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Background and Objectives: Soft tissue reconstruction after sarcoma ablation in the posterior aspect of the upper arm has been commonly addressed using the pedicled latissimus dorsi musculo-cutaneous flap. The use of a free flap for coverage of this region has not been reported in detail. The goal of this study was to characterize the anatomical configuration of the deep brachial artery in the posterior upper arm and assess its clinical utility as a recipient artery for free-flap transfers. Materials and Methods: In total, 18 upper arms from 9 cadavers were used for anatomical study to identify the deep brachial artery’s origin and point of crossing the x-axis, which was set from the acromion to the medial epicondyle of the humerus. Measurements of the diameter were taken at each point. The anatomic findings of the deep brachial artery were employed clinically in the reconstruction of the posterior upper arm after sarcoma resection using free flaps in 6 patients. Results: The deep brachial artery was found in all specimens between the long head and the lateral head of the triceps brachii muscle, and it crossed the x-axis at an average distance of 13.2 ± 2.9 cm from the acromion, with an average diameter of 1.9 ± 0.49 mm. In all 6 clinical cases, the superficial circumflex iliac perforator flap was transferred to cover the defect. The average size of the recipient artery, the deep brachial artery, was 1.8 mm (range, from 1.2 to 2.0 mm). The average diameter of the pedicle artery, the superficial circumflex iliac artery, was 1.5 mm (range, from 1.2 to 1.8 mm). All flaps survived completely with no postoperative complications. Conclusions: The deep brachial artery can be a reliable recipient artery in free-flap transfers for posterior upper arm reconstruction, given its anatomical consistency and sufficient diameter.

Despite the increasing popularity of autologous breast reconstruction, limited evidence is available. The aim of the present study was to compare the short-term outcomes of pedicled- and free-flap breast reconstructions.Using a nationwide Japanese inpatient database, we identified 13,838 patients who underwent breast reconstruction for breast cancer (July 2010-March 2020) using a pedicled or free-flap (pedicled- and free-flap groups, n = 8279 and 5559, respectively). One-to-one propensity score matching was performed to compare the occurrence of postoperative complications, duration of anesthesia, length of stay, and total costs between the two groups. We also performed subgroup analyses stratified by hospital volume.The propensity score-matched analysis involving 3524 pairs showed that the pedicled-flap group had significantly lower proportions of takeback (2.1% vs. 3.2%, p 0.001), thrombosis (0.6% vs. 1.7%, p 0.001), and postoperative bleeding (2.1% vs. 5.7%, p 0.001) than the free-flap group. No significant differences were found in wound dehiscence or tissue necrosis. Compared to the free-flap group, the pedicled-flap group had a short duration of anesthesia (412 vs. 647 min, p 0.001) and low total hospitalization costs (12 662 vs. 17 247 US dollars, p 0.001) but a prolonged postoperative length of stay (13 vs. 12 days, p 0.001). The subgroup analyses showed results compatible with those of the main analysis.In this large nationwide cohort of patients who underwent breast reconstruction, pedicled-flap reconstruction was associated with fewer postoperative complications (excluding necrosis and wound dehiscence) and lower hospitalization costs but a longer postoperative length of stay than free-flap reconstruction.

Severe trismus often causes significant compromise in quality of life due to severe impairment of oral functions. Treatment of trismus needs to be tailored to the cause. Here, we report the case of a successful treatment for severe trismus after maxillectomy using coronoidectomy, condylectomy, and vascularized fibula flap transfer. A 65-year-old female suffered from severe trismus due to temporomandibular joint (TMJ) ankylosis and contracture of the oral mucosa 5 years after partial maxillectomy for a squamous cell carcinoma. Surgical release including a masticatory muscle myotomy, a coronoidectomy, and a condylectomy was performed. After the surgical release, the size of the defect of the oral mucosa was 5 × 10 cm. Then a free vascularized fibula osteomusculocutaneous flap with a 5 × 12 cm skin paddle and a 5 cm fibula bone was transferred. The fibula bone was fixed to the hard palate and zygomatic body. The intraoperative final interincisal distance achieved 30 mm. The postoperative course was uneventful and the free fibula osteomusculocuateous flap survived completely. At 32-month follow-up, although the interincisal distance had regressed to 25 mm, the patient maintained an improvement in the patient's quality of life. Combined treatment with coronoidectomy, condylectomy and free tissue transfer may be effective for severe trismus having multiple causes: oral mucosa contracture and TMJ ankylosis.

Background Breast reconstruction using autologous tissue has been widely performed, and its safety and usefulness have been reported. However, there are few reports on the long-term morphological evaluation of autologous breast reconstruction cases. We evaluated long-term change of breast shape using Vectra, a 3-dimensional imaging device, for breast reconstruction cases with more than 10 years of follow-up. Methods The subjects had undergone autologous tissue breast reconstruction between 2007 and 2009. Sixteen deep inferior epigastric perforator flap cases were included in this study. For each patient, 4 items were measured as indicators: breast width, distance from the sternal notch to the nipple, distance from the nipple to the inframammary fold, and breast volume. The ratio of reconstructed breast to healthy breast was calculated for these 4 items. Results The long-term average ratio of breast width was 0.99, that of distance from the sternal notch to the nipple was 0.98, that of distance from the nipple to the inframammary fold was 0.94, and that of breast volume was 1.13. We evaluated the influence of body mass index and age at the time of the primary reconstructive surgery, but there was no significant difference in 2 body mass index groups (obese and nonobese groups) and 2 age groups (less than and more than 50 years old). Conclusion We assumed that the balance between the reconstructed breast and the contralateral native breast would become worse over time because of breast sagging and changes in breast elasticity. According to our study, the shape balance of left and right breasts was maintained over time. Limitation of this study is the fact that more than half of the cases included in this study had undergone small to moderate revision surgery during the course of follow-up.

