Lymphatic vessel thrombosis is a rare finding, and its role in the development of lymphedema remains unclear. Secondary lymphedema is usually related to oncologic lymph node dissection, radiotherapy, infection, or major tissue trauma. In contrast, focal lymphatic obstruction after minor limb trauma has rarely been described. We report the case of a 71-year-old woman who developed progressive Stage II lymphedema of the left lower limb after a minor trauma without fracture. Preoperative examination showed persistent lower-limb swelling with a focal medial proximal lower-leg nodule, and conservative treatment with manual lymphatic drainage and compression produced only partial improvement. Venous duplex ultrasound and magnetic resonance imaging excluded venous obstruction, tumor, or muscular injury. Ultrasound suggested a lymphatic rather than venous origin of the focal lesion, while lymphoscintigraphy with SPECT/CT demonstrated an interruption of lymphatic drainage at the medial proximal lower leg, associated with a 17-mm subcutaneous fluid collection consistent with a lymphocele. Intraoperatively, the lymphocele was excised and an intact but dilated collecting lymphatic vessel distal to the obstruction was identified. After opening the vessel, intraluminal thrombotic material was removed, resulting in restoration of spontaneous lymphatic flow. Lymphaticovenous anastomosis was then performed using the recovered lymphatic vessel, with intraoperative confirmation of patency and lymphatic washout. The postoperative course was uneventful, with significant clinical improvement confirmed at 6 months follow-up. This case supports the hypothesis that lymphatic thrombosis may occur after minor trauma and may directly contribute to secondary lymphedema, although longer follow-up and objective outcome assessment are required.
BACKGROUND:The "rib-sparing" method of autologous breast reconstruction has gained popularity alongside the historically used "rib-sacrificing" technique. Literature has endorsed benefits of the "rib-sparing" technique, including reduced contour irregularities, postoperative morphine use, and operative time. However, higher rates of fat necrosis and thromboembolic complications have been reported with this method. This study aims to compare postoperative complications in those undergoing rib-sparing and rib-sacrificing free flap breast reconstruction using a large-scale database. METHODS:A retrospective cohort study was conducted using the US Collaborative Network in TriNetX. Two cohorts were identified: those who underwent a free flap breast reconstruction (CPT 16634) and those who underwent a free flap breast reconstruction and a partial rib excision (CPT 21600). Propensity score matching for age and type of previous mastectomy was performed. Complications tabulated within 3 months of reconstruction were fat necrosis, hematoma/seroma, infection, dehiscence/necrosis, and venous thromboembolism. Mastodynia and deformity/disproportion within 8-18 months and reconstruction within 6-10 years of reconstruction were also tabulated. RESULTS:Propensity score matching yielded 992 subjects with a mean age of 50 ± 9.7 in each group. No difference was found between the rib-sparing and rib-sacrificing cohorts within the perioperative window for the included complications: hematoma/seroma (8.1% vs. 8.1%; p = 1.00), infection (p = 14.4% vs. 12.3%; 0.166), dehiscence/necrosis (9.2% vs. 7.6%; p = 0.195), and VTE (5.1% vs. 5.3%; p = 0.857). The rib sacrificing cohort were at 1.28 times increase risk for experiencing fat necrosis (12.9% vs. 10.1%; 95% CI: 1.00-1.64; p = 0.049). No difference was found in incidence of mastodynia (4.8% vs. 3.5%; p = 0.145) or dehiscence/necrosis (24.8% vs. 26.8%; p = 0.305) within 8-18 months. Subjects in the rib-sacrificing cohort were found to be at 1.21 (35.9% vs. 32.2%; 95% CI: 1.08-1.35;p < 0.001) times increased risk to undergo a revision within 6-10 years following initial reconstruction. CONCLUSIONS:Those who underwent rib-sacrificing reconstruction have a mild increased risk of experiencing fat necrosis and a revision in the 3 months and 6-10 years following initial reconstruction, respectively. Surgeons should consider the nuanced risks and benefits of both techniques and prioritize patient-centered decision-making.
