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Coquillard CL, Bai J, Ko JH. Thin and Thinned Anterolateral Thigh Flaps for Upper Extremity Reconstruction. Hand Clin 2024; 40:199-208. [PMID: 38553091 DOI: 10.1016/j.hcl.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Upper extremity reconstruction remains challenging due to the high functional and esthetic demands of this location. The anterolateral thigh (ALT) flap is a workhorse flap for microsurgical reconstruction of the upper extremity and can be elevated in various planes depending on desired thickness of the flap. Microsurgical reconstruction of the upper extremity often benefits from a thin flap that can resurface the extremity, which can provide improved functional and esthetic outcomes. This article reviews the anatomy, preoperative planning, and operative technique, as well as presents 4 cases to illustrate the outcomes and benefits of thin and thinned ALT flaps.
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Affiliation(s)
- Cristin L Coquillard
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, 259 East Erie Street Suite 2060, Chicago, IL 60611, USA
| | - Jennifer Bai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, 259 East Erie Street Suite 2060, Chicago, IL 60611, USA
| | - Jason H Ko
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, 259 East Erie Street Suite 2060, Chicago, IL 60611, USA; Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 259 East Erie Street Suite 2060, Chicago, IL 60611, USA.
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Izawa Y, Murakami H, Sato K, Tsuchida Y. Provisional resection of the nutrient artery in free anterolateral thigh flap debulking surgery. JPRAS Open 2024; 39:191-197. [PMID: 38293287 PMCID: PMC10826472 DOI: 10.1016/j.jpra.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 12/16/2023] [Indexed: 02/01/2024] Open
Abstract
Fix and flap surgery is the standard treatment for severe open-limb fractures. In cases of complex injuries, secondary surgeries such as additional osteosynthesis, implant removal, bone grafting, and debulking surgery may be required after the soft tissue condition has stabilized. During secondary surgery, if the nutrient vessels of the flap are resected haphazardly and an additional procedure is performed, flap necrosis may occur owing to insufficient blood flow. Creating a hemodynamic system that can withstand secondary surgery through increasing blood flow surrounding the flap is necessary in preventing necrosis. We report a case in which "provisional resection" of the nutrient artery was performed prior to the debulking surgery of a free anterolateral thigh flap. A 45-year-old man sustained an extensive degloving injury on the dorsum of the hand during a car accident. On the fifth day after injury, soft tissue reconstruction with a free anterolateral thigh flap was performed. Although the soft tissue condition was stable, debulking surgery was planned 4 months after the injury because of the thickness of the flap. Flap necrosis may occur if the nutrient artery was resected and debulking surgery was performed simultaneously. Therefore, staged surgery using "provisional resection" of the nutrient artery was selected. First, the nutrient artery was resected. After waiting for 1 week, skin graft removal and flap thinning were performed as the second step. No flap necrosis was observed. "Provisional resection" changes the hemodynamics of the flap to a random pattern due to the delay phenomenon and can prevent flap necrosis caused by secondary surgeries, such as debulking surgery.
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Affiliation(s)
- Yuta Izawa
- Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Kita 33 Jou Higashi 14 chome 3-1, Higashiku, Sapporo, Hokkaido, Japan
| | - Hiroko Murakami
- Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Kita 33 Jou Higashi 14 chome 3-1, Higashiku, Sapporo, Hokkaido, Japan
| | - Kazuo Sato
- Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Kita 33 Jou Higashi 14 chome 3-1, Higashiku, Sapporo, Hokkaido, Japan
| | - Yoshihiko Tsuchida
- Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Kita 33 Jou Higashi 14 chome 3-1, Higashiku, Sapporo, Hokkaido, Japan
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Dave A, Priyadarshini P, Wadhwani K, Laxmidhar M, Vanjarapu RNVK. Use of super-thin anterolateral thigh flap in intra-oral reconstruction of soft tissue defects. Microsurgery 2023; 43:782-789. [PMID: 37724463 DOI: 10.1002/micr.31115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 09/07/2023] [Accepted: 09/08/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Traditional sub-fascial anterolateral thigh (ALT) flaps are bulky and often give unsatisfactory outcomes in several head and neck reconstructions where thin pliable flaps are required. As a result, despite high incidence of donor site complications, radial forearm flap is still commonly used for tongue, buccal mucosa and lip defects where a traditional ALT flap would be too bulky. The objective of this report was to evaluate the usefulness of super-thin ALT flap as an alternative to radial forearm flap for intra-oral reconstruction. PATIENTS AND METHODS Retrospective evaluation was done of all head and neck reconstructions performed by a single surgeon between December 2021 and May 2022. Twenty-two patients who had undergone super-thin ALT flaps for intra-oral reconstruction of soft tissue defects were included in the report. These included buccal mucosa (n = 11), tongue (n = 8), and buccal mucosa with neck skin defects (n = 3). All patients had undergone wide excision of oral squamous cell carcinoma, and had history of chewing tobacco. Average age of patients was 54 years, 16 were males and 6 were females. Mean BMI of the patients was 25.2 kg/m2 (Range: 20.5-31.0 kg/m2 ). Super-thin ALT flap was elevated in the plane of superficial fascia of the thigh, thus leaving behind the deeper fat. The flaps were shaped as per the measurements obtained from the specimen as well as the defect and intra-oral inset was done prior to vascular anastomosis. RESULTS Mean flap dimension was 8.3 × 6.7 cm (range: 6 × 5 to 20 × 7 cm). Mean flap thickness was 9 mm (range: 4-20 mm). Mean flap elevation time was 70.9 min (Range: 48-105 min). None of the flaps needed a re-exploration. All flaps survived completely. One patient had surgical site infection at the flap donor site which was managed conservatively. Mean follow up was 5 months (range: 3-10 months). All patients were able to take soft oral diet at the last follow up. CONCLUSIONS Super-thin ALT flaps raised in superficial fascia plane are reliable and provide thin, pliable tissue for head and neck reconstruction. Unlike other thin flaps, these are not limited by donor site morbidity and flap dimension.
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Affiliation(s)
- Aniket Dave
- Plastic and Reconstructive Surgery, Apollo CBCC Cancer care, Ahmedabad, India
| | | | - Kamlesh Wadhwani
- Plastic Surgery, Apollo Hospitals International Limited, Ahmedabad, India
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Fricke A, Rassner M, Kiefer J, Eisenhardt SU. The esthetic outcome of recipient sites of gracilis muscle flaps versus anterolateral thigh flaps: A retrospective study. Microsurgery 2023; 43:800-808. [PMID: 36922726 DOI: 10.1002/micr.31035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 01/30/2023] [Accepted: 02/24/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Anterolateral thigh (ALT) and gracilis muscle flaps have been described as comparable reconstructive options regarding maximal flap dimension and indications. However, split-thickness skin-grafted muscle flaps are generally believed to be inferior to perforator flaps regarding the esthetic outcome of the recipient site. The purpose of this study was to challenge this assumption, comparing the long-term esthetic outcome of the gracilis and the ALT flap. METHODS One hundred forty-eight patients who had undergone free flap reconstruction with either free split-thickness skin-grafted gracilis muscle flaps (n = 86) or ALT flaps (n = 62) were evaluated in the study. Patients' satisfaction with the esthetic outcome, rates of flap loss, wound healing disorders and the necessity for thinning the flap or scar correction procedures were assessed. RESULTS Flap loss occurred in 4 of 86 gracilis flaps (4.7%) and 2 of 62 (3.2%) ALT flaps (p > .9999). Thinning or scar correction procedures were necessary for 6 of 86 gracilis (7.0%) and 4 of 62 (6.5%; p > .9999) ALT flap recipient sites. Regarding the overall patients' satisfaction with the esthetic outcome, scores were similar in both groups (2.667 [ALT] vs. 2.348 [gracilis]; p = .3739). Contour deformity, scar hypertrophy, and difference in flap color/texture in relation to the surrounding skin were comparable throughout the ALT and gracilis group (2.667 vs. 2.174, p = .2099; 3.333 vs. 2.739, p = .0912 and 2.500 vs. 2.174, p = .3159, respectively). CONCLUSION The gracilis and ALT flap are two equivalent reconstructive options regarding the esthetic outcome of the recipient site and long-term patient satisfaction.
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Affiliation(s)
- A Fricke
- Department of Plastic and Hand Surgery, Medical Faculty of the University of Freiburg, University of Freiburg Medical Centre, Freiburg, Germany
| | - M Rassner
- Department of Plastic and Hand Surgery, Medical Faculty of the University of Freiburg, University of Freiburg Medical Centre, Freiburg, Germany
| | - J Kiefer
- Department of Plastic and Hand Surgery, Medical Faculty of the University of Freiburg, University of Freiburg Medical Centre, Freiburg, Germany
| | - S U Eisenhardt
- Department of Plastic and Hand Surgery, Medical Faculty of the University of Freiburg, University of Freiburg Medical Centre, Freiburg, Germany
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Lin Z, Zhang X, Chen Y, Tian Y, Yang X, Zhao Z. Negative pressure wound therapy for flap closed-incisions after 3D-printed prosthesis implantation in patients with chronic osteomyelitis with soft tissue defects. BMC Musculoskelet Disord 2023; 24:827. [PMID: 37858142 PMCID: PMC10585842 DOI: 10.1186/s12891-023-06970-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/15/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND The flap closed-incisions healing after 3D-printed prosthesis implantation in Chronic Osteomyelitis with Soft Tissue Defects (COSTD) is critical. This study aimed to explore the safety and effectiveness of Negative Pressure Wound Therapy (NPWT) in promoting flap closed-incisions healing. METHODS Retrospective analysis of clinical data was performed, including baseline, surgical and hospitalization information. The efficacy of NPWT was assessed by comparing the ASEPSIS scores, Visual Analogue Scale (VAS), Activity of Daily Living Scale (ADLS), and Lower Extremity Functional Scale (LEFS), as well as the major postoperative complications. RESULTS The study included 20 patients, 13 received conventional dressing (Control group) and 7 received NPWT treatment (NPWT group). These two groups exhibited a notable disparity in the distribution of ASEPSIS scores, and the median scores were 24 in Control group and 9 in NPWT group (p = 0.001). Eight patients in the Control group experienced major incisional complications, including 7 cases of exudation, 3 cases of infection, 2 cases of non-healing, and 1 case of dehiscence, while none were observed in the NPWT group (p = 0.015). The VAS, ADLS, and LEFS scores were significantly improved in the NPWT group compared to the Control group (p = 0.003, 0.017, and 0.043, respectively). CONCLUSIONS The study findings suggest that NPWT applied to the healing process of flap closed-incisions after 3D prosthesis implantation in patients with COSTD can reduce the occurrence of postoperative major complications and promote the recovery of lower limb function and daily activities, which should be recommended for clinical practice.
