Pushing the Limits of Reach for the Pedicled Anterolateral Thigh Flap.

The pedicled anterolateral thigh flap, although tremendously versatile, may be limited in reach, especially in challenging clinical cases. Traditional methods to extend its reach may remain insufficient or unavailable. We describe two modifications to the conventional pedicled flap to extend its reach to the limits, namely (1) selecting a distal perforator supplemented by the nonsizeable perforator harvest technique, and (2) the double-pivot technique adding an additional rotation to the flap à la propeller perforator flap. The increased reach not only improves reconstructive success, but also opens up new applications for this workhorse flap.

Split Anterolateral Thigh Flap: A New Classification of Anatomical Variants and a Surgical Planning Algorithm.

BACKGROUND: Split anterolateral thigh flap is a versatile reconstruction option, yet long underestimated as no practical perforator classification and no optimal strategy were present. Harvesting "capillary nonsizable perforators" could potentially expand flap splits to those with no existing multiple sizable perforators. Concerns over defect characteristics, recipient vessels, pedicle length, and split timing should all be weighted equally in designing the suitable flap. Refinement is thus required to enable precise reconstructions. METHODS: All patients undergoing anterolateral thigh flap harvests between 2014 and 2021 performed by a single surgeon were included. The perforator patterns of sizable pedicle, course, origin, and further successful flap-split methods were documented. Surgical outcome of flap survival was analyzed. RESULTS: Anatomical variants of 134 (48.4%) dual, 123 (44.4%) single, and 20 (7.2%) no sizable perforators were found in a total of 277 anterolateral thigh flaps. The overall flap survival rate was 97.5%. Flap split was performed in 82 flaps, including 29 single and 5 no sizable perforator cases previously considered "unsplittable," by utilizing a series of direct skin paddle split, capillary nonsizable perforators harvesting, and flow-through anastomosis technique. Comparable flap survivals were found between split and nonsplit flaps as well as between split segments supplied by sizable and capillary nonsizable perforators. Primary closure was achieved in 98.9% of the thigh donor sites. CONCLUSION: A new classification of the common anterolateral thigh flap anatomical variants was proposed and a comprehensive algorithm of split flap strategy was developed along with the innovative "fabricate" concept.

A review of pharyngocutaneous fistula management in head and neck malignancies.

Pharyngocutaneous fistula is a serious complication after head and neck reconstruction and concurrent chemoradiotherapy, yet no consensus or practical protocols regarding the surgical timing and specific procedures could be found in the current literature. The authors aimed to review their clinical experience in surgical management and develop an algorithmic approach accordingly. A retrospective review of all hypopharyngeal cancer patients who developed pharyngocutaneous fistula during 2017 to 2021 at E-Da Hospital was conducted. Seventeen patients developed pharyngocutaneous fistula in all 321 pharyngeal cancer admissions during this period. Three patients received interventions at acute stage (≤2 weeks), with two direct repairs Three patients received interventions at acute stage (≤2 weeks), with two direct repairs and one regional flap coverage then negative pressure wound therapy. Nine received interventions at subacute stages (2 weeks to 3 months), with 4 resolved after debridement and direct repair yet another 4 underwent regional flap reconstruction and 1 free flap reconstruction. Five chronic fistula (>3 months) received secondary reconstructions utilizing a double-layered repair of local turn-over flaps for the internal mucosal opening and another flap harvest (four regional flaps and one free flap) to cover the outer skin defect. All patients after the palliative surgery achieved complete remission of fistula at follow follow-up. Different conservative and surgical approaches should be adopted according to the acute, subacute, and chronic stages of pharyngocutaneous fistula after palliative head and neck reconstructions.

Plantar forefoot reconstruction: A proposal of a management algorithm based on a case series analysis: Plantar forefoot reconstruction.

