Posteromedial thigh (PMT) propeller flap for perineoscrotal reconstruction: A case report

Fournier's gangrene can lead to extensive defects of the perineoscrotal area with exposure of the testes. Such defect poses challenging tasks for both functional and cosmetic reconstruction. Due to its proximity, medial thigh skin appeared to be the most versatile donor site for perineoscrotal reconstruction. In this report, we present a case of reconstruction of a large perineoscrotal defect because of Fournier's gangrene using a posteromedial thigh (PMT) perforator propeller flap. A 58 year‐old male who suffered from Fournier's gangrene resulted in a scrotal defect of 10 × 12 cm² with a large dead space. A pedicled PMT propeller flap measuring 9 × 23 cm² with two perforators that originated from the profunda femoris artery (PFA) was harvested for scrotal defect reconstruction and dead space obliteration. The flap survived completely, with no recipient or donor site morbidity. The length of followup was 3 months and was uneventful. The pedicled PMT propeller flap may be considered as a valid option for perineoscrotal reconstruction. © 2015 Wiley Periodicals, Inc. Microsurgery 35:569–572, 2015.     

Simultaneous deep inferior epigastric and bilateral anterolateral thigh perforator flap reconstruction of an extended perineoscrotal defect in Fournier's gangrene: A case report

Fournier's gangrene is lethal necrotizing fasciitis that involves the perineum and external genitalia. We describe the case of a 52‐year‐old man with Fournier's gangrene who underwent reconstruction of an extensive perineoscrotal defect using three pedicled perforator flaps. Three debridement procedures resulted in a skin and soft tissue defect of 36 × 18 cm involving the perineum, scrotum, groin, medial thigh, buttocks, and circumferential perianal area and left the perforating arteries originating from these locations unavailable for reconstruction. We repaired the defect using left deep inferior epigastric artery perforator (DIEP) (29 × 8 cm) and bilateral anterolateral thigh perforator (ALT) flaps (35 × 8 cm and 22 × 7 cm). The flaps reached the defect without tension, and the defect was successfully covered without a skin graft. No postoperative complications occurred except for epidermal necrosis involving a tiny part of the DIEP flap tip. Nine months postoperatively, the patient experienced no impairment of bowel function or hip joint movement. There was also no avulsion or ulceration of the reconstructed perineal skin, and the cosmetic appearances of the healed wound and donor site were satisfactory. The combination of these three perforator flaps enabled us to achieve a satisfactory outcome while avoiding skin grafts.     

Intérêt du lambeau fasciocutané médial de la cuisse dans la gangrène de Fournier

IntroductionThe authors propose a focus on the management of perineoscrotal defects caused by Fournier's gangrene, and emphasize the importance of the medial thigh fasciocutaneous flap.Patients and methodsThis a retrospective study of 12 cases of Fournier's gangrene managed initially by intensivists and urologists then addressed to plastic surgeons for skin coverage. The latter was achieved through a medial thigh fasciocutaneous flap, unilateral in some cases, bilateral in others.ResultsAll patients were male, 63 years on average, and the defect was perineoscrotal, associated in three cases with penile skin defect. The medial thigh fasciocutaneous flap was bilateral in 8 cases. We deplore two cases of partial necrosis. Long-term cosmetic results were satisfactory.Conclusioncoverage of perineoscrotal defect in Fournier's gangrene was dominated for a long time by burying the testicles and skin grafting. Certainly these two techniques are simple, but they are not always achievable. Compared to other flaps, musculocutaneous in this case, the medial thigh fasciocutaneous flap remains simple, useful, and is associated with lower morbidity. It must occupy a prominent place in the cover of such defects, especially in the elderly, in whom the desire for procreation is no longer a priority.     

The transverse upper gracilis flap for breast reconstruction following liposuction of the thigh

A particular flap with rising prominence in breast reconstruction is the transverse upper gracilis (TUG) flap. With the increasing prevalence of patients opting for various forms of elective liposuctions, breast reconstruction with flaps has necessitated a more meticulous yet perhaps more flexible screening for potential donor sites. We present a case of a bilateral breast reconstruction using TUG flaps in a patient with a previous history of liposuction to her abdomen and thighs. The dimensions of the TUG flaps were 7 × 31 cm². The patient did not undergo any flap or donor site complications. We speculate that perhaps much of the tissue and muscle in the medial thigh region is more robust than previously thought and that there is high potential for neo‐vascularization in the thigh region following a liposuction. Accordingly, we advocate the effective use of the TUG flap for breast reconstruction in spite of previous liposuctions to the thighs. © 2010 Wiley‐Liss, Inc. Microsurgery, 2010.     

