Neural Anatomy of the Anterolateral Thigh Flap

The anterolateral thigh (ALT) flap is one of the commonly used sensate flaps for intra-oral, hand, and foot reconstruction. The objective of this study was to describe the anatomic location of the sensory nerves supplying the ALT flap in relation to the surface landmarks and with the vascular pedicles. The dissections were carried out in 28 embalmed specimens. An axial line from the anterior superior iliac spine to the superolateral border of the patella and two circles with radii of 5 and 10 cm centered on the midpoint of the former line were used for the surface landmarks. At the intersection point of the axial line and the 10-cm circle, the main lateral femoral cutaneous nerve (LFCN) and its anterior branch were located within 1 and 2.4 cm, respectively. At the intersection point of the axial line and the 5-cm circle, the anterior branch of the LFCN was located within 2.8 cm. The anterior branch of the LFCN can be detected within 3 cm from the central perforator pedicle in all specimens. The posterior branch of the LFCN, superior perforator nerve, and median perforator nerve were found in more variable locations. The findings from our study provide additional information for clinical use in the planning of sensate ALT flap harvest.     

削薄股前外侧皮瓣游离移植修复舌癌术后缺损

目的探讨削薄游离股前外侧皮瓣修复舌癌术后缺损的效果。方法对2003年6月至2007年9月采用削薄游离股前外侧皮瓣同期修复舌癌术后组织缺损17例资料进行分析。结果17例游离皮瓣中，15例皮瓣全部成活，2例皮瓣远端近舌尖处部分坏死，1例腿部供区皮下积液，换药后痊愈。随访3个月-4年，舌功能良好，下肢无运动障碍。1例（T2N2M0）14个月后死亡，1例（T3N1M0）6个月后局部复发冉次手术。结论削薄股前外侧皮瓣游离移植，修复效果好，对供区影响小，是修复舌癌术后缺损较理想的方法。     

Reconstruction of Soft Tissue Defects in the Hand with a Free Anterolateral Thigh Deep Fascia Flap

ObjectiveTo report our experience in the reconstruction of soft tissue defects in the hand with a free anterolateral thigh deep fascia flap and describe the clinical outcomes.MethodsThis study was a retrospective trial. From November 2016 to January 2020, six patients (four men and two women) with soft tissue defects in the hand were included in this study. The average age of the patients was 33.7 ± 12.7 years (range, 20 to 50 years). All patients underwent reconstructions with free anterolateral thigh deep fascia flaps. Relevant clinical characteristics were recorded prior to surgery. The size and thickness of the deep fascia flap and the thickness of the skin were measured intraoperatively. The survival of the flaps and skin grafts and the occurrence of infection were recorded after the operation. At follow‐up, donor site complications and postoperative effects were evaluated according to the outcome satisfaction scale. The pain in the injured hand was assessed using the visual analog scale.ResultsThe average body mass index (BMI) was 26.6 ± 1.7 kg/m² (range, 23.9 to 28.7 kg/m²). The defect sizes ranged from 5 cm × 5 cm to 13 cm × 8 cm (average, 53.1 ± 27.9 cm²). The six anterolateral thigh deep fascia flaps ranged from 7 cm × 6 cm to 14 cm × 9 cm in size (average, 71.8 ± 29.1 cm²). The thicknesses of skin ranged from 25 mm to 40 mm (average, 32.5 ± 4.8 mm), and the thicknesses of the deep fascia flaps ranged from 2 mm to 3 mm (average, 2.5 ± 0.5 mm). After the operation, the blood supply of the deep fascia flap was normal in all cases. The second‐stage skin grafts of most patients survived completely. The skin graft in one case was partially necrotic and healed after a dressing change. No infection occurred. At follow‐up (average, 16.3 ± 6.9 months), there was only a linear scar and no loss of sensation at the donor site of each patient. According to the outcome satisfaction scale, the outcome satisfaction score ranged from 6 to 8 (average, 7.2 ± 0.9), all of which were satisfactory. Apart from one patient who reported mild pain, all the other patients reported no pain. Three typical cases are presented in this article.ConclusionsThe free anterolateral thigh deep fascia flap, which is suitable for reconstruction of soft tissue defects in the hand, can provide very good outcomes both functionally and aesthetically.     

