Chimeric Anterolateral Thigh Flap Research Articles

Chimeric Anterolateral Thigh Flap for Primary Functional Reconstruction of Complex, Composite Near Total Hemi Facial Post Excision Defects.

Microvascular free tissue transfer has revolutionized the management of complex composite head and neck defects. To evaluate the functional and aesthetic outcomes in the primary reconstruction of post-excisional near total hemifacial defects with the chimeric anterolateral thigh flaps (cALT). The author as a prelude to this clinical study has done a cadaveric study on the quadriceps artery angiosome. In this retrospective cohort study, data are collected from the records of 6 patients who had undergone primary cALT flap reconstruction for their post excisional near total hemifacial defects from January 2013 to December 2017. All 6 patients with various advanced malignancies involving the hemiface underwent wide local excision. Wide local excision resulted in the loss of skin and critical facial muscles that led to near total hemiface composite defects. Reconstructions were done with the cALT flaps that included segment of the vastus lateralis muscle harvested on its independent neurovascular perforator pedicle and the skin paddle on a separate perforator. In all cases, the facial nerve stumps were anastomosed to the nerve to vastus lateralis for reanimation of the face. In addition, 4 patients underwent primary radical neck dissection, but all had postoperative radiotherapy and chemotherapy. All patients attained well-pronounced nasolabial fold, symmetrical smile, and good oral competence in an average period of 10.75 months post operatively. In an average of 22 months follow up, none of them had locoregional recurrences. None required any secondary procedures. In the post excisional near total hemifacial composite defects, primary functional reconstruction with tailored cALT flaps can bring good aesthetic and functional results.

Treatment of chronictibial osteomyelitis with irrigation sequential Flow-through type anterolateral thigh chimeric myocutaneous flap

Objective To investigate the clinical effects of irrigation sequential Flow-through type anterolateral thigh chimeric myocutaneous flap in the treatment of chronic tibial osteomyelitis. Methods From January, 2012 to December, 2017, trench grooved sequential Flow-through anterolateral femoral chimeric flaps were used to treat chronic tibial osteomyelitis. On the basis of sensitive antibiotics, bone grooving and VSD grooved sequential Flow-through anterolateral thigh chimeric flaps were used to fill the bone cavity and cover the wound. The patients received the follow-up care in outpatient office and telephone regularly after hospital discharge. Results Among the 18 cases in this group, 2 cases were positive and 16 cases were negative in secondary bacteriological detection. The flaps and donor sites survived in one stage. Fifteen cases healed in one stage, and extravasate occurred in 3 cases after operation. After dressing change, the wounds healed in 25 days, 32 days and 43 days after flap operation, respectively. All the patients were followed-up for 12 to 30 months, with an average of 25 months. Local low toxicity infection symptom occurred again in 1 case with delayed healing 6 months after operation. After 1 week of antibiotic treatment, the symptom subsided. After 1 more week of antibiotic use, the patient was discharged from hospital. And followed-up for 1 year, no recurrence occurred. During the follow-up period, no recurrence of infection and no fracture occurred after primary fracture healing in other 17 cases. One year after the second operation, there was no obvious stenosis in the bridged vessels examined by Doppler ultrasonography and the blood flow velocity was the same as that of the contralateral limbs. Conclusion The application of irrigation and sequential Flow-through type anterolateral thigh chimeric myocutaneous flap for treatment of chronic tibial osteomyelitis can achieve good therapeutic effect and is worth popularizing. Key words: Tibial osteomyelitis; Chimeric myocutaneous flap, anterolateral thigh flap; Flow-through flap; Microsurgical technique

Application of a new classification of chimeric anterolateral thigh free flaps

BackgroundThe anterolateral thigh free flap is one of the most commonly used flaps in reconstructive procedures. The purpose of this study was to assess this new classification of chimeric anterolateral thigh free flaps. MethodsSixty-five patients underwent free anterolateral thigh chimeric free flap reconstruction of defects in the head and neck region. We summarized the anatomic features of perforators, including the number and origin of the perforators. ResultsSixty-five cases of femoral anterolateral double island flaps were divided into 3 types: trunk type (type I), 11 cases (16.9%), in which the perforators of two flaps originated in the descending branch and the transverse branch of the lateral femoral circumflex artery; branch type (type II), 45 cases (69.3%), in which both the perforators originated in the descending branch or the transverse branch of the lateral femoral circumflex artery; and bifurcation type (type III), 9 cases (13.8%), in which two perforators originated in the bifurcation of one perforator that originated in the descending branch or the transverse branch of the lateral femoral circumflex artery. All 65 flaps survived and none showed partial necrosis. ConclusionsThe anterolateral thigh chimeric flap can be divided into 3 types: trunk type (I type), branch type (II type) and bifurcation type (III type).

