The anterolateral thigh - Vastus lateralis conjoint flap for complex defects of the lower limb

The free vastus lateralis-And conjoined vastus lateralis anterolateral thigh/tensor fascia lata flap for oncological chest wall reconstruction

INTRODUCTION

A reconstructive option for extensive chest wall reconstruction is the free myocutaneous vastus lateralis muscle (VL) flap which can be performed in isolation or in conjunction with a fasciocutaneus anterolateral thigh (cVLALT) and/or myofasciocutaneous tensor fascia lata flap (cVLTFL). We aimed to directly compare the outcomes of these reconstructive options.

METHODS

Patients who underwent oncological chest wall reconstruction with a free VL, cVLALT, or cVLTFL flap between February 2010 and 2022 were included in this retrospective study. Patient demographics, surgical characteristics, as well as medical and reconstructive outcomes, were evaluated. The operative outcomes between myocutaneous VL, cVLALT, and cVLTFL flap reconstructions were compared.

RESULTS

A total of 41 patients underwent chest wall reconstruction with a free myocutaneous VL (n = 25; 61%), cVLALT (n = 14; 34%), or cVLTFL Three acute flap thromboses occurred in the entire cohort (3/41, 7%), with one myocutaneous VL flap failing because of recurrent venous thrombosis during the salvage procedure. Total flap necrosis was seen in two cases (5%; VL flap: n = 1; cVLALT flap: n = 1), and partial flap necrosis in one VL flap (1/25, 4%) and in the distal ALT portion of three cVLALT flaps (3/14, 21%). No significant difference was seen between isolated VL and conjoined VL flaps regarding the partial (p = .28) or total flap necrosis rate (p = .9).

CONCLUSION

The free (conjoined) VL flap provides reliable outcomes for obliterating dead space achieving durable reconstruction of complex chest wall defects.

Clinical application of digital technology in the use of anterolateral thigh lobulated perforator flaps to repair complex soft tissue defects of the limbs

Background

It is challenging to repair wide or irregular defects with traditional skin flaps, and anterolateral thigh (ALT) lobulated perforator flaps are an ideal choice for such defects. However, there are many variations in perforators, so good preoperative planning is very important. This study attempted to explore the feasibility and clinical effect of digital technology in the use of ALT lobulated perforator flaps for repairing complex soft tissue defects in limbs.

Methods

Computed tomography angiography (CTA) was performed on 28 patients with complex soft tissue defects of the limbs, and the CTA data were imported into Mimics 20.0 software in DICOM format. According to the perforation condition of the lateral circumflex femoral artery and the size of the limb defect, one thigh that had two or more perforators from the same source vessel was selected for 3D reconstruction of the ALT lobulated perforator flap model. Mimics 20.0 software was used to visualize the vascular anatomy, virtual design and harvest of the flap before surgery. The intraoperative design and excision of the ALT lobulated perforator flap were guided by the preoperative digital design, and the actual anatomical observations and measurements were recorded.

Results

Digital reconstruction was successfully performed in all patients before surgery; this reconstruction dynamically displayed the anatomical structure of the flap vasculature and accurately guided the design and harvest of the flap during surgery. The parameters of the harvested flaps were consistent with the preoperative parameters. Postoperative complications occurred in 7 patients, but all flaps survived uneventfully. All of the donor sites were closed directly. All patients were followed up for 13-27 months (mean, 19.75 months). The color and texture of each flap were satisfactory and each donor site exhibited a linear scar.

Conclusions

Digital technology can effectively and precisely assist in the design and harvest of ALT lobulated perforator flaps, provide an effective approach for individualized evaluation and flap design and reduce the risk and difficulty of surgery.

[Treatment strategies for fracture-related infections with concurrent soft tissue damage]

Fracture-related infections are the predominant complication following surgical fracture treatment. The distal lower leg, e.g., in pilon tibial fractures, is at a high risk of infection due to poor soft tissue coverage, particularly in cases of open fractures in this area. Fracture-related infections with significant soft tissue damage require special attention alongside treatment of the infection itself. In general, the principle is that healing of fracture-related infection is not possible without sufficient soft tissue coverage. Therefore, it is crucial to integrate both soft tissue damage and fracture-related infection into a comprehensive treatment plan from the beginning. An interdiscpilinary treatment approach between trauma and plastic surgery is often necessary and beneficial. In cases, where fracture fixation devices or bone is exposed, mid- or long-term use of vacuum-assisted wound therapy is not advisable due to a higher risk of reinfection. Hence, an interdisciplinary treatment strategy involving trauma and plastic surgery should prioritize early soft tissue closure, referred to as the "orthoplastic approach". If this cannot be done in the own hospital, early patient transfer is indicated to ensure optimal interdisciplinary therapy with early soft tissue closure and simultaneous trauma surgical treatment to control the infection and enable bone healing. Free fasciocutaneous or muscle flap techniques in combination with adequate trauma surgical and antibiotic therapy lead to good reliable results in these situations.

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.

