Circumflex Iliac Artery Research Articles

Do-It-Yourself Preoperative High-Resolution Ultrasound-Guided Flap Design of the Superficial Circumflex Iliac Artery Perforator Flap (SCIP).

The superficial circumflex iliac artery perforator (SCIP) flap is a well-documented, thin, free tissue flap with a minimal donor site morbidity, and has the potential to become the new method for resurfacing moderate-size skin defects. The aim of this study is to describe an easy, reliable, systematic, and standardized approach for preoperative SCIP flap design and perforator characterization, using color-coded duplex sonography (CCDS). A list of customized settings and a straightforward algorithm are presented, which are easily applied by an operator with minimal experience. Specific settings for SCIP flap perforator evaluation were investigated and tested on 12 patients. Deep and superficial superficial circumflex iliac artery (SCIA) branches, along with their corresponding perforators and cutaneous veins, were marked individually with a permanent marker and the anatomy was verified intraoperatively. From this, a simplified procedure for preoperative flap design of the SCIP flap was developed. Branches could be localized and evaluated in all patients. A preoperative structured procedure for ultrasonically guided flap design of the SCIP flap is described. A 100% correlation between the number and emergence points of the branches detected by preoperative CCDS mapping and the intraoperative anatomy was found.

A Possible Distal End for Perforasome of the Superficial Circumflex Iliac Artery Perforator Flap.

Flaps from the groin region have been attracting renewed interest since the advent of a superficial circumflex iliac artery (SCIA) perforator (SCIP) flap, which was recently nominated as one of the “best new flaps” by Brown et al.1 Its benefits include thinness of tissue, the capability of chimerization involving the muscle and bone, and minimal donor-site morbidity. However, reports on the usefulness of a SCIP flap have been limited to reconstructions of small- to medium-size defects.1 With a view to expanding the application of an SCIP flap for use on larger defects, a prime question is to what extent such a flap can be enlarged. Few reports have described the perfusion area (ie, perforasome) of an SCIP,2 and the limits of the distal border of the perforasome at which a flap may be expected to survive have yet to be determined. Herein, we propose a hypothesis regarding the location of the distal boarder of an SCIP perforasome by comparing 2 clinical cases with and without vascular supercharging. Case 1 was a 26-year-old man with scrotal lymphorrhea due to congenital lymphangioma, treated with resurfacing of the scrotum with a pedicled SCIP flap.3 To cover the scrotal defect with one unilateral flap, the SCIP flap was designed beyond the costal arch. It was elevated from above the deep fascia, including both the deep and superficial branches of the SCIA, and introduced to the scrotum subcutaneously with its distal tip located in the caudal part of the defect. However, postoperatively, full-thickness necrosis developed in the distal portion of the flap with a clear demarcation line identical to that of the costal arch. Case 2 was a 61-year-old male with scrotal lymphorrhea after chemoradiation therapy for anal cancer. He also underwent scrotal resurfacing with a unilateral pedicled SCIP flap spanned beyond the costal arch (Fig. 1). The flap was elevated as described in Case 1, and the intercostal artery perforator was also included at the rostral end of the flap.4,5 In this case, the intercostal artery perforator was anastomosed to a scrotal branch of the internal pudendal artery identified at the defect (Fig. 2). With intraoperative indocyanine green fluorescence imaging, the distal part of the flap harvested beyond the costal arch was not visible before anastomosis. (See figure, Supplemental Digital Content 1, which displays intraoperative indocyanine green fluorescence imaging of the pedicled superficial circumflex iliac artery perforator flap of Case 2 before vascular supercharging. The flap orients distally to the left side of the pictures. The distal portion of the flap beyond the costal arch did not fluoresce before anastomosis. https://links.lww.com/PRSGO/B662.) Following anastomosis, however, the distal portion was visible. The flap was completely viable postoperatively.Fig. 1.: Design of rostrally-extended SCIA perforator flap for Case 2. The distal end of the flap was spanned beyond the costal arch. Arrow: Distal portion of the flap beyond the costal arch; Arrowheads: Costal arch.Fig. 2.: Vascular supercharging for the pedicled SCIA perforator flap of Case 2. The flap was introduced subcutaneously to the scrotal defect. The intercostal artery perforator (included at the distal part of the flap) was anastomosed to a scrotal branch of the internal pudendal artery found at the defect (arrow).While limited to 2 cases, these results suggest that the distal boarder of the SCIP perforasome locates near the costal arch, hence vascular supercharging with the use of the intercostal artery perforator may be recommended when a larger/longer flap is needed. These findings may help open the door to application of an SCIP flap for larger or more remote defects and offer clues in overcoming size limitations. ACKNOWLEDGMENT This study was conducted in accordance with the Helsinki Declaration.

