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Shih HS, Chiu TH, Jeng SF, Chen J. Split Anterolateral Thigh Flap: A New Classification of Anatomical Variants and a Surgical Planning Algorithm. J Reconstr Microsurg 2024; 40:473-481. [PMID: 38211622 DOI: 10.1055/a-2242-7194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
BACKGROUND Split anterolateral thigh flap is a versatile reconstruction option, yet long underestimated as no practical perforator classification and no optimal strategy were present. Harvesting "capillary nonsizable perforators" could potentially expand flap splits to those with no existing multiple sizable perforators. Concerns over defect characteristics, recipient vessels, pedicle length, and split timing should all be weighted equally in designing the suitable flap. Refinement is thus required to enable precise reconstructions. METHODS All patients undergoing anterolateral thigh flap harvests between 2014 and 2021 performed by a single surgeon were included. The perforator patterns of sizable pedicle, course, origin, and further successful flap-split methods were documented. Surgical outcome of flap survival was analyzed. RESULTS Anatomical variants of 134 (48.4%) dual, 123 (44.4%) single, and 20 (7.2%) no sizable perforators were found in a total of 277 anterolateral thigh flaps. The overall flap survival rate was 97.5%. Flap split was performed in 82 flaps, including 29 single and 5 no sizable perforator cases previously considered "unsplittable," by utilizing a series of direct skin paddle split, capillary nonsizable perforators harvesting, and flow-through anastomosis technique. Comparable flap survivals were found between split and nonsplit flaps as well as between split segments supplied by sizable and capillary nonsizable perforators. Primary closure was achieved in 98.9% of the thigh donor sites. CONCLUSION A new classification of the common anterolateral thigh flap anatomical variants was proposed and a comprehensive algorithm of split flap strategy was developed along with the innovative "fabricate" concept.
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Affiliation(s)
- Hsiang-Shun Shih
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, Kaohsiung City, Taiwan, Republic of China
- College of Medicine, I-Shou University, Kaohsiung City, Taiwan, Republic of China
| | - Ting-Han Chiu
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, Kaohsiung City, Taiwan, Republic of China
| | - Seng-Feng Jeng
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, Kaohsiung City, Taiwan, Republic of China
| | - Jill Chen
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, Kaohsiung City, Taiwan, Republic of China
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Du Q, Liu Y, Zang M, Zhu S, Li S, Chen Z, Han T. Distally Based Anterolateral Thigh Flap Algorithm for Unexpected Situations during Soft-Tissue Defect Reconstruction around the Knee. Plast Reconstr Surg 2024; 153:728-738. [PMID: 37289943 DOI: 10.1097/prs.0000000000010814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND The distally based (d) anterolateral thigh (ALT) flap is an effective option for soft-tissue reconstruction around the knee; however, unexpected situations may occur intraoperatively, impeding flap harvest. The authors proposed an algorithm for surgical conversion for unexpected situations encountered intraoperatively. METHODS Between 2010 and 2021, 61 dALT flap harvests were attempted for soft-tissue defect reconstruction around the knee; 25 patients underwent surgical conversion for anomalies, including lack of a suitable perforator, hypoplasia of the descending branch, and compromised reverse flow from the descending branch. After excluding improper cases, 35 flaps were harvested as planned (group A) and 21 surgical conversion cases (group B) were finally enrolled for analysis. An algorithm was developed based on the cases in group B. Outcomes, including complication and flap loss rates, were compared between groups to verify the algorithm's rationality. RESULTS In group B, the dALT flap was converted to a distally based anteromedial thigh flap ( n = 8), bipedicled dALT flap ( n = 4), distally based rectus femoris muscle flap ( n = 3), free ALT flap ( n = 2), or other locoregional flap that required additional incision ( n = 4). No differences in outcomes were observed between the two groups. CONCLUSION The proposed contingency planning algorithm for dALT flap surgery proved rational, as surgical conversion could be made by means of the same incision in most cases, and outcomes generated by the algorithm were acceptable. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Qingyan Du
- From the Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Yuanbo Liu
- From the Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Mengqing Zang
- From the Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Shan Zhu
- From the Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Shanshan Li
- From the Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Zixiang Chen
- From the Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Tinglu Han
- From the Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
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Zang M, Wang M, Wang D, Du Q, Zhu S, Chen B, Li S, Chen Z, Liu Y. Extensive Defect Reconstruction With Pre-expanded Anterolateral Thigh Flap: Tissue Expansion of the "Outskirts". Ann Plast Surg 2023; 91:459-467. [PMID: 37713151 DOI: 10.1097/sap.0000000000003509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
BACKGROUND Previously reported pre-expansion techniques of the anterolateral thigh flap are mainly perforator-based. The expansion will interfere with the flap harvest if the requisite perforator is found unsuitable as a pedicle. Expansion of the peripheral territories of the flap donor site can minimize the interference from the expansion. METHODS Forty-eight peripheral pre-expansions of the anterolateral thigh flap were retrospectively reviewed in 38 patients from 2012 to 2021. The reconstructive outcomes, including flap success, increase in flap size, donor-site closure, and complications, were assessed. In addition, subgroup analysis was performed based on the expanded territories. RESULTS Rate of successful flap elevation of 100% and flap survival rate of 97.9% were achieved. One patient had total flap necrosis, which was salvaged with skin grafting. Peripheral expansion attained a mean 55.5% ± 19.6% increase in flap width. Primary donor-site closure was accomplished in 95.8% of flaps and fascial restoration in 97.9% of the donor sites. Three patients developed major expansion-related complications, which required surgical intervention. One patient had wound dehiscence in the donor site, which healed by secondary intention. Compared with other subgroups, the lateral-and-medial-side expansion provided a larger flap for reconstruction (P = 0.001). CONCLUSIONS If time is not of the essence, peripheral pre-expansion permits direct donor-site closure with size augment of the anterolateral thigh flap. In addition, it preserves the reliability and versatility of the anterolateral thigh flap.
