Unusual Anterolateral Fascio Cutaneous Tight Flap for Extremity Soft Tissue Reconstruction

Soft tissue sarcoma is rare neoplasms that affect mainly the extremities. Surgery is the mean treatment and the resection results in extensive muscle and skin loss. The anterolateral tight flap is a good option for sarcomas arising in knees, superior third of legs and the medial face of thigh. The anatomy knowledge and the multidisciplinary approach is very important for a successful reconstruction. The authors report a successful case treated with the anterolateral tight flap and a literature review.

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.

Study on the indications of cardiac operations through the right anterolateral thoracotomy

Objective: To define the indications for cardiac surgeries through right anterolateral thoracotomy, and render it clinically feasible in a carefully controlled scope. Methods: Ninety-eight patients requiring cardiac surgeries were operated through this approaach. Incisions were made in the fourth or on intercostal space. The upper costal cartilage near the incision was routinely removed. Aortic cannulation was performed through the lateral wall of the aorta. The procedures on the heart itself were the same as that of the median sternotomy. Results: The average lengths of the incisions, for the male and female patients, were (10.6±3.2) cm and (10.3 ± 2.2) cm respectively. The mean bypass time was (61.3 ±t 25. 1) min, and the mean heart arrest time was (49.5±19.2) min. The postoperative drainage was (410± 125) ml. All but 1 patient with aortic valve operation had satisfactory exposure . The complications included chest pain (n = 5), rib fracture (n =3), pleural effusion (n=5), and pneumothorax(n=6). Conclusion: The right anterolateral tholacotomy was a satisfactory alternative of median sternotomy for the surgeries that can be performed through a right atrium access.

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.

Anatomy of the anterolateral ligament of the knee joint

Despite remarkable improvements in clinical outcomes after anterior cruciate ligament reconstruction,the residual rotational instability of knee joints remains a major concern.The anterolateral ligament(ALL)has recently gained attention as a distinct ligamentous structure on the anterolateral aspect of the knee joint.Numerous studies investigated the anatomy,function,and biomechanics of ALL to establish its potential role as a stabilizer for anterolateral rotational instability.However,controversies regarding its existence,prevalence,and femoral and tibial insertions need to be addressed.According to a recent consensus,ALL exists as a distinct ligamentous structure on the anterolateral aspect of the knee joint,with some anatomic variations.The aim of this article was to review the updated anatomy of ALL and present the most accepted findings among the existing controversies.Generally,ALL originates slightly proximal and posterior to the lateral epicondyle of the distal femur and has an anteroinferior course toward the tibial insertion between the tip of the fibular head and Gerdy’s tubercle below the lateral tibial plateau.

Overview of the anterolateral complex of the knee

In the last few years,much more information on the anterolateral complex of the knee has become available.It has now been demonstrated how it works in conjunction with the anterior cruciate ligament(ACL)controlling anterolateral rotatory laxity.Biomechanical studies have shown that the anterolateral complex(ALC)has a role as a secondary stabilizer to the ACL in opposing anterior tibial translation and internal tibial rotation.It is of utmost importance that surgeons comprehend the intricate anatomy of the entire anterolateral aspect of the knee.Although most studies have only focused on the anterolateral ligament(ALL),the ALC of the knee consists of a functional unit formed by the layers of the iliotibial band combined with the anterolateral joint capsule.Considerable interest has also been given to imaging evaluation using magnetic resonance and several studies have targeted the evaluation of the ALC in the setting of ACL injury.Results are inconsistent with a lack of association between magnetic resonance imaging evidence of injury and clinical findings.Isolated ACL reconstruction may not always reestablish knee rotatory stability in patients with associated ALC injury.In such cases,additional procedures,such as anterolateral reconstruction or lateral tenodesis,may be indicated.There are several techniques available for ALL reconstruction.Graft options include the iliotibial band,gracilis or semitendinosus tendon autograft,or allograft.

