Search Results (57)

Background: Microsurgery and free tissue transfer with microanastomoses are common practices that are reliable for restoring anatomical function and/or morphology. Maintaining adequate blood flow to transferred tissue and preventing thrombosis are key challenges in improving the success of surgery. We conducted a systematic review to investigate the use, effects, and efficacy of lipo-prostaglandin E1 (lipo-PGE1) and PGE1, which have vasodilatory and anticoagulation effects, in microsurgery. Methods: Studies were reviewed for information about the administration of lipo-PGE1/PGE1, including the purpose, effectiveness, administered doses, and duration of use. This review included articles published up to 2024. Databases: PubMed, MEDLINE, and Embase were searched using the keywords: “flap” AND “prostaglandin E1” and “microsurgery” AND “prostaglandin E1.” Results: The initial database search yielded 359 citations; 14 were included in our study with qualitative analysis. These 14 original articles reported PGE1/lipo-PGE1 use in microsurgery for the reconstruction of different anatomical sites, with the most common being the head and neck. Twenty-one different flaps were used; the most common flaps used in head, neck, and lower limb reconstructions were anterolateral thigh flaps. Most studies reported using PGE1/lipo-PGE1 as an antithrombotic, an anticoagulant, a vasodilator, and a strategy to examine blood flow post administration. Only one study compared its effectiveness between two groups and showed significantly lower perfusion-related complications in the prostaglandin group than in the control group. Conclusions: Lipo-PGE1/PGE1 has potential vasodilator effects that increase blood flow through free flaps and potential anticoagulant properties that help prevent thrombosis in microanastomoses. However, multicenter, randomized controlled studies are needed to fully elucidate its benefits. Full article

Background: Recent advances in microsurgical techniques have established free flaps as a cornerstone in complex orthopedic reconstructions, particularly in trauma, infection, and tumor resection cases requiring reliable soft tissue coverage for healing and functional recovery. Among them, the anterolateral thigh (ALT) flap is highly recognized for its versatility and consistency; Methods: We conducted a retrospective case series of five patients who underwent orthopedic reconstructive surgery using a free ALT flap in our department. Demographic, surgical, and clinical data were collected, and outcomes were evaluated and compared with the current literature. Results: The ALT flap proved to be a reliable option across a wide range of orthopedic conditions, providing well-vascularized and adaptable tissue for complex reconstructions. Clinical outcomes in our series were consistent with the favorable results reported in the literature. Conclusions: The ALT flap served as one of the most effective and versatile solutions for orthopedic reconstruction. Its adaptability to diverse clinical scenarios, combined with reproducible positive outcomes, supports its role as a preferred option for managing challenging soft tissue in orthopedics, ultimately contributing to improved function and recovery. Full article

Background: Complex diabetic foot ulcers (DFUs) are a leading cause of morbidity and lower-limb amputation, and their management is profoundly challenging. Microvascular free tissue transfer is a primary limb salvage strategy, with the anterolateral thigh (ALT) free-flap recognized as a workhorse reconstructive solution. However, a quantitative summary of its performance specifically within this high-risk patient population is lacking. Methods: A systematic review and single-arm meta-analysis was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Five electronic databases (PubMed/MEDLINE, Embase, Scopus, Cochrane, and Web of Science Core Collection) were searched up to 9 September 2025 to identify studies reporting on outcomes of ALT free-flaps for diabetic foot reconstruction. The risk of bias was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Primary outcomes were set as the complete and partial flap necrosis rate. Secondary outcomes included functional recovery status and complication rates. All data were synthesized using a random-effects model. Results: Six retrospective cohort studies met the inclusion criteria, including a total of 162 patients. The pooled rate of total flap failure was 5.2% (95% CI: 2.5–10.6%), a finding that was highly consistent across all studies (I² = 0%). The pooled incidence of partial flap necrosis was 13.0% (95% CI: 6.3–25.1%), resulting in an overall weighted flap success rate of 81.8%. Notably, the pooled rate of return to ambulation was 95.2% (95% CI: 88.5–98.1%), which also demonstrated no statistical heterogeneity (I² = 0%). Conclusions: The anterolateral thigh free-flap appears to be a robust and highly reliable strategy for diabetic foot reconstruction, associated with low failure rates, minimal long-term complications, and excellent functional recovery. However, the current evidence is limited to a small number of poor-to-moderate-quality retrospective studies. High-quality, prospective, and comparative multicenter trials are necessary to confirm these findings and establish the ALT flap’s effectiveness in high-risk cohorts. Full article

