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.

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.

From laparoscopic to robotic-assisted Heller myotomy for achalasia in a single high-volume visceral surgery center: postoperative outcomes and quality of life.

BACKGROUND: Laparoscopic (LSC) Heller myotomy (HM) is considered the standard procedure for the treatment of achalasia. Robotic platforms, established over the last years, provide important advantages to surgeons, such as binocular 3-dimensional vision and improvement of fine motor control. However, whether perioperative outcomes and long-term results of robotic-assisted laparoscopic (RAL) HM are similar or even superior to LSC technique, especially concerning long-term follow-up, is still debated. Therefore, the aim of the present study was to evaluate intra- and postoperative results as well as long-term quality of life after RAL compared to LSC surgery for achalasia in a single high-volume visceral surgery center. METHODS: Between August 2007 and April 2020, 43 patients undergoing minimally invasive HM for achalasia in a single high-volume Swiss visceral surgery center, were included in the present study. Intra- and postoperative outcome parameters were collected and evaluated, and a long-term follow-up was performed using the gastroesophageal-reflux disease health-related quality of life (GERD-Hr-QuoL) questionnaire. RESULTS: A total of 11 patients undergoing RAL and 32 undergoing LSC HM were analyzed. Baseline demographics and clinical characteristics were similar. A trend (p = 0.052) towards a higher number of patients with ASA III score treated with RAL was detectable. Operation time was marginally, but significantly, shorter in LSC (140 min, IQR: 136-150) than in RAL (150 min, IQR: 150-187, p = 0.047). Postoperative complications graded Clavien-Dindo ≥ 3 were only observed in one patient in each group. Length of hospital stay was similar in both groups (LSC: 11 days, IQR: 10-13 vs. RAL: 11 days, IQR: 10-14, p = 0.712). Long-term follow-up (LSC: median 89 months, vs. RAL: median 28 months, p = 0.001) showed comparable results and patients from both groups expressed similar levels of satisfaction (p = 0.181). CONCLUSIONS: LSC and RAL HM show similar peri- and postoperative results and a high quality of life, even in long-term (> 24 months) follow-up. Prospective, randomized, controlled multicenter trials are needed to overcome difficulties associated to small sample sizes in a rare condition and to confirm the equality or demonstrate the superiority of robotic-assisted procedures for achalasia. Meanwhile, the choice of the treatment technique could be left to the operating surgeon's preferences.

Pedicled double-paddle vertical posteromedial thigh flap for double-layer closure and reconstruction of upper thigh defect after sarcoma resection: A case report.

Large soft tissue defects in the anterior upper thigh region represent a challenging problem in reconstructive surgery. Sarcomas are rather commonly localized in this area and they may reach extensive dimensions before surgery. The debulking procedures must be radical, which often leads to a displacement of major neurovascular structures. In the present work, we report the use of a pedicled double-paddle vertical posteromedial thigh (vPMT) flap to reconstruct a 16 cm × 8 cm soft tissue defect with exposure of the superficial and deep femoral vessels after resection of a myxoid liposarcoma. The vPMT flap was based on two perforators of the profunda femoris artery. Therefore, the cutaneous island could be split into two islands measuring 12 cm × 6 cm and 9 cm × 6 cm, which were exploited to fill the dead space below and over the vessels, reaching a satisfactory volume restoration and tension-free skin closure. The further post-operative course was uneventful. The perforator dissection might be complex and requires a good experience, however, we believe that in similar cases the pedicled double-paddle vPMT flap can be a valid solution when other options are not feasible. Moreover, this allows avoiding a free microsurgical transfer and fulfills the dictum of replacing "like-with-like tissue". No characterizations of the employment of a pedicled chimeric vPMT flap for locoregional multilayer reconstruction are available so far.