Reconstruction of posttraumatic defects of the foot by flow-through anterolateral or anteromedial thigh flaps with preservation of posterior tibial vessels

Anterolateral thigh flow-through flap: A versatile method for reconstruction of complex extremity defects

BACKGROUND

Flow-through flaps have been widely applied only for the reconstruction of complex defects in the extremities because they can be used for arterial reconstruction and soft tissue coverage simultaneously. This report attempts to fully demonstrate the role of the anterolateral thigh (ALT) flow-through flap as a versatile method for reconstructing complex defects in the extremities.

METHODS

From February 2011 to March 2017, we retrospectively analyzed the use of a reconstructive surgical technique based on the ALT flow-through flap to treat complex extremity defects in 87 patients (trauma, n = 79; diabetic ulcers, n = 5; squamous cell carcinoma, n = 3). Emergency surgery was performed in 12 patients to bridge a major artery gap and was followed by elective reconstruction in the remaining patients. Applications of the ALT flow-through flap included bridging major artery gaps, preserving recipient blood vessel integrity, reconstructing blood vessel continuity, protecting vascular anastomoses, avoiding difficult end-to-side anastomoses in the recipient area, and balancing blood flow, as well as combined application with an additional flap.

RESULTS

The flap size ranged from 6 × 3 cm to 17 × 9 cm. ALT flow-through flaps were used in combination with an additional flap (n = 4) and in vascular reconstruction (n = 83). Three patients required of the microvascular anastomostic reexploration for venous congestion, total necrosis occurred in two patients, and partial necrosis occurred in one patient. At the donor site, there were three cases of infection and two cases of wound dehiscence. At the recipient site, one case of infection and two cases of wound dehiscence were observed. One patient presented with deep infection secondary to renal failure and underwent amputation. During the follow-up period (range, 1-33 months), all other flaps (84 cases) survived uneventfully, with normal texture and color.

CONCLUSION

The ALT flow-through flap plays many roles as it is a versatile method for reconstructing complex defects of the extremities and serves various other clinical purposes.

Is the oblique branch of the lateral circumflex femoral artery a common variant?

The oblique branch of the lateral circumflex femoral artery, a short branch of the deep femoral artery, is highly prevalent (32-46%) and is usually considered a normal variant, although this is still controversial. This study aimed to evaluate whether the oblique branch of the lateral circumflex femoral artery is a variant. We reviewed medical record data of patients with skin and soft tissue defects of the extremities who underwent flap repair using free anterolateral thigh (ALT) flaps at our hospital in 2019. The anatomical characteristics of the flaps were examined intraoperatively by high-frequency color Doppler ultrasound. A total of 153 ALT flaps from 146 patients were included. Among the branches, 232 (73.7%) were oblique branches, and 83 (26.4%) were descending branches. Of the 232 oblique branches, 141 (60.8%) were from septocutaneous branches, and the other 83 (39.2%) were from musculocutaneous branches. In addition, 20 (24.1%) descending branches were from septocutaneous branches, and the other 63 (75.9%) were from musculocutaneous branches. Analyzing the prevalence of the oblique branch in septocutaneous branches, more than half of the patients had oblique branches rather than descending branches. The high proportion of oblique branches from septocutaneous branches (median: 100 (0-100) vs. 0 (0-50), p = 0.002) supports the understanding that the oblique branch is a normal anatomical element rather than a variant. The main type was the intramuscular branches, which required significantly less time for flap harvesting. The oblique branch may be the preferred vascular pedicle for free ALT flaps.

A Quantitative Evaluation of the Flow-Increasing Effect of Flow-Through Arterial Anastomosis in the Vascular Pedicle of Free Flaps: A Prospective Clinical Before-and-After Study

BACKGROUND

The clinical application of flow-through anastomosis has been reported in various studies; however, no studies have quantitatively evaluated and compared the actual hemodynamics in flow-through anastomosis and end-to-end anastomosis. This study quantitatively evaluated the blood inflow (volumetric flow rate) and vascular resistance (pulsatility index) of flow-through arterial anastomosis using an ultrasonic flowmeter, and compared these values with those of end-to-end anastomosis in actual clinical settings. In addition, factors affecting the outcomes have also been examined.

