Free Anterolateral Thigh Research Articles

Application of KISS anterolateral thigh flap in repairing soft tissue defect of dorsal side of multiple fingers

Objective To evaluate the surgical technique and clinical effect of free KISS anterolateral thigh flap in repairing soft tissue defect of dorsal side of fingers. Methods From January, 2014 to June, 2019, 7 patients with soft tissue defects in dorsal side of multiple fingers were treated. Step one, a KISS anterolateral thigh flap was used and a temporary syndactyly between adjacent affected fingers was created by suture of the digital palmar skin. The donor sites were sutured directly. Step two, a procedure of partial de-bulking and division of syndactyly was followed-up 1-3 months later. All cases were followed-up in observations of appearance, texture, functions and donor site of flaps. Results All flaps survived, and all went through disorders of no blood circulation. The followed-up time were 3 to 24 (average 12.5) months. The flaps had fine appearance, texture and colour. The dorsal aspects of reconstructed fingers demonstrated an aesthetically pleasing effect after the flap de-bulking and division of syndactyly. The donor site only left a linear scar, and the thigh had no functional deficit. Conclusion Free KISS anterolateral thigh flap in repairing defects of dorsal skin in multiple fingers could simplify the operation, shorten operative time and reduce surgical trauma. Key words: Anterolateral thigh flap; Finger; KISS flap; Repair; Microsurgical operation

Application of free anterolateral thigh tissue flap in repairation of tissue defects in total or near-total glossectomy

Objective To evaluate the functional outcomes of the flaps repaired with free anterolateral thigh tissue flap in patients who had total or near-total glossectomy. Methods From March, 2015 to May, 2018, 15 patients with tongue cancer were treated by total or near total tongue resection. The free anterolateral thigh tissue flaps were used to repair the defects of tongues after radical tumor resection. The size of 15 flaps were 6 cm×10 cm to 8 cm×15 cm. Patient data were retrospectively analyzed. Patients were requested to conduct the postoperative reviews. Results All 15 flaps survived, while 1 occurred vascular crisis which was survived after the exploration and corresponding treatment. As the results of 12 to 48 (average 30) months followed-up by clinic visits, the mouth and chewing function recovered well after 6 months, while the swallowing and pronouncing function were poor. The motion of thigh donor area was good, without numbness, pain and discomfort. Conclusion The defect being left after total or near-total tongue resection is repaired and reconstructed with anterior lateral cutaneous tissue flap, which is able to partially restore the functions and shape of the tongue. Key words: Tongue cancer; Anteriolateral thigh tissue flap; Reconstruction; 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.

Exploration on the method of aesthetic repair of the donor sites of flaps

Objective: To explore the excellent methods for aesthetic repair of the donor sites of flaps. Methods: From January 2013 to March 2018, 120 patients (94 males and 26 females, aged from 3 to 60 years) were admitted to the Department of Burns of Beijing Jishuitan Hospital. Wounds areas after debridement or removing scar were ranged from 8.0 cm×3.5 cm to 24.0 cm×18.0 cm. Twenty patients with facial and neck scar were repaired with expanded flaps, including 4 scalp flaps, 8 supraclavicular flaps, 4 deltoid flaps, and 4 trapezius myocutaneous flaps. The flaps in ideal donor sites were selected to repair the wounds in 40 patients, including 20 cases of hand wounds or scars repaired with inguinal flaps, 10 children of foot skin defects or scars repaired with cross inguinal skin flap, 10 cases of knee joint wounds repaired with medial or lateral thigh flaps. The optimal flap design was used to repair wounds in 50 patients. Among the patients, wounds of 36 patients were repaired with relaying flaps, including donor sites of free anterolateral thigh flaps of 8 patients repaired with anteromedial thigh perforator flaps and donor sites of free anterolateral thigh flaps of 8 patients repaired with ilioinguinal flaps or superficial abdominal artery flaps, and donor sites of flaps of 20 patients repaired with peroneal perforator relaying flaps. Besides, wounds of 9 patients were repaired with free lobulated anterolateral thigh flaps, and wounds of 5 patients were repaired with modified V-Y propelling latissimus dorsi myocutaneous flaps. The donor sites of flaps were repaired with allogenic acellular dermal matrix combined with autologous split-thickness skin grafts in 10 cases. The areas of the flaps or myocutaneous flaps were ranged from 6.0 cm×4.0 cm to 30.0 cm×20.0 cm. The survival of flap, myocutaneous flap, or skin graft and the repair of donor site after operation and during follow-up were observed. Results: Blood flow obstacle at 0.5 cm to the distal margin of the flap occurred in 1 patient repaired with expanded flap, which were healed after dressing change. Blood supply disorder occurred at the tip of the anteromedial thigh perforator flap of 1 patient repaired by optimal flap design, which were healed completely after second debridement and restitching. The other flaps or myocutaneous flaps survived well. The allogenic acellular dermal matrix and the autologous split-thickness skin graft survived with good color and texture. During follow-up of 3 months to 4 years, the donor sites of flaps had good appearance, only with linear scar and the function recovered well. The donor sites of skin grafts had no scar hyperplasia, only with scattered pigmentation. Conclusions: According to the characteristics of donor sites of flaps, individualized and reasonable design before the operation such as pre-expanding of the flaps, selecting the ideal donor sites, optimization of the flap design or allogenic acellular dermal matrix combined with autologous split-thickness skin graft to repair donor sites of flaps can minimize the damage for function and appearance of donor sites of flaps and achieve aesthetic effects of donor sites of flaps.

