Propeller Flap Research Articles

Propeller Flaps and Potential Lymphatic Damage.

Propeller Flaps and Potential Lymphatic Damage.

Indications and outcomes for locoregional perforator propeller flaps in head and neck reconstruction: Topographical approach in 83 patients

BackgroundLocal perforator flaps have been used in head and neck for coverage of relatively small defects. In this study, we aimed to present our results using a wide spectrum of locoregional flaps in perforator propeller fashion in reconstruction of moderate-to-large sized soft tissue defects of the head and neck. Patients and MethodsFrom August 2012 to June 2023, a total of 83 patients with moderate to large-sized soft tissue defects of the head and neck underwent reconstruction using locoregional perforator propeller flaps. Data on the etiology and location of the defect, the flap of choice and the postoperative course were gathered from patients’ charts retrospectively. Clinical outcome was evaluated based on parameters such as flap survival, color match, duration of hospitalization, and subjective satisfaction of the patient. ResultsA total of 92 locoregional perforator propeller flaps were used in 83 patients with skin and soft tissue defects of the head and neck. The follow-up period ranged from 3 and 36 months, with an average follow-up duration of 12 months. The duration of hospitalization varied between 1 and 6 days, averaging 3 days. Distal partial flap loss occurred in 3 patients, while no postoperative infection, hematomas or seromas were observed. ConclusionLocoregional perforator propeller flaps provide reproducible, functional and aesthetic results in reconstruction of moderate-to-large sized soft tissue defects of the head and neck.

Clinical application of perforator-based propeller flaps in repair of hand wound

To investigate the effectiveness of the perforator-based propeller flaps (PPFs) based on digital artery (DA) and dorsal metacarpal artery (DMA) in repairing hand wounds. The clinical data of 45 patients with hand wounds between January 2018 and March 2023 were retrospectively analyzed. There were 27 males and 18 females with an average age of 41.2 years (range, 14-72 years). The causes of injury included twist injury in 15 cases, crush injury in 19 cases, and cut injury in 11 cases. The injured parts included 32 cases of digits, 10 cases of dorsal hand, and 3 cases of palmar hand, all of which had tendon, joint, and bone exposure. The time from injury to operation ranged from 2 to 8 hours (mean, 4.3 hours). The wound sizes after debridement ranged from 1.8 cm×1.0 cm to 5.0 cm×3.5 cm. Twenty-eight cases were repaired by the PPFs based on DA and 17 cases were repaired by the PPFs based on DMA. The flap size ranged from 2.5 cm×1.1 cm to 8.5 cm×4.0 cm. The defects of the donor sites in 14 patients were closed directly and the defects in the left 31 patients were resurfaced with free full-thickness skin graft from the proximal medial forearm. All the flaps survived after operation. Two cases of the PPF based on DA and 1 case of the PPF based on DMA underwent partially blisters at the distal end and healed after dressing change. The incisions in the donor site healed by first intention and the skin grafts survived. All patients were followed up 10-33 months, with a mean of 15.4 months. At last follow-up, the static two-point discrimination of the PPFs based on DA and DMA were 4-14 mm and 8-20 mm with the averages of 8.1 mm and 13.3 mm, respectively. According to the Michigan Hand Outcomes Questionnaire, 20 patients were very satisfied with the appearance of the PPF based on DA and 8 patients were satisfied; 8 patients were very satisfied with the appearance of the PPF based on DMA and 9 patients were satisfied. Based on the Vancouver Scar Scale (VSS), the appearance scores of the donor site of the PPFs based on DA and DMA were 2-7 and 4-9, with the averages of 4.2 and 6.1, respectively. The two kinds of PPFs are reliable in blood supply and easy to harvest, which provide a good method for emergency repair of small and medium area wounds in the hand.

Superficial circumflex iliac artery perforator propeller flap for penoscrotal extramammary Paget's disease.

