Anterolateral thigh flap: systematic literature review of specific donor-site complications and their management

Evaluating the pro-survival potential of apoptotic bodies derived from 2D- and 3D- cultured adipose stem cells in ischaemic flaps

In the realm of large-area trauma flap transplantation, averting ischaemic necrosis emerges as a pivotal concern. Several key mechanisms, including the promotion of angiogenesis, the inhibition of oxidative stress, the suppression of cell death, and the mitigation of inflammation, are crucial for enhancing skin flap survival. Apoptotic bodies (ABs), arising from cell apoptosis, have recently emerged as significant contributors to these functions. This study engineered three-dimensional (3D)-ABs using tissue-like mouse adipose-derived stem cells (mADSCs) cultured in a 3D environment to compare their superior biological effects against 2D-ABs in bolstering skin flap survival. The findings reveal that 3D-ABs (85.74 ± 4.51) % outperform 2D-ABs (76.48 ± 5.04) % in enhancing the survival rate of ischaemic skin flaps (60.45 ± 8.95) % (all p < 0.05). Mechanistically, they stimulated angiogenesis, mitigated oxidative stress, suppressed apoptosis, and facilitated the transition of macrophages from M1 to M2 polarization (all p < 0.05). A comparative analysis of microRNA (miRNA) profiles in 3D- and 2D-ABs identified several specific miRNAs (miR-423-5p-up, miR30b-5p-down, etc.) with pertinent roles. In summary, ABs derived from mADSCs cultured in a 3D spheroid-like arrangement exhibit heightened biological activity compared to those from 2D-cultured mADSCs and are more effective in promoting ischaemic skin flap survival. These effects are attributed to their influence on specific miRNAs.

Decellularized tissue exhibits large differences of extracellular matrix properties dependent on decellularization method: novel insights from a standardized characterization on skeletal muscle

Decellularized matrices are an attractive choice of scaffold in regenerative medicine as they can provide the necessary extracellular matrix (ECM) components, signals and mechanical properties. Various detergent-based protocols have already been proposed for decellularization of skeletal muscle tissue. However, a proper comparison is difficult due to differences in species, muscle origin and sample sizes. Moreover, a thorough evaluation of the remaining acellular matrix is often lacking. We compared an in-house developed decellularization protocol to four previously published methods in a standardized manner. Porcine skeletal muscle samples with uniform thickness were subjected to in-depth histological, ultrastructural, biochemical and biomechanical analysis. In addition, 2D and three-dimensional cytocompatibility experiments were performed. We found that the decellularization methods had a differential effect on the properties of the resulting acellular matrices. Sodium deoxycholate combined with deoxyribonuclease I was not an effective method for decellularizing thick skeletal muscle tissue. Triton X-100 in combination with trypsin, on the other hand, removed nuclear material but not cytoplasmic proteins at low concentrations. Moreover, it led to significant alterations in the biomechanical properties. Finally, sodium dodecyl sulphate (SDS) seemed most promising, resulting in a drastic decrease in DNA content without major effects on the ECM composition and biomechanical properties. Moreover, cell attachment and metabolic activity were also found to be the highest on samples decellularized with SDS. Through a newly proposed standardized analysis, we provide a comprehensive understanding of the impact of different decellularizing agents on the structure and composition of skeletal muscle. Evaluation of nuclear content as well as ECM composition, biomechanical properties and cell growth are important parameters to assess. SDS comes forward as a detergent with the best balance between all measured parameters and holds the most promise for decellularization of skeletal muscle tissue.

Increasing Pedicle Reach with Musculocutaneous Perforator Dissection in Anterolateral Thigh Free Flaps

OBJECTIVE

To measure the increase in effective pedicle reach with microdissection of musculocutaneous perforators during anterolateral thigh (ALT) free tissue harvest.

METHODS

A review of our institution's free flap database was performed to identify ALT free tissue transfers. The distance from pedicle vessel origin to its perforator's insertion at the fascia lata (effective pedicle length [EPL]) was measured prior to and following intramuscular dissection of musculocutaneous perforators. Pertinent clinicopathologic variables were abstracted from the electronic medical record.

RESULTS

A total of 314 ALT free flaps were performed between February 2017 and August 2022. Of these, 85 had documentation of EPL before and after musculocutaneous perforator dissection. ALT reconstruction was primarily performed for reconstruction of oncologic ablative defects (66, 78%). The mean EPL prior to perforator microdissection was 8.8 cm (standard deviation, SD 2.8 cm; range 3-15 cm). Following perforator dissection, mean EPL significantly increased to 14.0 cm (SD 3.0 cm; range 7-22 cm) with a mean net gain of 5.2 cm in distance (95% confidence interval 4.8-5.6 cm; p < 0.001). Nine patients (11%) required operating room take-back for anastomosis revision (3, 3.5%), recipient site hematoma evacuation (4, 4.7%), and wound dehiscence (2, 2.3%); one complete flap loss due to venous thrombosis was observed.

CONCLUSION

Dissection of musculocutaneous perforators during ALT free flap harvest can increase effective pedicle reach by 5.2 cm or nearly 60%. This harvest technique can facilitate the performance of tension-free anastomoses when substantial vascular pedicle length or vascular pedicle tunneling is required.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:666-670, 2024.

Anatomical Relations of the Perforators from the Descending Lateral Femoral Circumflex Artery and Vastus Lateralis Motor Nerve Branches

Background

The anterolateral thigh (ALT) flap, which is nourished by perforators from the descending branch of the lateral femoral circumflex artery (P), is one of the most commonly used flaps in soft tissue reconstruction. With the growing use of ALT flaps, attention toward donor-site morbidity has increased in recent years. Damage to the motor nerve branches of the vastus lateralis muscle (N) is one of the causes of donor-site morbidity, particularly muscle weakness. This study investigated the anatomical locations of the P and N in fresh-frozen cadaveric specimens.

Methods

This study included 43 cadaver limbs. A silicone rubber compound (30 mL) was injected into the femoral artery to visualize the vessel. The locations of the P and motor points of N were measured to assess the risk of N injury during ALT flap harvesting.

Results

There were one to six (mean, 2.7) P and two to seven (mean, 4) N. When the two most proximal perforators were used for flap harvesting, an average of 1.5 motor nerve branches (42%) was damaged because transection of the motor nerve branches was required for flap harvesting. In 33% of the limbs, only one motor nerve branch remained after the flap harvest. However, there were no cases where all motor nerve branches were severed.

Conclusion

When an ALT flap with two perforators is harvested, weakness of the vastus lateralis muscle may occur in cases with a small number of motor nerve branches.

Comparative study of arterial and venous grafting for pedicle lengthening in head and neck microvascular reconstruction

BACKGROUND

In the field of head and neck microvascular reconstruction, no previous study has compared arterial and venous grafting as methods of anterolateral thigh (ALT) pedicle lengthening. Therefore, we conducted this comparative study to compare the outcomes between the two pedicle lengthening techniques.

METHODS

We performed comparative effectiveness research by conducting a retrospective chart review from January 2012 to December 2021 to identify patients who underwent head and neck reconstruction with non-descending branch ALT perforator flaps using either the in situ pedicle lengthening (ISPL) technique or the vein graft (VG) technique. A total of 26 patients were analyzed, including 14 who underwent ISPL, and 12 who underwent VG. The collected data, including patient demographics, surgical indications, history of prior free flap, prior neck dissection, radiation therapy, chemotherapy, graft length, and flap outcomes, were analyzed. The flap outcomes were categorized as total flap loss, partial flap loss, flap compromise that required operating room visits, or minor issues, including infection or dehiscence. The flap characteristics and postoperative outcomes were compared between the two groups.

