Bilateral Anterolateral Thigh Myocutaneous Flaps for Giant Complex Chest Wall Reconstruction

The free vastus lateralis-And conjoined vastus lateralis anterolateral thigh/tensor fascia lata flap for oncological chest wall reconstruction

INTRODUCTION

A reconstructive option for extensive chest wall reconstruction is the free myocutaneous vastus lateralis muscle (VL) flap which can be performed in isolation or in conjunction with a fasciocutaneus anterolateral thigh (cVLALT) and/or myofasciocutaneous tensor fascia lata flap (cVLTFL). We aimed to directly compare the outcomes of these reconstructive options.

METHODS

Patients who underwent oncological chest wall reconstruction with a free VL, cVLALT, or cVLTFL flap between February 2010 and 2022 were included in this retrospective study. Patient demographics, surgical characteristics, as well as medical and reconstructive outcomes, were evaluated. The operative outcomes between myocutaneous VL, cVLALT, and cVLTFL flap reconstructions were compared.

RESULTS

A total of 41 patients underwent chest wall reconstruction with a free myocutaneous VL (n = 25; 61%), cVLALT (n = 14; 34%), or cVLTFL Three acute flap thromboses occurred in the entire cohort (3/41, 7%), with one myocutaneous VL flap failing because of recurrent venous thrombosis during the salvage procedure. Total flap necrosis was seen in two cases (5%; VL flap: n = 1; cVLALT flap: n = 1), and partial flap necrosis in one VL flap (1/25, 4%) and in the distal ALT portion of three cVLALT flaps (3/14, 21%). No significant difference was seen between isolated VL and conjoined VL flaps regarding the partial (p = .28) or total flap necrosis rate (p = .9).

CONCLUSION

The free (conjoined) VL flap provides reliable outcomes for obliterating dead space achieving durable reconstruction of complex chest wall defects.

Postoperative Complications of Flap Procedures in Chest Wall Defect Reconstruction: A Two-Center Experience

Background and Objectives: Chest wall defect reconstruction is a complex procedure aimed at restoring thoracic structural integrity after trauma, tumor removal, or congenital issues. In this study, postoperative complications were investigated to improve the care of patients with these critical conditions. Materials and Methods: A retrospective study of chest wall reconstructions from 2004 to 2023 was conducted at Klinikum Nürnberg and Evangelisches Waldkrankenhaus Spandau-Berlin. Data included patient demographics, comorbidities, defect etiology, surgery details, and complications using the Clavien-Dindo classification. Results: Among the 30 patients included in the study, a total of 35 complications occurred in 35 thoracic wall defect reconstructions. These complications were classified into 22 major and 13 minor cases. Major complications were more common in patients with cancer-related defects, and considerable variations were observed between free flap and pedicled flap surgeries. Notably, the use of the anterolateral thigh (ALT) flap with vastus lateralis muscle demonstrated promise, exhibiting fewer complications in select cases. The reconstruction of chest wall defects is associated with substantial complications regardless of the etiology of the defect and the particular surgical procedure used. Interestingly, there was a lower complication rate with free flap surgery than with pedicled flaps. Conclusions: The ALT flap with vastus lateralis muscle deserves further research in this field of reconstruction. Multidisciplinary approaches and informed patient discussions are crucial in this complex surgical field, emphasizing the need for ongoing research and technique refinement.

Microsurgical reconstruction using thoracoacromial vessels as recipients for complicated chest wall defects

BACKGROUND

Free tissue transfer is often required for the reconstruction of complex and deep anterior chest wall wounds, for which the identification of suitable recipient vessels is crucial. Although the internal mammary arteries (IMAs) are a representative option, identifying secondary options when these vessels are compromised remains a challenge. This report evaluated the efficacy of using the thoracoacromial vessels (TAVs) as recipients for chest wall reconstruction by reviewing our experience.

METHODS

We conducted a retrospective review of patients undergoing free-flap-based chest wall reconstruction using TAVs as recipient vessels from February 2020 to March 2023. Patient demographics and surgery-related characteristics data were collected. The primary outcome of interest was the occurrence of flap perfusion-related complications.

RESULTS

In total, 12 cases utilized TAVs as recipients, primarily for defects following sternotomy, where bilateral IMA was unavailable due to prior surgery. The TAVs with reliable perfusion were consistently identified beneath the pectoralis major muscle. The anterolateral thigh flap was predominantly employed, with musculocutaneous or chimeric flaps introduced for bony defects. The mean pedicle length of the harvested flap was 7.2 cm (range, 3-13), and in cases with a vascular gap, the pedicle was extended using an arteriovenous interposition graft. This resulted in a mean pedicle length needed to reach recipient vessels of 9.9 cm (range, 6.5-19). All flaps survived, with only one experiencing partial necrosis.

CONCLUSIONS

The TAV could be considered as an attractive alternative recipient vessel in microsurgical reconstruction of complicated chest wall defects when the use of IMA is not feasible.

[Application of anterior serratus branch of thoracodorsal vessel in repairing chest wall defect]

OBJECTIVE

To investigate the application of anterior serratus branch of thoracodorsal vessel in repairing chest wall defect.