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Affiliation(s)
- Mengqing Zang
- From the Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Hsiao JC, Zelenski NA, Tseng YJ, Hsu CC, Chen SH, Lin CH, Lin CH. Evaluating Resource Utilization with Free or Pedicled Perforator Flaps in Distal Leg Reconstruction. J Reconstr Microsurg 2022. [DOI: 10.1055/s-0042-1759525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Abstract
Background The decision between local and free tissue coverage for distal lower leg defects has long been dictated by the location and size of defects. Recent reports of distal defects treated successfully with pedicled perforator flaps demonstrate equivalent clinical outcomes; however, the complication rate can be high. The goal of this study was to evaluate the cost equivalence of free versus pedicled perforator flap to assist decision-making and guide clinical care.
Methods The institutional database was searched for patients with acute injury over the distal lower extremity requiring free or pedicled perforator flap. Demographic, clinical, and total resource cost was gathered. Patients were matched to Gustilo–Anderson or Arbeitsgemeinschaft fur Osteosynthesefragen classification as well as size of defect and outcomes, and cost compared.
Results We have included 108 free flaps and 22 pedicled perforator flaps in the study. There was no difference in complication rate between groups. Free flaps had significantly more reoperations, required longer operative time, and had longer intensive care unit (ICU) care with higher cost of surgery and overall cost than pedicled flaps. When controlling for size of defect, surgical cost remained significantly different between groups (p = 0.013), but overall cost did not. Multivariable regression analysis indicated flap type to be the primary driver of cost of surgery, while body mass index elevated the total cost.
Conclusion Pedicled perforator flap coverage for small to medium-sized defects (< 70 cm2) is a viable and cost-effective option for distal lower leg soft tissue reconstruction after acute traumatic injury with similar clinical outcomes and shorter operative duration and ICU stay.
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Affiliation(s)
- Jo-Chun Hsiao
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Nicole A. Zelenski
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
- Department of Orthopedic Surgery, Emory University, Atlanta, Georgia
| | - Yi-Ju Tseng
- Department of Computer Science, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Chung-Chen Hsu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Shih-Heng Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Chih-Hung Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Hung Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
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Yang L, Cheng J, Liu Z, Ju J, Liu S, Li L, Zhang T, Hou R. Morphological study of branches of lateral femoral circumflex artery based on digital subtraction angiography. J Plast Reconstr Aesthet Surg 2022; 80:18-24. [PMID: 36965247 DOI: 10.1016/j.bjps.2022.08.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 03/19/2022] [Accepted: 08/17/2022] [Indexed: 11/06/2022]
Abstract
In this study, the digital subtraction angiography (DSA) data were used to describe the number, course, and distribution of the branches of the lateral circumflex femoral artery (LCFA), in order to provide an imaging basis for the application of the anterolateral thigh flap pedicled with each branch of the LCFA. The number, location, direction, and distribution of the branches of the LCFA were analyzed by selective DSA angiography in 113 patients who needed an anterolateral thigh flap to repair the wound. LCFA usually originates from the deep femoral artery or femoral artery and routinely sends out four main branches: ascending branch, transverse branch, oblique branch, and descending branch. The ascending branch is about 45 °outward and upward with the horizontal axis of the body; the transverse branch is roughly parallel to the horizontal axis of the body to the outside of the thigh or slightly upward or downward; the oblique branch is about 45 °outward and downward to the body's long axis or horizontal axis and gradually turns parallel to the body's long axis; the 5∼10 cm at the beginning of the descending branch is parallel to the long axis of the body, and the internal and external branches are separated near the midpoint of the line between the anterior superior iliac spine and the lateral edge of the patella. It is of high reference value to use DSA technology to analyze the morphological characteristics of LCFA.
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Affiliation(s)
- Lin Yang
- Department of Hand Surgery, Ruihua Affiliated Hospital of Soochow University, No. 5 Tayun Road, Yuexi Town, Wuzhong District, Suzhou 215104, China; Medical College of Soochow University, No. 199, Ren Ai Road, Suzhou, Jiangsu 215123, China
| | - Junnan Cheng
- Department of Hand Surgery, Ruihua Affiliated Hospital of Soochow University, No. 5 Tayun Road, Yuexi Town, Wuzhong District, Suzhou 215104, China; Medical College of Soochow University, No. 199, Ren Ai Road, Suzhou, Jiangsu 215123, China
| | - Zhijin Liu
- Department of Hand Surgery, Ruihua Affiliated Hospital of Soochow University, No. 5 Tayun Road, Yuexi Town, Wuzhong District, Suzhou 215104, China; Medical College of Soochow University, No. 199, Ren Ai Road, Suzhou, Jiangsu 215123, China
| | - Jihui Ju
- Department of Hand Surgery, Ruihua Affiliated Hospital of Soochow University, No. 5 Tayun Road, Yuexi Town, Wuzhong District, Suzhou 215104, China; Medical College of Soochow University, No. 199, Ren Ai Road, Suzhou, Jiangsu 215123, China.
