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.

A Safe Methodology for Suction Drain Placement in in Head & Neck Reconstruction after Free Tissue Transfer.

Introduction: Free tissue transfer is now done routinely for Head & neck reconstruction. A suction drain is needed for efficient drainage of the neck post-dissection & with it arises a new dilemma, challenge or obsession amidst the practicing surgeons about the safe and efficient placement of suction drain in an anatomical location so that it does not injure or impair the anastomosis but will still be able to carry out its role efficiently. No prior studies are available regarding the safe practice. Hence the aim of our study was to explore & establish a reliable manoeuvre where the drain could be introduced in a safe and efficient way. From April of 2017-February of 2024 a prospective study was carried out in which cases of 517 patients were taken into account who underwent head and neck reconstruction using a free tissue transfer procedure where the suction drain tube was placed in the dependent part of the neck (i.e. the posterior triangle region) & the margin of sternocleidomastoid muscle was fixed with the pre-vertebral layer of the cervical fascia. The drain was secured externally with a percutaneous non- absorbable suture. Study Design: A prospective Study. Study Period: April 2017- February 2024. Observation: A thorough observation was carried out & no evidence of drain induced anastomotic complications were reported. Conclusion: Hence it can be assumed that this particular method of drain placement is both safe & efficient and it can act as a beacon among the surgeons who suffer a from a dilemma & challenge about where to place the drain safely & efficiently.

Fentanyl versus Dexmedetomidine Infusion in Head and Neck Free Flap Surgery for Comparison of Hemodynamic Parameters and Anaesthetic Requirements: A Randomised Controlled Trial.

BACKGROUND: This prospective, double-blinded, randomized study aimed to compare the efficacy of dexmedetomidine and fentanyl infusions in maintaining hemodynamics during head and neck free flap surgery, as well as their impact on the relative amount of blood loss. METHODS: Twenty patients with American Society of Anesthesiologists physical status I and II scheduled for elective head and neck free flap surgery were enrolled. The patients were randomly assigned to receive either dexmedetomidine (1 µg/kg over 10 min at anesthesia induction, followed by 0.2 to 0.75 µg/kg per hour infusion during maintenance) or fentanyl (1 to 2 µg/kg per hour infusion during maintenance). Intraoperative hemodynamic parameters, blood loss, blood transfusion requirements, surgeon satisfaction, adverse drug effects, and free flap survival up to 7 days were recorded. RESULTS: The dexmedetomidine group achieved a mean arterial pressure (MAP) value between 60 and 70 mmHg at multiple time points (15 min, 3rd, 4th, 5th, and 6th hours), while the fentanyl group did not reach this range at any time point. The intergroup statistical analysis revealed a significant difference only at the 5th hour with (95% CI: -16.17 to -0.62) and P = 0.036. Additionally, the dexmedetomidine group exhibited lower heart rates (< 70/min) at several time points (15 min, 2nd, 3rd, 4th, 5th, and 6th hours) compared to the fentanyl group. The intergroup comparison indicated a statistically significant difference only at the 3rd hour with (95% CI: -20.94 to -0.45) and P = 0.042. CONCLUSION: Dexmedetomidine can be a useful adjuvant of GA for inducing controlled hypotension and decreasing bleeding in free flap surgery of the head and neck region without any detrimental effect on the free flap survival.

Feasibility of Super-thin Anterolateral Thigh Free Flap for Oral and Pharyngeal Reconstruction.

OBJECTIVES: To highlight the feasibility of employing super-thin ALT free flaps for reconstruction of complex oral cavity and oropharyngeal defects. METHODS: Retrospective chart review. RESULTS: Sixteen super-thin ALT free flaps were performed in 15 patients between 2020 and 2023 for reconstruction of oral cavity defects (seven oral tongue, three floor of mouth, three buccal, two oropharynx, one lower lip). Flap success rate was 100% with only minor complications reported, with no patient requiring return to the operating room within 30 days and no patient requiring radial forearm free flap reconstruction. One patient experienced partial flap failure, one patient experienced superficial necrosis of the distal skin paddle measuring 1 cm, and one patient was converted intraoperatively to a contralateral traditional ALT free flap due to insufficient perforator size. Average operative time was 509 min, average length of hospitalization was nine days, and two patients required gastrostomy placement prior to discharge for dysphagia. CONCLUSIONS: Super-thin ALT free flap harvest technique represents a feasible option for oral cavity and oropharyngeal reconstruction in select patients and does not require additional surgical training, invasive testing, or technology. It can be readily adopted by reconstructive surgeons with a simple adaptation in existing ALT harvest technique. LEVEL OF EVIDENCE: Level 4 Laryngoscope, 2024.