BACKGROUND:The use of intraoperative vasopressors during microvascular free flap reconstruction remains controversial due to concerns regarding vasoconstriction and impaired flap perfusion. This study evaluates the association between vasopressor use and postoperative outcomes across a large, multicenter cohort. METHODS:A retrospective cohort study was performed using the TriNetX Collaborative Network. Adult patients undergoing free flap reconstruction were identified and stratified by intraoperative vasopressor exposure. Propensity score matching (1:1) was used to balance baseline characteristics. Outcomes within 90 days included flap-related complications, wound complications, reoperation, and mortality. Subgroup analyses were conducted by flap type and vasopressor agent. RESULTS:A total of 43,157 patients were identified, with 17,970 matched pairs included. Overall vasopressor use was associated with increased risks of infection (RR 1.10, 95% CI 1.05-1.15; p < 0.01) and wound dehiscence (RR 1.09, 95% CI 1.02-1.15; p = 0.01), and decreased rates of debridement (RR 0.84, 95% CI 0.78-0.90; p < 0.01). Phenylephrine demonstrated the most consistent association with adverse wound outcomes, including infection (RR 1.17, 95% CI 1.10-1.24; p < 0.01), dehiscence (RR 1.15, 95% CI 1.06-1.24; p < 0.01), skin graft failure (RR 1.17, 95% CI 1.03-1.33; p = 0.02), and anastomotic revision (RR 1.29, 95% CI 1.02-1.65; p = 0.04). Breast reconstructions showed higher complication rates with vasopressor exposure, extremity reconstructions demonstrated minimal differences, and head and neck reconstructions showed increased infection, skin graft failure, and mortality. No consistent increase in flap failure or reoperation rates was observed. CONCLUSIONS:Intraoperative vasopressor use is associated with modest increases in select postoperative complications, with variability by agent and flap type. Phenylephrine may carry higher risk, while other agents demonstrate more neutral effects. These findings support a selective, context-dependent approach to vasopressor use during free flap reconstruction.
BACKGROUND:Venous congestion remains a leading cause of early free flap failure in lower extremity reconstruction. Although double venous anastomosis has been proposed to enhance venous outflow, its benefit over single venous anastomosis remains controversial. This study aimed to compare complication rates between single and double venous anastomoses in lower extremity free flap reconstruction across different etiologies. METHODS:A retrospective review was conducted of 134 patients who underwent lower extremity soft tissue reconstruction with free flaps between 2015 and 2023. Patients were divided into single venous anastomosis (Group 1, n = 81) and double venous anastomosis (Group 2, n = 53) groups. Group 2 was further subdivided according to venous drainage configuration (double superficial, double deep, and dual-system). Demographics, comorbidities, flap characteristics, and complication rates were analyzed. Major complications included total flap loss and return to the operating room (OR); minor complications included wound-related problems not requiring additional flap coverage. RESULTS:Overall, 26 major complications and 9 total flap losses occurred. Group 1 demonstrated significantly higher overall, major, and minor complication rates compared with Group 2 (p < 0.05). Total flap loss rates were comparable between groups. No significant differences were found among double venous anastomosis subgroups with respect to complication rates. CONCLUSIONS:Double venous anastomosis in lower extremity free flap reconstruction is associated with a significant reduction in overall and perioperative complications, although total flap survival remains similar. These findings support consideration of dual venous outflow, particularly in high-risk lower extremity reconstructions, while emphasizing the importance of individualized recipient vein selection.
BACKGROUND:Supination posture is a common secondary deformity in brachial plexus birth injury (BPBI) that results in functional upper limb impairment. Radioulnar synostosis using a vascularized ulnar periosteal flap has recently been reported, with dorsal forearm scarring as the main reported disadvantage. This report evaluates outcomes in a series of children with forearm supination deformity and complete pronation palsy secondary to severe BPBI undergoing radioulnar synostosis in slight pronation using a novel proximal pedicled vascularized radial periosteal flap (VRPF). METHODS:We completed a retrospective analysis of patients with residual BPBI who underwent radioulnar synostosis with an antegrade proximally pedicled VRPF transfer to the volar ulna. The interosseous membrane was released when necessary, and the forearm was fixed in 10°-20° of pronation for 4 weeks, using a Kirschner wire. Inclusion criteria included complete pronation paralysis, presence of active wrist extension, and a minimum of 6 months follow-up. Demographic information, preoperative passive pronation, postoperative forearm rotational position, radiographic union, and parental satisfaction using a 4-point Likert-type ordinal scale were evaluated. RESULTS:Twenty-one children with a mean age of 59 months (range 24-132 months) were included in this report. Mean preoperative passive forearm pronation was -9° (range -60° to 45°) and mean follow-up was 17.1 months (range 9-32 months). A partially ossified radioulnar synostosis was radiographically observed at 4 weeks in all cases. Mean postoperative rotational position measured 20° of pronation (range 0°-30°). All parents expressed satisfaction with both functional and cosmetic outcomes. CONCLUSIONS:Forearm fusion achieved by radioulnar synostosis using a proximally pedicled VRPF appears promising as an effective and rapid technique for correction of BPBI-associated supination deformity and should be further explored in the management of residual supination deformity.