RESULTS

The VG group had two flap losses, whereas the ISPL group had none. Although the failure rate was higher in the VG group than that in the ISPL group, the difference was not statistically significant (0% vs. 16.7%, p = 0.203). Additionally, there were no significant differences in flap take-back (14.3% vs. 16.7%, p = 1) and minor complications between the two groups (35.7% vs. 33.3%, p = 1).

CONCLUSIONS

If pedicle lengthening with vessel graft is inevitable in head and neck reconstruction, arterial graft may provide a reliable outcome and may be considered an effective alternative when compared to vein grafts.

Reconstruction of the severe Achilles tendon and soft-tissue loss with the bi-pedicled conjoined flap and vascularized fasciae latae: A consecutive case series of 15 patients

BACKGROUND

Historically, the segmental loss of the Achilles tendon with overlying soft-tissue defects had been frequently reconstructed with the composite anterolateral thigh (ALTP) flap, including the iliotibial tract or fasciae latae. This study aimed to present our modified combination using the bi-pedicled conjoined flap with vascularized fasciae latae, for the approximately total reconstruction of the Achilles tendon and extensive soft tissue.

METHODS

From May 2015 to March 2018, 15 patients (9 male and 6 female) with a mean age of 36 years (ranged, 18-52 years) underwent microvascular Achilles tendon reconstruction. Harvested on the abdomen and groin, the conjoined flap was chimeric with the vascularized fasciae latae. Primary donor-site closure was accomplished in all patients. A standard assessment of the functional and esthetical outcomes was completed.

RESULTS

Mean follow-up time was 42 months (ranged, 32-48 months). The average dimension of the conjoined flap was 25 × 14 cm (ranged, 18 × 10-35 × 18 cm), and the average size of the folded fasciae latae was 15 × 6 cm (ranged, 12 × 5-25 × 8 cm). At the last follow-up, the Thompson test was negative in all patients. The mean American Orthopedic Foot and Ankle Society (AOFAS) score was 91.0. The mean Achilles tendon total rupture score (ATRS) was 18.5. The mean Vancouver Scar Scale (VSS) score was 3.0.

CONCLUSIONS

The composite bi-pedicled flap including vascularized fasciae latae provides an alternative approach with great functional and esthetic outcomes, in selected patients who suffered severe Achilles tendon and skin defects. The one-stage procedure facilitates better rehabilitation postoperatively.

Profunda Artery Perforator Flaps From the Posteromedial Region of the Thigh for Head and Neck Reconstruction

OBJECTIVE

Profunda femoris artery perforator flaps (PAPFs) have not been widely used in head and neck reconstructions. The feasibility and outcomes of PAPFs for various head and neck reconstructions need to be investigated.

STUDY DESIGN

Retrospective analysis.

SETTING

A single-institution review.

METHODS

PAPFs were utilized in head and neck reconstructions from 2019 to 2021. Local anatomy, surgical technique, and complications were discussed. Chimeric PAPF applications with muscle components were described for coverage of extensive multiunit defects. Additionally, aesthetic and functional outcomes were compared with anterolateral thigh perforator flaps.

RESULTS

A total of 33 cases were included. The average age was 54.2 years (range, 30-74). The most common underlying pathology was oral squamous cell carcinoma (n = 26, 78.8%), while the mean ± SD body mass index was 25.4 ± 2.8 kg/m² . Middle perforators (n = 14, 42.4%) were the most commonly utilized ones. The perforator-based chimeric/composite applications were used in 9 (27.3%), with the muscular components consisting of gracilis (n = 3, 9.1%), adductor magnus (n = 5, 15.2%), or semimembranosus muscles (n = 1, 3.0%). Venous thromboses of the PAPFs were found in 2 (6.1%), though salvaged. The occurrence of postoperative 90-day morbidity (complication) was related to mandibulectomy/maxillectomy (P = .020). Postoperative validated questionnaires showed a trend of intermediate to high scores, indicating noninferior outcomes in several categories, when compared with the anterolateral thigh perforator flap counterparts.

CONCLUSION

PAPFs are a good reconstructive alternative for intermediate to large head and neck reconstructions. Besides, PAPFs can provide sufficient tissue volume and versatility of potentially incorporating adjacent muscle components.

Free Flap Donor-Site Complications and Management

Free flap harvest will occasionally result in donor-site complications and morbidity. Most of these complications are managed simply without producing lingering effects on activities of daily living. However, some patients will sustain limb weakness, gait issues, chronic pain, and nonhealing wounds. Frank preoperative discussion between surgeon and patient is essential to maximize postoperative outcome and manage expectations. Fastidious surgical technique will help minimize the risks of hematoma, seroma, and infection, while newer techniques can help prevent some issues with wound healing, limb weakness, and sensory changes. In this article, we describe the rates of common and rare complications at free flap donor sites, as well as techniques to prevent and manage them.

Tolerable degree of muscle sacrifice when harvesting a vastus lateralis or myocutaneous anterolateral thigh flap

The myocutaneous anterolateral thigh (ALT) and vastus lateralis (VL) flaps include a large muscle mass and a sufficient vascular pedicle, and they have been used for decades to reconstruct traumatic and acquired defects of the head and neck and extremities. In spite of these benefits, musculoskeletal dysfunction was reported in nearly 1 out of 20 patients at follow-up. It is unclear whether the recently proposed muscle-sparing flap-raising approach could preserve VL muscle function and whether patients at increased risk could benefit from such an approach. Therefore, we performed a predictive dynamic gait simulation based on a biological motion model with gradual weakening of the VL during a self-selected and fast walking speed to determine the compensable degree of VL muscle reduction. Muscle force, joint angle, and joint moment were measured. Our study showed that VL muscle reduction could be compensated up to a certain degree, which could explain the observed incidence of musculoskeletal dysfunction. In elderly or fragile patients, the VL muscle should not be reduced by 50% or more, which could be achieved by muscle-sparing flap-raising of the superficial partition only. In young or athletic patients, a VL muscle reduction of 10%, which corresponds to a muscle cuff, has no relevant effect. Yet, a reduction of more than 30% leads to relevant weakening of the quadriceps. Therefore, in this patient population with the need for a large portion of muscle, alternative flaps should be considered. This study can serve as the first basis for further investigations of human locomotion after flap-raising.

Challenges in the Management of Kidney Allograft Herniation With a Single-stage Pedicled Anterolateral Thigh Flap

Wound complications are the most common surgical complication after kidney allograft transplantation. Total wound rupture exposing the entire kidney is a rare and not well-described event. We present a successful treatment of this complication in a patient admitted to our unit. A single-stage procedure was performed combining debridement and reconstruction with a pedicled anterolateral thigh flap and an iliotibial band transferring. A short literature review is performed comparing the different treatment strategies and results.

Coverage of exposed ankle and foot with the conjoined lower abdomen and groin flaps

BACKGROUND

Extensive soft-tissue defects around the ankle and foot pose a difficult challenge to surgeons. Considering that natural contour, the ideal solution should match a thin and pliable skin flap to allow shoe fitting and provide a functional move. As the conjoined flaps were increasingly utilized in covering various defects, we present our experience using the bipedicle conjoined flap on the lower abdomen and groin site.

METHODS

From May 2018 to September 2020, 36 patients (27 male and 9 female) with a mean age of 32 years (ranged, 21-54 years) underwent the one-stage coverage of ankle and foot defects with the bipedicle conjoined flap. A suitable "Y" bifurcation was dissected to enlarge vessel size or participated in intra-flap anastomosis. The mean dimension of the defect was 30 × 12 cm² (ranged, 20 × 8 cm² to 38 × 16 cm²). Primary donor-site closure was accomplished in all patients.

