Anterolateral Thigh Flap Donor Site Research Articles

Perineural dexmedetomidine in femoral nerve blocks increases the duration of postoperative analgesia for anterolateral thigh flap donor sites in patients with oral cancer

Although the duration of analgesia provided by a single-shot nerve block is limited, perineural dexmedetomidine significantly enhances nerve blocks during extremity surgery. This study aimed to investigate the role of dexmedetomidine added to ropivacaine in femoral nerve blocks for postoperative analgesia of the anterolateral thigh (ALT) flap donor site in patients with oral cancer. Fifty-two participants scheduled for maxillofacial tumor resection and reconstruction using an anterolateral thigh flap were randomly allocated to either the Ropi group (femoral nerve block with ropivacaine) or the Ropi + Dex group (femoral nerve block with ropivacaine plus dexmedetomidine). The primary outcome was the duration of the sensory block, while the secondary outcomes were 24 h postoperative sufentanil use, number of patients using rescue analgesics, vital signs, postoperative pain score, incidence of agitation, and presence of adverse effects. Dexmedetomidine plus ropivacaine significantly prolonged the duration of sensory block compared with ropivacaine alone (10.4 ± 0.9 h vs 14.0 ± 1.3 h; P < 0.001). Age was positively correlated with increased duration of sensory block (r = 0.300; P = 0.033). Postoperative pain scores at the donor sites were lower in the Ropi + Dex group than in the Ropi group, at 12 h after surgery (P < 0.001). Although there were no statistically significant differences in the incidence of bradycardia between the two groups, four patients treated with dexmedetomidine experienced episodes of bradycardia. Perineural dexmedetomidine prolonged the duration of femoral nerve block and reduced postoperative pain scores at the ALT flap donor sites in patients with oral cancer.

A Bipedicled Flap for Closure of the Anterolateral Thigh Flap Donor Site.

Summary:Anterolateral thigh (ALT) free flaps have become reliable options for head-to-toe reconstruction. Although perforator anatomy is fairly predictable, in cases of eccentric perforator location, we proposed shifting the entire flap laterally and preserving a medial bipedicled flap between the original incision and the new medial flap margin. This facilitates primary donor site closure instead of harvesting a flap larger than anticipated. We conducted a retrospective chart review of ALT flaps performed between 2007 and 2019 and identified patients who underwent bipedicled closure of the donor site. Demographics, flap characteristics, and surgical technique were evaluated. Six patients had bipedicled donor site closure related to primary perforators located lateral to the original flap design. The mean defect size was 91 cm2, and bipedicled flap width ranged from 4 to 6 cm. All donor sites were closed primarily. Five of the donor thigh sites healed without complications, and 1 patient had superficial delayed healing of the medial bipedicled incision, which healed with local wound care. The ALT has become an invaluable flap in microsurgical reconstruction, yet it is not without limitations. Primary donor site closure is generally not feasible for larger flaps, thus necessitating skin grafting of the donor site and/or prolonged wound care. Our technique facilitates primary closure of the donor site in patients who otherwise would have required harvest of a larger than necessary flap based on eccentric perforator anatomy. The medial bipedicled flap is straightforward, reproducible, and allows for modifications of the original flap design to better fit the defect.

Comparison of the modified direct closure method and skin grafting for wounds at the anterolateral thigh flap donor site

ObjectiveThis study was performed to compare the modified direct closure method and traditional skin grafting for wounds at the anterolateral thigh (ALT) flap donor site.MethodsAmong 29 consecutive patients with wounds at the ALT flap donor site, 14 underwent the modified direct closure method (MDC group) and 15 underwent traditional skin grafting (SG group). The operative time, follow-up time, complications, Vancouver Scar Scale (VSS) score, and Scar Cosmesis Assessment and Rating (SCAR) score of the two groups were statistically analyzed.ResultsThe mean follow-up times in the MDC and SG group were 16.1 and 16.7 months, respectively. Two patients showed partial skin necrosis after skin grafting, but the remaining patients’ wounds healed uneventfully. The operative time in the MDC group was an average of about 64 minutes shorter than that in the SG group. The average VSS and SCAR scores in the MDC group were 2.1 and 3.0 points lower, respectively, than those in the SG group.ConclusionsCompared with traditional skin grafting, the modified direct closure method is more efficient for repair of wounds at the ALT flap donor site because of its shorter operative time, better postoperative appearance of the donor site, and higher patient satisfaction.