The efficacy of the use of the pedicled ALT flap for buttock defects has not been established in the literature. Here, we present a case of a successful reconstruction of a large gluteal defect after sarcoma resection using a pedicled ALT flap assisted by preoperative computed tomographic angiography (CTA) and intraoperative indocyanine green (ICG) angiography. A 94-year-old man underwent resection of a large soft tissue tumor in the gluteal region resulting in a 19 × 15 cm defect. Based on three-dimensional reconstructed images of the preoperative CTA, the length of the pedicle of an ALT flap was estimated. Perfusion of the whole flap was confirmed using intraoperative ICG angiography. The flap was inserted through a subcutaneous tunnel and covered the defect completely. The postoperative course was uneventful. The patient resumed ambulation 1 week after the operation. The follow-up at 2 months showed complete flap survival, and the patient was able to walk with a cane. The pedicled ALT flap transfer may be a reliable alternative for gluteal reconstruction when guided by pre- and intraoperative imaging modalities.

Background During elevation of the superficial circumflex iliac artery (SCIA) perforator (SCIP) flaps, the flap pedicle must often be converted from the superficial branch to the deep branch of the SCIA, complicating and prolonging the procedure. The goal of the present study was to demonstrate the effectiveness of high-resolution ultrasonography to decrease the conversion rate on which no previous report has focused, by making a comparison with a conventional method. Methods Forty-five consecutive cases where free SCIP flap transfer was performed for reconstruction were retrospectively reviewed. To preoperatively mark the course of the superficial branch, handheld Doppler ultrasonography was used in 27 cases (group 1) and a high-resolution ultrasound system in 18 cases (group 2). Results The conversion rate was significantly greater in group 1 than in group 2 (10/27 [37%] vs. 0/18 [0%], p = 0.003]. The frequency of use of multiple venous anastomoses was significantly higher in group 1 than in group 2 (21/27 [78%] vs. 2/18 [11%], p Conclusion The use of a preoperative high-resolution ultrasound system significantly decreased the rate from of intraoperative conversion from the superficial branch to the deep branch of the SCIA. It also resulted in significantly fewer venous anastomoses and a shorter operative time, while maintaining a low incidence of postoperative complications.

Background The use of intraoperative indocyanine green (ICG) angiography has been well documented for confirmation of arterial perfusion in transferred free flaps. However, no previous report has yet focused on whether ICG angiography can be used to detect congestion in free flaps. The present report investigates the feasibility of ICG angiography for detecting flap congestion intraoperatively through illustrative cases. Methods From September 2019 to September 2020, 65 consecutive female patients who underwent breast reconstructions using a free deep inferior epigastric perforator (DIEP) flap were enrolled in this study. Forty-eight patients with 52 DIEP flaps were eligible for the study after application of the exclusion criteria. ICG angiography was performed after elevation of the flap, after completion of the anastomoses, and after inset of the flap. Results In five cases (9.6%), an inadequate highlight was demonstrated with ICG angiography performed after flap elevation. All such cases were deemed congestive since robust bleeding was observed with the prick test. ICG angiography demonstrated sufficient highlight of the flap after removal of the clamp on the superficial inferior epigastric vein. In two cases (4.2%), kinking of the pedicle vein of the DIEP flap was found with ICG angiography performed after inset of the flap. In both cases, the pedicle and the flap were reinset. All flaps survived completely postoperatively. Conclusion ICG angiography can detect flap congestion, and the proposed 3-step protocol is useful for the prevention of postoperative complications.

Background Recently, the deep inferior epigastric perforator (DIEP) flap has become the gold standard for breast reconstruction, but it has some drawbacks such as abdominal bulging and hernia. To overcome these disadvantages, the superficial inferior epigastric artery perforator (SIEA) flap is used as an alternative option, but it has another problem, namely limited vascular territory and risk of vascular thrombosis. To solve these problems, we introduced our new technique, a combined SIEA and superficial circumflex iliac artery perforator (SCIP) based double pedicled abdominal flap. In this report, we present our experience of using this technique. Methods The SIEA and SCIP based double pedicled abdominal flap was used in five patients who wanted to have unilateral breast reconstruction after a mastectomy due to breast cancer. The average age was 48.2 (range 38-56) years, and the average BMI was 24.4 (range 19.2-31.4). The SIEA and SCIP based double pedicled abdominal flap was designed as a modified DIEP flap, and all flaps were placed in the vertical setting. The flap pedicles had two different vascular supplies, SIEA and SCIA, and the drainage systems, SIEV and SCIV, anastomosed to the internal mammary artery and vein in all cases. Results The harvested SIEA and SCIP based double pedicled abdominal flaps were a median volume of 925 g (range 452-1570 g) and average size of 491 cm2 (range 440-611 cm2 ). The average reconstructive time was 7:41 (range 6:31-9:17). In four out of the five cases, the SIEA and SCIA joined together to make a common pedicle artery trunk, and its average size was 1.08 mm. Four out of the five cases had a wide vascular territory crossing the abdominal midline as shown by ICG angiography. One case showed ICG fluorescence for the hemi-side of the abdominal flap. Postoperative course was uneventful, and there were no major perioperative complications, which need extra surgical procedures. Follow-up period averaged 273 days (range 194-312 days). Conclusion The SIEA and SCIP based double pedicled abdominal flap showed viable flap territory across the midline in all cases. The SIEA and SCIP based double pedicled abdominal flap might be another ideal option for breast reconstruction, when appropriate SIEA and SCIA pedicles are identified, and an adequate ICG fluorescence is obtained for the size of flap needed.

