Anterolateral Thigh Perforator Research Articles

Reconstruction of multiple long digital and hand defects using the multilobed anterolateral thigh perforator flap.

This study investigated the reconstruction of multiple long digital and hand defects using the multilobed anterolateral thigh perforator flap. From January 2018 to January 2021, 14 patients (hands) with multiple long digital defects were treated using the multilobed anterolateral thigh perforator flap. The mean age of the patients was 35 years (range, 18-55 years). The mean size (length × width) of the defects was 12.3 × 10.6 cm (range, 9 × 7 cm-16 × 12 cm). The mean size of the flap was 13.7 × 12.1 cm (range, 11 × 8 cm-19 × 14 cm). The total active motion was compared to the opposite side (100% normal, excellent; 75%-99% normal, good; 50%-74% normal, fair; <50% normal, poor). In this series, 12 flaps survived completely. Partial flap necrosis occurred in 2 patients but healed with wound care. The mean follow-up period was 28 months (range, 25-34 months). Based on the total active motion scoring system, we got 1 excellent, 7 good, 7 fair, and 1 poor result. A second surgery to separate the digits was not required. Multiple digital and hand defects can be reconstructed simultaneously using the multilobed anterolateral thigh perforator flap, allowing a length-to-width ratio of greater than 1.5:1 to resurface long digital defects. Level IV, Therapeutic Study.

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.

Application of Staged Negative Pressure Wound Therapy and Flap Surgery for Infection Control After Patellar Internal Fixation Surgery.

The anatomic position of the patella is superficial, making it vulnerable to injuries. Treatment of patella infection after internal fixation surgery remains a big challenge due to minimal soft tissue coverage and vital tissue exposure. Forty-two patients aged 10 to 59 years were admitted to the institution's burn unit between January 2010 and December 2019. Each presented with infection after patellar fracture surgery. Twenty-seven infections were superficial, whereas 15 were deep with pyogenous arthritis of the knee. Negative pressure wound therapy (NPWT) was applied after radical debridement to remove necrotic subcutaneous tissues and internal fixation devices. In addition, cases with septic arthritis were irrigated continuously with normal saline. After 5 to 10 days of NPWT treatment and irrigation, wound infection was well controlled. Afterward, 42 wounds were resurfaced with pedicled flaps, the 42 patients received 17 reverse-flow anterolateral thigh (ALT) perforator flap, 12 medial sural artery perforator flaps, 7 gastrocnemius musculocutaneous flaps, as well as 6 saphenous artery flaps. Thirty-seven flaps survived uneventfully. However, 3 flaps developed venous congestion in the distal end. Two flaps developed tip necrosis. All patients were followed up between 3 and 48 months. Infection beneath the flap occurred in 3 patients and healed after an additional debridement surgery. The staged NPWT and flap surgery strategy focus on thorough debridement and immediate internal fixation devices removal, effective fracture fixation, efficient NPWT application, targeted administration of antibiotics, and adequate soft tissue coverage. This study established that the procedure was effective in infection control after patellar internal fixation surgery.

Oncological Skull Base Reconstruction with Microvascular Tissue Transplantation in Advanced Relapsed Cases

Introduction: Tumors involving the skull base are real challenges to reconstructive surgeons. Many articles have been published about these reconstructions, especially in primary cases. In tumor relapses after previous surgeries or irradiation, the surgical options for reconstruction are extremely narrowed and is our opinion that microvascular autologous tissue transplantation is specially indicated in those patients, even though it requires a technically demanding procedure. Materials and Methods: We analyzed retrospectively all patients treated at our institution between March 2014 and December 2018 and that met all the inclusion criteria: 1) oncological surgery for a tumor involving the skull base; 2) previous surgical treatment for that tumor; 3) cranial base bone resection; 4) dural exposure or defect; 5) reconstruction done with a free flap. The patient's age, comorbidities, number of previous surgeries and/or irradiation, oncological excisional procedures, type of defect, type of reconstruction, postoperative complications and mortality were reviewed. Results: Fifteen flaps were used in the 14 patients that met all the inclusion criteria. The used flaps were: Anterolateral Thigh (ALT) perforator or chimeric ALT/Vastus Lateralis (VL) (n=6), profunda artery perforator (n=3), muscular Rectus Abdominis (n=2), Vertical Rectus Abdominis Myocutaneous (VRAM) (n=2), chimeric osteomuscular scapular tip/Latissimus Dorsi (LD) (n=1) and radial forearm (n=1). Dural defects were reconstructed with Pericranial or fascia Lata grafts in 7 patients. No total flap failures or vascular thrombotic events were noted and just one case of partial flap necrosis was registered (treated conservatively). There was one case of cerebrospinal fluid leakage, one diffuse cerebral edema and one donor site wound dehiscence, all successfully treated with conservative measures. The only complication that required a second operation was a cranioplasty prosthetic exposure that required a second free flap. One patient had a tracheostomy bleeding followed by a pneumothorax and died 8 weeks postoperatively with a nosocomial pneumonia. In the follow-up period, one patient died 19 months postoperatively with a local relapse and another with a metastatic disease (at month 15). Conclusion: Secondary or multiple relapsed cases in the skull base require reconstructions that are technically demanding and the defects are often extensive. The surgical options are extremely reduced by previous treatments and if the basic concepts of cranial base reconstruction were strictly respected, the microsurgical free flaps can offer the best chance to avoid severe complications. However, it is not without some postoperative complications and mortality can be significant in the follow-up because of the advanced stage of the oncologic disease.

