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Shih HS, Chiu TH, Jeng SF, Chen J. Split Anterolateral Thigh Flap: A New Classification of Anatomical Variants and a Surgical Planning Algorithm. J Reconstr Microsurg 2024; 40:473-481. [PMID: 38211622 DOI: 10.1055/a-2242-7194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
BACKGROUND Split anterolateral thigh flap is a versatile reconstruction option, yet long underestimated as no practical perforator classification and no optimal strategy were present. Harvesting "capillary nonsizable perforators" could potentially expand flap splits to those with no existing multiple sizable perforators. Concerns over defect characteristics, recipient vessels, pedicle length, and split timing should all be weighted equally in designing the suitable flap. Refinement is thus required to enable precise reconstructions. METHODS All patients undergoing anterolateral thigh flap harvests between 2014 and 2021 performed by a single surgeon were included. The perforator patterns of sizable pedicle, course, origin, and further successful flap-split methods were documented. Surgical outcome of flap survival was analyzed. RESULTS Anatomical variants of 134 (48.4%) dual, 123 (44.4%) single, and 20 (7.2%) no sizable perforators were found in a total of 277 anterolateral thigh flaps. The overall flap survival rate was 97.5%. Flap split was performed in 82 flaps, including 29 single and 5 no sizable perforator cases previously considered "unsplittable," by utilizing a series of direct skin paddle split, capillary nonsizable perforators harvesting, and flow-through anastomosis technique. Comparable flap survivals were found between split and nonsplit flaps as well as between split segments supplied by sizable and capillary nonsizable perforators. Primary closure was achieved in 98.9% of the thigh donor sites. CONCLUSION A new classification of the common anterolateral thigh flap anatomical variants was proposed and a comprehensive algorithm of split flap strategy was developed along with the innovative "fabricate" concept.
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Affiliation(s)
- Hsiang-Shun Shih
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, Kaohsiung City, Taiwan, Republic of China
- College of Medicine, I-Shou University, Kaohsiung City, Taiwan, Republic of China
| | - Ting-Han Chiu
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, Kaohsiung City, Taiwan, Republic of China
| | - Seng-Feng Jeng
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, Kaohsiung City, Taiwan, Republic of China
| | - Jill Chen
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, Kaohsiung City, Taiwan, Republic of China
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Shim HS, Ryoo HJ, Choi JS, Park JA, Kim YH. Principles and Clinical Application of Free-Style Capillary Perforator-Based Flap for Coverage of Facial Skin Cancer Defects. Cancers (Basel) 2024; 16:2206. [PMID: 38927912 PMCID: PMC11201941 DOI: 10.3390/cancers16122206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 06/07/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024] Open
Abstract
This study introduces a free-style perforator based island flap (PBIF) for the reconstruction of skin defects. From March 2012 to December 2022, a retrospective investigation was conducted on patients who underwent reconstruction for facial defects due to skin cancer. Data on the patients' gender, age, anesthesia method, diagnosis, defect location, flap size, complications, and follow-up periods were collected. There are several principles for designing the PBIF: finger-pinching method, alignment with the direction of wrinkles, the smaller width and longer length of the flap, and proximal attachment to the muscle. A total of 32 patients were included, with an average age of 63.6 years. Surgeries were performed in various regions, such as the infraorbital area, nose, cheek, philtrum, and the anterior/posterior/inferior auricular regions, with an average flap size of 7.63 cm2. There were no complications, such as venous congestion or vascular insufficiency in the skin flaps, although one case required revisional closure due to flap disruption. The PBIF is a useful and effective method for the restoration of facial defects. This method can provide simple yet aesthetically satisfying results, showing stable outcomes without complex surgeries or complications. This study indicates the potential for this method to be more widely employed in reconstructive surgeries in the future.
