Gluteal Artery Perforator Flap Research Articles

TH3.4 Perineal reconstruction following standard and extralevator abdominoperineal excision: results of a national practice questionnaire

Abstract Aims Challenging perineal defects resulting from extralevator (ELAPE) and standard abdominoperineal excision (APE) have resulted in a growing multidisciplinary approach between colorectal and plastic surgery colleagues. Currently there is a paucity of evidence on best practice in this emerging field. This study aims to define and describe current national practice within the United Kingdom (UK) in perineal reconstruction following APE/ELAPE. Methods A national practice questionnaire was designed using ‘Google Forms' and circulated via email to 41 units across the UK performing perineal reconstruction following APE/ELAPE. Results Complete responses were received from 23 units (response rate 56%), representing 12 regions across the UK. All units had a dedicated APE/ELAPE service. 70% had a standardised approach to reconstruction, with the Inferior Gluteal Artery Perforator (IGAP) flap being the most common approach (n = 11). Significant variation was observed in the reconstructive approach with regards to flap choice and routine use of pelvic acellular dermal matrix or mesh. Similar differences were observed in the perceived importance of various surgical factors that guide the reconstructive decision making process. Conclusions Our national practice questionnaire responses report nationally well established local networks between colorectal and plastic surgeons. However, the variation in results reflects a lack of national consensus on the optimal reconstructive method after APE/ELAPE. Our study highlight the need for the development of collaborative evidence based national guidance on best practice.

Does it Always have to be the Abdomen? Alternative Flaps in Autologous Breast Reconstruction

[English] Deep inferior epigastric artery perforator (DIEP) or muscle-sparing transverse rectus abdominis muscle (ms-TRAM) flaps remain the gold standard for autologous reconstruction in post-mastectomy patients, although many women may not be candidates for abdominally based free tissue transfer. In this scenario, there are several other donor site options based from the thigh (transverse and diagonal upper gracilis flaps, profunda artery perforator flap, lateral thigh flap), trunk (lumbar artery perforator flap), and buttock (superior and inferior gluteal artery perforator flaps). This article will provide insight into the history, relevant anatomy, surgical technique and novel applications (neurotization) for alternative flaps in autologous breast reconstruction.

Comparing Seroma Formation at the Deep Inferior Epigastric Perforator, Transverse Musculocutaneous Gracilis, and Superior Gluteal Artery Perforator Flap Donor Sites after Microsurgical Breast Reconstruction.

Background Seroma formation is the most common donor site complication following autologous breast reconstruction, along with hematoma. Seroma may lead to patient discomfort and may prolong hospital stay or delay adjuvant treatment. The aim of this study was to compare seroma rates between the deep inferior epigastric perforator (DIEP), transverse musculocutaneous gracilis (TMG), and superior gluteal artery perforator (SGAP) donor sites. Methods The authors conducted a retrospective single-center cohort study consisting of chart review of all patients who underwent microsurgical breast reconstruction from April 2018 to June 2020. The primary outcome studied was frequency of seroma formation at the different donor sites. The secondary outcome evaluated potential prognostic properties associated with seroma formation. Third, the number of donor site seroma evacuations was compared between the three donor sites. Results Overall, 242 breast reconstructions were performed in 189 patients. Demographic data were found statistically comparable between the three flap cohorts, except for body mass index (BMI). Frequency of seroma formation was highest at the SGAP donor site (75.0%), followed by the TMG (65.0%), and DIEP (28.6%) donor sites. No association was found between seroma formation and BMI, age at surgery, smoking status, diabetes mellitus, neoadjuvant chemotherapy, or DIEP laterality. The mean number of seroma evacuations was significantly higher in the SGAP and the TMG group compared with the DIEP group. Conclusion This study provides a single center's experience regarding seroma formation at the donor site after microsurgical breast reconstruction. The observed rate of donor site seroma formation was comparably high, especially in the TMG and SGAP group, necessitating an adaption of the surgical protocol.