Introduction: Tumors of the lateral skull base, particularly those arising from the external auditory canal and peri-retroauricular regions, present considerable surgical and reconstructive difficulties due to their intricate anatomy and aggressive nature. The anterolateral thigh (ALT) free flap offers a viable reconstruction option, enhancing oncological radicality while minimizing morbidity. Materials and Methods: A retrospective analysis was conducted on five cases of malignant tumors involving the external auditory canal and adjacent soft tissues, treated at a tertiary center from March 2023 to March 2025. All patients underwent radical resection, which included lateral or subtotal temporal bone resection, along with parotidectomy and neck dissection when necessary. Reconstruction was performed using myocutaneous anterolateral thigh free flaps. The study evaluated clinical outcomes, complications, and esthetic results. Results: The ALT flap was used in all cases without major postoperative complications. Two patients received adjuvant radiotherapy; one did not start treatment due to early recurrence. At follow-up, three patients were disease-free, while two had died from unrelated causes. Esthetic and functional outcomes were satisfactory in all patients. Conclusions: The ALT free flap is a universal and reliable option for the reconstruction of complex lateral skull base defects, especially in patients following the radical removal of tumors of the external auditory canal and peri-retroauricular areas. It offers excellent tissue coverage, facilitates adjuvant treatment, and has a low complication rate. While our experience supports its use in aggressive oncological resection, larger studies are needed to confirm these findings. Level of evidence: 4. Full article

Background: Reconstruction of distal forearm and hand soft tissue defects remains a complex surgical challenge due to the functional and aesthetic significance of the region. Several flap options have been established such as the posterior interosseous artery flap (PIA) or temporalis fascia flap (TFF), yet the anterolateral thigh flap (ALT) has gained increasing attention for its versatility and favorable risk profile. Methods: We retrospectively analyzed 12 patients (7 males, 5 females; mean age 51.8 years) who underwent free microvascular ALT reconstruction for distal forearm and hand defects between May 2020 and May 2025. Etiologies included infection, chemical burns, explosion injuries, and traffic accidents. The mean defect size was 75.4 cm², and the average operative time was 217 min. Secondary flap thinning was performed in eight cases. In one patient without available recipient veins, a pedicle vein was anastomosed using a coupler device anchored into a cortical window of the distal radius to establish venous outflow via the bone marrow. Results: All flaps demonstrated complete survival with successful integration. Minor complications included transient venous congestion in one case and superficial wound dehiscence in four cases. Functional outcomes were favorable, with postoperative hand function rated as very good in 10 of 12 patients at follow-up. The bone-anchored venous anastomosis provided effective venous drainage in the salvage case. Conclusions: The free microvascular ALT is a reliable and highly adaptable method for distal forearm and hand reconstruction. It provides excellent soft tissue coverage, allows for secondary contouring, and achieves both functional and aesthetic goals. Furthermore, intraosseous venous anastomosis using a coupler device might represent a novel adjunct that may expand reconstructive options in cases with absent or unusable recipient veins. Full article

Background: Post-traumatic osteomyelitis (PTO) of the lower extremity is among the most demanding problems in orthoplastic reconstructive surgery. It typically follows open fractures, failed osteosynthesis, or implant infection. Effective management requires coordinated infection control, stable skeletal fixation, and timely vascularized soft-tissue coverage. Methods: We conducted a retrospective case series of 20 consecutive patients with PTO of the lower limb treated between 2021 and 2024 at a tertiary orthoplastic center. All patients underwent radical debridement, culture-directed intravenous antibiotic administration, and soft-tissue reconstruction using local muscle, fasciocutaneous, or free flaps; vascularized bone flaps were used to select nonunion cases. The primary outcomes were flap survival, complications, infection resolution, and limb salvage. Exploratory analyses included descriptive subgroup summaries by flap category. Results: Among 20 patients (15 men, 5 women; mean age 53.6 years), reconstructions included reverse/pedicled sural flaps (n = 9), hemisoleus muscle flaps (n = 7), medial gastrocnemius muscle flaps (n = 2), peroneus brevis muscle flaps (n = 2), and free flaps (n = 6), which comprised anterolateral thigh (ALT), medial femoral condyle (MFC) osteoperiosteal, deep circumflex iliac artery (DCIA) osteocutaneous, and radial forearm free flaps (RFFFs). Single-flap reconstructions were performed in 13 cases, whereas multistage/multiflap strategies were used in 7. Overall flap survival was 90%. Major flap complications comprised partial necrosis in two reverse sural flaps and one complete loss of a reverse sural flap; two patients had minor wound dehiscence. Infection resolved in 18/20 patients (90%; 95% CI ≈ 0.70–0.97). One patient requested below-knee amputation due to persistent nonunion associated with a pathological fracture. At a mean 10-month follow-up, all limb-salvaged patients were ambulatory. Conclusions: Effective reconstruction of PTO is improved by using a patient-specific algorithm that considers the defect location, vascular status, and host comorbidities. Local muscle and fasciocutaneous flaps remain dependable for most defects, with free or vascularized bone flaps reserved for composite or recalcitrant cases. Early referral to high-volume centers, radical debridement, and orthoplastic collaboration are critical for optimizing limb salvage. Our findings should be interpreted in light of the study’s retrospective design and small sample size. Full article

