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.     

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.     

Anterolateral thigh flap salvage following failed deep inferior epigastric artery perforator breast reconstruction

The deep inferior epigastric artery perforator flap is an option for women desiring autologous tissue breast reconstruction. If this reconstruction fails, other autologous tissue flaps, including the gluteal artery perforator and latissimus dorsi flaps, may be used for salvage. The anterolateral thigh (ALT) flap offers adequate tissue volume for breast reconstruction, acceptable fat quality and a long vascular pedicle. Other advantages include obviating the need for intraoperative position changes and harvesting tissue outside of the radiation field. Two cases involving ALT flaps used in the setting of deep inferior epigastric artery perforator failure are presented with favourable results. A review of the anatomy of the ALT flap is included.     

Bilateral anterolateral thigh flaps for large-volume breast reconstruction

Autologous tissue reconstruction of a large breast in patients who are not candidates for a TRAM flap is a difficult problem. We present a case report of the use of bilateral free anterolateral thigh (ALT) flaps for immediate reconstruction of a unilateral large breast in a patient who had a previous abdominoplasty. Use of ALT flaps allows two or three surgical teams to work simultaneously, does not require intraoperative patient repositioning, has minimal donor-site morbidity, and can provide ample malleable soft tissue for breast reconstruction. These are advantages compared to the use of gluteal donor sites. The disadvantages include more conspicuous donor-site scarring on the anterior thighs.     

Using the proximal perforator‐based anterolateral thigh flap from the same donor site to salvage the reconstruction after failure of the distal perforator‐based anterolateral thigh flap

We presented a patient who experienced the anterolateral thigh (ALT) flap failure but the reconstruction was successfully salvaged by harvesting a second ALT flap from the same donor site 2 days after the first reconstruction. A 47‐year‐old man received cancer ablation for right mouth floor squamous cell carcinoma. The resultant defect was planned to be reconstructed with the ALT flap. During the flap dissection, we identified three proximal cutaneous perforators originating from the transverse branch of the lateral circumflex femoral artery (t‐LCFA) and two distal cutaneous perforators originating from the descending branch (d‐LCFA). We harvested a skin flap based on the distal two perforators and divided the d‐LCFA just distal to the bifurcation of the d‐LCFA and the t‐LCFA. Unfortunately, the ALT flap showed venous congestion on postoperative day 2 and eventually failed. We harvested a second ALT flap from the same donor site based on the previously preserved perforators. The recovery course was smooth thereafter. We believe that the harvest of a second ALT flap from the same donor site may be an option, to avoid other donor site violation, in some patients who experienced the first flap loss. © 2014 Wiley Periodicals, Inc. Microsurgery 34:409–412, 2014.     

Using the distal part of vastus lateralis muscle as chimeric anterolateral thigh free flap is a more flexible tool for head and neck reconstruction

The chimeric anterolateral thigh (ALT) free flap with vastus lateralis (VL) has been our workhorse for soft tissue head and neck reconstruction following cancer resection. Using the distal portion of the VL muscle, as part of the chimeric flap, which is based on the descending branch of the lateral circumflex femoral artery and supplied separately from the skin paddle of the flap, has proved to be a more flexible tool for coverage of these extensive and multidimensional defects. The ALT flap has been a reliable soft tissue source and has shown superiority over other flaps for head and neck reconstruction, especially over its main rival, the radial forearm flap. It offers many advantages and in spite of the intramuscular dissection of the perforator(s) being a challenge, having gained substantial experience in raising this flap, we think that the flap can be harvested safely using a careful dissection, refinements of the surgical technique and understanding of the variable anatomy of the thigh region. This flap solves the problems, which are often encountered by the reconstructive surgeon such as the pedicle length, flap inset, and deficiency of recipient vessels. The purpose of this study is to describe the operative technique, the clinical applications, and the advantages of this variation of the chimeric ALT flap.     

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.     

Anatomic analysis of the vascular network and vascular pedicle of the tensor fascia lata flap (angiographic and cadaver study)