The Preferred Reconstructive Choice for a Lower Third Tibial Exposure Defect: An Online Survey of 356 Microsurgeons

BACKGROUND

 One of the most challenging yet common areas in reconstructive surgery is the closure of defects in the lower leg. Surgeons can choose from several reconstructive options including local and free flaps. The aim of this study was to understand the reconstructive strategy for lower leg defects of different microsurgeons around the world by harnessing the power of social media and online questionnaires.

METHODS

 A case of a patient with an exposed plate over distal tibial fracture was presented via an online questionnaire distributed on various social media platforms. A total of 369 international microsurgeons replied with their preferred treatment choice. The data were analyzed according to geographic area, microsurgical training, seniority, and subspecialty.

RESULTS

 Among all the respondents (n = 369), 64% would have opted for a free flap reconstruction, while the remaining 36% would have opted for a local/pedicle flap. In the group that would have opted for a free flap, 63% would reconstruct the defect using a free fasciocutaneous flap, while the remaining 37% would have used a free muscle flap. In the local flap group, 60% would have used a local perforator while 30% would have chosen a conventional local flap. While North American and European microsurgeons had a clear preference toward free flaps, Asian, Middle Eastern, African, and South American surgeons were evenly divided between local and free flaps.

CONCLUSION

 In this study, we provide a current global overview of the reconstructive strategies for a lower limb with skin defect and bone or prosthesis exposure. We hope that this will be able to help global microsurgeons and patients worldwide.

Reconstruction of Upper and Lower Limb Defects with Medial Sural Artery Perforator Flaps: Is Aesthetics Worth the Effort? A Retrospective Analysis

Background  One of the most essential goals in managing complex limb defects is obtaining adequate soft tissue coverage with excellent functional and aesthetic outcomes. Free perforator skin flaps represent an optimal option for such defects. Therefore, our intention was to reconstruct these kinds of defects with thin fasciocutaneous flaps without the need for debulking. Herein, we define the legitimate use of the medial sural artery perforator (MSAP) flaps for small-moderate size defect coverage of the hand and foot. Patients and Methods  Seven patients received MSAP flaps for reconstruction of different hand and foot defects, of which the majority were males (4/7). Age, sex, flap size, location, number of perforators, recipient vessel, type of anastomosis, technique of donor site closure, and postoperative morbidity were recorded. Patients' age ranged from 48 to 84 years. Results  Single-stage debridement followed by reconstruction was performed. Flap sizes ranged from 6 to 18 cm in length and 4 to 10 cm in width. The pedicles of 6 flaps were anastomosed to the tibial artery system (three posterior tibial artery, three dorsalis pedis artery) and one to the ulnar artery. Conclusion  MSAP flap can be a versatile option for single-stage reconstruction of small-moderate size defects of the extremities, where thin, soft tissue envelope is required. This flap has lower donor site morbidity, more tedious elevation process, and has a good reconstructive and aesthetic result without the need for debulking in the future.

The use of the chimeric conjoint flap technique for complex defects reconstruction throughout the body: Clinical experience with 28 cases

BACKGROUND

Large soft tissue defects reconstruction represents a frequent and complex challenge in plastic surgery. A critical point regards the equilibrium between the need of large amount of tissue, while minimizing donor site morbidity. This is a common issue that plastic surgeons face in their clinical practice. In this context, the chimeric conjoint flap technique can be a valuable option, allowing to better exploit many well-known procedures. The purpose of the present work is to show the reconstructive efficacy and reliability of this technique resorting to many different well-known flaps. No such a comprehensive collection of cases is available so far dealing with this procedure.

PATIENTS AND METHODS

Twenty-eight patients presenting large defects throughout the body were treated by means of different flaps, designed according to the chimeric conjoint flap concept. Patients' mean age was 61.9 years old (range 18-82 years), 20 were males and 8 females. The size of the defects ranged from 7 cm × 6 cm to 25 cm × 18 and presented shapes or localizations that were complex to be covered with a regular flap. The defects were located in 11 cases in the lower limbs, in 9 cases in the head and neck region, in 5 cases in the groin, and in 2 cases in the thorax. Cause of the defect was tumor resection in 20 cases, trauma-induced necrosis in 5 cases, Fournier's gangrene in 2 cases, and a chronic ulcer in 1 case. Fourteen flaps were free flaps while 14 were pedicled flaps. The chimeric conjoint flap technique consists in splitting the skin paddle a flap into two smaller island that can be rearranged in order to match the particular requirements of the recipient site. Different flaps were employed: the anterolateral thigh (ALT) flap was used in 19 cases, latissimus dorsi (LD) musculocutaneous flap in 4 cases, deep inferior epigastric (DIEP) in 3 cases, medial sural artery perforator (MSAP) in 1 case, free radial forearm flap (RFFF) in 1 case.

RESULTS

All the 28 patients were successfully treated. In 6 cases minor complications were encountered, 5 at recipient site and 1 at donor site, who were all managed conservatively. No second procedures were required. The mean follow-up period was 8.4 months (range 3-12 months). At the last follow-up evaluation all the patients reached an acceptable cosmetic result and, when limbs were affected, complete range of motion restoration.

