Anterolateral Thigh Research Articles

The Effect of Leg Dominance in Patients on Perforator-Based Flaps Elevated From the Lower Extremities.

The lower extremities are the largest donor sites in the body for perforator flap reconstruction. Multislice row computed tomography angiography allows for a multiplanar assessment of perforators using a large number of three-dimensional images with high resolution. In this study, the effect of leg dominance on perforator flap donor site preference was investigated radiologically to increase preoperative perforator mapping precision and surgical success. The study included 40 patients. Superior gluteal artery perforator (SGAP) flap, inferior gluteal artery perforator (IGAP) flap, superficial circumflex iliac artery perforator flap, anterolateral thigh (ALT) flap, profunda artery perforator (PAP) flap, medial sural artery perforator (MSAP) flap, peroneal artery perforator (PP) flap, and posterior tibial artery perforator (PTAP) flap were analyzed according to their number of perforators (> 0.8-mm perforators counted, number of larger perforators [nLP]), dominant perforator diameter (DPD), related muscle thickness (RMT), and related subcutaneous tissue thickness (RSTT) in each leg. Of these 40 patients, 35 (87.5%) were right-leg dominant and 5 (12.5%) were left-leg dominant. The dominant leg had higher DPD for MSAP, PTAP, and PP than the nondominant leg (p = 0.08, p = 0.06, and p = 0.06, respectively). The dominant leg had a significantly higher nLP (> 0.8 mm) in MSAP, PTAP, and PP flaps than the nondominant leg (p < 0.05). Except for the PAP flap (adductor magnus muscle; p > 0.05), RMT of all other perforator flaps (SGAP, IGAP, ALT, MSAP, PTAP, and PP) was statistically higher in the dominant leg (p < 0.05). There was no statistically significant difference in RSTT between any of the two groups (p > 0.05). According to findings, the dominant leg could be considered a donor site preference to improve surgical outcomes and reduce microsurgical complications due to an increased nLP, perforator diameter, and RMT.

Effect of Low Molecular Weight Heparin Calcium on Prevention of Lower Limb Deep Venous Thrombosis in Oral Cancer Patients With Anterolateral Thigh Flap Reconstruction.

This study aimed to evaluate the effect of low molecular weight heparin calcium (LMWH-Ca) on the prevention of deep venous thrombosis (DVT) in patients with anterolateral thigh (ALT) flap reconstruction. In total, 1001 patients with oral cancer who underwent ALT flap reconstruction were recruited. Based on the postoperative use of LMWH-Ca, the patients were divided into case (n = 633) and control groups (n = 368). The incidence of postoperative DVT was compared between groups. There was no significant difference in DVT incidence between the two groups. Among patients older than 60 years, the incidence of lower limb DVT in the case group (0.813%) was significantly lower than that in the control group (8.108%, p = 0.012). The postoperative use of LMWH in oral cancer patients with ALT flap transfer does not prevent the development of lower limb DVT. However, patients older than 60 years old benefited from the postoperative use of LMWH-Ca.

Microsurgical Reconstruction with and without Microvascular Anastomosis of Oncological Defects of the Upper Limb.

The choice of the most adequate surgical technique for upper limb defects remains challenging. The aim of this article is to discuss the main microsurgical (pedicled or free) reconstructive options for the post-oncological reconstruction of different anatomical areas of the upper extremity. We reviewed different reconstructive methods reported in the literature needing microsurgical expertise and compared them to our clinical experience, in order to provide further guidance in the choice of different flaps for upper limb soft tissue reconstruction. Six clinical cases, one for each anatomical district, are presented as examples of possible solutions. We report the options available in the literature for post-oncologic upper limb reconstruction, dividing them by anatomical area and type of flap: local flaps, regional flaps, free flaps, and distant pedicled flaps. Our examples of the reconstruction of each anatomical area of the upper limb include one reverse ulnar pedicled perforator flap, one free Antero-Lateral Thigh (ALT) flow-through flap, one perforator-based lateral arm flap, two myocutaneous latissimus dorsi pedicled flaps, and one parascapular perforator-plus flap. In oncological cases, it is important to consider reconstructive options that provide stable tissue and allow for the early healing of the donor and recipient site if the patient needs to undergo adjuvant radiotherapy or chemotherapy. A wider range of flap options is essential when choosing the proper technique according to the patient's needs, surgeon's preference, and logistical possibilities. Perforator flaps combine the advantages of other flaps, but they require microsurgical expertise. Free flap reconstruction remains the gold standard to obtain a better overall and cosmetic outcome in complex and wide defects, where no suitable local pedicled flap option exists. The pedicled latissimus dorsi flap should still be included among the reconstructive options for its strong vascularization, size, and arc of transposition.

