Lateral Femoral Circumflex Vessels Research Articles

An anterolateral thigh free flap for reconstruction of extensive neck defect in diabetic patient: a case report

Introduction: Reconstruction of the head and neck has challenges due to its three-dimensional structure, tissue complexity, extent of the defect, and clinical scenarios. Advances in microsurgical techniques make free tissue transfer reconstruction a popular choice to address these issues. Anterolateral thigh perforator flap (ALT) is a workhorse flap for head and neck reconstruction due to its long and reliable pedicle, large volume, versatility in composition, and low donor morbidity. However, diabetes mellitus may contribute to developing postoperative complications, such as vascular occlusions and thrombosis, that endanger free flap survival and are associated with poor wound healing. This case report demonstrates the successful utilization of this approach in the closure of extensive neck defects in a diabetic patient. Case Presentation: A 56-year-old male was referred with a 21 cm x 15 cm defect following an odontogenic submandibular abscess. The flaw was extended from the intrabuccal, neck, and one-third of the upper anterior thorax, involving the skin, subcutaneous tissue, and exposed mandibular bone. The patient had previously uncontrolled diabetes mellitus. Surgical debridement, antibiotics, insulin for glucose control, and wound bed preparation were performed. A free fasciocutaneous ALT flap was used for defect closure. The flap was raised template-based, sized 24 × 15 cm, with a pedicle from the descending branch of a lateral circumflex femoral vessel. End-to-end anastomosis of one artery and vein of the superior thyroid vessel was performed. The donor site was closed using a split-thickness skin graft. The surgery and recovery were uneventful. Flap refinement was carried out one month later. The patient underwent a three-month follow-up period, expressing satisfaction with the aesthetic and functional outcomes. Conclusions: Anterolateral thigh perforator flap (ALT) is a workhorse flap for reconstruction of head and neck reconstruction due to its long and reliable pedicle, large tissue volume with various compositions, and low donor morbidity. The LD flap presents as an alternative for free tissue transfer. Regional pedicled flaps can be chosen where microsurgery is not available or suitable. However, vascular compromise and flap failure remain a challenge. Identifying and managing risk factors such as diabetes mellitus are needed to minimize significant complications.

Free Tissue Transfer to the Knee for a Complex Wound Coverage When Good Recipient Vessels Are Not Available

Free tissue transfer to the knee can be difficult due to limited options for reliable recipient vessels and vein grafts or arteriovenous loops may also be associated with an increased risk of flap failure. In this study, the authors describe our experience with creating proper recipient vessels for free flap reconstructions around the knee using the descending branch (DB) of the lateral circumflex femoral vessels (LCFV) or anterior tibial vessels (ATV). Three patients underwent free flap reconstruction of knee wounds secondary to trauma, prosthesis infection, and radiation therapy. The anterolateral thigh, rectus abdominis, and latissimus dorsi flaps were used to close the wounds, respectively. Dissection of the DB of LCFV was carried between the rectus femoris and vastus lateralis, and between the peroneus longus and brevis for the ATV. These recipient's vessels were created and placed in a more desirable location adjacent to the defect for microvascular anastomoses. The DB of LCFV and ATV were dissected successfully and both arterial and venous micro-anastomose were performed in an end-to-end manner with the recipient's vessels. All patients had successful free tissue reconstructions with uneventful postoperative courses. The flaps remained viable and reliable soft tissue coverage with acceptable contour had been accomplished during follow-up. Either DB of LCFV or ATV can serve as adequate recipient vessels after being placed adjacently to soft tissue defects for a straightforward free tissue transfer to the knee. The creation of such recipient vessels avoids vein grafts or arteriovenous loops and allows for a reliable free flap reconstruction of the knee.

Usefulness of Interposition Arteriovenous Bundle Grafts in Free Flap Surgery: A Case Series and Systematic Review.

