Objective To evaluate a modified anterolateral thigh fascial flap designed for the treatment of the soft tissue defects in the forearmsand hands. Methods From September 2000 to December 2003, a modified anterolateral thigh fascial flap combined with the intermediate split thickness skin graft was applied to the treatment of 13 patients with the soft tissue defects in the forearms or the hands. There were 8 males and 5 females, aged 19-43 years (average, 27.6 years). Three patients had a mangled injury, 4 had a belt injury, and 6 had a crush injury; 6 patients had their tissue defects on the palm side of the forearm, 6 had their tissue defects on the dorsal side of thehand, and 1 had the defect in the index finger (dorsal side of the hand). The tissue defects ranged in size from 17.5 cm×7.7 cm to 4.6 cm×3.4 cm.In addition, 4 of the patients had an accompanying fracture in the forearm or the hand,and the remaining 9 had an extenor tendon injury. All the patients underwent emergency debridement and reposition with an internal fixation for the fracture; 3-5 days after the repair of the injured nerves, muscle tendons and blood vessels, the tissue defects were repaired with the anterolateral thigh fascial flap combined with the intermediate split thickness skin graft. Results No vascular crisis developed after operation. All the flaps survived except one flap that developed a parial skin necrosis (2.0 cm ×1.0 cm) in the hand, but the skin survived after another skingrafting. The follow-up for 3-12 months revealed that all the flaps and skin grafts had a good appearance with no contracture of the skin. According to the evaluation criteria for the upper limbs recommended by the Hand Society of Chinese Medical Association, 9 patients had an excellent result, 2 had a good result, 1 had a fair result, and 1 had a poor result, with a good/excellence rate of 85%. Conclusion The modified anterolateral thigh fascial flap combined with the skin graft is one of the best methods for the treatment of the soft tissue defects in the forearms and the hands. This method has advantages of no requirement for a further flap reconstruction, no skin scar or contracture in the future, easy management for the donor site, and less wound formation.
Objective
To investigate the effectiveness of high frequency color Doppler ultrasound for detecting perforators in the anterolateral thigh (ALT) flap surgery.
Methods
Between February 2011 and July 2012, 8 patients underwent high frequency color Doppler ultrasound to detect the perforator anatomy before ALT flap surgery. There were 5 males and 3 females, aged 21-46 years (mean, 34 years). Defects were caused by excision of squamous cell carcinoma in 2 cases, by scalp avulsion in 2 cases, by soft tissue necrosis after neck trauma in 1 case, by excision of groin fibrosarcoma in 1 case, by excision of groin melanoma in 1 case, and by malformation of the face in 1 case. The defect size varied from 12 cm × 7 cm to 22 cm × 18 cm. The perforator with wider caliber, faster flow speed, and shorter intramuscular trajectory was selected, and the flap was designed according to the observed results, which size varied from 14 cm × 9 cm to 25 cm × 20 cm. The donnor sites were repaired by free skin graft.
Results
Totally, 19 perforators in the flap area were detected by high frequency color Doppler ultrasound, and 18 were identified during operation, with an accuracy rate of 94.7%. The point going out muscle, the travel and direction of perforators observed during operation were basically in accordance with those detected by high frequency color Doppler ultrasound. The other flaps survived, and obtained healing by first intention except 1 flap which had partial fat necrosis with healing by second intention. The skin graft at donor site survived. All patients followed up 4-16 months (mean, 8 months). The flaps had good color and texture.
Conclusion
High frequency color Doppler ultrasound is a valuable imaging modality for the preoperative assessment of the vascular supply for ALT flap.
In the present study, swine thighbone samples with different water contents were prepared through process of dehydration. The influence of water content on the biotribological behavior of the bone tissue was studied with nanoindentation test, reciprocating sliding test and impact wear test. It is shown that the water contents had significant influence on the mechanical properties and biotribological behavior of the swine thighbone samples. In this experiment condition, with decreasing water content, the hardness and elastic modulus of the swine thighbone samples increased, while the tribological properties significantly decreased. The viscoelasticity of bone tissue decreased with decreasing water content, which mainly resulted in different wear mechanisms of the bone tissue samples under applied loading.
ObjectiveTo investigate the surgical methods and effectiveness to use the iliac flap combined with anterolateral thigh flap for repair of the first metatarsal bone and large skin defect.
