Subdermal Dissection for Elevation of Pure Skin Perforator Flaps and Superthin Flaps: The Dermis as a Landmark for the Most Superficial Dissection Plane

Background: Pure skin perforator and superthin flaps have been reported and are becoming popular, as they allow one-stage thin skin reconstruction even from a thick donor site. However, currently reported elevation procedures use proximal-to-distal dissection requiring free-style perforator selection and primary thinning procedures. With distal-to-proximal dissection using the dermis as a landmark for dissection plane, it is expected that elevation of pure skin perforator or superthin flaps can be simplified. Methods: Patients who underwent pure skin perforator or superthin flap transfers with the subdermal dissection technique were included. Flaps were designed based on location of pure skin perforators visualized on color Doppler ultrasound, and elevated just below the dermis under an operating microscope. Medical charts were reviewed to obtain clinical and intraoperative findings. Characteristics of the patients, flaps, and postoperative courses were evaluated. Results: Thirty-six flaps were transferred in 34 patients, all of which were elevated as true perforator flaps (superficial circumflex iliac artery perforator flap in 29 cases, other perforator flaps in seven cases). Mean ± SD flap thickness was 2.24 ± 0.77 mm (range, 1.0 to 4.0 mm). Skin flap size ranged from 3.5 × 2 cm to 27 × 8 cm. Time for flap elevation was 27.4 ± 11.6 minutes. All flaps survived without flap atrophy/contracture 6 months after surgery, except for two cases of partial necrosis. Conclusion: The subdermal elevation technique allows straightforward and direct elevation of a pure skin perforator or superthin flap within 30 minutes on average without the necessity of primary thinning. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.