Defining Vascular Supply and Territory of Thinned Perforator Flaps: Part I. Anterolateral Thigh Perforator Flap

Thin and Thinned Anterolateral Thigh Flaps for Upper Extremity Reconstruction

Upper extremity reconstruction remains challenging due to the high functional and esthetic demands of this location. The anterolateral thigh (ALT) flap is a workhorse flap for microsurgical reconstruction of the upper extremity and can be elevated in various planes depending on desired thickness of the flap. Microsurgical reconstruction of the upper extremity often benefits from a thin flap that can resurface the extremity, which can provide improved functional and esthetic outcomes. This article reviews the anatomy, preoperative planning, and operative technique, as well as presents 4 cases to illustrate the outcomes and benefits of thin and thinned ALT flaps.

Hotspots of facial artery perforators and perforasomes for easier flap guidance: An anatomical study

BACKGROUND

The facial artery perforator flap is a valuable alternative for reconstruction of small to medium defects in the central midface and provide pleasing cosmetic results, allowing reconstruction in a one-stage procedure. Since Doppler ultrasound is not applicable to distinguish perforator from source artery, anatomical studies are needed to identify perforator areas along the course of the facial artery.

METHODS

Twenty facial arteries of 10 fresh anatomical head specimens were dissected. All perforators with an outer diameter of at least 0.50 mm were identified and injected with dye to color their respective vascular territories. Size and location of colored skin territories as well as the location of its perforators were documented and statistically analyzed.

RESULTS

In total, 89 perforators were identified. The average number of perforators per facial artery was 4.45±1.15. The mean outer diameter of the perforator at the origin of the facial artery was 0,65±0.14 mm. The mean size of the colored skin territories was 577.57±488.81 mm2. Perforator diameters were significantly associated with the size of its resulting perforasomes. Furthermore, perforators mostly originated in two specific areas: 3.5 cm lateral and caudal and 4.5 cm lateral and 5.5 cm caudal of the anterior nasal spine.

CONCLUSION

This study provides evidence of two predominant locations of emergence of facial artery perforators. Additionally, the significant correlation between perforator size and its appendant perforasomes as well as their location with reference to the anterior nasal spine as relevant osseous landmarks helps surgeons in decision making for flap design and surgery.

Superthin Flap Harvesting Procedure: Technical Note

The anterolateral thigh (ALT) flap has been extensively discussed in the literature as it allows for a wide variety and depth of tissues for complex wound coverage. Thanks to many cadaveric and angiographic studies of the subdermal plexus, it is to date ascertained that tailoring ALT thickness can be safely performed without compromising flap outcomes or causing additional morbidity. Recently, the authors applied and described a simpler, safer, and less time-consuming superthin ALT perforator (ALTP) free flap harvesting technique. The aim of this article is to show the versatility of the adipofascial flap harvested around the chosen perforators, which allowed us to safely expand the usage of ALTP superthin flaps.

The turbocharged wide anterolateral thigh perforator flap to reconstruct massive soft tissue defects in traumatized lower extremities: A case series

BACKGROUND

Extensive traumatic soft tissue defects in the lower extremities typically require complete coverage of exposed bone because inadequate coverage, such as partial flap loss, may result in bony infection and ultimately lead to limb salvage failure. To achieve complete coverage of these defects, we used the wide anterolateral thigh perforator flap in which the turbocharging procedure augments the blood flow. Herein, we describe our turbocharging technique and discuss its effectiveness.

METHODS

From January 2014 to December 2020, the turbocharged wide ALTP free flaps were used to treat 13 patients with massive traumatic soft tissue defects in the lower extremities, ranging in size from 22 × 10 cm2 (220 cm2) to 21 × 17 cm2 (357 cm2) (mean, 270 cm2). All ALTP flaps were supplied by perforators from both the transverse branch of the lateral circumflex artery (TB-LCFA) and descending branch of the lateral circumflex artery (DB-LCFA) simultaneously. The turbocharging procedure by connecting the TB-LCFA to a side branch of the DB-LCFA was carried out in all these flaps. A retrospective review of medical records for each patient was performed.

RESULTS

The size of the transferred ALTP flap ranged from 23 × 12 cm2 (276 cm2) to 23 × 19 (437 cm2) (mean, 331 cm2). The total number of perforators included in the flaps was three on average. All ALTP flaps survived completely without partial necrosis. The postoperative course was uneventful except for two cases with minor complications, including hematoma and partial necrosis of the recipient's skin.

CONCLUSION

Free transfer of the turbocharged wide ALTP flap can be a reliable and effective reconstructive method to obtain complete coverage of extensive traumatic soft tissue defects in the lower extremities and achieve successful limb salvage.

