Search Results (44)

Background: Complex elbow soft-tissue defects often combine exposed critical structures, unstable scars, and high mechanical stress, making durable coverage and early mobilization challenging. Among regional options, the reverse lateral arm flap provides thin fasciocutaneous tissue based on a reliable collateral circulation and preserves major forearm vessels. The aim of this study was to report our single-center experience with the pedicled reverse lateral arm flap for elbow soft-tissue reconstruction, focusing on stable coverage, donor-site morbidity, and functional recovery. Methods: A retrospective single-center case series was conducted at the Division of Plastic Surgery, University Hospital of Padua, Italy. All consecutive patients treated between 2013 and 2023 with a pedicled reverse lateral arm flap for elbow soft-tissue defects were included. Recorded variables included defect etiology, donor-site management, complications, range of motion, and follow-up. Elbow flexion–extension was recorded clinically preoperatively and at last follow-up. Minimum follow-up was 12 months in all patients. Results: Seven patients underwent reconstruction. Defect etiology was burn-related in four cases, shotgun trauma in one, crush injury in one, and melanoma resection in one. All defects were covered with a pedicled reverse lateral arm flap. All flaps survived completely without partial necrosis or flap-related reoperation. Donor-site closure was primary in four patients and required split-thickness skin grafting in three. One patient developed donor-site keloid, and one had donor-site skin-graft partial loss with delayed healing. Elbow flexion–extension improved in all seven cases, with a median gain in arc of motion of 25° (range 15–41°). Conclusions: In this series, the reverse lateral arm flap provided complete coverage of selected elbow defects with preserved motion and limited donor-site morbidity at a minimum follow-up of 12 months. Our findings suggest that it may represent a useful regional option in selected posterior and lateral elbow defects, particularly in post-burn and traumatic settings where thin vascularized tissue is needed, and free-flap reconstruction may be avoidable. Full article

Zygomatic implant perforated (ZIP) flap reconstruction offers immediate surgical rehabilitation following maxillectomy, integrating oncologic zygomatic implants with a fascio-cutaneous free flap. A critical technical challenge is safely perforating the free flap skin paddle to accommodate implants’ abutments without damaging its vasculature. Near-infrared (NIR) vein visualization technology provides real-time mapping of subcutaneous vessels and has been widely investigated in settings such as pediatric intravenous (IV) cannulation. By projecting vein pathways onto the skin, NIR visualization facilitates precise vascular identification, potentially reducing complications. We describe a case of ZIP flap reconstruction in a 25-year-old patient utilizing NIR vein visualization to preemptively locate flap vasculature and minimize the risk of vessel puncture. Our discussion places these findings within the context of the existing literature on NIR devices, underscoring their benefits of non-invasive operation, rapid imaging, and minimal need for advanced operator skills, and highlighting their utility in microvascular reconstructive surgery. Full article

Background/Objectives: Chronic wounds are a major source of morbidity in patients with paraplegia, often resulting in repeated treatment, prolonged hospitalization, and reduced quality of life. Reconstruction becomes particularly challenging when a wound arises in a scarred trunk region and is further complicated by deep infection, osteomyelitis, or enteric fistula. We describe the staged management of a complex left flank wound in a paraplegic patient, initially reconstructed with a quadrilateral pinwheel flap and later requiring multidisciplinary salvage for recurrence associated with rib osteomyelitis and a colocutaneous fistula. Methods: A paraplegic man in his 50s presented with a chronic left flank wound after repeated full-thickness skin graft failure and persistent Pseudomonas aeruginosa infection. After wide debridement, the approximately 7 × 7 cm defect was reconstructed with a quadrilateral pinwheel flap composed of four Limberg-style rhomboid fasciocutaneous flaps positioned at the 12, 3, 6, and 9 o’clock orientations, elevated at the level of the deep fascia, and transposed into the central defect, with adjunctive negative-pressure wound therapy (NPWT). Approximately 1 year later, recurrence with rib osteomyelitis required rib resection. During NPWT, feculent drainage led to the diagnosis of a colocutaneous fistula. Subsequent multidisciplinary treatment included fistula tract resection, colonic repair with omental patching, transposition of vascularized omentum into the chest wall cavity to obliterate dead space, continued NPWT, and delayed primary closure. Results: Initial local flap reconstruction achieved wound coverage, and immediate postoperative clinical assessment, including pinprick and refill testing, confirmed satisfactory flap perfusion; however, delayed recurrence developed in association with rib osteomyelitis. After definitive fistula surgery, dead-space management with vascularized omentum, wound conditioning with staged NPWT, and delayed primary closure, the wound healed completely. At 6 months after delayed closure, no recurrence of fistula, osteomyelitis, wound dehiscence, or soft-tissue breakdown was observed, and the patient’s daily comfort and functional independence were improved compared with the preoperative condition. Conclusions: A quadrilateral pinwheel flap may provide an effective tension-dispersing local fasciocutaneous option for selected scarred trunk defects in high-risk patients. However, when chronic wounds are compounded by deep infection and enteric fistula, durable healing depends not on flap design alone but on staged multidisciplinary management incorporating definitive source control, vascularized tissue transfer for dead-space elimination, NPWT, and appropriately timed closure. Full article