Background In the setting of the reconstruction for a large defect, we must make the maximum use of the limited human tissue with the minimum damage. In this article, we report on reconstruction using a combination of three-skin paddle latissimus dorsi and a scapular flap for a large defect after soft tissue sarcoma resection to minimize donor site morbidity. Methods From 2000 to 2012, six patients underwent primary reconstruction using free or pedicled triple-lobe combined latissimus dorsi and scapular flap after wide resection of soft tissue sarcoma. There were five male patient and one female, and their average age was 66.8 (range, 49-80 years). The location of the defects was the thoracic wall in three, the thigh in one, the knee in one, and the shoulder in one. The average size of the defect was 18.8 × 13.9 cm. Results The average size of the ascending scapular flap and the skin paddle of the latissimus dorsi flap was 6.8 × 13 cm and 7.3 × 14.7 cm. One patient had partial necrosis of the skin paddle of the latissimus dorsi flap, which was treated conservatively. The triple-lobe combined latissimus dorsi and scapular flaps survived completely in five cases. Neither anastomosis complications nor infections were encountered. The average follow-up period was 63.67 months. All patients were satisfied functionally and esthetically with the reconstruction outcomes at the end of follow-up. Conclusion In conclusion, the triple-lobe combined latissimus dorsi and scapular flap is one of the options for reconstruction of a large defect after sarcoma resection to minimize donor site morbidity.

Background The superficial circumflex iliac artery perforator (SCIP) flap cannot be used for coverage of large defects. We introduce a novel flap design to overcome the SCIP flap's size limitation. Methods Data of patients who underwent coverage of defects exceeding 113 cm2 (12 × 12 cm) using combined flaps composed of an SCIP flap and either a superficial inferior epigastric artery (SIEA) flap or a deep inferior epigastric artery perforator (DIEP) flap from September 2015 to September 2019 were retrospectively reviewed. After elevation of the SCIP flap, the SIEA was dissected. If the diameter of the SIEA was smaller than 0.5 mm, a DIEP included in the flap design was identified. For minimal donor site morbidity, the DIEP dissection was limited to its takeoff point from the deep inferior epigastric artery (DIEA), and a small T-portion of the DIEA was harvested. Results Six patients met inclusion criteria. The average defect size was 18.5 ± 2.3 × 15.7 ± 3.7 cm, and all defects were sufficiently covered. The mean dimensions of the SCIP flap, the SIEA flap, and the DIEP flap were 18.5 ± 2.5 × 7.5 ± 1.0 cm, 15.5 ± 2.1 × 6.6 ± 1.6 cm, and 17.5 ± 2.1 × 6.5 ± 0.7 cm, respectively. All flaps survived completely with no healing complications, and no donor site complications were observed. The SCIP flap was combined with the SIEA flap in four cases and with the DIEP flap in two cases. The average follow-up period was 12.7 ± 6.7 months. The final outcome was satisfactory in all cases. Conclusion Large defects (up to 20 × 20 cm) can be covered with minimal donor site morbidity, with primary closure, by combining either the SIEA or the DIEP flap with the SCIP flap.

Background Reconstruction after wide resection of a large sarcoma arising in the posterior trunk may require free-flap transfer to reduce the postoperative complications. Here, we describe the recipient vessels on the whole posterior trunk. Moreover, to show the reliability of these vessels, we describe an institutional series of free-flap reconstruction. Methods In the cadaveric study, 20 posterior trunk regions from 10 fixed cadavers were dissected. The location and the diameter of the perforating artery and vein on the posterior were documented. In the clinical study, 54 patients undergoing immediate reconstruction surgery with only a pedicled flap (n = 45) and with a free flap (n = 9) after sarcoma resection on the posterior trunk between July 2005 and September 2021 were identified. One-to-one propensity score matching was performed to compare the postoperative complications. Results In the cadaveric study, a total of 178 perforators were identified. The average diameter of the superficial cervical artery (SCA) and vein, dorsal scapular artery (DSA) and vein, medial branch of dorsal intercostal artery perforator (m-DICAP) and vein, lateral branch of dorsal intercostal artery perforator (l-DICAP) and vein, and dorsolateral intercostal artery perforator (DLICAP) and vein were 1.03, 1.67, 1.38, 1.84, 1.28, 1.84, 1.01, 1.60, 1.11, and 1.70 mm. In the clinical study, the propensity score-matched analysis involving eight pairs showed a significantly higher occurrence of total complications in the pedicled-flap group than the free-flap group (62.5 vs. 0%, p = 0.03). Conclusion The cadaveric study showed that the perforators from the SCA, DSA, and posterior intercostal artery are constantly present. The clinical study demonstrated the feasibility and reliability of a free-flap transfer.

Background and Objectives: Among many donor site options for autologous breast reconstruction, the use of the profunda femoris artery perforator (PAP) flap has become common in patients who are not suitable for the gold standard procedure, the deep inferior epigastric artery perforator flap. However, its limited volume has precluded its wide use in breast reconstruction. The aim of this report was to demonstrate the effectiveness of a method in which the anatomical position of the pectoralis major muscle was adjusted to augment the volume of the superior pole of the breast during PAP flap transfer. A comparison was made with a conventional PAP flap breast reconstruction. Materials and Methods: Fifty-nine consecutive cases where unilateral autologous breast reconstruction was performed using the vertically designed PAP flap were retrospectively reviewed. Conventional PAP flap transfer was performed in 36 patients (Group 1), and PAP flap transfer with pectoralis major muscle augmentation was performed in 23 patients (Group 2). Results: The patient satisfaction at 12 months postoperatively was statistically greater in Group 2, with the pectoralis major muscle augmentation, than in Group 1 [23/36 (64%) vs. 22/23 (96%), p = 0.005]. There were no significant differences in postoperative complication rates at the reconstructed site [2/36 (5.6%) vs. 0/23 (0%), p = 0.52]. Conclusions: Higher patient satisfaction could be achieved with pectoralis major muscle augmentation in PAP flap breast reconstruction without increasing the postoperative complication rate at the reconstructed site.

