Clinical application of the free thin anterolateral thigh flap in 31 consecutive patients

Clinical outcomes of reconstruction on tissue defects with thin anterolateral thigh flap versus commonly used free soft flaps: A meta-analysis

BACKGROUND

The thin anterolateral thigh flap (tALTF) is gaining attention in reconstructive surgery due to its aesthetic and functional advantages. However, its clinical safety and outcomes compared to other commonly used free soft flaps (CUFSFs) remain unclear.

METHODS

Studies were systematically searched from PubMed, EMBASE, Medline, Cochrane, Web of Science, and China National Knowledge Infrastructure Database up to November 2, 2024. Flap failure, donor and recipient site morbidity, secondary salvage surgery, and patient satisfaction were evaluated.

RESULTS

A total of 416 cases from 7 studies were included in our analysis. No significant difference was observed between the two groups in flap failure and secondary salvage surgery. However, tALTF showed significant advantages over CUFSFs in skin grafting, donor and recipient site morbidity, and patient satisfaction.

CONCLUSION

This meta-analysis highlights the clinical safety and superior outcomes of tALTF compared to CUFSFs in reconstructive surgery, suggesting its viability as a preferred option for surgeons. However, the retrospective design of the included studies and limited sample sizes necessitate further large-scale prospective studies to validate these results.

Facial reconstruction with thinned anterolateral thigh free flap

Facial reconstruction is challenging for plastic surgeons, as it can be difficult to decide the best approach. One technique that has been widely used is the anterolateral thigh (ALT) flap due to its numerous benefits. However, its thickness can be a drawback, especially regarding facial reconstruction. The thinning technique is not a new novel, but how to apply it to the ALT flap to get the best result hasn't been reported yet. Our study involved 117 patients, and we used 73 thinned ALT flaps to determine the best method to increase the flap's safety. After thinning, we significantly reduced the flap's thickness from an average of 22.5 mm to 5.9 mm, making it more suitable for contouring purposes. We apply a thinned ALT flap for coverage, contouring, and recreating the facial 3D structure. The 12/45 flap has the chance to make the multiple-paddle ALT flap, which helps to reconstruct difficult positions even more flexibly. The key to successfully thinning the ALT flap is understanding the perforator's structure and pathway through the fascia. With the thinning technique, we have overcome the limitations of the flap's thickness, making it suitable for use in whole-body reconstruction. The ALT flap can overcome the restriction of its thickness and can be applied even more extensively in whole-body reconstruction.

Reconstructive strategies following surgical resection of malignant sublingual gland tumors: A single institution experience

OBJECTIVE

To investigate the characteristics and treatment modalities of malignant tumors originating from the sublingual gland, as well as evaluate the therapeutic outcomes following free flap reconstruction.

METHODS

A retrospective statistical analysis was conducted on the clinical data of nine patients diagnosed with malignant neoplasms tumor of the sublingual gland.

RESULTS

Nine case of malignant tumors originated from the sublingual glandular tissue, encompassing eight adenoid cystic carcinoma (ACC) and a single case of bipartite differentiated carcinoma-a hybrid of epithelial-myoepithelial carcinoma and adenoid cystic carcinoma. Among the nine patients, four anterolateral thigh flaps were used (three of which were thin flaps), and five forearm flaps were also empoyed. The size of flaps varied, with the lengths ranging from 4 cm to 9 cm, and the widths ranging from 2.5 cm to 6 cm. The vessels chosen for anastomosis were the superior thyroid artery in seven cases, the facial artery in one case, and the lingual artery in one case. Among the eight patients who underwent dissection of cervical lymph nodes, metastasis were found in one case. Two patients underwent adjuvant radiotherapy. Upon postoperative follow-up, there was no recurrence in any of the nine patients .

CONCLUSION

The anterolateral thigh perforator flap thinning technique can be employed for postoperative reconstruction of malignant sublingual gland tumors.

Thin and Thinned Anterolateral Thigh Flaps for Upper Extremity Reconstruction

Upper extremity reconstruction remains challenging due to the high functional and esthetic demands of this location. The anterolateral thigh (ALT) flap is a workhorse flap for microsurgical reconstruction of the upper extremity and can be elevated in various planes depending on desired thickness of the flap. Microsurgical reconstruction of the upper extremity often benefits from a thin flap that can resurface the extremity, which can provide improved functional and esthetic outcomes. This article reviews the anatomy, preoperative planning, and operative technique, as well as presents 4 cases to illustrate the outcomes and benefits of thin and thinned ALT flaps.

Mid-term Clinical Outcome of Microvascular Gracilis Muscle Flaps for Defects of the Hand

PURPOSE

Gracilis muscle flaps are useful to cover defects of the hand. However, there are currently no studies describing outcome measurements after covering soft tissue defects using free flaps in the hand.

AIM

To analyze mid-term results of gracilis muscle flap coverage for defects on the hand, with regard to functional and esthetic integrity.

METHODS

16 patients aged 44.3 (range 20-70) years were re-examined after a mean follow-up of 23.6 (range 2-77) months. Mean defect size was 124 (range 52-300) cm2 located palmar (n = 9), dorsal (n = 6), or radial (n = 1). All flaps were performed as microvascular muscle flaps, covered by split thickness skin graft.

RESULTS

Flaps survived in 15 patients. 6 patients required reoperations. Reasons for revisions were venous anastomosis failure with total flap loss (n = 1) requiring a second gracilis muscle flap; necrosis at the tip of the flap (n = 1) with renewed split thickness skin cover. A surplus of the flap (n = 2) required flap thinning and scar corrections were performed in 2 patients. Mean grip strength was 25% (range 33.3-96.4%) compared to the contralateral side and mean patient-reported satisfaction 1.4 (range 1-3) (1 = excellent; 4 = poor).

CONCLUSIONS

Gracilis muscle flaps showed a survival rate of 94%. Patients showed good clinical outcomes with acceptable wrist movements and grip strength as well as high reported satisfaction rates. Compared to fasciocutaneous free flaps, pliability and thinness especially on the palmar aspect of the hand are advantageous. Hence, covering large defects of the hand with a gracilis muscle flap can be a very satisfactory procedure.

LEVEL OF EVIDENCE

IV observational.

Using Free Chimeric Anterolateral Thigh Flap For Reconstruction Of Composite Dorsal Hand Defect

Background

Simultaneous repair of the extensor tendons and soft tissues in hand injuries remains challenging. The free chimeric anterolateral thigh (ALT) flap with fascia lata (FL) flap represents an alternative for hand reconstruction. This report describes the reconstruction of the extensor tendon and skin defects using free chimeric ALT flaps with FL.

Methods

Eight patients (one female and seven male) underwent reconstruction of complex hand defects with free chimeric ALT and FL flaps. The defects were caused by crushing injuries, burns, snakebite scars, and animal bite wounds. The average skin defect was 116 cm2. Perforators were selected for the skin paddle and the FL flap. The thinning procedure was performed microsurgically.

