Comparison of surgical result of anterolateral thigh flap in reconstruction of through-and-through cheek defect with/without CT angiography guidance

Clinical applications of the chimeric anterolateral thigh (ALT) flap in head and neck reconstruction

BACKGROUND

Surgical site infection (SSI) is a common complication following head and neck surgery. Dead space at the excision site can increase the risk of infection, abscess formation, and mortality. Herein, we evaluated the performance of the chimeric anterolateral thigh (ALT) flap in addressing these concerns.

METHODS

Patients who underwent oncologic head and neck reconstruction between October 2016 and November 2021 were divided in two groups: a normal ALT flap and a chimeric dead space filling (DSF) ALT-vastus lateralis flap group. We evaluated the postoperative outcomes.

RESULTS

Twenty-five patients treated with normal ALT flaps (34.7%) and 47 with DSF ALT flap group (65.2%) were included. Only one ALT per case was necessary. Most of the cases involved tongue (31.9%) and lower gingival reconstruction (27.8%). The time to harvest the DSF ALT flap was 134.3 min when compared to the normal ALT flap (116.2 min, p < .001). Vascular occlusion, flap loss, partial necrosis, and fat necrosis were not observed among the different groups.

CONCLUSION

The DSF process can be used as a preventive measure for SSI or vessel exposure due to radiation-induced skin damage. This flap allows same-site reconstruction if the primary tumor recurs by using the pedicle of the chimeric flap for reattachment of another free flap.

Perforators Detected in Computed Tomography Angiography for Anterolateral Thigh Free Flap: Am I the Only One Who Feels Inaccurate?

BACKGROUND

The number, location, and pattern of perforators in anterolateral thigh(ALT) flap vary and predicting them preoperatively will aid in reconstructing complex head and neck defects. This article suggests guidelines for utilizing CTA imagery to predict perforators of ALT-free flaps.

METHODS

We retrospectively analyzed 53 Korean patients who underwent reconstruction with ALT flap in our department from March 2021 to July 2022. The location, course, origin, and pedicle lengths predicted in CTA and confirmed in the operation field were recorded and compared.

RESULTS

Among the 85 intraoperatively-found perforators, 79 were also identified in CTA. Six perforators unidentified in CTA were newly found intraoperatively. The positive predictive value of CTA for the perforator was 100%, with a sensitivity of 79/85 = 92.9%. Of the 79 perforators depicted by the CTA for the flap, CTA and intraoperative findings for the course were consistent in 52 cases, a 9.6 mm median discrepancy being noted between the actual location and CTA.

CONCLUSIONS

The overall pattern or location of perforation was not significantly different between the two, although some differences were observed. It is suggested that the addition of Doppler imaging, in conjunction with CTA, can aid in perforator detection and help minimize such discrepancies.

Flap Debulking and Secondary Revisions in Head and Neck Reconstruction: A Systematic Review with Clinical Applications

Flap debulking and secondary revisions are an integral factor in providing optimum outcomes to reconstructive patients. This review article summarizes systematically the available literature on flap debulking in head and neck reconstruction. The clinical applications of debulking techniques are discussed, including fractional direct excision, liposuction, and single-stage excision or planning with skin grafting. New technologies are also discussed.

Differential Subsampling with Cartesian Ordering Contrast-Enhanced Magnetic Resonance Angiography for the Preoperative Assessment of Anterolateral Thigh Flap

Objective

To investigate the clinical application of differential subsampling with Cartesian ordering (DISCO) contrast-enhanced (CE) magnetic resonance angiography for anterolateral thigh (ALT) flap transplantation, using operative findings as a reference.

Materials and Methods

Thirty patients (21 males and nine females; mean age ± standard deviation, 45.5 ± 15.6 years) who were scheduled to undergo reconstruction with ALT flaps between June 2020 and June 2021 were included in the prospective study. Before ALT flap transplantation, patients were scanned using CE-DISCO imaging. All acquired DISCO images of the 60 lower limbs (both sides from each patient) were analyzed using maximum intensity projection and volume rendering methods. Two experienced radiologists were employed to examine the patterns of the lateral circumflex femoral artery (LCFA), its branches, and perforators and their skin termini, which were compared with the operative findings.

Results

Using CE-DISCO, the patterns of the LCFA and its branches were clearly identified in all patients. Four different origins of the LCFA were found among the 60 blood vessels: type I (44/60, 73.3%), type II (6/60, 10.0%), type III (8/60, 13.3%), and type IV (2/60, 3.3%). Owing to a lack of perforators entering the skin, two patients did not undergo ALT flap transplantation. For the remaining 28 patients, the ALT flaps in 26 patients were successfully operated without flap re-selection during the operation, while the remaining two patients underwent other surgical procedures due to the thin diameter of the perforator or injury of the perforator during the operation. The success rate of flap transplantation was 92.8% (26/28). All transplanted flaps exhibited good blood supply and achieved primary healing without infection or delayed healing.

