Microsurgical reconstruction of the skull base and midface after orbitomaxillary resections for malignant tumors

Background. Orbitomaxillary resection includes exenteration of the orbital contents with resection of the inferior orbital and medial walls. The main goals are: reconstruction of soft tissue and bone structure defects, tamponade of the orbital cavity and/or its preparation for further ocular prosthetics, and reconstruction of the skull base defect. The purpose of the study to present the immediate results of orbitomaxillary resections in patients with malignant neoplasms of the skull base and midface. Material and methods. Between 2014 and 2020, 6 patients who previously underwent surgery for primary cancer (n=3) and recurrent cancer (n=3) were treated at the Head and Neck cancer department of N.N. Blokhin National medical Research center of oncology. To reconstruct defects after resection of bone structures (maxilla, frontal and nasal bones) and skin, a musculocutaneous alt-flap was used in 3 (50 %) cases and a fascial skin radial flap in 3 (50 %) cases. Results. The aesthetic result was assessed in 6 patients. In all cases, a satisfactory result was obtained. None of the patients who underwent resection of the dura mater followed by reconstruction had no symptoms of liquorrhea in the postoperative period. Conclusion. Flap selection depends on the defect size. In cases with a small defect size (up to 70 cm3), reconstruction with the radial fascial skin flap can be performed. If the defect size is more than 71 cm3, reconstruction with musculocutaneous alt flap can be the method of choice.

Color Doppler Ultrasound versus Computed Tomography Angiography for Preoperative Anterolateral Thigh Flap Perforator Imaging: A Systematic Review and Meta-Analysis

Background The anterolateral thigh (ALT) perforator flap is a commonly used flap with a predictable, though often variable, perforator anatomy. Preoperative imaging with color Doppler ultrasound (CDU) and computed tomography angiography (CTA) of ALT flap perforators can be a useful tool for flap planning. This study provides a complete review and analysis of the relevant preoperative ALT imaging literature. Methods Studies related to preoperative CDU and CTA imaging were reviewed, and information related to imaging method, sensitivity, false-positive rates, and perforator course identification (musculocutaneous vs. septocutaneous) were analyzed. Results A total of 23 studies related to preoperative ALT flap CDU and CTA imaging were included for review and analysis. Intraoperative perforator identification was compared with those found preoperatively using CDU (n = 672) and CTA (n = 531). Perforator identification sensitivity for CDU was 95.3% (95% CI: 90.9–97.6%) compared with the CTA sensitivity of 90.4% (95% confidence interval [CI]: 74.4–96.9%). The false-positive rate for CDU was 2.8% (95% CI: 1.1–4.5%) compared with 2.4% (95% CI: 0.7–4.1%) for CTA. Accuracy of perforator course identification was 95.5% (95% CI: 93.6–99.2%) for CDU and 96.9% (95% CI: 92.7–100.1%) for CTA. Conclusion CDU provides the reconstructive surgeon with greater preoperative perforator imaging sensitivity compared with CTA; however, false-positive rates are marginally higher with preoperative CDU. Preoperative imaging for ALT flap design is an effective tool, and the reconstructive surgeon should consider the data presented here when selecting a flap imaging modality.

Preoperative Computed Tomography Angiography for ALT Flaps Optimizes Design and Reduces Operative Time

Background Computed tomography angiography (CTA) has been widely used for perforator mapping in abdominal-based reconstruction, but it is less widespread in the anterolateral thigh (ALT) flap. However, CTA may be quite useful for ALT planning, as this flap has demonstrated substantial variability in intrapatient bilateral vascular anatomy. This study investigated whether standard use of preoperative CTA resulted in selection of the donor extremity with preferential perforator anatomy, and whether this affected operative time and postoperative outcomes. Methods A retrospective review of 105 patients who underwent proposed ALT flap reconstruction was performed. Seventy-nine patients received bilateral lower extremity CTAs, which were evaluated for dominant perforator anatomy (septocutaneous, musculoseptocutaneous, or musculocutaneous). Donor extremity selection was noted, and predicted perforator anatomy was compared with that encountered intraoperatively. Results Among the 73 patients who received bilateral imaging and ultimately received an ALT, congruent findings between imaging and surgical exploration were observed in 51 (69.8%) patients. Thirty (37.9%) patients had asymmetric perforator anatomy between their bilateral extremities on imaging. Among these, the leg with optimal perforator anatomy was selected in 70% of cases. There were no significant reductions among postoperative complication rates, but selection of the donor site with preferential anatomy was associated with a decrease in operative time (p = 0.049) among patients undergoing extremity reconstruction. Conclusion CTA is a useful tool for optimizing donor site selection for ALT flaps and reducing operative time. We believe that standard use of preoperative CTA in ALTs warrants further consideration.

Pedicled Anterolateral Thigh Flap As A Workhourse Flap for Reconstruction of Inguino-Scrotal Defects

Background: Reconstructions around inguinoscrotal region has been a challenging task owing to complex anatomy. There are variety of flap options available for reconstruction of Inguinoscrotal region. Our study was done to evaluate the use of pedicled anterolateral thigh flap for reconstruction of defects around inguinoscrotal regions. Methodology: In this study a total of 18 patients with various types of defects around inguinoscrotal region were evaluated. The etiology of defects included trauma (𝑛=6), infection (𝑛=8), malignancy (𝑛=2) and burn (𝑛=2). Patients were evaluated in terms of viability of the flap, number of perforators included, pedicled length and flap dimensions and donor site morbidity. Results: All flaps were survived well except 1 flap develop venous congestion in immediate post operative period due to tension over vascular pedicle which was managed by increasing pedicle length. 2 patients had developed partial loss of the skin graft at the donor site which got healed secondarily in due course. All patients were followed up for an average period of 6 months, ranging from 1 to 12 months. Donor site morbidity was minimal. Conclusion: Pedicled ALT flap is a versatile, reliable flap, with wide arc of rotation which makes it as an ideal flap for the coverage of defects around inguinoscrotal region.

