The Superficial Circumflex Iliac Artery Perforator Flap for Head and Neck Reconstruction

Head and neck defects present a unique challenge in reconstructive surgery due to the complex anatomy of this area. Different defects often require a variety of reconstructive techniques. The superficial circumflex iliac artery perforator (SCIP) flap is particularly notable for its versatility in this context. It provides a thin, pliable skin island that can be integrated with bone, muscle, fascia, and other structures. Additionally, the morbidity associated with the donor site of the SCIP flap is generally low and well tolerated. This article offers a comprehensive overview of the evolution of this technique.

Immediate foot reconstruction and revascularization of toes using an interposition superficial circumflex iliac artery perforator flow-through flap: A case report

Foot injuries, particularly degloving injuries, can lead to segmental loss of neurovascular structures in the toes, making simultaneous reconstruction of both the foot and toes challenging. This case report presents a technique using the superficial circumflex iliac artery perforator (SCIP) flap for immediate reconstruction of the dorsal foot and revascularization of multiple toes. A 28-year-old man suffered a degloving injury on the dorsum of his foot resulting in a 9 × 6cm skin defect, open fracture dislocations, exposure of tendons, and neurovascular injury, which included a 6-7.5 cm segmental defect of the vessels supplying the first, second, and third toes leaving all three toes ischemic. Immediate reconstruction was performed by harvesting a 12.5 × 5cm SCIP flap including both the superficial and deep branches and incorporating the superficial inferior epigastric vein (SIEV). The SCIP deep branch was used to revascularize the third and second toes and the SIEV vein graft used for the first toe. The patient recovered well, no complications were observed at the 2-year follow-up, preserving all three toes and regaining mobility. The use of the SCIP flap as a flow-through flap provides thin skin flap cover, good vessel caliber size match with digital vessels and reduces the need for vein grafts from distant sites improving surgical efficiency. These attributes make the flow-through interposition SCIP flap an excellent choice for reconstructing foot defects and revascularizing toes. We report this case to demonstrate the utility of the SCIP flap in immediate soft tissue cover and digit revascularization.

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.

Head and neck reconstruction with the superficial circumflex iliac artery perforator (SCIP) free flap: Lessons learned after 73 cases

BACKGROUND

Head and neck tissue defects after ablative surgery often require complex and composite reconstructions. The superficial circumflex iliac artery perforator (SCIP) flap is an extremely versatile perforator-based flap with minimal donor site morbidity, which may represent the optimal procedure in this setting. Over the last 5 years, we collected a large base of experience, including both simple and chimeric SCIP-based reconstruction, making this flap our first choice for head and neck reconstructions.

PATIENTS AND METHODS

Seventy-three patients undergoing ablative head and neck surgery for oncologic pathologies were treated by means of a SCIP flap reconstruction. Patients' mean age was 67 years old (range 37-89), 51 were males and 22 were females. Fifty-eight flaps were simple and 15 were chimeric reconstruction patterns. Indocyanine green perfusion imaging was performed in all cases.

RESULTS

All the patients were successfully treated with no flap losses were encountered. Twelve patients encountered postoperative complications: in four cases revision surgery was required for venous congestion, while the remaining cases were managed conservatively (four wound dehiscence and three infections). No patients showed donor site complications. The mean follow-up period was 11 months (range 3-24).

CONCLUSIONS

Our case series demonstrates the reliability and versatility of the SCIP flap for different kinds of head and neck reconstructions. The chimeric options combined with bone, double skin paddle, and muscle offer a broad variety of functional reconstructive solutions for complex head and neck surgeries. Intraoperative indocyanine green perfusion examination provides a valuable tool to assess and ascertain proper vascularization and post-anastomosis vessel patency in complex microvascular flap-based reconstructions.

Complex reconstruction of the clavicle with a prefabricated medial femur condyle chimeric flap including a superficial circumflex iliac artery perforator flap: A case report

The medial femur condyle (MFC) cortico-periosteal flap is a popular flap for bone reconstruction. The use of a chimeric version of this flap with a skin island has been described, but anatomical arterial variation can occur that prevent its harvest. Furthermore, the donor area of the skin paddle has been debated as poor because of the scarring in a visible area and because of the difficulty in obtaining pliable thin skin. We present a fabricated chimeric MFC cortico-periosteal flap joined with a superficial inferior epigastric perforator (SCIP) flap to reconstruct and augment a sclerotic and insufficient small clavicula with the skin paddle acting as a monitor and as a substitute for the overlying skin. A 52-year-old female patient had a history of multiple refractures of the right hypoplastic clavicle with a diameter of 7 mm, resulting in a sclerotic bone with a fibrotic scar. The reconstruction was done in one surgical session using a cortico-periosteal flap from the left medial condyle and a thin SCIP flap from the left groin. The area of the clavicle to be reconstructed was 3 cm, and the direct overlying skin (approximately 6 × 3 cm) was severely scarred and painful. The MFC flap was 5 × 4 cm, while the SCIP flap was 7 × 3.5 cm. The SCIP flap artery was anastomosed on the table end-to-side to the descending genicular (DG) artery of the MFC, and the vein was anastomosed end-to-end to a comitans vein of the DG artery. The flap fully survived after an initial congestion. At 12 months, we observed a satisfactory reconstruction of the clavicle with an enhanced diameter of 12 mm. The patient recovered full function of the shoulder with no pain. Using a fabricated chimeric flap composed of a medial femoral condyle and a superficial circumflex artery perforator flap may be an additional option for tailored reconstruction of complex osteo-cutaneous defect of clavicle.