Knowing the vascular network and properties of the vascular pedicle is of crucial importance for elevation of the tensor fascia lata (TFL) transpositional or free flap; therefore, the origin of the lateral circumflex femoral artery (LCFA), its diameter at the site of origin, the length of the vascular pedicle, the number of lateral branches, the number of terminal branches and the anastomosis of the LCFA ascending branch are of utmost importance for successful elevation and clinical application of this flap. The study was conducted on clinical (100 angiographic images of the femoral artery) and autopsy (48 preparations) material. The first part of the study comprised analysis of the angiographic images that were used to obtain the information on LCFA. The diameter of LCFA at its origin was measured to be 0.44 cm, while it was 0.33 cm at the origin of ascending branch. The mean value of the diameter at the bifurcation of the terminal branches of ascending branch (inside tensor fascia lata muscle) was 0.24 cm. It has been established that the vascular pedicle of the tensor fascia lata flap (ascending branch of LCFA) is anastomosed with the superior gluteal artery in all cases. Measurement of the tensor fascia lata muscle revealed an average length of 15.91 cm, width of 3.55 cm and thickness of 1.98 cm. Injection of colour-ink into the ascending branch LCFA that enters directly into the TFL muscle was used to measure the extent of the TFL flap vascularization and on the average, the TFL flap was 20.32 cm long and 16.57 cm wide while the surface was 17.52 cm³.     

Breast reconstruction with gluteal artery perforator flaps.

BACKGROUND: Several alternatives exist for breast cancer reconstruction with perforator flaps. For those patients in whom the buttock is the best choice as a source for autologous tissue, the IGAP and SGAP flaps are an excellent option. These flaps allow the reliable transfer of skin and soft tissue from the buttock without the associated donor site morbidity of a muscle flap. INDICATIONS: Most women requiring tissue transfer to the chest from the buttock for breast reconstruction or other reasons are candidates for IGAP or SGAP flaps. Do to an improved donor site contour and scar, we now prefer to use the IGAP to the SGAP flap. Absolute contraindications specific to perforator flap breast reconstruction in our practice include history of previous liposuction of the donor site or active smoking (within 1 month prior to surgery). ANATOMY AND TECHNIQUE: IGAP and SGAP flaps are based on perforators from either the superior or inferior gluteal artery. These perforators are carefully dissected free from the surrounding gluteus maximus muscle, which is spread in the direction of the muscle fibres and safely preserved. The vascular pedicle is anastomosed to recipient vessels in the chest and the donor site closed primarily. CONCLUSIONS: IGAP and SGAP flaps allow the safe and reliable transfer of tissue from the buttock for breast reconstruction as an alternative to soft tissue transfer from an abdominal donor site or even as a first choice in selected patients.     

Versatility of the free anterolateral thigh flap: clinical experience in a series of 20 patients

The main nutrient vessel of the anterolateral thigh flap is the perforator originating from the descending branch of the lateral circumflex femoral artery (LCFA). It supplies a large area of skin on the anterolateral aspect of the thigh. We present the experience of 20 consecutive anterolateral thigh flaps used for a variety of soft tissue defects. Fourteen flaps were used for lower leg reconstruction, four in the head and neck, and the remaining two in the hand. The largest flap was 30᎗ cm. All flaps survived except two which had partial skin necrosis, but the underlying adipose tissue survived and was grafted. Reexploration was needed for one patient in whom a thrombus blocking the vein was removed, and the flap survived completely. The anterolateral thigh flap has the advantage of a long vascular pedicle, large-caliber vessels, availability of a large skin flap area, and suitability as a flow-through flap.     

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.     

The versatility of vascularized iliac crest with internal oblique muscle flap for composite upper maxillary reconstruction

The middle third defects of the face following total or partial oncologic maxillectomy include very important facial structures, both for esthetical and for functional reasons. Among the outcomes, large oronasal or oromaxillary fistulas due to destruction of big bone segments and soft tissues have long been the consequences of such extensive surgical ablations. In the last few years, immediate reconstruction of maxillary bones and soft tissues has proved to be a reliable morphofunctional reconstruction technique following surgery for large oncological defects or the late effects of radiation therapy. Among other free flaps such as composite fibula, composite scapula, or composite radial, the use of vascularized iliac crest with the internal oblique flap has become our flap choice for morphofunctional maxillary reconstruction for bone segments within 6-15 cm of length, and when there is no need for overlying facial skin or oral sphincter reconstruction. The advantages of this composite bone flap are its available large and resizable bone stock; the quality of the bone for transfer (optimal height, depth, and contour to maintain a good facial profile); and the possibility to properly reconstruct the oral lining, orbital content; and maxillary soft tissues with a portion of the internal oblique muscle flap raised with the same pedicle. In addition, this flap's soft tissue will epithelialize during the healing stages.     