An anterolateral thigh free flap for reconstruction of extensive neck defect in diabetic patient: a case report

Introduction: Reconstruction of the head and neck has challenges due to its three-dimensional structure, tissue complexity, extent of the defect, and clinical scenarios. Advances in microsurgical techniques make free tissue transfer reconstruction a popular choice to address these issues. Anterolateral thigh perforator flap (ALT) is a workhorse flap for head and neck reconstruction due to its long and reliable pedicle, large volume, versatility in composition, and low donor morbidity. However, diabetes mellitus may contribute to developing postoperative complications, such as vascular occlusions and thrombosis, that endanger free flap survival and are associated with poor wound healing. This case report demonstrates the successful utilization of this approach in the closure of extensive neck defects in a diabetic patient. Case Presentation: A 56-year-old male was referred with a 21 cm x 15 cm defect following an odontogenic submandibular abscess. The flaw was extended from the intrabuccal, neck, and one-third of the upper anterior thorax, involving the skin, subcutaneous tissue, and exposed mandibular bone. The patient had previously uncontrolled diabetes mellitus. Surgical debridement, antibiotics, insulin for glucose control, and wound bed preparation were performed. A free fasciocutaneous ALT flap was used for defect closure. The flap was raised template-based, sized 24 × 15 cm, with a pedicle from the descending branch of a lateral circumflex femoral vessel. End-to-end anastomosis of one artery and vein of the superior thyroid vessel was performed. The donor site was closed using a split-thickness skin graft. The surgery and recovery were uneventful. Flap refinement was carried out one month later. The patient underwent a three-month follow-up period, expressing satisfaction with the aesthetic and functional outcomes. Conclusions: Anterolateral thigh perforator flap (ALT) is a workhorse flap for reconstruction of head and neck reconstruction due to its long and reliable pedicle, large tissue volume with various compositions, and low donor morbidity. The LD flap presents as an alternative for free tissue transfer. Regional pedicled flaps can be chosen where microsurgery is not available or suitable. However, vascular compromise and flap failure remain a challenge. Identifying and managing risk factors such as diabetes mellitus are needed to minimize significant complications.

Microsurgical thinned anterolateral thigh perforator flap to repair soft tissue defects of foot and ankle

