To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects

Mid-term Clinical Outcome of Microvascular Gracilis Muscle Flaps for Defects of the Hand

PURPOSE

Gracilis muscle flaps are useful to cover defects of the hand. However, there are currently no studies describing outcome measurements after covering soft tissue defects using free flaps in the hand.

AIM

To analyze mid-term results of gracilis muscle flap coverage for defects on the hand, with regard to functional and esthetic integrity.

METHODS

16 patients aged 44.3 (range 20-70) years were re-examined after a mean follow-up of 23.6 (range 2-77) months. Mean defect size was 124 (range 52-300) cm2 located palmar (n = 9), dorsal (n = 6), or radial (n = 1). All flaps were performed as microvascular muscle flaps, covered by split thickness skin graft.

RESULTS

Flaps survived in 15 patients. 6 patients required reoperations. Reasons for revisions were venous anastomosis failure with total flap loss (n = 1) requiring a second gracilis muscle flap; necrosis at the tip of the flap (n = 1) with renewed split thickness skin cover. A surplus of the flap (n = 2) required flap thinning and scar corrections were performed in 2 patients. Mean grip strength was 25% (range 33.3-96.4%) compared to the contralateral side and mean patient-reported satisfaction 1.4 (range 1-3) (1 = excellent; 4 = poor).

CONCLUSIONS

Gracilis muscle flaps showed a survival rate of 94%. Patients showed good clinical outcomes with acceptable wrist movements and grip strength as well as high reported satisfaction rates. Compared to fasciocutaneous free flaps, pliability and thinness especially on the palmar aspect of the hand are advantageous. Hence, covering large defects of the hand with a gracilis muscle flap can be a very satisfactory procedure.

LEVEL OF EVIDENCE

IV observational.

The esthetic outcome of recipient sites of gracilis muscle flaps versus anterolateral thigh flaps: A retrospective study

BACKGROUND

Anterolateral thigh (ALT) and gracilis muscle flaps have been described as comparable reconstructive options regarding maximal flap dimension and indications. However, split-thickness skin-grafted muscle flaps are generally believed to be inferior to perforator flaps regarding the esthetic outcome of the recipient site. The purpose of this study was to challenge this assumption, comparing the long-term esthetic outcome of the gracilis and the ALT flap.

METHODS

One hundred forty-eight patients who had undergone free flap reconstruction with either free split-thickness skin-grafted gracilis muscle flaps (n = 86) or ALT flaps (n = 62) were evaluated in the study. Patients' satisfaction with the esthetic outcome, rates of flap loss, wound healing disorders and the necessity for thinning the flap or scar correction procedures were assessed.

RESULTS

Flap loss occurred in 4 of 86 gracilis flaps (4.7%) and 2 of 62 (3.2%) ALT flaps (p > .9999). Thinning or scar correction procedures were necessary for 6 of 86 gracilis (7.0%) and 4 of 62 (6.5%; p > .9999) ALT flap recipient sites. Regarding the overall patients' satisfaction with the esthetic outcome, scores were similar in both groups (2.667 [ALT] vs. 2.348 [gracilis]; p = .3739). Contour deformity, scar hypertrophy, and difference in flap color/texture in relation to the surrounding skin were comparable throughout the ALT and gracilis group (2.667 vs. 2.174, p = .2099; 3.333 vs. 2.739, p = .0912 and 2.500 vs. 2.174, p = .3159, respectively).

CONCLUSION

The gracilis and ALT flap are two equivalent reconstructive options regarding the esthetic outcome of the recipient site and long-term patient satisfaction.

Comparison of The Thickness of Free Anterolateral Thigh Flap in Different Fascial Planes: Clinical Results of Subfascial and Superficial Fat Flap

Background  The anterolateral thigh (ALT) flap is a preferred option in the reconstruction of a wide variety of defects, enabling multiple tissue components and thicknesses. Methods  This study was conducted to investigate the correlation of the thickness of the traditional subfascial ALT flap and superficial fat flap with age, gender, and body mass index (BMI). A total of 42 patients (28 males and 14 females) were included in the study. Results  Mean age was 50.2 (range, 16-75) years and mean BMI was 24.68 ± 4.02 (range, 16.5-34.7) kg/m 2 . The subfascial flap thickness was significantly thinner in male patients (16.07 ± 2.77 mm) than in female patients (24.07 ± 3.93 mm; p  < 0.05), whereas no significant difference was found between male (4.28 ± 1.15 mm) and female patients (4.85 ± 1.09 mm) regarding superficial fat flap thickness ( p  = 0.13). The thickness of both flaps had a positive correlation with BMI, and the strongest correlation was found for subfascial ALT thickness in female patients ( r  = 0.81). Age had no effect on both flap thickness measurements. The anterior thigh is thicker in women than in men, although it varies according to BMI. This shows that flap elevation is important in the superthin plane, especially if a thin flap is desired in female patients in defect reconstruction with the ALT flap. Thus, a single-stage reconstruction is achieved without the need for a defatting procedure after subfascial dissection or a second defatting procedure 3 to 6 months later. Conclusion  The appropriate ALT flap plane should be selected considering the gender and BMI of the patient.

Ultrathin Anterolateral Thigh Free Flap: An Adipocutaneous Flap with the Most Superficial Elevation Plane

BACKGROUND

Although many efforts have been made to create thinner anterolateral thigh (ALT) flaps, their thickness varies among patients, and the flap may be still too thick to match shallow defects. The authors successfully harvested an ALT flap through the most superficial elevation plane, the superficial fat layer, which was useful to match the shallow defects.

