Repair of buccal defects with anterolateral thigh flaps

The ideal reconstructive method for the buccal mucosa should provide durable, stable coverage and a natural contour, while simultaneously minimizing morbidity of both the defect and donor sites. Since the first report of the anterolateral thigh flap in 1984, it has become one of the most commonly used flaps for the reconstruction of various soft-tissue defects. From March 2004-April 2005, 24 free anterolateral thigh flaps were used to reconstruct buccal defects, including the retromolar trigone and as far as the oral commissure, and in some cases with extension to the neighboring palatal region and tongue. The study comprised 1 female and 23 male patients, with ages ranging from 26-63 years (mean age, 45.8 years). Two flaps required reoperation due to vascular compromise, and both were salvaged with arterial and venous anastomosis revisions, giving an overall success rate of 100%. Primary thinning of the flap was performed in 10 cases. In 2 cases, additional vastus lateralis muscle was included in the flap to fill the large defect. In 2 cases, marginal necrosis with dehiscence of the flap was observed, one of these patients having a history of atherosclerosis and diabetes mellitus (marginal skin necrosis and infection of the donor area were also observed in this patient). In 2 patients, seroma collection was observed in the neck at the dissection site. Chart reviews showed that most patients had a history of betel-nut chewing (95.8%) or a combination of smoking and betel-nut chewing (79.2%). During the follow-up period of 4-12 months, a sufficient level of mouth-opening with interincisal distances of 34 mm, 44 mm, and 48 mm was achieved in all 3 cases reconstructed after release of the trismus. Although it has some variations in the vascular pedicle, irregularity in derivation from the main vessels, and minimal morbidity of the donor site, the anterolateral thigh flap, with its evident functional, structural, and cosmetic advantages, can be considered an excellent and ideal flap option, and a first choice for most buccal defects.     

Total scalp reconstruction with bilateral anterolateral thigh flaps

Large scalp defects can require complicated options for reconstruction, often only achieved with free flaps. In some cases, even a single free flap may not suffice. We review the literature for options in the coverage of all reported large scalp defects, and report a unique case in which total scalp reconstruction was required. In this case, two anterolateral thigh (ALT) flaps were used to resurface a large scalp and defect, covering a total of 743 cm(2). The defect occurred after resection and radiotherapy for desmoplastic melanoma, with several failed skin grafts and local flaps and osteoradionecrosis involving both inner and outer tables of the skull. The reconstruction was achieved as a single-stage reconstruction and involved wide resection of cranium and overlying soft-tissues and reconstruction with calcium phosphate bone graft substitute, titanium mesh, and two large ALT flaps. The reconstruction was successfully achieved, with minor postoperative complications including tip necrosis of one of the flaps and wound breakdown at one of the donor sites. This is the first reported case of two large ALT flaps for scalp resurfacing and may be the largest reported scalp defect to be completely resurfaced by free flaps. The use of bilateral ALT flaps can be a viable option for the reconstruction of large and/or complicated scalp defects.     

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.     

Patient-reported donor-site morbidity following anterolateral thigh free flaps

This study evaluated donor-site morbidity (retrospective chart review and followup questionnaire) in patients following reconstruction using an anterolateral thigh free flap. Twenty-one flaps were performed in 20 consecutive patients (mean age: 45.0 +/- 3.8 years). Primary wound closure was obtained in 52.4 percent. The perforators were intramuscular in 68 percent and septocutaneous in 32 percent. The early complications included infection (n = 2), wound dehiscence (n = 2), delayed healing (n = 8), and seroma (n = 1). Wound healing took 4.5 +/- 0.7 weeks, and leg weakness resolved completely (n = 13) by 6.6 +/- 2.0 weeks. More chronic complications (n = 19) included weakness (n = 5), pain/tightness (n = 6), contour deformity (n = 14), muscle herniation (n = 6), and unsatisfactory scar appearance (n = 6). No statistically significant differences existed in aesthetics or healing between wound-closure groups, nor in pain or weakness between perforator groups. Pain and weakness were significantly related to sacrifice of the deep fascia from the thigh through its elevation in the flap.     