RESULTS

Thirty-six flaps survived completely without significant complications, and mild venous congestion was observed in one flap. The average flap size was 35 × 15 cm² (ranged, 22 × 10 cm² to 42 × 18 cm²). All flaps were available for a mean follow-up of 18 months (ranged, 12 to 24 months). Natural shape and walking function were successfully achieved with restored protective sensation.

CONCLUSIONS

Bipedicle conjoined flap harvested from the lower abdomen and groin is a great alternative, in selected patients seeking one-stage coverage for the exposed ankle and foot. Compared to single-pedicle flaps, the increased skin allows the wider coverage for the large defect with less morbidity and better outcomes.

Short- and Long-Term Complications of Free Anterolateral Thigh Flap Reconstructions: A Single-Centre Experience of 92 Consecutive Cases

Background. The anterolateral thigh (ALT) flap has been amongst the most versatile components of the reconstructive surgeon’s armamentarium. The authors utilise these flaps for a variety of reconstructive procedures including lower limb reconstruction; postsarcoma excision; and open fractures. Few studies have discussed the extent of recipient site morbidity and subsequent revisional procedures. We will report our experience of the ALT flap in 92 consecutive reconstructions with focus on recipient site complications and revisional procedures. Methods. Retrospective data collection was done from 92 patients who underwent ALT flap reconstruction—for various large soft tissue defects—at our unit at the Royal Free Hospital, London. We evaluated primary recipient site complications and the requirements for secondary operations after flap transfer. Results. All flaps survived with the exception of 3 cases (97% survival rate) in which irreversible venous thrombosis was encountered. 16 of 92 patients (17%) required a second recipient site operation for the following: 7 patients experienced major recipient site complications that warranted early return to theatre and 9 patients required a secondary revision thinning procedure(s). 8 of the 16 patients (50%) requiring second operations had construction on their lower leg/ankle/feet (p value = 0.10). Conclusions. Our data demonstrated effective use of the ALT flap in the management of soft tissue reconstructive surgery. Partial flap necrosis was the main complication at the recipient site. In future work, secondary thinning procedures, particularly at the ankle/foot, should be separated from flap-specific complications. Furthermore, we demonstrate tailoring ALT thickness can be performed safely without compromising flap viability.

Persistent Postsurgical Pain in Oral Cancer Patients Reconstructed with Anterolateral Thigh Free Flap

Background and Objectives: The anterolateral thigh (ALT) flap is widely used in head and neck reconstruction, but the postoperative thigh sensory function lacks sufficient evaluation. The present study reports the postsurgical pain and cancer-related quality of life (QoL) in different stages of oral cancer patients receiving anterolateral thigh (ALT) flap reconstruction. Materials and Methods: Patients were subgrouped into postoperative early-, mid-, and late-recovery stages (postoperative 0.5–1 years, 1–2 years, and above 2 years) according to the time point of assessment. The QoL was examined using the EORTC C-30. Postsurgical donor and receipt site pain was evaluated through subjective reports and sensory tests. Results: Ninety-four patients were included in the final analysis. The functional and global health-related QoL significantly improved with time after surgery. However, spontaneous pain was reported in 57.7%, 72.3%, and 42% of patients in early-, mid-, and late-recovery stages, mainly in donor sites rather than in receipt sites. The highest incidence of donor site pain after ALT flap reconstruction in oral cancer surgery was in the mid-recovery stage but remained high in the late-recovery stage (56.8% and 36.7%, respectively). Conclusions: The postsurgical pain in the donor site might persist to or exhibit delayed onset one to two years postoperatively but is much improved after postoperatively two years later. A longer postsurgical follow-up for over two years for pain and sensory dysfunction is indicated.

Prophylactic fasciotomy of the anterolateral thigh donor site in head and neck reconstruction

INTRODUCTION

The free anterolateral thigh (ALT) flap is a versatile reconstructive option for head and neck defects. Donor site complications are rare but severe; with wound dehiscence, need for secondary closure, and compartment syndrome reported.

OBJECTIVES

We propose prophylactic thigh fasciotomy as a surgical technique to facilitate primary closure while preventing donor site complications during ALT flap harvest.

METHODS

We examined donor site wound characteristics, recipient site wound characteristics, and clinical outcomes for 24 consecutive ALT flaps performed for head and neck reconstruction from 2016 to 2018. All ALT donor sites underwent prophylactic fasciotomy.

RESULTS

There were no incidents of thigh compartment syndrome or wound dehiscence of donor site; one patient underwent primary donor site skin grafting.

CONCLUSION

Prophylactic thigh fasciotomy allows mobilization of soft tissue to facilitate primary tension-free closure of the ALT donor site even for free flaps with a large skin component, while reducing the possibility of compartment syndrome.

Preoperative Computed Tomography Angiography for ALT Flaps Optimizes Design and Reduces Operative Time

BACKGROUND

 Computed tomography angiography (CTA) has been widely used for perforator mapping in abdominal-based reconstruction, but it is less widespread in the anterolateral thigh (ALT) flap. However, CTA may be quite useful for ALT planning, as this flap has demonstrated substantial variability in intrapatient bilateral vascular anatomy. This study investigated whether standard use of preoperative CTA resulted in selection of the donor extremity with preferential perforator anatomy, and whether this affected operative time and postoperative outcomes.

METHODS

 A retrospective review of 105 patients who underwent proposed ALT flap reconstruction was performed. Seventy-nine patients received bilateral lower extremity CTAs, which were evaluated for dominant perforator anatomy (septocutaneous, musculoseptocutaneous, or musculocutaneous). Donor extremity selection was noted, and predicted perforator anatomy was compared with that encountered intraoperatively.

RESULTS

 Among the 73 patients who received bilateral imaging and ultimately received an ALT, congruent findings between imaging and surgical exploration were observed in 51 (69.8%) patients. Thirty (37.9%) patients had asymmetric perforator anatomy between their bilateral extremities on imaging. Among these, the leg with optimal perforator anatomy was selected in 70% of cases. There were no significant reductions among postoperative complication rates, but selection of the donor site with preferential anatomy was associated with a decrease in operative time (p = 0.049) among patients undergoing extremity reconstruction.

CONCLUSION

 CTA is a useful tool for optimizing donor site selection for ALT flaps and reducing operative time. We believe that standard use of preoperative CTA in ALTs warrants further consideration.

[The combination of anterolateral thigh perforator flap and other flaps for repairing the extreme circumferential defects on the limb]

OBJECTIVE

To investigate the effectiveness of the combination of the anterolateral thigh perforator (ALTP) flap and other flaps for repairing the extreme circumferential defects on the limb.

METHODS

Between October 2016 and June 2019, 9 patients with the extreme circumferential defects on the limb were admitted, which resulted by degloving injury, including 8 males and 1 female with a median age of 42 years (range, 32-65 years). The etiology involved twist injury in 5 cases, traffic accident in 2 cases, and high voltage electric injury in 2 cases. The location of the defects was left forearm in 2 cases, right forearm in 3, left foot in 3, and right foot in 1. The injected wound bed followed by the exposure of bone, joint, tendon, and blood vessel. The dimension of defects was 25 cm×20 cm to 40 cm×28 cm. The period between the injury and admission was 1-12 hours (mean, 5 hours). All contaminated wounds were taken thorough and radical debridement and covered by the vacuum sealing drainage device during the emergency operation. The ALTP flap and the other one flap were tailored according to the dimension of the wound when the wound surface became granulating, including the thoracodorsal artery perforator (TAP) flap in 3 cases, superficial inferior epigastric artery perforator flap in 3 cases, superficial circumflex iliac artery perforator flap in 3 cases. And the donor site was primary closure.