| | - Shengzhe Liu
- Department of Hand Surgery, Ruihua Affiliated Hospital of Soochow University, No. 5 Tayun Road, Yuexi Town, Wuzhong District, Suzhou 215104, China; Medical College of Soochow University, No. 199, Ren Ai Road, Suzhou, Jiangsu 215123, China
| | - Lei Li
- Department of Hand Surgery, Ruihua Affiliated Hospital of Soochow University, No. 5 Tayun Road, Yuexi Town, Wuzhong District, Suzhou 215104, China; Medical College of Soochow University, No. 199, Ren Ai Road, Suzhou, Jiangsu 215123, China
| | - Tao Zhang
- Department of Hand Surgery, Ruihua Affiliated Hospital of Soochow University, No. 5 Tayun Road, Yuexi Town, Wuzhong District, Suzhou 215104, China; Medical College of Soochow University, No. 199, Ren Ai Road, Suzhou, Jiangsu 215123, China
| | - Ruixing Hou
- Department of Hand Surgery, Ruihua Affiliated Hospital of Soochow University, No. 5 Tayun Road, Yuexi Town, Wuzhong District, Suzhou 215104, China; Medical College of Soochow University, No. 199, Ren Ai Road, Suzhou, Jiangsu 215123, China
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Microsurgical Strategies after Free Flap Failure in Soft Tissue Reconstruction of the Lower Extremity: A 17-Year Single-Center Experience. J Pers Med 2022; 12:jpm12101563. [PMID: 36294702 PMCID: PMC9604543 DOI: 10.3390/jpm12101563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/10/2022] [Accepted: 09/19/2022] [Indexed: 11/16/2022] Open
Abstract
Background: There is no clear consensus on the optimal surgical strategy for providing safe coverage in salvage free flap surgery after total free flap failure. Methods: A retrospective study was conducted to evaluate patients with total failure of the primary free flap in lower extremity reconstruction between 2000 and 2017. Results: In a cohort of 1.016 patients, we identified 43 cases of total flap failure (4.2%). A total of 30 patients received a salvage free flap with a success rate of 83.3% (25/30). One patient received a secondary salvage free flap. Overall limb salvage after primary free flap loss was 83.7% (36/43). Conclusions: Microsurgical management of free flap loss in the lower extremity is challenging and requires a decisive re-evaluation of risk factors and alternative strategies. This should include reconsidering the flap choice with a tendency towards traditional and safe workhorse flaps, a low-threshold switch to different recipient vessels, including arteriovenous (AV) loops, bypasses (especially in case of venous insufficiency) and back-up procedures, such as negative pressure wound therapy or dermal regeneration templates with skin grafting in cases of lower demand and critically ill patients. We derived one suggestion from our previous practice: replacing perforator flaps with axial pattern flaps (“safe workhorses”).
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Thomas B, Haug V, Falkner F, Arras C, Nagel SS, Boecker A, Schmidt VJ, Kneser U, Bigdeli AK. A single-center retrospective comparison of Duplex ultrasonography versus audible Doppler regarding anterolateral thigh perforator flap harvest and operative times. Microsurgery 2022; 42:40-49. [PMID: 34165203 DOI: 10.1002/micr.30775] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 03/15/2021] [Accepted: 05/18/2021] [Indexed: 12/21/2022]
Abstract
INTRODUCTION We reported on the superiority of preoperative Duplex mapping ("Duplex") over audible Dopplers ("Doppler") in anterolateral thigh perforator (ALT) free flaps for upper extremity reconstruction. To corroborate our findings on a larger cohort, we conducted this present study focusing on surgical efficiency and patient safety. METHODS 150 consecutive ALT free flaps were divided into 65 cases of preoperative Duplex versus 85 Doppler controls. We first compared patient demographics, operative details, and defect and flap characteristics. We then assessed group differences in the number and course of perforators pursued intraoperatively, flap harvest and operative times, and donor-site complications. Additionally, the impact of the training level of the primary microsurgeon was evaluated. RESULTS Cases and controls were comparable regarding age (p = .48), sex (p = .81), ASA class (p = .48), and BMI (p = .90). Duplex was associated with an increased likelihood of raising flaps on one single dominant perforator of purely septal course and significant reductions of flap harvest (68 ± 10 min, p < .0001) and operative times (74 ± 16 min, p < .0001), regardless of the experience of the primary microsurgeon. There were strong negative linear correlations between preoperative Duplex and both the flap harvest and operative times (p < .0001). Additionally, while there was no effect on the emergency take-back rate (OR = 1.3, p = .60), revisions were significantly less likely among duplexed patients (OR = 0.15, p = .04). CONCLUSIONS Preoperative Duplex is associated with a significant reduction in ALT free flap harvest and overall operative times, as well as donor-site revisions as opposed to Doppler planning, regardless of the training level of the primary microsurgeon.
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Affiliation(s)
- Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Florian Falkner
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Christian Arras
- Department of Regenerative Musculoskeletal Medicine, Institute of Musculoskeletal Medicine, Westfaelische Wilhelms University Muenster, Muenster, Germany
| | - Sarah S Nagel
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Arne Boecker
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Volker J Schmidt
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
- Department of Plastic and Breast Surgery, Zealand University Hospital, Roskilde, Denmark
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Amir K Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
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Sakarya AH, Tsai KY, Hsu CC, Chen SH, Do NK, Anggelia MR, Lin CH, Lin CH. Free tissue transfers for reconstruction of weight-bearing heel defects: Flap selection, ulceration management, and contour revisions. J Plast Reconstr Aesthet Surg 2021; 75:1557-1566. [PMID: 34969626 DOI: 10.1016/j.bjps.2021.11.095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 05/20/2021] [Accepted: 11/15/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Soft tissue defects in the weight-bearing heel represent a reconstructive challenge because of tissue complexity and lack of local/regional coverage. This study presents our reconstruction outcomes of different defect aetiologies, reconstruction timing, and flap selection. METHODS Patients with weight-bearing heel defects who underwent free tissue transfer from 2003 to 2014 and with at least 6 months of follow-up were retrospectively reviewed. Flap types (fasciocutaneous vs muscle/musculocutaneous), timing of reconstruction (early vs subacute vs delayed), and defect aetiology were compared in terms of flap failure, vascular complications, and ulceration. RESULTS Seventy-four flaps were used to reconstruct weight-bearing heel defects in 70 patients. Defect aetiology included trauma in 53 patients (75%), chronic wound in 12 patients (17%), and tumour resection in 6 patients (8%). Flap survival was 97% (72/74). There was no significant difference in flap failures between muscle and fasciocutaneous flaps. The timing of reconstruction showed no difference in flap survival. There was a significant difference in ulceration rate between the trauma and non-trauma groups (p = 0.001). Twenty-eight ulcers (39%) developed, 12 (43%) of which presented 3 years postoperatively, while only 6 cases (21%) presented within one year postoperatively. CONCLUSION Our experience represents one of the highest survival rates reported regarding free flap weight-bearing heel reconstruction. The anterolateral thigh flap was our first choice for extensive heel defects. Ulceration incidence was directly related to trauma and tends to develop 3 years after reconstruction. Delayed reconstruction was at least as safe as early or subacute reconstruction though with less need for debulking.
