Shifting toward total drainless approach in DIEP flap-based breast reconstruction: Evaluation of safety.

With increasing interest in swift postoperative recovery, there has been a trend toward omitting drains in deep inferior epigastric perforator (DIEP) flap-based breast reconstruction, ideally aiming to avoid drains in the breasts and abdomen. This study evaluated our transition toward total drainless reconstruction, focusing specifically on the safety of omitting drains in the breasts. Patients who underwent breast reconstruction with DIEP flap from 2018 to 2023 were reviewed. They were divided into 3 groups: group A (with drains in the abdomen and breast), group B (drains only in the breast), and group C (total drainless). For group C, routine ultrasound examinations were performed to check for fluid accumulation. Complication profiles were compared among the groups. In total, 294 cases were included, comprising 77 in group A, 112 in group B, and 105 in group C. Chronologically, a gradual increase in the proportion of cases in group C was observed, with the complication rates remaining stable. On comparing the complication profiles of the recipient and donor sites among the 3 groups, no significant differences were found. Breast seroma, persisting 1 month postoperatively, was exclusively detected in 6 (5.7%) cases within group C, all of whom were treated with outpatient clinic-based aspiration. When restricting the analysis to group C, a greater weight of mastectomy specimen and axillary lymph node dissections exhibited an independent association with breast seroma development. Smooth transition to total drainless DIEP breast reconstruction appears safe, without significantly increasing the risks of complication.

Reliability and Safety of Super-Thin ALT Flap: A Comprehensive Evaluation of Perfusion-Related Complications and Donor Morbidity.

BACKGROUND: With an increasing need for thin flap, the use of super-thin anterolateral thigh (ALT) flaps, raised above the supra-superficial fascia, has drawn great attention. Controversy remains regarding whether such thin flap elevation could affect postoperative outcomes, encompassing perfusion-related complications (PRC) and donor morbidities. This study aimed to evaluate the outcomes of super-thin ALT flap-based reconstruction compared with those of suprafascially elevated flaps. METHOD: Patients who underwent free ALT flap-based reconstruction between March 2017 and June 2023 were reviewed, and categorized into two groups based on flap elevation plane; super-thin, and suprafascial. Development of PRC and donor morbidities including paresthesia, were compared. Independent associations of the elevation plane with complication profiles were evaluated. Further analyses were conducted using propensity-score matching. RESULTS: In total, 208 cases were analyzed: 80 super-thin and 128 suprafascial ALT flaps. Nineteen cases (9.1%) experienced PRC, including four total and 14 partial necrosis. The incidence of overall and each type of PRC did not differ based on flap elevation plane even after adjusting for other variables. The super-thin group exhibited significantly lower donor complications compared to the others, upheld in multivariable analyses. Elevating the flaps with a super-thin fashion allowed for a higher rate of preservation of the lateral femoral cutaneous nerve, resulting in a significantly lower rate of postoperative paresthesia. Similar associations were observed in the propensity-score matching analysis. CONCLUSIONS: Super-thin ALT flap elevation might not appear to increase PRC risk, while reduces donor complications, compared to suprafascial elevation.

Association of Neoadjuvant Chemotherapy With Postoperative Outcomes in Immediate Prepectoral Prosthetic Breast Reconstruction.

