Free Anterolateral Thigh Perforator Flap Research Articles

The Value of Anterolateral Thigh Free Flap for the Reconstruction of Malignant Melanoma of the Sole of the Foot.

Wide excision of malignant melanoma on the foot usually results in an extensive function-destroying defect, and the reconstruction of foot defects remains challenging for reconstructive surgeons. We propose using anterolateral thigh perforator (ALT) free flaps for the reconstruction of widespread defects caused by malignant melanoma in the sole. This retrospective study included 34 patients who underwent reconstruction of sole defects caused by malignant melanoma resection with 35 ALT perforator free flaps between August 2005 and July 2021. In total, 18 male patients and 16 female patients were included (mean age at surgery, 65.4 years). The mean size of the flaps was 100.4 cm 2 . Thirty-three of the 35 flaps survived. Hematoma, seroma, and chronic ulceration were not identified in any cases. All patients achieved independent ambulation within the follow-up period, except 1 patient with gait discomfort. The 5-year overall and disease-free survival rates of patients were 64.4% and 56.6%, respectively. The ALT flap is a versatile surgical option that should be considered for reconstruction of the sole after malignant melanoma resection, considering its various surgical advantages and the functional aspects of independent ambulation, the aesthetic aspects of wearing conventional footwear, and the anatomical aspects of the sole.

Deep vein thrombosis in donor or recipient veins encountered during lower extremity reconstruction with a free anterolateral thigh perforator flap: How do we deal with it?

BackgroundThe free anterolateral thigh perforator (ALTP) flap has been successfully adopted to reconstruct traumatic soft tissue defects in the lower extremities. However, the occurrence of deep vein thrombosis (DVT) in donor or recipient veins has been overlooked, and there has been no reliable guideline to manage it. Therefore, in this study, we review our cases where the ALTP flaps were transferred to traumatic lower limbs even though DVT was found in the pedicle or recipient veins. Furthermore, based on our experiences, we suggest an algorithmic approach for dealing with DVT.Patients and methodsThis study included 108 patients who underwent lower extremity reconstruction using a free ALTP flap between January 2014 and January 2021. All medical records were reviewed, including preoperative assessment data, intraoperative findings, and postoperative complications. Notably, when DVT was found in both the donor and recipient veins, we thoroughly assessed operative findings, surgical solutions, and final outcomes.ResultsSixty-one of 108 (56.4%) patients underwent computed tomographic venography (CTV) preoperatively, revealing DVT in 11 of these 61 (18%) patients. Three of these 11 patients had iliofemoral DVT, and surgery was delayed more than two weeks after detection. The remaining eight patients had calf DVT and underwent free ALTP flap transfer as scheduled. Conversely, 47 of 108 (43.6%) patients did not undergo CTV, and an occult DVT was found in five of these 47 (10.6%) patients. In two of these five patients, free flap surgery was replaced with amputation and local flap coverage. In the remaining three patients and one patient with an occult DVT that was not found on CTV, the free ALTP flap transfer was carried out. In 15 patients with DVT, free ALTP flap transfer was performed using various alternative methods for venorrhaphy. Consequently, all flaps survived, with partial necrosis occurring in two patients.ConclusionIf DVT-affected veins are appropriately managed, the free ALTP flap can be successfully transferred to the traumatic lower limb even when DVT occurs in donor or recipient veins. The author's algorithm can help surgeons overcome the insufficiency of veins for pedicle anastomosis due to DVT and avoid postoperative thromboembolic complications.

Comparison Between Free Anterolateral Thigh Flap and Free Medial Sural Artery Perforator Flap in Reconstruction of Post Traumatic Soft Tissue Defects of the Dorsum of the Foot

Abstract Background: The objective of this study is to compare between the free anterolateral thigh flap and free medial sural artery perforator flap in reconstruction of post traumatic soft tissue defects of dorsum of the foot as regard the function, the aesthetic outcome, the complications and the patient satisfaction.Method: The study was conducted on 40 patients with post traumatic soft tissue defects of the dorsum of the foot between August 2018 and August 2019. Patients were allocated randomly into two groups. In group1 (20 patients), the defect was reconstructed with free anterolateral thigh perforator flap. In group 2 (20 patients), reconstruction was done by free medial sural artery perforator flap.Result: In group 1 (ALT flap), Complete flap survival was achieved in all cases. Thirteen patients required secondary debulking procedures and scar revisions.In group 2 (MSAP Flap), Complete flap survival was achieved in 17 cases with one flap totally lost and two flaps had distal necrosis. One patient needed scar revision and another patient needed flap advancement.Conclusion: MSAP flap is good alternative in soft tissue reconstruction of the dorsum of the foot. It has many advantages: it is thin, pliable, fitted to normal footwear, less hairy and there is no need for secondary procedures in most cases. ALT flap is better than MSAP flap in larger defects coverage but may need secondary debulking procedures or primary thinning at the time of reconstruction.