A fabricated chimeric SCIP flap with end-to-side anastomosis: A case report

Superficial circumflex iliac artery perforator flap (SCIP) is one of the most convenient flaps to cover distal extremity defects because it conceals the scar of the donor area well and can be raised as a thin or super-thin flap. In recent years, various chimeric SCIP flaps were reported, including the sartorius muscle, the lateral femoral cutaneous nerve, and the iliac bone. However, chimeric SCIP flap is sometimes difficult to be raised on one pedicle, because of the absence of communication between a skin branch and a branch to a chimeric tissue. We present a case in which end-side anastomosis of a sartorius muscle perforator to a SCIP flap pedicle is made to form a fabricated chimeric SCIP flap due to variation in the pedicle. This design aims to fill cavitary spaces and supply better perfusion for infection control.

Patient-specific surgical options for breast cancer-related lymphedema: technical tips.

In order to provide a physiological solution for patients with breast cancer-related lymphedema (BCRL), the surgeon must understand where and how the pathology of lymphedema occurred. Based on each patient’s pathology, the treatment plan should be carefully decided and individualized. At the authors’ institution, the treatment plan is made individually based on each patient’s symptoms and relative factors. Most early-stage patients first undergo decongestive therapy and then, depending on the efficacy of the treatment, a surgical approach is suggested. If the patient is indicated for surgery, all the points of lymphatic flow obstruction are carefully examined. Thus a BCRL patient can be considered for lymphaticovenous anastomosis (LVA), a lymph node flap, scar resection, or a combination thereof. LVA targets ectatic superficial collecting lymphatics, which are located within the deep fat layer, and preoperative mapping using ultrasonography is critical. If there is contracture on the axilla, axillary scar removal is indicated to relieve the vein pressure and allow better drainage. Furthermore, removing the scars and reconstructing the fat layer will allow a better chance for the lymphatics to regenerate. After complete removal of scar tissue, a regional fat flap or a superficial circumflex iliac artery perforator flap with lymph node transfer is performed. By deciding the surgical planning for BCRL based on each patient’s pathophysiology, optimal outcomes can be achieved. Depending on each patient’s pathophysiology, LVA, scar removal, vascularized lymph node transfer with a sufficient adipocutaneous flap, and simultaneous breast reconstruction should be planned.

Use of Preoperative High-Resolution Ultrasound System to Facilitate Elevation of the Superficial Circumflex Iliac Artery Perforator Flap.

