This study aimed to compare donor-site morbidity among three common major lower extremity free flaps: fibula (FFF), anterolateral thigh (ALT), and the medial sural perforator (MSAP) using an established patient-reported outcome measure (PROM), the Lower Extremity Functional Scale (LEFS). Patients who underwent head and neck reconstruction with either FFF, MSAP, or ALT were included. The primary outcome was functional recovery, assessed using the modified LEFS, a PROM measuring functional status, administered at multiple post-operative timepoints. Seventy-five patients were included in the analysis: 33 FFF, 22 MSAP and 20 ALT. Patients undergoing lower extremity free flap surgery overall recovered well. The LEFS scores at different time points demonstrated quicker recovery for the MSAP group, while ALT and FFF recovered later. After 360 days, the MSAP group also demonstrated improved functional outcomes compared to the ALT and FFF. Patients undergoing lower extremity free flap surgery recover well. The MSAP had the least donor-site morbidity. Donor-site morbidity should be considered when counseling patients.

Heparin is frequently used to mitigate the risk of thrombosis in microsurgical free tissue transfer. Although rare, heparin-induced thrombocytopenia (HIT) is a severe, life-threatening complication that can arise in patients exposed to heparin products. This systematic review aims to examine patterns in demographics, flap characteristics, diagnostic approaches, and treatment protocols for HIT following free flap reconstruction. A systematic search was conducted across PubMed, MEDLINE, and Web of Science, following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Search terms included "heparin-induced thrombocytopenia," "HIT syndrome," "free flaps," "microsurgery," "plastic surgery," and "reconstructive surgery." Case reports or series written in English that presented patients developing HIT following free flap procedures were included. Eligibility criteria are accessible on the International Prospective Register of Systematic Reviews (PROSPERO; CRD42025650125). A total of 15 articles were included, encompassing a total of 23 free flap reconstruction cases. The median patient age was 52 years, with male predominance (69.6). Lower extremity reconstruction was most common (47.8%), primarily using anterolateral thigh flaps (39.1%). Median 4T score was 6, median time to HIT diagnosis was 6 days, and median nadir platelet count was 72 × 103/μL. Thrombotic complications were common, with venous thrombosis (34.8%) predominating. Argatroban (26.1%) was the most frequently used alternative anticoagulant, while warfarin (30.4%) was the most common discharge medication. Overall flap survival was 43.5%. Meta-analysis revealed no significant difference in flap survival between anticoagulation strategies (95% CI: 0.38-2.63, p = 1.000). HIT represents a rare but devastating complication in free flap reconstruction, with approximately half of the affected flaps failing despite intervention. Although no single anticoagulation strategy demonstrated superior outcomes, expeditious diagnosis and treatment may improve flap salvage rates. This review provides a foundation for developing standardized protocols for HIT management in microsurgical patients.

Clinical study of the superthin anterolateral thigh flap for reconstruction of post-traumatic ankle joint soft-tissue defects.

Background:During the past 4 decades, the anterolateral thigh (ALT) flap has evolved into a cornerstone of reconstructive microsurgery. Since its first description in 1984, advances in perforator dissection and flap design have broadened its applications. Commemorating the 40th anniversary of the ALT flap, this review outlines key anatomical, technical, and clinical milestones that have shaped its evolution and enduring significance.Methods:A narrative review of clinical studies on the ALT flap was conducted, focusing on human, English-language publications from the past 40 years. Studies were selected based on relevance, innovation, and clinical impact. Data were extracted on technique, anatomy, and applications to highlight key advancements in flap evolution.Results:From 2712 articles screened, 138 met the inclusion criteria. Key advancements were categorized into anatomy and perforator patterns, composite and functional flap variants, vascular modifications, refinements in flap thickness, and novel applications with imaging integration.Conclusions:After 4 decades, the ALT flap remains a cornerstone in reconstructive microsurgery due to its reliable anatomy, design versatility, and low donor-site morbidity. Ongoing advances in imaging and surgical planning are expected to further optimize outcomes and expand its applications across complex reconstructive challenges.

