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Background: To perform head and neck reconstruction, the exact location of recipient vessels must be evaluated preoperatively. This study aimed to superimpose arterial and venous pathways identified by computed tomography angiography (CTA) on patients using augmented reality (AR) techniques to freely select recipient vessels., Methods: Patients who underwent reconstructive microsurgery due to defects on the scalp, forehead, and glabella from July 2019 to October 2019 were enrolled. The superficial temporal artery (STA) and superficial temporal vein (STV) were marked using hand-held Doppler. Furthermore, the three-dimensional reconstructed CTA image was superimposed on the patient's face using a smartphone application, Camera-Lucida, and marked. The accuracy of mapping was evaluated intraoperatively. Success rates and the time consumed for mapping were compared., Results: Twelve patients underwent preoperative marking. Success rates of STA mapping using the AR technology and hand-held Doppler were 100% and 83%, respectively (P = 0.48). The mean time consumed for STA marking was 90.2 ± 17.7 seconds and 121.0 ± 117.7 seconds, respectively (P  = 0.75). The success rate of STY marking with the AR technology was superior to that with hand-held Doppler (100% versus 58.3%; P = 0.037). STY marking was faster with the AR technology than with hand-held Doppler (mean time, 91.2 ± 25.7 seconds versus 94.5 ± 101.6 seconds; P = 0.007)., Conclusions: The AR technology could be the paradigm shift in the field of microsurgical reconstruction. it can connect threedimensional CTA data with patient topography, leading to not only more precise operations but also improved outcomes in patients undergoing microsurgical reconstruction., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Background: Perforator flaps have revolutionized lower limb reconstruction by offering single-stage thin, pliable coverage with an excellent aesthetic match. Although anastomosis of the flap to a major artery remains the gold standard, perforator-to-perforator anastomosis has several advantages, including expedient recipient dissection and increased recipient options in vessel-depleted extremities. The aim of this study was to compare flap survival when a perforator or major artery was used as a recipient vessel., Methods: A retrospective cohort of free perforator flaps for lower limb reconstruction was reviewed. Demographics, comorbidities, vascular status, defect characteristics, operative details, and complications were recorded. Outcomes for perforator and major artery recipients were compared., Results: Four hundred twenty-three flaps were performed for various reasons using perforator flaps. The total limb salvage rate was 98.8 percent. Total and partial flap failure rates were 6.1 percent and 9.0 percent, respectively. Comparing perforator recipients [n = 109 (25.8 percent)] to major artery recipients [n = 314 (74.2 percent)], there was no significant difference in total (p = 0.746) or partial flap failure (p = 0.212). Significant factors between the groups included larger flap size with major artery recipients (p = 0.001) and shorter operative time when using a perforator recipient (p = 0.012)., Conclusions: Perforator-to-perforator anastomosis is a reliable option that affords equivalent rates of flap success compared to major artery anastomosis in lower extremity reconstruction. The authors advocate using a major artery recipient in defects where the axial vessels are easily accessible. A perforator recipient is a viable alternative in defects where access to the axial vessels is inconvenient and in patients with limited recipient options., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Background: A superficial circumflex iliac artery perforator flap has several advantages, such as reduced thickness, minimal donor-site morbidity, and inconspicuous scar. However, the application of a superficial circumflex iliac artery perforator flap is restricted because of its limited pedicle length. The aim of this article was to outline the technical modifications of superficial circumflex iliac artery perforator flap elevation to obtain long pedicles., Methods: This is a prospective study of 31 consecutive patients who required a long pedicled superficial circumflex iliac artery perforator flap between September of 2016 and December of 2019 at the authors' center. According to a preoperatively marked pathway of the superficial branch of the superficial circumflex iliac artery, the superficial circumflex iliac artery perforator flap was designed. During the elevation, the design was modified according to the perforator location in the free-style technique. The characteristics of the patients and the flaps, including pedicle length, were recorded. The revision rate, complication rate, and need for a secondary procedure were analyzed., Results: The mean follow-up period was 563 days (range, 92 to 1383 days). The mean length of the pedicle obtained was 6.9 cm (range, 6 to 8 cm) from the point where the pedicle merges into the flap. Long pedicles were anastomosed to the main source vessel or branch without tension. No major complications were reported., Conclusions: Overcoming the short pedicle length of a superficial circumflex iliac artery perforator flap by designing the flap laterally and performing an intraflap dissection is a reliable option when a longer pedicle is required, irrespective of the specific anatomy of the superficial circumflex iliac artery., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background:  With the technological advances, microsurgery has evolved to the era of supermicrosurgery since its inception. With the popularization of these flaps, proficiency in using tools such as color Doppler ultrasound (CDU) has become crucial. Despite the increased interest, studies regarding the role of ultrasound in microsurgical reconstruction are scarce. Therefore, in this study, we discussed currently available imaging modalities for reconstructive surgeons, types of ultrasound, and the role of ultrasound in microsurgical reconstruction, and made recommendations for ultrasound use in reconstructive surgery., Methods:  We performed a computerized search of ultrasound in reconstructive surgery using the MEDLINE database. Data regarding ultrasound indications, usage, and outcomes were collected., Results:  Of the 115 articles identified, the majority was written on nonreconstructive ultrasound uses (51.4%). For the reconstructive uses, mapping of perforators was the most common usage (39.1%), followed by flap monitoring and volume measurement. In addition, we found that there are a limited number of literature on the role of CDU in reconstructive surgery, especially on its intraoperative and postoperative use., Conclusion:  CDU is a valuable and powerful tool for any reconstructive surgeons who are interested in performing microsurgery or supermicrosurgery. As the demand of customized flaps using superthin flaps, perforator-to-perforator anastomosis, and supermicrosurgery increases, understanding and becoming versatile in CDU will be critical. We hope our experience with using ultrasound and refinements that we made are helpful for those who would like to include it as a part of their armamentarium., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: The challenging issues are to prevent anastomotic leakage and provide sufficient flap monitoring in circumferential hypopharyngeal reconstruction. In this study, a newly designed flag-shaped anterolateral thigh (ALT) free flap was used for circumferential hypopharyngeal reconstruction to address these issues., Methods: Eighteen ALT flaps were harvested for reconstruction of circumferential hypopharyngeal defects from 2013 to 2016. The harvested ALT flap was sutured into a cylinder shape, and a triangular extension of the flap was used for dead space obliteration and flap monitoring. All data regarding outcomes and complications including radiographic investigations were collected retrospectively., Results: The flap had a rectangular shape with dimensions of 29 cm × 8 cm (range, 25-31 cm × 6-10 cm). For each flap, 2-4 perforators were included (average, 2.6 perforators/flap). All flaps survived. One venous thrombosis was diagnosed early through the monitoring portion of the flap, and the flap was salvaged after thrombectomy with a vein graft. The mean follow-up period was 28.9 months (10.3). There was one case of definitive fistula (4%), which never healed because of early tumor recurrence. Three postoperative strictures were noted (21.4%)., Conclusions: For a complete circumferential hypopharyngeal defect, the flag-shaped ALT free flap design offers monitoring flap and dead space obliteration and prevents anastomotic leakage., (Copyright © 2019 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)