Resurfacing of Face and Neck Using Superthin Thoracodorsal Artery Perforator Free Flaps.

BACKGROUND: Resurfacing of facial and neck defects is challenging due to the unique skin color, texture, and thickness of the region. With the development of microsurgical reconstruction, perforator- free flaps can provide adequate soft tissue. However, despite various modifications, such flaps hardly satisfy cosmetic requirements, due to differences in color and bulkiness. We have used superthin thoracodorsal artery perforator (TDAp) free flaps to overcome these limitations. METHODS: Between January 2012 and January 2020, 15 patients underwent reconstructive procedures for facial and neck soft tissue defects using superthin TDAp free flaps. First a perforator was found above the deep fascia and a flap was elevated over the superficial fascia layer. A process named "pushing with pressure and cutting" was carried out before pedicle ligation until all the superficial fat tissue had been removed except for around the perforator. Patient satisfaction was evaluated using a questionnaire about color, contour, and overall satisfaction a minimum of 12 months after surgery. RESULTS: Flap size ranged from 6 × 4 cm to 25 × 14 cm (mean, 126.3 cm2). Final flap thickness ranged from 4 to 6 mm. (mean, 4.97 mm). All flaps survived without any loss and there were no flap-related complications. After a mean follow-up period of 14.4 months, patients were satisfied with the aesthetic results, and cervical range of motion increased by 11.25 degree on average in burn scar contracture patients. CONCLUSIONS: The superthin TDAp free flap is an excellent alternative to face and neck resurfacing, providing a large and thin flap with excellent color matching and good vascularity.

Lumbar Flap versus the Gold Standard: Comparison to the DIEP Flap.

BACKGROUND: The lumbar artery perforator flap is an excellent free flap for breast reconstruction whenever the deep inferior epigastric perforator (DIEP) flap is not an option. The main indication is a lack of abdominal bulk, often seen in young BRCA-positive women seeking prophylactic amputation and immediate reconstruction. METHODS: Between October of 2010 and July of 2016, a total of 661 free flap breast reconstructions were performed. The authors retrospectively analyzed patient demographics, perioperative parameters, and secondary corrections. RESULTS: Seventy-six lumbar artery perforator flaps were retained and compared with a cohort of 560 DIEP flaps. The average body mass index for lumbar patients was 23.8 kg/m, with a mean age at operation of 46.3 years. Average body mass index for DIEP patients was 25.2 kg/m, with a mean age at operation of 48.8 years old. Lumbar artery perforator flap weight was 504 g (range, 77 to 1216 g) on average versus 530 g (range, 108 to 1968 g) for the DIEP flaps. The amount of corrective procedures performed was very similar in both cohorts: 13 percent of the lumbar artery perforator and 12 percent of the DIEP patients underwent no procedures, 62 percent in both groups underwent one procedure, and 25 percent versus 27 percent underwent two or more procedures. Lipofilling was performed in 48 percent of lumbar artery perforator flaps compared with 57 percent of the DIEP flaps (p = 0.14). Mean volume injected was 98.0 cc and 125.1 cc for lumbar artery perforator and DIEP flaps, respectively (p = 0.071). CONCLUSIONS: The lumbar flap is a good alternative whenever a DIEP flap is not possible. Bilateral autologous reconstruction is possible even in very thin patients, and secondary corrections are comparable to those for the DIEP.

Retalho VY de avanço após recidiva de neoplasia perianal: relato de caso e revisão da literatura / V-Y flap of advancement after the recurrence of perineal cancer: case report and literature review

Introdução: O câncer anal é uma doença rara, cuja incidência está aumentando. Os retalhos são opções complexas de fechamento quando abrangem grandes áreas. A região perineal pode ser acometida por extensas lesões, requerendo utilização de retalhos. Relato de Caso: Paciente feminina, 56 anos, diagnosticada com adenocarcinoma anal, foi submetida à cirurgia de amputação abdominoperineal do reto associada à radioterapia pós-operatória há 2 anos. Apresentou recidiva cutânea da lesão neoplásica, com indicação de ampliação de margem cirúrgica para controle da recidiva. Após ampla ressecção com margem de segurança o defeito cutâneo, optou-se por duplo retalho em V-Y com 15 cm de comprimento cada e espessura total do tecido celular subcutâneo (TCS) de região glútea para preenchimento do espaço morto deixado pela ressecção e avanço sobre o defeito. Implementou-se antibioticoprofilaxia endovenosa e profilaxia para trombose venosa profunda. Paciente evoluiu bem do procedimento sem intercorrências. Discussão: Retalho é um tecido que é mobilizado conforme sua anatomia vascular. Retalhos baseados no plexo subdérmico incluem os bipediculados, de avanço (V-Y), retalhos de rotação e transposição. Reconstruções de períneo são indicadas devido a tumores, traumas, infecções, queimaduras ou úlceras de pressão. A região anal é dividida em canal anal e margem anal. Dentre os tipos histológicos de neoplasia na região do canal anal, podem ser citados: carcinoma de células escamosas (histologia mais comum), adenocarcinoma, melanoma, carcinoma de pequenas células e sarcomas. O risco de recidiva locorregional, após tratamento, pode atingir cerca de 30% dos casos e é o padrão de recidiva mais frequente.

