Supercharged reverse pedicle anterolateral thigh flap in reconstruction of a massive defect: A case report

Reverse flow anterolateral thigh free flap in a case with significant atherosclerosis: A viable alternative for arterial microvascular anastomosis

BACKGROUND

The concept of reserve flow perfusion for free flap reconstruction has been demonstrated in various applications in the literature. As it relates to the anterolateral thigh (ALT) free flap, the reserve flow principle has been primarily described to either augment or "supercharge" a large ALT to optimize skin perforator supply or lengthen the vascular pedicle.

METHODS

We report a case of a 77-year old male with chronic renal failure who had extensive atherosclerosis of the proximal descending lateral circumflex femoral artery (LCFA) where arterial anastomosis was unable to be performed.

RESULTS

We were able to circumvent this limitation by establishing reserve flow perfusion solely through the distal end of the descending LCFA. We describe our technique within the context of current literature on the topic of reverse flow perfusion in free flap reconstruction.

CONCLUSION

This report uniquely describes applying the distally based, reverse arterial flow principle in an ALT flap to circumvent an atherosclerotic proximal pedicle.

Cross-leg free flaps and cross-leg vascular cable bridge flaps for lower limb salvage: experience before and after COVID-19

Background

Previous reports have evidenced the disruptive effect of the COVID-19 in microsurgical and reconstructive departments. We report our experience with cross-leg free flaps and (CLFF) and cross-leg vascular cable bridge flaps (CLVCBF) for lower limb salvage, technical consideration to decrease morbidity, and some structural modifications to our protocols for standard of care adapted to the COVID-19.

Methods

We retrospectively included consecutive patients undergoing reconstruction with CLFFs and CLVCBFs for lower limb salvage from January 2003 to May 2022. We extracted data on baseline demographic characteristics, mechanism of trauma, and surgical outcomes.

Results

Twenty-four patients were included, 11 (45.8%) underwent reconstruction with CLFF while 13 had CLVCBFs (54.2%). Fifteen patients (62.5%) underwent lower limb reconstruction under general anesthesia while 9 (37.5%) had combined spinal-epidural anesthesia. During COVID-19 pandemic, six CLFF cases were performed under S-E (25%). The average time for pedicle transection of muscle CLFFs and muscle CLVCBFs was comparable between groups (60 days versus 62 days, p = 0.864). A significantly shorter average time was evidenced for pedicle division of fasciocutaneous flaps in the CLFF group when compared to CLVCBFs (45 days versus 59 days, p = 0.002).

Conclusions

In selected patients, CLFFs and CLVCBFs offer an optimal alternative for lower limb salvage using recipient vessels out of the zone of injury from the contralateral limb. Modification in the surgical protocols can decrease improve resource allocation in the setting of severely ill patients during COVID-19.Level of evidence: Level III, Therapeutic.

Reconstruction of a knee defect in a morbidly obese patient with a pedicled reverse anterolateral thigh flap

The anterolateral thigh (ALT) flap is widely used in the reconstruction of a variety of soft tissue defects. Descriptions of patients with severe obesity in the literature are scarce. We report a case where a reverse pedicled fasciocutaneous ALT flap was successfully used for resurfacing of a knee defect measuring 12×6 cm in a patient with a body mass index (BMI) of 47.3. The flap was supercharged to the greater saphenous vein to optimise flap survival. Reconstruction of the soft tissue of the knee was achieved as planned. There were no flap or donor site complications.

Improving Outcomes in Anterolateral Thigh Flap Donor-Site Reconstruction Using Propeller Flaps: A Retrospective Comparative Study with Skin Grafting

BACKGROUND

 After anterolateral thigh (ALT) flap harvesting, skin graft of the donor site is commonly performed. When the defect width exceeds 8 cm or 16% of thigh circumference, it can determine lower limb function impairment and poor aesthetic outcomes. In our comparative study, we assessed the functional and aesthetic outcomes related to ALT donor-site closure with split-thickness skin graft compared with thigh propeller flap.