To explore method and clinical effect of microsurgical thinned anterolateral thigh perforator flap to repair soft tissue defects of foot and ankle. From March 2017 to January 2022, totally 20 patients with soft tissue defects of ankle joint were treated with micro-thinning anterolateral perforator flap for free transplantation, included 13 males and 7 females, aged from 22 to 58 years old with an average of (36.45±12.36) years old. The size of flap ranged from 8.0 cm×5.0 cm to 20.0 cm×12.0 cm. Before operation, perforating vessels on the anterolateral thigh region were detected and marked with a portable Doppler detector. For the defect width less than 8 cm, 11 patients were repaired with a single flap. For the defect width more than 8 cm, the wound could not be sutured directly, and the lobulated flap technique was used in 9 patients, the width was converted to length, and the donor site was closed directly. Under the microscope, all flaps were thinened in a stepwise manner from the center of the pedicle to the periphery. After operation, survival of the flap, the shape, texture, sensory function recovery were observes, and recovery of foot function was evaluated by Maryland foot function evaluation standard. All 20 patients with microsurgical thinned anterolateral thigh perforator flaps were survived. Venous crisis occurred in 1 patient due to subcutaneous hematoma, after removal of the hematoma, the crisis was relieved and the flap survived successfully. The wounds in the donor and recipient sites healed well, and only linear scars left in the donor sites. Twenty patients were followed up for 3 to 26 months after operation, good shape of flaps without bloated, and good texture. The two-point discrimination of free flaps ranged from 9.0 to 16.0 mm, and the protective sensation was restored. The ankle flexion and extension function recovered well and patients could walk normally. According to Maryland foot function evaluation standard, 8 patients got excellent result, 10 patients good and 2 middle. Microsurgical thinned anterolateral thigh perforator flap is an ideal method to repair soft tissue defects in functional area of foot and ankle, with good appearance and texture of the flap, no need for re-plastic surgery, reduced hospitalization costs, and less donor site damage.

Reconstruction of large-area wounds in limbs using two flow-through anterolateral thigh perforator flaps

IntroductionLimb salvage in large wounds is difficult because the disrupted blood supply does not support a flap. This study evaluated the clinical efficacy of using two flow-through anterolateral thigh perforator flaps for reconstructing large-area limb wounds. MethodsThis retrospective study included 45 patients who underwent reconstruction of large limb wounds using two flow-through anterolateral thigh perforator flaps at Ruihua Hospital between January 2015 and December 2020. Wound areas ranged from 15 cm × 13 cm to 46 cm × 18 cm. Single flap areas ranged from 16 cm × 8 cm to 46 cm × 9 cm. Blood supply locations were identified using color Doppler ultrasound or digital subtraction angiography (DSA) images. Primary outcomes were flap survival and complications at recipient or donor sites during at least 6-months follow-up. ResultsThe overall flap survival rate was 97% (87/90). All donor sites healed by first intention. Three cases developed vascular crises, which were alleviated by reoperation. One case had flexor contracture in left toes, relieved by cutting flexor tendons; 13 cases had flap bloat, relieved by flap thinning at 6 months. All cases showed properly healed wounds and functional reconstruction. ConclusionsReconstruction of large-area limb wounds using two flow-through anterolateral thigh perforator flaps provides safe and satisfactory effects without donor-site morbidity, and with proper healing and restored function.

Reconstruction of Finger Soft Tissue Defects With a Thinned Free Anterolateral Thigh Flap.

Reconstructing complex soft tissue defects of the finger requires both functional and aesthetic aspects. There are many free tissue transfers as suitable options for digital resurfacing. The anterolateral thigh (ALT) flap is not the first choice for reconstruction of this area because it has the disadvantage that the subcutaneous tissue is too thick; however, its use as a thinned form has yet to be described much. This study presents the flap thinning technique in the small-sized ALT flap for the finger soft tissue defect. From May 2009 to March 2018, 10 patients with complete circumferential or semicircumcision defects in the fingers underwent reconstructive procedures that included thinned ALT flap transfer. Finger soft tissue damage due to contusion trauma includes loss of skin and exposure of the bone and tendon. The flap is thinned in 2 different ways: peripheral thinning and total microsurgical thinning, which is selected based on the perforator vessel structure of the flap. The ALT flap sizes, averaging 4-9 cm wide and 6-12 cm long, were thinned to 4-7 mm. One perforator was included in the flaps with a pedicle length average of 6.1 cm. The flaps survived entirely in all patients except one with a 30% area in the distal part of the thinned ALT flap that became necrotic because of venous occlusion. Donor sites were closed primarily for all patients. No patients required secondary flap defatting. The small thinned ALT perforator flap can be an excellent option for full circumferential or semicircumferential soft tissue defects of the finger. Follow-up showed this as an excellent alternative for finger reconstruction in terms of aesthetic appearance and functional outcome.

Profunda Artery Perforator Flap Tongue Reconstruction: An Effective and Safe Alternative to the Anterolateral Thigh Flap.

