In the initial procedure, the suspicious lesion was excised, and suture marking is employed to delineate the margins. We advise incorporating a diagram to accurately represent the surgical specimen’s orientation for the pathologist’s reference. Temporary closure is achieved using negative pressure wound therapy (NPWT).

We performed a complete excision of the tumor, including the periosteum in the specimen.

The pathology report identified a squamous cell carcinoma (TNM: pT2, L0, V0, pM0, G3, R1) with incomplete surgical margins. Together with the patient, we decided to excise the entire skin-grafted area. After the resection, a soft tissue defect measuring 27 x 28 cm remained. NPWT was employed for temporary wound closure.

Again, we suggest drawing a precise diagram of the specimen and its orientation for the pathologist and including it in the pathology report. (The intraoperative sketch shown here was later redrawn for the pathology report)

The patient is put in the lateral decubitus position. We used a two team approach with one team raising the flap, while the other team was preparing the recipient site. First, the outer table of the skull in the previous tumor bed was resected together with the neurosurgery service for improved oncologic safety.

The superficial temporal vessels were meticulously dissected, with special attention given to preventing injury to the facial nerve within the preauricular space. A minimum of 2 to 3 cm of the vessels should be prepared for anastomosis (black arrow points at the superficial temporal vessels). Owing to the abundant blood supply in the facial region, the vessels can be sacrificed to facilitate end-to-end anastomosis.

The challenge was to address the extensive soft-tissue defect using one flap. In order to exhaust the maximum size of the myocutaneus latissimus dorsi flap, the anterior border of the muscle was precisely identified using sonography. The skin paddle was than designed critically extending the anterior border of the muscle. It was planned to use the myocutaneus flap part for reconstruction of the occipital and nuchal area.

The flap was elevated based on the thoracodorsal vessels, with particular care taken to include the entire muscle. Intraoperative indocyanine green fluorescence angiography indicated hypoperfusion in the distal portion of the flap (see 9 and 10). The designated resection area, visible in the congested distal region of the flap, is illustrated above in the broken white surrounding. This area was resected prior to flap transfer.

The intraoperative ICG angiography reveals optimal perfusion in the proximal parts of the flap (left is proximal, right is distal).

The most distal part of the skin flap incorpated in the lattisimus dorsi myocutaneous free flap showed an insufficient perfusion in the ICG angiography. It was marked and resected prior to flap transfer.

• In our experience, intraoperative ICG angiography is an extremely reliable procedure and may prevent partial flap loss.

We were able to realize the flap inset as planned. The flap is then anastomosed in an end-to-end fashion the temporal vessels. A venous coupler of 3.0 mm diameter is used for the venous anastomosis.

The muscle portion of the flap is covered with 0.2 mm-thick split-thickness skin grafts obtained from the thigh and meshed at a 1:1.5 ratio. Skin staples are utilized to secure the skin grafts in place.