Correlation Between Body Mass Index and Anterolateral Thigh Flap Thickness: A Retrospective Study From a Single Center in China

Background: During repair of oral and maxillofacial soft tissue defects, organ function is largely related to the amount of thickness of the flap. However, there are few studies on the influencing factors of the thickness of the flap. In this retrospective study, we aim to explore the correlation between body mass index (BMI) and anterolateral thigh (ALT) flap thickness by computed tomography (CT) and ultrasound and provide guidance for evaluating the ALT flap thickness before surgery.Methods: We selected three points A, B, and C on ALT flap and two skilled clinicians measured the thickness of these points. Age and gender as covariates and evaluated by the Chi-square analysis. Inter-group differences between the two BMI groups were examined by the student t test. Intra-group differences within each BMI group were tested by ANOVA. Linear regression analysis was performed to examine the relationship between BMI and ALT flap thickness.Results: One hundred sixty patients measured by CT were included in this study, and the ALT flap thickness measured by CT were 8.96 mm and 11.00 mm (P < 0.0001, t test) at point B in groups with BMI<24.0 and BMI≥24.0, respectively. The thicknesses at points A, B, and C were significantly correlated with the BMI (P < 0.001, correlation analysis, r = 0.462, 0.372, and 0.349 at the points A, B, and C, retrospectively, Pearson test).Conclusion: There was a significant correlation between the ALT flap thickness and BMI. A higher BMI was correlated with a thicker ALT flap.

Reconstruction of Complex Lateral Skull Base Defects After Oral Cancer Resection With Individualized Anterolateral Thigh Flap

ObjectivesComplex lateral skull base defects resulting from advanced or recurrent oral cancer resection are continuously challenging reconstructive surgeons. This study aimed to use reconstructive methods for lateral skull base defects, explore their feasibility, and evaluate the efficacy of defect reconstruction using anterolateral thigh (ALT) flaps.Patients and MethodsWe performed a retrospective case series of 37 patients who underwent lateral skull base defect reconstruction using the ALT/anteromedial thigh (AMT) flap between March 2016 and May 2021 at the Second Xiangya Hospital. The design and harvest of the flaps, methods for defect reconstruction, and reconstructive efficacy are described.ResultsOf the 37 patients, 3 were women and 34 were men, with a mean age of 51.7 years. Among the defects, 26 were through-and-through defects and were reconstructed using ALT chimeric flaps, double ALT flaps, folded ALT flap, combined ALT chimeric flaps and AMT flaps, or combined ALT chimeric flaps and pectoralis major flaps; the large lateral skull base dead spaces were filled with muscle tissues or fatty tissues. Postoperatively, 38 of the 39 ALT/AMT flaps survived completely, and the remaining flap experienced partial necrosis. Venous compromise occurred in one patient who was salvaged after operative exploration. Oral and maxillofacial wound infections occurred in two patients, salivary fistula in three patients, and thigh wound effusion in three patients. The wounds healed gradually in all patients after repeated dressing changes. Thirty-three patients were followed up for approximately 3–60 months; their oral functions and appearance were acceptable, and thigh motor dysfunction was not observed.ConclusionsWith the convenient flap design and muscle flap harvest, large and individualized tissue supply, feasible combination with other flaps, effective reduction or avoidance of wound complications, and acceptable donor site morbidity, the ALT flap is an appropriate choice for complex lateral skull base defect reconstruction.

Clinical and Surgical Outcomes in Extensive Scalp Reconstruction after Oncologic Resection: A Comparison of Anterolateral Thigh, Latissimus Dorsi and Omental Free Flaps

Microsurgical scalp reconstruction is indicated in patients with large scalp defects. The aim of this study was to compare the outcomes of scalp reconstruction in oncologic patients reconstructed with latissimus dorsi (LD), anterolateral thigh (ALT), and omental (OM) free flaps. Thirty oncologic patients underwent scalp reconstruction with LD (10), ALT (11), and OM (9) flaps. The length of the vascular pedicle, the operation time, the possibility of a two-team approach, the length of hospital stays, the complications, and the aesthetic results were evaluated. The OM flap was the flap with the shortest vascular pedicle length with a mean of 6.26 ± 0.16 cm, compared to the LD flap, which was 12.34 ± 0.55 cm and the ALT flap with 13.20 ± 0.26 cm (p < 0.05). The average time of surgery was 6.6 ± 0.14 h in patients reconstructed with OM, compared to the LD flap, which was 8.91 ± 0.32 h and the ALT flap with 7.53 ± 0.22 h (p < 0.05). A two-team approach was performed in all patients for OM flaps and ALT flaps, but only in two patients reconstructed with the LD flap (p < 0.001). In patients reconstructed with the OM flap, a very satisfactory or satisfactory result was reported in seven patients (77.8%). Eight patients reported a very unsatisfactory or unsatisfactory result with LD flap (80%) and 10 patients with ALT flap (90.9%) (p = 0.002). The mean hospital stay after surgery was not statistically significant (p > 0.05). As for complications, two patients reconstructed with OM flap, five LT flaps, and two ALT flaps developed complications, not statistically significant (p = 0.235). Omental flap, latissimus dorsi flap, and anterolateral thigh flap fulfill most of the characteristics for complex scalp reconstruction. The decision on which flap to use should be based on clinical aspects of the patients taking into account that the three flaps show similar rates of complications and length of hospital stay. Regarding the aesthetic outcome, OM flap or LD flap should be considered for reconstruction of extensive scalp defects.

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

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.