Evaluation of the Suprafascial Thin ALT Flap in Foot and Ankle Reconstruction

2021 ◽  
Author(s):  
J.R. Thiele ◽  
J. Weiß ◽  
D. Braig ◽  
J. Zeller ◽  
G.B. Stark ◽  
...  
Keyword(s):  
Perforator Flaps ◽  
Muscle Flaps ◽  
Distal Extremity ◽  
Limited Mobility ◽  
Flap Loss ◽  
Flap Design ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction ◽  
Alt Flap ◽  
Fascial Plane

Abstract Background Distal lower extremity reconstruction can be challenging in terms of flap design. Bulky flaps result in limited mobility accompanied with the need of customized footwear. Raising the ALT-flap in a superficial fascial plane (thin ALT-flap) can be beneficial. This study evaluates thin ALT-flaps for lower distal extremity reconstruction. Methods In a retrospective study, patients that underwent microvascular extremity reconstruction at the level of the ankle and dorsal foot at the University of Freiburg from 2008–2018 were reviewed. Results 95 patients could be included in the study (35 perforator flaps, 8 fascia flaps and 54 muscle flaps).Among the perforator flaps, 21 ALT-flaps were elevated conventionally and 14 in the superficial fascial plane (thin ALT-flap). Among the conventional ALT-flaps, there was one flap loss (5%) and one successful revision (5%). 5(24%) flaps received secondary thinning. 57%(n = 12) were able to wear conventional footwear. There were 2(15%) successful revisions of thin ALT-flaps. 100% of thin ALT-flaps survived and 85%(n = 11) of the patients wore ordinary footwear after defect coverage.Among fascial flaps, 50%(n = 4) had to be revised with 2(25%) complete and 1 (13%) partial flap loss. All patients achieved mobility in ordinary shoes (n = 8).In muscle flaps, there were 7(13%) revisions and 5(9%) flap losses. 5(9%) flaps received secondary thinning. Only 33%(n = 18) were mobile in ordinary footwear. Conclusion The thin ALT-flap is a save one-stage evolution for lower distal extremity reconstruction with a favorable flap survival rate. Compared with conventional ALT-flaps it might be beneficial in reducing the need for expensive custom fitted shoes and secondary thinning procedures.

Gracilis and Rectus Abdominis Flaps for Leg and Foot Reconstruction

2019 ◽  
pp. 897-908
Author(s):  
Alessandro G. Cusano ◽  
Lee L. Q. Pu ◽  
Michael S. Wong
Keyword(s):  
Lower Extremity ◽  
Donor Site ◽  
Free Tissue Transfer ◽  
Rectus Abdominis ◽  
Muscle Flaps ◽  
Case Examples ◽  
Flap Design ◽  
Lower Extremity Reconstruction ◽  
Foot Reconstruction ◽  
Extremity Reconstruction

Distal third wounds of the lower extremity are challenging to reconstruct because vital structures are frequently exposed and local options are often limited. Free tissue transfer is regarded as the reconstructive gold standard for defects of the distal leg, ankle, and foot. The gracilis and rectus abdominis muscle flaps have proved reliable for free flap reconstruction of the distal lower extremity. This chapter provides a general approach to lower extremity reconstruction and highlights the role of the gracilis and rectus abdominis muscles and musculocutaneous flaps in the reconstruction of the distal lower extremity. Each flap is reviewed with special attention given to its indications, contraindications, anatomy, preoperative preparation, room setup, flap design, and harvest, as well as to donor site management. Considerations for flap inset and anastomosis as well as postoperative care are also discussed. Four case examples are also provided.