Bivalirudin for unsalvageable venous congestion or obstruction in head and neck free flap reconstruction.

Microvascular free flap surgery permits single-stage reconstruction of complex head and neck ablative defects. Venous congestion can occur in the early postoperative period, risking partial or total flap loss. While prompt surgical re-exploration is often required, a number of adjunct medical treatments have been explored. Recently, there has been an anecdotal rise in the use of the anticoagulant bivalirudin, a recombinant derivative of hirudin. However, there has only been one case series report on the use of bivalirudin in head and neck free flap venous congestion. Here, we describe our team's experience with bivalirudin through a series of 7 patients.

Incidence of and risk factors for post-operative venous thromboembolism after free flap breast reconstruction in a London teaching hospital: A retrospective cohort study.

OBJECTIVE: The objective of this study was to determine the incidence of venous thromboembolism (VTE) following autologous breast reconstruction, assess risk factors that may predict incidence and assess the accuracy of the Caprini risk assessment model. BACKGROUND: VTE is a rare, but potentially lethal complication of autologous breast reconstruction. An accurate preoperative risk-stratification strategy is essential to improve patient outcomes by determining the patients who would benefit from extended thromboprophylaxis after surgery. METHODS: Patients who underwent autologous free flap breast reconstruction at a London teaching hospital from 2019-2021 were included. Risk factors for VTE were analysed. VTE incidence was assessed, and the risk factors were identified using multivariate analysis. RESULTS: Overall, 368 patients were included in the study. Among them, 10 (2.72%) had a confirmed diagnosis of post-operative VTE, at an average of 23 days after surgery (range 3-64 days). All VTEs occurred in deep, inferior epigastric artery perforator flap patients with a history of breast cancer. Multivariate regression analysis revealed a statistically significant correlation between the incidence of VTE and Caprini score (p = 0.030) and length of hospital stay (p = 0.007). Tamoxifen use was individually significant for VTE (p = 0.043) but non-significant (p = 0.106) when confounded for length of hospital stay (LOS) and Caprini score. CONCLUSIONS: Current VTE risk assessment tools do not accurately identify patients who are at risk of developing VTE following free flap breast reconstruction. The Caprini risk assessment model and LOS may be useful in predicting post-operative VTE in this cohort. These patients may benefit from extended chemoprophylaxis. Larger prospective studies are required to optimise risk prediction models in this cohort.

Efficacy of Surgical Reconstruction With Rectus Abdominis Flap Following en Bloc Resection of the Orbital Contents for Malignant Lacrimal Gland Cancer: A Case Series.

In cases of lacrimal gland carcinoma requiring surgical excision of the orbital contents, skull base, and surrounding bones, definitive blockage of the cranial cavity and reconstruction of the anterior skull base with irradiation-acceptable tissue (for possible subsequent radiotherapy) is necessary. However, considerations for quality of life, including cosmetic aspects, such as artificial eye placement and contour morphology, make reconstruction challenging. In three cases of advanced lacrimal gland carcinoma, we performed a reconstruction surgery following an en bloc resection of the orbital contents and lateral orbital bones. A rectus abdominis flap was used, considering both function and morphology. This flap, characterized by reliable anatomical structure and good blood flow, adequately filled the three-dimensional dead space. In our case, the flap fully survived, and no complications such as cerebrospinal fluid leakage or meningitis were observed. Six months after surgery, the flap volume was 31.7-73.3% of its initial size. Considering potential flap shrinkage in the future, it was deemed beneficial to use a slightly excessive volume.

