Pedicled circumflex scapular artery perforator flap with intra-axillary tunneling for axillary defect coverage after surgical excision of hidradenitis suppurativa: A case report and literature review.

Axillary defects represent a rather common issue in plastic surgery practice. Surgical resections related to skin disease are frequent in this region and their extension often requires soft tissue transfer for coverage. In this setting, locoregional pedicled flaps are usually preferred. The nearby tissues offer pliable but still resistant skin, which satisfy the "like-with-like" reconstructive principle. Over the years different procedures have been described for this purpose. Among them, a valuable and often underestimated technique is the circumflex scapular artery perforator flap (CSAP). This technique might be particularly suitable for thin but relatively large defects. Its main advantages are a low donor site morbidity, a very reliable anatomy, and a perforator pedicle able supply a large skin paddle. In the present work, we report the use of a pedicled vertical CSAP flap passed through the axillary canal in order to cover a 9 cm × 7 cm axillary defect after surgical excision of hidradenitis suppurativa resistant to conservative treatment. The perforator-based pedicled presented two branches, which allowed us to harvest safely a large skin paddle, which limited its range of motion. For this reason, we opted for a passage through the axillary canal for the flap inset. The postoperative course was uneventful and full shoulder range of motion was obtained at 3 months follow-up. Despite most of the descriptions of this flap available so far showed its employment for limb's reconstructions, we believe that it is a very useful tool also for locoregional coverage. Moreover, the unconventional passage below the axillary muscles allowed reaching the recipient site even with a shorter pedicle, such as the one encountered in this case.

Propeller flap's assisted recipient site closure after free SCIP flap coverage of medial ankle defect: A case report.

Defects in the distal lower limbs are common in the field of orthoplastic reconstruction. The ankle area presents little subcutaneous tissue and is often affected by high-energy traumas and bone fractures. Wounds in this region are frequently associated with severe edema that might prevent primary closure. Due to its thinness and tension, the skin overlying both the medial and lateral malleoli is prone to necrosis, which can further lead to large soft tissue defects. Vessels, nerves, and tendons can easily become exposed. The reconstructive approach should aim to provide high-quality tissue that is durable enough to withstand the weight-bearing pressures and the friction from shoes, while remaining sufficiently elastic to conform to the shape of the ankle and to permit the foot movement. In this study, we describe the use of an additional propeller flap to reduce skin tension at the recipient site. A superficial circumflex iliac artery perforator (SCIP) flap was utilized to cover a defect below the medial malleolus. However, after flap inset, achieving a primary closure of the proximal wound without tension was not possible. During the dissection of the posterior tibial artery, perforator vessels were identified and preserved. The larger of these vessels was then used to vascularize a propeller flap, which was then rotated toward the defect to aid a tension-free closure. The postoperative course was uneventful. This case may provide a valuable insight into the challenges often faced during wound closure, even after flap inset. Since the flap itself may increase the width of the dissection area, the present case shows the importance of preserving perforator vessels during the proximal dissection since they can allow the harvest of an additional flap to achieve primary closure and further alleviate tension.

The use of superficial circumflex iliac perforator (SCIP) pedicle vein for lymphovenous anastomosis to treat inguinal lymphatic fistula: A case report.

The management of lymphatic fistulas following surgical procedures, in particular after inguinal lymphadenectomy, represents a significant clinical challenge. The current case report shows the novel use of the superficial circumflex iliac perforator (SCIP) pedicle vein for lymphovenous anastomosis (LVA) to treat a chronic inguinal lymphatic fistula in a 58-year-old male patient. This patient had developed a persistent lymphorrhea and wound dehiscence after a right inguinal lymph node biopsy performed for oncological reasons 1.5 months before. Pre-operative assessment with indocyanine green (ICG) lymphography confirmed a substantial lymphatic contribution to the wound discharge, thus guiding the surgical strategy. During the procedure, a pedicled tissue segment containing the SCIV was dissected and utilized to fill the wound's dead space and facilitate LVA with the leaking lymphatic vessel. Notably, a coupler device was employed for the anastomosis due to the large caliber of the lymphatic vessel involved, a technique not commonly reported in lymphatic surgeries. The result of the procedure was successful, with intra-operative ICG imaging confirming the patency of the anastomosis. After surgery the wound healed without complications. This case illustrates the potential of SCIV employment in lymphatic fistula repair in the inguinal region. While further research is needed to validate these findings, this report provides an unconventional approach to a relatively common problem in clinical practice.

