Anterolateral Thigh Fasciocutaneous Flap Research Articles

Reconstruction after Salvage Total Laryngectomy

Over recent decades, there has been a trend toward non-surgical or “organ preservation” therapy for advanced staged laryngeal cancers, but up to 1/3 of patients will see a lack of long-term treatment response. As a result of this paradigm shift, total laryngectomy is increasingly performed in the ‘salvage’ setting. Salvage total laryngectomy is associated with high rates of complications from impaired wound healing from prior chemotherapy and/or radiotherapy, and reconstructive techniques aim to decrease these complications. Regional and free tissue flaps are used in contemporary reconstruction of salvage laryngectomy defects. In this article, the pectoralis major myocutaneous flap and the anterolateral thigh fasciocutaneous free flap are discussed in detail. Additionally, specific techniques are described in a defect-based approach with special attention to total laryngectomy with primary closure of the mucosa, as well as defects not amenable to primary closure, such as total laryngectomy with partial or total pharyngectomy and esophagectomy. This defect-based approach allows the author to present surgical scenarios commonly encountered during salvage total laryngectomy and walk the reader through various reconstructive techniques.

Diet Outcome in Patients With Hypopharyngeal Defects Repaired With Different Reconstruction Flaps: A Comparative Study.

To assess potential risk factors influencing diet outcomes after reconstruction of subtotal hypopharyngeal defects using free patch- or tube-shaped anterolateral thigh (ALT) fasciocutaneous flaps. Retrospective cohort study. First-level referral hospital. Between January 2011 and December 2020, we studied hypopharyngeal cancer patients who underwent the reconstruction of hypopharyngeal defects using free patch- or tube-shaped ALT fasciocutaneous flaps. The choice between patch- or tube-shaped ALT flaps depended on the defect's nature, favoring patch-shaped for subtotal defects and tube-shaped for circumferential defects. A restricted diet was characterized by a history of enterostomy or endoscopic esophageal dilation treatment postreconstruction. We analyzed patients with restricted diets at 1- and 3-year follow-up visits. Ninety-eight patients were enrolled; 39 patch-shaped flaps, and 59 tube-shaped flaps. No significances were noted in demographics, postoperative radiotherapy (RT) or chemotherapy, rates of free flap reoperation/salvage, or complications. However, a significant difference emerged in diet outcomes at the 1-year follow-up (P = .005). The rate of a restricted diet was 6.08 times higher in patients with tube-shaped flaps compared to patch-shaped flaps (95% confidence interval [CI]: 1.95-18.94). Stratifying based on postoperative RT revealed a 5.47 times higher rate of a restricted diet in tube-shaped flap recipients compared to patch-shaped flap recipients (95% CI: 1.44-20.48). No significances were observed in 5-year survival rates. Concerning postoperative RT, patch-shaped flaps exhibited a lower incidence of a restricted diet compared to tube-shaped flaps. Preservation of the posterior mucosa may play a crucial role in preventing RT-induced esophageal stricture.

Scalp and Dural Reconstruction With a Tensor Fascia Lata Myofascial and Anterolateral Thigh Fasciocutaneous Chimeric Flap: A Case Report

Composite scalp and cranial defects present a challenge due to the unique elements that need to be reconstructed. The goals of reconstruction are to protect intracranial contents, prevent cerebrospinal fluid leak (CSF) and infection, and to provide durable soft tissue coverage. We present a case of an immunocompromised patient with history of craniotomy who developed osteomyelitis and a cranial abscess resulting in a composite defect with dural, bony, and soft tissue loss. To achieve vascularized watertight dural repair and durable soft tissue coverage for resolution of infection and eventual staged cranioplasty, we performed a free tensor fascia lata (TFL) myofascial and anterolateral thigh (ALT) fasciocutaneous chimeric flap. The patient healed well without CSF leak or infection at 5-month follow-up and cranioplasty is planned. Use of a chimeric TFL and ALT flap is effective in the treatment of large, composite cranial defects in the setting of active infection.

