Surgery Spotlight: Superficial Circumflex Iliac Perforator (SCIP) Flap for Plantar Surface-Surgery Spotlight: Superficial Circumflex Iliac Perforator (SCIP) Flap for Plantar Surface

Surgery Spotlight: Superficial Circumflex Iliac Perforator (SCIP) Flap for Plantar Surface

Video Transcription

Hello everybody, my name is J.P. Hong. I work at Asan Medical Center in Seoul, Korea. Our hospital is also affiliated with University of Busan School of Medicine. Today I'll be  performing the skip flap superficial circumflex iliac artery perforator flap for a 53-year-old  female patient who has currently malignant melanoma on her right sole. We'll start with our orthopedic colleagues with the cancer resection first, followed by the lymph node  dissection from our general surgeon colleagues, and then finally we'll go in as the third team to reconstruct the defect. Usually a lot of these surgeries are done as a two-team  approach, but for the sake of the video, we'll be doing it as a sequential approach. Recently  I published a work regarding the skip flap in 200 of our previous cases, and I find this flap to be a very thin, fast, relatively constant perforator base flap, which could be used  as a propeller or local style, or as a free flap as well. So I hope you enjoy the flap elevation. I'll be going step by step from the pre-surgical design, talk about the skin  topography, and we'll do the actual surgery with the elevation, and then I'll show you the final result after insetting the flap. Our excision margin usually is from about  1.5 to 2 centimeters, so the anticipated defect is going to be that big. And when you draw the anticipated defect, it does involve part of the heel pad, so hence we'll perform  a flap reconstruction and light with light, so therefore we'll perform a skin perforator  flap to reconstruct the defect after the resection. As you can see here, it's very close to the posterior tibial, and probably we'll have a part of the posterior tibial or part of  the medial plantar exposed, so we believe that finding a recipient vessel that has a nice pulse should be easy after the resection. So our plan, and you can see the defect, is  going to be about 6 to about 7 centimeter width, about the same length, so our flap dimension is probably going to be about 10 by 5 centimeters to cover the defect. Also,  our general surgery colleagues are going to do lymph node dissection to remove all the lymph nodes, so we can't use the right side, so my preferred flap for this intermediate  size is always the skip flap, and this is where the flap is going to be harvested. Now, the markings usually involve, from our experience, as you can see here, the crease line, the  groin crease, and you can palpate the ASIS right here, and if you mark a line, an imaginary  line, this is where we think the axis of the perforator is going to be. Usually, the perforator,  one comes from medial, one comes from lateral, the one that comes from the lateral is so-called a deep perforator, which travels underneath the deep fascia and then comes out in the  lateral side. The one that comes out from the medial is usually the superficial, it's  a direct cutaneous type of perforator. So, having this line, we're going to start now to use the  Doppler to actually hear where the perforators are coming out, and then after the Doppler,  we're going to use a duplex scan to also see the velocity, and when we see a high velocity,  then that's the perforator that we usually like to use. So, I'm going to have my resident, Dr. Song, use a Doppler and start mapping out the perforators. Dr. Song?  So, the medial superficial perforator is very close to the femoral artery and vein,  so you have to make sure that that's not the femoral artery and vein.  So, we start to hear a nice sound, so he's probably going to mark that one.  And then, we're going to go to the lateral side and start to...  Yep, that's another perforator right there. So, here are two nice perforators that are coming  out from this axis. What's really great about this flap is that if you design the flap large  enough, what you can also include is the SIEA, superficial inferior epigastric artery perforator,  which comes out from here. If you design the flap a little bit to the medial, you also have  the superficial pudendal perforator. So, within the realm of the SCIP, you could actually include  at least three or four nice perforators. So, that's why you want to do a freestyle approach.  You want to start from the bottom, identify the perforators. If you don't see it, a little bit  advanced, a little bit more, and you'll be able to be salvaged by nice perforators from the SIEA  or the superficial pudendal branch. Okay, since now we've marked the perforators, we're going to  start to use duplex and actually see the velocity and, if possible, the diameter of the perforators.  This is a nice perforator that's coming out. So, that's the one that we probably traced.  And you can see the diameter is relatively very large and the velocity is  the mean velocity is about 36.3 sonometers per sec. So, that's a very nice perforator right there.  So, you can see the defect as we anticipated yesterday when we were designing the patient.  You can see the defect is involving part of the heel pad and also lateral portion here. So, I think using a flap is justified in this case. The defect is about 6.5 by 8.  