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

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

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

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

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

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

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

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

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

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

Breast Shape Evaluation After Free Flap Breast Reconstruction After More Than 10 Years Follow-up Using 3-Dimensional Imaging Device.

BACKGROUND: Breast reconstruction using autologous tissue has been widely performed, and its safety and usefulness have been reported. However, there are few reports on the long-term morphological evaluation of autologous breast reconstruction cases. We evaluated long-term change of breast shape using Vectra, a 3-dimensional imaging device, for breast reconstruction cases with more than 10 years of follow-up. METHODS: The subjects had undergone autologous tissue breast reconstruction between 2007 and 2009. Sixteen deep inferior epigastric perforator flap cases were included in this study. For each patient, 4 items were measured as indicators: breast width, distance from the sternal notch to the nipple, distance from the nipple to the inframammary fold, and breast volume. The ratio of reconstructed breast to healthy breast was calculated for these 4 items. RESULTS: The long-term average ratio of breast width was 0.99, that of distance from the sternal notch to the nipple was 0.98, that of distance from the nipple to the inframammary fold was 0.94, and that of breast volume was 1.13. We evaluated the influence of body mass index and age at the time of the primary reconstructive surgery, but there was no significant difference in 2 body mass index groups (obese and nonobese groups) and 2 age groups (less than and more than 50 years old). CONCLUSION: We assumed that the balance between the reconstructed breast and the contralateral native breast would become worse over time because of breast sagging and changes in breast elasticity. According to our study, the shape balance of left and right breasts was maintained over time. Limitation of this study is the fact that more than half of the cases included in this study had undergone small to moderate revision surgery during the course of follow-up.

Novel Classification of the Branching Patterns of the Superficial Branch and the Deep Branch of the Superficial Circumflex Iliac Artery and the Superficial Inferior Epigastric Artery on Computed Tomographic Angiography.

BACKGROUND: Recent advances in the superficial circumflex iliac artery (SCIA) perforator flap transfer emphasized the necessity to comprehensively understand the lower abdominal vasculature. This study aimed to clarify the relationship among the superficial inferior epigastric artery (SIEA), the superficial branch (SCIAs), and the deep branch (SCIAd) of the SCIA. METHODS: Computed tomographic angiography was retrospectively reviewed in 312 hemiabdomens in 161 female patients who underwent abdominal flap breast reconstruction. We assessed the presence, caliber, and branching patterns of the SCIA branches and the SIEA. RESULTS: The SIEA-SCIA common trunk was present in 40.1% of the hemiabdomen and was identified in either side of the abdomen in 63.6% of patients. At least one superficial vessel larger than 1.5 mm was found in 61.5% of hemiabdomens. Seven branching patterns of the SCIA-SIEA system were noted: (1) the SCIA and the SIEA originated together (17.0%); (2) the SIEA and the SCIAs shared an origin (22.8%), (3) the SCIA and the SIEA branched separately (17.0%), (4) each artery originated separately (8.0%); (5) the SCIAs and the SCIAd emerged together with the SIEA absent (17.3%); (6) the SCIAs and the SCIAd originated separately with the SIEA absent (13.1%); (7) the SIEA and SCIAd originated separately with the SCIAs absent (3.5%). CONCLUSION: SCIA-SIEA branching patterns were classified into seven distinctive patterns. This novel classification may help surgeons to choose the optimal pedicle when using the hemi-abdomen region as the donor site.

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

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

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

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

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

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

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

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

Thoracoacromial artery and vein as main recipient vessels in deep inferior epigastric artery perforator (DIEP) flap transfer for breast reconstruction.

BACKGROUND: The internal mammary artery/vein (IMA/V) are commonly used recipients for free flap breast reconstruction, but requires costal cartilage resection and limits future use of the IMA. This study aimed to evaluate the feasibility of the thoracoacromial artery/vein (TAA/V) as recipients for deep inferior epigastric artery perforator (DIEP) flap breast reconstruction compared with using the IMA/V. METHODS: Medical charts of patients who underwent free DIEP flap breast reconstruction using the TAA/V or the IMA/V as recipient vessels were reviewed. Patient and vessel characteristics, time for vessel preparation and anastomosis, and postoperative pain were compared between TAA/V and IMA/V groups. RESULTS: Thirty-four patients were included; 12 in TAA/V group, and 22 in IMA/V group. There was no flap failure in both groups. There were statistically significant differences between TAA/V and IMA/V groups in vessel preparation time (10.9 ± 3.7 min vs. 24.1 ± 6.0 min, p < .001), anastomosis time (31.2 ± 12.1 min vs. 42.1 ± 11.2 min, p = .017), and total dose of acetaminophen (4566.7 ± 1015.6 mg vs. 5436.4 ± 1323.3 mg, p = .041). CONCLUSIONS: The TAA/V could be safely used as recipient vessels for DIEP flap breast reconstruction with shorter time and less postoperative pain.