Pedicled neurocutaneous anterolateral thigh flap for groin reconstruction – A case report

Several different flaps based on the feeding vessels of sensitive nerves have been described in the limbs. This article reports the case of a neurocutaneous flap based on the lateral femoral cutaneous nerve (LFCN), employed for reconstruction of an inguinal defect. A 61‐years‐old female patient had undergone vulvectomy and bilateral inguinal lymphadenectomy for vulvar cancer with postoperative left groin wound breakdown. After a 3 weeks negative pressure therapy course, she presented a 10 × 4 cm skin and subcutaneous defect with undermined edges in the left inguinal area. Reconstruction with 14 × 6 cm pedicled left anterolateral thigh flap was planned. After the dissection of the vascular pedicle and of the sensitive nerve, complete thrombosis of both the veins and arterial spasm of perforating pedicle was detected. As the flap color was good, and slow marginal bleeding was present, we inspected the small vessels surrounding the nerve that were pulsating. To confirm the vascularization coming from the neural pedicle, we clamped the perforator and performed intraoperative indocyanine green (ICG) fluorescence angiography that showed a good fluorescence of the flap with a proximal to distal pattern of progression. The flap was transferred on the neural pedicle, survived completely, and wounds healed normally. Three months after surgery, the patient underwent radiotherapy, with uneventful course. In her last follow‐up, 2 years after surgery, patient was free of disease and the flap showed normal scarring. This is the first case reported of a pedicled neurocutaneous flap based on the LFCN, indicating that in case of unsuitable perforators it could be an alternative pedicle.     

Reconstruction of a large pelvic defect by transfer of a quadruplet combination of pedicled flaps from the medial thigh using bilateral muscular gracilis flaps and bilateral vertical posteromedial thigh (vPMT) propeller flaps—A case report

The reconstruction of defects of the perianal area and vagina places a high demand on a reconstructive surgeon. Different reconstructive methods include a skin graft, a local skin flap, a musculocutaneous flap, and a pedicled perforator flap. Here, we report the case of a 59-year-old female patient with a pelvic defect, who underwent reconstruction with a quadruplet combination of pedicled flaps from the medial thigh, due to an extensive resection of a recurrence of a squamous cell carcinoma of the anus, vulva, and partially the colon. The surgical oncologist performed a rectum amputation, a partial colectomy, a complete hysterectomy, and a resection of the dorso-lateral vaginal vault in order to achieve tumor-free margins. The resulting defect measured 14 × 11 cm² with 8 cm of deep space. The defect was covered and reconstructed by employing a bilateral pedicled gracilis muscle flap rotated about 120° and advanced to fill up the residual spare space in the deep and a bilateral vertical posteromedial thigh (vPMT) using a propeller flap measuring 27 × 10 cm² rotated 180° in order to reconstruct the vagina and the perianal area. All flaps survived without major post-operative complications. The donor site morbidity was minimal. The range of motion was not limited over both hip and knee joints. Patient had no problem with urination. Sexual intercourse was not highly considered due to patient's old age. The follow-up at 6 months showed acceptable cosmetic results with a satisfying contour of the coverage and reconstructed area. The combination of pedicled gracilis muscle flap and vPMT propeller flap may represent a valuable option in such a defect where deep space obliteration and reconstruction of the vagina with perianal contouring are needed.     

