Complex reconstruction of the clavicle with a prefabricated medial femur condyle chimeric flap including a superficial circumflex iliac artery perforator flap: A case report.

The medial femur condyle (MFC) cortico-periosteal flap is a popular flap for bone reconstruction. The use of a chimeric version of this flap with a skin island has been described, but anatomical arterial variation can occur that prevent its harvest. Furthermore, the donor area of the skin paddle has been debated as poor because of the scarring in a visible area and because of the difficulty in obtaining pliable thin skin. We present a fabricated chimeric MFC cortico-periosteal flap joined with a superficial inferior epigastric perforator (SCIP) flap to reconstruct and augment a sclerotic and insufficient small clavicula with the skin paddle acting as a monitor and as a substitute for the overlying skin. A 52-year-old female patient had a history of multiple refractures of the right hypoplastic clavicle with a diameter of 7 mm, resulting in a sclerotic bone with a fibrotic scar. The reconstruction was done in one surgical session using a cortico-periosteal flap from the left medial condyle and a thin SCIP flap from the left groin. The area of the clavicle to be reconstructed was 3 cm, and the direct overlying skin (approximately 6 × 3 cm) was severely scarred and painful. The MFC flap was 5 × 4 cm, while the SCIP flap was 7 × 3.5 cm. The SCIP flap artery was anastomosed on the table end-to-side to the descending genicular (DG) artery of the MFC, and the vein was anastomosed end-to-end to a comitans vein of the DG artery. The flap fully survived after an initial congestion. At 12 months, we observed a satisfactory reconstruction of the clavicle with an enhanced diameter of 12 mm. The patient recovered full function of the shoulder with no pain. Using a fabricated chimeric flap composed of a medial femoral condyle and a superficial circumflex artery perforator flap may be an additional option for tailored reconstruction of complex osteo-cutaneous defect of clavicle.

[Treatment of the contracted first Commissure of the Hand: Literature Overview and own Experiences]. / Die Behandlung der kontrakten ersten Kommissur der Hand: Literaturübersicht und eigene Erfahrungen.

The freely movable thumb is of central importance for the function of the human hand. This mobility is necessarily linked to an undisturbed function of the commissure between the thumb and the index finger or, if the index finger is missing, the middle finger. A significant contracture of the first commissure, caused by whatever genesis, inevitably results in a significant loss of function up to almost complete inability to use. The surgical treatment of the first commissure often only affects the contracted skin. In some cases, however, it requires a multi-stage approach to fascia, muscles and joints, at the end of which there is the soft tissue expansion of the interspatium between the thumb and index finger. We mention old insights on the subject, give an overview of the literature, present our own experiences based on 5 cases and - according to the severity of the contracture - make a therapy recommendation.

Chin Augmentation Techniques: A Systematic Review.

BACKGROUND: Chin augmentation has maintained a high level of popularity among patients and facial plastic surgeons. Several procedures exist to enhance the appearance of a small chin. The aim of this study was to perform a systematic literature review to determine outcomes and complications associated with the different techniques described. METHODS: MEDLINE, PubMed, PubMed Central (PMC), and Cochrane Central Registry of Controlled Trials (CENTRAL) databases were screened using a search algorithm. The techniques were classified, and related outcomes and complications tabulated and analyzed. RESULTS: A total of 54 studies on primary chin augmentation published from 1977 to 2020 met inclusion criteria, representing 4897 treated patients. Six main surgical techniques were identified: chin augmentation with implants (silicone, Gore-Tex, Mersilene, Prolene, Medpor, Proplast, hard tissue replacement, porous block hydroxyapatite, or acrylic; n = 3344), osteotomy ( n = 885), autologous grafts (fat, bone, derma, or cartilage; n = 398), fillers (hyaluronic acid, hydroxyapatite, or biphasic polymer; n = 233), local tissue rearrangements ( n = 32), and a combination of implant placement and osteotomy ( n = 5). All techniques provided consistently satisfactory cosmetic outcomes. The overall complication rate of the most represented groups was 15.7% for implants and 19.7% for osteotomy, including 2.4% and 16.4% cases of transient mental nerve-related injuries, respectively. CONCLUSIONS: All described chin augmentation techniques achieved good outcomes with high patient satisfaction. Thorough knowledge of each technique is essential to minimize each procedure's specific complications. Caution is generally needed to avoid nerve injuries and potential overcorrection or undercorrection.

