The Distribution of the Perforators in the Anterolateral Thigh and the Utility of Multidetector Row Computed Tomography Angiography in Preoperative Planning

Surface to Perforator Index: Assessing the Importance of the Number of Perforators in Successful Harvesting of the Anterolateral Thigh Flap

BACKGROUND

 The use of perforator flaps has become more popular with improvement of surgical technique, technology, as well as understanding of microvascular anatomy. The selection of well-perfused angiosomes is critical to the successful outcome of patients undergoing free tissue transfer. The number of perforators that are needed is dependent upon the surface area of the flap being harvested; however, there have been no studies to assess the optimal surface area supplied by each perforator. We hypothesized that the smaller the surface area supplied by each perforator correlated with fewer flap-related complications in the harvesting of the anterolateral thigh (ALT) flap.

METHODS

 All ALT flaps harvested from 2015 to 2021 at our institution were retrospectively reviewed. The surface area of the flap harvested was calculated as A = πab, where a is the long radius and b is the short radius of the ellipse. The surface-perforator index (SPI) was calculated for each flap by dividing the surface area of the ALT flap by the number of perforators supplying the flap. Our primary outcomes were flap-related complications that included: partial flap loss, dehiscence, and venous congestion.

RESULTS

 A total of 106 patients were identified. Twenty-four patients (22.6%) developed perforator-related complications. An increasing SPI and SPI to body surface area were strongly associated with development of complications (adjusted odds ratio [95% confidence interval], adjusted p: 1.02 [1.01, 1.03], < 0.001and 1.23 [1.12, 1.42], p < 0.001). An SPI of greater than 150 cm2/perforator was associated with a higher probability of complications (p < 0.001).

CONCLUSION

 Flap-related complications are significantly related to the number of perforators supplying the flap. The smaller the surface area supplied by a single perforator correlates with significantly fewer flap-related complications. SPI is a new index that may be used as a predictive tool to aid in identifying flaps that may be more prone to complications in free tissue transfer.

[Choice of flaps for phalloplasty: what is the contemporary standard? Consensus Statement of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels]

The ever-expanding number of transmen as well as their surgeons share an increasing interest in the construction of a neophallus. While the indication for surgery and the positive effect of a phalloplasty on the quality of life, mental health and sexual function has already been thoroughly analysed, there is a lack of data comparing and evaluating the surgical steps. During the consensus conference on the "choice of flaps for phalloplasty" at the annual meeting of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels, the current literature was discussed and a consensus on the surgical technique of a phalloplasty was reached. This manuscript publishes jointly developed recommendations on the following topics: choice of flaps for phalloplasty, preoperative diagnostic tests before phalloplasty, urethral construction in the radial forearm flap and anterior lateral thigh flap, preformation of the urethra at the forearm or thigh, venous drainage of the radial forearm flap, innervation of the phallus, staged phalloplasty, coronaplasty and managing the donor site of a radial forearm flap.

Improving the visualisation of perforator arteries for anterolateral thigh flaps harvest in CT angiography via sublingual glyceryl trinitrate

AIM

To investigate the improvement of image quality and visualisation of the anterolateral thigh (ALT) flap perforators on computed tomography angiography (CTA) after administration of sublingual glyceryl trinitrate (GTN).

MATERIALS AND METHODS

Sixty patients with oral lesions received thigh CTA examinations were divided randomly into two groups after administration of sublingual GTN (GTN group) or without administration of sublingual GTN (non-GTN group). Two radiologists calculated the signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and assessed the image quality of each vessel. Besides, the grade of thigh artery, the lumen diameter of deep femoral artery, lateral circumflex femoral artery (LCFA), the descending branch of LCFA and its proximal and distal perforators, and the number and type of visible perforators were evaluated quantitatively.

