Free Vastus Lateralis Muscle Flap Research Articles

Staged Intracranial Free Tissue Transfer and Cranioplasty for a Refractory Nasal-cranial Base Fistula

Summary: After a transnasal endoscopic resection of a high-grade adenoid cystic carcinoma that underwent adjuvant chemoradiation, there was delayed recurrence managed by en bloc resection through an open craniofacial approach. Subsequently, the patient developed a chronic nasocranial fistula with secondary infection and bone flap resorption. This resulted in infectious episodes with secondary scalp incisional dehiscence and hardware exposure which required multiple bone debridement procedures, hardware removal, prolonged IV antibiotics, and hyperbaric oxygen treatment. The nasocranial fistula and chronic frontal bone osteomyelitis persisted despite the previous interventions. The patient underwent a frontal bone removal and obliteration of the anterior cranial base fistula with a free vastus lateralis muscle flap. At 4 weeks postoperatively, the intranasal portion of the muscle flap had completely mucosalized. After a 6-week course of IV antibiotics, a secondary cranioplasty using a custom-made poly-ether-ether-ketone implant was performed. The patient remained disease- and infection-free for the duration of follow-up (17 months).

The Versatility of the Free Vastus Lateralis Muscle Flap: Orbital Reconstruction After Removal of Complex Vascular Malformation in a Pediatric Patient.

Introduction: Vascular orbital lesions in pediatric population represent a demanding therapeutic challenge which requires a multidisciplinary team. In severe cases, orbital enucleation can be considered. Surgical management of enucleated orbital region in children, differently from the adults, represents a challenging procedure owing to the intrinsic relation between volume replacement and normal orbital growth. Many reconstructive options have been proposed, and many donor sites have been utilized for this purpose but each one have demonstrated potential disadvantages. Despite its well-known versatility, no report of the vastus lateralis free flap in children requiring orbital reconstruction exists in literature. Herein, we propose this surgical strategy as a valid option for the reconstruction of an extended orbital defect in a pediatric patient suffering from a mixed type of vascular malformation.Material and Methods: A patient was referred from a foreign country with an unclear medical history, presenting exorbitism and exophthalmos, proptosis of the eyeball, visus 4/10, and limited ocular motility. We made clinical-instrumental investigations with a diagnosis of complex vascular malformation. It expanded in intraorbital and retrorbital space with bulb anterior dislocation and optic nerve involvement. We performed an emptying of the orbital content via transconjunctival and via coronal incision with eyelid preservation. A free vastus lateralis muscle flap was used for reconstruction, filling the orbital cavity. We anastomosed the flap on the superficial temporal artery. An ocular conformator was then positioned.Results: We report the result at 12 months, showing a good orbital rehabilitation with an adequate prosthetic cavity, a good recovery of volume and facial symmetry, guaranteeing balanced orbital and periorbital growth. There were no major or minor complications associated with the procedure.Discussion: The reconstruction of the orbit remains a “surgical challenge” both in adults, whose goal is the restoration of volume, adequate symmetry and facial esthetics, and children, in which correcting the asymmetry has the additional objective to balance orbital growth. Many reconstructive techniques have been proposed, including the use of free flaps. The versatility of the free vastus lateralis muscle flap is well-known. It offers adequate amount of tissue with minimal morbidity to the donor site, provides a long pedicle, gives the possibility of simultaneous work in a double team, and has a constant anatomy and a safe and rapid dissection. There are no descriptions of its use for pediatric orbital reconstructions.Conclusions: In our opinion, the free vastus lateralis flap should be included as one of the best option for orbital pediatric reconstruction after enucleation.

Free vastus lateralis muscle flap transplantation for postoperative chronic empyema: retrospective analysis of eight case series.