And now we're going to be starting to search the recipient vessel. What I want to do first is that  when I look at this field, I want to look for anything that's moving or pulsing. So, I'm just looking at the field and trying to see what's usable. So, usually in this depth,  the medial planter should be exposed. Also, a couple of nice vessels. You could already see  the medial part of the medial planter being exposed at this level.  So, we'll try to dig in here and try to find something, if anything's usable.  Okay. I like to dissect using a monopolar bowie. I'm currently using the cutting mode.  I think everybody has different methods or different ways that they want to do bipolar. So, we're beginning to see some nice pulsation here. I don't know if the camera  could capture that. This looks pretty nice. We'll try to isolate it, dissect it a little bit more.  All right. So, I think we've entered the medial planter ground right here.  So, right beneath. So, it looks pretty nice.  Okay. So, these are all the vessels from the medial planter.  You see a nice pulse. You see that? All right. So, that's it. All right. We're done here. And we'll start elevating the skip club, making a line to that ASIS. We've  Doppler, actually, duplex two. Nice. The medial superficial and the lateral deep. So,  these are probably the vicinity where the puffer is will be. As I recall, this had a velocity of  36 and this had a velocity of nearly 40. So, whatever comes and whatever is better, we'll use that pufferator. Okay. Again, looking at the topography here,  sempis pubis, if you draw a line from here to the ASIS in the middle, there should be a  superficial inferior epigastric artery here. Here, near to the pubis at this level around here,  is where the superficial pudendal is. Pudendal. So, if you make the flap large enough, you actually have more than four choices of possible pufferators coming out in the flap.  So, actually, you can't really miss not having a pufferator in the field.  Okay. So, the design, when we do the skip, usually, we say we do a pinch test. And usually, this is about average of eight centimeter width that you'll be able to take  because to ensure a primary closure.  All right. So, you could see the skin extensibility. It's very pliable. So, you could stretch out the skin if you make it thin enough.  So, usually, I like to take the flap just about the right size. And if you wanted to make the width larger, what you can do is you could actually flex the hip  and then you could stretch out the width to about 12 centimeters.  Now, if you use the lateral deep branch, this lateral deep branch is usually an axial pattern,  a branch that goes all the way to the flank. So, what you can do is you could actually elevate the skip large enough to be about 35 centimeters in length from the crease.  So, you could elevate this at a very fairly large size. But in that kind of case, you'll have to  base your flap on the deep branch because that travels toward the flank in an axial pattern manner. If I like to take a moderate size flap, I like to take a large size flap.  So, I'll take a large size flap and I'll make the width about eight to ten centimeters.  If I like to take a moderate size flap, I like to take the medial  superficial because this is a direct cutaneous type and it really has a very speedy,  non-muscular dissection. All right. So, that's the topography. We'll start elevation.  So, here we're taking about 11 times 6 centimeter flap. We actually needed a 7 by 8. But again, we're going to stretch out slightly like that and this will decrease the length.  So, I like to take the flap with an easier possible closure. I like to erase my markings before I start because these markings sometimes sort of like gives you a bluish color if you  don't erase it and then the residents get confused whether the flap is congested or not.  Okay. The traction is important. You can see my chief resident, Dr. Song,  is doing the traction. This makes it easy for me to actually  identify the superficial fascia. So, here you can see the fat lobule is relatively small and once you come to a slightly white film layer  that's where we know where the superficial fascia is. Here you can see the fat lobule is getting a little bit larger.  So here you can identify the superficial fascia right here, that's the superficial fascia. So that will be our plane of elevation. Elevate the upper margin as well.  Usually what I would recommend is that you start with a lower lateral approach. The lower lateral approach has the most distinctive layer of that superficial fascia.  So through this video you'll be learning two major skills. How to elevate the skip flap at the same time, how to actually see the superficial fascia  and do the elevation above that plane. Again the traction is an important part of the elevation. So this is the plane of elevation I was saying before.  You can actually see all these small micro-vessels come out. See multiple perforators already seen going into the flap. So this is probably the deep branch that we marked.  See that perforator? The deep branch is giving out multiple perforators as we've seen in the CT evaluation. Here's the superficial fascia right there.  Again this is the cutting mode. So after we identify these perforators, we identify the perforators, identify the plane, the rest is easy, just going through.  So here you see the deep branch going toward the ASIS, you see that? So that's the deep branch that's traveling in an axial pattern, just exactly like the CT angio showed.  So we don't need the distal part so we're going to ligate here. So here the flap is slightly thick because we're going underneath the superficial fascia  right now to include this deep axial pattern branch. Look at the humongous pulse, you guys see that?  