Limb salvage of xylazine associated wounds: a case series and technique paper

When microsurgical transfers are required in posttraumatic lower limb reconstruction, surgeons must choose among many types of free flaps. Historically, surgeons have advocated muscular flaps for coverage of open lower extremity wounds, but fasciocutaneous free flaps are now often used with good results. This study aimed to compare the functional and aesthetic outcome of reconstruction by free muscular latissimus dorsi (LD) flap and free fasciocutaneous anterolateral thigh (ALT) flap used for soft tissue coverage of distal lower extremity open fractures. We performed a single-center, retrospective study of subjects with distal lower limb open fractures treated with LD flaps or ALT flaps between 2008 and 2014. Patients with limited follow-up or incomplete data were excluded from the analysis. Donor and recipient sites, early complications and long-term outcomes (functional and aesthetic) were studied and compared according to the type of flap. A total of 47 patients were included: 27 patients in the LD flap group and 20 patients in the ALT flap group. No significant difference was found regarding early and late complications and long-term functional outcomes (bone healing, infectious bone complications, flap healing). As for aesthetic outcome and donor-site morbidity, reconstruction using the ALT free flap had significantly better results (p < 0.05). In posttraumatic lower limb injury, either LD or ALT free flaps can be used for wound coverage with comparable long-term functional outcomes. The ALT flap provides better cosmetic results than LD.

To investigate the hemodynamics evidence of the descending branch of lateral circumflex femoral artery in a reversed way. To explore the clinical result of using the reversed descending branch of the lateral circumflex femoral artery as the receipt artery for free flaps for reconstruction of the leg soft-tissue defect. From October 2005 to February 2012, 38 patients with severe leg soft-tissue defects were treated. The proximal antegrade and retrograde mean artery pressure of the descending branch of the lateral circumflex femoral artery in 16 of 38 patients were recorded during operation. All wounds had osteomyelitis, bone and tendon exposure requiring coverage reconstruction. And there was no recipient artery in the injured lower leg for free flaps in all 38 patients. Reversed descending branches of lateral femoral circumflex arteries were used as recipient arteries for free flaps (free latissimus dorsi flap, free thoracoumbilical flap, and free anterolateral thigh flap) in all patients. The flap donor site was closed directly or with the skin graft. The proximal antegrade mean artery pressure of the descending branch of lateral circumflex femoral artery was(81.6 +/- 12.4) mmHg. The proximal retrograde pressure was(48.2 +/- 10.7) mmHg. The proximal retrograde mean artery pressure was 59.07 percent of the proximal antegrade pressure. The donor skin graft survived and wound healed primarily. After operation, 2 flaps had distal partial necrosis and healing was achieved after dressing change. All the other flaps survived completely without vascular problems. All the patients were followed up for 11 months to 2.5 years (mean, 1.6 years). The flap appearance was satisfactory. The texture and color of flaps in all cases were good. The reverse descending branch of lateral circumflex femoral artery is a reliable recipient artery for the free flaps. It is an easy and simple technique that can be used for reconstruction of the defects in the lower leg, with the reversed descending branch of lateral circumflex femoral artery as recipient artery.

Latissimus dorsi (LD) free flap and reconstruction plate used for extensive maxillo-mandibular reconstruction after tumour ablation

