Male genital lymphedema (MGL) is a debilitating condition that may require surgical intervention. Lymphaticovenous anastomosis (LVA) can be ineffective in primary and advanced cases because of lymphatic disruption, whereas vascularized lymph node transfer (VLNT) can overcome this limitation by promoting neolymphangiogenesis but traditionally carries some risk of donor site complications. Gastroepiploic vascularized lymph node transfer (GEVLNT) has recently emerged as an effective treatment option for upper and lower limb lymphedema, with negligible complications. However, its role in genital lymphedema remains unexplored. This is the first short series reporting the use of GEVLNT in MGL. Three male patients (44, 61, and 52 years old) with GL underwent GEVLNT. The first patient had idiopathic disease, which relapsed after previous treatment with LVA; the other two had secondary lymphedema due to cancer treatment and hydrocele surgery, respectively. In all patients, the right gastroepiploic lymphosome was harvested laparoscopically, with flap sizes of 14 × 5 cm, 15 × 4 cm, and 12 × 4 cm, respectively. The recipient vessels were the deep inferior epigastric artery and vein in the first case, and the superficial external pudendal vessels in the other two. Post-operative courses were uneventful for all patients, with no complications reported. Follow-up periods were 36, 23, and 12 months, respectively. In all cases, GEVLNT resulted in significant clinical improvements and reductions in genital lymphedema severity (GLS) scores (7-1, 9-4, and 8-4). Our preliminary experience suggests that GEVLNT could be a viable and effective option for treating male genital lymphedema with minimal donor site morbidity and stable results over time. However, further research with larger patient cohorts, comparative studies, and long-term follow-up is needed to fully establish its efficacy.

Decision making about the selection of artery and vein anastomosis techniques is a challenging dilemma in free flap surgery, especially in trauma cases in which it is difficult to distinguish the zone of injury. This study aimed to analyze the effects of the selection of end to end (ETE) or end to side (ETS) artery anastomosis, one or two venous anastomoses, and the deep or superficial venous anastomoses on the flap survival and re-exploration rates. We further aimed to investigate whether there were any differences between lower and upper extremity free flaps. A total of 447 patients were included in the study. Upper and lower extremity reconstructions were performed in 281 and 166 patients, respectively. The most commonly used flap was the anterolateral thigh (ALT) flap (42%). Flap survival and re-exploration status, number of recipient veins, deep/concomitant or superficial/subcutaneous venous anastomosis, and type of arterial anastomosis were analyzed. The overall flap survival rate was 94.9%. Flap re-exploration and flap failure rates were higher in the ETE group, although the difference was not statistically significant. Single venous anastomosis was performed in 56.8% of flaps. Most flaps were anastomosed with the deep/concomitant venous system (45.6%). There were no statistically significant differences regarding these venous anastomosis data. There was not any statistically significant difference between upper and lower extremities, either. ETS or ETE arterial anastomosis, number of the veins or the selection of the deep/concomitant or superficial/subcutaneous system do not affect the flap survival and re-exploration rates, so the decision should be made according to the flap strategy or the condition of the vessels regarding the zone of injury. All techniques provide similar outcomes when performed properly.

Lower extremity (LE) muscle free flaps (MFF) require split-thickness skin grafts (STSG) for coverage. Medically comorbid patients undergoing MFFs have demonstrated surprisingly high rates of skin graft failure over the MFF. This study therefore characterizes the risks for STSG failure and the effect of staging STSG on graft outcomes in medically comorbid patients. A retrospective review of patients undergoing STSG for LE MFF coverage between 2011 and 2023 was performed. Demographics, comorbidities, MFF details, STSG details, and complications were collected. The primary outcome was graft failure. Ninety-one patients underwent MFF and STSG, with 65 (71.4%) undergoing immediate STSG and 26 (28.6%) undergoing delayed STSG, at a median of 12 days (IQR = 9) after MFF. The delayed group had a significantly higher Charlson Comorbidity Index (5.6 vs. 3.7, p < 0.001). The overall graft failure rate was 31.5%, with no differences between groups (immediate: 27% vs. delayed: 42.3%, p = 0.157). On multivariable analysis, elevated preoperative HbA1c (OR: 1.5, CI = 1.1-1.9), low levels of albumin preoperatively (OR: 0.3, CI: 0.1-0.9), and a history of Charcot arthropathy (OR: 8.6, CI: 1.3-55.2) were independent predictors of graft failure. Little evidence exists to help guide the decision to perform immediate versus delayed skin grafting of MFFs in a highly comorbid population undergoing limb salvage. Delaying skin grafts in patients with significant comorbidities that threaten flap viability and wound healing capacity may improve graft take. Patient comorbidities, nutritional status, and intraoperative factors should also be considered when determining the timing of skin grafts over MFF.

