Use of intraoperative indocyanine green angiography for detection and prediction of congestion in pedicled island flaps

Subdermal dissection technique for pure skin SCIA and ALT perforator flaps in burns and trauma defects: Clinical experience

BACKGROUND

The pure skin perforator (PSP) flap is gaining popularity for its remarkable thinness. The subdermal dissection technique was recently introduced, allowing for a quicker elevation of a PSP flap. In this report, we present our two-year experience utilizing subdermal dissection for harvesting PSP flaps.

METHODS

All patients who had undergone PSP flap reconstruction at our hospital from February 2021 to February 2023 were included. Demographic data, intraoperative variables, flap characteristics, and postoperative outcomes were collected. Surgical planning involved locating the perforator using ultrasound and harvesting the flap using the subdermal dissection technique.

RESULTS

A total of 26 PSP flap reconstructions were conducted on 24 patients aged between 15 and 86 years. The flaps were based on perforators issuing from the superficial circumflex iliac artery in 24 cases, and from the descending branch of the lateral circumflex femoral artery in 2 cases. Flap sizes ranged from 3 × 1.5 cm to 19 × 6 cm, with a mean thickness of 3.48 mm. The average time for flap harvest was 131.92 min. Postoperatively, we observed four cases of partial necrosis, 1 total flap loss, and 2 instances of vascular thrombosis at the anastomosis site. The flaps exhibited good pliability without contracture, and no debulking procedures were required during the follow-up period (minimum 6 months, range 6-24; mean 9.4615).

CONCLUSION

The subdermal dissection technique is a safe and efficient approach for elevating PSP flaps. Our initial experience with this technique has been encouraging, and it currently serves as our preferred reconstructive option for defects requiring thin reconstruction.

Is free nipple grafting necessary in patients undergoing reduction mammoplasty for gigantomastia? A systematic review and meta-analysis

BACKGROUND

Gigantomastia is a debilitating condition characterised by an excessive breast tissue growth impacting patients' quality of life. Surgically treatment options include the limited-length pedicle (LP) technique with free nipple grafting (FNG) and the elongated pedicle (EP) technique, which maintains continuity of the nipple-areola complex (NAC). Initially, despite the less satisfactory aesthetic outcome, FNG was preferred to treat hypertrophic breasts requiring resections over 1000 g of parenchymal and adipose tissue, due to concerns about NAC perfusion. Recently, many studies have questioned this indication. The aim of this study was therefore to evaluate the safety of the NAC-carrying EP technique in patients with gigantomastia eventually challenging the need for FNG.

METHODS

A literature search using PubMed and Cochrane databases was performed, including studies describing the outcome of EP technique for resection exceeding 1000 g of breast tissue. Thereby, a meta-analysis was conducted to evaluate the rate of NAC necrosis, whereas a descriptive statistic was applied to assess all other surgery-associated complications.

RESULTS

Twenty-five studies, encompassing 1355 patients (2656 breasts), were included. EP demonstrated an extremely low rate of NAC necrosis. Moreover, the analysis demonstrated a low rate of ischaemia-independent complications and a very high probability of maintaining NAC-sensation equal to the preoperative state.

CONCLUSION

Current evidence indicates that the EP technique should be the preferred surgical method to treat gigantomastia with or without massive ptosis whenever indicated. It has proven to be safe. Furthermore, it yields superior aesthetic and functional outcomes, including breast feeding and preservation of NAC-sensation compared to the LP technique.