Chest wall reconstruction in recurrent breast carcinoma – a case report

IntroductionComplex chest wall reconstruction after an oncological resection requires a multidisciplinary approach with the aim of curative resection.AimThe complexity of such reconstruction is challenged by prior reconstructions that limit the options for free tissue transfer and recipient vessels for microsurgical anastomoses.Case studyWe present a case of an immunocompromised patient with prior breast reconstruction for left breast carcinoma with a pedicled lattisimus dorsi flap who presents with a recurrence to the latissimus dorsi flap requiring a more extensive oncological resection.Results and discussionThis resulted in a large chest wall defect that is reconstructed with plating and an anterolateral thigh fasciocutaneous free flap for soft tissue coverage.ConclusionsThe radical resection allows for excellent overall survival and better quality of life.

Necrotizing Fasciitis in Charcot-Marie-Tooth Treated with Debridement, Free Flap, and Extra-Articular Reconstruction.

Necrotizing fasciitis of the foot is a relatively rare diagnosis and has traditionally been treated with distal amputation. A 30-year-old diabetic man with Charcot-Marie-Tooth muscular atrophy developed necrotizing fasciitis of the dorsal foot and underwent surgical debridement resulting in a significant wound with exposed tendons. Serial debridements were performed, eventually followed by a staged free flap reconstruction using an anterolateral thigh fasciocutaneous flap. After allowing time for flap healing, subsequent staged equinovarus reconstruction was also performed successfully. There were no flap or postoperative complications, and the patient is progressing as expected. Flap refinement procedures have been used to enhance cosmetic and functional outcomes. This report not only showcases the success of a procedure high on the reconstructive ladder in a patient at high risk for complications but also highlights an approach in which functional recovery is also optimized successfully in a planned staged multidisciplinary manner.

Graft and Flap: Orthoplastic Approach to Achilles Tendon Secondary Rupture.

Achilles tendon rupture represents one of the most common tendon ruptures. Although primary repair remains the treatment of choice, surgical complications, such as secondary rupture and tendon exposure, require salvage procedures. This article aims to present the authors' orthoplastic approach for the functional reconstruction of composite secondary Achilles tendon defects. Seven patients with chronic open-wound and large Achilles tendon defects (Kuwada type IV) underwent one-stage reconstruction between October of 2018 and October of 2020. The size of the average soft-tissue defect was 126.2 cm 2 (range, 86.1 to 175.9 cm 2 ), with a tendon gap of 8.2 cm (range, 7.1 to 10.3 cm). A combined team of orthoplastic surgeons performed the reconstructive procedure, using a turndown gastrocnemius fascial flap and a fascia lata autograft for the tendon reconstruction and a free fasciocutaneous anterolateral thigh flap for soft-tissue coverage (graft and flap). Subjective evaluation and quality-of-life measures were obtained preoperatively and 12 months postoperatively using the American Orthopedic Foot and Ankle Score and 36-Item Short-Form Health Survey questionnaire. Mean follow-up was 18.3 months (range, 12 to 24 months). The flap survival rate was 100%. Overall range of motion of the reconstructed side was 87% of the unaffected side (54 degrees versus 62 degrees). The American Orthopedic Foot and Ankle Score and 36-Item Short-Form Health Survey scores of all patients improved significantly ( P < 0.005) at 12 months of follow-up. A microsurgical approach combined with orthopedic techniques can solve complex cases of Achilles tendon secondary rupture, providing a reconstructed tendon that achieves satisfactory anatomic shape and function. Therapeutic, IV.

Challenges in Complex Oncological Chest Wall Reconstruction with Free Anterolateral Thigh Flap and Titanium Rib Plate.

Extensive chest wall tumor resection and reconstruction possess a formidable challenge and require good collaboration between thoracic and reconstructive surgeons. In this article, we reviewed our experience in six consecutive cases requiring complex chest wall resection and reconstruction with titanium rib plates and free anterolateral thigh fasciocutaneous flap with fascia lata with a minimum 24 months follow-up postoperatively. Six patients with a mean age of 54 were diagnosed to have locally advanced malignant ( n = 5) and benign ( n = 1) tumors. They underwent wide local excision with a mean of six ribs resected, and the average size of the soft tissue defect was 389cm 2 . The integrity of the thoracic cage was restored by using titanium rib plates. Fascia lata was harvested along with free anterolateral thigh fasciocutaneous flap to achieve near airtight closure of pleural space for soft tissue coverage. Two patients required early flap exploration with successful flap salvage. One flap failure was reported on postoperative day 11 due to a mechanical cause and a redo surgery was required. With an average stay of 3 days in the intensive care unit, no perioperative pulmonary complications were recorded. Complex oncological chest wall resection and reconstruction with titanium rib plates and free anterolateral thigh fasciocutaneous flap with fascia lata yielded satisfactory aesthetic and physiological functional outcomes.