Merkel cell carcinoma (MCC) is a rare, aggressive neuroendocrine skin malignancy. We report an exceptional case of a 71-year-old female presenting with a 5.7-cm MCC in the left parotid region, representing a rare case of true direct parotid parenchymal invasion-distinguished from the more common intraparotid nodal metastasis-alongside multiple regional nodal metastases. The patient underwent wide en bloc excision, superficial parotidectomy, and selective neck dissection. Despite tumor adherence, the main facial-nerve trunk was successfully preserved. The resulting 12×11cm composite defect was reconstructed using an anterolateral-thigh (ALT) free flap. Pathology confirmed cutaneous MCC with direct parotid parenchymal invasion, lymphovascular/perineural invasion, and metastatic nodes (Stage IIIB). Postoperatively, the flap remained viable, with successful functional preservation of facial-nerve function. Due to high-risk features, adjuvant chemoradiotherapy was initiated. This case highlights the importance of distinguishing invasion pathways for accurate staging and demonstrates that aggressive resection with functional reconstruction is feasible and effective for managing advanced craniofacial MCC. It also emphasizes the clinical importance of differentiating true parotid invasion from intraparotid nodal metastasis.

Flaps have become a pivotal surgical option in oral reconstruction due to their versatility and reliable reconstructive outcomes. Complications associated with flap reconstruction include venous compromise, infection, hematoma, and, rarely, postoperative epidermoid cyst formation. Reducing flap-related complications remains a major goal in reconstructive surgery. We present a diagnostically challenging case of an epidermoid cyst arising at the site of an anterolateral thigh flap (ALTF) 3 years after tongue cancer reconstruction; the lesion was initially suspected to be recurrent oral cancer. In addition, we describe a modified flap-mucosa suturing technique and present preliminary clinical observations suggesting that it may reduce the incidence of postoperative epidermoid cysts.

Six systematic reviews and meta-analyses (2019-2025) have compared reconstructive options for circumferential pharyngeal defects following total laryngopharyngectomy. This narrative review synthesises their findings, examines where they conflict and why their conclusions diverge, and weighs factors that fall below systematic-review level but affect flap selection. Free jejunal flap (FJF) demonstrates the lowest fistula rate (8-11%); in the largest network meta-analysis (1357 patients), FJF had a 93% probability of ranking first for fistula avoidance. Tubed anterolateral thigh (ALT) showed non-significant trends toward lower flap failure and 30-day mortality. Differences in fistula rates between FJF and ALT vary with analytical method. Stricture rates overlap (FJF 11-20%, ALT 13-19%) and should not drive flap choice. Adjuvant radiation therapy is associated with a near five-fold increase in FJF stricture; this concern recedes in salvage cases. The U-shaped pectoralis major flap had the lowest stricture rate in the network meta-analysis. Flap selection requires balancing fistula risk against perioperative mortality and donor-site morbidity, modified by defect extent, thigh adiposity, anticipated radiation therapy, and institutional experience. No randomised trials exist. Progress will require prospective comparative data and regionalisation.

Reconstruction of large segmental tibial bone defects remains one of the most challenging problems in orthopedic trauma surgery, particularly when complicated by infection and soft tissue compromise. Various techniques, including vascularized fibular grafting, induced membrane formation, and bone transport, have been described for limb salvage in such complex situations. Bone transport based on distraction osteogenesis enables biological reconstruction of bone defects while simultaneously improving the local biological environment. A 39-year-old male construction worker sustained an open comminuted tibial pilon fracture after falling approximately 5 meters from a roof. Despite multiple surgical interventions at previous institutions, including vascularized fibular grafting, anterolateral thigh flap reconstruction, and reverse sural artery flap reconstruction, the patient developed infected nonunion with severe distal tibial bone loss and a medial ankle soft tissue defect. A total of 19 procedures were performed, and below-knee amputation was recommended before referral. The patient was referred to our institution for limb salvage. Because the distal tibial articular surface had insufficient bone stock for joint preservation and local vascular conditions were considered to be severely compromised after repeated failed microsurgical reconstructions, ankle arthrodesis following bone transport was planned. Approximately 10 cm of infected bone was resected, and an antibiotic-loaded hydroxyapatite spacer containing vancomycin was inserted. Bone transport was initiated after proximal tibial corticotomy at a rate of 1 mm per day in four increments following a 1-week latency period. During transport, the soft tissue defect gradually epithelialized without additional flap reconstruction. Docking was achieved at 4 months, followed by autologous cancellous bone grafting, and the external fixator was removed 6 months after docking. Infection was controlled with systemic antibiotics, and soft tissue healing was achieved using negative pressure wound therapy followed by fibroblast growth factor application. No recurrence of infection was observed, and at 8-year follow-up, the patient had returned to full-time construction work with a Japanese Society for Surgery of the Foot (JSSF) score of 88 points and a visual analogue scale (VAS) pain score of 0. Bone transport using circular external fixation can serve as a rational and effective final limb salvage strategy for infected tibial pilon fracture nonunion with large bone defects, particularly after repeated failure of microsurgical reconstruction.