The paucity of reliable recipient vessels adjacent to defects poses a great challenge in free flap reconstruction. Although the use of interposition vein grafts to cover the vascular gap is common, its potential association with higher risks of flap compromise is often reported. Interposition arteriovenous bundle grafts have been introduced as an alternative. This study aimed to evaluate the outcomes of free tissue transfer using interposition arteriovenous bundle grafts and to conduct a systematic review of studies that reported the use of the technique. Patients who underwent free tissue transfer using the interposition arteriovenous bundle graft technique were assessed for flap perfusion-related complications. A systematic review of literature was performed using pooled analysis to calculate the rate of perfusion-related complications. Overall, 14 cases of free flap reconstruction used the interposition arteriovenous bundle graft technique to cover vascular gaps in diverse regions. The most common donor vessel of this graft was the descending branch of the lateral circumflex femoral vessels (mean length, 6.9 cm). All flaps survived except for 1 case of partial flap loss, showing a flap compromise rate of 7.1%. A systematic review identified 13 studies that represented 78 cases using this technique. In the pooled analysis, including the current series, the overall flap survival rate was 95.7%, reporting 4 of 92 cases of flap compromise. The interposition arteriovenous bundle graft technique may help overcome the challenges of pedicle shortage or lack of adjacent recipient vessels in free flap reconstruction.

In situ pedicle lengthening and perforator shifting technique for overcoming the perforator variation of the anterolateral thigh free flap during head and neck reconstruction.

Anterolateral thigh (ALT) free flap is one of the most popular options for surgeons when reconstructing head and neck defects. When the recipient vessels are located in a remote site, a flap with adequate pedicle length is essential. The conventional methods of either pedicle elongation or fabricating combined flap increase the total surgical time. We present the experience on the use of what in situ pedicle lengthening and perforator shifting technique to overcome these problems. Fifteen patients with an age range of 38-65 years underwent in situ vascular transposition microsurgery of the ALT free flap harvest during head and neck reconstruction. Fourteen patients were male and one was female. Indications for reconstruction were malignant neoplasm in 14 patients and osteoradionecrosis in one patient. In this series, the descending branch of the lateral circumflex femoral vessels was used for interposition grafts. If the pedicle length was insufficient, the interposition grafts were used to lengthen the pedicle. The interposition grafts could also bridge different perforasomes in the thigh region in complex head and neck reconstruction. Of the 15 patients, 11 received the in situ pedicle lengthening technique, while four patients received in situ fabricated combined techniques. After surgery, all of the patients were followed up for at least 3months. Two partial wounds involving poor healing occurred but finally healed after debridement. There were two major complications: one case involved venous thrombosis of the anastomosis and the other suffered from hematoma. Both cases were salvaged. All of the 15 free ALT flaps were successful. The alternative method employed in this series was able to solve the ALT flap perforator variation. Although the enrolled cases were confined to only head and neck reconstruction in the series, the in situ technique of the ALT flaps could be administered during reconstruction in other regions.

Reversed vascular pattern of descending branch of the lateral circumflex femoral vessel: an unreported entity

Reversed vascular pattern of descending branch of the lateral circumflex femoral vessel: an unreported entity

Extending the Reach of Craniofacial Free Flaps Using the Descending Branch of the Lateral Circumflex Femoral Vessels.

Craniofacial free tissue transfer is sometimes complicated by insufficient pedicle length and/or paucity of recipient vessels. A saphenous vein graft can be used to reach the high-flow, large-caliber vessels of the neck, but because of the vein's taper and thick wall, there is often a mismatch. Following the principle of like-for-like, the authors prefer the descending branch of the lateral circumflex femoral vessels to achieve a more anatomical pedicle extension for free tissue transfer in complex craniofacial reconstruction. The authors' experience using the descending branch of the lateral circumflex femoral pedicle extender from 2010 to 2019 was reviewed. Indications, patient characteristics, reconstruction site, flap type, pedicle length, recipient vessels, and vascular complications were noted. The authors reviewed two strategies for implementation of the pedicle extender: in some cases, the flap was first transferred and allowed to perfuse on the descending branch of the lateral circumflex femoral vessels in the thigh, and then transferred to the recipient vessels (double-ischemia transfer); and in other cases, the flap and pedicle extender were transferred such that the flap underwent a single period of ischemia (single-ischemia transfer). The descending branch of the lateral circumflex femoral pedicle extender was used in 17 craniofacial cases. Indications included tumor, trauma, osteoradionecrosis, and congenital. Double-ischemia transfer was used in eight cases and single-ischemia transfer in nine. The longest pedicle extender in the series was 15 cm. Arterial thrombosis occurred in one case. This case series demonstrates that the descending branch of the lateral circumflex femoral pedicle extender is a viable option for complex craniofacial free tissue transfer cases. It provides ample length and excellent vessel match, following the like-for-like principle. Therapeutic, IV.