Tranexamic Acid Use in Breast Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: The perioperative use of tranexamic acid (TXA) has become popular among plastic surgeons for a variety of surgical procedures. The aim of this study was to perform a systematic review and meta-analysis on the results reported in the literature regarding the effect of perioperative systemic TXA administration in breast surgery. METHODS: The PubMed, MEDLINE, Embase, CENTRAL, and CINAHL databases were searched for both randomized clinical trials and observational studies. Effect estimates were pooled across studies using random effects models and presented as weighted odds ratio with corresponding 95% confidence interval. RESULTS: A total of five studies encompassing 1139 patients undergoing mastectomy with or without immediate implant or free flap-based breast reconstruction or breast-conserving surgery with or without axillary lymph node dissection were included. Perioperative intravenous administration of TXA significantly reduced the risk for hematoma (7.3% versus 12.9%; OR, 0.43; 95% CI, 0.23 to 0.81) and seroma formation (11.5% versus 19.9%; OR, 0.57; 95% CI, 0.35 to 0.92) in comparison to the control group. In the studies measuring the postoperative drainage amount, the mean difference was 132 mL (95% CI, 220 to 44 mL). No thromboembolic event occurred in either group. The weighted surgical-site infection rate was higher in the control group (3.1% versus 1.5%). However, these data were too sparse to perform comparative meta-analysis. CONCLUSION: Evidence of this study suggests that perioperative administration of TXA significantly reduces the risk for postoperative hematoma and seroma formation in breast surgery, whereas the risk for thromboembolic events and postoperative infection is not increased.

The use of the chimeric conjoint flap technique for complex defects reconstruction throughout the body: Clinical experience with 28 cases.

BACKGROUND: Large soft tissue defects reconstruction represents a frequent and complex challenge in plastic surgery. A critical point regards the equilibrium between the need of large amount of tissue, while minimizing donor site morbidity. This is a common issue that plastic surgeons face in their clinical practice. In this context, the chimeric conjoint flap technique can be a valuable option, allowing to better exploit many well-known procedures. The purpose of the present work is to show the reconstructive efficacy and reliability of this technique resorting to many different well-known flaps. No such a comprehensive collection of cases is available so far dealing with this procedure. PATIENTS AND METHODS: Twenty-eight patients presenting large defects throughout the body were treated by means of different flaps, designed according to the chimeric conjoint flap concept. Patients' mean age was 61.9 years old (range 18-82 years), 20 were males and 8 females. The size of the defects ranged from 7 cm × 6 cm to 25 cm × 18 and presented shapes or localizations that were complex to be covered with a regular flap. The defects were located in 11 cases in the lower limbs, in 9 cases in the head and neck region, in 5 cases in the groin, and in 2 cases in the thorax. Cause of the defect was tumor resection in 20 cases, trauma-induced necrosis in 5 cases, Fournier's gangrene in 2 cases, and a chronic ulcer in 1 case. Fourteen flaps were free flaps while 14 were pedicled flaps. The chimeric conjoint flap technique consists in splitting the skin paddle a flap into two smaller island that can be rearranged in order to match the particular requirements of the recipient site. Different flaps were employed: the anterolateral thigh (ALT) flap was used in 19 cases, latissimus dorsi (LD) musculocutaneous flap in 4 cases, deep inferior epigastric (DIEP) in 3 cases, medial sural artery perforator (MSAP) in 1 case, free radial forearm flap (RFFF) in 1 case. RESULTS: All the 28 patients were successfully treated. In 6 cases minor complications were encountered, 5 at recipient site and 1 at donor site, who were all managed conservatively. No second procedures were required. The mean follow-up period was 8.4 months (range 3-12 months). At the last follow-up evaluation all the patients reached an acceptable cosmetic result and, when limbs were affected, complete range of motion restoration. CONCLUSIONS: The present case series provide promising evidence regarding the reliability and versatility of the chimeric conjoint flap technique for large and delicate defect reconstructions throughout the body.

