The Piggyback Superficial Circumflex Iliac Perforator Flap for Complex Free Flap Reconstructions.

This article introduces a reproducible strategy for complex reconstruction scenarios that require the use of two flaps. It specifically focuses on the utilization of the superficial circumflex iliac artery perforator (SCIP) flap as a secondary flap, particularly in complex cases where available arterial options are limited. In the first scenario, the SCIP flap is elevated simultaneously during elevation of a fibula bone flap. The pedicle of the fibula flap will be anastomosed to the recipient vessels, and the pedicle artery of the SCIP flap, the superficial circumflex iliac artery, will be anastomosed to the distal end of the peroneal artery. The SCIP flap pedicle offers greater length compared with a cutaneous flap sourced from the peroneal artery, thus providing increased flexibility for the flap inset. In the second scenario, the SCIP flap is combined with the anterolateral thigh (ALT) flap to manage a significant defect. The pedicle of the ALT flap is anastomosed to the recipient vessels, and the superficial circumflex iliac artery is anastomosed to the distal end of the pedicle artery of the ALT flap, the descending branch of the lateral circumflex femoral artery. The SCIP flap can be harvested simultaneously with a fibula flap or an ALT flap from the same side, and its arterial anastomosis can always be established with the distal ends of the arterial pedicle of these two flaps. This efficient and reproducible method can also contribute to minimal donor site morbidity and will be particularly valuable in settings where recipient artery choices are limited.

Supermicrosurgical Anastomosis Training Using Chick Embryos within the Egg-in-Cube System.

SUMMARY: Although supermicrosurgery techniques are essential skills for lymphatic surgery or perforator-flap surgery, an ideal training model is yet to be introduced. Living animal models, such as rodents, are considered to be ideal microsurgical training models. However, the use of living animal models is costly and involves bioethical considerations. Hence, the authors developed a novel, cost-effective, highly reproducible, and easy-to-handle supermicrosurgical anastomosis training system using the chicken embryo within the egg-in-cube system. Chick embryos were fertilized in the artificial cubic eggshell, which was fabricated by integrating a polycarbonate frame structure and five polydimethylsiloxane membranes. Seven days later, the trainees underwent supermicrosurgical training using the vitelline artery of the chick embryo. The trainees were able to perform supermicrosurgical training using all 11 surviving chicken embryos. The average diameter of the vitelline artery was 0.43 mm. Patency and pulsation were observed after the anastomosis in four of the 11 cases. The supermicrosurgical training system using the chicken embryo within the egg-in-cube system has several advantages. This system is ethically acceptable, less costly and easier to manage than other animal models, and suitable as a supermicrosurgical training model, such as for lymphovenular anastomosis, because the diameter of the vitelline artery was similar to that of the lymphatic vessels in patients with lymphedema. Moreover, the trainee can confirm patency and leakage after the anastomosis because this model has a circulation system. The trainee can practice the supermicrosurgical technique efficiently with simultaneous feedback on anastomosis results. CLINICAL RELEVANCE STATEMENT: This study introduces a novel, cost-effective supermicrosurgical training system using chicken embryos within an egg-in-cube, offering a practical and ethical alternative. Its close simulation to human lymphatic vessels supports skill enhancement for practicing surgeons.

Tube-in-Tube Phalloplasty with Tailor-made Bilateral Superficial Circumflex Iliac Artery Perforator Flaps Using Preoperative High-resolution Ultrasound.

