are a bunch of different CPT codes that you can see in the office, things like trigger fingers, carpal tunnel injections, et cetera. You get an additional reimbursement for visualization with ultrasound, the time of injection, and so ultimately, you add about $50 or $60 per, and again, depends, obviously, this is just Medicare reimbursement, but for Medicare, at least $50 or $60 per injection that you'd be doing, so if you have a $5,000 device and you're getting an extra $50 or $60, usually if you get 80 procedures out, you'd pay for it, so pretty quickly, if you have a busy hand practice, you can find that it will reimburse for what you are doing. Thanks for your time. Thank you so much, Ralph. That was great. Next up, we have Dr. Yoshimatsu, who will be talking to us about ultrasound for planning of skip flaps. Skip flap, I think it's a very good flap to have in your arsenal. The SCIA comes out, takes off from. run superficially actually so it's an axial flap and it's not a it's not a perforated flap but I think it's a very easy flap to harvest. I do proximal to distal elevation and for the past three years I started using it. a vessel as small as 50 micrometers, so that's pretty small. And I did a comparison. I used to use hand doppler for the marking of the pedicle, and when I was using hand doppler, in about 37% of the cases, I had to switch from the superficial branch to the deep branch. So when you want to go to the deep branch, that's a backup plan, and it makes it a little bit complicated, whereas when I started using this high-resolution ultrasound, I was able And I could get away with one venous anastomosis in 10 percent of the cases. This is because you can see the, where the vein is running inside your flap. And the operative time was shorter. So what you do is you should look for the distal portion of the SCIA, which is around the ASAS. So that's where the vessels run superficial. And you can, if you can visualize the vessels there, and you go from the distal part to the proximal. And this is the actual video. So with a high-resolution ultrasonography, you can see the pulsation of the artery. So I don't use color Doppler because I think it's not accurate. You can have higher resolution with this monom. And this is another trick, is that you should design the skin paddle so that the both branches, both pedicle, run right in the middle of the flap. So this becomes especially important when you are designing a very small flap, as you do in hand patients, hand coverage. So this is not a hand, this is kind of an extremity, but this is a phalloplasty. But for example, on the right, I could visualize the proximal part and the distal part. And this is what it looks like intraoperatively. So you know exactly where the vessels are running, and you'll have the pedicle right in the middle of your small flap. So, and I always use the ICG angiography after elevation to check the perfusion. And this is a phalloplasty, so I'm just gonna skip over. So what I do is you first mark out the vessels, the SCIV and the SCIV. And then what I do is I place, I cut, I make an incision right on top of the marking. So you know that the pedicles are gonna be there. And after you find this pedicle, all you do is kind of cookie cut the skin panel. And here's another trick. This is why I make an incision to the proximal part, because this part decides the length of the pedicle. So if you want a longer pedicle, you can kind of like make this incision longer. So that's gonna decide where your pedicle is gonna be. And another trick is, another point I would like to make is you should isolate the artery and vein before you go ischemic, because they do look alike. One of the disadvantages of the SCIV flap is that the pedicle, especially the artery, can be small. The average size is about 1.5, but if you're doing hands, I think it'll be okay. So here's a case, 52-year-old female with sarcoma of the hand, and this is what she looked like after resection. So I wanted a thin and pliable flap with a long pedicle, because I wanna go to the snuff box. So what I did was I mark out, I make an incision right on top of the pedicle, and this decides the length of the pedicle. And after you find this, all you have to do is cut around the skin paddle. And in my hands, this takes only about 20 minutes. So you can save all your energy for like anastomosis and inset. And this is what it looks like. And so I made a sub-Q tunnel, and I did it micro in a snuff box. And this is what I really regret, but she complains of this coupler. I use coupler for the venous, so I don't recommend using coupler for the hand cases anymore. So this is immediately on the table, and after eight months, I might go debulk it, but how thin can you go then? So this is 13-year-old boy with sarcoma of the palm, and he was kind of chubby, BMI was 38. So after elevation, we had this five centimeter thick, super thick, and you don't want this in your palm. So this is, anything underneath the superficial fascia can be get rid of safely. So just take a scissors, a pair of scissors, and