Pedicled superficial circumflex iliac artery perforator flap combined with lymphovenous anastomosis between the recipient site lymphatic vessels and flap superficial veins for reconstruction of groin/thigh tissue defect and creation of lymph flow-through to reduce lymphatic complications: A report of preliminary results.

BACKGROUND: Large locoregional defects affecting lymphatic-rich regions may be subject to serious lymphatic complications, such as lymphedema and recurrent lymphocele. In the last few years, a demeaning volume reconstruction combined with lymph flow restoration showed to effectively reduce their incidences. The purpose of this report is to present the preliminary results of the use of pedicled SCIP flap with LVA between the recipient site lymphatic vessels and flap superficial vein for reconstruction of soft tissue defect and creation of lymph flow-through to reduce lymphatic complications. PATIENTS AND METHODS: Between 2018 and 2020, 4 patients (2 males and 2 females), with a mean age of 56.5 years (ranging 42-76 years), presented a soft tissue defect with lymphatic drainage damage which was reconstructed by resorting to pedicled SCIP flap. Causes of the defect were tumoral surgical excision in 3 cases and severe trauma in 1 case. The defects were located in the medial thigh in 2 cases and groin area in 2 cases, with sizes ranging from 5 × 19 cm to 8 × 22 cm. The SCIP flap was raised by paying attention to preserve some suitable veins at the distal edge of the skin paddle. The flap was then turned 180 degrees and inset in order to match the direction of the recipient's lymphatic vessels. One or more LVAs were performed between the recipient site damaged lymphatics and a superficial flap's vein. RESULTS: The sizes of flaps ranged from 5 × 19 cm to 8 × 22 cm. The mean number of LVAs was 2.2 (ranging from 1 to 3). A minor post-operative complication was encountered (small infected seroma) in 1 case, which was conservatively managed. No secondary procedures were required. In all cases complete range of motion (ROM) of the hip joint and wound coverage at both donor and recipient site were achieved. The mean follow-up was 8 months (ranging 7-10 months). No signs of lymphedema and lymphocele were reported over this time. CONCLUSIONS: The pedicled SCIP flap with LVA between the recipient site lymphatic vessels and flap superficial vein may provide a solution for inguinal and upper thigh defects reconstructions that requires a lymphatic drainage restoration. Its superficial veins may be exploited to perform LVAs at recipient site, thus reducing the lymphatic complications in these delicate regions.

Stacked profunda artery perforator flaps with intra-flap anastomosis for moderate to large breast autologous reconstruction.

BACKGROUND: The profunda artery perforator (PAP) flap is a reliable alternative for autologous breast reconstruction; however, the amount of tissue provided is quite limited. For medium to large sized breast reconstruction two PAP flaps can be harvested and inset in "stacked" fashion. This procedure consists in placing the two flaps side by side, normally supplied by antegrade and retrograde anastomoses performed with the mammary vessels. In the present article, we report the employment of stacked PAP flaps with intra-flap anastomosis in breast reconstruction setting. PATIENTS AND METHODS: From April 2018 to December 2021, seven patients received unilateral breast reconstruction with stacked PAP flaps. Patients' average age was 47.5 (range 39-58 years old). Mean body mass index was 19.4 kg/m2 (range 18.5-20.1 kg/m2 ). The two flaps were linked by means of intra-flap anastomosis resorting to side branches of one of the two pedicles. In all cases the internal mammary vessels were dissected sparing the ribs and used as recipient vessels for antegrade end-to-end anastomosis. RESULTS: The flaps size ranged from 15 cm × 6 cm to 20 cm × 7 cm with an average weight of 250 g (range 190-290 g). The mean pedicle length was 11.1 cm (range 10-12.5 cm) on the left side and 7.9 cm (range 7-9 cm) on the right side. All flaps survived completely after surgery. The donor sites were all primarily closed with no morbidities. The mean follow-up was 8 months (range 6-12 months). All patients were satisfied with the result. CONCLUSIONS: Stacked PAP flaps performed with intra-flap anastomosis may represent a valid alternative solution for the reconstruction of moderate to large breast in case of unavailable abdominal tissue.

