Reconstruction of an upper posterior thigh extensive defect with a free split‐anterolateral thigh (s‐ALT) flap by perforator‐to‐perforator anastomosis: A case report

The anterolateral thigh (ALT) flap is one of the most commonly used flap worldwide in reconstructive surgery, as both free flap and pedicled local flap. Here, we report the use of a free split anterolateral thigh (s‐ALT) flap for reconstruction of a 14 cm × 16 cm soft tissue defect of the left upper posterior thigh region due to sarcoma resection in a patient. The ALT flap was harvested based on two musculocutaneous perforators from the right thigh and anastomosed to the contralateral descending branch of the lateral circumflex femoral artery (LCFA) in perforator‐to‐perforator manner, in order to gain more pedicle length and being able to cover the posterior thigh defect. The post‐operative course was uneventful and the patient was discharged at 1 week post‐operative. Eleven months after the operation, the aesthetic outcome was satisfactory with no functional deficit. Even though it requires technical skills and experience in perforator dissection, we believe that the s‐ALT flap anstomosed to the contralateral LCFA in perforator to perforator fashion, may be a good solution in case of such a difficultly located extensive defect of the posterior thigh.     

Abdominal wall reconstruction using anterolateral thigh flap with microsurgical pedicle lengthening technique: A case report

Pedicled anterolateral thigh (ALT) flap has been employed for coverage of low abdominal wall defects. However, its use is limited for defects located more on the cranial side because of insufficient pedicle length. We present a case of successful reconstruction of mid-abdominal wall defect using pedicled ALT flap, overcoming the issue of pedicle length shortage with a microsurgical pedicle lengthening technique. A 75-year-old man suffered from a 12 × 8 cm full-thickness soft tissue defect on his mid-abdominal wall originated from colon anastomosis site leakage after ileostomy takedown surgery. A pedicled ALT flap was planned for the defect coverage. After we performed debridement to prepare the wound bed, a 14 × 8.5 cm sized ALT flap based on two lateral circumflex femoral artery (LCFA) perforators was elevated. During intramuscular dissection of perforators, we dissected the distal portion of the LCFA descending branch. After full dissection of the pedicle to source vessels, we attempted to transfer the flap, but still the flap had short pedicle. We transected the pedicle just distal to the bifurcating point and reconnected it to the distal end of the dissected descending LCFA branch with microsurgical anastomosis. We passed the flap through a subcutaneous tunnel and conducted smooth flap insetting without any tension on the lengthened pedicle. Postoperatively, the wound healed successfully without complications. The patient was discharged 2 weeks after surgery and followed up at postoperative 3 months without adverse events. A local ALT flap with pedicle lengthened might be a reliable option for reconstruction of supraumbilical abdominal defects.     

Versatility of the free anterolateral thigh flap for reconstruction of soft-tissue defects: review of 140 cases

From August 1995 to June 1999, 140 free anterolateral thigh (ALT) flaps were transferred to reconstruct a variety of soft-tissue defects. The size of ALT flap ranged from 10 to 33 cm in length and 4 to 14 cm in width. Based on the anatomic variations of the perforators, the blood supply to the skin island came from the septocutaneous perforators only in 19 patients (13.6%), arising from the descending or transverse branch of the lateral circumflex femoral artery (LCFA), or originating directly from LCFA. The other flaps were supplied by musculocutaneous perforators that were elevated as a true perforator flap via intramuscular dissection (N = 34, 24.3%), or used a cuff of vastus lateralis muscle for added bulk (N = 87, 62.1%). The overall success rate was 92% (129 of 140). After a 2-year follow-up, all flaps have healed unevenffully and donor thigh morbidity is minimal. Anatomic variations must be considered if the ALT flap is to be used safely and reliably.     

