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

Lower Abdominal vs. Lateral Thigh Perforator Flaps in Microsurgical Sarcoma Reconstruction: The Aesthetics of Donor Site Matters

Introduction: Sarcoma resection often leaves patients with big defects only amenable through microsurgical reconstruction. In such cases, it is hard for the surgeon to uphold low donor-site morbidity with an aesthetic result. The purpose of this study was to investigate the clinical outcome and the patient's perception regarding the donor site in a cohort of patients undergoing microsurgical reconstruction with lateral thigh and lower abdominal perforator flaps. Methods: A retrospective evaluation of all patients who underwent sarcoma reconstruction with flaps harvested from the lower abdominal region (deep inferior epigastric artery perforator flap, superficial circumflex iliac artery perforator flap) or lateral thigh region (anterolateral thigh perforator flap and its variations) was performed. Only patients with defects greater than 100 cm2 were included. Patient demographics and operative variables were recorded, together with complications. Patient satisfaction and quality of life with the donor site were registered using the SCAR-Q questionnaire, which was administered at least six months post-operatively. Results: Eighteen anterolateral thigh (ALT) perforator flaps and twenty-two deep inferior epigastric artery perforator (DIEP) and superficial circumflex iliac artery perforator (SCIP) flap procedures were performed. The two groups were homogeneous for major post-operative complications (p > 0.999). Patient satisfaction with the donor site measured using the SCAR-Q questionnaire showed significantly higher scores in the DIEP/SCIP group when compared with the thigh group (p < 0.001), indicating a superiority of the lower abdominal area as an aesthetic donor site. Conclusions: The DIEP and SCIP flaps are a versatile option for reconstructing large soft-tissue defects following sarcoma resection. Therefore, flaps harvested from the lower abdomen yield a higher patient satisfaction with the donor site, which is a feature worth considering when planning a reconstructive procedure.

The Piggyback Superficial Circumflex Iliac Perforator Flap for Complex Free Flap Reconstructions

This article introduces a reproducible strategy for complex reconstruction scenarios that require the use of two flaps. It specifically focuses on the utilization of the superficial circumflex iliac artery perforator (SCIP) flap as a secondary flap, particularly in complex cases where available arterial options are limited. In the first scenario, the SCIP flap is elevated simultaneously during elevation of a fibula bone flap. The pedicle of the fibula flap will be anastomosed to the recipient vessels, and the pedicle artery of the SCIP flap, the superficial circumflex iliac artery, will be anastomosed to the distal end of the peroneal artery. The SCIP flap pedicle offers greater length compared with a cutaneous flap sourced from the peroneal artery, thus providing increased flexibility for the flap inset. In the second scenario, the SCIP flap is combined with the anterolateral thigh (ALT) flap to manage a significant defect. The pedicle of the ALT flap is anastomosed to the recipient vessels, and the superficial circumflex iliac artery is anastomosed to the distal end of the pedicle artery of the ALT flap, the descending branch of the lateral circumflex femoral artery. The SCIP flap can be harvested simultaneously with a fibula flap or an ALT flap from the same side, and its arterial anastomosis can always be established with the distal ends of the arterial pedicle of these two flaps. This efficient and reproducible method can also contribute to minimal donor site morbidity and will be particularly valuable in settings where recipient artery choices are limited.

Multiple Flap Transfer for Multiple Local Recurrence of Soft Tissue Sarcoma

Background and Objectives: Surgical management of local recurrence of soft tissue sarcomas (STS) is still challenging. In this article, we report on multiple flap reconstructions for multiple local recurrences of STS. Their feasibility will be validated by examining clinical cases. Materials and Methods: Patients who underwent multiple flap reconstructions for multiple local recurrences of STS between April 1997 and October 2021 were included in this retrospective study. Patient demographics, tumor characteristics, surgical characteristics, and postoperative complications were examined. Results: Twenty operations of eight patients were identified. The location of the defects was the back in two, the buttock in two, the groin in two, and the lower extremities in two. The average total number of wide resections was 4.0 and the average total number of flap reconstructions was 2.5. The average follow-up period was 109.4 months. The average size of the defect was 102.4 cm2 and the average flap size was 15.7 × 10.8 cm. The histological diagnoses were malignant fibrous histocytoma (MFH) in eight operations, osteosarcoma in two operations, myxoid liposarcoma in two operations, undifferentiated pleomorphic sarcoma (UPS) in six operations, and myxofibrosarcoma (MFS) in one operation. Of twelve subsequent operations, the resection of the previously transferred flap was performed in six operations (50%). The occurrence of take back, flap complications, and donor-site complications in the primary operation group was 25%, 25%, and 12.5%, respectively. The occurrence of take back, flap complications, and donor-site complications in the second and subsequent operation group was 0%, 0%, and 16.7%, respectively. Conclusions: Multiple operations including wide resections followed by flap reconstructions for multiple local recurrences are feasible. Reconstructive surgeons should choose the options of the flaps considering the future local recurrence for tumors with a high risk of recurrence.