in about three minutes, you'll have this pretty thin flap. And after a year, it wasn't that bad. So, but how thin can you go? We used to think that we needed this muscle to keep the skin fat alive. Now, if you can see this point where the vessels run into the dermis, then you can have this dermis flap. And that was my thought behind this dermal plexus flap. So if you look at these vessels right here, I'm going to trace this distally and vein and artery. And as you go distally with this ultrasonography. entering the dermis. So by using this pre-operative ultrasonography, I knew where the vessels are going into the dermis. And here is another video with higher definition. So the yellow zone shows the dermis and you can see the branching patterns inside the dermis. When you know that there are plexus in the dermis, you can get rid of all the adipose tissue beneath this dermis. So this is exactly what I started doing. After you find this dermis entry point, I got rid of all these adipose tissues and this is all dermis, so that's why it looks whitish. And this is a video of the actual thinning. I mark out the dermis entry point and just take a pair of scissors and get rid of all the unnecessary fat tissue. And you have this dermis flap. And I think this is very useful for hand cases. This is, I use this in hands and especially in elderly patients because you don't have to immobilize the joints after the flap transfer. So this is a dermis flap and this is how we used to drive, we used to have these maps. And now we have these nice fancy navigation systems. So I think the use of ultrasonography will greatly facilitate your flap surgery. Thank you so much. Thanks Ade. That was great as usual. It's great to hear from you, you're an expert of the skip. I will say that probably the average BMI of my patients is closer to 38. And yeah, I don't have the very nice ultrasound that you have, but we'll talk a little bit about that later on as well. So today I'll be talking about the Superthin Profunda Arterio-Perforator flap for hand and upper extremity reconstruction. So really in my practice, I've begun to use ultrasound more and more, and I find it really has made almost a paradigm shift for flap planning. It's useful for free perforator flap planning as we heard Hiday talk about. It can be used for thin Superthin flaps such as planning of Profunda Arterio-Perforator flaps, ALT flaps, as well as for pedicle perforator flap planning because you know exactly where the perforator is, so there's no guesswork at all when you try and design a propeller flap. In addition, I found it useful as well for mapping of axial vessels and pedicles. For example, I had a recent example, a recent case of a toe transfer. I wanted to see if it was a dorsal dominant or plantar dominant circulation. And with the ultrasound, you can tell beforehand, so then there's no guesswork at all, and you know your surgery is going to be easy or hard. So the Profunda Arterio-Perforator flap has become more popular recently for reconstruction in the breasts as well as the head and neck. And one of the reasons it's become so popular is because the donor site is hidden. But the advantages it has for the breast and head and neck also make it less suited for the extremities. It tends to be very thick with a good quantity of fat, hence there have been less publications on the traditional Profunda Arterio-Perforator flap for extremity reconstruction. So as mentioned, the disadvantages of the traditional PEP flap are that it's a thick flap. The flap artery can be small as well unless it's traced close to the origin, but a short pedicle flap caliber can be overcome with super microsurgery. The advantages of the PEP flap, however, are that there's a concealed donor site scar, relatively large perforators that can be easily visualized on preoperative CT or MRI, a long pedicle that goes up to about 10 to 12 centimeters routinely, as well as a straightforward pedicle dissection. So the concept of elevating a flap in the thin or super thin plane, which is on the scarpus fascia or superficial to that in the subcutaneous fat, was popularized by J.P. Hong and the group in Seoul, Korea. So in this concept, the flap is elevated really thinly on the scarpus. And as you can see, you can get some pretty nice results. So the concept relies on this hot and cold zone concept. So the flap elevation goes pretty fast in the cold zone and then slows down in the hot zone around the perforator, which you're able to map preoperatively using ultrasound. So when we first started doing a super thin PEP flap, we did a radiological analysis of CTs that were done for other purposes. There's a consecutive series of patients who had CT of the lower extremities, 80 of them, for various indications, and we identified the dominant profound artery perforator on both thighs. So here we're able to do some measurements by measuring the thickness from the deep fascia to the skin, as well as the thickness from the bifurcation point to the skin, as well as the proximal distal distance of the PEP perforator. And