A simplified classification and economical application of anterolateral thigh flap.

BACKGROUND: Anterolateral thigh (ALT) flaps have several anatomical variations and clinical uses. Here, a simplified classification and economical application are introduced. METHODS: A total of 168 ALT flap reconstructions performed between January 2013 and December 2016 were reviewed. Vascular anatomy of the flaps was classified into 5 types: type I (single perforator from the transverse branch), type II (single perforator from the descending branch), type III (multiple perforators from the transverse branch), type IV (multiple perforators from the descending branch), and type V (multiple perforators from both branches). Furthermore, flaps harvested via preservation of the proximal perforator were compared with those that were not. RESULTS: Vascular classification revealed that type IV (50.0%) and type V (32.1%) flaps were the most commonly used. Of these, 50.0% of type IV and 79.6% of type V were harvested as proximal-perforator-preserving distal ALT flaps. The proximal-perforator-preserving group had a smaller flap size (104.4 ± 84.3 cm2 versus 145.9 ± 94.1 cm2, p = 0.003), shorter reconstruction time (266.3 ± 76.1 min versus 302.0 ± 103.0 min, p = 0.013), and fewer donor-site complications (2.4% versus 13.3%, p = 0.009) than the traditional group, whereas the flap success rate was comparable (96.5% versus 96.4%) between them. Five cases received a second ALT flap from the same donor site after 3 failures and 2 metachronous defects. CONCLUSIONS: Multiple perforators in ALT flaps allow the harvesting of 2 ALT flaps from the same donor-site metachronously. Our classification and applications can improve efficiency while reducing donor-site morbidity.

Oral Squamous Cell Carcinoma Metastasis to Anterolateral Thigh Flap Donor Site: A Case Report.

In the realm of oncologic reconstructive surgery, local or distant autologous tissue is frequently used to improve function and appearance. Due to advances in microsurgery and intensive care, reconstructive free flap surgery has become the standard treatment for head and neck cancer. However, the complexity of interdisciplinary intervention and prolonged surgical time inevitably increase the risk of cross-contamination, potentially leading to donor site metastasis. According to the literature, tumor transmission to the donor site of free flaps is extremely rare. We present the case of a 54-year-old man with left tongue squamous cell carcinoma. Three months after tumor ablation and reconstruction with a free anterolateral thigh flap, the patient presented with a mass on the donor site of the left thigh, which was proven to be a metastasis. A systemic workup revealed multiple metastases. Six months after reconstruction, the patient died of COVID-19 pneumonia. The incidence and risk factors of donor site metastasis are not well known. The primary causes are direct implantation or hematogenous spread. Cross-contamination is primarily prevented by the surgeon's awareness and avoidance. The development of new-onset lesions at the donor site warrants additional testing to detect systemic disease progression during follow-up.

Impact of fibula osteoseptocutaneous flap laterality in mandibular and intraoral reconstruction.

BACKGROUND: The fibula flap has been the workhorse flap for mandibular reconstruction. However, relationships among the bone, skin, and vessels raise concerns about donor-side selection. This study aimed to clarify its impact on clinical outcomes. METHODS: Between September 2013 and June 2021, 61 cases of fibula osteoseptocutaneous flaps for mandibular and intraoral reconstruction were categorized into the landing-down (N = 25) and swing-up (N = 36) groups depending on whether the skin was easily accessible within the oral cavity. The demographics, operative findings, and outcomes of the cases were compared. RESULTS: Overall, seven (11%) flaps developed skin necrosis, including four partial and three total necrosis. The skin necrosis rate was higher in the swing-up than in the landing-down group (19% vs. 0%, p = 0.035). CONCLUSIONS: When using the fibula osteoseptocutaneous flap for mandibular and intraoral reconstructions, ensuring that the skin is properly located within the oral cavity could reduce the risk of skin necrosis.

Comparison of outcomes between circumferential and near-circumferential pharyngoesophageal reconstruction using anterolateral thigh flap.