Salvage of finger length in septicemic necrosis using 3 free flaps from a single anterolateral thigh donor site

Severe septicemic necrosis can result in extremely debilitating morbidity for patients, often resulting in 4-limb amputation. Further operative procedures to improve both function and cosmesis can be fraught with complexity and complications. The ideal aim in such patients would be to maintain sufficient length and provide soft tissue cover in a single 1-step procedure. We present a novel case in which twin free flaps were used acutely to provide 3 separate skin paddles to cover 2 hand stumps from a single anterolateral thigh donor site, thus maintaining the optimum digit length for subsequent function. We believe that this is the first reported case of using 3 separate flaps from 1 single anterolateral thigh donor site to resurface and salvage digit length in both hands following septicemic necrosis. Detailed knowledge of the anatomy of the anterolateral thigh flap and an understanding of the perforator flap concept can allow others to further develop the many and versatile uses of this flap.     

数字化三维重建技术在股前外侧皮瓣血供及其可视化中的应用

目的探讨数字化三维重建技术在股前外侧皮瓣血供与可视化中的应用。方法①健康志愿者6人经肘正中静脉注射造影剂，使用64排多层螺旋CT进行盆腔及双下肢扫描，观察旋股外侧动脉分布及彼此间的吻合情况，将大腿二维灰度．DICOM格式图像以三维体数据的形式输入计算机，应用Amira3．1软件对股前外侧皮瓣结构进行三维重建并立体显示。②明胶一氧化铅混悬液的灌注新鲜成人标本2具，16排多层螺旋CT进行全身连续扫描，观测旋股外侧动脉分布及彼此间的吻合情况，同法应用Amira3.1软件对股前外侧皮瓣结构进行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血供的解剖学结构。结论采用数字化三维重建技术可以提供正常股前外侧皮瓣的三维动态解剖，为其他皮瓣的数字化重建提供了参考。     

股前外侧双叶穿支皮瓣修复手部创面

目的：探讨股前外侧双叶穿支皮瓣修复手部创面的方法和疗效。方法2011年1月-2012年10月对9例手部创面采用游离股前外侧双叶穿支皮瓣修复,其中手部两处创面7例,另2例为洞穿性缺损。急诊修复创面桥接血管重建患肢血供1例,延期修复创面8例。结果本组9例皮瓣全部成活,术后随访3～6个月,供区外观仅为线状瘢痕,功能无明显影响。2例手部洞穿性缺损修复后外观满意,功能欠佳;其余7例创面修复后皮瓣质地柔软,外观稍臃肿,功能满意。结论股前外侧双叶穿支皮瓣可一次修复手部两个创面或通过拼接修复一处较大创面,而供区常可以直接缝合,优点明显。     

Composite anterolateral thigh perforator flaps in the management of complex hand injuries

The anterolateral thigh (ALT) fasciocutaneous flap has been well described for hand skin cover, however its use in its composite (multiple tissue) form incorporating bone, muscle and/or fascia has been less well described. We report the usefulness of the composite ALT flap in six complex hand trauma cases, four male and two female (age range 14-46 years). The palm of the hand was affected by injury in three cases, the dorsum in two cases, and the radial side in one case. The first web formed part of the injury in three cases. There was variable involvement of the tendons, nerves and bones. Fascia lata was included in the flap to provide a gliding surface in four cases, part of the vastus lateralis muscle was included to obliterate dead space in two cases and to create a first web in one case, and a bone block from the iliac crest was included to reconstruct the lost metacarpals in one case. All flaps survived with minimal complications. This work shows that the anterolateral thigh composite flap is a reliable option when multiple tissue types are required in hand reconstruction.     