BACKGROUND:Flap pedicle thrombosis is a frequent cause of flap compromise, which is a major complication following free flap breast reconstruction. This study aims to investigate the relationship between preoperative coagulation parameters and the risk of postoperative flap pedicle thrombosis, providing guidance for preoperative assessment and perioperative management. METHODS:A retrospective analysis was conducted on all patients who underwent free flap breast reconstruction at our institution between January 2021 and August 2025. Patient demographics, surgical details, preoperative coagulation test results (including prothrombin time, activated partial thromboplastin time, fibrinogen, thrombin time, and D-dimer) and outcomes were recorded. Patients were categorized according to their preoperative coagulation test results. Demographics, surgical information, and incidence of flap pedicle thrombosis were compared between groups. Furthermore, patients were divided according to the occurrence of flap pedicle thrombosis. Preoperative coagulation parameters were compared between the two groups, and a multivariate logistic regression was performed to identify potential risk factors. RESULTS:A total of 154 patients (160 breasts) were included. Fifty-two breasts (32.5%) were categorized to the asymptomatic hypercoagulable group, and 108 breasts (67.5%) to the non-hypercoagulable group. Postoperative flap pedicle thrombosis occurred in nine breasts (5.6%), including two arterial thromboses and seven venous thromboses. No significant difference in postoperative flap pedicle thrombosis was observed between the two groups (9.6% vs. 3.7%, p = 0.152). Multivariate logistic regression indicated that immediate flap breast reconstruction might be an independent risk factor (p = 0.028). CONCLUSION:This study suggested no significant association between preoperative coagulation parameters (including PT, APTT, FIB, TT, and D-dimer) and flap pedicle thrombosis following free flap breast reconstruction.
In degloving injuries without associated fracture, osteomyelitis may be difficult to recognize, potentially delaying definitive treatment. We report a case and describe the role of a chimeric superficial circumflex iliac artery perforator (SCIP) flap with a sartorius muscle component for simultaneous dead-space obliteration and soft-tissue resurfacing. A 44-year-old man underwent free anterolateral thigh flap coverage 1 month after a medial ankle degloving injury. Two years later, a painless noninflammatory cystic lesion developed on the flap and recurred over 4 years despite three local debridements. At 6 years after injury, ultrasound, computed tomography, and magnetic resonance imaging demonstrated a sinus tract communicating with the navicular bone. Definitive debridement identified a retained anchor fragment within the navicular fistula and purulent tissue along the tract, resulting in a 4 × 10 cm soft-tissue defect and an approximately 7 × 8 × 14 mm intraosseous dead space. Single-stage reconstruction was performed using a chimeric SCIP flap with a 12 × 5 cm skin paddle and a 6 × 4.5 cm sartorius muscle segment. The muscle component obliterated the navicular cavity, and the skin paddle resurfaced the medial ankle defect. Culture grew Pseudomonas aeruginosa, and targeted antibiotics were administered for 14 weeks. Healing was uneventful. At 1 year, the patient remained symptom-free without recurrence. The erythrocyte sedimentation rate had returned to the normal range, and MRI showed resolution of navicular marrow edema. This case highlights the importance of thorough imaging in recurrent wound problems after degloving injury, even when the initial injury appears limited to the skin and soft tissue. A chimeric SCIP flap with a sartorius muscle component may be a useful single-stage option for osteomyelitis treatment requiring dead-space obliteration and thin soft-tissue coverage.
