The Anterolateral Thigh Flap as the Flap of Choice for Scalp Reconstruction

Use of Free Anterolateral Thigh Flap and Free Latissimus Dorsi Myocutaneous Flap in Head and Neck Reconstruction: Comparison of Complications and Costs

Free anterolateral thigh flap (ALT) and latissimus dorsi myocutaneous flap (LDMF) are well-defined flaps frequently used to reconstruct head and neck defects. Our study aimed to compare the advantages and disadvantages of these flaps regarding esthetics, complications, and cost burden. The authors retrospectively evaluated 10 patients who applied to our clinic between January 2016 and December 2021 and required free flap reconstruction for the defect in the head and neck region. The first group consisted of 5 patients with ALT flaps, and the second group had 5 patients with LDMF flaps. The average cost burden of the first group was calculated as 18,373 TL, and the second group's was 23,362 TL. Our study found that the cost and complication rates were statistically higher in the LDMF flap group, and using an ALT flap was more reasonable due to its advantages.

A comparison of postoperative outcomes based on recipient vessels in scalp free flap reconstruction: A systematic review and meta-analysis

PURPOSE

The superficial temporal artery (STA) and facial artery (FA) are two commonly used recipient vessels when performing free tissue transfer to the head and neck. This meta-analysis compares the impact of recipient vessel location on free flap outcomes in scalp reconstruction.

METHODS

A systematic review was conducted following PRISMA-P guidelines using six databases. Studies reporting free tissue transfer using the STA or FA as a recipient vessel for reconstructing scalp defects were included. Outcomes of interest included flap loss, partial flap necrosis, wound dehiscence, venous thrombosis, and infection rates. Quality evaluation was performed using ASPS criteria and the ROBINS-I tool.

RESULTS

Of 3270 identified articles, 12 were included for final analysis. In total, 125 free flaps were identified (75 STA, 50 FA). Pooled analysis demonstrated an overall flap survival rate of 98.4% (STA 98.7% vs. FA 98.0%; p = .782). The mean defect size was significantly greater for flaps using the STA compared with the FA (223.7 ± 119.4 cm2 vs. 157.1 ± 96.5 cm2, p = .001). The FA group had a higher incidence of wound dehiscence than the STA group (14.0% vs. 1.3%, p = .005). However, meta-analysis demonstrated no significant difference in rates of wound dehiscence, flap loss, partial flap necrosis, venous congestion, or postoperative infection between groups.

CONCLUSION

This is the first systematic review and meta-analysis to assess recipient vessel selection in scalp reconstruction. Our results do not support a single vessel as the superior choice in scalp reconstruction. Rather, these findings suggest that the decision between using the STA or FA is multifaceted, requiring a flexible approach that considers the individual characteristics of each case. Further research is needed to explore additional factors influencing recipient vessel selection, including defect location, radiation therapy, and prior head and neck surgery.

Pushing boundaries: Anterolateral thigh free flaps for extensive scalp defects beyond previous limits, leveraging imaging modalities with ultrasound and indocyanine green

BACKGROUND

Scalp defect reconstruction poses considerable challenges, with ongoing debates regarding the most effective strategies. While the latissimus dorsi (LD) flap has traditionally been favored, the anterolateral thigh (ALT) flap has been well described as a versatile alternative for addressing extensive scalp defects. This study underscores the success of scalp reconstruction using ALT flaps, notably pushing the boundaries of previously reported flap sizes. Our approach leverages the use of indocyanine green (ICG) perfusion to guide precise preoperative planning and vascular modification, contributing to improved outcomes in challenging cases.

METHODS

We performed 43 ALT flap reconstructions for scalp defects between 2016 and 2023. We collected patients' demographic and clinical data and evaluated flap size and recipient vessels and additional surgical techniques. Detailed preoperative plans with ultrasound and ICG use for intraoperative plans were performed to find perforators location. The cohort was divided into two, with or without complications on flaps, and analyzed depending on its surgical details.

RESULTS

This study involved 38 patients with extensive scalp defects (mean age: 69.4 ± 11 years) who underwent ALT perforator flap transfers (mean flap size: 230.88 ± 145.6 cm2). There was only one case of unsuccessful flap transfer, and four cases had a few complications. The characteristics of the complication group included a large flap size (303.1 ± 170.9 vs. 214.9 ± 136.6 cm2, P = .211), few perforator numbers without pedicle manipulation, lack of intraoperative indocyanine green administration (75% vs. 25%, P = .607), and the use of superficial temporal vessels as recipient vessels.