Introduction: Anal cancer is a rare disease, with an increasing incidence. Flaps are complex options for closing large areas. The perineal region may be affected by extensive lesions that require the use of flaps for repair. Case Report: A 56-year-old female patient with anal adenocarcinoma underwent abdominoperineal amputation surgery of the rectum with postoperative radiotherapy for 2 years. She had cutaneous recurrence of the neoplastic lesion with indication of surgical margin expansion to control the local recurrence. After extensive resection with safety margins of the skin defect, we selected double V-Y flap of length 15 cm each and a total thickness of the gluteal subcutaneous tissue (ST) to fill up the dead space caused by resection and advancement of the defect. Intravenous antibiotic prophylaxis and deep venous thrombosis prophylaxis were administered. The patient progressed well from the procedure, with no problems. Discussion: A flap is a tissue that is mobilized based on vascular anatomy. Flaps based on the subdermal plexus include bipedicle, advancement (V-Y), rotation, and transposition flaps. Perineum reconstructions are often indicated for tumors, trauma, infections, burns, or pressure sores. The anal region is divided into the anal canal and the anal margin. Among the histological types of anal cancer, the most prevalent are squamous cell carcinoma (most common histology), adenocarcinoma, melanoma, small cell carcinoma, and sarcomas. The risk of regional recurrence after treatment can reach approximately 30% of cases and is the most frequent recurrence pattern.

Modified lumbar artery perforator flaps for gluteal pressure sore reconstruction.

BACKGROUND: Gluteal perforator flaps (GPFs) are the most useful for gluteal region pressure sore reconstruction. However, application is difficult if the surrounding area has scar tissue from previous operations or trauma, especially with recurrent sores. We describe the use of modified lumbar artery perforator flaps when GPFs cannot be used. METHODS: Between May 2009 and April 2014, 51 patients underwent gluteal pressure sore reconstructions with gluteal (n = 39) or modified lumbar artery (n = 12) perforator flaps. Patients in the modified lumbar artery perforator group had scar tissue from trauma or previous surgery. In this retrospective review, we analyzed patient age and sex, defect size and location, operative time, follow-up duration, immediate postoperative issues, flap necrosis, dehiscence, re-operation, donor-site morbidity and recurrence. Complications and clinical outcomes were compared between groups. RESULTS: We found no significant differences in patient demographics, surgical complications or clinical outcomes. There were eight cases of temporary congestion (20.51%) and four of partial flap necrosis (10.25%) in the gluteal perforator group. In the modified lumbar artery perforator group, there were three cases of temporary congestion (25%) and one of partial flap necrosis (8.33%). No pressure sores recurred during follow-up in either group. CONCLUSION: GPFs are the gold standards for gluteal pressure sores, but modified lumbar artery perforator flaps are relatively easy and useful when GPFs cannot be used due to scar tissue.

A postoperative analysis of perfusion dynamics in deep inferior epigastric perforator flap breast reconstruction: a noninvasive quantitative measurement of flap oxygen saturation and blood flow.

BACKGROUND: The blood supply of microvascular free flaps is rated as very critical, particularly in the first postoperative days. Only a timely recognition of a complication and its treatment can ensure the survival of the flap. To quantify the postoperative perfusion dynamics, we measured the oxygen supply and blood flow of the deep inferior epigastric perforator (DIEP) flaps. METHOD: A total of 23 patients undergoing DIEP flap breast reconstruction were involved in this study. Noninvasive measurements were performed with the O2C-device, which combines the determination of hemoglobin oxygenation and blood flow using white light and laser light. The first measurement was performed immediately after the flap anastomosis. Further measurements were carried out on the first, third, fifth, and seventh postoperative days. RESULTS: The preoperative value represents our baseline. With the exception of the third day, all postoperative measurements were above the baseline. On the third postoperative day, there was a decrease in the cutaneous oxygen saturation of 22% and a decrease in blood flow of 18% on average, regardless of the individual fluctuations of patient's blood pressure. CONCLUSIONS: The postoperative perfusion characteristics of the DIEP flap showed a critical drop in the cutaneous oxygen supply and blood flow on the third postoperative day. This represents a potential risk and should be considered in the postoperative management of the DIEP flap.