CONCLUSIONS

The present case series provide promising evidence regarding the reliability and versatility of the chimeric conjoint flap technique for large and delicate defect reconstructions throughout the body.

Defect Reconstruction Using the Propeller Flaps Based on the Perforators Derived From the Lateral Circumflex Femoral Artery System

BACKGROUND

Although propeller flaps are a useful option for soft tissue defect reconstruction, reports based on the perforators of the lateral circumflex femoral artery (LCFA) are rare. We aimed to present our experience in defect reconstruction using the propeller flaps based on perforators from different branches of LCFA and apply these flaps in soft tissue defect reconstruction of the lower extremities.

METHODS

Twenty nine patients (32 flaps) underwent defect reconstruction using propeller flaps based on the perforator of the LCFA. Defects were located from the groin to the proximal leg. According to the source vessels from which the perforator originated, flaps were categorized into types I, II, III and IV, which represented perforators from the transverse, descending, oblique, and rectus femoris branches, respectively. Type II flaps were subdivided into types IIa and IIb flaps based on antegrade and reverse flows of the descending branch.

RESULTS

Flap sizes ranged from 12 × 6 cm to 30 × 15 cm (average, 22.69 × 9.19 cm) with the length of the vascular pedicle ranging from 3 to 7 cm (average, 4.86 cm). Flaps were rotated from 60° to 180° (average, 144.06°). There were 3 type I, 10 type IIa, 4 type IIb, 13 type III and, and 2 type IV flaps. Twenty-nine flaps survived after surgery. Total flap necrosis and venous congestion of the distal flap portion occurred in 1 and 2 patients, respectively.

CONCLUSIONS

Reconstruction using propeller flaps based on perforators of the LCFA is a safe, reliable, and versatile option for defect reconstruction of the lower extremities; however, it requires meticulous surgical dissection and patience.

Resection and reconstruction of a giant primitive neuroectodermal tumour of the abdominal wall with an ultra-long lateral circumflex femoral artery musculocutaneous flap: a case report

Background

Primitive neuroectodermal tumours are clinically rare. Here, we report a case of a large peripheral primitive neuroectodermal tumour of the abdominal wall. The defect was reconstructed with the longest lateral circumflex femoral artery musculocutaneous flap reported to date.

Case presentation

A 15-year-old male suffered rupture and bleeding of an abdominal wall mass with a volume of approximately 23*18*10 cm³, involving the whole layer of the abdominal wall. Pathological examination revealed a peripheral primitive neuroectodermal tumour. The tumour was removed via oncologic resection, and the abdominal wall was reconstructed with a bilateral 44*8 cm² lateral circumflex femoral artery musculocutaneous flap combined with a titanium polypropylene patch. The patient had smooth recovery postoperative, and the functions of the donor and recipient areas of the flap were not significantly affected.

Conclusion

In this case report, we describe a rare primitive neuroectodermal tumour of the abdominal wall, which invaded almost the entire abdominal wall due to delay of treatment. After thoroughly removing the tumour, we immediately reconstructed the abdominal wall with an ultra-long lateral circumflex femoral artery musculocutaneous flap and achieved better appearance and function after the operation. This case suggests that we should adopt an integrated scheme of surgery combined with radiotherapy and chemotherapy in the treatment of peripheral primitive neuroectodermal tumours. Under the premise of determining the blood supply, the lateral circumflex femoral artery musculocutaneous flap can be cut to a sufficient length.

Flap coverage for necrotising soft tissue infections: A systematic review

BACKGROUND

Necrotising soft tissue infections (NSTI) are destructive and often life-threatening infections of the skin and soft tissue, necessitating prompt recognition and aggressive medical and surgical treatment. After debridement, the aim of surgical closure and reconstruction is to minimize disability and optimize appearance. Although skin grafting may fulfil this role, techniques higher on the reconstructive ladder, including local, regional and free flaps, are sometimes undertaken. This systematic review sought to determine the circumstances when this is true, which flaps were most commonly employed, and for which anatomical areas.

METHODS

A systematic review of the literature was conducted utilising electronic databases (Medline, Embase, Cochrane Library). Full text studies of flaps used for the management of NSTI's (including Necrotising Fasciitis and Fournier Gangrene) were included. The web-based program 'Covidence' facilitated storage of references and data management. Data obtained in the search included reference details (journal, date and title), the study design, the purpose of the study, the study findings, number of patients with NSTI included, the anatomical areas of NSTI involved, the types of flaps used, and the complication rate.

RESULTS

After screening 4555 references, 501 full text manuscripts were assessed for eligibility after duplicates and irrelevant studies were excluded. 230 full text manuscripts discussed the use of 888 flap closures in the context of NSTI in 733 patients; the majority of these were case series published in the last 20 years in a large variety of journals. Reconstruction of the perineum following Fournier's gangrene accounted for the majority of the reported flaps (58.6%). Free flaps were used infrequently (8%), whereas loco-regional muscle flaps (18%) and loco-regional fasciocutaneous flaps (71%) were employed more often. The reported rate of partial or complete flap loss was 3.3%.