PURPOSE: Neoadjuvant chemotherapy (NACT) followed by total mastectomy and immediate reconstruction has become an important strategy in the treatment of breast cancer. Although the safety of subpectoral implant-based breast reconstruction with NACT has been extensively evaluated, the safety in prepectoral reconstruction has not been clearly elucidated. We aimed to evaluate the association of NACT with immediate prepectoral breast reconstruction outcomes. METHODS: A retrospective review of patients who underwent total mastectomy and immediate implant-based prepectoral breast reconstruction between May and December 2021 was conducted. Patients were categorized into 2 groups: those receiving NACT and those not receiving it. Postoperative complication rates were compared between the 2 groups. The independent association between NACT and the complication profiles was evaluated. Propensity score matching was also conducted. RESULTS: We analyzed 343 cases, including 85 who received NACT treatment and 258 who did not. Compared with the non-NACT group, the NACT group was younger, had a higher body mass index, and a higher rate of adjuvant radiotherapy. There were no differences in the rates of overall complications or type of complication between the 2 groups. In the multivariable logistic analyses, NACT did not show a significant association with the development of adverse outcomes. Similar results were observed in propensity score matching analyses. CONCLUSIONS: Our results suggest that receiving NACT may not have a significant detrimental effect on the postoperative outcomes of immediate prepectoral prosthetic reconstructions. Conducting prepectoral implant-based reconstruction in the setting of NACT might be safe and provide acceptable outcomes.

Thin Free Perforator Flap as a Viable Option for Forefoot Reconstruction: Comprehensive Evaluation of Outcomes.

BACKGROUND: Reconstruction of forefoot defects often necessitates free tissue transfer due to the limited availability of local tissue. Microsurgical reconstruction of the forefoot remains challenging as it requires durable yet thin, soft tissue coverage for functional restoration. This study aimed to evaluate the efficacy of free thin perforator flaps for forefoot reconstruction, with a focus on functional outcomes. METHODS: Patients who underwent microsurgical forefoot reconstruction between March 2020 and September 2023 were reviewed. Development of postoperative complications and functional outcomes were evaluated. RESULTS: In total 53 patients were analyzed, with a mean age of 62.7 years. The most common etiology of defects was oncologic surgery, followed by chronic wound, with a majority involving the plantar side. Super-thin anterolateral thigh flap and superficial circumflex iliac artery perforator flap were predominantly used. The median thickness of the flap was 4.0 mm. Digital vessels were the most frequently used as recipients. All but one flap survived, resulting in a success rate of 98.1 percent. Postoperative flap-site complications developed in 20 patients, the majority of which were resolved with conservative treatment. The median hospital stay was 8.0 days, and the mean time for initiating weight-bearing ambulation was 12.4 days. In postoperative foot function index questionnaire survey, the overall score remained 9.41, showing minimal impairment, and did not differ according to defect size and locations. Secondary debulking operation was necessitated in seven patients. CONCLUSION: Use of thin free perforator flaps might provide reliable outcomes with rapid recovery and excellent postoperative function in the forefoot reconstruction.

Microsurgical reconstruction using thoracoacromial vessels as recipients for complicated chest wall defects.

BACKGROUND: Free tissue transfer is often required for the reconstruction of complex and deep anterior chest wall wounds, for which the identification of suitable recipient vessels is crucial. Although the internal mammary arteries (IMAs) are a representative option, identifying secondary options when these vessels are compromised remains a challenge. This report evaluated the efficacy of using the thoracoacromial vessels (TAVs) as recipients for chest wall reconstruction by reviewing our experience. METHODS: We conducted a retrospective review of patients undergoing free-flap-based chest wall reconstruction using TAVs as recipient vessels from February 2020 to March 2023. Patient demographics and surgery-related characteristics data were collected. The primary outcome of interest was the occurrence of flap perfusion-related complications. RESULTS: In total, 12 cases utilized TAVs as recipients, primarily for defects following sternotomy, where bilateral IMA was unavailable due to prior surgery. The TAVs with reliable perfusion were consistently identified beneath the pectoralis major muscle. The anterolateral thigh flap was predominantly employed, with musculocutaneous or chimeric flaps introduced for bony defects. The mean pedicle length of the harvested flap was 7.2 cm (range, 3-13), and in cases with a vascular gap, the pedicle was extended using an arteriovenous interposition graft. This resulted in a mean pedicle length needed to reach recipient vessels of 9.9 cm (range, 6.5-19). All flaps survived, with only one experiencing partial necrosis. CONCLUSIONS: The TAV could be considered as an attractive alternative recipient vessel in microsurgical reconstruction of complicated chest wall defects when the use of IMA is not feasible.

