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Chordomas are rare, slow-growing, locally aggressive malignant tumors arising from notochord remnants that commonly affect the sacrococcygeal area. Surgical resection with negative margins is crucial but often results in extended defects with exposed critical structures, necessitating complex reconstructions. The reconstruction techniques commonly employed and described in the literature often utilize musculocutaneous flaps, which are associated with higher donor site morbidity. Thus, the challenge remains to minimize donor site morbidity while ensuring effective reconstruction and long-term stability. This case report presents a novel technique for sacrococcygeal defect reconstruction after chordoma resection. This approach aims to help reconstructive surgeons to improve patient outcomes and broaden the range of available surgical strategies in this area while minimizing donor site morbidity. An 87-year-old male patient presented a sacrococcygeal chordoma measuring 51 × 41 × 58 mm, which caused the destruction of the coccygeal vertebrae and infiltrated the levator ani muscle. After a multi-disciplinary discussion, the patient underwent en-bloc tumor resection. The mass measured 11 × 8 cm and included the coccyx, the gluteus maximus insertion to the coccyx, and a portion of the levator ani muscle, leaving part of the rectum ampulla exposed. For the reconstruction, to create a strong barrier to minimize the risk of rectal herniation, obliterate the dead space, and cover the defect, we performed a bilateral advancement of the gluteus maximus and harvested two pedicled superior gluteal artery perforator (SGAP) flaps measuring 15 × 10 cm and centered on the perforator. The flaps were consequently tunneled below the gluteal skin, rotated 90°, and placed in the defect; one was de-epithelialized and buried into the defect, and the other was placed above it for surface coverage. The postoperative recovery was uneventful, and at a 1-year follow-up, the patient reported no motor dysfunction or problems during sitting, and no signs of rectal herniation were shown at the CT. The reconstruction with bilateral pedicled SGAP flaps arranged in a double-layer fashion could effectively address the key points of reconstruction of the sacrococcygeal area after chordoma resection, with several advantages since it causes minimal donor site morbidity and maintains the contour of the gluteal area with excellent functional outcomes. However, further studies are warranted to validate and refine this approach., (© 2024 Wiley Periodicals LLC.)

Head and neck defects present a unique challenge in reconstructive surgery due to the complex anatomy of this area. Different defects often require a variety of reconstructive techniques. The superficial circumflex iliac artery perforator (SCIP) flap is particularly notable for its versatility in this context. It provides a thin, pliable skin island that can be integrated with bone, muscle, fascia, and other structures. Additionally, the morbidity associated with the donor site of the SCIP flap is generally low and well tolerated. This article offers a comprehensive overview of the evolution of this technique., Competing Interests: Disclosure The authors have no financial conflicts nor commercial associations to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Vascularized lymphnode transfer (VLNT) is one of the most common surgical treatments for moderate and severe lymphedema. Various techniques have been described for harvesting lymph nodes from different donor sites. However, a standardized harvest procedure is still lacking. The transplantation of inguinal lymph nodes using the perforator-to-perforator technique may represent a significant advancement in this context. This approach relies always on the same vascular pedicle, offers a lower morbidity, and allows for a more superficial inset at the recipient site., Patients and Methods: Between 2019 and 2022, 12 patients received a perforator-to-perforator VLNT for the treatment of late stage (Late II) lymphedema, both primary and secondary. In all cases, the lymphnodes were harvested from the groin supplied by the superficial circumflex iliac artery perforator (SCIP) vessels. The average age was 62.2 years old (range 47-73 years old); nine patients were females and three were males. In 11 cases, the lower limb was affected, and in one case, the upper limb was affected. Eight patients received additional lymphovenous anastomosis., Results: All the patients reported an improvement of the symptoms after surgery in terms of tissue quality (tenderness, lymphangiectasia, and pain), and no cases of recurrent cellulitis were reported. Postoperative lymphoscintigraphy was performed at 6 months, and in all cases, the function of transplanted lymphnodes was confirmed. No complications were encountered, neither at donor nor at recipient site. The follow-up was at least 12 months in all patients., Conclusions: Despite being more technically demanding, the systematic implementation of the perforator-to-perforator technique for the transfer of SCIP-based inguinal lymphnodes can be a valuable evolution of VLNT. The aim of this study is to present how this technical approach may become a standardized procedure for inguinal-based VLNT, offering a reduced donor and recipient site morbidity and potentially enhancing the lymph draining effects due to a more superficial inset., (© 2024 Wiley Periodicals LLC.)

Defects in the distal lower limbs are common in the field of orthoplastic reconstruction. The ankle area presents little subcutaneous tissue and is often affected by high-energy traumas and bone fractures. Wounds in this region are frequently associated with severe edema that might prevent primary closure. Due to its thinness and tension, the skin overlying both the medial and lateral malleoli is prone to necrosis, which can further lead to large soft tissue defects. Vessels, nerves, and tendons can easily become exposed. The reconstructive approach should aim to provide high-quality tissue that is durable enough to withstand the weight-bearing pressures and the friction from shoes, while remaining sufficiently elastic to conform to the shape of the ankle and to permit the foot movement. In this study, we describe the use of an additional propeller flap to reduce skin tension at the recipient site. A superficial circumflex iliac artery perforator (SCIP) flap was utilized to cover a defect below the medial malleolus. However, after flap inset, achieving a primary closure of the proximal wound without tension was not possible. During the dissection of the posterior tibial artery, perforator vessels were identified and preserved. The larger of these vessels was then used to vascularize a propeller flap, which was then rotated toward the defect to aid a tension-free closure. The postoperative course was uneventful. This case may provide a valuable insight into the challenges often faced during wound closure, even after flap inset. Since the flap itself may increase the width of the dissection area, the present case shows the importance of preserving perforator vessels during the proximal dissection since they can allow the harvest of an additional flap to achieve primary closure and further alleviate tension., (© 2024 Wiley Periodicals LLC.)