Metatarsal artery perforator‐based propeller flap

Soft‐tissue defects of the distal foot that involve an exposed tendon and bone demonstrate a reconstructive challenge for plastic surgeons. This report investigates the feasibility and reliability of metatarsal artery perforator (MAP)‐based propeller flap for reconstruction of the distal foot soft‐tissue defects. Between July 2011 and June 2012, six patients underwent distal foot reconstruction with seven MAP‐based propeller flaps. Five flaps were based on the third metatarsal artery and two flaps were based on the first metatarsal artery. The flap size ranged from 4 × 2 cm to 8 × 4 cm. All flaps completely survived. Two patients developed transient distal venous congestion, which subsided spontaneously without complications. There were no donor site complications. All patients were ambulating without difficulty within the first month of surgery. MAP‐based propeller flaps can be used to repair the distal foot soft‐tissue defects, providing sufficient skin territory and excellent esthetic and functional recovery. © 2013 Wiley Periodicals, Inc. Microsurgery 34:287–291, 2014.     

The oblique branch trap in the harvest of the anterolateral thigh myocutaneous flap

A 67‐year‐old man with squamous cell carcinoma underwent reconstruction with a free anterolateral thigh myocutaneous flap. Unroofing the skin perforators found that the skin perforators originated from the oblique branch of the lateral circumflex femoral artery with no connections with the descending branch. Thus, the flap was harvested based on the oblique branch, leaving the descending branch in situ. Reconstruction was completed uneventfully and he had an excellent outcome at 1‐year follow‐up. The anterolateral thigh myocutaneous flap was reputed to be a technically easy flap to harvest. The perforators supplying the skin were visualized and a block of muscle incorporating the perforators harvested with the descending branch of the lateral circumflex femoral artery as the pedicle of the flap. However, not infrequently with this approach, the flap thus harvested has a well‐perfused muscle component, whereas the skin component was not viable. This situation is explained anatomically by the potential occurrence of an alternative pedicle that supplies the anterolateral thigh flap, called the oblique branch of the lateral circumflex femoral artery. Our case presented here was a “classic” intraoperative finding of this potential trap and the importance of defining the anatomy before committing oneself to the harvest by unroofing all the skin perforators was emphasized. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

Free anterolateral thigh flap in pediatric patients

The anterolateral thigh (ALT) flap represents a workhorse flap in reconstructive surgery. We describe our clinical experience with this flap in the pediatric population. A total of 20 patients with an average age of 9.5 years underwent a free ALT flap reconstruction. All flaps were commonly raised on 2 perforators. About 5 flaps were employed for head and neck reconstruction, 7 for upper and 8 for lower limb reconstruction. Traumatic defects and congenital malformations represented the predominant etiology. Sizable perforators were found in all patients. The caliber was smaller compared to adults, and the course of the perforator was shorter. There were no complete flap losses and no significant donor-site morbidity. Donor-site closure required closure with split-thickness skin grafts in 6 cases. Hypertrophic scars developed in 4 patients. Secondary procedures included flap debulking (5) and Z-plasties (2). In conclusion, children have well-developed perforators supplying the ALT flap. With proper technique, this flap can be harvested and employed safely and reliably for reconstruction of varied defects in children.     

Computed tomography angiography imaging for the chimeric anterolateral thigh flap in reconstruction of full thickness buccal defect

Background: Microvascular free flap transplantation is the current most common choice for reconstruction of difficult through‐and‐through buccal defect after cancer extirpation. The chimeric anterolateral thigh (ALT) flap is an ideal flap to cover this full thickness defect, but variation in the location of perforators is a major concern. Herein, we introduce computed tomographic angiography (CTA)‐guided mathematical perforators mapping for chimeric ALT flap design and harvest. Methods: Between September 2008 and March 2009, nine patients with head and neck tumour underwent preoperative CTA perforator mapping before free ALT flap reconstruction of full thickness buccal defects. The perforators were marked on a 64‐section multi‐detector CT image for each patient, and the actual perforator locations were correlated with the intra‐operative dissection. The donor limb of choice, either right or left, was also selected based on the dominant vascularity. Flap success rates, any associated morbidity and complications were recorded. Results: A total of 23 perforators were identified on CTA image preoperatively. Twenty‐two of these perforators were chosen for chimeric flap design, and all were located as the CTA predicted, with the rate of utilization being 95.7% (22/23). There were two post‐operative complications, including one partial flap necrosis and one microstomia. All of the ALT flaps survived, and there was no donor site morbidity. Conclusions: Preoperative CTA allows accurate perforator mapping and evaluation of the dominant vascularity. It helps the surgeon to get an ideal designing of the chimeric ALT flap with two skin paddles based on individual perforators, but only one vascular anastomosis in reconstruction of full thickness buccal defects.     

