Anterolateral Thigh Myocutaneous Flap Research Articles

Free anterolateral thigh myocutaneous flap combined with pedicled latissimus dorsi myocutaneous flap transfer for functional reconstruction after resection of huge shoulder tumor

Objective: To investigate the method and effect of free anterolateral thigh myocutaneous flap combined with pedicled latissimus dorsi myocutaneous flap transfer for functional reconstruction after resection of huge shoulder tumor. Methods: The clinical data of 6 patients who were treated with pedicled latissimus dorsi myocutaneous flap combined with free anterolateral thigh myocutaneous flap to repair large-area complex defects after shoulder tumor resection at Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital from December 2015 to December 2020 were retrospectively analyzed. There were 2 males and 4 females, with an average age of 41.7 years (range:29 to 56 years). There were 2 cases of synovial sarcoma,2 cases of phylloid cell sarcoma,1 case of liposarcoma and 1 case of fibrosarcoma. Before this operation, tumor resection had been performed for 1 to 5 times on each case,and the course of disease was 6 to 24 months. Pedicled latissimus dorsi myocutaneous flap combined with free anterolateral thigh myocutaneous flap were used to repair soft tissue defects and reconstruct deltoid function. Postoperative flap status, complications, appearance and function of upper limbs and tumor recurrence were recorded. Results: Six patients were followed up for an average of 21.6 months (range: 12 to 36 months). There were no serious complications after operation,and all flaps survived. No tumor recurrence was found. The appearance of shoulder contour reconstructed by flaps was satisfactory. The reinnervation effect of lateral femoral muscle was confirmed recovered smoothly by neuroelectromyography 3 months after operation. Shoulder function was mildly limited in 3 patients,moderately limited in 2 patients and severely limited in 1 patient. All patients reported significant improvement in shoulder discomfort.The overall functional results of all patients were satisfactory. Conclusion: Combined myocutaneous flaps transplantation can perfectly repair the wound left after the resection of huge shoulder tumor,minimize the recurrence of tumor,reconstruct the function of shoulder joint and greatly improve the quality of life of patients.

Primary Lymphoepithelial Carcinoma of Parotid Gland: Inadequate Preoperative Assessment Resulting in Extensive Surgery

Parotid lymphoepithelial carcinoma is extremely rare, and makes up only 0.4% of cases among the anaplastic variant of salivary gland carcinoma. We present a 63-year-old man who had progressive enlarging right neck swelling for one year. He sought treatment in another centre and underwent superficial parotidectomy, following an ultrasound assessment of the mass that was suggestive of a benign parotid tumour. There was no fine needle aspiration cytology or other radiological imaging performed prior to the surgery. However, the surgeon encountered difficulty intraoperatively and abandoned the surgery. The incisional biopsy of the tumour was reported as lymphoepithelial carcinoma. He then presented to us with the progression of the residual parotid malignant tumour. CT and MRI showed a locally aggressive parotid tumour that had infiltrated the subcutaneous tissue, external auditory canal, facial nerve, and multiple ipsilateral metastatic cervical lymph nodes. Subsequently, the patient underwent total parotidectomy with facial nerve resection, lateral temporal bone resection and ipsilateral modified radical neck dissection. The surgical site defect was reconstructed with anterolateral thigh myocutaneous free flap. Concurrent static facial reanimation with fascia lata sling was performed. The patient received adjuvant chemoradiation following the surgery. The extent of the local infiltration by the tumour and the resulting surgery could have been reduced if the tumour had been properly assessed and excised at the initial stage. A complete preoperative assessment of a parotid mass is essential to avoid misdiagnosis, unexpected intraoperative finding and delay in definitive treatment.

Free extended anterolateral thigh myocutaneous flap versus combined pedicled pectoralis major–latissimus dorsi myocutaneous flaps in deep and extensive sternal wound reconstruction