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Affiliation(s)
- Hyung-Sup Shim
- Department of Plastic and Reconstructive Surgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 16247, Republic of Korea; (H.-J.R.); (J.-S.C.)
| | - Hyun-Jung Ryoo
- Department of Plastic and Reconstructive Surgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 16247, Republic of Korea; (H.-J.R.); (J.-S.C.)
| | - Jae-Seon Choi
- Department of Plastic and Reconstructive Surgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 16247, Republic of Korea; (H.-J.R.); (J.-S.C.)
| | - Ji-Ah Park
- Design Lab of Technology Commercialization Center, Industry-University Cooperation Foundation of Hanyang University, Seoul 04763, Republic of Korea;
| | - Youn-Hwan Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul 04763, Republic of Korea
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Saad N, McGill M, Karamitros G, Cromack D, Wang H, Fisher S, Karamanos E. Surface to Perforator Index: Assessing the Importance of the Number of Perforators in Successful Harvesting of the Anterolateral Thigh Flap. J Reconstr Microsurg 2024; 40:392-397. [PMID: 38061389 DOI: 10.1055/s-0043-1776734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
BACKGROUND The use of perforator flaps has become more popular with improvement of surgical technique, technology, as well as understanding of microvascular anatomy. The selection of well-perfused angiosomes is critical to the successful outcome of patients undergoing free tissue transfer. The number of perforators that are needed is dependent upon the surface area of the flap being harvested; however, there have been no studies to assess the optimal surface area supplied by each perforator. We hypothesized that the smaller the surface area supplied by each perforator correlated with fewer flap-related complications in the harvesting of the anterolateral thigh (ALT) flap. METHODS All ALT flaps harvested from 2015 to 2021 at our institution were retrospectively reviewed. The surface area of the flap harvested was calculated as A = πab, where a is the long radius and b is the short radius of the ellipse. The surface-perforator index (SPI) was calculated for each flap by dividing the surface area of the ALT flap by the number of perforators supplying the flap. Our primary outcomes were flap-related complications that included: partial flap loss, dehiscence, and venous congestion. RESULTS A total of 106 patients were identified. Twenty-four patients (22.6%) developed perforator-related complications. An increasing SPI and SPI to body surface area were strongly associated with development of complications (adjusted odds ratio [95% confidence interval], adjusted p: 1.02 [1.01, 1.03], < 0.001and 1.23 [1.12, 1.42], p < 0.001). An SPI of greater than 150 cm2/perforator was associated with a higher probability of complications (p < 0.001). CONCLUSION Flap-related complications are significantly related to the number of perforators supplying the flap. The smaller the surface area supplied by a single perforator correlates with significantly fewer flap-related complications. SPI is a new index that may be used as a predictive tool to aid in identifying flaps that may be more prone to complications in free tissue transfer.
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Affiliation(s)
- Noah Saad
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Michelle McGill
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Georgios Karamitros
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Ioaninna, Ioaninna, Greece
| | - Douglas Cromack
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Howard Wang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Samuel Fisher
- University of Southern Illinois School of Medicine, Carbondale, Illinois
| | - Efstathios Karamanos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
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Liang W, Chen HF, Jeng SF, Shih HS. Pushing the Limits of Reach for the Pedicled Anterolateral Thigh Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5727. [PMID: 38596578 PMCID: PMC11000755 DOI: 10.1097/gox.0000000000005727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 02/15/2024] [Indexed: 04/11/2024]
Abstract
The pedicled anterolateral thigh flap, although tremendously versatile, may be limited in reach, especially in challenging clinical cases. Traditional methods to extend its reach may remain insufficient or unavailable. We describe two modifications to the conventional pedicled flap to extend its reach to the limits, namely (1) selecting a distal perforator supplemented by the nonsizeable perforator harvest technique, and (2) the double-pivot technique adding an additional rotation to the flap à la propeller perforator flap. The increased reach not only improves reconstructive success, but also opens up new applications for this workhorse flap.