Background/Objectives: Heel reconstruction is a complex procedure that requires soft tissue reconstruction resistant to weight, pressure, and shear stress. Various flap reconstruction methods have been reported; among them, free fasciocutaneous flaps have advantages in terms of function and aesthetics, but also have challenges due to the longer operation time required and the possibility of failure. The primary aim of this study was to examine the functional outcomes of heel reconstruction using free lateral arm fasciocutaneous flaps after wide excision of heel skin cancer. Methods: Between January 2014 and December 2020, eight patients underwent wide excision of skin cancer and reconstruction of the heel with a lateral arm free flap. Perioperative clinical data and postoperative outcomes, including flap survival, complications, Lower Extremity Functional Scale (LEFS) score, and American Orthopaedic Foot and Ankle Society scale (AOFAS) score, were analyzed from clinical records. Functional assessments were performed at a minimum of 12 months postoperatively (mean 18.3 months, range 12–24 months) by a single blinded examiner who was not involved in the surgical procedures. Both preoperative and postoperative LEFS and AOFAS scores were recorded for comparison. Results: The mean size of the skin and soft tissue defect was 32 cm², the mean duration of surgery was 179 (range: 160–215) minutes, and the mean duration of hospital stay after surgery was 17 (range: 14–19) days, with a mean follow-up period of 48 (range: 33–59) months. Among the eight patients, two had diabetes mellitus (25%), one had peripheral neuropathy (12.5%), and none had clinically significant peripheral vasculopathy. All flaps survived, with one congestive episode. Satisfactory aesthetic and functional results were observed in all patients. The mean preoperative LEFS score was 28 (SD ± 6.1), which improved significantly to a postoperative mean of 57 (SD ± 8.3). Similarly, the mean preoperative AOFAS score was 45 (SD ± 5.8), improving to a postoperative mean of 61 (SD ± 6.2). Minor donor site complications included hypertrophic scarring in two patients (25%) and transient sensory changes in the lateral arm region in three patients (38%), all of which resolved with conservative management. Conclusions: This research suggests that the lateral arm free flap can be considered a reliable option in heel reconstruction, resulting in acceptable functional and aesthetic outcomes. It provides excellent durability, with solid bony union and good contour in small to moderate-sized heel defect cases. Full article

Background and Objectives: Free tissue transfer for coverage of large defects is a common technique in plastic surgery. The kind of free tissue transfer depends on various factors such as the size of the defect, type and content of missing tissue, the location, and the weight-bearing demands of the area. Instead of performing bulky muscle free flaps, another alternative has bas been considered. Materials and Methods: This is a technical experience report for ALTP Flap Surgery conducted from 2013 to 2017 which included 15 surgery reviews out of 50 based on the inclusion criteria to identify the result of aesthetical reconstruction and to include such results with the current literature. In addition to that, a narrative review of the literature has been performed using PubMed and Google Scholar by using the ALT or ALTP Flap terms to determine the current practice and to compare with our results. Results: Single-stage debridement of all defects was followed by reconstruction in all surgeries. A total of 14 Flaps succeeded (93.3%) without any complications and only one of the flaps was complicated (6.7%) with vein thrombosis which resulted in the loss of that flap, leading to another revision being performed for that particular patient. No hematoma or infection has been noted. Conclusions: Using an extended-size ALTP flap can be a reliable option for the reconstruction of the weight-bearing area of the foot and offers a good postoperative function and esthetic result without the need of further subsequent debulking procedures. Full article

