Use of the pedicle of previously harvested pectoral myocutaneous flap as a recipient for free flaps in head and neck reconstruction

INTRODUCTION

The pectoral myocutaneous flap (PMF) is a workhorse regional reconstructive option for head and neck defects. It is commonly used for primary reconstructions due to its advantages or as a life-boat flap in the salvage of failed reconstructions of free flaps. However, it also has intrinsic drawbacks, such as perfusion problems and partial or complete flap loss. Although there are many studies about the advantages and use of PMF in the literature, the number of studies about salvage of this workhorse flap is inadequate. We aimed to present the use of the pedicle of previously performed PMF as a recipient for free flaps in head and neck reconstruction.

METHODS

Between January 2022 and August 2023, 10 free flaps were used in nine patients (three females and six males) who had previously undergone head and neck reconstruction with PMF. The age of the patients ranged from 54 to 74 years. Seven out of the nine PMFs were previously performed by different surgical teams. Squamous cell carcinoma (SCC) was the reason for primary surgeries in all patients and the PMFs were used for right lower lip and right submandibular defect, left lower lip and mentum defect, lower lip defect, right lower lip and right submandibular defect, right retromolar trigone defect, right buccal defect, left anterolateral esophageal defect, right retromolar trigone defect and left anterolateral pharyngoesophageal defect reconstructions. The problems were partial skin island necrosis and wound dehiscence in six patients and total skin necrosis in three patients. The partial skin island necroses already showed that the pedicles were unproblematic. For patients with total skin island necrosis the muscle stalks so the pedicles were also unproblematic which were confirmed by physical examination and Doppler device. After complications, the finally defects were located in the lower lip, left lower lip and mentum, right lower lip and right submandibular area, left anterolateral esophageal area and left neck, right buccal area, right retromolar trigon, left anterolateral pharyngoesophageal fistula and left neck. The sizes of the defects were between 3 × 4 cm and 11 × 17 cm. For all patients, the pedicle of the previously harvested PMF was used as a recipient for free flaps. Since the PMF was flipped over the clavicula for the reconstruction previously, the pedicle was so close to skin or skin graft which was used for coverage of the muscle stalk. The Doppler device was used first over the clavicle where the PMF was flipped for vessel identification. After marking the vessels, a vertical zigzag incision was made on the skin or skin graft. The perivascular fatty tissue and the pedicle were encountered with minimal dissection by the guidance of Doppler. After meticulous microscopic dissection, the pedicle of PMF was prepared for anastomoses as usual. Six radial forearm free flap (RFFF) and four anterolateral thigh flap (ALT) flaps were used in the head and neck reconstructions for the nine patients.

RESULTS

The sizes of the flaps were between 4 × 5 cm and 12 × 17 cm. The diameters of the recipient arteries were between 0.9 and 1.2 mm. Recipient veins were approximately the same diameter as the arteries. In one patient, two vein grafts were used for lengthening both the artery and vein to reach recipient vessels. End-to-end anastomoses without vein grafts were performed in the remaining patients. One arterial thrombosis that manifested on the first postoperative day was salvaged successfully. Hematoma was seen in two patients and wound dehiscence was seen in three patients. There was no partial or total flap necrosis and all flaps survived. The follow-up period ranged from 2 to 12 months. Despite successful reconstructions, two patients died during the follow-up period due to unrelated conditions. Functional results were acceptable in the remaining patients.

CONCLUSION

The pedicle of previously used pectoral myocutaneous flaps may be a useful alternative option as the recipient for free flaps in head and neck reconstruction.

[Rare case of reconstruction of the anterior thigh compartment after resection of high-grade sarcoma by hybrid technique: Latissimus dorsi free flap associated with a medial gastrocnemius pedicled flap]

INTRODUCTION

The soft tissue sarcomas of the limbs require extensive surgical excision. Reconstructive surgery plays an essential role in its management to preserve the limb, as exposed in a case of thigh sarcoma.

CLINICAL CASE

A 73-year-old patient has a large sarcoma within the quadriceps. Its excision requires resection of the entire anterior thigh compartment. Preservation of the limb is permitted by reconstruction by latissimus dorsi free flap and medial gastrocnemius pedicled flap. The patient resumed walking using an orthosis at 3 months.

CONCLUSION

Surgery to remove a sarcoma of a limb can threaten the integrity of the limb. Plastic surgery, with all the reconstruction techniques, contributes to the preservation of a functional limb.

The Anatomical Course of the Femoral Nerve with Regard to the Direct Anterior Approach for Total Hip Arthroplasty

BACKGROUND

Femoral nerve (FN) injury is noted as a serious neurological complication following total hip arthroplasty performed via a direct anterior approach (DAA). Therefore, we aimed to clarify the anatomical course of the FN around the acetabular rim and in relation to retractor placement during DAA.

METHODS

According to standard protocol, a DAA for total hip arthroplasty was performed on 69 hemipelves from formalin-preserved full-body donors. The surgery was halted after retractor placement at the anterior part of the acetabulum. Then dissection was performed to expose the FN and the iliopsoas muscle. Various measurements were taken using a reference line from the anterior superior iliac spine to the acetabulum's center. A total of 6 measurement points, one every 30° from 0° to 150° along the reference line were used to determine the association between the FN and the retractor tip (RT) and the anterior acetabular rim.

RESULTS

The mean distance from the RT to the FN was 22.5 millimeters (mm). The distance from the FN to the anterior acetabular rim decreased from 0 to 90°, where it was 18.8 mm, before increasing again to 27.3 mm at 150°.

CONCLUSIONS

In our cadaveric study, the FN was within 11 to 36 mm of the RT. Second, we found the FN to be closest to the anterior acetabular rim at 90° and 120°. Accordingly, special care should be taken during retractor placement, and if possible, placement at 90° and 120° avoided.

High-frequency ultrasound-assisted perforator mapping enhances efficiency in microsurgical reconstruction using thin ALT and SCIP flaps

BACKGROUND

With the growing demand for the use of thin perforator flaps, obtaining knowledge on the superficial anatomy of perforators is imperative for stable flap elevation. Conventional modalities for perforator mapping fall short in providing such information. High-frequency ultrasound (HFUS), known for visualizing the superficially located anatomic structures, may potentially fill this void. This study aimed to evaluate the effectiveness of HFUS in the outcome of anterolateral thigh (ALT) and superficial circumflex iliac artery perforator (SCIP) flap-based reconstructions.

METHODS

Consecutive patients who underwent free ALT or SCIP flap-based reconstruction from January 2021 to November 2022 were retrospectively reviewed. Perforator mapping was conducted using a handheld Doppler during the first year, while HFUS was used in the latter part. The two techniques were compared in terms of flap harvesting time and perfusion-related complication rates while considering the flap elevation plane.

RESULTS

In total, 123 cases were analyzed, including 82 ALT flaps (41 in each group) and 41 SCIP flaps (16 in the Doppler and 25 in the HFUS group). The time required for flap elevation exhibited a tendency to decrease in the HFUS group, with a significant difference observed in cases involving thin flap elevation (super-thin ALT flaps and pure-skin-perforator SCIP flaps). Compared with the Doppler group, the HFUS group demonstrated significantly lower rates of PRCs, particularly partial flap necrosis. This difference remained significant in multivariable analyses.

CONCLUSION

Our results suggest that HFUS might be an appealing modality for perforator mapping in cases requiring thin ALT and SCIP 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.

[Free thin anterolateral thigh flap in head and neck surgery]

Előrehaladott szájüregi daganatok eltávolítása után kialakult kiterjedt szövethiányok helyreállítására funkciómegtartó céllal a leggyakrabban alkalmazott eljárás a mikrovaszkuláris technikával végzett szabad szövetátültetés. Hazánkban a felületes szájüregi hiányok helyreállítására a leggyakrabban választott szabadlebeny a radiális alkarlebeny. Elsősorban vastagabb vagy nagyobb kiterjedésű hiányokra alkalmazzuk az anterolateralis comblebenyt. Az alkarlebeny esetén azonban a donorterületi szövődményráta jóval magasabb. Vékonyított anterolateralis comblebeny a hátrányokat kiiktatva alkalmas lehet az alkarlebeny intraoralis alkalmazása helyett.A korábban nyelvtumor miatt operált, alkarlebennyel rekonstruált és besugarazott 69 éves nőbetegnél a korábbi műtéti terület szélén a követéses kontrollvizsgálat során recidív tumort verifikáltunk. Az Onkoterápiás Bizottság döntését követően a recidíva eltávolítását, tangencionális mandibula reszekciót és szabad lebenyes helyreállítást terveztünk tracheotomiás védelemben. Előzetes kézi dopplerrel és duplex ultrahanggal történő perforátor meghatározás után, a jobb combon a perforátorra centrálva 6 × 8 cm-es superficialis fascia rétegében vékonyított anterolateralis comblebenyt preparáltunk. A lebeny vastagsága 6-8 mm, az érnyél hossza 12 cm volt, mely az intraoralis hiányra ideális volt. A nyakon elkészített mikrosebészeti anasztomózis után a donorterületet primeren zártuk.A lebeny keringése mindvégig kielégítő volt. A tracheotomiát a posztoperatív 11. napon megszüntettük, perorális táplálkozása a posztoperatív 14. napon helyreállt.Az anterolateralis comblebeny sokrétűsége az anatómiájában rejlik. A korábban csak nagyobb és vastagabb hiányokra használt anterolateralis comblebeny jó adaptálhatósága és megfelelő mérete miatt felületesebb hiányokra is alkalmas. A korábban alkarlebennyel helyreállított hiányok pótlására a hasonló tulajdonságokkal rendelkező vékonyított anterolateralis comblebeny is alkalmazható azzal a jelentős előnyével együtt, hogy a donorhely morbiditása minimális az alkarlebennyel szemben.