METHODS

Twenty-eight patients who underwent free flap reconstruction after tumor resection were subjected to flow-through arterial anastomosis and flow examination. First, in the end-to-end state, the proximal anastomotic site was measured. This was followed by the opening of the distal arterial clamp, and measurement was then continued (in the flow-through state).

RESULTS

In flow-through arterial anastomosis compared with end-to-end anastomosis, the volumetric flow rate was significantly increased (18.9 ± 14.1 ml/minute versus 6.0 ± 6.3 ml/minute) and the pulsatility index was significantly decreased (5.2 ± 3.7 versus 13.6 ± 10.2), when comparing paired data. Multiple regression analyses revealed that a perforator flap (versus a musculocutaneous flap) was independently associated with both reduced volumetric flow rate and increased pulsatility index in end-to-end anastomosis, and that hypertension was independently associated with an increased pulsatility index in end-to-end anastomosis. However, no factors in flow-through anastomosis were significantly associated with those values.

CONCLUSION

In terms of blood flow and vascular resistance, flow-through arterial anastomosis was considered to have promising quantitative effects and should be performed when the conditions of both the donor and recipient vessels meet the requirements.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Flow-through Anterolateral Thigh Flaps: Report of 3 Consecutive Cases and Review of its Utility

In the field of plastic and reconstructive surgery, soft tissue reconstruction of Gustilo 3B with peripheral vascular disease or 3C fractures is a complex treatment algorithm. The concomitant issue of soft tissue coverage with vascular reconstruction is the main challenge when opting for free tissue transfer. The flow-through flap offers the surgeon the ability to treat a vascular injury or high-grade stenosis to maintain distal perfusion, while also providing soft tissue coverage. In this study, we present a case series of 3 patients who underwent flow-through anterolateral thigh free flap for lower extremity soft tissue coverage. Each patient had a history of trauma and either single vessel runoff or a dominant branch with diminutive secondary blood flow to the foot. All patients successfully underwent free flap reconstruction of lower extremity wounds while concomitantly reconstructing diseased arterial supply. Only 1 patient suffered partial flap loss postoperatively that was treated with debridement and split thickness skin grafting. Flow-through free tissue transfer is a valuable treatment option not only in Gustilo 3C fractures requiring soft tissue coverage, but also in patients with Gustilo 3B fractures with peripheral vascular disease.

Flow-Through Free Anterolateral Thigh Flap in Reconstruction of Severe Limb Injury

Supplemental digital content is available in the text.

This study aimed to present the use of flow-through free anterolateral thigh (ALT) flap for the reconstruction of severe limb injury.

Flow-Through Free Fibula Osteocutaneous Flap in Reconstruction of Tibial Bone, Soft Tissue, and Main Artery Segmental Defects

OBJECTIVE

The aim of this report was to present the use of flow-through free fibula osteocutaneous flap for the repair of complex tibial bone, soft tissue, and main artery segmental defects.

PATIENTS AND METHODS

Five patients with bone, soft tissue, and segmental anterior tibial artery defects were included. The lengths of injured tibial bones ranged from 4 to 7 cm. The sizes of impaired soft tissues were between 9 × 4 and 15 × 6 cm. The lengths of defect of anterior tibial artery segments ranged from 6 to 10 cm. Two patients had distal limb perfusion problems. Flow-through free fibula osteocutaneous flap was performed for all 5 patients.

RESULTS

Patients were followed for 12 to 18 months. All wounds healed after 1-stage operation, and all flow-through flaps survived. The distal perfusion after vascular repair was normal in all patients. Superficial necrosis of flap edge was noted in 1 case. After the local debridement and partial thickness skin graft, the flap healed uneventfully, and the surgical operation did not increase injury to the donor site. Satisfactory bone union was achieved in all patients in 2 to 4 months postoperation. Enlargement of fibula graft was observed during follow-up from 12 to 18 months. The functions of adjacent joints were recovered, and all patients were able to walk normally.

CONCLUSIONS

Flow-through free fibula osteocutaneous flap was shown to be an effective and efficient technique for repairing composite tibial bone, soft tissue, and main artery segmental defects. This 1-stage operation should be useful in clinical practice for the treatment of complex bone, soft tissue, and vessel defects.