CONCLUSIONS

Scalp reconstruction using large ALT free flaps with the aid of imaging modalities facilitates the optimization of surgical techniques, such as pedicle manipulation, perforator numbers, and vein considerations, thereby contributing to successful reconstruction.

Scalp Reconstruction With Free Tissue Transfer as a Palliative Surgical Intervention in a High-Risk Population

Microvascular reconstruction of the scalp is frequently indicated in patients with locally advanced tumors, among other etiologies, in a relatively high-risk, older patient population that often has multiple medical comorbidities. A retrospective analysis was performed on patients undergoing microvascular scalp reconstruction at Emory University Hospital and Grady Memorial Hospital between 2011 and 2021. Patient demographics, wound characteristics, operative details, and complications were recorded. Statistical analysis using univariate and multivariate models was performed. Forty-two patients underwent 45 microvascular scalp reconstructive procedures during the study period. The median age was 63 years. Wounds were predominantly oncologic (n=38, 84.4%) and frequently involved deeper structures [calvarium (n=38, 84.4%), dura (n=17, 37.8%)]. At a median follow-up of 350 days, 33 patients (73.3%) had healed flaps, 9 (20.0%) had wound healing issues but ultimately successful reconstruction, and 3 (6.7%) experienced flap failure. Most patients (n=33, 80.9%) were discharged home or to a rehabilitation facility, while the remaining 8 patients (19.1%) were discharged to hospice or died. The 30-day mortality was 4 patients (8.9%) and the 6-month mortality was 8 patients (20.5%). There was a statistically significant difference in 30-day mortality (P=0.0001) on univariate analysis and 6-month mortality (P=0.003) on both univariate and multivariate analysis for patients >70 years. While age >70 years is a risk factor for mortality in patients undergoing microvascular scalp reconstruction, mortality was commonly related to underlying disease processes rather than complication of surgery. Microvascular reconstruction for scalp defects has a high success rate and can be offered as a palliative procedure for patients with locally advanced cancers, advanced age, and multiple comorbidities.

The Role of the Fascia-Only Anterolateral Thigh Flap in Extremity Reconstruction: The Fascia-Only Anterolateral Thigh Flap

BACKGROUND

Free flap selection in extremity reconstruction can be challenging. The ideal flap has to be thin and pliable to achieve optimal contour and function. We explore the role of the fascia-only anterolateral thigh (fALT) flap in extremity reconstruction.

METHODS

We conducted a retrospective review of our experience using fALT-free flap for extremity reconstruction over a 2-year period. Patient demographics, mechanism of injury, flap characteristics, complications- and follow-up were recorded. Descriptive statistics were calculated.

RESULTS

Twelve patients were included. The median (interquartile range [IQR]) age was 34 (28-52) years. One fALT flap was used for upper extremity reconstruction, while 11 flaps were used for lower extremity reconstruction (4 for lower third of the leg, 4 for dorsum of foot, and 3 for heel). The median (IQR) flap surface area was 90 (63-120) cm2 and time from injury to reconstruction was 10 (6-16) days. The postoperative course was uneventful for all flaps except for 1 flap failure and 1 delayed healing. The median (IQR) follow-up was 2 (1-4) months. In all cases, durable soft tissue reconstruction was achieved with no need for revisions.

CONCLUSIONS

The fALT-free flap can be successfully used in extremity reconstruction. The ALT fascia has robust perfusion that allows for the harvest of a large flap that can be surfaced with a split thickness skin graft. Its thin pliable tissue provides excellent contour for the hand, distal leg, and foot that does not require future thinning, optimizing the cosmetic and functional result.

Comparison of Antero-Lateral Thigh Flap and Vastus Lateralis Muscle Flap for the Treatment of Extensive Scalp Defects-A Retrospective Cohort Study

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.

A staged approach for complex scalp defects using titanium mesh and anterolateral thigh flaps: Two case reports

INTRODUCTION AND IMPORTANCE

Scalp tumors are diverse, with the characteristics of individual tumors depending on the cell lineage. Invasive squamous cell carcinoma and sarcomas of the scalp are a variety of uncommon, aggressive neoplasms of the head and neck. Resecting large invasive tumors causes extensive full-thickness scalp defects, and repairing these defects remains challenging.

CASE PRESENTATION

The authors present two successful cases using a staged approach with titanium mesh and free tissue transfer (anterolateral thigh flap) technique.