Two Cases of Distal Anterolateral Thigh Flap

We report our experience with two cases of anterolateral thigh flaps based on the musculocutaneous perforators arising from a more distal part of the descending branch than in the conventional anterolateral thigh flap. Case 1: A 53-year-old man with a skin ulcer over the anterior surface of the left tibia secondary to plate fixation for an open fracture. The perforator marked with preoperative Doppler was located 8 cm proximal to the superior border of the patella. Without thinning, the flap was 10 × 4 cm in size and 5 mm thick. Case 2: A 46-year-old man with necrosis of the right index finger after replantation. The flap was 5 × 3 cm in size and 3 mm in thickness. This “distal” anterolateral thigh flap can be raised as a quite thin flap with a long pedicle and, therefore, is considered useful in the reconstruction of various soft tissue defects.

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.

Optogenetics stimulates nerve reorganization in the contralesional anterolateral primary motor cortex in a mouse model of ischemic stroke

The anterolateral motor cortex of rodents is an important motor auxiliary area,and its function is similar to that of the premotor area in humans.Activation and inhibition of the contralesional anterolateral motor cortex(cALM)have been shown to have direct effects on motor behavior.However,the significance of cALM activation and inhibition in the treatment of stroke remains unclear.This study investigated the role of optogenetic cALM stimulation in a mouse model of cerebral stroke.The results showed that 21-day optogenetic cALM inhibition,but not activation,improved neurological function.In addition,optogenetic cALM stimulation substantially altered dendritic structural reorganization and dendritic spine plasticity,as optogenetic cALM inhibition resulted in increased dendritic length,number of dendritic spines,and number of perforated synapses,whereas optogenetic activation led to an increase in the number of multiple synapse boutons and the number of dendritic intersections.Furthermore,RNA-seq analysis showed that multiple biological processes regulated by the cALM were upregulated immediately after optogenetic cALM inhibition,and that several immediate-early genes(including cFOS,Erg1,and Sema3f)were expressed at higher levels after optogenetic inhibition than after optogenetic activation.These results were confirmed by quantitative reverse transcription-polymerase chain reaction.Finally,immunofluorescence analysis showed that the c-FOS signal in layer V of the primary motor cortex in the ischemic hemisphere was higher after optogenetic cALM activation than it was after optogenetic cALM inhibition.Taken together,these findings suggest that optogenetic cALM stimulation promotes neural reorganization in the primary motor cortex of the ischemic hemisphere,and that optogenetic cALM inhibition and activation have different effects on neural plasticity.The study was approved by the Experimental Animal Ethics Committee of Fudan University(approval No.201802173 S)on March 3,2018.

Graft choices for anterolateral ligament knee reconstruction surgery: Current concepts

The anterolateral ligament(ALL)is a primary structure of the anterolateral complex of the knee that contributes to internal rotational stability of the joint.Injury of the ALL is commonly associated with rupture of the anterior cruciate ligament.If left untreated,ALL lesions may lead to residual anterolateral rotational instability of the knee after anterior cruciate ligament reconstruction,which is a common cause of anterior cruciate ligament graft failure.The function of the ALL can be restored by lateral extraarticular tenodesis or anterolateral ligament reconstruction(ALLR).In the lateral extraarticular tenodesis procedure,a strip of the iliotibial band is placed in a non-anatomical position to restrain the internal rotation of the tibia,while in ALLR,a free graft is fixed at the insertion points of the native ALL.Gracilis and semitendinosus grafts have mainly been utilized for ALLR,but other autografts have also been suggested.Furthermore,allografts and synthetic grafts have been applied to minimize donor-site morbidity and maximize the size and strength of the graft.Nevertheless,there has been no strong evidence to fully support one method over another thus far.The present review presents a detailed description of the graft choices for ALLR and the current literature available in regard to the effectiveness and outcomes of published surgical techniques.

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.