Versatility of Free Cutaneous Flaps for Upper Extremity Soft Tissue Reconstruction

The goals of upper extremity soft tissue reconstruction should go well beyond providing coverage and restoring function. As the field of reconstructive microsurgery has evolved, free cutaneous flaps (FCFs) are gaining wider application. The advantages of FCF include minimizing donor-site morbidity by preserving the muscle and fascia, improving versatility of flap design, and superior aesthetic results. This review highlights the application of anterolateral thigh, superficial circumflex iliac artery, deep inferior epigastric perforator, superficial inferior epigastric artery, and flow-through flaps for reconstruction of upper extremity defects. These flaps share several qualities in common: well-concealed donor sites, preservation of major arteries responsible of providing inflow to distal extremity, and potential for a two-team approach (donor and recipient sites). While the choice of flaps should be decided based on individual patient and defect characteristics, FCF should be considered as excellent options to achieve the goals of upper extremity reconstruction.

A case series of flow-through free anterolateral thigh flap to augment the vascularity of ischaemic limbs with soft tissue defect

Introduction:

In a world of fast moving vehicles, heavy machinery and industries crush injury to limbs with vascular compromise and soft tissue defect is common. The traditional treatment is a 2 step one dealing with vascular repair and soft tissue cover separately, in the same operation. We report a series of single step vascular repair and soft tissue cover with flow through anterolateral thigh flap (ALT) flap for limb salvage.

Materials and Methods:

Ten patients with soft tissue defect and vascular injury were included in this study. A two team approach was used to minimise operative time, team one prepared the vessels and team 2 harvested the flap.

Observations and Results:

Of the ten patients operated (8 males), eight flaps were done for upper limb and two for lower limb salvage. Six anastomosis were done with ulnar vessels, two with radial and two with posterior tibial vessels. Nine extremities could be salvaged while one patient developed progressive thrombosis leading to amputation.

Conclusion:

The ALT flow-through flap is a versatile single step procedure that can be used to salvage an ischemic limb with soft tissue loss avoiding the need for interpositional vein graft.

Refinement of the myocutaneous anterolateral thigh flap for reconstruction of frontonasal fistula defects

BACKGROUND

Frontonasal fistulas can lead to life-threatening intracranial infections. Our refinement of the myocutaneous anterolateral thigh (ALT) flap for treating these fistulas is described.

METHODS

A retrospective review of the microsurgical treatment of frontonasal fistulas is presented. Demographics, etiologies, outcomes, and complications were evaluated.

RESULTS

Ten myocutaneous ALT flaps were used to reconstruct frontonasal fistula. The mean follow-up was 35 ± 2.5 months. Nine fistulas were secondary to oncologic resections, and one was due to a traumatic origin. Complications included a recurrent abscess in 1 case (10%); there were no cases of cerebrospinal fluid (CSF) leak or flap loss. Preoperative intracranial infections were present in 7 cases, with 6 successfully resolving their infection after surgical intervention and flap obliteration of their fistulas.

CONCLUSION

Refinements in the myocutaneous ALT flap design have been illustrated to provide robust dead-space obliteration with vascularized muscle and reliable simultaneous scalp coverage in the treatment of frontonasal fistulas. © 2015 Wiley Periodicals, Inc. Head Neck 38: E552-E558, 2016.

Combined serratus anterior and latissimus dorsi myocutaneous flap for obliteration of an irradiated pelvic exenteration defect and simultaneous site for colostomy revision

Background

Usually, several surgical methods are used, with re-suturing, free skin grafting and local flaps, for the reconstruction of wall defects after abdominoperineal resection. However, or larger defects, free flaps have been preferred because they can provide a large area of well-vascularized soft tissue, which is suitable for defect repair. We present the case of a large abdominal wall defect, which was treated with a free combined serratus anterior and latissimus dorsi myocutaneous flap, resulting in a successful outcome.

Case presentation

A 38-year-old female originally had squamous cell carcinoma of the cervix uteri, and had undergone radical hysterectomy and oophorectomy followed by radiotherapy. She had a recurrence of the cervical cancer after 13 years, and underwent pelvic exenteration. However, the mid-abdominal wound developed dehiscence and an abdominal full-thickness defect communicating with the pelvic cavity. Furthermore, the adhered colon developed necrosis, which drained stools into the pelvic cavity, resulting in chronic peritonitis. During surgery, the empty pelvic cavity was filled with a combined serratus anterior and latissimus dorsi myocutaneous flap to prevent chronic peritonitis, to create a new stoma in the skin paddle of the flap for the necrotic colon, and to separate the pelvic cavity from the drained stools. The patient could walk in the absence of abdominal hernia formation and relapse of infection.

