Reconstruction of the lower extremities has always been a challenge for Plastic Surgeons. The essential nature of the anatomical structures and the lack of usable excess tissues for reconstruction, bring us to continuously looking for least disabling and invasive techniques. The use of a microsurgical flap is often inevitable, frequently an anterolateral thigh flap (ALT) is the chosen one. Alternatives proposed have been numerous and, in some cases, very (too?) imaginative.
The versatility and the relative ALT's ease of execution make it a gold standard when is needed to intervene on lower limbs substance's losses. The musculo-cutaneous or septo-cutaneous perforators of the descending branch of the lateral circumflex femoral artery (LCFA) can be anastomosed both to the anterior tibial artery (ATA) and to the posterior tibial artery (PTA), even the peroneal artery (PA) can be used.
In the era of tissue regeneration, it has been proposed to modify the ALT free flap using the fascia in order to improve the regeneration of bone fragment in Gustillo fractures [Citation1].
The article is an enrichment in a much-discussed topic, taking inspiration from a technique already used in other body areas [Citation2]. In this context, multidisciplinary orthoplastic treatment is strongly needed. Several works underline the importance of a rapid and integrated intervention, supported by the skills and competences of different professional figures [Citation3, Citation4].
The use of the fascia as an osteoinductor is therefore a new extra surgical shrewdness in a procedure that has gradually been standardized [Citation5, Citation6]. It would be useful to reflect on the the speed needed to provide adequate tissue coverage. Different evidence from the literature show us the importance of ensuring fast surgery always respecting “damage control concept”. The complication rates are inversely proportional to the speed with which the therapeutic path is set [Citation7–10].
Once this first step has been completed, ensuring an ideal treatment of the complex lesion, further measures can be taken into consideration. The heart of the article is the need of a nutritive scaffold that allows the creation of an adequate tissue environment. A congruous environment is essential for the development, regeneration and consolidation of bone tissue.
It should be emphasized that in that complex limb lesions (Gustilo III b-c) the most important contraindication to covering the lesion with a flap is the presence of infected tissue.
Once we give the indication for a fast reconstruction, we must pay attention to the role of periosteum in the vascularization, assuming a theoretical replacement of its nutritional role with the muscular fascia. Improving the tropism and the local conditions in areas affected by pathological condition is a therapeutic key already used in several situations but finds a theoretical new application here. A wider series of cases and a refinement of the technique will surely be useful to better evaluate the effectiveness of the procedure.
Furthermore, considering the intrinsic characteristics of the traumatic pathology (by variable definition and difficult to classify) as well as the necessary use of numerous surgical devices (use of plaques, bone transplant, external fixer, antibiotic cement block) is difficult to evaluate the real impact of the wrapped fascia. Focusing on the vascular role of the periosteum in bone regeneration, some evidences underline how it is fundamental to guarantee an environment suitable for regeneration. Although there is a consensus on the use of ALT as a reference strip to cover the loss of substance, there are several alternatives proposed in the literature [Citation7, Citation11].
Lastly, we should reflect on future possibilities. The enhancement of the environment’s regenerative action above all. In literature we already have different examples of molecules used as important healer factors [Citation8, Citation12].
Future perspective will be to enhance the recovery process by acting on the molecular pathways involved, providing substrates and molecules necessary for tissue reconstitution.
The basis for an engineering of damaged tissues is assumed.
Declaration of Interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Funding
No commercial relationship or financial support or personal financial interest exist.
References
- Cherubino M, Corno M, Ronga M, et al. The adipo-fascial ALT flap in lower extremities reconstruction Gustillo IIIC-B fractures. An osteogenic inducer? J Invest Surg. doi: 10.1080/08941939.2019.1668092.
- Cherubino M, Ronga M, Sallam D, et al. Treatment of radial nonunion with corticocancellous bone graft and fascia of anterolateral thigh free flap: the wrap technique. Plast Reconstr Surg Glob Open. 2016;4(12):e1149. doi:10.1097/GOX.0000000000001149.
- Cherubino M, Stocco C, Sallam D, et al. Aesthetic functional surgery with ulnar artery perforator, an easier alternative to super-thin SCIP. Plast Reconstr Surg. 2018.
- Cuomo R, Sisti A, Grimaldi L, et al. Modified arrow flap technique for nipple reconstruction. Breast J. 2016;22(6):710–711. doi:10.1111/tbj.12659.
- Antonini A, Zacchigna S, Papa G, et al. Improved survival of rat ischemic cutaneous and musculocutaneous flaps after VEGF gene transfer. Microsurgery. 2007;27(5):439–445. doi:10.1002/micr.20378.
- Arnez ZM, Papa G, Ramella V, et al. Limb and flap salvage in Gustilo IIIC injuries treated by vascular repair and emergency free flap transfer. J Reconstr Microsurg. 2017;33(S 01):S03–S7. doi:10.1055/s-0037-1603737.
- Arnez ZM, Papa G, Novati F, et al. Macrovascular arteriovenous shunt (MAS) between ulnar artery and its venae comitantes: the cause of arterial thrombosis and insufficiency in a distally based ulnar forearm perforator (UAP) flap used for intraoral reconstruction. J Plast Reconstr Aesthet Surg. 2014;67(5):739–741. doi:10.1016/j.bjps.2013.12.001.
- Cuomo R, Sisti A, Grimaldi L, et al. Ischemic damage of the flaps: new treatments. J Invest Surg. 2018:1–2. doi:10.1080/08941939.2018.1484199.
- D'Onofrio N, Pieretti G, Ciccarelli F, et al. Abdominal fat SIRT6 expression and its relationship with inflammatory and metabolic pathways in pre-diabetic overweight patients. Int J Mol Sci. 2019;20(5).
- Nicoletti G, Saler M, Pellegatta T, et al. Ex vivo regenerative effects of a spring water. Biomed Rep. 2017;7(6):508–514.
- Sisti A, Cuomo R, Zerini I, et al. Complications associated with medial thigh lift: a comprehensive literature review. J Cutan Aesthet Surg. 2015;8(4):191–197. doi:10.4103/0974-2077.172189.
- Cuomo R, Nisi G, Brandi C, et al. Surgical implications of ischemia reperfusion damage and future perspectives. J Invest Surg. 2019:1–2. doi:10.1080/08941939.2019.1596333.