Anterolateral Thigh Perforator Flap Research Articles

Profunda Artery Perforator Flaps From the Posteromedial Region of the Thigh for Head and Neck Reconstruction.

Profunda femoris artery perforator flaps (PAPFs) have not been widely used in head and neck reconstructions. The feasibility and outcomes of PAPFs for various head and neck reconstructions need to be investigated. Retrospective analysis. A single-institution review. PAPFs were utilized in head and neck reconstructions from 2019 to 2021. Local anatomy, surgical technique, and complications were discussed. Chimeric PAPF applications with muscle components were described for coverage of extensive multiunit defects. Additionally, aesthetic and functional outcomes were compared with anterolateral thigh perforator flaps. A total of 33 cases were included. The average age was 54.2 years (range, 30-74). The most common underlying pathology was oral squamous cell carcinoma (n = 26, 78.8%), while the mean ± SD body mass index was 25.4 ± 2.8 kg/m2 . Middle perforators (n = 14, 42.4%) were the most commonly utilized ones. The perforator-based chimeric/composite applications were used in 9 (27.3%), with the muscular components consisting of gracilis (n = 3, 9.1%), adductor magnus (n = 5, 15.2%), or semimembranosus muscles (n = 1, 3.0%). Venous thromboses of the PAPFs were found in 2 (6.1%), though salvaged. The occurrence of postoperative 90-day morbidity (complication) was related to mandibulectomy/maxillectomy (P = .020). Postoperative validated questionnaires showed a trend of intermediate to high scores, indicating noninferior outcomes in several categories, when compared with the anterolateral thigh perforator flap counterparts. PAPFs are a good reconstructive alternative for intermediate to large head and neck reconstructions. Besides, PAPFs can provide sufficient tissue volume and versatility of potentially incorporating adjacent muscle components.

Diagnostic Accuracy of Peroperative Color Doppler Ultrasonography for Determining the Nature of Anterolateral Thigh Flap Perforators

Objective: To determine the diagnostic accuracy of color Doppler ultrasonography for diagnosing septocutaneous nature of anterolateral thigh flap perforators taking peroperative findings as gold standard among patients undergoing soft tissue reconstruction. Methodology: A total number of 100 patients undergoing soft tissue reconstruction using antero-lateral thigh flap perforators at plastic surgery unit, Pak Italian Modern Burn Center, Multan and fulfilling the selection criteria were approached. An informed consent were taken from them before enrolling in the study. Information regarding their demographic data were noted in the proforma. A high frequency color Doppler ultrasound was done by the consultant radiologist to determine the nature of the perforator (as per operational defination) and the results were noted in the proforma. The anterolateral thigh thin flap was undermined, but kept in situ. The elevation was performed either on superficial or sub-facial plane depending upon situation and surgical plan, and the points of emergence through the deep fascia and nature of its perforators, as they appeared during surgery, was noted in the proforma. Results: Age distribution of the patients was done, it showed that out of 100 patients, 17 %( n=17) were in age group of 15-27 years and 83%( n=83) were in age group of 28-40 years and mean age was calculated as 33.96±5.72 years. Gender distribution of the patients was done, it showed that 88 %( n=88) were male whereas 12 %( n=12) were females. In this study, Sensitivity and specifity of septocutaneous nature of perforator was 78.41% and 83.33% respectively and PPV was 97.18% and NPV was 34.48% and accuracy was 79%. Conclusion: Color doppler ultrasonography is the reliable test for the prediction of nature of anterolateral thigh flap perforator.

Thin Anterolateral Thigh Perforator Flap In Upper Limb Reconstruction

Thin Anterolateral Thigh Perforator Flap In Upper Limb Reconstruction

Reconstruction of Complex Soft Tissue Defects of the Heel With Versatile Double Skin Paddle Anterolateral Thigh Perforator Flaps: An Innovative Way to Restore Heel Shape.

