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.     

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.     

Pedicled vastus lateralis musculofascial flap as a new technique for repairing rectourethral fistula after radical prostatectomy

We present a case of successful operative management of an iatrogenic rectourethral fistula with a pedicled vastus lateralis musculofascial flap. The fistula was created during radical prostatectomy operation. During the operation, it was deemed possible to spare this patient from a diverting colostomy and primarily repair a rectal injury. Postoperatively, however, a rectourethral fistula occurred, which was confirmed on retrograde urethrogram. A first attempt failed to close the fistula utilizing the transanal rectal flap advancement technique. A novel technique was attempted using a pedicled vastus lateralis musculofascial flap. This is the first report to our knowledge of repairing a rectourethral fistula with a pedicled vastus lateralis musculofascial flap. © 2011 Wiley‐Liss, Inc. Microsurgery, 2011     

Uterine liposarcoma invading abdominal wall and inguinal region. Immediate reconstruction using a pedicled anterolateral thigh flap

The anterolateral thigh flap is a particular flap of the vastus lateralis musculocutaneous flap (perforator flap). This flap was used as a pedicled flap to reconstruct the abdominal wall and to cover the inguinal region following the resection of a voluminous tumor of the womb invading the abdominal wall, the femoral vessels and the skin. The flap included a large facial paddle nourishing a skin island and a little muscle paddle including the perforator vessel. This medially positioned facial paddle allowed to increase the area of useful flap. So it was possible to reconstruct a 10x15 cm abdominal wall defect, and to cover the vascular decking in inguinal region with this only flap. In spite of the harvesting of a small muscular paddle of vastus lateralis (with conservation of the motor nerve) the function of thigh extension has been preserved. Besides the subtlety described to increase the "solid" surface of the fragment, it seems that the anterolateral thigh flap is perfectly useful to cover defects of soft tissues in inguinal region after vascular surgery, indication which was not reported to our knowledge in spite of the high frequency of these losses defects.     

旋股外侧动脉降支多叶组织瓣修复多指(趾)软组织缺损

目的 探讨应用旋股外侧动脉降支为蒂的一蒂多叶组织瓣一次修复多指(趾)软组织缺损的方法和临床效果.方法 2005年6月至2008年12月,收治8例多指(趾)软组织缺损患者,男5例,女3例;年龄22～38岁,平均27.6岁.设计以旋股外侧动脉降支的肌皮穿支或肌间隙穿支为蒂形成股前外侧穿支皮瓣,带股外侧皮神经前支;以股外侧肌肌支、股直肌肌支、股中间肌肌支、远端肌间隔支为分叶瓣,依受区缺损面积及各指(趾)蹼间距切取各组织瓣,在肌瓣上植全厚皮,一次修复手(足)部创面.结果 术后8例患者均未发生血管危象,植皮均成活.全部病例获6个月～3年(平均10.5个月)随访,修复各创面外形均良好,无臃肿,植皮处轻微挛缩.肌瓣植皮处恢复保护性感觉,各皮瓣两点辨别觉约8～10 mm.修复1例左足一至三趾软组织缺损病例,术后患足无疼痛及不适,负重行走正常;修复7例手部缺损病例,按中华医学会手外科学会上肢部分功能评定试用标准进行评价:优1例,良4例,可2例,优良率71%.结论 以旋股外侧动脉降支为蒂多叶组织瓣能一次修复多指(趾)软组织缺损,仅需吻合一组血管,无需行分指及整形手术,是修复多指(趾)软组织缺损的理想方法.     

Proximal pedicled anterolateral thigh flap for reconstruction of trochanteric defect

We describe our experience using the proximal pedicled anterolateral thigh (ALT) flap for the reconstruction of trochanteric defects. Seven ALT island flap procedures were performed in 6 patients between September 2006 and May 2007. Four of the 7 patients had trochanteric pressure sores because of paraplegia. In these patients, intramuscular perforators were dissected to raise a fasciocutaneous flap. Three myocutaneous flaps of the vastus lateralis muscle were used to treat osteomyelitis of the trochanter with implant extrusion. The mean follow-up was 7 months (range, 2-12 months), and all flaps survived. Trochanteric coverage with the proximal pedicled ALT flap gave excellent results. We conclude that the ALT flap is a reliable flap for trochanteric coverage.     