During elevation of the superficial circumflex iliac artery (SCIA) perforator (SCIP) flaps, the flap pedicle must often be converted from the superficial branch to the deep branch of the SCIA, complicating and prolonging the procedure. The goal of the present study was to demonstrate the effectiveness of high-resolution ultrasonography to decrease the conversion rate on which no previous report has focused, by making a comparison with a conventional method. Forty-five consecutive cases where free SCIP flap transfer was performed for reconstruction were retrospectively reviewed. To preoperatively mark the course of the superficial branch, handheld Doppler ultrasonography was used in 27 cases (group 1) and a high-resolution ultrasound system in 18 cases (group 2). The conversion rate was significantly greater in group 1 than in group 2 (10/27 [37%] vs. 0/18 [0%], p = 0.003]. The frequency of use of multiple venous anastomoses was significantly higher in group 1 than in group 2 (21/27 [78%] vs. 2/18 [11%], p < 0.001). The operative time was significantly longer in group 1 than in group 2 (p = 0.038). There were no significant differences in postoperative complication rates (1/27 [4%] versus 0/18 [0%], p = 1.0). The use of a preoperative high-resolution ultrasound system significantly decreased the rate from of intraoperative conversion from the superficial branch to the deep branch of the SCIA. It also resulted in significantly fewer venous anastomoses and a shorter operative time, while maintaining a low incidence of postoperative complications.

Use of a combined SIEA and SCIP based double pedicled abdominal flap for breast reconstruction.

Recently, the deep inferior epigastric perforator (DIEP) flap has become the gold standard for breast reconstruction, but it has some drawbacks such as abdominal bulging and hernia. To overcome these disadvantages, the superficial inferior epigastric artery perforator (SIEA) flap is used as an alternative option, but it has another problem, namely limited vascular territory and risk of vascular thrombosis. To solve these problems, we introduced our new technique, a combined SIEA and superficial circumflex iliac artery perforator (SCIP) based double pedicled abdominal flap. In this report, we present our experience of using this technique. The SIEA and SCIP based double pedicled abdominal flap was used in five patients who wanted to have unilateral breast reconstruction after a mastectomy due to breast cancer. The average age was 48.2 (range 38-56) years, and the average BMI was 24.4 (range 19.2-31.4). The SIEA and SCIP based double pedicled abdominal flap was designed as a modified DIEP flap, and all flaps were placed in the vertical setting. The flap pedicles had two different vascular supplies, SIEA and SCIA, and the drainage systems, SIEV and SCIV, anastomosed to the internal mammary artery and vein in all cases. The harvested SIEA and SCIP based double pedicled abdominal flaps were a median volume of 925 g (range 452-1570 g) and average size of 491 cm2 (range 440-611 cm2 ). The average reconstructive time was 7:41 (range 6:31-9:17). In four out of the five cases, the SIEA and SCIA joined together to make a common pedicle artery trunk, and its average size was 1.08 mm. Four out of the five cases had a wide vascular territory crossing the abdominal midline as shown by ICG angiography. One case showed ICG fluorescence for the hemi-side of the abdominal flap. Postoperative course was uneventful, and there were no major perioperative complications, which need extra surgical procedures. Follow-up period averaged 273 days (range 194-312 days). The SIEA and SCIP based double pedicled abdominal flap showed viable flap territory across the midline in all cases. The SIEA and SCIP based double pedicled abdominal flap might be another ideal option for breast reconstruction, when appropriate SIEA and SCIA pedicles are identified, and an adequate ICG fluorescence is obtained for the size of flap needed.

Subdermal Dissection for Elevation of Pure Skin Perforator Flaps and Superthin Flaps: The Dermis as a Landmark for the Most Superficial Dissection Plane.

Pure skin perforator and superthin flaps have been reported and are becoming popular, as they allow one-stage thin skin reconstruction even from a thick donor site. However, currently reported elevation procedures use proximal-to-distal dissection requiring free-style perforator selection and primary thinning procedures. With distal-to-proximal dissection using the dermis as a landmark for dissection plane, it is expected that elevation of pure skin perforator or superthin flaps can be simplified. Patients who underwent pure skin perforator or superthin flap transfers with the subdermal dissection technique were included. Flaps were designed based on location of pure skin perforators visualized on color Doppler ultrasound, and elevated just below the dermis under an operating microscope. Medical charts were reviewed to obtain clinical and intraoperative findings. Characteristics of the patients, flaps, and postoperative courses were evaluated. Thirty-six flaps were transferred in 34 patients, all of which were elevated as true perforator flaps (superficial circumflex iliac artery perforator flap in 29 cases, other perforator flaps in seven cases). Mean ± SD flap thickness was 2.24 ± 0.77 mm (range, 1.0 to 4.0 mm). Skin flap size ranged from 3.5 × 2 cm to 27 × 8 cm. Time for flap elevation was 27.4 ± 11.6 minutes. All flaps survived without flap atrophy/contracture 6 months after surgery, except for two cases of partial necrosis. The subdermal elevation technique allows straightforward and direct elevation of a pure skin perforator or superthin flap within 30 minutes on average without the necessity of primary thinning. Therapeutic, IV.