Pure skin perforator (PSP) flaps had shown their reliability and usefulness for the reconstruction of thin soft-tissue defects. However, accurate localization of PSP is required for safe and fast flap elevation. This study aimed to evaluate the usefulness of conventional high-frequency ultrasound (US) for PSP flap elevation. Patients who underwent reconstruction using PSP flap based on the superficial branch of the superficial circumflex iliac artery (SCIA) were retrospectively included and divided into two groups according to the use of preoperative US mapping of SCIA PSPs; a portable US device with an 18 MHz probe was used to localize the PSP in a US group, whereas US was not used in a control group. Intraoperative findings and postoperative results were compared between the groups. Twenty-seven patients were included: 12 in the US group and 15 in the control group. There were no statistically significant differences in patient characteristics and postoperative results between the groups; both groups showed flap survival without major complications in all cases. Flap thickness ranged from 1.0 to 2.5 mm (average, 1.87 mm). Time for flap harvest was significantly shorter in the US group than in the control group (18.9 ± 4.5 vs. 50.5 ± 20.8 min, p < 0.001). Preoperative mapping of PSP using high-frequency US allowed reducing the surgical time for harvesting PSP flaps.

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

The optimal method for maintaining intraoperative blood pressure during microsurgical procedures remains controversial. While intravenous fluid administration is essential, overfilling can lead to complications. Vasopressor agents are used cautiously due to their vasoconstrictive effects, which could potentially lead to flap failure. Numerous studies have explored the possible link between amine administration and free flap failure, yielding inconsistent results. This study aims to determine whether intraoperative norepinephrine administration increases the flap failure rate in microsurgical breast reconstructions. All women (n = 335) who underwent breast reconstruction using DIEP or PAP flaps (n = 400) in 2018 and 2022 in the Plastic Surgery Department of Georges-Pompidou European Hospital (Paris, France) were included in the study. These patients were classified into two groups based on the intraoperative administration of norepinephrine: the N+ group (50 patients) and the N- group (285 patients). Norepinephrine was administered when systolic blood pressure fell below 90 mmHg or mean arterial pressure (MAP) dropped below 65 mmHg, following fluid resuscitation in 2018, or without prior fluid loading in 2022. The primary endpoint was total flap loss. Secondary endpoints included arterial and venous thrombosis and the need for revision surgeries. Norepinephrine administration significantly increased the risk of total flap loss in DIEP and PAP flap surgeries (p < 0.001). It also heightened the risk of arterial thrombosis (p = 0.002) and venous thrombosis (p = 0.04), and led to a greater number of revision surgeries (p < 0.001). Subgroup analysis indicated that PAP flaps are more sensitive to norepinephrine compared to DIEP flaps. Our study suggests that the intraoperative administration of any dose of norepinephrine is associated with an increased risk of flap failure in breast reconstructive microsurgery using DIEP and PAP flaps.

