The accessory vascularization of the tensor fasciae latae muscle: towards a new classification?

PURPOSE: The tensor fasciae latae (TFL) muscle is supplied by the lateral femoral circumflex artery (LCFA), arising from the deep femoral artery. However, it has been noted that there is also a consistent vascular anastomotic network. The aim of this study was to describe the accessory vascularization of the TFL muscle through a descriptive anatomical study, in order to hypothesize the feasibility of harvesting a TFL flap in the event of an injury to the main pedicle. In addition, we illustrate this hypothesis with a successful clinical case of Scarpa freconstruction following ligature of the deep femoral artery. METHODS: The description of the accessory vascularization was obtained by injecting dye into seven lateral femoral circumflex arteries (LCFA), six superficial circumflex iliac arteries (SCIA), and three inferior gluteal arteries (IGA). RESULTS: The TFL muscle was vascularized primarily by the LCFA. A vascular anastomotic network with the SCIA and the IGA was observed. After selective injection to the SCIAs and IGAs, the subsequent injection to the LCFA showed a diffusion of the TFL skin paddle with a perforasome overlapping between the different vascular territories. CONCLUSION: The ascending branch of the lateral femoral circumflex plays a dominant role in the vascularization of the TFL muscle. As a result of a periarticular anastomotic network of the hip, this artery establishes several connections with the proximal arteries. Consequently, in cases where blood flow through the LCFA is interrupted, it should be equally possible to harvest the TFL flap through its accessory vascularization.

Reconstruction of the severe Achilles tendon and soft-tissue loss with the bi-pedicled conjoined flap and vascularized fasciae latae: A consecutive case series of 15 patients.

BACKGROUND: Historically, the segmental loss of the Achilles tendon with overlying soft-tissue defects had been frequently reconstructed with the composite anterolateral thigh (ALTP) flap, including the iliotibial tract or fasciae latae. This study aimed to present our modified combination using the bi-pedicled conjoined flap with vascularized fasciae latae, for the approximately total reconstruction of the Achilles tendon and extensive soft tissue. METHODS: From May 2015 to March 2018, 15 patients (9 male and 6 female) with a mean age of 36 years (ranged, 18-52 years) underwent microvascular Achilles tendon reconstruction. Harvested on the abdomen and groin, the conjoined flap was chimeric with the vascularized fasciae latae. Primary donor-site closure was accomplished in all patients. A standard assessment of the functional and esthetical outcomes was completed. RESULTS: Mean follow-up time was 42 months (ranged, 32-48 months). The average dimension of the conjoined flap was 25 × 14 cm (ranged, 18 × 10-35 × 18 cm), and the average size of the folded fasciae latae was 15 × 6 cm (ranged, 12 × 5-25 × 8 cm). At the last follow-up, the Thompson test was negative in all patients. The mean American Orthopedic Foot and Ankle Society (AOFAS) score was 91.0. The mean Achilles tendon total rupture score (ATRS) was 18.5. The mean Vancouver Scar Scale (VSS) score was 3.0. CONCLUSIONS: The composite bi-pedicled flap including vascularized fasciae latae provides an alternative approach with great functional and esthetic outcomes, in selected patients who suffered severe Achilles tendon and skin defects. The one-stage procedure facilitates better rehabilitation postoperatively.

Predictors of Clinical Outcome after Reconstruction of Complex Soft Tissue Defects Involving the Achilles Tendon with the Composite Anterolateral Thigh Flap with Vascularized Fascia Lata.