小腿岛状穿支蒂螺旋桨皮瓣与股前外侧皮瓣修复足踝部复合组织缺损对比分析

目的:比较小腿岛状穿支蒂螺旋桨皮瓣与股前外侧皮瓣修复足踝部复合组织缺损的疗效.方法:按照随机数字表法将2019年1月-12月笔者医院收治的40例足踝部复合组织缺损患者分为A组与B组,每组20例.A组患者采用小腿岛状穿支蒂螺旋桨皮瓣进行修复,B组患者采用股前外侧皮瓣进行修复,术后随访12个月.比较两组的手术时间、皮瓣愈合...     

数字化与虚拟现实技术在皮瓣移植中的应用

目的研究数字化与虚拟现实技术在股前外侧皮瓣解剖设计与可视化中的应用。方法①应用“虚拟中国人”男性3号数据集,在薄层断面图像上观察旋股外侧动脉的主要解剖结构,应用Amira 3．1 (TGS)软件对股前外侧皮瓣结构进行计算机三维重建并立体显示。②明胶一氧化铅混悬液灌注的新鲜成人下肢标本1具,行连续螺旋CT扫描,观测旋股外侧动脉分布及彼此间的吻合情况,应用Amira 3．1软件对股前外侧皮瓣结构进行计算机三维重建并立体显示。结果重建的数字化模型可准确反映股前外侧皮瓣的解剖学结构特点。结论重建的图像可以提供正常股前外侧皮瓣三维动态解剖,为临床教学术前皮瓣设计提供了直观的数字化解剖依据；同时可为下一步虚拟手术的设计奠定良好的基础。     

股前外侧肌皮瓣修复小腿截肢残端软组织缺损

目的 探讨股前外侧肌皮瓣修复小腿截肢残端软组织缺损,保留小腿长度或膝关节以利于假肢装配.方法 2013年4月-2016年11月,应用股前外侧肌皮瓣对小腿截肢残端软组织缺损进行修复4例,其中游离肌皮瓣3例,带蒂肌皮瓣1例.患者均为男性,截肢肌创面位于小腿近端,年龄8~48岁,平均20岁,创面面积7.0 cm×6.0 cm^25.0 cm×10.0 cm.一期清创后二期修复,肌皮瓣面积13.0 cm×10.0 cm^28.0 cm×12.0 cm,保留胫骨长度5.2~9.4 cm.结果 肌皮瓣全部成活,1例肌皮瓣边缘出现浅表感染经换药处理后愈合,供区无并发症.所有患者随访12~37(平均19)个月,末次随访时皮瓣血运好、质地柔软、耐磨.皮瓣感觉恢复程度:S22例, S31例,S3+1例. 6 min步行测试:Ⅳ级2例,Ⅲ级2例;Stanmore运动分级:V级2例,Ⅳ级2例.结论 股前外侧肌皮瓣是修复小腿截肢残端软组织缺损的理想皮瓣.     

DIEP+TRAM联合皮瓣与双侧DIEP皮瓣乳房再造比较

目的 比较DIEP+TRAM皮瓣与双侧DIEP皮瓣乳房再造的特点,并探讨其适应证.方法 2003年8月至2006年6月,共采用双蒂下腹部皮瓣进行29例、32侧二期乳房再造.其中,采用TRAM+DIEP联合皮瓣再造乳房21例,均为单侧乳房再造;双侧DIEP皮瓣乳房再造8例,5例为单侧,3例为双侧乳房再造.结果 随访3月～3年,2组均取得较满意效果,联合皮瓣组术后皮瓣尖端部分血运障碍1例(4.8%),双侧DIEP组皮瓣血运障碍2例(25%);腹部切口脂肪液化联合皮瓣组7例(33.3%),DIEP组1例(12.5%).结论 当供区和受区条件均较理想时,可以选择双侧DIEP皮瓣进行乳房再造.如果受区血管曾受到放射治疗的损伤,以及患者同时合并内科疾病等情况下,采用DIEP+TRAM联合皮瓣是理想的乳房再造方法.     

A pedicled anterolateral thigh flap for abdominal reconstruction after previous degloving injury of the donor site: Revascularisation of the donor site

A pedicled anterolateral thigh flap was used to reconstruct an abdominal defect after traumatic degloving of the entire skin of the right upper leg two-and-a-half years earlier. There are few reports about revascularisation of skin flaps after previous interruption of the blood supply. As far as I know this is the first report of a revascularised (anterolateral thigh) perforator flap.     