METHODS

All patients who underwent ALT free flap reconstruction for upper and lower distal extremity defects were divided retrospectively into groups by ALT flap elevation plane: thin, above the deep fascia; superthin, at the superficial fascia; and ultrathin, through the superficial fat. Preoperative computed tomographic angiography and duplex ultrasonography planning were used for all patients. Anatomical characteristics of donor subcutaneous tissue and surgical details, including flap thickness, flap size, and incidence of flap necrosis were compared among the groups and between sexes.

RESULTS

The average deep and superficial fascial depths were 16.7 and 10.8 mm, 12.5 and 8.2 mm, and 9.1 and 5.6 mm ( P < 0.05), and the average flap thickness was 5.8 mm, 7.9 mm, and 7.8 mm ( P = 0.29) in the ultrathin, superthin, and thin ALT groups, respectively. No significant intergroup differences existed in flap size or complications. The deep and superficial fascia were located significantly deeper in female patients (9.4 and 6.0 mm in male patients and 14.9 and 9.6 mm in female patients, respectively).

CONCLUSIONS

With precise preoperative planning, the most superficially elevated, ultrathin ALT flap can achieve optimal reconstructions of thin body areas. Female patients with thicker thighs and patients with a high body mass index would benefit from this flap.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Single perforator-based anterolateral thigh flap, the workhorse flap, in oral cancer reconstruction: A tertiary care institution experience

Background

Ablative procedures of the oral cavity require composite removal of tissues, which results in compromise of both functional activities and esthetic mutilation and proves to be a reconstructive challenge. This paper focuses on the reliability and versatility of a single perforator-based anterolateral thigh (ALT) flap in oral cancer reconstruction.

Materials and Methods

All patients who underwent reconstruction with a single perforator-based ALT for oral cancer defects at our center were included in the study.

Results

Forty-seven patients who underwent reconstruction with a single perforator-based ALT flap were included in our study. The average flap size in our series was 111 cm2, with the largest measuring 375 cm2. They was a complete loss of flap in two patients; both of them underwent salvage procedure and were reconstructed with pectoralis major myocutaneous flap. One had a partial loss that underwent re-exploration.

Conclusion

We conclude that a single perforator-based ALT is a very safe, reliable, and versatile flap for head and neck reconstruction. The microvascular anastomosis may be expensive and technically a limitation; however, it has found a permanent place in our head and neck reconstructive toolkit and is the workhorse flap for head and neck reconstruction.

Lower Lip Reconstruction Using a Sensory Anterolateral Thigh Flap as the First Choice

Local flaps from the upper lip and cheeks have been the first choice for two-thirds to total resection of the lower lip. However, these local flap techniques involve many clinical problems, including small a mouth, drooling, scarring, and hypesthesia. The improvement of free anterolateral thigh (ALT) flap transfer can solve these problems with expansion of the application of free flaps for lower lip reconstruction. The patient in this case was a 56-year-old man with squamous cell carcinoma of the lower lip (cT3N1M0). Subtotal lower lip resection preserving both corners of the mouth with bilateral neck dissection was performed. Simultaneously, a sensory ALT flap was elevated with an 8 × 6 cm skin island and a lateral femoral cutaneous nerve. The lateral and medial sides of the fascia lata were processed into 1-cm-wide strings, which were tunneled through the orbicularis oris muscle of the upper lip and sutured to the orbicularis oris muscle at the mucosal side of the philtrum. The lateral femoral cutaneous nerve and right mental nerve were sutured. At 3 months, a second surgery was performed to replace the ALT flap on the white labial side with a clavicle full-thickness skin graft. This surgery achieved four important factors: opening and closing of the mouth, sensory function of the lower lip, cosmetic appearance, and minimization of donor-site damage. We believe the worldwide improvement of microsurgery techniques enables lower lip reconstruction using the sensory ALT flap to be selected as the first choice for two-thirds to total lower lip defects.

Evaluation of the predictive value of the body-mass-index choosing perforator flaps from different donor sites

BACKGROUND

Free flap design must fulfill different criteria to ensure functional and aesthetic reconstruction of different types of defects in different body areas. A four-dimensional planning concept was used including flap length, width, thickness and tissue composition. This study evaluates if body-mass-index (BMI) has a predictive value for flap design.

METHODS

A prospective study including hospitalized patients in the Department of Plastic, Aesthetic, Hand and Reconstructive Surgery was conducted. Not taking into account the reason for admission, the patients were examined based on age, weight, height, BMI and sex. The areas of a potential harvest of free fasciocutaneous and perforator flaps were measured using ultrasound examination to determine the thickness of the subcutaneous layers and prove blood perfusion.

RESULTS

Over the period of four months, a total of 101 patients (36 females and 65 males) were included in this study and gave written consent. No statistical significance regarding the demographic data such as age, sex and BMI could be identified. An average to high correlation between free flap thickness and BMI was shown for the thoracodorsal artery perforator (TDAP), anterior lateral thigh (ALT) and deep inferior epigastric perforator (DIEP) flap in both, male and female patients. Free flaps of distal body parts such as the interosseous posterior flap, showed a lower correlation. No correlation using the Pearson coefficient could be found for age and volume.

