case_images: PMC9645236_01
case_images: A clinical case showing reconstruction with a wide ALTP flap where the turbocharging procedure was performed before harvesting the flap. (Each arrow indicates as follows: yellow indicates a perforator from TB-LCFA; green indicates DB-LCFA; white indicates side branches of DB-LCFA). (A) A 73-year-old man presented with extensive soft tissue defects on the right lower leg caused by a traffic accident. (B) A wide ALTP flap (28 x 12 cm2) was elevated to cover exposed bone and plate after radical debridement and temporary bony fixation. (C) The ALTP flap included perforators from both DB-LCFA and TB-LCFA, and all vessels related to the turbocharging procedure were isolated and prepared. (D) The anastomosis was executed. (E) The harvested turbocharged wide ALTP flap (F) 16 months postoperatively. ALTP, anterolateral thigh perforator; TB-LCFA, transverse branch of lateral circumflex femoral artery; DB-LCFA, descending branch of lateral circumflex femoral artery.
case_images: fsurg-09-991094-g006.jpg
case_images: PMC9645236_01_fsurg-09-991094-g006.jpg
case_images: F6
case_images: A 73-year-old man was involved in a traffic accident and sustained substantial soft tissue injuries in the right lower leg (Figure 6A). A wide ALTP flap (28 x 12 cm2) was designed on the contralateral thigh for all exposed bones and plate coverage (Figure 6B). TB-LCFA and two perforators from the DB-LCFA were found during flap elevation. The turbocharging procedure was performed between these two types of perforators before flap harvesting because it was speculated that the main pedicle length would not be shortened after turbocharging (Figures 6C,D). ALTP flap anastomosed to the anterior tibial artery in an end-to-end manner (Figures 6E,F). Additionally, the residual wound around the transferred flap and the donor site was covered with a split-thickness skin graft.
case_images: PMC9645236_02
case_images: A clinical case demonstrating reconstruction with a wide ALTP flap where the turbocharging procedure was performed after harvesting the flap. (Each arrow indicates as follows: yellow indicates a perforator from TB-LCFA; green indicates DB-LCFA; white indicates side branches of DB-LCFA). (A) To reconstruct a massive soft tissue defect in the left lower leg, a wide ALTP flap (25 x 14 cm2) was designed on the contralateral thigh. (B) Perforators from both TB-LCFA and DB-LCFA supplied the ALTP flap. (C) The flap was harvested and transferred to the recipient site before the turbocharging procedure because its effects on the main pedicle anastomosis could not be assessed due to the ambiguous vessel anatomy in the destructed recipient wounds. (D) The main pedicle of the transferred ALTP flap was anastomosed to the recipient vessels, and the turbocharging procedure was performed. (E) An enlarged photograph of the part of the white dotted box in (D) shows the turbocharging procedure between TB-LCFA and a side branch of DB-LCFA (E) 23 days postoperatively. ALTP, anterolateral thigh perforator; TB-LCFA, transverse branch of lateral circumflex femoral artery; DB-LCFA, descending branch of lateral circumflex femoral artery.
case_images: fsurg-09-991094-g007.jpg
case_images: PMC9645236_02_fsurg-09-991094-g007.jpg
case_images: F7
case_images: Therefore, we decided to achieve soft tissue coverage using an extended ALTP free flap (25 x 14 cm2) and designed the flap on the contralateral thigh based on a template reflecting the size and shape of the defect (Figure 7A). The designed flap was harvested with long TB-LCFA and DB-LCFA with multiple side branches (Figures 7B,C) and transferred to the recipient site. The DB-LCFA of the flap was connected to the anterior tibial vessels in advance. Therefore, the turbocharging procedure was successfully executed (Figures 7D,E), and adequate coverage of soft tissue defects was obtained. The flap survived without any postoperative complication (Figure 7F).
case_images: PMC9645236_03
case_images: A clinical case presenting reconstruction with a wide ALTP flap where the turbocharging procedure was performed after harvesting the flap. (Each arrow indicates as follows: yellow indicates a perforator from TB-LCFA; white indicates side branches of DB-LCFA) (A) An 18-year-old man sustained severe bone and soft tissue injuries in the right lower leg from a motorcycle accident. (B) A wide ALTP flap (25 x 15 cm2) was designed. (C) The flap was harvested without the turbocharging procedure because the main pedicle was possibly expected to be critically shortened by adding a turbocharged supplying vessel because the flap already had three perforators from DB-LCFA. (D) A photograph was taken 21 months after reconstruction using a wide turbocharged ALTP flap.
case_images: fsurg-09-991094-g008.jpg
case_images: PMC9645236_03_fsurg-09-991094-g008.jpg
case_images: F8
case_images: Soft tissue reconstruction was essential to cover the resulting massive defect and salvage the limb (Figure 8A). TB-LCFA, was elevated from the contralateral thigh (Figures 8B,C). The addition of one more perforator to the main pedicle, which already had three perforators, seemed to significantly restrict its mobility (Figure 8C). Therefore, after connecting the main pedicle to the anterior tibial vessels, we selected the appropriate side branch of the DB-LCFA and performed an anastomosis between the selected branch and TB-LCFA. The flap completely survived (Figure 8D) and the patient was able to ambulate naturally without assistance at the last follow-up.