BackgroundComplex heel defects constitute a significant challenge for plastic surgeons.ObjectivesIn this study, versatilities of free double skin paddle ALT flaps in the reconstruction of complex soft tissue defects of heels were explored.MethodsFrom January 2010 to December 2019, 16 patients (13 male and 3 females) aged 16–74 years underwent double skin paddle ALT flap reconstruction in our department. All the patients had large defects located at the heel, and 5 had a dead space. Underlying structures such as vessels, bones, and tendons were exposed in all cases.ResultsFlap survival rate was 100% after the reconstruction. Eleven double skin paddle ALT flaps and 5 vastus lateralis muscle-chimeric double skin paddle ALT flaps were used. The size of the skin flap ranged from 9.5 × 4.5 cm2 to 22 × 10 cm2, and the size of a muscle segment ranged from 6 × 3 × 1 cm3 to 10 × 3 × 2 cm3. The mean follow-up was 22.6 months (range: 10–81 months). The wounds healed well, providing reliable soft tissue coverage and good heel contour. All the patients ambulated independently during the follow-up period. Most of them regained protective sensation. The average two-point discrimination was 32.7 mm (range: 27–37 mm).ConclusionDouble skin paddle ALT flaps are a feasible option for the reconstruction of complex heel defects, with good functional and aesthetic results. Nonetheless, further studies comparing double skin paddle ALT flaps to other flap techniques are needed.

Application of “chimeric” double anterolateral thigh flaps for reconstruction of massive postburn defect in head and face (Case report).

Head and neck tissue defects are frequently, especially deep and wide defects caused by burning. Choosing sufficient material is a big challenge for surgeons. Using double anterolateral thigh perforator flaps in chimeric type is a new method, a new idea with many advantages for providing large tissue volume to reconstruct extensive defects in face and head area.We were a success in treating a case of extensive facial burn with complicated lesions by using two anterolateral thighs free flap in chimeric type with single anastomosis. Postoperation, both flaps are survived completely and got good outcomes in both function and aesthetics.

Color Doppler Ultrasound versus Computed Tomography Angiography for Preoperative Anterolateral Thigh Flap Perforator Imaging: A Systematic Review and Meta-Analysis.

The anterolateral thigh (ALT) perforator flap is a commonly used flap with a predictable, though often variable, perforator anatomy. Preoperative imaging with color Doppler ultrasound (CDU) and computed tomography angiography (CTA) of ALT flap perforators can be a useful tool for flap planning. This study provides a complete review and analysis of the relevant preoperative ALT imaging literature. Studies related to preoperative CDU and CTA imaging were reviewed, and information related to imaging method, sensitivity, false-positive rates, and perforator course identification (musculocutaneous vs. septocutaneous) were analyzed. A total of 23 studies related to preoperative ALT flap CDU and CTA imaging were included for review and analysis. Intraoperative perforator identification was compared with those found preoperatively using CDU (n = 672) and CTA (n = 531). Perforator identification sensitivity for CDU was 95.3% (95% CI: 90.9-97.6%) compared with the CTA sensitivity of 90.4% (95% confidence interval [CI]: 74.4-96.9%). The false-positive rate for CDU was 2.8% (95% CI: 1.1-4.5%) compared with 2.4% (95% CI: 0.7-4.1%) for CTA. Accuracy of perforator course identification was 95.5% (95% CI: 93.6-99.2%) for CDU and 96.9% (95% CI: 92.7-100.1%) for CTA. CDU provides the reconstructive surgeon with greater preoperative perforator imaging sensitivity compared with CTA; however, false-positive rates are marginally higher with preoperative CDU. Preoperative imaging for ALT flap design is an effective tool, and the reconstructive surgeon should consider the data presented here when selecting a flap imaging modality.

Microsurgical Scalp Reconstruction: An Overview of the Contemporary Approach.

Microsurgical scalp reconstruction has evolved immensely in the last half-century. The core concepts of microsurgical scalp reconstruction have always been to transfer soft tissue of a sufficient quality to within the defect while minimizing donor site morbidity. Refinements in scalp reconstruction consist of both improvement in reducing donor site morbidity and enhancing recipient site contour and balance. Furthermore, technical advancements and the vast experience within our field have allowed for preoperative evaluation of recipient vessels that are more favorable in proximity to the scalp. In this review, we aim to describe the contemporary approach to microsurgical scalp reconstruction. This is to include the indications of choosing free flaps as well as how to select the ideal flap based on patient-oriented factors. The need for cranioplasty, recipient vessel selection, operative technique, and reoperations is also reviewed. In addition, our considerations and the nuances within each category are also described. Scalp reconstructions involve the fundamental tenants of plastic surgery and demand application of these principles to each case on an individual basis and a successful reconstruction must consider all aspects, with backup options at the ready. Two workhorse free flaps, the anterolateral thigh perforator and latissimus dorsi muscles flaps, serve a primary role in the contemporary approach to microsurgical scalp reconstruction. We hope this review can lay the foundation for which future plastic surgeons may continue to build and advance the approach to complex microsurgical scalp reconstruction.

