Reconstruction of plantar foot defects with free super-thin anterolateral thigh flap.

BACKGROUNDS: In the repair of plantar foot defects, it is important that the reconstructed area is compatible with surrounding tissue while weight-bearing ability continues. In our study, we present long-term results of plantar foot reconstruction with super-thin ALT flaps in patients that required reconstruction with free tissue transfer. METHODS: We evaluated 11 patients with plantar foot defects that underwent reconstruction with a super-thin ALT flap. Patients were evaluated for postoperative ulceration, ability to wear normal shoes, time to return to work/school, LEFS score and satisfaction with aesthetic results. RESULTS: No bone defects were observed in the patients included in our study, except for the phalanges and distal metatarsals. Defects with soft tissue loss were reconstructed. The mean flap thickness was 4.9 mm (range 3-6 mm). Follow-up period ranged from 16 to 59 months. One patient required grafting for partial flap necrosis and recovered totally. Another patient required debulking surgery. Two patients had superficial ulceration postoperatively, which responded well to conservative therapy. The mean VAS score for cosmetic satisfaction was 8 of 10 (range, 6-9). Eight patients were satisfied with the flap contour, while three others were fairly satisfied. Mean time to return to work/school after surgery was 2.5 months. The preoperative LEFS score increased from 32.03 ± 15.2 to 58.7 ± 10.6 in the postoperative period, this difference was statistically significant (P<0.01). CONCLUSION: We consider that the advantageous features of super-thin ALT flaps such as proper tightening, reduced postoperative atrophy, and better contouring features make these flaps suitable for plantar foot defects.

Comparison of The Thickness of Free Anterolateral Thigh Flap in Different Fascial Planes: Clinical Results of Subfascial and Superficial Fat Flap.

Background The anterolateral thigh (ALT) flap is a preferred option in the reconstruction of a wide variety of defects, enabling multiple tissue components and thicknesses. Methods This study was conducted to investigate the correlation of the thickness of the traditional subfascial ALT flap and superficial fat flap with age, gender, and body mass index (BMI). A total of 42 patients (28 males and 14 females) were included in the study. Results Mean age was 50.2 (range, 16-75) years and mean BMI was 24.68 ± 4.02 (range, 16.5-34.7) kg/m 2 . The subfascial flap thickness was significantly thinner in male patients (16.07 ± 2.77 mm) than in female patients (24.07 ± 3.93 mm; p < 0.05), whereas no significant difference was found between male (4.28 ± 1.15 mm) and female patients (4.85 ± 1.09 mm) regarding superficial fat flap thickness ( p = 0.13). The thickness of both flaps had a positive correlation with BMI, and the strongest correlation was found for subfascial ALT thickness in female patients ( r = 0.81). Age had no effect on both flap thickness measurements. The anterior thigh is thicker in women than in men, although it varies according to BMI. This shows that flap elevation is important in the superthin plane, especially if a thin flap is desired in female patients in defect reconstruction with the ALT flap. Thus, a single-stage reconstruction is achieved without the need for a defatting procedure after subfascial dissection or a second defatting procedure 3 to 6 months later. Conclusion The appropriate ALT flap plane should be selected considering the gender and BMI of the patient.

New Approach for Superthin Anterolateral Thigh Flap Elevation.

BACKGROUND: Anterolateral thigh (ALT) flaps are widely used for soft tissue reconstructions. They have several advantages, most notably a long pedicle, an appropriate pedicle caliber, low donor site morbidity, and the possibility of 2 teams working simultaneously. However, conventional, thick ALT flaps used for reconstructions of head and neck and lower extremity defects may cause postoperative range of motion limitations and cosmetic problems. The aim of this study was to develop and propose strategies to facilitate the harvest of superthin ALT flaps and minimize technical difficulties. This article provides step-by-step instructions for simple, quick, and reliable dissections of superthin ALT flaps. METHODS: This study retrospectively analyzed data from 60 free superthin ALT flaps used for soft tissue reconstructions in 56 patients between January 2018 and February 2019. Superthin flaps were elevated just above the superficial Scarpa's fascia using a vertical approach. RESULTS: Thirty-eight of the patients were operated on for lower extremity wounds, 16 were for head and neck defects, and 6 were for upper extremity wounds. The mean follow-up period was 7 months. The median hospital stay was 10 days. Total flap loss was observed in 4 cases (6.6%), and partial flap loss was observed in another 4 cases (6.6%). CONCLUSIONS: The superthin elevated ALT flap is a reliable and effective option for the reconstruction of soft tissue defects. In our vertical approach, the wide field of view of the flap perforator provides easy dissection, making it easier to elevate the superthin ALT flap.

The evaluation of the effect of free gracilis muscle transfer on cheek tone and oral competence in long-standing facial paralysis of patients by using Blasco index.