Regional flap: A reliable coverage for post-radiation ulcer.

Ulcer in radiation-damaged tissue is a dilemma with limited treatment strategies. The study aimed to evaluate the safety and efficacy of regional flaps for patients with post-radiation ulcers through a 10-year experience. A retrospective study of consecutive patients with post-radiation ulcers at a single institute from 2012 to 2022 was conducted. Reconstruction included complete excision of irradiated tissue and coverage with well-vascularised tissue, including local flaps, regional flaps and free flaps. Study outcomes included complications, reoperation rates, overall flap success and recurrence rates. Thirteen patients (six males and seven females; mean age, 56.85 ± 13.87 years) with a mean 10-month history of post-radiation ulcers were enrolled. Ulcers are predominantly located in the chest (n = 3, 23.1%), head (n = 2, 15.4%) and neck (n = 2, 15.4%), with a mean size of 33.1cm2 (range from 1cm2 to 120 cm2 ). Eleven patients underwent reconstruction with 15 regional flaps and three local flaps, one patient received a free anterolateral thigh fasciocutaneous flap and one patient underwent amputation. Among these 15 regional flaps, one (6.7%) had wound dehiscence and four (26.7%) had localised necrosis requiring reoperation. In addition, one patient with a non-healing sinus tract underwent reoperation. The overall success rate of the regional flap was 100% and no recurrence was observed with a mean follow-up of 23.3months. Regional flaps seem a safe and effective reconstructive method for post-radiation ulcers.

Fascio-cutaneous and fascio-periosteal free flaps for treatment of intermediate stage osteoradionecrosis of the jaws

Osteoradionecrosis (ORN) of the jaw is a potentially devastating consequence of head and neck irradiation. Despite recent advances, there are patients who fail to respond to conventional therapies. Historically, free flaps were reserved for advanced cases requiring segmental resection and composite reconstruction, with early and intermediate disease treated more conservatively. We have adopted a more active surgical approach in selected intermediate cases. A retrospective review of patients with intermediate stage ORN who received debridement and either fascio-cutaneous or fascio-periosteal free flap reconstruction was performed. Demographic data, ORN severity, treatment, and outcomes are described. From 2019, 9 cases in 7 patients were identified. All cases were Notani grade II. There were 6 Epstein stage IIa and 3 Epstein stage IIIa. The mandible was the most common site (n=8). Of the 7 patients, 2 had oropharyngeal primaries treated with chemoradiation, and 5 had oral cavity primaries treated with surgery and adjuvant radiation therapy. Three patients had prior hyperbaric oxygen therapy, and 2 had pentoxifylline/tocopherol therapy. After debridement, the radial forearm, ulnar artery perforator, and antero-lateral thigh fascio-cutaneous free flaps were each used in 1 case and the temporoparietal fascio-periosteal free flap was used in 6 cases. There was no recurrence or progression of ORN at the site of surgery, but 2 patients developed additional sites of ORN. For patients with unresponsive intermediate ORN, debridement and soft tissue free flap reconstruction is an alternative to ongoing conservative management or composite resection and reconstruction.