Extramammary Paget's disease (EMPD) is a rare intra-epidermal adenocarcinoma, and reconstruction of the penoscrotal region remains a clinical challenge. The superficial circumflex iliac artery perforator (SCIP) flap has been successfully used as a free flap, while its application as a propeller flap in the reconstruction of penoscrotal EMPD defect is rarely reported. The objective was to evaluate the safety and efficacy of the SCIP propeller flap in the reconstruction of penoscrotal defects in EMPD. Between September 2010 and August 2022, consecutive patients diagnosed with penoscrotal EMPD were enrolled. All patients underwent penoscrotal EMPD excision and reconstruction with SCIP propeller flap combined with other flaps or skin grafts on individual defects. Demographic information, surgical parameters, postoperative complications, patient satisfaction, and recurrence rates were analyzed. Twenty-four patients (mean age, 73 ± 8.8 years; mean BMI, 23.98 ± 3.62 kg/m2) with 33 SCIP propeller flaps (mean size 120.1 cm2; range, 24-208 cm2) were included, and the mean defect size was 67.4 cm2 (range, 12-255 cm2). The mean operative duration was 385.4 ± 146.8 min. Fifteen patients received autologous full-thickness skin grafts, and four received other flaps simultaneously. All flaps survived without total or partial loss, and all donor sites achieved primary closure, though local hematoma (one case) and limited skin graft necrosis (two cases) were observed. All patients experienced complete wound healing and maintained penoscrotal morphology and function without recurrent lesions over a mean follow-up of 59 months. The SCIP propeller flap seems a safe and effective reconstructive method for penoscrotal EMPD. IV.

Posterior Tibial Artery Perforator Based Propeller Flap for Reconstruction of 143 Skin and Soft Tissue Defect Around Ankle Joint

Background: Soft tissue coverage of distal leg and ankle region represents a challenge and such defect usually requires a free flap. However, this needs facility of microsurgery, may lead to donor site morbidity and is time consuming. With the introduction of perforator flap, management of small and medium size defects of distal leg and ankle region is easier, less time consuming, and with minimal donor site morbidity. When local perforator flap is designed as propeller and rotated to 180-degree, donor site can be closed primarily and increases the distance crossed by flap, thus increasing versatility. Objectives: To observe the outcome of soft tissue coverage of defects around ankle joint by posterior tibial artery perforator based propeller flaps. Methods: This was a prospective type of observational study carried out on 20 patients with skin and soft tissue defects in and around ankle joint for a period of 14 months in the Department of Burn and Plastic Surgery, Dhaka Medical College and Hospital. Results: Among 20 cases 17 were male and 3 females; age ranged from 11 to 60 years. Post operative outcome of flap were excellent in 11 cases, good in 6 cases, poor in 3 cases as per defined criteria. Uneventful outcome was observed in 14 cases and minor complications were observed in 5 cases; and total flap loss occurred in 1 case which required revision surgery. Conclusions: Perforator flap provides adequate soft tissue coverage for small & medium size wound around ankle. It is an easy, reliable & effective procedure with reasonable outcome. J Dhaka Med Coll. 2022; 31(2) : 243-250

Propeller Flap Reconstruction Following Pilonidal Cyst Excision: A Single-Center Experience With Same-Day Discharge.

Reconstruction following pilonidal cyst resection must balance risk of recurrence, healing time, and resumption of functional routine. Propeller flaps provide a reliable and effective reconstructive option. This study highlights our experience with propeller flap reconstruction following pilonidal cyst resection and demonstrates the efficacy of same-day discharge. A single-institution retrospective chart review was performed for propeller flap reconstructions completed from March 2018 to July 2022. Patient demographics, pilonidal cyst details, operative details, and postoperative outcomes were collected. Primary outcomes included flap survival, flap complications, and pilonidal disease recurrence. Twenty-eight outpatient propeller flap reconstructions following pilonidal cyst resections were identified in 26 patients, with two patients receiving a second propeller flap due to recurrence. Most patients were male (n = 15, 57.7%) with a mean age at time of index operation of 25.5 ± 5.8 years and mean body mass index of 26.5 ± 4.1 kg/m2. Mean symptom duration prior to index surgery was 39.3 months. Mean skin defect size following resection was 28.3 ± 15.3 cm2, with a mean flap size of 44.7 ± 35.5 cm2. Flap survival was 100% (n = 28), with five flaps (17.9%) experiencing minor wound complications and one patient (3.8%) requiring return to the operating room. Mean time to functional improvement was 24.0 ± 22.8 days. Pilonidal disease recurrence occurred in three patients (11.5%). Mean follow-up was 4.1 ± 5.4 months. Propeller flaps provide a successful and reliable reconstructive option for pilonidal disease defects. Because patients in our cohort experienced favorable outcomes and functional improvement, we advocate for same-day discharge in order to reduce hospital and patient burden.

