Advanced sarcoma treatment in complex anatomical regions such as the pelvis poses significant surgical challenges. This report details a case involving a 35-year-old man with recurrent osteosarcoma of the left hemipelvis, who underwent a 16 h surgery for hemipelvectomy and reconstruction using a free tibia and fibula fillet leg flap. The procedure, necessitated by an infected, exposed iliac prosthesis, utilized extracorporeal membrane oxygenation (ECMO) for 8 h to maintain flap viability. The flap, incorporating tibia, fibula, and associated musculature was successfully inset and anastomosed to the left common iliac artery and vein, with additional venous anastomosis to the right iliac vein. Despite postoperative challenges such as venous stasis and intestinal ischemia, necessitating further surgical interventions, the patient achieved mobility with a walker at 3 months post-surgery, with stable conditions observed during a 2 years follow-up. ECMO enabled successful preservation and integration of the free fillet leg flap, demonstrating its potential in complex reconstructive surgeries. Specifically, ECMO may extend free flap viability in complex cases, offering new possibilities for challenging oncological and reconstructive surgeries.

Soft-tissue sarcomas (STS) are rare solid tumors of mesenchymal cell origin and account for only 1% of adult malignancies. They tend to occur most commonly in the lower extremities. Reconstruction after sarcoma resection can be challenging, especially when important structures are involved and recurrences occur. Additionally, more attention is now being paid to reconstructing the lymphatic system to prevent lymphatic complications. In this case report, we presented the management of recurrent medial thigh sarcoma that necessitated multiple challenging reconstructions to provide valuable insights for lectures on similar cases. A 50-year-old male patient was diagnosed with an undifferentiated pleomorphic cell sarcoma (UPS) of the anteromedial thigh. After preoperative radiotherapy, a mass of 23 × 15 cm was removed, and reconstruction with a pedicled deep inferior epigastric artery perforator (p-DIEP) flap-based lymphatic flow through (LyFT) was performed. Six months later, the patient developed the first local recurrence with the presence of a distant metastasis. Following the tumor resection, the medial part of the DIEP flap was de-epithelized and buried in the defect for dead space obliteration. Another local recurrence arose 7 months after the second surgery. Therefore, a major debulking surgery involving the femoral neurovascular bundle was performed. The femoral artery was reconstructed with a synthetic graft, and the femoral vein with the great saphenous vein harvested from the contralateral thigh. A composite myocutaneous neurotized anterolateral thigh (ALT) flap from the contralateral thigh was used to obliterate the defect and restore the loss of function of the quadriceps femoris. Two lymphaticovenular anastomoses (LVAs) were performed at the ankle to reduce the risk of lymphatic sequelae. This case report highlights the importance of integrating various techniques to create a tailored approach that effectively addresses complex surgical requirements to avoid limb amputation and maintain functionality.

METHODS: A 51-year-old woman, who had previously undergone C5-C7 anterior cervical discectomy and fusion, presented with symptomatic hardware failure and subsequently underwent instrumentation removal. Her postoperative course was complicated by an esophageal perforation. Despite initial repair using a rotational flap, the leak persisted, prompting esophageal reconstruction with a radial forearm free flap (RFFF).
CONCLUSIONS: Persistent esophageal perforation is exceedingly rare and difficult to treat. This report discusses the surgical technique for RFFF, an excellent option for revising failed sternocleidomastoid rotational flaps. The decision between rotational repair and free flap reconstruction depends on factors such as defect size, vascularization, wound condition, and donor site morbidity.