Use of the superficial circumflex iliac artery perforator flap for reconstruction after sarcoma resection.

BACKGROUND: Postoperative complications after flap-coverage in sarcoma treatment can postpone postoperative adjunct treatments. Here, we present our experience with the use of the superficial circumflex iliac artery perforator (SCIP) flap after sarcoma resection. PATIENTS AND METHODS: Patients undergoing immediate reconstruction surgery with a flap after sarcoma resection at a single institution from February 2017 to April 2020 were identified. Patient demographics, tumor characteristics, surgical characteristics, and complications were examined. RESULTS: Thirty-five consecutive patients underwent reconstructions using a SCIP flap (34 free and one pedicled SCIP flaps). We also identified 47 consecutive patients who underwent reconstruction with other pedicled or free flaps over the same time period. No significant differences were found in patient age, gender, defect size, or operative time between these two groups. The incidences of overall complications (20/47 [42.6%] vs. 3/35 [8.5%], p < .001), flap dehiscence (7/47 [14.8%] vs. 0/35 [0%], p = .018), and total flap complications (15/47 [31.9%] vs. 2/35 [5.7%], p = .005) were statistically greater in the control group than in the SCIP group. CONCLUSION: With its minimal postoperative complication rate both in the reconstruction site and the donor site, the SCIP flap can be considered an optimal reconstruction option after sarcoma resection.

Pedicled anterolateral thigh flap transfer for the reconstruction of a large gluteal defect assisted by preoperative computed tomographic angiography and intraoperative indocyanine green angiography: A case report.

The efficacy of the use of the pedicled ALT flap for buttock defects has not been established in the literature. Here, we present a case of a successful reconstruction of a large gluteal defect after sarcoma resection using a pedicled ALT flap assisted by preoperative computed tomographic angiography (CTA) and intraoperative indocyanine green (ICG) angiography. A 94-year-old man underwent resection of a large soft tissue tumor in the gluteal region resulting in a 19 × 15 cm defect. Based on three-dimensional reconstructed images of the preoperative CTA, the length of the pedicle of an ALT flap was estimated. Perfusion of the whole flap was confirmed using intraoperative ICG angiography. The flap was inserted through a subcutaneous tunnel and covered the defect completely. The postoperative course was uneventful. The patient resumed ambulation 1 week after the operation. The follow-up at 2 months showed complete flap survival, and the patient was able to walk with a cane. The pedicled ALT flap transfer may be a reliable alternative for gluteal reconstruction when guided by pre- and intraoperative imaging modalities.

Application of intraoperative indocyanine green angiography for detecting flap congestion in the use of free deep inferior epigastric perforator flaps for breast reconstruction.

BACKGROUND: The use of intraoperative indocyanine green (ICG) angiography has been well documented for confirmation of arterial perfusion in transferred free flaps. However, no previous report has yet focused on whether ICG angiography can be used to detect congestion in free flaps. The present report investigates the feasibility of ICG angiography for detecting flap congestion intraoperatively through illustrative cases. METHODS: From September 2019 to September 2020, 65 consecutive female patients who underwent breast reconstructions using a free deep inferior epigastric perforator (DIEP) flap were enrolled in this study. Forty-eight patients with 52 DIEP flaps were eligible for the study after application of the exclusion criteria. ICG angiography was performed after elevation of the flap, after completion of the anastomoses, and after inset of the flap. RESULTS: In five cases (9.6%), an inadequate highlight was demonstrated with ICG angiography performed after flap elevation. All such cases were deemed congestive since robust bleeding was observed with the prick test. ICG angiography demonstrated sufficient highlight of the flap after removal of the clamp on the superficial inferior epigastric vein. In two cases (4.2%), kinking of the pedicle vein of the DIEP flap was found with ICG angiography performed after inset of the flap. In both cases, the pedicle and the flap were reinset. All flaps survived completely postoperatively. CONCLUSION: ICG angiography can detect flap congestion, and the proposed 3-step protocol is useful for the prevention of postoperative complications.

