Free Anterolateral Thigh Flap Research Articles

Reconstruction of Scalp and Skull Defects by a Free Anterolateral Thigh Flap Combined With Fascia Lata and Vastus Lateralis Muscle.

Reconstruction of composite scalp and skull defects is a great challenge for plastic surgeons, and this study aimed to report the therapeutic regimen of using free ALT flaps with fascia lata and vastus lateralis muscle to cover scalp and cranial defects. A retrospective analysis was performed including 10 patients with composite scalp and skull defects who were treated with a free ALT flap with fascia lata and vastus lateralis muscle from January 2012 to June 2020. All patients underwent a 1-stage operation and were followed up for 1 year with clinical data including sex, age, etiology, skull defect area, scalp defect area, flap area, dura mater involvement, recipient vessel, donor site repair, lumbar cistern drainage, and complications. All flaps survived well, 2 patients developed complications, one had cerebrospinal fluid leakage, and another experienced partial skin graft necrosis; All patients were satisfied with both the appearance and functional outcomes of the procedure. Free tissue transplantation is an effective method for large defects of the scalp and skull. The combination of a free ALT flap with fascia lata and vastus lateralis muscle, which has a long pedicle, convenient flap designs, less donor-site morbidity, and effective prevention of cerebrospinal fluid leakage, is an ideal choice to repair the composite scalp and cranial defects in stage 1.

Reconstruction of Partial Hypopharyngeal Defects following Total Laryngectomy: A Systematic Review and Meta-Analysis

Background: Various operative techniques exist to reconstruct partial hypopharyngeal defects following total laryngectomy. The current study aimed to investigate and compare complications and functional results following commonly used reconstructive techniques. Methods: A systematic review and meta-analysis were performed using studies that investigated outcomes after the reconstruction of a partial hypopharyngeal defect. The outcomes of interest were fistulas, strictures, flap failure, swallowing function and postoperative speech. Results: Of the 4035 studies identified, 23 were included in this review. Four common reconstructive techniques were reported, with a total of 794 patients: (1) pectoralis major myocutaneous and (2) myofascial flap, (3) anterolateral thigh free flap and (4) radial forearm free flap. Fistulas occurred significantly more often than pectoralis major myocutaneous flaps (34%, 95% CI 23–47%) compared with other flaps (p < 0.001). No significant differences in the rates of strictures or flap failure were observed. Pectoralis major myofascial flaps were non-inferior to free-flap reconstructions. Insufficient data were available to assess speech results between flap types. Conclusion: Pectoralis myocutaneous flaps should not be the preferred method of reconstruction for most patients, considering their significantly higher rate of fistulas. In contrast, pectoralis major myofascial flaps yield promising results compared to free-flap reconstructions, warranting further investigation.

Successful salvage of upper extremity following severe crush injury associated with vascular compromise using a supra thin free anterolateral thigh flap

Traumatic injuries of the upper limbs can often result in serious and challenging wounds involving multiple compartments such as skin, bone, tendons and neurovascular structures. These type of injuries of the upper extremity pose several challenges to the plastic surgeon. The main difficulty is to provide a stable, long lasting and aesthetically acceptable coverage that enables joints excursion so that patient can return to work at the earliest. Here, we present a case of 45 years old gentlemen who sustained severe crush injury associated with avulsed radial and ulnar artery of left upper limb following road traffic accident. At presentation, there was no pin prick in his hand and hand was pale. At first surgery, hand was revascularized using a vein graft in radial artery and skin grafting was done over the forearm defect as a temporary cover. After 12 hours, when the viability of hand was reassured, the defect was covered with free supra thin anterolateral thigh (ALT) flap. Patient’s hand and flap both survived and he was discharged in a satisfactory condition.

Comparative Study Between Pedicled Groin Flap and Free Anterolateral Thigh Flap in Reconstruction of Complex Soft Tissue Hand Defects

Comparative Study Between Pedicled Groin Flap and Free Anterolateral Thigh Flap in Reconstruction of Complex Soft Tissue Hand Defects

Utilizing the Subunit Concept to Achieve Better Outcomes in Lower Limb Reconstruction: A Clinical Experience in an Asian Population.