RESULTS

After operation, all the flaps survived except 1 case of partial necrosis at the edge of TAP flap and healed after secondary skin grafting, and the wounds in the donor and recipient areas healed by first intention. All patients were followed up 14-24 months (mean, 16 months). The shape of the flap was satisfactory and the texture was soft. There was no abnormal hair growth and obvious pigmentation during the follow-up. Only linear scar was left in the donor area, there was no complication such as abdominal wall hernia, and the activity of hip and knee was not affected. The functional reconstruction of upper limb and ankle was satisfactory, and the disabilities of the arm, shoulder, and hand (DASH) score was excellent in 4 cases and good in 1 case; the American Orthopaedic Foot and Ankle Association (AOFAS) score was excellent in 3 cases and good in 1 case.

CONCLUSION

ALTP flap combined with different flaps can reconstruct the circumferential extreme defects after limb damage in one-stage, which can achieve limb salvage to the greatest extent.

Multiple Sequential Free Flap Reconstructions of the Head and Neck: A Single-Center Experience

BACKGROUND

Free flap reconstruction is the standard of care in extensive defects of the head and neck area, and although most patients may be treated sufficiently with one flap, recurrence of a malignant tumor or failure of a previous reconstruction may make the use of a second (or more) flap necessary. The aim of this study was to evaluate the indications and success rates of multiple consecutive reconstructive procedures in a large cohort of patients.

METHODS

Nine hundred ninety-six free flap reconstructions were retrospectively analyzed and cases of sequential reconstructions in the same patient were identified. Indications, success rates, perioperative procedures, and frequently used flaps were evaluated.

RESULTS

Two hundred twenty cases of sequential microvascular reconstructions were identified, ranging from two to six flaps per patient. The overall flap success rate was 89.1 percent. A history of diabetes was identified as a risk factor for flap failure (p = 0.029). There was no association of flap loss with the number of reconstructive procedures per patient.

CONCLUSIONS

The use of several free flaps in the same patient is a feasible option for patients suffering from recurrent tumors or to improve quality of life by a secondary reconstruction. A salvage free flap transfer to replace a lost transplant exhibits good success rates.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Qualitative and Quantitative Analyses of Donor Site Morbidity Following a Graft of the Acellular Dermal Matrix Versus Primary Fascial Repair After ALT Flap Harvesting

Background

The anterolateral thigh (ALT) flap is one of the most useful flaps in reconstruction because of its reliability, large skin flap territory, and versatility. The relatively small number of side effects is a common reason for preferring this flap. Primary repair is usually performed at the donor site closure; however, this requires substantial tension and causes many donor site morbidities, including pain. We attempted to use acellular dermal matrix graft to overcome these problems.

Methods

We analyzed a total of 41 cases (41 flaps) in this study. Among these flaps, we conducted donor fascia suture with artificial dermis in 20 cases (study group) and primary fascial suture in 21cases (control group). Post-operative ambulation recovery times, pain scores, drainage removals, and wound problems of the donor site were recorded.

Results

There were no serious complications, including infection, at the donor sites of all 41 cases. Of 20 cases using the acellular dermal matrix, seroma occurred in 2 cases and partial skin necrosis occurred in 2 cases. In 1 case of skin necrosis, the acellular dermal matrix was removed. However, in comparison to the control group, the group using the artificial dermis recovered ambulatory ability 3.9 days earlier and had a 1.8-point lower visual analogue scale score 5 days post-operatively.

Conclusions

Our study suggested that, if used selectively, the acellular dermal matrix may play an effective role in donor site closure in cases with procedures involving the ALT flap.

Free Flap Reconstruction of Extremity Defects in Pediatric Patients

BACKGROUND

Microsurgical reconstruction of extremity defects with free flaps has been carried out for many years. The aim of this retrospective study is to characterize free flap surgery on children of 1 to 7 years old by evaluating a series of 20 cases of free flap surgeries that have been performed in pediatric patients.

METHODS

From February 2014 to January 2018, 20 patients, 10 boys and 10 girls aged from 1 to 7 years (average, 4.6 years), were engaged in this study. Several types of free flaps were used, including anterolateral thigh flaps (ALT), inferior ulnar collateral artery flap, latissimus dorsi flap, medial plantar flap, fibular osteocutaneous flap and hallux toenail flap. After operations, follow-up period was at least for 2 years and the average follow-up period was 48.5 months. The long-term outcomes were estimated by questionnaires derived from the American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collection Instrument (PODCI).

RESULTS

A total of 21free-flap reconstructions were performed on 20patients, including 15 ALT, 3 composite flaps, and 3 other cutaneous flaps. The size of the tissue flap ranged from 1.5 to 280 cm2 (average, 74.1cm2). The diameter of the anastomosed artery of the flap ranged from 0.7 to 1.2 mm. Among the 21 flaps, 20 survived and the success rate was about 95 %. Contour adaption was achieved in all flaps. Fifteen children received a secondary operation for debulking or functional improvement. Secondary deformity was present in 3 children, among which ankle joint valgus was seen in two children and a flexion deformity of injured toe occurred in one child. The mean global functioning score of PODCI was 94 (ranging from 81 to 98, maximum 100).

CONCLUSION

The success rate of free-flap surgery in pediatric patients was comparable to that achieved in adults. Post-operative caring for pediatric patients was easier than expected. For pediatric patients, the final outcomes were not varied remarkably from different types of free tissue transfer.

Full-Thickness Tumor Resection of Oral Cancer Involving the Facial Skin-Microsurgical Reconstruction of Extensive Defects after Radical Treatment of Advanced Squamous Cell Carcinoma

Simple Summary

Advanced malignant tumors of the oral cavity are challenging because they impose serious oncological and functional requirements on the treatment specialist. Depending on the localization and the extent of the primary tumor, a full-thickness resection affecting the facial skin may be necessary to achieve a complete tumor resection. The resulting defects need adequate reconstruction in order to restore the aesthetics and functionality of the orofacial system. In this retrospective analysis, the authors aimed to evaluate treatment techniques for these tumors and analyze the clinical outcome of the related procedures. Full-thickness tumor resection with free flap reconstruction due to advanced cancer was performed in 33 patients.

Abstract

Advanced tumors of the head and neck are challenging for the treatment specialist due to the need to synergize oncological and functional requirements. Free flap reconstruction has been established as the standard of care for defects following tumor resection. However, depending on the affected anatomic subsite, advanced tumors may impose specific difficulties regarding reconstruction, especially when full-thickness resection is required. This study aimed to evaluate reconstructive strategies and oncological outcomes in patients with full-thickness resection of the oral cavity. A total of 33 patients with extensive defects due to squamous cell carcinoma of the oral cavity were identified. Indications, reconstructive procedures, and clinical outcome were evaluated. Thirty-two patients (97%) presented locally advanced tumors (T3/T4). Complete tumor resection was achieved in 26 patients (78.8%). The anterolateral thigh flap was the most frequently used flap (47.1%), and the primary flap success rate was 84.8%. The cohort demonstrated a good local control rate and moderate overall and progression-free survival rates. Most patients regained full competence regarding oral alimentation and speech. Full-thickness tumor resections of the head and neck area may be necessary due to advanced tumors in critical anatomic areas. In many cases, radical surgical treatment leads to good oncological results. Free flap reconstruction has been shown to be a suitable option for extensive defects in aesthetically challenging regions.