Soft-tissue sarcomas (STS) are rare solid tumors of mesenchymal cell origin and account for only 1% of adult malignancies. They tend to occur most commonly in the lower extremities. Reconstruction after sarcoma resection can be challenging, especially when important structures are involved and recurrences occur. Additionally, more attention is now being paid to reconstructing the lymphatic system to prevent lymphatic complications. In this case report, we presented the management of recurrent medial thigh sarcoma that necessitated multiple challenging reconstructions to provide valuable insights for lectures on similar cases. A 50-year-old male patient was diagnosed with an undifferentiated pleomorphic cell sarcoma (UPS) of the anteromedial thigh. After preoperative radiotherapy, a mass of 23 × 15 cm was removed, and reconstruction with a pedicled deep inferior epigastric artery perforator (p-DIEP) flap-based lymphatic flow through (LyFT) was performed. Six months later, the patient developed the first local recurrence with the presence of a distant metastasis. Following the tumor resection, the medial part of the DIEP flap was de-epithelized and buried in the defect for dead space obliteration. Another local recurrence arose 7 months after the second surgery. Therefore, a major debulking surgery involving the femoral neurovascular bundle was performed. The femoral artery was reconstructed with a synthetic graft, and the femoral vein with the great saphenous vein harvested from the contralateral thigh. A composite myocutaneous neurotized anterolateral thigh (ALT) flap from the contralateral thigh was used to obliterate the defect and restore the loss of function of the quadriceps femoris. Two lymphaticovenular anastomoses (LVAs) were performed at the ankle to reduce the risk of lymphatic sequelae. This case report highlights the importance of integrating various techniques to create a tailored approach that effectively addresses complex surgical requirements to avoid limb amputation and maintain functionality., (© 2024 Wiley Periodicals LLC.)

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., (© 2024 Wiley Periodicals LLC.)

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., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

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., (© 2023 Wiley Periodicals LLC.)

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., (© 2023 Wiley Periodicals LLC.)

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., (© 2023 Wiley Periodicals LLC.)

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., (© 2023 Wiley Periodicals LLC.)

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., (© 2023 Wiley Periodicals LLC.)

Background: The profunda artery perforator (PAP) flap is a reliable alternative for autologous breast reconstruction; however, the amount of tissue provided is quite limited. For medium to large sized breast reconstruction two PAP flaps can be harvested and inset in "stacked" fashion. This procedure consists in placing the two flaps side by side, normally supplied by antegrade and retrograde anastomoses performed with the mammary vessels. In the present article, we report the employment of stacked PAP flaps with intra-flap anastomosis in breast reconstruction setting., Patients and Methods: From April 2018 to December 2021, seven patients received unilateral breast reconstruction with stacked PAP flaps. Patients' average age was 47.5 (range 39-58 years old). Mean body mass index was 19.4 kg/m 2 (range 18.5-20.1 kg/m 2 ). The two flaps were linked by means of intra-flap anastomosis resorting to side branches of one of the two pedicles. In all cases the internal mammary vessels were dissected sparing the ribs and used as recipient vessels for antegrade end-to-end anastomosis., Results: The flaps size ranged from 15 cm × 6 cm to 20 cm × 7 cm with an average weight of 250 g (range 190-290 g). The mean pedicle length was 11.1 cm (range 10-12.5 cm) on the left side and 7.9 cm (range 7-9 cm) on the right side. All flaps survived completely after surgery. The donor sites were all primarily closed with no morbidities. The mean follow-up was 8 months (range 6-12 months). All patients were satisfied with the result., Conclusions: Stacked PAP flaps performed with intra-flap anastomosis may represent a valid alternative solution for the reconstruction of moderate to large breast in case of unavailable abdominal tissue., (© 2022 Wiley Periodicals LLC.)

Among the various histologic subpopulations of soft tissue sarcomas, undifferentiated pleomorphic sarcoma (UPS) is one of the most common subtypes in the adult population. Radical surgery remains the primary treatment for UPS, associated with postsurgical radiotherapy or chemotherapy. We herein report the case of a 65-year-old man presenting a recurrent UPS in his right upper thigh region. The patient received radical resection of the tumor and the remaining defect measured ~22 cm × 18 cm. A soft tissue functional reconstruction with lymphatic-flow-through pedicled postero-medial thigh flap (PMT) was planned. A 24 cm × 16 cm flap was harvested in vertical fashion (vPMT), carefully preserving a superficial vein for the following lymphovenous anastomosis (LVA) at recipient site. The flap was then rotated and transferred to the defect area through a tunnel under the adductor longus muscle, and LVA was then performed between flap's additional venous pedicle and a nearby leaking lymphatic vessel. The postoperative course was uneventful and at 12 months follow-up no complications were encountered. No signs of lymphedema were reported. When dealing with the groin and upper thigh area, which is notably rich in lymphatic tissue, the possibility of prophylactically re-route lymphatic fluid into the venous system by means of microsurgical anastomosis, lays in the thrilling possibility to prevent secondary lymphedema, instead of curing it. With the described technique, we achieved optimal functional and esthetic outcomes setting at zero both donor and recipient sites morbidity., (© 2022 Wiley Periodicals LLC.)

Preservation of laryngeal functions after supraglottic laryngectomy depends on both the extent of surgical resection and the type of reconstruction. Any reconstructive modality faces the challenges of preserving voice and swallow function due to the complex and dynamic anatomy of the larynx. In this report, we present a case in which the entire affected unilateral supraglottis and piriform sinus were functionally reconstructed using a triple chimeric superficial circumflex iliac artery perforator (SCIP) free flap. An extended unilateral supraglottic laryngectomy and neck dissection were performed in a 78-year-old male patient presenting with a supraglottic cT4a cN0 cM0 laryngeal cancer. The resulting defect was reconstructed using a triple chimeric SCIP flap from the right inguinal region intended to reconstruct the different affected compartments. It was based on three perforators and consisted of a 4 cm × 3 cm fascial flap from the external oblique muscle and two fasciocutaneous paddles measuring 6 cm × 2 cm and 3 cm × 4 cm. The arterial and venous vessels were anastomosed to the superior thyroid artery and internal jugular vein. The fascial flap was used to reconstruct the aryepiglottic fold. The smaller fasciocutaneous paddle was utilized to reconstruct the affected piriform sinus and former thyroid cartilage compartment, while the larger fasciocutaneous paddle served as a monitor skin flap. The postoperative recovery was uneventful. Laryngeal functions including voice and deglutition were well-preserved after 4 months of rehabilitation. The patient showed no signs of chronic aspiration or tumor recurrence 6 and 12 months postoperatively. The pliable and versatile triple chimeric SCIP flap provides a useful free flap option for a tailored functional reconstruction after an extended supraglottic laryngectomy. Restoration of larynx elevation and mobility with the presented technique substantially improves swallow rehabilitation while preserving the voice., (© 2022 Wiley Periodicals LLC.)

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., (© 2022 Wiley Periodicals LLC.)