RESULTS

The SNR and CNR were not significantly different between the two groups (p>0.05). The image quality of CTA in the GTN group was significantly better than that in the non-GTN group (p<0.01). The lumen diameters of the deep femoral artery, LCFA, the descending branch of LCFA and its perforators were significantly larger in the GTN group than those in the non-GTN group (p<0.01). Compared with the non-GTN group, the number of visible perforators and the number of visible septocutaneous perforators were significantly more in the GTN group, and the qualitative grade of visible perforators was significantly higher (p<0.001).

CONCLUSIONS

The administration of sublingual GTN in preoperative thigh CTA can improve the image quality and visualisation of perforator vessels, thus could help surgeons to select the optimum ALT flaps.

Perforators Detected in Computed Tomography Angiography for Anterolateral Thigh Free Flap: Am I the Only One Who Feels Inaccurate?

BACKGROUND

The number, location, and pattern of perforators in anterolateral thigh(ALT) flap vary and predicting them preoperatively will aid in reconstructing complex head and neck defects. This article suggests guidelines for utilizing CTA imagery to predict perforators of ALT-free flaps.

METHODS

We retrospectively analyzed 53 Korean patients who underwent reconstruction with ALT flap in our department from March 2021 to July 2022. The location, course, origin, and pedicle lengths predicted in CTA and confirmed in the operation field were recorded and compared.

RESULTS

Among the 85 intraoperatively-found perforators, 79 were also identified in CTA. Six perforators unidentified in CTA were newly found intraoperatively. The positive predictive value of CTA for the perforator was 100%, with a sensitivity of 79/85 = 92.9%. Of the 79 perforators depicted by the CTA for the flap, CTA and intraoperative findings for the course were consistent in 52 cases, a 9.6 mm median discrepancy being noted between the actual location and CTA.

CONCLUSIONS

The overall pattern or location of perforation was not significantly different between the two, although some differences were observed. It is suggested that the addition of Doppler imaging, in conjunction with CTA, can aid in perforator detection and help minimize such discrepancies.

Limitations of Computed Tomography Angiography in Preoperative Planning of Peroneus Brevis Rotational Flap

The distally based peroneus brevis (PB) rotational flap has been shown to be a reliable method of coverage of distal third tibial wounds. The flap is perfused via retrograde flow from distal PB perforators located within 8 cm of the lateral malleolus. The ability to assess patency of these vessels preoperatively facilitates surgical planning, and computed tomography angiography (CTA) has been used for perforator assessment of other lower extremity flaps. The purpose of the present study is to establish the potential utility of standard CTA for locating distal PB perforators by examining uninjured lower extremities.

Methods

Twenty-five patients who underwent bilateral lower extremity CTAs using standard lower extremity protocol were retrospectively identified. Axial two-dimensional images were scanned craniocaudally using our institution's standard CT image viewing software, Merge Radsuite (Merge Healthcare, Hartland, Wis.).

Results

The average location of distal-most PB perforators identified on CT angiogram was 13.1 ± 5.1 cm proximal to the distal fibula, or 34.5% ± 13.5% of total fibular length. Standard CTA was only able to locate a pedicle within 8 cm of the lateral malleolus (20.9% of fibular length) in three of 25 patients (12%).

Conclusions

Previous studies have described a reliable pedicle within 8 cm of the distal fibular tip upon which to design a distally based PB rotational flap. The absence of such perforators in the CT angiogram suggests that standard CT angiogram is not a reliable technique for identifying the patency of such perforators when evaluating the utility of a distally based PB flap.

A novel computed tomography angiography technique: guided preoperative localization and design of anterolateral thigh perforator flap

BACKGROUND

Anterolateral thigh perforator (ALTP) flap is considered a versatile flap for soft tissue reconstruction. Computed tomography angiography (CTA) is used for mapping perforator in abdominal-based reconstruction; however, it is less commonly used in ALTP due to its poor imaging efficacy. In this study, we introduced a novel CTA technique for preoperative localization and design of ALTP flap and evaluated its value in directing surgical reconstruction.