Pre-expanded Brachial Artery Perforator Propeller Flap: An Addition to the Armamentarium for Postburn Axillary Contracture Reconstruction

Background: Postburn axillary contracture is a common complication that leads to functional impairment and unsatisfactory aesthetic outcomes. This article aims to present our experience with axillary contracture reconstruction using pre-expanded brachial artery perforator propeller (BAPP) flaps and provide a systematic review of other regional or free flaps. Methods: This retrospective study included patients who underwent postburn axillary contracture reconstruction using pre-expanded BAPP flaps from 2015 to 2022. Data on the flap characteristics and function of the affected shoulders were recorded. A systematic review was conducted by retrieving studies that assessed the outcomes of regional or free cutaneous/fasciocutaneous flaps for treating axillary contracture from PubMed, Web of Science, EMBASE, and Scopus published before October 1, 2023. Results: Twelve pre-expanded BAPP flaps measuring up to 26 cm × 11 cm (mean, 116.9 cm 2) survived completely with no major complications, and the donor sites were closed primarily. The average range of shoulder abduction increased from 77.9° to 141.7° (p=0.002). The systematic review included 34 articles, reporting 12 regional and three free flaps. The most reported flaps were the thoracodorsal artery perforator flap, scapular flap, and parascapular flap. The overall complication rate ranged from 0 to 25%, and the average change in shoulder abduction ranged from 72.5° to 99.4°. Conclusions: Pre-expanded BAPP flaps can be effectively used for reconstructing postburn anterior axillary fold contracture. The donor site availability and the specific axillary contracture type should be considered when selecting a regional or free flap.

Reconstructive Options for Pressure Ulcers in Pediatric Patients.

Pressure ulcers pose significant challenges in terms of treatment, often exhibiting a low success rate and a propensity for recurrence. Children with neurological impairments such as myelomeningocele and those with spinal injuries are particularly vulnerable to developing pressure ulcers. Despite advancements, achieving successful reconstruction remains a formidable task. Common sites prone to pressure ulcer formation include the sacral and ischial regions, as well as areas over bony prominences. Additionally, pressure ulcers attributable to medical devices facilitating ambulation are observed. While many pressure sores resolve spontaneously, conservative management may prove ineffective for some, especially in cases of stage 3 and 4 ulcers, necessitating surgical intervention. Various surgical techniques are employed for the treatment of decubitus ulcers, yet there exists no universally accepted gold standard for their management. This paper presents our institutional experience in this domain, highlighting differences in surgical approaches, treatment outcomes, complication rates, and long-term follow-up. This study involved a retrospective analysis of medical records from 11 children, ranging in age from 10 to 17 years, who presented with extensive pressure ulcers that were unresponsive to conservative treatment measures. Data collection spanned from February 2017 to June 2022. The pressure ulcers affected various anatomical regions, including the ischial area (5/11 patients), sacral region (3/11 patients), lower limb (1/11 patients), elbow (1/11 patients), and perineal area (1/11 patients). Surgical intervention was the chosen approach for all cases, employing techniques such as reconstructive surgery utilizing perforator, pediculated flaps, and locoregional flaps. Eleven patients with sore ulcers (stage 3 and 4) were treated surgically. We present our experience of using surgical methods, including pedicled anterolateral flaps, pedicled gracilis musculocutaneous flaps, propeller flaps and locoregional flaps. In some cases, surgery was performed after 60 days of hospitalization or ten years after ulcer occurrence. We reviewed the length of hospital stay, surgical management and patient satisfaction. Patients were followed up to 5 years post-surgery. All flaps survived except for one flap where partial necrosis was observed. The recurrence rate was 9.01% (1/11). One patient underwent another surgery. The general outcome was satisfactory. Conclusions: Our findings underscore the efficacy of flap reconstruction surgical techniques in the management of pressure ulcers among pediatric patients. Based on our experience and the outcomes observed, we advocate for considering reconstructive surgery as a viable therapeutic option early in the treatment course, particularly for stage 3 and 4 ulcers. This approach not only addresses the immediate needs of patients but also holds promise for long-term wound healing and prevention of recurrence.

