Complex Hand Reconstruction using a Novel Two-stage Temporary Ectopic Implantation of the Contralateral Upper Limb.

Ectopic transplantation of the hand remains a rare, innovative yet valuable operation in select cases of trauma and amputation. We aim to describe a novel technique of complex hand reconstruction using a two-stage ectopic implantation of the contralateral upper limb. A male patient with a near complete avulsion amputation of the right upper limb at the level of the mid-forearm and a crushing injury to his left hand was admitted after a farming accident. The right palm was ectopically transplanted to the left lower limb and both upper limbs underwent debridement with vacuum assisted dressings (VACs). There was eventual dieback of the left thumb, ring and little finger with a large palmar soft tissue defect that was eventually reconstructed using segments of the ectopically transplanted limb in two separate operations. The patient made an uneventful postoperative recovery and managed to regain protective sensation and gross motor function of his reconstructed hand.

Management of head & neck sarcomas in adults: A retrospective study.

The research purpose is to review the surgical approach and evaluate the results in adult patients with head and neck sarcomas. The histopathology varied, including two leiomyosarcomas, six malignant fibrous histiocytomas, two malignant peripheral nerve sheath tumors, four dermatofibrosarcomas protuberans, three osteosarcomas, two angiosarcomas, one liposarcoma, one Ewing sarcoma, one synovial sarcoma, two unclassified/non-differentiated sarcomas and one solitary fibrous tumor. Surgical resection included maxillectomy, mandibulectomy, craniectomy, parotidectomy, scalp resection, face skin resection and laminectomy. The reconstruction was performed with one rectus abdominis flap, four radial forearm flaps, two latissimus dorsi flaps, two vascularized fibula flaps, two pectoralis major myocutaneous flaps, two trapezius flaps, two temporalis flaps, seven scalp flaps and two nasolabial flaps. The total patient number was 24. The hospitalization was uncomplicated, followed by postoperative radiotherapy in the majority of cases. In a mean 15-year follow-up period, 11 patients are still alive and disease-free. There were four recurrences treated with palliative radiotherapy. The surgical approach for head and neck sarcomas, including the achievement of a functionally acceptable result by organ sparing techniques, remains challenging. Wide resection combined with the appropriate reconstruction, particularly with microsurgical techniques, and followed by adjuvant radiotherapy or chemotherapy offer improved prognosis and quality of life.

Quality of life and functional outcomes in tongue cancer patients: a long-term, prospective, comparative study

Background: The tongue has an indispensable role in communication, swallowing and breathing. Tongue cancer treatment involves direct resection of the tumor and surrounding tissue, which can limit many essential functions of the tongue. There are few patient-reported quality of life studies involving tongue cancer exclusively. There is also a lack of data on the outcomes of quality of life regarding different reconstructive methods, adjuvant nonsurgical therapies and other predicting factors. Our objective is to assess the quality of life, functional status, and predicting factors in patients with tongue cancer up to one year after surgical resection. Material and Methods: Thirty-six patients with tongue cancer were prospectively identified between October of 2017 and January 2021. Patients were examined before and one, three, six and twelve months after surgical resection with the validated University of Washington Quality of Life questionnaire (UW-QOL). Data collection included patient age, sex, TNM staging, size of resection, neck dissection, tracheostomy, reconstructive method and adjuvant therapies. Outcome scores were compared using the Friedman test. Multiple linear regression analysis was used to identify the predictors of quality of life and functional status. Results: The use of UWQOL scores as dependent variables revealed the following predicting factors: age, tobacco use, radiotherapy, chemotherapy, reconstruction method and neck dissection. Conclusions: The most relevant findings in our study are that flap reconstruction becomes increasingly necessary when a glossectomy resection is over 45 mm, in order to maintain tongue function. We established that the reconstructive flap type does not influence quality of life in the long term. Also, we have found that cervical sentinel node biopsy provides better quality of life over neck dissection in the first 3 months after surgery. (AU)

The Foot as a Donor Site for Reconstruction in the Hand.

The foot contains a unique collection of tissue types that can be used in the reconstruction of the hand. Numerous reconstructive options have been presented, some of which have been adopted, such as modifications to procedures that have been described in the past or even newly developed options for hand reconstruction. It is possible to reconstruct missing fingers and other hand structures using tissues taken from the foot rather than removing healthy tissue from a hand that has already been injured. This makes it possible to avoid having healthy tissue removed from an injured hand.