RESULTS

Thirty-five patients with soft tissue defects were consecutively enrolled. Modified CTA procedures, such as sharp convolution kernel, ADMIRE iterative reconstruction, 80 kV tube voltage, high flow contrast agent and cinematic rendering image reconstruction, were used to map ALTPs. A total of 287 perforators (including 884 sub-branches) were determined, with a mean of 5 perforators per thigh (range 2-11). The ALTPs were mainly concentrated in the "hot zone" (42%, 121/287) or the distal zone (41%, 118/287). Most perforators originated from the descending branch of the lateral circumflex femoral artery (76%, 219/287). Three perforator types, namely musculocutaneous (62%, 177/287), septocutaneous (33%, 96/287), and mixed pattern (5%, 14/287), were identified. The median pedicle length measured by two methods was 4.1 cm (range 0.7-20.3 cm) and 17.0 cm (range 4.7-33.9 cm), respectively, and the median diameter of the skin flap nourished by one perforator was 3.4 cm (IQR 2.1-5.7 cm). Twenty-eight ALTP flaps were obtained with the guidance of CTA, and 26 flaps survived after follow-up.

CONCLUSIONS

The proposed CTA mapping technique is a useful tool for preoperative localization and design of ALTP flap.

Using Duplex Ultrasound for Recipient Vessel Selection

INTRODUCTION

 Among the many factors involved in reconstructive microsurgery, identifying a good recipient vessel is one of the key elements leading to a successful result.

MATERIAL AND METHOD

 Multiple modalities have been used to identify recipient vessels from simple palpation of axial arteries to hand-held Doppler, duplex ultrasound, computed tomography angiograms, and other advanced techniques. Although these various modalities bring their own unique advantages, using the duplex ultrasound can provide far superior and real-time information based on the anatomy and physiology of the recipient vessel.

RESULT

 Duplex ultrasound is a valuable and powerful tool for reconstructive surgeons who are interested in performing microsurgery or supermicrosurgery.

CONCLUSION

 As we enter the era of individualized/customized reconstruction using superthin flaps, perforator-to-perforator anastomosis, and supermicrosurgery, understanding and becoming versatile with duplex ultrasound will be critical especially in choosing recipient vessels.

Preoperative Computed Tomography Angiography for ALT Flaps Optimizes Design and Reduces Operative Time

BACKGROUND

 Computed tomography angiography (CTA) has been widely used for perforator mapping in abdominal-based reconstruction, but it is less widespread in the anterolateral thigh (ALT) flap. However, CTA may be quite useful for ALT planning, as this flap has demonstrated substantial variability in intrapatient bilateral vascular anatomy. This study investigated whether standard use of preoperative CTA resulted in selection of the donor extremity with preferential perforator anatomy, and whether this affected operative time and postoperative outcomes.

METHODS

 A retrospective review of 105 patients who underwent proposed ALT flap reconstruction was performed. Seventy-nine patients received bilateral lower extremity CTAs, which were evaluated for dominant perforator anatomy (septocutaneous, musculoseptocutaneous, or musculocutaneous). Donor extremity selection was noted, and predicted perforator anatomy was compared with that encountered intraoperatively.

RESULTS

 Among the 73 patients who received bilateral imaging and ultimately received an ALT, congruent findings between imaging and surgical exploration were observed in 51 (69.8%) patients. Thirty (37.9%) patients had asymmetric perforator anatomy between their bilateral extremities on imaging. Among these, the leg with optimal perforator anatomy was selected in 70% of cases. There were no significant reductions among postoperative complication rates, but selection of the donor site with preferential anatomy was associated with a decrease in operative time (p = 0.049) among patients undergoing extremity reconstruction.

CONCLUSION

 CTA is a useful tool for optimizing donor site selection for ALT flaps and reducing operative time. We believe that standard use of preoperative CTA in ALTs warrants further consideration.

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.