CLINICAL DISCUSSION

Complex scalp defects are challenging to manage when insufficient local tissue is available. This frequently necessitates the use of microvascular free tissue transfer for reconstruction. The availability of microsurgery in developing countries such as ours has enabled functional and aesthetic reconstruction for patients presenting with such complex defects.

CONCLUSION

Free flaps are safe and reliable when scalp defects are significant and require both scalp and calvarial reconstructions. The ALT-free tissue transfer shows predictable results in both clinical cases.

Anterolateral thigh adipofascial flap combined with skin paddle in three-dimension scalp reconstruction: A case report

INTRODUCTION AND IMPORTANCE

Management of cranial and scalp defects is always challenging. Complication rates following cranioplasty are still high (10-40 %), including bone graft resorption, infection, and T-mesh implant exposure due to thinning of soft tissue (Yeap et al., 2019; Alkhaibary et al., 2020; Cho and Kang, 2017 [1-3]).

CASE PRESENTATION

We present a case of a 38-year-old male with autologous bone graft resorption accompanied by thinning of the forehead skin. He underwent cranioplasty with titanium mesh (T-mesh) and scalp reconstruction with an anterolateral thigh (ALT) flap in a single-stage operation. A 2-component ALT flap was used: the skin paddle covered the scalp defect to reduce closure tension, and especially the adipofascial flap lining beneath the forehead skin to increase thickness. Postoperative results were great in terms of coverage function and aesthetics.

CLINICAL DISCUSSION

The phenomenon of soft tissue thinning causing titanium mesh exposure is a common complication with a rate of 10-14 % (Yeap et al., 2019; Dong et al., 2020; Maqbool et al., 2018 [1, 4, 5]). Using adipofascial ALT flap as a sub-scalp filler material has many advantages over the latissimus dorsi (LD) flap to increase scalp thickness but still ensure aesthetics.

CONCLUSION

The results suggest a new direction in using adipofascial ALT flap as filler material to increase scalp thickness to reduce T-mesh exposure following cranioplasty.

Utility of Multimodal Treatment Protocols in the Management of Scalp Cutaneous Angiosarcoma

Cutaneous angiosarcomas are rare, aggressive tumors with high recurrence and poor prognosis. We share our experiences with the challenging surgical management of these lesions, focusing on both ablative and reconstructive outcomes.

Methods

Retrospective cross-sectional chart review was conducted of patients diagnosed with scalp cutaneous angiosarcoma between 2005 and 2021. Resectability, defect reconstruction, and survival outcomes were analyzed.

Results

Thirty patients were included, 27 (90%) men and three (10%) women, with a mean age at diagnosis of 71.77 ± 7.3 years, and mean follow-up of 429.43 ± 305.6 days. Only 12 patients completed their regular follow-up, while the remaining patients died. There was a median survival of 443.50 days (range, 42-1283) and median time to recurrence of 21 days (range, 30-1690). Multimodal therapy compared with surgery alone had a significantly better overall median survival (468 days versus 71 days; P = 0.021). Defect coverage was obtained in 24 cases (75%) through an anterolateral thigh flap, two patients (6%) with a local transposition flap, and one patient (3%) with a transverse rectus abdominis myocutaneous flap. The remaining three patients received a skin graft. All of the flaps survived, with one requiring a vein graft for venous congestion.

Conclusions

Timely multimodal therapy with a histologically safe margin, combined with adjuvant therapy, improves survival and delays recurrence and metastasis, in cutaneous angiosarcoma patients. An anterolateral thigh flap facilitates the coverage of wide defects. Further investigations of advanced treatment modalities such as immunotherapy and/or gene therapy are required to deal with this highly aggressive tumor.

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

BACKGROUND

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

RESULTS

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

CONCLUSIONS

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

Microsurgical Anterolateral Thigh Flap for Reconstruction of Extremity Soft Tissue Defects in Pediatric Patients

BACKGROUND

The anterolateral thigh flap is one of the most widely used flaps because it has the advantages of less damage to the donor site, no sacrifice of main blood vessels, and abundant soft tissue. However, the application of anterolateral thigh flap in children is relatively rare because of small blood vessels and rapid physiological changes. The aim of this study was to explore the effectiveness and characteristics of free anterolateral thigh flaps for the reconstruction of extremity soft tissue defects in pediatric patients.