BACKGROUND:Reconstruction of elbow extension is an important aim after brachial plexus injury. In extended partial brachial plexus injuries affecting elbow extension, a variety of nerve transfer techniques have been described to neurotize triceps. Spinal accessory, ulnar fascicles, axillary branches, intercostal and phrenic nerves have all been reported. These donors have mostly been transferred to triceps brachii nerves; however, more proximal transfers have also been reported. Results with these techniques have been inconsistent. In extensive partial brachial plexus palsy, radial fascicular transfers, primarily aiming for the extensor carpi radialis longus (ECRL) fibers as donors, warranted further investigation for their efficacy in the restoration of elbow extension. PATIENTS AND METHODS:Single-surgeon case series of four consecutive patients (mean age: 32 years, range 22-46 years) over a 5-year period with traumatic brachial plexus palsies, including complete triceps weakness, underwent radial fascicular transfers incorporating ECRL donor fibers direct to triceps nerves. All had previously undergone nerve transfers for restoration of elbow flexion and shoulder function. Expendable radial fascicles (primary to ECRL with possible inclusion of other extensors including ECRB) were coapted to motor branches of triceps (medial or lateral head) using standard microsurgical techniques. All patients were followed clinically (mean: 19 months) and assessed for elbow extension strength (Medical Research Council grade), range of motion and any donor-site deficits. RESULTS:All patients regained functional elbow extension. Mean follow-up was 19 months (range 10-24 months). At final follow-up, elbow extension strength was MRC ≥ 4/5 in all cases (three patients achieved MRC grade 4/5, one achieved MRC grade 5/5). Elbow active range of motion reached was excellent. There were no wrist or finger extensor weakness/donor site deficits or postoperative surgical complications. CONCLUSION:Radial fascicular transfers using ECRL donor fibers direct to triceps nerves represent a safe and effective surgical technique for the restoration of elbow extension. As demonstrated in these 4 consecutive successful cases, patients with brachial plexus palsy including triceps palsy with preserved function in wrist extensors warrant consideration for this technique.
Reconstruction of buccal mucosal defects requires thin, pliable, and well-vascularized tissue to preserve oral function and cheek mobility. While the radial forearm free flap remains widely used, alternative ultra-thin options are needed, particularly in obese patients where conventional perforator flaps may be excessively thick. We report the case of a 59-year-old obese man (BMI 32 kg/m2) undergoing resection of a superficial squamous cell carcinoma of the left buccal mucosa, resulting in a wide 6 × 6 cm defect. Reconstruction was performed using a super-thin external pudendal artery (STEPA) free flap harvested from the hemiscrotum. The fasciocutaneous flap, measuring 6 × 6 cm, demonstrated uniform near-millimetric thickness (2-3 mm), allowing direct intraoral inset without the need for thinning. Microvascular anastomoses were performed to the facial vessels, and donor-site closure was achieved primarily. The postoperative course was uneventful, with early enteral feeding, progressive oral intake from day 10, and no complications. At 3 months of follow-up, the flap showed complete integration with preserved cheek mobility and satisfactory mouth opening. This case highlights that the STEPA free flap may represent a useful ultra-thin reconstructive option for buccal mucosal defects in selected patients, particularly when minimal flap thickness is required.
BACKGROUND:Benign facial nerve tumors have unique presentations granting distinct diagnostic and management implications. Unlike acute-onset facial paralysis, the gradual, intermittent course complicates diagnosis, treatment strategy, and timing, especially when considering potential reanimation. This study presents our institutional experience and proposes approaches to management and evaluation of patients with slowly progressive facial weakness due to benign tumors. METHODS:A retrospective review included patients between August 2009 and April 2026 with slowly progressive facial weakness or hemifacial spasm due to a benign facial nerve tumor. Demographics, facial palsy history, tumor characteristics, treatment strategies, reanimation procedures, and outcomes were analyzed. RESULTS:Fifteen patients met inclusion criteria with a mean age of onset of 45 years. Sixty-seven percent were initially misdiagnosed. Forty-seven percent presented with synkinesis. The most common tumor type was facial nerve schwannoma (60%). Forty percent underwent complete resection, 27% received radiation, and 27% are under observation. Six patients underwent dynamic facial reanimation: proactively (before tumor extirpation) in three cases, with one undergoing both proactive and concomitant reanimation during extirpation, concomitantly with extirpation in one, and following radiation in one. All achieved recovery of motion on average 3.7 months (range 2-7) later. Two patients are currently planned for reanimation. CONCLUSIONS:Benign facial nerve tumors require individualized management based on functional trajectory, tumor characteristics, and patient preference. Treatment options range from observation and radiation to surgical extirpation, but due to the slowly progressive and partial nature of the facial paralysis, the reanimation strategy is guided not only by mimetic musculature viability but also by patient preference on timing. In patients with progressive weakness and anticipated nerve sacrifice during extirpation, proactive reanimation using nerve transfers, cross facial nerve grafts, and free functional muscle transfer should be considered early to establish reinnervation pathways before the denervation window closes, avoiding irreversible facial paralysis.
