Management of a Complex, Recurrent Case of Medial Thigh Sarcoma With Pedicled Deep Inferior Epigastric Artery Perforator (DIEP) Lymphatic Flow-Through (LyFT) Flap and Secondary Anterolateral Thigh (ALT) Free Flap With Innervated Vastus Lateralis Anastomosed to Synthetic Artery Graft: A Case Report.

Soft-tissue sarcomas (STS) are rare solid tumors of mesenchymal cell origin and account for only 1% of adult malignancies. They tend to occur most commonly in the lower extremities. Reconstruction after sarcoma resection can be challenging, especially when important structures are involved and recurrences occur. Additionally, more attention is now being paid to reconstructing the lymphatic system to prevent lymphatic complications. In this case report, we presented the management of recurrent medial thigh sarcoma that necessitated multiple challenging reconstructions to provide valuable insights for lectures on similar cases. A 50-year-old male patient was diagnosed with an undifferentiated pleomorphic cell sarcoma (UPS) of the anteromedial thigh. After preoperative radiotherapy, a mass of 23 × 15 cm was removed, and reconstruction with a pedicled deep inferior epigastric artery perforator (p-DIEP) flap-based lymphatic flow through (LyFT) was performed. Six months later, the patient developed the first local recurrence with the presence of a distant metastasis. Following the tumor resection, the medial part of the DIEP flap was de-epithelized and buried in the defect for dead space obliteration. Another local recurrence arose 7 months after the second surgery. Therefore, a major debulking surgery involving the femoral neurovascular bundle was performed. The femoral artery was reconstructed with a synthetic graft, and the femoral vein with the great saphenous vein harvested from the contralateral thigh. A composite myocutaneous neurotized anterolateral thigh (ALT) flap from the contralateral thigh was used to obliterate the defect and restore the loss of function of the quadriceps femoris. Two lymphaticovenular anastomoses (LVAs) were performed at the ankle to reduce the risk of lymphatic sequelae. This case report highlights the importance of integrating various techniques to create a tailored approach that effectively addresses complex surgical requirements to avoid limb amputation and maintain functionality.

Role of three-dimensional printing and laser scanning in aesthetic restoration of Parry Romberg's disease using de-epithelialized anterolateral thigh flap: a case report.

Parry Romberg syndrome also known as progressive hemifacial atrophy is an uncommon degenerative condition, characterized by unilateral, slow, and progressive atrophy of face. Patient presents with loss of facial symmetry and neurological manifestations. After the degenerative process settles, reconstructive surgeries are performed to address facial asymmetry. For accurate assessment of volume deficit, laser scanning and three- dimensional printing can be used which offers the advantage of precise surgical planning and good aesthetic outcome. We present a case of soft tissue reconstruction in Parry Romberg syndrome with anterolateral thigh flap with use of three- dimensional laser scanning.

Reconstructive management of a patient with Tessier number 10 cleft.

Tessier number 10 cleft is one of the rarest facial clefts. Surgical treatment of this type of cleft is challenging due to the complexity of periorbital and temporal soft tissue deformities. A 23-year-old male patient presented with typical facial deformities of Tessier number 10 cleft. The surgical procedure involved using a free anterolateral thigh flap to reconstruct the eye socket, while the superficial temporal artery pedicle scalp flap was used to reconstruct the eyebrow deformity. The patient had no complications and 16 months after surgery, the patient had good aesthetic results. A hair-bearing scalp flap with a pedicle of the frontal branch of the superficial temporal artery combined with an anterolateral thigh-free flap can effectively resolve most soft tissue deformities of Tessier number 10 cleft and reconstruct the orbital socket in a single surgery. At the same time, it augments the soft tissue of the frontotemporal area and provides good aesthetic results.

The Past, Present, and Future of Perforator Flaps in Head and Neck Surgery.

A perforator is a vessel that travels through muscle and perfuses the skin. Perforator flaps require intramuscular dissection and can be used as pedicled or free flap. With improved understanding of microvasculature, they can be tailored to have multiple skin paddles, multiple components, or shaped to conform to any defect. Reliable perforator flap-based reconstruction is a meticulous microvascular technique, ultimately allowing the surgeon to harvest any flap in a freestyle fashion and transplant to any recipient vessel. New technologies improve the safety and reproducibility of this type of reconstruction.

TFL Perforator Flap Complementing and Completing the ALT-AMT Flap Axis.