MethodsBetween January 2013 and January 2016, iliac flap combined with anterolateral thigh flap was used to repair the first metatarsal bone and large skin defect in 9 patients. There were 5 males and 4 females, with a median age of 15 years (range, 10 to 60 years). The causes included traffic accident injury in 6 cases and crush injury of machine in 3 cases. The average time from injury to operation was 3 hours to 14 days (mean, 7 days). The size of skin soft tissue defect ranged from 10 cm×6 cm to 20 cm×10 cm. The size of first metatarsal bone defect ranged from 2 cm×1 cm to 5 cm×1 cm. The size of iliac flap was 3.0 cm×1.5 cm to 6.0 cm×1.5 cm, and the size of anterolateral thigh flap was 10 cm×6 cm to 20 cm×10 cm. The donor site was directly sutured or repaired by free skin graft.
ResultsAfter operation, the composite flaps survived with primary healing of wound; the skin grafts at donor site survived and the incision healed by first intention. All patients were followed up 6 months to 2 years (mean, 1.6 years). X-ray examination showed that the bone healing time was 3.5-5.0 months (mean, 4 months). The flap had soft texture, good color and appearance. All patients could normally walk. According to the American Orthopaedic Foot and Ankle Society (AOFAS) standard, the foot function was excellent in 6 cases and good in 3 cases, and the excellent and good rate was 100% at last follow-up.
ConclusionThe iliac flap combined with anterolateral thigh flap for repair of the first metatarsal bone and large skin defect is a practical way with good shape at one stage.
Objective To improve the harvesting techniques of anterolateral thigh perforator flap, and to reduce the operation time. Methods Between January 2008 and June 2015, 400 patients undergoing repair with anterolateral thigh perforator flap were included to analyze the technical factors, including 370 cases (92.5%) obtaining primary healing and 30 cases (7.5%) receiving re-exploration. Combined with the literature, a modified flap dissection was made: reverse tracing and sequential dissection of the descending branch of the lateral circumflex femoral artery. Between June 2015 and June 2016, the modified free anterolateral thigh perforator flap was used in 100 cases. Of 100 cases, 76 were male and 24 were female, aged from 11 to 71 years (mean, 35.6 years). The wound size ranged from 8 cm×5 cm to 23 cm×9 cm. The time between injury and surgery ranged from 5 to 31 days (mean, 14.3 days). Results The operation time of modified flap dissection was reduced to (30.1±19.3) minutes from (85.0±30.2) minutes (unmodified flap dissection). Postoperatively, 94 flaps survived uneventfully, and incision healed by first intention. Six flaps received re-exploration surgery because of vascular compromise; the flap survived after removal of thrombosis in 4 cases of vein thrombosis; the flap necrosed in 2 cases of vein and artery thrombosis, and skin grafting was performed. Ninety-four patients whose flaps survived were followed up 3-12 months (mean, 6.3 months); the flaps had good color and appearance, and second stage operation was performed to make the flap thinner in 21 cases. Conclusion Improved harvesting technique of free anterolageral thigh perforator flap could decrease surgery time and difficulty in dissection.
Objective To compare the effectiveness of poly ether ether ketone (PEEK) localization marker combined with mixed reality technology versus color doppler ultrasound guidance for the vessel localization of anterolateral thigh perforator flap. Methods A retrospective analysis was conducted on 40 patients with tissue defects after oral cancer resection who underwent repair using the anterolateral thigh perforator flap between January 2022 and June 2023. According to the different intraoperative positioning methods of the anterolateral thigh perforator flap, they were randomly divided into PEEK group [using PEEK localization marker combined with mixed reality technology based on CT angiography (CTA) data] and color ultrasound group (using color ultrasound guidance), with 20 cases in each group. There was no significant difference in gender, age, etiology, and disease duration between the two groups (P>0.05). The number of perforator vessels identified in the two groups of regions of interest was recorded, and compared them with the intraoperative actually detected number to calculate the success identifying rate of perforator vessels; the distance between the perforating point and the actual puncture point was measured, the operation time of the two groups of flaps was recorded. ResultsIn the PEEK group, 32 perforator vessels were identified, 34 were detected by intraoperative exploration, and the success identifying rate was 94.1% (32/34); in the color ultrasound group, 29 perforator vessels were identified, 33 were detected by intraoperative exploration, and the success identifying rate was 87.8% (29/33); there was a significant difference in the success identifying rate between the two groups (P<0.05). The distance between the perforating point and the actual puncture point and the operation time in PEEK group were significantly shorter than those in color ultrasound group (P<0.05). Patients in both groups were followed up 6-30 months, with a median of 17 months; there was no significant difference in follow-up time between the two groups (P>0.05). In the PEEK group, there was 1 case of flap necrosis at the distal edge and delayed healing after trimming and dressing change. In the color ultrasound group, there was 1 case of flap necrosis at 7 days after operation and pectoralis major myocutaneous flap was selected for repair after removal of the necrotic flap. In the rest, the flap survived and the incision healed by first intention. Donor site infection occurred in 1 case in PEEK group and healed after anti-inflammatory treatment. The maxillofacial appearance of the two groups was good, the flap was not obviously bloated, and the patients were satisfied with the repair effect. Conclusion Compared with the traditional color ultrasound guidance, the PEEK localization marker combined with mixed reality technology based on CTA data in vessel localization of anterolateral thigh perforator flap has higher success identifying rate and positioning accuracy, and the flap production time is shorter, which has high clinical application value.