In the treatment of sarcoma, the reconstructive surgeon must consider not only limb salvage but also functional reconstruction. The aim of this study was to evaluate a functional reconstruction of a dorsal forearm defect after sarcoma resection using immediate tendon transfer. Patients who underwent reconstruction of a dorsal forearm defect after sarcoma resection with an immediate tendon transfer between 1997 and 2019 at our hospital were included in this retrospective study. Patient demographics, tumor characteristics, surgical characteristics and functional outcomes were examined. Nine patients were included in this study. Tendon transfer of the flexor carpi radialis (FCR) or the flexor carpi ulnaris (FCU) to the extensor digitorum communis (EDC), the brachioradialis (BR) to the EDC, and the palmaris longus (PL) tendon to the extensor pollicis longus (EPL) was performed in seven, two and five patients, respectively. Seven patients underwent reconstruction using a free flap. Neither anastomosis complications nor infections were encountered. Partial flap necrosis and donor site dehiscence were seen in one case each. The mean distal interphalangeal (DIP), proximal interphalangeal (PIP) and metacarpophalangeal (MP) joint active extension were 4.4°, 6.1° and 11.1° postoperatively. The mean Musculoskeletal Tumor Society (MSTS) score was 26. Immediate tendon transfers of the FCR or the FCU to the EDC and the PL tendon to the EPL can be considered an optimal functional reconstruction of a dorsal forearm defect after sarcoma resection.

Background The superficial circumflex iliac artery (SCIA) perforator (SCIP) flap has gained acceptance among reconstructive microsurgeons, the minimal donor site morbidity being its greatest advantage. The purpose of this article is to introduce the use of preoperative ultrasonography to facilitate elevation and to avoid postoperative complications of the SCIP flap. Methods Preoperative mapping of the SCIA and the superficial circumflex iliac vein (SCIV) using a high-resolution ultrasound system were performed in patients undergoing reconstruction using a free SCIP flap. The skin paddle was designed placing the SCIA and the SCIV in the middle of the flap. Results Preoperatively marked SCIA and SCIV were found intraoperatively in all cases. The skin paddle design for sufficient arterial inflow and venous drainage resulted in no postoperative flap complications. Conclusion The use of a preoperative high-resolution ultrasound system significantly facilitates elevation of the SCIP flap, notably via the following 2 points: 1) pedicle can always be found under the markings made with preoperative ultrasonography, 2) satisfactory perfusion of the flap can be guaranteed via a safe flap design that includes preoperatively marked vessels within the skin paddle.

Background Recent advances in the superficial circumflex iliac artery (SCIA) perforator flap transfer emphasized the necessity to comprehensively understand the lower abdominal vasculature. This study aimed to clarify the relationship among the superficial inferior epigastric artery (SIEA), the superficial branch (SCIAs), and the deep branch (SCIAd) of the SCIA. Methods Computed tomographic angiography was retrospectively reviewed in 312 hemiabdomens in 161 female patients who underwent abdominal flap breast reconstruction. We assessed the presence, caliber, and branching patterns of the SCIA branches and the SIEA. Results The SIEA-SCIA common trunk was present in 40.1% of the hemiabdomen and was identified in either side of the abdomen in 63.6% of patients. At least one superficial vessel larger than 1.5 mm was found in 61.5% of hemiabdomens. Seven branching patterns of the SCIA-SIEA system were noted: (1) the SCIA and the SIEA originated together (17.0%); (2) the SIEA and the SCIAs shared an origin (22.8%), (3) the SCIA and the SIEA branched separately (17.0%), (4) each artery originated separately (8.0%); (5) the SCIAs and the SCIAd emerged together with the SIEA absent (17.3%); (6) the SCIAs and the SCIAd originated separately with the SIEA absent (13.1%); (7) the SIEA and SCIAd originated separately with the SCIAs absent (3.5%). Conclusion SCIA-SIEA branching patterns were classified into seven distinctive patterns. This novel classification may help surgeons to choose the optimal pedicle when using the hemi-abdomen region as the donor site.

Fasciocutaneous free tissue transfer is an established limb salvage modality in lower extremity reconstruction. In severe cases, defect coverage is challenging due to the size and extent of the injury which may surpass the dimensions of most commonly utilized fasciocutaneous donor sites. This is further complicated by the considerable length between the recipient pedicle and most distal segment of the defect requiring coverage. Available donor sites that are able to provide free fasciocutaneous flaps extended length (40 cm) are combinations between the lateral thoracic, lower abdomen/groin and lateral thigh regions. Advantages of this include a single donor site that can be closed primarily, the ability to utilize healthy vessels outside the zone of trauma/injury for microvascular anastomosis and single stage reconstruction. In addition, from a logistical perspective, single flap harvest would theoretically be more efficient and less resource intensive than harvesting two separate flaps or performing large skin grafts. Herein, we present current available donor sites that allow harvest of long fasciocutaneous free flaps incorporating multiple pedicles with a single skin paddle for lower extremity reconstruction.

Background: Lymphaticovenular anastomosis (LVA) is a challenging procedure and requires a sophisticated supermicrosurgical technique. The aim of this study was to evaluate and establish a discrete supermicrosurgical anastomosis method using the “suture-stent technique”. Methods: Forty-eight LVA sites of twenty patients with lower extremity lymphedema who had undergone LVA between July 2020 and January 2021 were included in this study. LVA was performed with the conventional technique or with the suture-stent technique. The patency of the anastomoses was evaluated using an infrared camera system intraoperatively. The success rate on the first try and the final success rate for each group were compared. Results: After full application of the exclusion criteria, 35 LVAs of 16 patients including 20 limbs were included in the analysis. The ratio of good patency findings after anastomosis in the suture-stent technique group was 100%. The incidences of leakage or occlusion on the first try were statistically greater in the conventional technique group (29.4%) than in the suture-stent technique group (0%) (p = 0.0191). All anastomoses achieved good patency in the final results. Conclusion: With its minimal risk of catching the back wall during the anastomosis, the suture-stent technique can be considered an optimal anastomosis option for LVA.