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.

Anteromedial thigh septocutaneous perforator flap as a first choice for head and neck reconstruction: A clinical algorithm based on perforator-pedicle relationship

BACKGROUND

Anterolateral thigh perforator flaps (ALTPFs) have long been considered workhorse flaps for head and neck reconstructions. However, in some instances, anteromedial thigh septocutaneous perforator flaps (AMTPFs) are easier to harvest than ALTPFs. This study aimed to determine when and how the AMTPF should be considered the first choice as a reconstructive tool.

METHODS

A retrospective cohort study was performed in the Department of Oral and Maxillofacial Surgery-Head & Neck Oncology, Shanghai Ninth People Hospital, from January 2014 to December 2018. Both the perforator-pedicle relationships and postoperative functional outcomes were compared.

RESULTS

A total of 168 patients were included in this study, among whom 49 underwent AMTPF reconstructions. The AMTPF perforators in this study were mostly septocutaneous (n = 38, 77.5%). Notably, the AMTPF perforators mainly originated from the medial branch of the descending branches of the lateral circumflex femoral arteries (n = 44, 89.8%), while for the other 5 patients, the perforators were found to originate from the superficial femoral arteries. Additionally, the average pedicle length of the AMTPFs was 8.7 cm (range: 6.0 to 13.0 cm), which was comparable to that of the ALTPFs (8.9 cm) (p = 0.442). The postoperative complication rate and functional outcomes were comparable between the two groups. The algorithm and harvesting approaches are presented.

CONCLUSIONS

The role of AMTPF should not be downplayed. After careful preoperative evaluation, we believe that AMTPF should not be considered a second choice in patients with sizable septocutaneous perforators.

Super-thin ALT flap elevation using preoperative color doppler ultrasound planning: Identification of horizontally running pathway at the deep adipofascial layers

INTRODUCTION

Presently, super-thin ALT flap, which is elevated above the superficial fascial plane, is gaining popularity. Although there is a huge demand for thin flaps for various types of extremity reconstruction, the technique for ALT flap thinning remains controversial. In this study, we investigated the distance and vector between penetrating points of perforators in deep and superficial fascia using color duplex and clinical measurement to suggest a reliable super-thin flap elevation technique.

MATERIALS AND METHODS

From June 2018 to February 2020, 44 patients with various types of defects who were treated using super-thin ALT flaps were enrolled; 69 surgically detected perforators were analyzed. All patients' flap outcomes and characteristics of the perforators were analyzed. In addition, the effects of patients' body mass index (BMI) and thickness of super-thin flap were evaluated.

RESULTS

The average traveling length of perforator at the deep adipofascial layer (DAL) was 2.43 cm, and the vector of traveling was randomly arranged. The mean thickness of super-thin ALT flap was 6.8 mm. The thickness of super-thin flap was not significantly correlated with patients' BMI (ranged from 17.4 to 34.2 kg/m²; p = 0.183).

CONCLUSION

The novel elevation technique for super-thin ALT might be useful, as evidenced by perforator traveling distance and vector in DAL. Preoperative color duplex ultrasonography is helpful to detect the running course of the perforators during elevating the flap. This anatomic concept must be considered to obtain the reliability of the super-thin ALT flap.

Evaluating effects of primary defatting for flap thinning on the development of perfusion-related complications in free perforator flap reconstruction

BACKGROUND

Primary defatting is suggested as an effective and appealing technique for achieving flap thinning. There has been a long-standing concern regarding its potential adverse effects on flap perfusion, for which limited clinical evidence exists. This study aimed to investigate whether primary defatting negatively influences the outcomes of free perforator flap reconstruction.

METHODS

Patients who underwent upper or lower extremity reconstruction using free perforator flaps between 2002 and 2020 were investigated. They were categorized into two groups according to whether they underwent primary defatting. The association of primary defatting with the development of perfusion-related complications was evaluated.

RESULTS

A total of 421 patients were included in the analysis. Perfusion-related complications developed in 61 (14.5%) cases, including 12 cases (2.9%) of total flap loss. In total, 302 patients underwent primary defatting and 119 did not. The patients who underwent primary defatting had a higher body mass index (BMI), lower rate of comorbidities, and smaller harvested flaps than the controls. Both groups had similar rates of perfusion-related complications (13.9% vs. 16.0%, p = .589), including total flap loss (3.0% vs. 2.5%, p = .799). In the multivariate analyses, primary defatting was not associated with the development of perfusion-related complications (p = .957). In the subgroup analyses, the rate of perfusion-related complications did not differ between the two groups regardless of the BMI (≥25 or <25 kg/m² ), comorbidities, and flap size (≥200, 100-200, or <100 cm² ).