Surgical Algorithmic Approach to Facilitate Primary Closure of the Anterolateral Thigh Flap Donor Site in Head and Neck Reconstruction.

Use of the anterolateral thigh (ALT) flap has gained popularity in head and neck reconstruction. However, donor sites that cannot achieve primary closure are reported to have poorer functional and aesthetic outcomes. Therefore, we propose an algorithm to facilitate primary closure of the donor site. Since May 2013, when an attempt at donor site direct closure failed, we have used a VY advancement flap or a propeller flap for primary closure of the donor site, using the remnant lateral thigh perforator or nearby medial thigh perforator. Otherwise, a skin graft was used. A total of 91 patients were enrolled in this algorithmic approach. We retrospectively reviewed patients with head and neck cancer who underwent cancer ablation and immediate ALT flap reconstruction since August 2010. The patients were then categorized into a "before" group and an "after" group according to the application time of the algorithm. Their demographics, intraoperative findings, and postoperative outcomes were analyzed. A total of 321 patients (309 men, 12 women) were enrolled, with 230 patients in the before group and 91 patients in the after group, with a mean age of 52.9 years. The mean size of the flap was 130 cm, with a mean width of 8.1 cm. No statistical difference existed between the groups. The donor site was directly closed in 82 patients (35.7%) in the before group. Using the perforator-based flap in 21 patients (23.1%), the donor site was closed primarily in 72 patients (79.1%) in the after group, contributing to a significantly higher donor site closure rate (P < 0.001). The average operative time was 348.7 minutes. The overall flap survival rate was 97.2%, donor-site complication rate was 6.9%, and hospitalization length was 23.5 days. None showed statistical differences between the groups. The proposed algorithm may considerably increase the primary closure rate of the ALT flap donor site.

Risk factors for delayed healing at the free anterolateral thigh flap donor site.

BackgroundThe free anterolateral thigh (ALT) flap has been widely used for various kinds of reconstructions. However, delayed healing at the donor site occasionally occurs due to wound dehiscence or the partial loss of grafted skin at the donor site. The aim of the present study was to identify reliable predictive factors for delayed healing at the donor site after the harvest of a free ALT flap.MethodsThis study included 52 patients who underwent reconstructive procedures using free ALT flaps. The delayed healing group included patients with wounds at the donor site that had not healed over 3 weeks after surgery, and the normal healing group included patients who showed wound healing within 3 weeks after surgery. Multivariate logistic regression models were created to identify the risk factors for delayed healing at the ALT flap donor site.ResultsAmong the 52 patients, 24 (46.2%) showed delayed healing at the donor site, and 6 patients required additional operative treatment. A high preoperative body mass index (BMI), smoking, and skin grafting were found to be significantly associated with delayed healing at the ALT donor site. Of the 37 patients who underwent skin grafting, 23 (62%) experienced delayed healing at the donor site.ConclusionsA high preoperative BMI, smoking, and skin grafting were risk factors for delayed healing at the free ALT donor site. Skin grafting at the ALT donor site should be avoided in patients with a high BMI or a habit of smoking.

Application of perforators positioning technique in preventing anterolateral thigh flap donor site complications