The combined pedicled pectoralis major-latissimus dorsi (PM-LD) and free extended anterolateral thigh (ALT) myocutaneous flaps provide well-vascularized tissues for extensive sternal wound reconstruction. However, the outcomes and postoperative complications between the two surgical techniques are different. Thus, the aim of this study is to evaluate the feasibility of these two reconstructive options. This single-center, retrospective study was conducted between August 2011 and May 2019. Forty-four patients diagnosed with deep sternal wound infection (DSWI) and presented with grade four complications (sternal instability and necrotic bone tissue) were enrolled. Two reconstructive strategies, namely, combined pedicled PM-LD (n=24) and free extended ALT (n=20) myocutaneous flaps, were used according to the patients' hemodynamics. Data including age, gender, body mass index (BMI), hospital stay, follow-up, defect/flap size, number of surgical procedures before reconstruction, duration from the last debridement to flap coverage, comorbidities, and postoperative complications, were obtained for statistical analysis. The mean defect size in the combined PM-LD myocutaneous flap group was 188.4 (5*17-10*23) cm2 , and the mean flap size was 150.0 (8*12-15*15) cm2 and 205.0 (8*15-10*25) cm2 in PM and LD flap, respectively. The mean defect size in the free extended ALT myocutaneus flap group was 202.5 (6*16-10*21) cm2 , and the mean flap size was 285.2 (9*30-12*25) cm2 . No significant differences were observed between the free extended ALT and the combined pedicled PM-LD myocutaneous flaps in relation to age, gender, BMI, hospital days, follow-up, defect size, preoperative procedures, and comorbidities, except for the average operative time (443.2 ± 31.2 vs. 321.3 ± 54.3 mins, p=.048). The combined pedicled PM-LD myocutaneous flap had significantly more donor site complications, including seroma (21% vs. 0%, p=.030), bilateral nipple-areolar complex asymmetry (100% vs. 0%, p < .0001), and skin graft loss with infection (33% vs. 0%; p=.044) than the free extended ALT myocutaneous flap. The free extended ALT and the combined pedicled PM-LD myocutaneous flaps were both feasible and effective options for sternal wound reconstruction. Our findings suggested that the free extended ALT myocutaneous flap may be a better alternative for a comprehensive and extensive reconstruction of sternal wounds. Further studies based on these findings can be conducted.

Application of expanded anterolateral thigh myocutaneous flap in the repair of huge chest wall defect

To investigate the application of expanded anterolateral thigh myocutaneous flap in the repair of huge chest wall defect. Between August 2018 and December 2020, 12 patients, including 4 males and 8 females, were treated with expanded anterolateral thigh myocutaneous flap to repair huge complex defects after thoracic wall tumor surgery. The age ranged from 28 to 72 years, with an average of 54.9 years. There were 4 cases of phyllodes cell sarcoma, 2 cases of soft tissue sarcoma, 1 case of metastatic chest wall tumor of lung cancer, and 5 cases of breast cancer recurrence. All cases underwent 2-7 tumor resection operations, of which 3 cases had previously received lower abdominal flap transplantation and total flap failure occurred, the other 9 cases were thin and were not suitable to use the abdomen as the flap donor site. After thorough debridement, the area of secondary chest wall defect was 300-600 cm 2; the length of the flap was (24.7±0.7) cm, the width of the skin island was (10.6±0.7) cm, the length of the lateral femoral muscular flap was (26.8±0.5) cm, the width was (15.3±0.6) cm, and the length of the vascular pedicle was (7.9±0.6) cm. The myocutaneous flaps and the skin grafts on the muscular flaps were all survived in 11 patients, and the wounds in the donor and recipient sites healed by first intention. One male patient had a dehiscence of the chest wall incision, which was further repaired by omentum combined with skin graft. The appearance of the reconstructed chest wall in 12 patients was good, the texture was satisfactory, and there was no skin flap contracture and deformation. Only linear scar was left in the donor site of the flap, and slight hyperplastic scar was left in the skin harvesting site, which had no significant effect on the function of the thigh. All patients were followed up 9-15 months, with an average of 12.6 months. No tumor recurrence was found. The expanded anterolateral thigh myocutaneous flap surgery is easy to operate, the effective repair area is significantly increased, and multiple flap transplantation is avoided. It can be used as a rescue means for the repair of huge chest wall defects.

Free Flap Transfer, a Safe and Efficient Method for Reconstruction of Composite Skull Base Defects After Salvage Resection of Advanced Intracranial and Extracranial Communicating Tumors

Surgical treatment of advanced intracranial and extracranial communicating skull base tumors is challenging, especially for the reconstruction of the large composite defect left by tumor resection. The aim of the study is to evaluate the utility of the free flap reconstruction of the defects resulting from radical resection of these tumors in a single institution. The clinical data of 17 consecutive patients who underwent free flap reconstruction for defect left by salvage resection of advanced intracranial and extracranial communicating tumors from 2013 to 2019 were retrospectively collected and analyzed. There were 5 squamous cell carcinomas, 4 adenoid cystic carcinomas, 2 basal cell carcinomas, 2 meningiomas, 1 anaplastic hemangiopericytoma, 1 pleomorphic adenoma, 1 osteosarcoma, and 1 chondrosarcoma. All patients had recurrent neoplasms, 2 of whom had pulmonary metastasis. A modified radical cervical dissection was performed in 6 patients. The anterolateral thigh myocutaneous flap and rectus abdominis myocutaneous flap were used in 15 patients (88.2%) and 2 patients (11.8%), respectively. Complications were seen in 3 of 17 patients (17.6%) with 1 total flap loss. The median progression-free survival duration was 31 months. The 3- and 5-year progression-free survival rates were 0.47 and 0.24, respectively. The mean overall survival duration was 66 months. The 3- and 5-year overall survival rates were 0.85 and 0.68, respectively. Free flap transfer is a safe and effective method with acceptable complications, useful for reconstruction of large composite skull base defects after salvage resection of advanced intracranial and extracranial communicating tumors. The functional and cosmetic results are satisfying.