we found that there were two main morphologies of perforators. There's a T-pattern perforator, as you see on the top, where the bifurcation is pretty close to the skin. And you can see a video on the right side. I know it's hard to see, but you can see on the bottom left here that the bifurcation is very close to the skin. And then on the bottom here is a Y-pattern perforator, where the bifurcation is closer to the fascia. And you can see in the circle over here on the left side as well. So really, I'm going to talk a little bit about the relevance of this in just a little bit. But we found that the musculocutaneous perforators were predominant, there are a lot more T-perforators than Y-perforators. T-perforators were more common in women, and patients who had a T-perforator had a somewhat little bit higher mean BMI than a Y-perforator. So the relevance of this is that we found later on a clinical experience that the branch point of the thickness of the T-perforator correlates well with the thin flap thickness when you elevate a flap on the scapula's fascia. So what this means is that if you measure the thickness of the T-perforator branch point preoperatively, you can predict how thick your flap can be. But whereas if you have a Y-pattern perforator, it does not necessarily correlate because the branch point of the perforator is deeper towards the fascia. So I found that useful in deciding what perforator to choose. And I think in my practice, I still tend to prefer a T-pattern perforator because you can predict the thickness pretty accurately on the preoperative CT. So the protocol that we use now is the CT to localize the proximal distal location of the dominant perforator, and then the exact location is confirmed with colored Doppler or duplex ultrasound and handheld Doppler. And the flap is centered on the dominant perforator, and that the flap thickness can be customized based on the requirements of the defect and whether it's a T- or Y-dominant perforator. So for upper extremity defects or hand defects, I tend to go a lot thinner on the flap, whereas for lower extremities, it's useful to have some thickness because sometimes you have bone, very often you have bone or hardware exposed. So we recently published our early clinical experience with the SuperTint PAP flap. And again, the protocol relies on the duplex ultrasound for preoperative mapping of perforator together with the CT, and then a customized flap design for light-for-light reconstruction Doppler extremity. So let's look at some cases. So example of a forearm resurfacing, nine-year-old male with a MVC degloving injury. And the CT showed a Y-pattern perforator. So if you look on the bottom left, you can see that you can almost imagine a Y. So it's very hard to capture dynamic ultrasound images, but very often it correlates with what you see on the CT. And on the CT, you can see there's a Y-pattern branching when looking at the axial section. So in this case, we designed a fairly standard PAP flap, and we were able to elevate, in this case, mostly in the thin and SuperTint plane. You can see on the image on the right, a lot of the fat has been left behind. You know, whenever I show these pictures to an educated audience, they say I'm squeezing the flap to make it thinner, but really I'm not squeezing the flap. It actually is really that thin. It's really about six millimeters. And then here's the short-term postoperative result. Another example of a wrist wound, 70-year-old male who had a resection of wrist sarcoma with an ulnar-sided defect, exposed bone and tendon. And on the CT and ultrasound, you can see a T-pattern perforator, which bifurcates pretty close to the skin. So here's the ultrasound. And you can see, again, I apologize for the ultrasound images, it's really hard to capture a nice dynamic ultrasound, but you can see that it's going close to the deep fascia, and then it goes to the skin, through the skin, and you can see it's caused pretty well. So in this case, you don't see a very clear bifurcation on this, because bifurcation is very close to the skin, but you can appreciate that there isn't a very deep bifurcation like the Y-pattern perforator. And here, a pretty thin flap that's been elevated in the, this is more like in a thin plane, but a pretty wide flap, 18.5 centimeters by 10 centimeters wide. And this is like a three-month post-operative result for resurfacing of the ulnar wrist wound. Another patient with a web space contracture, 64-year-old female, who had burns. And you can see in this preoperative video that the thumb's range of motion is really quite restricted, so we need to release the first web space. So in this case, the imaging, as you can see on the CT on the left, showed a T-pattern perforator of a bifurcation pretty close to the skin. And this correlates very well with the ultrasound as well. Again on this image, you're just able to see one limb of the T, but you can see it goes pretty superficially all the way to the skin, correlating with the CT findings. So the intraoperative images, you can see how the