Versatility of the Pedicled Latissimus Dorsi Myocutaneous Flap in Reconstruction of Upper Limb and Trunk Soft Tissue Defects

Purpose The purpose of the study was to share our indications, technique, outcome, and complications associated with the pedicled latissimus dorsi myocutaneous flap (LDMF) for reconstructing various upper limb and trunk soft tissue defects. Patients and Methods We reviewed the prospectively collected data of the patients who underwent reconstruction of upper limb/trunk soft tissue defects with pedicled LDMF between January 2016 and March 2019. By analyzing the clinical scenarios, the location of flap inset, the arc of rotation, reach of the flap, and associated complications, we put forward few significant findings from our experience. Results Thirty-four patients were included in the study: 13 of them underwent LDMF for coverage of upper limb defects, 12 of them for postradical mastectomy soft tissue defects, 8 for posterior trunk reconstruction, and 1 for sternal wound infection. LDMF was successfully used to cover the scapula, anterior and posterior arms, axilla, cubital fossa, mid-forearm, breast, sternum, and midline dorsal wounds. When used reversely, the flap could cover the exposed spine in the midline dorsum. Three patients (9%) had major complications (two patients had partial flap necrosis which required additional debridement and skin grafting, and one patient required an additional transpositional flap). Three patients had minor complications (managed nonoperatively). Conclusion Pedicled LDMF is a straightforward and versatile option for reconstruction of the varied upper limb and trunk soft tissue defects with minimal complications. Level of Evidence This is a level IV, therapeutic, retrospective study.     

Reconstruction of Large Area of Deep Wound in the Foot and Ankle with Chimeric Anterolateral Thigh Perforator Flap

ObjectiveTo evaluate the clinical application and surgical efficacy of the chimeric perforator flap pedicled with the descending branch of the lateral circumflex femoral artery and the lateral thigh muscle flap for the reconstruction of the large area of deep wound in foot and ankle.MethodsClinical data of 32 cases who underwent chimeric anterolateral thigh perforator flap to repair the large area of deep wound of the foot and ankle from January 2015 to December 2018 were retrospectively analyzed. The sizes of the defects ranged from 18 cm × 10 cm to 35 cm × 20 cm, with exposed tendon and bone and/or partial defects and necrosis, contaminations, accompanied by different degrees of infection. Following the radical debridement and VSD, chimeric anterolateral thigh perforator flap was employed to repair the deep wounds according to the position, site and deep‐tissue injury of the soft‐tissue defects. The skin flap and muscle flap were fanned out on the wound, and single‐ or two‐staged split‐thickness skin grafting was performed on the muscle flap. The operation time and blood loss were recorded. The survival and healing conditions of the operational site with chimeric anterolateral thigh perforator flap were evaluated post‐operationally. Complications at both recipient site and donor site were carefully recorded.ResultsThe mean time of the operation was 325.5 min and average blood loss was 424.8 mL. Among the 32 cases, two cases developed vascular crisis, which were alleviated with intensive investigation and treatment; Four cases suffered from partial necrosis of the flap or skin graft on the muscle flap or on the residual local wound, which were improved after treatment of further dressing change and skin grafting. Another four cases experienced post‐traumatic osteomyelitis accompanied by bone defect were treated with simple bone grafting or Mesquelet bone grafting at 6–8 months after wound healing. Postoperatively, the wounds were properly healed, and the infection was effectively controlled without sinus tract forming. Overall, all 32 cases received satisfactory efficacy, without influencing subsequent functional reconstruction, and observed infection during the 12–36 months post‐operational follow‐up.ConclusionThe chimeric perforator flap pedicled with the descending branch of the lateral circumflex femoral artery and the lateral thigh muscle flap provides an effective and relative safe procedure for the repair of a large area of deep wound in the foot and ankle, particularly with irregular defect or deep dead space.     

Flap reconstruction of the knee: A review of current concepts and a proposed algorithm

A literature search focusing on flap knee reconstruction revealed much controversy regarding the optimal management of around the knee defects. Muscle flaps are the preferred option, mainly in infected wounds. Perforator flaps have recently been introduced in knee coverage with significant advantages due to low donor morbidity and long pedicles with wide arc of rotation. In the case of free flap the choice of recipient vessels is the key point to the reconstruction. Taking the published experience into account, a reconstructive algorithm is proposed according to the size and location of the wound, the presence of infection and/or 3-dimensional defect.     

