Full Thickness, Near-Total to Total Lower Lip Reconstruction Using Superficial Circumflex Iliac Artery Perforator Free Flap: A Case Report.

Near-total to total lower lip defects present significant challenges for reconstructive surgeons, requiring restoration of oral competency, maximization of oral aperture, and cosmetic appearance. This report explores a novel reconstructive option addressing all three needs. Traditionally, local flap options restore cosmesis and oral competency by recruiting local tissue of similar thickness, pliability, and appearance, but often result in microstomia. Conversely, free flaps prevent microstomia but can lead to bulky and cosmetically unacceptable reconstructions. We present the first case of using a super-thin superficial circumflex iliac artery perforator (SCIP) free flap for near-total, full-thickness lower lip reconstruction. The patient was a 66-year-old female with recurrent squamous cell carcinoma of the lower lip, requiring wide local excision and resulting in an 80% full-thickness defect with unilateral oral commissure loss. An 8 cm × 5 cm × 5 mm SCIP flap was raised with a 4.5-cm pedicle length and anastomosed to the facial artery and vein. Clear fluids were commenced 7 days postoperatively, wounds healed 2 weeks postoperatively, and a normal diet was resumed at this time. The SCIP flap offers an excellent additional option for managing full-thickness near-total to total lower lip defects. Its thin, pliable nature and minimal donor site morbidity help restore oral competency, maximize oral aperture, and achieve a pleasing cosmetic result.

Predicting the Timing and Cause of Microvascular Free Flap Failure: An Australian Study of 1569 Free Flaps.

BACKGROUND: The aim of the study is to assess the possible predictors of microvascular free flap failure and determine the critical postoperative timing of flap failure, thereby minimizing this adverse outcome. METHODS: This is a retrospective single-institutional review of 1569 free flap operations. All free flaps with outcome status recorded were analyzed for possible predictors in the development of microvascular compromise. Compromised cases were then analyzed for differences in time to compromise and time to theater takeback between salvaged versus failed free flaps. RESULTS: Of the assessable 1569 free flaps, 31 developed microvascular compromise (2.0%); the salvage rate was 20.0%, and overall failure rate was 1.5%. Osteocutaneous free flaps in head and neck had increased risk of developing free flap failure compared to other flaps (odds ratio = 3.8, 95% confidence interval: 1.2-12.7). Among breast patients, previous radiotherapy had a significant association with flap failure ( P < 0.001). Free flap salvage rates dropped from 38.5% to 7.7% for compromises detected after 24 hours ( P = 0.160), and from 57.1% to 11.1% for free flaps taken back to theater greater than 3 hours after compromise detection ( P = 0.032). CONCLUSIONS: Delays in compromise detection and flap takeback to theater resulted in reduced salvage rates, with the critical timing of takeback being under 3 hours. Standardized flap monitoring protocols and incorporation of newer technologies could see faster detection and improved salvage rates. Additional care is required when reconstructing: osteocutaneous head and neck free flaps and previously irradiated breast patients.

The reinforced pedicle technique: a case report of secondary mastopexy following nipple-sparing mastectomy with autologous breast reconstruction.

Background: Immediate autologous reconstruction after nipple-sparing mastectomy (NSM) is challenging in the ptotic breast due to the large skin envelope and reduced vascular supply to the nipple areolar complex (NAC). Patients with significant ptosis who want to preserve their NACs are often advised to undergo a two-stage procedure: first, a mammoplasty is performed to lift the NAC, and second, a delayed NSM with autologous reconstruction is performed. Unfortunately, patients with active cancer cannot delay their mastectomy; as such, they are often treated with skin-sparing mastectomy (SSM) instead. Case Description: The reinforced pedicle is an innovative technique that allows the NAC to be safely raised after NSM with immediate free flap reconstruction. In the first stage, patients with ptotic breasts undergo NSM and immediate autologous reconstruction. The reconstruction itself also appears ptotic, but the dermal blood supply to the NAC is preserved. In the second stage, the ptotic free flap reconstruction is revised using the reinforced pedicle technique, which allows the flap to be reduced and the nipple raised in the manner of a standard superior pedicle breast reduction. Using this technique, we have successfully raised a patient's NAC by 2.5 cm. Conclusions: The reinforced pedicle technique adds to the scant literature on secondary revision techniques after autologous breast reconstruction. While further research on this technique is needed, it has the potential to alter the paradigm of immediate autologous reconstruction in the ptotic breast, allowing such patients to preserve their native NACs.