In phalloplasty, the radial forearm free flap is the most commonly used flap, followed by the anterolateral thigh flap. Superficial circumflex iliac artery perforator (SCIP) flaps have been used in phalloplasty, but bulkiness and unstable perfusion have precluded their common use. In this report, we present a case in which tube-in-tube phalloplasty was performed using bilateral SCIP flaps assisted by preoperative high-resolution ultrasonography. A 67-year-old man underwent resection of his penis for treatment of carcinoma. A year later, phalloplasty using bilateral SCIP flaps was planned. After mapping out the superficial circumflex iliac artery and the superficial circumflex iliac vein to their terminal portions using preoperative high-resolution ultrasonography, a 12 cm × 8 cm rectangular flap was designed on the right groin for reconstruction of the phallus, and a 10 cm × 4 cm rectangular flap was designed on the left groin for reconstruction of the urethra. Both flaps were harvested above the superficial fascia, and the thickness of both flaps was 4 mm. The Foley catheter was removed three weeks after the operation, and the patient began urinating in the standing position. No fistula or urethral stenosis had occurred as of 12 months after the reconstruction, and the patient was satisfied with the cosmesis. The use of preoperative high-resolution ultrasonography played a decisive role in ensuring the perfusion of the flap, resulting in prevention of postoperative complications such as fistula and/or urethral stenosis caused by malperfusion of the flap.

Multiple Flap Transfer for Multiple Local Recurrence of Soft Tissue Sarcoma.

Background and Objectives: Surgical management of local recurrence of soft tissue sarcomas (STS) is still challenging. In this article, we report on multiple flap reconstructions for multiple local recurrences of STS. Their feasibility will be validated by examining clinical cases. Materials and Methods: Patients who underwent multiple flap reconstructions for multiple local recurrences of STS between April 1997 and October 2021 were included in this retrospective study. Patient demographics, tumor characteristics, surgical characteristics, and postoperative complications were examined. Results: Twenty operations of eight patients were identified. The location of the defects was the back in two, the buttock in two, the groin in two, and the lower extremities in two. The average total number of wide resections was 4.0 and the average total number of flap reconstructions was 2.5. The average follow-up period was 109.4 months. The average size of the defect was 102.4 cm2 and the average flap size was 15.7 × 10.8 cm. The histological diagnoses were malignant fibrous histocytoma (MFH) in eight operations, osteosarcoma in two operations, myxoid liposarcoma in two operations, undifferentiated pleomorphic sarcoma (UPS) in six operations, and myxofibrosarcoma (MFS) in one operation. Of twelve subsequent operations, the resection of the previously transferred flap was performed in six operations (50%). The occurrence of take back, flap complications, and donor-site complications in the primary operation group was 25%, 25%, and 12.5%, respectively. The occurrence of take back, flap complications, and donor-site complications in the second and subsequent operation group was 0%, 0%, and 16.7%, respectively. Conclusions: Multiple operations including wide resections followed by flap reconstructions for multiple local recurrences are feasible. Reconstructive surgeons should choose the options of the flaps considering the future local recurrence for tumors with a high risk of recurrence.

Bilateral Transposition Flap for Postoperative Anal Stenosis after Reconstruction for Paget Disease.

One of the complications of anal surgery or disease is anal stenosis. To release the tension of the anus, a tension-releasing incision in the perianal skin and various anoplasty procedures are usually considered. The aim of this article is to describe a straightforward technique with local flaps for severe anal stenosis after anal reconstruction. A 57-year-old man presented to the clinic with diverticulitis secondary to severe anal stenosis, and reported difficulty with defecation after perianal skin resection around the anus and surgery to create a V-Y advancement flap for perianal primary Paget disease 9 months previously. After improvement of the diverticulitis using antibiotics, bilateral transposition flaps were transferred to release the anal stenosis. The surgical treatment for severe anal stenosis has been known to entail several complications, including infection, incontinence, anal mucosal ectropion, pruritus, wound dehiscence, and restenosis. In this severe case, because the scars were situated at the 6 o'clock and 12 o'clock positions on the anus due to the previous V-Y advancement flap, bilateral rotation flaps were transferred from the 3 o'clock and 9 o'clock positions of the anus to prevent wound dehiscence and partial flap necrosis. Three months later, the size of the anus was unchanged, but additional surgery was performed at the patient's request. A bilateral transposition flap procedure was used, with flaps designed and elevated from the 6 o'clock and 12 o'clock positions. The postoperative course was uneventful, and the anal stenosis was improved.

