Superficial Circumflex Iliac Artery Flap Research Articles

Use of the superficial circumflex iliac artery perforator flap for urethra and/or shaft reconstruction in gender diverse persons: 10-year single center experience.

Although the free radial forearm flap (FRFF) is the gold standard for phalloplasty, the conspicuous donor-site scar, need for microsurgery and the tendency for the phallus to deflate over time makes both patients and surgeons look for alternatives. We describe our long-term experience with the pedicled superficial circumflex iliac artery (SCIP) flap for urethral and/or penile shaft reconstruction. This flap can be applied for similar indications as FRFF-phalloplasty, but with primary closure of the donor site(s) and without microsurgery. We retrospectively reviewed surgical outcomes of all patients who underwent urethra and/or shaft reconstruction using SCIP-flaps as part of phalloplasty for gender-affirming surgery in our center between 2012 and 2022. Over a 10-year period, 55 SCIP-flaps were performed as part of phalloplasty. This included 47 unilateral SCIP-flaps, of which 10 were used for shaft reconstructions and 37 for urethra reconstructions. Primary closure was achieved in 100% of patients. No failures were observed for shaft reconstructions.For urethra reconstructions, 8 SCIP-urethras (14%) failed completely, and 3 SCIP-flaps were converted to free flaps. In total, 82% of patients with a SCIP-urethra reconstruction were able to stand while voiding.Eight bilateral SCIP-flaps were performed for one-stage shaft and urethra creation, of which 3 patients (38%) experienced urethral fistulas and/or strictures. This study shows that the SCIP-flap is a technically feasible and safe pedicled alternative for urethral and penile shaft reconstruction in gender diverse individuals, with similar urethral complication rates compared to FRFF and ALT-phalloplasty, however, with potentially lower shaft sensation.

Clinical study on anterolateral femoral interregional flap with turbocharge technique in the repair of large limb wounds.

To compare the clinical outcomes of anterolateral femoral interregional flap with turbocharge technique and traditional anterolateral femoral flap in repair of large limb wounds. Clinical data of 38 patients with large limb surface wound (11 cm×39 cm-16 cm×65 cm) admitted to the Sir Run Run Shaw Hospital, Zhejiang University School of Medicine from May 2018 to May 2022 were retrospectively analyzed. Eighteen patients were treated by anterolateral thigh perforator flap combined with superficial circumflex iliac artery flap (ALTP-SCIAP) with turbocharge technique (interregional flap group); while 20 patients were treated with unilateral or bilateral anterolateral femoral flaps, combined with skin grafting if necessary (traditional anterolateral femoral flap group). The survival of skin flap, repair of donor area, complications and patient satisfaction were compared between the two groups. In interregional flap group, 18 flaps were harvested and transplanted, the flap width, length and the viable area were (9.9±2.0) cm, (44.2±3.5) cm and (343.2±79.9) cm2, respectively. In traditional anterolateral femoral flap group, 29 flaps were harvested and transplanted, the flap width, length and the viable area were (11.0±2.8) cm, (21.7±3.2) cm and (186.4±49.2) cm2, respectively. There were significant differences in the flap length and the viable area between the two groups (t=22.365 and 8.345, both P<0.05). In the interregional flap group, the donor site of flap was closed by direct suture in 11 flaps, by skin retractor assisted suture in 6 flaps, and by skin grafting in one flap. In traditional anterolateral femoral flap group, the donor site of flap was closed by direct suture in 12 flaps, by skin retractor assisted suture in 11 flaps, and by skin grafting in 6 flaps. The skin graft rates of the two groups were 5.6% (1/18) and 20.7% (6/29), respectively (χ2=2.007, P>0.05). The interregional flap group had lower postoperative complications rate (5.6% vs. 35.0%, χ2=4.942, P<0.05) and higher patient satisfaction rate (94.4% vs. 70.0%, χ2=4.448, P<0.05) than traditional anterolateral femoral flap group. Compared with the traditional anterolateral femoral flap, the anterolateral femoral interregional flap with turbocharge technique has a larger flap area, most of the donor areas of the flap can be sutured directly without skin grafting and with less complications and a higher patient satisfaction rate.