Background:. Soft tissue sarcomas are rare neoplasms that can occur on any part of the body. The operative position for the resection is determined depending on the site of the soft tissue sarcomas; intraoperative repositioning may be needed for reconstruction. We present the profunda femoris artery perforator (PAP) flap harvest technique (wherein the flap can be used in any position), and suggest that the PAP flap transfer can eliminate the need for intraoperative repositioning. Methods:. From December 2018 to January 2020, 7 patients with an average age of 68 years underwent reconstructions using a PAP flap after wide resection of STS. The mean defect size was 11.3 × 16.5 cm (range, 5.5–25 × 11–26 cm). The location of the defects was the medial thigh in 2 patients, the posterior thigh in 1, the popliteal fossa in 1, the groin in 1, and the buttock in 2. The PAP flap was elevated in the supine “frog-leg” position, the prone position, the jack-knife position, or the lateral “crisscross” position; the lateral decubitus position with the donor lower extremity on the bottom. Results:. Of the 7 cases, the operations were performed in the supine “frog-leg” position in 3 cases, the prone position in 2 cases, the jack-knife position in 1 case, and the lateral “crisscross” position in 1 case. There were no intraoperative position changes in all cases. The mean size of the PAP flap was 8.7 × 19.9 cm (range, 6–11 × 17–24 cm). One patient had donor site dehiscence, which was treated conservatively. The PAP flaps survived completely in all cases. The mean follow-up period was 10.5 months (range, 6–17 months). Conclusion:. Since the PAP flap elevation is feasible in every position, the PAP flap can be considered a versatile reconstruction option after sarcoma resection.

Summary:. A deep inferior epigastric perforator (DIEP) flap is one of the gold standards for autologous breast reconstructions. However, this flap cannot be chosen again if asynchronous contralateral breast cancer occurs in the future. To solve this problem, we propose an idea and design for a hemi-abdominal DIEP flap. The patient was a 50-year-old woman who was suffering from right invasive ductal carcinoma. In using a hemi-abdominal DIEP flap, the poor postoperative appearance of the donor site might be a problem. To obtain a good donor site shape, we use a specific design to make the appearance of the donor site as good as possible. Specifically, we make an oblique spindle-shaped flap that can cover the deep inferior epigastric perforators, the superficial circumflex iliac artery, and the superficial inferior epigastric artery and avoid dog-ears, without passing over the median line. The flap weight was 800 g, the operating time was 6 hours and 22 minutes, and the bleeding amount was 110 ml. The patient had a minor wound infection in the donor site, and it was treated with a local wound treatment. The patient is satisfied with the result. We believe our flap design could minimize the unfavorable appearance of the donor site. This method might be suited to cases where the patients present with excess skin and fat on the abdomen, and half the abdominal tissue is enough to create the necessary volume of the breast. Although more cases and studies will be required to justify our technique, this case may show the possibility of a new option for breast reconstructions.

BACKGROUND Postoperative complications after flap-coverage in sarcoma treatment can postpone postoperative adjunct treatments. Here, we present our experience with the use of the superficial circumflex iliac artery perforator (SCIP) flap after sarcoma resection. PATIENTS AND METHODS Patients undergoing immediate reconstruction surgery with a flap after sarcoma resection at a single institution from February 2017 to April 2020 were identified. Patient demographics, tumor characteristics, surgical characteristics, and complications were examined. RESULTS Thirty-five consecutive patients underwent reconstructions using a SCIP flap (34 free and one pedicled SCIP flaps). We also identified 47 consecutive patients who underwent reconstruction with other pedicled or free flaps over the same time period. No significant differences were found in patient age, gender, defect size, or operative time between these two groups. The incidences of overall complications (20/47 [42.6%] vs. 3/35 [8.5%], p

Summary:. Thanks to the introduction of virtual surgical planning (VSP), mandibular reconstruction using a fibula flap has become simplified, and patient-specific reconstruction is now possible. With a VSP software, surgical “cutting guides” and custom-made titanium plates can be designed to help surgeons. However, they are expensive and require extended periods of time either for prototyping or to acquire the advanced knowledge necessary for operating the VSP software. The aim of this article is to introduce a new easy and low-cost method of surgical planning for mandible reconstruction using a computer-aided design and the syringe-aided manufacturing technique. Simulations of fibula osteotomy are performed using regular and commercially available 10-ml syringes. The syringes are cut into separate segments to fit the defect of the 3-dimensional mandible model and to match the prebent titanium plate. The syringe segments are then connected together 3-dimensionally to confirm that the shape matched both the contour of the defect and the angles of the mandible. The simulated syringe segments are used as cutting guides. Then osteotomies are performed according to the cutting guide to obtain the exact lengths and angles required to achieve precise bony reconstruction. The mandibular reconstruction procedures are successful, with a good match between the preoperative planned syringe models and the final results of the surgery. Although further clinical investigation will be required to confirm its efficacy, the computer-aided design and the syringe-aided manufacturing method has the potential to be a useful technique for mandible reconstruction using a vascularized fibula flap.