The Pedicled Anterolateral Thigh Flap for Donor Site Closure after a Large Superficial Circumflex Iliac Artery Perforator Flap Harvest.

The superficial circumflex iliac artery perforator (SCIP) flap is useful for covering defects in the extremities because its pedicle size can match many recipient options. However, when harvesting a large flap, skin grafting of the donor site is not highly recommended because of the mobility of the hip joint and occasional lymphorrhea. Here, we present a case of a successful reconstruction of a defect in the lower leg after sarcoma resection, using a large SCIP flap. A 58-year-old man underwent resection of a large soft tissue tumor in the lower leg, resulting in a 16 × 14 cm defect. A 25 × 14 cm SCIP flap was harvested from the groin, and the superficial circumflex iliac artery and the superficial circumflex iliac vein were anastomosed to the saphenous artery and the great saphenous vein, respectively, in an end-to-end fashion. For coverage of the groin donor site, a 25 × 8 cm pedicled anterolateral thigh (ALT) flap was harvested from the ipsilateral lateral thigh and was pulled through a subcutaneous tunnel to the groin. The additional operative time for pedicled ALT flap elevation and transfer was approximately 15 minutes. With this pedicled ALT flap, the donor site of the SCIP flap could be closed directly over a drain. The follow-up at 3 months showed complete survival of both flaps, and the patient was able to walk with a cane. The pedicled ALT flap allows for direct closure of the donor site after a large SCIP flap harvest.

Comparison of outcomes following pedicled and free flap transfers for the defect after shoulder sarcoma resection.

BACKGROUND: Reconstruction after wide resection of a sarcoma arising in the shoulder girdle is challenging, and little evidence is available to compare short-term outcomes between pedicled-flap and free-flap reconstruction. PATIENTS AND METHODS: Thirty-eight patients undergoing immediate reconstruction surgery with only a pedicled-flap (n = 18) and with a free-flap (n = 20) after sarcoma resection on the shoulder girdle between July 2005 and March 2022 were identified. One-to-one propensity score matching was performed to compare the postoperative complications. RESULTS: Transferred flaps survived completely in 20 cases in the free-flap group. In the all-patient analysis of binary outcomes, the occurrences of total complications, takebacks, total flap complications, and flap dehiscence were higher in the pedicled-flap group than in the free-flap group. The propensity score-matched analysis showed the occurrence of total complications was significantly higher in the pedicled-flap group than the free-flap group (53.8% vs. 7.7%, p = 0.03). In the propensity score-matched analysis of continuous outcomes, the pedicled-flap group demonstrated a shorter operation time than the free-flap group (279 vs. 381 min, p = 0.05). CONCLUSIONS: This clinical study demonstrated the feasibility and reliability of a free-flap transfer for the defect after wide resection of a sarcoma arising in the shoulder girdle.

The Use of the Deep Brachial Artery as the Recipient Artery for Free Perforator Flap Transfer: An Anatomic Study and Clinical Applications.

Background and Objectives: Soft tissue reconstruction after sarcoma ablation in the posterior aspect of the upper arm has been commonly addressed using the pedicled latissimus dorsi musculo-cutaneous flap. The use of a free flap for coverage of this region has not been reported in detail. The goal of this study was to characterize the anatomical configuration of the deep brachial artery in the posterior upper arm and assess its clinical utility as a recipient artery for free-flap transfers. Materials and Methods: In total, 18 upper arms from 9 cadavers were used for anatomical study to identify the deep brachial artery's origin and point of crossing the x-axis, which was set from the acromion to the medial epicondyle of the humerus. Measurements of the diameter were taken at each point. The anatomic findings of the deep brachial artery were employed clinically in the reconstruction of the posterior upper arm after sarcoma resection using free flaps in 6 patients. Results: The deep brachial artery was found in all specimens between the long head and the lateral head of the triceps brachii muscle, and it crossed the x-axis at an average distance of 13.2 ± 2.9 cm from the acromion, with an average diameter of 1.9 ± 0.49 mm. In all 6 clinical cases, the superficial circumflex iliac perforator flap was transferred to cover the defect. The average size of the recipient artery, the deep brachial artery, was 1.8 mm (range, from 1.2 to 2.0 mm). The average diameter of the pedicle artery, the superficial circumflex iliac artery, was 1.5 mm (range, from 1.2 to 1.8 mm). All flaps survived completely with no postoperative complications. Conclusions: The deep brachial artery can be a reliable recipient artery in free-flap transfers for posterior upper arm reconstruction, given its anatomical consistency and sufficient diameter.