A leftover narrow strip of the posterior pharyngeal wall may form after laryngopharyngectomy, and whether to retain it during reconstruction remains debated owing to the differing views on the incidence of leakage and strictures. This study aimed to ascertain whether this remnant posterior pharyngeal wall is advantageous or disadvantageous to surgeons performing pharyngoesophageal reconstruction. We reviewed the data of patients with circumferential or near-circumferential pharyngoesophageal defects following oncological laryngopharyngectomy who underwent reconstructive surgery utilizing the anterolateral thigh flap. They were then categorized into two groups: circumferential and near-circumferential. Thereafter, their demographics, operative findings, and postoperative outcomes were compared. Forty patients (20 in each group) with an average age of 57.2 ± 6.7 years (range: 40-72) were enrolled in the study. All flaps except one survived. During a mean follow-up of 41.1 ± 24.6 (range: 6-95) months, the stricture rate was significantly lower in the near-circumferential group (one vs. nine [from 17 patients who had resumed oral intake postoperatively] patients in the near-circumferential and circumferential groups, respectively, p = 0.002). Oral intake was viable in all patients with near-circumferential defects but only in 11 patients with circumferential defects (p = 0.003). The near-circumferential group had fewer strictures and better tolerance of oral nutrition, supporting the incorporation of the residual posterior pharyngeal wall via near-circumferential reconstruction instead of discarding it to facilitate circumferential reconstruction.

Functional Chimeric Double-barrel Fibula and Reinnervated Peroneus Brevis Osteomyocutaneous Flap for One-stage Forearm Reconstruction.

Reconstructing a mangled limb is complex and requires expertise in both bone and soft-tissue reconstruction, particularly when there is significant muscle loss. Typically, multistage surgery is necessary, starting with soft-tissue coverage, followed by bone grafting and tendon transfers. Sometimes, microsurgical techniques such as vascularized bone grafts and free functional muscle transfers are necessary, especially when there is a bone defect of over 6 cm; the soft-tissue environment is infected, scarred, or poorly vascularized; or there are extensive musculotendinous injuries. We treated a 34-year-old man who had a crushed left forearm resulting in an 18 × 8 cm open wound, 5-cm radius and 7-cm ulna bone defects, loss of the extensor pollicis longus and brevis muscles, and extensive injuries to the other musculotendinous structures of the forearm. To accomplish a one-stage reconstruction, we used a chimeric fibula osteomyocutaneous flap that included a 20 × 10 cm skin flap, peroneus brevis muscle with its motor nerve, and two segments of fibula. The proximal and distal fibula segments were used for ulnar and radial bone reconstruction, respectively, preserving forearm supination and pronation. The peroneus brevis tendon was sutured to the extensor pollicis longus tendon, and its motor nerve was coaptated with the posterior interosseous nerve to restore thumb extension. The skin flap provided complete coverage of all exposed bone and tendon structures. At the 12-month follow-up, the patient regained full extension of the thumb, and there were no difficulties with forearm supination and pronation or with foot eversion and plantar flexion at the donor leg.

Plate-related complication and health-related quality of life after mandibular reconstruction by fibula flap with reconstruction plate or miniplate versus anterolateral thigh flap with reconstruction plate.

