1
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Kim TH, Choi JW, Jeong WS. Pushing boundaries: Anterolateral thigh free flaps for extensive scalp defects beyond previous limits, leveraging imaging modalities with ultrasound and indocyanine green. Microsurgery 2024; 44:e31190. [PMID: 38828550 DOI: 10.1002/micr.31190] [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: 12/02/2023] [Revised: 03/28/2024] [Accepted: 05/10/2024] [Indexed: 06/05/2024]
Abstract
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.
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Affiliation(s)
- Tae Hyung Kim
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jong Woo Choi
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Woo Shik Jeong
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Lu G, Su Y, Jiang Y, Yang L, Wang Y, Shi G, Zhang F, Duan X, Hu H. Improving the visualisation of perforator arteries for anterolateral thigh flaps harvest in CT angiography via sublingual glyceryl trinitrate. Clin Radiol 2023; 78:e791-e797. [PMID: 37574403 DOI: 10.1016/j.crad.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 07/05/2023] [Accepted: 07/08/2023] [Indexed: 08/15/2023]
Abstract
AIM To investigate the improvement of image quality and visualisation of the anterolateral thigh (ALT) flap perforators on computed tomography angiography (CTA) after administration of sublingual glyceryl trinitrate (GTN). MATERIALS AND METHODS Sixty patients with oral lesions received thigh CTA examinations were divided randomly into two groups after administration of sublingual GTN (GTN group) or without administration of sublingual GTN (non-GTN group). Two radiologists calculated the signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and assessed the image quality of each vessel. Besides, the grade of thigh artery, the lumen diameter of deep femoral artery, lateral circumflex femoral artery (LCFA), the descending branch of LCFA and its proximal and distal perforators, and the number and type of visible perforators were evaluated quantitatively. RESULTS The SNR and CNR were not significantly different between the two groups (p>0.05). The image quality of CTA in the GTN group was significantly better than that in the non-GTN group (p<0.01). The lumen diameters of the deep femoral artery, LCFA, the descending branch of LCFA and its perforators were significantly larger in the GTN group than those in the non-GTN group (p<0.01). Compared with the non-GTN group, the number of visible perforators and the number of visible septocutaneous perforators were significantly more in the GTN group, and the qualitative grade of visible perforators was significantly higher (p<0.001). CONCLUSIONS The administration of sublingual GTN in preoperative thigh CTA can improve the image quality and visualisation of perforator vessels, thus could help surgeons to select the optimum ALT flaps.
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Affiliation(s)
- G Lu
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - Y Su
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - Y Jiang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - L Yang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - Y Wang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - G Shi
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - F Zhang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - X Duan
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China.
| | - H Hu
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China.
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3
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Kim H, Cha IH, Kim HJ, Nam W, Yang H, Shin G, Lee C, Kim D. Perforators Detected in Computed Tomography Angiography for Anterolateral Thigh Free Flap: Am I the Only One Who Feels Inaccurate? J Clin Med 2023; 12:4139. [PMID: 37373832 DOI: 10.3390/jcm12124139] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND The number, location, and pattern of perforators in anterolateral thigh(ALT) flap vary and predicting them preoperatively will aid in reconstructing complex head and neck defects. This article suggests guidelines for utilizing CTA imagery to predict perforators of ALT-free flaps. METHODS We retrospectively analyzed 53 Korean patients who underwent reconstruction with ALT flap in our department from March 2021 to July 2022. The location, course, origin, and pedicle lengths predicted in CTA and confirmed in the operation field were recorded and compared. RESULTS Among the 85 intraoperatively-found perforators, 79 were also identified in CTA. Six perforators unidentified in CTA were newly found intraoperatively. The positive predictive value of CTA for the perforator was 100%, with a sensitivity of 79/85 = 92.9%. Of the 79 perforators depicted by the CTA for the flap, CTA and intraoperative findings for the course were consistent in 52 cases, a 9.6 mm median discrepancy being noted between the actual location and CTA. CONCLUSIONS The overall pattern or location of perforation was not significantly different between the two, although some differences were observed. It is suggested that the addition of Doppler imaging, in conjunction with CTA, can aid in perforator detection and help minimize such discrepancies.
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Affiliation(s)
- Hyounmin Kim
- Department of Oral & Maxillofacial Surgery, Yonsei University College of Dentistry, Seoul 03722, Republic of Korea
| | - In-Ho Cha
- Department of Oral & Maxillofacial Surgery, Yonsei University College of Dentistry, Seoul 03722, Republic of Korea
| | - Hyung Jun Kim
- Department of Oral & Maxillofacial Surgery, Yonsei University College of Dentistry, Seoul 03722, Republic of Korea
| | - Woong Nam
- Department of Oral & Maxillofacial Surgery, Yonsei University College of Dentistry, Seoul 03722, Republic of Korea
| | - Hyunwoo Yang
- Department of Oral & Maxillofacial Surgery, Yonsei University College of Dentistry, Seoul 03722, Republic of Korea
| | - Gibum Shin
- Department of Oral & Maxillofacial Surgery, Yonsei University College of Dentistry, Seoul 03722, Republic of Korea
| | - Chena Lee
- Department of Oral and Maxillofacial Radiology, Yonsei University College of Dentistry, Seoul 03722, Republic of Korea
| | - Dongwook Kim
- Department of Oral & Maxillofacial Surgery, Yonsei University College of Dentistry, Seoul 03722, Republic of Korea
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4
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Jeong SH, Koo DY, Moon KC, Dhong ES, Han SK. The turbocharged wide anterolateral thigh perforator flap to reconstruct massive soft tissue defects in traumatized lower extremities: A case series. Front Surg 2022; 9:991094. [PMID: 36386520 PMCID: PMC9645236 DOI: 10.3389/fsurg.2022.991094] [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: 07/11/2022] [Accepted: 10/04/2022] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND Extensive traumatic soft tissue defects in the lower extremities typically require complete coverage of exposed bone because inadequate coverage, such as partial flap loss, may result in bony infection and ultimately lead to limb salvage failure. To achieve complete coverage of these defects, we used the wide anterolateral thigh perforator flap in which the turbocharging procedure augments the blood flow. Herein, we describe our turbocharging technique and discuss its effectiveness. METHODS From January 2014 to December 2020, the turbocharged wide ALTP free flaps were used to treat 13 patients with massive traumatic soft tissue defects in the lower extremities, ranging in size from 22 × 10 cm2 (220 cm2) to 21 × 17 cm2 (357 cm2) (mean, 270 cm2). All ALTP flaps were supplied by perforators from both the transverse branch of the lateral circumflex artery (TB-LCFA) and descending branch of the lateral circumflex artery (DB-LCFA) simultaneously. The turbocharging procedure by connecting the TB-LCFA to a side branch of the DB-LCFA was carried out in all these flaps. A retrospective review of medical records for each patient was performed. RESULTS The size of the transferred ALTP flap ranged from 23 × 12 cm2 (276 cm2) to 23 × 19 (437 cm2) (mean, 331 cm2). The total number of perforators included in the flaps was three on average. All ALTP flaps survived completely without partial necrosis. The postoperative course was uneventful except for two cases with minor complications, including hematoma and partial necrosis of the recipient's skin. CONCLUSION Free transfer of the turbocharged wide ALTP flap can be a reliable and effective reconstructive method to obtain complete coverage of extensive traumatic soft tissue defects in the lower extremities and achieve successful limb salvage.