The Treatment Experience of Different Types of Flaps for Repairing Soft Tissue Defects of the Heel.

ObjectiveTo summarize the clinical application effects of three different types of flaps for repairing soft tissue defects of the heel, and to discuss the importance of tissue repair and heel reconstruction.MethodsA total of 46 cases with skin tissue defects of the heel with deep tissue exposure were treated. The reasons for the defect were trauma (n = 26), burns and electric shocks (n = 12), chronic ulcers (n = 2), postoperative infection of the calcaneus and Achilles tendon (n = 5), and tumor resection (n = 1). The scope of wound defect was 2.0×2.5 to approximately 15.0×20.0 cm. The flaps used were medial plantar island flaps (n = 9), distal pedicled sural neurovascular island flaps (n = 23), and free anterolateral thigh (perforator) flaps (n = 14). The flap cutting range was 3.0×3.5 to approximately 16.0×22.0 cm.ResultsAfter surgery, all 46 flaps survived. In two cases, patients experienced partial epidermal necrosis at the distal end of the flap that healed after local dressing exchange, and after this treatment, the complete skin grafts survived. Follow-up was conducted in 40 cases, with an average follow-up duration of 8.2 months (3–44 months) and the two-point discrimination of 5–14 mm. The average American Orthopaedic Foot and Ankle Society scale was 89.2 points with good flap color and texture, satisfactory appearance, and normal gait.ConclusionThe repair method should be selected according to the“5-zone method”: The plantar medial island flap is suitable for small area (<5 cm) of medial, posterior and plantar defects. The distal pedicled sural neurovascular flap is suitable for lateral, posterior, and medium-range (6–10 cm) joint area defects. The free anterolateral thigh perforator flap is suitable for large-scale (>10 cm) joint area defects.

[Clinical effect of perforator flap combined with toe transplantation for repairing thumb damage with soft tissue defect of hand].

Objective: To investigate the clinical effect of perforator flap combined with toe transplantation for repairing thumb damage with soft tissue defect of hand. Methods: The retrospective observational study method was used. From May 2014 to June 2019, 8 patients with thumb damage and soft tissue defect of hand were admitted to the 988th Hospital of Joint Logistic Support Force of PLA, including 6 males and 2 females, aged from 25 to 46 years. Among them, thumb damage in 3 cases were degree Ⅱ, 1 case was degree Ⅲ, and 4 cases were degree Ⅳ. All thumb damage were repaired with perforator flap combined with toe transplantation. The skin and soft tissue defects of hand were repaired by free anterolateral thigh perforator flap in 6 cases and free deep inferior epigastric perforator flap in 2 cases. The thumb damage of degree Ⅱ was repaired by the first toe transplantation combined with perforator flap, and thumb damage of degree Ⅲ or Ⅳ was repaired by the second toe transplantation combined with perforator flap. The survival and blood supply of reconstructed thumbs and flaps, and wound healing of donor sites were observed after surgery. All the patients were followed up for 10 to 18 months, the appearance of the reconstructed thumbs, sensory recovery, and foot walking function were observed. At the final follow-up, the functional reconstruction of the thumb was evaluated. Results: All the blood supply and survival of the reconstructed thumbs and flaps were good, and all the wounds of donor sites healed well. During the follow-up, the appearances of the reconstructed thumb and flap were good, the sensation of pain and touch of the finger pulp recovered well, and no significant impact on foot walking function was observed. At the final follow-up, the function of reconstructed thumb was evaluated as excellent in 4 cases, good in 3 cases, and fair in 1 case. Conclusions: The repair method of perforator flap combined with toe transplantation technique can complete the targeted repair of thumb damage with skin and soft tissue defect of hand in one stage, minimizing the foot donor site injury and shortening the course of disease and early rehabilitation, which is one of the ideal methods for the treatment of complex thumb damage.

Free ALT Perforator Flap in Nonobese Patients: The Recontouring of Soft Tissue Defects Around Foot.

The anterolateral thigh (ALT) perforator flap is well-described and versatile option for reconstruction of soft tissue defects around foot and ankle. This retrospective review was performed for reconstruction of soft tissue defects around foot with ALT perforator flaps in patients with normal and overweight body mass index (BMI). Between January 2016 and November 2020, ALT flaps were used in 30 patients for foot defects. Etiologic factors were trauma (18 patients), diabetic foot ulcer (6 patients), tumor (3 patients), infection (2 patients) and burn contracture (1 patient). Mean body mass index (BMI) value was 24.9 ± 4.1 (17-30). Mean flap dimension was 145 ± 86 (40-420) cm2. Recipient vessels were anterior tibial artery in 17 patients (56%), posterior tibial artery in 12 patients (40%), reversed flow dorsalis pedis artery in 1 patient (3.3%). In 24 patients (80%), 2 vein anastomoses were done. Debulking were applied in two patients (6.6%). Donor area was grafted in four patients (13.3%). Mean flap score was 1.25 ± 0.5. Mean flap thickness was 10 ± 2 (7-14) mm. Visual Analogue Scale (VAS) score was 7.75 ± 1.04 (6-10). The patients were followed up for a mean of 14 ± 11 (1-30) months. We think that ALT flap is still reliable and precious option because it provides ideal soft tissue reconstruction by means of recontouring of foot in nonobese patients.