Usefulness of using the superficial temporal pedicle as the recipient site for microvascular anastomosis in facial reconstruction: A retrospective study of 94 cases.

In cranio-cervico-facial reconstructive surgery, it is accepted that the use of free flaps is the treatment of choice. The multiple antecedents can place the surgeon in situations of vascular deserts. The aim of our study is to report and analyse our experience of the use of temporal vessels in primary and secondary reconstructive surgery. A retrospective study was conducted between 01/01/2010 and 31/03/2023. Patients who underwent cranio-cervico-facial reconstruction using free flaps, with use of the superficial temporal pedicle as the recipient site for the vascular anastomosis were included. Early and late complication and failure rates were analysed according to type of reconstruction, location and risk factors for free flap failure. A total of 94 patients underwent craniocervical-facial reconstruction using a free flap anastomosed to the superficial temporal pedicle (in primary or secondary situations). Ten patients underwent reconstruction of the upper third, 58 the middle third and 26 the lower third. With an overall complication rate of 28.7% (21.3% minor complications and 7.4% major complications). Our study proves the reliability of the superficial temporal pedicle, both in the primary situation (with a success rate of 93.9%) and in the secondary situation (with a success rate of 89.3%), as well as its versatility whatever the cranio-cervico-facial level to be reconstructed. This study demonstrates the value of preserving the superficial temporal pedicle in craniofacial reconstruction surgery. This is because it is a preferred recipient site for reconstructions of the upper and middle thirds in the primary situation or in the event of recourse.

Advances in Microsurgical Treatment Options to Optimize Autologous Free Flap Breast Reconstruction.

Introduction: Reconstructive plastic surgeons have made great strides in the field of breast reconstruction to achieve the best results for patients undergoing treatment for breast cancer. As microsurgical techniques have evolved, these patients can benefit from additional treatment modalities to optimize the results of the reconstruction. Free tissue transfer from alternative donor sites for breast reconstruction is routinely performed, which was not possible in the past. Neurotization is now possible to address the numbness and lack of sensation to the reconstructed breast. For those patients who develop lymphedema of the upper extremity as a result of their breast cancer care, supermicrosurgical options are now available to treat and even to prevent the development of lymphedema. This study presents a narrative review regarding the latest microsurgical advancements in autologous free flap breast reconstruction. Methods: A literature review was performed on PubMed with the key words "autologous free flap breast reconstruction", "deep inferior epigastric perforator flap", "transverse upper gracilis flap", "profunda artery perforator flap", "superior gluteal artery perforator flap", "inferior gluteal artery perforator flap", "lumbar artery perforator flap", "breast neurotization", "lymphovenous bypass and anastomosis", and "vascularized lymph node transfer". Articles that specifically focused on free flap breast reconstruction, breast neurotization, and lymphedema surgery in the setting of breast cancer were evaluated and included in this literature review. Results: The literature search yielded a total of 4948 articles which were screened. After the initial screening, 413 articles were reviewed to assess the relevance and applicability to the current study. Conclusions: Breast reconstruction has evolved tremendously in recent years to provide the most natural and cosmetically pleasing results for those patients undergoing treatment for breast cancer. As technology and surgical techniques have progressed, breast cancer patients now have many more options, particularly if they are interested in autologous reconstruction. These advancements also provide the possibility of restoring sensibility to the reconstructed breast as well as treating the sequela of lymphedema due to their cancer treatment.

Functionality and Scar Evaluation of the Donor Site in Extended Radial Forearm Flap Phalloplasty: How Affected Is the Arm in Day-to-Day Life?