The Value of Anterolateral Thigh Free Flap for the Reconstruction of Malignant Melanoma of the Sole of the Foot

BACKGROUND

Wide excision of malignant melanoma on the foot usually results in an extensive function-destroying defect, and the reconstruction of foot defects remains challenging for reconstructive surgeons. We propose using anterolateral thigh perforator (ALT) free flaps for the reconstruction of widespread defects caused by malignant melanoma in the sole.

METHODS

This retrospective study included 34 patients who underwent reconstruction of sole defects caused by malignant melanoma resection with 35 ALT perforator free flaps between August 2005 and July 2021.

RESULTS

In total, 18 male patients and 16 female patients were included (mean age at surgery, 65.4 years). The mean size of the flaps was 100.4 cm 2 . Thirty-three of the 35 flaps survived. Hematoma, seroma, and chronic ulceration were not identified in any cases. All patients achieved independent ambulation within the follow-up period, except 1 patient with gait discomfort. The 5-year overall and disease-free survival rates of patients were 64.4% and 56.6%, respectively.

CONCLUSIONS

The ALT flap is a versatile surgical option that should be considered for reconstruction of the sole after malignant melanoma resection, considering its various surgical advantages and the functional aspects of independent ambulation, the aesthetic aspects of wearing conventional footwear, and the anatomical aspects of the sole.

Unilateral Sacral Erector Spinae Plane Block for Thigh Amputation: Case Report

Selection of anesthetic technique for thigh amputation is complicated by patients' comorbid conditions. The sacral erector spinae plane block (ESPB) is an emerging technique with potential as a primary anesthetic for thigh amputation. We detail a case involving a 79-year-old undergoing thigh amputation, where sacral ESPB proved insufficient, prompting a shift to spinal anesthesia. This instance underscores the necessity for further investigation into the reliability of the sacral ESPB for lower limb surgeries. Until such evidence is established, caution is advised in relying solely on the sacral ESPB for thigh amputations, and consideration of alternative techniques is recommended.

The Role of the Fascia-Only Anterolateral Thigh Flap in Extremity Reconstruction: The Fascia-Only Anterolateral Thigh Flap

BACKGROUND

Free flap selection in extremity reconstruction can be challenging. The ideal flap has to be thin and pliable to achieve optimal contour and function. We explore the role of the fascia-only anterolateral thigh (fALT) flap in extremity reconstruction.

METHODS

We conducted a retrospective review of our experience using fALT-free flap for extremity reconstruction over a 2-year period. Patient demographics, mechanism of injury, flap characteristics, complications- and follow-up were recorded. Descriptive statistics were calculated.

RESULTS

Twelve patients were included. The median (interquartile range [IQR]) age was 34 (28-52) years. One fALT flap was used for upper extremity reconstruction, while 11 flaps were used for lower extremity reconstruction (4 for lower third of the leg, 4 for dorsum of foot, and 3 for heel). The median (IQR) flap surface area was 90 (63-120) cm2 and time from injury to reconstruction was 10 (6-16) days. The postoperative course was uneventful for all flaps except for 1 flap failure and 1 delayed healing. The median (IQR) follow-up was 2 (1-4) months. In all cases, durable soft tissue reconstruction was achieved with no need for revisions.

CONCLUSIONS

The fALT-free flap can be successfully used in extremity reconstruction. The ALT fascia has robust perfusion that allows for the harvest of a large flap that can be surfaced with a split thickness skin graft. Its thin pliable tissue provides excellent contour for the hand, distal leg, and foot that does not require future thinning, optimizing the cosmetic and functional result.

Clinical, functional, and patient-reported outcomes of radial forearm versus anterolateral thigh free tissue transfer for reconstruction of glossectomy defects

BACKGROUND

There is a lack of literature of health-related quality of life endpoints for radial forearm (RF) versus anterolateral thigh (ALT) free flap reconstruction for glossectomy defects. Our goal was to perform a comprehensive evaluation of clinical, functional, and quality of life outcomes after glossectomy reconstruction using a RF or ALT flap.

METHODS

A retrospective review was performed on patients who underwent glossectomy and immediate reconstruction with RF or ALT flaps between 2016 and 2021. Outcomes of interest included readmission and reoperation rates, functional assessments, tracheostomy and gastrostomy tube status, and FACE-Q Head and Neck Cancer scores.

RESULTS

Seventy-eight patients consisting of 54 RF and 24 ALT free flaps were included. ALT patients had a larger median flap size (72 vs. 48 cm2 , p = 0.021) and underwent mandibulotomy (50% vs. 7.4%, p < 0.0001) and base of tongue resection (58.3% vs. 24.1%, p = 0.005) at higher rates. No significant differences were found with respect to other outcomes.

CONCLUSION

The RF and ALT flaps are suitable for glossectomy reconstruction, with minimal differences seen in postoperative outcomes. Our study suggests that ALT can be used in patients with base of tongue and larger defect sizes, while providing similar functional and clinical outcomes to RF reconstruction.

Robotic harvest of the free gracilis muscle flap

The conventional approach to harvest of the gracilis muscle flap necessitates a medial thigh incision that is often related to several donor site complications. In this report we describe the robotic harvest of the free gracilis muscle flap in order to reduce the morbidity associated with the open incision. Through three ports, the robotic system (Da Vinci Xi, Intuitive Surgical) enables precise dissection of the gracilis muscle, the vascular pedicle, and the obturator nerve; thus, enhancing surgical control, optimizing visualization through magnification, aiding in detailed vascular pedicle dissection and minimizing human error. We believe that the technique of totally robotic harvest of the free gracilis muscle flap, herein introduced, is a feasible and effective approach, and confers specific advantages over traditional harvest technique.

Distally Based Anterolateral Thigh Flap Algorithm for Unexpected Situations during Soft-Tissue Defect Reconstruction around the Knee

BACKGROUND

The distally based (d) anterolateral thigh (ALT) flap is an effective option for soft-tissue reconstruction around the knee; however, unexpected situations may occur intraoperatively, impeding flap harvest. The authors proposed an algorithm for surgical conversion for unexpected situations encountered intraoperatively.

METHODS

Between 2010 and 2021, 61 dALT flap harvests were attempted for soft-tissue defect reconstruction around the knee; 25 patients underwent surgical conversion for anomalies, including lack of a suitable perforator, hypoplasia of the descending branch, and compromised reverse flow from the descending branch. After excluding improper cases, 35 flaps were harvested as planned (group A) and 21 surgical conversion cases (group B) were finally enrolled for analysis. An algorithm was developed based on the cases in group B. Outcomes, including complication and flap loss rates, were compared between groups to verify the algorithm's rationality.

RESULTS

In group B, the dALT flap was converted to a distally based anteromedial thigh flap ( n = 8), bipedicled dALT flap ( n = 4), distally based rectus femoris muscle flap ( n = 3), free ALT flap ( n = 2), or other locoregional flap that required additional incision ( n = 4). No differences in outcomes were observed between the two groups.

CONCLUSION

The proposed contingency planning algorithm for dALT flap surgery proved rational, as surgical conversion could be made by means of the same incision in most cases, and outcomes generated by the algorithm were acceptable.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

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.