Feasibility of Super-thin Anterolateral Thigh Free Flap for Oral and Pharyngeal Reconstruction.

To highlight the feasibility of employing super-thin ALT free flaps for reconstruction of complex oral cavity and oropharyngeal defects. Retrospective chart review. Sixteen super-thin ALT free flaps were performed in 15 patients between 2020 and 2023 for reconstruction of oral cavity defects (seven oral tongue, three floor of mouth, three buccal, two oropharynx, one lower lip). Flap success rate was 100% with only minor complications reported, with no patient requiring return to the operating room within 30 days and no patient requiring radial forearm free flap reconstruction. One patient experienced partial flap failure, one patient experienced superficial necrosis of the distal skin paddle measuring 1 cm, and one patient was converted intraoperatively to a contralateral traditional ALT free flap due to insufficient perforator size. Average operative time was 509 min, average length of hospitalization was nine days, and two patients required gastrostomy placement prior to discharge for dysphagia. Super-thin ALT free flap harvest technique represents a feasible option for oral cavity and oropharyngeal reconstruction in select patients and does not require additional surgical training, invasive testing, or technology. It can be readily adopted by reconstructive surgeons with a simple adaptation in existing ALT harvest technique. Level 4 Laryngoscope, 2024.

Effect of dexmedetomidine combined with ropivacaine block on flap blood flow and patient satisfaction after flap transfer for hand trauma: a randomized controlled trial.

I.

Facial reconstruction with thinned anterolateral thigh free flap

Facial reconstruction is challenging for plastic surgeons, as it can be difficult to decide the best approach. One technique that has been widely used is the anterolateral thigh (ALT) flap due to its numerous benefits. However, its thickness can be a drawback, especially regarding facial reconstruction. The thinning technique is not a new novel, but how to apply it to the ALT flap to get the best result hasn’t been reported yet. Our study involved 117 patients, and we used 73 thinned ALT flaps to determine the best method to increase the flap’s safety. After thinning, we significantly reduced the flap’s thickness from an average of 22.5 mm to 5.9 mm, making it more suitable for contouring purposes. We apply a thinned ALT flap for coverage, contouring, and recreating the facial 3D structure. The 12/45 flap has the chance to make the multiple-paddle ALT flap, which helps to reconstruct difficult positions even more flexibly. The key to successfully thinning the ALT flap is understanding the perforator’s structure and pathway through the fascia. With the thinning technique, we have overcome the limitations of the flap’s thickness, making it suitable for use in whole-body reconstruction. The ALT flap can overcome the restriction of its thickness and can be applied even more extensively in whole-body reconstruction.

Viability of Free Bone Graft in Combination With Free Tissue Transfer and Post-Operative RT in Orbital Floor Reconstruction.

Orbital floor reconstruction post cancer ablation is challenging especially when associated with extensive soft tissue defects. Due consideration is to be given to the possible toxicities of adjuvant radiotherapy as well. Free bone-soft tissue flaps are ideally suited in such situations. However, a single flap may fall inadequate for large defects. Using two free flaps in combination increases operating time and donor site morbidities. Non-vascularized bone grafts combined with large soft tissue flaps harbor the risk of bone resorption and osteo-radio necrosis. Alloplastic implants can lead to exposure and infection. We conducted a study researching the outcome of non-vascularized cortico-cancellous iliac bone graft (NVCIBG) used in orbital floor reconstruction along with free anterolateral thigh (FALT) flap in subjects undergoing extensive surgical ablation and adjuvant radiotherapy. Ten consecutive subjects who underwent maxillo-mandibular resection with or without skin were included in the study. The parameters assessed were diplopia, ectropion, bone viability, and osteointegration. Subjects were assessed in the immediate post-operative period, 1 month after surgery, and after 1 year of radiotherapy. The size of iliac bone harvested ranged from 3 to 5.5 cm (mean 4.8 cm). Forty percent subjects complained of binocular diplopia in the initial post-operative period which subsided subsequently. Thirty percent subjects developed ectropion all of whom required external skin reconstruction. None developed osteoradionecrosis. NVCIBG along with FALT flap is an excellent reconstructive option for orbital floor defects. It can withstand the toxicities of adjuvant radiotherapy and avoids the need for double free flap reconstruction. 4 Laryngoscope, 2024.

