Pedicle Length Research Articles

Medial sural artery perforator free flap for small- to medium-sized defects in head and neck reconstruction: a suitable replacement for radial forearm free flap

Background and objectivesTo compare clinical outcomes and donor site morbidity between medial sural artery perforator (MSAP) flap and radial forearm free (RFF) flap for soft tissue reconstruction of head and neck.MethodsForty-six patients who underwent free flap reconstruction at the head and neck cancer center from February 2019 to March 2021 were included, of which 25 RFF flaps and 21 MSAP flaps. The patient and flap characteristics (age, sex, flap size, harvest time, etc.) and outcomes (success rate, donor site complications including infection, hematoma, and fistula, donor site morbidity including abnormal sensation, weakness, range of motion, postoperative oral function) were recorded and compared. Patients were followed up for at least 12 months after surgery. The patients were assessed subjective donor-site morbidity and satisfaction with overall functional results using a self-reported questionnaire.ResultsThe success rates of RFF flaps and MSAP flaps were 96% and 95.2%. There were no significant differences in age, sex, flap size, pedicle length, postoperative treatment, and postoperative oral function. MSAP flap showed less donor site morbidity and better subjective satisfaction at the donor site than RFF flap did after a 12-month follow-up. A dominant perforator of the medial sural artery emerges constantly near the point which is approximately 15 cm from the popliteal fossa center vertically, and 3 cm from the postor midline of the leg horizontally.ConclusionDue to less donor site morbidity and higher patient satisfaction, MSAP flap can be used as a replacement for RFF flap for small to medium-sized defects in head and neck reconstruction.

The Prevalence of Congenital Cervical Stenosis Differs based on Race.

Congenital cervical stenosis (CCS) is a rare condition involving a narrowed spinal canal due to developmental anomalies. CCS heightens the risk of neurologic deficits and acute spinal cord injury post-trauma, influencing return-to-play decisions for contact athletes. Additionally, CCS patients are prone to cervical myelopathy as degenerative changes progress with age. Limited evidence-based literature exists addressing the epidemiology of CCS, including the effects of race. To investigate the anatomical differences and prevalence of CCS as it pertains to race and ethnicity. Single center retrospective cross-sectional study. A total of 343 patients with cervicalgia between the years of 1999-2023. Radiographic measurements of anatomical parameters were collected and CCS was defined as a sagittal canal diameter (SCD) of less than 10 mm at 2 or more vertebral levels (C3-7) at the pedicle. We screened 5395 cervical MRIs from a single institution. Exclusion criteria included patients under 18 and over 50 years, prior cervical spine surgery, congenital fusions, spinal malignancy, or active smoking history. For each patient, axial measurements were taken at each level, including coronal vertebral body length, anteroposterior vertebral body length, pedicle width, pedicle length, laminar length, anteroposterior lateral mass length, posterior canal distance, apex-to-vertebral body, lamina-disc angle (LDA), lamina-pedicle angle, and anteroposterior spinal cord diameter. CCS prevalence varied significantly among ethnic groups; Black (39.3%), Asian (33.6%), and Hispanic (22%) patients demonstrated significantly higher CCS rates than White patients (7.5%) [x2 (3, N=343) = 30.04, p <0.05)]. Blacks and Asians showed consistently smaller SCDs at all pedicle levels compared to Whites, who had the largest SCDs overall (p<0.001). Average SCDs were 11.4 mm (White), 10.4 mm (Black), 10.5 mm (Asian), and 11 mm (Hispanic). Additionally, LDAs were larger in Asians, Blacks, and Hispanics compared to Whites, leading to a significantly decreased cross-sectional canal area (p<0.001). Our study indicates a statistically significant correlation between race/ethnicity and CCS prevalence. Black and Asian patients had the highest CCS rates, smallest SCDs, and largest LDAs. These anatomical differences may predispose these subjects to the development of cervical myelopathy compared to those with normal spinal canal diameters. Increased knowledge base of the epidemiology of this condition may lead to personalized clinical management and possibly early intervention to prevent spinal cord injuries in these patients.