Pedicled ipsilateral anterolateral thigh (ALT) with flow‐through to a secondary contralateral‐free ALT flap for coverage of large thigh, trochanteric, and gluteal area defects: A case report

Reconstruction of the trochanteric area can be difficult in extensive defects postsarcoma resection. It requires a robust flap. In reconstructing the upper thigh, trochanteric, and gluteal area, a pedicled anterolateral thigh (ALT) flap is a good option. If the defect extends further than the pivot point of a single pedicled ALT, this can be used a flow-through for a secondary free flap. Here we describe a case of a 66-year-old gentleman with a 25 cm × 15 cm defect in the trochanteric and gluteal area where a single pedicled ALT was insufficient for coverage and hence a second ALT from the contralateral leg is anastomosed to the distal runoff of the descending branch of the lateral circumflex femoral vessel of the pedicled ALT, using it as the flow-through donor vessel. This method requires less time if a second free flap is required and a smaller range of dissection, and it also facilitates anastomosis, as the vessel can be brought to the surface for anastomosis while supine before inset. The patient healed with no complications and received radiotherapy to the area. On 1-year follow-up, the area has healed well despite some contraction secondary to the radiotherapy. Using the pedicled ALT as a flow-through for a second free flap is a useful adjunct to large defects in the gluteal and trochanteric area, which is a difficult area to reconstruct with limited donor vessels.

Anatomical Study of the Descending Branch of the Lateral Femoral Circumflex Artery and Veins in Vascular Grafting in Japanese Cadavers.

Background:In microsurgery development, autologous vein grafting is necessary when there are no suitable blood vessels for anastomosis around the flap recipient site or when the vascular pedicle of the flap is short. The descending branches of the lateral femoral circumflex artery (LFCA) and vein have been used as a vascular bundle instead of vein grafts, but to our knowledge, there have been no reports on the relationship between thigh length and vessel length. In this study, we performed a macroscopic examination of the LFCA descending branch length required for grafting.Methods:The length of the LFCA descending branches and veins as well as thigh length were measured in 16 preserved cadaveric legs.Results:The average length of the thigh was 42.6 cm. It was possible to harvest a mean length of 14.2 cm of the descending branches of the lateral femoral circumflex vessels. Descending branches of the LFCA and veins were identified in all cases. It was estimated that the length of the LFCA descending branch and veins could be collected in 20% of the thigh length in 98% of cases.Conclusion:When preparing a preoperative plan, it is important to thoroughly consider the required length of blood vessels for grafting and whether it is possible to harvest vessels with sufficient length.

The extended latissimus dorsi–serratus anterior chimeric local free flap for salvage of the complicated posterolateral thoractomy incision