数字化股前外侧皮瓣的可视技术在临床中的初步应用

目的 探讨股前外侧皮瓣的三维重建技术在临床中的初步应用. 方法 对需游离股前外侧皮瓣创面修复的8例患者,术前注射造影剂后采用CT或MRI扫描,应用Amira 4.1软件对股前外侧皮瓣结构进行三维重建,构建患者个性化皮瓣.根据三维构建的个性化皮瓣,于患者股部进行股前外侧皮瓣的点、线、面描记,用以指导手术切取.结果 三维重建患者个性化皮瓣8例,所重建个性化股前外侧皮瓣,能够清晰显示血管、皮肤及其毗邻结构的三维关系.其中5例显示皮瓣主要穿支及主干,与术中检查相符;3例显示皮瓣主干血管,但穿支显示不清,术中探查2例最大穿支血管约0.5mm,1例穿支均小于0.3 mm.术后7例皮瓣全部成活,1例皮瓣边缘出现部分坏死. 结论 通过血管造影下肢CT或MRI扫描,采用数字化三维重建技术可以提供股前外侧皮瓣的三维动态解剖,重建皮瓣能够准确指导术中的皮瓣切取.     

插入式腹部薄皮瓣修复手和腕部严重烧伤

目的　探讨插入式腹部薄皮瓣修复手和腕部广泛深度烧伤的可行性 ,积累临床治疗经验。　方法　 12例手严重烧伤患者 ,均伴有多指背及手腕的创面。供瓣区选上腹部 4例 ,下腹部 8例。皮瓣断蒂时间为 10～ 13d。　结果　除 2例皮瓣远端有 2cm× 2cm及 1cm× 1cm大小坏死外 ,其余均全部成活。患者手功能及外形恢复满意。　结论　腹部真皮下血管网皮瓣修复手和腕部严重烧伤是一种比较好的手术方法。     

Free deepithelialized anterolateral thigh myocutaneous flaps for chronic intractable empyema with bronchopleural fistula

BACKGROUND: Free deepithelialized anterolateral thigh (DALT) flaps have been used for treatment of chronic intractable empyema with bronchopleural fistula at Chang Gung Memorial Hospital since 1997. METHODS: Twelve patients with chronic empyema were treated at Chang Gung Memorial Hospital from January 1997 to January 2001. Their age ranged from 31 to 70 years (mean age 48.6 years). Left-sided involvement was predominant (left to right ratio = 9:3). All patients had bronchopleural fistula, and all were cured. The average numbers of previous thoracotomy were 5.4. The ipsilateral DALT flaps were harvested with primary closure of donor site. RESULTS: At a mean follow-up of 1 year, no recurrence was noted. All flaps survived well. The average hospital stay was 25.8 days. Complications after reconstruction included chrondritis, partial muscle necrosis, and wound dehiscence (1 patient each). There was no donor site morbidity. CONCLUSIONS: Free DALT flaps can be selected according to different situations during surgery as long as they meet the following requirements: (1) tissue of sufficient volume and good blood supply, and (2) closure of the bronchial leak. Based on this retrospective study, use of free DALT flaps with technical refinement is a reliable method for treatment of chronic intractable empyema combined with bronchopleural fistula.     

Usefulness in combined free anterolateral thigh and vastus lateralis muscle flaps

Background

The anterolateral thigh flap has been a popular flap in reconstructive surgery. However, the details concerning the anterolateral thigh flap combined with the vastus lateralis muscle flap have not been reported. We described the surgical procedures, complication of the donor site, and advantages and disadvantages of this combined flap.

Methods

We analyzed 29 patients who underwent reconstruction with an anterolateral thigh flap–vastus lateralis muscle flap.

Results

The recipient sites were in the head and neck area (n?=?25), extremities (n?=?3), and trunk (n?=?1). The vastus lateralis was used as a muscle flap in 28 cases. The rectus femoris was harvested in one case because the vastus lateralis could not be harvested with a skin flap. Four cases required two vastus lateralis muscle flaps with a skin flap. Partial ischemia of the muscle flap occurred in one case. Additional donor-site surgery was required in two cases. No donor-site dysfunction was observed in our series.

Conclusion

This combined flap is advantageous in that the volume and number of muscle flaps can be adjusted and the skin and muscle flaps can be placed in separate positions. Although harvesting this flap is safe and not difficult, attention should be paid to anatomical variations of the vascular pedicle supplying the skin and muscle flap and to the circulation of the muscle flap. Level of Evidence: level IV, therapeutic study.     

