Utility of Preoperative Positron Emission Tomography (PET) in Localizing Perforator Vessels of Anterolateral Thigh Free Flap

Objectives: The anterolateral thigh (ALT) flap is often considered the workhorse in soft tissue reconstruction of head and neck defects secondary to trauma, infection, or tumor resection. Despite its many advantages, ALT flaps have been criticized due to variability in vasculature, which may result in inadequate or non-existent perforators. This retrospective study aims to investigate the utility and validity of positron emission tomography (PET) scan to identify the location and characteristics of perforators to the ALT flap. Methods: We performed a 10-year retrospective review of ALT flaps at our institution to identify patients with preoperative PET scans available for analysis. Three reviewers (attending physician, fellow, and resident) were asked to identify the number, location, and characteristics (myocutaneous versus septocutaneous) of ALT perforators on imaging, and reviewer agreement was assessed. Results were then compared to available operative data. Results: One hundred twenty-one patients were identified who underwent ALT free flap surgery. Thirty-eight preoperative PET scans were identified for review. At least one perforator was identified in 92.1% of scans. Agreement percentages regarding the number of perforators ranged from 53% - 61% whereas agreement regarding the location of a single perforator ranged from 79% - 90%. However, reviewers did not agree regarding the type of perforator, with agreement ranging from 34% - 53%. Poor agreement was observed when compared to intraoperative data, with the number of perforators ranging from 26% - 34% and the type of perforator 11% - 24%. These findings are likely due to insufficient data available in operative reports. Conclusion: Although initial studies suggest that PET scan shows promising evidence to support the capacity to preoperatively identify ALT perforators, future prospective studies are warranted to fully validate these findings.

Clinical observation of endoscopic skull base reconstruction with an anterolateral thigh free fascia flap

Objective:Radiation osteonecrosis of the skull base after radiotherapy for nasopharyngeal carcinoma is one of the most serious complications,affecting patient survival and quality of life.To date,surgical resection is the main treatment for radiation osteonecrosis.The repair after the operation is very important.Inappropriate repair or lack of repair can easily cause local infection that can even spread to the brain,aggravating osteonecrosis.This study aimed to verify the feasibility and safety of the ante-rolateral thigh free fascia flap in repairing large skull base defects.Methods:From June 2021 to July 2022,a total of 12 patients with a history of radiotherapy for naso-pharyngeal carcinoma received surgical treatment at the Department of Otolaryngology Head&Neck Surgery,Sir Run Run Shaw Hospital,Zhejiang University School of Medicine.All patients were diagnosed with radiation osteonecrosis of the skull base with large skull base defects.During the endoscopic operation,a free anterolateral thigh fascia flap was used to repair the skull base and complete vascular anastomosis reconstruction.The preoperative and postoperative pain scores were retrospectively analyzed,and the dynamic changes in endoscopic surgery sites were observed.Results:The 12 patients had a median age of 58 y,with 8(66.7%)males and 4(33.3%)females.The median headache score for the patients was 5(4-7)before surgery.The patient's headache was significantly relieved postoperatively,with 11 patients having a score of 0 and one patient having a score of 1.The stench was completely resolved after the operation.There were no serious complications during the perioperative period or 12 months after the operation.Conclusion:The application of anterolateral thigh free fascia flap in skull base reconstruction is a safe and reliable reconstruction technique suitable for endoscopic surgical repair of large-scale skull base necrosis.