Reconstruction of nasal airway in patients of class IIId maxillary defect with vastus lateralis muscle-chimeric double skin paddle ALT flap

A reconstructive challenge in patients with class IIId maxillary defect is how to obliterate the defect and restore a patent nasal airway. The current strategy using the single anterolateral thigh (ALT) fasciocutaneous flap for reconstruction may result in permanent mouth breathing. As the ALT flap was a common option in reconstruction processes, this study aimed to evaluate the benefits of vastus lateralis (VL) muscle-chimeric double skin paddle ALT flap in simultaneous defect and nasal airway reconstruction. This study included 21 patients with class IIId maxillary defect who underwent free ALT flap reconstruction (n = 11, single ALT flap group; n = 10, VL muscle-chimeric double skin paddle ALT flap (chimeric ALT flap) group) at the China Medical University Hospital from August 2015 to September 2019. Associated parameters collected for analysis included gender, age, body mass index (BMI), operative time, hospitalization, clinical stage, preoperative treatment, flap/defect size, comorbidities, postoperative RT, mouth breathing and short/long term complications. No significant differences were observed in age, BMI, hospitalization, clinical stage, preoperative treatment, defect size, comorbidities, and postoperative RT between the two groups; however, the chimeric ALT flap group as dominated by male patients (p = 0.009), and had longer operative times (12.1h vs. 10.1h, p = 0.002) and larger flap sizes (180 cm2 vs. 96.7 cm2, p = 0.013). Compared with the chimeric ALT flap group, the single ALT flap group suffered from permanent mouth breathing. Nasal airway reconstruction should be considered in patients with class IIId maxillary defect. Compared to the single ALT flap, the chimeric ALT flap is a superior reconstructive option for patients with class IIId maxillary defect, although a longer surgical duration and larger flap size are required.

Pedicled chimeric muscle and anterolateral thigh fasciocutaneous flap reconstruction of trochanteric pressure wounds: Presentation of two cases

Abstract Trochanteric pressure wounds are a significant cause of morbidity among paraplegic and comorbid patients. Their surgical management requires femoral head ostectomy followed by robust soft tissue coverage both for dead space obliteration and for skin and subcutaneous tissue replacement. Many flap options and their variations have been presented for this purpose. We present a unique methodology utilizing a chimeric pedicled muscle and anterolateral thigh (ALT) flap for reconstruction. First, we present a paraplegic 39-year-old male who underwent a right Girdlestone procedure followed by a pedicled chimeric vastus lateralis and ALT flap for trochanteric pressure wound reconstruction. Secondly, we present a 55-year-old paraplegic male with a similar pathology on the left, who underwent a pedicled chimeric rectus femoris and ALT flap reconstruction. Both surgical courses were uncomplicated and with no wound recurrence. Our cases demonstrate that this modification of previously described reconstructions is a viable option for the reconstruction of trochanteric pressure wounds. The literature abounds with reconstructive options for trochanteric wound reconstruction, but none without limitations. We add another durable and robust coverage modality to the reconstructive surgeon’s armamentarium. The chimeric pedicle muscle and ALT flap surgical reconstruction is a viable technique in management of trochanteric pressure wound reconstruction. • Chimeric flap design provides benefits of both muscle and fasciocutaneous flaps. • Chimeric flap design is a viable technique for trochanteric pressure wounds. • There are many options for paddle selections. • Donor site morbidity is minimal and it creates nominally, if any, more scar burden.

From Esthetic Medicine to Optimizing Reconstructive Outcome: A Feasibility Trial on Secondary Refinement of Fasciocutaneous Anterolateral Thigh Flaps with Cryolipolysis.

Free adipocutaneous anterolateral thigh (ALT) flaps have evolved as workhorse flaps to reconstruct complex, multicompound defects. While coverage is safely achieved, flaps may remain bulky. As a standard of care, flaps are refined with liposuction, partial excision, or combination of both. Cryolipolysis is widely used for fat reduction in esthetic medicine. This pilot comparative study analyses whether cryolipolysis may serve as a safe alternative method to effectively reduce volume in fasciocutaneous flaps. Moreover, patients' satisfaction with the procedure is evaluated. In this single-center, retrospective, interventional comparative cohort study, 10 patients with free subfascial ALT flaps for distal extremity reconstruction underwent cryolipolysis (60 minutes, -9°C). Circumference of the extremities and subcutaneous fat thickness were determined before (T1) and 12 weeks (T2) after cryolipolysis. Patient satisfaction was evaluated with a questionnaire of Likert's scale questions. Duration of hospital stay, intervention time, costs, and possible complications were analyzed and compared with surgical flap contouring (n = 12). All patients undergoing cryolipolysis were male, with a median age of 52 years without arterial disease-like state or deep vein thrombosis (DVT). At T2, a significant reduction of circumference of 1.8 ± 0.9 cm (p < 0.001) and subcutaneous fat layer of 7.7 ± 3.0 mm (p < 0.0001) was recorded. Overall, 90% of the patients were satisfied with the result. Cryolipolysis was well tolerated. One patient developed a second-degree frostbite which healed without further intervention. Cryolipolysis proofed to be as safe as surgical flap contouring. Hospital stay was significantly shorter (p < 0.01) and personal resources were spared when flap contouring was performed with cryolipolysis. This is a novel application of evolving body-contouring cryolipolysis from esthetic medicine into optimizing outcomes in reconstructive surgery. Cryolipolysis has been shown to be relatively safe and effective to reduce ALT's volume with high patients' satisfaction. This successful pilot study encourages further investigation with a prospective randomized control trial.