Results

The skin paddle size ranged from 12 to 23 cm in length and 6 to 11 cm in width, and the FL flaps ranged from 3 × 5 to 12 × 5 cm. The mean pedicle length was 7.88 cm. Nine extensor tendons were repaired with FL flaps. The flap thickness after thinning was only 3-6 mm. The donor site was closed primarily in six patients, and skin grafts were used in two cases. All flaps survived without complications. The follow-up period lasted from 17 to 80 months. Range of motion was achieved with satisfaction.

Conclusion

The chimeric-thinned ALT and FL flap is a valuable material, and it should be considered a reconstructive option for hand soft tissue and extensor tendon reconstruction. This technique allows us to achieve a good appearance and extensor function without donor-site morbidity.

Reconstruction of plantar foot defects with free super-thin anterolateral thigh flap

BACKGROUNDS

In the repair of plantar foot defects, it is important that the reconstructed area is compatible with surrounding tissue while weight-bearing ability continues. In our study, we present long-term results of plantar foot reconstruction with super-thin ALT flaps in patients that required reconstruction with free tissue transfer.

METHODS

We evaluated 11 patients with plantar foot defects that underwent reconstruction with a super-thin ALT flap. Patients were evaluated for postoperative ulceration, ability to wear normal shoes, time to return to work/school, LEFS score and satisfaction with aesthetic results.

RESULTS

No bone defects were observed in the patients included in our study, except for the phalanges and distal metatarsals. Defects with soft tissue loss were reconstructed. The mean flap thickness was 4.9 mm (range 3-6 mm). Follow-up period ranged from 16 to 59 months. One patient required grafting for partial flap necrosis and recovered totally. Another patient required debulking surgery. Two patients had superficial ulceration postoperatively, which responded well to conservative therapy. The mean VAS score for cosmetic satisfaction was 8 of 10 (range, 6-9). Eight patients were satisfied with the flap contour, while three others were fairly satisfied. Mean time to return to work/school after surgery was 2.5 months. The preoperative LEFS score increased from 32.03 ± 15.2 to 58.7 ± 10.6 in the postoperative period, this difference was statistically significant (P<0.01).

CONCLUSION

We consider that the advantageous features of super-thin ALT flaps such as proper tightening, reduced postoperative atrophy, and better contouring features make these flaps suitable for plantar foot defects.

Predictors, management and prognosis of initial hyperemia of free flap

In free flap operation, temporary hyperemia of the transferred flaps can often be encountered in the early postoperative period, appearing reddish and rapid capillary refilling time, which mimics venous congestion. This study aimed to investigate the factors associated with the development of hyperemia and evaluate clinical course. Consecutive patients who underwent free flap-based reconstruction between December 2019 and October 2021 were reviewed. Independent risk factors associated with its development were assessed. Flap showing initial hyperemic features were assessed using flap blood glucose measurement (BGM). If it showed over 60 mg/dL, they were closely observed without management. Their clinical outcomes were evaluated. In total, 204 cases were analyzed, of which 35 (17.2%) showed initial hyperemia. Multivariable analyses showed that using thoracodorsal artery perforator flaps and muscle containing flaps (musculocutaneous/muscle-chimeric flaps) and conducting end-to-end arterial anastomosis (vs. end-to-side) were independent predictors. All cases with initial hyperemia showed over 60 mg/dL in BGM. The phenomenon resolved spontaneously within 6.9 h averagely. Overall perfusion-related complications developed in 10 (4.9%) cases, which rate did not differ between the two groups. Several factors might be associated with the development of initial hyperemia after free flap surgery. With proper assessment, this condition can be successfully managed without unnecessary intervention.

Comparison of The Thickness of Free Anterolateral Thigh Flap in Different Fascial Planes: Clinical Results of Subfascial and Superficial Fat Flap

Background  The anterolateral thigh (ALT) flap is a preferred option in the reconstruction of a wide variety of defects, enabling multiple tissue components and thicknesses. Methods  This study was conducted to investigate the correlation of the thickness of the traditional subfascial ALT flap and superficial fat flap with age, gender, and body mass index (BMI). A total of 42 patients (28 males and 14 females) were included in the study. Results  Mean age was 50.2 (range, 16-75) years and mean BMI was 24.68 ± 4.02 (range, 16.5-34.7) kg/m 2 . The subfascial flap thickness was significantly thinner in male patients (16.07 ± 2.77 mm) than in female patients (24.07 ± 3.93 mm; p  < 0.05), whereas no significant difference was found between male (4.28 ± 1.15 mm) and female patients (4.85 ± 1.09 mm) regarding superficial fat flap thickness ( p  = 0.13). The thickness of both flaps had a positive correlation with BMI, and the strongest correlation was found for subfascial ALT thickness in female patients ( r  = 0.81). Age had no effect on both flap thickness measurements. The anterior thigh is thicker in women than in men, although it varies according to BMI. This shows that flap elevation is important in the superthin plane, especially if a thin flap is desired in female patients in defect reconstruction with the ALT flap. Thus, a single-stage reconstruction is achieved without the need for a defatting procedure after subfascial dissection or a second defatting procedure 3 to 6 months later. Conclusion  The appropriate ALT flap plane should be selected considering the gender and BMI of the patient.

Ultrathin Anterolateral Thigh Free Flap: An Adipocutaneous Flap with the Most Superficial Elevation Plane

BACKGROUND

Although many efforts have been made to create thinner anterolateral thigh (ALT) flaps, their thickness varies among patients, and the flap may be still too thick to match shallow defects. The authors successfully harvested an ALT flap through the most superficial elevation plane, the superficial fat layer, which was useful to match the shallow defects.

METHODS

All patients who underwent ALT free flap reconstruction for upper and lower distal extremity defects were divided retrospectively into groups by ALT flap elevation plane: thin, above the deep fascia; superthin, at the superficial fascia; and ultrathin, through the superficial fat. Preoperative computed tomographic angiography and duplex ultrasonography planning were used for all patients. Anatomical characteristics of donor subcutaneous tissue and surgical details, including flap thickness, flap size, and incidence of flap necrosis were compared among the groups and between sexes.

RESULTS

The average deep and superficial fascial depths were 16.7 and 10.8 mm, 12.5 and 8.2 mm, and 9.1 and 5.6 mm ( P < 0.05), and the average flap thickness was 5.8 mm, 7.9 mm, and 7.8 mm ( P = 0.29) in the ultrathin, superthin, and thin ALT groups, respectively. No significant intergroup differences existed in flap size or complications. The deep and superficial fascia were located significantly deeper in female patients (9.4 and 6.0 mm in male patients and 14.9 and 9.6 mm in female patients, respectively).

CONCLUSIONS

With precise preoperative planning, the most superficially elevated, ultrathin ALT flap can achieve optimal reconstructions of thin body areas. Female patients with thicker thighs and patients with a high body mass index would benefit from this flap.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

The medial sural artery perforator flap for retromolar trigone reconstruction: A multicenter case series

BACKGROUND

Retromolar trigone (RMT) cancer is a rare malignancy, which develops in a narrow area of the oral cavity. Surgical intervention requires wide excision and appropriate reconstruction usually with a free tissue transfer. Little has been published regarding the ideal microvascular reconstruction, mainly focusing on radial forearm and anterolateral thigh free flap. The medial sural artery perforator flap (MSAP) is not new for head and neck reconstruction but its use for RMT reconstruction has not been previously explored. The purpose of the study is to present a multicentric case series investigating the reliability of MSAP flap for RMT reconstruction.