Free Flow-through Anterolateral Thigh Flaps for Wrist High-tension Electrical Burns:A Retrospective Case Series

Objective The objective of this report was to demonstrate the clinical application of free flow-through anterolateral thigh flaps for the treatment of high-tension electrical wrist burns.Methods We collected the data of 8 patients with high-tension electrical wrist burns admitted to Beijing Jishuitan Hospital from January 2014 to December 2018.The clinical and pathological data were extracted from electronic hospital medical records.We obtained follow-up information through clinic visits.Results The injury sites for all 8 patients were the wrists,specifically 5 right and 3 left wrists,all of which were on the flexor side.Five patients had ulnar artery embolism necrosis and patency,with injury to the radial artery.Two patients had ulnar and radial arterial embolization and necrosis.The last patient had ulnar arterial embolization and necrosis with a normal radial artery.After debridement,the wound area ranged from 12 cm×9 cm to 25 cm×16 cm.The diagnoses for the eight patients were type II to type III high-tension electrical wrist burns.Free flow-through anterolateral thigh flaps(combined with great saphenous vein transplantation if necessary)were used to repair the wounds.The prognosis for all patients was good after six months to one year of follow-up.Conclusion Treating wrist types II and III high-tension electrical burns is still challenging in clinical practice.The use of free flow-through anterolateral thigh flaps(combined with great saphenous vein transplantation if necessary)to repair the wound and to restore the blood supply for the hand at the same time is a good choice for treating severe wrist electrical burns.

The application of anterolateral thigh flap in post-operative repairing of vulva tumor

Objective： The aim of this study was to evaluate the value of the application of anterolateral thigh flap in postoperative repairing of vulva tumor. Methods： Anterolateral thigh flap with the descending branch of the lateral circumflex femoral artery and the pedicle of anterolaterat thigh cutaneous nerve was used in primary repairing of the defect from postoperative vulva tumor, the sizes of the flaps ranged from 10 cm ×14 cm-14 cm× 20 cm. Results： All flaps survived, during a follow-up of 2 to 12 months, the appearance of the flaps was satisfactory with sensitive function without local recurrences. Conclusion： Anterelateral thigh flap has fairly long vessel pedicle, wider vessel diameter, and is in the covert area. Anterolateral thigh flap with sensory nerve is the ideal choice for postoperative repairing of vulva tumor.

Repair of a severe palm injury with anterolateral thigh and ilioinguinal flaps: A case report

BACKGROUND In daily life and work,there are more and more patients with trauma to the hand,which often results in skin and soft tissue defects.Although there are many repair methods,the function and appearance of the fingers will be adversely affected if the repair is inadequate.CASE SUMMARY In the present report we describe an 18-year-old male patient whose right hand was mangled by a machine.X-ray imaging showed that a right hand bone(middle finger)was absent and the alignment was poor.After hospitalization,he was diagnosed with a severe right hand injury,skin and soft tissue defects,partial finger defects,and a skin degloving injury.He underwent reconstructive surgery with anterolateral thigh and ilioinguinal flaps.After two repair operations,satisfactory results were obtained,including good fracture healing,good skin flap shape,and good wrist joint function.CONCLUSION This case highlights the good effect of anterolateral thigh and ilioinguinal flaps repair technique on severe palm injury.

Scalp and Dura Matter Complex Reconstruction Using Free Anterolateral Thigh Flap with Vascularized Fascia

The reconstruction of large scalp and dural defects is difficult. Anterolateral thigh (ALT) flap is now widely used because of its reliable blood supply to the skin paddle. Additionally, ALT can be harvested with a large skin paddle and large, well-vascularized fascia. We have successfully treated eight scalp and dural composite defect cases (five male and three female) using ALT with vascularized fascia. The patients’ mean age was 59.1 ± 20.4 years ranging from 31 to 83 years. The mean dural defect size was 73 ± 21 cm2, ranging from 50 to 120 cm2. There were no postoperative infections, bleeding, cerebrospinal fluid leakage, or meningitis. Further discussion about the usefulness of vascularized fascia may be required and we believe that plastic surgeons, head and neck surgeons, and neurosurgeons should report on the results of dural reconstruction.