Microvascular Free Tissue Transfer for Reconstruction of Complex Abdominal Wall Defects.

Patients with significant loss of abdominal wall soft tissue represent a reconstructive challenge. The purpose of this study was to describe the authors' experience using microvascular free tissue transfer to repair complex abdominal wall defects with insufficient overlying soft tissue. In this report, the authors highlight their techniques and experiences in performing microvascular free tissue transfer to the abdominal wall for these massive, complex defects. In total, 14 patients who underwent 16 free-flap reconstructions were included in the series. The patients' mean age was 50 ± 14 years, and mean body mass index was 27 ± 5 kg/m2. The mean hernia defect size was 412 ± 149 cm2. Ten flaps were fasciocutaneous anterolateral thigh flaps, one myocutaneous anterolateral thigh flap, two subtotal thigh flaps, one myocutaneous latissimus dorsi flap, one parascapular/latissimus dorsi flap, and one free filet of the lower leg. Five cases (36 percent) developed hernia recurrence, and seven developed surgical site complications. All flaps survived, with no total flap loss. This report highlights that microsurgical free tissue transfer in combination with mesh repair is a safe and reliable method for restoring complex, large, full-thickness abdominal wall defects. This case series illustrates a number of techniques and considerations that are of importance to achieve a favorable outcome when faced with these complex defects. Therapeutic, IV.

Correction of eating disorders in patients with oral and oropharyngeal cancer after reconstructive plastic surgery

The study objective – to evaluate the feasibility of correcting eating disorders in patients undergoing surgery for oral and oropharyngeal cancers using various reconstructive techniques to restore postoperative defects.Materials and methods. Between 2012 and 2019, a total of 56 patients with stage II–IV oral and oropharyngeal cancer underwent reconstructive surgery after either hemiglossectomy or glossectomy. The patients ranged in age from 26 to 70 years. The patients were divided into two groups. Group I consisted of 36 (64.3 %) patients who underwent tongue reconstruction using rotation flaps. For reconstruction of hemiglossectomy defects, a chin flap was used, and for reconstruction of glossectomy defects, a pectoral flap was used. Group II comprised 20 (35.7 %) patients who underwent tongue reconstruction using free revascularized flaps. For the tongue reconstruction after hemiglossectomy, the radial flap, medial sural perforator flap and fasciocutaneous anterolateral thigh flap were used. For the tongue reconstruction after glossectomy, the fasciocutaneous anterolateral thigh flap was used. The acts of chewing and swallowing were restored during speech rehabilitation due to the activation and coordination of the work of the muscles of the cheeks, lips, soft palate, pharynx, and the reconstructed tongue. Eating disorders were assessed by interviewing patients. A comparative analysis of eating disorders included mobility and coordination of facial muscles and reconstructed tongue, increased sensitive in the oral cavity, the presence of aspiration and nasal regurgitation, and subjective difficulties of patients. The time before the start of rehabilitation and its duration were taken into account. Patients were interviewed before the start of the combined treatment, at the beginning and after the completion of rehabilitation.Results. After the completion of rehabilitation, all patients received food by the oral route. The best outcomes were achieved in group 2a patients, who underwent tongue reconstruction with free revascularized flaps. This group of patients had a lower percentage of the asymmetry of facial muscles and limited mobility of the tongue compared to other groups of patients.In the subgroups of patients undergoing glosssectomy, most of the studied parameters did not have statistically significant differences in values. However, it should be noted that in group 2b, the period from the date of surgical treatment to the beginning of rehabilitation was significantly longer than in group 1b.Conclusion. The use of the microvascular surgical techniques using various donor flaps creates the basis for a more complete functional recovery and expands the rehabilitation potential of patients after surgical treatment of oral and oropharyngeal cancer.