Surgical Management of Hidradenitis Suppurativa.

Hidradenitis suppurativa (HS) is a chronic, relapsing inflammatory disease of the skin, characterized by recurrent draining sinuses and abscesses, predominantly in skin folds carrying terminal hairs and apocrine glands. Treatment for this debilitating disease has been medical management with antibiotics and immune modulators. With the advent of better reconstructive surgical techniques, the role of surgery in the treatment of HS has expanded, from being a last resort to a modality that is deployed earlier. Larger defects can be more easily reconstructed, allowing for a more radical excision of diseased areas. Locoregional flaps, perforator flaps, and propeller flaps that use the fasciocutaneous tissue allow reconstruction of defects with similar tissue, and provide better cosmetic and functional outcomes. They are easy to execute and can be performed even in resource-poor settings with concurrent use of immune modulators and postoperative antibiotics. Hidradenitis can be successfully treated with surgery in early stages as well as severe disease, due to the advances in understanding disease behavior, multidisciplinary care, and advanced reconstructive techniques. Coupled with a multidisciplinary care team, surgery offers a durable, lasting cure for HS, significantly reducing disease morbidity.

Piperacillin/tazobactam-induced sudden severe thrombocytopenia in a patient with a pressure ulcer: a case report

The standard treatment for an infected pressure ulcer (PU) with osteomyelitis is debridement, wound coverage and antibiotic administration. However, systemic administration of antibiotics in patients with osteomyelitis is controversial, and the optimal treatment duration for chronic osteomyelitis has not been standardised. We report a case of sudden severe thrombocytopenia induced by piperacillin/tazobactam (PIPC/TAZ) in a patient with PU-related osteomyelitis. A 57-year-old male patient with paraplegia, using a wheelchair full-time, presented to our plastic surgery department with infection of a stage IV hard-to-heal ischial PU. We surgically debrided the necrotising tissue and raised an ipsilateral biceps femoris musculocutaneous propeller flap for wound coverage. Polymicrobial infections, including Pseudomonas aeruginosa, were detected in the bone biopsy sample; therefore, systemic PIPC/TAZ was administered for the osteomyelitis. Unexpectedly, during the next 12 days of antibiotic administration, the patient's platelet count acutely dropped to 1×103/μl over three days. Based on a series of examinations, PIPC/TAZ was suspected to be the most likely cause of the severe thrombocytopenia. After drug discontinuation, the thrombocytopenia gradually improved. PIPC/TAZ is one of the most widely used antibiotic combinations in the plastic surgery field; it is conventionally administered for hard-to-heal wounds such as PUs and diabetic foot. The present case suggests that surgeons must take special precautions for patients undergoing PIPC/TAZ treatment. In this report, PIPC/TAZ-induced thrombocytopenia and the efficacy of antibiotic treatment for PU-related osteomyelitis are discussed in light of the available literature.

