Yi-Tien Liu

Free anterolateral thigh flap for extremity reconstruction: clinical experience and functional assessment of donor site

From August of 1995 through July of 1998, 38 free anterolateral thigh flaps were transferred to reconstruct soft‐tissue defects. The overall success rate was 97 percent. Among 38 anterolateral thigh flaps, four were elevated as cutaneous flaps based on the septocutaneous perforators. The other 34 were harvested as myocutaneous flaps including a cuff of vastus lateralis muscle (15 to 40 cm3), either because of bulk requirements (33 cases) or because of the absence of a septocutaneous perforator (one case). However, vastus lateralis muscle is the largest compartment of the quadriceps, which is the prime extensor of the knee. Losing a portion of the vastus lateralis muscle may affect knee stability. Objective functional assessments of the donor sites were performed at least 6 months postoperatively in 20 patients who had a cuff of vastus lateralis muscle incorporated as part of the myocutaneous flap; assessments were made using a kinetic communicator machine. The isometric power test of the ratios of quadriceps muscle at 30 and 60 degrees of flexion between donor and normal thighs revealed no significant difference (p > 0.05). The isokinetic peak torque ratio of the quadriceps and hamstring muscles, including concentric and eccentric contraction tests, showed no significant difference (p > 0.05), except the concentric contraction test of the quadriceps muscle, which revealed mild weakness of the donor thigh (p < 0.05). In summary, the functional impairment of the donor thighs was minimal after free anterolateral thigh myocutaneous flap transfer. (Plast. Reconstr. Surg. 107: 1766, 2001.)

Versatility of the free anterolateral thigh flap for reconstruction of soft-tissue defects: review of 140 cases.

From August 1995 to June 1999, 140 free anterolateral thigh (ALT) flaps were transferred to reconstruct a variety of soft-tissue defects. The size of ALT flap ranged from 10 to 33 cm in length and 4 to 14 cm in width. Based on the anatomic variations of the perforators, the blood supply to the skin island came from the septocutaneous perforators only in 19 patients (13.6%), arising from the descending or transverse branch of the lateral circumflex femoral artery (LCFA), or originating directly from LCFA. The other flaps were supplied by musculocutaneous perforators that were elevated as a true perforator flap via intramuscular dissection (N = 34, 24.3%), or used a cuff of vastus lateralis muscle for added bulk (N = 87, 62.1%). The overall success rate was 92% (129 of 140). After a 2-year follow-up, all flaps have healed uneventfully and donor thigh morbidity is minimal. Anatomic variations must be considered if the ALT flap is to be used safely and reliably.

One-stage reconstruction of soft tissue and Achilles tendon defects using a composite free anterolateral thigh flap with vascularized fascia lata: Clinical experience and functional assessment

The combined loss of the Achilles tendon with overlying soft tissue is a reconstructive challenge. To achieve acceptable rehabilitation, such patients need skin coverage including functional repair of the Achilles tendon. This article presents four such patients who were treated successfully by means of an anterolateral thigh (ALT) composite flap with vascularized fascia lata. The size of the ALT flaps ranged from 10 to 16 cm in length and 6 to 9 cm in width. All flaps included vascularized fascia lata, which was rolled to serve as vascularized tendon graft (range 8 × 6 cm to 10 × 8 cm) for reconstruction of the Achilles tendon defect. Flap success rate was 100%. All patients could walk and climb stairs without support; however, mild difficulty when running was reported. Functional outcome of the recipient ankle and donor thigh morbidity were investigated by using a kinetic dynamometer comparing reconstructed sides with the healthy contralateral limbs. This assessment was performed in two patients at 2 years postoperatively. In the reconstructed ankles, isokinetic concentric measurements of dorsiflexion and plantar flexion showed a deficit of 30% and 40%, respectively. Functional evaluation of quadriceps femoris muscle contraction forces after free ALT composite flap harvest showed a 10% to 25% deficit. However, there were no difficulties in daily ambulating. In summary, the free composite ALT flap with vascularized fascia lata provides an alternative option for Achilles tendon reconstruction in complex defects.

One-Stage Reconstruction of Large Midline Abdominal Wall Defects Using a Composite Free Anterolateral Thigh Flap With Vascularized Fascia Lata

Objective:Large midline abdominal wall defects are continuously a challenge for reconstructive surgeons. Adequate skin coverage and fascia repair of the abdominal wall is necessary for achieving acceptable results. The purpose of this paper is to present a new approach to abdominal wall reconstruction using a free vascularized composite anterolateral thigh (ALT) flap with fascia lata. Methods:Seven patients with large full-thickness abdominal wall defects were successfully reconstructed by means of a composite ALT flap combined with vascularized fascia lata. The size of the skin islands ranged from 20 to 32 cm in length and 10 to 22 cm in width, and the vascularized fascia lata sheath measured 14 to 28 cm and 8 to 18 cm, respectively. Functional outcome of the abdominal wall strength and donor thigh morbidity were investigated by using a Cybex kinetic dynamometer. Results:All flaps survived. No postoperative ventral hernia occurred except for one mild inguinal incision hernia. Subjectively there were no significant donor site problems. Objective assessment was performed in 4 patients 2 years postoperatively. In the reconstructed abdomen, isokinetic concentric and eccentric measurements of extension/flexion ratios of the abdominal wall strength showed no apparent decrease compared with other references. Functional evaluation of quadriceps femoris muscle contraction forces after free ALT composite flap harvest showed an averaged deficit of 30% as compared with the contralateral legs. However, no difficulties in daily ambulating were reported by the patients. Conclusion:The free composite ALT myocutaneous flap with vascularized fascia lata provides an alternative option for a stable repair in complex abdominal wall defects.