Objectives: The application of fasciocutaneous free flaps for reconstruction of head and neck defects following oncological surgery has increased since the 1970s, coinciding with developments in microvascular techniques. Although reported success rates are between 90% and 99%, flap failure continues to occur, most frequently due to venous congestion. This study examines the rates of re-exploration and flap failure according to the number of venous anastomoses in patients receiving free flap reconstruction after head and neck cancer surgery. Materials and Methods: This retrospective analysis included 163 patients who underwent head and neck reconstruction with free flaps (radial forearm free flap [RFFF] and anterolateral thigh flap [ALTF]) at the University Hospital of Verona between January 2019 and June 2024. Variables examined comprised the type of flap performed, donor and recipient vessels utilized, and number of venous anastomoses, as well as the type (end-to-end [ETE] versus end-to-side [ETS]) and site (internal jugular vein versus external jugular vein) of venous anastomosis. Results: The overall success rate was 93.3%, with no significant difference between single and dual venous anastomosis groups. Prompt re-exploration upon detecting signs of flap failure is critical, as approximately one-third of such failures may be prevented through timely intervention. Conclusions: Single venous end-to-end anastomosis utilizing the internal jugular vein system is typically effective. Further research is warranted to clarify the indications for dual anastomosis involving the external jugular vein system. Full article

Background and Objectives: Reconstructive outcomes following head and neck (H&N) cancer resection in pediatric patients remain understudied, particularly regarding the comparative efficacy of free versus local tissue transfer. Materials and Methods: A retrospective review was conducted on pediatric patients undergoing malignant H&N tumor resection at a tertiary center from 2007 to 2024. Patients were stratified by reconstruction type (free vs. local flap), and outcomes assessed included flap failure, wound complications, revision rates, operative time, hospital stay, and 30-day readmission. Results: A total of 41 patients (mean age: 10.6 years) met inclusion criteria; 18 underwent free flaps and 23 received local flaps. Common diagnoses included osteosarcoma (21.9%) and rhabdomyosarcoma (12.2%). Anterolateral thigh (44.4%) and fibula (33.3%) were the most common free flaps; temporalis (21.7%) and pectoralis (13.0%) were common local flaps. Flap survival was high in both groups (94.4% vs. 100%). However, local flaps had significantly higher rates of hardware exposure (34.7% vs. 5.5%, p = 0.025) and wound dehiscence (39.1% vs. 5.5%, p = 0.045). Free flaps were associated with longer operative times (10.3 vs. 6.5 h, p = 0.011) and hospital stays (29.1 vs. 13.9 days, p = 0.036). Conclusions: While both approaches achieved high flap survival, free flaps may offer more durable reconstruction and reduce wound-related complications in complex pediatric H&N oncologic cases. Full article

Introduction: The indication for a free flap in acute burn reconstruction is very specific. It should avoid several complications that are more common in the burned patient population. We propose an anterolateral thigh (ALT) flap as a first option for primary burn reconstruction in microvascular free flap reconstruction in burned patients. Patients and Methods: A retrospective review of all acutely burned patients treated with microvascular ALT free flap reconstruction between the years 2005 and 2022 in the Vall d’Hebron Barcelona Hospital Campus Burn Centre was conducted. Results: We performed 30 ALT flaps for primary burn reconstruction. The majority of patients were male (87.5%), with a mean age of 36.7 years, and 37% of patients were smokers. High-voltage electrical burns were the most common etiology. The mean time between burn injury and microsurgery was 22 days. The main recipient site was the lower limb. The flap survival rate was 96.6%. One patient required a meshed skin graft to cover a defect in the proximal third due to peripheral flap necrosis. One flap experienced mild congestion, which resolved spontaneously. Another flap had a local infection, which resolved with antibiotic therapy and surgical debridement. Conclusions: An ALT flap offers several advantages to a burned patient, provided that the surgical technique and postoperative management described in this study are followed. We propose it as the first option for primary burn reconstruction using free flaps in a burned patient. Full article