Use of intraoperative indocyanine green angiography for detection and prediction of congestion in pedicled island flaps.

BACKGROUND: Pedicled island flaps, including pedicled propeller flaps and pedicled transposition flaps, are widely used especially for coverage of soft tissue defects in the extremities and the trunk. However, due to its mobility limitations, the inset of the pedicled flaps can be challenging at times, especially when rotation or pressure is applied to the pedicle. The aim of this report is to evaluate the feasibility of intraoperative indocyanine green (ICG) angiography for detection and prediction of intraoperative and postoperative flap congestion in pedicled island flaps. PATIENTS AND METHODS: From June 2018 to November 2021, 26 consecutive patients who underwent immediate reconstruction using the pedicled island flap after sarcoma resection were enrolled. ICG angiography was performed after elevation of the flap, after temporary flap fixation, and after final flap inset. Sensitivity and specificity of the last ICG angiography were calculated. RESULTS: In 22 cases where the last ICG angiography highlighting showed a satisfactory flap, the flap survived completely. In four cases where the flap was not highlighted by the final ICG angiography but did not show other clinical signs of congestion, all flaps underwent total loss due to congestion. The sensitivity and specificity of the final ICG angiography for predicting postoperative flap congestion were both 100%. CONCLUSION: ICG angiography can accurately predict postoperative congestion of the pedicled island flap, with extremely high sensitivity and specificity. When the flap is insufficiently highlighted after final flap inset, other measures should be considered.

Immediate tendon transfer for functional reconstruction of a dorsal forearm defect after sarcoma resection.

In the treatment of sarcoma, the reconstructive surgeon must consider not only limb salvage but also functional reconstruction. The aim of this study was to evaluate a functional reconstruction of a dorsal forearm defect after sarcoma resection using immediate tendon transfer. Patients who underwent reconstruction of a dorsal forearm defect after sarcoma resection with an immediate tendon transfer between 1997 and 2019 at our hospital were included in this retrospective study. Patient demographics, tumor characteristics, surgical characteristics and functional outcomes were examined. Nine patients were included in this study. Tendon transfer of the flexor carpi radialis (FCR) or the flexor carpi ulnaris (FCU) to the extensor digitorum communis (EDC), the brachioradialis (BR) to the EDC, and the palmaris longus (PL) tendon to the extensor pollicis longus (EPL) was performed in seven, two and five patients, respectively. Seven patients underwent reconstruction using a free flap. Neither anastomosis complications nor infections were encountered. Partial flap necrosis and donor site dehiscence were seen in one case each. The mean distal interphalangeal (DIP), proximal interphalangeal (PIP) and metacarpophalangeal (MP) joint active extension were 4.4°, 6.1° and 11.1° postoperatively. The mean Musculoskeletal Tumor Society (MSTS) score was 26. Immediate tendon transfers of the FCR or the FCU to the EDC and the PL tendon to the EPL can be considered an optimal functional reconstruction of a dorsal forearm defect after sarcoma resection.

Comparing seroma formation rate after harvest of the deep inferior epigastric artery perforator flap and the superficial abdominal perforator flaps in autologous breast reconstruction: A propensity-matched analysis.

