No abstract

Lower abdominal, perineal, and groin (LAPG) reconstruction may be performed in a single stage. Anterolateral thigh (ALT) flaps are preferred here and taken as fasciocutaneous (ALT-FC), myocutaneous (ALT-MC), or vastus lateralis myocutaneous (VL-MC) flaps. We aim to present the results of reconstruction from a series of patients and guide flap selection with an algorithmic approach to LAPG reconstruction that optimizes outcomes and minimizes morbidity. Lower abdomen, groin, perineum, vulva, vagina, scrotum, and bladder wounds reconstructed in 22 patients using ALT flaps between 2000 and 2013 were retrospectively studied. Five ALT-FC, eight ALT-MC, and nine VL-MC flaps were performed. All flaps survived. Venous congestion occurred in three VL-MC flaps from mechanical cause. Wound infection occurred in six cases. Urinary leak occurred in three cases of bladder reconstruction. One patient died from congestive heart failure. The ALT flap is time tested and dependably addresses most LAPG defects; flap variations are suited for niche defects. We propose a novel algorithm to guide reconstructive decision-making.

Summary Background: The use of pedicled perforator flaps provides an alternative to free tissue transfer for lower limb reconstruction. We use computer-aided image analysis to investigate the versatility of pedicled perforator flaps for the reconstruction of lower limb defects. Patients and methods: Between April 2007 and April 2011, a case series of 61 patients with wounds of the lower extremity from knee to ankle were reconstructed with pedicled perforator flaps. We performed 16 pedicled reverse-flow anterolateral thigh (RF-ALT) flaps, 8 pedicled medial sural artery perforator (MSAP) flaps, 26 pedicled peroneal artery perforator (PAP) flaps, and 11 pedicled posterior tibial artery perforator (PTAP) flaps. Digital planimetry of defects covered was analyzed and the "efficiency" of each flap was calculated, which allowed the assessment of the merits of each flap in the management of lower limb defects. Results: Flaps healed primarily in 82% of cases (50/61). Approximately 50% of the secondary donor sites required skin grafting. Complications requiring secondary surgery occurred in 18% (11/61) of the cases. Six required secondary skin grafting (10%). One RF-ALT flap was converted into a free flap, one PAP required arterial supercharging, and three pedicled RF-ALT flaps required venous supercharging. Image analysis showed that these pedicled perforator flaps could cover 75% of the surface area of the lower leg. The higher length of perforator allowed for greater "flap efficiency" and better versatility of tissue cover.

This study showed that a protocol that promotes controlled bleeding from the fingertip is essential to achieve consistent high success rates in fingertip replantation. The protocol is safe and reliable, as it avoids the use of medical leeches and the removal of nail plate from the replanted finger. However, full informed patient consent must include the potential need for transfusion and extended hospital stay.

Therapeutic, III.

The free medial sural artery perforator flap transfer is appropriate for small- to medium-sized hand defect reconstruction. The donor site not only supplies a thin fasciocutaneous flap but also provides the option to harvest a segment of tendon or nerve graft through the same incision for composite tissue reconstruction in a single stage.

The distally-based anterolateral thigh flap is an attractive option for proximal leg and knee coverage but venous congestion is common. Restoration of antegrade venous drainage via great saphenous vein supercharge to the proximal flap vein is proposed. The purpose of this study was to evaluate and compare outcomes of 18 large, distally-based anterolateral thigh flaps with and without venous augmentation on the basis of flap size, venous congestion, and clinical course. The average age of 12 men and 6 women was 35.9-year old (range, 16-50 years old). Wounds resulting from trauma, burn sequela, sarcoma, and infection were localized to the knee, proximal leg, knee stump and popliteal fossa. The mean defect was 17.6 × 9.4 cm(2) (range, 6 × 7 cm(2) to 22 × 20 cm(2) ). The mean flap size was 21.4 × 8.8 cm(2) (range, 12 × 6 to 27 × 12 cm(2)). There were 14 cases in the venous supercharged group and 4 cases in the group without supercharge. The mean size of flaps in the venous supercharged group was significantly larger than that in the group without supercharge (22.6 ± 3.8 × 9.1 ± 1.7 cm vs. 17.5 ± 4.4 × 7.8 ± 1.7 cm, P = 0.03). Venous congestion occurred in all four flaps without supercharge that lasted 3-7 days and partial flap loss occurred in two cases. There was no early venous congestion and partial flap loss in supercharged flaps but venous congestion secondary to anastomotic occlusion developed in two cases. Early exploration with vein grafting resolved venous congestion in one case. Late exploration in the other resulted in flap loss. Preventive venous supercharge is suggested for the large, distally-based anterolateral thigh flap.

The anterolateral thigh flap has been popularized as the versatile flap for soft-tissue reconstruction. It has many advantages, including long pedicle length, large skin territory, flow-though and chimeric concept design, a two-team approach, and no need for changing the position. Thus, it is suitable as the immediate emergency flap for upper extremity salvage.