UNASSIGNED: Immediate autologous reconstruction after nipple-sparing mastectomy (NSM) is challenging in the ptotic breast due to the large skin envelope and reduced vascular supply to the nipple areolar complex (NAC). Patients with significant ptosis who want to preserve their NACs are often advised to undergo a two-stage procedure: first, a mammoplasty is performed to lift the NAC, and second, a delayed NSM with autologous reconstruction is performed. Unfortunately, patients with active cancer cannot delay their mastectomy; as such, they are often treated with skin-sparing mastectomy (SSM) instead.
UNASSIGNED: The reinforced pedicle is an innovative technique that allows the NAC to be safely raised after NSM with immediate free flap reconstruction. In the first stage, patients with ptotic breasts undergo NSM and immediate autologous reconstruction. The reconstruction itself also appears ptotic, but the dermal blood supply to the NAC is preserved. In the second stage, the ptotic free flap reconstruction is revised using the reinforced pedicle technique, which allows the flap to be reduced and the nipple raised in the manner of a standard superior pedicle breast reduction. Using this technique, we have successfully raised a patient\'s NAC by 2.5 cm.
UNASSIGNED: The reinforced pedicle technique adds to the scant literature on secondary revision techniques after autologous breast reconstruction. While further research on this technique is needed, it has the potential to alter the paradigm of immediate autologous reconstruction in the ptotic breast, allowing such patients to preserve their native NACs.

Reconstruction of large soft tissue foot defects were considered a difficult issue due to weight-bearing function of the foot. The reconstruction becomes more difficult when both plantar and dorsal soft tissues are involved. The options for the reconstruction were variable, in 2016 Hao Wu et al. presented a combined flap for coverage of combined fore-foot plantar and dorsal soft tissue defects. We used combined flaps in two cases and present our experience in this article.

BACKGROUND: There are several surgical options for osteonecrosis of the lunate, and confirming the effectiveness of various surgical methods remains challenging. Here, we present a case of stage IIIB osteonecrosis of the lunate repaired with a free medial femoral condyle osteocutaneous flap.
METHODS: A 43-year-old male construction worker was admitted to our hospital due to right wrist pain, impaired mobility, and pain aggravated by activity for 10 months. The patient was diagnosed with stage IIIB osteonecrosis of the lunate based on the orthopantomogram and magnetic resonance imaging of the right wrist. Considering the patient\'s medical history, physical examination, auxiliary examination, and wishes, reconstruction was performed using a free medial femoral condyle osteocutaneous flap. After the flap survived completely, the K-wires were removed one month after the operation, the external brace was removed two months after the operation, and functional wrist rehabilitation was initiated. After six months of follow-up, the wrist swelling and pain resolved, and the reconstructed lunate bone was viable. Additionally, the last follow-up was conducted in the sixth month after surgery; the affected hand grip strength improved from about 70% (28 kg) to 80% (32 kg) compared with the healthy side (40 kg); the visual analog scale score decreased from 6.5 points before the operation to 1 point; and the MAYO score increased from 60 points before the operation to 85 points.
CONCLUSIONS: The success of this case reinforces the potential of the free medial femoral condyle osteocutaneous flap as a new treatment option for stage IIIB osteonecrosis of the lunate and further expands the existing treatment options. Using a free medial femoral condyle osteocutaneous flap to reconstruct the lunate and restore the carpal anatomy may.

Defects in the distal lower limbs are common in the field of orthoplastic reconstruction. The ankle area presents little subcutaneous tissue and is often affected by high-energy traumas and bone fractures. Wounds in this region are frequently associated with severe edema that might prevent primary closure. Due to its thinness and tension, the skin overlying both the medial and lateral malleoli is prone to necrosis, which can further lead to large soft tissue defects. Vessels, nerves, and tendons can easily become exposed. The reconstructive approach should aim to provide high-quality tissue that is durable enough to withstand the weight-bearing pressures and the friction from shoes, while remaining sufficiently elastic to conform to the shape of the ankle and to permit the foot movement. In this study, we describe the use of an additional propeller flap to reduce skin tension at the recipient site. A superficial circumflex iliac artery perforator (SCIP) flap was utilized to cover a defect below the medial malleolus. However, after flap inset, achieving a primary closure of the proximal wound without tension was not possible. During the dissection of the posterior tibial artery, perforator vessels were identified and preserved. The larger of these vessels was then used to vascularize a propeller flap, which was then rotated toward the defect to aid a tension-free closure. The postoperative course was uneventful. This case may provide a valuable insight into the challenges often faced during wound closure, even after flap inset. Since the flap itself may increase the width of the dissection area, the present case shows the importance of preserving perforator vessels during the proximal dissection since they can allow the harvest of an additional flap to achieve primary closure and further alleviate tension.

