Reconstruction of a large full-thickness abdominal wall defect with flow-through-based alt flaps: A case report

Anterolateral thigh flow-through flap: A versatile method for reconstruction of complex extremity defects

BACKGROUND

Flow-through flaps have been widely applied only for the reconstruction of complex defects in the extremities because they can be used for arterial reconstruction and soft tissue coverage simultaneously. This report attempts to fully demonstrate the role of the anterolateral thigh (ALT) flow-through flap as a versatile method for reconstructing complex defects in the extremities.

METHODS

From February 2011 to March 2017, we retrospectively analyzed the use of a reconstructive surgical technique based on the ALT flow-through flap to treat complex extremity defects in 87 patients (trauma, n = 79; diabetic ulcers, n = 5; squamous cell carcinoma, n = 3). Emergency surgery was performed in 12 patients to bridge a major artery gap and was followed by elective reconstruction in the remaining patients. Applications of the ALT flow-through flap included bridging major artery gaps, preserving recipient blood vessel integrity, reconstructing blood vessel continuity, protecting vascular anastomoses, avoiding difficult end-to-side anastomoses in the recipient area, and balancing blood flow, as well as combined application with an additional flap.

RESULTS

The flap size ranged from 6 × 3 cm to 17 × 9 cm. ALT flow-through flaps were used in combination with an additional flap (n = 4) and in vascular reconstruction (n = 83). Three patients required of the microvascular anastomostic reexploration for venous congestion, total necrosis occurred in two patients, and partial necrosis occurred in one patient. At the donor site, there were three cases of infection and two cases of wound dehiscence. At the recipient site, one case of infection and two cases of wound dehiscence were observed. One patient presented with deep infection secondary to renal failure and underwent amputation. During the follow-up period (range, 1-33 months), all other flaps (84 cases) survived uneventfully, with normal texture and color.

CONCLUSION

The ALT flow-through flap plays many roles as it is a versatile method for reconstructing complex defects of the extremities and serves various other clinical purposes.

Large wounds reconstruction of the lower extremity with combined latissimus dorsi musculocutaneous flap and flow-through anterolateral thigh perforator flap transfer

BACKGROUND

Management of large wounds of the lower extremities remains a challenge for plastic and reconstructive surgeons. Herein, a surgical technique and clinical algorithm using the combined transfer of a latissimus dorsi (LD) musculocutaneous flap and flow-through anterolateral thigh (ALT) perforator flap for the treatment of extensive soft-tissue defects is described.

METHODS

From January 2012 to September 2018, 12 patients (six men and six women) aged 6-37 years, sustained injuries in road traffic accidents with large soft-tissue defects in the lower extremities. Seven cases were Gustillo Anderson type IIIB open fractures and two cases were Gustillo Anderson type IIIC open fractures. Two wounds were located in the knee joint, four in the calf, and six in the ankle and foot. The skin defect size ranged from 25 × 20 cm² to 36 × 25 cm² . All patients in this series underwent reconstruction using combined transfer of the LD musculocutaneous flap and flow-through ALT perforator flap, wherein the LD was attached through its pedicle to the distal continuation of the ALT flap.

RESULTS

The size of the flow-through ALT perforator flaps ranged from 13.5 × 6.5 cm² to 31 × 8.5 cm² . The size of the LD musculocutaneous skin paddle ranged from 25 × 6 cm² to 34 × 7 cm² , and that of the muscle paddle ranged from 13 × 3.5 cm² to 30 × 11 cm² . One patient experienced postoperative thrombosis of the venous pedicle, and the flap was salvaged after emergency re-exploration and thrombectomy. No other complications were observed postoperatively. The mean follow-up period was 26.8 months. All patients were able to ambulate independently at the end of the follow-up period.

CONCLUSIONS

The combined transfer of the LD musculocutaneous flap and flow-through ALT perforator flap ensured adequate surface coverage, making it a feasible procedure for large soft-tissue defects.

Free superficial circumflex iliac artery perforator fascial flap for reconstruction of upper abdominal wall with extensive infected herniation: A case report

Complex abdominal wall reconstruction is challenging, and vascularized fascia is preferred for active infection cases. Pedicled tensor fascia lata flap is commonly used for lower abdominal wall reconstruction, and free vascularized fascial flap based on the lateral circumflex femoral artery (LCFA) is used for upper abdominal wall reconstruction. However, LCFA-based flap transfer requires invasive and time-consuming muscle dissection and a large recipient vessel. The purpose of this report was to present a new application of superficial circumflex iliac artery (SCIA) perforator (SCIP)-based fascial flap for upper abdominal wall reconstruction. A 70-year-old male suffered from a long-lasting extensive abdominal wall herniation complicated with mesh infection and cutaneous fistulae following multiple herniation repair with synthetic mesh. After complete debridement of infected tissues, there was a 29 x 26 cm full-thickness abdominal wall defect. Components separation was performed to minimize the defect size, after which 12 x 7 cm defect remained in the upper abdominal wall. A 20 x 10 cm SCIP deep fascial flap was elevated based on the deep branch of the SCIA. The SCIP flap was transferred to the defect to reconstruct the upper abdominal wall. The SCIP was anastomosed to the deep inferior epigastric artery perforator with supermicrosurgical perforator-to-perforator anastomosis. Postoperative course was uneventful with good functional and esthetic results of the donor and recipient sites 11 months after the surgery. Although further studies are required, SCIP fascial flap may be an option for upper abdominal wall reconstruction.

Combined use of ipsilateral latissimus dorsi flap and anterolateral thigh flap to reconstruct extensive trunk defects

Reconstruction of a full-thickness trunk defect is challenging because of the complex nature of such defects, which include the chest wall, abdominal wall, and diaphragm. We herein describe three patients in whom extensive trunk defects after sarcoma resection were reconstructed with a latissimus dorsi flap and an anterolateral thigh flap. In two patients, the defect included both the chest wall and the abdominal wall. The other patient had an extensive full-thickness chest wall defect. The size of the anterolateral thigh flap for each patient was 34 × 10 cm, 26 × 15 cm, and 23 × 5 cm, respectively. Although one patient required take-back for additional venous drainage, all wounds healed with no other complications. No respiratory dysfunction or abdominal wall hernia occurred in any patients. The combined use of a latissimus dorsi flap and an anterolateral thigh flap may provide reliable coverage of an extensive trunk defect and robust support of the chest and abdominal walls. Additionally, the availability of a two-team approach without a positional change makes this combination a versatile reconstructive option.