CONCLUSION

Complex skin and soft tissue defects from NSTIs, not amenable to skin grafting, can be more effectively and durably covered using a spectrum of flaps. This systematic review highlights the important contribution that the plastic surgeon makes as an integral member of multidisciplinary teams managing these patients.

Novel Design of the Chimeric Deep Inferior Epigastric Artery Perforator Flap that Provides for Three-Dimensional Reconstruction of Composite Tissue Defects of the Heel in Children

Objective

The aim of the present study was to report a novel design of the chimeric deep inferior epigastric artery perforator flap (DIEP) to achieve dead space filling, Achilles tendon bridging, and skin resurfacing simultaneously with minimal donor‐site morbidity.

Methods

From September 2012 to May 2016, a retrospective study was carried out on six pediatric patients with composite soft tissue defects of the heel that were repaired with the chimeric DIEP flap. The chimeric flap design included a flap of the anterior sheath of the rectus, a block of rectus muscle, and a large skin paddle. All the parts were supplied by a common artery. After harvesting the flap, all element parts were inserted at the corresponding sites in a tension‐free manner. With one set of vessel anastomoses at the recipient site, accurate repair with tendon reconstruction, dead space elimination, and wound covering were accomplished. The donor site incisions were closed initially. Data on patient age, medical history, injury severity, defect size, flap dimensions, recipient vessels, donor site closure, complications, and follow‐up were collected and reviewed.

Results

Five of the six chimeric DIEP flaps survived without complications. The remaining one case experienced partial necrosis of the skin paddle caused by venous congestion, which healed after routine dressing changes. Primary donor site closure was accomplished in all cases. The mean follow‐up was 18.6 months (range, 10–36 months). Five patients had satisfactory aesthetic and functional outcomes; one patient needed a secondary debulking procedure. Compared to the unaffected side, the affected side showed no obvious difference for ankle movement, tiptoe function, and patient gait during the follow‐up period. Good ankle function was observed in all patients. There was no donor site breakdown, with only a slightly noticeable linear scar.

Conclusion

The chimeric DIEP flap reduced the operative time, solved the problem of deficiency of recipient vessels, and attained satisfactory functional and aesthetic outcomes with low donor site morbidity. Therefore, it is a promising option for three‐dimensional reconstruction of composite defects with dead space and Achilles tendon defects as well as skin loss in children.

Versatile design of compound vastus lateralis muscle and anterolateral thigh musculocutaneous perforator free flaps for customized reconstruction of complex skin and soft tissue defects in the extremities

BACKGROUND

Compound anterolateral thigh flaps are popular for three-dimensional reconstruction of complex soft tissue defects. We present our 10-year experience using compound vastus lateralis (VL) muscle and anterolateral thigh musculocutaneous perforator (ALTP) flaps, and introduce three versatile customizations of this flap for individualized reconstruction of complex three-dimensional soft tissue defects.

METHODS

From May 2008 to June 2017, compound VL muscle and ALTP flaps were performed in 67 consecutive patients aged 14-75 years (62 men and 5 women). The defects were in either the lower (n = 53) or upper extremity (n = 14), and ranged in size from 8 × 4 cm2 to 25 × 6 cm2. Dead space volume ranged from 4 × 2 × 1 cm3 to 20 × 3 × 2 cm3, and all flaps were harvested from patients' thighs as one of three types. In type A, a single perforator supplied both the skin and muscle components, with the vascular bundle penetrating the muscle component. In type B, a single perforator supplied both skin and muscle components with separate branches to the skin and muscle. In type C, separate vessels supplied the skin and muscle.

RESULTS

In the 67 patients, 65 flaps survived, and the donor site was closed directly. Vascular compromise occurred in four patients on the first postoperative day. Two flaps were salvaged after emergency re-exploration. Flap loss occurred in two patients, and these defects were repaired using other flaps. The follow-up period ranged from 8 to 60 months (mean, 11.9 months). All flaps had satisfactory appearance and texture, and no patients experienced limited hip and knee joint mobility from the donor site operation.

CONCLUSIONS

Compound VL muscle and ALTP flaps are a reliable option to reconstruct complex defects of the extremities. Identifying three flap types allowed for more precise customization to cover complex defects with limited donor site morbidity.

Selecting a free flap for soft tissue coverage in lower extremity reconstruction

BACKGROUND

Goals of lower extremity microvascular reconstruction (LEMR) include the restoration of function, prevention of infection, and optimal cosmesis. Indications for LEMR include large defects that are not amenable to pedicled options, a large zone of injury, and large complex defects. The novice microsurgeon should first master a handful of free flaps to develop an armamentarium of options for addressing such defects. The scope of this review is to provide free flap options for LEMR in any of the thirds of the lower leg. After reading this article, the reader will understand variations, advantages, disadvantages, indications, and tips for raising each of these flaps.