Super-Thin and Suprafascial Anterolateral Thigh Perforator Flaps for Extremity Reconstruction

2017 ◽  
Vol 33 (07) ◽  
pp. 466-473 ◽  
Author(s):  
Akhil Seth ◽  
Matthew Iorio
Keyword(s):  
Soft Tissue ◽  
Soft Tissue Reconstruction ◽  
Flap Reconstruction ◽  
Venous Anastomosis ◽  
Distal Extremity ◽  
Anterolateral Thigh ◽  
Effective Option ◽  
Tissue Reconstruction ◽  
Extremity Reconstruction ◽  
Alt Flap

Background The anterolateral thigh (ALT) flap remains a workhorse for soft tissue reconstruction. However, the traditional ALT flap is often too bulky for resurfacing shallow, distal extremity defects, prohibiting adequate function, or well-fitted orthotics. This study evaluates extremity reconstruction using ALT flaps elevated in the suprafascial or super-thin plane. Methods Retrospective review of ALT free flap reconstruction from October 2014 to July 2016 was performed. Suprafascial and super-thin flaps were those elevated just above the crural fascia and within the superficial scarpal plane, respectively. Adjunct operative procedures, demographics, and complications were recorded. Results A total of 25 patients underwent suprafascial (n = 14) or super-thin (n = 11) ALT flap reconstruction for primarily lower extremity wounds (n = 19), with an average age and body mass index of 53.8 years and 26.3 kg/m2, respectively. Follow-up was 6.3 months. Comorbidities included smoking (n = 7), diabetes (n = 8), peripheral vascular disease (n = 6), and hypertension (n = 8). The presence of hardware (n = 9), trauma (n = 10), and chronic infection (n = 12) were common risk factors. Average flap size was 8.2 × 21.5 cm, with 64% (n = 16) taken on one perforator. Forty-eight percent (n = 12) were end-to-side anastomoses and 62% (n = 13) utilized one venous anastomosis. Mean hospital stay was 7.8 days with a 24% (n = 6) complication rate. There were no partial or complete flap losses. Conclusion The ALT flap, elevated in a suprafascial or super-thin plane, is a safe, effective option for extremity soft tissue reconstruction. The decreased flap volume and bulk provides the improved contour and pliability necessary for appropriate distal extremity function. The potential versatility of super-thin flaps reinforces the importance of continued innovation by reconstructive microsurgeons.

The Essential Local Muscle Flaps for Lower Extremity Reconstruction

2020 ◽  
Author(s):  
Andrew Atia ◽  
Rebecca Vernon ◽  
Bryan J. Pyfer ◽  
Ronnie L. Shammas ◽  
Scott T. Hollenbeck
Keyword(s):  
Quality Of Life ◽  
Decision Making ◽  
Lower Extremity ◽  
Postoperative Management ◽  
Soft Tissue Defects ◽  
Muscle Flaps ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction ◽  
Tissue Defects

Abstract Background Lower extremity reconstruction is often a challenging prospect with major implications on a patient’s quality of life. For complex defects of the lower extremity, special consideration must be given to ensure suitable and durable coverage. In the following article, we present the essential local muscle flaps for lower extremity reconstruction and discuss guiding principles for the reconstructive surgeon to consider. Methods A thorough literature review was performed using PubMed to identify commonly used local muscle flaps for lower extremity reconstruction. Common considerations for each identified flap were noted. Results The essential local muscle flaps for lower extremity reconstruction were identified and classified based on anatomical region of the defect to be reconstructed. General considerations and postoperative management were discussed to aid in operative decision making. Conclusion While many factors must be taken into account when performing lower extremity reconstruction, there are numerous reliable local muscle flaps which can be used to successfully provide durable coverage for a variety of soft tissue defects of the lower extremity.

