Background Interposition vein grafts (IVG) and vascular bridge flaps (VBF) have been exploited as vascular conduit in challenging head and neck reconstructions. Methods A retrospective review was conducted on 6025 flaps. The effect of patients' characteristics and length of IVG on flap compromise and loss were analyzed. Comparison between IVG and VBF was performed. Results The flap compromise and loss rates for the overall group were 8.2% and 3.2%, respectively. An IVG was used in 309 free flaps. The average length of the vein grafts was 6.9 ± 4.2 cm. An unplanned return to the operation room occurred in 32 cases (10.4%) and failure of the flap in 12 patients (3.9%). Binary logistic regression found a significant association between flap compromise and loss rates and length of IVG, hypertension, prior radiation, and neck dissection. In the multiple regression model, length of IVG and prior radiation significantly influenced the outcomes. Thirty‐nine patients underwent reconstruction with a long IVG (>10 cm). Twenty‐six patients underwent surgical reconstruction with radial forearm flap as a VBF. The rate of flap compromise was higher in the group with a long IVG (P = .01). Conclusions In head and neck free flap reconstruction, the length of IVGs and history of radiotherapy are associated with flap compromise and loss. In case of long distance between the pedicle and the recipient site, the use of a VBF bridge should be considered as a safe alternative.

Background and ObjectivesIn patients with lymphedema, the disruption of the lymphatic network increases skin turgor and fibrosis of subcutaneous tissue, delays wound healing, causing recurrent ulcerations and infections. In these cases, management of ulcers can be challenging.MethodsBetween January 2016 and June 2018, patients presenting with lymphedema were enrolled at our Institution. We selected patients with severe lymphedema and ulcers of lower limbs and we performed a surgical approach, involving free gastroepiploic lymph nodes and omentum flap, harvested through laparoscopy.ResultsWe enrolled 135 patients presenting for lymphedema. Among them, 10 eligible cases underwent excision of the ulcer and reconstruction with omentum flap. Mean age was 57.8 years and average follow‐up 24.1 months. Circumferences and skin tonicity significantly decreased from the preoperative period. Lymphoscintigraphy showed improvement of the lymphatic drainage and restoration of lymphatic network. No episodes of infection were recorded in the postoperative period.ConclusionsOur combined procedure merges free flap techniques and lymphedema surgery: omentum covers the defect while providing a new source of lymph nodes, improving the lymphatic networks of the affected limb. This technique can highly increase the quality of life of the patient in a single‐stage operation with fast recovery and low donor site morbidity.

Pedicled and free composite flaps derived from the thoracodorsal artery system, including the latissimus dorsi‐rib (LD‐R) and the serratus anterior‐rib (SA‐R) osteo‐muscular or osteo‐myocutaneous flaps, are potential options to address head and neck, thorax, upper and lower extremity bone, and soft tissue defects' reconstruction. We aimed to report our series of LD/SA‐R composite pedicled and free flaps, evaluating outcomes and complications, and to systematically identify all literature reporting results following LD/SA‐rib reconstructions.

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In this report, we discuss the postoperative protocol for patients undergoing lymphaticovenous anastomosis (LVA) in our unit. Immediately after LVA, the incision site is closed over a small Penrose drain and a simple gauze dressing is applied without compression. In the first 5 days, ambulation is allowed, but limb elevation is actively encouraged to promote lymphatic flow across the newly formed anastomosis. Prophylactic antibiotics are routinely given to prevent infection because this patient group is susceptible to infections, which could trigger thrombosis in the anastomosis.

Summary: End-to-side arterial anastomoses require a high level of technical competency. The main challenge to a successfully patent anastomosis is intimal interposition during the standardized microvascular suturing. Technical errors during arteriotomy pose a significant challenge for the microsurgical technique, making the end-to-side anastomosis prone to failure. We describe a basic yet fundamental method of performing an arteriotomy, the “crater” technique, which facilitates good visualization of all vessel layers before placement of microsurgical sutures. Using curved microsurgical scissors, the adventitia layer is dissected off the outer surface of the side vessel, a V-shaped cut is then made obliquely at a 30–45 degrees angle to the longitudinal axis of the vessel, and a full thickness oblique cut is made along an elliptical circumference, as the curved scissors enable the creation of a slope-like crater. This concept ensures the intimal layer is adequately exposed through the complete circumference of the arteriotomy rim, while enabling a variable increase in the arterial wall hypotenuse-width circumference. When performed in a standardized manner, the crater arteriotomy can minimize the risk of endothelial misalignment and further technical errors during suturing, thus minimizing the risk of anastomotic failure.