Bilateral Anterolateral Thigh Myocutaneous Flaps for Giant Complex Chest Wall Reconstruction.

Extensive reconstruction of complex full-thickness chest wall oncological defects is challenging. Bilateral free anterolateral thigh (ALT) myocutaneous flap transfer for the complex reconstruction of a large area of the chest wall is discussed. We reported a single unit's experience in 1-staged multilayered reconstruction of large full-thickness chest wall defects in 22 patients (16 primary chest wall tumor cases, 5 locally advanced breast cancer cases, and 1 osteoradionecrosis case) treated between 2011 and 2018. Bilateral ALT myocutaneous flaps together with traditional cement implant or unmovable/movable joint conformable titanium struts were used for chest wall reconstruction. The anatomical characteristics of pedicle origin and pattern of the venae comitantes of the ALT myocutaneous flap, recipient vessels, and anastomosis patterns were described. Bilateral ALT myocutaneous flaps were used for soft tissue reconstruction in 22 cases. Different methods of flap harvesting and vascular anastomosis were selected as needed. No vein grafts or arteriovenous loops were required. We observed 3 vascular patterns of the flap pedicle, including 1 oblique branch and descending branch (59.1%, n = 26), 2 single descending branch (9.1%, n = 4), and 3 double branches of the descending branch (31.8%, n = 14). The flap was harvested pedicled with solely the oblique branch in 7 (15.9%) cases, solely the descending branch in 28 (63.6%) cases to minimize the donor site morbidity, and pedicled with the oblique and descending branch in 9 (20.5%) cases to achieve multiple vascular anastomosis choices. Stable skeletal reconstructions were achieved using traditional cement implant (13.6%, n = 3) or conformable titanium struts (86.4%, n = 19), with good fixation strength. Complication risk was low. An algorithmic approach to management is presented and recommended. Various forms of bilateral ALT myocutaneous flap transfer with different skeletal reconstruction presents as a reliable treatment for patients with large full-thickness chest wall defects. Anatomical variations in the pedicle and pattern of venae comitantes of the ALT myocutaneous flap are reported. In some challenging cases, finding the vessels in the recipient area is difficult. The clinical significance of each vascular pattern is delineated, and surgical technical considerations are discussed on the basis of the recipient area requirements and types of a flap's vascular anatomy.

The pedicled anterolateral thigh flap for trochanteric pressure sore reconstruction: Technical notes to optimize surgical outcomes

BackgroundThe pedicled anterolateral thigh (ALT) flap has become more popular for the reconstruction of soft-tissue defects in neighboring areas. Nonetheless, few studies in the literature have explored the use of this flap for trochanteric ulcer reconstruction. The aim of our study is to present the author’s experience of utilizing the ALT flap, with a focus on technical elements regarding the flap design and the tunneling method to maximize the reach of the flap.MethodsThe medical records of patients who received pedicled ALT flaps for the reconstruction of trochanteric pressure sores were retrospectively reviewed. The patients’ demographic data, operative details, and postoperative complications were evaluated.ResultsBetween October 2018 and December 2019, 10 consecutive patients (age range, 13–45 years) underwent 11 pedicled ALT myocutaneous flaps for trochanteric pressure sore reconstruction. Each flap was designed around the most distal cutaneous perforator that was included in the proximal third of the skin paddle. The flaps ranged in size from 11×6 to 14×8 cm. The ALT flap was transposed through a lateral subcutaneous tunnel in five patients, while the open tunnel technique was used in six patients. All flaps survived, and no vascular compromise was observed.ConclusionsThe pedicled ALT flap is a safe and reliable option for reconstructing trochanteric pressure sores. An appropriate flap design and a good choice of the tunneling method are crucial for successful flap transposition.

"Sushi roll" technique for precise total tongue functional reconstruction using a pre-sutured femoral anterolateral myocutaneous flap.