Comparison between Free Anterolateral Thigh Flap and Free Medial Sural Artery Perforator Flap in Reconstruction of Post Traumatic Soft Tissue Defects of Dorsum of the Foot

Background: The objective of this study was to compare the pliability, the function, aesthetic outcome, complications and patient satisfaction between free anterolateral thigh flap and free medial sural artery perforator flap in reconstruction of post traumatic soft tissue defects of dorsum of the foot. Method: The study was conducted on forty patients with post traumatic soft tissue defects of the dorsum of the foot between August 2018 and August 2019. Patients were divided randomly into two groups. In group1 (20 patients), the defects were reconstructed with free anterolateral thigh perforator flap. In group 2 (20 patients), reconstruction was done by free medial sural artery perforator flap. Result: In group 1 (ALT flap), Complete flap survival was achieved in 100% of cases. Thirteen patients required secondary debulking procedures and scar revisions. In group 2 (MSAP Flap), Complete flap survival was achieved in 85% with one flap totally lost and two flaps had distal necrosis. One patient needed scar revision and another patient needed flap advancement. Conclusion: MSAP flap is superior to ALT flap. It has many advantages: it is thin, pliable, fitted to normal footwear, less hairy and there is no need for secondary procedures in most cases.

A single-center retrospective comparison of Duplex ultrasonography versus audible Doppler regarding anterolateral thigh perforator flap harvest and operative times.

We reported on the superiority of preoperative Duplex mapping ("Duplex") over audible Dopplers ("Doppler") in anterolateral thigh perforator (ALT) free flaps for upper extremity reconstruction. To corroborate our findings on a larger cohort, we conducted this present study focusing on surgical efficiency and patient safety. 150 consecutive ALT free flaps were divided into 65 cases of preoperative Duplex versus 85 Doppler controls. We first compared patient demographics, operative details, and defect and flap characteristics. We then assessed group differences in the number and course of perforators pursued intraoperatively, flap harvest and operative times, and donor-site complications. Additionally, the impact of the training level of the primary microsurgeon was evaluated. Cases and controls were comparable regarding age (p= .48), sex (p= .81), ASA class (p= .48), and BMI (p= .90). Duplex was associated with an increased likelihood of raising flaps on one single dominant perforator of purely septal course and significant reductions of flap harvest (68 ± 10min, p< .0001) and operative times (74 ± 16 min, p< .0001), regardless of the experience of the primary microsurgeon. There were strong negative linear correlations between preoperative Duplex and both the flap harvest and operative times (p< .0001). Additionally, while there was no effect on the emergency take-back rate (OR=1.3, p= .60), revisions were significantly less likely among duplexed patients (OR=0.15, p= .04). Preoperative Duplex is associated with a significant reduction in ALT free flap harvest and overall operative times, as well as donor-site revisions as opposed to Doppler planning, regardless of the training level of the primary microsurgeon.

[Indications, selection, and effect of flap application in repairing scar carcinoma in the lower leg and ankle].

Objective: To explore the indications, selection, and effect of flap application in repairing scar carcinoma in the lower leg and ankle. Methods: A retrospective cohort study was conducted. From June 2008 to December 2018, six male patients with scar carcinoma in the lower leg and ankle were treated in Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, aged 48-64 years, with the area of lesion ranging from 3 cm×2 cm to 15 cm×6 cm. After extended resection, the defect area ranged from 8 cm×5 cm to 22 cm×9 cm, with tissue of tendon or bone exposed. Free anterolateral thigh perforator flap, latissimus dorsi myocutaneous flap, or pedicled sural neurovascular flap was selected to repair the wound according to the location of wound in the lower extremity, selection of operation position, the location of the anastomotic vessels in the recipient area, and whether there was good skin and soft tissue available in the lower leg. The size of flap was 11 cm×8 cm-26 cm×10 cm. The donor site of free flap or myocutaneous flap was closed directly by suturing in 5 cases, and the donor site of pedicled flap was repaired with full-thickness skin graft in 1 case. The blood supply and survival of flap, quality of skin graft survival, and complication were observed postoperatively. During the follow-up period, the recurrence and metastasis of scar carcinoma, and the appearance and function of donor and recipient sites were observed. Results: All the patients completed the operation successfully, all the transplanted flaps survived with good blood supply, and the skin graft in one donor site survived well. The wounds in the donor and recipient sites of all the patients healed well without infection, effusion, or dehiscence, etc. All the patients were followed up for 1-5 years. No local recurrence or distant metastasis of scar carcinoma was found. The quality of the transplanted flaps was good. The shape of the recipient area was quite good, and the function of the affected limb was fine. The appearance of the donor area was good without dysfunction. Conclusions: Flap transplantation is suitable for the patients with tendon and bone exposure after the excision of scar carcinoma in the lower leg and ankle. The flap can be selected according to the location of scar carcinoma, operation position, the location of anastomotic vessels in the recipient area, and whether there is good skin and soft tissue available in the lower leg. The free anterolateral thigh perforator flap or latissimus dorsi myocutaneous flap is an ideal choice for repair, which can be obtained in a large area, and the donor site can be directly sutured without affecting the function.