Ischial pressure sores: Reconstruction using the perforator‐based reverse flow musculocutaneous 180° propeller flap

The treatment of pressure sores requires soft tissue reconstruction with thick tissue to provide padding of bony prominences and obliterate dead space. Fasciocutaneous flaps may not provide adequate bulk. Propeller flaps (180°) based on perforators from the gluteal artery may be harvested as a reverse flow musculocutaneous flap including a muscle plug to reconstruct deep cavities. Three patients presenting with deep pressure sores required reconstruction of large cavities. In addition to a regular 180° propeller flap, a muscle plug based on a perforator found in the blade of the propeller was used to add bulk to the flap and obliterate the cavity with well‐vascularized tissue. One flap required secondary closure of the donor site due to dehiscence, one hematoma required drainage. All flaps survived completely. No recurrence of osteomyelitis or pressure sores was seen. The 180° propeller flap can be harvested as a reverse flow musculocutaneous flap including a muscle plug in the distal blade. This adds volume which is required to adequately obliterate large cavities in cases of osteomyelitis. This new technique may be useful in other areas as well. © 2009 Wiley‐Liss, Inc. Microsurgery 2009.     

Modification of pedicle lengthening through perforator transposition in free anterolateral thigh flaps with pedicle size discrepancy: A case report

In spite of thorough presurgical planning, emergency situations requiring longer pedicle length may arise during anterolateral thigh (ALT) free flap surgeries. While performing vessel graft for pedicle lengthening, discrepancy may occur because of a certain genetic predisposition or vascular variation at the anastomosis site of the graft vessel and the flap pedicle. A 76‐year‐old male patient with neurofibromatosis type I had a 15 x 10 cm defect, which was caused by radical excision of a malignant peripheral nerve sheath tumor on his back. A 15 x 10 cm sized free ALT flap was obtained. The distance between the recipient vessels and the defect area was 20 cm. The diameters of vessels in the harvested flap were as follows: proximal end of the descending branch of the lateral circumflex femoral artery (LCFA)—artery/vein: 3.0/2.5 mm, distal end of the descending branch of the LCFA—artery/vein: 1.0/1.0 mm, and perforator in the ALT flap—artery/vein: 0.8/1.0 mm. The conventional method requires transfer of the distal portion of the LCFA (below the bifurcation) which mandates us to perform anastomoses with a vessel diameter discrepancy of 2 mm. As an alternative, a bifurcating perforator‐including flap was transposed to the most distal part of the descending branch of the LCFA. An ALT flap with a pedicle having a total length of 20 cm was constructed. The flap survived without any complications. This technique may provide an option for resolving size discrepancy between the graft vessel and the ALT pedicle.     

Bilateral pedicle anterolateral thigh (ALT) flap combined with bilateral sartorius muscle flap for reconstruction of extensive perineoscrotal and medial thigh defect because of Fournier's gangrene

Fournier's gangrene is an acute and potentially lethal necrotizing fasciitis that can lead to extensive defects of the perineoscrotal area and lower abdominal wall as well. Such defect poses challenging tasks for both functional and cosmetic reconstruction. Local perforator pedicle flaps and muscle flaps can be employed and combined for such a reconstruction. In this report we present a case of reconstruction of a massive perineoscrotal and upper medial thigh defect because of Fournier's gangrene using a bilateral pedicle anterolateral thigh (ALT) flap and sartorius muscle flap. A 61 year‐old male who suffered from Fournier's gangrene resulted in a perineal, scrotal, and medial thigh defect of 27 × 30 cm² with exposure of the femoral vessels. A bilateral pedicle ALT flap measuring 30 × 9 cm² based on two perforators and a bilateral sartorius muscle flap were harvested for soft tissue defect reconstruction and inguinal vessels coverage, respectively. The flaps survived completely, with no recipient or donor site morbidity. The length of follow‐up was 6 months and was uneventful. A bilateral pedicle ALT flap combined with bilateral sartorius flap may be considered as a valid and safe option for an extensive inguinal and perineoscrotal reconstruction in selected cases. © 2016 Wiley Periodicals, Inc. Microsurgery 37:669–673, 2017.     