High-frequency ultrasound-assisted perforator mapping enhances efficiency in microsurgical reconstruction using thin ALT and SCIP flaps.

BACKGROUND: With the growing demand for the use of thin perforator flaps, obtaining knowledge on the superficial anatomy of perforators is imperative for stable flap elevation. Conventional modalities for perforator mapping fall short in providing such information. High-frequency ultrasound (HFUS), known for visualizing the superficially located anatomic structures, may potentially fill this void. This study aimed to evaluate the effectiveness of HFUS in the outcome of anterolateral thigh (ALT) and superficial circumflex iliac artery perforator (SCIP) flap-based reconstructions. METHODS: Consecutive patients who underwent free ALT or SCIP flap-based reconstruction from January 2021 to November 2022 were retrospectively reviewed. Perforator mapping was conducted using a handheld Doppler during the first year, while HFUS was used in the latter part. The two techniques were compared in terms of flap harvesting time and perfusion-related complication rates while considering the flap elevation plane. RESULTS: In total, 123 cases were analyzed, including 82 ALT flaps (41 in each group) and 41 SCIP flaps (16 in the Doppler and 25 in the HFUS group). The time required for flap elevation exhibited a tendency to decrease in the HFUS group, with a significant difference observed in cases involving thin flap elevation (super-thin ALT flaps and pure-skin-perforator SCIP flaps). Compared with the Doppler group, the HFUS group demonstrated significantly lower rates of PRCs, particularly partial flap necrosis. This difference remained significant in multivariable analyses. CONCLUSION: Our results suggest that HFUS might be an appealing modality for perforator mapping in cases requiring thin ALT and SCIP flap.

Efficacy of the enhanced recovery after surgery protocol on reducing surgical disparities related to overweight/obesity in deep inferior epigastric perforator flap breast reconstruction.

BACKGROUND: When choosing a method of deep inferior epigastric perforator (DIEP) flap for breast reconstruction, concerns regarding the potentially detrimental effects of obesity on postoperative recovery remain. Enhanced recovery after surgery (ERAS) is known to facilitate rapid postoperative recovery. This study aimed to examine the effect of the ERAS protocol on the disparity between normal/underweight and overweight/obese patients after DIEP flap breast reconstruction. METHODS: A retrospective review of consecutive patients who underwent DIEP flap breast reconstruction between January 2015 and November 2022 was conducted. The patients were categorized into two groups: pre-ERAS and post-ERAS. In each group, associations between overweight/obese patients (BMI ≥25 kg/m2 ) and postoperative course were evaluated. RESULTS: In total, 217 patients in the pre-ERAS group (including 71 overweight/obese) and 165 in the post-ERAS group (including 58 overweight/obese) were analyzed. The post-ERAS group had shorter length of stay (LOS) (8.0 versus 7.0 days, p-value <.001) and lower postoperative pain scores (5.0 versus 3.0 at postoperative day (POD) 1, p-value <.001) than the pre-ERAS group. The complication profiles did not differ according to ERAS adoption. In the pre-ERAS group, overweight/obese patients showed a significantly longer LOS (8.0 versus 9.0 days, p-value = .017) and a higher postoperative pain score (3.0 versus 4.0 at POD 2, p-value = .018) than normal/underweight patients; however, these differences disappeared in the post-ERAS group, showing similar LOS, pain scores, and analgesic consumption. CONCLUSIONS: Implementation of the ERAS protocol in DIEP free-flap breast reconstruction may reduce overweight/obesity-related disparities in postoperative recovery.

Identification of optimal flap types for color matching in free flap-based facial reconstruction in Asian population.