BACKGROUND:Reliable localization of septocutaneous fibular artery perforators is essential for fibula free flap planning. However, the influence of lower-leg vascular anatomy on perforator number and spatial distribution remains unclear. This study aimed to analyze perforator number and spatial distribution using computed tomography angiography (CTA) with both fibula- and artery-based reference systems. METHODS:In this retrospective study, patients undergoing lower-extremity CTA before mandibular continuity resection were screened. Parameters included run-off status, Kim classification, vascular anomalies, atherosclerotic plaque, and morphometric characteristics of the fibula and fibular artery. Perforator number per limb and relative perforator position were assessed using fibula- and artery-based reference systems. Associations were evaluated using nonparametric tests and multivariable regression models. RESULTS:A total of 491 limbs from 247 patients were included, yielding 812 septocutaneous perforators. Limbs with fibular artery stenosis showed fewer perforators compared with limbs without stenosis (median 0.5 [0-2] vs. 2 [1-2], p < 0.001). Perforator distribution was nonuniform in both reference systems, with clustering in mid-segments (p < 0.001). Notably, spatial distribution patterns differed depending on the reference system used. In multivariable analyses, non-1A Kim run-off classification was associated with a more proximal perforator position along the fibula (β = -10.0 percentage points, p < 0.001), whereas no limb-level factor was associated with artery-referenced perforator position, indicating greater stability of artery-based mapping. CONCLUSION:Septocutaneous fibular artery perforators show reference-dependent spatial variability. Fibular artery stenosis is associated with fewer perforators, whereas only Kim run-off classification affects fibula-referenced location. These findings support artery-based mapping for fibula flap planning.
BACKGROUD:Laser Doppler flowmetry (LDF) is an established tool for monitoring free flaps, yet traditional devices are often bulky and difficult to interpret the value. We utilized portable LDF (pLDF), which is lightweight and allows for easier mobilization compared to conventional LDF systems. This study aimed to identify systemic factors affecting pLDF values to enable more objective clinical interpretation. METHODS:We retrospectively reviewed 65 free flaps in 64 patients over a 3-year period. All flaps were monitored using pLDF. A mixed-effects model was employed to explore factors influencing pLDF values. RESULTS:Two flaps (2.9%) developed vascular compromise, one of which was successfully salvaged after emergency reoperation. Statistical analysis revealed that pLDF values were significantly influenced by mean blood pressure (mBP) and hemoglobin concentration (Hb). Specifically, every 1 mmHg increase in mBP resulted in a 0.098 mL/min increase in the pLDF value (p < 0.001), and every 1 g/dL decrease in Hb resulted in a -0.883 mL/min increase in the pLDF value (p < 0.001). Other factors, including age, sex, recipient site, and history of smoking or hypertension, diabetes, demonstrated no significant differences. CONCLUSIONS:This study defined the quantitative relationship between systemic parameters and flap blood flow; specifically, 1 g/dL change in Hb is equivalent to 9 mmHg change in mBP in its effect on pLDF values. These findings provide a novel, objective formula for interpreting LDF data, allowing clinicians to distinguish systemic physiological changes from local vascular complications without relying solely on subjective experience.