The superficial temporal artery (STA) bifurcates into frontal and parietal branches. The parietal branch is used as a recipient vessel for scalp reconstruction, but it is absent in approximately 16.3% of individuals. In this case, a 72-year-old woman with an occipital scalp defect lacked both the parietal branch of the STA and the superficial temporal vein. To address this anatomic variation, we used the frontal branch of the STA and the posterior auricular vein as alternative recipient vessels for anterolateral thigh free flap reconstruction. The surgical procedure involved end-to-end microvascular anastomosis of one artery and one vein. Partial flap necrosis occurred postoperatively, but eventually resolved with debridement. The frontal branch of the STA and the posterior auricular vein can serve as reliable alternatives in the absence of the parietal branch. Reconstructive surgeons should be aware of anatomic variations of the STA and adapt their surgical approach accordingly.

BACKGROUND: Postoperative delirium is a severe complication of flap transplantation surgery, adversely affecting surgical prognoses. The intricate pathophysiology of postoperative delirium renders the elucidation of its risk factors challenging. This research aims to delineate the prevalence and the specific risk factors of postoperative delirium in patients with cancer undergoing free flap reconstruction through a systematic review and meta-analysis to enlighten proactive prevention measures.
METHODS: The researchers systematically queried both the international and Chinese databases. Searches were performed for publications from inception until September 14, 2023, using the terms \"free tissue flaps,\" \"delirium,\" \"neoplasms,\" and \"risk factors.\" Data synthesis and statistical analysis were conducted using Stata SE (version 15.0) to calculate the combined effect size for identified risk factors. Reported outcomes included weighted mean differences or odds ratios with their respective 95% confidence intervals.
RESULTS: Twelve case-control studies were included (ntotal = 3,256). Among them, 515 patients developed postoperative delirium after free flap surgery, compared with 2,741 patients who did not. The outcomes suggest that the risk factors include but are not limited to age, male, late neoplasm staging, use of hypnotic or antipsychotic, history of background diseases, psychiatric review, tracheotomy, and impaired wound healing. In contrast, early neoplasm staging and others are the protective factors with statistical significance. Multivariate analysis further identified significant correlations between preoperative albumin, perioperative blood transfusion, sleep disturbance, postoperative visual analog scale, postoperative albumin, smoking, and the appearance of postoperative delirium.
CONCLUSIONS: The determined risk factors were grouped into preoperative, intraoperative, and postoperative categories substantiated by current data to present instructions for postoperative delirium prevention.

Epidermolysis bullosa (EB) encompasses a range of rare genetic dermatological conditions characterized by mucocutaneous fragility and a predisposition to blister formation, often triggered by minimal trauma. Blisters in the pharynx and esophagus are well-documented, particularly in dystrophic EB (DEB). However, there have been few reports of mucocutaneous squamous cell carcinoma (SCC) in the head and neck region, for which surgery is usually avoided. This report presents the first case of free jejunal flap reconstruction after total pharyngolaryngoesophagectomy for hypopharyngeal cancer in a 57-year-old patient with DEB. The patient with a known diagnosis of DEB had a history of SCC of the left hand and esophageal dilatation for esophageal stricture. PET-CT imaging during examination of systemic metastases associated with the left-hand SCC revealed abnormal accumulation in the hypopharynx, which was confirmed as SCC by biopsy. Total pharyngolaryngoesophagectomy was performed, followed by reconstruction of the defect using a free jejunal flap. A segment of the jejunum, approximately 15 cm in length, was transplanted with multiple vascular pedicles. The patient made an uneventful recovery postoperatively and was able to continue oral intake 15 months later with no complications and no recurrence of SCC in the head and neck region. While cutaneous SCC is common in DEB, extracutaneous SCC is relatively rare. In most previous cases, non-surgical approaches with radiotherapy and chemotherapy were chosen due to skin fragility and multimorbidity. In the present case, vascular fragility and mucosal damage of the intestinal tract were not observed, and routine vascular and enteric anastomoses could be performed, with an uneventful postoperative course. Our findings suggest that highly invasive surgery, including free tissue transplantation such as with a free jejunal flap, can be performed in patients with DEB.