Outcomes of Subfascial, Suprafascial, and Super-Thin Anterolateral Thigh Flaps: Tailoring Thickness without Added Morbidity

Diamond, Shawn; Seth, Akhil K.; Chattha, Anmol; Iorio, Mathew L.

doi:10.1055/s-0037-1607426

Cited by 33 publications

(53 citation statements)

References 35 publications

(37 reference statements)

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“…Hong and coworkers in Asan Medical Center, Seoul, have extensively demonstrated the feasibility of using the superficial fascia layer as a plane for perforator flap elevation for various types of free flaps (Goh et al, 2015;Hong, Choi, et al, 2014;Hong & Chung, 2013;Hong, Yim, et al, 2014). Iorio and colleagues have described the successful use of super-thin ALT flaps dissected at the level of the superficial Scarpa's fascia for limb reconstruction (Seth & Iorio, 2017;Diamond, Seth, Chattha, & Iorio, 2018). No other groups have published their experiences with this method.…”

Section: Discussionmentioning

confidence: 99%

The thin profunda femoral artery perforator flap for tongue reconstruction

et al. 2019

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Background With the ongoing global epidemic of obesity in the Western countries, thigh flaps such as the profunda artery perforator (PAP) free flap, have been less favorable for glossectomy reconstruction due to large bulk of adipose tissue associated with traditional subfascial harvest. In this article, we present a series of 10 patients who underwent reconstruction with suprafascial PAP free flaps following oncologic tongue resection. Methods Our series included six men and four women with an average age of 53.9 years old (range, 28–71 years). All patients underwent preoperative computed tomographic angiography (CTA) for selection of the most suitable perforator and preoperative design of its customized thickness. Flap elevation was performed at the superficial fascia layer while modifying the plane of dissection according to the specific bulk needs in each case. Results Flaps survived in nine patients; one flap failed due to vasospasm. Mean pedicle length was 7.4 cm (range, 6–8 cm). Skin paddle dimensions varied between 8 × 6 and 15 × 9 cm. Flaps thicknesses ranged from 0.4 to 3 cm. Functional outcome was evaluated at 6 months follow up: good speech and deglutition functional outcomes relative to extent of resection were observed. Conclusions The dissection above the superficial fascia layer represents an important refinement to the traditional fasciocutaneous PAP flap. Flap thickness can be tailored to avoid excess of bulk in the medial thigh observed in larger BMI populations.

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Section: Discussionmentioning

confidence: 99%

The thin profunda femoral artery perforator flap for tongue reconstruction

et al. 2019

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“…Limb salvage techniques are utilizing thinner flap techniques more frequently as outcomes are proving to be equivalent to the standard anterolateral thigh (ALT) flap with the added benefit of reduced re-operations and revisions for debulking, as seen in Figure 1 [20,21] . In a series of 25 super-thin or supra-fascial ALT flaps, Seth et al [21] had no episodes of partial or total flap losses.…”

Section: Discussionmentioning

confidence: 99%

Skin grafting the vascular pedicle: a useful technique to avoid microvascular collapse in free tissue transfer for limb salvage

Kovar¹,

Diamond²,

Iorio³

2019

PAR

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Aim: Free tissue transfer is essential for extremity reconstruction following traumatic injuries, oncologic resection, and diabetic complications. However, given the circumferential shape of the arm and leg, a small amount of ongoing edema can prevent a tension-free closure. Additionally, intraoperative thrombosis, vascular disease can lead to proximal exposure of the pedicle or vein grafts. This study evaluates the outcomes of microvascular transfers that utilized a skin graft for closure over the pedicle, in comparison with a matched cohort with a tension-free primary closure. Methods: A retrospective review was completed of all patients that underwent free flap reconstruction of an extremity defect from January 2014 to December 2017 at a single academic institution. Flaps that utilized skin grafting for closure were compared to those closed primarily. Adjunct operative procedures, demographics, and complications were evaluated. Results: A total of 71 patients fulfilled the inclusion criteria. The 11 flaps in 10 patients underwent skin grafting over the pedicle. The two cohorts were comparable in age, gender, BMI, and co-morbidities, excluding renal disease which was present in 40% (n = 4) of skin grafted group compared to 6.5% (n = 4) in the primary closure group. Flap area, operative time, and anastomosis technique were comparable between the two groups. There was no significant difference in the rates of post-operative complications including partial flap loss, complete flap loss, infection. Mean follow up time in the skin grafting group was 14.2 months and 20.2 months for the primary closure group. Conclusion: As per the principal, a tension-free closure is paramount to preventing tissue complications including direct compression of a microvascular pedicle. However, with ongoing tissue edema skin grafting should be considered as a reliable technique to ensure both protection of the pedicle as well as prevention of direct compression without additional complications and comparable post-operative outcomes.

