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

Precise maxillofacial soft tissue reconstruction: A combination of cone beam computed tomography and 3dMD photogrammetry system

Introduction

The reconstruction of both extra- and intra-oral soft tissue defects, particularly in restoring the morphology of the lip and the corners of the mouth, has posed a significant challenge for surgeons. Inappropriate methods often lead to maxillofacial deformity which then causes psychological and functional problems. This study aimed to address the challenge of reconstructing extensive and complex maxillofacial soft tissue defects, mainly focusing on the lip, the corners of the mouth, and the surrounding areas.

Materials and methods

We developed a reconstruction approach by combining the 3dMDface System (3dMD) with the cone beam computed tomography (CBCT). Firstly, with the extra-oral incision line, we evaluated the shape and the size of the extra-oral defect with 3dMD digitally. Then we used the corresponding maxillary and mandible tooth positions to record the intra-oral defect, which was then converted to digital images by combining 3dMD and CBCT. The islands of the anterolateral thigh perforator flap were then designed after the locations of the perforators were detected with Doppler ultrasonography.

Results

A clinical case diagnosed as dermatofibrosarcoma protuberans was presented to illustrate the approach. The patient's tumor resection and the size of multiple defects were measured and simulated via the virtual surgery system. A three-island perforator flap from the descending branch of the lateral femoral circumflex artery was designed accurately. Two weeks postoperatively, the flap was healed as anticipated and the patient was satisfied with the profile.

Conclusion

The combination of the 3dMD and CBCT technologies improves the accuracy and fitness of extra- and intra-oral soft tissue reconstruction.

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.

SCIP flap in head and neck reconstruction after oncologic ablative surgery: a systematic review

BACKGROUND

In the surgical treatment of head and neck locally advanced malignancies, microvascular free flaps represent the most valuable solution to reconstruct the tissue defect after resection of the primary neoplasm. In particular, microvascular free flaps allow to restore the functional and aesthetical features of the head and neck compartments. The superficial circumflex iliac perforator (SCIP) flap represents, as an evolution of the groin flap, a valid alternative to the radial fasciocutaneous free (RFFF) flap or the anterolateral thigh (ALT) flap.

METHODS

This systematic review adhered to the recommendations of the Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) 2009 guidelines. A computerized MEDLINE search was performed using the PubMed service of the U.S. National Library of Medicine ( www.pubmed.org ) and Scopus database ( www.scopus.com ). Two authors screened the articles, then selected and extracted data on malignancies characteristics, reconstructive techniques, outcomes, and complications.

RESULTS

A total of 25 articles were selected and reviewed among the 39 identified through the search string. Six out of the selected 25 articles were case reports, while the remaining 19 articles were retrospective case series. The whole study population was represented by 174 oncologic patients undergoing ablation of a head and neck tumor and reconstruction with a SCIP flap. The site of reconstruction was the oral cavity in 125 (71.0%) patients, being the tongue the most common subsite in 73 (41.5%) patients, the pharynx in 10 (5.7%) cases, the larynx in 3 (1.7%) and head and neck skin in 36 (20.4%) patients. Only two cases of total flap loss were reported. Partial flap loss or shrinkage requiring minor surgical revisions was observed in 11 patients (6.32%). Primary closure of the donor site was achieved in the whole study population, according to the available data.

CONCLUSIONS

In head and neck postoncological reconstruction, despite the caliber and the length of the pedicle, SCIP flap offers a pliable and thin skin paddle, allowing single-stage resurfacing, medium to large skin paddle, possibility of composite-fashion harvest and a well-concealed donor site.

Expanding the Armamentarium of Donor Sites in Microvascular Head and Neck Reconstruction

The field of microsurgical head and neck reconstruction has witnessed tremendous advancements in recent years. While the historic goals of reconstruction were simply to maximize flap survival, optimizing both aesthetic and functional outcomes has now become the priority. With an increased understanding of perforator anatomy, improved technology in instruments and microscopes, and high flap success rates, the reconstructive microsurgeon can push the envelope in harvesting and designing the ideal flap to aid patients following tumor extirpation. Furthermore, with improvements in cancer treatment leading to improved patient survival and prognosis, it becomes increasingly important to have a broader repertoire of donor sites. The present review aims to provide a review of newly emerging soft tissue flap options in head and neck reconstruction. While certainly a number of bony flap options also exist, the present review will focus on soft tissue flaps that can be harvested reliably from a variety of alternate donor sites. From the upper extremity, the ulnar forearm as well as the lateral arm, and from the lower extremity, the profunda artery perforator, medial sural artery perforator, and superficial circumflex iliac perforator flaps will be discussed, and we will provide details to aid reconstructive microsurgeons in incorporating these alternative flaps into their armamentarium.