[Clinical effect of anterolateral thigh flow-through chimeric perforator free flap transplantation in the treatment of upper limb complex tissue defects with main artery injury]

Objective: To investigate the clinical effect of anterolateral thigh flow-through chimeric perforator free flap transplantation in the treatment of upper limb complex tissue defects with main artery injury. Methods: The study was a retrospective observational study. From May 2019 to January 2022, 11 patients with upper limb complex tissue defects combined with main artery injury who met the inclusion criteria were admitted to the Department of Hand, Foot and Ankle Surgery of General Hospital of Ningxia Medical University, including 7 males and 4 females, aged from 18 to 56 years. After debridement, the area of skin and soft tissue defects was from 20 cm×6 cm to 32 cm×10 cm, and the exposed area of dead cavity or deep tissue was from 7 cm×4 cm to 10 cm×7 cm. Three patients had radial artery defects with a length of 4 to 7 cm; two patients had ulnar artery defects with a length of 5 to 8 cm; 4 patients had defects in both ulnar and radial arteries with a length of 3 to 7 cm; and in two patients, the ulnar, radial and brachial arteries were all defective with a length of 4 to 8 cm. The anterolateral thigh flow-through chimeric perforator flap was designed and cut. The skin flap area was from 22 cm×7 cm to 32 cm×11 cm, the chimeric muscle flap area was from 7 cm×4 cm to 10 cm×7 cm, and the length of the flow-through vessel in the "T" shaped vessel pedicle was from 4 to 8 cm. When transplanting the skin flap, the proximal end of the vascular pedicle was anastomosed with the proximal end of the recipient site, and the distal end of the vascular pedicle was anastomosed with the more normal blood vessel at the distal end of the forearm; the invalid cavity was filled with the muscle flap. The donor site wounds of tissue flap were closed directly or treated with skin grafting. After operation, the blood supply and survival of the flap, the survival of the distal limb, and the survival of the skin graft at the flap donor site were observed. Computed tomography angiography (CTA) was performed to observe the patency of the proximal and distal anastomotic arteries from 2 to 4 weeks after surgery. During follow-up, the texture of the flap, the survival of the grafted skin and the healing of the donor area were observed. Results: One patient (complete forearm disconnection) developed distal limb blood disorder on 5 days after surgery. CTA examination suggested embolization of the distal anastomosis of the flow-through artery. more muscle and skin and soft tissue necrosis of the distal limb showed in emergency exploration. So, amputation was performed ultimately. No vascular crisis occurred in the skin flaps of the remaining 10 patients, and all skin flaps, distal limbs and the skin grafts in flap donor sites survived well. Two to 4 weeks after surgery, the proximal and distal ends of the anastomosed arteries were good in the patency. Follow-up for 11-37 months, the flap texture was good, and all donor site wounds healed well. Conclusions: The use of anterolateral thigh flow-through chimeric perforator flap to repair upper limb complex tissue defects accompanied by main artery injury can improve the success rate of limb salvage, which can be promoted in clinical practice.

[Effect of accurately localized mini anterolateral thigh perforator flap in repairing medium-sized skin and soft tissue defects in fingers]

Objective: To explore the effect of accurately localized mini anterolateral thigh perforator flap in repairing medium-sized skin and soft tissue defects in fingers. Methods: The study was a retrospective observational study. From December 2019 to September 2022, 15 patients with medium-sized skin and soft tissue defects who met the inclusion criteria in fingers were admitted to the Second Affiliated Hospital of Wenzhou Medical University, including 12 males and 3 females, aged 23 to 62 years. After debridement, the wounds were all accompanied by exposed tendons, bones, vessels and nerves, with an area from 4.0 cm×3.0 cm to 8.0 cm×3.5 cm. Computed tomography angiography and color Doppler ultrasonography examinations were performed on both lower limbs of the patient before surgery to accurately locate the anterolateral thigh perforators. When the flap with area from 6.0 cm×3.0 cm to 11.0 cm×4.0 cm was harvested, the flap was thinned. The artery and vein perforators of the flap were anastomosed respectively with the digital artery and dorsal metacarpal vein. If there was avulsion injury, infection, or burn in the recipient area, the main arterial and veinous vessels carried by the skin flap was anastomosed with the radial artery and accompanying vein. The lateral thigh cutaneous nerve carried by the flap was anastomosed with the stump of the digital nerve. The types of perforators of the lateral thigh artery were observed during operation and compared with the location of the vessels before operation. After operation, the survival and adverse complication of the flap were closely observed. During follow-up, the skin flap color, texture, and shape were observed; the wound healing in donor area was observed. At the last follow-up, the two-point discriminative distance of the affected finger pulp was measured, and the function of the affected finger was evaluated using the trial standard for the evaluation of functions of upper limbs of Hand Surgery Society of Chinese Medical Association, and the interphalangeal joint movement of the affected finger was observed; the patients' complaints about the adverse effects of flap resection on lower limbs were recorded. Results: During the operation, it was observed that the perforators of the flaps in 11 patients were the descending branch of the lateral circumflex thigh artery, in two patients, the perforators of skin flaps were the oblique branch of the lateral thigh artery, and the perforators in another two patients were the transverse branch of the lateral circumflex thigh artery, which were consistent with the preoperative vascular localization. After operation, all flaps survived without vascular crisis and infection. The patients were followed up for 6-12 months, the flaps had excellent color, texture, and appearance; only linear scars remained on the donor wound. At the last follow-up, the two-point discrimination distance in the finger pulp was 7-11 mm; the affected finger function was rated as excellent in 6 cases, good in 6 cases, and fair in 3 cases; the flexion and extension function of the finger was not affected; two patients complained of numbness in the lateral thigh after excision of the skin flap, and the other 13 patients had no complain of adverse complaints. Conclusions: The perforating branch in lateral thigh region can be accurately located by computed tomography angiography and color Doppler ultrasonography, accurate positioning of perforators before operation can reduce the damage to the donor area during the incision of the flap, the appearance and function of the affected finger can be restored to the maximum extent by thinning the transplanted flap and rebuilding the finger sensation. Therefore, it is an effective and reliable way to repair the medium-sized skin and soft tissue defects of fingers with the mini thigh anterolateral perforator flap.

[Repairing partial suprahyoid epiglottis-preserved circumferential defect in near total laryngectomy with anterior medial thigh flap in advanced laryngeal cancer]

Objective

To explore the feasibility to restore pronunciation function by repairing partial suprahyoid epiglottis-preserved circumferential defect in near total laryngectomy with anterior medial thigh flap in advanced laryngeal cancer.

Methods

A retrospective study of 5 male patients with advanced laryngeal cancer between August 2019 and October 2022, aged 56-73 years, with an average age of 65 years were reviewed. The disease duration ranged from 3 to 24 months, with an average of 8 months. Tumor classification by location: 2 cases of glottic type, 2 cases of supraglottic type, and 1 case of subglottic type; TNM staging: 3 cases of T 4N 0M 0 stage, 1 case of T 4N 1M 0 stage, and 1 case of T 4N 2M 0 stage; American Joint Committee on Cancer (AJCC) staging (2017): stage Ⅳ. Near total laryngectomy with partial suprahyoid epiglottis-preserved and selective bilateral neck dissection were performed before the anterior medial thigh flap was used to repair the circumferential defects. The flap size ranged from 6 cm×5 cm to 8 cm×6 cm. Four patients underwent adjuvant radiotherapy and chemotherapy after operation, while 1 patient did not receive any other adjuvant treatment such as radiochemotherapy.

Results

The flaps of all 5 patients survived without obvious neck infection. One patient developed a slight pharyngeal fistula after oral feeding at 1 month after operation, which healed after another week of gastric feeding. Primary healing also achieved in the thigh donor area. One patient had bilateral cervical lymph node metastasis, and 1 patient had lymph node metastasis on one side. The remaining 3 patients had no cervical nodes metastasis on both sides. All 5 patients were followed up 12-36 months, with an average of 27.6 months. Four patients had clear, audible, and hoarse voice while 1 patient (case 3) had pronunciation similar to whispering. Laryngoscopy showed that the reconstructed laryngeal inlet was fissure-shape and the reconstructed laryngo-trachea canal below the laryngeal inlet was gradually enlarged. At 1 month after operation, the gastric tube was withdrawn and the food was taken orally. There was no obvious aspiration pneumonia. The tracheostomy tube could be blocked in 4 patients for from 30 seconds to 3 minutes. Among them, 3 patients were able to make a noticeable pronunciation even when the tube was not blocked, and they were able to engage in barrier-free language communication; the tracheostomy tube could not be blocked in 1 patient who had a pronunciation similar to whispering. Preliminary voice analysis showed that the patients have a relaxed and natural pronunciation, without obvious breath-holding or air-swallowing movement, compared to patients with esophageal pronunciation. Decannulation did not achieved until the last follow-up in all 5 patients.

Conclusion

The anterior medial thigh flap can repair circumferential defects after near total laryngectomy in advanced laryngeal cancer patients and achieve satisfactory pronunciation, thus can serve as an effective pronunciation rehabilitation method. The preserved part of epiglottis may play a role to prevent postoperative aspiration.

