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

Application of tensor fascia lata perforator flap in head and neck reconstruction

The aim of this study was to describe the authors' experience in head and neck reconstruction with the tensor fascia lata perforator flap (TFLPF). Between April 2009 and August 2020, 16 patients underwent head and neck reconstruction with a TFLPF. The flaps were designed in a vertical or transverse fashion based on perforators traveling along the medial or lateral aspect of the posterior edge of the tensor fascia lata muscle. Clinical details and postoperative results were recorded and analyzed. The size of the flap ranged from 7 × 5 cm2 to 25 × 9 cm2. The perforators were mostly septocutaneous (11 patients), allowing a simple and straightforward dissection of the perforator and TFLPF in most patients. There were either one or two perforators in all cases. The overall flap survival rate was 100%. All of the flaps healed uneventfully with no delayed wound healing or donor site dysfunction. Follow-up ranged from 18 to 120 months, during which all patients experienced satisfactory functional and aesthetic results, without serious complications at either the recipient or donor site. The TFLPF is a pliable and reliable flap that could be a first choice in selected head and neck reconstruction cases.

Thigh reconstruction between form and function: An algorithm for flap selection based on a series of 70 oncological patients

INTRODUCTION

Thigh reconstruction after oncological resection represents a challenge in terms of ideal morphological and functional outcomes to aim for. Very few papers presented a comprehensive approach to this topic, most of them being only small cases series. The purpose of this article was to review our institutional experience in the field of thigh soft-tissue reconstruction, proposing an algorithm to choose the most convenient pedicled or free flap approach according to the different clinical scenarios and the specific morpho-functional requirements of the case.

PATIENTS AND METHODS

The authors retrospectively reviewed patients who received flap reconstruction for thigh soft-tissue defects after oncological resection between 2014 and 2021. Demographic and operative data were recorded. Twelve months post-operatively, patients were asked to rate the esthetic and functional outcomes of the reconstructive procedure on a 5-point Likert scale. Additionally, for patients receiving a free functional muscle transfer to restore quadriceps or hamstring function, recovery was evaluated with the Medical Research Council Scale for Muscle Strength.

RESULTS

Seventy flap reconstructions of the thigh were, respectively, performed after sarcoma (n = 43), melanoma (n = 13) and non-melanoma skin cancer (n = 14) resection. Pedicled flaps were used in 55 patients: 46 perforator flaps (32 ALT, 4 AMT, 4 PAP, 2 TFL, 2 MSAP, 2 DIEP) and 9 muscle or myocutaneous flaps (4 medial gastrocnemius, 2 gracilis, and 3 VRAM). Microsurgical reconstruction was performed in 15 patients for extensive defects (2 SCIP, 1 latissimus dorsi-LD, 1 thoracodorsal artery perforator-TDAP, 1 ALT, 2 DIEP flaps) or when >50% of the quadriceps or hamstring compartments were resected (eight free functional muscle transfer including five vastus lateralis, two LD, and one rectus femoris). Extensive defect surface, previous irradiation and neoadjuvant chemotherapy appeared to be predictors of free flap reconstruction. Complication (49% vs. 26.6%; p > .05) and readmission rates (32.7% vs. 13.3%; p > .05) were comparable between pedicled and free flap groups, as well as complications severity scores according to Clavien-Dindo classification (1.15 vs. 1.29; p > .05). However, patients with previous irradiation experienced worse outcomes when receiving pedicled rather than free flaps in terms of reintervention (87.5% vs. 28.6%; p = .04) and readmission rates (87.5% vs. 14.29%; p = .01), and severity of surgical complications. Overall patients' satisfaction was high, with esthetic and functional mean score of 4.31 and 4.12, respectively (p > .05). In the FFMT group, M5, M4, M3, and M2 strength was observed in 3, 3, 1, and 1 patients, respectively.

CONCLUSION

Oncological thigh defects are usually well addressed with pedicled perforator flaps. Microsurgical reconstruction offers reliable and reproducible results in extensive defects and in previously irradiated fields or when functional restoration is indicated.

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.

Case report of Hand salvage post burn using pedicled tensor fascia lata (TFL)

INTRODUCTION AND IMPORTANCE

Burn still the major cause of disabilities and challenge facing both patient and surgeon, and when hands were affected a comprehensive planning and work must be obtained to restore functional and aesthetic aspects of hand. Tensor fascia lata (TFL) considered since centuries a useful tool to save hand post burn either it was been harvested with pedicle or as free flap. Although pedicle TFL became seldom but it may be the best option for hand reconstruction. In this article we report a case of hand burn that was managed by pedicle TFL.