Propeller flaps for closure of lower limb defects post-fibular free flap harvest: a technical note

Propeller flaps for closure of lower limb defects post-fibular free flap harvest: a technical note

D108. Propeller Flap Closure Is Superior to Skin Grafts for Reconstruction of the Osteocutaneous Fibula Flap Donor Site: Anatomical Considerations and Outcomes

D108. Propeller Flap Closure Is Superior to Skin Grafts for Reconstruction of the Osteocutaneous Fibula Flap Donor Site: Anatomical Considerations and Outcomes

Clinical outcomes of perforator-based propeller flaps versus free flaps in soft tissue reconstruction for lower leg and foot trauma: a retrospective single-centre comparative study.

The efficacy and safety of perforator-based propeller flaps (PPF) versus free flaps (FF) in traumatic lower leg and foot reconstructions are debated. PPFs are perceived as simpler due to advantages like avoiding microsurgery, but concerns about complications, such as flap congestion and necrosis, persist. This study aimed to compare outcomes of PPF and FF in trauma-related distal lower extremity soft tissue reconstruction. We retrospectively studied 38 flaps in 33 patients who underwent lower leg and foot soft tissue reconstruction due to trauma at our hospital from 2015 until 2022. Flap-related outcomes and complications were compared between the PPF group (18 flaps in 15 patients) and the FF group (20 flaps in 18 patients). These included complete and partial flap necrosis, venous congestion, delayed osteomyelitis, and the coverage failure rate, defined as the need for secondary flaps due to flap necrosis. The coverage failure rate was 22% in the PPF group and 5% in the FF group, with complete necrosis observed in 11% of the PPF group and 5% of the FF group, and partial necrosis in 39% of the PPF group and 10% of the FF group, indicating no significant difference between the two groups. However, venous congestion was significantly higher in 72% of the PPF group compared to 10% of the FF group. Four PPFs and one FF required FF reconstruction due to implant/fracture exposure from necrosis. Additionally, four PPFs developed delayed osteomyelitis post-healing, requiring reconstruction using free vascularized bone graft in three out of four cases. Flap necrosis in traumatic lower-leg defects can lead to reconstructive failure, exposing implants or fractures and potentially causing catastrophic outcomes like osteomyelitis, jeopardizing limb salvage. Surgeons should be cautious about deeming PPFs as straightforward and microsurgery-free procedures, given the increased complication rates compared to FFs in traumatic reconstruction. The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Propeller vs. free fasciocutaneous flap in reconstruction of complex lower limb defects–A prospective study

BackgroundOf all body regions, lower extremity wounds have been and remain the greatest challenge. Free flaps have been accepted as a reasonable option to solve this dilemma, but they require the complexity of microsurgery. This study aimed to compare the postoperative and clinical outcomes of propeller flap and fasciocutaneous free flap in the reconstruction of complex lower limb defects. Materials and methodsThis randomized controlled trial was conducted from July 2021 to June 2023. Selected patients were randomized into two groups: the propeller flap group and fasciocutaneous free flap group. Demographic data, preoperative parameters, and postoperative parameter, including esthetic analysis, scar assessment, neurosensory analysis, psychosocial analysis, and lower extremity function, were estimated and statistically significant compared between the two study groups. ResultsRoad traffic accident (73.3%) was the most common etiology for lower limb defects in both groups. The foot and lower third of the leg were the most common site of defect, constituting 79.99%. The duration of surgery was significantly shorter in propeller flap as compared to fasciocutaneous free flaps. Flap size was smaller, with better neurosensory improvements in propeller flap group. Esthetic analysis, scar assessment, psychosocial analysis, and lower extremity functional analysis yielded similar results in both study groups. ConclusionPropeller flap has better outcomes compared to free flap in terms of smaller size of flap, shorter duration of surgery, and reduced length of hospital stay. Comparable results were obtained with respect to esthetic score, scar assessment score, psychosocial analysis, and neurosensory recovery and lower extremity functional score.

