Anterolateral thigh fasciocutaneous flap in the difficult perineogenital reconstruction

A pedicled anterolateral thigh fasciocutaneous flap that was used to cover a complicated perineogenital defect after bilateral gracilis myocutaneous flap for perineal reconstruction is presented. The indications and advantages of this approach are outlined. This technique offers to the plastic surgeon and gynecologic oncologist a new option in the armamentarium for reconstruction of the perineum, and it offers the patient reduced donor-site morbidity.     

Anterolateral thigh flap for postmastectomy breast reconstruction

Most postmastectomy defects are reconstructed by use of lower abdominal-wall tissue either as a pedicled or free flap. However, there are some contraindications for using lower abdominal flaps in breast reconstruction, such as inadequate soft-tissue volume, previous abdominoplasty, lower paramedian or multiple abdominal scars, and plans for future pregnancy. In such situations, a gluteal flap has often been the second choice. However, the quality of the adipose tissue of gluteal flaps is inferior to that of lower abdominal flaps, the pedicle is short, and a two-team approach is not possible because creation of the gluteal flap requires that the patient's position be changed during the operation. In 2000, five cases of breast reconstructions were performed with anterolateral thigh flaps in the authors' institution. Two of them were secondary and three were immediate unilateral breast reconstructions. The mean weight of the specimen removed was 350 g in the three patients who underwent immediate reconstruction, and the mean weight of the entire anterolateral thigh flap was 410 g. Skin islands ranged in size from 4 x 8 cm to 7 x 22 cm, with the underlying fat pad ranging in size from 10 x 12 cm to 14 x 22 cm. The mean pedicle length was 11 cm (range, 7 to 15 cm). All flaps were completely successful, except for one that involved some fat necrosis. The quality of the skin and underlying fat and the pliability of the anterolateral thigh flap are much superior to those of gluteal flaps and are similar to those of lower abdominal flaps. In thin patients, more subcutaneous fat can be harvested by extending the flap under the skin. Use of a thigh flap allows a two-team approach with the patient in a supine position, and no change of patient position is required during the operation. However, the position of the scar may not be acceptable to some patients. Therefore, when an abdominal flap is unavailable or contraindicated, the creation of an anterolateral thigh flap for primary and secondary breast reconstruction is an alternative to the use of lower abdominal and gluteal tissues.     

Anterolateral thigh flap for abdominal wall reconstruction

The free or pedicled anterolateral thigh flap was introduced for the reconstruction of large abdominal wall defects. This flap is superior to the tensor fasciae latae musculocutaneous flap in several respects. These include the wide, reliable skin territory (which can reach the level of the knee) and the long pedicle. Therefore, a pedicled anterolateral thigh flap with reliable blood circulation can easily be positioned above the umbilicus. In addition, the free anterolateral thigh flap has greater freedom of orientation and can be used to repair larger abdominal wall defects than can the tensor fasciae latae flap. Seven patients in whom abdominal wall defects had been reconstructed with pedicled or free anterolateral thigh flaps were reviewed. Their average age was 47.1 years (range, 21 to 74 years), and the average follow-up period was 10.7 months (range, 2 to 21 months). The size of the abdominal wall defects ranged from 12 x 12 cm to 18 x 24 cm, and the size of the transferred flap ranged from 10 x 20 cm to 20 x 20 cm. Three flaps were pedicled and four were free, of which three incorporated the tensor fasciae latae flap. All flaps survived completely, and no postoperative abdominal hernias developed. Despite some variations in vascular anatomy and technical difficulties in elevating the anterolateral thigh flap, the authors conclude that the pedicled or free anterolateral thigh flap is superior to the tensor fasciae latae flap for reconstruction of large abdominal wall defects.     

Innervated island flaps in morphofunctional vulvar reconstruction

In this article, the authors present their own experience in vulvar reconstruction following vulvectomy using two different innervated island flaps according to the size and site of the defect. Island-flap mobilization is possible thanks to the rich blood supply of the perineal region. The methods described are a "V-Y amplified sliding flap from the pubis" and a "fasciocutaneous island flap" raised from one or both gluteal folds. The V-Y amplified sliding flap from the pubis is indicated when the defect is symmetric and located anteriorly. This flap is harvested from the pubis and vascularized by the deep arterial network of the pubis. Sensory innervation is provided by branches of the ileo-inguinal nerve. The fasciocutaneous island flap, raised from one or both gluteal folds, can be used following hemivulvectomy or radical vulvectomy, respectively, to cover posteriorly located defects. Vascularization is provided by the musculocutaneous perforating branches of the pudendal artery, whereas sensory innervation is maintained through the perineal branches of the pudendal nerve. Twenty-two patients have undergone reconstructive surgery of the vulvar region from 1989 to date. On 14 patients, a V-Y amplified sliding flap was used; on 7 patients, reconstruction was carried out by island flaps raised from the gluteal fold. Both techniques are compatible with inguino-femoral lymphadenectomy, and they allow for a correct morphofunctional reconstruction and provide good local sensibility. The final result is aesthetically satisfactory, as all final scars are hidden in natural folds.     

