Objective To investigate the effectiveness of the combination of the anterolateral thigh perforator (ALTP) flap and other flaps for repairing the extreme circumferential defects on the limb. Methods Between October 2016 and June 2019, 9 patients with the extreme circumferential defects on the limb were admitted, which resulted by degloving injury, including 8 males and 1 female with a median age of 42 years (range, 32-65 years). The etiology involved twist injury in 5 cases, traffic accident in 2 cases, and high voltage electric injury in 2 cases. The location of the defects was left forearm in 2 cases, right forearm in 3, left foot in 3, and right foot in 1. The injected wound bed followed by the exposure of bone, joint, tendon, and blood vessel. The dimension of defects was 25 cm×20 cm to 40 cm×28 cm. The period between the injury and admission was 1-12 hours (mean, 5 hours). All contaminated wounds were taken thorough and radical debridement and covered by the vacuum sealing drainage device during the emergency operation. The ALTP flap and the other one flap were tailored according to the dimension of the wound when the wound surface became granulating, including the thoracodorsal artery perforator (TAP) flap in 3 cases, superficial inferior epigastric artery perforator flap in 3 cases, superficial circumflex iliac artery perforator flap in 3 cases. And the donor site was primary closure. Results After operation, all the flaps survived except 1 case of partial necrosis at the edge of TAP flap and healed after secondary skin grafting, and the wounds in the donor and recipient areas healed by first intention. All patients were followed up 14-24 months (mean, 16 months). The shape of the flap was satisfactory and the texture was soft. There was no abnormal hair growth and obvious pigmentation during the follow-up. Only linear scar was left in the donor area, there was no complication such as abdominal wall hernia, and the activity of hip and knee was not affected. The functional reconstruction of upper limb and ankle was satisfactory, and the disabilities of the arm, shoulder, and hand (DASH) score was excellent in 4 cases and good in 1 case; the American Orthopaedic Foot and Ankle Association (AOFAS) score was excellent in 3 cases and good in 1 case. Conclusion ALTP flap combined with different flaps can reconstruct the circumferential extreme defects after limb damage in one-stage, which can achieve limb salvage to the greatest extent.
ObjectiveTo explore the feasibility to restore pronunciation function by repairing partial suprahyoid epiglottis-preserved circumferential defect in near total laryngectomy with anterior medial thigh flap in advanced laryngeal cancer. Methods A retrospective study of 5 male patients with advanced laryngeal cancer between August 2019 and October 2022, aged 56-73 years, with an average age of 65 years were reviewed. The disease duration ranged from 3 to 24 months, with an average of 8 months. Tumor classification by location: 2 cases of glottic type, 2 cases of supraglottic type, and 1 case of subglottic type; TNM staging: 3 cases of T4N0M0 stage, 1 case of T4N1M0 stage, and 1 case of T4N2M0 stage; American Joint Committee on Cancer (AJCC) staging (2017): stage Ⅳ. Near total laryngectomy with partial suprahyoid epiglottis-preserved and selective bilateral neck dissection were performed before the anterior medial thigh flap was used to repair the circumferential defects. The flap size ranged from 6 cm×5 cm to 8 cm×6 cm. Four patients underwent adjuvant radiotherapy and chemotherapy after operation, while 1 patient did not receive any other adjuvant treatment such as radiochemotherapy. Results The flaps of all 5 patients survived without obvious neck infection. One patient developed a slight pharyngeal fistula after oral feeding at 1 month after operation, which healed after another week of gastric feeding. Primary healing also achieved in the thigh donor area. One patient had bilateral cervical lymph node metastasis, and 1 patient had lymph node metastasis on one side. The remaining 3 patients had no cervical nodes metastasis on both sides. All 5 patients were followed up 12-36 months, with an average of 27.6 months. Four patients had clear, audible, and hoarse voice while 1 patient (case 3) had pronunciation similar to whispering. Laryngoscopy showed that the reconstructed laryngeal inlet was fissure-shape and the reconstructed laryngo-trachea canal below the laryngeal inlet was gradually enlarged. At 1 month after operation, the gastric tube was withdrawn and the food was taken orally. There was no obvious aspiration pneumonia. The tracheostomy tube could be blocked in 4 patients for from 30 seconds to 3 minutes. Among them, 3 patients were able to make a noticeable pronunciation even when the tube was not blocked, and they were able to engage in barrier-free language communication; the tracheostomy tube could not be blocked in 1 patient who had a pronunciation similar to whispering. Preliminary voice analysis showed that the patients have a relaxed and natural pronunciation, without obvious breath-holding or air-swallowing movement, compared to patients with esophageal pronunciation. Decannulation did not achieved until the last follow-up in all 5 patients. ConclusionThe anterior medial thigh flap can repair circumferential defects after near total laryngectomy in advanced laryngeal cancer patients and achieve satisfactory pronunciation, thus can serve as an effective pronunciation rehabilitation method. The preserved part of epiglottis may play a role to prevent postoperative aspiration.