Pedicled superficial circumflex iliac artery perforator flap for male genital reconstruction: A case series.

BACKGROUND: Different issues may cause defects in the genital region, including urological, infective, oncological and genetic problems which often lead to significant defects. This is a very delicate region and a successful coverage requires a thin, pliable and reliable solution. In this setting the SCIP flap might be an outstanding procedure. Despite being a well-known solution in the groin region, its employment for genital reconstructions is still poorly described. For this reason, we gather our experience with this procedure showing the efficacy of the SCIP flap in this specific region. PATIENTS AND METHODS: In the present case series we included 6 male patients who received a soft tissue defect reconstruction by means of pedicled SCIP flap over the last year. The average age was 53.6 years old (range 34-79 years). Among them, 5 patients received a surgical excision because of severe acne (2 cases), Fournier's gangrene (2 cases), or scrotal squamous cell carcinoma (1 case). In 1 case the cause of the missing volume was testicle agenesis and the reconstruction was performed for cosmetic purposes. Size of the defects ranged from 7 cm × 4 cm to 20 cm × 6 cm. Elliptical shaped flaps were designed either mono- or bilaterally according to the need. All the flaps were supplied by the superficial branch of the SCIA. The range of rotation varied between 150° and 180° in order to reach the affected area. RESULTS: The flaps' dimension ranged from 8 cm × 4 cm to 20 cm × 6 cm. All the patients were successfully treated. In 1 case we encountered a small wound dehiscence, which was managed conservatively. The mean follow-up was 9.5 months (range 6-12 months). Good cosmetic result was achieved in all cases and no urinary or sexual dysfunctions were reported. CONCLUSIONS: The pedicle SCIP flap represents a reliable solution for genital and inguinal defects reconstructions. Its versatility can be exploited throughout the region providing very good quality tissues that can be used for the most disparate situations.

Our experience with the anterior interosseous artery fasciocutaneous flap for local and distant soft tissue reconstructions.

BACKGROUND: Martin and his colleagues in 1989 described for the first time a fasciocutaneous flap based on a posterior branch of the anterior interosseous artery (AIA). Despite its promising characteristics, this flap never achieved popularity and the literature about it is limited. The aim of the present study is to share our experience with the AIA flap both as a local and free flap in reconstructing defects of various body regions. PATIENTS AND METHODS: A retrospective review of 26 consecutive patients operated between January2001 and August 2020 was conducted. Seventeen male and nine female patients, mean age 52 years, underwent reconstruction of local and distant soft tissue defects using the AIA flap. Fourteen flaps were raised as free flap and 12 as local flaps for a total of 26 flaps. The locations of the defects included the face, the lower limb, the hand dorsum, and fingers. RESULTS: Twenty-four out of 26 flaps survived completely, and two pedicled flaps presented partial necrosis, with one requiring a new free flap procedure. One free anterior interosseous flap required revision of the venous anastomosis. Two donor site dehiscence were observed, and they both healed by secondary intention healing. Follow-ups were conducted for a mean of 18 months. All patients showed good contour restoration of the affected body part. CONCLUSIONS: The AIA flap, either free or pedicled, represents a reliable tool to perform "like-with-like" reconstructions of hand defects. In some occasions, it is well suited for shallow defects in other body parts.

Soft Tissue Defect Reconstruction and Lymphatic Complications Prevention: The Lymphatic Flow-Through (LyFT) Concept.