Extended anterolateral thigh pedicled flap for reconstruction of trochanteric and gluteal defects: A new & innovative approach for reconstruction

Descending branch of the lateral circumflex femoral artery (LCFA) is commonly used pedicle for anterolateral thigh (ALT) flap. Oblique branch of LCFA is an alternative pedicle that can be used in microvascular surgery. According to review of literature and to the best of our knowledge we could not find the use of oblique branch of LCFA as a pedicle of the ALT flap in regional soft tissue reconstruction. Here we presented a case of a 55-year-old man sustaining soft tissue injury and wound over the left trochanteric and gluteal region following a road traffic accident, who was treated by the use of extended ALT pedicle flap with oblique branch of LCFA as the pedicle for reconstruction of soft tissue defect in trochanteric and gluteal regions with successful outcome.     

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

Introduction:

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

Materials and Methods:

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

Results and Conclusion:

The result was always satisfactory in terms of the donor site morbidity and reconstructive outcome.KEY WORDS: Anterolateral thigh flap, perforator flap, tensor fascia lata, tensor fascia lata     

Variations in perforators of anterolateral thigh flap

In our study of anterolateral thigh flaps, ten patients had musculocutaneous perforators (58%), four patients had septocutaneous perforators (24%), and three patients had both types of perforators (18%). Average number of perforators found in each flap was 1.9 (range 1–4). The maximum number of perforators in a single case was four. A single perforator was found in seven patients. In patients with both types of perforators, larger flaps could be harvested and there were no complications. The study was carried out over a period of 3 years and included 17 patients treated with free anterolateral thigh flaps in our hospital from April 2004 to August 2007. All age groups and both sexes were included in the study. A cadaveric study was done on ten fresh cadavers in the anatomy department of the same hospital. Although the majority of free anterolateral thigh free flaps are based on musculocutaneous perforators and fewer flaps are based on septocutaneous perforators, our study shows that this versatile free flap can be based on a combination of both septocutaneous and musculocutaneous perforators. Though our cadaveric study did not show any flap to be based on the combination of both types of perforators, our clinical study in which we had three cases of this type definitely shows that the ALT flap can be based on a combination of both septocutaneous and musculocutaneous perforators. Further in these cases with both types of perforators, larger flaps could be harvested and with greater flap success.     

Anatomical variations in the harvest of anterolateral thigh flap perforators: a cadaveric and clinical study

Background: The anterolateral thigh (ALT) flap has become increasingly popular due to its versatility and minimal donor site morbidity. Its major limitation has been uncertainty in predicting perforator anatomy, with the occasional absence of suitable perforators and high variability in their size and course. The variability of this anatomy has not been adequately explored previously. Methods: A cadaveric study was undertaken, in which 19 thighs (from 10 fresh cadavers) underwent contrast injection and angiographic imaging. Anatomical variations of the vasculature were recorded. A clinical study of 44 patients undergoing ALT flap reconstruction was also undertaken. Perforator anatomy was described in the first 32 patients, and the subsequent 12 patients underwent computed tomography angiography with a view to predicting individual anatomy and improving operative outcome. Results: Cadaver angiography was able to highlight and classify the variations in arterial anatomy, with four patterns observed and marked variability between cases. In 32 patients undergoing ALT flaps without preoperative CT angiography (CTA), five patients (16%) did not have any suitable perforators from the descending branch of the lateral circumflex femoral artery. By selecting the limb of choice with preoperative CTA, the incidence of flap unsuitability was reduced to 0%. Comparing CTA with Doppler, CTA was more accurate (sensitivity 100%) and provided more information. Conclusion: The perforators supplying the ALT flap show significant variability in location and course, with the potential for unsuitable perforators limiting flap success. Preoperative CTA can demonstrate the vascular anatomy and can aid perforator selection and operative success. © 2008 Wiley‐Liss, Inc. Microsurgery, 2009. [This is a corrected version of the abstract first published online on 22 October 2008 — the corrected version appears in print.]     