The use of double free flaps with intra-flap anastomosis for complex defects reconstruction.

BACKGROUND: Over the years, the improvements in microsurgical field allowed the reconstruction of increasingly larger and more complex defects. In this context, we conceived linking more flaps with a single vascular supply. The double free flaps with intra-flap anastomosis offer a better match with recipient site requirements, still having a minimal donor and recipient site morbidity. In the present paper, we describe our experience with this procedure, focusing on its features and providing a collection of cases in different areas and clinical settings. PATIENTS AND METHODS: Consecutive single-center case series with 16 patients who received defect reconstruction using double free flaps with intra-flap anastomosis between February 2019 and August 2021. The median age was 58 years old (range 39-77). Nine patients were men and seven were women. The defects were located throughout the body, including breast, head and neck, lower and upper limbs. In 12 cases, the cause of the defect was surgical removal of a tumor, while in four cases the cause was trauma. The main indication for this procedure was related to the need of covering a large defect, either in terms of volume or surface, resorting to only one vascular axis. RESULTS: A total of 32 flaps were harvested, including 10 different techniques. The flaps size ranged from 6 × 3 cm to 24 × 8 cm. Eleven patients completely healed without any complications. No flaps were lost. Three patients developed a minor wound dehiscence and one a wound infection treated conservatively with antibiotic therapy. One patient experienced both of these complications. The median follow up was 12 months and ranged between 6 and 24 months. At the final clinical evaluation, the reconstructive result was stable in all cases and all the patients had a complete resumption of their daily activities. CONCLUSIONS: Double free flaps reconstruction with intra-flap anastomosis represents a valid and reliable option for the coverage of complex defects in case of depleted recipient sites. This procedure allows us to transfer high amounts of tissue resorting to a single vascular axis. However, it represents a technical challenge and a highly experienced microsurgical team is required.

Pedicled double-paddle conjoined medial sural artery perforator flap for popliteal defect coverage after skin tumor excision: A case report.

Defect coverage in the popliteal region represents a challenging task because of its peculiar features. The tissue here has to be thin and pliable, to enable proper function, but also resistant to the high stress forces typical of this region. In addition, the adjacent skin is limited in availability and mobility. Therefore, complex reconstruction procedures are usually required to cover defects in the popliteal region. The medial sural artery perforator (MSAP) flap is a thin and pliable flap, with a long arc of rotation provided by its pedicle length, which makes it a suitable procedure for local and regional defects reconstruction. In the present work, we report the use of a pedicled double-paddle conjoined MSAP flap to reconstruct a 7 cm × 7 cm soft tissue defect after resection of a basal cell carcinoma in the popliteal fossa. The MSAP flap was based on two perforators of the medial sural artery. Therefore, the cutaneous island could be split into two islands, which were rearranged to cover the defect side by side in a so-called "kissing flap" technique. The further postoperative course was uneventful. Despite the complex perforator dissection, which can be challenging because of its intramuscular dissection, we believe that the MSAP flap represents a valid solution for local defect coverage in the popliteal region, providing a sufficient amount of tissue and meeting the "like-with-like" criteria.

Combined use of lower medial thigh perforator (LMTP) flap and pedicled medial sural artery perforator flap (MSAP) for lateral knee defects coverage after sarcoma resection: A case report and literature review of soft tissue defect around knee reconstruction.