PATIENTS AND METHODS

This study included 26 pediatric patients, with an average age of 6.7 years (range, 2-13 years). There were 5 cases of upper limb defects and 21 cases of lower limb defects, all of which were accompanied by exposed bones or tendons. The causes of defects included traffic injury in 9 cases, mechanical injury in 7 cases, collision injury in 4 cases, spoke injury in 3 cases, cicatricial contracture in 2 cases, and fibroma in 1 case. All defects were reconstructed with free anterolateral thigh flaps.

RESULTS

Twenty-six anterolateral thigh flaps were harvested, including 15 fasciocutaneous flaps and 11 musculocutaneous flaps. The mean size of the flap was 73.4 cm2 (range, 4 × 3 to 24 × 8 cm). The donor sites were sutured directly in 19 cases and underwent split-thickness skin grafting in 7 cases. There were 3 cases of vascular crisis, 3 cases of flap edge necrosis, 3 cases of infection, 1 case of pressure ulcer, and 1 case of dehiscence after surgery. Eleven patients had scar hyperplasia in the donor site. A total of 34 reoperations were performed, including 14 flap debulking, 7 debridement, 4 skin graft, 3 vascular crisis re-exploration, and 6 other procedures.

CONCLUSIONS

Free anterolateral thigh flap was a safe and reliable option for reconstructing soft tissue defects of extremities in pediatric patients. Notably, the incidence of scar hyperplasia in the donor site and the possibility of reoperation in pediatric patients were higher than those in adult patients.

Current trends in craniofacial reconstruction

Reconstruction of the head and neck continues to pose a variety of difficult functional and aesthetic challenges to the plastic surgeon. While the surgical treatment for midfacial and skull base tumours continues to advance, the three-dimensional reconstruction predicaments continue to increase in complexity. Reconstructive strategies of the head and neck require the restoration of intricate skeletal architecture and large volumes of both internal and external soft tissue envelopes that can withstand adjuvant therapies. Vascularized bone grafts in combination with microsurgical techniques is the current trend of most reconstruction and has replaced local and pedicle flaps as the preferred modality for large defects. This article will focus on concise areas of difficulty in craniofacial reconstruction, including mandibular, midfacial, scalp and base of skull reconstruction. As our goals now move from flap survival to refinement, more complex and innovative reconstructions are executed. The problems with each modality are examined, and the frontiers of head and neck reconstruction are explored. With the potential combination of virtual surgery and tissue engineered biotechnology, we may someday be able to expand our reconstructive capabilities beyond free tissue transfer.

Reconstruction of Complex Scalp Defects in Different Locations: Suggestions for Puzzle

Objective

Scalp defects may occur following trauma, radiotherapy, oncologic resection, and recurrent surgeries. The hair-bearing scalp has a dual role, which consists of protecting the calvarium and contributing to aesthetic appearance. While the "reconstructive ladder" approach may be used to close small and medium-sized scalp defects, it is not the case for larger ones involving the calvarium or with a radiation therapy history. The aim of this study is to present cases operated due to complex scalp defects, analyze complications, and discuss the choice of reconstruction.

Material and Methods

The study consists of 14 patients who were operated between December 2017 and August 2019 due to a complex scalp defect. Patient were evaluated according to age, gender, etiology, radiation therapy history, defect size and location, reconstruction steps, cranioplasty and duraplasty options, type of free flap, recipient artery, vein graft requirement, and complications.

Results

The mean age of patients, which consists of 11 men and three women, was 56.7 years. The etiology for scalp defects included basosquamous carcinoma, squamous cell carcinoma, giant basal cell carcinoma, atypical meningioma, glioblastoma multiforme, angiosarcoma, and anaplastic oligodendroglioma. The defect involved the full thickness of calvarium in nine cases and pericranium in five cases. Cranioplasties were made with rib graft (n=1), bone graft (n=1), and titanium mesh (n=7). Free flaps used for reconstruction were musculocutaneous latissimus dorsi (LD) (n=4), LD muscle (n=3), anterolateral thigh (ALT) (n=4), musculocutaneous ALT (n=1), vastus lateralis muscle (1), and rectus abdominis muscle (n=1). Flap loss was not observed. Complications occurred in four of the patients; include a partial graft loss, a wound dehiscence, seroma, and an unsatisfactory esthetic result.

Conclusion

Free tissue transfers rather than local flaps should be opted to reconstruct complex scalp defects, as failure of the latter, could create much greater defects, and worse consequences. There are many options for proper reconstruction, and it is essential to select the appropriate one, taking into account the comorbid conditions of each case.