Anterolateral Thigh Flap Design by Using Suprafascial Course of the Perforator

OBJECTIVES

Recently, anterolateral thigh flap has become one of the most commonly used free flaps in reconstructive surgery. Although its pedicle has relatively sufficient length, it falls short in some circumstances. Eccentric perforator location can be used to lengthen the pedicle, but flap tip viability can be a problem in this case. In addition, partial flap loss can be encountered in perforator flaps. The aim of this study was the use of multidetector computed tomographic angiography in preoperative mapping to overcome these problems.

MATERIALS AND METHODS

Anterolateral thigh perforator flap was planned for various soft-tissue reconstructions in 19 patients. There were 15 males and 4 female patients with ages ranging from 19 to 65 years. These patients were evaluated with preoperative multidetector computed tomographic angiography to choose and to trace the course of the perforators. Flaps were designed according to the suprafascial course of the perforators. Perforators were safely located eccentrically when needed. Pedicle length and complications, such as infection, wound dehiscence, and partial or total flap loss, were recorded.

RESULTS

Perforators were located eccentrically in 8 patients and centrally in the other 11 patients. Eleven flaps were used in lower leg reconstruction, 2 flaps in popliteal region, and 6 flaps in head and neck. All flaps survived and any partial or total loss did not occur. There was not any infection and wound problem.

CONCLUSIONS

Multidetector computed tomographic angiography can reveal the suprafascial course of the perforator and help design anterolateral thigh perforator flap. By using this kind of mapping, perforators can be safely located eccentrically to lengthen the pedicle and partial flap loss can be prevented.

Musculoseptocutaneous Perforator of Anterolateral Thigh Flap: A Clinical Study

BACKGROUND

The anterolateral thigh flap is one of the most useful workhorse flaps for microsurgical reconstruction. However, it can pose a great challenge to surgeons because of its anatomical variability. As the technology advances, not only septocutaneous or musculocutaneous courses of anterolateral thigh perforators but also a hybrid musculoseptocutaneous perforator pattern have been identified on computerized imaging and on cadaveric study. However, there is a paucity of clinical study in the literature. The aim of this investigation was to identify the features of this pattern.

METHODS

All patients undergoing anterolateral thigh flap harvest between September of 2017 and May of 2018 performed by a single surgeon are included. Every pulsatile perforator was dissected to document its location on the thigh, emerging location (septum/muscle), size, course, and origin.

RESULTS

Thirty-seven patients with 115 perforators were identified. Ten percent of perforators were septocutaneous, 37 percent were musculoseptocutaneous, and 52 percent were musculocutaneous. Forty-seven percent of perforators emerged on the septum between the rectus femoris and the vastus lateralis. Eighty-one percent of patients had one or more perforators in the "hot zone." Medium and large perforators were more frequently located in the proximal and hot zones. All perforators originated from the vascular tree of the lateral circumflex femoral artery, with 10 percent originating from the transverse branch, 28 percent originating from the oblique branch, and 62 percent originating from the descending branch.

CONCLUSIONS

A high proportion of musculoseptocutaneous perforators were identified. The clinical relevance of this is to be very cautious on the skin paddle design while harvesting the flap.

Stratification of Surgical Risk in DIEP Breast Reconstruction Based on Classification of Obesity

BACKGROUND

 From both a medical and surgical perspective, obese breast cancer patients are considered to possess higher risk when undergoing autologous breast reconstruction relative to nonobese patients. However, few studies have evaluated the continuum of risk across the full range of obesity. This study sought to compare surgical risk between the three World Health Organization (WHO) classes of obesity in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction.

METHODS

 A retrospective review of 219 obese patients receiving 306 individual DIEP flaps was performed. Subjects were stratified into WHO obesity classes I (body mass index [BMI]: 30-34), II (BMI: 35-39), and III (BMI: ≥ 40) and assessed for risk factors and postoperative donor and recipient site complications.

RESULTS

 When examined together, the rate of any complication between the three groups only trended toward significance (p = 0.07), and there were no significant differences among rates of specific individual complications. However, logistic regression analysis showed that class III obesity was an independent risk factor for both flap (odds ratio [OR]: 1.71, 95% confidence interval [CI]: 0.91-3.20, p = 0.03) and donor site (OR: 2.34, 95% CI: 1.09-5.05, p = 0.03) complications.