METHODS

The study is designed as a retrospective case series. All patients diagnosed with RMT cancer and undergone surgical resection and immediate reconstruction with a MSAP flap between February 2016 and March 2020 were identified. Patients' demographics and surgical details were collected. Functional results were evaluated using the Head and Neck Module of the European Organization for Research and Treatment of Cancer at 12 months of follow-up. A total of 34 patients with a mean age of 58 years were included in the study. An average defect size of 31.5 cm2 was observed after RMT tumor resection.

RESULTS

The MSAP flaps' average dimensions were 11 ± 3.1 cm in length and 4.7 ± 1.6 cm in width with a mean thickness of 1.4 ± 0.8 cm. No flap complications were observed in 28 cases; four patients developed an orocutaneous fistula. One patient needed surgical revision for venous congestion while only one case of flap failure was observed. At 12 months of follow-up, 87% of the patient cohort had normal, understandable speech. No patient experienced complete loss of swallowing. Results of the H&N35 module showed a significative postoperative improvement in mouth soreness, mouth opening and social (p < .05*). No patient complained difficulty in motility at the donor site.

CONCLUSIONS

The MSAP flap appears to be appropriate for RMT reconstruction and could be considered the workhorse for small to medium size defect of RTM region. It has a long pedicle of matching caliber and provides adequate tissue volume with minimal donor site morbidity.

Reconstruction of Finger Soft Tissue Defects With a Thinned Free Anterolateral Thigh Flap

BACKGROUND

Reconstructing complex soft tissue defects of the finger requires both functional and aesthetic aspects. There are many free tissue transfers as suitable options for digital resurfacing. The anterolateral thigh (ALT) flap is not the first choice for reconstruction of this area because it has the disadvantage that the subcutaneous tissue is too thick; however, its use as a thinned form has yet to be described much. This study presents the flap thinning technique in the small-sized ALT flap for the finger soft tissue defect.

METHOD

From May 2009 to March 2018, 10 patients with complete circumferential or semicircumcision defects in the fingers underwent reconstructive procedures that included thinned ALT flap transfer. Finger soft tissue damage due to contusion trauma includes loss of skin and exposure of the bone and tendon. The flap is thinned in 2 different ways: peripheral thinning and total microsurgical thinning, which is selected based on the perforator vessel structure of the flap.

RESULT

The ALT flap sizes, averaging 4-9 cm wide and 6-12 cm long, were thinned to 4-7 mm. One perforator was included in the flaps with a pedicle length average of 6.1 cm. The flaps survived entirely in all patients except one with a 30% area in the distal part of the thinned ALT flap that became necrotic because of venous occlusion. Donor sites were closed primarily for all patients. No patients required secondary flap defatting.

CONCLUSIONS

The small thinned ALT perforator flap can be an excellent option for full circumferential or semicircumferential soft tissue defects of the finger. Follow-up showed this as an excellent alternative for finger reconstruction in terms of aesthetic appearance and functional outcome.

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.

Free Flap Donor Sites in Head and Neck Reconstruction

Microvascular free tissue transfer, also referred to as free flaps surgery, is a reconstructive technique that has become a foundational component of complex head and neck reconstruction. There have been considerable advancements in the field over the last 30 years including the number and variety of free flaps. Each of these free flaps has unique characteristics that must be considered for the defect when selecting a donor site. Here, the authors focus on the most common free flaps used in head and neck reconstruction.

Trismus surgery and microsurgical reconstruction after oral cancer treatment

INTRODUCTION

Trismus after oral cancer is frequent, with scarce evidence of surgical release treatment in these patients.

OBJECTIVES

The objective of this study is to determine the results of trismus release and free flap reconstruction after oral cancer treatment, establish immediate and long-term results, and detect factors that influence outcome.

MATERIALS AND METHODS

A retrospective study was performed. Preoperative, intraoperative, and follow-up interincisal distances were measured. The intraoperative, long-term gain, and postoperative loss were calculated. Analysis of the long-term results with the preoperative and intraoperative variables was performed.

RESULTS

Surgical release immediately increased the interincisal distance by 29.25 mm. Sixty-six percent of this gain was lost due to trismus recurrence, giving a long-term interincisal gain of 9.90 mm. Worse results were observed in patients with previous high-stage tumors, maxillectomies, skin resections, and previous radiotherapy. The were no significant differences in the results depending on the type of release or reconstruction performed, with the exception of the reconstruction with the sural flap, which presented worse results. Patients with trismus of ≤10 mm could have more range for improvement after this surgery.

CONCLUSIONS

The results of this surgery are moderate in the long term due to high trismus recurrence in spite of aggressive treatment.

Introducing the thin and ultrathin submental artery perforator flaps for precise reconstruction following T1-2 oral cavity cancer resection

We reported a case series of thin (n = 32) and ultrathin (n = 4) submental artery perforator flaps (SMAPF) for precise reconstruction following T1-2 oral cavity cancer resection. The former is indicated for tongue reconstruction involving the tongue tip, and buccal lining replacement involving the mouth corner, while the latter is specifically tailored to restore superficial buccal defects after resection of small early cancer originating from oral submucous fibrosis. All flaps survived. Most flap reconstructions reached satisfactory cosmetic results. Based on this series, we discussed the indications of thin and ultrathin SMAPFs in intaoral reconstruction, and surgical tips for flap thinning.

One-stage reconstruction of the massive overlying skin and Achilles tendon defects using a free chimeric anterolateral thigh flap with fascia lata

BACKGROUND

Treatment for large defects in the non-weight-bearing Achilles tendon and soft tissues remains a reconstructive challenge. The free composite anterolateral thigh flap (ALT) with fascia lata (FL) has been indicated in the single-stage reconstruction of the Achilles tendon and soft tissue defect and this technique remain some disadvantages, such as the inability to perform primary flap thinning, requiring secondary flap thinning, and the delayed normalization of the range of motion of the ankle joint. The free chimeric ALT flap with FL was introduced as a novel alternative with many advantages in reconstructing the Achilles tendon and soft tissue defects. This paper reports the reconstruction of the massive Achilles tendon and overlying skin defects using free chimeric ALT flaps with FL.

METHODS

From June 2017 to October 2020, we performed on a series of 5 patients receiving free chimeric ALT flaps with FL to reconstruct the Achilles tendon and soft tissue defects. The age of patients ranged from 43 to 62 years old. All five patients had full-layer defects of the Achilles tendon with infection. The sizes of the skin defects ranged from 6 × 4 cm to 12 × 10 cm. The perforators from the descending branch of the lateral circumflex femoral arteries are located using a handheld Doppler. The perforators help to design the outline of the ALT flap and fascia flap. The skin flap was thinned under microscopy if the flap was too thick. The anastomosis was accomplished before insetting the flaps into the defect.