Summary Background Autologous repair using costal cartilage grafts remains the most widely accepted method of microtia reconstruction. A major complication of current techniques is loss of ear shape caused by scarring, contracture and cartilage absorption. We present a new surgical technique utilizing the posterior auricular artery free flap in microsurgical reconstruction of the retroauricular sulcus in microtia. Method Reconstruction is performed in two stages. In the first stage, a fabricated costal cartilage framework is inserted into a skin pocket as described by Nagata. In the second stage, the ear framework is elevated from the scalp and held by an additional cartilage wedge. Following indocyanine green angiography perforator mapping, a posterior auricular artery perforator flap is harvested from the contralateral (normal) ear and used to reconstruct the posterior auricular sulcus covering the cartilage framework and elevating wedge. Results The technique was applied to three patients aged 11–15 years with a follow-up time of 8 months to 3 years. The average flap artery diameter was 0.73 mm and the vein was 0.7 mm. Venous congestion occurred in one case and was resolved with a vein graft leading to complete flap recovery. Good ear shape, elevation, projection, skin color and texture were achieved in all the cases. Conclusion Posterior auricular artery flap reconstruction of the retroauricular sulcus in microtia repair is a useful alternative to the current skin graft and tissue expander-based techniques. It provides the ideal skin color and texture match and may improve the overall results of microtia reconstruction by enhancing vascularity.

Summary:. A phyllodes tumor of the breast is a rare neoplasm, accounting for 0.3%–1% of all breast cancers. The size is 4–5 cm on average but sometimes the tumor grows more and involves the entire breast. As for treatment, complete surgical resection is the standard for localized breast phyllodes tumors. The reconstruction of a large defect is challenging. Herein, we present a case where a deep inferior epigastric artery perforator (DIEP) flap was used in breast reconstruction for a 48-year-old woman who was suffering from a giant phyllodes tumor. Immediate reconstruction was performed after tumor excision; the specimen weighed 4,230 g and the skin defect was 22 × 24 cm. The deep inferior epigastric artery and vein were anastomosed to the right internal mammary artery and vein, and the superficial inferior epigastric vein was anastomosed to the right lateral thoracic vein. The postoperative course was uneventful and the DIEP flap survived completely. In the setting of the reconstruction for a large defect, we must make maximum use of the limited human tissue available and ensure minimum damage, while also considering the functional and aesthetic outcome of the donor site. Various ideas and technologies have been reported that can assist in achieving this goal, but few reports have commented especially on the reconstruction of giant phyllodes tumor using autologous tissues. There were some other options for the way of the reconstruction such as a latissimus dorsi flap and a rectus abdominis flap. Compared with these approaches, using a DIEP flap has some disadvantages such as the need for the microsurgical skill and the risk of postoperative hernia. However, a DIEP flap provides the enough tissue to cover the large defect without any damage of the muscle. To our knowledge, this case was the largest phyllodes tumor reconstruction ever, in terms of the amount of the skin needed and resected tissue involved. Although more studies and longer follow-up will be required in the future, this case may show the usefulness of DIEP flaps for reconstruction of a giant phyllodes tumor.

A 59-year-old female was brought to our emergency department with hypovolemic shock caused by massive bleeding from neck stab wounds inflicted by herself in a committed suicide. The patient complained of comparatively strong pain on her lower back and there was sensory and motor disturbance of bilateral lower limbs, but there was no trauma on the lumber region, the spine, or the vertebrae. After hemostasis, we performed magnetic resonance imaging, which demonstrated high intensity signal in the spinal and longitudinal area from the Th8 to the conus medullaris, and at center of the frontal horn on the upper thoracic spinal cord (owl's eye appearance) on T2 weighted images. This case was diagnosed as spinal infarction caused by low blood pressure as a result of massive bleeding. The basis of diagnosis were as follows: 1) an acute onset; 2) when the ambulance arrived, she was in hypovolemic shock caused by massive hemorrhage; 3) there was no trauma on the lumber region, the spine, or the vertebrae; 4) with CT taken on admission, aortic disease was not detected; and 5) she was not on any antipsychotic drugs which could cause thrombosis. We treated the patient following management protocol of cerebral infarction, but recovery of sensory and motor disorders was minimal. Keywords: Spinal cord infarction, Massive hemorrhage, Hypovolemic shock, Incise wound

Summary:. Aplasia Cutis Congenita (ACC) in the scalp is a rare congenital malformation. The treatment for ACC with large defects involving the scalp, bone, and the dura is challenging. Local debridement of necrotic tissue is important to prevent lethal complications such as infection and meningitis. However, debridement has the risk of damaging the sagittal sinus or the dura. Recent developments in ultra-high-frequency ultrasound(US) systems provide frequencies of 70 MHz and capability resolution as fine as 30 μm, which could allow precise imaging of small and thin anatomical structures. The study aimed to describe the methods of precise evaluation of the defect in the scalp and safe debridement using ultra-high-frequency US. This is the first report on direct observation of a newborn’s brain using ultra-high-frequency US. The boy was delivered spontaneously with a large defect of the scalp and bone. After 14 days, due to signs of infection, local debridement was performed carefully under ultra-high-frequency US-based evaluation. The dura, the sagittal sinus, and the small anatomical structures such as arachnoid granulations could be observed. Because the brain herniation gradually aggravated, dural reconstruction using fascia lata and scalp reconstruction using transposition flap was performed. Finally, good skin coverage over the defects was obtained. This method minimizes the risk of damaging the sagittal sinus and the brain parenchyma, which may cause fatal complications. Although further clinical investigations will be required to confirm its efficacy, ultra-high-frequency US has the potential to be a useful device for ACC treatment.

Summary:. Although soft tissue sarcoma, especially in the sole of the foot, is a rare disease, weight-bearing region reconstruction considering postoperative gait is needed. For functionally satisfactory sole reconstruction, it is important to cover the weight-bearing region with a nonbulky but durable skin paddle that can withstand a significant amount of shear pressure. We herein present a case in which a free contralateral medial plantar flap was used for reconstruction of the weight-bearing mid plantar region for a 41-year-old man who suffered from mid-foot sarcoma. Gait analysis was performed 6 months after the operation with the lower limb loading gauge sheet, and the result indicated that postoperative balanced gait was obtained. The free medial plantar flap transfer after sole sarcoma resection has several advantages. First, the characteristic of this flap with solid anchoring to deep tissue to resist shearing makes it possible to lower the chances of postoperative ulceration. Second, the medial plantar flap has optimal thickness and good color and texture match for sole reconstruction. Third, a sensate flap can be achieved if the medial plantar nerve is included. Although further clinical investigations such as long-term follow-up will be required to confirm its efficacy, this method would be one option for treating sole sarcoma.

