A comparison of thinning and conventional free-flap transfers to the lower extremity

Reconstruction of plantar foot defects with free super-thin anterolateral thigh flap

BACKGROUNDS

In the repair of plantar foot defects, it is important that the reconstructed area is compatible with surrounding tissue while weight-bearing ability continues. In our study, we present long-term results of plantar foot reconstruction with super-thin ALT flaps in patients that required reconstruction with free tissue transfer.

METHODS

We evaluated 11 patients with plantar foot defects that underwent reconstruction with a super-thin ALT flap. Patients were evaluated for postoperative ulceration, ability to wear normal shoes, time to return to work/school, LEFS score and satisfaction with aesthetic results.

RESULTS

No bone defects were observed in the patients included in our study, except for the phalanges and distal metatarsals. Defects with soft tissue loss were reconstructed. The mean flap thickness was 4.9 mm (range 3-6 mm). Follow-up period ranged from 16 to 59 months. One patient required grafting for partial flap necrosis and recovered totally. Another patient required debulking surgery. Two patients had superficial ulceration postoperatively, which responded well to conservative therapy. The mean VAS score for cosmetic satisfaction was 8 of 10 (range, 6-9). Eight patients were satisfied with the flap contour, while three others were fairly satisfied. Mean time to return to work/school after surgery was 2.5 months. The preoperative LEFS score increased from 32.03 ± 15.2 to 58.7 ± 10.6 in the postoperative period, this difference was statistically significant (P<0.01).

CONCLUSION

We consider that the advantageous features of super-thin ALT flaps such as proper tightening, reduced postoperative atrophy, and better contouring features make these flaps suitable for plantar foot defects.

Outcomes of Free Muscle Flaps versus Free Fasciocutaneous Flaps for Lower Limb Reconstruction following Trauma: A Systematic Review and Meta-Analysis

BACKGROUND

 Free flap reconstruction of the lower limb following trauma often suffers higher complication rates than other areas of the body. The choice of muscle or fasciocutaneous free flap is an area of active debate.

METHODS

 A systematic review of EMBASE, MEDLINE, PubMed, and Cochrane Register from inception to April 1, 2022 was performed. Articles were assessed using the methodological index for non-randomized studies instrument. The primary outcome was to assess and compare the major surgical outcomes of partial or total flap failure, reoperation, and amputation rates.

RESULTS

 Seventeen studies were included. All studies were retrospective in nature, of level three evidence, and published between 1986 and 2021. The most common muscle and fasciocutaneous free flaps used were latissimus dorsi flap (38.1%) and anterolateral thigh (ALT) flap (64.8%), respectively. Meta-analysis found no significance difference in rates of total flap failure, takeback operations, or limb salvage, whereas partial flap failure rate was significantly lower for fasciocutaneous flaps. The majority of studies found no significant difference in complication rates, osteomyelitis, time to fracture union, or time to functional recovery. Most, 82.4% (14/17), of the included studies were of high methodological quality.

CONCLUSION

 The rate of total flap failure, reoperation, or limb salvage is not significantly different between muscle and fasciocutaneous free flaps after lower limb reconstruction following trauma. Partial flap failure rates appear to be lower with fasciocutaneous free flaps. Outcomes traditionally thought to be managed better with muscle free flaps, such as osteomyelitis and rates of fracture union, were comparable.

Virtual planning of the anterolateral thigh free flap for heel reconstruction

PURPOSE

three dimensional (3-D) virtual planning is an example of computer assisted surgery that improved management of composite tissue defects. However, converting the 3-D construct into two dimensional format is challenging. The purpose of this study was to assess 3-D virtual planning of complex heel defects for better optimized reconstruction.

PATIENTS AND METHODS

a prospective analysis of 10 patients [9 male and 1 female; mean age = 27.9 years] with post-traumatic heel defects was performed. Heel defects comprised types II (three patients) or III (seven patients) according to Hidalgo and Shaw and were managed using anterolateral thigh (ALT) free flap adopting 3-D virtual planning of the actual defect which was converted into a silicone two dimensional mold. The mean definitive size of the defects was 63.4 cm³ . Functional, aesthetic, and sensory evaluations of both donor and recipient sites were performed 1 year after surgery.