Background: Large locoregional defects affecting lymphatic-rich regions may be subject to serious lymphatic complications, such as lymphedema and recurrent lymphocele. In the last few years, a demeaning volume reconstruction combined with lymph flow restoration showed to effectively reduce their incidences. The purpose of this report is to present the preliminary results of the use of pedicled SCIP flap with LVA between the recipient site lymphatic vessels and flap superficial vein for reconstruction of soft tissue defect and creation of lymph flow-through to reduce lymphatic complications., Patients and Methods: Between 2018 and 2020, 4 patients (2 males and 2 females), with a mean age of 56.5 years (ranging 42-76 years), presented a soft tissue defect with lymphatic drainage damage which was reconstructed by resorting to pedicled SCIP flap. Causes of the defect were tumoral surgical excision in 3 cases and severe trauma in 1 case. The defects were located in the medial thigh in 2 cases and groin area in 2 cases, with sizes ranging from 5 × 19 cm to 8 × 22 cm. The SCIP flap was raised by paying attention to preserve some suitable veins at the distal edge of the skin paddle. The flap was then turned 180 degrees and inset in order to match the direction of the recipient's lymphatic vessels. One or more LVAs were performed between the recipient site damaged lymphatics and a superficial flap's vein., Results: The sizes of flaps ranged from 5 × 19 cm to 8 × 22 cm. The mean number of LVAs was 2.2 (ranging from 1 to 3). A minor post-operative complication was encountered (small infected seroma) in 1 case, which was conservatively managed. No secondary procedures were required. In all cases complete range of motion (ROM) of the hip joint and wound coverage at both donor and recipient site were achieved. The mean follow-up was 8 months (ranging 7-10 months). No signs of lymphedema and lymphocele were reported over this time., Conclusions: The pedicled SCIP flap with LVA between the recipient site lymphatic vessels and flap superficial vein may provide a solution for inguinal and upper thigh defects reconstructions that requires a lymphatic drainage restoration. Its superficial veins may be exploited to perform LVAs at recipient site, thus reducing the lymphatic complications in these delicate regions., (© 2021 Wiley Periodicals LLC.)

Background: Different issues may cause defects in the genital region, including urological, infective, oncological and genetic problems which often lead to significant defects. This is a very delicate region and a successful coverage requires a thin, pliable and reliable solution. In this setting the SCIP flap might be an outstanding procedure. Despite being a well-known solution in the groin region, its employment for genital reconstructions is still poorly described. For this reason, we gather our experience with this procedure showing the efficacy of the SCIP flap in this specific region., Patients and Methods: In the present case series we included 6 male patients who received a soft tissue defect reconstruction by means of pedicled SCIP flap over the last year. The average age was 53.6 years old (range 34-79 years). Among them, 5 patients received a surgical excision because of severe acne (2 cases), Fournier's gangrene (2 cases), or scrotal squamous cell carcinoma (1 case). In 1 case the cause of the missing volume was testicle agenesis and the reconstruction was performed for cosmetic purposes. Size of the defects ranged from 7 cm × 4 cm to 20 cm × 6 cm. Elliptical shaped flaps were designed either mono- or bilaterally according to the need. All the flaps were supplied by the superficial branch of the SCIA. The range of rotation varied between 150° and 180° in order to reach the affected area., Results: The flaps' dimension ranged from 8 cm × 4 cm to 20 cm × 6 cm. All the patients were successfully treated. In 1 case we encountered a small wound dehiscence, which was managed conservatively. The mean follow-up was 9.5 months (range 6-12 months). Good cosmetic result was achieved in all cases and no urinary or sexual dysfunctions were reported., Conclusions: The pedicle SCIP flap represents a reliable solution for genital and inguinal defects reconstructions. Its versatility can be exploited throughout the region providing very good quality tissues that can be used for the most disparate situations., (© 2022 Wiley Periodicals LLC.)

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., (© 2022 Wiley Periodicals LLC.)

Background: Lower extremity defects have been and remain one of the greatest challenges in reconstructive surgery. Perforator flaps have been accepted as a valid procedure to cover such a defect. Different techniques have been described and nowadays many options are available. However, there were not studies that comprehensively review the most modern techniques and clinical application of the use of perforator flaps in the lower extremity reconstruction. In the present report, we gathered most of them, presenting an updated and large case series where different pedicled and free perforators flaps were employed in simple and complex scenarios in a large series of cases., Patients and Methods: Eighty-seven patients presenting soft tissue defects of the lower extremities were treated by means of different perforator-based flaps, in either free or pedicled fashion. The flaps were based on different perforator vessels, namely deep lateral circumflex femoral artery, profunda femoris artery, superficial femoral artery, medial sural artery, peroneal artery, posterior tibial artery, anterior tibial artery, and medial plantar artery. Patients' mean age was 61.9 years old (range 21-87 years old), 58 were males and 29 females. The 12 patients received sequential flaps and 9 received double free flaps, for a total sum of 106 flaps. The causes of the defects were trauma in 41 patients and tumors in 46 patients, located throughout the lower limbs. Size of the defect ranged from 3 cm × 4 cm to 25 cm × 9 cm., Results: The dimensions of the flap skin paddles ranged from 3 cm × 4 cm to 16 cm × 5 cm for the pedicled flaps (42 cases) and from 6 cm × 4 cm to 25 cm × 8 cm for the free ones (45 cases). Mean flap's size was 48 cm 2 (range 12-80 cm 2 ) for the pedicle flaps and 104 cm 2 (range 24-200 cm 2 ) for free flaps. In two pedicled cases, a distal congestion was encountered, requiring a second surgery. Debulking procedures were performed in 2 patients. All the patients were successfully treated and no flaps were lost. Mean follow-up period was 8.4 months (range 3-12 months). No range of motion impairment was encountered after surgery and all the patients were able to return to habitual life., Conclusions: The present case series highlights the reliability and versatility of perforator flaps for lower extremity defect coverage. Following careful consideration of the etiology, dimensions, location, patient comorbidities, and presence of adequate perforators, a pedicled or free perforator flap can be potentially successful in the most disparate circumstances., (© 2022 Wiley Periodicals LLC.)