BACKGROUND: Several loco-regional flaps have been described for plantar forefoot coverage. We, herein, report our single-centre experience in plantar forefoot reconstruction and propose a decision-making process based on the defect's size. METHODS: This is a retrospective case series study of all patients who underwent plantar forefoot reconstruction in a 10-year period. We propose a treatment algorithm, based on the defect size. Defects are classified into small, moderate and large. Small defects (<10cm2) can be covered with the hemi-pulp toe flap. Patients with moderate defects (10-25cm2) can be treated with the reverse medial plantar artery flap (MPAF) from the instep area. For large defects (>25cm2), we recommend regional flaps, that is the distally based sural flap (DBSF) from the ipsilateral calf, or free flaps, such as the anterolateral thigh flap (ALT) or the skin-grafted gracilis flap. RESULTS: The data of 51 patients were collected and analysed. The median age was 58 years (range 19-84). Nine patients had small defects and underwent hemi-pulp toe flap reconstruction. Three patients presented with moderate defects that were covered with reverse MPFs. The vast majority of the patients (39 patients) had large defects. Of these, eight cases were treated with DBSF and 31 cases with free flaps. Free flap transfers were successful in 97% of the cases. Overall complication rate was 25%. CONCLUSION: We conclude that local flaps should be preferred in plantar forefoot reconstruction as they provide like-tissue for small to moderate defects, for large defects regional flaps or free flaps were indicated. A defect-based approach can facilitate the decision-making process.

Freestyle Local Island Pedicle Flap in Lower Leg Reconstruction.

The freestyle local perforator flap is an advanced version of the conventional island pedicle flap. Intramuscular dissection can provide a longer pedicle, which allows restoration of defects that are future from the donor site. Without microsurgery, the flap can be either rotated or advanced toward the defect, making it particularly useful for reconstructing soft tissue defects in the lower third of the leg. Careful preoperative design with vessel mapping, skillful intramuscular dissection of the pedicle, and a well-considered backup plan in case of unexpected difficulty are crucial for freestyle local perforator flaps to be successful.

Harvesting the anterolateral thigh flap with non-sizable perforators.

BACKGROUND: The anterolateral thigh flap (ALT) has proven over time to be one of the best reconstructive workhorses due to its versatility and reliability. Without preoperative imaging, vascular anomalies such as having no sizable perforator are sometimes encountered during dissection. We propose a technique, based on a modified version of the traditional myocutaneous ALT to allow harvest of the flap based on non-sizable perforators. This technique can also enable the splitting of a flap when only one sizable perforator is present. METHODS: A retrospective review of patients who received reconstruction with free ALT flap from 2013 to 2019 by the senior author HSS was performed and included all flaps in which non-sizable perforators were harvested. Data collected for analysis included patient demographics, flap size, defect location, inset type, and flap survival. SURGICAL TECHNIQUE: Despite detachment of the majority of skin paddle from the muscle, the flap is harvested with a sleeve of areolar tissue containing preferably more than one non-sizable perforator attached to a small muscular segment of the vastus lateralis containing the pedicle. RESULTS: A total of 349 ALT flaps were performed during the review period by senior author HSS, and 25 flaps were harvested with non-sizable perforator, 10 of which were to enable a split. There were no total losses and 6 partial losses; 2 were amenable to direct closure after debridement, 1 required skin graft, and 3 required a new flap for wound coverage. Incorporating more than one non-sizable perforator increases the reliability of the flap. This technique should be used with caution in patients with multiple underlying comorbidities and when a flow-through flap is required. We were able to achieve primary closure of all donor sites. CONCLUSIONS: It is possible to harvest the anterolateral thigh flap without sizable perforators by conversion to a modified version of the myocutaneous flap. In well-selected patients, using our technique, several non-sizable perforators can reliably perfuse an ALT without the need to use an alternative donor site. This maximizes the number of harvestable ALTs and increases the reconstructive potential by splitting previously "un-splitable" flaps.

Involvement of Aquaporins in the Intense Pulsed Light-Enhanced Wound Healing in Diabetic Rats.