Background/Objectives: Free gracilis (GM) and latissimus dorsi muscle (LDM) flaps are reliable options for complex defect coverage, but long-term sensory outcomes remain underexplored. Sensory impairment, especially the loss of protective cutaneous sensation, increases the risk of injury, thermal damage, and ulceration in reconstructed areas. This study aimed to systematically assess multidimensional sensory recovery after free muscle flap (FMF) reconstruction. Methods: In a prospective single-center study, 94 patients (49 GM, 45 LDM) underwent standardized sensory testing following FMF transfer. Five modalities were evaluated: pressure detection (Semmes-Weinstein monofilaments), vibration perception, two-point discrimination (2PD), sharp–dull differentiation, and temperature differentiation. Measurements were compared to contralateral healthy skin (CHS). Subgroup analyses were performed by anatomical region (head, trunk, extremities). Results: All sensory modalities were significantly impaired in FMF compared to CHS (p < 0.0001). Mean pressure thresholds were markedly higher in FMF (248.8 g) versus CHS (46.8 g). Vibration perception scores were reduced (FMF 3.97 vs. CHS 5.31), and 2PD was significantly poorer (11.6 cm vs. 4.7 cm). Sharp–dull and thermal discrimination were largely absent in FMF (positivity rates < 20%), with 58.5% of patients demonstrating only deep pressure sensation (≥300 g). No significant differences were found between GM and LDM in most modalities, except for worse 2PD in GM. Subgroup analyses confirmed uniform deficits across all anatomical regions. Conclusions: FMFs without neurotization result in profound, persistent sensory deficits, particularly the loss of protective sensation. Clinically, fascio-cutaneous flaps with nerve coaptation should be considered in functionally critical regions. Future strategies should focus on neurotization techniques to enhance sensory recovery. Full article

Introduction: Perforator-based fasciocutaneous flaps are particularly suitable for soft tissue reconstruction of the lower extremities. The most commonly used flap is the microvascular Anterior Lateral Thigh Flap (ALT). Pedicled propeller-type flaps are less frequently utilized due to higher complication rates. The aim of this study was to compare postoperative perfusion patterns of these fundamentally different flaps to increase their basic understanding. Methods: A retrospective data analysis was performed (2017–2022), including patients who underwent flap reconstruction of the lower extremity either with a perforator-based pedicled Propeller flap or free tissue transfer with an ALT flap. Only patients with documented postoperative perfusion monitoring of the flap using the laser Doppler spectrophotometry system (LDSP) were included. Demographic data, comorbidities and perioperative data as well as perfusion profiles given by the LDSP were analyzed. Results: Seven patients who received a propeller flap and 18 who received a free ALT were identified. Defects were most often due to trauma (Propeller flap n = 5; 71.1%; ALT n = 7; 38.9%) and chronic wounds (Propeller flap n = 1; 14.3%; ALT n = 5; 27.8%). The most common complication was prolonged wound healing (Propeller flap n = 3; 42.9%; ALT n = 8; 44.4%). In cases with postoperative surgical complications, a distinctly delayed recovery in perfusion of propeller flaps was seen during the first 72 h after surgery. Conclusions: Propeller and ALT flaps exhibit distinct perfusion patterns, with Propeller flaps showing a congestion-prone profile (elevated rHB, delayed hyperperfusion) and ALT flaps an inflow-dependent, ischemia-driven profile (lower rHB and SO₂). Full article