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Affiliation(s)
- Seong-Ho Jeong
- Department of Plastic Surgery, Korea University Guro Hospital, Seoul, South Korea
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Kalra GS, Gupta S, Kalra S. Pedicle First Anterior Approach to Harvest Anterolateral Thigh Flap—Review of 304 Cases. Indian J Plast Surg 2022; 55:272-276. [PMID: 36325079 PMCID: PMC9622332 DOI: 10.1055/s-0042-1756128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background
Although considered as a workhorse flap, the anterolateral thigh (ALT) flap has a steep learning curve that makes it difficult for microsurgeons to perform it early in their practice. In over 85% of patients, the perforator takes an intramuscular course making it difficult for beginners to safely secure the perforator dissection. In this technique, the pedicle is dissected first, utilizing the proximal incision by palpating the groove in between vastus lateralis and rectus femoris on the anterior aspect and extending the incision from 2 to 3 cm distal to the inguinal ligament to the flap markings caudally. Exposing the pedicle first makes it easier to proceed toward the skin perforator due to its easy identification and larger size at its origin.
Patients and Methods
This retrospective study was conducted from 2005 to 2020 in which 304 ALT flaps were performed by the pedicle first technique. Flap harvest time, incidence of injury to the skin perforator during harvest, flap re-exploration rates, and postoperative complications including incidence of flap necrosis, infection, and bleeding were the parameters that were measured.
Results
This study included a total of 304 patients of which 220 were male (72.3%). The average flap harvest time was 26 ± 3.2 minutes. Adverse events included perforator injury (
n
= 1), flap re-exploration (
n
= 15), and complete flap loss (
n
= 8). The last eight patients were reconstructed secondarily with ALT flap from the opposite side and free latissimus dorsi flap (
n
= 2).
Conclusion
The pedicle first technique makes ALT flap harvest easy, safe, and faster for plastic surgeons. The chances of injury to the skin perforator are markedly less thereby reducing postoperative complications.
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Affiliation(s)
- GS Kalra
- Department of Plastic, Reconstructive and Burns Surgery, SMS Hospital Jaipur, Rajasthan, India
| | - Samarth Gupta
- Department of Plastic, Reconstructive and Burns Surgery, SMS Hospital Jaipur, Rajasthan, India
| | - Sushrut Kalra
- Department of Plastic, Reconstructive and Burns Surgery, SMS Hospital Jaipur, Rajasthan, India
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Illg C, Krauss S, Rachunek K, Thiel JT, Daigeler A, Schäfer RC. Thermography Supported Color Duplex Ultrasound Accelerates ALT Perforator Imaging. J Reconstr Microsurg 2022; 39:295-300. [PMID: 36150693 DOI: 10.1055/s-0042-1755614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND The anterolateral thigh flap is a versatile and dependable perforator flap and is a popular choice in the reconstruction of various body sites. The variable perforator anatomy suggests preoperative perforator imaging to improve safety and speed of dissection. An innovative perforator imaging technique is thermography, which lately gained attention in plastic surgery. METHODS Thirty-two healthy participants were included in this randomized study. One thigh was examined with dynamic infrared thermography and consecutively with ultrasound, while the contralateral thigh was examined with ultrasound as standalone technology. RESULTS The application of dynamic infrared thermography prior to ultrasound perforator identification significantly accelerated the ultrasound examination duration by 90 to 130 seconds. The mean duplex ultrasound examination duration correlated positively with the hotspot and perforator quantity per thigh. CONCLUSION The addition of thermographic perforator mapping can accelerate color duplex ultrasound anterolateral thigh perforator imaging. Furthermore, thermography supplements color duplex ultrasound with crucial information on angiosome location.
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Affiliation(s)
- Claudius Illg
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Sabrina Krauss
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Katarzyna Rachunek
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Johannes Tobias Thiel
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Adrien Daigeler
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Ruth Christine Schäfer
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
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7
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Lee SS, Hong JW, Lee WJ, Yun IS. Perforating patterns of cutaneous perforator vessels in anterolateral thigh flaps for head and neck reconstruction and clinical outcomes. Arch Craniofac Surg 2022; 23:64-70. [PMID: 35526841 PMCID: PMC9081423 DOI: 10.7181/acfs.2022.00171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 11/30/2022] Open
Abstract
Background Anterolateral thigh (ALT) flaps are versatile soft tissue flaps that have become the standard soft-tissue flaps used for head and neck reconstruction. They provide a long vascular pedicle, constant vessel diameter, abundant soft tissue coverage, and minimal donor site morbidity. The ALT flap was initially designed on the basis of a septocutaneous (SC) perforator. However, more recent research has shown that a substantial number of ALT flaps are now based on musculocutaneous (MC) perforators, and the ratio between MC and SC perforators varies among studies. In this study, we analyzed the perforating pattern of ALT flaps along with their clinical outcomes during head and neck reconstruction in the Korean population. Methods From October 2016 to July 2020, 68 patients who had undergone an ALT flap procedure for head and neck reconstruction were enrolled retrospectively. The perforating pattern of the cutaneous perforator vessel (MC perforator/SC perforator/oblique branch), pedicle length, and flap size were analyzed intraoperatively. Patient demographics and flap necrosis rates were also calculated. Results The highest number of cutaneous perforator vessels supplying the ALT flap were the MC perforators (87%). The proportion of MC perforators was significantly higher than that of the SC perforators and oblique branches. Flap necrosis occurred in seven cases (11.86%); sex, hypertension, diabetes mellitus, coronary artery disease, perforator course, and history of radiotherapy did not significantly affect flap necrosis. Conclusion The ALT free flap procedure remains popular for reconstruction of the head and neck. In this study, we observed that the majority of cutaneous vessels supplying the flaps were MC perforators (87%). When using the MC perforator during flap elevation, careful dissection of the perforator is required to achieve successful ALT flaps because intramuscular dissection is difficult. Perforator pattern and history of radiotherapy did not affect flap necrosis.
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Affiliation(s)
- Sang Soo Lee
- Department of Plastic and Reconstructive Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Won Hong
- Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, Korea
- Department of Plastic and Reconstructive Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Won Jae Lee
- Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, Korea
- Department of Plastic and Reconstructive Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - In-Sik Yun
- Department of Plastic and Reconstructive Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, Korea
- Correspondence: In-Sik Yun Department of Plastic and Reconstructive Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea E-mail:
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Hung NT, Doan LV, Trung VH, Cuong NV. A vascular anatomical study of the anterolateral thigh flap in the Vietnamese’s adult cadavers. Ann Med Surg (Lond) 2022; 76:103416. [PMID: 35308429 PMCID: PMC8928132 DOI: 10.1016/j.amsu.2022.103416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/14/2022] [Accepted: 02/21/2022] [Indexed: 11/04/2022] Open
Abstract
Background The aim of this study was to confirm the morphometry of the anterolateral thigh (ALT) pedicle and the location of the perforators in the adult Vietnamese population. Material and methods Forty dissections of the thigh were carried out in 20 Vietnamese dedicate cadavers. Including 13 cadavers were fixed by Formalin and 7 cadavers were fixed by fridge. The number, origin, location of the perforators and the diameter of the ALT pedicles were studied and measured. Results The length of the thigh was 39.9 ± 2.8 cm. 39/40 cases (97.5%) were a perforator of a 4 cm circle drawn at the midpoint thigh. There were 161 perforators. In 82.7% of perforators were musculocutaneous perforators and 17.3% perforators were septocutaneous perforators. There were 5 types of vascular pedicles. Type 1: the perforators originated from the descending branch were 65%; Type 2: from the oblique branch were 22.5%; Type 3: from the transverse branch were 5%; Type 4: from profunda femoris were 5%; Type5: from femoral artery were 2,5%. The average length of the flap pedicle was 11.6 ± 2.4 cm, the diameter of the artery was 2.51 ± 0.52 mm, the vein was 2.95 ± 0,56 mm and 2.18 ± 0,46. Conclusion The ALT flap is a constant vascular supply, a long pedicle with a suitable diameter for anastomoses. The ALT can be harvest widely and reliable with a perforator of a 4 cm circle drawn at the midpoint thigh. The types of perforators pedicles originating from lateral circumflex femoral artery. Confirm the morphometry and the location of the vascular pedicle of the anterolateral thigh (ALT) flap in the adult Vietnamese population. The ALT flap can be harvested widely and reliable with a perforator of a 4cm circle drawn at the midpoint of the thigh.