Outcomes of the Pedicled Medial Sural Artery Perforator Flap for Soft Tissue Reconstruction Around the Knee: When to Use It and How to Look After It

Introduction  The medial gastrocnemius flap is an established workhorse flap to cover proximal leg defects due to its reliability and simplicity to raise. However, it has the disadvantage of being bulky, requiring a skin graft for coverage, and is associated with loss of muscle power. The pedicled medial sural artery perforator (MSAP) flap has gained popularity as a reconstructive alternative for defects of the lower extremities. We present a case series of pedicled MSAP flaps for reconstructing defects around the knee as an alternative to the medial gastrocnemius flap. Materials and Methods  A consecutive series of patients with proximal leg defects following trauma, osteomyelitis, burns, and chronic wounds were included. A hand-held Doppler was used to map out the MSAPs. Defects were reconstructed using pedicled MSAP flaps, preserving the nerve supply to the gastrocnemius muscle. Patient outcomes were recorded, including their Enneking scores postreconstruction. Results  A total of 10 pedicled flaps was performed to reconstruct defects around the knee joint between October 2017 and November 2018. All the patients were discharged 1 week postoperatively, and rehabilitation consisted of graduated flexion in a knee brace by means of controlled passive mobilization. Three out of the ten patients developed complications: one patient developed flap congestion, one developed epidermolysis of the tip of the flap, and the other patient had partial necrosis of the skin paddle. The average Enneking score was 29 out of 35. Conclusion  The pedicled MSAP flap is a good reconstructive option for proximal leg defects as it is associated with lower donor site morbidity and provides an aesthetically pleasing reconstruction.     

Pedicled Chimeric Perforator Flap Based on Inferior Gluteal Vessel Axis for the Reconstruction of Stage-Four Primary Ischial Pressure Sores—A New Design

Background  “Subfascial void reconstruction” in ischial pressure sores (IPSs) goes a long way in the amelioration of the common complications like persistent drainage, infection, wound dehiscence, and late recurrence. No locoregional flaps suffice this requirement. So we have designed a chimeric pedicled flap based on the inferior gluteal vessel axis (IGVA) perforators with two tissue components: (1) Pacman-style fasciocutaneous flap on a perforator and (2) gluteus maximus muscle (inferior portion) on another independent perforator. Aim and Methods  After confirming the feasibility of novel design of chimeric pedicled IGVA perforator flap with cadaver study, we embarked on the clinical study with this chimeric flap. In this prospective cohort study, the study and the control existed in the same patient so that the biological factors affecting the wound healing would be the same. Results  Twenty-one patients were included whose mean age was 39 years. Late recurrence occurred in one patient (4.8%) of chimeric flap while the control group (who had undergone conventional reconstruction) had recurrence in 11 patients (52.4%). On assessment with overall institutional score, grade A was observed in 18 patients of the chimeric IGVA flap group ( p < 0.045), and in only 3 patients of the control group. Conclusions  This anatomically construed flap, a new addendum in the armamentarium of reconstruction of IPSs, with its potential to congruently fill the ischiogluteal subfascial void may provide a lasting solution for preventing recurrences.     

The Reverse-Flow Facial Artery Buccinator Flap for Skull Base Reconstruction: Key Anatomical and Technical Considerations

Objective To highlight key anatomical and technical considerations for facial artery identification, and harvest and transposition of the facial artery buccinator (FAB) flap to facilitate its future use in anterior skull base reconstruction. Only a few studies have evaluated the reverse-flow FAB flap for skull base defects. Design Eight FAB flaps were raised in four cadaveric heads and divided into thirds; the facial artery''s course at the superior and inferior borders of the flap was measured noting in which incisional third of the flap it laid. The flap''s reach to the anterior cranial fossa, sella turcica, clival recess, and contralateral cribriform plate were studied. A clinical case and operative video are also presented. Results The facial artery had a near vertical course and stayed with the middle (⅝) or posterior third (⅜) of the flap in the inferior and superior incisions. Seven of eight flaps covered the sellar/planar regions. Only four of eight flaps covered the contralateral cribriform region. Lastly, none reached the middle third of the clivus. Conclusions The FAB flap requires an understanding of the facial artery''s course, generally seen in the middle third of the flap, and is an appropriate alternative for sellar/planar and ipsilateral cribriform defects.