The combination of anterolateral thigh perforator flap and other flaps for repairing the extreme circumferential defects on the limb

To investigate the effectiveness of the combination of the anterolateral thigh perforator (ALTP) flap and other flaps for repairing the extreme circumferential defects on the limb. Between October 2016 and June 2019, 9 patients with the extreme circumferential defects on the limb were admitted, which resulted by degloving injury, including 8 males and 1 female with a median age of 42 years (range, 32-65 years). The etiology involved twist injury in 5 cases, traffic accident in 2 cases, and high voltage electric injury in 2 cases. The location of the defects was left forearm in 2 cases, right forearm in 3, left foot in 3, and right foot in 1. The injected wound bed followed by the exposure of bone, joint, tendon, and blood vessel. The dimension of defects was 25 cm×20 cm to 40 cm×28 cm. The period between the injury and admission was 1-12 hours (mean, 5 hours). All contaminated wounds were taken thorough and radical debridement and covered by the vacuum sealing drainage device during the emergency operation. The ALTP flap and the other one flap were tailored according to the dimension of the wound when the wound surface became granulating, including the thoracodorsal artery perforator (TAP) flap in 3 cases, superficial inferior epigastric artery perforator flap in 3 cases, superficial circumflex iliac artery perforator flap in 3 cases. And the donor site was primary closure. After operation, all the flaps survived except 1 case of partial necrosis at the edge of TAP flap and healed after secondary skin grafting, and the wounds in the donor and recipient areas healed by first intention. All patients were followed up 14-24 months (mean, 16 months). The shape of the flap was satisfactory and the texture was soft. There was no abnormal hair growth and obvious pigmentation during the follow-up. Only linear scar was left in the donor area, there was no complication such as abdominal wall hernia, and the activity of hip and knee was not affected. The functional reconstruction of upper limb and ankle was satisfactory, and the disabilities of the arm, shoulder, and hand (DASH) score was excellent in 4 cases and good in 1 case; the American Orthopaedic Foot and Ankle Association (AOFAS) score was excellent in 3 cases and good in 1 case. ALTP flap combined with different flaps can reconstruct the circumferential extreme defects after limb damage in one-stage, which can achieve limb salvage to the greatest extent.

Comparison Between Free Anterolateral Thigh Flap and Free Medial Sural Artery Perforator Flap in Reconstruction of Post Traumatic Soft Tissue Defects of the Dorsum of the Foot

Abstract Background: The objective of this study is to compare between the free anterolateral thigh flap and free medial sural artery perforator flap in reconstruction of post traumatic soft tissue defects of dorsum of the foot as regard the function, the aesthetic outcome, the complications and the patient satisfaction.Method: The study was conducted on 40 patients with post traumatic soft tissue defects of the dorsum of the foot between August 2018 and August 2019. Patients were allocated randomly into two groups. In group1 (20 patients), the defect was reconstructed with free anterolateral thigh perforator flap. In group 2 (20 patients), reconstruction was done by free medial sural artery perforator flap.Result: In group 1 (ALT flap), Complete flap survival was achieved in all cases. Thirteen patients required secondary debulking procedures and scar revisions.In group 2 (MSAP Flap), Complete flap survival was achieved in 17 cases with one flap totally lost and two flaps had distal necrosis. One patient needed scar revision and another patient needed flap advancement.Conclusion: MSAP flap is good alternative in soft tissue reconstruction of the dorsum of the foot. It has many advantages: it is thin, pliable, fitted to normal footwear, less hairy and there is no need for secondary procedures in most cases. ALT flap is better than MSAP flap in larger defects coverage but may need secondary debulking procedures or primary thinning at the time of reconstruction.