Anatomy and ultrasonic evaluation of superficial circumflex iliac artery flap vessels

Anatomy and ultrasonic evaluation of superficial circumflex iliac artery flap vessels

Intravascular flipping technique for end-to-side microvascular anastomosis

Recent advances in minimally invasive perforator flaps, such as the superficial circumflex iliac artery (SCIP) flap, have increased the demand for anastomosing vessels with diameters less than 0.8mm. However, discrepancies in size can occur, underscoring the significance of end-to-side anastomosis. Nevertheless, the conventional interrupted end-to-side suturing technique with vessel turnover presents challenges in situations with a limited operative field, short vascular pedicle, and tiny vessels. Therefore, we developed an intravascular flipping technique for end-to-side microvascular anastomosis with an inside technique or rotation-outside technique. The study involved 20 rats and with 15 arteries in 10 rats undergoing the flipping technique with inside or outside rotation. Both the inside and rotation-outside techniques exhibited a 100% immediate patency rate in the rats; however, after 1 week, this decreased to 80% and 86%, respectively. The SCIP flap and replantation procedures were successfully performed. The flipping technique offers several advantages, including ease of vessel manipulation using nylon threads and vascular clips, improved vessel visualisation, and spontaneous widening of the vessel lumen.

Superficial Circumflex Iliac Artery Perforator-Free Flaps in Head and Neck Reconstruction: A Report on 10 Cases

Abstract The superficial circumflex iliac artery flap or as it was traditionally called the groin flap has gained a growing interest recently with the concept of perforators that revolutionized our understanding of many other classic flaps like the deep inferior epigastric artery, the thoracodorsal artery-based flaps, and many others. This revisiting process was brought about by further deeper knowledge of the anatomy of these flaps at finer levels. These advances made it possible to raise flaps with minimal donor site morbidities as well as to expand the applications for certain flaps to include different tissue components that serve the reconstructive needs better. Recent studies investigated its vascular supply, and a refined approach was adopted for using it in reconstruction. Another factor for revisiting this flap, is the lymph nodes that lie in its territory that may be used for lymph node transplant in lymphedema cases. Our objective from this report on 10 cases, is to display the flexibility and uses of the superficial circumflex iliac artery perforator (SCIP) free flap. We utilized the SCIP flap for ten sequential patients between November 2019 to August 2020 that were reconstructed with primary or secondary reconstruction in the head and neck region. All were performed by the same primary surgeon and his team. The serial cases incorporated 6 females and 4 males with a mean age of 51.5 years (range 16–80 years). In two cases, this flap was designed in a chimeric fashion including a bony segment from the iliac crest. In conclusion, we have found that the superficial circumflex iliac artery perforator flap has a reliable anatomy which facilitates a fast and easy dissection. Among others, this flap has shown that it has a strong advantage since it displayed minimal donor site morbidity.

Superficial Circumflex Iliac Artery Free Flap for Coverage of Hand Injuries.

Open de-gloving hand injuries with exposed tendons and bones require coverage by a flap.Conventionally used groin or abdominal flaps are cumbersome to patients due to extensive dressing and prolonged passive positioning of the hand until pedicle division. Superficial circumflex iliac artery (SCIA) flap is evolved from a traditional groin flap, and because of its thinness, pliability, and concealed donor site, it is an ideal option for single-stage reconstruction of traumatic hand defects avoiding discomforting passive hand position, joint stiffness, and unexpected flap avulsion which were associated with traditional groin flap.All patients with exposed bones or tendons due to traumatic hand injuries who opted for free flap coverage during the year 2018 to 2020 were enrolled in our study. After initial debridement, the wound was covered with a free SCIA flap. Duration of hospital stay, days out of work, the number of dressings required, postoperative complications, and any secondary procedures for flap readjustment were noted till six months postoperatively. A total of eight patients were included in the study. The mechanism of injury was road traffic accidents in a single patient and occupational injury in eight patients. The average duration of hospital stay was six days after reconstructive surgery. The average number of dressings a patient had was 18, and only two patients required flap thinning. Only one patient had a postoperative infection which was managed with dressings and antibiotics. One patient had peripheral flap necrosis. We had zero flap re-exploration. Therefore, we conclude that hand defects coverage with SCIA flap leads to a smaller number of working days lost and rarely requires secondary procedures.