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Moore R, Mullner D, Nichols G, Scomacao I, Herrera F. Color Doppler Ultrasound versus Computed Tomography Angiography for Preoperative Anterolateral Thigh Flap Perforator Imaging: A Systematic Review and Meta-Analysis. J Reconstr Microsurg 2021; 38:563-570. [PMID: 34959247 DOI: 10.1055/s-0041-1740958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The anterolateral thigh (ALT) perforator flap is a commonly used flap with a predictable, though often variable, perforator anatomy. Preoperative imaging with color Doppler ultrasound (CDU) and computed tomography angiography (CTA) of ALT flap perforators can be a useful tool for flap planning. This study provides a complete review and analysis of the relevant preoperative ALT imaging literature. METHODS Studies related to preoperative CDU and CTA imaging were reviewed, and information related to imaging method, sensitivity, false-positive rates, and perforator course identification (musculocutaneous vs. septocutaneous) were analyzed. RESULTS A total of 23 studies related to preoperative ALT flap CDU and CTA imaging were included for review and analysis. Intraoperative perforator identification was compared with those found preoperatively using CDU (n = 672) and CTA (n = 531). Perforator identification sensitivity for CDU was 95.3% (95% CI: 90.9-97.6%) compared with the CTA sensitivity of 90.4% (95% confidence interval [CI]: 74.4-96.9%). The false-positive rate for CDU was 2.8% (95% CI: 1.1-4.5%) compared with 2.4% (95% CI: 0.7-4.1%) for CTA. Accuracy of perforator course identification was 95.5% (95% CI: 93.6-99.2%) for CDU and 96.9% (95% CI: 92.7-100.1%) for CTA. CONCLUSION CDU provides the reconstructive surgeon with greater preoperative perforator imaging sensitivity compared with CTA; however, false-positive rates are marginally higher with preoperative CDU. Preoperative imaging for ALT flap design is an effective tool, and the reconstructive surgeon should consider the data presented here when selecting a flap imaging modality.
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Affiliation(s)
- Reece Moore
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Donna Mullner
- Division of Plastic and Reconstructive Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Georgina Nichols
- Division of Plastic and Reconstructive Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Isis Scomacao
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina.,Division of Plastic and Reconstructive Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Fernando Herrera
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina.,Division of Plastic and Reconstructive Surgery, Medical University of South Carolina, Charleston, South Carolina
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Anatomical variations in the origins of the lateral circumflex femoral arteries in a South African sample: A cadaver study. TRANSLATIONAL RESEARCH IN ANATOMY 2021. [DOI: 10.1016/j.tria.2020.100098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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11
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Zapata-Ospina A, Chen J, Tee R, Jeng SF, Karki B, Shih HS. Harvesting the anterolateral thigh flap with non-sizable perforators. J Plast Reconstr Aesthet Surg 2020; 74:1022-1030. [PMID: 33551361 DOI: 10.1016/j.bjps.2020.10.063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/30/2020] [Accepted: 10/20/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The anterolateral thigh flap (ALT) has proven over time to be one of the best reconstructive workhorses due to its versatility and reliability. Without preoperative imaging, vascular anomalies such as having no sizable perforator are sometimes encountered during dissection. We propose a technique, based on a modified version of the traditional myocutaneous ALT to allow harvest of the flap based on non-sizable perforators. This technique can also enable the splitting of a flap when only one sizable perforator is present. METHODS A retrospective review of patients who received reconstruction with free ALT flap from 2013 to 2019 by the senior author HSS was performed and included all flaps in which non-sizable perforators were harvested. Data collected for analysis included patient demographics, flap size, defect location, inset type, and flap survival. SURGICAL TECHNIQUE Despite detachment of the majority of skin paddle from the muscle, the flap is harvested with a sleeve of areolar tissue containing preferably more than one non-sizable perforator attached to a small muscular segment of the vastus lateralis containing the pedicle. RESULTS A total of 349 ALT flaps were performed during the review period by senior author HSS, and 25 flaps were harvested with non-sizable perforator, 10 of which were to enable a split. There were no total losses and 6 partial losses; 2 were amenable to direct closure after debridement, 1 required skin graft, and 3 required a new flap for wound coverage. Incorporating more than one non-sizable perforator increases the reliability of the flap. This technique should be used with caution in patients with multiple underlying comorbidities and when a flow-through flap is required. We were able to achieve primary closure of all donor sites. CONCLUSIONS It is possible to harvest the anterolateral thigh flap without sizable perforators by conversion to a modified version of the myocutaneous flap. In well-selected patients, using our technique, several non-sizable perforators can reliably perfuse an ALT without the need to use an alternative donor site. This maximizes the number of harvestable ALTs and increases the reconstructive potential by splitting previously "un-splitable" flaps.
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Affiliation(s)
- Alejandro Zapata-Ospina
- Plastic, Reconstructive and Microsurgery Department, Pablo Tobón Uribe Hospital, Cl. 78b #69-240, Medellín, Antioquia, Colombia
| | - Jill Chen
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, No.1 Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City 82445, Taiwan, R.O.C
| | - Richard Tee
- Auckland Regional Plastic Reconstructive and Hand Surgery Service, Middlemore Hospital, 100 Hospital Road, Auckland, New Zealand
| | - Seng-Feng Jeng
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, No.1 Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City 82445, Taiwan, R.O.C
| | - Bishal Karki
- Department of Burns, Plastic & Reconstructive Surgery, Kirtipur Hospital, Swet Binayak Marg, Thapathali-11, Kathmandu, Nepal
| | - Hsiang-Shun Shih
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, No.1 Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City 82445, Taiwan, R.O.C..
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Zubler C, Haberthür D, Hlushchuk R, Djonov V, Constantinescu MA, Olariu R. The anatomical reliability of the superficial circumflex iliac artery perforator (SCIP) flap. Ann Anat 2020; 234:151624. [PMID: 33129977 DOI: 10.1016/j.aanat.2020.151624] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 08/23/2020] [Accepted: 10/12/2020] [Indexed: 12/31/2022]
Abstract
INTRODUCTION In order to achieve a satisfactory functional and aesthetic result a thin skin flap is often required in surgical reconstruction of various body regions. Perforator flaps based on either the superficial or deep branch of the superficial circumflex iliac artery (SCIA) have been used for this purpose mainly in the Asian population. Recently the superficial plane has been established as a new way of elevating the flap. Anatomical studies and details of this new flap are lacking. MATERIAL AND METHODS Wide areas were harvested subfascially from the groin of Thiel-fixated cadavers. Both deep and superficial branches of the superficial circumflex iliac artery were carefully dissected and individually injected with μAngiofil. After CT-imaging the flaps were raised on the superficial plane, perforators were marked and the flaps subsequently rescanned. High-resolution images of regions of interest were taken using micro-CT. RESULTS A total of 21 flaps were harvested and analyzed. Both the deep and superficial branch provided more than three perforators per branch, however, the deep branch based flap was significantly larger (202 vs. 112 cm2, p < 0.01) and had a longer pedicle (9.1 vs. 6.6 cm, p < 0.01). Raising the flap in the superficial plane reliably reduces bulk and increases homogeneity. CONCLUSIONS The SCIP flap appears to have a reliable vascular blood supply. The SCIA and its main branches and perforators have a consistent vascular pattern. The deep branch of the SCIA has the anatomic potential to be the preferred pedicle in case larger flaps with longer pedicles are necessary.