PurposeRobotic-assisted surgery currently is evolving as a new field in microsurgery with potential benefits for reconstructive surgery. The Symani® Surgical System has shown feasibility in performing microsurgical anastomosis. Reconstruction of the soft tissue of the scalp is commonly necessary after brain surgery with reconstruction of the cranium using foreign materials such as PEEK (Polyether ether ketone). We describe our experience with free soft tissue transfer with a free anterolateral thigh (ALT) flap or free latissimus dorsi (LD) flap for reconstruction of the scalp using the Symani® Surgical System for microsurgical anastomosis.MethodsWe analyzed 6 patients with soft tissue defects of the scalp from September 2023 to January 2024 undergoing soft tissue reconstruction with a free ALT or LD flap. Robotic-assisted microsurgical anastomoses were performed using the Symani® Surgical System.Results4 male patients and 2 female patients (age 61-81 years, mean 71.8 years) were included. Mean hospital stay was 10 (8-13) days. The most common recipient vessels were the Superficial temporal artery and vein (66.7%). In other cases, we used the facial artery and vein. All arterial anastomoses were performed by using the Symani® Surgical System. The mean operative time was 387 (328-48) minutes. The mean anastomosis time using the Symani® Surgical System was 32.5 (19-44) minutes. No flap loss was observed. One patient suffered from a PEEK infection as a delayed post-operative complication.ConclusionFor reconstruction of soft tissue defects of the scalp, a free ALT or LD flap represents a proper treatment option. Performing microanastomosis using the Symani® Surgical System is a safe technology and is leading to satisfactory outcomes.

Free flap reconstruction of elbow soft tissue defects: Lessons learned from 15 years of experience.

The anterolateral thigh (ALT) free flap is widely used for various reconstructions in the head and neck. However, its use in the oropharynx has not been widely evaluated, so we have reviewed our experience. We retrospectively reviewed the medical records of 28 patients with oropharyngeal cancer, who were treated with immediate reconstruction with an ALT free flap after excision. We recorded history, stage of tumour, course of operation, postoperative period, oncological treatment, clinical outcome, and follow-up. The mean age of the patients was 61 years (range 44–83). Ten of the patients had clinically relevant coexisting conditions. Most of the patients had T3-4 tumours and involved neck nodes. The operations included resection of the tumour, neck dissection, and reconstruction of the oropharynx with an ALT free flap. All donor sites were closed primarily. Eight patients (29%) developed early local complications that required reoperation. Ten patients (36%) had postoperative cardiopulmonary problems. Twenty-seven flaps succeeded; one was lost. There were no other complications or late problems of the donor site except one seroma. Twenty-one patients were given postoperative radiotherapy. After the mean follow-up period of 40 months (range 13–68) 20 patients (71%) were disease-free. Three patients required a permanent gastrostomy and one a permanent tracheostomy. We conclude that the ALT free flap can be used successfully for reconstruction of a lateral oropharyngeal defect with manageable postoperative morbidity.

The use of free flaps greatly improves reconstruction options and quality of life for patients undergoing oncological resections. The anterolateral thigh (ALT) free flap is frequently used in the head and neck. The aim of this review was to provide a summary of published evidence assessing perforator anatomy of this flap. A broad search was undertaken through the PubMed database using the terms "anterolateral thigh free flap" and "perforator". Search limits included English language and human subjects. Studies that examined more than or equal to ten patients were analysed. A total of 23 studies were identified, which included both clinical and cadaver studies. 1251 thighs were examined with the mean number of perforators ranging from 1.15 to 4.26. In the majority of cases, the descending branch of the lateral circumflex femoral artery was the dominant pedicle and took a musculocutaneous route. In some series, up to 5.4% of thighs were identified as having no cutaneous perforators. Venous data is limited with most studies reporting the presence of two concomitant veins of which the largest concomitant vein is selected for venous anastomoses. The ALT free flap is a reconstruction option in head and neck cancer. Adequate perforators for reconstruction are identified in the majority of cases. Increased anatomical perforator knowledge may lead to further uptake of ALT free flap reconstruction and improved intraoperative troubleshooting. Further studies investigating those patients with no perforators in the ALT may lead to improved clinical outcomes.

Optimizing functional upper extremity reconstruction-Simultaneous free anterolateral thigh flap and tendon transfers-A case report.

