Kosutic Damir
Consultant Plastic and Reconstructive Surgeon, Department of Plastic Surgery, The Christie NHS Foundation Trust, Wilmslow Road, M20 4BX Manchester, United Kingdom.
J Plast Reconstr Aesthet Surg. 2020 Apr;73(4):758-763. doi: 10.1016/j.bjps.2019.11.036. Epub 2019 Dec 1.
Soft tissue reconstruction around the knee is challenging from a functional and aesthetic perspective. While locoregional options remain limited, free flaps produce additional scarring and longer hospitalization. We describe the most distal "D-perforator" of ALT-axis and present our 4-year experience with a distal perforator-only propeller anterolateral thigh (D-POP ALT) flap for reconstruction around the knee.
Seventeen patients (7 males, 10 females, mean age 57 years), had distal perforator-only propeller (D-POP) ALT flap reconstruction of defects following the wide local excision of melanoma around the knee joint between May 2014 and December 2018. The most distal perforator in the line between spina illiaca anterior superior (SIAS) and the upper lateral border of patella was identified and marked with audible-Doppler and perforator-only propeller ALT (POP-ALT) flap, which was designed around it. Perforators were dissected intramuscularly or intraseptally to allow adequate flap mobilization, but no division of main pedicle was ever performed to ensure anterograde blood supply. Flaps were rotated into defects while all donor-sites were closed directly.
The largest flap measured 25 × 6 cm. The perforator was found between 4 and 9 cm proximal to the upper lateral border of patella in all cases. It was found to be septal in 10 cases and intramuscular in 7 cases. Healing was uneventful in all cases, and patients were ambulatory immediately postoperatively. All patients were discharged on postoperative day 1. Excellent long-term outcomes were observed on follow-up by the senior author.
In our experience, this technique is simple, reliable, and versatile. Thin and pliable flaps can be safely raised based on the most distal (D-POP) ALT perforator. In addition, sizeable flaps can be performed while still preserving the main ALT pedicle, if free flap is required for the same patient in the future.
从功能和美学角度来看，膝关节周围的软组织重建具有挑战性。尽管局部区域的选择仍然有限，但游离皮瓣会产生额外的瘢痕并延长住院时间。我们描述了股前外侧（ALT）轴最远端的“D穿支”，并介绍了我们使用仅含远端穿支的推进式股前外侧（D-POP ALT）皮瓣进行膝关节周围重建的4年经验。
2014年5月至2018年12月期间，17例患者（7例男性，10例女性，平均年龄57岁）在膝关节周围黑色素瘤广泛局部切除术后，采用仅含远端穿支的推进式（D-POP）ALT皮瓣重建缺损。确定并标记出髂前上棘（SIAS）与髌骨上外侧缘连线中最远端的穿支，使用可听式多普勒和仅含穿支的推进式ALT（POP-ALT）皮瓣围绕其进行设计。穿支在肌肉内或肌间隔内进行解剖，以确保皮瓣有足够的活动度，但从未切断主要蒂部以确保顺行血供。皮瓣旋转至缺损处，同时直接关闭所有供区。
最大的皮瓣尺寸为25×6 cm。所有病例中，穿支均位于髌骨上外侧缘近端4至9 cm之间。其中10例为肌间隔穿支，7例为肌肉内穿支。所有病例愈合顺利，患者术后立即可下床活动。所有患者均于术后第1天出院。资深作者随访观察到长期效果良好。
根据我们的经验，该技术简单、可靠且用途广泛。基于最远端的（D-POP）ALT穿支可安全地掀起薄且柔韧的皮瓣。此外，如果未来同一患者需要游离皮瓣，在保留ALT主要蒂部的同时仍可切取较大尺寸的皮瓣。