Background: The radial forearm flap remains the gold standard in phalloplasty in gender-affirming surgery due to its versatility and functional outcome, but the significant donor site morbidity and its impact on daily functioning and aesthetic perception remains understudied. This study provides valuable insights into the mid-term functional and aesthetic outcomes of the forearm in transgender individuals following radial forearm flap phalloplasty using widespread instruments for assessment scoring systems and for the evaluation of postoperative wound healing of surgical interventions in general. Methods: Between January 2013 and March 2018, a total of 47 patients underwent radial phalloplasty at AGAPLESION Markus Hospital, and 20 consented to participate in this cross-sectional, retrospective study evaluating functional and aesthetic outcomes post-radial forearm flap phalloplasty using standardized questionnaires (DASH, POSAS, and SBSES). A univariate median regression of each score was performed to determine the associations with selected variables, and correlation analyses between scores was performed using a nonparametric Spearman rank correlation. Results: Among the 20 participants, the median Quick DASH, DASH functionality, DASH sport and music, and DASH work scores indicated minimal to no functional impairment. Scar evaluations using the PSAS, OSAS, and SBSES scales showed overall patient satisfaction with minimal concerns regarding pigmentation and scar texture. Notably, an increase of 0.27 cm2 in wound surface area added one point to the DASH sport and music score (p = 0.037). Statistical analysis also demonstrated a significant correlation between functional and aesthetic assessment scores. Conclusions: The radial forearm phalloplasty donor site, evaluated by the PSAS, OSAS, and SBSES scales, leads to minimal or no functional impairment; however, the worsening of the DASH sport and music score with increasing wound surface reflects a direct relation between wound size and functional impairment.

Long-Term Outcomes of Dental Implants Placed in Fibula-free Flaps Used for Reconstruction of Maxillo-Mandibular Defects.

The use of dental implants and prostheses in the oral rehabilitation process after maxillofacial ablation procedures is now regarded as standard practice. Numerous donor sites for free vascularized bone transfer in head and neck reconstruction have been well-documented in the literature including the ribs, ilium, fibula, scapula, and radius. Among these, the fibula is the most commonly used and studied for placing endosseous implants and for rehabilitation purposes. There are benefits and drawbacks to the fibula flap. This paper aims to provide a review of the current research on the long-term success rates of implants in fibula free flaps.

Evolving role of staging CT scans during CT-angiography for DIEP flap reconstruction planning.

BACKGROUND: Preoperative planning with CT-angiography (CTA) in deep inferior epigastric perforator (DIEP) flap reconstruction is an essential preoperative tool. The aim of this study was to describe the management of the incidental findings following the introduction and further modification of a combined CTA and CT-staging preoperative protocol which includes chest, abdomen, pelvis, and musculoskeletal system. MATERIAL AND METHODS: A retrospective case series of 292 patients (Group 1) with breast cancer who underwent DIEP flap between 2015 and 2019. This was followed by a re-assessment between 2019 and 2021 of 101 patients (Group 2) following modification of the staging-CT protocol to include only those patients who received chemotherapy. Group 1 included immediate and delayed reconstruction; whereas Group 2 included only the high-risk delayed reconstruction cases. Both groups had CT staging. RESULT: Overall, 30% of Group 1, most likely those who had the delayed reconstruction, had findings which were recommended for further follow-up. This led to a change in staging of the high-risk patients only at the end of 2019 to those who underwent chemotherapy and had delayed reconstruction. Briefly, 56.4% of Group 2 demonstrated incidental findings, 42.1% of them required repeat scanning, 7% were referred to other specialties, and 47.4% did not require further action. There were no cases of occult metastatic breast cancer in either series; however, 1% were diagnosed with de novo primary cancers at non breast sites only in the first series. CONCLUSION: The screening of patients with asymptomatic breast cancer as part of CTA scanning prior to autologous reconstruction is not universally practiced and not supported by the NICE guidelines. This unit changed the practice to stop preoperative staging for low-risk patients by the end of 2019, and reserved it for the high-risk patient groups to reduce cost.

Salvage Reconstruction of Composite Defects of the Anterior Mandible, Floor of Mouth, and Lip.