Variations in deep iliac circumflex artery perforator chimeric flap design for single-stage customized-reconstruction of composite bone and soft-tissue defect

BACKGROUND

The deep iliac circumflex artery (DICA) perforator (DICAP) chimeric flap is a valuable treatment strategy for single-stage reconstruction of composite bone and soft-tissue defects in upper and lower extremities. However, its utilization rate remains low owing to anatomical variations that lead to challenges when identifying and dissecting perforators.

METHODS

A comprehensive anatomical investigation was conducted on the DICA system by injecting lead oxide into 12 fresh cadavers following a standardized procedure. From January 2008 to December 2020, 30 patients with composite bone and soft-tissue defects received reconstruction surgery with DICAP chimeric flap. One of the four specified surgical techniques was used to create a modified DICAP chimeric flap for the patients based on the size, shape, and location of the defect.

RESULTS

Two branching patterns of DICA, transverse and ascending branches, were observed, and the former gave off the osteomusculocutaneous perforators and terminal musculocutaneous perforators. Thirty DICAP chimeric flaps were elevated successfully. The size of the skin paddles measured from 9 × 4.5 cm to 22 × 9 cm, and the bone components ranged from 3 × 2.5 × 1.5 cm to 6 × 3.5 × 2 cm. All flaps survived successfully after the operation, and all patients achieved primary closure of the donor sites. No patient encountered the fracture of transferred iliac segments. The mean bone union time was 5.5 months (ranging from 4 to 8 months).

CONCLUSION

The DICA system is a suitable source for harvesting the DICAP chimeric flap to reconstruct composite bone and soft-tissue defects. It provides a flexible design for individualized coverage of such defects with limited donor-site morbidity.

Extremity reconstruction with superficial circumflex iliac artery perforator free flap: Refinements and innovations after 101 cases

INTRODUCTION

The superficial circumflex iliac artery perforator flap is based on perforators originated on the superficial circumflex iliac artery. This flap is thin and pliable, of moderate size, and has a concealed donor site. The authors report their experience, innovations, and refinements in both planning and execution, and the outcomes obtained after 101 extremity reconstruction consecutive cases.

PATIENTS AND METHODS

A total of 101 superficial circumflex iliac artery perforator flaps were prospectively reviewed and followed up for at least one year at Hospital del Trabajador. The flaps were used for both upper (n = 21) and lower limbs (n = 80), planned with computed tomography angiography/augmented reality, and raised above the superficial fascia using a standardized approach. Demographic data, anatomy of the flap, surgical technique, and the results were assessed.

RESULTS

Average flap size was 90.5 cm2, ranging from 25 to 212 cm2. Total flap loss occurred in 6 flaps (5.9%). Four patients developed complications at the donor site. Debulking surgery was performed in 7 patients (6.9%). The average follow-up period was 850 days (range, 370-1405 days).

CONCLUSIONS

The superficial circumflex iliac artery perforator flap is versatile, thin, and pliable, suitable for covering even large defects in either the upper or lower extremities, obtaining a shallow contour and optimal esthetics results. The elevation can be standardized, but requires training and proper planning. This is the largest series in a Western country reporting the experience, refinements, and innovation that allows for better results in limb reconstruction.

Coverage of exposed ankle and foot with the conjoined lower abdomen and groin flaps

BACKGROUND

Extensive soft-tissue defects around the ankle and foot pose a difficult challenge to surgeons. Considering that natural contour, the ideal solution should match a thin and pliable skin flap to allow shoe fitting and provide a functional move. As the conjoined flaps were increasingly utilized in covering various defects, we present our experience using the bipedicle conjoined flap on the lower abdomen and groin site.

METHODS

From May 2018 to September 2020, 36 patients (27 male and 9 female) with a mean age of 32 years (ranged, 21-54 years) underwent the one-stage coverage of ankle and foot defects with the bipedicle conjoined flap. A suitable "Y" bifurcation was dissected to enlarge vessel size or participated in intra-flap anastomosis. The mean dimension of the defect was 30 × 12 cm² (ranged, 20 × 8 cm² to 38 × 16 cm²). Primary donor-site closure was accomplished in all patients.