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“…Flap thickness was tailored to match defect surface contour and volume of dead space. Our technique for elevation in the desired plane has been previously described [15,16] . Superthin flaps were defined as those elevated at the superficial scarpal fascia within the subcutaneous fat.…”

Section: Reconstructive Techniquementioning

confidence: 99%

“…Over time, a deeper understanding of perforasome anatomy [12] , microsurgical technical refinements [13][14][15][16] , perioperative protocols and improved instrumentation has empowered reconstructive surgeons to reliably utilize skin-only and fasciocutaneous flaps for coverage of lower extremity defects [17] . Nonetheless, challenges remain as traditional perforator-based flap thickness can interfere with post-operative function, particularly in the lower extremity, wherein bulky, thick, flaps can interfere with footwear, contour across joints, irregular weight bearing surface and can lead to flap breakdown [2,13,14] .…”

Section: Introductionmentioning

confidence: 99%

“…Recent reports consistently demonstrate that elevation of the ALT flap in different planes allow for the possibility of safe, consistent, and definitive distal extremity reconstruction in a single stage [15,18,19] . However, limited data exists for successful limb salvage with use of thin fasciocutaneous flaps in the setting of osteomyelitis, limb ischemia and the Charcot foot.…”

Section: Introductionmentioning

confidence: 99%

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Limb preservation with suprafascial and thin perforator flaps: salvaging osteomyelitis, Charcot collapse and critical limb ischemia

Diamond¹,

Doval²,

Scott³

et al. 2019

PAR

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Aim: There are limited reports in the United States demonstrating outcomes of primarily thinned fasciocutaneous flaps in the setting of critical limb ischemia, Charcot collapse and osteomyelitis. We hope to determine patient and flap related outcomes in advanced lower extremity disease. Methods:The authors conducted a retrospective review of fasciocutaneous free flaps of variable thickness for lower extremity salvage. Osteomyelitis and non-osteomyelitis patients were compared according to our primary outcome measures: functional ambulation, bone healing and complications to flap and patient. Subgroups with critical limb ischemia, Charcot collapse and diabetic foot were analyzed separately.Results: Fifty-nine patients underwent free flap reconstruction: osteomyelitis (n = 20, 34%), Charcot collapse (n = 22, 37%), and/or critical limb ischemia (n = 12, 20%). All patients underwent anterolateral thigh flaps tailored for defectspecific thicknesses: 17 superthin, 25 suprafascial, 17 subfascial. There were no significant differences between groups in terms of partial and complete flap loss (P = 1.000 and P = 0.108). Ninety-one percent of patients were ambulatory at follow up. Eighty-five percent of individuals with osteomyelitis cleared their infection demonstrating radiographic bone healing. Two patients developed recalcitrant deep space infections ultimately requiring amputation. Subgroup analysis did not show any differences in flap related complications within the diabetic Charcot population. In multivariate regression, preoperative revascularization was independently associated with failure of limb salvage. Conclusion:Primarily thinned perforator flaps performed well in the setting of lower extremity limb salvage, critical limb ischemia, osteomyelitis, and the Charcot foot -expanding their role in the armamentarium for lower extremity care.

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Outcomes of Subfascial, Suprafascial, and Super-Thin Anterolateral Thigh Flaps: Tailoring Thickness without Added Morbidity

Abstract: Tailoring ALT thickness can be performed safely without compromising flap outcomes or patient morbidity. Suprafascial and super-thin ALTs allowed for safe, precise solutions for tissue coverage.

Cited by 33 publications

References 35 publications

The thin profunda femoral artery perforator flap for tongue reconstruction

The thin profunda femoral artery perforator flap for tongue reconstruction

Skin grafting the vascular pedicle: a useful technique to avoid microvascular collapse in free tissue transfer for limb salvage

Limb preservation with suprafascial and thin perforator flaps: salvaging osteomyelitis, Charcot collapse and critical limb ischemia

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