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.

Head and neck reconstruction with the superficial circumflex iliac artery perforator (SCIP) free flap: Lessons learned after 73 cases.

BACKGROUND: Head and neck tissue defects after ablative 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, which may represent the optimal procedure in this setting. Over the last 5 years, we collected a large base of experience, including both simple and chimeric SCIP-based reconstruction, making this flap our first choice for head and neck reconstructions. PATIENTS AND METHODS: Seventy-three patients undergoing ablative head and neck surgery for oncologic pathologies were treated by means of a SCIP flap reconstruction. Patients' mean age was 67 years old (range 37-89), 51 were males and 22 were females. Fifty-eight flaps were simple and 15 were chimeric reconstruction patterns. Indocyanine green perfusion imaging was performed in all cases. RESULTS: All the patients were successfully treated with no flap losses were encountered. Twelve patients encountered postoperative complications: in four cases revision surgery was required for venous congestion, while the remaining cases were managed conservatively (four wound dehiscence and three infections). No patients showed donor site complications. The mean follow-up period was 11 months (range 3-24). CONCLUSIONS: Our case series demonstrates the reliability and versatility of the SCIP flap for different kinds of head and neck reconstructions. The chimeric options combined with bone, double skin paddle, and muscle offer a broad variety of functional reconstructive solutions for complex head and neck surgeries. Intraoperative indocyanine green perfusion examination provides a valuable tool to assess and ascertain proper vascularization and post-anastomosis vessel patency in complex microvascular flap-based reconstructions.

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.

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 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.

Revisiting the pedicled circumflex scapular artery (pCSA) perforator flap: From simple to complex locoregional reconstructions.

BACKGROUND: Soft tissue defects involving the axilla and the upper back region are often complex to treat. The complexity of these defects may be extremely different, ranging from superficial skin damage to large loss of substance with lymphatic drainage impairment. The pedicled circumflex scapular artery (pCSA) perforator flap represents a valid procedure in this setting. It can be tailored according to the patient's needs, and its intraseptal pedicle allows a quick dissection with a wide range of motion. PATIENTS AND METHODS: Twenty-four consecutive patients treated by means of pCSA perforator flap were included. All the flaps were pedicled and were used for locoregional reconstructions. The etiology of the defects was an oncologic resection in 15 cases, acne/hidradenitis suppurativa resection in 6 cases, lymphatic complication in 2 cases, and burn in 1 case. Patients' mean age was 61 years old; seventeen were males and seven were females. RESULTS: All the patients were successfully treated with good aesthetic and functional results. One patient presented with a wound dehiscence, which required secondary surgical treatment. No partial or complete flap losses were encountered. Primary closure of the donor site was achieved in all cases. The mean follow-up period was 10.5 months (range 6-12). CONCLUSIONS: This case series shows the reliability and versatility of the pCSA perforator flap for locoregional reconstructions. Because of its rich vascularisation, extensive or unconventionally-shaped flaps are possible. Moreover, its lymphatic rich tissues make it suitable for the treatment of complications related to axillary lymphadenectomy.

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.

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.

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.

Unlocking the Power of Benchmarking: Real-World-Time Data Analysis for Enhanced Sarcoma Patient Outcomes.

Benchmarking is crucial for healthcare providers to enhance quality and efficiency, notably for complex conditions like sarcomas. Multidisciplinary teams/sarcoma boards (MDT/SBs) are vital in sarcoma management, but differences in their processes can affect patient outcomes and treatment costs, despite adherence to international guidelines. To address this issue, this study aimed to compare two MDT/SBs and establish an interoperable digital platform, Sarconnector®, for real-time-world data assessment and automated analysis. The study included 983 patients, 46.0% of whom female, with a median age of 58 years, and 4.5% of patients presented with metastasis at diagnosis. Differences were observed in the number of first-time presentations, follow-up presentations, primary sarcomas, biopsies and chemotherapy indications between the two MDT/SB. The results highlight the importance of benchmarking and utilizing a harmonized data approach, such as the RWT approach provided by the Sarconnector®, to standardize and evaluate quality and cost metrics. By identifying areas of improvement and making data-driven decisions on the meta-level, healthcare providers can optimize resources and improve patient outcomes. In conclusion, benchmarking with the RWT harmonized data approach provided by the Sarconnector® can help healthcare providers improve the overall effectiveness of the healthcare system and achieve better outcomes for their patients in terms of both outcomes and costs.

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 Sarcoma-Specific Instrument to Longitudinally Assess Health-Related Outcomes of the Routine Care Cycle.

Patient-based health related quality of life (HRQoL) measurements are associated with an improvement in quality of care and outcomes. For a complex disease such as sarcoma, there is no disease-specific questionnaire available which covers all clinically relevant dimensions. Herein, we report on the development of an electronically implemented, sarcoma-specific instrument to assess health-related outcomes, which encompasses a combination of generic questionnaires tailored to the respective disease and treatment status covering the entire longitudinal care cycle. An interoperable digital platform was designed to provide a node between patients and physicians and to integrate the sarcoma-specific HRQoL instrument with patient and physician-based quality indicators to allow longitudinal structured real-world-time data evidence analytics. This approach enables the prediction modeling of disease, and by attributing cost tags to quality indicators, treatment effectiveness for a given disease will be directly correlated with financial expenses, which may ultimately lead to a more sustainable healthcare system.

How Is the Spectrum of Sarcoma Surgery Assessed?

PURPOSE: To meet the challenges of the precision medicine era, quality assessment of shared sarcoma care becomes pivotal. The MDT approach is the most important parameter for a successful outcome. Of all MDT disciplines, surgery is the key step to rendering sarcoma patients disease free; therefore, defining its spectrum is critical. To the best of the authors' knowledge, a comprehensive interoperable digital platform to assess the scope of sarcoma surgery in its full complexity is lacking. METHODS: An interoperable digital platform on sarcoma surgery has been created to assess the clinical exposure, tumor characteristics, and surgical settings and techniques applied for both resections and reconstructions of sarcomas. RESULTS: The surgical exposure of an individual surgeon over time served as a pilot. Over the study period of 10 years, there were 723 sarcoma board/MDT meetings discussing 3130 patients. A total of 1094 patients underwent 1250 surgical interventions on mesenchymal tumors by one single sarcoma surgeon. These included 615 deep soft tissue tumors (197 benign, 102 intermediate, 281 malignant, 27 simulator, 7 metastasis, 1 blood); 116 superficial soft tissue tumors (45 benign, 12 intermediate, 40 malignant, 18 simulator, 1 blood); and 519 bone tumors (129 benign, 112 intermediate, 182 malignant, 18 simulator, 46 metastasis, 14 blood, and 18 sequelae of first treatment). Detailed types of resections and reconstructions were analyzed. CONCLUSIONS: An interoperable digital data platform on sarcoma surgery with transparent real-time descriptive analytics is feasible and enables large-scale definition of the spectrum of sarcoma surgery to meet the challenges of sarcoma precision care in the future.

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.

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.