Background and Objectives: When a lymphatic-rich area is severely damaged, either after trauma or a surgical procedure, both soft tissue defect reconstruction and lymphatic drainage restoration are necessary. In this setting, we aim to show the potential of the lymphatic flow-through flap (LyFT) concept, which might be an attractive new solution to reduce postoperative lymphatic complications. Materials and Methods: Between 2018 and 2021, 12 patients presenting a soft tissue defect involving damage to the lymphatic drainage pathway received a lymphatic flow-through flap for volume and lymphatic drainage restoration. Different flaps were employed: 3 pedicled superficial circumflex iliac artery perforator (SCIP) flaps, 2 free SCIP flaps, 3 pedicled deep inferior epigastric perforator (DIEP) flaps, 2 pedicled vertical posteromedial thigh (vPMT) flaps, and 2 pedicled anterolateral thigh (ALT) flaps. A range of 1 to 3 lymphovenous anastomosis (LVA) with flap's veins was performed (mean 1.9). For a better dead space obliteration, an additional vastus lateralis muscle flap was performed in one case. Indocyanine green (ICG) lymphography was used in all cases to identify the lymphatic pathway, make the preoperative markings, and check the patency of the anastomoses. Results: In all cases, the reconstructive results were satisfactory from both the functional and aesthetic points of view. No secondary surgeries were required, and only one minor complication was encountered: an infected seroma that was managed conservatively. The mean follow-up was 9.9 months (range 6-14 months). Conclusions: Lymphatic flow-through flaps seem to effectively reduce the risk of lymphatic complications after the reconstruction of soft tissue defects with a compromised lymph pathway. This is a versatile solution that might be used in different body regions resorting to different flap types.

Versatility of perforator flaps for lower extremity defect coverage: Technical highlights and single center experience with 87 consecutive cases.

BACKGROUND: Lower extremity defects have been and remain one of the greatest challenges in reconstructive surgery. Perforator flaps have been accepted as a valid procedure to cover such a defect. Different techniques have been described and nowadays many options are available. However, there were not studies that comprehensively review the most modern techniques and clinical application of the use of perforator flaps in the lower extremity reconstruction. In the present report, we gathered most of them, presenting an updated and large case series where different pedicled and free perforators flaps were employed in simple and complex scenarios in a large series of cases. PATIENTS AND METHODS: Eighty-seven patients presenting soft tissue defects of the lower extremities were treated by means of different perforator-based flaps, in either free or pedicled fashion. The flaps were based on different perforator vessels, namely deep lateral circumflex femoral artery, profunda femoris artery, superficial femoral artery, medial sural artery, peroneal artery, posterior tibial artery, anterior tibial artery, and medial plantar artery. Patients' mean age was 61.9 years old (range 21-87 years old), 58 were males and 29 females. The 12 patients received sequential flaps and 9 received double free flaps, for a total sum of 106 flaps. The causes of the defects were trauma in 41 patients and tumors in 46 patients, located throughout the lower limbs. Size of the defect ranged from 3 cm × 4 cm to 25 cm × 9 cm. RESULTS: The dimensions of the flap skin paddles ranged from 3 cm × 4 cm to 16 cm × 5 cm for the pedicled flaps (42 cases) and from 6 cm × 4 cm to 25 cm × 8 cm for the free ones (45 cases). Mean flap's size was 48 cm2 (range 12-80 cm2 ) for the pedicle flaps and 104 cm2 (range 24-200 cm2 ) for free flaps. In two pedicled cases, a distal congestion was encountered, requiring a second surgery. Debulking procedures were performed in 2 patients. All the patients were successfully treated and no flaps were lost. Mean follow-up period was 8.4 months (range 3-12 months). No range of motion impairment was encountered after surgery and all the patients were able to return to habitual life. CONCLUSIONS: The present case series highlights the reliability and versatility of perforator flaps for lower extremity defect coverage. Following careful consideration of the etiology, dimensions, location, patient comorbidities, and presence of adequate perforators, a pedicled or free perforator flap can be potentially successful in the most disparate circumstances.

Lymphatic Complications Prevention and Soft Tissue Reconstruction after Soft Tissue Sarcoma Resection in the Limbs.