The versatility of the pudendal thigh fasciocutaneous flap used as an island flap

The pudendal thigh flap is a sensate fasciocutaneous flap based on the terminal branches of the superficial perineal artery, which is a continuation of the internal pudendal artery. Several authors have reported using this axial patterned flap in a bilateral fashion to reconstruct the vagina, mostly in patients with vaginal atresia. The technique is simple, safe, and reliable, and no stents or dilators are required. The reconstructed vagina has a natural angle and is sensate. The donor site in the groin can be closed primarily with an inconspicuous scar.The distinct advantages of this flap widen its indications to several other pathologies. In this article, the authors report on the bilateral use of the flap to reconstruct a vagina in patients with congenital atresia (n = 8) and after oncological resection (n = 5). Furthermore, the versatility of this island flap is also demonstrated by its use in a unilateral fashion in patients with recurrent or complex rectovaginal fistulas (n = 4) and in two patients with a defect of the posterior urethra in a heavily scarred perineum.All 31 pudendal thigh flaps survived completely. Some wound dehiscence was observed in two patients. Two other patients required a minor correction at the introitus of the vagina. The functional outcome was excellent in all patients, despite the presence of some hair growth in the flaps.This article discusses the expanding indications of this versatile flap and the refinements in operative technique.     

Forefoot reconstruction by reversed island flaps in diabetic patients

Soft-tissue coverage of the foot is often difficult, especially when the distal third of the foot (dorsal or plantar aspects) is involved. The clinical situation can be further complicated when diabetic patients are affected by painful and unstable wounds of this kind because of the familiar phenomenon of vasculopathy. The purpose of this study was to evaluate the possibility of using distally based foot flaps to cover forefoot defects in diabetic patients. Preoperative selection of patients was the key to this study; those who had other major disease, chronic infection, bone involvement, and/or insufficient foot vascularization were excluded from the study. The authors report a series of 12 diabetic patients in whom the reconstruction of medium-sized defects (ranging from 1.5 x 2.0 cm to 3.0 x 7.0 cm) of the forefoot was performed using distally based dorsalis pedis flaps or medial plantar flaps. The transferred flaps survived and adapted well to the defects, except for one flap in a patient who had a slight venous insufficiency at outset. Wearing their own footwear, patients could walk after 20 to 30 days. After the follow-up period (3 months to 3 years), no skin breakdown in the treated areas was observed. Temporary donor-site pain was reported by medial plantar flap patients, and partial skin graft loss at the donor site occurred in some of the dorsalis pedis patients. The authors suggest that in selected cases, medium-sized soft-tissue defects involving the dorsal aspects or the weight-bearing areas of the diabetic foot can be successfully covered with distally based island flaps.     

Anterolateral thigh flap donor-site complications and morbidity

The authors examined donor-site complications and morbidity in 37 patients after reconstruction with free or pedicled anterolateral thigh flaps. Intraoperative assessment included damage to the vastus lateralis muscle and whether the main pedicle of the rectus femoris muscle had been killed. Postoperative assessment of the donor site included wound healing, range of motion, muscle strength, gait, and sensation. Patients were surveyed with a questionnaire about fatigue in their activities of daily life and the appearance of the donor site. All 32 patients who underwent primary skin closure could perform activities of daily life normally, and most (87.5 percent) reported that donor-site appearance was satisfactory. However, the severity of donor-site dysfunction was related to the degree of damage to the vastus lateralis muscle, and most patients (87.5 percent) had some loss of sensation at the anterolateral aspect of the thigh. Because of adhesions between the meshed skin graft and the underlying fascia, range of motion at the hip and knee was limited in significantly more patients who had received split-thickness skin grafts (60 percent) than patients who had undergone primary skin closure (3.1 percent). Therefore, wider flaps or flaps harvested nearer the knee may increase donor-site morbidity. The authors concluded that the incidence of long-term morbidity with the anterolateral thigh flap is low, although it is increased when the flap includes the vastus lateralis muscle or is wider and requires additional skin grafting at the donor site.     

Soft-tissue reconstruction of open fractures of the lower limb: muscle versus fasciocutaneous flaps

Early vascularized soft-tissue closure has long been recognized to be essential in achieving eventual infection-free union. The question of whether muscle or fasciocutaneous tissue is superior in terms of promoting fracture healing remains unresolved. In this article, the authors review the experimental and clinical evidence for the different tissue types and advocate that the biological role of flaps should be included as a key consideration during flap selection.     

Distal lower leg local random fasciocutaneous flaps

Significant open wounds of the distal third of the lower leg that require some form of vascularized flap have historically been covered with distant cross-leg flaps or more appropriately with microsurgical tissue transfers. The rediscovery of the "random" fasciocutaneous flap as a reliable single-stage option for proximal lower leg defects has been extended distally to allow an expedient alternative in lieu of these more complicated procedures. Over the past 7 years, 17 selected patients had closure of distal leg and ankle wounds with 19 local antegrade-oriented fasciocutaneous flaps. All eventually healed without serious sequelae, although 5 (26 percent) had minor complications, except for one case that could only be salvaged with a free-tissue transfer in order to prevent limb amputation. For small- or moderate-sized, uncontaminated injuries, this approach warrants consideration under appropriate circumstances as a simpler option that may permit satisfactory healing and avoids the known risks of microsurgical tissue transfers.