RESULTS

The size of the ALT flap ranged from 10 × 5 cm to 15 × 12 cm, and the size of the FL flap ranged from 7 × 4 cm to 10 × 8 cm. The mean perforator length for the skin flap and fascia lata was 3.3 cm (range, 2.5-5.0 cm) and 5.3 cm (range, 3.5-7.0 cm), respectively. Four patients received skin flap thinning up to 57%-79% of the flap thickness, while one patient did not need to debulk. The thickness of the ALT flap ranged from 6 to 13 mm. All the flaps survived completely and postoperative courses were uneventful without any complications. The follow-up time ranged from 12 to 51 months. All patients were able to stand and ambulate, and they were satisfied with the reconstructive results.

CONCLUSIONS

The free thin chimeric ALT with FL flap is appeared to be an appropriate treatment for the massive Achilles tendon and overlying skin defects. This may be a practical approach to improve the functional outcomes of patients with infected massive Achilles tendon and overlying skin defects.

Functional and Aesthetic Outcomes of the Anterolateral Thigh Flap in Reconstruction of Upper Limb Defects: A Systematic Review

Background

Soft tissue coverage in the upper limb after trauma, burn injury, or tumour removal is a commonly addressed problem by the plastic surgeon. The anterolateral thigh flap (ALT) is recognized as a popular free flap option for covering various types of soft tissue defects due to its versatility. We aimed to assess the functional and aesthetic outcomes of the ALT flap for reconstruction of upper limb defects.

Methods

Four electronic databases were searched (MEDLINE (PubMed), Scopus, Web of Science, and Cochrane) from inception to Feb 2021. Two reviewers independently extracted the data and performed risk assessment using the modified Downs and Black (MDB) quality assessment tool and the modified Newcastle Ottawa Scale for case series.

Results

This review included seven studies for quantitative assessment. The eligible studies had 67 patients. Included studies had used a varied number of validated upper extremity functional scoring systems; the most commonly used score was QuickDASH with mean of 21.24, DASH score was 15.5. In regard to aesthetic outcome, an overall satisfactory result was reported. A secondary debulking procedure was performed in 7 patients.

Conclusion

Further studies are recommended to ascertain the functional and aesthetic outcomes of the ALT free flap for upper limb defects, especially using standardized outcome scoring systems. This may be supplemented with a questionnaire that addresses common patient concerns (such as colour, contour, textile and hair growth) for the aesthetic outcome. Nevertheless, based on our review, the ALT flap may be a good reliable reconstructive option for upper limb defects with good functional outcome and satisfactory aesthetic results.

Adipofascial anterolateral thigh free flap in hypopharyngeal and oropharyngeal reconstruction

BACKGROUND

The anterolateral thigh (ALT) flap is a popular choice for head and neck reconstruction surgery, but its ungainly thickness makes it of limited value in some intracavitary reconstructions. The ALT adipofascial flap is an improved flap without skin or muscle. Here, we seek to further illustrate the ALT adipofascial flap as an alternate method of hypopharyngeal and oropharyngeal reconstruction in head and neck.

METHODS

A retrospective review of 9 patients (7 men, 2 women) ranging from 28 to 67 years (mean age, 53.1 years) who underwent reconstruction with the ALT adipofascial flap after hypopharyngeal carcinoma (4 patients) or oropharyngeal carcinoma (5 patients) resections from August 2018 to December 2019 was performed. Surgical outcomes and functional resoration were assessed.

RESULTS

The size of the flaps ranged from 6 × 4 cm² to 6 × 12 cm² . The average flap thickness was 0.14 cm (range, 0.1-0.2 cm) and the average pedicle length was 9.8 cm (range, 7-12 cm). The postoperative course was uneventful in eight patients. Reconstruction was successful in all cases during 7-23 months of follow-up (mean time, 14.3 months). All patients resumed oral feeding for 2-8 weeks (mean time, 4.9 weeks) and the tracheal cannula was successfully removed 0.5-4 months postsurgery (mean time, 2.4 months).

CONCLUSION

The ALT adipofascial flap is a viable choice for hypopharyngeal and oropharyngeal reconstructions and is thinner than the ALT flap. It could be harvested as a single-pedicled double-island flap for complex defect reconstruction.

Imaging for thinned perforator flap harvest: current status and future perspectives

With advances in anatomical knowledge and technology, increased interest has been directed towards reconstruction with enhanced aesthetic and functional outcomes. A myriad of thinned perforator flap harvest approaches have been developed for this purpose; however, concerns about jeopardizing their vascularity remain. To ensure optimum reconstructive outcome without hampering the flap's microcirculation, it is important to make good use of the existing advanced imaging modalities that can provide clear visualization of perforator branches, particularly in the adipose layer, and an accurate assessment of flap perfusion. Therefore, this review will highlight the imaging modalities that have been utilized for harvesting a thinned perforator flap from these two perspectives, along with future insights into creating both functionally and aesthetically satisfying, yet simultaneously safe, thinned perforator flaps for the best reconstructive outcomes for patients.

Super-thin ALT flap elevation using preoperative color doppler ultrasound planning: Identification of horizontally running pathway at the deep adipofascial layers

INTRODUCTION

Presently, super-thin ALT flap, which is elevated above the superficial fascial plane, is gaining popularity. Although there is a huge demand for thin flaps for various types of extremity reconstruction, the technique for ALT flap thinning remains controversial. In this study, we investigated the distance and vector between penetrating points of perforators in deep and superficial fascia using color duplex and clinical measurement to suggest a reliable super-thin flap elevation technique.

MATERIALS AND METHODS

From June 2018 to February 2020, 44 patients with various types of defects who were treated using super-thin ALT flaps were enrolled; 69 surgically detected perforators were analyzed. All patients' flap outcomes and characteristics of the perforators were analyzed. In addition, the effects of patients' body mass index (BMI) and thickness of super-thin flap were evaluated.

RESULTS

The average traveling length of perforator at the deep adipofascial layer (DAL) was 2.43 cm, and the vector of traveling was randomly arranged. The mean thickness of super-thin ALT flap was 6.8 mm. The thickness of super-thin flap was not significantly correlated with patients' BMI (ranged from 17.4 to 34.2 kg/m²; p = 0.183).

CONCLUSION

The novel elevation technique for super-thin ALT might be useful, as evidenced by perforator traveling distance and vector in DAL. Preoperative color duplex ultrasonography is helpful to detect the running course of the perforators during elevating the flap. This anatomic concept must be considered to obtain the reliability of the super-thin ALT flap.

Aesthetic and functional outcomes of thinned anterolateral thigh flap in reconstruction of complex wounds of the upper limb

We studied outcomes of reconstruction of complex upper limb wounds using thinned anterolateral thigh flaps. There were 18 patients with a mean age of 27.5 years. The mean thickness of the flap before and after thinning was 23 mm and 5 mm, respectively. Two patients had partial tip necrosis that was treated conservatively. Aesthetic and functional evaluations were performed using a 5-point Likert scale, QuickDASH score, passive range of motion and power grip at 12 months after surgery. The study showed good results in the aesthetic evaluation by a panel of plastic surgeons (mean score: 19.7) and patient self-assessment (mean score: 18.1). There was a significant correlation between the total scores of the panel and the patients. The mean QuickDASH score was 21, with a high percentage in the middle category 'had a problem but working'. The thinned anterolateral thigh flap is versatile and safe in upper limb reconstruction with good aesthetic and functional results.Level of evidence: 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.