Background: Post-traumatic osteomyelitis (PTO) of the lower extremity is among the most demanding problems in orthoplastic reconstructive surgery. It typically follows open fractures, failed osteosynthesis, or implant infection. Effective management requires coordinated infection control, stable skeletal fixation, and timely vascularized soft-tissue coverage. Methods: We conducted a retrospective case series of 20 consecutive patients with PTO of the lower limb treated between 2021 and 2024 at a tertiary orthoplastic center. All patients underwent radical debridement, culture-directed intravenous antibiotic administration, and soft-tissue reconstruction using local muscle, fasciocutaneous, or free flaps; vascularized bone flaps were used to select nonunion cases. The primary outcomes were flap survival, complications, infection resolution, and limb salvage. Exploratory analyses included descriptive subgroup summaries by flap category. Results: Among 20 patients (15 men, 5 women; mean age 53.6 years), reconstructions included reverse/pedicled sural flaps (n = 9), hemisoleus muscle flaps (n = 7), medial gastrocnemius muscle flaps (n = 2), peroneus brevis muscle flaps (n = 2), and free flaps (n = 6), which comprised anterolateral thigh (ALT), medial femoral condyle (MFC) osteoperiosteal, deep circumflex iliac artery (DCIA) osteocutaneous, and radial forearm free flaps (RFFFs). Single-flap reconstructions were performed in 13 cases, whereas multistage/multiflap strategies were used in 7. Overall flap survival was 90%. Major flap complications comprised partial necrosis in two reverse sural flaps and one complete loss of a reverse sural flap; two patients had minor wound dehiscence. Infection resolved in 18/20 patients (90%; 95% CI ≈ 0.70–0.97). One patient requested below-knee amputation due to persistent nonunion associated with a pathological fracture. At a mean 10-month follow-up, all limb-salvaged patients were ambulatory. Conclusions: Effective reconstruction of PTO is improved by using a patient-specific algorithm that considers the defect location, vascular status, and host comorbidities. Local muscle and fasciocutaneous flaps remain dependable for most defects, with free or vascularized bone flaps reserved for composite or recalcitrant cases. Early referral to high-volume centers, radical debridement, and orthoplastic collaboration are critical for optimizing limb salvage. Our findings should be interpreted in light of the study’s retrospective design and small sample size. Full article

Background: Propeller perforator flaps (PPFs) have gained increasing popularity in lower limb reconstruction. While their use in elective settings is well described, their role in acute post-traumatic reconstruction remains less defined. Methods: A systematic review was conducted following PRISMA 2020 guidelines. PubMed, Scopus, and Cochrane Library were searched on 2 June 2025, for studies reporting on the use of propeller flaps in lower limb reconstruction after trauma. Only studies rated as “good” quality using the NIH quality assessment tool were included. Data on anatomical location, flap survival, complications, reinterventions, and functional and patient-reported outcomes were extracted and analyzed descriptively. Results: Twenty-eight studies published between 2008 and 2024 were included, accounting for 619 propeller flaps in a population of 838 patients. The majority of flaps were fasciocutaneous, with the posterior tibial artery being the most commonly used source vessel. Among the flaps included, 422 (68.2%) achieved complete survival without necrosis, 84 (13.6%) developed partial necrosis, and 23 (3.7%) failed completely. Considering all flaps that remained viable after any required revisions or conservative management, the overall survival rate was 97%. Venous congestion was the leading cause of flap compromise. The overall complication rate was 21.8%, increasing to 35.1% in acute trauma cases. A statistically significant correlation was found between wide rotation angles (≥150°) and higher complication rates (p = 0.015). The mean follow-up duration was 12.5 months. Functional and aesthetic outcomes were poorly reported, but when available, they were generally favorable. Conclusions: PPFs represent a valuable option for lower limb reconstruction, providing reliable coverage while preserving major vascular axes. Their application in acute trauma settings appears promising, although current evidence is limited by small verified cohorts and predominantly retrospective study designs. Despite higher complication rates in acute cases, flap survival remains consistently high, supporting their use in carefully selected patients. Further prospective studies with standardized outcome reporting are needed to clarify long-term functional results and refine selection strategies. Full article