Utility of Preoperative Multidetector-Row Computed Tomographic Angiography after Sublingual Nitroglycerin with Three-Dimensional Reconstruction in Planning of the Anterolateral Thigh Flap.

The utility of nitroglycerin is well established in coronary angiography but less so in other surgical fields. In this study, the authors investigated the utility of preoperative computed tomographic angiography after sublingual nitroglycerin followed by three-dimensional visualization for selecting suitable perforators in planning the free anterolateral thigh flap. The authors performed preoperative computed tomographic angiography following sublingual nitroglycerin (after screening for contraindications) in patients for whom reconstructive surgery with the free anterolateral thigh flap was planned. Data were reconstructed three-dimensionally, mapping location and course of source arteries and perforators. Suitable perforators were selected, and flap design was planned. The characteristics of perforators were analyzed statistically. Of 14 patients for whom surgery was planned, two had contraindications to nitroglycerin and underwent computed tomographic angiography alone. Nitroglycerin allowed for the visualization of more peripheral branches. The Hounsfield units at the deep fascia of perforators selected for surgery were significantly higher than for those not selected (p = 0.003). The distance from the intermuscular septum to the selected perforators was significantly shorter than the distance to nonselected perforators (p = 0.017). There were no adverse events, and all flaps survived. Sublingual nitroglycerin before computed tomographic angiography was safe and increased the visibility of perforators, enabling preoperative planning of flap design based on the three-dimensionally-reconstructed image. The authors highly recommend this procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Diagnostic, IV.

Successful Reconstruction of Osteocutaneous Defect of Calcaneal Area with Allogeneic Bone Graft and Anterolateral Thigh Flap

Calcaneus is a unique-shaped hindbone, therefore the reconstruction of complex osteocutaneous defects of heel-calcaneal area remain challenging. Management of a complex defect in the complicated calcaneal area with allogenic tibia and free anterolateral thigh flap is presented. A 37-year-old male patient was presented with a heel defect after a mine injury. The patient underwent serial debridement, thereafter allogeneic proximal tibia defect was properly shaped, hammered and forged into the tibia medullary defect without any fixation material. The graft was covered with free sensate anterolateral thigh flap. The most important disadvantage of allogeneic bone grafts is the lack of blood supply. In the presented case, the blood supply of the bone graft was provided thanks to the blood supply from the medulla of the tibia. Therefore, it was possible to pass the blood inside the allograft. It can be predicted that this intramedullary vascularization also carries stem cells into the medium, further triggering recovery and regeneration.

Reconstruction of burn contractures with free anterolateral thigh flap in various anatomic sites.