Single-Double-Single Barrel (1-2-1) Fibula Free Flap Design for Functional and Esthetic Brown Class III Mandibular Reconstruction.

This novel hybrid single-double-single barrel (1-2-1) design for fibula free flap reconstruction addresses the unique challenges presented by Brown Class III mandibular defects, which involve long-span defects at both bodies of the mandible and the chin. The importance of this design lies in its ability to overcome the limitations of traditional approaches in terms of mandible height and pedicle length, while optimizing both functional and esthetic outcomes.The technique utilizes a combination of single-double-single barrel fibula segments to achieve ideal esthetics and support for dental prosthesis across different areas of the mandible. At the chin, a double barrel design provides proper chin and lower lip projection and supports dental prosthesis at the alveolus, while single barrel segments are used for the mandibular bodies to allow adequate restorative space for dental rehabilitation and save the pedicle length.Favorable outcomes were demonstrated in terms of flap survival, dental implant osseointegration, bony healing, facial aesthetics, and occlusal rehabilitation. By addressing both functional and aesthetic requirements, this technique represents an important advancement in mandibular reconstruction for complex Brown Class III defects. The approach showcases the potential of computer-assisted surgery and innovative flap designs to improve patient outcomes in challenging reconstructive scenarios.

Technical Pearls for Breast Reconstruction in Low BMI Asian Women With the Profunda Artery Perforator Flap

ABSTRACTBackgroundThe deep inferior epigastric perforator (DIEP) flap is currently the gold standard for autologous breast reconstruction. In cases where the DIEP is contraindicated, the profunda artery perforator (PAP) flap is now the preferred second‐line option in our institution. The PAP flap poses unique challenges to the reconstructive surgeon, especially in Asian women with low body mass index (BMI). Herein, we share the unique technical pearls when performing breast reconstruction in this population.MethodsThis is a retrospective cohort studies, where data were collected on all consecutive patients who underwent breast reconstruction by the senior author, from June 2015 to February 2023. Only patients who underwent the PAP free flap reconstructions were included in this study. The PAP flap design was based on the transverse pattern in the upper medial third of the thigh. The flap is inset in the transverse fashion in the mastectomy pocket, utilizing either the internal mammary pedicle, lateral thoracic pedicle, or the thoracodorsal pedicle.ResultsA total of 32 free PAP flaps were performed for 31 Asian patients. The average age was 39.5 years old (range 25–60), and the average BMI was 21.3 (range 18.5–27.4). An average of 5.0 of myocutaneous perforators (range 1–7) can be identified in each donor site. The average flap was 7.8 cm wide (range 6–10), 21.3 cm long (range 15–30), weighing 259.6 g (range 145–555), with an average of 1.3 perforators (range 1–3) and a pedicle length 5.9 cm (range 4–10). The critical steps to a successful reconstruction with the PAP flap lie with the appropriate patient selection, pre‐operative imaging, flap design, inset, and donor site management.ConclusionsEast Asian women tend to have lower BMI and smaller breasts and are good candidates for the PAP flap.

A Novel Reconstruction Approach After Skin Cancer Ablation Using Lateral Arm Free Flap: A Serial Case Report.