Various forms of anterolateral thigh flap for lower extremity and ankle amputation with extensive skin and soft tissue defect reconstruction

Objective To explore the application of various forms of anterolateral thigh flap in lower extremity and ankle amputation with extensive skin and soft tissue defect reconstruction. Methods From September 2011 to December 2015, 26 cases of lower extremity and ankle amputation with extensive skin and soft tissue defect reconstruction (included 20 male patients and 6 female patients) were admitted, the age ranged from 22 to 61 years old (38.6±4.5). Among these cases, 10 cases received flow-through anterolateral thigh flap, 16 cases used chimeric anterolateral thigh flap with vastus lateralis thigh muscle flap, 15 flaps were thinned in one-staged, 5 flaps were harvested in double-paddled form. The flap size ranged from 10 cm×6 cm to 28 cm×12 cm. The donor site was closed directly in all cases. Results All flaps and replanted extremities survived uneventfully. All patients were followed up for 8 to 30 months with satisfied esthetic and functional results in reconstructed foot and ankle, the texture of flaps was good, no bulky was noted and no second revision was needed. No local ulcer happened and regained protective sensation. Only linear scar left in the donor sites, no hernia occurred. Conclusions Various forms of anterolateral thigh flap is the effective choice in lower extremity and ankle amputation with extensive skin and soft tissue defect reconstruction. Key words: Thigh/SU; Surgical flaps; Ankle injuries/SU; Soft tissue injuries/SU

An anterolateral thigh chimeric flap for dynamic facial and esthetic reconstruction after oncological surgery in the maxillofacial region: a case report

BackgroundThe surgical management of malignant tumors in the head and neck region often leads to functional and esthetic defects that impair the quality of life of the patients. Reconstruction can be solved with prostheses in these cases, but various types of microsurgical free flaps can provide a better clinical outcome.Case presentationIn this case report, the tumor and parts of the involved facial muscles and nerve were excised surgically from a 42-year-old patient after a third relapse of basal cell carcinoma in the left midface. The tissue defect was reconstructed with an anterolateral thigh chimeric type I fascio-myocutaneous flap, where the facial palsy was restored with a segmental branch of the femoral nerve and the involved mouth corner elevator muscles for the segmented vastus lateralis muscle. The 6-month follow-up revealed a good esthetic outcome, the soft tissue defect reconstruction with good functional activity of the reconstructed facial nerve and with acceptable mimic movements. There has been no subsequent recurrence.ConclusionsIt is concluded that the chimeric type I anterolateral fascio-myocutaneous free flap can offer a good option for the esthetic and functional reconstruction of an extensive tissue defect in the maxillofacial region.

Reconstruction of quadriceps function with composite free tissue transfers following sarcoma resection.

Patients were retrospectively reviewed who underwent deep STS resection of the anterior compartment of the thigh with functional reconstruction of knee extension using a contralateral free anterolateral thigh (ALT) flap. Three patients with an average age 53.6 years (range: 33-66) were included. Average follow-up was 82 weeks (76-92 months). Full active extension was regained in 66% of patients with all patients regaining active extensor capabilities beyond 100°. The mean Knee Society Score was 83.3 (range; 76-92) and Musculoskeletal Tumor Society Score 21.6 (range; 19-21). Isometric knee extensor strength exceeded 4+/5 in all patients. Following soft tissue sarcoma resections of the lower extremity, chimeric anterolateral thigh flaps for restoration of knee extension can provide significant improvements in the potential for ambulation and regaining quadriceps function.

Tripaddled anterolateral thigh chimeric flap for extensive full-thickness cheek reconstruction after radical resection of advanced buccal cancer

Tripaddled Anterolateral Thigh Chimeric Flap for Extensive Full-thickness Cheek Reconstruction after Radical Resection of Advanced Buccal Cancer

Computed Tomography Angiography for the Chimeric Anterolateral Thigh Flap in the Reconstruction of the Upper Extremity.