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Affiliation(s)
- Zhiyu Lin
- Department of Plastic Surgery , Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Xinling Zhang
- Department of Plastic Surgery, Beijing Hospital, Beijing, China
| | - Yujie Chen
- Department of Plastic Surgery , Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Yun Tian
- Department of Orthopaedics, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Xin Yang
- Department of Plastic Surgery , Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China.
| | - Zhenmin Zhao
- Department of Plastic Surgery , Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China.
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Cha HG, Hur J, Ahn C, Hong JP, Suh HP. Ultrathin Anterolateral Thigh Free Flap: An Adipocutaneous Flap with the Most Superficial Elevation Plane. Plast Reconstr Surg 2023; 152:718e-723e. [PMID: 36780355 DOI: 10.1097/prs.0000000000010295] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
BACKGROUND Although many efforts have been made to create thinner anterolateral thigh (ALT) flaps, their thickness varies among patients, and the flap may be still too thick to match shallow defects. The authors successfully harvested an ALT flap through the most superficial elevation plane, the superficial fat layer, which was useful to match the shallow defects. METHODS All patients who underwent ALT free flap reconstruction for upper and lower distal extremity defects were divided retrospectively into groups by ALT flap elevation plane: thin, above the deep fascia; superthin, at the superficial fascia; and ultrathin, through the superficial fat. Preoperative computed tomographic angiography and duplex ultrasonography planning were used for all patients. Anatomical characteristics of donor subcutaneous tissue and surgical details, including flap thickness, flap size, and incidence of flap necrosis were compared among the groups and between sexes. RESULTS The average deep and superficial fascial depths were 16.7 and 10.8 mm, 12.5 and 8.2 mm, and 9.1 and 5.6 mm ( P < 0.05), and the average flap thickness was 5.8 mm, 7.9 mm, and 7.8 mm ( P = 0.29) in the ultrathin, superthin, and thin ALT groups, respectively. No significant intergroup differences existed in flap size or complications. The deep and superficial fascia were located significantly deeper in female patients (9.4 and 6.0 mm in male patients and 14.9 and 9.6 mm in female patients, respectively). CONCLUSIONS With precise preoperative planning, the most superficially elevated, ultrathin ALT flap can achieve optimal reconstructions of thin body areas. Female patients with thicker thighs and patients with a high body mass index would benefit from this flap. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Han Gyu Cha
- From the Department of Plastic and Reconstructive Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine
| | - Joon Hur
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Chris Ahn
- Department of Plastic and Reconstructive Surgery, Sydney South West Cancer Therapy Service
| | - Joon Pio Hong
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Hyunsuk Peter Suh
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine
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Danielian A, Cheng MY, Han PS, Blackwell KE, Kerr RPR. Medial Sural Artery Perforator Flap: A Middle Ground Between Anterolateral Thigh and Radial Forearm Flaps. Otolaryngol Head Neck Surg 2023; 169:852-857. [PMID: 37051889 DOI: 10.1002/ohn.348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/20/2023] [Accepted: 03/25/2023] [Indexed: 04/14/2023]
Abstract
OBJECTIVE The medial sural artery perforator (MSAP) flap has gained popularity in head and neck reconstruction primarily as a less morbid alternative to the radial forearm free flap (RFFF). However, no direct comparison of thickness exists among the MSAP, RFFF, and anterolateral thigh (ALT) flaps, which together represent the commonly utilized nonosseus-free flaps in head and neck reconstruction. Thus, this study aimed to compare these flap sites and identify predictors of thickness that will aid in reconstructive surgical planning. STUDY DESIGN Cross-sectional study. SETTING Tertiary referral hospital. METHODS The thickness of skin and subcutaneous tissue at the RFFF, MSAP, and ALT donor sites were measured in 54 adult patients using Doppler ultrasound. General linear models were generated to identify predictors of flap thickness. RESULTS The mean thickness of the RFFF, MSAP, and ALT flaps was 3.8 ± 2.2 mm, 7.4 ± 3.8 mm, and 9.6 ± 4.7 mm. Body mass index (BMI) was the only statistically significant contributing factor (p < .0001, coefficient: 0.15) for the RFFF. MSAP was affected by age (p = .006, coefficient = 0.06), female gender (p < .0001, coefficient = 3.2), and BMI (p < .001, coefficient = 0.25), while the ALT was affected by female gender (p = .0005, coefficient = 3.3) and BMI (p < .0001, coefficient = 0.35). Thus, the ratio of increase for flap thickness with respect to BMI is 3:5:7 for the RFFF, MSAP, and ALT flaps, respectively. CONCLUSION The MSAP is about twice the thickness of the RFFF and 2 mm thinner than the ALT; however, 22% of patients had thicker MSAP than ALT flaps. As the strongest predictors of flap thickness, female gender, and BMI may be taken into consideration during surgical planning for reconstruction.
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Affiliation(s)
- Arman Danielian
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | | | - Peter S Han
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Keith E Blackwell
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Rhorie P R Kerr
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Moratin J, Dao Trong P, Semmelmayer K, Mrosek J, Zittel S, Bleymehl M, Ristow O, Freudlsperger C, Hoffmann J, Engel M. Comparison of Antero-Lateral Thigh Flap and Vastus Lateralis Muscle Flap for the Treatment of Extensive Scalp Defects-A Retrospective Cohort Study. J Clin Med 2023; 12:6208. [PMID: 37834851 PMCID: PMC10573281 DOI: 10.3390/jcm12196208] [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: 08/08/2023] [Revised: 08/31/2023] [Accepted: 09/23/2023] [Indexed: 10/15/2023] Open
Abstract
Free flap reconstruction is the standard of care for extensive defects of the head and neck area. In this study, two types of free flaps, the antero-lateral thigh flap (ALT) and the vastus lateralis muscle flap, were compared. The primary endpoint was flap success, secondary endpoints were complication rates, hospitalization and surgery time. Cases with defect situations of the scalp and consecutive microvascular free flap reconstructions using either ALT flaps or vastus lateralis muscle flaps between 2014 and 2022 were retrospectively analyzed. Indications, perioperative handling and outcomes were compared. Twenty patients were included in the analysis. Ten patients (50%) received a free flap reconstruction using an ALT flap and ten patients (50%) received a vastus lateralis flap. A simultaneous two-team approach was possible in each case and the flap success rate was 100% with the need for one successful anastomosis revision. The mean defect size in our cohort was 147 ± 46 cm2. There were no significant differences in surgery time, duration of hospitalization or complication rate between both cohorts. Both free flaps, the ALT and the vastus lateralis flap, are suitable for the closure of large scalp defects. They provide high success rates, short surgery times without the need for patient repositioning and low donor-site morbidity. The vastus lateralis muscle flap bares the advantage of being perforator-independent and allows for the preparation of long vessels for anastomosis if needed while baring the disadvantage of a prolonged period of healing via granulation or the need for secondary surgery in terms of covering by split-thickness skin grafts which may interfere with necessary adjuvant treatment in oncological patients.
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Affiliation(s)
- Julius Moratin
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Philip Dao Trong
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany;
| | - Karl Semmelmayer
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Jan Mrosek
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Sven Zittel
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Moritz Bleymehl
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Oliver Ristow
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Christian Freudlsperger
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Jürgen Hoffmann
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Michael Engel
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
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Danker S, Shuck JW, Taher A, Mujtaba B, Chang EI, Chu CK, Liu J, Garvey PB, Hanna E, Yu P, Largo RD. The lateral forearm flap versus traditional upper extremity flaps: A comparison of donor site morbidity and flap thickness. Head Neck 2023; 45:2413-2423. [PMID: 37464915 DOI: 10.1002/hed.27446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/14/2023] [Accepted: 06/20/2023] [Indexed: 07/20/2023] Open
Abstract
INTRODUCTION The lateral forearm flap (LFF) is a thin fasciocutaneous flap with a donor site that can be closed primarily. METHODS A retrospective analysis of donor site morbidity and hand function was performed in patients who underwent a radial forearm flap (RFF), ulnar artery perforator flap (UAPF), or LFF. Flap thickness was evaluated radiographically in 50 control patients. RESULTS Of 134 patients (lateral forearm flap: n = 49, RFF: n = 47, UAPF: n = 38), the LFF demonstrated significantly faster return to baseline hand grip strength (3 months vs. 12 months in RFF and UAPF; p < 0.001), had significantly fewer donor site complications (6.1% compared to 6.4% in RFF and 28.9% in UAPF; p = 0.003) and fewer sensory deficits (2.0% compared to 6.4% in RFF and 15.8% in UAPF sites; p = 0.013). The radiographic study confirmed the LFF to be the thinnest of all upper extremity flap options. CONCLUSIONS The LFF is an excellent forearm-based flap option with thin, pliable tissue and low donor site morbidity.
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Affiliation(s)
- Sara Danker
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - John W Shuck
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Ahmed Taher
- Department of Radiology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Bilal Mujtaba
- Department of Radiology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Edward I Chang
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Carrie K Chu
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Jun Liu
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Patrick B Garvey
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Ehab Hanna
- Department of Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Peirong Yu
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Rene D Largo
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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Ryoo HJ, Park SH, Park JA, Kim YH, Shim HS. Multiple digit resurfacing with a lateral thoracic free flap: Two-stage mitten hand and division procedures. Microsurgery 2023; 43:570-579. [PMID: 37415509 DOI: 10.1002/micr.31090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 05/23/2023] [Accepted: 06/28/2023] [Indexed: 07/08/2023]
Abstract
PURPOSE The conventional abdominal and groin flaps for resurfacing the defect have several disadvantages, including the risk of flap failure due to accidental traction or detachment, immobilization of the arm before division, and aesthetic dissatisfaction because of the flap bulkiness. The aim of this study was to share our experiences with the free lateral thoracic flap and elucidate the optimal timing of division in complex hand reconstruction, which yielded favorable outcomes in terms of both functionality and aesthetics. METHODS This article is a retrospective review of multiple digit resurfacing using free tissue transfer from 2012 to 2022. Patients who underwent two-stage operation including mitten hand creation using superthin thoracodorsal artery perforator (TDAp) free flap and secondary division were included. A flap was elevated over the superficial fascia layer the midportion between the anterior border of the latissimus dorsi and pectoralis major muscles and once the pedicle was found, an outline that matched the defect was created. A process named "pushing with pressure and cutting" was carried out before pedicle ligation until all the superficial fat tissue had been removed except for around the perforator. Two cases (18%) involved defects of the entire fingers reconstructed by TDAp flap with anterolateral thigh flap. Six cases (55%) had a super-thin TDAp flap only. In two cases (18%), non-vascularized iliac bone grafting was required for finger lengthening. One case (9%) was resurfaced with a TDAp chimeric flap including a skin paddle with the serratus anterior muscle. The primary outcome was defined as the survival or failure of the flap, while the secondary outcomes associated complications such as infection and partial flap necrosis. A statistical analysis was not performed due to the size of the case series. RESULTS All 13 flaps survived completely without any complications. Flap dimension ranged from 12 cm × 7 cm to 30 cm × 15 cm. Mitten hand duration prior to division was 41.9 days on average which was essential for the optimal result. During the division procedures, there were nine cases of debulking (82%), six cases of split-thickness skin graft (STSG) (55%), and three cases of Z-plasty performed on the first web space (27%). The mean follow-up period was 20.2 months. Mean Disability of the Arm, Shoulder, and Hand (DASH) Questionnaire score was 10.76. CONCLUSIONS We resurfaced severe soft tissue defects of multiple fingers with thin to super-thin free flaps, mainly TDAp flaps. Surgeons can restore original hand shape using a two-stage reconstructive strategy of mitten hand creation and proper division timing to create a 3-dimensional hand structure, even in severely injured hands with multiple soft tissue defects of the digits.