BackgroundComposite chest wall reconstruction, following the assurance of chest wall stability, often requires well-vascularized soft tissue coverage with flaps to insure adequate wound healing. Unfortunately, prior surgical approaches such as the posterolateral thoractomy incision or extensive wound breakdown may impede the availability of local or regional choices. A free flap would then be a reasonable option, but in the unstable patient a new donor site is unreasonable. Instead, the otherwise inadequate muscle remnants often transected by the usual thoracotomy incision can be extended by microvascular grafts to provide the necessary reach to the defect. MethodThe ipsilateral cephalic latissimus dorsi and/or serratus anterior muscle remnants following their transection by a posterolateral thoractomy incision can be simultaneously raised as a chimeric flap pedicled in common by the thoracodorsal vessels. The distance the pedicle must be extended to reach the defect requiring coverage is measured, and a vascular graft from the descending branch of the lateral circumflex femoral vessels of the same length is harvested. The thoracodorsal vessels are divided, the vascular graft inserted and anastomosed end-to-end to the cut ends of the former, and then the flap can be stretched the required distance for insetting. ResultA case example of use of the ipsilateral latissimus dorsi–serratus anterior muscle remnants used after extension with arterial and venous grafts to the thoracodorsal vessels as the recipient site is presented with successful salvage of a life-threatening posteriolateral thoractomy wound dehiscence. ConclusionTransection of muscles from a posterolateral thoracotomy incision does not preclude their use as flaps in extenuating circumstances. Their pedicle can be extended using vascular grafts and microvascular techniques in a sense to create a local free flap to provide another solution to a challenging problem.

Clinical effect of free anterolateral thigh flap in repairing large annular soft tissue defect of lower leg after burn

Objective: To explore the clinical effect of free anterolateral thigh flap in repairing large annular soft tissue defect of lower leg after burn. Methods: From January 2014 to December 2018, 9 patients with large annular soft tissue defects of lower legs after burns were hospitalized in Zhengzhou First People's Hospital, including 1 case with wounds on both legs. After debridement, area of wounds was 16 cm×11 cm-38 cm×21 cm, and the burn wounds were repaired with free anterolateral thigh flaps in the area of 18 cm×12 cm-32 cm×24 cm. End-to-end anastomosis of posterior tibial vessels or anterior tibial vessels with lateral circumflex femoral vessels was performed in manual way or by microvascular stapler. For the affected legs without condition for anastomosis, the sound medial lower leg flaps with areas of 10 cm×8 cm-15 cm×10 cm were excised and made into skin tubes, the posterior tibial vessels of the flaps were anastomosed with the vessels of free anterolateral femoral flaps, and the wounds of the injured lower legs were repaired by bridge-type cross-over free transplantation of anterolateral thigh flaps. The pedicles were broken 4 to 5 weeks later. The donor site was transplanted with autologous intermediate split-thickness skin graft from thigh. The outcome of the treatment, the number of perforators included in the flaps, and the anastomotic vessel in the recipient area of patients were recorded. The anastomosis time between manual way and microvascular staplers was recorded and compared. The patency of blood vessels, methods of free transplantation, and follow-up condition were recorded. Data were processed with Wilcoxon rank sum test for two independent samples. Results: All the 10 free flaps and skin grafts of 9 patients survived, and all the wounds were closed by primary operation. Seven flaps contained two perforators each, and three flaps contained three perforators each. The anastomotic vessels were posterior tibial vessels in 6 recipient areas and anterior tibial vessels in 4 recipient areas. Microvascular stapler was used to anastomose 12 veins, while 8 veins and 10 arteries were anstomosed manually. The time consumed by the former method was 4.00 (3.55, 4.38) min, significantly shorter than 12.80 (12.13, 13.40) min of the latter (W=78.00, P<0.01). The patency rates of veins and arteries were 100%. There was no vascular crisis due to vascular anastomosis. Three patients underwent bridge-type cross-over free transplantation, while the others underwent conventional free transplantation. Follow-up for 3 to 30 months showed that the donor site of the thigh had good motor function, without numbness or pain, but hypertrophy of scar could be seen. Four patients had slightly overstaffed flaps transplanted in the recipient area of the lower legs, while the other patients were satisfied with their appearance, and the walking function of the affected limbs gradually recovered. Conclusions: Free anterolateral thigh flap transplantation is a safe and reliable clinical limb salvage method for the repair of large annular soft tissue defect of lower leg after burn. Intraoperative application of microvascular stapler for venous anastomosis can shorten the time of vascular anastomosis and has great clinical application value.

Anatomy of the pedicled anterolateral thigh flap for phalloplasty in transitioning-males.

