Microsurgery最新文献

Free fillet flap reconstruction transfers composite tissue from an unsalvageable limb to repair a separate defect. We report a case of free fillet flaps based on the posterior tibial artery (PTA) and anterior tibial artery (ATA). A 41-year-old man was crushed under a truck; his right leg suffered an open tibia and fibula fracture (Gustilo IIIB) with extensive soft tissue loss, while his left foot was amputated at the tarsal level. He initially underwent Chopart-level amputation of the left limb, which was subsequently revised to a below-knee amputation. Two free fillet flaps were harvested from the amputated limb: one based on the PTA (15 × 13 cm) and the other based on the ATA (20 × 8 cm). Two chain-linked fillet flaps via flow-through anastomosis were used to cover the soft tissue defect exposing the right tibia. Postoperatively, partial necrosis occurred in the ATA-based fillet flap, which healed after reoperation. The patient regained mobility with a prosthesis. Free chain-linked fillet flaps harvested from a limited amputation segment are a feasible and useful option for reconstructing complex soft tissue defects without additional donor site morbidity.

Head and neck lymphedema is a common complication of head and neck cancer treatment. Lymphovenous bypass is a promising surgical treatment but may not be an option for all patients after radiotherapy due to the obliteration of local lymphatic targets for bypass. We aim to present vascularized lymph node transfer (VLNT) as a solution to this problem. We report the case of a 38-year-old patient with Stage 2 face and neck lymphedema after treatment for T4aN1oral squamous cell carcinoma, who had no targets for lymphovenous bypass. The patient was treated with a 6 by 14 cm fasciocutaneous VLNT based on the left superficial circumflex iliac artery and vein, to the right facial vein and facial artery. The patient was given a low-dose heparin infusion, placed in a head bolster to prevent neck rotation, and discharged with low-dose aspirin. 4.5 months after free flap reconstruction, the patient underwent revision of the flap including indocyanine green lymphatic mapping, thinning with lymph-sparing liposuction, and re-advancement with Z-plasty for contour. At 11 months, the patient experienced a reduction of swelling, improvement of symptoms, and no further need for compression and manual lymphatic drainage. The area of greatest mobility impairment was resurfaced with flap skin, improving subjective tightness. Indocyanine green imaging at 4 months and 11 months revealed linear lymphatics traversing from the facial skin into the flap. Facial dermal thickness on ultrasound decreased from 1.43 to 1.09 mm between 4 and 11 months postoperatively. Fasciocutaneous VLNT has the potential to restore lymphatic drainage, improving swelling and tightness for patients with head and neck lymphedema who do not have lymphatic targets for bypass. Future studies on head and neck lymphedema should routinely employ ultrasound measurement of dermal thickness as an objective measure.

Chronic osteomyelitis of the midfoot, particularly following high-energy trauma such as a landmine injury, presents a formidable challenge due to the region's limited soft tissue envelope, complex anatomy, and the critical need for effective and durable dead space obliteration. While various flap options have been described, there remains no consensus on the optimal approach for managing deep defects in the midfoot, especially in cases complicated by prior surgical procedures. We present the case of a 23-year-old male who developed chronic midfoot osteomyelitis following a landmine explosion. Despite multiple debridements, targeted antibiotic therapy, and initial soft tissue coverage with an anterolateral thigh (ALT) flap, a persistent 6 × 5 cm (30 cm³) dead space remained, consistent with a Cierny–Mader type III-A classification. A segmentally harvested gracilis muscle flap was designed and sculpted to conform to the dimensions of the cavity, then inset into the defect. Microvascular end-to-side anastomosis was performed to the anterior tibial artery and two accompanying veins, and the flap was covered with a split-thickness skin graft. The postoperative course was uneventful at the recipient site. Mild serous drainage from the donor site, attributed to fat necrosis, resolved completely with conservative elastic compression therapy. At 12-month follow-up, the patient remained infection-free, was fully ambulatory without assistance, and imaging confirmed complete obliteration of the dead space. This case suggests that a segmentally harvested gracilis muscle flap may offer a viable, anatomically conforming single-stage option for managing complex midfoot osteomyelitis in selected patients. In individuals with prior treatment failure, this approach may help reduce surgical burden, enhance infection control, and support not only physical but also psychological recovery through resolution of a prolonged disease course.

In recent years, the thoracoacromial artery perforator (TAAP) flap has emerged as a promising option for the reconstruction of facial defects, typically utilized in the form of a pedicled flap. However, there remains relatively limited experience in using a free TAAP to repair facial defects. This case describes the first application of a free bilobed TAAP for one-stage reconstruction of multiple facial defects after resecting cutaneous squamous cell carcinomas (cSCC). The patient was a 76-year-old man who noticed progressive enlargement of two black neoplasms around the left and right nose for over 1 year and 3 months, respectively. A preoperative biopsy confirmed both lesions as cSCC. During surgery, two skin and soft tissue defects, measuring approximately 6.5 cm × 3.0 cm and 3.5 cm × 2.0 cm, were left in the bilateral paranasal regions after the removal of tumors. A free bilobed TAAP flap of the appropriate size was designed and harvested to repair these defects. The postoperative course was uneventful, and the patient recovered without complications. Good esthetic and functional outcomes were achieved during a 14-month follow-up period. This report suggests that a free bilobed TAAP flap may be an option for reconstructing multiple facial defects caused by trauma, tumor resection, or other lesions.