Summary Background and Objectives The profunda femoris artery perforator (PAP) flap is gaining popularity in microsurgical reconstruction. The complications that can occur after the PAP flap harvest include donor-site lymphedema, seroma, or cellulitis. The aim of this study was to evaluate and establish a safer technique for the elevation of lymphatic vessels preserving profunda femoris artery perforator (LpPAP) flap using pre- and intraoperative ICG lymphography. In this article, we also evaluate the anatomical relationship between the PAP flap and lymph-collecting vessels. Methods From July of 2018 to January of 2019, 24 patients with soft tissue defects after tumor resection underwent reconstruction using PAP flaps. The lymph-collecting vessels at the medial thigh area were identified using pre- and intraoperative ICG lymphography. A PAP flap was elevated taking care not to damage lymph-collecting vessels. After flap elevation, the anatomical correlation between lymph-collecting vessels and the anterior edge of the gracilis muscle was measured. The postoperative complications were assessed. Results PAP flaps survived completely in all cases. In all cases, using intraoperative ICG lymphography, surgeons confirmed that the lymph-collecting vessels in the medial thigh region were left intact. There were no donor site complications such as lymphedema, lymphorrhea, or cellulitis. Conclusion The elevation technique of an LpPAP flap is effective in reducing the risk of damage to lymph-collecting vessels, and thus reducing chances of postoperative lymphorrhea or iatrogenic lower limb lymphedema.

Background The profunda femoris artery perforator (PAP) flap is gaining popularity in microsurgical reconstruction. To establish a safer flap elevation technique, we focused on the topology of the accessory saphenous vein in the medial thigh area. We hypothesize that including the accessory saphenous vein in a PAP flap results in safer PAP flap transfer with two venous drainage systems. The aim of this study was to describe the anatomical relationship between the perforators and the accessory saphenous vein in the PAP flap using fresh cadavers and to describe the relationship through two clinical cases. Methods For the anatomical study, 19 posterior medial thigh regions from 10 fresh cadavers were dissected. We recorded the number, site of origin, the length, and the diameter of the pedicle. We also documented the course, the length, and the diameter of the accessory saphenous vein. PAP flap transfer with additional accessory saphenous vein anastomosis was performed in two clinical cases; a 40-year-old female with tongue cancer and a 51-year-old female with breast cancer. Results In all cadaveric specimens, the accessory saphenous vein was found above the deep fascia. The average distance between the proximal thigh crease and the intersection of the anterior edge of the gracilis muscle and the accessory saphenous vein was 7.7 ± 2.5 cm. The diameter of the accessory saphenous vein averaged 3.1 ± 1.1 mm. The average accessory saphenous vein length from its takeoff from the great saphenous vein to the anterior edge of the gracilis muscle was 4.2 ± 1.3 cm. In clinical cases, the flap size was 6 x 18 cm and 8 x 21 cm and the follow-up length was 12 and 3 months, respectively. In both cases, the postoperative course was uneventful and the flap survived completely. Conclusion Anatomical study confirmed that the accessory saphenous vein did exist in all specimens and it could be included in the PAP flap with sufficient length and relatively large diameter. Although further clinical investigation will be required to confirm its efficacy, a PAP flap including the accessory saphenous vein may decrease the chances of flap congestion.

Summary:. Microtia with congenital aural atresia is challenging to achieve aesthetically and functionally good results. We herein present a case where a vascularized superthin superficial circumflex iliac artery perforator (SCIP) flap was used for reconstruction of the external auditory canal (EAC) and a full-thickness skin graft was used for reconstruction of the postauricular region for a 10-year-old male who suffered from microtia with congenital aural atresia. After costal cartilage grafting (the first operation), EAC reconstruction and auricle elevation (the second surgery) was performed. After the atticoantrostomy, a superthin SCIP flap was rolled up in a sac and was inset to the newly created EAC. The postauricular skin defect was covered with full-thickness skin graft. The SCIP flap survived completely and good patency of the reconstructed EAC was accomplished, which results in an improvement of previous hearing loss. The skin graft survived completely, which eventually demonstrated aesthetically satisfactory results.

Background The deep branch of the superficial circumflex iliac artery (SCIA) should be included when a large superficial circumflex iliac artery perforator (SCIP) flap is necessary, or when anatomical structures perfused by the deep branch are procured. The aim of this study was first to describe the anatomical features of the "transverse branch" of the deep branch of the SCIA in cadavers, and then to assess the efficacy of its use as a landmark for identification and dissection of the deep branch of the SCIA through clinical applications. Methods Twenty groin regions from 10 cadavers were dissected. The course and the takeoff point of the transverse branch were documented. With the transverse branch used as a landmark for pedicle dissection, 27 patients (16 males and 11 females) with an average age of 51.7 years underwent reconstructions that used vascularized structures nourished by the deep branch of the SCIA. Aside from the skin paddle, an iliac bone flap was used in 10 cases, a lateral femoral cutaneous nerve flap in four cases, and a sartorius muscle flap in three cases. The defect locations included the head (seven cases), the foot (six cases), the hand (six cases), the arm (five cases), and the leg (three cases). The causes of reconstruction were tumors in 13 patients, trauma in six patients, infection in four patients, surgical procedures in three patients, and refractory ulcer in one patient. Results In all specimens, the transverse branch was found underneath the deep fascia caudal to the anterior superior iliac spine (ASIS). The average distance from the ASIS to the transverse branch was 25.5 ± 13.0 mm (range, 5-50 mm). The average dimension of the flap was 13.1 × 5.9 cm2 . All the flaps survived completely after the surgery; lymphorrhea was seen in one patient at the donor site. The average follow-up period was 12.9 months (range, from 2 to 42 months), and all patients had good functional recovery with satisfactory esthetic results. Conclusions The transverse branch was found in all specimens, branching from the deep branch of the SCIA. Successful results were achieved by using it as the landmark for identification and dissection of the deep branch of the SCIA. This method allows safe elevation of a large SCIP flap or a chimeric SCIP flap.