Propeller Flap: A Feasible Flap for Distal Third of Leg Defects – Two Cases Done at the Plastic Surgery Unit of the Greater Accra Regional Hospital

Introduction: The traditional way of reconstructing soft tissue defects of the lower limb utilized muscle flaps as the ‘gold standard’ for Gustillo Anderson Grade III B fractures of the upper and middle thirds of the leg. Defects of the lower third of the leg are usually reconstructed with free flaps because of paucity and decreased reach of muscles. In resource constrained environments where free flaps are not routine with high failure rates, fasciocuataneous flaps are the only option left. We present our experience with the novel pedicled propeller perforator flaps for reconstruction of soft tissue defects in the lower limb. Case Presentation: Between June and October 2020, 2 consecutive patients - a 34-year-old male and a 51-year-old female, were referred for cover for their distal leg defects from the Orthopedics and trauma Unit. All patients were operated on under spinal anaesthesia. Perforators from posterior tibial and peroneal arteries respectively, were identified pre-operatively with hand-held doppler and the propeller-pattern skin paddle was designed around the perforator closest to defect. After elevation of flaps and skeletonization of perforators, they were then rotated (180 degrees) and inset into defects. Case 1 had whole flap (104 cm2) surviving with only minor marginal epidemiolysis at tip whilst the second flap (58.5cm2) had necrosis of only the business end of the flap but subsequently healed by secondary intention after serial dressings. Both had secondary defects proximally after the rotation, which were skin grafted with 100% take. Conclusion: Propeller flap in our experience, is a feasible versatile option for reconstruction of soft tissue defects in the distal third of the leg.

Comment on: Conjoined thoracodorsal perforator-supercharged dorsal intercostal artery perforator propeller flap for reconstruction of a complex upper back defect: Case report and review of the literature on supercharged pedicled perforator flaps.

Comment on: Conjoined thoracodorsal perforator-supercharged dorsal intercostal artery perforator propeller flap for reconstruction of a complex upper back defect: Case report and review of the literature on supercharged pedicled perforator flaps.

The use of augmented reality for preoperative preparation of perforated flaps: a pilot study

Augmented reality (AR - augmented reality) is the addition of digital information to one or more senses, which allows the user to perform tasks more efficiently. This can be achieved by overlaying images, videos, or computer models. The aim the study is to study the use of AR for preoperative planning of perforant flaps and compare the results of visualization accuracy of various research methods. 3 patients with oncological diseases were examined, who were planned to lift and transplant a SCIP flap (in two cases) and a propeller flap on the perforant branch of the peroneal artery (in one case). All patients underwent a high-frequency ultrasound of 75 GHz examination of the donor zone and marking along it in the area of the planned flap lift. A CT scan of the donor area was also performed, followed by the superimposition of a segmentation image using HoloLens 2 virtual reality glasses. 7 measurements were obtained. AR for microsurgical planning was performed in two inguinal regions and was 100% correlated with the results of high-frequency ultrasound, in the case of perforant vessels of the peroneal artery, a discrepancy of 5 mm was noted for the X and Y axes in three perforant vessels. Augmented reality allows the reconstructive surgeon to see the anatomy of the area of interest in a particular patient before the incision. This area of medicine is certainly in demand, promising and requires further research with larger patient samples and randomization.

Phalloplasty Flap Salvage Using a Superficial Circumflex Iliac Artery Perforator Propeller Flap.

Partial phalloplasty flap loss presents an evolving challenge, largely due to the complex demands required for both aesthetics and function. We describe our novel experience using the superficial circumflex iliac perforator (SCIP) propeller flap for neophallus salvage when skin grafting alone provides insufficient soft tissue bulk or coverage. We retrospectively reviewed patients who underwent SCIP propeller flap reconstruction after phalloplasty partial flap loss. After suprafascial dissection, superficial circumflex iliac vessel perforator(s) were isolated toward the femoral origin. The flap was rotated 180 degrees and inset into the ventral or distal neophallus depending on the region of flap loss. If glans reconstruction was required, the flap was tubularized before inset. Division and inset were performed at a second stage, followed by subsequent glansplasty, urethral creation, and/or penile implant placement. SCIP propeller flap reconstruction was performed for four patients after one to six debridements at a mean of 6.5 (range 1.0-19.2) months following the initial phalloplasty. Three patients had lost the ventral phallus due to venous insufficiency, arterial insufficiency, and excessive postoperative swelling, respectively. The fourth patient experienced near-total loss of the glans following penile implant insertion. Division and inset was performed at an average of 7.5 (range 5.0-12.0) weeks after SCIP flap. There were no complications related to SCIP flap viability. The SCIP propeller flap allows salvage of partial flap loss following phalloplasty by providing thin, pliable soft tissue bulk and skin coverage with minimal donor site morbidity, without the need for microsurgery, allowing progression with subsequent reconstructive stages.