BACKGROUND: Plate-related complications are major long-term complications in mandible reconstruction. There are controversies regarding the use of a reconstruction plate versus miniplates and a bone flap versus a soft tissue flap with a bridging plate. Direct comparisons of a fibula flap and an anterolateral thigh flap, the applicability between a reconstruction plate and miniplate, and the correlation between plate-related complications and quality of life remain unclarified. Therefore, this study aimed to the explore complications of different flaps and plates and how they impact the patients' quality of life. METHODS: We retrospectively reviewed the medical records of a total of 205 patients aged >18 years who underwent segmental mandibulectomy and reconstruction using fibula flap with reconstruction plate (FR; n = 86), fibula flap with miniplate (FM; n = 61), and anterolateral thigh flap with reconstruction plate (AR; n = 58) due to cancer ablation, osteoradionecrosis, or benign tumor excision between August 2010 and December 2019. Data on characteristics, complications, and health-related quality of life were collected and analyzed. RESULTS: The plate-related complication rate was the highest in the AR group (37.9%), then in the FR group (25.6%), and was the lowest in the FM group (13.1%; p = 0.0079). The plate exposure rate was the highest in the AR group (24.1%), then in the FR group (15.7%), and was the lowest in the FM group (4.9%; p = 0.0128). The plate fracture and dislodge rates for the AR group were both higher than those for the FR and FM groups (24.1% versus 9.3% versus 9.8%, respectively; p = 0.023). The AR group had worse complication-free survival (hazard ratio [HR]: 3.61, 95% CI: 1.99-6.56, and p < 0.0001) than the FR and FM groups. Osteoradionecrosis (HR: 6.19, 95% CI: 2.11-18.21, and p = 0.0009) and postoperative radiotherapy (HR: 2.87, 95% CI: 1.34-6.12, and p = 0.0402) were both independent adverse factors for complication-free survival, whereas patient treated primarily (HR: 0.35, 95% CI: 0.17-0.73, and p = 0.0048) was an independent protective factor. Plate-related complication negatively impacted the quality of life based on pain scores (ß: -0.56, SE: 0.26, and p = 0.034). CONCLUSIONS: Using a fibular flap fixed with miniplates and avoiding the use of a reconstruction plate may yield a reduced plate exposure rate and better health-related quality of life, particularly for patients with osteoradionecrosis or those who need postoperative radiotherapy.

Chimeric Anterolateral Thigh Flap for One-stage Reconstruction after Cervical Exenteration with Anterior Mediastinal Tracheostomy.

Cervical exenteration with anterior mediastinal tracheostomy is rarely performed for extensive cervicothoracic malignancies. Although it provides effective palliation and occasional cure, reconstruction remains a formidable challenge owing to its complexity and high mortality. The resultant defects usually require an intestinal flap or tubed skin flap to restore the alimentary tract, soft-tissue interposition to separate the relocated trachea from the innominate artery, and another tubed or fenestrated skin flap to create a tension-free tracheocutaneous anastomosis and provide coverage for the exposed vessels, hopefully in one stage. We report a case involving a 60-year-old woman with recurrent medullary thyroid cancer who developed dyspnea and dysphagia. Salvage cervical exenteration and anterior mediastinal tracheostomy were complicated by tissue fibrosis caused by previous surgical and radiation therapies, resulting in complex defects with segmental loss of the esophagus, a short stump of trachea incapable of tracheocutaneous anastomosis, and great-vessel exposure. We used a chimeric anterolateral thigh flap consisting of a tubed skin flap for pharyngoesophageal reconstruction, a fenestrated skin flap for tracheostomy and neck coverage, and a vastus lateralis muscle bulk to separate the innominate artery from the relocated trachea. To our knowledge, this is the first report describing the reconstruction of such a complex defect with a single skin flap in a single stage.

Giant Basal Cell Carcinoma of the Axilla: 8-year Follow-up of a Case Treated with Excision, Vismodegib, and Radiotherapy.

Axillary giant basal cell carcinoma is extremely rare and remains challenging for physicians. The few reported cases have a relatively short-term follow-up, and none were treated with an oral hedgehog pathway inhibitor. Herein, we report the case of a 71-year-old man with a giant basal cell carcinoma in the axilla. The primary treatment instituted was surgical excision and adjuvant radiotherapy. The tumor recurred 4.5 years later, and 6-month treatment with vismodegib, a hedgehog pathway inhibitor, was effective. The disease progression re-occurred 1.5 years after discontinuing vismodegib. Palliative radiotherapy was administered, and the disease remained stable for > 1 year. Our case illustrates a rare disease with an 8-year follow-up, involving different therapeutic strategies against multiple recurrences. J Drugs Dermatol. 2022;21(5):531-533. doi:10.36849/JDD.6583.

Anterolateral Thigh Flap for Low-Voltage Fourth-Degree Electrical Burn Injury With Immediate Radial Nerve Palsy at the Elbow: A Case Report.