Free flap reconstruction after wide resection of sarcomas around the knee is challenging due to anatomical complexity and limited recipient vessels. The medial vastus branch of the descending genicular artery (DGA) may serve as a favorable recipient artery, but its anatomical characteristics and clinical applicability remain unclear. An anatomical study was conducted on 30 lower limbs from 15 formalin-fixed cadavers to investigate the course and diameter of the medial vastus branch of the DGA. In addition, the clinical applicability of this vessel was evaluated in knee reconstruction. The medial vastus branch was identified in 86.7% of specimens, with an average diameter of 1.4 mm (range: 1.0-1.7), 1.6 mm (range: 1.2-1.9), 1.7 mm (range: 1.3-2.0), and 1.9 mm (range: 1.6-2.3), at 2.5, 5.0, 7.5, and 10-cm above the medial upper margin of the patella. Its superficial location allowed for easy dissection and anastomosis. The medial vastus branch of the DGA was successfully used as a recipient artery for free flap transfer in clinical application. The medial vastus branch of the DGA is a reliable recipient artery for free flap reconstruction around the knee. Its favorable anatomical characteristics enable safe dissection and vascular anastomosis without the need for positional changes during surgery. This vessel may be a valuable option for complex soft tissue reconstructions around the knee defects.

IntroductionReconstruction of complex nasal defects involves restoring external skin, internal lining, and support within a 3D framework. While the forehead flap is considered the gold standard, free tissue transfer is used when local tissues are unavailable. Historically, the radial forearm flap (RFF) was favored for its thinness and pliability. The anterolateral thigh (ALT) flap, once limited by bulkiness, has been refined. This study examines the evolution and current role of the ALT flap in the nasal reconstruction algorithm.MethodsA sequence of patients with nasal defects received reconstruction with a free ALT flap. Additionally, a targeted literature review was performed to explore recent advances in perforator dissection, flap thinning, and chimeric design relevant to nasal reconstruction. The study assessed flap configuration, thinning techniques, structural repair, complications, and long-term results.ResultsEighteen flaps were performed: twelve for nasal reconstruction and six for adjacent facial subunits. Five patients required total nasal reconstruction. The mean flap thickness decreased from 24.6 ± 5.5 mm to 5.7 ± 2.4 mm after combined primary and microdissection thinning, a 77% reduction. Chimeric and multi-paddle configurations enabled simultaneous restoration of skin, lining, and composite defects. Flaps were viable with no partial necrosis. Long-term follow-up over 1 to 8 years demonstrated stable airway function and maintained satisfactory contour.ConclusionsThe ALT flap has evolved from a secondary reconstructive option to a refined material for complex nasal defects. Advances in perforator-based thinning and hybrid designs have expanded its use, making it a viable alternative to traditional forearm reconstruction in some patients.

(281) Predictors of Complications and Flap Survival in Cisgender Total Phallic Construction: A Tertiary Referral Center Analysis

Complex head and neck defects often require chimeric anterolateral thigh (ALT) perforator flaps for reconstruction. However, the variable anatomy of the lateral circumflex femoral artery (LCFA) makes preoperative perforator mapping essential for successful harvest of multiple skin paddles. We developed a standardized protocol combining computed tomography angiography (CTA) with color Doppler ultrasound (CDU). First, bilateral lower extremity CTA scans from 52 patients (104 thighs) were analyzed to characterize perforator distribution from the descending branch of the LCFA. This protocol was then applied to 12 patients with complex head and neck defects. CDU was used to localize and mark cutaneous perforator exit points before CTA scanning. Perforator characteristics were analyzed, and three-dimensional models created. Detailed vessel data were then transferred through a coordinate system to optimize flap design. All 12 chimeric ALT flaps were harvested successfully according to the preoperative plan, with satisfactory flap viability and favorable clinical outcomes. Integrating CDU identification with subsequent CTA mapping provides a reliable preoperative strategy that enhances the precision and safety of chimeric ALT flap reconstruction for complex head and neck defects.