Free-Flap Lower Extremity Reconstruction: A Cohort Study and Meta-Analysis of Flap Anastomotic Outcomes between Perforator and Nonperforator Flaps

2018 ◽  
Vol 34 (06) ◽  
pp. 455-464 ◽  
Author(s):  
Christopher Song ◽  
Keith Koh ◽  
Bien-Keem Tan ◽  
Terence Goh
Keyword(s):  
Cohort Study ◽  
Lower Extremity ◽  
Free Flap ◽  
Meta Analysis ◽  
Relevant Literature ◽  
Success Rates ◽  
Perforator Flaps ◽  
Anastomotic Complications ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction

Introduction Free-flap outcomes in lower extremity reconstruction carry the lowest anastomotic success rates compared with other anatomical sites. Despite their advantages over traditional nonperforator flaps, free perforator flaps have only recently become established in this area due to the additional challenges faced. It is therefore crucial to assess the anastomotic outcomes of perforator and nonperforator free flaps. Methods We performed a single-center retrospective cohort study and combined this with a meta-analysis of the relevant literature. We evaluated three flap anastomotic outcomes: reexploration, operative salvage, and flap failure rates. Results Between January 2010 and June 2015, our center managed 161 patients who underwent lower extremity free-flap reconstruction, which included 76 perforator flaps and 85 nonperforator flaps. The perforator flaps had higher reexploration rates compared with the nonperforator flaps, but this was not statistically significant (18.4 and 10.6%; p = 0.18). Perforator flaps had a higher flap salvage rate but were not statistically significant (78.6 and 22.2%; p = 0.374). Lastly, although not statistically significant, perforator flaps had a lower rate of complete failure due to anastomotic complications (3.9 and 8.2%; p = 0.336). The meta-analysis included 12 studies (inclusive of the index study) and found no statistical difference in all three outcomes. Conclusion Our meta-analysis is the first reported study and serves as an indication that free perforator flaps in lower extremity are as reliable as their traditional nonperforator counterparts. This does come with the prerequisite appreciation of the anatomical variations, the delicate handling of these flaps, and a low threshold for reexploration.

scholarly journals Perforator-Pedicled Propeller Flaps for Lower Extremity Reconstruction

2020 ◽  
Vol 34 (03) ◽  
pp. 200-206
Author(s):  
Mohamed A. Ellabban ◽  
Ahmed I. Awad ◽  
Geoffrey G. Hallock
Keyword(s):  
Lower Extremity ◽  
Donor Site ◽  
Free Flaps ◽  
Donor Site Morbidity ◽  
Peripheral Vascular ◽  
Perforator Flaps ◽  
Vascular Insufficiency ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction ◽  
Bone Exposure

AbstractReconstruction of the lower extremity is considered a major challenge due to frequent bone exposure and the absence of local tissue redundancy, as well as often due to the presence of vascular insufficiency. Many surgeons have preferred free flaps especially for reconstructing the more distal lower limb defects until the evolution of pedicled perforator flaps and propeller flaps in particular provided a like-with-like reconstruction of the lower extremity without affecting the main vessels of the limb or the underlying muscles, and without the risk of any microanastomosis especially in patients with multiple comorbidities. Perforator-pedicled propeller flaps as local flaps in the lower extremity are best suited for small- and medium-sized defects with minimal donor-site morbidity, regardless of the cause of the defect. Any of the three source vessels of the leg can provide reliable perforators for propeller flap coverage of the distal leg and foot. The three main risk factors that are relative contraindications may be advanced age, diabetes mellitus, and atherosclerotic peripheral vascular disease.

Secondary Refinements of Free Perforator Flaps for Lower Extremity Reconstruction

2011 ◽  
Vol 127 (1) ◽  
pp. 248-257 ◽  
Author(s):  
Helen G. Hui-Chou ◽  
Jay Sulek ◽  
Rachel Bluebond-Langner ◽  
Eduardo D. Rodriguez
Keyword(s):  
Lower Extremity ◽  
Perforator Flaps ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction

Donor-Site Morbidity of Free Muscle and Perforator Flaps: Comparison of the Gracilis Muscle Flap and the Anterolateral Thigh Flap

2017 ◽  
Vol 33 (07) ◽  
pp. 526-532 ◽  
Author(s):  
M. Rassner ◽  
J. Kiefer ◽  
H. Bannasch ◽  
G. Stark ◽  
S. Eisenhardt ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Donor Site ◽  
Muscle Flap ◽  
Donor Site Morbidity ◽  
Gracilis Muscle ◽  
Perforator Flaps ◽  
Muscle Flaps ◽  
Gracilis Muscle Flap ◽  
Anterolateral Thigh ◽  
Alt Flap