Free superficial circumflex iliac artery flap combined with deep inferior epigastric perforator flap for repair of large soft tissue defects of upper extremities

To investigate the effectiveness of free superficial circumflex iliac artery flap (SCIP) combined with deep inferior epigastric perforator flap (DIEP) in repairing large soft tissue defects of upper extremities. Between February 2017 and January 2021, free SCIP combined with DIEP was used to repair 15 patients with large soft tissue defects of upper extremities. There were 12 males and 3 females, aged from 34 to 52 years, with a median age of 41 years. The causes of injury were mechanical injury in 11 cases and traffic accident injury in 4 cases. There were 9 cases of circular skin defect in the forearm and 6 cases of skin defect around the upper arm and elbow joint, with the defect in size of 15.5 cm×10.5 cm to 26.5 cm×15.5 cm, accompanied by exposure of deep tissues such as tendons and bones. There were 7 cases with open fractures and 8 cases with vascular and nerve injuries. The time from injury to operation ranged from 7 to 14 days, with an average of 7.5 days. The flaps in size of 16.0 cm×11.0 cm to 27.0 cm×16.0 cm were harvested; the thickness of the flaps was 0.8-1.3 cm, and the excess fat tissue was removed under the microscope after harvesting. The length of proximal vascular pedicle was 5.0-7.0 cm, and of distal vascular pedicle was 3.0-5.0 cm. The donor site was closed and sutured directly, and the navel was reconstructed. The flaps survived successfully in 14 cases, and the arterial crisis occurred in 1 case at 10 hours after operation, and the flap survived after surgical exploration. All the wounds in the donor and recipient sites healed by first intention. All 15 patients were followed up 3-14 months, with an average of 10.5 months. The appearance, elasticity, and texture of flap were good without obvious bloat, contracture, or adhesion. The donor site healed well, no abdominal wall hernia was found, and the appearance of reconstructed navel was good, only linear scar left. At last follow-up, 12 cases were evaluated as excellent and 3 cases were good according to the evaluation criteria of flap function of the Chinese Medical Association Microsurgery Branch. The sensation recovered to in 7 cases and in 8 cases. Free SCIP combined with DIEP has a large excision area and excellent skin ductility. It is an effective clinical method for repairing large soft tissue defects of upper extremities.

Clinical application of digital technology in the reconstruction of soft tissue defects of the lower extremity with free superficial circumflex iliac arteryflap.

ObjectiveThis paper aims to investigate the feasibility and clinical effectiveness of digital technology in the clinical application of free superficial circumflex iliac artery flap (SCIP) for repairing soft-tissue defects in the lower extremities.MethodsFrom January 2020 to December 2021, 16 patients with lower extremity soft tissue defects requiring flap repair were selected, and preoperative 3D digital reconstruction of the abdominal donor area and lower extremity recipient area were performed using digital technology combined with highly selective abdominal computed tomography angiography, and virtual design and flap cutting were performed using the software self-contained tool. During the actual surgery, the intraoperative design and excision of the superficial iliac circumflex artery were guided by the preoperative digital design, and the donor sites of the flap were closed directly.ResultsIn all cases, digital models of the donor area of the abdominal SCIP were successfully established, which could clearly showed the distribution, course, and diameter of the main trunk and the perforators and other relevant anatomical information and successfully guided the design and excision of the flap during surgery. All flaps successfully survived after surgery, and both the flap recipient and donor sites healed in one stage. All patients were followed up for 2–12 months on average (mean 8.6 months), and the flaps were not bulky and had a satisfactory appearance, with no significant difference in color compared with the surrounding skin and a little pigmentation around the flap. Only linear scarring was left in the donor areas, and there was no restriction of hip movement.ConclusionThis study used digital technology combined with a SCIP to repair lower extremity soft-tissue defects. The preoperative three-dimensional reconstruction of the digital model of the flap optimally designed the surgical plan, reduced the surgical risk and difficulty, shortened the surgical time, and had some significance for clinical precision, safety, and personalized design of the abdominal flap.

