Salvage Free Anterolateral Thigh Composite Flap Transfer Based on the Musculocutaneous Perforator Retrograde Blood Flow Principle

Reverse flow anterolateral thigh free flap in a case with significant atherosclerosis: A viable alternative for arterial microvascular anastomosis

BACKGROUND

The concept of reserve flow perfusion for free flap reconstruction has been demonstrated in various applications in the literature. As it relates to the anterolateral thigh (ALT) free flap, the reserve flow principle has been primarily described to either augment or "supercharge" a large ALT to optimize skin perforator supply or lengthen the vascular pedicle.

METHODS

We report a case of a 77-year old male with chronic renal failure who had extensive atherosclerosis of the proximal descending lateral circumflex femoral artery (LCFA) where arterial anastomosis was unable to be performed.

RESULTS

We were able to circumvent this limitation by establishing reserve flow perfusion solely through the distal end of the descending LCFA. We describe our technique within the context of current literature on the topic of reverse flow perfusion in free flap reconstruction.

CONCLUSION

This report uniquely describes applying the distally based, reverse arterial flow principle in an ALT flap to circumvent an atherosclerotic proximal pedicle.

Chimeric Anterolateral Thigh Flap in Skull Base Reconstruction: A Case-Based Update and Literature Review

Oncologic and traumatic neurosurgery may have to cope with the issue of skull base defects, which are associated with increased risk of meningitis, epidural abscess and cerebro-spinal fluid (CSF) leak. The aim of skull base reconstruction is to repair the dural exposure and to separate the intracranial contents from the nonsterile sino-nasal cavities and extracranial space. Currently, many different surgical techniques have been described, and one of the most performed is the use free flap. In the present paper we performed a case-based update and literature review of the use of chimeric anterolateral thigh free flap harvested from rectus femoris, reporting the case of a 68-year-old man with recurrent spheno-ethmoidalis plane meningioma.

Supermicrosurgical reconstruction of nasal tip defects using the preauricular reversed superficial temporal artery flap

BACKGROUND

Microsurgical reconstruction of nasal tip defects is difficult to achieve. The free composite auricular flap allows for repair in a one-stage procedure. However, anastomosis to the recipient facial artery is often complicated because of its variable anatomy and the need for a vessel graft. In this study, we describe our experience using the alar artery and angular vein as recipient vessels for direct super microsurgical anastomosis.

METHOD

From February 2004 to December 2015, thirty-two patients with different degrees of full-thickness multi-subunit nasal tip defects were included in this study. The superficial temporal vessels, alar artery, and angular vein were marked preoperatively by ultrasound detection. The preauricular reversed superficial temporal artery flap was harvested and transferred to the nasal tip defect region as a free flap using a supermicrosurgical technique. Patient pictures were taken before surgery and at 1, 3, and 6 months of follow-up. Outcomes and complications were recorded and analyzed. Moreover, a postoperative patient satisfaction survey was performed.

RESULTS

The reversed superficial temporal artery flap was used in a total of 32 patients for the reconstruction of nasal tip defects in a one-stage procedure. In all cases, the alar artery and angular vein showed no anatomical variations and were used as recipient vessels. The size of the harvested preauricular flap size was 2.5 × 2.0 to 4.0 × 3.6 cm², and the average flap size was 3.6 × 2.7 cm². The length of the arterial pedicle was 4.0 to 6.7 cm, 5.58 cm on average. The length of the venous pedicle was 5.0 to 6.8 cm, 6.21 cm on average. Direct anastomosis was achieved in all patients, and in none of the cases, a vascular graft was needed. Donor sites were all closed primarily. Flap survival was complete, except for one case of vascular thrombosis, resulting in a 10% flap necrosis. Temporary hematoma was noted in one patient. The postoperative outcome showed excellent functional coverage and improved esthetic appearance. The average follow-up period was 12 months. The majority of patients (98.5%) rated their postoperative outcome as highly improved and improved. No late recurrence or other complications were seen in any of the patients. Twenty-two patients underwent a secondary debulking procedure of the flap for fine adjustment.

CONCLUSION

Our results demonstrate that the alar artery and angular vein are suitable recipient vessels for the super microsurgical reconstruction of nasal tip defects. Surgical planning and procedure are facilitated by their reliable anatomy without the need for a vessel graft. This technique may offer wider applications by extension to other facial cutaneous defects.