BACKGROUND: The composite anterolateral thigh flap with vascularized fascia lata (ALT-FL flap) for covering complex soft tissue defects involving the Achilles tendon has shown promising results. The age and body mass index (BMI) are important predictors of clinical outcome after surgical treatment of Achilles tendon ruptures. In this study, we investigate whether these also influence the outcome of patients after Achilles tendon reconstruction using the ALT-FL flap. METHODS: Twenty patients (mean age: 55.9 ± 8.7 years) with complex tissue defects involving the Achilles tendon underwent reconstruction with the ALT-FL flap. Both the Achilles tendon Total Rupture Score (ATRS) and the American Orthopaedic Foot and Ankle Society (AOFAS) score were assessed preoperatively and 12 months postoperatively. In addition, postoperative magnetic resonance imaging (MRI) studies and measurements of the ankle range of motion were performed and results compared with existing literature. RESULTS: All flaps survived and MRI studies confirmed complete anatomical integration of the fascia lata as "neotendon" at the recipient site. In our patient cohort, the age did not correlate with the outcome measurements, whereas the BMI showed significant negative correlation with the postoperative ATRS (p < 0.001) and AOFAS scores (p < 0.05). The ATRS and AOFAS scores of all patients improved significantly (p < 0.001). However, obese patients with a BMI of more than 30 kg/m2 achieved significant lower ATRS (p < 0.001) and AOFAS scores (p < 0.01), as well as patients with peripheral artery disease (PAD) (p < 0.05). The mean ankle range of motion after ALT-FL flap reconstruction remained statistical insignificant compared with previous avascular or vascularized tendon repairs of the Achilles tendon. CONCLUSION: The ALT-FL flap enables reconstruction of complex tissue defects involving the Achilles tendon with good functional results. However, the presence of an increased BMI or PAD, but not necessarily the age, proves to be a predictor of poor clinical outcome and therefore should be subject to scrutiny during patient selection.

[Effects of anteriolateral thigh perforator flap and fascia lata transplantation in combination with computed tomography angiography on repair of electrical burn wounds of head with skull exposure and necrosis].

Objective: To explore the effects of anteriolateral thigh perforator flap and fascia lata transplantation in combination with computed tomography angiography (CTA) on repair of electrical burn wounds of head with skull exposure and necrosis. Methods: Seven patients with head electrical burns accompanied by skull exposure and necrosis were admitted to our burn center from March 2016 to December 2017. Head CTA was performed before the operation. The diameters of the facial artery and vein or the superficial temporal artery and vein were measured, and their locations were marked on the body surface. Preoperative CTA for flap donor sites in lower extremities were also performed to track the descending branch of the lateral circumflex femoral artery with the similar diameter as the recipient vessels on the head, and their locations were marked on the body surface. Routine wound debridement and skull drilling were performed successively. The size of the wounds after debridement ranged from 12 cm×8 cm to 20 cm×12 cm, and the areas of skull exposure ranged from 8 cm×6 cm to 15 cm×10 cm. Anteriolateral thigh perforator flaps with areas from 13 cm×9 cm to 21 cm×13 cm containing 5-10 cm long vascular pedicles were designed and dissected accordingly. The fascia lata under the flap with area from 5 cm×2 cm to 10 cm×3 cm was dissected according to the length of vascular pedicle. The fascia lata was transplanted to cover the exposed skull, and the anteriolateral thigh perforator flap was transplanted afterwards. The descending branch of the lateral circumflex femoral artery and its accompanying vein of the flap were anastomosed with superficial temporal artery and vein or facial artery and vein before the suture of flap. The flap donor sites were covered by intermediate split-thickness skin graft collected from contralateral thigh or abdomen. Results: The descending branch of the lateral circumflex femoral artery and its accompanying vein were anastomosed with superficial temporal artery and vein in six patients, while those with facial artery and vein in one patient. All the flaps survived after the operation, and no vascular crisis was observed. Wound healing was satisfactory. One patient was lost to follow up. Six patients were followed up for 6 to 10 months. The patients were bald in the head operation area with acceptable appearance. No psychiatric symptom such as headache or epileptic seizure was reported. The flap donor sites were normal in appearance. The muscle strength of the lower extremities all reached grade V. The sensation and movement of the lower extremities were normal. Conclusions: Anterolateral thigh perforator flap with fascia lata transplantation can effectively repair electrical burn wounds of head with skull exposure and necrosis. The fascia lata can be used to protect the vascular pedicle of flaps, which is beneficial to the survival of the flap. Preoperative head and lower extremities CTA can provide reference for intraoperative vascular exploration in donor site and recipient area, so as to shorten operation time.

Single stage functional reconstruction of both peroneal tendons and overlying skin with an anterolateral thigh flap and vascularized fascia lata: A case report.