And actually from this branch you can see actually one, two nice perforators going into the flap itself. So that's the superficial fascia right here.  So the reason why I don't like to include the superficial fascia, you see the deep branch going way underneath?  So this part of the harvest is really about identifying the perforators that you want to use. So once we identify the deep perforators, what I want to do is now I want to go medial  and identify that superficial perforator that I saw. If I like what I see, then I just ligate the deep part and just elevate based on that superficial perforator only.  So sometimes if you include the deep lateral branch, it makes the flap very thick as you can see here with all these deeper fat lobules.  But here we're going very superficial, above the superficial fascia. So we know that this nice deep vein, this deep lateral perforator has one to a couple  of perforators here going right directly to the skin. So this is a pretty good choice. I could stop the dissection here. Look at the pulsation. Beautiful, huh?  I could just decide to use this or I could go in now and search the superficial here. So for sake of education, usually I would stop here if I see what I like because I don't  need a long pedicle. I think the orientation to the recipient vessel is very nice. And then I'll do the rest of the elevation based on this perforator. Very nice. Very nice.  All right, so here you could see nice superficial vein also draining out. I think this is the medial direct cutaneous perforator here.  The medial one's coming out, direct septal cutaneous, I mean direct cutaneous. That's the direct cutaneous. You could see that there's no muscle segment here.  So either I could choose to take that one or take this one, but this definitely has multiple branches. It looks much better.  So here now I'm going to make a decision to cut this and then just focus on this perforator here. All right, so we're going to cut this, ligate this. There we go.  And also here for this superficial vein, you could see that it is relatively nicely included in the flap, and I know that a lot of times this deep vein is going to eventually  meet with the superficial vein. But I think the accompanying vein here is a relatively nice size vein.  So I think I'll decide to use this instead of going to the superficial vein as well. So we're going to dissect out the vein as well.  All right, so a very nice perforator here.  So in this case, the accompanying vein is also very nice, nice caliber. So we decided not to dissect the superficial vein, but just take the deep, lateral deep branch.  All right, so just going back to the anatomy here, we're still above the deep fascia. You can see a very distinctive demarcation between the superficial fascia, the superficial  fat and the deeper fats. Now we're dissecting through the deeper fat. The lymph nodes should be all clustered here in this, beneath the superficial fascia.  So you can see that we're not injuring any lymph nodes. A lot of times when you do the skip flap, I get a lot of emails or, you know, from friends  saying that, oh, they have problems with lymphoria. But if you stay above the superficial fascia, you don't have that problem. Okay, so this is more than the length we need.  So we'll stop here. We won't go in deeper. We'll dissect, we'll elevate the flap. You can see from this perspective, the flap thickness here is relatively deeper because  we're using a deep branch. But this is the ideal plane. And that's the perforator right there. So from the flap, the perforator, I think length is about five centimeters.  You could always go deeper and if you're not comfortable with the caliber or the length, you could always go beneath the deep fascia and you wouldn't have to struggle  with a smaller caliber one. Okay. All right, so now we're going to measure the velocity again to have a baseline.  So when we monitor post-op, what we want to do is we want to look at the velocity. Okay, I like to skeletonize all my vessels before I do the micro-anastomosis because  when I go down there, there's just too much work. So I want to finish all the preparation as much as possible when I harvest the flap.  A lot of times, the perforators are not this big. Today's case, I think we're lucky with today's case because the perforators are really, especially the vein.  The perforator is a really sizable, nice perforator. Okay. All right, so we're going to use a duplex just to try to see what's the baseline velocity when the flap's elevated.  So the average velocity is about 26. It's probably reduced because of a spasm during the elevation. So 26 is our baseline. Okay. Clamp.  Okay, we're now going to cut the pedicle to one-eighth single. I always like to use a vessel clamp to actually remind me which one is the artery.  You can see here at this level, above the deep fascia, the vein and the artery is almost the same caliber and almost the same character.  So sometimes it's very difficult to say which is which.  So this is definitely the artery.  Okay. Mini-clip.  Straight.  Okay, we want to make sure that there's no bleeders. We know that we're not going to have any problems closing, but we just want to approximate so  it won't stretch out too much before the stapler.  Okay, we'll start the anastomosis now. So, regarding the sutures, I only use 11-0 basically for lymphovenous anastomosis, where the lymphatic vessels are really, really fragile.  For a supermicro, perforator-perforator, I rarely use 11-0.  