LAUSR

We read with great interest the case report by Brunetti et al. (2023). which offered a series of interesting insights. They illustrated the case of a patient presenting a large soft tissue defect in the back, covered by a local perforator-based flap. Intraoperatively, the flap encountered a partial insufficient vascularization, confirmed with indocyanine green (ICG) imaging. The cause for this issue was defined as a venous congestion and it subsequently improved after a supercharge venous anastomosis, resulting in a remarkable final outcome. This case is particularly interesting as it encompasses various aspects that significantly impact our clinical practice. Reconstructing large defects in the back can be challenging due to the tension requirements in this region. While the choice of using a DICAP and TDAP flap is well-described in similar scenarios, their limitation lies in significant anatomical variation. To address this issue, we have recently described a relatively large case series demonstrating the efficacy of the pedicle circumflex scapular artery perforator (CSAP) flap. Despite providing a relatively lateral and short pedicle, this procedure offers an excellent vascular supply with constant anatomy, enabling the movement of a substantial amount of tissue (Meroni & Scaglioni, 2023). When harvesting such large flaps, the vascular supply becomes a critical point. For this reason, we agree that intra-operative ICG imaging