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Affiliation(s)
- Ahmet H Sakarya
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Kun-Yu Tsai
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Chung-Chen Hsu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Shih-Heng Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Nicholas K Do
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Madonna R Anggelia
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Chih-Hung Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Hung Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan.
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Suh YC, Kim SH, Baek WY, Hong JW, Lee WJ, Jun YJ. Super-thin ALT flap elevation using preoperative color doppler ultrasound planning: Identification of horizontally running pathway at the deep adipofascial layers. J Plast Reconstr Aesthet Surg 2021; 75:665-673. [PMID: 34815192 DOI: 10.1016/j.bjps.2021.09.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Young Chul Suh
- Department of Plastic and Reconstructive Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Shin Hyun Kim
- Department of Plastic and Reconstructive Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Woo Yeol Baek
- Department of Plastic and Reconstructive Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Won Hong
- Department of Plastic and Reconstructive Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Department of Plastic and Reconstructive Surgery, Seoul St. Mary Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Won Jai Lee
- Department of Plastic and Reconstructive Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Joon Jun
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea.
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Hsu CC, Loh CYY, Wei FC. The Anterolateral Thigh Perforator Flap: Its Expanding Role in Lower Extremity Reconstruction. Clin Plast Surg 2021; 48:235-248. [PMID: 33674045 DOI: 10.1016/j.cps.2020.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The anterolateral thigh (ALT) flap is a popular flap for lower extremity reconstruction despite its varied pedicle anatomy. Beyond its use for soft tissue coverage, using the chimeric flap concept, the ALT flap is useful for tendon and ligament reconstruction and the creation of a gliding surface with the fascia lata component. The vastus lateralis muscle can be included for dead-space obliteration. The main pedicle is long and is a similar size match for major artery reconstruction. If several perforators are available, a split flap could be fashioned into a multitude of shapes all arising from the same pedicle.
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Affiliation(s)
- Chung-Chen Hsu
- Department of Plastic and Reconstructive Surgery, Linkou Medical Center, Chang Gung Memorial Hospital, Chang Gung University, 5 Fu-hsing Street, Gueishan, Taoyuan 333, Taiwan, ROC
| | | | - Fu-Chan Wei
- Department of Plastic and Reconstructive Surgery, Linkou Medical Center, Chang Gung Memorial Hospital, Chang Gung University, 5 Fu-hsing Street, Gueishan, Taoyuan 333, Taiwan, ROC.
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Zapata-Ospina A, Chen J, Tee R, Jeng SF, Karki B, Shih HS. Harvesting the anterolateral thigh flap with non-sizable perforators. J Plast Reconstr Aesthet Surg 2020; 74:1022-1030. [PMID: 33551361 DOI: 10.1016/j.bjps.2020.10.063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/30/2020] [Accepted: 10/20/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The anterolateral thigh flap (ALT) has proven over time to be one of the best reconstructive workhorses due to its versatility and reliability. Without preoperative imaging, vascular anomalies such as having no sizable perforator are sometimes encountered during dissection. We propose a technique, based on a modified version of the traditional myocutaneous ALT to allow harvest of the flap based on non-sizable perforators. This technique can also enable the splitting of a flap when only one sizable perforator is present. METHODS A retrospective review of patients who received reconstruction with free ALT flap from 2013 to 2019 by the senior author HSS was performed and included all flaps in which non-sizable perforators were harvested. Data collected for analysis included patient demographics, flap size, defect location, inset type, and flap survival. SURGICAL TECHNIQUE Despite detachment of the majority of skin paddle from the muscle, the flap is harvested with a sleeve of areolar tissue containing preferably more than one non-sizable perforator attached to a small muscular segment of the vastus lateralis containing the pedicle. RESULTS A total of 349 ALT flaps were performed during the review period by senior author HSS, and 25 flaps were harvested with non-sizable perforator, 10 of which were to enable a split. There were no total losses and 6 partial losses; 2 were amenable to direct closure after debridement, 1 required skin graft, and 3 required a new flap for wound coverage. Incorporating more than one non-sizable perforator increases the reliability of the flap. This technique should be used with caution in patients with multiple underlying comorbidities and when a flow-through flap is required. We were able to achieve primary closure of all donor sites. CONCLUSIONS It is possible to harvest the anterolateral thigh flap without sizable perforators by conversion to a modified version of the myocutaneous flap. In well-selected patients, using our technique, several non-sizable perforators can reliably perfuse an ALT without the need to use an alternative donor site. This maximizes the number of harvestable ALTs and increases the reconstructive potential by splitting previously "un-splitable" flaps.