BACKGROUND:Robot-assisted microsurgery with the Symani surgical system has emerged as a potential adjunct in complex reconstructive procedures. Its application in head and neck reconstruction remains early and incompletely characterized. We performed a systematic review to evaluate indications, technical utilization, and reported clinical outcomes of Symani-assisted microsurgery in head and neck reconstruction. METHODS:A systematic review was conducted in accordance with PRISMA guidelines. PubMed (MEDLINE), Embase, Scopus, and the Cochrane Library were searched for studies reporting Symani-assisted microsurgery in head and neck reconstruction. Primary outcomes were flap success and anastomotic complications. Secondary outcomes included operative time, conversion to conventional technique, ischemia time, reported learning curve metrics, and risk of bias. RESULTS:A total of eight studies encompassing 157 patients with 157 flaps were included. Study designs consisted primarily of case reports and retrospective case series. The Symani was used for arterial and/or venous anastomosis in free flap reconstruction, most commonly in radial forearm flaps and most commonly to the facial vessels. Flap success rates were high (> 95%) with only five requiring return to operating room and two flap losses; random-effects meta-analysis demonstrated a pooled flap loss rate of 3.3% (95% CI, 1.1%-9.1%; I2 = 0%). Anastomotic complication rates were reported to be low with conversion to conventional technique occurring in one case due to technical malfunction. Anastomosis times were poorly reported across studies. CONCLUSIONS:Early clinical experience suggests that robot-assisted microsurgery with the Symani surgical system in head and neck reconstruction is technically feasible with acceptable short-term outcomes in selected cases. However, evidence remains limited to small, heterogeneous series. Prospective comparative studies are required to determine whether robotic assistance confers meaningful clinical or efficiency advantages over conventional microsurgery and determine optimal operative indications.
The tracheoesophageal fistula (TOF) is defined as a pathological connection between the trachea and esophagus, both congenital and acquired. The latter is often associated with malignancies or their treatments. Reconstruction in this context is particularly challenging due to the defect's location, size, and compromised tissue quality. Here, we present for the first time the surgical treatment of TOF using a free superficial circumflex iliac artery perforator (SCIP) flap. Three patients were included in the present report (84-year-old female, 74-year-old male, 62-year-old male). Two patients developed a TOF following total laryngectomy combined with partial pharyngectomy, and one patient, following total laryngectomy without partial pharyngectomy. All the patients received a surgical treatment for a head and neck malignancy. The TOFs were successfully closed in three patients using a SCIP-Flap. The elevated SCIP-Flap measured on average 15 × 8 cm. In two cases, the return to a normal, oral diet was established within 1-3 months with successful vocal rehabilitation. The third case did not return to a complete oral diet because of a dehiscence and ongoing palliative chemotherapy. The other two patient underwent 1-year follow-up without complications. This report suggests that the SCIP flap could be a feasible low morbidity and relatively straightforward reconstructive option, yielding favorable postoperative outcomes for TOF even in cases of multiple prior surgeries and adjuvant radiochemotherapy treatment.
BACKGROUND:Delayed abdominal wound healing remains a common complication following abdominally based autologous breast reconstruction. We hypothesized that the type of umbilical inset incision impacts the incidence of delayed wound healing due to differential disruption of abdominal wall vascularity, particularly in the infraumbilical region. METHODS:A retrospective review was conducted of all patients undergoing abdominally based autologous breast reconstruction at a single center between 2014 and 2021. The primary outcome was delayed abdominal wound healing, classified as major (requiring readmission or reoperation), minor (managed with outpatient care, antibiotics, or debridement), or both. Umbilical inset incision type was evaluated as a predictor using univariate and multivariate analysis. RESULTS:Four hundred and eighty-eight patients and 791 flaps were included. Patients were on average 51 ± 9 years old and had a median body mass index of 28 (IQR 7) kg/m2. The most used umbilical incision was an elliptical incision (193, 40%) followed by vertical (141, 29%), inverted-U (30, 6%), other (39, 8%), and unknown (81, 17%). Abdominal wound healing complications occurred in 63 (13%) patients. The incidence of abdominal wound healing complications was lowest with elliptical incisions (p < 0.001). In a multivariate regression model controlling for age, BMI, diabetes, smoking history, and flap weight, umbilical incision predicted abdominal wound healing complications, with inverted-U and vertical incisions conferring higher odds of abdominal wound healing complications (OR 5.9, 95% CI [1.6, 20.8] and OR 4.6, 95% CI [2.0, 11.4], p < 0.05) as compared to elliptical incisions. CONCLUSION:Abdominal wall vascularity likely plays a critical role in donor site healing following autologous reconstruction. In this large cohort, inverted-U and vertical umbilical inset incisions were associated with the highest rates of wound healing complications.