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Affiliation(s)
- Cédric Zubler
- Institute of Anatomy, University of Bern, Baltzerstrasse 2, 3012 Bern, Switzerland; Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - David Haberthür
- Institute of Anatomy, University of Bern, Baltzerstrasse 2, 3012 Bern, Switzerland
| | - Ruslan Hlushchuk
- Institute of Anatomy, University of Bern, Baltzerstrasse 2, 3012 Bern, Switzerland
| | - Valentin Djonov
- Institute of Anatomy, University of Bern, Baltzerstrasse 2, 3012 Bern, Switzerland
| | - Mihai A Constantinescu
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Radu Olariu
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, Freiburgstrasse, 3010 Bern, Switzerland.
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Ritschl LM, Fichter AM, Bomhard AV, Koerdt S, Kehl V, Kolk A, Wolff KD, Grill FD. Comparison between Different Perforator Imaging Modalities for the Anterolateral Thigh Perforator Flap Transfer: A Prospective Study. J Reconstr Microsurg 2020; 36:686-693. [PMID: 32712944 DOI: 10.1055/s-0040-1714425] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Perforator imaging is routinely performed before perforator flap harvest. Hand-held Doppler (hhD) and color duplex ultrasonography (CDU) are currently the most popular radiation-free methods for this purpose that can be applied by the surgeon alone. The aim of this study was to compare the accuracy, reliability, and feasibility of hhD and CDU with indocyanine green angiography (ICGA) in the anterolateral thigh perforator flap (ALTPF). METHODS All consecutive ALTPF procedures between May 2017 and April 2018 were included in this prospective study. The perforators were visualized by three investigators independently and randomized, applying hhD, CDU, and ICGA. The presence and the distance to the identified perforator were registered. Further, body mass index (BMI), American Society of Anesthesiologists-status, and the patient's history regarding smoking, alcohol use, and diabetes mellitus were registered alongside gender and age to analyze possible confounders. RESULTS A total of 12 patients were enrolled with a median age of 67 (52-87) years. In total, 30 perforators were detected intraoperatively as well as with the ICGA. The latter visualized the perforators significantly more precisely than hhD and CDU (p < 0.001 and p = 0.001). The sensitivity and positive predictive value were 67 and 62% for hhD, 73 and 64% for CDU, and 100 and 100% for ICGA, respectively. CONCLUSION According to this study, ICGA visualized perforators more accurately than the standard methods hhD and CDU. Further, it was associated with the highest sensitivity and positive predictive value. ICGA consistently delivered excellent results, whereas hhD and CDU showed variability.
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Affiliation(s)
- Lucas M Ritschl
- Department of Oral and Maxillofacial Surgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Andreas M Fichter
- Department of Oral and Maxillofacial Surgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Achim von Bomhard
- Department of Oral and Maxillofacial Surgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Steffen Koerdt
- Charité - Universitätsmedizin Berlin, Berlin, Germany.,Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Department of Oral and Maxillofacial Surgery, Berlin Institute of Health, Berlin, Germany
| | - Victoria Kehl
- Institute of Medical Informatics, Statistics and Epidemiology, Technical University of Munich, School of Medicine, Munich, Germany
| | - Andreas Kolk
- Department of Oral and Maxillofacial Surgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Klaus-Dietrich Wolff
- Department of Oral and Maxillofacial Surgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Florian D Grill
- Department of Oral and Maxillofacial Surgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
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Cohen OD, Abdou SA, Nolan IT, Saadeh PB. Perforator Variability of the Anterolateral Thigh Flap Identified on Computed Tomographic Angiography: Anatomic and Clinical Implications. J Reconstr Microsurg 2020; 36:616-624. [PMID: 32643763 DOI: 10.1055/s-0040-1713668] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The anterolateral thigh (ALT) flap is a useful flap with minimal donor site morbidity. Preoperative computed tomographic angiography (CTA) for lower extremity reconstruction can determine vessel integrity and plan for recipient vascular targets. This study reviews lower extremity CTAs to further characterize ALT vascular anatomy and associated clinical implications thereof. PATIENTS AND METHODS Lower extremity CTA studies were retrospectively reviewed, and information on ALT cutaneous perforator location, origin, and course was collected. RESULTS A total of 58 lateral circumflex femoral artery (LCFA) systems in 31 patients were included. Average age was 38.8 ± 15.9 years with mean body mass index of 27.2 ± 5.7 kg/m2. The majority of patients were females (23, 74.2%). The LCFA most commonly originated from the profunda femoris artery (87.3%), followed by the distal common femoral artery (9.1%). On average, there were 1.66 ± 0.69 cm perforators per extremity, with an average of 5.38 cm between adjacent perforators. Perforators originated from the descending branch of the LCFA in 89.6% of studies. Perforator caliber was <1 mm (29, 30.2%), 1 to 2 mm (55, 57.3%), or >2 mm (12, 12.5%). Mean distance from the most proximal perforator to the anterior superior iliac spine was 20.4 ± 4.82 cm. Perforators were musculocutaneous (46.9%), septocutaneous (34.4%), or septomyocutaneous (18.8%). In 58.1% of patients, only one thigh had easily dissectable septocutaneous and/or septomyocutaneous perforators, in which case preoperative CTA aided in donor thigh selection. CONCLUSION ALT flap cutaneous perforator anatomy varies considerably. Using CTA, we report on rates of septocutaneous, myocutaneous, and septomyocutaneous perforators and underscore its utility in perforator selection.
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Affiliation(s)
- Oriana D Cohen
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Salma A Abdou
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Ian T Nolan
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Pierre B Saadeh
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
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Secondary Reconstruction of Calvarial Defects by Using Free Flap: Report of Consecutive Cases and Analysis of Strategy. J Craniofac Surg 2019; 30:e151-e155. [PMID: 30614995 DOI: 10.1097/scs.0000000000005099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Guo Y, Wei Z, Zeng K, Zhang F, Deng C, Zhang W, Wang D. [Application of high frequency color Doppler ultrasound combined with wide-field imaging in the preoperative navigation of anterolateral thigh perforator flap surgery]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:190-194. [PMID: 30739413 DOI: 10.7507/1002-1892.201810025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To investigate the application of high frequency color Doppler ultrasound (HFCDU) combined with wide-field imaging in the preoperative navigation of anterolateral thigh perforator flap graft. Methods Between January 2017 and March 2018, 28 patients with skin and soft tissue defects were treated, including 22 males and 6 females, with an average age of 33.5 years (range, 17-66 years). The causes of injury included 2 cases of scald scar, 7 cases of heavy object crushing injury, 12 cases of traffic accident injury, 4 cases of fall injury, 2 cases of machine injury, and 1 case of infection ulcer. Injury sites included 6 cases of hand and wrist, 12 cases of lower leg, 10 cases of foot. After debridement, the wound area ranged from 6.0 cm×3.5 cm to 24.0 cm×9.0 cm, and all patients were treated with free circumflex femoral artery perforator flap graft. Combo of HFCDU and wide-field imaging navigation were done preoperatively to detect the origin, quantity, course, surface location, hemodynamic characteristics, and the relationship with body area of perforator branch of lateral circumflex femoral artery. According to the perforator information displayed by wide-field imaging of source artery, the dominant perforator was determined to be a pedicle for designed flap. The flap size ranged from 7.0 cm×4.5 cm to 26.0 cm×7.0 cm. The flap donor area was sutured directly. Results The dominant perforator was successfully detected by HFCDU combined with wide-field imaging in 28 patients before operation. The existence of the perforator was confirmed during operation, and the location was accurate. The course characteristics of the perforate were consistent with the results of wide-field imaging. The grafted flaps survived completely among 27 patients after operation. Necrosis at the edge of the flap was observed in 1 patient, which healed after dressing change. All patients were followed up 3-12 months, with an average of 9 months. All the flaps have good blood supply, good elasticity and shape. The donor areas healed perfectly. Conclusion Using HFCDU and wide-field imaging navigation for designing of anterolateral thigh perforator flaps can clearly show the characteristics of perforators, hemodynamic information, and the relationship with body area, so that the surgeons can understand the perforators more accurately and intuitively, and improve the success and efficiency of flap graft surgery.