CONCLUSION

 DIEP breast reconstruction in the obese patient is more complex for both the patient and the surgeon. Although not a contraindication to undergoing surgery, obese patients should be diligently counseled regarding potential complications and undergo preoperative optimization of health parameters. Morbidly obese (class III) patients should be approached with additional caution, and perhaps even delay major reconstruction until specific BMI goals are met.

Best New Flaps and Tips for Success in Microsurgery

LEARNING OBJECTIVES

After reviewing this article, the participant should be able to: 1. Understand the trends in reconstruction using flaps. 2. Understand the surgical anatomy and elevation of the three best flaps: superficial circumflex iliac artery perforator, profunda artery perforator, and thin anterolateral thigh perforator. 3. Understand the core principle and the modern evolution of microsurgery. 4. Be acquainted with new microsurgical tips to maximize outcomes.

SUMMARY

Plastic surgery has a long history of innovation expanding the conditions we can treat, and microsurgical reconstruction has played a pivotal role. Freestyle free flaps now create another paradigm shift in reconstructive surgery, relying on a better understanding of anatomy and physiology, opening the door to patient-specific customized reconstruction. This article aims to provide information regarding useful and practical new advances in the field of microsurgery.

Maximizing the Utility of the Pedicled Anterolateral Thigh Flap for Locoregional Reconstruction: Technical Pearls and Pitfalls

The pedicled anterolateral thigh (PALT) flap is an underutilized flap for locoregional reconstruction largely because methods to maximize its reach are neither universally implemented nor fully understood. In addition, most of the available literature has focused on the utility of the free anterolateral thigh flap with less emphasis on the PALT flap. Moreover, flap design concepts to maximize its utility and reach and optimize outcomes have not been comprehensively described. In an effort to address this knowledge gap, the authors sought to review their institution's experience with the PALT flap for locoregional reconstruction.

Comparison between Different Perforator Imaging Modalities for the Anterolateral Thigh Perforator Flap Transfer: A Prospective Study

BACKGROUND

 Perforator imaging is routinely performed before perforator flap harvest. Hand-held Doppler (hhD) and color duplex ultrasonography (CDU) are currently the most popular radiation-free methods for this purpose that can be applied by the surgeon alone. The aim of this study was to compare the accuracy, reliability, and feasibility of hhD and CDU with indocyanine green angiography (ICGA) in the anterolateral thigh perforator flap (ALTPF).

METHODS

 All consecutive ALTPF procedures between May 2017 and April 2018 were included in this prospective study. The perforators were visualized by three investigators independently and randomized, applying hhD, CDU, and ICGA. The presence and the distance to the identified perforator were registered. Further, body mass index (BMI), American Society of Anesthesiologists-status, and the patient's history regarding smoking, alcohol use, and diabetes mellitus were registered alongside gender and age to analyze possible confounders.

RESULTS

 A total of 12 patients were enrolled with a median age of 67 (52-87) years. In total, 30 perforators were detected intraoperatively as well as with the ICGA. The latter visualized the perforators significantly more precisely than hhD and CDU (p < 0.001 and p = 0.001). The sensitivity and positive predictive value were 67 and 62% for hhD, 73 and 64% for CDU, and 100 and 100% for ICGA, respectively.

CONCLUSION

 According to this study, ICGA visualized perforators more accurately than the standard methods hhD and CDU. Further, it was associated with the highest sensitivity and positive predictive value. ICGA consistently delivered excellent results, whereas hhD and CDU showed variability.

Perforator Variability of the Anterolateral Thigh Flap Identified on Computed Tomographic Angiography: Anatomic and Clinical Implications

BACKGROUND

 The anterolateral thigh (ALT) flap is a useful flap with minimal donor site morbidity. Preoperative computed tomographic angiography (CTA) for lower extremity reconstruction can determine vessel integrity and plan for recipient vascular targets. This study reviews lower extremity CTAs to further characterize ALT vascular anatomy and associated clinical implications thereof.