The anterolateral thigh (ALT) perforator flap is a workhorse flap for tongue reconstruction. The authors present an alternative option using the profunda artery perforator (PAP) flap for glossectomy reconstruction compared to the ALT flap. A retrospective review was conducted of 65 patients who underwent subtotal or total glossectomy reconstruction between 2016 and 2020 (46 ALT vs. 19 PAP flaps). Flap volume was assessed using CT scans at two different time points. Quality of life and functional outcomes were measured using the MD Anderson Symptom Inventory for head and neck cancer (MDASI-HN). Patients undergoing a PAP flap had significantly lower BMI compared to ALT flaps (22.7±5.0 vs. 25.8±5.1; p=0.014). Donor site and recipient site complications were similar as was the mean flap volume seven months after surgery (30.9% for ALT vs. 28.1% for PAP; p=0.93). Radiation and chemotherapy did not appear to have a significant effect on flap volume change over time. The most frequently reported high-severity items in MDASI-HN were swallowing/chewing and voice/speech for both cohorts. Patients who had reconstruction with a PAP flap had significantly better swallowing function (p=0.034). Both the PAP and ALT flaps appear to be safe and effective choices for subtotal and total tongue reconstruction. The PAP flap can serve as an alternative donor site, especially in the setting of malnourished patients with thin lateral thigh thickness undergoing reconstruction of extensive glossectomy defects.

Value of the combination of a smartphone-compatible infrared camera and a hand-held doppler ultrasound in preoperative localization of perforators in flaps

This study was conducted to evaluate the effectiveness of the FLIR ONE PRO, a thermal imaging camera for smartphones, combined with handheld Doppler (HHD) in the localization of perforator arteries and to assess the efficacy of the FLIR ONE PRO in distinguishing perforators of the descending branch of the lateral circumflex femoral artery (LCFA) from other perforators of the anterolateral thigh perforator (ALTP) flap. We enrolled 29 free perforator flaps from 22 patients in our study. Before surgery, dynamic infrared thermography was performed using a FLIR ONE PRO to visualize hotspots on the flaps. Subsequently, HHD was used to further determine the perforators under the hotspots, which were ultimately identified and confirmed through intraoperative findings. Additionally, infrared images of the ALTP flap were analyzed using FLIR Tools. The performances of the FLIR ONE PRO and FLIR ONE PRO + HHD groups were evaluated by comparing the intraoperative findings. Using FLIR ONE PRO + HHD, 119 hotspots and 106 perforators were identified during surgery. Using FLIR ONE PRO + HHD, sensitivity and positive predictive value were 97.87% and 88.46%, respectively, in the young (age≤45 years). In the elderly group (age>45 years), these percentages were 93.22% and 82.09%, respectively. In addition, we found that the FLIR ONE PRO could be useful for differentiating perforators in the descending branch of the LCFA from other perforators within 5 min. The results showed a sensitivity of 96.15%, a specificity of 98.9%, a positive predictive value of 96.15%, and a negative predictive value of 98.9%. Compared to using FLIR ONE PRO alone, the combined application of HHD and FLIR ONE PRO had a higher value in perforator localization by increasing the positive predictive value. The FLIR ONE PRO may have significance in the rapid prediction of perforators deriving from the descending branch of the LCFA.

Clinical Feasibility of a Low-dose Computed Tomography Angiography Protocol with an Iterative Reconstruction Algorithm in Preoperative Examinations for Anterolateral Thigh Perforator Flap Surgery

Background: In the past several years, emerging imaging techniques, such as computed tomography angiography (CTA), Doppler ultrasound, and magnetic resonance imaging (MRI), have been used for investigating the anatomy and perfusion of perforator complexes. Preoperative CTA can provide explicit information on perforator flaps, which not only helps surgeons to evaluate the optimal design of flaps with respect to the lateral circumflex femoral artery (LCFA) territory and the concomitant venous drainage pattern, but also reduces postoperative complications and secondary operation rates. Objectives: This study aimed to evaluate the clinical feasibility of a low-dose CTA protocol with adaptive statistical iterative reconstruction (ASIR) for patients scheduled for anterolateral thigh perforator flap (ALTPF) surgery. Patients and Methods: This prospective randomized controlled trial was conducted in a single institution from August 2016 to July 2017. A total of 60 inpatients scheduled for the ALTPF surgery were randomly allocated into three groups (n = 20 per group): Group A, filtered back projection (FBP) reconstruction with a tube voltage of 120 kVp; group B, ASIR with a tube voltage of 100 kVp; and group C, ASIR with a tube voltage of 80 kVp. The vessel attenuation value, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and figure of merit (FOM) were compared between the three groups. Additionally, a four-point Likert scale was used to evaluate the subjective quality of images. The scan length, dose-length product (DLP), CT dose index (CTDI), and effective dose (ED) were also recorded and compared. Results: The age, sex, and body mass index (BMI) were not significantly different between the three groups (P &gt; 0.05 for all). The FOM of images in the three segments was significantly higher in group C compared to the other two groups (P &lt; 0.001 for all). The results of subjective evaluation revealed no poor-quality images, and the Likert score did not significantly differ between the groups. Compared to group A and group B, significant reductions were observed in CTDI, DLP, and ED in group C. Conclusion: The 80-kVp protocol with ASIR not only reduced the radiation dose, but also exhibited lower performance compared to the 120-kVp protocol with FBP and the 80-kVp protocol with ASIR; it also yielded relatively satisfactory image quality.