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Affiliation(s)
- Alejandro Zapata-Ospina
- Plastic, Reconstructive and Microsurgery Department, Pablo Tobón Uribe Hospital, Cl. 78b #69-240, Medellín, Antioquia, Colombia
| | - Jill Chen
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, No.1 Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City 82445, Taiwan, R.O.C
| | - Richard Tee
- Auckland Regional Plastic Reconstructive and Hand Surgery Service, Middlemore Hospital, 100 Hospital Road, Auckland, New Zealand
| | - Seng-Feng Jeng
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, No.1 Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City 82445, Taiwan, R.O.C
| | - Bishal Karki
- Department of Burns, Plastic & Reconstructive Surgery, Kirtipur Hospital, Swet Binayak Marg, Thapathali-11, Kathmandu, Nepal
| | - Hsiang-Shun Shih
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, No.1 Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City 82445, Taiwan, R.O.C..
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Kehrer A, Lonic D, Heidekrueger P, Bosselmann T, Taeger CD, Lamby P, Kehrer M, Jung EM, Prantl L, Platz Batista da Silva N. Feasibility study of preoperative microvessel evaluation and characterization in perforator flaps using various modes of color-coded duplex sonography (CCDS). Microsurgery 2020; 40:750-759. [PMID: 32931078 DOI: 10.1002/micr.30648] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 07/14/2020] [Accepted: 08/21/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Color-coded duplex sonography (CCDS) is useful for perforator flap design showing the highest sensitivity in identifying microvessels. This prospective study evaluates the feasibility of different ultrasound (US) modes applied by the microsurgeon in daily practice suggesting quantifiable reference values. METHODS Twenty-four patients aged between 17 and 68 years (mean 43.3 ± 14.2 years) with 18 anterolateral thigh (ALT) and 6 superficial circumflex iliac artery (SCIP) flaps were included. Indications were traumatic (n = 12), infectious (n = 6), ischemic (n = 4), or tumor-associated defects (n = 2). Different US modes were evaluated regarding applicability using multifrequency linear probes (5-15 MHz). Vessels diameter, peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) were measured. Preoperative results were correlated to intraoperative findings. RESULTS In the examined patient group with 24 perforator flaps a 100% correlation was seen when comparing perforators detected with CCDS/PD with intraoperative findings using optimized US settings. Sensitivity, PPV, and accuracy of CCDS were 100% respectively. Mean PSV of 16.99 ± 6.07 cm/s, mean EDV of 5.01 ± 1.84 cm/s and RI of 0.7 ± 0.07 were measured in microvessels (PW-mode). CCDS proved to be superior compared to PD in correct diameter assessment showing a mean diameter of 1.65 ± 0.45 mm, compared to PD-mode 1.31 ± 0.24 mm. Mean PSV and EDV were higher in ALT than in SCIP flaps, RI was slightly higher in SCIP flaps (p > .05). There were no significant differences in size of different flaps' perforators (p > .05). CONCLUSION CCDS represents a highly valuable tool in the daily practice of free flap reconstructions using optimized low flow US settings and multifrequency linear probes.
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Affiliation(s)
- Andreas Kehrer
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Germany
| | - Daniel Lonic
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Germany
| | - Paul Heidekrueger
- Bogenhausen Hospital, Academic Teaching Hospital of Technical University Munich, Department of Plastic, Reconstructive, Hand and Burn Surgery, Germany
| | - Talia Bosselmann
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Germany
| | - Christian D Taeger
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Germany
| | - Philipp Lamby
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Germany
| | - Michael Kehrer
- Department of Trauma Surgery, University Hospital Bonn, Germany
| | | | - Lukas Prantl
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Germany
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13
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Combined anterolateral thigh and tensor fasciae latae flap using intraflap flow-through anastomoses in a case of chest wall reconstruction. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-019-01567-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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14
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Thomas B, Warszawski J, Falkner F, Nagel SS, Schmidt VJ, Kneser U, Bigdeli AK. A comparative study of preoperative
color‐coded
Duplex ultrasonography versus handheld audible Dopplers in
ALT
flap planning. Microsurgery 2020; 40:561-567. [DOI: 10.1002/micr.30599] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 03/03/2020] [Accepted: 04/24/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Benjamin Thomas
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
| | - Jan Warszawski
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
| | - Florian Falkner
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
| | - Sarah S. Nagel
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
| | - Volker J. Schmidt
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
| | - Amir K. Bigdeli
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
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Tzouma G, Kopanakis NA, Tsakotos G, Skandalakis PN, Filippou D. Anatomic Variations of the Deep Femoral Artery and Its Branches: Clinical Implications on Anterolateral Thigh Harvesting. Cureus 2020; 12:e7867. [PMID: 32489722 PMCID: PMC7255544 DOI: 10.7759/cureus.7867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The deep femoral artery (DFA) is the largest branch of the common femoral artery (CFA), supplying with its branches, the medial circumflex femoral artery (MCFA) and lateral circumflex femoral artery (LCFA), the thigh muscles, the hip joint, and the femur. Their anatomical variations have a great impact on both interventional and surgical procedures. The anterolateral thigh (ALT) flap, a versatile soft tissue with highly increasing use in reconstructive surgery, is noticeably influenced by this variability. A total of 25 articles were incorporated into the review. Studies conducted after the year 2009 were included. After the assessment of all studies included, we concluded that the DFΑ arises from the CFA with a varying site of origin, the posterolateral being the prevalent one found in 51.32% of cases. Of all cases studied, the MCFA and the LCFA most often originated from the DFA in 63.125% and 74.92%, respectively, but the CFA constitutes another frequent source of origin in 27% and 12.12% of cases, respectively. The descending branch of the lateral circumflex femoral artery (dLCFA) is the prominent pedicle in the ALT flap, originating from the LCFA in 83.55% of cases. However, the presence of an oblique lateral circumflex femoral artery (oLCFA) branch with changeable origination was observed. Knowledge of the anatomical variants in the deep femoral artery is imperative both for interventional radiologists and surgeons. Especially in reconstructive surgery, the possibility for different sources supplying the skin and the pedicle compel surgeons to acquire an awareness of this subject.