PURPOSE: Smile and eyelid reanimation are generally emphasized in facial reanimation, but the loss of cheek tone provided by the buccinator muscle is not adequately addressed. The use of free gracilis muscle flap for facial reanimation has become widespread since it was used in head and neck reconstruction by Harii et al. The effect of free gracilis muscle transfer on drooling is not clearly defined in the literature. In our study, we aimed to evaluate the effect of free gracilis muscle transfer on drooling in patients with facial paralysis (FP) by using Blasco index. Smile function was overemphasized in the literature, but drooling was not evaluated. What happens to drooling after free functional muscle transfer was not clear, so this study was designed to evaluate improvement in drooling. PATIENTS AND METHODS: Drooling and smile were evaluated in 11 patients (4 male, 7 female) who underwent facial reanimation with a free functional gracilis muscle transfer (FFGMT), in long-standing FP. The mean age was 39.9 years (range 22-56 years). Etiology was idiopathic in two patients, trauma in five patients, and intracranial tumor in four patients. Photographs and video recordings were taken preoperatively and at the first year postoperatively. The muscle was stitched to the upper lip, corner of the mouth, lower lip and the preauricular region. Masseteric nerve was preferred as donor nerve. Smile restoration was evaluated according to the five-stage classification defined by Terzis and Noah. RESULTS: Flap dimensions differed from 12 cm× 5 cm to 15 cm× 6 cm. Oral intake was stopped for 5 days, and speaking was restricted postoperatively. Patients exercised for about 1 h starting from the postoperative third month. Patients were followed up for an average of 26.5 (14-48) months postoperatively. Postop courses were uneventful, and we did not observe any complications in these patients. Preoperative Blasco index score was 3 in 6 patients, 2 in 5 patients and the mean scores were 2.54 ± 0.52. Patients were followed for 1 year. No drooling was observed in the postoperative first year. The Blasco index score was 0 for all patients. The decrease in postoperative scores was found to be statistically significant (p < .01). Smile restoration was evaluated according to the five-stage classification defined by Terzis and Noah for facial reanimation after muscle transfer. Excellent results (grade 5) were obtained in 6 patients, good results (grade 4) in 4 patients and moderate results (grade 3) in 1 patient. CONCLUSION: Free functional gracilis muscle transfer improves chewing functions and prevents drooling. This case series reveals that FFGMT can be a good option to enable cheek tone in long-standing FP of patients.

Total nasal reconstruction with pre-laminated, super-thin anterolateral thigh flap: A case report.

Many techniques for nasal reconstruction have been described to achieve aesthetically and functionally favorable results. Local tissues, specifically the forehead flap, provide the best tissue match with the nose. However, when local tissue donor sites are limited, alternative options such as free tissue transfers should be considered. Herein, we describe a case of a 72-year-old male patient who had a total nasal and left malar defect reconstructed with a two-staged, pre-laminated, super-thin anterolateral thigh (ALT) flap. The patient's nasectomy was performed 15 years ago. The adjacent left malar defect was due to recent squamous cell carcinoma excision. Local tissues were unavailable for reconstruction due to previous tumor excisions. For the 8.5 × 5 cm defect, a 12.5 × 8 cm ALT flap was planned, with 7.5 × 8 cm for nasal reconstruction and 5 × 4 cm for malar reconstruction. During the first stage, a super-thin fascial ALT flap was raised without dissecting the perforators, and the nasal skeleton was laminated between these two flaps. Costal cartilages were harvested for the nasal skeleton and positioned between the suprafascial and the fascial ALT flaps. During the second stage, two perforators were dissected to the pedicle on the pre-laminated flap, and the flap was divided from the donor site. The nasal skeleton was fixed and anastomosis with the facial vessels was established. After both stages, no complications were observed. After one month, a revision surgery was performed to enhance the transition between the reconstructed nose and the cheek, and improve the nasal projection. Postoperatively, after one year, the patient had a stable nasal reconstruction with good breathing. Prelaminated, super-thin ALT flaps provide the advantages of a wide and versatile donor site and an acceptable donor site scar. They may be an option for patients who are not amenable to traditional reconstruction methods.

Reconstruction of lower lip defects with free super-thin anterolateral thigh flap.

BACKGROUND: Lower lip is a vital organ with important functions as well as aesthetic importance. It is critical to provide an aesthetically appealing lower facial subunit with maintenance of understandable speech and oral competence. Achieving these targets is very difficult especially in total lower lip defects. This report presents a technique using super-thin anterolateral thigh (ALT) flaps with fascia graft for reconstruction of large, complex oral sphincter defects. PATIENTS AND METHODS: Six patients with squamous cell carcinoma (SCC) and one patient with a gunshot injury were presented in this report. All of them had full-thickness defects including skin, orbicularis muscle and oral mucosa. The mean age was 58 (range, 32-85) years. Defects of the lower lip were reconstructed with a super-thin ALT flap. Super-thin flaps were obtained by planning as close to the knee as possible and elevating at the level of superficial fascia. The fascia graft was used for achieving lip suspension. RESULTS: Overall flap survival was 100%. The flap size ranged from 8 × 6 cm to 14 × 10 cm. The follow-up periods ranged from 6 to 14 months. All the patients achieved acceptable oral competence, both in the resting condition and during speaking and eating, except for one patient who had a drooping lower lip developed in the post-operative 3rd month and underwent a secondary tightening procedure. Another patient needed liposuction due to bulky appearance. CONCLUSION: Super-thin ALT flaps seem to be a useful option for functional and aesthetic reconstruction of extensive lip defects.