Burn contractures that cause a restriction in extremity movements have to be reconstructed. Free microvascular flaps are generally needed in cases of severe contractures. The ideal free flap for severe contracture defects has to have a large skin island without bulk and a long pedicle for preventing recurrence and tension-free adaptation. Anterolateral thigh flap (ALT flap) that meets these features has widely been used for several indications in reconstructive surgery. Usage of ALT flap in burn contracture was described for burn and axillary contractures in literature. In this study, the usage of free ALT flaps in various anatomic contracture sites was reported. Fifteen free ALT flaps were performed in 14 (12 male, two female) patients with a mean age of 36.6. Burn contracture defects in neck, axilla, popliteal, cubital region, plantar foot and hand were reconstructed with ALT flap. No total flap loss was encountered. Distal flap necrosis was seen in one case. All patients had significant improvement in a range of motions. Recurrence in contracture was seen in one patient with hand flexor contracture due to lack of physical treatment. ALT flap can safely be used in various anatomic contracture sites. Suprafascial elevation of the flap can be preferred for better adaptation in the neck, hand and foot and prevention of bulky appearance.

3D-CTA assisted anterolateral thigh lobulated perforator flap in repairing soft tissue defect of limb: 11 cases report

Objective To investigate the effectiveness of preoperative 3D-CTA in assisting the preparation of free thinned anterolateral thigh lobulated perforator flap with nerve in repairing soft tissue defect of limb. Methods Between February, 2010 and May, 2018, free super-thin anterolateral thigh lobulated perforator flap with nerve was transferred to repair soft tissue defect of limbs in 11 cases. There were 8 males and 3 females with an average age of 35 (range, 22-56) years. The defect area was 8.0 cm×11.0 cm-9.0 cm×23.0 cm. Preoperation CT scan of the free flap donor site was performed to obtain 3D images of the region with arterial blood supply by digital 3D reconstruction CT, and to determine the origin, direction, classification, length, diameter and the position of pedicle perforator. Postoperative regular followed-up was carried according to the Upper Limb Function Evaluation Trial Standards of Chinese Medical Association of Hand Surgery and Enneking Evaluation System. Results All 11 flaps survived. No vascular crisis happened. All 11 cases were followed-up for 3 to 12 (average, 5) months. The flaps were supple and elastic with near normal color. There was no bulkiness. Sensory function was recovered well and two point discrimination was 3.0-6.0 mm. According to the Upper Limb Function Evaluation of Upper Limb of Chinese Medical Association of Hand Surgery, the results were excellent in 1 case, good in 3 cases and fair in 1 case. The Enneking system was used to assesse the lower limbs recovery. The average score was 21, an average of 70% of limb function restored. Conclusion The free super-thin anterolateral thigh lobulated perforator flap with nerve offers advantages to the traditional anterolateral thigh flap. The survived flaps are ideal in terms of covering limb defects and restoring functions. Preoperative 3D-CTA in the anterolateral thigh perforator flap transplantation is an accurate and useful method. It helps a safer and successful operation with optimal outcome. Key words: 3D-CTA; Anterolateral thigh perforator flap; Lobulated flap; Repair; Limb

Free Versus Pedicled Anterolateral Thigh Flap for Abdominal Wall Reconstruction.

Large full thickness abdominal wall defects following malignancies can be a reconstructive challenge. The purpose of this study was to analyze long-term outcomes and complications following abdominal wall reconstruction using composite antero-lateral thigh (ALT) flaps. The study retrospectively investigated 16 consecutive patients who underwent abdominal wall reconstruction with autologous flap between May 2003 and March 2018. Volumetric flap analysis was used to assess flap atrophy over time, evaluating the role of denervation and reinnervation. The long-term outcome was assessed to compare the two groups (free vs. pedicled ALT flap reconstructions). All flaps successfully covered the defects. We found a significant increase in flap resorption in free flaps when compared to pedicled ones. Abdominal bulging was seen in 3 out of 16 (19%) patients after more than 12 months follow-up, in close correlation with mesh absence. Free flaps were shown to be equally effective as their pedicled counterparts, without significant increase in complication rate.

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

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

Clinical application effect of blood circulation enhancement technique in repairing large area of skin and soft tissue defects of extremities with super large free anterolateral thigh flap