[Exploration on clinical treatment of incisional wound infection after orthopedic internal fixation for lower extremity joint injuries].

Objective: To explore the clinical treatment of incisional wound infection after orthopedic internal fixation for lower extremity joint injuries. Methods: A retrospective cohort study was conducted. From February 2014 to December 2019, 214 patients with lower limb closed injury were treated in Beijing Jishuitan Hospital, including 143 males and 71 females, aged from 16 to 65 years. All patients underwent orthopedic internal fixation, after which incisional wound infection developed in 42 cases of postoperative wounds of patellar fracture, 30 cases of postoperative wounds of tibial plateau fracture, 72 cases of postoperative wounds of Achilles tendon rupture, 45 cases of postoperative wounds of calcaneal fracture, and 25 cases of postoperative wounds of Pilon fracture with 31 cases of superficial infection and 183 cases of deep infection. According to the postoperative evaluation of the incisional wounds, dressing change and/or thorough debridement (with wound area from 4 cm×3 cm to 11 cm×5 cm after debridement), and internal fixation treatment were performed. After thorough debridement, wounds were treated with continuous vacuum sealing drainage (VSD), and then direct suture+VSD or flap transplantation were performed according to the incision and its surrounding skin tissue, infection, suture tension, exposure of internal fixation or bone or Achilles tendon tissue. According to the wound site and injury, the flap types of retrograde anterolateral thigh perforator flap, medial sural artery perforator flap, gastrocnemius myocutaneous flap, sural neurovascular flap, peroneal brevis muscle flap, posterior tibial artery perforator flap, and free anterolateral thigh perforator flap could be selected. The donor site wound was closed by direct suture or grafted with split-thickness skin graft. The removal of internal fixation, wound repair method, type and size of flaps, survival of flaps, and wound healing were recorded. The recurrence of infection, appearance of donor and recipient areas, and recovery of lower limb joint function were followed up. Results: All the internal fixations were removed in patients with postoperative wounds of patellar fracture, among whom 36 cases were repaired with retrograde anterolateral thigh perforator flap, and 6 cases were repaired with medial sural artery perforator flap. Among the patients with postoperative wounds of tibial plateau fracture, the internal fixation was completely retained in 18 cases, partially removed in 6 cases, and completely removed in 6 cases, while the wound was closed by direct suture in 8 cases, transplanted with gastrocnemius myocutaneous flap in 21 cases, and transplanted with medial sural artery perforator flap in 1 case. Among the patients with postoperative wounds of Achilles tendon rupture, the internal fixation was completely retained in 10 cases and completely removed in 62 cases, and the wound was closed by direct suture in 10 cases and transplanted with sural neurovascular flap in 62 cases. Among the patients with postoperative wounds of calcaneal fracture, the internal fixation was completely removed in 32 cases and completely retained in 13 cases, and the wound was healed by dressing change in 5 cases, closed by direct suture in 5 cases, transplanted with sural neurovascular flap in 23 cases, and transplanted with sural neurovascular flap combined with peroneal brevis muscle flap in 12 cases. Among the patients with postoperative wounds of Pilon fracture, the internal fixation was partially removed in 5 cases, completely retained in 17 cases, and completely removed in 3 cases; the wound was closed by direct suture in 4 cases, transplanted with posterior tibial artery perforator flap in 18 cases, and transplanted with free anterolateral thigh flap in 3 cases. The area of flaps/myocutaneous flaps ranged from 5 cm×3 cm to 18 cm×8 cm, and the area of muscle flaps were from 13.0 cm×1.5 cm to 15.0 cm×2.5 cm. All the wounds closed by direct suture healed. Blood flow obstacle occurred in the distal margin of sural neurovascular flap transplanted in 5 patients and posterior tibial artery perforator flap transplanted in one patient, which healed successfully after dressing change. The other flaps survived well, and the wounds were healed. The patients were followed up for 5 months to 5 years, and no recurrence of infection occurred. The direct suture of the flap donor site left linear scar, and the appearance of the skin graft was good. Three patients with tibial plateau fracture and 2 patients with Pilon fracture had limited joint movement, while the joint activity of the other patients was normal. The patients with Achilles tendon rupture and calcaneal fracture had normal ground motion. The sural neurovascular flap grafted on the wound after calcaneal fracture was bloated resulting in inconvenience in wearing shoes, the gastrocnemius myocutaneous flap grafted on the postoperative wound after tibial plateau fracture was bloated, whereas the appearance of the other flaps was good. Conclusions: For incisional wound infection after orthopedic internal fixation for lower extremity joint injuries, the treatment should be classified according to wound infection and wound site. Dressing change, thorough debridement, reasonable disposal of internal fixation, direct suture after application of VSD, and flap covering, etc. not only ensure the infection control and the wound closure, but also restore the function of the lower limbs to the greatest extent, so as to maximize the benefit of the patient.