A new phalloplasty technique: the free anterolateral thigh flap phalloplasty

The primary strategy for treating oral squamous cell carcinoma (OSCC) is therapeutic resection, with the trismus resection defect reconstructed via free flap. The most popular free flaps include the radial forearm free flap (RFFF) and anterolateral thigh free flap (ALT). This study investigated the relationships between the hospitalization period and a variety of surgical outcomes, as well as maximum inter-incisor distance (IID), in trismus patients who chewed betel nuts. Forty-nine primary OSCC patients who chewed betel nuts and underwent surgical resection and reconstruction between 2010 and 2016 were enrolled in this retrospective study. The data were from a single center in Taiwan. The outcome variable after flap recovery surgery was the duration of postoperative hospitalization. Other factors that were analyzed comprised correlations between hospitalization and a variety of factors, including postoperative inter-incisor distances (IIDs), operative time, gender, and WBC count, upon stratification into two reconstruction groups. The mean postoperative hospitalization duration in the ALT group was 22.9 ± 7.2days, which was significantly shorter than that in the RFFF group (27.8 ± 7.0days; p = 0.019). Two-week postoperative IID (ALT group: 16.1 ± 0.8mm; RFFF group: 7.0 ± 0.6mm) was inversely related to the duration of hospitalization (p = 0.022, r = - 0.372). The ALT flap is more effective than the RFFF flap to reduce the length of hospitalization in trismus patients. The ALT flap should be considered as a first-line technique in OSCC reconstruction in trismus patient reconstruction.

Traditionally, the anterolateral thigh (ALT) free flap is used in distal lower extremity reconstruction. Reverse ALT flap has become one of the most popular choices for knee joint soft tissue defects. A 53-year-old man sustained a degloving injury in the right lateral side of the lower extremity from the lateral malleolar area to the knee joint area. The contamination was severe, necessitating serial debridement and negative pressure wound therapy. After 4 weeks, no more soft tissue necrosis was evident. No more microorganism growth was confirmed by swab culture. ALT free flap using proximal perforator was planned for lateral malleolar area reconstruction and reverse ALT flap using distal perforator was planned to cover knee joint after confirming the pedicle length was sufficient for simultaneous knee and lateral malleolar area reconstruction.

Electrical injuries, often caused by high-voltage currents from sources like arc flashes or ignited clothing, frequently result in extensive burns, particularly to the hands. The upper extremities, being common contact points for electrical injuries, are susceptible to severe tissue damage, including burns, nerve, muscle, and vascular damage. High-voltage electrical burns often require surgical intervention, with an emphasis on restoring both function and form. This study aims to compare the effectiveness of two free flap techniques—Anterolateral Thigh (ALT) and Superficial Circumflex Iliac Artery Perforator (SCIP)—in the reconstruction of hand burns resulting from electrical injuries. Authors conducted a literature review based on cases from the burn unit at Pertamina Central Hospital, Jakarta, focusing on two patients who underwent reconstruction using the ALT and SCIP free flaps. The ALT free flap, characterized by its versatile and reliable tissue coverage, was utilized in one case, while the SCIP free flap, known for its thin and pliable tissue, was employed in the other. The study reviews the anatomy, advantages, and limitations of each flap, considering factors such as functional outcomes, aesthetic results, donor site morbidity, and surgical complexity. Both techniques were shown to offer significant benefits in reconstructing complex burn injuries, with the ALT flap providing robust coverage and the SCIP flap offering superior contour and functional outcomes for smaller defects. The findings underscore the versatility of both flaps in electrical burn reconstruction, highlighting the importance of choosing the appropriate technique based on the size and location of the defect. This study contributes valuable insights into the selection of free flap techniques for reconstructing hand injuries caused by electrical burns, aiming to optimize patient outcomes in terms of both functionality and aesthetics.