Orthoplastic approach to infected type 3B open tibial fractures: Management and complications.

The anterolateral thigh (ALT) free flap is widely used in reconstructive surgery, but intramuscular perforator dissection remains technically demanding and time-consuming. Electrocautery may cause collateral thermal injury and slower dissection rates. Advanced bipolar energy devices, such as LigaSure, offer precise vessel sealing with reduced thermal spread, potentially enabling faster and more controlled dissection. This study aimed to directly compare electrocautery with LigaSure during ALT flap harvest, evaluating dissection efficiency and operative duration. A combined retrospective-prospective study was conducted. Group A retrospectively analyzed 20 ALT flaps by a single surgeon (10 with electrocautery, 10 with LigaSure), comparing flap harvest time. Group B prospectively analyzed 10 ALT flaps, where 2 surgeons each alternately dissected a perforator within the same flap using either electrocautery or LigaSure, facilitating direct comparison. Primary outcomes were flap harvest time and perforator dissection speed (time per centimeter of perforator length). LigaSure significantly reduced flap harvest time. In group A, flap harvest time was shorter with LigaSure versus electrocautery. In group B, perforator dissection was significantly faster with LigaSure, averaging 11.5 versus 39.4 minutes with electrocautery. Normalized to perforator length, LigaSure achieved 1.61 minutes per centimeter compared with 6.29 minutes per centimeter with electrocautery, approximately 3.9 times faster (P < 0.05). LigaSure significantly enhances ALT flap dissection efficiency, especially along the intramuscular perforator course, thereby reducing flap harvest time. Its adoption can streamline workflow and improve procedural consistency in ALT flap harvest.

Salvage of composite soft tissue and extensor mechanism defects of the knee using free anterolateral thigh flaps with vascularized fascia lata.

Background:Treating complex hand defects from cobra bites is a significant challenge for plastic surgeons. Microsurgical fascia flaps, especially the free anterolateral thigh (ALT) fascial flap, have been successfully used to reconstruct exposed tendons and soft-tissue injuries in single-stage procedures.Methods:This study discusses the use of the free ALT adipofascial (AF) flap for the successful reconstruction of venomous cobra bite injuries. After debridement, the resulting wounds were complex, often presenting full-thickness soft-tissue defects with exposed tendons. We covered these with the flap and immediately applied full-thickness skin grafts.Results:Thirty free ALT-AF flaps were used, with an average flap length of 11 cm and width of 5.6 cm, covering an area of 65.8 cm2, with a thickness of 2–3 mm. Donor sites were primarily closed, and the overall flap success rate was 97.7%. Hand function recovered to approximately two-thirds of the normal range of motion. There was 1 total flap failure and 2 partial skin graft losses. No secondary flap defatting or donor-site complications occurred.Conclusions:The free ALT-AF flap with a skin graft is effective for reconstructing complex hand injuries and may improve aesthetic and functional outcomes in snakebite cases.

Soft tissue sarcomas (STS) of the foot are rare, accounting for 2-5% of musculoskeletal sarcomas, and are often associated with higher amputation rates due to limited soft tissue coverage, complex anatomy, and the functional demands of weight-bearing. We report the case of a 70-year-old woman with a myxoinflammatory fibroblastic sarcoma involving the 2nd-4th metatarsals. Limb salvage surgery was performed, consisting of en bloc resection with preservation of the metatarso-phalangeal joints, skeletal fixation with titanium plates, tendon reconstruction using tensor fascia lata, and soft-tissue coverage with an anterolateral thigh free flap. Intraoperative, interstitial brachytherapy catheters were placed, enabling 36Gy/9 fractions safely without wound or flap complications. At 6months, the patient was disease-free and ambulatory without disability. This case demonstrates that with multidisciplinary planning, complex reconstruction and adjuvant brachytherapy can achieve durable local control and preserve function in selected patients with foot sarcoma.