Reconstruction of the total tongue after cancer resection remains one of the challenges in head and neck surgery. Inadequate reconstruction after subtotal or total glossectomy defects leads to poor quality of life. The aim of this study was to explore an economical, practical and effective flap design for functional tongue reconstruction. Sixty patients were randomly divided into two groups, namely, a "Sushi roll" technique group (30 patients) and a conventional surgery group (30 patients). Then, the patients underwent total or subtotal tongue reconstruction. Swallowing function, speech intelligibility, cosmetic results, and quality of life were assessed with the appropriate scales. Outcomes were analysed, and a p-value <0.05 was considered significant. The perioperative recovery of the "Sushi roll" group was superior to that of the conventional group. Relative to patients in the conventional group, patients in the "Sushi roll" group showed significantly improved speech intelligibility (p=0.025), cosmetic results (p<0.001) and swallowing function (p<0.001). The innovative "Sushi roll" anterolateral thigh myocutaneous flap approach for total tongue reconstruction creates a free neotongue tip with adequate volume and protuberance and causes minimal damage to the donor site, producing acceptable swallowing function and speech intelligibility.

Anterolateral Thigh Myocutaneous Flap for Reconstruction of a Large Anterior Neck Sinus Caused by Tuberculous Lymphadenitis: a Case Report

Tuberculosis remains a major global health problem and persistent lymphadenitis or incorrect treatment may result in sinus formation. We present a case of a large anterior neck sinus caused by tuberculous lymphadenitis. We designed an anterolateral thigh myocutaneous flap with 6 × 5 cm of skin and 10 × 7 cm of muscle for the reconstruction of the large sinus. The descending branch of the lateral circumflex femoral artery and 2 venae comitantes were anastomosed with superior thyroid arteries and two anterior neck veins. The patient experienced complete survival of the flap and did not complain of any discomfort. The donor site healed well, and weakness of the lower limb was absent. In conclusion, an anterolateral thigh myocutaneous flap is a good choice for the reconstruction of a neck sinus caused by tuberculous lymphadenitis.

Modified pedicled anterolateral thigh myocutaneous flap for large full-thickness abdominal defect reconstruction

To investigate the reconstructive methods and effectiveness of modified pedicled anterolateral thigh (ALT) myocutaneous flap for large full-thickness abdominal defect reconstruction. Between January 2016 and June 2018, 5 patients of large full-thickness abdominal defects were reconstructed with modified pedicled ALT myocutaneous flaps. There were 3 males and 2 females with an average age of 43.7 years (range, 32-65 years). Histologic diagnosis included desmoid tumor in 3 cases and sarcoma in 2 cases. The size of abdominal wall defect ranged from 20 cm×12 cm to 23 cm×16 cm. Peritoneum continuity was reconstructed with mesh; lateral vastus muscular flap was used to fill the dead space and rebuild the abdominal wall strength; skin grafting was applied on the muscular flap, the rest abdominal wall soft tissue defects were repaired with pedicled ALT flap. The size of lateral vastus muscular flap ranged from 20 cm×12 cm to 23 cm×16 cm, the size of ALT flap ranged from 20 cm×8 cm to 23 cm×10 cm. The donor site was closed directly. All flaps and skin grafts survived totally, and incisions healed by first intention. All patients were followed up 6-36 months (mean, 14.7 months). No tumor recurrence occurred, and abdominal function and appearance were satisfying. No abdominal hernia was noted. Only linear scar left in the donor sites, and the function and appearance were satisfying. Modified pedicled ALT myocutaneous flap is efficient for large full-thickness abdominal defect reconstruction, decrease the donor site morbidity, and improve the donor site and recipient site appearance.

Application of pedicled anterolateral thigh myocutaneous flap for full-thickness abdominal wall reconstruction after tumor resection

To explore the effectiveness of pedicled anterolateral thigh myocutaneous flap for full-thickness abdominal wall reconstruction after tumor resection. Between September 2010 and December 2017, 18 patients with abdominal wall tumors were collected. There were 11 males and 7 females, with an average age of 45.2 years (range, 29-68 years). Histologic diagnosis included desmoid tumor in 8 cases, sarcomas in 6 cases, malignant teratoma in 2 cases, and colon adenocarcinoma in 2 cases. All abdominal wall defects were full-thickness defects. Peritoneum continuity was reconstructed with mesh; the lateral vastus muscular flaps were used to fill the dead space and rebuild the abdominal wall strength; the abdominal wall soft tissue defects were repaired with pedicled anterolateral thigh flaps. The size of abdominal wall defects ranged from 15 cm×6 cm to 25 cm×22 cm; the size of lateral vastus muscular flap ranged from 10 cm×8 cm to 22 cm×10 cm; the size of anterolateral thigh flap ranged from 14.0 cm×8.0 cm to 21.0 cm×8.5 cm. The bilateral pedicled anterolateral thigh myocutaneous flaps were harvested to repair the extensive abdominal wall defects in 2 cases. All donor sites were sutured directly. All wounds healed smoothly and all flaps survived totally. All donor sites healed smoothly. The mean follow-up time was 22.5 months (range, 11-56 months). No tumor recurrence occurred, the abdominal function and appearance were satisfactory, no abdominal hernia was noted. Only linear scar left at the donor sites. Pedicled anterolateral thigh myocutaneous flap combined with mesh is fit for large full-thickness abdominal defect reconstruction.