Background: Necrotizing soft tissue infections (NSTIs) of the lower extremities represent a surgical emergency with high morbidity, complex reconstruction, and considerable healthcare demands. Free tissue transfer (FTT) is increasingly utilized for limb salvage in extensive soft tissue defects, yet its implications for hospital resource utilization remain unclear. This study aims to compare clinical outcomes and perioperative resource demands between FTT and local flap (LF) reconstruction in NSTI patients. Methods: A retrospective case series was conducted at a tertiary referral center between September 2022 and January 2025, including eight patients with NSTI of the lower extremity (FTT, n = 4; LF, n = 4). Demographic data, comorbidities, surgical timing, complication profiles, and resource utilization metrics—including operative duration, hospitalization length, and number of procedures—were analyzed. All FTT cases underwent preoperative CT angiography as part of institutional protocol. Results: Mean time to definitive reconstruction was longer in the FTT group (17.25 vs. 8 days, p = 0.15), reflecting staged infection control. FTT procedures demonstrated significantly longer operative times (331.75 vs. 170.25 minutes, p = 0.015), but there was no significant difference in total hospital stay (34.75 vs. 27.71 days, p = 0.65). No cases of flap loss or venous congestion were observed, and outcomes were optimized via delayed dangling protocols. Conclusions: FTT is a viable and effective reconstructive modality for lower extremity NSTIs. Despite increased surgical complexity, FTT did not significantly increase hospital resource utilization, supporting its role in limb preservation among appropriately selected patients. Full article

Background and Objectives: Sternal resections, although rare, pose significant challenges for the reconstruction of large anterior chest wall defects. Both stability and soft tissue reconstruction are essential for preventing respiratory complications and ensure structural stability. Despite the variety of techniques proposed, no consensus exists on an optimal method. Herein, we present our institutional experience using the novel “spider-web” technique combined with an anterolateral thigh (ALT) free flap for chest wall and soft tissue reconstruction following extensive sternectomies. Materials and Methods: Between January 2023 and November 2024, five female patients underwent partial or total sternectomy for oncologic indications. Chest wall stability was restored using the “spider-web” technique–based on non-resorbable polyester threads arranged in a geometric web pattern reinforced with polypropylene mesh–followed by soft tissue reconstruction using a free ALT myocutaneous flap. Data on demographics, surgical details, postoperative outcomes, and complications were prospectively analyzed. Results: Resections included two partial and three total sternectomies. The mean operative time was 385 min (range: 330–435 min). All patients were extubated postoperatively without the need for respiratory support. The “spider-web” construct provided adequate chest wall stability with no cases of paradoxical movement or chronic pain. No flap loss occurred; one case required revision for venous thrombosis, and one hematoma at the donor site was evacuated. No infections or wound dehiscence were observed. The median hospital stay was 11 days (SD ± 1.67 days), and 30-day mortality was 0%. Median follow-up was 10 months (SD ± 6.55 months), without long-term complications. Conclusions: The “spider-web” technique, combined with ALT myocutaneous free flap, is a simple, reliable, and cost-effective method for the reconstructing extensive chest wall defects following sternectomy. Its technical versatility and favorable outcomes suggest it as a valuable option, offering both structural stability and soft tissue coverage with minimal morbidity. Full article

Planning and harvesting anterolateral thigh flaps (ALT) requires precise perforator selection and accurate tissue perfusion assessment. Unfortunately, variable perforator anatomy and perfusion patterns often result in extensive exploratory dissection. We aimed to assess the impact of preoperative color-coded duplex sonography (CCDS) and intraoperative indocyanine green fluorescence angiography (ICGFA) on perforator selection and operative morbidity. Fifty-three ALTs were performed with preoperative CCDS and intraoperative ICGFA. Flaps had one, two, or three suitable perforators. Additional perforators were either included, or ligated following temporary clamping with ICGFA-based perfusion assessment. If perfusion was sufficient, further dissecting of additional perforators of unfavorable course was abstained from. The impact on perforator selection and operative outcomes was studied. Seven flaps were raised on a single, 34 on 2, and 12 on 3 perforators. There was no flap loss. Comparing the subgroups of fully dissected versus partially clamped and subsequently ligated perforators revealed significantly shorter harvest times in the latter (268 ± 71 versus 216 ± 47 min, p = 0.006). The unnecessary dissection of 21 additional perforators in 16 cases was avoided. Combining preoperative CCDS and intraoperative ICGFA aids in designing ALTs and guarantees the intraoperative selection of suitable perforators. This allows for significant reductions in operative time and donor-site morbidity by limiting unnecessary dissection. Full article