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.

Craniectomy with soft tissue reconstruction for locally advanced non-melanoma skin cancer of scalp with calvarial invasion: The Nottingham experience.

INTRODUCTION: Locally advanced non-melanoma skin cancer (NMSC) involving the periosteum or calvarium poses a clinical challenge for patients who are unfit for immunotherapy due to medical comorbidities and/or frailty. This case series aims to investigate outcomes for patients undergoing craniectomy and soft tissue reconstruction. METHOD: Patients who underwent craniectomy and soft tissue reconstruction for invasive NMSC with calvarium or periosteal invasion between 2016 and 2022 were included. Data, including demographics, operative details, and clinical outcomes, were gathered from Nottingham University Hospitals' digital health record and the histopathology electronic database. RESULT: Eight patients (average age: 78.4 years, 3 females 5 males) with significant comorbidities and varying degrees of periosteal or bone invasion fulfilled the inclusion criteria. Diagnoses included four squamous cell carcinomas, two basal cell carcinomas, and two pleomorphic dermal sarcomas. Five patients had a history of prior incomplete deep margin excision. The median sizes for soft tissue defect, tumor and bone defect size were 51.83 cm2, 34.63 cm2 and 42.25 cm2, respectively. Intraoperative complications included one dural tear. Four patients underwent local flap reconstruction and with split-thickness skin grafting, four patients underwent free flap reconstruction. Adjuvant radiotherapy was administered to three patients. Complications comprised partial graft loss in two and complete graft loss in one. There was partial flap loss in one case. One patient required subsequent parotidectomy due to regional progression before achieving disease control. All patients achieved lasting locoregional disease control (average follow-up 29.7 months). CONCLUSION: Craniectomy with soft tissue reconstruction proves to be a safe and effective treatment option in advanced NMSC of the scalp in patients unsuitable for immunotherapy due to frailty or medical co-morbidity.

Seguridad y factibilidad de la reconstrucción microquirúrgica en tumores de cabeza y cuello en pacientes mayores de 70 años / Safety and feasibility of free-flap reconstruction in head and neck tumors in patients aged 70 years or older

RESUMEN Antecedentes: debido al aumento en la expectativa de vida, se ha incrementado la incidencia de tumores de cabeza y cuello en pacientes añosos. Objetivo: evaluar los resultados de la reconstrucción con colgajos microquirúrgicos luego de la resección radical (RRMC) de tumores de cabeza y cuello en pacientes de 70 años o mayores. Material y métodos: se analizó una serie de pacientes sometidos a RRCM por tumores de cabeza y cuello en el período 2000-2020. Se dividió la muestra en dos grupos: G1: ≥ de 70 años y G2: < de 70 años. Se analizaron variables demográficas, quirúrgicas, posoperatorias y factores de riesgo de trombosis del colgajo en los pacientes ≥ de 70 años. Resultados: se incluyó un total de 178 pacientes, 61 en G1 y 117 en G2. Ambos grupos fueron homogéneos respecto del sexo, IMC (índice de masa corporal), alcoholismo, tabaquismo, tratamiento neoadyuvante e incidencia de HPV (virus del papiloma humano). Hubo mayor cantidad de pacientes con riesgo ASA ≥ III en G1 vs. G2; (p: 0,005). En G1, 33 (54%) correspondieron a estadio oncológico ≥ III vs. 99 (87%) en G2 (p: 0,001). Cuarenta y dos (69%) pacientes en G1 recibieron adyuvancia vs. 94 (83%) en G2 (p: 0,02) y no hubo diferencias en la morbimortalidad global y en fallas del colgajo. El sexo femenino fue el único factor de riesgo de trombosis del pedículo vascular (p: 0,05). Conclusión: la RRCM para tumores de cabeza y cuello es factible y segura en pacientes añosos, con una incidencia de morbimortalidad similar a la del resto de la población.

