Microsurgery最新文献

Reconstruction of complex Achilles tendon defects involving both the tendon and the overlying soft tissues represents a challenging scenario for plastic surgeons. In this report, we present an innovative technique of hybrid total Achilles tendon reconstruction combining acellular dermal matrix placement to restore the full-thickness continuity of the tendon and free latissimus dorsi (LD) flap coverage to allow graft integration and simultaneously resurface the soft tissue defect, ultimately leading to lower limb salvage. Between August 2023 and February 2024 two patients received microsurgical hybrid reconstruction of complex defects, measuring 10 × 10 cm and 17 × 14 cm, respectively, involving the lower third of the leg and the Achilles tendon region, due to trauma with multiple previous failed surgeries and sarcoma resection. The full-thickness continuity of the tendon was reconstructed by use of an XCM BIOLOGIC Tissue Matrix (DePuy Synthes, Johnson & Johnson), measuring 6 and 10 cm long, respectively, folded in a three-layered tridimensional structure to recreate the shape and function of a new tendon. Subsequently, a free myo-cutaneous LD flap, was used to wrap and revascularize the neo-tendon and resurface the soft tissue defect. In both patients the flaps healed uneventfully, and neo-tendon integration was documented by MRI examination. The follow-up was uneventful. Long-term functional evaluation showed almost normal tendon excursion with both patients walking without assistance. The proposed hybrid approach may be a good alternative and innovative solution for the reconstruction of complex Achilles tendon defects consequent to trauma or oncological resection. Such results are more than promising for future studies on large series of patients.

Free-flap reconstruction of head-and-neck defects is often complicated by a vessel-depleted neck after prior surgery or radiotherapy. Conventional alternatives—such as using contralateral vessels, distant recipient vessels, or interpositional vein grafts—are technically demanding and associated with additional risks. We present two salvage reconstructions in which the vascular pedicle of a previously transferred free flap was reused as recipient vessels when standard options were unavailable. A 79-year-old man developed exposure of a titanium mandibular plate 6 years after mandibular resection reconstructed with a free anterolateral thigh (ALT) flap. Preoperative ultrasonography and contrast-enhanced computed tomography confirmed patency of the ALT flap pedicle despite dense fibrosis. After removal of the exposed plate, the pedicle was carefully dissected, and a scapular osteocutaneous flap (9 × 12 cm skin, 2.5 × 11 cm bone) was anastomosed to the lateral circumflex femoral artery and vein of the existing pedicle. Both flaps survived, and postoperative cholecystitis was managed conservatively. In another case, a 63-year-old man with a history of reconstruction using a free ALT flap for recurrent temporal meningioma developed another recurrence 2 years later. Imaging confirmed patency of the previous pedicle. During salvage surgery, the pedicle was dissected, and a free rectus-abdominis flap (9 × 20 cm) was harvested. Arterial anastomosis was performed to the artery of the previous ALT pedicle, and venous drainage was established directly into the internal jugular vein due to insufficient pedicle vein caliber. Intraoperative indocyanine green fluorescence angiography confirmed flap perfusion, and both flaps healed uneventfully. These cases show that reusing the vascular pedicle of a prior free flap may provide a practical salvage option in vessel-depleted necks. Careful preoperative imaging, intraoperative assessment of flap viability, and meticulous microsurgical technique are essential for success. This approach suggests that pedicle reuse may simplify salvage reconstruction while preserving previously transferred flaps when conventional recipient vessels are unavailable.