Use of the superficial circumflex iliac artery perforator flap for reconstruction after sarcoma resection.

Postoperative complications after flap-coverage in sarcoma treatment can postpone postoperative adjunct treatments. Here, we present our experience with the use of the superficial circumflex iliac artery perforator (SCIP) flap after sarcoma resection. Patients undergoing immediate reconstruction surgery with a flap after sarcoma resection at a single institution from February 2017 to April 2020 were identified. Patient demographics, tumor characteristics, surgical characteristics, and complications were examined. Thirty-five consecutive patients underwent reconstructions using a SCIP flap (34 free and one pedicled SCIP flaps). We also identified 47 consecutive patients who underwent reconstruction with other pedicled or free flaps over the same time period. No significant differences were found in patient age, gender, defect size, or operative time between these two groups. The incidences of overall complications (20/47 [42.6%] vs. 3/35 [8.5%], p < .001), flap dehiscence (7/47 [14.8%] vs. 0/35 [0%], p = .018), and total flap complications (15/47 [31.9%] vs. 2/35 [5.7%], p = .005) were statistically greater in the control group than in the SCIP group. With its minimal postoperative complication rate both in the reconstruction site and the donor site, the SCIP flap can be considered an optimal reconstruction option after sarcoma resection.

The vascular exploration of the proximal femoral artery perforator region, an ideal donor site to choose cutaneous flaps of thin, supple, and glabrous skin: A cadaveric study

The thigh region is a well-known area for harvesting cutaneous flaps for microsurgery replacement, given the characteristics of the skin: thin, flexible, and glabrous. We investigated the vascular pattern of 32 cadaveric anteroproximal thighs for the possibility of an extended harvesting area, which we call the proximal femoral artery perforator region. We injected colored, radio opaque latex in the external iliac artery and investigated the perforator branches from the superficial circumflex iliac, femoral common, superficial, and deep femoral (profunda femoris) arteries to the skin of the proximal femoral artery perforator region. This region was divided into 3 equal subregions (superior, medial, and lateral), and their perforators were counted and measured. There was no significant difference in the number of arterial pedicles across the three subregions: 30 superior, 35 inferolateral, and 27 inferomedial. The perforators had a cutaneous path in 81% of the cases, while 6% were musculocutaneous and 5% septocutaneous, without a significant difference in their proportion in the three subregions. The mean length and diameter of the pedicles were 5.39 ± 2.1 cm and 1.07 ± 0.4 mm, respectively, without significant differences in the three subregions. The proximal femoral artery perforator region is a suitable area to generate flaps of various sizes and shapes, as needed by the surgeon. All perforators were constant and possessed a sufficient diameter and length for a successful anastomosis during the surgical procedure. The donor site retains all technical advantages to successfully replace areas of glabrous skin.