Background/Objectives: Isolated defects of the posterior hypopharyngeal/upper esophageal wall are rare, typically arising after cancer resection or complications following cervical spine osteosynthesis. Various local and free flaps are available for reconstruction, but we opted for a double-island anterolateral thigh (ALT) flap in this case. Methods: A scoping review was conducted (June 2024) following PRISMAScR 2018 guidelines in order to examine the coverage options available in the literature for posterior hypopharyngeal/upper esophagus wall defects while also presenting a case where such a defect was covered with a double-island anterolateral thigh (ALT) flap. Eligibility criteria: Human studies describing defect coverage of the posterior hypopharyngeal/upper esophagus wall were included. Sources of evidence: A literature search was conducted in PubMed, Cochrane Library, and Google Scholar, following PRISMAScR guidelines. Charting methods: Data on surgical techniques, outcomes, and complications were extracted and analyzed by two independent reviewers. Case report: A 57-year-old female developed a chronic posterior wall perforation following Zenker’s diverticulum treatment and C5/6 cage osteosynthesis. Reconstruction was performed using a free fasciocutaneous ALT flap with two skin paddles: one (2 × 2 cm) for the esophageal mucosa and an additional vascularized fascia layer (4 × 8 cm) to separate the cage from the hypopharyngeal defect. To enable flap monitoring in the otherwise hidden defect, a second skin island was externalized cervically. Results: Postoperative recovery was uneventful, with a continuous viable flap signal. A Gastrografin swallow test confirmed an intact esophagus without leaks or dehiscences. Oral intake resumed after 10 days. The literature review highlighted 239 cases with multiple reconstructive techniques, each with advantages and limitations. Conclusions: The double-paddle free fasciocutaneous ALT flap is a viable option for posterior hypopharyngeal/upper esophageal wall reconstruction, allowing effective postoperative monitoring. This approach offers a valuable modification for complex cases requiring enhanced structural integrity and flap assessment. Full article

Background/Objectives: Pedicled anterolateral thigh (ALT) flaps have proven their versatility through various applications including in different tissue compositions in locoregional reconstructions. However, they are underutilized compared to their free counterparts. Our aim is to systematically review the studies published on the utilization of pedicled ALT flaps in various anatomical regions. Methods: A search was conducted using the PubMed and Embase databases including the terms: (“pedicled” OR “island”) AND (“ALT” OR “anterolateral thigh flap” OR “lateral circumflex femoral” OR “vastus lateralis” OR “rectus femoris”). Outcomes regarding etiology, location, number and composition of flaps, flap and defect size, tunnel of the pedicle, flap viability and complications were collected. Results: A total number of 133 studies met the inclusion criteria, of which the majority were case series. After excluding the case reports (n = 49), studies included in the review were grouped based on anatomical locations such as abdominal (n = 12), groin (n = 12), perineal–vaginal–vulvar (n = 11), penile (n = 15), trochanteric–ischial–sacrogluteal (n = 8) and multiple (n = 19). Among a total of 1227 flaps, there were 46 partial (3.7%) and 16 total losses (1.3%). Conclusions: The pedicled ALT flap has been gaining popularity in the past decade. The overall flap loss rate is relatively low. However, the level of therapeutic evidence of published studies is not high, and there is a large heterogeneity among methods. There is a need in the literature for comparative studies with larger cohorts. Further studies will help to establish guidelines and possible algorithms that could include pedicled ALT flaps as first-line management options in different anatomical locations. Full article

Background/Objectives: The reconstruction of hand defects, especially involving the dorsal region of the hand, has remained a challenge for surgeons because of its anatomical features and complex functions. The goal of reconstruction should include functional restoration as well as being esthetically pleasing. The flap transfer reconstruction strategy is essential for satisfying these requirements. Methods: Free flaps were used to cover traumatic defects of the hand dorsum in eleven patients from 2016 to 2022. Eight males and three females with a mean age of 41 years were enrolled. The size of the flaps ranged from 6 × 5 cm to 20 × 9 cm, and the selected flaps included five anterolateral thigh flaps, three lateral arm flaps, and three superficial circumflex iliac artery flaps. Results: All flaps survived, with one case of partial necrosis. One patient experienced joint stiffness during recovery. The donor sites were closed primarily, and there was no need for skin grafting. Secondary debulking or thinning was also not required. The majority of cases recovered excellent function of the hand (mean Q_DASH: 2.5) with satisfactory esthetic outcomes. The postoperative observations were followed by more than six months. Conclusions: Small defects can be treated using local, pedicled, and island-type flaps. However, larger defects involving the exposure of tendons, nerves, and other critical structures commonly require free tissue transfers. The flap reconstruction for hand dorsum in the study is feasible to produce acceptable outcomes in large sized defects. Full article