Background The chimeric anterolateral thigh (ALT) flap has been an ideal option for restoring complex soft tissue defects. However, as the vascular anatomy of the ALT is variable, the positions of its perforators are uncertain, which makes the surgery more challenging. Therefore, our study utilized computed tomographic angiography (CTA) for preoperative perforator mapping. Methods From October 2013 to October 2015, 37 patients suffering upper extremity soft tissue defects underwent CTA before ALT flap reconstruction. Perforators originating from the same source vessel were mapped by CTA, and the donor thigh and preferred perforators were selected accordingly. All preoperative parameters of perforators detected by CTA were checked during operation. Results Thirty-three dual-skin paddles, three tri-skin paddles, and one quad-skin paddles flap were designed and used in this study. Eighty-seven perforators were mapped by CTA preoperatively. Seventy-nine (90.8%) were used; 97.5% of these were musculocutaneous and 2.5% septocutaneous. All perforators used intraoperatively were consistent with preoperative parameters. Post-operatively, 2 patients experienced complications but there was 100% flap survival overall. The donor sites primarily underwent primary closure, apart for 7 cases which underwent skin grafting. There was no donor site morbidity. Conclusion Preoperative mapping by CTA is a useful, fast, and noninvasive method for assessing the source vessels, and can be a significant aid in chimeric ALT flap surgery.

Chimeric anterolateral thigh free flap for reconstruction of complex cranio-orbito-facial defects after skull base cancers resection.

Complex cranio-orbito-facial defects after skull base cancers resection entail a functional and esthetic reconstruction. The introduction of endoscopic assisted techniques for excision surgery with the advances in reconstructive surgery and anesthesiology allowed to improve the management of such critical patients. We report a series of chimeric anterolateral thigh (ALT) flaps used to reconstruct complex cranio-orbital-facial defects after skull base surgery. A retrospective review of patients that underwent cranio-orbito-facial reconstruction using a chimeric ALT flap from March 2013 to October 2015 at a single tertiary care referral Institute was performed. All patients were affected by locally-advanced malignant tumor and the resulting defects involved the skull base in all cases. The ALT flaps were perforator-based flaps with different components: fascia, skin and muscle. The different flap territories had independent vascular supply and were independent of any physical interconnection except where linked by a common source vessel. Ten patients were included in the study. Three patients underwent adjuvant radiotherapy and to chemotherapy. The mean hospitalization time was 21 days (range, 8-24 days). One failure was observed. After a mean follow-up of 12.4 months, 3 patients died of the disease, 2 are alive with disease, while 5 patients (50%) are currently alive without evidence of disease. Chimeric ALT flap is a reliable and versatile reconstructive option for complex cranio-orbito-facial defects resulting from skull base surgery. The chimeric flap composed of different territories proved to be adequate for a patient-tailored three-dimensional reconstruction of the defects as well as able to resist to the postoperative adjuvant treatments.

Multipaddled anterolateral thigh chimeric flap for reconstruction of complex defects in head and neck

Background: The anterolateral thigh flap has been the workhouse flap for coverage of soft-tissue defects in head and neck for decades. However, the reconstruction of multiple and complex soft-tissue defects in head and neck with multipaddled anterolateral thigh chimeric flaps is still a challenge.

Choice of flap affects fistula rate after salvage laryngopharyngectomy.

Due to the significant morbidity and mortality associated with pharyngocutaneous fistula in pharyngoesophageal reconstruction following cancer resection, the purpose of this retrospective study is to examine the selection of tubed skin flaps that impact anastomotic integrity. The flaps evaluated included radial forearm flap versus anterolateral thigh flap, and fasciocutaneous anterolateral thigh flap versus chimeric anterolateral thigh flap. The outcome of interest is the incidence of pharyngocutaneous fistula. The radial forearm group had a significantly higher rate of fistula than the anterolateral thigh group (56.6% vs. 30.2%, p = 0.03). No significant difference in the incidence of fistula was demonstrated between fasciocutaneous and chimeric anterolateral thigh flap (36.8% vs. 25%, p = 0.51). The anastomotic integrity in pharyngoesopharyngeal reconstruction is affected by choice of skin flaps. Anterolateral thigh flap appears to be a viable option for pharyngoesophageal reconstruction. The more technical demand of the anterolateral thigh flap must be weighed against an easily harvested radial forearm flap.