BACKGROUND:Deep inferior epigastric artery perforator (DIEP) flaps are widely used in autologous breast reconstruction and increasingly favored due to superior patient-reported outcomes. Preoperative imaging is central to efficient and safe DIEP flap planning, yet the optimal modality remains debated. While computed tomography angiography (CTA) is recommended by ERAS protocols, concerns over radiation exposure and cost have prompted interest in alternatives such as ultrasound (US) and magnetic resonance angiography (MRA). METHODS:A systematic review following PRISMA guidelines was conducted across five major databases, including clinical trials and observational studies published through 2025. Studies included patients undergoing DIEP flap reconstruction with preoperative imaging using CTA, US, MRA, or other modalities. Data extracted included imaging-to-surgical perforator correlation, operative time, complication rates, and flap outcomes. Meta-analyses and heterogeneity assessments were performed using STATA. RESULTS:Thirty-two studies encompassing 3238 patients were included. CTA was used in nearly all studies; US, MRA, SPY/ICG, and DIRT were evaluated in a subset. Pooled perforator utilization was highest with MRA (92%), followed by CTA (87%) and US (85%). Among 2967 patients with complication data, 410 (13.8%) experienced adverse outcomes. Complication rates differed significantly across strategies. Patients utilizing US alone experienced the highest complication rates (17.3%), compared to CTA alone (13.9%) and CTA and US (10.8%). The complication rate difference between US alone patients and CTA and US alone patients was statistically greater (RR = 0.63, p = 0.0123). The complication rates between CTA alone and US alone or CTA and US were not statistically different (US alone: RR = 0.81, p = 0.1040; CTA and US: RR = 0.78, p = 0.11). Complete flap loss occurred in 8.0% of complications, partial flap loss in 14%, and fat necrosis in 19%. CONCLUSION:CTA remains the most studied imaging modality for DIEP flap surgical planning, demonstrating high perforator utilization and low complication rates. Combining CTA with US may further improve outcomes by integrating anatomical precision with dynamic feedback. As newer, lower-risk imaging technologies emerge, comparative studies are needed to determine whether they can match or exceed the performance of CTA in DIEP reconstruction.
BACKGROUND:Selection of recipient vessels in phalloplasty is challenging due to the absence of adequate vessels in the immediate proximity. There is no consensus on the appropriate vessel selection. We hypothesized that recipient vessel selection in phalloplasty is associated with differences in complications and flap survival. METHODS:A literature search following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines across Ovid MEDLINE/PubMed, Embase, and CENTRAL databases identified 46 articles. Collected data included demographics, surgical details, donor and recipient vessels, use of interpositional grafts, number of venous anastomoses, and outcomes. Statistical analysis followed the random-effects model. RESULTS:One thousand nine hundred and seventy six phalloplasty cases were identified. The deep inferior epigastric artery (DIEA) was used in 1413 cases (71.5%) and the femoral artery (FA) was used in 563 cases (28.5%). Pooled proportions of arterial and venous thrombosis were 2.0% and 2.2%, respectively. The use of an interpositional vein graft or arteriovenous loop with the FA was associated with a significantly higher arterial thrombosis rate (16.0%) compared to direct anastomosis to the FA (0.1%, p < 0.001) and to the DIEA (1.2%, p < 0.001). In the absence of vascular thrombosis, partial flap necrosis occurred significantly less often with direct anastomosis to the FA (0.6%) than with the DIEA (6.2%, p = 0.016). CONCLUSIONS:The choice of recipient vessels is an important consideration in phalloplasty flap survival. The DIEA is associated with a low thrombosis rate. However, the significantly higher proportion of thrombosis observed with the FA may be attributable to the use of an interpositional vein graft or arteriovenous loop. Despite lower thrombosis rates, the use of the DIEA was associated with a higher proportion of partial flap necrosis when vessels were patent.