Back to groin:Re-Knocking the door

AbstractBackgroundOld but solid gold. This is the first thing that comes to our mind when we hear the word “Groin Flap”.The inimitable flap holds the advantages of being easily harvested with a relatively concealed donor site and very low morbidity.Recently, the goals of reconstruction have rapidly progressed from merely filling a hole to providing an improved function, pleasing aesthetic outcome and minimal to no donor site morbidity. Compared to the bulky conventional groin flap, the Superficial Circumflex Iliac artery Flap perforator(SCIP) fulfills the later requirements by being an already thin flap upon harvest, that doesn’t require further de-bulking.This yields thin, pliable tissue with a well-concealed donor site scar and minimal donor site morbidity.In the current study, we represent our experience in using the SCIP flap for various defects of the hand due to different etiologies.Methods: Twenty SCIP flaps were raised superficial to the breaching fascia to cover various defects of the hand and distal forearm during the period of June 2018 to June 2019. Accordingly, with the preservation of the fascia, the flap relies wholly on the superficial branch of the superficial circumflex iliac artery, along with the sub-dermal plexus, sparing the deep branch. Results: Twenty patients (14 males and 6 females) with various injuries to the hand were treated with supra-fascial groin SCIP flap. The mean age was 26.9 years (range 8-50 years, SD 10.70).Mean BMI was 27.56 Kg/m2 (20-30 Kg/ m2, SD 5). Supra-fascial flaps were taken as large as (10 cm x 20 cm). Mean operative time was 3.05 hours (± 0. 83), and mean follow up was eight months (6 – 12 months, SD 2.1). All injuries did not require further flap thinning or refashioning.Conclusion:SCIP flap with its supra-fascial dissection can be safely used as an alternative to the conventional groin flap. With its thin nature, better flap in-setting is obtained, the aesthetic outcome is more pleasant and the need for further revisionary debulking surgeries is almost eliminated.

Feasibility study of preoperative microvessel evaluation and characterization in perforator flaps using various modes of color-coded duplex sonography (CCDS).

Color-coded duplex sonography (CCDS) is useful for perforator flap design showing the highest sensitivity in identifying microvessels. This prospective study evaluates the feasibility of different ultrasound (US) modes applied by the microsurgeon in daily practice suggesting quantifiable reference values. Twenty-four patients aged between 17 and 68 years (mean 43.3 ± 14.2 years) with 18 anterolateral thigh (ALT) and 6 superficial circumflex iliac artery (SCIP) flaps were included. Indications were traumatic (n = 12), infectious (n = 6), ischemic (n = 4), or tumor-associated defects (n = 2). Different US modes were evaluated regarding applicability using multifrequency linear probes (5-15 MHz). Vessels diameter, peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) were measured. Preoperative results were correlated to intraoperative findings. In the examined patient group with 24 perforator flaps a 100% correlation was seen when comparing perforators detected with CCDS/PD with intraoperative findings using optimized US settings. Sensitivity, PPV, and accuracy of CCDS were 100% respectively. Mean PSV of 16.99 ± 6.07 cm/s, mean EDV of 5.01 ± 1.84 cm/s and RI of 0.7 ± 0.07 were measured in microvessels (PW-mode). CCDS proved to be superior compared to PD in correct diameter assessment showing a mean diameter of 1.65 ± 0.45 mm, compared to PD-mode 1.31 ± 0.24 mm. Mean PSV and EDV were higher in ALT than in SCIP flaps, RI was slightly higher in SCIP flaps (p > .05). There were no significant differences in size of different flaps' perforators (p > .05). CCDS represents a highly valuable tool in the daily practice of free flap reconstructions using optimized low flow US settings and multifrequency linear probes.

