
==== Front
Plast Reconstr Surg Glob Open
Plast Reconstr Surg Glob Open
GOX
Plastic and Reconstructive Surgery Global Open
2169-7574
Lippincott Williams & Wilkins Hagerstown, MD

GOX-D-24-00621
00069
10.1097/GOX.0000000000006184
3
Reconstructive
Case Report
Using Descending Genicular Artery as the Recipient Artery for Free Superficial Circumflex Iliac Artery Perforator Flap
Shirota Maiko MD 1
Karakawa Ryo MD 1
Yano Tomoyuki MD 1
Yoshimatsu Hidehiko MD 1
From the Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan.
Hidehiko Yoshimatsu, MD, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan, E-mail: hidehiko.yoshimatsu@gmail.com
9 2024
19 9 2024
12 9 e61845 6 2024
30 7 2024
Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Summary:

This case report presents the use of the superficial circumflex iliac perforator (SCIP) flap for soft tissue reconstruction of the knee, using the descending genicular artery (DGA) as the recipient vessel. A 14-year-old female table-tennis player presented with a right knee mass diagnosed as angiomatoid fibrous histiocytoma. Following resection of the mass, which left a 6.5 × 5.5 cm soft tissue defect over the patella, a free SCIP flap was harvested and used for reconstruction. The SCIP flap was chosen for its thinness and flexibility, making it suitable for the highly mobile knee joint. The superficial circumflex iliac artery (1.2 mm) was anastomosed to the DGA (1.5 mm) in an end-to-end fashion. The flap and deepithelialized skin paddle were routed through a subcutaneous tunnel, and the donor site was closed directly over a drain. The flap survived completely with no postoperative complications. Six months later, despite hyperpigmentation of the scar, the contour was satisfactory with no limitations in knee range of motion. This case underscores the advantages of the SCIP flap, particularly its compatibility with the DGA, reduced donor site morbidity, and excellent aesthetic and functional outcomes. The SCIP flap, combined with the DGA as the recipient vessel, provides an effective solution for complex knee reconstructions, offering a primary option for similar cases.

OPEN-ACCESSTRUE
COUNTRYJAPAN
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pmcSoft tissue defects in the knee area pose significant reconstructive challenges due to the intricate anatomy and the requirement of a flap that accommodates the high mobility of the joint. A thin flap is required for aesthetic satisfaction. The gastrocnemius flap has been the workhorse for this purpose. Although the gastrocnemius flap is considered expendable, a free perforator flap transfer is preferable, especially in active, young patients.

Choosing or finding sufficient recipient vessels is another challenge for free flap transfers to the knee region.1 The popliteal artery and its branches have been the gold standard for this purpose, although there have been some reports on the use of the descending genicular artery (DGA).2,3 Herein, we report a case where a soft tissue defect over the patella was reconstructed using a superficial circumflex iliac artery perforator (SCIP) flap, choosing the DGA as the recipient artery.

CASE REPORT

A 14-year-old girl with a body mass index of 20.5 presented with a right knee mass diagnosed as angiomatoid fibrous histiocytoma. Resection of the mass and immediate reconstruction using a free SCIP flap were planned. The tumor was excised with a margin, leaving a 6.5 × 5.5 cm soft tissue defect above the patella (Fig. 1). The patellar tendon was preserved. The superficial circumflex iliac artery (SCIA) and the superficial circumflex iliac vein (SCIV), both of which were identified with preoperative ultrasonography, were first dissected out in the left groin, and a 14 × 7 cm SCIP flap was harvested as described in our previous report.4 The length of the flap pedicle was 4.0 cm. For recipient vessel exposure, a curvilinear incision was made on the medial lower thigh. The great saphenous vein was dissected out first, and the dissection was advanced to the tibia to dissect out the DGA. The SCIA, with a diameter of 1.2 mm, was anastomosed to the DGA, with a diameter of 1.5 mm, in an end-to-end fashion using 10-0 nylon sutures. The SCIV, with a diameter of 2.5 mm, was anastomosed to the great saphenous vein, with a diameter of 3.0 mm, using a 2.5-mm coupling device (Fig. 2). The proximal half of the skin paddle was deepithelialized so that the pedicle could reach the recipient vessels. The flap pedicle and the deepithelialized skin paddle were routed through a subcutaneous tunnel created between the defect and the recipient vessels (Fig. 3). The donor site was closed directly over a drain. The flap survived completely, and ambulation was resumed one week after the operation. There were no postoperative complications in the donor site. After discharge from the hospital the patient underwent a structured physiotherapy regimen to restore and maintain the range of motion and strength in the knee. This included flexibility training and specific knee-strengthening activities. The physiotherapy program played a crucial role in achieving the excellent functional outcome observed. After a 6-month follow-up period, although hyperpigmentation of the scar was still conspicuous, the contour was satisfactory and there were no limitations regarding the range of motion of the knee (Fig. 4). The ranges of motion for knee flexion and extension were 140 degrees and 2 degrees, respectively.