CONCLUSIONS

Primary defatting does not appear to be associated with the development of perfusion-related complications in free perforator flap extremity reconstruction.

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.

Air Flow Cooling Improves Anterolateral Thigh Perforator Mapping Using the FLIR ONE Thermal Camera

BACKGROUND

 Due to the variable vascular anatomy preoperative perforator mapping facilitates anterolateral thigh (ALT) free flap harvesting. Dynamic infrared perforator imaging can assist preoperative planning by displaying hot spots that represent angiosomes. This study aims to compare previously described precooling methods to develop a standardized simplified protocol for ALT perforator planning.

METHODS

 Fifty thighs were examined with a FLIR ONE thermal camera. Four different cold challenges, including alcoholic disinfection, wet laparotomy sponge cooling, fan cooling, and cold pack application, were compared. Hot spot locations within a 250 mm × 80 mm area were compared double-blinded to perforator locations determined by Doppler ultrasonography considered as gold standard.

RESULTS

 The matching rate of thermographic hot spots and sonographically identified perforators was 34.9 ± 22.2%. An increased matching rate of 62.2 ± 42.2% was noted taking only favored perforators (septocutaneous course, diameter >1 mm, distance <3 cm to the center, and visible concomitant veins) into account. Precooling with a fan followed by alcoholic disinfection provided clearest thermograms and fastest results.

CONCLUSION

 Thermographic imaging is a reliable method for perforator imaging. Its supplemental use to ultrasound may reduce examination time and yield additional information. Precooling by air flow or alcoholic disinfection can be easily implemented and provide the best thermograms. The matching rate of thermographic hot spots and perforators increases when taking only clinically relevant perforators into account. Thermal perforator mapping therefore reduces distraction by negligible perforators.

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.

Harvesting the anterolateral thigh flap with non-sizable perforators

BACKGROUND

The anterolateral thigh flap (ALT) has proven over time to be one of the best reconstructive workhorses due to its versatility and reliability. Without preoperative imaging, vascular anomalies such as having no sizable perforator are sometimes encountered during dissection. We propose a technique, based on a modified version of the traditional myocutaneous ALT to allow harvest of the flap based on non-sizable perforators. This technique can also enable the splitting of a flap when only one sizable perforator is present.

METHODS

A retrospective review of patients who received reconstruction with free ALT flap from 2013 to 2019 by the senior author HSS was performed and included all flaps in which non-sizable perforators were harvested. Data collected for analysis included patient demographics, flap size, defect location, inset type, and flap survival.

SURGICAL TECHNIQUE

Despite detachment of the majority of skin paddle from the muscle, the flap is harvested with a sleeve of areolar tissue containing preferably more than one non-sizable perforator attached to a small muscular segment of the vastus lateralis containing the pedicle.

RESULTS

A total of 349 ALT flaps were performed during the review period by senior author HSS, and 25 flaps were harvested with non-sizable perforator, 10 of which were to enable a split. There were no total losses and 6 partial losses; 2 were amenable to direct closure after debridement, 1 required skin graft, and 3 required a new flap for wound coverage. Incorporating more than one non-sizable perforator increases the reliability of the flap. This technique should be used with caution in patients with multiple underlying comorbidities and when a flow-through flap is required. We were able to achieve primary closure of all donor sites.

CONCLUSIONS

It is possible to harvest the anterolateral thigh flap without sizable perforators by conversion to a modified version of the myocutaneous flap. In well-selected patients, using our technique, several non-sizable perforators can reliably perfuse an ALT without the need to use an alternative donor site. This maximizes the number of harvestable ALTs and increases the reconstructive potential by splitting previously "un-splitable" flaps.

Anatomical Understanding of Target Subcutaneous Tissue Layer for Thinning Procedures in Thoracodorsal Artery Perforator, Superficial Circumflex Iliac Artery Perforator, and Anterolateral Thigh Perforator Flaps

BACKGROUND

Thinned perforator flaps, reported techniques, and degree of thinning differ by study. This study investigated the anatomy of subcutaneous tissue according to the varying fattiness and identified which component and how much of the subcutaneous tissue layer needed to be excluded to meet target flap thickness using computed tomography.

METHODS

Three stratified fattiness groups consisting of 30 donors were formed for thoracodorsal artery perforator, superficial circumflex iliac artery perforator, and anterolateral thigh flaps. Thickness of the superficial fat and the deep fat layers was measured at specific points in donor sites of the three flaps and the proportion of superficial and deep fat layers to exclude to reach the target flap thickness (4, 6, and 8 mm) was calculated.