Background and Objectives: The lateral arm flap has been a very useful choice for the reconstruction of small to medium-sized defects, such as in the hands, extremities, and oral head and neck area. Its versatile characteristics and surgical feasibility allow this flap to be widely applied, but its reconstructive potential in the facial subunit after tumor ablation procedures has never been reported. In this study, we aimed to utilize the advantages of this flap to carry out facial temple subunit defect reconstruction. Materials and Methods: Between 2020 and 2023, 12 patients underwent temple reconstruction with lateral arm free flaps after wide malignant tumor excisions. There were seven women and five men, and the mean patient age was 60.6 years. Among the patients with cancer, six had squamous cell carcinoma, five had basal cell carcinoma, and one had myxofibrosarcoma. All flaps were elevated under general anesthesia. Alprostadil (PGE1, Eglandin®, Mitsubishi Tanabe Korea, Seoul, Republic of Korea) was administered postoperatively. Results: All flaps were the fasciocutaneous type, with sizes that varied from 3 cm × 4 cm to 5 cm × 7 cm (average size: 22.7 cm2). The average pedicle length was 6.1 cm. The versatility of the lateral arm flap enabled successful coverage in all cases, with no specific complications. Good functional outcomes and good ranges of motion in the donor arms were observed after surgery. Conclusions: The authors successfully verified the advantages of lateral arm flaps in the treatment of medium-sized facial temple subunit defects.

Free medial sural artery perforator flap for soft tissue defects in the hand: a cadaver study.

We carried out a cadaver study using 10 fresh-frozen adult legs and hands to explore technical feasibility and reproducibility of the free Medial Sural Artery Perforator flap and its applicability for covering soft tissue defects in the hand. A mean of 2 cutaneous perforators (1-4) were found. Each flap had a pedicle composed of a main perforator that arose from the medial sural artery. Distance between the middle of the popliteal fossa and the emergence of the main perforator was 10 ± 1.9 cm. The pedicle length was 13 ± 1.6 cm. It included an artery (diameter: 2.5 ± 0.6 mm) and a vein (diameter: 3.2 ± 1.2 mm). Skin paddle thickness was 8.5 ± 1.9 mm. Using an 8 x 8 cm skin paddle, it was always possible to cover the entire palmar and dorsal sides of the hand. Our findings suggest that this free flap is a reliable and reproducible option for large cutaneous defects of the hand, offering an effective alternative to conventional flaps. LEVEL OF EVIDENCE: IV.

The Effect of Medial Circumflex Artery Variation on the Success Rate of Gracilis Flap Procedures: A Systematic Review.

This systematic review examines the impact of anatomical variations in the medial circumflex artery (MCA) on the outcomes of gracilis flap procedures in reconstructive surgery. Incorporating 16 studies, this review analyzes how different MCA variants influence the success rates of these procedures. Findings highlight critical MCA variations, including cases of split and double pedicles and differences in pedicle length and branching patterns, which can complicate flap harvesting and vascular anastomosis. The studies consistently underscore the need for precise preoperative imaging and intraoperative adaptability to manage these anatomical differences effectively. Notably, variants with shorter or branched pedicles present higher risks of partial flap loss and complications, particularly in autologous breast reconstruction and lower extremity repairs. The findings support the adoption of advanced imaging protocols, such as high-resolution Doppler and CT angiography, to enable detailed vascular mapping. Interdisciplinary collaboration among anatomists, radiologists, and surgeons is essential for developing comprehensive strategies tailored to individual anatomical landscapes, optimizing both the success and viability of gracilis flaps. The review emphasizes that understanding MCA variability is crucial for enhancing surgical precision and improving patient outcomes. Standardizing preoperative assessment protocols and exploring alternative flap techniques may mitigate risks associated with MCA variations, advancing the field of reconstructive surgery.

A New Method of Orbital Septal Fat Flap in Transconjunctival Approach.

Orbital fat release is critical in blepharoplasty for correcting tear trough deformities, but traditional transconjunctival approaches often face limitations due to restricted fat volume and pedicle length. This study introduces an innovative technique by reconstructing the orbital fat flap, aiming to improve tear trough coverage and optimize Aesthet outcomes. The technique is achieved by reconstructing the orbital fat flap. To enhance fat survival, meticulous preservation of the pedicle's vascular supply was ensured during surgery. Microsurgical techniques were employed to precisely dissect and position the fat flap, ensuring full coverage of the tear trough area while maintaining facial symmetry. Postoperative follow-up was conducted to evaluate functional and Aesthet outcomes. The modified technique resulted in complete tear trough coverage and significant reduction in postoperative retraction. Patients reported improved Aesthet outcomes, with natural restoration of the lower eyelid contour and preservation of the culturally significant "Lower-lid Pretarsal Roll" appearance. No major complications such as fat atrophy or eyelid retraction were observed. This new technique for extending the orbital fat flap in blepharoplasty offers better coverage of tear trough deformities, reduces the risk of postoperative complications, and improves patient satisfaction, making it an important advancement in eye contour surgery. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Clinical Outcomes and Applicability of Serratus Anterior Muscle Flap With Split Thickness Skin Graft in Thin Resurfacing Reconstructive Surgeries: A Retrospective Analysis.

