The anterolateral thigh (ALT) fasciocutaneous flap has been well described for hand skin cover, however its use in its composite (multiple tissue) form incorporating bone, muscle and/or fascia has been less well described. We report the usefulness of the composite ALT flap in six complex hand trauma cases, four male and two female (age range 14-46 years). The palm of the hand was affected by injury in three cases, the dorsum in two cases, and the radial side in one case. The first web formed part of the injury in three cases. There was variable involvement of the tendons, nerves and bones. Fascia lata was included in the flap to provide a gliding surface in four cases, part of the vastus lateralis muscle was included to obliterate dead space in two cases and to create a first web in one case, and a bone block from the iliac crest was included to reconstruct the lost metacarpals in one case. All flaps survived with minimal complications. This work shows that the anterolateral thigh composite flap is a reliable option when multiple tissue types are required in hand reconstruction.

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Background: Significant weight loss patients have diverse soft tissue laxity that involve every area of their body. The aim of surgical interventions is to help these patients regain their form, function, and most importantly through minimal scars. The traditional excisional procedures inevitably end up with multiple noticeable scars that have mostly equal concern and complain to pre-excision soft tissue laxity. LAL is a bet new modality that proved its efficacy in reducing fat and induce skin tightening Non-MWL patients. The study her proved its efficacy in MWL patients. Material and Methods:The study was classified into 2 time-period related groups. They were before and after introduction of LAL in the author's practice. The study was conducted over 537 post MWL patients (194 and 343 patients in 1 st and 2 nd groups respectively). The number of total procedures for all were 1235 procedures. The follow-up period was from 5 M-2 Y. The number of bariatric to non-bariatric weight loss in the first group was 89:105 (45.9%: 54.1%). In the second group, it was 102:241 (bariatric: non-bariatric weight loss) in a percentage of (29.7%: 70.3%). Results:There was no significant difference in the age, weight, and regional skin redundancy and subcutaneous fat thickness in the baseline between two groups (p 0.05). When analyzing the data it was found that, 1-The number of MWL patients presented for body contouring increased after the author introduced LAL in his work, 2-A reversal in number of patients that had loss of weight through bariatric surgery and number of patients who lost weight through diet and exercise between 1 st and 2 nd groups (112/82:136/207), 3-The second group patients tended to have multiple procedures comparing to first group patients n -276 (1.4) Vs n -959 (2.9), 4-There was a little variable difference in number of procedures between patients that have loss of weight through bariatric and diet and exercise in either group (1.6-2.3 versus 2.8-4.3), 5-The number of excisional procedures was decreased in the second group (33% vs 77.5%), 6-The overall patients' satisfaction showed variable results with (81%) of second group being very satisfied in contrast to (55.5%) in first group, 7-The number of non-bariatric weight loss was higher in the second group (73.8% Vs 55.6%), 8-Improvement in skin appearance was more higher in the 1 st than 2 nd group (79.3% Vs 72.2%). Conclusion:The outcome of this study proved the efficacy and safety of LAL-ST in post MWL patients. 317

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