Tripaddled anterolateral thigh flap for simultaneous reconstruction of bilateral buccal defects after buccal cancer ablation and severe oral submucous fibrosis release: A case report

For buccal squamous cell carcinoma (SCC) patients accompanied with severe oral submucous fibrosis (OSF), it is a challenge to simultaneously reconstruct bilateral buccal defects created from cancer resection and contralateral OSF release to improve postoperative mouth opening. Herein, we present a case of reconstruction of bilateral buccal defects in a 46‐year‐old patient who had left buccal SCC accompanied with severe OSF. Extensive ablation involved the left full‐thickness cheek as well as part of mandible and a release of right OSF tissue were performed. A tripaddled anterolateral thigh (ALT) flap with three independent sets of perforators was harvested for reconstruction. The flap survived in its entirety. No donor or recipient site complication occurred. The preoperative inter‐incisor distance (IID) was 1 mm, while the postoperative IID was 23 mm. This is the first report on the use of one tripaddled ALT flap for reconstruction of bilateral buccal defects created from cancer ablation and severe contralateral OSF release. © 2013 Wiley Periodicals, Inc. Microsurgery 33:667–671, 2013.     

Intraoperative flap design using ICG monitoring of a conjoined fabricated anterolateral thigh/tensor fasciae latae perforator flap in a case of extensive soft tissue reconstruction at the lower extremity

In this report, we present a case of the use of a conjoined fabricated free anterolateral thigh (ALT)/tensor fascia latae (TFL) perforator flap for reconstruction of the lower extremity with intraoperative flap design using intraoperative indocyanine green (ICG) monitoring. The flap was used for reconstruction of a 16 cm × 28 cm sized defect of the lower leg in a 24‐year‐old man. The defect was caused by a third degree open fracture to the tibia. Upon dissection of the ALT perforators, ICG monitoring showed that both dominant ALT perforators did not yield a sufficient perforasome (～16 cm × 17 cm) for the larger flap needed. An adjacent TFL perforator also supplied a large perforasome (～15 cm × 11 cm), so a conjoined fabricated flap was harvested and transplanted to cover an extensive lower leg defect. The artery of the TFL perforator pedicle was being in‐flap anastomosed to a side branch of the ALT pedicle. Postoperative course was uneventful and there were no complications. Length of follow‐up was 6 months, aesthetic and functional outcome was good. The patient was very satisfied with the aesthetic outcome. Both legs were fully mobile after intensive physiotherapy for the reconstructed leg. The leg where the flap had been harvested showed full strength in knee joint flexion. This case could show that identification of the supplying vessels may be possible by ICG monitoring. © 2015 Wiley Periodicals, Inc. Microsurgery 36:684–688, 2016.     

Reconstruction of a radical total vulvectomy defect with a single split anterolateral thigh perforator flap: A case report and review of the literature

Reconstruction following total vulvectomy is a reconstructive challenge. Previously described techniques typically require bilateral flaps and the associated donor site morbidity. We present a case of reconstruction after radical total vulvectomy using a single split anterolateral thigh (ALT) perforator flap with a design that optimizes perfusion while allowing for primary donor site closure. A 68‐year‐old female with a history of vulvar squamous cell carcinoma who had previously undergone vulvectomy and radiation therapy presented with local recurrence. The patient required a radical total vulvectomy, resulting in a 12 × 10 cm vulvar defect. A 2‐perforator ALT flap (25 × 7 cm) was harvested, split transversely, and then inset in a circumferential manner around the vulva. This approach contrasts with previous reports, which split the ALT flap longitudinally or centrally, and can compromise perfusion and/or preclude primary donor site closure. The patient healed without complication with 6 months of follow‐up. The described approach allows for total vulvectomy reconstruction using a single ALT flap with a perforator configuration that maximizes perfusion while obviating the need for donor site grafting.     

The combined free partial vastus lateralis with anterolateral thigh perforator flap reconstruction of extensive composite defects.

