A comparison of free anterolateral thigh and latissimus dorsi flaps in soft tissue reconstruction of extensive defects in the head and neck region.

Tailoring the most suitable reconstructive approach to each patient remains challenging especially in the head and neck region. To compare the applicability of the latissimus dorsi (LD) and anterolateral thigh (ALT) flap, we retrospectively analyzed patients who had reconstruction of extensive and/or bulky composite tissue defects in the head and neck area. We performed 85 free tissue transfers (44 LD and 41 ALT flaps). LD mean flap surface was 115.8 cm(2). ALT mean flap surface was 67.0 cm(2). Pedicle length ranged from 8 to 16 cm in LD and 11-16 cm in ALT flaps. The survival rate was 93% in ALT and 91% in LD flaps. Donor site morbidity occurred in 5% (ALT) and 7% (LD). A Two-team-approach was possible in 24% of the LD group, whereas all ALT flaps were raised in a Two-team-approach. Both flaps present excellent opportunities for the reconstruction of extensive and/or bulky defects. They largely meet the requirements of an ideal soft tissue flap in terms of versatility, skin texture and tissue stock. Both flaps can be raised with a double skin paddle. The advantages and disadvantages of each flap have to be weighed up against each other and both flaps should be in the repertoire of every microvascular surgeon.

Horn D ，Jonas R ，Engel M ，Freier K ，Hoffmann J ，Freudlsperger C ... -  《-》

Free extended anterolateral thigh myocutaneous flap versus combined pedicled pectoralis major-latissimus dorsi myocutaneous flaps in deep and extensive sternal wound reconstruction.

The combined pedicled pectoralis major-latissimus dorsi (PM-LD) and free extended anterolateral thigh (ALT) myocutaneous flaps provide well-vascularized tissues for extensive sternal wound reconstruction. However, the outcomes and postoperative complications between the two surgical techniques are different. Thus, the aim of this study is to evaluate the feasibility of these two reconstructive options. This single-center, retrospective study was conducted between August 2011 and May 2019. Forty-four patients diagnosed with deep sternal wound infection (DSWI) and presented with grade four complications (sternal instability and necrotic bone tissue) were enrolled. Two reconstructive strategies, namely, combined pedicled PM-LD (n = 24) and free extended ALT (n = 20) myocutaneous flaps, were used according to the patients' hemodynamics. Data including age, gender, body mass index (BMI), hospital stay, follow-up, defect/flap size, number of surgical procedures before reconstruction, duration from the last debridement to flap coverage, comorbidities, and postoperative complications, were obtained for statistical analysis. The mean defect size in the combined PM-LD myocutaneous flap group was 188.4 (5*17-10*23) cm2 , and the mean flap size was 150.0 (8*12-15*15) cm2 and 205.0 (8*15-10*25) cm2 in PM and LD flap, respectively. The mean defect size in the free extended ALT myocutaneus flap group was 202.5 (6*16-10*21) cm2 , and the mean flap size was 285.2 (9*30-12*25) cm2 . No significant differences were observed between the free extended ALT and the combined pedicled PM-LD myocutaneous flaps in relation to age, gender, BMI, hospital days, follow-up, defect size, preoperative procedures, and comorbidities, except for the average operative time (443.2 ± 31.2 vs. 321.3 ± 54.3 mins, p = .048). The combined pedicled PM-LD myocutaneous flap had significantly more donor site complications, including seroma (21% vs. 0%, p = .030), bilateral nipple-areolar complex asymmetry (100% vs. 0%, p < .0001), and skin graft loss with infection (33% vs. 0%; p = .044) than the free extended ALT myocutaneous flap. The free extended ALT and the combined pedicled PM-LD myocutaneous flaps were both feasible and effective options for sternal wound reconstruction. Our findings suggested that the free extended ALT myocutaneous flap may be a better alternative for a comprehensive and extensive reconstruction of sternal wounds. Further studies based on these findings can be conducted.

Wee SJ ，Hsu SY ，Shih PK ，Chen JX ，Chang CC ... -  《-》

Soft Tissue Coverage in Distal Lower Extremity Open Fractures: Comparison of Free Anterolateral Thigh and Free Latissimus Dorsi Flaps.