ABSTRACT Background: The higher life expectancy has increased the incidence of head and neck tumors in elder patients. Objective: the aim of this study was to evaluate the outcomes of free flap reconstructions after radical resection (FFRR) of head and neck tumors in patients aged 70 years or older. Material and methods: We analyzed a series of patients undergoing FFR due to head and neck tumors between 2000-2020. The patients were divided into two groups: G1: ≥ 70 years, and G2: < 70 years. The demographic, operative and postoperative variables and the risk factors for flap thrombosis in patients ≥ 70 years were analyzed. Results: A total of 178 patients were included, 61 in G1 and 117 in G2. Both groups were homogeneous regarding sex, BMI (body mass index), alcohol consumption, smoking habits, neoadjuvant treatment, and incidence of HPV (human papillomavirus). The incidence of ASA grade ≥ III was significantly higher in G1 vs. G2; (p: 0,005). In G1, 33 patients (54%) corresponded to cancer stage ≥ III vs. 99 (87%) in G2 (p: 0.001). Forty-two (69%) patients in G1 received adjuvant therapy vs. 94 (83%) in G2 (p = 0.02) and there were no differences in overall morbidity and mortality and in flap failure. Female sex was the only predictor of vascular flap thrombosis (p = 0.05). Conclusion: FFRR in head and neck tumors is feasible and safe in elderly patients, with morbidity and mortality rates similar to those of the general population.

Use of a Fibula Free Flap for Mandibular Reconstruction in Severe Craniofacial Microsomia in Children with Obstructive Sleep Apnea.

This is a retrospective study describing a multi-stage protocol for the management of severe mandibular hypoplasia in craniofacial microsomia (CFM) with accompanying obstructive sleep apnea (OSA). Patients with severe mandibular hypoplasia require reconstruction functionality and esthetical features. In the cohort, reconstructions based on free fibular flaps (FFF) may be the most effective way. Patients aged 4-17 years with severe mandibular hypoplasia were treated with FFF, which initially improved the respiratory function assessed on polysomnography (AHI). In the next stages of treatment of cases with respiratory deterioration, it was indicated to perform distraction osteogenesis (DO) of the mandible and the structures reconstructed with FFF. All surgeries were planned in accordance with virtual surgery planning VSP. The aim of the study was to prospectively assess the effectiveness of multi-stage mandibular reconstruction in craniofacial microsomia with the use of a free fibula flap in terms of improving respiratory failure due to obstructive sleep apnea (OSA). The FFF reconstruction method, performed with virtual surgical planning (VSP), is proving to be an effective alternative to traditional methods of mandibular reconstruction in patients with severe CFM with OSA.

Long-Term Results of Microsurgical Brachial Plexus Reconstruction in Late-Presenting Cases of Brachial Plexus Birth Injury.

PURPOSE: The role of primary surgery in delayed presenting cases of brachial plexus birth injury is still debated. The purpose of this study was to evaluate the results of brachial plexus reconstruction performed at the age of ≥12 months. METHODS: Twenty-nine cases were included. Five cases had upper (C5-6) palsy, 4 had upper/middle (C5-7), and 20 had total (C5-8 and T1) palsy. RESULTS: The age at the time of primary surgery was an average of 15.6 months. The brachial plexus was formally explored and neurolysis, grafting, and neurotization were used in different combinations. Exploration revealed that 27% of the roots were avulsed and 32% were ruptured. The follow-up was an average of 7.9 years. Generally, the best functional recovery was elbow flexion followed by shoulder external rotation. Satisfactory shoulder abduction (≥6 on the Toronto Active Movement Scale [TAMS]) was achieved in 31% of cases. The abduction range was an average of 79° ± 35°; 50° in upper palsy, 103° in upper/middle palsy, and 82° in total palsy. Shoulder external rotation ≥6 on the TAMS was achieved in 62% of cases. External rotation range was an average of 58° ± 29°; 78° in upper palsy, 68° in upper/middle palsy, and 52° in total palsy. Elbow flexion and extension of ≥6 on the TAMS were achieved in 69% and 58% of cases, respectively. Wrist flexion and finger flexion of ≥6 on the TAMS were achieved in 35% and 12.5%, whereas wrist and finger extension of >6 on the TAMS were achieved in 25% and 4% of cases, respectively. CONCLUSION: In the delayed presentation of brachial plexus birth injury, brachial plexus reconstruction results in good functional recovery of elbow flexion and shoulder external rotation but modest functional recovery of finger flexion and wrist extension. The rate of functional recovery of the elbow flexion was similar following nerve grafting and transfer. Nerve transfer for shoulder external rotation should be considered even in infants with available roots for grafting. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Refinements in the reconstruction of bisphosphonate-related osteonecrosis of the jaw.

