Single stage reconstruction of complex head and neck defects involving the skin with a single ALT flap: A ten year review

VRAM Versus ALT Flap Reconstruction for Large Head and Neck Defects: Does Weight Influence Complication Rate?

Background: Obesity remains a high-level risk factor for various cancers. Yet, some research has shown that higher BMIs may improve survival outcomes, particularly for head and neck squamous cell carcinoma (HNSCC). While this is a clear deviation from the norm, it raises the question of what other effects obesity may have on head and neck cancer patients, including surgical outcomes. Choosing the most appropriate flap for patients can be difficult for even experienced surgeons. Head and neck reconstructive surgeries are no exception to this rule and can be especially challenging. To produce the most favorable outcomes, a physician must be able to combine all flap attributes including donor and recipient site location, flap thickness, as well as each patient's individual risk factors such as prior radiation. Purpose: The purpose of this study was to compare the outcomes of vertical rectus femoris myocutaneous (VRAM) and anterolateral thigh (ALT) flaps in overweight and obese individuals with varying head and neck cancers leaving large-sized defects to the outcomes in normal and underweight patients. Methods: A retrospective chart review was conducted of VRAM and ALT flaps performed over a period of 12 months at our university hospital for large head and neck reconstruction. Results: Of the 17 ALT patients, 80% (4/5) of the underweight patients, 57% (4/7) of the normal weight patients, 50% (1/2) of the overweight patients, and 33% (1/3) of the obese patients experienced complications. Of the 15 VRAM patients, 40% (2/5) of the underweight patients, 83% (5/6) of the overweight patients, and 50% (1/2) of the obese patients experienced complications. Conclusions: In our small sample size, a smaller percentage of obese patients with head and neck cancer who underwent flap reconstruction surgery had complications when undergoing ALT flaps than VRAM flaps, which contrasts with the normal and underweight patients, who had less complications with VRAM flaps than ALT flaps.

Single perforator-based anterolateral thigh flap, the workhorse flap, in oral cancer reconstruction: A tertiary care institution experience

Background

Ablative procedures of the oral cavity require composite removal of tissues, which results in compromise of both functional activities and esthetic mutilation and proves to be a reconstructive challenge. This paper focuses on the reliability and versatility of a single perforator-based anterolateral thigh (ALT) flap in oral cancer reconstruction.

Materials and Methods

All patients who underwent reconstruction with a single perforator-based ALT for oral cancer defects at our center were included in the study.

Results

Forty-seven patients who underwent reconstruction with a single perforator-based ALT flap were included in our study. The average flap size in our series was 111 cm2, with the largest measuring 375 cm2. They was a complete loss of flap in two patients; both of them underwent salvage procedure and were reconstructed with pectoralis major myocutaneous flap. One had a partial loss that underwent re-exploration.

Conclusion

We conclude that a single perforator-based ALT is a very safe, reliable, and versatile flap for head and neck reconstruction. The microvascular anastomosis may be expensive and technically a limitation; however, it has found a permanent place in our head and neck reconstructive toolkit and is the workhorse flap for head and neck reconstruction.

Utility of Multimodal Treatment Protocols in the Management of Scalp Cutaneous Angiosarcoma

Cutaneous angiosarcomas are rare, aggressive tumors with high recurrence and poor prognosis. We share our experiences with the challenging surgical management of these lesions, focusing on both ablative and reconstructive outcomes.

Methods

Retrospective cross-sectional chart review was conducted of patients diagnosed with scalp cutaneous angiosarcoma between 2005 and 2021. Resectability, defect reconstruction, and survival outcomes were analyzed.

Results

Thirty patients were included, 27 (90%) men and three (10%) women, with a mean age at diagnosis of 71.77 ± 7.3 years, and mean follow-up of 429.43 ± 305.6 days. Only 12 patients completed their regular follow-up, while the remaining patients died. There was a median survival of 443.50 days (range, 42-1283) and median time to recurrence of 21 days (range, 30-1690). Multimodal therapy compared with surgery alone had a significantly better overall median survival (468 days versus 71 days; P = 0.021). Defect coverage was obtained in 24 cases (75%) through an anterolateral thigh flap, two patients (6%) with a local transposition flap, and one patient (3%) with a transverse rectus abdominis myocutaneous flap. The remaining three patients received a skin graft. All of the flaps survived, with one requiring a vein graft for venous congestion.

Conclusions

Timely multimodal therapy with a histologically safe margin, combined with adjuvant therapy, improves survival and delays recurrence and metastasis, in cutaneous angiosarcoma patients. An anterolateral thigh flap facilitates the coverage of wide defects. Further investigations of advanced treatment modalities such as immunotherapy and/or gene therapy are required to deal with this highly aggressive tumor.

Preoperative perforator mapping of anterolateral thigh flaps using computed tomographic angiography and visual coordinate system for the reconstruction of head and neck defects

OBJECTIVES

The anterolateral thigh (ALT) flap is a versatile workhorse flap for the reconstruction of head and neck defects; however, variations in the location of perforators are a significant concern. This prospective study proposes a rapid, effective, and convenient method for mapping the location of sizeable perforators on the curved thigh skin surface using the visual coordinate system in computed tomographic angiography (CTA) images.

METHODS

Fourteen patients suffering from defects after head and neck carcinoma resection underwent CTA prior to ALT flap reconstruction at the Department of Otolaryngology-Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, from January 2018 to August 2021. Using sterile gauze swab developing lines pasted on the patients' thighs, we established a coordinate system visualized both in CTA images and the thighs. The perforator information was then compared between the CTA and intraoperative findings.

RESULTS

Twenty-one perforators were detected on CTA in the designed flaps, which were also confirmed during the operation with a visual pulse. The course and source of the perforators were consistent with the intraoperative findings. The distances of perforator coordinate points between CTA and intraoperative findings were <5 mm. Another five perforators (mostly without visual pulse) found intraoperatively could not be identified on preoperative CTA. Most flaps survived in their entirety, and one flap suffered a small area of necrosis due to perforator compression.

CONCLUSION

This study demonstrated the efficacy of a novel perforator mapping method for anterolateral thigh flaps.

Reconstructing abdominal wall defects with a free composite tissue flap: A case report

BACKGROUND

Reconstructive repair of huge full-thickness abdominal wall defects following debridement for abdominal electric burns remains a clinically challenging task. An ideal abdominal wall repair means a re-closure of the defected abdominal wall with pedicled neurovascular myofascial flaps, restoration of the abdominal wall integrity, and maintenance of the abdominal wall muscle tension to prevent the occurrence of abdominal wall hernia. When treating huge full-thickness defects, composite autologous tissue flaps are a good option for the repair.

CASE SUMMARY

This study reported the case of a 43-year-old male patient suffering from full-thickness abdominal wall defects complicated with necrosis of multiple bowel segments and duodenal leak following high-voltage burns involving the left upper limb and abdomen. After debridement for abdominal electric burns and end-to-end anastomosis for the necrotic bowels, reconstruction with acellular dermal matrix grafting and vacuum sealing drainage were performed for temporary abdominal closure. The remaining 18 cm × 15 cm full-thickness abdominal wall defect was repaired using a combined anterolateral thigh and tensor fascia lata free flap. The proposed method achieved the functional reconstruction of the abdominal wall.

CONCLUSION

This approach restored the abdominal wall integrity, maintained certain muscle tension, avoided abdominal hernia, reached satisfactory aesthetic effect, and resulted in no complications in the grafting regions.