Objective To explore the reliability and effectiveness of prediction of the pedicle length of the proximally-based anterolateral thigh (pALT) flap which was used to repair the defects following the resection of various malignant tumors using computed tomographic angiography (CTA). Methods The clinical data of 12 patients who met the selection criteria by using pALT flap to repair wounds left after malignant tumor resection between June 2015 and December 2020 were retrospectively analyzed. There were 5 males and 7 females; the age ranged from 16 to 80 years, with an average age of 54.4 years. After tumor resection, the soft tissue defect ranged from 15 cm×5 cm to 30 cm×12 cm; defect sites included 4 cases of lower abdomen, 3 cases of groin, 2 cases of thigh, and 3 cases of buttocks. Preoperative CTA was used to obtain the location information of the descending branch of the lateral femoral circumflex artery and its perforators by maximum density projection, and the length of the pedicle of pALT flap was estimated. Fasciocutaneous flap (5 cases) or myocutaneous flap (7 cases) were cut during operation to repair the defect, and the size of flap ranged from 20 cm×7 cm to 30 cm×12 cm. The donor site of thigh was directly sutured (11 cases) or repaired with skin graft (1 case). Bland-Altman analysis was used to detect the consistency between the pALT flap vascular pedicle length estimated by CTA and the pALT flap vascular pedicle length actually obtained during operation. ResultsOne case had distal blood supply disturbance of the flap and was repaired with skin graft after debridement; the remaining 11 flaps survived. All donor and recipient incisions healed by first intention. All 12 cases were followed up 1-12 months, with an average of 4.3 months. One patient died of pelvic tumor recurrence at 6 months after operation, and no tumor recurrence was found in the other patients. Preoperative CTA estimated that the length of pALT flap vascular pedicle was 9.3-24.7 cm, with an average of 14.7 cm; the actual length of pALT flap vascular pedicle was 9.5-25.0 cm, with an average of 14.8 cm. Bland-Altman analysis showed that there was no significant difference between the pALT flap vascular pedicle length estimated by CTA before operation and the pALT flap vascular pedicle length actually obtained during operation, and the average difference was 0.1 (95% consistency limit: –0.89, 0.74), indicating that they had good consistency. ConclusionCTA can be accurately used to localize the perforator and predict the possible pedicle length of the pALT flap. When performing a pALT flap surgery, preoperative CTA is helpful for surgeons to make a preliminary assessment of the difficult of the operation. The time for exploration of perforators and dissection of the vascular pedicle, and complications can be reduced, and the safety of the operation can be improved.
ObjectiveTo investigate the effectiveness of multiple tension reduction suture of in-situ return needle vertical mattress suture and in-situ return needle horizontal mattress suture combination with intradermal intermittent continuous suture (denominated as Zunyi’s Suture Method) on suturing the donor site of the anterolateral thigh flap. MethodsBetween January 2019 and December 2019, 62 patients were treated with anterolateral thigh flaps to repair wounds. There were 46 males and 16 females, aged 9-67 years (mean, 31 years). The size of anterolateral thigh flap ranged from 6 cm×5 cm to 25 cm×7 cm. The donor site of the flap was sutured directly by the Zunyi’s Suture Method. The skin on both sides of the incision was advanced to the middle, and the wound edge was attached and in a state of negative tension. The intradermal suture line was removed at 7 days after operation. The complications and scars at donor site were observed during follow-up. The Vancouver Scar Scale was used to assess the appearance of scars and the width of scars were measured at 6 months after operation.ResultsThe flaps survived smoothly, and the wounds healed by first intention. The incisions at donor sites healed by first intention at 2 to 3 weeks after operation. All patients were followed up 7-16 months, with an average of 10.7 months. There was no ischemic necrosis of the donor site or skin threading. There was pigmentation of the needle back point in the early stage, and the pigmentation completely disappeared after 3 to 6 months without scar hyperplasia. At 6 months after operation, liner scars were achieved in all the patients with an average Vancouver Scar Scale score of 2.5 (range, 1.0-3.5) and an average width of 2.4 mm (range, 0.8-9.1 mm). ConclusionThe suture of the donor site of the anterolateral thigh flap with Zunyi’s Suture Method can effectively reduce the tension on wound edges and scar hyperplasia.