Chimeric flaps pedicled with the lateral circumflex femoral artery for individualised reconstruction of through-and-through oral and maxillofacial defects

Reconstruction of through-and-through oral and maxillofacial defects has always been difficult. We have evaluated the feasibility and reconstructive efficacy of chimeric flaps pedicled with the lateral circumflex femoral artery in the reconstruction of 41 through-and-through oral and maxillofacial defects after resections for cancer. There were 29 chimeric anterolateral thigh and anterolateral thigh flaps and 12 chimeric anterolateral thigh and anteromedial thigh flaps, the sizes of which ranged from 5×8 to 9×11cm. The chimeric flaps provided separate flaps to reconstruct the intraoral mucosa and extraoral skin defects, and 40/41 of them survived. The appearance and function were satisfactory in all patients after the reconstruction. Chimeric flaps pedicled with the lateral circumflex femoral artery are a good choice for the reconstruction of through-and-through oral and maxillofacial defects.

Head and Neck Reconstruction with Chimeric Anterolateral Thigh Free Flap: Indications, Outcomes, and Technical Considerations

Objectives: Chimeric anterolateral thigh (ALT) free flaps are comprised of multiple skin paddles or muscular components, which allow for the reconstruction of complex 3-dimensional defects. There is a paucity of data in the literature regarding the outcomes with this reconstructive option. We sought to describe our results with this technique and identify outcome predictors. Methods: Retrospective review of 24 patients undergoing reconstruction with a chimeric ALT free flap at an academic tertiary institution between 2009 and 2013. Demographics, indications, comorbidities, flap and functional outcomes were retrieved from the medical records and review of intraoperative photography. SPSS was used for data analysis. Results: The mean age was 57 years and the cohort primarily consisted of males (87.5%). The most frequent defects were: through-and-through pharyngoesophageal, n = 12 (50%) and skull base, n = 6 (25%). The flap consisted of double skin paddles in 11 cases (45.3%) and a skin paddle with an independent muscular component in 13 (54.7%). The mean skin paddle area was 62 cm2. There were no total flap losses; partial loss (secondary skin paddle) was observed in 3 cases and was related to severe congestive heart failure ( P = .005) and malnutrition ( P = .002). Postoperative fistula was associated to immunodeficiency ( P = .02) and malnutrition ( P = .004). All except one patient who underwent pharyngeal reconstruction resumed oral diet. The mean time to resume diet was 27 days. Conclusions: Chimeric ALT flaps represent an excellent alternative for reconstruction of complex defects. Patients with congestive heart failure, with immunodeficiency, and who are malnourished are at higher risk of partial flap loss. A second muscle paddle might be indicated in these cases.

Turbocharged Chimeric Anterolateral Thigh Flap and Vastus Lateralis Double Mini-flaps for Repair of Intractable Fistulae Communicating with the Knee Joint

Turbocharged Chimeric Anterolateral Thigh Flap and Vastus Lateralis Double Mini-flaps for Repair of Intractable Fistulae Communicating with the Knee Joint

Reconstruction of Wide-apart Double Defect Using a Branch-based Chimeric Anterolateral Thigh Flap.

Summary:Wide-apart double defect in head and neck region is rare and difficult to reconstruct at one time. Double free flaps are normally used for this scenario and often tedious and technically complicated. This study presented a technique using branch-based anterolateral thigh free flap to simultaneously reconstruct the 2 defects separated wide apart. The concept, indications, surgical technique, and anatomical variations are discussed. Branch-based anterolateral thigh flap is a safe technique and the dissection will be easy when the oblique branch is present.

Application of Anteromedial Thigh Flap for the Reconstruction of Oral and Maxillofacial Defects

To discuss the vascular anatomy of the anteromedial thigh (AMT) flap and to evaluate the feasibility of the AMT flap for the reconstruction of oral and maxillofacial defects. A retrospective review was performed of 18 patients who underwent reconstruction of oral and maxillofacial defects with AMT flaps from January 2009 through December 2011 in the Second Xiangya Hospital. Eleven unifoliate AMT flaps were elevated to reconstruct defects of the tongue, soft palate, and floor of the mouth and 7 chimeric anterolateral thigh (ALT) and AMT flaps were harvested to reconstruct through-and-through cheek defects. The flaps were 4 × 6 to 9 × 11 cm(2). All the AMT flaps were nourished by the descending branch (DB) of the lateral circumflex femoral artery. The cutaneous perforators were derived from the rectus femoris branch of the DB in 15 cases and directly from the DB in the other 3 cases. Postoperatively, all flaps survived completely, without major complications. Of the 18 donor sites, 14 were closed directly, leaving only linear scars, and 4 were closed using full-thickness skin grafts owing to larger defects. All patients were followed for approximately 6 to 30 months, and they were satisfied with the esthetic and functional results of the donor and recipient sites after the reconstruction. Because of easy perforator dissection, the AMT flap can be used as an alternative to the ALT flap or harvested with the ALT flap as chimeric ALT and AMT flaps for the reconstruction of oral and maxillofacial defects.