Abstract: A Study on the Length of Flap in the Thigh for Abdominal Wall Reconstruction

INTRODUCTION: A pedicled or free tissue thigh flap has been used for large abdominal wall defect reconstruction.1, 2 Anterolateral thigh flaps, tensor fascia lata musculocutaneous flaps, and their combination are reliable and are often used.3, 4 Despite the reported efficacy, it is unclear how large an abdominal defect can be closed with a single thigh flap. The objective of this study was to compare the length of the abdomen and thigh, and to determine whether a thigh flap is suitable for all abdominal wall reconstruction procedures. METHODS: A total of 100 adult Japanese subjects (men: 50, women: 50) with no medical history of musculoskeletal disease or injury were recruited. The length from the xiphoid process to the pubic tubercle was defined as the length of the abdomen (AL). The length of the thigh (TL) was defined as the distance from the anterior superior iliac spine to the upper lateral edge of the ipsilateral patella. The height of each subject and the difference between the TL and AL (TL – AL) were recorded. Statistical analysis was performed. RESULTS: The average age was 42.6 years in men and 41.8 years in women. The average height and standard deviation was 172.65 ± 6.53 cm in men and 158.00 ± 5.14 cm in women. The averages and standard deviations of the TL, AL, and TL – AL were 45.26 ± 3.20 cm, 32.70 ± 2.78 cm, and 12.57 ± 3.73 cm in men, and 40..82 ± 1.68 cm, 32.69 ± 2.93 cm, and 7.91 ± 3.17 cm in women, respectively. The height showed no correlation with AL in female subjects. AL showed no correlation between the male and female subjects. A height of less than 170 cm in males showed a clear correlation with TL – AL. CONCLUSION: Since the TL was larger than the AL in all subjects, a thigh flap is suitable for abdominal wall reconstruction in most cases. AL was consistent according to height in female subjects. In female and male subjects less than 170 cm in height, the thigh flap may be too short for abdominal wall reconstruction. Reference Citations: 1. Kimata Y, Uchiyama K, Sekido M, et al. Anterolateral thigh flap for abdominal wall reconstruction. Plast Reconstr Surg. 1999; 103: 1191–1197. 2. Williams JK, Carlson GW, Howell RL, Wagner JD. The tensor fascia lata free flap in abdominal-wall reconstruction. J Reconstr Microsurg. 1997; 13: 83–90. 3. Lv Y, Cao D, Guo F, Qian Y. Abdominal wall reconstruction using a combination of free tensor fasciae lata and anterolateral thigh myocutaneous flap: a prospective study in 16 patients. Am J Surg. 2015; 210: 365–373. 4. Sasaki K, Nozaki K, Nakazawa H, Kukuchi Y. Reconstruction of a large abdominal wall defect using combined free tensor fasciae lata musculocutaneous flap and anterolateral thigh flap. Plast Reconstr Surg. 1998; 102: 2244–2252.

Reconstruction of oral and maxillofacial soft tissue defects with anterolateral thigh (myocutaneous) flap assisted by computed tomography angiography