Fig. 1. A 14-year-old girl presented with a tumor over the right knee. Tumor excision resulted in a 6.5 × 5.5 cm soft tissue defect over the patella.

Fig. 2. The SCIA, with a diameter of 1.2 mm, was anastomosed to the DGA (white arrow), with a diameter of 1.5 mm, in an end-to-end fashion using 10-0 nylon sutures. The SCIV, with a diameter of 2.5 mm, was anastomosed to the great saphenous vein (blue arrow), with a diameter of 3.0 mm, using a 2.5-mm coupling device.

Fig. 3. The proximal half of the skin paddle was deepithelialized. The flap pedicle and the deepithelialized skin paddle were routed through a subcutaneous tunnel created between the defect and the recipient vessels.

Fig. 4. Postoperative view at 6 months. Although hyperpigmentation of the scar was still conspicuous, the contour was satisfactory and there were no limitations regarding the range of motion of the knee.

DISCUSSION

Choosing an optimal recipient vessel is crucial for successful free flap transplantation around the knee. The DGA has little anatomical variation among individuals, making it a reliable recipient vessel.2,3 This consistency simplifies the surgical planning and execution, reducing the potential for unexpected anatomical challenges during the procedure.

By using the DGA, surgeons can avoid the positioning challenges associated with other recipient vessels like the popliteal artery, leading to a safer faster procedure. In addition, the DGA is much closer to the knee than the popliteal artery, which allows use of flaps with shorter pedicles. Although the pedicle length of the SCIP flap can exceed 10 cm when the deep branch of the SCIA is chosen as the pedicle, the same result can be achieved by deepithelialization of the skin paddle, as shown in this report.5

The DGA typically has a vessel diameter of 1.5–2.0 mm, which matches well with the SCIP flap vessels, the average diameter of the SCIA being 1.2–1.5 mm.6 This compatibility reduces the risk of vessel caliber mismatch, facilitating a smoother and more reliable anastomosis. In the reported case, the SCIP flap’s attributes, particularly its size and flexibility, made it an ideal candidate for covering the knee defect. This approach mitigates the challenges associated with more traditional flaps and supports the SCIP flap as a primary option for similar cases.

A pedicle medial sural artery perforator flap could have been an option for this case, sparing the medial gastrocnemius muscle.7 However, using the medial sural artery perforator flap might have necessitated a split-thickness skin graft to close the donor site, which is not aesthetically ideal for a young female patient. Additionally, considering the patient’s status as a competitive table-tennis player, the intramuscular dissection of the pedicle through the gastrocnemius muscle was deemed unfavorable. Therefore, we concluded that the SCIP flap was more suitable for this case.

The soft tissue defect was relatively small in this case, but the SCIP flap is capable of covering large defects, as large as 20 × 20 cm, when combined with the superficial inferior epigastric artery flap or the deep inferior epigastric artery perforator flap.8 The SCIP flap, with the DGA as the recipient vessel, provides a viable and effective solution for reconstructing complex soft tissue defects around the knee. The use of the DGA as the recipient artery in free flap reconstruction of the knee has been reported, but the SCIP flap has not been used in previous reports.4 With better compatibility with the DGA, we believe this case highlights the SCIP flap’s potential advantages, including reduced donor site morbidity and excellent aesthetic and functional outcomes, when used in free flap reconstruction of the knee region.

One of the main drawbacks of using the SCIP flap for knee reconstruction is that although it is not reported in literature, the SCIP flap is prone to hyperpigmentation after its transfer. It did not occur in this particular case, but it could have significantly affected the cosmesis of the reconstructed site.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

Published online 19 September 2024.

Disclosure statements are at the end of this article, following the correspondence information.
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