Large soft tissue defects of the face often require free flap-based reconstruction. To avoid a conspicuous patch-like appearance, choosing flaps with a color similar to that of the adjacent facial skin is crucial. This study aimed to identify the flap types that show the best color match via objective color evaluation. Patients who underwent free flap-based facial reconstruction between 2013 and 2023 were retrospectively reviewed. Based on standardized photographs, average color samples of the flap skin paddle and adjacent skin were obtained. The color differences were compared by flap type at two different time points, early (within 1-3 months, post-operative) and late (after 1 year, post-operative), using the delta E value. Fifty-eight free flaps were analyzed, including 22 thoracodorsal artery perforator (TDAP) flaps, 17 anterolateral thigh (ALT) flaps, nine superficial circumflex iliac artery perforator (SCIP) flaps, and eight radial forearm (RF) flaps. In the analysis of early outcomes, the RF flaps showed the least color difference, followed by the SCIP and TDAP flaps, and the ALT flaps showed the greatest difference, with the differences being significant. Most cases showed generally improved color matching over time. Time-dependent changes were significant in the ALT and TDAP flap groups. In the analysis of late outcomes, all flap types showed delta E values less than 10, with the RF flaps showing the least color difference, followed by the SCIP flap. The four workhorse flaps provided acceptable outcomes with long-term improvements. The RF flaps provided the best color matching in the long run.

Predictors, management and prognosis of initial hyperemia of free flap.

In free flap operation, temporary hyperemia of the transferred flaps can often be encountered in the early postoperative period, appearing reddish and rapid capillary refilling time, which mimics venous congestion. This study aimed to investigate the factors associated with the development of hyperemia and evaluate clinical course. Consecutive patients who underwent free flap-based reconstruction between December 2019 and October 2021 were reviewed. Independent risk factors associated with its development were assessed. Flap showing initial hyperemic features were assessed using flap blood glucose measurement (BGM). If it showed over 60 mg/dL, they were closely observed without management. Their clinical outcomes were evaluated. In total, 204 cases were analyzed, of which 35 (17.2%) showed initial hyperemia. Multivariable analyses showed that using thoracodorsal artery perforator flaps and muscle containing flaps (musculocutaneous/muscle-chimeric flaps) and conducting end-to-end arterial anastomosis (vs. end-to-side) were independent predictors. All cases with initial hyperemia showed over 60 mg/dL in BGM. The phenomenon resolved spontaneously within 6.9 h averagely. Overall perfusion-related complications developed in 10 (4.9%) cases, which rate did not differ between the two groups. Several factors might be associated with the development of initial hyperemia after free flap surgery. With proper assessment, this condition can be successfully managed without unnecessary intervention.

The early postoperative effects of rinsing the breast pocket with tranexamic acid in prepectoral prosthetic breast reconstruction.

BACKGROUND: The efficacy of tranexamic acid (TXA) has been reported in breast surgery; however, its application and duration have varied across studies. This study aimed to assess the early postoperative outcomes of rinsing the breast pocket with TXA during prepectoral prosthetic breast reconstruction using an acellular dermal matrix (ADM). METHODS: A retrospective chart review was conducted in consecutive patients who underwent immediate prosthetic prepectoral reconstruction between August 2021 and December 2022. For cases performed during the earlier part of the study period (up to April 2022), TXA was not administered (non-TXA group), whereas those performed after April 2022 received topical TXA application during surgery (TXA group). Postoperative outcomes including hematoma, seroma, drainage volume, and drain maintenance duration were compared between the two groups using propensity score matching (PSM). RESULTS: A total of 674 breasts were analyzed; 280 in the TXA group and 394 were in the non-TXA group. There were 251 breasts in each group after PSM, and their characteristics were similar. The incidence of hematoma in the first 24 hours and total drain output were significantly lower in the TXA group than the non-TXA group. In cases of direct-to-implant cases, the TXA group showed a significantly lower seroma rate. CONCLUSIONS: Rinsing the breast pocket with TXA can potentially reduce the occurrence of hematoma and decrease drain output in prepectoral ADM-assisted prosthetic breast reconstruction. Moreover, this approach may be beneficial in lowering the incidence of seroma in direct-to-implant reconstruction.