Conclusions

A combined serratus anterior and latissimus dorsi myocutaneous free flap was applied to cover the raw surface and reinforce the abdominal wall and to fashion a new colostomy, as well as successfully filling the pelvic cavity with a large muscle body and long vascular pedicle. This is the optimal method for reconstructing severe abdominal wall defects that have many complications.

Reconstruction of lateral forefoot using reversed medial plantar flap with free anterolateral thigh flap

Skin defects of the heel have frequently been reconstructed using the medial plantar flap; however, forefoot coverage has remained a challenge, because the alternatives for flap coverage have been very limited. We describe a case of malignant melanoma on the lateral forefoot that was radically removed and reconstructed successfully with a distally based medial plantar flap, together with a free anterolateral thigh flap. The advantages of this flap include that it does not reduce the vascular supply to the foot owing to reconstruction of the medial plantar vascular systems, reduces the risk of flap congestion, minimizes donor site morbidity, and enables the transport of structurally similar tissues to the plantar forefoot. We believe this technique is a reasonable reconstructive option for large lateral plantar forefoot defects.

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

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

Is primary thinning of the anterolateral thigh flap recommended?

BACKGROUND

Although primary thinning of the anterolateral thigh (ALT) flap has been successful in Asia, clinical and anatomic studies have demonstrated that this may be inadvisable in Western patients. Recent reports have demonstrated successful thinning of the ALT using smaller flaps. A systematic review was attempted, to assess whether ALT size affects the incidence of vascular compromise after primary thinning.

METHODS

A systematic review was undertaken to examine the relevant literature. Student t-test was used to compare flaps that did and did not have complications. Fisher exact test was used to compare outcomes of flaps measuring less than and greater than 150 cm2.

RESULTS

Eleven articles met the inclusion criteria. Eighty-eight ALT flaps were reported, and vascular compromise was seen in 11 (12.5%). The average size of flaps that demonstrated necrosis was 180.73 cm2; those without necrosis averaged 123.19 cm2 (P = 0.06). Flaps >150 cm2 had a significantly increased rate of compromise (25.93% vs. 6.56%; P < 0.05).

CONCLUSIONS

A systematic literature review confirms that it is inadvisable to primarily thin large ALT flaps in the Western population. When large ALT flaps are required, primary thinning must be avoided to keep linking vessels intact.

Anterolateral thigh flap

The anterolateral thigh (ALT) flap is a versatile soft tissue flap. It can be harvested as a fasciocutaneous or myocutaneous flap. Vascularized fascia can be included or the pedicle may be harvested as a flow-through flap. The flap can also be harvested incorporating multiple skin islands or as a chimeric flap incorporating separate skin and muscle components. When a large flap is needed, the entire lateral thigh can be harvested by combining the ALT with either the tensor fascia lata or the anteromedial thigh flap as a conjoined flap. Morbidity is remarkably minimal despite the availability of such generous amounts of tissue. The purported difficulty with the use of this flap is because of the anatomical variations that may render this flap unreliable. This paper clarifies the vascular anatomy of the flap and elaborates an approach to flap harvest that can be used to reliably harvest the flap in spite of the anomalies that may be encountered.

Angio computed tomography preoperative evaluation for anterolateral thigh flap harvesting

The vascular anatomy of the anterolateral thigh flap (ALTF) has many possible variations, and none of the currently used mapping techniques (eg, Echo Color Doppler) gives a thorough knowledge of all details. Among the last generation of angiographic diagnostic techniques, multi detector computed tomography, popularly known as Angio CT, has emerged as an outstanding noninvasive operator independent option, and has been described for deep inferior epigastric perforator and pedicled transverse rectus abdominis muscle planning. This study was conducted to evaluate its usefulness prior to ALTF harvesting.Nine consecutive patients were considered for oral or lower extremity reconstruction with the ALTF. After written informed consent was obtained from all patients, a preoperative Angio-CT study was performed for surgical planning. Accurate identification of septocutaneous or musculocutaneous perforator vessels was achieved and their location, course, and anatomic variations were reported and influenced surgery. Angio CT allows a complete vascular study of the donor area of the ALTF and evaluation of the best perforator vessels before surgery allows surgeons to get an ideal planning of the flap. This imaging method is currently proposed to every patient undergoing ALT flap reconstruction.