Myocutaneous (MC) free flaps are useful for many reconstructive indications. Perforator flaps have become standard of care. The anterolateral thigh flap (ALT) donor site is popular. With the ALT flap varying sizes of vastus lateralis (VL) muscle can be harvested as a MC flap. The skin islands of these flaps have a great range of freedom when dissected on their perforator. It was hypothesised that the VL-ALT perforator flap would offer adequate tissue volume combining maximal freedom in planning with minimal donor site morbidity. From November 2001 to February 2003 a free partial VL with ALT perforator flap was used in 11 patients to reconstruct large defects. Indications for adding a muscular component were exposed bone, skull base, (artificial) dura, or osteosynthesis material, open sinuses, and lack of muscular bulk. Flaps were planned as standard ALT flaps, after which three types of dissection were performed: I. true MC flap; II. muscle flap with a skin island on one perforator, which could be rotated up to 180 degrees ; III. chimera skin perforator flap with muscle being harvested on a separate branch from the source vessel or on a side branch of the skin perforator. Mean skin size of the MC-ALT flaps was 131 cm2. Mean muscle part size of the MC-ALT flaps was 268 cm3. Muscular parts were custom designed for all defects. No total or partial flap failures were seen. Colour mismatch was seen in 6 of 8 patients, when skin was used in the facial area in this all white population. Excessive flap bulk was found in 8 of 11 patients at 6 weeks, however, only in 2 of 11 patients after 6 months. Patients were satisfied with the functional result (8 of 11 patients) as well as the cosmetic result of their reconstruction (7 of 11 patients). All less satisfied patients had received their flap for external facial skin reconstruction. Donor site morbidity was minimal. The combined free partial VL with ALT perforator flap proved valuable as a (chimera type) MC flap with maximal freedom of planning to meet specific reconstructive demands and minimal donor site morbidity.     

Soft-tissue reconstruction using a free anterolateral thigh flap: experience with 28 patients

The authors present their experience using the free anterolateral thigh fasciocutaneous flap for head and neck and extremity reconstruction. From January 2000 through March 2002, 28 free anterolateral thigh flaps were transferred to reconstruct various soft-tissue defects. All patients were operated by two teams. All flaps were elevated based on one perforator only. The sizes of the flaps ranged from 9 x 11 to 20 x 26 cm. The success rate was 96.5% (27 of 28), with one partial failure. The cutaneous perforators were always found. Septocutaneous perforators were found in 3 of 28 patients (10.7%). Musculocutaneous perforators (89.3%) were found in the remaining patients, and the number of perforators ranged from two to five (average, three perforators). In 4 patients, flaps were used for sensate reconstruction. The authors used the anterolateral thigh flap as a thin flap in 10 patients. Mean follow-up was 13.5 months (range, 2-25 months). Soft-tissue reconstruction with the free anterolateral thigh flap in various regions of the body provides an excellent functional and cosmetic result with minimal donor site morbidity. The anterolateral thigh flap has many advantages over other conventional free flaps and it seems to be an ideal choice for the reconstruction of soft-tissue defects.     

Customized reconstruction with the free anterolateral thigh perforator flap

From April of 2003 through September of 2006, 70 free anterolateral thigh (ALT) flaps were transferred for reconstructing soft-tissue defects. The overall success rate was 96%. Among 70 free ALT flaps, 11 were elevated as cutaneous ALT septocutaneous vessel flaps. Fifty-seven were harvested as cutaneous ALT myocutaneous "true" perforator flaps. Two flaps were used as fasciocutaneous perforator flaps based on independent skin vessels. Fifty-four ALT flaps were used for lower extremity reconstruction, 11 flaps were used for upper extremity reconstruction, 3 flaps were used for trunk reconstruction, and 1 flap was used for head and neck reconstruction. Total flap failure occurred in 3 patients (4.28% of the flaps), and partial failure occurred in 5 patients (7.14% of the flaps). The three flaps that failed completely were reconstructed with a free radial forearm flap, a latissimus dorsi flap and skin grafting, respectively. Among the five flaps that failed partially, three were reconstructed with skin grafting, one with a sural flap, and one with primary closure. The free ALT flap has become the workhorse for covering defects in most clinical situations in our center. It is a reliable flap with consistent anatomy and a long, constant pedicle diameter. Its versatility, in which thickness and volume can be adjusted, leads to a perfect match for customized reconstruction of complex defects.