The Charles procedure (CP) is a potentially devastating treatment; however, in cases of an end stage of untreated or improperly treated lymphedema, it is the ultimate surgical therapy. As a life-saving solution, it quickly relieves patients with giant, hypertrophic extremities, mostly in ambulation and hygiene maintenance. Nevertheless, long-term results may disappoint both doctors and patients, who struggle with social stigma, the need for lifelong compression, massive lymphoedema in the distal parts of the feet, badly fitting shoes, excessive skin fibrosis, severe keratinization of skin-grafted surfaces, periodic lymphorrhea from the resected areas, or acute and chronic inflammation. For these reasons, patients may seek further surgical help, even many years after treatment. This article describes findings in fluorescent lymphography with indocyanine green (ICG-L) in four patients (49, 56, 56 years old females and 35 years old males) after CP and outcomes of treatment with lymphaticovenous anastomosis (LVA). In all patients, nonresected areas of the dorsum of the feet showed massive lymphedema stage II to III with dermal backflow (DB). In two patients, resected and skin-grafted areas showed deep subfascial lymphatics with lazy flow and no DB. In the remaining two cases, resected areas showed massive DB. Patients were reluctant to undergo further extensive surgical treatment with lymph node transfers due to the trauma experienced after CP. Since they still struggle with residual lower extremity lymphedema in unresected areas of the lower limbs, we performed minimally invasive, physiologic LVA surgeries in their feet, and in one patient in proximal thighs. In all cases, the postoperative course was uneventful. The treatment brought relief, reducing the circumference of the feet by ~2 cm, and allowed the return to previously used shoes in a follow-up of 18-36 months. This is the first report of ICG-L findings in CP patients, who benefit from minimal invasive LVA surgery. This information might help improve the life quality of patients after CP.

Open abdomen treatment (OAT) is associated with significant morbidity and mortality. In cases where primary or delayed fascial closure cannot be achieved, vacuum-assisted wound closure and mesh-mediated fascial traction are indicated, which often result in a planned ventral hernia. If secondary skin closure is not feasible, common treatment of granulated abdominal defects involves split-thickness skin-grafting or healing by secondary intention leading to significant scarring and sometimes mutilating defects. Late enteroatmospheric fistulae may develop as a result of instable scar tissue or insufficient soft tissue coverage. Perforator propeller flaps have been described for reconstruction of soft tissue defects of the abdomen; however, not for OAT-induced abdominal defects. We report two complex cases of OAT-induced abdominal wall defects of 20 × 8 and 22 × 10 cm, which were reconstructed with a propeller flap based on the superior epigastric artery perforator in the first case and the deep inferior epigastric artery perforator in the second case. The flaps were rotated into each of the abdominal defects following the propeller flap concept with primary closure of the donor sites and successful reconstruction of both defects. At 1-year follow-up, both patients developed asymptomatic incisional ventral hernias. Secondary-stage abdominal wall reconstruction was not considered due to satisfaction with the reconstructive result and feared complications. Pedicled perforator flaps designed based on either the superior or deep inferior epigastric artery system are useful reconstructive options for midline abdominal defects without necessity for pedicle lengthening, microsurgical anastomosis, or another donor site beyond the abdomen. In conclusion, soft tissue coverage of OAT-induced abdominal defects in critically ill patients can be achieved with the presented propeller flaps avoiding poor results of skin grafting or secondary intention healing.

Intraoral anastomosis is a widely used technique for microvascular alveolar ridge augmentation and midface reconstruction. However, the predictable anatomical positioning of facial structures, such as the vessels, parotid duct, and facial nerve in the buccal region, has remained unclear. Therefore, we aimed to obtain the anatomical characteristics of these locations to establish surgical landmarks for the intraoral anastomosis of facial vessels. A total of 26 sides from 13 formaldehyde-fixed cadavers approximately a month after fixation with a mean age at death of 86.6 ± 11.2 years (range: 55-104 years) were anatomically examined. Facial vessels, nerves, and the parotid duct were dissected intraorally. From the oral cavity side, the X-axis was defined as the line from the labial commissure to the lowest point of the intertragic notch. From the oral cavity side, all branches of the facial nerve were found under the facial artery and vein. The positioning order along the X-axis was the facial artery, vein, and parotid duct exit. The facial artery was 21.3 ± 2.2 mm and the facial vein was 39.2 ± 2.7 mm from the labial commissure. Ninety-two percent of facial veins were found within 15-20 mm of the facial artery on the X-axis. The parotid duct exit was 46.8 ± 2.0 mm from the labial commissure. In the buccal region, the vessel calibers of the facial artery and vein were 1.8 ± 0.2 and 2.1 ± 0.2 mm, respectively. Knowledge of the anatomical relations among the facial artery, vein, parotid duct, and facial nerve from the oral cavity side can enhance the safety and efficacy of midface reconstruction surgeries involving intraoral anastomosis procedures.