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Affiliation(s)
- Hyun Jung Ryoo
- Department of Plastic and Reconstructive Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sang Hyun Park
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, South Korea
| | - Ji Ah Park
- Design Lab of Technology Commercialization Center, Industry-University Cooperation Foundation of Hanyang University, Seoul, South Korea
| | - Youn Hwan Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, South Korea
| | - Hyung-Sup Shim
- Department of Plastic and Reconstructive Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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11
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Sơn TT, Việt Dung PT, Nghĩa PT, Hồng Thúy TT. Reconstruction of Finger Soft Tissue Defects With a Thinned Free Anterolateral Thigh Flap. Ann Plast Surg 2023; 91:238-244. [PMID: 37489965 PMCID: PMC10399930 DOI: 10.1097/sap.0000000000003612] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
BACKGROUND Reconstructing complex soft tissue defects of the finger requires both functional and aesthetic aspects. There are many free tissue transfers as suitable options for digital resurfacing. The anterolateral thigh (ALT) flap is not the first choice for reconstruction of this area because it has the disadvantage that the subcutaneous tissue is too thick; however, its use as a thinned form has yet to be described much. This study presents the flap thinning technique in the small-sized ALT flap for the finger soft tissue defect. METHOD From May 2009 to March 2018, 10 patients with complete circumferential or semicircumcision defects in the fingers underwent reconstructive procedures that included thinned ALT flap transfer. Finger soft tissue damage due to contusion trauma includes loss of skin and exposure of the bone and tendon. The flap is thinned in 2 different ways: peripheral thinning and total microsurgical thinning, which is selected based on the perforator vessel structure of the flap. RESULT The ALT flap sizes, averaging 4-9 cm wide and 6-12 cm long, were thinned to 4-7 mm. One perforator was included in the flaps with a pedicle length average of 6.1 cm. The flaps survived entirely in all patients except one with a 30% area in the distal part of the thinned ALT flap that became necrotic because of venous occlusion. Donor sites were closed primarily for all patients. No patients required secondary flap defatting. CONCLUSIONS The small thinned ALT perforator flap can be an excellent option for full circumferential or semicircumferential soft tissue defects of the finger. Follow-up showed this as an excellent alternative for finger reconstruction in terms of aesthetic appearance and functional outcome.
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12
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Al Omran Y, Evans E, Jordan C, Borg TM, AlOmran S, Sepehripour S, Akhavani MA. The Medial Sural Artery Perforator Flap versus Other Free Flaps in Head and Neck Reconstruction: A Systematic Review. Arch Plast Surg 2023; 50:264-273. [PMID: 37256040 PMCID: PMC10226800 DOI: 10.1055/a-2059-4009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 03/07/2023] [Indexed: 06/01/2023] Open
Abstract
The medial sural artery perforator (MSAP) flap is a versatile fasciocutaneous flap, and yet is less commonly utilized than other free flaps in microvascular reconstructions of the head and neck. The aim is to conduct a high-quality Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)- and Assessment of Multiple Systematic Reviews 2 (AMSTAR 2)-compliant systematic review comparing the use of the MSAP flap to other microvascular free flaps in the head and neck. Medline, Embase, and Web of Science databases were searched to identify all original comparative studies comparing patients undergoing head and neck reconstruction with an MSAP flap to the radial forearm free flap (RFFF) or anterolateral thigh (ALT) flap from inception to February 2021. Outcome studied were the recipient-site and donor-site morbidities as well as speech and swallow function. A total of 473 articles were identified from title and abstract review. Four studies met the inclusion criteria. Compared with the RFFF and the ALT flaps, the MSAP flap had more recipient-site complications (6.0 vs 10.4%) but less donor-site complications (20.2 vs 7.8%). The MSAP flap demonstrated better overall donor-site appearance and function than the RFFF and ALT flaps ( p = 0.0006) but no statistical difference in speech and swallowing function following reconstruction ( p = 0.28). Although higher quality studies reviewing the use of the MSAP flap to other free flaps are needed, the MSAP flap provides a viable and effective reconstructive option and should be strongly considered for reconstruction of head and neck defects.
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Affiliation(s)
- Yasser Al Omran
- Department of Plastic Surgery, Royal Free National Health Service Foundation Trust, London, United Kingdom
| | - Ellie Evans
- Department of Plastic Surgery, Royal Free National Health Service Foundation Trust, London, United Kingdom
| | - Chloe Jordan
- Department of Plastic Surgery, Barts and The London School of Medicine and Dentistry, London, United Kingdom
| | - Tiffanie-Marie Borg
- Academic Plastic Surgery Group, Barts and The London School of Medicine and Dentistry, London, United Kingdom
| | - Samar AlOmran
- Department of ENT, Salmaniya Medical Complex, Kingdom of Bahrain
| | - Sarvnaz Sepehripour
- Department of Plastic Surgery, Royal Free National Health Service Foundation Trust, London, United Kingdom
| | - Mohammed Ali Akhavani
- Department of Plastic Surgery, Royal Free National Health Service Foundation Trust, London, United Kingdom
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13
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Kwon JG, Brown E, Suh HP, Pak CJ, Hong JP. Planes for Perforator/Skin Flap Elevation-Definition, Classification, and Techniques. J Reconstr Microsurg 2023; 39:179-186. [PMID: 36413994 DOI: 10.1055/s-0042-1750127] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Elevation in different layers achieving thin flaps are becoming relatively common practice for perforator flaps. Although postreconstruction debulking achieves pleasing aesthetic results and is widely practiced, customized approach during elevation to achieve the ideal thickness will increase efficiency while achieving the best possible aesthetic outcome. Multiple planes for elevation have been reported along with different techniques but it is quite confusing and may lack correspondence to the innate anatomy of the skin and subcutaneous tissue. METHODS This article reviews the different planes of elevation and aims to clarify the definition and classification in accordance to anatomy and present the pros and cons of elevation based on the different layers and provide technical tips for elevation. RESULTS Five different planes of elevation for perforator flaps are identified: subfascial, suprafacial, superthin, ultrathin, and subdermal (pure skin) layers based on experience, literature, and anatomy. CONCLUSION These planes all have their unique properties and challenges. Understanding the benefits and limits along with the technical aspect will allow the surgeon to better apply the perforator flaps.
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Affiliation(s)
- Jin Geun Kwon
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan Collage of Medicine, Songpa-gu, Seoul, Republic of Korea
| | - Erin Brown
- Department of Plastic and Reconstructive Surgery, University of British Columbia, Vancouver, British Columbia
| | - Hyunsuk Peter Suh
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan Collage of Medicine, Songpa-gu, Seoul, Republic of Korea
| | - Changsik John Pak
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan Collage of Medicine, Songpa-gu, Seoul, Republic of Korea
| | - Joon Pio Hong
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan Collage of Medicine, Songpa-gu, Seoul, Republic of Korea
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14
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Illg C, Krauss S, Rachunek K, Hoffmann S, Denzinger M, Kolbenschlag J, Daigeler A, Schäfer RC. Does leg dominance influence anterolateral thigh flap perforators? Microsurgery 2022; 42:817-823. [PMID: 36200703 DOI: 10.1002/micr.30968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/20/2022] [Accepted: 09/19/2022] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Thorough knowledge of perforator anatomy can facilitate anterolateral thigh (ALT) free flap harvest. The selection of the right or left thigh as donor area may be supported by preoperative perforator imaging and practical considerations. The study aims to determine if the leg dominance should be taken into account, when choosing the donor thigh for ALT free flap harvest, as muscle mass and perfusion might influence perforator quantity. METHODS ALT perforators were localized by color-coded duplex sonography and dynamic infrared thermography on both thighs within a defined 250 × 80 mm area in 24 subjects. Perforator number and thickness of subcutaneous tissue and muscle layer were compared in dominant and nondominant legs. RESULTS We found no statistically significant difference comparing sonographically identified ALT perforator numbers and hot spot numbers in dominant and nondominant legs. Yet, we found high interindividual differences. The comparison of subcutaneous tissue and muscle thickness yielded no significant difference. CONCLUSIONS Our study yielded no evidence for preference of the dominant or nondominant leg in ALT free flap harvesting. As we found high interindividual differences in perforator number, we suggest to rely on preoperative perforator imaging when choosing the ALT free flap donor thigh.