Clinical effects of different types of flaps selected according to local conditions in the treatment of diabetic foot defects

BackgroundThe repair of diabetic foot defects (DFD) is a major challenge in clinical practice. The purpose of this study was to investigate the difference in clinical efficacy of different flap techniques in repairing DFD wounds, and to compare the difference in clinical efficacy of anterolateral thigh perforator flap (ALTP) in repairing DFD and non-DFD.MethodsThis study is a retrospective clinical study of different types of flap reconstruction in patients with DFD admitted to our hospital from January 2010 to December 2021. A total of 40 patients with DFD and 43 patients with non-DFD were included in this study. Detailed preoperative basic information, intraoperative details, postoperative complications and long-term follow-up results were collected.ResultThe comorbidities, wound infection and wound duration of DFD group were more serious than those of non-DFD group. In addition, the incidence of complications was higher in DFD group, the wound healing time was longer, the aesthetic evaluation, the functional recovery rate of ankle joint and the sensory recovery effect of flaps were worse.ConclusionIn this study, it is concluded that different flap techniques can obtain better clinical efficacy in repairing DFD wounds. Compared with non-DFD wounds, the postoperative risk of DFD wounds using free ALTP flaps is higher, but the risk can be reduced by reasonable preoperative vascular examination. Free flap can deal with various irregular wounds and provide more options for clinical repair.Level of evidenceIII, Case–control study.

Reconstruction of Complex Oral and Maxillofacial Defects After Oral Cancer Resection With Individualized Anterolateral Thigh Multiple Paddle Flaps.

This study aimed to use reconstructive methods for complex oral and maxillofacial defects, explore their feasibility, and evaluate the efficacy of defect reconstruction using anterolateral thigh (ALT) multiple paddle flaps. The authors performed a retrospective case series of 33 patients who underwent oral and maxillofacial defect reconstruction using the ALT multiple paddle flaps. The design and harvest of the flaps, methods for defects reconstruction, and reconstructive efficacy are described. All 33 patients were men, with a mean age of 49.5 years. Of the flaps, triple skin paddles plus muscle paddles were included in 3 cases, triple skin paddles were included in 1 case, 2 skin paddles plus muscle paddles were included in 29 cases. The skin paddles measured 3×5cm to 10×16cm. Postoperatively, all flaps survived completely. Parotid salivary fistula and orocutaneous fistula occurred in 1 patient of each, thigh wound infection and effusion occurred in 1 and 2 patients, respectively. All patients were followed up for ~2 to 93 months; most patients' oral functions and appearance were acceptable, and thigh motor dysfunction was not observed. With separate skin paddles for defects of different positions, individualized muscle flap for dead spaces, combination of different skin paddles for larger defects, effective reduction or avoidance of wound complications, and acceptable donor site morbidity, the ALT multiple paddle flaps are an ideal candidate for complex oral and maxillofacial defects reconstruction.

On a hunt for the "true" septocutaneous perforator - a histology cross section study.

Modern trends in reconstructive surgery involve the use of free perforator flaps to reduce the donor site morbidity. The course of perforator vessels has a great anatomic variability and demands a careful knowledge of the anatomical relationships and the variability of the course of the perforators. The numerous modifications of perforator nomenclature were proposed by many authors and brought confusion rather than a simplification. In our study we focused on a hypothesis, that septocutaneous perforator passes from the given source vessel to the deep fascia adherent to, but not to within the septum itself. 69 septocutaneous perforators from three different limb donor sites (Lateral Arm Flap, Anterolateral Thigh Flap, Radial Forearm Free Flap) were collected from gross pathology specimens of 14 fresh cadavers. The gross picture and the cross sections with the histological cross sections on different levels were examined to determine the position of vessel to the septal tissue. Of the observed 69 septal perforators, 61 (88,5%) perforators were adherent to but not within the septum. Remaining eight (12,5%) perforators passed through the septum. All these eight perforators were found in multiple different cross section levels. (two of 19 in Lateral Arm Flap, three of 27 in Anterolateral Thigh Flap, three of 23 in Radial Forearm Free Flap). Although macroscopically identical septocutaneous vessels, microscopically we observe two types of vessels - with paraseptal and intraseptal pathways. The majority are merely adherent to the septum having a paraseptal pathway. A minority are within the septum, and are "true" septocutaneous perforators. It is advisable to dissect with a piece of the septum in order to avoid damage any injury of perforator.