This retrospective study evaluates the efficacy of the serratus anterior muscle (SAm) free flap combined with a split thickness skin graft (STSG) for thin resurfacing in reconstructive surgery, presenting an alternative to pure skin perforator flaps. It analyzes 14 SAm free flap procedures performed between January 2015 and December 2023. The study cohort comprised 5 women and 9 men, aged 31-80 years, addressing defects caused by infection, malignancy, burn, and trauma, located in various body parts.The study involves harvesting the SAm flap while focusing on anatomical features such as the distinct direction of muscle fibers and the surface location of the vascular pedicle for efficient dissection. It emphasizes the anatomical advantages of the SAm flap, such as robust vascular supply, controlled flap thickness, and preservation of the long thoracic nerve, making it suitable for a range of surgical needs. Complications included STSG loss, partial necrosis, and infection, all managed effectively. Postoperative shoulder function assessment showed no significant impairment.Results demonstrated the successful application of the SAm flap in all cases, with an average flap dimension of 38.21 cm2 and pedicle length of 7.3 cm. The average operation time was 122.1 minutes. The study underscores the SAm flap's adaptability, versatility, and minimal donor site morbidity.It concludes that the SAm flap, in conjunction with STSG, is a viable alternative for thin resurfacing in reconstructive surgery. However, limitations such as the small sample size and procedural variability suggest the need for further research to fully establish the flap's potential in diverse surgical contexts.

CT imaging analysis of the C7 pedicle and lateral mass in children aged 0–14 years

Background and objectiveThere is currently a lack of anatomical research on the C7 pedicle and lateral mass in children aged 0–14 years, and experience with pediatric lower cervical spine surgeries remains limited. This study aims to investigate the anatomical structure of the C7 pedicle and lateral mass in a large pediatric sample to understand their growth patterns, providing imaging and anatomical references for pediatric lower cervical spine surgeries and the design of pediatric C7 screws. MethodsWe measured 12 parameters, including the width, length, height, and angles of the C7 pedicle and lateral mass in children aged 0–14 years. The t-test was used to analyze bilateral and gender differences, and least squares regression was applied for curve fitting analysis. ResultsThe size parameters of the C7 pedicle and lateral mass generally increased with age, while angular parameters fluctuated within specific ranges. The average values for each parameter between ages 0–14 were as follows: D1: 2.78–5.28 mm, D2: 18.15–30.54 mm, D3: 2.44–6.01 mm, angle A: 38.05–44.48°; D4: 6.81–10.94 mm, D5: 5.37–11.23 mm, D6: 8.07–13.28 mm, D7: 1.94–4.88 mm, D8: 5.67–9.39 mm, angle C: 18.50–28.80°, angle D: 43.23–52.01°, angle E: 33.74–44.96°. Bilateral analysis showed no significant differences for most parameters across most age groups, with differences mainly observed in angle A, angle C, D6, and D8. Gender differences were primarily noted in length parameters across different age groups, especially in the 3–4, 6–7, 9–11, and 13–14 age groups. Regression analysis indicated that most parameters followed cubic function curves, while a few followed power or quadratic function curves. ConclusionThis study provides detailed CT imaging anatomy of the C7 pedicle and lateral mass in children aged 0–14 years. Preoperative thin-slice CT scans and careful measurements of key parameters are essential for pediatric lower cervical spine surgeries. The findings offer valuable imaging and anatomical references for pediatric posterior cervical fixation surgery and screw design.