A clinical study of ultrasonic localization-assisted combined transplantation of a bilateral anterolateral thigh perforator flap for the repair of large-area skin and soft tissue defects of the extremities.

The aim of this study was to investigate the clinical efficacy of the combined transplantation of a bilateral anterolateral thigh perforator (ALTP) flap for the repair of large-area skin and soft tissue defects of the extremities. Twelve patients who had received bilateral ALTP flap reconstructions for large-area skin and soft tissue defects of the extremities were retrospectively analyzed. The areas of the skin and soft tissue defects were measured preoperatively (18.0×11.0 ‒ 38.0×15.0 cm2). The wounds were on the forearm, elbow, upper arm, foot, and lower leg. Color Duplex Sonography (CDS) was used to localize the site where the perforator artery of the bilateral thighs penetrated the deep fascia. The selected area was evaluated according to the number of perforating branches and the range of supply. The flap areas and repairable range were further evaluated according to the number of perforating branches detected during the operation to determine whether to retain the deep fascia. It is important to design and adjust the anastomosis of the vascular pedicle according to the specific situation on transfer of the flap to the recipient site. The donor sites of all the patients in the study were closed in the first stage. The amount of bleeding and the blood supply to the flap after vascular anastomosis were evaluated during the operation. The postoperative survival of the flap and complications, such as bleeding, infection, and arteriovenous crisis, were closely monitored. All patients were followed-up at one, three, and six months after surgery to assess their satisfaction with the appearance of the flap transplantation and the recovery of limb function. The bilateral ATLP flaps survived successfully in all 12 cases and all donor sites were closed in the first stage. No post-surgery complications, including hematoma, wound dehiscence, and infection, were observed at the donor sites, resulting in high patient satisfaction. Combined transplantation of bilateral ALTP flaps can repair large-area skin and soft tissue defects in one stage, which not only reduces the number of operations and hospitalization costs but also reduces the damage to the limbs caused by the cutting of large-area flaps from only one side. The accuracy of the surgery was improved by ultrasound-assisted localization. In summary, combined transplantation of bilateral ALTP is a rational yet effective way to repair large-area skin and soft tissue defects of the extremities.

Technique and clinical application of free lobed anteromedial thigh perforator flap

To introduce the technique and clinical application of free lobed anteromedial thigh perforator flap. Between October 2017 and December 2021, 65 patients with buccal and oral cancer penetrating defects were planned to treat with free lobed anterolateral thigh flap transplantation, of which 15 cases were found that the sole anterolateral thigh perforator was actually a branch of the anteromedial thigh perforator, and then the free lobed anteromedial thigh perforator flap was harvested for repair. There were 12 males and 3 females with an average age of 34.6 years (range, 29-55 years). According to Union for International Cancer Control (UICC) TNM staging, there were 7 cases of T 4N 0M 0, 4 cases of T 4N 1M 0, 2 cases of T 3N 1M 0, and 2 cases of T 3N 2M 0. The disease duration was 1-10 months (mean, 6.3 months), and the area of secondary soft tissue defect left after radical resection of buccal and oral cancer was from 5 cm×4 cm to 10 cm×6 cm. The anterolateral thigh skin flap ranged from 5 cm×4 cm to 13 cm×6 cm, and the anteromedial thigh skin flap ranged from 5 cm×3 cm to 10 cm×6 cm. The free trilobed anteromedial thigh flap was prepared according to the actual branches of the main trunk of the anteromedial thigh perforator in 4 cases, and the vastus medialis muscle flap was used to fill the cavity defect of the floor of mouth in 7 cases. Among the 15 patients, the vessel pedicles of the anteromedial thigh perforators were derived from the main femoral artery and vein in 8 cases, from the main descending branch of the lateral femoral circumflex artery in 4 cases, and from the main lateral femoral circumflex artery in 3 cases. Hematoma occurred in 2 cases after operation, which was successfully saved after emergency exploration. No vascular crisis occurred, and partial necrosis of anterolateral femoral skin island occurred in 1 case, which was healed with debridement. The remaining flaps survived successfully, and the wounds and donor site incisions healed by first intention. All the patients were followed up 12-36 months (mean, 14.6 months). The appearance of the flap was satisfactory, and no obvious swelling was found; the mouth opening and language function were satisfactory; only linear scar was left in the donor area, and the thigh function was not significantly affected. Local recurrence occurred in 3 cases, and the defect after tumor resection was repaired with pedicled pectoralis major myocutaneous flap. Four patients with neck lymph node metastasis, including ipsilateral side in 3 patients and contralateral side in the other 1 patient, all underwent neck lymph node dissection again. The 3-year survival rate was 86.7% (13/15). The anteromedial thigh perforator vessels distributed in the anterolateral region of the thigh can be used to prepare the anterolateral thigh split lobed flap to repair the buccal and oral cancer penetrating defects.