The tumors affecting the thigh region are complex to manage, requiring a patient-tailored and multidisciplinary approach. Because of their aggressiveness, soft tissue sarcomas (STS) often grow very quickly and they must be removed before they might cause major impairments. A safe margin excision may lead to large defects that require a surgical reconstruction with either free or pedicled flaps. Another relevant aspect, which is gaining more and more attention in the last few years, regards the lymphatic complications that commonly occur after these procedures. The thigh region anatomically accommodates the major lymphatics responsible for the whole leg drainage, and these vessels are often inevitably compromised during the tumor removal. For this reason, plastic surgeons should take into account not only to the aesthetic and functional result, but they should also try to prevent lymphatic sequelae such as lymphocele and lymphedema. The purpose of this report is to describe the potential of a pedicled SCIP flap, used as a lymphatic interpositional flap, in order to restore the lymphatic drainage of the thigh after a major impairment. A 57-year-old patient presenting a thigh sarcoma received a surgical excision leaving a 35 cm × 25 cm defect affecting the anterior compartment. To fulfill all these concerns, a lymphatic interpositional SCIP flap was performed, in pedicled and chimeric fashion. It allowed to completely bury a large (35 cm × 16 cm) soft tissue island, preserving a smaller (5 cm × 4 cm) skin paddle to monitor the whole flap survival. Moreover, the lymphatic issue was faced by preserving the lymphatic vessels running into the flap and moving them into the affected area in order to enhance the lymphatic neo-angiogenesis and offering an additional pattern for lymph drainage. Post-operative course was uneventful and at 9 months follow up the reconstructive result was successful with no signs of lymphatic sequelae. Therefore, we believe that the SCIP flap might be a promising solution for small-to-moderate size thigh defect reconstructions since it is able to satisfy all the typical requirements of this delicate region., (© 2021 Wiley Periodicals LLC.)

Background and Objectives: When a lymphatic-rich area is severely damaged, either after trauma or a surgical procedure, both soft tissue defect reconstruction and lymphatic drainage restoration are necessary. In this setting, we aim to show the potential of the lymphatic flow-through flap (LyFT) concept, which might be an attractive new solution to reduce postoperative lymphatic complications. Materials and Methods: Between 2018 and 2021, 12 patients presenting a soft tissue defect involving damage to the lymphatic drainage pathway received a lymphatic flow-through flap for volume and lymphatic drainage restoration. Different flaps were employed: 3 pedicled superficial circumflex iliac artery perforator (SCIP) flaps, 2 free SCIP flaps, 3 pedicled deep inferior epigastric perforator (DIEP) flaps, 2 pedicled vertical posteromedial thigh (vPMT) flaps, and 2 pedicled anterolateral thigh (ALT) flaps. A range of 1 to 3 lymphovenous anastomosis (LVA) with flap's veins was performed (mean 1.9). For a better dead space obliteration, an additional vastus lateralis muscle flap was performed in one case. Indocyanine green (ICG) lymphography was used in all cases to identify the lymphatic pathway, make the preoperative markings, and check the patency of the anastomoses. Results: In all cases, the reconstructive results were satisfactory from both the functional and aesthetic points of view. No secondary surgeries were required, and only one minor complication was encountered: an infected seroma that was managed conservatively. The mean follow-up was 9.9 months (range 6-14 months). Conclusions: Lymphatic flow-through flaps seem to effectively reduce the risk of lymphatic complications after the reconstruction of soft tissue defects with a compromised lymph pathway. This is a versatile solution that might be used in different body regions resorting to different flap types.

The thigh region is often site of soft tissue tumors development. Leiomyosarcoma, in particular, is a malignant tumor that, if not promptly treated, presents a growth rate that often results in large masses. The safest treatment in these cases is margin-free extensive surgical resection. This leads to rather large defects that in a delicate region, such as the medial thigh, implies a series of possible complications from the lymphatic point of view. In this region run major lymphatic vessels, appointed to drain the whole leg. Now that one is aware of this issue, the best solution is trying to obtain an efficient reconstruction and preventing the development of postoperative lymphedema and lymphocele. Here, we present a case of great saphenous vein leiomyosarcoma resection in the right medial thigh reconstructed by means of two superficial circumflex iliac artery perforator (SCIP) flaps with lymphatic tissue preservation, combined with preventive lymphovenous anastomosis (LVA). A 67-years-old woman presented a 22 × 16 cm soft tissue defect after the surgical excision. To fill the defect, we resorted to a larger SCIP flap island, supplied by both the superficial and deep branches of the superficial circumflex iliac artery anastomosed in perforator-to-perforator fashion, and to a smaller SCIP flap island supplied only by the superficial branch. Before surgery, the lymphatic vessels running in the flaps area were identified with indocyanine green lymphography and were carefully preserved during the harvest procedure. They were then transferred with the surrounding tissue and orientated in order to match the lymphatic flow direction, providing further fluid drainage. To boost the lymphatic drainage, an LVA was also performed at the superior-edge-of-the-knee incision point joining a functioning lymphatic vessel to a nearby reflux-free vein. The postoperative course was uneventful and at 7 months follow-up, the patient showed good cosmetic and functional outcomes with no swelling and no signs of tumor relapse. This report provides a series of technical insights and adds further evidence to support the efficacy of this procedure for management of soft tissue defects in the medial thigh region., (© 2021 Wiley Periodicals LLC.)

Background: Head and neck tissue defects after ablative head and neck 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. The authors present their experience with both simple and chimeric SCIP flap reconstructions for complex defects in various head and neck regions., Methods: Twenty-two patients undergoing ablative head and neck surgery for oncologic abnormalities were treated by means of a SCIP flap reconstruction. Patients' mean age was 62 years; 21 were men and one was a woman. Seventeen flaps were simple and five were chimeric reconstruction patterns. Indocyanine green perfusion imaging was performed in all cases., Results: Twenty-one of 22 patients (95.5 percent) were successfully treated with good aesthetic and functional results. Two patients (9 percent) showed minor donor-site complications that were managed conservatively. The mean follow-up period was 5.3 months (range, 2 to 8 months)., Conclusions: This case series demonstrates the reliability and versatility of the SCIP flap for head and neck reconstruction. The chimeric options combined with bone, double-skin paddle, and muscle offer a broad variety of functional reconstructive solutions for complex head and neck surgery. Intraoperative indocyanine green perfusion examinations are a valuable tool to assess and ascertain proper inset, vitality, and postanastomosis vessel patency in these complex microvascular flap reconstructions. ., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Extensive surgical removal is often required to treat soft tissue sarcomas. When they are localized in the groin-upper medial thigh region, the excision is particularly demanding because of the rich lymphatic network and lymph nodes present in that area. The lymphatic vessels with respective lymph nodes draining the whole leg are most of the time inevitably damaged, causing a series of debilitating sequelae such as lymphocele and lymphedema. To prevent these issues, together with the defect coverage, additional lymphovenous anastomoses (LVA) showed encouraging results. Here we present a case of resected groin sarcoma reconstructed by means of pedicled lower deep inferior epigastric perforator (DIEP) flap combined with multiple LVAs. In particular, the superficial veins of the DIEP flap have been employed as the donor veins for LVAs. A 76-year-old patient presented a leiomyosarcoma in the right trigonum femorale which was surgically excised leaving a defect of about 12 cm × 7 cm with exposed femoral vessels and nerves. The remaining defect was then filled with a pedicled DIEP flap, and three leaking lymphatic vessels in the thigh were anastomosed with three branches of a superficial vein originating from the DIEP flap. The postoperative course was uneventful and at 12 months follow-up no signs of either seroma or lymphocele. This result suggests that the concept of lymphatic flow-through (LyFT) DIEP flap might be a modern and particularly useful solution for those cases that require both dead space obliteration and lymphatic drainage restoration., (© 2021 Wiley Periodicals LLC.)