RESULTS

Six patients received thinned ALT (mean size = 139 cm³ ) while four patients received musculofasciocutaneous ALT flap (mean size = 199 cm³ ). One flap exhibited partial skin flap necrosis. Another flap was salvaged after re-exploration secondary to venous congestion. The mean follow-up was 20.2 months. The Maryland foot score showed 4 excellent, 5 good, and 1 fair cases. The mean American Orthopedic Foot and Ankle hind foot scoring was 76.3 (range: 69-86). All patients regained their walking capability.

CONCLUSIONS

3-D virtual planning of complex heel defects facilitates covering non-elliptical defects while harvesting a conventional elliptical flap with providing satisfactory functional outcomes and near-normal contour, volume, and sensibility.

Reconstruction of extensive plantar forefoot defects with free anterolateral thigh flap

PURPOSE

The aim of the soft tissue reconstruction of plantar forefoot should yield weight-bearing function and aesthetic contour, which poses a significant challenge for reconstructive surgeons to provide an appropriate flap according to the "like for like" reconstructive principle. Local flaps and pedicled flaps have been described for the reconstruction of small- to medium-sized defects of plantar forefoot and achieved optimal results. However, reconstruction of extensive defects of plantar forefoot is rarely investigated. In this study, we present our experience using the free anterolateral thigh (ALT) flap in the reconstruction of extensive defects of plantar forefoot.

METHODS

Between November 2011 and April 2017, 9 patients were treated for extensive soft tissue defects in the plantar forefoot areas with ALT flaps. The mean age at the time of surgery was 39.3 years (range, 25-64 years).

RESULTS

The follow-up period ranged from 12 to 77 months, with a mean of 31 months. All flaps survived well, and the patients were satisfied with the aesthetic and functional results. The size of the flaps ranged from 63 to 455 cm, with a mean of 197.7 cm. Seven patients with no bony involvement began to gradually weight-bear at 3 weeks postoperatively. During the follow-up time, postoperative ulceration at the reconstructed weight-bearing areas was not encountered.

CONCLUSION

The ALT flap is a reliable option for treatment of extensive defects of plantar forefoot, resulting in an optimal functional and aesthetic outcome. Even when a total plantar loss exits, excellent results can be achieved.

Technical refinements of the free medial sural artery perforator (MSAP) flap in reconstruction of multifaceted ankle soft tissue defects

BACKGROUND

Peri-ankle defects are difficult to reconstruct due to sharp contours, thin skin, aesthetic value, function and footwear impact. The medial sural artery perforator flap (MSAP) is increasing in popularity as a thin and pliable flap. This study aims to demonstrate its versatility in reconstructing defects around the ankle area and our approach to insetting these flaps in difficult areas around the ankle without the need for subsequent flap revisions.

METHODS

A retrospective review of the senior author's series of peri-ankle reconstructions using the MSAP flap was undertaken.

RESULTS

Between 2011-2015, 15 patients underwent peri-ankle reconstruction with the MSAP flap. There were 4 dorsal foot, 4 medial malleolar, 4 lateral malleolar, and 3 tendo-achilles defects. All flaps in this series survived. There was one episode of partial flap necrosis in one patient and no incidences of donor site dehiscence. All patients returned to full ambulation and none required subsequent flap revision.

CONCLUSIONS

The MSAP flap offers the benefits of a fasciocutaneous flap, whilst providing a thin, pliable, single stage and robust reconstruction for peri-ankle defects, with a cosmetically ideal donor site.

Lower extremity soft tissue defect reconstruction with the serratus anterior flap

Reconstruction of limb-threatening lower extremity defects presents unique challenges. The selected method must provide adequate coverage of exposed bone, joints, and tendons while maximizing function of the limb. The traditional workhorse flaps, the free latissimus dorsi and rectus abdominis flaps, have been associated with donor site morbidity and bulkiness that can impair rehabilitation. We report a case series (n = 18) in which the free serratus anterior muscle flap and split thickness skin graft (STSG) was used for lower limb soft tissue coverage. Injuries were due to diabetes (9/18), trauma (7/18), and chronic venous stasis (2/18). A 94% flap survival rate was observed and all but one patient was ambulatory. No donor site morbidity was reported. Our series demonstrates that serratus anterior is an advantageous, reliable free flap with minimal donor site morbidity.