The recommended treatment strategy for stage 3 bisphosphonate-related osteonecrosis of the jaw (BRONJ) is currently rigid plate fixation without bone reconstruction. However, a recent systematic review indicated the utility of microsurgical reconstruction after resection of BRONJ. Several types of flaps have been described but their applications are controversial. Here we present a detailed reconstruction plan for obtaining better outcomes in patients with maxillary and mandibular BRONJ. Given that progressive maxillary BRONJ is often invasive to the skin, including the eyelid, leading to functional loss such as leakage of discharge and ectropion, several revision surgeries are needed to increase the volume in the defect after the free flap transfer. For progressive mandibular BRONJ, hemi-mandibulectomy to subtotal mandibulectomy with an adequate margin from the necrotic bone is necessary, followed by a well-designed fibular free flap.

Thromboelastography in Microsurgical Reconstruction: A Systematic Review.

The aim of this review was to identify studies that used thromboelastography (TEG) or rotational thromboelastometry (ROTEM) in microsurgical free flap reconstruction and analyse whether it is a useful adjunct at predicting and identifying thrombotic complications. A search was conducted using the MEDLINE database using the keywords "thromboelastogram", "TEG", "thromboelastography", "free flaps" and "free tissue transfer" using a two-component search with the Boolean operators "OR" and "AND". Eight studies were retrieved using the search criteria. Seven studies met the inclusion criteria, and a further study was found citing several articles from the initial search. Combined, there were 528 patients who underwent 600 free flaps. A total of 10.3% (62) arterial and venous thromboses were reported in the studies, and the combined flap failure rate was 5.2% (26). A total of 67% (4/6) of the studies supported the use of TEG as a predictive tool to detect thromboses, including three retrospective case series and one prospective cohort, which were all statistically significant. There is low-quality evidence (level IV) that a pre-operative TEG and functional fibrinogen to platelet ratio of ≥42 can identify patients at risk of adverse post-operative thrombotic events following free flap surgery; however, further validation is required. Higher quality, standardised prospective or randomised control trials are required to further evaluate the predictive value of TEG. As a pre-operative screening tool, TEG can help to detect pathological changes in coagulation, aid in the transfusion of blood products, target anticoagulation therapy and predict possible adverse events aiding to further reduce patient morbidity.

Risk Factors for 30-Day Mortality After Head and Neck Microsurgical Reconstruction for Cancer: NSQIP Analysis.

OBJECTIVE: To identify the incidence and risk factors for 30-day postoperative mortality after microsurgical head and neck reconstruction following oncological resection. STUDY DESIGN: Retrospective case-control study. SETTING: American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. METHODS: Microsurgical head and neck reconstructive cases were identified from 2005 to 2018 using Current Procedural Terminology codes and oncologic procedures using the International Classification of Disease 9 and 10 codes. The outcome of interest was 30-day mortality. RESULTS: The 30-day postoperative mortality rate was 1.2%. Univariate logistic regression analysis identified the following associations: age >80 years, hypertension, poor functional status, preoperative wound infection, renal insufficiency, malnutrition, anemia, and prolonged operating time. Multivariable logistic regression models were used to stratify further by the degree of malnutrition and anemia. Hematocrit <30% was found to be an independent risk factor for 30-day postoperative mortality (odds ratio [OR] = 9.59, confidence interval [CI] 2.32-39.65, P < .1) with albumin <3.5 g/dL. This association was even stronger with albumin <2.5 g/dL (OR = 11.64, CI 3.06-44.25, P < .01). One-third of patients (36.6%) had preoperative anemia, of which less than 1% required preoperative transfusion, although one-quarter (24.6%) required intraoperative or 72 hours postoperative transfusion. CONCLUSIONS: Preoperative anemia is a risk factor for 30-day postoperative mortality. This association seems to get stronger with worsening anemia. Identification and optimization of such patients preoperatively may mitigate the incidence of 30-day postoperative mortality.

[Odyssey of the iliac. "Mandibular reconstruction by bone free flaps"]. / L'Odyssée de l'iliaque. « De la reconstruction mandibulaire par autotransplantation ¼.

The authors proposed here a retrospective analysis of a surgical procedure they performed for long time. It allows to put into questions some established principles, to find some unkwown datas which could be important to predict complications. It is also interesting to discuss about the use of indication and choice of the flaps along years of reconstructive surgery history in the way to improve protocoles and management of those large reconstruction. During ten years in one maxillofacial surgery departement, more than 200 bone free flaps (essentially fibula and iliac crest) have been used for mandibular reconstruction and analyse with a three years follow-up. The global failure rate is estimated as 28 % included all various complications from fistulas to infections. Five different points are discussed from the ambiguity of the reported studies to the way of doing of such surgery. It is also pointed out the importance of the biological dimension of all surgical procedures and the place of clinical figures regarding of the technical processes which usually forget the main clinical purpose.