RESULTS

Thirty-six flaps survived completely without significant complications, and mild venous congestion was observed in one flap. The average flap size was 35 × 15 cm² (ranged, 22 × 10 cm² to 42 × 18 cm²). All flaps were available for a mean follow-up of 18 months (ranged, 12 to 24 months). Natural shape and walking function were successfully achieved with restored protective sensation.

CONCLUSIONS

Bipedicle conjoined flap harvested from the lower abdomen and groin is a great alternative, in selected patients seeking one-stage coverage for the exposed ankle and foot. Compared to single-pedicle flaps, the increased skin allows the wider coverage for the large defect with less morbidity and better outcomes.

Superficial Circumflex Iliac Artery Perforator Flap in Advanced Head and Neck Reconstruction: From Simple to Its Chimeric Patterns and Clinical Experience with 22 Cases

BACKGROUND

Head and neck tissue defects after ablative head and neck surgery often require complex and composite reconstructions. The superficial circumflex iliac artery perforator (SCIP) flap is an extremely versatile perforator-based flap with minimal donor-site morbidity. The authors present their experience with both simple and chimeric SCIP flap reconstructions for complex defects in various head and neck regions.

METHODS

Twenty-two patients undergoing ablative head and neck surgery for oncologic abnormalities were treated by means of a SCIP flap reconstruction. Patients' mean age was 62 years; 21 were men and one was a woman. Seventeen flaps were simple and five were chimeric reconstruction patterns. Indocyanine green perfusion imaging was performed in all cases.

RESULTS

Twenty-one of 22 patients (95.5 percent) were successfully treated with good aesthetic and functional results. Two patients (9 percent) showed minor donor-site complications that were managed conservatively. The mean follow-up period was 5.3 months (range, 2 to 8 months).

CONCLUSIONS

This case series demonstrates the reliability and versatility of the SCIP flap for head and neck reconstruction. The chimeric options combined with bone, double-skin paddle, and muscle offer a broad variety of functional reconstructive solutions for complex head and neck surgery. Intraoperative indocyanine green perfusion examinations area valuable tool to assess and ascertain proper inset, vitality, and postanastomosis vessel patency in these complex microvascular flap reconstructions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Superficial Circumflex Iliac Artery Perforator Flap Elevation Using Preoperative High-Resolution Ultrasonography for Vessel Mapping and Flap Design

BACKGROUND

 The superficial circumflex iliac artery (SCIA) perforator (SCIP) flap has gained acceptance among reconstructive microsurgeons, the minimal donor site morbidity being its greatest advantage. The purpose of this article is to introduce the use of preoperative ultrasonography to facilitate elevation and to avoid postoperative complications of the SCIP flap.

METHODS

 Preoperative mapping of the SCIA and the superficial circumflex iliac vein (SCIV) using a high-resolution ultrasound system were performed in patients undergoing reconstruction using a free SCIP flap. The skin paddle was designed placing the SCIA and the SCIV in the middle of the flap.

RESULTS

 Preoperatively marked SCIA and SCIV were found intraoperatively in all cases. The skin paddle design for sufficient arterial inflow and venous drainage resulted in no postoperative flap complications.

CONCLUSION

 The use of a preoperative high-resolution ultrasound system significantly facilitates elevation of the SCIP flap, notably via the following 2 points: 1) pedicle can always be found under the markings made with preoperative ultrasonography, 2) satisfactory perfusion of the flap can be guaranteed via a safe flap design that includes preoperatively marked vessels within the skin paddle.

[A systematic approach to plastic surgical foot reconstruction]

BACKGROUND

Soft tissue defects of the foot are very common sequelae after trauma and require an individual reconstructive approach.

OBJECTIVE

Recommendations for the treatment of soft tissue injuries to the foot are given.

MATERIAL AND METHODS

The criteria of soft tissue reconstruction, postoperative follow-up and complications are first discussed before the therapeutic approach is explained depending on the reconstruction site. Case examples are given for illustration.

RESULTS

Decision making for soft tissue reconstruction of the foot is based on the location, the 3‑dimensional extent of the defect, the patient requirements and concomitant diseases. Standardized treatment algorithms are usually applied that need to be adapted according to individual patient factors. Randomized and local pedicled flaps can be applied for foot reconstruction; however, these options involve a significant risk of complications. Consequently, free flaps are frequently indicated after appropriate preoperative diagnostics of the perfusion of the foot. Due to the vast variety of donor sites, free flaps allow an individualized reconstruction, which is adapted to local and patient requirements.

CONCLUSION

Precise preoperative reconstructive planning and analysis of the vascularization form the foundation for a successful soft tissue reconstruction of the foot. The aims of the individualized approach to soft tissue reconstruction of the foot are stable soft tissue coverage, resistance to weight bearing of the sole of the foot, the ability to wear normal shoes and maintenance of sensibility.