The Treatment Experience of Different Types of Flaps for Repairing Soft Tissue Defects of the Heel.

ObjectiveTo summarize the clinical application effects of three different types of flaps for repairing soft tissue defects of the heel, and to discuss the importance of tissue repair and heel reconstruction.MethodsA total of 46 cases with skin tissue defects of the heel with deep tissue exposure were treated. The reasons for the defect were trauma (n = 26), burns and electric shocks (n = 12), chronic ulcers (n = 2), postoperative infection of the calcaneus and Achilles tendon (n = 5), and tumor resection (n = 1). The scope of wound defect was 2.0×2.5 to approximately 15.0×20.0 cm. The flaps used were medial plantar island flaps (n = 9), distal pedicled sural neurovascular island flaps (n = 23), and free anterolateral thigh (perforator) flaps (n = 14). The flap cutting range was 3.0×3.5 to approximately 16.0×22.0 cm.ResultsAfter surgery, all 46 flaps survived. In two cases, patients experienced partial epidermal necrosis at the distal end of the flap that healed after local dressing exchange, and after this treatment, the complete skin grafts survived. Follow-up was conducted in 40 cases, with an average follow-up duration of 8.2 months (3–44 months) and the two-point discrimination of 5–14 mm. The average American Orthopaedic Foot and Ankle Society scale was 89.2 points with good flap color and texture, satisfactory appearance, and normal gait.ConclusionThe repair method should be selected according to the“5-zone method”: The plantar medial island flap is suitable for small area (<5 cm) of medial, posterior and plantar defects. The distal pedicled sural neurovascular flap is suitable for lateral, posterior, and medium-range (6–10 cm) joint area defects. The free anterolateral thigh perforator flap is suitable for large-scale (>10 cm) joint area defects.

Application value of CTA combined with digital technology in the design of anterolateral thigh flap in repairing operative defect of head, neck and maxillofacial tumor resection

Objective:To explore the value of computed tomography angiography （CTA） combined with digital technology in the vascular anatomy of the anterior thigh flap in patients with operative defects after head, neck and maxillofacial tumor operation, and in the design of preoperative and intraoperative flaps. Methods:Twenty-five cases of patients with postoperative defect after head, neck and maxillofacial tumor surgery admitted to our hospital from April 2018 to April 2019 were selected. Preoperative CTA and digital technology were used to clarify vascular anatomy and other related conditions, and the operation was carried out. Consistency analysis was applied to evaluate the value of CTA, digital technology and CTA combined digital technology in the localization of anterolateral thigh perforator flap with operative defects after head, neck and maxillofacial tumor resection, and the diagnostic efficacy of the three methods was compared. Results:The preoperative CTA examination revealed that there were 26 intermuscular perforators with a diameter greater than 0.8 mm in the flap donor site, and 17 musculocutaneous perforators with a diameter greater than 1.0 mm. During the operation, it was actually found that there were 27 intermuscular perforators with a diameter greater than 0.8 mm and 17 musculocutaneous perforators with a diameter greater than 1.0 mm. The accuracy rates of Pre-operative examination were 96.29% and 100.00%, respectively.In addition, the lateral femoral circumflex artery determined by digital technology. The starting position of the descending branch, the diameter of the vessel, the direction of the perforating vessel, and the maximum length of the pedicle that can be cut were consistent with the actual observation during the operation. All the patients in the group successfully underwent flap removal and repair. After the operation, 2 skin flaps suffered from vascular crisis, and survived under the managements of anticoagulation, lifting of restraint, and massage. The rest of the flaps survived smoothly. The patients were followed up for 3-12 months postoperatively. Twenty-four cases of skin flaps had good appearance. One case had swollen wound And the appearance of the skin flap was satisfactory after elective secondary thinning. Among the 25 patients with head and neck defects, in the perforator location examination, 18 cases were detected by CTA, with a sensitivity of 90.0%, a specificity of 60.0%, an accuracy of 84.0%, and Kappa=0.500. 19 cases was detected by digital technology, with a sensitivity of 86.36%, a specificity of 66.67%, a accuracy rate of 84.00%, and Kappa=0.412. 21 cases was detected by CTA combined with digital technology,with a sensitivity of 95.45%, a specificity of 66.67%, a accuracy of 92.00%, and Kappa=0.621. The accuracy of CTA combined with digital technology in the perforator positioning of patients with head and neck tumor defects was significantly higher than that of the single method（P<0.05）. Conclusion:CTA has good application value in the positioning of perforator in patients with head, neck and maxillofacial tumor defects. In addition, the combination of CTA and digital technology can improve the accuracy of the vascular anatomy of the anterior thighflap and the design of the preoperative and intraoperative flaps, which is beneficial to surgery clinical implementation.