METHODS

Six most commonly used free flaps for LEMR are described in this paper, including the anterolateral thigh flap (ALT) and its variations, the radial forearm flap (RFFF), the lateral arm flap (LAF), the gracilis muscle flap, the rectus abdominis flap (RAF) and the latissimus dorsi flap and its variations. Indications, advantages, disadvantages and technique tips are discussed for each flap. Moreover, selection of the recipient vessels, preoperative management along with an algorithm are also provided.

CONCLUSIONS

The ALT flap is a workhorse in covering defects of the leg, foot, and ankle. It's the flap of choice at our institution, especially given the number of traumatic wounds seen as a result of motor vehicles, all-terrain vehicles (ATV), lawnmowers, and gunshot wounds (GSW). At times, the lower extremity zone of injury requires a distant donor site. The RAF can also provide coverage for large soft tissue defects but donor-site morbidity remains its main drawback. The LAF and RFFF provide two pliable options, one that provides pliable soft tissue with minimal donor site morbidity and another that provides a long pedicle. The free gracilis flap is an excellent choice for crossing the ankle joint. Lastly, the free latissimus dorsi is indicated for large defects of the lower extremity independently of the location.

A retrospective analysis of latissimus dorsi-serratus anterior chimeric flap reconstruction in 47 patients with extensive lower extremity trauma

Background:

Many flaps have been described for reconstruction of lower extremity defects, including, Latissimus Dorsi, Rectus abdominis, Anterolateral thigh perforator flaps, each having advantages and disadvantages. The defect location, size and specific geometric pattern of defect influences the type of flap that can be used. In this case series, we describe the specific situations where the use of chimeric latissimus dorsi–serratus anterior (LD + SA) free flaps are of advantage in providing complete wound cover.

Materials and Methods:

Case records of all patients who underwent LD + SA free flap transfer for lower extremity trauma at Amandeep Hospital, from Feb 2006 to Feb 2017 were reviewed. Patients were categorised based on the anatomical location and size of defect. The method of usage of the chimeric segments, recipient vessels and type of anastomosis were noted. Flap complications, if any were reviewed.

Result:

47 patients with lower limb defects were included in the study. All cases were post traumatic in nature. Defect size ranged from 180 sq cm to 1050 sq cm. Average defect size was 487.70 sq cm. All patients underwent soft tissue reconstruction with LD + SA flap. Complete wound cover was obtained.

Conclusion:

Latissimus dorsi + Serratus anterior free tissue transfer is an effective, reliable method of providing cover to extensive lower limb traumatic defects with minimal donor site morbidity, with added freedom of inset and flap positioning. Specific use is seen in patients with broad proximal defect, long defect in the leg, defects involving adjacent anatomical areas and in large defect with dead space.

Management of Post-Traumatic Composite Bone and Soft Tissue Defect of Leg

Management of composite defects of leg following trauma requires a planned ortho-plastic approach right from the outset. Timely, planned intervention results in reduced amputation rates and improved limb salvage and function. Right from the time of presentation of the patient to the emergency with such injury, the process of decision making in terms of salvage or amputation, local flap cover/free flap cover, bone reconstruction first or soft tissue or both combined, come into play. Guidelines on management are unclear for such defects, a literature search yielding various methods being used by different authors.

This article is a review of current literature on management of composite leg defects.

A summary of the literature search in terms of various management options given by various authors including the rationale, advantages and disadvantages of each strategy has been provided in this article. The management protocol and method followed by the author in his institute for management of such composite defects have been described in detail. The article seeks to provide readers with an understanding of the management strategies so that appropriate method could be chosen to provide best result.

Colour Doppler sonography in the preoperative assessment of the vascular pedicle from the anterolateral thigh flap: proposal for a mathematical formula to predict pedicle length

Introduction

The anterolateral thigh flap (ALT) is one of the most commonly used grafts in head and neck reconstructive surgery. In this type of surgery, it is essential that the vascular pedicle be long enough to ensure proper vascular anastomosis. However, it is difficult to accurately estimate the pedicle length preoperatively. In this context, the current study had two aims: (1) to assess the value of colour Doppler sonography (CDS) in the preoperative assessment of the vascular pedicle and (2) to develop a mathematical model to predict the length of the vascular pedicle based on the ultrasound findings.

Materials and methods

Retrospective review of patients who underwent primary surgery for head and neck cancer followed by ALT flap reconstruction at our institution from 2014 to 2018. All patients underwent CDS prior to surgical excision of the flap.

Results

Preoperative CDS was useful to identify the location of the vascular perforators, to estimate the pedicle length, and to identify the vascularization variant. Using the proposed mathematical formula, the estimated minimum pedicle length and actual length agreed in 73.9% of cases, increasing to 84.1% when a 5 mm margin of error was allowed. Moreover, preoperative ultrasound accurately distinguished the two anatomical variants of the ALT vasculature in nearly all cases (97.1%).

Conclusion

This study confirms the value of preoperative colour Doppler sonography for ALT flap reconstruction. The proposed mathematical model provides a highly accurate method of preoperatively assessing the length of the vascular pedicle, which may be of value in head and neck surgery.