Technical tips for safe perforator vessel dissection applicable to all perforator flaps

The introduction of perforator flaps by Koshima and Soeda in 1989 was met with much animosity in the surgical community. The flaps challenged conventional teaching and were often branded as being unsafe. Surgeries using perforator flaps are now routinely practiced all over the world, with increasing emphasis on minimizing donor site morbidity, and perforator flaps are becoming the current gold standard. The simple principles and techniques of perforator dissection can be applied to all perforator flaps, provided the surgeon has an intimate knowledge of the regional anatomy. Thus, virtually any piece of skin can be harvested as long as it incorporates a feeding vessel. This article highlights the essential techniques in planning and raising perforator flaps and the common pitfalls to be avoided.

Comparison of free anterolateral thigh flaps and free muscle-musculocutaneous flaps in soft tissue reconstruction of lower extremity

BACKGROUND

The objective of this study was to compare the free muscle-musculocutaneous flaps and free perforator skin flaps used for soft tissue reconstruction of the lower extremities.

METHODS

Fifty-three patients whose skin and soft tissue of the lower extremities had been reconstructed were divided into two groups: a perforator flap group, reconstructed using anterolateral thigh (ALT) free flap (23 cases), and a muscle-musculocutaneous flap group, in whom latissimus dorsi and rectus abdominus muscle-musculocutaneous free flaps were used (30 cases). Postoperative complications, long-term results, and donor site morbidities were studied in the two groups.

RESULTS

Complete flap survival was 78.3% with four total and one partial flap loss in the ALT group and 90.0% with one total and two partial failure in the muscle-musculocutaneous flap group. Muscle-musculocutaneous flaps were the flaps of choice in Gustillo grade IIIB-C injuries and for reconstruction of more proximal localizations. ALT was preferred in relatively younger patients and was typically used for coverage of the distally localized defects. Flap complication rate was significantly higher in the ALT group, but the overall complication rate was similar between the groups.

CONCLUSION

ALT perforator flap is a precious option for lower extremity soft tissue reconstruction with minimal donor site morbidity. Nevertheless, the beginners should be attentive to an increased rate of flap complications with the ALT flap and free axial muscle-musculocutaneous flaps would still be the tissue of choice for coverage of leg defects for a surgeon before gaining enough experience with perforator flap dissection.

The thin circumflex scapular artery perforator flap

The development of microsurgery has most recently been focused upon the evolution of perforator flaps, with the aim of minimising donor site morbidity, and avoiding the transfer of functionally unnecessary tissues. The vascular basis of perforator flaps also facilitates radical primary thinning prior to flap transfer, when appropriate. Based upon initial clinical observations, cadaveric, and radiological studies, we describe a new, thin, perforator flap based upon the circumflex scapular artery (CSA). A perforator vessel was found to arise within 1.5cm of the CSA bifurcation (arising from the main trunk, or the descending branch). The perforator arborises into the sub-dermal vascular plexus of the dorsal scapular skin, permitting the elevation and primary thinning of a skin flap. This thin flap has been employed in a series of five clinical cases to reconstruct defects of the axilla (two cases of hidradenitis suppurativa; pedicled transfers), and upper limb (one sarcoma, one brachial to radial artery flowthrough revascularisation plus antecubital fossa reconstruction, and one hand reconstruction with a chimeric flap incorporating vascularised bone, fascia, and thin skin flaps; free tissue transfers). No intramuscular perforator dissection is required; pedicle length is 8-10cm and vessel diameter 2-4mm. There was no significant peri-operative complication or flap failure, all donor sites were closed primarily, patient satisfaction was high, and initial reconstructive aims were achieved in all cases. Surgical technique, and the vascular basis of the flap are described. The thin circumflex scapular artery perforator flap requires no intramuscular dissection yet provides high quality skin (whose characteristics can be varied by orientation of the skin paddle), and multiple chimeric options. The donor site is relatively hair-free, has favourable cosmesis and no known functional morbidity. This flap represents a promising addition to the existing range of perforator flaps.

