Pushing boundaries: Anterolateral thigh free flaps for extensive scalp defects beyond previous limits, leveraging imaging modalities with ultrasound and indocyanine green.

BACKGROUND: Scalp defect reconstruction poses considerable challenges, with ongoing debates regarding the most effective strategies. While the latissimus dorsi (LD) flap has traditionally been favored, the anterolateral thigh (ALT) flap has been well described as a versatile alternative for addressing extensive scalp defects. This study underscores the success of scalp reconstruction using ALT flaps, notably pushing the boundaries of previously reported flap sizes. Our approach leverages the use of indocyanine green (ICG) perfusion to guide precise preoperative planning and vascular modification, contributing to improved outcomes in challenging cases. METHODS: We performed 43 ALT flap reconstructions for scalp defects between 2016 and 2023. We collected patients' demographic and clinical data and evaluated flap size and recipient vessels and additional surgical techniques. Detailed preoperative plans with ultrasound and ICG use for intraoperative plans were performed to find perforators location. The cohort was divided into two, with or without complications on flaps, and analyzed depending on its surgical details. RESULTS: This study involved 38 patients with extensive scalp defects (mean age: 69.4 ± 11 years) who underwent ALT perforator flap transfers (mean flap size: 230.88 ± 145.6 cm2). There was only one case of unsuccessful flap transfer, and four cases had a few complications. The characteristics of the complication group included a large flap size (303.1 ± 170.9 vs. 214.9 ± 136.6 cm2, P = .211), few perforator numbers without pedicle manipulation, lack of intraoperative indocyanine green administration (75% vs. 25%, P = .607), and the use of superficial temporal vessels as recipient vessels. CONCLUSIONS: Scalp reconstruction using large ALT free flaps with the aid of imaging modalities facilitates the optimization of surgical techniques, such as pedicle manipulation, perforator numbers, and vein considerations, thereby contributing to successful reconstruction.

Development of a porcine training model for microvascular fasciocutaneous free flap reconstruction.

BACKGROUND: In reconstructive surgery, improvements are needed in the effective teaching of free flap surgery. There is a need for easily accessible and widely available training without high financial costs or ethical concerns while still providing a realistic experience. Our aim was to develop an appropriate training model for microvascular flaps. METHODS: We identified pig head halves as most appropriate regarding availability, cost, and realism. These accrue largely by the food industry, so no animals need to be sacrificed, making it more ethical from an animal welfare perspective. We evaluated the suitability as flap donor site and analyzed the vascular anatomy of 51 specimens. RESULTS: Anatomical evaluation revealed a reliable and constant vascular anatomy, allowing the design of a flap model that can effectively illustrate the entire process of microvascular flap surgery. The process was divided into 6 key steps. The flap can be harvested after marking the vascular pedicle 5.3 cm from the lateral corner of the mouth. Skin island design and subsequent tissue dissection follow until a fasciocutaneous flap is raised, similar to a radial flap. Upon completion of flap harvesting, it can be freely transferred for defect reconstruction. Microvascular anastomosis can be performed on recipient vessels in the cervical region, and the difficulty can be individually adjusted. CONCLUSIONS: The developed training model is a reasonable compromise in terms of surgical realism, availability, didactic value, and cost/time effectiveness. We believe it is a powerful and effective tool with high potential for improving surgical education and training.

[Application of mixed reality technology in free fibular flap transplantation for repairing mandibular defects].