Incidence of transexualism and request for neophalloplasty is increasing yielding a current prevalence of trans-male in the USA of 1:2500. Surgeons have explored various techniques to improve desirable outcomes of neophallic construction, decrease the length of surgery, and minimize stigmatizing scars. The anterolateral thigh (ALT) flap is an alternative to the traditional radial forearm flap for patients who do not want a forearm scar. Surgical text descriptions were enhanced by the creation of new anatomic illustrations. Anatomy of the donor and recipient sites as well as the surgical technique leading to creation of the neophallus are demonstrated in detail with new relevant illustrations. The ALT flap is a skin, fat and fascia flap that is usually supplied by the descending branch of the lateral circumflex femoral vessels and the lateral femoral cutaneous nerve. However, variability in neurovascular supply does exist with important clinical implications. In the pedicled surgical procedure, neurovascular supply is left partly attached to the donor site ("pedicle") and simply transposed to the perineum, keeping the pedicle intact as a conduit to supply the tissue with blood and innervation. ALT flap offers clinical advantages of less obvious donor site concealable with clothing, decreased surgical time, preservation of erogenous sensation and vascular supply of the flap without microsurgical anastomosis of nerves and vessels, and good potential for urethroplasty. This surgery may be difficult in patients with thicker skin and more subcutaneous thigh fat. Clin. Anat, 2017. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.

Anatomy on chimeric flaps of lateral circumflex femoral vessel and application for the reconstruction of complex oral and maxillofacial defects

Objective To discuss the anatomic basis for design of chimeric flaps pedicled with lateral circumflex femoral vessel and to evaluate the feasibility of the chimeric flaps for the reconstruction of complex oral and maxillofacial defects.Methods Sixty-six patients who underwent oral and maxillofacial malignant tumor resection and reconstruction with the flaps pedicled with lateral circumflex femoral vessel from October,2008 to April,2009 in the Second Xiangya Hospital were selected as the subjects.The distribution,number,type and origin of cutaneous perforators arising from lateral circumflex femoral vessel in the anterior thigh region were explored by anatomic observation.A retrospective review was performed of 29 patients who underwent reconstruction of through-and-through oral and maxillofacial defects with chimeric flaps pedicled with lateral circumflex femoral vessel from October 2008 to October2011.The chimeric flaps were harvested to reconstruct through-and-through cheek defects in 26 cases,through-and-through defects from floor of the mouth to mental region in 2 cases,through-and-through defects of basis nasi in 1 case.Results In the 66 cases,333 cutaneous perforators originating from the lateral circumflex femoral vessel were present in the anterior thigh region (5.0 perforators per case on average; range,1 to 9).And 282 cutaneous perforators were present in the anterolateral thigh region (4.3 perforators per case on average; range,1 to 8).78.7％ of cutaneous perforators in the anterolateral thigh region derived from the descending branch of the lateral circumflex femoral artery (LCFA),19.9％ derived from the transverse branch of the LCFA,1.4％ derived from the ascending branch of the LCFA.Further,most perforators (85.5％) in the anterolateral thigh region were musculocutaneous perforators; the rest (14.5％) were septocutaneous perforators.In addition,38 cases of patients had cutaneous perforators deriving from the lateral circumflex femoral vessel in the anteromedial thigh region.Postoperatively,28 of 29 cases of chimeric flaps survived completely,providing a success rate of 96.6 percent.All patients were followed for approximately 6 to 36 months,and they were satisfied with the esthetic and functional results of the donor and recipient sites after the reconstruction.Conclusion With the convenient design of the flaps,chimeric flaps pedicled with lateral circumflex femoral vessel are suitable for the reconstruction of complex oral and maxillofacial defects. Key words: Oral and maxillofacial region; Lateral circumflex femoral vessel; Chimeric flap; Microsurgical operation

Using the Descending Branch of the Lateral Circumflex Femoral Artery and Vein as Recipient Vessel for Free Tissue Transfer to the Difficult Areas of the Lower Extremity