Prophylactic Chimera Anterolateral Thigh/Vastus Lateralis Flap: Preventing Complications in High-Risk Head and Neck Reconstruction

In high-risk head and neck cases treated with tumor resection and associated radical neck dissection, orocutaneous fistulas and wound breakdowns in the neck are relatively frequent and can have serious consequences, such as carotid blowout syndrome (CBS), the need for salvage reoperations, and prolonged recovery time. The authors present the application of a prophylactic chimeric anterolateral thigh (ALT) and vastus lateralis (VL) flap to prevent complications. A retrospective review was performed of a historical group (96 patients) of patients with head and neck cancer treated with tumor resection, radical neck dissection, and microsurgical reconstruction of the tumor site only and a prospective cohort (21 patients) in which a chimeric ALT-VL flap was used to simultaneously reconstruct the tumor site and sternocleidomastoid muscle to fill dead space and protect the carotid artery. The rate of complications was higher in the historical group: CBS occurred in 4.1% and orocutaneous fistulas in 11.5% of patients; 5.2% of patients required major salvage surgery for a wound complication. In the cohort group, no CBS or orocutaneous fistula occurred and no major salvage surgical procedure was needed. Prophylactic ALT-VL flaps in high-risk head and neck cancers provide adequate and long-lasting soft tissue coverage for the carotid artery, with minimal additional morbidity, and could be beneficial in preventing serious and life-threatening wound complications and the need for reoperation.

Reconstruction of two separate defects in the upper extremity using anterolateral thigh chimeric flap

We presented our experience on the use of anterolateral thigh (ALT) chimeric flap to reconstruct two separate defects in upper extremity. From December 2009 to August 2012, we used this ALT chimeric flap to reconstruct two separate defects in upper extremity on five patients (mean age: 36.6 years; range: 15 ∼ 47 years). The locations of defect were palm and fingers in four patients and forearm in the other patient. The sizes of defect ranged from 4.5 × 1.5 cm to 20 × 10 cm. A minimum of two separate perforator vessels in the flap were identified. The skin paddle was then split between the two perforators to shape two separate paddles with a common vascular supply. There were no cases of flap failure or re-exploration. Four donor sites were directly closed and one was covered by a skin graft. Donor-site morbidity was negligible. The ALT chimeric flap provides customized cover for two separate defects in upper extremity.

Sequential Chimeric Anterolateral Thigh Flap for Reconstruction of Through-and-Through Oropharyngeal Defects with No Suitable Neck Recipient Vessels

The anterolateral thigh flap is currently the frontline choice for head and neck reconstruction. The authors used a chimeric anterolateral thigh flap for reconstruction of a through-and-through oropharyngeal defect. Because of the absence of suitable recipient vessels in the proximity of the defect, the authors recruited the internal mammary vessels. To gain extra pedicle length, the authors converted the chimeric anterolateral thigh flap into a sequential iatrogenic chimeric anterolateral thigh flap. This new flap concept consists essentially of the division of the skin paddle of the anterolateral thigh that is based on two perforators, and the creation of a sequential chimeric flap by reconnecting the pedicles in the opposite order. A functionally good and aesthetically pleasing result was obtained.

Partially failing ALT flap salvaged using its own distal run-off vessel

This case report presents salvage of a partially failing anterolateral thigh flap. A 37-year-old male, a victim of head and neck squamous cell carcinoma, received tumor ablation and a chimeric anterolateral thigh skin and vastus lateralis muscle flap reconstruction. Before ligation of pedicle, both skin and muscle portions had robust blood supply; however, only the vastus lateralis muscular component remained revascularized rather than the skin paddle with some underlying muscle 30 minutes after patent microanastomosis with recipient vessel. The skin paddle flap was then salvaged by perfusion from a new anastomosis between the distal run-off of the pedicle artery and the perforator artery of this skin flap. From this experience, we recommend to preserve longer distal run-off of the pedicle in chimeric anterolateral thigh flap harvest for necessary “self-revascularization” in similar cases.