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Affiliation(s)
- Yu Guo
- Department of Burn and Plastic Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi Guizhou, 563000, P.R.China
| | - Zairong Wei
- Department of Burn and Plastic Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi Guizhou, 563000,
| | - Kewei Zeng
- Department of Burn and Plastic Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi Guizhou, 563000, P.R.China
| | - Fengling Zhang
- Department of Burn and Plastic Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi Guizhou, 563000, P.R.China
| | - Chengliang Deng
- Department of Burn and Plastic Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi Guizhou, 563000, P.R.China
| | - Wenduo Zhang
- Department of Burn and Plastic Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi Guizhou, 563000, P.R.China
| | - Dali Wang
- Department of Burn and Plastic Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi Guizhou, 563000, P.R.China
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Zhao F, Chen W, Zhao H, Zhang H, Chen Z, Luo Y, Chen T. Therapeutic effects of anterolateral thigh flap transfer in repairing oral and maxillofacial defects after ablative surgery of neoplasms. MINERVA CHIR 2019; 74:452-457. [PMID: 30600961 DOI: 10.23736/s0026-4733.18.07820-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND To investigate the therapeutic effects of anterolateral thigh flap transfer in repairing oral and maxillofacial defects after ablative surgery of neoplasms and to discuss perioperative psychological care. METHODS A total of 80 patients who received oral and maxillofacial surgery for tumor resection in Nanfang Hospital from October 2014 to August 2016 were selected. Patients were randomly divided into control group and observation group, 40 patients in each group. Patients in control group received forearm flap transfer, while patients in observation group were treated with anterolateral thigh flap transfer. RESULTS The survival rate of flap, food intake ability, quality of life and incidence of complication were compared between groups. There was no significant difference in survival rate of the flaps between two groups (P>0.05). No significant difference in food intake was found between groups at 3 months after operation (P>0.05). The UW-QOL scores of the two groups at 1 year after operation were significantly higher than those before operation (P<0.05), and no significant differences in UW-QOL scores were found between two groups at 1 year after operation (P>0.05). Incidence of temporary dysfunction, hyperplastic scar, permanent dysfunction, pigmentation and pruritus was significantly lower in observation group than in control group (P<0.05). There was no significant difference in the incidence of necrosis between two groups (P>0.05). CONCLUSIONS The results showed that anterolateral thigh flap transfer has similar therapeutic effects to those of forearm flap transfer in repairing oral and maxillofacial defects after ablative surgery of neoplasms and improving food intake and quality of life. But Anterolateral thigh flap transfer can reduce the incidence of postoperative complications, so this treatment should be popularized.
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Affiliation(s)
- Fang Zhao
- Department of Stomatology, Nanfang Hospital (The First School of Clinical Medicine), Southern Medical University, Guangzhou, China -
| | - Wei Chen
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China
| | - Hui Zhao
- Department of Blood Transfusion, Nanfang Hospital (The First School of Clinical Medicine), Southern Medical University, Guangzhou, China
| | - Hongxia Zhang
- Department of Stomatology, Nanfang Hospital (The First School of Clinical Medicine), Southern Medical University, Guangzhou, China
| | - Zhifeng Chen
- Department of Stomatology, Nanfang Hospital (The First School of Clinical Medicine), Southern Medical University, Guangzhou, China
| | - Yuling Luo
- Department of Oncology, Nanfang Hospital (The First School of Clinical Medicine), Southern Medical University, Guangzhou, China
| | - Ting Chen
- Department of Nephrology, Nanfang Hospital (The First School of Clinical Medicine), Southern Medical University, Guangzhou, China
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Reconstruction of Thin and Pliable Oral Mucosa After Wide Excision of Oral Cancer Using a Trimmed Anterolateral Thigh Free Flap as an Adipofascial Flap. J Craniofac Surg 2018; 29:e394-e396. [DOI: 10.1097/scs.0000000000004404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Computed Tomographic Angiography Used for Localization of the Cutaneous Perforators and Selection of Anterolateral Thigh Flap "Bail-Out" Branches. Ann Plast Surg 2018; 81:87-95. [PMID: 29746278 DOI: 10.1097/sap.0000000000001433] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the territory supplied by the lateral circumflex femoral artery for the consistency of a proximal perforator that could be used as an alternative pedicle for the anterolateral thigh flap if a tedious intramuscular course is encountered during elevation of the perforator used to develop the initial surgical plan. It is hypothesized that a consistent "bail-out" perforator supplying the proximal thigh would facilitate a simpler anterolateral thigh flap harvest, with minimal modification to flap design. METHODS Computed tomographic images of 9 fresh cadavers were imported using Materialize's Interactive Medical Imaging Control System software to create surface-rendered 3-dimensional reconstructions of 15 lower limbs. Perforators emerging proximally and laterally to a 3-cm radius circle drawn at the midpoint of the anterior superior iliac spine and superolateral patella were considered potential bail-out perforators and evaluated for their number emerging diameter, length, course, and location relative to the anterior superior iliac spine. RESULTS An average of 2.9 ± 1.8 perforators per limb were identified. Mean pedicle length was 111 ± 20 mm, measured from the origin in the lateral circumflex femoral artery to where the perforators emerged through the deep fascia directly overlying the thigh muscles. Average diameter at origin in the lateral circumflex femoral artery was 2.8 ± 0.8 mm, and that at emergence through the deep fascia was 1.1 ± 0.3 mm. Vessel course was predominantly musculocutaneous (90%). CONCLUSIONS A significant bail-out perforator routinely supplies the proximal anterolateral thigh and may be used as an alternative vascular pedicle for an anterolateral thigh flap if a tedious intramuscular course is encountered during elevation of a perforator identified within the conventional landmarks (3-cm radius circle at the midpoint of the anterior superior iliac spine and superolateral patella).
