One-stage reconstruction of large scalp defects: anterolateral thigh flap

Seven patients with large scalp and calvarial defects underwent reconstruction with free tissue transfer. Patients fell into two groups according to etiology: tumoral (five) or traumatic (two). A single type of free flap was used in each patient, i.e., the anterolateral thigh flap. Duraplasties with the flaps' vascularized fasciae were performed in two patients with minor calvarial defects, and nonvascularized fasciae were used in another two, with a cranioplasty using methylmethacrylate. One postoperative death and one venous congestion necessitating exploration were observed. The explored anastomosis revealed occlusion of the venous anastomosis; drainage with a venous graft into the neck veins was performed. Minor tissue loss with secondary healing was observed in the flap. Extensive scalp defects often necessitate challenging reconstructive procedures. Single-stage reconstruction with good qualified tissue is possible with a free tissue transfer. The anterolateral thigh flap provides a large amount of tissue with decreased donor-site morbidity and good cosmetic results.     

Reconstruction of large palatal defects using the free anterolateral thigh flap

The ideal reconstructive method for the palatal defect should provide durable, stable coverage, and a natural contour, while simultaneously minimizing morbidity of both the defect and donor sites. Although small and usual palatal defects can be repaired easily using local adjacent tissues, successful closure of large, complex defects is still a challenging problem. Numerous free tissue options have to date been described for large palatal defects. Although the radial forearm flap constitutes a good option for ideal reconstructive goals, the sacrifice of a major artery to the hand and the skin graft to the forearm with its high potential risk of complications are evident problems attendant upon this donor site. Since the first report of the anterolateral thigh flap, this has become one of the most commonly used flaps for the reconstruction of various soft-tissue defects. Between April 2005 and May 2009, 8 free anterolateral thigh flaps were used to reconstruct defects of the palate. The study involved 6 male and 2 female patients, their ages ranging from 3 to 45. Five patients had palatal defects due to congenital cleft palate deformity, 2 patients had defects due to tumor resection, and the remaining patient had a palatal defect due to a gunshot wound. The size of the flaps ranged from 8 to 14 cm in length and from 4 to 7 cm in width. Facial vessels were used as recipient vascular sources in all patients. Primary thinning of the flap was performed in all cases. Donor sites were closed directly and healed uneventfully in all patients. There were no postoperative complications and all flaps survived totally. No debulking was needed. All patients, and their families in the case of child patients, were satisfied with the results of their surgical treatment. In conclusion, although it has some irregularity in derivation from the main vessels, with its evident structural and cosmetic advantages the anterolateral thigh flap can be considered an excellent and ideal free flap option for most large palatal defects that cannot be closed by regional tissue in selected patients. It can reconstruct defects in single stage with well-vascularized tissue, resulting in minimal donor site morbidity.     

Aesthetic and functional advantages of the anterolateral thigh flap in reconstruction of tumor-related scalp defects

Eleven patients underwent free-flap reconstruction of tumor-related defects of the scalp, forehead, and temporal region. Flap selection aimed at achieving acceptable functional and aesthetic results combined with negligible donor-site morbidity. Ten males and one female, aged 61.3 +/- 14.3 years, were included in this study. Eight patients presented with tumor recurrences after previous surgery, irradiation, and/or chemotherapy. The average extension of defects was 169.5 (range, 30-600) qcm. Free flaps employed for reconstruction included antero-lateral thigh flaps (8), suprafascial radial forearm flap (1), lateral arm flap (1), latissimus dorsi muscle flap (1), and myocutaneous vertical rectus abdominis flap (1). Other procedures included nerve grafts to the facial nerve (2), ectropion correction (2), and fascia lata slings for static procedure in facial palsy (2). There was no pedicle revision and no flap failure. Donor-site morbidity was negligible. Hospitalization averaged 9.2 +/- 1.7 days. The anterolateral thigh perforator flap offers excellent coverage of tumor-related defects of the scalp, which require a thin flap for adequate contouring. The customized harvested myocutaneous anterolateral thigh flap is regarded as an elegant option for covering defects which consist of both deep and superficial areas. Fascia lata and nerve grafts are available at the same donor site. This easily allows additional procedures for cosmetic and functional improvement that are of high benefit for patients.     