Objective: To explore the feasibility and effectiveness of mixed reality technology for localizing perforator vessels in the repair of mandibular defects using free fibular flap. Methods: Between June 2020 and June 2023, 12 patients with mandibular defects were repaired with free fibular flap. There were 8 males and 4 females, with an average age of 61 years (range, 35-78 years). There were 9 cases of ameloblastomas and 3 cases of squamous cell carcinomas involving the mandible. The disease duration ranged from 15 days to 2 years (median, 14.2 months). The length of mandibular defects ranged from 5 to 14 cm (mean, 8.5 cm). The area of soft tissue defects ranged from 5 cm×4 cm to 8 cm×6 cm. Preoperative enhanced CT scans of the maxillofacial region and CT angiography of the lower limbs were performed, and the data was used to create three-dimensional models of the mandible and lower limb perforator vessels. During operation, the mixed reality technology was used to overlay the three-dimensional model of perforator vessels onto the body surface for harvesting the free fibular flap. The length of the fibula harvested ranged from 6 to 15 cm, with a mean of 9.5 cm; the size of the flap ranged from 6 cm×5 cm to 10 cm×8 cm. The donor sites were sutured directly in 7 cases and repaired with free skin grafting in 5 cases. Results: Thirty perforator vessels were located by mixed reality technology before operation, with an average of 2.5 vessels per case; the distance between the exit point of the perforator vessels located before operation and the actual exit point ranged from 1 to 4 mm, with a mean of 2.8 mm. All fibular flaps survived; 1 case had necrosis at the distal end of flap, which healed after dressing changes. One donor site had infection, which healed after anti-inflammatory dressing changes; the remaining incisions healed by first intention, and the grafts survived smoothly. All patients were followed up 8-36 months (median, 21 months). The repaired facial appearance was satisfactory, with no flap swelling. Among the patients underwent postoperative radiotherapy, 2 patients had normal bone healing and 1 had delayed healing at 6 months. Conclusion: In free fibular flap reconstruction of mandibular defects, the use of mixed reality technology for perforator vessel localization can achieve three-dimensional visualization, simplify surgical procedures, and reduce errors.

The Role of Microsurgery in Burn Surgery.

Acute burn reconstruction involves intricate strategies such as skin grafting and innovative technologies, addressing challenges in coverage and minimizing donor site morbidity. Despite being rarely used, flap reconstruction becomes necessary when critical structures are exposed, offering robust coverage and reducing complications. However, free flaps in acute burns face challenges, including a higher failure rate attributed to hyperinflammatory states and hypercoagulability. Surgical optimization strategies involve careful timing, patient preparation, and meticulous postoperative care. In delayed burn reconstruction, free flaps proved effective in functional and aesthetic restoration, with low flap loss rates and minimal contracture recurrence. Prefabricated and prelaminated flaps emerged as a solution for complex cases, ensuring the best functional and aesthetic possible outcomes in challenging facial burn reconstructions.

Robotic-Assisted Anastomosis in Orthoplastic Surgery: Preliminary Data.

BACKGROUND: The evolution of microsurgery has relied on advancements in operating microscopes and surgical instruments. Pioneering advancements, however, especially within the domain of "super-microsurgery", challenge the limits of human dexterity by dealing with anastomoses between vessels smaller than 0.8 mm. Based on these premises, the Symani robotic system was designed and developed. This platform utilizes teleoperation and motion-scaled movement to provide surgeons with precision and accuracy in manipulating millimetre and submillimetre-sized anatomical structures. In this study, we present our experience in performing robotic-assisted anastomoses using the Symani Surgical System in free flap reconstruction. METHODS: We present a comprehensive analysis of all reconstructive procedures involving microsurgical free flaps performed using the Symani robotic platform at the orthoplastic unit of the Rizzoli Orthopaedic Institute from 1 October 2022 to 1 May 2023. RESULTS: Sixteen microsurgical reconstructions using free flaps were performed, involving a total of 40 anastomoses on vessel calibres ranging from 0.6 mm to 2.5 mm. In each case, the anastomosis was executed with the assistance of the robotic platform, achieving a 100+% success rate in patent anastomoses, and no major complications occurred.Conclusion The Symani system has proven to be safe and reliable in performing microsurgical anastomoses. While this platform demonstrated successful in various vessel calibres, its most promising potential lies in anastomoses below the size of a millimetre. Larger patient cohorts and extended investigation periods will be essential to explore whether robotics in microsurgery offers advantages across all microsurgical procedures or should be reserved for selected cases.

The use of vascularized fibula flap with allograft in post-oncologic microsurgical bone reconstruction of lower limbs in pediatric patients.