Objective: To observe the clinical application effect of blood circulation enhancement technique in repairing large area of skin and soft tissue defects of extremities with super large free anterolateral thigh flap. Methods: From March 2014 to March 2017, 6 patients with large area of skin and soft tissue defects of extremities were hospitalized in our unit, including 5 males and 1 female, aged 27-65 years, 1 case of electric injury, 2 cases of coal burn, 3 cases of traffic injury, 2 cases involving upper limb, and 4 cases involving lower limb. After debridement, the wound area ranged from 26 cm×8 cm to 36 cm×15 cm, and the bone exposure area ranged from 24 cm×7 cm to 35 cm×14 cm. The blood circulation enhancement technique was used when the wound with bone exposure was repaired with super large free anterolateral thigh flap. The area of flaps ranged from 28 cm×10 cm to 38 cm×16 cm. The donor site of flap and the primary wound without bone exposure were repaired with medial thigh split-thickness skin graft of the donor leg of flap. The blood circulation enhancement technique mode during operation and the survival of flaps after operation were recorded, and the recovery of donor and recipient areas and the occurrence of complications were followed up. Results: Three patients were treated with simple vascular supercharging technique during flap transplantation, and the other 3 patients were treated with vascular supercharging and turbocharging technique during flap transplantation. All the flaps survived well in 6 patients without vascular crisis. Follow-up for 3 to 12 months after surgery showed that the blood flow of the flaps was good and the depth and superficial sensation recovered to varying degrees. Except for 1 case of upper limb flap, the other flaps had no obvious swelling and needed no second thinning. There were only depressed scars in the donor sites, and no obvious scar hyperplasia in the area without bone exposure repaired by the skin grafts. No short-term or long-term complications were found. Conclusions: The application of blood circulation enhancement technique in repairing large area of skin and soft tissue defects of extremities with super large free anterolateral thigh flaps provides reliable blood supply for the flaps and results in good effect after operation, which is worth popularizing.

Repairing massive soft tissue defects of shank and foot with combined flaps with the help of 3D-CTA technique

Objective To explore the clinical value of repairing massive soft tissue defects of shank and foot with diverse combined flaps with the help of 3D-CTA technique. Methods From March, 2011 to May, 2018, 7 patients with massive soft tissue defects (defect area: 21 cm×14 cm-53 cm×16 cm) of shank and foot were treated with combined flaps, including free anterolateral thigh flaps (ALTP) combined with local transferred sural neurocutaneous vascular flaps in 2 cases, free ALTP combined with local transferred supracondylar flap in 2 cases, free thoraco-umbilical flaps plus local transferred gastrocnemius muscular flaps in 1 case, and free ALTP plus free thoraco-umbilical flap in 1 case. Free ALTP and free thoraco-umbilical flap respectively combined with double bridge flaps using the both ends of posterior tibial vessel from the healthy limb to form vascular pedicles in 1 case. All cases received 3D-CTA to observe the distribution and anastomosis of perforator vessel. Regular followed-up was made post-operatively. Results All patients had been followed-up for 6-18 months. Outpatient service combined with telephone follow-up was adopted. All flaps survived, and flap shape, colour and lustre, elasticity got good recover. At the last follow-up, thermann scale function assessment: 4 cases were excellent, 2 were good, and 1 was fair. Conclusion It is a feasible and effective method to repair massive soft tissue defects of shank and foot using differently combined flaps. Although the surgery can be risky, the method can effectively reduce the rate of limb disability, restore the limb function and shorten the course of treatment. Preoperative 3D-CTA can get the vessel anatomical structure and diameter at donor and recipient sites, which will guide the operation program design and implementation so as to shorten the operation time and improve the accuracy rate of vascular anastomosis. Key words: 3D-CTA; Combined flaps; Anterolateral thigh perforater flaps; Shank injury; Foot injury; Repair

One-stage repair of soft tissue defects in open leg fracture

Objective To evaluate one-stage repair of leg open fracture with soft tissue defect by fixation plus skin flap. Methods From January 2011 to January 2018, 34 patients with leg open fracture plus soft tissue defect were treated at Department of Orthopedics, The Second Affiliated Hospital to Harbin Medical University. They were 31 males and 3 females, aged from 13 to 54 years(average, 35 years). According to the Gustilo classification, the defects were type ⅢA in 31 cases and type ⅢB in 3 cases. The wound size ranged from 6 cm×3 cm to 25 cm×10 cm. All patients were treated with emergency fracture fixation and flap repair by one stage after thorough debridement. Internal bone plating was performed in 32 patients and external fixation at a single arm in 2 patients. All defects were repaired with a free anterolateral thigh flap. Flap survival, vascular crisis and bone infection were followed up postoperatively. Results All the free flaps survived in the 34 cases with no vascular crisis. These patients were followed up for 6 months to 3 years (average, 10 years). The flaps healed well, with good appearance and soft texture. No bone infection occurred at the defective sites. After postoperative rehabilitation, the knee extension ranged from 160° to 180°, knee flexion from 90° to 110°, ankle dorsal extension from 90° to 110°, and ankle plantar flexion from 100° to 120°. Conclusion Soft tissue defects in leg open fracture can be effectively treated by flap repair after thorough debridement at the same time of fracture fixation, because the primary wound healing can avoid infection and lead to fine survival of the flap. Key words: Fractures, open; Soft tissue defects; Surgical flaps; Reconstructive surgical procedures; Legs