Objective By preoperative perforator positioning of anterolateral thigh flap and intraoperative surgical method improved to prevent and reduce the incidence of anterolateral thigh flap donor site complications. Methods From October, 2013 to October, 2015, total of 134 cases underwent the surgery of more than 6.0 cm width of anterolateral thigh flap repairing limb wounds. Preoperative perforator positioning of the anterolateral thigh flap through the method of CT angiography (CTA) combined color Doppler ultrasound (CDS) . After ensure the location and caliber of perforators, when cut flaps made some improvements as follows: ① Retain the integrity of the donor site fascia lata. Harvest super-thin flaps so that the flap donor sites whose width were in 8.0 cm or less can be sutured directly. ② For the cases that the width of flaps were over 8cm, single block flap with its longitudinal direction is divided into two leaves according to the wounds..After harvesting the flaps, .donor sites were primary closed. ③ Based on preoperative traveling positioning on descending branch of lateral femoral circumflex artery and perforating branches, reduced the trauma to muscle and protected the femoral nerve branches of vastus lateralis muscle. Results Surgery confirmed perforator coincidence rate of 93.22%. 97 cases of unifoliate flap account for 72.39% of the total cases. Among total unifoliate flap, there were super-thin flap 69 cases and their donor site was closed directly with 1 case of short-term complications; the rest 28 cases of unifoliated flap whose width were more than 8.0 cm were grafted with the full-thickness skin graft coming from the both ends of donor site, all skin grafts survived and the wound were primary healing. 37cases of lobulated flap account for 27.61% of the total cases, donor site were closed directly. All 134 cases survived and the survival rate was 100%. At postoperative 3-24 months, conducted follow-up about the flap donor site scar, vastus lateralis muscle function and lateral femoral sensation and so on. Direct closed wound were linear scar, long-term complications occurred in 1 case, donor sites were with no local discomfort and pain, vastus lateralis muscle function was good. According the number of short-term complications and long-term complications, the donor site complication rate was 1.49%. Conclusion Perforator positioning technology has played a guiding role to the preoperative design of anterolateral thigh flap. By modified operation of the harvesting flap including reserving the fascia lata of donor site and reducing the flap width that try to make the donor site primary closed or the least amount of skin graft to significantly reduced the incidence of donor site complications. Key words: Anterolateral thigh flap; Complications; Perforators; CTA; CDS

Free groin flap for aesthetic and functional donor-site closure of the anterolateral thigh flap

Better methods for anterolateral thigh flap donor-site reconstruction are desirable in cases when direct closure is impossible. Multiple surgical strategies have been attempted, and each has its shortcomings. The use of a contralateral free groin flap to repair the anterolateral thigh flap donor site is investigated in this report. From October 2015 to February 2016, free groin flaps were harvested on six patients for aesthetic and functional donor-site closure of the anterolateral thigh flap, which could not be directly closed. In these cases, the reverse-flow distal portion of the descending branch of the lateral circumflex femoral artery and vein were used as recipient vessels and anastomosed to the superficial circumflex iliac artery and vein, respectively. One flap had presented a few blisters on the distal margin; the other five flaps fully survived without any complications. Patients were highly satisfied with the aesthetic outcomes of both the anterolateral thigh area and the groin site. Although with theoretical risks of compromised venous blood flow, free groin flaps are an effective strategy for closure of massive anterolateral donor-site defects and can be safely performed with thoughtful planning and meticulous microsurgical techniques.

Achieving Direct Closure of the Anterolateral Thigh Flap Donor Site—An Algorithmic Approach

Background:Minimizing donor-site morbidity after free flap harvest is of paramount importance. In this article, we share our experience with achieving primary closure of 58 anterolateral thigh (ALT) free flap donor sites using a simple algorithm in cases where primary closure would otherwise have not been possible.Methods:Between 2004 and 2010, 58 patients who underwent free ALT flap reconstruction were included in the study. The inclusion criteria were those who had flap width requirements that were wider than 16% of the thigh circumference and had achieved direct primary closure of the donor site by the use of our technique.Results:Primary closure of the donor sites was facilitated in all cases by the use of 3 distinct techniques. This included the use of the V-Y advancement technique in 13 patients, split skin paddle technique in 7 patients, and the tubed skin paddle design in 38 patients. No episodes of postoperative wound dehiscence at the donor site were encountered; however, 2 cases were complicated by superficial wound infections that settled with a course of antibiotics.Conclusions:Direct primary closure of the ALT donor site can be facilitated by the use of our simple algorithm. Certain strategies need to be adopted at the design stage; however, the techniques used are simple and reliable, produce superior cosmetic results at the donor site, save time, and spare the patient the morbidity associated with the harvest of a skin graft.

Clinical application of anteromedial thigh perforator flap for coverage of anterolateral thigh flap donor site

Objective To investigate the clinical outcomes of repairing the donor site of anterolateral thigh (ALT) flap by a V-Y flap pedicled with anteromedial thigh perforator.Methods From June 2012 to March 2013,6 cases of skin defects in the foot or hand were treated with anterolateral thigh flap.The donor site in these cases was simultaneously repaired with a V-Y flap pedicled with anteromedial thigh perforator.Results All the anterolateral thigh flaps survived uneventfully.Five of the 6 perforating branch V-Y flaps survived,while 1 flap had partial necrosis at the distal end of the flap which healed by dressing change.The patients were followup for 3 to 6 months,with an average of 4 months.The appearance and the texture of the flaps were good.The anterolateral thigh donor area wound healing was leveled with even skin tone.Quadriceps muscle strength and knee movement were normal.There was no numbness of the V-Y flap.Conclusion This procedure is easy and effective.The treatment outcome is satisfactory.It is an improvement over traditional methods to treat donor site defects upon anterolateral thigh flap harvest. Key words: Surgical flaps; Wounds and injuries; Perforator