perforator is isolated on the top two images. And then down here, the flap's been elevated, and you can appreciate that the pedicle itself is really pretty long. In this case, you know, you can see it is at least about 8 to 10 centimeters. And here's the flap, still a bit bulky, that's used to resurface. Another example of a hand wound, 24-year-old male who was involved in the MVC, also sustained extensor tendon injury, and ultrasound in this case showed a Y-pattern perforator. So again, you can see on the images on the right side where the perforator exits the deep fascia. And again, on that last part of the video. Again, pretty much elevated on a thin plane, to squeeze the flap to prove that it really was thin. And this is the short-term post-operative result. It looks a bit more bulky on the ulnar side because I did have to hook up to the vessels in the anatomical snuff box. I was concerned about hooking up to the ulnar artery, but this settled down a little bit with time. It's still a relatively nice contour for a dorsal hand defect. More proximal injuries, an arm wound, 15-year-old female who sustained a high-velocity gunshot wound to the arm in a drive-by accidental shooting with exposed plate. So in this case, a super-thin PEP flap. And this is really pretty much super-thin in many instances. You can see the amount of fat we've left behind. And because the arm tends to be thicker, this is a much nicer post-operative result as well. You can see the contour matches the biceps pretty nicely. And in terms of the donor side scar as well, I think really one of the main advantages of the PEP flap is that the donor side is really hidden. So you can see the scar when the patient is like, you know, showing it to you with the thigh abducted, but from the front, you cannot even see the scar at all. So, you know, I like it much better as a personal preference than the ALT flap, which very often has a visible scar. Medial elbow wound. 18-year-old female who was involved in a motor vehicle accident. No local flap options due to previous interventions. Had previously attempted failed local flap coverage, previous nerve transfer, so really couldn't do a radial forearm flap. Referred for coverage of a medial elbow wound with exposed plate. So here it is. And then a pretty small super-thin PEP flap. And on the bottom right, you see what happens when a plastic surgeon assembles an external fixator. But, you know, the aim is just to offload the flap and we don't really care about the way it looks. So I'm just kidding. But actually, it did actually serve to immobilize the elbow as well as offload the flap. And this is a short-term post-operative result with a nice contour of the flap. Lateral elbow wound. 65-year-old male, motor vehicle accident with exposed elbow joint. Had a collateral ligament reconstruction by the auto trauma team. And in this case, this guy was actually thin, so like pretty atypical for my patients. So we're able to get like a three millimeter flap, you know, and this was even superficial in many instances. And here's a very nice contour of the flap on the lateral elbow. So in conclusion, pre-operative CT and duplex allows design of customized single perforator flaps. And the advantages of the super-thin profonta artery perforator flap, at least I've found, are that it's a thin flap with customized thickness and a concealed donor site. And this is a flap that's well-suited for upper and lower extremity reconstruction. So thank you very much for your attention. Thank you. Next, we have Dr. John Park. As I mentioned, Dr. Park is not able to join us because of a family emergency, but he was kind enough to send over a video, so let's have a look at his video. Good morning, everyone. My name is John, Changsik John Park from Seoul Asan Medical Center, and today I want to talk about the ultrasound mapping of the anterior trapezius when you are doing upper extremity reconstruction. And use of ultrasound in extremity reconstruction, we are using the ultrasound to prepare the recipient vessel, and flat vascular evaluations, and the post-operative monitoring of the flap. Actually, because I want to, today I want to talk about the AAD flap vascular evaluation of the, using the ultrasound. This is the, about five years ago, I have bought by myself about used ultrasound, which is about 10 megahertz of the proof, Samsung Medicine. It was enough to doing a free flap, because it shows enough information for us to doing a free flap, and also we can check the velocity and the interactual course of the flap. But techniques are really advanced, and now we are using a Canon brand of the ultrasound, which is the high ultra, it's not ultra high frequency, but it's 33 megahertz of the ultrasound, and also it is really helpful for the flap evaluation and the lymphedema surgery, and also it can give us very high resolution images and videos, and also a lot of function. So when we are doing a flap vascular evaluation, I want to talk about these two flaps, AAD flap and SCIF flap. AAD flap and SCIF flap is now, we are focusing to