Reconstruction of pediatric hand injuries caused by automatic cup-sealing machines in Taiwan

ObjectiveThis study was performed to share our clinical experience and provide treatment strategies for pediatric hand injuries caused by automatic cup-sealing machines in Taiwan.MethodsThirteen pediatric patients with an average age of 3.6 years were included in this retrospective study. Treatment was based on the location and depth of the injury and included full-thickness skin grafts, free or local flaps, and digital replantation. Some patients underwent contracture release during follow-up.ResultsThermal crush injuries affected the left hand in five patients and right hand in eight. Four patients with nine amputated fingers were treated by emergent digital replantation, four were treated by skin grafting, one was treated by nail bed repair, one underwent reconstruction with a local reversed dorsal digital and metacarpal island flap, one underwent reconstruction with a fascia graft for extensor tendon repair and pedicled groin flap coverage, and two underwent reconstruction with free anterolateral thigh fasciocutaneous flaps with a vascularized fascia lata graft for dorsal hand defects. All replanted fingers survived.ConclusionPediatric hand injuries, especially those caused by cup-sealing machines, can be devastating. Aggressive treatments including early reconstruction and rehabilitation should be performed for all pediatric hand injuries to achieve satisfactory functional restoration.

Anterolateral thigh free flap in reconstruction of lateral skull base defects after oncological resection

PurposeEvaluation of the utility of the free anterolateral thigh flap reconstruction of the defects resulting from radical temporal bone resection in the management of lateral skull base malignancies in a single institution.MethodsAn analysis of 17 en bloc subtotal petrosectomies for removal of malignant tumours was performed. There were 12 squamous cell carcinomas, 4 basal cell carcinomas and 1 adenoid cystic carcinoma. The tumours were staged with the University of Pittsburgh TNM system. In all patients, the lateral temporal bone with the preservation of the petrous apex and carotid artery was performed. All patients had parotid gland resection. The post-resection defect was reconstructed with an ALT free flap.ResultsTumour radical resection and defect reconstruction with an ALT flap was achieved in all patients without intraoperative complications. The transplants were harvested as fasciocutaneous flaps, 11 perfused by musculocutaneous and 6 by septocutaneous perforators. The ALT flaps had a mean pedicle length of 8 cm (6–12 cm), and the flap size ranged between 6 × 15 cm and 15 × 30 cm. The flaps were supplied by nine facial, five occipital and three maxillary arteries. Recipient-site veins included eight internal jugular, seven facial, one retromandibular and one external jugular vein. All arterial pedicles were anastomosed in an end-to-end manner. The veins were anastomosed with interrupted sutures and in 11 cases with Synovis-Coupler® devices. All the flap transfers were performed successfully. Three patients experienced postoperative complications.ConclusionsThe ALT flap proved to be effective for covering large temporal skull base defects resulting from the radical removal of temporal bone malignancies. The functional and cosmetic results were acceptable with a low complication rate.

Anterolateral Thigh Flap-the Optimal Flap in Coverage of Severe Elbow Injuries.

Introduction Traditionally, the latissimus dorsi muscle with or without skin paddle has been the flap of choice for coverage of elbow defects. The ALT flap has found application in elective upper limb defects on account of it’s ability to be tailor made for individual defects. Our series of 10 cases shows the advantages of using this flap for acute trauma defects. Materials and Methods Consecutive 10 cases of severe elbow injuries, involving varying amounts of the lower arm and proximal forearm underwent debridement followed by coverage using the free anterolateral thigh flap. Nine of 10 arterial anastomosis were done end to side to the brachial artery and venous anastomosis to the veins accompanying the artery. Seven of these patients had long bone fractures and elbow dislocations, stabilised using external fixator. Four patients needed primary muscle or tendon repair and nerve repair or graft. Results There was 1 total flap loss, intraoperatively where a TFL flap had been used in a 71 year-old patient. Nine of 10 had successful wound coverage. Using Jupiter criteria, 2 had excellent, 3 had good, 3 had fair, and 1 had poor outcome. Conclusion This consecutive series of moderate and severe elbow injuries demonstrates that the ALT flap should be considered as the flap of first choice, specifically when there is a need.