Background Anterolateral thigh (ALT) flap is the most common soft tissue flap used for microvascular reconstruction of head and neck. Its harvest is associated with some unpredictability due to variability in perforator characteristics, injury or unfavorable configuration for complex defects. Anteromedial thigh (AMT) flap is an option, but the low incidence and thickness restrict its utility. Tensor fascia lata (TFL) perforator (TFLP) flap is an excellent option to complement ALT. Its perforator is consistent, robust, in vicinity, and lends itself with the ALT perforator. Methods This study was an analysis of 29 cases with a free flap for head neck reconstruction with an element of TFLP flap from July 2017 to May 2021. Results All cases were primarily planned for an ALT reconstruction. There was absence of the ALT perforator in 16 cases but a sizable TFL perforator was available. In 13 cases, the complex defect warranted use of both ALT plus TFL in a conjoint (5), chimeric (5), and multiple (3) free flaps manner. Most common perforator location was septocutaneous between the TFL and gluteus medius. There was complete flap loss in two cases and partial necrosis in two. No adjuvant therapy was delayed. Conclusion TFLP can reliably complement the ALT/AMT axis. Chimeric ALT-TFL can be harvested for large, complex, multicomponent, and multidimensional defects.

Reconstructive techniques for radiation-induced hemifacial sequelae: A hemangioma case study.

INTRODUCTION AND IMPORTANCE: The use of radiation therapy for infantile hemangiomas 30 years ago has led to severe consequences in adulthood. CASE PRESENTATION: This article shares the experience of using multiple reconstructive procedures to treat radiation-induced hemifacial sequelae for capillary malformations. Based on the damaged anatomical surgical units, appropriate reconstructive materials are used for the surgery. Thin antero-lateral thigh (ALT) flaps cover lesions on the forehead and cheeks, while a skin expander covers the temporal scalp lesion. Autologous grafting covers damage in both eyelids. CLINICAL DISCUSSION: Choosing a suitable reconstructive material will provide aesthetic outcomes such as facial symmetry, skin color compatibility, and textural similarity in the constructive areas for the patient. The patients were highly satisfied with the surgical results. CONCLUSION: Using appropriate surgical techniques and materials, along with meticulous attention to facial integrity, can achieve optimal aesthetic and functional outcomes in patients with severe facial disfigurement from radiation therapy. A thorough understanding of pathophysiology and anatomy, along with skillful execution, can result in a successful outcome and improved quality of life.

Pedicled ALT-flap for soft tissue reconstruction in the trochanteric area.

BACKGROUND: Coverage of soft tissue defects following surgery at the trochanteric area is challenging. Revision surgery in case of compromised wound healing may lead to soft tissue defects requiring reconstruction with pedicled or free flaps. Previous access to the hip joint may jeopardize neurovascular structures relevant to the flap. OBJECTIVE: In this study, we evaluated if the use of a pedicled anterior lateral thigh (ALT) flap is a valuable option for soft tissue reconstruction. METHODS: In this retrospective study, seven patients were included. Defect etiology was tumor resection in one case, screw osteosynthesis in another case and total hip arthroplasty in three cases. All patients underwent reconstruction by proximal pedicled anterior lateral thigh (ALT) flap. RESULTS: Pedicled ALT flap was a safe procedure in all cases. One patient showed delayed wound healing with need for additional surgery. No further complications were observed. CONCLUSIONS: Pedicled ALT flap transfer represents a reliable option for soft tissue coverage in the trochanteric area after primary surgery such as hip arthroplasty, osteosynthesis or tumor resection.

Thin and Thinned Anterolateral Thigh Flaps for Upper Extremity Reconstruction.

Upper extremity reconstruction remains challenging due to the high functional and esthetic demands of this location. The anterolateral thigh (ALT) flap is a workhorse flap for microsurgical reconstruction of the upper extremity and can be elevated in various planes depending on desired thickness of the flap. Microsurgical reconstruction of the upper extremity often benefits from a thin flap that can resurface the extremity, which can provide improved functional and esthetic outcomes. This article reviews the anatomy, preoperative planning, and operative technique, as well as presents 4 cases to illustrate the outcomes and benefits of thin and thinned ALT flaps.

The free anterolateral thigh flap substituted for a pedicled biparietal flap in reconstructing complex frontal defect.

Complex scalp defects involving soft and hard tissues pose challenges for plastic surgeons. The solution for each defect must depend on various factors and even the technical development of the infrastructure. We present a case study in which the patient had a significant total frontal defect. The first surgery was a bi-parietal flap as a salvage option to cover the defect. However, aesthetic satisfaction was not achieved. The second surgery used the anterolateral thigh flap to enhance the aesthetic result, and the placement of titanium mesh was an appropriate choice. This case may be an example of how different solutions can lead to variable results and what needs to be considered when dealing with complex scalp defects.