Objective To summarize the cl inical effect of anterolateral thigh pedicle or free perforator flap in repairing soft tissue defect in the extremities. Methods From March 2000 to January 2009, 32 cases of soft tissue defect were treated with pedicle or free anterolateral thigh perforator flap. There were 30 males and 2 females with an median age of28 years (4-53 years). Soft tissue defects included left radial side in 3 cases, the left lateral elbow in 1 case, knee in 5 cases, calf in 14 cases, dorsal is pedis in 5 cases, and planta pedis in 4 cases. The defect area ranged from 9 cm × 6 cm to 15 cm × 13 cm. Nine cases compl icated by bone defect and 1 case by radial nerve defect. The time from injury to hospital ization was 1 hourto 4 months (mean 5 days). Defects in 27 cases were repaired by anterolateral thigh perforator flap, simultaneously combined with transplantation with the second toe in 1 case, with sural nerve using arterial ized small saphenous vein in 1 case, nd with fibular or il ium in 4 cases. Defects in other 5 cases were repaired with flaps pedicled with superior lateral genicular artery. Neuroanastomosis was performed in 14 cases of the flaps. The size of the flaps ranged from 10 cm × 8 cm to 16 cm × 15 cm. Skin defects at donor site were repaired with spl it thickness skin graft or sutured directly. Results All patients were followed up from 8 months to 9 years with an average of 18 months. The flaps survived well and the wounds healed by first intention in 29 cases, 3 flaps necrosed and cured after symptomatic management. Skin graft at donor site survived completely in 9 cases. The color and texture and thickness of the flaps were similar to those of recipient site. After 6 months, the sensation of the flaps recovered to grade S3-4 in 14 patients whose cutaneous nerve were anastomosed, partial recovery was observed in other patients. In 4 patients receiving transplantation of fibular or il ium, the bony heal ing was achieved within 4 to 6 months. No obvious dysfunction was found at the donor site. Conclusion The pedicle anterolateral thigh perforator flap is long and thick with constant location. Anastomosis or transferring is easy to perform. It can provide big area and feel ing recovery by nerve anastomosis. It is an effective method to repair soft tissue defect of the extremities.
Objective To investigate the reconstructive methods and effectiveness of modified pedicled anterolateral thigh (ALT) myocutaneous flap for large full-thickness abdominal defect reconstruction. Methods Between January 2016 and June 2018, 5 patients of large full-thickness abdominal defects were reconstructed with modified pedicled ALT myocutaneous flaps. There were 3 males and 2 females with an average age of 43.7 years (range, 32-65 years). Histologic diagnosis included desmoid tumor in 3 cases and sarcoma in 2 cases. The size of abdominal wall defect ranged from 20 cm×12 cm to 23 cm×16 cm. Peritoneum continuity was reconstructed with mesh; lateral vastus muscular flap was used to fill the dead space and rebuild the abdominal wall strength; skin grafting was applied on the muscular flap, the rest abdominal wall soft tissue defects were repaired with pedicled ALT flap. The size of lateral vastus muscular flap ranged from 20 cm×12 cm to 23 cm×16 cm, the size of ALT flap ranged from 20 cm×8 cm to 23 cm×10 cm. The donor site was closed directly. Results All flaps and skin grafts survived totally, and incisions healed by first intention. All patients were followed up 6-36 months (mean, 14.7 months). No tumor recurrence occurred, and abdominal function and appearance were satisfying. No abdominal hernia was noted. Only linear scar left in the donor sites, and the function and appearance were satisfying. Conclusion Modified pedicled ALT myocutaneous flap is efficient for large full-thickness abdominal defect reconstruction, decrease the donor site morbidity, and improve the donor site and recipient site appearance.