While high-voltage electrical injuries usually cause severe burn wounds and axonal polyneuropathy, low-voltage electrical injuries cause limited cutaneous wounds and demyelinating mononeuropathy, of which the median and ulnar nerves are the most commonly involved. We present the case of a 42-year-old man who suffered a 480-voltage electrical injury at his right elbow, resulting in a 24 × 10 cm fourth-degree burn wound and immediate radial nerve palsy. The burn wound was debrided with confirmation and preservation of radial nerve continuity. The wound was covered with a free anterolateral thigh flap and it healed uneventfully. The Tinel's sign continued to advance at follow-up, and electrodiagnostic studies showed progressive reinnervation. His radial nerve function recovered completely in 9 months. This is a rare case of low-voltage electrical injury with a fourth-degree burn wound and immediate radial nerve palsy. We treated the wound aggressively with early debridement and prompt flap coverage, but conservatively treated the radial nerve injury. The nerve recovery course indicates that it had a "shocked-cooked" injury and served itself as a well-placed nerve graft for the subsequent regeneration. We believe that our successful outcome in this case can provide more insights into the management of such injuries.

Simplifying the Combined Use of Fibula Flap and Anterolateral Thigh Flap for Oromandibular Reconstruction.

Although the preferred technique for reconstruction of extensive composite oromandibular defects involves the use of a fibula flap for the inner mucosal lining and mandibular bone reconstruction and an anterolateral thigh flap for outer skin coverage and soft tissue replenishment, this approach is complicated and manpower-dependent. It also often involves prolonged operations requiring nighttime surgery with insufficient manpower in an era of restricted working hours for residents, which can negatively affect the surgical outcomes. Traditionally, the mucosal defect is first defined and the fibula flap is then dissected to ensure a size-matching skin flap for the inner lining. This flap is transferred first after mandibulectomy is completed, but is delayed by the fibula bone shaping process. Finalizing the flap inset is a sophisticated process involving the fibula bone, fibula skin, and anterolateral thigh skin. Thus, we developed a strategy to overcome the late start of fibula flap harvest, the delayed initiation of defect-site reconstruction, and the troublesome flap inset. Briefly, we dissected both flaps sequentially or simultaneously from contralateral limbs before the mucosal defect was defined, so that the flaps were ready in the daytime. Once the mandibulectomy was completed, we transferred the anterolateral thigh flap first while the fibula bone was shaped, and simplified the flap inset by using the anterolateral thigh skin for the inner lining and outer coverage and the fibula skin as a monitoring flap. We employed this approach in five patients and completed postmandibulectomy reconstruction in as fast as 4 hours.

Dynamic Traction Splint as an Alternative Surgical Treatment for Comminuted Intraarticular Fracture of Metacarpophalangeal Joint.

BACKGROUND: Comminuted intraarticular fractures of the metacarpophalangeal joint (MPJ) are difficult to treat. We evaluated the clinical outcomes of using a dynamic traction splint to treat comminuted intraarticular fracture of MPJ. PATIENTS AND METHODS: We conducted a retrospective chart review on patients with comminuted intraarticular fracture of the MPJ treated with a dynamic traction splint at National Cheng Kung University Hospital between March 2014 and February 2018. The surgical procedures consisted of a transverse Kirschner wire insertion and treatment for concomitant injuries. The patients then received staged regular rehabilitation programs under a hand therapists' supervision for 14 weeks. Active range of motion (ROM) of injured digits, Visual Analog Scale score for pain, and return-to-work status were recorded to evaluate functional outcomes. RESULTS: A total of 10 patients were included. All were male patients and aged 8 to 66 years. The most common injury mechanism was motor vehicle accident (70%). The locations of fractures were 1 at the metacarpal head and 9 at the proximal phalangeal bases. Half of the fractures were open. Concomitant injuries were 1 digital nerve severance, 1 extensor tendon rupture, and 3 dorsal skin avulsions. There were no postoperative complications. The active ROM of the MPJ ranged from 40° to 90° with a median ROM of 80°. The Visual Analog Scale score for pain was 0 in 8 patients and 1 in the other 2 patients. All patients returned to their original workplace after rehabilitation. CONCLUSIONS: Dynamic traction splints and postoperative rehabilitation programs could be an alternative treatment for comminuted intraarticular fracture of the MPJ.