Use of a combined SIEA and SCIP based double pedicled abdominal flap for breast reconstruction.

BACKGROUND: Recently, the deep inferior epigastric perforator (DIEP) flap has become the gold standard for breast reconstruction, but it has some drawbacks such as abdominal bulging and hernia. To overcome these disadvantages, the superficial inferior epigastric artery perforator (SIEA) flap is used as an alternative option, but it has another problem, namely limited vascular territory and risk of vascular thrombosis. To solve these problems, we introduced our new technique, a combined SIEA and superficial circumflex iliac artery perforator (SCIP) based double pedicled abdominal flap. In this report, we present our experience of using this technique. METHODS: The SIEA and SCIP based double pedicled abdominal flap was used in five patients who wanted to have unilateral breast reconstruction after a mastectomy due to breast cancer. The average age was 48.2 (range 38-56) years, and the average BMI was 24.4 (range 19.2-31.4). The SIEA and SCIP based double pedicled abdominal flap was designed as a modified DIEP flap, and all flaps were placed in the vertical setting. The flap pedicles had two different vascular supplies, SIEA and SCIA, and the drainage systems, SIEV and SCIV, anastomosed to the internal mammary artery and vein in all cases. RESULTS: The harvested SIEA and SCIP based double pedicled abdominal flaps were a median volume of 925 g (range 452-1570 g) and average size of 491 cm2 (range 440-611 cm2 ). The average reconstructive time was 7:41 (range 6:31-9:17). In four out of the five cases, the SIEA and SCIA joined together to make a common pedicle artery trunk, and its average size was 1.08 mm. Four out of the five cases had a wide vascular territory crossing the abdominal midline as shown by ICG angiography. One case showed ICG fluorescence for the hemi-side of the abdominal flap. Postoperative course was uneventful, and there were no major perioperative complications, which need extra surgical procedures. Follow-up period averaged 273 days (range 194-312 days). CONCLUSION: The SIEA and SCIP based double pedicled abdominal flap showed viable flap territory across the midline in all cases. The SIEA and SCIP based double pedicled abdominal flap might be another ideal option for breast reconstruction, when appropriate SIEA and SCIA pedicles are identified, and an adequate ICG fluorescence is obtained for the size of flap needed.

Free tensor fascia lata true-perforator flap transfer for reconstruction of the calcaneal soft tissue defect complicated with osteomyelitis in a patient with alcohol-induced Charcot foot: A case report and literature review.

Charcot foot is can result in bone deformities and soft tissue defects. We report a case of alcohol-induced Charcot (AIC) foot with soft tissue defect including the weight-bearing zone of the heel and osteomyelitis, which was successfully reconstructed with free tensor fascia lata true-perforator flap (TFLtp). A 56-year-old male suffered from AIC foot with an 18 × 6 cm defect. Based on the preoperative ultrasound, we identified the overlying upper thigh area offering one of the thickest dermis. A TFLtp flap was raised sparing the TFL muscle based on one perforator without including the main trunk of the transverse/ascending branch of the lateral femoral circumflex vessel. The TFLtp flap was transferred to the heel and anastomosed to the posterior tibial artery in an end-to-side fashion. The patient complained no postoperative discomfort of the donor site and was able to walk on his foot after 5 weeks. This case report highlights that the TFLtp flap may offer thick dermis, faster surgery due to perforator level dissection and a concealed donor site.

Use of Preoperative High-Resolution Ultrasound System to Facilitate Elevation of the Superficial Circumflex Iliac Artery Perforator Flap.