Free anterolateral thigh flap for reconstruction of major craniofacial defects

Free-tissue transfer has revolutionized skull-base surgery by expanding the ability to perform cranial base resection and by improving the quality of reconstruction. The anterolateral thigh flap has come recently into use in the field of head and neck reconstruction. Its role in craniofacial and midface reconstruction has not been specifically defined. This study involved a total of 18 patients who were treated over a 5-year period from 1998 to 2003. Seventeen patients had locally advanced head and neck cancer, requiring craniofacial resection, and one patient had a complicated gun shot wound of the forehead. Thirteen patients were treated at the National Cancer Institute, Cairo University, Egypt, and five patients at the University of Miami, Florida. The patients presented with defects of the anterior skull base (5), lateral skull base (3), scalp and calvarium (3), and the midface (7). The anterolateral thigh flap was used as a myocutaneous flap in 11 cases and as a perforator fasciocutaneous flap in seven cases. Musculocutaneous perforators supplied the majority of flaps (17/18). Total flap survival occurred in 17 cases; one patient developed complete flap necrosis. The most commonly used recipient vessels were the facial vessels and the external jugular vein. Major complications included one case with meningitis; the patient died after failure of treatment. Another patient died 6 weeks postoperatively from pulmonary embolism. One patient developed CSF leak that stopped spontaneously. In addition, two patients developed minor wound dehiscence that healed spontaneously. The donor-site wound healed without problems except in two cases. One patient had an incomplete take of the skin graft; the other developed wound infection and superficial sloughing. Both wounds healed spontaneously. In addition to the feasibility of simultaneous flap harvesting with tumor resection, the flap's advantage in skull base reconstruction is its reliable blood supply, which can provide adequate dural cover and protection of the brain. Its size and moderate thickness are suitable for reconstruction of scalp and calvarial defects. The abundance of reliably vascularized fat in the flap may be an advantage in long-term maintenance of the volume of the flap in midface reconstruction. Similar to other soft tissue flaps, additional skeletal reconstruction may still be required to achieve an optimal functional and aesthetic result.     

Functional outcomes after laryngopharyngectomy with anterolateral thigh flap reconstruction

BACKGROUND: We examined speech and swallowing outcomes and complications in patients with anterolateral thigh (ALT) flap reconstruction of cervical esophageal defects. METHODS: We retrospectively reviewed 29 patients treated with laryngopharyngectomy and ALT flap reconstruction at The University of Texas M. D. Anderson Cancer Center from March 2002 to July 2004. We compared complication rates, nutritional intake, number of tracheoesophageal punctures (TEPs), speech fluency and use, operative defects, and radiotherapy effects. RESULTS: Twenty-two patients had circumferential defects, and seven had partial defects. Twenty-four patients had radiotherapy. Eleven patients underwent TEP. Higher complication rates in patients after TEP compared with those without TEP were not statistically significant (p = .268). Ninety percent of patients with TEP spoke fluently. Ninety percent of all patients returned to oral alimentation without significant effect from TEP (p = 1.00), complications (p = 1.00), radiation therapy (p = 1.00), or surgical defect (p = .56). CONCLUSIONS: The ALT flap successfully reconstructs laryngopharyngeal defects with excellent speech and swallowing results.     

携血管化阔筋膜的股前外侧皮瓣动力性修复下唇大型缺损

目的探讨应用携血管化阔筋膜的股前外侧皮瓣修复下唇大型复杂缺损的临床效果。方法回顾性分析2013年1月至2020年6月,上海交通大学医学院附属第九人民医院口腔颌面-头颈肿瘤科同一课题组应用携血管化阔筋膜的股前外侧皮瓣修复的下唇大型复杂缺损患者的临床资料。股前外侧皮瓣用于恢复缺损的组织,重建下唇外形,阔筋膜与余留的口轮匝肌形成"闭环"结构进行动力性重建。术后每2~3个月随访1次,观察皮瓣存活情况、唇部外形、张闭口及饮水等情况。结果共纳入4例患者,均为男性,年龄26~63岁,2例为下颌骨鳞状细胞癌侵犯下唇,1例为下唇动静脉畸形栓塞术后,1例为下唇鳞状细胞癌。4例患者均顺利完成下唇的修复重建,移植皮瓣面积18 cm×7 cm~26 cm×8 cm,两端携带(5~8)cm×1 cm的阔筋膜,皮瓣均全部存活。术后随访时间6~80个月,患者下唇外形良好,张口度2~3横指,闭口时能完全密封,饮水达到基本不漏水。结论携血管化阔筋膜的股前外侧皮瓣可对下唇大型复杂缺损进行外形修复及动力性重建,能达到较好的临床效果。     

The role of the anterolateral thigh flap in complex defects of the scalp and cranium

In this study, we introduced scalp reconstruction using free anterolateral thigh (ALT) flaps and evaluated postoperative outcomes in nine patients between March 2000 and April 2012. Five patients had problems of exposed prosthesis, three required reconstruction after resection of scalp tumor and one patient presented with third degree flame burns of the scalp. All flaps survived without re‐exploration, except three flaps with tip necrosis requiring secondary procedures of debridement and small Z‐plasty reconstructions. The superficial temporal artery and its concomitant vein were used as recipient vessels, apart from two cases where previous surgery and flame burns excluded these choices, for which facial arteries and veins were used instead. Primary closure of the donor‐site was possible in six cases; with skin grafting performed for the other three patients. All donor sites healed without complications. The ALT flap offers the advantage of customizable size, option of fascia lata as vascularized dural replacement, and minimal flap atrophy typical of muscle flaps. Indications include very large defects, defects with exposed prosthesis, or defects with bone or dural loss. Our experience lends credible support to the use of customized free ALT flaps to achieve functional and cosmetically superior result for the reconstruction of large scalp defects, especially with bone exposure. © 2013 Wiley Periodicals, Inc. Microsurgery 34:14–19, 2014.     