Expanding horizons of reconstructive microsurgery in Lebanon: Reconstruction of complex traumatic wounds with anterolateral thigh perforator flaps in paediatrics patients less than 10 years of age.

Paediatric complex wounds pose a challenge to the reconstructive surgeon due to the intricacy of reconstructive options required. Developments in microsurgery and microsurgical technique have brought free tissue transfer ever closer to the comfort zone of the reconstructive surgeon for reconstruction of paediatric traumatic complex wounds. We present our experience of microsurgical reconstruction in Lebanon for complex traumatic wounds in paediatric patients under the age of 10 years using the free anterolateral thigh (ALT) flap. The ALT flap has proven its value as a safe, adaptable, and aesthetically acceptable reconstructive option in paediatric complex trauma.

An algorithmic approach to soft-tissue reconstruction around the knee using anterolateral thigh perforator flap in patients with post-traumatic knee osteomyelitis.

Free tissue transfer to the knee region in patients with chronic post-traumatic knee osteomyelitis (CTKOM) poses a great challenge to surgeons because the remaining soft tissues adjacent to defects, including vascular structures, are usually damaged by chronic inflammation and multiple debridements. Thus, we developed an algorithm to help select the optimal recipient vessels and appropriate anterolateral thigh perforator (ALTP) flap type. In addition, we performed surgery using this algorithm and achieved successful reconstructions. This study aims to review our experiences in algorithmic reconstruction and assess its efficacy. According to the defect size and location, our algorithm suggested the use of various-shaped ALTP flaps with centrally located perforators (Cen-ALTP flap) or eccentrically located perforators (Ecc-ALTP flap). Besides, through the algorithm, one recipient vessel was selected among three candidates, including descending branch of the lateral circumflex femoral artery (DB-LCFA), anterior tibial artery (ATA), and posterior tibial artery (PTA). Based on this algorithmic decision, we performed individualized soft tissue reconstructions of the knee in 21 patients with CTKOM, between March 2013 and June 2021. The medical records of the patients were retrospectively reviewed. The Cen-ALTP flap (n = 15) and ATA (n = 9) were the most commonly used for reconstruction. The Cen-ALTP flap anastomosed to the ATA was most commonly selected (n = 7) using the algorithm, followed by the Cen-ALTP flap anastomosed to the DB-LCFA (n = 5), and the Cen-ALTP flap anastomosed to the PTA (n = 3). All transferred ALTP flaps survived the follow-up period. Postoperative venous congestion in two patients and hematoma in one patient were resolved by immediate treatment. The postoperative course was uneventful. During free ALTP flap transfer to CTKOM-related knee defects, we could select the optimal recipient vessel and appropriate flap type using our algorithm and obtain excellent reconstructive outcomes. Therefore, we believe that our algorithm could provide helpful guidance to reconstructive surgeons on free ALTP flap transfer to reconstruct CTKOM-related soft tissue defects.