CONCLUSION

Our study demonstrated that the BMI is a predictive indicator that can be used in the preoperative planning of reconstructions using free flaps. Depending on the defect location, the BMI can be considered to predict the thickness of the free flap and may influence the surgeon's choice. On the other hand, a lower correlation between BMI and flap thickness encourages the use of standard flaps if more volume is desired, as the DIEP flap might be sufficient even in normal-weight women. Flaps of distal body parts, such as the forearm or lower leg, are not prone to such predictions and require other selection criteria.

Planes for Perforator/Skin Flap Elevation-Definition, Classification, and Techniques

BACKGROUND

 Elevation in different layers achieving thin flaps are becoming relatively common practice for perforator flaps. Although postreconstruction debulking achieves pleasing aesthetic results and is widely practiced, customized approach during elevation to achieve the ideal thickness will increase efficiency while achieving the best possible aesthetic outcome. Multiple planes for elevation have been reported along with different techniques but it is quite confusing and may lack correspondence to the innate anatomy of the skin and subcutaneous tissue.

METHODS

 This article reviews the different planes of elevation and aims to clarify the definition and classification in accordance to anatomy and present the pros and cons of elevation based on the different layers and provide technical tips for elevation.

RESULTS

 Five different planes of elevation for perforator flaps are identified: subfascial, suprafacial, superthin, ultrathin, and subdermal (pure skin) layers based on experience, literature, and anatomy.

CONCLUSION

 These planes all have their unique properties and challenges. Understanding the benefits and limits along with the technical aspect will allow the surgeon to better apply the perforator flaps.

Evaluation of anterolateral thigh flap dimensions with virtual flap models

Free flaps are commonly used for head and neck reconstruction. However, flap dimensions are still evaluated by visual and tactile assessment. The aim of this study was to enable preoperative planning of flap dimensions for soft tissue reconstruction based on clinical parameters. Computed tomography records from 230 patients dated from 2009 to 2019 were analysed retrospectively. A virtual, three-dimensional anterolateral thigh flap model was standardized, aligned to segmented leg models in two positions, and flap thicknesses and volumes were determined. Associations of flap thickness and volume with clinical parameters were evaluated, and an approximative calculation method was derived. The laterally positioned anterolateral thigh flap showed an average (interquartile range) thickness of 15.6 mm (8.7 mm) and volume of 1.5 cm³ (0.9 cm³) per cm². The medially positioned anterolateral thigh flap showed an average (interquartile range) thickness of 16.3 mm (8.7 mm) and volume of 1.6 cm³ (0.9 cm³) per cm². For both flap positions, leg circumference was the strongest predictor of flap thickness (β = 0.545, P < 0.001 and β = 0.529, P < 0.001) and flap volume (β = 0.523, P < 0.001 and β = 0.480, P < 0.001). Flap dimensions can be calculated based on leg circumference, and this preoperative planning of flap dimensions can help the surgeon to select the appropriate flap.

The First Dorsal Metacarpal Artery Perforator Free Flap: The Comet Flap

BACKGROUND

Distal extremity defects pose a particular challenge to the reconstructive surgeon, however, advances in perforator flaps have expanded the armamentarium of potential reconstructive options. Herein, we present our experience in reconstructing distal extremity defects using a thin, cutaneous free flap based on the perforator of the first dorsal metacarpal artery - "the Comet flap."

METHODS

A retrospective review was performed on all patients who presented with a distal extremity defect and underwent reconstruction using a Comet flap between 2015 and 2019. Patient demographics, flap anatomy and harvest, and postoperative course were reviewed and analyzed.

RESULTS

A total of sixteen patients were included. The mean patient age was 36.5 years old. Trauma was the most common etiology. The average defect size was 5.4x3.2cm. The average pedicle length of the Comet flap ranged from 3.5 to 30cm, depending on involvement of the radial vessels. All donor sites underwent uncomplicated closure with local rhomboid flaps. One flap was complicated by an acute venous thrombosis that was successfully treated operatively. Flap survival rate was 95%. All patients were able to maintain their preoperative range of motion and were satisfied with their final outcome. Follow-up time ranged from 6 to 50 months.

CONCLUSION

Local flaps remain an important reconstructive approach for distal extremity defects; however, in complex soft tissue injuries, free tissue transfers become necessary. The Comet flap is a safe, versatile, and reliable flap for reconstructing upper and lower extremity defects that can be performed in a single procedure under regional anesthesia.

Preoperative Computed Tomography Angiography for ALT Flaps Optimizes Design and Reduces Operative Time

BACKGROUND

 Computed tomography angiography (CTA) has been widely used for perforator mapping in abdominal-based reconstruction, but it is less widespread in the anterolateral thigh (ALT) flap. However, CTA may be quite useful for ALT planning, as this flap has demonstrated substantial variability in intrapatient bilateral vascular anatomy. This study investigated whether standard use of preoperative CTA resulted in selection of the donor extremity with preferential perforator anatomy, and whether this affected operative time and postoperative outcomes.

METHODS

 A retrospective review of 105 patients who underwent proposed ALT flap reconstruction was performed. Seventy-nine patients received bilateral lower extremity CTAs, which were evaluated for dominant perforator anatomy (septocutaneous, musculoseptocutaneous, or musculocutaneous). Donor extremity selection was noted, and predicted perforator anatomy was compared with that encountered intraoperatively.

RESULTS

 Among the 73 patients who received bilateral imaging and ultimately received an ALT, congruent findings between imaging and surgical exploration were observed in 51 (69.8%) patients. Thirty (37.9%) patients had asymmetric perforator anatomy between their bilateral extremities on imaging. Among these, the leg with optimal perforator anatomy was selected in 70% of cases. There were no significant reductions among postoperative complication rates, but selection of the donor site with preferential anatomy was associated with a decrease in operative time (p = 0.049) among patients undergoing extremity reconstruction.