A Case of Harvesting Anterolateral Thigh Flaps Twice from the Ipsilateral Thigh of a Single Patient in Separate Operations

Until now, harvesting of flap elevations from the ipsilateral thigh twice in the same patient in two operations has not been reported. We harvested thigh flaps twice from the ipsilateral thigh of a single patient in separate operations. A 44-year-old man had skin defects of the right thumb and the left middle finger. In the first operation, his right thumb was reconstructed by the hemi-pulp flap. The anterolateral thigh flap harvested from the left thigh transferred to the donor site defect of the hemi-pulp flap. Sixteen days after the first operation, another anterolateral thigh flap harvested from the left thigh transferred to the defect of the left middle finger. This operative procedure is very useful for cases requiring multi-flap transfer.

Prefabricated Anterolateral Thigh Flaps for Phalloplasty in Female-to-Male Transsexuals

Background Phalloplasty is still a challenging operation because of the high urethral complication rate.Several options regarding different flaps can be chosen,but there is still no perfect solution for phalloplasty in female-to-male(FTM)transgender patients.Our group tried to use prefabricated anterolateral thigh(ALT)flaps for phalloplasty to overcome the urethral complications.Methods A total of 21 transgender patients were included from 2010 to 2019.A twostage operation was performed to reconstruct the phallus.The vaginal mucosa was prefabricated as neourethra at the first stage,and the shaft of the phallus was reconstructed at the second stage.Results All reconstructed phallus survived completely in our study,and the satisfaction rate was 76.2%.The total complication rate was 57.1%.The occurrence of fistula and strictures after the operation was 52.4%and 5.8%,respectively Conclusion Prefabricated ALT flaps with vaginal mucosa have a lower stricture rate.This technique provides a simple,effective surgical option in FTM transsexuals.

Unusual case of a free anterolateral thigh flap partial necrosis in a COVID-19 positive young male following extremity reconstruction

Free flap procedure provides an overall success rate of 97%, which decreases to 85% in hypercoagulable states. COVID-19, as a pro-thrombotic disorder, therefore seems detrimental to free flap survival. We encountered a case of unique pattern of free flap partial failure in a young male who underwent extremity reconstruction. The patient was diagnosed as COVID-19 positive on the 3rd day post-reconstruction. The flap survived well for the first 7 days post-operatively, but gradually the skin got necrosed and the subcutaneous fat layer was preserved when debriding. To our knowledge, this is the only case in which the skin of the free flap of a COVID-19 positive patient was necrosed almost entirely subsequently, while the subcutaneous fat was relatively preserved.

Extended anterolateral thigh pedicled flap for reconstruction of trochanteric and gluteal defects： A new 8： innovative approach for reconstruction

Descending branch of the lateral circumflex femoral artery （LCFA） is commonly used pedicle for anterolateral thigh （ALT） flap. Oblique branch of LCFA is an alternative pedicle that can be used in microvascular surgery. According to review of literature and to the best of our knowledge we could not find the use of oblique branch of LCFA as a pedicle of the ALT flap in regional soft tissue reconstruction. Here we presented a case of a 55-year-old man sustaining soft tissue injury and wound over the left trochanteric and gluteal region following a road traffic accident, who was treated by the use of extended ALT pedicle flap with oblique branch of LCFA as the pedicle for reconstruction of soft tissue defect in trochanteric and gluteal regions with successful outcome.

Utility of multi-detector row computed tomography angiography versus Doppler in localization of perforators of anterolateral thigh flaps