Free tissue transfer to the areas around the knee or hip can be difficult because there are limited options for reliable recipient vessels, but extended vein grafts may decrease the chance for success. The purpose of this study was to describe our experience with creating a proper recipient vessel for free flap reconstructions in these areas using the descending branch of the lateral circumflex femoral vessels in the thigh. Two patients underwent free flap reconstruction of a complex knee wound after orthopedic trauma and a complex hip wound after arthroplasty. A contralateral anterior lateral thigh perforator flap and a latissimus dorsi flap were used to close the wounds, respectively. Dissection was carried between the rectus femoris and vastus lateralis and a recipient vessel was created and placed in more desirable location adjacent to the defect for microvascular anastomoses. A long 12-cm recipient vessel measuring 1.5 to 2.5 cm in diameter for both artery and vein was dissected and placed in an area adjacent to the defect for a straightforward microvascular microanastomosis. Both patients had successful free tissue reconstructions with uneventful postoperative recoveries. The flaps remained viable and the wounds healed with follow-up, revealing reliable soft tissue and good contour in the reconstructed areas. The descending branch of the lateral circumflex femoral vessels can be dissected out and serve as a recipient vessel after being placed adjacent to the defect for free tissue transfer to the difficult areas of the lower extremity. Creation of such a recipient vessel would avoid using vein grafts and ease free flap reconstruction to those difficult reconstructive areas.

Columella Lengthening by a Vascularized Preauricular Flap

A short columella can result in significant cosmetic and functional deformities. Various techniques such as local flap transfer and composite grafts have been reported for columellar lengthening, but the overall results remain unsatisfactory. Transferring a local flap cannot provide new tissue for the columella, which limits its application. Composite grafting can provide new tissue volume, and the composite tissue from the preauricular region has an excellent color and texture match. However, the lack of a stable blood supply for the composite graft restricts its clinical application due to problems such as viability, dimensions, and atrophy. To overcome these limitations, the authors harvested a vascularized preauricular flap for columella lengthening. Based on the superficial temporal vessels, the vascularized preauricular flap was harvested as a free flap and transferred to the columella region. The recipient vessels were angular vessels or facial vessels, and microsurgical anastomosis was performed between recipient vessels and the pedicle. The lateral femoral circumflex vessels were used as vascular grafts when the pedicle was not long enough. Eight patients who had short columellas were reconstructed with vascularized preauricular flaps. Six flaps were harvested in a reverse fashion, and the remaining two flaps were harvested in an anterograde direction. All the flaps survived well and showed a good color and texture match without hypertrophic scars. An average of 13.3mm improvement in length was obtained for the eight patients. Two patients underwent a secondary debulking procedure to thin the flap. The free vascularized preauricular flap procedure is a reliable method for columellar lengthening and has wide clinical application. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Clinical Course of Reverse-flow Anterolateral Thigh Flap: Need to Prepare for Venous Congestion and Salvage Operation

The Clinical Course of Reverse-flow Anterolateral Thigh Flap: Need to Prepare for Venous Congestion and Salvage Operation

Repair of Severe Composite Tissue Defects in the Lower Leg Using Two Different Cross-Leg Free Composite Tissue Flaps

This article reports 2 cross-leg free composite tissue flaps for repairing the severe composite tissue defects in lower leg without suitable adjacent recipient vasculature for microvascular anastomosis. The osseous myocutaneous flap of ilium and tensor fascia lata pedicled with ascending branch of lateral femoral circumflex vessels and the osseous muscle flap of scapula and latissimus dorsi pedicled with subscapular vessels were performed, respectively, to reconstruct the bone and soft-tissue defects in the lower leg of 2 patients. Both donor vessels were the posterior tibial artery and great saphenous vein from the contralateral lower leg. The legs and the bone flaps were immobilized by an external fixator. The periods of pedicle division were 43 and 67 days, respectively, after transplantation. Both flaps survived after pedicle division and the patients regained the ability to walk. There were no such complications as joint stiffness or donor site morbidity except for a linear scar. The 2 cross-leg free composite tissue flaps were optional methods for salvaging limbs that were otherwise nonreconstructable. But the indication for cross-leg free-tissue flap should be limited strictly.