Thirty-year experience of utility of island groin flap for scrotal defect single-stage reconstruction

For the last 32years, we have been using island groin flap successfully to cover the scrotal defects in a single stage with good results. This flap utility for single-stage urethral fistula repair was first reported by the senior author in 1987 and was published in Br J Urol.¹We have performed single-stage repair of scrotal defects of medium and moderate size with this flap in 25 cases of Fournier's gangrene and in 4 cases of scrotal avulsion injuries due to road traffic accidents. All had good aesthetic results. More than 50% scrotal size defects were treated by a single groin flap alone. In cases with total loss of the scrotum, the groin flap was used along with two superior medial pedicle thigh flaps. Here, we have included cases of single-stage reconstruction of scrotal reconstruction by island groin flap alone. All our patients were operated under spinal anaesthesia. The results were satisfactory for the patients. We conclude from our 30 years of experience of utilizing this vascular island groin flap for a single-stage repair of scrotal defects of moderate size to be a procedure of better choice.     

A pedicled split extended vertical deep inferior epigastric (s-vDIEP) flap and an adipo-dermal thigh local flap for the reconstruction of the medial thigh compartment after sarcoma resection: A case report

Large upper medial thigh defects in prior irradiated tissue require challenging reconstructions. Several techniques have been reported to reconstruct this region and according to the literature, pedicled perforator flaps are the first reconstructive option. The anterolateral thigh flap is considered the gold standard, while surprisingly the pedicle deep inferior epigastric (DIEP) flap in vertical fashion has not been frequently employed, if compared with its muscular counterpart, the pedicle vertical rectus abdomins flap (vRAM). We report a case of a multilayered flaps reconstruction of the left medial thigh after an excision of a sarcoma involving the whole adductors compartment. A 75-year-old male patient underwent a free margins resection of the sarcoma. After the resection, a soft tissue defect of 24 cm × 14 cm × 14 cm spreading from the groin to the medial tuberosity of the tibia, was left. We performed a reconstructive technique based on a pedicled split extended vertical deep inferior epigastric (s-vDIEP) flap and an adipo-dermal thigh local flap in order to fill and cover the thigh defect. The s-vDIEP had 2 islands: a cranial de-epithelialized island to fill the dead space and a caudal for the skin closure. The postoperative follow-up was complicated by seroma formation and it was managed by sclerotherapy and at the 6 months follow-up the patient showed good cosmetic and functional outcomes with no sign of tumor relapse. Our result suggests that the proposed multilayered reconstruction may be employed for the restoration of large and deep upper medial thigh defects.     

Pedicled anterolateral thigh flap for contralateral groin composite defect

Pedicled anterolateral thigh flap has been well described for ipsilateral groin defects. Its versatility depends on the intact femoral vessels. When the external iliac and the femoral vessels are absent, especially secondary to wide surgical tumour ablations in the groin region, ipsilateral ALT flap is not an option. Free flaps also are difficult because of lack of recipient vessels. We report a case of composite groin defect following wide resection of recurrent liposarcoma along with encased vessels which was covered with a pedicled anterolateral thigh flap from the opposite thigh. The technique of lengthening the vascular pedicle and medializing the pedicle, to effectively increase its reach to the contralateral anterior superior iliac spine without vascular compromise, is described.     

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.     

Customized reconstruction of complex soft tissue defects in the upper extremities with variants of double skin paddle anterolateral thigh perforator flap

BackgroundComplex soft tissue defects in the upper extremities are challenging to reconstruct. The purpose of this study was to share our experience with using four variants of double skin paddle Anterolateral Thigh Perforator (ALT) flap to achieve the customized reconstruction of the complex defects.Patients and methodsFrom January 2007 to December 2019, 15 patients (14 male and 1 female) aged 15–61 years underwent double skin paddle ALT flap reconstruction of the upper extremities. 10 wounds were located in the wrist or hand, while four wounds were located in the forearm, and one wound in the elbow. All the wounds were large with non-adjacent defects and with or without a dead space. Four variants of double skin paddle anterolateral thigh perforator flaps were harvested according to the patient's needs.ResultsThe flaps received were consisted of 7 classic double skin paddle ALT flap, 4 vastus lateralis muscle-chimeric double skin paddle ALT flap, 2 microdissected thin double skin paddle ALT flap, and 2 flow-through double skin paddle ALT flap. The size of the skin flap ranged from 6 × 6 cm² to 26 × 7 cm², and the size of the muscle segment ranged from 5 × 2 × 1 cm³ to 16× 6 × 2 cm³. Flap necrosis related to the pedicle kinking was observed in one patient, while the rest of the flaps survived without complications. The follow-up period ranged from 7 to 54 months, with a median of 15.6 months. The mean value of the qDASH scores at the last follow-up was 27.12 ± 16.51 (range, 11.4–59.1). None of the patients showed wrist flexion deformity. Postoperatively, three patients developed finger joint stiffness, which correlated with the severity of the injury.ConclusionsVariants of double skin paddle ALT flaps provide versatile design and allow customized reconstruction of complex soft tissue defects in the upper extremities with limited donor site morbidity. We believe that the algorithm provided will help the surgeons with deciding among variants of double skin paddle ALT flap.     