The surgical management of extra-cranial trigeminal nerve palsies: A retrospective case series

To assess for functional improvement in outcomes following supermicrosurgical restoration across a cohort of patients with a spectrum of trigeminal nerve disorders. In a retrospective case series over three years (2016-18), twenty patients were included in a cohort of trigeminal nerve palsy patients. Eleven patients with corneal anaesthesia underwent corneal neurotisation procedures and were followed up using Cochet-Bonnet aesthesiometry. Six patients with sensory trigeminal nerve injuries had direct nerve coaptation and neuroma excision. Three patients with trigeminal motor nerve palsies were followed up with photography for contour improvement. Regarding corneal neurotisation, there was evidence of significant improvement in protective corneal sensation and also blinking frequency. Regarding facial sensory disturbances, all patients had full resolution of painful trigeminal neuroma symptoms. In two cases of iatrogenic trigeminal motor palsies with contour defects, adipo-fascial variants of the superficial circumflex iliac artery (SCIP) free flap achieved excellent restoration of facial contour in lieu of facial lipofilling. In another case of a necrotising infection of the head and neck with loss of all masticatory muscles, a free functional muscle using a chimaeric vastus lateralis-ALT flap was used to restore masticatory and facial movement in a single stage procedure. Using combinations and permutations of current surgical techniques, it is possible to successfully restore both form and function for patients with sensory as well as motor trigeminal nerve palsies. This sets a precedent for the expansion of cranial nerve surgery as an evolving sub-speciality.

Tạo hình khuyết hổng bằng vạt SCIP sau phẫu thuật cắt nửa lưỡi do ung thư tại bệnh viện trung ương huế cơ sở 2: nhân 1 trường hợp

Objective: This study to evaluate the effectiveness of superficial circumflex iliac artery perforator (SCIP) flap in reconstruction after hemiglossectomy due to cancer. Method: The author reports a clinical case using SCIP flap to reconstruct tongue of the patient with half-tongue defects after tongue cancer surgery at Oncology-Palliative care Department of Hue Central Hospital branch 2. Result: The patient did not have accumulating of liquid, wound infection and bleeding after surgery, the flap survived well. The patient was taken nasogastric tube out after ten days and discharged after two weeks. Postoperative functional assessments (speech, swallowing) as well as aesthetic of tongue (symmetry) have significant improvement over the 1 month, 3 months and 6 months. Conclusion: SCIP flap is a choice for the patients with large flaws at tongue and floor of the mouth. It ensures both functional and aesthetic for the regenerative tongue and donor-site. The disadvantage of the flap: the length of the flap is moderate, the diameter of the arteries and veins is small.

Fabricating Flaps in the Forearm Prior to Tracheal Reconstruction.

Background The process of reconstruction of tracheal defects is complex and still not optimum. Options range from using staged reconstructions, combining flaps with autologous or alloplastic implants, as well as use of tissue-engineered constructs combined with vascularized tissues which are lined with cell cultures. Staged reconstructions using prelaminated epithelium, and prefabricated flaps, help in reconstruction of this complex structure. Prefabricating the flap at a different site allows for integration of the tissues prior to its transfer. Method This article reports two patients planned for tracheal reconstruction for the purpose of advanced papillary carcinoma of the thyroid invading the trachea. Staged reconstruction using a prefabricated radial artery forearm flap (RAFF) and split rib cartilage was performed. In the second patient, a young girl, a similar construct of the RAFF, prelaminated with buccal mucosa, was performed. However, in the latter case, an intraoperative decision by the head and neck team to limit excision of the trachea sparing the mucosa was taken; the reconstruct in the forearm was redundant and needed to be discarded, replacing the defect with a free superficial circumflex iliac artery perforator (SCIP) flap. Result At 3 years follow-up, both the patients are free of disease, with the construct serving its purpose in the older female.

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.

Best New Flaps and Tips for Success in Microsurgery.

After reviewing this article, the participant should be able to: 1. Understand the trends in reconstruction using flaps. 2. Understand the surgical anatomy and elevation of the three best flaps: superficial circumflex iliac artery perforator, profunda artery perforator, and thin anterolateral thigh perforator. 3. Understand the core principle and the modern evolution of microsurgery. 4. Be acquainted with new microsurgical tips to maximize outcomes. Plastic surgery has a long history of innovation expanding the conditions we can treat, and microsurgical reconstruction has played a pivotal role. Freestyle free flaps now create another paradigm shift in reconstructive surgery, relying on a better understanding of anatomy and physiology, opening the door to patient-specific customized reconstruction. This article aims to provide information regarding useful and practical new advances in the field of microsurgery.