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Affiliation(s)
- Claudius Illg
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Sabrina Krauss
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Katarzyna Rachunek
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Sebastian Hoffmann
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Markus Denzinger
- Department of Pediatric Surgery, University Medical Center, Regensburg, Germany
| | - Jonas Kolbenschlag
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Adrien Daigeler
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Ruth Christine Schäfer
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University, Tuebingen, Germany
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15
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Tailored Skin Flaps for Hand Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4538. [PMID: 36203738 PMCID: PMC9529032 DOI: 10.1097/gox.0000000000004538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/27/2022] [Indexed: 11/27/2022]
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16
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Mai L, Mashrah MA, Lin ZY, Yan LJ, Xie S, Pan C. Posterior tibial artery flap versus radial forearm flap in oral cavity reconstruction and donor site morbidity. Int J Oral Maxillofac Surg 2022; 51:1401-1411. [PMID: 35597669 DOI: 10.1016/j.ijom.2022.03.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 11/29/2022]
Abstract
The repair of soft tissue defects after oral cavity cancer resection is challenging. The aim of this study was to compare the outcomes and donor site morbidity of the radial forearm free flap (RFF) and posterior tibial artery perforator flap (PTAF) for oral cavity reconstruction after cancer ablation. All patients who underwent oral cavity reconstruction with a RFF or PTAF between January 2017 and December 2019 were included retrospectively in this study. All flaps were harvested with a long adipofascial extension. The donor site defects were closed with a triangular full-thickness skin graft harvested adjacent to the flap. Flap outcomes and donor site complications were recorded and compared. The study included 145 patients; 30 underwent reconstruction with a RFF and 115 with a PTAF. No significant difference between the PTAF and RFF was observed concerning the flap survival rate (98.3% vs 96.7%), flap harvest time (53.39 vs 49.28 min), hospital stay (12.3 vs 15.2 days), or subjective functional and cosmetic outcomes. The PTAF showed a larger vascular calibre (P < 0.05), greater flap thickness (P = 0.002), and lower frequency of surgical site infection (P = 0.055) when compared to the RFF. No significant difference was observed between the pre- and postoperative ranges of ankle and wrist movements. The PTAF is an excellent alternative to the RFF for the repair of oral cavity defects, with the additional advantages of a well-hidden scar on the lower extremity, larger vascular calibre, and lower frequencies of postoperative donor site morbidities.
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Affiliation(s)
- L Mai
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - M A Mashrah
- Key Laboratory of Oral Medicine, Guangzhou Institute of Oral Disease, Stomatology Hospital of Guangzhou Medical University, Guangdong, Guangzhou, China
| | - Z Y Lin
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - L J Yan
- Key Laboratory of Oral Medicine, Guangzhou Institute of Oral Disease, Stomatology Hospital of Guangzhou Medical University, Guangdong, Guangzhou, China
| | - S Xie
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - C Pan
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.
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17
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Arakelyan S, Aydogan E, Spindler N, Langer S, Bota O. A retrospective evaluation of 182 free flaps in extremity reconstruction and review of the literature. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2022; 11:Doc01. [PMID: 35111561 PMCID: PMC8779818 DOI: 10.3205/iprs000162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Introduction: During the past decades, free flaps have been given a central role in the reconstructive surgery. Especially in the extremities, where there is a scarcity of available tissues for local flaps, free flaps play a central part. The aim of this study was to evaluate the risk factors contributing to partial and total flap failure. Patients and methods: In a retrospective cohort study, all data concerning patients who underwent free flap reconstruction of the extremities during the first five years since the founding of the department of plastic surgery were gathered. Patient- and surgery-related risk factors were analyzed in correlation to the postoperative complications. Results: In total, 182 free flaps were included in this study. Partial and total flap failure were noted in 21.42% and 17.03%, respectively. A correlation was seen between the time lapsed from debridement until flap coverage, with flaps performed between day 4 and 14 having the least quote of flap failure (p=0.022). Gender, age, arterial hypertension, nicotine abuse, diabetes mellitus, peripheral arterial disease and the number of anastomosed veins were not significantly associated with free flap failure. Conclusion: Our study showed that free flaps can be safely performed in healthy patients as well as in patients with risk factors, with an acceptable flap loss rate. Randomized controlled studies are needed to clarify the exact role of each risk factor in free flap surgery.
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Affiliation(s)
- Sergey Arakelyan
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Germany,*To whom correspondence should be addressed: Sergey Arakelyan, Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany, E-mail:
| | - Emrah Aydogan
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Germany
| | - Nick Spindler
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Germany
| | - Stefan Langer
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Germany
| | - Olimpiu Bota
- University Center of Orthopaedic, Trauma and Plastic Surgery University Hospital Carl Gustav Carus, TU Dresden, Germany
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18
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Yin J, Wang L, Yang G, Qin X, Xiong P. Correlation Between Body Mass Index and Anterolateral Thigh Flap Thickness: A Retrospective Study From a Single Center in China. Front Surg 2021; 8:748799. [PMID: 34708071 PMCID: PMC8542684 DOI: 10.3389/fsurg.2021.748799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/13/2021] [Indexed: 11/13/2022] Open
Abstract
Background: During repair of oral and maxillofacial soft tissue defects, organ function is largely related to the amount of thickness of the flap. However, there are few studies on the influencing factors of the thickness of the flap. In this retrospective study, we aim to explore the correlation between body mass index (BMI) and anterolateral thigh (ALT) flap thickness by computed tomography (CT) and ultrasound and provide guidance for evaluating the ALT flap thickness before surgery. Methods: We selected three points A, B, and C on ALT flap and two skilled clinicians measured the thickness of these points. Age and gender as covariates and evaluated by the Chi-square analysis. Inter-group differences between the two BMI groups were examined by the student t test. Intra-group differences within each BMI group were tested by ANOVA. Linear regression analysis was performed to examine the relationship between BMI and ALT flap thickness. Results: One hundred sixty patients measured by CT were included in this study, and the ALT flap thickness measured by CT were 8.96 mm and 11.00 mm (P < 0.0001, t test) at point B in groups with BMI<24.0 and BMI≥24.0, respectively. The thicknesses at points A, B, and C were significantly correlated with the BMI (P < 0.001, correlation analysis, r = 0.462, 0.372, and 0.349 at the points A, B, and C, retrospectively, Pearson test). Conclusion: There was a significant correlation between the ALT flap thickness and BMI. A higher BMI was correlated with a thicker ALT flap.
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Affiliation(s)
- Jianxin Yin
- Department of Ultrasound, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lei Wang
- Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Department of Oral and Maxillofacial Surgery, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou, China
| | - Gongxin Yang
- Department of Radiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xingjun Qin
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,National Clinical Research Center for Oral Diseases, Shanghai, China.,Shanghai Key Laboratory of Stomatology and Shanghai Research Institute of Stomatology, Shanghai, China
| | - Ping Xiong
- Department of Ultrasound, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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19
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Mohammed A, Lee KT, Mun GH. Evaluating effects of primary defatting for flap thinning on the development of perfusion-related complications in free perforator flap reconstruction. Microsurgery 2021; 41:716-725. [PMID: 34609025 DOI: 10.1002/micr.30819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 07/23/2021] [Accepted: 09/10/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Primary defatting is suggested as an effective and appealing technique for achieving flap thinning. There has been a long-standing concern regarding its potential adverse effects on flap perfusion, for which limited clinical evidence exists. This study aimed to investigate whether primary defatting negatively influences the outcomes of free perforator flap reconstruction. METHODS Patients who underwent upper or lower extremity reconstruction using free perforator flaps between 2002 and 2020 were investigated. They were categorized into two groups according to whether they underwent primary defatting. The association of primary defatting with the development of perfusion-related complications was evaluated. RESULTS A total of 421 patients were included in the analysis. Perfusion-related complications developed in 61 (14.5%) cases, including 12 cases (2.9%) of total flap loss. In total, 302 patients underwent primary defatting and 119 did not. The patients who underwent primary defatting had a higher body mass index (BMI), lower rate of comorbidities, and smaller harvested flaps than the controls. Both groups had similar rates of perfusion-related complications (13.9% vs. 16.0%, p = .589), including total flap loss (3.0% vs. 2.5%, p = .799). In the multivariate analyses, primary defatting was not associated with the development of perfusion-related complications (p = .957). In the subgroup analyses, the rate of perfusion-related complications did not differ between the two groups regardless of the BMI (≥25 or <25 kg/m2 ), comorbidities, and flap size (≥200, 100-200, or <100 cm2 ). CONCLUSIONS Primary defatting does not appear to be associated with the development of perfusion-related complications in free perforator flap extremity reconstruction.
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Affiliation(s)
- Alfawzan Mohammed
- Plastic Surgery Division, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Kyeong-Tae Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Goo-Hyun Mun
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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20
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Thiele JR, Weiß J, Braig D, Zeller J, Stark GB, Eisenhardt SU. Evaluation of the Suprafascial Thin ALT Flap in Foot and Ankle Reconstruction. J Reconstr Microsurg 2021; 38:151-159. [PMID: 34404104 DOI: 10.1055/s-0041-1731763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Distal lower extremity reconstruction can be challenging in terms of flap design. Bulky flaps result in limited mobility accompanied with the need of customized footwear. Raising the ALT-flap in a superficial fascial plane (thin ALT-flap) can be beneficial. This study evaluates thin ALT-flaps for lower distal extremity reconstruction. METHODS In a retrospective study, patients that underwent microvascular extremity reconstruction at the level of the ankle and dorsal foot at the University of Freiburg from 2008-2018 were reviewed. RESULTS 95 patients could be included in the study (35 perforator flaps, 8 fascia flaps and 54 muscle flaps).Among the perforator flaps, 21 ALT-flaps were elevated conventionally and 14 in the superficial fascial plane (thin ALT-flap). Among the conventional ALT-flaps, there was one flap loss (5%) and one successful revision (5%). 5(24%) flaps received secondary thinning. 57%(n = 12) were able to wear conventional footwear. There were 2(15%) successful revisions of thin ALT-flaps. 100% of thin ALT-flaps survived and 85%(n = 11) of the patients wore ordinary footwear after defect coverage.Among fascial flaps, 50%(n = 4) had to be revised with 2(25%) complete and 1 (13%) partial flap loss. All patients achieved mobility in ordinary shoes (n = 8).In muscle flaps, there were 7(13%) revisions and 5(9%) flap losses. 5(9%) flaps received secondary thinning. Only 33%(n = 18) were mobile in ordinary footwear. CONCLUSION The thin ALT-flap is a save one-stage evolution for lower distal extremity reconstruction with a favorable flap survival rate. Compared with conventional ALT-flaps it might be beneficial in reducing the need for expensive custom fitted shoes and secondary thinning procedures.