The goals of reconstruction have progressed from filling a defect to enhancing function and aesthetic appearance. We aimed to achieve better aesthetic and functional outcomes in terms of shoe fitting and mobility. This is accomplished via a classification of the subunits and aesthetic considerations of the lower limb. Between April 2017 and December 2021, 66 cases of lower extremity free fasciocutaneous flap reconstruction cases were included in this retrospective study. Data parameters include age, sex, comorbidities, etiology of lower limb wounds, choice of free flap reconstruction, recipient arterial vessels, complications of flap reconstruction, and need for secondary debulking procedures. Physiotherapy records were also examined to determine the time to independent ambulation. In total, 66 subjects were identified. The mean age was 48.6. An estimated 74.2% (n = 49) were men, 50% (n = 33) had diabetes, and 16.6% (n = 11) had peripheral vascular disease. Of the total wounds, 65.1% (n = 43) were caused by infection, whereas the remaining 34.9% (n = 23) were due to trauma. Of the cases, 72.7% (n = 48) had free anterolateral thigh flap reconstruction, 25.8% (n = 17) were reconstructed with superficial circumflex iliac artery perforator flaps, and 1.5% (n = 1) was reconstructed with medial sural artery perforator flaps. Cases that required secondary debulking procedures comprised 7.6% (n = 5). Free fasciocutaneous flaps are useful in lower extremity reconstruction. Based on the subunit principle and aesthetic considerations for lower limb reconstruction, it can aid in optimizing functional rehabilitation and decreasing secondary procedures.

Letter to the Editor: A Response to "Ultra-Thin Anterolateral Thigh Free Flap: An Adipocutaneous Flap with the Most Superficial Elevation Plane".

Letter to the Editor: A Response to "Ultra-Thin Anterolateral Thigh Free Flap: An Adipocutaneous Flap with the Most Superficial Elevation Plane".

Reconstruction of Extensive Maxillary Defects Using Flow-Through Fibula Free Flap With Anterolateral Thigh Free Flap.

The maxillary defects left unreconstructed or inadequately reconstructed often result in significant functional and esthetic impairments. Adequate reconstruction of extensive maxillary defects requires a sufficient volume of hard and soft tissues. A 48-year-old male presenting bilateral extensive maxillary defects underwent secondary reconstruction with a flow-through fibula free flap in combination with an anterolateral thigh free flap. The use of flow-through technique allowed minimizing the problem of limited recipient vessels and the length of free flap vascular pedicle usually encountered in secondary reconstruction. The bilateral maxillary defects were successfully reconstructed, and the postoperative outcomes were uneventful. The patient was satisfied with the treatment outcomes. He is being followed up and was referred to the implantology department for the placement of osseointegrated dental implants. The flow-through fibula free flap, in combination with the anterolateral thigh free flap, was found reliable and feasible for this case of secondary reconstruction of bilateral maxillary defects. This technique has provided satisfactory functional and esthetic outcomes and effectively improved the patient's self-esteem.

(040) Anterolateral Thigh Flap Phalloplasty: Outcomes Following Genital Gender Affirmation Surgery

