"Extra-anatomical Pedicle Rerouting" An alternative technique to obtain new recipient vessels for microsurgical reconstruction in unfavorable clinical situations.

BACKGROUND: Lack of adequate recipient vessels in certain anatomically unfavorable locations or in complex clinical situations is still a limitation to successful microsurgical transfer. To address such complex cases, advanced microsurgical techniques should be applied. In this paper, the authors describe their experience with the Extra-anatomical Pedicle Rerouting (EPR) technique, an alternative approach that was used in selected cases throughout the body to obtain healthy recipient vessels for microsurgical reconstruction in unfavorable clinical situations where suitable recipient vessels were difficult to find. PATIENTS AND METHODS: Fifteen patients with defects of variable etiology (oncological resection, trauma, previous surgeries) located in the trunk or upper and lower extremities received EPR free flap reconstruction at our Institution. Operative data, postoperative course, and complications were recorded. Clinical and photographic follow-ups were also documented. RESULTS: A total of 15 flaps (6 antero-lateral thigh (ALT), 6 latissimus dorsi/thoracodorsal artery perforator flap (LD/TDAP), 3 deep inferior epigastric artery perforator flap (DIEP)) were transferred adopting the EPR technique for oncological (11) and post-traumatic (4) defects. According to the different clinical scenarios, the rerouted vessels were the thoraco-acromial, posterior circumflex humeral, thoracodorsal, deep inferior epigastric, lateral circumflex femoral, anterior tibial, and medial sural pedicles. Mean length of the rerouted vascular conduits was 6.53 cm. Mean operative time was 420 minutes. No major complications were registered. Minor wound dehiscence was observed and managed conservatively in 3 patients. CONCLUSIONS: The EPR technique proved to be useful in a reliable and reproducible manner in different regions of the body as an alternative solution to obtain healthy recipient vessels in anatomically and surgically unfavorable clinical situations.

Lower Abdominal vs. Lateral Thigh Perforator Flaps in Microsurgical Sarcoma Reconstruction: The Aesthetics of Donor Site Matters.

Introduction: Sarcoma resection often leaves patients with big defects only amenable through microsurgical reconstruction. In such cases, it is hard for the surgeon to uphold low donor-site morbidity with an aesthetic result. The purpose of this study was to investigate the clinical outcome and the patient's perception regarding the donor site in a cohort of patients undergoing microsurgical reconstruction with lateral thigh and lower abdominal perforator flaps. Methods: A retrospective evaluation of all patients who underwent sarcoma reconstruction with flaps harvested from the lower abdominal region (deep inferior epigastric artery perforator flap, superficial circumflex iliac artery perforator flap) or lateral thigh region (anterolateral thigh perforator flap and its variations) was performed. Only patients with defects greater than 100 cm2 were included. Patient demographics and operative variables were recorded, together with complications. Patient satisfaction and quality of life with the donor site were registered using the SCAR-Q questionnaire, which was administered at least six months post-operatively. Results: Eighteen anterolateral thigh (ALT) perforator flaps and twenty-two deep inferior epigastric artery perforator (DIEP) and superficial circumflex iliac artery perforator (SCIP) flap procedures were performed. The two groups were homogeneous for major post-operative complications (p > 0.999). Patient satisfaction with the donor site measured using the SCAR-Q questionnaire showed significantly higher scores in the DIEP/SCIP group when compared with the thigh group (p < 0.001), indicating a superiority of the lower abdominal area as an aesthetic donor site. Conclusions: The DIEP and SCIP flaps are a versatile option for reconstructing large soft-tissue defects following sarcoma resection. Therefore, flaps harvested from the lower abdomen yield a higher patient satisfaction with the donor site, which is a feature worth considering when planning a reconstructive procedure.