Oncologic Outcomes of Immediate Breast Reconstruction in the Setting of Neoadjuvant Chemotherapy: A Long-term Follow-up Study of a Matched Cohort.

PURPOSE: Despite the increasing use of immediate breast reconstruction (IBR), its oncologic safety in the setting of neoadjuvant chemotherapy (NACT) needs to be comprehensively clarified in breast cancer management. The objective of the present study was to analyze the oncologic safety of IBR following NACT. METHODS: In total, 587 patients with breast cancer who underwent a total mastectomy (TM) with IBR after NACT between 2008 and 2017 at a single institution were retrospectively reviewed. The reviewed patients with IBR following skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM) were matched 1:3 to patients who underwent TM alone after NACT. Matching variables included age, clinical T and N stages before NACT, response to NACT, pathologic T and N stages, and molecular subtypes. RESULTS: After propensity score matching, 95 patients who underwent IBR following SSM/NSM after NACT (IBR group) and 228 patients who underwent TM alone after NACT (TM group) were selected. The median follow-up period was 73 (range, 5-181) months after matching. After matching, there were no significant differences between the two groups in 5-year locoregional recurrence-free survival (88.8% vs. 91.2%, p = 0.516), disease-free survival (67.3% vs. 76.6%, p = 0.099), distant metastasis-free survival (71.9% vs. 81.9%, p = 0.057), or overall survival (84.1% vs. 91.5, p = 0.061) rates. In multivariate analyses, conducting IBR was not associated with increased risks for locoregional recurrence, any recurrence, distant metastasis, or overall death. CONCLUSION: Our findings suggest that IBR following SSM/NSM elicits comparable long-term oncologic outcomes to those of TM alone in the setting of NACT.

Latissimus dorsi myocutaneous free flap for post-sacrectomy reconstruction: Outcomes compared with gluteal muscle flap.

BACKGROUND: Excision of sacral tumor results in extensive defects and vital organ exposure, requiring soft tissue reconstruction for dead space obliteration. Diverse reconstruction options, mainly regional flaps, have been utilized but are limited by high postoperative morbidity. A reliable reconstructive method with low morbidity and facilitated recovery has yet been sought for. In this study, we aimed to evaluate the use of free latissimus dorsi (LD) flap for post-sacrectomy defect reconstruction by comparing its outcomes with local gluteus maximus (GM) flap. METHODS: A retrospective review was conducted of all patients with sacral malignancy who underwent partial or total sacrectomy and immediate reconstruction with LD or GM flap between 2013 and 2022. Nineteen patients were analyzed, including 10 GM flaps and nine LD flaps. Postoperative outcomes were compared between the two groups. RESULTS: The average size of LD flaps was 173.8 cm2 . Seven patients developed complication in the GM group and two patients in the LD group. Complication rate at sacrectomy site was lower in the LD group (p = .003) showing complication-free sacrectomy site and two donor site seromas. The LD group resulted in shorter hospital stay (p = .033) and earlier ambulation than the GM group (p = .001). Mean follow-up period was 63 months for GM group and 17 months for LD group. Three patients in the GM group underwent re-operation, while no delayed complication was observed in the LD group. CONCLUSION: Free LD flaps may provide reliable outcomes with early recovery and may be considered an effective option for sacrectomy defect reconstruction.

Reconstruction of circumferential fingertip defect using free superficial palmar branch of the radial artery flap: Report of two cases.