Microsurgical reconstruction of maxillary defects after limited resections for malignant tumors

Introduction. Partial maxillectomy involves resection of 1 or 2 walls of the upper jaw, usually medial and anterior ones. The main purposes of reconstruction include the formation of an adequate support for the eyeball; isolation of the orbit from the nasal cavity, nasopharynx, and anterior skull base; normal symmetry; good aesthetic result.Materials and methods. Between 2014 and 2020, we followed up 13 patients. Nine of them (69 %) had combined defects involving the inferior orbital, anterior, and medial walls of the maxilla (class V according to according to the Brown–Shaw classification, 2010), as well as skin on the buccal and zygomatic areas; 1 patient also had lower eyelid affected. Four individuals (31 %) had isolated defects involving the inferior orbital, anterior, and medial walls of the maxilla (class V according to according to the Brown–Shaw classification, 2010). Twelve patients have undergone preoperative 3D-computer simulation. We divided patients into 2 groups according to the size of their defects and resection areas in the anterior wall of the maxillary sinus. Group 1 included 5 patients with partial maxillary defects (involving 25–40 % of the total area), whereas Group 2 comprised 7 patients with limited maxillary defects (involving 25–40 % of the total area).Five patients have undergone reconstructive surgeries with fasciocutaneous flaps, including anterolateral thigh flaps used in 4 individuals (31 %) and thoracodorsal flap used in 1 individual (8 %). Eight patients had their defects repaired using radial fasciocutaneous flaps. The inferior orbital wall was reconstructed using an individual titanium mesh implant.Results. All patients from Group 1 after defect repair with anterolateral thigh flaps and thoracodorsal flaps (4 individuals) had satisfactory aesthetic result. One patient had an unsatisfactory aesthetic result after reconstruction with a radial fasciocutaneous flap due to mesh implant protrusion and formation of an opening in the nasal cavity. The assessment of the eyeball position demonstrated that symmetry was achieved in 4 patients (80 %) after reconstruction using anterolateral thigh flaps (3 patients) and thoracodorsal flap (1 patient). Five patients from Group 2 (72 %) had excellent results, while 2 patients (28 %) had satisfactory results. The assessment of the eyeball position demonstrated that symmetry was achieved in 5 patients (70 %); two participants (28 %) had lower eyelid ectropion.Conclusion. Patients with large maxillary defects (involving 41–60 % of the total area of the anterior wall of the maxillary sinus and the alveolar process of the maxilla) should undergo reconstructive surgeries with fasciocutaneous anterolateral thigh flaps. In case of relatively small defects (involving 25–40 % of the total area of the anterior wall of the maxillary sinus and the alveolar process of the maxilla) the best option is defect repair with radial fasciocutaneous flaps. Such strategy ensures excellent aesthetic and functional results in 75 % of patients.

Intraadiposal Pedicle Dissection when Performing Free Tissue Transfer: A Means to Address a Short Pedicle

A 77-year-old male patient with a diabetic foot ulcer on his right great toe visited the outpatient clinic. As necrosis of the toe had already progressed, the patient underwent toe amputation to prevent extensive gangrene. With the goal of enabling future ambulation, an anterolateral thigh fasciocutaneous free flap was planned to preserve the metatarsal head and to cover the defect. Subfascial dissection was performed when elevating the fasciocutaneous flap, but the sole healthy perforator was in an extremely proximal area and allowed only a 4-cm-long pedicle. The pedicle had to be at least 8 cm long to ensure secure anastomosis to the medial plantar artery. To overcome this unexpected challenge, we pierced the deep fascia near the perforator and dissected the perforator distally within the deep adipose layer. The necessary additional length of the pedicle was obtained through intraadiposal dissection. The flap survived without any complications, and the foot was reconstructed with successful ambulation. This case demonstrates the value of attempting intraadiposal pedicle dissection when the pedicle turns out to be unmanageably short.