Characteristics of the Superficial Circumflex Iliac Artery Perforator Flap in a Western Population and a Practice Approach for Free Flap Reconstruction.

There has been increasing interest in the superficial circumflex iliac artery perforator (SCIP) flap as a source of thin, pliable soft tissue combined with a favorable donor site. Despite several clinical series from Asia, barriers to adoption include reluctance to perform submillimeter "supermicrosurgery" and the effect of body habitus on flap feasibility. The purpose of this study is to distinguish vascular anatomic characteristics of the SCIP flap in a North American population. Computed tomography angiography was examined in 84 flaps in healthy prospective renal donor patients from a radiographic database. Descriptive statistics as well as linear regression comparing variables to body mass index (BMI) were performed. Mean BMI was 27.1 ± 3.5 kg/m2, while the mean patient age was 47.8 ± 11.4 years. The superficial circumflex iliac artery (SCIA) originated from the common femoral artery in 92% cases, with remainder originating from the profunda femoris. The mean vessel diameter was 1.85 mm at source vessel origin. Distance from skin to source vessel averaged 30.7 mm. Suprascarpal subcutaneous thickness averaged 16.5 mm. The mean distance from Scarpa's fascia to vessel origin was 14.1 mm. Direct three-dimensional distance from vessel origin to pubic tubercle was 50.2 mm. A medial and lateral perforator split off of the SCIA was observed in 38 cases (45%). Significant differences were shown when comparing BMI to skin to source vessel distance (p < 0.001), suprascarpal subcutaneous fat thickness (p < 0.001), and fascial distance to vessel origin (p < 0.001). BMI did not significantly affect vessel diameter. Despite a significantly higher BMI than many previously published cohorts, the SCIP remains an excellent source of thin and pliable tissue. When dissected closer to the source vessel, a vessel caliber of nearly 2 mm can be achieved, which may obviate the need for "supermicrosurgery" in this population.

The anatomical reliability of the superficial circumflex iliac artery perforator (SCIP) flap

IntroductionIn order to achieve a satisfactory functional and aesthetic result a thin skin flap is often required in surgical reconstruction of various body regions. Perforator flaps based on either the superficial or deep branch of the superficial circumflex iliac artery (SCIA) have been used for this purpose mainly in the Asian population. Recently the superficial plane has been established as a new way of elevating the flap. Anatomical studies and details of this new flap are lacking. Material and methodsWide areas were harvested subfascially from the groin of Thiel-fixated cadavers. Both deep and superficial branches of the superficial circumflex iliac artery were carefully dissected and individually injected with μAngiofil. After CT-imaging the flaps were raised on the superficial plane, perforators were marked and the flaps subsequently rescanned. High-resolution images of regions of interest were taken using micro-CT. ResultsA total of 21 flaps were harvested and analyzed. Both the deep and superficial branch provided more than three perforators per branch, however, the deep branch based flap was significantly larger (202 vs. 112 cm2, p < 0.01) and had a longer pedicle (9.1 vs. 6.6 cm, p < 0.01). Raising the flap in the superficial plane reliably reduces bulk and increases homogeneity. ConclusionsThe SCIP flap appears to have a reliable vascular blood supply. The SCIA and its main branches and perforators have a consistent vascular pattern. The deep branch of the SCIA has the anatomic potential to be the preferred pedicle in case larger flaps with longer pedicles are necessary.