Wide local excision of noninvasive malignant melanomas has been increasingly performed instead of digit amputation, which often results in extensive fingertip defects. Owing to the unique anatomical characteristics of the fingertips, achieving favorable outcomes in both function and cosmesis is challenging during reconstruction. The free superficial palmar branch of the radial artery (SPBRA) flap is advantageous for finger reconstruction. However, its application in circumferential fingertip defects has rarely been reported. In this report, we describe two cases of circumferential fingertip defect reconstruction using a free SPBRA flap after wide local excision of subungual melanoma. The patients were women aged 74 and 63 years at the time of surgery. They presented with subungual melanoma on the right fourth finger and left thumb, in which both biopsies confirmed malignant melanoma in situ (Tis N0 M0), Breslow thickness of 0 mm (noninvasive). After wide local excision, circumferential defects, sized 2.5 × 6 and 2.7 × 7 cm, were formed on their fingertips. A vertically designed free SPBRA flap measuring 2.7 × 6 and 3 × 6 cm was elevated from the unaffected palm in each patient. After performing microvascular anastomosis, the flap was inserted transversely, wrapping the exposed phalangeal bone in a conical shape. The donor site was primarily closed. All flaps survived, and postoperative complications did not develop. Neither local recurrence nor distant metastasis was detected at the latest follow-up in either patient at 24 or 28 months postoperatively. The patients were satisfied with the natural contour of the reconstructed fingertip and recovered functions. In the evaluation of subjective sensory recovery using four scales (excellent, good, fair, and poor), they responded "fair" and "good," respectively. We suggest that the free SPBRA flap could be a reliable reconstructive method for circumferential fingertip defects.

Impact of Initial Filling Medium on Outcomes of Subpectoral, Two-Stage, Implant-Based Breast Reconstruction: Air versus Saline.

BACKGROUND: In two-stage expander-based breast reconstruction, the use of air as the initial filling medium has been suggested to confer clinical advantages over conventional saline, but this has not been demonstrated in a large series. This study aimed to evaluate the association between material type (air versus saline) for initial expander filling and postoperative outcomes. METHODS: This retrospective study included patients who underwent immediate, subpectoral, tissue expander-based breast reconstruction between January of 2018 and March of 2021. The participants were categorized into two groups according to the material used for initial filling: saline-inflated expanders, which were used during the first 22 months consecutively, and air-inflated expanders, which were used during the latter 17 months consecutively. Complications including mastectomy flap necrosis and postoperative expansion profiles were compared. Multivariable analyses were performed to identify independent predictors of postoperative complications. RESULTS: A total of 443 breasts (400 patients), including 161 air-filled and 282 saline-filled breasts, were analyzed. The two groups had similar baseline characteristics. The air-filled group showed a significantly lower rate of mastectomy flap necrosis; this difference remained significant after adjustment for other variables in the multivariable analysis. The rates of other complications did not differ between the two groups. The air-filled group had fewer office visits and a shorter period to complete expansion. CONCLUSIONS: The use of air for initial expander filling could provide safe and reliable outcomes with reduced patient discomfort during postoperative expansion; thus, air-filled expanders might be an effective alternative to saline-filled expanders. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Usefulness of Free Tissue Transfer for the Reconstruction of Extensive Thigh Defects.

BACKGROUND: Despite the increasing popularity of free tissue transfer, thigh defects have been alienated from their potential indication, owing to the abundance of regional reconstruction options. However, some challenging situations where locoregional modalities may lead to suboptimal outcomes often require free flap. Due to lacking studies regarding microvascular reconstruction of thigh defects, this study aimed to investigate the versatility of free tissue transfer for reconstruction of thigh defects. METHODS: A retrospective review was performed for patients who underwent microvascular reconstruction of thigh defects between 2003 and 2021. Their demographics and operation-related data were summarized and postoperative outcomes were evaluated. RESULTS: Sixty-five patients were analyzed, with a median follow-up period of 15.5 months. Most common situations requiring free tissue transfer were extensive defects, followed by large dead space with exposure of major neurovascular bundle and chronic wounds surrounded by unhealthy regional tissue. Defects were most frequently located in the anterior compartment horizontally and in the distal thigh vertically. The median surface area of the defects was 180.0 cm2. The latissimus dorsi musculocutaneous and thoracodorsal artery perforator flaps were the two most commonly used flaps. Reliable recipient vessels could generally be easily found in the vicinity of defects. Overall complications developed in 12 cases (18.5%), including two of partial flap necrosis. No total flap loss was encountered. CONCLUSION: Free tissue transfer could provide reliable outcomes and facilitate rapid recovery, and could be actively considered for reconstruction of thigh defects in situations unfavorable to the locoregional option.