Breast Reconstruction Using the Lateral Femoral Circumflex Artery Perforator Flap

The development of microsurgical breast reconstruction has resulted in not only the lower abdomen as a source of donor site tissue but also interest in alternative donor sites. These have included perforator-based flaps at the sites of previously described myocutaneous flaps (e.g., superior or inferior gluteal arteries) and the use of myocutaneous flaps not previously used for breast reconstruction (e.g., gracilis or transverse upper gracilis). We present our experience with a unique form of the tensor fascia lata flap and describe the first reported use of the lateral femoral circumflex artery (LFCA) perforator flap for breast reconstruction. A patient with minimal abdominal fat but lipodystrophy of the upper lateral thighs presented for breast reconstruction. Perforator flaps based on the lateral femoral circumflex vessels were designed. The LFCA perforator flap from one side was successfully used for breast reconstruction. The flap on the contralateral side did not have a suitable perforator. The LFCA perforator flap offers another option for women seeking autogenous breast reconstruction. Advances in preoperative imaging will likely make this a more reliable option.

Repair the complex defect of lateral side of ankle with free anterolateral thigh musculocutaneous flap

Objective To explore the long-time clinical results and effection of free anterolateral thigh musculocutaneous flap for repairing the complex defects involving lateral or medial malleolar of the ankle and heel,especially for reconstructing stability of the ankle joints. Methods Thirteen patients with complex tissue defects,involving lateral or medial malleolar of the ankle and heel,were treated by free anterolateral thigh fasciomusculocutaneous flap.The fascia lata which was involved in the flap was fixed with the adjacent tissue of the recipient area.The descending branches of the lateral circumflex femoral vessels were anastomosed with the vessels in the recipient area.The largest area of the flap was 20 cm × 12 cm.The ankle joint was fixed in functional position with plaster in the early 3 months post-operatively.The following time ranged from 1.5 years to 20 years.The stability of the ankle joint were evatuated with the patients' objective feeling and clinical symptoms and imaging study.Results The stability of the ankle should be protected by external fixation in the early 3 months postoperatively,and was restored at 6 months usually.In all cases,ten cases were followed over 10 years,six cases were followed over 6 years,three cases were followed over 15 years.Though radiological discovering suggesting traumatic esteoarthritis exited in 3 cases with a follow-up more than 5 years,the clinical manifestations were fair and no one need undergo arthredesis. Conclusion Using ant erolateral thigh musculocutaneous flap for reconstructing the complex defects involving lateral or medial malleolar of the ankle and heel repairing stability of the joint and ovoiding off early arthrodosis of the joint is one of the favorable choice,especially for the teen-agers. Key words: Foot; Ankle; Ankle joint; Anterolateral thigh musculocutaneous flap; Microsurgical operation

Reconstruction of Complex Ankle Joint Defects Using a Composite Free Anterolateral Thigh Musculocutaneous Flap with Vascularized Fascia Lata: A 20-Year Follow-Up