Review of the superficial circumflex iliac artery perforator flap: recommendations to the approach of a groin perforator flap

Introduction: The superficial circumflex iliac artery perforator (SCIP) flap has gained in popularity due to its thinness and superior donor site scar. However, there exist inconsistencies in the description of the surgical anatomy of the SCIP flap. The aim of this quantitative review was to provide a summary of published evidence to the surgical approach to such flaps. Methodology: A literature review of the MEDLINE® and Cochrane databases was conducted. Articles were assessed by two reviewers using predefined data fields and selected using specific inclusion criteria. The two authors independently reviewed the literature and discrepancies were resolved by consensus. Results: Included for evaluation were 39 articles. Of these, 30 fulfilled the criteria for surgical dissection, 16 for surgical anatomy and nine for preoperative imaging. The arterial anatomy of the groin perforator flap is variable and in 0.9 per cent of cases the pedicle originates from the superficial inferior epigastric artery rather than the superficial circumflex iliac artery (SCIA). The flap pedicle length is probably dependent on patient build and the course of the source vessel, rather than which groin perforator it is based on. CT is the gold standard preoperative imaging and should be used given the anatomical unpredictability. Lymphatics under the inguinal ligament and medial to the femoral artery should be preserved. Conclusion: This quantitative study provides a guide to safe groin perforator flap harvest and surgical pearls to consider for surgical planning. The usage of this flap remains novel and further long-term outcomes have yet to be established.

Combined pedicled superficial circumflex iliac artery perforator (SCIP) flap with lymphatic tissue preservation and lymphovenous anastomosis (LVA) for defect reconstruction and lymphedema–lymphocele prevention in thigh sarcoma surgery: Preliminary results

Sarcoma surgery often requires large tissue resection to be treated safely. When the tumor is localized in the groin and/or medial thigh, lymphocele and lymphedema are common complications because of the rich lymphatic network present there. The aim of this study is to share the outcome of seven patients who received defect reconstruction in this area with combined pedicled superficial circumflex artery perforator (SCIP) flap with lymphatic tissue preservation and lymphovenous anastomosis (LVA) for prevention of lymphatic complications. Seven patients who underwent surgical resection of sarcoma in the groin and/or adductors compartment received defect reconstruction with pedicled SCIP flap combined with LVA. For a better dead space obliteration, four of them also received an additional tissue flap: two pedicled deep inferior epigastric perforator flaps and two free anterolateral thigh flaps. Indocyanine green lymphography was performed in all cases to identify the lymphatic pathway, make the preoperative marking and check the patency of the anastomoses. All seven patients were successfully treated reaching a good aesthetic result and a full range of motion. No immediate nor delayed complications such as lymphocele or lymphorrhea and early extremity lymphedema were observed during the follow up (range: 6-9 months; mean: 7.3) and no secondary procedures were required. The combination of the pedicle SCIP lymphatic tissue transfer with LVA seems to be effective in preventing the development of lymphatic sequelae after large resections in the medial thigh.

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.

Nerve vascularity in free vascularized nerve flaps.

The blood supply of peripheral nerves consists of a complex internal vessels' network, feeding external vessels and the interlinking vasa nervorum. Patients with nerve damage may require nerve substitution. While the commonly performed avascular nerve grafts obtain vascularization only from random and slow inosculation into the vasa nervorum, their insufficient revascularization causes loss of the graft's potential due to central necrosis. This gets more relevant with the larger diameter of nerves injured. Examples for neurovascular flaps are the lateral femoral cutaneous nerve vascularized via the superficial circumflex iliac artery perforator (LFCN-SCIP) flap or the iliohypogastric nerve graft vascularized via the superficial inferior epigastric artery (SIEA). LFCN-SCIP shows a well concealed donor scar site with a maintained vascularization and a minor donor site morbidity. Therefore, the guaranteed axial nerve vascularity in LFCN-SCIP makes it a preferred autologous vascularized nerve therapy for peripheral nerve defects. A further option example is the anterior lateral thigh (ALT) flap with the LFCN.