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Affiliation(s)
- Weihao Liang
- From the Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore, Singapore
| | - Hsing-Fu Chen
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, Kaohsiung City, Taiwan
- College of Medicine, I-Shou University, Kaohsiung City, Taiwan
| | - Seng-Feng Jeng
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, Kaohsiung City, Taiwan
- College of Medicine, I-Shou University, Kaohsiung City, Taiwan
| | - Hsiang-Shun Shih
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, Kaohsiung City, Taiwan
- College of Medicine, I-Shou University, Kaohsiung City, Taiwan
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Lu G, Su Y, Jiang Y, Yang L, Wang Y, Shi G, Zhang F, Duan X, Hu H. Improving the visualisation of perforator arteries for anterolateral thigh flaps harvest in CT angiography via sublingual glyceryl trinitrate. Clin Radiol 2023; 78:e791-e797. [PMID: 37574403 DOI: 10.1016/j.crad.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 07/05/2023] [Accepted: 07/08/2023] [Indexed: 08/15/2023]
Abstract
AIM To investigate the improvement of image quality and visualisation of the anterolateral thigh (ALT) flap perforators on computed tomography angiography (CTA) after administration of sublingual glyceryl trinitrate (GTN). MATERIALS AND METHODS Sixty patients with oral lesions received thigh CTA examinations were divided randomly into two groups after administration of sublingual GTN (GTN group) or without administration of sublingual GTN (non-GTN group). Two radiologists calculated the signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and assessed the image quality of each vessel. Besides, the grade of thigh artery, the lumen diameter of deep femoral artery, lateral circumflex femoral artery (LCFA), the descending branch of LCFA and its proximal and distal perforators, and the number and type of visible perforators were evaluated quantitatively. RESULTS The SNR and CNR were not significantly different between the two groups (p>0.05). The image quality of CTA in the GTN group was significantly better than that in the non-GTN group (p<0.01). The lumen diameters of the deep femoral artery, LCFA, the descending branch of LCFA and its perforators were significantly larger in the GTN group than those in the non-GTN group (p<0.01). Compared with the non-GTN group, the number of visible perforators and the number of visible septocutaneous perforators were significantly more in the GTN group, and the qualitative grade of visible perforators was significantly higher (p<0.001). CONCLUSIONS The administration of sublingual GTN in preoperative thigh CTA can improve the image quality and visualisation of perforator vessels, thus could help surgeons to select the optimum ALT flaps.
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Affiliation(s)
- G Lu
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - Y Su
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - Y Jiang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - L Yang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - Y Wang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - G Shi
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - F Zhang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - X Duan
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China.
| | - H Hu
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China.
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Lamba S, Reddy KA, Gohil AJ, Gupta AK. A Simple Method of Intraoperative Identification of a Reliable Perforator while Dissecting an Anterolateral Thigh Flap. J Reconstr Microsurg 2023; 39:e1-e2. [PMID: 34492714 DOI: 10.1055/s-0041-1733921] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Shashank Lamba
- Department of Plastic & Reconstructive Surgery, Christian Medical College & Hospital, Vellore, Tamilnadu affiliated to The Tamilnadu Dr. M.G.R. Medical University, Tamilnadu, India
| | - Komala Abhishek Reddy
- Department of Plastic & Reconstructive Surgery, Christian Medical College & Hospital, Vellore, Tamilnadu affiliated to The Tamilnadu Dr. M.G.R. Medical University, Tamilnadu, India
| | - Amish Jayantilal Gohil
- Department of Plastic & Reconstructive Surgery, Christian Medical College & Hospital, Vellore, Tamilnadu affiliated to The Tamilnadu Dr. M.G.R. Medical University, Tamilnadu, India
| | - Ashish Kumar Gupta
- Department of Plastic & Reconstructive Surgery, Christian Medical College & Hospital, Vellore, Tamilnadu affiliated to The Tamilnadu Dr. M.G.R. Medical University, Tamilnadu, India
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Lin J, Wang Z, Zhang H, Pei Y, Zhu L, Xu Q. Abdominal Wall Skin Loss Defects Reconstruction Using Pedicled Anterolateral Thigh Flap. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03454-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
AbstractIt was extremely difficult to deal with the complex full-thickness abdominal wall defect post serious trauma. The pedicled anterolateral thigh flap had been reported to be applied in reconstructing full-thickness abdominal wall defect in lower abdomen and groin. However, less cases in upper abdominal wall defect reconstructed by anterolateral thigh flap were reported due to some limitations. The aim of this study was to introduce our experiences in applying anterolateral thigh flap in upper abdominal wall defect reconstructing. In this study, seven patients with a large area of upper full-thickness defect in abdominal wall complicated with multiple organ damage were retrospectively identified due to acute trauma. Immediate organ-repair surgeries were performed. Meanwhile, the patients underwent complete debridement in the zone of abdominal wall defect, together with anti-infective treatment. Then, the appropriate timing was chosen to perform pedicled anterolateral thigh flap for reconstructing large area of full-thickness defect involving the upper abdomen. Postoperative follow-up data demonstrated that all the flaps survived, with no hernia complications or other discomforts. The outcome of the patients was also good. Thus, we conclude that pedicled anterolateral thigh flap was feasible to repair full-thickness defect in upper abdominal wall as long as well designed.
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