Reconstruction of an Extensive Maxillofacial Avulsion Injury Caused by Bear Attack With a Double-Island Anterolateral Thigh Free Flap

ABSTRACT

Bear attack, a relatively rare cause of maxillofacial trauma, could lead to severe facial deformity as well as functional impairment. A 45-year-old male ranger was attacked by a bear and suffered an extensive maxillofacial avulsion injury, resulting in massive soft tissue loss (17.5 × 10 cm2) on his left temporal-facial region with an intraoral defect (3 × 2 cm2), surrounded by pus and necrotic tissue. Computed tomography revealed a comminuted fracture of the mandible, as well as bone defects in the left zygomatic bone, zygomatic arch, and part of the lateral orbital wall. In contrast with tumor resection, this large defect wound resulting from trauma was an infected wound with extensive loss of soft tissue and bone, which presented many operational challenges. The initial goal was to control local infection and then repair the maxillofacial and intraoral defects simultaneously. The left oral mucosal lining and maxillofacial skin after infection control were repaired by transposition of a double-island anterolateral thigh flap, and the fractured mandible was fixed, achieving primary closure for the reconstruction of large soft and hard tissue injuries in the oral and maxillofacial region. Five months postoperatively, the flap had healed and the patient was satisfied with the profile. This patient demonstrated how a rare severe injury caused by a bear attack was treated by preliminary closure of an extremely large post-traumatic oral and maxillofacial defect. The authors recommend the 1 pedicled double-island free anterolateral thigh flap as a worthwhile choice for the reconstruction of complicated oral and maxillofacial tissue defects combined with an intraoral defect. To our knowledge, this is the largest clinical application reported to date of an anterolateral thigh flap (approximately 200 cm2) for a post-traumatic oral and maxillofacial defect.

Scalp and Forehead Injury: Management of Acute and Secondary Defects

The primary challenges in scalp reconstruction are the relative inelasticity of native scalp tissue and the convex shape of the calvarium. All rungs of the reconstructive ladder can be applied to scalp reconstruction, albeit in a nuanced fashion due to the unique anatomy and vascular supply to the scalp. Important defect variables to incorporate into the reconstructive decision include site, potential hairline distortion, size, depth, concomitant infection, prior radiation therapy, planned adjuvant therapy, medical comorbidities, patient desires, and potential calvarium and dura defects.

Two-stage Reconstruction of the Scalp with Facial AV Loop

We present the case of a 65-year-old woman with extensive osteoradionecrosis of the scalp and calvaria after external beam radiation therapy for follicular lymphoma. Due to the compromise of her adjacent vasculature including the superficial temporal vessels, she underwent two-stage reconstruction with the creation of an AVL (arteriovenous loop) graft utilizing her great saphenous vein. This was anastomosed to her right facial artery and vein, which was then matured. She underwent resection of the necrotic portions of calvaria and soft tissue of approximately 180 cm2, and a vascularized free latissimus dorsi muscle flap was harvested and anastomosed to her new conduit. This free muscle flap was then covered with a split-thickness skin graft harvested from her thigh. She achieved satisfactory functional and cosmetic results with minimal morbidity and without complication despite her age, multiple co-morbidities, and extensive and complex disease process.

Serially expanded flap use to treat large hairless scalp lesions

Hairless scalp areas can occur due to trauma, tumors, or congenital disease. This aesthetically unpleasing condition can lead to psychosocial distress, and thin skin flaps may be prone to scarring. Treating the hairless scalp by simple excision is challenging because of skin tension. Tissue expanders are a good option for hairless scalp resurfacing. However, a single expansion may be inadequate to cover the entire defect. This report describes good results obtained using a serial resurfacing method involving re-expansion of the flap with a tissue expander to treat two patients with large lesions: one due to aplasia cutis congenital and another who underwent dermatofibrosarcoma protuberance resection. The results suggest that scalp resurfacing by serial tissue expansion using a tissue expander can be used for extensive lesions.

A Standard Algorithm for Reconstruction of Scalp Defects With Simultaneous Free Flaps in an Interdisciplinary Two-Team Approach

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.

Secondary Reconstruction of Calvarial Defects by Using Free Flap: Report of Consecutive Cases and Analysis of Strategy

INTRODUCTION

Multiplication of incisions and/or radiotherapy on the scalp, lead to skin necrosis and chronic osteitis. In this situation, reconstructive surgery can be useful to cover complex lack of tissue.