Flow-through anterolateral thigh flap for simultaneous soft tissue and long vascular gap reconstruction in extremity injuries: anatomical study and case report

47 dissections of cadaver thigh were studied to investigate pedicle configurations in the lateral descending branch of the lateral circumflex femoral arterial system, which can be used in harvesting a flow-through anterolateral thigh flap. The descending branch arose from the lateral circumflex femoral artery in 38 of the dissections, and the mean diameter at its origin was 3.0mm (range, 2.2-4.0mm). Skin peforators were of the solely musculocutaneous type in 37 dissections and were a combined septo-musculocutaneous type in 10 dissections. Pure septocutaneous perforator was not found in this study. During the descending branch's journey to the distal part of the thigh, several branches went into the vastus lateralis and vastus intermedius muscles. The diameters were tapering and the mean terminal diameter was 1.3mm (range 0.9-1.8mm), which required intraoperative judgment for proper matching of diameter of the flow-through pedicle and the recipient artery. The mean total length of the descending branch from its origin to terminus was 30.3 cm (range 22.5-37.1cm). In four dissections, the descending branch could not be used as a flow-through anterolateral thigh flap because the origin of the perforator arose from the transverse branch. A flow-through anterolateral thigh flap has several advantages, including a large cutaneous area, acceptable donor-site morbidity, adjustable thickness, the ability to combine adjacent muscle or fascia lata and the possibility of simultaneous reconstruction of long arterial gap and soft-tissue defects. Four patients with severe injury and a vascular gap of longer than 10 cm in the extremities were used to confirm the usefulness of this application.

Le lambeau antérolatéral de cuisse: de l’étude anatomique à la technique chirurgicale

Anterolateral thigh flap is a perforator flap, which is vascularised by the descending branch of the lateral circonflex femoral artery. It has been described first by Song in 1984 and is essentially developed in Asia. This flap can be pedicled but it is widely used as a free flap for reconstruction of head and neck defects. Knowing that its vascular anatomy and the variation's origins of the perforators are well documented, our study's objective is to locate the main points of the dissection and its traps, starting from an anatomic study including 15 inferior members. The first constraint is the localisation and the individualisation of intermuscular septum between rectus femoris and vastus lateralis. The perforators of the flap can be septo-cutaneous (14.4%) and then the dissection of the flap is easy but can usually be musculo-cutaneous (86.6%) and the intramuscular dissection in the vastus lateralis represents then the second most difficult period of the intervention. This flap would be frequently used in France thanks to its intrinsic qualities, but due to the difficulty of the dissection of perforators vessels, teams who are intending this operation must make a previous work of anatomic dissection.

Flow-through flaps: A review of current knowledge and a novel classification system

Flaps have long been recognized as an essential tool for soft-tissue reconstruction. Flaps range in complexity from local to free and perforator flaps and can include a variety of composite tissues. The concept of a flow-through flap, in which both the proximal and the distal ends of the vascular pedicle of a free flap are anastamosed to provide blood flow to distal tissues, was first described by Soutar et al. in 1983. An uninterrupted arterial flow was established by Soutar et al. between the external carotid and distal facial artery via a radial forearm flap for head and neck reconstruction (Soutar et al., Br J Plast Surg 1983;36:1-8). Shortly thereafter, Foucher et al. were the first to report the reconstruction of an extremity with a simultaneous vascular defect by utilizing a radial forearm flow-through flap (Foucher et al., Br J Plast Surg 1984;37:139-148). The utility of the flow-through flap is now well established, and its indications for use continue to grow. The principle advantage of this flap is that it provides the opportunity for a single stage composite reconstruction of both soft tissue and vascular defects, making it particularly useful in the reconstruction of ischemic extremities and defects from oncologic ablations. Improvements in microsurgical equipment and techniques are making early difficulties with these flaps irrelevant, giving plastic surgeons opportunities to become more creative in the choices and uses of flow-through flaps. The literature consists mostly of case reports and series. The nomenclature used to describe the types of flow-through flaps is confusing and inconsistent. The purpose of this article is to provide an organized review of flow-through flaps and to classify these flaps based on their inflow, outflow, and the nature of their vascular conduit. Additionally, we have included a discussion on the physiology of these flaps, reviewed the current literature, and summarized the various types of flow-through flaps in a reference guide that can aid in flap selection.