BACKGROUND: Post-oncologic surgical reconstruction of lower limbs in pediatrics remains a challenging topic. Microsurgical techniques allow reconstructions of large bony defects. The use of vascularized fibular flap with allograft has proven to be an ideal biologic construct. We aim to assess the success rate of this operation, including flap survival, bony union, weight-bearing ambulation, and complications in a long-term follow-up in our case series compared to the literature. PATIENTS AND METHODS: Our case-series includes 18 femoral resections (9 osteosarcomas, 8 Ewing sarcoma, and 1 desmoid tumor) and 15 tibial resections (10 osteosarcoma, 4 Ewing sarcoma, and 1 Malignant Fibrous Histiocytoma). We collected patients' demographics, type of tumor, type of resection, defect size, fibula-flap length, method of fixation, anastomosis site, follow-up data, complications, and their management. All survivals were examined by X-ray and CT-scan to evaluate the morphological changes of the vascularized fibula and follow-up. The functional evaluation was performed by the 30-point Musculoskeletal Tumor Society Rating Score (MSTS) for the lower limb (Enneking et al., Clinical Orthopaedics and Related Research 1993(286):241-246). RESULTS: The mean age of the femur resection patients' group was 11.2 years with a mean defect size of 14 cm and a mean length of the fibular flap of 18 cm; for the tibia the mean age was 12 years with a mean defect size of 14 cm and a mean length of the fibular flap of 16.6 cm. The overall survival of the reconstructions at 5 years follow-up was 17 out 18 cases for the femur and 13 out of 15 cases for the tibia. MSTS score was 28.2 for the femur and 23.7 for the tibia. The average time of union of the fibula was seen after 5 months, while allograft consolidation was observed around 19.7 months. The mean time of follow-up was 144.5 months for the femur and 139.2 months for the tibia. The complication rate observed was 7 out of 18 for the femur and 7 out of 15 for the tibia reconstructions. CONCLUSIONS: The viability of the fibula is a cornerstone in the success of reconstruction as well as the successful management of complications in intercalary defects after tumor resection in pediatrics to restore good functionality. Our results are in line with those reported in the literature in terms of overall complication rates. The high primary union of allograft, the high MSTS score obtained, and the low rate of severe complications reflect the mechanical role of this reconstructive technique over a long follow-up.

Syndactylized glabrous flaps for multiple finger palmar defects.

BACKGROUND: Palmar finger or pulp defects require coverage with glabrous tissue to achieve a good match with the lost tissue. The management of multiple finger palmar or pulp defects is challenging because these defects may not always be suitable for local or pedicled flaps. In such situations, syndactylizing free or pedicled flaps can be used. PATIENTS AND METHODS: We evaluated the results of free glabrous flaps syndactylizing across multiple finger defects. The two flaps used were the superficial branch of the radial artery (SUPBRA) flap and hypothenar free flap. Seven syndactylized glabrous free flaps were used to cover the defects in 16 fingers. The functional results and complaints were also assessed. RESULTS: Mean flap size was 14.35 cm2. Six flaps survived. Postoperative evaluation data were obtained for the 13 fingers. All the patients returned to their previous work. All patients had a diminished protective sensation of at least 4.31 according to the SWM test. The mean two-point discrimination score of the patients was 9.9 mm (7-14). One finger had a PIP joint flexion contracture of 30°, no donor-site complaints were observed. CONCLUSION: The advantages of these flaps include single operation site, strong glabrous tissue coverage, low risk of flexion contracture, and adequate tissue size for large defects. Disadvantages include two-stage and complex microsurgical operations, prolonged treatment, and hospital stay.

Reverse flow anterolateral thigh free flap in a case with significant atherosclerosis: A viable alternative for arterial microvascular anastomosis.

BACKGROUND: The concept of reserve flow perfusion for free flap reconstruction has been demonstrated in various applications in the literature. As it relates to the anterolateral thigh (ALT) free flap, the reserve flow principle has been primarily described to either augment or "supercharge" a large ALT to optimize skin perforator supply or lengthen the vascular pedicle. METHODS: We report a case of a 77-year old male with chronic renal failure who had extensive atherosclerosis of the proximal descending lateral circumflex femoral artery (LCFA) where arterial anastomosis was unable to be performed. RESULTS: We were able to circumvent this limitation by establishing reserve flow perfusion solely through the distal end of the descending LCFA. We describe our technique within the context of current literature on the topic of reverse flow perfusion in free flap reconstruction. CONCLUSION: This report uniquely describes applying the distally based, reverse arterial flow principle in an ALT flap to circumvent an atherosclerotic proximal pedicle.

Catastrophic complications following microvascular free tissue transfer: A 10-year review of NSQIP data.