RESULT

The median proportion for the superficial fat layer varies depending on donor fattiness. The estimated percentage reduction of thickness after thin flap elevation along superficial fascia was approximately one-third of the whole layer. A variable proportion of each fat layer needs to be excluded to obtain required thinness and in very thick groups, part of the superficial fat layer must be removed to reach any of the target thicknesses for the three flaps.

CONCLUSIONS

The present study demonstrated the frequent need for superficial fat layer manipulation when obtaining a thin perforator flap. To cope with various combinations of donor-site fattiness and different required thicknesses effectively, an appropriate thinning method should have increased adaptability, including the ability to control superficial fat layer thickness.

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.

The Superficial Femoral Artery Flap: A 3-Dimensional Anatomical Study

BACKGROUND

The superficial femoral artery perforator (SFAP) flap offers advantages for pedicled transfer including consistent perforators and vascular territory, well-hidden donor site scar, and hairless flap skin. This article provides a historical overview of the SFAP flap and describes the vascular anatomy of the SFAP by 3-dimensional analysis and angiography.

METHODS

Ten fresh cadavers were injected using the lead oxide technique through the femoral artery. Spiral computed tomographic scanning and 3-dimensional evaluation were used to describe the SFAP number, diameter, length, type, and location.

RESULTS

A total of 288 perforators in 15 cadaver limbs were identified; 19 ± 8 perforators per thigh ≥0.5 mm in diameter, with an average diameter of 0.8 ± 0.3 mm and a range of 0.5 to 2.1 mm; the mean length of each perforator was 68 ± 31 mm; 45% were septocutaneous and 55% were musculocutaneous. The medial thigh region was divided into 6 areas (anterior and posterior halves, then the proximal third, middle third, and distal third of each). The majority of the perforators were located in the middle and distal thirds of the anteromedial thigh (33% each).

CONCLUSIONS

Using 3-dimensional vascular anatomical analysis, the number, location, length, type, and diameter of the SFAP were documented. In the literature, relatively few reports of the use of the SFAP flap are available, however, this is a valid donor site with consistent cutaneous perforators suitable for harvest as a local or regional flap transfer. This is the first 3-dimensional vascular anatomical study to comprehensively document the vascular anatomy of the SFAP flap.

Versatility of Free Cutaneous Flaps for Upper Extremity Soft Tissue Reconstruction

The goals of upper extremity soft tissue reconstruction should go well beyond providing coverage and restoring function. As the field of reconstructive microsurgery has evolved, free cutaneous flaps (FCFs) are gaining wider application. The advantages of FCF include minimizing donor-site morbidity by preserving the muscle and fascia, improving versatility of flap design, and superior aesthetic results. This review highlights the application of anterolateral thigh, superficial circumflex iliac artery, deep inferior epigastric perforator, superficial inferior epigastric artery, and flow-through flaps for reconstruction of upper extremity defects. These flaps share several qualities in common: well-concealed donor sites, preservation of major arteries responsible of providing inflow to distal extremity, and potential for a two-team approach (donor and recipient sites). While the choice of flaps should be decided based on individual patient and defect characteristics, FCF should be considered as excellent options to achieve the goals of upper extremity reconstruction.

Calf Perforator Flaps: A Freestyle Solution for Oral Cavity Reconstruction

BACKGROUND

Reconstruction of oral cavity defects requires a thin, pliable flap for optimal functional results. Traditional flap choices are imperfect: the anterolateral thigh flap is excessively thick, whereas the radial forearm flap has a poor donor site. The authors therefore favor calf perforator flaps such as the medial sural artery perforator flap to provide thin tissue with an acceptable donor site. This two-part study aims to demonstrate their suitability for intraoral reconstruction.

METHODS

In the radiologic part of the study, the authors compared thigh and calf tissue thickness by examining lower limb computed tomographic scans of 100 legs. For their clinical study, they collected data prospectively on 20 cases of oral cavity reconstruction using calf perforator flaps.

RESULTS

The mean thickness of the calf tissue envelope was significantly less than that of the thigh (8.4 mm compared with 17 mm) based on computed tomographic analysis. In the clinical study, a medial sural artery perforator was used in the majority of cases (17 of 20). The mean pedicle length was 10.2 cm and the mean time to raise a flap was 85 minutes. There were no flap losses. One patient was returned to the operating room for management of late hematoma and wound dehiscence.