CONCLUSION

 CTA is a useful tool for optimizing donor site selection for ALT flaps and reducing operative time. We believe that standard use of preoperative CTA in ALTs warrants further consideration.

Comparison of Thigh-Based versus Groin-Based versus Lateral-Thoracic-Based Flaps for Hand Resurfacing: A Review Article

BACKGROUND

Thigh-based, groin-based and lateral-thoracic-based flaps are available for microsurgical hand resurfacing – which is the best?

METHODS

BestBETS methodology was used to systematically evaluate the advantages and disadvantages. PubMed, EMBASE and Cochrane databases were searched up until Sep 2020, using the search strategy: hand re-surfacing, free-flap, groin-flap, thigh-flap, lateral thoracic-flap, advantages, and disadvantages.

RESULTS

Overall, 31 papers were identified which were used to synthesize the discussion and conclusions.

CONCLUSION

Thigh-based anterolateral thigh (ALT) flaps offer the greatest versatility.

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

BACKGROUND

The anterolateral thigh (ALT) perforator flap is well-described and versatile option for reconstruction of soft tissue defects around foot and ankle. This retrospective review was performed for reconstruction of soft tissue defects around foot with ALT perforator flaps in patients with normal and overweight body mass index (BMI).

METHODS

Between January 2016 and November 2020, ALT flaps were used in 30 patients for foot defects.

RESULTS

Etiologic factors were trauma (18 patients), diabetic foot ulcer (6 patients), tumor (3 patients), infection (2 patients) and burn contracture (1 patient). Mean body mass index (BMI) value was 24.9 ± 4.1 (17-30). Mean flap dimension was 145 ± 86 (40-420) cm². Recipient vessels were anterior tibial artery in 17 patients (56%), posterior tibial artery in 12 patients (40%), reversed flow dorsalis pedis artery in 1 patient (3.3%). In 24 patients (80%), 2 vein anastomoses were done. Debulking were applied in two patients (6.6%). Donor area was grafted in four patients (13.3%). Mean flap score was 1.25 ± 0.5. Mean flap thickness was 10 ± 2 (7-14) mm. Visual Analogue Scale (VAS) score was 7.75 ± 1.04 (6-10). The patients were followed up for a mean of 14 ± 11 (1-30) months.

CONCLUSION

We think that ALT flap is still reliable and precious option because it provides ideal soft tissue reconstruction by means of recontouring of foot in nonobese patients.

The external pudendal artery free flap in women: Anatomical study of a novel flap for buccopharyngeal reconstruction

BACKGROUND

Because of the widespread and high reliability of free flaps in head and neck reconstruction, the challenge today is to reduce donor site morbidity. The external pudendal artery (EPA) free flap has been described in men and provides a minimal functional and cosmetic impact. This study aimed to assess the feasibility of the EPA free flap in women for buccopharyngeal reconstruction.

METHODS

A dissection of the inguinal region was performed bilaterally on fresh female cadavers. The anatomy of the EPA and its angiosome were described, along with the design of the EPA free flap. A computed tomography angiographic study of the flap perfusion was performed.

RESULTS

Fourteen cadavers were dissected. The EPA was constant. Its diameter ranged from 1.12 to 2.96 mm (median 2.0 mm). The mean area of its angiosome was 167.3 ± 38.5 cm². An axial fasciocutaneous flap was designed with a horizontal skin paddle measuring on average 9.2 × 6 cm and a pedicle length of 8.4 ± 1.9 cm. The mean flap thickness was 11.7 ± 6.8 mm and depended on individual factors. A primary closure was achieved in all cases with a scar hidden in the underwear.

CONCLUSIONS

This anatomical study demonstrates that the EPA seems constant despite variations in its origin pattern. Its diameter and angiosome allow the design of an EPA free flap in women. A clinical study should confirm that this flap is suitable for the repair of buccopharyngeal defects and could be added to the armamentarium of the head and neck reconstructive surgeon.

Evaluation of the Suprafascial Thin ALT Flap in Foot and Ankle Reconstruction

BACKGROUND

 Distal lower extremity reconstruction can be challenging in terms of flap design. Bulky flaps result in limited mobility accompanied with the need of customized footwear. Raising the ALT-flap in a superficial fascial plane (thin ALT-flap) can be beneficial. This study evaluates thin ALT-flaps for lower distal extremity reconstruction.

METHODS

 In a retrospective study, patients that underwent microvascular extremity reconstruction at the level of the ankle and dorsal foot at the University of Freiburg from 2008-2018 were reviewed.

RESULTS

 95 patients could be included in the study (35 perforator flaps, 8 fascia flaps and 54 muscle flaps).Among the perforator flaps, 21 ALT-flaps were elevated conventionally and 14 in the superficial fascial plane (thin ALT-flap). Among the conventional ALT-flaps, there was one flap loss (5%) and one successful revision (5%). 5(24%) flaps received secondary thinning. 57%(n = 12) were able to wear conventional footwear. There were 2(15%) successful revisions of thin ALT-flaps. 100% of thin ALT-flaps survived and 85%(n = 11) of the patients wore ordinary footwear after defect coverage.Among fascial flaps, 50%(n = 4) had to be revised with 2(25%) complete and 1 (13%) partial flap loss. All patients achieved mobility in ordinary shoes (n = 8).In muscle flaps, there were 7(13%) revisions and 5(9%) flap losses. 5(9%) flaps received secondary thinning. Only 33%(n = 18) were mobile in ordinary footwear.