MATERIALS AND METHODS

The 5 patients were treated with the neurosurgery department of our hospital. The procedure included debridement of the infected calvarian bone and tissues and coverage by free antebrachial flap. A 2 stages skin graft, using a dermal regeneration template, or direct closure was used for the donor site. Evaluation of flap quality and donor site morbidity was done during hospitalization and 3 months after the procedure.

RESULTS

The procedure was achieved on 5 patients. All the patients were healed 3 months after surgery. For 1 patient, a second procedure was done in emergency for anastomosis revision. There was non-complication concerning the donor site. All the patients healed with a good coverage.

CONCLUSION

Treatment of calvarian bone necrosis needs a very good and reliable coverage, such as free flap can provide. In our opinion, the antebrachial free flap is an interesting option, despite the fact that it is still underused for scalp coverage.

Free Tissue Reconstruction of the Scalp

Reconstruction of scalp defects can be accomplished by many methods, but larger defects, especially those in which the periosteum is absent or calvarial defects are present, require free tissue transfer. Various methods of scalp reconstruction, as guided by the defect components and size, are presented herein, with a focus on free tissue transfer. Different free flaps for scalp reconstructed are described with a comparison of their advantages and disadvantages. Overall, free tissue transfer for scalp defects provides a reliable, durable, and cosmetically adequate reconstructive option.

Colour Doppler sonography in the preoperative assessment of the vascular pedicle from the anterolateral thigh flap: proposal for a mathematical formula to predict pedicle length

Introduction

The anterolateral thigh flap (ALT) is one of the most commonly used grafts in head and neck reconstructive surgery. In this type of surgery, it is essential that the vascular pedicle be long enough to ensure proper vascular anastomosis. However, it is difficult to accurately estimate the pedicle length preoperatively. In this context, the current study had two aims: (1) to assess the value of colour Doppler sonography (CDS) in the preoperative assessment of the vascular pedicle and (2) to develop a mathematical model to predict the length of the vascular pedicle based on the ultrasound findings.

Materials and methods

Retrospective review of patients who underwent primary surgery for head and neck cancer followed by ALT flap reconstruction at our institution from 2014 to 2018. All patients underwent CDS prior to surgical excision of the flap.

Results

Preoperative CDS was useful to identify the location of the vascular perforators, to estimate the pedicle length, and to identify the vascularization variant. Using the proposed mathematical formula, the estimated minimum pedicle length and actual length agreed in 73.9% of cases, increasing to 84.1% when a 5 mm margin of error was allowed. Moreover, preoperative ultrasound accurately distinguished the two anatomical variants of the ALT vasculature in nearly all cases (97.1%).

Conclusion

This study confirms the value of preoperative colour Doppler sonography for ALT flap reconstruction. The proposed mathematical model provides a highly accurate method of preoperatively assessing the length of the vascular pedicle, which may be of value in head and neck surgery.

Comparison of Musculocutaneous and Fasciocutaneous Free Flaps for the Reconstruction of the Extensive Composite Scalp and Cranium Defects

Composite scalp and cranium defects, which require microsurgical reconstruction, result from tumor resection, radiation, trauma, severe burn injuries, and rarely vasculitic disorders. In the current study, the authors aim to compare the outcomes of the fasciocutaneous flaps and musculocutaneous free flaps used for the reconstruction of extensive composite scalp and cranium defects. From 2010 to 2017, 21 patients who underwent composite scalp and cranium defect reconstruction with a free flap were retrospectively identified. Eighteen patients had squamous cell carcinoma, 2 patients had meningioma, and 1 patient had Ewing sarcoma. Thirteen musculocutaneous free flaps including latissimus dorsi and vertical rectus abdominis flaps and 9 free fasciocutaneous flaps including radial forearm and anterolateral thigh flaps were used. Only 1 flap loss was encountered. No neurologic impairment in postoperative period was reported. The mean length of stay in the hospital, the duration of surgery, and total volume of blood transfusion for the fasciocutaneous flap group were significantly shorter than those for musculocutaneous flap group. No flap atrophy was reported in fasciocutaneous flap group. Reconstruction of the composite scalp and cranium defects with fasciocutaneous free flaps allows shorter hospitalization, less blood transfusion and less flap atrophy than those of musculocutaneous flaps. To this respect, their usage should be prioritized in such challenging patients.