To investigate the efficacy of anterolateral thigh (myocutaneous) flap designed with computed tomography angiography (CTA) to reconstruct oral and maxillofacial soft tissue defects. Between January 2011 and December 2015, 23 cases of oral and maxillofacial tumors were treated. There were 14 males and 9 females with the age range from 45 to 72 years (mean, 56.8 years). There were 12 cases of tongue carcinoma, 5 cases of buccal mucosa carcinoma, 4 cases of mouth floor carcinoma, and 2 cases of oropharynx carcinoma; all were squamous cell carcinoma. According to standard TNM staging of the Union for International Cancer Control (UICC), 8 cases were rated as T 2N 0M 0, 3 cases as T 2N 1M 0, 1 case as T 2N 2M 0, 4 cases as T 3N 0M 0, 2 cases as T 3N 1M 0, 2 cases as T 3N 2M 0, 2 cases as T 4N 1M 0, and 1 case as T 4N 2M 0. The course of disease was 1-6 months (mean, 2.4 months). CTA was performed before operation to locate the perforator vessel and its surface projection of emerging point and to design anterolateral thigh (myocutaneous) flap by computer. The defects of soft tissue ranged from 6 cm×4 cm to 11 cm×7 cm after resection of tumor. The flap was used to repair defects, including 14 thinned anterolateral thigh flaps, 7 anterolateral thigh myocutaneous flaps, and 2 anterolateral bilobed flaps; and the flap area ranged from 7 cm× 5 cm to 12 cm×8 cm. The donor sites were sutured directly. CTA showed that myocutaneous perforators penetrated at the fascias of the vastus lateralis muscles in 22 cases with a location rate of 95.7% (22/23). Submandibular fistula occurred in 1 case at 5 days after operation and fistula healed after changed dressings. Other wounds at recipient site and donor site healed at primary stage. Anastomose with 2 vein was performed because of poor venous return in 1 case, and the flap survived. The other flaps survived well. All the patients were followed up 6-36 months (mean, 16.4 months). At 3 months after operation, the simplified recovery standard of speech function and swallow function was established according to the University of Washington Quality of Life Scale (UW-QOL). The speech and swallow function recovered satisfactorily in 22 cases, and not very satisfactorily in 1 case of well differentiated squamous cell carcinoma of the right mouth floor (T 4N 1M 0). No obvious tissue atrophy was observed in 23 cases. No dysfunction was found at the donor site. There was no tumor recurrence in 21 patients; 1 patient accepted the second operation due to lymphonodi metastasis of contralateral neck at 6 months after first operation, who died after 23 months; 1 patient died of distant metastasis at 10 months after first operation. The anterolateral thigh (myocutaneous) flap designed with CTA could well recover the morphology and function of the recipient site.

Reconstruction of maxillofacial defect using free anterolateral thigh flaps after resection

Objective To explore the value of free anterolateral thigh flaps in the reconstruction of maxillofacial defects after resection. Methods Patients were recruited from January, 2008 to March, 2016 in the Department of Oral and Maxillofacial Surgery of Nanjing University. All patients sunder when reconstructive surgery employing anterolateral thigh myocutaneous flaps follow-up of 3 months to 84 months after operation. Results Among 422 cases, survived completely with satisfied configuration, the survival rate was 98.6%. Postoerative vessel thrombosis occurred in flaps, 21 patients required operative exploration in the perioperative period including 10 flaps with thrombotic events and 11 flaps with venous thrombosis were complete survival after the salvages, and 6 flaps were failure. The mean follow-up was 36.5 months (range: 3 to 84 months). Conclusion The free anterolateral thigh flap is an ideal choice for reconstruction of maxillofacial defects, as it has many advantages such as abundance volume, easily molding and adjusting the thickness, possessing, long vascular pedicle, composition need to be adjusted according to defects, easily concealed donor site, and little donor site complications and malformation. Key words: Anterolateral thigh flap; Maxillofacial defect; Reconstruction; Microsurgical technique

Combination of Vascular Intervention Surgery and Free Tissue Transfer for Critical Diabetic Limb Salvage.

Complex, nontraumatic diabetic foot ulcers with peripheral vascular compromise often lead to extensive lower-limb amputation. The aim of this study is to determine the outcome of combined vascular intervention and free tissue transfer for critical diabetic limb salvage. A total of 26 consecutive diabetic patients with 28 legs with diabetic foot ulcers who underwent limb salvage with a combination of revascularization (bypass surgery or endovascular angioplasty) and free flap transfers were reviewed. There were 14 male and 12 female patients. The average age was 58.8 years (range, 35-85 years). Amputation-free survival and complete wound healing were defined as the primary endpoints. All preoperative and postoperative data were retrospectively analyzed. Thirty flaps were used for reconstruction in 28 legs, including 21 free anterolateral thigh (ALT) perforator flaps, 3 ALT myocutaneous flaps, 5 gracilis muscle flaps, and 1 latissimus dorsi muscle flap. All flaps used end-to-side anastomoses for the recipient artery and end-to-end anastomoses for the recipient vein. The overall flap success rate was 90% (27/30). Two flaps failed completely because of severe arteriosclerosis, which resulted in anastomosed vessel thrombosis. New flaps were applied in both cases after debridement and trimming of necrotic tissue. One flap failed because of restenosis and inadequate perfusion combined with severe infection, resulting in pedicle thrombosis. A below-knee amputation was subsequently performed. Seven flaps exhibited a partial loss, including 6 ALT perforator flaps and 1 latissimus dorsi flap, because of inadequate margin perfusion. After debridement, the flap revision and wound care, 5 flaps healed uneventfully without additional intervention. The remaining 2 ALT perforator flaps required debridement with a skin graft. The limb-salvage rates were 92.8% after 1 year and 89.2% after 5 years. The combination of peripheral arterial intervention and free tissue transfer resulted in successful wound healing and limb salvage instead of amputation in select diabetic patients with difficult-to-heal wounds.