METHODS

Between October 2018 and March 2021, bilateral free lower abdominal flaps were used to repair large-area complex defects after chest wall tumor surgery in 23 patients. The patients were all female; the age ranged from 23 to 71 years, with an average age of 48.5 years. There were 11 cases of locally advanced breast cancer, 4 cases of phyllodes cell sarcoma, 3 cases of soft tissue sarcoma, 3 cases of recurrence of breast cancer, and 2 case of osteoradionecrosis. The size of secondary chest wall defect after tumor resection and wound debridement ranged from 20 cm×10 cm to 38 cm×14 cm, the size of flap ranged from 25 cm×12 cm to 38 cm×15 cm, the length of vascular pedicle was 9-12 cm (mean, 11.4 cm). Fourteen cases of simple soft tissue defects were repaired by flap transplantation; 5 cases of rib defects (<3 ribs) and soft tissue defects were repaired by simple mesh combined with flap transplantation; and 4 cases of full-thickness chest wall defect with large-scale rib defect (>3 ribs) were repaired by "mesh plus bone cement" rigid internal fixation combined with flap transplantation. The anterior serratus branch of thoracodorsal vessel was selected as the recipient vessel in all cases, the revascularization methods include 3 types: the proximal end of the anterior serratus branch plus other recipient vessels (13 cases), proximal and distal ends of anterior serratus branch (6 cases), and proximal ends of two anterior serratus branches (4 cases).

RESULTS

The main trunk of thoracodorsal vessels was preserved completely in 23 patients. All patients were followed up 10-18 months, with an average of 13.9 months. After operation, the flap survived completely, the shape of reconstructed chest wall was good, the texture was satisfactory, and there was no flap contracture deformation. There was only a linear scar left in the flap donor site, and the abdominal wall function was not significantly affected. There was no tumor recurrence during follow-up.

CONCLUSION

The anterior serratus branch of thoracodorsal vessel has a constant anatomy and causes little damage to the recipient site, so it can provide reliable blood supply for free flap transplantation.

[Application of expanded anterolateral thigh myocutaneous flap in the repair of huge chest wall defect]

OBJECTIVE

To investigate the application of expanded anterolateral thigh myocutaneous flap in the repair of huge chest wall defect.

METHODS

Between August 2018 and December 2020, 12 patients, including 4 males and 8 females, were treated with expanded anterolateral thigh myocutaneous flap to repair huge complex defects after thoracic wall tumor surgery. The age ranged from 28 to 72 years, with an average of 54.9 years. There were 4 cases of phyllodes cell sarcoma, 2 cases of soft tissue sarcoma, 1 case of metastatic chest wall tumor of lung cancer, and 5 cases of breast cancer recurrence. All cases underwent 2-7 tumor resection operations, of which 3 cases had previously received lower abdominal flap transplantation and total flap failure occurred, the other 9 cases were thin and were not suitable to use the abdomen as the flap donor site. After thorough debridement, the area of secondary chest wall defect was 300-600 cm ²; the length of the flap was (24.7±0.7) cm, the width of the skin island was (10.6±0.7) cm, the length of the lateral femoral muscular flap was (26.8±0.5) cm, the width was (15.3±0.6) cm, and the length of the vascular pedicle was (7.9±0.6) cm.

RESULTS

The myocutaneous flaps and the skin grafts on the muscular flaps were all survived in 11 patients, and the wounds in the donor and recipient sites healed by first intention. One male patient had a dehiscence of the chest wall incision, which was further repaired by omentum combined with skin graft. The appearance of the reconstructed chest wall in 12 patients was good, the texture was satisfactory, and there was no skin flap contracture and deformation. Only linear scar was left in the donor site of the flap, and slight hyperplastic scar was left in the skin harvesting site, which had no significant effect on the function of the thigh. All patients were followed up 9-15 months, with an average of 12.6 months. No tumor recurrence was found.

CONCLUSION

The expanded anterolateral thigh myocutaneous flap surgery is easy to operate, the effective repair area is significantly increased, and multiple flap transplantation is avoided. It can be used as a rescue means for the repair of huge chest wall defects.

Intraoperative salvaging of failure to harvest the bi-paddle anterolateral thigh flap: a case series

Background

The size and versatility of anterolateral thigh (ALT) flap enables a bi-paddle flap to cover complex and extensive defects optimally. However, it is characterized by variations in the sources of blood vessels and in the number of perforators, which increases the chances of failure of harvesting a bi-paddle flap. We present our method to overcome such failure. This is the first study exploring the optimal salvaging algorithm to overcome harvesting failure with the bi-paddle ALT flap.

Methods

From January 2014 to December 2020, in 9 patients to be treated with bi-paddle ALT flap for soft-tissue defects (range, 48–288 cm²), there was failure of flap harvest because of perforator variations. We redesigned and converted the flaps to other forms for harvest intraoperatively, based on the characteristics of the defect, and the number and sources of perforators.

Results

Salvage of flap harvest was successfully performed in all 9 cases. In 4 cases the flap with a single perforator was converted to widened-single-perforator flaps; in 2 cases, a single perforator was converted to a de-epithelialized flap; in 2 cases of 2 perforators from different main branches, conversion was to sequential chimeric flaps; in the remaining case of 2 perforators from the descending branch and transverse branch, conversion was to a combined transverse-and-descending branches flap. Venous compromise occurred in only 1 case, and the patient survived after revised surgery. Local infection in the receiving area occurred in 3 cases, and was cured by wound dressing. All flaps survived (follow-up 5–24 months).

Conclusions

Despite preoperative preparation, anatomic variations resulted in failure of bi-paddle ALT flap harvesting. As shown by our results, it is feasible to redesign and convert the bi-paddle flap to other forms based on the defect characteristics, and the number and sources of perforators.