Single stage aesthetic and functional reconstruction of composite facial gunshot wound with a chimeric functioning muscle and fibular osseous flap. Case report and review of the literature

The current concepts in the aesthetic and functional reconstruction of complex oromandibular defects are presented with a case of a patient with self‐inflicted gunshot wound to the face. The patient presented with a 6 cm composite mandibular defect; the buccomandibular and suborbital aesthetic zones of the cheek along with the mucosa lining, and the ipsilateral facial musculature were missing. A rapid prototyping model of the facial skeleton was used to assist in preoperative planning. A single stage reconstruction with two free flaps was planned; a free fibula osseous flap to reconstruct the mandibular defect, and a free chimeric ALT/functioning vastus lateralis muscle. The one skin paddle of the chimeric flap reconstructed the buccomandibular/suborbital zones of the cheek, and the other the lining of the mouth. The functional muscle provided reanimation of the corner of the mouth by coapting the muscle's motor nerve to the ipsilateral marginal mandibular nerve. A good facial contour and reanimation of the mouth with oral continence was achieved, and the patient presented with good social and emotional smile. This first report of combined use of a fibula osseous flap with a chimeric functional ALT/Vastus Lateralis flap suggests that the chimeric flap principle may be used in complex aesthetic and functional challenges of severe facial trauma.     

The proximal pedicled anterolateral thigh flap for lower limb coverage

Although primarily considered as a versatile free-flap donor site, the anterolateral thigh can also be a source of a local muscle perforator flap. This attribute has previously been rarely considered for lower limb coverage. This small series of 3 additional cases demonstrates the usefulness of a proximal pedicled anterolateral thigh flap for medial and lateral thigh wounds. This flap can also be part of a combined flap, in particular when transferred with the vastus lateralis muscle as a local chimeric flap. The peninsular version of the anterolateral thigh local flap avoids venous congestion and is very reliable. The orthograde pedicled anterolateral thigh muscle perforator flap should be considered as another useful alternative for any upper thigh wound if a flap is essential.     

旋股外侧动脉降支多叶组织瓣修复手部多部位软组织缺损

目的 探讨旋股外侧动脉降支多叶瓣修复手部多部位软组织缺损的手术方法和临床效果。方法对手部多部位软组织缺损15例,采用旋股外侧动脉降支多叶瓣修复,根据手部缺损情况设计股前外侧皮瓣,沿皮瓣穿支血管向远端继续解剖旋股外侧动脉降支,考虑好手部各缺损处间距,按需切取分叶穿支皮瓣、阔筋膜瓣、股直肌肌瓣、股外侧肌肌瓣、股中间肌肌瓣或旋股外侧动脉降支远端肌间隔瓣。形成以旋股外侧动脉降支为主干的一蒂多叶瓣,在肌瓣及阔筋膜瓣上植皮,一次修复手部多部位软组织缺损。 结果 术后无血管危象发生。修复各创面在肌瓣、阔筋膜瓣或旋股外侧动脉降支远端血管肌间隔上植皮均成活良好,外形无臃肿,植皮处恢复保护性感觉,供区创面愈合好,股四头肌肌力及膝关节屈、伸活动均正常。全部病例获得随访,随访时间6 ～ 20个月,平均8.7个月。按中华医学会手外科学会上肢部分功能评定标准：优3例,良9例,可3例,优良率80％。 结论 旋股外侧动脉降支多叶瓣能一次修复手部多部位软组织缺损,缩短手术时间及疗程,手部功能恢复良好,外形满意,是修复手部多部位软组织缺损的理想方法。     

A new technique of transferring island pedicled anterolateral thigh and vastus lateralis myocutaneous flaps for reconstruction of recurrent ischial pressure sores.

