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into the skin. A mark was then made on the skin paddle at ten fasciocutaneous flaps (4 in Group 1 and 6 in Group 2),
this site. This point was then plotted on the X- and Y-axis five musculocutaneous (MC) flap (2 in Group 1 and 3 in
after resuturing the skin paddle (subtracting the specified Group 2), and one vastus lateralis muscle flap (in Group 1)
2
distance) to eliminate the obliquity of perforator entrance were performed. Skin paddle size varied between 63 cm
secondary to flap retraction/sagging. Care was taken to and 264 cm in Group 1 and between 90 cm and 220 cm
2
2
2
identify all perforators to the skin paddle which were in Group 2 with a mean of 173.78 cm and 170.10 cm ,
2
2
preserved until the very end before committing to base respectively (P = 0.89).
the flap on the sizable perforators.
Perforator number and type
Surgeons’ stress level MDCTA picked up all seven septocutaneous (SC)
Surgeon’s perceived (subjective) stress level during flap perforators, 4/7 MC perforators of which 1/4 were semi-
harvest was scored on a four-point visual analog scale (VAS) septocutaneous (SSC). There were no differences between
and recorded as follows: MDCTA and intraoperative findings for the distribution of
type of perforators (P = 0.68).
• Grade 1 = no stress (preoperative perforator location
matched intraoperative findings with only minor Perforator source
discrepancies (< 2 cm) in perforator location); Perforators were compared based on their source vessel:
• Grade 2 = mild stress (discrepancy measured more descending branch of the lateral circumflex femoral artery
than 2 cm in perforator location between preoperative (DBLCFA), anteromedial thigh (AMT) perforator arising
and intraoperative findings); from the DBLCFA, the transverse branch of the lateral
• Grade 3 = moderate stress (gross difference in the circumflex femoral artery (TBLCFA), or the oblique branch
perforator location, source, and course); and of the lateral circumflex femoral artery (OBLCFA). MDCTA
• Grade 4 = severe stress (no perforator was present, accurately detected 8 out of 9 perforators arising from the
or inadvertent perforator injury occurred during DBLCFA and 3 of the 4 perforators arising from the TBLCFA.
dissection). Two AMT perforators were identified intraoperatively
(both in Group 2). There were no differences between
Time taken for flap harvest and surgical outcome were preoperative MDCTA and intraoperative findings for the
also noted. source vessel and origin of the perforators (P = 0.832).

Statistical analysis Sizable perforators
Statistical Package for the Social Science, version 19, IBM In our study, any perforator over 0.8 mm was considered
(2010) was used. The Kolmogorov-Smirnov test was applied to be sizable. MDCTA detected all sizable SC perforators,
[8]
to determine the distribution of data, and if data was 4/5 sizable MC perforators of which 1/2 was SSC. Doppler
skewed, Mann-Whitney test was applied. For comparison signals localized sizable perforators accurately in only 2
of categorical data, the Fischer exact and Chi-squared tests of 9 patients in Group 1 and 4 of 11 patients in Group
were applied. Kappa inter-rater agreement was applied to 2. Sizable perforators were further compared based on
determine agreement between the preoperative findings their source vessel, i.e. DBLCFA, DBLCFA-AMT, TBLCFA,
of MDCTA versus Doppler using intraoperative findings as or OBLCFA. MDCTA localized all sizable perforators
the gold standard. arising from the DBLCFA and TBLCFA. Overall sensitivity
and specificity of MDCTA in demonstrating the sizable
RESULTS perforator in segments 4 and 5 was 90% and had an
accuracy of 88.88% with a kappa value of 0.78 (good
A total of 20 patients over a period of 1 year who underwent agreement) for each segment.
free ALT flap coverage at our hospital were allocated
randomly into two groups. Concordance of MDCTA versus Doppler
for perforator localization
Patient demographics A difference of more than 2 cm between preoperative
In Group 1, the mean age of patients was 37.5 years ± localization and intraoperative findings was considered
11.49 years, and in Group 2, it was 43 years ± 14.29 years to be discordant. In Group 1, MDCTA had a concordance
(P = 0.35). There was a total of six patients with post head level of 100% (12/12) while Doppler had concordance
and neck cancer resection defects (3 in each group) while of 46% (6/13). Overall concordance of Doppler was
one patient in the Group 1 had invasive aspergillosis of the only 52% (13/25). This further establishes the accuracy
maxillary sinus. Eight patients had lower limb traumatic of MDCTA in localization of perforators. The Bland-
defects (5 in Group 1 and 3 in Group 2), and five patients Altman plot [Figure 1] was used to depict the inter-rater
had upper limb traumatic defects (1 in Group 1 and 4 in agreement between the two variables (MDCTA with
Group 2). Traumatic limb defects accounted for 65% of intraoperative findings in the first plot and Doppler
cases while nontraumatic defects accounted for 35%. with intraoperative findings in the second plot) by
plotting the average of the distance of perforators
Anterolateral thigh flap characteristics noted by both the variables against its difference from
Four cutaneous ALT flaps (3 in Group 1 and 1 in Group 2), the mean. This demonstrates that the values were
54 Plast Aesthet Res || Vol 3 || Issue 2 || Feb 29, 2016