游离削薄股前外侧皮瓣修复手腕部软组织缺损

目的探讨游离削薄型股前外侧皮瓣修复手腕部较大面积软组织缺损的临床效果方法首先对手腕部创面控制感染，减少分泌物，术中彻底清创，对受区血管状况做出判断，保证吻合血管质量，其次切取股前外侧皮瓣后，断蒂前修薄皮瓣至浅筋膜层，一般保留穿支血管周围1．5～2．0cm血管袖组织，可仅保留1支穿支血管。皮瓣移植修复创面后密切观察血供，及时处理血管危象：结果临床应用19例，移植皮瓣均成活，其中2例手术后24h出现血液循环危象，经及时处理后恢复皮瓣血液循环。结论削薄型股前外侧皮瓣厚度适宜，供区隐蔽、简便实用，可用于手腕部创面缺损修复，尤其适用于较大面积及肌腱、血管、神经外露创面的修复     

Simultaneous reconstruction of large maxillary and mandibular defects with a fibular osteocutaneous flap combined with an anterolateral thigh flap

This article reports the simultaneous reconstruction of maxillary and mandibular defects caused by a close-range gunshot blast to the face with one fibular osteocutaneous flap combined with an anteroateral fasciocutaneous flap. A fibular osteocutaneous flap was used for both mandibular and maxillary defects, using multiple osteotomies and discarding a central bony segment and an oral floor defect. An anterolateral thigh flap was used to cover a three-dimensional defect of both the intraoral mucosal region, as well as external skin and soft tissue defects, including some on the upper and lower lips. The results demonstrated that the method was a good choice in the reconstruction of large composite facial defects, both aesthetically and functionally.     

One-stage reconstruction of large midline abdominal wall defects using a composite free anterolateral thigh flap with vascularized fascia lata

OBJECTIVE: Large midline abdominal wall defects are continuously a challenge for reconstructive surgeons. Adequate skin coverage and fascia repair of the abdominal wall is necessary for achieving acceptable results. The purpose of this paper is to present a new approach to abdominal wall reconstruction using a free vascularized composite anterolateral thigh (ALT) flap with fascia lata. METHODS: Seven patients with large full-thickness abdominal wall defects were successfully reconstructed by means of a composite ALT flap combined with vascularized fascia lata. The size of the skin islands ranged from 20 to 32 cm in length and 10 to 22 cm in width, and the vascularized fascia lata sheath measured 14 to 28 cm and 8 to 18 cm, respectively. Functional outcome of the abdominal wall strength and donor thigh morbidity were investigated by using a Cybex kinetic dynamometer. RESULTS: All flaps survived. No postoperative ventral hernia occurred except for one mild inguinal incision hernia. Subjectively there were no significant donor site problems. Objective assessment was performed in 4 patients 2 years postoperatively. In the reconstructed abdomen, isokinetic concentric and eccentric measurements of extension/flexion ratios of the abdominal wall strength showed no apparent decrease compared with other references. Functional evaluation of quadriceps femoris muscle contraction forces after free ALT composite flap harvest showed an averaged deficit of 30% as compared with the contralateral legs. However, no difficulties in daily ambulating were reported by the patients. CONCLUSION: The free composite ALT myocutaneous flap with vascularized fascia lata provides an alternative option for a stable repair in complex abdominal wall defects.     

Frontal scalp flap for aesthetic eyebrow reconstruction

The eyebrow is an important subunit of facial aesthetics and expression. Partial or total absence of the eyebrow is an unacceptable and disturbing condition. Aesthetic eyebrow reconstruction is a challenging problem for the reconstructive surgeon. In this paper a simple and reliable procedure for eyebrow reconstruction is presented. An aesthetically satisfactory result was obtained and a perfect match with the undamaged eyebrow was achieved. In selected cases this technique may be a strong alternative to the procedures that had been defined earlier.     

Recontouring commissuroplasty after reconstruction of large defects after resections for head and neck cancer with commissure involvement using an anterolateral thigh flap

The aim of this study was to describe our technique for recontouring commissuroplasty after reconstruction of large, through-and-through perioral defects in patients with head and neck cancer with emphasis on functional and cosmetic outcome. This technique was used in 15 patients aged between 33 and 66 years. Recontouring required liposuction, arrow-headed advancement flap, and anchoring vector sutures. All patients had satisfactory functional and cosmetic results and healed without complication. Function was evaluated to find out whether the patient was free of drooling and able to accommodate more food postoperatively. Aesthetic evaluation was subjective, and the patients themselves decided using a visual analogue cosmesis scale. Our combined procedures provide a predictable way of creating a new oral commissure, improving postoperative drooling, and increasing the intraoral space after reconstruction.