Large wounds reconstruction of the lower extremity with combined latissimus dorsi musculocutaneous flap and flow‐through anterolateral thigh perforator flap transfer

Abstract

Background: Management of large wounds of the lower extremities remains a challenge for plastic and reconstructive surgeons. Herein, a surgical technique and clinical algorithm using the combined transfer of a latissimus dorsi (LD) musculocutaneous flap and flow-through anterolateral thigh (ALT) perforator flap for the treatment of extensive soft-tissue defects is described. Methods: From January 2012 to September 2018, 12 patients (six men and six women) aged 6-37 years, sustained injuries in road traffic accidents with large softtissue defects in the lower extremities. Seven cases were Gustillo Anderson type IIIB open fractures and two cases were Gustillo Anderson type IIIC open fractures. Two wounds were located in the knee joint, four in the calf, and six in the ankle and foot. The skin defect size ranged from 25 Â 20 cm 2 to 36 Â 25 cm 2 . All patients in this series underwent reconstruction using combined transfer of the LD musculocutaneous flap and flow-through ALT perforator flap, wherein the LD was attached through its pedicle to the distal continuation of the ALT flap.Results: The size of the flow-through ALT perforator flaps ranged from 13.5 Â 6.5 cm 2 to 31 Â 8.5 cm 2 . The size of the LD musculocutaneous skin paddle ranged from 25 Â 6 cm 2 to 34 Â 7 cm 2 , and that of the muscle paddle ranged from 13 Â 3.5 cm 2 to 30 Â 11 cm 2 . One patient experienced postoperative thrombosis of the venous pedicle, and the flap was salvaged after emergency re-exploration and thrombectomy.No other complications were observed postoperatively. The mean follow-up period was 26.8 months. All patients were able to ambulate independently at the end of the follow-up period. Conclusions:The combined transfer of the LD musculocutaneous flap and flowthrough ALT perforator flap ensured adequate surface coverage, making it a feasible procedure for large soft-tissue defects. | INTRODUCTIONHigh-energy traumatic injury often causes significant soft-tissue loss.Early reconstruction of extensive soft-tissue defects is essential to salvage an extremity and restore its functionality (Soni et al., 2012;Zeltzer & Van Landuyt, 2012;Zhu et al., 2013). Fabricated chimeric flaps or sequential chimeric flaps based on the flow-through anterolateral thigh (ALT) perforator flap were commonly used to restore complex lower extremity defects. However, several reports have focused on the simultaneous transfer of microsurgically

Melatonin Improved the Survival of Multi-Territory Perforator Flaps by Promoting Angiogenesis and Inhibiting Apoptosis via the NRF2/FUNDC1 Axis

“…Conjoined flap supplied by two adjacent angiosomes to expand the incision area of the flap by applying technology of supercharged or tubercharged ( Hallock 2008 ), which have the disadvantage of being difficult to harvest. Combined flap is a combination of two different skin flaps, which has the disadvantage of sacrificing the second donor site ( He et al, 2021 ). While multi-territory perforator flap has the advantages of simple incision and large acquisition area.…”

Resurfacing of lower extremities: Versatility of thigh flap as pedicle extension graft with consecutive thoracodorsal artery perforator‐based flap

“…To resurface defects distant from the AMT or ALT pedicle, such as the extremities, a free ALT flap was planned. The ALT flap and pedicle were harvested routinely, as described by many authors (He et al, 2021; Park et al, 2012; Qing et al, 2015; Wu et al, 2021). When resurfacing of penoscrotal defects was needed, a pedicled AMT flap was planned.…”

“…Because most surgeons are familiar with harvesting the TDAp or LD flap in the lateral decubitus position, those flaps have not gained popularity in extremity reconstruction, especially in sequential chimeric flap harvesting. Tang J reported 12 cases of reconstruction using combined transfer of a flow-through ALT flap and LD flap, but the LD flap was harvested in the lateral decubitus position, so patient's position had to be changed during the operation to anastomose to the recipient vessels and to harvest ALT flap(He et al, 2021).The first advantage of TDAp and LDms flaps is their large flap dimension, which can cover the entire lower leg (J. T. Kim, 2003). The reason why most surgeons are reluctant to use these flaps in lower extremity reconstruction is that they are most familiar with harvesting a flap in the lateral decubitus position, which eventually requires a position change.…”

The turbocharged wide anterolateral thigh perforator flap to reconstruct massive soft tissue defects in traumatized lower extremities: A case series

“…There have been several reports on free flap options for reconstructing extensive soft tissue defects in the lower extremities (3)(4)(5)(6)(7)(8)(9). Diverse reconstructive options using a single tissue or a combination of various body tissues have been introduced in these reports; however, the anterolateral thigh perforator (ALTP) flap is currently recognized as the most promising choice owing to its proven vascular reliability and versatility (10)(11)(12)(13)(14).…”