PATIENTS AND METHODS

 Lower extremity CTA studies were retrospectively reviewed, and information on ALT cutaneous perforator location, origin, and course was collected.

RESULTS

 A total of 58 lateral circumflex femoral artery (LCFA) systems in 31 patients were included. Average age was 38.8 ± 15.9 years with mean body mass index of 27.2 ± 5.7 kg/m². The majority of patients were females (23, 74.2%). The LCFA most commonly originated from the profunda femoris artery (87.3%), followed by the distal common femoral artery (9.1%). On average, there were 1.66 ± 0.69 cm perforators per extremity, with an average of 5.38 cm between adjacent perforators. Perforators originated from the descending branch of the LCFA in 89.6% of studies. Perforator caliber was <1 mm (29, 30.2%), 1 to 2 mm (55, 57.3%), or >2 mm (12, 12.5%). Mean distance from the most proximal perforator to the anterior superior iliac spine was 20.4 ± 4.82 cm. Perforators were musculocutaneous (46.9%), septocutaneous (34.4%), or septomyocutaneous (18.8%). In 58.1% of patients, only one thigh had easily dissectable septocutaneous and/or septomyocutaneous perforators, in which case preoperative CTA aided in donor thigh selection.

CONCLUSION

 ALT flap cutaneous perforator anatomy varies considerably. Using CTA, we report on rates of septocutaneous, myocutaneous, and septomyocutaneous perforators and underscore its utility in perforator selection.

[Application of high frequency color Doppler ultrasound combined with wide-field imaging in the preoperative navigation of anterolateral thigh perforator flap surgery]

Objective

To investigate the application of high frequency color Doppler ultrasound (HFCDU) combined with wide-field imaging in the preoperative navigation of anterolateral thigh perforator flap graft.

Methods

Between January 2017 and March 2018, 28 patients with skin and soft tissue defects were treated, including 22 males and 6 females, with an average age of 33.5 years (range, 17-66 years). The causes of injury included 2 cases of scald scar, 7 cases of heavy object crushing injury, 12 cases of traffic accident injury, 4 cases of fall injury, 2 cases of machine injury, and 1 case of infection ulcer. Injury sites included 6 cases of hand and wrist, 12 cases of lower leg, 10 cases of foot. After debridement, the wound area ranged from 6.0 cm×3.5 cm to 24.0 cm×9.0 cm, and all patients were treated with free circumflex femoral artery perforator flap graft. Combo of HFCDU and wide-field imaging navigation were done preoperatively to detect the origin, quantity, course, surface location, hemodynamic characteristics, and the relationship with body area of perforator branch of lateral circumflex femoral artery. According to the perforator information displayed by wide-field imaging of source artery, the dominant perforator was determined to be a pedicle for designed flap. The flap size ranged from 7.0 cm×4.5 cm to 26.0 cm×7.0 cm. The flap donor area was sutured directly.

Results

The dominant perforator was successfully detected by HFCDU combined with wide-field imaging in 28 patients before operation. The existence of the perforator was confirmed during operation, and the location was accurate. The course characteristics of the perforate were consistent with the results of wide-field imaging. The grafted flaps survived completely among 27 patients after operation. Necrosis at the edge of the flap was observed in 1 patient, which healed after dressing change. All patients were followed up 3-12 months, with an average of 9 months. All the flaps have good blood supply, good elasticity and shape. The donor areas healed perfectly.

Conclusion

Using HFCDU and wide-field imaging navigation for designing of anterolateral thigh perforator flaps can clearly show the characteristics of perforators, hemodynamic information, and the relationship with body area, so that the surgeons can understand the perforators more accurately and intuitively, and improve the success and efficiency of flap graft surgery.