CONCLUSIONS

Calf perforator flaps provide ideal tissue for intraoral reconstruction and are significantly thinner than anterolateral thigh flaps. In addition to medial sural artery perforator flaps, the authors raised both sural and soleal artery perforator flaps in this series. Opportunistic use of the calf donor site allows the harvest of thin tissue with minimal donor-site morbidity.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Combined Use of an Anterolateral Thigh Flap and Superficial Inferior Epigastric Artery Flap for Reconstruction of an Extensive Abdominal Wall Defect

Reconstruction of large abdominal wall defects is challenging. We herein report the successful reconstruction of an extensive abdominal wall defect using a novel combination of flaps after sarcoma resection. A 74-year-old man presented with a dedifferentiated liposarcoma on his abdominal wall. He underwent excision of the tumor, which resulted in an extensive abdominal wall defect. The defect was reconstructed with a pedicled anterolateral thigh flap with an iliotibial tract and a pedicled superficial inferior epigastric artery flap. No skin graft was necessary. The wounds healed successfully, and no herniation occurred. The combination of an anterolateral thigh flap and a superficial inferior epigastric artery flap is a versatile option for reconstruction of extensive abdominal wall defects.

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.

Reconstruction of foot and ankle defects with a superthin innervated anterolateral thigh perforator flap

BACKGROUND

An anterolateral thigh (ALT) perforator flap can be thinned to an extent to which it is vascularised only by the subdermal plexus. This study presents an innervated flap thinning technique and its application for dorsal foot and ankle resurfacing.

METHODS

A superthin innervated ALT perforator flap was used to repair the dorsal foot and ankle of 12 patients. The perforators were classified according to their variations in the adipose layer, and the corresponding microdissection technique was then applied. The branch of the lateral femoral cutaneous nerve and its accompanying vessels were adopted to construct a sensory flap.

RESULTS

The flap thickness before defatting, which was measured immediately after flap elevation, ranged from 25-45 mm. The average flap thickness after defatting was 4.55 mm (range = 3-6 mm). A total of 11 flaps completely survived, and one flap presented superficial necrosis within a small area (2 cm ×2 cm) in the distal part of the flap. No further flap revision or defatting procedures were required for these patients during an average follow-up period of 16.5 months (range = 10-24 months). In the transferred flap, protective sensibility existed in all cases, and the static two-point discrimination was 13-16 mm.

CONCLUSIONS

The superthin innervated ALT perforator flap may be considered as an ideal strategy for foot and ankle reconstruction.

Aesthetic and functional outcomes of the innervated and thinned anterolateral thigh flap in reconstruction of upper limb defects

Background. The anterolateral thigh (ALT) flap has been widely described in reconstruction of the upper extremity. However, some details require refinement to improve both functional and aesthetic results. Methods. After reconstruction of upper extremity defects using thinned and innervated ALT flaps, functional and aesthetic outcomes were evaluated with the QuickDASH scale and a Likert scale for aesthetic assessment of free flaps, respectively. Results. Seven patients with a mean follow-up of 11.57 months and average flap thickness of 5 mm underwent innervation by an end-to-end neurorrhaphy. The average percentage of disability (QuickDASH) was 21.88% with tenderness, pain, temperature, and two-point discrimination present in 100% of cases, and the aesthetic result gave an overall result of 15.40 (good) with the best scores in color and texture. Conclusions. Simultaneous thinning and innervation of the ALT flap lead to a good cosmetic result and functional outcome with a low percentage of disability, which could result in minor surgical procedures and better recovery of motor and sensory function. Level of Evidence. IV.

Practical considerations for perforator flap thinning procedures revisited

BACKGROUND

A thin perforator flap is one of the best methods for covering defects. This study aimed to revisit and further test the rapidly advancing field of flap thinning techniques.

METHODS

We performed two cadaveric studies to test the known flap thinning methods, and then applied these methods to a clinical series. In the first study, five cadavers were used to observe the anatomical relation of the perforator with the subdermal plexuses and the subcutaneous fat layer by injecting a colored latex solution. The second study was done on four cadavers independently from the first study. Last, a clinical series was performed on 15 patients.

RESULTS

The areolar fat lobules of 10 anterolateral thigh perforator (ALT), seven deep inferior epigastric artery perforator (DIEAP), and six thoracodorsal artery perforator (TAP) flaps were dissected to reduce the flap thickness guided by the colored vascular pattern. On average, the ALT, DIEAP, and TAP flaps were reduced to 32.76%±9.76%, 37.01%±9.21%, and 35.42%±9.41%, respectively. In the second study, the areolar fat lobules were directly dissected in six ALT, six TAP, and four MSAP flaps, and an average reduction in flap thickness of 53.41%±5.64%, 52.30%±2.88%, and 47.87%±6.41%, respectively, was found. In the clinical series, 13 out of the 15 cases yielded satisfactory outcomes with an average thickness reduction of 37.91%±7.15%.