METHODS

 We enrolled 60 patients with ALT flap donor sites. We considered two groups of ALT donor-site reconstructions: graft group (30 patients) with split-thickness skin graft and flap group (30 patients) with local perforator-based propeller flap. We assessed for each patient the range of motion (ROM) at the hip and knee, tension, numbness, paresthesia, tactile sensitivity, and gait. Regarding the impact on daily life activities, patients completed the lower extremity functional scale (LEFS) questionnaire. Patient satisfaction for aesthetic outcome was obtained with a 5-point Likert scale (from very poor to excellent).

RESULTS

 In the propeller flap group, the ROMs of hip and knee and the LEFS score were significantly higher. At 12-month follow-up, in the graft group, 23 patients reported tension, 19 numbness, 16 paresthesia, 22 reduction of tactile sensitivity, and 5 alteration of gait versus only 5 patients experienced paresthesia and 7 reduction of tactile sensitivity in the propeller flap group. The satisfaction for aesthetic outcome was significantly higher in the propeller flap group.

CONCLUSION

 In high-tension ALT donor-site closure, the propeller perforator flap should always be considered to avoid split-thickness skin graft with related functional and aesthetic poor results.

Lower limb perforator flaps: Current concept

Following a long period dominated by random fasciocutaneous flaps or muscle flaps, solutions to cover the lower limb have been largely diversified by the advent of so-called "perforator" flaps. Extended knowledge of vascular anatomy has propagated the development of this innovative procedure, in the objective of reducing morbidity. The existence of close to 400 perforator vessels in the body makes it possible to offer new flap perspectives for many defects, which were sometimes previously impossible to manage before except by free flap. For us, perforator flaps have become the current first-line solutions for small to medium size loss of substances. Understanding of vascular physiology and surgical experience are essential in choosing indications, detecting perforators, and modeling flaps to be optimally positioned in the reconstructive decisional algorithm. New skills are needed to master this type of reconstruction and limit failures, which implies a learning curve not only for flap design, perforator detection and surgical procedure, but also for monitoring and management of complications. In this manuscript, we outline the concepts and principles of the majority of the pedicled perforator flaps available for coverage of the lower limb, based on experience of more than 400 perforator flaps suitable for this localization.

Knee reconstruction using a distally based anterolateral thigh flap: an anatomical cadaveric study

OBJECTIVE

To study the vascular territory of the descending branch of the lateral circumflex femoral artery and its anastomosis around the knee and to identify the cutaneous perforator supply to the distally-based or reverse flow anterolateral thigh (dbALT) flap. In particular, the distance of the first perforator branch arising from the knee and above region, as well as the number of branches and position of each perforator, beneficial for effective flap design, are also examined.

METHOD

Fresh cadaveric lower limbs were dissected and the distance of the first perforator branch arising from the knee and above regions, which are vascular supplies for flaps, as well as the number of branches and position of each perforator are described.

RESULTS

A total of 54 thigh cadavers had at least two cutaneous perforator branches above the knee 10cm from the superior border of the lateral patella. The mean (± standard deviation) of the first perforator distance was 2.57±0.93cm above the superior-lateral border of the patella. All perforating branches were 4±2cm, 93% were 10±2cm from the superior lateral border of patella, and 100% were at 20±3cm (mid-thigh length) which were the traditional anterolateral thigh flap.

CONCLUSION

The dbALT flap technique resulted in constant and reliable references about perforator sites. Thus, this type of flap is a viable option in patients who present with soft tissue defects around the knee and upper third of the leg.

Distally-based free anterolateral thigh flap with a modified vena comitans

With the recent development in microsurgery, the use of a perforator flap has been widely implemented. If the length of the ALT flap pedicle is insufficient despite adequate preoperative planning, pedicle length extension is necessary. We planned for a reverse ALT free flap using the distal vessel of the descending branch for pedicle length extension in the case of ALT perforator branch originating from the proximal portion of the descending branch. For the management of venous congestion, the distal venae comitantes were anastomosed to the proximal venous stump in an antegrade manner, successfully resolving the venous congestion. Modified reverse-flow ALT free flap, wherein the venae comitantes are anastomosed to the proximal vein stump, is a good option that allows for relatively simple pedicle extension within the same operative field when securing an adequate pedicle length is difficult because of the origin of the perforator from the proximal descending branch, unlike the initial surgical plan.