A Safer Way to Harvest a Superthin Perforator Flap

The updated knowledge of perforasome anatomy and the evolution of microsurgical techniques have enabled surgeons to safely harvest a thin flap. Recently, the anterolateral thigh perforator flap, the current workhorse in soft-tissue reconstruction, has started to be designed and harvested on the superficial fascia, which divides the deep from the superficial fat. This allows elevation of a very thin flap tailored to the defect. Faithful to the ultrathin concept, in an attempt to make flap dissection simpler and safer, the authors describe a revisited harvesting technique of superthin anterolateral thigh perforator flap. This study presents the outlined technique performed in 16 patients with complex soft-tissue defects after trauma or tumor ablation. All of them underwent primary reconstruction using superthin anterolateral thigh perforator free flaps by superficial fascia elevation harvested according to the described surgical procedure. Complications and functional outcomes were assessed. The authors' series of anterolateral thigh perforator superthin flaps demonstrated an overall 100 percent survival rate. Of 16 anterolateral thigh perforators, 12 (75 percent) had no complications and four (25 percent) had minor complications. No major complications such as total flap loss requiring additional salvage surgery were reported. In no case was secondary debulking performed. The superthin anterolateral thigh perforator flap harvested with the described approach was used successfully in microsurgical reconstruction, providing an excellent outer skin cover tailored to the defect. The dissection procedure was safe, quick, simple, and free of major complications. With minimal donor- and recipient-site morbidity, it provided great aesthetic results, avoiding secondary operations. Therapeutic, IV.

Assessment of Quality of Life of Free Anterolateral Thigh Flap for Reconstruction of Tissue Defects of Total or Near-Total Glossectomy.

Background The aim of this study was to evaluate quality of life of free anterolateral thigh flap (ALTFF) for reconstruction of tissue defects of total or near-total glossectomy. Methods Quality of life was assessed by means of the University of Washington Quality of Life (UW-QOL) and the 14-item Oral Health Impact Profile (OHIP-14), after 12 months postoperatively. Results 65 of 79 questionnaires were returned (82.27%). In the UW-QOL, the best-scoring domain was “shoulder,” whereas the lowest scores were for “chewing” and “pain.” In the OHIP-14, the lowest-scoring domain was “handicap,” followed by “Social disability” and “Psychological disability.” Conclusion Free anterolateral thigh perforator flaps for reconstruction of total or near-total glossectomy defects after cancer resection would have significantly influenced the patients' oral functions and quality of life.

Malignant Hidradenocarcinoma Initially Diagnosed as an Apocrine Hidrocystoma: a Case Report and Literature Review

Hidradenocarcinoma is a rare malignant tumor with an aggressive clinical course, and it accounts for < 0.05% of all malignant tumors. It is known to mainly develop de novo, and rarely seen observed to arise from an existing hidradenoma. In this report, we describe a rare case of hidradenocarcinoma that was initially diagnosed as an apocrine hidrocystoma on punch biopsy. During follow-up, the lesion recurred, and complete excision biopsy confirmed the diagnosis of hidradenocarcinoma. Because of the aggressive nature of the disease, we performed wide excision of the lesion, and the defect was reconstructed with a thin free anterolateral thigh perforator flap. No evidence of recurrence was observed during the 11-month follow-up period.

Should We Consider Preparing Patients for Future Face Transplant when Managing Complex Facial Trauma?