CONCLUSIONS

These multiple studies showed that the deep fat layer could be safely removed to obtain a thin yet viable perforator flap. This evidence suggests that the macroscopic flap thinning technique can achieve thin flaps. Surgeons should consider this technique before embracing the latest technique of supermicrosurgery.

Anterolateral thigh flap thinning: techniques and complications

BACKGROUND

A thinned anterolateral thigh flap is often necessary to achieve optimal skin resurfacing. In this article, we describe the techniques available for immediate flap thinning and the vascular complications that can follow trimming.

MATERIALS AND METHODS

A systematic literature review was performed to identify the different thinning techniques and any possible complications. Data were identified by performing a systematic search on Medline, Ovid, Embase, the Cochrane Database of Systematic Reviews, Current Contents, PubMed, Google, and Google Scholar. We cross-referenced the identified articles and conference abstracts in the English and French languages.

RESULTS

The study selection process was adapted from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, and 34 were articles compiled by using the study inclusion criteria. These articles were then reviewed for the author name(s), the publication year, the flap dimensions, the flap thickness (both before and after thinning), the perforator type, the type of flap transfer, the complications that followed the thinning, the thinning technique used, the amount of deep fascia preserved around the perforator, the number of cases in the study, the area of application, and the technique used for donor-site closure. We analyzed the possible vascular complications that stemmed from the flap area site selected, the flap thickness, the thinning technique used, and whether the deep fascia was spared.

CONCLUSIONS

The subfascial dissection of anterolateral thigh flaps revealed that the safest method for minimizing vascular complications accounted for a 3.1% probability for marginal necrosis, which can be managed conservatively. The overall breakdown of the vascular-related complications that followed flap thinning totals 13.4% and can be broken down as follows: partial flap loss of 4.1%, partial distal necrosis of 3.5%, marginal necrosis of 3.1%, and total flap loss of 2.5%.

Tensor fascia latae perforator flap: An alternative reconstructive choice for anterolateral thigh flap when no sizable skin perforator is available

Introduction:

The anterolateral thigh flap (ALT) is a versatile flap and very useful for the reconstruction of different anatomical districts. The main disadvantage of this flap is the anatomical variability in number and location of perforators. In general, absence of perforators is extremely rare. In literature, it is reported to be from 0.89% to 5.4%. If no sizable perforators are found, an alternative reconstructive strategy must be considered. Tensor fascia lata (TFL) perforator flap can be a good alternative in these cases: Perforator vessels are always present, the anatomy is more constant and it is possible to harvest it through the same surgical access. The skin island of the flap can be very large and can be thinned removing a large part of the muscle allowing its use for almost the same indications of the ALT flap.

Materials and Methods:

We report 11 cases of reconstruction firstly planned with the ALT flap, then converted into TFL perforator flap.

Results and Conclusion:

The result was always satisfactory in terms of the donor site morbidity and reconstructive outcome.

The superficial fascia as a new plane of elevation for anterolateral thigh flaps

The elevation plane for the anterolateral thigh perforator flap is either subfascial or suprafascial approach. But extensive debulking is frequently performed with possibilities of endangering viability. We hypothesized that by elevating the flap in the layer between the deep and the superficial fat, the superficial fascia, we will be able to achieve elevation of a thin and hemodynamically reliable flap without wasting human tissue. This approach was performed on 54 cases. The average weight was 68.1 kg, and average body mass index was 24.6 kg/m. Primary closure was performed on 18 cases and skin grafts on 36 cases. Evaluation for flap survival, contour of the flap, and donor site were performed. All 54 flaps were successfully elevated with at least one viable perforator with this approach. Total flap loss was noted in 1 case, resulting in a 98% survival rate. Secondary debulking was performed on 3 cases whose body mass index was >29. Regarding donor site, the primarily closed sites showed no complications, and the grafted skin over the deep fat leads to similar contour compared with the contralateral side. The study shows that this new plane can be used as a level of elevation while acting as a guide to promise adequate blood supply based on the subdermal plexus.

Clinical application of thin anterolateral thigh flap in the reconstruction of intraoral defects

OBJECTIVE

The purpose of this study was to assess the clinical features and therapeutic efficacy of intraoral defect reconstruction with thin anterolateral thigh flaps.