Reconstruction of knee defects still represents a challenge for reconstructive surgeons. After an extensive resection, the primary aim is to reach a stable result, while maintaining a good range of motion and aesthetic unity. The use of pedicled perforator-based flaps makes it possible to achieve these goals. Many are the flaps that can be used in this region, and the pedicle medial sural artery perforator (mSAP) flap is considered among one of the first-choice techniques. The purpose of this case report is to describe for the first time the use of pedicled mSAP flap to cover a lateral knee defect. A 79-year-old patient underwent extensive excision of sarcoma on the lateral side of the left knee, with removal of distal portion of the vastus lateralis muscle and portion of the biceps femoris tendon. The resulting defect from the excision measured 10 cm × 10 cm. To cover the postero-inferior part of the defect we decided to use a mSAP flap, with a skin paddle 10 cm × 5 cm, which was tunneled posteriorly to the popliteal artery and vein in order to reach the affected site. We then used a lower medial thigh perforator (pLMT) flap with a 15 cm × 5 cm skin paddle, rotated by 90° in a propeller fashion to cover the antero-superior portion of the defect. The decision to use two flaps was justified by the fact we wanted to close the donor areas with direct suturing for a better aesthetic result. The post-operative course was regular with only a small wound dehiscence that had healed by secondary intention. At 6 months postoperatively, the patient showed a complete active range of motion of the knee joint and absolute aesthetic satisfaction with flaps donor site and knee shape. A review of literature is also provided, with a specific focus on the different procedures for soft tissue defects reconstruction around the knee. According to our experience, the pedicle of the MSAP flap may be safely used as an additional reconstructive option for lateral knee defects.

Combined perforator flaps and lymphatic procedures in reconstructions after sarcoma resection.

BACKGROUND: Soft tissue sarcomas are a subtle category of tumors that often require an extensive surgical resection for definitive treatment. This kind of intervention inevitably leads to large tissue damage and, when regions with rich lymphatic network are involved, postoperative complications such as lymphocele or lymphedema are quite common. In this report we present our experience with the combination of lymphatic procedures with perforator flaps for defects reconstruction and lymphatic complications preventions after sarcoma resection throughout the body. METHODS: Between 2019 and 2021, 15 patients underwent a surgical resection of soft tissue sarcoma, also including bone tissue in 2 cases, requiring soft tissue reconstruction. A perforator flap reconstruction surgery was performed in all cases. The median age was 59.8 years old (ranging 23-84), 8 patients were females and 7 were males. The lymphovenous anastomosis (LVA) surgery concept was applied to all cases, while other additional lymphatic procedures were chosen individually for every patient. RESULTS: All patients were successfully treated without any perioperative complications. In 3 cases infected seroma was encountered in the acceptor site and then successfully treated by means of debridement and vacuum assisted closure (VAC) therapy. 2 patients experienced postoperative lymphedema in the acceptor site which was managed by secondary procedures. Good functional and aesthetic outcomes were achieved in all cases. The mean follow-up was 19.6 months (range 10-33 months). CONCLUSIONS: Different combinations of modern lymphatic procedures can be created to find the best solution and tailor the treatment to the patient's needs. Preventative measures regarding lymphatic complications can be highly effective and should be taken into consideration in every reconstructive approach following large soft tissue defects with impairment of the lymphatic network.

Pedicled SCIP-based vascularized lymphnode and lymphatic vessels transfer (VLNT and VLVT) for deep lymphatic system reconstruction and dead space obliteration after medial thigh sarcoma resection: A case report.