PURPOSE: The anterolateral thigh (ALT) free flap is one of the most commonly used flaps for head and neck reconstruction. Given that perforators of an ALT flap routinely arise sequentially from the descending branch of the lateral circumflex artery as it descends down the thigh, a long ALT flap can be more reliably harvested than a wide ALT flap. The purpose of this study is to demonstrate indications and outcomes for single-pedicle ALT free flaps compared to double-pedicle ALT flaps as well as multiple simultaneous thigh (MST) flaps. METHODS: Our series of 81 consecutive patients undergoing head and neck reconstruction with an ALT flap was retrospectively reviewed. Patients with a composite mandibular defect who underwent reconstruction with both a fibular free flap and an ALT free flap were excluded. Receiver operating characteristics curve analysis was performed to determine our cut-off values for width and length of single-pedicle versus double-pedicle ALT flaps. RESULTS: Fifty-seven and 18 patients were reconstructed with an ALT flap with one or two pedicles, respectively. Six patients underwent MST flaps. Defect size (width ≥12 cm, length ≥17 cm) for cutaneous defects (p<0.05), the presence of divergent mucosal defects, and through-and-through oral cavity or pharyngeal defects were associated with the use of two pedicles. There was one flap failure of a single-pedicle ALT flap. While operative time was increased for the groups of double-pedicle ALT flaps and MST flaps, there were no flap complications including partial flap loss, venous congestion, or wound healing issues from poor flap perfusion. CONCLUSION: Harvesting an ALT flap with two pedicles has the potential to reduce flap complications and should be considered for divergent and extremely wide (>12 cm) or extremely long (>17 cm) defects. Our proposed algorithms will help guide flap choice when designing an ALT free flap for a cutaneous and/or mucosal defect of the head and neck. B.B. Trinh: None. I.E. Rodriguez: None. F.W. Deleyiannis: None.

Tracheoesophageal fistulae (TEF) are pathologic connections formed between the trachea and esophagus.1 In adults, TEF is a rare acquired condition presenting with dysphagia, recurrent pulmonary infections, and respiratory distress.1 Acquired TEF carries high risk of mortality due to complications of pulmonary infection and interference with nutrition.1 Surgical management is required, with common approaches including direct suture closure, tracheal resection and anastomosis, esophageal diversion, and local muscle flaps.2, 3 We present novel use of an anterolateral thigh (ALT) free flap to repair acquired nonmalignant TEF. This study was approved by the Houston Methodist Hospital Institutional Review Board (No. PRO00032976, approved 06/20/22). The patient provided written consent for the publication of study data. A 55-year-old female was admitted for atrial fibrillation with rapid ventricular rate secondary to thyrotoxicosis and acute pulmonary edema, requiring endotracheal intubation and mechanical ventilation. Tracheostomy was performed three weeks after admission for acute hypoxic respiratory failure secondary to MSSA pneumonia. Over the next month, she was unable to tolerate oral feeding due to oropharyngeal dysphagia and recurrent aspiration. Computed tomography (CT) imaging demonstrated TEF and the distal tracheostomy canula in the esophagus. The TEF was confirmed by bronchoscopy in the proximal subglottic trachea (Figure 1A). The defect measured 1.4 × 1.7 cm in aperture and 3 cm in craniocaudal length (Figure 1B,C). The patient underwent left neck exploration and TEF repair with an ALT free flap. The left neck was dissected until the tracheoesophageal groove was visualized. Separation of the laryngotracheal complex and cervical esophagus revealed the fistula (Figure 2A). A single-perforator fasciocutaneous ALT flap was harvested from the left leg and primary closure of the donor site was performed (Figure 2B). The fascial surface of the flap was inset circumferentially within the fistula site along the trachealis margin. The adipose surface of the flap was sewn to the esophageal myomucosal margin of the fistula mouth and the remaining paddle was sewn to the pre-vertebral fascia. The superior thyroid artery and middle thyroid vein were anastomosed to the flap pedicle (Figure 2C). Microvascular arterial anastomosis was performed between the descending circumflex femoral artery and superior thyroid artery. A 2.0 mm coupler was used between the dominant vena comitante of the flap and middle thyroid vein. The neck was closed in layers with placement of two passive Penrose drains. After closure, the endotracheal tube was replaced with a cuffed flexible tracheostomy tube (Figure 2D). The patient was monitored for two weeks postoperatively and had an uncomplicated hospital course. Three weeks postoperatively, her tracheostomy was decannulated and she was able to advance to full oral intake 1 month postoperatively. Around this time, she experienced intermittent tracheal stenosis due to formation of granulation tissue. She underwent four endoscopic dilations with laser excisions of stenotic tissue. The stenotic segment was cultured and treated with inhaled and systemic steroids as well as culture-directed antibiotics. Currently, the patient undergoes monthly bronchoscopies and the mucosa at the prior site of stenosis has stabilized. The flap reconstruction healed well and there is no evidence of recurrent fistula at 11 months (Figure 2E). Acquired nonmalignant TEF is a rare but dangerous complication, occurring in 0.5% of patients who undergo tracheostomy.3 Our patient had multiple risk factors for TEF development including thyrotoxicosis, long-term ventilation, MSSA pneumonia, corticosteroid use, and protein-calorie malnutrition. Free-tissue transfer is a well-established reconstructive option for TEF repair with radial forearm free flaps having been described for repair of malignant, postradiated, and acquired nonmalignant TEF.4, 5 In these patients, local tissue may not be suitable for repair, or the defect may be too complex to close with limited tissue. Since our patient was cachectic with poor tissue thickness and quality at the forearm site, we used a de-epithelialized ALT free flap trimmed in the supra-fascial plane to improve vascularization at the repair site and maximize the chance of successful repair. Although the patient required post-operative management of tracheal stenosis, there was no fistula recurrence and she was able to breathe comfortably and resume oral intake within a month of repair. We describe a case of acquired nonmalignant TEF repaired with ALT free flap, a novel application of a previously described reconstructive technique. We affirm that free flaps are a viable alternative to local muscle flaps for TEF repair and reconstruction. The authors have no funding to report. Sindhura Sridhar, manuscript writing—original draft; study conception and design. Aatin K. Dhanda, manuscript writing—review and editing; study conception and design. Nadia G. Mohyuddin, manuscript writing—review and editing. Joshua J. Kain, manuscript writing—review and editing; supervision; study conception and design. The authors declare no conflict of interest. No financial support was received.