Anterior mandible defects result in loss of support for the tongue, floor of the mouth and lower lip, resulting in impairment of airway, feeding, and speech. We treated four patients with these "Andy Gump" deformities. Reconstruction was performed with two free flaps: a fibula osteocutaneous flap for the anterior mandible and floor of the mouth, and a soft tissue free flap for the lip, chin, and anterior neck. The lower lip was suspended cranially with fascia or tendon grafts ± mini-temporalis turndown flaps. All flaps survived completely. All patients were tube feed-dependent before surgery; they all resumed an oral diet. All tracheostomies were decannulated. Lip competence was restored as evidenced by cessation of drooling. Speech improved from unintelligible to intelligible with frequent repetitions. Objective assessment was performed with the functional intraoral Glasgow scale; the mean FIGS score improved from 3.25 (range 3-4) to 11 (range 9-13). We conclude that composite anterior mandible and tongue defects have large tissue requirements that require multiple free flaps. Reconstruction leads to significant improvement in function.

Reevaluation of Recipient Vessel Selection in Breast Free Flap Reconstruction.

BACKGROUND: Current consensus has established the internal mammary vessels (IMV) over the thoracodorsal vessels (TDV) as the preferred recipients for microvascular breast reconstruction due to their superior flow rates and long-established outcomes. Yet, there are occurrences where the IMVs are not reliable and may subsequently prompt intraoperative decision-making. Several options exist, including the contralateral IMVs, thoracoacromial vessels, and TDVs. The appropriate sequence for vessel choice is not universally agreed upon. This study reevaluates the TDVs to highlight their viability as a second-line intraoperative alternative to the IMV and provide reference to the straightforward dissection required for harvest. METHODS: A retrospective, single-institution, breast-level analysis examining 4754 breast free flaps from 2978 patients undergoing bilateral free flap reconstruction was conducted. Postoperative complications within 180 days were evaluated, and cohorts based on anatomic anastomosis (IMV vs. TDV) were created to compare outcomes. Subanalysis was conducted based on flap laterality as well as whether a flap was planned or converted intraoperatively. RESULTS: Of 4754 breast free flaps, 4269 (89.8%) used the IMV while 485 (10.2%) used the TDV. Most complication rates between the TVD and IMV were not significantly different. Rates of flap loss were 1.0% and 1.2% for the IMV and TDV anastomosis (p = 0.59). IMV and TDV anastomosed flaps experienced similar rates of fat necrosis (6.3% vs. 6.2%, p = 0.915). However, multivariable analysis of all breasts regardless of laterality showed that skin necrosis was significantly less likely in TDV breasts (OR 0.45, 95% CI 0.29-0.71, p < 0.001). CONCLUSIONS: Given the relative similarity in cohort outcomes, TDV anastomosis can be considered a viable alternative to the IMV when the IMV is unavailable or technically disadvantageous. The TDV artery remains a robust and reliable option in the present-day plastic surgeon's repertoire for breast reconstruction.

Noninvasive visualization of the midline-crossing arterial variation in the deep inferior epigastric artery perforator flap using photoacoustic tomography for application in patients with abdominal scars.

BACKGROUND: The importance of the subcutaneous arterial network crossing the midline in transverse abdominal flaps has been reported. Photoacoustic tomography can be used to noninvasively visualize subcutaneous vascular networks. We applied this novel technology preoperatively in patients undergoing breast reconstruction to detect individual variations in the midline-crossing arteries. METHODS: Six patients scheduled to undergo breast reconstruction using free deep inferior epigastric artery perforator flaps were examined. Each scan of the 12 × 8-cm region took approximately 8 min. The accuracy of the tentative artery evaluation defined by photoacoustic tomography was compared with the arterial phase detected by intraoperative indocyanine green angiography. The number of perforator vessels used for the flap, surgical time for flap elevation, and perfusion area ratio were compared with those of the control group. RESULTS: The average match rate between tentative artery prediction by photoacoustic tomography and arterial-phase assessment by intraoperative angiography in five patients was 79.8%. Each midline-crossing artery showed individual variations. The photoacoustic tomography group (PAT-1 to 5) showed 1.8 perforators per flap, 163 min for flap elevation, and 93% perfusion area, with no significant differences from the control group (N = 5). A 63-year-old woman (PAT-6) with abdominal scars, including a midline abdominal incision, showed a preserved midline-crossing artery. The planned single perforator deep inferior epigastric perforator flap was successfully applied to the contralateral perfusion area. CONCLUSIONS: Photoacoustic tomography noninvasively visualizes the subcutaneous midline-crossing arterial networks. Understanding individual vascular variations can support preoperative planning and surgical indication of abdominal flaps, especially in patients with postsurgical scars.