Use of Anterolateral Thigh Flap and Fibula Flap in Oncologic Maxillary Reconstruction: An Algorithm Approach.

BACKGROUND: Maxillary defects after oncologic resection can lead to not only cosmetic deformity but also functional problem. Reconstruction of maxillary defects remains the most challenging endeavor for plastic surgeons. An algorithm to guide plastic surgeons in selecting either the anterolateral thigh flap or the fibula flap for oncologic maxillary reconstruction has not been well established. METHODS: Patients who underwent oncologic maxillectomy and free flap reconstruction from August 2012 to April 2018 were enrolled for retrospective chart review. Their operative findings and postoperative outcomes were analyzed as a case series. The reconstructive plan was decided using the 4 essential components in sequence: the anterior maxillary arch, orbital floor, eyeball, and oro-sinonasal communication, which are the main considerations in the established classification systems. Accordingly, when the anterior maxillary arch was lost or when the orbital floor was lost with eyeball preservation, a fibula flap was used. Otherwise, an anterolateral thigh flap was used. RESULTS: Various maxillectomy defects were successfully reconstructed using an anterolateral thigh flap and a fibula flap. The defect types and corresponding reconstruction were fit into our proposed algorithm and classification. The corresponding outcomes were satisfactory. CONCLUSION: The proposed algorithm by using the anterolateral thigh flap and the fibula flap for oncologic maxillary reconstruction is feasible, simple, and effective.

Treatment outcomes for one-stage concurrent surgical resection and reconstruction of synchronous esophageal and head and neck squamous cell carcinoma.

PURPOSE: It is not uncommon to see the synchronous presentation of esophageal squamous carcinoma (ESCC) and head and neck cancer (HNC), and most patients were treated with staged interventions. This study retrospectively reported the outcomes of patients with synchronous ESCC and HNC treated with one-stage concurrent surgical resection and reconstruction. METHODS: We identified 17 consecutive patients with synchronous ESCC and HNC undergoing primary concurrent surgical resections between 2011 and 2017 at our hospital. All patients had received esophageal screenings prior to treatment. RESULTS: The HNC patients in this study had the following subsite involvements: oral cavity (n = 5), oropharynx (n = 4), larynx (n = 1), hypopharynx (n = 9), and thyroid gland (n = 1). Eighty percent of the HNC subsites (16/20) were treated in advanced stages, while most ESCCs were treated at early stages. The mean follow-up time was 3.2 ± 1.6 years. Surgery-associated morbidity and mortality were 94.1% and 0%, respectively, and the most common complication was anastomotic leakage. The two-year overall survival, 2-year loco-regional recurrence-free survival, and 2-year distant metastasis-free survival were 86.7%, 85.6%, and 78.7%, respectively. No significant difference was found between overall survival and HNC subsite or anastomotic leakage. Four patients (23.5%) developed secondary primary malignancies (SPMs) within a mean follow-up period of 2.9 years (standard deviation 1.6 years). CONCLUSION: Although one-stage concurrent surgical resection and reconstruction of synchronous ESCC and HNC were highly invasive and complicated, survival was promising. Isolated distant metastasis remained the most common failure pattern. Vigilant follow-up strategy is mandatory to detect secondary primary malignancies (SPMs), especially within the first 3 years following initial treatment.

Tumor Endothelial Marker 1 (TEM1/Endosialin/CD248) Enhances Wound Healing by Interacting with Platelet-Derived Growth Factor Receptors.

