Vascular malformations often become symptomatic during childhood and require multidisciplinary intervention. However, reports of resection followed by free flap reconstruction in pediatric patients remain rare. We report two toddler cases of vascular malformations reconstructed with free anterolateral thigh (ALT) flaps. Case 1 was a 2-year-old boy with a submandibular venous malformation complicated by coagulopathy. After lesion resection with overlying skin (5 × 10 cm), an ALT flap (5.5 × 12 cm) was transferred. The flap artery was interposed with the transected facial artery, and the veins were anastomosed end-to-side to the internal and external jugular veins. The flap survived completely, and coagulation parameters normalized. Case 2 was a 3-year-old boy with a painful forearm ulcer caused by a capillary lymphatic venous malformation. After ulcer debridement (5.5 × 13 cm), the defect was reconstructed with an ALT flap (6 × 14 cm). The flap vessels were anastomosed to the radial artery and its concomitant veins in a flow-through manner. Partial flap necrosis required secondary wound closure, but the ulcer did not recur, and the pain resolved completely. No anastomotic failure or donor-site complications occurred in either case. Extensive resection followed by ALT flap reconstruction is a reliable option for pediatric vascular malformations. Meticulous microvascular techniques and multiple anastomoses may reduce microvascular complications in young patients.
Reconstruction of the columella, one of the smallest facial subunits, presents significant aesthetic and functional challenges due to its complex anatomy, limited local tissue for repair, and restricted vascularisation. Although many methods are described, literature on microsurgical solutions for complex secondary reconstructions, especially after conventional methods have failed, remains limited. This report introduces a tailored, single-stage approach that combines a first web space free flap from the foot with an iliac bone graft to provide both soft tissue coverage and structural support, while also reviewing other microsurgical techniques. A 24-year-old patient presented with a severe deformity, including a shortened columella, depressed nasal tip, and a scar extending to the right upper lip, causing alopecia in the mustache area due to a shrapnel injury during the Palestine War. After excising scar tissue and a necrotic L-strut from a previous failed surgery, a 2 × 3 cm columellar and septal defect was created. A fasciocutaneous free flap from the first web space of the foot was planned as a 2.5 × 4 cm rectangle, positioned transversely over the first web space and microsurgically transferred for end-to-end anastomosis to the angular artery and vein, then folded over an iliac bone graft to provide both external skin coverage and internal lining. The postoperative course was uneventful, and the patient was discharged on the fifth day. At the one-year follow-up, the reconstructed columella remained stable, and the patient expressed high satisfaction with the final aesthetic and functional results. This report shows that the first web space free flap, combined with a structural bone graft, offers a single-stage solution for complex columellar defects, providing a tailored approach when conventional methods have failed or are insufficient. The novelty of this approach lies in using an iliac bone graft, which offers strong and durable support capable of resisting scar contracture and maintaining long-term nasal tip projection despite heavily scarred tissue. Compared with other reviewed techniques, this single-stage approach avoids the multiple procedures required for prefabricated flaps and reduces donor site morbidity or bulkiness. Furthermore, its long vascular pedicle is an advantage over shorter-pedicled auricular or hand flaps, while the robust bone graft supplies a more durable framework against the contractile forces of compromised local tissue than cartilage-based reconstructions.
Traditional oropharyngeal resection may require lip-split mandibulotomy approach (LSMA) which risks high morbidity. Transoral robotic surgery (TORS) through the oral pharynx mitigates these risks. Free flap (FF) inset following resection is challenging and may require open approaches, negating the benefits of TORS resection. We present our case series utilizing the single port (SP) robot for FF inset, which has improved visualization and functionality compared with a multiport robot.
A retrospective review of robotic FF inset following TORS using the SP from 2021 to 2022. Patient and tumor characteristics as well as operative and postoperative details were gathered.
Five cases were performed with an average age of 62.4 (50–78) years. Radial forearm FF was used in three cases and anterolateral thigh flap in two. Mean operative time was 528 (423–742) minutes with an average ischemia time of 156.6 (124–198) min. Average functional oral intake score was 5.8 (3–7) out of 7. There were no FF losses or wound healing issues at an average of 17.6 (7–27) months follow-up.
Robotic FF inset following TORS is feasible with the SP robot already used by ENTs for resection. The platform has 6 mm instruments capable of 7 degrees of freedom, use of a third arm for dynamic retraction, and the ability to assume a “cobra-like” position to leverage a tight space. This gives plastic surgeons an opportunity to decrease the complication profile from FF inset that would otherwise require potentially morbid exposures.