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Affiliation(s)
- J R Thiele
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Freiburg, Germany
| | - J Weiß
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Freiburg, Germany
| | - D Braig
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Freiburg, Germany.,Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - J Zeller
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Freiburg, Germany
| | - G B Stark
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Freiburg, Germany
| | - S U Eisenhardt
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Freiburg, Germany
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21
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Customized reconstruction of complex soft tissue defects in the upper extremities with variants of double skin paddle anterolateral thigh perforator flap. Injury 2021; 52:1771-1777. [PMID: 33994191 DOI: 10.1016/j.injury.2021.04.067] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 04/22/2021] [Accepted: 04/25/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Complex soft tissue defects in the upper extremities are challenging to reconstruct. The purpose of this study was to share our experience with using four variants of double skin paddle Anterolateral Thigh Perforator (ALT) flap to achieve the customized reconstruction of the complex defects. PATIENTS AND METHODS From January 2007 to December 2019, 15 patients (14 male and 1 female) aged 15-61 years underwent double skin paddle ALT flap reconstruction of the upper extremities. 10 wounds were located in the wrist or hand, while four wounds were located in the forearm, and one wound in the elbow. All the wounds were large with non-adjacent defects and with or without a dead space. Four variants of double skin paddle anterolateral thigh perforator flaps were harvested according to the patient's needs. RESULTS The flaps received were consisted of 7 classic double skin paddle ALT flap, 4 vastus lateralis muscle-chimeric double skin paddle ALT flap, 2 microdissected thin double skin paddle ALT flap, and 2 flow-through double skin paddle ALT flap. The size of the skin flap ranged from 6 × 6 cm2 to 26 × 7 cm2, and the size of the muscle segment ranged from 5 × 2 × 1 cm3 to 16× 6 × 2 cm3. Flap necrosis related to the pedicle kinking was observed in one patient, while the rest of the flaps survived without complications. The follow-up period ranged from 7 to 54 months, with a median of 15.6 months. The mean value of the qDASH scores at the last follow-up was 27.12 ± 16.51 (range, 11.4-59.1). None of the patients showed wrist flexion deformity. Postoperatively, three patients developed finger joint stiffness, which correlated with the severity of the injury. CONCLUSIONS Variants of double skin paddle ALT flaps provide versatile design and allow customized reconstruction of complex soft tissue defects in the upper extremities with limited donor site morbidity. We believe that the algorithm provided will help the surgeons with deciding among variants of double skin paddle ALT flap.
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22
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Wang L, Liu H, Ma T, Wu X, Zhang L. Reconstruction of Soft Tissue Defects in the Hand with a Free Anterolateral Thigh Deep Fascia Flap. Orthop Surg 2021; 13:758-767. [PMID: 33666370 PMCID: PMC8126942 DOI: 10.1111/os.12948] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 12/27/2020] [Accepted: 01/16/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To report our experience in the reconstruction of soft tissue defects in the hand with a free anterolateral thigh deep fascia flap and describe the clinical outcomes. METHODS This study was a retrospective trial. From November 2016 to January 2020, six patients (four men and two women) with soft tissue defects in the hand were included in this study. The average age of the patients was 33.7 ± 12.7 years (range, 20 to 50 years). All patients underwent reconstructions with free anterolateral thigh deep fascia flaps. Relevant clinical characteristics were recorded prior to surgery. The size and thickness of the deep fascia flap and the thickness of the skin were measured intraoperatively. The survival of the flaps and skin grafts and the occurrence of infection were recorded after the operation. At follow-up, donor site complications and postoperative effects were evaluated according to the outcome satisfaction scale. The pain in the injured hand was assessed using the visual analog scale. RESULTS The average body mass index (BMI) was 26.6 ± 1.7 kg/m2 (range, 23.9 to 28.7 kg/m2 ). The defect sizes ranged from 5 cm × 5 cm to 13 cm × 8 cm (average, 53.1 ± 27.9 cm2 ). The six anterolateral thigh deep fascia flaps ranged from 7 cm × 6 cm to 14 cm × 9 cm in size (average, 71.8 ± 29.1 cm2 ). The thicknesses of skin ranged from 25 mm to 40 mm (average, 32.5 ± 4.8 mm), and the thicknesses of the deep fascia flaps ranged from 2 mm to 3 mm (average, 2.5 ± 0.5 mm). After the operation, the blood supply of the deep fascia flap was normal in all cases. The second-stage skin grafts of most patients survived completely. The skin graft in one case was partially necrotic and healed after a dressing change. No infection occurred. At follow-up (average, 16.3 ± 6.9 months), there was only a linear scar and no loss of sensation at the donor site of each patient. According to the outcome satisfaction scale, the outcome satisfaction score ranged from 6 to 8 (average, 7.2 ± 0.9), all of which were satisfactory. Apart from one patient who reported mild pain, all the other patients reported no pain. Three typical cases are presented in this article. CONCLUSIONS The free anterolateral thigh deep fascia flap, which is suitable for reconstruction of soft tissue defects in the hand, can provide very good outcomes both functionally and aesthetically.
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Affiliation(s)
- Li Wang
- Department of Orthopedic Surgery, Hebei Medical University, Shijiazhuang, China.,Department of Hand Surgery, The Second Hospital of Tangshan, Tangshan, China
| | - Huiren Liu
- Department of Hand Surgery, The Second Hospital of Tangshan, Tangshan, China
| | - Tiepeng Ma
- Department of Hand Surgery, The Second Hospital of Tangshan, Tangshan, China
| | - Xueqiang Wu
- Department of Hand Surgery, The Second Hospital of Tangshan, Tangshan, China
| | - Liu Zhang
- Department of Orthopedic Surgery, Hebei Medical University, Shijiazhuang, China.,Department of Orthopedic Surgery, Emergency General Hospital, Beijing, China
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Kim JH, Yoo H, Eun S. Reconstruction of Extensive Soft Tissue Defects of Lower Extremity With the Extended Anterolateral Thigh Flap. INT J LOW EXTR WOUND 2021; 21:601-608. [PMID: 33626958 DOI: 10.1177/1534734620982238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The anterolateral thigh flap is a classic flap used for various reconstruction defects. However, the flap viability of extended large skin paddles (ie, 240 cm2) was doubted by many surgeons. This study reports successful experience of reconstructing extensive soft tissue defects of lower extremity using extended large skin paddles. Twelve consecutive patients who had undergone reconstruction of defects using an extended anterolateral thigh flap were identified. Patient characteristics (age, sex, defect location, injured structures, and type of flap) and outcome data were analyzed retrospectively. One artery and 2 accompanying veins were anastomosed to vascularize each flap. Follow-up periods ranged from 10 to 91 months postoperatively. The average size of the flaps was 268.75 cm2 (range = 220-391 cm2). All flaps were perforator flaps with one perforator except that 2 perforators were used in 3 patients. Two patients suffered partial flap necrosis of the distal portion with delayed healing. In conclusion, the extended anterolateral thigh flap is a considerable option for massive defects requiring composite tissue coverage. This flap is advantageous for reconstructing various complex defects in the lower extremities, providing a pliable and vascularized tissue to cover exposed extensive defects including tendons, nerves, and bones.
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Affiliation(s)
- Jong-Ho Kim
- Seoul National University, Seoul, Republic of Korea.,Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hyokyung Yoo
- Seoul National University, Seoul, Republic of Korea.,Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Seokchan Eun
- Seoul National University, Seoul, Republic of Korea.,Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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24
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Peroneal flap: How to harvest and clinical appraisal for head and neck reconstruction. J Plast Reconstr Aesthet Surg 2020; 74:1515-1523. [PMID: 33358676 DOI: 10.1016/j.bjps.2020.11.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 08/26/2020] [Accepted: 11/22/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND A peroneal flap, the boneless version of fibula flap, is considered as the equivalent of radial forearm flap of the lower leg. Because it is thinner than an anterolateral thigh (ALT) flap, the use of a peroneal flap is a viable option for the repair of soft tissue defects when a thin flap could bring about better functional and cosmetic outcomes. In this article, we describe the details of peroneal flap harvest and present our experience with the use of peroneal flaps for head and neck reconstruction. MATERIALS AND METHODS Between 1996 and 2017, a total of 265 peroneal flaps were used to reconstruct a variety of head and neck defects. With the same vascular anatomy and slight modifications to the harvesting technique of a fibula flap, a peroneal flap can be harvested within 1-2 h. All medical records were retrospectively reviewed. RESULTS A peroneal flap can be harvested as different types of chimeric flaps to fit a variety of head and neck defects. The peroneal flap failure rate was 3.4% and the postoperative complication rate was 12.8%. CONCLUSION A peroneal flap might be an alternative option for the reconstruction of head and neck defects.
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25
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Al-Himdani S, Din A, Wright TC, Wheble G, Chapman TWL, Khan U. The medial sural artery perforator (MSAP) flap: A versatile flap for lower extremity reconstruction. Injury 2020; 51:1077-1085. [PMID: 32192717 DOI: 10.1016/j.injury.2020.02.060] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 02/02/2020] [Accepted: 02/10/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The medial sural artery perforator (MSAP) flap provides a thin, pliable and durable soft tissue reconstruction with adequate pedicle length and low donor morbidity. It is an ideal choice for small-to-moderate defects of the lower extremity, although it does have limitations. We report our experience of the flap in a three-pronged anatomical, clinical and patient reported outcome-based study. METHODS Cadaveric fresh frozen lower limbs (n = 10) were used for anatomical dissections to assess pertinent and clinically relevant findings. Data relating to MSAP flaps was collected from a prospectively maintained database over a 2-year period. Both clinical data and modified Enneking scores were analysed. RESULTS Anatomical study: A mean of 2.1 ± 0.99 perforators arose from the medial sural artery, located 11.9 cm ± 2.07 along the line between the popliteal fossa and medial malleolus. The largest perforator was located 13.58 cm ± 2.01 from the popliteal artery. The distance from the dominant perforator to the first branching point within the gastrocnemius was 7.39 ± 1.50 (range 5-9.2 cm). The short saphenous vein was located on average 3.08 cm ± 0.77 from the dominant perforator. Clinical study: Twenty free and nine pedicled MSAPs were included (n = 29). Open lower limb fractures (n = 18, 62%) and infection (n = 10, 35%) were the most common aetiologies. Defects sites included: foot-and-ankle (n = 12, 55%), knee (n = 9, 31%) and anterior leg (n = 4, 14%). Four patients (14%) required SSG to for donor site coverage. Venous congestion was responsible for partial flap necrosis in 6.9%(n = 2) of patients. All wounds were healed at discharge. At 14 months, the mean Enneking score was 72.5%. All patients were ambulant, 96% returned to work and 87% were using pre-operative footwear. CONCLUSIONS The MSAP provides robust foot-and-ankle reconstruction, whilst permitting glide when over the knee. Patient satisfaction and functional outcomes are excellent with careful patient selection. Care should be taken to avoid compression or kinking of the large, thin walled veins as the most commonly observed complication was venous congestion. We advocate MSAP as a first choice flap for small-to-moderate foot, ankle or knee defects.