Wound Surface Area as a Risk Factor for Flap Complications among Patients with Open Fractures

BACKGROUND

Soft-tissue complications often dictate the success of limb salvage and the overall outcome of open fractures. Based on prior work at the R Adams Cowley Shock Trauma Center, the authors hypothesize that wounds larger than 200 cm are associated with a greater likelihood of both flap-related reoperation and wound complications among patients requiring soft-tissue reconstruction with a rotational flap or free tissue transfer.

METHODS

This study was a secondary analysis of Fluid Lavage in Open Wounds trial data that included all patients who received a rotational or free tissue flap transfer for an open fracture. The primary outcome was flap-related reoperation within 12 months of injury. The secondary outcome was wound complication, which included events treated operatively or nonoperatively. Multivariable logistic regression was used to assess the association between wound size and outcomes, adjusting for confounders.

RESULTS

Seventeen percent of the 112 patients required a flap-related reoperation. A wound size greater than 200 cm(2) was not associated with reoperation in an unadjusted model (p = 0.64) or adjusting for Gustilo type (p = 0.70). The sample had an overall wound complication rate of 47.3 percent. Patients with a wound size of greater than 200 cm(2) were three times more likely to experience wound complications (OR, 3.05; 95 percent CI, 1.08 to 8.62; p = 0.04) when adjusting for moderate to severe wound contamination and wound closure in the operating room.

CONCLUSION

The findings of this study demonstrate that wound surface area is an integral determinant for wound complication following soft-tissue flap treatment, but found no association between wound surface area and flap-related reoperation rates.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

[Clinical applications of distally based anterolateral thigh flaps based on perforating vessels from lateral circumflex femoral artery oblique branch]

Objective

To explore the feasibility and technical points of soft tissue defect reconstruction of the lower extremity using the distally based anterolateral thigh (dALT) flap based on perforating vessels from the lateral circumflex femoral artery (LCFA) oblique branch.

Methods

Between July 2010 and July 2016, 7 patients underwent defect reconstruction of the lower extremities using the dALT flap based on perforating vessels from the LCFA oblique branch. There were 4 males and 3 females with an average age of 26.7 years (range, 3-58 years). The etiologies included angiofibrolipoma in 1 case, malignant fibrous sarcoma in 1 case, soft tissue sarcoma in 1 case, and post-burn scar contracture in 4 cases. The disease duration was 13 years, 1 year, and 8 months in 3 patients with tumors respectively, and was from 6 months to 35 years in 4 patients with post-burn scar contracture. After resection of lesion tissues, the defect size ranged from 8 cm×6 cm to 24 cm×8 cm. The flap size ranged from 9 cm×7 cm to 24 cm×8 cm. The length of the pedicle ranged from 12 to 22 cm (mean, 16.6 cm). The distance from the flap pivot point to the superolateral border of the patella ranged from 9.5 to 14.0 cm (mean, 11.8 cm). The donor sites were directly closed in 6 cases and covered with the split-thickness skin graft in 1 case.

Results

All flaps survived after surgery without any major complications. All wounds at the donor and the recipient sites healed primarily. The patients were followed up from 5 to 54 months (mean, 30.7 months). The color, texture, and thickness of the flaps were similar to those of the surrounding skin. No tumor recurrence was observed. The range of motion of flexion and extension of the knee joint were greatly improved in the patients with post-burn scar contracture.

Conclusion

For patients who have the oblique branch from the LCFA descending branch which sends out perforating vessels to the skin of the anterolateral thigh region, a dALT flap could be used to reconstruct soft tissue defects of the lower extremities.

One plus one: Two free flaps from same donor thigh for simultaneous coverage of two different defects

Introduction:

Primary microvascular reconstruction of multiple defects is challenging particularly if it has to be simultaneous. In trauma cases, harvesting two independent free flaps from different sites is very time-consuming and adds to morbidity. To eliminate these disadvantages, we sought to find out a reliable alternative method of harvesting two independent free flaps based on the descending branch of circumflex femoral artery, i.e., one anterolateral thigh (ALT) flap and one rectus femoris muscle flap.

Aim:

To study the feasibility of transferring two free flaps, i.e., ALT and rectus femoris muscle flap simultaneously from the same thigh for coverage of two different limb defects.

Materials and Methods:

From 2003 to 2012, five patients with two defects each were managed with a total of ten flaps harvested from five donor sites based on independent pedicles of descending branch of lateral circumflex femoral artery and used to cover severe injuries of extremities. Three cases had both lower limb defects and two cases had one upper limb and one lower limb defect. In each case, one ALT flap and one rectus femoris muscle flap were used for coverage.

Results:

All reconstructive procedures were completed without any major complications. All flaps survived well. There were no re-explorations and no complications related to donor sites.

Conclusion:

We conclude that our approach of simultaneous harvest of ALT and rectus femoris muscle from the same thigh offers two flaps for two different defects in terms of economy of donor site and operating time.