The Pedicled Sensate Osteocutaneous Groin Flap for Reconstruction of the Forearm and Hand

BACKGROUND

The groin flap is axial pedicled and versatile. Until now, this flap has been used with many modifications for the reconstruction of forearm and hand defects. However, this flap has not been used in forearm, hand, and thumb reconstruction as a pedicled sensate osteocutaneous flap. In this study, a pedicled sensate osteocutaneous groin flap was used for the reconstruction of composite tissue defects on the forearm, hand, and thumb.

PATIENTS AND METHODS

A pedicled sensate osteocutaneous groin flap was used to reconstruction composite tissue defects on the forearm, hand, and thumb in 7 patients. The mean age of the patients was 42 years. The defects were located on the dorsal surface of the forearm and hand in 2 patients, the dorsal surface of the hand and finger in 2 patients, and the thumb in 3 patients. The dimensions of the flap skin paddle ranged from 7 × 11 cm to 8 × 23 cm, and the dimensions of the bone component ranged from 1 × 1.5 × 3.5 cm to 1 × 1.5 × 5 cm. The mean follow-up duration was 26 months.

RESULTS

All the flaps survived. Flap debulking was performed using 3 flaps. Sensory recovery in the flaps was completed approximately 18 months after the first operation. When the results of static 2-point discrimination test and Semmes-Weinstein monofilament test were evaluated at 18 months postoperatively, it showed that protective sensation was obtained. Except for 1 patient, motion restriction did not develop in the wrist, elbow, or shoulder joints. An acceptable aesthetic result, minimal donor site deformity, and protective sensation were obtained in all patients.

CONCLUSIONS

The pedicled sensate osteocutaneous groin flap can be safely used in the reconstruction of forearm and hand composite tissue defects that do not have available vascular structures for free flaps in the recipient area and in thumb reconstruction where toe transfer and pollicization cannot be performed.

Superficial Circumflex Iliac Artery Perforator Flap with Bilobed Design for the Donor Defect after Wrap-Around Flap Transfer Reconstruction

OBJECTIVE

The repair of great toe donor site defect after wrap-around flap transfer is still controversial. The bilobed superficial circumflex iliac artery perforator (SCIP) flap can improve the aesthetics of the great toe while maintaining its function. Thus, this study aimed to report our experience in the reconstruction of big toe donor site defects with the bilobed SCIP flap and describe the clinical outcomes.

METHODS

This study was a retrospective trial. From May 2017 to May 2020, 13 patients with the great toe donor site defect after wrap-around flap transfer were included in this study. The average age of the patients was 44 years (range, 23-60 years). All patients received free bilobed SCIP flaps to reconstruct the donor site defect of the great toe. Relevant clinical features were recorded preoperatively. The thickness and design of the SCIP flap and the harvesting layer of the flap were measured during the operation. The survival rate of flaps and skin grafts and the incidence of infection were recorded after operation. At follow-up, donor site complications and postoperative outcomes were evaluated.

RESULTS

In all cases, the SCIP flap covering the donor site of the great toe survived. All patients were followed up for 24-40 months (mean, 30.5 months). The average thickness of the SCIP flap was 0.38cm. All SCIP flaps were harvested from the superficial fascial layer except for three obese patients. The thin SCIP flap had a bilobed design with no further defatting procedures. Postoperatively, the great toe-nail flap donor site regained its original appearance without bloating or flap necrosis. There was a hidden linear scar in the groin donor site, which did not affect hip joint movement. All patients were satisfied with the aesthetics of the surgical site.

CONCLUSION

The SCIP flap with bilobed design for repairing the donor defect of the great toe after wrap-around flap transfer is a kind of surgical method with excellent contour, meeting the requirements of function and aesthetics.

Treatment of Advanced Male Genital Lymphedema With a Complete Functional Lymphatic System Pedicled Transfer

OBJECTIVE

To evaluate the functional efficacy of the superficial circumflex iliac artery perforator (SCIP) -lymphatic pedicled flap in the treatment of advanced male genital lymphedema.

METHODS

From February 2018 to January 2022, we treated 26 male patients with scrotal and penoscrotal advanced lymphedema using reconstructive lymphatic surgery. Isolated scrotal involvement was seen in 15 patients, and 11 patients had penoscrotal involvement. Excision of genital lymphedematous fibrotic tissue was followed by reconstruction utilizing the SCIP-lymphatic flap. Patient characteristics, intraoperative data, and postoperative results were evaluated.

RESULTS

The mean patient age was 39 ± 4.6, and the mean follow-up time was 44.9 months. the SCIP-lymphatic flap was used to reconstruct partial (n = 11) or total (n = 15) scrotum and used to reconstruct total penile skin in 9 cases and partial in 2 cases. The flap survival rate was 100%. Cellulitis rates were dramatically reduced after reconstruction (P value <.001). The mean genital lymphedema score (GLS) after surgery was 0.05, which was significantly lower than the preoperative 1, 6.2 (P < .001). The median Glasgow Benefit Inventory (GBI) total score was +41, all 26 patients (100%) showed a degree of quality of life improvement.