Cross-Leg Microvascular Free Anterolateral Thigh Flap as a Safe, Viable, and Reserve Option for Reconstruction in a Vessel-Depleted Limb

Cross-Leg Microvascular Free Anterolateral Thigh Flap as a Safe, Viable, and Reserve Option for Reconstruction in a Vessel-Depleted Limb

Pedicled Anterolateral Thigh Flap (ALT) for Vulva Reconstruction: Journey to a New Horizon

AbstractSurgery for vulval malignancies necessitates extensive resection necessitating the use of musculocutaneous grafts. We present one such case where the patient needed both a V–Y plasty and an anterolateral thigh flap to ensure a tension-free repair. She underwent a partial deep vulvectomy followed by V–Y plasty and ALT flap. The procedure has been described in detail along with intraoperative photographs. She recovered uneventfully and is receiving post-operative adjuvant radiotherapy. We would like to highlight this “additional skill” of plastic surgery which will empower surgeons to undertake radical surgeries to ensure the best outcomes for patients.

Pharyngostoma reconstruction after laryngectomy and radiotherapy: A retrospective study and literature review

BackgroundThe occurrence of pharyngocutaneous fistula or pharyngostoma after oncologic head and neck surgery is a serious complication. It is the most common complication after major hypopharyngeal and laryngeal ablative surgery. AimThe purpose of this study is to review the surgical approach and evaluate the results regarding reconstruction methods of pharyngostoma, caused after laryngectomy and radiotherapy. Patients & MethodsThe total patient number is 15. Pharyngostoma caused swallowing difficulties, as well as frequent aspiration pneumonia. The intervention interval from laryngectomy to pharyngeal reconstruction varied between one to three years, depending on the symptoms’ severity and after the complete failure of conservative rehabilitation methods. Pharyngostoma reconstruction was performed mainly with pectoralis major myocutaneous flap in eleven cases. The radial forearm free flap (RFF) and the anterolateral thigh free flap (ALT) were also used in the rest four cases. ResultsThe postoperative course was uncomplicated and in most cases the feeding with soft food started after a barium meal between 15-20 days postoperatively. Complications include wound dehiscence and leak treated conservatively and one case of carotid rupture. ConclusionsThe gold standard for pharyngostoma reconstruction, after laryngectomy and cervical radiotherapy, remains the use of pectoralis major myocutaneous flap. In cases of extensive neck radionecrosis free flaps are preferable. Reliable and stable cover of the large vessels of the neck beside with the reconstruction of the digestive tract and the function of swallowing are issues, which are analysed in corelation with the avoidance of stenosis and swallowing difficulties.

Functional tongue reconstruction after compartmental surgery: a schematic model for planning and insetting of the anterolateral thigh free flap

Functional tongue reconstruction after compartmental surgery: a schematic model for planning and insetting of the anterolateral thigh free flap

Anterolateral thigh free flap surgery for medial malleoli fracture with extensive dorsal foot skin defect: A case report

Severe foot deformities, especially those affecting the dorsum of the foot, can make it difficult to perform daily activities. For example, mild pain when walking can be felt on the dorsal aspect of the foot, and toe contractures can make it difficult to wear non supportive shoes. Reconstructive surgeons face a great deal of difficulty in providing a suitable flap in accordance with the "like for like" reconstructive principle. The best outcomes for reconstructing small- to medium-sized dorsal foot lesions have been reported using local flaps and pedicled flaps. Reconstruction of large dorsal foot deformities is, however, hardly studied. In this work, we report our experience reconstructing large dorsal foot lesions using the free anterolateral thigh (ALT) flap.