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A Description of the Vascular Anatomy of the Tensor Fascia Lata Perforator Flap Using Computed Tomography Angiography. Ann Plast Surg 2018; 80:S421-S425. [PMID: 29668509 DOI: 10.1097/sap.0000000000001424] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The perforator anatomy of the tensor fascia lata (TFL) flap has been studied using cadaver dissection; however, exact descriptions of location, size, and origin of perforator vessels using preoperative imaging modalities remain limited. The aims of this study are to describe TFL perforator anatomy using high-resolution computed tomography angiography (CTA) and to correlate these findings with landmarks for the anterolateral thigh flap to facilitate flap planning. METHODS We identified 33 patients who previously underwent bilateral lower extremity CTAs for preoperative planning of free-flap reconstruction. The images were retrospectively reviewed, and the TFL perforator number, size, type, location, and overall pedicle origin and length were recorded. RESULTS Thirty-three patients and 59 thighs were included in the study. There was an average of 2.5 perforators per TFL. All perforators arose from the ascending branch of the lateral circumflex femoral artery with an average pedicle length of 8.3 cm (range, 6.0-11.2 cm). Sixty-six percent of perforators were septocutaneous and 34% were musculocutaneous. The average perforator size as measured on CTA was 3 mm. The average perforator location was 10.1 cm inferior and 8.5 cm lateral to the line drawn from the anterior superior iliac spine to the superolateral patella. CONCLUSIONS To our knowledge, this is the first study to characterize the vascular anatomy of the TFL perforator flap using high-resolution CTA and correlate this with well-established landmarks used in the planning for other thigh-based flaps. We believe data will facilitate flap design and dissection; potentially shortening operating room times, limiting exploratory incisions used to confirm the presence of thigh based perforators, and improving overall outcomes for patients.
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Terrell M, Roberts W, Price CW, Slater M, Loukas M, Schober J. Anatomy of the pedicled anterolateral thigh flap for phalloplasty in transitioning-males. Clin Anat 2017; 31:160-168. [PMID: 29178184 DOI: 10.1002/ca.23017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 11/22/2017] [Indexed: 11/10/2022]
Abstract
Incidence of transexualism and request for neophalloplasty is increasing yielding a current prevalence of trans-male in the USA of 1:2500. Surgeons have explored various techniques to improve desirable outcomes of neophallic construction, decrease the length of surgery, and minimize stigmatizing scars. The anterolateral thigh (ALT) flap is an alternative to the traditional radial forearm flap for patients who do not want a forearm scar. Surgical text descriptions were enhanced by the creation of new anatomic illustrations. Anatomy of the donor and recipient sites as well as the surgical technique leading to creation of the neophallus are demonstrated in detail with new relevant illustrations. The ALT flap is a skin, fat and fascia flap that is usually supplied by the descending branch of the lateral circumflex femoral vessels and the lateral femoral cutaneous nerve. However, variability in neurovascular supply does exist with important clinical implications. In the pedicled surgical procedure, neurovascular supply is left partly attached to the donor site ("pedicle") and simply transposed to the perineum, keeping the pedicle intact as a conduit to supply the tissue with blood and innervation. ALT flap offers clinical advantages of less obvious donor site concealable with clothing, decreased surgical time, preservation of erogenous sensation and vascular supply of the flap without microsurgical anastomosis of nerves and vessels, and good potential for urethroplasty. This surgery may be difficult in patients with thicker skin and more subcutaneous thigh fat. Clin. Anat, 2017. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Mark Terrell
- Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania
| | | | | | - Michael Slater
- Lake Erie College of Osteopathic Medicine-Bradenton, Bradenton, Florida
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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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Perforator variability in the anterolateral thigh free flap: a systematic review. Surg Radiol Anat 2017; 39:779-789. [DOI: 10.1007/s00276-016-1802-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 11/17/2016] [Indexed: 11/25/2022]
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Abstract
OBJECTIVE This video article will review the relevant vascular anatomy of the anterolateral thigh flap, describe the CT angiography (CTA) image acquisition, and describe how to report the locations of the perforating arteries along with characteristics that may be important to the surgeon. CONCLUSION Our method of performing and reporting CTA for patients scheduled to undergo anterolateral thigh flap reconstruction provides a reproducible method of identifying perforating vessels and communicating their location to surgeons.
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Kim JW, Kim DY, Ahn KM, Lee JH. Surgical implications of anatomical variation in anterolateral thigh flaps for the reconstruction of oral and maxillofacial soft tissue defects: focus on perforators and pedicles. J Korean Assoc Oral Maxillofac Surg 2016; 42:265-270. [PMID: 27847734 PMCID: PMC5104868 DOI: 10.5125/jkaoms.2016.42.5.265] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 09/08/2016] [Accepted: 09/21/2016] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES To gain information on anatomical variation in anterolateral thigh (ALT) flaps in a series of clinical cases, with special focus on perforators and pedicles, for potential use in reconstruction of oral and maxillofacial soft tissue defects. MATERIALS AND METHODS Eight patients who underwent microvascular reconstructive surgery with ALT free flaps after ablative surgery for oral cancer were included. The number of perforators included in cutaneous flaps, location of perforators (septocutaneous or musculocutaneous), and the course of vascular pedicles were intraoperatively investigated. RESULTS Four cases with a single perforator and four cases with multiple perforators were included in the ALT flap designed along the line from anterior superior iliac spine to patella. Three cases had perforators running the septum between the vastus lateralis and rectus femoris muscle (septocutaneous type), and five cases had perforators running in the vastus lateralis muscle (musculocutaneous type). Regarding the course of vascular pedicles, five cases were derived from the descending branch of the lateral circumflex femoral artery (type I), and three cases were from the transverse branch (type II). CONCLUSION Anatomical variation affecting the distribution of perforators and the course of pedicles might prevent use of an ALT free flap in various reconstruction cases. However, these issues can be overcome with an understanding of anatomical variation and meticulous surgical dissection. ALT free flaps are considered reliable options for reconstruction of soft tissue defects of the oral and maxillofacial area.
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Affiliation(s)
- Ji-Wan Kim
- Department of Oral and Maxillofacial Surgery, Asan Medical Center, Seoul, Korea
| | - Dong-Young Kim
- Department of Oral and Maxillofacial Surgery, Asan Medical Center, Seoul, Korea
| | - Kang-Min Ahn
- Department of Oral and Maxillofacial Surgery, Asan Medical Center, Seoul, Korea
| | - Jee-Ho Lee
- Department of Oral and Maxillofacial Surgery, Asan Medical Center, Seoul, Korea
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Effect of Atherosclerosis on the Lateral Circumflex Femoral Artery and Its Descending Branch: Comparative Study to Nonatherosclerotic Risk. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 4:e856. [PMID: 27757321 PMCID: PMC5054987 DOI: 10.1097/gox.0000000000000849] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 06/17/2016] [Indexed: 02/06/2023]
Abstract
The anterolateral thigh (ALT) flap has been widely used for reconstructions. Nevertheless, the atherosclerotic risk factors that affect the lateral circumflex femoral artery (LCFA) are still inconclusive. The aim was to study the effect of atherosclerosis on the LCFA and descending branch (dLCFA) visualized by computer tomographic angiography (CTA) between nonatherosclerosis and atherosclerosis.
