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Background and Aims Primary medical institutions commonly employ perforator‐pedicled propeller (PPP) flaps and V‐Y flaps as the main methods for managing small soft tissue defects resulting from trauma or lesion resection. However, both surgical techniques have inherent limitations. Therefore, this study aims to investigate the feasibility of utilizing perforator‐pedicled (PP) V‐Y flaps for reconstructing small area soft tissue defects and evaluate their clinical effectiveness. Methods The study conducted a retrospective analysis from January 2010 to December 2022, involving 49 patients with small soft tissue defects resulting from trauma or lesion resection (21 PP V‐Y flaps and 28 PPP flaps). Evaluation criteria encompassed intraoperative conditions, postoperative short‐ and long‐term complications, and aesthetic outcomes. Results The results of this study showed that all flaps in the PP V‐Y flap group survived, while six cases in the PPP flap group had partial necrosis. The donor area was closed directly in one stage for the group of perforator pedicled V‐Y flaps, while skin grafting was required to repair the donor area for eight cases from the group of PPP flaps, leading to delayed healing in this region. Furthermore, aesthetic evaluation favored PP V‐Y flaps as they exhibited significantly better appearances in both donor and recipient areas. Conclusion In this study, compared to the PPP flap, the PP V‐Y flap demonstrates superior outcomes with regard to reduced postoperative complications and enhanced aesthetic appearance. PP V‐Y flap is an ideal technique for repairing small soft tissue defects of limbs, which is suitable for implementation in primary medical institutions. Level of evidence: III, Case–control study.

Background The objective of this study was to perform morphometry of the gracilis muscle and understand the topographical basis of the entry of its pedicles. Methods We studied forty-four cadaveric lower extremities fixed in formalin. The length and width of the gracilis were measured at three locations: the origin, midpoint, and musculotendinous junction. The topographic location of the gracilis pedicles was also studied. Results The gracilis muscle’s length was 369.9±34.1 mm and 359.6±29.6 mm over the right and left sides. The width of right gracilis was 25±8.4 mm, 20.4±6.2 mm and 10.6±5.6 mm at the origin, midpoint and at the musculotendinous junction. The same over the left side were 26.7±8.6 mm, 20.6±9.1 mm and 10.4±6.4 mm respectively. The number of gracilis ranged from one to three. The location of first pedicle was 93.6±35.6 mm and 68.9±35.8 mm away from the pubic tubercle on the right and left sides, respectively. The second and third pedicles were entering at a distance of 153.1±38.8 mm and 101.3±20.8 mm, 214.6±86.8 mm and 145.3±124.4 mm over the right side and left side. The accessory head of the origin of the gracilis was observed in only one cadaver (2.3%), which originated from the adductor longus. Conclusions It is believed that the morphological data of the gracilis and its neurovascular pedicles will be enlightening to the operating surgeon. They will guide the procedures for reconstructive plastic surgery.

Background: Dorsal pedicle skin flap application is a cover procedure frequently used by plastic surgeons to cover acute and chronic wounds, but preventing postoperative flap loss and disruption of the wound healing process has not yet been achieved. Injecting boron nitride during the transfer of the dorsal pedicle skin flap may increase flap survival. Objective: This study investigated the efficacy of hexagonal boron nitride (hBN) injection in enhancing the survival of pedicled skin flaps harvested from the dorsal region of rats. Method: This study employed an experimental design. A total of 24 Wistar albino rats were divided into three groups of eight each: Control (Group 1), Sham (Group 2), and Experimental (Group 3). A 27 cm2 (3 cm × 9 cm) dorsal skin flap with a proximal pedicle was harvested at the level of the iliac crests, with the flap extending cranially, and then reattached. During flap transfer, no intervention was performed in Group 1, physiological saline was injected into Group 2, and hBN was injected into Group 3. After a certain period of time, sections were taken from the proximal pedicle skin flap on the dorsal side of the rats, and histochemical examination and biochemical analyses were performed on these sections. Results: In this study, it was observed that the epithelial integrity of the epidermal layer was disrupted and the epithelium was thinned in places in Group 2. Compared to Group 1, collagen fiber density was lower, collagen fiber arrangement was irregular, and mast cell density was higher. In Group 3, similar to Group 1, the epidermis and dermis layers were composed of multilayered flat keratinized epithelium, collagen fiber density was high and had a regular arrangement, and elastic fiber structure was of normal density. The TGF-β1 and MMP-1 measurement results for the three groups were compared, and no statistically significant difference was found between the groups (p > 0.05). Conclusions: The results of this study support the benefit of hBN injection in improving flap survival after proximal pedicle skin flap application on the dorsal side of rats. Although the improved healing of skin layers after flap transfer with hBN suggests that it supports cell proliferation, the mechanism of action and pathophysiology remain unclear.