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

The reported complications' rate of perforator propeller flaps is variably high, but the etiology of distal flap necrosis, potentially linked to vascular insufficiency, is yet to be clarified. Vascular augmentation procedures have been previously described involving an extra anastomosis of a superficial vein, while a perforator-to-perforator supercharging approach has been only sporadically documented in literature. We present a case of perforator-to-perforator vascular supercharging of an extended dorsal intercostal artery perforator (DICAP) propeller flap to provide a salvage option for pedicled flap complicated by venous congestion. A 71-year-old male patient underwent Dermatofibrosarcoma Protuberans resection in the upper back, leading to a 17 × 17 cm defect with bone exposure. A 30 × 9 cm DICAP propeller flap was planned, with the distal third of the flap designed over the adjacent Thoracodorsal artery perforasome, in a conjoined fashion. Considering the small DICAP pedicle caliber and the flap lateral extension, a thoracodorsal artery perforator vein was dissected and included in the distal flap. Once the flap was raised on its main pedicle, the skin paddle turned blue, showing signs of venous insufficiency. Indocyanine green angiography (ICG) showed a viable proximal half of the flap. Hence, after rotating the skin paddle to reach the upper margin of the defect, an additional anastomosis between the perforating thoracodorsal vein and the perforating vein of the dorsal scapular pedicle was performed according to the perforator-to-perforator approach. Doing so, both clinical and ICG examinations showed a well perfused flap, with normal capillary refill. The postoperative course was uneventful, and the patient obtained a good oncological and reconstructive result 4 months postoperatively. The second Vasconez law ("all of the flap will survive except the part that you need") is often encountered in propeller flaps surgery. Our case shows that it is possible to prevent or overcome this problem by planning appropriate vascular augmentation procedures according to the perforator-to-perforator approach, being guided by advanced vascular imaging tools like ICG.

Treatment of Freiberg's disease using a reverse pedicled metatarsal bone flap: Case report

Despite no surgical procedures receiving unanimous support for treating Freiberg's disease, several surgical treatment options have been described. For the past few years, bone flaps have been shown in children to present promising regenerative properties. We report a novel technique using a reverse pedicled metatarsal bone flap from the first metatarsal to treat one case of Freiberg's disease in a 13-year-old female. The patient presented 100% involvement of the second metatarsal head, with a 6 × 2 mm defect, unresponsive to 16 months of conservative measures. A 7 mm × 3 mm pedicled metatarsal bone flap (PMBF) was obtained from the lateral proximal first metatarsal metaphysis, mobilized and pedicled distally. It was inserted at the dorsum of the distal metaphysis of the second metacarpal towards the center of the metatarsal head, reaching the subchondral bone. Initial favorable clinical and radiological results were maintained for over 36 months during the last follow-up. Based on the powerful vasculogenic and osteogenic properties of bone flaps, this novel technique could effectively induce bone revascularization and prevent further collapse of the metatarsal's head.

Indocyanine green angiography in oncoplastic breast surgery, a prospective study

INTRODUCTION

The use of Indocyanine green angiography (ICG-A) in oncoplastic breast-conserving surgery (OBCS) has not yet been investigated. This prospective trial applied ICG-A in volume displacement and replacement OBCS to localize perforators and determine tissue supplied by the perforator. Furthermore, to investigate and correlate the intraoperative ICG-A to postoperative surgical site infection, skin necrosis, epidermolysis, and timely onset of adjuvant therapy.

METHODS

ICG-A was performed at three pre-set timepoints during surgery; after lumpectomy, upon dissection of possible perforators, and after wound closure. All patients were followed with clinical evaluations before surgery, 4 weeks, 4-6 months, and 12 months postoperatively.

RESULTS

Eleven patients were included: seven volume displacement and four volume replacement OBCS. ICG-A located the tissue supplied by the perforator and demonstrated sufficient perfusion in all cases. The ICG-A corresponded to the surgeons' clinical assessment. One patient developed a postoperative infection and seroma and was treated conservatively. No patients had postoperative necrosis, loss of reconstruction, or lymphedema of the arm. Edema of the breast occurred in four patients (36.4%). Scar assessments were significantly worse at 4-weeks and 4-6 months. The quality of life improved significantly during follow-up. Adjuvant treatment was administered timely in all cases.

CONCLUSION

ICG-A was feasible for OBCS in assessing intraoperative perfusion. Perfusion was sufficient in all patients and corresponded to the surgeon's clinical evaluation. No patients developed postoperative necrosis. Though edema of the breast occurred in 36.4%, a larger sample size is needed to investigate a possible correlation with ICG-A. Further studies, which includes patients requiring extensive tissue replacement challenging the borders of perfusion, are needed.