Hand Reconstruction Using the Thin Anterolateral Thigh Flap
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Background: Perforator flaps have been introduced for various kinds of reconstruction and resurfacing; in particular, the free thin anterolateral thigh flap is becoming one of the most preferred options for reconstruction of soft-tissue defects. Methods: Between 1999 and 2002, the authors used this flap as a free flap for nine cases for covering hand defects after burn, crushing injuries, or severe scar contracture release. There were eight men and one woman, the mean age of the patients was 31 years, and the size of the flaps ranged from 7 × 3.5 cm to 15 × 9 cm; thinning was performed in all flaps. Results: All flaps survived completely, and the donor site was closed directly in seven cases; in two cases, the exposed muscle was covered with split-thickness skin graft. Conclusions: The anterolateral thigh flap was thin enough for defects on the dorsum and/or palm of the hand and for first web reconstruction after scar contracture release. It has many advantages in free flap surgery including a long pedicle with a suitable vessel diameter, and the donor-site morbidity is acceptable. The thin anterolateral thigh flap is a versatile soft-tissue flap that achieves good hand contour with low donor-site morbidity.Keywords:
Perforator flaps
Partial free flap failure can sometimes be more exasperating than total failure as the reason may be unknown, the best potential recipient site has already been violated, and the risk of undertaking a mandatory second free flap perhaps too extenuating. Muscle perforator flaps, often for inexplicable reasons, are also susceptible to partial flap necrosis. However, the large source vessel to their requisite perforator(s) can serve as a convenient second recipient site for attachment as a “flow-through” to another perforator free flap to salvage the overall reconstruction. In a metachronous fashion, this would represent a sequential chimeric perforator-based free flap and proves to be yet another inherent advantage of muscle perforator flaps.
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Many reports about free perforator flaps have been published. Among them, the free true perforator flap (classified by Koshima) is the least invasive flap because the main vessels in both donor and recipient sites are preserved. Two cases of reconstruction with free true perforator flaps in the hand and forearm region are reported. This is the first report of free true perforator flaps.
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In planning the sequential transfer of free flaps with an adequate time interval, the transferred prior flap can be considered a potential donor site when it becomes partially dispensable as a result of redundancy. Increased control of the range of flap thickness is one of the advantages of a perforator flap. Therefore, a transferred perforator flap with a redundancy in thickness could be reelevated later as a thin perforator flap that leaves significant subcutaneous tissue intact. We present an unusual case in which a prior free perforator flap was reelevated as a thin flap and transferred as a free flap to another location. Two years after the first transfer, the medial thigh septocutaneous perforator-based flap in the calf region was elevated again, with only the inclusion of a thin subcutaneous layer based on the same perforator pedicle, and was moved as a free flap to the anterior tibial region. The use of a prior perforator flap as a donor site for a later flap can avoid the additional sacrifice of a new donor site. The recycling of redundant perforator flaps to yield another flap through tangential splitting is another advantage of perforator flaps.
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A perforator flap consists of skin and fat harvested from a donor site nourished by myocutaneous perforators while sparing the donor muscle for function and strength. This flap type has revolutionized microvascular free tissue transfer and the techni
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The gluteal thigh flap is a myofascio-cutaneous flap receiving its blood supply from a descending branch of the inferior gluteal artery. The gluteal thigh flap was first described by Hurwitz in 1980; since then numerous articles have reported on the successful use of this flap, as a transposition or a pedicled island flap, to cover wounds in the sacrogluteal and perineal regions. In contrast to its widespread use as a pedicled flap, employment of the gluteal thigh flap as a free flap is almost unreported in the literature, despite its extremely low donor morbidity and numerous articles on successful (other) free flap reconstructions based on the (same) inferior gluteal artery (e.g., in breast reconstruction). In this article we report on the successful use of the gluteal thigh flap as a purely fascio-cutaneous free flap in limb reconstruction. The literature on the microvascular anatomy of the gluteal thigh flap is reviewed in detail, and a precise description is given of the preoperative measures and surgical manoeuvres required to increase the reliability of this free flap. From the anatomical data and the problems encountered in this case, it should be concluded that, despite the many advantages of this flap and an ultimately successful outcome, the gluteal thigh flap is not a first choice flap for microvascular transfer. © 1997 Wiley-Liss, Inc. MICROSURGERY 17:386–390 1996
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Perforator flaps should no longer be considered an exotic or complicated option for microsurgical tissue transfer. However, despite a proper design and attention to detail, as with any free flap, failure can be anticipated sometimes to occur. If a free flap is then still indicated, the big question is what to do next? In our series of 314 perforator free flaps over the past decade, 21 (7%) total failures occurred. A second free flap was attempted for 17 (81%) of these cases. Overall these were successful for 16 (94%) patients, including 11 perforator free flaps that were 100% successful. The anterolateral thigh (ALT) free flap proved to be the "workhorse" alternative. It can be concluded that if failure of a free flap can best be rectified by a second free flap, failure of a perforator free flap can also be reliably salvaged by a second perforator free flap.
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