BACKGROUND: Donor site seroma formation and prolonged drainage duration are commonly seen after harvest of perforator-based abdominal flaps. The lymphatic network including the lymphatic vessels and the lymph nodes can be traumatized during harvest of a perforator-based abdominal flap, eventually causing seroma formation. The aim of this study was to compare postoperative seroma occurrence rates between the deep system group including the deep inferior epigastric artery perforator (DIEP) flap and the superficial system group comprised of the superficial inferior epigastric artery (SIEA) flap, the superficial circumflex iliac artery perforator (SCIP) flap, and the SIEA-SCIP combined flap. PATIENTS AND METHODS: A retrospective analysis of all patients who underwent unilateral breast reconstruction using perforator-based abdominal flaps from June 2020 to May 2021 was performed. The patients were divided into the deep system group and the superficial system group. Propensity score matching was used to compare in the two groups the mean duration of drainage in the donor site and the occurrence of postoperative aspiration. Covariates included sex, age, body mass index, history of smoking, past history of diabetes mellitus. One hundred and fifteen patients (the deep system group, n = 100 and the superficial system group, n = 15) met inclusion criteria for a 1:1 match performed on 14 deep system group patients using propensity scores, with 14 superficial system group patients having similar characteristics. RESULTS: The mean duration of drainage in the donor site was shorter in the deep system group (6.6 ± 1.9 days) than in the superficial system group (9.3 ± 2.3 days, p < .01). The occurrence rate of postoperative aspiration was lower in the deep system group (0%) than in the superficial system group (50%, p < .01). CONCLUSIONS: Although superficial abdominal perforator flaps are considered to be less invasive than the DIEP flap, they are associated with prolonged donor site drainage and more frequent occurrence rate of postoperative aspiration.

Donor-site Chyle Leakage after Breast Reconstruction Using a Deep Inferior Epigastric Artery Perforator Flap.

Postoperative chyle leakage is an uncommon type of lymphorrhea characterized by a milky white lymphatic fluid. Here, we report a case of postoperative donor-site chyle leakage after breast reconstruction using a deep inferior epigastric artery perforator (DIEP) flap. A 50-year-old woman underwent unilateral secondary breast reconstruction using a DIEP flap. On postoperative day (POD) 3, 50 mL of clear white liquid was observed in the abdominal suction drain over 12 hours. On POD 6, the amount of white-colored fluid in the left side suction drain increased to 190 mL/d with high triglyceride 674 mg/dL. The computed tomography scan showed no fluid collections intraabdominally, within the rectus abdominis muscle, or in the subcutaneous area. Based on the diagnosis of donor-site subcutaneous chyle leakage, the patient was treated with a low-fat diet, a medium-chain triglyceride diet, and compression of the contralateral groin area. The fluid became clear and decreased in quantity, and we removed the drain on POD 9. No abdominal fluid was observed after the discharge. Combined treatment with a low-fat diet and compression of the groin area may be effective for donor-site chyle leakage after breast reconstruction using the DIEP flap.

Comparison of short-term outcomes between pedicled- and free-flap autologous breast reconstruction: a nationwide inpatient database study in Japan.