Surgical refinements and sensory and functional outcomes of using thinned sensate anterolateral thigh perforator flaps for foot and ankle reconstruction: A retrospective study.

To improve the use of sensate anterolateral thigh (ALT) flaps for foot and ankle reconstruction, we employed a thinned nerve-selective harvesting technique. The data of 31 patients in whom sensate ALT perforator flaps were transferred for reconstruction of soft-tissue defects in the foot and ankle were reviewed. Flaps were elevated with 2 refinements. The first is the initial selection of the "true" sensory branch in the medial incision on the suprafascial plane. The second is flap thinning by keeping a cuff of thin deep fat surrounding the point where the perforator or nerve branch inserts into the superficial fat layer. The recipient site assessment consisted of complications, monofilament touch perception, sharp-blunt discrimination, axial circumference, and American Orthopedic Foot and Ankle Society score. After a mean follow-up of 31.7 months, all flaps survived uneventfully, except for marginal necrosis in 1 patient, infection in 1 patient, ulceration in 2 patients, and secondary thinning in 3 patients. The sensation of each flap was restored. A total of 87% and 90% of the patients exhibited 5 or more positive response points in the Semmes-Weinstein monofilament touch and sharp-blunt discrimination testings, respectively. The mean axial circumference of the reconstructed foot was 27.4 cm (the unaffected side was 25.8 cm). All patients achieved mobility in ordinary shoes with a mean functional score of 74.6. The thinned nerve-selective sensate ALT perforator flap can be a favorable option for foot and ankle reconstruction. This method also offers the possibility of preserving the nerve branch at the donor thigh.

Delayed maxillary reconstruction following mucormycosis: A comprehensive analysis of surgical strategies and outcomes

Study designThis study is a prospective observational study conducted over two years from December 2020 to March 2023 at the Department of Plastic and Reconstructive Surgery. ObjectiveTo evaluate the outcomes of delayed reconstruction in patients with maxillectomy defects post-COVID-19 associated mucormycosis, focusing on safety, morbidity, and aesthetic results. MethodsFifty patients with post-COVID-19 mucormycosis and maxillectomy defects without skin involvement were included. These patients underwent radical debridement and were treated with Amphotericin B followed by Posaconazole therapy until clinical and radiological resolution of the disease. Reconstruction was performed after a minimum of six months post-maxillectomy. Flaps used for reconstruction included the radial forearm free flap (RAFF), anterolateral thigh flap (ALT), and free fibula osteomyocutaneous flap, planned using a 3D-printed model. Follow-up was conducted weekly for the first month and monthly for the next two months, with semiannual visits thereafter. ResultsOf the 50 patients, 42 % were male, and 58 % were female, with a mean age of 43 ± 8.75 years. Most patients (88 %) were diabetic. Maxillectomy defects were categorized as type IIA, IIB, IIIA, IIIB, and IV based on the Cordeiro classification. Four flaps (8 %) required re-exploration, with three salvaged. Complications included marginal flap necrosis (4 %) and oro-nasal fistula (2 %). The average hospital stay was six days, extended to ten days for re-explored cases. Flap dimensions varied with the largest being 62 cm² for the free fibula flap. ConclusionsDelayed reconstruction using free flaps in patients with post-COVID-19 mucormycosis maxillectomy defects without skin involvement is a safe approach with minimal morbidity. This method allows confirmation of disease resolution before major reconstructive surgery, resulting in excellent aesthetic and functional outcomes.

Managing malignant sublingual gland tumors: a single institution experience with 23 patients