Microsurgical free tissue transfer is nowadays considered to be one of the main options for head and neck reconstruction. The free posterior tibial artery perforator (PTAP) flap is a well-known reconstructive technique for local defect coverage in the distal leg, and only recently has been employed for head and neck reconstructions. Being a very thin and pliable flap, with low donor site morbidity and constant anatomy, the PTA perforator-based flap could be a great alternative to the more commonly-employed radial forearm free flap (RFFF). The present case report shows a complex head and neck defect coverage by means of a free double-paddle PTA flap, with a concise literature review of previous PTA flap descriptions in this setting. A 59-year-old male patient presented with a hypopharynx leakage after radiotherapy due to hypopharynx carcinoma. Since the patient had an occluded ulnar artery on the left side and an arterial line in the radial artery on the right side, both a RFFF and an ulnar artery perforator (UAP) flap were contraindicated. Moreover, two different cutaneous flaps were needed to reconstruct a 6 × 8 cm 2 defect, one for the reconstruction of the hypopharynx and one for the resurfacing of the neck, since previous surgeries and radiotherapy led to severe fibrosis of the neck. The patient had a BMI of 25.4 kg/m 2, which led us to exclude the anterolateral thigh (ALT) flap because of its thickness. For the forementioned reasons, an unconventional double-paddle PTAP flap based on two perforator vessels was chosen. Based on two perforators, two skin islands were harvested, building a double-paddle PTA perforator-based flap. The proximal skin island was 6 × 7 cm 2 and the distal one was 6 × 4 cm 2 . The larger skin flap was set at the leakage of the hypopharynx. The smaller skin island was used to monitor the survival of the whole flap and for resurfacing the outer side of the neck. The postoperative course was uneventful and at 3 months follow up the reconstructive result was good with no functional drawback. In view of the obtained result, we can consider that the PTA flap might be a reliable alternative to the much widely used RFFF, with a minor donor site morbidity, for delicate head and neck reconstructions., (© 2021 Wiley Periodicals LLC.)

Background: Over the last few years, the increasing employment of perforators as both donor and recipient vessels for free flap tissue transfer lead the surgeons to perform increasingly smaller anastomosis. Size discrepancy is a common problem that might affect the patency rate. This has many implications in the outcome of the procedure and the "Open-Y" technique might be useful to perform an easier anastomosis by using a bifurcation area., Patients and Methods: Between April 2018 and April 2020 a total of 98 patients who received a free tissue transfer reconstruction throughout the body were retrospectively recruited. The "Open-Y" technique of anastomosis was used in the recipient artery of 40 perforator-based flaps, while in 58 cases a conventional anastomosis with nonperforator vessel was performed. The size discrepancy rate and the arterial anastomotic site-related complications were evaluated and compared., Results: The flap success rate was 100% (40/40) in the "Open-Y" group, slightly better than the conventional group (96.5%; 56/58) despite a higher size discrepancy rate in the "Open-Y" group (27.5%; 11/40) compared to the conventional one (12%; 7/58) (p value, .053). The rate of complications was different, too. Better results were obtained in the "Open-Y" group with 4/40 (10%) complications compared to the 18/58 (31%) of the conventional group (p value, .013)., Conclusions: The "Open-Y" technique is a simple and interesting procedure to increase the vessels' diameter thus reducing size discrepancy and increasing the reliability of the anastomosis. This is extremely valuable in the perforator-to-perforator free tissue transfer setting where surgeons are often forced to work in a supermicrosurgical field. Every time a suitable bifurcation is encountered this might be a useful procedure to increase the end-surface available for the anastomosis or to reduce vessels size discrepancy., (© 2021 Wiley Periodicals LLC.)

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., (© 2021 Wiley Periodicals LLC.)

Background: Resorting to perforators as recipient vessels is a valid alternative that might offer a series of advantages in many situations. They allow the use of a shorter pedicle, reduce the time of dissection, and are a good solution when deep vessels are difficult to reach. The aim of this study is to investigate the efficacy of P-to-P tissue transfer for reconstructing defects in different areas of the body., Patients and Methods: Between April 2018 and February 2020, 40 patients presenting soft tissue defects were reconstructed by using P-to-P-anastomosed free flap transfer. The cause of the defect was trauma in 16 cases and surgically excised tumor in 24. Five defects were located in the upper extremities, 1 in the neck, 1 in the thorax, and 21 in the lower limb, and 13 cases were breast reconstructions, 2 of which bilateral (43 total flaps)., Results: Of all 43 flaps, 22 were abdominal flaps, 17 flaps were harvested from the upper thigh, and 4 were harvested from the lower leg. At the 9 month follow-up, 42 flaps were successfully healed, 36 without complications, 3 after wound dehiscence, and 3 after wound infection, and only 1 flap was lost requiring further surgery. Flap failure rate was 2.3%., Conclusions: Free flaps anastomosed in perforator-to-perforator fashion can be safely used in different settings throughout the body. Even if they are technically more demanding, they may allow a quicker operation time and lower morbidity. With the developments in microsurgical instruments, we believe that this technique may become the gold standard for tissue-defect reconstruction., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Head and neck defect reconstruction is a common challenge for plastic surgeons. Microsurgical free tissue transfer is a frequently used solution but its success strictly depends on the quality of recipient vessels. A particularly demanding situation occurs when there are no nearby available vessels because of previous extensive neck dissection and radiotherapy. In similar cases, it is necessary to resort to other and farther vessels. Common alternatives might be the thoraco-acromial vessels, the transverse cervical vessels, and the internal mammary vessel. Recently, the perforator vessels of the internal mammary artery and vein were shown to be safe alternatives as recipient vessels for autologous breast reconstruction, causing less morbidity and allowing adequate perfusion of rather large flaps. Here we present a floor of the mouth reconstruction after cancer relapse resection. In this case, we employed a chimeric anterolateral thigh (ALT) free flap anastomosed to the internal mammary perforator vessels in end-to-end fashion. A 46-years-old male patient presented a defect in the floor of the mouth and base of the tongue after cancer removal. No nearby vessels were available because of extensive fibrosis and damages due to previous surgeries and radiotherapy. Therefore, on the basis of our experience in autologous breast reconstruction, we chose the internal mammary perforator vessels in the recipient side and we harvested a chimeric ALT-based skin island then split into two parts for mouth reconstruction and monitoring. We performed the anastomosis resorting to internal mammary perforator vessels and we obtained a satisfactory result from both the functional and aesthetic point of view. Postoperative course was uneventful and at 6 months follow up the reconstructive result was good with no functional issue. We believe that this might be a valid and modern evolution of the use of internal mammary vessels as recipient vessels and that it is a worthy addition in the field of perforator-anastomosed flaps, extending its application also to head and neck reconstructions. Moreover, a brief literature review about alternative recipient vessels for depleted neck is also provided., (© 2020 Wiley Periodicals LLC.)