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Affiliation(s)
- Sarah Al-Himdani
- Southmead Hospital, North Bristol NHS Trust Westbury-on-Trym, Bristol, BS10 5NB, United Kingdom
| | - Asmat Din
- Southmead Hospital, North Bristol NHS Trust Westbury-on-Trym, Bristol, BS10 5NB, United Kingdom
| | - Thomas C Wright
- Southmead Hospital, North Bristol NHS Trust Westbury-on-Trym, Bristol, BS10 5NB, United Kingdom
| | - George Wheble
- Southmead Hospital, North Bristol NHS Trust Westbury-on-Trym, Bristol, BS10 5NB, United Kingdom
| | - Thomas W L Chapman
- Southmead Hospital, North Bristol NHS Trust Westbury-on-Trym, Bristol, BS10 5NB, United Kingdom
| | - Umraz Khan
- Southmead Hospital, North Bristol NHS Trust Westbury-on-Trym, Bristol, BS10 5NB, United Kingdom.
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26
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Chimeric posterior tibial artery flap: clinical application in oral and maxillofacial reconstruction. Int J Oral Maxillofac Surg 2020; 49:993-999. [PMID: 31926825 DOI: 10.1016/j.ijom.2019.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/15/2019] [Accepted: 12/20/2019] [Indexed: 11/20/2022]
Abstract
The objective was to describe the utility of the chimeric posterior tibial artery flap (CPTAF) in the restoration of compound defects in the oral and maxillofacial region. Patients who underwent head and neck reconstruction using a CPTAF between February 2018 and February 2019 were included. Special consideration was given to the distribution of septocutaneous perforators (SPs), indications, flap survival, and complications. Nine patients were included. All flaps survived. One patient developed a surgical site infection, which was managed conservatively. The CPTAF was raised as a bipaddle skin flap without muscle (n=1), with the gastrocnemius muscle (n=6), or with the soleus muscle (n=2). The number of SPs ranged from three to five (mean 4±0.8). The SPs were mostly located between 4cm and 20cm proximal to the medial malleolus (mean 9.5±3.8cm). The skin paddle was used to reconstruct skin or mucosal defects, whereas the muscle part was used to fill the dead space (n=7) or to support the orbital contents (n=1). The donor site healed with no associated functional complications. The CPTAF is a good option for the restoration of composite tissue defects in the head and neck region. It offers flexibility during flap inset and provides the appropriate bulk to repair defects in multiple planes.
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27
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Mashrah MA, Mai L, Wan Q, Huang Z, Wang J, Lin Z, Fan S, Pan C. Posterior Tibial Artery Flap with an Adipofascial Extension. Plast Reconstr Surg 2020; 145:142e-152e. [DOI: 10.1097/prs.0000000000006396] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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28
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Young AMH, Bache S, Segaren N, Murphy S, Maraka J, Durrani AJ. Free Flap Selection and Outcomes of Soft Tissue Reconstruction Following Resection of Intra-oral Malignancy. Front Surg 2019; 6:53. [PMID: 31921882 PMCID: PMC6932995 DOI: 10.3389/fsurg.2019.00053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 08/27/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction: Surgery to resect intra-oral malignancy is a well-established mode of primary treatment. The tissue requirement in this area is for a thin, pliable flap with minimal bulk and this has historically been provided by free tissue transfer with a radial forearm free flap (RFFF). More recently, a role for the anterolateral thigh free flap (ALTFF) has been described, although in populations with a westernized diet, body habitus may preclude use of an ALTFF due to flap thickness, relative to a radial forearm free flap. Methods: An analysis of data was performed retrospectively for 90 consecutive patients with intra-oral malignancy, requiring immediate soft tissue reconstruction by the senior author, at Addenbrooke's Hospital between July 2008 and April 2016. Cases requiring bony reconstruction were excluded. Data on patient age, sex, indication for surgery, tumor location and defect type, complications, success rates, and length of stay were recorded. Results: The majority of patients received an ALTFF (n = 56) with 38% receiving a RFFF (n = 34). Surgical resection took place in the floor of the mouth most frequently. These were closed with ALTFF and RFFF in 41 and 28 occasions, respectively. A success rate of 97% was observed in the RFFF group; 1 flap developed partial necrosis and required complete revision. In the ALTFF group, there was a 100% flap success rate. ALTFF usage resulted in a reduction in the number of intraoperative (p = 0.021) in addition a reduction in the number of days in ITU (p = 0.01) and post-operative clinic visits (p = 0.025). Conclusion: We present a series that used predominately the ALTFF to reconstruct intra-oral defects following resection of squamous cell carcinoma in a Western population. The results demonstrate that this treatment can produce at least as comparable results as to the use of a RFFF repair in this population, whilst avoiding the donor site morbidity and aesthetic compromise of a RFFF.
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Affiliation(s)
- Adam M H Young
- Department of Plastic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Sarah Bache
- Department of Plastic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Nicolas Segaren
- Department of Plastic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Suzane Murphy
- Department of Plastic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Jane Maraka
- Department of Plastic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Amer J Durrani
- Department of Plastic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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29
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Weitz J, Spaas C, Wolff KD, Meyer B, Shiban E, Ritschl LM. A Standard Algorithm for Reconstruction of Scalp Defects With Simultaneous Free Flaps in an Interdisciplinary Two-Team Approach. Front Oncol 2019; 9:1130. [PMID: 31709189 PMCID: PMC6823187 DOI: 10.3389/fonc.2019.01130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/09/2019] [Indexed: 11/30/2022] Open
Abstract
Reconstructions of complex scalp after ablative resection or by post-traumatic tissue loss, can present difficulties regarding recipient vessel selection, functional, and aesthetic outcome. The harvesting method for many microvascular free flaps requires a need for changing patients position during surgery and makes a simultaneous interdisciplinary two-team approach complicated, which is a major disadvantage regarding safety and operation time. The ideal flap for scalp reconstruction has yet to be described, although the microvascular latissimus dorsi flap is frequently referred to as the first choice in this context, especially after resection of large defects. The purpose of this study is to compare two different microvascular free flaps for a simultaneous scalp reconstruction in an interdisciplinary two-team approach applying a standardized algorithm. All consecutively operated complex scalp defects after ablative surgery from April 2017 until August 2018 were included in this retrospective study. The indications were divided into neoplasm or wound healing disorder. Two microvascular flaps (latissimus dorsi or parascapular flap) were used to cover the soft tissue component of the resulting defects. Seventeen patients met the inclusion criterion and were treated in an interdisciplinary two-team approach. Skull reconstruction with a CAD/CAM implant was performed in 10 cases of which four were in a secondary stage. Nine patients received a parascapular flap and eight patients were treated with latissimus dorsi flap with split thickness skin graft. Anastomosis was performed with no exception to the temporal vessels. One parascapular flap had venous insufficiency after 1 week followed by flap loss. One latissimus dorsi flap had necrosis of the serratus part of the flap. All other flaps healed uneventful and could be further treated with adjuvant therapy or CAD/CAM calvarial implants. Regarding overall complications, flap related complications, flap loss, and inpatient stay no statistical differences were seen between the diagnosis or type of reconstruction. The parascapular flap seems to be a good alternative for reconstruction of complex tumor defects of the scalp besides the latissimus dorsi flap. Stable long-term results and little donor site morbidity are enabled with good aesthetic outcomes and shorter operation time in an interdisciplinary two-team approach.
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Affiliation(s)
- Jochen Weitz
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
| | - Christophe Spaas
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
| | - Klaus-Dietrich Wolff
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Ehab Shiban
- Department of Neurosurgery, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany.,Neurosurgery Department, University Hospital of Augsburg, Augsburg, Germany
| | - Lucas M Ritschl
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
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30
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Peripheral Pruning: A Safe Approach to Thinning Extra-Large Anterolateral Thigh Flaps. Ann Plast Surg 2019; 80:S164-S167. [PMID: 29553978 DOI: 10.1097/sap.0000000000001401] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Thinning of anterolateral thigh (ALT) flaps has been described to achieve optimal contouring. Previous studies caution against thinning large flaps owing to the risk of vascular compromise leading to partial or total flap necrosis. This study aims to demonstrate a reliably safe method for thinning extra-large (>240 cm) flaps. METHODS A retrospective review of 53 consecutive ALT flaps performed at a single institution was completed. Of these flaps, 18 (34%) were thinned primarily by sharp excision of sub-Scarpa's fat along the periphery of the flap using loupe magnification. A central cuff of fat is left to surround and protect the perforator. RESULTS There were 53 total flaps in our series. Eighteen of the flaps were thinned by peripheral pruning. Eleven (61%) of the flaps reconstructed defects of the lower extremity, whereas 4 (22%) reconstructed upper extremity defects and 3 (17%) reconstructed scalp defects (Table 1). The mean size of the thinned flap group was 35% larger than the nonthinned group (n = 18, 261 cm ± 109 cm vs n = 35, 192 cm ± 146 cm). Ten thinned flaps (55%) were extra large, with flap areas over 240 cm. The average amount of excised fat weighed 41 g ± 18 g. The average body mass index in the thinned flap group was 28.8 kg/m, which is classified as overweight. The average body mass index in the nonthinned flap group was 24.6 kg/m, which is classified as normal weight (Table 2). There were no cases of partial flap necrosis in the thinned flap group. A single case of total flap loss occurred in the thinned flap group secondary to hematoma formation during administration of therapeutic heparin for a mechanical heart valve. There were no other complications in the thinned flap group. CONCLUSIONS This is the first study to demonstrate a reliable technique for primary thinning of extra-large ALT flaps in the Western population. No complications related to thinning were observed. Peripheral pruning of sub-Scarpa's fat is a safe and reliable method of thinning extra-large ALT flaps without increasing the risk of flap necrosis.