Reconstruction of upper limb soft-tissue defects after sarcoma resection with free flaps: A systematic review.

BACKGROUND AND OBJECTIVES: Upper limb preservation after soft tissue sarcoma (STS) surgical excision is now the accepted gold standard and it often requires reconstruction with free flaps. The purpose of this review is to summarize current literature on upper limb reconstruction with free flaps after STS resection. METHODS: A systematic review was performed in July 2019 in PubMed and MedLine Ovid databases according to the PRISMA guidelines. RESULTS: A total of 17 studies were included in the final analysis, with 132 patients. The most common diagnosis was Malignant Fibrous Histiocytoma. The most frequent timing of flap coverage was immediate. The success rate was almost always 100%. The length of follow-up was reported in 11 studies with a range of 2-187 months. The most commonly reported patient-centered outcome was the MSTS Score. Based on the evidence of the literature collected, we divided the upper limb into four parts (shoulder, elbow and arm, forearm and wrist, and hand) and described the most common and functional free flaps used for reconstruction after STS resection. CONCLUSIONS: Free flaps in the treatment of STS of the upper extremity have a good overall outcome, with a low postoperative complication rate. A wide array of free flaps is available for reconstruction, and the choice of flap is based on defect size, types of tissue required, postoperative functional goal, and surgeon preference. A greater degree of standardization is needed in the reporting of patient-centered outcomes to facilitate future comparative studies.

Keystone Flap as a Reconstructive Option for selected areas; A Prospective Study.

OBJECTIVE: A very few flaps would be described as versatile as the Keystone Flap. There is an increasing demand for coverage of defects in lower limb due to traumatic defects as well as other parts of the body. Keystone flap is one of its kind, which is simple and easy to perform. It is a safe option for conditions where microsurgery may not be a viable option. The relative simplicity of this flap makes it a to go option at many places. METHODS: A prospective study was developed from October 2017 to December 2019 at SMS Hospital, Jaipur. We assessed the size of the flap, operation time, average hospital stay and the complications. Perforators over the leg were Doppler marked preoperatively over which the flap was raised. RESULTS: 50 patients were taken into the study. 30 key stone flaps were done to cover lower limb defects, 10 flaps were done for upper limb defects and the remaining 10 were for trunk defects. The average intraoperative time from skin incision to final suture was 50 min (range 20-90 min). The largest defect covered by keystone flap in our series measured 50 × 20 cm and the smallest defect covered was 8 × 4 cm. The average hospital stay was 3 days. We observed partial flap necrosis in 2 cases which required skin grafting. 3 other cases had wound infection leading to wound dehiscence, which required secondary suturing. The overall success rate was 95%. CONCLUSION: The Keystone flap being a versatile flap with its qualities of replacing "like with like", easy to perform, use of local tissue, good vascularity and a low complication rate makes it an excellent flap for a variety of defects. The KeyStone flap allows reconstruction in a single stage and is a relatively easy and fast technique for the beginner as well as the experienced surgeon. We believe it should be incorporated more into a surgeons practice.

Custom surgical management of invasive malignant tumors of the scalp.

BACKGROUND: There is no universal management protocol concerning invasive malignant tumors of the scalp with bone and dura mater invasion. The aims of this study were to report and discuss our experience in the management of these forms of tumors. METHODS: We retrospectively reviewed all consecutive patients of microsurgical scalp reconstruction performed after resection of invasive cutaneous malignancies of the scalp, calvarium, and dura mater from 2017 to 2019, at Pitié-Salpêtrière University Hospital (Paris, France). RESULTS: Five patients met inclusion criteria. There were three squamous cell carcinomas and two sarcomas. Mean age at surgery was 63.6 years. The sex ratio male/female was 4. Two received radiation prior to resection and two patients had a history of prior scalp tumor surgery. All the patients underwent craniectomy and the mean cranial defect size was 41 cm2. Cranioplasty was performed in one patient. Soft tissue coverage was provided by free tissue transfer of latissimus dorsi muscle in all patients. In four patients, split thickness skin graft was performed in a second surgical stage few weeks later. There were no intraoperative complications and no complications into the donor site for the tissue transfer or the skin graft. Two patients had flap necrosis that healed after a new free flap of latissimus dorsi. CONCLUSIONS: Wide resection with craniectomy and reconstruction with microvascular free tissue transfer provides safe and reliable treatment of recalcitrant invasive scalp skin cancers. The surgical management of these complex patients is a challenge that must be conducted by trained, experienced, and multidisciplinary teams.