Delayed reconstruction of the combat-related mandibular defects with non-vascularized iliac crest grafts: Defining the optimal conditions for a positive outcome in the retrospective study.

BACKGROUND: Reconstruction of mandibular defects caused by combat injuries is challenging for clinicians due to soft tissue defects and high complication risk. This study evaluated the outcomes of mandibular continuous defects reconstruction with non-vascularized iliac crest graft (NVICG) in patients with combat injuries. MATERIAL AND METHODS: Patients with continuous mandibular defects acquired by high-velocity agents, who received NVICG reconstruction with or without microvascular-free soft tissue or regional flaps, were included in the study. The outcome variable was graft loss due to postoperative complications or full (more than 90 %) resorption. The primary predictor variable was soft tissue defect in the recipient area. The secondary predictor variable was the length of the defect. Variables related to patients, defect site, surgery, and other complications were also evaluated. Statistical analysis was performed with the usage of independent sample t-test, Pearson's chi-squared and Fisher's exact tests with a significance level of P < 0.05 RESULTS: The study included 24 patients with 27 mandibular defects. Overall, the general success rate of reconstructions was 59.3 %. Soft tissue defects were significantly associated with graft failure and other complications (p < 0.05), which were mostly related to soft tissue defects. The graft success rate was only 14.3 % even in minor soft tissue defects. In turn, in reconstructions with sufficient soft tissue coverage, the graft survived in 75.0 % of the cases. In addition, patients with more delayed reconstruction had significantly fewer graft failures than those with earlier surgery (p < 0.05). No associations were found between defect size and complications. CONCLUSION: The sufficient soft tissue coverage is essential in the reconstruction of mandibular defects caused by combat injuries. Also, minor soft tissue defects should be covered with soft tissue flaps to avoid complications and graft loss in these specific injuries. Even large defects can be reconstructed with NIVICG if the soft tissue coverage is sufficient.

Favorable effects of open surgery on patients with extensive skull base osteoradionecrosis through a personalized sequential approach: A case series.

The present study aimed to investigate outcomes following open surgery for extensive skull base ORN. Open surgery through a personalized sequential approach was employed to deal with five cases of extensive skull base ORN. Two patients with mild cases underwent regional debridement and sequestrectomy, and three patients with severe cases underwent extensive resection with reconstruction using free anterolateral thigh (ALT) flap. Biological glues and vascularized flaps were used for obturation of the skull base bony defect to prevent postoperative cerebrospinal fluid (CSF) leakage. The infections were controlled by antibiotic administrations which strictly followed the principles of antimicrobial stewardship (AMS). As results, both regional debridement plus sequestrectomy and extensive resection achieved satisfied outcomes in all patients. No severe complications and delayed hospitalization occurred. During the follow-up period (8-19 months), all patients were alive, pain free, without crusting or purulent discharge, and no sequestration or CSF leakage occurred. In conclusion, a personalized sequential approach including open surgery, pedicled/vascularized free flap reconstruction and AMS was advocated for patients with extensive skull base ORN.

Using Free Chimeric Anterolateral Thigh Flap For Reconstruction Of Composite Dorsal Hand Defect.

Background: Simultaneous repair of the extensor tendons and soft tissues in hand injuries remains challenging. The free chimeric anterolateral thigh (ALT) flap with fascia lata (FL) flap represents an alternative for hand reconstruction. This report describes the reconstruction of the extensor tendon and skin defects using free chimeric ALT flaps with FL. Methods: Eight patients (one female and seven male) underwent reconstruction of complex hand defects with free chimeric ALT and FL flaps. The defects were caused by crushing injuries, burns, snakebite scars, and animal bite wounds. The average skin defect was 116 cm2. Perforators were selected for the skin paddle and the FL flap. The thinning procedure was performed microsurgically. Results: The skin paddle size ranged from 12 to 23 cm in length and 6 to 11 cm in width, and the FL flaps ranged from 3 × 5 to 12 × 5 cm. The mean pedicle length was 7.88 cm. Nine extensor tendons were repaired with FL flaps. The flap thickness after thinning was only 3-6 mm. The donor site was closed primarily in six patients, and skin grafts were used in two cases. All flaps survived without complications. The follow-up period lasted from 17 to 80 months. Range of motion was achieved with satisfaction. Conclusion: The chimeric-thinned ALT and FL flap is a valuable material, and it should be considered a reconstructive option for hand soft tissue and extensor tendon reconstruction. This technique allows us to achieve a good appearance and extensor function without donor-site morbidity.

3D printing for an anterolateral thigh phalloplasty.