Use of free sensate SCIA flap for reconstruction of distal limb defects of moderate size

Recent attempts have been made to direct the sensory neurotisation of free superficial circumflex iliac artery (SCIA) flaps. However, donor nerves enabling sensory recovery are limited. We report our findings in fifteen patients who underwent distal limb defect reconstruction using a sensate SCIA flap, including the lateral cutaneous branch of the subcostal nerve (LCSN), between August 2017 and September 2018. The distance from the anterosuperior iliac spine to the point where the LCSN crossed the iliac crest ranged between 6.5 and 10cm. The diameter ranged between 1.5 and 4.0mm. The flap size ranged between 8×4 and 13×10cm2. All of the flaps survived uneventfully. Tests of sensory modalities, including the Semmes-Weinstein (SW) touch, vibration, pinprick, temperature and static two-point discrimination (s2PD) tests were applied in nine regions of each flap post-operatively. One or more modalities were present in at least one region at 6 months post-operatively, and the recovery of vibration perception was more consistent than that of SW touch and pinprick perception. The recovery of s2PD was noted in 4 cases over a follow-up period of more than 12 months. A reliable sensate flap with the LCSN can be considered as an attractive option for the sensory reconstruction of distal limb defects of moderate size.

Concepts in Early Reconstruction of the Burned Hand.

Early reconstruction of burn sequelae of the hand can be challenging owing to high goals for functional and aesthetic outcome. A variety of reconstructive procedures with ascending levels of complexity exists and warrants careful indication. In this case series, the main reconstructive techniques for reconstruction of burn defects of the hand are described, illustrated, and discussed: split thickness skin grafting (STSG) with fibrin glue, dermal matrices with STSG, distant random pattern (abdominal bridge) flap, distant pedicled flap (superficial circumflex iliac artery flap), and free microvascular tissue transfer (anterolateral thigh flap). An algorithm for decision making in the reconstructive process is proposed. Split thickness skin grafting provides sufficient coverage for partial thickness defects without exposure of functional structures; fixation with fibrin glue avoids unnecessary stapling. Dermal matrices under STSG provide vascularized granulation tissue on full thickness defects and can be used as salvage procedure on functional structures. Distant random pattern or pedicled flaps provide sufficient coverage of large full thickness defects with exposed functional structures but pose some challenges regarding patient compliance and immobilization. Free tissue transfer allows tailored reconstruction of large full thickness defects with exposed functional structures and can be safely and feasibly performed. Secondary and tertiary procedures are needed with more complex techniques; if applied correctly and consequently, all methods can yield favorable functional and aesthetic outcomes. Reconstruction of the burned hand may require a broad armamentarium of surgical techniques with different levels of complexity, versatility, and applicability. Excellent results can be achieved with the right procedure for the right patient.

Brief introduction of perforator flap

In 600 BC, the first pedicled direct cutaneous artery perforator flap-the supravicular artery perforator flap was harvested by Sushruta. In 1973, the first free perforator flap-the superficial circumflex iliac artery flap in the groin was reported by Daniel and Taylor. In 1982, the septocutaneous perforator flap was reported by academician Zhong Shizhen. In 1989, the misculocutaneous perforator flap was reported by Koshima. Reviewing the history of flap surgery, there was a fact that the main evolutionary line was the course of perforator flap. In the future, the clinical application of the traditional random flap (reticulated blood supply flap) and traditional axial flap will be more and more less, whereas the clinical application of perforator flap, especially the direct cutaneous perforator flap and the special type of perforator flap will be more and more extensive.