Effect of Atherosclerosis on the Lateral Circumflex Femoral Artery and Its Descending Branch: Comparative Study to Nonatherosclerotic Risk

The anterolateral thigh (ALT) flap has been widely used for reconstructions. Nevertheless, the atherosclerotic risk factors that affect the lateral circumflex femoral artery (LCFA) are still inconclusive. The aim was to study the effect of atherosclerosis on the LCFA and descending branch (dLCFA) visualized by computer tomographic angiography (CTA) between nonatherosclerosis and atherosclerosis.

Surgical treatment options for septic non-union of the tibia: two staged operation, Flow-through anastomosis of FVFG, and continuous local intraarterial infusion of heparin

BACKGROUND

The treatment of septic non-union of the tibia is a challenging area.　The objective of this clinical study was to improve the treatment outcomes in patients with a highly active infection by the three strategies consisting of a two-staged operation, a flow-through technique for vascular anastomosis of a free vascularized fibular graft (FVFG), and continuous local intra-arterial infusion of heparin.

PATIENTS & METHOD

Five patients with septic non-union of the tibia who were treated with an FVFG (mean age: 52.8 years) were enrolled.　The mean postoperative follow-up period was 47.2 months, and the mean length of the bone defect was 111 mm.　A two-staged operation, in which polymethylmethacrylate (PMMA) beads containing antibiotics were inserted into a bone defect followed by bone reconstruction performed with an FVFG later.　Vascular anastomosis was performed with the flow-through technique in all patients.　Immediately after FVFG, heparin was continuously infused through a femoral arterial catheter for 1 week.

RESULT

Bone union was confirmed an average of 18.8 weeks after-surgery in all patients without reoperation for thrombus.

CONCLUSION

Our attempt to apply the strategies appears to be a viable treatment option for septic non-union of the tibia.

A thoracodorsal artery perforator chimeric free flap for prevention of microvascular pedicle compression in lower extremity reconstruction

BACKGROUND

Chimeric flaps are often used in reconstructive fields for multiple defects, different functional defects, and extensive defects. In this article, we present the results of the use of thoracodorsal artery perforator (TDAp) chimeric flaps including a latissimus dorsi (LD) or serratus anterior (SA) muscle to prevent pedicle compression for lower extremity reconstruction.

METHODS

Nineteen TDAp chimeric flaps were used to prevent pedicle compression. Seven were female and 12 male. Patients' age ranged from 32 to 73 years. After harvesting TDAp skin flap, LD or SA muscle could be harvested along with the thoracodorsal vessels. Skin flap was incorporated into the main defect and muscle cuffs were positioned along the vascular pedicle.

RESULTS

In 11 cases, there were two components, a skin flap and a muscle flap, and the other 8 were three components, a skin flap and two muscle flaps. The dimensions of the skin flaps ranged from 8 × 5 to 18 × 10 cm, and the muscle flaps ranged from 3 × 2 cm to 8 × 6 cm. The recipient vessel was anterior tibial artery or dorsalis pedis artery. All flap survived. Five cases suffered minor complications including donor site wound disruption, skin flap wound disruption, partial loss of the skin flap, and partial loss of the SA muscle flap. The mean follow-up was 13.9 months. All the patients were able to wear shoes without debulking procedures.

CONCLUSION

The TDAp chimeric flaps including LD or SA muscle flaps were useful for covering the vascular pedicle and relieved vascular compression during lower extremity reconstruction. © 2015 Wiley Periodicals, Inc. Microsurgery, 38:46-50, 2018..

Reconstruction of complex soft-tissue defects around the knee joint with distally based split vastus lateralis musculocutaneous flap: a new technique

AIMS

The aim of this study was to report our experience of using distally based spilt vastus lateralis musculocutaneous flaps for soft-tissue defects around the knee joint - a new technique.

MATERIAL AND METHODS

Cadaver dissection studies were conducted in three cadavers to demonstrate perforators entering the lower third of the vastus lateralis muscle arising from the superior lateral genicular artery. Its application in eight clinical cases for the reconstruction of soft-tissue defects around the knee joint is reported.

RESULTS

Seven out of eight flaps survived well without any flap loss. One flap with a skin island measuring 12 × 20 cm suffered a loss of 2 cm distally. This was later treated with skin grafting. Six out of eight donor sites were closed primarily. Six patients achieved full functional range of motion by 3 months. One patient had a 10° limitation of knee extension. One patient had foot drop due to primary injury and walks with a limping gait.

CONCLUSIONS

This flap is a new reconstructive option for knee defects. It can reach distally up to the tibial tuberosity and does not require an intraoperative change of position. The donor site can be closed primarily and is hidden inside the clothing. The function of the knee is not affected as the majority of the muscle is kept in continuity.

Reconstruction of extensive lower limb defects with thoracodorsal axis chimeric flaps

BACKGROUND

Extensive defects of the lower extremities are usually reconstructed with microvascular free flaps because of inadequate local tissues and wound complexity. Many attempts have been made to reconstruct such defects using the chimeric flap concept, enabling flaps with larger surface areas to be used while maintaining economical tissue use. The latissimus dorsi chimeric flap is one of the most useful tools for resurfacing extensive limb defects.