Sir: The reconstruction of complicated composite defects around the ankle is always a challenge for the plastic surgeon. With recent advances in microsurgical techniques, the free anterolateral thigh flap has emerged as one of the major resources for lower extremity salvage.1 We have attempted several techniques and now favor single-stage reconstruction of lower limb defects after open trauma using an anterolateral thigh myocutaneous flap with vascularized fascia lata. We report the case of a 17-year-old boy who sustained a car tire injury to his left foot, resulting in crush avulsion of the soft tissues, talofibular and calcaneofibular ligaments, and peroneus tendons, and partial loss of the fibula and talus. A 20 × 11-cm composite anterolateral thigh musculocutaneous flap including a 10 × 7-cm strip of vascularized fascia lata along with a cuff of vastus lateralis was harvested from the right thigh. The exposed ankle joint where the malleolar sclerotin was lacking was obturated by the vastus lateralis muscle of the flap. The fascial strip was rolled and interwoven to connect the peroneus musculotendinous junction and the lateral ankle ligament. End-to-end microvascular anastomoses were performed between the anterior tibialis vessels and the descending branch of the lateral circumflex femoral vessels. Most of the donor site was closed, and the residual area was covered by a split-thickness skin graft harvested from the opposite thigh (Fig. 1). The patient's postoperative course was uneventful. Two months postoperatively, the patient resumed his daily ambulating without any support, although a slight varus deformity of the left ankle was exhibited on physical examination. Three years postoperatively, the varus deformity had disappeared, and the patient could take part in physical training. Twenty years after the initial procedure, the patient was recontacted, and the function of the left ankle was evaluated by clinical examination. Although there was some loss of ankle activity, the patient did not have any problems with the stability of the joint and was sufficiently competent for his job (Fig. 2).Fig. 1.: A 17-year-old boy sustained a car tire injury to his left foot resulting in extensive crush avulsion (above, left). After débridement, a 20 × 11-cm composite anterolateral thigh musculocutaneous flap including a 10 × 7-cm strip of vascularized fascia lata was used to salvage the foot (above, right and below).Fig. 2.: Follow-up at 20 years revealed a well-contoured foot with acceptable activity of the ankle joint (above) and a narrow joint space with trauma-arthritic changes on the radiographic images (below).The reconstruction of combined defects including a large, deep defect of bone and soft tissue around the ankle is always clinically challenging and technically demanding.2 The use of traditional local flaps for reconstruction is limited, as these flaps only supply coverage of soft-tissue defects rather than preserving the stability and function of ankle joints.3 In contrast, the one-stage reconstruction associated with the anterolateral thigh flap offers many advantages to reconstructive surgeons, such as suitability for a two-team approach, rapid healing, high resistance to infection, and minimal donor-site morbidity.4 We favored the composite anterolateral thigh flap in this case because it meets most reconstructive needs for total ankle reconstruction as described above and has some other special advantages. First, in the case of wound infection, a musculocutaneous flap is safe because well-vascularized muscle tissue under the skin island prevents exposure of the joint and decreases the rate of infection after single-stage reconstruction. Second, in this case, the fascia lata was anchored to the distal and proximal remnants of peroneus muscles, which recovered the integrity and function of the evertors. More importantly, through the application of this composite flap, we successfully restored the ankle stability without arthrodesis, which would probably have resulted in additional postoperative complications for the patient. Twenty years postoperatively, although the radiographic image showed a narrow joint space with trauma-arthritic changes, the patient has achieved acceptable ankle power strength and range of motion (Fig. 2). In conclusion, the composite anterolateral thigh musculocutaneous flap with vascularized fascia lata represents an excellent option for covering complex defects around the ankle joint. The long-term functional and aesthetic results are good. We believe that this flap should be used as an alternative for reconstruction of extensive defects around the ankle. Kai Huang, M.D. Xiao-wen Zhang, M.D. Li-feng Shen, M.D. Qiao-feng Guo, M.D. Chun Zhang, M.D. Department of Orthopedics Tongde Hospital of Zhejiang Province Health Bureau of Zhejiang Province Hangzhou, Zhejiang, People's Republic of China DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Use of the descending branch of the lateral femoral circumflex vessels as a composite interposition graft in lower extremity reconstruction

The prevailing treatment for distal third lower extremity defects is with autologous free tissue transfers. In the trauma patient, these reconstructions are wrought with challenges, including the selection of appropriate recipient vessels, avoiding the zone of injury, and choosing the appropriate flap for transfer, all while maintaining perfusion to the foot. With distal defects and a large zone of injury, the free flap pedicle may need additional length to cover the defect and reach the recipient vessels without excess tension. The creation of an arteriovenous loop from an autologous vein graft is the usual solution. We present a case where additional pedicle length was needed to have a free flap completely cover a distal leg defect and connect to the anterior tibial vessels proximally. The saphenous vein was not available as an interposition graft; therefore, the descending branch of the lateral femoral circumflex artery and venae comitantes were used as a composite arteriovenous interposition graft.