Lower leg reconstruction after resection of a squamous cell carcinoma on necrobiosis lipoidica with a pedicled fibula and an extended anterolateral thigh flap—a case report

BackgroundExtensive loss of soft tissue and bone due to neoplasia, trauma, or infection in extremities often leads to amputation.Case presentationWe present the case of a 72-year-old female patient presenting with an extended cutaneous squamous cell carcinoma of the lower leg, developed on top of necrobiosis lipoidica. After achieving the R0 resection, a 26 × 20-cm soft tissue and 15-cm tibial bone defect resulted. The contralateral leg had been lost due to the same disease 18 years before. We achieved a successful reconstruction of the leg using a pedicled fibula transplantation, an extended anterolateral thigh perforator flap, and an internal fixation with plate and screws. Two years after the original surgery, the patient is relapse-free and mobile, with adequate function of the reconstructed foot.ConclusionsOur case presented a unique combination of pedicled fibula transplantation and free extended ALT perforator flap to reconstruct an extensive defect after resection of a rare cSCC on top of NL. In selected cases, the boundaries of limb salvage can be pushed far beyond the current standards of treatment.

Comparison of the free thinned anterolateral thigh perforator flap and the free medial sural artery perforator flap for reconstructing head, neck and extremity defects

BACKGROUNDThe free anterolateral thigh (ALTP) and free medial sural artery perforator (MSAP) flaps are time tested donor for head and neck, and extremities defect reconstruction. Proponents of either flap have concluded each as workhorse flap in their large cohort studies. However, we could not find any literature comparing the donor morbidities, or recipient site outcomes of these flaps, objectively.METHODSRetrospective data, such as demographic details, flap characteristics and post operative course, from patients who underwent free thinned ALTP (25 patients) and MSAP flap (20 patients) were included. At follow-up, donor site morbidity and recipient site outcomes were assessed, using previously defined protocols. These were compared in-between the two groups. RESULTSFree thinned ALTP (tALTP) flap had significantly more pedicle length and vessel diameter and harvest time than free MSAP flap (p value&lt;.00). The differences in incidence of hyperpigmentation, itching, hypertrophic scar, numbness, sensory impairment and cold intolerance at the donor site in-between the two groups, were not significant statistically. Scar at free MSAP donor site was considered a significant social stigma (p value=.005). Recipient site cosmetic outcome was comparable (p value=.86), measured using aesthetic numeric analogue.CONCLUSIONSThe free tALTP flap is superior to free MSAP flap in terms of pedicle length, vessel diameter, donor site morbidity, while the latter takes lesser time for harvest.

Anterolateral thigh perforator flap made by customized 3D-printing fabrication of fixed positioning guide for oromaxillofacial reconstruction: a preliminary study.

Oromaxillofacial carcinomas frequently result in serious tissue defect due to enlarged resection for treating their extensive invasion, which require challenging reconstruction. Three-dimensional (3D) printing is an advanced technology which has greatly promoted the progress of craniomaxillofacial reconstructive surgery. This present study aimed to investigate the advantages of anterolateral thigh (ALT) perforator flap manufactured by 3D printing fixed positioning guide template in curing oromaxillofacial defect. Twenty patients with oromaxillofacial defects resulted from severe primary malignant tumors were divided into experimental group assisted by digital technique (n=8) and controlled group conventionally aided by ultrasound (n=12). The therapeutic effectiveness, flap preparation time, amount of bleeding, deviation of perforator vessel location, aesthetic satisfaction of donor site, postoperative complications, adverse symptom of flap, and LEFS scores were compared. For experimental group, flap preparation time was significantly shorter; and it has obviously less bleeding, minor deviation of perforator vessel location, and better aesthetic satisfaction of donor site (P<.001). There was no statistical difference in postoperative complications and LEFS scores between two groups (P>.05). The study suggests 3D printing template of fixed positioning guide provides a brand-new method for orienting perforated vessels of ALT flap, which is more accurate in clinical application. It can improve the operative efficacy, and increase the successful rate of operation as well.