Background and Objectives: The definitive treatment of soft tissue sarcomas (STS) requires a radical surgical removal of the tumor, which often leads to large soft tissue defects. When they are located in the limbs, significant damage to the lymphatic pathways is not uncommon. In the present article, we present different techniques aimed at both reconstructing the defect and restoring sufficient lymph drainage, thus preventing short- and long-term lymphatic complications. Materials and Methods: Between 2018 and 2020, 10 patients presenting a soft tissue defect with lymphatic impairment received a locoregional reconstruction by means of either pedicled or free SCIP flap. Seven patients required a second flap to reach a good dead space obliteration. In six cases, we performed an interpositional flap, namely a soft tissue transfer with lymphatic tissue preservation, and in four cases a lymphatic flow-through flap. In all cases, the cause of the defect was STS surgical excision. The average age was 60.5 years old (ranging 39-84), seven patients were females and six were males. Results: All the patients were successfully treated. In two cases, minor post-operative complications were encountered (infected seroma), which were conservatively managed. No secondary procedures were required. The average follow-up was 8.9 months (ranging 7-12 months). No signs of lymphedema were reported during this time. In all cases, complete range of motion (ROM) and a good cosmetic result were achieved. Conclusions: A reconstructive procedure that aims not only to restore the missing volume, but also the lymphatic drainage might successfully reduce the rate of postoperative complications. Both lymphatic interpositional flaps and lymphatic flow-through flaps could be effective, and the right choice must be done according to each patient's needs.

Superficial Circumflex Iliac Artery Perforator Flap in Advanced Head and Neck Reconstruction: From Simple to Its Chimeric Patterns and Clinical Experience with 22 Cases.

BACKGROUND: Head and neck tissue defects after ablative head and neck surgery often require complex and composite reconstructions. The superficial circumflex iliac artery perforator (SCIP) flap is an extremely versatile perforator-based flap with minimal donor-site morbidity. The authors present their experience with both simple and chimeric SCIP flap reconstructions for complex defects in various head and neck regions. METHODS: Twenty-two patients undergoing ablative head and neck surgery for oncologic abnormalities were treated by means of a SCIP flap reconstruction. Patients' mean age was 62 years; 21 were men and one was a woman. Seventeen flaps were simple and five were chimeric reconstruction patterns. Indocyanine green perfusion imaging was performed in all cases. RESULTS: Twenty-one of 22 patients (95.5 percent) were successfully treated with good aesthetic and functional results. Two patients (9 percent) showed minor donor-site complications that were managed conservatively. The mean follow-up period was 5.3 months (range, 2 to 8 months). CONCLUSIONS: This case series demonstrates the reliability and versatility of the SCIP flap for head and neck reconstruction. The chimeric options combined with bone, double-skin paddle, and muscle offer a broad variety of functional reconstructive solutions for complex head and neck surgery. Intraoperative indocyanine green perfusion examinations are a valuable tool to assess and ascertain proper inset, vitality, and postanastomosis vessel patency in these complex microvascular flap reconstructions. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The use of pedicled chimeric superficial circumflex iliac artery perforator (SCIP) flap as lymphatic interpositional flap for deep thigh defect reconstruction: A case report.

The tumors affecting the thigh region are complex to manage, requiring a patient-tailored and multidisciplinary approach. Because of their aggressiveness, soft tissue sarcomas (STS) often grow very quickly and they must be removed before they might cause major impairments. A safe margin excision may lead to large defects that require a surgical reconstruction with either free or pedicled flaps. Another relevant aspect, which is gaining more and more attention in the last few years, regards the lymphatic complications that commonly occur after these procedures. The thigh region anatomically accommodates the major lymphatics responsible for the whole leg drainage, and these vessels are often inevitably compromised during the tumor removal. For this reason, plastic surgeons should take into account not only to the aesthetic and functional result, but they should also try to prevent lymphatic sequelae such as lymphocele and lymphedema. The purpose of this report is to describe the potential of a pedicled SCIP flap, used as a lymphatic interpositional flap, in order to restore the lymphatic drainage of the thigh after a major impairment. A 57-year-old patient presenting a thigh sarcoma received a surgical excision leaving a 35 cm × 25 cm defect affecting the anterior compartment. To fulfill all these concerns, a lymphatic interpositional SCIP flap was performed, in pedicled and chimeric fashion. It allowed to completely bury a large (35 cm × 16 cm) soft tissue island, preserving a smaller (5 cm × 4 cm) skin paddle to monitor the whole flap survival. Moreover, the lymphatic issue was faced by preserving the lymphatic vessels running into the flap and moving them into the affected area in order to enhance the lymphatic neo-angiogenesis and offering an additional pattern for lymph drainage. Post-operative course was uneventful and at 9 months follow up the reconstructive result was successful with no signs of lymphatic sequelae. Therefore, we believe that the SCIP flap might be a promising solution for small-to-moderate size thigh defect reconstructions since it is able to satisfy all the typical requirements of this delicate region.