Aesthetic Implications of Bilateral Profunda Artery Perforator Flaps on Thigh and Buttock Proportions

BACKGROUND

 The profunda artery perforator (PAP) flap has emerged as an excellent secondary option for autologous breast reconstruction. Despite the increased acceptance, potential secondary benefits concerning aesthetic proportions of proximal thigh and buttock at the donor site have never been systematically investigated.

METHODS

 A retrospective review of 151 patients who underwent breast reconstruction with horizontally designed PAP flaps (292 flaps) from 2012 to 2020 was performed. Patient characteristics, complications, and numbers of revision surgeries were collected. In bilateral reconstructions, pre- and postoperative standardized patient photographs were analyzed to identify postoperative changes in proximal thigh and buttock contour. The patients' own perception of postoperative aesthetic changes was determined by an electronic survey.

RESULTS

 The patients had a mean age of 51 and a mean body mass index of 26.3 kg/m2. The most common complications were minor and major wound complications affecting 35.1% of patients, followed by cellulitis (12.6%), seroma (7.9%), and hematoma (4.0%). A total of 38 patients (25.2%) underwent revision of the donor site. After reconstruction, patients were found to have aesthetically improved proximal thigh and buttock proportions, indicated by a wider thigh gap (thigh gap-hip ratio: 0.05 ± 0.04 vs. 0.13 ± 0.05, p < 0.0001) and reduction in lateral thigh-to-buttock ratio (0.85 ± 0.05 vs. 0.76 ± 0.05, p < 0.0001). Among the 85 patients who responded to the survey (56.3% response rate), 70.6% felt that PAP surgery had aesthetically either improved their thigh contour (54.12%) or not changed it (16.47%), whereas only 29.4% reported that the surgery negatively impacted their thigh contour.

CONCLUSION

 PAP flap breast reconstruction leads to improved aesthetic proportions of the proximal thigh and buttock. This approach is ideal for patients with ptotic tissue of the inferior buttocks and medial thigh, a poorly defined infragluteal fold, and inadequate anterior-posterior buttock projection.

The profunda artery perforators: Anatomical study and radiological findings using computed tomography angiography in patients undergoing PAP flap breast reconstruction

BACKGROUND

The popularity of the profunda femoris artery perforator (PAP) flap is increasing; however, knowledge concerning the standardization of radiological findings and their clinical implications is limited. We evaluated the radiological architecture of posterior thigh perforators using Computed Tomography Angiography (CTA) to identify landmarks to facilitate flap dissection.

METHODS

A retrospective study was conducted on 35 patients who underwent unilateral breast reconstruction with a PAP flap. The preoperative CTA scans were analyzed, and the perforator characteristics were evaluated. The perforators were mapped using a Cartesian coordinate system. Data were normalized by anatomical landmarks and overlapped. Perioperative and postoperative results were analyzed. Radiological and intraoperative were compared.

RESULTS

Two CTA scans were excluded; 66 thighs were examined. The mean perforator number was 3.2. The mean diameter of chosen perforators was 2.7 mm (DS ± 0.6 mm) at the origin, 2.2 mm (DS ± 0.4 mm) at the adductor space midpoint, and 1.7 mm (DS ± 0.3 mm) at the deep fascia. The mean adipose tissue thickness was 3.35 cm (DS ± 0.94) at the deep fascia and 3.59 cm (DS ± 1.19) at the adductor space midpoint. Intraoperatively, the perforator was located 3.22 cm (DS ± 0.87) from the posterior border of the gracilis muscle and 8.98 cm (DS ± 1.44) from the inferior gluteal crease. A radiological area located 9.33 cm (DS ± 4.81) from the y-axis and 7.48 cm (DS ± 1.88) from the x-axis was identified.

CONCLUSIONS

CTA using the volume-rendering technique is a valuable method to study in vivo the radiological anatomy of the posterior thigh perforators.

Lateral Femoral Cutaneous Nerve Cryoneurolysis for Meralgia Paresthetica: A Case Report

Meralgia paresthetica (MP) is a disorder of lateral femoral cutaneous nerve mononeuropathy caused by entrapment or compression of the nerve. It is characterized by numbing, tingling, and burning pain in the lateral aspect of the thigh. The current treatments for MP include conventional medical management, peripheral nerve blocks, and surgical interventions. Some patients who suffer from MP can experience intractable pain and medical management of MP is often inadequate to provide satisfactory pain control. Although regional anesthesia provides excellent pain relief, the analgesic effects of peripheral nerve block are short-lived. Emerging evidence suggests that cryoneurolysis has a low-risk safety profile and can provide prolonged pain relief of superficial nerves when administered appropriately. We present a successful case of a patient with intractable neuropathic pain resulting from MP treated with cryoneurolysis therapy. The patient demonstrated immediate pain relief by 100% after the procedure followed by 80% and 60% pain reduction at 1-month and 3-months follow-up, respectively. Cryoneurolysis may be an alternative modality for patients who fail at conventional medical treatments of neuropathic pain.

Increasing Pedicle Reach with Musculocutaneous Perforator Dissection in Anterolateral Thigh Free Flaps

OBJECTIVE

To measure the increase in effective pedicle reach with microdissection of musculocutaneous perforators during anterolateral thigh (ALT) free tissue harvest.

METHODS

A review of our institution's free flap database was performed to identify ALT free tissue transfers. The distance from pedicle vessel origin to its perforator's insertion at the fascia lata (effective pedicle length [EPL]) was measured prior to and following intramuscular dissection of musculocutaneous perforators. Pertinent clinicopathologic variables were abstracted from the electronic medical record.

RESULTS

A total of 314 ALT free flaps were performed between February 2017 and August 2022. Of these, 85 had documentation of EPL before and after musculocutaneous perforator dissection. ALT reconstruction was primarily performed for reconstruction of oncologic ablative defects (66, 78%). The mean EPL prior to perforator microdissection was 8.8 cm (standard deviation, SD 2.8 cm; range 3-15 cm). Following perforator dissection, mean EPL significantly increased to 14.0 cm (SD 3.0 cm; range 7-22 cm) with a mean net gain of 5.2 cm in distance (95% confidence interval 4.8-5.6 cm; p < 0.001). Nine patients (11%) required operating room take-back for anastomosis revision (3, 3.5%), recipient site hematoma evacuation (4, 4.7%), and wound dehiscence (2, 2.3%); one complete flap loss due to venous thrombosis was observed.

CONCLUSION

Dissection of musculocutaneous perforators during ALT free flap harvest can increase effective pedicle reach by 5.2 cm or nearly 60%. This harvest technique can facilitate the performance of tension-free anastomoses when substantial vascular pedicle length or vascular pedicle tunneling is required.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:666-670, 2024.

Double microvascular free flap reconstruction for bilateral lower extremity injury in a paediatric patient

Many challenges have been described by microsurgeons in paediatric free flaps. With the advancement in microsurgical expertise, it is now possible to achieve excellent results. We present a case of a female child with car-tyre friction injury of bilateral feet with associated extradural haemorrhage who underwent emergency bilateral anterolateral thigh flap. A secondary tendon reconstruction of the left foot was performed at 6 months. No complications were observed in the postoperative period after both procedures and good functional recovery was achieved at 1 year follow-up. The problems unique to this case were the presence of head injury and bilateral extremity injury in the paediatric patient. The technical details of planning, execution, difficulties and recommendations to minimise the risk in such cases are discussed. To the best of our knowledge, this is the only case report of bilateral lower limb paediatric emergency free flap with associated head injury.

[A prospective study of super-thin anterolateral thigh flap harvesting assisted by high-frequency color Doppler ultrasound in detecting perforators in deep adipose layers]

Objective

To investigate the clinical application of high-frequency color Doppler ultrasound (HFCDU) in detecting perforators in the deep adipose layers for harvesting super-thin anterolateral thigh flap (ALTF).

Methods

Between August 2019 and January 2023, 45 patients (46 sides) with skin and soft tissue defects in the foot and ankle were treated, including 29 males and 16 females, aged from 22 to 62 years, with an average of 46.7 years. The body mass index ranged from 19.6 to 36.2 kg/m 2, with an average of 23.62 kg/m 2. The causes of injury included traffic accident injury in 15 cases, heavy object crush injury in 20 cases, mechanical injury in 8 cases, heat crush injury in 1 case, and chronic infection in 1 case. There were 20 cases on the left side, 24 cases on the right side, and 1 case on both sides. After thorough debridement, the wound size ranged from 5 cm×4 cm to 17 cm×11 cm. All patients underwent free super-thin ALTF transplantation repair. HFCDU was used to detect the location of the perforators piercing the deep and superficial fascia, as well as the direction and branches of the perforators within the deep adipose layers before operation. According to the preoperative HFCDU findings, the dimensions of the super-thin ALTF ranged from 6 cm×4 cm to 18 cm×12 cm. The donor sites of the flaps were directly sutured.