INTRODUCTION: There is an absence of literature regarding the risks of catastrophic medical outcomes (CMOs) such as stroke, cardiac arrest, and pulmonary embolism in microvascular free tissue transfer. This study aims to determine the CMO and mortality rates, as well as risk factors, associated with microvascular reconstruction of the head and neck, extremity, and breast. METHODS: This study uses data from the American College of Surgeons National Surgical Quality Improvement Program. Cases of microvascular free tissue transfer from 2012 to 2021 were analyzed to assess the 30-day rates of CMOs, including death, as well as associated risk factors. RESULTS: Of the 22,839 included patients, 785 (3.44%) experienced 1043 CMOs, including 99 (0.43%) deaths. Pulmonary complications of prolonged respiratory failure and pulmonary embolism were the most common. Independent risk factors included age, male sex, underweight status, longer operation times, American Society of Anesthesiologists (ASA) class of III or above, wound classification other than clean, and underlying conditions such as diabetes, hypertension, chronic obstructive pulmonary disorder, dyspnea, metastatic cancer, and ventilator dependence. CMOs were associated with an average 10-day delay in hospital discharge. Multivariate regression analysis revealed that head and neck reconstructions were associated with increased risk of CMO (OR 4.96; p < 0.0001). CONCLUSION: This is the largest study to examine CMOs following microvascular free tissue transfer. Compared to previous literature spanning the period between 2006 and 2011, we observed a decreased rate of CMOs but a slight increase in 30-day mortality. Our data provide updated and comprehensive criteria for risk stratification and patient counseling. The modifiable risk factors reported in our study should be considered in elective, non-urgent cases of microvascular reconstruction.

Analysis of Operation Duration in Thoracodorsal Artery Perforator Free-Flap Surgery of the Lower Extremities.

PURPOSE: This retrospective study aimed to identify the factors that affect the duration of thoracodorsal artery perforator (TDAP) free-flap surgery and to offer strategies for optimizing the surgical procedure. METHODS: We analyzed 80 TDAP flap surgeries performed by a single surgeon between January 2020 and December 2022, specifically focusing on free flaps used for lower-extremity defects with single-artery and single-vein anastomosis. The operation duration was defined as the time between the surgeon's initial incision and completion of reconstruction. Linear regression analyses were conducted to identify the factors affecting operation duration. RESULTS: The average operative duration was 149 minutes (range, 80-245 minutes). All flaps survived, although 8 patients experienced partial flap loss. The operative duration decreased with increasing patient age and when end-to-end arterial anastomosis was performed. However, the risk increased with larger flap sizes and in patients with end-stage renal disease. CONCLUSIONS: Our study identified several factors and methods that could accelerate TDAP free-flap procedures. These findings offer valuable insights for optimizing surgical processes and improving overall surgical outcomes. Although further research is needed to confirm and expand upon these findings, our study provides important guidance for surgeons in developing effective strategies for TDAP flap surgery.

Ortho-oncoplastic surgery in foot and ankle: A narrative overview on reconstruction of soft-tissue defects after oncologic resections.

INTRODUCTION: Malignant tumors of the foot are rare, and treatment strategies are challenging considering the complex anatomy of this area. In recent years, dramatic advances in technology and collaborations between different specialties (such as orthopedic, oncology, radiology, plastic, and vascular surgery) significantly changed the approach to complex malignant tumors without resorting to limb removal. The combination of the strengths of both orthopedic surgery and plastic surgery constitutes the modern definition of "orthoplasty." The aim of this review article is to provide treatment strategies that are available for reconstruction of foot and ankle in limb-salvage surgery after tumor resection, with a specific focus on microsurgical techniques in plastic surgery. METHODS: We conducted a comprehensive search for relevant papers across PubMed, Scopus, Embase, and Web of Science. We included patient-based studies reporting on procedures for soft-tissue reconstruction with small and large soft tissue defects. Indications, pros and cons, and technique tips are discussed for each type of reconstructive technique. RESULTS: The search was done using literature of the past 30 years (from 1990 to date), resulting in about 725 articles describing over 2000 cases. Cutaneous flaps included lateral supramalleolar flap, medial plantar flap, reverse sural neurocutaneous island flap, medial leg flap, and lateral leg flap. Free flaps included anterolateral thigh flap, radial forearm flap, latissimus dorsi flap, gracilis muscle flap, lateral arm flap, and rectus abdominis flap. CONCLUSIONS: The orthoplastic approach in musculoskeletal oncology is a collaborative model of orthopedic and plastic surgeons working together, resulting in a higher rate of successful limb salvage in patients at risk for amputation. Protocols, biologic substitutes, and surgical techniques are largely improved in the last decades increasing the possibility of functional reconstruction. Microsurgical strategies represent the new frontiers in these demanding reconstructions.