Aim:Anterolateral thigh(ALT)flap is widely used in reconstruction of various defects.Preoperative imaging facilitates perforator mapping,overcoming intraoperative uncertainty.The purpose of this study was to investigate the utility of multi-detector row computed tomography angiography(MDCTA)and a handheld Doppler in locating ALT perforators.Methods:Twenty patients were randomized into two groups.Group 1 patients received MDCTA and Doppler studies whereas Group 2 received only a Doppler study.The number,location,course,and source of all cutaneous and sizable perforators were compared with intraoperative findings.Surgeons’stress levels during flap harvest and flap harvest time were compared.Results:MDCTA findings correlated well with intraoperative findings for perforator type and segmental distribution with 100%concordance.Doppler alone had a 52%rate of concordance.The sensitivity and specificity for MDCTA in demonstrating the presence of perforators were 85.71%and 97.22%,respectively;whereas for Doppler alone the sensitivity and specificity were 80%and 87.91%,respectively.In demonstrating perforator source,MDCTA showed a sensitivity of 100%and specificity of 91.66%,with 100%accuracy.Sensitivity and specificity for sizable perforators were 90%each,with 88.88%accuracy.Doppler studies were unable to provide this information.Comparison of surgeon stress levels showed no differences between the two groups,although the time for flap harvest was significantly shorter in Group 1.Conclusion:MDCTA compared to Doppler is more sensitive,specific,and accurate with respect to location,course,and source of perforators.

The Antero-Lateral Thigh Flap in Coverage of Extensive Post Traumatic Upper Limb Defects

Objective: To assess the role of antero-lateral thigh flaps in coverage in cases with traumatic injury to the upper limb. Methods: A total of fifteen cases of upper limb trauma were studied between May 2014 and February 2016. Antero-lateral thigh flaps were performed to cover post traumatic upper limb soft tissue defects. Brachial interposition grafts were used in all cases. Harvesting was performed using saphenous vein graft. A 10% larger than defect, flap was used to cover defect. Results: The age range was 15 to 46 years. All 15 cases were male. The indication for soft tissue reconstruction was trauma all patients. Each procedure was performed by a “two team” approach with an experienced surgeon raising the flap and a team preparing the recipient vessels. Flap size ranged from 15 to 25 cm in length and from 8 to 10 cm in width. Ischaemic time ranged from 91 to 157 min. We experienced a 100% flap success rate, with good cosmesis and return to function in all cases. Only two anastomoses required explorations or revision. Minor complications were seen in two patients including a superficial wound infection and a small wound dehiscence. The donor site was closed directly all cases, light dressing with slab support was utilized in all patients Early postoperative management warming the patient, half-hourly flap observations, and ensuring adequate hydration and urinary output. All patients received antithrombotic therapy. Conclusion: The anterolateral thigh flap is one of the most versatile and useful perforator flaps for multidimensional reconstructions for head and neck, limb, trunk, and perineal region. It can be ultrathin flap for resurfacing and filling dead spaces with superior functional and aesthetic outcomes.

Successful reconstruction of an ankle defect with free tissue transfer in a hemophilia A patient with repetitive hemoarthrosis:A case report

BACKGROUND Hemophilia, an uncommon yet consequential hereditary bleeding disorder, manifests as two clinically indistinguishable forms that hinder the normal functioning of the coagulation cascade. This impairment renders individuals more susceptible to excessive bleeding during significant surgical interventions. Moreover, individuals with severe hemophilia frequently encounter recurring hemarthrosis, resulting in progressive joint destruction and, subsequently, the need for hip and knee replacement surgeries.CASE SUMMARY The patient was a 53-year-old man with hemophilia A as the underlying disease and had self-injected factor Ⅷ twice weekly for several decades. He had undergone ankle fusion surgery for recurrent hemarthrosis at the Department of Orthopedic Surgery 1 mo prior and was referred to our department because of skin necrosis after a hematoma at the surgical site. An anterolateral thigh perforator free flap was created after three cycles of factor Ⅷ administration in addition to the concomitant administration of tranexamic acid(TXA)(Transamin 250 mg cap, 1 cap tid, q8h). After the operation, from postoperative days(PODs) 1-5, the factor Ⅷ dose and interval were maintained, and q12h administration was tapered to q24h administration after POD 6. Because the patient’s flap was stable 12 d after the operation, factor Ⅷ administration was tapered to twice a week. At 6 mo follow-up, the patient recovered well without any complications.CONCLUSION To the best of our knowledge, there are very few reports of successful free flaps in patients with hemophilia, and none have been reported in patients with hemophilia A. Moreover, there are several reports on the efficacy of TXA in free flaps in general patients;however, there are no case reports of combining factor Ⅷ and TXA in patients with hemophilia. Therefore, we report this case to contribute to future academic research.