Abstract Introduction Genital gender affirmation surgery (gGAS) is a key part of the management of patients with gender dysphoria. The anterolateral thigh (ALT) free flap was proposed as an alternative to the more common radial forearm free flap (RFFP) phalloplasty due to the twin advantages of a more easily hidden scar and improved flexibility in the length of the flap. A pedicled variant of the ALT flap offers greater security of vascular supply for suitable patients, and if suitable and desired the flap can be formed with an integrated urethra, facilitating voiding while standing. Objective The aim of the study is to report the contemporary surgical and functional outcomes of ALT phalloplasty. Methods All individuals undergoing ALT flap phalloplasty for genital gender affirmation surgery (GAS) between 2009 and 2023 nationwide were included. Individuals were managed in accordance with the World Professional Association for Transgender Health (WPATH) Standards of Care version 7. Data were extracted from a prospectively collected single surgeon database and medical records. Functional outcomes were assessed by non-validated questionnaire. Statistical analysis included Mann-Whitney, chi-squared, Fisher’s exact and unpaired T tests. Results Surgical outcomes: A total of 87 patients were included in the study. More than half (45, 51.7%) had an integrated urethra. The median length of stay following surgery was six days (IQR 6-7). Eleven patients (12.6%) had a 30-day Clavien-Dindo 3b complication or greater. Three patients (3.4%) experienced total flap loss. A further three patients (3.4%) had partial flap loss. Three patients (3.4%) required a salvage phalloplasty later. Thirteen patients (out of 42, 31.0%) without an integrated urethra went onto have a free flap urethroplasty. Functional outcomes: Thirty-nine individuals (44.8%) completed the patient reported outcomes questionnaire. Most patients (77%) were generally satisfied with their phalloplasty. More than half (56%) with an erectile device used their phallus for penetrative intercourse, while one in five reported experiencing orgasm using their phallus alone. Following urethral lengthening, all respondents were able to void standing. There was no significant difference in mean satisfaction scores for those with an integrated urethra compared to those without (4.18/5 vs 3.82/5, p=.45), as well as between those with or without an erectile device, respectively (3.78/5 vs 4.10/5, p=.26). Conclusions This study is one of the largest single centre cohorts of ALT flap phalloplasty reported to date. It further supports the use of the ALT flap as one of the main genital GAS options for transmen. Over half of the patients studied had an integrated urethra, the gold standard for urethral lengthening. Patient reported functional outcomes were promising, with similar scores regardless of urethral lengthening or erectile device insertion. Disclosure No.

Reconstruction Using a Free Anterolateral Thigh Flap for the Treatment of Rocker-Bottom Deformity and Ulcer Associated with Diabetic Charcot Foot

Reconstruction Using a Free Anterolateral Thigh Flap for the Treatment of Rocker-Bottom Deformity and Ulcer Associated with Diabetic Charcot Foot

Free flap reconstruction at a rural-based tertiary medical college hospital: Barriers and outcomes.

In a rural-based setting, providing optimal treatment is often difficult owing to the limited resources and financial constraints being rampant in cancer care delivery. Oncological resections often result in large, complex defects requiring free flap reconstruction to achieve cosmetic and/or functional goals. This article focuses on our experience of starting and promoting microvascular reconstruction in a rural tertiary medical college hospital. Retrospective observational study of patients undergoing free flap reconstruction for oncological indications was included. Standard oncological principles were followed for cancer extirpation. Free flap reconstruction was done using loupes of 4× magnification. Flap-related outcomes and barriers in doing free flap reconstruction were analysed. A total of 56 patients were included. The most common free flap undertaken was free anterolateral thighflap in 21 (37.5%) patients. The mean duration of reconstruction was 438 min. Re-exploration was undertaken in 17 patients (30.4%). Nonsalvageable flap loss was 19.64%. Adjuvant treatment was administered in all patients as per oncological indications, albeit with some delay in 12.5%. Barriers to reconstruction were noted in the pre-, intra- and postoperative periods. Reconstruction with free flaps is feasible in a resource-constrained setup with careful planning and a multidisciplinary team approach to overcome the barriers.

Latissimus dorsi myocutaneous free flap for the laryngopharyngectomy defect.

Partial or total laryngopharyngectomy defects have traditionally been reconstructed using the radial forearm, anterolateral thigh, or jejunal free flaps. The latissimus dorsi myocutaneous free flap (LDMFF) is an option for high-risk patients with complex laryngopharyngeal ± cutaneous neck defects. Retrospective single-surgeon case series from 2017 to 2022. Outcomes were assessed at both the back donor site and head and neck. Twenty-four patients were identified. Flap survival was 100%. There was 1 (4.2%) pharyngocutaneous fistula and 2 (8.3%) tracheo-esophageal peristomal fistulas. At last follow-up, 17 (71%) were sustaining weight on oral intake, and 7 (29%) were G-tube dependent with 4 of these able to do some type of oral intake. Seven (29.2%) had post-operative stricture/stenosis requiring dilation. There were only minor donor site complications, all managed conservatively. The LDMFF can be a robust reconstructive option, particularly for radiated high-risk patients with complex pharyngeal defects, including skin.