doing flap surgery, you know, extramedullary reconstruction, and AAD flap is more deeper, and the intramuscular course is a little bit longer than a SCIF flap, and also the dimension is a little bit complex, and because of the arterial course is a little bit complex than the SCIF flap. So I want to talk about AAD flap, and when we are checking the AAD flap, we always find a perforator from using the ultrasound, and check the penetrating point of the deep fascia, because after about the deep fascia, arterial course are very different in a different flap, so maybe we have to know the course of the perforating vessel above the fascia, because it should be very helpful to identifying the course of the perforator, and it is really helpful to seeing the flap, and also the type of the descending branch, because to doing a lot of information, we can get a lot of information using the ultrasound. So when you are doing a flip flap, you can see our resident is coming, checking the ultrasound of the site, and you can see the deep fascia, and also the perforating vessel above the fascia. So it can give you a lot of information for doing the flip flap information. Also arterial venous flow is also checked, and penetrating of the fascia, and now he is checking the velocity of the vessels. And after checking the mapping, the fascia, we make a marking on our skin, and it should be really helpful to doing a flip flap. This is another video to mapping the step-by-step of the perforator of the ALT flap. The marking landmark is tracing, and the middle of the center, the circle, and checking the perforator sound using handheld. We have checked two perforators, and also we use infrared camera, which is very helpful to identifying the rough location of the perforator. In the CT images, you can see the muscular course of the perforator, and also we can render in the 3D images, and perforator is coming from the descending branch to the deep fascia. And also you can check the perforating penetrating point of the fascia, and also if you're looking at more superficial layer of the perforator, it's coarse. The coursing of that layer is important, because if you elevate the flap above the fascia, it is easy to damage of the wrong course of the perforator. So if we check the 3D images, or you can imagine the course, you can see the very unique course of in this flap, you can see the very unique course of the perforating vessel, and also you can see in a high frequency mode, and the course of the perforator to the skin, even to the skin, is well identified. So final interface course within two branches is making different above the fascia, it is diverse. So maybe we can check all the courses. This is another case, duplex ultrasound mapping using the different patient, and also you can see the penetrating point of the fascia, piercing the fascia, and also you can see the high frequency mode, and you can see the perforating point of the fascia, and also the course, interface course is well identified. So maybe you can see the perforator is coming up and going to the skin. And this information is very helpful to identifying the perforator and thinning the flap. When we are planning to doing a thin AIT flap, intra-fat course is very important. Also, the tiny vessel to the skin, perforator to the skin is very small. So maybe if you are planning to doing a free flap, imagine just like this 3D images. And also, this is the real video harvesting. And also, we have already identified the tiny perforator to the skin and the intra-fat cores. And also, you can see the perforator above the superficial fascia. This is a proximal perforator, and when we identify the proximal perforators, we are making more deeper. And sometimes, we can harvest some deep fascia not to damage the arterial system of the fascia. So make an incision to the deep fascia, and you can make it more easier to not damage the arterial systems. And also, you can harvest a very thin flap. So my personal reason using ultrasound in an ART free flap is I usually do an ART free flap more than the skin flap, because ART free flap is, once you are using the ultrasound, it is really easy to understand the course of the perforator after the descending branch. And also, it is very easy to identify the course of perforator above the fascia. And it is very helpful to understand the 3D course of the perforator, and it should be really helpful for you to make a thin flap elevation. And this is my contact, and thank you. Thank you for listening. Thank you. Well, I would like to thank all our speakers. We have some time, so if you have any questions, please feel free to come up to the microphone. We would love to answer your questions. There's one question that came in on the poll, and I guess I'm going to start us out by asking a related question. So Hiday, you mentioned you use high frequency ultrasound routinely in your practice. Do you ever use ultra high frequency ultrasound or conventional ultrasound for flap planning for any reason? Yeah, thanks for the question. I used to use handheld Doppler, and