METHODS

Twelve patients with extensive lower leg defects underwent reconstruction with latissimus dorsi chimeric flaps between January of 2008 and March of 2012. A skin flap based on the cutaneous perforators, a latissimus dorsi muscle flap based on the muscular branches, and a serratus anterior muscle flap based on the branch from the thoracodorsal artery were harvested accordingly; the flap design depended on the dimensions and characteristics of the defect.

RESULTS

A total of 12 chimeric flaps were harvested and used, with the average surface area, including skin and muscle components, being 614 cm. The mean surface area of the skin flaps used was 355.6 cm. The mean area of the latissimus dorsi muscle flap was approximately 228 cm, and the surface areas of the three serratus anterior flaps used were 56 cm, 70 cm, and 180 cm. Flaps survived in all cases. Primary closure was used for all of the donor sites except one, and there was minimal donor-site morbidity.

CONCLUSION

The authors' results show that the latissimus dorsi chimeric free flap is a useful and versatile reconstructive option for extensive defects of the lower extremities.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Free flap transplantation combined with skin grafting and vacuum sealing drainage for repair of circumferential or sub-circumferential soft-tissue wounds of the lower leg

Background

This study is aimed at evaluating the operation techniques and clinical significance of free flap transplantation combined with skin grafting and vacuum sealing drainage (VSD) in repairing severe traumatic extensive circumferential or semi-circumferential soft-tissue defects of the lower leg.

Material/Methods

Thirty patients with severe lower leg injuries were treated by free flap transplantation combined with skin grafting and VSD from January 2008 to June 2011. The size of the wounds ranged from 23×8 cm to 44×28 cm and all affected more 70% of the low leg circumferential area. Wounds were complicated by exposure, necrosis, or infection of deep tissues. The wounds were first debrided and covered by VSD. When the condition of the wound had improved (5 to 7 days later), free flaps were harvested to reconstruct damaged tissue and skin grafts and VSD was used to cover granulation tissues around the transplanted flap.

Results

Granulation tissues developed and the area requiring flap cover decreased in all 30 patients after debridement and VSD. In 28 of 30 cases, the transplanted flaps grew well without complication. Peripheral necrosis was observed in only 2 cases, which required a second debridement and skin graft. Ten wound areas covered by grafts were left with scattered peripheral wounds, which healed with the help of 1 more skin graft or dressing change. Morphological appearance and functional recovery were satisfactory in all 30 cases.

Conclusions

Initial debridement and the temporary VSD cover followed after several days by free flap transplantation combined with skin grafting and VSD protection is a reliable treatment regimen for traumatic large circumferential or sub-circumferential soft tissue wounds of the lower leg with deep tissue exposure.

Soft-tissue reconstruction of open fractures of the lower limb: muscle versus fasciocutaneous flaps

Early vascularized soft-tissue closure has long been recognized to be essential in achieving eventual infection-free union. The question of whether muscle or fasciocutaneous tissue is superior in terms of promoting fracture healing remains unresolved. In this article, the authors review the experimental and clinical evidence for the different tissue types and advocate that the biological role of flaps should be included as a key consideration during flap selection.

The oblique branch trap in the harvest of the anterolateral thigh myocutaneous flap

A 67-year-old man with squamous cell carcinoma underwent reconstruction with a free anterolateral thigh myocutaneous flap. Unroofing the skin perforators found that the skin perforators originated from the oblique branch of the lateral circumflex femoral artery with no connections with the descending branch. Thus, the flap was harvested based on the oblique branch, leaving the descending branch in situ. Reconstruction was completed uneventfully and he had an excellent outcome at 1-year follow-up. The anterolateral thigh myocutaneous flap was reputed to be a technically easy flap to harvest. The perforators supplying the skin were visualized and a block of muscle incorporating the perforators harvested with the descending branch of the lateral circumflex femoral artery as the pedicle of the flap. However, not infrequently with this approach, the flap thus harvested has a well-perfused muscle component, whereas the skin component was not viable. This situation is explained anatomically by the potential occurrence of an alternative pedicle that supplies the anterolateral thigh flap, called the oblique branch of the lateral circumflex femoral artery. Our case presented here was a "classic" intraoperative finding of this potential trap and the importance of defining the anatomy before committing oneself to the harvest by unroofing all the skin perforators was emphasized.

Reconstruction of lower extremity complex wounds with combined free tissue transfer using the anterolateral thigh flap as a link

In this report, the authors present the experience on the reconstruction of the totally degloved foot and extremely long soft tissue defect of a lower limb with the combined free tissue transfer using the anterolateral thigh flap as a link in two male patients between October 2009 and December 2010. The anterolateral thigh flap has been commonly used as a link between the recipient site and the distal flap. The anterolateral thigh flap and latissimus dorsi muscle flap were selected for the distal flap, according to their reconstructive needs. Two combined free flaps survived without major complication. The authors could salvage of the lower extremity through the reconstruction of complex wound with the combined free tissue transfer using the anterolateral thigh flap as a link. This combined flap may be an alternative for reconstruction of complex soft tissue defect in the lower extremity.