Analysis of clinical and patient-reported outcomes in post-ELAPE perineal reconstruction with IGAP flap – A 5-year review

Background: Extralevator abdominoperineal excisions (ELAPE) are now the accepted treatment option for low rectal cancers, which result in large perineal defects necessitating reconstruction. The aim of our study was to assess the clinical outcomes as well as the quality-of-life parameters (QOLP) following these reconstructions. Methods: A series of 27 patients who underwent ELAPE and immediate reconstruction with inferior gluteal artery perforator flaps (IGAP) between December 2013 to December 2018 were retrospectively analysed on patient demographics, disease and treatment, complications, and QOLP. Results: With a mean age of 71.6 years, all patients had low rectal cancers and underwent ELAPE (24 open, 3 lap-assisted) and immediate IGAP flap reconstruction. The follow-up period was 1 year. The overall perineal early minor complication rate was 25.9% and the early major complication rate of 14.8%. QOLP, such as tolerance to sit, perineal pain, perineal aesthetics, showed high patient satisfaction of 77.7%, 40.74%, and 66.6%, respectively at 1 year. The perineal hernia rate was 14.8% with all patients being female (p 0.0407; significant). Conclusion: IGAP flaps are a reliable option for reconstructing post-ELAPE defects with good patient satisfaction and outcomes.

A Comparative Study between Excision and Reconstruction Using Superior Gluteal Artery Perforator Flap and Lay Open in Cases of Recurrent Pilonidal Sinuses

A Comparative Study between Excision and Reconstruction Using Superior Gluteal Artery Perforator Flap and Lay Open in Cases of Recurrent Pilonidal Sinuses

Correlation of vascular change with TRPV1, TRPV4, and TRPA1 in a rat model of inferior gluteal artery perforator flap.

Maximum survival area after perforator flap elevation is mainly achieved through vasodilation and angiogenesis, and endothelial Ca2+ signals play a pivotal role in both of them. Transient receptor potential (TRP) channels modulate many endothelial cell functions via mediating the extracellular Ca2+ entry. This study aims to investigate the correlation of TRPV4, TRPV1, and TRPA1 with vascular change after the inferior gluteal artery perforator flap elevation. A total of 50 adult male SD rats were used in this study. Ten rats were used in the part one to assess the flap viability on postoperative day 7. Twenty rats were used in the part two to evaluate blood flow change after flap elevation. The correlation of vascular change with TRPV1, TRPV4, and TRPA1 protein changes was investigated in 20 rats in the part three. The mean flap survival area percentage was 55 ± 5.7%. Blood flow in the overall flap and Zone II after the flap elevation markedly increased from the postoperative day 3. The most marked change of the vasodilation occurred on Days 3 and 5 after flap elevation. The angiogenesis occurred on Day 5 after flap elevation and the microvessel density peaked also on Day 5. Moreover, TRPA1 expression showed a trend towards continuous reduction over time. The expression of TRPV1 and TRPV4 reached the peak value on Day 3. The endothelial NO synthase expression showed an increasing trend at first, followed by a reduction over time, while VEGF expression reached the peak value on Day 3. The vascular changes after flap elevation might be associated with the changes in TRPV4, TRPV1, and TRPA1.

A Single Superior Gluteal Artery Perforator Flap in Reconstruction of Large Midline Sacral Defects: A Method for Practical Harvest and Safe Closure.

Large midline sacral defects are reconstructive challenges. Superior gluteal artery perforator (SGAP) flap provides enough tissue and versatility to cover large defects; however, a single flap may be insufficient. We present a technique to cover large defects using single SGAP flaps. Large sacral defects (>100 cm2) reconstructed with single SGAP flaps were included. Angle of transposition (45°-60°) was determined based on the tissue laxity and mobility of gluteal area. Perforator identification, intramuscular dissection, or skeletonization was not performed. Outcomes were measured as achieving durable reconstruction, flap viability, and complications. There were 17 patients (12 male, 5 females; aged 25-72 years) with different etiologies. The mean flap surface area (136.1 ± 45.6 cm2, between 9 × 8 and 26 × 10 cm) was smaller than the mean defect surface area (211.1 ± 87.2 cm2, between 10 × 10 and 28 × 14 cm) (P < 0.001). All flaps survived with no partial or complete flap loss. Minor dehiscence in 4 patients (2 at donor site and 2 at recipient site) healed with dressing changes or using negative-pressure vacuum therapy. All patients had durable outcomes without any recurrence. Single unilateral SGAP flaps can be used to completely cover midline large sacral defects. It is important to design the flaps to have a joint side with the defect in the proximal part and use the intrinsic mobility of gluteal soft tissues for the closure. Flaps can be (1) planned to be smaller than the defects, (2) harvested with no intramuscular perforator dissection or pedicle skeletonization, and (3) transposed with an angle less than 60°.