CASE PRESENTATION

A 32 year- old man was involved in thermal burn affected multiple areas of his torso and limbs. He was referred to hospital from primary health care center. At hospital reassessment of the patient done was hemodynamic stable and inhalation injury was excluded. Burn estimated at 36 % total body surface area (TBSA) distributed through trunk and left upper limb, but left hand was the most affected area.

CLINICAL DISSOCIATION

After stabilization, he underwent serial debridement and dorsum of hand became skeletonized with exposed bones and tendon. Pedicled tensor fascia lata eventually choose to resurface hand, and fortunately enough covered all hand.

CONCLUSION

Tensor fascia late flap still has favorable use, easy applicable and expected outcome. in this article we report post burn hand injury that managed by pedicled tensor fascia lata.

Successful functional salvage of a hindfoot injury with isolated soft tissue reconstruction: a case report

Calcaneus has an important functional role in walking, running, gait and transferring 80% of total weight. Due to the paramount role of the calcaneus in function, there is a trend toward ‘below knee amputation’ for such heel injuries, associated with complete loss of calcaneus. Complex calcaneal defects represent a reconstructive challenge, due to few reported cases in the literatures, limited surgical options, and lack of long-term outcomes. We present a young patient regaining near normal function, weight bearing and independent walking after sustaining complex hindfoot defect that resulted in total loss of the calcaneus secondary to a landmine blast injury managed by soft tissue reconstruction only without skeletal reconstruction.

Chimeric ALT Plus TFL Perforator Flap for Breast Reconstruction Post Radical Mastectomy with Large Skin Defect

A 17-year-old girl with large malignant phyllodes tumor of left breast underwent a radical mastectomy with large skin excision resulting in defect of 20 cm × 18 cm. Postoperative radiation therapy necessitated robust cover with flap. The challenge was compounded by her body habitus. Both abdomen and back were deficient as donor sites and a single-island anterolateral thigh (ALT) flap would need skin grafts, volume deficit withstanding. We harvested chimeric ALT plus tensor fascia lata (TFL) perforator free flap sparing all muscles and nerves. Microvascular anastomoses were done to the second internal mammary artery (IMA) perforator artery and vein. The donor site was closed primarily. The TFL flap territory recruited almost three times the volume of ALT territory and allowed us to create a matching breast mound in addition to covering the defect. She tolerated 40 Gy radiation well and doesn’t desire further augmentation. Consistency of ALT and TFL perforators makes this a replicable procedure.

Chimeric Anterolateral Thigh Flap for Primary Functional Reconstruction of Complex, Composite Near Total Hemi Facial Post Excision Defects

INTRODUCTION

Microvascular free tissue transfer has revolutionized the management of complex composite head and neck defects.

AIM

To evaluate the functional and aesthetic outcomes in the primary reconstruction of post-excisional near total hemifacial defects with the chimeric anterolateral thigh flaps (cALT).

MATERIALS AND METHODS

The author as a prelude to this clinical study has done a cadaveric study on the quadriceps artery angiosome. In this retrospective cohort study, data are collected from the records of 6 patients who had undergone primary cALT flap reconstruction for their post excisional near total hemifacial defects from January 2013 to December 2017. All 6 patients with various advanced malignancies involving the hemiface underwent wide local excision. Wide local excision resulted in the loss of skin and critical facial muscles that led to near total hemiface composite defects. Reconstructions were done with the cALT flaps that included segment of the vastus lateralis muscle harvested on its independent neurovascular perforator pedicle and the skin paddle on a separate perforator. In all cases, the facial nerve stumps were anastomosed to the nerve to vastus lateralis for reanimation of the face. In addition, 4 patients underwent primary radical neck dissection, but all had postoperative radiotherapy and chemotherapy.

RESULTS

All patients attained well-pronounced nasolabial fold, symmetrical smile, and good oral competence in an average period of 10.75 months post operatively. In an average of 22 months follow up, none of them had locoregional recurrences. None required any secondary procedures.

CONCLUSION

In the post excisional near total hemifacial composite defects, primary functional reconstruction with tailored cALT flaps can bring good aesthetic and functional results.

Perforator Variability of the Anterolateral Thigh Flap Identified on Computed Tomographic Angiography: Anatomic and Clinical Implications

BACKGROUND

 The anterolateral thigh (ALT) flap is a useful flap with minimal donor site morbidity. Preoperative computed tomographic angiography (CTA) for lower extremity reconstruction can determine vessel integrity and plan for recipient vascular targets. This study reviews lower extremity CTAs to further characterize ALT vascular anatomy and associated clinical implications thereof.