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Algorithmic approach to anterolateral thigh flaps lacking suitable perforators in lower extremity reconstruction. Plast Reconstr Surg 2015; 135:1476-1485. [PMID: 25835248 DOI: 10.1097/prs.0000000000001168] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The anterolateral thigh flap is preferred at the authors' institution for lower extremity reconstruction. When variations in vascular anatomy preclude flap harvest, the authors follow an algorithm for contingency planning. The authors compared outcomes of contingency strategies to anterolateral thigh flaps that go as planned. METHODS Between January of 2001 and February of 2012, 548 free anterolateral thigh flaps were planned for lower extremity reconstruction at Chang Gung Memorial Hospital. In 30 cases, the flap could not be used because perforators were not identified (n = 12), unreliably small (n = 14), or injured (n = 4). Using the authors' algorithm, the flap was converted to an ipsilateral tensor fasciae latae (n = 21), anteromedial thigh (n = 5), or contralateral vastus lateralis myocutaneous flap (n = 4). Outcomes, including flap failure, necrosis, and re-exploration rate, were compared in successful cases and those that required conversion. RESULTS The incidence of unreliably small or absent perforators was 4.8 percent. Adding cases of iatrogenic perforator injury, the incidence was 5.5 percent. There was no difference in flap survival, flap loss, or need for re-exploration regardless of whether or not the anterolateral thigh flap was used. In 70 percent of cases, the authors favored the tensor fasciae latae flap; partial flap necrosis occurred in six of 21 cases, and total flap loss occurred in one. CONCLUSIONS Without preoperative imaging, dilemmas may be encountered in roughly one of 20 anterolateral thigh flaps raised. Using the authors' algorithm, alternative options can reliably confer results comparable to those of planned anterolateral thigh flaps. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Ren ZH, Wu HJ, Wang K, Zhang S, Tan HY, Gong ZJ. Anterolateral thigh myocutaneous flaps as the preferred flaps for reconstruction of oral and maxillofacial defects. J Craniomaxillofac Surg 2014; 42:1583-9. [PMID: 25246225 DOI: 10.1016/j.jcms.2014.04.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 02/28/2014] [Accepted: 04/22/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND The anterolateral thigh myocutaneous flap is one of the most commonly used flaps in reconstructive procedures, but its application in oral and maxillofacial defects has not been fully determined. Herein, we summarize the application of 1212 anterolateral thigh myocutaneous flaps in the repair of oral and maxillofacial defects and examine their benefits in maxillofacial reconstruction of these defects. METHODS Patients were recruited from February 2002 to June 2013 in the Department of Oral and Maxillofacial Surgery of Central South University. All patients underwent reconstructive surgery employing anterolateral thigh myocutaneous flaps. Patient ages ranged from 6 to 82 years with a mean age of 51.2 years. There are 1015 flaps showing single lobe and 197 flaps showing a multi-island pedicle and one of which carries the iliac bone. The largest area among the single flaps was 28 × 12 cm(2), and the smallest was 3 × 2 cm(2). RESULTS Among the 1212 transferred flaps, 1176 survived and 36 showed necrosis, a survival rate of about 97.0%. The common complications at flap donor site were poor wound healing (10.1%), localized paraesthesia (50.1%), and altered quadriceps force (11.0%). No cases presented with local serious complications, and 90% of patients achieved good functional recovery and aesthetically acceptable results after reconstruction of oral and maxillofacial defects at various locations using anterolateral thigh myocutaneous flaps. The time (23-121 min; average 51 min) for anastomosis of one vein and one artery was significantly less than that for two veins and one artery (45-153 min, average 83 min; p = 0.0003), which indicates one vein anastomosis can significantly reduce the operating time. CONCLUSION The anterolateral thigh myocutaneous flaps can be easily obtained and can provide a good amount of muscle for filling dead space and fascia lata. These flaps can be prepared into a separate fat flap, multi-island fascia with iliac bone, and other composite pedicle flaps to meet the various requirements of oral and maxillofacial defects. The subcutaneous fat thickness of the anterolateral area can vary considerably and thus can be used to repair defects requiring different flap thickness. Therefore, the anterolateral thigh myocutaneous free flaps are more suitable for oral and maxillofacial defects than other flaps.
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Affiliation(s)
- Zhen-Hu Ren
- Department of Oral and Maxillofacial Surgery, The Second Xiangya Hospital of Central South University, Renmin Road, No 139, Changsha, Hunan 410011, China.
| | - Han-Jiang Wu
- Department of Oral and Maxillofacial Surgery, The Second Xiangya Hospital of Central South University, Renmin Road, No 139, Changsha, Hunan 410011, China.
| | - Kai Wang
- Department of Oral and Maxillofacial Surgery, The Second Xiangya Hospital of Central South University, Renmin Road, No 139, Changsha, Hunan 410011, China
| | - Sheng Zhang
- Department of Oral and Maxillofacial Surgery, The Second Xiangya Hospital of Central South University, Renmin Road, No 139, Changsha, Hunan 410011, China
| | - Hong Yu Tan
- Department of Oral and Maxillofacial Surgery, The Second Xiangya Hospital of Central South University, Renmin Road, No 139, Changsha, Hunan 410011, China
| | - Zhao Jian Gong
- Department of Oral and Maxillofacial Surgery, The Second Xiangya Hospital of Central South University, Renmin Road, No 139, Changsha, Hunan 410011, China
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Seetharaman SS, Yadav PS, Shankhdhar VK, Dushyant J, Prashant P. Anthropomorphic and perforator analysis of anterolateral thigh flap in Indian population. Indian J Plast Surg 2013; 46:59-68. [PMID: 23960307 PMCID: PMC3745123 DOI: 10.4103/0970-0358.113709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Anterolateral thigh (ALT) flap is one of the most common flaps in the reconstruction armamentarium of plastic surgeons, but there is no published data about the flap characteristics in the Indian population. The aim of this study is to analyse the anthropomorphic characteristics of the ALT flap and the perforator details in Indian population. Materials and Methods: ALT flap details were studied in 65 patients of Indian origin comprising 45 males and 20 females. The study period is from August 2011 to July 2012. A prospective database of the Doppler findings, perforator and pedicle details and the flap morphology were maintained. The variables are analysed by using the SPSS, PASW statistics 18 software IBM®. Results: In nearly 75% of cases, the perforator was found within 4 cm of the pre-operative Doppler markings. The percentage of musculocutaneous and septocutaneous perforators was 61.8% and 38.2% respectively. The pedicle variation was found in 6 cases (9.23%). The average thickness of the thigh skin in Indians is similar to the western people, but thicker than the other Asian people. Flap thinning was performed in nine patients without any major complications. Conclusion: The perforator details and type in the Indian population are similar to the published reports from other parts of the world. We advise pre-operative Doppler examination in possible cases. The variation in pedicle anatomy should not be overlooked to avoid complications. The thickness of subcutaneous tissue of the flap is higher in Indians, but still can be safely thinned. The data of this study will serve as a guide for the ALT flap characteristics in Indian patients.
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Sequential Chimeric Anterolateral Thigh Flap for Reconstruction of Through-and-Through Oropharyngeal Defects with No Suitable Neck Recipient Vessels. Plast Reconstr Surg 2013; 131:1087-1090. [DOI: 10.1097/prs.0b013e3182879f32] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Perforator flap from adjacent thigh skin to improve the repair of the donor site of the anterolateral thigh flap. Microsurgery 2013; 33:249-50. [DOI: 10.1002/micr.22076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 11/05/2012] [Accepted: 11/08/2012] [Indexed: 11/07/2022]
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Lower Extremity Reconstruction Using Vastus Lateralis Myocutaneous Flap versus Anterolateral Thigh Fasciocutaneous Flap. Arch Plast Surg 2012; 39:367-75. [PMID: 22872841 PMCID: PMC3408283 DOI: 10.5999/aps.2012.39.4.367] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 06/12/2012] [Accepted: 06/19/2012] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The anterolateral thigh (ALT) perforator flap has become a popular option for treating soft tissue defects of lower extremity reconstruction and can be combined with a segment of the vastus lateralis muscle. We present a comparison of the use of the ALT fasciocutaneous (ALT-FC) and myocutaneous flaps. METHODS We retrospectively reviewed patients in whom free-tissue transfer was performed between 2005 and 2011 for the reconstruction of lower extremity soft-tissue defects. Twenty-four patients were divided into two groups: reconstruction using an ALT-FC flap (12 cases) and reconstruction using a vastus lateralis myocutaneous (VL-MC) flap (12 cases). Postoperative complications, functional results, cosmetic results, and donor-site morbidities were studied. RESULTS Complete flap survival was 100% in both groups. A flap complication was noted in one case (marginal dehiscence) of the ALT-FC group, and no complications were noted in the VL-MC group. In both groups, one case of partial skin graft loss occurred at the donor site, and debulking surgeries were needed for two cases. There were no significant differences in the mean scores for either functional or cosmetic outcomes in either group. CONCLUSIONS The VL-MC flap is able to fill occasional dead space and has comparable survival rates to ALT-FC with minimal donor-site morbidity. Additionally, the VL-MC flap is easily elevated without myocutaneous perforator injury.