Facilitated self-assembly of a prevascularized dermal/epidermal collagen scaffold

Introduction: Resurfacing complex full thickness wounds requires free tissue transfer which creates donor site morbidity. We describe a method to fabricate a skin flap equivalent with a hierarchical microvascular network. Materials & methods: We fabricated a flap of skin-like tissue containing a hierarchical vascular network by sacrificing Pluronic^® F127 macrofibers and interwoven microfibers within collagen encapsulating human pericytes and fibroblasts. Channels were seeded with smooth muscle and endothelial cells. Constructs were topically seeded with keratinocytes. Results: After 28 days in culture, multiphoton microscopy revealed a hierarchical interconnected network of macro- and micro-vessels; larger vessels (>100 μm) were lined with a monolayer endothelial neointima and a subendothelial smooth muscle neomedia. Neoangiogenic sprouts formed in the collagen protodermis and pericytes self-assembled around both fabricated vessels and neoangiogenic sprouts. Conclusion: We fabricated a prevascularized scaffold containing a hierarchical 3D network of interconnected macro- and microchannels within a collagen protodermis subjacent to an overlying protoepidermis with the potential for recipient microvascular anastomosis.

Revisiting the Blood Supply of the Rectus Femoris: A Case Report and Computed Tomography Angiography Study

BACKGROUND

Rectus femoris necrosis is a rare but severe complication after anterolateral thigh flap (ALTF) harvesting. It has been previously reported that the blood supply of the rectus femoris (RF) often arises from the same source artery as the ALTF; however, precise descriptions of the relationship remain limited. This article revisits the blood supply of the RF based on computed tomography angiography (CTA) and analyzes the possible influence of the blood supply on the RF during ALTF harvesting.

METHODS

Between December 2017 and June 2018, CTA images of the bilateral lower extremities of 25 patients were studied. The RF length, number, and diameter of branches at the entry point into muscle, location, and overall branch vessel origins were recorded.

RESULTS

The average ± SD RF length was 384.73 ± 19.28 mm. There were 170 branches (mean ± SD, 3.4 ± 0.96 branches per thigh), mainly arising from the lateral circumflex femoral artery. The average ± SD diameter was 1.90 ± 0.51 mm. The first branch was located at 1/5 of the proximal site of the RF, and 91% of all branches were located above the midpoint. The RF vascularity can be classified into 2 types: type 1 (36% of sides) has branches that arise from a single artery (descending lateral circumflex femoral artery or femoral artery), whereas type 2 (64% of sides) has branches at the 1/5 proximal and 4/5 distal parts, which arise from different arteries.

CONCLUSIONS

Preoperative CTA can provide anatomic information about the RF's nutrient vessel(s) and helps to optimize ALTF design.

Comparison of the outcomes between free anteromedial thigh flap and anterolateral thigh flap in head and neck cancer reconstruction: Analysis of propensity-score-matched patient cohorts

BACKGROUND

The anterolateral thigh (ALT) flap is a workhorse flap in head and neck cancer reconstruction. The anteromedial thigh (AMT) flap was developed as a rescue or alternative flap whenever the ALT flap is not available; however, the harvest of AMT flap seems to be more challenging in the sense that perforators have multiple variations. This study was designed to compare the outcome of the AMT and ALT flaps in head and neck cancer reconstruction.

METHODS

A total of 1,547 ALT and 57 AMT flaps were used for head and neck cancer reconstruction between March 1, 2008 and February 28, 2017. Differences in patient and operative characteristics were compared between the patients undergoing AMT and ALT flap reconstruction. The primary outcome of the free flap was its survival or failure, while the second outcome was the associated complications.

RESULTS

Compared to those who had ALT flap reconstruction, the patients who underwent AMT flap reconstruction had a higher rate of conditions that required reconstruction after previous cancer ablation and recurrence but a lower rate of primary cancer and deeply located cancer. Analysis of the 40 well-balanced pairs of propensity-score-matched patient cohorts revealed that the AMT flaps were associated with a significantly higher failure rate than the ALT flaps (15.0 vs. 0.0%, respectively; p = .026).

CONCLUSION

This study revealed that AMT flaps were associated with a significantly higher failure rate than ALT flaps in head and neck cancer reconstruction in the cohort of total patients and the propensity-score-matched cohorts.

The esthetic outcome of lower limb reconstruction

BACKGROUND

In recent years, the progress of anatomical knowledge and microsurgical techniques, in particular the development of perforator flaps, has risen the number of flaps available for lower leg reconstruction. The esthetic consequences of flap choice and harvest do have an impact on patients' quality of life. Nowadays, more researchers evaluate the esthetic changes following lower limb reconstruction.

OBJECTIVES

This review aims to summarize the available evidence on the esthetic outcome of lower limb reconstruction.

DATA SOURCES

A systematic review was planned to identify the most relevant indexed articles on this subject. The search was performed on Pubmed database without date of publication limits.

STUDY ELIGIBILITY CRITERIA

All papers about reporting information about the esthetic outcome of lower limb reconstruction were selected. Case reports and the articles not including specific information about complications, secondary procedures, and outcomes were excluded. The articles were categorized according to their topic and date of publication. The full texts of all the articles were obtained and read thoroughly. The references for each article were screened to identify articles that were eventually left outside our database search.

PARTICIPANTS, AND INTERVENTIONS

One hundred and eight articles were retained for the definitive review. Eleven review articles were kept because they represented a good source of information. Thirty-three articles were added after reading the full texts. The articles appear highly heterogeneous and at, this stage, only a critical and qualitative analysis could be performed.

RESULTS

We found information about 7895 lower reconstructions, 1295 local flaps, 6546 free flaps.

LIMITATIONS

The esthetic evaluation is intrinsic subjective. Many psychological and cultural factors influence both the patient and the surgeon. There is not a validated assessment tool for the esthetic outcome of lower leg reconstruction. Therefore, no quantitative analysis was performed.

CONCLUSIONS

Some ancient techniques are today obsolete, like the rectus abdominis free muscle flaps and perhaps free forearm flap, others are always useful, like gracilis and latissimus dorsi free flap. ALT flap is the most versatile perforator flap today available, but the SCIP flap is gaining the favor of a growing number of surgeons. Local flaps will be always performed with success but their indications should not be pushed beyond the medium-size defects. The best cosmetic outcome for each patient cannot necessarily be obtained neither with the easiest techniques nor with the most technically demanding ones. It is necessary to develop validated tools to assess the cosmetic outcome of lower limb reconstruction.

Use of Free Anterolateral Thigh Flap in Reconstruction of Soft Tissue Defects in Orthopedic Oncology: What are the Outcomes?

INTRODUCTION

Soft tissue defects due to trauma with crush injuries and post-tumor excision are large in size. Free anterolateral flap provides a stable and durable coverage of soft tissue defects and leads to good functional outcomes.

MATERIALS AND METHODS

Between January 2017 and January 2019, eight males and six female patients with soft tissue defects were operated upon using a free anterolateral thigh flaps. The defects in ten patients were due to post-tumor extirpation and in four patients due to wound breakdown following post-tumor extirpation.

RESULTS

The average flap dimension was 14 cm × 12 cm. The mean follow-up was 11 months (4-28 months). All the flaps survived well except in one patient who with an upper limb defect, had flap necrosis owing to which patient needed to undergo abdominal flap coverage. Two patients with sarcoma developed local recurrence and had to undergo above‑knee amputation.

CONCLUSION

The method of reconstruction depends on the size of defect and area to be covered and need of post-surgery mobilization and need for radiotherapy. The free anterolateral thigh flap has varied uses in orthopedics with very good extent of coverage and provides very potent coverage of neurovascular structures, bones, tendons, and implants.

Acute compartment syndrome secondary to anterolateral thigh flap harvesting in a pediatric patient: A case report

INTRODUCTION

The anterolateral thigh (ALT) flap is the most popularly used flap for major soft tissue reconstruction. Although it is widely used, acute compartment syndrome (ACS) in pediatric patients has rarely been reported in the literature. We herein reported a case of ACS in a 6-year-old girl after ALT flap harvest with direct closure of the donor site.