Objective: To assess the versatility of pedicled perforator flaps in lower one third of leg in terms of outcomes, postoperative complications and role in early rehabilitation of patients. Study Design: Observational study. Place and Duration of Study: Department of Plastic Surgery, Combined Military Hospital, Rawalpindi Pakistan, from Dec 2019 to Dec 2020. Methodology: Thirty-seven patients meeting the exclusion and inclusion criteria for reconstruction of lower 1/3rd of leg were included. Pedicled perforator flaps based on the perforators of anterior tibial artery, posterior tibial artery or peroneal artery was harvested for wound reconstruction. Outcomes of the flaps were measured in terms of wound healing time, donor site management, its complication and return to the work of all patients. Result: Overall success of pedicled perforator flaps in lower one third of leg was seen in 33(81.1%) patients. Donor site was covered with partial thickness skin graft in 33(89.2%) patients. Complications included 4(10.8%) wound infection, 2(5.4%) partial flap necrosis and 1(2.7%) case of flap failure. Mean healing time of flap was 18.56±11.50 days and patients returned to work in 3±1.39 months. Conclusion: Pedicled perforator flaps are a technically straightforward procedure, provide localized like-for-like skin coverage of complex wound in lower 1/3rd of leg with excellent results and significantly low complication rate.  

Tian Wang, Han Li, Zhaochao Chen, Lan SunDepartment of Dermatology, Nanjing Medical University Affiliated Suzhou Hospital, Suzhou, People’s Republic of China*These authors contributed equally to this workCorrespondence: Zhaochao Chen, Department of Dermatology, Nanjing Medical University Affiliated Suzhou Hospital, Suzhou, People’s Republic of China, Email czc3h75@sina.com Lan Sun, Department of Dermatology, Nanjing Medical University Affiliated Suzhou Hospital, Suzhou, People’s Republic of China, Email slszsy@126.comAbstract: Extramammary Paget’s disease (EMPD) is a rare malignant neoplasm arising from apocrine gland–bearing skin, with involvement of the axilla being particularly uncommon. Surgical excision remains the first-line treatment. However, management can be challenging because wide excision to achieve tumor-free margins may result in a large axillary defect in a high mobility region where scar contracture can compromise shoulder function. Here, we report a single case of axillary EMPD managed with surgical excision and reconstruction using a pedicled thoracodorsal artery perforator (TDAP) flap. This case highlights the pedicled TDAP flap as a reliable, muscle-sparing reconstructive option for managing large axillary defects after EMPD excision, offering favorable functional and aesthetic outcomes with minimal donor-site morbidity.Keywords: extramammary Paget’s disease, axilla, thoracodorsal artery perforator flap, pedicled flap, reconstruction

Extramammary Paget's disease (EMPD) is a rare malignant neoplasm arising from apocrine gland-bearing skin, with involvement of the axilla being particularly uncommon. Surgical excision remains the first-line treatment. However, management can be challenging because wide excision to achieve tumor-free margins may result in a large axillary defect in a high mobility region where scar contracture can compromise shoulder function. Here, we report a single case of axillary EMPD managed with surgical excision and reconstruction using a pedicled thoracodorsal artery perforator (TDAP) flap. This case highlights the pedicled TDAP flap as a reliable, muscle-sparing reconstructive option for managing large axillary defects after EMPD excision, offering favorable functional and aesthetic outcomes with minimal donor-site morbidity.

Objectives The objective of this article is to review options for regional pedicled reconstruction for large head and neck defects in a salvage setting. Methods Relevant regional pedicled flaps were identified and reviewed. Expert opinion and supporting literature were used to summarize and describe the available options. Results Specific regional pedicled flap options are presented including the pectoralis major flap, deltopectoral flap, supraclavicular flap, submental flap, latissimus flap, and trapezius flap. Conclusions Regional pedicled flaps are useful options in a salvage setting even for large defects and should be in the armamentarium of any reconstructive head and neck surgeon. Each flap option carries specific characteristics and considerations. This is a review article of different regional pedicled flaps for reconstruction of large salvage defects in the head and neck.

