Introduction: The use of free‐style and propeller perforator‐based flaps has been popularized for the reconstruction of moderate size defects in the trunk and extremities, while their application in the field of abdominal reconstruction is seldom reported. The purpose of this report is to describe the authors experience with the use of pedicled perforator‐based flaps in abdominal wall reconstruction, presenting the innovative concept of transition from angiosomal to bi‐angiosomal and extra‐angiosomal perforator flaps and showing applications of the different flap designs according to the multiple clinical scenarios.Patients and Methods: A total of 15 patients underwent abdominal wall reconstruction with angiosomal, bi‐angiosomal, and extra‐angiosomal pedicled perforator‐based flaps harvested from the surrounding abdominal subunits for superficial or full thickness defects of the abdominal wall of moderate and large dimensions. The defects were consequent to soft‐tissue sarcomas (STS) and non‐melanoma skin cancer (NMSC) resection in 11 and 4 cases, respectively. Operative data, post‐operative course, and complications were recorded. Moreover, at 12 months follow‐up, patients were asked to rate the esthetic and functional outcomes of the reconstructive procedure on a 5‐point Likert scale.Results: Ten angiosomal perforator flaps (4 DIEP, 4 SCIP, 1 SEAP, and 1 LICAP flaps) and 5 bi‐angiosomal and extra‐angiosomal conjoined perforator flaps including different vascular territories (3 bilateral DIEP, 1 bilateral SEAP, and 1 ipsilateral DIEP‐SEAP flap) were successfully transferred in 15 patients. In two patients, microsurgical anastomoses were performed to guarantee proper vascularization of the additional cutaneous territory. Mean age was 59.3 years. Defect sizes ranged from 98 to 408 cm² (mean size was 194.7 cm²). Mean operative time was 280 min. Flap surface ranged from 108 to 336 cm² (mean surface was 209.3 cm²). No major complications were registered. One bi‐angiosomal bilateral DIEP flap suffered from partial necrosis and required an additional flap reconstruction. All patients underwent a 12‐month follow‐up except one, who did not show for clinical follow‐up but responded at the Likert scale at clinical follow‐up at 9 months. Overall patients' satisfaction was high, with mean esthetic and functional ratings of 4.27 and 3.87.Conclusion: The use of local tissues is an under‐utilized solution in the field of abdominal wall reconstruction. Angiosomal, bi‐angiosomal, and extra‐angiosomal perforator flaps proved to be a reliable option to provide the transfer of a significant amount of tissue and offer like with like reconstruction while maximizing flap survival.

Introduction: Sarcoma resection often leaves patients with big defects only amenable through microsurgical reconstruction. In such cases, it is hard for the surgeon to uphold low donor-site morbidity with an aesthetic result. The purpose of this study was to investigate the clinical outcome and the patient’s perception regarding the donor site in a cohort of patients undergoing microsurgical reconstruction with lateral thigh and lower abdominal perforator flaps. Methods: A retrospective evaluation of all patients who underwent sarcoma reconstruction with flaps harvested from the lower abdominal region (deep inferior epigastric artery perforator flap, superficial circumflex iliac artery perforator flap) or lateral thigh region (anterolateral thigh perforator flap and its variations) was performed. Only patients with defects greater than 100 cm² were included. Patient demographics and operative variables were recorded, together with complications. Patient satisfaction and quality of life with the donor site were registered using the SCAR-Q questionnaire, which was administered at least six months post-operatively. Results: Eighteen anterolateral thigh (ALT) perforator flaps and twenty-two deep inferior epigastric artery perforator (DIEP) and superficial circumflex iliac artery perforator (SCIP) flap procedures were performed. The two groups were homogeneous for major post-operative complications (p > 0.999). Patient satisfaction with the donor site measured using the SCAR-Q questionnaire showed significantly higher scores in the DIEP/SCIP group when compared with the thigh group (p < 0.001), indicating a superiority of the lower abdominal area as an aesthetic donor site. Conclusions: The DIEP and SCIP flaps are a versatile option for reconstructing large soft-tissue defects following sarcoma resection. Therefore, flaps harvested from the lower abdomen yield a higher patient satisfaction with the donor site, which is a feature worth considering when planning a reconstructive procedure.

Background: The deep inferior epigastric perforator (DIEP) flap is the gold standard for autologous breast reconstruction, but donor site morbidity, such as abdominal bulging, remains a concern. Rectus fascia plication is a recognized treatment for rectus abdominis diastasis, yet its role in DIEP closure is scarcely evaluated. This study investigates whether plication reduces abdominal morbidity and improves patient satisfaction. Methods: A multicenter retrospective case–control study was performed on women who underwent unilateral DIEP breast reconstruction between 2018 and 2024. Patients were allocated to the plication or control group according to operative notes. Outcomes included abdominal complications, postoperative bulging (clinically and photographically assessed), and patient-reported satisfaction using the BREAST-Q. Standardized postoperative photographs were also rated by blinded expert surgeons. Results: Sixty-two patients met the inclusion criteria: 25 with fascia plication and 37 without. Groups were comparable in demographics and surgical details, though diastasis was more prevalent in the plication group (4.1 cm vs. 0 cm, p < 0.0001). Plication did not increase early or late complications. Abdominal bulge occurred in 16.2% of controls and 0% of the plication group (p = 0.0727). Logistic regression confirmed a significant protective effect (OR = 0.095, 95% CI 0.001–0.87, p = 0.034). BREAST-Q “Physical well-being: abdomen” scores were higher with plication (35.7 ± 18.0 vs. 23.0 ± 17.2, p = 0.0316), which was confirmed by multivariate analysis. Expert photographic assessments showed no significant differences. Conclusions: Rectus fascia plication during DIEP flap breast reconstruction is safe, improves abdominal well-being, and reduces postoperative bulging, especially in patients with preoperative diastasis. This additional step may represent a simple and effective strategy to enhance donor site outcomes.