A systematic review of anterolateral thigh flap donor site morbidity

The anterolateral thigh (ALT) flap is widely used in reconstruction. Its advantage over other flaps is its purported minimal donor site morbidity. The present systematic review summarizes the types of complications and their incidence with this flap. A secondary objective is to delineate factors that influence these complications and make recommendations to avoid them. Two independent assessors undertook a systematic review of the literature using multiple databases. All patients with ALT flap reconstruction for any defect were included. Donor site complications including lateral thigh paresthesia, musculoskeletal dysfunction, hypertrophic scarring, wound breakdown, infection, donor site pain, seroma, hematoma, compartment syndrome and muscle necrosis were extracted from identified articles and tabulated. Based on the number of pooled events and the number of cases performed, an incidence rate was calculated. Forty-two relevant articles were identified that included 2324 flaps. Of the 2324 flaps, the majority were fasciocutaneous (n=737), and 1303 of the flaps were used in head and neck reconstruction. The incidence of complications were: lateral thigh paresthesia (24.0%); musculoskeletal dysfunction (4.8%); hypertrophic scarring or wound dehiscence (4.8%); donor site pain (3.3%); seroma (2.4%); infection (2.2%); hematoma (0.7%); compartment syndrome (0.09%); and partial muscle necrosis (0.09%). Lateral thigh paresthesia is the most common complication. Severe complications such as compartment syndrome and muscle necrosis can occur, but are rare. Preservation of the lateral cutaneous nerve of the thigh, femoral motor nerve branches and deep fascia decreases the risk of complications. The degree of vastus lateralis disruption did not show a significant impact on musculoskeletal dysfunction.

A systematic review of anterolateral thigh flap donor site morbidity

A systematic review of anterolateral thigh flap donor site morbidity

Critical assessment of the anterolateral thigh flap donor site

The free anterolateral thigh flap (ALT) is now used as a 'workhorse flap'. The donor site morbidity is thought to be minimal, although most evidence derives from questionnaire-based studies rather than rigorous objective clinical assessment. In particular, robust quantitative data on thigh sensibility and quadriceps function is lacking. The aim of this study was to provide a comprehensive clinical assessment of donor site morbidity. We performed a prospective study of consecutive free ALT perforator flaps performed at Salisbury Foundation Trust between March 2008 and April 2010. The donor site was assessed at six months including a questionnaire (symptoms, function), scar analysis (Vancouver Scar Scale, VSS), and evaluation of quadriceps power and lateral thigh sensibility (compared with the contralateral unoperated thigh). One hundred ALT flaps were performed on 97 patients (mean age 46.8 years). The donor site was closed directly in 88 cases and using a split skin graft in 12 cases. At follow-up (n=68), tingling was the most common reported symptom (59%), whereas pain, itching and muscle herniation were reported infrequently. Donor site scars were mostly flat, pale and soft but widened. Pathological scarring was rare. Sensibility was reduced in donor thighs (p<0.001) and correlated with flap width but peak quadriceps contraction was similar between donor and unoperated thighs. There was a high throughput and diverse application of ALT flap reconstructions during the study period. Reduced sensibility was common around the scar but rarely troublesome. Quadriceps function was not affected even when dissection of intramuscular perforators was required. The ALT is a versatile flap that can deliver a large skin paddle with minimal impact on thigh function.