Safety of Drainless Donor Closure in DIEP Flap-Based Breast Reconstruction: A Prospective Analysis Using Ultrasound.

BACKGROUND: Although drainless donor closure with progressive tension suture (PTS) technique has been attempted to further reduce donor morbidity in deep inferior epigastric perforator (DIEP) flap-based breast reconstruction, its clinical safety has not yet been fully elucidated. This study prospectively investigated donor morbidity after DIEP flap elevation and drain-free donor closure. METHODS: A prospective cohort study was performed on 125 patients who underwent DIEP flap-based breast reconstruction and drainless donor closure. Postoperatively, the donor site was evaluated repetitively using ultrasonography. Development of donor complications, including any fluid accumulation and seroma (defined as detection of fluid accumulation after postoperative one month), was prospectively noted, and independent predictors for the adverse events were evaluated. RESULTS: On ultrasound examination conducted within postoperative 2 weeks, 48 patients were detected to have fluid accumulation at the donor site, which were more frequently detected in cases of delayed reconstruction and those with lesser number of PTS conducted. The majority of those events (95.8%) were resolved with one- or two-times ultrasound-guided aspirations. Five patients (4.0%) showed persistent fluid accumulation after postoperative 1 month, which were successfully treated with repetitive aspiration without requiring reoperation. No other abdominal complications developed except for three of delayed wound healing. On multivariable analyses, harvesting larger-sized flap and conducting lesser number of PTS were independent predictors for the development of fluid accumulation. CONCLUSION: The results of this prospective study suggest that drainless donor closure of the DIEP flap with meticulous placement of PTS followed by postoperative ultrasound surveillance appears to be safe and effective.

Use of Super-thin Superficial Circumflex Iliac Artery Perforator Flap for Reconstruction of Lower Lip Defect.

SUMMARY: Wide local excision remains the main treatment modality for primary lip cancer, which often results in considerable deficits of lip tissue and requires reconstruction using free tissue transfer. Although diverse free flaps, such as radial forearm flap or anterolateral thigh flap, have been used, their application is often limited by their inherent limitations including donor morbidity and flap bulkiness. This report details our experience of lower lip reconstruction using a super-thin superficial circumflex iliac artery perforator (SCIP) free flap.

Coverage of radial forearm free flap donor site defect using another free flap.

BACKGROUND: Donor site defects following the radial forearm flap (RFF) harvest have been usually covered with skin grafting, which often lead to suboptimal outcomes and donor morbidities, including delayed healing and scar contractures. The present report aimed to evaluate the outcomes of using another free flap, the domino flap, for coverage of donor site defects following RFFF harvest. METHODS: Five patients (two males and three females) who underwent coverage of donor defects of RFFF using another free flap between 2019 and 2021 were reviewed. Their mean age was 74 years and the mean dimension of the defect of the RFF donor site was 8.7 × 5.6 cm. Four patients used an anterolateral thigh flap and one used a superficial circumflex iliac artery perforator flap. RESULTS: The mean size of the domino flaps were 12.2 × 5.8 cm. Distal stumps of radial vessels adopting retrograde flow were used as recipients in four cases, and proximal ones adopting anterograde in one. The donor site of the domino flaps was primarily closed. All patients recovered well without any postoperative complications. Aesthetically pleasing outcomes with no functional impairment related to scar contractures were observed in the donor site of RFF during the mean follow-up of 15.7 months. CONCLUSIONS: Use of another free flap for coverage of RFFF donor defects may provide rapid wound healing and satisfactory outcomes, and may be considered an alternative option in cases with large-sized defects that are expected to take a long time to achieve complete healing with skin grafting.