METHODS

A total of 34 patients underwent simultaneous tumor resection and intraoral defect reconstruction with free thin anterolateral thigh flaps.

RESULTS

There were 16 male and 18 female patients; the ratio of males to females was 0.9:1; the mean age was 55.4 years. In these 34 patients, 26 flaps were musculocutaneous perforators (76.5%) and 8 flaps were septocutaneous perforators (23.5%). Partial loss of flap occurred in 2 patients (5.9%).

CONCLUSIONS

The free thin anterolateral thigh flap was the ideal soft tissue flap in intraoral defect reconstruction. This thin flap presents good functional results at the receiving site with the additional advantages of minimal donor-site morbidity and a high level of patient satisfaction.

Free-flap harvesting from paralytic limbs of poliomyelitis patients--a safe and feasible option

BACKGROUND

Many patients who had childhood poliomyelitis are still suffering from the late sequalae of the condition. Free-flap harvesting from the paralytic limbs from these patients is a logical approach for functional preservation. However, concerns have been raised regarding its safety due to its hypoplastic vascular system and potential donor site healing problems.

CASE REPORT

A 53-year-old man with known childhood poliomyelitis presented with left facial sarcoma. After wide excision, the defect was reconstructed with a dual-island fasciocutaneous-free anterolateral thigh flap harvested from his paralytic limb. The pedicle and perforators were found to be no different from those in normal limbs. His recovery was smooth without complications.

CONCLUSIONS

On the basis of our experience and current evidence in the literature, we believe that free-flap harvesting from the paralytic lower limb in poliomyelitis patients is a safe option that incurs no additional risk and allows maximal function preservation.

Clinical applications of the pedicled anterolateral thigh flap in complex abdominal-pelvic reconstruction

BACKGROUND

The free anterolateral thigh (ALT) flap has become a reconstructive workhorse with great versatility throughout the body. However, the utility of the pedicled ALT flap is less described for complex defects. A skin paddle with reliable blood circulation and wide range of reach, low donor site morbidity along with the avoidance of many of the complications plaguing free flaps, are just some of the several benefits offered by the pedicled ALT flap. We investigated specific clinical examples within our ALT flap database where the pedicled ALT flap was used for coverage of complex wounds and highlight its advantages.

METHODS

We conducted a retrospective chart review on those patients in whom a pedicled ALT flap was used for complex wound reconstruction over a 7-year period between July 2002 and October 2009 at The R Adams Cowley Shock Trauma Center performed by a single surgeon.

RESULTS

: Four patients underwent a pedicled ALT flap as part of their reconstruction. Flaps ranged in size from 75 to 648 cm, and all but one were cutaneous in nature with the other one being fasciocutaneous. The flaps averaged 2 perforators (range, 1-3) and the donor sites were all closed primarily except for one.

CONCLUSIONS

When faced with a complex defect in the abdominal-pelvic region, we propose that the pedicled ALT flap has several advantages to other types of tissue coverage and is an excellent option for the reconstructive surgeon.

Is primary thinning of the anterolateral thigh flap recommended?

BACKGROUND

Although primary thinning of the anterolateral thigh (ALT) flap has been successful in Asia, clinical and anatomic studies have demonstrated that this may be inadvisable in Western patients. Recent reports have demonstrated successful thinning of the ALT using smaller flaps. A systematic review was attempted, to assess whether ALT size affects the incidence of vascular compromise after primary thinning.

METHODS

A systematic review was undertaken to examine the relevant literature. Student t-test was used to compare flaps that did and did not have complications. Fisher exact test was used to compare outcomes of flaps measuring less than and greater than 150 cm2.

RESULTS

Eleven articles met the inclusion criteria. Eighty-eight ALT flaps were reported, and vascular compromise was seen in 11 (12.5%). The average size of flaps that demonstrated necrosis was 180.73 cm2; those without necrosis averaged 123.19 cm2 (P = 0.06). Flaps >150 cm2 had a significantly increased rate of compromise (25.93% vs. 6.56%; P < 0.05).

CONCLUSIONS

A systematic literature review confirms that it is inadvisable to primarily thin large ALT flaps in the Western population. When large ALT flaps are required, primary thinning must be avoided to keep linking vessels intact.

Reconstruction of soft-tissue defects of the head and neck: radial forearm flap or anterolateral thigh flap?