Summary:With advancements in microsurgical technique and experience, face transplantation is becoming a clinical reality and acceptable procedure. Preparation of the maxillofacial skeleton and initial soft-tissue coverage for face transplant candidates is essential for optimizing the ultimate outcome by providing immediate coverage of vital structures, functionality, and a stable skeletal framework. We present our experience of preparing such a patient who underwent a successful face transplant, with an excellent outcome. A 24-year-old man sustained a self-inflicted ballistic injury to his face. Composite tissue deficits included significant soft-tissue loss in the central lower and midface, comminuted fractures of midface, and large bone gaps of the maxilla and mandible. He underwent open reduction internal fixation of bilateral LeFort III, zygomaticomaxillary complex, and complex maxillary and mandibular fractures with titanium plates and a free anterolateral thigh perforator flap to the midface with concomitant pedicled left supraclavicular artery fasciocutaneous flap to the lower face. He subsequently underwent a second free anterolateral thigh perforator for the exposed mandibular hardware due to partial necrosis of the supraclavicular artery fasciocutaneous flap. The patient achieved stable bone reconstruction and soft-tissue coverage and was discharged home. He was placed on the waiting list for a face transplant by another center in the country and eventually underwent a successful face transplant. We believe that the preparation of the patient with complex craniomaxillofacial trauma for face transplant should be considered when the extent of injury exceeds conventional reconstructive limits. Our approach provides the best opportunity for an optimal face transplant outcome while minimizing flap donor site morbidity.

Emergency repair of Gustillo III C limb extremities with free Flow-through chimeric anterolateral thigh perforator flap

Objective To explore the clinical effects of a single stage reconstruction and revascularization using a free Flow-through chimeric anterolateral thigh perforator (ALTP) flap in Gustillo III C limb injuries. Methods From January, 2010 to December, 2017, 17 patients with Gustillo III C injury of extremities were repaired with Flow-through chimeric ALTP in emergency surgeries. The patients were 16 males and 1 female with mean age of 32.4 (19-55) years. The size of wounds ranged from 16 cm×8 cm-45 cm×30 cm. The injured arteries were Flow-through anastomosed with the descending branch of the lateral circumflex femoral artery to regain blood flow. The deep dead space was filled with vastus lateralis flap, and the skin flap and fascia flap were used for superficial covering. The donor site was closed directly in 6 patients, simultaneous skin grafts were applied in 11 patients. Results The followed-up time ranged 5 to 60 (average 21.8) months, and conducted by clinic visits and by telephone or WeChat interviews. Fifteen flaps survived, and 2 flaps failed with limb amputated. Six patients were repaired with skin and fascia flaps and 11 patients received flaps comprising the skin, fascia and vastus lateralis muscle. Four flaps healed in stage I. Partial necrosis were observed in 11 flaps. Of which, 1 healed by change of dressing and 10 healed by skin grafting. No complications occurred in donor site in all patients. Conclusion The Flow-through chimeric ALTP flap can be used in stage I reconstruction of the blood supply of limbs and meanwhile achieve the 3-D repair of defects. It is one of the reliable methods in the reconstruction of Gustillo III C injuries in the extremities. Key words: Anteriolateral thigh perforator flap; Flow-through; Chimeric flap; Reconstruction; Gustillo type; Microsurgical technique

Reconstruction of burn contractures of the anterior neck with pre-expanded free anterolateral thigh flaps

Burn contractures of the anterior neck result in severe functional and aesthetic deformities. The release of wide contractures leads to defects that cannot be closed with local flaps. In these cases, tissue expansion of local tissues may be a solution. However, when local tissues are also burned or inadequate, microsurgical free tissue transfer may be necessary. In order to increase the surface are of the transferred flap, pre-expansion of the donor site can be combined with the procedure. Five patients with burn contractures of the anterior neck were treated using pre-expanded free anterolateral thigh (ALT) perforator flaps. The anterolateral thigh was dissected on top of the fascia lata in an avascular plane. The borders of the dissection were kept 2 cm lateral to the pre-identified perforators. A 1000cc rectangular tissue expander was placed. The time of expansion ranged from 4–11 months with a final over expanded volume of 1200cc. The defect sizes ranged from 10 × 21 cm to 20 × 27 cm. There were either one or two perforators included in the flaps. All flaps survived completely with good functional and aesthetic outcomes. Donor areas were closed primarily in one patient and with various amounts of skin grafts in five patients. Overall, pre-expansion decreased the amount of total skin grafted area in the donor site. Pre-expanded ALT perforator flap can be a good option in extensive burns with wide contractures where the regional donor areas are also affected. This technique has several advantages: 1) large flaps can be safely harvested, 2) the expanded skin thins out making it more aesthetically appropriate to resurface superficial defects, 3) expansion period of the thigh is well tolerated by the patients, 4) two teams can work simultaneously, decreasing the operating time, 5) the donor area can be closed either primarily or with minimal skin graft application, and 6) there is no functional loss in the donor area and the donor scar stays under the clothes.

Attributes of Perforator Flaps for Prophylatic Soft Tissue Augmentation Prior to Definitive Total Knee Arthroplasty.