Superficial circumflex iliac perforator flaps for maxilla defects with intraoral anastomosis or pedicle elongation techniques

BackgroundTo evaluate the feasibility and safety of the superficial circumflex iliac perforator flap (SCIP) for maxillary reconstruction with intraoral anastomosis, pedicle elongation, and super-microsurgery techniques to overcome its anatomical shortcomings due to the attractive merits of the flap.MethodsPatients who underwent reconstruction of maxillary defects with SCIPs from July 2020 to December 2022 were included. Intraoral anastomosis, pedicle elongation, and super-microsurgery were performed during surgery with or without a neck incision. The sizes, pedicle lengths, inner calibres of vessels, complications and flap survival statuses were recorded.ResultsA total of 12 patients were included, with 3 males and 9 females, and the median age was 45 years, ranging from 14 to 74 years. There were 5 class IIa and 7 class IIb defects, 6 cases underwent maxillary defect reconstruction via SCIPs with intraoral anastomosis, and the other 6 cases with distally design and/or de-epidermis pedicle elongation. Super-microsurgery interventions were needed in 5 patients. The size ranged from 3 cm×4 cm to 6 cm×8 cm. The pedicle length ranged from 4 cm to 12 cm, with a median of 6 cm. The inner caliber of the arteries ranged from 0.7 mm to 2 mm, with a median of 1 mm, and the veins ranged from 1.5 mm to 4 mm, with a median of 2.5 mm. All the flaps survived, and no donor site complications occurred.ConclusionSuperficial circumflex iliac perforator flaps can be regarded as feasible and safe choices for maxillary defects with the support of intraoral anastomosis, pedicle elongation and super-microsurgery.

A comparative analysis of free fibula flap donor leg and recipient vessel selection in composite oromandibular defect reconstructions

BackgroundThe fibula free flap (FFF) is acknowledged as the primary choice for reconstructing composite oromandibular defects (COMD), yet the impact of donor leg selection remains inadequately explored. This study aims to investigate the correlation between flap failure and the choice of donor leg and recipient vessel side. Materials & MethodsIn a retrospective analysis spanning 2011 to 2020, FFFs for COMD were examined using electronic records. Patient data, comorbidities, radiation history, FFF details, and intraoperative variables were considered. Laterality was categorized into "Cis" and "Trans" groups, further subclassified based on blood supply. Analyses involved logistic regression, bivariate analysis, and propensity score matching. ResultsA total of 155 subjects with intraoral mucosal defects repaired only by the skin paddle of FFF were included. Cases were categorized into "Cis" (n=65; 42%) and "Trans" (n=90; 58%) groups based on COMD side and donor leg selection. No significant baseline differences emerged. Logistic regression found no laterality impact on total FFF failure. Initially, gender correlated with flap failure, but adjustment diminished the association. Partial skin paddle necrosis correlated with diabetes, not laterality. Propensity score matching revealed no significant differences between right and left legs in laterality or total flap failure risk. Subgroup analysis found no differences in parameters or flap failure rates within "Cis" and "Trans" groups. ConclusionDonor leg selection in COMD reconstruction with FFFs does not exhibit specificity. Furthermore, despite potential limitations in vessel anastomosis due to pedicle length or trauma history, recipient vessel side selection does not evidently affect flap failure.

Thinning of the Medial Sural Artery Perforator Flap: The Anatomical Examination of the Medial Sural Artery Perforator Branch.