Hand Reconstruction Using Anterolateral Thigh Free Flap by Terminal Perforator-to-Digital Artery Anastomosis: Retrospective Analysis.

This study aimed to analyze cases of anterolateral thigh (ALT) free flap used for hand reconstruction with terminal perforator-to-digital artery anastomosis. Patients who underwent ALT free flap placement with terminal perforator-to-digital artery anastomosis for hand reconstruction between January 2011 and August 2021 were included. The number, length, and diameter of the perforators and veins, flap size, and operative time were investigated through a retrospective review of charts and photographs. The occurrences of arterial thrombosis, venous thrombosis, arterial spasm, and flap necrosis were analyzed. In total, 50 patients were included in this study. The mean diameter and length of the perforators were 0.68 mm and 3.25 cm, respectively, and the mean number of veins anastomosed was 1.88, with a mean diameter of 0.54 mm. Complications included four cases of arterial thrombosis, one case of venous thrombosis, seven cases of partial necrosis, and one case of total flap failure. Regression analysis showed that a longer perforator was associated with arterial thrombosis whereas larger flap size and number of anastomosed veins were associated with partial necrosis ( p < 0.05). The terminal perforator-to-digital artery anastomosis offers advantages in using compact free flaps with short pedicle lengths to cover small hand defects.

Pedicle Lengthening with Reducing Size Mismatch in Free Anterolateral Free Flap.

When plastic surgeons reconstruct the defects for recurrent cancer, a longer vascular pedicle is often necessary because usable vessels are sacrificed in previous surgeries or radiotherapy. In this case, we would like to present another method for free anterolateral thigh flap pedicle elongation. A 59-year-old man was referred to our clinic for reconstruction after unilateral total maxillectomy and orbital exenteration due to recurrent squamous cell carcinoma. We need to cover the full-thickness defect in the left orbital area (8×7cm sized), intraoral area (5×7cm sized), and orbital floor. Due to prior surgeries and radiotherapy, we needed a vascular pedicle up to 15cm for a distant recipient vessel. When harvesting the flap, we transected just proximal to the bifurcation site, harvested a muscular branch to vastus intermedius together, and used it for pedicle elongation by vessel turning over. A 17×6cm sized musculocutaneous flap was harvested, and the total length of the pedicle was 15cm. As the anastomosis was done at the distal portion of the vastus intermedius branch, there was no size mismatch with the superior thyroid artery. Both skin defects and the orbital floor were covered without any tension. The reconstruction was successful without any flap compromise 1 year after surgery. This case suggests another option for microsurgeons to lengthen the flap pedicle and reduce size mismatch using anatomical variability of the lateral circumflex femoral artery.

Favorable effects of open surgery on patients with extensive skull base osteoradionecrosis through a personalized sequential approach: A case series

The present study aimed to investigate outcomes following open surgery for extensive skull base ORN. Open surgery through a personalized sequential approach was employed to deal with five cases of extensive skull base ORN. Two patients with mild cases underwent regional debridement and sequestrectomy, and three patients with severe cases underwent extensive resection with reconstruction using free anterolateral thigh (ALT) flap. Biological glues and vascularized flaps were used for obturation of the skull base bony defect to prevent postoperative cerebrospinal fluid (CSF) leakage. The infections were controlled by antibiotic administrations which strictly followed the principles of antimicrobial stewardship (AMS). As results, both regional debridement plus sequestrectomy and extensive resection achieved satisfied outcomes in all patients. No severe complications and delayed hospitalization occurred. During the follow-up period (8–19 months), all patients were alive, pain free, without crusting or purulent discharge, and no sequestration or CSF leakage occurred. In conclusion, a personalized sequential approach including open surgery, pedicled/vascularized free flap reconstruction and AMS was advocated for patients with extensive skull base ORN.