As our population ages, the demand for total knee arthroplasty (TKA) will dramatically increase to ensure an independent lifestyle with unimpeded and pain-free ambulation. Complications will be inevitable, especially in that patient with preexisting soft tissue deficits or extensive scarring in the knee region. Under these circumstances, prophylactic soft tissue augmentation should be strongly considered and be extremely beneficial. A retrospective review of all TKA procedures at our institutions over the past two decades revealed seven patients who specifically had soft tissue augmentation prior to their definitive TKA. Each had a single perforator flap used to achieve this. In no cases was a muscle flap used for this purpose. Excluded were all patients who had a flap of any kind for coverage of an exposed prosthesis or to accomplish wound healing after the TKA. Seven perforator flaps were utilized in seven patients for soft tissue replacement prior to the ultimate TKA. For smaller defects in three patients, a local island medial sural artery perforator flap was used. For larger defects in four patients, an anterolateral thigh perforator free flap was necessary. All flaps were successful. The only complication was an implant infection after one anterolateral thigh free flap that required a revision arthroplasty that eventually allowed salvage. Unrestricted ambulation was possible in all patients except for one who had a preexisting contralateral below-knee amputation. As the number of TKA procedures in the near future increases, prevention of the absolute number of complications becomes even more important. An awareness that any knee region suboptimal soft tissue base can lead to wound breakdown and then periprosthetic infection should alert all involved that prevention of this sequela can be best achieved by prior soft tissue augmentation. Preferably, this may be possible by capturing the assets of local and free perforator flaps.

Comparison of donor site complications of supra- versus subfascially harvested anterolateral thigh perforator free flaps: A meta-analysis

ObjectiveThis study aimed to compare the complications at the donor site of supra- versus subfascially harvested anterolateral thigh perforator free flaps. MethodWe searched PubMed, Web of Science, EMBASE, the Chinese BioMedical Literature Database (CBM) and the Cochrane Library until December 31, 2018, to identify studies that compared complications at the donor site of the supra- versus subfascially raised anterolateral thigh perforator free flaps. Two authors individually extracted the data and performed the quality assessments. Skin grafting, the rate of poor healing in the donor site, dysfunction at the donor site and sensory functions at the donor site were evaluated. ResultSeven studies with a total of 525 patients were included in our analysis. No significant differences were found regarding skin grafting and sensory functions between the 2 groups. However, in regard to the rate of poor healing and dysfunction at the donor site, the SPF group showed significantly better outcomes than the SBF group after the operation. ConclusionOur meta-analysis suggested that, in regards to skin grafting and sensory recovery, the SPF and SBF groups were similar. With regard to donor site healing and functional recovery, the SPF group exhibited better outcomes than the SBF group.

[Application of infrared thermal imaging technology in the design of free anterolateral thigh perforator flap transplantation].

To explore clinical effect of infrared thermal imaging technology for the treatment of free anterolateral thigh perforator flap transplantation. From June 2014 to June 2018, 31 patients with skin defect at various degrees treated by free anterolateral thigh perforator flap transplantation, including 21 males and 10 females aged from 16 to 59 years old with an average age of(35.3±1.5) years old, the courses of disease ranged from 2 to 4 weeks with an average of (1.8±0.6) weeks. The number of perforating branch, the position of the perforating branch, the perforating branch vitality detected by Doppler blood stream detector and parameters of thermal imaging image in order to guide design of skin flap, and compared results with the data of perforator arteries observed during the operation. Totally 52 branches of perforating arteries were detected by Doppler blood stream detector during operation, and 38 perforator branches were confirmed in operation, the accuracy rate was 73.1%. Thirty-eight branches of perforating arteries were detected by infrared thermography during operation, and 35 branches of perforating branches were confirmed in operation, the accuracy rate was 92.1%; there were statistical difference. The most dynamic perforating pivot found by Doppler blood stream detector was confirmed by intraoperative diagnosis, with an accuracy rate of 80.6%. The most dynamic perforating pivot found by infrared thermography is confirmed by intraoperative diagnosis, with an accuracy rate of 100%; there were statistical difference. Thirty-one flaps were survived without vascular crisis occurred. All patients were followed up from 6 to 18 months with an average of(10.7±1.2) months. The flaps survived with soft texture and good blood circulation, the defect was not bloated, the color of skin flap was basically the same as that of the normal skin, and the limbs appearance and function recovered well. Infrared infrared thermal imaging technology could be used as a new technology in localization of perforator artery in free anterolateral thigh perforator flap transplantation.

[Clinical application of lobulated transplantation of free anterolateral thigh perforator flap in the treatment of electric burns of limbs].