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31
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Cherubino M, Stocco C, Ronga M, Tamborini F, Maggiulli F, Di Giovanna D, Campisi C, Di Summa P, Valdatta L. Comparisons of fascio‐cutaneous anterolateral thigh and sandwich fascial ALT free flap in the distal extremity reconstruction. Microsurgery 2019; 40:452-459. [DOI: 10.1002/micr.30515] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 08/14/2019] [Accepted: 08/23/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Mario Cherubino
- Division of Plastic and Reconstructive Surgery, Microsurgery and Lymphatic Surgery Research Center, Department of Biotechnology and Life SciencesUniversity of Insubria Varese Italy
| | - Chiara Stocco
- Department of Medical, Surgical and Health Sciences, Plastic and Reconstructive Surgery UnitUniversity of Trieste Trieste Italy
| | - Mario Ronga
- Department of Medicine and Health Sciences “Vincenzo Tiberio”University of Molise Campobasso Italy
| | - Federico Tamborini
- Division of Plastic and Reconstructive Surgery, Microsurgery and Lymphatic Surgery Research Center, Department of Biotechnology and Life SciencesUniversity of Insubria Varese Italy
| | - Francesca Maggiulli
- Division of Plastic and Reconstructive Surgery, Microsurgery and Lymphatic Surgery Research Center, Department of Biotechnology and Life SciencesUniversity of Insubria Varese Italy
| | - Danilo Di Giovanna
- Division of Plastic and Reconstructive Surgery, Microsurgery and Lymphatic Surgery Research Center, Department of Biotechnology and Life SciencesUniversity of Insubria Varese Italy
| | - Corrado Campisi
- Plastic, Reconstructive and Aesthetic Surgery, Lymphatic Surgery and MicrosurgeryICLAS, GVM Care & Research Rapallo Genoa Italy
| | - Pietro Di Summa
- Department of Plastic and Hand SurgeryCentre Hospitalier Universitaire Vaudois (CHUV) Lausanne Switzerland
| | - Luigi Valdatta
- Division of Plastic and Reconstructive Surgery, Microsurgery and Lymphatic Surgery Research Center, Department of Biotechnology and Life SciencesUniversity of Insubria Varese Italy
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32
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A Unifying Algorithm in Microvascular Reconstruction of Oral Cavity Defects Using the Trilaminar Concept. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2267. [PMID: 31942327 PMCID: PMC6952141 DOI: 10.1097/gox.0000000000002267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 04/02/2019] [Indexed: 12/20/2022]
Abstract
Although many algorithms exist to classify oral cavity defects, they are limited by either considering a single subsite or failing to provide a concise reconstructive algorithm for the breadth of defects. Based upon our experience as a tertiary referral center, a unifying algorithm is presented that guides free flap selection in this heterogenous population.
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33
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Jiang C, Yang Y, Zeng F, Wang X, Fang B. [Research progress in thin flap and flap thinning technique]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:912-916. [PMID: 31298013 PMCID: PMC8337439 DOI: 10.7507/1002-1892.201901090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 04/15/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To review the historical origin and development of thin flap and flap thinning technique. METHODS A wide range of domestic and foreign literatures on thin flaps and flap thinning technique were reviewed. The background, definition, methods, problems, challenges, and future development of thin flap and flap thinning technique were summarized and analysed. RESULTS Thin flap and flap thinning technique play an important role in the development of flap surgery, leading flap surgery towards a more rational and refined direction. CONCLUSION Thin flap and flap thinning technique are still hot topics in the future. With the development of thin flap and flap thinning technique, clinicians will have more "free" choices.
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Affiliation(s)
- Conghang Jiang
- Department of Burn and Plastic Surgery, the Second Xiangya Hospital, Central South University, Changsha Hunan, 410011, P.R.China
| | - Yuanming Yang
- Department of Burn and Plastic Surgery, the Second Xiangya Hospital, Central South University, Changsha Hunan, 410011, P.R.China
| | - Fanglin Zeng
- Department of Burn and Plastic Surgery, the Second Xiangya Hospital, Central South University, Changsha Hunan, 410011, P.R.China
| | - Xiancheng Wang
- Department of Burn and Plastic Surgery, the Second Xiangya Hospital, Central South University, Changsha Hunan, 410011,
| | - Bairong Fang
- Department of Burn and Plastic Surgery, the Second Xiangya Hospital, Central South University, Changsha Hunan, 410011, P.R.China
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34
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Reconstruction of Diabetic Foot Defects With the Proximal Lateral Leg Perforator Flap. Ann Plast Surg 2019; 82:546-551. [DOI: 10.1097/sap.0000000000001745] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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35
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Free Gracilis Muscle Flap for Sarcoma Reconstruction: 19 Years of Clinical Experience. Sarcoma 2019; 2019:3975020. [PMID: 30863198 PMCID: PMC6378001 DOI: 10.1155/2019/3975020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 11/26/2018] [Accepted: 01/10/2019] [Indexed: 11/24/2022] Open
Abstract
Background Sarcoma treatment necessitates high-dose chemoradiation therapy and wide surgical margins that create wounds that are difficult to reconstruct. Many techniques have been developed to cover these defects, originating with muscle flaps such as the rectus abdominis and latissimus dorsi. The gracilis flap, which is best known in contemporary practice as a microneurovascular flap for functional reconstructions, is not usually considered a robust option for reconstruction after sarcoma extirpation. Methods We reviewed records of 22 patients (9 women) at our institution who underwent reconstructive surgery after sarcoma extirpation using gracilis flaps for soft-tissue coverage from 1998 to 2017. Neurotized gracilis flaps were excluded. The mean patient age was 51 years (range, 18–85 years), and mean length of follow-up was 53 months (range, 9–156 months). Patients had 7 tumor types, with fibrosarcomas and undifferentiated tumors being most common. There were 23 defects (mean size, 118 cm2 (range, 54–200 cm2)). Defects were located most commonly in the foot and leg (n=9 each), upper extremity (n=4), and head and neck (n=1). The primary outcome was the flap success rate. Secondary outcomes were rates of major complications (unplanned reoperations, infections requiring intravenous antibiotics, and amputations); minor complications (superficial infections, partial skin-graft loss, partial flap necrosis, fluid collections treated in the office, and cosmetic reoperations); and sarcoma recurrence. Results Twenty-one flaps (91%) survived. Six patients (27%) experienced a major complication, and 12 patients (54%) experienced a minor complication. There were 2 amputations, for a limb salvage rate of 91%. Conclusions This series shows that the gracilis is well suited to covering large, compromised wounds across diverse anatomic features, which are the hallmark of sarcoma resections. The high rate of limb salvage and minimal donor-site morbidity further support the use of this flap as a first-line option for sarcoma reconstruction.
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36
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Is the Medial Sural Artery Perforator Flap a New Workhorse Flap? A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2019; 143:393e-403e. [DOI: 10.1097/prs.0000000000005204] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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37
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Anatomical Understanding of Target Subcutaneous Tissue Layer for Thinning Procedures in Thoracodorsal Artery Perforator, Superficial Circumflex Iliac Artery Perforator, and Anterolateral Thigh Perforator Flaps. Plast Reconstr Surg 2019; 142:521-534. [PMID: 29889740 DOI: 10.1097/prs.0000000000004619] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Thinned perforator flaps, reported techniques, and degree of thinning differ by study. This study investigated the anatomy of subcutaneous tissue according to the varying fattiness and identified which component and how much of the subcutaneous tissue layer needed to be excluded to meet target flap thickness using computed tomography. METHODS Three stratified fattiness groups consisting of 30 donors were formed for thoracodorsal artery perforator, superficial circumflex iliac artery perforator, and anterolateral thigh flaps. Thickness of the superficial fat and the deep fat layers was measured at specific points in donor sites of the three flaps and the proportion of superficial and deep fat layers to exclude to reach the target flap thickness (4, 6, and 8 mm) was calculated. RESULT The median proportion for the superficial fat layer varies depending on donor fattiness. The estimated percentage reduction of thickness after thin flap elevation along superficial fascia was approximately one-third of the whole layer. A variable proportion of each fat layer needs to be excluded to obtain required thinness and in very thick groups, part of the superficial fat layer must be removed to reach any of the target thicknesses for the three flaps. CONCLUSIONS The present study demonstrated the frequent need for superficial fat layer manipulation when obtaining a thin perforator flap. To cope with various combinations of donor-site fattiness and different required thicknesses effectively, an appropriate thinning method should have increased adaptability, including the ability to control superficial fat layer thickness.
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38
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39
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Flap thinning: Defatting after conventional elevation. Arch Plast Surg 2018; 45:314-318. [PMID: 30037190 PMCID: PMC6062701 DOI: 10.5999/aps.2018.00787] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 07/11/2018] [Indexed: 11/29/2022] Open
Abstract
Perforator flaps become a reliable option for coverage of various defects and the interest is change from survival of perforator flaps to make thin flaps for better aesthetic and functional outcomes. Multiple flap thinning methods have been demonstrated but it has not been widely attempted because of concerns about compromising circulation of flap thinning. This article will demonstrate the feasibility and benefits of flap thinning technique: defatting after conventional flap elevation.
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40
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Thin elevation: A technique for achieving thin perforator flaps. Arch Plast Surg 2018; 45:304-313. [PMID: 30037189 PMCID: PMC6062703 DOI: 10.5999/aps.2017.01529] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 06/26/2018] [Indexed: 11/21/2022] Open
Abstract
Elevating thin flaps has long been a goal of reconstructive surgeons. Thin flaps have numerous advantages in reconstruction. In this study, we present a surgical method for elevating a thin flap and demonstrate the safety of the procedure. A retrospective review was performed of the electronic medical records of patients who underwent thin flap elevation for lower extremity reconstruction from April 2016 to September 2016 at the Department of Plastic Surgery of Asan Medical Center. All flaps included in this study were elevated above the superficial fascia. A total of 15 superficial circumflex iliac artery free flaps and 13 anterolateral thigh free flaps were enrolled in the study. The total complication rate was 17.56% (n=5), with total loss of the flap in one patient (3.57%) and partial necrosis of the flap in four patients (14.28%). No wound dehiscence or graft loss at the donor wound took place. Elevation above the superficial fascia is not inferior in terms of flap necrosis risk and is superior for reducing donor site morbidity. In addition to its safety, it yields good aesthetic results.
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Abstract
Flap thinning is a procedure for making a thick flap thinner. This procedure does more than simply fill in the defected area, and it is better for reconstructing the area both functionally and aesthetically. However, because flap thinning is a rather blind procedure, it may have harmful effects on flap vascularity. Therefore, the vasculature of a flap must be understood before performing flap thinning. This paper analyzes the basic anatomy underlying flap thinning based on the previous anatomic study that categorized flaps into 6 types by their vascular structures. This paper also reviews specific studies of frequently practiced flap procedures (deep inferior epigastric artery perforator flap, thoracodorsal artery perforator flap, and anterolateral thigh flap) and presents important precautions for flap thinning procedures. Finally, this paper briefly examines the axiality of the subdermal plexus, which needs to be taken into account when performing flap thinning.