Background: Flap-based and podoplastic limb salvage in the foot and ankle is difficult due to the presence of biomechanical forces that can impact flap healing and complication rates and, in turn, limb salvage rates. For this reason, external fixation is indicated to neutralize forces across the flap interface and allow for optimal flap take and healing. Although external fixation for flap immobilization is the current standard of care, not much is known about how duration and timing may impact complication and salvage rates. Methods: We retrospectively identified and analyzed complication and limb salvage rates in 18 patients who underwent flap-frame immobilization with a multiplanar external fixator during a 4.75-year period. Results: Patients ranged in age from 40 to 75 years (mean, 55.5 years). Sixteen patients (88.9%) had diabetes mellitus, and all had defects that were a mean of 110.9 cm² (range, 36–500 cm²) and required the use of a local or free flap. Thirteen defects (72.2%) were in the plantar region, with the remaining five (27.8%) in nonplantar regions. Eleven flaps (61.1%) were fasciocutaneous, and the remaining seven (38.9%) were vascularized muscle flaps. All of the flaps were immobilized with either a three- or four-ring circular external fixator. Overall, a 66.7% limb salvage rate (12 of 18) was observed with mean follow-up of 2.4 years, or 892.6 days (range, 222–1,555 days). Seven minor flap complications (38.9%) required a return to the operating room. Conclusions: External fixation is an essential tool in flap-based limb salvage. These findings hint that the “Goldilocks zone” of duration is approximately 28 to 35 days. Furthermore, we believe that risk factors such as open amputation, increased defect size, and presence of Charcot’s neuroarthropathy impact limb salvage rates regardless of duration and timing of flap-frame immobilization. Full article

Objectives: The application of fasciocutaneous free flaps for reconstruction of head and neck defects following oncological surgery has increased since the 1970s, coinciding with developments in microvascular techniques. Although reported success rates are between 90% and 99%, flap failure continues to occur, most frequently due to venous congestion. This study examines the rates of re-exploration and flap failure according to the number of venous anastomoses in patients receiving free flap reconstruction after head and neck cancer surgery. Materials and Methods: This retrospective analysis included 163 patients who underwent head and neck reconstruction with free flaps (radial forearm free flap [RFFF] and anterolateral thigh flap [ALTF]) at the University Hospital of Verona between January 2019 and June 2024. Variables examined comprised the type of flap performed, donor and recipient vessels utilized, and number of venous anastomoses, as well as the type (end-to-end [ETE] versus end-to-side [ETS]) and site (internal jugular vein versus external jugular vein) of venous anastomosis. Results: The overall success rate was 93.3%, with no significant difference between single and dual venous anastomosis groups. Prompt re-exploration upon detecting signs of flap failure is critical, as approximately one-third of such failures may be prevented through timely intervention. Conclusions: Single venous end-to-end anastomosis utilizing the internal jugular vein system is typically effective. Further research is warranted to clarify the indications for dual anastomosis involving the external jugular vein system. Full article

Background/Objectives: To prevent flap failure, adequate tissue perfusion and effective regenerative processes, undisturbed wound healing are essential, among others. To improve wound healing, various locally and systematically administered pharmacons can be used. This study investigated the effect of PACAP 1-38 (pituitary adenylate cyclase activating polypeptide) and BGP-15 (a nicotinic amidoxime derivative) on the healing of epigastric fasciocutaneous flaps exposed to ischemia–reperfusion (I/R). Methods: Wistar rats were randomly divided into control (no substance), PACAP 1-38, and BGP-15 groups. Groin flaps were prepared bilaterally. The left flap was exposed to 120 min of ischemia prior to suturing it back. We applied wound gels containing substances. Laboratory tests (hematology, erythrocyte deformability, and aggregation) were performed before surgery on the 1st, 3rd, and 7th postoperative days. Lastly, flap skin samples were taken for histological and tensile strength measurements. Results: Impaired erythrocyte deformability and enhanced aggregation were found because of flap I/R. The pharmacons were able to reduce the systemic micro-rheological impairment to varying degrees. The tensile strength increased in the areas of better perfusion. Conclusions: The anti-inflammatory effects of PACAP 1-38 and BPG-15, as well as the impact of PACAP 1-38 on collagen and elastic fiber composition, have been demonstrated. Full article