Background The repair of Lower eyelid defect is a medical challenge for plastic surgeons. Objective to investigate the clinical effect of repairing inferomedial eyelid defects with temporal island flaps pedicled with the orbicularis oculi muscle. Methods A retrospective analysis was conducted on 12 cases of inferomedial eyelid defects caused by tumors, scars or other reasons, in The First Affiliated Hospital of Anhui Medical University from January 2021 to October 2022. Temporal island flaps pedicled with the orbicularis oculi muscle or traditional nasolabial fold flaps were used to repair the inferomedial eyelid defects, and the patients were followed up for 2 to 13 months to observe postoperative tumor residue, scar release degree, flap survival, lower eyelid ectropion. Descriptive statistical methods were used to evaluate the treatment effect. Results In 11 out of 12 patients, the tumors were completely resected with no residual at the margins and bases. In 1 patient with lower eyelid ectropion, it was completely corrected, which the scar was completely released and the lower eyelid was restored. The flaps in all 12 patients survived completely, and in one case, there was partial epidermal necrosis, which healed after dressing change and delayed healing. One patient designed the nasolabial V–Y advancement flap developed eyelid ectropion and retraction. During the follow-up period of 2 to 13 months, no lower eyelid ectropion or epiphora occurred. Conclusion The orbicularis oculi muscle-pedicled temporal island flap demonstrates significant clinical efficacy in reconstructing inferomedial eyelid defects, particularly due to its combination of surgical practicality and favorable tissue characteristics. This technique offers three distinct advantages: (1) straightforward surgical preparation with minimal donor site morbidity, (2) optimal tissue compatibility through preserved eyelid texture and robust vascular supply, and (3) enhanced rotational capacity and generous flap dimensions. Level of Evidence Level IV, therapeutic study.

Background: Free and pedicled flaps are both valuable surgical strategies for lower limb reconstruction. Evidence that compares both techniques is scarce. Our aim is to synthetise all the comparative studies by conducting a meta-analysis to identify post-operative outcomes. Method: A systematic review of pubmed, EMBASE, Cochrane library, and Web of Science was conducted, aiming at articles comparing the outcomes of free versus pedicled flaps in lower limb reconstruction. A pooled analysis with the Mantel and Haenszel methods and random effect analysis provided results as a risk ratio with a 95% confidence interval. Results: 10 retrospective studies were selected. While the flap necrosis rate did not differ significantly between techniques (RR 1.35, 95%CI 0.76–2.39, p = 0.31), the partial flap necrosis rate was significantly lower in free flaps (RR 0.45, 95%CI 0.22–0.91, p = 0.03). The overall complication rate (RR 0.83, 95%CI 0.64–1.07, p = 0.16) and revision surgery rate (RR 1.38, 95%CI 0.55–3.50, p = 0.49) did not differ significantly. No significant difference was found in the high aesthetic satisfaction rate (RR 1.76, 95%CI 0.57–5.41, p = 0.32) and post-operative infection rate (RR 0.85, 95%CI 0.55–1.33, p = 0.48). Conclusion: Despite important variability in the choice of flaps and outcomes reported among studies, free and pedicled flaps appear to be reliable surgical strategies for lower limb reconstruction with similar surgical outcomes.

Background Lower limb injuries are very common in high-speed trauma. Soft tissue cover over vital structures of the leg is of paramount importance as the ultimate goal of treatment is to have a stable and pain-free limb for walking. Though microvascular flaps are the gold standard in soft tissue coverage of the leg, pedicled medial gastrocnemius, hemi-soleus and fasciocutaneous flaps still hold an important role. The classical exposure of medial gastrocnemius and medial hemi-soleus flaps is posterior midline or an incision 2-cm medial to the tibial border. We describe a method of defensive approach for raising muscle flaps preserving the medial fasciocutaneous flap. Methods A retrospective study comprising of 45 patients from January 2014 to February 2020 who presented with leg defects which were managed by muscle flaps through defensive approach was done. The location of the defects, the aetiology, outcome and the complications were analysed. Results Of the 45 patients, 29 underwent medial gastrocnemius flaps, 11 hemi-soleus and 4 both. Among them, four had failure of initial muscle flaps which were salvaged with the delayed fasciocutaneous flap as a result of the defensive approach. Conclusions Defensive approach skin incision is a safe and easy way to raise muscle flaps in the leg which preserves the option for a fasciocutaneous flap as lifeboat if needed. Level of evidence: Level IV, therapeutic.