BACKGROUND: Despite the increasing popularity of autologous breast reconstruction, limited evidence is available. The aim of the present study was to compare the short-term outcomes of pedicled- and free-flap breast reconstructions. METHODS: Using a nationwide Japanese inpatient database, we identified 13,838 patients who underwent breast reconstruction for breast cancer (July 2010-March 2020) using a pedicled or free-flap (pedicled- and free-flap groups, n = 8279 and 5559, respectively). One-to-one propensity score matching was performed to compare the occurrence of postoperative complications, duration of anesthesia, length of stay, and total costs between the two groups. We also performed subgroup analyses stratified by hospital volume. RESULTS: The propensity score-matched analysis involving 3524 pairs showed that the pedicled-flap group had significantly lower proportions of takeback (2.1% vs. 3.2%, p < 0.001), thrombosis (0.6% vs. 1.7%, p < 0.001), and postoperative bleeding (2.1% vs. 5.7%, p < 0.001) than the free-flap group. No significant differences were found in wound dehiscence or tissue necrosis. Compared to the free-flap group, the pedicled-flap group had a short duration of anesthesia (412 vs. 647 min, p < 0.001) and low total hospitalization costs (12 662 vs. 17 247 US dollars, p < 0.001) but a prolonged postoperative length of stay (13 vs. 12 days, p < 0.001). The subgroup analyses showed results compatible with those of the main analysis. CONCLUSIONS: In this large nationwide cohort of patients who underwent breast reconstruction, pedicled-flap reconstruction was associated with fewer postoperative complications (excluding necrosis and wound dehiscence) and lower hospitalization costs but a longer postoperative length of stay than free-flap reconstruction.

Deep Fat Saving Elevation of the Superficial Circumflex Iliac Artery Perforator Flap.

Background and Objectives: Prolonged drain stay and lymphorrhea are often problems at the donor site of the superficial circumflex iliac artery perforator (SCIP) flap. This study aimed to introduce a novel technique of the SCIP flap elevation: Deep Fat Saving (DFS) technique. Materials and Methods: Thirty-two patients who underwent the SCIP flap transfer were divided based on the flap-elevated layer: above the deep fascia or the Camper fascia saving the deep fat. The duration of drain stay and the rates of flap survival and donor-site complications were compared between the groups. The inverse probability weighting (IPW) method was conducted to balance confounders. Results: By IPW, two balanced pseudo-populations were created: DFS = 33.9 and Conventional = 31.3. There were no significant differences in the rate of flap survival (DFS: 100% verses Conventional: 95.8%, p = 0.32) and donor site complications (DFS: 2.4% versus Conventional: 1.3%, p = 0.68, respectively). The duration of drain stay was shorter in the DFS group (weighted median: 6 versus 8 days; weighted difference: -1.6 days (95% confidence interval: -2.8 to -0.4), p = 0.01). Conclusions: An SCIP flap can be reliably harvested using the Deep Fat Saving technique.

Filling the Upper Pole with the Pectoralis Major Muscle Flap in Profunda Femoris Artery Perforator Flap Breast Reconstruction.

Background and Objectives: Among many donor site options for autologous breast reconstruction, the use of the profunda femoris artery perforator (PAP) flap has become common in patients who are not suitable for the gold standard procedure, the deep inferior epigastric artery perforator flap. However, its limited volume has precluded its wide use in breast reconstruction. The aim of this report was to demonstrate the effectiveness of a method in which the anatomical position of the pectoralis major muscle was adjusted to augment the volume of the superior pole of the breast during PAP flap transfer. A comparison was made with a conventional PAP flap breast reconstruction. Materials and Methods: Fifty-nine consecutive cases where unilateral autologous breast reconstruction was performed using the vertically designed PAP flap were retrospectively reviewed. Conventional PAP flap transfer was performed in 36 patients (Group 1), and PAP flap transfer with pectoralis major muscle augmentation was performed in 23 patients (Group 2). Results: The patient satisfaction at 12 months postoperatively was statistically greater in Group 2, with the pectoralis major muscle augmentation, than in Group 1 [23/36 (64%) vs. 22/23 (96%), p = 0.005]. There were no significant differences in postoperative complication rates at the reconstructed site [2/36 (5.6%) vs. 0/23 (0%), p = 0.52]. Conclusions: Higher patient satisfaction could be achieved with pectoralis major muscle augmentation in PAP flap breast reconstruction without increasing the postoperative complication rate at the reconstructed site.

An Anatomical Study of Posterior Trunk Recipient Vessels, and Comparisons of Outcome following Pedicled- and Free-Flap Transfers for Treatment of Sarcoma in the Posterior Trunk.