Reconstruction of complex soft tissue defects in the distal lower leg remains challenging, since anatomical constraints limit the local options available in this area. In this report, we present a case of single stage functional reconstruction of both peroneal tendons and overlying skin with an anterolateral thigh flap and vascularized fascia lata. A 55-year-old patient underwent wide excision of a synovial sarcoma in the distal lower leg, which resulted in a complex defect including the peroneus longus and brevis tendons (10 cm), and the overlying skin (14 × 8 cm). Functional reconstruction was achieved in a single stage with a composite anterolateral thigh flap with vascularized fascia lata of similar dimensions to those of the defect. The fascia lata component of the flap was longitudinally split in two segments. Each of them was rolled up, and that way, two separate vascularized neotendons were created. The neotendons bridged the gap of peroneal tendons, whereas the skin paddle of the flap provided stable soft tissue coverage to the reconstructed tendons. Flap pedicle was anastomosed to the anterior tibial vessels. Early and late postoperative periods were uneventful. Follow up at 1 year postoperatively showed excellent neotendon incorporation, as well as a very good functional and aesthetic outcome. The use of the method described may be a useful alternative in single stage functional reconstruction of composite defects comprising two or even more tendons and the overlying skin.

[Effects of axial vascular network flap of scalp or anterolateral thigh perforator flap with fascia lata on repairing defects after radical resection of scalp carcinoma in patients].

Objective: To observe the effects of axial vascular network flap of scalp or anterolateral thigh perforator flap with fascia lata on repairing defects after radical resection of scalp carcinoma in patients. Methods: From February 2006 to December 2015, twenty-one patients with scalp carcinoma were admitted to our hospital, and the carcinoma invaded external lamina or full-thickness of skull and dura mater. After perfect preoperative examination, carcinoma and scalp tissue in 3 to 5 cm from the edge of carcinoma, external lamina or full-thickness of skull and invaded dura mater were resected and sentinel lymph nodes around carcinoma were cleaned in 3 to 4 days after admission. The postoperative defects with size reached from 11 cm×8 cm to 22 cm×18 cm. The flap transplantation was performed at the same time when quick frozen pathological examination results of resected scalp carcinoma margin tissue, skull, dura mater margin and basal tissue, and sentinel lymph nodes showed completely negative. Defects in 3 elderly patients were repaired by single or multiple axial scalp vascular network flaps, with the resected flaps size ranged from 12 cm×7 cm to 19 cm×14 cm. Defects in the other 18 patients were repaired by anterolateral thigh perforator flaps with fascia lata, with the resected flaps size ranged from 13 cm×10 cm to 23 cm×19 cm and the resected fascia lata size ranged from 8 cm×7 cm to 10 cm×10 cm. The head donor site of flap was repaired by medium thickness skin of head and back; the thigh donor site of flap was repaired by medium thickness skin of thigh on the same side. All patients gave up postoperative radiotherapy, chemotherapy, and other follow-up treatments. Results: After operation, the flap and skin in all patients survived completely, with no vascular crisis or other condition. During the follow-up for 6 months to 9 years, all patients showed good appearance except for baldness in operation area of head, with no obvious malformation in head donor site of flap and skin, no swollen external hernia in the brain tissue, and no local recurrence or distant metastasis of carcinoma. The appearance of thigh donor site of flap and skin was good, with normal muscle strength and movement of lower limbs. Conclusions: Patients with scalp carcinoma were performed with radical resection of carcinoma, and axial vascular network flap of scalp or anterolateral thigh perforator flap with fascia lata were applied to repair the postoperative defects, with good appearance of head operation area and no local recurrence or distant metastasis of carcinoma.

Vascularized Fascia Lata for Prevention of Postoperative Parotid Fistula Arising From Partial Parotidectomy During Neck Dissection.

PURPOSE: Postoperative parotid fistula can occur after partial parotidectomy, which is a routine surgical procedure during neck dissection of oral cancers arising from or close to the oropharyngeal area. The aim of this study was to evaluate the reliability of vascularized fascia lata for the prevention of postoperative parotid fistula after neck dissection. MATERIALS AND METHODS: A retrospective review was conducted of patients with oral cancer who underwent ablative resection involving the parotid tail and reconstruction using the anterolateral thigh (ALT) flap with a vascularized fascia lata paddle. The vascularized fascia lata paddle was used to seal off the parotid stump by tightly suturing the edges of the fascia lata and parotid wound together. RESULTS: Twenty-three patients (18 men and 5 women) with primary oral cancer arising from or close to the oropharyngeal area were enrolled. The mean area of parotid defect was 16.7 cm2 and the mean area of fascia lata harvested was 21.8 cm2. All flaps survived. Pressure dressing or anticholinergic drugs were not used in any case. During the follow-up period, there was no clinical evidence of the development of parotid fistula. CONCLUSION: The vascularized fascia lata paddle is a reliable option for the prevention of postoperative parotid fistula after neck dissection of oral cancer.