The medial sural artery perforator (MSAP) flap is thin, pliable, and versatile. This study aims to understand the anatomical basis of the MSAP flap and the subcutaneous course of the perforator for safe flap thinning. A total of 24 MSAP flaps were dissected under red silicone dye injection guidance. Full-thickness horizontal slides of flaps were performed, and the perforator courses were identified in the subcutaneous plane. Slides were placed on a millimeter board, and the perforator patterns were photographed and observed with loupes. A total of 68 perforator courses were identified: type 1: 30.9%, type 2: 57.3%, and type 3: 11.8%. They traveled 1-25 mm to the subdermal plexus, with percentile 2.5 at 1 mm, percentile 90 at 18.2 mm, percentile 95 at 21.65 mm, and percentile 100 at 25 mm. The mean flap thickness was 7.75 ± 1.7 mm, with an average of 5.7 ± 1.3 perforators per flap. Perforators clustered between 2 and 18.4 cm from the popliteal crease and 0-8 cm from the posterior midline of the leg. The dominant perforators accounted for 45.2% (62 of 137), averaging 2.58 per flap. The medial sural artery branching pattern types were type 1: 37.5%, type 2: 50%, and type 3: 12.5%. The average pedicle length was 16.2 ± 1.3 cm, and the mean external diameter of the medial sural artery was 1.98 ± 0.13 mm. MSAPs branch within a maximal radius of 2.5 cm after emerging from the deep fascia. To maintain vascularity, the safe suprafascial dissection should be 2.5 cm apart from the point of emerging.

Artery Grafting for Arterial Anastomoses in Head and Neck Free Tissue Transfer Reconstruction.

Vessel grafting is an important technique in head and neck free tissue transfer (FTT) reconstruction when a tension-free anastomosis is not otherwise feasible. To our knowledge, there are limited data regarding interposition artery grafts for arterial anastomoses in head and neck reconstruction. Here, we present a multi-institutional cohort of arterial interposition grafts for FTT reconstruction for head and neck defects. A retrospective review was conducted at four tertiary care institutions for patients who underwent FTT reconstruction for head and neck defects which utilized an interposition artery graft for the arterial anastomosis. Charts were reviewed for type and length of artery grafts harvested, surgical indication, indication for artery graft, types of flaps harvested, and various preoperative characteristics (including history of radiation or previous FTT reconstruction surgery). Postoperative complications within postoperative day 30 were measured and reported. Nine patients met inclusion criteria. The lateral circumflex femoral artery (either transverse or descending branches) (n = 3) and facial artery (n = 3) were the most commonly harvested arteries. The scalp (n = 5) was the most common primary defect site. Seven grafts were harvested initially and in a planned fashion, while two were harvested as salvage techniques (either for flap salvage or vein graft failure). In planned grafts, arteries were the preferred interposition grafting method due to either size match preferences (n = 4) or similarities in wall thickness (n = 3) between graft and recipient artery. There were no reported cases of unplanned readmission, postoperative hematoma, fistula formation, wound infection, or donor site morbidities. Two patients required unplanned return to the operating room for flap compromise, both of which ultimately resulted in flap failure secondary to clot formation at both arterial and venous anastomoses. When arterial pedicle length is insufficient, interposition artery grafting is both a feasible and viable technique to achieve tension-free arterial anastomoses for select cases of highly complex head and neck free tissue reconstruction.

Scalp Reconstruction With Free Tissue Transfer Using Descending Branch of Lateral Circumflex Femoral Vessels as Interposition Graft.

Despite the rich blood supply to the scalp, postoperative skin necrosis at the surgical site sometimes occurs, and unresolved defects often present a significant challenge for the surgeon. When planning a free flap for scalp reconstruction, distant anastomoses may be necessary if local recipient vessels are unavailable due to previous surgery. This study presents the authors' treatment strategy, which includes extending the pedicle length with arteriovenous bundle interposition grafts. Two patients who experienced surgical wound necrosis after bypass surgery for moyamoya disease underwent reconstruction for skin and soft tissue coverage. To evaluate the altered anatomical structures after the previous surgery, three-dimensional computed tomography angiography was performed, and preoperative photos were taken to accurately measure the expected defect. The surgical strategy was designed to accommodate their unique conditions, utilizing an arteriovenous interposition graft, which included 2 stages of microvascular anastomoses, for pedicle lengthening. The procedure successfully bridged the gap between distant recipient vessels and the extensive defect, and the wounds healed without major complications such as venous congestion or total flap loss. Both patients were satisfied with the surgical outcomes. Arteriovenous bundle interposition grafts can be a useful option for patients with complex scalp defects who lack local recipient vessels. The use of an anterolateral thigh flap with artery-to-artery anastomosis, utilizing the lateral circumflex femoral artery from the opposite side in this study, offers many advantages compared with traditional pedicle lengthening tools utilizing vein-to-artery anastomosis.