CONCLUSION

 The thin ALT-flap is a save one-stage evolution for lower distal extremity reconstruction with a favorable flap survival rate. Compared with conventional ALT-flaps it might be beneficial in reducing the need for expensive custom fitted shoes and secondary thinning procedures.

Reconstruction of Soft Tissue Defects in the Hand with a Free Anterolateral Thigh Deep Fascia Flap

OBJECTIVE

To report our experience in the reconstruction of soft tissue defects in the hand with a free anterolateral thigh deep fascia flap and describe the clinical outcomes.

METHODS

This study was a retrospective trial. From November 2016 to January 2020, six patients (four men and two women) with soft tissue defects in the hand were included in this study. The average age of the patients was 33.7 ± 12.7 years (range, 20 to 50 years). All patients underwent reconstructions with free anterolateral thigh deep fascia flaps. Relevant clinical characteristics were recorded prior to surgery. The size and thickness of the deep fascia flap and the thickness of the skin were measured intraoperatively. The survival of the flaps and skin grafts and the occurrence of infection were recorded after the operation. At follow-up, donor site complications and postoperative effects were evaluated according to the outcome satisfaction scale. The pain in the injured hand was assessed using the visual analog scale.

RESULTS

The average body mass index (BMI) was 26.6 ± 1.7 kg/m² (range, 23.9 to 28.7 kg/m² ). The defect sizes ranged from 5 cm × 5 cm to 13 cm × 8 cm (average, 53.1 ± 27.9 cm² ). The six anterolateral thigh deep fascia flaps ranged from 7 cm × 6 cm to 14 cm × 9 cm in size (average, 71.8 ± 29.1 cm² ). The thicknesses of skin ranged from 25 mm to 40 mm (average, 32.5 ± 4.8 mm), and the thicknesses of the deep fascia flaps ranged from 2 mm to 3 mm (average, 2.5 ± 0.5 mm). After the operation, the blood supply of the deep fascia flap was normal in all cases. The second-stage skin grafts of most patients survived completely. The skin graft in one case was partially necrotic and healed after a dressing change. No infection occurred. At follow-up (average, 16.3 ± 6.9 months), there was only a linear scar and no loss of sensation at the donor site of each patient. According to the outcome satisfaction scale, the outcome satisfaction score ranged from 6 to 8 (average, 7.2 ± 0.9), all of which were satisfactory. Apart from one patient who reported mild pain, all the other patients reported no pain. Three typical cases are presented in this article.

CONCLUSIONS

The free anterolateral thigh deep fascia flap, which is suitable for reconstruction of soft tissue defects in the hand, can provide very good outcomes both functionally and aesthetically.

The surgical management of locally advanced well-differentiated thyroid carcinoma: changes over the years according to the AJCC 8th edition Cancer Staging Manual

Background

Well-differentiated thyroid carcinoma is defined as locally advanced in the presence of an extra thyroid extension, e.g., when the surrounding structures such as the trachea, larynx, esophagus and main blood vessels are invaded by cancer. The 8th edition AJCC Cancer Staging Manual states that this is the main characteristic to evaluate for the staging and consequently for the prognosis in patients over 55 years old.

Main body

Distinguishing different forms of locally advanced thyroid cancer is essential, and the various anatomical structures and the clinical and therapeutic consequences must be taken into account. An accurate diagnosis of the organs invaded by thyroid cancer is necessary for the planning of surgical treatment, and both aspects are crucial to improving the patients’ survival. Patients affected by thyroid cancer with extra thyroid extension have a poor prognosis and the removal of the entire neoplasm represents a key factor for better disease-free survival.

Conclusions

We discuss the changes introduced by the 8th edition AJCC Cancer Staging Manual, in terms of the diagnostic and surgical management of extra thyroid extension, in patients affected by papillary and follicular thyroid cancer.

Peripheral Pruning: A Safe Approach to Thinning Extra-Large Anterolateral Thigh Flaps

BACKGROUND

Thinning of anterolateral thigh (ALT) flaps has been described to achieve optimal contouring. Previous studies caution against thinning large flaps owing to the risk of vascular compromise leading to partial or total flap necrosis. This study aims to demonstrate a reliably safe method for thinning extra-large (>240 cm) flaps.

METHODS

A retrospective review of 53 consecutive ALT flaps performed at a single institution was completed. Of these flaps, 18 (34%) were thinned primarily by sharp excision of sub-Scarpa's fat along the periphery of the flap using loupe magnification. A central cuff of fat is left to surround and protect the perforator.

RESULTS

There were 53 total flaps in our series. Eighteen of the flaps were thinned by peripheral pruning. Eleven (61%) of the flaps reconstructed defects of the lower extremity, whereas 4 (22%) reconstructed upper extremity defects and 3 (17%) reconstructed scalp defects (Table 1). The mean size of the thinned flap group was 35% larger than the nonthinned group (n = 18, 261 cm ± 109 cm vs n = 35, 192 cm ± 146 cm). Ten thinned flaps (55%) were extra large, with flap areas over 240 cm. The average amount of excised fat weighed 41 g ± 18 g. The average body mass index in the thinned flap group was 28.8 kg/m, which is classified as overweight. The average body mass index in the nonthinned flap group was 24.6 kg/m, which is classified as normal weight (Table 2). There were no cases of partial flap necrosis in the thinned flap group. A single case of total flap loss occurred in the thinned flap group secondary to hematoma formation during administration of therapeutic heparin for a mechanical heart valve. There were no other complications in the thinned flap group.