Observation of the Absence of Ulnar Artery in a Patient Planned to Free Dorsoulnar Artery Perforator Flap for Finger Defect: Is Preoperative Doppler evaluation of Perforator Alone Sufficient?

Background Volar finger defects where critical structures exposed are always challenging for plastic surgeons. In these types of defects, local flaps, cross finger flaps, abdominal flaps, and free flaps are used. Free dorsoulnar artery perforator (DUAP) flaps and superficial palmar branch of radial artery (SPBRA) flaps are also used. In this case, we present a patient who was scheduled to receive a DUAP flap to address defect on the second finger of right hand; however, we repaired the defect with a SPBRA flap because intraoperative absence of the ulnar artery was observed.

Materials and Methods A 34-year-old male patient was admitted with a wound that exposed the tendon and neurovascular bundle on the volar side of the second finger of the right hand. A free DUAP flap was planned for the patient. A perforator was detected during the preoperative Doppler ultrasound examination. While dissecting the perforator, we noted the absence of an ulnar artery proximal to the perforator vessel. The elevated SPBRA flap from same extremity and the defect were closed.

Results Postoperative computer tomography showed an absence of the ulnar artery distal to the right antecubital region. No complications were seen in the donor and recipient areas. Long-term motor movements were natural, and the patient's quality of life was good.

Conclusion Determining the perforator site using Doppler alone may not be sufficient in preoperative evaluation of patients scheduled to receive DUAP flaps. Performing an Allen test and using advanced imaging methods can prevent surgeons from encountering a bad surprise.

Reconstruction of firearm and blast injuries in Syrian war refugees

BACKGROUND

War injuries differ from other injuries owing to the large tissue defects they cause and their high risk of contamination. As fragments scattered by high-energy firearms and explosives cause serious composite tissue damage, repair of such injuries is difficult and requires a long treatment period. We discuss the treatment methods used for injured Syrian War refugees admitted to our clinic and present the most effective repair methods for war-related tissue defects for each region of the body.

METHODS

A total of 61 patients treated between June 2012 and April 2015 were retrospectively evaluated in terms of age, gender, duration of hospitalisation, injury site and repair method employed. The patients were grouped by region injured (head/neck, extremities and trunk).

RESULTS

The female-to-male ratio of the patients was 16/45, and their mean age was 25.2 (range, 3-51) years. Twenty-two patients were under the age of 18. The mean duration of hospitalisation was 28.5 days. A total of 130 operations were performed on the patients, including debridement and revisions. Repairs were conducted with free flaps in 17 patients (6 on the head/neck region, 11 on extremities) and with pedicle flaps in 28 patients (11 on the head/neck region, 12 on extremities, 5 on the trunk). Two patients experienced flap loss without other complications, and other patients experienced complications including bleeding, infection, flap detachment, hematoma and seroma.

CONCLUSIONS

War injuries cause tissue damage of a composite and extensive nature. Most affect the extremities, followed by the head/neck and trunk regions. They are primarily sustained by the young population, not usually easy to treat, and require long hospitalisation periods. A variety of methods may be preferred to treat these injuries.

Reconstruction of Soft Tissue Defects in the Hand with a Free Anterolateral Thigh Deep Fascia Flap

OBJECTIVE

To report our experience in the reconstruction of soft tissue defects in the hand with a free anterolateral thigh deep fascia flap and describe the clinical outcomes.

METHODS

This study was a retrospective trial. From November 2016 to January 2020, six patients (four men and two women) with soft tissue defects in the hand were included in this study. The average age of the patients was 33.7 ± 12.7 years (range, 20 to 50 years). All patients underwent reconstructions with free anterolateral thigh deep fascia flaps. Relevant clinical characteristics were recorded prior to surgery. The size and thickness of the deep fascia flap and the thickness of the skin were measured intraoperatively. The survival of the flaps and skin grafts and the occurrence of infection were recorded after the operation. At follow-up, donor site complications and postoperative effects were evaluated according to the outcome satisfaction scale. The pain in the injured hand was assessed using the visual analog scale.

RESULTS

The average body mass index (BMI) was 26.6 ± 1.7 kg/m² (range, 23.9 to 28.7 kg/m² ). The defect sizes ranged from 5 cm × 5 cm to 13 cm × 8 cm (average, 53.1 ± 27.9 cm² ). The six anterolateral thigh deep fascia flaps ranged from 7 cm × 6 cm to 14 cm × 9 cm in size (average, 71.8 ± 29.1 cm² ). The thicknesses of skin ranged from 25 mm to 40 mm (average, 32.5 ± 4.8 mm), and the thicknesses of the deep fascia flaps ranged from 2 mm to 3 mm (average, 2.5 ± 0.5 mm). After the operation, the blood supply of the deep fascia flap was normal in all cases. The second-stage skin grafts of most patients survived completely. The skin graft in one case was partially necrotic and healed after a dressing change. No infection occurred. At follow-up (average, 16.3 ± 6.9 months), there was only a linear scar and no loss of sensation at the donor site of each patient. According to the outcome satisfaction scale, the outcome satisfaction score ranged from 6 to 8 (average, 7.2 ± 0.9), all of which were satisfactory. Apart from one patient who reported mild pain, all the other patients reported no pain. Three typical cases are presented in this article.

CONCLUSIONS

The free anterolateral thigh deep fascia flap, which is suitable for reconstruction of soft tissue defects in the hand, can provide very good outcomes both functionally and aesthetically.

The perforator-centralizing technique for super-thin anterolateral thigh perforator flaps: Minimizing the partial necrosis rate

Background

Despite the wide demand for thin flaps for various types of extremity reconstruction, the thin elevation technique for anterolateral thigh (ALT) flaps is not very popular because of its technical difficulty and safety concerns. This study proposes a novel perforatorcentralizing technique for super-thin ALT flaps and analyzes its effects in comparison with a skewed-perforator group.

Methods

From June 2018 to January 2020, 41 patients who required coverage of various types of defects with a single perforator-based super-thin ALT free flap were enrolled. The incidence of partial necrosis and proportion of the necrotic area were analyzed on postoperative day 20 according to the location of superficial penetrating perforators along the flap. The centralized-perforator group was defined as having a perforator anchored to the middle third of the x- and y-axes of the flap, while the skewed-perforator group was defined as having a perforator anchored outside of the middle third of the x- and y-axes of the flap.

Results

No statistically significant difference in flap thickness and dimension was found between the two groups. The arterial and venous anastomosis patterns of patients in both groups were not significantly different. Only the mean partial necrotic area showed a statistically significant difference between the two groups (centralized-perforator group, 3.4%±2.2%; skewed-perforator group, 15.8%±8.6%; P=0.022).

Conclusions

The present study demonstrated that super-thin ALT perforator flaps can be elevated safely, with minimal partial necrosis, using the perforator-centralizing technique.