BACKGROUND AND OBJECTIVES: We previously demonstrated that intense pulsed light (IPL) irradiation prior to wounding improved the wound healing in rats with diabetes mellitus (DM). Also, we found that IPL upregulated the expression of aquaporin 3 (AQP3), a protein that is crucial for wound healing, in normal rats. This present study aimed to examine the involvement of AQPs in the IPL-enhanced wound healing in diabetic rats. STUDY DESIGN/MATERIALS AND METHODS: Streptozotocin was used to induce diabetes in Sprague-Dawley rats. Animals were divided into four groups: normal group, DM only group, DM rats with IPL treatment 2 weeks before wounding (DM + IPL-Pre group), and DM rats with concurrent IPL irradiation and wounding (DM + IPL-Con group). Wounds were created on the dorsal skin of rats. The expressions of AQP1, 3, 4, 7, and 9 in the pre-injured skin, periwound, and wound were determined. RESULTS: Among all the AQPs analyzed, only the expressions of AQP3 and AQP7 were significantly altered. Unirradiated diabetic rats showed much higher expression level of AQP3 in the regenerating skin compared with normal rats. IPL pretreatment, but not concurrent treatment, attenuated the expression toward the level detected in the normal wounds. In contrast, a lower expression level of AQP7 was noted in the regenerating skin of DM only rats and IPL pretreatment upregulated the expression to a level similar to that in the normal rats. CONCLUSION: The beneficial effect of IPL pretreatment on the wound healing in diabetic rats might involve a mechanism by which the expression of AQPs is regulated. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Experience on primary closure of fibular flap donor sites and development of an algorithm for closure based on different flap designs.

BACKGROUND: Most skin paddles of the fibula flap are harvested from the distal third of the lower leg, skin grafting for the donor-site is necessary. METHODS: A retrospective review was done on patients with large bony defects using free fibula osteocutaneous flaps (FOSCFF) for head and neck reconstruction. We focus on the techniques for closure of donor sites were skin grafting, primary closure with tear drop design and propeller flap technique on the donor site closure using skin graft, primary closure and local propeller flap based on the different location of perforators of FOSCFF. Postoperative follow up include incidence of wound complications, postoperative days to ambulation and cosmetic outcome. RESULTS: A total of 48 patients were included. Twenty five patients had skin graft (Group A), and 23 patients had primary closure (Group B); in 16 patients tear-drop design was used, 6 had propeller flap, and the remaining 1 patient received a chimeric flap. Group A had more wound complication rates compared to Group B; 20% versus 4.3%, respectively (p = .19). The average postoperative days to ambulation for Group A were 15.1 days versus 7.3 days for Group B (p < .001). The cosmetic score in the B group (2.71) versus A group (4.89) was also statistically significant (p = .007). All the patients ambulated well at follow up. CONCLUSION: Primary closure using the tear drop technique and propeller flap is superior to skin grafting in terms of better cosmetic appearance, earlier postoperative ambulation, and no need for another donor site for skin graft.

Beneficial Effect of Intense Pulsed Light on the Wound Healing in Diabetic Rats.

BACKGROUND AND OBJECTIVE: Wound healing in diabetes mellitus (DM) patients is one of the major health concerns globally. Intense pulsed light (IPL) has been widely used in cosmetic dermatology via mechanisms involving fibroblast stimulation, collagen synthesis, and dermal remodeling, which are events that also occur during the process of wound healing. This present study was aimed to evaluate the possible beneficial effect of IPL on the wound healing in diabetic rats. MATERIALS AND METHODS: Diabetes was induced in Sprague-Dawley rats using streptozotocin. The rats were randomly divided into four groups: normal group, DM only group, DM rats with IPL treatment 2 weeks before wounding (DM + IPL-Pre group), and DM rats with concurrent IPL exposure and wounding (DM + IPL-Con group). The wounds were created on the dorsal skin of rats. Wound closure rate, collagen deposition, and angiogenesis were assessed. RESULTS: There were no significant differences in the wound closure rate and mean time to wound closure between IPL-treated diabetic rats and normal rats. By contrast, delayed wound closure and prolonged mean time to wound closure were both noticed in DM only group. Enhanced collagen deposition and angiogenesis were observed in IPL-Pre, but not IPL-Con diabetic rats, as compared with untreated DM rats. CONCLUSION: Results of this study may provide novel insight into future preventive strategies using IPL for the management of wounds in diabetic patients. Lasers Surg Med. © 2019 Wiley Periodicals, Inc.

The medial sural artery perforator pedicled propeller flap for coverage of middle-third leg defects.