CONCLUSIONS

This is the first study to demonstrate a reliable technique for primary thinning of extra-large ALT flaps in the Western population. No complications related to thinning were observed. Peripheral pruning of sub-Scarpa's fat is a safe and reliable method of thinning extra-large ALT flaps without increasing the risk of flap necrosis.

Simultaneous tracheal and esophageal reconstruction for thyroid cancer involving trachea and esophagus using a free bipaddled posterior tibial artery perforator flap

BACKGROUND

Simultaneous tracheal and esophageal reconstruction after tumor resection is a great challenge. Here we present an innovative operative technique to simultaneously reconstruct tracheal and esophageal defects, in which a free posterior tibial artery perforator flap was made into a free bipaddled flap to cover both tracheal and esophageal defects.

METHODS

A free bipaddled posterior tibial artery perforator flap was utilized to conduct simultaneous tracheal and esophageal reconstruction for a 72-year-old female patient with papillary thyroid carcinoma and massive trachea and esophagus invasion, who underwent radical resection.

RESULTS

Satisfactory breathing and swallowing functions were gained independent of nasal feeding and tracheotomy. Voice was still hoarse due to tumor invasion of left recurrent laryngeal nerve. During a period of 2-year follow-up, no sign of tumor recurrence was observed.

CONCLUSION

A free bipaddled posterior tibial artery perforator flap could be a decent choice for simultaneous reconstruction of large tracheal and esophageal defects.

Reconstruction of moderate-sized soft tissue defects in foot and ankle in children: Free deep inferior epigastric artery perforator flap versus circumflex scapular artery perforator flap

BACKGROUND

This retrospective study was conducted to compare the outcomes between the free deep inferior epigastric artery perforator (DIEP) flap and the circumflex scapular artery perforator (CSAP) flap in reconstruction of moderate-sized soft tissue defects in the foot and ankle of pediatric patients.

PATIENTS AND METHODS

From January 2004 to December 2016, 42 patients, ranging from 2 to 13 years old, underwent foot and ankle reconstruction, with a free DIEP flap in 21 cases and a free CSAP flap in the other 21cases.

RESULTS

All the flaps survived. No marked differences were observed in the demographics, flap size, recipient vessels, and overall early or late complication rate (p > 0.05). The CSAP group had a shorter operation time (134.3 ± 25 min vs. 202.4 ± 24.3 min, p < 0.05) and flap harvest time (29.7 ± 8.1 min vs. 52.2 ± 9.8 min, p < 0.05) than the DIEP group had. In long-term follow-up, the CSAP group showed a lower fat hyperplasia rate (14% vs. 52%, p < 0.05) and better cosmetic outcomes than the DIEP group did (p < 0.05). The functional outcomes had no marked differences (p > 0.05).

CONCLUSIONS

The DIEP flap and the CSAP flap are both good options for foot and ankle reconstruction of moderate-sized defects in pediatric patients. The CSAP flap has a shorter operation time and flap harvest time, a lower fat hyperplasia rate, and better long-term cosmetic outcomes than the DIEP flap does.

Aesthetic and Functional Evaluation of Large Full-Thickness Vermilion and Lower Lip Defects Reconstruction

BACKGROUND

It is hardly to reconstruct a huge defect of lower lip by using of partial flap which brings no mouth closing functional problem. In this study, we would like to introduce our experience in large full-thickness vermilion and lower lip/chin defects reconstruction, and also focus on the evaluation of the surgery effects.

METHODS

The large lower lip and chin (include vermilion) reconstruction were performed in Sichuan Provincial People's Hospital (2012-2015). The surgery experience was introduced in this study first. In the following section, after a statement of these basic problems, various situations involving are investigated, such as the surgical effects of aesthetic and function that were evaluated through a visual analogue scale (VAS) by doctors and patients separately. The VAS score assessments of 2 kinds of surgery were collected and compared.

RESULTS

A total of 7 patients use the tongue flap alone. Four patients use the combination of the free forearm flap and the anterior ventral tongue flap (COMBO flap). The VAS score of doctors group was significantly lower than the patients group (P < 0.05), and the aesthetic appearance was excellent (>90 points). Language features were not affected (>90 points). Slight mouth opening problems exist on these patients who were used COMBO flaps (>80 points; <90 points). The drooling and drumming gas problems were not observed. These 11 patients had no recurrence within 12 months after the operation.

CONCLUSION

The 1:1 ratio between upper and lower lip is crucial to the design of anterior ventral tongue flap which brings with an excellent 3-dimensional morphologic and anatomic structure outcome. The bite block might become an essential operation step for vermilion reconstruction by using of tongue flap. And the COMBO flap may enhance the facial aesthetics and oral function for the reconstruction.