We describe island pedicled anterolateral thigh and vastus lateralis myocutaneous flaps for reconstruction of the difficult, recurrent ischial pressure sore. Rather than transfer through a subcutaneous tunnel, the flap is transferred directly through the upper thigh to the ischial defect. A total of 15 patients with 16 recurrent ischial pressure sores were treated between May 2003 and April 2005. Eleven sores were treated with pedicled island anterolateral thigh flaps and five sores with vastus lateralis myocutaneous flaps. There was no difficulty in transferring the flap to reach the ischial defect in any patient. The length of the pedicle ranged from 8.5 to 14 cm. All donor sites were closed primarily. Fifteen of the 16 flaps survived completely. Total necrosis occurred in one vastus lateralis myocutaneous flap, which was located at the distal third of the thigh. We conclude this flap can be added to the repertoire for the treatment of recurrent, difficult ischial pressure sores.     

Flow-through嵌合ALTP急诊修复四肢Gustillo III C型损伤

目的探讨Flow-through嵌合股前外侧穿支皮瓣(ALTP)急诊一期修复四肢Gustillo III C型损伤的临床疗效。方法2010年1月至2017年12月,采用Flow-through嵌合ALTP急诊修复四肢Gustillo III C型损伤患者17例。其中男16例,女1例;年龄19~55岁,平均32.4岁。创面范围16 cm×8 cm^45 cm×30 cm。旋股外侧动脉降支Flow-through吻合受区动脉以重建肢体血供,股外侧肌瓣填塞深部死腔,皮瓣和筋膜瓣覆盖浅表创面。供区皮肤直接闭合6例,腹部取皮植皮11例。结果术后采用门诊结合微信、电话随访,时间5~60个月,平均21.8个月。皮瓣成活15例,2例失败并截肢。6例采用皮瓣和筋膜瓣修复,11例采用皮瓣、筋膜瓣和肌瓣修复。术后4例皮瓣一期愈合;11例患者皮瓣边缘出现坏死,其中1例换药后瘢痕愈合,其余10例患者二期植皮愈合。所有患者供区未出现并发症。结论急诊Flow-through嵌合ALTP在重建肢体血供的同时实现创面三维立体修复,是修复四肢Gustillo III C型损伤的有效方法之一。     

Anterolateral thigh flap: from anatomic study to surgical technique

Anterolateral thigh flap is a perforator flap, which is vascularised by the descending branch of the lateral circonflex femoral artery. It has been described first by Song in 1984 and is essentially developed in Asia. This flap can be pedicled but it is widely used as a free flap for reconstruction of head and neck defects. Knowing that its vascular anatomy and the variation's origins of the perforators are well documented, our study's objective is to locate the main points of the dissection and its traps, starting from an anatomic study including 15 inferior members. The first constraint is the localisation and the individualisation of intermuscular septum between rectus femoris and vastus lateralis. The perforators of the flap can be septo-cutaneous (14.4%) and then the dissection of the flap is easy but can usually be musculo-cutaneous (86.6%) and the intramuscular dissection in the vastus lateralis represents then the second most difficult period of the intervention. This flap would be frequently used in France thanks to its intrinsic qualities, but due to the difficulty of the dissection of perforators vessels, teams who are intending this operation must make a previous work of anatomic dissection.     

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.     

以隐血管为蒂的逆行股骨内侧髁骨瓣骨皮瓣的解剖学研究及临床应用

目的　为治疗胫骨骨不连和骨缺损提供一种新方法。方法　通过解剖学观察膝降动脉关节支及隐支的关系,并摹拟手术证实以隐血管为蒂的逆行股骨内侧髁骨瓣的切取可能。结果　尸体摹拟手术4例,切取后关节支均有墨汁显示。临床应用2例,切取骨瓣分别为5.0cm×2.0cm×1.5cm及4.5cm×1.5cm×1.5cm均有活跃渗血。随访8～12周,骨折愈合良好。结论　应用以隐血管为蒂的逆行股骨内侧髁骨瓣骨皮瓣治疗胫骨骨不连和骨缺损具有手术方法简便,疗效可靠,易于推广等优点。     

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.     