Alternative Flap Options for Upper Extremity Reconstruction.

For major upper limb defects, a wide range of established pedicled and free flap options can be used. These include the latissimus dorsi/thoracodorsal artery perforator, lateral arm, posterior interosseous artery, rectus abdominis, gracilis, and anterolateral thigh flaps. Technical proficiency is essential, and favorable success rates in terms of functional and esthetic outcomes can be achieved. Herein, alternative flap options (both pedicled and free) are introduced and discussed through a few illustrative case examples.

Use of the pedicle of previously harvested pectoral myocutaneous flap as a recipient for free flaps in head and neck reconstruction.

INTRODUCTION: The pectoral myocutaneous flap (PMF) is a workhorse regional reconstructive option for head and neck defects. It is commonly used for primary reconstructions due to its advantages or as a life-boat flap in the salvage of failed reconstructions of free flaps. However, it also has intrinsic drawbacks, such as perfusion problems and partial or complete flap loss. Although there are many studies about the advantages and use of PMF in the literature, the number of studies about salvage of this workhorse flap is inadequate. We aimed to present the use of the pedicle of previously performed PMF as a recipient for free flaps in head and neck reconstruction. METHODS: Between January 2022 and August 2023, 10 free flaps were used in nine patients (three females and six males) who had previously undergone head and neck reconstruction with PMF. The age of the patients ranged from 54 to 74 years. Seven out of the nine PMFs were previously performed by different surgical teams. Squamous cell carcinoma (SCC) was the reason for primary surgeries in all patients and the PMFs were used for right lower lip and right submandibular defect, left lower lip and mentum defect, lower lip defect, right lower lip and right submandibular defect, right retromolar trigone defect, right buccal defect, left anterolateral esophageal defect, right retromolar trigone defect and left anterolateral pharyngoesophageal defect reconstructions. The problems were partial skin island necrosis and wound dehiscence in six patients and total skin necrosis in three patients. The partial skin island necroses already showed that the pedicles were unproblematic. For patients with total skin island necrosis the muscle stalks so the pedicles were also unproblematic which were confirmed by physical examination and Doppler device. After complications, the finally defects were located in the lower lip, left lower lip and mentum, right lower lip and right submandibular area, left anterolateral esophageal area and left neck, right buccal area, right retromolar trigon, left anterolateral pharyngoesophageal fistula and left neck. The sizes of the defects were between 3 × 4 cm and 11 × 17 cm. For all patients, the pedicle of the previously harvested PMF was used as a recipient for free flaps. Since the PMF was flipped over the clavicula for the reconstruction previously, the pedicle was so close to skin or skin graft which was used for coverage of the muscle stalk. The Doppler device was used first over the clavicle where the PMF was flipped for vessel identification. After marking the vessels, a vertical zigzag incision was made on the skin or skin graft. The perivascular fatty tissue and the pedicle were encountered with minimal dissection by the guidance of Doppler. After meticulous microscopic dissection, the pedicle of PMF was prepared for anastomoses as usual. Six radial forearm free flap (RFFF) and four anterolateral thigh flap (ALT) flaps were used in the head and neck reconstructions for the nine patients. RESULTS: The sizes of the flaps were between 4 × 5 cm and 12 × 17 cm. The diameters of the recipient arteries were between 0.9 and 1.2 mm. Recipient veins were approximately the same diameter as the arteries. In one patient, two vein grafts were used for lengthening both the artery and vein to reach recipient vessels. End-to-end anastomoses without vein grafts were performed in the remaining patients. One arterial thrombosis that manifested on the first postoperative day was salvaged successfully. Hematoma was seen in two patients and wound dehiscence was seen in three patients. There was no partial or total flap necrosis and all flaps survived. The follow-up period ranged from 2 to 12 months. Despite successful reconstructions, two patients died during the follow-up period due to unrelated conditions. Functional results were acceptable in the remaining patients. CONCLUSION: The pedicle of previously used pectoral myocutaneous flaps may be a useful alternative option as the recipient for free flaps in head and neck reconstruction.