Tumor endothelial marker 1 (TEM1), also known as endosialin or CD248, is a type I transmembrane glycoprotein containing a C-type lectin-like domain. It is highly expressed in pericytes and fibroblasts. Dermal fibroblasts play a pivotal role during cutaneous wound healing, especially in the proliferative phase. However, the physiological function of TEM1 in wound healing is still undetermined. During the process of wound healing, the expression of both TEM1 and platelet-derived growth factor (PDGF) receptor α was highly upregulated in myofibroblasts. In vivo, fibroblast activation and collagen deposition in granulation tissues were attenuated, and wound healing was retarded in TEM1-deleted mice. In vitro, the migration, adhesion, and proliferation of NIH3T3 cells were suppressed following TEM1 knockdown by short hairpin RNA. In PDGF-BB-treated NIH3T3 cells, the downstream signal and mitogenic, and chemoattractive effects were inhibited by TEM1 knockdown. In addition, TEM1 and PDGF receptor α were colocalized in subcellular organelles in fibroblasts, and the association of TEM1 and PDGF receptor α was demonstrated by coimmunoprecipitation. In summary, these findings suggested that TEM1, in combination with PDGF receptor α, plays a critical role in wound healing by enhancing the mitogenic and chemoattractive effects of PDGF-BB and collagen deposition in myofibroblasts.

Esophageal reconstruction after oncological total laryngopharyngoesophagectomy: Algorithmic approach.

BACKGROUND: Reconstruction for total laryngopharyngoesophagectomy is accomplished mainly by gastrointestinal transposition but can be complicated by anastomotic tension or associated neck-skin defect. Here, we present the results of total esophageal reconstruction by gastrointestinal transposition alone or with additional free tissue transfer and propose an algorithm accordingly. METHODS: We reviewed patients who had oncologic total laryngopharyngoesophagectomy between January 2012 and January 2016. Twenty-four men and one woman were included with a mean age of 54 (range, 41-72) years. Patients were grouped by reconstruction into the gastric pull-up (GP, n = 15), colon interposition (CI, n = 2), GP combined with free jejunal flap (GPFJ, n = 6), or GP combined with anterolateral thigh flap (GPALT, n = 2) group to compare clinical outcomes. RESULTS: The mean operation time was 1037.3 minutes and was significantly longer in the GPALT group than in the GP group (1235.0 ± 50.0 minutes vs. 929.7 ± 137.7 minutes, p =.009). All flaps survived. After a mean follow-up of 18 months, the overall leakage, stricture, and successful swallowing rates were 44%, 4%, and 76%, respectively. There was no significant difference in the leakage (53.3%, 50.0%, 16.7%, and 50.0%, p =.581), stricture (6.7%, 0%, 0%, and 0%, p = 1.000), or successful swallowing (73.3%, 50.0%, 83.3%, and 100%, p =.783) rates between GP, CI, GPFJ, and GPALT groups, respectively. CONCLUSIONS: The proposed algorithm that ranks gastric pull-up as a priority and uses additional free tissue transfer to overcome the anastomotic tension or associated neck-skin defect is feasible.

Comparison of flap outcomes between single- and multiple-perforator-based free anterolateral thigh flap in head and neck reconstruction.

INTRODUCTION: The number of perforators required for safe perfusion remains under debate. This study aimed to determine whether a single- or multiple-perforator-based anterolateral thigh flap yields better flap outcomes in head and neck reconstruction. PATIENTS AND METHODS: Between August 2012 and July 2016, 180 men and 4 women with a mean age of 52.8 ± 9.8 years underwent head and neck anterolateral thigh flap reconstruction for oncologic defect in 181 cases, plate exposure in two cases, and trismus release in one case. The flap was patched for inner or external lining, folded for through-through defect, or tubed for cervical esophageal reconstruction. Of 184 flaps, 136 (73.9%) were based on multiple perforators (range, 2-5 perforators), whereas 48 (26.1%) were based on a single perforator. The demographics, operative findings, and flap outcomes were compared. RESULTS: The prevalence of systemic diseases between groups was comparable. The mean flap size in the single-perforator group was smaller (92.8 ± 36.8 vs. 140.5 ± 99.9 cm2 , P < .0001). Twenty-one flaps (11.4%) required emergency take-back and 13 (61.9%) were successfully salvaged. Eight flaps failed, yielding a 95.7% flap survival rate. The single-perforator group had a significantly higher rate of emergency take-back for vascular compromise (8/48 (16.7%) vs. 8/136 (5.9%), P = .035), a decreased salvage success rate (2/8 (25.0%) vs. 11/13 (84.6%), P = .018), and a corresponding lower flap survival rate (42/48 (87.5%) vs. 134/136 (98.5%), P = .004). CONCLUSION: Whenever possible, we recommend including multiple cutaneous perforators in anterolateral thigh flaps to yield better flap outcomes in head and neck reconstruction.