Results

A total of 55 perforators were detected by HFCDU before operation, but 1 was not found during operation. During operation, a total of 56 perforators were found, and 2 perforators were not detected by HFCDU. The positive predictive value of HFCDU for identifying perforator vessels was 98.2%, and the sensitivity was 96.4%. Among the 54 perforators accurately located by HFCDU, the orientation of the perforators in the deep adipose layers was confirmed during operation. There were 21 perforators (38.9%) traveled laterally and inferiorly, 12 (22.2%) traveled medially and inferiorly, 14 (25.9%) traveled laterally and superiorly, 5 (9.3%) traveled medially and superiorly, and 2 (3.7%) ran almost vertically to the body surface. Among the 54 perforators accurately located by HFCDU, 35 were identified as type 1 perforators and 12 as type 2 perforators (HFCDU misidentified 7 type 2 perforators as type 1 perforators). The sensitivity of HFCDU in identifying type 1 perforators was 100%, with a positive predictive value of 83.3%. For type 2 perforators, the sensitivity was 63.2%, and the positive predictive value was 100%. The surgeries were successfully completed. The super-thin ALTF had a thickness ranging from 2 to 6 mm, with an average of 3.56 mm. All super-thin ALTF survived, however, 1 flap experienced a venous crisis at 1 day after operation, but it survived after emergency exploration and re-anastomosis of the veins; 1 flap developed venous crisis at 3 days after operation but survived after bleeding with several small incisions; 3 flaps had necrosis at the distal edge of the epidermis, which healed after undergoing dressing changes. All 45 patients were followed up 6-18 months (mean, 13.6 months). Three flaps required secondary defatting procedures, while the rest had the appropriate thickness, and the overall appearance was satisfactory.

Conclusion

Preoperative application of HFCDU to detect the perforator in the deep adipose layers can improve the success and safety of the procedure by facilitating the harvest of super-thin ALTF.

Subtotal Thigh Flap for Large Abdominal Wall Defect Reconstruction in Patient With Recurrent Dermatofibrosarcoma Protuberans: A Case Report and Literature Review

BACKGROUND

Harvesting an adequate-sized flap is challenging for reconstructing large defects on the abdominal wall. A subtotal thigh flap would be one of the choices as it provides a well-vascularized large flap with muscle components. Moreover, dermatofibrosarcoma protuberans (DFSP) is a low-grade dermal neoplasm with a high recurrence rate. There is still no consensus on the extent of resection to prevent a recurrence.

OBJECTIVES

We present a case of a patient who underwent the reconstruction of a large abdominal wall defect with a subtotal thigh flap after the resection of recurrent DFSP.

MATERIALS AND METHODS

A 59-year-old man killed from a recurrent huge mass in the lower abdomen with an invasion of the small intestine. His baseline characteristics and records of operations, medications, and outcomes were reviewed.

RESULT

After tumor excision, a 28 × 30-cm subtotal thigh flap was harvested from his left thigh to reconstruct the abdominal defect. A microvascular anastomosis with left deep inferior epigastric vessels was made eventually. The flap was in good condition, and the donor site was covered with a split-thickness skin graft.

CONCLUSIONS

Subtotal thigh flap may be considered for large abdominal wall defect reconstruction as it allows good perfusion of relatively large skin paddles compared with other free flaps. Also, patients with DFSP need definite margin-free resection and close follow-up to prevent a recurrence.

The Pedicled Anterolateral Thigh Flap as a Versatile Option for Resurfacing Extensive Lower Trunk Defects

BACKGROUND

The resurfacing of large abdominal and perineal defects is a major concern, and it poses a great challenge to the reconstructive surgeon. The main target in the reconstruction of the abdomen is to ensure a stable soft-tissue cover, and a strong and reliable fascia to prevent hernia recurrence and fecal contamination. The pedicled anterolateral thigh flap (ALT) either in the myocutaneous or fasciocutaneous form is a work-horse for the closure of abdominal and perineal defects.

AIM

There is a paucity of studies on the use of the anterolateral thigh flap among black Africans especially in Nigeria; hence, we present our experience with the use of this flap for extensive abdominal and perineal defects.

PATIENTS AND METHODS

The folders of all patients who had pedicled anterolateral thigh flap between January 2019 and July 2022 in our institution were reviewed. The patients' demographic data and the available details about the flap reconstruction were extracted from the folders.

RESULTS

There were three males and two females, and the age range was between 22 and 48 years. Four cases resulted from tumor extirpation, while one was following extensive necrotizing fasciitis of the lower anterior abdominal wall. No gross anatomical variations were encountered intraoperatively. Four flaps had full survival, while one had marginal flap tip loss.

CONCLUSION

The pedicled anterolateral thigh flap is an excellent reconstructive tool for the coverage of extensive abdominal and perineal defects.

Profunda Femoris Pseudoaneurysm and Fatal Hemorrhage 2 Weeks After Modified Girdlestone Resection Arthroplasty: A Case Report

CASE

A 62-year-old nonambulatory female patient presented with wound dehiscence and purulent bloody drainage 2 weeks after modified Girdlestone resection arthroplasty for subtrochanteric femur fracture. On developing an enlarging thigh hematoma and hemodynamic instability, the patient was taken to the vascular suite where a profunda femoris artery pseudoaneurysm was identified and ligated by the vascular surgery team. The proximal free edge of the resected femur was determined to be the likely cause of arterial injury. Two days later, the patient was taken by the orthopaedic surgery team for debridement and revision resection arthroplasty, but she ultimately decompensated and died.

CONCLUSION

We believe this to be the first reported case of this serious complication of the Girdlestone procedure. We hope this case helps bring awareness to the complication and aids in early detection and prompt treatment of femoral artery complications.

Comparative study of arterial and venous grafting for pedicle lengthening in head and neck microvascular reconstruction

BACKGROUND

In the field of head and neck microvascular reconstruction, no previous study has compared arterial and venous grafting as methods of anterolateral thigh (ALT) pedicle lengthening. Therefore, we conducted this comparative study to compare the outcomes between the two pedicle lengthening techniques.

METHODS

We performed comparative effectiveness research by conducting a retrospective chart review from January 2012 to December 2021 to identify patients who underwent head and neck reconstruction with non-descending branch ALT perforator flaps using either the in situ pedicle lengthening (ISPL) technique or the vein graft (VG) technique. A total of 26 patients were analyzed, including 14 who underwent ISPL, and 12 who underwent VG. The collected data, including patient demographics, surgical indications, history of prior free flap, prior neck dissection, radiation therapy, chemotherapy, graft length, and flap outcomes, were analyzed. The flap outcomes were categorized as total flap loss, partial flap loss, flap compromise that required operating room visits, or minor issues, including infection or dehiscence. The flap characteristics and postoperative outcomes were compared between the two groups.

RESULTS

The VG group had two flap losses, whereas the ISPL group had none. Although the failure rate was higher in the VG group than that in the ISPL group, the difference was not statistically significant (0% vs. 16.7%, p = 0.203). Additionally, there were no significant differences in flap take-back (14.3% vs. 16.7%, p = 1) and minor complications between the two groups (35.7% vs. 33.3%, p = 1).

CONCLUSIONS

If pedicle lengthening with vessel graft is inevitable in head and neck reconstruction, arterial graft may provide a reliable outcome and may be considered an effective alternative when compared to vein grafts.

Usefulness of Free Tissue Transfer for the Reconstruction of Extensive Thigh Defects

BACKGROUND

 Despite the increasing popularity of free tissue transfer, thigh defects have been alienated from their potential indication, owing to the abundance of regional reconstruction options. However, some challenging situations where locoregional modalities may lead to suboptimal outcomes often require free flap. Due to lacking studies regarding microvascular reconstruction of thigh defects, this study aimed to investigate the versatility of free tissue transfer for reconstruction of thigh defects.

METHODS

 A retrospective review was performed for patients who underwent microvascular reconstruction of thigh defects between 2003 and 2021. Their demographics and operation-related data were summarized and postoperative outcomes were evaluated.

RESULTS

 Sixty-five patients were analyzed, with a median follow-up period of 15.5 months. Most common situations requiring free tissue transfer were extensive defects, followed by large dead space with exposure of major neurovascular bundle and chronic wounds surrounded by unhealthy regional tissue. Defects were most frequently located in the anterior compartment horizontally and in the distal thigh vertically. The median surface area of the defects was 180.0 cm2. The latissimus dorsi musculocutaneous and thoracodorsal artery perforator flaps were the two most commonly used flaps. Reliable recipient vessels could generally be easily found in the vicinity of defects. Overall complications developed in 12 cases (18.5%), including two of partial flap necrosis. No total flap loss was encountered.