PATIENT CONCERNS

A 6-year-old girl was admitted to the Second Hospital of Jilin University with crush injury on the palmar aspect of the right hand and wrist.

DIAGNOSIS

Examination showed soft tissue defect of the hand and wrist, damage on the thenar muscles, lightly crushed flexor tendons, crushed median nerve, and ulnar artery thrombosis.

INTERVENTIONS

The defect was closed with an ipsilateral ALT flap measuring 9 cm in length by 6 cm in width.

OUTCOMES

After debridement was performed 3 times, the majority of the rectus femoris and lateral femoris were removed. Secondary closure by skin grafting was performed 2 weeks later. Three days after the procedure, necrotic tissues were noted on the edges of the wound. The diagnosis of ACS of the right was made. A second exploration was decided, and an extensive anterior compartment fasciotomy was performed. After 6 weeks of vacuum sealing drainage therapy, the defect was closed with a free latissimus dorsi musculocutaneous flap. At 4 months of follow-up, the right thigh wound had healed. At 6 months of follow-up, quadriceps muscle weakness remained. At 1 year of follow-up, the patient's mobility had been significantly improved, but diminished sensation remained on the lateral aspect of the thigh.

CONCLUSION

ACS can occur after ALT flap harvesting in pediatric patients and should be recognized as early as possible to avoid devastating complications.

Comparison of the modified direct closure method and skin grafting for wounds at the anterolateral thigh flap donor site

OBJECTIVE

This study was performed to compare the modified direct closure method and traditional skin grafting for wounds at the anterolateral thigh (ALT) flap donor site.

METHODS

Among 29 consecutive patients with wounds at the ALT flap donor site, 14 underwent the modified direct closure method (MDC group) and 15 underwent traditional skin grafting (SG group). The operative time, follow-up time, complications, Vancouver Scar Scale (VSS) score, and Scar Cosmesis Assessment and Rating (SCAR) score of the two groups were statistically analyzed.

RESULTS

The mean follow-up times in the MDC and SG group were 16.1 and 16.7 months, respectively. Two patients showed partial skin necrosis after skin grafting, but the remaining patients' wounds healed uneventfully. The operative time in the MDC group was an average of about 64 minutes shorter than that in the SG group. The average VSS and SCAR scores in the MDC group were 2.1 and 3.0 points lower, respectively, than those in the SG group.

CONCLUSIONS

Compared with traditional skin grafting, the modified direct closure method is more efficient for repair of wounds at the ALT flap donor site because of its shorter operative time, better postoperative appearance of the donor site, and higher patient satisfaction.

Customized reconstruction of complex soft-tissue defect in the hand and forearm with individual design of chain-linked bilateral anterolateral thigh perforator flaps

BACKGROUND

Complex soft-tissue defects of upper extremities still have a high rate of amputation, as the reconstruction of complex soft-tissue defects is always difficult even with the largest conventional free flap. The anterolateral thigh perforator (ALTP) flap is one of the most popular procedures used for the coverage of complex soft-tissue defects of extremities. However, problems associated with donor-site morbidity and inability to repair complex soft-tissue defects in a one-stage procedure persist. The purpose of this study was to present a novel design of using chain-linked bilateral ALTP flap and its various designs for customized reconstruction of complex soft-tissue defects in the hands and forearms.

METHODS

From June 2009 to June 2017, we retrospectively analyzed 15 patients with complex soft-tissue defects in the hands and forearms. All patients in this series underwent extremity reconstruction using the chain-linked bilateral ALTP flaps. Three different types of chain-linked bilateral ALTP flaps were created in this study based on wound characteristics and the maximum available skin paddle size at all donor sites.

RESULTS

The chain-linked bilateral ALTP flaps were successfully harvested for the reconstruction of complex soft-tissue defects in the hands and forearms. Among them, ten cases were repaired with chain-linked bipaddle ALTP flaps, two cases were treated with chain-linked tripaddle ALTP flaps, and the remaining three cases were used with chain-linked multi-lobed ALTP chimeric flaps. The sizes of the skin paddles ranged from 11 cm × 7 cm to 42 cm × 8 cm. The areas of the total flaps ranged from 245 cm² to 650 cm² (mean 419.6 cm²). Only one case required re-exploration because of the venous congestion. The donor sites were closed directly. The mean follow-up time was 16.4 months. Most cases showed satisfactory contour.

CONCLUSION

The chain-linked bilateral ALTP flap is a reliable option for one-stage reconstruction of complex soft-tissue defects in the hands and forearms with limited donor-site morbidity. It also provides various flap designs, which allow for more individualized treatment approaches.

Microstructured hydrogel scaffolds containing differential density interfaces promote rapid cellular invasion and vascularization

INTRODUCTION

Insufficient vascularization of currently available clinical biomaterials has limited their application to optimal wound beds. We designed a hydrogel scaffold with a unique internal microstructure of differential collagen densities to induce cellular invasion and neovascularization.

METHODS

Microsphere scaffolds (MSS) were fabricated by encasing 1% (w/v) type 1 collagen microspheres 50-150 μm in diameter in 0.3% collagen bulk. 1% and 0.3% monophase collagen scaffolds and Integra® disks served as controls. Mechanical characterization as well as in vitro and in vivo invasion assays were performed. Cell number and depth of invasion were analyzed using Imaris™. Cell identity was assessed immunohistochemically.

RESULTS

In vitro, MSS exhibited significantly greater average depth of cellular invasion than Integra® and monophase collagen controls. MSS also demonstrated significantly higher cell counts than controls. In vivo, MSS revealed significantly more cellular invasion spanning the entire scaffold depth at 14 days than Integra®. CD31+ expressing luminal structures suggestive of neovasculature were seen within MSS at 7 days and were more prevalent after 14 days. Multiphoton microscopy of MSS demonstrated erythrocytes within luminal structures after 14 days.

CONCLUSION

By harnessing simple architectural cues to induce cellular migration, MSS holds great potential for clinical translation as the next generation dermal replacement product.

STATEMENT OF SIGNIFICANCE

Large skin wounds require tissue engineered dermal substitutes in order to promote healing. Currently available dermal replacement products do not always adequately incorporate into the body, especially in complex wounds, due to poor neovascularization. In this paper, we present a hydrogel with an innovative microarchitecture that is composed of dense type I collagen microspheres suspended in a less-dense collagen bulk. We show that cell invasion into the scaffold is driven solely by mechanical cues inherent within this differential density interface, and that this induces robust vascular cell invasion both in vitro and in a rodent model. Our hydrogel performs favorably compared to the current clinical gold standard, Integra®. We believe this hydrogel scaffold may be the first of the next generation of dermal replacement products.

Coculture Method to Obtain Endothelial Networks Within Human Tissue-Engineered Skeletal Muscle

Skeletal muscle tissue engineering aims at creating functional skeletal muscle in vitro. Human muscle organoids can be used for potential applications in regenerative medicine, but also as an in vitro model for myogenesis or myopathology. However, the thickness of constructs is limited due to passive diffusion of nutrients and oxygen. Introduction of a vascular network in vitro may solve this limitation. Here, we describe tissue engineering of in vitro skeletal muscle consisting of human aligned myofibers with interspersed endothelial networks. To create bio-artificial muscle (BAM), human muscle progenitor cells are cocultured with human umbilical vein endothelial cells (HUVECs) in a fibrin hydrogel. The cell-gel mix is cast into silicone molds with end attachment sites and cultured in endothelial growth medium (EGM-2) for 1 week. The passive forces generated in the contracted hydrogel align the myogenic cells parallel to the long axis of the contracted gel such that they fuse into aligned multinucleated myofibers. This results in the formation of a 2 cm long and ~1.5 mm tick human BAM construct with endothelial networks.