Spiralised supraclavicular artery island flap for total pharyngeal reconstruction: a technical note

Total pharyngeal reconstruction is often undertaken following salvage surgery, when patients have undergone previous chemoradiotherapy, and it is associated with significant morbidity. Optimal reconstruction restores pharyngo-oesophageal continuity to permit swallowing postoperatively. There are a number of reconstructive options described, typically requiring free tissue transfer with a fasciocutaneous anterolateral thigh flap (ALT) or radial forearm flap (RFF).1 When a pedicled flap is desired, pectoralis major flaps are frequently employed, but these are bulky and are associated with significant donor site morbidity.

Options for soft tissue reconstruction in pseudarthrosis

Pseudarthrosis can develop as acomplication after conservative or operative fracture treatment and after elective orthopedic surgery. The treatment is challenging and is made more difficult when accompanied by large soft tissue defects or impairments in wound healing. In this case close and early coordination between trauma and plastic surgeons is crucial in order to develop acoherent and interdisciplinary treatment plan. Due to the positive effects on bone consolidation and osteomyelitis, timely soft tissue reconstruction via apedicled vascularized flap or free flap coverage should be preferred. If blood circulation in the affected extremity appears to be compromised, this should first be optimized by vascular intervention or bypass surgery. In atrophic, aseptic pseudarthrosis, bone and soft tissue reconstruction can be performed consecutively in one single procedure, whereas septic pseudarthrosis always require complete resection of all infected debris prior to wound closure. Examples of two commonly used free flaps are the latissimus dorsi muscle flap and the fasciocutaneous anterolateral thigh (ALT) flap. As multiple variations have been described for both procedures, the reconstructive portfolio lists many additional options available for soft tissue reconstruction. Fasciocutaneous flaps should be preferred whenever bone consolidation requires additional surgical interventions in the future.

Single Artery Upper Extremity Salvage with Two Free Flap End-to-Side Brachial Artery Anastomoses

Abstract Background A 36-year-old male was involved in a motor vehicle accident, presenting with a Guistillo's IIIB crush injury to the upper extremity. A severely comminuted ulnar fracture resulted in a 10-cm bone defect with significant overlying soft tissue injury. Methods The injury resulted in a wide zone of injury with inadequate collateral vascularity at the level of the elbow and distal viability dependent on the brachial artery. An osteocutaneous free fibular flap and fasciocutaneous anterolateral thigh flap were used to reconstruct the defect with both flaps anastomosed in an end-to-side fashion to the brachial artery. Results The upper extremity was successfully salvaged, and the patient discharged from hospital at postoperative day 10. Both free flaps survived with no donor or recipient site complications at a follow-up period of 2 years. Conclusion The case illustrates the challenges inherent to significant Guistillo's IIIB injuries with insufficient recipient vessels over a large zone of injury. While performing anastomoses outside the zone of injury is preferred, this case demonstrates the success of performing multiple anastomoses to the brachial artery in an end-to-side fashion within the zone of injury.

One Stage Microsurgical Reconstruction with Chimeric Flap for Salvaging a Complex Hand Injuries

Hand injuries, involving extensor tendon with carpal bone loss are catastrophic events. Reconstructive surgeons typically face difficulties in minimizing the number of operations, recovery period and restoring its functions with an acceptable aesthetic outcome. However, chimeric flap, which consists of multiple composite flaps from one of the sources of main vascular system is a promising option for reconstruction. This paper presents a case of near-amputated degloving injury over the extensor tendon with carpal bone loss on left hand due to road traffic accidents. The patient had a hand reconstruction with chimeric flap consisted of free fasciocutaneous anterolateral thigh flap and vascularized osteomyocutaneous iliac bone graft with tensor fascia lata from the lateral circumflex femoral vascular system. As a result, the hand functioned well and appeared aesthetically acceptable. Thus, this surgery is an effective option in recovering and reconstructing a complex and traumatic hand injury that involved multiple composite tissue defects.