Conclusion

CE-DISCO imaging can be an effective method for preoperative perforator imaging before ALT flap transplantation.

Perforator Variability of the Anterolateral Thigh Flap Identified on Computed Tomographic Angiography: Anatomic and Clinical Implications

BACKGROUND

 The anterolateral thigh (ALT) flap is a useful flap with minimal donor site morbidity. Preoperative computed tomographic angiography (CTA) for lower extremity reconstruction can determine vessel integrity and plan for recipient vascular targets. This study reviews lower extremity CTAs to further characterize ALT vascular anatomy and associated clinical implications thereof.

PATIENTS AND METHODS

 Lower extremity CTA studies were retrospectively reviewed, and information on ALT cutaneous perforator location, origin, and course was collected.

RESULTS

 A total of 58 lateral circumflex femoral artery (LCFA) systems in 31 patients were included. Average age was 38.8 ± 15.9 years with mean body mass index of 27.2 ± 5.7 kg/m². The majority of patients were females (23, 74.2%). The LCFA most commonly originated from the profunda femoris artery (87.3%), followed by the distal common femoral artery (9.1%). On average, there were 1.66 ± 0.69 cm perforators per extremity, with an average of 5.38 cm between adjacent perforators. Perforators originated from the descending branch of the LCFA in 89.6% of studies. Perforator caliber was <1 mm (29, 30.2%), 1 to 2 mm (55, 57.3%), or >2 mm (12, 12.5%). Mean distance from the most proximal perforator to the anterior superior iliac spine was 20.4 ± 4.82 cm. Perforators were musculocutaneous (46.9%), septocutaneous (34.4%), or septomyocutaneous (18.8%). In 58.1% of patients, only one thigh had easily dissectable septocutaneous and/or septomyocutaneous perforators, in which case preoperative CTA aided in donor thigh selection.

CONCLUSION

 ALT flap cutaneous perforator anatomy varies considerably. Using CTA, we report on rates of septocutaneous, myocutaneous, and septomyocutaneous perforators and underscore its utility in perforator selection.

A Case Report of Aberrant Vascular Anatomy of the Anterolateral Thigh Flap

Soft tissue free flaps are used for a variety of head and neck reconstructions. The anterolateral thigh (ALT) flap has been a versatile tool in head and neck reconstruction since the mainstream use of microvascular anastomosis for free tissue transfer. The ALT flap has a known history of variable vascular anatomy. Most of this variability lies within perforator anatomy and vascular aberrations distal to the lateral circumflex femoral artery (LCF). Few vascular aberrancies have been described proximal to the LCF. Here we present a case of report of an ALT whose arterial vascular pedicle was a branch directly off the femoral artery. The case highlights an unusual anatomical variant of the ALT flap, and the importance of a thorough and meticulous dissection.

Therapeutic effects of anterolateral thigh flap transfer in repairing oral and maxillofacial defects after ablative surgery of neoplasms

BACKGROUND

To investigate the therapeutic effects of anterolateral thigh flap transfer in repairing oral and maxillofacial defects after ablative surgery of neoplasms and to discuss perioperative psychological care.

METHODS

A total of 80 patients who received oral and maxillofacial surgery for tumor resection in Nanfang Hospital from October 2014 to August 2016 were selected. Patients were randomly divided into control group and observation group, 40 patients in each group. Patients in control group received forearm flap transfer, while patients in observation group were treated with anterolateral thigh flap transfer.

RESULTS

The survival rate of flap, food intake ability, quality of life and incidence of complication were compared between groups. There was no significant difference in survival rate of the flaps between two groups (P>0.05). No significant difference in food intake was found between groups at 3 months after operation (P>0.05). The UW-QOL scores of the two groups at 1 year after operation were significantly higher than those before operation (P<0.05), and no significant differences in UW-QOL scores were found between two groups at 1 year after operation (P>0.05). Incidence of temporary dysfunction, hyperplastic scar, permanent dysfunction, pigmentation and pruritus was significantly lower in observation group than in control group (P<0.05). There was no significant difference in the incidence of necrosis between two groups (P>0.05).

CONCLUSIONS

The results showed that anterolateral thigh flap transfer has similar therapeutic effects to those of forearm flap transfer in repairing oral and maxillofacial defects after ablative surgery of neoplasms and improving food intake and quality of life. But Anterolateral thigh flap transfer can reduce the incidence of postoperative complications, so this treatment should be popularized.