Inferior gluteal artery perforator (IGAP) flap versus profunda artery perforator (PAP) flap as an alternative option for free autologous breast reconstruction

When patients are unsuitable for deep inferior epigastric perforator (DIEP) flap breast reconstruction, the inferior gluteal artery perforator (IGAP) flap has been used as an alternative option. However, the profunda artery perforator (PAP) flap is also gaining popularity as an alternative to the DIEP flap for several reasons. This retrospective cohort study compares baseline characteristics, peri- and post-operative outcomes following IGAP flap and PAP flap breast reconstructions after mastectomy for cancer. In a single center in the UK, from September 2008 through December 2016, 43 women underwent IGAP Flap(s) breast reconstruction and 51 received PAP flap(s) breast reconstructions. Statistical analysis was performed to compare baseline, peri-operative and post-operative variables between the two reconstruction methods. Perioperative complications requiring reoperation were experienced in women undergoing IGAP flap breast reconstructions only (21% versus 0%, p=0.001), principally due to the risk of total flap failure (12% versus 0%, p=0.01). Women undergoing IGAP flap breast reconstructions were at significantly higher odds of revision surgery (OR 17 [95% CI: 5.5-53], p<0.001), which was unchanged after adjusting for bilateral reconstructions (adjusted OR 18 [95% CI: 5.3-58], p<0.001). PAP flaps appear to be associated with significantly fewer complications and revision surgeries than IGAP flaps for breast reconstruction in women undergoing mastectomy for cancer and who are unsuitable for a DIEP flap breast reconstruction.

Outcome of Closure of Wide Based Defects by Various Rotational Flaps

Aim: To observe the outcome of closure of wide based defects by various rotational flaps for meningomyelocele defects. Study setting: Neurosurgery Department, Sheikh Zayed Hospital, Rahim yar khan Duration: From Oct 2018 to Oct 2020, Methodology: We included 15 patients with wide based myelomeningocele anomalies in the neurosurgery department, Sheikh Zayed Hospital, Rahim yar khan. Age ranged from four days to eight years. The flaw had a diameter of between 8x5cm and 12x8cm. Rotational flaps were used to restore soft tissue defects in all cases. Result: In this study, we did posterior intercostal artery perforator flap(superiorly based) in 40% patients, double rotation flap (yin yang) in 26.7% patients, superior gluteal artery perforator flap in 20 % patients and z plasty in 13.3 % patients. Regarding complications, 2 (13.3%) individuals had a superficial wound dehiscence. One individual (6.7%) developed necrosis of the distal portion of the flap, which was conventionally handled. Postoperatively, no neurosurgical problem occurred. After an average of 6 months, no patient experienced reappearance or dural sac herniation. Conclusion: Restoration of large meningomyelocele defects using local rotational flaps is a secure and reliable approach for abnormalities in the lumbosacral region. Keywords: Meningomyelocele, rotational flaps

Immediate vaginal and perineal reconstruction after abdominoperineal excision using the Inferior Gluteal Artery Perforator Flap (V-IGAP)

The fasciocutaneous inferior gluteal artery perforator (IGAP) has been previously demonstrated to be a robust reconstructive choice after abdominoperineal excision (APE), with comparably low morbidity relative to other flaps. In patients who undergo concurrent vaginectomy, we demonstrate in this retrospective cohort study how IGAP modification allows simultaneous vaginal reconstruction with a favourable complication profile and long-term return to sexual activity. Oncological resection was completed with the patient prone. Unilateral or bilateral IGAP flaps may be used based on vaginal defect size and surgeon preference. In this study, important features of flap design, mobilisation and inset are presented, together with a retrospective cohort study of all cases who underwent vaginal reconstruction. Clinical outcomes were determined by the length of stay, early to late complications, and quality of life assessment including a return to sexual function. Over a 10-year period, 207 patients underwent abdominoperineal resection (APE) in our cross-centre study (86% subject to neoadjuvant chemoradiotherapy), with 22/84 female patients electing for vaginal reconstruction (19 partial, 3 total vaginectomies). Minor complications were observed in 6/22 cases, with two patients progressing to healing after-theatre debridement (major). The median follow-up time was 410 days. Quality of life questionnaires reported high patient satisfaction, with 70% of patients returning to sexual activity. For patients undergoing APE with concurrent vaginectomy, the IGAP flap can be used alone for both perineal dead space management and neovaginal reconstruction, negating the need for an alternative second flap and avoiding significant donor morbidity. This study shows excellent long-term clinical outcomes, including a return to sexual activity.