Usefulness of Color Doppler Ultrasonography for the Preoperative Evaluation of Thin Anterolateral Thigh Flap Perforators

Purpose: The anterolateral thigh flap is commonly applied to various body sites for reconstruction. However, surgeons often struggle against unexpected locations and the nature of perforator vessels during surgery. Thus, this study aimed to assess the accuracy and usefulness of color Doppler ultrasonography as a preoperative tool for the perforator position and course of anterolateral thigh flaps.Methods: A prospective study involving 77 anterolateral thigh flaps was conducted between March 2016 and February 2021. Among them, 37 perforators (group A) were detected using the preoperative color Doppler ultrasound, and the other 40 perforators (group B) were tested using a hand-held Doppler only. All patients in group A underwent color Doppler ultrasonography performed by a radiologist at our institution. The nature and course of the perforator vessels were recorded, and their precise locations were plotted in an orthonormal coordinate system.Results: A total of 37 anterolateral thigh perforator flaps (group A) were successfully dissected. The median distance between the preoperative color Doppler ultrasonography and the real location during surgery of the perforators was 7.50 mm, which was statistically smaller than 10 mm (p&lt;0.001). This preoperative ultrasound test also had a success rate of 94.6% to determine the nature of the perforators (musculocutaneous type vs. septocutaneous type).Conclusion: Preoperative color Doppler ultrasonography provides a harmless, reliable, and accurate technique for visualizing the vascular anatomy of anterolateral thigh flaps. It has a high correlation with surgical findings, allowing surgeons to cope with variable vascular anatomy.

Effect of Anterolateral Thigh Perforator Flap Repair on the Appearance, Language and Masticatory Function of Oral Cancer Patients after Radical Surgery

Purpose: The purpose was to explore the application effect of anterolateral thigh perforator flap (ALTP) and pectoralis major myocutaneous flap on repairing the tissuedefects after oral cancer surgery. Methods: 100 oral cancer patients treated in our hospital from January 2018 to December 2020 were selected as the research objects. After both groups of patients received extended resection of tumors, neck lymph node dissection and other routine treatment, the control group was repaired by pectoralis major myocutaneous flap while the study group was repaired by ALTP to compare the flap survival rate, language, masticatory function and other related indicators between the two groups. Results: The flap harvesting time and defect repair time in the control group were shorter than those in the study group (P&lt;0.05); The language, masticatory function and swallowing function in both groups after treatment were significantly better than those before treatment (P&lt;0.05); The total incidence of complications in the study group was significantly lower than that in the control group (P&lt;0.05); After treatment, the quality of life scores in both groups were significantly higher than those before treatment (P&lt;0.05). Conclusion: Both ALTP and pectoralis major myocutaneous flap can be used to repair the tissue defects after radical resection of oral cancer, which can effective improve the postoperative appearance, language and masticatory function of oral cancer patients. However, pectoralis major myocutaneous flap has easier operation and shorter operation time while ALTP can significantly reduce the incidence of postoperative complications with higher safety.