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The Use of a Honeycomb Technique Combined with Ultrasonic Aspirators and Indocyanine Green Fluorescence Angiography for a Superthin Anterolateral Thigh Flap. Plast Reconstr Surg 2018; 141:902e-910e. [DOI: 10.1097/prs.0000000000004411] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Combined Use of Liposuction and Arthroscopic Shaving for Delayed Debulking of Free Flaps in Head and Neck Reconstruction. Ann Plast Surg 2018; 80:S36-S39. [PMID: 29369909 DOI: 10.1097/sap.0000000000001302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bulky appearance after free flap reconstruction in patients with head and neck cancer is common and requires revision to achieve improved final outcomes. Although different delayed debulking methods have been reported, the procedure can be technically difficult in patients with severe scaring after adjuvant radiotherapy. The present study proposes a combined method of liposuction and arthroscopic shaving for delayed contouring of free flaps in head and neck reconstruction. METHODS In this study, 12 patients with head and neck cancer who had bulky flaps after cancer ablation surgery and immediate free anterolateral thigh flap reconstruction were included. These patients underwent delayed debulking through the combined arthroscopic shaving and liposuction method at least 3 months after the initial reconstruction or the completion of adjuvant radiotherapy (if required). Age, sex, cancer stages, the presence or absence of adjuvant radiotherapy, the interval between the initial free flap reconstruction and the debulking procedure, complications, and subjective satisfaction ratings were recorded 1 and 6 months after the revision surgery. RESULTS All patients were men, with an average age of 56.3 years (43-69 years), and 9 (75%) patients underwent adjuvant radiotherapy. Partial flap loss was not observed in the study patients, and subjective satisfaction ratings improved after the debulking procedure. CONCLUSIONS The combined liposuction and arthroscopic shaving method can facilitate the debulking and contouring procedures in patients with head and neck cancer after free flap reconstruction. With appropriate timing, the combined procedure can be simple and safe, even in patients with severe scaring after adjuvant radiotherapy.
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Retrospective Review of Free Anterolateral Thigh Flaps for Limb Salvage in Severely Injured High-Voltage Electrical Burn Patients. Ann Plast Surg 2018; 80:232-237. [PMID: 29309334 DOI: 10.1097/sap.0000000000001283] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND High-voltage electrical injuries usually cause extensive and devastating damages to the extremities. Timely and effective coverage of the wounds to maximally preserve the viable tissue is important for salvage and the ultimate functional outcome of the involved extremities. In this study, free anterolateral thigh flaps with a single-perforator pedicle were conducted to maximize tissue salvage and decrease late skeletal and neuromuscular complications of the involved extremities injured by high-voltage electricity. METHODS From June 2012 to December 2015, 12 patients with high-voltage electrical injuries on the extremities were recruited. After primary or secondary debridement, free anterolateral thigh flaps with a single-perforator pedicle were used for limb salvage. Patients' clinical records, including etiology, sex, age, perforator type, defect location, duration before admission, defect and flap size, timing of reconstruction, and complications, were extracted and analyzed. RESULTS All patients were followed up ranging from 10 to 25 months, with an average follow-up of 15.9 months. Free anterolateral thigh flap with a single-perforator pedicle was performed for 12 consecutive patients with high-voltage electrical injuries. The mean time taken before the transplantation of the flap was 5.25 days, with a range from 2 to 8 days. The average size of the resultant defects after debridement was 187.0 cm (84-350 cm), the average size of the flaps was 265.3 cm (119-448 cm), and the average time of the surgical operation was 314.6 minutes (260-355 minutes). All flaps healed uneventfully without associated complications. No weakness of the donor thigh was observed in all cases. CONCLUSIONS Free anterolateral thigh flaps with a single-perforator pedicle were an effective and reliable therapeutic intervention for the management of severe high-voltage electrical injuries on the extremities.
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Struk S, Schaff JB, Qassemyar Q. [The sural medial perforator flap: Anatomical bases, surgical technique and indications in head and neck reconstruction]. ANN CHIR PLAST ESTH 2017; 63:117-125. [PMID: 29203066 DOI: 10.1016/j.anplas.2017.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 11/08/2017] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The medial sural artery perforator (MSAP) flap is defined as a thin cutaneo-adipose perforator flap harvested on the medial aspect of the leg. The aims of this study were to describe the anatomical basis as well as the surgical technique and discuss the indications in head and neck reconstructive surgery. MATERIAL AND METHODS We harvested 10 MSAP flap on 5 fresh cadavers. For each case, the number and the location of the perforators were recorded. For each flap, the length of pedicle, the diameter of source vessels and the thickness of the flap were studied. Finally, we performed a clinical application of a MSAP flap. RESULTS A total of 23 perforators with a diameter superior than 1mm were dissected on 10 legs. The medial sural artery provided between 1 and 4 musculocutaneous perforators. Perforators were located in average at 10.3cm±2cm from the popliteal fossa and at 3.6cm±1cm from the median line of the calf. The mean pedicle length was 12.1cm±2.5cm. At its origin, the source artery diameter was 1.8mm±0.25mm and source veins diameters were 2.45mm±0.9mm in average. There was no complication in our clinical application. DISCUSSION This study confirms the reliability of previous anatomical descriptions of the medial sural artery perforator flap. This flap was reported as thin and particularly adapted for oral cavity reconstruction and for facial or limb resurfacing. Sequelae might be reduced as compared to those of the radial forearm flap with comparable results.
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Affiliation(s)
- S Struk
- Département de chirurgie plastique et reconstructrice, Gustave-Roussy, Cancer Campus Grand Paris, 114, rue Edouard-Vaillant, 94805 Villejuif, France
| | - J-B Schaff
- Département de chirurgie plastique et reconstructrice, Gustave-Roussy, Cancer Campus Grand Paris, 114, rue Edouard-Vaillant, 94805 Villejuif, France
| | - Q Qassemyar
- Service chirurgie plastique, reconstructrice et esthétique, hôpital Tenon, université Pierre-et-Marie-Curie Paris VI, AP-HP, 4, rue de la Chine, 75970 Paris cedex 20, France.
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Razzano S, Ramadan S, Figus A, Haywood RM. Tear drop-free anterolateral thigh flap, a versatile design for lower limb reconstruction after trauma. Microsurgery 2017; 38:278-286. [DOI: 10.1002/micr.30235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 07/24/2017] [Accepted: 08/25/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Sergio Razzano
- Department of Plastic and Reconstructive Surgery; Norfolk and Norwich University Hospital NHS Foundation Trust; Norwich United Kingdom
| | - Sami Ramadan
- Department of Plastic and Reconstructive Surgery; Norfolk and Norwich University Hospital NHS Foundation Trust; Norwich United Kingdom
| | - Andrea Figus
- Department of Plastic and Reconstructive Surgery; Norfolk and Norwich University Hospital NHS Foundation Trust; Norwich United Kingdom
- Department of Surgical Sciences; Plastic Surgery and Microsurgery Unit, University of Cagliari; Sardinia Italy
| | - Richard M. Haywood
- Department of Plastic and Reconstructive Surgery; Norfolk and Norwich University Hospital NHS Foundation Trust; Norwich United Kingdom
- Department of Medical Education; Norwich Medical School, University of East Anglia; Norwich United Kingdom
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Aladimi MT, Han B, Li C, Helal H, Gao Z, Li L. Factors to Consider When Deciding on the Type of Free-Flap Reconstruction of Head and Neck Soft Tissue Defects. ORL J Otorhinolaryngol Relat Spec 2017; 79:230-238. [DOI: 10.1159/000478103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 05/31/2017] [Indexed: 11/19/2022]
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Merter A, Armangil M, Kaya B, Bilgin S. Immediate emergency free anterolateral thigh flap after car-tyre friction injury: A case report with eight years follow-up. Int J Surg Case Rep 2017; 38:102-106. [PMID: 28755614 PMCID: PMC5537393 DOI: 10.1016/j.ijscr.2017.06.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 05/31/2017] [Accepted: 06/04/2017] [Indexed: 11/20/2022] Open
Abstract
The car-tyre friction injury has differences from other injuries. The components of injury which are burn, crushing, shearing, and degloving occur. Many treatment options can be performed for coverage of wound which are Vacuum Assisted Closure system (V.A.C), skin grafting, free flaps, local flaps and cross leg flap.
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Affiliation(s)
- Abdullah Merter
- Kahramanmaras Afsin State Hospital, Orthopedic Clinic, Turkey.
| | - Mehmet Armangil
- Ankara University, School of Medicine, Ibn-i Sina Hospital, Department of Orthopedics, Division of Hand Surgery, Turkey
| | - Burak Kaya
- Ankara University, School of Medicine, Cebeci Hospital, Department of Plastic and Reconstructive Surgery, Turkey
| | - Sinan Bilgin
- Ankara University, School of Medicine, Ibn-i Sina Hospital, Department of Orthopedics, Division of Hand Surgery, Turkey
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Abstract
BACKGROUND Reconstruction of oral cavity defects requires a thin, pliable flap for optimal functional results. Traditional flap choices are imperfect: the anterolateral thigh flap is excessively thick, whereas the radial forearm flap has a poor donor site. The authors therefore favor calf perforator flaps such as the medial sural artery perforator flap to provide thin tissue with an acceptable donor site. This two-part study aims to demonstrate their suitability for intraoral reconstruction. METHODS In the radiologic part of the study, the authors compared thigh and calf tissue thickness by examining lower limb computed tomographic scans of 100 legs. For their clinical study, they collected data prospectively on 20 cases of oral cavity reconstruction using calf perforator flaps. RESULTS The mean thickness of the calf tissue envelope was significantly less than that of the thigh (8.4 mm compared with 17 mm) based on computed tomographic analysis. In the clinical study, a medial sural artery perforator was used in the majority of cases (17 of 20). The mean pedicle length was 10.2 cm and the mean time to raise a flap was 85 minutes. There were no flap losses. One patient was returned to the operating room for management of late hematoma and wound dehiscence. CONCLUSIONS Calf perforator flaps provide ideal tissue for intraoral reconstruction and are significantly thinner than anterolateral thigh flaps. In addition to medial sural artery perforator flaps, the authors raised both sural and soleal artery perforator flaps in this series. Opportunistic use of the calf donor site allows the harvest of thin tissue with minimal donor-site morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Hsu KC, Tsai WH, Ting PS, Hsueh JH, Chen LW, Lin YS. Comparison between anterolateral thigh, radial forearm, and peroneal artery flap donor site thickness in Asian patients-A sonographic study. Microsurgery 2017; 37:655-660. [PMID: 28205260 DOI: 10.1002/micr.30164] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 01/15/2017] [Accepted: 02/02/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Kuei-Chang Hsu
- Division of Plastic and Reconstructive Surgery; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan 813, Republic of China
- Department of Surgery; National Defense Medical Center; Taipei Taiwan
| | - Wei-Hsuan Tsai
- Division of Plastic and Reconstructive Surgery; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan 813, Republic of China
| | - Pei-San Ting
- Division of Plastic and Reconstructive Surgery; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan 813, Republic of China
| | - Jung-Hua Hsueh
- Division of Plastic and Reconstructive Surgery; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan 813, Republic of China
| | - Lee-Wei Chen
- Division of Plastic and Reconstructive Surgery; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan 813, Republic of China
| | - Ying-Sheng Lin
- Division of Plastic and Reconstructive Surgery; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan 813, Republic of China
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