Soft-tissue sarcomas represent a cohort of rare and heterogeneous malignant tumors that could affect various body parts, with a higher incidence in the lower extremity. When these tumors are surgically removed, both the superficial and deep lymphatic pathways could also be damaged and might require immediate reconstruction to prevent lymphatic complications. In the present report, we describe a case of a patient affected by a high-grade (G3) spindle cell pleomorphic rhabdomyosarcoma of the upper medial thigh. A 22 × 20 cm mass was removed with exposure of the deep femoral vessels and the great saphenous vein. After intraoperative indocyanine green lymphography, it was determined that the superficial lymphatic vessels were intact, but the deep lymphatic system was unavoidably damaged. As a reconstructive procedure, we performed a pedicled SCIP-based vascularized lymphatic vessel transfer and vascularized lymph node transfer to restore the deep lymphatic system and dead space obliteration. The procedure was successful, and no signs of lymphatic impairment were observed during the two-year follow-up period. We believe that this novel approach might be helpful in cases of large and profound defects that involve the deep lymphatic system. The combination of these two techniques could help restore deep lymph drainage, minimizing the risk of superficial system overload and lymphatic dysfunction. No other cases have been described so far employing the same approach. Considering the obtained results, this procedure might be worth further investigation.

Utilization of the internal mammary perforators as the recipient vessels for microsurgical breast reconstruction: A systematic review and meta-analysis of the literature.

BACKGROUND: The selection of reliable recipient vessels is essential for successful free tissue transfer. The use of internal mammary intercostal perforators (IMAPs), instead of the internal mammary vessels as the recipient vessels, has been described in breast reconstruction. Debates exist regarding the reliability of these perforators as recipient vessels because of their variability in location and caliber. The aim of this paper was to conduct a systematic literature review and meta-analysis to determine the reliability of the IMAPs as recipient vessels. METHODS: A systematic literature review was performed on the "PubMed," "Medline," "Ovid," and "Cochrane library" databases for articles published from January 1990 to March 2021. Exclusion criteria were non-English studies, reports with case number less than 5, cadaveric or animal studies, and studies with incomplete postoperative outcomes. The reliability of using IMAPs for breast reconstruction was determined by assessing the reported rates of partial or complete flap failure and other complications (fat necrosis, skin necrosis, and requirement for revision surgery). RESULTS: Three hundred and sixteen cases in 13 studies were included for further analysis with more than 85% of the IMAPs suitable for anastomosis being located in the second and third intercostal spaces. Partial or total flap failure was reported in three of 316 patients (0.95%). The rate of other complications such as fat necrosis, skin necrosis, and requirement for revision surgery were all less than 5%. CONCLUSION: With deliberate preoperative planning, delicate perioperative manipulation, and meticulous microvascular anastomosis, the internal mammary perforators can be used as reliable recipient vessels in microvascular breast reconstruction.

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.

Functional reconstruction of the unilateral supraglottis and piriform sinus with a triple chimeric superficial circumflex iliac artery perforator flap after supraglottic laryngectomy: A case report.

Preservation of laryngeal functions after supraglottic laryngectomy depends on both the extent of surgical resection and the type of reconstruction. Any reconstructive modality faces the challenges of preserving voice and swallow function due to the complex and dynamic anatomy of the larynx. In this report, we present a case in which the entire affected unilateral supraglottis and piriform sinus were functionally reconstructed using a triple chimeric superficial circumflex iliac artery perforator (SCIP) free flap. An extended unilateral supraglottic laryngectomy and neck dissection were performed in a 78-year-old male patient presenting with a supraglottic cT4a cN0 cM0 laryngeal cancer. The resulting defect was reconstructed using a triple chimeric SCIP flap from the right inguinal region intended to reconstruct the different affected compartments. It was based on three perforators and consisted of a 4 cm × 3 cm fascial flap from the external oblique muscle and two fasciocutaneous paddles measuring 6 cm × 2 cm and 3 cm × 4 cm. The arterial and venous vessels were anastomosed to the superior thyroid artery and internal jugular vein. The fascial flap was used to reconstruct the aryepiglottic fold. The smaller fasciocutaneous paddle was utilized to reconstruct the affected piriform sinus and former thyroid cartilage compartment, while the larger fasciocutaneous paddle served as a monitor skin flap. The postoperative recovery was uneventful. Laryngeal functions including voice and deglutition were well-preserved after 4 months of rehabilitation. The patient showed no signs of chronic aspiration or tumor recurrence 6 and 12 months postoperatively. The pliable and versatile triple chimeric SCIP flap provides a useful free flap option for a tailored functional reconstruction after an extended supraglottic laryngectomy. Restoration of larynx elevation and mobility with the presented technique substantially improves swallow rehabilitation while preserving the voice.