Keyhole anterolateral thigh flap: A special way of partition for reconstruction around a protruding structure or cavity/tunnel

Background : Anterolateral thigh (ALT) flap is now a workhorse flap for reconstruction of skin and soft tissue defects. However, there are some drawbacks in its application, and revisions are often needed after surgery. Here, we present the results of the use of a special type of partition for ALT flap based on the concept of perforator flap vascular anatomy for reconstruction around a protruding structure, a cavity or a canal, in patients. Patients and methods : We used the keyhole design for reconstruction with ALT flaps in five patients. Wounds involved circumferential soft tissue defects around the following structures: thumb (two cases), penis, ear canal, and anus. Defects arose following excision of scar contracture, arterio‐venous malformation, Paget's disease, squamous cell carcinoma, and Fournier's gangrene, respectively. The ALT flap was raised based on perforators. The flap was partitioned with a keyhole incision performed in a zone between two perforators or distal to them, avoiding complete split of the flap and minimizing disruption of its vascular crossover. The circulation of the flap was well preserved. The closure of the flap had no tension. Results : All the flaps had 100% viability without partial loss. Mean follow‐up was of 7.4 months (range 4 ? 11 months). Significant functional improvement was achieved in the two thumb cases. Adequate patency of the ear and anal canals was obtained. No contracture around the penis was observed. Conclusion : The keyhole design may be a valuable method of partition of the ALT flap for specific reconstructions around protruding organs, cavities, or canals. © 2015 Wiley Periodicals, Inc. Microsurgery 35:356–363, 2015.     

Free anteromedial thigh flap: clinical application and review of literature

The anteromedial thigh (AMT) flap is reviewed in terms of its vascular anatomy and previous clinical reports in the literature. Our own series of 5 patients treated with this flap for defects in the head and neck region and lower extremity is presented. Although several authors controversially discussed vasculature, we constantly found the pedicle as an emerging septocutaneous perforator at a point where the medial border of the rectus femoris muscle is crossed by the sartorius muscle. In all 5 patients, the AMT flap provided stable coverage with no flap loss. Based on our findings, we conclude that the anteromedial thigh flap offers all the advantages of fasciocutaneous flaps. Therefore, we recommend this flap as an alternative for defects requiring coverages of thin to moderate skin thickness. However, it should be remembered that variations in vascular anatomy are possible.     

Pedicled posteromedial thigh (PMT) flap: A new alternative for groin defect reconstruction

The posterior medial thigh is mainly vascularized by the profunda femoris artery (PFA), which nourishes the adductor magnus muscle and overlying skin, to supply a number of perforators that can potentially be used as pedicles for local perforator flaps. Here we present two cases utilizing the pedicled posteromedial thigh flap (PMT) to reconstruct the groin defects. Two patients underwent resection for metastatic malignant melanoma resulting in large defects of the groin with exposure of major inguinal vessels; the dimensions of the skin defects were 15 cm × 5 cm and 16 cm × 6 cm, two ipsilateral pedicled PMT flaps were designed to cover the defects. The pedicled PMT flaps were based on perforators arising from the PFA and were transposed through a submuscular tunnel into the defect. The postoperative course was uneventful and the wounds were reconstructed successfully. The pedicled PMT flap may be an option for reconstruction of groin defects and could be incorporated into the armamentarium of the reconstructive microsurgeon. © 2015 Wiley Periodicals, Inc. Microsurgery 37:339–343, 2017.     

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.     