Objective: Microsurgery has found early application in pediatric population despite the initial concerns on the technically challenging microanastomosis. Complex injuries of lower extremities in children have not received the same attention in the international literature, but some specific accidental foot injuries seem to have a particularly high frequency in that age group. The muscle flaps were initially the choice for the coverage of distal lower limb deficits; however, the donor site morbidity and the bulky appearance attracted attention to more delicate flaps, with the fasciocutaneous anterolateral thigh (ALT) flap becoming a basic reconstructive option. The present study considered all journal abstracts and articles on the use of free flaps in children’s extremities in order to evaluate the use of the free ALT flap in pediatric patients. The literature search was performed with “PubMed” and “MEDLINE” databases according to PRISMA guidelines with the systematic review clustering eventually the results of 12 different studies. We investigated the use of 102 free ALT flaps for the reconstruction of traumatic foot defects in children with 95.1% flap survival rate and only 2 complete flap losses noted due to venous thrombosis; 6 flaps went for urgent re-exploration resulting in the unavoidable loss of one flap and the partial necrosis of 3 others. In the vast majority of cases the reconstruction was delayed and the total complication rate was 21.57%. It is reaffirmed that hypertrophic scarring tends to be more common in pediatric patients and split thickness skin graft should be avoided whenever primary closure without extensive tension is possible. More than a quarter (27.27%) of the children necessitated a secondary revision surgery, as the child’s growth and the additional fat tissue make secondary debulking procedures really common. Special perioperative care, atraumatic dissection technique, and well established microsurgical experience are absolutely required when performing a free flap reconstruction in children. Nevertheless, the good functional outcome and the high survival rate of our review highlight the reliability of the free ALT flap for traumatic defects in pediatric foot.