Okay, let's see the diameter after dilation. So the dilation is the key. So, you can see that after the dilation, the diameter is well above one millimeter.  So it makes it really easy to do the anastomosis. In this case, I think it's about one point, almost as large as 1.3.  So in this case, I'm using 9-0.  Okay.  Toward the end of the anastomosis, I like to have the resident or the assistant spray some heparin inside the lumen.  It not only washes the clots away, but it gives you a good idea if you did the back wall or not. Here, you can see they're expanding perfectly.  So I'm pretty sure that I didn't get any back walls.  All right, so that's that.  With the vein, we'll start the artery.  Nice pulsation for the artery. We're just going to trim the artery here.  Okay, again, dilation, another important part to make your anastomosis easier.  Also identifying the lumen, if there's any blood clots or unwanted substance inside the lumen.  All right, because we know the distal part of this artery is ligated, there's no use in doing an end-to-side to preserve the distal circulation.  So we're just going to cut it and do an end-to-end.  I like to use my 10-0 needle holders. This is a titanium needle holder because it doesn't magnetize the needle.  10-0 needles are a little bit lighter, so I like to use the titanium needle holders for my 10-0 sutures.  Alright, so there's a proximal segment spasm here. Lidocaine, now we're going to start to use Lidocaine.  For proximal segment spasms, what I like to also do is remove the adventitia. So this is where the spasm occurs. And once you do that, the spasm usually goes away.  So there's many physical things that you could do. And also you could ask the anesthesiologist, like we're asking now, to elevate the systolic pressure.  So they're going to start using Dobutamine to do that. There we go. Okay, now the spasm's gone. Alright, we're done with the anastomosis, now we'll insert the flap.  Okay, again, we're looking at the relationship here. Make sure that there's absolutely no tension in the anastomosis. There's no tension. Looks good, nice pulse.  Okay, we're going to start closing up. We're going to cut the tip off. Look at that nice contour, very thin. We started, what, around 11.40? Now the time is 1.10.  So I think it's going to take about 30 minutes to close. And we should be done in about a couple of, I mean, totally a couple of hours.  When you're suturing the plantar surface, it's very imperative that you have a nice dermal-to-dermal contact.  If you have a small gap, what it's going to do is it's going to cause scarring and it's going to cause a lot of callus formation.  So doing this dermal-to-dermal contact suture is important. Okay, 25. So the velocity is 25. The baseline velocity is 25. So we want to maintain.  Remember, the perforator that was going in here, what was it, about 30, 35? Yeah, 35. Right. So it would gradually rise up to about 35 within about one or two days.  All right, so let's look at the final result. We just did an end-to-end anastomosis to what I believe was a medial plantar artery. We elevated the skip flap.  We took the lateral deep branch, did an end-to-end on the medial plantar artery, and we also used the accompanying veins. Right now, wonderful refill.  Remember, we made the width a little bit narrow, but you can see that the skip flap stretched out very beautifully, provided the right contour.  All right, so now also we measured the velocity, which is about 25, and we wanted to maintain that way. All right, so now we're going to apply a splint, a dorsal splint,  make sure that the patient doesn't move the ankle, because if you move the ankle, it may stretch out the posterior tibial.  We don't want that to happen or something accidentally to happen, so we're going to put a dorsal splint. We're going to wrap it, and then we're going to start waking up the patient.  One thing I do different in the post-operative time is that I like to start relatively strong compression on day five.  We use compression garments like the Jobs garment, about minus 50 millimeter mercury. I think these compressions really allow the flap to mold and to minimize edema  and to drain the hematoma if there's anything below the flap.  This was also discussed briefly in the previous papers that I published regarding reconstruction using flaps.  Special medication, although there's no really critical scientific evidence using heparin, I like to use heparin if I'm using small caliber vessels.  I also like to use routinely vessel dilators. We have postaglandin E1s here in Korea, so I like to use that for four or five days as well.  Other pharmacological agents, I might use aspirin after we stop using heparin for the first five or seven days.  We usually discharge the patient on day seven, or it could be as early as day five. When we start the compression on day five, we let the patient walk mildly,  and then if the patient's able to ambulate reasonably, then we discharge the patient on day six and seven. So that's the usual protocol, the postoperative protocol that we have.  I think I also want to mention one critical issue here. When you're doing lower extremity reconstruction or when you're using small vessels, hydration is the most important thing.  If the patient becomes dehydrated, the first thing that goes is the peripheral circulation,  and the further away from the heart, it's more likely the vessels are going to shut down first when there's dehydration.  Hydration also is one of the critically important factors in maintaining a good circulation, especially in the distal extremity.