Clinical effect of perforator flap combined with toe transplantation for repairing thumb damage with soft tissue defect of hand

Objective: To investigate the clinical effect of perforator flap combined with toe transplantation for repairing thumb damage with soft tissue defect of hand. Methods: The retrospective observational study method was used. From May 2014 to June 2019, 8 patients with thumb damage and soft tissue defect of hand were admitted to the 988th Hospital of Joint Logistic Support Force of PLA, including 6 males and 2 females, aged from 25 to 46 years. Among them, thumb damage in 3 cases were degree Ⅱ, 1 case was degree Ⅲ, and 4 cases were degree Ⅳ. All thumb damage were repaired with perforator flap combined with toe transplantation. The skin and soft tissue defects of hand were repaired by free anterolateral thigh perforator flap in 6 cases and free deep inferior epigastric perforator flap in 2 cases. The thumb damage of degree Ⅱ was repaired by the first toe transplantation combined with perforator flap, and thumb damage of degree Ⅲ or Ⅳ was repaired by the second toe transplantation combined with perforator flap. The survival and blood supply of reconstructed thumbs and flaps, and wound healing of donor sites were observed after surgery. All the patients were followed up for 10 to 18 months, the appearance of the reconstructed thumbs, sensory recovery, and foot walking function were observed. At the final follow-up, the functional reconstruction of the thumb was evaluated. Results: All the blood supply and survival of the reconstructed thumbs and flaps were good, and all the wounds of donor sites healed well. During the follow-up, the appearances of the reconstructed thumb and flap were good, the sensation of pain and touch of the finger pulp recovered well, and no significant impact on foot walking function was observed. At the final follow-up, the function of reconstructed thumb was evaluated as excellent in 4 cases, good in 3 cases, and fair in 1 case. Conclusions: The repair method of perforator flap combined with toe transplantation technique can complete the targeted repair of thumb damage with skin and soft tissue defect of hand in one stage, minimizing the foot donor site injury and shortening the course of disease and early rehabilitation, which is one of the ideal methods for the treatment of complex thumb damage.

Free ALT Perforator Flap in Nonobese Patients: The Recontouring of Soft Tissue Defects Around Foot.

The anterolateral thigh (ALT) perforator flap is well-described and versatile option for reconstruction of soft tissue defects around foot and ankle. This retrospective review was performed for reconstruction of soft tissue defects around foot with ALT perforator flaps in patients with normal and overweight body mass index (BMI). Between January 2016 and November 2020, ALT flaps were used in 30 patients for foot defects. Etiologic factors were trauma (18 patients), diabetic foot ulcer (6 patients), tumor (3 patients), infection (2 patients) and burn contracture (1 patient). Mean body mass index (BMI) value was 24.9 ± 4.1 (17-30). Mean flap dimension was 145 ± 86 (40-420) cm2. Recipient vessels were anterior tibial artery in 17 patients (56%), posterior tibial artery in 12 patients (40%), reversed flow dorsalis pedis artery in 1 patient (3.3%). In 24 patients (80%), 2 vein anastomoses were done. Debulking were applied in two patients (6.6%). Donor area was grafted in four patients (13.3%). Mean flap score was 1.25 ± 0.5. Mean flap thickness was 10 ± 2 (7-14) mm. Visual Analogue Scale (VAS) score was 7.75 ± 1.04 (6-10). The patients were followed up for a mean of 14 ± 11 (1-30) months. We think that ALT flap is still reliable and precious option because it provides ideal soft tissue reconstruction by means of recontouring of foot in nonobese patients.

In situ pedicle lengthening and perforator shifting technique for overcoming the perforator variation of the anterolateral thigh free flap during head and neck reconstruction.

Anterolateral thigh (ALT) free flap is one of the most popular options for surgeons when reconstructing head and neck defects. When the recipient vessels are located in a remote site, a flap with adequate pedicle length is essential. The conventional methods of either pedicle elongation or fabricating combined flap increase the total surgical time. We present the experience on the use of what in situ pedicle lengthening and perforator shifting technique to overcome these problems. Fifteen patients with an age range of 38-65 years underwent in situ vascular transposition microsurgery of the ALT free flap harvest during head and neck reconstruction. Fourteen patients were male and one was female. Indications for reconstruction were malignant neoplasm in 14 patients and osteoradionecrosis in one patient. In this series, the descending branch of the lateral circumflex femoral vessels was used for interposition grafts. If the pedicle length was insufficient, the interposition grafts were used to lengthen the pedicle. The interposition grafts could also bridge different perforasomes in the thigh region in complex head and neck reconstruction. Of the 15 patients, 11 received the in situ pedicle lengthening technique, while four patients received in situ fabricated combined techniques. After surgery, all of the patients were followed up for at least 3months. Two partial wounds involving poor healing occurred but finally healed after debridement. There were two major complications: one case involved venous thrombosis of the anastomosis and the other suffered from hematoma. Both cases were salvaged. All of the 15 free ALT flaps were successful. The alternative method employed in this series was able to solve the ALT flap perforator variation. Although the enrolled cases were confined to only head and neck reconstruction in the series, the in situ technique of the ALT flaps could be administered during reconstruction in other regions.

