A 41-year-old male patient was referred to our clinic for a recurrent tumour lesion on the left side of the base of the neck, 10 cm in diameter, with a central ulcerated area, bleeding and adhering to deep planes. The patient had been diagnosed with solitary neurofibroma for 30 years and was treated on three occasions with partial resection and coverage with an acromial flap and graft. He developed a retractable keloid scar on the left lateral neck area and was treated with 15 sessions of radiotherapy, which caused significant limitation of lateral movements in the cervical area.

We proceeded to perform an imaging study of the lesion by magnetic resonance imaging with coronal and sagittal axial slices in Fast Spin Echo sequence, enhanced in T1, T2, GRE and T1 with gadolinium, finding a solid mass of neoplastic type, with well-defined borders of 10.4x5.8x12. 4 cm in its longitudinal, anteroposterior and transverse axes respectively, occupying the left anterior region of the base of the neck, superior to the sternoclavicular joint, with origin in the upper and medial area of the left pectoral muscle and at the insertion level of the sternocleidomastoid muscle in the clavicular area. No involvement of vascular structures of the neck or intrathoracic extension was observed. After gadolinium administration, moderate enhancement of the tumour was observed.
The patient underwent surgery by the Oncology Department in conjunction with the Plastic and Reconstructive Surgery Department, with preoperative marking for complete resection of the neurofibroma and immediate reconstruction.

The Oncology team carried out the en bloc resection of the neurofibroma, generating a soft tissue defect of 20x10 cm in diameter with exposure of the pectoral muscle, left parasternal area, medial area of the first costal arch and clavicle.

The Plastic Surgery team was in charge of the restoration of the defect by subfascial dissection, with 2.5 x magnification loupes, of an anterolateral free flap of the left thigh based on 2 perforating vessels of the descending branch of the lateral circumflex femoral artery, with dimensions of 24x11 cm, and pedicle of 12 cm in length, performing termino-terminal anastomosis with nylon 9-0 to superior thyroid vessels contralateral to the lesion and transposition of the acromial flap previously performed to its native location. The donor area of the anterolateral thigh flap was closed by first intention without complications.
The coordination of work in 2 teams by Oncology and Plastic Surgery facilitated a total operative time of 5 hours, with the patient not requiring transfusions or a stay in the Intensive Care Unit. Adequate planning, by locating 2 perforating vessels in the left thigh area with a manual 8 MhZ acoustic doppler, ensured that a flap with the necessary dimensions for coverage could be obtained.
The histopathological report of the resection piece corroborated the diagnosis of neurofibroma, with dimensions of 16x10.5x6.5 cm, showing mesenchymal cells, fibroblasts, Schwann cells, perineural tissue and mast cells, and with deep surgical margins free of lesion.

The patient spent 6 days in hospital, with intravenous antibiotic therapy with cefazolin 1 g every 8 hours, acetylsalicylic acid 100 mg once a day orally, and anti-inflammatory/analgesic treatment with ketoprofen 25 mg every 8 hours. We did not immobilise either the recipient or the donor site, and only left open Penrose drainage in the recipient site for 48 hours.
We monitored the flap by clinically assessing capillary filling, colour and local temperature every hour for the first 24 hours, and then every 2 hours for a further 48 hours. We also used 8MhZ manual Doppler to assess the patency and permeability of the venous and arterial anastomosis. During the hospital stay there was no evidence of venous congestion or arterial insufficiency, with adequate coverage of the defect created by the resection.
We started neck physiotherapy 6 weeks after the operation, based on flexion-extension and lateral neck movements.
We followed up the patient in the outpatient clinic every 3 weeks for a period of 18 months, during which time the neck area improved in contour and mobility, with a better aesthetic-functional result and without the need for secondary surgical treatment.