Objective: To explore the clinical efficacy of lobulated transplantation of free anterolateral thigh perforator flap in repairing electric burn wounds of limbs. Methods: From August 2014 to April 2019, 19 patients with electric burns in the limbs were hospitalized in our unit, including 18 males and 1 female, aged 20-58 years. There were 37 wounds deep to bone. The area of wounds ranged from 3.0 cm×2.0 cm to 40.0 cm×8.0 cm. Multiple-perforator-based anterolateral thigh flap was designed and resected. Then the flap was lobulated taking the respective perforators of the lateral circumflex femoral artery as the axial vessels before being transplanted to the debrided wounds in the limbs. The blood vessel trunk or the perforator vessels of flap lobes were anastomosed with the respective vessels in the recipient sites. The wounds were repaired with respective lobes of the flap when repairing multiple wounds in one surgical procedure, whereas the lobes were spliced or staggered to cover the wound to fit the shape of wound when repairing a single irregular wound in one surgical procedure. For the limb with distal blood supply disorder, the blood supply branch of flap was used to reconstruct the blood supply. If necessary, an appropriate length of vein was taken for transplantation. The improvement of reconstructed blood supply was observed. The number of surgeries, the number of anterolateral thigh perforator flaps, the number and size of flap lobes, the number of anastomosed vessels in each surgery, the treatment of the donor sites, the length of each surgery, the postoperative complications and survival condition of flap lobes were recorded. The upper extremity function was evaluated with the Carroll's Upper Extremity Function Test Scale, and the patients' satisfaction degree with the therapeutic effect of each surgery was investigated with a 5-point Likert Scale during follow-up. Surgeries were divided into single wound group of repairing one wound at one time and multiple wounds group of repairing two or more wounds at one time. The number of anastomosed vessels in each surgery, the treatment of the donor sites, the length of each surgery, and the postoperative survival condition of the flap lobes were compared between the two groups. Surgeries were divided into early group of performing surgery within post burn day 7 and late group of performing surgery on post burn day 7 and beyond. The postoperative complications and survival condition of flap lobes, the evaluation score of upper limb function and the patients' satisfaction degree with the therapeutic effect of each surgery at the last follow-up were compared between the two groups. Data were processed with independent sample t test, Mann-Whitney U test, or Fisher's exact probability test. Results: The blood supply of 5 patients with distal hand or finger blood supply disorder recovered or improved significantly after vascular transplantation. A total of 46 lobes [(2.2±0.4) lobes per flap] were obtained from 21 anterolateral thigh perforator flaps in 19 patients with 21 surgeries. The area of flap lobes ranged from 4.0 cm×3.0 cm to 24.0 cm×13.0 cm. In each surgery, 2.0 (1.5, 3.0) arteries and 3.0 (2.0, 3.0) veins were anastomosed. Six donor sites were repaired by thin split-thickness scalp, and 15 donor sites were closed directly. The duration of each surgery was (8.9±1.7) h. After surgery, bleeding and hematoma occurred in 2 flap lobes and local infection occurred in 5 flap lobes, which were improved after management. Vascular crisis occurred in 4 flap lobes, and exploratory surgeries were performed, after which 2 lobes survived, while the other 2 lobes necrotized and were repaired by other methods. The rest flap lobes survived well. After each postoperative follow-up of 3 to 60 months, the flap covering areas of the limbs were well-recovered. At the last follow-up, the function evaluation score of 20 affected upper limbs was 85 (63, 90) points, and the score of patients' satisfaction degree with the therapeutic effect of each surgery was (4.4±0.7) points. A total of 30 flap lobes were obtained in 14 surgeries and repaired 30 wounds respectively in multiple wounds group, and 16 flap lobes were obtained in 7 surgeries and were spliced to repair 7 large irregular wounds in single wound group. There were no statistically significant differences in the number of anastomosed artery or vein in each surgery, and the duration of each surgery between multiple wounds group and single wound group (Z=0.240, 0.081, t=0.180, P>0.05), and the condition of skin grafting in the donor sites and the postoperative survival of the flap lobes in multiple wounds group were similar to those in single wound group (P>0.05). A total of 22 flap lobes were obtained in 10 surgeries and repaired 18 wounds in early group, and 24 flap lobes were obtained in 11 surgeries and repaired 19 wounds in late group. The incidence of postoperative hematoma, infection, vascular crisis, and survival of flap lobes in early group were similar to those in late group (P>0.05). There were no statistically significant differences in the patients' satisfaction degree with the therapeutic effect of each surgery at the last follow-up between early group and late group (t=0.701, P>0.05). At the last follow-up, the function evaluation score of 9 upper limbs in early group was 90 (85, 97) points, significantly higher than 80 (40, 85) points of 11 upper limbs in late group (Z=2.431, P<0.05). Conclusions: Free lobulated anterolateral thigh perforator flap is suitable for simultaneous repair of multiple electric burn wounds of limbs, as well as the repair of a single large irregular wound. It has the clinical advantages of less damage to the donor site and good repair quality. The early flap transplantation is beneficial to improve the function of limbs with electric burns.