Anatomical study and clinical application of medial sural artery perforator flap for oral cavity reconstruction

The present study aims to provide anatomical evidence for clinical application of the medial sural artery perforator (MSAP) flap. The current study investigated the vascular anatomy of the flap, evaluated the postoperative appearance and function of the donor and recipient sites, and investigate the clinical value in reconstruction of oral cavity. Six lower limbs of Chinese adult cadavers were microsurgically dissected. The locations and courses of the medial sural artery perforators were identified and recorded, which provided an anatomical basis for clinical application. Then, 16 clinical cases employing this flap were evaluated, ranging from 3×4cm to 6×8cm, and were employed for defects in the oral cavity region. Sixteen clinical cases with intraoral soft tissue defects, which included four clinical cases with inner cheek defects, were successfully followed up for 10-47 months (24 months on average). The donor site function, contour of recipient site and oral function recovery were evaluated as acceptable or better in cases with intraoral soft tissue defect, which were further verifying the value of clinical application of MSAP in repairing oral cavity defects. Moreover, two typical clinical cases were described in detail. To conclude, the MSAP flap is a favorable choice for small- to medium-size defects based on minor donor site morbidity, satisfactory oral function recovery, perforator stability and adaptation of the pedicle for anastomosis in the oral cavity region.

Peripheral Pruning: A Safe Approach to Thinning Extra-Large Anterolateral Thigh Flaps

BACKGROUND

Thinning of anterolateral thigh (ALT) flaps has been described to achieve optimal contouring. Previous studies caution against thinning large flaps owing to the risk of vascular compromise leading to partial or total flap necrosis. This study aims to demonstrate a reliably safe method for thinning extra-large (>240 cm) flaps.

METHODS

A retrospective review of 53 consecutive ALT flaps performed at a single institution was completed. Of these flaps, 18 (34%) were thinned primarily by sharp excision of sub-Scarpa's fat along the periphery of the flap using loupe magnification. A central cuff of fat is left to surround and protect the perforator.

RESULTS

There were 53 total flaps in our series. Eighteen of the flaps were thinned by peripheral pruning. Eleven (61%) of the flaps reconstructed defects of the lower extremity, whereas 4 (22%) reconstructed upper extremity defects and 3 (17%) reconstructed scalp defects (Table 1). The mean size of the thinned flap group was 35% larger than the nonthinned group (n = 18, 261 cm ± 109 cm vs n = 35, 192 cm ± 146 cm). Ten thinned flaps (55%) were extra large, with flap areas over 240 cm. The average amount of excised fat weighed 41 g ± 18 g. The average body mass index in the thinned flap group was 28.8 kg/m, which is classified as overweight. The average body mass index in the nonthinned flap group was 24.6 kg/m, which is classified as normal weight (Table 2). There were no cases of partial flap necrosis in the thinned flap group. A single case of total flap loss occurred in the thinned flap group secondary to hematoma formation during administration of therapeutic heparin for a mechanical heart valve. There were no other complications in the thinned flap group.

CONCLUSIONS

This is the first study to demonstrate a reliable technique for primary thinning of extra-large ALT flaps in the Western population. No complications related to thinning were observed. Peripheral pruning of sub-Scarpa's fat is a safe and reliable method of thinning extra-large ALT flaps without increasing the risk of flap necrosis.

Thin Perforator Flaps for Reconstruction of the Lower Extremity

Thin flaps, a modification of traditional flaps that minimize the need for debulking and revision, offer unique advantages in the field of lower limb reconstruction. Advances in the field of microsurgery have made this streamlined method of reconstruction a viable solution for soft tissue coverage in patients with both trauma and nonhealing wounds. Better understanding of anatomy has allowed for flap harvest above the fascia level and the Scarpal plane. These modifications allow for flap transfer with thicknesses more comparable to the native anatomy of the lower leg, ankle, and foot. Flap survival is comparable to traditional techniques with greater potential for improved patient-centered outcomes.

[Research progress in thin flap and flap thinning technique]

OBJECTIVE

To review the historical origin and development of thin flap and flap thinning technique.

METHODS

A wide range of domestic and foreign literatures on thin flaps and flap thinning technique were reviewed. The background, definition, methods, problems, challenges, and future development of thin flap and flap thinning technique were summarized and analysed.

RESULTS

Thin flap and flap thinning technique play an important role in the development of flap surgery, leading flap surgery towards a more rational and refined direction.

CONCLUSION

Thin flap and flap thinning technique are still hot topics in the future. With the development of thin flap and flap thinning technique, clinicians will have more "free" choices.

Reconstruction of moderate-sized soft tissue defects in foot and ankle in children: Free deep inferior epigastric artery perforator flap versus circumflex scapular artery perforator flap

BACKGROUND

This retrospective study was conducted to compare the outcomes between the free deep inferior epigastric artery perforator (DIEP) flap and the circumflex scapular artery perforator (CSAP) flap in reconstruction of moderate-sized soft tissue defects in the foot and ankle of pediatric patients.

PATIENTS AND METHODS

From January 2004 to December 2016, 42 patients, ranging from 2 to 13 years old, underwent foot and ankle reconstruction, with a free DIEP flap in 21 cases and a free CSAP flap in the other 21cases.

RESULTS

All the flaps survived. No marked differences were observed in the demographics, flap size, recipient vessels, and overall early or late complication rate (p > 0.05). The CSAP group had a shorter operation time (134.3 ± 25 min vs. 202.4 ± 24.3 min, p < 0.05) and flap harvest time (29.7 ± 8.1 min vs. 52.2 ± 9.8 min, p < 0.05) than the DIEP group had. In long-term follow-up, the CSAP group showed a lower fat hyperplasia rate (14% vs. 52%, p < 0.05) and better cosmetic outcomes than the DIEP group did (p < 0.05). The functional outcomes had no marked differences (p > 0.05).

CONCLUSIONS

The DIEP flap and the CSAP flap are both good options for foot and ankle reconstruction of moderate-sized defects in pediatric patients. The CSAP flap has a shorter operation time and flap harvest time, a lower fat hyperplasia rate, and better long-term cosmetic outcomes than the DIEP flap does.

Anatomical Understanding of Target Subcutaneous Tissue Layer for Thinning Procedures in Thoracodorsal Artery Perforator, Superficial Circumflex Iliac Artery Perforator, and Anterolateral Thigh Perforator Flaps

BACKGROUND

Thinned perforator flaps, reported techniques, and degree of thinning differ by study. This study investigated the anatomy of subcutaneous tissue according to the varying fattiness and identified which component and how much of the subcutaneous tissue layer needed to be excluded to meet target flap thickness using computed tomography.

METHODS

Three stratified fattiness groups consisting of 30 donors were formed for thoracodorsal artery perforator, superficial circumflex iliac artery perforator, and anterolateral thigh flaps. Thickness of the superficial fat and the deep fat layers was measured at specific points in donor sites of the three flaps and the proportion of superficial and deep fat layers to exclude to reach the target flap thickness (4, 6, and 8 mm) was calculated.

RESULT

The median proportion for the superficial fat layer varies depending on donor fattiness. The estimated percentage reduction of thickness after thin flap elevation along superficial fascia was approximately one-third of the whole layer. A variable proportion of each fat layer needs to be excluded to obtain required thinness and in very thick groups, part of the superficial fat layer must be removed to reach any of the target thicknesses for the three flaps.