CONCLUSION

 Free tissue transfer could provide reliable outcomes and facilitate rapid recovery, and could be actively considered for reconstruction of thigh defects in situations unfavorable to the locoregional option.

A simplified classification and economical application of anterolateral thigh flap

BACKGROUND

Anterolateral thigh (ALT) flaps have several anatomical variations and clinical uses. Here, a simplified classification and economical application are introduced.

METHODS

A total of 168 ALT flap reconstructions performed between January 2013 and December 2016 were reviewed. Vascular anatomy of the flaps was classified into 5 types: type I (single perforator from the transverse branch), type II (single perforator from the descending branch), type III (multiple perforators from the transverse branch), type IV (multiple perforators from the descending branch), and type V (multiple perforators from both branches). Furthermore, flaps harvested via preservation of the proximal perforator were compared with those that were not.

RESULTS

Vascular classification revealed that type IV (50.0%) and type V (32.1%) flaps were the most commonly used. Of these, 50.0% of type IV and 79.6% of type V were harvested as proximal-perforator-preserving distal ALT flaps. The proximal-perforator-preserving group had a smaller flap size (104.4 ± 84.3 cm2 versus 145.9 ± 94.1 cm2, p = 0.003), shorter reconstruction time (266.3 ± 76.1 min versus 302.0 ± 103.0 min, p = 0.013), and fewer donor-site complications (2.4% versus 13.3%, p = 0.009) than the traditional group, whereas the flap success rate was comparable (96.5% versus 96.4%) between them. Five cases received a second ALT flap from the same donor site after 3 failures and 2 metachronous defects.

CONCLUSIONS

Multiple perforators in ALT flaps allow the harvesting of 2 ALT flaps from the same donor-site metachronously. Our classification and applications can improve efficiency while reducing donor-site morbidity.

Turbocharging as a strategy to boost extended perforator flap vascularity in head and neck reconstruction-A report of two cases

Perforator flap has been applied as the most common flap for soft tissue defect reconstruction. Here, we presented two cases using turbocharging procedure of perforator to perforator as a salvage strategy. The first case was a 54-year-old male with recurrent squamous cell carcinoma (SCC) in the left buccal area and mouth floor. A 6 × 22 cm posteromedial thigh (PMT) flap was designed for reconstruction. The two eccentric perforators of the PMT flap could not conjoin together during dissection nearby the main pedicle of profunda femoral artery (PFA) resulting in inadequate perfusion. Side branched stump before clipped the branch of distal perforator was preserved, then the proximal perforator was divided and end-to-end anastomosis of side branch of distal perforator was done successfully. The second case was a 52-year-old male underwent wide composite excision of right tongue SCC. After excision, anterolateral thigh (ALT) flap around 7 × 15 cm was harvested from left thigh and two perforators were included which one tiny perforator supplied by the descending branch (DB) and the other major perforator originated from oblique branch (OB) of lateral circumflex femoral artery (LCFA). However, the OB main perforator injury showed inadequate perfusion of flap. We trimmed the injury zone of OB perforator, and shift to re-anastomosis of OB perforators to side branch of DB of LCFA directly. The flap demonstrated excellent perfusion immediately after the operation, and it exhibited complete survival 2 weeks postoperatively. These results indicated that the turbocharging procedure, from perforator to perforator, could serve as a strategy for salvaging perfusion-compromised flaps, especially in cases of eccentric perforators or perforator injury resulting in inadequate perfusion.

Reconstruction With Flow-Through Chimeric Anterolateral Thigh Flap Combining Vascularized Fibular Bone Graft for Extensive Composite Tissue Defect of the Forearm: A Case Report

ABSTRACT

The management of critical limb trauma is challenging because limb salvage is preferable to amputation. For upper limb reconstruction, the surgical restoration of functionality, and appearance, a multidisciplinary approach is needed. We report the case of an extensive composite tissue defect of the forearm caused by a machine-crushing injury that was repaired by a flow-through chimeric anterolateral thigh flap with a vascularized fibular graft. Reconstruction was performed as a single-stage procedure; no complications occurred, and both functional and aesthetic outcomes were satisfactory.

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.

Reconstruction of multiple long digital and hand defects using the multilobed anterolateral thigh perforator flap

OBJECTIVE

This study investigated the reconstruction of multiple long digital and hand defects using the multilobed anterolateral thigh perforator flap.

METHODS

From January 2018 to January 2021, 14 patients (hands) with multiple long digital defects were treated using the multilobed anterolateral thigh perforator flap. The mean age of the patients was 35 years (range, 18-55 years). The mean size (length × width) of the defects was 12.3 × 10.6 cm (range, 9 × 7 cm-16 × 12 cm). The mean size of the flap was 13.7 × 12.1 cm (range, 11 × 8 cm-19 × 14 cm). The total active motion was compared to the opposite side (100% normal, excellent; 75%-99% normal, good; 50%-74% normal, fair; <50% normal, poor).

RESULTS

In this series, 12 flaps survived completely. Partial flap necrosis occurred in 2 patients but healed with wound care. The mean follow-up period was 28 months (range, 25-34 months). Based on the total active motion scoring system, we got 1 excellent, 7 good, 7 fair, and 1 poor result. A second surgery to separate the digits was not required.

CONCLUSION

Multiple digital and hand defects can be reconstructed simultaneously using the multilobed anterolateral thigh perforator flap, allowing a length-to-width ratio of greater than 1.5:1 to resurface long digital defects.

LEVEL OF EVIDENCE

Level IV, Therapeutic Study.

Combined use of lower medial thigh perforator (LMTP) flap and pedicled medial sural artery perforator flap (MSAP) for lateral knee defects coverage after sarcoma resection: A case report and literature review of soft tissue defect around knee reconstruction

Reconstruction of knee defects still represents a challenge for reconstructive surgeons. After an extensive resection, the primary aim is to reach a stable result, while maintaining a good range of motion and aesthetic unity. The use of pedicled perforator-based flaps makes it possible to achieve these goals. Many are the flaps that can be used in this region, and the pedicle medial sural artery perforator (mSAP) flap is considered among one of the first-choice techniques. The purpose of this case report is to describe for the first time the use of pedicled mSAP flap to cover a lateral knee defect. A 79-year-old patient underwent extensive excision of sarcoma on the lateral side of the left knee, with removal of distal portion of the vastus lateralis muscle and portion of the biceps femoris tendon. The resulting defect from the excision measured 10 cm × 10 cm. To cover the postero-inferior part of the defect we decided to use a mSAP flap, with a skin paddle 10 cm × 5 cm, which was tunneled posteriorly to the popliteal artery and vein in order to reach the affected site. We then used a lower medial thigh perforator (pLMT) flap with a 15 cm × 5 cm skin paddle, rotated by 90° in a propeller fashion to cover the antero-superior portion of the defect. The decision to use two flaps was justified by the fact we wanted to close the donor areas with direct suturing for a better aesthetic result. The post-operative course was regular with only a small wound dehiscence that had healed by secondary intention. At 6 months postoperatively, the patient showed a complete active range of motion of the knee joint and absolute aesthetic satisfaction with flaps donor site and knee shape. A review of literature is also provided, with a specific focus on the different procedures for soft tissue defects reconstruction around the knee. According to our experience, the pedicle of the MSAP flap may be safely used as an additional reconstructive option for lateral knee defects.

Evaluation of the factors affecting survival and local recurrence in thigh soft tissue sarcomas

OBJECTIVES

The aim of this study was to evaluate the factors affecting local recurrence and survival in patients with soft-tissue sarcomas located in the thigh.

PATIENTS AND METHODS

This retrospective cross-sectional study evaluated 41 soft tissue sarcoma patients (21 males, 20 females; mean age: 57.9±13.7 years; range, 18 to 90 years) with thigh involvement between January 2010 and December 2020. All surgical intervention was performed by one surgeon with an experience of 15 years in orthopedic oncologic surgery. Epidemiological, radiological, histopathological, and metabolic features, as well as surgical and oncological treatments and prognoses, were assessed. The data was statistically analyzed to determine factors affecting local recurrence and survival in these cases, staged using Enneking and the American Joint Committee on Cancer classifications.

RESULTS

Liposarcomas were the most common type of tumor (39%), followed by undifferentiated pleomorphic sarcomas (32%). Tumors >10 cm were associated with decreased survival rates. High-grade tumors, tumor necrosis, Ki-67 index >20%, and positive surgical margins were also associated with lower survival rates. Metastatic patients had significantly lower survival rates. Local recurrence was significantly more frequent in patients with positive surgical margins. Survival rates were significantly lower in metastatic patients.