In vivo comparison of microcirculation and histomorphology of two different flap donor sites

In soft tissue reconstruction surgery using free flaps, different donor sites from various anatomical regions should be considered. Local microperfusion and histomorphology at these donor sites are often neglected during planning and operation of free tissue transfers. The aim of this in vivo study was to evaluate the microperfusion and, simultaneously, the tissue morphology of two potential free fasciocutaneous flap donor sites on the upper and lower extremity. In 23 healthy nonsmoking individuals (aged 30 ± 8.4 years), potential free-flap donor sites for the radial forearm flap (RFF) and the anterolateral thigh flap (ALTF) were investigated using high-resolution in vivo Reflectance-Mode-Confocal-Microscopy (Vivascope 1500, Lucid, Rochester, NY). The following parameters were evaluated: quantitative blood-cell flow; density of functional dermal capillaries; minimal epidermal thickness, and viable thickness of the epidermis. The quantitative blood-cell flow was higher in the RFF donor site (62 ± 3.1 cells/min) compared with the ALTF donor site (51 ± 2.4 cells/min, P < 0.05). The density of functional dermal capillaries at the RFF donor site was higher than at the ALTF donor site (38 ± 3 vs. 22 ± 2.2 capillaries/mm(2) , P < 0.05). The minimal epidermal thickness was thinner at the RFF donor site compared with the ALTF donor site (44 ± 2.9 vs. 55 ± 3.8 μm, P < 0.05). The viable thickness of the epidermis of the RFF region was thinner compared with the region of the ALTF (31 ± 2.1 vs. 42 ± 2.7 μm, P < 0.05). For the first time, significant differences in the in vivo microperfusion and histomorphology could be shown when comparing two different free-flap donor sites. The correlation to flap failure needs to be substantiated in further systematic trials.

A Reliable Parameter for Primary Closure of the Free Anterolateral Thigh Flap Donor Site

Primary closure of the donor site after flap harvest is key to achieving a satisfactory result. The authors investigated the width of the harvested anterolateral thigh flap allowing primary closure of the donor site. Sixty-five consecutive patients undergoing reconstructive procedures using anterolateral thigh flaps were divided into two groups: group A, primary closure of the donor site; and group B, donor site covered with split-thickness skin graft. Maximum flap width and thigh circumference were measured at the midpoint of the line connecting the lateral superior margin of the patella and the anterior superior iliac spine. The maximum flap width-to-thigh circumference ratio was calculated. Patients' body mass index and age were recorded. The outcome was evaluated by the surgeon. Primary closure of the donor site was possible in 56 patients (86 percent), and in nine patients (14 percent) a split-thickness skin graft was necessary. All of the donor sites were closed primarily when the flap width was less than 16 percent of the thigh circumference. There was a significant correlation between body mass index and the ratio (p<0.001, r=-0.573) and between patient age and the ratio (p=0.033, r=0.267). Muscle herniation was significantly higher in group B (p=0.029). The flap width-to-thigh circumference ratio is a reliable parameter for preoperative planning of primary closure of the anterolateral thigh flap donor site. Primary closure can be achieved if the flap width-to-thigh circumference ratio is less than 16 percent. The patient's body mass index and age have to be taken into consideration.

Compartment Syndrome After Closure of the Anterolateral Thigh Flap Donor Site: A Report of Two Cases

Two male sarcoma patients developed a compartment syndrome in the thigh after the harvest and direct closure of the anterolateral thigh flap donor site. In each case, the absence of signs or symptoms led to a delay in diagnosis and treatment. Although use of the anterolateral thigh flap is increasingly popular for soft tissue reconstruction, this complication has not yet been reported. The cases and likely etiological factors are discussed as are recommendations for avoiding this devastating complication.

Functional evaluation of anterolateral thigh flap donor sites: Isokinetic torque comparisons for knee function

The anterolateral thigh flap is thought to have minor donor site morbidity, but muscle dissection is unavoidable when skin perforator vessels run through the vastus lateralis muscle. The purpose of this study was to investigate the functional problems associated with the anterolateral thigh flap donor site. We evaluated 12 patients who underwent free anterolateral thigh flap transfer between March 2003 and November 2005. A questionnaire and dynamic functional evaluation of the knee joint using the Biodex System were performed preoperatively and 6 months postoperatively. No patients reported any disturbance in their daily life. No significant differences were found between donor and normal thighs on isokinetic power tests of the quadriceps muscle. The function of the donor site after harvesting the anterolateral thigh flap was maintained. Damage to or functional disturbance of the donor site is minimal even if muscle is injured when harvesting the flap.

Does Fascia Lata Repair Facilitate Closure and Does It Affect Compartment Pressures of the Anterolateral Thigh Flap Donor Site?

Does Fascia Lata Repair Facilitate Closure and Does It Affect Compartment Pressures of the Anterolateral Thigh Flap Donor Site?