Anatomy of Y-Shaped Configurations in the Subscapular Arterial System and Clinical Application to Harvesting Flow-Through Flaps

BACKGROUND

A flow-through flap is useful in cases where the recipient artery must not be sacrificed. The aim of this study was to investigate Y-shaped configurations in the subscapular arterial system that can safely be used in harvesting a flow-through flap from the scapular region.

METHODS

Sixteen dissections of the subscapular arterial system were carried out in eight embalmed cadavers. The origins and external diameters of branches in the subscapular arterial system were recorded. The distances between the origins of each branch were measured.

RESULTS

The branches that showed a consistent presence and had a reliable diameter of more than 1.0 mm were the circumflex scapular artery, the bony branch of the circumflex scapular artery, the thoracodorsal artery, the angular branch, and branches to the serratus anterior and latissimus dorsi muscles. It was demonstrated that using the Y-shaped configuration between these branches enables the harvesting of a flow-through flap in various length versions of the Y-shaped vascular pedicles. A significant anatomical variation (i.e., both the thoracodorsal and circumflex scapular artery arose directly from the axillary artery) was found in three of 16 dissections. In this vascular variation, sacrificing the axillary artery must be avoided, so Y-shaped pedicles using the origin of the thoracodorsal or circumflex scapular artery cannot be created. On the basis of these results, flow-through flaps using this arterial system were applied in 10 patients for reconstruction of lower extremities, and satisfactory results were obtained.

CONCLUSIONS

The results of our study are available for determining preoperatively and intraoperatively which Y-shaped configuration to use in harvesting a flow-through flap from the scapular region.

Anterolateral thigh flap technique in hand and upper extremity reconstruction

The anterolateral thigh flap is an extremely versatile flap first described in 1984. The flap is based on either a septocutaneous or musculocutaneous perforator of the descending branch of the lateral circumflex femoral system. It can be designed as a skin and subcutaneous flap, fasciocutaneous, or musculocutaneous flap. Furthermore, it can be harvested as a sensate flap by taking the lateral cutaneous nerve of the thigh. Technique for harvesting the flap is described in detail. Complications include flap failure and donor site morbidity. Due to its versatility, the anterolateral thigh flap is particularly useful for upper extremity reconstruction.

Free anteromedial thigh flap: Clinical application and review of literature

The anteromedial thigh (AMT) flap is reviewed in terms of its vascular anatomy and previous clinical reports in the literature. Our own series of 5 patients treated with this flap for defects in the head and neck region and lower extremity is presented. Although several authors controversially discussed vasculature, we constantly found the pedicle as an emerging septocutaneous perforator at a point where the medial border of the rectus femoris muscle is crossed by the sartorius muscle. In all 5 patients, the AMT flap provided stable coverage with no flap loss. Based on our findings, we conclude that the anteromedial thigh flap offers all the advantages of fasciocutaneous flaps. Therefore, we recommend this flap as an alternative for defects requiring coverages of thin to moderate skin thickness. However, it should be remembered that variations in vascular anatomy are possible.

Soft-tissue reconstruction using a free anterolateral thigh flap: experience with 28 patients

The authors present their experience using the free anterolateral thigh fasciocutaneous flap for head and neck and extremity reconstruction. From January 2000 through March 2002, 28 free anterolateral thigh flaps were transferred to reconstruct various soft-tissue defects. All patients were operated by two teams. All flaps were elevated based on one perforator only. The sizes of the flaps ranged from 9 x 11 to 20 x 26 cm. The success rate was 96.5% (27 of 28), with one partial failure. The cutaneous perforators were always found. Septocutaneous perforators were found in 3 of 28 patients (10.7%). Musculocutaneous perforators (89.3%) were found in the remaining patients, and the number of perforators ranged from two to five (average, three perforators). In 4 patients, flaps were used for sensate reconstruction. The authors used the anterolateral thigh flap as a thin flap in 10 patients. Mean follow-up was 13.5 months (range, 2-25 months). Soft-tissue reconstruction with the free anterolateral thigh flap in various regions of the body provides an excellent functional and cosmetic result with minimal donor site morbidity. The anterolateral thigh flap has many advantages over other conventional free flaps and it seems to be an ideal choice for the reconstruction of soft-tissue defects.

Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps

The free anterolateral thigh flap is becoming one of the most preferred options for soft-tissue reconstruction. Between June of 1996 and August of 2000, 672 anterolateral thigh flaps were used in 660 patients at Chang Gung Memorial Hospital. Four hundred eighty-four anterolateral thigh flaps were used for head and neck region recontruction in 475 patients, 58 flaps were used for upper extremity reconstruction in 58 patients, 121 flaps were used for lower extremity reconstruction in 119 patients, and nine flaps were used for trunk reconstruction in nine patients. Of the 672 flaps used in total, a majority (439) were musculocutaneous perforator flaps. Sixty-five were septocutaneous vessel flaps. Of these 504 flaps, 350 were fasciocutaneous and 154 were cutaneous flaps. Of the remaining 168 flaps, 95 were musculocutaneous flaps, 63 were chimeric flaps, and the remaining ten were composite musculocutaneous perforator flaps with the tensor fasciae latae. Total flap failure occurred in 12 patients (1.79 percent of the flaps) and partial failure occurred in 17 patients (2.53 percent of the flaps). Of the 12 flaps that failed completely, five were reconstructed with second anterolateral thigh flaps, four with pedicled flaps, one with a free radial forearm flap, one with skin grafting, and one with primary closure. Of the 17 flaps that failed partially, three were reconstructed with anterolateral thigh flaps, one with a free radial forearm flap, five with pedicled flaps, and eight with primary suture, skin grafting, and conservative methods. In this large series, a consistent anatomy of the main pedicle of the anterolateral thigh flap was observed. In cutaneous and fasciocutaneous flaps, the skin vessels (musculocutaneous perforators or septocutaneous vessels) were found and followed until they reached the main pedicle, regardless of the anatomic position. There were only six cases in this series in which no skin vessels were identified during the harvesting of cutaneous or fasciocutaneous anterolateral thigh flaps. In 87.1 percent of the cutaneous or fasciocutaneous flaps, the skin vessels were found to be musculocutaneous perforators; in 12.9 percent, they were found as septocutaneous vessels. The anterolateral thigh flap is a reliable flap that supplies a large area of skin. This flap can be harvested irrespective of whether the skin vessels are septocutaneous or musculocutaneous. It is a versatile soft-tissue flap in which thickness and volume can be adjusted for the extent of the defect, and it can replace most soft-tissue free flaps in most clinical situations.

Versatility of the free anterolateral thigh flap for reconstruction of soft-tissue defects: review of 140 cases

From August 1995 to June 1999, 140 free anterolateral thigh (ALT) flaps were transferred to reconstruct a variety of soft-tissue defects. The size of ALT flap ranged from 10 to 33 cm in length and 4 to 14 cm in width. Based on the anatomic variations of the perforators, the blood supply to the skin island came from the septocutaneous perforators only in 19 patients (13.6%), arising from the descending or transverse branch of the lateral circumflex femoral artery (LCFA), or originating directly from LCFA. The other flaps were supplied by musculocutaneous perforators that were elevated as a true perforator flap via intramuscular dissection (N = 34, 24.3%), or used a cuff of vastus lateralis muscle for added bulk (N = 87, 62.1%). The overall success rate was 92% (129 of 140). After a 2-year follow-up, all flaps have healed unevenffully and donor thigh morbidity is minimal. Anatomic variations must be considered if the ALT flap is to be used safely and reliably.