Photoacoustic Tomography Shows the Branching Pattern of Anterolateral Thigh Perforators In Vivo

The distal branching pattern of perforators is associated with thin anterolateral thigh flap failure. The purpose of this study was to investigate the feasibility of using photoacoustic tomography as a diagnostic imaging modality to identify anterolateral thigh perforators and their branching patterns in the subcutaneous layer. Ten thighs in five healthy men were studied. The anterolateral aspect of the midthigh was examined using photoacoustic tomography. The correlation between photoacoustic tomography and ultrasound findings was evaluated. To determine the detectability of photoacoustic tomography by depth, the depth of vessels in the stem portion was compared to the depth of the deep fascia measured by ultrasound. Branching patterns of vessels in the adipose and suprafascial layers were evaluated by three-dimensional observation. A total of 18 perforators were visualized by photoacoustic tomography. Photoacoustic tomography and ultrasound had comparable diagnostic potential for the detection of perforators. Photoacoustic tomography visualized microvessels in the subcutaneous layer, especially those in oblique or horizontal orientations. The estimated mean depth of visualized vessels was 9 mm; the maximum depth was 13 mm. There was a strong correlation between the depth of visualized vessels in the stem portion and the depth of the deep fascia. Three-dimensional observation of photoacoustic tomographic images showed the branching morphology of perforators. This study showed the applicability of photoacoustic tomography to identification of the branching patterns of anterolateral thigh perforators in vivo, although limited visualization of subfascial vessels is a technical issue. The authors believe that photoacoustic tomography has the potential to be a new imaging modality for thin anterolateral thigh flap surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, IV.

Distally based anterolateral thigh flap: an underutilized option for peri-patellar wound coverage

Wound coverage in the supra-patellar area presents a significant challenge for orthopaedic and reconstructive surgeons due to the need for preservation of knee joint function but the paucity of regional soft tissue flaps available. While many orthopaedic and reconstructive surgeons make use of the rotational gastrocnemius flap for coverage of peri-patellar defects, this flap has certain limitations. The goal of this study was to report a single-centre experience with the use of the distally based anterolateral thigh flap (ALT) and review the current literature on the use of the ALT for peri-patellar defects. In this report, both a single-centre experience using distally based anterolateral thigh (ALT) island flaps for supra-patellar wound coverage and the existing literature on this topic were reviewed. A systematic literature review was performed to assess the use of the ALT for peri-patellar wounds. Five patients with a mean age of 69 underwent a distally based ALT flap for coverage of peri-patellar defects. Four out of 5 flaps survived at the end of their respective follow-up. Based on this combined experience, the distally based reverse-flow anterolateral thigh island flap represents a useful but relatively underutilized option for appropriately selected supra-patellar wounds due to minimal donor site morbidity, multiple flap components, and predictable pedicle anatomy. The flap’s major weakness is its potentially unreliable venous drainage, requiring delay or secondary venous outflow anastomosis. Given the ALT flap’s favourable profile, the authors recommend consideration for its use when managing a peri-patellar coverage wound issue.

Flap thinning: Defatting after conventional elevation

Perforator flaps become a reliable option for coverage of various defects and the interest is change from survival of perforator flaps to make thin flaps for better aesthetic and functional outcomes. Multiple flap thinning methods have been demonstrated but it has not been widely attempted because of concerns about compromising circulation of flap thinning. This article will demonstrate the feasibility and benefits of flap thinning technique: defatting after conventional flap elevation.

Anatomic basis for flap thinning

Flap thinning is a procedure for making a thick flap thinner. This procedure does more than simply fill in the defected area, and it is better for reconstructing the area both functionally and aesthetically. However, because flap thinning is a rather blind procedure, it may have harmful effects on flap vascularity. Therefore, the vasculature of a flap must be understood before performing flap thinning. This paper analyzes the basic anatomy underlying flap thinning based on the previous anatomic study that categorized flaps into 6 types by their vascular structures. This paper also reviews specific studies of frequently practiced flap procedures (deep inferior epigastric artery perforator flap, thoracodorsal artery perforator flap, and anterolateral thigh flap) and presents important precautions for flap thinning procedures. Finally, this paper briefly examines the axiality of the subdermal plexus, which needs to be taken into account when performing flap thinning.

[The sural medial perforator flap: Anatomical bases, surgical technique and indications in head and neck reconstruction]

INTRODUCTION

The medial sural artery perforator (MSAP) flap is defined as a thin cutaneo-adipose perforator flap harvested on the medial aspect of the leg. The aims of this study were to describe the anatomical basis as well as the surgical technique and discuss the indications in head and neck reconstructive surgery.

MATERIAL AND METHODS

We harvested 10 MSAP flap on 5 fresh cadavers. For each case, the number and the location of the perforators were recorded. For each flap, the length of pedicle, the diameter of source vessels and the thickness of the flap were studied. Finally, we performed a clinical application of a MSAP flap.

RESULTS

A total of 23 perforators with a diameter superior than 1mm were dissected on 10 legs. The medial sural artery provided between 1 and 4 musculocutaneous perforators. Perforators were located in average at 10.3cm±2cm from the popliteal fossa and at 3.6cm±1cm from the median line of the calf. The mean pedicle length was 12.1cm±2.5cm. At its origin, the source artery diameter was 1.8mm±0.25mm and source veins diameters were 2.45mm±0.9mm in average. There was no complication in our clinical application.

DISCUSSION

This study confirms the reliability of previous anatomical descriptions of the medial sural artery perforator flap. This flap was reported as thin and particularly adapted for oral cavity reconstruction and for facial or limb resurfacing. Sequelae might be reduced as compared to those of the radial forearm flap with comparable results.