Abdominal wall reconstruction using a combination of free tensor fasciae lata and anterolateral thigh myocutaneous flap: a prospective study in 16 patients

BackgroundReconstruction of the abdominal wall continues to be a challenging problem for plastic surgeons. Transposition of well-vascularized flap tissue is the most effective way to repair composite abdominal wall defects. We retrospectively reviewed the treatment of such patients and assessed the reconstructive technique using combination of an inlay of bioprosthetic materials and a united thigh flap. MethodsA retrospective review of patients' records in the department was carried out. In total, 16 patients who underwent immediate abdominal wall reconstruction between 2000 and 2013 were identified. Patients' health status, defect sizes, and surgical technique were obtained from medical charts. ResultsThe immediate reconstruction surgery of the abdominal wall was successful in all patients. One patient with dermatofibrosarcoma protuberans experienced recurrences at the former site. One patient died because of liver metastases at 21 months after surgery. No incisional hernia or infection in this series of patients was observed. ConclusionFull-thickness, giant defects of the complicated abdominal wall can be repaired successfully with relatively minor complications using this reconstructive technique.

Application of 909 anterolateral thigh myocutaneous flaps in the reconstruction of oral and maxillofacial defects

To summarize the application of 909 anterolateral thigh myocutaneous flaps in the repair of oral and maxillofacial defects and to examine their benefits in maxillofacial reconstruction of these defects. Patients were recruited from January 2004 to December 2012 in the Department of Oral and Maxillofacial Surgery of the Second Xiangya Hospital of Central South University. All patients underwent reconstructive surgery with anterolateral thigh myocutaneous flaps, and patient age ranged from 19 to 81 years with a mean of 51.2 years. There were 761 flaps showing single lobe and 148 flaps showing a multi-island pedicle. The largest area among the single flaps was 28 cm × 12 cm, and the smallest was 4 cm × 2 cm. Among the 909 transferred flaps, 882 survived and 27 showed necrosis, with a survival rate of about 97.0%. The common complications at flap donor site were poor wound healing 9.6% (87/909), localized paresthesia 61.0% (500/820), and altered quadriceps force 15.0% (123/820). No case was presented with local serious complications, and 90% of the patients achieved good functional recovery and aesthetically acceptable results after the reconstruction by anterolateral thigh myocutaneous flaps. The anterolateral thigh myocutaneous free flaps are more suitable for oral and maxillofacial defects than other flaps and should be preferred.

A technical pearl to ensure reliable harvest of the anterolateral thigh myocutaneous flap.