Experience with the distally based sural neurofasciocutaneous flap supplied by the terminal perforator of peroneal vessels for ankle and foot reconstruction

The distally based sural fasciocutaneous flap has been proved an excellent option for coverage of the soft tissue defects of the lower third of the leg, ankle, and foot. In this article, we reported on a series of foot and ankle reconstructions with a distally based sural neurofasciocutaneous flap supplied by the terminal perforating branch of the peroneal artery. The vascular pedicle of the flap includes the terminal perforator branch of the peroneal artery and concomitant veins. The pivot point is approximately 5 cm above the tip of lateral malleolus. Fifteen patients with soft tissue defects of the foot and/or ankle underwent the procedures of reconstruction. The flaps were designed with the size measuring 8 x 9 cm to 13 x 31 cm. Thirteen flaps survived completely and 2 with partial or margin necrosis. Our experience has demonstrated that this sural flap with a thin perforator pedicle can be easily rotated, used for coverage of a large tissue defect including the forefoot area, and provide a good texture match and contour for the recipient area.     

岛状臀大肌肌皮瓣在臀部软组织缺损修复中的应用

目的：探讨岛状臀大肌肌皮瓣在臀部软组织缺损尤其是骶尾部褥疮修复中的应用。方法：以臀大肌臀上动脉穿出点为旋转轴,利用臀上动脉和臀下动脉交通支所在的臀大肌外缘肌为蒂,以旋转点至缺损区最近点为肌皮瓣蒂长度,根据缺损部位及大小进行肌皮瓣设计,形成岛状肌皮瓣,肌皮瓣面积稍大于缺损区创面。蒂部仅含臀大肌外缘肌肉,宽度1.5～2.0cm。沿设计线切开皮肤找到臀大肌臀上动脉穿出点及臀大肌外缘,向远端解剖,在臀大肌下形成的岛状皮瓣,通过皮下隧道将肌皮瓣转移到缺损区,逐层缝合切口。供区视大小可行直接拉拢缝合或邻近皮瓣转移或植皮修复。结果：应用岛状臀大肌肌皮瓣修复臀部软组织缺损7例,术后肌皮瓣全部成活,被修复处色泽、厚度及外形均满意。结论：岛状臀大肌肌皮瓣血供丰富,血管恒定,抗感染能力强,切取及转移方便,是修复臀部软组织缺损尤其是骶尾部褥疮的理想肌皮瓣。     

Salvage of knee joint tumor prosthesis using turnover reverse-flow descending branch of lateral circumflex femoral artery as recipient vessel for the free ALT flap: a case report

To report an unusual case using free anterolateral thigh (ALT) fasciocutaneous flap to salvage a knee joint tumor prosthesis. The turnover reverse-flow descending branch of the ipsilateral lateral circumflex femoral artery (LCFA) was successfully used as a recipient vessel for the contralateral free ALT flap. A 30-year-old male patient with high-grade and fibroblastic-type osteogenic sarcoma at the right proximal tibia received a tumor resection and tumor prosthesis to salvage the right knee joint. No local antegrade recipient vessels were available near the defect at the right knee. No sizable perforator could be found when trying to harvest the reverse ipsilateral ALT flap. The turnover reverse-flow descending branch of the ipsilateral LCFA and its concomitant veins were used as recipient vessels to supply the contralateral free ALT flap. The flap survived well without obvious venous congestion or sequela. The turnover reverse-flow descending branch of the LCFA and its concomitant veins can be successfully used as recipient vessels to supply a free ALT flap.     

Free tensor fasciae latae flap for abdominal wall reconstruction: overview and new innovation

Extensive abdominal wall defects may result from tumor extirpation, traumatic injury, or soft tissue infections. Extensive traumatic injuries can often disrupt the soft tissue content of the abdomen as well as the bony support provided by the pelvis. Reconstruction of the lower abdomen should aim to recreate dynamic stability. Five patients with extensive lower abdominal wall disruption following traumatic injuries or infection were treated using a novel flap for functional reconstruction. We devised a free neurotized osteomyocutaneous tensor fasciae latae (TFL) flap that would restore bony continuity by providing a vascularized bone graft and simultaneously maintain the integrity of the attachment of the tensor fascia latae muscle to the iliac crest, reestablishing musculofascial continuity. A branch of the superior gluteal nerve was harvested with this composite flap and coapted to an intercostal nerve for reinnervation, thereby creating a dynamic muscle in these patients. All patients underwent successful free tissue reconstruction with 100% flap survival. The lower abdominal wall and bony integrity of the pelvis were successfully reconstructed. Reinnervation has shown clinical signs of maintained dynamic stability. The innervated TFL osteomyocutaneous flap is an ideal option for lower abdominal reconstruction in patients with complex abdominoperineal defects with loss of bony integrity.     