BACKGROUND: Reconstruction after wide resection of a large sarcoma arising in the posterior trunk may require free-flap transfer to reduce the postoperative complications. Here, we describe the recipient vessels on the whole posterior trunk. Moreover, to show the reliability of these vessels, we describe an institutional series of free-flap reconstruction. METHODS: In the cadaveric study, 20 posterior trunk regions from 10 fixed cadavers were dissected. The location and the diameter of the perforating artery and vein on the posterior were documented. In the clinical study, 54 patients undergoing immediate reconstruction surgery with only a pedicled flap (n = 45) and with a free flap (n = 9) after sarcoma resection on the posterior trunk between July 2005 and September 2021 were identified. One-to-one propensity score matching was performed to compare the postoperative complications. RESULTS: In the cadaveric study, a total of 178 perforators were identified. The average diameter of the superficial cervical artery (SCA) and vein, dorsal scapular artery (DSA) and vein, medial branch of dorsal intercostal artery perforator (m-DICAP) and vein, lateral branch of dorsal intercostal artery perforator (l-DICAP) and vein, and dorsolateral intercostal artery perforator (DLICAP) and vein were 1.03, 1.67, 1.38, 1.84, 1.28, 1.84, 1.01, 1.60, 1.11, and 1.70 mm. In the clinical study, the propensity score-matched analysis involving eight pairs showed a significantly higher occurrence of total complications in the pedicled-flap group than the free-flap group (62.5 vs. 0%, p = 0.03). CONCLUSION: The cadaveric study showed that the perforators from the SCA, DSA, and posterior intercostal artery are constantly present. The clinical study demonstrated the feasibility and reliability of a free-flap transfer.

Lymph-Venous Anastomosis for Breast Cancer-Related Lymphoedema after Docetaxel-Based Chemotherapy.

Docetaxel-based chemotherapy, which is administered before or after axillary lymph node dissection (ALND) in breast cancer patients with positive axillary lymph nodes, is reported as an independent risk factor for development of breast cancer-related lymphoedema (BCRL). Severe hardening of the soft tissue, which is a typical manifestation of BCRL with a history of docetaxel-based chemotherapy, has been considered a contraindication for lymph-venous anastomosis (LVA). This study aimed to evaluate the efficacy of LVA for BCRL with a history of the use of docetaxel. Twenty-six consecutive BCRL patients who underwent LVA were reviewed retrospectively. All patients underwent ALND. Amongst 23 patients who had chemotherapy for breast cancer, docetaxel-based chemotherapy was administered in 12 patients. The postoperative change of the limb circumferences and the improvement of subjective symptoms were assessed. Overall, patients showed improvements of the limb circumferences at the wrist, the elbow, and 5 cm above and below the elbow. There were no statistical differences of the postoperative changes of the circumferences between the docetaxel-administered and non-administered groups (0.25% vs. 2.8% at 5 cm above the elbow (p = 0.23), -0.4% vs. 0.7% at 5 cm below the elbow (p = 0.56), and 2.5% vs. 2.5 % at the wrist (p = 0.82)). LVA is comparably effective for lymphedematous patients who had undergone docetaxel-based chemotherapy before or after ALND.

Simultaneous Lymphatic Superficial Circumflex Iliac Artery Perforator Flap Transfer from the Zone 4 Region in Autologous Breast Reconstruction Using the Deep Inferior Epigastric Artery Perforator Flap: A Proof-of-Concept Study.