Reconstructive microsurgery in upper limb reconstruction: 30 years' experience of a single surgeon.

The reconstruction of compound tissue defects in upper extremity injuries often represents a challenge. The goal of reconstruction is to obtain not only a good cosmetic result, but also the best possible function. Microsurgery highly contributes to the management of upper limb simple or complex defects by offering a large number of surgical possibilities. Due to advances in understanding of blood supply to tissues and microsurgical techniques in the last 50 years, microsurgeons have renounced more and more to the use of traditional flaps in favour of the more reliable perforator flaps. This article presents the experience of a single surgeon performing post-traumatic upper limb reconstructive microsurgery over the last 30 years.

Treatment of diaphyseal clavicular nonunion with special emphasis on microsurgery.

Diaphyseal fractures of the clavicle had until recently the reputation to always heal with abundant callus formation, except if operated, due to a reported high rate of nonunion after plate fixation by older series. The reason would be that the bone has only periosteal vascularization, easily destroyed by periosteal stripping for implant apposition. Bone autograft and external fixation has been reported as the best technique to heal a nonunited clavicle nonunion. Are these classical considerations still valid nowadays? The purposes of this article focusing only on diaphyseal clavicular fractures are to review the vascularization of the bone, the rate of nonunion after nonoperative treatment, the indications and techniques of osteosynthesis, and the treatment possibilities of an established nonunion. This article will not deal with the specific problems of the lateral clavicular fractures, which are equivalent to acromio-clavicular fracture-dislocations, nor of medial fractures, close to the sterno-clavicular joint.

Supermicrosurgical reconstruction of nasal tip defects using the preauricular reversed superficial temporal artery flap.

BACKGROUND: Microsurgical reconstruction of nasal tip defects is difficult to achieve. The free composite auricular flap allows for repair in a one-stage procedure. However, anastomosis to the recipient facial artery is often complicated because of its variable anatomy and the need for a vessel graft. In this study, we describe our experience using the alar artery and angular vein as recipient vessels for direct super microsurgical anastomosis. METHOD: From February 2004 to December 2015, thirty-two patients with different degrees of full-thickness multi-subunit nasal tip defects were included in this study. The superficial temporal vessels, alar artery, and angular vein were marked preoperatively by ultrasound detection. The preauricular reversed superficial temporal artery flap was harvested and transferred to the nasal tip defect region as a free flap using a supermicrosurgical technique. Patient pictures were taken before surgery and at 1, 3, and 6 months of follow-up. Outcomes and complications were recorded and analyzed. Moreover, a postoperative patient satisfaction survey was performed. RESULTS: The reversed superficial temporal artery flap was used in a total of 32 patients for the reconstruction of nasal tip defects in a one-stage procedure. In all cases, the alar artery and angular vein showed no anatomical variations and were used as recipient vessels. The size of the harvested preauricular flap size was 2.5 × 2.0 to 4.0 × 3.6 cm2, and the average flap size was 3.6 × 2.7 cm2. The length of the arterial pedicle was 4.0 to 6.7 cm, 5.58 cm on average. The length of the venous pedicle was 5.0 to 6.8 cm, 6.21 cm on average. Direct anastomosis was achieved in all patients, and in none of the cases, a vascular graft was needed. Donor sites were all closed primarily. Flap survival was complete, except for one case of vascular thrombosis, resulting in a 10% flap necrosis. Temporary hematoma was noted in one patient. The postoperative outcome showed excellent functional coverage and improved esthetic appearance. The average follow-up period was 12 months. The majority of patients (98.5%) rated their postoperative outcome as highly improved and improved. No late recurrence or other complications were seen in any of the patients. Twenty-two patients underwent a secondary debulking procedure of the flap for fine adjustment. CONCLUSION: Our results demonstrate that the alar artery and angular vein are suitable recipient vessels for the super microsurgical reconstruction of nasal tip defects. Surgical planning and procedure are facilitated by their reliable anatomy without the need for a vessel graft. This technique may offer wider applications by extension to other facial cutaneous defects.