The SCIP propeller flap: Versatility for reconstruction of locoregional defect✰

Abdominopelvic defect is frequently a challenge. Several local flaps exist for this anatomical region, but sequelae of the donor site, particularly with regard to morbidity on the anterior abdominal wall, are frequent. Although the utility of the superficial circumflex iliac artery flap is well established in its free form as well as its pedicled form described by McGregor, the superficial circumflex iliac artery perforator (SCIP) propeller flap is rarely reported. The purpose of this study is to highlight the possible range of locoregional coverage using the SCIP propeller flap. Between 2012 and 2018, 72 SCIP flaps were made in the propeller version to cover locoregional defects of various etiologies in our units. The dimensions of SCIP flaps were on average 20.2 cm long (9-39) by 8.2 cm wide (5-18). The average rotation angle was 163.3° (range 130-180). In sixteen patients, SCIP flaps were bilateral. In five cases, the reconstruction was combined with a contralateral Tensor Fascia Lata (TFL) flap to cover a very large defect. Two SCIP flaps necrotized following global venous congestion and a TFL flap was performed in rescue. No complications appeared on the donor site and the patients did not have any functional complications related to the reconstruction. Particular care was taken to respect the lateral cutaneous nerve of the thigh. The SCIP propeller flap provides a reliable and versatile method for reconstructing abdominoperineal defect, including the thigh root region to the trochanters with low donor site morbidity.

Application of free ilioinguinal flap for repair of hand skin and soft tissue defects

Objective To investigate the clinical effect of individualized free ilioinguinal flap in repairing hand skin and soft tissue defects. Methods From January 2013 to December 2017, 97 cases of hand skin and soft tissue defects were treated with free ilioinguinal flap. There were 63 cases of superficial circumflex iliac artery flap (26 cases of superficial circumflex iliac artery flap with iliac bone), 15 cases of superficial abdominal artery flap and 19 cases of combined flap of superficial circumflex iliac artery and superficial abdominal artery (7 cases of lobulated flap). The area of skin defects ranged from 4 cm×6 cm to 11 cm×23 cm. During the operation, end to end anastomosis of flap artery and the end branch of radial artery in 5 cases, end to side anastomosis of radial artery in 58 cases, end to side anastomosis of ulnar artery in 20 cases, end to side anastomosis of common digital artery in 14 cases. All the superficial circumflex iliac veins and superficial abdominal veins were repaired (a concomitant vein were repaired at the same time in 31 cases). The donor site was sutured directly after flexion of hip and knee without skin grafting. Three weeks, 1.5 months, 3 months, 6 months, 1 year and 2 years after the operation, the healing of donor area and the appearance and sensory recovery of recipient area skin flaps were observed. Results Postoperatively 94 cases survived successfully. Arterial crisis occurred in 1 case and venous crisis in 2 cases. 2 cases received surgical exploration and 1 case received conservative treatment. After that, 1 case survived smoothly and 2 cases suffered skin necrosis. Subcutaneous soft tissue survived after secondary escharectomy and survived after skin grafting. In one case of abdominal donor site, the incision dehiscence occurred in the first week of walking upright after operation, and healed after secondary suture. The remaining donor sites achieved primary healing. The follow-up period ranged from 0.5 to 1.5 years. The flaps were soft and slightly swollen, and the sensation returned to S2 or S3. There were only linear scars in the abdominal donor site. Conclusion According to the skin and soft tissue defects in the recipient area of the hand, the individualized free ilioinguinal flap transplantation can meet the different needs of the recipient area. The donor site is concealed, the cutting area is large, and it can be directly sutured. It belongs to the axial skin flaps. The blood vessels are constant, the cutting is convenient, the main blood vessels are not destroyed, and the operation time is short. Therefore, it is one of the ideal methods to repair the skin and soft tissue defects of limbs. Key words: Hand injuries; Surgical flaps; Skin and soft tissue defects; Free; Individualized

Quantifying Lymph Nodes During Lymph Node Transplantation: The Role of Intraoperative Ultrasound.