Clinical and mechanical outcomes in isolated anterior cruciate ligament reconstruction vs additional lateral extra-articular tenodesis or anterolateral ligament reconstruction

BACKGROUND Anterior cruciate ligament(ACL) reconstruction has been a successful treatment for ACL rupture.However ongoing rotational instability can be an issue.Several surgical techniques have been recommended to overcome this including lateral extra-articular tenodesis(LET) and more recently anterolateral ligament reconstruction(ALLR).AIM To compare the clinical outcomes following ACL reconstruction(ACLR) alone or ACLR with either LET or ALLR.METHODS A systematic review was conducted by means of four databases(MEDLINE,EMBASE,Cochrane and Clinical.Trials.Gov),and the Reference Citaion Analysis(https://www.referencecitationanalysis.com/) to identify all studies investigating either or both of LET and ALLR.The Critical Appraisal Skills Programme checklist for cohort studies was employed for critical appraisal and evaluation of all twenty-four studies which met the inclusion criteria.RESULTS Pooled meta-analyses illustrated that ACLR with additional LET or ALLR results in improved pivot shift test scores,compared to isolated ACLR.There was no statistically significant difference in International Knee Documentation Committee(IKDC) clinical scores with addition of either LET or ALLR.ACL re-rupture rates were compared between LET and ALLR techniques.There was a statistically significant difference between techniques,with a 1.14% rupture rate in ACLR +ALLR,and 4.03% rupture rate in ACLR + LET.Isolated ACLR re-rupture rates were 12.59%,significantly higher than when augmented with either ALLR or LET(P < 0.0001 for both groups).There were no statistical differences in pivot shift test or IKDC scores between LET and ALLR techniques.CONCLUSION This meta-analysis has found that use of either LET or ALLR in addition to ACLR results in improved mechanical outcomes suggesting surgeons should consider augmenting ACLR with an extra-articular procedure in patients with rotatory instability.Furthermore,both anterolateral extra articular procedures in addition to ACLR lead to reduced ACL re-rupture rates compared to isolated ACLR.Moreover,ALLR results in reduced ACL re-rupture rates,compared to LET.More research is needed to compare the two respective extra-articular procedures.

The application of thin flap repairing method after reascularization in femoral anterolateral free flap

Objective: To summarize the application and effect of thin flap repairing method after reascularization in femoral anterolateral free flap. Methods: From May 2013 to October 2015, 20 cases of patients received femoral anterolateral free flap transplantation, with the flap transported to the recipient site. After reascularization, the phase I of thin flap repairing was performed in each 'vein type'area. Among those, there existed 8 cases of direct suture in the donor site, and 12 cases of skin transplantation by intermediate split thickness skin graft. Results: All the postoperative flaps survived, with 2 cases of vascular crisis and 2 cases of poor venous return at the edge of flap. No complications such as flap infection and necrosis occurred. Wounds and incisions in donor and recipient sites were healed in phase I. 20 cases of patients had been followed up for 5-24 months, and the average follow-up time was 15 months. The skin texture of flap was similar to the surrounding skin, with good abrasion resistance, no ulceration and no phase II flap repairing;the sensation of flap recovered to S3-S4 level;the two-point discrimination was 3.5-6.0 mm, with the average value of 5.0 mm. The function of patients' fingers recovered well without any complications such as contracture and deformity etc. In the last follow-up, Testative Evaluation Standard of Upper Limb Function, which was established by Chinese Medical Society for Surgery of Hand, was used to assess efficacy, and the evaluation results were as follows: excellent in 9 cases, good in 5 cases, fair in 6 cases;in accordance with the evaluation criteria listed in Michigan Hand Outcome Questionnaire (used to assess patients' satisfaction with the appearance of flaps after operation, and the results were as follows: very satisfactory in 9 cases, satisfactory in 9 cases, and moderate in 2 cases. Conclusions: After reascularization in femoral anterolateral free flap grafting, phase I of thin repairing has small effects on flap vascularization, with a satisfactory appearance of the flap.

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.