BACKGROUND: Pedicled medial sural artery perforator (MSAP) flap has been described primarily for the coverage of knee and proximal-third leg defects. The technique for reaching the middle third and its use as a retrograde-flow flap were never demonstrated with clarity. This retrospective case-series aimed to report the author's experience in these regards. PATIENTS AND METHODS: Details of all patients who underwent pedicled MSAP flap for lower limb reconstruction over a 7-year period were collected. Surgical outcomes were examined retrospectively. For defects in the anterior middle third of the leg, the "pedicled propeller flap" design was utilized. To determine more distal defects beyond the reach of the anterograde-flow MSAP flap, retrograde-flow pedicled MSAP flaps were used. RESULTS: Eleven anterograde-flow pedicled MSAP flaps were used for defects ranging from the knee to the middle third of the leg. The etiologies of defects included trauma, chronic ulcer, and skin malignancy. All 11 anterograde pedicled MSAP flaps survived and achieved good outcomes. The mean pedicle length was 11.3 cm (range 7-18 cm), and the mean arc length after double pivoting (n = 4) was 29 cm (range 22-36 cm). Of three retrograde-flow pedicled MSAP flaps, two achieved the goal of wound coverage and one suffered complete flap loss. CONCLUSION: The "pedicled propeller flap" design extends the reach of the anterograde-flow pedicled MSAP flap as far as the middle-third anterior leg defects. Our preliminary experience with retrograde-flow MSAP flap has mixed results. Further studies are required to examine its reliability.

Superficial temporal vessels, both anterograde and retrograde limbs, are viable recipient vessels for recurrent head and neck reconstruction in patients with frozen neck.

BACKGROUND: Reconstruction of recurrent head and neck malignancy especially in the presence of a frozen neck is challenging. The superficial temporal vessels would be ideal as recipient vessels because they lie out of the previous surgical and radiation field. METHODS: We conducted a retrospective case-control study based on our database between January 2013 and June 2016. A total of 581 primary cases were selected as controls. The 60 test group patients had (a) recurrent head and neck reconstruction, (b) previous surgery and irradiation, (c) frozen neck, and (d) superficial temporal vessels as recipients. RESULTS: There was no significant difference between vascular compromise rates of superficial temporal vessels (anterograde and retrograde limbs) and controls (P > .05). Flap success rate of the test and control group is comparable, 95% vs 98% respectively. CONCLUSION: Superficial temporal vessels, both anterograde and retrograde, should be the first consideration for recurrent intraoral, facial, and scalp reconstruction with frozen necks.

Versatility of the Free Anterolateral Thigh Flap in the Reconstruction of Large Defects of the Weight-Bearing Foot: A Single-Center Experience with 20 Consecutive Cases.

Background Reconstruction of the weight-bearing surface of the foot represents a challenging task. With very little scope to borrow glabrous tissue from adjacent areas means that achieving a "like for like" reconstruction is rarely possible. In this setting, alternative approaches need to be considered. In this article we present our experience with various differing designs of the anterolateral thigh flap (ALT) in the reconstruction of 20 large defects of the weight-bearing sole. Methods Twenty patients with complex soft tissue defects of the weight-bearing sole underwent reconstruction over a 5-year period. Five cases were complicated by osteomyelitis resulting in significant calcaneal defects. The follow-up period ranged from 8 to 48 months and outcomes were assessed by two-point discrimination and protective sensation, observation of gait, and the ability of the patient to return to wearing normal footwear. Results All flaps survived with the exception of two partial skin necrosis. Sensory nerve coaptation was performed in 12/20 cases. One patient underwent second-stage total calcaneal reconstruction with a fibula osteocutaneous flap. Five large defects were reconstructed with the split skin paddle technique to allow for direct donor-site closure. No evidence of postoperative ulceration was noted in any of the patients over the follow-up period and all were satisfied regarding the functional and aesthetic results achieved. Conclusion Complex defects of the weight-bearing sole can be successfully reconstructed using the free ALT flap resulting in very favorable functional outcomes. Even when calcaneal osteomyelitis has set in, excellent outcomes can be achieved.

Local Free-Style Perforator Flaps in Head and Neck Reconstruction: An Update and a Useful Classification.