A before and after evaluation of patient reported outcomes assessed by Breast Q following LICAP turnover flap in breast conservative therapy.

Chest-wall perforator-based techniques to replace volume for breast conservative therapy allow excision of large breast areas with minimal sequalae, such as the nipple-areolar complex displacement, parenchymal indentation or contour deformity. Furthermore, chest wall perforator flaps facilitate the maintenance of breast symmetry, hence decreasing the need for contralateral surgery. Lateral intercostal flap was described in numerous variants among which the most famous are the propeller flap and the turnover version. The turnover version is the easiest and fastest version that allows the replacement of large amount of volume. In this paper, we evaluate patients reported outcomes, before and after surgery, collected through the Breast Q. This study was conducted on 21 patients who were admitted to the plastic surgery department. A prospectively maintained database was used to identify the patients and their records were assessed retrospectively. The pre/post operative patients data were collected. The Breast-Q questionnaire was administered before the surgery and at least 1year after. No major surgical complications were reported. Mean Breast-Q scores were evaluated at least 1year after surgery and radiotherapy and compared with pre-surgical scores. Among all the modules, no significant differences between the pre-surgical and post-surgical Breast-Q scores were observed. Until now, the lateral intercostal artery perforator flap has not been widely used, due to a difficult dissection and a challenging preoperative planning. According to the reported surgical technique, the execution is easy. This technique provides the same breast-related quality of life compared to preoperative values, reduces the mastectomy rate and increases the overall survival.

System describing surgical field extension associated with flap reconstruction after resection of a superficial malignant soft tissue tumor.

Flap reconstruction after resection of a superficial malignant soft tissue tumor extends the surgical field and is an indicator for potential recurrence sites. To describe a grading system for surgical field extension of soft tissue sarcomas. Grading system: CD-grading is a description system consisting of C and D values in the surgical field extension, which are related to the compartmental position of the flap beyond the nearby large joint and deeper extension for the pedicle, respectively. C1/D1 are positive values and C0/D0 are negative. With a known location, 1/0 values can be "p" (proximal), "d" (distal), and "b" (in the tumor bed), and the description method is as follows: flap type, CxDx [x = 0, 1, p, d or b]. Four representative patients with subcutaneous sarcomas who underwent reconstruction using fasciocutaneous flaps are presented. The cases involved a distal upper arm (elbow) synovial sarcoma reconstructed using a pedicled latissimus dorsi (pedicled flap: CpDp); a distal upper arm (elbow) pleomorphic rhabdomyosarcoma reconstructed using a transpositional flap from the forearm (transpositional flap: CdD0); an undifferentiated pleomorphic sarcoma in the buttocks reconstructed using a transpositional flap (transpositional flap: C0D0); and a myxofibrosarcoma in the buttocks reconstructed using a propeller flap from the thigh (pedicled flap: CdDd). The reconstruction method is chosen by the surgeon based on size, location, and other tumor characteristics; however, the final surgical field cannot be determined based on preoperative images alone. CD-grading is a description system consisting of C and D values in the surgical field extension that are related to the compartmental position of the flap beyond the nearby large joint and deeper extension for the pedicle, respectively. The CD-grading system gives a new perspective to the flap reconstruction classification. The CD-grading system also provides important information for follow-up imaging of a possible recurrence.