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Seth R, Manz RM, Dahan IJ, Nuara MJ, Meltzer NE, McLennan G, Alam DS. Comprehensive Analysis of the Anterolateral Thigh Flap Vascular
Anatomy. ACTA ACUST UNITED AC 2011. [DOI: 10.1001/archfaci.2011.16] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Rahul Seth
- Section of Facial Aesthetic and Reconstructive Surgery, Head and Neck Institute, Cleveland Clinic (Drs Seth, Manz, Nuara, Meltzer, and Alam), Case Western Reserve University School of Medicine (Mr Dahan), and Imaging Institute, Cleveland Clinic (Dr McLennan), Cleveland, Ohio
| | - Ryan M. Manz
- Section of Facial Aesthetic and Reconstructive Surgery, Head and Neck Institute, Cleveland Clinic (Drs Seth, Manz, Nuara, Meltzer, and Alam), Case Western Reserve University School of Medicine (Mr Dahan), and Imaging Institute, Cleveland Clinic (Dr McLennan), Cleveland, Ohio
| | - Isaac J. Dahan
- Section of Facial Aesthetic and Reconstructive Surgery, Head and Neck Institute, Cleveland Clinic (Drs Seth, Manz, Nuara, Meltzer, and Alam), Case Western Reserve University School of Medicine (Mr Dahan), and Imaging Institute, Cleveland Clinic (Dr McLennan), Cleveland, Ohio
| | - Michael J. Nuara
- Section of Facial Aesthetic and Reconstructive Surgery, Head and Neck Institute, Cleveland Clinic (Drs Seth, Manz, Nuara, Meltzer, and Alam), Case Western Reserve University School of Medicine (Mr Dahan), and Imaging Institute, Cleveland Clinic (Dr McLennan), Cleveland, Ohio
| | - Noah E. Meltzer
- Section of Facial Aesthetic and Reconstructive Surgery, Head and Neck Institute, Cleveland Clinic (Drs Seth, Manz, Nuara, Meltzer, and Alam), Case Western Reserve University School of Medicine (Mr Dahan), and Imaging Institute, Cleveland Clinic (Dr McLennan), Cleveland, Ohio
| | - Gordon McLennan
- Section of Facial Aesthetic and Reconstructive Surgery, Head and Neck Institute, Cleveland Clinic (Drs Seth, Manz, Nuara, Meltzer, and Alam), Case Western Reserve University School of Medicine (Mr Dahan), and Imaging Institute, Cleveland Clinic (Dr McLennan), Cleveland, Ohio
| | - Daniel S. Alam
- Section of Facial Aesthetic and Reconstructive Surgery, Head and Neck Institute, Cleveland Clinic (Drs Seth, Manz, Nuara, Meltzer, and Alam), Case Western Reserve University School of Medicine (Mr Dahan), and Imaging Institute, Cleveland Clinic (Dr McLennan), Cleveland, Ohio
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Chen SY, Lin WC, Deng SC, Chang SC, Fu JP, Dai NT, Chen SL, Chen TM, Chen SG. Assessment of the perforators of anterolateral thigh flaps using 64-section multidetector computed tomographic angiography in head and neck cancer reconstruction. Eur J Surg Oncol 2010; 36:1004-11. [PMID: 20719469 DOI: 10.1016/j.ejso.2010.07.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Revised: 06/20/2010] [Accepted: 07/15/2010] [Indexed: 11/17/2022] Open
Affiliation(s)
- S Y Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Gung Road, Taipei 11490, Taiwan
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The Distribution of the Perforators in the Anterolateral Thigh and the Utility of Multidetector Row Computed Tomography Angiography in Preoperative Planning. Ann Plast Surg 2010; 65:155-60. [DOI: 10.1097/sap.0b013e3181c60f60] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Karonidis A, Ren Chang L. Using the distal part of vastus lateralis muscle as chimeric anterolateral thigh free flap is a more flexible tool for head and neck reconstruction. EUROPEAN JOURNAL OF PLASTIC SURGERY 2010. [DOI: 10.1007/s00238-009-0365-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Gacto P, Barrera F, Sicilia-Castro D, Miralles F, Collell M, Leal S, De La Higuera J, Parra C, Gómez-Cía T. A three-dimensional virtual reality model for limb reconstruction in burned patients. Burns 2009; 35:1042-6. [DOI: 10.1016/j.burns.2008.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2008] [Accepted: 09/01/2008] [Indexed: 11/16/2022]
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Rozen WM, Ashton MW, Pan WR, Kiil BJ, McClure VK, Grinsell D, Stella DL, Corlett RJ. Anatomical variations in the harvest of anterolateral thigh flap perforators: a cadaveric and clinical study. Microsurgery 2009; 29:16-23. [PMID: 18942652 DOI: 10.1002/micr.20550] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The anterolateral thigh (ALT) flap has become increasingly popular due to its versatility and minimal donor site morbidity. Its major limitation has been uncertainty in predicting perforator anatomy, with the occasional absence of suitable perforators and high variability in their size and course. The variability of this anatomy has not been adequately explored previously. METHODS A cadaveric study was undertaken, in which 19 thighs (from 10 fresh cadavers) underwent contrast injection and angiographic imaging. Anatomical variations of the vasculature were recorded. A clinical study of 44 patients undergoing ALT flap reconstruction was also undertaken. Perforator anatomy was described in the first 32 patients, and the subsequent 12 patients underwent computed tomography angiography with a view to predicting individual anatomy and improving operative outcome. RESULTS Cadaver angiography was able to highlight and classify the variations in arterial anatomy, with four patterns observed and marked variability between cases. In 32 patients undergoing ALT flaps without preoperative CT angiography (CTA), five patients (16%) did not have any suitable perforators from the descending branch of the lateral circumflex femoral artery. By selecting the limb of choice with preoperative CTA, the incidence of flap unsuitability was reduced to 0%. Comparing CTA with Doppler, CTA was more accurate (sensitivity 100%) and provided more information. CONCLUSION The perforators supplying the ALT flap show significant variability in location and course, with the potential for unsuitable perforators limiting flap success. Preoperative CTA can demonstrate the vascular anatomy and can aid perforator selection and operative success.
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Affiliation(s)
- Warren M Rozen
- Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy and Cell Biology, The University of Melbourne, Victoria, Australia.
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Harvesting the Lateral Femoral Circumflex Chimera Free Flap: Guidelines for Elevation. Plast Reconstr Surg 2009; 123:918-925. [DOI: 10.1097/prs.0b013e318199f51c] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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