CONCLUSION

There are many factors that affect local recurrence and survival of soft tissue sarcomas. The size of the mass, the presence of necrosis, a high Ki-67 index, positive surgical margins, and the presence of metastasis are the main factors that should be taken into consideration.

[Clinical effects of different types of tissue flaps in repairing the wounds with steel plate exposure and infection after proximal tibial fracture surgery]

Objective: To investigate the clinical effects of different types of tissue flaps in repairing the wounds with steel plate exposure and infection after proximal tibial fracture surgery. Methods: A retrospective observational study was conducted. From January 2015 to December 2021, 11 patients with steel plate exposure and infected wounds after proximal tibial fracture surgery who met the inclusion criteria were admitted to Jiangxi Provincial General Hospital of Armed Police, including 9 males and 2 females, aged 26 to 61 years. The wounds were located on the lateral side of the proximal leg in 5 cases, on the medial side of the proximal leg in 2 cases, and on the medial side of the proximal leg and the anterior tibia below the knee in 4 cases. After debridement, the wound area was 14 cm×6 cm-22 cm×11 cm. The wounds were repaired with different types of tissue flaps, and the steel plates were removed immediately if necessary, according to the infection around the steel plates. The reverse anterolateral thigh myocutaneous flap pedicled with the muscle containing the terminal small branch of the descending branch of the lateral circumflex femoral artery was used in 3 cases; the medial gastrocnemius muscle flap combined with the medial half of soleus muscle flap was used in 6 cases, and the lateral gastrocnemius muscle flap combined with the anterior tibial muscle flap was used in 2 cases. After the muscle flaps had stable blood supply, the wounds were closed with thin intermediate thickness skin graft from the healthy thigh. The area of myocutaneous flap ranged from 15 cm×7 cm to 18 cm×8 cm, and the area of muscle flap ranged from 6.0 cm×4.0 cm to 18.0 cm×12.0 cm. Among the 3 patients who were treated with reverse anterolateral thigh myocutaneous flap, the wounds of flap donor site on thighs were closed by direct suturing in 2 cases, and the wound in the flap donor site of thigh in 1 case that was not closed after suture was repaired with thin intermediate thickness skin graft from healthy thigh. The incisions in the flap donor sites of 8 cases treated with calf muscle flaps were sutured directly. After surgery, the survivals of tissue flap and skin graft on the muscle flap, wound healing status and wound healing time in recipient sites of tissue flaps, suture site healing in flap donor site, and survival of skin graft were observed and recorded. Whether the steel plate was removed after operation and during follow-up was recorded. During follow-up, the shape and texture of tissue flap, whether the recipient site of tissue flap had redness, swelling, ulceration, or sinus formation were observed, the fracture healing time was recorded. At the last follow-up, the knee joint flexion and extension range of motion was measured and the knee joint function was evaluated according to Hohl's knee joint function evaluation criteria; the plantar flexor muscle strength of ankle joint was measured in 8 patients who were treated with calf muscle flaps for wound repair; the Vancouver scar scale (VSS) was used to evaluate the scar condition in the flap donor site, and whether the scar affected the movement of the affected limbs was observed. Results: Tissue flaps of 11 patients all survived after surgery. The distal end of the reverse anterolateral thigh myocutaneous flaps was necrotic in 1 patient, and the wound was healed after dressing change and grafting with thin intermediate thickness skin from healthy thigh. The distal muscle necrosis of the medial gastrocnemius muscle flap was observed in 2 patients, and the granulation tissue grew well after dressing change. The skin graft on the muscle flap survived well. All the wounds in the recipient sites of tissue flaps were healed, and the healing time was 13 to 42 days after tissue flap transplantation. The suture site of flap donor site healed, and the skin graft survived well. In 1 patient, the steel plate was removed when the wound was repaired with the medial gastrocnemius muscle flap combined with the medial half of soleus muscle flap. One patient still had exudation after 3 weeks of wound repair with the reverse anterolateral thigh myocutaneous flap pedicled with the muscle containing the terminal small branch of the descending branch of the lateral circumflex femoral artery, and the wound was healed after removing the steel plate. The steel plates of the other patients were preserved. During the follow-up of 6-25 months, except for 1 reverse anterolateral thigh myocutaneous flap had bloated pedicle, the other tissue flaps had good appearance and texture. One patient had redness and swelling in the recipient site of the tissue flap at 6 weeks after discharge, and the redness and swelling subsided without recurrence after anti-infection treatment. In 1 patient, repeated rupture and exudation occurred in the recipient site of tissue flap in 3 months after discharge, resulting in sinus tract formation, which was healed after the removing of steel plate. The fracture healing time of patients ranged from 6 to 15 months after injury. At the last follow-up, the knee joint function was evaluated as excellent in 4 cases, good in 6 cases, and poor in 1 case. Among the 8 patients who were treated with calf muscle flaps for wound repair, 7 patients had ankle joint plantar flexor muscle strength of grade Ⅵ, and 1 patient had ankle plantar flexor muscle strength of grade Ⅴ. The VSS scores of scars in the flap donor sites ranged from 2 to 7, and scars did not significantly affect the movement of the affected limbs. Conclusions: The reverse anterolateral thigh myocutaneous flap pedicled with the muscle containing the terminal small branch of the descending branch of the lateral circumflex femoral artery and the gastrocnemius muscle flap combined with soleus muscle flap or anterior tibial muscle flap are the derived types of the commonly used reverse anterolateral thigh myocutaneous flap and gastrocnemius muscle flap. Using them to repair the wounds with steel plate exposure and infection after proximal tibial fracture surgery can not only ensure the smooth operation, but also preserve the steel plate and promote fracture healing as much as possible, without significantly affecting the function of the affected limb.

Various soft tissue defect reconstructions using anterolateral thigh and vascularized fascia lata composite free flap

The anterolateral thigh flap (ALT) is versatile for soft-tissue reconstruction of various body defects because of its thick and vascularized fascia component. We present our clinical experience with the functional one-stage reconstruction of complicated soft-tissue defects using ALTs with vascularized fascia lata (FL). Between April 2018 and February 2022, we transferred ALTs with FL components for various soft-tissue defects in 15 patients. The FL component was used for reconstruction of hand & forearm tendon, medial and lateral patellar synovial membrane, plantar aponeurosis, abdominal wall, dura and Achilles tendon. Functional outcomes were evaluated in each patient. Partial flap necrosis occurred in 2 patients and were treated successfully with minimal surgical debridement and dressing. The vascularized fascia could replace a tendon and fascial component and all the patients achieved satisfactory results without major postoperative complications. Anterolateral thigh flaps with vascularized FL provide reliable fascial and tendon components for single-stage reconstruction of complex soft tissue defects.

Variability of anterolateral thigh flap perforator locations - clinical implications

<b><br>Introduction:</b> The anterolateral thigh flap is an example of a free flap widely applied for reconstruction of tissues within various areas of the body.</br> <b><br>Aim:</b> The aim of the study was to determine the most common locations of the ALT flap perforators in men and women as well as to clarify any potential differences in the location of the vessel in male vs. female subjects.</br> <b><br>Material and method:</b> In years 2021-2022, a study was conducted at the Plastic, Reconstructive, and Aesthetic Surgery Clinic in a group of 90 volunteers (45 women and 45 men, a total of 180 lower extremities) to determine the location of the anterolateral thigh flap perforator against the flap surface using a portable Doppler probe.</br> <b><br>Results:</b> Variable locations were revealed for the anterolateral thigh flap perforator within the study. In women, the perforator is located more distally from the anterior superior iliac spine, most frequently within the inferolateral quadrant, while being located closer to the anterior superior iliac spine, and most frequently within the superolateral quadrant, in men. No perforator was found in 3.3% of the examined limbs. No statistically significant differences were observed between the course of the perforators within the left and right lower limbs in individual patients.</br> <b><br>Conclusions:</b> The location of the ALT flap perforator is subject to sexual dimorphism, which facilitates the investigation area being narrowed down to the well-defined locations of its most frequent occurrence when planning anterolateral thigh flap reconstructive procedures.</br>.