BackgroundDue to the relative rarity of malignant sublingual gland tumors, diagnosing and treating them clinically pose challenges. Hence, there’s a need to explore the pathological types, characteristics, treatment methods, and prognosis of primary malignant tumors of the sublingual gland to improve our understanding and management of these rare yet highly malignant conditions.MethodsThis study reviewed cases of primary malignant sublingual gland tumors, analyzing their characteristics. The treatment methods included surgical excision, with additional radiotherapy, or brachytherapy for advanced stages or positive surgical margins. The study also summarized different treatment approaches, including lymph node dissection and soft tissue reconstruction using free flaps such as the anterolateral thigh flap and forearm flap.ResultsWe have gathered 23 cases of sublingual gland malignancies treated at the Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, from January 2013 to May 2024. The most common pathological types were adenoid cystic carcinoma and mucoepidermoid carcinoma, with rare cases of mucosa-associated lymphoid tissue (MALT) lymphoma and nonspecific salivary gland clear cell carcinoma. Early diagnosis and surgical intervention were crucial for a favorable prognosis. Marginal mandibulectomy was necessary for cases involving the mandible. Patients with positive preoperative lymph node detection required cervical lymph node dissection. Extensive tissue defects in the floor of the mouth were effectively reconstructed with free flaps to prevent oral-mandibular fistula.ConclusionSurgical excision remains the preferred treatment for malignant sublingual gland tumors. Early diagnosis and comprehensive surgical management are essential for improving prognosis. The study’s limitations include a small sample size and short follow-up duration, necessitating further research with larger clinical samples to confirm these findings.

A new surgical strategy for T4 stage posterior buccal carcinoma: anatomical unit resection

Objective: To investigate the effect of anatomical unit resection on the overall survival rate of patients with T4 stage posterior buccal carcinoma. Methods: We conducted a retrospective study on 79 patients with T4 stage posterior buccal squamous cell carcinoma underwent radical surgery for buccal mucosa cancer and reconstruction with free anterolateral thigh flap in the Department of Oral and Maxillofacial Surgery, the Second Xiangya Hospital, Central South University from March 2014 to December 2019. The 74 patients were males and the 5 patients were females, aged from 28 to 72 years old. The 40 patients in control group underwent traditional extended resection (1.5-2.0 cm safe margin), and 39 patients in the experimental group underwent anatomical unit resection. The clinicopathological parameters of patients were collected and followed up regularly. The overall survival rate was assessed by Log-rank and Cox proportional risk regression model. Multivariate analysis was performed by linear regression model. Results: There were significant differences between experimental group and control group in overall survival rates (61.53% vs 27.50%, χ2=6.624, P=0.010) and local disease control rates (74.36% vs 27.50%, χ2=17.350, P<0.001). Multiple linear regression analysis showed that local disease control rate was significantly correlated with anatomical unit resection (t=3.880, P<0.001) and lymph node metastasis (t=2.619, P=0.011), and also Cox proportional hazards regression model analysis identified that overall survival rate was significantly correlated with anatomical unit resection (Z=2.421, P=0.016) and lymph node metastasis (Z=2.793, P=0.005). Conclusion: For posterior buccal carcinoma with multiple anatomical units involved, anatomical unit resection can significantly reduce local recurrence and improve overall survival rate of patients.

Clinical effect of free chimeric anterolateral thigh flap and chimeric thoracodorsal artery perforator flap in chronic osteomyelitis

BackgroundChronic osteomyelitis poses a formidable challenge for orthopedic practitioners in the realm of clinical practice. Chimeric perforator flap is a commonly used repair method for chronic osteomyelitis. The purpose of this study was to compare the clinical efficacy of chimeric anterolateral thigh flap (C-ALTP) and chimeric thoracodorsal artery perforator flap (C-TDAP) for the treatment of chronic osteomyelitis. MethodsA retrospective analysis was performed on patients with chronic osteomyelitis of the lower extremity who underwent two kinds of treatment with chimeric perforator flaps from January 2014 to March 2022. The preoperative basic data, the operative and postoperative basic information of the two groups were collected and statistically analyzed. ResultsSixty-six patients were included in this study, and both groups achieved good aesthetic and functional results. Intraoperative results showed that the intraoperative blood loss and flap acquisition time in the C-TDAP group were less than those in the C-ALTP group. The incidence of postoperative complications in the donor and recipient sites in the C-TDAP group was significantly lower than that in the C-ALTP group, which led to a high reoperation rate in the C-ALTP group. Long-term follow-up showed that the wound healing time and weight-bearing walking time in the C-TDAP group were less than those in the C-ALTP group. ConclusionsBoth chimeric perforator flaps can effectively treat osteomyelitis with composite tissue defects, effectively eliminate inflammation of affected limbs and promote wound healing. However, C-TDAP flaps have more reliable healing effects on wounds and donor sites, and have fewer complications. Level of evidenceIII, Case–control study.