The Pedicled Anterolateral Thigh Flap for Donor Site Closure after a Large Superficial Circumflex Iliac Artery Perforator Flap Harvest

The superficial circumflex iliac artery perforator (SCIP) flap is useful for covering defects in the extremities because its pedicle size can match many recipient options. However, when harvesting a large flap, skin grafting of the donor site is not highly recommended because of the mobility of the hip joint and occasional lymphorrhea. Here, we present a case of a successful reconstruction of a defect in the lower leg after sarcoma resection, using a large SCIP flap. A 58-year-old man underwent resection of a large soft tissue tumor in the lower leg, resulting in a 16 × 14 cm defect. A 25 × 14 cm SCIP flap was harvested from the groin, and the superficial circumflex iliac artery and the superficial circumflex iliac vein were anastomosed to the saphenous artery and the great saphenous vein, respectively, in an end-to-end fashion. For coverage of the groin donor site, a 25 × 8 cm pedicled anterolateral thigh (ALT) flap was harvested from the ipsilateral lateral thigh and was pulled through a subcutaneous tunnel to the groin. The additional operative time for pedicled ALT flap elevation and transfer was approximately 15 minutes. With this pedicled ALT flap, the donor site of the SCIP flap could be closed directly over a drain. The follow-up at 3 months showed complete survival of both flaps, and the patient was able to walk with a cane. The pedicled ALT flap allows for direct closure of the donor site after a large SCIP flap harvest.

The Use of the Deep Brachial Artery as the Recipient Artery for Free Perforator Flap Transfer: An Anatomic Study and Clinical Applications

Background and Objectives: Soft tissue reconstruction after sarcoma ablation in the posterior aspect of the upper arm has been commonly addressed using the pedicled latissimus dorsi musculo-cutaneous flap. The use of a free flap for coverage of this region has not been reported in detail. The goal of this study was to characterize the anatomical configuration of the deep brachial artery in the posterior upper arm and assess its clinical utility as a recipient artery for free-flap transfers. Materials and Methods: In total, 18 upper arms from 9 cadavers were used for anatomical study to identify the deep brachial artery's origin and point of crossing the x-axis, which was set from the acromion to the medial epicondyle of the humerus. Measurements of the diameter were taken at each point. The anatomic findings of the deep brachial artery were employed clinically in the reconstruction of the posterior upper arm after sarcoma resection using free flaps in 6 patients. Results: The deep brachial artery was found in all specimens between the long head and the lateral head of the triceps brachii muscle, and it crossed the x-axis at an average distance of 13.2 ± 2.9 cm from the acromion, with an average diameter of 1.9 ± 0.49 mm. In all 6 clinical cases, the superficial circumflex iliac perforator flap was transferred to cover the defect. The average size of the recipient artery, the deep brachial artery, was 1.8 mm (range, from 1.2 to 2.0 mm). The average diameter of the pedicle artery, the superficial circumflex iliac artery, was 1.5 mm (range, from 1.2 to 1.8 mm). All flaps survived completely with no postoperative complications. Conclusions: The deep brachial artery can be a reliable recipient artery in free-flap transfers for posterior upper arm reconstruction, given its anatomical consistency and sufficient diameter.

Comparison of outcomes following pedicled and free flap transfers for the defect after shoulder sarcoma resection

BACKGROUND

Reconstruction after wide resection of a sarcoma arising in the shoulder girdle is challenging, and little evidence is available to compare short-term outcomes between pedicled-flap and free-flap reconstruction.

PATIENTS AND METHODS

Thirty-eight patients undergoing immediate reconstruction surgery with only a pedicled-flap (n = 18) and with a free-flap (n = 20) after sarcoma resection on the shoulder girdle between July 2005 and March 2022 were identified. One-to-one propensity score matching was performed to compare the postoperative complications.

RESULTS

Transferred flaps survived completely in 20 cases in the free-flap group. In the all-patient analysis of binary outcomes, the occurrences of total complications, takebacks, total flap complications, and flap dehiscence were higher in the pedicled-flap group than in the free-flap group. The propensity score-matched analysis showed the occurrence of total complications was significantly higher in the pedicled-flap group than the free-flap group (53.8% vs. 7.7%, p = 0.03). In the propensity score-matched analysis of continuous outcomes, the pedicled-flap group demonstrated a shorter operation time than the free-flap group (279 vs. 381 min, p = 0.05).