Reconstruction of traumatic Stensen duct defect using a vein graft as a conduit: two case reports.

Treatment of Stensen duct defect is still controversial. The authors describe the successful use of a retrograde vein graft as a conduit for traumatic segmental Stensen duct defect reconstruction. One patient sustained facial trauma with severe duct crushing and severance, the other had multiple cutting injuries with segmental duct defect. However, primary repair was impossible. A retrograde vein graft harvested from forearm for Stensen duct defect reconstruction was performed using microsurgical technique. A silicon stent was retained for 8 weeks. The sialographic examination showed good functional results without stricture postoperatively. This could be an option for treating such a complicated defect.

Management of Skin Paddle without Visible Sizable Perforator in the Fibula Osteoseptocutaneous Flap for the Mandibular Reconstruction after Cancer Ablation-Two Cases Report

The reliability of the fibula osteocutaneous flap is still controversial. Most authors suggested discarding the skin paddle immediately when the harvested skin paddle lacks sizable perforators. Herein, we report two cases without sizable perforator of skin paddles of the fibula osteocutaneous flaps (skin paddle 12×4 and 10×5 cm in size) for mandibular and buccal defects reconstruction. Although not well vascularized, the skin paddle was retained for intraoral lining temporarily on a wait and see policy, and served as a biological barrier to prevent the salivary from pooling around the vacularized bone graft. The skin paddle was removed two weeks later due to complete devascularization. Spontaneous mucosalization developed to resurface the fibula bone graft uneventfully; no further reconstruction was needed.

Complete Spontaneous Regression of Primary Lesion in Metastatic Melanoma of Thigh- A Case Report

Complete spontaneous regression is generally defined as disappearance of a whole tumor without any treatment or with treatment generally considered inadequate to exert any influence on its general progression. Its prognostic significance is controversial; but when accompanied by metastasis, poor prognosis is regarded. A-77-year old female found a mass over her groin area for months. Incisional biopsy had performed and histology showed metastatic undifferentiated carcinoma, and she went to our clinic due to wound infection one week later. Tracing her history and serial examinations, metastatic melanoma with complete spontaneous regression of primary lesion was suspected. In the present case, combinations of wide tumor excision, superficial groin lymph node dissection, and further chemotherapy got satisfactory result.

Reconstruction of the Degloving Injury of Hand and Fingers-A Case Report

Reconstruction of the complete degloving injury of the hand is a difficult problem in plastic and reconstructive surgery. Many reconstructive options including skin graft, regional flap, distant flap or free flap have been tried to salvage the denuded skin of the fingers and hand. However, the functional and cosmetic results are as yet not satisfactory. We present a case of a complete degloved hand initially treated with skin grafting, and then with a delayed free toe flap for the thumb and free web-space flap for two opposable fingers to provide tripod pinch. The final result was satisfied both functionally and cosmetically.

Forehead Flap for Nasal Reconstruction

Color, thickness, and texture of nasal skin are most accurately matched in forehead skin. Yet, the morbidity of visible donor site in oriental people would disturb the reconstructive surgeon. We collect 15 patients of nasal defects to be reconstructed with forehead flaps and observe the long-term results of donor site. The 15 patients (13 males and 2 females) had accepted a ten-year period of treatment, and the ages ranged from 3 to 70. The size of nasal defects ranged from 5.5X4 cm^2 to 2.0×2.0 cm^2. The etiology of defects came from 6 patients of skin cancer excision, 7 of traumatism, and 2 of secondary deformity after surgical treatments. The forehead flap based on supratrocblear artery was used to reconstruct the defects. The donor site defects could be through primary closure as the width of wound was less than 2.5 cm; if not, secondary healing with occlusive dressing for larger defect. All the reconstructions were successful without any major complications. The forehead donor sites were primarily repaired in 6 patients and healed by secondary intention in 9 patients whose wounds were healed within 4 to 5 weeks. All the patients were satisfied with the outcome functionally and cosmetically. Forehead flaps for nasal defects will get the most accurate color match and texture; and the donor site wound is acceptable for oriental patients, compared with the Caucasian.

Bacteriology Analysis of Wound Infection Following Oral Cancer Surgery

Wound infection following major oral cancer sugery is a common complication which leads to a significant morbidity and prolonged hospitalization. Bacteria of wound discharges was studied in 25 patients after major oral cancer surgery from Jan. 1990 to Jan. 1995 in Kaohsiung CGMH, polymicrobials were identified in 92% (23/25) of cases. Among aerobic culture, Streptococcus are the most common, especially Streptococcus viridans species (15/25), followed by Pseudomonas aeruginosa (9/25), Enterococcus (8/25) and Escherichia coli (6/25). Among anaerobic culture, Bacteroid melaninogenicus (9/25) and Bacteroid species (6/25) are the most common pathogens. Proper selection of antibiotics for perioperative use is still important for the prophylactic option. The priority of treatment of infected wound is adequate open drainage by suture removal and accompanied by broad spectrum antibiotics coverage. Sensitivity test of the bacteria shows penicillin group (Ticarcillin, Pipril, Ampicillin), aminoglycoside group (Amikacin, Netilmicin, Gentamicin) or 3° Cephalosporin are effective. Clindamycin and metronidazole groups are selected for combat anaerobic bacteroids. There is no septic mortality in our series.