Pelvic Reconstruction following Abdominoperineal Resection and Pelvic Exenteration: Management Practices among Plastic and Colorectal Surgeons.

Pelvic reconstruction with a muscle flap significantly improves postoperative outcomes following abdominoperineal resection (APR). Despite it being the gold standard, significant surgeon-selection bias remains with respect to the necessity of pelvic obliteration, flap choice, and ostomy placement. The objective of the study was to characterize management practices among colorectal surgeons (CSs) and plastic surgeons (PSs). Specialty-specific surveys were distributed electronically to CSs and PSs via surgical societies. Surveys were designed to illustrate geographic and specialty-specific differences in management. Of 106 (54 CSs and 52 PSs) respondents (58% Canada, 21% Europe, 14% the United States, and 6% Asia/Africa), significant interdisciplinary differences in practices were observed. Most respondents indicated that multidisciplinary meetings were not performed (74% of CSs and 78% of PSs). For a nonradiated pelvic dead space with small perineal defect, 91% of CSs and 56% of PSs indicated that flap reconstruction was not required. For a radiated pelvic dead space with small perineal defect, only 54% of CSs and 6% of PSs indicated that there was no need for flap reconstruction. With respect to ostomy placement, 87% of CSs and 21% of PSs indicated that stoma placement through the rectus was superior. When two ostomies were required, most CSs preferred exteriorizing ostomies through bilateral recti and requesting thigh-based reconstruction. PSs favored the vertical rectus abdominis muscle (VRAM; 52%) over the gracilis (23%) and inferior gluteal artery perforator (IGAP; 23%) flaps. Among PSs, North Americans favor abdominally based flaps (VRAM 60%), while Europeans favor gluteal-based flaps (IGAP 78%). A lack of standardization continues to exist with respect to the reconstruction of pelvic defects following APR and pelvic exenteration. Geographic and interdisciplinary biases with respect to ostomy placement, flap choice, and role for pelvic obliteration continues to influence reconstructive practices. These cases should continue to be approached on a case by case basis, driven by pathology, presence of radiation, comorbidities, and the size of the pelvic and perineal defect.

Association of Clinical Complications of Chemotherapy and Patient-Reported Outcomes After Immediate Breast Reconstruction

Women undergoing immediate breast reconstruction often require chemotherapy. The effects of chemotherapy on reconstruction are not well described. To evaluate the association of neoadjuvant and adjuvant chemotherapy with complications and patient-reported outcomes (PROs) in immediate reconstruction. The Mastectomy Reconstruction Outcomes Consortium Study is a cohort study that prospectively assessed PROs and retrospectively evaluated complications in patients undergoing immediate implant-based or autologous reconstruction at 11 centers from January 1, 2012, to December 31, 2017. Women 18 years or older undergoing immediate reconstruction after mastectomy with 2 years of follow-up were included. Patients were excluded if they had prophylactic mastectomy; delayed reconstruction; mixed-timing reconstruction; mixed reconstruction; a latissimus dorsi, superior gluteal artery perforator, or inferior gluteal artery perforator flap; or both neoadjuvant and adjuvant chemotherapy. Data were analyzed from May 1 to June 30, 2018. Complications and PROs (satisfaction with breast and physical, psychosocial, and sexual well-being) using the BREAST-Q questionnaire, a validated, condition-specific PRO measure. Baseline patient characteristics were collected. A total of 1881 women were included in the analysis (mean [SD] age, 49.9 [9.9] years). Of these, 1373 (73.0%) underwent implant-based procedures; 508 (27.0%), autologous reconstruction; 200 (10.6%), neoadjuvant chemotherapy; 668 (35.5%), adjuvant chemotherapy; and 1013 (53.9%), no chemotherapy. Patients without chemotherapy were significantly older (mean [SD] age, 51.6 [9.4] years; P < .001), and patients with chemotherapy were more likely to have received radiotherapy (108 of 200 [54.0%] for neoadjuvant chemotherapy and 321 of 668 [48.1%] for adjuvant chemotherapy; P < .001). Among the cohort undergoing implant-based reconstruction, the rates of any complication were significantly different, with higher rates seen for adjuvant (153 of 490 [31.2%]) and neoadjuvant (44 of 153 [28.8%]) chemotherapy compared with no chemotherapy (176 of 730 [24.1%]; P = .02). On multivariable analysis, these differences were not statistically significant. For autologous reconstruction, no significant differences in complications were observed. Controlling for clinical covariates, no significant differences were seen across chemotherapy groups for the BREAST-Q subscales except for sexual well-being in the implant cohort, in which adjuvant chemotherapy had significantly lower scores (β, -4.97 [95% CI, -8.68 to -1.27]; P = .009). In this cohort study, neither neoadjuvant nor adjuvant chemotherapy was associated with the likelihood of complications in patients undergoing implant-based or autologous reconstruction, and chemotherapy was not associated with patient satisfaction with reconstruction or psychosocial well-being. This information can help patients and clinicians make informed decisions about breast reconstruction in the setting of chemotherapy.