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Affiliation(s)
- Georgia Tzouma
- General Surgery, Metaxa Memorial Cancer Hospital, Piraeus, GRC
| | | | - George Tsakotos
- Anatomy, National and Kapodistrian University of Athens Medical School, Athens, GRC
| | | | - Dimitrios Filippou
- Surgery, National and Kapodistrian University of Athens Medical School, Athens, GRC
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Step-by-step guide to ultrasound-based design of alt flaps by the microsurgeon - Basic and advanced applications and device settings. J Plast Reconstr Aesthet Surg 2019; 73:1081-1090. [PMID: 32249187 DOI: 10.1016/j.bjps.2019.11.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 08/02/2019] [Accepted: 11/22/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The anterolateral thigh (ALT) perforator flap is a popular reconstructive tissue transfer. Consistent with the "hot/cold zone" concept for rapid dissection and thin flap harvest, reliable preoperative perforator mapping is mandatory. Color-coded duplex sonography (CCDS) has been shown to have the highest pooled sensitivity and positive predictive value to identify ALT perforating vessels. By reviewing this guide, the reader should learn: 1. Probe selection and basic/advanced device settings 2. Interpreting tissue morphology 3. Structured mapping approach 4. Pedicle position planning 5. Safe flap design 6. Assess subcutaneous course and flap's thickness for subfascial/epifascial/suprafascial harvest 7. Implement perforators identified into a tailor-made flap design including chimeric flaps. METHODS Experiences with ultrasound-guided flap design gained from 125 ALT perforator flap free tissue transfers performed in two reconstructive centers was the basis of our guide. Our structured method comprises standardized markings, patient positioning, and simple ergonomics. Basic and advanced CCDS settings, selection, and conventional probe guidance are outlined for the microsurgeon. RESULTS Linear multifrequency probes (6-15 MHz) were used. Best preset programs were breast, thyroid, and vascular. Favorable device properties were depth focused to 2-5 cm, pulse repetition frequency (PRF/Scale) set low to 0.5-1.5 kHz/3-10 cm/s, color gain high, and wall filter (WF) low/off (< 50 Hz). Additional parameters were discussed. A 100% concordance rate was seen comparing preoperative perforator visualization with CCDS and intraoperative findings. Detailed picture and video material were demonstrated. CONCLUSION CCDS is a powerful tool for preoperative perforator mapping in perforator flaps such as the ALT.
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Thomas WW, Calcagno HE, Azzi J, Petrisor D, Cave T, Barber B, Miles B, Gomez ED, Cannady S, Bhadkamkar M, Hanasono MM, Wax MK. Incidence of inadequate perforators and salvage options for the anterior lateral thigh free flap. Laryngoscope 2019; 130:343-346. [DOI: 10.1002/lary.28176] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 06/11/2019] [Accepted: 06/18/2019] [Indexed: 11/09/2022]
Affiliation(s)
| | | | - James Azzi
- Oregon Health Sciences University Portland Oregon
| | | | - Taylor Cave
- Oregon Health Sciences University Portland Oregon
| | | | | | - Ernest D. Gomez
- Mount Sinai of the University of Pennsylvania Philadelphia Pennsylvania
| | - Steven Cannady
- Mount Sinai of the University of Pennsylvania Philadelphia Pennsylvania
| | | | | | - Mark K. Wax
- Oregon Health Sciences University Portland Oregon
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18
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Gentileschi S, Albanese R, Servillo M, Pino V, Stefanizzi G, Garganese G, Scambia G, Salgarello M. Pedicled neurocutaneous anterolateral thigh flap for groin reconstruction - A case report. Microsurgery 2019; 39:447-451. [PMID: 30957283 DOI: 10.1002/micr.30454] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/08/2019] [Accepted: 03/22/2019] [Indexed: 11/06/2022]
Abstract
Several different flaps based on the feeding vessels of sensitive nerves have been described in the limbs. This article reports the case of a neurocutaneous flap based on the lateral femoral cutaneous nerve (LFCN), employed for reconstruction of an inguinal defect. A 61-years-old female patient had undergone vulvectomy and bilateral inguinal lymphadenectomy for vulvar cancer with postoperative left groin wound breakdown. After a 3 weeks negative pressure therapy course, she presented a 10 × 4 cm skin and subcutaneous defect with undermined edges in the left inguinal area. Reconstruction with 14 × 6 cm pedicled left anterolateral thigh flap was planned. After the dissection of the vascular pedicle and of the sensitive nerve, complete thrombosis of both the veins and arterial spasm of perforating pedicle was detected. As the flap color was good, and slow marginal bleeding was present, we inspected the small vessels surrounding the nerve that were pulsating. To confirm the vascularization coming from the neural pedicle, we clamped the perforator and performed intraoperative indocyanine green (ICG) fluorescence angiography that showed a good fluorescence of the flap with a proximal to distal pattern of progression. The flap was transferred on the neural pedicle, survived completely, and wounds healed normally. Three months after surgery, the patient underwent radiotherapy, with uneventful course. In her last follow-up, 2 years after surgery, patient was free of disease and the flap showed normal scarring. This is the first case reported of a pedicled neurocutaneous flap based on the LFCN, indicating that in case of unsuitable perforators it could be an alternative pedicle.