Vascular Augmentation in Renal Transplantation: Supercharging and Turbocharging

The most common anatomic variant seen in donor kidneys for renal transplantation is the presence of multiple renal arteries, which can cause an increased risk of complications. Accessory renal arteries should be anastomosed to the proper source arteries to improve renal perfusion via the appropriate vascular reconstruction techniques. In microsurgery, 2 kinds of vascular augmentation methods, known as ‘supercharging’ and ‘turbocharging,’ have been introduced to ensure vascular perfusion in the transferred flap. Supercharging uses a distant source of the vessels, while turbocharging uses vascular sources within the same flap territory. These technical concepts can also be applied in renal transplantation, and in this report, we describe 2 patients who underwent procedures using supercharging and turbocharging. In one case, the ipsilateral deep inferior epigastric artery was transposed to the accessory renal artery (supercharging), and in the other case, the accessory renal artery was anastomosed to the corresponding main renal artery with a vascular graft (turbocharging). The transplanted kidneys showed good perfusion and proper function. No cases of renal failure, hypertension, rejection, or urologic complications were observed. These microsurgical techniques can be safely utilized for renal transplantation with donor kidneys that have multiple arteries with a lower complication rate and better outcome.

Distal anastomosis patterns of the descending branch of the lateral circumflex femoral artery

BACKGROUND

The reverse anterolateral thigh (ALT) flap has shown good results in the treatment of patients who have skin and soft tissue defects around the knee and shin. The objective of this study was to show the anastomotic patterns of the descending branch of lateral femoral circumflex artery (db-LCFA) and locate the appropriate pivot point for reverse ALT flap.

MATERIALS AND METHODS

Fifty thighs from 25 embalmed cadavers from the Anatomy Department, Khon Kaen University in 2012, were dissected. The patterns of distal anastomoses of db-LCFA were recorded and appropriate pivot points for the reverse ALT flap were measured.

RESULTS

Three patterns of distal anastomosis of the db-LCFA were identified, including the anastomoses to the superolateral genicular arteries (46%), anastomoses to the profunda femoral arteries (28%), and unidentified distal anastomoses (26%). The mean distance of the pivot point was 9.4 ± 3.7 cm from the lateral epicondyle. The mean pedicular length was 13.2 ± 5.4 cm (mean ± SD). Most cadavers, 76%, showed a single db-LCFA. In cases where there was more than one db-LCFA, the distal anastomoses were found to be originating from the most medial db-LCFA.

CONCLUSION

The reverse ALT flap technique showed good results in the treatment of patients with skin and soft tissue defects around the knee and shin. Variations of the anastomoses and branching patterns of the db-LCFA may influence flap survival. Additional preoperative vascular evaluations would be helpful in defining the most compatible area from which to harvest the flap.

[Coverage of anterior knee defect by reverse flow anterolateral thigh flap: About two cases]

The coverage of soft-tissue defects concerning the front of the knee and the proximal lower leg is a complex procedure. The reverse flow anterolateral thigh flap represents a good solution for this defects, especially when the coverage surface is large-sized and a free flap is not appropriate regarding the difficulty of the process. Flap retrograde vascularization is based on the anastomosis between the descending branch of the circumflex femoral artery and lateral superior genicular artery. It is an easy solution with low morbidity. The authors have chosen this flap to cover soft-tissue defect of anterior knee from two patients with total knee prothesis.

Limb salvage in musculoskeletal oncology: Recent advances

The treatment of musculoskeletal sarcomas has made vast strides in the last few decades. From an era where amputation was the only option to the current day function preserving resections and complex reconstructions has been a major advance. The objectives of extremity reconstruction after oncologic resection include providing skeletal stability where necessary, adequate wound coverage to allow early subsequent adjuvant therapy, optimising the aesthetic outcome and preservation of functional capability with early return to function. This article highlights the concepts of surgical margins in oncology, discusses the principles governing safe surgical resection in these tumors and summarises the current modalities and recent developments relevant to reconstruction after limb salvage. The rationale of choice of a particular resection modality, the unique challenges of reconstruction in skeletally immature individuals and the impact of adjuvant modalities like chemotherapy and radiotherapy on surgical outcomes are also discussed.