PATIENTS AND METHODS

 Lower extremity CTA studies were retrospectively reviewed, and information on ALT cutaneous perforator location, origin, and course was collected.

RESULTS

 A total of 58 lateral circumflex femoral artery (LCFA) systems in 31 patients were included. Average age was 38.8 ± 15.9 years with mean body mass index of 27.2 ± 5.7 kg/m². The majority of patients were females (23, 74.2%). The LCFA most commonly originated from the profunda femoris artery (87.3%), followed by the distal common femoral artery (9.1%). On average, there were 1.66 ± 0.69 cm perforators per extremity, with an average of 5.38 cm between adjacent perforators. Perforators originated from the descending branch of the LCFA in 89.6% of studies. Perforator caliber was <1 mm (29, 30.2%), 1 to 2 mm (55, 57.3%), or >2 mm (12, 12.5%). Mean distance from the most proximal perforator to the anterior superior iliac spine was 20.4 ± 4.82 cm. Perforators were musculocutaneous (46.9%), septocutaneous (34.4%), or septomyocutaneous (18.8%). In 58.1% of patients, only one thigh had easily dissectable septocutaneous and/or septomyocutaneous perforators, in which case preoperative CTA aided in donor thigh selection.

CONCLUSION

 ALT flap cutaneous perforator anatomy varies considerably. Using CTA, we report on rates of septocutaneous, myocutaneous, and septomyocutaneous perforators and underscore its utility in perforator selection.

A Description of the Vascular Anatomy of the Tensor Fascia Lata Perforator Flap Using Computed Tomography Angiography

BACKGROUND

The perforator anatomy of the tensor fascia lata (TFL) flap has been studied using cadaver dissection; however, exact descriptions of location, size, and origin of perforator vessels using preoperative imaging modalities remain limited. The aims of this study are to describe TFL perforator anatomy using high-resolution computed tomography angiography (CTA) and to correlate these findings with landmarks for the anterolateral thigh flap to facilitate flap planning.

METHODS

We identified 33 patients who previously underwent bilateral lower extremity CTAs for preoperative planning of free-flap reconstruction. The images were retrospectively reviewed, and the TFL perforator number, size, type, location, and overall pedicle origin and length were recorded.

RESULTS

Thirty-three patients and 59 thighs were included in the study. There was an average of 2.5 perforators per TFL. All perforators arose from the ascending branch of the lateral circumflex femoral artery with an average pedicle length of 8.3 cm (range, 6.0-11.2 cm). Sixty-six percent of perforators were septocutaneous and 34% were musculocutaneous. The average perforator size as measured on CTA was 3 mm. The average perforator location was 10.1 cm inferior and 8.5 cm lateral to the line drawn from the anterior superior iliac spine to the superolateral patella.

CONCLUSIONS

To our knowledge, this is the first study to characterize the vascular anatomy of the TFL perforator flap using high-resolution CTA and correlate this with well-established landmarks used in the planning for other thigh-based flaps. We believe data will facilitate flap design and dissection; potentially shortening operating room times, limiting exploratory incisions used to confirm the presence of thigh based perforators, and improving overall outcomes for patients.

Versatility of pedicled tensor fascia lata flap: a useful and reliable technique for reconstruction of different anatomical districts

Aims and Objectives. The aim of this study was to evaluate the versatility of pedicled tensor fascia lata flap for reconstruction of various anatomical regions. Materials and Methods. In this retrospective study a total of 34 patients with defects over various anatomical regions were included. The defects were located over the trochanter (n = 12), groin (n = 8), perineum (n = 6), lower anterior abdomen (n = 6), gluteal region (n = 1), and ischial region (n = 1). The etiology of defects included trauma (n = 12), infection (n = 8), pressure sores (n = 8), and malignancy (n = 6). Reconstruction was performed using pedicled tensor fascia lata flaps. Patients were evaluated in terms of viability of the flap and donor site morbidity. The technical details of the operative procedure have also been outlined. Results. All the flaps survived well except 5 patients in which minor complications were noted and 1 who experienced complete flap loss. Of those with minor complications, 1 patient developed distal marginal necrosis and 1 developed infection which subsided within three days by dressings and antibiotics and in 2 patients partial loss of the skin graft occurred at the donor site out of which 1 required regrafting and another one healed completely with dressing and antibiotics. All the patients were followed up for an average period of 6 months, ranging from 1 to 12 months. Donor site morbidity was minimal. Conclusion. It was concluded that the pedicled tensor fascia lata flap is a versatile, reliable, easy, and less time consuming procedure for the coverage of defects around trochanter, groin, lower anterior abdomen, perineum, and ischial region.