Unique hybrid double apposing flap in a Z-plasty technique to reconstruct major perianal defect resulting from chondyloma acuminatum resection - Case report.

Perianal area is anatomically challenging location to reconstruct after wide extensive local excision especially when preserving the anus anatomy anal sphincter continence is a requirement. That is the case in many benign locally aggressive conditions, due to high risk of suture line disruption, wound dehiscence, and wound infection. Many surgical options like primary closure, loco reginal flaps, distant or pedicled flaps, or even free flaps are available for such reconstruction. This is a report of a case of locally aggressive infection that was initially confused as complex perianal fistula, then sarcoma after the initial resection. Surprisingly, the permanent pathology confirmed the diagnosis of a giant condyloma acuminatum extending to the anal area, for which an extensive wide local resection with margin and temporary colostomy was done, this resulted in a large defect necessitating a reconstruction with hybrid double apposing Superior gluteal artery perforator flap (SGAP flap) and Inferior gluteal artery perforator flap (IGAP flap) in Z-plasty fashion. That healed completely with no local complication.

Reconstruction of lumbosacral defect with pedicled superior gluteal artery perforator flap: A case report and literature review

Lumbosacral defect after instrumented spinal fusion is a serious complication that challenges orthopedic surgeons. We report a case of a 63-year-old woman who underwent instrumented thoracolumbosacral correction and reconstruction surgery. Deep operative wound infection and dehiscence occurred. The wound cultures yielded Staphylococcus aureus, which was sensitive to oxacillin. After extensive debridement and negative pressure vacuum-assisted closure therapy, the soft tissue reconstruction team of our department was consulted for her irreparable lumbosacral wound defect with partial implant exposure. A pedicled superior gluteal artery perforator flap was used as a salvage procedure for lumbosacral soft tissue reconstruction. She was satisfied with the surgical results and returned to her daily activities with good recovery.

Septocutaneous gluteal artery perforator flap in breast reconstruction: An insight into the related anatomy and preoperative imaging

Although without a widespread popularity, the septocutaneous gluteal artery perforator flap (sc-GAP) can be an excellent choice in breast reconstruction. The purpose of the article is to further study the preoperative imaging anatomy and surgical technique for a safe operation. A clinical experience in four unilateral breast reconstructions is reported, and an analysis is made of the computed tomography angiography (CTA) variables (36 studies/72 sides) that might define the microsurgical consistency and reliability of the technique. After a careful preoperative imaging evaluation, the surgical operation confirmed a predictable, although not straightforward, anatomy. All the flaps were raised in the supine position. With a remarkably quick postoperative recovery, the resulting scar was well hidden and did not significantly distort the gluteal aesthetics although contralateral contouring liposuction might be desirable in unilateral cases. Good aesthetic results were obtained in all the patients. In the evaluation of the CTA studies, a right/left septocutaneous perforator arising from the superficial branch of the superior gluteal artery could be found in 80.6% of the patients, with a few patients having 2-3 perforators on one side. Although with an overall suitable pedicle length (mean 7.4 cm), the arterial diameter at the suture site was found to be small (mean 1.6 mm). Given the adequate body habitus and reconstructive requirements, the sc-GAP can be a good choice even in large breasts. However, the technique requires the appropriate surgical expertise and mandates a thorough preoperative imaging evaluation that defines whether the technique should be done in a particular patient.