Combined double superficial circumflex iliac artery perforator flap with lymphatic tissue preservation and lymphovenous anastomosis for lymphatic sequelae prevention in thigh defect reconstruction: A case report.

The thigh region is often site of soft tissue tumors development. Leiomyosarcoma, in particular, is a malignant tumor that, if not promptly treated, presents a growth rate that often results in large masses. The safest treatment in these cases is margin-free extensive surgical resection. This leads to rather large defects that in a delicate region, such as the medial thigh, implies a series of possible complications from the lymphatic point of view. In this region run major lymphatic vessels, appointed to drain the whole leg. Now that one is aware of this issue, the best solution is trying to obtain an efficient reconstruction and preventing the development of postoperative lymphedema and lymphocele. Here, we present a case of great saphenous vein leiomyosarcoma resection in the right medial thigh reconstructed by means of two superficial circumflex iliac artery perforator (SCIP) flaps with lymphatic tissue preservation, combined with preventive lymphovenous anastomosis (LVA). A 67-years-old woman presented a 22 × 16 cm soft tissue defect after the surgical excision. To fill the defect, we resorted to a larger SCIP flap island, supplied by both the superficial and deep branches of the superficial circumflex iliac artery anastomosed in perforator-to-perforator fashion, and to a smaller SCIP flap island supplied only by the superficial branch. Before surgery, the lymphatic vessels running in the flaps area were identified with indocyanine green lymphography and were carefully preserved during the harvest procedure. They were then transferred with the surrounding tissue and orientated in order to match the lymphatic flow direction, providing further fluid drainage. To boost the lymphatic drainage, an LVA was also performed at the superior-edge-of-the-knee incision point joining a functioning lymphatic vessel to a nearby reflux-free vein. The postoperative course was uneventful and at 7 months follow-up, the patient showed good cosmetic and functional outcomes with no swelling and no signs of tumor relapse. This report provides a series of technical insights and adds further evidence to support the efficacy of this procedure for management of soft tissue defects in the medial thigh region.

Combining superficial and deep lymphovenous anastomosis for lymphedema treatment: Preliminary results.

BACKGROUND: Superficial lymphovenous anastomosis (LVA) is a widely accepted procedure for treatment of mild-to-moderate lymphedema throughout the body. Anyway, not always are the superficial lymphatic vessels suitable for the anastomosis nor do they provide a sufficient drainage to significantly improve the condition. The continuous progress of supermicrosurgical technique over the last few years and the recent anatomical researches about the deep lymphatic network opened new perspectives for those lymphedema cases refractory to conventional procedures. Resorting to deep lymphatic vessels offer an additional opportunity to further improve the result obtained by means of superficial LVA. The aim of this report is to describe our experience treating lymphedema with superficial and deep lymphatic vessels LVA. PATIENTS AND METHODS: Eight female patients presenting secondary (seven cases) and primary (one case) lymphedema, previously treated by means of multiple superficial LVAs, were considered eligible for deep lymphatics surgery to further improve their results. The affected area was the upper limb in one case and the lower limbs in seven cases. All the patients were evaluated preoperatively and postoperatively resorting to Campisi criteria. Four cases were initially classified as stage III, two stage IV, and two stage II. Five patients received deep LVA in the groin, two patients in the ankle along the posterior tibial artery and one in the wrist along the radial artery. RESULTS: In all eight patients both subjective and objective improvements of the condition were reported with decrease of swelling and relief from heaviness sensation. The postoperative course was always uneventful and at the 9 months follow up none of the patients presented recurrence of the disease, even with the complete removal of compressive therapy. CONCLUSIONS: Deep lymphatic vessels LVA might represent a valid alternative to the superficial ones to treat lymphedema when previous results are not satisfactory nor when no superficial lymphatic vessels are available for anastomosis.