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Affiliation(s)
- Stefano Gentileschi
- Dipartimento Scienze della Salute della Donna e del Bambino, Unità di Chirurgia Plastica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Istituto di Clinica Chirurgica, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Roberta Albanese
- Istituto di Clinica Chirurgica, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Maria Servillo
- Istituto di Clinica Chirurgica, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Valentina Pino
- Istituto di Clinica Chirurgica, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Gianluigi Stefanizzi
- Dipartimento Scienze della Salute della Donna e del Bambino, Unità di Chirurgia Plastica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Giorgia Garganese
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Giovanni Scambia
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Marzia Salgarello
- Dipartimento Scienze della Salute della Donna e del Bambino, Unità di Chirurgia Plastica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Istituto di Clinica Chirurgica, Università Cattolica del Sacro Cuore, Roma, Italy
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Lu D, Chan P, Ferris S, Shayan R, Angliss M, Bruscino‐Raiola F. Anatomic symmetry of anterolateral thigh flap perforators: a computed tomography angiographic study. ANZ J Surg 2019; 89:584-588. [DOI: 10.1111/ans.15005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/13/2018] [Accepted: 10/15/2018] [Indexed: 11/26/2022]
Affiliation(s)
- David Lu
- J Anstee Research Group, Department of Plastic, Hand and Faciomaxillary SurgeryAlfred Health Melbourne Victoria Australia
| | - Philip Chan
- Department of RadiologyAlfred Health Melbourne Victoria Australia
| | - Scott Ferris
- J Anstee Research Group, Department of Plastic, Hand and Faciomaxillary SurgeryAlfred Health Melbourne Victoria Australia
| | - Ramin Shayan
- J Anstee Research Group, Department of Plastic, Hand and Faciomaxillary SurgeryAlfred Health Melbourne Victoria Australia
| | - Margaret Angliss
- J Anstee Research Group, Department of Plastic, Hand and Faciomaxillary SurgeryAlfred Health Melbourne Victoria Australia
| | - Frank Bruscino‐Raiola
- J Anstee Research Group, Department of Plastic, Hand and Faciomaxillary SurgeryAlfred Health Melbourne Victoria Australia
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Abstract
The upper limb is involved in burns in a high percentage of cases and its reconstruction is extremely important, given the functional impact of this anatomical region. Among the reconstruction choices for severe and large structural defects, the pedicled anterolateral thigh flap is an available option. This case study discusses the utilization of the pedicled anterolateral thigh flap for reconstruction of a complex full-thickness hand burn, when adequate arterial perforators were not available. Complex hand burns can often present challenges for reconstructive coverage, because of the complex anatomy of the upper extremity and the need to preserve as much function as possible. The use the anterolateral thigh free flap is one option that can be utilized for coverage of these large hand defects, in the face of poor local tissue advancement options. The finding of inadequate or lack of perforator vessels necessitates intraoperative changes in the surgical approach. In these cases, different alternatives exist depending on the dimensions and characteristics of the required coverage, the dissection of a pedicled flap being one of them. The pedicled anterolateral thigh flap represents an alternative for the coverage of large hand defects in the absence of valid perforators during free-flap dissection.
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21
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The anteromedial thigh free flap: a primary reconstructive option or second best? Curr Opin Otolaryngol Head Neck Surg 2018; 26:312-318. [DOI: 10.1097/moo.0000000000000475] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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22
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Gelidan AG. Salvage of planned ALT flap with rectus femoris free flap for pediatric lower extremity reconstruction: A demonstrative case report. Int J Surg Case Rep 2018; 51:67-70. [PMID: 30144713 PMCID: PMC6108076 DOI: 10.1016/j.ijscr.2018.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 08/02/2018] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Free tissue transfer in children represents a good option for reconstruction in skilled hands despite the technical difficulties, and represent a significant challenge in microsurgery. With Anteriorlateral thigh flap is a popular option even in pediatric age group. PRESENTATION OF CASE We report here a case of 9 year old girl that sustained a lower extremity trauma with exposed ankle joint secondary to Motor Vehicle Crash, That was planned for (ALT) Anterior Lateral Thigh flap reconstruction, and was not completed and salvaged by rectus femoris flap as an alternative option on table to complete the reconstruction. DISCUSSION Such case was successfully reconstructed by rectus femoris muscle free flap when ALT (Anterior lateral thigh) flap could not be completed as planned although it's the workhorse flap in majority of cases, due to absence of perforator utilizing the same vascular anatomical blood supply with no significant donor site morbidity. CONCLUSION Based on this case report the rectus femoris flap was successfully performed, and we believe it's an effective and reliable backup option to reconstruct complex lower extremity wound even in pediatric age group.
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Affiliation(s)
- Adnan G Gelidan
- The Division of Plastic Surgery, King Saud University, P.O. Box 7805, Riyadh, 11462, Saudi Arabia.