Background: Defects in the knee area, popliteal fossa region, and upper third of the lower extremity can pose a challenge for reconstructive plastic surgeons. The purpose of this article is to report the authors' experience with the use of the pedicled medial sural artery perforator flap in its simple and chimeric form for reconstruction of defects in three different regions: knee, popliteal fossa, and proximal lower leg., Methods: From April of 2018 to April of 2019, 37 patients (29 men and eight women) with a mean age of 51 years (range, 18 to 78 years) underwent reconstruction with 37 pedicled medial sural artery perforator flaps. All flaps were harvested as pedicled perforator flaps in conventional or chimeric fashion and were based on one or two perforators. The defect locations included the knee (18 cases), popliteal fossa (seven cases), and proximal lower leg (12 cases). The cause of reconstruction was trauma in 22 patients (59 percent), tumor in 10 patients (27 percent), and donor-site closure of free medial sural artery perforator in five patients (14 percent)., Results: The flap sizes varied from 3.5 × 5 cm to 5 × 10 cm. All but one flap, which showed distal tip necrosis, survived completely after surgery. The donor sites were all closed primarily. Minor complications included flap dehiscence (two cases) and minor wound infection delaying the healing process (four cases). All complications were treated conservatively. Follow-up observations were conducted for 3 to 12 months, and all patients had good functional recovery with satisfactory cosmetic results., Conclusion: The pedicled medial sural artery perforator flap can be considered an optimal method of reconstruction for covering defects not only in the knee area but also in the popliteal fossa and upper lower leg., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Consecutive or simultaneous contralateral breast reduction is a frequent request from patients undergoing unilateral breast reconstruction. Both procedures can be combined using otherwise discarded tissue as a split breast graft for reconstruction of the contralateral side. There have been few reports on the use of pedicled split breast grafts. We present a 75-year-old female with multicentric mammary carcinoma following chemotherapy, mastectomy, axillary lymph node dissection and radiotherapy. She requested a reconstruction of the left breast as well as reduction of the right breast. Risk factors, including heavy alcohol and tobacco dependence and COPD, limited the surgical options. While a free flap breast reconstruction was the standard feasible option, we opted for a procedure with minimal surgery-related morbidity. The right breast was evidently tumor-free, and the patient had no family history of breast cancer. Reconstruction was performed 22 months postmastectomy. The split-breast free flap was based on the right internal mammary artery (IMA) perforator and harvested during the right-sided breast reduction. Microsurgical anastomosis was performed on the IMA perforator on the left side. Mastopexy was performed on the right side and the nipple-areola complex (NAC) was transferred to its new position as a free graft to complete the breast reduction. A tattoo of the left NAC was performed 4 months postreconstruction. There was complete flap survival with a pleasant cosmetic result. Split breast reconstruction could be an alternative to more common procedures. However, this approach is only feasible in patients with hypertrophic contralateral breast and absence of risk factors for developing a second primary breast cancer., (© 2021 Wiley Periodicals LLC.)

Introduction: Perianal and genital defects occur because of a vast etiology making the reconstruction of function and esthetics remain challenging. Depending on the extent of the defect, different techniques have been employed for coverage including skin grafts, local skin flaps, musculocutaneous flaps, and pedicled perforator flaps. The pedicled vertical posteromedial thigh (vPMT) flap is a new perforator flap that has rarely been employed for this kind of reconstruction. The purpose of this article is to focus on the vPMT perforator flap, which is mainly used as a propeller flap, for reconstructing the perianal and genital region as a feasible option in this area., Patients and Methods: From July 2013 to December 2018, we treated twelve patients with extensive perianal and/or genital defects with 21 pedicled vPMT flaps. Three patients needed unilateral reconstruction, while 9 patients bilateral needed bilateral reconstruction. The location of the defects included the scrotal region (3 cases), the perianal region (8 cases), and the vulvar region (5 cases), whereby some cases had combined defects., Results: The flap sizes varied from 5-9 cm in width to 18-35 cm in length and all flaps were harvested as perforator-based island flaps. The flap movements used for defect coverage included V-Y advancement in three cases and rotation in propeller fashion in eighteen cases. All flaps survived without any major complications and all donor sites were closed primarily., Conclusion: Our case series showed an exemplary model for the coverage of the perianal and genital region by using the pedicle vPMT flap and the achievement of a sustainable treatment with a minor morbidity of the donor site. We believe that the vPMT flap could be an alternative option for the reconstruction of the perianal and genital region and could be inserted in the armamentarium of the reconstructive microsurgeon., Competing Interests: Declaration of Competing Interest The authors have no financial conflicts or commercial associations to disclose., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Sarcoma surgery often requires large tissue resection to be treated safely. When the tumor is localized in the groin and/or medial thigh, lymphocele and lymphedema are common complications because of the rich lymphatic network present there. The aim of this study is to share the outcome of seven patients who received defect reconstruction in this area with combined pedicled superficial circumflex artery perforator (SCIP) flap with lymphatic tissue preservation and lymphovenous anastomosis (LVA) for prevention of lymphatic complications., Patients and Methods: Seven patients who underwent surgical resection of sarcoma in the groin and/or adductors compartment received defect reconstruction with pedicled SCIP flap combined with LVA. For a better dead space obliteration, four of them also received an additional tissue flap: two pedicled deep inferior epigastric perforator flaps and two free anterolateral thigh flaps. Indocyanine green lymphography was performed in all cases to identify the lymphatic pathway, make the preoperative marking and check the patency of the anastomoses., Results: All seven patients were successfully treated reaching a good aesthetic result and a full range of motion. No immediate nor delayed complications such as lymphocele or lymphorrhea and early extremity lymphedema were observed during the follow up (range: 6-9 months; mean: 7.3) and no secondary procedures were required., Conclusions: The combination of the pedicle SCIP lymphatic tissue transfer with LVA seems to be effective in preventing the development of lymphatic sequelae after large resections in the medial thigh., (© 2020 Wiley Periodicals LLC.)