Free anterolateral thigh flap for extremity reconstruction: clinical experience and functional assessment of donor site

From August of 1995 through July of 1998, 38 free anterolateral thigh flaps were transferred to reconstruct soft-tissue defects. The overall success rate was 97 percent. Among 38 anterolateral thigh flaps, four were elevated as cutaneous flaps based on the septocutaneous perforators. The other 34 were harvested as myocutaneous flaps including a cuff of vastus lateralis muscle (15 to 40 cm3), either because of bulk requirements (33 cases) or because of the absence of a septocutaneous perforator (one case). However, vastus lateralis muscle is the largest compartment of the quadriceps, which is the prime extensor of the knee. Losing a portion of the vastus lateralis muscle may affect knee stability. Objective functional assessments of the donor sites were performed at least 6 months postoperatively in 20 patients who had a cuff of vastus lateralis muscle incorporated as part of the myocutaneous flap; assessments were made using a kinetic communicator machine. The isometric power test of the ratios of quadriceps muscle at 30 and 60 degrees of flexion between donor and normal thighs revealed no significant difference (p > 0.05). The isokinetic peak torque ratio of the quadriceps and hamstring muscles, including concentric and eccentric contraction tests, showed no significant difference (p > 0.05), except the concentric contraction test of the quadriceps muscle, which revealed mild weakness of the donor thigh (p < 0.05). In summary, the functional impairment of the donor thighs was minimal after free anterolateral thigh myocutaneous flap transfer.

Vaginal reconstruction with the femoral veno-neuroaccompanying artery fasciocutaneous flap

The arterial anatomy of the anteromedial thigh was investigated in ten fresh cadavers that had been systemically injected with a lead oxide-gelatin mixture. The arteries accompanying the great saphenous vein and the anterior cutaneous branches of the femoral nerve were found to have branches not only to the cutaneous vein and nerve, but also to the skin. On the basis of the anatomy of these accompanying arteries, a pedicled fasciocutaneous flap containing them was developed consisting of an adipofascial pedicle and a skin island. This flap has been named the femoral veno-neuroaccompanying artery fasciocutaneous flap (the femoral V-NAF flap, the great saphenous-femoral V-NAF flap) and has been applied in three cases of vaginal reconstruction.

Combined anterior thigh flaps and vascularised fibular graft for reconstruction of massive composite oromandibular defects

Six massive, composite oromandibular defects were reconstructed using combined anterior (anterolateral and anteromedial) thigh flaps and vascularised fibular graft in bridge or chimeric fashion. Except for minor dehiscence in one case and infection in another, all flaps survived without complication. Anterior thigh flaps provide large-calibre, long vascular pedicles while derivative branches from the lateral circumflex femoral system facilitate simultaneous transplantation of multiple components. Because the pedicle of the vascularised fibular graft is of insufficient length, the lateral circumflex femoral vessels provide a remote vascular source as a flow-through vascular conduit. A combined flap using the lateral circumflex femoral system is considered to be most suitable for reconstruction of through-and-through defects of the head and neck. The authors describe the advantages of this method and the detailed anatomy of the cutaneous perforators of the anterior thigh flaps.

Value of routine angiography before traumatic lower-limb reconstruction with microvascular free tissue transplantation

From November 1993 to June 1997, long-bone defects in 40 trauma patients were reconstructed with free osteoseptocutaneous fibula flaps. To determine the necessity of routine angiography in traumatized lower limbs before free flap transplantation, a prospective study was carried out. The study subjects were 34 patients, 25 males and 9 females, with an average age of 40.6 years. Reconstruction was performed primarily for bone defects after Gustillo type III b open fractures in 17 patients and secondarily for malunion and osteomyelitis in 17 patients. Reconstructed bone defects included 25 tibias and 9 femurs. Normal pedal pulses were palpable in 31 patients. Angiographic findings were abnormal in seven patients. In the three patients with abnormal pedal pulses, the particular nonpalpable pulses correlated with the vascular lesions shown in the angiograms (one in the tibial anterior artery and two in the tibial posterior artery). Four patients with either injury of the peroneal artery (three cases) or pseudoaneurysm of the tibial anterior artery (one case) had normal pedal pulses. In all patients, microvascular transplantations were performed successfully. Our study demonstrates the importance of thorough clinical evaluation. Preoperative angiography of the injured lower limbs did not provide relevant additional informations in this series. Familiarity with all available techniques makes it possible to cope with almost any difficult posttraumatic vascular condition. Routine recipient-site angiography before microsurgical reconstruction, therefore, seems unjustified.