Quantifying lymph nodes in vascularized lymph node transfer (VLNT) has been performed using preoperative percutaneous ultrasound. The higher resolution and accuracy of intraoperative ultrasound (IOUS) over transcutaneous ultrasound has been demonstrated in the radiology literature for the identification and characterization of finer structures including hepatic lesions, pancreatic lesions, and biliary or pancreatic ducts. We hypothesize that IOUS during VLNT would be a superior method to quantify and map lymph nodes in our flaps. A prospectively collected database of patients undergoing VLNT over 3 years (October 2014 to October 2017) was reviewed. Patients who underwent IOUS during flap harvest, before pedicle ligation to simultaneously map and quantify the number of lymph nodes were included in the study. Twenty-one patients with an average age of 58.7 years and a mean BMI of 32.3 underwent VLNT with IOUS for chronic lymphedema during the study period. Extremity lymphedema was classified as Campisi IB (n = 7), IIA (n = 7), IIB (n = 5), and IIIA (n = 2). There were 14 superficial circumflex iliac artery flaps, including 4 performed concomitantly with a deep inferior epigastric perforator flap, 1 transverse cervical artery flap, and 6 omental flaps. The average number of lymph nodes transferred per IOUS was 4.3 for superficial circumflex iliac artery flaps, 4 for the transverse cervical artery flap, and 5.2 for the omental flaps. Intraoperative ultrasound allows the lymphatic surgeon to precisely map the location of lymph nodes which can guide intraoperative decision making. As there is no data correlating the number of lymph nodes transferred and outcomes after VLNT, developing a precise intraoperative quantification method is important.

Repairing donor site of foot after improved toe-to-thumb reconstruction utilizing superficial circumflex iliac ar-tery perforator chimeric flap

Objective To evaluate the clinical outcome of the method of repairing donor site of foot after im-proved toe-to-thumb reconstruction utilizing superficial circumflex iliac artery perforator (SCIAP) chimeric flap. Meth-ods Fourteen cases of thumb defect were recruited from April, 2012 to January, 2016. According to Gu Yudong’s clas-sification, 5 cases met the criterion of type I, 4 cases met the criterion of type II, and 5 cases met the criterion of type III. For type I, the thumb was reconstructed with the great toe wrap-around flap. For type II and III, the thumb was recon-structed by the combined tissue with mutual artery (great toe wrap-around flap, and the bone-tendon tissue of the sec-ond toe). All the donor sites of foot were repaired utilizing SCIAP chimeric flap. Results All the reconstructed thumbs survived. Among 14 free flaps of donor site, 1 case suffered venous crisis and survived after exploration and rescue sur-gery. Dorsal skin necrosis of the second toe was found in 1 case, which was healed by local skin flap transposition. All pa-tients were followed-up ranged from 3 to 30 months (averaged at 16 months). In spite of slightly bloated, the color and texture of all the flaps’was satisfied, and the average healing time of the bone in the donor sites was 2.5 months. All pa-tients did not feel painful and had no adverse effect when walking and running. Three months after the operation, 5 slight-ly bloated flaps in the donor sites under went flap plastic and achieved better appearance. On the part of iliaca, there was only one inconspicuous linear scar without any discomfort. Conclusion Repairing donor site of foot after improved toe-to-thumb reconstruction utilizing SCIAP chimeric flap was an ideal method. Using this method, the reconstructed thumb can achieve good appearance and function, all the toes of donor site were reserved, and the disability of the donor site is minimized. Key words: Superficial circumflex iliac artery; Chimeric flap, perforator flap; Tissue transplantation; Thumb reconstruction; Donor site; Microsurgical technique

3D Printing Technology in Planning Thumb Reconstructions with Second Toe Transplant