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

BACKGROUND

 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.

PATIENTS AND METHODS

 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).

RESULTS

 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).

CONCLUSION

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

BACKGROUND

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 AND METHODS

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.

RESULTS

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.

CONCLUSION

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.

Combined Tissue Transfer for Extensive Lower Limb Complex Defects: Flow-through Flaps, Chimera, and "Orochi" Flaps

Perforator flaps can be raised anywhere in the body, with minimal donor-site deformity, and can be made into custom-made combined composite flaps, especially for severe complex defects such as osteomyelitis of the lower limbs. Here, we report on the representative application of the combined tissue transfers for complex leg defects. For a wide range of complex defects in the lower extremity, it is necessary to perform reliable revascularization by bypass or flow-through type or vein graft. At the same time, a chimeric or "Orochi" type combined transfer using a minimally invasive perforator flaps and a well-vascularized bone flap are useful. In the case of nerve palsy, it could be possible to combine vascularized nerve flaps. Combined tissue transfers with less invasive donor will be more available in the future.

Use of the transverse branch of the superficial circumflex iliac artery as a landmark facilitating identification and dissection of the deep branch of the superficial circumflex iliac artery for free flap pedicle: Anatomical study and clinical applications

BACKGROUND

The deep branch of the superficial circumflex iliac artery (SCIA) should be included when a large superficial circumflex iliac artery perforator (SCIP) flap is necessary, or when anatomical structures perfused by the deep branch are procured. The aim of this study was first to describe the anatomical features of the "transverse branch" of the deep branch of the SCIA in cadavers, and then to assess the efficacy of its use as a landmark for identification and dissection of the deep branch of the SCIA through clinical applications.

METHODS

Twenty groin regions from 10 cadavers were dissected. The course and the takeoff point of the transverse branch were documented. With the transverse branch used as a landmark for pedicle dissection, 27 patients (16 males and 11 females) with an average age of 51.7 years underwent reconstructions that used vascularized structures nourished by the deep branch of the SCIA. Aside from the skin paddle, an iliac bone flap was used in 10 cases, a lateral femoral cutaneous nerve flap in four cases, and a sartorius muscle flap in three cases. The defect locations included the head (seven cases), the foot (six cases), the hand (six cases), the arm (five cases), and the leg (three cases). The causes of reconstruction were tumors in 13 patients, trauma in six patients, infection in four patients, surgical procedures in three patients, and refractory ulcer in one patient.

RESULTS

In all specimens, the transverse branch was found underneath the deep fascia caudal to the anterior superior iliac spine (ASIS). The average distance from the ASIS to the transverse branch was 25.5 ± 13.0 mm (range, 5-50 mm). The average dimension of the flap was 13.1 × 5.9 cm² . All the flaps survived completely after the surgery; lymphorrhea was seen in one patient at the donor site. The average follow-up period was 12.9 months (range, from 2 to 42 months), and all patients had good functional recovery with satisfactory esthetic results.

CONCLUSIONS

The transverse branch was found in all specimens, branching from the deep branch of the SCIA. Successful results were achieved by using it as the landmark for identification and dissection of the deep branch of the SCIA. This method allows safe elevation of a large SCIP flap or a chimeric SCIP flap.

A Simple Skin Incision Design for Pediatric Superficial Branch of Superficial Circumflex Iliac Artery

Supplemental Digital Content is available in the text.

Background:

Superficial circumflex iliac artery (SCIA) perforator flap is one of the demanding flaps. However, little is known about SCIA anatomy, which is crucial for successful SCIA perforator flap elevation, in children. We assessed the efficacy of our incision design to detect the superficial branch of the SCIA in vivo.

Methods:

Eleven consecutive pediatric patients who required harvesting (eg, skin grafts or vascularized lymph node transfer) were assessed. All possible congenital vascular malformation cases were excluded. To reduce potential bias, all groin procedures were performed on the contralateral side of malformations. After inguinal area mapping, 1.5-cm skin incision was made. From the window opened by the skin incision, tiny perforation to the skin surface was detected for further dissection. Following the tiny branch, the main trunk of the superficial circumflex vascular bundle was dissected. The whole vascular bundle, artery, and major vein from the bundle were dissected and their sizes were measured.

Results:

Of the 11 patients, 4 were boys; the age range was 5 months to 14 years (mean age: 3.2 years). Vessel bundle size was 0.7–1.5 (mean: 1.1 mm). In all cases, the bundle was detected within 5 min (1–5, mean: 2.5 min). No vascular damage was observed, and all arteries pulsated well, without requiring additional skin incision. The superficial branch of the SCIA was mainly detected right below the initial skin incision.

Conclusions:

Our skin incision design can effectively detect the SCIA in pediatric patients and may be used in adult patients.