The Cutaneous Arteries of the Anterior Abdominal Wall: A Three-Dimensional Study

BACKGROUND

Abdominal perforator flaps represent a natural progression in the quest to minimize abdominal wall morbidity. Their one disadvantage is the significant rate of vascular complications to which they are subject in some series. The authors examined the vascular anatomy of the abdominal integument, to determine why such complications occur and how they may be prevented.

METHODS

In 10 fresh cadavers, major arteries supplying the abdominal wall were injected with a lead-based contrast medium. The abdominal integument of each cadaver was imaged using a 16-slice spiral computed tomography scanner, to produce three-dimensional reconstructions of the arterial anatomy. Reconstructions were observed for orientation, course, and morphology of the major perforators within the abdominal integument.

RESULTS

Perforators of the deep inferior epigastric artery (DIEA) varied markedly in their orientation, course, and morphology among specimens. By contrast, perforators of the superior epigastric artery (SEA) were relatively consistent in their morphology and orientation. In eight of 10 specimens, SEA perforators with extensive anatomical "territories" orientated toward the umbilicus were present. These SEA perforators pierced the rectus sheath within 4 cm of the costal margin and were present bilaterally in seven of eight specimens.

CONCLUSIONS

The unpredictable orientation and course of DIEA perforators indicate that the blood supply of abdominal perforator flaps, raised without clear knowledge of their unique vascular anatomy, may often be more random than axial. This may account for much of the ischemia-related morbidity observed with DIEA-based perforator flaps. Preservation of SEA perforators adjacent to the costal margin during abdominoplasty will likely improve abdominal wall perfusion and reduce donor-site morbidity.

Functional outcomes and donor site morbidity following circumferential pharyngoesophageal reconstruction using an anterolateral thigh flap and salivary bypass tube

BACKGROUND

This study reports our experience with fasciocutaneous reconstruction of circumferential pharyngoesophageal defects using an anterolateral thigh flap wrapped around a salivary bypass tube.

METHODS

The charts of 14 patients were reviewed. All patients who had reconstruction of a pharyngoesophageal defect using an anterolateral thigh flap with a salivary bypass tube between 2001 and 2005 were included.

RESULTS

There were 10 men and 4 women (mean age, 61 years). There were no fistulae reported, and the stricture rate was 14%. Eleven patients achieved oral diet sufficient to have the gastrostomy or jejunal tube removed. The patients who had tracheoesophageal puncture for voice developed functional speech. There were no flap losses. However, problems with salivary tube migration in the early cases have led to technique refinement.

CONCLUSIONS

The low complication rates and the excellent functional outcomes make the anterolateral thigh flap in combination with a salivary bypass tube a viable option for reconstruction of these difficult defects.

Sole Reconstruction Using Anterolateral Thigh Perforator Free Flaps

BACKGROUND

The goal of sole reconstruction should be functional and aesthetic. These goals can be achieved by providing the sole with a durable and comfortable weight-bearing surface, adequate contour, protective sensation, and solid anchoring to deep tissue to resist shearing. Various flaps such as fasciocutaneous, musculocutaneous, or split skin grafted muscle flaps have been reported for reconstruction of the weight-bearing foot. The perforator flap, however, deserves attention in the debate for the ideal flap because of its anatomical characteristics.

METHODS

Between June of 2002 and February of 2005, 69 patients were treated for soft-tissue defects in the plantar areas with anterolateral thigh perforator free flaps. Sensory nerve coaptation was performed in 17 cases. The follow-up period ranged from 4 to 38 months, with a mean of 14.7 months.

RESULTS

Satisfactory aesthetic and functional results were observed using 4- to 6-mm-thick anterolateral thigh perforator flaps. All flaps survived, with the exception of one case. Partial necrosis and dehiscence of the wound developed in three cases, but secondary healing was achieved and final outcome was not impaired. Partial weight bearing began at 3 weeks, and acceptable gait recovery was noted by 3 months as evaluated by clinical observation and gait analysis. Most patients regained protective sensation by 12 months regardless of nerve coaptation, but earlier sensory recovery was noted in patients who underwent reconstruction with sensate flaps.

CONCLUSION

This article suggests the anterolateral thigh perforator flap to be a reliable option in sole reconstruction, resulting in an acceptable functional and aesthetic outcome.