Comparison between Free Anterolateral Thigh Flap and Free Medial Sural Artery Perforator Flap in Reconstruction of Post Traumatic Soft Tissue Defects of Dorsum of the Foot

Background: The objective of this study was to compare the pliability, the function, aesthetic outcome, complications and patient satisfaction between free anterolateral thigh flap and free medial sural artery perforator flap in reconstruction of post traumatic soft tissue defects of dorsum of the foot. Method: The study was conducted on forty patients with post traumatic soft tissue defects of the dorsum of the foot between August 2018 and August 2019. Patients were divided randomly into two groups. In group1 (20 patients), the defects were reconstructed with free anterolateral thigh perforator flap. In group 2 (20 patients), reconstruction was done by free medial sural artery perforator flap. Result: In group 1 (ALT flap), Complete flap survival was achieved in 100% of cases. Thirteen patients required secondary debulking procedures and scar revisions. In group 2 (MSAP Flap), Complete flap survival was achieved in 85% with one flap totally lost and two flaps had distal necrosis. One patient needed scar revision and another patient needed flap advancement. Conclusion: MSAP flap is superior to ALT flap. It has many advantages: it is thin, pliable, fitted to normal footwear, less hairy and there is no need for secondary procedures in most cases.

Application of modified three longitudinal and five transverse method in perforating branch location before anterolateral thigh perforator flap repair

To explore the feasibility and accuracy of modified three longitudinal and five transverse method in locating perforating branches before anterolateral thigh perforator flap (ALTP) repair. Between January 2019 and December 2019, 41 patients with skin and soft tissue defects were repaired with ALTP. There were 31 males and 10 females. The age ranged from 18 to 61 years, with an average of 32 years. The soft tissue defects were caused by trauma in 38 cases, and the time from injury to operation was 3-7 days, with an average of 4 days. The wounds left after excision of scar contracture deformity because of burn in 3 cases. Soft tissue defects located at upper limbs in 16 cases and lower limbs in 25 cases. The size of soft tissue defects ranged from 10 cm×4 cm to 25 cm×12 cm. Before operation, zonesⅠ, Ⅱ, Ⅲ, and Ⅳwere formed on the anterolateral thigh by modified three longitudinal and five transverse method. The perforating branches were detected in these four zones by Doppler ultrasound, and the skin flaps were designed according to the wound area. The perforating branches were explored during operation, and the distribution and types of perforating branches in each zone and the relationship between perforating branches and lateral femoral cutaneous nerve were observed. The ALTP with the size of 12 cm×5 cm to 30 cm×10 cm was used to repair the wound, and the donor site was sutured directly or repaired with the flap. A total of 117 perforating branches were detected in 41 patients before operation, and 111 perforating branches were found during operation, with a false positive rate of 5%. The probability of perforating branches in zonesⅠ, Ⅱ, Ⅲ, and Ⅳ were 56%, 73%, 76%, and 66% respectively, and the false positive rates were -9%, 7%, 16%, and 4%, respectively. All perforating branches located near the trunk of lateral femoral cutaneous nerve, especially in posterolateral area. There were only 1 perforating branch in 6 cases, 2 perforating branches in 12 cases, 3 perforating branches in 10 cases, and 4 perforating branches in 13 cases. The main types of perforating branches in zonesⅠ, Ⅱ, Ⅲ, and Ⅳ were transverse perforating branches, oblique perforating branches, descending perforating branches, and descending perforating branches, respectively. Partial distal necrosis occurred in 2 cases and complete necrosis occurred in 1 case after operation, and the wounds were repaired with skin grafts. The remaining 38 flaps survived successfully, and the wounds and the incisions of donor sites healed by first intention. All patients were followed up 3 to 12 months, with an average of 6 months. The appearance and texture of the skin flap were acceptable, and linear scar remained in the donor site. It can simply locate and distinguish the perforating branches and better protect the lateral femoral cutaneous nerve by using the modified three longitudinal and five transverse method before ALTP repair.