Introduction: Propeller flaps have gained great popularity among reconstructive surgeons; however, the inability to directly close the donor site of large propeller flaps constitutes a well-known limitation of this technique. Skin grafting of the donor area is not always feasible nor desirable. To address large propeller flaps secondary defects, we investigated the use of a second propeller flap harvested from a nearby region of relative skin redundancy to assist the donor site closure generated by the first. Since the donor defect of the second flap is closed by direct suture, the aim of this "sequential" propeller flaps technique is to achieve complete, like-with-like, soft tissue restoration while avoiding skin grafting., Methods: From April 2018 to September 2019, eight patients presenting post-traumatic soft tissue defects were planned to be reconstructed by means of the sequential propeller flaps technique, for a total of 16 propeller flaps. The locations of the defects included the distal leg in four cases, the heel in two cases, the proximal lateral thigh in one case and proximal posterior thigh in the remaining one. All the flaps but one were harvested as a perforator-based propeller type and rotated by different degrees around the skeletonized perforator. In one patient, due to an intraoperative complication following the first flap harvest, the harvest of the second flap was abandoned., Results: In all but one patient, a complete, tension free primary closure of all wounds was achieved without complications, the functional recovery as well the esthetic outcome were excellent. One patient showed intraoperative signs of vascular insufficiency involving 15% of the first flap. The plan of harvesting the second flap was intraoperatively abandoned and the definitive wound closure with a free muscle gracilis was carried out the following week., Conclusion: In some selected cases, the use of multiple propeller flaps performed in sequence allows the surgeon to obtain complete, like-with-like wound closure with vascularized tissue avoiding a free tissue transfer procedure, however, it requires a vast experience with propeller flaps and meticulous preoperative planning., Competing Interests: Declaration of Competing Interest The authors have no financial conflicts or commercial associations to disclose., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Soft tissue defects in the buttock area are often related to decubitus ulcers, which are usually small to medium-large size and can be regularly treated with local flaps. However, when the defects have bigger size, such as those involving the whole gluteal region, the coverage can become more challenging, since this specific area needs both a good resistance to pressure and an acceptable functional result. The most common solution for similar cases is the use of multiple local flaps, or, in extreme situations, a free flap. In particular, local flaps based on perforator vessels are, in selected cases, a consolidated alternative to free flap allowing an efficient reconstruction of soft tissue defects using adjacent similar tissues, providing the benefit of "like with like" coverage. Here we present a case of a large mycosis fungoides nidus of the gluteal region measuring 25 cm × 18 cm reconstructed using two large perforator flaps adjacent to the defect combined with a remote one for coverage of the donor site. The cranial flap was designed based on a perforator arising from the superior gluteal artery and transferred into the defect by means of a V-Y advancement, while the two caudal propeller flaps in the posterior thigh were both based on perforators of the profunda femoris artery and rotated 180°, respectively. To obtain a tension-free cover of the donor site defect we applied the concept of "sequential" propeller flaps. Post-operative course was uneventful and the patient was ambulatory with assistive devices after 1 week. At 6 months follow-up, wounds were completely healed without complications and a good functional result was obtained. This report showed the great coverage potential of multiple perforator-based local flaps when properly combined allowing primary closure of the donor site. In particular, we managed to reconstruct a total gluteal defect using just ipsilateral side tissue, reducing morbidity, and obtaining a stable result., (© 2020 Wiley Periodicals, Inc.)

Soft tissue sarcomas are a rare group of malignant tumors that often require an extensive surgical resection to be safely treated. When they are localized in the upper medial thigh, this treatment inevitably leads to large defects frequently causing a series of early and late postoperative complications. Among these, lymphocele and lymphedema are rather common and should try to be avoided. Many solutions with a demonstrated efficacy have been described for this purpose after groin dissection procedure, ranging from lymphovenous anastomosis to pedicled or free flaps. Anyway, there is much less information regarding the medial thigh. Here we present a case of resected sarcoma involving the adductors compartment reconstructed using a pedicled deep inferior epigastric (DIEP) flap with lymphatic tissue transfer, combined with preventive lymphovenous anastomosis (LVA) performed at the superior-edge-of-the-knee incision (SEKI) point. A 58-year-old patient presented a 10 cm × 12 cm soft tissue defect after margin free sarcoma removal. To fill this defect, we harvest a 24 × 9 cm pedicled DIEP flap conserving its lymphatic vessels running from the upper margin to the right groin lymphnodes. Then we rotated it maintaining the lymphnodes in their original site and moved it through an inguinal tunnel in the area of the defect. The distal part was de-epithelized and folded down to cover the deeper region. The postoperative course was uneventful and at the 6 months follow up the patient showed a good outcome with no swelling and no signs of tumor relapse. This result therefore may suggest that this kind of combined treatment might be an effective technique to prevent all those complications linked to the impairment of lymphatic system drainage in the proximal medial thigh., (© 2020 Wiley Periodicals, Inc.)

The reconstruction of defects of the perianal area and vagina places a high demand on a reconstructive surgeon. Different reconstructive methods include a skin graft, a local skin flap, a musculocutaneous flap, and a pedicled perforator flap. Here, we report the case of a 59-year-old female patient with a pelvic defect, who underwent reconstruction with a quadruplet combination of pedicled flaps from the medial thigh, due to an extensive resection of a recurrence of a squamous cell carcinoma of the anus, vulva, and partially the colon. The surgical oncologist performed a rectum amputation, a partial colectomy, a complete hysterectomy, and a resection of the dorso-lateral vaginal vault in order to achieve tumor-free margins. The resulting defect measured 14 × 11 cm 2 with 8 cm of deep space. The defect was covered and reconstructed by employing a bilateral pedicled gracilis muscle flap rotated about 120° and advanced to fill up the residual spare space in the deep and a bilateral vertical posteromedial thigh (vPMT) using a propeller flap measuring 27 × 10 cm 2 rotated 180° in order to reconstruct the vagina and the perianal area. All flaps survived without major post-operative complications. The donor site morbidity was minimal. The range of motion was not limited over both hip and knee joints. Patient had no problem with urination. Sexual intercourse was not highly considered due to patient's old age. The follow-up at 6 months showed acceptable cosmetic results with a satisfying contour of the coverage and reconstructed area. The combination of pedicled gracilis muscle flap and vPMT propeller flap may represent a valuable option in such a defect where deep space obliteration and reconstruction of the vagina with perianal contouring are needed., (© 2019 Wiley Periodicals, Inc.)