[Application of preoperative vascular localization techniques for perforator flaps]

With the development of microvascular technology, perforator flaps have gradually become a good alternative for reconstruction of tissue defects. However, the major limitations of perforator flaps include uncertainty in predicting anatomical location of perforators and high variability in perforator size and course, which require preoperative localization techniques. Recently, as one of the preoperative localization techniques, computed tomography angiography was used to determine the number, size, course, and exact emerging point of perforator flaps. Clinicians can reduce surgical complications and shorten operative time by using computed tomography angiography. However, only several studies reported clinical applications of computed tomography angiography. This article reviews characteristics, classification, and preoperative location techniques for perforator flaps and its problems.

[Reconstruction of oral and maxillofacial soft tissue defects with anterolateral thigh (myocutaneous) flap assisted by computed tomography angiography]

Objective

To investigate the efficacy of anterolateral thigh (myocutaneous) flap designed with computed tomography angiography (CTA) to reconstruct oral and maxillofacial soft tissue defects.

Methods

Between January 2011 and December 2015, 23 cases of oral and maxillofacial tumors were treated. There were 14 males and 9 females with the age range from 45 to 72 years (mean, 56.8 years). There were 12 cases of tongue carcinoma, 5 cases of buccal mucosa carcinoma, 4 cases of mouth floor carcinoma, and 2 cases of oropharynx carcinoma; all were squamous cell carcinoma. According to standard TNM staging of the Union for International Cancer Control (UICC), 8 cases were rated as T ₂N ₀M ₀, 3 cases as T ₂N ₁M ₀, 1 case as T ₂N ₂M ₀, 4 cases as T ₃N ₀M ₀, 2 cases as T ₃N ₁M ₀, 2 cases as T ₃N ₂M ₀, 2 cases as T ₄N ₁M ₀, and 1 case as T ₄N ₂M ₀. The course of disease was 1-6 months (mean, 2.4 months). CTA was performed before operation to locate the perforator vessel and its surface projection of emerging point and to design anterolateral thigh (myocutaneous) flap by computer. The defects of soft tissue ranged from 6 cm×4 cm to 11 cm×7 cm after resection of tumor. The flap was used to repair defects, including 14 thinned anterolateral thigh flaps, 7 anterolateral thigh myocutaneous flaps, and 2 anterolateral bilobed flaps; and the flap area ranged from 7 cm× 5 cm to 12 cm×8 cm. The donor sites were sutured directly.

Results

CTA showed that myocutaneous perforators penetrated at the fascias of the vastus lateralis muscles in 22 cases with a location rate of 95.7% (22/23). Submandibular fistula occurred in 1 case at 5 days after operation and fistula healed after changed dressings. Other wounds at recipient site and donor site healed at primary stage. Anastomose with 2 vein was performed because of poor venous return in 1 case, and the flap survived. The other flaps survived well. All the patients were followed up 6-36 months (mean, 16.4 months). At 3 months after operation, the simplified recovery standard of speech function and swallow function was established according to the University of Washington Quality of Life Scale (UW-QOL). The speech and swallow function recovered satisfactorily in 22 cases, and not very satisfactorily in 1 case of well differentiated squamous cell carcinoma of the right mouth floor (T ₄N ₁M ₀). No obvious tissue atrophy was observed in 23 cases. No dysfunction was found at the donor site. There was no tumor recurrence in 21 patients; 1 patient accepted the second operation due to lymphonodi metastasis of contralateral neck at 6 months after first operation, who died after 23 months; 1 patient died of distant metastasis at 10 months after first operation.

Conclusion

The anterolateral thigh (myocutaneous) flap designed with CTA could well recover the morphology and function of the recipient site.

VIDEO: Preoperative CT Angiography for Anterolateral Thigh Flap Reconstructions

OBJECTIVE

This video article will review the relevant vascular anatomy of the anterolateral thigh flap, describe the CT angiography (CTA) image acquisition, and describe how to report the locations of the perforating arteries along with characteristics that may be important to the surgeon.

CONCLUSION

Our method of performing and reporting CTA for patients scheduled to undergo anterolateral thigh flap reconstruction provides a reproducible method of identifying perforating vessels and communicating their location to surgeons.

Three-dimensional contrast-enhanced magnetic resonance angiography for anterolateral thigh flap outlining: A retrospective case series of 68 patients

Flap transfer is increasingly used for repairing limb defects secondary to trauma or tumor, and appropriate preoperative planning plays a critical role. The present study aimed to examine the use of three-dimensional (3D) contrast-enhanced magnetic resonance angiography (CE-MRA) in evaluating the blood supply distribution and perforating branch pattern of anterolateral thigh (ALT) flaps. Bilateral donor lower limbs were scanned in 68 patients (136 limbs) using a Siemens Avanto 1.5 T magnetic resonance imaging scanner with a 3D fast low-angle shot sequence, following the thin-slab maximum intensity projection (TS-MIP) technique. The lateral femoral circumflex artery (LFCA) was visualized in all patients: 101 limbs (101/136, 74.3%) were type I; 20 limbs (20/136, 14.7%) were type II; 3 limbs (3/136, 2.2%) were type III; and 12 limbs (12/136, 8.8%) were type IV. Tertiary branches were identified in 94 limbs (94/136, 69.1%). Donor flaps were outlined according to MRA TS-MIP findings in 4 patients. All flaps survived uneventfully following the transfer. In donor flap outlining, 3D CE-MRA with the TS-MIP technique allowed an accurate, direct visualization of the branching pattern and distribution profile of the LFCA supplying the ALT flap.

