An Unexpected Late Recurrence of Breast Irradiation-Induced Angiosarcoma Following Autologous Microvascular Breast Reconstruction.

The authors present the case of a 68-year-old female who developed recurrent angiosarcoma, a rare but recognized complication after breast irradiation therapy in the treatment of breast cancer. Microvascular breast reconstruction was performed after the completion of 10 years of disease-free clinical surveillance. Abdominal tissue was harvested and transferred onto the chest wall with restoration of its blood supply using microsurgical techniques to recreate the breast. Unexpectedly, local recurrence of irradiation-induced angiosarcoma was confirmed in the reconstructed breast 12 years later, a unique finding, given the long latent period and recruitment of tissues from a distant site. It is vital to consider the potential of late recurrence before embarking on complex reconstructions, and this should be discussed with patients who have a history of angiosarcoma. This further emphasizes the importance of long-term surveillance in such a rare, yet aggressive tumor at specialist centers.

New technique for in-continuity axillary and supraclavicular lymphadenectomy for advanced metastatic melanoma using intraoperative image guidance: a case report.

Simultaneousinvolvement of the supraclavicular and axillary lymphatic basins is known to occur in metastatic skin cancers. We present the case of a 35-year-old male with metastatic melanoma present in the right neck and axillary lymph nodes. He underwent a combined, in-continuity dissection of both basins using intraoperative ultrasound to ensure full clearance of lymph nodes from the cervicoaxillary canal, which otherwise would have been impossible to achieve without clavicle osteotomy. This allowed us to avoid a division of the clavicle and related morbidity. Postoperative imaging confirmed no residual disease, and no local recurrence subsequently. We conclude that intraoperative use of ultrasound can help guide surgeons trying to achieve clearance of metastatic disease in anatomically complex regions, avoiding unnecessary morbidity.

Free ALT-flap can treat chronic seroma: a case report.

Seroma formation after axillary lymph node dissection for metastatic melanoma is a common problem. We present the use of free microvascular tissue transfer to treat a chronic postoperative seroma developed after axillary lymph node dissection for metastatic melanoma.

Distal perforator-only propeller (D-POP) anterolateral thigh flap for reconstructions around the knee: 4-year experience.

INTRODUCTION: Soft tissue reconstruction around the knee is challenging from a functional and aesthetic perspective. While locoregional options remain limited, free flaps produce additional scarring and longer hospitalization. We describe the most distal "D-perforator" of ALT-axis and present our 4-year experience with a distal perforator-only propeller anterolateral thigh (D-POP ALT) flap for reconstruction around the knee. METHODS: Seventeen patients (7 males, 10 females, mean age 57 years), had distal perforator-only propeller (D-POP) ALT flap reconstruction of defects following the wide local excision of melanoma around the knee joint between May 2014 and December 2018. The most distal perforator in the line between spina illiaca anterior superior (SIAS) and the upper lateral border of patella was identified and marked with audible-Doppler and perforator-only propeller ALT (POP-ALT) flap, which was designed around it. Perforators were dissected intramuscularly or intraseptally to allow adequate flap mobilization, but no division of main pedicle was ever performed to ensure anterograde blood supply. Flaps were rotated into defects while all donor-sites were closed directly. RESULTS: The largest flap measured 25 × 6 cm. The perforator was found between 4 and 9 cm proximal to the upper lateral border of patella in all cases. It was found to be septal in 10 cases and intramuscular in 7 cases. Healing was uneventful in all cases, and patients were ambulatory immediately postoperatively. All patients were discharged on postoperative day 1. Excellent long-term outcomes were observed on follow-up by the senior author. CONCLUSIONS: In our experience, this technique is simple, reliable, and versatile. Thin and pliable flaps can be safely raised based on the most distal (D-POP) ALT perforator. In addition, sizeable flaps can be performed while still preserving the main ALT pedicle, if free flap is required for the same patient in the future.

Hybrid perforator flaps: Introducing a new concept in perforator flap surgery.