The repair of complex penile defect with composite anterolateral thigh and vascularized fascia lata flap.

One-stage reconstruction of complex penile defects with functional and cosmetic results is a challenging procedure. The selection of proper technique and materials for reconstruction depends on the type of the deficient tissue components, the size of the wound surface, and the donor site. This article presented a case of a partial penile and urethral defect due to an infection in the previous surgical site. The patient was treated with a perforator based pedicled composite anterolateral thigh flap combined with vascularized fascia lata. The urethral defect was reconstructed with the vascularized fascia lata. The remaining part of the flap was used for the resurfacing of the right cavernous body and penile skin defect. There was no fistula and the urinary caliber was accepted as good. The pedicled composite anterolateral thigh flap contains various tissue components suitable for a functional and cosmetic reconstruction of complex penile defects using the one-stage technique.

[The plasty for the hip region sores, using the flap, consisting of M. tensor fasciae latae].

The method of plasty for the hip region sores, based on transposition of proximal part of m. tensor fascia latae in content of the flap, using her transsection between place of attachment to spina iliaca anterior superior and place of the main vascular pedicle entry into the muscle, was proposed, what permits to prevent vast mobilization of the muscle and to secure existing in normal conditions and formed in pathological conditions anas- tomoses between vascular net of the flap and surrounding tissues. The method proposed was successfully applied for plasty of the hip region sores of degrees III-IV in 2 patients.

Combined free tissue transfer for the management of composite Achilles defects: functional outcomes and patient satisfaction following thigh-based vascularized reconstruction with a neotendon construct.

BACKGROUND: Functional outcomes and quality-of-life measures following salvage reconstruction of composite Achilles/posterior leg defects are limited. We present our experience with combined Achilles defect reconstruction utilizing free tissue transfer with vascularized neotendon constructs. METHODS: Between 2011 and 2012, six patients underwent vascularized reconstruction of complex Achilles defects by a single surgeon. Demographic and functional data were collected for each patient. Subjective evaluation and quality-of-life measures were obtained preoperatively and postoperatively using American Orthopaedic Foot and Ankle Score (AOFAS) Ankle-Hindfoot and SF-36 scores. Early and late complications were noted for each case. RESULTS: All defects were reconstructed utilizing vascularized composite free tissue from the thigh. Average soft tissue defect was 76.7 cm(2) (range, 40-90 cm2) with a tendon gap of 7.8 cm (range, 5-10 cm). Mean follow-up was 17 months (range, 15-23 months). Flap survival was 100%. Overall range of motion of the reconstructed side was 82% of the unaffected side (48.2 degrees vs. 59 degrees, p = 0.004). Average percent increase in AOFAS and SF-36 scores were 71% (54 vs. 93, p = 0.0005) and 22% (86 vs. 104, p = 0.003), respectively. Operative revision was required for two patients with delayed-onset soft tissue infections and one donor site hematoma. Distal flap ischemia was managed with hyperbaric oxygen therapy in one patient. Functional and esthetic outcomes were judged good to excellent by all patients. CONCLUSIONS: Free tissue transfer with vascularized tendon reconstruction is a viable option for combined Achilles tendon/posterior leg defects, as both functional and quality-of-life measures appeared to be significantly improved at 1-year follow-up.

Surgical technique: Gluteus maximus and tensor fascia lata transfer for primary deficiency of the abductors of the hip.