Reconstructing abdominal wall defects with a free composite tissue flap:A case report

BACKGROUND Reconstructive repair of huge full-thickness abdominal wall defects following debridement for abdominal electric burns remains a clinically challenging task.An ideal abdominal wall repair means a re-closure of the defected abdominal wall with pedicled neurovascular myofascial flaps,restoration of the abdominal wall integrity,and maintenance of the abdominal wall muscle tension to prevent the occurrence of abdominal wall hernia.When treating huge full-thickness defects,composite autologous tissue flaps are a good option for the repair.CASE SUMMARY This study reported the case of a 43-year-old male patient suffering from fullthickness abdominal wall defects complicated with necrosis of multiple bowel segments and duodenal leak following high-voltage burns involving the left upper limb and abdomen.After debridement for abdominal electric burns and end-to-end anastomosis for the necrotic bowels,reconstruction with acellular dermal matrix grafting and vacuum sealing drainage were performed for temporary abdominal closure.The remaining 18 cm×15 cm full-thickness abdominal wall defect was repaired using a combined anterolateral thigh and tensor fascia lata free flap.The proposed method achieved the functional reconstruction of the abdominal wall.CONCLUSION This approach restored the abdominal wall integrity,maintained certain muscle tension,avoided abdominal hernia,reached satisfactory aesthetic effect,and resulted in no complications in the grafting regions.

Established and experimental techniques to improve phalloplasty outcomes/optimization of a hypercomplex surgery

An increasing number of transgender and gender non-conforming patients are seeking genital gender affirming surgeries in order to better align their physical characteristics with their innate gender identity and treat gender dysphoria.Phalloplasty is the most complex of these surgeries,and this complexity creates a wide range of potential complications.Some of the most common complications and therefore,targets for improvement in outcomes,concern neourethral fistula/stricture,efficacy of reinnervation of the phalloplasty flap,postoperative flap monitoring,and donor site morbidity.In the setting of no established"gold standard",this review seeks to describe the components and staging of phalloplasty,with an emphasis on established and experimental solutions to the most common and vexing problems.

Penoscrotal defect:a functional,esthetic,and psychological challenge

Aim:Penoscrotal defects may be caused by a variety of events.Reconstruction of the penoscrotal region is required not only for aesthetic appearance but also for functional and psychological reasons.Numerous techniques have been described for penoscrotal reconstruction reflecting the challenge and complexity of the region involved.This suggests that no single method is satisfactory for all types and degrees of tissue defects.This prospective study was conducted in a tertiary care hospital in India,over a period of 5 years.Methods:Eighteen patients with penoscrotal defects of varying etiology were included in the study and underwent different surgical techniques.Age of the patients ranged from 20 to 60 years.The etiology of penoscrotal defect was Fournier’s gangrene in 12 cases,trauma in 4 cases,and burn in 2 cases.The patients with Fournier’s gangrene were initially treated by debridement,drainage,and antibiotics.The penoscrotal defects were treated with local flap advancement with skin grafting(n=7),pedicled anterolateral thigh flap(n=4),gracilis muscle flap with split skin grafting(n=4),and medial thigh flap(n=3).Results:There was complete healing in 16 patients with minor complications in the form of partial skin graft loss(n=1)and wound dehiscence(n=1).Results were highly satisfactory in 6 patients,satisfactory in 8 patients,and not satisfactory in 4 patients.Scarring at the donor site was limited and acceptable.Conclusion:The vast arsenal of options for penoscrotal defect coverage ranges from skin grafting to flaps,and every case needs a customized approach with regard to its feasibility,outcome,and complication rate.Flaps should be the preferred choice over the skin grafts because of the superior functional and aesthetic results and better compliance.