Anterolateral thigh versus pectoralis major flaps in reconstruction of the lateral temporal bone defect

BACKGROUND

Free tissue reconstruction is reliable in suitable patients but patient selection remains a challenge for the reconstructive surgeon. The anterolateral thigh (ALT) free flap and pedicled pectoralis major myocutaneous flap (PMMF) are two common reconstructive options for a lateral temporal bone resection defect. The threshold at which free tissue reconstruction should be considered over locoregional reconstruction is not defined. We sought to define reconstructive flap choice in the setting of medical comorbidities that may dissuade free tissue transfer.

METHODS

A retrospective analysis of lateral temporal bone defects at a single institution was undertaken. The primary outcomes were flap survival, surgical complications and durations of surgery and stay. Data regarding medical comorbidities and potential confounders were examined.

RESULTS

Sixty patients with lateral temporal bone defects were identified. Twenty-four (40%) patients underwent PMMF reconstruction and 36 (60%) were reconstructed with ALT. The former were significantly older (73 versus 62 years), though with similar Anesthesiologists Risk Classification System status. Free-flap reconstruction resulted in significantly less flap loss (two versus six) but a longer operating time (790 versus 671 min).

CONCLUSION

Patients suffering head and neck cancer with medical comorbidities can make selection of a suitable reconstruction difficult. We found that while patients undergoing ALT reconstruction were typically younger, the comorbidity profile of those patients was similar to patients undergoing PMMF reconstruction. ALT flaps were more reliable than the PMMF, lending credence to the view that free tissue transfer should be the preferred reconstructive option in suitable candidates and defects.

Minimizing free flap donor-site morbidity

PURPOSE OF REVIEW

Fasciocutaneous and osteocutaneous free flap reconstruction has significantly changed the way surgeons reconstruct defects following ablation of head and neck tumors. Over time, success rates of free flaps have approached 98%, allowing surgeons to shift their focus to minimizing morbidities associated with the donor sites. The radial forearm, anterolateral thigh, and fibula free flaps are the three most commonly used flaps in head and neck reconstruction, and therefore each of their advantages and associated morbidities are of particular interest. The present article aims to review the morbidities associated with each of the commonly used head and neck free flaps and techniques to minimize them that are described in the most recent literature.

RECENT FINDINGS

New techniques such as negative-pressure wound therapy, full thickness grafts, and rotational flaps have been developed recently that minimize these morbidities.

SUMMARY

The techniques described in the current review may improve long-term patient outcomes both esthetically and functionally.

Perfusion decellularization of a human limb: A novel platform for composite tissue engineering and reconstructive surgery

Muscle and fasciocutaneous flaps taken from autologous donor sites are currently the most utilized approach for trauma repair, accounting annually for 4.5 million procedures in the US alone. However, the donor tissue size is limited and the complications related to these surgical techniques lead to morbidities, often involving the donor sites. Alternatively, recent reports indicated that extracellular matrix (ECM) scaffolds boost the regenerative potential of the injured site, as shown in a small cohort of volumetric muscle loss patients. Perfusion decellularization is a bioengineering technology that allows the generation of clinical-scale ECM scaffolds with preserved complex architecture and with an intact vascular template, from a variety of donor organs and tissues. We recently reported that this technology is amenable to generate full composite tissue scaffolds from rat and non-human primate limbs. Translating this platform to human extremities could substantially benefit soft tissue and volumetric muscle loss patients providing tissue- and species-specific grafts. In this proof-of-concept study, we show the successful generation a large-scale, acellular composite tissue scaffold from a full cadaveric human upper extremity. This construct retained its morphological architecture and perfusable vascular conduits. Histological and biochemical validation confirmed the successful removal of nuclear and cellular components, and highlighted the preservation of the native extracellular matrix components. Our results indicate that perfusion decellularization can be applied to produce human composite tissue acellular scaffolds. With its preserved structure and vascular template, these biocompatible constructs, could have significant advantages over the currently implanted matrices by means of nutrient distribution, size-scalability and immunological response.

Risk factors for delayed healing at the free anterolateral thigh flap donor site

BACKGROUND

The free anterolateral thigh (ALT) flap has been widely used for various kinds of reconstructions. However, delayed healing at the donor site occasionally occurs due to wound dehiscence or the partial loss of grafted skin at the donor site. The aim of the present study was to identify reliable predictive factors for delayed healing at the donor site after the harvest of a free ALT flap.

METHODS

This study included 52 patients who underwent reconstructive procedures using free ALT flaps. The delayed healing group included patients with wounds at the donor site that had not healed over 3 weeks after surgery, and the normal healing group included patients who showed wound healing within 3 weeks after surgery. Multivariate logistic regression models were created to identify the risk factors for delayed healing at the ALT flap donor site.

RESULTS

Among the 52 patients, 24 (46.2%) showed delayed healing at the donor site, and 6 patients required additional operative treatment. A high preoperative body mass index (BMI), smoking, and skin grafting were found to be significantly associated with delayed healing at the ALT donor site. Of the 37 patients who underwent skin grafting, 23 (62%) experienced delayed healing at the donor site.

CONCLUSIONS

A high preoperative BMI, smoking, and skin grafting were risk factors for delayed healing at the free ALT donor site. Skin grafting at the ALT donor site should be avoided in patients with a high BMI or a habit of smoking.

Retrospective Review of Free Anterolateral Thigh Flaps for Limb Salvage in Severely Injured High-Voltage Electrical Burn Patients

BACKGROUND

High-voltage electrical injuries usually cause extensive and devastating damages to the extremities. Timely and effective coverage of the wounds to maximally preserve the viable tissue is important for salvage and the ultimate functional outcome of the involved extremities. In this study, free anterolateral thigh flaps with a single-perforator pedicle were conducted to maximize tissue salvage and decrease late skeletal and neuromuscular complications of the involved extremities injured by high-voltage electricity.

METHODS

From June 2012 to December 2015, 12 patients with high-voltage electrical injuries on the extremities were recruited. After primary or secondary debridement, free anterolateral thigh flaps with a single-perforator pedicle were used for limb salvage. Patients' clinical records, including etiology, sex, age, perforator type, defect location, duration before admission, defect and flap size, timing of reconstruction, and complications, were extracted and analyzed.

RESULTS

All patients were followed up ranging from 10 to 25 months, with an average follow-up of 15.9 months. Free anterolateral thigh flap with a single-perforator pedicle was performed for 12 consecutive patients with high-voltage electrical injuries. The mean time taken before the transplantation of the flap was 5.25 days, with a range from 2 to 8 days. The average size of the resultant defects after debridement was 187.0 cm (84-350 cm), the average size of the flaps was 265.3 cm (119-448 cm), and the average time of the surgical operation was 314.6 minutes (260-355 minutes). All flaps healed uneventfully without associated complications. No weakness of the donor thigh was observed in all cases.

CONCLUSIONS

Free anterolateral thigh flaps with a single-perforator pedicle were an effective and reliable therapeutic intervention for the management of severe high-voltage electrical injuries on the extremities.

Soft palate reconstruction after radionecrosis: Combined anterolateral thigh adipofascial and nasoseptal flaps

Although radiation-based treatment for nasopharyngeal cancer may achieve excellent long term oncologic results, late effects of therapy may lead to soft tissue radionecrosis and velopharyngeal insufficiency (VPI). Repair of these oro- and nasopharyngeal defects presents a complex reconstructive challenge. We present a case of a long-term survivor treated with chemoradiotherapy for nasopharyngeal cancer who developed progressive dysphagia, velopharyngeal insufficiency, and radionecrosis of the nasopharynx and soft palate, leading to tracheostomy and gastrostomy tube dependence. A staged reconstruction was performed, initially with a tubed nasoseptal flap for a creation of a mucosal-lined nasopharyngeal port. An adipofascial anterolateral thigh free flap was subsequently performed for soft palate reconstruction. Within 2 months, the oropharyngeal reconstruction had remucosalized and she was decannulated, taking an oral diet. Her speech was intelligible and she had good nasal breathing without symptoms of velopharyngeal insufficiency.