CONCLUSION

The pedicled SCIP lymphatic transfer approach in advanced male genital lymphedema can provide a durable complete functional lymphatic system that improves the appearance and genital lymphatic drainage. This leads to an improvement in quality of life as well as in sexual functions.

[Comparative analysis of the groin and SCIP flap in reconstructive microsurgery of soft tissues of the maxillofacial area and oral cavity]

Most of the articles on the groin flap were published in the period from 1975 to 2010, from 2015 to 2022, the SCIP flap surpassed the groin flap in the number of publications. According to the results of a literature search in PubMed and RINC, 30 articles were found and selected, including 288 flaps from the iliac region. The length of the vascular pedicle, the diameter of the vessels, the complications, the prevalence of the flap in the reconstruction of the head and neck, the thickness and the size of the flap were evaluated. Both of these flaps have the same nutrition, but different levels of dissection. In comparison with the groin flap, the SCIP flap has a longer vascular pedicle, which can be enlarged due to new techniques, which also allows it to be used as an ultra-thin flap, and it reduces the need for secondary procedures for defatting and reduces the risks of the complications in the donor area. The thickness of the SCIP flap is less than the groin one, which, according to the author, increases the aesthetic level of operations in the facial area in the case of the texture and color of the flap. Vascular anatomy of the SCIP flap is variable, therefore, the use of preoperative planning is necessary. Despite this, complications in the donor or recipient area during reconstruction with a SCIP flap are minimal. It has been proved that the SCIP flap is versatile and safe in all aspects of reconstruction. It can be concluded that the SCIP flap should be considered as a «workhorse» in reconstructive microsurgery of soft tissues of the throat and oral cavity.

The durability of thin superficial circumflex iliac artery perforator flap in sole reconstruction: Clinical experience with 18 cases

BACKGROUND

The superficial circumflex iliac artery perforator flap's overall success in the reconstruction of the lower limb has been acceptable, but the sole of the foot remains more challenging. The purpose of this article is to report our experience employing the SCIP flap and evaluate its durability in reconstructing different units of the foot's sole, heel, middle, and forefoot.

PATIENTS AND METHODS

This retrospective study reviewed 18 patients with sole defect reconstructed with free SCIP flap from 2017 to 2019. 18 free SCIP flaps were harvested depending on the superficial branch of SCIA (n = 16) or deep branch (n = 2). All flaps were thin and elevated above the scrapa's fascia. The heel (n = 10), middle foot sole (n = 5), forefoot sole (n = 2), and combined heel and midfoot in one patient were among the defect locations. Sole defects were caused by trauma in 10 patients (55.5%), while the rest of the causes were melanoma (three patients, 16.7%), diabetic ulcer (three patients, 16.7%), and unstable scar (one patient), and calcaneal osteomyelitis (one patient). The defect size ranged from 24 to 230 cm² .

RESULTS

The flap dimensions ranged from 6 × 4 to 18 × 11 cm. Mean follow-up observations were 42.5 months. 72.2% of our patients developed protective sensation between 12-18 months. No ulcerations were observed, and all of the patients had successful functional recoveries with satisfying cosmetic outcomes.

CONCLUSION

The SCIP flap can be an optimal durable skin flap for weight-bearing sole reconstruction. SCIP flap has the advantage of being thin minimizing the problem of shearing, the need for secondary procedures, and the faster recovery of protective sensation that could prevent ulceration.

Deep Fat Saving Elevation of the Superficial Circumflex Iliac Artery Perforator Flap

Background and Objectives: Prolonged drain stay and lymphorrhea are often problems at the donor site of the superficial circumflex iliac artery perforator (SCIP) flap. This study aimed to introduce a novel technique of the SCIP flap elevation: Deep Fat Saving (DFS) technique. Materials and Methods: Thirty-two patients who underwent the SCIP flap transfer were divided based on the flap-elevated layer: above the deep fascia or the Camper fascia saving the deep fat. The duration of drain stay and the rates of flap survival and donor-site complications were compared between the groups. The inverse probability weighting (IPW) method was conducted to balance confounders. Results: By IPW, two balanced pseudo-populations were created: DFS = 33.9 and Conventional = 31.3. There were no significant differences in the rate of flap survival (DFS: 100% verses Conventional: 95.8%, p = 0.32) and donor site complications (DFS: 2.4% versus Conventional: 1.3%, p = 0.68, respectively). The duration of drain stay was shorter in the DFS group (weighted median: 6 versus 8 days; weighted difference: -1.6 days (95% confidence interval: -2.8 to -0.4), p = 0.01). Conclusions: An SCIP flap can be reliably harvested using the Deep Fat Saving technique.