then I went to the conventional ultrasound. But when you're dealing with the small vessels, it was really, I was sometimes like, I think the color duplex, you see the signals, but when you see it interoperatively, they were too small. So I kind of like went back to handheld Doppler. And then when the high frequency one came, I thought it was much more useful than the conventional one. So I think that's more suitable for looking for small vessels. So that's my take on it. And then this question actually asks, do you think ultra high frequency ultrasound is necessary for tracing the dermal perfusion pattern for skip flap planning? When you want to look into the dermal ones, I think you would have to, you would need a, like when you're using a probe, like John was using a 30 megahertz, and I think that's like a, I think you would have to have at least like 30 or 40 if you want to look into the dermis branches. Okay. And Raf, do you have any comments on this? Yeah, so I don't do dermal flaps. I think that the, you know, using a probe that 12 megahertz, you can see the perforators, like I'll use it for planning my ALTs. And I think it's helpful to kind of know exactly where they are. So rather than just, because I think that the traditional handheld Doppler, you're not really sure if it's the perforator, if it's the longitudinal vessel, if they're kind of close to each other. So I think it allows me to really, particularly when I have a smaller flap and I can kind of design it better, remedially over the perforator, as opposed to finding out that I'm a little bit eccentric. Great. Thank you. So personally, in my experience, I use a conventional low-frequency ultrasound, it goes up to about 15 megahertz. And the reason is because I'm not able to get a high-frequency, ultra high-frequency ultrasound, because as you all may know, it's rather expensive. So it's great that, you know, Hiday, you have access to that, but unfortunately I do not. But also I think the aim of ultrasound in these instances is different. So when you're planning a skip, it's very necessary for Hiday to trace the whole course of the perforator, because the skip is very much an axial flap. Yeah, that's the point I want to make. It's an axial flap, it's not a perforator flap, it's an axial flap. So I think tracing the whole course is really important. So you hear a lot of people losing the groin flaps and the skip flaps, that's because their design is wrong, I think. So when you know where the vessels are running, you can design it without any having malperfusion or complications. Absolutely. So when you're designing a PEP flap or an ALT flap, I think your aim is to localize the perforator, and you can look at the course of it through the deep fascia into the superficial fascia. So in that case, personally, I find the color Doppler ultrasound better, especially when you use a lower-frequency machine. So I think John seems to have used a combination of normal 2D ultrasound, M-mode ultrasound, as well as color Doppler ultrasound to plan the ALT flaps. But again, the principle is different. We are planning skip flaps compared to, like, PEP and ALT flaps. John, you have a question? Question for you, Harvey. Congrats on your recent paper, by the way. You implied that you may decide on how thin to make your flap based on the branching pattern. I was wondering if you could talk a little bit about how you decide on the thinness. I think that from Hide's, it was clear, but just with the PEP. Sure. So the PEP is, unlike the skip, is a single perforator flap. So I think if I have a T-perforator, I'm very comfortable just going very close to the perforator origin. So the flap is elevated first in the thin and super-thin plane, and then in the cold zone. And then when you get to the hot zone, then we go deeper to preserve this cuff of fat around the perforator. And if it's a T-pattern perforator, I'm pretty sure that I can go pretty close and pretty much just take a small cylinder of fat. But for Y-pattern perforator, I'm just a lot more careful. And then in regards to the thickness, the thickness is really customized. So I can elevate it in the scar pus fascia in a thin plane for like a leg wound. But in a hand wound, for example, I can really go in the subcutaneous fat and then really close to the perforator. And then after it's free, similarly go around it and harvest it like really thin. So that's what I mean by customizing the thickness of the flap. Yeah. So you have a question? Yeah. First of all, thank you very much for this panel. I think it's great. I guess my question is, well, there's a few questions. One, I'd like each of you to comment on how you got trained to do the ultrasound and how you got sort of, you know, how you learned to do it reliably. I was wondering if any of you got pushback from the radiology departments in your hospital regarding this. And particularly with, you mentioned charging for it in the office and how you dealt with that as well. Sure. So in terms of charging, it's only for procedures. So the codes for injection under ultrasound