The utility of the musculocutaneous anterolateral thigh flap in pharyngolaryngeal reconstruction in the high-risk patient

BACKGROUND AND OBJECTIVES

Prior radiotherapy leads to increased wound complication rates for microsurgical reconstruction of pharyngolaryngeal (PL) defects. Incorporating vastus lateralis muscle together with anterolateral thigh flap (ALT) skin in defect reconstruction is useful in protecting vital structures and reinforcing irradiated neck skin and suture lines. This study shows the utility of the musculocutaneous ALT (MC ALT) in PL reconstruction in previously irradiated patients.

METHODS

A single-surgeon, retrospective chart review of all patients with defects of the PL region where an MC ALT was used for reconstruction from February 2014 to May 2016. The harvest of the MC ALT is described.

RESULTS

Thirteen consecutive patients underwent reconstruction with a MC ALT flap. All 13 patients had received previous radiotherapy. PL defects included five partial, five subtotal, and three total. There was a 100% flap survival rate with five early recipient site complications including three fistulas, one neck abscess, and one partial muscle necrosis. Three patients (23%) developed strictures requiring dilatation, two of whom had received post-reconstruction radiotherapy.

CONCLUSIONS

The use of the MC ALT for reconstruction of PL defects should be considered to mitigate the negative effects of prior irradiation and provide a back-up plan in instances where complications occur.

Fascial Free Flap for Reconstruction of the Dorsolateral Hand and Digits: The Advantage of a Thin Contour

Background

Fascial free flaps have been widely used for reconstruction of the hand because they are thin. However, studies reporting objective data regarding the advantages of this approach are lacking. Thus, we report our experience with such flaps.

Methods

Forty-five cases of fascial free flaps between November 2006 and March 2014 were reviewed. Nine cases involving reconstructed dorsal or lateral defects were included. Four anterolateral thigh fascial free flaps and 5 lateral arm fascial free flaps were examined. Maximal flap contour was assessed by measuring reconstructed tissue thickness at the central area from the surface of the skin to below the bone in a vertical manner using ultrasonography and X-ray data. Contralateral regions were examined in the same manner and a comparative analysis was performed. A questionnaire survey regarding aesthetic satisfaction was also administered.

Results

All reconstructed parts had a thicker contour than the contralateral side. The average relative percentage of reconstructed tissue thickness was found to be 152% using ultrasonography and 143% using X-ray imaging. According to the aesthetic satisfaction survey, the average rate of satisfaction for patients was 62%, and satisfaction with the flap contour was 72%.

Conclusions

Using a fascial free flap, the reconstructed tissue was approximately 1.5× as thick as the contour of the normal side, which led to positive responses regarding aesthetic satisfaction.

The free medial sural artery perforator flap: Versatile option for soft tissue reconstruction in small-to-moderate size defects of the foot and ankle

BACKGROUND

The medial sural artery perforator (MSAP) flap shows advantages for reconstruction in the foot and ankle, where bulk is a liability. We evaluated the versatility of this flap and provide further evidence on its use for covering small-to-moderate size defects by comparing the outcome depending on the region of reconstruction.

METHODS

Twenty-two patients with variable defects of 4 × 4 to 18 × 7 cm underwent MSAP flap reconstruction. Final outcomes of all patients were evaluated 12-months postoperatively using the AOFAS ankle-hindfoot, midfoot and hallux scale for clinical-functional evaluation, and the SF-36 health survey for quality-of-life measurement. The scores were compared in three groups according to the anatomic region of MSAP flap reconstruction.

RESULTS

The flap size ranged between 6 × 4 and 21 × 9 cm. One venous congestion was salvaged by venous thrombectomy and reanastomosis, and one marginal flap necrosis healed by secondary intention. All flaps survived, and all patients returned to ambulation. Patients with reconstruction of the ankle-hindfoot or hallux showed significantly lower AOFAS ankle-hindfoot (P = 0.021) or hallux scores (P = 0.034), whereas reconstruction of the midfoot led to equal AOFAS midfoot scores (P = 0.265) as compared with patients without reconstruction in the respective region. Comparison of SF-36 physical (P = 0.936) and mental (P = 0.855) scores of all three regions remained insignificant.

CONCLUSION

The MSAP flap provides thin soft tissue coverage, enabling good functional recovery after defect reconstruction all around the foot and ankle, with evident advantages in the midfoot. However, the functional outcomes after reconstruction of the ankle-hindfoot or hallux region depend on the preexistent functional impairment.

Reconstructive Indications of Anterolateral Thigh Free Flaps in Head and Neck Reconstruction

Anterolateral thigh (ALT) free flap is a common flap with multitude of indications. The purpose of this article is to review the reconstructive indications of the flap in head and neck defects. This is a retrospective study of 194 consecutive ALT flaps. Data including patient characteristics (age, sex, comorbidities), disease characteristics (histology, T stage), and flap characteristics (size of the flap, type of closure of ALT donor site) were collected. The outcome in terms of flap success rate, surgical, and donor site morbidity were studied. A total of 194 flaps were performed in 193 patients over a period of 10 years. Mean age of the patients was 55 years (range 16-80 years). Out of the 193 patients, 91 (47.1%) patients had oromandibular defects, 52 (26.9%) had tongue defects, 15 (7.7%) had pharyngeal defects, 17 (8.8%) had skull base defects, 4 (2%) had scalp defects, and 14 (7.2%) had contour defects of the neck. The overall flap success rate was 95.8% (8 total flap loss out of 194). Hypertrophic scar was the commonest donor site problem seen in 20 (10.3%) patients. This study shows the versatility of free ALT flap in head and neck reconstruction. It is a reliable and safe. Donor site morbidity is minimal.