Sir: The anterolateral thigh flap is qualified to be close to an ideal soft-tissue flap.1 The flap has the versatility of transferring different tissue components to fulfill the requirements of reconstruction. In particular, the muscle is invaluable for providing bulk, obliterating dead space, or neutralizing a hostile wound. Muscle viability is therefore of utmost importance.2 The myocutaneous anterolateral thigh flap is traditionally harvested en bloc without skin vessel dissection.3 This approach does not provide the opportunity to visualize the vascular connection between the muscle and skin to confirm the presence of reliable circulation in between, it does not address vascular variations of the anterolateral thigh flap, and it may result in skin vessel/muscular vessel injury during muscle cut, leading to skin paddle or even total flap loss, especially if the muscle segment is small.2–4 The authors propose using a perforator dissection technique for safe dissection of the anterolateral thigh myocutaneous flap. A video for demonstration is also presented. Marking is performed in standard fashion and then ultrasound Doppler imaging is used to identify skin vessels. The anteromedial border is incised down to the deep fascia. Dissection proceeds laterally either suprafascially or subfascially. Skin vessels are identified, and then a suitable vein (or veins) is selected. After that, chosen skin vessels are unroofed by cutting the minimal amount of muscle fibers covering them. Vessel unroofing is complete when the entire course of the musculocutaneous perforator and its source artery are exposed. The vascularly robust muscle needed is then marked. The designed muscle is dissected with meticulous hemostasis. The posterior border of the skin paddle is cut once the defect is clear. The flap is then divided and transferred to the defect and the donor site is closed primarily. (SeeVideo, Supplemental Digital Content 1, which shows part 1 of stepwise harvest of the anterolateral thigh myocutaneous flap with retrograde vessel unroofing, https://links.lww.com/PRS/B240; Video, Supplemental Digital Content 2, which shows part 2, https://links.lww.com/PRS/B241; and Video, Supplemental Digital Content 3, which shows part 3, https://links.lww.com/PRS/B242.)Video 1: Supplemental Digital Content 1 shows part 1 of stepwise harvest of the anterolateral thigh myocutaneous flap with retrograde vessel unroofing, https://links.lww.com/PRS/B240.Video 2: Supplemental Digital Content 2 shows part 2 of stepwise harvest of the anterolateral thigh myocutaneous flap with retrograde vessel unroofing, https://links.lww.com/PRS/B241.Video 3: Supplemental Digital Content 3 shows part 3 of stepwise harvest of the anterolateral thigh myocutaneous flap with retrograde vessel unroofing, https://links.lww.com/PRS/B242.The indisputable advantages of the anterolateral thigh flap are as follows: two-team approach, composite reconstruction, long pedicle, and minimal donor-site morbidity.1 The flap’s vascular anatomy variations are its curse. Kimata et al. reported a 15.7 percent variability in the perforator’s vascular origin.4 Wong et al. reported a 14 percent rate of using the oblique branch as a reliable alternative pedicle.5 These findings imply that in the anterolateral thigh myocutaneous flap, the skin and muscle could be nourished by different vessels, and failure to address this during flap dissection may jeopardize the flap’s skin or muscle viability.4 The anterolateral thigh myocutaneous flap is different from the vastus lateralis myocutaneous flap in that only a segment of the vastus lateralis muscle, not all of it, is harvested with the skin paddle.2 Therefore, (1) fewer skin vessels are captured in the flap’s territory, necessitating utmost protection to chosen perforator; and (2) there is an increased risk of perforator injury during muscle cut unless its path is clear. Thus, vessel unroofing increases the safety and reliability of the technique. The authors’ proposed technique could slightly increase flap harvest time compared with the classic method. However, the benefits as seen warrant the utmost emphasis. In conclusion, the proposed technique is easy to perform. It prevents accidental injury to skin/muscle nourishing vessel(s) and addresses possible anatomical variations. This technique is invaluable for young surgeons. DISCLOSURE The authors have no financial interest to declare. Nidal Farhan ALDeek, M.D., M.Sc. Chung-Kan Tsao, M.D. Huang-Kai Kao, M.D. Fu-Chan Wei, M.D. Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital Chang Gung Medical College and Chang Gung University Taipei, Taiwan

Anterolateral thigh myocutaneous flaps as the preferred flaps for reconstruction of oral and maxillofacial defects

BackgroundThe 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. MethodsPatients 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 cm2, and the smallest was 3 × 2 cm2. ResultsAmong 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. ConclusionThe 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.

The gluteal fold flap: A versatile option for perineal reconstruction following anorectal cancer resection

Gluteal fold flaps (GFFs) have been extensively reported for vulvo-vaginal reconstruction but there are no published series of their use for perineal reconstruction following anorectal cancer excision. In this context, abdominal myocutaneous flaps remain the method of choice but may be unavailable because of pre-existing abdominal scars, or need for a colostomy/urostomy. In addition, their abdominal wall morbidity makes them less acceptable, especially given the increasing use of laparoscopic techniques for the extirpative surgery. We document our experience using GFFs following radical anorectal cancer excision. Data were collected from a single surgeon's consecutive cases performed over a five-year period (October 2007-May 2012). The indication, surgical procedure, complications and follow-up were recorded, as was the incidence of neoadjuvant/adjuvant therapy. Ten gluteal fold fasciocutaneous flaps were performed in seven patients at the time of radical anorectal excision. The GFFs were performed alone (unilateral n=3, bilateral n=3) or in combination with a contralateral anterolateral thigh (ALT) myocutaneous flap (n=1). The indications for anorectal excision were rectal adenocarcinoma (n=3), anal squamous cell carcinoma (n=3) and anal adenocarcinoma (n=1). All flaps survived completely although two patients required further surgery, one for evacuation of a late donor site haematoma and another to close a small, persistent wound dehiscence. The mean follow-up period was 24 months (range 2-57). The GFF is a reliable, versatile and robust option for perineal reconstruction after extended anorectal excision, despite local irradiation, and should be considered for medium and selected large defects in this context.