This study compared the reliability, practicability and impact to donor site functionality of radial forearm (RF) and anterolateral thigh (ALT) flaps used for the reconstruction of head and neck soft-tissue defects. The clinical data of patients who underwent reconstruction using RF flaps (n = 53) and ALT flaps (n = 21) after tumour ablation were reviewed. Pedicle length, skin area harvested and flap survival rate were compared between the two flap types. A questionnaire was used to compare the patients' perceptions of donor site functionality. Pedicle length did not significantly differ between RF and ALT flaps (7.5 vs. 9 cm, p = 0.733). A significantly larger mean area of skin was harvested in the ALT group than in the RF group (65 vs. 38 cm(2), p = 0.001). Flap survival rates did not differ between the two groups (p = 0.554). Patients in the ALT group were more satisfied with the appearance of the donor sites than were those in the RF group (p = 0.029). Significantly more patients in the RF group complained of donor site numbness than in the ALT group (p = 0.014). No ALT group patients complained of movement impairment or weakness at the donor sites, but 10% of RF group patients experienced impairment (p = 0.014) and 35% felt weakness (p = 0.001). The ALT and RF flaps showed similar practicability and reliability for the reconstruction of soft-tissue defects, but ALT flaps had fewer impacts to donor site functionality than RF flaps.

The use of the extended anterolateral thigh flap for reconstruction of massive oncologic defects

BACKGROUND

Although the anterolateral thigh flap has been used extensively in reconstruction, the use of large or extended skin paddles (i.e., >240 cm) is thought to be associated with an increased risk of partial flap necrosis. This assumption may be attributable to cadaver perfusion studies of isolated anterolateral thigh flaps. The authors' clinical experience has shown, however, that significantly larger flaps can be reliably harvested based on the standard skin perforators. The purpose of this report was therefore to evaluate the authors' clinical experience with the extended anterolateral thigh flap for reconstruction of oncologic defects.

METHODS

All consecutive patients who had undergone reconstruction of oncologic defects using an extended anterolateral thigh flap (defined as >or=240 cm) were identified. Patient characteristics and outcome data were analyzed.

RESULTS

Fifteen patients met the inclusion criteria (flap size >240 cm) during the study period. The average size of the flaps was 341 cm (range, 240 to 480 cm). All flaps were perforator flaps and most had one perforator. In two patients, anterolateral thigh- and tensor fasciae latae-based perforators were used. There was one total flap loss on postoperative day 7 caused by recipient vessel spasm. One patient had partial necrosis of the distal portion of the flap with delayed healing.

CONCLUSIONS

The anterolateral thigh flap is an excellent choice for massive defects requiring skin and soft-tissue coverage. The flap can be extended safely beyond the limit of 240 cm as suggested by cadaver perfusion studies. Inclusion of tensor fasciae latae perforators may increase the blood supply of the flap proximally; however, in general, a single perforator is capable of supplying a large area of the lateral thigh.

Use of the descending branch of lateral circumflex femoral artery as a recipient pedicle for coverage of a knee defect with free flap: anatomical and clinical study

BACKGROUND

With recent advances in free tissue transfer, soft tissue defects involving the knee can be covered perfectly utilizing various free flaps. Yet the success of this operation depends on a secure nontraumatic recipient pedicle around the knee area. The purpose of this study is to introduce the descending branch (DB) of the lateral circumflex femoral artery (LCFA) as a new recipient pedicle for knee defect coverage.

METHODS

Through autopsies of eight cadavers and a total of 11 extremities involving the area 10- and 15-cm above the upper margin of the patella, the number and sizes of the artery and vein of the descending branch of the lateral circumflex femoral artery were investigated. In a clinical setting, two cases of soft tissue defects in the area of the knee were reconstructed utilizing the DB of the LCFA with an anterolateral thigh perforator (ALTP) free flap on the ipsilateral side.

RESULTS

Anatomical: The descending branches of the lateral circumflex femoral vessels measuring 10- and 15-cm above the lateral aspect of the patella numbered 1 artery and about 1.5 veins. The diameters of these vessels ranged from 1.0 to 2.0 mm (1.4 +/- 0.4 mm) for the artery at 10-cm site and 1.0 to 3.0 mm (1.9 +/- 0.5 mm) at the 15-cm site and 0.8 to 2.0 mm (1.2 +/- 0.4 mm) for the vein at the 10-cm site and 1.0 to 3.0 mm (1.9 +/- 0.5 mm) at the 15-cm site. Under clinical conditions, the two case flaps survived well without major complications. The clinical follow-up period was from 12 to 14 months (mean: 13 months).

CONCLUSIONS

The advantage in using this recipient pedicle lies not only in its superficial aspect but also in the protection offered by the surrounding muscle. Thus the defect could be reconstructed efficiently without stress upon the surgeon; if the ALTP flap of the ipsilateral side was used, the defect could be reconstructed efficiently within the same surgical field.