Total groin defect reconstruction by lymphatic flow-through (LyFT) pedicled deep inferior epigastric artery perforator (DIEP) flap resorting to its superficial veins for lymphovenous anastomosis (LVA): A case report.

Extensive surgical removal is often required to treat soft tissue sarcomas. When they are localized in the groin-upper medial thigh region, the excision is particularly demanding because of the rich lymphatic network and lymph nodes present in that area. The lymphatic vessels with respective lymph nodes draining the whole leg are most of the time inevitably damaged, causing a series of debilitating sequelae such as lymphocele and lymphedema. To prevent these issues, together with the defect coverage, additional lymphovenous anastomoses (LVA) showed encouraging results. Here we present a case of resected groin sarcoma reconstructed by means of pedicled lower deep inferior epigastric perforator (DIEP) flap combined with multiple LVAs. In particular, the superficial veins of the DIEP flap have been employed as the donor veins for LVAs. A 76-year-old patient presented a leiomyosarcoma in the right trigonum femorale which was surgically excised leaving a defect of about 12 cm × 7 cm with exposed femoral vessels and nerves. The remaining defect was then filled with a pedicled DIEP flap, and three leaking lymphatic vessels in the thigh were anastomosed with three branches of a superficial vein originating from the DIEP flap. The postoperative course was uneventful and at 12 months follow-up no signs of either seroma or lymphocele. This result suggests that the concept of lymphatic flow-through (LyFT) DIEP flap might be a modern and particularly useful solution for those cases that require both dead space obliteration and lymphatic drainage restoration.

The Role of Free Tissue Transfers for Defect Coverage over the Body in Geriatric Populations.

The treatment of soft tissue defects in multimorbid frail patients requires optimized preoperative and perioperative management with a differentiated interdisciplinary approach. Preoperative assessment with established scores, such as the ASA score, is important in order to stratify the operative complication risk. Following the reconstructive ladder is important to avoid unnecessary long operations and consecutively higher operative risks. In cases where a free flap procedure is needed, infections should be treated properly, and vascular status and coagulation should be optimized before performing a free flap procedure. Attention should be paid to maintain independency, functionality and quality of life while choosing the best treatment option.

Free double-paddle posterior tibial artery perforator flap for hypopharynx reconstruction: A case report and literature review.

Microsurgical free tissue transfer is nowadays considered to be one of the main options for head and neck reconstruction. The free posterior tibial artery perforator (PTAP) flap is a well-known reconstructive technique for local defect coverage in the distal leg, and only recently has been employed for head and neck reconstructions. Being a very thin and pliable flap, with low donor site morbidity and constant anatomy, the PTA perforator-based flap could be a great alternative to the more commonly-employed radial forearm free flap (RFFF). The present case report shows a complex head and neck defect coverage by means of a free double-paddle PTA flap, with a concise literature review of previous PTA flap descriptions in this setting. A 59-year-old male patient presented with a hypopharynx leakage after radiotherapy due to hypopharynx carcinoma. Since the patient had an occluded ulnar artery on the left side and an arterial line in the radial artery on the right side, both a RFFF and an ulnar artery perforator (UAP) flap were contraindicated. Moreover, two different cutaneous flaps were needed to reconstruct a 6 × 8 cm2 defect, one for the reconstruction of the hypopharynx and one for the resurfacing of the neck, since previous surgeries and radiotherapy led to severe fibrosis of the neck. The patient had a BMI of 25.4 kg/m2, which led us to exclude the anterolateral thigh (ALT) flap because of its thickness. For the forementioned reasons, an unconventional double-paddle PTAP flap based on two perforator vessels was chosen. Based on two perforators, two skin islands were harvested, building a double-paddle PTA perforator-based flap. The proximal skin island was 6 × 7 cm2 and the distal one was 6 × 4 cm2 . The larger skin flap was set at the leakage of the hypopharynx. The smaller skin island was used to monitor the survival of the whole flap and for resurfacing the outer side of the neck. The postoperative course was uneventful and at 3 months follow up the reconstructive result was good with no functional drawback. In view of the obtained result, we can consider that the PTA flap might be a reliable alternative to the much widely used RFFF, with a minor donor site morbidity, for delicate head and neck reconstructions.