Staged repair strategy for chronic sacrococcygeal radiation ulcer

Objective: To investigate the clinical effect of staged repair strategy for chronic sacrococcygeal radiation ulcer. Methods: The retrospective cohort study method was applied. Twelve patients with chronic sacrococcygeal radiation ulcer were admitted to Beijing Jishuitan Hospital from January 2010 to June 2020, including 7 males and 5 females, aged 38-74 years. The thorough debridement was performed in the first stage, with wounds area after debridement ranging from 8 cm×6 cm to 22 cm×14 cm, and continuous vacuum sealing drainage (VSD) was performed after the debridement operation. In the second stage, personalized surgery scheme was formulated according to the patient's age, systemic condition, vascular condition, and the position, size, and depth of wound. Six cases were reconstructed with superior/inferior gluteal artery perforator flaps, 4 cases were repaired with gluteus maximus myocutaneous flaps, 1 case was repaired with pedicled latissimus dorsi myocutaneous flap, and 1 case was reconstructed with free transplantation of latissimus dorsi myocutaneous flap. The area of flaps or myocutaneous flaps ranged from 10 cm×8 cm to 25 cm×18 cm. Donor sites of the flaps were sutured primarily in 9 patients and in the other 3 patients were repaired with intermediate split-thickness skin graft in back. The survival of flap or myocutaneous flap after operation, recurrence of tumor, and the appearance and texture of flap or myocutaneous flap, and wound healing were observed during follow-up. Results: Flaps or myocutaneous flaps in 11 patients survived after operation, and superior gluteal artery perforator flap in 1 patient had partial distal necrosis, which was covered again with flap pushed to the distal after debridement and resection of the necrotic tissue. The wounds in 8 patients achieved primary healing, 1 patient repaired with superior gluteal artery perforator flap experienced subcutaneous infection, 1 patient repaired with superior gluteal artery perforator flap suffered distal venous congestion of the flap, and 1 patient repaired with gluteus maximus myocutaneous flap had hematoma under myocutaneous flap, and 1 patient repaired with retrograde latissimus dorsi myocutaneous flap had incision exudation and dehiscence, which were all healed after dressing change, etc. There was no recurrence of tumor after the operation. The wounds healed well during follow-up of 2-52 months after discharge, with no recurrence of infection, and the flaps were soft in texture, with satisfactory appearance and well healed donor sites. Conclusions: On the basis of thorough debridement and VSD in the first stage, superior/inferior gluteal artery perforator flap, gluteus maximus myocutaneous flap, or pedicled/free latissimus dorsi myocutaneous flap with abundant blood supply is applied to repair chronic sacrococcygeal radiation ulcer in the second stage. The staged operation is reliable, with minimal injury to the donor site of flap and satisfactory therapeutic effect.

Dual Reconstruction of Lumbar and Gluteal Defects with Freestyle Propeller Flap and Muscle Flap.

Background:The reconstruction of complex tissue defects in the lumbar and gluteal areas is a surgical challenge. The use of freestyle perforator-based flaps has gained popularity in the reconstruction of these defects due to several advantages: versatility, minimal donor-site morbidity, and tension-free closure. The present study reports the outcome of using a dual coverage of lumbar and gluteal defects with a gluteus maximus rotation flap as a deep layer and a freestyle propeller perforator-based flap as a superficial layer.Methods:A retrospective analysis of 18 patients who had a dual coverage of complex wounds of the lumbar and the gluteal areas was conducted. Different propeller flaps were used as superior gluteal artery perforator flap (SGAP), inferior gluteal artery perforator flap (IGAP), and posterior thigh perforator flap (PTP).Results:The study included 15 men and 3 women. The mean age was 26.3 years. The causes of the defects were: pressure ulcers in 14 patients and post-traumatic in 4 patients. A total of 28 freestyle flaps was used: 11 patients had 1 flap, 4 had 2 flaps, and 3 had 3 flaps. The mean postoperative follow-up was 12.2 months. The complications registered in the medical records were venous congestion in 2 patients, partial flap necrosis in 2 patients, and wound dehiscence in 1 patient.Conclusions:A freestyle propeller perforator-based flap combined with a gluteus maximus muscle flap is a solution that provides well-padding over bony prominence with a low complication rate. However, a long-term follow-up is needed to verify these results.