Postoperative chronic empyema (PPE) remains a complex challenge for thoracic surgeons. We retrospectively investigated patients with PPE who were treated with free vastus lateralis muscle flap transplantation, and report our results. Eight patients with PPE and persistent bronchopleural fistula (BPF) treated in our hospital from January 2015 to June 2019 were retrospectively analyzed, the time since onset of empyema ranged from 5 to 72 months. The operation was performed in two stages, stage I surgery included empyema debridement, rib resection drainage or open-window thoracostomy (OWT), meanwhile, BPF was treated under bronchoscope. Stage II surgery included obliteration of the pleural space by free muscle flap transplantation. The keys to the operation are thorough debridement, closure of the BPF, and complete obliteration of the residual pleural space. The challenge lies in the anastomosis of the lateral femoral circumflex artery and vein that supply the vastus lateralis muscle flap to the thoracodorsal vessels. The free muscle flaps survived in all eight patients. The abscess cavity was completely obliterated with the muscle flap. Good efficacy was achieved with primary wound healing. No serious perioperative complications were reported. No empyema recurrence, atrophy, infection, or necrosis of the muscle flap was seen during the 18- to 72-month follow-up. The vastus lateralis muscle flap has a large volume with good blood supply and strong antibacterial ability. It can be used for effective obliteration of a large residual cavity caused by empyema and maintains a good thoracic shape. It is an ideal choice for the treatment of postoperative chronic refractory empyema.

The free vastus lateralis muscle flap. A smart less used flap for soft tissue reconstruction of the weight-bearing foot

BackgroundThe lateral circumflex femoral artery one of the most favoured donor-site for a wide array of free flaps including either cutaneous, fascial and muscle components or a combination thereof. Here, we provide evidence on the safe use of the free vastus lateralis muscle flap and its feasibility for optimal soft tissue coverage of the weight-bearing foot. MethodsEighteen consecutive patients with soft tissue defects of the heel (n = 3, 16.6%) and plantar aspect of the mid- and forefoot (n = 15, 83.3%) of either post traumatic (n = 10), diabetic (n = 6) or ischemic (n = 2) etiology, received nineteen free vastus lateralis muscle free flaps covered with split-thickness skin grafts. The postoperative results in terms of wound healing, weight-bearing function, patient satisfaction were evaluated. In patients with chronic conditions (n = 8) the AOFAS (American Orthopaedic Foot and Ankle Society) scoring system was used preoperatively and 6 months postoperatively for evaluation of reconstruction outcomes. ResultsAll flaps survived. Their complete anatomical integration allowed regaining normal walking in all patients. In five patients, partial loss of the skin graft which either healed spontaneously or necessitated a redo skin grafting was noted. One patient developed a late flap-skin interface ulcer, which was solved by primary excision and direct closure. Compared with the preoperative values, the mean AOFAS score in the evaluated patients (n = 8) improved significantly (34.13 vs. 77.63, p < 0.001). ConclusionThe skin-grafted free vastus lateralis muscle flap can safely be used as a “smart” tool for coverage of weight-bearing foot providing optimal cushioning and functional results without fearing donor-side morbidity.

Avoiding Facial Incisions with Midface Free Tissue Transfer.

Background:We have adopted an intraoral microsurgical anastomosis to the facial vessels to eliminate the need for any visible facial incisions.Methods:Cadaveric dissection was used to demonstrate accessibility of the facial artery and vein through an intraoral approach. Additionally, 5 patients underwent free tissue transfer for reconstruction of major defects of the midface through an intraoral, transmucosal approach, obviating the need for visible skin incisions.Results:The pathology included palatal defects due to mucoepidermoid carcinoma and ischemic necrosis from cocaine abuse, maxillary defects secondary to fibrous dysplasia and avascular necrosis from traumatic blast injury, and a residual posttraumatic bony deformity of the zygoma. Reconstructions were performed with a free ulnar forearm flap, a free vastus lateralis muscle flap, a deep circumflex iliac artery myoosseous flap, a free fibula flap, and a deep circumflex iliac artery osseous flap, respectively. The facial artery and vein were used as recipient vessels for microvascular anastomosis for all cases. Mean follow-up was 12.2 months. All free tissue transfers were successful, and each patient had a satisfactory aesthetic outcome with no associated facial scars.Conclusion:This technique can be employed during reconstruction of an array of bony or soft-tissue midface deficits with minimal morbidity. This small series effectively demonstrates the varied pathologies and tissue deficiencies that can be successfully reconstructed with free tissue transfer using an entirely intraoral approach to the recipient facial vessels, resulting in no visible scars on the face and an improvement in the overall aesthetic outcome.