Reconstruction of pretibial defects remains challenging due to frequent bone exposure, lack of local flap options, and thin soft tissue coverage. These factors make achieving durable and aesthetically pleasing coverage difficult, often necessitating the use of free flaps to ensure successful reconstruction. This case report presents the case of a 68-year-old woman with a pretibial undifferentiated pleomorphic sarcoma treated with neoadjuvant radiotherapy and wide local excision, resulting in a 12 × 10 cm soft tissue defect with tibial bone exposure. Reconstruction was achieved using a combination of two perforator-based local flaps: A pedicled medial sural artery perforator (MSAP) flap for the medial aspect and a V-Y advancement flap based on an anterior tibial artery perforator for the lateral aspect. Postoperative recovery was uneventful. At one-year follow-up, the reconstruction showed stable coverage, satisfactory contour, and no signs of recurrence of the tumor or lymphedema. The combination of local perforator flaps offers a reliable and aesthetically favorable solution for complex pretibial defects. It allows surgeons to avoid microsurgical procedures, thereby reducing operative time, technical demands, and perioperative risks. This case highlights the potential of combining local flaps, preserving uninvolved donor sites, and minimizing overall morbidity. This solution represents a practical and effective alternative to free flap reconstruction and may contribute to expanding the reconstructive options available for managing complex lower limb defects.
The radial forearm free flap (RFFF) is a versatile free flap in the reconstruction of head and neck defects. There is little consensus on the optimal technique for reconstructing RFFF donor site defects. Our group previously reported early results using staged reconstruction with initial placement of Integra, a dermal regeneration matrix, followed by a split thickness skin graft (STSG), resulting in excellent aesthetic and functional outcomes. Here we provide our long-term experience using staged STSG compared to primary STSG for the reconstruction of RFFF donor site defects.
Patients undergoing RFFF reconstruction of head and neck defects at a single institution between May 2012 and April 2023 were retrospectively reviewed. Primary versus staged STSG placement was compared in terms of donor site morbidity.
A total of 179 patients were included: 46 (25.7%) primary STSG and 133 (73.3%) staged STSG. Following primary STSG, 34 (73.9%) patients had a vacuum-assisted closure (VAC) and 12 (26.1%) had an iodine-coated petroleum gauze bolster placed. In the staged STSG group, all patients had a VAC after Integra placement. After the second stage, 30 (22.6%) patients had a VAC, and 103 (77.4%) patients had a bolster placed. Compared to the staged group, the primary group had a significantly higher rate of skin graft breakdown (21.7% vs. 6.0%; p = 0.008) and tendon exposure (19.6% vs. 3.8%; p = 0.002). In the staged group, bolster placement was associated with a lower rate of skin graft breakdown compared to VAC (2.9% vs. 16.7%; p = 0.015).
When reconstructing donor site defects following RFFFs, staged reconstruction with initial placement of Integra followed by STSG and bolster placement may result in lower rates of skin graft breakdown and tendon exposure.
Phalloplasty plays an important role in female-to-male (FTM) gender affirmation surgery to create a neophallus that prioritizes aesthetic and functional outcomes. Patients have a variety of flap choices for phalloplasty, but they can often come with complications. This study aimed to evaluate the impact of flap choice on the rate of complications in phalloplasty.
This retrospective cohort study was conducted at a single institution of adult patients who underwent either phalloplasty with radial forearm (RFFF), anterolateral thigh (ALT) pedicled flaps, or pedicled abdominal flaps. Complications of urethral stricture, urethral fistula, necrosis of neophallus, infection, wound dehiscence, and flap loss were analyzed.
A total of 57 patients underwent phalloplasty. RFFF was used in 25 (43.9%) patients, ALT flaps in 10 (17.5%) patients, and pedicled abdominal flaps in 22 (38.6%) patients. The overall complication rate was 61.4%. RFFF had the highest complication rate (80%), followed by ALT (60%) and pedicled abdominal flaps (40.9%) (p = 0.023). RFFF had the highest rate of urological complications (60%) (p = 0.013), including fistulas (48%) compared to ALT (20%) and pedicled abdominal flaps (9.1%) (p = 0.011), and urethral strictures (44%) compared to ALT (20%) and pedicled abdominal flaps (22.7%) (p = 0.24). RFFF required more reoperations (64%) compared to ALT (40%) and pedicled abdominal flaps (31.8%) (p = 0.082). On multivariate analysis, patients experiencing complications were more likely to have blood thinners (OR = 1.85, 95% CI: 1.05–3.25, p = 0.039) and less likely to undergo staged phalloplasty (OR = 0.91, 95% CI: 0.32–2.61).
Flap choice for phalloplasty requires careful consideration between patients and providers. Pedicled abdominal flaps were associated with fewer complications, such as fistulas, urethral strictures, and reoperations. However, patients may opt for RFFF to maximize aesthetic outcomes despite such risks. Insight into clinical outcomes is vital to both surgeons and their patients to enhance the shared decision-making process.
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