 When microsurgical transfers are required in posttraumatic lower limb reconstruction, surgeons must choose among many types of free flaps. Historically, surgeons have advocated muscular flaps for coverage of open lower extremity wounds, but fasciocutaneous free flaps are now often used with good results. This study aimed to compare the functional and aesthetic outcome of reconstruction by free muscular latissimus dorsi (LD) flap and free fasciocutaneous anterolateral thigh (ALT) flap used for soft tissue coverage of distal lower extremity open fractures.  We performed a single-center, retrospective study of subjects with distal lower limb open fractures treated with LD flaps or ALT flaps between 2008 and 2014. Patients with limited follow-up or incomplete data were excluded from the analysis. Donor and recipient sites, early complications and long-term outcomes (functional and aesthetic) were studied and compared according to the type of flap.  A total of 47 patients were included: 27 patients in the LD flap group and 20 patients in the ALT flap group. No significant difference was found regarding early and late complications and long-term functional outcomes (bone healing, infectious bone complications, flap healing). As for aesthetic outcome and donor-site morbidity, reconstruction using the ALT free flap had significantly better results (p < 0.05).  In posttraumatic lower limb injury, either LD or ALT free flaps can be used for wound coverage with comparable long-term functional outcomes. The ALT flap provides better cosmetic results than LD.

Philandrianos C ，Moullot P ，Gay AM ，Bertrand B ，Legré R ，Kerfant N ，Casanova D ... -  《-》

Application of Thinned Anterolateral Thigh Flap for the Reconstruction of Head and Neck Defects.

To evaluate the feasibility and reconstructive efficacy of the thinned anterolateral thigh (ALT) flap for the reconstruction of head and neck defects. A retrospective review was performed of 43 patients who had undergone reconstruction of head and neck defects with a thinned ALT flap from January 2009 through December 2013 at the Second Xiangya Hospital. The methods for flap thinning and defect reconstruction and reconstructive efficacy are reported. The flaps were 5 cm × 7 cm to 9 cm × 14 cm, and all were harvested from a single cutaneous perforator. Postoperatively, 40 flaps survived completely and 3 flaps experienced partial necrosis. Venous compromise occurred in 2 cases, both of which were salvaged after operative exploration. Of the 43 donor sites, 41 were closed directly and resulted in only linear scars, and 2 were closed using full-thickness skin grafts because the defect was larger. All the patients were followed for approximately 6 to 36 months, and they were satisfied with the esthetic and functional results of the donor and recipient sites after reconstruction. With the high success rate of flap transplantation, satisfactory functional and esthetic results, and lower complication rates at the donor and recipient sites, the use of thinned ALT flaps can be a good choice for the reconstruction of head and neck defects in obese patients.

Gong ZJ ，Wang K ，Tan HY ，Zhang S ，He ZJ ，Wu HJ ... -  《-》

Combined Anterolateral Thigh and Tensor Fasciae Latae Flaps: An Option for Reconstruction of Large Head and Neck Defects.

The advent of microvascular free tissue transfer has provided the reconstructive surgeon with an enormous array of treatment options for reconstruction of large head and neck defects. However, when indicated by defect size, the need for more than 1 flap not only increases surgical complexity but also patient morbidity. The combination of the anterolateral thigh (ALT) flap and the tensor fascia latae (TFL) flap can be used to reconstruct such complex head and neck defects, thereby minimizing any additional morbidity that would be imposed by an additional flap harvest site. The present study reports on the use of the combined ALT-TFL flap to reconstruct large and complex head and neck defects. A retrospective chart review was conducted of all microvascular head and neck reconstructions performed by the Maxillofacial Tumor and Reconstructive Surgery Service at the University of Miami/Jackson Health System (Miami, FL) from 2013 through 2016. Inclusion criteria for the study were head and neck defects at least 20 m × 10 cm and reconstruction with soft tissue flaps using perforating vasculature to the TFL and ALT vascular territories. Other study data included disease history, location of defect, flap size, recipient vessels, harvest time, ischemia time, surgical complications, and overall flap survival. Seven patients met the inclusion criteria. Five patients were treated for the diagnosis of stage III osteoradionecrosis and 2 patients underwent reconstruction in conjunction with ablative surgery for head and neck carcinoma. All 7 patients underwent successful head and neck reconstructions using the ALT-TFL flap. There was no partial or total flap failure. One patient had a wound healing complication at the donor site that did not require surgical intervention. Reconstruction of a large head and neck soft tissue defect with a combined ALT-TFL flap is a reliable method with minimal donor site morbidity and no major postoperative complications. This combined flap should be considered when the defect size extends beyond the bounds allowed by the ALT flap alone.

Tursun R ，Marwan H ，Green JM 3rd ，Alotaibi F ，LeDoux A ... -  《-》