Anatomic Parameters for Diagnosing Congenital Lumbar Stenosis Based on Computed Tomography of 1,000 Patients.

Quantitative parameters for diagnosis of congenital lumbar stenosis (CLS) have yet to be universally accepted. This study establishes parameters for CLS using CT, assessing the influences of patient sex, race, ethnicity, and anthropometric characteristics. Interpedicular distance (IPD), pedicle length, canal diameter, and canal area were measured using 1,000 patients between 18 and 35 years of age who were without spinal pathology. Irrespective of disk level, threshold values for CLS were 16.1 mm for IPD, 3.9 mm for pedicle length, 11.5 mm for canal diameter, and 142.5 mm 2 for canal area. Notable differences based on patient sex were observed, with men demonstrating larger CLS threshold values with respect to IPD and canal area across all vertebral levels from L1 to L5. Based on patient anthropometric factors, no strong or moderate associations were observed between any spinal measurement and patient height, weight, or body mass index across all levels from L1 to L5. However, notable differences were observed based on patient race and ethnicity from L1 to L5. Asian patients demonstrated the largest pedicle lengths, followed by White, Hispanic, and Black patients in descending order. White patients demonstrated the largest IPD, canal AP diameter, and canal area, followed by Asian, Hispanic, and Black patients in descending order. Black patients demonstrated the smallest values across all anatomic measurements relative to Asian, White, and Hispanic patients. This study reports 25,000 measurements of lumbar central canal dimensions to establish quantitative thresholds for the diagnosis of CLS. Although not influenced by patient height, weight, or body mass index as one might intuit, canal dimensions were influenced by patient sex, race, and ethnicity. These findings may help explain differences in predisposition or prevalence of lumbar nerve root compression among patients of different races, which can be important when considering rates of surgery and access to care.

Reconstruction of Defects After Oral Cancer Surgery With the Superior Thyroid Artery Perforator Flap.

The superior thyroid artery perforator flap (STAPF) was previously presented as a type of locoregional pedicled flap for lateral facial and temple defects. In this study, we aimed to present our clinical experience with this flap for the reconstruction of soft tissue defects after oral cancer surgery. From February 2019 to December 2022, 24 patients with oral cancers at the School and Hospital of Stomatology,Peking University were included. Among these patients, 10 had cancers located in the tongue, five in the cheek inside the oral cavity, three in the lower gingiva, two in the upper gingiva, two in the floor of the mouth, and two in the palate. All patients were treated with extended tumor resection, neck dissection, and STAPFs to reconstruct the soft tissue defects. The details of the flap, including the flap size, venous flow, vascular pedicle length, the attatched muscle, and operation time were evaluated. The dimensions of the flap skin paddle ranged from 3 cm × 5 cm to 6 × 14 cm. Fourteen patients had a closely concomitant superior thyroid vein perforator. Ten patients had non-closely concomitant superior thyroid veins perforators which retrograde external jugular vein. The vascular pedicle length ranged from 5 to 9 cm. The infrahyoid muscle group or sternocleidomastoid muscle was included in the flaps in three patients. A total of 23/24 flaps were successful. The STAPF is a viable reconstructive option for patients with oral cancers. It has the advantages of being robust, being thin, short operation time, and minor donor site complications. 4 Laryngoscope, 135:104-109, 2025.

Management of large head and neck defects in the vessel-depleted neck.