The Free Flap Reconstruction of Facial Defects after Squamous Cell Carcinoma Excision.

Background and Objectives: Cutaneous squamous cell carcinoma is the second most common skin cancer. There are many methods for the reconstruction of facial subunit defects after skin cancer excision. The face is vital to a person's life and should be reconstructed considering functional and aesthetic aspects. Despite a variety of flap types and techniques, it is still challenging to meet the various demands. The aim of this study was to compare free flaps for facial reconstruction after resection of cutaneous squamous cell carcinoma. Materials and Methods: This study included 14 patients from January 2021 to June 2023. Patients who underwent facial SCC resection and subsequent reconstruction using free flaps were analyzed retrospectively. Age, sex, and localization were recorded. Follow-ups ranged from 5 to 21 months, with an average of 13 months. Results: All free flaps survived well except one case of partial flap necrosis. In most patients, good to excellent functional and aesthetic results were obtained. The donor site healed uneventfully in all patients. Conclusions: Free flap reconstruction is an excellent choice in wide skin oncologic defects. In terms of texture, it also could be a good surgical method. The use of a fraxel laser can progressively facilitate improved color matching with the surrounding skin.

The Precision of Colour Doppler Ultrasonography Combined with Dynamic Infrared Thermography in Perforator Mapping for Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

Background: Perforator mapping is a mandatory tool for the preoperative planning of a microsurgical free flap, especially in breast reconstruction. Numerous methods for mapping have been described. In this study, we investigate the combined use of Dynamic Infrared Thermography (DIRT) and Colour Doppler Ultrasonography (CDUS) only to see whether it can eliminate the need for Computed Tomography Angiography (CTA). Methods: A prospective study was conducted on 33 patients with deep inferior epigastric perforator (DIEP) flaps for breast reconstruction. DIRT, followed by CDUS and CTA, was performed preoperatively and perforators were confirmed intraoperatively. Results: From 135 hot spots found on DIRT, 123 perforators were confirmed by CDUS (91.11%). A total of 86.66% of the perforator vessels detected on CTA have their correspondent on DIRT, while 95.12% have their correspondent on CDUS. No statistically significant difference (p > 0.05) was found comparing DIRT vs. CTA and CDU vs. CTA. The average DIRT time was 121.54 s and CDUS 232.09 s. The mean sensitivity for DIRT was 95.72% and 93.16% for CDUS. Conclusion: DIRT combined with CDUS can precisely and efficiently identify suitable perforators without the need for CTA in DIEP breast reconstruction.

Efficacy of superficial femoral artery as a recipient in free flap reconstruction around the knee: Four case reports and a literature review.

Purpose: Reconstructing soft tissue defects around the knee with free flaps presents challenges in recipient vessel selection. Although the superficial femoral artery (SFA) offers exposure ease and anatomical stability, concerns arise regarding its distance from the defect site, difficulty in performing anastomosis and potential peripheral ischaemia. This study aimed to reassess the suitability of SFA as a recipient vessel for knee reconstructions by examining our cases and those from previous reports. Methods: We reviewed four cases of knee soft tissue defects reconstructed with free flaps using the SFA, detailing surgical techniques and outcomes. Additionally, a comprehensive literature search was conducted for articles on using SFA as a recipient vessel for knee free flaps, using PubMed, Web of Science and EBSCOhost databases. Results: In all four cases, latissimus dorsi (LD) flaps were used, with end-to-side anastomosis performed using a large slit-shaped arteriotomy. All flaps demonstrated successful survival without complications. Our analysis included 85 cases, comprising four of our cases and 81 cases from 16 articles. Sarcoma resection was the most common aetiology, followed by total knee prosthesis-related defects, trauma and osteomyelitis. Complete flap necrosis occurred in 5% of cases. The LD flap was the predominant choice, alongside other long-pedicle flaps. The SFA provided coverage for all knee areas except the distal lateral patellar region. Conclusion: Despite the limited evidence, the SFA appears to be a reliable recipient vessel for knee soft tissue reconstruction. Comprehensive understanding of the characteristics of the SFA and flaps used enhances the safety and efficacy of soft tissue defect reconstruction around the knee.