BACKGROUND: Any standard skin flap of the body including a detectable or identified perforator at its axis can be safely designed and harvested in a free-style fashion. METHODS: Fifty-six local free-style perforator flaps in the head and neck region, 33 primary and 23 recycle flaps, were performed in 53 patients. The authors introduced the term "recycle" to describe a perforator flap harvested within the borders of a previously transferred flap. A Doppler device was routinely used preoperatively for locating perforators in the area adjacent to a given defect. The final flap design and degree of mobilization were decided intraoperatively, depending on the location of the most suitable perforator and the ability to achieve primary closure of the donor site. Based on clinical experience, the authors suggest a useful classification of local free-style perforator flaps. RESULTS: All primary and 20 of 23 recycle free-style perforator flaps survived completely, providing tension-free coverage and a pleasing final contour for patients. In the remaining three recycle cases, the skeletonization of the pedicle resulted in pedicle damage, because of surrounding postradiotherapy scarring and flap failure. All donor sites except one were closed primarily, and all of them healed without any complications. CONCLUSIONS: The free-style concept has significantly increased the potential and versatility of the standard local and recycled head and neck flap alternatives for moderate to large defects, providing a more robust, custom-made, tissue-sparing, and cosmetically superior outcome in a one-stage procedure, with minimal donor-site morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Effect of intense pulsed light on the expression of aquaporin 3 in rat skin.

Intense pulsed light (IPL) technology has been popularly employed in clinical treatments for dermatological and cosmetic purposes in recent years; yet, the underlying mechanisms of its functions are not fully elucidated. On the other hand, aquaporin (AQP) 3, a member of a subgroup of the aquaporin family that transports both water and small solutes, such as glycerol, has been documented to play an important role in the skin homeostasis. We thus examined the possible involvement of AQP3 in the functional mechanisms of IPL irradiation. Rat dorsal skin areas were irradiated one to three times with IPL at doses of 15, 25, and 35 J/cm2. Skin specimens were collected 7 days after the final irradiation and analyzed for changes in histology, skin hydration, mRNA, and protein expressions of AQP3. IPL induced no significant variations in the mRNA expression levels. Twice or thrice irradiation at the dose of 25 or 35 J/cm2 significantly enhanced AQP3 protein expression. Immunofluorescence study revealed that AQP3 was mainly localized to keratinocyte membranes in the basal layer of epidermis, and the localization was unaltered by IPL. In addition, the pattern of IPL-induced changes in skin hydration was generally coincided with the expression profile of AQP3. These results suggest the possibility that one of the functional mechanisms of IPL might be related to the regulation of AQP3 protein expression.

Heterotopic Procedures in Mutilating Hand Injuries: A Synopsis of Essential Reconstructive Tools.

BACKGROUND: In the complex and challenging treatment of a mutilating hand injury, any available resources need to be primarily recruited. Besides direct digital replantation, the tissue of the nonreplantable "spare parts" could often be "recycled," and also some replantable or injured structures could be "redistributed" in a more functional individualized pattern, irrespective of their initial origin. METHODS: Ten patients, six male and four female, were treated for multidigital mutilating injury with various "heterotopic" procedures. Immediate digital heterotopic replantations were performed in seven patients. In one case, the bone and skin of a nonreplantable digital part were used as grafts in the reconstruction of a metacarpal bone and the overlying skin defect. A neurovascular fillet flap from a nonreplantable finger for the reconstruction of the webspace and a pollicization of an injured index were undertaken in two further cases. Another patient underwent pedicled transfer of the proximal interphalangeal joint and metacarpal bone of an impaired index to the middle finger. RESULTS: Sensate prehensile function was restored in 100 percent of the cases, and the ability for tripod pinch and more subtle tasks was restored in 90 percent. The minimum of two long fingers and a thumb was restored in every case, and the patients judged the appearance of their hands as "acceptable." CONCLUSION: In the reconstruction of a mutilating hand injury, besides and beyond the straightforward microsurgery, the various heterotopic procedures are essential reconstructive tools that can enhance the versatility of the hand surgeon when pursuing a better outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Pedicled free-style perforator flaps for trunk reconstruction: a reliable method.