CONCLUSIONS

The present study demonstrated the frequent need for superficial fat layer manipulation when obtaining a thin perforator flap. To cope with various combinations of donor-site fattiness and different required thicknesses effectively, an appropriate thinning method should have increased adaptability, including the ability to control superficial fat layer thickness.

Simultaneous flap thinning with ultrasound-assisted liposuction during free flap surgery: Preliminary results

BACKGROUND

Ultrasound-assisted liposuction (UAL) has been previously used for postoperative flap thinning. Although it had been reported that UAL causes less damage to the vessels, the simultaneous use of UAL with free flap reconstruction has not been reported. The aim of this report was to determine the results and the complication rates of simultaneous use of UAL with free flap reconstruction.

PATIENTS AND METHODS

Twelve patients who underwent simultaneous flap thinning with UAL during free anterolateral thigh flap surgery between 2014 and 2016 were included in this prospective study. The mean age of the patients was 46.7 (ranging 10-76) years. The mean body mass index of the patients was 26.81 (ranging 25.2-29.8). Flaps were thinned with UAL before harvesting. The mean flap thicknesses were measured using a metal ruler before and after the UAL procedure. Biopsies were performed lateral to the center of the flaps, after completion of the UAL procedure. Vascular and collagen structures were histopathologically examined. The Likert scale, which evaluates the general appearance, shape, color, and texture, was used to assess the aesthetic results of the UAL procedure.

RESULTS

The average flap size was 13 × 9 cm. The mean pedicle length was 8.3 (ranging 7-10) cm. The mean flap thickness was 23 (ranging 19-27) mm and decreased to a mean of 8.1 (ranging 5-11) mm. Wound dehiscence and partial skin necrosis was observed in 2 patients (2/12, 16.66%). None of the patients had total flap necrosis. Vascular and collagen structures of the biopsied samples were normal. Patients were followed for an average of 13 months post UAL. The mean Likert score was 17.1 (ranging 15-19).

CONCLUSIONS

Flap thinning with UAL can be safely performed during the initial free flap reconstruction operation.

Anatomic basis for flap thinning

Flap thinning is a procedure for making a thick flap thinner. This procedure does more than simply fill in the defected area, and it is better for reconstructing the area both functionally and aesthetically. However, because flap thinning is a rather blind procedure, it may have harmful effects on flap vascularity. Therefore, the vasculature of a flap must be understood before performing flap thinning. This paper analyzes the basic anatomy underlying flap thinning based on the previous anatomic study that categorized flaps into 6 types by their vascular structures. This paper also reviews specific studies of frequently practiced flap procedures (deep inferior epigastric artery perforator flap, thoracodorsal artery perforator flap, and anterolateral thigh flap) and presents important precautions for flap thinning procedures. Finally, this paper briefly examines the axiality of the subdermal plexus, which needs to be taken into account when performing flap thinning.

Ablation of Buccal Cancer and Functionality Buccal Reconstruction Using an Individuation Anterolateral Thigh Flap

The complex area for reconstruction of the head and the neck is the buccal because of difficult anatomy of this region. This article aimed to describe our individualized design for the reconstruction of the buccal using an different categories anterolateral thigh (ALT) flap. Ninety-four patients were involved in this study. Among 94cases, the number of using the musculocutaneous ALT flap was 57, using the fasciocutaneous ALT flap was 25, and using the thin ALT flap was 12. Postoperative vessel thrombosis occurred in 8 flaps, and required operative exploration in the perioperative period, 6 flaps were complete survival after the salvages, 2 flap was failure. The ALT flap represents a very good choice for the reconstruction of the complex defects at the cheek level. The flap can replace large volumes of tissues and the skin island is large and can be used both for the tegument reconstruction and for the oral mucosa reconstruction.

Preoperative planning for advanced modelling of anterolateral thigh flaps in the treatment of severe haemifacial atrophy in Parry-Romberg and Goldenhar syndrome

Background

Technological advancement in medical science is constantly innovating solutions to the varied and complex challenges of surgery. Digital diagnostics and prospective microsurgery are rapidly evolving. Three-dimensional (3-D) imagery and computed tomography (CT) scanning can determine accurate dimensions of many defects. Subsequently, a thorough understanding of micro-vasculature and application of microsurgical techniques allows modelling of flaps to obtain an accurate transplant resulting in an aesthetic outcome following the very first operation.

Methods

Two patients with Parry–Romberg syndrome and one patient with haemifacial microsomia (Goldenhar syndrome) were treated with anterolateral thigh (ALT) flaps to restore facial volume, contour, and symmetry. In each case, a different approach in planning and performing the intervention was applied:

The patient in the first case had a full-thickness ALT flap transplant with significant overcorrection.

The patient in the second case had reconstruction with a partially thinned ALT flap guided by a clinically formed template made per manual measurements.

The patient in the third case had reconstruction with a precise primary thinned ALT flap with a template made according to data obtained from superimposed 3-D photographs and CT scans.

Results

All flaps survived. In cases 1 and 2, a corrective intervention was required to achieve acceptable facial symmetry. In case 3, a very good aesthetic result was achieved immediately after the first operation.

Conclusions

Digital methods of 3-D analysis offer great opportunities in creating a precise operative plan, and modern surgical techniques make it feasible to implement it intra-operatively. Overall, these methods shortened the rehabilitation time by avoiding further revision surgeries.

Combined Use of Liposuction and Arthroscopic Shaving for Delayed Debulking of Free Flaps in Head and Neck Reconstruction

BACKGROUND

Bulky appearance after free flap reconstruction in patients with head and neck cancer is common and requires revision to achieve improved final outcomes. Although different delayed debulking methods have been reported, the procedure can be technically difficult in patients with severe scaring after adjuvant radiotherapy. The present study proposes a combined method of liposuction and arthroscopic shaving for delayed contouring of free flaps in head and neck reconstruction.

METHODS

In this study, 12 patients with head and neck cancer who had bulky flaps after cancer ablation surgery and immediate free anterolateral thigh flap reconstruction were included. These patients underwent delayed debulking through the combined arthroscopic shaving and liposuction method at least 3 months after the initial reconstruction or the completion of adjuvant radiotherapy (if required). Age, sex, cancer stages, the presence or absence of adjuvant radiotherapy, the interval between the initial free flap reconstruction and the debulking procedure, complications, and subjective satisfaction ratings were recorded 1 and 6 months after the revision surgery.

RESULTS

All patients were men, with an average age of 56.3 years (43-69 years), and 9 (75%) patients underwent adjuvant radiotherapy. Partial flap loss was not observed in the study patients, and subjective satisfaction ratings improved after the debulking procedure.

CONCLUSIONS

The combined liposuction and arthroscopic shaving method can facilitate the debulking and contouring procedures in patients with head and neck cancer after free flap reconstruction. With appropriate timing, the combined procedure can be simple and safe, even in patients with severe scaring after adjuvant radiotherapy.

Microdissected thin anterolateral thigh perforator flaps with multiple perforators: A series of case reports

INTRODUCTION

The study aimed to explore the effect of microdissected thin anterolateral thigh (MTALT) perforator flap with multiple perforators on patients with complex defects on the hand, elbow, heel, or knee.