Background: Skin and soft-tissue defects around the knee are common and their reconstruction is still challenging and argued. Thin, pliable and well-vascularized tissues are required in order to restore the aesthetic appearance of the knee and facilitate joint function. Historically local muscle flaps were employed for the upper third of the lower limb reconstruction; however, since their introduction, different perforator flaps have been proposed for this purpose. The aim of this report is to share our clinical experience with the pedicled lower medial thigh perforator (p-LMT) flap for the reconstruction of skin and soft tissue defects around the knee., Patients and Methods: Between August 2013 and July 20, 2018, patients underwent pedicled LMT propeller flap reconstruction for defects around the knee. The subunits of the defects were the suprapatellar, the infrapatellar and patellar area and in two cases a full around the knee defect was reported. Cause of defects included trauma (13), tumor (4) and infection after knee operation (3) and defect sizes ranged from 4 × 3 cm 2 to 7 × 8 cm 2 ., Results: Flap sizes ranged from 4 × 9 cm 2 to 6 × 16 cm 2 . One to two perforators based on the superficial femoral artery or descending genicular artery were found between the septum of satorius and vastus medialis, or piercing the vastus medialis during dissection. All flaps were rotated 180° in propeller fashion. All the donor sites were primarily closed and no complication at the donor site was detected. In the two cases of the total knee soft tissue defect, a double pedicled flaps reconstruction was required. After a 6 months follow-up, all the patients in the series achieved a full range of motion., Conclusions: Fasciocutaneous flaps are currently the first reconstructive option for the soft tissue defects around the knee. The p-LMT flap reconstruction in this case series achieved good aesthetic and functional outcomes and this flap may be a valuable option for the reconstruction of the small to medium soft tissue defects around the knee., (© 2019 Wiley Periodicals, Inc.)

Despite some ongoing criticisms, propeller flaps are still gaining popularity among plastic surgeons. The need of skin grafting of the donor site is one of those limitations that sometime affect the beauty and the efficacy of this reconstructive technique. Similar to a classic bi-lobed skin flap in which the second lobe of the same flap is mobilized to cover the donor site defect of the first lobe, a second, discrete propeller flap can be harvested adjacent to the first, in order to close the first donor site defect, thus avoiding the need for a skin graft. We applied this concept of "sequential" propeller flaps to cover a 4.5 × 4 cm full thickness soft tissue defect at the level of the heel in a 54-year-old patient who underwent melanoma excision and sentinel node biopsy.The first and second propeller flaps of 10 × 4.5 cm respectively were rotated on a distal and on a more proximal perforator of the posterior tibial artery (PTA) respectively, obtaining a tension free closure along the entire wound. The post-operative course was uneventful and the patient returned to full normal activities after 4 weeks. Follow up at 6 months showed a stable reconstruction with no functional deficit. This option, that relies on two separate perforator propeller flaps performed in sequence to obtain complete wound closure, may be kept in mind when dealing with soft tissue defects eligible for propeller flap reconstruction, as long as sizeable perforators in a favorable position are available. Moreover, a brief literature review on propeller flap use in flap donor site closure is also provided., (© 2019 Wiley Periodicals, Inc.)

Introduction: Groin defects with exposed complex structures are challenging to treat. Perforator flaps provide a contemporary alternative to established muscle flaps to cover all varieties of groin defects, with minimum donor site morbidity, less postoperative pain, and faster rehabilitation. In this retrospective single-center analysis, we aimed to show that pedicled perforator flaps are a valid option for groin defect reconstruction. We present three different pedicled perforator flaps and discuss the flap selection process and their distinct advantages and disadvantages., Methods: A series of 54 consecutive cases of patients with groin defects were allocated into three different treatment groups. Reconstruction was performed utilizing the anterolateral thigh (ALT) flap, the pedicled posteromedial thigh (PMT) perforator flap, and the vertical deep inferior epigastric artery perforator (vDIEP) flap., Results: All 54 flaps survived. Early complications included one hematoma (vDIEP) and two infections (ALT and PMT). Delayed complications occurred in three recipient-site seromas (ALT, PMT, and vDIEP), one donor-site seroma (vDIEP), and one flap dehiscence (ALT). All flaps provided stable coverage during 3-12 months of follow-up., Conclusion: We propose pedicled perforator flaps to be a safe and reliable option for groin defect reconstruction. The pedicled PMT flap should be the first choice if the profunda femoris artery and its perforators are available. The ALT flap can be applied as a second choice, especially if complex groin defect with exposed vascular prosthesis reconstruction is needed because of its versatile expansion options, for example, as a chimeric flap using a portion of the vastus lateralis muscle. In cases where the profunda femoris artery is not available, the vDIEP flap should be the preferred method., (Copyright © 2019 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Complex defects resulting in ablation of the scalp, the calvaria, the dura, and the underlying brain are still challenging. These defects require cranioplasty to restore the bone cosmetic and functional roles and free-flap soft tissue reconstruction to prevent cranioplasty exposure and further infection. Different materials have been used in cranioplasty, while different free flaps have been proposed in those cases. In this article, we present a case series of cranioplasty reconstruction with thoracodorsal artery perforator flap (TDAP)., Patients and Methods: From April 2016 to January 2018, 5 patients underwent cranioplasty reconstruction using alloplastics and TDAP flap. Two patients underwent primary cranioplasty and 3 patients underwent secondary cranioplasty. The superficial temporal vessels were always dissected as recipient vessels., Results: The flap sizes range from 40 to 80 cm 2 (mean 57 cm 2 ) and the maximum pedicle length was 12 cm (mean 10 cm). All the donor sites were closed primary with minimal morbidity. No postoperative complications were experienced. All the flaps provided stable coverage with an acceptable color match. The mean follow-up time was 4 months., Conclusions: Our data suggest that the TDAP may be employed in postcranioplasty reconstruction. The TDAP has more advantages compared to other flaps used in alloplastic reconstruction: a broad large surface, a long pedicle, and a thinner thickness., (© 2018 Wiley Periodicals, Inc.)