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.     

膝降动脉穿支蒂股内侧皮神经营养血管皮瓣的应用解剖

目的 为膝降动脉穿支蒂股内侧皮神经营养血管皮瓣提供解剖学基础.方法 在40侧动脉内灌注红色乳胶的成人下肢标本上,以股骨内侧髁为观测标志解剖观测:股内侧皮神经走行与分布;膝降动脉穿支与股内侧皮神经营养血管间的吻合关系.另1侧新鲜标本进行摹拟手术.结果 股内侧皮神经体表投影为腹股沟韧带中点与股骨内侧髁的连线;膝降动脉(髌下支)穿支于股骨内侧髁下缘上约4 cm,在股内侧肌、大收肌腱与股骨内侧髁所围成的三角形凹陷内穿过深筋膜至皮下,并分出众多的细小血管与股内侧皮神经的神经旁和神经干血管链(网)密切吻合,在大腿内侧形成顺沿股内侧皮神经纵轴的血管丛.结论 根据膝降动脉穿支与股内侧皮神经营养血管吻合关系,可形成膝降动脉穿支蒂股内侧皮神经营养血管皮瓣转位修复膝部软组织缺损.     

Use of the vastus lateralis muscle flap with a grooving procedure in the surgical treatment of chronic osteomyelitis of the femur

Severe femoral fractures may be associated with devascularization of cortical bone, soft-tissue loss, and significant morbidity. After surgical treatment of these femoral fractures, chronic infection may ensue and requires additional reconstructive procedures. Local muscle flap coverage is used to treat chronic osteomyelitis. A new procedure-the vastus lateralis muscle flap with grooving of the femoral shaft-was used for the treatment of chronic osteomyelitis of the femoral shaft. The authors present 6 patients with chronic osteomyelitis of the femur who were treated with a vastus lateralis muscle flap. Five of the patients were male and the other was female. The average age of the patients was 33.8 years (range, 17-54 years). All patients experienced infection during the early postoperative period. Drainage of abscess, debridement, sequestrectomy repair of fistula, and mini fenestration were performed at least 3 times, and antibiotics were administered several times. During the operations, tissue samples were evaluated for bacterial cultivation. Staphylococcus aureus was seen in 4 patients, S. epidermidis in 1 patient, and Pseudomonas aeruginosa in the remaining patient. A vastus lateralis muscle flap with grooving of the infected femoral shaft is presented. The authors have not encountered a recurrence of infection during a minimum 3.9 years of follow-up. They think this technique is an alternative to the current techniques for the surgical treatment of chronic osteomyelitis of the femur.     

应用股外侧肌肌瓣旋转填塞治疗大转子褥疮

目的探讨应用股外侧肌肌瓣旋转填塞治疗大转子部位深度褥疮的疗效。方法采用股外侧肌肌瓣旋转填塞治疗大转子部位深度褥疮12例15侧。切取肌瓣为20 cm×10 cm大小。肌瓣填塞后均取中厚皮片一期移植。结果肌瓣均成活。13处移植皮片完全成活,2处移植植皮片部分成活,边缘因感染坏死,经换药3~4周后愈合。10例患者获得随访,时间6~18（11±0.2）个月。植皮处颜色好,局部柔软,弹性佳,均未有褥疮复发。结论应用股外侧肌瓣旋转填塞治疗大转子部位深度褥疮,操作简单、转移方便、组织量大、手术风险小,临床效果较好。     

The vastus lateralis muscle flap: technique and applications

The vastus lateralis muscle can provide a broad sheet of muscle for repair of defects of the lower abdomen, groin, perineum, hip, and ischium. The authors limit the use of the vastus lateralis muscle to situations in which more traditional techniques are not feasible. This muscle is especially suitable for defects involving irradiated tissue, infected bone, or infected prosthetic material. Although the vastus lateralis muscle has no cutaneous component, it may be used to augment an overlying tensor fascia lata flap.