To describe the use, indications, and outcomes of a limited transoral approach for segmental mandibulectomy reconstruction with minimal access vessel isolation and anastomoses in patients with mandibular osteoradionecrosis. Retrospective review of patients who have undergone FFF reconstruction of segmental mandibulectomy via transoral plating and inset at our institution from 2022 to 2024. Nine patients (median age of 66, 100% male) with mandibular ORN underwent FFF reconstruction via transoral approach with minimal access vessels isolation. The majority of patients failed conservative management of ORN, with eight patients receiving prior antibiotic therapy and seven undergoing hyperbaric oxygen therapy. Preoperative fracture/nonunion and fistula were noted in seven and four patients, respectively. The median length of hospitalization following this procedure was 6 days (range: 4-9). One patient developed nonunion in the postoperative period and required revision with anterolateral thigh fascia lata free flap and iliac crest bone grafting. An additional patient required takeback for hematoma and successful vascular salvage; however, complications were otherwise minimal, with no other patients experiencing operating room takeback, readmission within 30 days, hematoma, fistulas, or flap compromise. All patients demonstrated clinical and radiographic arrest of ORN at most recent follow-up. Median follow-up length was 13.9 months (range 7.7-34). Mandibular reconstruction using a transoral approach with FFF provides a promising alternative to the traditional transcervical approach for patients with osteoradionecrosis, potentially reducing morbidity and improving outcomes.

While standard treatments for mandibular osteoradionecrosis (MORN) exist for mild/superficial and severe/full thickness disease, there is no consensus on treatment for advanced, partial thickness disease. In this niche, the anterolateral thigh fascia lata (ALTFL) "rescue" flap has managed MORN successfully. This study aimed to compare ALTFL with fibula free flap (FFF) reconstruction to determine differences in outcomes, complications, and postoperative logistics. A retrospective chart review of patients undergoing ALTFL or FFF for MORN between 2008 and 2024 was carried out. Fifty-one patients with Grade III (n = 26) or IV (n = 25) MORN underwent FFF (n = 22) or ALTFL (n = 29). ALTFL patients were older but did not differ in preoperative MORN treatment or risk factors compared to FFF. Median operative time for ALTFL was significantly less than FFF in both Grade III (298 min vs. 516 min) and IV (298 min vs. 599 min), without differences in subsites of mandible involved. Hospitalization for ALTFL was significantly shorter than FFF for both Grade III (2 days vs. 7 days) and IV (4.5 days vs. 7 days) without differences in peri-operative complications, flap failure or MORN resolution. Tracheotomy was performed more often for patients undergoing FFF for Grade III MORN. Patients who underwent ALTFL were more likely to return to a diet beyond soft within the follow-up period. The ALTFL rescue flap offers reduced morbidity and improved resource allocation compared to FFF for the treatment of advanced, partial thickness MORN with similar outcomes.

Complex dorsal hand and forearm injuries with extensor tendon and soft tissue loss are challenging to manage. Single-stage reconstruction using composite anterolateral thigh (ALT) fasciocutaneous free flaps with vascularized fascia lata may reduce the need for multiple surgeries and accelerate functional recovery, but clinical evidence is limited. We conducted a retrospective case series of nine patients with complex extensor tendon and soft tissue defects who underwent single-stage reconstruction with composite ALT flaps between 2009 and 2018. Six patients were available for long-term follow-up (average 2–3 years). Data included demographics, injury characteristics, operative details, complications, and functional outcomes assessed using Miller's criteria. One donor site hematoma resolved without sequelae. Functional assessment revealed that two patients achieved excellent and poor outcomes in wrist and finger extension, respectively, while one patient demonstrated good and fair results. Poor outcomes were associated with missed follow-up, prolonged immobilization, and concomitant skeletal injuries. All patients returned to work and reported satisfaction with their functional status. This approach offers durable soft tissue coverage, restores tendon continuity, and allows early rehabilitation with minimal donor site morbidity.