Alternative flaps in autologous breast reconstruction.

The gold standard for autologous reconstruction in the post-mastectomy patient remains the deep inferior epigastric artery perforator flap, although many women may not be candidates for abdominally based free tissue transfer. In this scenario, there are several other donor site options based from the thigh (transverse and diagonal upper gracilis flaps, profunda artery perforator flap, lateral thigh flap) and trunk (lumbar artery perforator flap, superior and inferior gluteal artery perforator flaps). This study will review the history, relevant anatomy, surgical technique and outcomes for alternative flaps in autologous reconstruction. Additionally, preoperative imaging (CTA, MRA) and novel applications (stacking flaps, neurotization) in breast reconstructive microsurgery will be discussed.

The Effect of Intraoperative Radiotherapy on Healing and Complications After Sacrectomy and Immediate Reconstruction.

Sacropelvic resection is the treatment of choice for pelvic bone tumors and can be associated with intraoperative electron radiotherapy (IOERT) to optimize local control of the disease. Reconstruction with flaps also is essential to avoid pelvic complications. There is scarcity of publications evaluating outcomes of reconstructive procedures associated with IOERT. A prospective study in 53 patients between 2005 and 2018 was performed. Thirty-four patients received IOERT (group I [GI]) and 19 did not (GII). We examined demographic characteristics, tumor pathology, type of resection and volume of surgical specimen, timing of surgery, IOERT doses, postoperative stay, and complications. We used it for reconstruction rectus abdominis, gluteal, omental and gracilis, superior gluteal artery perforator flap, and free flaps. Colonic adenocarcinoma and chordoma were the most frequent tumors. The median (interquartile range) IOERT dose was 1250 (1000-1250) cGy; operating time was 10.15 (8.6-14.0) hours versus 6.0 (5.0-13.0) hours, hospital stay was 37 (21.2-63.0) days versus 26.0 (12.0-60.0) days, and volume of surgical specimen was 480.5 (88.7-1488.0) mL versus 400 (220.0-6700.0) mL in GI and GII, respectively. Operating time was significantly longer in GI (P < 0.03). There were significant positive correlations between operating time, hospital stay, and volume of surgical specimen. Main complications were exudative wounds (50% vs 31.5%), wound dehiscence (41.1% vs 31.5%), and seroma (29.4% vs 26.3%) in GI and GII, respectively. Complications were similar to previous studies with or without radiotherapy. Under a reconstructive approach, IOERT did not harm flap survival nor increased pelvic complications when compared with similar cases without IOERT.

Versatility of Gluteal Arteries Perforator Flaps for Local Coverage Relative to Defect Size, Site, and Different Pathological Conditions

Background: Superior and inferior gluteal artery perforator flaps have evolved in the last few decades for both free and local tissue transfer because of having the advantages of being voluminous with a relatively inconspicuous donor site. Therefore focusing on the details of such a reconstructive procedure would be of importance when thinking of skin defect coverage in the lower back, gluteal, and upper thigh areas. Patients and methods: This study was done on 14 cases, 10 of them had defects due to pressure sores, and 4 cases due to other inflammatory and neoplastic conditions. All cases were done by the same surgical team with a follow up period ranging from 2 to 18 months. Results: Thirteen out fourteen flaps (92%) passed completely and uneventfully with no need for additional surgery throughout eighteen months of follow up. However, two cases developed wound dehiscence that required secondary sutures to one of them, two cases developed seroma, and one case developed partial flap loss which re-advanced by V-Y technique.Conclusion: The superior and inferior gluteal artery perforator flaps are versatile reconstructive coverage option for gluteal defects of different size, site and pathology. They are easy to perform; suitable for large defect reconstruction of the lower back, buttock, and upper thigh areas.