BACKGROUND: Avulsion of the abductor muscles of the hip may cause severe limp and pain. Limited literature is available on treatment approaches for this problem, and each has shortcomings. This study describes a muscle transfer technique to treat complete irreparable avulsion of the hip abductor muscles and tendons. DESCRIPTION OF TECHNIQUE: Ten adult cadaver specimens were dissected to determine nerve and blood supply point of entry in the gluteus maximus and tensor fascia lata (TFL) and evaluate the feasibility and safety of transferring these muscles to substitute for the gluteus medius and minimus. In this technique, the anterior portion of the gluteus maximus and the entire TFL are mobilized and transferred to the greater trochanter such that the muscle fiber direction of the transferred muscles closely matches that of the gluteus medius and minimus. METHODS: Five patients (five hips) were treated for primary irreparable disruption of the hip abductor muscles using this technique between January 2008 and April 2011. All patients had severe or moderate pain, severe abductor limp, and positive Trendelenburg sign. Patients were evaluated for pain and function at a mean of 28 months (range, 18-60 months) after surgery. RESULTS: All patients could actively abduct 3 months postoperatively. At 1 year postoperatively, three patients had no hip pain, two had mild pain that did not limit their activity, three had no limp, and one had mild limp. One patient fell, fractured his greater trochanter, and has persistent limp and abduction weakness. CONCLUSIONS: The anterior portion of the gluteus maximus and the TFL can be transferred to the greater trochanter to substitute for abductor deficiency. In this small series, the surgical procedure was reproducible and effective; further studies with more patients and longer followup are needed to confirm this.

The inferior gluteal artery myocutaneous flap with vascularized fascia lata to reconstruct extended abdominoperineal defects.

UNLABELLED: Abdominoperineal resections have evolved to the point where increasing amounts of skin and pelvic floor are removed, resulting in extensive defects. Many patients receive neoadjuvant chemoradiotherapy and may require adjuvant treatment; thus, primary wound healing is essential. Existing reconstructive techniques may be inadequate and predispose to postoperative complications including wound breakdown and perineal herniation. The authors have developed a novel innervated gluteal flap reconstruction with significant advantages, including preservation of abdominal wall integrity, prone harvest, reliable vascularity, bulky volume, and tailored inset. This robust technique addresses all components required for successful perineal reconstruction comprising dead space obliteration, reconstruction and maintenance of perineal floor integrity, and importation of nonirradiated skin to facilitate primary wound healing. Indications can be extended to include reconstruction of the posterior vaginal wall and large sarcoma/sacrectomy defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Usefulness of the anterolateral thigh flap with vascularized fascia lata for reconstruction of orbital floor and nasal surface after total maxillectomy.

OBJECTIVES/HYPOTHESIS: The aim of this study was to describe a technique using the fascia lata (FL) component of the anterolateral thigh (ALT) flap to re-create the orbital floor and lateral nasal wall after total maxillectomy. STUDY DESIGN: Retrospective analysis of medical records. METHODS: A total of 22 patients underwent maxillary reconstruction using a composite ALT-FL flap following cancer resection. All patients underwent total maxillectomies via the Weber-Ferguson approach. The ALT flap was harvested with the deep fascia of the thigh with the aim of using it for lining of the orbital floor and lateral nasal cavity. The FL was sutured to the palatine bone inferiorly, nasal bone and zygomatic bone superiorly, and nasopharyngeal mucosa posteriorly to provide an orbital floor and make a neonasal cavity. RESULTS: There was 100% free flap survival. Speech was normal in eight (36%) patients, near normal in 10 (46%), and intelligible in four (18%). Seventeen (77%) patients gained a good facial appearance, and five (23%) a fair appearance. Sixteen (73%) patients complained of mild nasal crust formation, and the rest (27%) developed moderate crust. CONCLUSIONS: Microvascular reconstruction using a composite ALT-FL flap provided a reliable fascial component for orbital floor and nasal surface reconstruction of total maxillectomy defects.

Donor site morbidity of an islanded inferior gluteal artery myocutaneous flap with vascularized fascia lata.

