Enhanced three-dimensional visualization reconstruction for perforator flaps: A case series on clinical applications and outcomes.

INTRODUCTION

Perforator flaps play a vital role in soft tissue repair; however, they face challenges due to anatomical variability. Although computed tomography angiography (CTA)-based three-dimensional visualization can assist in surgical planning, it is limited by image quality and vessel extraction accuracy. This study presents advanced 3D techniques designed to enhance accuracy and evaluates their clinical outcomes.

METHODS

This case series investigated the clinical applications and outcomes of enhanced three-dimensional visualization for anterolateral thigh perforator (ALTP) flaps in 12 patients (13 flaps) treated between January 2021 and December 2024. Technical enhancements included: 1) optimized CTA protocols (adjusted voltage based on body mass index, high-contrast injection, and nitroglycerin administration); 2) an "Indirect Extraction Method" with a reduced threshold (105-115 HU) for small vessel reconstruction; 3) manual tracing of perforators; 4) "Digital Reverse Flap Design" (an expanded wound model projected onto the donor site); and 5) 3D-printed surgical guides for enhanced precision. The outcomes assessed were perforator accuracy, flap fit, survival, and complications.

RESULTS

All flaps were successfully transplanted in the present study. Perforator localization was excellent (<1 cm) (81.3%, n = 13/16) and moderate (1-2 cm) (18.8%, n = 3/16). Surgical findings were consistent with 3D planning in 100% of cases regarding perforator type, source artery, and pedicle route. The flap fit was excellent (84.6%, n = 11/13) and moderate (15.4%, n = 2/13). The survival rate was 100% (n = 13/13). Foot function, assessed by the American Orthopaedic Foot & Ankle Society (AOFAS) score, was good in both cases. Hand function, measured by the Michigan Hand Outcomes Questionnaire (MHQ), was rated as excellent or good in 60% (n = 6/10) of cases. Complications occurred in two cases (12.5%), including infection (n = 1) and delayed fracture healing (n = 1).

CONCLUSION

The advanced 3D technique enhances perforator localization, flap design, and surgical precision, resulting in high success rates. Limitations of the present study include a small sample size and its retrospective design.