Robotic-assisted deep inferior epigastric perforator (DIEP) flap harvest minimizes donor-site morbidity by reducing fascial disruption and preserving rectus muscle integrity. Traditional criteria for robotic DIEP have limited use to short intramuscular perforators, but this case demonstrates the feasibility of a totally extraperitoneal (TEP) approach in a patient with a long (91.6 mm) intramuscular perforator. Using a multi-port robotic system and a 3 cm anterior fascial incision, we successfully dissected a 17 cm pedicle without muscle sacrifice or mesh reinforcement. A literature review highlights the rarity of TEP techniques, especially for long perforators. This case supports expanding robotic DIEP criteria based on perforator anatomy rather than strict length cutoffs and illustrates the potential of TEP dissection to avoid intra-abdominal entry while preserving abdominal wall integrity.

Nasal septum defects cause significant functional and aesthetic morbidity. In large septal defects requiring reconstruction, the goal is to achieve appropriate tissue matching, obtain well-vascularized tissue, and minimize donor site morbidity. Repair alternatives are quite limited in large defects. The medial femoral condyle (MFC) free flap is a preferred option in craniofacial reconstructions due to its vascularized, cortical bone with periostal architecture. In this article, we present a patient who underwent successful reconstruction of a severely advanced nasal septum defect using a medial femoral condyle free flap. A 63-year-old male patient underwent repair with a free MFC flap for an anterior septal defect approximately 2 × 2 cm in size. The cause of the septal defect was previous tumor surgery. A free flap from the medial femoral condyle was designed for repair; the flap bone size was approximately 2 × 2 cm, and the periosteum size was approximately 2 × 4 cm. The patient was followed up for 18 months, and no problems were detected during follow-up. The MFC free flap may be a suitable option for the reconstruction of large septal defects, providing structural support without the need for additional tissue transfer for mucosal covering. It may be kept in mind for the repair of large septal defects.

Extensive lumbosacral defects remain a major reconstructive challenge because of limited regional tissue mobility, contamination risk, proximity to neural structures, and frequent association with prior surgery or spinal instrumentation. Although lumbar artery perforator (LAP) flaps are recognized as muscle-sparing options for posterior trunk reconstruction, their capacity to safely reconstruct very large midline lumbosacral defects and their applicability in rare adult presentations of lumbosacral myelomeningocele remain insufficiently defined. We report two adult female patients who underwent reconstruction of extensive midline lumbosacral defects using bilateral pedicled LAP flaps to illustrate the applicability of this approach in exceptionally large post-instrumentation and adult dysraphic defects. The first patient, a 19-year-old woman, presented with a 36 × 28 cm post-instrumentation defect with exposed L4-S1 hardware following multi-trauma and repeated soft-tissue necrosis. After serial debridements and prolonged culture-directed intravenous antibiotic therapy, bilateral LAP flaps measuring 22 × 12 cm were elevated based on bilateral L4 perforators identified by computed tomography angiography and Doppler ultrasonography. The second patient, a 28-year-old paraplegic woman with spina bifida, presented with recurrent cerebrospinal fluid leakage associated with a 22 × 16 cm lumbosacral myelomeningocele defect. Following neurosurgical dural repair, bilateral LAP flaps measuring 18 × 10 cm were harvested based on medially displaced L4 perforators. In both cases, the flaps were designed according to defect geometry and perforator location, then rotated approximately 90° medially to achieve tension-reduced midline closure while facilitating primary donor-site closure. Complete flap survival was achieved in both patients without venous congestion or total flap loss. In the first case, limited wound dehiscence related to hardware prominence was successfully revised with a local V-Y advancement flap, and a small donor-site tension area was managed with split-thickness skin grafting. In the second case, a limited lateral donor defect also required split-thickness skin graft coverage. At 13 months, spinal instrumentation was electively removed in the first patient after adequate osseous stabilization, while flap stability was preserved. At 15 and 9 months of follow-up, respectively, both patients demonstrated durable soft-tissue coverage without recurrent breakdown or cerebrospinal fluid leakage. These cases suggest that bilateral pedicled LAP flaps may facilitate stable, muscle-sparing reconstruction in selected extensive lumbosacral defects, including exceptionally large post-instrumentation wounds and rare adult presentations of lumbosacral myelomeningocele.

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.