UNLABELLED: The perineal defect following extended abdominoperineal resection (APR) is commonly reconstructed with a pedicled vertical rectus abdominus muscle (VRAM) flap. To avoid unnecessary insult to the abdominal wall the authors have preferred an islanded inferior gluteal artery myocutaneous (IGAM) flap with vascularized fascia lata. The gluteal region is not without its own documented morbidity concerns which in this patient demographic is further complicated by nearby irradiated tissue and oncological surgery. This prospective review examines the donor site morbidity of patients following modified IGAM flaps. MATERIAL & METHODS: The records of all APR patients who had IGAM flap reconstruction performed by the senior author (August 2008-August 2012) were retrospectively reviewed for outcomes and complications, and then prospectively followed-up using a purpose-specific assessment tool. Outcome measures included (i) wound healing, (ii) posterior cutaneous nerve of the thigh (PCNT) and sciatic nerve function, (iii) gluteus maximus (GM) and tensor fascia lata (TFL) strength, and (iv) post-operative functional levels assessed using the 'Timed-Up-and-Go' (TUG) test and Oswestry Disability Index. RESULTS: Of the 35 patients who satisfied the inclusion criteria 32/35 (91%) patients completed the prescribed follow-up. The average age was 62 years (range 22-82) and mean follow-up period was 10.5 (range 3-32) months. All patients had rectal cancer and received neoadjuvant chemoradiotherapy, and all except two reconstructions were performed primarily. There were 3 cases (9%) of wound dehiscence none of which were attributed to wound infection or haematoma. Scar tenderness in 5 patients (16%) was the most common post-operative complaint. PCNT hypoesthesia affected 10/32 (31%) patients while there was no significant GM or TFL weakness. Mean TUG time was 9.6 (range 3.2-15) seconds, while mean ODI score was 6.6 (range 0-40). CONCLUSIONS: In spite of challenging circumstances the IGAM flap can provide appropriate wound coverage with surprisingly little donor site morbidity contrary to previous reports.

Free anterolateral thigh fascia lata flap for complex nasal lining defects.

OBJECTIVE: To introduce a novel technique for the reconstruction of complex nasal lining defects using the free vascularized anterolateral thigh fascia lata flap. METHODS: Free anterolateral thigh fascia lata flaps were used to replace nasal lining in 5 patients with total or subtotal rhinectomy defects. We performed a retrospective medical record review. RESULTS: No flap failure or lining loss was observed, and harvest site morbidity was negligible. Patients achieved satisfactory nasal form and patent nasal airways without a need for repeated revisions. In 2 patients, the anterolateral thigh flap was used simultaneously to restore the midface contour or to repair anterior skull base defects. CONCLUSIONS: In this case series, we demonstrate the novel use of vascularized fascia lata to provide viable nasal lining in total and subtotal nasal defect reconstruction. Potential advantages offered by this technique compared with more established methods include (1) single-stage replacement of nasal lining, structure, and skin coverage; (2) fewer additional stages of reconstruction to achieve functional and aesthetic results; (3) thin lining to allow for optimal airway contour; (4) less harvest site morbidity; and (5) development of composite soft tissue, cutaneous, and/or muscle flaps to repair adjacent defects.

Reconstruction of the Achilles tendon and overlying soft tissue by free composite anterolateral thigh flap with vascularized fascia lata.

Segmental loss of the Achilles tendon with overlying soft tissue and skin defect remains a complex reconstructive challenge. Successful reconstruction combines tendon repair with coverage of the defect by soft tissue flaps, creating an entity that meets up to three predetermined goals: (1) approaching preinjury functionality, (2) resisting shearing forces, and (3) achieving an esthetic result. From June 2009 to June 2011, our center submitted six patients to a one-stage procedure correcting the Achilles tendon using a composite free anterolateral thigh (ALT) flap with vascularized fascia lata. The flap sizes ranged from 5 to 8 cm in width and 16 to 20 cm in length and all flaps included vascularized fascia lata which was rolled to serve as an Achilles tendon. After reconstruction our patients showed good functional results, these patients could walk, climb stairs, and tiptoe again without support. Moreover, normal footwear could be worn. A free composite ALT flap with vascularized fascia lata is a reliable option for coverage of Achilles tendon and overlying soft tissue defects, even in elderly patients.

The harvesting and insetting of a chimeric anterolateral thigh flap to reconstruct through and through cheek defects.

This technical note describes the harvesting and insetting of a chimeric anterolateral thigh (ALT) flap to reconstruct a through and through cheek defect. Two perforators originating from the lateral circumflex femoral system that joined to the same mother vascular source were identified. Two separate skin paddles based on the perforators were designed and appropriately inset to repair the mucosal lining and the cheek skin. Careful harvesting and insetting of the chimeric ALT flap ensures a good cosmetic and reconstructive effect in the reconstruction of the through and through cheek defect.