Background Both the gracilis muscle flap and the anterolateral thigh (ALT) flap have been described as successful reconstructive options for defect coverage after trauma or tumor resection. In general, free perforator flaps are considered to generate less donor-site morbidity than muscle flaps. Here, we put this hypothesis to the test. Methods In this study, 193 patients who had undergone free flap reconstruction with either free gracilis muscle flaps (n = 131) or ALT flaps (n = 62) were included. Subjective patient satisfaction with the aesthetic and functional outcome of the donor sites was assessed using a self-report questionnaire as well as the Lower Extremity Functional Scale (LEFS). Results Comparing the donor-site morbidity of free ALT and gracilis flaps, the LEFS revealed no significant differences in functional impairment (p = 0.6447) of the lower extremity. The donor-site scar was significantly longer after ALT flap harvest (mean: 21.16 cm) than after gracilis muscle flap harvest (mean: 14.17 cm; p < 0.0001). Furthermore, donor-site numbness was significantly greater in the ALT group than in the gracilis group (p = 0.0068). Conclusion No significant differences in functional impairment of the lower extremity were reported after gracilis muscle and ALT flap harvest. Regarding scar length and level of numbness of the donor site, the gracilis muscle flap was shown to be superior to the ALT flap.

Vein Grafting in Microsurgical Lower Extremity Reconstruction: Outcome Analysis of Primary versus Secondary Salvage Procedures

2021 ◽  
Author(s):  
Emre Gazyakan ◽  
Lingyun Xiong ◽  
Jiaming Sun ◽  
Ulrich Kneser ◽  
Christoph Hirche
Keyword(s):  
Lower Extremity ◽  
Free Flap ◽  
Free Flaps ◽  
Matched Pair ◽  
Complication Rates ◽  
Matched Pair Analysis ◽  
Flap Loss ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction ◽  
Pair Analysis

Abstract Objective Many microsurgeons fear high complication rates and free flap loss when vein grafting is necessary to restore blood flow at the recipient site. The aims of this study were to comparatively analyze surgical outcomes of interposition vein grafts (VG) in microsurgical primary lower extremity reconstruction and secondary salvage procedures. Patients and Methods A retrospective study was conducted on 58 patients undergoing free flap transfers with vein grafting for primary lower extremity reconstruction (cohort 1) and secondary salvage procedures (cohort 2) between 2002 and 2016. A matched-pair analysis of both cohorts and 58 non-VG flaps was performed. Patient data, preoperative conditions, flap and vein graft characteristics, postoperative outcomes such as flap failure, thrombosis, and wound complications were analyzed. Results A total of 726 free flap transfers were performed. In total, 36 primary reconstructions (5%) utilized 41 interposition VG (cohort 1). Postoperative vascular compromise was observed in 65 free flaps (9%). In total, 22 out of 65 secondary salvage procedures (33.8%) utilized 26 interposition VG (cohort 2). Two total flap losses occurred in each cohort (5.6 vs. 9.1%; p = 0.63). Postoperative complications were observed in 38.9% of free flaps in cohort 1 and 72.7% in cohort 2 (p = 0.01). Takeback for microvascular compromise was comparable in both cohorts (19.4 vs. 22.7%; p = 0.75). Microvascular complications occurred more often in cohort 2 (22.7%) than in cohort 1 (8.3%; p = 0.28). Lower extremity salvage rates were high among both cohorts (94.4 vs. 90.9%; p = 0.63). Matched-pair analysis did not show any relevant differences on takebacks and flap loss (p = 0.32 and p = 1.0). Conclusion In complex lower extremity reconstructions, VG can be performed with acceptable complication rates and outcomes in primary and especially in salvage cases. With careful planning and a consistent surgical protocol, VG can provide reliable success rates in limb salvage.

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