BACKGROUND: During elevation of the superficial circumflex iliac artery (SCIA) perforator (SCIP) flaps, the flap pedicle must often be converted from the superficial branch to the deep branch of the SCIA, complicating and prolonging the procedure. The goal of the present study was to demonstrate the effectiveness of high-resolution ultrasonography to decrease the conversion rate on which no previous report has focused, by making a comparison with a conventional method. METHODS: Forty-five consecutive cases where free SCIP flap transfer was performed for reconstruction were retrospectively reviewed. To preoperatively mark the course of the superficial branch, handheld Doppler ultrasonography was used in 27 cases (group 1) and a high-resolution ultrasound system in 18 cases (group 2). RESULTS: The conversion rate was significantly greater in group 1 than in group 2 (10/27 [37%] vs. 0/18 [0%], p = 0.003]. The frequency of use of multiple venous anastomoses was significantly higher in group 1 than in group 2 (21/27 [78%] vs. 2/18 [11%], p < 0.001). The operative time was significantly longer in group 1 than in group 2 (p = 0.038). There were no significant differences in postoperative complication rates (1/27 [4%] versus 0/18 [0%], p = 1.0). CONCLUSION: The use of a preoperative high-resolution ultrasound system significantly decreased the rate from of intraoperative conversion from the superficial branch to the deep branch of the SCIA. It also resulted in significantly fewer venous anastomoses and a shorter operative time, while maintaining a low incidence of postoperative complications.

Combination of Dual Wavelength Picosecond and Nanosecond Pulse Width Neodymium-Doped Yttrium-Aluminum-Garnet Lasers for Tattoo Removal.

BACKGROUND AND OBJECTIVES: Tattoo removal by laser has been mostly performed using Q-switched laser, which has nanosecond pulse width. In recent years, the efficacy of treatment with picosecond pulse width laser has also been reported. STUDY DESIGN/MATERIALS AND METHODS: Using a picosecond-domain, neodymium-doped yttrium-aluminum-garnet laser with a potassium-titanyl-phosphate frequency-doubling crystal, we performed a retrospective clinical study with combination treatment using pulse widths of 750 ps and 2 ns. The number of treatments was compared with the Kirby-Desai score. Tissue changes immediately after laser irradiation at 2 ns and 750 ps were compared using an electron microscope. RESULTS: The combination treatment using pulse widths of 2 ns and 750 ps was safe and more effective than the Q-switched neodymium-doped yttrium-aluminum-garnet laser treatment. Tattoo removal was possible with significantly fewer treatment numbers than the Kirby-Desai score, without adverse events. The results from the scanning electron microscope revealed that ink particles irradiated by 750 ps were more dispersed than those by 2 ns. CONCLUSIONS: The combination treatment with pulse widths of 2 ns and 750 ps and 1064 nm and 532 nm wavelengths using the neodymium-doped yttrium-aluminum-garnet laser was safe and effective and can be a useful option for tattoo removal. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

The correlation of the perforators and the accessory saphenous vein in a profunda femoris artery perforator flap for additional venous anastomosis: A cadaveric study and clinical application.

BACKGROUND: The profunda femoris artery perforator (PAP) flap is gaining popularity in microsurgical reconstruction. To establish a safer flap elevation technique, we focused on the topology of the accessory saphenous vein in the medial thigh area. We hypothesize that including the accessory saphenous vein in a PAP flap results in safer PAP flap transfer with two venous drainage systems. The aim of this study was to describe the anatomical relationship between the perforators and the accessory saphenous vein in the PAP flap using fresh cadavers and to describe the relationship through two clinical cases. METHODS: For the anatomical study, 19 posterior medial thigh regions from 10 fresh cadavers were dissected. We recorded the number, site of origin, the length, and the diameter of the pedicle. We also documented the course, the length, and the diameter of the accessory saphenous vein. PAP flap transfer with additional accessory saphenous vein anastomosis was performed in two clinical cases; a 40-year-old female with tongue cancer and a 51-year-old female with breast cancer. RESULTS: In all cadaveric specimens, the accessory saphenous vein was found above the deep fascia. The average distance between the proximal thigh crease and the intersection of the anterior edge of the gracilis muscle and the accessory saphenous vein was 7.7 ± 2.5 cm. The diameter of the accessory saphenous vein averaged 3.1 ± 1.1 mm. The average accessory saphenous vein length from its takeoff from the great saphenous vein to the anterior edge of the gracilis muscle was 4.2 ± 1.3 cm. In clinical cases, the flap size was 6 x 18 cm and 8 x 21 cm and the follow-up length was 12 and 3 months, respectively. In both cases, the postoperative course was uneventful and the flap survived completely. CONCLUSION: Anatomical study confirmed that the accessory saphenous vein did exist in all specimens and it could be included in the PAP flap with sufficient length and relatively large diameter. Although further clinical investigation will be required to confirm its efficacy, a PAP flap including the accessory saphenous vein may decrease the chances of flap congestion.