Flap loss in head and neck reconstruction: Is there a singular cause for failure?

Despite the high success rates reported in head and neck reconstruction, free flap failures continue to persist. Understanding the factors associated with flap loss and improving overall success are paramount. This study aimed to comprehensively assess the factors influencing flap revision and free tissue transfer survival in head and neck reconstruction. The study included 70 patients with defects in the lower two-thirds of the head and neck region and underwent reconstruction using free flaps. Patient age, gender, smoking status, comorbidities and data on the location and aetiology of the defect, the specific type of flap employed, the recipient artery and vein chosen, instances of revision and the overall success of the flap were collected. The investigation aimed to establish correlations between these variables as well as flap success and revision rates. No statistically significant differences were observed in arterial and venous anastomosis revision rates, or flap survival, in relation to variables such as age, gender, flap type, smoking status, comorbidities, recipient artery or vein and the number of vein anastomoses. The malignant tumour group exhibited a lower requirement for arterial revision and a higher flap survival rate compared to the benign tumour group. This study underscores the comparable safety profiles of perforator-based and conventional flaps in head and neck reconstruction. Furthermore, it reveals that patient characteristics are not contraindications for free tissue transfer. Additionally, the quantity of the veins and choice of recipient vessels are flexible and do not significantly impact flap success. The higher rates of flap success in patients with malignant aetiology requires further investigation.

[Robot-assisted Microsurgery in Lower Extremity Reconstruction]. / Roboter-assistierte Mikrochirurgie in der Rekonstruktion der unteren Extremität.

BACKGROUND: In recent years, various robotic systems specifically designed for microsurgical tasks have been developed and approved. There is not much evidence for these systems to date. In our study, we examined the use of robot-assisted microsurgery in the reconstruction of the lower extremity. PATIENTS/MATERIAL AND METHODS: Data was prospectively collected between February and November 2023. The Symani robotic system was used in 42 robot-assisted microsurgical procedures on the lower extremity, and the results were evaluated and documented. RESULTS: The average age of the patients was 57±18 years. A total of 39 free flap reconstructions (95%), one lymphatic surgical procedure (3%) and two nerve transfers (5%) were performed. In total, 46 anastomoses and coaptations were carried out. This included six arterial end-to-end anastomoses (11%), seven arterial end-to-side anastomoses (13%), 36 venous end-to-end anastomoses (65%), two lymphovenous anastomoses (4%), and five epineural coaptations in the context of nerve transfers (9%). Arterial end-to-end anastomoses took an average of 26±12 minutes, and arterial end-to-side anastomoses took 42±21 minutes. The venous anastomoses took an average of 33±12 minutes. Epineural coaptations took an average of 24±13 minutes. In no procedure was there a need for a conversion to conventional hand suturing. There were two arterial thromboses (5%), one of which was successfully revised to save the flap. One total flap loss occurred, but there were no partial flap losses. CONCLUSION: Using the Symani robotic system for microsurgical reconstruction of the lower extremity, we were able to demonstrate results that are comparable to conventional microsurgery.

Free vascularized fibula leads to hallux toe flexion deformity due to ischemic muscle contracture of flexor hallucis longus.

BACKGROUND: This study aimed to investigate the incidence of toe flexion deformity after fibular free flap transplantation and to analyze the etiology of the deformity. METHODS: Fifty patients underwent vascularized fibular free flap transplantation were retrospectively included. Statistical analysis examined correlations between deformity occurrence and resected fibula length and residual distal fibula length using the χ2 test. Doppler ultrasound and anatomical evaluations were conducted. RESULTS: Flexion deformity of the first toe was observed in all patients (100%), exacerbated by ankle dorsiflexion. χ2 test revealed no significant correlation between fibula length, distal residual fibula length, and flexion deformity. Doppler ultrasound revealed elevated echoes and blurred textures in the flexor hallucis longus post-fibular transplantation, while anatomical evaluation confirmed the peroneal artery as its primary nutrient supplier. CONCLUSION: This study reports a 100% incidence of toe flexion deformity post-transplantation. The deformity correlated strongly with ischemic contracture of the flexor hallucis longus.