Free Vastus Lateralis Muscle and Musculocutaneous Flaps: a Versatile Alternative to other Musculocutaneous or Muscle Flaps in Complex and Complicated Defects

Free Vastus Lateralis Muscle and Musculocutaneous Flaps: a Versatile Alternative to other Musculocutaneous or Muscle Flaps in Complex and Complicated Defects

Usefulness in combined free anterolateral thigh and vastus lateralis muscle flaps

Background The anterolateral thigh flap has been a popular flap in reconstructive surgery. However, the details concerning the anterolateral thigh flap combined with the vastus lateralis muscle flap have not been reported. We described the surgical procedures, complication of the donor site, and advantages and disadvantages of this combined flap.

Repair of Recurrent Cleft Palate with Free Vastus Lateralis Muscle Flap

A 6-year-old girl presented with a large recalcitrant oronasal fistula after bilateral cleft lip and palate repair and numerous secondary attempts at fistula closure. Incomplete palmar arches precluded a free radial forearm flap. A free vastus lateralis muscle flap was successfully transferred. No fistula recurrence was observed at 18 months. There was no perceived thigh weakness. The surgical scar healed inconspicuously. Free flaps should no longer be considered the last resort for treatment of recalcitrant fistulas after cleft palate repair. A free vastus lateralis muscle flap is an excellent alternative, and possibly a superior option, to other previously described free flaps.

A Novel Technique for Lower Extremity Limb Salvage: The Vastus Lateralis Muscle Flap with Concurrent Use of the Vacuum-Assisted Closure Device

Free tissue transfer is an essential component of lower extremity limb reconstruction and has dramatically improved salvage attempts. In this report, we examine the use of the underutilized free vastus lateralis muscle flap and describe our treatment protocol that involves a novel application for the vacuum-assisted closure device in an effort to reduce edema and congestion in lower extremity limb salvage. Thirteen patients underwent reconstruction with 14 vastus lateralis flaps with closure occurring on average 35.2 days after injury and an average case duration of 4:34 days. We report one flap failure, one superficial abscess, and one donor site hematoma. All patients were ambulatory at 6 months. Our early experience using this underutilized flap and novel protocol demonstrate successful lower extremity reconstruction with few complications, and good function and contour. Given its advantages, this versatile flap should be included as an option in lower extremity limb salvage operations.

Management of Extensive and Complex Scalp Defects in Patients of Neoplasm

Background: Reconstruction of extensive and complex scalp defects in patients of neoplasm remains a significant challenge because of cerebrospinal fluid leak, bacterial contamination from sinus exposure, effect of radiation therapy, neoadjuvant or postoperative chemotherapy, and functional and cosmetic deformity from the size and location of the defect. In this series, we present our experience in the management of extensive defects Materials and Methods: Between 1993 and 2008, ten patients with scalp defects received reconstruction with a variety of free flaps: four free vastus lateralis muscle flaps, three anterolateral thigh flaps, three latissimus dorsi flaps with fasciocutaneous extension and one radial forearm flap. These defects had a wide spectrum of complexities including extensive multilaminar defects with exposed brain and dura, irradiation damage, infection of the wounds and central nervous systems. The flaps were used to cover the defects resulting from the radical debridement or tumor ablation with or without radiation in patients ranging from 35 to 61 years of age. Follow-up ranged from one to ten years. The patients' demographics, surgical indications, type of flaps and exposed structures, comorbidity, complications and outcomes were assessed. Fisher's exact test was used to evaluate the correlation between CSF leakage and postoperative complications and mortality. Results: All patients were referred from our neurologic surgeons after ablative surgery with or without adjuvant radiotherapy. Among the ten patients, six had a cerebrospinal fluid leak at the time of the reconstruction. Of the six patients, one had total flap loss requiring another free flap reconstruction and two had partial flap necrosis, demanding debridement and split-thickness skin grafting. Four flaps totally survived and the cerebrospinal fluid leak all resolved in the six patients. In comparison, of the four patients without a cerebrospinal fluid leak, all flaps survived. The perioperative mortality is 10% and the overall mortality is 20%. One patient died of sepsis 1.5 months later and the other one died of primary cancer 1.5 years after reconstruction. Conclusion: Although our case number is very small, our results support that free flap reconstruction is a life-saving procedure in this high-risk population and that success is possible. Comparing to fasciocutaneous flaps, muscle flaps with primary or secondary split-thickness skin grafting can provide better cosmetic result. Difficult problems, such as severe central nervous system infection, recurrent cerebrospinal fluid leaks and large irradiated wounds including osteoradionecrosis, can be managed and resolved successfully using this technique.