Maximizing the Utility of the Pedicled Anterolateral Thigh Flap for Locoregional Reconstruction: Technical Pearls and Pitfalls

The pedicled anterolateral thigh (PALT) flap is an underutilized flap for locoregional reconstruction largely because methods to maximize its reach are neither universally implemented nor fully understood. In addition, most of the available literature has focused on the utility of the free anterolateral thigh flap with less emphasis on the PALT flap. Moreover, flap design concepts to maximize its utility and reach and optimize outcomes have not been comprehensively described. In an effort to address this knowledge gap, the authors sought to review their institution's experience with the PALT flap for locoregional reconstruction.

VIDEO: Preoperative CT Angiography for Anterolateral Thigh Flap Reconstructions

OBJECTIVE

This video article will review the relevant vascular anatomy of the anterolateral thigh flap, describe the CT angiography (CTA) image acquisition, and describe how to report the locations of the perforating arteries along with characteristics that may be important to the surgeon.

CONCLUSION

Our method of performing and reporting CTA for patients scheduled to undergo anterolateral thigh flap reconstruction provides a reproducible method of identifying perforating vessels and communicating their location to surgeons.

A free anterolateral thigh flap and iliotibial band for reconstruction of soft tissue defects at children's feet and ankles

BACKGROUND AND PURPOSE

High-energy injury to children caused by a traffic accident is usually characterised by extensive soft tissue defects with exposure or loss of tendons and bone at the foot. Segmental loss of the Achilles tendon along with soft tissue defects is a great challenge for microsurgical reconstruction. Free anterolateral thigh (ALT) flap is indicated for reconstruction of such defects because limited local tissues are available. Additionally, iliotibial band in the donor area can be used to reconstruct the damaged tendon.

MATERIALS AND METHODS

Here we described our successful management of 25 paediatric patients with such high-energy injury at feet and ankles in one-stage transplantation of a free ALT flap and an iliotibial band from January 2008 to January 2013. The tendon defect, ranging from 3 to 16cm in length, was reconstructed with an iliotibial band. The flaps ranged from 5 to 12cm in width and 8 to 18cm in length.

RESULTS

All the flaps survived completely and no donor site complications were observed. In two flaps there was a small area of distal necrosis which was healed by dressing changes. The mean follow-up time was 14.2 months (from 6 to 24 months). Limb function was assessed using the Maryland Foot Score. The excellent and good rate was 92%.

CONCLUSIONS

We believe a free ALT flap is ideal for reconstruction of massive soft tissue defects at the foot and ankle in children and an iliotibial band from the same donor site can be used for reconstruction of a damaged tendon.

Evidence-based medicine: lower extremity acute trauma

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the steps for evaluation of a patient with a lower extremity wound before initiating medical or surgical intervention. 2. Acknowledge that limb amputation and salvage can both be appropriate definitive treatment options. 3. Select proper nonsurgical or surgical techniques for wound management. 4. Appreciate the difference in the expected outcome according to the perspective of the physician versus the patient.

SUMMARY

Lower extremity acute trauma is a common occurrence. Ultimate functional outcomes are similar whether amputation or salvage by limb reconstruction is the treatment pathway chosen. The reconstructive surgeon must be knowledgeable enough to assist in making the correct decision for either option. Débridement is the cornerstone of management before embarking on definitive wound closure. Nonsurgical devices have provided a transition to optimize the wound, sometimes even replacing or lessening the need for vascularized tissues to permit this coverage. Nevertheless, flaps will always have a role varying according to the involved region of the lower extremity. Traditional muscle flaps can often today be supplemented by the use of perforator flaps. The latter have great versatility as pedicled flaps for all zones of the lower limb, in addition to being a dependable free flap alternative. Horrendous injuries can now be expected to be salvaged, with a reasonable aesthetic result possible and with minimal donor-site morbidity. Preferences by both physicians and patients tend to favor the course to limb salvage, but it must be appreciated by the caregiver that it is always the patient who has to live with the residua of an altered limb and lifestyle.