Surgery, radiation, and chemotherapy are often utilized in the treatment of head and neck cancer. These treatments can cause extensive scarring within the neck and can limit the viability of recipient vessels for further microvascular reconstruction. Patients with vessel-depleted necks provide a significant challenge for microvascular surgeons and are a topic of much discussion in the field. While reconstruction in the vessel-depleted neck is an active area of interest, the patient population is rare. Therefore, single institution series with small numbers comprise the majority of published literature. Recent publications describe techniques for identifying adequate recipient vessel options outside of the field of treatment with excellent free flap outcomes. Further, recent summary articles describe techniques for addressing issues with pedicle length that can arise when using vessels that are far from the defect to be reconstructed. When viable vessel options are available within the treatment field, these recipient vessels can be used with good reliability and free flap success. If in-field recipient vessels are not available, minimal access incisions can be used to identify superficial temporal, angular, contralateral facial, or transverse cervical vessels. Further away from the treatment field, internal mammary vessels can be harvested through open or robotic approaches. If the use of these distant vessels creates issues with pedicle length, interposition vein grafts, arteriovenous (AV) loops, or flow-through flaps can be used to augment vessel length.

Effectiveness of the proximal medial branch in DIEP flaps for breast reconstruction using Hartrampf zone IV

BackgroundWhen performing breast reconstruction using a deep inferior epigastric artery perforator (DIEP) flap, including Hartrampf zone IV, the bipedicled DIEP flap has been argued to be necessary to ensure stable perfusion. However, a proximal medial branch (PMB), which is the most proximal perforator of the deep inferior epigastric artery, may make it possible to obtain adequate perfusion in a unilateral DIEP flap. This study aimed to clarify the detailed anatomical characteristics of PMB and its potential clinical application in breast reconstruction. MethodsThis retrospective study was conducted on breast reconstruction using the DIEP flap between May 2020 and July 2023. Data on PMB anatomy were collected from preoperative contrast-enhanced computed tomography angiography, and contralateral perfusion of the flap was estimated using intraoperative indocyanine green angiography. ResultsThe PMB was present in approximately 85% of cases, arising near the lateral border of the rectus abdominis, branching caudomedially in over half of the cases, and perforating 2.3cm laterally and 8.8cm caudally on average from the umbilicus. The average perfusion area of both zones II and IV significantly expanded to 96.5% and 74.2%, respectively, when the PMB was included in the DIEP flap, and 9 of 22 cases showed contrast extending to the entire zone IV. ConclusionsThe use of the DIEP flap with PMB is a good option for substantial-volume breast reconstruction. When utilizing the PMB, it is important to consider its specific anatomy, location of the main perforator, and pedicle length.

Versatility of Proximal Sural Island Sensate Fasciocutaneous Flap in Reconstruction of Soft Tissue Defects of Knee and Proximal Leg

Background: The proximal sural island sensate (PSIS) fasciocutaneous flap presents an ideal alternative in reconstruction of defects of the knee and proximal leg. It provides a thin sensate flap with good aesthetic outcomes and reduced donor site morbidity. However, only limited reports exist in the literature about this flap.Methods: This is a retrospective study done between December 2018 and December 2021 including 30 patients, among which seven cases had defects located on the knee and 23 cases in the proximal part of the leg. Mean age of the study population was 41 years. The maximum flap size was 8×12 cm, while the maximum pedicle length was 15 cm.Results: All 30 flaps survived well with only minimal complications occurring in a few patients such as epidermal loss and distal tip necrosis. No arterial or venous crisis occurred postoperatively in any case. Donor sites were managed with one-stage primary closure or split-thickness skin grafts. Functional deficits were not detected in any of the cases.Conclusion: We found the PSIS fasciocutaneous flap to be a simple and reliable technique to perform. The flap offers extensive coverage, reaching from the knee to the proximal leg, and provides thin, pliable, and sensate skin, resulting in excellent aesthetic and functional outcomes.