Head and neck reconstruction with the superficial circumflex iliac artery perforator (SCIP) free flap: Lessons learned after 73 cases.

BACKGROUND: Head and neck tissue defects after ablative surgery often require complex and composite reconstructions. The superficial circumflex iliac artery perforator (SCIP) flap is an extremely versatile perforator-based flap with minimal donor site morbidity, which may represent the optimal procedure in this setting. Over the last 5 years, we collected a large base of experience, including both simple and chimeric SCIP-based reconstruction, making this flap our first choice for head and neck reconstructions. PATIENTS AND METHODS: Seventy-three patients undergoing ablative head and neck surgery for oncologic pathologies were treated by means of a SCIP flap reconstruction. Patients' mean age was 67 years old (range 37-89), 51 were males and 22 were females. Fifty-eight flaps were simple and 15 were chimeric reconstruction patterns. Indocyanine green perfusion imaging was performed in all cases. RESULTS: All the patients were successfully treated with no flap losses were encountered. Twelve patients encountered postoperative complications: in four cases revision surgery was required for venous congestion, while the remaining cases were managed conservatively (four wound dehiscence and three infections). No patients showed donor site complications. The mean follow-up period was 11 months (range 3-24). CONCLUSIONS: Our case series demonstrates the reliability and versatility of the SCIP flap for different kinds of head and neck reconstructions. The chimeric options combined with bone, double skin paddle, and muscle offer a broad variety of functional reconstructive solutions for complex head and neck surgeries. Intraoperative indocyanine green perfusion examination provides a valuable tool to assess and ascertain proper vascularization and post-anastomosis vessel patency in complex microvascular flap-based reconstructions.

Clinical application of a free flap supplied by the osteocutaneous branch of the anterior interosseous artery.

OBJECTIVES: To explore the clinical application and efficacy of transplantation of free composite flaps supplied by radial osteocutaneous branch of the dorsal branch of the anterior interosseous artery for reconstructing bone and skin defects in the hand. MATERIAL AND METHODS: Anatomically, the radial osteocutaneous branch of the dorsal branch of the anterior interosseous artery has constant collateral anastomoses which can provide a large dorsoradial flap from the dorsum of the forearm. This flap was used for reconstruction in five cases of cutaneous and phalangeal defects. RESULTS: Reconstruction was successful in all five cases, with consolidated phalanx and good cosmetic results. All donor sites could be closed directly. CONCLUSION: Reconstruction with dorsoradial forearm flaps is a reliable procedure which causes minimal trauma. Thus, it is an ideal approach for repairing cutaneous and phalangeal defects.

Secondary solution for breast reconstruction following total DIEP flap loss: A single-center experience after 3270 DIEP flaps.

BACKGROUND: Total deep inferior epigastric perforator (DIEP) flap failure is a significant concern in autologous breast reconstruction. Literature on secondary reconstruction options following total flap failure is limited. This study outlines the outcomes of patients who underwent reconstruction post-DIEP flap failure at our institution. METHODS: We conducted a retrospective analysis of patients receiving autologous breast reconstruction between 2004 and 2021. We aimed to identify causes of total DIEP flap failure, outcomes of revision surgery, and outcomes of secondary breast reconstruction procedures. RESULTS: From 2004 to 2021, 3456 free flaps for breast reconstruction were performed, with 3270 being DIEP flaps for 2756 patients. DIEP flap failure was observed in 40 cases (1.22%). Bilateral reconstructions had a higher failure rate (2.31%) than unilateral (0.72%). The primary cause was intraoperative complications during flap harvest (18 cases), followed by insufficient arterial perfusion (seven cases). Other causes included postoperative hematoma (seven cases), venous congestion (six cases), and late-onset fat necrosis (two cases). Post-failure, five patients received a second free flap with three cases of repeated flap failure. Twenty patients received implant-based reconstruction with two cases of reconstruction failure, while seven patients received a pedicled latissimus dorsi (LD) flap reconstructions with no cases of reconstruction failure. Eight patients declined further reconstruction. CONCLUSION: A second free flap post-DIEP failure was associated with a high risk of reconstruction failure, suggesting the need for careful patient selection. Implant-based and pedicled LD flap seem to be reliable secondary reconstruction options.