CONCLUSIONS

This clinical study demonstrated the feasibility and reliability of a free-flap transfer for the defect after wide resection of a sarcoma arising in the shoulder girdle.

Immediate tendon transfer for functional reconstruction of a dorsal forearm defect after sarcoma resection

In the treatment of sarcoma, the reconstructive surgeon must consider not only limb salvage but also functional reconstruction. The aim of this study was to evaluate a functional reconstruction of a dorsal forearm defect after sarcoma resection using immediate tendon transfer. Patients who underwent reconstruction of a dorsal forearm defect after sarcoma resection with an immediate tendon transfer between 1997 and 2019 at our hospital were included in this retrospective study. Patient demographics, tumor characteristics, surgical characteristics and functional outcomes were examined. Nine patients were included in this study. Tendon transfer of the flexor carpi radialis (FCR) or the flexor carpi ulnaris (FCU) to the extensor digitorum communis (EDC), the brachioradialis (BR) to the EDC, and the palmaris longus (PL) tendon to the extensor pollicis longus (EPL) was performed in seven, two and five patients, respectively. Seven patients underwent reconstruction using a free flap. Neither anastomosis complications nor infections were encountered. Partial flap necrosis and donor site dehiscence were seen in one case each. The mean distal interphalangeal (DIP), proximal interphalangeal (PIP) and metacarpophalangeal (MP) joint active extension were 4.4°, 6.1° and 11.1° postoperatively. The mean Musculoskeletal Tumor Society (MSTS) score was 26. Immediate tendon transfers of the FCR or the FCU to the EDC and the PL tendon to the EPL can be considered an optimal functional reconstruction of a dorsal forearm defect after sarcoma resection.

Clinical application of free inguinal flaps with retrograde blood supply anastomotic to repair soft tissue defects of extremities

To observe the clinical efficacy of free inguinal flaps with retrograde blood supply anastomosis to repair skin and soft tissue defects in the limbs. A total of 25 patients with soft tissue defects of the limbs treated from January 2019 to December 2021 were selected and repaired with free inguinal flaps anastomotic with retrograde blood supply. All 25 skin flaps survived; 1 patient had skin flap infection and the wound healed gradually after symptomatic treatment, and 1 patient had venous embolism and the skin flap survived after re-anastomosis. The patients were followed up for 6 to 18 months after the operation. After healing, the patient recovered satisfactorily, and the flap had a good appearance, texture, and flexibility; a reoperation was not required. The patient was satisfied with the effect of the treatment. Retrograde vascular anastomosis with the anterolateral femoral perforator flap is safe and reliable for repairing the soft tissue defects of the limbs. It is convenient for micromanipulation and can achieve satisfactory clinical results, and thus is an ideal repair method.

An Anatomical Study of Posterior Trunk Recipient Vessels, and Comparisons of Outcome following Pedicled- and Free-Flap Transfers for Treatment of Sarcoma in the Posterior Trunk

BACKGROUND

 Reconstruction after wide resection of a large sarcoma arising in the posterior trunk may require free-flap transfer to reduce the postoperative complications. Here, we describe the recipient vessels on the whole posterior trunk. Moreover, to show the reliability of these vessels, we describe an institutional series of free-flap reconstruction.

METHODS

 In the cadaveric study, 20 posterior trunk regions from 10 fixed cadavers were dissected. The location and the diameter of the perforating artery and vein on the posterior were documented. In the clinical study, 54 patients undergoing immediate reconstruction surgery with only a pedicled flap (n = 45) and with a free flap (n = 9) after sarcoma resection on the posterior trunk between July 2005 and September 2021 were identified. One-to-one propensity score matching was performed to compare the postoperative complications.

RESULTS

 In the cadaveric study, a total of 178 perforators were identified. The average diameter of the superficial cervical artery (SCA) and vein, dorsal scapular artery (DSA) and vein, medial branch of dorsal intercostal artery perforator (m-DICAP) and vein, lateral branch of dorsal intercostal artery perforator (l-DICAP) and vein, and dorsolateral intercostal artery perforator (DLICAP) and vein were 1.03, 1.67, 1.38, 1.84, 1.28, 1.84, 1.01, 1.60, 1.11, and 1.70 mm. In the clinical study, the propensity score-matched analysis involving eight pairs showed a significantly higher occurrence of total complications in the pedicled-flap group than the free-flap group (62.5 vs. 0%, p = 0.03).

CONCLUSION

 The cadaveric study showed that the perforators from the SCA, DSA, and posterior intercostal artery are constantly present. The clinical study demonstrated the feasibility and reliability of a free-flap transfer.