The vascular pedicle of the anterolateral thigh flap as an alternative recipient site for thigh free flaps

The indications for a free flap for thigh defects are relatively uncommon. Regardless, a reasonable recipient site will always be of paramount importance. The major femoral vessels, usually accessed via the medial thigh, would be a conventional selection. If these are at risk within the zone of injury, or if the defect is more lateral, the descending branch of the lateral circumflex femoral vessels might be a more suitable alternative. The surgical approach is virtually identical to that used to raise the familiar anterolateral thigh flap, where in a similar fashion a long pedicle of large caliber can be obtained to simplify end-to-end microanastomoses. This has proven to be an invaluable resource as demonstrated in two clinical cases.     

Perforator-based anterolateral thigh adipofascial or dermal fat flaps for facial contour augmentation

We describe our experience with perforator-based anterolateral thigh (ALT) flaps for facial contour augmentations in a standardized two-step procedure. In a series of eight consecutive patients (two men, six women) suffering from contour deformities due to different reasons (scleroderma: three, Parry-Romberg syndrome: three, trauma: one, tumor: one), soft tissue augmentations were performed via a preauricular approach. Flaps were harvested from the ALT as perforator-based dermofat (two) or adipofascial flaps (six) with only a small sheet of fascia and a minimal cuff of muscle around the perforators. All flaps were anastomosed to the superficial temporal vessels. For refinement of the primary result, excess volume was removed and minor contour irregularities were smoothed out after 6 months. Despite the small-vessel caliber, anastomoses caused no problems, and all flaps healed well. Because defects were located close to the temporal vessels, the length of the perforator pedicle was always sufficient. Facial contour could further be improved after secondary reshaping of the healed flaps. This led to nearly perfect long-term facial symmetry in all cases. The ALT proved to be a reliable donor site, providing enough well-vascularized fatty tissue for facial contour augmentation in normal-weight patients. No submandibular incision is necessary if the perforators are anastomosed to the superficial temporal vessels. The preauricular incision gives an excellent view to the operating field.     

同种异体肌腱联合股前外侧皮瓣一期修复手背软组织缺损

目的 评价同种异体肌腱加皮瓣对手背复合软组织缺损一期修复重建的临床疗效. 方法 2006年7月至2011年7月,对15例手背复合软组织缺损患者一期采用股前外侧皮瓣联合同种异体肌腱行手背伸肌腱修复和创面覆盖,皮瓣大小9 cm×5 cm ～ 14 cm×11 cm,每例修复手背肌腱缺损2～4条,术后2周皮瓣成活后利用被动伸指支具进行早期康复训练. 结果 15例皮瓣均成活,12例患者术后获得随访12 ～ 24个月,平均16个月.2例患者因肌腱粘连术后6个月行肌腱松解,其余10例患者手指屈伸良好.随访结束时,患手腕关节主动屈40°～ 70°,伸25°～50°,掌指关节60°～85°、指间关节80°～90°活动范围,总体优良率达92％. 结论 一期同种异体肌腱联合皮瓣修复手背皮肤及伸指肌腱缺损的方法安全可靠,疗效肯定.同期异体肌腱重建不仅可以避免自体肌腱移植引起的新创伤,而且可以确保及时的手指康复训练,避免了延期手术所致的伸指功能丢失.     

股前外侧游离皮瓣移植修复小腿及足踝部软组织缺损

目的 探讨应用股前外侧游离皮瓣修复小腿及足踝部软组织缺损的临床疗效.方法 采用游离股前外侧皮瓣修复12例小腿及足踝部深部软组织缺损患者,创面缺损面积11 cm×6 cm～20 cm×13 cm.结果 12例皮瓣全部成活,未发生血管危象,无皮瓣边缘坏死.12例均获随访,时间9～12个月.皮瓣质地、色泽及感觉功能恢复满意.结论 应用股前外侧游离皮瓣移植修复小腿及足踝部软组织缺损疗效满意.