Background The profunda artery perforator (PAP) flap has recently been widely used for head and neck as well as breast reconstruction. Although this flap has various advantages, its vascular pedicle is relatively smaller and shorter than that of other workhorse flaps such as the anterolateral thigh flap. The posterior accessory saphenous vein (pASV) is a branch of the great saphenous vein, which runs in the posteromedial aspect of the thigh and can be included in the PAP flap. Here, we present the anatomical characteristics of the pASV and feasibility of its use in PAP flap transfers. Patients and methods An anatomical study of the pASV was conducted in nine lower extremities of five patients using ultrasonography. Several landmarks such as point A (the point where the pASV crosses the posterior border of the adductor longus muscle), point B (the point where the pASV merges with the great saphenous vein) and the inguinal crease, were marked. Distribution of the pASV was plotted, and several distances were measured. On the basis of the anatomical study, nine free PAP flap transfers were performed. Results In the anatomical study, the mean diameter of the pASV was 3.4 and 4.9 mm at points A and B, respectively. The mean available length of the pASV was 9.4 cm. In clinical cases, all flaps completely survived. No flap-related complication was observed. The pASV was included in the PAP flap in eight cases. The mean length of the harvested pASV was 8.6 cm, and the mean diameter was 3.3 mm. Indocyanine green angiography showed effective drainage using the pASV alone. Conclusions The use of the pASV can be an effective option, particularly for head and neck reconstruction, and its application in various types of reconstructive surgery can be widened.

Supplemental Digital Content is available in the text., Background: In free-flap reconstruction of the midface, options for the recipient artery are quite limited; the superficial temporal artery and the facial artery are the most commonly used arteries. We report our approach for the use of the angular artery (the terminal branch of the facial artery) as the recipient artery in free-flap reconstruction of the midface. Methods: Nine patients with midface defects underwent free-flap reconstructions using the angular artery as the recipient artery. Identification and marking of the facial artery were performed preoperatively using handheld Doppler ultrasound. The angular artery was located through an incision made on the side of the nose. When present, a vena comitans of the facial artery or any subcutaneous vein in the vicinity of the defect was used as the recipient vein. In other cases, the facial vein in the submandibular region was chosen as the recipient vein, using a vein graft. Results: The average diameter of the angular artery was 0.9 mm (range, 0.7–1.0 mm). In all cases, arterial anastomosis was performed in an end-to-end fashion, and flaps survived completely. In 4 cases, a vein graft was used to bridge the pedicle vein and the facial vein. Conclusions: Although supermicrosurgical skills may be required for its anastomosis, the angular artery is an anatomically consistent artery, which is suitable for use as the recipient artery in free-flap reconstruction of the midface. Use of the angular artery as the recipient artery allows shorter flap pedicles and decreases the number of vein grafts necessary.

Background:. Vascularized lymph node transfer is the most common physiological procedure indicated for severe lymphedema. We describe a new physiological treatment strategy for lymphedema, lymphatic system transfer (LYST), which comprises transfer of the vascularized afferent lymphatic vessels along with their draining lymph nodes. Methods:. All patients undergoing LYST for treatment of lymphedema from 2017 to 2018 were identified. Patient demographics, intraoperative factors, and postoperative outcomes were reviewed. Results:. Three patients underwent LYST. Average patient age and body mass index were 65.3 years and 23.6 kg/m2, respectively. Indications for LYST were upper extremity lymphedema following mastectomy, radiation, and lymphadenectomy (2) and unilateral lower extremity lymphedema following total hysterectomy and bilateral pelvic lymphadenectomy (1). In all patients, lymphatic vessels could not be visualized by preoperative lymphoscintigraphy. All LYST flaps were procured from the groin region. A superficial circumflex iliac artery perforator flap, including the afferent lymphatic vessels and their draining lymph nodes, was elevated. A large portion of the skin paddle was deepithelialized, and the LYST flap was inset into a subcutaneous tunnel made in the lymphedematous limb. All LYST flaps survived completely. No donor site complications were observed. The average rate of estimated volume decrease in the patients at eighth month follow-up was 21.9%. Average follow-up was 11 months. Conclusions:. Because the afferent lymphatic vessels are transferred with the lymph nodes, a presumably lesser degree of lymphangiogenesis is required for a LYST flap to commence its physiological function. Its real-time physiological lymphatic drainage is demonstrated in a video.

Supplemental Digital Content is available in the text.

The complex reconstruction of nerves and soft tissue in the head and neck region is still challenging, especially in cases requiring external auditory canal reconstruction with facial nerve reconstruction. We report a case of left facial schwannoma extending into the external auditory canal beyond the tympanic membrane with facial paralysis in which the reconstruction of both the facial nerve and external auditory canal was successfully performed using an anterolateral thigh flap as a super-thin full-thickness skin flap, including vascularized lateral femoral cutaneous nerve. Resection of 20 mm × 46 mm facial schwannoma, including the skin of the external auditory canal, tympanic membrane, incus and malleus, was performed. The 8-cm nerve gap was repaired using a vascularized lateral femoral cutaneous nerve included in the anterolateral thigh flap. An 8 cm × 2 cm super-thin, free anterolateral thigh flap was then rolled up as a sac (diameter of 2 cm, height of 2 cm) and inset to the external auditory canal defect. The postoperative course was uneventful, and the flap survived completely. One year and nine months after the surgery, the patient’s facial movement has improved to the pre-surgery level.