Background and Objectives: Lower limb defects often present significant reconstructive challenges due to limited soft tissue availability and exposure of critical structures. Perforator-based flaps offer reliable solutions, with minimal donor site morbidity. This study aimed to evaluate the efficacy of infrared thermography (IRT) in preoperative planning and postoperative monitoring of perforator-based flaps, assessing its accuracy in identifying perforators, predicting complications, and optimizing outcomes. Materials and Methods: A prospective observational study was conducted on 76 patients undergoing lower limb reconstruction with fascio-cutaneous perforator flaps between 2022 and 2024. Perforator mapping was performed concurrently with IRT and Doppler ultrasonography (D-US), with intraoperative confirmation. Flap design variables and systemic parameters were recorded. Postoperative monitoring employed thermal imaging on days 1 and 7. Outcomes were correlated with thermal, anatomical, and systemic factors using statistical analyses, including t-tests and Pearson correlation. Results: IRT showed high sensitivity (97.4%) and positive predictive value (96.8%) for perforator detection. A total of nine minor complications occurred, predominantly in patients with diabetes mellitus and/or elevated glycemia (p = 0.05). Larger flap-to-defect ratios (A/C and B/C) correlated with increased complications in propeller flaps, while smaller ratios posed risks for V-Y and Keystone flaps. Thermal analysis indicated significantly lower flap temperatures and greater temperature gradients in flaps with complications by postoperative day 7 (p < 0.05). CRP levels correlated with glycemia and white blood cell counts, highlighting systemic inflammation’s impact on outcomes. Conclusions: IRT proves to be a reliable, non-invasive method for perforator localization and flap monitoring, enhancing surgical planning and early complication detection. Combined with D-US, it improves perforator selection and perfusion assessment. Thermographic parameters, systemic factors, and flap design metrics collectively predict flap viability. Integration of IRT into surgical workflows offers a cost-effective tool for optimizing reconstructive outcomes in lower limb surgery. Full article

Vulvar and perineal reconstruction represents a significant surgical challenge, particularly in the context of oncological resections, trauma, or postpartum injuries. Vulvar cancer, predominantly squamous cell carcinoma, often necessitates extensive resections, leading to significant tissue defects and high rates of postoperative complications. Reconstructive procedures, encompassing skin grafts and local, regional, and distant flaps, are intended to restore the anatomical structure, protect internal organs, and enhance functional outcomes and quality of life. The selection of technique is contingent upon the dimensions of the defect, its location, the patient’s condition, and the availability of suitable tissue. The management of minor defects can be accomplished through local advancements, while more extensive or complex cases necessitate the utilization of musculocutaneous (e.g., VRAM) or fasciocutaneous (e.g., ALT) flaps. The present article provides a review of surgical methods of vulvar and perineal reconstruction, with a focus on indications, techniques, and potential complications. Full article

Background/Objectives: Isolated defects of the posterior hypopharyngeal/upper esophageal wall are rare, typically arising after cancer resection or complications following cervical spine osteosynthesis. Various local and free flaps are available for reconstruction, but we opted for a double-island anterolateral thigh (ALT) flap in this case. Methods: A scoping review was conducted (June 2024) following PRISMAScR 2018 guidelines in order to examine the coverage options available in the literature for posterior hypopharyngeal/upper esophagus wall defects while also presenting a case where such a defect was covered with a double-island anterolateral thigh (ALT) flap. Eligibility criteria: Human studies describing defect coverage of the posterior hypopharyngeal/upper esophagus wall were included. Sources of evidence: A literature search was conducted in PubMed, Cochrane Library, and Google Scholar, following PRISMAScR guidelines. Charting methods: Data on surgical techniques, outcomes, and complications were extracted and analyzed by two independent reviewers. Case report: A 57-year-old female developed a chronic posterior wall perforation following Zenker’s diverticulum treatment and C5/6 cage osteosynthesis. Reconstruction was performed using a free fasciocutaneous ALT flap with two skin paddles: one (2 × 2 cm) for the esophageal mucosa and an additional vascularized fascia layer (4 × 8 cm) to separate the cage from the hypopharyngeal defect. To enable flap monitoring in the otherwise hidden defect, a second skin island was externalized cervically. Results: Postoperative recovery was uneventful, with a continuous viable flap signal. A Gastrografin swallow test confirmed an intact esophagus without leaks or dehiscences. Oral intake resumed after 10 days. The literature review highlighted 239 cases with multiple reconstructive techniques, each with advantages and limitations. Conclusions: The double-paddle free fasciocutaneous ALT flap is a viable option for posterior hypopharyngeal/upper esophageal wall reconstruction, allowing effective postoperative monitoring. This approach offers a valuable modification for complex cases requiring enhanced structural integrity and flap assessment. Full article