Algorithm for the reconstruction of the parotid region: a single institution experience

ObjectiveThis study aims to discuss the characteristics and treatment methods of malignant tumors in the parotid region, as well as the therapeutic effects of immediate free flap reconstruction of soft tissue for postoperative defects.Materials and methodsA retrospective review was conducted on 11 cases of soft tissue flap reconstruction for postoperative defects following the resection of malignant tumors in the parotid region. Statistical analysis was performed based on clinical data.ResultsAmong the 11 cases of malignant tumors in the parotid region, there were 2 cases of secretory carcinoma (SC) of the salivary gland, 2 cases of squamous cell carcinoma (SCC), 2 cases of carcinosarcoma, 1 case of mucoepidermoid carcinoma (MEC), 1 case of epithelial-myoepithelial carcinoma (EMC), 1 case of salivary duct carcinoma (SDC), 1 case of basal cell carcinoma (BCC), and 1 case of osteosarcoma. Among these cases, 4 were initial diagnoses and 7 were recurrent tumors. The defect repairs involved: 8 cases with anterolateral thigh free flap (ALTF), 2 cases with pectoralis major muscle flaps, and 1 case with forearm flap. The size of the flaps ranged from approximately 1 cm × 3 cm to 7 cm × 15 cm. The recipient vessels included: 4 cases with the facial artery, 4 cases with the superior thyroid artery, and 1 case with the external carotid artery. The ratio of recipient vein anastomosis was: 57% for branches of the internal jugular vein, 29% for the facial vein, and 14% for the external jugular vein. Among the 8 cases that underwent neck lymph node dissection, one case showed lymph node metastasis on pathological examination. In the initial diagnosis cases, 2 cases received postoperative radiotherapy, and 1 case received 125I seed implantation therapeutic treatment after experiencing two recurrences. Postoperative follow-up revealed that 2 cases underwent reoperation due to local tumor recurrence, and there were 2 cases lost to follow-up. The survival outcomes after treatment included: one case of distant metastasis and one case of death from non-cancerous diseases.ConclusionImmediate soft tissue flap reconstruction is an important and valuable option to address postoperative defects in patients afflicted with malignant tumors in the parotid region.

The Value of Anterolateral Thigh Free Flap for the Reconstruction of Malignant Melanoma of the Sole of the Foot.

Wide excision of malignant melanoma on the foot usually results in an extensive function-destroying defect, and the reconstruction of foot defects remains challenging for reconstructive surgeons. We propose using anterolateral thigh perforator (ALT) free flaps for the reconstruction of widespread defects caused by malignant melanoma in the sole. This retrospective study included 34 patients who underwent reconstruction of sole defects caused by malignant melanoma resection with 35 ALT perforator free flaps between August 2005 and July 2021. In total, 18 male patients and 16 female patients were included (mean age at surgery, 65.4 years). The mean size of the flaps was 100.4 cm 2 . Thirty-three of the 35 flaps survived. Hematoma, seroma, and chronic ulceration were not identified in any cases. All patients achieved independent ambulation within the follow-up period, except 1 patient with gait discomfort. The 5-year overall and disease-free survival rates of patients were 64.4% and 56.6%, respectively. The ALT flap is a versatile surgical option that should be considered for reconstruction of the sole after malignant melanoma resection, considering its various surgical advantages and the functional aspects of independent ambulation, the aesthetic aspects of wearing conventional footwear, and the anatomical aspects of the sole.