Flap raising on pulsatile perfused cadaveric tissue: a novel method for surgical teaching and exercise

Exercising flap raising procedures on cadavers is considered a prerequisite to prepare for clinical practise. To improve teaching and create conditions as realistic as possible, a perfusion device was developed providing pulsatile flow through the vessels of different donor sites. A plastic bag filled with red stained tab water was placed into a pump, which was driven by an electric motor. The bag was set under rhythmic compression with variable frequency and pressure. The pedicles of the radial forearm, anterolateral thigh, rectus abdominis, fibular and iliac crest flap were cannulated at the origin from their source arteries. Flap raising was performed under pulsatile perfusion in 15 fresh bodies and subsequently in 6 Thiel-embalmed cadavers during a flap raising course. We regularly observed staining of the skin and skin bleeding in fresh bodies and less reliable in embalmed cadavers. All flap pedicles showed pulsatile movements, and the radial pulse became palpable. Most perforators of the anterolateral thigh and osteocutaneous fibular flap could be identified by their pulse. Bleeding from bony tissue and venous return was seldom observed. We conclude that pulsatile perfusion of cadaveric tissue creates more realistic conditions for flap raising and improves teaching for beginners and advanced surgeons.

Reconstruction of extensive through-and-through cheek defects with free anterolateral thigh flap

OBJECTIVE

The purpose of this study was to assess the clinical features and therapeutic efficacy of extensive through-and-through cheek defects reconstruction with free anterolateral thigh flap.

METHODS

A total of 11 patients underwent simultaneous tumor radical resection and through-and-through cheek defects reconstruction with free anterolateral thigh flap.

RESULTS

In these 11 patients, 7 patients had undergone the reconstruction of through-and-through cheek defects with the folded anterolateral thigh flap (2 skin islands and an intervening de-epithelialized zone); 4 patients had undergone the reconstruction of through-and-through cheek defects with the 2 separate skin paddles anterolateral thigh flap in 1 single pedicle. All of these 11 flaps were free fasciocutaneous anterolateral thigh flaps. The subcutaneous fat thickness of the anterolateral thigh flap is less than 1.5 cm.

CONCLUSIONS

The free anterolateral thigh flap was one of the versatile soft tissue flaps in the extensive through-and-through cheek defects reconstruction.

CT angiography for surgical planning in face transplantation candidates

SUMMARY

Facial allotransplantation replaces missing facial structures with anatomically identical tissues, providing desired functional, esthetic, and psychosocial benefits far superior to those of conventional methods. On the basis of very encouraging initial results, it is likely that more procedures will be performed in the near future. Typical candidates have extremely complex vascular anatomy due to severe injury and/or multiple prior reconstructive attempts; thus, each procedure is uniquely determined by the defects and vascular anatomy of the candidate. We detail CT angiography vascular mapping, noting the clinical relevance of the imaging, the angiosome concept and noninvasive delineation of the key vessels, and current controversies related to the vascular anastomoses.

Preoperative three-dimensional reconstruction in vascularized fibular flap transfer

OBJECTIVE

The objective of this study was to investigate the added value of preoperative computerized tomographic angiography (CTA) and three-dimensional reconstruction of the lower limb in vascularized fibular flap transfer.

METHODS

Eighteen patients who underwent mandibular or maxillary reconstruction with a vascularized fibular flap were studied retrospectively by image analysis. The original DICOM data of preoperative CTA were analysed and applied to the reconstruction of the lower limb using SimPlant Pro software (version 11.04).

RESULTS

The course of the peroneal artery in 17 patients was the same except for one patient. The peroneal artery originates from the posterior tibial artery. The original external diameters of the peroneal artery were 2.99 ± 0.64 mm. The perpendicular lengths from fibular head to the origin of the peroneal artery and to the fibular perforator vessel were 42.88 ± 8.84 mm and 174.55 ± 25.62 mm, respectively.

CONCLUSION

The course of peroneal artery was relatively invariable, its original external diameter was thick. Preoperative CTA and three-dimensional reconstruction of the lower limb, which are noninvasive, accurate and direct-viewing methods, play an important, preoperative role in vascularized fibular flap transfer for lower limb vascular assessment.