A single-center retrospective comparison of Duplex ultrasonography versus audible Doppler regarding anterolateral thigh perforator flap harvest and operative times.

We reported on the superiority of preoperative Duplex mapping ("Duplex") over audible Dopplers ("Doppler") in anterolateral thigh perforator (ALT) free flaps for upper extremity reconstruction. To corroborate our findings on a larger cohort, we conducted this present study focusing on surgical efficiency and patient safety. 150 consecutive ALT free flaps were divided into 65 cases of preoperative Duplex versus 85 Doppler controls. We first compared patient demographics, operative details, and defect and flap characteristics. We then assessed group differences in the number and course of perforators pursued intraoperatively, flap harvest and operative times, and donor-site complications. Additionally, the impact of the training level of the primary microsurgeon was evaluated. Cases and controls were comparable regarding age (p= .48), sex (p= .81), ASA class (p= .48), and BMI (p= .90). Duplex was associated with an increased likelihood of raising flaps on one single dominant perforator of purely septal course and significant reductions of flap harvest (68 ± 10min, p< .0001) and operative times (74 ± 16 min, p< .0001), regardless of the experience of the primary microsurgeon. There were strong negative linear correlations between preoperative Duplex and both the flap harvest and operative times (p< .0001). Additionally, while there was no effect on the emergency take-back rate (OR=1.3, p= .60), revisions were significantly less likely among duplexed patients (OR=0.15, p= .04). Preoperative Duplex is associated with a significant reduction in ALT free flap harvest and overall operative times, as well as donor-site revisions as opposed to Doppler planning, regardless of the training level of the primary microsurgeon.

Reconstruction of Large Area of Deep Wound in the Foot and Ankle with Chimeric Anterolateral Thigh Perforator Flap.

ObjectiveTo evaluate the clinical application and surgical efficacy of the chimeric perforator flap pedicled with the descending branch of the lateral circumflex femoral artery and the lateral thigh muscle flap for the reconstruction of the large area of deep wound in foot and ankle.MethodsClinical data of 32 cases who underwent chimeric anterolateral thigh perforator flap to repair the large area of deep wound of the foot and ankle from January 2015 to December 2018 were retrospectively analyzed. The sizes of the defects ranged from 18 cm × 10 cm to 35 cm × 20 cm, with exposed tendon and bone and/or partial defects and necrosis, contaminations, accompanied by different degrees of infection. Following the radical debridement and VSD, chimeric anterolateral thigh perforator flap was employed to repair the deep wounds according to the position, site and deep‐tissue injury of the soft‐tissue defects. The skin flap and muscle flap were fanned out on the wound, and single‐ or two‐staged split‐thickness skin grafting was performed on the muscle flap. The operation time and blood loss were recorded. The survival and healing conditions of the operational site with chimeric anterolateral thigh perforator flap were evaluated post‐operationally. Complications at both recipient site and donor site were carefully recorded.ResultsThe mean time of the operation was 325.5 min and average blood loss was 424.8 mL. Among the 32 cases, two cases developed vascular crisis, which were alleviated with intensive investigation and treatment; Four cases suffered from partial necrosis of the flap or skin graft on the muscle flap or on the residual local wound, which were improved after treatment of further dressing change and skin grafting. Another four cases experienced post‐traumatic osteomyelitis accompanied by bone defect were treated with simple bone grafting or Mesquelet bone grafting at 6–8 months after wound healing. Postoperatively, the wounds were properly healed, and the infection was effectively controlled without sinus tract forming. Overall, all 32 cases received satisfactory efficacy, without influencing subsequent functional reconstruction, and observed infection during the 12–36 months post‐operational follow‐up.ConclusionThe chimeric perforator flap pedicled with the descending branch of the lateral circumflex femoral artery and the lateral thigh muscle flap provides an effective and relative safe procedure for the repair of a large area of deep wound in the foot and ankle, particularly with irregular defect or deep dead space.