Preoperative imaging for perforator flaps in reconstructive surgery: a systematic review of the evidence for current techniques

BACKGROUND

Although preoperative imaging of perforator vasculature in planning microvascular reconstruction is commonplace, there has not been any clear demonstration of the evidence for this practice, or data comparing the many available modalities in an evidence-based approach. This article aims to provide an objective, evidence-based review of the literature on this subject.

METHODS

The evidence supporting the use of various modalities of imaging was investigated by performing focused searches of the PubMed and Medline databases. The articles were ranked according to the criteria set out in March 2009 Oxford Centre for Evidence-Based Medicine definitions. Endpoints comprised objective outcome data supporting the use of imaging, including flap loss, unplanned returns to theater, operative time reduction, and surgeon-reported stress.

RESULTS

The objective high level of evidence for any form of preoperative perforator imaging is low with only small number of comparative studies or case series investigating computed tomographic angiography (CTA), magnetic resonance angiography, handheld Doppler, color duplex, and classic angiography. Of all modalities, there is a growing body of level 2b evidence supporting the use of CTA.

CONCLUSION

While further multicenter trials testing hard outcomes are needed to conclusively validate preoperative imaging in reconstructive surgery, sufficient evidence exists to demonstrate that preoperative imaging can statistically improve outcomes, and that CTA is the current gold standard for perforator mapping.

Comparison of pedicled and free anterolateral thigh flaps for reconstruction of complex defects of the abdominal wall: review of 20 consecutive cases

BACKGROUND

The reconstruction of large, complex defects of the abdominal wall after the ablation of malignant tumours can be challenging. The transfer of an anterolateral thigh (ALT) flap is an attractive option. This study compared free ALT flaps and pedicled ALT flaps for abdominal wall reconstruction.

METHODS

From 1996 through 2011, 20 patients underwent abdominal wall reconstruction with ALT flaps. The flaps were pedicled in 12 patients and free in eight patients. Medical records were reviewed for complications and clinical and demographic data. Abdominal wall defects were classified into the following four groups: upper midline, lower midline, upper quadrants and lower quadrants.

RESULTS

Pedicled flaps were transferred to the upper midline region in one patient, the lower midline region in six patients and lower quadrants in five patients. Free flaps were transferred to the lower midline region in two patients, upper quadrants in four patients and lower quadrants in two patients. Mean reconstructive time was significantly longer with free flaps (6 h 32 min) than with pedicled flaps (4 h 55 min, p = 0.035). Although free flaps (mean size, 360 cm(2)) were larger than pedicled flaps (mean size, 289 cm(2)), the difference was not significant (p = 0.218). The rates of complications did not differ between free flaps and pedicled flaps. No total flap loss occurred, and there was partial loss of only a single pedicled flap, which was the flap furthest from the pivot point. Infections developed of two pedicled flaps and three free flaps.

CONCLUSION

This study suggests that complication rates do not differ between free and pedicled ALT flaps. The choice of flap depends on the size and location of the defect and the length of the vascular pedicle.

The role of preoperative radiological assessment of vascular injury on surgical decision making in mutilating injuries of the upper extremity

Preoperative assessment of the extent of vascular injury is important in patients with mutilating injuries of the upper extremity. The aim of this report was to discuss the influence of computed tomography angiography (CTA) and digital subtraction angiography (DSA) on the operating room decision-making in mutilating injuries and limb-salvage procedures of the traumatic upper extremity. Four DSA and 3 CTA were performed in 7 patients with a mean age of 28.3 (range, 4-48) years. The results of the DSA and CTA altered the preoperative planning. In 5 patients, the reconstructive decision of the type of flap was altered, whereas in all 7 patients, either the level or type of anastomosis was changed after radiologic investigations. The mean follow-up period was 37.8 months. During the follow-up period, all patients underwent subsequent procedures such as sensory restoration, tendon reconstruction, or capsulotomy. The effects of radiologic results in which flap selection, target donor vessel, and level and type of anastomosis have changed are discussed in correlation with intraoperative findings.