INTRODUCTION: Although perforator propeller flaps provide a safe and reliable reconstructive option, they are often limited in size, reach and degrees of freedom due to venous insufficiency. As a result, partial flap necrosis, particularly at the tip of the flap, may occur in some cases causing the loss of substance. To overcome this problem, we present a new concept of hybrid perforator flaps. METHODS: From May 2014 to October 2017, 25 Hybrid perforator flaps were performed to reconstruct a variety of defects in upper and lower extremities following the removal of soft-tissue malignancies. Hybrid flaps included 14 hybrid radial collateral artery perforator propeller (RCAP) flaps, 7 hybrid propeller anterolateral thigh perforators (ALTs), 3 hybrid medial sural perforator flaps and one hybrid saphenous perforator flap. Following the excision of malignancy, several superficial skin veins were dissected on the edge of defect to be used as potential recipient vessels for venous supercharging. Hybrid flap design included the dissection of one or two superficial veins on the edge of the flap, which was used for prophylactic supercharging. The perforator flap was then raised in a usual fashion and rotated into the defect. Microsurgical venous anastomosis was performed between the previously prepared superficial flap vein and vein on the edge of defect. RESULTS: Venous stasis was encountered following flap rotation in 12 out of 25 flaps and was immediately resolved following venous anastomosis. No venous congestion was encountered perioperatively in the remaining 13 flaps. Healing was uneventful in 24 flaps with 100% flap surface area healed primarily and excellent functional/aesthetic outcome. Partial loss was found in only one single flap, with overall 96% success rate and 4% complication rate. CONCLUSIONS: Hybrid perforator flaps have the advantage of improved reliability, versatility and safety. In the author's experience, technique is reliable and obviates the need for flap monitoring. By including a superficial vein in the initial flap design and resectional defect, larger flaps can be harvested more reliably. The hybrid flap concept could potentially improve outcomes of propeller flaps. Our experience shows reduced complications when this technique is utilised with success rates comparable to free flaps.

Combined Karapandzic-Abbé/Estlander/Stein flap for subtotal and total lower lip reconstruction.

BACKGROUND: Lower lip reconstruction remains a challenging task due to multi-functional and high aesthetic requirements that have to be achieved for successful outcome. This is particularly true to near-total lower lip defects, encompassing over 70% of lower lip loss due to cancer, trauma or burns. Despite the fact that numerous flaps and their modifications have been described over the past century, only a few valuable techniques and concepts withstood the test of time for sub-total lower lip defects, each having their own drawbacks. We describe a new approach to these defects combining bilateral Karapandzic and Abbe/Estlander/Stein flaps, not reported so far, and present our long term outcomes. METHODS: From 2012 to 2016, five patients with T4 lower lip squamous cell carcinoma (SCC) underwent near-total and total lower lip resection and reconstruction with a combination of bilateral Karapandzic flap and double Abbé/Estlander/Stein flaps from the upper lip. RESULTS: Our patients were between 44 and 88 years old (mean 66.6). All flaps healed uneventfully in all patients. Patients were followed up between 18 and 60 months (mean follow up 33.6 months). There were no local tumor recurrencies. All patients were able to eat perorally whilst reconstructed lips were fully functional. No drooling was observed and aesthetic outcomes were excellent. CONCLUSIONS: Combined bilateral Karapandzic and Abbe/Estlander/Stein flaps can produce excellent functional and aesthetic outcomes in near total and total lower lip reconstructions and should be considered a reliable reconstructive option in patients with more then 70% of lower lip loss.

Contrast CT-scan for preoperative planning of VSLN (vascularized submental lymph-node) transfer.