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.

The use of vertical postero-medial thigh flap as lymphatic flow-through flap for upper thigh defect reconstruction and lymphatic sequelae prevention in sarcoma surgery: A case report.

Among the various histologic subpopulations of soft tissue sarcomas, undifferentiated pleomorphic sarcoma (UPS) is one of the most common subtypes in the adult population. Radical surgery remains the primary treatment for UPS, associated with postsurgical radiotherapy or chemotherapy. We herein report the case of a 65-year-old man presenting a recurrent UPS in his right upper thigh region. The patient received radical resection of the tumor and the remaining defect measured ~22 cm × 18 cm. A soft tissue functional reconstruction with lymphatic-flow-through pedicled postero-medial thigh flap (PMT) was planned. A 24 cm × 16 cm flap was harvested in vertical fashion (vPMT), carefully preserving a superficial vein for the following lymphovenous anastomosis (LVA) at recipient site. The flap was then rotated and transferred to the defect area through a tunnel under the adductor longus muscle, and LVA was then performed between flap's additional venous pedicle and a nearby leaking lymphatic vessel. The postoperative course was uneventful and at 12 months follow-up no complications were encountered. No signs of lymphedema were reported. When dealing with the groin and upper thigh area, which is notably rich in lymphatic tissue, the possibility of prophylactically re-route lymphatic fluid into the venous system by means of microsurgical anastomosis, lays in the thrilling possibility to prevent secondary lymphedema, instead of curing it. With the described technique, we achieved optimal functional and esthetic outcomes setting at zero both donor and recipient sites morbidity.

Combination of four pedicled flaps for multilayer reconstruction of massive pelvic defect: A case report.

Tumors affecting the perineal region are a subtle and difficult to diagnose type of malignancy. In particular, soft tissue sarcomas (STS) may be already very large at time of diagnosis, thus impairing a normal life. In such severe cases, debulking surgery is the only possibility to offer the patient an acceptable quality of life again. These procedures inevitably result in massive defects. Depending on the affected area, there are different reconstructive options available so far, and sometimes a combination of multiple flaps is required. With the present report, we would like to share our experience with a complex genital and perineal defect. A 75-year-old patient presenting a massive epithelioid sarcoma in the ischio-rectal and anal fossae underwent a surgical excision with safe margins, which included the resection of the external genitalia, the pubis, and the rectum. The end result of this procedure was a massive defect measuring 31 cm (length) × 8 cm (width) × 6 cm (depth). To accomplish the requirements of this particular case we planned to utilize mostly the nearby tissues. The reconstruction was performed layer by layer. We resorted to a pedicled chimeric anterolateral thigh (ALT) flap measuring 8 cm × 6 cm, with a large amount of the vastus lateralis (20 cm × 8 cm) to fill the deeper defect, and a duplicated fascia lata (20 cm × 6 cm) to restore the abdominal support of the pubis. Then the external coverage was completed combining a pedicled superficial circumflex (SCIP) flap measuring 9 cm × 8 cm, a pedicled gracilis flap measuring 27 cm × 4 cm and a pedicled posteromedial thigh (PMT) flap measuring 22 cm × 8 cm harvested in vertical fashion. The postoperative course was uneventful, and at 6 months follow up the reconstructive result was successful with a stable soft tissue coverage and no complaints from the patient. With the present case report, we would like to show the importance of mastering different reconstructive procedures, whose combination might be the only solution to cover very large and complex defects.

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.

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.

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.

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.

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.

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.