股前外侧皮瓣穿支解剖学特征与定位方法的专家共识(2024版)

股前外侧皮瓣(Anterolateral thigh flap,ALTF)是以股前外侧为组织供区、主要以旋股外侧动脉(Lateral circumflex femoral artery,LCFA)穿支为供血系统的外科皮瓣。ALTF作为一种经典的“万能皮瓣”广泛应用于临床修复重建领域。为了对ALTF穿支解剖特征与定位方法的研究成果进行系统的梳理和总结,由中华医学会显微外科学分会与中国解剖学会临床解剖学分会牵头,《中国临床解剖学杂志》编辑部组织国内多名从事显微修复重建外科的专家共同讨论,拟定《股前外侧皮瓣穿支解剖特征与定位方法的专家共识(2024版)》,旨在进一步推广其临床应用并展示我国学者在ALTF发展过程中所做的贡献。

标准冠状位MRI与多平面重建用于评估膝关节前外侧韧带

目的 对比MRI标准冠状位与多平面重建(MPR)图像评估前外侧韧带(ALL)的价值。方法 纳入130例接受膝关节MR检查患者,分别针对标准冠状位MRI及MPR图识别ALL,并将ALL分为完全可见、部分可见及不可见;比较双侧ALL在2种图像中的可见性,并以Kappa检验进行一致性分析。结果 130例中,标准冠状位MRI及MPR图中,左侧ALL分别有93例及83例完全可见、21例及12例部分可见、26例及25例不可见,右侧ALL分别有66例及80例完全可见、29例及15例部分可见、各有35例不可见。双侧ALL在标准冠状位MRI和MPR图中的可见性差异均有统计学意义(P均<0.05)而一致性均极好(Kappa均>0.80)。结论 MPR显示ALL效果较标准冠状位MRI更佳,但在无法满足其扫描条件时,利用标准冠状位MRI也可较准确地评估ALL。

股前外侧穿支皮瓣的个性化精准设计:十年1079例临床疗效分析

目的探讨个性化精准设计的股前外侧穿支皮瓣重建各种复杂组织缺损的临床疗效。方法回顾分析我科2013年1月-2023年1月采用个性化精准设计的各种股前外侧穿支皮瓣修复的1079例患者的临床疗效。以旋股外侧动脉降支为血管蒂切取1013例(其中小儿65例)、横支为血管蒂切取40例、斜支为血管蒂切取26例(小儿1例),以旋股内侧动脉或股动脉来源穿支为蒂切取9例。其中传统股前外侧穿支皮瓣游离移植441例、带蒂转移27例、特殊形式穿支皮瓣基本术式511例、衍生术式100例。修复下肢787例,上肢264例,躯干部17例,头颈部4例,上述多部位7例。并对各种个性化精准设计的股前外侧穿支皮瓣术后临床疗效及并发症发生率进行统计比较。结果本组1079例股前外侧穿支皮瓣中,术后顺利成活1063例,其中发生血管危象行探查术成活14例,总成功率为98.52%。比较游离股前外侧穿支皮瓣、带蒂转移、特殊形式穿支皮瓣基本术式和衍生术式各组成功率,结果显示各组间成功率无明显差异(P>0.05)。本组1079例股前外侧穿支皮瓣主要并发症发生情况:静脉危象35例(3.24%),动脉危象22例(2.04%),感染19例(1.76%),切口延迟愈合6例(0.56%),完全坏死16例(1.48%),部分坏死35例(3.24%)。统计学分析显示静脉危象方面特殊形式穿支皮瓣基本类型组发生率低于衍生术式组(P<0.001),切口感染方面带蒂转移组发生率高于特殊形式穿支皮瓣组(P=0.007),切口延迟愈合方面传统游离移植组发生率高于特殊形式穿支皮瓣组(P=0.04),皮瓣部分坏死方面带蒂转移组发生率高于特殊形式穿支皮瓣组(P=0.008)。结论股前外侧穿支皮瓣个性化精准设计,可以获得良好的临床疗效,值得临床推广应用。