Combined thigh flap for closure of massive trunk defect

A massive trunk defect resulting from resection of recurrent sarcoma was reconstructed with a combined free flap incorporating medial, anterior, and lateral thigh tissues. This flap included the tensor fasciae latae, lateral thigh perforator, and rectus femoris, all based on the lateral femoral circumflex pedicle. A saphenous vein conduit enabled this flap to replace resected tissues at the lower thorax. Combining the three different commonly used thigh flaps on a single large pedicle enabled transfer of a 47.5 x 33.5-cm mega-flap.     

Suitability of the anterolateral thigh perforator flap and the soleus perforator flap for intraoral reconstruction: a retrospective study

Perforator flaps are suitable for numerous reconstructive purposes. However, there are few data about their usefulness for intraoral reconstruction. We reviewed data of 101 patients who were reconstructed by two types of perforator flaps after oral cancer. Forty-six soleus perforator flaps and fifty-five anterolateral thigh (ALT) perforator flaps were performed. Procedural data and outcome measures were analyzed. One ALT and four soleus perforator flaps were lost, resulting in success rates of 97.8% and 91.4%, respectively. Soleus perforator flaps were more challenging due to short and small-caliber vessels, higher susceptibility to vascular spasm, and difficult prediction of the location of the vascular pedicle. All donor sites in both groups except one were closed directly, and their morbidity was negligible. Perforator flaps from both donor sites can be used for intraoral reconstruction with good functional results; however, despite primary thinning, the ALT flap can be voluminous in small and flat defects. Here, soleus perforator flaps adapt better to the oral mucosa. The ALT perforator flap is more reliable and serves as a safe alternative to the radial forearm flap.     

Combined use of medial thigh skin flaps and gracilis musculocutaneous flaps for the reconstruction of scrotum

Summary A case of combined use of bilateral medial thigh skin flaps and gracilis musculocutaneous flaps for the reconstruction of a scrotal defect resulting from Fournier's gangrene is presented. The procedure provided a sac-like scrotum, and the donor sites were successfully reconstructed using bilateral gracilis musculocutaneous V-Y advancement flaps.     

Vulvo-perineal reconstruction: medial thigh septo-fascio-cutaneous island flap

From 1996 through 2001, the authors performed 26 vulvo-perineal reconstructions after vulvar cancer resection. A unilateral or bilateral medial thigh septo-fascio-cutaneous island flap was used in all cases. The vascular supply to this flap is guaranteed by the underlying fascial plexus that arises from the convergence of three longitudinal rows of vessels (anterior, medial, and posterior). The flap is fashioned in a triangle shape and incorporates the underlying muscular fascia, sparing the intermuscular septal perforators. It is advanced in a V-Y fashion and is easily adapted and secured to the recipient site. Competent urethral and anal meati are reconstructed with multiple intercalated flaps. Scarring at the donor site is limited and acceptable. The nerve supply guarantees acceptable sensation at the reconstructed area. The medial thigh septo-fascio-cutaneous flap allows a valid one-stage vulvo-perineal reconstruction with a simple surgical execution process after superficial soft tissue resections.     

Reconstruction of the ankle complex wound with a fabricated superficial circumflex iliac artery chimeric flap including the sartorius muscle: A case report

Free flap reconstruction of the foot and ankle can be challenging in that it must fulfill functional and esthetic demands. Injury of this region is often associated with fractures, and muscle flaps are sometimes preferred. Here we present a case of the use of superficial circumflex iliac artery (SCIA) chimeric flap for reconstruction of ankle complex wound. A 78‐year‐old lady sustained open fractures of the left distal tibia, fibula, and talus, with a 10 × 6 cm² soft‐tissue defect over the lateral aspect of her left ankle due to an automobile accident. A 7 × 3 cm² sartorius muscle component was inset to cover the exposed left ankle joint capsule, and a 5 × 10 cm² SCIP skin paddle was used for coverage of the defect. The postoperative course was uneventful, and the sartorius muscle component and the SCIP skin paddle survived completely. Six months after the reconstruction, the flap and the donor site showed pleasing cosmesis, and the patient could ambulate with a supple ankle without crutches. The sartorius muscle component was elevated based on the deep branch of the SCIA, and was chimerically combined with a SCIP skin paddle for reconstruction of a complex ankle injury. © 2015 Wiley Periodicals, Inc. Microsurgery 37:421–425, 2017.