Usefulness of indocyanine green angiography in the intraoperative evaluation of recipient vessels for microsurgical lower extremity reconstruction in ischemic vasculopathy: Report of three cases.

Choosing reliable recipient vessels is crucial for successful free flap reconstruction of lower extremity defects, especially in patients with ischemic vasculopathy. This report describes our experience with the intraoperative use of indocyanine green angiography (ICGA) for selecting recipient vessels in lower extremity free flap reconstruction cases. Three patients with lower extremity defects and ischemic vasculopathy underwent free flap reconstruction. Intraoperatively, the candidate vessels were evaluated using ICGA. In the first case, a 10 × 6 cm defect on the anterior side of the lower third of the leg caused by minor trauma and associated with peripheral arterial occlusive disease was reconstructed using a super-thin anterolateral thigh flap based on one perforator. In the second case, a 12 × 8 cm defect on the posterior side of the right lower leg caused by a dog bite and associated with severe atherosclerosis throughout all three major vessels in the lower leg was reconstructed using a muscle-sparing latissimus dorsi myocutaneous flap. In the third case, a 13.5 × 5.5 cm defect on the right lateral malleolar region, where the peroneus longus tendon was exposed due to Buerger's disease, was reconstructed using a one perforator-based super-thin anterolateral thigh flap. In all cases, ICGA was used to evaluate the functionality of the candidate recipient vessels. In two cases, the candidate vessels showed acceptable blood flow, and the operations proceeded as planned. In the third case, the planned vessels of posterior tibial vessels were not identified to have sufficient blood flow, and one of their branches showing enhancement in ICGA was selected and used as a recipient vessel. All flaps survived completely. No adverse events occurred during the follow-up period of postoperative 3 months. Our results suggest that ICGA may be a valuable diagnostic tool for evaluating the quality of candidate recipient vessels in cases where their functionality cannot be guaranteed with conventional imaging modalities.

Selective Application of Blood Glucose Monitoring After Free Flap Surgery: Potential Indications in Real-World Practice.

BACKGROUND: For free-flap monitoring, physical examination still serves as the criterion standard. Blood glucose measurement (BGM) has been suggested to be useful in identifying flap perfusion status. Nonetheless, its routine use may not be cost-effective in real-world settings. This study aimed to share the experiences of using BGM for flap monitoring and suggest its potential indications. METHODS: Of cases of free flap reconstruction conducted between March 2017 and May 2021, those using BGM for flap monitoring were reviewed. Blood glucose measurement was selectively conducted for the following specific situations, which included encountering a flap showing a reddish discoloration and/or rapid capillary refilling time in the immediate postoperative period, monitoring discolored flaps after conducting a salvage operation, and conducting bloodletting therapy for salvaging congestive flaps. The clinical course and outcomes were evaluated. RESULTS: Of a total of 203 cases, 35 used BGM for flap monitoring in addition to clinical examination. In 29 cases, BGM was performed to distinguish early hyperemia from true venous insufficiency. All flaps showed BGM greater than 60 mg/dL with a mean value of 115.42, suggesting early hyperemia, and had uneventful postoperative courses. In 3 cases with already discolored flaps after a salvage operation, BGM was conducted 4 times serially every 3 hours and showed a mean value of 81.6 mg/dL with increasing trends. The flaps recovered completely. In the other 3 cases requiring bloodletting therapy, BGM was conducted an average of 11 times at a median interval of 7 hours. The bloodletting therapy was terminated with reference to the value of BGM when it showed greater than 60 mg/dL while the therapy was on hold. All flaps were successfully salvaged except one showing partial necrosis. CONCLUSIONS: Blood glucose measurement may be helpful in assessing flap perfusion and decision making in certain clinical situations and may be useful as an ancillary tool for flap monitoring. Selective application of BGM may contribute to achieving optimal outcomes.