guidance is a separate CPT code. And there's no pushback there. If you're trying to do diagnostic ultrasound, that's where you'd get yourself into trouble. And the reason actually is less about radiology and more about liability. Because if you're doing a diagnostic ultrasound and billing for it, you have to comment on everything in that field. So that means that if you were doing a flap in your office, preoperatively, you were trying to scan the leg and trying to plan it, and you wanted to use that as a diagnostic code, you'd have to make sure that you didn't see any abnormal lesions, there was no DVT, etc. And that's obviously a much stickier thing. So the biggest hurdle to being able to bill for it, particularly if you are in a big health care system, is the IT part. So you have to take a photo of the ultrasound at the time of the needle placement to put in the EMR to be able to be, like, something someone can search for later to be able to bill for it. Ida, do you have any comments? Yeah, I'm going to talk about the learning curve. So I used to use handheld, and I went to the conventional, the ultrasound with the color duplex. And it's really confusing, because you have to, like, set the window of the velocity and all that. And it was so confusing. So I kind of stopped using it, and now I'm using this without color duplex, because it's so easier. So all you have to do is kind of, like, apply the probe over the vessels, and you can play around with it. And I think the learning curve is, like, when you look into, like, two or three patients, or just by looking at your colleagues, you know, you'll get very familiar with it. So the learning curve was very steep with this high-resolution ultrasound. So I'm not good at, like, adjusting the velocity and all that. So I have a similar experience. I basically learned ultrasound just after watching, like, you know, like, Hideh do it, or, you know, some of our colleagues in Asia. And then I just started playing around with our ultrasound. I have a conventional, low-frequency anesthesia ultrasound, which all of us have, which is not great. And I just started playing with it one day, and then just learning to map the perforators. I don't do very advanced things like measuring the flow velocity and all that that often. So for me, the purpose is more to map the location and cost of the perforators. But also, I don't really rely on radiology. I do everything myself. And now, you know, it's pretty quick. We just map the perforator on the table before we do the surgery. It takes less than five minutes. And it really provides so much more information. Yeah. Any other questions? I have a question for you. Do you think you'll get away from doing CT and geography since you're visualizing the perforator and you can see the course with ultrasound? I think there's a role for CT and geography for, like, ALT and PEP. This is my personal view, and obviously, people disagree on this. But because you can scan the whole thigh and try and find a perforator. But if you have a CT and geography, it gives you some preliminary idea of where you're going to scan on the thigh. So that's what I find the main purpose of the CT and geography. So I can localize the dominant perforator, and I just have to scan that small zone around it instead of, like, you know, scanning the whole thigh. What do you think, Ade? So for my skip flap elevation, I don't rely on CT-ANGIO, but I always use CT-ANGIO for looking for recipient vessels. So I think CT-ANGIO is the most reliable modality for when you're looking for the recipient artery. And for PEP flap, I mean, I do a lot of DF flaps, but I do use CT-ANGIO. So for skip, I just do ultrasonography. Sure, I think there are two ways to do a pet flap, you know, the people who do like breast reconstruction sometimes will put the patient in lithotomy and stirrups and then go sit in between the legs and that's fine. But for me, I just harvested in the supine front leg position. So you know, we're basically like just abducting the leg to get the flap out. And then after that, so it's pretty comfortable, you can actually sit down, you're directly opposite the patient. I mean, on the opposite side, I like for ALT flap, but you're sitting down, and then you're just like dissecting straight ahead of you. So you know, it's pretty comfortable. And I use like hooks for retraction. So I don't really need a very dedicated assistant until I go kind of deeper on the pedicle. Then I need my assistant to kind of pull a little bit with like a diva or something like that. But I find it's pretty comfortable and I'm not as fast as today, I don't harvest a flap in 20 minutes, but I still can harvest in like an hour for pet flap. So total surgical time is not that long. Any other questions? All right, well, if no other questions, we'll end a little early. Thank you so much for coming to this session. I hope it was informative.

ultrasound

reconstructive surgery

preoperative planning

flap design

intraoperative evaluation

therapeutic potential

cost-effective alternative

diagnostics