Analyzing the Vascular Architecture of the Free TRAM Flap Using Intraoperative Ex Vivo Angiography

BACKGROUND

Using ex vivo intraoperative angiography to analyze 14 flaps from 12 breast reconstruction patients, the authors investigated the vascular architecture of free transverse rectus abdominis musculocutaneous (TRAM) flaps nourished by the deep inferior epigastric artery.

METHODS

Contrast medium was injected through the deep inferior epigastric artery and flaps were radiographed to observe their vascular patterns.

RESULTS

TRAM flaps showed one or two segmental arteries stained on their ipsilateral side (zones 1 and 3) and serving as the flap's axial artery. These segmental arteries directly connect to the large perforators (axial perforators) and emerge not only from the paraumbilical perforators but also from the caudal branches of the deep inferior epigastric artery. Arterial density is always lower in the contralateral area (zones 2 and 4) than in the ipsilateral area (zones 1 and 3).

CONCLUSIONS

Because the cephalic half of zone 2 and all of zone 4 remain unstained, these areas are prone to skin or fat necrosis, especially in high-risk patients. Ex vivo angiography, by providing specific information about the individual flap and by reflecting its flow physiology, enables one to observe and to chart the vascular architecture of free TRAM flaps nourished by the deep inferior epigastric artery.

Ex vivo intraoperative angiography for rectus abdominis musculocutaneous free flaps

In this study, the vascular architecture of rectus abdominis free flaps nourished by deep inferior epigastric vessels was investigated using an ex vivo intraoperative angiogram. Oblique rectus abdominis free flaps were elevated and isolated from the donor site. In 11 patients, the vascular architecture of these flaps was analyzed before the flap was thinned. Radiographic study identified an average of 2.1 large deep inferior epigastric arterial perforators in each flap. In nine of the 11 flaps, the axial artery was visible. In four flaps, the axial artery originated from the perforator of the lateral branch of the deep inferior epigastric artery; in five others, it originated from the medial branch. In each flap, the angle of the axial perforator from its anterior rectus sheath in the vertical plane was measured; its mean was 50.6 degrees. All flaps survived, although three showed partial necrosis in the distal portions. In two of these three flaps, the axial artery was not visible in the angiograms, and the third revealed a one-sided distribution of axial flap arteries. Using ex vivo intraoperative angiography, the architecture of the individual flap, its axial perforator, and its connecting axial flap vessel could be investigated. This information can help the surgeon safely thin and separate the flap.

Free flap reconstruction of the sole of the foot with or without sensory nerve coaptation

The authors present a retrospective study on major plantar foot reconstruction to evaluate the role of the free fasciocutaneous flap and the importance of sensory nerve reconstruction in improving long-term results. Between 1995 and 1999, 20 patients with major defects of the sole of the foot underwent free forearm flap reconstruction performed by the senior author (F.S.). Sensory nerve reconstruction was added to this technique in 1997. The age and sex of the patients and the cause, location, and dimensions of their defects were recorded. The patients were clinically and neurophysiologically evaluated at 3, 6, and 12 months after the procedure for the following parameters: flap contour, flap stability, load capacity, walking ability, touch sensation, pain sensation, static two-point discrimination, and thermal sensibility. Dermatomic somatosensory-evoked potentials were also tested at 12 months. Follow-up ranged from 1 to 5 years. Patients were divided into two groups according to sensory nerve reconstruction. Group A consisted of 11 patients with nerve repair, and group B consisted of nine patients without nerve repair. One patient from group A who had an idiopathic neuropathy was excluded from the study because of interference with the reinnervation process. Five more patients (three from group A and two from group B) were lost at follow-up and excluded from the study. The final sample size in each group was seven. Data from both groups were compared and statistically analyzed with the Mann-Whitney test and the Fisher exact test. Long-term results confirmed in all reconstructions long-lasting stability. During the first postoperative year, patients with sensory nerve reconstruction showed better sensibility. The statistical analyses confirmed significant differences between the two groups to be dependent upon surgical technique at 3 and 6 months. Two-point discrimination and dermatomic somatosensory-evoked potentials were recorded. After 12 months, flaps without surgical nerve repair showed progressive improvement of sensitive thresholds, achieving a good protective sensibility, similar to that of the other group, but these flaps never regained two-point discrimination or dermatomic somatosensory-evoked potentials.