Combined anterolateral thigh and tensor fasciae latae flap using intraflap flow-through anastomoses in a case of chest wall reconstruction

We report a 74-year-old man with malignant tumor of the chest wall. He underwent wide local excision and reconstruction with combined free anterolateral thigh (ALT) and tensor fascia latae (TFL) flap using intraflap flow-through anastomoses. The designed flap was 20 × 11 cm in size; however, the flap pedicles of the ALT perforators were smaller than expected. Considering that the ALT perforators would not have yielded a sufficient perforasome, we included TFL perforator in the flap. Intraflap anastomosis of the artery and vein of the TFL perforator was performed with the distal end of the descending branches of the lateral circumflex artery and vein. This combined flap was transplanted to cover the chest wall defect. The flap healed without postoperative complications. This report shows that intraflap anastomoses for two different pedicles can be useful for no more than one artery and vein at the recipient site and also allows for preservation of the other lateral circumflex branches. Level of evidence: Level V, therapeutic study.

Neurotized Free Tissue Transfer for Foot Reconstruction: A Systematic Review.

Soft tissue reconstruction of the foot represents a complex reconstructive challenge given the unique anatomical properties of the glabrous plantar skin. For large soft tissue defects and/or complex injuries, free tissue transfer is often the optimal reconstructive modality. The decision to pursue a neurotized free flap remains controversial and an area of debate. Given the trend toward increasing use of neurotized free flaps, we performed a systematic review to determine if nerve coaptation is a beneficial adjunct to free tissue transfer. A systematic search of the English literature using PubMed and Web of Science was performed. Studies were identified between 1985 and 2018. Manuscripts were eligible if they contained original clinical outcomes research of patients who underwent free tissue transfer to the foot or heel with neurotization. A total of 189 studies were identified with initial screening and 19 studies were included in our analysis. A total of 175 patients underwent free flap reconstruction to the foot; of these, 107 patients had a nerve coaptation performed. Patients who underwent neurotization had improved sensory characteristics (two-point discrimination, light touch, and pain sensation), quicker return to ambulation and activities of daily living, and decreased ulcer formation compared with those who did not. Overall complications were infrequent, with ulceration being the most common. Neurotized free flaps appear to have an overall decreased rate of ulceration, improved sensory discrimination, and quicker return to ambulation/activities of daily living in comparison to nonneurotized free flaps. However, when examining free anterolateral thigh (ALT) and free medial plantar artery (MPA) fasciocutaneous flaps, durability (i.e., frequency of ulcer formation) and functionality (ambulation and return to activities of daily living) do not appear to be significantly different between neurotized and nonneurotized flaps.

The use of CTA combined augmented reality navigation in free anterolateral thigh perforator flap for tongue reconstruction: 9 cases report

Objective To explore the value of CTA combined augmented reality(AR) navigation in tongue reconstruction with free anterolateral thigh perforator (ALTP) flaps. Methods From December, 2016 to December, 2018, 9 cases of tongue cancer patients were treated with lingual reconstruction with the free ALTP flap. The dominant perforator was selected according to CTA before operation. The origin, course, locations at the level passing through the fascia lata of the perforators and digital flaps were located and marked under the guidance of AR navigation technology. The flaps area were 6 cm×8 cm-8 cm×12 cm, and the donor sites were closed directly. The effect of the AR navigation was explored intraoperatively. The function of reconstructed tongue and donor site were followed-up 3 to 6 months post-operatively. Results All navigation-positioned perforators were confirmed by AR preoperatively. Intraoperative exploration showed that the perforators were accurately located. All flaps survived, and no vascular crisis occurred. The donor sites healed primarily with linear scars. The tongue was plump, and the function of voice and swallowing were favorable. Conclusion CTA combined AR navigation has the advantages of accurate location, easy to use and low cost in tongue reconstruction with free ALTP flaps. It is a worthy method to be popularized. Key words: Anterolateral thigh perforator flap; Tongue reconstruction; Augmented reality technology; CT angiography; Microsurgical technique