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23
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Zhu S, Zang M, Yu S, Xu B, Liu Y. Distally based anteromedial thigh flaps pedicled on the rectus femoris branch of the lateral circumflex femoral artery for reconstruction of soft-tissue defect of the knee. J Plast Reconstr Aesthet Surg 2018; 71:743-749. [PMID: 29428585 DOI: 10.1016/j.bjps.2018.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 12/05/2017] [Accepted: 01/21/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Anteromedial thigh flaps are far less clinically appealing than their anterolateral counterparts, and are occasionally considered as an alternative to the anterolateral thigh flap. Herein, we report the study of soft-tissue defects reconstruction in the knee using a distally based anteromedial thigh flap pedicled on the rectus femoris branch of the descending branch of the lateral circumflex femoral artery. PATIENTS AND METHODS Between July 2008 and September 2016, a distally based anteromedial thigh flap was used to reconstruct soft-tissue defects of the knee in 5 patients (3 males, 2 females; age range at surgery 4-55 years old). The perforating vessels supplying anteromedial thigh were derived from the rectus femoris branch of the lateral circumflex femoral artery. The rectus femoris branch shared a common trunk with the descending branches of the lateral circumflex femoral artery. Defect etiologies included malignant neoplasms in 2 cases and post-burn scar contracture in the remaining 3 cases. RESULTS The average flap size was 19.6 × 9.2 cm (range: 15-24 × 6-12 cm). There was no flap loss. Postoperative muscle weakness occurred in one case. The average follow-up time was 17.8 months (range: 5-36 months). No recurrence of tumor or scar contracture was noted. CONCLUSIONS Distally based anteromedial thigh flaps pedicled on the rectus femoris branch of the descending branch of the lateral circumflex femoral artery may serve as an alternative option to the distally based anterolateral thigh flap for soft-tissue defect reconstruction of the knee.
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Affiliation(s)
- Shan Zhu
- Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 33 Ba-Da-Chu Road, Beijing, 100144, China
| | - Mengqing Zang
- Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 33 Ba-Da-Chu Road, Beijing, 100144, China
| | - Shengji Yu
- Cancer Institute and Hospital, Chinese Academy of Medical Sciences, 17 Panjiayuan Nanli, Beijing, 100021, China
| | - Boyang Xu
- Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 33 Ba-Da-Chu Road, Beijing, 100144, China
| | - Yuanbo Liu
- Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 33 Ba-Da-Chu Road, Beijing, 100144, China.
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25
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26
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Perforator variability in the anterolateral thigh free flap: a systematic review. Surg Radiol Anat 2017; 39:779-789. [DOI: 10.1007/s00276-016-1802-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 11/17/2016] [Indexed: 11/25/2022]
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27
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Lóderer Z, Janovszky Á, Lázár P, Piffkó J. Surgical Management of Progressive Hemifacial Atrophy With De-Epithelialized Profunda Artery Perforator Flap: A Case Report. J Oral Maxillofac Surg 2016; 75:596-602. [PMID: 27883877 DOI: 10.1016/j.joms.2016.10.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 10/04/2016] [Accepted: 10/10/2016] [Indexed: 10/20/2022]
Abstract
Progressive hemifacial atrophy (PHA) is a rare disorder characterized by slow, unilateral atrophy of the soft tissues and bones of the craniofacial region. The defect becomes more pronounced with age, leading to esthetic and functional deficits. However, the proper timing and method of surgical reconstruction are still debated. The correction of this defect markedly influencing the quality of life of the patient can be achieved with less invasive to more invasive surgical approaches. A 21-year-old female patient with hemifacial atrophy and extensive alopecia presented to our clinic. Considering the body type and the expectations of the patient, a profunda artery perforator flap was applied for the reconstruction and esthetic improvement of the facial region. The facial asymmetry attenuated after the reconvalescence period. This case shows that in the up-to-date surgical treatment of severe PHA, the use of microvascular free flaps may provide a better approach when trying to achieve an acceptable esthetic result. This is the first time that a profunda artery perforator flap was used to restore facial asymmetry caused by PHA.
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Affiliation(s)
- Zoltán Lóderer
- Plastic Surgeon, Department of Oral and Maxillofacial Surgery, University of Szeged, Szeged, Hungary
| | - Ágnes Janovszky
- Resident, Department of Oral and Maxillofacial Surgery, University of Szeged, Szeged, Hungary.
| | - Péter Lázár
- Resident, Department of Oral and Maxillofacial Surgery, University of Szeged, Szeged, Hungary
| | - József Piffkó
- Professor and Head of Department, Department of Oral and Maxillofacial Surgery, University of Szeged, Szeged, Hungary
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Effect of Atherosclerosis on the Lateral Circumflex Femoral Artery and Its Descending Branch: Comparative Study to Nonatherosclerotic Risk. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 4:e856. [PMID: 27757321 PMCID: PMC5054987 DOI: 10.1097/gox.0000000000000849] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 06/17/2016] [Indexed: 02/06/2023]
Abstract
The anterolateral thigh (ALT) flap has been widely used for reconstructions. Nevertheless, the atherosclerotic risk factors that affect the lateral circumflex femoral artery (LCFA) are still inconclusive. The aim was to study the effect of atherosclerosis on the LCFA and descending branch (dLCFA) visualized by computer tomographic angiography (CTA) between nonatherosclerosis and atherosclerosis.
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Cho A, Hall FT. Review of perforator flaps in head and neck cancer surgery. Curr Opin Otolaryngol Head Neck Surg 2016; 24:440-6. [PMID: 27471790 DOI: 10.1097/moo.0000000000000293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Perforator flaps are increasingly being used to reconstruct head and neck defects. They offer several advantages over nonperforator-based flaps with lower donor site morbidity and a versatile range of reconstructive options. The anterolateral thigh flap is well established in the head and neck and is a good example of a reliable perforator free flap. With the increasing use of both free and regional perforator-based flaps, it is timely to review their anatomy, clinical applications, and role in head and neck reconstruction. We also discuss increasingly popular perforator flaps such as the submental flap for the head and neck. RECENT FINDINGS The anterolateral thigh flap is now commonly used to reconstruct a wide variety of head and neck defects. The submental flap fills a niche role for reconstruction of intraoral defects. SUMMARY Perforator flaps are now mainstream reconstructive options in the head and neck surgeon's armamentarium.
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In-Flap Anastomosis as Back-Up Option for Anterolateral Thigh Flaps Lacking Suitable Perforators. Plast Reconstr Surg 2015; 137:250e-251e. [PMID: 26397798 DOI: 10.1097/prs.0000000000001915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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