Reconstruction for sternal osteomyelitis at the lower third of sternum

Sternal wound infection causes considerable morbidity and mortality for open-heart patients. Treatment of the wounds at the upper two-thirds is easier with pectoralis major muscle or other flaps. However, there would be more problems with the lower one-third sternal wounds. From 1983 to 2007, 32 patients of osteomyelitis involving the lower sternum were treated with one of the following methods: (1) Latissimus dorsi with fasciocutaneous extension flap (2) Tri-pedicled pectoralis major musculocutaneous flap (3) Pectoralis major muscle with rectus abdominis muscle flap (4) Pectoralis major muscle with omentum flap (5) Free vastus lateralis muscle flap and skin grafting The viability of these flaps was good except for one of the five patients with pectoralis major-rectus abdominis muscle. One of the patients from the free vastus lateralis muscle group died of heart failure 6 weeks after surgery, but the coverage of sternal wound was successful. No recurrent sternal infection was found. For coverage of sternal wounds, the transferred tissue must have optimal blood supply in order to overcome the infection. According to the descending degree of ease, the ladder of reconstruction is from (1) to (5), depending on the relative length of the sternal wound and the arc of rotation of these flaps. In pectoralis major with rectus abdominis flap group, it is suggested that the upper sternal wound be covered with pectoralis major muscle but lower third sternal wounds with omentum instead of rectus abdominis muscle.

Versatility of the Free Vastus Lateralis Muscle Flap

A flap that carries sufficient tissue with satisfactory pedicle length or diameter and with minor donor site morbidity is an ideal option for the reconstructive surgeon. Many flaps have been described with each one having specific advantages. The vastus lateralis (VL)-muscle flap is among them, but no special attention has been given to its valuable use. To evaluate and to propagate the versatility of the free VL-muscle flap, this flap was used in different pathology and in different anatomic areas. Twenty-three patients with various defects after trauma and cancer therapy underwent reconstruction with 24 free VL-muscle flaps. The flap provided excellent reconstruction in all cases. All flaps were successful. Secondary operations included two debulking procedures, respectively, and one regrafting of parts of the flap because of partial skin graft loss. The donor site morbidity was minimal and no patient suffered from permanent partial limb dysfunction. The free VL-muscle flap is a versatile flap that offers specific advantages such as constant anatomy, ease of dissection in supine position, long pedicle length, large vessel diameter, good esthetic outcome, and minor donor site morbidity. This flap has proven to be most valuable also in difficult cases, including head and neck and lower limb reconstruction.

Beauty of skin-grafted free muscle flaps in head and neck reconstruction

In the era of perforator flaps, muscle flaps might seem "out of fashion" for use in microvascular reconstructions. In this presentation, the advantages of pure muscle flaps covered with full-thickness (FTSG) or split-thickness (STSG) skin grafts employed in certain head and neck reconstructions shall be demonstrated. The free vastus lateralis muscle flap (n = 13) and latissimus dorsi flap (n = 1), covered with either FTSG (n = 8) or STSG (n = 6), were used for major head and neck reconstructions in a total of 13 patients. There was no revision, no partial flap necrosis, and no flap loss. All skin grafts healed in. After initial swelling, all flaps developed an adequate form according to the respective skin level, with adequate texture and color match. This was especially the case when FTSG was used. No cosmetic corrections were necessary. Donor-site morbidity was negligible. In conclusion, a free muscle flap covered with FTSG is a safe and fast reconstruction that provides good cosmetic and functional results, combined with negligible donor-site morbidity.