Training in microvascular anastomosis - A randomized comparative study between chicken thigh specimen and live rat

Training in microsurgical techniques on live rats is the gold standard, but raises ethical issues related to animal welfare and cost. The aim of this study was to compare acquisition of microsurgical techniques with primary training on chicken thigh specimens. Seventy six students were randomly assigned: 23 to exclusive rat training and 53 to primary chicken-leg training. Both groups were then evaluated on aortic suture and jugular aortic bypass surgery in live rats. The primary criterion for successful anastomosis was the patency test. The survival of the rat, the number of severe vascular wounds and the quality of the dissection were also assessed. Aortic anastomoses were of significantly better quality in the chicken group (p = 0.041). There was no significant difference in the number of serious injuries, rat mortality, or quality of dissection (p > 0.05). For jugular aortic bypass surgery, dissection quality (p = 0.02) and patency test (p = 0.05) were better in the chicken-leg group. There was no significant difference in number of severe wounds or rat mortality (p > 0.05). Students who started their microsurgical training on a chicken leg did not perform worse than those with exclusive live rat training. Initial training on chicken thigh specimens seems to be a reliable alternative to training on live models. LEVEL OF EVIDENCE: Level II - Randomized controlled trial.

Fasciocutaneous Flap Perineal Closure with Testicular Thigh Pouch for Scrotal Defects: Surgical Technique and Initial Experience

OBJECTIVE

To describe the surgical technique and evaluate the safety, feasibility, and preliminary outcomes of perineal closure with fasciocutaneous flaps as an alternative to scrotoplasty for large genital wounds.

METHODS

Cases of perineal closure with fasciocutaneous flaps and thigh pouch creation for patients having undergone scrotectomy from January 2015 until August 2022 were reviewed for operative details and surgical outcomes.

RESULTS

Twenty patients were identified undergoing this procedure. Patients had a median age of 64 (Inter-quartile range [IQR] 58-70), body mass index of 34 (IQR 29-40) and Charlson comorbidity index of 5 (IQR 4-8). Median total wound area was 443 cm2 (IQR 225-600). Operative technique in all cases included testicular thigh pouch and fasciocutaneous flap creation for perineal closure; these flaps were raised from the thigh in 18 patients and abdominal wall in 8. This technique resulted in 100% closure rate of the perineum with 3 patients required abdominal split thickness skin grafting (STSG) to complete closure. Complication occurred in 3 patients (15%) with 1 wound infection and 2 episodes of bleeding. Forty percent of patients were discharged home. Median follow-up was 9 months with only 1 patient reporting pain related to thigh pouches and none desiring elective scrotoplasty.

CONCLUSIONS

Despite large defects, perineal closure was completed in all patients with minimal use of STSG. Complication rates were comparable to other methods despite significant patient frailty and no patients desired staged scrotoplasty. This method of closure adds an option for the complex perineal reconstruction patient.

Introduction of the L-PAP Flap: Bipedicled, Conjoined, and Stacked Thigh-Based Flaps for Autologous Breast Reconstruction

SUMMARY

Thigh-based flaps are increasingly popular options for autologous breast reconstruction in the setting of abdominal donor-site inadequacy, previous surgery, or patient preference, but the volume and skin associated with these flaps are often lacking relative to the abdomen. An individualized, shared decision-making approach to donor-site selection was adopted based on body shape, surgical history, lifestyle, reconstructive needs, and patient expectations. Different thigh-based flaps combined in stacked, bipedicled, or conjoined configurations were selected to maximize efficient use of available soft-tissue skin and volume while optimizing donor-site aesthetics. A total of 23 thigh-based stacked, bipedicled, or conjoined profunda artery perforator (PAP), lateral thigh perforator (LTP), or gracilis musculocutaneous flap components were used in six patients. Configurations included bilateral stacked PAP and LTP flaps, bipedicled posterolateral thigh flaps based on the LTP and PAP (L-PAP), and bipedicled thigh flaps based on the gracilis and PAP pedicles. Most anastomoses were performed to the antegrade and retrograde internal mammary vessels; intraflap anastomoses were performed in one case. There were no partial or total flap losses. There was one donor-site seroma. Design of stacked, bipedicled, and conjoined thigh-based flaps using multiple conventional flap components allows for tailored approaches to donor-site utilization based on individual body shape in selected patients. Bipedicled design with the L-PAP flap represents one strategy in appropriate cases to overcome skin and volume deficiencies while facilitating coning and projection.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Improving the outcome of distally based anterolateral thigh flap reconstruction: New classification and surgical guidelines

BACKGROUND

The distally based anterolateral thigh (dALT) flap is associated with a high incidence of venous congestion. This study aimed to investigate factors associated with vascular compromise to improve the outcomes.

METHODS

We retrospectively analyzed 41 dALT flap reconstructions performed between November 2010 and February 2023. The dALT flap was classified into type I, II, or III based on the origin (the descending, oblique, or transverse branch) of the chosen perforator. The distance from the pivot point to the superolateral patella, pedicle length, flap reach, complications, and loss rates were analyzed to identify different dALT flap characteristics.

RESULTS

The type Ⅰ flap had a shorter pedicle length (type Ⅰ vs. type Ⅱ, p = 0.000; type Ⅰ vs. type Ⅲ, p = 0.000) that primarily reached closer regions (distal third of the thigh anterior/lateral knee). Pedicle lengths were similar between type Ⅱ and Ⅲ flaps (p = 1.000), most of which reached more distal regions (medial/posterior knee or proximal third of the leg). However, the type Ⅲ flaps had a higher complication rate and flap loss rate, although no significant differences were observed (complication rate, p = 0.094; flap loss rate, p = 0.071).

CONCLUSIONS

To achieve more desirable outcomes using the dALT flap, preoperative assessment of flap pedicle length and proper intraoperative maneuvers that avoid compromising the reverse blood circulation are necessary.

Long-term surgical and functional outcomes after anterolateral thigh flap and free jejunal transfer reconstruction of circumferential pharyngoesophageal defects

BACKGROUND

Circumferential pharyngoesophageal defects resulting from total pharyngolaryngectomy are commonly reconstructed using free jejunal (FJ) transfer or an anterolateral thigh (ALT) free flap.

METHODS

We reviewed the medical records of 92 patients with ALT free flaps and 140 who underwent FJ transfer between 2009 and 2022, and compared their surgical outcomes.

RESULTS

Total flap loss occurred in two (2%) and five (4%) patients in the ALT free flap and FJ transfer groups, respectively. Fistula rates were 5% in both groups. Stricture rates were 21% and 5% in the ALT free flap and FJ transfer groups, respectively (p < 0.01). At the 5-year follow-up evaluation, intelligible speech was achieved by 83% and 28% of patients (p < 0.01) in the ALT free flap and FJ transfer groups, respectively.

CONCLUSIONS

Each reconstructive method can be further optimized by proficient surgeons with expertise in the available methods and by considering patient-specific factors and available evidence.

Supercharged deep inferior epigastric perforator flap for reconstruction of soft tissue defect after excision of giant invasive squamous cell carcinoma of the thigh in a refractory diabetic with Pseudomonas aeruginosa infection

Patients with large defects after oncologic surgery often require enhanced surgical planning to optimize reconstructive outcomes. As such, medically complex patients require innovative solutions when utilizing abdominal flaps due to concern for ischemia of the distal tissue. Vascular augmentations, such as supercharging or turbocharging, serve to increase perfusion in these medical complex patients to ensure flap survival. In this report, we highlight the use of a supercharged bilateral pedicled deep inferior epigastric perforator (DIEP) flap in a patient with a 231 cm2 thigh defect in the setting of uncontrolled diabetes. A 57-year-old male with poorly-controlled diabetes (blood sugar prior to surgery 510 mg/dL) and iron deficiency anemia presented with a two-year history of a large nonmetastatic squamous cell carcinoma (SCC) measuring 19 × 9 cm2 on the right thigh. Positron emission tomography/computed tomography and biopsies of the right retroperitoneal and inguinal lymph nodes diagnosed the mass as Stage 3 localized SCC. After excision, we performed immediate reconstruction of the resultant defect with a supercharged bilateral pedicled DIEP flap. The flap was pedicled on the ipsilateral DIEP and the contralateral perforator was anastomosed to the descending branch of the lateral circumflex femoral artery (DLCFA) at the inferior aspect of the defect. A venous coupler was used for the veins and the arteries were hand-sewn in end-to-end fashion. The supercharged bilateral pedicled DIEP flap was utilized for enhanced augmented perfusion to the distal edge of the pedicled flap in a high-risk patient. The patient's clinical course was complicated by a Pseudomonas infection of a small hematoma requiring operative washout and debridement of necrotic fat. However, the flap survived and covered the defect completely. The patient required outpatient antibiotics for the Pseudomonas infection which resolved completely without further need for operative intervention. At 6-month follow up, the reconstruction was stable with no tumor recurrence on clinical exam. Our results suggest that a supercharged pedicled DIEP flap may be a viable option for large defects of the thigh and can may be utilized in medically complex patients with poor capacity for wound healing.