BACKGROUND: By exploring the perforating vessels that supply the soft tissues adjacent to a given defect, a perforator flap can be designed in free-style fashion. METHODS: From 2009 to 2013, 14 defects of the trunk (excluding the abdomen) were reconstructed using pedicle free-style perforator flaps at the Department of Plastic Surgery, E-Da Hospital, Taiwan. Several perforators at the periphery of the defect were detected and marked preoperatively using a handheld Doppler probe. Then, they were explored intraoperatively through the existing wound edge after wide excision of lesions. The most suitable perforator was selected by means of direct vision and chosen as the pivot point, and then the flap was designed around it, taking into consideration the axiality of the vessel and the ability to achieve direct donor-site closure. RESULTS: All of the flaps survived completely, except for one flap that partially failed because of congestion, and for which the salvage procedure was a skin graft. Full coverage of the defect with excellent contour and color matching and primary closure of the donor sites was achieved in all of the patients. CONCLUSIONS: The free-style approach to trunk reconstruction allows the surgeon to complete a robust like-for-like reconstruction while confining the scar burden to a single site. Using the handheld Doppler device and visualizing the perforators directly through the wound edge eliminates the need for preoperative imaging, and allows for the optimal flap to be designed based on vessel size and quality and minimizes donor-site morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A "green" approach to secondary reconstruction: the concept of the recycle flap and a classification.

BACKGROUND: Harvesting soft tissue from a previously transferred flap allows for flap reshaping and simultaneously raising tissue for a secondary procedure. This is done without increasing the number of donor sites and is therefore a very attractive reconstructive option. METHODS: Between March of 2011 and October of 2013, the authors performed 60 recycle flaps on 60 patients (three women and 57 men) who had undergone previous flap reconstruction (52 free and eight pedicled). The recycle flaps were raised as either random pattern or perforator flaps. Mean time between primary reconstruction and the recycle procedure was 28.3 months (range, 6 months to 20 years), and the mean age of our patients was 57 years (range, 21 to 78 years). RESULTS: Of 60 recycle flaps raised for secondary reconstruction, 58 survived completely (97 percent). Two cases of total flap necrosis were encountered resulting from pedicle damage during attempted perforator dissection within a previously irradiated flap. Twenty-nine flaps were raised as random pattern flaps, 29 were raised as pedicled perforator flaps (20 with perforator skeletonization), and two were raised as free perforator flaps. CONCLUSIONS: There are a number of ways to safely "recycle" the soft tissues used in a previous reconstruction. This provides new tissue for a secondary procedure while debulking and refining the primary flap. Raising perforator flaps from previously irradiated flaps is, however, technically challenging and carries a high risk of flap necrosis (40 percent in our series) and should be advised against. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Free Pulp Transfer for Fingertip Reconstruction-The Algorithm for Complicated Allen Fingertip Defect.

UNLABELLED: We present a review of all the cases of free toe pulp transfer and an algorithm for application of free pulp transfer in complicated Allen fingertip defect. METHODS: Seventeen patients underwent free toe pulp transfer for fingertip reconstruction by the senior author. Twelve cases were Allen type II with oblique pulp defect, 4 were Allen type III, and 1 patient had 2 fingertip injuries classified both as type IV. According to the algorithm presented, for the type III defects where the germinal matrix is still preserved, we use free pulp transfer and nail bed graft to preserve the nail growth instead of toe to hand transfer. For the type IV injuries with multiple defects, a combination of web flap from both big toe and second toe is possible for 1-stage reconstruction. RESULTS: All pulp flaps survived completely. Static 2-point discrimination ranged from 6 to 15 mm (mean: 10.5 mm). No patient presented dysesthesia, hyperesthesia, pain at rest, or cold intolerance. The donor site did not present any nuisances apart from partial skin graft loss in 3 cases. CONCLUSIONS: We tried to classify and modify the defects' reconstruction according to Allen classification. Free toe pulp transfer is a "like with like" reconstruction that provides sensate, glabrous skin with good color and texture match for fingertip trauma, and minimal donor site morbidity compared with traditional toe to hand transfer.