METHODS

From March 2012 to February 2013, 5 patients with complex defects on the hand, elbow, heel, or knee were included. During the flap preparation, 2 to 3 perforators penetrating the fascia of the anterolateral femoral area were initially detected, and the deep fascia was incised. The superficial fascia layer of the flap and the deep adipose were then dissected, and removed after verifying the distribution of the blood vessels using an operating microscope. The whole flap was then elevated, and transposed to the recipient areas for microsurgical reparation.

RESULTS

Two cases of post-burn scar contracture and 3 cases of traumatic tissue defects were successfully reconstructed with these multiple-perforator MTALT flaps. No complication was reported, and secondary operative procedure was not needed in any patient in the follow-up.

CONCLUSION

MTALT perforator flap with multiple perforators is safe and reliable for patients with complex defects on the hand, elbow, heel, or knee.

[The sural medial perforator flap: Anatomical bases, surgical technique and indications in head and neck reconstruction]

INTRODUCTION

The medial sural artery perforator (MSAP) flap is defined as a thin cutaneo-adipose perforator flap harvested on the medial aspect of the leg. The aims of this study were to describe the anatomical basis as well as the surgical technique and discuss the indications in head and neck reconstructive surgery.

MATERIAL AND METHODS

We harvested 10 MSAP flap on 5 fresh cadavers. For each case, the number and the location of the perforators were recorded. For each flap, the length of pedicle, the diameter of source vessels and the thickness of the flap were studied. Finally, we performed a clinical application of a MSAP flap.

RESULTS

A total of 23 perforators with a diameter superior than 1mm were dissected on 10 legs. The medial sural artery provided between 1 and 4 musculocutaneous perforators. Perforators were located in average at 10.3cm±2cm from the popliteal fossa and at 3.6cm±1cm from the median line of the calf. The mean pedicle length was 12.1cm±2.5cm. At its origin, the source artery diameter was 1.8mm±0.25mm and source veins diameters were 2.45mm±0.9mm in average. There was no complication in our clinical application.

DISCUSSION

This study confirms the reliability of previous anatomical descriptions of the medial sural artery perforator flap. This flap was reported as thin and particularly adapted for oral cavity reconstruction and for facial or limb resurfacing. Sequelae might be reduced as compared to those of the radial forearm flap with comparable results.

[Repair of the donor defect after wrap-around flap transfer with free thinned innervated anterolateral thigh perforator flap]

Objective

To explore the feasibility of harvesting free thinned innervated anterolateral thigh (ALT) perforator flap for repairing the donor defect after wrap-around flap transfer.

Methods

Between May 2011 and December 2013, free thinned innervated ALT perforator flap was used to repair the donor defects after wrap-around flap transfer in 9 patients. There were 8 males and 1 female, with a mean age of 31.2 years (range, 19-42 years). The interval time between injury and admission was 3-12 hours (mean, 6.5 hours). Injury causes included machine crush injury (4 cases), traffic accident injury (3 cases), and twisting injury (2 cases). The wrap-around flaps were transferred to reconstruct thumb defects. And the size of donor site defect ranged from 3 cm×2 cm to 8 cm×5 cm. A branch of the lateral femoral cutaneous nerve was carried to make innervated ALT perforator flap for donor site repair. The size of innervated ALT perforator flap ranged from 3.0 cm×2.0 cm to 8.5 cm×5.0 cm. The thickness of innervated ALT perforator flap before defatting ranged from 2.0 to 4.5 cm (mean, 3.2 cm); the thickness after defatting ranged from 0.4 to 0.6 cm (mean, 0.5 cm). The defect at the anterolateral thigh was primarily closed in all cases.

Results

All reconstructed thumbs and ALT perforator flaps survived. All patients were followed up 6-30 months (mean, 15.8 months). The ALT perforator flaps had good appearance and color, with no further flap revision or defatting procedures. The static two-point discrimination was 8-15 mm (mean, 10.5 mm). All patients could walk and run normally without postoperative skin erosions or ulcerations.

Conclusion

The free thinned innervated ALT perforator flap is pliable and thin. It is suitable for repairing the donor site defects after wrap-around flap transfer for thumb reconstruction.

Fascial Free Flap for Reconstruction of the Dorsolateral Hand and Digits: The Advantage of a Thin Contour

Background

Fascial free flaps have been widely used for reconstruction of the hand because they are thin. However, studies reporting objective data regarding the advantages of this approach are lacking. Thus, we report our experience with such flaps.

Methods

Forty-five cases of fascial free flaps between November 2006 and March 2014 were reviewed. Nine cases involving reconstructed dorsal or lateral defects were included. Four anterolateral thigh fascial free flaps and 5 lateral arm fascial free flaps were examined. Maximal flap contour was assessed by measuring reconstructed tissue thickness at the central area from the surface of the skin to below the bone in a vertical manner using ultrasonography and X-ray data. Contralateral regions were examined in the same manner and a comparative analysis was performed. A questionnaire survey regarding aesthetic satisfaction was also administered.

Results

All reconstructed parts had a thicker contour than the contralateral side. The average relative percentage of reconstructed tissue thickness was found to be 152% using ultrasonography and 143% using X-ray imaging. According to the aesthetic satisfaction survey, the average rate of satisfaction for patients was 62%, and satisfaction with the flap contour was 72%.

Conclusions

Using a fascial free flap, the reconstructed tissue was approximately 1.5× as thick as the contour of the normal side, which led to positive responses regarding aesthetic satisfaction.

The free medial sural artery perforator flap: Versatile option for soft tissue reconstruction in small-to-moderate size defects of the foot and ankle

BACKGROUND

The medial sural artery perforator (MSAP) flap shows advantages for reconstruction in the foot and ankle, where bulk is a liability. We evaluated the versatility of this flap and provide further evidence on its use for covering small-to-moderate size defects by comparing the outcome depending on the region of reconstruction.

METHODS

Twenty-two patients with variable defects of 4 × 4 to 18 × 7 cm underwent MSAP flap reconstruction. Final outcomes of all patients were evaluated 12-months postoperatively using the AOFAS ankle-hindfoot, midfoot and hallux scale for clinical-functional evaluation, and the SF-36 health survey for quality-of-life measurement. The scores were compared in three groups according to the anatomic region of MSAP flap reconstruction.

RESULTS

The flap size ranged between 6 × 4 and 21 × 9 cm. One venous congestion was salvaged by venous thrombectomy and reanastomosis, and one marginal flap necrosis healed by secondary intention. All flaps survived, and all patients returned to ambulation. Patients with reconstruction of the ankle-hindfoot or hallux showed significantly lower AOFAS ankle-hindfoot (P = 0.021) or hallux scores (P = 0.034), whereas reconstruction of the midfoot led to equal AOFAS midfoot scores (P = 0.265) as compared with patients without reconstruction in the respective region. Comparison of SF-36 physical (P = 0.936) and mental (P = 0.855) scores of all three regions remained insignificant.

CONCLUSION

The MSAP flap provides thin soft tissue coverage, enabling good functional recovery after defect reconstruction all around the foot and ankle, with evident advantages in the midfoot. However, the functional outcomes after reconstruction of the ankle-hindfoot or hallux region depend on the preexistent functional impairment.