Video Summary

Dr. J.P. Hong from Asan Medical Center in Seoul discusses a surgical procedure to reconstruct tissue for a patient with malignant melanoma on her foot. The surgery involves a skip flap superficial circumflex iliac artery perforator (SCIP) flap. Initially, orthopedic surgeons perform cancer resection, followed by general surgeons removing lymph nodes. Dr. Hong's team concludes by reconstructing the defect with the SCIP flap, which is favored for its thinness, speed, and reliable perforator base. Using Doppler and duplex scanning, perforators are identified and mapped. The planned flap reconstruction matches the defect size from cancer excision. Anastomosis is performed using microvascular techniques, ensuring no tension in attachments and maintaining blood flow. Dr. Hong emphasizes careful closure to prevent scarring and advises post-operative monitoring, splinting, and gradual reintroduction of leg movement to ensure healing. Effective hydration is crucial for maintaining peripheral circulation, particularly when dealing with small vessel reconstructions. This meticulous approach aims to achieve optimal surgical outcomes and patient recovery.

Asset Caption

Joon Pio Hong, MD, presents the Superficial Circumflex Iliac Perforator Flap (SCIP flap). The surgical markings and vascular anatomy of this thin, pliable, fasciocutaneous flap are described. A detailed video of a clinical case in which the SCIP flap is used for plantar foot reconstruction following a melanoma resection demonstrates the techniques of SCIP flap elevation, inset, and donor site closure of this versatile flap.

Surgeon JP Hong, MD

Disclosure Dr. Hong has nothing to disclose.All ASPS staff members managing this activity have no relevant financial relationships or affiliations to disclose. All identified conflicts of interest have been resolved and the educational content thoroughly vetted by ASPS for fair balance, scientific objectivity, and appropriateness of patient care recommendations. The ASPS also requires faculty/authors to disclose when off-label/unapproved uses of a product are discussed in a CME activity or included in related materials. This product is not certified for CME.

Keywords

surgery spotlight

Surgical Videos

Reconstructive

Microsurgery

JP Hong MD; Memben

malignant melanoma

SCIP flap

tissue reconstruction

microvascular techniques

perforator mapping

post-operative care

surgical outcomes