BACKGROUND AND OBJECTIVES: Vascularized submental lymph-node (VSLN) transfer is gaining popularity as a reliable donor-site in microsurgical treatment of lymphedema. However, variations in number, location, and blood supply to submental lymph-nodes as well as associate skin-paddle make a predictable flap harvest a challenging task. We analyzed this region on preoperative imaging, to improve accuracy of VSLN transfers. METHODS: Contrast CT-scan analysis of VSLN-flap areas was performed in 58 patients. Number and location of visibly vascularized lymph nodes as well as submental artery perforators were identified, documented, and compared. RESULTS: About 409 lymph-nodes were found in 50 patients. No significant difference was found in the number of nodes between the right and left side. Significantly more lymph-nodes were found in zones 1B than zones 1A. In eight patients nodes were not identified. In the remaining 50 patients position of the visibly vascularized submental lymph-node was predictable. CONCLUSION: Significantly less lymph-nodes can be found in zone 1a then zone 1b. Location of visibly vascularized lymph nodes can be identified predictably in relation to bony landmarks. Blood supply to 1a nodes and particularly location of dominant skin perforator is unpredictable due to potential crossover. Contrast CT scan can help identify location and blood supply to submental lymph-nodes in most patients. J. Surg. Oncol. 2017;115:23-26. © 2016 Wiley Periodicals, Inc.

Double perforators-based superior gluteal artery propeller flap for reconstruction of lumbar defects.

Wide local excision of skin cancer in the lumbar area is a challenge to reconstruct. We report on the successful use of a two perforators-based superior gluteal artery perforator propeller flap, for the reconstruction of a lumbar defect.

Haemostatic property of cyanoacrylate in pedicled flaps.

We present a technique that can, in principle, be applied to any pedicled flap that is routinely used for reconstructions of the forehead. In our experience, cyanoacrylate glue applied to the pedicle before the flap is inserted decreases postoperative bleeding and wound exudate.

Chimeric Upper Eyelid--Supraorbital Flap Reconstruction.

Wide local excision of a lesion that encompasses several facial subunits including medial canthus, nasal sidewall, and cheek provides multiple aesthetic and reconstructive challenges to restore both orbital function as well as appearance. We report the first successful use of a chimeric upper eyelid--supraorbital flap to reconstruct a facial defect, secondary to a wide local excision of the lower eyelid, entire nasal sidewall, and infraorbital cheek in a patient with a biopsy-proven diagnosis of malignant melanoma. Chimeric upper eyelid--supraorbital flap provides simultaneous reconstruction of lower eyelid, nasal sidewall, and infraorbital areas, therefore replacing multiple facial aesthetic subunits at the same time providing unparalleled tissue quality match to all areas as well as excellent functional and aesthetic outcomes.

Complete mapping of lateral and medial sural artery perforators: anatomical study with Duplex-Doppler ultrasound correlation.

INTRODUCTION: The precise vascular anatomy of posterior lower leg skin is not well understood. Despite being a potential donor site for sural artery perforator flaps, this region is rarely used and underestimated. The aim of this study was to provide exact preoperative planning for medial and lateral sural artery perforator flap harvest. METHODS: An anatomical study on 16 cadaveric lower legs was performed to determine the number and location of all medial and lateral sural artery perforators in relation to five fixed points (medial and lateral maleolus, calcaneus, medial and lateral condyle). A Duplex study on 32 lower legs determined the number and location of dominant medial and lateral sural artery perforators in relation to same anatomical points. Results of the two studies were correlated. RESULTS: A total of 234 perforators were found in the anatomical (134) and Duplex studies (100). A dominant lateral sural artery perforator was found in 9.4% of all lateral perforators in 31% of dissected legs. A dominant medial sural artery perforator was found in 37% of all medial perforators in 94% of legs. The difference in the number of dominant medial and lateral perforators was significant (p < 0.001) in the anatomical study, while no significant difference was found in the Duplex study (p = 0.920). CONCLUSION: The anatomical study showed relative unreliability of sural region regarding number of dominant perforators. Therefore, harvest of medial and particularly lateral sural artery perforator flap is unsafe without preoperative perforator mapping. No significant difference in location of dominant perforators was found between Duplex and anatomical studies. Duplex proved reliable for planning of sural artery perforator flaps due to high precision in detecting location of dominant perforators.