Surgical Algorithmic Approach to Facilitate Primary Closure of the Anterolateral Thigh Flap Donor Site in Head and Neck Reconstruction.

BACKGROUND: Use of the anterolateral thigh (ALT) flap has gained popularity in head and neck reconstruction. However, donor sites that cannot achieve primary closure are reported to have poorer functional and aesthetic outcomes. Therefore, we propose an algorithm to facilitate primary closure of the donor site. METHODS: Since May 2013, when an attempt at donor site direct closure failed, we have used a VY advancement flap or a propeller flap for primary closure of the donor site, using the remnant lateral thigh perforator or nearby medial thigh perforator. Otherwise, a skin graft was used. A total of 91 patients were enrolled in this algorithmic approach. We retrospectively reviewed patients with head and neck cancer who underwent cancer ablation and immediate ALT flap reconstruction since August 2010. The patients were then categorized into a "before" group and an "after" group according to the application time of the algorithm. Their demographics, intraoperative findings, and postoperative outcomes were analyzed. RESULTS: A total of 321 patients (309 men, 12 women) were enrolled, with 230 patients in the before group and 91 patients in the after group, with a mean age of 52.9 years. The mean size of the flap was 130 cm, with a mean width of 8.1 cm. No statistical difference existed between the groups. The donor site was directly closed in 82 patients (35.7%) in the before group. Using the perforator-based flap in 21 patients (23.1%), the donor site was closed primarily in 72 patients (79.1%) in the after group, contributing to a significantly higher donor site closure rate (P < 0.001). The average operative time was 348.7 minutes. The overall flap survival rate was 97.2%, donor-site complication rate was 6.9%, and hospitalization length was 23.5 days. None showed statistical differences between the groups. CONCLUSIONS: The proposed algorithm may considerably increase the primary closure rate of the ALT flap donor site.

Temporary Ectopic Implantation of an Amputated Leg Using the Distal Runoff Vessel of the Anterolateral Thigh Flap Followed by Subsequent Prefabricated Chimeric Replantation.

AIM: Infrapopliteal replantation is indicated in selected patients. When the patient is hemodynamically unstable or the amputation site is severely contaminated, temporary ectopic implantation of the amputated limb is an option. To the best of our knowledge, this is the first case report using the distal runoff vessel of the anterolateral thigh flap for temporary ectopic implantation of an amputated leg followed by replantation with the prefabricated anterolateral thigh flap. PATIENT AND METHODS: A 28-year-old male driver had left leg avulsion amputation after a car accident. Because of concerns about the high-energy trauma mechanism and extensive trauma zone, temporary ectopic implantation was planned to avoid a lengthy replantation procedure and to enable future replantation. The amputated leg was implanted to the thigh using the distal runoff vessel of the descending branch of the lateral circumflex femoral system in the preservation of proximal cutaneous perforator. When the patient became hemodynamically stable and the amputated stump was relatively clean and healthy, we replanted the amputated leg with the prefabricated anterolateral thigh flap on day 7. RESULTS: The replanted leg and anterolateral thigh flap survived well after the procedure. At the 15-month follow-up, the patient could walk independently. There was no need for custom-made shoes because there was no obvious leg length discrepancy and the flap was not bulky. CONCLUSIONS: We believe that the distal runoff vessel of the descending branch of the lateral circumflex femoral system can not only serve as a recipient site for temporary ectopic implantation but also enable the harvest of a prefabricated anterolateral thigh flap with the amputated part at the replantation stage. This prefabricated tissue containing the anterolateral thigh flap and the amputated part needs only 1 set of vascular anastomosis to accomplish replantation and simultaneous revascularization of the anterolateral thigh flap. Most importantly, this ectopically prefabricated chimeric tissue minimizes the need for extensive bone shortening after radial debridement by providing sufficient soft tissue coverage at the replantation stage.