Lu Johnny Chuieng-Yi, Zelken Jonathan, Hsu Chung-Chen, Chang Nai-Jen, Lin Chih-Hung, Wei Fu-Chan, Lin Cheng-Hung
Taipei, Taiwan From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, and Chang Gung University.
Plast Reconstr Surg. 2015 May;135(5):1476-1485. doi: 10.1097/PRS.0000000000001168.
The anterolateral thigh flap is preferred at the authors' institution for lower extremity reconstruction. When variations in vascular anatomy preclude flap harvest, the authors follow an algorithm for contingency planning. The authors compared outcomes of contingency strategies to anterolateral thigh flaps that go as planned.
Between January of 2001 and February of 2012, 548 free anterolateral thigh flaps were planned for lower extremity reconstruction at Chang Gung Memorial Hospital. In 30 cases, the flap could not be used because perforators were not identified (n = 12), unreliably small (n = 14), or injured (n = 4). Using the authors' algorithm, the flap was converted to an ipsilateral tensor fasciae latae (n = 21), anteromedial thigh (n = 5), or contralateral vastus lateralis myocutaneous flap (n = 4). Outcomes, including flap failure, necrosis, and re-exploration rate, were compared in successful cases and those that required conversion.
The incidence of unreliably small or absent perforators was 4.8 percent. Adding cases of iatrogenic perforator injury, the incidence was 5.5 percent. There was no difference in flap survival, flap loss, or need for re-exploration regardless of whether or not the anterolateral thigh flap was used. In 70 percent of cases, the authors favored the tensor fasciae latae flap; partial flap necrosis occurred in six of 21 cases, and total flap loss occurred in one.
Without preoperative imaging, dilemmas may be encountered in roughly one of 20 anterolateral thigh flaps raised. Using the authors' algorithm, alternative options can reliably confer results comparable to those of planned anterolateral thigh flaps.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
在作者所在机构，股前外侧皮瓣是下肢重建的首选皮瓣。当血管解剖变异妨碍皮瓣切取时，作者遵循一种应急计划算法。作者将应急策略的结果与按计划切取的股前外侧皮瓣的结果进行了比较。
2001年1月至2012年2月期间，长庚纪念医院计划切取548例游离股前外侧皮瓣用于下肢重建。在30例中，由于未识别出穿支（n = 12）、穿支过小不可靠（n = 14）或穿支受损（n = 4），皮瓣无法使用。根据作者的算法，将皮瓣转换为同侧阔筋膜张肌皮瓣（n = 21）、股内侧皮瓣（n = 5）或对侧股外侧肌肌皮瓣（n = 4）。比较成功病例和需要转换的病例的结果，包括皮瓣失败、坏死和再次探查率。
穿支过小不可靠或缺失的发生率为4.8%。加上医源性穿支损伤病例，发生率为5.5%。无论是否使用股前外侧皮瓣，皮瓣存活、皮瓣丢失或再次探查的需求均无差异。在70%的病例中，作者倾向于使用阔筋膜张肌皮瓣；21例中有6例发生部分皮瓣坏死，1例发生皮瓣完全丢失。
在未进行术前影像学检查的情况下，每20例切取的股前外侧皮瓣中大约会遇到1例困境。使用作者的算法，替代方案能够可靠地获得与计划切取的股前外侧皮瓣相当的结果。
临床问题/证据级别：治疗性，III级。