BACKGROUND: Phalloplasty procedures are performed to create a phallus, typically as a gender-affirming surgery for treating gender dysphoria. Due to the controversial nature of this specific procedure, more innovation is needed to directly assist surgical teams in this field. As a result, surgeons are left to improvise and adapt tools created for other procedures to improve surgical outcomes. This study developed a patient-specific 3D printed model from segmented computed tomography (CT) scans to accurately represent the relevant vasculature necessary for anterolateral thigh (ALT) flap phalloplasty. The surgical procedure seeks to maintain intact vessels that derive from the descending branch of the lateral circumflex femoral artery, typically found traveling within the intermuscular septum between the rectus femoris and vastus lateralis. METHODS: In this study, we created and printed 3D models of the leg and vasculature using two techniques: (1) a standard segmentation technique with the addition of a reference grid and (2) a bitmap method in which the total CT volume is colorized and printed. RESULTS: The results gathered included the physician's view on the model's accuracy and visualization of relevant anatomy. Bitmap-printed models resulted in a high amount of detail, eliciting surgeons' undesirable reactions due to the excess of information. The hybrid method produced favorable results, indicating positive feasibility. CONCLUSIONS: This study tested the ability to accurately print a patient-specific 3D model that could represent the vasculature necessary for ALT flap procedures and potentially be used in surgical reference and planning in the future. A surgeon performing phalloplasty procedures discussed their approval of both models and their preference for grid creation and application.

[Interdisciplinary defect reconstruction of upper aerodigestive fistulas-case series and treatment algorithm]. / Interdisziplinäre Defektrekonstruktion bei Fisteln des oberen Aerodigestivtrakts ­ Fallserie und Behandlungsalgorithmus.

BACKGROUND: Persistent complex defects and dysfunctions of the upper aerodigestive tract after tumor surgery represent a major challenge. The aim of this study was to evaluate the effectiveness of an interdisciplinary approach using the free anterolateral thigh flap (ALT) as a reconstruction option in the upper aerodigestive tract. MATERIALS AND METHODS: The retrospective study identified 5 patients with complex defects after laryngectomy/pharyngolaryngectomy (LE/PLE) and multiple revision surgeries between 2017 and 2023. The operations were performed by an interdisciplinary team from otolaryngology, plastic surgery, and visceral/thoracic surgery. The results of the microsurgical reconstruction were analyzed. RESULTS: There was an average of six previous operations. The defects included tracheoesophageal fistulas, pharyngocutaneous fistulas, neopharyngeal stenosis, and combinations thereof. Successful reconstruction was achieved in 100% of patients using the ALT flap. In 2 patients, ALT flow-through flaps were used with an additional free jejunal interposition (JI) and in 3 patients split-ALT flaps were used. The major complication rate was 40% and the minor complication rate was 20%. CONCLUSION: Complex defects of the upper aerodigestive tract with multiple previous operations can be successfully reconstructed. Because of its versatility, the ALT flap seems to be a very good option. Prerequisite for this is an interdisciplinary treatment approach with a critical assessment of patient- and disease-specific factors.

Morpheaform basal cell carcinoma of the nasal ala associated with multiple familial trichoepithelioma reconstructed by anterolateral thigh flap: a case report.

The right nasal ala had been destroyed and was diagnosed as morpheaform basal cell carcinoma associated with multiple familial trichoepithelioma (Brooke-Spiegler syndrome). After extended resection, the right buccal and nasal ala defect was reconstructed with a flow-through type anterolateral thigh (ALT) flap, which achieved good functional and cosmetic results.

Pedicled anterolateral thigh flap: A versatile flap for complex regional defect reconstruction.

Objectives: Soft-tissue defects of the lower abdomen, perineum, groin, and trochanteric area often involve the loss of composite tissue components and are technically challenging to reconstruct. The goals of reconstruction should include the replacement of the defect with a suitable soft-tissue flap that provides stable coverage while protecting important exposed structures. However, there are limited locations in this region for the creation of pedicled flaps for complex defect reconstruction. The pedicled anterolateral thigh (ALT) flap is considered superior to other comparable flaps due to its varying soft-tissue components and long pedicle with consistent anatomy that allow the reconstruction of locations that are difficult to reach without significant flap donor site morbidity. Herein, we present a case series of our experience of using a pedicled ALT flap to reconstruct regional defects over a range of locations. Methods: The present study comprised ten patients who underwent surgical reconstruction of soft-tissue defects of the lower abdomen, groin, trochanteric, scrotal, and penoscrotal defects using a pedicled ALT flap over a two-year period. The flap was customized according to the defect when required. Results: In our case series, flap loss was not observed with only a few minor complications. All patients accepted the aesthetic appearance of the flap recipient site area without requesting revision surgery. The donor site was closed primarily in half of all cases, with split skin grafting applied in the remaining patients. Graft take at the flap donor site was satisfactory in all cases. Conclusion: A pedicled ALT flap is a reliable and suitable option for complex soft-tissue reconstruction for regional soft-tissue defects of the lower abdomen and perineum.