The incidence of upper extremity lymphedema after breast cancer treatment is reported to be 14% after axillary lymph node dissection (ALND) and 33% after ALND and regional lymph node dissection. The present report describes a novel method in which the afferent lymphatic vessels are harvested with their lymph nodes from the Zone 4 region as a separate flap, the superficial circumflex iliac artery perforator (SCIP) flap, in the setting of autologous breast reconstruction using the deep inferior epigastric artery perforator (DIEP) flap. From September 2017 to September 2020, seven female patients with an average age of 46.9 years (range: 39 to 54 years) underwent autologous breast reconstruction using the DIEP flap and the lymphatic SCIP flap procured separately from the Zone 4 region. All patients had undergone ALND, four patients had undergone radiation therapy, and three patients had established lymphedema at the time of reconstruction. All lymphatic SCIP flaps survived completely. Lymphedema did not occur in any of the four patients to whom the lymphatic flap was transferred for a preventive purpose (average follow-up: 37.5 months). In three patients with established lymphedema at the time of reconstruction, the average rate of estimated volume decrease at the last follow-up (average: 29.0 months) was 12.6%. A lymphatic SCIP flap procured from the Zone 4 region in DIEP flap breast reconstruction can contribute to improvement or prevention of lymphedema with no additional donor site.

Domino Free Flap Transfer Using a Superficial Circumflex Iliac Artery Perforator Flap for the Toe Flap Donor Site.

BACKGROUND: Toe-to-hand transfer is a favorable option for finger reconstruction, but donor site healing can be challenging. The superficial circumflex iliac artery perforator (SCIP) flap has yet to be used widely for toe reconstruction. The purpose of this report was to validate the efficacy of the sequential simultaneous free SCIP flap transfer for the toe flap donor site in a consecutive case series. METHODS: The medical records of 18 consecutive patients who underwent a simultaneous SCIP flap transfer and a toe-to-hand transplant were reviewed. Free SCIP flap reconstruction was performed in a simultaneous 2-team approach. The SCIP flaps were transferred to various toe flap donor sites: a great toe wraparound flap in 9 cases, a second toe distal phalangeal flap in 4 cases, a great toe osteo-onycho-cutaneous flap in 3 cases, a twisted wraparound flap in 1 case, and a great toe hemipulp flap in 1 case. RESULTS: The size of the SCIP flap ranged from 5 × 3 to 16 × 8 cm. A mean of the total operative time was 229.2 minutes (range, 118-441 minutes; SD, 75.8 minutes). All the SCIP and toe flaps survived completely. Minor wound dehiscence was seen in 2 cases, and the wound healed by conservative treatment. The mean follow-up period was 23.7 months (range, 7-44 months; SD, 9.7 months). No patient had gait dysfunction postoperatively. CONCLUSIONS: A sequential SCIP flap transfer was performed simultaneously without additional time, allowing secure soft tissue coverage of the toe flap donor even with avascular tissue such as bone or tendon exposed. The sequential SCIP flap transfer can be a useful option for reconstruction of toe flap donor site, when multiple microsurgeons and microscopes are available.

Superficial Circumflex Iliac Artery Perforator Flap Elevation Using Preoperative High-Resolution Ultrasonography for Vessel Mapping and Flap Design.

BACKGROUND: The superficial circumflex iliac artery (SCIA) perforator (SCIP) flap has gained acceptance among reconstructive microsurgeons, the minimal donor site morbidity being its greatest advantage. The purpose of this article is to introduce the use of preoperative ultrasonography to facilitate elevation and to avoid postoperative complications of the SCIP flap. METHODS: Preoperative mapping of the SCIA and the superficial circumflex iliac vein (SCIV) using a high-resolution ultrasound system were performed in patients undergoing reconstruction using a free SCIP flap. The skin paddle was designed placing the SCIA and the SCIV in the middle of the flap. RESULTS: Preoperatively marked SCIA and SCIV were found intraoperatively in all cases. The skin paddle design for sufficient arterial inflow and venous drainage resulted in no postoperative flap complications. CONCLUSION: The use of a preoperative high-resolution ultrasound system significantly facilitates elevation of the SCIP flap, notably via the following 2 points: 1) pedicle can always be found under the markings made with preoperative ultrasonography, 2) satisfactory perfusion of the flap can be guaranteed via a safe flap design that includes preoperatively marked vessels within the skin paddle.