Feasibility and Advantages of Full Thickness Skin Graft from the Anterolateral Thigh

BACKGROUND

Full thickness skin graft (FTSG) gives better outcomes than split thickness skin graft (STSG), but it has the drawback of limited donor sites. Anterolateral thigh (ALT), a popular donor site of STSG, is also a popular donor site of perforator flaps. This area has the advantage of large flap size available with primary closure. Based on this we harvested FTSG instead of STSG from the ALT.

METHODS

We retrospectively reviewed 10 cases of FTSG from the ALT, with the recipient site of foot in 3, ankle in 2, lower leg in 2, forearm in 2, and wrist in 1 patient. In all cases elliptical full thickness skin was harvested from the ALT, and the donor site was closed primarily. The skin was defatted and placed onto the defect with vacuum-assisted closure (VAC). The skin size ranged 7-30 cm in length and 3-12 cm in width. Mean follow up period was 7 months (range, 3-13).

RESULTS

FTSG from the ALT provided durable wound coverage, with excellent color and texture matching. Partial (< 20%) graft failure was observed in 1 case, but no additional surgery was necessary. No patient reported donor site pain at postoperative 2 weeks. No donor site complications were encountered. No patient complained a feeling of tension in the thigh at final follow-up.

CONCLUSIONS

FTSG from the ALT is feasible with the aid of VAC. Considering the skin quality, large skin size available, early pain relief, and little donor site morbidity, the ALT should be revisited as a donor site of FTSG.

Sandwich Fascial Anterolateral Thigh Flap in Head and Neck Reconstruction: Evolution or Revolution?

Supplemental Digital Content is available in the text.

Introduction:

The anterolateral thigh perforator flap (ALT) represents the workhorse for most reconstructive efforts in the head and neck regions. The main advantages of this flap are its versatility, the length of the pedicle, and the low morbidity of the donor site. The major drawback is the bulkiness of this flap with the frequent need for secondary revisions. To overcome this, we have developed a novel way to harvest and inset the ALT, called the sandwich fascial ALT flap (SALT).

Methods:

All patients undergoing head and neck reconstruction using the SALT flap from January 2013 to March 2016 were included in this retrospective analysis. The SALT flap was harvested as a composite flap including the superficial fascia, the subscarpal fat, and the deep fascia. At the recipient site, the flap was inset with the deep fascia facing out. A split thickness skin graft (± dermal substitute) was used to cover the deep fascia and the pedicle.

Results:

Eleven patients were included: 8 cases of orbital exenteration, 1 case of forehead reconstruction, and 2 cases of palatal reconstruction after radical maxillectomy. Flap survival was 100%. One patient required an early take back for venous thrombosis. The reconstruction was effective in all cases, allowing a prosthetic rehabilitation when required. Donor-site morbidity was minimal.

Conclusions:

The reconstruction of head and neck defects with a bulky fasciocutaneous ALT flap might not be the best option in every case. The SALT flap could represent a valid alternative for selected cases, with encouraging functional and cosmetic outcomes.

Sternocleidomastoid contour restoration: an added benefit of the anterolateral thigh free flap during facial reconstruction

PURPOSE

To demonstrate the potential of the anterolateral thigh free flap for neck contour restoration.

STUDY DESIGN

Retrospective chart review at a tertiary care medical center of patients who underwent radical parotidectomy with sternocleidomastoid sacrifice, with or without temporal bone resection, and reconstruction of both facial and cervical contour with the anterolateral thigh free flap between November 2011 and March 2015. Seven patients were included and demographics, flap viability, pathology and tumor staging, surgical intervention, adjunctive reanimation procedures, ischemia time, and pre-operative and post-operative photos were recorded and analyzed.

RESULTS

There were no flap failures and the mean ischemia time was 82 minutes. There were 2 recipient site complications. Post-operative neck symmetry was improved for all 7 patients.

CONCLUSIONS

The adipofascial anterolateral thigh flap is useful for improving the aesthetic contour of the neck among patients undergoing sternocleidomastoid muscle resection/disinsertion following total parotidectomy with/without temporal bone resection. Contour restoration may be performed with minimal added morbidity and with relatively little additional operative time. This technique may be adapted for other complex facial and neck defects caused by ablative surgery.

LEVEL OF EVIDENCE

4.

Use of modified lateral upper arm free flap for reconstruction of soft tissue defect after resection of oral cancer

BACKGROUND

To evaluate the suitability of a modified lateral upper arm free flap (LAFF) for reconstruction of soft tissue defects after resection of oral cancer.

METHODS

Eighteen cases of soft tissue defect repair performed between January 2011 and December 2013 using a modified LAFF after resection of oral cancer were reviewed. The design and harvest of the LAFF, the reconstruction procedure, and postoperative morbidity were reviewed and evaluated over a follow-up period of at least 12 months.

RESULTS

The overall flap survival was 94.4 % (17/18 patients). A broad scar at the donor site was the most common morbidity, but patients did not report dissatisfaction with the scar because they could easily cover it. All wounds at the donor site achieved primary recovery. One case of flap loss was repaired with a radial forearm free flap. One case complicated by diabetes mellitus involved infection of the flap with one-third of the flap becoming necrotic. This flap survived after removal of the necrotic tissue. In one other case, fat liquefactive necrosis (1.5 × 1.0 cm) occurred in the flap on the tip of the tongue, and this flap survived after debridement. Overall, the shape and function of the reconstructed tissues were well restored, and there was no severe morbidity at the donor site in any case.

CONCLUSION

The modified LAFF was safe and reliable for the reconstruction of soft tissue defects after resection of oral cancer.

Reconstruction of complex soft-tissue defects in the extremities with chimeric anterolateral thigh perforator flap

INTRODUCTION

The reconstruction of extensive three-dimensional defects in the extremities is a difficult challenge. 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 anterolateral thigh (ALT) chimeric flap is one of the most useful tools for the reconstruction of complex three-dimensional defects in the extremities.

METHODS

From January 2010 to March 2012, Twenty-two patients underwent extremity reconstruction using chimeric ALT perforator flaps, which consists of a skin component on its isolated perforator and a portion of the fascia and muscle flaps on the same pedicle from the descending branch of the lateral circumflex femoral artery (LCFA). The defects were in either a lower (n = 10) or an upper extremity (n = 12). The area of the soft tissue defects ranged from 43 × 35 cm to 19 × 9 cm (mean, 25 × 18 cm), containing extensive, irregular, ring-like soft tissue defects or degloving injuries.

RESULTS

The mean dimension of skin flap was 19.8 × 11.2 cm. The mean dimension of fascia flap was 8.9 × 7.1 cm. The mean dimension of muscle flap was 11.1 × 7.5 cm. No total flap loss occurred. One patient presented with venous thrombosis, and re-anastomosis and vein grafting were performed. Two cases exhibiting partial skin graft loss at the site at which the fascia flap was inset were treated via secondary skin grafts. During a follow-up period of 18 months-30 months, patients were satisfied with the functional and aesthetic outcome. No serious donor-site complications occurred.

DISCUSSION

Chimeric anterolateral thigh perforator flap can be one of the best choice for reconstruction of complex soft-tissue defects in the extremities.

CONCLUSIONS

The various tissue components and maximal freedom offered by chimeric tissue flaps associated with the same descending branch of the LCFA provide versatile coverage of large, complex, and irregular soft-tissue defects in the extremities.