Anterolateral thigh adipofascial flap combined with skin paddle in three-dimension scalp reconstruction: A case report.

INTRODUCTION AND IMPORTANCE: Management of cranial and scalp defects is always challenging. Complication rates following cranioplasty are still high (10-40 %), including bone graft resorption, infection, and T-mesh implant exposure due to thinning of soft tissue (Yeap et al., 2019; Alkhaibary et al., 2020; Cho and Kang, 2017 [1-3]). CASE PRESENTATION: We present a case of a 38-year-old male with autologous bone graft resorption accompanied by thinning of the forehead skin. He underwent cranioplasty with titanium mesh (T-mesh) and scalp reconstruction with an anterolateral thigh (ALT) flap in a single-stage operation. A 2-component ALT flap was used: the skin paddle covered the scalp defect to reduce closure tension, and especially the adipofascial flap lining beneath the forehead skin to increase thickness. Postoperative results were great in terms of coverage function and aesthetics. CLINICAL DISCUSSION: The phenomenon of soft tissue thinning causing titanium mesh exposure is a common complication with a rate of 10-14 % (Yeap et al., 2019; Dong et al., 2020; Maqbool et al., 2018 [1, 4, 5]). Using adipofascial ALT flap as a sub-scalp filler material has many advantages over the latissimus dorsi (LD) flap to increase scalp thickness but still ensure aesthetics. CONCLUSION: The results suggest a new direction in using adipofascial ALT flap as filler material to increase scalp thickness to reduce T-mesh exposure following cranioplasty.

Comparison of outcomes following pedicled and free flap transfers for the defect after shoulder sarcoma resection.

BACKGROUND: Reconstruction after wide resection of a sarcoma arising in the shoulder girdle is challenging, and little evidence is available to compare short-term outcomes between pedicled-flap and free-flap reconstruction. PATIENTS AND METHODS: Thirty-eight patients undergoing immediate reconstruction surgery with only a pedicled-flap (n = 18) and with a free-flap (n = 20) after sarcoma resection on the shoulder girdle between July 2005 and March 2022 were identified. One-to-one propensity score matching was performed to compare the postoperative complications. RESULTS: Transferred flaps survived completely in 20 cases in the free-flap group. In the all-patient analysis of binary outcomes, the occurrences of total complications, takebacks, total flap complications, and flap dehiscence were higher in the pedicled-flap group than in the free-flap group. The propensity score-matched analysis showed the occurrence of total complications was significantly higher in the pedicled-flap group than the free-flap group (53.8% vs. 7.7%, p = 0.03). In the propensity score-matched analysis of continuous outcomes, the pedicled-flap group demonstrated a shorter operation time than the free-flap group (279 vs. 381 min, p = 0.05). CONCLUSIONS: This clinical study demonstrated the feasibility and reliability of a free-flap transfer for the defect after wide resection of a sarcoma arising in the shoulder girdle.

In-Situ 'Divide' and 'Deliver': A Simple Technique to Preserve Nerves in Chimeric Anterolateral Thigh Flap Harvest.

Anterolateral thigh (ALT) flap is the workhorse for reconstruction in head and neck post cancer excision. Chimeric multi-paddle flaps are useful for composite defects involving skin, mucosa, and soft tissue. The nerve to vastus lateralis (VL) runs along the pedicle, frequently interdigitating with it or the perforators. Sometimes, the nerve may be preserved during harvest but needs to be sacrificed frequently, leading to increased donor site morbidity. We recommend a simple technique to preserve the nerve, wherein the skin paddles or chimeric components are divided in-situ and manipulated around it without causing injury. This technique was used in 27 cases over 5 years. All involved nerves, perforators and pedicles were preserved. The technique can be extended to any flap harvest with multiple perforators with nerves in proximity, when multiple skin islands are desired.

Anterolateral thigh flap for abdominal wall reconstruction. A case report.

Abdominal wall reconstruction aims at restoring the anatomical, functional and aesthetic integrity of this region, while providing protection of abdominal viscera and prevent herniation. There are various techniques used for abdominal wall reconstruction. We present a difficult case of abdominal wall reconstruction performed with a pedicled antero-lateral thigh (ALT] flap with good postoperative results.