[Free medial sural artery perforator flap for reconstruction of hand defects]. / Freie Medial-Sural-Artery-Perforator(MSAP)-Lappenplastik zur Rekonstruktion von Weichteildefekten an der Hand.

OBJECTIVE: Defect reconstruction of the hand by means of the free medial sural artery perforator (MSAP) flap. INDICATIONS: Reconstruction of full-thickness defects on the hand with a thin non-bulky flap in cases of exposure of functional structures or in combination with simultaneous osteosynthetic procedures. CONTRAINDICATIONS: Prior surgery at the donor site or progressive peripheral artery occlusive disease. Defect size that exceeds the maximum width of the free MSAP flap for primary closure of the donor site. Lack of patient consent or compliance. SURGICAL TECHNIQUE: Suitable perforators are identified through a medial incision on the calf. The vascular pedicle is then completely followed subfascially along the gastrocnemius muscle until its source vessel the medial sural artery is reached. Subsequently, the flap design is adapted to the perforator anatomy and the flap is completely elevated. Indocyanine green fluorescence angiography can be used to identify the size of the reliable angiosome. POSTOPERATIVE MANAGEMENT: Close monitoring of the flap is required for the first 48 hours after surgery. Anticoagulation with low-molecular weight heparin should be administered for thrombosis prophylaxis. The hand can be mobilized on the first day after surgery. RESULTS: Between May 2017 and March 2022 a total of 16 free MSAP flaps were carried out for hand defect reconstruction. All donor sites were primarily closed. The reconstruction was successful in all cases. In one patient venous thrombosis occurred postoperatively, which was successfully revised. In two flaps, surgical hematoma evacuation was necessary within 24 hours after surgery. Complications or wound healing disorders at the donor site were not observed.

Preoperative Vascular Imaging in Lower Extremity Free Flap Reconstruction: Comparison Between Imaging Modalities.

BACKGROUND: Adequate vascular anatomy and perfusion status are essential for successful lower extremity free tissue transfer. Computed tomography angiography (CTA) is widely available, minimally invasive, and enables visualization of soft tissues and bones. Angiography permits temporal evaluation of flow, identifies potential needs for concurrent endovascular interventions, and enhances visibility in the setting of hardware. Despite widespread availability of these imaging modalities, no standardized algorithm for preoperative imaging prior to lower extremity free flap reconstruction exists. METHODS: Current Procedural Terminology (CPT) codes identified patients undergoing free flap reconstruction of the lower extremity over an 18-year period (2002-2020). Electronic medical records were reviewed for patient, treatment, and imaging characteristics, and pre- and post-imaging laboratory values. Outcomes included imaging findings and related complications and surgical outcomes. RESULTS: In total, 405 patients were identified, with 59% (n = 238) undergoing preoperative imaging with angiography, 10% (n = 42) with CTA, 7.2% (n = 29) with both imaging modalities, and 24% (n = 96) with neither performed. Forty percent (122 of 309) of patients who underwent preoperative imaging had less than 3-vessel runoff. Four patients developed contrast-induced nephropathy (CIN) after angiography only and one after having both CTA and angiography. Vessel runoff on CTA and angiography demonstrated moderate correlation. CONCLUSION: Most patients undergoing lower extremity free tissue transfer underwent preoperative imaging with angiography and/or CTA, 40% of which had less than 3-vessel runoff. Both angiography and CTA had low complication rates, with no statistically significant risk factors identified. Specifically, the incidence of CIN was not found to be significant using either modality. We discuss our institutional algorithm to aid in decision-making for preoperative imaging prior to lower extremity free flap reconstruction. Specifically, we recommend angiography for patients with peripheral vascular disease, internal hardware, or distal defects secondary to trauma.