Clinical application of anterolateral thigh perforator flap pedicled with oblique branch in intramuscular of lateral circumflex femoral artery

To explore the characteristics and clinical application of the anterolateral thigh flap pedicled with the oblique branch in the intramuscular of lateral circumflex femoral artery. The clinical data of 25 patients with skin and soft tissue defects of extremities admitted between December 2020 and April 2021 were retrospectively analyzed, including 16 males and 9 females, aged 14-75 years, with the median age of 43 years. The defect site included 13 cases of hand, 2 cases of forearm, 2 cases of calf, and 8 cases of foot and ankle. The wound area ranged from 6 cm×4 cm to 35 cm×22 cm. Twenty-four patients with trauma were admitted to hospital immediately after injury, and 1 patient with diabetic foot infection was transferred to the hospital after ineffective treatment in other hospital. Flap surgery was performed from 0 to 56 days (median, 22 days) after admission. A total of 26 thigh flaps were harvested in 25 patients, with unilateral flaps in size of 7 cm×5 cm to 40 cm×10 cm. The type, caliber, and location of the perforating branch were recorded during the operation, and the anatomical characteristics of the oblique branch of the intramuscular trunk were mainly observed. The flap harvesting time was recorded; the flap survival and wound healing time were observed; at last follow-up, XIAO Feipeng et al. flap comprehensive efficacy evaluation table was used to evaluate the effectiveness of flap repair from three aspects of donor site, recipient site, and subjective satisfaction of doctors and patients. After the oblique branch in intramuscular of lateral circumflex femoral artery was sent out, it ran 2-3 cm obliquely laterally and inferiorly in the intermuscular septum and then entered the vastus lateralis muscle, and sent out perforating branches to nourish the skin. A total of 61 perforating branches were marked in 26 thighs of 25 patients before operation, and 70 perforating branches were found during operation, including 9 transverse branches, 29 descending branches, and 32 oblique branches, all of the oblique branches were musculocutaneous perforators. All 25 patients were followed up 6-10 months, with an average of 8 months. The time of unilateral thigh flap harvesting ranged from 13 to 90 minutes, with an average of 48 minutes. One patient with diabetes developed disturbance of blood supply and complete necrosis of the flap at 1 month after operation, and then the flap was repaired with skin graft; 1 case developed arterial crisis after operation, which survived after timely exploration; and the rest of the flaps survived smoothly. The wound healing time of the recipient site ranged from 10 to 44 days, with an average of 19 days, and the donor site of the thigh healed by first intention. At last follow-up, the color and texture of the flap was good and the sensation recovered to S 1-S 2. Only linear scar was left in the donor site, no scar contracture, pain, and other discomfort occurred, and no other serious complications occurred. Evaluated by flap comprehensive efficacy evaluation table, the score was 74-93, with an average of 88, of which 10 cases were excellent, 13 cases were good, and 2 cases were fair, with an excellent and good rate of 92%. The intramuscular trunk oblique branch is not uncommon, and its trunk course and perforators distribution are regular. To improve the understanding of this type of oblique branch and adopt appropriate methods during operation can improve the success rate of skin flap extraction.

A novel computed tomography angiography technique: guided preoperative localization and design of anterolateral thigh perforator flap

BackgroundAnterolateral thigh perforator (ALTP) flap is considered a versatile flap for soft tissue reconstruction. Computed tomography angiography (CTA) is used for mapping perforator in abdominal-based reconstruction; however, it is less commonly used in ALTP due to its poor imaging efficacy. In this study, we introduced a novel CTA technique for preoperative localization and design of ALTP flap and evaluated its value in directing surgical reconstruction.ResultsThirty-five patients with soft tissue defects were consecutively enrolled. Modified CTA procedures, such as sharp convolution kernel, ADMIRE iterative reconstruction, 80 kV tube voltage, high flow contrast agent and cinematic rendering image reconstruction, were used to map ALTPs. A total of 287 perforators (including 884 sub-branches) were determined, with a mean of 5 perforators per thigh (range 2–11). The ALTPs were mainly concentrated in the “hot zone” (42%, 121/287) or the distal zone (41%, 118/287). Most perforators originated from the descending branch of the lateral circumflex femoral artery (76%, 219/287). Three perforator types, namely musculocutaneous (62%, 177/287), septocutaneous (33%, 96/287), and mixed pattern (5%, 14/287), were identified. The median pedicle length measured by two methods was 4.1 cm (range 0.7–20.3 cm) and 17.0 cm (range 4.7–33.9 cm), respectively, and the median diameter of the skin flap nourished by one perforator was 3.4 cm (IQR 2.1–5.7 cm). Twenty-eight ALTP flaps were obtained with the guidance of CTA, and 26 flaps survived after follow-up.ConclusionsThe proposed CTA mapping technique is a useful tool for preoperative localization and design of ALTP flap.