Strategies for Complex Scalp Reconstruction in Patients With Poor Recipient Vessels

Complex scalp defects with poor recipient vessels represent a challenge for plastic surgeons. In these cases, free flaps are the last resort for solving the problem. The authors present 5 difficult cases with complex large scalp and calvarium defects with unsuitable small recipient vessels for anastomoses. For these cases, the lesser saphenous vein was harvested and used as an interposition graft between the external carotid artery, the jugular vein, and the flap. Latissimus Dorsi, Anterolateral Thigh, and serratus anterior were the flaps used for reconstruction. Cranioplasty was simultaneously performed in 4 cases. The scalp defects varied from 83 to 288 cm. All flaps survived. In 1 case (extended Latissimus Dorsi) there was local infection and wound dehiscence with marginal flap necrosis that required flap readvancement. In conclusion, end-to-end anastomosis to the external carotid artery offers strong outflow through the vein graft and flap. A large vein graft allows good outflow and is more resistant to the pressure of the skin envelope. Anastomosis to large neck vessels (internal or external jugular) facilitates drainage since there is also an aspiration effect due to the venous flow circulation through it.

Double-island anterolateral thigh free flap used in reconstruction for salvage surgery for locally recurrent head and neck carcinoma

Salvage surgery is usually the only treatment for recurrent head and neck tumors but often poses a challenge to surgeons due to post-resected defects at 2 or more sites. Here we present the outcomes and rationale for reconstruction by a double-island anterolateral thigh (ALT) free flap following the salvage surgery.Patients treated with double-island ALT free flaps in salvage surgery between September 2012 and January 2017 at West China Hospital, Sichuan University were retrospectively viewed.A total of 18 patients (15 males) underwent reconstruction with double-island ALT free flaps (range from 40 to 77 years old). All patients had recurrent tumors after surgery and/or chemoradiotherapy and were selected for salvage surgery by a multidisciplinary team. The flaps were initially harvested as 7 cm × 7 cm to 16 cm × 10 cm single blocks and then divided into double-island flaps with each individual paddle ranging from5 cm × 3 cm to 10 cm × 8 cm. The average flap thickness was 3.5 cm (range from 2 to 6 cm), and the average pedicle length was 8 cm (range from 6 to 10 cm). A total of 18 arteries and 32 veins were anastomosed. Three patients developed fistula, 1 developed flap failure due to thrombosis and was re-operated with a pedicle flap. One patient died of pulmonary infection 6 months after the operation.Flap reconstruction for complex head and neck defects after salvage surgery remains challenging, but double-island ALT free flap reconstruction conducted by a multidisciplinary team and experienced surgeons would have a role in this setting.

Head and Neck Reconstructive Surgery

Head and neck reconstruction following surgical extirpative management of head and neck cancer requires critical assessment and meticulous correction of both aesthetic and functional deficits to optimize the physical and psychological well-being of the patient. Unique to head and neck cancers is the potential alteration of one's senses, breathing, speech, and swallowing functions, as well as overall head and neck aesthetics. When possible, tissue defects are replaced with similar tissues, though donor sites may be anatomically local, regional, or distant. The "reconstructive ladder" provides a heuristic approach to restoring the functional and aesthetic integrity of the head and neck cancer patient. Local tissue-rearrangement, grafts, flaps, and prosthetics are all options in the armamentarium of the reconstructive surgeon. The aim of this chapter is to familiarize the reader with the aims of reconstructive surgery, techniques employed to restore form and function as well as challenges and outcomes.

Evolution of the anterolateral thigh free flap

PURPOSE OF REVIEW

To review the recent literature on the evolution and advanced uses of the anterolateral thigh (ALT) free flap in reconstruction of oncologic defects of the head and neck.

RECENT FINDINGS

The ALT free flap is a versatile flap that can be harvested in a chimeric fashion with independent, vascularized skin, muscle, fascia, nerve and bone. Various techniques for chimeric flap harvest and flap inset have been described for reconstruction of pharyngocutaneous, oromandibular and radical parotidectomy defects. These reports expand the indications for the ALT free flap while demonstrating good functional and aesthetic outcomes.

SUMMARY

The ALT free flap remains popular for reconstruction of head and neck oncologic defects because of its versatility. Continued evolution in chimeric flap harvest techniques for pharyngocutaneous, osseous and radical parotidectomy defects highlights novel advanced reconstructive uses for the ALT free flap.