To report preoperative planning using 3D printing to plan thumb reconstructions with second toe transplant. Between December 2013 and October 2015, the thumbs of five patients with grade 3 thumb defects were reconstructed using a wrap-around flap and second toe transplant aided by 3D printing technology. CT scans of hands and feet were analyzed using Boholo surgical simulator software (www.boholo.com). This allowed for the creation of a mirror image of the healthy thumb using the uninjured thumb. Using 3D images of the reconstructed thumb, a model of the big toe and the second toe was created to understand the dimensions of the donor site. This model was also used to repair the donor site defect by designing appropriate iliac bone and superficial circumflex iliac artery flaps. The polylactic acid model of the donor toes and reconstructed thumb was produced using 3D printing. Surgically, the wrap-around flap of the first dorsal metatarsal artery and vein combined with the joint and bone of the second toe was based upon the model donor site. Sensation was reconstructed by anastomosing the dorsal nerve of the foot and the plantar digital nerve of the great toe. Patients commenced exercises 2 weeks after surgery. All reconstructed thumbs survived, although partial flap necrosis occurred in one case. This was managed with regular dressing changes. Patients were followed up for 3-15 months. The lengths of the reconstructed thumbs are 34-49 mm. The widths of the thumb nail beds are 16-19 mm, and the thickness of the digital pulp is 16-20 mm. The thumb opposition function was 0-1.5 cm; the extension angle was 5°-20° (mean, 16°), and the angle of flexion was 38°-55° (mean, 47°). Two-point discrimination was 9-11 mm (mean, 9.6 mm). The reconstructed thumbs had good appearance, function and sensation. Based on the criteria set forth by the Standard on Approval of Reconstructed Thumb and Finger Functional Assessment of the Chinese Medical Association, the results were considered excellent for four cases and good for one case. The success rate was 100%. When planning a wrap-around flap and second toe transplant to reconstruct a thumb, both the donor and recipient sites can be modeled using 3D printing. This can shorten the operative time by supplying digital and accurate schematics for the operation. It can also optimize the function and appearance of the reconstructed thumb while minimizing damage to the donor site.

Immediate Bilateral Breast Reconstruction with Unilateral Deep Superior Epigastric Artery and Superficial Circumflex Iliac Artery Flaps.

Autologous breast reconstruction utilizing a perforator flap is an increasingly popular method for reducing donor site morbidity and implant-related complications. However, aberrant anatomy not readily visible on computed tomography angiography is a rare albeit real risk when undergoing perforator flap reconstruction. We present an operative case of a patient who successfully underwent a bilateral breast reconstruction sourced from a unilateral abdominal flap divided into deep superior epigastric artery and superficial circumflex iliac artery flap segments.

Breast Reconstruction with SIEA Flaps: A Single-Institution Experience with 145 Free Flaps.

Refinements in microsurgical breast reconstruction have refined superficial inferior epigastric artery (SIEA) and superficial circumflex iliac artery (SCIA) flaps, yet technical difficulties and varied success rates limit widespread acceptance. The authors present the outcomes of their experience with 145 consecutive SIEA/SCIA flaps and suggest technical tips to improve success with this important flap. An institutional review board-approved retrospective chart review of all SIEA/SCIA free flaps performed by the senior authors between January 1, 2006, and February 6, 2014, was conducted. Data on patient demographics, flap characteristics, and complications were collected. There were 145 flaps performed in 119 patients. Arterial donor and recipient mismatch occurred in 55 instances (38 percent). In these cases, 48 arteries (87 percent) were spatulated and seven (13 percent) were back-cut to improve size concordance. Nine flaps required operative return for flap viability concerns. Five were arterial, three were venous, and one flap had concomitant arterial and venous thrombosis. Total flap loss rate attributable to thrombotic events was 4.8 percent. No flaps with arterial thrombosis on reoperation were salvageable. Furthermore, 80 percent had arterial revisions at initial operation. No patients had an abdominal bulge or hernia, and the fat necrosis rate was 10.3 percent. SIEA/SCIA breast reconstruction can be reliably performed; however, flaps exhibiting postoperative arterial thrombosis with revision at initial surgery are unlikely salvageable on reoperation. Spatulation did not correlate with an increased thrombosis rate; in fact, the authors advocate for donor artery manipulation to manage size mismatch. Therapeutic, IV.