Limitation of microdissected thinning in free anterolateral thigh flap for hand reconstruction

BackgroundHand defects, especially complex defects involving tendon or bone exposure, are challenging to reconstruct. With the limited size and options of local flaps, the free-thinned anterolateral thigh (ALT) flap remains an excellent choice. However, many authors have described thinning procedures differently, leading to inconsistent outcomes. We present our clinical experience of immediate thinning ALT flaps depending on the anatomical structure of the perforator.Materials and methodsBetween 2007 and 2021, we used a free ALT flap in 42 cases to cover hand defects after crushing and friction injuries, burning and burn scars, and animal bite wounds. There were 38 males and 4 females; the mean patient age was 31.2 years. Thinning procedure was performed in all flaps. The primary and microdissected thinning procedure was performed for 35 single flaps and 7 chimeric flaps, including 14 flaps for the fingers (29%), 4 flaps for the palm (8%), 12 flaps for the hand dorsum (24%), and 19 flaps for combined areas (39%).ResultsThe mean flap thickness was 18.6 (11–30) mm before defatting and 6.0 (3–12) mm after defatting, an approximately 65% reduction. The retained fascia island around the perforator was ≤ 1 cm in 73.5% of cases, 2–3 cm in 18.4%, and the remaining 8.1% had a fascia size ≥ 4 cm. The incidence of a well-survive flap was 93.9%. Three cases had partial to total necrosis. None of the patients required a secondary defatting procedure.ConclusionEvery case has a perforator pattern after running through the fascia, which allows surgeons to choose the appropriate thinning method. Perforators that run parallel to the superficial fascia are not good candidates for thinning. Instead, the thinning process should be performed with more perpendicular perforators.Level of evidence: Level IV, therapeutic study

Institutional experience with total pharyngectomy reconstruction: Exploring the role of the salivary bypass tube.

There is a lack of consensus regarding the effectiveness of salivary bypass tubes during total pharyngectomy reconstruction to prevent pharyngocutaneous fistula or pharyngoesophageal stricture. Our study examined tubed free flap reconstruction outcomes for total pharyngectomy defects over 11 years at a single tertiary referral center. We compared postoperative fistula and stricture rates between two groups: those with salivary bypass tubes inserted during reconstruction and those without. Among 36 patients, 26 had radial forearm, and 10 had anterolateral thigh free flap reconstruction. 53% received salivary bypass tubes. However, the tubes did not significantly reduce the relative risks of fistula or stricture. Notably, neck dissection during total pharyngectomy was associated with increased fistula incidence. Minor salivary bypass tube-related complications affected 21% of subjects. The role of salivary bypass tubes in total pharyngectomy reconstruction remains uncertain.

Lower-Limb Salvage Procedure using Anterolateral Thigh Free Flap and Multiple Tendon Grafts in a Road Injury Patient: A Case Report

Introduction: The free anterolateral thigh (ALT) flap is commonly used to repair a large loss of soft tissue following a lower-limb injury. An issue to be managed is the choice of adequate recipient vessels when the tibial arteries result damaged. In this scenario, vein grafts can be interposed to connect a healthy recipient vessel to the ALT flap pedicle. Case Report: We present a report of a 19-year-old male who suffered a Gustilo fracture type IIIc after a road injury involving the right lower limb. After a failed first attempt of limb salvage with reconstruction of extensor tendons and a free ALT flap, a second procedure was performed using another ALT flap with interposed vein grafts to reach very proximal recipient vessels. Results: The patient demonstrated excellent recovery and restored ambulation. The effectiveness of the most complex reconstructive options for a high-demanding patient with no comorbidities is demonstrated in this case. Conclusion: The key to success in even the most complex injury cases is early intervention, meticulous surgical planning, and a multidisciplinary approach. Keywords: Anterolateral thigh flap, vein graft, gustilo fracture, ankle, tendon graft, limb salvage.

Surgical Treatment of Malignant Peripheral Nerve Sheath Tumor of the Scalp With Intracranial and Extracranial Extension: A Rare Case Report.

Malignant peripheral nerve sheath tumors of the scalp are rare neoplasms of the peripheral nervous system. Here, we describe an unusual malignant peripheral nerve sheath tumor of the scalp in an 84-year-old Asian man. The tumor was associated with bony destruction, intracranial, and extracranial extension. Trans-arterial embolization was done twice preoperatively. En block excision was performed and the dura and soft tissue defect were reconstructed by anterolateral thigh free fasciocutaneous flap. There is no recurrence and the wound healed well during follow-up.