股后侧岛状皮瓣和肌皮瓣的临床应用

目的 探讨应用股后侧岛状皮瓣修复大转子、骶部等处软组织缺损的临床效果.方法 应用顺行股后侧岛状皮瓣修复大转子软组织缺损4例、骶部2例;逆行股后侧岛状皮瓣修复腘窝部皮肤缺损2例;肌皮瓣修复坐骨结节褥疮4例;供区直接缝合.结果 除 1例岛状皮瓣远端发生尖部坏死经植皮愈合外,余病例术后全部成活.随访1～5年,供区愈合良好、受区外形、质地及厚薄均较满意.结论 该皮瓣以臀下动脉股后皮支及股深动脉穿动脉为其血供,解剖恒定,具有血运丰富、血管蒂长和切取容易等优点,适宜修复大转子、骶部坐骨结节及腘窝部等处软组织缺损.     

伤指背筋膜岛状皮瓣修复手指软组织缺损

目的 介绍以伤指指背筋膜为蒂，带指固有神经背侧支的岛状皮瓣顺行或逆行转移修复指腹或指背软组织缺损的方法。方法 在手指近、中节背侧沿指固有神经背侧支走行方向设计并切取筋膜蒂皮瓣，切取皮瓣时蒂部带一矩形皮瓣，以减轻转位后皮瓣蒂部的张力。皮瓣顺行转移不需缝合神经，逆行转移时与受区神经缝合。皮瓣切取范围不超过手指侧中线，切取面在腱周浅层，皮瓣转移轴线沿指固有神经背侧支走向。结果 本组17例22指皮瓣全部成活。结论 采用伤指指背筋膜蒂岛状皮瓣转移修复指腹或指背皮肤缺损是一种简单安全，行之有效的手术方法。     

Clinical experience with the lateral septocutaneous superior gluteal artery perforator flap for autologous breast reconstruction

Background: Superior gluteal artery perforator (SGAP) flaps are a useful adjunct for autologous microvascular breast reconstruction. However, limitations of short pedicle length, complex anatomy, and donor site deformity make it an unpopular choice. Our goals were to define the anatomic characteristics of SGAPs in cadavers, and report preliminary clinical and radiographic results of using the lateral septocutaneous perforating branches of the superior gluteal artery (LSGAP) as the basis for a modified gluteal flap. Methods: We performed 12 cadaveric dissections and retrospectively reviewed 12 consecutive breast reconstruction patients with gluteal flaps (19 flaps: 9 LSGAP, 10 traditional SGAP) over a 12‐month period. The LSGAP flap was converted to traditional SGAP in 53% of flaps because of dominance of a traditional intramuscular perforator. Preoperative 3D computed tomography angiography (CTA) and cadaveric dissections were used to define anatomy. Anatomic, demographic, radiographic, perioperative, and outcomes data were analyzed. Mean follow‐up was 4 ± 3.4 months (range 4 weeks to 10 months). Results: Compared with the pedicle in the SGAP flap, the mean pedicle length in the LSGAP flap was 1.54 times longer by CTA, 2.05 times longer by cadaver dissection, and 2.36 times longer by intraoperative bilateral measurement. These differences were statistically significant (P < 0.001). Clinically, 100% of the flaps survived. Conclusions: LSGAP flap reconstruction is advantageous, when feasible, because of the septocutaneous pedicle dissection and gain in pedicle length that make microsurgical anastomoses easier without compromising gluteus function. © 2010 Wiley‐Liss, Inc. Microsurgery 30:339–347, 2010.     

Der freie ALT-Oberschenkellappen in der traumatologischen und onkologischen Defektdeckung

BACKGROUND: The anterolateral thigh flap (ALT) has become one of the most preferred options for soft tissue defect reconstruction in Asia with an increasing popularity in Europe. The article presents the authors' experience using the ALT flap for various indications in the upper and lower extremities. METHODS: Between January 2005 and March 2007, 60 free ALT flaps were operated for reconstruction of various soft tissue defects. The causes of soft tissue defects included trauma (13), infection (26), and sarcoma resection (21). We operated on 39 male and 19 female patients with an average age of 50.9 years (range: 16-84 years). RESULTS: The flap survival rate was 95.0% percent (57 of 60 flaps); 5% of the flaps died. The donor site was closed primarily in all cases. Donor site complications were minimal. The average operative time was 282 min (69-544 min). Flap-related major complications occurred in 35.0% of patients including reexploration of the anastomoses and partial flap necrosis. Minor complications, e.g., wound infection, hematoma, and swelling were seen in 23 cases. CONCLUSIONS: Our experience indicates that the free ALT flap is a reliable method for soft tissue defect reconstruction. The use of the ALT offers many advantages such as a long and large caliber vascular pedicle, a large skin island as well as minimal donor site morbidity. The surgery can simultaneously performed by two teams with the patient in a supine position.