Use of the Extended-Pedicle Vastus Lateralis Free Flap for Lower Extremity Reconstruction

Soft-tissue coverage in the lower extremity usually requires a flap with a long pedicle, low donor-site morbidity, and versatility in terms of shape and volume. The extended-pedicle free vastus lateralis muscle flap has previously been described for head and neck cancer, and it fulfills these requirements. Twelve patients with lower extremity defects underwent reconstruction with an ipsilateral free vastus lateralis muscle flap. The flap included a segment of the distalmost part of the muscle, distal to the entry point of the motor nerve to the vastus lateralis, based on the descending branch of the lateral femoral circumflex vessels. Up to 20 cm of vascular pedicle with a large caliber was obtained. In three cases, a combined distal vastus lateralis and anterolateral thigh flap was used as a chimeric flap. All flaps were successful. Infection developed in two cases and required flap reelevation and new wound debridement. There was no substantial subjective donor-site morbidity. Elevation of the flap can be performed with the patient in the supine position and is extremely fast and straightforward, without the added difficulty of anatomical variation or extensive intramuscular vascular dissection. The pedicle is long and of large caliber. Although the series is short, the authors conclude that this is a useful free flap for lower extremity reconstruction.

Free Vastus Lateralis Muscle Flap in Lower Extremity Reconstruction: Clinical Experiences

Free-tissue transfers have become an accepted new method of treatments in reconstruction of the lower extremity since 1972. This treatment option has profoundly influenced the fate of many salvaged limbs that in retrospect would have been amputated. From Dec 2001 to Jul 2003, seven patients with defects over the lower extremity underwent reconstructions using a free vastus lateralis muscle flap. There were six males and one female with an average age of 58.1 years (range 48 to 66 years). All flaps except one were successful without major complications. The average follow-up was 9 months (range 6 to 12 months). The six patients with established wound complications experienced complete resolution of their ability. Limb salvage was achieved in these six patients and their ambulation was restored. In comparison with other muscle flaps, we found the vastus lateralis muscle flap is an excellent option for lower extremity reconstruction due to its advantages of ease in harvesting, allowing two-team approach, relatively long vascular pedicle as well as availability of adequate muscle volume and lower donor-site morbidity. Also, preoperative angiographic or Doppler confirmation is valuable to decrease flap complication.

Use of the free vastus lateralis flap in skull base reconstruction.

Free flaps in skull base reconstruction are indicated for providing an effective separation of the intracranial cavity from the oronasal space, for eliminating a dead space, and for the treatment of established wound complications such as dural exposures and cerebrospinal fluid leaks. Seven patients with cranial base defects underwent reconstructions using a free vastus lateralis muscle flap. In two cases, a vastus lateralis flap was raised to incorporate the anterolateral thigh skin as a myocutaneous flap. In four cases, a free flap was indicated for reconstruction following tumor ablation, and in three cases, for the resolution of wound or cerebrospinal fluid leak complications following previous cranial base surgery. All flaps were successful, with no partial failures. In those patients undergoing tumor ablative surgery, the cranial cavity was effectively sealed from the oronasal cavity. Patients with established wound complications following previous cranial base surgery had a complete resolution of their symptoms. This report discusses the suitability of the vastus lateralis flap for skull base reconstruction in terms of the availability of adequate muscle volume to fill dead space, vascularized fascia to augment dural repairs, and the freedom to use skin if required for internal lining or external skin cover. This flap also provides an extremely long pedicle, allows simultaneous flap harvest, and has low donor site morbidity.

Microvascular vastus lateralis muscle flap for chronic empyema associated with a large cavity

Thoracic empyema can be disabling and may need microvascular free flaps in some intractable cases. After repeated failure of conventional thoracic surgical procedures, 2 patients with empyema were treated with microvascular free vastus lateralis muscle flaps for obliteration of the large empyema cavity. The reconstruction was successful in wound closure and eradication of infection. The donor site morbidity was minimal, and the patients resumed normal daily activities. Microvascular vastus lateralis muscle flap is the best option if free flaps are required for reconstruction of empyema.